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Version 3 - 19-11-08 Page 1 of 3
Clinical Approach CPG A0101
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Stop Primary Survey / Life Threat Status
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Standard Precautions: Gloves, goggles, PPE, Immediate Mx + Sitrep
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mask, vest required (Utilise ETHANE
Dangers mnemonic)
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Response
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Airway – Cervical spine immobilization if required
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Breathing Assist ventilations if VT inadequate
V
Circulation Commence CPR if required
e
Haemorrhage Control life threatening haemorrhage
c e A
Action
n c
Rapport, Rest and Reassurance In order of clinical need
n
Posture / Position of comfort If clinically applicable,
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assess Hx prior to
a
Oxygen as required (e.g. hypoxia, respiratory distress)
physical contact with Pt
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Establish if Refusal of Treatment documented
e.g. VSS, applying monitor,
a
exposing chest
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Assess History
b o r
Brief clinical Hx Accurate Hx + assessment
essential for problem
t
Event prior to Ambulance call
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recognition
Past medical Hx
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Pain – Verbal analogue score
A i c
Medications
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Allergies
© e V V Clinical Approach CPG A0101 1

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Assess Vital Sign Survey
m o o
GCS Determine time criticality to
t t
PSA Mx accordingly
Accurate body system
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RSA
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assessment in all Pts
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Pattern / mechanism of injury / medical condition
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Assessment Tools / Secondary Survey
V
Secondary Survey Thorough physical
e
examination
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SpO2
- Head to toe
A
Monitor/ECG (12 lead if available)
c c
Temp - Inspection, palpation,
auscultation
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EtCO2
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More detailed Hx
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BGL - Blood Glucose Level
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Determine Main
a
Presenting Problem
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The combination of subjective (PHx, Hx, Med’s) and Confirm clinical reasoning
b
objective (physical) data allows identification of with assessment data
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clinical problems
t
Multiple problems may be identified and prioritised to
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provide treatment order
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Some overlap in treatment may address multiple
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problems
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Action
m o o
Further Sitrep / Resource requirements as required
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Consider time to hospital vs time to R/V with MICA
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Paramedic
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IV access if required
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Specific treatment - appropriate CPG applied to
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Mx clinical problems
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Transport to appropriate facility
Reassess frequently and adapt Mx as appropriate
e e
Final assessment at destination/handover
n c n c A
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m b to r
t
This Clinical Approach is to be applied to all Pts as a basic level of care. There is an assumption in each CPG
A c
that this is the minimum level of care that the Pt will receive prior to the application of the Guideline.
i c
The exception to this rule is the Pt in immediate life threat that requires intervention during the Primary Survey.
© e V V i Clinical Approach CPG A0101 3

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Version 2 - 01.09.03 Page 1 of 2
Perfusion and Respiratory Assessment CPG A0102
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Special Notes
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Special Notes
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These observations and criteria need to be taken in • Respiratory Assessment
m t o
context with: The Respiratory Status Assessment table represents
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- The Pt’s presenting problem a graded progression from normal to severe
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- The Pt’s prescribed medication respiratory status.
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- Repeated observations and the trends shown
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- Response to management.
V V
• Perfusion Definition
The ability of the cardiovascular system to provide
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tissues with an adequate blood supply to meet their
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functional demands at that time and to effectively
c c A
remove the associated metabolic waste products.
• Perfusion Assessment
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Other factors may affect the interpretation of the
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observations made, e.g., the environment, both cold
a
and warm ambient temp. may affect skin signs; anxiety
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may affect pulse rate; and the many causes of altered
a
conscious state or unconsciousness. Other conditions
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may affect conscious state observations such as poor
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cerebral perfusion, respiratory hypoxia, head injuries,
b
hypoglycaemia and drug overdoses.
o
The Perfusion Status Assessment table represents a
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graded progression from adequate to no perfusion.
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Perfusion Status Assessment CPG A0102
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Skin Pulse BP Conscious Status
m o o
Adequate Warm, pink, 60 – 100/min > 100mmHg Alert and orientated
t t
Perfusion dry systolic in time and place

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Borderline Cool, pale, 50 – 100/min 80 – 100mmHg Alert and orientated
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Perfusion clammy systolic in time and place
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Inadequate Cool, pale, < 50/min, or 60 – 80mmHg Either alert and orientated
V
Perfusion clammy > 100/min systolic in time and place
or altered
e e
Extremely Cool, pale, < 50/min, or < 60mmHg Altered or
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Poor clammy > 110/min systolic or unconscious
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Perfusion unrecordable
n n
No Perfusion Cool, pale, Absence of Unrecordable Unconscious
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clammy palpable pulse
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© e V Perfusion Criteria CPG A0102 5
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Respiratory Status Assessment CPG A0103
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Normal Mild Distress Moderate Distress Severe Distress (Life Threat)
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General Appearance Calm, quiet Calm or mildly anxious Distressed or anxious Distressed, anxious, fighting to
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breathe, exhausted, catatonic
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Speech Clear and steady Full sentences Short phrases only Words only or unable to speak
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sentences
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Breath Sounds Usually quiet Able to cough Able to cough Unable to cough
V
And no wheeze
V
Chest Auscultation Asthma: mild expiratory Asthma: expiratory Asthma: expiratory wheeze +/–
wheeze wheeze, +/– inspiratory inspiratory wheeze, maybe no
e
wheeze breath sounds (late).
c e A
No crackles or LVF: may be some fine LVF: crackles at bases - LVF: fine crackles – full field, with
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scattered fine basal crackles at bases to mid-zone possible wheeze
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crackles, Upper Airway Obstruction:
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e.g. postural Inspiratory stridor
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Respiratory Rate 12 – 16 16 – 20 > 20 > 20
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Bradypnoea (< 6 – 8)
Respiratory Rhythm Regular even cycles Asthma: may be slightly Asthma: prolonged Asthma: prolonged expiratory
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prolonged expiratory expiratory phase phase
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phase
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Breathing Effort Normal chest Slight increase in normal Marked chest movement Marked chest movement with
movement chest movement +/– use of accessory accessory muscles, intercostal
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muscles. retraction +/– tracheal tugging
m t
Pulse Rate 60 – 100 60 – 100 100 – 120 > 120, bradycardia late sign
A c t
Skin Normal Normal Pale and sweaty Pale and sweaty, +/– cyanosis
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Conscious State Alert Alert May be altered Altered or unconscious
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Conscious State Assessment CPG A0104
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Glasgow Coma Score
m t o or
A. Eye Opening Score
t
Spontaneous 4
ic c
To Voice 3
i
To Pain 2
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None 1 A:
B. Verbal Response Score
e e
Orientated 5
c A
Confused 4
c
Inappropriate words 3
n n
Incomprehensible sounds 2
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None 1 B:
a
C. Motor Response Score
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Obeys Command 6
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Localises to pain 5
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Withdraws (pain) 4
b
Flexion (pain) 3
o
Extension (pain) 2
m t
None 1 C:
c t
Total GCS (Max. Score = 15)
A i c
(A+B+C)=
© e V V i Conscious State Assessment CPG A0104 7

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Time Critical Guidelines CPG A0105
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Introduction
t t
The concept of the “Time Critical” Pt allows the recognition of the severity of a Pt’s condition or the likelihood of
c
deterioration. This identification directs appropriate clinical management and the appropriate destination to improve
i c
outcome. Covered within the Time Critical Guidelines are:
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- Triage decisions for a Pt with Major Trauma
V V
- Triage decisions for a Pt with significant Medical Conditions
- Requests for additional resources including MICA Paramedic and Aeromedical services
e e
- Judicious scene time management (e.g. should not exceed 20min. for non-trapped major trauma Pt)
c A
- Appropriate receiving hospital and early notification
c
It is important to note that the presence of time criticality does not infer a directive for speed of transport, but rather
n n
the concept implies there be a “Time Consciousness” in the management of all aspects of Pt care and transport.
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Time Critical Definitions
l
Actual At the time the vital signs survey is taken, the Pt is in actual physiological distress.
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Emergent At the time the vital signs survey is taken, the Pt is not physiologically distressed but does have
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a “Pattern of Injury or Significant Medical Condition” which is known to have a high probability of
b
deteriorating to actual physiological distress.
o
Potential At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no
m t
significant “Pattern of actual Injury/Illness”, but does have a “Mechanism of Injury/Illness” known to
t
have the potential to deteriorate to actual physiological distress.
A V ic ic
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Time Critical Guidelines CPG A0105
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Trauma Triage
t t
Pts meeting the criteria for Major Trauma should be triaged to the highest level of Trauma care available within
c
30min. transport time of the incident in accordance with Victorian State Trauma System requirements and AV
i c
policies and procedures.
i
The receiving hospital must also be notified to ensure an appropriate reception team and facilities are available.
V V
Mechanism of Injury (MOI)
A Pt under the Trauma Triage Guidelines meets the criteria for Major Trauma if they have a combination of MOI and
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other Co-morbidities constituting:
c c A
• Systemic illness limiting normal activity / Systemic illness constant threat to life. Examples include:
- Poorly controlled hypertension
n n
- Morbid obesity
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- Controlled or uncontrolled Congestive Cardiac Failure
a
- Symptomatic COPD
l
- Ischaemic heart disease
a
- Chronic renal failure or liver disease
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• Pregnancy
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• Age < 15 or > 55
b
Medical Triage
to
Pts meeting the time critical criteria for Medical conditions are regarded as having, or potentially having, a clinical
m
problem of major significance. These Pts are time critical to the nearest appropriate hospital.
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© e V Time Critical Guidelines CPG A0105 9
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Trauma Time Critical Guidelines
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b
or
Actual Time Critical Emergent Time Critical

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a
? Status
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• Possible major trauma

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c
A
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Assess Vital Signs
8 Vital Signs are normal
?
i
• Any of the following: • May have Pattern of Injury

o
- Respiratory Rate < 8 or > 20
V
- BP < 100
©
Assess Pattern of Injury

8
- Pulse < 50 or > 100
t
- GCS < 13 • Any of the following:
- Oxygen saturation < 90% • Penetrating Injuries
c
e
- Head / Neck / Chest / Abdomen / Pelvis /
Axilla / Groin
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• Blunt Injuries
c
a
V
- Significant injury to a single region:
Head / Neck / Chest / Abdomen / Axilla / Groin
- Injuries involving two or more of the above body
n
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regions
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• S
pecific Injuries
e
V
a
- Limb amputations / limb threatening injuries
o
- Suspected spinal cord injury
- Burns > 20% or involving respiratory tract
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t - Serious crush injury
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- Major compound fracture or open dislocation

c - Fracture to two or more of the following:
Femur / Tibia / Humerus
c
b
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- Fractured pelvis
V
n
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Significant Pattern of Injury
?
A
?
Vital Signs not normal • Vital Signs normal
c
Action
✔ Action
✔
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• Triage to highest level of trauma service • Triage to highest level of trauma service
within 30min. within 30min.
©
• Consider MICA / Aeromedical support • Consider MICA / Aeromedical support
b
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? Status Stop 8 Assess 8 Consider ✔ Action ✔ MICA Action
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A
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CPG A0105
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or
Potentially Time Critical Not Time Critical

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No Pattern of Injury
t
• Vital Signs are normal
• May have Mechanism of Injury
c
e
Assess Mechanism of Injury (MOI)
8 ?
No MOI
✔
i
c
a
• Any of the following: • Vital Signs are normal
V
- Ejection from vehicle • No Pattern of Injury
- Motor/cyclist impact > 30km/h
✔
Action
n
i
- Fall from height > 3m
- Struck on head by falling object > 3m • Triage to nearest appropriate facility if required
r
i
- Explosion
e
V
a
- High speed MCA > 60km/h
o
- Vehicle rollover
- Fatality in same vehicle
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- Pedestrian impact
t
- Prolonged extrication > 30min.
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e
c
Assess Co-morbidities
8
c
b
i
• Any of the following:
- Age > 55
V
- Pregnancy
n
m
- Significant underlying medical condition
a
e
?
Positive MOI and Co-morbidities ?
Positive MOI and no Co-morbidities
A
• Vital Signs are normal • Vital Signs are normal
l • No Pattern of Injury • No Pattern of Injury
c
u
Action
✔ ✔
Action
• Triage to highest level of trauma service • Triage to nearest appropriate facility
©
within 30min. with notification
b
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Trauma Time Critical Guidelines CPG A0105 11
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A
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a
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Trauma Time Critical Guidelines (Paediatric)
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or

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a
?
Status
t
• Possible major trauma

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c
A
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Assess Vital Signs
8 Vital Signs are normal
?
i
• May have Pattern of Injury

o Newborn Infant
V
< 2 weeks < 1 year
©
Respiratory Rate < 40 or > 60 < 20 or > 50 Assess Pattern of Injury

8
BP
t N/A < 60 mm Hg • Any of the following:

Pulse < 100 or > 170 < 90 or > 170
• Penetrating Injuries
c
Conscious State GCS < 15 GCS < 15
e
- Head / Neck / Chest / Abdomen / Pelvis /
O2 saturation N/A N/A
Axilla / Groin
Skin cold/pale/ cold/pale/
i
clammy clammy • Blunt Injuries
c
a
V
- Significant injury to a single region:
Child Large Child Head / Neck / Chest / Abdomen / Axilla / Groin
1 - 8 years 9 - 15 years - Injuries involving two or more of the above body
n
i
Respiratory Rate < 20 > 35 < 15 or > 25 regions
r
i
BP < 70 mm Hg < 80 mm Hg • Specific Injuries
e
Pulse < 75 or > 130 <65 or > 100
V
a
- Limb amputations / limb threatening injuries
o
Conscious State GCS < 15 GCS < 15
- Suspected spinal cord injury
O2 saturation N/A < 90%
Skin cold/pale/ cold/pale/ - Burns > 20% or involving respiratory tract
l
t clammy clammy - Serious crush injury
u
e
- Major compound fracture or open dislocation

c - Fracture to two or more of the following:
Femur / Tibia / Humerus
c
b
i
- Fractured pelvis
V
n
m
a
e
?
Significant Pattern of Injury
A
?
l Action
c
Action
✔ ✔
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• Triage to highest level of trauma service • Triage to highest level of trauma service
within 30min. within 30min.
©
b
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t
A
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CPG A0105
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b
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Potentially Time Critical Not Time Critical

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t
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V
©
?
No Pattern of Injury
t
• May have Mechanism of Injury
c
e
Assess Mechanism of Injury (MOI)
8 ?
No MOI
✔
i
c
a
• Any of the following: • Vital Signs are normal
V
- Ejection from vehicle • No Pattern of Injury
- Motor/cyclist impact > 30km/h
Action
✔
n
i
- Fall from height > 3m
- Struck on head by falling object > 3m • Triage to nearest appropriate facility if required
r
i
- Explosion
e
V
a
- High speed MCA > 60km/h
o
- Vehicle rollover
- Fatality in same vehicle
l
- Pedestrian impact
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- Prolonged extrication > 30min.
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c
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Positive MOI
A
l • No Pattern of Injury
c
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Action
✔
• Triage to highest level of trauma service
©
within 30min.
b
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Trauma Time Critical Guidelines (Paediatric) CPG A0105 13
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A
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a
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©
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Medical Time Critical Guidelines CPG A0105
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or

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a
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Status
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• Possible Medical time critical

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c
A
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Assess Vital Signs
8 ?
Vital Signs are normal
i
• Any of the following: • May have Significant Medical Condition

o
- Moderate or Severe Respiratory Distress
V
- Oxygen saturation < 90% Room Air / 93%
©
Assess Medical Condition

8
supplemental O2
t
- < Adequate Perfusion Any of the following:
- GCS < 13 (unless normal for Pt) • Medical Symptoms / Syndromes
c
e
- Acute Coronary Syndrome
- Acute stroke
i
- Severe sepsis, including suspected
c
a
meningococcal disease
V
- Possible Abdominal Aortic Aneurysm
- Undiagnosed severe pain
n
i
• Need for possible hyperbaric treatment e.g.
acute decompression illness or cyanide
r
i
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poisoning
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• Hypothermia or Hyperthermia
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t
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Significant Medical Condition
A
?
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Action
✔ Action
✔
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• Triage to nearest appropriate facility • Triage to nearest appropriate facility
with notification with notification
©
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Mental Status Assessment CPG A0106
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Observations
m o o
A mental status assessment is a systematic method used to evaluate a Pt’s mental function. In undertaking a
t t
mental status assessment, the main emphasis is on the person’s behaviour. This assessment is designed to
c
provide Paramedics with a guide to the Pt’s behaviour, not to label or diagnose a Pt with a specific condition.
i ic
1. Appearance Neatness, cleanliness
V
Pupils – size
V
Extraocular movements
2. Behaviour Bizarre or inappropriate
e e
Threatening or violent
A
Unusual motor activity, such as grimacing or tremors
c c
Impaired gait
Psychomotor retardation or agitation
n n
3. Speech Rate, volume, quantity, content
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4. Mood Depressed, agitated, excited or irritable
l
5. Response Flat – unresponsive facial expression
a
Appropriate/inappropriate
u i
6. Perceptions Hallucinations
b r
7. Thought content Delusions (i.e., false beliefs)
o
Suicidal thoughts
t
Overly concerned with body functions (eg. Bowels)
m t
8 Thought flow Jumping irrationally from one thought to another
A ic
9. Concentration Poor ability to organise thoughts
c
Short attention span Impaired judgement
V i
Poor memory Lack of insight
© e V Mental Status Assessment CPG A0106 15

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Stroke Assessment CPG A0107
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? Stroke signs and symptoms Assess/Consider
8
Assessment
✔ Findings • Intoxication drug/alcohol
o
8 8
m o
• Hypo/hyperglycemia
t
Facial Droop Pt shows teeth or Normal - both sides Abnormal - one side of
t
• Seizures
smiles of face move equally face does not move as well • Brain tumour primary/secondary
c c
as the other
i
• Syncope
i
Speech The Pt repeats Normal - the Pt says Abnormal - the Pt slurs • Middle ear disorder
V
“You can’t teach an the correct words, no words, says the wrong • Migraine
V
old dog new tricks” slurring words, or is unable to • Subdural haematoma
speak or understand • Sepsis
e
• Electrolyte disturbances
e
Hand grip Test as for GCS Normal - equal grip Abnormal - unilateral
c A
weakness
c
Possible
8 Co-morbidities
Blood Test for BGL Abnormal -if Normal BGL
n n
glucose hypoglycemia • Dementia
manage as per • Significant pre-existing physical
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CPG A0702 disability
l
Hypoglycemia
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Assessing
8 onset timeframe
r
8 Consider and exclude stroke mimics • If Pt wakes with a deficit or
b
inability to communicate, the
o
time is taken from when the Pt
Determine and document exact time of onset of stroke symptoms
t
was last seen deficit free.
m
Accurate timeframe for onset of
c t
✔ Notify receiving hospital if no co-morbidities and onset of symptoms < than 6hr. symptoms is critical for Rx:
A i
< 3hr. for IV thrombolytic
c
< 6hr. for other therapies
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8 Continue management and transport to a hospital offering an acute stroke service
if appropriate
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Cardiac Arrest CPG A0201
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Principles of CPR
m o o
CPR Adjustment for temperature
t t
• Assumption that CPR is commenced immediately and > 32˚C
c
continued throughout cardiac arrest as required
• Standard Cardiac Arrest Guidelines
i c
• Generic for all adult cardiac arrest conditions
i
• Must not be interrupted for more than 10 sec. during rhythm / 30 - 32˚C
V V
pulse checks. If unsure of pulse, recommence CPR immediately
• Double dosage intervals in relevant
• Change operators every 2min. to improve CPR performance cardiac arrest Guideline
e
and reduce fatigue • Do not rewarm beyond 33˚C if ROSC
e
• Depth 50% chest volume
c c A
• Rhythm/Pulse check every 2min. < 30˚C
n
• CPR commenced immediately after defibrillation and pulse • Continue CPR and rewarming
n
check after 2min. until temp. > 30˚C
la a ©
• One defibrillation shock only
Ratios of compressions to ventilations
l
• One dose of Adrenaline
Not intubated
a
• One dose of Atropine
u i
• 30 : 2
• Rate: Approximately 100 compressions per min. • One dose of Amiodarone
b r
- Pause for ventilations • Withhold NaHCO3 8.4% IV
o
Intubated / LMA inserted
• 15 : 1
m t
• Rate: Approximately 100 compressions per min.
c t
- < 8 ventilations/min.
A i
- No pause for ventilations
© V V ic
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Cardiac Arrest CPG A0201
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Action
r
✔
• Immediately commence CPR 30 : 2
m t o to
? Unconscious/Pulseless VF/VT ? Pulseless Electrical Activity (PEA) ? Asystole
c c
Action Identify and Rx causes
i
✔
i
• Unwitnessed arrest - Hypoxia
V
Defibrillate 200J Biphasic - Anaphylaxis
V
(360J Monophasic) - Asthma
- Repeat @ 2/60 intervals if - Exsanguination
e e
VF/VT persists - Upper airway obstruction
- Tension pneumothorax
A
• Paramedic witnessed arrest
c c
3 x 200J Biphasic
n
(360J Monophasic)
n
- Rhythm check between shocks
la ©
- Continue with single shocks
a
@ 2/60 intervals if VF/VT
l
persists
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? VF/VT persists
ria ? PEA persists ? Asystole
o
Action
✔ Action
✔ Action
✔
m t
• IV access/Normal Saline TKVO • IV access/Normal Saline TKVO • IV access/Normal Saline TKVO
c t
• Adrenaline 1mg IV • Adrenaline 1mg IV • Adrenaline 1mg IV
A i
- Repeat @ 3/60 if no output - Repeat @ 3/60 if no output - Repeat @ 3/60 if no output
V ic
• Consider I/O if delay in IV access • Consider I/O if delay in IV access • Consider I/O if delay in IV access
- Adrenaline 1mg I/O - Adrenaline 1mg I/O - Adrenaline 1mg I/O
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? VF/VT persists ? PEA persists ? Asystole persists
l ©
Action
✔ Action
✔ Action
✔
u a
• Insert LMA • Insert LMA • Insert LMA
i a
• Change CPR ratio to 15 : 1 • Change CPR ratio to 15 : 1 • Change CPR ratio to 15 : 1
b r i
• Intubate • Intubate • Intubate
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• If unable to obtain IV or I/O • If unable to obtain IV or I/O • If unable to obtain IV or I/O
m o o
- Adrenaline 2mg via ETT - Adrenaline 2mg via ETT - Adrenaline 2mg via ETT
t t
• Change CPR ratio to 15 : 1 • Change CPR ratio to 15 : 1 • Change CPR ratio to 15 : 1
ic ic
? VF/VT persists ? PEA persists ? Asystole persists
V
Action Action Action
V
✔ ✔ ✔
• Amiodarone 300mg IV • Normal Saline 20ml/kg IV • Atropine 3mg IV
e e
? VF/VT persists ? PEA persists - HR < 60
c c A
Action
✔ ✔ Action
n
• Repeat Amiodarone 150mg IV • Atropine 3mg IV
n
(max. combined dose 450mg)
la la ©
? VF/VT persists ?
PEA persists ?
Asystole persists
u ia
• After 15/60 Paramedic CPR • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR
r
Action
✔ Action
✔ Action
✔
b
• Sodium Bicarbonate 8.4% • Sodium Bicarbonate 8.4% • Sodium Bicarbonate 8.4%
o
50ml IV 50ml IV 50ml IV
m ct t
? ROSC ? ROSC ? ROSC
A i c
Action
✔ Action
✔ Action
✔
V i
• Treat as per ROSC Mx • Treat as per ROSC Mx • Treat as per ROSC Mx
©? Status
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8 Assess 8 Consider ✔ Action ✔ MICA Action
Cardiac Arrest CPG A0201 19
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Cardiac Arrest (ROSC Management) CPG A0202
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Special Notes General Care
o
CPG A0407 Inadequate Perfusion (Cardiogenic • Therapeutic Hypothermia
m t o
Causes) Ensure fluid is < 8 degrees prior to administration.
t
CPG A0302 Endotracheal Intubation
• Sodium Bicarbonate may be administered earlier
c
CPG A0406 Pulmonary Oedema
c
in algorithm if hyperkalaemia suspected or in cardiac
i i
arrest secondary to TCA overdose.
e V e V
n c n c A
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Cardiac Arrest (ROSC Management) CPG A0202
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?
Status
• Post cardiac arrest
m o o
- Return of spontaneous circulation (ROSC)
ic t
?
Unintubated
ic t ?
Perfusion management ?
Therapeutic cooling ?
Transport
V V
• GCS < 10 post ROSC Action
✔ • Pt intubated Action
✔
Action
✔ • Maintain BP > 120 or Pt’s • Collapse to ROSC > 10/60 • Appropriate receiving
e
• Collapse to ROSC > 10/60 usual BP (if known) • Normal functional status hospital
e
- RSI as per CPG A0302 • Normal Saline and (independent with ADLs) • Notify early
c c A
- Therapeutic cooling Adrenaline to be used as • Temp. > 34.5 • 12 lead ECG if available
• Collapse to ROSC < 10/60 required per CPG A0407
n
• No pulmonary oedema
n
- No therapeutic cooling • Accurately assess pulse evident
la ©
- RSI as per CPG A0302 during movement/loading
a
• Cardiac arrest not due to
if coma persists despite to ensure output
l
bleeding
initial oxygenation and maintained throughout
a
perfusion Mx • Rx as per appropriate
u i
Action
✔
Guideline if condition
r
• Assess Pt temp.
b
changes
• Sedation/paralysis
o
• Do not administer
- Midazolam 1-5mg IV
Amiodarone unless
m t
- Pancuronium 8mg IV
breakthrough VF/VT
t
• Rapid infusion cold
c
occurs
A i
Normal Saline
c
2000ml IV if available
V i
- Cease if APO occurs
and Rx as per CPG
© V
A0406
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Cardiac Arrest (ROSC Management) CPG A0202 21
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Withholding and/or Ceasing Pre-hospital resuscitation CPG A0203
u la a © a ©
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Special Notes Special Notes
o
• A Refusal of Treatment Certificate may be completed by: • Ambulance crews must clearly record full details of
m t o
- a person aged 18 years or older; the information given to them and the basis for their
t
- an agent, where a person aged 18 years or older has decision regarding resuscitation on the PCR. This is
c
completed an Enduring Power of Attorney (Medical particularly important in circumstances where a copy
i c
Treatment) of the Refusal of Treatment Certificate has not been
i
- a guardian appointed by the Victorian Civil and sighted as it will serve if necessary as evidence of their
V
Administrative Tribunal (VCAT). good faith.
V
• A Refusal of Treatment Certificate may be sighted by • Under the Medical Treatment Act 1988 a person
the attending Ambulance crew, or they may accept in acting under the direction of a Registered Medical
e e
good faith the advice of those present at the scene. If Practitioner who, in good faith and in reliance on a
there is any doubt about the application of a certificate
c A
Refusal of Treatment Certificate, refuses to perform or
c
the default position of resuscitation should be adopted. continue medical treatment is not guilty of professional
n
• A Refusal of Treatment Certificate may only be misconduct or guilty of an offence or liable in any
n
completed in relation to a current condition. When civil proceedings because of the failure to perform or
la ©
ceasing or withholding resuscitative efforts in these continue that treatment.
a
circumstances the attending Ambulance or MICA
l
Paramedic needs to be satisfied that the Pt’s cardiac
a
arrest is most likely due to this current condition.
b u o ri
A m ict ct
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Withholding and/or Ceasing Pre-hospital resuscitation CPG A0203
u la a © a ©
b o r i ori
m
• Circumstances where resuscitation efforts may be withheld
t t
- Likely risk to Paramedic health and safety
c c
- Clear evidence of prolonged cardiac arrest (e.g. rigor mortis, decomposition, postmortem lividity)
i i
- Injuries incompatible with life (e.g. decapitation)
V
- Inadequate resources to deal with all Pts (e.g. multi-casualty incidents)
V
- Death declared by Medical Officer who is, or has been, at the scene
e
- An adult (18 years or older), where a Refusal of Treatment Certificate has been completed for a current
e
condition which most likely caused the cardiac arrest
c c A
- A child (< 18 years), where a Court Order is provided to the attending Ambulance crew indicating that
Cardiopulmonary Resuscitation is not to be commenced
n n
- An adult (18 years or older) whose initial cardiac rhythm is asystole (over a minimum 30 sec. period),
la ©
provided the time interval between the onset of cardiac arrest, i.e. collapse, and arrival of the crew at the Pt
a
has exceeded 10min. and there are no compelling reasons to continue, such as suspected hypothermia,
l
suspected drug overdose, a child (< 18 years) or family/bystander requests continued efforts
u ia
• Circumstances where resuscitation efforts may be ceased
b r
- An adult (18 years or older) who, after 30min. of Advanced Life Support resuscitation (including advanced
airway management, defibrillation and/or Adrenaline) has no return of spontaneous circulation, is not in VF or
o
VT, has no other signs of life present such as gasps or pupil reaction and hypothermia or drug overdose are
m t
not suspected.
A V ic ict
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Laryngeal Mask Airway (LMA) CPG A0301
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o
• The LMA provides improved airway and ventilation • If insertion fails and ventilation is difficult or inadequate,
m t o
Mx compared with a facemask and OPA. The LMA check position of LMA cuff using a laryngoscope. If
t
does not protect against aspiration, although studies minor adjustment fails to correct the problem, remove
c
have shown it to be as low as 3.5% with an LMA the LMA inflated. Immediately insert an OPA/NPA and
i c
compared to 12.4% with a Bag Valve Mask (BVM). ventilate the Pt using a BVM.
i
The LMA should therefore not be regarded as • Only one attempt may be made to reinsert LMA.
V
the equivalent of endotracheal intubation.
V
If insertion fails on the 2nd attempt, do not delay
• The LMA forms a low pressure seal around the returning to BVM using an OPA/NPA.
posterior perimeter of the larynx and when correctly
e
• Do not over-inflate cuff.
e
inserted is seated superior to the oesophageal
• The LMA may be used for the unconscious APO
c A
sphincter thus enabling positive pressure ventilation
c
Pt. However, gentle assisted ventilation should be
via BVM or closed circuit resuscitator. Unconscious
provided using a closed circuit resuscitator.
n
Pts who accept an OPA are generally suitable for
n
insertion of an LMA. • The LMA may be inserted in left or right lateral
la ©
positions or if entrapped, in a sitting position. Pts
• Pt with morbid obesity have a naturally increased
a
may be managed in the lateral position when the
l
work of breathing and during assisted or intermittent
LMA has been correctly inserted and taped in situ,
positive pressure ventilation require higher pressures
a
using Transpore or Sleek, however, in general, it is
u
to inflate the lungs. They also have a higher
i
recommended that Pts be Mx supine and carefully
incidence of hiatus hernia resulting in an increased
r
observed for aspiration.
b
likelihood of passive regurgitation of stomach
contents. • If the conscious state of the Pt improves and there is
o
an attempt to reject the LMA, remove the LMA with
t
the cuff inflated.
A m ic ict
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Laryngeal Mask Airway (LMA) CPG A0301
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? Status
8 LMA Size Chart
• Unconscious Pt without gag reflex
o
Portex
m t o
• Ineffective ventilation with BVM/oxysaver and airway Size Wt Inflation
t
Mx (OPA/NPA) 3 Small Adult 30 - 50kg 25 ml
c
4 Normal Adult 50 - 70kg 35 ml
c
• >10/60 assisted ventilation required
i i
• Unable to intubate/difficult intubation 5 Larger Adult 70kg - 140kg 55 ml
V V
Unique
Stop Size Wt Inflation
e
• Contraindications 3 Small Adult 30 - 50kg 20 ml
e
- Intact gag reflex or resistance to insertion 4 Normal Adult 50 - 70kg 30 ml
c A
5 Larger Adult 70kg - 140kg 40 ml
c
- Strong jaw tone + trismus
- Suspected epiglottitis or upper airway obstruction
lan 8
la n
Consider
• Precautions
©
u a
- Inability to prepare the Pt in the “sniffing position”
i
- Pts who require high airway pressures, e.g. advanced pregnancy, morbid obesity, decreased pulmonary
b r
compliance (stiff lungs due to pulmonary fibrosis) or increased airway resistance (severe asthma)
- Pts < 14 years of age due to enlarged tonsils
o
- Significant volume of vomit in airway
m t
• Side Effects
c t
- Correct placement of the LMA does not prevent passive regurgitation or gastric distension
A V i V ic
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Laryngeal Mask Airway (LMA) CPG A0301 27
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Endotracheal Intubation Guide CPG A0302
u la a © a ©
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o
• The Medical Standards Committee has authorised
m t o
endotracheal intubation by MICA Paramedics in
t
selected Pts.
c c
• There are three intubation techniques available:
i i
- Intubation without drugs (Unassisted Endotracheal
V
Intubation)
V
- Intubation Faciliitated by Sedation (IFS)
- Rapid Sequence Intubation (RSI)
e e
The appropriate technique will vary according to the
c A
clinical setting and a Paramedic’s authorised scope of
c
practice.
n n
• A MICA Paramedic operating alone may elect not
to use IFS or RSI until a second MICA Paramedic is
la a ©
present.
l
• All intubations facilitated or maintained with drug
a
therapy will be reviewed as part of AV Clinical
u i
governance processes.
r
• The use of cricothyroidotomy is restricted to AV MICA
b
Paramedics specifically accredited in this skill by the
o
Medical Standards Committee.
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Endotracheal Intubation Guide CPG A0302
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Status
• Endotracheal intubation
m c t o c to
i i
? Primary indications ? Preparation ? Insertion of ETT ? Failed intubation
V V
• Respiratory arrest • See CPG A0303
• Cardiac arrest ? Drugs to facilitate intubation
e
• GCS < 10 due to: • Intubation Facilitated by Sedation (IFS) ? Care and maintenance
e
- Respiratory failure
A
• Rapid Sequence Intubation (RSI)
c
• Sedation
c
- Neurological injury
- Overdose • Sedation and paralysis
n n
- Status epilepticus
- DKA
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Endotracheal Intubation Indications, Precautions, C/Is CPG A0302
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o
• Primary Neurological Injury • Uncontrolled bleeding
m t o
- In Pts with uncontrolled bleeding (e.g. ruptured AAA,
t
- RSI should be provided unless Pt is in cardiac arrest.
This includes Pts with absent airway reflexes. ruptured ectopic pregnancy, penetrating truncal
c
trauma, intra-abdominal trauma, limb avulsion),
i c
- Midazolam should not be used to control
i
ongoing bleeding may lead to poor cerebral
combativeness prior to RSI in head injury.
perfusion and coma.
V
Judicious pain relief with narcotic should be used.
V
If combativeness is preventing preoxygenation (this - RSI in these Pts is potentially harmful. The
is rare), then once all preparations have been made sedation may drop blood pressure further and
e
for RSI the Fentanyl should be given. This should the added scene time increases total blood loss.
e
settle the Pt sufficiently to enable preoxygenation for The appropriate treatment for these Pts is urgent
c A
transport and immediate surgery.
c
2-3min., then the Midazolam and Suxamethonium
should be given and the Pt intubated. - RSI should NOT be undertaken in Pts who
n n
become unconscious when the coma is likely to be
• Status epilepticus
secondary to blood loss, unless RSI is judged to
la a ©
- A continuous or recurrent seizure of 10min. duration be absolutely essential (unmanageably combative
l
or no return of consciousness between episodes may and / or impractical to transport unintubated). This
require intubation where there is airway/ventilation
a
applies to Pts being transported both by road and air
u
compromise which is unable to be effectively
i
Ambulance.
managed using BVM and OPA/NPA.
r
- Airway management with BVM is to be maintained
b
• Suspected tricyclic antidepressant O/D in conjunction with prompt transport. Intubation
o
- Requiring hyperventilation for cardiac arrhythmia (without drugs) should be considered if airway
t
prevention or management. reflexes are lost, bearing in mind the risks of delay to
m
definitive surgical care.
c t
• Overdose
• Severe hyperthermia
A i
- The intent of the OD (difficult extrication) indication
c
- May result from drug OD or heat exposure. If after
i
for RSI is for the Pt to be intubated at the scene to
V
enable safer extrication. 10/60 of active cooling Pt temp. remains > 39.5°C
and GCS < 10, then Pt should be intubated with RSI.
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Endotracheal Intubation Indications, Precautions, C/Is CPG A0302
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Unassisted Endotracheal Intubation IFS RSI
r
?
Indication ?
Indication GCS < 10 ?
Indication GCS < 10
m t o o
• Respiratory arrest • Respiratory failure • Primary Neurological Injury
t
• Cardiac arrest - Unresponsive to non-invasive - Traumatic brain injury (TBI)
c
ventilation and drug therapy - Non-traumatic brain injury
c
• Absent airway reflexes
i
- Stroke/Subarachnoid haemorrhage
i
• DKA
- Diabetic Ketoacidosis with BGL • Hypoxic brain injury
V V
reading “High” - Post-hanging, near drowning
- ROSC as per CPG A0202 Cardiac Arrest
e
8
General Precautions • Overdose with any of:
e
- Suspected tricyclic antidepressant O/D
A
• Time to intubation at hospital
c
- Difficult extrication
c
versus time to intubate at scene 8
Precautions for IFS
- Prolonged transport time (>30/60)
n
• Poor baseline neurological • As per General Precautions - O2 sat. unable to be maintained > 90%
n
function and major co-morbidities • Anticipation of difficulty with BVM • Severe hyperthermia
la a ©
• Advanced Care Plan / Refusal ventilation - > 39.5°C despite 10/60 of management
l
of Medical Treatment document • Anticipation of a difficult intubation, • Status epilepticus
specifies “Not for Intubation”
a
e.g. morbid obesity, short neck or
u i
facial trauma
r
• In general if transport time < 10/60 8
Precautions for RSI
b
then no IFS • As per General Precautions IFS
o
• In general if transport time < 10/60 then no RSI
m t
Contraindication (CIs)
c t
• Clinical situations where failed intubation Contraindication (CIs)
A i c
drill would not be feasible • As per first two Contraindications IFS
V i
• No functional electronic capnograph • Any contraindications to Suxamethonium
• Pts indicated for RSI • Coma due to uncontrolled bleeding
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Endotracheal Intubation Preparation
© ©
CPG A0302
bu r
Special Notes
ia ri a
General Care
m c t o c to
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Endotracheal Intubation Preparation CPG A0302
u la a © a ©
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o r
?
General preparation for intubation ?
Preparation for IFS ? Preparation for RSI
m t o

t
Action
✔ Action
✔ Action
✔
• As per General preparation for intubation • As per General preparation for intubation
c
• Position Pt. If a cervical collar is fitted
i c
it should be opened while maintaining • Pre-hydrate with Normal Saline fluid • Pre-hydrate with Normal Saline fluid
i
manual cervical support bolus 10 ml/kg IV unless APO bolus 10 ml/kg IV
V V
• Pre-oxygenate with 100% O2 • If Pt hypotensive and/or tachycardic, • If Pt hypotensive and/or tachycardic,
and electronic capnograph attached follow relevant CPG in conjunction with follow relevant CPG in conjunction with
the intubation process the intubation process
e
• Ensure pulse oximeter and cardiac
e
monitor are functional • Draw up and label drugs as appropriate • Adrenaline not to be given in
c A
Hypovolaemic shock
c
• Prepare equipment and assistance
- Suction
• Draw up and label drugs as appropriate
n n
- ETT (plus one size smaller than
predicted immediately available) with
la a ©
introducer
l
- Oesophageal Detector Device (ODD).
a
- Ensure equipment for a difficult / failed
u i
intubation is immediately available,
including bougie, LMA,
b r
cricothyroidotomy kit
- Mark cricothyroid membrane as
o
necessary
m t
- Brief assistant to provide cricoid
t
pressure, where appropriate
A ic
- If suspected spinal injury, where
c
possible a second assistant should be
V i
available to stabilise the head and neck
• Ensure functional and secure IV access
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Endotracheal Intubation Drugs CPG A0302
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Special Notes Dosage RSI
Age < 60 Dose
o
• Sedation doses for RSI are based on initial
m t o
observations. This is especially important in BP < 80 1/4 or 1/2 Fentanyl
t
multi-trauma with TBI. Initial fluid challenges may Midazolam 1mg
c
resolve tachycardia and/or hypotension, however the
c
BP 80 - 100 Half
i
Pt is still at risk of cardiovascular compromise and
i
BP > 100, HR > 100 (TBI only) Half
the blood pressure must be strenuously supported.
V
Half doses (or less) of sedation are required in this BP > 100 , HR > 100 (all other) Full
V
situation.
Age > 60
e
• In Pts with extremely poor perfusion, treat with fluid
e
BP < 80 1/4 or 1/2 Fentanyl
therapy +/- Adrenaline infusion concurrently with
Midazolam 1mg
c A
IFS or RSI. Consider quarter doses of sedation.
c
BP > 80 Half
• Frail, elderly or hypotensive Pts have prolonged
n n
circulation times. Allow for this when giving a second
©
Dosage IFS
la
dose of sedation during IFS.
a
Age < 60 Dose
l
BP < 100 Half
u ia
BP > 100 Full
b r
Age > 60 Half dose for all
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Endotracheal Intubation Drugs CPG A0302
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Adjusted sedation dose required Adjusted sedation dose required
o
Action
✔
m t o
• Proceed with intubation
t
- no drugs required ?
Half dose sedation required ?
Reduced dose sedation required if either:
c c
• BP < 100 and / or age > 60 • BP < 80
i i
Action
✔ • BP 80 - 100
• HR > 100 (TBI only)
V V
• Fentanyl 50mcg IV
• Age > 60
• Midazolam 0.05mg/kg IV (max. 5mg)
e
Action
✔
e A
?
Full dose sedation required • Fentanyl 50mcg IV
c c
• BP > 100 and age < 60 • Midazolam 0.05mg/kg IV (max. 5mg)
n
- If BP < 80 give Midazolam 1mg IV
n
Action
✔
©
la a
• Midazolam 0.1mg/kg IV (max. 10mg) ?
Full dose sedation required
l
• BP > 100 and age < 60
u ia
?
If unable to intubate due to Action
✔
excessive tone
r
b
Action
✔ • Midazolam 0.1mg/kg IV (max. 10mg)
o
• If GR 1 or 2 view but respiratory effort or
m t
airway reflexes are preventing intubation
?
Paralysing agent
t
- R
epeat same dose of sedation and
c
✔
Action
A i
reattempt intubation once only
c
• If Pt bradycardic at any stage
i
• If GR 3 or 4 view
- Atropine 600mcg IV
V
- Proceed to Failed Intubation Drill
• Suxamethonium 1.5mg/kg IV
© V
round up to nearest 25mg (max. 150mg)
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Endotracheal Intubation Insertion of ETT CPG A0302
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Insertion of Endotracheal Tube General Care of the Intubated Pt
o
• Observe passage of ETT through cords noting AS • Reconfirm tracheal placement using EtCO2 after every
m t o
standard markings and grade of view. Pt movement. Disconnect and hold ETT during all
t
• Check ETT position using Oesophageal Detector transfers.
c
Device (ODD). • If electronic capnography fails after intubation, use
i ic
• Inflate cuff. colourimetric capnometry.
• Suction ETT and oropharynx in all Pts.
V
• Confirm tracheal placement via capnography (note: Pt
V
in cardiac arrest may not have CO2 initially detectable). • If time permits, insert orogastric or nasogastric tube,
• Exclude right main bronchus intubation by performing aspirate and connect to drainage bag. The orogastric
e
route must be used in head or facial trauma.
e
the cuff palpation (“tracheal squash”) test and by
comparing air entry at the axillae. • Ventilate using 100% oxygen and tidal volume
c c A
• Note length of ETT at lips/teeth. of 10 ml/kg. Aim to maintain SpO2 > 95% and
EtCO2 at 30 - 35mmHg (except asthma / COPD
n
• Auscultate chest / epigastrium.
n
where a higher EtCO2 may be permitted, tricyclic
• Note supplemental cues of correct placement (e.g.
la ©
OD where the target is 20 - 25mmHg, and DKA
a
tube “misting”, bag movement in the spontaneously where the EtCO2 should be maintained at the level
l
ventilating Pt, improved oxygen saturation and colour). detected immediately post-intubation, with a max. of
a
• Secure the ETT and insert a bite block if required. 25mmHg).
u i
• If there is ANY doubt about tracheal placement, • Document all checks and observations made to
r
the ETT must be removed. confirm correct ETT placement.
b
• If unable to intubate after ensuring correct technique
o
and problem solving then proceed to Failed
m t
Intubation Drill.
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Endotracheal Intubation Insertion of ETT CPG A0302
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?
Status
8 Indications
• Insertion / General care of ETT
m o o
- Unassisted Endotracheal Intubation
t t
- IFS
- RSI
ic c

V Vi ? Insertion and checks of ETT
e
Action
✔
e A
• ODD ? General care / ventilation
c c
• Capnography - EtCO2 Action
✔
n
• Length lips/teeth
n
• ETT checks with each Pt movement
• Cuff Palpation
la ©
• Provide circulatory support if hypotension present
a
• Auscutate chest/epigastrium • Use colourimetric capnometry if capnography fails
l
- Chest rise and fall, bag movement, SpO2,
• Suction ETT and oropharynx
a
colour, tube misting
u i
• Specific insertion instructions as per Insertion • Insert OG/NG tube
r
of Endotracheal Tube • Ventilate VT 10ml / per kg, EtCO2 30 - 35mmHg
b
if appropriate to Pt condition
• If there is ANY doubt about tracheal
o
placement, the ETT must be removed • Disconnect and hold ETT during transfers
m t
• Specific instructions as per General Care
t
of the Intubated Pt
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Version 4 - 19-11-08 Page 10 of 11
Endotracheal Intubation Care and Mx. of Intubated Pt CPG A0302
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• For Pts who become hypotensive after intubation, • Infusion
m t o
consider reducing the dose of sedation, in association - Morphine 30mg + Midazolam 30mg/30ml D5W or
t
with additional fluid +/- Adrenaline infusion according Normal Saline
c
to the clinical setting. - 1ml = 1mg each drug
i ic
• Not all Pts receiving RSI will require paralysis post - 1ml/hr = 1mg/hr
intubation, e.g. continuous convulsions, OD other than • Handover
V V
tricyclic.
- The EtCO2 and respiratory wave form immediately
• Some Pts receiving IFS may require paralysis post prior to Pt handover must be demonstrated to the
e
intubation to control ventilation e.g. asthmatic Pt. receiving physician and documented on the PCR.
e
• Primary Neurological Pts require paralysis post
c c A
intubation to prevent gagging and elevation
in ICP. Ideally this should be given before the
n n
Suxamethonium wears off, provided tracheal
placement is confirmed and the tube is secured.
la a ©
• Paralysis is C/I in status epilepticus, where clinical
l
monitoring of seizure activity is required. Use additional
a
doses of Midazolam as required.
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Version 4 - 19-11-08 Page 11 of 11
Endotracheal Intubation Care and Mx. of Intubated Pt CPG A0302
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Status
8 Indications 8
Consider
• Intubated Pt • Does Pt require sedation or sedation / paralysis to maintain intubation and ventilation
m c t o
? Post
8
c to
Intubation Sedation
Indications ?
Post Intubation Paralysis
Indications
i
8
i
• Restlessness / signs of under sedation in the absence of • Prevention of shivering for Pts receiving therapeutic cooling
V
other noxious stimuli
V
• Primary Neurological Pts
- e.g. ETT too deep / irritating, occult pain
• Where sedation alone is ineffective at maintaining intubation or
• Signs of inadequate sedation
e
allowing adequate ventilation / oxygenation
e
Non Paralysed Pt Paralysed Pt • As prescribed for interhospital transfer
c A
- As per Paralysed - HR and BP trending up together
c
- Cough/gag/movement - Tearing
n
- Diaphoresis
n
Stop
©
• All Pts receiving paralysis MUST receive ongoing sedation
la a
?
Sedation • The ETT must be secured and tracheal placement reconfirmed with
l
Action
✔ electronic capnography
u a
• C/I for Pt in Status epilepticus
i
• Morphine/Midazolam infusion 1 - 10mg/hr IV
r
- 0.5mg - 5mg IV boluses as required
b
• Until Morphine/Midazolam infusion established: ?
Sedation and Paralysis
o
- Midazolam 0.5mg - 5mg IV as required or Action
✔
m t
- Midazolam/Morphine 0.5mg - 5mg IV each drug • Sedate as per Post Intubation Sedation
c t
• Pancuronium 8mg IV
A i c
- Repeat if evidence of returning muscular activity
i
(movement, chewing, cough, gag, curare cleft)
©? Status
e V
Stop
V
Vi V i b l
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Failed Intubation Drill CPG A0303
u la a © a ©
i i
? Post Intubation Sedation
Indications
b r r
• Unable to see vocal cords during initial laryngoscopy
m t o o
Action
✔
t
• Insert OP Airway and ventilate with 100% O2
ic ic
Action
✔
V V
• Reattempt intubation using bougie with blind placement
of ETT over bougie
e e
Yes
A
Consider
8 Action
c
✔
c
• Objective confirmation of tracheal placement using EtCO2 • Continue Management in accordance with relevant CPG
n n
No
©
Action
la
✔
a
• Immediately remove ETT, insert OPA/NPA and ventilate with 100% O2
u l ia
Consider
8 Yes
r
• Able to ventilate and oxygenate
b
No
o
Action
✔
m t
• Insert LMA
A ic ct
Consider
8 Yes
V i
• Able to ventilate and oxygenate
V
No Action
✔
© e
Action
✔ • If sedation /relaxant drugs administered allow these to
• Cricothyroidotomy wear off and Pt to resume normal respiration
Vi V i b l
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Cricothyroidotomy CPG A0304
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b r i i
? Status
8 Stop
o r
• Unconscious Pt unable to be oxygenated and • Contraindications
m o
ventilated using Bag and Mask, OP / NP airway, LMA
t
- Nil in circumstances where oxygenation and
t
or ETT where: ventilation are not possible using alternative
c
- RSI has been attempted but intubation has not techniques.
i ic
been achieved
- RSI is not authorised
V V
- Massive facial trauma is present and RSI is
considered unsafe due to the inability to undertake
e
the failed intubation drill
e
- RSI is not possible due to lack of intravenous
c c A
access
n
- Upper airway obstruction is present due to a
n
pharyngeal or an impacted foreign body which is
©
Action
✔
la
unable to be removed using manual techniques and
a
Magill forceps
l
• Perform Cricothyroidotomy using approved kit.
- Partial airway obstruction is present and transport
u a
by Air Ambulance is required and expertise for
i
alternative techniques are not available.
m b to r
A V ic ict
©? Status
e Stop
V
Cricothyroidotomy CPG A0304 41
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la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
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la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
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Acute Coronary Syndrome CPG A0401
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• Acute Coronary Syndrome (ACS) is a spectrum of
m t o
illnesses including:
t
- Unstable Angina
c
- Non-ST Elevation Myocardial Infarction (NSTEMI)
i c
- ST-Elevation Myocardial Infarction (STEMI)
i
• Not all Pts with ACS will present with pain, e.g. diabetic
V V
Pts, atypical presentations, elderly Pts.
• The absence of ischaemic signs on the ECG does not
e
exclude AMI. AMI is diagnosed by presenting history,
e
serial ECGs and serial blood enzyme tests
c c A
• Suspected ACS related pain that has spontaneously
resolved warrants investigation in hospital.
n n
• The goal of management in ACS is to resolve pain
la ©
completely if safe to do so. This reduces cardiac
a
workload.
l
• The IM route of administration is relatively
a
contraindicated in ACS if Pt is eligible for thrombolysis.
u i
• Current evidence suggests transport to a PCI-enabled
b r
facility improves Pt outcomes in Stemi transport
time < 90mins.
A m cto t
© V i V ic
e
Vi V i b l
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n
Acute Coronary Syndrome CPG A0401
u la a © a ©
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Status Consider
8
• Consider the spectrum of
o
• Acute Coronary Syndrome (ACS)
m o
illnesses within ACS
t
- UA
t
- NSTEMI
c
- STEMI
V i Vic
e
?
ACS Mx ?
Nausea/Vomiting ?
LVF ?
Inadequate Perfusion
e A
Action Action Action Action
c
✔ ✔ ✔ ✔
c
• General Principles • See CPG A0701 • See CPG A0406 • See CPG A0407
n
of ACS Mx
la a n ©
?
Arrhythmia Mx
l
Action
✔
u ia
• See
CPG A0201 VF / Pulseless VT
b r
CPG A0402 Bradycardia
CPG A0403 Supraventricular Tachyarrhythmias
o
CPG A0404 Ventricular Tachycardia
m t
CPG A0405 Accelerated Idioventricular Rhythm
A V ic ict
©? Status
e
Stop
V
Acute Coronary Syndrome CPG A0401 45
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Acute Coronary Syndrome General Management Principles CPG A0401
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o
• GTN is a potent venodilator that can decrease venous
m t o
return therefore decreasing right ventricular (RV) filling
t
and fibre stretch with a reduction in cardiac output.
c
The use of GTN is contraindicated in Inferior and RV
i c
infarcts.
i
• Up to 50% of Inferior AMIs have RV involvement and
V V
cannot compensate to a drop in venous return due to
myocardial insufficiency.
e
• Signs of an Inferior AMI include ST elevation in leads II
e
and III. Bradycardia is not unusual in an Inferior AMI due
c A
to the involvement of the right coronary artery and the
c
SA / AV nodes.
n n
• Nitrates are C/I in bradycardia (HR < 50) due to the
Pt’s inability to compensate to a decrease in venous
la a ©
return by increasing HR to improve cardiac output.
l
- C.O. = HR x SV
b u ria
A m cto t
© V i V ic
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Acute Coronary Syndrome General Management Principles CPG A0401
u la a © a ©
b r i ri
?
Status Assess requirement for:
8
• ACS • Pain relief/nitrates
m t o o
• Control of hypertension
t
• Antiplatelet Rx
V ic ? Nitrates
Action
✔✔
Vic ? Antiplatelet Rx
Action
✔✔
? Pain Relief
Action
✔✔
e
• BP > 110 • Aspirin 300mg oral • Pain relief as per CPG A0501
e
- GTN 300mcg S/L/Buccal (no prev. admin.) or Pain Relief
c c A
- GTN 600mcg S/L/Buccal - Rx until pain free vs < 2/10
• If symptoms continue and BP remains > 110 pain for non-cardiac Pt
n n
- Repeat 300 - 600mcg S/L/ Buccal @ 5/60
la ©
• BP > 90
a
- GTN Patch 50mg (0.4mg/hr) upper torso / arms
l
- If BP falls < 90, remove patch
u ria
? Hypertension +/- symptoms
b
- Systolic BP > 160 or
✔
o
- Diastolic BP > 100
m t
• Control pain as per CPG A0501 Pain Relief
c t
• GTN 300 mcg S/L/Buccal
A i c
- Repeat 300mcg @ 5/60 if hypertension persists
©? Status
e VStop
V i
Acute Coronary Syndrome CPG A0401 47
Vi V i b l
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Bradycardia CPG A0402
u la a © a ©
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o
• Atropine is unlikely to be effective in complete heart • Adrenaline Infusion
m t o
block. - 3mg Adrenaline added to make 50ml with
t
• If side effects occur during Adrenaline infusion, cease D5W or Normal Saline.
c
infusion and recommence once side effects resolve - 1ml/hr = 1mcg/min
i ic
titrating to Pt response. • If no response from Adrenaline infusion @ 20mcg/min.,
• If no increase in HR, pacing is likely to be required. increasing infusion rate is unlikely to have additional
V V
• Notify appropriate hospital capable of managing a Pt chronotropic effects.
likely to require pacing.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
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Bradycardia CPG A0402
u la a © a ©
b r i i
8
r
?
Status Assess
• Evidence of Bradycardia • Perfusion status
m c t o c to
? Adequate Perfusion ? Less than Adequate Perfusion
i i
✔
✔ Action ✔
✔ Action
V V
• BLS • Atropine 600mcg IV
• Rx as per < Adequate - If no response after 3 - 5/60
- Repeat 600mcg IV
e
perfusion if Pt deteriorates
n c n ce A ?
©
? Adequate Perfusion achieved Inadequate or Extremely Poor Perfusion persists
la a
✔
✔ Action Action
✔
l
• Continue current management • Adrenaline Infusion (3mg/50ml D5W/Normal Saline)
u a
commencing @ 5mcg/min. (5ml/hr)
i
• Transport
- Increase by 5mcg/min. @ 2/60 until adequate perfusion/side
b r
effects (max. 20mcg/min.)
o
- If syringe pump unavailable/malfunction
t
- Adrenaline 10mcg IV
m
- repeat 10mcg IV @ 2/60 until adequate perfusion/side
c t
effects
A i c
• If poor perfusion persists treat as per CPG A0407 Inadequate
i
Perfusion Cardiogenic Causes
©? Status
e V
Stop
V
Bradycardia CPG A0402 49
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la n
Tachyarrhythmias - Adult
© ©
CPG A0403
bu r
Special Notes
ia ri a
General Care
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
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Vi V i b l
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Tachyarrhythmias - Adult CPG A0403
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?
Status
• Tachyarrhythmias
m c t o c to
i i
?
QRS < 0.12 sec ?
QRS > 0.12 sec
V V
• Rate > 100 • VT > 30 sec
• Absent or abnormal p waves • Rate > 100
e
- SVT (AV nodal rhythms or AVRT) • Wide and bizarre
e
- Atrial fibrillation / flutter
A
• Generally regular
c c
- Sinus tachycardia
• AV dissociation / absence of p waves
- Atrial tachycardia
lan la n ©
? Adequate Perfusion ? < Adequate Perfusion / Unstable ? Ventricular Tachycardia
u ia
Action
✔ Action
✔ Action
✔
r
• See CPG A0403 SVT • See CPG A0403 SVT • See CPG A0404 VT
m b to
A V ic ict
©? Status
e
Stop 8 Assess
V 8 Consider ✔ Action ✔ MICA Action
Tachyarrhythmias - Adult CPG A0403 51
Vi V i b l
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n
Supraventricular Tachyarrhythmias (SVT) CPG A0403
u la a © a ©
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o
• Symptomatic signs and symptoms • Valsalva instruction
m t o
- Rate related severe or persistent chest pain - Evidence suggests a greater reversion rate with an
t
- Shortness of breath with crackles abdominal valsalva manoeuvre with the following
c
3 elements.
i ic
1. Position
- Supine
V V
2. Pressure
- At least 40mmHg for max. vagal tone. Best achieved
e
with Pt blowing into a 10ml syringe hard enough to
e
move the plunger to create this pressure.
c c A
3. Duration
- At least 15sec. if tolerated by Pt
n n
Ref. G Smith, A Morgans, and M Boyle
la a ©
Emerg Med J 2009; 26: 8-10. doi:10.1136
l
emj.2008.061572
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
u la a © a ©
b r i ri
?
Status
• SVT
m t o to
? Adequate perfusion
c c
• BP > 100
V i Vi
? Asymptomatic ? Symptomatic
e
✔ Action ✔ Action
e
• Abdominal valsalva • Abdominal valsalva
c c A
manoeuvre manoeuvre
n n ©
✔ Action
la a
• BLS ? Reversion ? No Reversion
l
• If Pt deteriorates, Rx as ✔ Action • If > 30/60 transport time and SOB with
u a
per Symptomatic or crackles or chest pain
i
• BLS
< Adequate Perfusion
r
Action
✔
b
• Verapamil 5mg IV given over 1/60
o
- Repeat 1mg IV @ 1/60 until either:
m t
- Arrhythmia reversion
- BP < 100
c t
- max. 10mg IV
A i
• Verapamil is C/I for Pt on Beta blockers
© V V ic
? Status
Supraventricular Tachyarrhythmias (SVT) CPG A0403 53
Vi V i b l
c e A m
n
u la a © a ©
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o
• A Pt eye opening to pain but not to voice commands • If wide complex QRS or unsure of diagnosis treat as for
m t o
would also be likely to be making incomprehensible CPG A0404 Ventricular Tachycardia.
t
sounds and making purposeful movements in response • Treat Pt symptomatically in accordance with appropriate
c
to pain. i.e. a GCS of 9, (E2, V2, M5). Sedation should Guideline and transport for further assessment and
i c
be used cautiously in these Pts.
i
treatment.
• The effectiveness of the Pt’s respirations should be • If Pt is unconscious or becomes unconscious at any
V V
continuously monitored. time during treatment, perform immediate synchronised
cardioversion.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
u la a © a ©
b r i i
?
Status
r
• SVT (AV nodal rhythms or AVRT) or Unstable / rapidly deteriorating, SVT, AF, Atrial Flutter
m c t o c to ? < Adequate perfusion ? Unstable
i i
• SVT (AV nodal rhythms or AVRT) • Rapidly deteriorating, altered conscious state
V
(includes SVT, AF, Atrial Flutter)
V
• BP < 100
e
? Symptomatic
e
? Unstable / rapidly deteriorating
✔ Action
c A
Action
✔✔
c
• Abdominal valsalva manoeuvre • Synchronised cardioversion
n
- Sedate: Fentanyl 25 mcg IV single dose only +
n
Midazolam 2.5mg IV
la ©
- Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not
a
? Reversion ? No reversion
l
respond to verbal stimuli but does respond to pain
✔ Action • If > 30/60 transport time and - Cardioversion: Biphasic 75J (Monophasic 100J)
u a
SOB with crackles or chest pain - If unsuccessful repeat using Biphasic 150J (Monophasic
i
• BLS
200J then 360J) if required
b r
Action
?
o
• Metaraminol 0.5mg IV given over 1/60
m t
- Repeat 0.5mg IV @ 2/60 until either:
c t
- Arrhythmia reversion ? Loss of output ? Reversion
A i
- BP > 100
c
✔ Action
✔ Action
✔
- max. 5mg IV delivered
V i
• As per appropriate CPG • BLS
• If BP increases to > 100
V
- Consider Verapamil as per Adequate Perfusion
©? Status
e
Stop 8 Assess 8 Consider ✔ Action ✔ MICA Action
Supraventricular Tachyarrhythmias (SVT) CPG A0403 55
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Ventricular Tachycardia (VT) CPG A0404
u la a © a ©
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o
• A Pt eye opening to pain but not to voice commands • ALS /QAP crews should consider MICA R/V vs
m t o
would also be likely to be making incomprehensible transport to appropriate hospital as these Pts are
t
sounds and making purposeful movements in response dynamic and have a potential to deteriorate.
c
to pain, i.e. a GCS of 9, (E2, V2, M5). Sedation should • Pt presenting symptomatic and poorly perfused is likely
i c
be used cautiously in these Pts.
i
to require sync. cardioversion prior to Amiodarone
• The effectiveness of the Pt’s respirations should be administration.
V V
continuously monitored. • Amiodarone infusion
- Amiodarone 300mg diluted with 30ml D5W or
e
equivalent volume run over 10 - 20/60.
n c n ce A
la u la ia ©
m b to r
A V ic ict
© e V
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Ventricular Tachycardia (VT) CPG A0404
u la a © a ©
b r i ri
? Status
• Confirm Ventricular Tachycardia
m o o
- VT > 30sec. - QRS > 0.12sec. - Rate > 100
t t
- Mostly regular - A-V dissociation / absence of p waves
V ic Action
✔✔
Vic
? Stable: Adequately perfused ? Unstable / Rapidly Deteriorating
Action
✔✔
e
• Amiodarone infusion 5mg/kg IV • Synchronised cardioversion
e
(max. 300mg) over 10 - 20/60 once only - Sedate: Fentanyl 25 mcg IV single dose only +
c c A
• Rx as per Unstable if Pt deteriorates Midazolam 2.5mg IV
- Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not respond to
n
Only dilute Amiodarone with D5W
n
verbal stimuli but does respond to pain
- Cardioversion: Biphasic 150J (Monophasic 200J)
la a ©
- If unsuccessful repeat using Biphasic 150J (Monophasic 360J)
l
if required
b u ria ? Loss of output ? Reversion
o
✔ Action
✔ Action
✔✔
m t
• As per appropriate CPG • Narrow complex
c t
- Amiodarone infusion as above
A i
(if not already running)
ic
• Other rhythms
V
- Rx as per appropriate CPG
©? Status
e Stop
V
Ventricular Tachycardia (VT) CPG A0404 57
Vi V i b l
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Accelerated Idioventricular Rhythm (AIVR) CPG A0405
u la a © a ©
b r i ri
o
• AIVR is usually a benign rhythm but may be associated
m t o
with AMI, reperfusion or drug toxicity.
t
• Commonly seen in post cardiac arrest Pts.
c c
• May be associated with Adrenaline administration.
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
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Accelerated Idioventricular Rhythm (AIVR) CPG A0405
u la a © a ©
b r i ri
? Status Assess
8
• AIVR • Perfusion status
m c t o c to
i i
? Adequate Perfusion ? < Adequate Perfusion ? No Perfusion
V V
Action
✔✔ Action
✔✔
• BLS • Rx as per CPG A0201
e
• Transport Pulseless Electrical Activity
n c n ce A
? Ventricular rate < 60 ? Ventricular rate 60-100 ? Ventricular rate > 100
la a ©
✔ Action
✔ ✔ Action
✔ ✔ Action
✔
l
• Rx as per CPG A0402 • Normal Saline 250ml IV bolus • Rx as per CPG A0404
u a
Bradycardia - Repeat 250ml IV if perfusion Ventricular Tachycardia
i
status not improved
m b to r
A V ic ict
©? Status
e Stop
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Accelerated Idioventricular Rhythm (AIVR) CPG A0405 59
Vi V i b l
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n
Pulmonary Oedema CPG A0406
u la a © a ©
b r i ri
o
• This Guideline is primarily directed at cardiogenic • Manage chest pain as per CPG A0401 Acute
m t o
pulmonary oedema, secondary to LVF or CCF. Other Coronary Syndrome.
t
medical causes of pulmonary oedema should not be • Frusemide should be used cautiously in the
c
treated under this Guideline. hypotensive Pt.
i ic
• Non-medical causes include: smoke inhalation/toxic • Pts with pulmonary oedema presenting with a wheeze
gases, near drowning (aspiration) and anaphylaxis. should only be managed as per CPG A0601 Asthma
V V
Pulmonary oedema is likely a result of altered if a history of bronchospasm can be confirmed.
permeability. These causes should be treated with
• Avoid the use of Salbutamol in the setting of
oxygen therapy and assisted ventilations and do not
e
pulmonary oedema where possible.
e
require nitrates.
• Remove GTN patch if BP decreases < 90.
n c n c A
la u la ia ©
m b to r
A V ic ict
© e V
Vi V i b l
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Pulmonary Oedema CPG A0406
u la a © a ©
b r i i
8
r
?
Status Assess
• Pulmonary Oedema • Consider causes: LVF/CCF, nutritional deficiency, liver disease, renal disease, fluid overload
m t o o
• Respiratory status
c c t
? Not Short of Breath ?
Short of Breath
i i
✔
✔ Action
V V
• BLS
• If deteriorates, treat as ? Full Field Crackles
e
for Short of Breath ✔ Action
✔
e A
• GTN as per Basal/Midzone Crackles
c c
? Basal/Midzone Crackles • Frusemide 40mg IV or Pt’s daily dose IV as
n
a single dose (max. 100mg)
n
Action
✔✔
©
• BP > 110 • If alert and anxious
la a
- GTN 300mcg S/L/Buccal (no prev. admin.) or - Consider Morphine 1–2mg IV
l
- GTN 600mcg S/L/Buccal
a
- If BP > 110 and symptoms continue repeat
u i
300 - 600mcg S/L/ Buccal @ 5/60 ? No improvement or deteriorates
r
• BP > 90 • Suction if required
b
- GTN Patch 50mg (0.4mg/hr) upper torso/arms - Provide assisted ventilation with PEEP
o
• Frusemide 20 - 40mg IV • CPAP if available
m t
• Intubate if necessary as per CPG A0302
c t
Endotracheal Intubation
?
No improvement or deteriorates
A i c
• Treat as for Full Field Crackles
©? Status
e V Stop
V i
Pulmonary Oedema CPG A0406 61
Vi V i b l
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Inadequate Perfusion Cardiogenic causes CPG A0407
u la a © a ©
b r i ri
o
• Any intravenous infusions established under this • Adrenaline infusion > 50mcg/min. may be required
m t o
Guideline must be clearly labelled with the name and to manage these Pts. Ensure delivery system is fully
t
dose of any additive drugs and their dilution. operational (e.g. tube not kinked, IV patent) prior to
c
• A Pt presenting with inadequate to extremely poor increasing dose.
i ic
perfusion resulting from a cardiac event may not always • Unstable Pts may require bolus Adrenaline
have associated chest pain, e.g. silent myocardial concurrently with the infusion.
V V
infarction, cardiomyopathy. • Adrenaline infusion
• Pts presenting with suspected pulmonary embolus - 3mg Adrenaline added to make 50ml with D5W or
e
with inadequate to extremely poor perfusion should Normal Saline.
e
be managed with this Guideline. Pulmonary embolus
- 1ml/hr = 1mcg/min
c A
is not specifically a cardiac problem but may lead to
c
cardiogenic shock due to an obstruction to venous
n
return and the Pt may require fluid and Adrenaline
n
therapy.
la u la ia ©
m b to r
A V ic ict
© e V
Vi V i b l
c e A m
n
Inadequate Perfusion Cardiogenic causes CPG A0407
u la a © a ©
b r i ri
?
Status Stop
• Inadequate perfusion: cardiogenic causes • Manage other causes, e.g. arrhythmia, pain, hypovolaemia
m t o to
8
Assess
c c
• Signs of pulmonary oedema (crackles)
V i ? Crackles
Vi ?
No Crackles
e
Action ✔ Action
e
✔
A
• Adrenaline infusion as per • Normal Saline 250ml IV
c c
Inadequate or Extremely Poor - Repeat 250ml IV if chest clear and Inadequate or Extremely Poor Perfusion
Perfusion persists
lan ?
a n ©
Inadequate or Extremely Poor Perfusion persists
l
Action
✔
u ia
• Adrenaline infusion (3mg/50ml D5W/Normal Saline) commencing @ 5mcg/min. (5ml/hr)
- Increase by 5mcg/min. @ 2/60 until adequate perfusion/side effects
b r
- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50mcg/min
o
- If syringe pump unavailable/malfunction:
m t
t
- repeat 10mcg @ 2/60 until adequate perfusion/side effects
A c
- If poor response
i c
- Adrenaline 50 - 100mcg IV as required
V i
- NB. Doses > 100mcg may be required
© V
• If chest clear continue Normal Saline 250ml IV boluses up to 20ml/kg
? Status
Inadequate Perfusion Cardiogenic causes CPG A0407 63
Vi V i b l
c e A m
n
Secondary to Erectile Dysfunction Agents
Inadequate Perfusion CPG A0408
a ©
and GTN Administration
u l ia i a ©
b r r
o
• Erectile Dysfunction agents for the purposes of this
m t o
Guideline are PDE5 inhibitors such as Viagra, Cialis
t
and Levitra.
c
• The combination of these drugs with GTN can
i ic
cause a dramatic drop in BP.
e V e V
n c n c A
la u la ia ©
m b to r
A V ic ict
© e V
Vi V i b l
c e A m
n
Secondary to Erectile Dysfunction Agents
Inadequate Perfusion CPG A0408
a ©
and GTN Administration
u l ia i a ©
b r r
?
Status
Assess / Consider
8
o
• Concurrent use of erectile
m o
dysfunction agents and Glyceryl
t
• Perfusion status
t
Trinitrate
• Exclude / Rx other causes, e.g. hypovolaemia, arrhythmia, pain
V ic Vic
?
Action
✔
e
• Metaraminol Bitartrate 0.5mg IV given over 1/60
e
- Repeat 0.5mg IV @ 2/60 until either:
c c A
- BP > 100
- max. 5mg IV is given
n n
• If BP has not responded to max. dose, discuss Mx with receiving
la a ©
hospital
u l ria
m b to
A V ic ict
©? Status
eStop
V
8 Assess 8 Consider ✔ Action
Inadequate Perfusion Secondary to Erectile Dysfunction Agents
✔ MICA Action
and GTN Administration CPG A0408 65
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Pain Relief CPG A0501
u la a © a ©
b r i ri
o
• The max. dose of Methoxyflurane is 6ml per 24hr. • ALS Paramedics must consult prior to exceeding the
m t o
period. 20mg max. dose of Morphine and administer according
t
• If IV access is not available, or delayed, consider to Pt need or the onset of adverse side effects.
c
intranasal Fentanyl and /or Methoxyflurane. • The effect of Morphine IM on pain relief is slow and
i ic
• Exercise caution if using Fentanyl and Morphine in variable. This route must be used as a last resort and
combination. Smaller doses will be required. strictly within indicated Guidelines.
V V
• If respiratory depression occurs due to narcotic • Do not administer IM medications if Pt likely to receive
administration should be managed as per thrombolysis.
e
CPG A0707 Management of Overdose. • Narcotic pain relief should not be administered during
e
• Pts with undiagnosed headache (i.e. new onset, late second stage of labour. In the event of precipitous
c c A
sudden severe headache) cannot be given Morphine delivery following narcotic analgesia, consult with the
by Ambulance Paramedics without consultation with Royal Children’s Hospital regarding the appropriate use
n n
a Medical Officer at the receiving hospital. MICA of Naloxone for the newborn.
©
Paramedics may administer Morphine or Fentanyl in
la a
this setting without consultation.
u l ia
Fentanyl IN preparation
b r
Fentanyl IN 900mcg/3ml preparation To administer IN Fentanyl, draw up desired
o
All Adult doses must be prepared from 900mcg/3ml in a 1ml syringe
volume according to dose table for the
t
corresponding weight and age then atomise
m
Age < 60 or Wt. > 60kg Age > 60 or Wt.< 60kg
into Pt’s nostril.
c t
Initial dose 200mcg 100mcg
The max. amount to be atomised into any
A i
Volume 0.75ml 0.45ml
c
nostril is 1ml. In some instances it may be
i
Subsequent dose 50mcg 50mcg
appropriate to administer half of the volume into
V
Volume 0.25ml 0.25ml each nostril as optimal absorption occurs with
© V
volumes of 0.3 - 0.5ml. This is also dependent
All doses include 0.1ml to account for atomiser dead space.
e
Doses have been rounded to the nearest 0.05ml. on Pt compliance.
Vi V i b l
c e A m
n
Pain Relief CPG A0501
u la a © a ©
b r i ri
?
Status Assess
8
• Complaint of pain • Pain score > 2
m t o o
• Determine requirement for non IV therapy vs IV
ic ic t
? Non IV therapy ? IV therapy
V
• Pain likely to be controlled by non IV therapy or • Pain may require IV narcotic and ongoing therapy
V
• Unable to obtain IV Action
✔
e
If✔
Action • Morphine up to 5mg IV
e
- Repeat up to 5mg IV @ 5/60 (max. 20mg)
A
• Consider Methoxyflurane and/or Fentanyl IN if
c c
appropriate or while establishing IV access titrated to pain or side effects
n
• Unable to obtain IV access
n
• Methoxyflurane 3ml
- Repeat 3ml if required (max. 6ml) - > 60kg : Morphine 10mg IM
la ©
- Repeat 5mg IM after 15/60 (once only)
a
• Fentanyl IN if required
l
- If age < 60 and > 60kg : Fentanyl 200mcg IN - < 60kg : Morphine 0.1mg/kg IM
a
- Repeat up to 50mcg IN @ 5/60 titrated to pain or - Single dose only - consult for further dose
u i
side effects (max. dose 400mcg)
r
- If age > 60 and/or < 60kg : Fentanyl 100mcg IN • Morphine as above - no max. dose
b
- Repeat up to 50mcg IN @ 5/60 titrated to pain or
• If allergic to Morphine
o
side effects (max. dose 200mcg)
- F entanyl 25 - 50mcg IV
m t
• If pain not controlled by above Rx as per IV therapy - Repeat 25 - 50mcg IV @ 5/60 titrated to
c t
pain or side effects
A V i ic
? Nausea
V
Action
✔
© e
• Rx as per CPG A0701 Nausea and Vomiting
Pain Relief CPG A0501 69

Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
?
Status Assess
8
• Respiratory distress
o
• Severity of Asthma / COPD presentation
m ic t c to
i
?
Mild/Moderate/Severe ?
Exacerbation of COPD ?
Unconscious ?
No cardiac output
V V
Action
✔ Action
✔ Action
✔ Action
✔
• See CPG A0601 • See CPG A0601 • See CPG A0601 • Loses cardiac output
e
See CPG A0601
e
• PEA as per CPG A0201
n c n c A
la u la ia ©
m b to r
A V ic ict
©? Status
eStop
V
Asthma CPG A0601 71
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
o
• Asthmatic Pts are dynamic and can show initial • Salbutamol infusion
m t o
improvement with treatment then deteriorate rapidly. - 1mg Salbutamol added to make 50ml with
t
• Consider MICA support but do not delay transport D5W or Normal Saline.
c
waiting for backup.
c
- 15mcg/min. = 45ml/hr
i i
• Despite hypoxaemia being a late sign of deterioration,
pulse oximetry should be used throughout Pt contact (if
V V
available).
• An improvement in SpO2 may not be a sign of
e
improvement in clinical condition.
e
• Beware of Pt presenting wheeze associated with heart
c c A
failure and no asthma / COPD Hx.
n
• pMDI = Pressurised Metered Dose Inhaler
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
?
Status Assess
8
• Respiratory distress • Severity of distress
m t o o
• If Pt’s asthma Mx plan has been activated
ic ic t
? Mild or Moderate ?
Severe
V V
Action
✔ Action
✔
• Salbutamol pMDI and spacer • Salbutamol 10mg (5ml) and Ipratropium
e
- Deliver 4 puffs @ 4/60 until resolution of symptoms Bromide 500mcg (2ml) Nebulised
e
• If pMDI spacer unavailable - Repeat Salbutamol 5mg (2.5ml)
c A
Nebulised @ 5/60 if required
c
- Salbutamol 10mg (5ml) Nebulised
- Repeat 5mg (2.5ml) Nebulised @ 5/60 if required
n
•
n
Salbutamol 250mcg IV
la ©
- Repeat 125mcg IV @ 5/60 if required
a
(max. 500mcg)
l
? Adequate Response ?
No Significant Response after 10/60 • Dexamethasone 8mg IV
u ia
Action
✔ Action
✔ If unimproved
• Salbutamol infusion IV @ 15mcg/min.
r
• Transport with continued • Rx as per Severe
b
reassessment (45ml/hr)
A m cto t
© V i V ic
? Status
Asthma CPG A0601 73
Vi V i b l
c e A m
la n
COPD Chronic Obstructive Pulmonary Disease
© ©
CPG A0601
bu r
Special Notes
ia ri a
General Care
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
COPD Chronic Obstructive Pulmonary Disease CPG A0601
u la a © a ©
b r i ri
?
Status
• Exacerbation of COPD
m t o to
?
All exacerbations of COPD
c c
Action
i
✔
i
• If Severe
V V
- Treat as per appropriate section of CPG A0601 Asthma
• Irrespective of severity
e
- Salbutamol 10mg + Ipratropium Bromide 500mcg Nebulised
e A
• Dexamethasone 8mg IV
n c ?
n c ©
Adequate response ?
Inadequate response
la a
Action
✔ Action
✔
l
• Titrate O2 flow to target SpO2 90% • Continue Mx as per CPG A0601 Asthma
u a
- Consider low flow O2, e.g. Nasal Prong O2
b o ri
A m ict ct
©? Status
e V
Stop
V i
COPD CPG A0601 75
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
o
• High EtCO2 levels should be anticipated in the intubated
m t o
asthmatic Pt. EtCO2 levels of 120mmHg in this setting
t
is considered safe, and managing ventilation should be
c
conscious of the effect of gas trapping when attempting
i c
to reduce EtCO2.
i
• Extreme care must be taken with assisted ventilation as
V V
gas trapping and barotrauma occurs easily in asthmatic
Pts with already high airway pressures.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
?
Status
• Unconscious / Becomes Unconscious
m o o
- with poor or no ventilation but still with
t
Pt requires immediate assisted ventilation
t
cardiac output
Action
8
c c
• Ventilate @ 5 - 8 ventilations/min., VT 10ml/kg
i i
• Moderately high respiratory pressures
V V
• Allow for prolonged expiratory phase
• Gentle lateral chest pressure during expiration if required
n c e ?
ce
Adequate Response
Action
✔
A
?
Inadequate Response
n
Action
✔
• Rx as per Severe Respiratory Distress
©
• If unable to gain IV or unaccredited in IV Salbutamol
la a
- Adrenaline 300mcg IM (1 : 1,000)
l
- Repeat 300mcg IM @ 20/60 as required (max. 900mcg IM)
u ia
• Rx as per Severe Respiratory Distress
r
• Consider intubation per CPG A0302 Endotracheal Intubation
b
If Pt loses output at any stage, see CPG A0601
A m cto t
© V i V ic
? Status
Asthma CPG A0601 77
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
o
• Consider potential for tension pneumothorax and Mx.
m t o
• Due to high intrathoracic pressure due to gas trapping,
t
venous return is lost and Pt may lose cardiac output.
c
Apnoea allows the gas trapping to decrease.
V i Vic
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Asthma CPG A0601
u la a © a ©
b r i ri
?
Status
• Pt loses cardiac output
m o o
- especially during assisted ventilation and
t t
bag becomes stiff
ic ic
Pt requires immediate intervention
V
✔
V
Action
• Apnoea 1 min
e
- Exclude tension pneumothorax
e
- Gentle lateral chest pressure
c A
- Prepare for potential resuscitation
n n c ©
la a
?
Cardiac output returns ?
Cartoid pulse, no BP ?
No return of output
l
Action
✔ Action
✔ Action
✔
u ia
• Treat as per CPG A0601 • Adrenaline 50mcg IV • Mx as per appropriate Guideline
- Repeat 50 - 100mcg IV @1/60 as required
b r
• Normal Saline 20ml/kg IV
A m cto t
© V i V ic
? Status
e
Stop 8 Assess 8 Consider ✔ Action ✔ MICA Action
Asthma CPG A0601 79
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Nausea and Vomiting CPG A0701
u la a © a ©
b r i ri
o
• Prochlorperazine must only be administered via the • If there are no contraindications and the IV route is
m t o
IM route. Metoclopramide and Prochlorperazine unobtainable with a long transport time, then administer
t
should not be administered in the same episode of Pt Metoclopramide IM.
c
care without medical consultation with the receiving • If nausea and vomiting tolerated, basic care and
i c
hospital.
i
transport is the only required treatment.
• Antiemetics should never be administered if the Pt has • Take care with Metoclopramide Polyamp as it is
V V
been suspected of taking an oral drug overdose. This similar to Ipratroprium Bromide and Atropine
will increase the absorption of the ingested substance. Polyamps in appearance.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Nausea and Vomiting CPG A0701
u la a © a ©
b r i ri
?
Status Assess for:
8
• Actual or potential for nausea • Nausea and vomiting or
m o o
and vomiting
t
• Spinal cord injury / Eye trauma or
t
• Potential motion sickness
V ic
ic
? Nausea and vomiting associated with:
V
- Cardiac chest pain
? Prophylaxis for:
- Potential for motion sickness
? Prophylaxis for:
• Awake Pt (GCS 13 – 15) with
e
- Iatrogenic secondary to narcotic analgesia - Planned aeromedical evacuation suspected spinal injuries who
e
- Previous diagnosed migraine are immobilized on the stretcher
A
Action
✔
c
✔
c
- Secondary to cytotoxic drugs or radiotherapy • Eye trauma
• Prochlorperazine 12.5mg IM
- Severe gastroenteritis - e.g. penetrating eye injury,
n n
• Prochlorperazine must never be given IV hyphema
©
Action
la
✔✔
a
• Metoclopramide 10mg IV/IM Action
✔✔
l
- Repeat 10mg IV/IM after 10/60 if symptoms • Metoclopramide 10mg IV/IM
a
persist (max. 20mg)
u
- Repeat 10mg IV/IM after
i
• If known allergy or contraindication to 10/60 if symptoms persist
b r
Metoclopramide (max. 20mg)
- Prochlorperazine 12.5mg IM
o
• Prochlorperazine must never be given IV
m ct t
? If dehydrated
A i c
Action
✔✔
V i
• Manage as per CPG A0801 Hypovolaemia
©? Status
e Stop
V
Nausea and Vomiting CPG A0701 83
Vi V i b l
c e A m
n
Hypoglycaemia CPG A0702
u la a © a ©
b r i ri
o
• Pt may be aggressive during management. • If Pt’s next meal more than 20min. away, encourage the
m t o
• Ensure IV patent before administering Dextrose. Pt to eat a long acting carbohydrate (e.g. sandwich,
t
Extravasation of Dextrose can cause tissue necrosis. piece of fruit, glass of milk) to sustain BGL to next meal.
c
• If adequate response, maintain initial Mx and transport.
c
• Ensure sufficient advice on further management and
i i
follow-up if Pt refuses transport. • If the Pt refuses transport, repeat the advice for transport
using friend/relative assistance. If Pt still refuses
V V
transport, document the refusal, and leave Pt with a
responsible third person and advise the third person of
e
actions to take if symptoms re-occur and of the need to
e
make early contact with LMO for follow up.
c c A
• If inadequate response transport without undue delay.
• Maintain general care of unconscious Pt and ensure
n n
adequate airway and ventilation.
la ©
• Further dose of Dextrose 10% may be required in
a
some Hypoglycaemic episodes. Consider consultation
l
if BGL remains less than 4 mmol/L and unable to
a
administer oral carbohydrates
u i
• Continue initial Mx and transport.
m b to r
A V ic ict
© e V
Vi V i b l
c e A m
n
Hypoglycaemia CPG A0702
u la a © a ©
b r i ri
?
Status
• Evidence of probable Hypoglycaemia Assess
o
8
m o
- e.g. Hx diabetes, unconscious, pale, diaphoretic
t
• BGL
ic ic t
V V

?
BGL > 4 ? BGL < 4 Responds to commands ?
BGL < 4 Does not respond to commands
e
Action
✔ ✔
✔ Action Action
e
✔ ✔
A
• BLS • Glucose 15g Oral • IV cannula in a large vein
c c
• Consider other causes of • Confirm IV patency
n
altered conscious state
n
• Dextrose 10% 15g (150ml) IV
- e.g. stroke, seizure, - Normal Saline 10ml flush
la ©
hypovolaemia
a
• If IV access not possible/unsuccessful –
l
Glucagon 1mg (1 IU) IM
b u ?
ria
Adequate response ? Poor response ?
Adequate response ?
Inadequate response
o
Action
✔✔ Action
✔✔ - GCS 15 - GCS < 15 after 3/60
m t
• Consider transport • Consider Dextrose IV or Action
✔
✔ Action
✔
✔
c t
Glucagon IM • Cease Dextrose if still • Repeat Dextrose 10%
A i c
being given 10g (100ml) IV titrating
i
to Pt conscious state
V
- Normal Saline 10ml
V
flush
©? Status
Hypoglycaemia CPG A0702 85
Vi V i b l
c e A m
n
Continuous Tonic-Clonic Seizures CPG A0703
u la a © a ©
b r i ri
o
• For seizures other than generalised tonic-clonic seizures, • Frequent errors in drug dosage administration occur
m t o
Midazolam may only be administered following medical within AV in this Guideline.
t
consultation. • Ensure accurate dose calculation and confirm with
c
• Seizures may not always present with tonic-clonic other Paramedics on scene.
i ic
limb activity, e.g. unconsciousness with flicking eye • Midazolam can have pronounced effects on BP,
movements (nystagmus) may indicate ongoing seizure conscious state and airway tone.
V V
activity.
• Calculate the dose each time as stock strength may
• If a single seizure has spontaneously terminated continue change with manufacturer and familiarity may lead to
e
with initial management and transport. errors.
e
• If Pt has a past history of seizures and refuses transport,
c c A
leave them in the care of a responsible third party.
Advise the person of the actions to take for immediate
n n
continuing care if symptoms reoccur, and the importance Adult Dosage Calculation for Midazolam IM
of early contact with their primary care physician for
la ©
Strength required
a
follow-up. x Stock volume
Stock strength
l
e.g. 80kg Pt @ 0.1mg/kg = 8mg Stock strength 15mg/3ml
u a

i
8mg 8mg
x 3ml same as x 2ml
15mg 10mg
b r
8mg =
= x 1ml 0.8 x 2ml
5mg
o
Dose required = 1.6ml = 1.6ml
A m ict t
c
© e V V i
Vi V i b l
c e A m
n
Continuous Tonic-Clonic Seizures CPG A0703
u la a © a ©
b r i ri
?
Status Assess
✔ / Manage
• Continuous recurrent seizures • Protect Pt • Consider other causes e.g. BGL
m t o o
• Continuously monitor airway • Consider Pt’s own management
t
and ventilation - assist as required plan and treatment already given
ic ic
? Continuous Tonic-Clonic Seizure
V V
Ensure accurate dosage - 1/2 dose for age > 60 yr
✔ Action
✔
e
• Age > 60 - Midazolam 0.05mg/kg IM
e
• Age < 60 - Midazolam 0.1mg/kg IM (max. single dose 10mg)
n c n c A
©
? Seizure activity ceases ? Seizure activity continues > 5/60 ? Seizure activity continues >10/60
la a
✔ Action - IV access / accreditation - No IV access / no accreditation
l
• BLS Action
✔
✔ ✔
✔ Action
u ia
• Monitor airway and BP • Midazolam 0.05mg/kg IV • Repeat original Midazolam IM
- Repeat 0.05mg/kg IV @ 2 - 5/60 as required dose once only
b r
- max. combined dose IM + IV 0.25mg/kg • Consult for further doses
o
• Consult for further doses • Monitor airway and BP
m t
• Consider intubation as per CPG A0302
c t
Pancuronium contraindicated
A V i V ic
©? Status
Continuous Tonic-Clonic Seizures CPG A0703 87
Vi V i b l
c e A m
n
Anaphylaxis CPG A0704
u la a © a ©
b r i i
General Care
r
Special Notes
o
• All Pts with suspected anaphylaxis must be transported
m t o
to hospital regardless of the severity of their presentation
t
or response to management.
c
• Angio-oedema (vascular oedema) leads to increased
i ic
tissue fluid, presenting as swelling, upper airway
obstruction (throat tightness), orbital oedema and other
V V
systemic signs of swelling.
• Identify history of exposure to substances known
e
to cause anaphylactic reaction, e.g. recent insect
e
bite, medications, exposure to food known to cause
c A
anaphylactic reaction and presenting with evidence of
c
systemic involvement.
n n
• Research indicates most deaths from anaphylaxis
occurred with a delay in administration of Adrenaline
la a ©
in severe reactions.
u l ria
m b to
A V ic ict
© e V
Vi V i b l
c e A m
n
Anaphylaxis CPG A0704
u la a © a ©
b r i ri
? Status
• Evidence of anaphylaxis
m o o
• Exposure to foreign antigen
c t +
c t
Assess Physiological Distress
i
Assess for Systemic Involvement
8 8
i
• Angio-oedema or • Respiratory distress / bronchospasm or
V V
• Urticaria or Plus at least one • Less than Adequate Perfusion or
of these
• GIT disturbance • Altered Conscious State
n c e ? Mild
ce A
? Moderate ? Severe
n
• No Physiological Distress • < Borderline to Inadequate Perfusion • Extremely Poor Perfusion
©
• Local allergic reaction ✔ Action ✔ Action
la a
e.g. red rash / itchy • Monitor Pt for cardiac arrthythmias • Treat as per Moderate
l
✔ Action • Adrenaline 300mcg IM (1 : 1,000) • Adrenaline 50 mcg IV (1 : 10,000)
u a
- Repeat 300mcg IM @ 5/60 until - Repeat 50 - 100 mcg IV @ 1/60 until
i
• BLS
satisfactory results or side effects occur satisfactory results or side effects occur
b r
• Treat bronchospasm as per A0601 Asthma • IV fluid as per CPG A0801 Hypovolaemia
o
• Consider fluid as per CPG A0801 • Dexamethasone 8mg IV
t
Hypovolaemia • If no IV access Rx as per Moderate
m t
• If no IV access consider I/O
c
• Dexamethasone 8mg IV
A i
• If intubated
c
- Adrenaline 200mcg via ETT @ 5/60
©? Status
e V
Stop
V i
Anaphylaxis CPG A0704 89
Vi V i b l
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Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A0705
u la a © a ©
b r i ri
o
• Any infusions established under this Guideline must be • Adrenaline infusion > 50mcg/min. may be required
m t o
clearly labelled with the name and dose of any additive to manage these Pts. Ensure delivery system is fully
t
drugs and their dilution. operational (eg. tube not kinked, IV patent) prior to
c
• Sepsis criteria are relevant in the presence of an increasing dose.
i ic
infection or severe clinical insult such multi trauma • Unstable Pts may require bolus Adrenaline
leading to SIRS (Systemic Inflammatory Response concurrently with the infusion.
V V
Syndrome). • Adrenaline infusion
- 2 or more of: - 3mg Adrenaline added to make 50ml with D5W or
e
- Temp > 38˚ or < 36˚ Normal Saline.
e
- HR > 90
- 1ml/hr = 1mcg/min.
c A
- RR > 20
c
- BP < 90 • If sepsis suspected and prolonged transport times
n
exist, consider consultation for Ceftriaxone 1g IV,
n
Dexamethasone (dose on consult)
la u la ia ©
m b to r
A V ic ict
© e V
Vi V i b l
c e A m
n
Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A0705
u la a © a ©
b r i i
8
r
?
Status Assess
• Suspected Sepsis • Perfusion status
m t o o
• Other causes of • Sepsis criteria
t
non-cardiogenic, • Other possible causes
c
non-hypovolaemic shock
i ic
?
Inadequate or Extremely poor perfusion
V V
Action
✔
• Normal Saline up to 20ml/kg IV
n c e ?
ce
Adequately Perfusion
A
?
n
✔ Action ✔
Action
©
• BLS
la
• Adrenaline infusion (3mg/50ml D5W/Normal Saline) commencing @ 5mcg/min. (5ml/hr)
la
- Increase by 5mcg/min. @ 2/60 until adequate perfusion/side effects
a
- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate
u i
beyond 50mcg/min
r
- If syringe pump unavailable/malfunction
b
o
- repeat 10mcg @ 2/60 until adequate perfusion/side effects
t
- If poor response
m
- Adrenaline 50 - 100mcg IV as required
c t
- NB. Doses > 100mcg may be required
A i c
• If chest clear, continue Normal Saline 20ml/kg IV boluses as per CPG A0801 Hypovolaemia
©? Status
e V
Stop
V
8 Assess
i8 Consider ✔ Action ✔ MICA Action
Inadequate Perfusion
Non-cardiogenic / Non-hypovolaemic CPG A0705
91
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Version 3 - 01.011.05 Page 1 of 2
Meningococcal Septicaemia CPG A0706
u la a © a ©
b r i ri
o
• Meningococcal is transmitted by close personal Ceftriaxone preparation
m t o
exposure to airway secretions/droplets. • Dilute Ceftriaxone 1g with 9.5ml of water for
t
• Ensure face mask protection especially during injection and administer 1g IV over approximately
c
intubation/suctioning. 2/60.
i ic
• Ensure medical follow up for staff post exposure. • If unable to obtain IV access, or not accredited in
IV cannulation, dilute Ceftriaxone 1g with 3.5ml 1%
V V
Lignocaine HCL and administer 1g IM into the upper
lateral thigh or other large muscle mass.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
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Version 3 - 01.011.05 Page 2 of 2
Meningococcal Septicaemia CPG A0706
u la a © a ©
b r i ri
?
Status
• Possible meningococcal septicaemia
m t o to
PPE
ic ic
Confirm Meningococcal Septicaemia
8
V V
• Typical purpuric rash
• Evidence of septicaemia
e
- Headache, fever, joint pain, altered conscious state, hypotension
e
and/or tachycardia
n c ?
n c A ?
©
IV Access No IV Access
la a
Action
✔ - Unable to gain
l
• Ceftriaxone 1g IV - Not IV accredited
u a
- Dilute with water for injection to
i
Action
✔
make 10ml
r
• Ceftriaxone 1g IM
b
- Administer slowly over 2/60
- Dilute with 3.5ml 1% Lignocaine HCL to
o
make 4ml
t
- Administer into upper lateral thigh or other
m
large muscle mass
A V ic ict
©? Status
eStop
V
Meningococcal Septicaemia CPG A0706 93
Vi V i b l
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n
Management of Overdose CPG A0707
u la a © a ©
b r i ri
General Care General Care
o
• Provide Supportive Care (all cases) • Confirm clinical evidence of substance use or exposure
m t o
- Provide appropriate airway management and - Identify which substance/s are involved and collect if
t
ventilatory support possible.
c c
- If Pt is in an altered conscious state, assess random - Identify by which route the substance/s had been
i i
blood glucose and if necessary manage as per taken (e.g. ingestion).
CPG A0801 Hypoglycaemia
V
- Establish the time the substance/s were taken.
V
- If Pt is bradycardic with poor perfusion manage as - Establish the amount of substance/s taken.
per CPG A0402 Bradycardia
- What were the substance/s mixed with when taken
e e
- If Pt is inadequately perfused, manage as per (e.g.: alcohol, water)?
CPG A0801 Hypovolaemia
c A
- What treatment has been initiated prior to Ambulance
c
- Assess Pt temp. and manage as per arrival (e.g. induced vomiting)?
n
CPG A0901 Hypothermia / Cold Injury, or
n
CPG A0902 Environmental Hyperthermia /
la ©
Heat Stress
u la ia
m b to r
A V ic ict
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Vi V i b l
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Management of Overdose CPG A0707
u la a © a ©
b r i ri
?
Status Assess
8
• Suspected overdose
o
• Substance involved
m ic t c to
i
?
Narcotics ?
TCA Antidepressants ?
Sedatives ?
Psychostimulants
V V
e.g. - Heroin e.g. - Amitriptyline e.g. - GHB e.g. - Cocaine
- Morphine - Nortriptyline - Alcohol - Amphetamines
- Codeine - Dothiepin - Benzodiazepines
e e
- Other narcotic - Volatile agents
c A
preparations
n n c ©
la u la ia
m b to r
A V ic ict
©? Status
eStop
V
Management of Overdose CPG A0707 95
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Management of Overdose: Narcotics CPG A0707
u la a © a ©
b r i ri
o
• Narcotics may be in the form of IV preparations such • If inadequate response after 10/60, Pt is likely to require
m t o
as Heroin or Morphine and oral preparations such as transport without delay.
t
Codeine, Endone, MS Contin. Some of these drugs - Maintain general care of the unconscious Pt and
c
also come as suppositories. ensure adequate airway and ventilation.
i ic
• Not all narcotic overdoses are from IV administration of - Consider other causes e.g. head injury,
the drug. hypoglycaemia polypharmacy overdose.
V V
- Beware of Pt becoming aggressive.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
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Vi V i b l
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Management of Overdose: Narcotics CPG A0707
u la a © a ©
b r i ri
? Status Stop
• Possible narcotic overdose • Ensure personal / crew safety
m t o o
• Scene may have concealed syringes
c c t
Assess evidence of narcotic overdose
i
8
i
- Altered conscious state - Pin point pupils
V
- Respiratory depression - Track marks
V
- Substance involved
- Exclude other causes (inc. no obvious head injury)
n c e ce A
? Narcotic overdose
n
✔ Action
©
• Assist and maintain airway/ventilation
la a
• Naloxone 1.6mg – 2mg IM
u l ria
? Adequate response ? Inadequate response after 10/60
b
o
• BLS • Naloxone 0.8 mg IM
m t
• Consider transport • Consider airway Mx CPG A0301 Laryngeal Mask
c t
• Naloxone 0.8 mg IM or IV
A i c
• Consider airway Mx
i
©? Status
e V
Stop
V
Management of Overdose: Narcotics CPG A0707 97
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Management of Overdose: Tricyclic Antidepressants (TCA) CPG A0707
u la a © a ©
b r i ri
o
Signs and Symptoms of TCA Toxicity ECG changes
m t o
• Mild to moderate OD ECG changes include prolonged PR, QRS and QT intervals
t
- Drowsiness, confusion associated with an increased risk of seizures if QRS > 0.10
c
- Tachycardia sec. and ventricular arrhythmias if QRS > 0.16 sec.
i ic
- Slurred speech
- Hyperreflexia How to measure a QT interval is shown below.
V V
- Ataxia
- Mild hypertension
- Dry mucus membranes
e e
- Respiratory depression
c c A
• Severe toxicity (within 6hr. ingestion)
- Coma
n n
- Respiratory depression/hypoventilation
- Conduction delays
la a ©
- Premature Ventricular Contractions (PVCs)
l
- SVT
- VT
u ia
- Hypotension
- Seizures
b r
- ECG changes
o
This could lead to aspiration, hyperthermia,
m t
rhabdomyolysis and acute pulmonary oedema.
c t
A V i V ic
© e
Vi V i b l
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n
Management of Overdose: Tricyclic Antidepressants (TCA) CPG A0707
u la a © a ©
b r i ri
? Status Assess
8
• Possible TCA overdose • Substance involved
m t o o
t
• ECG criteria
V ic ✔ Action
Vic
? No toxicity ? Signs of TCA toxicity
Any of the following
e
• BLS - Less than adequate perfusion
e
- QRS > 0.12 sec. (> 0.16 sec. indicates severe toxicity)
A
• Consider potential to develop signs of toxicity
c
- QT prolongation (> 1/2 R-R interval)
n n
✔ Action
©
• Sodium Bicarbonate 8.4% 100ml IV given over 3/60
la a
- Repeat 100ml IV after 10/60 if signs of toxicity persist
l
- Severe cases may require continuing doses - Consult
a
• Consider Intubation as per CPG A0302 Endotracheal
u i
Intubation if signs of toxicity and GCS < 10 persist after
r
initial Mx
b
- Hyperventilate with 100% O2 - rate 20 - 24bpm
o
- EtCO2 target 20-25mmHg if intubated
A m ict ct
©? Status
e V
Stop
V i
Management of Overdose:
Tricyclic Antidepressants (TCA) CPG A0707 99
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Management of Overdose: Sedative Agents/Psychostimulants CPG A0707
u la a © a ©
b r i ri
o
• If Pt still refuses transport after repeating the advice for • If a young person makes it known they are involved
m t o
transport using friend/relative assistance, advise the Pt with DHS Child Protection and they give permission,
t
and responsible third person of follow-up, counselling an attempt should be made on their behalf to contact
c
facilities and actions to take for continuing care if the young person’s Child Protection practitioner,
i c
symptoms reoccur. Region or Child Protection After Hours Service (24hr.
i
• For young persons, Paramedics should strongly on 131 278) to advise of the Ambulance attendance
V
and treatment. The intent is to make arrangements
V
encourage them to make contact with a responsible
adult. for ongoing care for this Pt. Such contact is best
made through the senior clinician in operations/
e
• Paramedics should call the Police if in their professional
e
communication centre.
judgement there appears to be factors that place the Pt
c A
at increased risk, such as: • In such situations if the Police are contacted, they
c
will notify Department of Human Services Child
- is subject to violence (e.g. from a parent, guardian or
n
Protection if they believe the young person is in need
n
care giver)
of protection.
la ©
- is likely to be, or is in danger of sexual exploitation
• Hyperthermic psychostimulant OD
a
In particular for children where:
l
In hyperthermic psychostimulant OD the trigger point
- the supply of drugs appears to be from a parent/
a
for intervention in the Mx of agitation/aggression is
u
guardian/care giver.
i
lowered. Sedation should be initiated early to assist
- there is other evidence of child abuse/maltreatment with cooling and avoid further increases in temp.
b r
or evidence of serious untreated injuries. associated with agitation.
o
• If Pt claims to have taken an overdose of a potentially
t
life-threatening substance then they must be
m
transported to hospital. Police assistance should be
c t
sought to facilitate this as required.
A i c
• Documentation of refusal and actions taken must be
i
recorded on the PCR.
© e V V
Vi V i b l
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n
Management of Overdose: Sedative Agents/Psychostimulants CPG A0707
u la a © a ©
b r i ri
? Status Assess
8
• Sedative agents • Substance involved
m t o o
• Psychostimulants
ic ic t
? Sedative agents ? Psychostimulants
V V
• Be aware for potential for agitation / aggression • Be aware of potential for violent behaviour, particularly with
e
particularly in GHB / volatile substance abuse Methamphetamines
e
• Pt may require airway management • Reduce stimulus by calming and controlling Pt environment
c c A
• Manage agitation / aggression as per CPG A0708 • Manage seizures as per CPG A0703 Continuous
Tonic-Clonic Seizures
n
The Agitated Patient
n
• Manage cardiac chest pain as per CPG A0401 Acute
la ©
Coronary Syndrome
la
• Manage temp. as per CPG A0902 Hyperthermia/
a
Heat Stress or A0901 Hypothermia / Cold exposure
u i
• Manage agitation / aggression as per CPG A0708 The
r
Agitated Patient
m b to
A V ic ict
©? Status
e Stop
V
Management of Overdose:
Sedative Agents/Psychostimulants CPG A0707 101
Vi V i b l
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la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
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© V i V ic
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The Agitated Patient CPG A0708
u la a © a ©
b r i ri
o
• This Guideline does not apply to Pts who have been • Paramedic safety is to be considered paramount at all
m t o
recommended for transport under the Mental Health times. Do not attempt any element of this Guideline
t
Act. If sedation is required in these circumstances then unless all necessary assistance is available.
c
the Act requires that this only be administered by a • Provide supportive care in all cases where sedation
i c
prescribed Medical Practitioner or Registered Nurse.
i
administered.
• The indications for the use of sedation and/or restraint • Provide airway management appropriate to the clinical
V V
must be clearly documented on the PCR. condition, administer oxygen to all Pts and assist
• Mechanical restraint may also be utilised without the ventilation as required.
e
use of sedation in circumstances where the Pt will not • If less than adequate perfusion manage as per CPG
e
sustain further harm by fighting against the restraints. A0705 Inadequate Perfusion (Non-cardiogenic /
c c A
• Mechanical restraints must be removed if there is Non-hypovolaemic).
any indication that the restraint is compromising the • Continue to assess Pt temp. and manage as per CPG
n n
provision of supportive care. A0902 Environmental Hyperthermia / Heat Stress,
©
or CPG A0901 Hypothermia / Cold Injury.
la
• The type of restraint used and its time of application
a
and/or removal must be clearly documented on the • If not already completed, ensure that all possible clinical
l
PCR. causes of agitation are assessed and managed by the
a
Hyperthermia appropriate Guideline.
u i
• Sedation should be initiated early in hyperthermic Pts Head Injury
r
who have been using psychostimulants to assist with
b
• In Pts with mild to moderate head injury (GCS 10 - 14),
cooling and avoid further increases in temp. secondary sedation cannot be given without medical consultation
o
to agitation. with a Major or Regional Trauma Service.
A m ict ct
© e V V i The Agitated Patient CPG A0708 103
Vi V i b l
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The Agitated Patient CPG A0708
u la a © a ©
b r i i
?
Status Stop
r
• Agitated Pt
o
• Observe for and manage as appropriate
m o
- Hazards - Body fluids
t t
- Violence - Sharps
c
- Clear egress - Reduce stimuli
i c
- Paramedic safety is paramount
V Vi ?
Agitated Pt
e
✔ Action
✔
e A
• Communicate with Pt
c c
- Avoid confrontational behaviour
n
- Gain Pt co-operation for assessment
n
- Utilise verbal de-escalation strategies
la la ©
8
Assess/Consider
u ia
• Assess and manage clinical causes (as far as possible)
- Hypoglycaemia - Drug withdrawal
b r
- Hypoxia - Intracerebral pathology
o
- Post-ictal - Mild to moderate head injury
- Drug intoxication (consult with MTS for sedation)
m t
(initiate sedation early - Acute psychiatric condition
c t
in hyperthermic
A i
psychostimulant Pt)
© V V ic
e
Vi V i b l
c e A m
la n © ©
u a
?
Able to Mx without restraint/sedation ?
Requires restraint/sedation
i i a
✔
✔ Action • Does not respond to verbal de-escalation
b r r
• Mx cause as appropriate • Clinical causes have been excluded
• Continue to treat cause of agitation • Pt risk to themselves or others
m o o
- e.g. combative, agitated or aggressive
t
• Beware Pt condition may change and agitation
t
increase requiring restraint/sedation
c c
Stop
i i
• Ensure Pt is not recommended under the Mental Health Act
V
- Sedation by Paramedics is contraindicated for these Pts
V
• Ensure sufficient physical assistance
e
• Reduced sedation dose for age / BP
e
• Mild to moderate head injury GCS 10 - 14 (consult for sedation)
n c n c A
✔
✔ Action
©
• Age > 60 and/or BP < 100
la a
- Midazolam 0.05mg/kg IM (max. 5mg per dose)
l
- Repeat initial dose @ 10/60 IM (max. 4 doses) as required
u a
• Age < 60 and BP > 100
i
- Midazolam 0.05 - 0.1mg/kg IM (max. 10mg per dose)
b r
- Repeat initial dose @ 10/60 IM (max. 4 doses) as required
o
• Apply mechanical restraint devices if required
t
• Above doses may be given IV and repeated @ 5/60 as required
m t
• IM injections may be indicated until IV access has been established
A V ic ic
©? Status
e
Stop
V
The Agitated Patient CPG A0708 105
Vi V i b l
c e A m
n
Organophosphate Poisoning CPG A0709
u la a © a ©
b r i ri
o
• Notification to receiving hospital essential to allow for • Where possible, remove contaminated clothing and
m t o
Pt isolation. wash skin thoroughly with soap and water.
t
• The key word to look for on the label is • If possible minimise the number of staff exposed.
c
anticholinesterase. There are a vast number of
c
• Attempt to minimise transfers between vehicles.
i i
organophosphates which are used not only used
commercially but also domestically.
V V
• If a potential contamination by a possible
organophosphate has occurred, the container
e
identifying trade and generic names should be identified
e
and the Poisons Information Centre contacted for
c A
confirmation and advice.
n n c ©
la u la ia
m b to r
A V ic ict
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Vi V i b l
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n
Organophosphate Poisoning CPG A0709
u la a © a ©
b r i ri
? Status
• Possible organophosphate exposure
m t o to
Stop
c c
• Avoid self contamination - wear PPE
i i
• Pt decontamination if possible
V +
V
Confirm evidence of suspected poisoning 8 Evidence of excessive cholinergic effects
e
• Cholinergic effects: salivation, bronchospasm, • Salivation compromising the airway or
e
sweating, nausea or bradycardia bronchospasm and /or
c c A
• The key word to look for on the label is Plus • Bradycardia with Inadequate or Extremely
anticholinesterase Poor Perfusion
lan la n ©
? No excessive cholinergic effects ? Excessive cholinergic effects
u ia
r
• Transport to nearest appropriate hospital • Atropine Sulphate 1200mcg IV
b
• Monitor for excessive cholinergic effects - Repeat 1200mcg IV @ 5/10 until excessive cholinergic effects resolve
o
• Consult with receiving hospital for further management if required
m t
• The use of Suxamethonium Hydrochloride is contraindicated
c t
in Pts with suspected Organophosphate Poisoning
A V i V ic
©? Status
Organophosphate Poisoning CPG A0709 107
Vi V i b l
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Autonomic Dysreflexia CPG A0710
u la a © a ©
b r i ri
o
• Transport the Pt even if the symptoms are relieved
m t o
as this presentation meets the criteria of Autonomic
t
Dysreflexia, a medical emergency that requires
c
identification of probable cause and treatment in
i c
hospital to prevent cerebrovascular catastrophe.
V Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Autonomic Dysreflexia CPG A0710
u la a © a ©
b r i ri
? Status Confirm Autonomic Dysreflexia
8
• Possible autonomic dysreflexia • Previous spinal cord injury at T6 or above
m t o o
- Severe headache
t
- Systolic BP > 160
ic ic
Identify & treat possible causes - remove the stimulus
V V
• If distended bladder (common), ensure indwelling catheter is not kinked
• Manage pain, e.g. fractures, burns, labour
e e
? If systolic BP remains > 160
c c A
Action
✔
n n
• GTN 300mcg S/L/Buccal (nil prev. admin.) or
GTN 600mcg S/L/Buccal
la u la ia ©
? Adequate response ? Inadequate response - BP remains > 160
r
Action
✔ Action
✔
b
• Transport to nearest appropriate hospital • Repeat initial dose of GTN @ 10/60 until either:
o
- Symptoms resolve
m t
- Onset of side effects
t
- BP < 160
A ic
• Transport to nearest appropriate hospital
© V V ic
? Status
Autonomic Dysreflexia CPG A0710 109
Vi V i b l
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la n © ©
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V i Vi
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la la n ©
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A m cto t
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Vi V i b l
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la n © ©
bu r ia ri a
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V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
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Vi V i b l
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Inadequate Perfusion Associated with Hypovolaemia CPG A0801
u la a © a ©
b r i ri
General Care General Care
o
• Titrate fluid administration to Pt response.
m t o
• Aim for HR < 100, BP > 100.
t
• Consider establishing IV en route. Do not delay
c c
transport for IV therapy.
i i
• Always consider tension pneumothorax, particularly
V
in the Pt with a chest injury not responding to fluid
V
therapy and persistently hypotensive.
• Excessive fluid should not be given if spinal cord injury
e e
is an isolated injury.
n c n c A
la u la
Modifying factors
ia ©
r
• Complete spinal cord transection Rx as per CPG A0804 Management of Potential Spinal Cord Injury
b
- Pt with isolated neurogenic shock can be given up to 500ml Normal Saline bolus to correct hypotension. No further
o
fluid should be given if SCI is the sole injury.
m t
• Chest injury - Consider tension pneumothorax Rx as per CPG A0802 Chest Injury S (Rural)
t
• Penetrating Trunk Injury, aortic aneurysm or uncontrolled haemorrhage.
A c
- Accept palpable carotid pulse and transport immediately
© V i V ic
e
Vi V i b l
c e A m
n
Inadequate Perfusion Associated with Hypovolaemia CPG A0801
u la a © a ©
b r i ri
?
Status Stop
• Evidence of Hypovolaemia • Identify and manage
m o o
Haemorrhage, fractures, pain, tension pneumothorax, hypoxia
c t c t
Consider Modifying factors/Assess HR/BP
8
i i
• SCI, chest injury penetrating trunk injury, AAA, uncontrolled haemorrhage
V V
? HR<100 BP>100 ? Isolated Tachycardia ? Hypotension
e
Action • HR > 100 BP > 100 • BP < 100
e
✔
A
• Fluid not required Action Action
c
✔ ✔
c
• Normal Saline 20ml/kg IV • Normal Saline 20ml/kg IV
lan
Action
✔
la n
? HR<100 BP>100
©
? HR>100 and/or BP<100
Action
✔
? BP>100 HR<100
Action
✔
? BP<100 and/or HR>100
Action
✔
u ia
• No further fluid required • Repeat Normal Saline 20ml/kg • No further fluid required • Insert second IV
r
• Repeat Normal Saline 20ml/kg
b
? BP remains < 100
o
• After 40ml/kg ? BP remains < 100
m t
Action
✔ • After 40ml/kg
c t
• Consult with MTS Action
✔
A i c
• If unavailable repeat • Consult with MTS
i
Normal Saline 20ml/kg IV
V
• If unavailable repeat
V
Normal Saline 20ml/kg IV
©? Status
Inadequate Perfusion Associated with Hypovolaemia CPG A0801 113
Vi V i b l
c e A m
la n
Chest Injuries
©
CPG A0802
©
bu r
Special Notes
ia ri
General Care
a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
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© V i V ic
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Vi V i b l
c e A m
n
Chest Injuries CPG A0802
u la a © a ©
b r i ri
?
Status Assess
8
• Chest injury • Respiratory status
m o o
- Traumatic
t
• Type of chest injury
t
- Spontaneous
- Iatrogenic
c c
Action
i
✔
i
• Supplemental oxygen
V V
• Pain relief as per CPG A0501 Pain Relief
• Position Pt upright if possible unless
e
perfusion is < adequate, altered
e
consciousness, associated barotrauma
c A
or potential spinal injury
n n c ©
la a
? Flail segment/Rib fractures ? Open chest wound ? Pneumothorax
l
Action
✔ Action
✔ • Signs of pneumothorax
u ia
• May require ventilatory support • 3 sided sterile occlusive dressing Action
✔
if decreased VT
r
• See CPG A0802
m b to
A V ic ict
©? Status
eStop
V
Chest Injuries CPG A0802 115
Vi V i b l
c e A m
n
u la a © a ©
b r i ri
o
• In IPPV setting, equal air entry is not an exclusion • Tension Pneumothorax (TPT)
m t o
criteria for TPT. - If some clinical signs of TPT are present and the Pt is
t
• Chest injury Pts receiving IPPV have a high risk of deteriorating with decreasing conscious state and/
c
developing a TPT. Solution for poor perfusion in this or poor perfusion, immediately decompress chest by
i c
inserting a long 14G cannula or Intercostal Catheter.
i
setting includes bilateral chest decompression.
• Cardiac arrest Pts are at risk of developing chest injury - If air escapes, or air and blood bubble through the
V V
during CPR. cannula/intercostal catheter, or no air/blood detected,
leave insitu and secure.
• Troubleshooting
e
- Pt may re-tension as lung inflates if catheter kinks off. - If no air escapes but copious blood flows through the
e
- Catheter may also clot off. Flush with sterile Normal cannula/intercostal Catheter then a major haemothorax
c A
is present. Remove, then cover the insertion site.
c
Saline.
• If a 14G Cannula is used initially, it should be replaced • Needle Test
n n
with an intercostal catheter (if available) as soon as - If TPT suspected, but the assessment is not obvious,
test for a TPT with a needle at least 45mm length (long
la ©
practicable.
a
14/16G) attached to Normal Saline filled syringe.
• Insertion site for cannula/intercostal catheter
l
- Second intercostal space - If needle test is suggestive of TPT, withdraw needle and
a
- Mid clavicular line (avoiding medial placement) immediately decompress chest.
u i
- Above rib below (avoiding neurovascular bundle) - If needle test is not suggestive of TPT, withdraw needle,
r
- Right angles to chest (towards body of vertebrae) cover insertion site with a clear adhesive dressing and
b
circle the insertion site with a pen
o
- Be aware that a needle test for TPT can be prone to
m t
false readings and does not exclude TPT in all cases.
A V ic ict
© e V
Vi V i b l
c e A m
n
u la a © a ©
b r i ri
?
Status Assess
8
• Pneumothorax • Criteria for Simple vs Tension
m o o
- Simple Pneumothorax
t t
- Tension
V ic Vic ? Simple pneumothorax

• Any of the following:
? Tension pneumothorax (TPT)

• Any of the following +/- signs of Simple Pneumothorax:
e
- Unequal breath sounds in -  Peak inspiratory pressure (ventilator) / stiff bag
e
spontaneously ventilating Pt -  EtCO2
c A
- Low SpO2 on room air - Poor Perfusion or  HR +/-  BP
c
- Subcutaneous emphysema -  Jugular Venous Pressure (JVP)
n
-  Conscious state in the awake Pt
n
Action - Tracheal shift
la ©
✔
a
- Low SpO2 on supplemental O2 (late)
• Continue BLS and supplemental O2
l
• Monitor closely for possible development Action
✔
u a
of TPT
i
• Chest decompression as per General Care S-Rural
m b to r
A V ic ict
©? Status
e
Stop
V
Chest Injuries CPG A0802 117
Vi V i b l
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n
Severe Traumatic Head Injury CPG A0803
u la a © a ©
b r i ri
o
• Dress open skull fractures/wounds with sterile combine
m t o
soaked in sterile Normal Saline 0.9%.
t
• Maintain manual in-line neck stabilisation and apply
c c
cervical collar when convenient. If intubation is required,
i i
apply cervical collar after intubation. Attempt to minimise
jugular vein compression.
V V
• Attempt to maintain normal temp.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Severe Traumatic Head Injury CPG A0803
u la a © a ©
b r i ri
?
Status
• Severe traumatic head injury
m c t
?
o c to ? ? ?
i
Airway Ventilation Perfusion General Care
i
Action
✔ Action
✔ Action
✔ Action
✔
V V
• If airway patent and VT • Ensure adequate • Manage with Normal • Treat sustained seizure
adequate (with trismus), ventilation and Saline as per CPG A0801 activity with Midazolam
do not insert NPA VT of 10ml/kg Hypovolaemia (unless in the as per CPG A0703
e e
• If airway not patent and • Maintain SpO2 setting of penetrating truncal Continuous Tonic –
A
Clonic Seizures
c
gag is present, insert > 95% and trauma or uncontrolled overt
c
NPA and ventilate treat causes of bleeding) • Measure BGL and
n
hypoxia • Aim for systolic BP > 120 rectify hypoglycaemia
n
• If GCS < 10, regardless
of airway reflexes, • Maintain EtCO2 • After 40ml/kg reassess. If as per CPG A0702
la ©
Hypoglycaemia
a
intubate as per CPG at 30 - 35mmHg systolic BP < 100, discuss
l
A0302 Endotracheal Avoid hypo/ ongoing resuscitation with the • Triage to highest
Intubation - RSI hypercapnia receiving Regional or Major level of care as per
u ia
• If intubation is not Trauma Service while continuing Trauma Time Critical
to transport Guidelines
r
possible/ authorised and
b
gag is absent insert LMA • If consult is unavailable
o
administer a further Normal
t
Saline 20ml/kg IV and
m
reassess
A V ic ict
©? Status
eStop
V
Severe Traumatic Head Injury CPG A0803 119
Vi V i b l
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Spinal Cord Injury (SCI) Management CPG A0804
u la a © a ©
b r i ri
o
• A cervical collar alone does not immobilise the cervical • If a cervical collar is applied then it must be properly
m t o
spine. If the neck needs immobilising then the whole fitted and applied directly to the skin, not over clothing
t
spine needs immobilising. This may include the use and not placing any pressure on the neck veins.
c
of “head rolls” or other approved proprietary devices • Where there is no immediate risk to life and extrication
i c
and the whole body immobilised on a spineboard or
i
is required then an extrication device (e.g. KED) should
Ambulance stretcher in a manner that is appropriate be considered.
V
for the presenting problem. A spineboard must be
V
• Pts with a SCI may develop pressure areas within as
restrained to the Ambulance stretcher during transport.
little as 30min. following placement on a spine board
• The head should not be independently restrained.
e
and the duration on a spine board must therefore be
e
• In Pts with a diseased vertebral column, a lesser noted on the PCR.
c A
mechanism of injury may result in SCI and should be
c
• For transport times in excess of 30min. consideration
managed accordingly. should be given to removing the Pt from a spineboard
n n
• Spinal immobilisation with neutral alignment may not and appropriately securing them to the Ambulance
be possible in a Pt with a diseased vertebral column stretcher.
la a ©
with associated anatomical deformity and should be • Pts with isolated neurogenic shock should be given a
l
modified accordingly e.g. position of comfort. small fluid bolus (up to 500ml Normal Saline IV) to
a
• Spinal immobilisation is not without risk. Complications correct hypotension. No further fluid should be given if
u i
may include head and neck pain, detrimental effects on SCI is the sole injury.
r
pulmonary function and subsequent neurological • The Pt with multi trauma and SCI may not mount a
b
deficit (particularly in the elderly). sympathetic response to hypovolaemia. Fluid should be
o
given based on estimated blood loss.
A m ict ct
© e V V i
Vi V i b l
c e A m
n
Spinal Cord Injury (SCI) Management CPG A0804
u la a © a ©
b r i ri
? Status Assess
8
• Potential SCI • Major Trauma Criteria
m c t o c to
? If Pt Meets Major Trauma Criteria ? Does Not Meet Major Trauma Criteria
i i
✔ Action • Has Positive Mechanism of Injury
V V
• Manage airway as appropriate ✔ Action
• Provide spinal immobilisation • If any of the following present then provide spinal
e
• Administer pain relief as required immobilisation
e
- Age > 55 years
A
• Immobilise and support fractures
c
- History of bone disease (e.g. osteoporosis,
c
• Manage hypovolaemia as per osteoarthritis or rheumatoid arthritis)
n
CPG A0801 Hypovolaemia - Unconscious or altered conscious state (GCS < 15)
n
• Transport without delay to an appropriate receiving or period of loss of consciousness
la a ©
hospital in accordance with Trauma Triage Guidelines - Drug or alcohol affected
l
- Significant distracting injury e.g. extremity fracture
or dislocation
u a
- Spinal column pain / bony tenderness
i
- Neurological deficit
b r
• If none of the above present then spinal
o
immobilisation / cervical collar not necessary
m t
• If any doubt exists as to history or the above
c t
assessment, or if there is inability to adequately
A i
assess the Pt, then spinal immobilisation must be
c
provided
V i
• This Guideline is not to be used for Paediatric Pts
©? Status
e Stop
V
Spinal Cord Injury (SCI) Management CPG A0804 121
Vi V i b l
c e A m
n
Adult Burns CPG A0805
u la a © a ©
b r i ri
Wallace Rule of Nines General Care
o
• Cool burn area
m t o
- Running water if possible
t
- Normal Saline or wet combine as substitute
c
- Avoid/eliminate shivering
i c
- Avoid ice or ice water
i
• Cover cooled area with appropriate dressing
V V
- Ensure cling wrap is applied longitudinally to allow for
swelling.
e
• Assess Pt temp. and manage as required.
e
• Cause should be given when considering fluid
c c A
replacement for Pt with airway burns. Fluid therapy
can lead to extensive systemic oedema and airway
n n
compromise. Consider early intubation.
la ©
• Volume replacement is for burn injury only. Manage
a
other injuries accordingly including requirement for
l
additional fluid.
a
• Consider additional fluid for major electrical burn.
b u o ri
A m ict ct
© e V V i
Vi V i b l
c e A m
n
Adult Burns CPG A0805
u la a © a ©
b r i ri
? Status Assess mechanism of burn and burn injury
8
• Evidence of burn injury • Assess burn injury
m o o
- Airway injury
t t
- Degree of burn injury - Refer to Wallace Rule of Nines
- Burn classification e.g. full/partial thickness
V ic Vic
? Initial burn management
Action
✔
e
• Cool burn area • Analgesia as per CPG A0501 Pain Relief
e A
• Cover cooled area with appropriate dressing • Assess Pt temp. and manage as required
n c n c ©
? All other burn presentations ? Partial or full thickness burns > 15%
la a
Action
✔ Action
✔
l
• BLS/first aid • Normal Saline IV fluid replacement
u a
- % of burn area x wt (kg) = volume given in ml
i
• Transport to an appropriate facility
over 2hr. from time of burn
b r
• Transport to an appropriate facility
A m cto t
© V i V ic
? Status
Adult Burns CPG A0805 123
Vi V i b l
c e A m
n

Fracture Management CPG A0806
u la a © a ©
b r i ri
Principles of Fracture Management
m o o
• General principles for Fracture Management
t t
- Control external haemorrhage
c
- Support the injured area
i c
- Immobilise the joint above and below the fracture site
i
- Evaluate and record neurovascular condition distal to the fracture site
V V
• Provide appropriate pain relief and correct hypovolaemia.
• Appropriate splinting can assist in pain reduction and arrest of haemorrhage.
c e e A
• Before and after splinting
c
- Realign long bone fractures in as close to normal position as possible.
n
- Open fractures with exposed bone should be irrigated with a sterile isotonic solution prior to realignment
n
and splinting.
la ©
- If joints are involved there is an increased possibility of neurovascular impairment and reduction is not
a
recommended.
l
- Femoral shaft fractures and fractures of the upper 2/3 of the tibia and fibula should be managed with
a
a traction splint unless there are distal dislocations or fractures.
u i
• In suspected fractures of the pelvis the legs should be anatomically splinted together (to internally rotate
r
the feet) and the pelvis splinted with a sheet wrap or other appropriate device.
b o
• Pts who meet major trauma criteria are time critical but appropriate splinting should be considered part of
essential Ambulance management and should not be compromised in order to decrease time at scene.
A m ict ct
© e V V i
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Hypothermia/Cold Exposure CPG A0901
u la a © a ©
b r i ri
o
• Hypothermia is insidious and rarely occurs in isolation. • Shelter from wind in heated environment.
m t o
Where the Pt is in a group environment other members • Remove all damp or wet clothing.
t
of the group should be carefully assessed for signs of
• Gently dry Pt with towels / blankets.
c
hypothermia.
i c
• Wrap in warm sheet / blanket - cocoon.
i
• Arrhythmia in hypothermia is associated with
temp. below 33˚C. • Cover head with towel / blanket - hood.
V V
• Atrial arrhythmias, bradycardia, or atrioventricular block • Use thermal / space / plastic blanket if available.
do not generally require treatment with anti-arrhythmic • Only warm frostbite if no chance of refreezing prior to
e
agents unless decompensated, and resolve on arrival at hospital.
e
rewarming. • Assess BGL if altered conscious state.
c c A
• Defibrillation and cardioactive drugs may not be
effective at temp. below 30˚C. VF may resolve Warmed fluid
n n
spontaneously upon rewarming. • Normal Saline warmed between 37 - 42˚C should be
given to correct moderate / severe hypothermia and
la ©
• The onset and duration of drugs is prolonged in
a
hypothermia and the interval between doses is maintain perfusion if available. Fluid < 37˚C could be
l
therefore doubled, for example doses of Adrenaline detrimental to Pt.
a
become 6 minutely.
b u o ri
A m ict ct
© e V V i
Vi V i b l
c e A m
n
Hypothermia/Cold Exposure CPG A0901
u la a © a ©
b r i ri
?
Status Assess
8
• Hypothermia • Mild Hypothermia 32 - 35˚C
m t o o
• Moderate Hypothermia 28 - 32˚C
t
• Severe Hypothermia < 28˚C
c c
• If alteration to Cardiac Arrest Mx required
V i Vi
? Non cardiac arrest ? Cardiac Arrest
e
• Moderate/Severe Hypothermia < 28 - 32˚C
e A
• Warmed Normal Saline 10ml/kg IV
c c
- Repeat 10ml/kg IV (max. 40ml/kg) ?
> 32˚C ? 30 - 32˚C ?
< 30˚C
to maintain perfusion
n n
Action
✔ Action
✔ Action
✔
• Avoid drug Mx of cardiac arrhythmia
©
• Standard Cardiac • Double dosage • Continue CPR and rewarming
la a
unless decompensated and until Arrest Guidelines intervals in until temp. > 30˚C
l
rewarming has commenced relevant cardiac • One defibrillation shock only
a
arrest Guideline
u
• One dose of Adrenaline
i
- Do not rewarm
r
beyond 33˚C if • One dose of Atropine
b
ROSC • One dose of Amiodarone
o
• Withhold NaHCO3 8.4% IV
A m ict ct
©? Status
e V Stop
V i
Hypothermia/Cold Exposure CPG A0901 127
Vi V i b l
c e A m
n
Environmental Hyperthermia Heat Stress CPG A0902
u la a © a ©
b r i ri
o
• During cooling, Pt should be monitored for the onset
m t o
of shivering. Shivering may increase heat production
t
and cooling measures should be adjusted to avoid
c
its onset.
i ic
• Gentle handling of Pt is essential. Position flat or
lateral and avoid head up position to avoid causing
V V
arrhythmias.
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e
Vi V i b l
c e A m
n
Environmental Hyperthermia Heat Stress CPG A0902
u la a © a ©
b r i ri
? Status Assess
8
• Hyperthermia / Heat stress
o
• Accurately assess temperature
m t o
• BGL if altered conscious state
t
V ic Vic ? Requires active cooling

✔ Action
e
• Cooling techniques - initiated and maintained until temp. is < 38˚C
e
- Shelter / remove from heat source - Remove all clothing except underwear
c c A
- Ensure airflow over Pt - Apply tepid water using spray bottle or wet towels
• Treat inadequate perfusion per CPG A0702 Hypovolaemia
n n
- Cooled fluid preferable if available
la ©
• Treat low BGL as per CPG A0801 Hypoglycaemia
la
• Airway and ventilation support with 100% O2 as required
b u ria ? Adequate response ? Poor response after 10/60
o
✔ Action • Severe cases - Temp. > 39.5˚C
m t
• BLS • GCS < 10
c t
• Transport ✔ Action
A i c
• Consider intubation as per CPG A0302
i
Endotracheal Intubation
V
• If intubated, sedation and paralysis essential to
© V
prevent shivering and reduce heat production
? Status
Environmental Hyperthermia Heat Stress CPG A0902 129
Vi V i b l
c e A m
la n © ©
bu r ia ri a
m c t o c to
V i Vi
n c e ce A
la la n ©
b u ria
A m cto t
© V i V ic
e

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Vi V i b l

Clinical Approach CPG A0101

© e V V Clinical Approach CPG A0101 1

Clinical Approach CPG A0101

Clinical Approach CPG A0101

© e V V i Clinical Approach CPG A0101 3

Perfusion and Respiratory Assessment CPG A0102

Perfusion Status Assessment CPG A0102

Respiratory Status Assessment CPG A0103

Conscious State Assessment CPG A0104

© e V V i Conscious State Assessment CPG A0104 7

Actual Time Critical Emergent Time Critical

• Possible major trauma

• Any of the following: • May have Pattern of Injury

Assess Pattern of Injury

-  Major compound fracture or open dislocation

Potentially Time Critical Not Time Critical

• Any of the following: • Vital Signs are normal

l • No Pattern of Injury • No Pattern of Injury

Actual Time Critical Emergent Time Critical

• Possible major trauma

• May have Pattern of Injury

Respiratory Rate < 40 or > 60 < 20 or > 50 Assess Pattern of Injury

t N/A < 60 mm Hg • Any of the following:

BP < 70 mm Hg < 80 mm Hg • Specific Injuries

-  Major compound fracture or open dislocation

Potentially Time Critical Not Time Critical

• Any of the following: • Vital Signs are normal

Actual Time Critical Emergent Time Critical

• Possible Medical time critical

• Any of the following: • May have Significant Medical Condition

Assess Medical Condition

© e V Mental Status Assessment CPG A0106 15

Stroke Assessment CPG A0107

Cardiac Arrest CPG A0201

ria ? PEA persists ? Asystole

Cardiac Arrest (ROSC Management) CPG A0202

Cardiac Arrest (ROSC Management) CPG A0202

Withholding and/or Ceasing Pre-hospital resuscitation CPG A0203

Laryngeal Mask Airway (LMA) CPG A0301

Laryngeal Mask Airway (LMA) CPG A0301

Endotracheal Intubation Guide CPG A0302

Endotracheal Intubation Guide CPG A0302

Endotracheal Intubation Indications, Precautions, C/Is CPG A0302

Endotracheal Intubation Indications, Precautions, C/Is CPG A0302

Endotracheal Intubation Preparation CPG A0302

Endotracheal Intubation Drugs CPG A0302

Endotracheal Intubation Drugs CPG A0302

Endotracheal Intubation Insertion of ETT CPG A0302

Endotracheal Intubation Insertion of ETT CPG A0302

V Vi ? Insertion and checks of ETT

Endotracheal Intubation Care and Mx. of Intubated Pt CPG A0302

Endotracheal Intubation Care and Mx. of Intubated Pt CPG A0302

Failed Intubation Drill CPG A0303

Cricothyroidotomy CPG A0304

Acute Coronary Syndrome CPG A0401

Acute Coronary Syndrome CPG A0401

Acute Coronary Syndrome General Management Principles CPG A0401

Acute Coronary Syndrome General Management Principles CPG A0401

Bradycardia CPG A0402

Bradycardia CPG A0402

Tachyarrhythmias - Adult CPG A0403

Supraventricular Tachyarrhythmias (SVT) CPG A0403

- Major compound fracture or open dislocation

BP < 70 mm Hg < 80 mm Hg • Specific Injuries

- Major compound fracture or open dislocation