Clinical Practice Guidelines Paramedic V33 - March 2019

Clinical Practice Guidelines
for Ambulance Care in
UNCONTROLLED WHEN PRINTED

Western Australia
Paramedic
Version 33
Published: June 2018
© Copyright St John Ambulance Australia (Western Australia) Inc.

TABLE OF CONTENTS
June 2018
Preface
CPG / Skill Key
Summary Of Changes
General
1.1A Patient Assessment May 2014

1.1B Patient Charter May 2014
1.1C Patient Consent May 2014
1.1D Authority to Practice February 2017
1.1E Major Trauma Guidelines July 2016
1.1F Inter-Facility Mental Health Transfer March 2016
1.5 Use Of Oxygen February 2017
1.6 Relief Of Pain November 2016
1.7 Bridge House – Alcohol and Drug Intoxication May 2014
1.8 Silver Chain Priority Assessment (PRA) July 2017
1.9A Urgent Care Centre June 2018
Neurological
2.1 Fainting (Syncope) November 2011
2.2 Unconsciousness July 2017
2.3 Seizures July 2017
2.4 Stroke/Cerebro-Vascular Accident (C.V.A) July 2017
2.5 Disturbed and Abnormal Behaviour July 2017
Respiratory
3.1 Dyspnoea and Respiratory Distress September 2012
3.2 Asthma July 2017
3.3 Chronic Obstructive Pulmonary Disease July 2017
3.4 Ventilatory Emergencies November 2016
3.5 Advanced Airway Management July 2017
3.6 Croup July 2016
3.7 Choking July 2017
Circulation
4.1 Chest Pain/Acute Coronary Syndrome July 2016
4.2 Cardiac Dysrhythmias July 2017
4.3 Acute Cardiogenic Pulmonary Oedema September 2011
4.4 Chronic Congestive Cardiac Failure (CCF) (Right Heart Failure) June 2002
4.5.1 Hypovolaemic Shock July 2017
© Copyright St John Ambulance Western Australia Ltd Paramedic - Table of Contents

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4.5.2 Cardiogenic Shock September 2011
4.5.3 Neurogenic Shock September 2011
4.5.4 Anaphylactic Shock July 2017
4.5.5 Septic Shock September 2011
4.6A Cardiac Arrest – Adult July 2017
4.6B1 Cardiac Arrest – Infant - Paediatric July 2017
4.6B2 Newborn Life Support July 2017

4.6C Post Resuscitation Care (ROSC) July 2016
4.6D Determination of Death (ROLE) July 2017
Trauma
5.1 Trauma: Management Principles February 2014
5.2 Spinal Trauma November 2016
5.4 Haemorrhage July 2017
5.5 Limb Trauma February 2014
5.6 Pelvic Trauma February 2014
5.8 Traumatic Brain Injury July 2017
5.9 Thoracic Trauma February 2014
5.11 Abdominal Trauma July 2017
5.15 Burn Trauma November 2016
5.16 Pneumothorax June 2018
Obstetrics and Gynaecological
6.1 Management of Obstetric Emergencies July 2017
6.2A Haemorrhage During Pregnancy July 2017
6.2B Pre-Eclampsia and Eclampsia July 2017
6.2C Preterm Labour and Birth July 2017
6.3 Normal Birth July 2017
6.4A Birthing Complications / Difficult Birth - Cord Prolapse July 2017
6.4B Birthing Complications / Difficult Birth - Shoulder Dystocia July 2017
6.4C Birthing Complications / Difficult Birth - Breech Presentation July 2017
6.5 Postpartum Haemorrhage (PPH) July 2017
Metabolic
7.1A Hypoglycaemia March 2012
7.1B Hyperglycaemia March 2012
7.2 Home Renal Dialysis Emergencies June 2002
Environmental
8.1 Hyperthermia March 2013
8.2 Hypothermia July 2017

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8.3 Immersion July 2017
8.4 Diving Emergencies July 2015
8.5 Radiation Exposure September 2002
Anaphylaxis
9.1 Anaphylaxis – Severe Allergic Reaction July 2017
Toxicology
10.1 Poisons and Overdoses July 2017

10.2A Snake Bite July 2017
10.2B Spider and Insect Bites July 2017
10.2C Jellyfish and Fish Venom July 2017
10.2D Marine Creatures: Blue-Ringed Octopus and Cone Shell Bites
and Stings July 2017
10.3 Smoke or Noxious Gas Inhalation November 2005
10.4 Carbon Monoxide Poisoning November 2005
Critical Care Paramedics
CCP Guideline 5 – Cardiac Dysrhythmias July 2017
CCP Guideline 7 – Non-invasive Pacing November 2016
CCP Guideline 8 – Rapid Sequence Induction July 2017
CCP Guideline 9 – Naso/Orogastric Tube January 2013
Special Operations Paramedics
PSO Guideline 1 – Wound Management with Steri-Strips November 2016
PSO Guideline 2 – Eye Washing and Irrigation November 2016
PSO Guideline 3 – Non-Steroidal Anti-Inflammatory Drugs November 2016
PSO Guideline 4 – Tension Pneumothorax July 2017
Primary Care
Primary Care Guideline 1 – Burns December 2010
Primary Care Guideline 2 – ECG December 2010
Medications
Medications Matrix June 2018
11.4 Aspirin (Acetylsalicylic Acid) (Unscheduled) July 2017
11.5 Adrenaline (Epinephrine) (S3) July 2017
11.6 Adrenaline Autoinjector ‘Epipen®’ (S3) July 2017
11.7 Amiodarone (S4) July 2017
11.9 Atropine Sulphate (S4) July 2017
Codeine Containing Drugs (S4) January 2011
11.10 Cophenylcaine (S2) July 2017
11.11 Dextrose 5% (Unscheduled) September 2011

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11.13 Fentanyl (S8) July 2017
11.15 Glucagon (S3) March 2012
11.16 Glucose Oral Gel (Unscheduled) March 2012
11.17 Heparin Sodium (S4) September 2012
11.18 Ipratropium Bromide (Atrovent) (S4) July 2017
11.19 IV Crystalloid Solutions (Unscheduled) July 2017
11.20 Intravenous Glucose 10% (unscheduled) July 2017

11.21 Glyceryl Trinitrate (GTN) (S3) July 2015
11.23 Ketamine (S8) July 2017
11.24 Lignocaine 1% (Xylocaine) (S4) September 2011
11.25 Methoxyflurane (S4) July 2016
11.26 Metoclopramide (Maxolon) (S4) August 2008
11.27 Midazolam (Hypnovel) (S4) November 2016
11.28 Morphine Sulphate (S8) June 2018
11.29 Naloxone (Narcan) (S4) June 2018
Non-Steroidal Anti-Inflammatory Drugs November 2016
11.30 Ondansetron (S4) July 2016
11.31 Paracetamol (Acetaminophen) (S2*) July 2017
11.32 Packed Red Cells (Unscheduled) June 2018
11.33 Rocuronium Bromide (Esmeron) (S4) July 2017
11.34 Salbutamol Sulphate (Ventolin) (S3) June 2018
11.35 Suxamethonium Chloride (S4) January 2013
11.36 Prednisolone Oral (S4) June 2018
11.37 Metaraminol Tartrate (Aramine) (S4) June 2018
Infection Control Policy
12.1 Standard and Additional Precautions and Infectious Disease June 2018
12.2 Hand Hygiene and Skin Care July 2017
12.3 Transport of a Patient March 2016
12.4 Personal Protective Equipment (PPE) March 2016
12.5 Handling and Disposal of Sharps March 2016
12.6 Cleaning of Reusable Equipment and Surfaces March 2016
12.7 Immunisation Pre-Employment Health Screening and Pregnancy March 2016
12.8 Management of Occupation Exposure March 2016
12.10 Infection Control CPG Glossary March 2016

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PREFACE
This publication is specifically for use by personnel trained by The College of Pre-
Hospital Care of St John Ambulance Western Australia Ltd. (St John Ambulance),
and for no other purpose whatsoever:
Officers may use only those Clinical Practice Guidelines for which they have

been trained and authorised by St John Ambulance.
The extent and standard of the clinical care practiced within St John Ambulance is
established through the provision of the Clinical Practice Guidelines. The delivery of
patient care in accordance with these guidelines is cover by the organisation’s
“Professional Indemnity” insurance policy.
Any person issued, purchasing or otherwise acquiring a copy of this publication does
so on the specific understanding that it is that person’s sole responsibility to take
action in updating their edition of the Clinical Practice Guidelines. St John
Ambulance has no obligation to update or advise of changes except to its own staff.
AUTHORITY
TONY AHERN
CHIEF EXECUTIVE OFFICER

DISCLAIMER
Once this document is printed and / or downloaded, it is uncontrolled. It is advised
that periodically, all St. John Ambulance clinical staff refer to the Clinical
Governance intranet page to ensure they have the most up to date version identified
by the specific version number.

Each page has been watermarked as a reminder that once printed / downloaded, it
is uncontrolled.

CPG / SKILL KEY
It has been the intent of Clinical Governance to embrace safety into our design of our CPG’s;
previously this was demonstrated by the precautions / contra-indication sections of the CPG.
In recent times we have endeavoured to build this principle into the flow charts.
At a glance we want to utilise colours that we see daily with associated meanings, as per the
examples below:

Grey – neutral – setting context / problem statement
Green - safe zone / safe guide sign to follow / general

requirement.
Blue – mandatory action as per PPE symbols.

This is an action that is required in such a circumstance
Amber/Yellow – caution, consideration and information that is

relevant in terms of patient safety.
Red - warning, stop, contra-indication, critical information.
The “red flag” is a metaphor that indicates / draws attention to a

particular issue / problem requiring special attention /
consideration.
The ‘pinch point’ symbol indicates a point at which it is possible

for a person or part of person’s body to be caught between
moving parts. This symbol is used to caution users from keeping
body parts clear when equipment is in operation.
TRAFFIC LIGHT SYSTEM:

Another use of the colour association has been the inclusion of the red / amber / green risk
level tool, otherwise referred to as the traffic light system.
The uses of such systems have become wide spread in the hospital environment and it is
mainly directed towards assessing patient risk in terms of patient deterioration. This system
has been incorporated into the SJA ePCR environment through the PEWS scoring system. It
has now also been incorporated into the CPG and Quick Reference Guides (pocket cards).
Red high risk - life threatening / poor outcome expected
Amber intermediate risk – potential to deteriorate
Green low risk – stable / no critical action required

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PARAMEDIC SUMMARY OF CHANGES
June 2018
Section
Updated/Added Details of Change
General Amendment to acceptance criteria of

1.9A Urgent Care Centre
patient
Reference to new finger thoracostomy
Trauma 5.16 Pneumothorax skill in management of patients with

tension pneumothorax
Included the schedule for each
medication, changes to CPG 11.6, 11.9,
Medications Matrix 11.19 & 11.36 for AO, AO G1, AO G2,
Added the Medication Administration
Rights.
Addition information in description and
11.28 Morphine Sulphate dosage increase for adults for sedation to
maintain intubation (CCP Only)
Amendments made to adult IV/IO dosing
11.29 Naloxone as per Medical Practice Committee (MPC)
recommendations
- Paediatric management added and
Medications blood sample purple and red tubes
removed.
11.32 Packed Red Cells
- Additional blood checks included and
time changed for temperature checks.
- Admin changes.
Amendment to not allow administration to
11.34 Salbutamol
patients under the age of 12 months.
Weight-based calculation and maximum
11.36 Prednisolone Oral single dose of 25mg added to
management/dose; chart as a guide only
Infusion rates added as per MPC
11.37 Metaraminol Tartrate (Aramine)
recommendations (CCP Only).
- Minor changes to the wording.
- Expansion of the standard and
transmission based precautions
section
12.1 Standard and Transmission
Infection Control - Additional diseases added to the
Based Precautions and Infectious
Policy Specific Infectious Diseases Table
Disease
- Minor changes to the PPE
requirements for contact precautions
(removal of the necessity to wear a
facemask)
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GENERAL
1.1A PATIENT ASSESSMENT
May 2014
S.O.A.P. System:

 Subjective:
PC - Presenting condition information from patient regarding
their main complaint.
HPC – History of the main complaint including:
Onset, Location, Characteristics, Alleviating and Aggravating
factors
Quality of pain, Radiation
Duration of symptoms or signs
 Objective:
Scene and patient observations including:
Environment
Vital Signs
Previous Medical History
Medications
Allergies
 Assessment:
Focussed enquiry of the chief complaint:
Physical Examination
Inspection
Auscultation
Palpation
Review of systems to develop differential diagnosis
© Copyright St John Ambulance Western Australia Ltd. Table of Contents

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 Plan:
How you plan to manage these or treatment provided.
Impress
Immediate and secondary plans
Results of commencing interventions
© Copyright St John Ambulance Western Australia Ltd. 1.1A Patient Assessment

Review Date: May 2019
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GENERAL
1.1B PATIENT CHARTER
May 2014
Patient Charter:

 Access: Patients have a right to healthcare and access to
services to meet their health care needs.
 Safety: Patients have a right to receive safe and high quality

care provided with skill and competence.
 Respect: Patients have a right to be shown respect, dignity and

consideration in reference to their cultural beliefs, values
and personal characteristics.
 Communication: Patients have a right to be informed about services,

treatment options and costs in a clear and open way.
 Participation: Patients have a right to be included in decisions and

choices about their care.
 Privacy: Patients have a right to privacy and confidentiality of

their personal information.
 Comment: Patients have a right to comment on their care and to

have their concerns addressed properly and promptly.
Reference: Australian Charter of Healthcare Rights.

Note: Pre-hospital requests for information regarding costs should be directed to the accounts
and billing department in all circumstances.
© Copyright St John Ambulance Western Australia Ltd. 1.1B Patient Care

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GENERAL
1.1C PATIENT CONSENT
May 2014
Patient Consent:

Consent is a patient’s agreement for health professionals to provide treatment.
Patients should be provided with all information that will assist them to reach an
informed decision, which is whether or not to consent to the proposed
assessment or treatment. It is always the patient’s right to determine whether or
not to consent to receiving the treatment recommended by the health
professional.
If the patient refuses to agree to the proposed treatment, it is essential that this
refusal and the circumstances in which consent was refused are properly
recorded in the patient’s health care record.
Treatment in an emergency:
 A “medical emergency” is defined as a situation where urgent treatment is
necessary to avert a serious and imminent threat to the patient’s life, or
physical or mental health.
 In the case of a medical emergency the requirements to obtain consent

differ from the above. In a medical emergency where a patient is
competent there is a requirement to address the consent process within
the time constraints of necessity and the patient’s best interest.
 In a medical emergency where a patient is incompetent and thus not

able to consent (because of their clinical condition, or under 12 years old
with no parent or legal guardian present), treatment that is immediately
necessary to save the patient’s life or prevent a serious deterioration in
their condition can be provided without consent.
Reference: The office of Safety and Quality in Healthcare (OSQH WADOH)
© Copyright St John Ambulance Western Australia Ltd. 1.1C Patient Consent

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© Copyright St John Ambulance Western Australia Ltd

GENERAL
1.1D AUTHORITY TO PRACTICE
February 2017
Authority to Practice:
Pre-hospital clinical care is undertaken within St John Ambulance by a variety of Health Care
Professionals in many differing roles, responsibilities and locations. This document serves to
outline the requirements for authorisation to practice within St John Ambulance WA (SJA). This is

to ensure compliance with the relevant clinical governance and professional / medical indemnity
requirements.
Ambulance Paramedics
 Ambulance Paramedics employed by SJA are authorised to practice within the role specific
Clinical Practice Guidelines and skills as published by SJA. Where Paramedics employed by
SJA undertake volunteer roles within SJA they are authorised to practice at a level equivalent
to their employed status.
Ambulance Officers
 Ambulance Officers employed by SJA are authorised to practice within the role specific
Clinical Practice Guidelines and skills as published by SJA under the supervision of a senior
paramedic. Where Ambulance Officers employed by SJA undertake volunteer roles they are
authorised to practice under the specific volunteer Clinical Practice Guidelines as published
by SJA and appropriate to their level of volunteer training as outlined in the outlined in the
medication and skills matrices.
Industrial Paramedics
 Industrial Paramedics employed by SJA are authorised to practice within the role specific
Clinical Practice Guidelines and skills as published by SJA. Where Industrial Paramedics
employed by SJA undertake volunteer roles within SJA they are authorised to practice within
SJA under the specific volunteer Clinical Practice Guidelines as published by SJA and
appropriate to their level of volunteer training as outlined in the outlined in the medication and
skills matrices.
Medic
 Medics employed by SJA are authorised to practice within the role specific Clinical Practice
Guidelines and skills as published by SJA. Where Medics employed by SJA undertake
volunteer roles they are authorised to practice within SJA under the specific volunteer Clinical
Practice Guidelines as published by SJA and appropriate to their level of volunteer training as
outlined in the outlined in the medication and skills matrices.
Specialist Ambulance Paramedic Roles

 Ambulance Paramedics undertaking specialist roles (Critical Care, Industrial, Special
Operations, Community or Clinical Support) employed by SJA are authorised to practice
within the role specific Clinical Practice Guidelines and skills as published by SJA. Such
authority to practice applies only when directly engaged in undertaking these specialist
paramedic roles as designated by SJA.
© Copyright St John Ambulance Western Australia Ltd. 1.1D Authority to Practice

Review Date: February 2022
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GENERAL
1.1E MAJOR TRAUMA GUIDELINE
July 2016
MAJOR TRAUMA GUIDELINE:

In accordance with the trauma services plan developed by the Department of Health, patients suffering
major trauma should be taken to hospitals designated as Major Trauma Centres. Within the plan Royal Perth
Hospital (RPH) is designated the State Major Adult Trauma centre and Princess Margaret Hospital (PMH) the
State Major Paediatric Trauma centre. Sir Charles Gairdner (SCGH) and Fiona Stanley Hospital (FSH) are
designated metropolitan trauma services.
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many
causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, and gunshot wounds.
Depending on the severity of injury, quick management and transport to the appropriate Trauma Centre may
be necessary to prevent loss of life or limb.
The following should be followed in regards to patients with suspected major trauma:
Adult:
1. All patients with major trauma should be taken directly to RPH where possible.
2. Where the patient’s condition appears imminently life threatening, diversion to the nearest
appropriate emergency department for stabilisation should be undertaken.
3. Trauma patients with obvious spinal injuries, who are pregnant or have major pelvic injuries, should
always be taken to RPH except in imminent life threatening situations where stabilisation is required
prior to transfer to RPH.
4. Burns: Patients should be taken to FSH where possible. Should significant major trauma also be
present, they should be taken to RPH.
5. All country hospital transfers of major adult trauma should be taken to RPH. RFDS transfers will have a
designated receiving hospital and crews should follow this.
Paediatrics:
6. All major paediatric (patients age less than 14 years) trauma (including burns) should be taken to PMH
unless urgent stabilisation is required at the nearest appropriate emergency department prior to
transfer to PMH.
Patients not suffering major trauma as defined in this guideline are to be transported to the hospital
designated by the ANC. Should the patient need specialised care, as defined by the current Transport
Circular; Ambulance Distribution to Hospitals and the Clinical Matrix, the ANC should be contacted to inform
them of the change of destination.
Clinical Matrix is located at Clinical Governance Aide Memoire.
© Copyright St John Ambulance Western Australia Ltd 1.1E Major Trauma Guideline
Review Date: July 2021
Page 1 of 4
CLINICAL DECISION MAKING TOOL FOR TRAUMATIC CARDIAC
ARREST / PERI ARREST
OBJECTIVE:
Clinical assist tool to aid on scene times and manage patients to an extent that allows rapid transport to a
tertiary facility. Rapid transport of traumatic cardiac arrest or peri arrest patients to definitive care whereby
bloods, surgery and trauma surgeons are available allows for a higher and improved recovery rate.

PROCEDURE:
The attached time lined guide assist to highlight skills which are appropriate to traumatic cardiac arrest
cases. The skills are limited but prove to be rapid and effective. Using the timeline to establish which skill has
to be performed within that proposed time will assist with on scene times of less than 10 minutes. Failure to
perform the skill should not prevent delayed on scene times, i.e.: failure to secure an IV within the allocated
5 minute mark should not delay extrication.
PRECAUTIONS / NOTES:
Cardiac arrest caused by catastrophic haemorrhage or of trauma related aetiology is seldom rectified in the
prehospital environment. Key interventions are surgical in nature and or the administration of blood
products, neither of which are available pre-hospital. The best possible outcome for these patients is rapid
transport to these facilities.
In accordance with the trauma services plan developed by the Department of Health, patients suffering
major trauma should be taken to hospitals designated as Major Trauma Centres. Within this plan; Royal
Perth Hospital (RPH) is designated the State Major Adult Trauma Centre.
Hospital notification ideally occurs once the decision is made that the patient will be transported under
priority conditions. Consider State Trauma Unit (STU) if within 20 minutes from Royal Perth Hospital (RPH) on
priority driving conditions.
REFERENCES / AUTHORITY:
Director of Trauma Services Royal Perth Hospital / State Director of Trauma (WA).
European Resuscitation Council Guidelines for Resuscitation 2015, Section 4. Cardiac arrest in special
circumstances.
Luna GK, Pavlin EG, Kirkman T, Copass MK, Rice CL. Hemodynamic effects ofexternal cardiac massage in
trauma shock. J Trauma 1989;29:1430–3.170. Willis CD, Cameron PA, Bernard SA, Fitzgerald M.
Cardiopulmonary resuscita-tion after traumatic cardiac arrest is not always futile. Injury 2006;37:448–54.171.
Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the sur-vivors? Ann Emerg Med
2006;48:240–4.172. Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest asso-ciated
with trauma. Resuscitation 2007;75:29–34.
Page 2 of 4
Identify Trauma
ELAPSED TIME
Obvious non -reversible Cause – Do not resuscitate Non Traumatic Cause- Universal ALS algorithm
DAMAGE CONTROL AND MANAGEMENT OF REVERSIBLE CAUSES ARRIVAL
A: Insert OPA / NPA / LMA with c-spine control (Time allows

for basic interventions only)
B: BVM Ventilations x2. Maximize Oxygenation (Skill 314)

Bilateral chest decompression in suspected
pneumothorax / chest trauma. (Clinical Skill 808)
C: Stop any life threatening haemorrhage.

Consider CAT (Clinical Skill 915)
Consider T-Pod (Clinical Skill 913) 5 MIN TREATMENT
Establish IV / IO Access (Limited to 1 attempt).
D: Apply Defib Pads. Only 7.5% of traumatic cardiac arrest are

initially in VF or VT
Compressions- Chest compressions should not delay the

treatment of reversible causes listed above or transportation.
In cardiac arrest caused by hypovolaemia, cardiac tamponade
or tension pneumothorax, chest compressions are unlikely to
be as effective as in normovolaemia patients.
PREPARE FOR EXTRICATION

Prepare for IMMEDIATE rapid extrication. Secure patient to 7 MIN PREPARE
scoop or load onto stretcher
NOTIFY RECEIVING HOSPITAL NOTIFY

9 MIN
HOSPITAL
TRANSPORT
Perform only lifesaving interventions.
(e.g.: CPR, IV access, Fluids, and Adrenaline) 10 MIN TRANSPORT
Immediate transport to appropriate hospital.
BLUNT TRAUMA
Prolonged CPR in BLUNT trauma cardiac arrest after reversible causes have been addressed is almost
never associated with a good outcome. If delivery to an Emergency Department cannot be achieved within
25 minutes from arrival on scene, it is reasonable to terminate resuscitation if no ROSC after 10 minutes of
resuscitation post correction of reversible causes / damage control measures and termination criteria are
met (CPG 4.6D).
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MAJOR TRAUMA CRITERIA
In accordance with the trauma services plan developed by the Department of Health, patients
suffering major trauma should be taken to hospitals designated as Major Trauma Centres.
Major Trauma should be considered in any one of the following criteria:

MECHANISM
• MBA > 30 km/h with injuries.
• MVA > 60 km/h with injuries.
• Ejection from vehicle
• Penetrating injury to head, neck, torso or proximal extremities.
• Fall > 3m
• Fatality on scene whereby the patient was in the same vehicle.
• Pedestrian or cyclist with speed impact > 25km/h
ANATOMICAL CRITERIA
• Flail Chest
• Pelvic Fractures
• Amputation / crush Injury proximal to hand and foot.
• 2 or more long bone fractures
• Suspected Spinal Injury
• Polytrauma
• Open or depressed skull fracture
• De-gloving or mangled extremity proximal to hand and foot.
Page 4 of 4
GENERAL
1.1F INTER-FACILITY MENTAL HEALTH
TRANSFER
March 2016
INTER-FACILITY MENTAL HEALTH TRANSFER

People with mental illness may need to be taken to or from a hospital or mental health

service. Conveyance choices should be appropriate to the person and their circumstances
and should use the least restrictive option possible. At times, ambulances are the most
appropriate transport option.
The Mental Health Act 2014 (2014 Act) sets out the requirements associated with the
management and transport of a person with mental illness.
A person who is on a transport order may be transported by ambulance, escorted by a police
officer or mental health transport officer. A mental health transport officer is a specially trained
person who is employed to undertake transport orders. This means that if you are asked to
transport someone on a transport order, either a police officer or a transport officer will
accompany you. If a patient is on a Form 1A only, then they can be transported without an
escort.
Transporting patients under the Mental Health Act 2014 (2014 Act):
 Voluntary patients – as per normal medical calls
 Involuntary patients – need to be accompanied by the correct forms.
Current Forms used:
Mental Health Act 2014 form Mental Health Act 1996 form Mental Health Act 2014
name number equivalent form number
Referral for examination by

Form 1 Form 1A
psychiatrist
Detention order No equivalent Form 3A
Continuation of detention No equivalent Form 3B
Order that person cannot

No equivalent Form 3E
continue to be detained
Transport order Form 3 Form 4A
Record of search and

No equivalent Form 8A and 8B
seizure
Transfer order Form 7 Form 4C
© Copyright St John Ambulance Western Australia Ltd. 1.1F Inter-Facility Mental Health Transfer
Review Date: March 2021
Page 1 of 2
The 2014 Act specifically allows clinical staff, police officers, and transport officers, to use
reasonable force to apprehend or detain a person. If a clinician or officer requests assistance
from an ambulance officer in apprehending or detaining a person, the ambulance officer is
also authorised to use reasonable force.
An ambulance officer still has the power to use force to prevent harm to a person under a duty
of care. (Refer CPG 2.5)
Further, the Mental Health Act 2014 (2014 Act) does not impact on the provision in the

Criminal Code that provides a defence where force is used in relation to a person with mental
impairment to prevent violence or damage to property.
Where can I find further information?

SJA inter-facility and Mental Health Transfer policy.
eLearning package: www.mhc.wa.gov.au
Clinicians’ Practice Guide: www.chiefpsychiatrist.wa.gov.au
Mental Health Act Handbook: www.mhc.wa.gov.au
Approved forms: www.chiefpsychiatrist.wa.gov.au
© Copyright St John Ambulance Western Australia Ltd. 1.1F Inter-Facility Mental Health Transfer
Review Date: March 2021
Page 2 of 2
GENERAL
1.5 USE OF OXYGEN
February 2017
Description Contra-indications
 Oxygen is a treatment for hypoxaemia  Explosive or flammable environments

and has not been shown to have any
 Normoxia
effect on breathlessness in non-
hypoxaemic patients.

Indications Precautions/Notes
Adults: Oxygen should be titrated to achieve  If the target saturations cannot be

oxygen saturations of between 94 – 98% maintained with the nasal cannula or
(88 – 92% for COPD patients). These are medium concentration mask then change
achieved through the use of different flow to a non-rebreather oxygen mask.
rates and oxygen masks.  Oxygen increases the toxicity in paraquat
Children: All children with significant illness poisoning, target saturations of 88–92%.
or injury should receive oxygen. Newborn  Remember that some conditions can
resuscitation should ideally be commenced affect SpO2 readings e.g. carbon
with room air for the first couple of breaths. monoxide poisoning and cold digits
Management/Dose Complications/Side Effects
 Aim for target saturations of between Patients with acute episodes of COPD are
94 – 98% for critical conditions requiring at risk of developing carbon dioxide
supplemental oxygen, maintained via retention if they are given excessive
bag-valve-mask or reservoir bag. supplemental oxygen. This can cause
 In patients with COPD or other conditions acidosis and subsequent organ dysfunction.
requiring controlled or low-dose
supplemental oxygen aim for target
oxygen saturations range of 88 – 92% (or High oxygen concentrations can lead to
the patient’s prescribed range). increased production of reactive free
radicals resulting in cellular damage. This
 If the patient is hypoxaemic, oxygen
may be responsible for the detrimental
saturations of between 94 – 98% should
effects observed with the use of high flow
be maintained through the use of a mask
oxygen in myocardial infarction and stroke.
or nasal cannulae as appropriate.
At the correct flow rate the following devices
will deliver the following approximate FiO2:
 Nasal cannulae = 24 – 35% at 1– 4 L/min
 Simple face mask = 40 – 60% at 5 – 8
L/min
 Non-rebreather mask = 60 – 100% at 10-
15 L/min
 Bag-valve-mask = 95 – 100% at 15 L/min
© Copyright St John Ambulance Western Australia Ltd 1.5 Use of Oxygen

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© Copyright St John Ambulance Western Australia Ltd 1.5 Use of Oxygen

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GENERAL
1.6 RELIEF OF PAIN
November 2016
Introduction Disposition
Pain is an unpleasant sensation and emotional  Hypoventilation is a common side effect of
response to that sensation. analgesics, all patients receiving pain
 Onset medication should be monitored with a pulse
oximeter.

 Provocation or palliation.
 Quality of pain.
 Region and radiation.
 Severity.
 Time
Assessment Special Considerations

 Choice of pain relief is dependent on the  Beware of the synergistic effects of
aetiology of the pain and the pharmacology combining pain relieving medications.
of the medication.  Allow sufficient time for medication to take
− E.g. GTN are for cardiac chest pain. effect, and follow the time intervals as
 PAINLOGTM is a visual analogue for described in the individual CPG’s.
assessing changes in pain level. Ask the
patient to slide the pointer to match their
pain level and record the score. Reassess
as required.
 Record pain score before and after
treatment to assess effectiveness.
 Regular vital signs recordings are necessary
to confirm effectiveness as well as checking
for possible adverse effects.
Management
 Medications:
− Paracetamol (CPG 11.31).
− Cophenylcaine (CPG 11.10).
− Methoxyflurane (CPG 11.25).
− Fentanyl (CPG 11.13).
− Ketamine (CPG 11.23).
− Lignocaine (CPG 11.24).
− Morphine – CCP only (CPG 11.58).
 Immobilisation/positioning.
Discarding unused S8 medication (and Midazolam) must be

witnessed and countersigned by attendant and credible witness.
© Copyright St John Ambulance Australia (Western Australia) Inc. 1.6 Relief of Pain
Review Date: November 2021
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GENERAL
1.7 BRIDGE HOUSE – ALCOHOL AND DRUG
INTOXICATION
May 2014
Introduction Contra-indications
Bridge House run by The Salvation Army,  Patients who have any injury or acute

provides a sobering facility for patients under illness.
the influence of alcohol or other drugs.  Patients under the age of 18 years.
 Patients who are aggressive or excessively
The facility has the capacity to look after 10 agitated.
male and 4 female patients and is available 24  Patients suffering from an acute mental
hours, seven days per week. health event.
 Patients who are unconscious or unable to
The facility is designed for patients to sleep.
walk with limited assistance.
Assessment Disposition
Patients with the following conditions:  Staff at Bridge House, are not medically
 Requiring a safe environment at which to qualified and Paramedics need to ensure
recover following an excessive intake of that the referral is appropriate.
alcohol or other drugs.
 Patients who can walk with limited or
no assistance.
 Aged 18 years or older.
Management Special Considerations

 Determine if patient meets clinical criteria for  Staff at Bridge House have the right to
referral to Bridge House. refuse a patient.
 Contact Bridge House on # 9227 8086 to  If there are any clinical indications of acute
discuss referral. illness or injury, patients are to be
 If accepted by Bridge House, take patient to transported to hospital as per current
Bridge House 11-15 Wright Street, practice.
Highgate.
 If Bridge House does not accept patient,
transport to hospital as per current clinical
practice.
© Copyright St John Ambulance Western Australia Ltd. 1.7 Bridge House Referral
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GENERAL
1.8 SILVER CHAIN PRIORITY ASSESSMENT (PRA)

July 2017
Silver Chain provides a Priority Response  Patients who cannot wait 4 hours to be

Assessment (PRA) service. The PRA service is reviewed by the PRA service.
available 0700-2100, and patients accepted will  Patients that are medically or mentally
be seen by a nurse with advanced assessment unstable.
skills within 4 hours. Acceptance is assessed
 Patients refusing to use the PRA service.
both medically and from a staffing capacity level
within the PRA Service.  Where hospital care is clearly indicated or a
GP has requested transport to ED.
The service provides acute assessment and
treatment intervention with medical governance.  Patient under the age of 18 years.
The purpose of PRA is to facilitate patient  Patients greater than 22 weeks pregnant.
treatment in their home (or residential care  Patient has a history of alcohol or IV drug
facility) in preference of being treated in an abuse and where the environment is
Emergency Department. potentially unsafe for the PRA service to
visit. Being mindful of the service being a
single nurse visit.
 Patients who have a septic picture such as
increased temperature, pulse, decreased
BP, increased confusion.
 Patients with a PEWS score of 3 or above
must be conveyed to hospital, unless patient
refuses.
Assessment Disposition
Patients with the following conditions:  It is essential that an accurate and adequate
− Problems with catheters/PEGs - history and clinical assessment are
unblocking or re-insertion (not first performed.
change)  This needs to be conveyed when referring
− Acute urinary retention. to the PRA service so they can make a valid
assessment as to whether to accept the
− Uncomplicated infections – cellulitis,
patient.
urinary tract infection, community
acquired pneumonia.  Findings of the assessment and any
management provided need to be well
− Acute wound assessment.
documented on the ePCR.
− Generally deteriorating patients living in
 Emergency care is out of scope for PRA.
Residential Care Facilities.
 Notify COMMS / SOC that you have handed
− Uncomplicated constipation.
the patient over to PRA.
© Copyright St John Ambulance Western Australia Ltd. 1.8 Sliver Chain Priority Assessment (PRA)
Page 1 of 4
 Determine if patient meets clinical criteria for General Practitioner Referral
referral to PRA.
1. If the patient has been seen by a GP and the
 Discuss PRA referral with patient.
GP has advised transport to ED – SJA must
 Contact Silver Chain Liaison Nurse (ALN) on transport to ED.
#9242 0347 to discuss referral.

 If accepted, ensure patient is safe to be left 2. If the nurse/ family member has spoken to
for up to 4 hours pending arrival of PRA. the GP for this specific incident and the GP
has advised transport to ED – SJA must
 If PRA does not accept patient, transport to transport to ED.
hospital as per current clinical practice.
Contact the CSP in SOC stating the reason 3. If patient refuses to go to ED (after either 1
for the refusal. or 2) - SJA must contact GP prior to
making referral to PRA.
 Complete ePCR and under ANR section
4. If SJA are unable to contact the GP (after 3)
choose Silver Chain PRA.
– SJA can contact PRA – normal
acceptance criteria applies.
5. If GP has only provided general advice to
patient i.e. not specific to this incident “if ever
you are unwell you should call an
ambulance” - then SJA can assess
suitability on this occasion for referral to
PRA.
In all instances – document any decisions
regarding GPs to show that all reasonable steps
were taken.
Page 2 of 4
PATIENT EARLY WARNING SYSTEM Assessment Tool
Reference Card
Parameters Score Values
3 2 1 0 1 2 3

Respiratory ≤8 9 – 20 21 – 31 – ≥ 36
Rate 30 35
Sp02 < 85 85 - 90 - 92 ≥ 93
89
Temperature ≤34 34.1 – 35.1 – 36 – 38 – ≥ 38.5

35 35.9 37.9 38.4
Systolic BP ≤70 71 - 81 – 99 100 – ≥ 200

80 199
Pulse Rate ≤30 31 – 41 – 50 51 – 100 – 110 - ≥ 130

40 99 109 129
Neuro Unresp Pain Voice Alert

Response
Total
Page 3 of 4
PATIENT EARLY WARNING SYSTEM Assessment tool guidelines
Other considerations
There are a number of clinical presentations when a BSL should be

BSL considered; in particular an altered level of consciousness and/or a

raised respiratory rate.
Pain is an individual’s perception. As part of your assessment, pain

should be considered and managed appropriately. Ensure that if
Pain
leaving someone at home, they have the ability to deal with their
level of pain appropriately.
PEWS does not replace clinical judgement. It is a tool to assist in

clinical decision making and should not be used in isolation to
assess a patient. Some patients may have a low PEWS score but a
serious underlying illness or injury or have the potential their
condition will deteriorate.
Some examples include:
• Chest pain
• Head injury
• Abdominal pain
Conditions • Stroke i.e – FAST positive
PEWS must be considered as part of the full clinical assessment.

PEWS can alert to a change in a patient’s condition as well as
effectiveness of treatment. The recording of PEWS provides a
prehospital benchmark for handover and within the patient care
record.
PEWS is not applicable in:
• Patients less than 16 years of age

• Obstetrics
Patients should be referred to another Healthcare Professional with
a PEWS > 3, with an isolated red parameter or where there is
PEWS > 3 clinical concern with a PEWS ≤ 3 (e.g GP, Out of Hours, Specialist
practitioner or transported to hospital). These patients SHOULD
NOT be discharged under treat and not transport.
Consideration can be taken to pre-alert the receiving hospital with

PEWS 6 and above a PEWS of 6 or more and/or those with a PEWS increase of 2 or
more, and a P1 transport is required.
Page 4 of 4
GENERAL
1.9A URGENT CARE CENTRE
June 2018
St John Urgent Care Centres allow for patients Urgent Care Centre treatment will usually not be
with a variety of non-life-threatening illnesses appropriate in the following cases:

and injuries to be cared for in a General Practice
 Over 65yrs of age
ED
setting. Initially, ambulance patients whose
primary problem relates home or sporting  Patients with Multiple Co-morbidities
incidents (either backyard or in more formal  Any loss of consciousness.
settings) in otherwise fit and healthy persons;  Head injury with loss of consciousness.
can receive the most appropriate care without  Inebriated or drug affected patients.
 Patients suffering psychosis or delirium.
the need to attend an emergency department.
 Joint dislocations.
Common sense should apply at all times.
 Injuries that require c-spine
As time goes on it is likely we will expand the
D
immobilisation.
group of ambulance patients suitable for
 Open fractures or fractures with
transport to an Urgent Care Centre.
significant limb deformity.
 Patients with multiple co-morbidities.
The centers offer a high quality, safe and timely 
EN
Opioid pain medication administered.
alternate care pathway for unscheduled care,
and if necessary, x-rays (plain films), plaster
immobilisation and simple wound care including
suturing onsite.
SP
Urgent Care Centre treatment will usually be  St John Urgent Care centers are open 7
appropriate in the following cases: days a week: Cockburn and Joondalup
SU
 Sprains / strains / possible simple closed 8am – 10pm and Armadale 10am – 6pm.
fractures. Ambulance patients will be accepted up
 Simple lacerations needing closure. until 1 hour before closing (i.e 21:00 or
17:00).
 Mild back pain not requiring prehospital
opioids.  Patients will be bulk billed using their
current Medicare card for urgent care
 Head injury without loss of
center treatment (bulk billing is only
consciousness.
made available for current Medicare
 Soft tissue injuries. cardholders where a benefit exists).
 Ambulance fees still apply.
© Copyright St John Ambulance Western Australia Ltd. 1.9A Urgent Care Centre
Page 1 of 2
Management/Dose Locations
ADMISSION PROCEDURE: LOCATIONS:
 Ensure patient is suitable for admission  Joondalup Gate
and fits criteria. 21 Joondalup Drive
 Contact relevant Urgent Care Centre via Joondalup
telephone to discuss suitability of your
Tel: (08) 9400 7000
patient and acceptance from the Doctor,

patient cannot be accepted via
 Cockburn Gateway Shopping City
ED
Administration or Nursing staff,
 Request a wheelchair if necessary. 816 Beeliar Drive
 Contact SOC and change destination to Cockburn
the nearest Urgent Care Centre. Tel: (08) 6174 6000
 Complete ePCR.
 Armadale Shopping Centre
Shop 62/63
D
10 Orchard Ave.
Armadale
Tel: (08) 9399 0970
EN
SP
SU
© Copyright St John Ambulance Western Australia Ltd. 1.9A Urgent Care Centre
Page 2 of 2
NEUROLOGICAL
2.1 FAINTING (SYNCOPE)
November 2011
Syncope is a sudden, transient, loss of  N/A
consciousness and postural tone with the
potential for full recovery. It should not be

confused with seizures, shock or any other
cause of loss of consciousness. Vasovagal
syncope is the most common type of syncope
and may be caused by standing for prolonged
periods, pain, illness, fatigue, fear or emotional
distress.
Signs/Symptoms Precautions/Notes
 Dizziness or light-headedness  Brain injury or death can occur if the patient
 Pallor is kept upright
 Sweatiness  Abnormal vital signs post faint or symptoms
 Anxiety and/or restlessness such as exertional onset, chest pain,
dyspnoea, severe headache or neurological
 Nausea
deficits may indicate causes other than
 Unconsciousness (for a few seconds to one
syncope
to two minutes)
 Fainting whilst lying down usually indicates a
 Rapid return of consciousness once lying
cardiac cause
flat
 Confusion lasting >30 seconds may
 Full recovery after a few minutes
indicate a post-ictal state favouring a
seizure rather than a episode of syncope
Management/ Dose Complications/Side effects

 Open, clear and maintain the airway  Some pre hospital procedures such as
 Lateral position if unconscious (Use left injections may precipitate syncope in
lateral position for pregnant women) susceptible patients. Patient position should
 Oxygen be considered to avoid potential injury.
 Vital signs
 ECG
 Assess for secondary injury
© Copyright St John Ambulance Western Australia Ltd 2.1 Fainting

Review date: November 2015
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NEUROLOGICAL
2.2 UNCONSCIOUSNESS
July 2017
Specific Information Needed:

 Present history:
- When last well.
- Onset and progression of present state.

 Past History:
- Previous medical or psychiatric problems.
- Previous symptoms such as headaches, seizures, confusion, etc., trauma clues.
 Medications / Illicit drugs: Use and / or abuse.
 Surroundings:
- Check for pill bottles, syringes, etc., and bring with patient.
- Note — Odour in house (alcohol, cannabis, ketones).
- Does patient have a Medic Alert tag?
- Evidence of diabetes? (possible hyper/hypoglycaemia)
Specific physical findings:

 Vital Signs and oxygen saturation.
 Level of consciousness and neurological status.
 Signs of trauma e.g. head, body.
 Odour of breath (ketone smell of diabetes, alcohol, etc); needle tracks
(possible IV narcotic overdose).
 Check blood sugar level and Medic Alert tag.
Management:
 Danger, Response, Airway, Breathing, Circulation, Disability, Exposure.
 Consider spinal precautions if mechanism or history suggest trauma.
 Airway: protect as needed, e.g. oropharyngeal airway if unresponsive.
 Consider advanced airway (if trained and authorised) if unresponsive/ areflexic.
 If the patient is unresponsive, lifeless and has no or abnormal breathing consider
the patient to be in cardiac arrest (CPG 4.6A, 4.6B1 & 4.6B2).
 Oxygen, as per CPG 1.5, ventilator support might be needed.
 Consider vascular access or if insitu KVO or as directed.
 Transport in lateral position, if spinal precautions are not applicable. Transport of the
spinal patient will be done on their back and required vigilance in managing the
airway.
 Monitor Vital Signs and oxygen saturation during transport and record.
© Copyright St John Ambulance Australia (Western Australia) Inc. 2.2 Unconsciousness

Page 1 of 2
Precautions / Notes:
 Be particularly attentive to airway.
 Difficulties with secretions, regurgitation or vomiting, and inadequate tidal
volume are common.
 Hypoglycaemia may present as a focal neurological deficit or coma.
Hyperglycaemia can lead to complications that can also result in unconsciousness.
All patients with an altered GCS (i.e. abnormal for the individual) should have a
BSL test preformed and managed appropriately if Symptomatic.
Consider Possible Causes:

AEIOU-TIPS is a mnemonic acronym used to recall the possible causes for altered
mental status.
Component(s) of acronym Examples
Alcohol or drug intoxication

Alcohol/Abuse of substances.
A Acidosis
Diabetic ketoacidosis; hypoventilation due to COPD, asthmatic
airway obstruction, or neuromuscular disease
Hypothermia; hyperthermia
Environmental
Epileptic seizure (or seizure for any other reason)
Epilepsy
Hyponatremia; hypernatremia; hypocalcaemia; hypercalcemia
E Electrolytes
Wernicke's encephalopathy; Chronic traumatic encephalopathy
Encephalopathy
(CTE)
Endocrine disease
Adrenal insufficiency; thyroid disease
I Infection Encephalitis, meningitis, meningoencephalitis; sepsis
Prescription or non-prescription drug overdose

Overdose
O Hypoxia due to pulmonary oedema or tension pneumothorax;
Oxygen deficiency
hypoxic brain injury due to cardiac arrest.
Insufficient dose of prescription medications

Under dose
U Uraemia
Excess urea in the blood due to kidney failure, congestive heart
failure, urinary obstruction
Concussion; traumatic brain injury; increased intracranial pressure

Trauma
T due to epidural haemorrhage
Tumour
Brain tumour; metastasis to the brain; paraneoplastic syndrome
I Insulin Hypoglycaemia; hyperosmolar hyperglycaemic state
Psychogenic Psychosis; pseudo seizure; conversion disorder

P Poisons Carbon monoxide poisoning; lead poisoning; iron poisoning
Haemorrhagic stroke due to arteriovenous malformation (AVM)

Stroke
S Shock
Neurogenic shock due to spinal cord injury; cardiogenic shock due
to myocardial infarction

Page 2 of 2
I Insulin Hypoglycaemia; hyperosmolar hyperglycaemic state
Psychogenic Psychosis; pseudo seizure; conversion disorder

P
Poisons Carbon monoxide poisoning; lead poisoning; iron poisoning
Haemorrhagic stroke due to arteriovenous malformation

Stroke (AVM)
S
Shock Neurogenic shock due to spinal cord injury; cardiogenic
shock due to myocardial infarction

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NEUROLOGICAL
2.3 SEIZURES
July 2017
A seizure is an abnormal paroxysmal discharge of  N/A
cerebral neurons which manifests clinically as
changes in motor, sensory, behavioural or
autonomic function. A seizure may have several

aetiologies:
 CNS : epilepsy, head injury, stroke, brain
tumour, hypoxic insult
 Metabolic: hypoglycaemia, hyponatremia
 Toxicological: poisons, abuse or
withdrawal from alcohol, medications or
other drugs.
 Infectious: fever (especially in children
<5years), meningitis, malaria, encephalitis
 Environmental: stress, fatigue, medical
non-compliance.
 Eclampsia
 Generalised seizure activity should be  Protect the patient from danger where
considered an emergency where: possible.
- The seizure is prolonged (> 5mins),  Do not actively cool a febrile child by
or sponging as shivering will increase
- Multiple seizures occur, or temperature
- The patient doesn’t regain  The pharmacological management of
other seizure types requires ASMA
consciousness.
consult and authorisation.
 Focal seizure activity associated where:
 Airway evaluation, management and
- The seizure is prolonged (> 5mins) vigilance during and after seizure activity
and is associated with a GCS ≤ 12. are required.

 Open, clear and maintain the airway  Incontinence
 Lateral position if unresponsive (use left  Secondary injury (including intra-oral
lateral position for pregnant women) trauma)
 Oxygen as per CPG 1.5  Aspiration
 Identify and address cause where possible  Hypoxia
 Vital signs, ECG, IV  Hyperthermia
 Midazolam as per CPG 11.27  Dysrhythmias
 Consider prehospital bloods  Brain damage
 Transport  Death
© Copyright St John Ambulance Western Australia Ltd. 2.3 Seizures

Page 1 of 2
© Copyright St John Ambulance Western Australia Ltd. 2.3 Seizures

Page 2 of 2
NEUROLOGICAL
2.4 STROKE / CEREBRO-VASCULAR ACCIDENT
(C.V.A.)
July 2017
Description
Stroke occurs when arterial blood supply to the brain is suddenly disrupted due to obstruction by a thrombus
or plaque (Ischaemic stroke 85%), or because an artery ruptures (Haemorrhagic stroke 15%).

Transient ischaemic attack (T.I.A.) is also significant as it may precede a stroke.
Maintain a high index of suspicion of cerebrovascular accident in persons presenting with neurological
symptoms over the past 24 hours, excluding obvious causes for these neurological symptoms such as
hypoglycaemia.
Patients who present with any of the following
FAST is a rapid diagnostic tool for the evaluation of
should be assessed for a cerebrovascular
stroke like symptoms. If 2 or more abnormalities exist,
accident:
then the patient is considered FAST+
 Weakness, numbness or paralysis of the Rapid Arterial oCclusion Evaluation (RACE) is a
face, arm or leg (unilateral or bilateral); quantifying tool used to assess the likelihood of a large
 Dysphasia, language difficulties; vessel occlusion and identifies the patients’ that may
 Dizziness, ataxia, loss of balance or an require urgent neuroendovascular clot retrieval.
unexplained fall;
Terminology used in RACE:
 Loss of vision, visual field disturbances,
Asomatognosia: Loss of awareness of body part
double vision, or sudden blurred or Anosognosia: Not aware of impaired ability.
decreased vision in one or both eyes; Paretic limb: Affected limb
 Headache, usually severe and of abrupt Acute Stroke Centre – FAST+ & RACE Score 1 - 4
onset;
SCGH, FSH, RPH, SJ/GMID:
 Dysphagia, difficulty in swallowing.
 Monday – Sunday, 24 hours a day.
Conduct Face, Arm, Speech and Time of onset
test. If FAST+, (two or more) stroke is likely Neuroendovascular Unit – FAST+ & RACE Score ≥ 5
diagnosis. Sir Charles Gardiner Hospital
Conduct RACE to identify Large Vessel
 Monday – Sunday, 24 hours a day
Occlusion (LVO), note:
 FAST+ and RACE score of 1 - 4 requires Fiona Stanley Hospital
evaluation at an Acute Stroke Centre  Monday – Friday, 08:00 -16:00
(ASC), for possible thrombolytic (arrival to ED within these prescribed times)
treatment. Regional Areas
 FAST+ and RACE score of ≥ 5 requires  Early Notification to hospital via patch line is
management at an Acute essential for all FAST and RACE positive patients
Neuroendovascular Unit (ANU), for
Improved Stroke patient outcomes rely on:
possible clot retrieval.
 Rapid on-scene assessments,
 Early ED, ASC or ANU notification,
 Urgent transportation and
 Information gathering, inclusive of time of
onset/last seen well and NOK details.
© Copyright St John Ambulance Western Australia Ltd. 2.4 Stroke

Page 1 of 4
Management Complications
 Open, clear and maintain the airway  Permanent Disability
 Oxygen (CPG 1.5)  Brain damage
 Vital signs – Including BSL  Death
 ECG
 Conduct FAST evaluation, if FAST+
 Obtain RACE score
 IV Access – ACF preferable
 Collect bloods

 Aim for on scene time <15 mins
 Transport (Priority 1)
 Hospital pre-notification via ED patch.
 Delivery to appropriate destination:
As per flowchart P3:

Stroke bypass to Acute Stroke Centre is
indicated when:
 FAST+ & RACE score 1 - 4
 Time of symptom onset < 6 hrs
 Patient possess full Activities of Daily Living
(ADL)
 BSL between 4-22
Stroke bypass to Neuroendovascular Unit is

indicated when:
 FAST+ & RACE score of ≥ 5
 Time of symptom onset < 6 hrs
 Patient possess full Activities of Daily Living
(ADL)
 BSL between 4-22
Regional Centres
 If both FAST and RACE positive and within
approximately 100km of the main regional
hospital, consider calling that ED for potential
bypass instructions if onset of symptoms is
< 6 hours.
Stroke bypass is not indicated where:

 The above criteria are not met.
 An urgent intervention is required at closest
ED.

Page 2 of 4
Rapid Arterial oCclusion Evaluation (RACE)
* Note that out of a possible 11 points, due to hemiparesis a maximum score of ≤ 9 can be attained in most patients
Item Instruction RACE Score
Facial Palsy Ask the patient to smile, if GCS decreased, Absent (symmetrical movement) 0
note any facial asymmetry. Mild (slightly asymmetrical) 1
Moderate to severe (completely asymmetrical) 2
Arm Motor Extending the arm of the patient, Normal to mild (limb upheld more than 10
0
Function 90° degrees (if sitting) or seconds)
45° degrees (if supine) Moderate (limb upheld less than 10 seconds) 1
Severe (patient do not rise the arm against
2
gravity)
Leg Motor Extending the leg of the patient Normal to mild (limb upheld more than 5
0
Function 30° degrees (in supine) seconds)
Moderate (limb upheld less than 5 seconds) 1
Severe (patient do not rise the leg against 2
gravity)
Head & Observe eyes and head deviation to one Absent (eye movement to both sides were
0
Gaze Deviation side possible and cephalic deviation was observed)
Present (eyes and cephalic deviation to one side
1
was observed)
Aphasia Ask the patient two verbal orders Normal (performs both tasks correctly) 0
(for RIGHT sided
~ "Close your eyes" Moderate (performs one task correctly) 1
hemiparesis only)
Test: Understanding of ~ "Make a fist"
Severe (performs neither tasks) 2
words
Agnosia Ask patient: 1. "Whose arm is this? - While Normal
(for LEFT sided
0
showing him/her the affected arm. (Recognises arm, and attempts movement)
hemiparesis only) Asomatognosia – unaware or in denial of illness. Moderate
Test: Cognitive
2. “Can you move your arm?"
1
(No arm recognition OR is unaware of arm)
recognition
Anosognosia – unaware of difficulties. Severe (Unable to recognise & unaware of arm)
2
Both questions answered unconvincingly
Score Total: 0-9/11

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Page 4 of 4
NEUROLOGICAL
2.5 DISTURBED AND ABNORMAL BEHAVIOUR
July 2017
Present behaviour causing concern with a history  Known sensitivity to sedative agents.
of a recent crisis, emotional trauma, bizarre or
abrupt changes in behaviour, suicidal ideas,
alcohol/drug intoxication, and toxic exposure.

Organic causes of the abnormal behaviour, for
example hypoxia and hypoglycaemia have to be
eliminated or managed first.
 Most common psychiatric emergencies
are:
- Acute psychotic state
- Acutely depressed and/or suicidal
- Drug or chemical intoxication
- Acute situational crisis
Indications Precautions
Intervention is indicated if it is suspected on  Be aware of personal safety.
reasonable grounds that the person:  Transporting patients under the Mental Health
 Is acutely disturbed and poses a threat to the Act of 2014. (CPG 1.1F)
health and safety of themselves; any other
person or to prevent serious damage to
property.
Only the police and mental health transport

officers have legislated authority to apprehend
persons in mental health circumstances (section
156 (1) Mental Health Act 2014).

 Attempt to establish rapport – (appropriate  Police may be required to apprehend the
questioning and non-confrontational patient or provide restraint in threatening
technique). situations.
 Consider and address organic causes for
disturbed behaviour as soon as practicable
(head injury, hypoxia, hypoglycaemia and
overdose).
- section 243 of Criminal Code (7.4.2) states
it is lawful for any person to use such force
as is necessary in order to prevent a
mentally impaired person from doing
violence to any person or property.
- Midazolam, (CPG 11.27).
© Copyright St John Ambulance Western Australia Ltd. 2.5 Disturbed and Abnormal Behaviour
Page 1 of 2
- Ketamine, (CPG 11.23). Second line
agent, 5 minutes after the use of
Midazolam, only where Midazolam has
been ineffective and the patient still poses
a physical threat to others or themselves.
 If emergency treatment is unnecessary,
intervene as little as possible, except to
reassure, during transport.
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RESPIRATORY
3.1 DYSPNOEA AND RESPIRATORY DISTRESS
September 2012
Dyspnoea and respiratory distress is difficulty in
breathing or shortness of breath. It is a sign of a
variety of disorders and is primarily an indication of
inadequate ventilation or of insufficient oxygen.

 Shortness of breath.  Epiglottitis is inflammation of the tissue that
 Tachypnoea. covers the trachea. It is a life-threatening
 Accessory muscle use/retractive breathing disease and medical emergency. Spasm may
cause the airways to close abruptly. Patients
 Tachycardia.
suspected of suffering epiglottitis should be
 Anxiety, progressing to drowsiness and
handled with care.
confusion.
 Hypoxemia.
 Stridor.
 Cyanosis.

 Position- sitting upright or position of comfort.  Respiratory arrest.
 Oxygen.  Cardiac arrest.
 Treat airway obstruction (skill 309, 310, 311).
 Treat severe croup with retractive breathing
with adrenaline (CPG 11.5).
 Record observations and response to therapy.
© Copyright St John Ambulance Australia (Western Australia) Inc. 3.1 Dyspnoea and Respiratory Distress
Review Date: September 2017
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RESPIRATORY
3.2 ASTHMA
July 2017
Asthma is characterised by hyper-reactive  Nil
airways and inflammation leading to episodic,
reversible bronchoconstriction in response to a
variety of stimuli.

Alveolar hypoventilation ensues leading to VQ
mismatch, CO2 retention and air trapping.
Extrinsic asthma- classic allergic asthma

Precautions/Notes
resulting in bronchospasm, increased mucous
secretions, and increased vascular permeability. Mild/Moderate Severe Life-threatening
Can walk, speak whole Use of accessory Reduced
sentences in one breath muscles of neck or consciousness or
Intrinsic asthma- non-immune mechanisms such intercostal muscles collapse
as respiratory infections; drugs such as aspirin or 'tracheal tug'
during inspiration
and beta-blockers; pollutants; emotions; exercise. or subcostal
recession
('abdominal
breathing')
Oxygen saturation Unable to complete Exhaustion
Indications >94% sentences in one
breath due to
dyspnoea
 Respiratory distress
Wheeze might be Obvious Cyanosis
 Expiratory wheeze evident respiratory distress
 Hyperinflated chest Oxygen saturation Oxygen saturation

90–94% <90%
 Pulsus paradoxus in severe attacks Audible wheezing Poor respiratory effort,
 Silent chest soft/absent breath
sounds
Adapted from the Australian Asthma Handbook, 2017

Management/Dose  Risk factors for life threatening asthma: Prior ICU
admission; Prior intubation; >3 ED visits in past
 Position- sitting upright or position of
year; >2 hospital admissions in past year; >1
comfort
bronchodilator canister used in past month; Use of
 Oxygen As per CPG 1.5 bronchodilators > every 4 hours; Chronic use of
 Salbutamol (CPG 11.34) steroids; Progressive symptoms in spite of
 Ipratropium Bromide (CPG 11.18) aggressive treatment.
 IM Adrenaline (CPG 11.5) for life  SPO2 is not a reliable isolated indicator of severity
threatening asthma  Asthma is less likely to be the cause of wheezing in
 IV access- consider fluid therapy (CPG infants less than 12 months old. If symptoms do not
11.19) respond, reconsider the diagnosis
 In an asthmatic cardiac arrest, if a tension  Titrate oxygen saturation to target of 92–95% for
pneumothorax is suspected, undertake adults and at least 95% for children.
bilateral chest decompression (Skill 808)
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Complications/Side Effects
 Respiratory arrest
 Cardiac arrest

3.2 ASTHMA
Assess and address ABC
Consider risk
factors for life
Determine severity threatening asthma
Mild / Moderate Severe Life

MONITOR Threatening
PATIENT
· Respiration rate
· Pulse
· SPO2 • Salbutamol MDI or • Nebulised Salbutamol • Continuous nebulised
· BP nebulised (CPG 11.34) (CPG 11.34) & Salbutamol
· GCS
· BGL • Ipratropium Bromide
(CPG 11.34), &
· TEMP
• Ipratropium Bromide
· ECG (CPG 11.18)
(CPG 11.18)
• Adrenaline (CPG 11.5)
If ineffective
Reassess severity, monitor
continuously breathing, assist
ventilations
4-6/min (Skill 314)
P1 transport if ABC
compromised
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RESPIRATORY
3.3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE
July 2017
Chronic obstructive pulmonary disease (COPD)  Nil
also known as chronic obstructive airway disease
(COAD), chronic airflow limitation (CAL), is a lung
disease characterised by chronic obstruction of

lung airflow that interferes with normal breathing
and is not fully reversible.
 Respiratory distress  COPD is an under-diagnosed, life-threatening
 Sputum production lung disease (World Health Organisation).
 Cough
 History of exposure to risk factors for the
disease
Management/Dose Complications/Side effects

 Position- sitting upright or position of  Respiratory arrest
comfort  Cardiac arrest
 Oxygen (as per CPG 1.5)
 Salbutamol (CPG 11.34) – via MDI and
Space Chamber (Skill 613) or by Nebuliser
(Skill 602)
 Ipratropium Bromide (CPG 11.18)
 Record observations and response to
therapy
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RESPIRATORY
3.4 VENTILATORY EMERGENCIES
November 2016
On occasion officers may find themselves in a situation whereby they have difficulty
ventilating a patient. A failure to ventilate situation can occur at any stage of patient
management. When faced with the failure to ventilate situation, officers should perform a
D.O.P.E.S check.

D - Displacement
• Re-evaluate for breath sounds over the epigastrium.
• If gurgling is heard withdraw ETT immediately (Skill 307), suction if required
(Skill 302/303).
• Consider tube depth, right main bronchus or oesophageal intubation.
• Check ETT/LMA placement after every movement of patient.
O - Obstruction
• Resistance to ventilation is a strong indicator of obstruction. This includes both

upper airway obstruction (as with laryngeal obstruction, see Skill 311) or lower
airway obstruction (as with Asthma).
• If obstruction present, pre ventilate with 100% O2 and suction to remove

obstruction.
P - Pneumothorax
• Consider the signs and symptoms of a pneumothorax or pneumo-haemothorax
(CPG 5.9 Chest Injuries).
• Consider ventilator settings.
E - Equipment failure
• Consider failure in equipment from the ETT tube to the oxygen cylinder and back.
S - Secretions
• Thick secretions can form an obstruction of the ETT tube. Soft suction of the ETT
tube may be required (Skill 307).
• Secretions may need to be diluted with 5 -10 mls of NaCl before suctioning of ETT
tube.
Management:
 Systematically exclude possible causes using D.O.P.E.S. check:
 Supply high concentration oxygen once ventilatory solution is found.
Note: Document ventilatory failure and D.O.P.E.S. solution on ePCR.
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RESPIRATORY
3.5 ADVANCED AIRWAY MANAGEMENT
July 2017
 Advanced airway management is the  Intact gag reflex
assessment and protection of a Endotracheal Intubation:
compromised airway via the use of patient  Not to be attempted if no waveform

positioning, suction, oropharyngeal, Capnography available.
supraglottic, ETT and surgical airway  Patients smaller than a small adult.
(Cricothyrotomy).
 A Vortex-like approach should be utilised
for a considered and structured
management approach.
 Cardiac arrest patients  In most cases, a supraglottic airway device
 Patients with an unprotected airway that should be utilised as the initial airway
has risk of compromise: device. If the patient is adequately
- A-reflexic patients with a GCS ≤8, oxygenated, then there would be no need to
especially head trauma, without a gag move to ETT.
 CCP only – Induction.  Officer managing airway is to control all
patient movements. All airway adjuncts,
ventilations and capnography waveform to
be assessed following all patients
movements.
 Nasopharyngeal Airway should be
considered with caution in patients that
suffered significant nasal or mid-facial
trauma.

The most competent and confident clinician • Laryngeal spasm
in relation to airway management should - Displacement during patient
manage/coordinate the process: movements/transfer; care should be
taken, i.e. disconnect the BVM when
 Airway assessment (LEMON) moving patients, re-assess after moves,
L - look externally see notes above.
E - evaluate 3:3:2
M - mallampati airway difficulty grade 1-4
O - obstructions
 Suction (Skill 302/303)
 Magill forceps (Skill 310)
N - neck mobility (query spinal injury)
 Vortex approach to airway management:
 Patient positioning
 Airway Adjuncts OPA, NPA (Skill
305/306)
 BVM – rise and fall of chest (Skill 206)
 Laryngeal Mask / iGel (Skill 306)
If this fails to provide an airway then:
© Copyright St John Ambulance Australia (Western Australia) Inc. 3.5 Advanced Airway Management
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 Intubation (Skill 307)
 Surgical Cricothyrotomy (Skill 311)
 Ventilation assessment rise and fall of
chest, auscultation of epigastric area and
both left and right lungs.
© Copyright St John Ambulance Australia (Western Australia) Inc. 3.5 Advanced Airway Management
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RESPIRATORY
3.6 CROUP
July 2016
Croup (acute laryngotracheobronchitis) is one of  NA
the more common childhood respiratory
illnesses.

Croup is a Viral inflammation of the upper
airway, larynx, trachea and bronchi.
Generally worse at night - peak night two or
three in the morning.
Signs / Symptoms Precautions/Notes

Croup is a viral infection of the throat and  Steroids have been shown to decrease the
trachea that causes some or all of the following: severity of croup, reduce the length of
 Noisy breathing (stridor) – a high-pitched hospital stay, need for nebulised Adrenaline
sound. and other interventions
 Hoarse voice.  Children with croup usually have a cold first
 Harsh- barking cough. – a runny nose, cough and slight
temperature. Then the child wakes during
 Increased Respiratory rate
the night with a barking cough and difficulty
 Intercostal and supraclavicular recession
breathing.
 Tracheal Tug
 Do not delay transportation.
 Nasal Flaring
 Fever.

Do not forcibly change a child's posture - they  No improvement- Reconsider diagnosis.
will adopt the posture that minimises airways (Acute upper airway obstruction.)
obstruction.
 Oxygen if required. (CPG 1.5)

 For mild to moderate Croup - Oral
Prednisolone 1mg/kg (CPG 11.36) without
the need to use nebulised Adrenaline.
 For severe Croup with signs of severe
respiratory distress - nebulised
Adrenaline (CPG 11.5), 5mg/5mls then
Prednisolone (CPG 11.36)
 Record observations and response to
therapy.
© Copyright St John Ambulance Australia (Western Australia) Inc. 3.6 Croup

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RESPIRATORY
3.7 CHOKING
July 2017
Foreign bodies may cause either mild or severe  N/A
airway obstruction.

General Signs of Choking Back Blows:
- Attack occurs while eating - Stand to the side and slightly behind
- Patient may clutch at neck patient
- Support the chest with one hand and lean
Signs of Mild airway obstruction the patient forwards
- Patient able to speak, cough and breathe - Give up to 5 sharp blows between the
- Scapulae at a 90° with the heel of the
Signs of severe airway obstruction hand
- Patient unable to speak - Check after each back blow to see if
- Attempts at coughing are silent airway obstruction has been relieved.
- Wheeze Chest Thrusts:
- Unconscious - Identify the same compression point as
- Unable to breathe for CPR
- Give up to five chest thrusts which are
similar to chest compressions but sharper
and delivered at a slower rate
If patient showing signs of mild airway obstruction N/A
- Encourage coughing
- Constant observation preparing for
deterioration
If patient shows signs of severe airway
obstruction and is conscious
- Give up to 5 back blows
- If back blows fail to relieve airway
obstruction give up to 5 chest thrusts
- If obstruction still unrelieved continue
alternating 5 back blows with chest thrusts
If patient becomes unconscious
- Commence CPR
- Attempt to remove visible obstruction and if
necessary utilise laryngoscope and Magill
forceps (Skill 310) – if trained and
authorised to do so.
- Attempt to ventilate, if unsuccessful,
consider Cricothyrotomy (Skill 311) - if
trained and authorised to do so.
- Transport urgently
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CIRCULATION
4.1 CHEST PAIN / ACUTE CORONARY SYNDROME
July 2016
Acute coronary syndrome (ACS) represents a  N/A
continuum of clinical presentations sharing
common pathology, ranging from worsening
angina through to ST-elevation MI (STEMI).

Most patients present with prolonged (>10mins)
or recurrent central chest discomfort described
as tightness, heaviness, squeezing or crushing
sensation. The absence of these symptoms
does not rule out ACS.
 Chest pain/discomfort of presumed cardiac  A Normal ECG does not rule out ACS.
origin.  Glyceryl Trinitrate (GTN) administration can
precipitate severe hypotension in susceptible
patients however it is a rare occurrence.
 Limit patient’s exertion as much as is
practically possible.
 LBBB with associated chest pain should be
treated as acute until proven otherwise.

 Oxygen - If hypoxic with SpO2 <94%  Clinical Deterioration.
 Vital signs - (Monitor regularly including pre-  Dysrhythmias.
and-post intervention pain scores)  Cardiac arrest.
 12 lead ECG – telemetry to receiving hospital
as indicated (attached protocol).
 Aspirin (CPG 11.4).
 Glyceryl Trinitrate (GTN) (CPG 11.21). Give
early.
 Analgesia (Acute Coronary Syndromes
where GTN failed to relieve the chest pain
completely).
- IN Fentanyl (CPG 11.13).
- IV Fentanyl Citrate (CPG 11.13).
 IV access if indicated.
 Ondansetron if required (CPG 11.30).
 Heparin if confirmed STEMI from receiving
hospital and patient going straight to Cardiac
Catheterisation Lab (CPG 11.17).
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CIRCULATION
4.2 CARDIAC DYSRYTHMIAS
July 2017
 A dysrhythmia refers to an abnormality of the  Nil
heart rhythm.
 Although not all patients will become unstable

and show adverse signs, brady-dysrhythmias
(<60bpm) and tachy-dysrhythmias (>100bpm)
have the potential to severely compromise
cardiac output and lead to cardiac arrest.
 Supraventricular tachycardia (SVT) is a
common cardiac dysrhythmic disturbance,
evident by rapid onset and rates of
approximately 180bpm or above which are
regular, as a norm, SVT is not life threatening
and can be self-resolving.
 Patients presenting with cardiac dysrhythmia,
demonstrating adverse signs require urgent
transport.
 Unstable bradycardia (with pulse and not  Nil
associated with traumatic cause):
- Poor signs of perfusion, including:
 Hypotension
 Altered conscious state
 Diaphoresis  Resuscitation equipment should be at hand.
 Shortness of breath and/or cyanosis  Consider unstable patient as being time –
 Syncope critical, possible peri-arrest.
 Unstable tachycardia (with pulse)
- Unstable indicates that cardiac output is
reduced to produce blood pressure
changes, altered mental status, ischaemic
chest pain, hypotension, syncope or other
signs of shock.
 Supraventricular tachycardia (SVT):
- Pulse >180bpm, rapid onset, regular, with
© Copyright St John Ambulance Western Australia Ltd. 4.2 Cardiac Dysrhythmias

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diaphoresis and signs or symptoms of
reduced cardiac output.
Management/Dose

 Unstable Bradycardia:
- Address reversible cause.
 If inferior/right ventricular MI associated with bradycardia and hypotension, consider fluid to
address cardiogenic shock, NaCl CPG 11.19 and follow STEMI protocol CPG 4.1.
 Hypovolaemia, Hypoxia and some Toxins that can be addressed in the field.
- Consider Atropine Sulphate CPG 11.9, if likely to have effect. Atropine would not be effective in 3rd
degree Heart Blocks or in wide complex bradycardias.
- Consider ASMA consult for advice.
 Unstable tachycardia:
- Early recognition.
- 12 Lead ECG should not delay transport.
- Consider proximity to ED; consider ASMA consult if delivery to ED will be delayed.
- Consider patient in peri-arrest state.
 Supraventricular tachycardia: Narrow Complex, rapid rate, regular:
- Consider – Modified Valsalva Manoeuvre (MVM), Skill 805.

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Heart Blocks

4.2a BRADYCARDIA
Symptomatic Bradycardia Asymptomatic Bradycardia

Assess: ABCDE, O2, IV, ECG-12
Precautions Signs of Poor Perfusion Fit, healthy and normal for
Resuscitation patient
equipment should
Reversible Causes
be at hand.
Hypoxia, shock, toxins, AMI, electrolyte
Consider unstable
abnormal. Vasovagal, head injury and/or stroke. Re-evaluate
patient as being Risk of Asystole:
time –critical, Ventricular pause > 3 sec
possible peri-arrest. AV block: Type 2
Atropine as per CPG 11.9

3° Block CCP only
transcutaneous pacing
Re-evaluate
Re-evaluate
Atropine as per CPG 11.9
Consider ASMA for further advice
P1 transport if ABC compromise

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4.2b TACHYCARDIA
Unstable Tachycardia Assess: ABCDE, O2, IV, ECG SVT Stable Tachycardia
Signs of Poor Perfusion Narrow QRS, rapid onset, Living with AF, VT but
high rate, regular. asymptomatic
Reversible Causes
Exercise induced
Hypoxia, Shock, Toxins, AMI,
Evaluate &
Electrolyte imbalance.
Monitor
Precautions
Resuscitation Evaluate & Evaluate &
equipment should • Sinus tachycardia is not a Monitor Monitor
be at hand. dysrhythmia

Consider unstable
• No cardioversion if >48hrs Consider Valsalva
patient as being
in AF If unsuccessful,
time –critical,
possible peri- • Valsalva contraindicated consider Atrial Flutter
as per Skill 805, severe or repeat.
arrest.
coronary artery disease
and recent MI < 6 wks. Evaluate &
Consider ASMA for further
advice • Always consider Monitor
hypersensitivity to
pharmacology
Re-evaluate
P1 transport if ABC
compromised

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CIRCULATION
4.3 ACUTE CARDIOGENIC PULMONARY OEDEMA
September 2011
ACPO is usually as a consequence of left sided heart  Do not suction ETT.
failure. In the acutely decompensated state the
hydrostatic flow of fluid from the capillaries to the lung
parenchyma is favoured causing oedema. This impairs

gas exchange resulting in severe respiratory symptoms.
 Shortness of breath  Hypoxic aggression/ irritability
 Orthopnoea  Carefully titrate fluid to effect
 Cyanosis  Limit patients exertion as much as is
 Pink frothy sputum practically possible
 Diaphoresis  If unstable transport P1
 Crackles
 Wheeze

 Oxygen  Clinical Deterioration
 Vital signs  Dysrhythmias
 ECG  Respiratory arrest
 IV Access TKVO  Cardiac arrest
 GTN (CPG 11.21)
© Copyright St John Ambulance Australia (Western Australia) Inc. 4.3 Acute Cardiogenic Pulmonary Odema
(Left Heart Failure)
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CIRCULATION
4.4 CHRONIC CONGESTIVE CARDIAC FAILURE
(CCF) (RIGHT HEART FAILURE)
June 2002
Note: Chronic congestive cardiac failure produces venous congestion, and results in
peripheral oedema and / or swollen veins. It is due to Right Heart Failure.
Eventually left heart failure may follow, with shortness of breath. This cannot be
treated in the same way as Acute Left Heart failure.

Specific information needed:
Enquire and record:
 Slow progressive history of deterioration.
 Precipitating factors.
 Long past history of heart and lung problems.
 Medications.
 Associated symptoms.
Specific critical findings:

 Vital Signs and oxygen saturation. May be hypotensive.
 Distended neck veins, cyanosis, particularly peripheral.
 Swelling of ankles, lower legs, over sacrum.
 If severe failure, may also be breathless, lack of energy.
Management:
 Oxygen, high concentration or 100% (ventilate if necessary).
 Remember nasal catheter if appropriate.
 Sitting position, preferably with legs hanging down.
 Monitor Vital Signs and oxygen saturation.
 Transport.
Specific precautions / notes:

Mental confusion may occur — due to hypoxia. Ensure Oxygen, even if patient trying
to reject it, as rejection may be due to hypoxia. Do not use GTN in CCF.
May over-stimulate a failing heart.
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(Right Heart Failure)
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CIRCULATION
4.5.1 HYPOVOLAEMIC SHOCK
July 2017
Inadequate tissue perfusion as consequence of  N/A
circulatory fluid loss.
 Haemorrhage classification:

Class 1 <15% few signs
Class 2 15-30% Increased Pulse/RR,
decreased pulse
pressure
Class 3 30-40% Pulse>120, RR 30-40,
decompensation (Syst BP
<90 mmHg)
Class 4 > 40% Pulse>140, marked decrease
in systolic bp, profound
lethargy.
 Decreased mental status  Level of consciousness is a good indicator of
 Symptomatic hypotension cerebral perfusion
 Hypotension is a late sign of shock
 Tachycardia  Beta blockers blunt cardio vascular responses
 Cardiovascular response (pulse or blood to hypovolaemia
pressure) to changes in posture  Aggressive fluid management may dislodge
clots from micro circulation
 Tachypnoea  Minimise on scene time as much as is
practical with ongoing management
undertaken during transport.

 Control haemorrhage as per CPG 5.4  Clinical deterioration
 Oxygen  Hemodynamic instability
 Vital Signs  Disseminated intravascular coagulation
 ECG  Cardiac Arrest
 IV access
 Fluid therapy as per CPG 11.19
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CIRCULATION
4.5.2 CARDIOGENIC SHOCK
September 2011
Inadequate tissue perfusion as consequence of  N/A
cardiac failure.

 Decreased mental status  Do not administer NaCl 0.9% bolus with
 Pulmonary oedema pulmonary oedema unless the patient is
 Dysrhythmias symptomatic from hypotension. In this
scenario careful titration of fluid is
 Symptomatic hypotension
needed.
 Wheeze

 Oxygen  Clinical deterioration
 Position sitting or semi-recumbent (BP permitting)  Hemodynamic instability
 Vital signs  Dysrhythmias
 ECG  Cardiac Arrest
 IV access
 Transport P1 to appropriate facility
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CIRCULATION
4.5.3 NEUROGENIC SHOCK
September 2011
Occurs after an injury to the spinal cord. Sympathetic  N/A
outflow is disrupted resulting in unopposed vagal
tone.

 Decreased mental status  Respiratory depression
 Symptomatic hypotension  Hypothermia
 Bradycardia (dependant on level of injury)  Beware of fluid overload
 Skin: warm & dry  Neurogenic shock must be differentiated from
“spinal” shock. Spinal shock is defined as
temporary loss of spinal reflex activity
occurring below a total or near-total spinal
cord injury.

 Oxygen  Clinical deterioration
 Use spinal precautions as per CPG 5.2 if  Hemodynamic instability
appropriate  Dysrhythmias
 Vital signs  Cardiac Arrest
 ECG
 IV access
 Transport to appropriate facility as per major
trauma guidelines
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CIRCULATION
4.5.4 ANAPHYLACTIC SHOCK
July 2017
As per CPG 9.1 “Any acute onset of hypotension  N/A
or bronchospasm or upper airway obstruction
where anaphylaxis is considered possible, even if
typical skin features are not present OR any

acute onset illness with typical skin features
(urticarial rash or erythema/flushing, and/or
angioedema), Plus involvement of respiratory
and/or cardiovascular and/or persistent severe
gastrointestinal symptoms”, (ASCIA, 2010).
 Subjective airway impairment or swelling  Antihistamines given prior to arrival may
(swollen tongue, laryngeal oedema, stridor) produce sleepiness
 Dyspnoea : Lower airway obstruction  Upright positioning coupled with significant
(wheeze) hypotension can precipitate death
 Chest tightness  Hypotension in adults can be defined as a
systolic BP of less than 90 mmHg or greater
 Hypotension than 30% decrease from that person’s
 Nausea baseline and in children less than:
 Urticaria and Itching (70 mmHg + [2 x age]) from 1 to 10 years i.
 Decreased mental status
 Remove the cause if still present e.g. stings.  Clinical deterioration
 Patient should be placed in the recovery  Hemodynamic instability
position, unless respiratory distress  Airway compromise
predominates.
 Dysrhythmias
 If indicated IM Adrenaline (CPG 11.5)
 Cardiac Arrest
 Consider the need for advanced airway
management
 Oxygen as per CPG 1.5
 IV access
 Fluid therapy as per CPG 11.19, combined
with adrenaline therapy is concomitant in the
presence of shock.
 If indicated repeat IM Adrenaline (CPG 11.5)
 If wheeze only consider Salbutamol
(CPG11.34)
 ECG
 Transport P1 if clinically indicated
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Further Reading:
1
Allergy, Asthma & Clinical Immunology (2011), DOI: 10.1186/1710-1492-7-S1-S6
© Copyright St John Ambulance Western Australia Ltd. 4.5.4 Anaphylactic Shock

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CIRCULATION
4.5.5 SEPTIC SHOCK
September 2011
Septic shock is decreased tissue perfusion and  N/A
oxygen delivery as a result of severe infection and
sepsis. Persistent arterial hypotension remains
despite adequate fluid resuscitation.

 Decreased mental status  The young and elderly may have reduced
 Hyperventilation fever responses.
 Hypotension  An ill, non-responsive infant should be
 Skin; warm dry considered septic until proven otherwise
 Evidence of infection

 Oxygen therapy  Clinical deterioration
 Vital signs  Hemodynamic instability
 ECG  Dysrhythmias
 IV access  Multiple organ dysfunction syndrome
 Fluid therapy as per CPG 11.19  Disseminated intravascular coagulation
 Cardiac Arrest
© Copyright St John Ambulance Australia (Western Australia) Inc. 4.5.5 Septic Shock
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CIRCULATION
4.6A CARDIAC ARREST – ADULT
(12 YEARS & OVER)
July 2017
Introduction

Cardiac arrest is a time critical condition requiring immediate intervention. The ALS algorithm allows for a
systematic approach to cardiac arrest and assumes basic life support (BLS) measures have been initiated
and remain ongoing.
 Following a primary survey, resuscitation must  If trauma is the cause, follow the Traumatic
be commenced on all patients in suspected Cardiac Arrest CPG.
cardiac arrest not meeting the criteria set out in  Consider early transportation for non-asystolic
CPG 4.6D, in line with Australian Resuscitation patients as they will not meet the clinical criteria
Council (ARC) guidelines. for termination of resuscitation efforts.
 If circulation is restored, please refer to  If vascular access is unobtainable, continue
CPG 4.6C – ROSC. resuscitative efforts without medications.

Follow ARC Flowcharts. Cardiac Arrest secondary to Hypothermia:
 Hypothermia in Western Australia as a cause of
 Apply Q-CPR puck to monitor CPR
performance quality. cardiac arrest is extremely rare and mostly
accidental e.g. locked in a cool room. If you
 Minimise interruption to chest compressions.
suspect that the cardiac arrest was secondary to
Good quality CPR is associated with improved
hypothermia, the emphasis is on high
clinical outcomes.
performance CPR and transport.
 Shockable Rhythms - VF, Pulseless VT (as
Pregnancy – Relieve aortocaval compression
per Skill 501).
 Manual Uterine Displacement, Skill 705.
 Non-Shockable Rhythms - PEA, Asystole. If this is not possible, place padding, such as a
 Status / rhythm check every 2 minutes. towel, under the right hip to tilt the patient’s hips
 Once an advanced airway (ETT or LMA) is approximately 15-30°.
confirmed in position, compressions are Refer to CPG 4.6D for ROLE and TOR.
continuous and ventilations asynchronous at 6-
10 per minute.
(N.B 4-6 per minute for asthmatic arrests).
© Copyright St John Ambulance Western Australia Ltd 4.6A Cardiac Arrest Adult
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© Copyright St John Ambulance Western Australia Ltd 4.6A Cardiac Arrest Adult
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CIRCULATION
4.6B1 CARDIAC ARREST – INFANT / PAEDIATRIC
(3 HOURS TO 12 YEARS)
July 2017
Introduction
The majority of cardiorespiratory arrests in infants and children are secondary to hypoxaemia and/or
hypotension. This CPG refers to patients 3 hours old to 12 years of age.

Cardiac arrest is a time critical condition requiring immediate intervention. The ALS algorithm allows for
a systematic approach to cardiac arrest and assumes basic life support (BLS) measures have been
initiated and remain ongoing.
Respiratory arrest may occur alone, but if treated promptly may not progress to cardio-respiratory arrest.
Respiratory arrest with adequate cardiac output should be treated as per post resuscitation care.
 Following a primary survey, resuscitation must  If trauma is the cause, follow the Traumatic
be commenced on all patients in suspected Cardiac Arrest CPG.
cardiac arrest not meeting the criteria set out  Consider early transportation for non-asystole
in CPG 4.6D, in line with Australian patients as they will not meet the clinical
Resuscitation Council (ARC) guidelines. criteria for termination of resuscitation efforts.
 Bradycardia is an ominous sign in
 Ensure appropriate padding for neutral
infants/paediatrics. If their pulse is <60bpm, alignment to open the airway.
they are unconscious AND display signs of
 Effective airway control and adequate
poor perfusion, CPR is appropriate.
ventilation with oxygen supplementation are
 If circulation is restored, please refer to CPG
the keys to favourable outcomes in infants
4.6C – ROSC. and children.
 In infants (3 hrs to 1yr), the 2 thumb encircling
technique is recommended when there is
more than one responder. Alternatively, when
there is only one responder the 2 finger
technique is recommended.
 If vascular access is unobtainable, continue
resuscitative efforts without medications
 Calculations are based on weight in
kilograms.
 If weight is unknown then calculate as follows:
 ≤ 9 years = (age +4) x 2.
 ≥ 10 years = age x 3.3.
© Copyright St John Ambulance Western Australia Ltd 4.6B1 Cardiac Arrest – Paediatric
Page 1 of 2
Follow ARC Flowcharts. Refer to CPG 4.6D for ROLE and TOR.
 If ≥ 8 years old, apply Q-CPR puck to monitor
and correct CPR performance. Cardiac Arrest secondary to Hypothermia:
 Shockable Rhythms – VF, Pulseless VT:  Hypothermia in Western Australia as a cause
of cardiac arrest is extremely rare and mostly
- Defibrillation dose 4J/kg.
accidental e.g. locked in a cool room. If you
 Non-Shockable Rhythms - PEA, Asystole. suspect that the cardiac arrest was secondary

 Medication Formulas: to hypothermia, the emphasis is on high
- Fluid therapy 20ml/kg. performance CPR and transport.
- Adrenaline 10mcg/kg  ASMA available for advice.
- Amiodarone 5mg/kg.
- Glucose 2.5ml/kg.
 Once an advanced airway (LMA) is insitu,
compressions are continuous and ventilations
asynchronous at rate for age.
© Copyright St John Ambulance Western Australia Ltd 4.6B1 Cardiac Arrest – Paediatric
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CIRCULATION
4.6B2 NEWBORN LIFE SUPPORT
(0 TO 3 HOURS)
July 2017
Introduction
The term “newborn” refers to the infant in the first minutes to 3 hours following birth.
The vast majority of babies born at term will initiate spontaneous respirations within 10 to 30 seconds of
birth. A small percentage will respond during drying and stimulation. Approximately 10% require

ventilation and only about 1% require more extensive chest compressions and medications.
Management Notes
Follow SJA flowchart  Appropriate padding for neutral alignment to
 Medications: open the airway.
- Oxygen  Effective airway control and adequate
ventilation are the keys to favourable outcomes
- Priority is to ensure lung inflation,
in newborn patients.
supplemental O2 should be delivered
when no improvement is evident from  As expanding the lungs is imperative in
effective ventilations on room air. newborns, ensure that you get chest rise with
initial inflation breaths, if poor response attempt
- Reduce supplemental O2 when SPO2 to troubleshoot:
reading exceeds 90%.
− Two person technique
- Preterm newborns (<32 weeks) provide
blended air (1 L/m) using BVM. − Introduce an OPA
- Fluid therapy 10ml/kg. − Suction is not routinely recommended
with newborns and may cause
- Adrenaline 10mcg/kg IV / IO,
bradycardia and airway damage. Only
every 3-5 minutes;
suction if there is a clear indication for its
- Glucose 2ml/kg IV / IO bolus of 10% use - meconium or blood clots in airway.
Dextrose, (only if cause for low BSL
 Initial positive pressure ventilation should be
strongly suspected).
delivered via BVM using room air.
- Flush 3-5ml NaCl
 On assessment of pulse; If <100bpm, oxygen
should be delivered via BVM;
If pulse <60bpm, initiate CPR.
 When there is more than one responder,
compressions are recommended to be done
with the 2 thumb encircling technique. When
there is only one responder, the 2 finger
technique is recommended.
 Newborn < 3kg, IO only in extremis such as
cardiac arrest.
 If IO access cannot be obtained, continue
resuscitation efforts without medications.
 For medication calculations, if weight is
unknown, assume 3.5kg.
 Hypoglycaemia is evident if BSL is < 2.0mmol.
 Preventing heat loss: Set ambient temperature
to minimum of 26oC where possible.
© Copyright St John Ambulance Western Australia Ltd 4.6B2 Newborn Life Support
Page 1 of 2
Assessment Special Considerations
Refer to SJA Newborn Life Support Flowchart Termination of Resuscitation requires an ASMA
consult via CSP in SOC.
All newborn resuscitations must be transported
with active resuscitation to the nearest receiving Cardiac Arrest secondary to Hypothermia:
ED. • Hypothermia in Western Australia as a cause of
cardiac arrest is extremely rare and mostly
accidental. If you suspect that the cardiac arrest
was secondary to hypothermia, the emphasis is
on high performance CPR and transport.

Newborn Life Support
Further Reading:
Neonatal resuscitation in resource-limited settings: Titrating oxygen delivery without an

oxygen blender. The Journal of Paediatrics 2014 165(2):256-260.
© Copyright St John Ambulance Western Australia Ltd 4.6B2 Newborn Life Support
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CIRCULATION
4.6C POST RESUSCITATION CARE (ROSC)
July 2016
Description
Systematic post-resuscitation care after return of spontaneous circulation (ROSC) can improve the
likelihood of patient survival with good quality of life.

Indications Management/Dose
 Revaluate ABCDE
 Patients with a return of spontaneous
 12-lead ECG
circulation following cardiac arrest
 Treat precipitating causes
 Treat hypotension:
Precautions/Notes - IV/IO Fluids:
o Adults (SBP < 90mmHg):
The focus of post resuscitation care is on
 250ml bolus and reassess, if still
ensuring adequate cerebral perfusion,
hypotensive a further 250ml bolus and
oxygenation and supportive treatment to allow
reassess.
the recovery of vital organs.
o Paediatrics (SBP < 80mmHg):
 Recovery of infants and children is  10ml/kg bolus and reassess if still
typically slower than adults as cardiac hypotensive a further 10ml/kg and
arrest is usually secondary to reassess (bolus max. 250ml)
prolonged hypoxaemia. - If still hypotensive Adrenaline (CPG 11.5).
 Re-evaluate oxygenation and ventilation:
- Titrate oxygen delivery as required,
aiming for SpO2 between 94 - 98%
- Avoid hyperventilation. Start at age
appropriate ventilations to a target
EtCO2 of 35 – 40mmHg.
Newborn 40-60
3hrs <1yr 30-40
1-2yrs 25-35
2-5yrs 25-30
5-12yrs 20-25
>12yrs 15-20
Adult 10-12
 Temperature:
- Unless profoundly hypothermic (<300C)
DO NOT actively rewarm as mild
hypothermia has been proven to be
beneficial post ROSC.
 Glucose: Avoid hypoglycaemia.
 In suspected opiate overdose, once
circulation is restored, consider Naloxone as
per CPG (11.29).
© Copyright St John Ambulance Western Australia Ltd 4.6C Post Resuscitation Care
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© Copyright St John Ambulance Western Australia Ltd 4.6C Post Resuscitation Care
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CIRCULATION
4.6D RECOGNITION OF LIFE EXTINCT (ROLE) AND
TERMINATION OF RESUSCITATION (TOR)
July 2017
Determination of Death / ROLE:

Recognition of Life Extinct:
Resuscitation must be commenced on ALL patients in suspected cardiac arrest NOT meeting

the following criteria:
a) Advanced Body Decomposition, signs of larval infestation or putrefaction.
OR
b) Death has clearly occurred with signs of Rigor Mortis and/or Gravitational Dependent
Post-Mortem Hypostasis present. 1
i. For true hypostasis to be present, other signs would be evident, such as
asystole. Document ALL relevant findings
OR
c) If the cardiac arrest was not witnessed or no by-stander CPR was performed and the
down time was estimated to be greater than 15 minutes, the following clinical features 2
should be present in order to declare the patient deceased:
i. Asystole in all three leads, for 30 seconds or more, and;
ii. Fixed and dilated pupils, and;
iii. Absent breath sounds on auscultation, and;
iv. Absent heart sounds on auscultation or no palpable carotid pulses, and;
v. Absent corneal reflexes
OR
d) Major traumatic injuries incompatible with life, such as:
• Decapitation, incineration, evisceration of brain or thoracic organs
• Hemicorporectomy or translumbar amputation.
OR
e) Palliative care patients where death was expected and imminent due to that illness.
OR
f) An Advance Directive being in place, where it is clearly communicated 3 that it is/was
the patient’s wishes not be resuscitated.
When in doubt regarding termination, please contact the State Operations Centre Clinical
Support Paramedic for guidance.
1
Gravitational Dependent Hypostasis can be misdiagnosed due to blotching and bruising and therefore cannot be used as the singular reason for not initiating a
resuscitation effort.
2
These clinical features are indicative of a prolonged downtime. If in doubt, initiate the resuscitation until Recognition of Life Extinct becomes evident. Asystole
alone is not a sufficient cause not to initiate resuscitation. Hypothermia and drug use should be excluded as possible causes for the arrest prior to declaring life
extinct.
3
These do not have to be in writing, and can be communicated to the clinician verbally as long as it is from a trusted source, for further information see
Guardianship and Administration Act 1990.
© Copyright St John Ambulance Western Australia Ltd 4.6D ROLE/TOR

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Termination of Resuscitation (TOR):
Termination of resuscitation may be appropriate where:
a) No response to maximal directed resuscitation by SJA clinical staff for at least 20
minutes, AND
b) The arrest was not paramedic/officer/nurse or volunteer witnessed, AND
c) The patient is in asystole (confirmed in all 3 leads) for 30 seconds, AND
d) No defibrillation was delivered during any stage of the resuscitation attempt (including
pre-ambulance care).

It is also appropriate to terminate resuscitation when:
e) Information comes to light indicating that resuscitation attempts were inappropriate in the
first place – Palliative Care/ Advanced Directive, OR
f) An ASMA consult has occurred supporting termination of resuscitation in special
circumstance such as; hypothermic cardiac arrest, pacemaker, cardiac arrest involving
pregnancy and the newborn.
g) In cases where there is a long transport time to hospital (> 30 minutes), AND the patient
remains in a non-shockable rhythm and unresponsive to treatment.
h) Prolonged CPR in blunt trauma cardiac arrest after reversible causes have been
addressed is almost never associated with a good outcome. If delivery to an Emergency
Department cannot be achieved within 25 minutes from arrival on scene, it is reasonable
to terminate resuscitation if no ROSC is achieved after 10 minutes and TOR criteria b
to d are met.
Determination of Death as per ROLE/TOR.

A Medical Practitioner may certify Life Extinct. They may also issue a Cause of Death Certificate
where they believe the death had a known cause and the deceased is known to them.
Ambulance Officers may certify Life Extinct under the provisions of the Coroner. A Life Extinct
Form, electronic or paper, is required for any deceased patient that SJA attends.
Reportable Deaths: Deaths in these categories require notification to the coroner.

 Appears to have been unexpected, unnatural or violent or to have resulted, directly or
indirectly, from injury.
 Person who immediately before death was a person held in care. (*)
 Appears to have been caused or contributed to by any action of a member of the Police
Force.
 A person whose identity is unknown.
(*) The term “person held in care” means a person held:

 Under the Child Welfare Act.
 In custody under the Prisons Act.
 In any centre under the Alcohol and Drug Authority Act 1974.
 As an involuntary patient or apprehended or detained within the meaning of the Mental
Health Act 2014.
 As a detainee under the Young Offenders Act 1994.

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An important point to understand is that once the decision has been made to report the death to
the Coroner, all evidence of medical intervention in the deceased must remained untouched.
This means that all tubes, intravenous lines and other aspects of medical intervention must be
left in situ as these could be examined in detail. In the case of children, the endotracheal tube
may be cut off at the lips if there is to be a viewing of the body.
Obvious Deaths:
This is the only category in which Police Officers may/will issue a Life Extinct form.

Suspicious Deaths:
Suspicious deaths may include criminal acts, suicides, stabbings, shootings, overdoses or
where the information gathered does not make sense. Where Officers suspect a suspicious
death Police need to be called immediately and the scene secured. Documentation is important
and any details you gather should be included. This is evidence and may be required by a court.
Patient care to others should not be delayed. If CPR is stopped please leave the scene as is.
Should this happen Officers need to be aware that they will contribute to evidence at the scene
and may inadvertently contaminate the scene. In cases of a hanging; the knot used to form a
noose should be left tied and the rope cut away from the knot where possible. Do not cut down
the deceased if there is an obvious death and CPR is not considered.
Non Suspicious Deaths:

Non suspicious circumstances may include deaths at home of natural causes. If there are no
suspicious circumstances, the Medical Practitioner may be phoned and once given the
circumstances surrounding the death asked if a Cause of Death Certificate will be forthcoming.
If so there is no need to contact Police. The relatives may then be advised to contact a funeral
service of their choice and make all further arrangements. The name of the Medical Practitioner
and time contacted must be documented.
Should the deceased’s Medical Practitioner be unavailable or a Death Certificate is not
forthcoming, then the Police must be called and advised of the situation. Officers may be
required to take the deceased to the mortuary on request of police.
Wellbeing and Support Services:

Officers who attend these deaths may be subject to unforeseen stress and may need to contact
Wellbeing and Support. This service is available to everyone 24 hours a day 7 days a week.
Many people, especially relatives, may require assistance and Wellbeing and Support may be
contacted for advice and support.
Wellbeing and Support:

All hours contact: 08 9373 3827
wellbeingandsupport@stjohnambulance.com.au

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TRAUMA
5.1 TRAUMA: MANAGEMENT PRINCIPLES
February 2014
All trauma patients should be systematically

assessed and managed using the Primary
Survey to identify any time critical patients.
Indications Precautions/ Notes

 All trauma patients.  Catastrophic haemorrhage can be defined
as extreme bleeding likely to cause death in
minutes.
 For patients with serious trauma, on scene
time should ideally be less than ten minutes
unless trapped.
 Scene assessment;
 Catastrophic bleeding (with haemorrhage
control as required);
 Primary Survey (with C-Spine consideration);
 Airway management/ventilatory support (as
required);
 Oxygen therapy as per CPG 1.5;
 Haemorrhage control as per CPG 5.4;
 Immobilisation (as required);
 Consider IV fluids if hypotensive and signs of
poor organ perfusion;
 Secondary / CNS Survey (as required);
 Consider analgesia;
 Consider ECG monitoring;
 Consider prevention of hypothermia.
© Copyright St John Ambulance Western Australia Ltd 5.1 Trauma: Management Principles
Review Date: As required
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© Copyright St John Ambulance Western Australia Ltd 5.1 Trauma: Management Principles
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TRAUMA
5.2 SPINAL TRAUMA
November 2016
Trauma to the spine may cause injuries  Disease process may not allow for neutral
involving the spinal cord, vertebrae or both. positioning (e.g. Kyphosis). If there is
significant deformity, patients should be

Spinal cord injury (SCI) can be identified when
transported in a position of comfort.
neurologic function above the injury is intact and
function below the injury is absent or markedly
diminished. Specific manifestations will depend
on the exact level of injury.

NEXUS criteria: Spinal immobilisation is  An altered state of mental alertness can be
indicated where any of the following (stepwise) demonstrated by: GCS < 15; disorientation
assessment findings are present and associated to time, place, person or event; delayed or
with relevant trauma: inappropriate response to stimulus.
 Altered mental status at time of initial  Focal neurologic deficit includes weakness,
assessment; numbness or paraesthesia found on motor
or sensory examination.
 Intoxication or drug affected;
 The patient is considered to be intoxicated
 Midline cervical tenderness; if: they, or an observer, reports a recent
 Focal neurological deficit; history of intoxication or consumption of
intoxicating substances; evidence exists of
 Distracting injury;
intoxication (such as odour of alcoholic
Once the above is ruled out: beverage, ataxia, slurred speech, dysmetria
 As per Canadian C-Spine rule - Clinical or any behaviour suggestive of intoxication);
assessment, including or a positive result in alcohol or drug tests.
 Bruising or deformity to spinal region;  A distracting injury is defined as any injury

that has the potential to impair the patient’s
 Full range of active neck motion cannot ability to recognise other injuries, examples
be performed, by the patient, without include: burns; long bone fractures;
pain (including 45o rotation to the left and extensive lacerations; and degloving or
right). crush injuries.
The above criteria constitute a clinical decision  Immobilisation in the restless patient can
tool for use in the initial assessment of increase forces on the injured spine.
conscious adult patients to indicate those at very Reversible causes of restlessness (e.g.
low risk of cervical spine injury. Concerning hypoxia, pain) should be managed.
children, no dedicated clinical decision tool for
 Some patients are at a greater risk of SCI
paediatric cervical spine trauma exists i. due to pre-existing medical conditions or
In both these patient groups, if the assessing pre-disposing factors, such as Down
clinician has any concern immobilisation must syndrome, Ankylosing spondylitis, brittle
be applied until full history and assessment bone disease, osteoporosis, spinal
(inclusive of imaging) prove spinal precautions degeneration joint disease and extremities
could be discontinued. of age. The clinical assessment process,
especially with non-traumatic SCI, should
© Copyright St John Ambulance Western Australia Ltd 5.2 Spinal Injury

Page 1 of 6
identify the best method of transportation to
reduce the risk of secondary damage.
 Children < 8yo, might require padding under
their shoulders to obtain neutral spinal
alignment.
 SPEED (Spinal Emergency Evaluation of
Deficits) assessment should be done on
patients with suspected vertebral column
injury with neurological deficits due to
possible spinal cord injury.

 Principles of management as per CPG 5.1  Cervical collars can raise intracranial
pressure and spinal immobilisation can
 Combined NEXUS criteria and clinical
increase the aspiration risk and potentially
assessment as per Canadian C-Spine rule
reduce airway opening and respiratory
 Spinal immobilisation equipment, including: efficacy.
 Cervical collar;  Pressure injury can develop after as little as
 Head blocks; 20 minutes on a hard surface. Patients that
are not time critical must be removed from
 Extrication board, orthopaedic (scoop) the extrication boards or scoop stretchers.
stretcher or vacuum mattress;
 To promote haemostasis and avoid
 KED; unnecessary movement, patients should be
 Anti-emetic as per CPG 11.30 managed with the principles of minimal
handling (minimise movement and
 Complete a SPEED assessment, as per
avoidance, where possible, of log rolls).
pocket card/ePCR.
 Do not secure the head blocks base plate or
 Should a time critical patient be transported
towel rolls to the Ferno stretcher. The head
on an extrication board or scoop, full spinal
and chin straps should be used to keep the
immobilisation equipment should be used
blocks in place and prevent lateral
(Cervical collar, head blocks and Spider
movement or rolling of the head.
harness). The packaged patient must then
be secured on the Ferno 50E stretcher.  Assessment against NEXUS criteria cannot
be performed after administration of
 In Traumatic Cardiac Arrest, the principles
Scheduled pain or sedation medication.
outlined in the CPG 1.1E, takes preference
over standard care.
 For inter-facility transfers, the Vacuum
Mattress should ideally be utilised if available
as per Clinical Skill 917.
Use of the combined NEXUS criteria and
Canadian C-Spine rule assessment findings
have to be documented on the patient care
record.

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Altered mental status? Yes
No
Yes
Intoxication/Drug affected?

No
Midline cervical tenderness on Yes

palpation?
No
Focal neurological deficit? Yes
No
Immobilise
Yes
Distracting injury?
No
Clinical examination:
Yes
Bruising or deformity
No
Full range of active neck

motion can be performed No
without pain (including 45'
rotation to left and right)?
Yes
Immobilisation not indicated

Page 3 of 6
ii

Page 4 of 6
i
The Royal Australian and New Zealand College of Radiologists. (2015). Paediatric Cervical Spine Trauma .
Retrieved November 16, 2016, from RANZCR:
http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiA
uICcjKzQAhWBOpQKHfktCHwQFggaMAA&url=http%3A%2F%2Fwww.ranzcr.edu.au%2Fdocuments-
download%2F3838-print-version-paediatric-cervical-spine&usg=AFQjCNEq8s_27djnYqzb6s
ii
Assessed by paramedics within 2 hours of injury.

Suspected vertebral column injury (any level) with neurological deficits* due to possible SCI.
Admitted to participating hospitals within 24 hours post-injury.
*Neurological deficits defined as: any weakness, paralysis or change in sensation of one or more limbs
reported by participant or found on examination.
https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12616000687493

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TRAUMA
5.4 HAEMORRHAGE
July 2017
Catastrophic bleeding must be managed as a  N/A
priority. Assess for blood loss in five places:
 External;

 Chest;
 Abdomen;
 Pelvis;
 Long bones.
Consider hypovolaemic shock, early signs  Catastrophic haemorrhage can be defined
include: as extreme bleeding likely to cause death in
minutes.
 Pallor;
 Cool peripheries / > 2 seconds CRT;  Decompensating patients might present with
Bradycardia.
 Anxiety, abnormal behaviour, decreased
mental status;  Adult permissive hypotension = SBP
70mmHg.
 Increased respiratory rate; and
 In the TBI, adult patient attempts should be
 Tachycardia.
made to maintain SBP at 90mmHg.
 In general, hypotension in adults can be
defined as a systolic BP of less than 90
mmHg or greater than 30% decrease from
that person’s baseline and in children less
than: (70 mmHg + [2 x age]) from 1 – 10yo.
 Principles of management as per CPG 5.1  N/A
 Arresting external haemorrhage by:
- Direct pressure;
- Limbs: CAT Tourniquet (catastrophic or
uncontrolled);
 Consider T-PoD® and/or splinting;
 Adult patients with blunt trauma and / or
isolated head injury with hypotension and
signs of impaired organ perfusion – see CPG
11.19;
 Adult patients with penetrating trauma,
ectopic pregnancy or aortic aneurysm with
hypotension and signs of impaired organ
perfusion may benefit from permissive
© Copyright St John Ambulance Western Australia Ltd 5.4 Haemorrhage

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hypotension - see CPG 11.19;
 Adult patients with a head injury and
penetrating trauma with hypotension and
signs of impaired organ perfusion – see CPG
11.19;
 Hypotensive paediatric patients should
receive IV fluids – see CPG 11.19.
© Copyright St John Ambulance Western Australia Ltd 5.4 Haemorrhage

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TRAUMA
5.5 LIMB TRAUMA
February 2014
Injury occurring to one or more of the limbs,  Time-critical injuries always take priority.
including amputations (including partial
amputations), fractures, dislocations and soft

tissue injury (i.e. avulsions and degloving).

Clinical assessment can identify: The principles of splinting involve:
 Localised pain or tenderness;  Arrest of external haemorrhage;
 Loss of function, limitation of motion,  Support of injured area;
guarding;
 Immobilisation of the joint above and below
 Bizarre angulations, deep lacerations or the injury; and
exposed bone;
 Re-evaluation of the circulatory and
 Crepitus; neurological function before and after
splinting.
 Presence of altered distal pulses and
sensation; and Any fracture or dislocation which threatens the
neurovascular status of the limb should be
 Full or partial amputation of limb or
treated with urgency.
extremity.
In the pre-hospital environment, it can be
difficult to differentiate between ligament sprain
and a fracture. The injury should be managed
as a fracture until proven otherwise.
Remove jewellery from affected limbs before
oedema occurs.
 Principles of management as per CPG 5.1;  Fat embolism;
 Haemorrhage control, including tourniquet (as  Compartment syndrome: Signs of ischaemia
required) as per CPG 5.4; include:
 Splinting (including traction) and wound - Pain;
dressing (as required);
- Pallor;
 Soft tissue injury: Rest, ice, compression and
elevation (RICE); - Paresthesia;
 Management of the amputated part includes: - Pulselessness or reduced CRT; and
- Wrap in sterile gauze (or similar),
preserving all amputated material; - Cool or cold limb.
- Moisten with sterile saline if available;
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- Place in watertight container. Place
container on ice (do not freeze or place
amputated part in direct contact with ice).
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TRAUMA
5.6 PELVIC TRAUMA
February 2014
Major pelvic injuries are often associated with a  Compression or distraction (e.g. springing)
range of complications and deaths often occur of the pelvis.

as a result of associated injuries and
complications rather than the actual pelvic
injury.
Haemorrhage is the cause of death in almost
half of all pelvic trauma victims and the major
cause of death in unstable pelvic fractures.

Mechanism of injury and clinical presentation  Log rolling of the patient should be avoided
should be used to identify possible pelvic where possible;
fractures. Clinical assessment can identify:
 Where possible, patient movement should
 Bruising; be limited to less than a 15o tilt;
 Haemorrhage;  Circumferential pressure should be applied
across the greater trochanters and not the
 Deformity;
iliac crests;
 Oedema;
 Do not reduce the pelvis beyond its normal
 Urge to urinate; and anatomical position.
 Limb shortening.
A relevant mechanism of injury and associated
hypotension should be assumed as having a
time-critical pelvic injury until proven otherwise.
 Principles of management as per CPG 5.1;  Hypotension;
 Stabilisation of pelvic ring – T-POD;  Urogenitial injuries;
 Often associated with intra-thoracic and
intra-abdominal injuries.
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TRAUMA
5.8 TRAUMATIC BRAIN INJURY
July 2017
Traumatic brain injury, also known as head  Do not use 300 elevation in the
injury or intracranial injury is the result of hypovolaemic patient.
physical trauma causing brain damage and can
result from a closed or penetrating head injury. It

is classified as mild, moderate or severe and
can also be divided into two separate categories
- primary and secondary brain injury.
Assessment Precautions/Notes
 Mechanism or pattern of injury suggesting  Primary injury is generally irreversible
head trauma. therefore the aim of treatment is to prevent
 Abnormal behaviour or deteriorating mental secondary injury by supporting cerebral
status / abnormal neurological exam: haemodynamics and metabolism. Hypoxia
and hypotension cause the most prominent
- Asymmetric or non-reactive pupils
secondary injuries and may more than
- Visual disturbances/headaches
double mortality.
- Seizures.  Hyperventilation should be avoided as it
 Possible CSF leakage. exacerbates cerebral ischaemia and can
 Periorbital / retroauricular bruising. reduce venous return. It is generally used as
- (Raccoon eyes / Battle’s sign). a last resort where signs of impending
cerebral herniation are evident.
 Indicators of raised ICP:
 Exercise caution when considering
- Systolic hypertension / widening pulse
Nasopharyngeal Airway during treatment of
pressure
a patient with a suspected base of skull
- Bradycardia, abnormal respirations. i.e. fracture.
“Cushing’s triad”.

 Open, clear, maintain and protect the airway  Seizures
(consider C- Spine injury).  Combativeness or agitation
 Oxygen – maintain SpO2 > 90%.  Clinical deterioration
 IV/IO Access.  Death.
 Manage and prevent hypotension.
 30º head elevation if condition permits to
improve venous drainage.
 Maintain euglycaemia (BSL > 4mmol).
 Consider Ondansetron (CPG 11.30).
 Consider Ketamine for combativeness (CPG
11.23).
 Frequent vital sign monitoring.
 Urgent transport (preferably to a trauma
centre).
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TRAUMA
5.9 THORACIC TRAUMA
February 2014
Injury occurring in the chest wall, lungs, pleura,
thoracic great vessels, diaphragm, heart,
trachea, bronchus and oesophagus.

Respiratory assessment will identify any  Adequate analgesia may improve
impairment to ventilation including identify any: ventilation by allowing improved chest wall
expansion but high dose of opioids may
 Tracheal deviation;
induce respiratory depression.
 Wounds, bleeding or bruising;
 Emphysema (surgical);
 Laryngeal crepitus;
 Haemoptysis;
 Venous engorgement; and
 Pneumothorax, tension pneumothorax,
haemothorax or flail chest.
 Principles of management as per CPG 5.1;
 Oxygen therapy as per CPG 1.5;
 Immobilisation of impaled objects and
positioning (as required);
 Cover open chest wounds with an occlusive
dressing taped down on three sides;
 ECG monitoring;
 In cardiac arrest decompress tension
pneumothorax;
 Decompression of tension pneumothorax in
non-arrested patients (CCP only).
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TRAUMA
5.11 ABDOMINAL TRAUMA
July 2017

Abdominal trauma is blunt or penetrating trauma  N/A
that may involve one or more of the major
organs contained in the abdominal cavity.
Suggestive mechanism of injury associated with:  Assess for tenderness, guarding and rigidity
by gentle palpation of all four quadrants of
 Pain;
the abdomen.
 Tenderness;
 Shoulder tip pain may be indicative of
 Nausea and/or vomiting; pathology in the abdomen and reflect an
 Bruising; or injury which is irritating the diaphragm.
 Guarding or rigidity.
 Principles of management as per CPG 5.1;  Upper abdominal wounds, especially
penetrating trauma, may also cause major
 Cover exposed organs using sterile
thoracic damage.
dressing(s) (as required);
 Immobilisation of impaled objects and
positioning (as required).
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TRAUMA
5.15 BURN TRAUMA
November 2016
A burn is an injury caused by thermal (e.g. heat) 

and non-thermal (e.g. electrical) causes.

This guideline encompasses burn injuries
caused by electricity, heat, chemicals, light,
radiation or friction.
Assess airway burns for:  Document the time of burn injury;

 Assessment of the patient includes
 Soot in nasal and mouth cavities;
inhalation injury; % TBSA affected; site and
 Cough and hoarseness;
depth of wounds; the patient’s age; the
 Black sputum; presence of other injuries, the mechanism of
 Difficulty in breathing and swallowing; injury; any areas of circumferential burns,

co-morbidities and psychosocial issues;
 Blistering around mouth and tongue;
 Reddened and intact skin areas should not
 Scorched hair, eyebrows or facial hair be included when calculating % TBSA burnt;
 There may be entry and exit point for
electrical burn injuries;
 Patient suffering electrocution injuries
should be monitored for dysrhythmias and
12-lead performed;
 Hydrogels gel dressings can be applied in
the absence of water to cool, but this is not
preferred.
 Severe oedema;
 Principles of management as per CPG 5.1;
 Inhalation of superheated smoke, stream or
 Burn injury assessment (Rule of 9’s);
gases can induce airway oedema and rapid
 Cool burn area for a minimum of 20 minutes,
deterioration of airway patency.
avoid hypothermia;
 Compartment syndrome: Signs of
 Remove jewellery and clothing unless
ischaemia include:
adhered to wound;
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 Apply damp sterile dressings after - Pain;
cooling and/or hydrogels; - Pallor;
 Salbutamol (as required); - Paresthesia;
 Analgesia; - Pulselessness or >2 seconds CRT;
 Consider direct transfer to Burns Unit: - Cool or cold limb.
- ≥ 10% TBSA burnt;
- Airway burns;

- Burns to face, hands, feet,
perineum, genitalia.
 Fluid replacement formula:
Adults:
 < 15% TBSA = no fluid;

 15 – 25% TBSA and > 30 minutes for
transportation to ED = 1 litre over 1 hour
(Max 1 litre);
 > 25% TBSA = 1 litre stat followed by 1
litre over 1 hour (Max 2 litres);
Paediatrics:
 > 10% TBSA and > 30 minutes for

transportation to ED = 10ml /Kg over 1
hour;
 Consult ASMA for advice if further fluid
therapy is required.

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The Rule of Nines

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.

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TRAUMA
5.16 TENSION PNEUMOTHORAX
June 2018
Tension Pneumothorax is a life threatening • Simple Pneumothorax
condition that develops when air becomes • < 12 years

trapped in the pleural cavity under pressure.
The progressive build-up of pressure in the
pleural space can collapse the lung, displace
the mediastinum and obstruct venous return to
the heart. This leads to compromised
cardiopulmonary function and may result in
cardiac arrest.
Cardiac arrest with suspected tension • Positive pressure ventilation may
pneumothorax caused by trauma or exacerbate the one way valve effect of a
asthma
tension pneumothorax
• The presence of a needle or chest tube
For CCP / CSP if trained & authorised only: does not mean the patient cannot re-
• Traumatic cardiac arrest with torso develop a tension pneumothorax.
involvement • Tension pneumothorax may also persist if
• Positive pressure ventilation with signs of there is an injury to the major airways or
barotrauma bronchial tree.
• Suspected tension pneumothorax with • Beware of the patient with bilateral tension
respiratory and/or haemodynamic pneumothoraces. The trachea may be
compromise central with decrease air entry on both
Signs & Symptoms: Chest pain, dyspnoea, sides. These patients are usually
tachypnoea, surgical emphysema, diminished haemodynamically compromised and
breath sounds on affected side, tracheal require bilateral chest decompression.
deviation (contralateral side), cyanosis • Whenever there is deterioration in the
tachycardia, altered level of consciousness, patient’s oxygenation or ventilator status
hypotension, jugular vein distension (may not be the chest should be re-examined and a
present with hypovolemia/hypotension). tension pneumothorax excluded.
Hyper-resonance (loud and/or low pitched
sounds) is indicative of a tension pneumothorax.
Hypo-resonance (dull or thud-like sounds) is
indicative of a haemothorax.
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• Needle thoracentesis:
2nd intercostal space, mid-clavicular line.
(Skill 808 – Thoracentesis)
For CCP / CSP if trained & authorised only:
• Finger thoracostomy via blunt dissection:

4th or 5th intercostal space, between
mid-axillary line and anterior axillary line
(Skill 917 – Finger Thoracostomy)
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OBSTETRIC EMERGENCIES
6.1 MANAGEMENT OF OBSTETRIC EMERGENCIES
July 2017
 While most pregnancies and births are
uneventful, all pregnancies are at risk.
Around 15% of all pregnant women develop

a potentially life-threatening complication.
 Pregnancy is timed from the first day of the
Last Menstrual Period (LMP), and normal
term delivery ranges from >37-41+6.
 The pregnancy is divided into first, second
and third trimester, each trimester is 13
weeks.
 Obstetric emergencies should be considered Physiological changes
for any female of child bearing age Pregnancy causes many physiological changes
presenting with abdominal pain and/or PV that need to be considered during maternal
bleeding. assessment.
 Cardiac Output increases 30-50%. As
pregnancy progresses, cardiac output can
be compromised by patient positioning as
the uterus compresses the vena cava,
consider position for transport to reduce
aortocaval compression – Left Lateral Tilt
OR Manual Uterine Displacement (skill
705)
 Tidal Volume increases by up to 40% at
term. Lung capacity remains unchanged,
and therefore maternal ability to
compensate for increased oxygen demand
is decreased. Monitor SPO2 closely.
 Blood Volume rises throughout pregnancy
up to 50% in the 3rd trimester. Plasma also
increases, but at a slower rate, so the blood
plasma concentration is effectively reduced.
Maternal patients compensate for blood loss
by restricting blood flow to the uterus.
Therefore, physiological signs of significant
bleeding may be a late sign and
consideration for rapid transport should be
made.
 Heart rate increases to approximately 85-
100 at the end of the 3rd trimester
 Blood pressure falls in the first trimester.
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Structured Assessment Early Pregnancy Bleeding
 Gestation? Late pregnancy/APH ≥20 weeks
 Complications expected? – Gestational  Placenta Abruption/praevia
diabetes, Pre-eclampsia, multipara,  Gestational HTN and Pre-eclampsia
mal-presentation, placenta praevia, previous
complications. Supine Hypotension Syndrome
 Membranes ruptured? What was the colour Thromboembolic Disease

of the amniotic fluid? Multiple Births
Pre Term Delivery
 Have contractions started? Frequency and
Malpresentation
duration?
Cord Prolapse
 Is there an urge to Push? PPH
 Fetal Movements – increased, absent?
 Any current complaints? Bleeding, Increased
BP, Pain, Trauma
 Maternal medical history, blood group and
obstetric history
 National Pregnancy Records if available
Transport
 <20 weeks – nearest/allocated ED
 ≥20 weeks – obstetric unit
 ALL pregnant patients suffering major
trauma. Follow major trauma guideline (CPG
1.1E)
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6.2A COMPLICATIONS IN PREGNANCY
HAEMORRHAGE DURING PREGNANCY
July 2017
Early Pregnancy Bleeding <20 weeks  Vaginal Examination is NOT to be

 Miscarriage – Spontaneous loss of performed by SJA officers
pregnancy
 Ectopic Pregnancy - extra uterine gestation
usually in the fallopian tube. Ruptured
ectopic pregnancy usually occurs between
6-10 weeks gestation
Late Pregnancy bleeding (APH) ≥20 weeks
 Onset of labour (bloody show)
 Placenta Praevia – placenta is implanted in
lower uterine
 Placenta Abruption - premature separation
of the placenta from the uterus
 Vaginal bleeding (may be concealed)  Early pregnancy loss cannot be prevented
 Abdominal Pain  Early pregnancy bleeding does NOT
 Rigid abdomen always result in miscarriage and some can
go onto have a normal pregnancy
 Signs of shock
 Ectopic pregnancy should be suspected in
 Shoulder tip pain (Kehr’s sign) ALL sexually active women presenting with
any of the associated features

 Support and reassurance
Liaise with obstetrics unit in the metro area
 Patient Positioning (avoid aortocaval recording all advice on EPCR
compression)
Liaise with local hospitals in country recording
 Oxygen (CPG 1.5) all advice given on EPCR
 Vital Signs
 ECG
 IV access
 Consider analgesia
 Duration, amount, colour, consistency and
pattern of blood loss
 Apply a clean pad and retain all
swabs/dressings etc.
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.2A Haemorrhage During Pregnancy
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Transport
 <20 weeks – nearest/allocated ED
 ≥20 weeks – obstetric unit
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OBSTERIC EMERGENCIES
6.2B COMPLICATIONS IN PREGNANCY
PRE-ECLAMPSIA/ECLAMPSIA
July 2017
Hypertension occurs in 4% of all pregnancies in  N/A
WA.

Hypertension in pregnancy is defined as;
 Systolic BP ≥140mmHg and/or diastolic
≥90mmHg
 Severe hypertension systolic ≥170mmHg
and/or diastolic ≥110mmHg
Gestational
 Hypertension ≥20 weeks gestation
Pre-eclampsia
 Hypertension ≥20 weeks gestation with one
or more signs of organ involvement
Eclampsia
 Rare condition where hypertension results
in seizures
 Increasing BP  N/A
 Severe headache
 Visual disturbances – flashing lights
 Nausea and Vomiting
 Abdominal pain
 Hyper-reflexia
 Convulsions/seizures – eclampsia
 Increased bleeding/bruising
 Intrauterine growth restrictions

 Support and reassurance Liaise with Obstetrics units in the metro area,
 Open, clear and maintain the airway recording all advise given on EPCR
 Patient Positioning (avoid aortocaval Liaise with local hospitals in country, recording
compression) all advice given on EPCR
 Oxygen (CPG 1.5)
 Vital Signs
 ECG
 IV access
 Treat seizures as per CPG 2.3
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6.2C COMPLICATIONS IN PREGNANCY
PRETERM LABOUR & BIRTH
July 2017
Preterm refers to <37 weeks gestation  N/A

 Contractions  Not all women presenting with preterm
 Abdominal Pain contractions will progress to actual labour
and birth.
 Vaginal loss (mucous, blood, fluid)
 Extreme prematurity (<28 weeks) is a
 Lower back pain
multifactorial condition associated with a
 Pelvic pressure high risk of serious illness or mortality.
 If in doubt whether to initiate or withhold
resuscitation, it is best to start until the
situation is clarified later.
 Premature infants are at risk of
hypothermia, skin to skin contact is strongly
recommended.

 Support and reassurance Liaise with Obstetrics unit in the metro area,
 Patient Positioning (avoid aortocaval recording all advise given on EPCR
compression) Liaise with local hospitals in country, recording
 Oxygen (CPG 1.5) all advise given on EPCR
 Vital Signs
 ECG
 IV access
 If preterm birth is inevitable, prepare for
delivery as per normal birth CPG 6.3
 Prepare for malpresentation CPG 6.4A/B/C
 Prepare for newborn resuscitation CPG
4.6B2
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6.3 NORMAL BIRTH
July 2017
The physiological process by which the foetus,  Avoid supine position
placenta and membranes are expelled  Do not attempt delivery of malpresentation

through the birth canal. unless imminent
 Spontaneous onset between 37 and 42  Do NOT pull on the cord
weeks’ gestation.
 The progress of labour is within acceptable
limits.
Stages of labour;
Precautions/Notes
 1st Stage from the start of labour until the
cervix is fully dilated (several to many  Consider vehicle for back-up
hours).
 Be prepared to stop the vehicle for delivery
 2nd Stage full dilation of the cervix until the
 Fentanyl may provide limited relief of pain
birth of the baby (few minutes to several
during labour. Where possible obtain
hours).
mothers consent and advice of possible
 3rd Stage after birth of the baby until the effects on both mother and baby, which may
placenta and membranes have delivered last several days. Fentanyl use may also
(few minutes to an hour). interfere with breastfeeding. Document
 4th Stage the first few hours after birth accordingly.
 Suction is not routinely recommended with
newborns and may cause bradycardia and
airway damage. Only suction if there is a
clear indication for its use - meconium or
blood clots in airway. Refer to Skill 304
baby mucus extractor
Indications Complications/Side Effects

Signs of imminent birth  Haemorrhage during pregnancy
 Loss of operculum plug (bloody show)  Pre term labour
occurs when the cervix dilates and the  Pre-eclampsia/Eclampsia
mucous plug dislodges
 Shoulder dystocia
 Increasing frequency and severity of
 Breech presentation
contractions (3-5 contractions in a 10-minute
 Cord prolapse
period)
 Urge to push or open bowels  PPH
 Bulging perineum/anal pouting

 Crowning/presentation of part of the baby
 Spontaneous rupture of membranes can
occur during the 1st or 2nd stage of labour
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Management/Dose
1st Stage Labour
 Maternal Vital Signs – Heart rate, blood pressure, SPO2, BSL, temperature
 Position – Support the mother to find a position of comfort. Avoid placing the mother supine to
prevent compression of the inferior vena cava
 Exclude cord prolapse CPG 6.4B/skill 702
 IV assess

 Consider analgaesia (methoxyflurane is not contraindicated in labour, and should only be
withheld if the mother gets too drowsy)
 Assess stage of labour, if birth imminent, prepare for delivery as per Skill 701
Care of the Newborn

 Record time of delivery
 Stimulate the baby to induce crying e.g. rubbing towel on the baby’s back.
 Place the baby onto the mothers abdomen and encourage skin to skin contact. Place a dry
towel on top and allow the baby to suckle to assist with the release of oxytocin and delivery of
the placenta
 Assess APGAR at 1 minute, 5 and 10 minutes after birth
 Clamp and cut the umbilical cord with two cord clamps. Place the first clamp 4 fingers from the
baby’s body, place the second 2 fingers from the first clamp. Wait for the cord to stop pulsating
and cut the cord in between the 2 clamps. If bleeding present, apply a third clamp.
 Refer to CPG 4.62B for Newborn Life Support.
3rd Stage Labour

 Apply pad to vagina and ensure no excessive blood loss has occurred. Refer to CPG 6.5 Post
Birth Complications
 Suckling of the newborn will induce the delivery of the placenta. The mother will experience the
same contractions as with delivery of the baby
 Do not try to deliver the placenta
 If the placenta delivers spontaneously, place in a biohazard bag and transport with the mother
 Cover mother and keep warm
 Monitor mother and baby en route to hospital
Transport to Booked Obstetric Unit with pre notification.
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APGAR was designed to help health care providers assess a newborns overall physical
condition so that they could quickly determine whether the baby needed immediate medical
care. It was not designed to predict the baby’s long term health.
≥ 7 at 1 minute after birth is generally considered in good health.
A slightly low APGAR score (especially at 1 minuet) is normal for some newborns, especially
those born after a high-risk pregnancy, e.g. caesarean section, or a complicated labour and delivery.
Lower APGAR scores are also seen in premature babies, who usually have less muscle tone than full-
term baby’s and in many cases, will require extra monitoring and breathing assistance because of
their immature lungs.
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6.4A BIRTHING COMPLICATIONS/DIFFICULT BIRTH
CORD PROLAPSE
July 2017
Umbilical cord prolapse is an obstetric  Do NOT touch the cord or push back in

emergency occurring in 0.2-0.4 of births (KEMH,
2014).
Definitions;
 Umbilical cord presentation (Figure A)
the umbilical cord lies in front of the
presenting part, the membranes are intact.
 Umbilical cord prolapse (Figure B)
the cord lies in front of the presenting part
and the membranes are ruptured.
 Occult umbilical cord
presentation/prolapse (Figure C)
 the cord lies trapped beside the presenting
part, rather than below it.
(KEMH, 2014)
If the cord is visible at the vaginal opening after  Delays in recognition and management are
the membranes have ruptured. This should be associated with significant perinatal
considered in all women at high risk for cord morbidity and mortality due mainly to
prolapse; complication associated with preterm birth
 Malpresentation and birth asphyxia. Therefore, cord
 Low birth weight prolapse required urgent intervention and
 Multiple gestation assistance.
 Multiparity  During emergency ambulance transfer, the
 Preterm Labour knee–chest position is potentially unsafe,
 Abnormally long umbilical cord the exaggerated Sims position should be
assumed (left lateral with pillow under hip).
 Handling the cord risks continued cord
compression and vasospasm.

 Support and reassurance Liaise with obstetrics unit in the metro area
 Note the time recording all advise on ePCR
 Patient positioning – Place the mother in a
Liaise with local hospitals in country recording all
knee to chest position (Figure D) and
transport in the exaggerated sims position advise given on ePCR
(Figure E) to keep fetal presenting part off
the cord
 Vital Signs
 Cover the mother with a sheet/blanket to
maintain dignity and body heat. Do not
touch the cord.
 If birth is imminent and the mother is
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4A Cord Prolapse
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actively pushing, deliver the baby as soon
as possible
4.6B2
Transport P1 immediately as this requires
immediate C-section. Provide early notification
to the receiving unit to enable preparation.

Cord Presentation (Figure A) Cord Prolapse (Figure B) Occult Cord (Figure C)
Source http://accessmedicine.mhmedical.com/Content.aspx?bookId=498&sectionId=41008609 accessed 04/05/2017
Knees to chest (Figure D) Exaggerated Sims Position (Figure E)
Source https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/cord-prolapse.pdf accessed

04/05/2017
Further Reading:
King Edward Memorial Hospital Clinical Guidelines: Obstetric & Midwifery (2014). Umbilical Cord
Prolapse. Perth WA
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/11/b11.3.2.pdf
https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4A Cord Prolapse
Page 2 of 2
6.4B BIRTHING COMPLICATIONS/DIFFICULT BIRTH
SHOULDER DYSTOCIA
July 2017
Shoulder dystocia is best defined as the need

for additional obstetric manoeuvres to effect the
birth of the shoulders of the baby. The
incidence varies around 1%, with a high
associated perinatal morbidity and mortality
despite appropriate management. Maternal
morbidity is increased due mostly to post-
partum haemorrhage (PPH) and fourth degree
perineal tears. The most common fetal injury is
brachial plexus palsies; with research indicating
that the frequency of injury remains constant
regardless of operator expertise (KEMH, 2016).
Shoulder Dystocia occurs when one shoulder of

the baby lodges against the mothers pubic
bone (symphysis pubis) and prevents further
progress through the birth canal.
 Difficulty with birth of the face and chin Maternal Risk Factors
 The fetal head retracts against the  Increasing maternal age
perineum referred to as ‘turtle’ sign  Maternal obesity
 Failure of the fetal head to restitute  Maternal birth weight
 Failure of the shoulders to descend  Prolonged pregnancy
 Short stature
 Previous history of Shoulder Dystocia
 Gestational Diabetes
 Post dates (over due)
 Abnormal pelvic anatomy
Foetal risk factors
 Suspected Macrosomia (>4.5kg)
 rotracted active 1st stage of labour
 Protracted 2nd stage of labour
 Anomalies (e.g. Hydrocephalus)
 Co-joined twins

 Support and reassurance  Bracheal Plexus Injury
 Oxygen (CPG 1.5)  Perineal tears
 Vital Signs  PPH
 Perinatal morbidity and mortality
 Proceed immediately to shoulder dystocia
manoeuvres as per Skill 702
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4B Shoulder Dystocia
Page 1 of 2
 McRoberts Position is flexion and Liaise with obstetrics unit in the metro area
abduction of the maternal hips, positioning recording all advise on ePCR
the maternal thighs on her abdomen.
Liaise with local hospitals in country recording all
 Rubin manoeuvre is continuous suprapubic
pressure applied in the McRoberts position advise given on ePCR
to improve success rate.
 Rockin rubin is then adopted in an attempt
to deliver the impacted shoulder.
 The mother is then positioned on all fours
(reverse McRoberts) in an attempt to

deliver the none impacted shoulder.
 Prepare for resuscitation of both patients
Transport Priority 1 to nearest obstetric unit

repeating all manoeuvres en route.
Source: http://www.slk-art.com/shoulder-dystocia/ assessed 04/05/2017
Further Reading:
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/5/b5.9.5.p
df
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4B Shoulder Dystocia
Page 2 of 2
6.4C BIRTHING COMPLICATIONS/DIFFICULT BIRTH
BREECH PRESENTATION
July 2017
Breech presentation means the baby is lying  Delivery should NOT be attempted unless it

longitudinally with its bottom and/or feet is absolutely inevitable
presenting first to the lower part of the mother’s  Delivery of a footling should NOT be
attempted in the pre-hospital setting
uterus. (RANZCOG, 2016).
 Do NOT attempt to push the baby back in
or pull on baby
Breech occurs in 3-4% of term deliveries and is
more common in preterm.
Presentation of any part of the baby other than Risk Factors;
the head.  Nulliparous women
 Frank breech  Previous Breech presentation
 Buttock presentation  Pre-term delivery
 Complete breech  Multiple pregnancies
 Footling breech  Placenta praevia
 Malformation of uterus or foetus
 Uterine and congenital abnormalities

 Support and reassurance  Significant cord compression is common
 Maternal Vital Signs – Heart rate, blood (CPG 6.4A)
pressure, SPO2, BSL, temperature
 IV assess Increased risk of short term complications;
 Oxygen (CPG 1.5)  Erb’s palsy (paralysis of the arm)
 Consider analgaesia (methoxyflurane is not  Fractures to the clavical, humerus & femur
contraindicated in labour, and should only  Dislocations of the hips and shoulders
be withheld if the mother gets too drowsy)
 If delivery is inevitable, follow skill 703 Liaise with obstetrics unit in the metro area
 Position – Lithotomy Position
recording all advise on EPCR
 Exclude cord prolapse CPG 6.4B/skill 702
 If the baby’s head does not deliver Liaise with local hospitals in country recording all
spontaneously, a modified Mauriceau advise given on EPCR
Smellie Veit (MSV) manoeuvre may need
to be considered.
4.6B2
Transport Priority 1 to nearest obstetric unit
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4C Breech Presentation
Page 1 of 2
Further Reading:
http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.10.3.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2016).
Management of breech presentations at term.
https://www.ranzcog.edu.au/RANZCOG_SITE/media/DOCMAN-
ARCHIVE/Management%20of%20breech%20presentation%20at%20term%20(C-
Obs%2011)%20Review%20%20July%202016.pdf Accessed 05/05/2017
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.4C Breech Presentation
Page 2 of 2
6.5 POSTPARTUM HAEMORRHAGE (PPH)
July 2017
PPH is defined as blood loss >500ml after
childbirth / or blood loss that significantly
compromises the mother. In Australia PPH has

an incidence rate of between 5 to 15% and
remains a leading cause of maternal death.
PPH can lead to hypovolaemic shock and
maternal death if not managed. Most birth
cases require minimal active management but a
small percentage of patients may become
compromised.
Causes of PPH include the four Ts;
 Tone - lack of the uterine tone (Atony)
 Trauma - uterus, cervix, vagina or
perineum
 Tissue - retained products of conception
 Thrombin – Blood clotting disorders
Blood loss >500ml after birth Visual estimation of blood loss is often
underestimated. Clinical signs of poor
perfusion should prompt a thorough
assessment (CPG 4.5.1). Display a high
degree of suspicion with frequent observations
for all patients with PPH.
Consider additional resources for care of the

newborn, maintain momentum in care and
commence transport as soon as possible to
definitive care.
Atony may be present if you fail to locate the

fundus, or it feels soft.

 Support and reassurance Liaise with obstetrics unit in the metro area
 Keep the patient warm recording all advice on ePCR.
Liaise with local hospitals in country recording
 Encourage mother to empty bladder
all advice given on ePCR.
 Maternal Vital Signs
 IV access
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.5 Postpartum Haemorrhage
Page 1 of 2
 Encourage breast-feeding (stimulates
uterine contraction)
 Fundus massage to stimulate uterine
contractions (Skill 704)
 External Aortic compression only in life-
threatening uncontrolled haemorrhage

(Skill 704)
 Apply direct pressure to any visible external
bleeding tissue
 Call for specialist obstetric advice
Transport Priority 1 to nearest obstetric unit if
compromised.
Further Reading:
World Health Organization (2012), WHO recommendations for the prevention and treatment of
postpartum haemorrhage, http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
Accessed 16/06/2017
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2016).
Management of Postpartum Haemorrhage,
https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-
MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Management-
of-Postpartum-Haemorrhage-C-Obs-43-Amended-February-2016.pdf?ext=.pdf Accessed 15/06/2017
© Copyright St John Ambulance Australia (Western Australia) Inc. 6.5 Postpartum Haemorrhage
Page 2 of 2
METABOLIC
7.1A HYPOGLYCAEMIA
March 2012
When the Blood Glucose Level (BGL) falls
below that required for optimal physiological
function, (usually < 4mmol/L) with demonstrable
signs or symptoms.

 Weakness, trembling, shaking.  Diabetic patients taking Glucobay
 Diaphoresis. (Acarbose) have a greater glucose
 Headache. requirement due to stimulation of pancreatic
insulin release.
 Abnormal behaviour.
 Consider the aetiology of hypoglycaemia
 Altered conscious state.
when selecting the most appropriate
 Tachycardia.
treatment (eg: glucagon will be ineffective in
 Seizure the absence of adequate hepatic glycogen
stores).
 Chronic poorly controlled diabetes may be
hypoglycaemic despite a BGL >4mmol/L.
 Encourage transport post treatment.

 Assess BGL.  Seizure
 If GCS permits, give oral carbohydrate  Coma
 If GCS does not permit oral intake:  Brain Damage
 10% glucose as per CPG 11.20 if IV
access in situ or readily obtainable.
 IM Glucagon as per CPG 11.15 if IV
access is delayed or not obtainable.
 Reassess after 10 minutes. If the BGL is
still low and the patient symptomatic:
 Encourage oral intake or complex
carbohydrates, patient condition
permitting.
 Repeat IV Glucose as per CPG 11.20
or IM Glucagon as per CPG 11.15
where patient condition does not
warrant oral intake.
© Copyright St John Ambulance Australia (Western Australia) Inc. 7.1A Hypoglycaemia

Review Date March 2017
Page 1 of 2
HYPOGLYCAEMIA
Patient is conscious and

Yes able to tolerate oral intake No

Oral Carbohydrates IV access available /
easy to obtain
Examples:
Yes No
▪ 15g Glucose gel
▪ 3 teaspoons sugar
dissolved in liquid
▪ 5 – 7 jelly beans
▪ 1 glass soft drink
Give IV bolus of Give IM
Glucose 10% as Glucagon as
Follow up with: per CPG 11.20 per CPG 11.15
▪ A sandwich
▪ 1 glass of milk
▪ Piece of fruit
Hypoglycaemia
Still in 10 minutes or not
recovery of full mental
status and unable to
Hypoglycaemia tolerate oral carbohydrates
Still in 10 minutes
© Copyright St John Ambulance Australia (Western Australia) Inc. 7.1A Hypoglycaemia

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METABOLIC
7.1B HYPERGLYCAEMIA
March 2012
Significant hyperglycaemia can present as:
 Diabetic Ketoacidosis (DKA) – normally seen
in Type 1
 Hyperosmolar Hyperglycaemic State

(HHS) – normally seen in Type 2.
Caused by: Illness, infections, stress, too much
carbohydrate, not enough medication, insulin
pump failure, and medicines such as steroids.
 Polydipsia  HHS usually presents in older patients with
type 2 diabetes mellitus and carries a higher
 Polyuria
mortality rate than, and is less common than
 Fatigue DKA.
 Blurred vision  Ketoacidosis is not normally seen with type
 Nausea/vomiting 2 diabetic patients as they have some
insulin production preventing severe
 BGL usually > 16mmol/L
lipolysis.
 Ketone breath (DKA)
 Kussmaul breathing (DKA)
 Tachycardia
 Hypotension
 Dehydration, dry skin, sunken eyes
 Altered conscious state

 Oxygen  Severe dehydration
 Vital signs  Electrolyte imbalance
 Cardiac monitor  Coma
 IV access  Death
 Allow fully conscious patient to self-
administer insulin
© Copyright St John Ambulance Australia (Western Australia) Inc. 7.1B Hyperglycaemia

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METABOLIC
7.2 HOME RENAL DIALYSIS EMERGENCIES
June 2002

 What happened?
 When did it happen?
 Did the patient have altered consciousness?

 Was there any fitting? (usually follows air embolism).
 Special physical findings:
 Disconnection of lines.
 Air in the tubes.
 Seizure or having suffered a stroke-like problem.
 Patient unconscious.
Management:
 Oxygen, high concentration or 100%.
 Immediately remove the patient from the machine by turning off the power at
the wall and clamping both blood lines about 25 cm from the arm. Then cut
the plastic lines between the clamps and the machine with a pair of scissors.
 If major blood loss has occurred, consider cannulation and fluid infusion.
 Monitor the ECG and look for abnormal complexes and arrhythmias. Record.
 Treat seizure as per CPG Neurological 2.3 Fits and Seizures.
 Suspect venous air embolism by the history of air in the venous return line of
the shunt.
 If present, treat with 100% 0xygen and position lying down on the side.
 Take care to avoid unnecessary contact with blood as serum hepatitis is
common in dialysis patients.
 However, intact skin completely protects against transmission of blood-borne
infections.
Critical points for patient record:

 Type of dialysis machine.
 Main problem.
 Other problems.
© Copyright St John Ambulance Australia (Western Australia) Inc. 7.2 Home Renal Dialysis Emergencies
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ENVIRONMENTAL
8.1 HYPERTHERMIA
March 2013
Mild to severe reactions to high temperature due
to inadequate or inappropriate responses of

heat-regulating mechanisms.
O
 Core temperature greater than 38 C  Active cooling should be ceased once core
 Heat Cramps: Painful, involuntary muscle temperature reaches 38O C, as shivering
cramps usually in the lower extremities may occur which will increase core
 Heat Exhaustion: Excessive fluid loss temperature and oxygen consumption.
leading to hypovolemia.  Paracetamol has not proved effective in
 Heat Stroke: Life-threatening form of reducing hyperthermia secondary to heat
heat related illness. Core temperature stroke.
greater than 40.5O C in the presence of  In the initial stages of heat stroke, CNS
thermoregulatory system failure and an dysfunction is observed. These are the first
altered mental state. signs of thermoregulatory failure.
 Heat stroke has been the cause of death in
children locked in cars on hot days. An
unventilated car acts like an oven, with the
temperature inside rising to 54-60O C over a
10 min period.

 Remove patient from source of heat.  Direct thermal damage to cerebral tissue
 Remove clothing. combined with decreased cerebral blood flow
 Cool patient (ice packs, fan, moist cloths). often produces cerebral oedema, further
exacerbating CNS dysfunction.
 Oxygen if hypoxic (SaO2 < 95%).
 Hepatic damage, Rhabdomyolysis, DIC
 IV access - consider fluid therapy (CPG
(disseminated intravascular coagulopathy),
11.19) - Give cool IV fluids if possible.
Multiple organ failure, Hypoglycaemia, ARDS,
 Monitor temperature and BSL.
acid base imbalance.
 Position supine.
 Aspiration and seizures.

8.1 Hyperthermia
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ENVIRONMENTAL
8.2 HYPOTHERMIA
July 2017
Hypothermia is defined as a core temperature  Nil.
below 35OC.
Definitions:
O

 Mild hypothermia: temp 32-35 C
O
 Moderate hypothermia: temp 30-32 C
O
 Severe hypothermia: temp < 30 C.
Assessment Precautions/Notes
Signs and Symptoms:  Avoid sudden motion, which may trigger
O
 32-35 C: decreased RR, lethargy, ventricular arrhythmia in moderate to severe
weakness, slurred speech, ataxia, shivering hypothermia.
may cease.  Controlled hypothermia can play a positive
O
 30-32 C: muscle rigidity, poor reflexes, role in managing a patient post cardiac
dilated pupils, hypotension, bradycardia. arrest. In this situation hypothermia is used
O
 < 30 C: flaccid muscles, fixed pupils, to protect the patient from the detrimental
arrhythmias, cardiac arrest. effects of reduced cerebral perfusion (32-
34ºC).
 Immersion hypothermia generally develops
more rapidly as well as in patients where
thermo- regulation is impaired (the elderly
and very young).
 On the ECG of a hypothermic patient there
are often characteristic Osborne (J) waves.
An Osborne wave is a slow, positive
deflection at the end of the QRS complex,
most prominent in lead II and V3-V6.
 Remove from cold environment. Cardiac Arrest secondary to Hypothermia:
 Give warm oral fluids if the patient is fully  Hypothermia in Western Australia as a
conscious. cause of cardiac arrest is extremely rare
and mostly accidental e.g. locked in a cool
 Position - recumbent or position of comfort. room. If you suspect that the cardiac arrest
 Oxygen if hypoxic (SpO2 < 95%). was secondary to hypothermia, the
emphasis is on high performance CPR and
 Remove wet and cold clothing.
transport.
 Passively re-warm (blankets and warm
 ASMA available for advice.
surroundings).
 Monitor temperature and BSL.
© Copyright St John Ambulance Western Australia Ltd 8.2 Hypothermia

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© Copyright St John Ambulance Western Australia Ltd 8.2 Hypothermia

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ENVIRONMENTAL
8.3 IMMERSION
July 2017
Drowning is the process of primary respiratory  N/A
impairment resulting from immersion /
submersion in a liquid medium.

 Immersion of the face in water (or other  Vomiting and regurgitation often occur
liquid). following immersion.
 Breath-holding.  Consciousness is not synonymous with
 Vigorous breathing efforts. Water may be recovery, since delayed death from hypoxia
drawn into the airway causing laryngeal can occur.
spasm.  Gastric distension. Do not attempt to empty
 Swallowing of air and water. This usually the stomach by external pressure.
causes vomiting or regurgitation.  Potential spinal injury.
 Laryngeal spasm relaxes after loss of  Soiled airway.
consciousness and water and vomit may be  Hypothermia.
drawn into the lungs.

 Remove victim from water as soon as
possible and only begin rescue breathing in
water if immediate exit is impossible.
 Position lateral and check for breathing.
 Initial resuscitation if patient in cardiac
arrest (CPG 4.6).
 Oxygen.
 Monitor (ECG, Sp02, Temp, BSL).
 Spinal immobilization if indicated.
 Treat Hypothermia (CPG 8.2).
 Fluid resuscitation to correct hypovolemia
but avoid excessive volumes (CPG 11.19).
© Copyright St John Ambulance Western Australia Ltd 8.3 Immersion

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© Copyright St John Ambulance Western Australia Ltd 8.3 Immersion

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ENVIRONMENTAL
8.4 DIVING EMERGENCIES
July 2015
Diving injuries include but are not limited to:
 Arterial Gas Embolism.
 Decompression Sickness.

Pulmonary barotrauma.
Decompression illness (DCS and AGE):  Note circumstances surrounding the
 Decompression Sickness (DCS): Where event including dive history — depth,
the nitrogen absorbed into the body’s duration, repetitive dives, ascent, time of
tissues during a dive as a result of onset of problem.
pressure changes does not have time to  Definitive treatment for decompression
diffuse from the tissue back into the illness is recompression and should be
bloodstream and be eliminated by the sought as soon as possible. Fiona
lungs. That nitrogen stays as bubbles in Stanley Hospital provides hyperbaric
the tissue, blood or lymphatic system. treatment for Western Australia.
Any organ in the body may be affected.  A supine posture without leg elevation is
recommended in injured divers suspected
 Arterial Gas Embolism (AGE): A bolus of of DCI as it has been shown to increase
the rate of inert gas elimination. It may
gas or air within the blood vessels, which
may be caused by over-inflation of the also reduce the likelihood of arterial
lungs following traumatic chest injury, bubbles migrating to the brain.
secondary to distension or barotraumatic  However, if a conscious diver is having
rupture of alveoli due to trapped gases in increased SOB when supine, they can be
scuba divers. Can also occur during placed in a position of comfort.
mechanical ventilation.  Administration of 100% oxygen reduces
the size and number of gas bubbles in the
bloodstream and tissue by helping to
Clinical Presentation
eliminate the inert gas in the bubbles and
o Extreme fatigue
blood.
o Numbness/tingling
 Symptoms of arterial gas embolism
o Headache or other body pain
almost always begin within 10 minutes of
(joint)
surfacing and are primarily neurological in
o Poor balance/coordination nature.
© Copyright St John Ambulance Australia (Western Australia) Inc. 8.4 Diving Emergencies
Review Date: June 2020
Page 1 of 2
o Irritability, confusion, decreased  Joint pain can occur at depths less than
GCS 10 m, and any joint pain within 24-48
o Weakness, paralysis hours of a dive should be treated as
o Rash decompression sickness.
o Speech, visual/hearing  Obesity lengthens the time during which
disturbances the diver is at risk of DCI, as nitrogen is
slowly absorbed and slowly released.
 Coronary artery emboli may present as an
Pulmonary Barotrauma
acute myocardial infarction or

 Pulmonary Barotrauma: Injury produced
dysrhythmia.
as the result of volume increases in air-
filled cavities expanding on ascent.
Clinical Presentation
o Chest pain
o SOB, coughing, cyanosis
o Dysphagia
o Surgical emphysema around
neck
 Decreased GCS

 Position: supine if possible
 Oxygen – high flow (100%)
 Monitor
 Fluid resuscitation (CPG 11.19)
 Hypothermia (CPG 8.1)
 Analgesia
© Copyright St John Ambulance Australia (Western Australia) Inc. 8.4 Diving Emergencies
Review Date: June 2020
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ENVIRONMENTAL
8.5 RADIATION EXPOSURE
September 2002
Specific information needed: Note on patient record:

 Type of hazard.
 Radioisotopes involved.
 Irradiation from solid sources.

 Industrial and laboratory waste.
 Duration of exposure.
 Type of contamination.

 None peculiar to irradiation in the acute phase.
 All normal care as for any casualty.
Management:
 Danger (assess likely level of risk).
 Gather HAZCHEM information, advise Communications Centre then take
direction from the Hazard Management Agency or Combat Agency.
 If the patient has not been adequately decontaminated or decontamination
cannot be assured, then put on appropriate protective equipment as soon as
practical.
 Response, Airway, Breathing, Circulation, Disability, Exposure.
 Treat presenting medical problems.
 If possible, remove the patient and all other people involved, injured or not
from the source of contamination. If required, follow decontamination
instructions from the Hazard Management Agency or Combat Agency.
 Instruct patients, especially if not seriously injured, not to leave the scene until
experienced specialists have tested them with monitors to ascertain whether
or not they have been contaminated.
 Put a sheet on the stretcher and wrap the patient. This will minimise spread
of contamination to attendants, ambulance and later on, in the hospital. Patient
is of course unwrapped if continuing medical care is needed.
 If possible advise Hospital of nature of incident prior to arrival. Following
handover to hospital staff, assist at their direction.
© Copyright St John Ambulance Australia (Western Australia) Inc. 8.5 Radiation Exposure
Page 1 of 3
 The irradiated patient is no hazard to the attendants unless loose
contaminants remain on the external surfaces (similar to the burned patient).
 Contamination is never a medical emergency. Even with spill of a vanload of
medical isotopes, significant medical hazard is almost inconceivable. The
extent of radiation from an uncontrolled source cannot be guaranteed until
measured by Radiation Health or the Chem. Centre.
 The most common radiation incident arises from the daily transportation of
numerous radioactive industrial and medical materials.

 Accidents may cause mechanical damage to containers, and there may be
physically injured patients.
 Handling of radiation accidents must be demystified. The Officer need never
hesitate to give medical attention to victims, due to the "radioactive material"
sign displayed on the vehicles. Simple basic rules apply.
 The Officer is protected from the radiation source by distance, a reduction of
exposure time, and shielding.
 Surface contaminations are not life threatening, and no patient has ever died
from secondary exposure to surface contamination. For the Officer it is a
nuisance, which needs special precautions essentially to prevent the spread of
contamination to attendants, ambulance, hospital emergency facilities, etc.
At the scene:
 Gather HAZCHEM information, advise Communications Centre then take
direction from the Hazard Management Agency or Combat Agency.
 If a vehicle displays the radioactive HAZCHEM sign, the Officer must assume
that some form of radiation is present.
 Officers should try not to spread the contamination unnecessarily i.e. into
ambulances, hospitals or to other workers and to follow instructions from their
Supervisors or the Hazard Management Agency or Combat Agency.
 Washing removes contamination.
At the Hospital:
 If possible give hospital prior warning of arrival and details of incident.
 Assist hospital staff to follow their procedures for the handling the patient.
 This may include:
 Place sheet on floor, place stretcher on sheet, unwrap the patient, cut off
patient's clothing avoiding shaking the material and distributing
contaminated material more than necessary.
 Leave patient’s clothing and the stretcher. This will remove at least 90% of
the radioactive material in the case of surface contamination.
 Emergency Department Staff will be gowned and gloved. They will lift
patient onto a clean stretcher or decontamination tabletop where they will
be further decontaminated by soap and water washing. Nail, hair and skin
samples are taken for radioactivity dose measurement.
Page 2 of 3
 Officers may now need to remove their outer clothing if so instructed by a
Radiation Officer, and place either in a plastic bag or with stretcher and
clothing. Stretcher, patient’s clothes, and any other possibly contaminated
clothes are carefully wrapped.
 Officer and others wash with soap and water, face first, then hands, and
discard washcloths.
 Await monitor check for any residual radiation.
 Decontamination of the Officer and equipment depends on the type of hazard
encountered. Decontamination remains the responsibility of the Hazard
Management Agency or Combat Agency. It may not be possible for Officers

who have been contaminated to leave the scene. Patients may have to be
handed to non-affected Officers and vehicles.
 The removal of the CBR PPE should be supervised and the contaminated suit
bagged as per correct disposal methods. The respirator should be bagged and
kept separate, as these will be cleaned. Please follow the Information Sheet
provided with the CBR PPE and Standing Operational Policies regarding these
matters.
 Decontamination of the ambulance and equipment should be carried out at the
direction of the Hazard Management Agency. In the absence of clear
instruction, the vehicle should be cleaned internally and externally with water
and detergent.
 Note:
Radiation hazard to emergency professionals is extremely small. Basic
common-sense precautions are used. Chances of an Officer sustaining
significant radiation are virtually nil. Precautions are to avoid prolonged
contact of material with skin, which could, over a long time, produce a
significant dose.
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ANAPHYLAXIS
9.1 ANAPHYLAXIS — SEVERE
ALLERGIC REACTION
July 2017
“Any acute onset of hypotension or  There are no absolute contraindications for
bronchospasm or upper airway obstruction where adrenaline.
anaphylaxis is considered possible, even if typical
skin features are not present OR any acute onset

illness with typical skin features (urticarial rash or
erythema/flushing, and/or angioedema), PLUS
involvement of respiratory and/or cardiovascular
and/or persistent severe gastrointestinal
symptoms”, (ASCIA, 2010).
 Consider the need for advanced airway
Mild to moderate allergic reactions: management.
 Swelling of lip, face, eyes.  Position appropriately with dependent
 Hives or welts (weal-like swellings). drainage for secretions – this is usually
 Tingling mouth. on the side, or sometimes in the sitting
 Abdominal pain, vomiting (these are signs of position for the conscious patient, but
severe allergic reaction to insects). avoid standing or walking even if they
Anaphylaxis: appear to have recovered. ASCIA
advise that patients should not walk
 Difficult/noisy breathing.
post EpiPen / IM Adrenaline
 Swelling of tongue. administration due to risk of collapse.
 Swelling/tightness in throat.  Be cautious of atypical presentations, if
 Difficulty talking and/or hoarse voice. hypotensive and non-traumatic /
 Wheeze or persistent cough. cardiogenic cause, consider
 Hypotension. anaphylaxis.
 Pale and floppy (young children).
 Remove trigger / injection mechanism if  Clinical deterioration. Catastrophic
possible. hypotension could render IM Adrenaline
 Patient should be placed in the recovery ineffective.
position, unless respiratory distress  Airway compromise
predominates.  Dysrhythmia.
 Give Adrenaline (CPG 11.5).  Cardiac arrest.
 Vital Signs.  Patient should be taken to a medical facility
 Oxygen if indicated. where they can be monitored for 4 hours
 IV access/treat for shock if indicated (CPG after the last dose of adrenaline.
4.5.4).
 ECG.
 Salbutamol (CPG 11.34) if required for
persistent wheeze.
© Copyright St John Ambulance Western Australia Ltd. 9.1 Anaphylaxis

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© Copyright St John Ambulance Western Australia Ltd. 9.1 Anaphylaxis

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TOXICOLOGY
10.1 POISONS AND OVERDOSES
July 2017
Specific Information Needed:

 Type of Ingestion:
- What, when and how much was ingested?
- Bring the poison, the container, sample of emesis, and anything relevant in the
area with the patient to the emergency department.
 Reason for Ingestion:

- Tactfully screen for suicidal problems, domestic or relational problems.
 Relevant Past History:

- Medications.
- Diseases.
 Action Taken By Bystanders:

- Induced emesis? "Antidote" given?
Specific Physical Findings:

 Level of consciousness.
 Breath odour.
 Neurological status.
 Vomitus.
 Substance abuse evidence.
Management:
 External contamination:
- Protect medical personnel.
- Remove contaminated clothing.
- Flush contaminated skin and eyes with copious amounts of water.
 Internal Ingestion:
- When in doubt — call for advice from Poisons Information Centre.
- Do not induce vomiting or administer charcoal or ipecacuanha – No longer
recommended.
- Do not try to neutralise alkalis with acids.
- Do not try to neutralise acids with alkalis.
- Within first 10 minutes of ingestion of corrosives or acids it is permissible to try to
give 100ml of water in slow sips if patient can tolerate this, to dilute the
substance (after this there may be penetrating ulcers or burns).
 If patient is poorly responsive or has depressed respirations:
- Assess danger, response and support ABCs.
- Oxygen, high concentration or 100% ventilate if necessary.
 If shocked consider, cannulation and fluid infusion.
 Ventilate patient if respiratory depression requires this.
 Transport in lateral position if indicated.
© Copyright St John Ambulance Western Australia Ltd 10.1 Poisons and Overdoses
Page 1 of 4
 Monitor cardiac rhythm. Arrhythmias likely if antidepressant drugs ingested.
Specific Precautions / Notes:

 There are few specific "antidotes", and only relevant if long or delayed transport. It
is permissible to follow the instructions on the poisons container, but follow up with
Poisons Information Centre. If the information conflicts — Poisons Information
Centre's management takes priority. Watch the A.B.C., these are important.
 Inhalation poisoning is potentially dangerous to rescuers. Recognise an
environment with continuing contamination and extricate rapidly from a toxic

atmosphere.
Narcotic Overdose:
 If narcotic overdose is suspected, initial and preferred management is by
maintaining a clear airway, providing 100% Oxygen, and ventilation as necessary.
 Naloxone (CPG 11.29) is indicated for the reversal of respiratory depression
in a suspected narcotic overdose. This patient may present, unresponsive
with abnormal breathing and CPR may be a reasonable approach until
pertinent facts come to light, which suggest an opioid overdose.
 Address hypoxia prior to the administration of the opioid antagonist.
- Crews may encounter peer Naloxone in the community.
- The half-life of Naloxone may be shorter than that of the opioid.
- Consideration to personal safety, in relation to Carfentanyl should be taken,
as it comes in various forms such as including powder, blotter paper, tablets,
and spray. The substance can be absorbed through the skin or accidental
inhalation of airborne powder.
 Many overdose patients are poly-drug users. Patients using narcotics often take
other drugs in conjunction with the narcotic. These are some of the easiest patients
to ventilate, and do not necessarily need Priority 1 transport. Patient condition and
ease of control dictates professional decision on transport priority.
Organophosphate Poisoning
 Uncommon but high level of mortality
 Organophosphate (OP) pesticides are widely used in Australia as insecticides on
fruit, vegetables & grain crops.
 OP is found in herbicides, pesticides and nerve gas.
 OP pesticides can be absorbed (skin exposure), inhaled or ingested.
 Risk of arrhythmias.
 Signs / Symptoms – the result of parasympathetic overdrive
- Salivation, Lacrimation, Urination, Defecation, Gastrointestinal cramps, Emesis,
Bradycardia, Bronchospasm, and/or Bronchorrhea - SLUDGEBBB – Mnemonic.
 Management and Treatment
- Decontamination, including removal of all soiled clothing and vigorous irrigation
of all affected areas
- Airway control and adequate oxygenation and ventilation support may be
required
- Atropine (CPG 11.9) is a muscarinic antagonist – blocks action of
Acetylcholinesterase
Page 2 of 4
 In organophosphate poisoning, Atropinisation might require significant repeat
dosages and is achieved when with an increased pulse, dilated pupils and
decreased secretion, do not delay transport as atropinisation might not be
achievable in the pre-hospital setting.
Tricyclic (Antidepressant) Overdose:

 Risk of arrhythmias.
 Can deteriorate rapidly and it can be fatal, consider peri-arrest if signs of instability.
 URGENT transport.
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Page 4 of 4
TOXICOLOGY
10.2A SNAKE BITES
July 2017
Snakes produce venom in modified salivary  DO NOT apply a Pressure Immobilization
glands, administering this through fangs which Technique if the bite did not occur on a
pierce the skin. Many snakes in Australia limb.

 DO NOT cut/incise, Wash or Suck the site
(including sea snakes) are capable of delivering
of the bite.
doses of toxin lethal to humans. In reality true  DO NOT utilise an artery tourniquet, this
envenomation is rare. should be replaced with PIT if encountered
in the field.
Life-threatening effects of toxins include:  DO NOT trap/catch or kill the snake.
Medical services do not rely on visual
 Neurotoxic muscle paralysis leading to identification for anti-venom selection.
respiratory arrest;
 Coagulation failure leading to excessive
bleeding;
 Muscle damage which leads to kidney
failure.
 Several snake species in WA pose a
threat to humans. Tiger, Coastal Taipan,
King Brown, Dugite and Death Adder
snakes are all highly venomous.
Snake Bite Indications  The size of the patient in relation to the
volume of venom will be determinants in
 Puncture mark(s) or scratch predicting the rate of envenomation. For
 Bite may be painless, without any visible infants and paediatric patients the rate of
marks (localized bruising or redness is envenomation would be faster than that of
uncommon in Australian snake bites). larger adults.
 Headache, nausea/vomiting, abdominal  It is advisable that all potential snake bite
pain. victims be transported to a medical facility
 Swollen or tender lymphatic glands at for assessment.
groin/axilla of bitten limb.  Most venom reaches the blood stream via
the lymphatic system. Research by the
Symptoms can resemble dysfunction of the ARC indicates little venom reaches the
CNS: circulation, even after several hours, if a
Pressure Immobilization Technique is
 Confusion, collapse, visual disturbances applied IMMEDIATELY and
or drooping eyelids, difficulty speaking, MAINTAINED1. These patients are NOT
swallowing or breathing, considered time critical, unless signs of
weakness/paralysis, respiratory envenomation is evident.
weakness/arrest, seizure.  Venom Identification kits are used to
detect type of venom on patient skin or
clothing.
 Anti-venom is available for all venomous
1
ANZCOR, Guideline 9.4.1 (2011)
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2A Snake Bite
Page 1 of 2
Australian snake bites.
 Paralysis may be long lasting and where
possible treatment for respiratory or
cardiac arrest should continue until arrival
at an appropriate medical facility.
 Keep patient at rest and reassured. Limit
movement by the patient.
 CPG 4.6A / B for cardiac arrest, or assist

ventilations as required.
 Apply Pressure Immobilization Technique
to bitten limb as per Skill 809. If applied
correctly, and in a timely fashion, the PIT
should slow the progression of venom.
 Limb can be splinted to minimize
movement.
 Monitor and re-evaluate continuously.
 Vital signs, oxygen saturation, ECG, IV.
 Monitor for respiratory depression, if
required assist ventilations
 Keep the patient and limb completely at
rest. Do not walk the patient.
 Consider prehospital bloods, where
available.
 Urgently transport if signs and symptoms
of envenomation is evident.
 DO NOT remove bandages or splint prior
to arrival at a suitable hospital for
treatment.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2A Snake Bite
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TOXICOLOGY
10.2B SPIDER AND INSECT BITES
July 2017
Bites from spiders, bees, ticks and other  Pressure Immobilization Technique
insects can cause redness and pain locally. (PIT), is not to be used on spider or

insect bites (except the Funnel web
Insect bites can be painful, but rarely result spider).
in a serious reaction, unless the patient has
an allergy to the venom, previously known or
unknown.
 In susceptible individuals  Venom of the Redback spider can
allergy/anaphylaxis may occur. Watch pose a threat to life in children.
for respiratory and gastrointestinal  Venom from spider and insect bites
symptoms, and treat for anaphylaxis if spreads slowly and may take up to 3
identified. Follow CPG 9.1 for hours to develop.
treatment of anaphylaxis.  Pressure at the site of the bite will
 Intense localised pain, redness and increase pain 1.
swelling at the site. Pain may become Funnel Web Spider
intense and spread.  The Funnel web spider is the only
 Nausea, vomiting and abdominal pain. spider in Australia which can cause a
 Tender glands in the groin or armpit of threat to life in adults, but is not known
envenomed limb. to be found in WA2.
 Keep patient at rest and prevent  N/A
movement.
 In bee sting, remove sting as quickly
as possible, to prevent further venom
injection through the sting.
 In tick, if no history of allergy, remove
immediately.
 If known allergy, tick must remain in
place to prevent further envenomation
occurring on removal. The hospital will
kill the tick in position prior to removal 3.
 Use cold compress to reduce pain and
swelling at sight 4.
1
ANZCOR Guideline 9.4.2 (2014)
2
Queensland Museum, Funnel-Web Spiders Fact Sheet, (2015).
3
ANZCOR Guideline 9.4.3, (2016)
4
ANZCOR Guideline 9.4.2 (2014)
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2B Spider and Insect Bites
Page 1 of 2
 Consider alternative analgesia as
required for pain relief.
 Observe closely and monitor vital
signs.
 Observe the patient closely for
anaphylaxis, if identified, treat as per
CPG 9.1.
 Transport.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2B Spider and Insect Bites
Page 2 of 2
TOXICOLOGY
10.2C JELLYFISH AND FISH VENOM
July 2017
Jellyfish inject venom on contact with skin,  PIT not indicated for management of
through microscopic nematocyst tubules located jellyfish or fish envenomation.
on the tentacles or bulb of the animal.

Nematocysts from different species of jellyfish
are inhibited by different substances used for
first-aid, those being hot water and vinegar. Precautions/Notes
TROPICAL JELLYFISH  Children are at increased risk of
envenomation due to small body size.
Tropical waters range approximately from
Geraldton and extends north around the coast  Vinegar- - will deactivate non-discharged
line of Western Australia.
nematocysts, but not reduce the pain of
Box jellyfish venom already injected.
 Inhabit estuarine and on shore coastal  Antivenom is available for some Box
tropical waters. Jellyfish species.
 Can cause respiratory and cardiac arrest  Patients initially stable but suffering severe
within minutes in large stings. symptoms within 30 minutes may have an
Irukandji sting and require immediate
Jellyfish producing Irukandji syndrome medical attention.
 Sting can be minor, followed in 5-40
 Contact the CSP in SOC if further
minutes time by severe generalised pain
information or advice is needed.
and cramping, nausea and vomiting,
difficulty breathing, sweating, anxiety and
feeling of impending doom.
 Heart failure, severe hypertension,

pulmonary oedema and hypertensive
stroke.
NON-TROPICAL JELLYFISH
In other regions of Australia, the objective of

treatment is pain relief.
VENOMOUS FISH
Venom is deposited through spines causing

excruciating pain. Cardiovascular toxic effects
can occur, but are rare.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2C Jellyfish

Page 1 of 4
Indications Complications/Side Effects
 Pain, from mild irritation to intense, sharp or  N/A
burning.
 Muscle aches and cramps, moderate to

severe.
 Nausea, vomiting, headache.

 Whips and wheel marks, may be visible or
absent varying by species.
 Raised welts.
 Sweating at the site.
 Restlessness, anxiety and irrational

behavior.
 In Irukandji: severe hypertension, sense of

impending doom, development of
pulmonary oedema.
 Difficulty breathing.
 Collapse, followed by respiratory or cardiac

arrest.
Management/Dose
 Keep patient at rest and reassured, limit movement where possible.
 Ventilation support or CPG 4.6A / B for cardiac arrest only as required.
 Observe the patient closely for anaphylaxis, if identified, treat as per CPG 9.1.
 Refer to treatment for TROPICAL/NON-TROPICAL Jellyfish sting OR VENOMOUS FISH

below.
 Use cold compress to reduce pain and swelling at the site if specific treatment below cannot be
carried out.
 Consider further analgesia as per CPGs as required for pain relief.
 Consider antiemetic if indicated.
 Observe closely and monitor vital signs.
TROPICAL jellyfish:
 Liberally douse/spray area with vinegar for 30 seconds to neutralize visible stinging cells.
 If no vinegar is available: remove tentacles with gloved hands and wash well with sea water,
NOT fresh water.

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 Antivenom is available for some box jellyfish
 Transport URGENTLY.
NON-TROPICAL JELLYFISH:
 Remove any visible tentacles and rinse well with sea water, NOT fresh water.
 Where possible, place the stung area in hot water for 20 minutes (as hot as the patient can
comfortably tolerate).

 If pain not relieved by heat or hot water unavailable, apply cold pack.
VENOMOUS FISH
 Treat for hemorrhage or impaled object if required (CPG 5.1).
 If stung on a limb, immerse stung area in hot water (as hot as the patient can comfortably
tolerate).

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TOXICOLOGY
10.2D MARINE CREATURES: BLUE-RINGED OCTOPUS
AND CONE SHELL BITES/STINGS
July 2017
Some marine creatures are capable of injecting  DO NOT utilise an artery tourniquet.

venom causing paralysis and respiratory failure
within 30 minutes. Most venom reaches the  DO NOT apply a Pressure Immobilization
blood stream via the lymphatic system. Technique if the bite does not occur on a
Research by the ARC indicates little venom limb.
reaches the circulation, even after several hours,
if a Pressure Immobilization Technique is
applied IMMEDIATELY and MAINTAINED.
 Blue-ringed octopuses are present in all

Australian coastal waters, often found in
tidal pools and can inflict a potentially fatal
bite when handled.
 Cone shells are found in tropical waters,

and deliver venom through a dart like
barb 1.
Blue-ringed Octopus and Cone shell  The amount of toxin administered at the
indications time of envenomation AND the weight of
 Painless bite, spot of blood at the site. the patient dictates the speed with which
life-threatening signs and symptoms may
 Numbness to lips and tongue. develop.
 Progressive weakness of respiratory  It is advised that such patients be
muscles, hypoventilation and respiratory transported to a medical facility for
arrest. assessment and observation.
 Headache, nausea/vomiting, abdominal  Venom from both Cone Shell and Blue-
pain. ringed Octopus can cause paralysis and
 Swollen or tender lymphatic glands at respiratory failure within 30 minutes,
groin/axilla of bitten limb. without direct effects on the heart, the
treatment for which is basic life support to
Symptoms can resemble dysfunction of the assist respiration.
CNS:
 Confusion, collapse, visual disturbances or  Paralysis may be long lasting and where
drooping eyelids, difficulty speaking, possible treatment for respiratory or cardiac
swallowing or breathing, arrest should continue until arrival at an
weakness/paralysis, respiratory appropriate medical facility.
1
ANZCOR Guideline 9.4.6, (2014)
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2D Marine Creatures, Blue-Ringed
Octopus and Cone Shell Bites and Stings
Page 1 of 2
weakness/arrest, seizure.
 It is uncommon for a patient with an

effectively applied PIT to be time critical in
the absence of signs and symptoms of
envenomation

 Keep patient at rest and reassured. Limit  Despite paralysis, the patient may still be

movement by the patient. able to hear surroundings
 CPG 4.6 A / B for cardiac arrest, or assist

ventilations as required.
 Apply Pressure Immobilization Technique

to bitten limb as per Skill 809. If applied
correctly, and in a timely fashion, the PIT
should slow the progression of venom.
 Limb can be splinted to minimize

movement.
 Monitor for respiratory depression, if

required assist ventilations
 Vital signs, oxygen saturation, ECG, IV,

Consider prehospital bloods.
 Keep the patient and limb completely at

rest. Do not walk the patient.
 DO NOT remove bandages or splint prior to

arrival at a suitable hospital for treatment.
 Transport decisions should be based on

evidence of envenomation.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.2D Marine Creatures, Blue-Ringed
Octopus and Cone Shell Bites and Stings
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TOXICOLOGY
10.3 SMOKE OR NOXIOUS GAS INHALATION
November 2005

 Is there still danger?
 What happened?
 What gas / vapour / agent involved?

 Consciousness.
 Cyanosis.
Management:
 If there is any suspicion of danger seek further expert advice: i.e Fire and
Rescue, if on site contact mine site rescue before entering.
 Immediately it is safe to do so, quickly remove the patient from the
environment.
 Beware of self-asphyxiation. (Some gases are colourless, tasteless and
odourless).
 May need the assistance of the Fire and Emergency Service with breathing
equipment, etc.
 Oxygen, high concentration or 100% to clear the noxious gas.
 Monitor Vital Signs.
 If there are signs of skin irritation, shower for 20 minutes and / or continue
irrigation en route.
 Collect clothing and place in contamination waste bag and seal (may be
needed for identification purposes).
 Salbutamol if wheeze present as per CPG Medication 11.32 Salbutamol
Sulphate (Ventolin).
 Main complication is acute Pulmonary Oedema. The onset may be delayed
by some hours so always transport to hospital for observation.
 Advise hospital.

 Use HAZCHEM system.
 Refer to Material Safety Data Sheet for specific instructions.
 Contact Poison Information centre if required.
 No place for dead heroes.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.3 Some or Noxious Gas Inhalation
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TOXICOLOGY
10.4 CARBON MONOXIDE POISONING
November 2005

 Circumstances.
 Duration of exposure.
 Vomiting or fitting.

 History of loss of consciousness.

 The cherry pink skin colour is rare, and usually after death!
Management:
 Remove patient from carbon monoxide. Beware danger.
 Oxygen, high concentration or 100%, ventilate if necessary.
 Monitor Vital Signs.
 Note: oxygen saturation monitoring. Carbon monoxide poisoning produces
abnormal haemoglobins which causes readings to be inaccurate.
 Monitor rhythm by ECG or pulse.
 Transport.

 Decision will be made at nearest Emergency Department regarding the need
for emergency hyperbaric Oxygen therapy. Unconsciousness or
significantly altered consciousness at any time, is main indication, or changes
in behaviour, neurological, or mental status.
 May have delayed mental changes.
© Copyright St John Ambulance Australia (Western Australia) Inc. 10.4 Carbon Monoxide Poisoning
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Critical Practice Guidelines
for
Critical Care Paramedics
in Western Australia

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CCP GUIDELINE 5 - CARDIAC ARRHYTHMIAS
July 2017
Description
A dysrhythmia refers to an abnormality of the heart rhythm. Although not all patients will
become unstable and show adverse signs, Brady-dysrhythmias (<60bpm) and Tachy-
dysrhythmias (>100bpm) have the potential to severely compromise cardiac output and

lead to cardiac arrest. Supraventricular tachycardia (SVT) is a common cardiac
dysrhythmic disturbance, evident by rapid onset and rates of approximately 180bpm or
above which are regular, as a norm SVT is not life threatening and can be self-
resolving.
Patients presenting with cardiac dysrhythmia, demonstrating adverse signs require

urgent transport.
Indications
 Unstable bradycardia, with pulse (not associated with traumatic cause):
 Poor signs of perfusion, including:
- Hypotension,
- Altered conscious state,
- Diaphoresis,
- Shortness of breath, and/or
- Cyanosis.
- Syncope
 Unstable tachycardia, with pulse.
 Unstable indicates that cardiac output is reduced to produce blood
pressure changes, altered mental status, ischaemic chest pain,
hypotension, syncope or other signs of shock.
 Supraventricular tachycardia (SVT):
 Pulse > 180bpm, rapid onset, with diaphoresis and signs or symptoms of
reduced cardiac output.
Management
 Unstable bradycardia (not associated with traumatic cause):
 Address reversible cause.
- If inferior/right ventricular MI associated with bradycardia and
hypotension, consider fluid to address cardiogenic shock, NaCl CPG
11.19
- Hypovolaemia, Hypoxia and some toxins can be addressed in the
field.
 Consider Atropine Sulphate CPG 11.9, if likely to have effect.
 Consider transcutaneous pacing, (CCP - G7)
 Consider ASMA consult for advice.
 Unstable tachycardia:
 Early recognition.
 12 Lead ECG should not delay transport.
 Synchronised cardioversion.
 Consider Amiodarone if cardioversion unsuccessful.
© Copyright St John Ambulance Australia (Western Australia) Inc. CCP Guideline 5 - Cardiac Dysrhythmias
Page 1 of 4
 Supraventricular tachycardia: Narrow Complex, rapid rate, regular:
 Consider – Modified Valsalva Manoeuvre (MVM), Skill 805.
 Narrow complex tachycardia: Irregular:
 If Atrial Fibrillation, consider Amiodarone if onset < 48hours .
 Transport for rate control.
 Broad complex tachycardia: Regular:
 Early recognition.
 12 Lead ECG should not delay transport.

 Synchronised cardioversion.
 Consider Amiodarone if cardioversion unsuccessful.
 Broad complex tachycardia: Irregular:
 Transport for expert care.
 Resuscitation equipment should be at hand.
 Consider unstable patient as being time –critical, possible peri-arrest.
Further Reading:
1. Medi, C., Kalman, J. M., & Freedman, S. B. (2009). Supraventricular tachycardia. Med J
Aust, 255-260.
2. ANZCOR Guideline 11.9, 2009
Page 2 of 4
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CCP GUIDELINE 7 — NON-INVASIVE PACING
November 2016
Non-invasive Pacing Using Zoll M Series Defibrillator Follow Clinical
Practice Guidelines for Non-invasive Pacing. Indications:

 Sinus bradycardia.

 AV blocks.
 Idioventricular rhythm.
Prepare patient:
 Remove clothing from chest and dry if necessary.

 Attach ECG leads:
- Apply ECG leads and electrodes and adjust ECG size and lead for a
convenient waveform to display an R wave. Verify a proper R wave
detection. The heart shape symbol flashes with each R wave when proper
detection is taking place.
 Attach MFE pads Anterior and posterior positions:
- Anterior: Place pad left midclavicular line and fourth intercostal space.
Avoid nipple.
- Posterior: Pace pad under the left scapula next to the spine.
- If unable to place anterior or posterior then revert to normal defibrillation
positions.
- Note: MFE pads should be replaced after 8 hours (2 hours if using
radiolucent stat-padz).
Demand pacing:
 Demand pacing using the M series Monitor Defibrillator. The unit monitors the
patient pulse via the ECG cable and delivers selected energy level only when
the patient’s intrinsic rate falls below the set pacer rate. If the rate does not
fall below this rate the pacer will not send a stimulus.
 Turn selector switch to PACER. Display as per figure 1.
© Copyright St John Ambulance Australia (Western Australia) Inc. CCP Guideline 7 – Non-invasive Pacing
For Review: November 2021
Page 1 of 4
FIGURE 1
 Turn the PACER RATE knob clockwise until screen displays the desired
pacing rate. Variable rate from 30-180 pulse per minute (ppm).

 Verify that pacing markers display on the ECG trace.
 Turn the PACER OUTPUT (milliamps) knob clockwise slowly until ventricular
capture is consistently achieved. Generally the amount of current varies
widely however the range is normally between 50-90mA. The maximum
current on the external pacer is 140mA.
 Increase pacer output until symptoms resolve or rate of 100ppm is reached.
 Note: when the unit is switched out of Pacer mode into defib or monitor
modes and back again the pacer settings will remain unchanged. If the unit is
turned off for more than ten seconds the pacer default settings will be
restored.
 Check for electrical capture by the presence of a pacing spike followed by a
widened QRS complex (response to the stimuli), the loss of any underlying
intrinsic rhythm, and the appearance of an extended, and sometimes
enlarged T wave.
 Check for mechanical capture by taking a pulse on the femoral, brachial or
radial artery. Mechanical capture will be evident by a palpable pulse, rise in
blood pressure and improvement in conscious state (if not sedated and
paralysed).
 Caution. If you suspect an inaccurate beat detection, change the selected
lead to view the heart from a different angle. If this does not solve the
suspected problem, change the selected size.
Standby pacing:
For certain patients at risk of symptomatic bradycardia, it may be advisable to use
the unit in standby mode. In this mode the unit automatically provides a pacing
stimulus whenever the patient’s pulse drops below a predetermined level. Patient’s
ECG must be monitored using ECG leads and patient cables.
Establish effective pacing. Note:

 mA output at capture and run an ECG strip to document ECG morphology
during capture.
 Set mA output to 10% higher than the minimum mA output necessary to
effect consistent ventricular capture.
Page 2 of 4
 Turn the pacing rate (ppm) below the patient’s pulse. The pacing rate
should be set at a level sufficient for adequate cardiac output.
 Check threshold periodically.
Asynchronous pacing:
 During asynchronous pacing the M series unit delivers an electrical stimulus
regardless of patient’s pulse. If any of the following conditions are present, it
may be necessary to operate the pacemaker asynchronously:
- ECG electrodes are not available.

- ECG artefact is present.
- Patient has Ventricular Tachycardia.
 Asynchronous pacing should only be performed in emergency situations
when there are no other alternatives.
 If ECG cables are used during asynchronous pacing, ECG waveforms display
and you can determine whether capture was achieved. While asynchronous
pacing without ECG cables, no ECG activity displays, so other means for
determining capture such as checking pulse are necessary.
To pace asynchronously:
 Turn Selector Switch to PACER.
 Press the Async Pacing On/Off softkey.
 Confirm that the ASYNC PACE message displays.
 While pacing a patient you should occasionally check the patient’s underlying
rhythm to see if pacing is still required. This can be done quickly using the 4.1
Button.
 Whilst the 4.1 button is held down the pacer delivers an electrical impulse at
one quarter the displayed rate. This enables you to see the patient’s
underlying rhythm while safely pacing. Releasing the button will return the unit
to normal pacing.
Page 3 of 4
Problem Solving
Patient discomfort:
 Explain procedure; consider changing pad placement to anterior /posterior
positions, initiate pain management.
 Diaphragmatic pacing is relatively frequent and may require sedation and
ventilatory support at times.
Pacing problems, failure to:

Capture:

 Where pacing spikes are not followed by a broad QRS complex, the current is
insufficient to stimulate the heartbeat. Increase current and consider other
causes that might alter the threshold such as hypoxia, metabolic and
electrolyte derangements. Another possibility is that the patient is moribund.
Sense:
 Over sensing occurs when the pacer interprets artefact as intrinsic rhythm
and inhibits itself from firing. This may result in blood pressure drop.
Reposition leads or electrodes and select the non-demand mode.
 Under sensing is when the pacer fails to detect intrinsic activity and paces
inappropriately. Change the lead, and increase ECG size or reposition the
electrodes.
Pace:
 Document the rate threshold, output, underlying rhythm and any adjustments
made.
Page 4 of 4
Critical Care Guideline 8
RAPID SEQUENCE INDUCTION
July 2017
 Rapid sequence induction is the  Total airway obstruction
administration of a potent induction agent  Known or suspected epiglottitis
(anaesthetic) followed by a rapidly acting

neuromuscular blocking agent to induce
unconsciousness and motor paralysis for
tracheal intubation
 Respiratory Failure  Children under 8 years in conjunction
 Failure to maintain airway tone with ASMA consult where
(anaphylaxis/ infection/trauma) communication allows.
 Combative patient (after ruling out  All patients receiving paralysis must
reversible causes) receive ongoing sedation
 Status Epilepticus (not responding to other  Caution if ETCO2 (waveform
therapy) capnography) not available
 Airway burns with inhalation  RSI Fentanyl/Midazolam with
 Anticipated clinical course requiring Suxamethonium or Rocuronium
anaesthetics Exercise caution and evaluate  RSI Fentanyl/Ketamine with Rocuronium
risk benefit ratio. or Suxamethonium
 Rocuronium preferred in crash intubation
 Humanitarian reasons
 Global management of the multiple injured Complications/Side Effects
patient
 Failure to intubate
 Aspiration
 Oesophageal intubation
 Hypotension/Bradycardia
 Right mainstem intubation
Management/Dose
 PREPARATION
 Establish IV/IO access
 Assemble equipment for ET intubation
 Monitoring (Sp02, EtCO2, NIBP, ECG)
 Induction, Paralysis and ongoing sedation medication
 Failed intubation equipment
 Risk assessment for difficult intubation (CPG to develop).
© Copyright St John Ambulance Australia (Western Australia) Inc. CCP Guideline 8 – Rapid Sequence Induction
Page 1 of 4
 PREOXYGENATION
 Oxygenate and/or ventilate patient with BVM/ non rebreather mask as appropriate
 100% 02 for 3 min or 8 vital capacity breaths
 Apnoeic oxygenation nasal prongs 15ltr
 PRE-TREATMENT
 NaCl 0.9% bolus at 10ml/kg where patient haemodynamic status allows

 POSITIONING
 Position the patient in the sniffing position
 (BUHE) bed up head elevated position if practical
 Manually immobilize the head and neck in the neutral position for suspected cervical
spine injury
 PARALYSIS WITH INDUCTION

 Induction Agents Adult:
 Fentanyl (CPG 11:13)
 Midazolam (CPG 11:27)
 Ketamine (CPG 11.23)
PARALYSIS WITH INDUCTION (Caution amend dose to patients current haemodynamic

status)
Fentanyl/Midazolam
 Fentanyl 1-3mcg/Kg
 Midazolam 0-0.1mg/Kg
 Fentanyl/Ketamine
 Fentanyl 1-3mcg/Kg
 Ketamine 1-2mg/Kg
 Induction Agents Paediatric (>8 YEARS):

 Fentanyl/Midazolam
 Fentanyl: 1mcg/kg
 Midazolam:0-0.1mg/kg
Or
 Fentanyl/Ketamine
 Fentanyl: 1mcg/Kg
 Ketamine: 1 – 2mgKg
 Muscle Relaxants:
 Suxamethonium (CPG 11:35)
 Rocuronium (CPG 11.33)
 PROTECTION
Page 2 of 4
 Sellick’s Manoeuvre/BURP
 PLACEMENT WITH PROOF

 Perform intubation (CPG 3:5)
 Confirm tube placement (visualization, auscultation, end tidal C02) (skill 307)
 Follow failed intubation guideline for unsuccessful intubation (Skill 313)
 POST INTUBATION MANAGEMENT

 Maintain infusion for sedation:
 Adult:
 Morphine 30mg + Midazolam 30mg / normal saline made up to 30ml.
 1ml = 1mg each drug
 1ml/hr = 1mg/hr
 Infusion Dose: 1-10ml/hr IV/IO
 Bolus Dose: 0.5-5mg PRN
 Paediatric (>8 YEARS):

 Morphine 15mg + Midazolam 15mg/15ml normal saline.
 1ml = 1mg each drug
 1ml/hr = 1mg/hr
 Infusion Dose: 0.1-0.2mg/kg/hr IV/IO
 Bolus Dose: 0.1mg/kg PRN
 SIGNS OF INADEQUATE SEDATION:

 Pulse and BP trending up together
 Tearing
 Diaphoresis
 Cough/gag/movement
 Maintain paralysis with Rocuronium
 ECG/SP02/NIBP/ETC02
 Consider Metaraminol (CPG 11.36)
 Naso-/Orogastric tube (CCP Guideline 9)
Page 3 of 4
THIS PAGE HAS BEEN
Page 4 of 4
Critical Care Guideline 9
NASO / OROGASTRIC TUBE
January 2013
 Gastric tube insertion involves the placement of  Base of skull fracture (Naso gastric
a dual lumen tube into the stomach via the insertion contraindicated).
oro/nasopharynx to facilitate gastric suctioning
and /or decompression.
- Nasogastric: Insertion via the nose.

- Orogastric: Inserted via the mouth.
 Demonstrated gastric decompression, including  Passage of the tube into the trachea.
maintenance of a decompressed state after  Coiling of the tube in the posterior
endotracheal intubation. pharynx
 Head trauma.
 Max of 2 attempts and should not be
undertaken in preference to other
urgent interventions.
Management/Dose Complications/ Side Effects

 Identify the appropriate size:  Pulmonary aspiration.
- Paediatric: FG 8-10  Oesophageal perforation.
- Adult: FG 12-16  Intracranial placement.
 Measure the length from the tip of the patient’s  Trauma to nasal / oropharynx with
nose to the earlobe and then to the xiphisternum. associated bleeding.
 Lubricate the end of the tube.
 Insert the tube into the oral/nasal cavity and
direct the tube downward through the oropharynx
to the premeasured length.
 Examine oral cavity during insertion to detect
coiling.
 If resistance is met during insertion, stop
advancement and adjust direction slightly before
reattempting.
 Laryngoscopy and a Magill forceps may be
required to assist placement.
 Confirm placement by:
- Aspirating gastric content with a 50ml
catheter syringe and check pH with pH paper
(pH should be 5,5 or below).
 Secure tube with tape onto nose or side of face.
 Connect drainage bag to tube/suction as
required.
© Copyright St John Ambulance Western Australia Ltd CCP Guideline 9 Naso / Orogastric Tube
Review Date: as required
Page 1 of 1
THIS PAGE HAS BEEN

CLINICAL
PRACTICE
GUIDELINES FOR
SPECIAL
OPERATIONS
PARAMEDIC
Only to be utilised under emergency management

conditions in the capacity of Special Operations
Paramedic

THIS PAGE HAS BEEN

PARAMEDIC SPECIAL OPERATIONS
PSO GUIDELINE 1- WOUND MANAGEMENT WITH
STERI-STRIPS
November 2016

Steri-Strips are narrow adhesive strips that help • Wounds involving the facial region where
to close the edges of a small wound and scarring will be evident and have an
encourage the wound to heal. adverse effect on the patient’s long term
SkinLink comes with an adhesive which assists wellbeing
to reinforce the structure and strength of the • Presence of infection- these need referral to
closures a medical physician

For the management of taskforce member • Wound closure of facial regions and hands
wounds in the field where access or evacuation should be avoided in the field and attended
to a medical centre is not possible or identified to only by suitably skilled physicians
as required.
• Areas where the skin moves a lot, such as
For wounds where: over joints
• Shallow lacerations less than 5cm long • Wounds need to be assessed for infection
• Wounds on the fingers over the next few days. If in doubt, refer to a
physician.
• Wounds that allow the injured person to
continue working in the same or similar
role at the incident.
Maintain aseptic techniques
• Closure failure
Inspect, irrigate and clean the wound with Saline • Infection
or clean water and ensure the base of the
wound can be visualised • Bleeding
• Scar formation
Irrigate and clean the wound with saline or clean
water
Inspect the wound for debris. Remove these by

irrigation or tweezers.
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 1 – Wound Management with Steri-
Strips Review Date: November 2021
Page 1 of 2
Assess the wound and distal regions for colour,
warmth, sensation and movement. Any deficit
should be immediately referred to an appropriate
specialist physician.
Gently dry the wound surroundings with sterile

gauze

Apply antiseptic Medi-Prep Cetrimide around the
perimeter of the wound and leave for 30
seconds to dry
IF USING STERI-STRIPS:
For minor lacerations on areas where movement
is not an issue- use Steri-Strips
For lacerations over joints or areas prone to
movement, oily skin or where the Steri-Strips
may fail- use, consider referring to physician.
Beginning in the middle, apply Steri-Strip to one
edge of the wound, align and bring the wound
together. Continue applying Steri-Strip along the
length of the wound from the middle out, leaving
a 3-5mm gap between Steri-Strips to allow for
drainage.
Apply two strips across the Steri-Strips at 90º to
aid in anchoring and prevent premature lifting
IF USING SKIN LINK:
• Light pressure must be applied to the
Steri-Strip to activate the pressure
sensitive coating.
• Open the vial of surgical adhesive and
apply to each dot on the Steri-Strip,
taking care to avoid the wound site.
• Carefully peel off the transparent
membranes using tweezers before
adhesive sets (10-15 seconds after
application)
Protect the wound with a suitable dressing such
as Opsite island dressing and bandage
Refer to physician for wound management
within the next few days.
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 1 – Wound Management with Steri-
Strips Review Date: November 2021
Page 2 of 2
PSO GUIDELINE 2- EYE WASHING AND IRRIGATION
November 2016
Ocular injury due to foreign bodies and • Penetrating eye injuries

chemicals has the ability to cause ongoing
• Suspected or actual rupture of the globe
discomfort and permanent injury to the eye.
Flushing with water for a suitable period of time
has the ability to reduce or eliminate further
injury and damage

Foreign body irritant due to: • Only use NaCl 0.9% or clean, potable water
• Dust • Water should be tepid. Water too cold or hot
could cause further damage to the eye and
• Smoke particles
surrounding fluid.
• Other foreign bodies that are on the
• Minimise the application pressure. This
surface of the eye
should be enough to gently shower and
Ocular injury due to: flood the eye. Avoid high pressure at all
• Acid or solvent burns times.
• Gasoline
• Detergents
• Alkali burns
• Chemical splashes
Oleoresin Capsaicum(OC) spray
• Locate the eye wash station •
• Twist the irrigator clockwise to open the
saline bottle
• Remove the dust cap on the applicator
• The head should be pointed downwards to
assist with drainage and avoid spent fluid
entering the bottle
• Hold the eye(s) open with the fingers
• Begin to flush the eyes
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 2 – Eye Washing and Irrigation
Page 1 of 2
• Have the patient gently roll their eyes from
left to right and up and down to be sure that
all areas of the eyes are flushed
In the event of a chemical injury- flush for a full
15 minutes to allow appropriate dilution and
clearance.
In the event of ongoing discomfort or injury, the

patient should be referred to a specialist
physician for follow up.
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 2 – Eye Washing and Irrigation
Page 2 of 2
PSO GUIDELINE 3 - NON-STEROIDAL ANTI-
INFLAMMATORY DRUGS
November 2016

• Ibuprofen 200mg • Known hypersensitivity
• Possess analgesic, antipyretic and anti- • Asthmatic that is aspirin or NSAID sensitive
inflammatory properties
• Active gastrointestinal bleeding or peptic
ulceration
• Pregnant patients
• Medications containing codeine.

SPECIAL OPERATIONS ACTIVITIES ONLY • Previous history of GI haemorrhage or
ulcers
• Fever (pyrexia)
• Asthmatics who have not previously taken
• Inflammation due to musculoskeletal and
an NSAID
soft tissue injury
• Hepatic, renal or cardiac impairment
• Mild to moderate pain where inflammation is
present • Age over 65 years due to increased risk of
side effects
• ADULTS: • Ibuprofen interferes with the stability of INR
and may increase risk of severe bleeding
- Initial dose: 400mg (2 tablets)
and sometimes fatal haemorrhage,
- After 4-6 hours, the patient should be especially from the gastrointestinal tract.
reassessed. If required a Subsequent Ibuprofen should only be used in patients
dose of 200-400mg. taking Warfarin if absolutely necessary and
- Maximum 1200mg in 24 hours they must be closely monitored.
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 3 – Non-Steroidal Anti-Inflammatory Drugs
Page 1 of 2
THIS PAGE HAS BEEN
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 3 – Non-Steroidal Anti-Inflammatory Drugs
Page 2 of 2
PSO GUIDELINE 4 - TENSION PNEUMOTHORAX
July 2017
Tension Pneumothorax is a life threatening  Simple Pneumothorax
condition that develops when air becomes 

Major traumatic injuries incompatible with
trapped in the pleural cavity under pressure. life, such as:
- Decapitation, incineration,
evisceration of brain or thoracic
organs
- Hemicorporectomy or translumbar
amputation.
 Cardiac arrest with no ROSC > 20 minutes.
Clinical diagnosed tension pneumothorax with  Positive pressure ventilation may
associated: exacerbate the one way valve effect of a
- Respiratory distress, tachypnea tension pneumothorax
- Tachycardia  Whenever there is deterioration in the
- Hypotension patient’s oxygenation or ventilator status
the chest should be re-examined and a
- Unilateral absence/decrease of breath
tension pneumothorax excluded.
sounds
 The presence of a needle or chest tube
- Neck vein distension
does not mean the patient cannot develop
- Cyanosis
a tension pneumothorax.
- Hypoxia
 Tension pneumothorax may also persist if
- Tracheal deviation (late sign) there is an injury to the major airways or
bronchial tree.
 Beware of the patient with bilateral tension
pneumothoraces. The trachea may be
central with decrease air entry on both
sides. These patients are usually
haemodynamically compromised and
require bilateral chest decompression.

 Needle Thoracentesis: 2nd intercostal  Needle thoracentesis might not reach the
space, mid-clavicular line, on affected side pleural cavity at all especially in heavy-set
only. patients with thick chest walls.
 Lung laceration with a needle
thoracentesis.
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 4 – Tension Pneumothorax
Page 1 of 2
THIS PAGE HAS BEEN
© Copyright St John Ambulance Australia (Western Australia) Inc. SOP Guideline 4 – Tension Pneumothorax
Page 2 of 2
Primary Care
Clinical Practice
Guidelines in
Western Australia
Authorised by Clinical Governance

THIS PAGE HAS BEEN

Primary Care Clinical Practice Guidelines in Western Australia
January 2011
Preamble:
 The Primary Care Clinical practice Guidelines have been developed to provide
guidance for those employees involved in Primary Health Care. This includes
(but is not limited to) Industrial Medics / Paramedics and Community
Paramedics.
 These supplementary Clinical Practice Guidelines is to be used in conjunction

with the current Ambulance Paramedic Clinical Practice Guidelines, and are
only to be used by authorised employees in these specific circumstances,
when working for St John, having been trained and currently authorised to use
them by St John Ambulance.
 Any new skill, procedure, medications or non-standard equipment must be
endorsed by the Clinical Governance Operations Group and approved by the
Medical Policy Committee prior to it being introduced to the site, depot or sub-
centre.
Authority:
 Ambulance Paramedics, employed by St John Ambulance as Industrial
Paramedics have authorisation to use skills and medications for which they
have been trained and authorised as per current Ambulance Paramedic
Clinical Practice Guidelines, as well as the skills, procedures and medications
contained in the Primary Care Clinical Practice Guidelines.
 Industrial Paramedics / Medics have authorisation to use the paramedic
initiated skills and medications for which they have been trained and
authorised as per Clinical Governance approved schedule medication list for
industrial paramedics found at:
http://webserver.ambulance.net.au/quality/protocols_(non-medical).htm
Authority to Practice outside current Clinical Practice Guidelines:

 All skills, procedures or medications not authorised in the current Clinical
Practice Guidelines will need to be approved by a nominated Medical
Practitioner prior to this procedure being performed or medication
administered.
Royal Flying Doctor Service (RFDS)

Some sites may require the assistance of the RFDS. Many sites have RFDS medical
kits. The medical control physician or nominated practitioner must be contacted prior
to involvement of the RFDS where possible.
Skills Requiring Authorisation on Each Occasion:

 All skills or procedures not covered by the current Clinical Practice Guidelines,
including suturing.
 All prescription and scheduled medications not covered in the current Clinical
Practice Guidelines (excluding non-prescription medications).

Primary Care Initiated Intervention
PC Guideline 1 - Burns
PC Guideline 2 - ECG (5 and 12 lead)

Medications
Codeine Containing Drugs
Non-Steroidal Anti-Inflammatory Drugs
Ondansetron

PC GUIDELINE 1 — BURNS
December 2010

 Consider Danger to yourself and others first!
 Cause of burn and circumstances (chemical, steam, flame, extreme cold,
accompanying explosion, toxic fumes, confined space, smoke exposure).
 Time elapsed since burn.

 Identify if patient was exposed to any contamination (e.g. cooled off in a dam,
local lake or by bore water).

 Extent of burns:
 Description of areas involved, estimate using the Rule of Nines.
 Cause of burn?
 Depth of burns:
 Partial — redness or blistered only.
 Full thickness – severely damaged skin or tissues.
Management:
 Oxygen, high concentration or 100%.
 Pain relief — cooling with clean water, analgesia, burn dressing/gel/pads or
wetted dressing/sheets. Avoid hypothermia.
 Carefully remove jewellery and clothing unless stuck.
 Cover burned area. Apply acticoat dressing directly to wound, then gel/pads
or wet sheet as appropriate — keep wet and blow air over or fan if possible to
maintain cooling. Use water spray for patient comfort.
 Commence IV fluids to manage shock if indicated, continue with maintenance
infusion as per Parkland’s formula for any second or third degree burns
(4ml/kg x %surface area burnt), ½ of which to be administered within first 8
hours. Document total volume given.
 If IV not attainable, consider oral rehydration, little and often, if practicable.
 Monitor cardiac rhythm (where possible).
 Transport to a burns unit directly if no immediate life threat.
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 1 - Burns

Review Date: December 2015
Page 1 of 2
 Leave unbroken blisters intact.
 Suspect airway burns and potential airway compromise in any facial burns or
burns received in a closed space.
 Cooling of burn should ALWAYS utilise clean water to prevent infection.
 Deaths in the first 24 hours after burn injury are due to either airway burns or
fluid loss, following this infection is a major cause of morbidity, as such
Acticoat dressings should be applied ASAP.
 Consider carbon monoxide and cyanide poisoning (cyanide fumes arise

from burning plastics, and are present in the smoke) in all closed space burns.
Always consider non-burn injuries.
 Bypass to burns unit directly, with phone/radio patch to burns unit if:
 >15% in adult, >10% in child.
 Airway burns (if no immediate life-threat), burns of face, hands, feet, large
joints, circumferential limb burns, perineum, and genitalia.
For Rule of Nines chart refer to CPG 5.15 Burns Trauma.
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 1 - Burns

Page 1 of 2
PC GUIDELINE 2 — ECG
December 2010
ECG Leads 5 and 12 Using Zoll M Series
Preparing to monitor with 12 leads:
Preparing patient:

 Remove all clothing covering the patient’s chest.
 Clean and dry the patient’s skin.
 Clip excessive chest hair with scissors.
 Clean oily skin with alcohol swab.
 Briskly rub to dry and remove dead skin.
Attaching leads:
 Locate limb lead junction box in middle of ECG monitoring cable.
 Remove protective cap from the connector labelled V1-V6.
 Place end of V lead cable into connector.
Before applying ECG leads select V1 site:

 Place your finger on top of the jugular notch.
 Move your finger slowly down about 3.8cm (1.5 inches) until you feel a slight
horizontal ridge.
 This location, known as the angle of Louis, is where the manubrium joins the
sternum.
 Locate the second intercostal space on the right side lateral to and just below
the angle of Louis.
 Move your finger down two more intercostal spaces to the fourth intercostal
space.
 This location is the proper application site for the V1 lead.
 After you have located the V1 lead site, select the remaining application sites
using figures 1, 2, 3 and 4.
 If the patient is shivering and arm placement not viable then place on torso as
per figure 3.
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 2 – ECG

Page 4 of 4
FIGURE 1 FIGURE 2

FIGURE 3
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 2 - ECG

Page 2 of 4
FIGURE 4
AHA Labels IEC Labels LOCATION
RA (white) R (red) Right arm
LA (black) L (yellow) Left arm
RL (green) N (black) Right leg

LL (red) F (green) Left leg
V1 C1 red As above
V2 C2 yellow Fourth intercostal space, on left

midclavicular line.*
V3 C3 green Fifth rib, between leads V2 and V4.*
V4 C4 brown Fifth intercostal space, on the left

midclavicular line.*
V5 C5 black Left anterior axillary line, at the

horizontal level of V4.*
V6 C6 purple Left midaxillary line, at the horizontal

level of V4.*
* For female lead placement of V1, V2, V3, V4, V5 and V6 place electrode under the
breast rather than on the breast.
Displaying the 12 lead menu:

 Turn the selector switch to monitor.
 Press the lead button to display any lead except pads.
 Press the 12 softkey.
The 12 lead menu displays at the bottom of the screen:
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 2 - ECG

Page 3 of 4
To acquire 12 lead waveforms:
 Press the soft key under display Acquire.
 The unit will display acquiring ECG message, wait ten seconds for the
acquisition complete message to appear. The 12 lead data automatically
prints after acquisition.
 If the leads have not been properly attached, one of the following messages
displays:
Display message Description Action

VX LEAD OFF V lead not properly attached to Reattach
patient. X denotes lead number.
ECG LEAD OFF One or more limb leads are not Reattach
properly attached to patient.
 To abort 12 lead monitoring press HALT key.
Reading 12 lead print out:

 First 2.5 seconds of each of the 12 leads is printed.
 Patient information.
 ECG analysis results using GE/Marquette 12SL TM Analysis Program.
 Detailed measurements of each segment of each lead.
Five lead placements are as per figure 5.
FIGURE 5
© Copyright St John Ambulance Australia (Western Australia) Inc. PC Guideline 2 – ECG

Page 4 of 4
CLINICAL PRACTICE
GUIDELINES
FOR
ADMINISTRATION
OF
MEDICATIONS

THIS PAGE HAS BEEN

MEDICATIONS MATRIX

St John Ambulance Western Australia Ltd Authority to Administer Medication(s) Matrix
June 2018
Care Paramedic
Special Ops
MEDICATIONS
Ambulance
Ambulance
Ambulance
Ambulance
Grade Two
Grade One
Paramedic
Paramedic
Paramedic
Industrial
St. John Ambulance Western Australia Ltd.
Critical
Officer
Officer
Officer
Authority to Administer Medication(s) Matrix
Medic
CPG 11.4 Aspirin (Unscheduled) X X X X X X X X
CPG 11.5 Adrenaline (S3) S S S *X *X X X X
CPG 11.6 Adrenaline Autoinjector EpiPen, Anapen (S3) S S S X X X X X
CPG 11.7 Amiodarone (S4) S S S S X X X
CPG 11.9 Atropine Sulphate (S4) S S S X X X
CPG 11.10 Cophenylcaine (S2) S X X X X X X X
CPG 11.11 Dextrose 5% (Unscheduled) X
CPG 11.13 Fentanyl (S8) S S S S S X X X
CPG 11.15 Glucagon (S3) S X X *X X X X X
CPG 11.16 Glucose Oral Gel (Unscheduled) X X X X X X X X
CPG 11.17 Heparin Sodium (S4) S S S X X X
CPG 11.18 Ipratropium Bromide (Atrovent) (S4) S X X *X X X X X
CPG 11.19 IV Crystalloid Solutions (Unscheduled) S X X S X X X
CPG 11.20 Intravenous Glucose 10% (Unscheduled) S S S S X X X
CPG 11.21 Glyceryl Trinitrate (GTN) (S3) X X X S X X X X
CPG 11.23 Ketamine (S8) S S S S X X X
CPG 11.24 Lignocaine 1% (Xylocaine) (S4) S S S S X X X
CPG 11.25 Methoxyflurane (S4) S X X X X X X X
CPG 11.26 Metoclopramide (Maxalon) (S4) X
CPG 11.27 Midazolam (S4) S S S S X X X
CPG 11.28 Morphine Sulphate (S8) X
* 11.5 Adrenaline: IM only for the treatment of anaphylaxis and status asthmaticus
* 11.15 Glucagon and *11.18 Atrovent are for Industrial Paramedic administration only.
* 11.30 Ondansetron refers to oral ondansetron wafers only.
Medications Matrix
© Copyright St. John Ambulance Western Australia Ltd. Page 1 of 4
MEDICATIONS MATRIX

St John Ambulance Western Australia Ltd Authority to Administer Medication(s) Matrix
June 2018
Care Paramedic
MEDICATIONS
Special Ops
Ambulance
Ambulance
Ambulance
Ambulance
Grade Two
Grade One
Paramedic
Paramedic
Paramedic
Industrial
St. John Ambulance Western Australia Ltd.
Critical
Authority to Administer Medication(s) Matrix
Officer
Officer
Officer
Medic
CPG 11.29 Naloxone (Narcan) (S4) S S S S X X X
N/A Non-Steroidal Anti-Inflammatory Drugs S X X
CPG 11.30 Ondansetron (S4) S S S *X *X X X X
CPG 11.31 Paracetamol (S2*) X X X X X X X X
CPG 11.32 Packed Red Cells (N/A) X
CPG 11.33 Rocuronium Bromide (Esmeron) (S4) X
CPG 11.34 Salbutamol Sulphate (Ventolin) (S3) S X X X X X X X
CPG 11.35 Suxamethonium Chloride (S4) X
CPG 11.36 Prednisolone Oral (S4) S X X S X X X
CPG 11.37 Metaraminol Tartrate (Aramine) (S4) X
KEY:
Independent Administration X Supervised Administration S Unable to administer (Shaded Area)
NOTE:
1. Ambulance Officers studying for the Paramedic degree supervised by a Paramedic may draw up all medications as used by the
Paramedic, but only administer as indicated in the Matrix.
2. Volunteer matrix has moved to the Volunteer Clinical Practice Guidelines.
* 11.5 Adrenaline: IM only for the treatment of anaphylaxis and status asthmaticus
* 11.15 Glucagon and *11.18 Atrovent are for Industrial Paramedic administration only.
* 11.30 Ondansetron refers to oral ondansetron wafers only.
Medications Matrix
MEDICATIONS ADMINISTRATION
June 2018
Medications are only to be administered by trained and authorised staff. Prior to
medication administration, the following RIGHTS must be observed:
Right Patient Ensure this medication is indicated for this patient and not
contraindicated.

Right Medication Ensure that the medication chosen to be administered is correct
and in date. Read aloud the following (ideally to partner, but in
general as is good practice), the medication label, the
presentation and expiry date.
Right Dose Staff should not rely on knowledge of the CPG’s and are
encouraged to cross check the latest version of the CPG’s or
Pocket Reference Guide and to confirm with partner that the
dosage and concentration match CPG and/or Pocket Reference
Guide and is correct for the patients presenting condition.
Right Time If the medication administration is to be repeated or if the patient
has already self-administered a medication, ensure the
appropriate time has passed before readministering.
Right Route Staff should not rely on knowledge of the CPG’s and are
encouraged to cross check the latest version of the CPG’s or
Pocket Reference Guide and to confirm with partner that the
medication being administered is being done so in the correct
dosage via the correct route.
Right Documentation
The minimum documentation standard for any medication
administered (which is automatically populated when entered
into ePCR interventions) is:
- The name of the medication
- The time that the medication was administered
- The route administered
- The dosage/size of the medication administered
- The effectiveness of medication treating the indicated cause
- The AP number of the administering officer
ePCR Incident/Patient Assessment Details

For full disclosure to the receiving facility, it is good practice to
document in the ePCR free-text all medications administered in
total amounts, their effectiveness and clinical rationale.
Medications Matrix
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Medications Matrix
MEDICATIONS
11.4 ASPIRIN (ACETYLSALICYLIC ACID)
July 2017
Aspirin has the following pharmacological  Known hypersensitivity to aspirin /
actions. salicylates.
 Analgesic  Children < 12 years of age.
 Antipyretic
 Anti-inflammatory

 Anti-platelet aggregation agent
Reduces mortality significantly in Acute
Myocardial Infarction by minimising platelet
aggregation and thrombus formation in order to
retard the progression of coronary artery
thrombosis.
 Chest pain / discomfort of presumed  Actively bleeding peptic ulcers.
cardiac origin.  Suspected AAA.
 Aspirin / salicylate-sensitive asthmatics

 300mg oral administration, preferably  Heart burn, nausea, GI bleeding.
chewed.  Increased bleeding time.
 Administered even if patient has taken  Anaphylactic reaction (some patients,
aspirin that day or on anticoagulants. especially asthmatics) exhibit notable
sensitivity to aspirin, which may provoke
various hypersensitivity / allergic reactions)
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MEDICATIONS
11.5 ADRENALINE (EPINEPHRINE)
July 2017
Pharmacology and Action:  Nil.

 1mg in 1ml (1:1000);
 A naturally occurring sympathomimetic

agent;
 Causes peripheral vasoconstriction;
 Stimulation of cardiac conduction system
causes increased contractions;
 Causes bronchodilation and dilation of
blood vessels in muscles;
 IV/IO: Onset 30 seconds, peak 3-5
minutes, duration 5-10 minutes;
 IM: Onset 30-90 seconds, peak 5-10
minutes, duration 5-10 minutes.
 Cardiac arrest;  Ischaemic Heart Disease;

 Anaphylaxis;  Do not walk patient pre/post IM adrenaline
administration in anaphylaxis.
 Life –threatening asthma (as per CPG
3.2);  See CPG 4.6
 Severe croup (as per CPG 3.6);
 Post ROSC.

Cardiac Arrest:
 Dysrhythmias;
 Adult: 1mg IV/IO every 3-5 minutes;  Hypertension;
 Paediatric / Newborn: Adrenaline:  Pupil dilation;
Dilute 1mg Adrenaline in 9ml Normal
Saline (1000 mcg in 10mls, 1:10000);  Tremor;
10mcg/kg = 0.1ml/kg (1:10000) every 3-5  Anxiety;
minutes.
 Palpitations.
Post Resus Care:
 Dilute 1mg Adrenaline in 9ml normal

saline (1000 mcg in 10mls);
 Adults: 50 mcg (0.5ml) every 3-5 min as
required to maintain SBP > 90mmHg;
 Paediatric: 1mcg/kg every 3-5 min (max
© Copyright St John Ambulance Western Australia Ltd 11.5 Adrenaline (Epinephrine)

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bolus 50mcg) to maintain SBP > 80
mmHg;
 Titrate Adrenaline as required, to achieve
and / or maintain the SBP requirements
as listed above.
Anaphylaxis/Life-Threatening Asthma:
 Adult: 0.5mg IM into lateral mid-thigh

(0.5ml of 1:1000), repeat if required;

 Pregnant Females experiencing
anaphylaxis: 0.3mg IM into lateral mid-
thigh (0.3ml of 1:1000), repeat if required; 1
 Paediatric: IM into lateral mid-thigh,
0.01mg/kg:
AGE WEIGHT ADRENALINE
(KG) VOLUME
1:1000
<1 5-10 0.05-0.1mL
1-3 10-15 0.15mL
4-12 16-40 0.3mL
>12 >40 0.5mL
Note: Repeat every 5 minutes as clinically

required for adults and paediatrics.
Croup
 Infants/Paediatric: 5mg / 5mls nebulised
once only.
1
ASCIA Guidelines: ADVANCED Acute Management of Anaphylaxis 2016
© Copyright St John Ambulance Western Australia Ltd 11.5 Adrenaline (Epinephrine)
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MEDICATIONS
11.6 ADRENALINE AUTOINJECTOR
‘EPIPEN®’
July 2017
Presentation  There are no absolute contraindications for

 EpiPen® (yellow label) = 0.3mg. adrenaline.
 EpiPen® Jnr (green label) = 0.15mg.

Pharmacology and Action
agent
 Causes peripheral vasoconstriction
causes increased contractions
 Causes bronchodilation and dilation of blood
vessels in muscles
 Anaphylaxis / Severe Allergic Reaction–  “ALWAYS give EpiPen® FIRST, and then
(see definition as per CPG 9.1 asthma reliever puffer if someone with
known asthma and allergy to food, insects
or medication has SUDDEN BREATHING
DIFFICULTY (including wheeze, persistent
cough or hoarse voice) even if there are no
skin symptoms” i.
 Patient’s own injector may be used.
 Do not walk patient pre/post EpiPen
administration.
 Advise transport to a medical facility due to
risk of bi-phasic reactions.

 Position patient supine, or in recovery  Tachycardia, arrhythmias
position if unconscious.  Increase in blood pressure (may be
Dose: Prepare EpiPen and give - lateral mid-thigh. marked)
Adult/Paediatric ≥ 20kg/≥5yo  Tremor, anxiety
 0.3mg repeat every 5 min as clinically
indicated
Infant/Paediatric <20kg/<5yo
indicated
Onset:
 Onset 30-90 seconds, lasting up to 20 min.
i
https://www.allergy.org.au/images/stories/anaphylaxis/2016/Anaphylaxis_EpiPen_General_Action_Plan_2016_WEB.pdf
© Copyright St John Ambulance Western Australia Ltd. 11.6 Adrenaline Autoinjector ‘EpiPen’
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MEDICATIONS
11.6 ADRENALINE AUTOINJECTOR
‘EPIPEN®’
July 2017
Presentation  There are no absolute contraindications for

 EpiPen® (yellow label) = 0.3mg. adrenaline.
 EpiPen® Jnr (green label) = 0.15mg.

Pharmacology and Action
agent
 Causes peripheral vasoconstriction
causes increased contractions
 Causes bronchodilation and dilation of blood
vessels in muscles
 Anaphylaxis / Severe Allergic Reaction–  “ALWAYS give EpiPen® FIRST, and then
(see definition as per CPG 9.1 asthma reliever puffer if someone with
known asthma and allergy to food, insects
or medication has SUDDEN BREATHING
DIFFICULTY (including wheeze, persistent
cough or hoarse voice) even if there are no
skin symptoms” i.
 Patient’s own injector may be used.
 Do not walk patient pre/post EpiPen
administration.
 Advise transport to a medical facility due to
risk of bi-phasic reactions.

 Position patient supine, or in recovery  Tachycardia, arrhythmias
position if unconscious.  Increase in blood pressure (may be
Dose: Prepare EpiPen and give - lateral mid-thigh. marked)
Adult/Paediatric ≥ 20kg/≥5yo  Tremor, anxiety
indicated
Infant/Paediatric <20kg/<5yo
indicated
Onset:
 Onset 30-90 seconds, lasting up to 20 min.
i
https://www.allergy.org.au/images/stories/anaphylaxis/2016/Anaphylaxis_EpiPen_General_Action_Plan_2016_WEB.pdf
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MEDICATIONS
11.7 AMIODARONE
July 2017
 150mg in a 3ml ampoule NO CONTRAINDICATIONS IN CARDIAC
 Amiodarone has effects within the first four ARREST
classes of the Vaughan-Williams In Tachydysrhythmias:

classification. However it is primarily  Hypersensitivity to Amiodarone or iodine
classified as a Class III antidysrhythmic  Bradycardia or AV block
agent that prolongs the action potential
 Sick sinus syndrome
duration and hence the refractory period of
 Severe conduction disorders
atrial, nodal and ventricular tissue. It has
characteristics of all Vaughan-Williams  Hypotension
classes of antidysrhythmics  Severe respiratory failure
 Immediate onset, peak <10min, duration  Circulatory collapse
30-60mins
 Cardiac Arrest with persistent/shock  Heart failure
resistant Ventricular Fibrillation/pulseless  Thyroid dysfunction
Ventricular Tachycardia, post 3rd shock  Glucose 5% must be used as a diluent
(ANZCOR 2016). when administered as an infusion in the
conscious patient
 Tachydysrhythmias including (CCP only):  Amiodarone is only indicated for shock
− SVT resistant or recurrent VF/pVT
− Nodal and Ventricular tachycardia
− Atrial flutter and fibrillation
− WPW syndrome

• Cardiac Arrest:  Bradycardia
− Adult: 300mg in 6ml IV/IO once only;  Hypotension
− Paediatric / Infant: 5mg/kg IV/IO once  Polymorphic tachycardias
only  Nausea
 Tachydysrhythmias (CCP only):  Tremor
− 300mg infusion over 20 minutes.  Dizziness
 Paraesthesia
 Headaches
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MEDICATIONS
11.9 ATROPINE SULPHATE
July 2017
 1.2mg in 1ml plastic vial  Known hypersensitivity
 An anticholinergic agent that inhibits the  Third-degree atrioventricular (AV) block
action of acetylcholine on post ganglionic  Patients with cardiac transplant
nerves at the neuroeffector site. This blocks

vagal stimulation to allow the sympathetic
response to increase pulse rate by
increasing SA node firing rate, and
increasing the conduction velocity through
the AV node
 An antidote to reverse the effects of
cholinesterase inhibitors such as seen with
organophosphate poisoning
 Symptomatic Bradycardia,  Isolated Bradycardia or link to traumatic
haemodynamically unstable due to the cause is not an indication for atropine. All
bradycardia and associated with poor signs reversible causes should be addressed
of perfusion, including: prior to consideration of Atropine.
- Hypotension  It is advisable that a 12 Lead ECG is
- Altered conscious state conducted prior to medication
- Diaphoresis administration to rule out Acute Myocardial
- Shortness of breath, and/or cyanosis Infarction (STEMI) and Third-degree
- Syncope atrioventricular (AV) block.
 Organophosphate poisoning with - If in doubt transmit 12-lead ECG to
cholinergic effects CSP SOC to discuss, or seek ASMA
advice
 Bradycardia in children is usually a result
of hypoxia or vagal stimulation. Ensure all
reversible causes addressed and
consider CPR as per CPG 4.6B if
unresponsive.
 Atropine may affect patients with
glaucoma
 The maximum dose of Atropine that has
shown to produce the desired effect in
healthy adults is up to 3mg for
bradycardia. In organophosphate
poisoning: atropinisation might require
significant repeat dosages and is achieved
when with an increased HR, dilated pupils
and decreased secretion, do not delay
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transport as atropinisation might not be
achievable in the pre-hospital setting.

IV/IO  Tachycardia and/or palpitations
 Symptomatic Bradycardia:  Dilated pupils and/or blurred vision

- Adult: 0.6mg in 0.5ml every 3-5  Dry mouth and/or urinary retention
minutes titrated to effect. Maximum
 Confusion, restlessness (large doses)
dose 3mg
 Hot, dry skin (large doses)
- Child: (ASMA consult required)
(CCP 0.02mg/kg Maximum

Only) minimum initial dose
0.01mg/kg 1mg.
 Organophosphate poisoning:
- Adult: 1 - 2mg, repeat every 5
minutes until atropinisation is evident
- Child: 0.02mg/kg, repeat every 5
minutes until atropinisation is evident
© Copyright St John Ambulance Western Australia Ltd. 11.9 Atropine Sulphate

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Primary Care Guideline
CODEINE CONTAINING DRUGS
January 2011
Presentation Dose
 Aspalgin (Aspirin 300mg, Codeine 8mg) Ibuprofen + Codeine (Nurofen Plus)
(See Aspirin guideline as well).  Adults and children from 12 years: 2
 Ibuprofen 200mg + Codeine 12,8mg tablets, then 1 or 2 tablets every 4 hours
(See NSAID guideline as well). as necessary (maximum 6 tablets in 24
hours).

Pharmacology and Action  Not for children under 12 years.
 Codeine is considered a prodrug, since it
is metabolised in vivo to the primary Side Effects
active compounds morphine and  Respiratory depression in large enough
codeine-6-glucuronide (C6G). Roughly 5- doses.
10% of codeine will be converted to  Constipation.
morphine, with the remainder either free,  Nausea.
conjugated to form codeine-6-  Euphoria.
glucuronide (~70%), or converted to  Drowsiness.
norcodeine (~10%) and hydromorphone  Dry mouth.
(~1%).  Miosis.
 See side effects of Aspirin and NSAIDS
Primary Indication
 Moderate to strong pain. Precautions
 See NSAID indications.  See NSAIDS and Aspirin precautions.
 Can develop dependency with long term
Contraindication use.
 Known hypersensitivity to codeine,
aspirin or ibuprofen. Administration
 Asthmatic that is aspirin or NSAID  Check with partner — correct medication
sensitive. and dose.
 Active gastrointestinal bleeding or peptic  Give orally, with water to swallow.
ulceration.
 Pregnant patients.
 Need to drive, operate heavy machinery,
or work at heights.
 Constipated patients.
Route of Administration
 Oral.
Dose
Aspirin and Codeine (Aspalgin)
 2 tablets every 4 hours to a maximum of
8 tablets per day.
 Dissolve the tablets in a little water
before swallowing them.
 Aspalgin can be taken with or without
food.
 Not recommended for children under 12
years of age.
© Copyright St John Ambulance Australia (Western Australia) Inc. Codeine Containing Drugs
Page 1 of 1
Review Date: January 2016
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MEDICATIONS
11.10 COPHENYLCAINE
July 2017
 Topical pump spray containing:  Hypersensitivity to phenylephrine,
- Lignocaine hydrochloride 50mg/ml lignocaine or other anaesthetics
- Phenylephrine 5mg/ml  Children <2yrs

 Pregnancy
 A topical local anaesthetic and haemorrhage
control agent for the relief of surface pain,
nasal and oral bleeding
 Local pain: abrasions, small cuts and  Used with caution in patients with
wounds cardiovascular, hepatic and/or renal
 Relief of mild and moderate epistaxis disease.
 Post tonsillectomy haemorrhage  For oral use, nozzle inserted within the
 Intra-oral haemorrhage anterior 1/3 of mouth to avoid gag
stimulation.
 Each spray delivers 100 microlitres of fluid.

The dose of lignocaine in each squirt is 5
mg and the dose of phenylephrine in each
squirt is 0.5mg

 ADULT:  Oral administration may cause a transient
bitter taste. Pause between subsequent
- Intranasal: Max 10 squirts (5 squirts per doses.
nostril)
- Topically: Max 5 squirts
- Oral use: 1 spray then pause, repeat if
required to max. 5 sprays.
 PAEDIATRIC:
- Intranasal:
- 2-4 years: 1 squirt per nostril
- 4-8 years: 2 squirts per nostril
- 8-12 years: 3 squirts per nostril
- Topically: Max 5 squirts
- Oral use: 1 spray then pause, repeat if
required to max. 5 sprays.
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MEDICATIONS FOR CRITICAL CARE PARAMEDICS
11.11 DEXTROSE 5%
September 2011
 100ml infusion soft pack  Not for volume replacement
 An isotonic crystalloid solution
 Half life is 20-30 minutes

 Vehicle for diluting and administrating  Nil
emergency drugs

 N/A  Nil
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MEDICATIONS
11.13 FENTANYL
July 2017
A short acting synthetic narcotic analgesic  Hypersensitivity to Fentanyl
 Fentanyl: 600mcg in 2.0ml (300mcg/ml) -
 Less than 1 year of age (IV IO only)
Intra-nasal only

 Occluded nasal passages or epistaxis (IN
 Fentanyl Citrate (Sublimaze): 100mcg in
only)
2ml ampoule (50mcg/ml) - IV/IO
 Moderate to severe pain.  Elderly patients
 Acute Coronary Syndromes where GTN  Respiratory depression: especially those at
has been ineffective. risk e.g. patients with severe COPD
 Patients on MAO inhibitors
 Caution in larger doses of women in active
labour
 Use of IV Ketamine as analgesic prior to
minimum (age dependant) dose of IV
Fentanyl requires ASMA authorisation:
- PAEDIATRIC: 100 mcg
- Adult <70 years old: 200mcg
- Adult >70 (or frail): 100mcg
 Administer slowly
 Cease administration prior to calculated
dose if desired effect is obtained.
 Nausea/vomiting
 Respiratory depression – monitor pulse
oximetry for all patients having IV / IN
Fentanyl
 Cardiovascular effects:
- Bradycardia
- Hypotension (rare)
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Management/Dose
 IV/IO FENTANYL CITRATE:
 ADULT <70 years old:
Loading dose: Titrate 1mcg/kg slow IV push (maximum single dose - 100mcg)
Subsequent dose: 25mcg to effect every 5 minutes
 ADULT >70 years old or frail:
Loading dose: Titrate 0.5mcg/kg slow IV push (maximum single dose - 50mcg)

Subsequent dose: 25mcg to effect every 5 minutes
 PAEDIATRIC
Loading dose: Titrate 1mcg/kg slow IV push (maximum single dose – 25mcg)
Subsequent dose: 1mcg/kg (up to 25mcg) to effect every 5 minutes.
 Dilute 100mcg in 2ml with 8ml NaCl 0/9% to produce 10mcg/1ml
OR
 Dilute 100mcg in 2ml with 18ml NaCl 0.9% to produce 5mcg/1ml
INTRANASAL:
Age First dose Subsequent at 5 mins Subsequent IV Dose if
≤ 5 years < 1 x 0.05ml 1 x 0.05ml (15mcg) Up toi 1mcg/kg
d titrated to
20Kg (15mcg) effect every 5 minutes
(Maximum bolus dose
25mcg each time).
6-10 years 21- 1 x 0.10ml 1 x 0.10ml (30mcg) Up to 1mcg/kg titrated to
30Kg (30mcg) effect every 5 minutes
(Maximum bolus dose
25mcg each time).
Subsequent at 5mins
>10-15 years 1 x 0.15ml 1 x 0.15ml (45mcg) Subsequent dose 25mcg

31-40Kg (45mcg) titrated to effect every 5
minutes
Small / elderly 2 x 0.2ml 1 x 0.2ml (60mcg) Subsequent dose 25mcg
/ frail (120mcg) titrated to effect every 5
minutes
Adult 3 x 0.2ml 1 x 0.2ml (60mcg) Subsequent dose 25mcg
(180mcg) titrated to effect every 5
minutes
CRITICAL CARE ONLY (CCP)
IV/IO FENTANYL CITRATE:
• ADULT
Loading dose: Titrate 1mcg/kg slow IV push (maximum single dose - 100mcg)
Subsequent dose: 25-50mcg to affect every 5 minutes
CCP Induction dose IV/IO:
• ADULT 1-3mcg/kg
• PAEDIATRIC 1mcg/kg
Discarding unused medication must be witnessed and countersigned by attendant

and credible witness.
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MEDICATIONS
11.15 GLUCAGON
March 2012
 1mg in 1ml vial, accompanied by diluent for  Hypersensitivity.
injection.  Known pheochromocytoma
 A hyperglycaemic agent that converts
stored liver glycogen to glucose to increase
blood glucose concentration.

 Onset 4–7 minutes, duration 10–30
minutes.
 For demonstrated hypoglycaemia where  Glucagon is effective in treating
oral glucose cannot be administered and IV hypoglycaemia only if sufficient liver
access cannot be obtained in a safe and glycogen is present (eg: it does not work on
timely manner. alcohol or anorexia induced
 Altered conscious state in a known hypoglycaemia).
Diabetic.  Even if fully recovered patients should be
encouraged to be transported to a medical
 Altered conscious state of unknown
facility to ensure effective follow up and
medical cause, where blood glucose
review.
level is below 4mmol/L.

Intramuscular injection into deltoid muscle or  Nausea/vomiting
mid-lateral thigh  Gastric pain
 Adult:  Transient rise of blood pressure for patients
 1mg in 1ml IM. taking beta blockers.
 Repeat IM Glucagon after 10 minutes if
unable to obtain IV access and pt still
has inadequate GCS and blood glucose
Level.
 Paediatric:
 <5 years: 0.5mg in 0.5ml
 6-12 years: 1.0mg in 1.0ml
 Single dose only
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MEDICATIONS
11.16 GLUCOSE ORAL GEL
March 2012
 15g glucose gel in tube.  N/A
 Rapidly absorbed from oral/buccal mucosa
to increase blood glucose concentration.
 Onset 2-5 minutes, duration 12-25 minutes.

 Demonstrated hypoglycaemia in:  Have patients airway patent and in lateral
 Altered conscious state in a known position if unconscious.
Diabetic.  Always consider patient’s airway when
 Altered conscious state of unknown administering gel.
medical cause, where blood glucose  Even if fully recovered, patients should be
Level is below 4mmol/L. encouraged to be transported to a medical
facility to ensure effective follow up and
review.
 Will liquefy over 300, however it is still
useable.

 Adult: squeeze contents of tube (or as much  Airway obstruction.
as practical) into lower cheek pouch over
gums/cheek and externally massage cheek.
 Paediatric: use proportion of tube.
 Repeat after 10 minutes if still altered
consciousness or deteriorating.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.16 Glucose Oral Gel
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MEDICATIONS
11.17 HEPARIN SODIUM
September 2012
 A naturally occurring anticoagulant which  Hypersensitivity to Heparin
inhibits the clotting of blood by  Presence of known haemorrhagic states
enhancing the rate at which antithrombin
III neutralises thrombin and activated
factor X (Xa).

 Ampoules 5,000 IU/5ml.
 Onset of action is immediate following IV
administration.
 Patients with STEMI going directly to  Haemorrhagic risks in case of possible
Cardiac Catheterisation Laboratory as trauma.
per receiving hospital 12-lead ECG
interpretation.

 IV only- 5000IU/ 5ml bolus dose flushed  Haemorrhage.
with NaCl 0.9%.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.17 Heparin Sodium
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MEDICATIONS
11.18 IPRATROPIUM BROMIDE (ATROVENT)
July 2017
 Presents as 250mcg in 1ml nebule.  Hypersensitivity.
 An anticholinergic bronchodilator. It

inhibits the vagal reflexes that mediate
bronchospasm.
 Combined with a nebulised beta-2
agonist (Salbutamol), Ipratropium
bromide produces significantly greater
bronchodilation than a beta-2 agonist
alone.
Severe bronchospasm:  Glaucoma.
 Paediatric- severe to life-threatening  Avoid contact with eyes.
asthma (CPG 3.2).  Ipratropium Bromide can be
 Adult- severe to life-threatening asthma administered concurrently with a
(CPG 3.2) and COPD (CPG 3.3). nebulised Salbutamol solution.

ADULT: Nebulised  Headache.
 500mcg in 2ml  Nausea.
 Repeat dose every 20mins; max of  Dry Mouth.
three doses.  Skin rash.
PAEDIATRIC: Nebulised
< 6 years ≥ 6 years
250mcg in 1 ml 500mcg in 2ml
 Repeat every 20mins; max of 3 doses
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.18 Ipratropium Bromide (Atrovent)
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© Copyright St John Ambulance Australia (Western Australia) Inc. 11.18 Ipratropium Bromide (Atrovent)
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MEDICATIONS
11.19 IV CRYSTALLOID SOLUTIONS
July 2017
 Normal saline (NaCl 0.9%) in 1000ml soft  Severe Pulmonary Oedema.
plastic bag.
 Normal saline (NaCl 0.9%) in 250ml soft

plastic bag.
 10 ml plastic vial.
 A sterile isotonic crystalloid solution.
 Fluid replacement (volume expansion) for  IV access/ fluid administration should be
the treatment of shock, fluid loss, and avoided in patients on the side of
cardiac arrest. mastectomy or lymph node removal unless
life-saving.
 IV Crystalloids should be given with care in
isolated penetrating trauma.
 Adult permissive hypotension = SBP at
70mmHg.
 In the TBI, adult patient attempts should
be made to maintain SBP at 90mmHg.
 Adult hypotension is defined as a SBP
<90 mmHg or 30% less than their normal
SBP.
 Hypotension in Infants and Paediatric
patients is defined as SBP less than
70mmHg in patients from 1 month to 1yo
and less than (70mmHg + [2 x age]), from
1 - 10yo.
 Reassess between each infusion.
 If patient is unresponsive to fluid volume
replacement in shock, consider ASMA
consult if not in close proximity to
Emergency departments.
 Hypervolaemia.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.19 IV Crystalloid Solutions
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Management/Dose
 KVO- 20 drops per minute (20 drops = 1ml)
 FLUID THERAPY- Shock, DKA & Hyperosmolar Hyperglycaemic State1
- Adult: 250ml boluses to a maximum total of 2000ml.
- Small adult/elderly 250ml boluses up to maximum total of 1000ml.
- Paediatric: 10ml/kg over 5-10 minutes. Repeat once only.
 CARDIAC ARREST

- Adult/Paed 20ml/kg bolus as a reversible cause of hypovolaemia
- Newborn 10ml/kg as a reversible cause of Hypovolaemia
 POST ROSC
- Adult 250ml boluses to a maximum total of 500ml with reassessment between each
infusion.
- Paediatric 10ml/kg, repeat once only with reassessment between each infusion (bolus
max. 250ml).
 BURNS
- Adult 1 litre stat, followed by 1 litre over 1 hour for TBSA >25% (Max. 2 litres).
- Or 1 litre over 1 hour for TBSA 15%-25% and 30 minutes transport time (Max. 1 litre).
- Paediatric 10ml/kg over 1 hour for TBSA > 10% and 30 minutes transport time.
 HAEMORRHAGE (As per CPG 5.4)

- Adult infuse 250ml boluses maximum total 2000ml with reassessment between each
infusion.
- Paediatric Hypotensive paediatric patients should receive IV fluids – 10ml/kg (max. 250ml
bolus) reassessment between each bolus (max. x 4) to a total infusion not exceeding
1000ml.
1
Initial fluid therapy is directed toward expansion of the intravascular, interstitial, and intracellular volume, all of which
are reduced in hyperglycaemic crises and restoration of renal perfusion.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699725/pdf/zdc1335.pdf
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.19 IV Crystalloid Solutions
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MEDICATIONS
11.20 INTRAVENOUS GLUCOSE 10%
July 2017
 500ml bag 10% glucose (10g per 100ml).  Not to be used if there is no patent IV
 A hypertonic crystalloid solution that access.

provides a readily available source of
energy (Glucose).
 Onset within 1 minute.
 Demonstrated hypoglycaemia where oral  High concentration of IV glucose may
glucose administration is inappropriate in: aggravate dehydration due to its
− Altered conscious state in known hypertonicity whereby it draws water
diabetic. from the cells.
− Altered conscious state of unknown  IV glucose is corrosive and IV patency
medical cause with blood glucose level must be ensured before administration.
below 4mmol/L.  Careful titration of glucose in head
− Cardiac arrest, only if hypoglycaemia injured patients is vital as glucose
is suspected as a contributory cause of leaking into CNS tissue will aggravate
the arrest, not an early indication. the injury, resulting in cerebral oedema.
 Monitor blood glucose level carefully;
beware of drop in level again after the
patient has recovered.
 Even if fully recovered, patients should
be encouraged to be transported to a
medical facility to ensure effective follow
up and review.
 IO administration is only as a last resort
after all other avenues have been
exhausted and the patient needs
lifesaving glucose.
 Do not wait on scene for glucose to take
effect.
© Copyright St John Ambulance Western Australia Ltd 11.20 Intravenous Glucose 10%
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 ADULT: 10g (100ml of 10%) IV Repeat  Hyperglycaemia.
dose up to 10g (100ml) if patient remains  Diuresis.
hypoglycaemic.  Tissue necrosis.
Maximum total dose is 20g.
 Thrombophlebitis.
 PAEDIATRIC: 2.5ml/kg (0.25g/kg or

250mg/kg) up to 100ml (10g) IV/IO.
Repeat dose up to 2.5ml/kg, once only
Maximum total dose is 20g.
 NEWBORN: 2ml/kg (0.20g/kg or

200mg/kg). Repeat once only, if clinically
indicated.
Patients should ideally be cannulated with a

large gauge cannula into a large vein, with
patency confirmed with a free flowing bolus
(>20ml) of 0.9% normal saline, before
administering glucose 10% using a 20ml
syringe via the injection port, titrated to effect.
Administration via an IO should utilise a 20ml
syringe and a three way tap.
© Copyright St John Ambulance Western Australia Ltd 11.20 Intravenous Glucose 10%
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MEDICATIONS
11.21 GLYCERYL TRINITRATE (GTN)
July 2015
Glyceryl Trinitrate (GTN): Spray bottle  Hypersensitivity.
Containing 200 x 0.4mg atomised sprays.  Hypotension < 90mmHg.
Nitrates cause the relaxation of vascular  Medications used for erectile dysfunction within
smooth muscle resulting in: 24 hours (e.g. Sildenafil®, Vardenafil®).

 Vasodilation.
 Peripheral pooling and reduced venous
return.
 Reduced left ventricular and diastolic
pressure (preload).
 Reduced systemic vascular resistance
(afterload).
 Reduced myocardial energy and oxygen
requirements.
 Relaxes spasm of coronary arteries.
 Chest pain/discomfort of presumed cardiac origin  Nitrates are an early intervention and
not relieved by rest and reassurance with systolic should not be delayed until on the stretcher or inside
BP > 90mmHg. the ambulance.
 Acute Cardiac Pulmonary Oedema with systolic BP  Administer to the patient in a seated or semi-
>90mmHg. recumbent position.
 Do not shake GTN bottle prior to administration.
 Assess BP before every dose.
 Severe hypotension is an uncommon
side effect.
Management/Dose Complications / Side Effects

Cardiac Chest pain - Hypotension (rare).
- 0.4mg (1 spray) sublingually. If pain persists after - Tachycardia.
5 minutes and BP maintained, consider further - Flushing.
sprays of GTN at 5 minute intervals. Should the - Headache.
first 3 doses provide some relief but symptoms
persist, continue with further doses at 5 minute
intervals if no contra-indications.
Acute Pulmonary Oedema
- 0.4mg (1 spray) sublingually. If BP maintained,
consider further sprays of GTN at 5 minute
intervals. Should the first 3 doses provide some
relief but symptoms persist, continue with further
doses at 5 minute intervals if no contra-indications.
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MEDICATIONS
11.23 KETAMINE
July 2017
 Hypersensitivity
 200mg in 2ml
 Age <12 months
 Rapid acting dissociative anaesthetic
 Non traumatic pain

 IM onset: 5-10 minutes
 Active cardiovascular disease including
 IV onset: 1 minute
cardiac chest pain, heart failure, severe or
poorly controlled hypertension
 Active psychiatric condition (unless pre-
treatment with midazolam)
 Used with caution in patients with stable
 IV - Second line agent for severe pain of
psychiatric disorders such as
traumatic origin post IV Fentanyl
Schizophrenia (unless pre-treatment with
administration. ASMA consult needed if IV
midazolam)
Fentanyl minimum dose (age dependant
 Use with caution in patients with
as per CPG11.13) has not been given prior
hyperthyroidism or receiving thyroid
to IV Ketamine administration.
replacement due to increased risk of
 IM - first line agent for severe pain of
hypertension and tachycardia.
traumatic origin should other means of
 IV Fentanyl minimum dose (age dependant
administering pain medication not be
as per CPG11.13) should be given prior to
available
IV Ketamine administration
 Actively disturbed patients requiring sedation
where midazolam has already been utilised
 Combative Traumatic Brain Injury
 Blood pressure and pulse frequently

elevated
 Random purposeless movements, muscle
twitching and rash are common
 Hypersalivation
 Emergence reactions (10%). Transient
laryngospasm
 Transient apnoea or respiratory depression
© Copyright St John Ambulance Western Australia Ltd. 11.23 Ketamine

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Management
Analgesia:
 IM:
- Initial does: 1 mg/kg;
- Subsequent doses at 5 minute intervals – 0.5mg/kg;
- Dilution: 200mg/2ml = 100mg/ml

100kg 75kg 50kg 25kg
100mg 75mg 50mg 25mg

(1ml) (0.75ml) (0.5ml) (0.25ml)
 IV Adults:
- Initial dose: 10-20mg (1-2ml)
- Subsequent doses at 5 minute intervals – 10mg (1ml)
- Dilution: 200mg/2ml added to 18ml NaCl 0.9% = 10mg/ml
 IV Paediatrics:
- 0.1mg/kg administered slowly titrated to effect
- Repeated at 5 minute intervals as required
Sedation:
- Abnormal and Disturbed Behaviour or Combative Traumatic Brain Injury
 IM:
- Initial dose: 2mg/Kg to a max of 200mg
- IV access obtained as soon as possible
 IV:
- 0.5mg/Kg repeated every 5 minutes until required level of sedation achieved
CRITICAL CARE PARAMEDIC ONLY

IV/IO Analgesia
Adult:
- Initial dose: 10-20mg.
- Subsequent dose 10 -30mg at > 3min intervals
Paediatric:
- 12 months initial dos: 0.1-0.2mg/Kg. Repeat >3min intervals
Rapid Sequence Intubation
Adult/Paediatric Induction (RSI): IV/IO

- 2mg/Kg
- 1mg/Kg Haemodynamically compromised

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CRITICAL CARE PARAMEDIC ONLY
Infusion
Sedation
Adult/Paediatric Infusion
- 0.25mg/Kg/Hr – 1mg/Kg/hr. Commence 0.5mg/Kg/Hr

- 200mg in 2mL dilute up to 50mL NaCl 0.9%. (4mg/mL)

Analgesia
- 0.1mg/Kg/Hr - 0.5mg/Kg/Hr Commence lower dose 0.2mg/Kg/Hr

- 200mg in 2mL dilute up to 50mL NaCl 0.9%. (4mg/mL)
Rate of infusion syringe driver (Ketamine)
Dose 10Kg 20Kg 30Kg 40Kg 50Kg 70Kg 100Kg
0.1mg/Kg/Hr 2.5mL/Hr 0.5mL/Hr 0.75mL/Hr 1.0mL/Hr 1.25mL/Hr 1.87mL/Hr 2.5mL/Hr
0.5mg/Kg/Hr 1.25mL/Hr 2.5mL/Hr 3.75mL/Hr 5mL/Hr 6.25L/Hr 8.75mL/Hr 12.5mL/Hr
1.0mg/Kg/Hr 2.5mL/Hr 5mL/Hr 7.5mL/Hr 10mL/Hr 12.5mL/Hr 17.5mL/Hr 25mL/Hr
Discarding unused medication must be witnessed and countersigned by attendant and

credible witness.

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MEDICATIONS
11.24 LIGNOCAINE 1% (XYLOCAINE)
September 2011
 20mg/2ml - (1%) in a plastic ampoule  Hypersensitivity
 Sodium Channel blocker
 Onset 1-2 minutes

 Local anaesthesia for:  Adverse drug reactions are rare when
 IV cannulation lignocaine is used as a local anaesthetic
 IO infusion and is administered correctly.
 Suturing
Management/Dose Complications / Side Effects

 INTRADERMAL:  Tinnitus, dizziness, anxiety, confusion,
 0.1ml perioral numbness
 INTRAOSSEUS:  Cardiovascular effects: Bradycardia,
 Small child: 10mg in 1ml hypotension, dysrhythmias
 CNS effects
 Small adult/large child : 20mg in 2ml
 Respiratory depression
 Adult: 40mg in 4ml (2 ampoules)
 May be repeated at a second site if needed.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.24 Lignocaine 1% (Xylocaine)
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MEDICATIONS
11.25 METHOXYFLURANE
July 2016
 3ml Ampoule.  Patients who are unable to understand or
 A halogenated ether that produces co-operate.
powerful modification of the awareness of  Patients with severe renal impairment.
pain with an associated light headed  Patients with head injury and altered

sensation. consciousness that prevents co-
operation with its use.
 6-8 breaths/ 1-2 min onset with
 Hypersensitivity e.g. malignant
maximum level after 2-4 minutes.
hyperthermia
 Pain  Use PenthroxTM inhaler with charcoal
filter attached (see Clinical Skill 603).
 Where administration in transit is
necessary, the rear extractor fan must be
used and the rear facing seat should
remain vacant. (see WISE 04)
 Instruct the patient to breathe in through
their mouth and out through their mouth
via the inhaler. For maximum effect cover
the air dilutor hole.
 Initial breath is strong and may cause the
patient to cough, so advise to take gently.
 Watch for drowsiness.
 If oxygen is required deliver separately.
 Place in a sealed plastic bag when not in
use

 Initial dose: 1 x 3ml ampoule.  Lightheaded.
 Subsequent dose: 1 x 3ml ampoule  Dizziness.
after 15 minutes if still in severe pain or  Drowsy.
pain returns, once only.  Nausea.
 Maximum dose 6ml/24 hrs or 15ml (5  Malignant hyperthermia
doses) per week.
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11.26 METOCLOPRAMIDE (MAXOLON)
August 2008
Metoclopramide “Maxolon” Side Effects

 Drowsiness.
 Lethargy.
Presentation
 Dry mouth.
 10mg in 2ml ampoule.
 Muscle tremor.
 Extrapyramidal reactions, including

Pharmacology restlessness and dystonia.
 An anti-emetic.
 Accelerates gastric emptying and
Special Notes
peristalsis.
 Not effective for established motion
sickness.
Metabolism  Not effective for prevention of nausea /
 By the liver and excreted by the kidneys. vomiting associated with opiate use.
Primary Emergency Indications Onset and Duration

 Nausea and vomiting associated with pain Intravenous Effects:
and / or GI disturbance.  Onset: 3-5 min.
 Prophylaxis in penetrating eye injuries.  Peak: 10-15 min.
 Duration: 30-60 min.
Precautions
 Children < 12 years of age.
Route of Administration
 Intravenous.
 Intramuscular.
Dose
 10mg IV / IM.
 May be repeated after 10-20 minutes if
ineffective.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.26 Metoclopramide (Maxolon)
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MEDICATIONS
11.27 MIDAZOLAM (HYPNOVEL)
November 2016
 15mg in 3mls (5mg/ml).  Hypersensitivity.
 A water-soluble benzodiazepine that has

anxiolytic, sedative and anticonvulsive
characteristics. This is due to its bonding
with receptors in the CNS; its action to
increase the inhibitory effect of the
g-aminobutyric acid (GABA)
neurotransmitter on the GABA receptors
and subsequent membrane threshold.
 Midazolam is lipid-soluble in physiological
pH and it reaches the CNS quickly.
 Prolonged seizure activity - generalised  Draw up 15mg/3ml with 12ml NaCl 0.9%
seizure lasting ≥ 5 minutes OR recurrent / to produce 15mg/15ml = 1mg/ml Or
status seizure activity as per CPG 2.3. draw up 10mg/2ml with 8ml Nacl 0.9%
 Focal seizure activity associated with to produce 10mg/10ml = 1mg/1ml.
decreased conscious state as per CPG 2.3  EARLY MONITORING, where practicable is
 Disturbed and/or abnormal behaviour that required when administering midazolam,
poses a threat to others or themselves as ideally this would include SPO2, RR, pulse
per CPG 2.5. and blood pressure.
 For the purpose of providing and  Psychostimulants, in toxic levels can
maintaining sedation during pacing, produce severe agitation and psychotic
cardioversion and RSI (CCP only) behaviour.

SEIZURES/SEDATION NON-TBI  Respiratory depression.
 Adult <70 years:  Hypotension.
- IV/IO 2.5 - 5mg, repeat dose 2.5mg  Anterograde and retrograde amnesia.
every 5 min as needed to 15mg max.
 Myasthenia Gravis
- IM 5mg, repeat once after 10 min if
needed and no IV access.
Discarding unused medication must be
witnessed and countersigned by attendant
 Adult ≥70 years or frail: and a credible witness.
- IV/IO 2.5mg, repeat dose 1mg every 5
min as needed to 15mg max.
- IM 2.5mg, repeat once after 10 min if
required and no IV access.
© Copyright St John Ambulance Western Australia Ltd 11.27 Midazolam

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 Paediatric:
- IV/IO 0.1mg/kg to a max single bolus
dose of 2.5mg, repeat as needed every
5 min to a 10mg max.
- IM 0.2mg/kg max single bolus 5mg, Discarding unused medication must be
repeat once after 10 min if needed and witnessed and countersigned by attendant

no IV access. and a credible witness.
The use of Midazolam in both Adults and

Paediatric patients for other seizure types,
outside of CPG 2.3, requires ASMA authority.
DRUG INDUCED PSYCHOSIS

- IM 10 mg (half doses for the paediatric,
small, or frail patient).
© Copyright St John Ambulance Western Australia Ltd 11.27 Midazolam

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Medications for Critical Care Paramedics
11.28 MORPHINE SULPHATE
June 2018
 15mg in 1ml ampoule  Hypersensitivity
 A narcotic analgesic acting on CNS by  Late second stage of labour
binding with opioid receptors.

 Also combines to cause respiratory
depression, vasodilation, decreases gag
reflex and slows AV node conduction.
 Analgesia  Elderly patients
 Sedation to maintain intubation  Hypotension
 Respiratory depression
 Respiratory tract burns
 Patients on monoamine oxidase inhibitor
 IM onset 10-30 min, peak 30-60 min,
duration 1-2 hours
 IV/IO: onset 2-5 min, peak 10min,
duration 1-2 hours

ADULT:  Bradycardia
 5-10mg IM  Hypotension
 2-5mg IV/IO  Drowsiness
 Repeat every 5 minutes  Nausea and/or vomiting
 Pinpoint pupils
Sedation to maintain intubation:
 Respiratory Depression
 1–20mg/hr IV/IO. Consider co- administration
with Midazolam
 Commence at 5mg/Hr titrate to effect
PAEDIATRIC:
 0.1-0.2mg/kg IM
 0.05-0.1mg/kg IV/IO titrated to effect
 Maximum dose 0.4mg/kg
 Do not exceed 20mg
Sedation to maintain intubation:
 0.1 – 0.2 mg/kg/hr IV/IO Consider co-
administration with Midazolam.
 Single dose not to exceed 2.5mg
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MEDICATIONS
11.29 NALOXONE (NARCAN)
June 2018
 0.4mg (400mcg) in 1ml vial  Nil.
 Naloxone is a pure opioid antagonist that
exerts its effect by competitive inhibition at
the opioid receptor sites. It prevents or

reverses the effects of opioids, including
respiratory depression, sedation and
hypotension. In the absence of opioids it
exhibits essentially no pharmacological
activity.
 Reversal of respiratory depression in a  Polypharmacy overdose.
suspected narcotic overdose.  Naloxone half-life may be less than that of the
opioid.

Dilute 0.4mg (400mcg) /1ml with 9mls NaCl for  Withdrawal symptoms eg: aggression,
IV/IO administration agitation, nausea, vomiting, dilated pupils, and
lacrimation.
ADULT:
 IM: 0.4mg (400mcg) every 5 minutes as

needed up to 10mg
 IV/IO: Administer up to 400mcg Titrated to
effect. Repeat every 2 minutes as clinically
required to a maximum of 10mg.
PAEDIATRIC:
 IM: 0.4mg (400mcg) every 5-10 minutes as

required up to 2mg.
 IV/IO: 0.01mg (10mcg)/kg initial dose.

Subsequent dose 0.1mg (100mcg)/kg if
required up to 2mg.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.29 Naloxone

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Primary Care Guideline for Medication
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
November 2016
Presentation Mefenamic Acid (Ponstan)

 Ibuprofen 200mg.  Adults: 2 Tablets 3 times a day with meals.
 Ibuprofen 200mg + Codeine 12,8mg (See Not for children under 12 years.
Codeine guideline as well).
 Mefenamic Acid 250mg. Side Effects
 Nausea, Heartburn, Stomach ulcers,

Pharmacology and Action Diarrhoea, stomach cramps.
 Ibuprofen possesses analgesic, antipyretic  Drug Interactions:
and anti-inflammatory properties. Its  Anticoagulants, including Warfarin –
mechanism of action is unknown, but is ibuprofen interferes with the stability of INR
thought to be through peripheral inhibition and may increase risk of severe bleeding
of cyclo-oxygenases and subsequent and sometimes fatal haemorrhage,
prostaglandin synthetase inhibition. especially from the gastrointestinal tract.
Ibuprofen should only be used in patients
Primary Indication taking Warfarin if absolutely necessary and
 Fever (pyrexia), inflammation (anti- they must be closely monitored.
inflammatory), and mild to moderate pain  Ibuprofen may decrease renal clearance
(especially where inflammation is present. and increase plasma concentration of
lithium
Contra Indication  Ibuprofen may reduce the anti-hypertensive
 Known hypersensitivity or idiosyncratic effect of ACE inhibitors, beta-blockers and
reaction to Ibuprofen (or any of the other diuretics and may cause natriuresis and
ingredients in the product) hyperkalemia in patients under these
 Known hypersensitivity to aspirin and other treatments
NSAIDs  Ibuprofen reduces methotrexate clearance
 Asthmatic that is aspirin or NSAID sensitive  Ibuprofen may increase plasma levels of
 Active gastrointestinal bleeding or peptic cardiac glycoside
ulceration
 Pregnant patients. Precautions
Ibuprofen should be used with caution in
Route of Administration patients with:
 Oral.  Previous history of gastrointestinal
haemorrhage or ulcers
Dose  Asthma who have not previously taken an
Ibuprofen (Nurofen) NSAID
 Adults and children over 12 years of age:  Hepatic, renal or cardiac impairment.
initial dose 2 tablets, then 1-2 tablets every  Age over 65 years due to increased chance
4-6 hours (maximum 6 per 24 hours). of side effects.
 Children (7 - 12 years of age): 1 tablet  Should not operate heavy machinery or
every 4-6 hours if necessary (maximum 4 drive if taking codeine.
per 24 hours).
Administration
 Check with partner-correct medication and
Ibuprofen + Codeine (Nurofen Plus)
dose.
 Adults and children from 12 years: 2 tablets,
 Give orally, with water to swallow
then 1 or 2 tablets every 4 hours as
necessary (maximum 6 tablets in 24 hours).
Not for children under 12 years.
© Copyright St John Ambulance Australia (Western Australia) Inc. Non-steroidal Anti-Inflammatory Drugs
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© Copyright St John Ambulance Australia (Western Australia) Inc. Non-steroidal Anti-

Inflammatory Drugs
Review Date:
November 2021
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MEDICATIONS
11.30 ONDANSETRON
July 2016
 4mg in 2mls ampoule  Paediatrics less than 2 years old
 4mg Oral wafers.
 Hypersensitivity
 Anti-nauseant and anti-emetic
 Selective 5-HT3 receptor antagonist

blocking serotonin centrally in the
chemoreceptor trigger zone and
peripherally on Vagus nerve terminals.
 Onset of action up to 30 minutes
 Moderate to severe nausea  Administer IV Ondansetron slowly over 2

 Active vomiting minutes (neat or diluted) to prevent
 Prophylaxis for eye and spinal injuries blurred vision and dizziness.
 Preferred method for paediatric patients
is oral wafer.

 Adults Oral:  Headache
- 4mg Wafer, repeat dose after 30  Malaise/fatigue
minutes if required.  Drowsiness
IM or Slow IV:  Dizziness
- 4mg in 2ml. repeat the dose after 30  Rash/allergic reaction
minutes if required.
 Paediatric:
Oral (preferred):
- <15kg = 2mg (1/2 wafer)
- 15 – 30kg = 4mg (1 wafer)
- Over 30kg (as per adult dose)
 IM (single dose only):

Age Dose
2 – 5 years 1mg in 0.5mls
6 – 9 years 2mg in 1ml
10 – 12 years 3mg in 1.5mls
>12 years or >40kg 4mg in 2mls
 (Slow IV for CCP only):

Weight Dose
<40kg 0.1mg/kg
>40kg 4mg
© Copyright St John Ambulance Western Australia Ltd 11.30 Ondansetron

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MEDICATIONS
11.31 PARACETAMOL (ACETAMINOPHEN)
July 2017
 Paracetamol is a p-aminophenol derivative  Known hypersensitivity to Paracetamol.
that exhibits analgesic and antipyretic  Do not give if patient has had Paracetamol in
activity.
the preceding 4 hours.
 Presented in a 500mg tablet, or 100mg/ml
(2000mg/20ml) suspension  Cannot exceed the maximum allowed single

 Delayed onset of action with peak effect via dose or exceed the maximum allowed
oral route achieved in ≥ 60 minutes. paracetamol daily dose (24hrs).
 Mild to moderate pain  There is no evidence that fever itself
- For example, headache, sprain/strain, worsens the course of an illness. The
toothache, etc. primary goal should be to improve overall
- Or as a component of a multimodal comfort. i
analgesic regime.
 SJA do not support the use of paracetamol in
infants < 6 months.
 20 ml Paracetamol suspension bottle is
single patient use only.
 Only used enteral syringe/dropper with
suspension. ii

 Adult: 500mg tablet  Nil known at therapeutic doses.
-P.O. (oral), 500-1000mg (1-2 tablets).
-Adults: Max single dose 1000mg; Max
dose in 24-hours not to exceed 4000mg.
 Paediatric: 100mg/ml (oral suspension),
- 6 months - 12yo: 10-15mg/kg
AGE WEIGHT DOSE
6 - 12mth 8 – 10 Kg 1 ml
1 – 2yo 10 – 12 Kg 1.2 ml
3 – 4yo 14 - 16 Kg 1.4 – 1.6 ml
5 – 6yo 18 - 20 Kg 1.8 – 2 ml
7 – 8yo 22 – 24 Kg 2.2 – 2.4 ml
2.6ml or ½
9 - 12yo 26 - 40kg
tablet
- Paediatric Max single dose: 15mg/kg,
not exceeding 1g;: Max dose in
24-hours not to exceed 60mg/kg.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.31 Paracetamol (Acetaminophen)
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Further Reading:
i
Janice E. Sullivan, H. C. (n.d.). Clinical Report - Fever and Antipyretic use in Children. The American Academy
of Pediatrics.
ii
Safe administration of oral, enteral, or nebuliser solutions (Use of oral syringes for administration of oral,
enteral or nebuliser solutions) http://www.health.wa.gov.au/circularsnew/pdfs/12982.pdf
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.31 Paracetamol (Acetaminophen)
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MEDICATIONS
11.32 PACKED RED CELLS
June 2018
Packed Red Cells O negative  Once blood is opened or “spiked”, the blood
components worwill expire 4 hours after
Packed red blood cells replace lost haemoglobin

opening and must be infused in this time.
with the intent of improving O2 carrying capacity
 Presence of medical directive/ advanced
of the circulation.
directive / Alert card expressing that they
Approx. 260ml - 300ml bag IV refuse blood under any circumstances. E.g.:
“Treatment of haemorrhagic shock involves Jehovah’s Witnesses or Non consenting
maintaining blood pressure and tissue perfusion patient
until the bleeding is controlled” Kwan I et al. The  A temperature rise to >38 degrees should
Cochrane Library 2000 result in immediate cessation of the
transfusion.
 Exercise caution in hypothermic patient with
rise >1 degree C who have commenced
active warming’
Indications Notes
TRAUMA PRIMARY  Routine warming of blood is not necessary.
 Severe reactions are uncommon, however
<12yrsTo be administered in conjunction
they are most likely to occur within the first
with ASMA consult where communication
15 minutes/50mls of each unit and patients
allows.
should be closely observed during this
Trauma Principles of management as per CPG
period especially for signs of fever and loin
5.1 and Haemorrhage control as per CPG 5.4.
pain or discomfort.
The goal is to improve organ perfusion and the  Blood transfusion should never be a
haemodynamic status in patients with substitute for meticulous haemorrhage
haemorrhagic shock who have failed to respond control.
to initial fluid therapy.  No medications or solutions (except 0.9%
These patients may present with the following: Sodium Chloride solution) should be added
to the blood bag or co-administered through
 Blood loss between (30 – 40% of total the same giving set.
volume)  As a minimum; the vital signs of
 Tachycardia >120 b/min temperature, pulse, respiration rate and
 Anxious confused state blood pressure prior to commencing infusion
 Tachypnea >30 b/min and every 15 minutes thereafter.
 Hypotension
Reassess after first unit and repeat if indicated.
© Copyright St John Ambulance Western Australia Ltd 11.32 Packed Red Cells
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Complications / Side Effects
 Febrile (non-haemolytic) transfusion reaction.
 Acute and delayed haemolytic reaction.
 Allergy / Anaphylaxis.
 Transfusion-related circulatory overload (TACO).

Management / Dose
 Administer IV fluids as per CPG 11.19.
 Obtain ASMA approval <12yrs 10ml/Kg maximum 1 unit.
PAEDIATRIC
- If bleeding is the obvious cause, is not fully controlled and there is evidence of inadequate
organ perfusion. Give the blood 1st line. Crystalloid 1st will only further dilute the clotting
factors and platelets.
- If the cause of LOC / Hypotension / Tachycardia is unclear then IV fluids 1st might be more
appropriate.
- Once dose achieved leave PRC in situ if less than 3 hours from use.
 Check external blood box thermometer reading within range of 2.5 - 6 degrees C.
If not - do not use.
 Check internal data logger ensure temp within 2.5 -6 degrees C If not- do not use
 Check blood product details (ensure O negative).
 Check expiry date and time of blood.

 All attempts should be made to maintain patient momentum to definitive care.
 Obtain verbal consent from patient where possible including discussion of proposed red cell
transfusion risks and benefits of transfusion, including risks of doing nothing. Document verbal
consent in ePCR.
 Check that the integrity of the blood product is confirmed. No leaks at ports / packing seams, no
evidence of haemolysis (unusual discolouration or turbidity), or large clots. If identified / if in
doubt - do not transfuse.
 Ensure large bore IV access; take blood for laboratory. (Pink)
 Transfuse through filtered IV Giving set approved for blood administration (170-20um Filter) to
remove clots and aggregates. Ensure primed with Saline.
 Ascertain base line observations and document accordingly.
 Monitor patient for adverse effects.
Any concerns about transfusion reaction: » cease transfusion and manage appropriately. Report
all transfusion reactions to receiving medical team and ASMA post case. Document in ePCR.
» Should a transfusion reaction have taken place, keep the blood bag and handover to medical
team.
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 Incomplete transfusion bags to be left with medical staff / nursing staff at receiving hospital.
 Unused units to remain in Pelican case and returned to HEM base if temp remains within range
2.5-6 C
 Complete blood issuing paperwork.
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MEDICATIONS
11.33 ROCURONIUM BROMIDE (ESMERON)
July 2017
 50mg in 5ml ampoule  Hypersensitivity
 A non-depolarising neuromuscular

blocking agent
 Due to weak vagolytic action, a slight
rise in pulse rate and MAP may be
expected.
 To facilitate paralysis  Sedatives to be administered prior to
 Maintain paralysis Rocuronium Bromide unless patient
hemodynamically unstable and
performing crash intubation
 Continuous SpO2 and ETCO2
monitoring is a high priority
 Patients with Myasthenia Gravis should
be given smaller doses and monitored
carefully due to the potential of
increased degree of neuromuscular
block.
 Keep refrigerated at 2-8oC.
 Onset 2-3 min, peak 8-10 min. Duration
30 min dose dependant
 Crash intubation preferred over
Suxamethonium

Adult/Paediatric: IV/IO  Slight increase in pulse
 Induction:1.2mg/Kg  Slight increase in MAP
 Initial dose: 0.6mg/kg (usually 50mg in
adults) post Suxamethonium dose only
 Maintenance : 0.1-0.2mg/kg repeat PRN
 Infusion: 0.5 – 1.0 mg/Kg/Hr
© Copyright St John Ambulance Western Australia Ltd 11.33 Rocuronium Bromide (Esmeron)
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MEDICATIONS
11.34 SALBUTAMOL SULPHATE (VENTOLIN)
June 2018
 5mg in 2.5ml plastic nebule  Known hypersensitivity to Salbutamol
 100mcg dose per puff from MDI.  Cardiogenic Pulmonary Oedema

 Age <12 months
 Sympathomimetic — a short acting
synthetic beta 2 adrenoreceptor stimulant
that causes relaxation of bronchial
smooth muscle (bronchodilation).
 Initial effect 2-5 minutes maximum by 10
minutes.
 Bronchospasm and respiratory distress  Tachycardia
associated with wheeze:  A spacer / MDI is the preferred route for
- Acute Bronchial Asthma (CPG 3.2) Salbutamol administration where the patient
- Bronchitis presents with influenza like illness.
- Smoke inhalation  If hypoxic, nebulise Salbutamol in preference
- Severe allergic / anaphylactic reactions to MDI, to address both hypoxia and
- Acute Pulmonary Oedema of non- bronchospasm. The nebulised route also
cardiac origin makes it possible to administer Ipratropium
- Salt Water Aspiration Syndrome (SCUBA Bromide simultaneously.
divers)
- Chronic Obstructive Pulmonary Disease
(COPD)

 MDI / Space chamber (Skill 613)  Muscle tremor
1. Press once firmly on the MDI to fire 1 puff  Tachycardia
into the spacer.
2. Instruct the patient to take 4 breaths in
and out.
3. Repeat 1 puff at a time until 4 puffs have
been taken.
 Nebulised (Skill 602)
- One to two ‘Nebule' (5mg in 2.5ml) with
6-8L/min Oxygen.
- Give salbutamol via continuous
nebulisation in life threatening asthma
- Repeat as clinically required.
© Copyright St John Ambulance Western Australia Ltd. 11.34 Salbutamol Sulphate

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MEDICATIONS
11.35 SUXAMETHONIUM CHLORIDE
January 2013
 100mg in 2ml ampoule  Known hypersensitivity to

 Depolarising neuromuscular blocking Suxamethonium
agent  Upper airway obstruction
 A short acting muscle relaxant  Severe respiratory distress
 Known history of Suxamethonium
apnoea
 ECG signs of hyperkalaemia in
conditions such as
 muscle necrosis and renal failure
 Organophosphate poisoning
 Known history of malignant
hyperthermia
 Avoid in chronic neuromuscular
disease (if known)
 Complete muscle relaxation to facilitate  Sedation is required prior to use
endotracheal intubation.  A second dose of Suxamethonium
 • ASMA consult if Suxamethonium usually causes profound bradycardia
contraindicated or as required  Complete muscle relaxation occurs
within 30-60 sec, persist for about 2-
3min.
 Keep refrigerated at 2-8C

Adult:  Muscular fasciculations
 1-2mg/kg IV/IO  Increased intraocular pressure
 Repeat dose if indicated  Increased intragastric pressure
Paediatric:  Elevated serum potassium levels
 2mg/kg IV/IO  Bradycardia
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MEDICATIONS
11.36 PREDNISOLONE ORAL
June 2018
 Redipred Oral 30ml elixir for oral  Known Hypersensitivity to Corticosteroids.
administration.  Live virus immunisation within last 48 hours

 Prednisolone is a steroid. It prevents the (e.g. MMR, Chicken Pox, Yellow Fever).
release of inflammatory mediators.
 Peak effect within 1hr.
 Mild / Moderate Croup  30ml Bottle is single patient use only.
 Severe Croup after nebulised Adrenaline  Children who are on immunosuppressant
administration (CPG 11.5). drugs are more susceptible to infections than
healthy children, e.g.: Chicken pox and
measles.
 Impaired immune responsiveness
Management / Dose Complications / Side Effects

 Each 1ml of solution contains 5mg of  Side effects occur following prolonged use
prednisolone. and are of little consequence in an
 Administer 1mg/kg to maximum single dose emergency setting.
of 25mg.  Vomiting
 Single dose only.
Age Weight (kg) Dose
10 mg
<12 months < 10 kg
(2 mL)
10 - 15 mg
1 - 3 years 10 - 15 kg
(2 - 3 mL)
15 - 20 mg
4 - 5 years 15 - 20 kg
(3 - 4 mL)
20 - 25 mg
6 - 8 years 20 - 25 kg
(4 - 5 mL)
Chart is a guide only and weight-based
calculations should be utilised where possible.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.36 Prednisolone Oral
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11.37 METARAMINOL TARTRATE (ARAMINE)
June 2018
Presentation: 10mg/ml  Hypersensitivity.
Metaraminol is a sympathomimetic,  Hypovolaemia
adrenoceptor stimulant.  MAOIs or within 14 days of such treatment
 It directly and indirectly stimulates the alpha

receptors in the sympathetic nervous
system.
 Alpha stimulation causes vasoconstriction
with an increase in both systolic and
diastolic blood pressure and an increase in
systemic vascular resistance.
 It has a positive inotropic effect on the heart
and a peripheral vasoconstrictor action
Adjunctive treatment of hypotension after  Use of Metaraminol with (MAOI’s) or tricyclic
adequate fluid resuscitation due to: antidepressants may result in potentiation of
 Post anaesthesia the pressor effect.
 Haemorrhage  Onset 1 to 2 minutes
 Cardiogenic shock  Duration up to 20 minutes
 Septicaemia.  Half-life minutes
 Hypotension can be defines as less than
30% of the patients base line SBP or in
children (70mmHg +(2xage)) in the 1- 10yo.
 Asthma – risk of allergy to sulphides
 Digitalised patients – risk of arrythmias

 Please see next page for complete dose Administer dose cautiously as rapidly induced
regime. hypertensive response may cause:
 Arrhythmias
 Pulmonary oedema
 Cerebral haemorrhage
 Cardiac arrest.
Causes tissue necrosis, avoid extravasation.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.37 Metaraminol Tartrate
Page 1 of 2
Management/Dose PTO
 Adult: IV/IO
− IV/IO 0.5mg - 1mg, repeat >3 min
− Dilute 10mg/1ml into 20ml NaCl 0.9% to provide a solution of 0.5mg/ml.
 Adult Infusion:
− 20mg in 50ml in NaCl 0.9% at 0.5 to 5 ml/hr (0.4mg/ml) titrate to BP/haemodynamic status

Dose Range Rate of infusion (SD)
0.05μg/kg/min 0.5mL/hr
0.1μg/kg/min 1mL/hr
 Paediatric: IV/IO
− 0.01mg/kg, repeat >3 min
− Dilute 5mg/0.5ml into 50ml NaCl 0.9% to provide solution of 0.1mg/ml
 Paediatric Infusion:
− 0.15mg/Kg in 50ml in NaCl 9% at 1 to 10 ml/hr (0.05-0.5mcg/kg/min) titrate to
BP/haemodynamic status.
− 5kg use 0.75mg 10kg use 1.5mg 15kg use 2.25mg 20kg use 3mg
30kg use 4.5mg 40Kg use 6mg 50Kg use 7.5mg
Dose Range Rate of infusion (SD)

 Titrate to effect. Closely monitor BP.
© Copyright St John Ambulance Australia (Western Australia) Inc. 11.37 Metaraminol Tartrate
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INFECTION CONTROL CPG
June 2018
12.1 STANDARD & TRANSMISSION BASED
PRECAUTIONS & INFECTIOUS DISEASES:
• GENERAL INFORMATION
Introduction

- The following applies to St John Ambulance (WA) from here on will be referred to as
the Ambulance Service.
- The procedures set out within the following pages have been developed to aid staff in
minimising the risks of transmission associated with infectious diseases. This process
is dynamic, particularly in situations faced by ambulance staff daily. Safe practice can
be achieved by ensuring staff:
1. Are supported by the Ambulance Service to deliver recommendations within
these procedures;
2. Have received infection prevention and control training; and
3. Understand and can apply the principles of risk assessment to minimise the risks
of transmission of infectious diseases.
- The Ambulance Service is committed to tackling the risks involved and reducing the
impact of healthcare associated infections on patients, staff and the organisation.
Infection prevention and control must be integral to the role of all clinical staff and must
reflect their commitment to the provision of a safe environment for patients and staff.
- All staff engaged in clinical practice on behalf of the Ambulance Service must be aware
of and familiar with the following procedures for their own protection and that of their
patients, and to support the service’s efforts towards reducing the incidence of
healthcare associated infection.
• STANDARD AND TRANSMISSION BASED PRECAUTIONS

- Successful infection prevention and control involves implementing work practices that
prevent the transmission of infectious agents through a two-tiered approach:
1. Standard precautions – the routine application of basic infection prevention and
control strategies to minimise risk to both patients and staff, such as hand
hygiene, personal protective equipment, cleaning and management of linen and
waste.
2. Transmission based precautions – use of work practices that effectively manage
infectious agents where standard precautions may not be sufficient by
interrupting the mode of transmission.
Standard Precautions
- Standard Precautions refer to those work practices that are applied to everyone,
regardless of their perceived or confirmed infectious status, and ensure a basic level of
infection prevention and control. It is essential that standard precautions are applied at all
times as:
1. people may be placed at risk of infection from others who carry infectious agents
2. people may be infectious before signs or symptoms of disease are recognised or
detected, or before laboratory tests are confirmed in time to contribute to care
3. people may be at risk from infectious agents present in the surrounding
environment including environmental surfaces or from equipment
4. there may be an increased risk of transmission associated with specific
12.1 Standard & Transmission based Precautions & Infectious Diseases

Page 1 of 6
procedures and practices
- Implementing standard precautions prevents or minimises the risk of transmission of
infectious agents, even in high-risk situations, and maintains high standards of hygiene of
the environment and equipment.
- Standard precautions consist of:

1. Hand hygiene, consistent with the 5 moments for hand hygiene, where
practicable
2. The use of personal protective equipment
3. The safe use and disposal of sharps
4. Routine environmental cleaning

5. Reprocessing of reusable medical equipment
6. Aseptic technique
7. Waste management
8. Appropriate handling of linen
- Standard Precautions should also be used in the handling of: blood (including dried blood);
all other body fluids, secretions and excretions (excluding sweat), regardless of whether
they contain visible blood; and non-intact skin and mucous membranes.
Transmission-Based Precautions
- Transmission-based precautions are recommended as extra work practices in situations
where standard precautions alone may be insufficient to prevent transmission.
- Transmission-Based Precautions are used for patients known or suspected to be

infected or colonised with epidemiologically important or highly transmissible pathogens.
- Transmission-Based Precautions are tailored to the particular infectious agent involved

and the mode of transmission, and may include one or any combination of the following:
1. Continued implementation of Standard Precautions;
2. Wearing specific personal protective equipment (including gloves, coveralls,
surgical masks or P2 mask, and protective eyewear);
3. Providing patient-dedicated equipment; and
4. Enhanced cleaning and disinfection of ambulance surfaces and equipment using
a TGA approved detergent/disinfectant with label claims specifying its
effectiveness against specific infectious organisms including spores.
Contact Precautions
- Contact precautions are used when there is a known or suspected risk of direct or indirect
contact transmission of infectious agents that are not effectively contained by standard
precautions alone.
1. Direct transmission occurs when infectious agents are transferred from one
person to another person. For example, blood or other body substances from an
infectious person may come into contact with a mucous membrane or breaks in
the skin of another person.
2. Indirect transmission involves the transfer of an infectious agent through a
contaminated intermediate object (fomite) or person. Contaminated hands of
healthcare workers have been shown to be important contributors to indirect
contact transmission.

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Droplet Precautions
- A number of infectious agents can be transmitted through respiratory droplets (ie large
particle droplets ≥ 5 microns) that are generated by a patient who is coughing, sneezing or
talking. Transmission requires close contact as the droplets do not remain suspended in
the air and only travel over short distances (around 1-2 metres). They can however,
contaminate horizontal surfaces close to the source patient, and the hands of healthcare
workers can become contaminated through contact with those surfaces. Droplet
precautions prevent the inhalation of the infectious microorganisms, and also prevents
contact with mucous membranes.

Airborne Precautions
- Certain infectious agents are disseminated through airborne droplet nuclei or small
particles that remain infective over time and distance when suspended in the air. Airborne
precautions prevent the inhalation of the infectious microorganisms.
Application of standard and transmission-based precautions
Type of Gloves Coveralls Mask Eye Equipment

Precautions Protection Handling
Standard
Standard precautions apply for all work practices to prevent likelihood of
transmission of infection
Contact     Single use or

reprocess
before reuse on
next patient
Droplet     Single use or

P2 mask reprocess
before reuse on
next patient
Airborne 
   Single use or
P2 mask reprocess
before reuse on
 next patient
 Essential component of transmission-based precautions

 Face mask required by patient if infectious agents suspected/isolated in sputum
 As required:
1. Coveralls to be worn for procedures when there is the potential of direct or indirect
contact to body substances
2. Face and eye protection to be worn when there is the potential of exposure to
splashes or spray to mucosa (including during aerosol-generating procedures).

Page 3 of 6
Type of Precautions Required for Specific Infectious Diseases Table
- The infectious disease section, whilst not exhaustive, contains a list of common infectious
diseases and should provide a framework for risk assessment. It is updated when
applicable.
Disease Infective Material Precautions
Anthrax (pulmonary, systemic Respiratory secretions, blood,

Contact Precautions
and cutaneous expressions of wound exudate depending on
(cutaneous cases)
the disease) disease symptoms

Bronchiolitis Respiratory secretions Contact/Droplet Precautions
Airborne Precautions for

Chickenpox and shingles Respiratory secretions and chickenpox
(Varicella-Zoster Virus) exudate from lesions Contact Precautions for
shingles
Clostridium difficile infection
Faeces Contact Precautions
(Pseudomembraneous colitis)
Conjunctivitis Purulent exudate Standard Precautions
Creutzfeldt-Jakob Disease
Brain tissue & CSF Standard Precautions
(CJD)
Diphtheria Respiratory secretions Airborne Precautions
Gastroenteritis – bacterial &
parasitic (Salmonella,
Shigella, Campylobacter,
Giardia)
Gastroenteritis - viral
(Rotavirus, Adenovirus,
Aerosolised vomit Droplet Precautions
Norovirus)
Glandular fever
Saliva Standard Precautions
(Infectious mononucleosis)
Hand, foot and mouth disease Respiratory secretions,
Contact Precautions
(Coxsackievirus A16) faeces, lesions
Hepatitis A & E Faeces Contact Precautions
Hepatitis B, C & D Blood and body fluids Standard Precautions

Human Immunodeficiency
Blood and body fluids Standard Precautions
Virus (HIV)
Impetigo
Staphylococcus aureus Exudate from lesions Contact Precautions
Streptococcus pyogenes
Influenza Respiratory secretions Contact/Droplet Precautions
Inhalation of aerosolised
Legionellosis
contaminated water (not Standard Precautions
Legionnaires’ Disease
person to person)
Lice - Head Eggs and lice (nits) in hair,
Contact Precautions
(Pediculosis) clothing and headgear
Lice - Body Eggs and lice (nits) in hair,
Standard Precautions
(Pediculosis) clothing and headgear

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Ingestion of contaminated
Listeriosis Standard Precautions
foods
Measles Respiratory secretions Airborne Precautions
Meningococcal infection –
Bacterial Respiratory secretions Droplet Precautions
(Neisseria meningitidis)
Purulent discharge, direct Contact Precautions.

Methicillin-resistant
contact with a person with Droplet Precautions with MRSA
Staphylococcus aureus

asymptomatic carriage respiratory tract infections
Respiratory secretions
Mumps Droplet Precautions
Saliva
Pertussis (whooping cough) Respiratory secretions Droplet Precautions
Rubella Respiratory secretions Droplet Precautions
Scabies Skin parasite Contact Precautions
Tuberculosis Respiratory secretions Airborne Precautions
Patient Assessment (when Infectious Disease is suspected)

- Purpose:
1. To assess each individual patient for signs, symptoms and/or history which suggest
the presence of infectious disease requiring staff to implement appropriate
transmission based precautions including wearing the correct personal protective
equipment (PPE).
Process
- Assess does patient have:
1. Worsening cough; or
2. Fever (temperature > 380C); or
3. Rash in the presence of fever; or
4. Been hospitalised outside of Western Australia in the past 12 months.
5. Acute/unexplained diarrhoea and/or vomiting
- If YES to any of the above questions don the following before completion of assessment:
1. Gloves;
2. Eye protection;
3. With consideration given to P2 mask;
- If patient requires immediate attention or patient unable to accurately report on symptoms,

don gloves and eye protection before one metre gap to patient is closed.
References
National Health & Medical Research Council and the Australian Commission on Safety and
Quality in Healthcare. (2010). Australian guidelines for the prevention and control
of infection in healthcare. Canberra, Australia: Commonwealth of Australia.

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July 2017
12.2 HAND HYGIENE and SKIN CARE:
1. Hand Hygiene
1.1 Purpose

Effective hand hygiene is widely recognised as the single most important strategy for the
prevention of healthcare associated infections.
Effective hand hygiene reduces or inhibits the growth of microorganisms and prevents the
transmission of pathogens between patients and healthcare workers
1.2 Definition
Hand Hygiene is a general term referring to any action of hand cleansing. There are three
ways hand hygiene can be performed:
1. Applying a waterless antimicrobial hand rub to the surface of the hands (e.g. alcohol
based hand rub).
2. Washing hands with the use of a water and soap or a soap solution, either non-
antimicrobial or antimicrobial.
3. Use of the approved detergent wipes (this should always be followed with ABHR).
ABHR is gold standard for hand hygiene for all clinical situations where hands are visibly
clean.
Wash with soap and water when hands are visibly dirty, when visibly soiled with blood or
other body fluids, or when caring for patients with symptoms of gastroenteritis.
When there is no readily available access to hand washing facilities, the approved detergent
wipes can be used, followed by ABHR. It is recommended to wash hands with soap and
water as soon practical.
1.3 Indications
Five Moments for Hand Hygiene have been identified as the critical times when hand
hygiene should be performed to protect:
- Patients against acquiring infectious agents from the hands of healthcare workers
- Patients from infectious agents (including their own) entering their bodies during
procedures
- Healthcare workers and the healthcare environment from acquiring patients’ infectious
agents
© Copyright St John Ambulance Western Australia Ltd. 12.2 Hand Hygiene and Skin Care
Page 1 of 6
1.4 “5 Moments for Hand Hygiene (WHO)”

Moment 1: Before Touching A Examples:
Patient - Shaking hands, assisting patient to move
To protect the patient against - Taking a pulse, taking a BP, chest auscultation,
acquiring harmful micro-organisms abdominal palpation, applying ECG electrodes
from the hands of the healthcare - Applying an oxygen mask or fitting nasal cannula
worker - Preparation and administration of oral medications
Moment 2: Before a Procedure Examples:
To protect the patient from harmful - Intravenous cannulation, intraosseous cannulation
micro-organisms from entering their BGL, subcutaneous or intramuscular injections,
body cricothyrotomy, needle thoracocentesis,
- Insertion of an airway device
- Preparation and administration of medications
- Suctioning of the airways
- Disconnecting vascular access giving sets
- Wound/burn dressings,
- Obstetric procedures
Moment 3: After a Procedure or Examples:
Body Fluid Exposure - After any moment 2
To protect the healthcare worker - After contact with blood or any body fluid
and the environment from harmful
micro-organisms
Moment 4: After Touching a Examples:
Patient - After any moment 1
To protect the healthcare worker
micro-organisms
Moment 5: After Touching the Examples:

Patient’s Surroundings - When leaving the patient’s house
To protect the healthcare worker - After touching the patient’s belongings
micro-organisms
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Other opportunities to decontaminate hands include (but are not exclusive to):
- At beginning and end of shift

- Before and after removal of gloves and other PPE
- Before and after handling food
- Before and after smoking
- Before and after using the bathroom
- After performing respiratory hygiene/coughing into hands
- Any time hands are visibly contaminated.
- After vehicle checking
After patient equipment/stretcher contact

-
- After cleaning equipment/vehicle
- On entering (where practical) and leaving the Emergency Department
1.4 Process
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1.5 To minimize the possible barriers to hand hygiene:
Keep fingernails short (i.e. the length of the finger pad) and clean. Nail varnish, artificial nails,
extenders or tips are not to be worn.
Rings with ridges and stones must not be worn. A plain metal ring is acceptable.
It is recommended for all operational staff to be bare below the elbows however a wrist watch
may be worn. The watch must be cleaned regularly and removed prior to washing hands with
soap and water. It is advised that the watch be waterproof and made from a wipeable material,
with a flat, smooth wrist band to minimize the risk of harboring pathogens.

Long sleeved jackets can easily become contaminated, and impede access to the wrist for
hand hygiene. Long sleeved jackets must be removed, and sleeves shortened to mid forearm
unless long sleeves are required as part of PPE such as the wearing of high visibility jackets,
coveralls, helicopter paramedic uniform.
2. Hand/Skin Care
Healthy intact skin is an effective barrier against infection. It is important to take of your hands
by using the correct hand hygiene method.
ABHR is recommended for routine hand hygiene, unless hands are visibly soiled.
Use warm water and not hot for hand washing.
Ensure hands are dried thoroughly after washing. Pat dry hands using a paper towel.
Regularly use a hand moisturizer to prevent drying and cracking of the skin.
Cover cuts, abrasions and lesions with a water resistant, occlusive dressing and change as
necessary whilst on duty.
2.1 Skin Irritation and Allergy
All clinical staff and volunteers are screened for skin irritation/conditions and latex sensitivity
during the pre-employment interview process.
The main type of occupational skin irritation associated with hand hygiene is irritant contact
dermatitis. Symptoms include dryness, irritation, itching, and sometimes cracking of the skin.
Allergic contact dermatitis is rare and is due to an allergy from an ingredient in a hand
hygiene product.
Report all skin conditions (e.g. dermatitis, allergic eczema, weeping lesions) to your Manager
and seek medical advice from GP or attend an Apollo Health Centre.
Complete Skin Care Questionnaire and Assessment form

http://www.hha.org.au/UserFiles/file/Manual/GenericSkinAssessmentForm.pdf
and send to Safety and Injury Management Services with a completed incident form.
Staff who have skin conditions such as exudative lesions or weeping dermatitis should be
removed from direct patient care until the condition resolves. Seek guidance from your
Manager and Safety and Injury Support Services.
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2.2 Flow chart
WHAT TO DO IF YOU HAVE SKIN

IRRITATION
Report Problem to Your Manager & SISS
 This facilitates monitoring of skin problems across the

organisation

 Report skin problems early to allow early intervention
Good Skin Care Practice:

Use ABHR Use Moisturiser
 Reduce handwashing (unless  Moisturise hands

hands visibly soiled) and use regularly while at work –
ABHR where possible. before the start of the
 ABHR may sting hands if shift, during meal breaks
split/cracked. It does not and at end of shift.
mean you are allergic to it.  Moisturise hands
 At home, use soap substitutes regularly while at home
where possible
See GP or Attend Apollo Health Clinic
If the previous advice has not improved your skin integrity, you will need
to assessed by a doctor:
1. You may need script for topical corticosteroid ointment or cream to

apply to your hands
2. You may need to have a blood test to determine if you are allergic to
latex (RAST)
3. You may need some time off to let your skin heal, or a rostering
change
Referral to a Dermatologist
 If there has still not been improvement, you may need a referral from your
GP to see a dermatologist
 You may be referred to a special clinic for patch testing.
 Patch testing is used to diagnose an allergy to something that your skin is
coming into contact with.
Adapted from Occupational Dermatology Research and Education Centre flowchart for
healthcare workers
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Further Reading:
Government of Western Australia. (2013). Operational Directive 0429/13 National Hand Hygiene
Initiative in Western Australian Hospitals. Perth: Department of Health.
Hand Hygiene Australia. (2017). Retrieved from http://www.hha.org.au/
Occupational Dermatology Research and Education Centre. (2017). Retrieved from

http://www.occderm.asn.au/
World Health Organization. (2009). WHO Guidelines on Hand Hygiene in Health Care. First Global
Patient Safety Challenge. Clean Care is Safer Care. Geneva: WHO.
Page 6 of 6
March 2016
12.3 TRANSPORT OF PATIENT:
1. Transport of Patient
1.1 Ambulance-Patient Transfer to Hospital

Driver compartment - is designated as the clean area and PPE (with exemption of
reflective vest) is not worn in this area as this practice may cause surfaces and equipment
to become contaminated.
Patient compartment –
NO Infectious Disease risk identified in 3.1
• Hand hygiene – before and at the end of patient care and after vehicle and equipment
cleaning.
• PPE – Nitrile gloves only.
• Linen - remove linen from patient stretcher and place in the designated linen
carrier at hospital. Place heavily soiled/contaminated linen in clinical waste bin. Only
replace clean linen after the stretcher has been cleaned.
• Waste – place in general waste bin at hospital.
• Cleaning – after each patient transfer:
o Emphasis on patient care area of the stretcher. Clean the stretcher rails,
mattress, and any other areas that are visibly soiled.
o In Ambulance clean monitor area, BP cuff, SPO2 Probe and any other areas
that are visibly soiled.
o Use approved disposable impregnated detergent/disinfectant wipes.
o Dispose of the wipes after use into hospital waste bin.
KNOWN OR SUSPECTED Infectious Disease risk identified in 3.1
• Notify CSP in SOC if significant infection risk is present for further clarity and
discussion – type of precautions (i.e. contact, droplet, airborne) being used so that
appropriate patient hospital accommodation can be prepared.
• People travelling in ambulance - only essential, as determined by clinical staff.
• Ambulance air conditioning -
o Turn on exhaust fan for duration of journey.
o Leave exhaust fan on after transport with windows and doors closed to facilitate
a complete air exchange and remove all infectious airborne particles.
• Patient – wears non-vented P2 mask.
Patient requires oxygen therapy – high-concentration/low flow mask

• Hand Hygiene – before and at the end of patient care and after vehicle and
equipment cleaning.
• PPE -
o Nitrile gloves
o Vented P2 mask
o Protective eyewear/faceshield where available
o Discard after patient handover.
12.3 Transport of Patient
Review Date: April 2021
Page 1 of 6
• Linen - remove linen from patient stretcher and place in the designated linen
carrier at hospital (before removal of gloves). Place heavily soiled/contaminated
linen in clinical waste bin. Only replace clean linen after the stretcher has been
cleaned.
• Waste – place in general waste bin at hospital (before removal of gloves).
• Cleaning – after each patient transfer:
o Don new gloves and other appropriate PPE.
o Emphasis on patient care area of the stretcher. Clean the stretcher rails,
mattress, and any other areas that re visibly soiled.
o In Ambulance clean monitor area, BP cuff, SPO2 Probe and any other areas
that are visibly soiled.

o Use approved disposable impregnated detergent/disinfectant wipes and here
applicable anti-sporicidal wipes.
o Dispose of wipes after use into hospital waste bin.
o Remove gloves and appropriate PPE.
o Perform hand hygiene.
1.2 During a Call
Minimise opportunities for contamination within the ambulance.
If gloves become contaminated during patient care, remove them, perform hand hygiene,
and don a new pair before touching the patient again.
Note any equipment and surfaces contacted by the patient or clinical staff in the
ambulance. These items will need to be cleaned and disinfected after the call.
Place all reusable equipment which is contaminated (i.e. stethoscope, BP cuff, SPO2
probe) in designated “dirty zone” on incontinent pad after use to minimise contamination of
ambulance surfaces.
1.3 References
National Health & Medical Research Council and the Australian Commission on Safety and Quality
in Healthcare. (2010). Australian guidelines for the prevention and control of infection in healthcare.
Canberra, Australia: Commonwealth of Australia.
Ontario Emergency Services Branch Ministry of Health and Long-Term Care. (2007). Infection
Prevention and Control Best Practices Manual for Land Ambulance Paramedics.
http://www.ambulance-
transition.com/pdf_documents/infection_prevention_&_control_best_practices_manual.pdf
1.4 Aseptic Non-Touch Technique (ANTT®) and Invasive Procedures
1.4.1 Purpose
ANTT® is used in pre-hospital setting by clinical staff to minimise, as far as

practicable, the patient’s risk of exposure to pathogenic microorganisms while the
body’s natural defenses are breached during invasive clinical procedures.
ANTT are the infection prevention work practices taken during invasive clinical
procedures to prevent the transfer of microorganisms from the clinical staff,
procedure equipment or the immediate environment to the patient.
This is necessary to:

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• protect patients from endogenous and exogenous infection for all invasive
procedures;
• protect key-parts and key-sites from microorganisms transferred from clinical staff and
the immediate surroundings;
• use a risk assessment approach to select the appropriate method of ANTT®;
• standardise clinical aseptic technique/practice; and
• deliver safe and efficient patient care.
1.4.2 Process

ANTT® is achieved by:
• Performing hand hygiene to reduce the number of microorganisms on the skin.
• Using antiseptics for patient skin preparation before invasive procedures to reduces
the number of microorganisms that could be introduced into the patient’s body.
• Routine cleaning and disinfection of the environment and equipment to reduce
microorganisms that could then be transferred from the equipment to a future patient or
paramedic.
• Wearing clean gloves when performing a procedure, and changing gloves after
invasive procedures, or after touching the patient’s non-intact skin or mucous
membranes, or when gloves are visibly soiled.
• Wearing PPE; gloves, goggles and faceshield (where available) when there is a
possibility of blood/body-fluid splash.
• Using the ‘No Touch’ method of wound dressing application to maintain the sterility of
the dressing. This method involves manipulating the dressing by touching the outside
only, so the side that contacts the patient’s wound remains sterile.
• Avoiding contamination of sterile devices such as IV catheters, surgical airways,
obstetrical kits, burn dressings, and chest needles. If a sterile device is contaminated
before use, discard and use a new sterile device. Do not pre-open packages of
equipment that are used for invasive procedures such as intubation. This contaminates
the equipment and could introduce pathogenic material into the patient.
1.5 Invasive Procedures
1.5.1 Blood Glucose Testing (Refer to Clinical Skill 108 Blood Glucose Testing)
1.5.2 Suctioning Secretions from Oropharynx (Refer to Clinical Skill 302 Yankauer
Suction, Clinical Skill 303 Oropharyngeal Aspiration Flexible Catheter, Clinical Skill 304
Baby Mucus Extractor)
1.5.3 Oropharyngeal Airway (Refer to Clinical Skill 305 Oropharyngeal Airway [OPA])
1.5.4 Laryngeal Mask Airway (Refer to Clinical Skill 306 Laryngeal Mask Airway [LMA])
1.5.5 Endotracheal Intubation (Refer to Clinical Skill 307 Endotracheal Intubation

[ET])
1.5.6 Intravenous Access (Refer to Clinical Skill 608 Vascular Access)
Intravenous (IV) access is commonly used in pre-hospital care as a means of

administering medication or fluid volume and can be a source of HAI.
1.5.7 Removal of Foreign Body Upper Airway (Refer to Clinical Skill 310 Laryngoscope &
Magill Forceps)
1.5.8 Cricothyrotomy (Refer to Clinical Skill 311 Cricothyrotomy)

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1.5.9 Nasopharyngeal Airway (Refer to Clinical Skill 312 Nasopharyngeal Airway
[NPA])
1.5.10 Intramuscular Injection (Refer to Clinical Skill 605 Intramuscular Injections)
1.5.11 Suturing (Refer to Clinical Skill 804 Suturing & Steri Strips)
1.5.12 Needle Aspiration Thoracocentesis (Refer to Clinical Skill 808 Needle

Thoroacocentesis)
1.6 Single Use

To avoid cross infection or contamination between patients and avoid material degradation,
bio-compatability reactions, endotoxic reactions caused by residues from reprocessing and
device failure the following principles are adhered to:
• Single-use medications, solutions, injectables, equipment and other medical devices

are used wherever the clinical situation dictates such practice.
• Single-use labeled devices are discarded after each single use.
• Single patient use labelled equipment and other medical devices are reprocessed in
accordance with the manufacturer’s instructions and reused on the same patient only,
not put into general supply.
• Any single-use item or instrument that has penetrated the skin, mucous membrane or
other tissue must be discarded after use or at the end of the procedure, whichever is
more appropriate.
1.7 Storage of Sterile Supplies
There are a variety of sterile supplies that are used in pre-hospital care. The
following is a non-exhaustive list of these supplies:
• Pressure dressing
• Gauze bandage
• Airways
• Suction catheters
• Endotracheal tubes
• All intravenous supplies
• Syringes and needles.
Proper storage includes but not exclusively:
• Closed cupboard doors at the Depot/Station.

• Designated Ambulance lockers.
• Protection from moisture.
• Protection from extremes of temperature.
• Protection from soiling.
• Protection from exhaust fumes.
• Checking all sterile equipment before and after opening packages to ensure the
products are not damaged due to wear and tear, and are in date
1.8 References
Australasian College for Infection Prevention and Control. (2012). Position statement:
Single-use devices. Brisbane, Queensland: Australasian College for Infection Prevention
and Control.
Department of Health Government of Western Australia. OD 0531/14. Re-use of single

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use devices. Perth, Australia: Department of Health Government of Western Australia.
Quality in Healthcare. (2010). Australian guidelines for the prevention and control of
infection in healthcare. Canberra, Australia: Commonwealth of Australia.
Ontario Emergency Services Branch Ministry of Health and Long-Term Care (2007).
Infection Prevention and Control Best Practices Manual for Land Ambulance Paramedics.
http://www.ambulance-

Standards Australia/Standards New Zealand. AS/NZS 4815:2006. Office-based health
care facilities. Reprocessing of reusable medical and surgical instruments and equipment,
and maintenance of the associated environment. Sydney, Australia: Standards Australia
International Ltd and Standards New Zealand.
The Association for Safe Aseptic Practice. (2014). The ANTT clinical practice framework
for clinical practice. From surgery to community care (Version 3.3). United Kingdom: The
ANTT Organization.

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March 2016
12.4 PERSONAL PROTECTIVE EQUIPMENT (PPE):

1 Personal Protective Equipment (PPE)
1.1.1 Purpose

To protect clinical staff and patients from exposure to blood and body fluids, potentially
infectious agents; and reduce the occurrence of healthcare associated infections.
1.1.2 Requirements
Personal protective equipment (PPE) includes:

 Nitrile gloves
 P2 mask
 Protective eyewear, including goggles or face shield (where available)
 Coveralls
 Uniforms.
1.1.3 Nitrile Gloves
Nitrile gloves are provided for all clinical staff. Wearing the correct size glove will provide the best
protection and the best tactile feel.
 Clean gloves are applied at the point of patient contact for every patient, removed and hand hygiene
performed when patient contact is concluded.
 When cleaning vehicle and equipment following patient transport.
Note: When the clinical staff members who is driving the ambulance leaves the patient in the patient care
compartment with his/her crewmate, used gloves must be removed. They must never be worn in the cab
of an ambulance and never dropped/discarded in the driver section of ambulance.
Hand hygiene is required regardless of glove use.
1.1.4 P2 Mask
P2 masks are provided for protection from diseases transmitted through both the airborne and droplet
route. They prevent pathogens from being able to be breathed into the lungs.
The mask is used in a non-oil environment and will filter out at least 95% of particles that are 0.3 microns
in size or greater.
As airborne particles always clump together, a filter for particles 0.3 in size or larger is therefore excellent
protection against all known airborne transmitted diseases.
Indications for use of a P2 mask:
© Copyright St John Ambulance Australia (Western Australia) Inc. 12.4 Personal Protective Equipment (PPE)
Page 1 of 5
 If a patient is febrile (temperature > 380C);
 If the patient has a new or worsening cough and the diagnosis is unknown;
 When treating and transporting a person with a known/suspected communicable disease that is
transmitted by droplet or airborne routes;
 When treating and transporting a patient with symptoms of febrile respiratory illness;
 When blood or body fluid splash is likely or expected, and a face shield is not available, as it provides a
covering for the mucous membranes of the nose and mouth;
 When performing invasive procedures such as intubation or suctioning; and
 When required by a SJA directive.

The outer surface of the P2 mask is contaminated and care must be taken to prevent accidental self-
innoculation with the pathogens on the outside of the mask both during wear and while taking it off.
The P2 mask is designed for single patient use and is to be discarded following use.
Do not wear the mask around the neck or on top of the head as this can result in self-inoculation.
When removing the P2 mask, take it away from the face in a straight line, and place it directly in an
appropriate waste container.
If a P2 mask must be worn by the driver during transport, then the used mask should be removed at break
of patient contact, hand hygiene performed and a new, unused P2 mask should be put on before going
into the cab of the ambulance.
Used PPE must never be worn in the cab of the ambulance. Never drop used PPE in the cab of the
ambulance.
Protect against crushing of the P2 mask because a crushed mask has a reduced capacity to seal properly
which will minimise its effectiveness. Discard any P2 mask that has been crushed.
The P2 mask must stay as dry as possible, as wet masks are less effective.
Change wet P2 mask in a dry area as soon as possible.
1.1.5 Protective Eyewear
Protective eyewear protects the conjunctiva from exposure to blood, body fluids, and secretions propelled
into the air by coughing or sneezing.
Reusable protective eyewear should be cleaned and disinfected following use.
Where available full face shields are provided and are to be discarded after use.
Prescription eyewear is not considered protective as it allows contaminants to travel between the lens and
the face.
Indications for the use of protective eyewear:
 If a patient is febrile (temperature >380C);
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 If a patient has a new or worsening cough where diagnosis is unknown;
 When treating and transporting a person with a known/suspected communicable disease that
is transmitted by indirect or direct contact, droplet or airborne routes;
 When treating and transporting a patient with symptoms of febrile respiratory illness;
 When blood or body fluid splash is likely or expected;
 When performing invasive procedures such as intubation or suction;
 When cleaning large amounts of effluvia, blood or body fluid;
1.1.6 Disposable Coveralls

Disposable water-resistant coveralls are used to prevent forearms and uniforms being contaminated with
blood/ body fluids.
Indications for the use of coveralls:
 When large volume blood/ body fluid is likely/expected (e.g. uncontrolled hemorrhage).
1.1.7 Donning and Removal of Personal Protective Equipment (PPE)
Proper donning and removal of personal protective equipment (PPE) is essential to avoid the possibility of
transmission of disease.
Proper removal of PPE is essential to prevent accidental contamination/infection through contact with
potentially contaminated PPE as they are removed.
Follow the SJA Donning and Doffing of PPE Workplace Instruction when droplet or airborne precautions
are indicated.
Follow the SJA Level 1 Viral Haemorrhagic Fever PPE – Don and Doff Workplace instruction.
BA trained members should follow the appropriate Department of Fire and Emergency Services workplace
instructions regarding Donning and Doffing of BA and Other Related Specialist PPE.
1.1.8 P2 Respirator Masks
Where indicated staff will be provided with a P2 Respirator Mask.
All clinical staff must ensure their P2 respirator mask fits snugly against the skin which prevents air from
being able to bypass the filtering effect of the mask upon inspiration.
Significant body changes can cause a mask to fit improperly.
 During the later stages of pregnancy

 Major dental work (braces, dentures)
 Other facial changes due to illness or injury.
Facial hair may cause an improper seal, which can result in air leaking around the edges of the respirator.
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The area where the P2 respirator mask seals to the face should be clean shaven.
1.1.9 Fit Testing a P2 Respirator Mask
Fit checking is necessary each time the mask is worn. The manufacturer’s instructions for fit checking of
individual brands and types of P2 respirator masks should be referred to at all times.

1. Place the mask on the face.
2. Place the headband over the head and at the base of the neck.
3. Compress the mask to ensure a seal across the face, cheeks and the bridge of the nose.
4. Check the positive pressure seal of the mask by gently exhaling. If air escapes, the mask needs to
be adjusted.
5. Check the negative pressure seal of the mask by gently inhaling. If the mask is not drawn in
towards the face, or air leaks around the face seal, readjust the mask and repeat process, or check
for defects in the mask.
1.1.10 References
Government of Western Australia Department of Health. (2013). IC: 0142/13 Fit testing and fit checking
of particulate filter respirators (masks) in Western Australian healthcare facilities. Perth, Australia:
Author.
National Health & Medical Research Council and the Australian Commission on Safety and Quality in
Healthcare. (2010). Australian guidelines for the prevention and control of infection in healthcare.
Ontario Emergency Services Branch Ministry of Health and Long-Term Care. (2007). Infection Prevention
and Control Best Practices Manual for Land Ambulance Paramedics. http://www.ambulance-
South Western Ambulance Service NHS Trust. (2010). Guidance and procedures for infection prevention
and control. Managing healthcare associated infection and control of serious communicable diseases.
United Kingdom: South Western Ambulance Service NHS Trust.
Standards Australia/Standards New Zealand. AS/NZS 4011:1997/Amdt 1:1998. Single-use examination

gloves - Specification. Sydney, Australia: Standards Australia International Limited.
Standards Australia. AS 4381:2002. Single-use face masks for use in healthcare. Sydney, Australia:
Standards Australia International Limited.
Standards Australia/Standards New Zealand. AS/NZS 1716:2003/Amdt 1:2005. Respiratory protective

devices. Sydney, Australia: Standards Australia International Limited.
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Standards Australia/Standards New Zealand. AS/NZS 1715:1994. Selection, use and maintenance of
respiratory protective devices. Sydney, Australia: Standards Australia International Limited.
Standards Australia/Standards New Zealand. AS/NZS 1336:1997/Amdt 1:1997. Recommended practices

for occupational eye protection. Sydney, Australia: Standards Australia International Limited.
Standards Australia/Standards New Zealand. AS/NZS 1337:1992/Amdt 1:1994/Amdt 2:1997. Eye

protectors for industrial application. Sydney, Australia: Standards Australia International Limited.
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12.5 HANDLING AND DISPOSAL OF SHARPS:
1 Handling and Disposal of Sharps
1.1.1 Purpose

To handle, transport and dispose of sharps safely so as to prevent exposure to clinical staff,
contractors or the public to any foreseeable risk of injury or other adverse exposure.
1.1.2 Process
The safe handling and immediate disposal of sharps at the point of use is the responsibility of the
person who has used the sharp.
1.1.3 Handling and Disposal of Sharps
Use Safety Engineered Medical Devices (SEMDs)/needle-less systems wherever available.
Read and understand the instructions for use prior to using sharp devices.
Wear gloves for all procedures involving sharps.
Minimise proximity of other persons before exposing a sharp.
Never pass an exposed needle to another person.
Never accept a used sharp from a patient/bystander or other health care provider
Never re-cap or re-sheath used needles by hand, remove from disposable syringes by hand, or
purposely bend, break or otherwise manipulate by hand.
Immediate dispose of sharps post use into a sharps container by the user.
SJA provides sharps collectors that are specific for use at the scene and within the ambulance.
Sharps containers are stored and transported securely within the vehicle until ready for disposal.
If sharps or needlestick injury occurs-see CPG 12.8 Management of Occupational Exposure.
1.1.4 Disposal of Sharps Containers
Dispose of sharps containers when they are 3/4 full (see fill-line).
© Copyright St John Ambulance Australia (Western Australia) Inc. 12.5 Handling & Disposal of Sharps
Page 1 of 2
Full sharps containers are disposed of at major hospitals in the designated clinical/sharps waste
system.
1.1.5 References
Biohazard Waste Industry [BWI]. (2010). Industry code of practice for the management of clinical
and related wastes (6th ed.). New South Wales, Australia: Biohazard Waste Industry [BWI].

Department of Health Government of Western Australia. OD/IC 0260/09. Clinical and related waste
management: General requirements. Perth, Australia: Department of Health Government of
Western Australia.
Department of Health Government of Western Australia. OD 0259/09. Clinical and related waste
management: Clinical wastes. Perth, Australia: Department of Health Government of Western
Australia.
Standards Australia. AS 4031-1992 and Amendment 1 (1996). Non-reusable containers for the
collection of sharp medical items in health care areas. Sydney, Australia: Standards Australia
International Limited.
Standards Australia/Standards New Zealand. AS/NZS 3816:1998. Management of clinical and related
wastes. Sydney, Australia: Standards Australia International Limited.
Standards Australia/Standards New Zealand. AS/NZS 4262:1994 and Amendment 1 (1997). Reusable
containers for the collection of sharp medical items used in human and animal medical applications.
Sydney, Australia: Standards Australia International Limited.
Western Australian Government Gazette. (2004). Environmental Protection (Controlled Waste)

Regulations. Perth, Australia: Government Printer.
© Copyright St John Ambulance Australia (Western Australia) Inc. 12.5 Handling & Disposal of Sharps
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March 2016
12.6 CLEANING OF REUSABLE EQUIPMENT AND

SURFACES (INCLUDING WASTE MANAGEMENT AND
LINEN HANDLING):
1 Cleaning and Disinfection of Reusable Equipment and Surfaces (including Waste Management and

Linen Handling
1.1 Purpose
To maintain equipment and surfaces in a manner that eliminates or minimises the risk of infection,
thereby promoting a safe environment for patients and clinical staff.
1.1.1 Process
Cleaning is a process of physically removing all visible and non-visible contamination from a surface
using soap and water, detergent and water.
Cleaning includes the removal of blood, body fluids, and other biological material from a surface.
The act of cleaning is more important than the cleaning product used; it is the friction created by the
physical action of cleaning that actually removes infectious agents from surfaces.
Cleaning should always be performed from the “cleanest” (least contaminated) area to the “dirtiest”
(most contaminated) area to prevent the spread of contaminants.
Disinfection is a process which kills pathogenic microorganisms (with the exception of bacterial
spores) on a surface. Three levels of disinfection are recognized; high, medium, and low.
The level of disinfection required for reusable equipment is determined by the degree of contact
with the patient and the contamination risk to the patient.
1.1.2 Categories of items for patient care
Level of Risk Application Process Storage SJA WA

Critical Entry or Sterilization by Sterility must be All critical devices
penetration into steam under maintained used are single
sterile tissue, pressure use and are
cavity or (autoclaving), or a Integrity of the sterilized by the
bloodstream minimum of an package must be manufacturer, and
automated low- maintained must be disposed
temperature of appropriately
chemical sterilant after use
system, other Store to protect
© Copyright St John Ambulance Australia (Western Australia) Inc. 12.6 Cleaning of Reusable Equipment and Surfaces
Page 1 of 6
liquid chemical from
sterilant or environmental
ethylene oxide contamination
sterilization.
Semi-critical Contact with intact Sterilization by Store to protect All semi-critical

mucous steam or at least from devices used are
membranes or minimum of high environmental single use and are
non-intact skin level thermal contamination sterilized by the
disinfection manufacturer, and

must be disposed
of appropriately
after use
Non-critical Contact with intact Cleaning with Store in clean, dry All non-critical
skin but not approved place reusable devices
mucous disposable are cleaned and
membranes impregnated disinfected after
neutral each individual
detergent/low or patient use
mid level Sphygmoman-
disinfectant wipes ometers
BP cuffs
Oral
thermometers
Stethoscopes
Cardiac monitors
Suction units
Stretchers and
compartment
surfaces
1.1.3 Daily Clinical Cleaning and Disinfection of the Ambulance
The ambulance units and all patient care equipment are cleaned and disinfected on a daily basis.
Emphasis should be placed on the patient care area of the ambulance and the areas/surfaces that
come in contact with patients and paramedics.
Hand hygiene must be performed following cleaning and disinfection procedures.
New nitrile gloves must be worn when performing general cleaning and disinfection procedures.
A P2 mask and eye protection should be worn when cleaning the ambulance following a call when
the patient may have had a febrile respiratory illness (FRI).
Coveralls, face shields and/or eye protection should be worn while cleaning if there is the possibility
of splashing of blood or body fluids.
Page 2 of 6
1.1.4 At End of Each Call (including Last Call)
The cleaning and disinfection of surfaces and equipment between calls protects clinical staff and
their patients.
Remove and dispose of PPE used during patient care and perform hand hygiene.
Clean and disinfect reusable eye protection worn during the call with approved
detergent/disinfectant wipes.

Put on new gloves before beginning cleaning.
Remove soiled/used linen and discard in linen receptacle at the hospital.
Dispose of all single use and single patient use equipment in the appropriate general or clinical waste
bin at the hospital.
Clean and disinfect reusable equipment used to treat the patient with approved
detergent/disinfectant wipes and allow contact time recommended by the manufacturer. This may
include but is not limited to:
 Cardiac monitor
 Suction unit
 Stethoscope
 BP cuff
 Pulse oximeter
 Oxygen regulator and tank
 Spinal and extrication equipment
 Equipment bags (external surfaces).
Inform Area Manager of heavily soiled equipment and follow their direction.
Clean and disinfect all compartment surfaces including stretcher, mattress and straps, in contact with
the patient with approved detergent/disinfectant wipes and allow contact time recommended by
the manufacturer.
If patient had signs and symptoms of a febrile respiratory illness (FRI), clean and disinfect all
compartment surfaces that may have been contaminated by respiratory droplets within one (1)
metre of the patient.
Dispose of all waste in the appropriate general or clinical waste bins. Clinical and sharps waste is to
be disposed of in the designated clinical waste bins at hospital.
Remove and dispose of PPE in general waste bin, and perform hand hygiene.
Put clean linen on the stretcher.
1.1.5 At End of a Shift
Page 3 of 6
Clean and disinfect all exposed surfaces of patient compartment with approved
detergent/disinfectant wipes and allow contact time recommended by the manufacturer.
Replace full sharps containers when 3/4 full with empty containers, ensuring the sharps container is
well sealed and appropriately discarded in designated clinical waste bin at hospital.
Dispose of other non-clinical waste in general waste bin.
Clean and disinfect all common/high touch surfaces of driver compartment (i.e. steering wheel, seat
belts, door handles, radios, etc) with approved detergent/disinfectant wipes and allow contact time

recommended by the manufacturer.
Wipe down personal equipment such as pens, iPads, pagers, stethoscopes, pen-lights, scissors, Kelly
clamps with approved detergent//disinfectant wipes and allow contact time recommended by the
manufacturer.
Sweep and mop the ambulance floor with cleaning equipment designated for this purpose.
Manually wash mop head in detergent, rinse and hang to dry. Discard if in poor state and replace.
Remove and dispose of gloves and other PPE in general waste bin, and perform hand hygiene.
1.1.6 Following a Blood or Body Substance Spill
Consideration should be made to remove the vehicle from service, contact Manager to discuss this.
If cleaning is applicable:
Select and put on appropriate PPE.
Remove necessary equipment from the vehicle to prevent further contamination
Manage the blood and body fluids spill by:

 Confinement (prevent spread of contamination).
 Containment (cover spill with absorbent material, towel, sheet etc., to absorb the bulk of the blood
or body substance)
 Disposal (treat as clinical waste).
 Use cleaning methods that reduce the chance of splashing or contamination of clothing, or the
environment, to remove the gross spillage.
 When the gross spillage has been removed, use the routine cleaning of vehicles procedure to
complete the task, paying special attention to the cleaning of all equipment, stretcher, fittings and
surfaces.
 It is illegal to allow contaminates to enter into public storm-water drains etc. However, separate soak
wells at Stations which are not connected to public storm-water drains may be used. Officers must
contact the Property and Supply department to confirm suitability before use.
Page 4 of 6
 When cleaning is complete, restock and prepare the vehicle for operational use. A full vehicle
inventory check is recommended at this point.
 Remove PPE and perform hand hygiene.
1.1.7 Linen Handling
Handle used/soiled linen as little as possible in order to minimise agitation when removing it from

the stretcher.
Wear gloves when handling used linen, especially when it is soiled with blood or body fluids. After
every transport where the patient was placed on the stretcher, remove used linen from the stretcher
and immediately place it in the designated linen receptacle at the hospital.
When linen receptacle is not available, place used/soiled linen in clinical waste bag for containment
and transportation to the hospital.
Carefully handle and store all clean linen to maintain its cleanliness and minimise contamination.
1.1.8 Laundering of Uniforms
Safe handling of used/soiled uniforms and good hygiene practice will help prevent transmission of
infection.
Used/soiled uniforms are changed daily and home laundered. Laundering must involve the use of an
appropriate laundry detergent and warm/hot water (≥500C). If hot water is not available, uniforms
should be washed separately from other household linen and a clothes dryer should be used for
drying.
If a uniform becomes visibly soiled with blood or body substances:
 Return to the Station/Depot and remove contaminated uniform.

 Place in a designated leak-proof clear plastic bag or clinical waste bag and tie securely.
 If the skin is soiled, irrespective of whether cuts or abrasions are present, wash area
well with soap and water. Alternatively, shower.
 Put on a clean uniform.
 Extensive skin soiling requires immediate assessment of the skin for areas that are non-
intact.
 If non-intact skin has been in contact with blood or body substances, clinical staff should
undergo medical assessment in accordance with Management of Occupational Exposure
Procedure 12.8.
 Heavily soiled uniforms may be considered too contaminated for home laundering and will
be disposed of professionally cleaned by agreement with the Manager.
1.1.9 References
Healthcare. (2010). Australian guidelines for the prevention and control of infection on healthcare.
Page 5 of 6
National Occupational Health and Safety Commission. (2011). National Code of Practice for the
preparation of material safety data sheet (2nd ed.). [NOHSC: 2011(2003)]. Canberra, Australia:
Australian Government Publishing Services.
Royal College of Nursing. (2011). The selection and use of disinfectant wipes. RCN guidance.
London, United Kingdom: Royal College of Nursing.
Standards Australia/Standards New Zealand. AS/NZS 4815:2006. Office-based health care facilities.

Reprocessing of reusable medical and surgical instruments and equipment, and maintenance of the
associated environment. Sydney, Australia: Standards Australia International Ltd and Standards New
Zealand.
Standards Australia/Standards New Zealand. AS/NZS 4146:2000. Laundry practice. Strathfield,

Australia: Standards Australia International Ltd.
Page 6 of 6
March 2016
12.7 IMMUNISATION PRE-EMPLOYEMENT HEALTH SCREENING AND

PREGNANCY:
1 CLINICAL STAFF HEALTH AND SAFETY
1.1 Pre-Employment Health Screening and Immunisation

1.1.1 Purpose
To ensure the health and immune/immunisation status of prospective clinical staff and paid
volunteers is current and appropriate at the time of employment so that they are not unnecessarily
exposed to infection.
1.1.2 Process
The organisation encourages and supports current clinical staff and volunteers to ensure their health
and immune/immunisation status is current and appropriate so that they and/or patients are not
unnecessarily exposed to infection.
All prospective clinical staff and volunteers who have patient contact are screened and assessed by
definite history, vaccination and/or serological evidence via the online Clinical Services Personnel
Immunisation form. The form can be found on the intranet in the Human Resources Directorate
section under immunization.
Category A staff and volunteers are required to provide evidence of vaccination history and/or
immunity before employment/rostering.
The organisation maintains and regularly updates immune status/immunisation records of all clinical
staff and volunteers during their employment.
Further reading and guidance can be found in HR policy Immunisation located on their Intranet site.
1.1.3 Definitions
The following vaccine preventable disease (VPD) risk categories can be used to guide MRSA and
vaccination requirements:
Risk Category Staff

Category A – Direct contact with blood or All clinical staff, volunteers and students,
other body substances maintenance staff who service equipment,
those who are responsible for cleaning and
disposal of contaminated materials including
© Copyright St John Ambulance Australia (Western Australia) Inc. 12.7 Immunisation Pre-Employment Health Screening & Pregnancy
Page 1 of 6
waste
Category B –Indirect contact with blood or Includes staff who rarely have direct contact
other body substances with patients or with blood or body
substances. These staff may be exposed to
droplet or airborne VPDs but are unlikely to
be at risk of blood-borne diseases.
Category C – Minimal Patient Contact Other staff groups that have no greater
exposure to VPDs than the general public
(e.g. Administrative positions)

Screening of Staff by Contact Category
Risk Condition Category A Category B Category C

Skin conditions Yes Yes Yes
MRSA Yes No No
Diphtheria/Tetanus Yes Yes Yes
Measles-Mumps-Rubella (MMR) Yes Yes Yes
Whooping Cough (Pertussis) Yes Yes No
Chicken pox (Varicella) Yes Yes No
Hepatitis B Yes No No
Tuberculosis Yes No No
Influenza Yes Yes Yes
Hepatitis A No No No
1.1.4 Personal Medical History
All prospective clinical staff and volunteers who have direct patient contact are health
screened and assessed by definite history and/or required to provide vaccination or serological
evidence to the following:
 Exfoliative and weeping skin conditions

 Latex allergy
 Immune disorders (including medications such as immunosuppressants)
 Methicllin-Resistant Staphylococcus aureus (MRSA)
 Diphtheria-tetanus
 Measles-Mumps-Rubella (MMR)
 Whooping cough (Pertussis)
 Chicken Pox (Varicella)
 Hepatitis B
 Tuberculosis
 Influenza
 Hepatitis A.
1.1.5 Skin Conditions (Non-Infectious)
All prospective clinical staff and volunteers with either shedding and/or weeping skin conditions
(allergic eczema, psoriasis and exfoliative dermatitis) or damaged skin may be readily colonised
by micro-organisms (e.g. MRSA). These clinical staff may not be harmed by these micro-
organisms but may spread them widely to patients. Staff will be advised of the problems posed
Page 2 of 6
by their skin conditions and to seek medical attention.
1.1.6 MRSA Screening
Further reading and guidance can be found in HR policy MRSA Screening located on
their
intranet site.
1.1.7 Immunisation

Each individual has a responsibility to ensure their immunisation status is current and
appropriate.
Vaccination and/or screening is undertaken by the preferred provider identified by
Workforce Services.
Further reading and guidance can be found in HR policy Immunisation located on their intranet site.
1.1.7.1 Metropolitan Perth
Any clinical staff who wish to have vaccinations should contact Workforce Services to arrange for
immunisation.
1.1.7.2 Regional WA
Any paid volunteer who wishes to have vaccinations should contact their Regional Manager
or Assistant Regional Manager in country areas to arrange for vaccination. Clinical staff should
contact Workforce Services to arrange for immunisation.
1.1.7.3 Diphtheria/Tetanus – Category A Clinical Staff/Volunteers
Record a history of having received a primary course of at least 3 doses of diphtheria-tetanus

vaccine (dT). Immune clinical staff/volunteers should be strongly advised to undertake dT booster
doses 10 and 20 years after the primary course.
Clinical staff/volunteers who reach the age of 50 years without receiving a booster dose of tetanus-
containing vaccine in the previous 10 years, are strongly advised to undertake a further dose dT or
preferably diphtheria-tetanus-pertussis (dTpa), if a booster dose of pertussis-containing vaccine, had
not been given previously, to protect against pertussis (whooping cough).
Unvaccinated prospective clinical staff/volunteers are strongly advised to undertake 3 doses of dT

containing vaccine at minimum monthly intervals. The first of these doses should be dTPa to
provide boosting to natural immunity from exposure to pertussis.
All immunisation records are to be submitted confidentially by the employee/volunteer to Workforce

Services.
1.1.7.4 Measles – Category A, B and C Clinical Staff/Volunteers
All prospective clinical staff/volunteers must provide a record of documented history of having
Page 3 of 6
received a primary course of least 2 doses of measles-containing vaccine administered at least one
month apart or documented serological (i.e. blood test) evidence of immunity to measles.
Prospective clinical staff/volunteers without a definite documented history of measles vaccination

must undergo blood testing at the earliest opportunity to determine immunity. Non-immune clinical
staff/volunteers must undertake 2 doses of measles-mumps-rubella (MMR) vaccine at minimum
monthly intervals, unless pregnant or immunosuppressed.

Services.

1.1.7.5 Mumps and Rubella (German Measles) - Category A and B Clinical Staff/Volunteers
Record a documented vaccination history of having received a rubella-containing vaccine or

documented serological (blood test) evidence of immunity to rubella.
Non-immune male and female prospective staff/volunteers are strongly advised to undertake MMR
vaccination for their own protection and to avoid transmitting rubella to pregnant fellow
employees/volunteers.
Testing for immunity to rubella should be undertaken 2 months after vaccination and revaccinated if
remain non-immune.

Services.
1.1.7.6 Whooping Cough (Pertussis) – All Category A and B Clinical Staff/Volunteers
Record a documented history of having received a primary course of at least 3 doses of pertussis-
containing vaccine.
Non-immune prospective clinical staff/volunteers are strongly advised to undertake a primary

course of pertussis-containing vaccine at minimum two monthly intervals.
A single booster dose (given as dTpa) is strongly advised for prospective clinical staff/volunteers
have not previously had a documented booster dose of dTpa.

Services.
1.1.7.7 Chickenpox (Varicella Zoster) – Category A and B Clinical Staff/Volunteers
Record a definite history of having had chickenpox/shingles, documented history of having received
2 doses of varicella vaccine or documented serological (blood test) evidence of immunity to
chickenpox.
Prospective clinical staff/volunteers without a definite history of chicken pox or shingles are advised
to undergo blood testing at the earliest opportunity to determine immunity. Non-immune clinical
staff/volunteers are strongly advised to undertake 2 doses of varicella vaccine at minimum monthly
Page 4 of 6
intervals, unless pregnant or immunosuppressed.

Services.
1.1.7.8 Hepatitis B – Category A Clinical Staff/Volunteers
Record a documented history of having received a primary course of 3 doses of hepatitis B vaccine or
documented serological (blood test) evidence of immunity post hepatitis B vaccination or having had
previous hepatitis B infection.

Non-immune prospective clinical staff/volunteers are strongly advised to undertake 3 doses of
hepatitis B vaccine at an interval of 1 to 2 months between the first and second dose with a third
dose 2 to 5 months after the second dose.
Serological (blood) testing to confirm immunity is undertaken 1 - 2 months after the third dose of
vaccine. If protective antibody levels are not reached following the third dose of vaccine, hepatitis B
carriage (HBsAg) should be investigated.
Clinical staff/volunteers who do not have adequate hepatitis B antibody levels are strongly advised to
undertake a further 3 single doses of vaccine at monthly intervals with serological (blood) testing
four weeks after the last dose.
Persistent non-responders are informed about the need for hepatitis B immunoglobulin (HBIG)
within 48 hours of parenteral exposure to hepatitis B.
Booster doses of hepatitis B vaccine are no longer recommended. Serological (blood) testing does
not need to be repeated following initial testing post vaccination.
All immunisation records are to be submitted confidentially by the employee/volunteers to

Workforce Services.
1.1.7.9 Tuberculosis – Category A Clinical Staff/Volunteers
Record a documented history of baseline TB screening (results from previous tests are transferable
to all subsequent workplaces).
Prospective clinical staff/volunteers at risk of future occupational exposure to TB or have a history

indicating risk for prior TB infection (i.e. country of birth has a high TB incidence, residence and/or
work in a high incidence country for more than 6 months, past history of work or personal contact
with TB) and who have never had a Tuberculin skin or equivalent test performed or are at risk of
active or latent TB infection are strongly advised to attend the preferred provider identified by
Workforce Services.
All screening records are to be submitted confidentially by the employee/volunteer to Workforce

Services.
BCG vaccine is no longer recommended for health care workers.
1.1.7.10 Influenza
Page 5 of 6
Influenza vaccination is strongly advised each year (March – May). Vaccination is provided by SJA as
part of the annual ongoing clinical staff/volunteers health immunisation program.
1.1.7.11 Hepatitis A*
Record a documented history of having received a primary course of 2 doses of hepatitis A vaccine or
3 doses of combined hepatitis A/B vaccine.

Hepatitis A vaccination is only indicated for clinical staff/volunteers who live with or make frequent
visits to remote Indigenous communities in WA, who are in regular contact with untreated sewerage
and carers of the intellectually disabled.

Services.
1.1.8 References
Department of Health Government of Western Australia. Tuberculosis control program policy

documents. Available from http://www.health.wa.gov.au/acc/tb/hp.cfm
Department of Health Government of Western Australia. (OD 0478/13). Infection prevention and
control of Methicillin-resistant Staphylococcus aureus (MRSA) in Western Australian healthcare
facilities. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0388/12. Health care worker

immunisation policy. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0342/11. Tuberculosis and health care
workers. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0294/10. Infection prevention and

control of influenza-like illnesses in Western Australian healthcare facilities. Perth, Australia:
Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0237/09. Hepatitis B vaccination

program. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OP 1800/04. Guidelines for health care
workers with herpes lesions. Perth, Australia: Department of Health Government of Western
Australia.
National Health and Medical Research Council. (2013). The Australian immunisation handbook
(10th ed.). Canberra, Australia: Australian Government Publishing Service.
Page 6 of 6
March 2016
12.8 MANAGEMENT OF OCCUPATIONAL EXPOSURE:
1 Management of Occupational Exposure (Needlestick/Sharps and Muco-cutaneous Blood and

Body Fluid Exposures)

1.1 Purpose
To ensure clinical staff, paid volunteers and students receive prompt risk assessment and
appropriate management following occupational exposure to blood and/or body fluids.
1.1.2 Process
Standard Precautions are used in the handling and disposal of blood and/or body fluids regardless of
the patient’s perceived infectious status.
Clinical staff, paid volunteers and students should report any exposure involving exposure to blood
or body fluids, including needlesticks or cuts with contaminated sharp objects, splashes to the eye,
mouth, nose or broken skin. Broken skin includes cuts, abrasion, human bites, clenched fist injuries
and skin conditions such as eczema and dermatitis.
Staff/volunteers should receive appropriate risk assessment, blood testing and management
following an exposure.
Confidentiality of staff/volunteer/patient records must be maintained.
Agency clinical staff and students sustaining an accidental exposure to blood or body substances
should be reassured and given first aid. The exposure is then to be reported to the employing
agency/education campus who will be responsible for any subsequent follow-up.
1.1.3 Definitions
Exposed Person – the person exposed to blood and/or body fluid (e.g. clinical staff)
Source - the person (e.g. patient) whose blood and/or body fluid was inoculated or splashed onto
the exposed person. The source may sometimes not be identifiable (e.g. when an exposed person
has been injured by a needle/instrument and it is not known on whom it was used).
Exposure - contact with blood or body fluids contaminated with blood. The following categories are
used to assess the risk of exposure:
Non Parenteral Exposure
• Intact skin visibly contaminated with blood and/or body fluid.
Doubtful Parenteral Exposure
• Intradermal ("superficial") injury with a needle considered not to be contaminated with blood or
body fluid.
• A superficial wound not associated with visible bleeding produced by an instrument
considered not to be contaminated with blood and/or body fluid.
• Prior wound or skin lesion contaminated with a body fluid other than blood and with no trace of
blood (e.g. urine).
• Mucous membrane or conjunctival contact with a body fluid other than blood.
The following exposures should be considerate high risk and appropriate care and follow-up
12.8 Management of Occupational Exposure
Page 1 of 6
provided
Possible Parenteral Exposure
• Intradermal ("superficial") injury with a needle contaminated with blood or body fluid.
• A wound not associated with visible bleeding caused by an instrument contaminated with
blood or body fluid.
• Prior (not fresh) wound or skin lesion contaminated with blood or body fluid.
• Mucous membrane or conjunctival contact with blood.
Definite Parenteral Exposure

Skin penetrating injury with a needle contaminated with blood or body fluid.
• Injection of blood/body fluid not included under "Massive Exposure".
• Laceration or similar wound which causes bleeding and is produced by an instrument that is
visibly contaminated with blood or body fluid.
• In laboratory settings, any direct inoculation with human immunodeficiency virus (HIV) tissue
or material likely to contain HIV, HBV or HCV not included above.
Massive Exposure
• Transfusion of blood.
• Injection of large volume of blood/body fluids (>1ml).
• Parenteral exposure to laboratory specimens containing high titre of virus.
1.1.4 Risk Assessment
Human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) may be transmitted
by significant exposure to blood or other body substances, or by exposure to blood through
contaminated needles or other sharp instruments which cause injury to the skin allowing potential
exposure to blood-borne viruses.
Prospective studies of heath care workers occupationally exposed to HIV have estimated the
average risk of HIV transmission after an exposure to HIV-infected blood is 0.3% (3 in 1000) and
after mucous membrane exposures is 0.09% (9 in 10,000).
The risk of HBV transmission from a person who is HBV surface antigen positive is approximately 6
– 30%, while the risk of transmission of HCV from a person who is HCV antibody positive is 1.8 –
10%. The highest risk of transmission for any BBV is associated with:
• deep injury with a device visibly contaminated with blood;

• injuries associated with contaminated hollow bore needles;
• source patient with late stage HIV infection;
• source patient with HBV who is HBeAg positive;
• source patient with HCV who is HCV RNA PCR positive.
1.1.5 First Aid (Immediate)
If the skin is penetrated, wash the exposed area well with soap and water (alcohol-based hand rub
should be used if water is not available), and apply a waterproof sealed dressing. Further
management of wound will be dependent on nature of injury (e.g. suturing).
If blood gets on the skin, irrespective of whether there are cuts or abrasions wash the area well with
soap and water.
If the eyes are contaminated, rinse gently but thoroughly with water or normal saline, while the eyes
are open. If contact lenses are worn, remove after flushing eye and clean as usual.
If blood gets into the mouth, spit it out and then rinse the mouth with water several times.
Remove any contaminated clothing.

Page 2 of 6
1.1.6 Reporting and Recording
Report all exposure incidents (no matter how trivial) to the Metropolitan Shift Area Manager or
Country Regional Manager immediately after the exposure incident
Area Manager will arrange immediate medical assessment with a local hospital/ED or GP for
evaluation and risk assessment of all exposures as soon as possible.
Country staff should proceed for assessment without delay and report to Regional Manager.
Complete an Incident Investigation Report Form available on the intranet.
Send all documentation related to the exposure (including blood test results and Workers
Compensation Form) to your Manager in a sealed envelope marked ‘confidential’.

1.1.7 Regional Manager Responsibilities
Provide clinical staff with an information pack (Incident Form, 2B Claim Form, Workers
Compensation information).
Maintain the confidentiality of the exposed person and provide all assistance where possible.
Ensure the exposed person has initiated first aid treatment.
Ensure the exposed person has been referred for evaluation and risk assessment as soon as
possible (within 24 hours).
Ensure the provision of peer support or counselling is provided.
Document refusal by the exposed person to undergo risk assessment and evaluation.
Make every effort to identify the source (e.g. patient) of the exposure. If the exposure is defined as
massive, definite or possible exposure, contact the receiving hospital to conduct an assessment
to determine the risk factors for hepatitis B, hepatitis C and HIV, (unless status of the source known
at the time of the incident)
In addition for Country staff exposed personnel to Make every effort to identify the source (e.g.
patient) of the exposure. If the exposure is determined by the SOC CSP* as massive, definite or
possible exposure, CSP is to contact the receiving hospital to conduct an assessment to determine
the risk factors for hepatitis B, hepatitis C and HIV, (unless status of the source known at the time of
the incident). (* Where the Regional Manager cannot be contacted)
It is the hospital’s responsibility to obtain consent for hepatitis and HIV testing if indicated, and
provide pre-test counselling prior to collection of blood.
Further information, support and counselling are available from the Well Being and Support Services.
1.1.8 Management of Source by Nominated Service Provider
Obtain informed consent from the source to perform serology testing for HBV, HCV and HIV status.
If written or verbal consent is unable to be obtained then attempts should be make to obtain consent
from next-of-kin. In the event, consent cannot be obtained at the time of the incident, delayed testing
of the source should be considered.
Ensure prompt reporting of BBV test results to the exposed person and to the source.
1.1.9 Source Negative for BBV
If the source is found to be HBV, HCV and HIV negative, further testing of the source is not required
unless there is reason to suspect that the source is high risk for BBV infection.

Page 3 of 6
1.1.9 Source Likely to be Positive for BBV
Where it is suspected that the source is in the window period for a BBV, the source should receive
appropriate counselling and be asked to consent to follow-up at appropriate intervals (usually 6
weeks and 12 weeks) to ascertain whether or not they develop a BBV. Testing should include HIV
antibody, HBsAg and HCV antibody. Ensure HCV-RNA testing is ordered if the source is positive for
antibody to HCV and HBeAg and HBV quantative PCR (or HBV DNA) if the source is positive for
HBsAg.
1.1.10 Management of Exposed Person by Nominated Service Provider
Conduct a risk assessment and evaluation of the exposure that includes defining:

• the nature and extent of the injury;
• the nature of the object causing the exposure;
• the volume of blood or body fluid that the person was exposed to;
• the vaccination and immune status of the exposed person;
• the BBV status of the source; and
• the likelihood of an unidentified source being HBV, HCV or HIV positive.
Obtain informed consent with pre-test counselling from the exposed person to perform baseline
serology to determine current HBV, HCV and HIV status.
If the incident involved non-parenteral or doubtful parenteral exposure, no further testing or

examination is required other than the possibility of further counseling. This should be determined
according to the individual circumstances. The opportunity can be taken to reinforce safe work
practices.
If the source is unknown, appropriate follow-up should be determined on an individual basis

depending on:
• Type of exposure;
• Likelihood of source being positive for a blood-borne virus; and
• Prevalence of HIV, HBV and HCV in the setting in which the exposure occurs.
If the exposure involved massive, definite or possible parenteral exposure then arrangements for
follow-up assessment of the exposed person should be made when the status of the source is
confirmed:
1.1.11 Source Negative for HIV, HBV and HCV
When the source is confirmed negative for BBV, the exposed person should be offered follow-up
serology testing at 3 months for reassurance. No behavioural or work practice modifications are
required by the exposed person.
1.1.12 Source Unknown or Unable to be Tested
If after every effort has been made to ascertain the BBV status of the source or if the source remains
unknown, the probable risk of the source being positive for a BBV must be inferred when considering
management of the exposed person. The probable risk of the source being positive and the risk to
the exposed person must be assessed from epidemiological and historical information (i.e. type of
exposure, probability that the vehicle was contaminated with blood/body fluids and the prevalence of
HBV, HCV and HIV in the community from which the source came) and the exposed person treated
as appropriate.
If it is considered there is a high risk of the source being infected with a BBV, then the exposed
person is managed in accordance with the sections below relating of a source being positive for a
BBV.
1.1.13 Source HBV Positive (Or Likely To Be Positive)
If the exposed person is immune to HBV, no further treatment or special precautions needs to be

Page 4 of 6
taken.
If the exposed person is not immune to HBV or is of unknown immune status, the schedule below
should be followed.
Vaccination and antibody Status of Source

response status of exposed
person Unknown or not available for
HBsAg-Positive
Testing
Unvaccinated • Give HBIG (1 • Initiate hepatitis B vaccination
dose) and initiate – preferably within 24 hours of
hepatitis B exposure
vaccination-

preferably within
24 hours of
exposure
Previously vaccinated:
• Known responder • No treatment • No treatment
• Known non-responder • Give HBIG (2 • If suspected high-risk

doses) or HBIG (1 source, treat as if source
dose) and initiate were HBsAg-positive
re-vaccination -
preferably within
24 hours of
exposure
Response Unknown • Test exposed • Test exposed person for
person for anti- anti-HBs:
HBs:
• If inadequate give vaccine
• If inadequate, give 1 booster dose
dose HBIG and
vaccine booster dose If adequate, no treatment
If adequate, no treatment
1.1.14 Source Positive for HCV (or likely to be positive)
Currently there is no known treatment that can alter the likelihood of transmission of HCV.
If the source is found to be HCV RNA PCR positive, the exposed person should be referred to an
Infectious Diseases Physician, Clinical Microbiologist or Hepatologist with expertise in managing
HCV infection.
If source HCV RNA positive, exposed person baseline and follow-up testing should include:
• HCV RNA PCR and ALT at 4, 8 and 12 weeks post exposure; and
• HCV antibody at 12 and 26 weeks.
Ongoing counselling and support of the exposed person must be continued for the duration of the
post exposure follow-up. Support and counselling must be extended to significant contacts of the
exposed person.
1.1.15 Source Positive for HIV (or likely to be positive)
If the source is found to be HIV positive, then the exposed person must be referred immediately to
a medical specialist with expertise in managing HIV infection for consideration of initiation of
prophylactic treatment (HIV specialists are available on call 24 hours a day via Fremantle, Royal
Perth, Fiona Stanley and Sir Charles Gairdner Hospital switchboards).
1.1.16 Prevention of Other Potential Pathogens

Page 5 of 6
Human bites and clenched fist injuries often become infected. While there is the potential that other
infectious diseases such as HBV, tetanus and to a lesser extent HIV, may be spread following a
human bite, instances of this occurring have rarely been documented.
Thorough cleaning, debridement, elevation, immobilisation and prophylactic antibiotics is the

recommended management for such injuries.
Appropriate follow-up shall also determine the risk of tetanus. Depending on the circumstances of
the exposure, the following may need to be considered:
• Tetanus immunoglobulin;
• A course of adsorbed diphtheria tetanus vaccine – adult formulation (Td); or
•

Td booster.
1.1.17 References
Department of Health Government of Western Australia. OD 0388/12. Health care worker

immunisation policy. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0237/09. Hepatitis B vaccination

program. Perth, Australia: Department of Health Government of Western Australia.
Department of Health Government of Western Australia. OD 0090/07. Management of occupational

exposure to blood and body fluids in the health care setting. Perth: Department of Health
Government of Western Australia.
National Health and Medical Research Council. (2013). The Australian immunisation handbook
th
(10 ed.). Canberra, Australia: Australian Government Publishing Service.
National Health & Medical Research Council and the Australian Commission on Safety and Quality
in Healthcare. (2010). Australian guidelines for the prevention and control of infection in healthcare.

Page 6 of 6
March 2016
12.10 INFECTION CONTROL CPG GLOSSARY:
1 GLOSSARY

Term The way used in this Guideline
Airborne precautions A set of practices used for patients known or suspected to be infected
with agents transmitted person-to-person by the airborne route
Alcohol-based hand A TGA-registered alcohol-containing preparation designed for reducing
rub the number of viable microorganisms on the hands without the use or
aid of running water and which is included on the ARTG as a medicinal
product
Antisepsis The use of chemical or physical methods to prevent infection by
destroying or inhibiting the growth of harmful microorganisms
Antiseptic Is a substance that is recommended by its manufacturer for application
to the skin or mucous membrane of a patient to deactivate or prevent
the growth of micro-organisms to a level that may cause clinical
infection
Asepsis ‘Freedom from infection or infectious (pathogenic) material'
Aseptic Non Touch
A practice framework for aseptic technique
Technique (ANTT)
Aseptic technique An aseptic technique aims to prevent microorganisms on hands,
surfaces and equipment from being introduced to susceptible sites.
Therefore, unlike sterile techniques, aseptic techniques can be
achieved in typical ward and home settings.
Categories of items The approach to disinfection and sterilisation of patient-care items and
for patient care equipment devised by Spaulding over 30 years ago has been retained
and refined and is still successfully used by infection control
professionals and others when planning methods for disinfection or
sterilisation (Rutala & Weber 2008). The system is based on
instruments and items for patient care being categorised into critical,
semi-critical and non-critical, according to the degree of risk for infection
involved in use of the items.

12.10 Infection Control CPG Glossary
Page 1 of 5
Clean technique Clean technique refers to practices that reduce the number of infectious
agents, and should be considered the minimum level of infection control
for non-invasive patient-care activities. Practices include: personal
hygiene, particularly hand hygiene, to reduce the number of infectious
agents on the skin; use of barriers to reduce transmission of infectious
agents (including proper handling and disposal of sharps);
environmental cleaning; and reprocessing of equipment between
patient uses.

Clinical waste Waste material that consists wholly or partly of human or animal tissue,
blood or body substances, excretions, drugs or other pharmaceutical
products, swabs/ dressings, syringes, needles or other sharp
instruments.
Contact The touching of any patient or their immediate surroundings or
performing any procedure.
Contact point The area of direct contact of skin to equipment.
Contact precautions A set of practices used to prevent transmission of infectious agents that
are spread by direct or indirect contact with the patient or the patient’s
environment.
Critical items These items confer a high risk for infection if they are contaminated with
any microorganism and must be sterile at the time of use. This includes
any objects that enter sterile tissue or the vascular system, because
any microbial contamination could transmit disease.
Decontamination Use of physical or chemical means to remove, inactivate, or destroy
pathogens on a surface or item so that they are no longer capable of
transmitting infectious particles and the surface or item is rendered safe
for handling, use, or disposal.
Detergent solution A medical-grade detergent product (that is registered as a Class I
Medical Device with the TGA and which is intended to be used in the
cleaning of surfaces or other medical devices) diluted with water as per
manufacturer’s instructions.
Disinfectant A TGA-registered disinfectant chemical product that is intended for use
in disinfection of surfaces or medical devices.
Disinfection Destruction of pathogenic and other kinds of microorganisms by
physical or chemical means.
Droplet precautions A set of practices used for patients known or suspected to be infected
with agents transmitted by respiratory droplets.

Page 2 of 5
Droplets Small particles of moisture generated when a person coughs or
sneezes, or when water is converted to a fine mist by an aerator or
shower head. These particles, intermediate in size between drops and
droplet nuclei, can contain infectious microorganisms and tend to
quickly settle from the air such that risk of disease transmission is
usually limited to persons in close proximity (e.g. at least 1 metre) to the
droplet source.
Fit check A quick check to ensure that the respirator is fitting each time it is put

on.
Fit test A method of ensuring that a P2 mask is fitted correctly and suitable for
use by a specific individual.
Hand hygiene A general term applying to processes aiming to reduce the number of
microorganisms on hands. This includes: application of a waterless
antimicrobial agent (e.g. alcohol-based hand rub) to the surface of the
hands; and use of soap/solution (plain or antimicrobial) and water (if
hands are visibly soiled), followed by patting dry with single-use towels.
Healthcare worker All people delivering healthcare services, including students and
trainees, who have contact with patients or with blood or body
substances.
Healthcare- Infections acquired in healthcare facilities (‘nosocomial’ infections) and
associated infections infections that occur as a result of healthcare interventions (‘iatrogenic’
(HAI) infections), and which may manifest after people leave the healthcare
facility.
High level Minimum treatment recommended for reprocessing instruments and
disinfection devices that cannot be sterilised for use in semi-critical sites.
High-efficiency
An air filter that removes >99.97% of particles > 0.3 microns (the most
particulate air
penetrating particle size) at a specified flow rate of air.
(HEPA) filter
Hospital-grade A TGA-registered disinfectant for surfaces for use in healthcare or
disinfectant healthcare-related applications.
Immunocompromised Having an immune system that has been impaired by disease or
treatment.
Infectious agent An infectious agent (also called a pathogen or germ) is a biological
agent that causes disease or illness to its host. Most infectious agents
are microorganisms, such as bacteria, viruses, fungi, parasites and
prions.

Page 3 of 5
Instrument
A TGA-registered disinfectant for medical devices.
disinfectant
Intermediate level Minimum treatment recommended for reprocessing instruments and
disinfection devices for use in non-critical sites, or where there are specific
concerns regarding contamination of surfaces with species of
mycobacteria (e.g. Mycobacterium tuberculosis).
Invasive procedure Entry into tissues, cavities or organs or repair of traumatic injuries.

Key parts Parts of the procedure equipment or solutions that must remain aseptic
throughout clinical procedures, in order to protect the patient from
contamination or infection. For example a wound dressing, catheter
lubrication, syringe tip, needle etc. In IV therapy, key parts are usually
those that come into direct contact with the liquid infusion e.g. needles,
syringe tips, exposed central line lumens.
Key sites Susceptible open or broken wounds, surgical or intravenous access
sites.
Medical device A device that is intended for use with humans and used in therapeutic
processes, being entered onto the ARTG.
Non-critical items These items come into contact with intact skin but not mucous
membranes. Thorough cleaning is sufficient for most non-critical items
after each individual use, although either intermediate or low-level
disinfection may be appropriate in specific circumstances.
P2 mask (respirator) A particulate filter personal respiratory protection device or P2
mask/respirator is a close fitting mask worn for airborne precautions,
which is capable of filtering 0.3μm particles. A P2 mask must comply
with AS/NZS 1716:2009.
Personal protective A variety of barriers used alone or in combination to protect mucous
equipment (PPE) membranes, skin, and clothing from contact with infectious agents. PPE
includes gloves, masks, respirators, protective eyewear, face shields,
and gowns.
Procedure An act of care for a patient where there is a risk of direct introduction of
a pathogen to the patient.
Respiratory hygiene A combination of measures designed to minimise the transmission of
and cough etiquette respiratory pathogens via droplet or airborne routes in healthcare
settings.
Routine Performed as part of usual practice (as opposed to the use of additional
measures in specific circumstances e.g. where invasive procedures are

Page 4 of 5
conducted or in the event of an outbreak).
Semi-critical Items These items come into contact mucous membranes or non-intact skin,
and should be single use or sterilized after each use. If this is not
possible, high-level disinfection is the minimum level of reprocessing
that is acceptable.
Sharps Instruments used in delivering healthcare that can inflict a penetrating
injury e.g. needles, lancets and scalpels.

Single-use Single-use means the medical device is intended to be used on an
individual patient during a single procedure and then discarded. It is not
intended to be reprocessed and used on another patient. Some single-
use devices are marketed as non-sterile which require processing to
make them sterile and ready for use. The manufacturer of the device
will include appropriate processing instructions to make it ready for use.
Single-use devices Single-use devices are medical devices that are labelled by the original
(SUDS) manufacturer as ‘single use’ and are only intended to be used once.
Standard precautions Work practices that constitute the first-line approach to infection
prevention and control in the healthcare environment. These are
recommended for the treatment and care of all patients.
Standard-ANTT An approach to ANTT used for technically simple aseptic procedures.
Sterile Free from all living microorganisms; usually described as a probability
(e.g. the probability of a surviving microorganism being 1 in 1 million).
Surgical masks Loose fitting, single-use items that cover the nose and mouth. These
include products labelled as dental, medical procedure, isolation and
laser masks.
Transmission-based Extra work practices in situations where standard precautions alone
precautions may be insufficient to prevent infection (e.g. for patients known or
suspected to be infected or colonised with infectious agents that may
not be contained with standard precautions alone).
1.1 References
Quality in Healthcare. (2010). Australian guidelines for the prevention and control of infection on
healthcare.

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© Copyright St John Ambulance Western Australia Ltd Paramedic - Table of Contents

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© Copyright St John Ambulance Western Australia Ltd Paramedic - Table of Contents

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© Copyright St John Ambulance Western Australia Ltd Paramedic - Table of Contents

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© Copyright St John Ambulance Western Australia Ltd Paramedic - Table of Contents

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© Copyright St John Ambulance Australia (Western Australia) Inc.

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Green - safe zone / safe guide sign to follow / general

Blue – mandatory action as per PPE symbols.

Amber/Yellow – caution, consideration and information that is

Red - warning, stop, contra-indication, critical information.

The “red flag” is a metaphor that indicates / draws attention to a

The ‘pinch point’ symbol indicates a point at which it is possible

TRAFFIC LIGHT SYSTEM:

Red high risk - life threatening / poor outcome expected

Amber intermediate risk – potential to deteriorate

Green low risk – stable / no critical action required

© Copyright St John Ambulance Australia (Western Australia) Inc.

© Copyright St John Ambulance Australia (Western Australia) Inc.

General Amendment to acceptance criteria of

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INTENTIONALLY LEFT BLANK

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© Copyright St John Ambulance Western Australia Ltd. Table of Contents

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© Copyright St John Ambulance Western Australia Ltd. 1.1A Patient Assessment

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 Safety: Patients have a right to receive safe and high quality

 Respect: Patients have a right to be shown respect, dignity and

 Communication: Patients have a right to be informed about services,

 Participation: Patients have a right to be included in decisions and

 Privacy: Patients have a right to privacy and confidentiality of

 Comment: Patients have a right to comment on their care and to

Reference: Australian Charter of Healthcare Rights.

© Copyright St John Ambulance Western Australia Ltd. 1.1B Patient Care

© Copyright St John Ambulance Western Australia Ltd.

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 In the case of a medical emergency the requirements to obtain consent

 In a medical emergency where a patient is incompetent and thus not

Reference: The office of Safety and Quality in Healthcare (OSQH WADOH)

© Copyright St John Ambulance Western Australia Ltd. 1.1C Patient Consent

© Copyright St John Ambulance Western Australia Ltd

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Specialist Ambulance Paramedic Roles

© Copyright St John Ambulance Western Australia Ltd. 1.1D Authority to Practice

© Copyright St John Ambulance Western Australia Ltd. 1.1D Authority to Practice

MAJOR TRAUMA GUIDELINE:

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DAMAGE CONTROL AND MANAGEMENT OF REVERSIBLE CAUSES ARRIVAL

A: Insert OPA / NPA / LMA with c-spine control (Time allows

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B: BVM Ventilations x2. Maximize Oxygenation (Skill 314)

C: Stop any life threatening haemorrhage.