(C) AMBULANCE VICTORIA

Transcription

1 Oxygen Therapy Introduction - This CPG should only be applied to adult Pts aged 16 years. Mx principles - O 2 is a Rx for hypoxaemia, not breathlessness. O 2 has not been shown to have any effect on the sensation of breathlessness in non-hypoxaemic Pts. - Rx is aimed at achieving normal or near normal SpO 2 in acutely ill Pts. O 2 should be administered to achieve a target SpO 2 while continuously monitoring the Pt for any changes in condition. - O 2 should not be administered routinely to Pts with normal SpO 2. This includes those with stroke, ACS and arrhythmias. - In Pts who are acutely SOB, the administration of O 2 should be prioritised before obtaining an O 2 saturation reading. O 2 can later be titrated to reach a desired target saturation range. - If pulse oximetry is not available or unreliable, provide an initial O 2 dose of 2-6 L/min via nasal cannulae or 5-10 L/min via face mask until a reliable SpO 2 reading can be obtained. Special circumstances - Early aggressive O 2 administration may benefit Pts who develop critical illnesses and are haemodynamically unstable, such as cardiac arrest or resuscitation; major trauma / head injury; carbon monoxide poisoning; shock; severe sepsis; and anaphylaxis. In the first instance, O 2 should be administered with the aim of achieving an SpO 2 of 100%. Once the Pt is haemodynamically stable, O 2 dose should be titrated to normal levels. - Pts with chronic hypoxaemia (e.g. COPD, neuromuscular disorders, class i, ii or iii obesity etc.) who develop critical illnesses as above should have the same initial aggressive O 2 administration, pending the results of blood gas measurements. - If a diagnosis of COPD is unknown, it should be assumed in any Pt who is > 50 years and are long-term smokers or ex-smokers with a Hx of long standing breathlessness on minor exertion. Pts with COPD may also use terms such as chronic bronchitis and emphysema to describe their condition but sometimes mistakenly use asthma. Version Page 1 of 3 CPG A0001 O'Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(SUPPL. 6):vi1-vi68. Oxygen Therapy CPG A0001 1

2 Oxygen Therapy Special Notes Pulse oximetry may be particularly unreliable in Pts with peripheral vascular disease, severe asthma, severe anaemia, cold extremities or peripherally 'shut down', severe hypotension and carbon monoxide poisoning. Pulse oximetry can be unreliable in the setting of severe hypoxaemia. An SpO 2 reading below 80% increases the chance of being inaccurate. All Pts with suspected carbon monoxide poisoning or pneumothorax should be given high dose O 2 until arrival at hospital. Pts who show no clinical evidence of breathlessness or hypoxaemia may still benefit from this practice. Poisoning with substances other than carbon monoxide should be given O 2 to maintain an SpO 2 of 94-98%. Special circumstances occur in the setting of paraquat and bleomycin poisoning where the use of O 2 therapy may prove detrimental to the Pt. The maintenance of prophylactic hypoxaemia in these Pts (SpO 2 of 88-92%) is recommended. Irrespective of SpO 2 Pt V T should be assessed to ensure ventilation is adequate. General Care O 2 exchange is at its greatest in the upright position. Unless other clinical problems determine otherwise, the upright position is the preferred position when administering O 2. Ensure the Pt's fingertips are clean of soil or nail polish. Both may affect the reliability of the pulse oximeter reading. The presence of nail infection may also cause falsely low readings. Take due care with Pts who show evidence of anxiety/ panic disorders (e.g. hyperventilation syndrome). O 2 is not required however no attempt should be made to retain CO 2 (e.g. paper bag breathing). All women with evidence of hypoxaemia who are more than 20 weeks pregnant should be Mx with left lateral tilt to improve output. Face masks should not be used for flow rates < 5 L/min due to the risk of CO 2 retention. Nasal cannulae are likely to be just as effective with mouth-breathers. However, where nasal passages are congested or blocked, face masks should be used to deliver O 2 therapy. Version Page 2 of 3 CPG A0001

3 Oxygen Therapy SpO 2 94% Action No O 2 required, reassure Pt Status Evidence of hypoxaemia Breathlessness hypoxaemia SpO % Action 8 Assess Titrate O 2 flow to SpO 2 of 94-98% - Initial dose of 2-6 L/min via nasal cannulae - Consider simple face mask 5-10 L/min Acute or chronic Respiratory status Status Stop 8 Assess 8 Consider MICA Action Assess and monitor SpO 2 continuously Consider causes of hypoxaemia Adequate SpO 2 Mild-moderate Moderate-severe hypoxaemia SpO 2 < 85 Critical illnesses, e.g. Cardiac arrest or resuscitation Major trauma/head injury Carbon monoxide poisoning Shock Severe sepsis Anaphylaxis Decompression illness Action Initial Mx - Initial dose nonrebreather mask L/min - If inadequate V T, consider BVM ventilation with 100% O 2 Once pt haemodynamically stable - Titrate O 2 flow to SpO 2 of 94-98% If Pt deteriorates or SpO 2 remains < 85% - BVM ventilation with 100% O 2 - Consider LMA as per CPG A0301 Laryngeal Mask Airway Version Page 3 of 3 CPG A0001 Chronic hypoxaemia COPD/pulmonary disease Neuromuscular disorders Obesity High-concentration O 2 may be harmful in the COPD Pt at risk of hypercapnic respiratory failure Action Titrate O 2 flow to SpO 2 of 88-92% If no critical illness present - Initial dose of 2-6 L/min via nasal cannulae - Consider simple face mask 5-10 L/min If Pt deteriorates or SpO 2 remains < 88% - Rx as per Moderate-severe hypoxaemia - Consider ETT as per CPG A0302 Endotracheal Intubation Oxygen Therapy CPG A0001 3

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5 Clinical Approach This Clinical Approach is to be applied to all Pts as a basic level of care. There is an assumption in each CPG that this is the minimum level of care that the Pt will receive prior to the application of CPG. The exception to this rule is the Pt in immediate life threat that requires intervention during the Primary survey. Stop Action Primary survey / life threat status Standard precautions and PPE Dangers Response Airway Consider potential for cervical spine injury Breathing Assist ventilations if V T inadequate Circulation CPR as required Haemorrhage Control if life threatening Rapport, rest and reassurance Position the Pt appropriately O 2 Establish if refusal or limitation of Rx documented Immediate Mx + Sitrep required (utilise ETHANE mnemonic) Apply assessment tools in order of relevance Determine need for Hx taking vs use of assessment tools Version Page 1 of 3 CPG A0101 Clinical Approach CPG A0101 5

6 Clinical Approach Assess Assess Assess History Hx of presenting complaint Pain - verbal analogue score Past medical Hx Medications Allergies Other information e.g. witnesses, doctor, Poisons Information etc. Vital signs survey GCS PSA RSA Pattern / mechanism of injury / medical condition Secondary survey Head to toe assessment including evaluating pattern of injury SpO 2 ECG - 12 lead if required Temp EtCO 2 BGL - if required More detailed Hx Accurate Hx and assessment essential for problem recognition Hx should include assessment of mechanism of injury Determine time criticality to Mx accordingly Accurate and thorough assessment in all Pts Early recognition of time critical patient allows appropriate Mx, early request for further resources and timely Tx Version Page 2 of 3 CPG A0101

7 Clinical Approach Determine Main Presenting Problem Action Action The combination of subjective (PHx, Hx, Meds) and objective (physical) data allows identification and prioritisation of clinical problems Further sitrep/resource requests as needed Consider time to hospital vs time to MICA support Tx to appropriate facility Mx clinical problems with appropriate CPG multiple CPGs may be required IV access if clinically indicated Reassess frequently and adapt Mx as appropriate Final assessment at destination/handover Provide MICA Mx in a timely manner Avoid unnecessary prehospital delays Confirm clinical reasoning with assessment data Version Page 3 of 3 CPG A0101 Clinical Approach CPG A0101 7

8 Perfusion Assessment Special Notes These observations and criteria need to be taken in context with: - The Pt s presenting problem. - The Pt s prescribed meds. - Repeated observations and the trends shown. - Response to Mx. BP alone does not determine perfusion status. Perfusion definition The ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to meet their functional demands at that time and to effectively remove the associated metabolic waste products. Perfusion assessment Other factors may affect the interpretation of the observations made, including: - cold or warm ambient temp. - anxiety. - any cause of altered consciousness. Special Notes Version Page 1 of 3 CPG A0102

9 Perfusion Assessment Perfusion status assessment Skin Pulse BP Conscious status Adequate Warm, pink, bpm > 100 mmhg Alert and orientated perfusion dry systolic to time and place Borderline Cool, pale, bpm mmhg Alert and orientated perfusion clammy systolic to time and place Inadequate Cool, pale, < 50 bpm or > 100 bpm mmhg Either alert and orientated perfusion clammy systolic to time and place or altered Extremely Cool, pale, < 50 bpm or > 110 bpm < 60 mmhg Altered or poor clammy systolic or unconscious perfusion unrecordable No perfusion Cool, pale, No palpable Unrecordable Unconscious clammy pulse Version Page 2 of 4 CPG A0102 Perfusion Assessment CPG A0102 9

10 Respiratory Assessment Respiratory status assessment Version Page 3 of 4 CPG A0103 Normal Mild distress Moderate distress Severe distress (life threat) General appearance Calm, quiet Calm or mildly anxious Distressed or anxious Distressed, anxious, fighting to breathe, exhausted, catatonic Speech Breath sounds and chest auscultation Clear and steady sentences Usually quiet no wheeze No crackles or scattered fine basal crackles, e.g. postural Full sentences Short phrases only Words only or unable to speak Able to cough Asthma: mild expiratory wheeze LVF: may be some fine crackles at bases Able to cough Asthma: expiratory wheeze, +/ inspiratory wheeze LVF: crackles at bases - to mid-zone Unable to cough Asthma: expiratory wheeze +/ inspiratory wheeze, maybe no breath sounds (late) LVF: fine crackles full field, with possible wheeze Upper Airway Obstruction: Inspiratory stridor Respiratory rate > 20 > 20 Bradypnoea (< 8) Respiratory rhythm Regular even cycles Asthma: may have slightly prolonged expiratory phase Breathing effort Normal chest movement Slight increase in normal chest movement Asthma: prolonged expiratory phase Marked chest movement +/ use of accessory muscles Asthma: prolonged expiratory phase Marked chest movement with accessory muscle use, intercostal retraction +/ tracheal tugging HR bpm bpm bpm > 120 bpm Bradycardia late sign Skin Normal Normal Pale and sweaty Pale and sweaty, +/ cyanosis Conscious state Alert Alert May be altered Altered or unconscious

11 Conscious Assessment Glasgow Coma Score A. Eye opening Score Spontaneous 4 To voice 3 To pain 2 None 1 B. Verbal response Score Orientated 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 C. Motor response Score Obeys command 6 Localises to pain 5 Withdraws (pain) 4 Abnormal flexion (pain) 3 Extension (pain) 2 None 1 Total GCS (Max. score = 15) ( A + B + C ) = A: Version Page 4 of 4 CPG A0104 B: C: Conscious Assessment CPG A

12 Time Critical Guidelines Introduction The concept of the Time Critical Pt allows the recognition of the severity of a Pt s condition or the likelihood of deterioration. This identification directs appropriate clinical Mx and the appropriate destination to improve outcome. Covered within the Time Critical Guidelines are: - Triage decisions for a Pt with major trauma - Triage decisions for a Pt with significant medical conditions - Requests for additional resources including MICA and Aeromedical services - Judicious scene time Mx (e.g. should not exceed 20 min for non-trapped major trauma Pt) - Appropriate receiving hospital and early notification It is important to note that the presence of time criticality does not infer a directive for speed of Tx, but rather the concept implies there be a time consciousness in the Mx of all aspects of Pt care and Tx. Time critical definitions Actual Emergent Potential At the time the vital signs survey is taken, the Pt is in actual physiological distress. At the time the vital signs survey is taken, the Pt is not physiologically distressed but does have a pattern of injury or significant medical condition which is known to have a high probability of deteriorating to actual physiological distress. At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no significant pattern of actual Injury/illness, but does have a mechanism of injury/illness known to have the potential to deteriorate to actual physiological distress. Version Page 1 of 7 CPG A0105

13 Time Critical Guidelines Trauma triage Pts meeting the criteria for major trauma should be triaged to the highest level of trauma care available within 45 min Tx time of the incident in accordance with Victorian State Trauma System requirements and AV policies and procedures. The receiving hospital must also be notified to ensure an appropriate reception team and facilities are available. Mechanism of injury (MOI) A Pt under the Trauma Triage Guidelines meets the criteria for major trauma if they have a combination of MOI and other co-morbidities constituting: Systemic illness limiting normal activity / systemic illness constant threat to life. Examples include: - Poorly controlled hypertension - Obesity - Controlled or uncontrolled CCF - Symptomatic COPD - Ischaemic heart disease - Chronic renal failure or liver disease Pregnancy Age < 15 or > 55 Medical triage Pts meeting the time critical criteria for medical conditions are regarded as having, or potentially having, a clinical problem of major significance. These Pts are time critical and should be Tx to the nearest appropriate hospital. Version Page 2 of 7 CPG A0105 Time Critical Guidelines CPG A

14 Status Stop 8 Assess 8 Consider MICA Action Ambulance Victoria 2013 Consider MICA / Aeromedical support Consider MICA / Aeromedical support Triage to highest level of trauma service within 45 min Triage to highest level of trauma service within 45 min Vital signs not normal Vital signs normal Significant pattern of injury - fractured pelvis - fracture to two or more of the following: femur / tibia / humerus - major compound fracture or open dislocation - serious crush injury - burns > 20% or involving respiratory tract - suspected spinal cord injury Specific injuries - limb amputations / limb threatening injuries - injuries involving two or more of the above body regions Blunt injuries - significant injury to a single region: head / chest / abdomen / axilla / groin Penetrating injuries - head / neck / chest / abdomen / pelvis / axilla / groin Any of the following: - Respiratory rate < 12 or > 24 - BP < 90 mmhg systolic - Pulse > GCS < 13 - SpO 2 < 90% Any of the following: 8 Assess pattern of injury May have pattern of injury 8 Assess vital signs Vital signs are normal Possible major trauma Status Actual Time Critical Emergent Time Critical Time Critical Guidelines (Trauma Triage)

15 Time Critical Guidelines CPG A Ambulance Victoria 2013 Triage to highest level of trauma service within 45 min Triage to nearest appropriate facility with notification Vital signs are normal No pattern of injury Vital signs are normal No pattern of Injury Positive MOI and co-morbidities Positive MOI and NO co-morbidities Any of the following: - Age > 55 - Pregnancy - Significant underlying medical condition 8 Assess co-morbidities Any of the following: - Ejection from vehicle - Motor / cyclist impact > 30 km/hr - Fall from height > 3 m - Struck on head by falling object > 3 m - Explosion - High speed MCA > 60 km/hr - Pedestrian impact - Prolonged extrication > 30 min Triage to nearest appropriate facility if required Vital signs are normal No pattern of Injury 8 Assess mechanism of injury (MOI) No MOI Vital signs are normal May have mechanism of Injury No pattern of injury Potentially Time Critical Not Time Critical CPG A0105

16 Status Stop 8 Assess 8 Consider Action MICA Action Ambulance Victoria 2013 Consider MICA / Aeromedical support Consider MICA / Aeromedical support Triage to nearest appropriate facility with notification Triage to nearest appropriate facility with notification Vital signs not normal Vital signs normal Significant medical condition Hypothermia or hyperthermia Need for possible hyperbaric treatment e.g. acute decompression illness or cyanide poisoning Medical symptoms / syndromes - ACS - Acute stroke - Severe sepsis, including suspected meningococcal disease - Possible AAA - Undiagnosed severe pain Any of the following: - Moderate or severe respiratory distress - Oxygen saturation < 90% room air / 93% supplemental O 2 - < Adequate perfusion - GCS < 13 (unless normal for Pt) Any of the following: 8 Assess medical condition May have significant medical condition 8 Assess vital signs Vital signs are normal Possible medical time critical Status Actual Time Critical Emergent Time Critical Time Critical Guidelines (Medical) CPG A0105

17 Mental Status Assessment Observations A mental status assessment is a systematic method used to evaluate a Pt s mental function. In undertaking a mental status assessment, the main emphasis is on the person s behaviour. This assessment is designed to provide Paramedics with a guide to the Pt s behaviour, not to label or diagnose a Pt with a specific condition. 1. Appearance Neatness, cleanliness Pupils size Extraocular movements 2. Behaviour Bizarre or inappropriate Threatening or violent Unusual motor activity, such as grimacing or tremors Impaired gait Psychomotor retardation or agitation 3. Speech Rate, volume, quantity, content 4. Mood Depressed, agitated, excited or irritable 5. Response Flat unresponsive facial expression Appropriate/inappropriate 6. Perceptions Hallucinations 7. Thought content Delusions (i.e., false beliefs) Suicidal thoughts Overly concerned with body functions (e.g. bowels) 8 Thought flow Jumping irrationally from one thought to another 9. Concentration Poor ability to organise thoughts Short attention span Poor memory Impaired judgement Lack of insight Version Page 1 of 1 CPG A0106 Mental Status Assessment CPG A

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19 Cardiac Arrest Principles of CPR CPR It is assumed that CPR is commenced immediately and continued throughout cardiac arrest as required Generic for all adult cardiac arrest conditions Must not be interrupted for more than 10 sec during rhythm and pulse checks. If no pulse or unsure of pulse, recommence CPR immediately Change operators every 2 min to improve CPR performance and reduce fatigue Compression depth = 1/3 chest depth Rhythm / pulse check every 2 min Recommence compressions immediately post DCCS without performing a pulse check This CPG contains the recommended joules for biphasic defibrillators used in manual mode. Modern defibrillators used in automatic mode will deliver acceptable pre-set joules. If using a monophasic device please refer to manufacturer instructions. Ratios of compressions to ventilations Not intubated 30 : 2 Rate: approximately 100 compressions per min - Pause for ventilations Intubated / LMA inserted 15 : 1 Rate: approximately 100 compressions per min - < 8 ventilations/min - No pause for ventilations Adjustment for temperature > 32 C Standard cardiac arrest CPG C Double intervals between drug doses in this CPG Normal DCCS intervals Do not rewarm beyond 33 o C if ROSC < 30 C Version Page 1 of 3 CPG A0201 Continue CPR and rewarming until temp > 30 C One DCCS shock only One dose of Adrenaline One dose of Amiodarone Withhold Sodium Bicarbonate 8.4% IV Cardiac Arrest CPG A

20 Cardiac Arrest Immediately commence CPR 30 : 2. Change to 15 : 1 once airway secured with ETT/LMA VF/VT (pulseless) Defibrillate single shock 200J Repeat DCCS every 2/60 if VF/VT persists VF/VT persists IV access / Normal Saline TKVO Adrenaline 1 mg IV every 3/60 if no output If no IV access Adrenaline 1 mg IO every 3/60 if no output VF/VT persists Identify and Rx causes - Hypoxia - Exsanguination - Asthma - TPT - Anaphylaxis - Upper airway obstruction PEA persists IV access / Normal Saline TKVO Adrenaline 1 mg IV every 3/60 if no output If no IV access Adrenaline 1 mg IO every 3/60 if no output LMA ETT First rhythm analysis should be conducted in AED mode. All subsequent analyses are at Paramedic discretion. If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output PEA LMA ETT If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output Version Page 2 of 3 CPG A0201 Confirm rhythm with printed ECG strip Consider CPG A0203 Withholding or Ceasing Resuscitation Asystole Asystole persists IV access / Normal Saline TKVO Adrenaline 1 mg IV every 3/60 if no output If no IV access Adrenaline 1 mg IO every 3/60 if no output PEA persists Asystole persists LMA ETT If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output

21 VF/VT persists PEA persists Amiodarone 300 mg IV / IO Repeat Amiodarone 150 mg IV / IO (max. combined dose 450 mg) Sodium Bicarbonate 8.4% 50 ml IV / IO Amiodarone is C/I in confirmed or suspected TCA OD VF/VT persists Action Status Stop 8 Assess 8 Consider MICA Action Normal Saline 20 ml/kg IV OR Normal Saline 20 ml/kg IO Sodium Bicarbonate 8.4% may be administered earlier in the algorithm if hyperkalaemia suspected or in cardiac arrest secondary to TCA OD VF/VT persists After 15/60 Paramedic CPR Outcome If ROSC refer CPG A0202 If no ROSC refer CPG A0203 PEA persists Asystole persists After 15/60 Paramedic CPR Sodium Bicarbonate 8.4% 50 ml IV / IO Outcome If ROSC refer CPG A0202 If no ROSC refer CPG A0203 After 15/60 Paramedic CPR Sodium Bicarbonate 8.4% 50 ml IV / IO Outcome If ROSC refer CPG A0202 If no ROSC refer CPG A0203 If during CPR Pt gag reflex prevents ETT, a small dose of Midazolam (1-2 mg IV) may be administered to facilitate intubation. The use of sedation to either assist placement of, or to maintain placement of an LMA is C/I. Cardiac Arrest CPG A

22 Cardiac Arrest (ROSC Management) Special Notes CPG A0407 Inadequate Perfusion (Cardiogenic Causes) CPG A0302 Endotracheal Intubation CPG A0406 Pulmonary Oedema General Care Therapeutic hypothermia Ensure fluid is < 8 o C prior to administration. Version Page 1 of 2 CPG A0202

23 Cardiac Arrest (ROSC Management) Unintubated GCS < 10 post ROSC Collapse to ROSC > 10/60 - RSI as per CPG A0302 Endotracheal Intubation - Therapeutic cooling Collapse to ROSC < 10/60 - No therapeutic cooling - RSI as per CPG A0302 Endotracheal Intubation if coma persists despite initial oxygenation and perfusion Mx Status Status Stop 8 Assess 8 Consider MICA Action Post cardiac arrest - Return of spontaneous circulation (ROSC) Perfusion Mx Maintain BP > 120 mmhg or Pt s usual BP (if known) Normal Saline and Adrenaline to be used as required per CPG A0407 Inadequate Perfusion Accurately assess HR during movement/loading to ensure output maintained throughout Rx as per appropriate CPG if condition changes Do not administer Amiodarone unless breakthrough VF/VT occurs Therapeutic cooling Pt intubated Collapse to ROSC > 10/60 Normal functional status (independent with ADLs) Temp > 34.5 o C No pulmonary oedema evident Cardiac arrest not due to bleeding Assess Pt temp Sedation/paralysis - Midazolam 1-5 mg IV - Pancuronium 8 mg IV Rapid infusion cold Normal Saline up to 2000 ml IV if available - Cease if APO occurs and Rx as per CPG A0406 Pulmonary Oedema - Maintain temp range C Version Page 2 of 2 CPG A0202 Transport Appropriate receiving hospital Notify early 12 lead ECG if available Cardiac Arrest (ROSC Management) CPG A

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25 Withholding or Ceasing Resuscitation Special Notes Mass casualty incidents are in part characterised by the available resources being overwhelmed by larger Pt numbers. Where this is the case AV Emergency Management Unit provide trauma triage guidelines for Pt assessment that may differ significantly from guidelines used in other patient situations. Prolonged cardiac arrest may be determined in two ways. The first is where there is clear evidence of decomposition / putrefaction, rigor mortis or morbid lividity. Prolonged cardiac arrest may also be an adult presenting in asystole (verified with three monitoring leads over > 30 sec) with the interval between cardiac arrest onset i.e. collapse and arrival of the crew at the Pt > 10 min and where there are no compelling reasons to continue. Compelling reasons to commence or continue resuscitation include: - suspected hypothermia - suspected drug OD - a child (< 18) - a family member requests continued effort - any signs of life observed including pupil reaction or agonal/ineffective gasping respiration - Pt in VF or VT. Injuries incompatible with life are where there is no possibility of having survived i.e. decapitation, incineration and there are no signs of life. This is distinct from where it may be believed that there is no prospect for eventual survival due to injury severity. Traumatic cardiac arrest outcomes are poor but not futile. Poor prognostic factors in cardiac arrest resuscitation include unwitnessed arrest, no prior bystander CPR and duration of cardiac arrest exceeding 30 min. Special Notes An Advanced Care Directive (ACD), which may include a Refusal of Treatment Certificate (ROTC) may be completed by an adult ( 18), an agent with enduring power of attorney or a Victorian Civil and Administrative Tribunal appointed guardian. An ACD or ROTC may be sighted by attending Paramedics or they may accept in good faith the advice of those present at the scene. If there is any doubt about the application of a certificate the default position of resuscitation should be adopted. A ROTC may only be completed in relation to a current condition. When ceasing or withholding resuscitative efforts in these circumstances the attending Paramedic must be satisfied that the Pt s cardiac arrest is most likely due to this current condition. A Paediatric Emergency Treatment Plan includes words to the effect that in the event of a significant deterioration or cardiac / respiratory arrest CPR is not to be commenced. It should be signed by the parent / guardian and treating doctor or medical team. Paramedic crews must clearly record full details of the information given to them and the basis for their decision regrading resuscitation on the PCR. This is particularly important where a copy of the ROTC has not been sighted as it will serve if necessary as evidence of their good faith. Under the Medical Treatment Act 1988 a person acting under the direction of a registered medical practitioner who, in good faith and in reliance on a ROTC, refuses to perform or continue medical Rx is not guilty of professional misconduct or guilty of an offence or liable in any civil proceedings because of the failure to perform or continue that Rx. Version Page 1 of 4 CPG A0203 Withholding or Ceasing Resuscitation CPG A

26 Withholding or Ceasing Resuscitation Status Absent signs of life 8 Assess Stop Signs of life evident Response to stimuli Spontaneous respiratory effort Palpable carotid pulse Do not attempt Pt Mx if there is risk to Paramedic safety If uncertain of life status, commence immediate resuscitation No signs of life evident Is this a mass casualty situation Pain may require IV If Yes, refer applicable AV Emergency Response Plan If No, continue Hx / assessment Is there no prospect of resuscitation Clear evidence of prolonged cardiac arrest or Injuries incompatible with life or Death declared by a doctor who is, or has been at the scene If Yes, do not commence resuscitation and Confirm the determinants of death are present and Consider verification of death If No, continue Hx / assessment Version Page 2 of 4 CPG A0203 One or more signs of life present Mx as per appropriate CPG

27 Withholding or Ceasing Resuscitation Are there compelling reasons to withhold resuscitation P Adult ( 18) with an ACD or ROTC or Child (< 18) with a valid Emergency Treatment Plan to not commence resuscitation If Yes, do not commence resuscitation Confirm the determinants of death are present Consider verification of death If No, commence resuscitation All other presentations with no signs of life evident P Commence immediate resuscitation Cessation of resuscitation Adult ( 18) who, after 30-45/60 of ALS resuscitation (including DCCS / drug therapy) has nil ROSC, no signs of life including pupil reaction and agonal / gasping respiration and no compelling reason to continue Cease resuscitation Confirm the determinants of death are present Consider Verification of Death Version Page 3 of 4 CPG A0203 Withholding or Ceasing Resuscitation CPG A

28 Withholding or Ceasing Resuscitation Verification of death Verification of Death refers to establishing that a death has occurred after thorough clinical assessment of a body. Qualified Paramedics can provide verification if in the context of employment and if there is certainty of death. Providing verification of death is not mandatory for Paramedics. Certification of death must still ultimately be provided by a Medical Practitioner as to cause of death. This falls outside the scope of verification of death. Clinical assessment of a deceased person includes 6 clinical elements. These are the determinants of death : - No palpable carotid pulse. - No heart sounds heard for 2 min. - No breath sounds heard for 2 min. - Fixed (non responsive to light) and dilated pupils (may be varied from underlying eye illness). - No response to centralised stimulus (supraorbital pressure, mandibular pressure or sternal pressure). - No motor (withdrawal) response or facial grimace to painful stimulus (pinching inner aspect of elbow or nail bed pressure). N.B. ECG strip that shows asystole over 2 min is a seventh and optional finding that may be included. Ideally the determinants of death should be evaluated 5-10 min after cessation of resuscitation to ensure late ROSC does not occur. The Verification of Death form should include all findings along with the full name of person (if known), location of death, estimated date and time of death (if known), name of the Paramedic conducting the assessment and if the treating doctor has been notified. Police must be notified in cases of reportable or reviewable death with the attending crew remaining on scene until their arrival. SIDS are considered reportable. A reportable death would include unexpected, unnatural or violent death, death following a medical procedure, death of a person held in custody or care (alcohol or mental health), a person otherwise under the auspice of the Mental Health Act but not in care or a person unknown. A reviewable death is required following death of a child (< 18) where the death is the second or subsequent death of a child of the parent, guardian or foster parent. The original Verification of Death form should be left with the deceased and the copy attached to the printed PCR. Version Page 4 of 4 CPG A0203

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30 Laryngeal Mask Airway (LMA) Special Notes The LMA provides improved airway and ventilation Mx compared with a facemask and OPA. The LMA does not protect against aspiration, although studies have shown it to be as low as 3.5% with an LMA compared to 12.4% with a BVM. The LMA should therefore not be regarded as the equivalent of endotracheal intubation. The LMA forms a low pressure seal around the posterior perimeter of the larynx and when correctly inserted is seated superior to the oesophageal sphincter, thus enabling positive pressure ventilation via BVM or closed circuit resuscitator. Unconscious Pts who accept an OPA are generally suitable for insertion of an LMA. Obese Pts have a naturally increased WOB. During assisted or intermittent positive pressure ventilation they will require higher airway pressures to inflate the lungs. They also have a higher incidence of hiatus hernia resulting in an increased likelihood of passive regurgitation of stomach contents. General Care If insertion fails and ventilation is difficult or inadequate, check position of LMA cuff using a laryngoscope. If minor adjustment fails to correct the problem, remove the LMA inflated. Immediately insert an OPA / NPA and ventilate the Pt using a BVM. Only one attempt may be made to reinsert LMA. If insertion fails on the second attempt, do not delay returning to BVM using an OPA / NPA. Do not over-inflate cuff. The LMA may be used for the unconscious APO Pt. However, gentle assisted ventilation should be provided using a closed circuit resuscitator. The LMA may be inserted in left or right lateral positions, or if entrapped, in a sitting position. Pts may be Mx in the lateral position when the LMA has been correctly inserted and taped in situ, using Transpore or Sleek, however, in general, it is recommended that Pts be Mx supine and carefully observed for aspiration. If the conscious state of the Pt improves and there is an attempt to reject the LMA, remove the LMA with the cuff inflated. Version Page 1 of 2 CPG A0301

31 Laryngeal Mask Airway (LMA) 8 Status Unconscious Pt without gag reflex Ineffective ventilation with BVM / oxysaver and airway Mx (OPA / NPA) > 10/60 assisted ventilation required Unable to intubate/difficult intubation Stop Contraindications - Intact gag reflex or resistance to insertion - Strong jaw tone and/or trismus - Suspected epiglottitis or upper airway obstruction - The use of sedation to either assist placement of, or to maintain placement of an LMA is C/I 8 Consider Precautions - Inability to prepare the Pt in the sniffing position - Pts who require high airway pressures, e.g. advanced pregnancy, morbid obesity, decreased pulmonary compliance (stiff lungs due to pulmonary fibrosis) or increased airway resistance (severe asthma) - Pts 14 years due to enlarged tonsils - Significant volume of vomit in airway Side effects - Correct placement of the LMA does not prevent passive regurgitation or gastric distension Status Stop 8 Assess 8 Consider MICA Action LMA Size Chart Portex Size Wt Inflation 3 Small adult kg 25 ml 4 Normal adult kg 35 ml 5 Larger adult kg 55 ml Unique Size Wt Inflation 3 Small adult kg 20 ml 4 Normal adult kg 30 ml 5 Larger adult kg 40 ml i-gel quick reference guide i-gel size Pt weight guide* Max size of gastric tube kg N/A kg kg kg kg kg kg 14 *This is a guide only. Please ensure correct size is chosen corresponding to Pt airway size Version Page 2 of 2 CPG A0301 Laryngeal Mask Airway (LMA) CPG A

32 Endotracheal Intubation Guide Special Notes The Medical Advisory Committee has authorised endotracheal intubation by MICA Paramedics in selected Pts. There are three intubation techniques available: - Intubation without drugs (unassisted endotracheal intubation) - Intubation facilitated by sedation (IFS) - Rapid sequence intubation (RSI) The appropriate technique will vary according to the clinical setting and a Paramedic s authorised scope of practice. A MICA Paramedic operating alone may elect not to use IFS or RSI until a second MICA Paramedic is present. All intubations facilitated or maintained with drug therapy will be reviewed as part of AV's clinical governance processes. The use of cricothyroidotomy is restricted to AV MICA Paramedics specifically accredited in this skill by the Medical Advisory Committee. General Care Version Page 1 of 11 CPG A0302

33 Endotracheal Intubation Guide Primary indications Respiratory arrest Cardiac arrest GCS < 10 due to: - Respiratory failure - Neurological injury - OD - Status epilepticus - DKA Status Endotracheal intubation Status Stop 8 Assess 8 Consider MICA Action Preparation Drugs to facilitate intubation IFS RSI Insertion of ETT Care and maintenance Sedation Sedation and paralysis Version Page 2 of 11 CPG A0302 Failed intubation See CPG A0303 Failed Intubation Drill Endotracheal Intubation CPG A

34 Endotracheal Intubation Indications, Precautions, C/Is Special Notes Primary neurological injury - RSI should be provided unless Pt is in cardiac arrest. This includes Pts with absent airway reflexes. - Midazolam should not be used to control combativeness prior to RSI in head injury. Judicious pain relief with opioids should be used. If combativeness is preventing preoxygenation (this is rare), then once all preparations have been made for RSI the Fentanyl should be given. This should settle the Pt sufficiently to enable preoxygenation for 2-3 min, then the Midazolam and Suxamethonium should be given and the Pt intubated. Status epilepticus - A continuous or recurrent seizure of 10 min duration or no return of consciousness between episodes may require intubation where there is airway / ventilation compromise which is unable to be effectively Mx using BVM and OPA / NPA. Suspected TCA OD - Requiring hyperventilation for cardiac arrhythmia prevention or Mx. Overdose - The intent of the OD (difficult extrication) indication for RSI is for the Pt to be intubated at the scene to enable safer extrication. Special Notes Uncontrolled bleeding - In Pts with uncontrolled bleeding (e.g. ruptured AAA, ruptured ectopic pregnancy, penetrating truncal trauma, intra-abdominal trauma, limb avulsion), ongoing bleeding may lead to poor cerebral perfusion and coma. - RSI in these Pts is potentially harmful. The sedation may drop BP further and the added scene time increases total blood loss. The appropriate Rx for these Pts is urgent Tx and immediate surgery. - RSI should NOT be undertaken in Pts who become unconscious when the coma is likely to be secondary to blood loss, unless RSI is judged to be absolutely essential (unmanageably combative and/or impractical to Tx unintubated). This applies to Pts being Tx both by road and air Ambulance. - Airway Mx with BVM is to be maintained in conjunction with prompt Tx. Intubation (without drugs) should be considered if airway reflexes are lost, bearing in mind the risks of delay to definitive surgical care. Severe hyperthermia - May result from drug OD or heat exposure. If after 10/60 of active cooling Pt temp remains > 39.5 C and GCS < 10, then Pt should be intubated with RSI. Version Page 3 of 11 CPG A0302

35 Endotracheal Intubation Indications, Precautions, C/Is Unassisted Endotracheal Intubation Indication Indication GCS < 10 Respiratory arrest Cardiac arrest Absent airway reflexes 8 General precautions Time to intubation at hospital vs time to intubate at scene Poor baseline neurological function and major co-morbidities Advanced Care Plan / Refusal of Medical Treatment document specifies not for intubation IFS Contraindications Status Stop 8 Assess 8 Consider MICA Action Respiratory failure - Unresponsive to non-invasive ventilation and drug therapy DKA - DKA with BGL reading 'high' 8 Precautions for IFS As per General precautions Anticipation of difficulty with BVM ventilation Anticipation of a difficult intubation, e.g. obesity, short neck or facial trauma In general if Tx time < 10/60 then no IFS Clinical situations where failed intubation drill would not be feasible No functional electronic capnograph Pts indicated for RSI RSI Indication GCS < 10 Traumatic brain injury (TBI) Contraindications CIs As per first two C/I IFS Any C/I to Suxamethonium Version Page 4 of 11 CPG A0302 Non-traumatic brain injury - Stroke / subarachnoid haemorrhage Hypoxic brain injury - Post-hanging, near drowning - ROSC as per CPG A0202 Cardiac Arrest OD with any of: - Suspected TCA OD - Difficult extrication - Prolonged Tx time (> 30/60) - SpO 2 unable to be maintained > 90% Severe hyperthermia - > 39.5 C despite 10/60 of active cooling Status epilepticus Suspected airway burns consult only 8 Precautions for RSI As per General precautions IFS In general if Tx time < 10/60 then no RSI Coma due to uncontrolled bleeding Endotracheal Intubation CPG A

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37 Endotracheal Intubation Preparation Unassisted Endotracheal Intubation General preparation for intubation Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support Pre-oxygenate with 100% O 2 and electronic capnograph attached Ensure pulse oximeter and cardiac monitor are functional Prepare equipment and assistance - Suction - ETT (plus one size smaller than predicted immediately available) with introducer - ODD - Ensure equipment for a difficult / failed intubation is immediately available, including bougie, LMA, cricothyroidotomy kit - Mark cricothyroid membrane as necessary - Brief assistant to provide cricoid pressure, where appropriate - If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck Ensure functional and secure IV access IFS Status Stop 8 Assess 8 Consider MICA Action Preparation for IFS As per General preparation for intubation Pre-hydrate with Normal Saline 10 ml/kg IV bolus unless APO If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process Draw up and label drugs as appropriate RSI Preparation for RSI Version Page 5 of 11 CPG A0302 As per General preparation for intubation Pre-hydrate with Normal Saline 10 ml/kg IV bolus If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process Adrenaline not to be given in hypovolaemic shock Draw up and label drugs as appropriate Endotracheal Intubation CPG A

38 Endotracheal Intubation Drugs Special Notes Sedation doses for RSI are based on initial observations. This is especially important in multi-trauma with TBI. Initial fluid challenges may resolve tachycardia and/or hypotension, however the Pt is still at risk of cardiovascular compromise and the BP must be strenuously supported. Half doses (or less) of sedation are required in this situation. In Pts with extremely poor perfusion, Rx with fluid therapy +/- Adrenaline infusion concurrently with IFS or RSI. Consider quarter doses of sedation. Frail, elderly or hypotensive Pts have prolonged circulation times. Allow for this when giving a second dose of sedation during IFS. Dosage RSI Age < 60 BP < 80 mmhg BP mmhg BP > 100 mmhg, HR > 100 bpm (TBI only) BP > 100, HR > 100 bpm (all other) Age 60 BP < 80 mmhg BP > 80 mmhg Dosage IFS Age < 60 BP < 100 mmhg BP > 100 mmhg Age 60 Version Page 6 of 11 CPG A0302 Dose Half Full Dose 1/4 or 1/2 Fentanyl Midazolam 1 mg Half Half Full 1/4 or 1/2 Fentanyl Midazolam 1 mg Half Half dose for all

39 Endotracheal Intubation Drugs Unassisted Endotracheal Intubation Status Stop 8 Assess 8 Consider MICA Action Full dose sedation required BP > 100 mmhg and age < 60 Version Page 7 of 11 CPG A0302 Adjusted sedation dose required Adjusted sedation dose required Proceed with intubation - no drugs required IFS Half dose sedation required BP < 100 mmhg and/or age 60 Fentanyl 50 mcg IV Midazolam 0.05 mg/kg IV (max. 5 mg) Fentanyl 100 mcg IV Midazolam 0.1 mg/kg IV (max. 10mg) If unable to intubate due to excessive tone If GR 1 or 2 view but respiratory effort or airway reflexes are preventing intubation - Repeat same dose of sedation and reattempt intubation once only If GR 3 or 4 view - Refer to CPG A0303 Failed Intubation Drill RSI Reduced dose sedation required if either: BP < 80 mmhg BP mmhg HR > 100 mmhg (TBI only) Age 60 Fentanyl 50 mcg IV Paralysing agent - If BP < 80 mmhg consider Fentanyl 25 mcg IV Midazolam 0.05 mg/kg IV (max. 5 mg) - If BP < 80 mmhg give Midazolam 1 mg IV Full dose sedation required BP > 100 mmhg and age < 60 Fentanyl 100 mcg IV Midazolam 0.1 mg/kg IV (max. 10 mg) If Pt bradycardic at any stage - Atropine 600 mcg IV Suxamethonium 1.5 mg/kg IV round up to nearest 25 mg (max. 150 mg) Endotracheal Intubation CPG A

40 Endotracheal Intubation Insertion of ETT Insertion of Endotracheal Tube Observe passage of ETT through cords noting Australian Standard (AS) markings and grade of view. Check ETT position using ODD. Inflate cuff. Confirm tracheal placement via capnography (NB: Pt in cardiac arrest may not have CO 2 initially detectable). Exclude right main bronchus intubation by performing the cuff palpation (tracheal squash) test and by comparing air entry at the axillae. Note length of ETT at lips/teeth. Auscultate chest / epigastrium. Note supplemental cues of correct placement (e.g. tube misting, bag movement in the spontaneously ventilating Pt, improved O 2 saturation and colour). Secure the ETT and insert a bite block if required. If there is ANY doubt about tracheal placement, the ETT must be removed. If unable to intubate after ensuring correct technique proceed to CPG A0303 Failed Intubation Drill. General Care of the Intubated Pt Reconfirm tracheal placement using EtCO 2 after every Pt movement. Disconnect and hold ETT during all transfers. If electronic capnography fails after intubation, use colourimetric capnometry. Suction ETT and oropharynx in all Pts. If time permits, insert OG or NG tube, aspirate and connect to drainage bag. The OG route must be used in head or facial trauma. Ventilate using 100% O 2 and tidal volume of 10 ml/ kg. Aim to maintain SpO 2 > 95% and EtCO 2 at mmhg (except asthma / COPD where a higher EtCO 2 may be permitted, TCA OD where the target is mmhg and DKA where the EtCO 2 should be maintained at the level detected immediately post-intubation, with a max. of 25 mmhg). Document all checks and observations made to confirm correct ETT placement. Version Page 8 of 11 CPG A0302

41 Endotracheal Intubation Insertion of ETT 8 Indications Status Insertion / general care of ETT - Unassisted endotracheal intubation - IFS - RSI Insertion and checks of ETT ODD Capnography - EtCO 2 Length lips / teeth Cuff palpation Auscultate chest / epigastrium - Chest rise and fall, bag movement, SpO 2, colour, tube misting Specific insertion instructions as per Insertion of ETT If there is ANY doubt about tracheal placement, the ETT must be removed Status Stop 8 Assess 8 Consider MICA Action General care / ventilation ETT checks with each Pt movement Provide circulatory support if hypotension present Use colourimetric capnometry if capnography fails Suction ETT and oropharynx Insert OG / NG tube Ventilate V T 10 ml/kg, EtCO mmhg if appropriate to Pt condition Disconnect and hold ETT during transfers Specific instructions as per General care of the intubated Pt Version Page 9 of 11 CPG A0302 Endotracheal Intubation CPG A

42 Endotracheal Intubation Care and Mx of Intubated Pt Special Notes For Pts who become hypotensive after intubation, consider reducing the dose of sedation, in association with additional fluid +/- Adrenaline infusion according to the clinical setting. Not all Pts receiving RSI will require paralysis post intubation, e.g. continuous convulsions, OD other than TCA. Some Pts receiving IFS may require paralysis post intubation to control ventilation e.g. asthmatic Pt. TBI Pts require paralysis post intubation to prevent gagging and elevation in ICP. Ideally this should be given before the Suxamethonium wears off, provided tracheal placement is confirmed and the ETT is secured. Non traumatic brain injured Pts i.e. stroke, SAH, do not routinely require paralysis post intubation. Administer where sedation alone cannot maintain intubation. General Care Infusion - Morphine 30 mg + Midazolam 30 mg in 30 ml D5W or Normal Saline - 1 ml = 1 mg each drug - 1 ml/hr = 1 mg/hr Fentanyl 300 mcg + Midazolam 30 mg in 30 ml D5W or Normal Saline - 1 ml = 1 mg Midazolam + 10 mcg Fentanyl Handover - The EtCO 2 and respiratory wave form immediately prior to Pt handover must be demonstrated to the receiving physician and documented on the PCR. Paralysis is C/I in status epilepticus, where clinical monitoring of seizure activity is required. Use additional doses of Midazolam as required. Version Page 10 of 11 CPG A0302

43 Endotracheal Intubation Care and Mx of Intubated Pt 8 Status Indications 8 Consider Intubated Pt 8 Indications Post intubation sedation Restlessness / signs of under-sedation in the absence of other noxious stimuli - e.g. ETT too deep / irritating, occult pain Signs of inadequate sedation Paralysed Pt Non paralysed Pt - HR and BP trending up together - As per Paralysed - Lacrimation - Cough / gag / movement - Diaphoresis Sedation Morphine / Midazolam infusion 1-10 ml/hr IV mg - 5 mg IV boluses as required Until Morphine / Midazolam infusion established: - Midazolam 0.5 mg - 5 mg IV as required or - Midazolam / Morphine 0.5 mg - 5 mg IV each drug OR Fentanyl / Midazolam infusion 1-10 ml/hr Status Stop 8 Assess 8 Consider MICA Action If Pt requires sedation or sedation and paralysis to maintain intubation and ventilation 8 Post Indications intubation paralysis Stop All Pts receiving paralysis MUST receive ongoing sedation Version Page 11 of 11 CPG A0302 Prevention of shivering for Pts receiving therapeutic cooling Primary neurological Pts Where sedation alone is ineffective at maintaining intubation or allowing adequate ventilation / oxygenation As prescribed for interhospital transfer Reduction of metabolic heat production in hyperthermia The ETT must be secured and tracheal placement reconfirmed with electronic capnography C/I for Pt in status epilepticus Sedation and paralysis Sedate as per Post intubation sedation Pancuronium 8 mg IV - Repeat if evidence of returning muscular activity (movement, chewing, cough, gag, curare cleft) Endotracheal Intubation CPG A

44 Failed Intubation Drill Failed Indications Intubation Unable to see vocal cords during initial laryngoscopy Insert OPA and ventilate with 100% O 2 8 Consider Objective confirmation of tracheal placement using EtCO 2 Immediately remove ETT, insert OPA / NPA and ventilate with 100% O 2 8 Consider Able to ventilate and oxygenate Insert LMA 8 Consider Able to ventilate and oxygenate Cricothyroidotomy Reattempt intubation using bougie with blind placement of ETT over bougie No No No Yes Yes Yes Continue Mx in accordance with relevant CPG Version Page 1 of 1 CPG A0303 If sedation / relaxant drugs administered allow these to wear off and Pt to resume normal respiration

45 Cricothyroidotomy 8 Status Unconscious Pt unable to be oxygenated and ventilated using BVM and OPA, NPA, LMA or ETT where: - RSI has been attempted but intubation has not been achieved - RSI is not authorised - Massive facial trauma is present and RSI is considered unsafe due to the inability to undertake the failed intubation drill - RSI is not possible due to lack of IV / IO access - Upper airway obstruction is present due to a pharyngeal or an impacted foreign body which is unable to be removed using manual techniques and Magill's forceps - Partial airway obstruction is present and Tx by Air Ambulance is required and expertise for alternative techniques is not available. Status Stop 8 Assess 8 Consider MICA Action Stop Contraindications - There are no C/Is when oxygenation and ventilation cannot occur with other techniques Perform cricothyroidotomy using approved kit Version Page 1 of 1 CPG A0304 Cricothyroidotomy CPG A

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48 Acute Coronary Syndromes Special Notes ACS is a spectrum of illnesses including: - UA - STEMI - NSTEACS Not all Pts with ACS will present with pain, e.g. diabetic Pts, atypical presentations, elderly Pts. The absence of ischaemic signs on the ECG does not exclude AMI. AMI is diagnosed by presenting Hx, serial ECGs and serial blood enzyme tests. Suspected ACS related pain that has spontaneously resolved warrants investigation in hospital. The goals of prehospital Mx in ACS are to facilitate timely reperfusion where available and resolve pain completely to reduce cardiac workload. In patients who may be eligible for thrombolysis, invasive procedures should only be conducted according to clinical need and with the potential for increased bleeding risk in mind. Current evidence suggests Tx to a PCI-enabled facility improves Pt outcomes in STEMI Tx time < 90 min. General Care Version Page 1 of 4 CPG A0401

49 Acute Coronary Syndromes ACS Mx Status ACS - UA - STEMI - NSTEACS General Principles of ACS Mx Nausea / vomiting See CPG A0701 Nausea and vomiting Status Stop 8 Assess 8 Consider MICA Action 8 Consider Consider the spectrum of illnesses within ACS LVF See CPG A0406 Pulmonary Oedema Inadequate perfusion See CPG A0407 Inadequate Perfusion Arrhythmia Mx Version Page 2 of 4 CPG A0401 See CPG A0201 VF/VT (pulseless) CPG A0402 Bradycardia CPG A0403 Supraventricular Tachyarrhythmias CPG A0404 Ventricular Tachycardia CPG A0405 Accelerated Idioventricular Rhythm Acute Coronary Syndromes CPG A

50 Acute Coronary Syndromes General Mx Principles Special Notes GTN is a potent venodilator. It reduces C.O. via reduced venous return. Signs of an inferior AMI include ST elevation in leads II and III. Bradycardia is not unusual in an inferior AMI due to the involvement of the right coronary artery and the SA and A-V nodes. Nitrates are C/I in bradycardia (HR < 50 bpm) due to the Pt s inability to compensate for a decrease in venous return by increasing HR to improve cardiac output. - C.O. = HR X SV Where this CPG refers to GTN S/L, buccal administration can be substituted if required. General Care The use of GTN is C/I in suspected inferior or right ventricular infarcts, as these Pts may not compensate for a drop in venous return. Version Page 3 of 4 CPG A0401

51 Acute Coronary Syndromes General Mx Principles Status ACS Antiplatelet Rx Nitrates Pain Relief Aspirin 300 mg oral 8 Assess requirement for: Pain relief / nitrates Control of hypertension Antiplatelet Rx Status Stop 8 Assess 8 Consider MICA Action BP > 110 mmhg - GTN 300 mcg S/L (no prev. admin.) or - GTN 600 mcg S/L If symptoms continue and BP remains > 110 mmhg - Repeat mcg 5/60 BP > 90 mmhg - GTN patch 50 mg (0.4 mg/hr) upper torso / arms - If BP falls < 90 mmhg, remove patch Hypertension +/- symptoms - SBP > 160 mmhg or - DBP > 100 mmhg Control pain as per CPG A0501 Pain Relief GTN 300 mcg S/L - Repeat 300 5/60 if hypertension persists Version Page 4 of 4 CPG A0401 Pain relief as per CPG A0501 Pain Relief - Rx until pain free Acute Coronary Syndromes CPG A

52 Bradycardia Special Notes Atropine is unlikely to be effective in complete heart block, however should still be administered. If side effects occur during Adrenaline infusion, cease infusion and recommence once side effects resolve titrating to Pt response. If no increase in HR, pacing is likely to be required. Notify appropriate hospital capable of managing a Pt likely to require pacing. Bradycardia is technically defined as less than 60 bpm. In practical purposes many Pts will have a normal HR between 50 bpm and 60 bpm. Decisions to Rx should consider this and the more likely need to consider 50 bpm as the limiting point for Mx. General Care Adrenaline Infusion - Adrenaline 3 mg added to make 50 ml with D5W or Normal Saline. - 1 ml/hr = 1 mcg/min If no response from Adrenaline 20 mcg/min, increasing infusion rate is unlikely to have additional chronotropic effects. Version Page 1 of 2 CPG A0402

53 Bradycardia Status Evidence of bradycardia Stable Asymptomatic Adequate perfusion HR > 20 bpm Action 8 Assess Perfusion status Cardiac rhythm Heart failure Ischaemic chest pain BLS Rx as per Unstable if Pt deteriorates HR < 20 bpm Action Atropine 600 mcg IV - If no 3-5/60 repeat 600 mcg (max mcg) Adequate perfusion achieved Inadequate or extremely poor perfusion persists Action Continue current Mx Adrenaline infusion (3 mg/50 ml D5W / Normal Saline) Tx 5 mcg/min (5 ml/hr) - Increase by 5 2/60 until adequate perfusion/side effects (max. 20 mcg/min) - If syringe pump unavailable - Adrenaline 10 mcg IV - Repeat 10 mcg 2/60 until adequate perfusion / side effects Status Stop 8 Assess 8 Consider MICA Action Unstable Less than adequate perfusion - including acute STEMI and ischaemic chest pain Profound bradycardia (HR < 40 bpm) and full field APO Runs of VT or ventricular escape rhythms If poor perfusion persists Rx as per CPG A0407 Inadequate Perfusion Cardiogenic Causes Version Page 2 of 2 CPG A0402 Bradycardia CPG A

54 Tachyarrhythmias Special Notes This CPG contains the recommended joules for biphasic defibrillators used in manual mode. If using a monophasic device please refer to manufacturer instructions. General Care CPG A0403

55 Tachyarrhythmias QRS 0.12 sec Rate > 100 bpm Adequate perfusion See CPG A0403 Supraventricular Tachyarrhythmias Status Absent or abnormal P waves - SVT (A-V nodal rhythms or AVRT) - AF, atrial flutter - Sinus tachycardia - Atrial tachycardia Tachyarrhythmias Status Stop 8 Assess 8 Consider MICA Action < Adequate perfusion / unstable See CPG A0403 Supraventricular Tachyarrhythmias QRS > 0.12 sec VT > 30 sec Rate > 100 bpm Wide and bizarre Version Page 1 of 1 CPG A0403 Generally regular A-V dissociation / absence of P waves VT See CPG A0404 Ventricular Tachycardia Tachyarrhythmias CPG A

56 Supraventricular Tachyarrhythmias Special Notes Symptomatic S/S - Rate related severe or persistent chest pain. - SOB with crackles. A Pt eye opening to pain but not to voice commands would also be likely to be making incomprehensible sounds and making purposeful movements in response to pain. i.e. a GCS of 9 (E2, V2, M5). Sedation should be used cautiously in these Pts. I f Pt is unconscious or becomes unconscious at any time during Rx perform immediate synchronised cardioversion. If the available device does not select 75 J, select nearest option up or down. The effectiveness of the Pt s respirations should be continuously monitored. Atrial flutter and AF should not be treated under this CPG except if the Pt is rapidly deteriorating. If wide complex QRS or unsure of diagnosis, Rx as for CPG A0404 Ventricular Tachycardia. IV Adenosine should be administered through a large vein closer to the heart such as in the cubital fossa. General Care The valsalva manoeuvre is reserved exclusively for Pts with a BP 100 mmhg. Where available a 12 lead ECG should be recorded prior to Mx unless the Pt requires immediate Rx. Perform 3 lead ECG where 12 lead is unavailable. Valsalva instruction Evidence suggests a greater reversion rate with an abdominal valsalva manoeuvre with the following 3 elements. 1. Position - supine. 2. Pressure - At least 40 mmhg for max. vagal tone. Best achieved with Pt blowing into a 10 ml syringe hard enough to move the plunger to create this pressure. 3. Duration - At least 15 sec if tolerated by Pt. Ref. G. Smith, A. Morgans and M. Boyle Emerg Med J 2009; 26: doi: emj Expect transient ectopic activity for up to 30 sec. If present, administer O 2 therapy until signs resolve. Ongoing arrhythmia should be Mx as per appropriate CPG. Rx Pt symptomatically in accordance with appropriate CPG and Tx for further assessment and Rx. Version Page 1 of 2 CPG A0403

57 Supraventricular Tachyarrhythmias Status SVT (AVNRT or AVRT) Unstable deteriorating rapidly SVT, AF, atrial flutter BLS Stop Exclude AF and atrial flutter SVT Stable BP 100 SVT - Unstable not rapidly Where available, record 12 Lead ECG prior to commencing Mx Abdominal valsalva - Repeat x 2/60 deteriorating BP < 100 Where available, record 12 Lead ECG prior to commencing Mx Adenosine 6 mg IV push If no reversion after 2/60 - Adenosine 12 mg IV push If no reversion after further 2/60 - Adenosine 12 mg IV push O 2 therapy if any ectopic activity is observed Mx as per SVT unstable not rapidly deteriorating 8 Assess Perfusion status Patient stability Status Stop 8 Assess 8 Consider MICA Action Narrow complex tachycardia BLS O 2 therapy if any ectopic activity is observed Version Page 2 of 2 CPG A0403 Unstable deteriorating rapidly Rapidly deteriorating Altered conscious state Includes AF, atrial flutter Pain relief as per CPG A0501 Pain Relief BLS Synchronised cardioversion - Sedate Midazolam 2.5mg IV - Repeat Midazolam 2.5mg 2/60 until Pt does not respond to verbal stimuli but does respond to pain - Cardioversion: DCCS 75 J single shock - If unsuccessful repeat DCCS using 150 J if required Reversion No reversion Reversion No reversion Loss of output As per appropriate CPG Supraventricular Tachyarrhythmias CPG A

58 Ventricular Tachycardia (VT) Special Notes A Pt eye opening to pain but not to voice commands would also be likely to be making incomprehensible sounds and making purposeful movements in response to pain, i.e. a GCS of 9 (E2, V2, M5). Sedation should be used cautiously in these Pts. The effectiveness of the Pt s respirations should be continuously monitored Amiodarone and Fentanyl have the potential to interact adversely. Concurrent administration should be avoided. If Fentanyl has already been administered, monitor the Pt closely when administering Amiodarone. General Care ALS crews should considerer MICA R/V vs Tx to appropriate hospital as these Pts are dynamic and have a potential to deteriorate Pt presenting symptomatic and poorly perfused is likely to require sync. cardioversion prior to Amiodarone administration. Version Page 1 of 2 CPG A0404

59 Ventricular Tachycardia (VT) Status 8 Assess VT Stable: Adequately perfused Amiodarone infusion 5mg/kg IV (max. 300mg) over 20/60 once only Rx as per Unstable if Pt deteriorates Only dilute Amiodarone with D5W Do not administer Amiodarone if suspected TCA OD. Mx as per CPG A0707 Overdose: TCA Confirm VT - VT > 30 sec - Mostly regular - QRS > 0.12 sec - Rate > 100 bpm - A-V dissociation / absence of P waves Status Stop 8 Assess 8 Consider MICA Action Unstable / Rapidly deteriorating Synchronised cardioversion - Sedate: Midazolam 2.5mg IV - Repeat Midazolam 2.5mg 2/60 until Pt does not respond to verbal stimuli but does respond to pain - Cardioversion 150 J - If unsuccessful repeat using 150 J if required Loss of output Reversion As per appropriate CPG Narrow complex - Amiodarone infusion as above (if not already established) Other rhythms - Rx as per appropriate CPG Version Page 2 of 2 CPG A0404 Ventricular Tachycardia (VT) CPG A

60 Accelerated Idioventricular Rhythm (AIVR) Special Notes AIVR is usually a benign rhythm but may be associated with AMI, reperfusion or drug toxicity. Commonly seen in post cardiac arrest Pts. May be associated with Adrenaline administration. General Care Version Page 1 of 2 CPG A0405

61 Accelerated Idioventricular Rhythm (AIVR) Status AIVR Perfusion status Adequate perfusion < Adequate perfusion BLS Tx Ventricular rate < 60 bpm Rx as per CPG A0402 Bradycardia Status Stop 8 Assess 8 Consider MICA Action 8 Assess Ventricular rate bpm Normal Saline 250 ml IV bolus - Repeat 250 ml IV if perfusion status not improved No perfusion Rx as per CPG A0201 Pulseless Electrical Activity Ventricular rate > 100 bpm Rx as per CPG A0404 Ventricular Tachycardia Version Page 2 of 2 CPG A0405 Accelerated Idioventricular Rhythm (AIVR) CPG A

62 Pulmonary Oedema Special Notes This CPG is primarily directed at cardiogenic pulmonary oedema, secondary to LVF or CCF. Other medical causes of pulmonary oedema should not be treated under this CPG. Non-medical causes include: smoke inhalation / toxic gases, near drowning (aspiration) and anaphylaxis. In these cases pulmonary oedema is likely a result of altered permeability. These causes should be treated with O 2 therapy and assisted ventilations and do not require nitrates. Where this CPG refers to GTN S/L, buccal administration can be substituted if required. General Care Mx chest pain as per CPG A0401 Acute Coronary Syndromes. Frusemide should be used cautiously in the hypotensive Pt. Pts with pulmonary oedema presenting with a wheeze should only be Mx as per CPG A0601 Asthma if a PHx of bronchospasm can be confirmed. Avoid the use of Salbutamol in the setting of pulmonary oedema where possible. Version Page 1 of 2 CPG A0406

63 Pulmonary Oedema Status Pulmonary oedema Not short of breath Action BLS If deteriorates, Rx as per SOB 8 Assess Basal / midzone crackles Status Stop 8 Assess 8 Consider MICA Action Consider causes: LVF / CCF, nutritional deficiency, liver disease, renal disease, fluid overload Respiratory status No improvement or deteriorates Rx as for Full field crackles Short of breath BP > 110 mmhg - GTN 300 mcg S/L (no prev. admin.) or - GTN 600 mcg S/L - If BP > 110 mmhg and symptoms continue repeat mcg 5/60 BP > 90 - GTN patch 50 mg (0.4 mg/hr) upper torso/arms Remove GTN patch if BP decreases < 90 mmhg Frusemide mg IV Full field crackles Action GTN as per Basal / midzone crackles Frusemide 40 mg IV or Pt s daily dose IV as a single dose (max. 100 mg) If alert and anxious - Consider Morphine 1-2 mg IV No improvement or deteriorates Suction if required - Provide assisted ventilation with 100% O 2 if inadequate V T or RR CPAP if available Consider ETT as per CPG A0302 Endotracheal Intubation Version Page 2 of 2 CPG A0406 Pulmonary Oedema CPG A

64 Inadequate Perfusion Cardiogenic causes Special Notes Any IV infusions established under this CPG must be clearly labelled with the name and dose of any additive drugs and their dilution. A Pt presenting with inadequate to extremely poor perfusion resulting from a cardiac event may not always have associated chest pain, e.g. silent MI, cardiomyopathy. Pts presenting with suspected PE with inadequate to extremely poor perfusion should be Mx with this CPG. PE is not specifically a cardiac problem but may lead to cardiogenic shock due to an obstruction to venous return and the Pt may require fluid and Adrenaline therapy. General Care Adrenaline infusion > 50 mcg/min may be required to Mx these Pts. Ensure delivery system is fully operational (e.g. tube not kinked, IV patent) prior to increasing dose. Unstable Pts may require bolus Adrenaline concurrently with the infusion. Adrenaline infusion - Adrenaline 3 mg added to make 50 ml with D5W or Normal Saline. - 1 ml/hr = 1 mcg/min Version Page 1 of 2 CPG A0407

65 Inadequate Perfusion Cardiogenic causes Status Stop Inadequate perfusion: cardiogenic causes Mx other causes, e.g. arrhythmia, pain, hypovolaemia Adrenaline infusion as per Inadequate or extremely poor perfusion Crackles No crackles Inadequate or extremely poor perfusion persists Status Stop 8 Assess 8 Consider MICA Action Normal Saline 250 ml IV - Repeat 250 ml IV if chest clear and inadequate or extremely poor perfusion persists Adrenaline infusion (3 mg/50ml D5W / Normal Saline) 5 mcg/min (5 ml/hr) - Increase by 5 2/60 until adequate perfusion/side effects - If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min - If syringe pump unavailable: 8 Assess - Adrenaline 10 mcg IV - repeat 10 2/60 until adequate perfusion / side effects - If poor response - Adrenaline mcg IV as required - NB. Doses > 100 mcg may be required If chest clear continue Normal Saline 250 ml IV boluses up to 20 ml/kg Signs of pulmonary oedema (crackles) Version Page 2 of 2 CPG A0407 Inadequate Perfusion Cardiogenic causes CPG A

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68 Pain Relief Special Notes The preferred choice for non IV therapy is IN Fentanyl. The administration of Methoxyflurane and IN Fentanyl should not routinely occur in the same Pt. The max. dose of Methoxyflurane is 6 ml per 24 hr period. Be cautious of administering Fentanyl and Morphine to the same Pt. If respiratory depression occurs due to opioid administration Mx as per CPG A0707 Overdose. Headache should be Mx as per this CPG Severe headache. Fentanyl IN preparation All adult doses must be prepared from 600 mcg/2 ml in a 1 ml syringe All doses include 0.1 ml to account for atomiser dead space Doses have been rounded to the nearest 0.05 ml. Age < 60 and Wt > 60 kg Age 60 and/or Wt 60 kg Initial dose 200 mcg 100 mcg Volume 0.75 ml 0.45 ml Subsequent dose 50 mcg 50 mcg Volume 0.25 ml 0.25 ml Subsequent dose 25 mcg 25 mcg Volume 0.2 ml 0.2 ml Special Notes ALS Paramedics must consult prior to exceeding the 20 mg max. dose of Morphine and administer according to Pt need or the onset of adverse side effects. The effect of Morphine IM on pain relief is slow and variable. This route must be used as a last resort and strictly within indicated CPGs. Opioid pain relief should not be administered during late second stage of labour. If opioids have been administered, Naloxone should not be administered to the newborn. To administer Fentanyl, draw up desired vol according to dose table for the corresponding weight and age then atomise into Pt s nostril. The max. amount to be atomised into any nostril is 1 ml. In some instances it may be appropriate to administer half of the vol into each nostril as optimal absorption occurs with volumes of ml. This is also dependent on Pt compliance. Version Page 1 of 4 CPG A0501

69 Pain Relief Status 8 Assess Complaint of pain Pain score > 2 Non IV therapy Pain likely to be controlled by non IV therapy or Unable to obtain IV If Fentanyl IN - If age < 60 and > 60kg : Fentanyl 200 mcg IN - Repeat up to 50 mcg 5/60 titrated to pain or side effects (max. dose 400 mcg) - If age 60 and/or 60 kg : Fentanyl 100 mcg IN - Repeat up to 50 mcg 5/60 titrated to pain or side effects (max. dose 200 mcg) If unable to administer IN Fentanyl Methoxyflurane 3 ml - Repeat 3 ml if required (max. 6 ml) If pain not controlled by above Rx as per IV therapy Nausea Rx as per CPG A0701 Nausea and Vomiting Status Stop 8 Assess 8 Consider MICA Action Determine requirement for IV vs non IV therapy IV therapy Pain may require IV opioid and ongoing therapy Morphine up to 5 mg IV - Repeat Morphine up to 5 mg 5/60 (max. 20 mg) titrated to pain or side effects Version Page 2 of 4 CPG A0501 Unable to obtain IV access - > 60 kg : Morphine 10 mg IM - Repeat Morphine 5 mg IM after 15/60 (once only) if required - 60 kg : Morphine 0.1 mg/kg IM - Single dose only - consult for further dose Morphine as above - no max. dose If allergic or sensitive to Morphine - Fentanyl mcg IV - Repeat Fentanyl mcg 5/60 titrated to pain or side effects (max. 200 mcg) Fentanyl as above - no max. dose Pain Relief CPG A

70 Pain Relief Severe Headache Special Notes Non steroidal anti-inflammatory medications, as well as paracetamol and ibuprofen, in mild to moderate headache is acceptable for Pt self administration. Paramedics do not administer Aspirin for headache. Opioids are of limited benefit in the Rx of migraine. Morphine may not be effective and may be associated with delayed recovery on occasions. It should only be used to Rx severe prolonged diagnosed headache where other measures have failed and where Tx to the treating facility is prolonged. Prochlorperazine is indicated for headache considered or diagnosed to be migraine irrespective of nausea and vomiting. Paramedics do not diagnose headache. The term migraine may be used mistakenly to describe a severe headache. Headache Mx is usually dependant upon a diagnosis and tailored accordingly. Prehospital Mx seeks to provide interim relief until a more appropriate diagnosis and Mx can be provided. Prochlorperazine is unlikely to offer any clinical benefit for intracranial haemorrhage or SAH. It may be omitted in this case. Many such Pts will have signs of CNS depression in which case Prochlorperazine should not be administered. General Care Many Pts who suffer migraines may already have a preset Rx plan in place. Most Pts will seek emergency care when such Rx has failed. Sudden onset severe headache, sometimes referred to as 'thunderclap' or 'worst in life', should prompt concern for serious intracranial pathology. Particular attention should be given to Pts whose headache intensity increases within secs to a min of onset. Other warning signs that may be suggestive of serious intracranial event include: - Abnormal neurological finding or atypical aura - New onset headache in elderly Pts or those with a Hx of cancer - Altered level of consciousness or collapse - Seizure activity - Fever and/or neck stiffness. Metoclopramide may also be effective in the Mx of headache. Prochlorperazine is the preferred option for severe headache. Metoclopramide and Prochlorperazine should not be administered to the same Pt due to the increased risk of extrapyramidal reactions. The Mx of severe dehydration where indicated may be of assistance in the Mx of severe headache. Version Page 3 of 44 CPG A0501

71 Pain Relief Severe Headache Status Severe headache: Pain score > 7 Severe Headache Stop 8 Assess Status Stop 8 Assess 8 Consider MICA Action Suspected cerebral bleed Potential meningeal infection If uncertain, Mx as suspected intracranial bleed as per CPG A0711 Suspected Stroke or TIA Mx seizures as per CPG A0703 Continuous Seizures If suspected meningococcal infection Mx as per CPG A0706 Meningococcal Septicaemia In the first instance consider Mx all headache type and severity: - Methoxyflurane 3 ml - If effective, repeat 3 ml if required (max. 6 ml) - Prochlorperazine 12.5 mg IM If after 15 min of above therapy and Pt still c/o severe pain (>7) and destination hospital remains > 15 min - Morphine 2.5 mg 5/60 titrated to pain or side effects (max. dose 20 mg) - Aim is to reduce pain to < 7 - If allergic or sensitive to Morphine administer Fentanyl 25 mcg 5/60 titrated to pain or side effects (max. dose 200 mcg) If unable to obtain IV Access If age < 60 and > 60 kg: Fentanyl 100 mcg IN - Repeat up to 25 mcg 5/60 titrated to pain or side effects (max. dose 200 mcg) If age 60 and/or 60 kg: Fentanyl 50 mcg IN - Repeat up to 25 mcg 5/60 titrated to pain or side effects (max. dose 100 mcg) Version Page 4 of 4 CPG A0501 Pain Relief CPG A

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73 Asthma Status Respiratory distress Mild / moderate / severe See CPG A0601 Status Stop 8 Assess 8 Consider MICA Action See CPG A Assess Exacerbation of COPD Severity of asthma / COPD presentation Stop This CPG should be read in conjunction with CPG A0001 Oxygen Therapy Unconscious See CPG A0601 No cardiac output Loses C.O. See CPG A0601 PEA as per CPG A0201 Cardiac Arrest Version Page 1 of 8 CPG A0601 Asthma CPG A

74 Asthma Special Notes Asthmatic Pts are dynamic and can show initial improvement with Rx then deteriorate rapidly. Consider MICA support but do not delay Tx waiting for backup. Despite hypoxaemia being a late sign of deterioration, pulse oximetry should be used throughout Pt contact (if available). An improvement in SpO 2 may not be a sign of improvement in clinical condition. Beware of Pt presenting with wheeze associated with heart failure and no asthma / COPD Hx. General Care Salbutamol infusion - Salbutamol 1 mg added to make 50 ml with D5W or Normal Saline mcg/min = 45 ml/hr Version Page 2 of 8 CPG A0601

75 Asthma Status Respiratory distress Mild or moderate Salbutamol pmdi and spacer - Deliver 4 4/60 until resolution of symptoms - Pt to take 4 breaths for each dose If pmdi spacer unavailable - Salbutamol 10 mg (5 ml) Nebulised - Repeat 5 mg (2.5 ml) 5/60 if required Adequate Response Tx with continued reassessment Action Rx as per Severe Status Stop 8 Assess 8 Consider MICA Action 8 Assess Severity of distress If Pt s asthma Mx plan has been activated No Significant Response after 10/60 Severe Version Page 3 of 8 CPG A0601 Salbutamol 10 mg (5 ml) and Ipratropium Bromide 500 mcg (2 ml) Nebulised - Repeat Salbutamol 5 mg (2.5 ml) 5/60 if required Salbutamol 250 mcg IV - Repeat 125 mcg 5/60 if required (max. 500 mcg) Dexamethasone 8 mg IV If unimproved Salbutamol infusion 15 mcg/min (45 ml/hr) Asthma CPG A

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77 COPD Chronic Obstructive Pulmonary Disease Adequate response Status Exacerbation of COPD All exacerbations of COPD If Severe - Rx as per appropriate section of CPG A0601 Asthma Irrespective of severity - Salbutamol 10 mg + Ipratropium Bromide 500 mcg Nebulised Dexamethasone 8 mg IV Titrate O 2 flow to target SpO 2 90% - Consider low flow O 2, e.g. nasal prongs O 2 Status Stop 8 Assess 8 Consider MICA Action Inadequate response Continue Mx as per CPG A0601 Asthma Version Page 4 of 8 CPG A0601 COPD CPG A

78 Asthma Special Notes High EtCO 2 levels should be anticipated in the intubated asthmatic Pt. EtCO 2 levels of 120 mmhg in this setting are considered safe and Paramedics Mx ventilation should be conscious of the effect of gas trapping when attempting to reduce EtCO 2. Extreme care must be taken with assisted ventilation as gas trapping and barotrauma occurs easily in asthmatic Pts with already high airway pressures. General Care Version Page 5 of 8 CPG A0601

79 Asthma Status Unconscious / becomes unconscious - with poor or no ventilation but still with C.O. Adequate response Rx as per Severe respiratory distress Status Stop 8 Assess 8 Consider MICA Action Pt requires immediate assisted ventilation 8 Action Ventilate V T ventilations/min Moderately high respiratory pressures Allow for prolonged expiratory phase Gentle lateral chest pressure during expiration if required Inadequate response Action If unable to gain IV or unaccredited in IV Salbutamol - Adrenaline 300 mcg IM (1 : 1,000) - Repeat 300 mcg 20/60 as required (max. 900 mcg IM) Rx as per Severe respiratory distress Consider ETT as per CPG A0302 Endotracheal Intubation If unable to obtain IV or IO - Salbutamol 2 x IV / IO dose via ETT If Pt loses C.O. at any stage, see CPG A0601 Version Page 6 of 8 CPG A0601 Asthma CPG A

80 Asthma Special Notes Consider potential for TPT and Mx. High intrathoracic pressures result from gas trapping, decreasing venous return, leading to loss of C.O. Apnoea allows the gas trapping to decrease. General Care Version Page 7 of 8 CPG A0601

81 Asthma Status Cardiac output returns Pt loses C.O. - especially during assisted ventilation and bag becomes stiff Pt requires immediate intervention Apnoea 1 min - Exclude TPT - Gentle lateral chest pressure - Prepare for potential resuscitation Rx as per CPG A0601 Adrenaline 50 mcg IV - Repeat mcg as required Normal Saline 20 ml/kg IV Status Stop 8 Assess 8 Consider MICA Action Carotid pulse, no BP No return of output Version Page 8 of 8 CPG A0601 Mx as per appropriate CPG A0201 Cardiac Arrest Asthma CPG A

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84 Nausea and Vomiting Special Notes Prochlorperazine must only be administered via the IM route. General Care If there are no C/Is and the IV route is unobtainable with a long Tx time, then administer Metoclopramide IM. If nausea and vomiting is being tolerated, basic care and Tx is the only required Rx. Take care with Metoclopramide polyamp as it is similar to Ipratroprium Bromide and Atropine polyamps in appearance. Version Page 1 of 2 CPG A0701

85 Nausea and Vomiting Nausea and vomiting associated with: Prophylaxis for: - Cardiac chest pain - Iatrogenic secondary to opioid analgesia - Previous diagnosed migraine - Secondary to cytotoxic drugs or radiotherapy - Severe gastroenteritis Dehydrated Status 8 Assess for: Actual or potential for nausea and vomiting Metoclopramide 10 mg IV / IM - Repeat 10 mg IV / IM after 10/60 if symptoms persist (max. 20 mg) If known allergy or C/I to Metoclopramide - Prochlorperazine 12.5 mg IM Mx as per CPG A0801 Hypovolaemia Stop Status Stop 8 Assess 8 Consider MICA Action Nausea and vomiting or Potential spinal injury / eye trauma or Potential motion sickness or Vertigo Prochlorperazine must not be given IV Metoclopramide and Prochlorperazine should not be administered in the same episode of Pt care without consultation - Potential for motion sickness - Planned aeromedical evacuation Prochlorperazine 12.5 mg IM Prophylaxis for: Version Page 2 of 2 CPG A0701 Awake Pt (GCS 13 15) with potential spinal injuries who is immobilised on the stretcher Eye trauma - e.g. penetrating eye injury, hyphema Metoclopramide 10 mg IV / IM - Repeat 10 mg IV / IM after 10/60 if symptoms persist (max. 20 mg) Nausea and Vomiting CPG A

86 Hypoglycaemia Special Notes Pt may be aggressive during Mx. Ensure IV is patent before administering Dextrose. Extravasation of Dextrose can cause tissue necrosis. All IVs should be well flushed before and after Dextrose administration (minimum 10 ml Normal Saline). Ensure sufficient advice on further Mx and follow-up if Pt refuses Tx. General Care If next meal is more than 20/60 away, encourage Pt to eat a long acting carbohydrate (e.g. sandwich, fruit, glass of milk) to sustain BGL until next meal. If the Pt refuses Tx, repeat the advice for Tx using friend / relative assistance. If Pt still refuses Tx, document the refusal and leave Pt with a responsible third person and advise the third person of actions to take if symptoms recur and of the need to make early contact with LMO for follow up. If inadequate response Tx without undue delay. Maintain general care of unconscious Pt and ensure adequate airway and ventilation. Further dose of Dextrose 10% may be required in some hypoglycaemic episodes. Consider consultation if BGL remains less than 4 mmol/l and unable to administer oral carbohydrates Continue initial Mx and Tx. Version Page 1 of 2 CPG A0702

87 Hypoglycaemia Status Evidence of probable hypoglycaemia - e.g. Hx diabetes, unconscious, pale, diaphoretic BGL > 4 mmol/l BLS Consider other causes of altered conscious state - e.g. stroke, seizure, hypovolaemia Status Stop 8 Assess 8 Consider MICA Action 8 Assess BGL BGL < 4 mmol/l Responds to commands Action Glucose 15 g oral Adequate response Poor response Consider Tx Consider Dextrose IV or Glucagon 1 IU IM Adequate response - GCS 15 Action Cease administration of IV Dextrose Version Page 2 of 2 CPG A0702 BGL < 4 mmol/l Does not respond to commands IV cannula in a large vein Confirm IV patency Dextrose 10% 15 g (150 ml) IV - Normal Saline 10 ml flush If unable to insert IV Glucagon 1 IU IM Inadequate response - GCS < 15 after 3/60 Action Repeat Dextrose 10% 10g (100 ml) IV titrating to Pt conscious state - Normal Saline 10 ml flush Hypoglycaemia CPG A

88 Continuous Tonic-clonic Seizures Special Notes For seizures other than generalised tonic-clonic seizures, Midazolam may only be administered following medical consultation. Seizures may not always present with tonic-clonic limb activity, e.g. unconsciousness with flicking eye movements (nystagmus) may indicate ongoing seizure activity. If a single seizure has spontaneously terminated continue with initial Mx and Tx. If Pt has a PHx of seizures and refuses Tx, leave them in the care of a responsible third party. Advise the person of the actions to take for immediate continuing care if symptoms recur and the importance of early contact with their primary care physician for follow-up. General Care Frequent errors in drug dosage administration occur within AV in this CPG. Ensure accurate dose calculation and confirm with other Paramedics on scene. Midazolam can have pronounced effects on BP, conscious state, ventilations and airway tone. Calculate the dose each time as stock strength may change with manufacturer and familiarity may lead to errors. Adult Dos Calculation for Midazolam IM Strength required Stock strength x Stock volume e.g. 80 kg 0.1 mg/kg = 8 mg 8 mg x 3mL same as 8 mg x 2 ml 15 mg 10 mg = 8 mg x 1mL = 0.8 x 2 ml 5 mg Dose required = 1.6 ml = 1.6 ml Stock strength 15 mg/3 ml Version Page 1 of 2 CPG A0703

89 Continuous Tonic-clonic Seizures Status Assess Continuous tonic-clonic seizures Status Stop 8 Assess 8 Consider MICA Action Protect Pt Continuously monitor airway and ventilation - assist as required Consider other causes e.g. hypoglycaemia Consider Pt s own Mx plan and Rx already given Continuous tonic-clonic seizure Ensure accurate dosage - 1/2 dose for age 60 years Age 60 - Midazolam 0.05mg/kg IM (max. single dose 5mg) Age < 60 - Midazolam 0.1mg/kg IM (max. single dose 10mg) Seizure activity ceases Seizure activity continues > 5/60 BLS Monitor airway and BP Midazolam 0.05 mg/kg IV - Repeat 0.05 mg/kg 2-5/60 as required - Max. combined dose IM + IV 0.25 mg/kg Consult for further doses Consider ETT as per CPG A0302 Endotracheal Intubation Pancuronium C/I Seizure activity continues >10/60 - No IV access/no accreditation Action Repeat original Midazolam IM dose once only Consult for further doses Version Page 2 of 2 CPG A0703 Continuous Tonic-clonic Seizures CPG A

90 Anaphylaxis Special Notes All Pts with suspected anaphylaxis must be Tx to hospital regardless of the severity of their presentation or response to Mx. Angio-oedema (vascular oedema) leads to increased tissue fluid, presenting as swelling, upper airway obstruction (throat tightness), orbital oedema and other systemic signs of swelling. Identify Hx of exposure to substances known to cause anaphylactic reaction, e.g. - recent insect bite - medications - exposure to food known to cause anaphylactic reaction and presenting with evidence of systemic involvement. Research indicates most deaths from anaphylaxis occurred after a delay in administration of Adrenaline. Absence of an obvious trigger does not exclude anaphylaxis. General Care Version Page 1 of 2 CPG A0704

91 Anaphylaxis Status Evidence of anaphylaxis Hx of exposure to antigen 8 + Assess for systemic involvement 8 Assess physiological distress Angio-oedema or Respiratory distress / bronchospasm or Urticaria or GIT disturbance Plus at least one of these Less than adequate perfusion or Altered conscious state Mild Moderate Severe No physiological distress Local allergic reaction e.g. red rash, itchiness Borderline to inadequate perfusion Mild to moderate respiratory distress Altered conscious state BLS Monitor Pt for cardiac arrhythmias Rx as per Moderate Status Stop 8 Assess 8 Consider MICA Action Adrenaline 300 mcg IM (1 : 1,000) - Repeat 300 mcg 5/60 until satisfactory results or side effects occur Rx bronchospasm as per A0601 Asthma Consider fluid as per CPG A0801 Hypovolaemia Dexamethasone 8 mg IV Extremely poor perfusion Severe respiratory distress Unconscious Version Page 2 of 2 CPG A0704 Adrenaline 50 mcg IV (1 : 10,000) - Repeat mcg 1/60 until satisfactory results or side effects occur IV fluid as per CPG A0801 Hypovolaemia Dexamethasone 8 mg IV If no IV access Rx as per Moderate If no IV access consider IO If intubated - Adrenaline 200 mcg via 5/60 Anaphylaxis CPG A

92 Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic Special Notes Any infusions established under this CPG must be clearly labelled with the name and dose of any additive drugs and their dilution. Sepsis criteria are relevant in the presence of an infection or severe clinical insult such as multi trauma leading to systemic inflammatory response syndrome (SIRS). 2 or more of: - Temp > 38ºC or < 36ºC - HR > 90 bpm - RR > 20/min - BP < 90 mmhg General Care Adrenaline infusion > 50 mcg/min may be required to Mx these Pts. Ensure delivery system is fully operational (e.g. tube not kinked, IV patent) prior to increasing dose. Unstable Pts may require bolus Adrenaline concurrently with the infusion. Adrenaline infusion Adrenaline 3 mg added to make 50 ml with 5% Dextrose or Normal Saline 1 ml/hr = 1 mcg/min If sepsis is suspected and prolonged Tx times exist (>1 hr) consider Ceftriaxone 1g IV (consult). Version Page 1 of 2 CPG A0705

93 Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic BLS Tx Status Suspected sepsis Other causes of non-cardiogenic, non-hypovolaemic shock Adequate perfusion Status Stop 8 Assess 8 Consider MICA Action 8 Assess Perfusion status Respiratory status Sepsis criteria Other possible causes Inadequate or extremely poor perfusion If sepsis is suspected and chest is clear and MICA is not immediately available: - Confirm request for MICA support - Normal Saline up to 20 ml/kg IV over 30 min Normal Saline up to 20 ml/kg IV Inadequate or extremely poor perfusion persists Adrenaline infusion (3 mg in 50 ml D5W/Normal Saline) 5 mcg/min (5 ml/hr) - Increase by 5 2/60 until adequate perfusion or side effects Version Page 2 of 2 CPG A If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min - If syringe pump unavailable - Adrenaline 10 mcg IV - repeat 10 2/60 until adequate perfusion or side effects - If poor response - Adrenaline mcg IV as required - Doses > 100 mcg may be required If chest clear, continue Normal Saline 20 ml/kg IV boluses as per CPG A0801 Hypovolaemia Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A

94 Meningococcal Septicaemia Special Notes Meningococcal septicaemia is transmitted by close personal exposure to airway secretions / droplets. Ensure face mask protection especially during intubation / suctioning. Ensure medical follow up for staff post exposure. General Care Ceftriaxone preparation Dilute Ceftriaxone 1 g with 9.5 ml of Water for Injection and administer 1 g IV over approximately 2/60. If unable to obtain IV access, or not accredited in IV cannulation, dilute Ceftriaxone 1 g with 3.5 ml 1% Lignocaine HCL and administer 1 g IM into the upper lateral thigh or other large muscle mass. Version Page 1 of 2 CPG A0706

95 Meningococcal Septicaemia Status Suspected meningococcal septicaemia PPE IV access Ceftriaxone 1 g IV - Dilute with Water for Injection to make 10 ml - Administer slowly over 2/60 If inadequate perfusion Rx as per CPG A0705 Inadequate Perfusion 8 Confirm meningococcal septicaemia Typical purpuric rash Septicaemia signs - Fever, rigor, joint and muscle pain - Cold hands and feet - Tachycardia, hypotension - Tachypnoea Meningeal signs - Headache, photophobia, neck stiffness - Nausea and vomiting - Altered conscious state Status Stop 8 Assess 8 Consider MICA Action No IV access - Unable to gain - Not IV accredited Ceftriaxone 1 g IM - Dilute with 3.5 ml 1% Lignocaine HCL to make 4 ml - Administer into upper lateral thigh or other large muscle mass Version Page 2 of 2 CPG A0706 Meningococcal Septicaemia CPG A

96 Overdose General Care Provide supportive care (all cases) - Provide appropriate airway Mx and ventilatory support - If Pt is in an altered conscious state, assess BGL and if necessary Mx as per CPG A0801 Hypoglycaemia - If Pt is bradycardic with poor perfusion Mx as per CPG A0402 Bradycardia - If Pt is inadequately perfused, Mx as per appropriate CPG. - Assess Pt temp and Mx as per CPG A0901 Hypothermia / Cold Exposure, or CPG A0902 Environmental Hyperthermia / Heat Stress Confirm clinical evidence of substance use or exposure - Identify which substance/s are involved and collect any packets if possible. - Identify by which route the substance/s have been taken (e.g. ingestion). - Establish the time the substance/s were taken. - Establish the amount of substance/s taken. - Establish what the substance/s were mixed with when taken (e.g. alcohol, water). - Establish if any Rx has been initiated prior to Ambulance arrival (e.g. induced vomiting). Special Notes If Pt still refuses Tx, after repeating the advice for Tx using friend / relative assistance, advise the Pt and responsible third person of follow-up, counselling facilities and actions to take for continuing care if symptoms recur. For young persons, Paramedics should strongly encourage them to make contact with a responsible adult. Paramedics should call the Police if, in their professional judgement, there appear to be factors that place the Pt at increased risk, such as the Pt: - is subject to violence (e.g. from a parent, guardian or care giver) - is likely to be, or is in danger of sexual exploitation. In particular for children where: - the supply of drugs appears to be from a parent / guardian / care giver. - there is other evidence of child abuse / maltreatment or evidence of serious untreated injuries. If the Pt claims to have taken an OD of a potentially life-threatening substance or as a suicide attempt then they must be Tx to hospital. Police assistance should be sought to facilitate this as required. Documentation of refusal and actions taken must be recorded on the PCR. When dealing with cases of OD, if Paramedics are unfamiliar with a substance or unsure of the effects it may have, then consultation with Poisons Information should take place. They can be contacted via the Clinician, or on Version Page 1 of 8 CPG A0707

97 Overdose Opioids Status Suspected OD e.g. - Heroin - Morphine - Codeine - Other opioid preparations 8 Assess Substance/s involved TCA Antidepressants Sedatives Psychostimulants e.g. - Amitriptyline - Nortriptyline - Dothiepin Status Stop 8 Assess 8 Consider MICA Action e.g. - GHB - Alcohol - Benzodiazepines - Volatile agents e.g. - Cocaine - Amphetamines - Ecstacy - PCP Version Page 2 of 8 CPG A0707 Overdose CPG A

98 Overdose: Opioids Special Notes Opioids may be in the form of IV preparations such as Heroin or Morphine and oral preparations such as Codeine, Endone, MS Contin. Some of these drugs also come as suppositories and topical patches. Not all opioid ODs are from IV administration of the drug. General Care If inadequate response after 10/60, the Pt is likely to require Tx without delay. - Maintain general care of the unconscious Pt and ensure adequate airway and ventilation. - Consider other causes e.g. head injury, hypoglycaemia, polypharmaceutical OD. - Beware of Pt becoming aggressive. Version Page 3 of 8 CPG A0707

99 Overdose: Opioids Status Stop Possible opioid OD Status Stop 8 Assess 8 Consider MICA Action Ensure personal / crew safety Scene may have concealed syringes 8 Assess evidence of opioid OD - Altered conscious state - Respiratory depression - Substance involved - Exclude other causes (inc. no obvious head injury) - Pin point pupils - Track marks Opioid OD Adequate response BLS Consider Tx Assist and maintain airway / ventilation Naloxone 1.6 mg 2 mg IM Inadequate response after 10/60 Naloxone 0.8 mg IM Consider airway Mx CPG A0301 Laryngeal Mask Naloxone 0.8 mg IM/IV Consider ETT as per CPG A0302 Endotracheal Intubation Version Page 4 of 8 CPG A0707 Overdose: Opioids CPG A

100 Overdose: Tricyclic Antidepressants (TCA) Special Notes Signs and symptoms of TCA toxicity Mild to moderate OD - Drowsiness, confusion - Tachycardia - Slurred speech - Hyperreflexia - Ataxia - Mild hypertension - Dry mucus membranes - Respiratory depression Severe toxicity (within 6 hr ingestion) - Coma - Respiratory depression / hypoventilation - Conduction delays - PVCs - SVT - VT - Hypotension - Seizures - ECG changes This could lead to aspiration, hyperthermia, rhabdomyolysis and APO. Special Notes ECG changes ECG changes include prolonged PR, QRS and QT intervals associated with an increased risk of seizures if QRS > 0.10 sec and ventricular arrhythmias if QRS > 0.16 sec. How to measure a QT interval is shown below. TCAs may be prescribed to Rx medical conditions other than depression (e.g. chronic pain). Version Page 5 of 8 CPG A0707

101 Overdose: Tricyclic Antidepressants (TCA) Status 8 Assess Possible TCA OD Substance involved Perfusion status ECG criteria No toxicity Signs of TCA toxicity Any of the following BLS - Less than adequate perfusion - QRS > 0.12 sec (> 0.16 sec indicates severe toxicity) Consider potential to develop signs of toxicity - QT prolongation (> 1/2 R-R interval) Stop Amiodarone is C/I in the setting of confirmed or suspected TCA OD Status Stop 8 Assess 8 Consider MICA Action Version Page 6 of 8 CPG A0707 Sodium Bicarbonate 8.4% 100 ml IV given over 3/60 - Repeat 100 ml IV after 10/60 if signs of toxicity persist - Consult for further doses if signs of toxicity persist Consider ETT as per CPG A0302 Endotracheal Intubation if signs of toxicity and GCS < 10 persist after initial Mx - Hyperventilate with 100% O 2 - rate 20-24/min - EtCO 2 target mmhg if intubated Overdose: Tricyclic Antidepressants (TCA) CPG A

102 Overdose: Sedative Agents / Psychostimulants Special Notes Hyperthermic psychostimulant OD In hyperthermic psychostimulant OD the trigger point for intervention in the Mx of agitation / aggression is lowered. Sedation should be initiated early to assist with cooling and avoid further increases in temp associated with agitation. Version Page 7 of 8 CPG A0707

103 Overdose: Sedative Agents / Psychostimulants Status 8 Assess Sedative agents Psychostimulants Status Stop 8 Assess 8 Consider MICA Action Substance involved Pt may require airway Mx Mx agitation / aggression as per CPG A0708 The Agitated Patient Mx inadequate perfusion as per CPG A0705 Inadequate Perfusion Stop Ensure personal / crew safety Be aware of the potential for agitation / aggression / violence Sedative agents Psychostimulants Version Page 8 of 8 CPG A0707 Reduce stimuli by calming and controlling the Pt's environment Mx seizures as per CPG A0703 Continuous Tonic-clonic Seizures Mx cardiac chest pain as per CPG A0401 Acute Coronary Syndromes Mx temp as per CPG A0902 Hyperthermia / Heat Stress or A0901 Hypothermia / Cold exposure Mx agitation / aggression as per CPG A0708 The Agitated Patient Overdose: Sedative Agents/Psychostimulants CPG A

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105 The Agitated Patient Special Notes This CPG does not apply to Pts who have been recommended for Tx under the Mental Health Act. If sedation is required in these circumstances then the Act requires that this only be administered by a prescribed Medical Practitioner or Registered Nurse. This CPG is appropriate for Pts under Section 10 of the Mental Health Act. The indications for the use of sedation and/or restraint must be clearly documented on the PCR. Mechanical restraint may also be utilised without the use of sedation in circumstances where the Pt will not sustain further harm by fighting against the restraints. Mechanical restraints must be removed if there is any indication that the restraint is compromising the provision of supportive care. The type of restraint used and its time of application and/or removal must be clearly documented on the PCR. Hyperthermic psychostimulant OD Sedation should be initiated early in hyperthermic Pts who have been using psychostimulants to assist with cooling and avoid further increases in temp secondary to agitation. General Care Paramedic safety is to be considered paramount at all times. Do not attempt any element of this CPG unless all necessary assistance is available. Provide supportive care in all cases where sedation administered. Provide airway Mx appropriate to the clinical condition, administer O 2 to all Pts and assist ventilation as required. If less than adequate perfusion Mx as per CPG A0705 Inadequate Perfusion (Non-cardiogenic / Nonhypovolaemic). Continue to assess Pt temp and Mx as per CPG A0902 Environmental Hyperthermia / Heat Stress or CPG A0901 Hypothermia / Cold Injury. If not already completed, ensure that all possible clinical causes of agitation are assessed and Mx by the appropriate CPG. Traumatic head injury In Pts with mild to moderate acute traumatic head injury (GCS 10-14), sedation cannot be given without medical consultation with a Major or Regional Trauma Service. Version Page 1 of 3 CPG A0708 The Agitated Patient CPG A

106 The Agitated Patient Status Stop Agitated Pt 8Assess / consider Observe for and Mx as appropriate - Hazards - Body fluids - Violence - Sharps - Clear egress - Reduce stimuli Paramedic safety is paramount Agitated Pt Communicate with Pt - Avoid confrontational behaviour - Gain Pt co-operation for assessment - Utilise verbal de-escalation strategies Assess and Mx clinical causes (as far as possible) - Hypoglycaemia - Hypoxia - Post-ictal - Drug intoxication (initiate sedation early in hyperthermic psychostimulant OD) - Drug withdrawal - Intracerebral pathology - Mild to moderate acute traumatic head injury (consult with MTS for sedation) - Acute psychiatric condition - Pain Version Page 2 of 3 CPG A0708

107 Able to Mx without restraint / sedation Requires restraint / sedation Action Mx causes as per appropriate CPG Beware Pt condition may change and agitation increase requiring restraint / sedation Action Tx to appropriate destination Ensure sufficient assistance in transit Provide early notification to receiving hospital Consider Rx as per Requires restraint / sedation if Pt becomes agitated / aggressive Status Stop 8 Assess 8 Consider MICA Action Does not respond to verbal de-escalation Clinical causes have been excluded Pt risk to themselves or others - e.g. combative, agitated or aggressive Stop Ensure Pt is not recommended under the Mental Health Act - Sedation by Paramedics is not permitted within the Mental Health Act for these Pts Ensure sufficient physical assistance Reduced sedation dose for age / BP Mild to moderate head injury GCS (Mx pain, consult if sedation required) Age 60 or BP 100 mmhg - Midazolam 0.05 mg/kg IM (max. 5 mg per dose) - Repeat initial 10/60 IM (max. 4 doses) as required Age < 60 and BP > 100 mmhg - Midazolam mg/kg IM (max. 10 mg per dose) - Repeat initial 10/60 IM (max. 4 doses) as required Apply mechanical restraint devices if required Above doses may be given IV and 5/60 as required IM injections may be indicated until IV access has been established The Agitated Patient CPG A

108 Organophosphate Poisoning Special Notes Notification to receiving hospital essential to allow for Pt isolation and decontamination. The key word to look for on the label is anticholinesterase. There are a vast number of organophosphates which are used not only commercially but also domestically. Given potential contamination by a possible organophosphate, the container identifying trade and generic names should be identified and the Poisons Information Centre contacted for confirmation and advice (via Clinician or ). General Care Where possible, remove contaminated clothing and wash skin thoroughly with soap and water. If possible minimise the number of staff exposed. Attempt to minimise transfers between vehicles. Version Page 1 of 2 CPG A0709

109 Organophosphate Poisoning Status Possible organophosphate exposure 8 Confirm evidence of suspected poisoning 8 Evidence of excessive cholinergic effects Stop Avoid self contamination - wear PPE Decontaminate Pt if possible Cholinergic effects: salivation, bronchospasm, sweating, nausea or bradycardia The key word to look for on the label is anticholinesterase Tx to nearest appropriate hospital Monitor for excessive cholinergic effects Status Stop 8 Assess 8 Consider MICA Action +Plus No excessive cholinergic effects Salivation compromising the airway or bronchospasm and /or Bradycardia with inadequate or extremely poor perfusion Excessive cholinergic effects Version Page 2 of 2 CPG A0709 Atropine 1200 mcg IV - Repeat 1200 mcg 5/60 until excessive cholinergic effects resolve Consult with receiving hospital for further Mx if required The use of Suxamethonium is C/I in Pts with suspected organophosphate poisoning Organophosphate Poisoning CPG A

110 Autonomic Dysreflexia Special Notes Tx the Pt even if the symptoms are relieved as this presentation meets the criteria of autonomic dysreflexia, a medical emergency that requires identification of probable cause and Rx in hospital to prevent cerebrovascular catastrophe. General Care Version Page 1 of 2 CPG A0710

111 Autonomic Dysreflexia Status 8 Confirm Autonomic Dysreflexia Possible autonomic dysreflexia Adequate response Tx to nearest appropriate hospital Status Stop 8 Assess 8 Consider MICA Action Identify and Rx possible causes - remove the stimulus If distended bladder (common), ensure indwelling catheter is not kinked Mx pain, e.g. fractures, burns, labour If systolic BP remains > 160 mmhg Previous spinal cord injury at T6 or above - Severe headache and/or - SBP > 160 mmhg GTN 300 mcg S/L (no prev. admin) or GTN 600 mcg S/L Inadequate response - BP remains > 160 mmhg Version Page 2 of 2 CPG A0710 Repeat initial dose of 10/60 until either: - Symptoms resolve - Onset of side effects - BP < 160 mmhg Tx to nearest appropriate hospital Autonomic Dysreflexia CPG A

112 Stroke / TIA Special Notes Suspected stroke is a time critical emergency early assessment and exclusion of stroke mimics is important Symptom onset time is taken from when last seen symptom free (e.g. if wakes with symptoms then time Pt went to bed). Rx times from symptom onset are: - thrombolysis up to 4.5 hrs Diagnosing and Mx stroke Pts with thrombolysis is a priority over seeking neurosurgical support. Urgent secondary transfer of stroke Pts to a centre with Stroke Unit Care may be organised and involve the Clinician / AAV / ARV. TIA can only be suspected if S/S completely resolve, otherwise Pt should be treated as a suspected stroke. TIA is often a sign of an impending stroke all TIAs should be conveyed to hospital for investigation. Approximately 15% of strokes are intracranial haemorrhage (ICH). These Pts have potential for rapid deterioration. Intracranial haemorrhage can be suspected where: - GCS < 10 and the Pt is not alert - The Pt complained of severe headache - Nausea and vomiting is present - Slow pulse and hypertension is noted - Pupil abnormalities are noted - Abnormal patterns of respiration are noted MASS Melbourne Ambulance Stroke Screen. Validated criteria used in prehospital stroke assessment. General Care Intubation by MICA Paramedics should be considered where there is difficulty maintaining adequate airway, oxygenation and ventilation. Intubation should not be considered as a mandatory practice in Mx of all these Pts. Time to hospital versus time to undertake the procedure should be considered. Gagging should be avoided in the Mx of the non traumatic intracranial event Pt. The effect of gagging may vary in its detriment compared to the traumatic head injured Pt. The use of longer acting muscle relaxants post intubation is not as essential in the suspected stroke Pt as it is with head trauma. Sedation alone is preferred unless gagging becomes problematic. They should not be used following evidence of seizure activity without significant head injury. Anti-emetics have the potential to cause drowsiness. Their use must be balanced against a potential reduction in conscious state in these Pts. The use of Prochlorperazine is indicated as an analgesia adjunct for the Mx of severe headache. It is unlikely to have a beneficial effect for intracranial haemorrhage/sah. O 2 therapy should be reserved for hypoxic Pts with an SpO 2 < 94%. The use of routine O 2 therapy is not recommended. Version Page 1 of 2 CPG A0711

113 Stroke / TIA Status Suspected stroke or TIA Assess for MASS criteria Stroke signs and symptoms 8 Assessment findings 8 Facial Droop Speech Pt shows teeth or smiles The Pt repeats You can t teach an old dog new tricks Normal - both sides of face move equally Normal - the Pt says the correct words, no slurring Hand grip Test as for GCS Normal - equal grip Blood glucose Test for BGL Abnormal -if hypoglycemia Mx as per CPG A0702 Hypoglycemia Abnormal - one side of face does not move as well as the other Abnormal - the Pt slurs words, says the wrong words, or is unable to speak or understand Abnormal - unilateral weakness Normal BGL Status Stop 8 Assess 8 Consider MICA Action Management Version Page 2 of 2 CPG A Assess 8 Stroke Mimics 8 Co-morbidities Symptom onset time Stroke mimics Co-morbidities In the setting of normal BGL, a finding of one or more of the symptoms below is indicative of stroke: Intoxication drug/ alcohol Hypo/hyperglycaemia Seizures Brain tumour Syncope BLS maintain adequate airway and ventilation Mx symptomatically support affected limbs Dementia Significant pre-existing physical disability Provide analgesia as per CPG A0501 Pain Relief: Severe Headache Rx sustained seizure activity as per CPG A0703 Continuous Tonic clonic Seizures If GCS < 10 consider ETT as per CPG A0302 Endotracheal Intubation Transport Middle ear disorder Migraine Subdural haematoma Sepsis Electrolyte disturbances Where Pt is unstable consider time to appropriate receiving hospital versus R/V with MICA / AAV. If Pt is stable with no significant co-morbidities, onset time < 4.5 hr and Tx time < 1 hr then transfer to the nearest hospital providing thrombolysis or stroke unit care and notify of pending arrival. If Pt does not meet criteria above then Tx to a closer centre preferably with stroke unit care / CT imaging. If Pt deteriorates consider R/V with MICA / AAV Stroke / TIA CPG A

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116 Hypovolaemia Special Notes Titrate fluid administration to Pt response. Aim for HR < 100 bpm and BP > 100 mmhg if perfusion is altered. Consider establishing IV en route. Do not delay Tx for IV therapy. Always consider TPT, particularly in the Pt with a chest injury not responding to fluid therapy and persistently hypotensive. Excessive fluid should not be given if SCI is an isolated injury. Clinical signs of significant dehydration include: - Postural perfusion changes including tachycardia, hypotension or dizziness - Decreased sweating and urination - Poor skin turgor, dry mouth, dry tongue - Fatigue and altered consciousness - Evidence of poor fluid intake compared to fluid loss. Dehydration in the hyperglycaemic Pt should be Mx using this CPG. Modifying factors Complete spinal cord transection Rx as per CPG A0804 Spinal Injury - Pt with isolated neurogenic shock can be given up to Normal Saline 500 ml bolus to correct hypotension. No further fluid should be given if SCI is the sole injury. Chest injury Consider TPT Rx as per CPG A0802 Chest Injury Penetrating trunk Injury, aortic aneurysm or uncontrolled haemorrhage. - Accept palpable carotid pulse and Tx immediately General Care Haemorrhage from blunt trauma is not considered as uncontrolled in the context of this CPG and should be Mx as defined within. GI bleeding has potential to be uncontrolled in the context of this CPG and should be considered as a modifying factor. GI haemorrhage consider lesser volumes of fluid and accepting a blood pressure of mmhg. Version Page 1 of 2 CPG A0801

117 Hypovolaemia Status Stop Evidence of hypovolaemia 8 Assess HR / BP Consider modifying factors Fluid not required unless signs of significant dehydration Normal Saline up to 20 ml/kg IV over 30 min - SCI, chest injury, penetrating trunk injury, AAA, uncontrolled external haemorrhage, GI haemorrhage HR < 100 bpm; BP > 100 mmhg If significantly dehydrated HR < 100 bpm BP > 100 mmhg No further fluid required Status Stop 8 Assess 8 Consider MICA Action Identify and Mx - Haemorrhage, fractures, pain, TPT, hypoxia Isolated tachycardia HR > 100 bpm; BP > 100 mmhg HR > 100 bpm and/or BP < 100 mmhg Normal Saline 20 ml/kg IV Repeat Normal Saline 20 ml/kg HR < 100 bpm BP > 100 mmhg If unavailable repeat Normal Saline 20 ml/kg IV Hypotension < 100 mmhg Normal Saline 20 ml/kg IV Version Page 2 of 2 CPG A0801 BP remains < 100 mmhg After 40 ml/kg BP remains < 100 mmhg After 40 ml/kg Consult with MTS Consult with MTS If unavailable repeat Normal Saline 20 ml/kg IV HR > 100 bpm and/or BP < 100 mmhg No further fluid required Insert second IV Repeat Normal Saline 20 ml/kg Hypovolaemia CPG A

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119 Chest Injuries Status Chest injury - Traumatic - Spontaneous - Iatrogenic Flail segment / rib fractures May require ventilatory support if decreased V T 8 Assess Respiratory status Type of chest injury Status Stop 8 Assess 8 Consider MICA Action Supplemental O 2 if indicated Pain relief as per CPG A0501 Pain Relief Position Pt upright if possible unless perfusion is < adequate, altered conscious state, associated barotrauma or potential spinal injury Open chest wound 3 sided sterile occlusive dressing Pneumothorax Signs of pneumothorax See CPG A0802 Version Page 1 of 3 CPG A0802 Chest Injuries CPG A

120 Chest Injuries Special Notes In the setting of IPPV, equal air entry is NOT an exclusion criterion for TPT. Chest injury Pts receiving IPPV have a high risk of developing a TPT. The solution for poor perfusion in this setting includes bilateral chest decompression. Cardiac arrest Pts are at risk of developing chest injury during CPR. Troubleshooting - Pt may re-tension as lung inflates if catheter kinks off. - Catheter may also clot off. Flush with sterile Normal Saline. If a 14g cannula is used initially, it should be replaced with an intercostal catheter (if available) as soon as practicable. Insertion site for cannula/intercostal catheter - Second intercostal space - Mid - clavicular line (avoiding medial placement) - Above rib below (avoiding neurovascular bundle) - Right angles to chest (towards body of vertebrae). General Care Tension Pneumothorax (TPT) - If some clinical signs of TPT are present and the Pt is deteriorating with decreasing conscious state and/ or poor perfusion, immediately decompress chest by inserting a long 14g cannula or intercostal catheter. - If air escapes, or air and blood bubble through the cannula / intercostal catheter, or no air / blood detected, leave in situ and secure. - If no air escapes but copious blood flows through the cannula / intercostal catheter then a major haemothorax is present. Remove, then cover the insertion site. Needle test - If TPT suspected, but the assessment is not obvious, test for a TPT with a needle at least 45mm length (long 14/16 G) attached to Normal Saline filled syringe. - If needle test is suggestive of TPT, withdraw needle and immediately decompress chest. - If pneumocath not available, leave plastic cannula in situ refer to appropriate CWI. - If needle test is not suggestive of TPT, withdraw needle, cover insertion site with a clear adhesive dressing and circle the insertion site with a pen. - Be aware that a needle test for TPT can be prone to false readings and does not exclude TPT in all cases. Version Page 2 of 3 CPG A0802

121 Chest Injuries Status 8 Assess Pneumothorax - Simple - Tension Simple pneumothorax Any of the following: - Unequal breath sounds in spontaneously ventilating Pt - Low SpO 2 on room air - Subcutaneous emphysema Continue BLS and supplemental O 2 Status Stop 8 Assess 8 Consider MICA Action Criteria for simple vs tension pneumothorax Monitor closely for possible development of TPT TPT Any of the following +/- signs of Simple pneumothorax: - Peak inspiratory pressure (ventilator) / stiff bag - EtCO 2 - Poor perfusion or HR +/- BP - JVP - Conscious state in the awake Pt - Tracheal shift - Low SpO on supplemental O 2 2 (late) Chest decompression as per General care (including accredited rural ALS) Version Page 3 of 3 CPG A0802 Chest Injuries CPG A

122 Traumatic Head Injury Special Notes The Trauma Time Critical Guidelines require Pts with significant blunt trauma to a single region to be triaged to the highest level of care. When assessing the pattern of injury, the Pt can be considered to have a significant blunt head injury in the setting of blunt head trauma with or without loss of consciousness / amnesia and GCS with any of: - Any loss of consciousness exceeding 5/60. - Skull fracture (depressed, open or base of skull). - Vomiting more than once. - Neurological deficit. - Seizure. Elderly Pts with standing height falls who meet no other time critical criteria but are on anti-coagulant, antiplatelet agents or have bleeding disorders should not be underestimated. Tx to an appropriate level of care. General Care Dress open skull fractures / wounds with sterile combine soaked in sterile Normal Saline. Maintain manual in-line neck stabilisation and apply cervical collar when convenient. If intubation is required, apply cervical collar after intubation. Attempt to minimise jugular vein compression. Attempt to maintain normal temp. Version Page 1 of 2 CPG A0803

123 Traumatic Head Injury Status Traumatic head injury Airway If airway patent and V T adequate (with trismus), do not insert NPA If airway not patent and gag is present, insert NPA and ventilate If GCS < 10, regardless of airway reflexes, intubate as per CPG A0302 Endotracheal Intubation - RSI If intubation is not possible / authorised and gag is absent insert LMA Ventilation Status Stop 8 Assess 8 Consider MICA Action Perfusion Ensure adequate ventilation and V T of 10 ml/kg Maintain SpO 2 > 95% and Rx causes of hypoxia Maintain EtCO 2 at mmhg Avoid hypo/ hypercapnia 8 Assess Time critical head injury Other head injury Mx with Normal Saline as per CPG A0801 Hypovolaemia (unless in the setting of penetrating truncal trauma or uncontrolled overt bleeding) Aim for SBP > 120 mmhg After 40 ml/kg reassess. If SBP < 100 mmhg, discuss ongoing resuscitation with the receiving Regional or Major Trauma Service while continuing to Tx If consult is unavailable administer a further Normal Saline 20 ml/kg IV and reassess Version Page 2 of 2 CPG A0803 General care Rx sustained seizure activity with Midazolam as per CPG A0703 Continuous Tonic Clonic Seizures Measure BGL and rectify hypoglycaemia as per CPG A0702 Hypoglycaemia Triage to highest level of care as per Time Critical Guidelines (Trauma Triage) If Pt does not meet Time Critical Guidelines (Trauma Triage) criteria, triage Pt to next highest or appropriate level of trauma care Traumatic Head Injury CPG A

124 Spinal Injury Special Notes A cervical collar alone does not immobilise the cervical spine. If the neck needs immobilising then the whole spine needs immobilising. This may include the use of head rolls or other approved proprietary devices and the whole body immobilised on a spine board or ambulance stretcher in a manner that is appropriate for the presenting problem. A spine board must be restrained to the ambulance stretcher during Tx. The head should not be independently restrained. In Pts with a diseased vertebral column, a lesser mechanism of injury may result in SCI and should be Mx accordingly. Spinal immobilisation with neutral alignment may not be possible in a Pt with a diseased vertebral column with associated anatomical deformity and should be modified accordingly e.g. position of comfort. Spinal immobilisation is not without risk. Complications may include head and neck pain, detrimental effects on pulmonary function and subsequent neurological deficit (particularly in the elderly). Special Notes If a cervical collar is applied then it must be properly fitted and applied directly to the skin, not over clothing and not placing any pressure on the neck veins. Where there is no immediate risk to life and extrication is required then an extrication device (e.g. KED) should be considered. Pts with a SCI may develop pressure areas within as little as 30 min following placement on a spine board and the duration on a spine board must be noted on the PCR. Effective padding should be applied to protect pressure areas. For Tx times in excess of 60 min consideration should be given to removing the Pt from a spine board and appropriately securing them to the ambulance stretcher. Pts with isolated neurogenic shock should be given a small fluid bolus (up to 500 ml Normal Saline IV) to correct hypotension. No further fluid should be given if SCI is the sole injury. The Pt with multi trauma and SCI may not mount a sympathetic response to hypovolaemia. Fluid should be given based on estimated blood loss. Version Page 1 of 2 CPG A0804

125 Spinal Injury Status 8 Assess Potential or suspected spinal injury Mx airway as appropriate Provide spinal immobilisation Administer pain relief as required as per CPG A0501 Pain Relief Mx hypovolaemia as per CPG A0801 Hypovolaemia Tx without delay to an appropriate receiving hospital as per CPG A0105 Time Critical Guidelines (Trauma Triage) Status Stop 8 Assess 8 Consider MICA Action Spinal column injury Spinal cord injury If Pt meets major trauma criteria If Pt does not meet major trauma criteria If any of the following present provide spinal immobilisation: Version Page 2 of 2 CPG A0804 Has any mechanism of injury with potential to cause spinal injury Increased injury risk - Age > 55 years - History of bone disease (e.g. osetoporosis, osteoarthritis, rheumatoid arthritis) or muscular weakness disease (e.g. muscular dystrophy) Difficult Pt assessment - Unconsciousness or any acute or chronic altered conscious state (GCS < 15) or period of loss of consciousness - Drug or alcohol affected - Significant distracting injury e.g. extremity fracture or dislocation Actual evidence of structural injury - Spinal column pain / bony tenderness Actual evidence of spinal cord injury - Neurological deficit or changes - Mx as per emergent time critical trauma criteria If none of the above present then spinal immobilisation / cervical collar not necessary If any doubt exists as to Hx or the above assessment, or if there is inability to adequately assess the Pt, provide spinal immobilisation. Clearance criteria within this CPG are not to be used for paediatric Pts. No paediatric Pt should be spinally cleared prehospital after major trauma. Apply all spinal care. Spinal Injury CPG A

126 Burns Special Notes All chemical burns should be irrigated for at least 20 min. Avoid flushing chemical onto uncontaminated areas. Remove burnt clothing or that containing chemical hot liquid when safe to do so. Do not remove clothing that adheres to underlying tissue. Jewellery should be removed prior to swelling occurring. Vol replacement is for the burn injury only. Mx other injuries accordingly including requirement for additional fluid. Electrical burns should receive fluid therapy to maintain adequate renal perfusion. S/S of airway burns include: - Evidence of burns to upper torso, neck and face - Facial and upper airway oedema - Sooty sputum - Burns that have occurred in an enclosed space - Singed facial hair (nasal hair, eyebrows, eyelashes, beards) - Respiratory distress (dyspnoea +/- wheeze and associated tachycardia, stridor) - Hypoxia (restlessness, irritability, cyanosis, decreased GCS). General Care Burn cooling Burn cooling should be for 20 min. Consider shorter periods for Pts with large TBSA where hypothermia may be induced. Cooling may be completed prior to Tx. Cooling provided prior to ambulance arrival should be included in the total cooling time. Burn cooling should be with gentle running water that is between 5-15 C. Ice and ice water is not desirable. Similarly, dirty (i.e. dam) water should be avoided given the significant risk of infection. If running water is not available, cooling may be commenced by immersing the affected area in still water. This water should be refreshed every few min to avoid it warming. Maintaining normothermia is vital. Protect remainder of Pt from heat loss where possible - Assess temp as soon as practicable and monitor - Cover the Pt with blankets etc. - Avoid Pt shivering. If clinically appropriate, elevation of the affected area in transit will assist in minimising burn wound oedema. Burn dressings Cling wrap is an appropriate burn dressing. It should be applied longitudinally to allow for swelling. Cling wrap is the preferred burns dressing for all burns. Water gel dressings (e.g. Burnaid ) may be considered as a cooling agent where no other cooling method exists. Cooling with water is the preferred method of cooling. After prescribed cooling times remove and replace with cling wrap dressing. Version Page 1 of 3 CPG A0805

127 Burns BLS Status Tx to appropriate facility Evidence of burn injury Stop Status Stop 8 Assess 8 Consider MICA Action 8 Assess mechanism of burn and burn injury Ensure safety and removal from burn mechanism - Avoid chemical contamination or spreading to unaffected areas Cool the burn, warm the Pt Cool burn area refer general care notes Protect remainder of Pt from heat loss where possible Provide analgesia as per CPG A0501 Pain Relief Cover cooled burn area with appropriate dressing refer General care notes If TBSA is >15% Airway injury TBSA Mechanism of burn injury Severity of burn injury Initial burn Mx All other burn presentations Partial or full thickness burns >15% BSA Suspected airway burns Normal Saline IV fluid replacement - % TBSA x Pt wt (kg) = vol (ml) - given over 2 hr from time of burn Tx to an appropriate facility For Pts with GCS up to 15 Version Page 2 of 3 CPG A0805 Consider ETT as per CPG A0302 Endotracheal Intubation - Consult with Clinician - Use RSI method unless C/I Burns CPG A

128 Burns Special Notes Tx Any burns involving the face, hands, feet, genitalia, major joints or circumferential burns of the chest or limbs or involving > 20% TBSA require assessment by a specialised burns service. For regional transfers this may be via secondary transfer. Metropolitan: All burns Pts who meet the time critical trauma criteria should be Tx to the Alfred Hospital in preference if within 45 min. If > 45 min, Tx to nearest alternative highest level of trauma service. Rural: Tx to highest designated trauma receiving centre within 45 min. In all cases of prolonged Tx, consider alternative air Tx. In all cases, appropriate consultations should occur and hospital notification provided General Care Adult Rule of Nines expressed as a % of body surface area Note: Chest + Abdomen = 18% Front or 18% Back. Limbs are measured circumferentially. Version Page 3 of 3 CPG A0805

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130 Fracture Management Principles of fracture Mx General principles - Control external haemorrhage. - Support the injured area. - Immobilise the joint above and below the fracture. - Assess neurovascular status distal to the fracture before and after splinting Provide pain relief and correct hypovolaemia as per appropriate CPGs. Appropriate splinting can assist in pain reduction and arrest of haemorrhage Actions before and after splinting: - Realign long bone fractures in as close to normal position as possible. - Open fractures with exposed bone should be irrigated with a sterile isotonic solution prior to realignment and splinting. - If joints are involved there is an increased possibility of neurovascular impairment and reduction is not recommended. - Mx femoral shaft fractures and fractures of the upper 2/3 of the tibia and fibula with a traction splint unless there are distal dislocations or fractures. In suspected fractures of the pelvis, the legs should be anatomically splinted together (to internally rotate the feet) and the pelvis splinted with a sheet wrap or other appropriate device. Pts who meet the major trauma criteria are time critical but appropriate splinting should be considered part of essential prehospital Mx. Version Page 1 of 1 CPG A0806

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132 Diving Related Emergencies Special Notes Pts with GCS < 15 and/or onset of symptoms < min after surfacing, any seizure, LOC or altered conscious state have a higher probability of cerebral arterial gas embolism (CAGE) and are time critical. Consider air Tx for these Pts, preferably by helicopter at < 300 metres. DCI S/S may include musculoskeletal pain, itching, any neurological changes or respiratory complaint Specific Hx is important. This should include: number of dives performed surface interval between dives max. depth(s) and bottom time(s) type of ascent (controlled/rapid) decompression or safety stops breathing gas mixture used level of exertion during and after dive which symptoms presented and when first aid was provided. It is essential that any divers computers and gauges from during the dive be Tx to the recompression facility. This CPG is for Pts who have suffered a recent diving incident. Pts with a GCS of 15 who have been suffering symptoms for >12-24 hours before calling can be kept on a simple face mask but still need to be Tx to a recompression facility with their equipment. At time of publication the only public recompression facility in Victoria is at the Alfred Hospital. There is also a facility at Royal Adelaide Hospital. General Care Primary goals for Pts with a diving related injury are allow nitrogen to off-gas, increase O 2 delivery and rehydrate. Removal of N 2 can be best achieved by the highest O 2 delivery system available. Ideally for conscious Pts this can be done using the oxy-saver allowing expired air to vent to the atmosphere. Unconscious and intubated Pts must be ventilated using a BVM with 15 L of O 2 if possible. A closed O 2 delivery system is C/I for dysbaric patients. Extended Tx times may require the oxy-saver to be connected to the D-cylinders via the adaptor hose. Post immersion Pts can have isolated hypotension. Be aware of the potential for inadequate perfusion without hypovolaemia. Titrate fluid administration to Pt response. Warming tissues can result in dissolved N 2 undissolving. Pts < 32ºC should be warmed to that level to avoid arrhythmia risk Any potential CAGE Pt must be kept supine or in the lateral position. The Pt should not be allowed to sit up or stand at any time. Pts who cannot be maintained in this position due to respiratory compromise may be kept semi-recumbent. If there is an indication for opioid analgesia, then consult with the Alfred hospital before administration. Opioids may mask symptoms for the receiving physician when assessing potential recompression Rx. Prochlorperazine may also mask the symptom of vertigo. Version page 2 of 2 CPG A0807

133 Diving Related Emergencies Status History of recent diving incident (SCUBA) Stable (GCS = 15) Unstable (GCS < 15) Symptomatic Position Pt supine or lateral Mx nausea as per CPG A0701 Nausea and Vomiting Administer 100% O 2 via oxy-saver regardless of respiratory status or SpO 2 allowing expired air to exhaust. Maintain throughout regardless of any resolution of symptoms Avoid rapid increases in body temp Tx directly to a recompression chamber Mx other signs and symptoms as per appropriate CPG Mx as per Unstable (GCS < 15) if deterioration noted Hydrate Pt as per Perfusion below Status Stop 8 Assess 8 Consider MICA Action Perfusion 8 Assess Perfusion status Respiratory status GCS S/S for DRE Dehydration Less than adequate perfusion Symptomatic with altered conscious state If adequately perfused and chest clear administer Normal Saline 1000 ml over min to rehydrate Pt. Continue Normal 1000 ml every 4 hr If less than adequate perfusion, titrate fluid administration to Pt response as per CPG A0801 Hypovolaemia Do not use warmed fluid Version page 1 of 2 CPG A0807 Mx as per GCS 15 Be aware of the greater potential for chest injuries and Mx as per CPG A0802 Chest Injuries Mx as per CPG A0803 Severe Traumatic Head Injury Consider distance to a recompression chamber and the need for MICA and/or aeromedical Tx Tx directly to a recompression chamber Hydrate Pt as per Perfusion below Diving Related Emergencies CPG A

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136 Hypothermia / Cold Exposure Special Notes Hypothermia is insidious and rarely occurs in isolation. Where the Pt is in a group environment other members of the group should be carefully assessed for signs of hypothermia. Arrhythmia in hypothermia is associated with temp below 33 C. Atrial arrhythmias, bradycardias or A-V blocks do not generally require Rx with anti-arrhythmic agents unless decompensated and resolve on rewarming. Defibrillation and cardioactive drugs may not be effective at temp below 30 C. VF may resolve spontaneously upon rewarming. The onset and duration of drugs is prolonged in hypothermia and the interval between doses is therefore doubled, e.g. doses of Adrenaline become 6 minutely. General Care Shelter from wind in heated environment. Remove all damp or wet clothing. Gently dry Pt with towels/blankets. Wrap in warm sheet/blanket - cocoon. Cover head with towel/blanket - hood. Use thermal/space/plastic blankets above and below the Pt if available. Only warm frostbite if no chance of refreezing prior to arrival at hospital. Assess BGL if altered conscious state. Warmed fluid Normal Saline warmed between C should be given to correct moderate/severe hypothermia and maintain perfusion if available. Fluid < 37 C could be detrimental to Pt. Version Page 1 of 2 CPG A0901

137 Hypothermia / Cold Exposure Status Hypothermia Non cardiac arrest Moderate/severe hypothermia < C Warmed Normal Saline 10 ml/kg IV Repeat Normal Saline 10 ml/kg IV (max. 40 ml/kg) to maintain perfusion Avoid drug Mx of cardiac arrhythmias unless decompensated and until rewarming has commenced 8 Assess Status Stop 8 Assess 8 Consider MICA Action Mild hypothermia C Moderate hypothermia C Severe hypothermia < 28 C If alteration to cardiac arrest Mx required > 32 C Standard cardiac arrest CPG Cardiac arrest C Double intervals between doses in relevant cardiac arrest CPG - Do not rewarm beyond 33 C if ROSC < 30 C Version Page 2 of 2 CPG A0901 Continue CPR and rewarming until temp > 30 C One DCCS only One dose of Adrenaline One dose of Amiodarone Withhold Sodium Bicarbonate 8.4% IV Hypothermia / Cold Exposure CPG A

138 Environmental Hyperthermia Heat Stress Special Notes Pt body temp of < 40 C may usually be Mx with basic cooling techniques alone. Be wary of fluid volumes in renal dialysis Pts causing fluid overload. Administer judicious increments with volumes not usually exceeding 10 ml/kg. This CPG is not intended for the Mx of the febrile Pt due to infection. General Care During cooling, the Pt should be monitored for the onset of shivering. Shivering may increase heat production and cooling measures should be adjusted to avoid its onset. Gentle handling of the Pt is essential. Position flat or lateral and avoid head up position to avoid causing arrhythmias. Version Page 1 of 2 CPG A0902

139 Environmental Hyperthermia Heat Stress Status Hyperthermia / heat stress Requires active cooling Status Stop 8 Assess 8 Consider MICA Action Cooling techniques - initiated and maintained until temp is < 38 C - Shelter / remove from heat source - Remove all clothing except underwear - Ensure airflow over Pt - Apply tepid water using spray bottle or wet towels If significant dehydration or poor perfusion, Rx as per CPG A0801 Hypovolaemia Provide initial Normal Saline 20 ml/kg IV and reassess VSS and temp - If Pt temp > 40 C use cool fluids if available (stored usually at < 8 C) Continue to administer Normal Saline if Pt remains poorly perfused or significantly dehydrated - If cool fluids intiated, return to ambient temp once Pt temp is < 39 C Rx low BGL as per CPG A0702 Hypoglycaemia Airway and ventilation support with 100% O 2 as required Adequate response BLS Tx 8 Assess Accurately assess temp BGL if altered conscious state Perfusion status and dehydration Assess Version Page 2 of 2 CPG A0902 Severe cases - temp > 39.5 C GCS < 10 Consider ETT as per CPG A0302 Endotracheal Intubation If intubated, sedation and paralysis essential to prevent shivering and reduce heat production Environmental Hyperthermia Heat Stress CPG A

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