CLINICAL PRACTICE GUIDELINES

Transcription

1 CLINICAL RACTICE GUIDELINES For re-hospital Emergency Care 2012 Version CFR OFA EFR EMERGENCY MEDICAL TECHNICIAN A

2 CLINICAL RACTICE GUIDELINES - ublished 2012 The re-hospital Emergency Care Council (HECC) is an independent statutory body with responsibility for standards, education and training in the field of pre-hospital emergency care in Ireland. HECC s primary role is to protect the public. MISSION STATEMENT The re-hospital Emergency Care Council protects the public by independently specifying, reviewing, maintaining and monitoring standards of excellence for the delivery of quality pre-hospital emergency care for people in Ireland. The Council was established as a body corporate by the Minister for Health and Children by Statutory Instrument Number 109 of 2000 (Establishment Order) which was amended by Statutory Instrument Number 575 of 2004 (Amendment Order). These Orders were made under the Health (Corporate Bodies) Act, 1961 as amended and the Health (Miscellaneous rovisions) Act 2007.

3 CLINICAL RACTICE GUIDELINES Version ractitioner Emergency Medical Technician

4 HECC Clinical ractice Guidelines First Edition 2001 Second Edition 2004 Third Edition 2009 Third Edition Version Edition April 2012 ublished by: re-hospital Emergency Care Council Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland hone: (0) Fax: (0) info@phecc.ie Web: ISBN re-hospital Emergency Care Council 2012 Any part of this publication may be reproduced for educational purposes and quality improvement programmes subject to the inclusion of an acknowledgement of the source. It may not be used for commercial purposes.

5 TABLE OF CONTENTS REFACE FOREWORD...6 ACCETED ABBREVIATIONS...7 ACKNOWLEDGEMENTS...9 INTRODUCTION...11 IMLEMENTATION AND USE OF CLINICAL RACTICE GUIDELINES CLINICAL RACTICE GUIDELINES KEY/CODES EXLANATION...16 CLINICAL RACTICE GUIDELINES - INDEX...17 SECTION 2 ATIENT ASSESSMENT...19 SECTION 3 RESIRATORY EMERGENCIES...24 SECTION 4 MEDICAL EMERGENCIES...27 SECTION 5 OBSTETRIC EMERGENCIES...53 SECTION 6 TRAUMA...55 SECTION 7 AEDIATRIC EMERGENCIES...62 SECTION 8 RE-HOSITAL EMERGENCY CARE OERATIONS...76 Appendix 1 - Medication Formulary...79 Appendix 2 Medications & Skills Matrix...92 Appendix 3 Critical Incident Stress Management...99 Appendix 4 CG Updates for Emergency Medical Technicians Appendix 5 re-hospital defibrillation position paper

6 FOREWORD It is my pleasure to write the foreword to this HECC Clinical Handbook comprising Clinical ractice Guidelines (CGs) and Medication Formulary. There are now 236 CGs in all, to guide integrated care across the six levels of Responder and ractitioner. My understanding is that it is a world first to have a Cardiac First Responder using guidance from the same integrated set as all levels of Responders and ractitioners up to Advanced aramedic. We have come a long way since the publication of the first set of guidelines numbering 35 in 2001, and applying to s only at the time. I was appointed Chair in June 2008 to what is essentially the second Council since HECC was established in I pay great tribute to the hard work of the previous Medical Advisory Group chaired by Mark Doyle, in developing these CGs with oversight from the Clinical Care Committee chaired by Sean Creamer, and guidance and authority of the first Council chaired by aul Robinson. The development and publication of CGs is an important part of HECC s main functions which are: 1. To ensure training institutions and course content in First Response and Emergency Medical Technology reflect contemporary best practice. 2. To ensure pre-hospital emergency care Responders and ractitioners achieve and maintain competency at the appropriate performance standard. 3. To sponsor and promote the implementation of best practice guidelines in pre-hospital emergency care. 4. To source, sponsor and promote relevant research to guide Council in the development of pre-hospital emergency care in Ireland. 5. To recommend other pre-hospital emergency care standards as appropriate. 6. To establish and maintain a register of pre-hospital emergency care practitioners. 7. To recognise those pre-hospital emergency care providers which undertake to implement the clinical practice guidelines. The CGs, in conjunction with relevant ongoing training and review of practice, are fundamental to achieve best practice in pre-hospital emergency care. I welcome this revised Clinical Handbook and look forward to the contribution Responders and ractitioners will make with its guidance. Mr Tom Mooney, Chair, re-hospital Emergency Care Council 6

7 ACCETED ABBREVIATIONS Advanced aramedic Advanced Life Support Airway, breathing & circulation All terrain vehicle Altered level of consciousness Automated External Defibrillator Bag Valve Mask Basic Life Support Blood Glucose Blood ressure A ALS ABC ATV ALoC AED BVM BLS BG B Carbon dioxide CO 2 Cardiopulmonary Resuscitation CR Cervical spine C-spine Chronic obstructive pulmonary disease COD Clinical ractice Guideline CG Degree o Degrees Centigrade o C Dextrose 10% in water D 10 W Drop (gutta) gtt Electrocardiogram ECG Emergency Department ED Emergency Medical Technician Endotracheal tube ETT Foreign body airway obstruction FBAO Fracture # General ractitioner G Glasgow Coma Scale GCS Gram g Greater than > Greater than or equal to Heart rate HR History Hx Impedance Threshold Device ITD Inhalation Inh Intramuscular IM Intranasal IN Intraosseous IO Intravenous IV Keep vein open KVO Kilogram Kg Less than < 7

8 ACCETED ABBREVIATIONS (Cont.) Less than or equal to Litre Maximum Microgram Milligram Millilitre Millimole Minute Modified Early Warning Score Motor vehicle collision Myocardial infarction Nasopharyngeal airway Milliequivalent Millimetres of mercury Nebulised Negative decadic logarithm of the H+ ion concentration Orally (per os) Oropharyngeal airway L Max mcg mg ml mmol min MEWS MVC MI NA meq mmhg NEB ph O OA Oxygen O 2 aramedic eak expiratory flow EF er rectum R ercutaneous coronary intervention CI ersonal rotective Equipment E ulseless electrical activity EA Respiration rate RR Return of spontaneous circulation ROSC Revised Trauma Score RTS Saturation of arterial oxygen SpO 2 ST elevation myocardial infarction STEMI Subcutaneous SC Sublingual SL Systolic blood pressure SB Therefore Total body surface area TBSA Ventricular Fibrillation VF Ventricular Tachycardia VT When necessary (pro re nata) prn 8

9 SECTION ACKNOWLEDGEMENTS 2 - ATIENT ASSESSMENT rimary Survey Adult The process of developing CGs has been long and detailed. The quality of the finished product is due to the painstaking work of many people, who through their expertise and review of the literature, ensured a world-class publication. ROJECT LEADER & EDITOR Mr Brian ower, rogramme Development Officer, HECC. INITIAL CLINICAL REVIEW Dr Geoff King, Director, HECC. Ms auline Dempsey, rogramme Development Officer, HECC. Ms Jacqueline Egan, rogramme Development Officer, HECC. MEDICAL ADVISORY GROU Dr Zelie Gaffney, (Chair) General ractitioner Dr David Janes, (Vice Chair) General ractitioner rof Gerard Bury, rofessor of General ractitioner University College Dublin Dr Niamh Collins, Locum Consultant in Emergency Medicine, St James s Hospital rof Stephen Cusack, Consultant in Emergency Medicine, Area Medical Advisor, National Ambulance Service South Mr Mark Doyle, Consultant in Emergency Medicine, Deputy Medical Director HSE National Ambulance Service Mr Conor Egleston, Consultant in Emergency Medicine, Our lady of Lourdes Hospital, Drogheda Mr Michael Garry, aramedic, Chair of Accreditation Committee Mr Macartan Hughes, Advanced aramedic, Head of Education & Competency Assurance, HSE National Ambulance Service Mr Lawrence Kenna, Advanced aramedic, Education & Competency Assurance Manager, HSE National Ambulance Service Mr aul Lambert, Advanced aramedic, Station Officer Dublin Fire Brigade Mr Declan Lonergan, Advanced aramedic, Education & Competency Assurance Manager, HSE National Ambulance Service Mr aul Meehan, Regional Training Officer, rthern Ireland Ambulance Service Dr David Menzies, Medical Director A programme NASC/UCD Dr David McManus, Medical Director, rthern Ireland Ambulance Service Dr eter O Connor, Consultant in Emergency Medicine, Medical Advisor Dublin Fire Brigade Mr Cathal O Donnell, Consultant in Emergency Medicine, Medical Director HSE National Ambulance Service Mr John O Donnell, Consultant in Emergency Medicine, Area Medical Advisor, National Ambulance Service West Mr Frank O Malley, aramedic, Chair of Clinical Care Committee Mr Martin O Reilly, Advanced aramedic, District Officer Dublin Fire Brigade Dr Sean O Rourke, Consultant in Emergency Medicine, Area Medical Advisor, National Ambulance Service rth Leinster 9

10 SECTION ACKNOWLEDGEMENTS 2 - ATIENT ASSESSMENT rimary Survey Adult Ms Valerie Small, Nurse ractitioner, St James s Hospital, Vice Chair Council Dr Sean Walsh, Consultant in aediatric Emergency Medicine, Our Lady s Hospital for Sick Children Crumlin Mr Brendan Whelan, Advanced aramedic, Education & Competency Assurance Manager, HSE National Ambulance Service EXTERNAL CONTRIBUTORS Mr Fergal Hickey, Consultant in Emergency Medicine, Sligo General Hospital Mr George Little, Consultant in Emergency Medicine, Naas Hospital Mr Richard Lynch, Consultant in Emergency Medicine, Midlands Regional Hospital Mulingar Ms Celena Barrett, Chief Fire Officer, Kildare County Fire Service. Ms Diane Brady, CNM II, Delivery Suite, Castlebar Hospital. Dr Donal Collins, Chief Medical Officer, An Garda Síochána. Dr Ronan Collins, Director of Stroke Services, Age Related Health Care, Adelaide & Meath Hospital, Tallaght. Dr eter Crean, Consultant Cardiologist, St. James s Hospital. rof Kieran Daly, Consultant Cardiologist, University Hospital Galway Dr Mark Delargy, Consultant in Rehabilitation, National Rehabilitation Centre. Dr Joseph Harbison, Lead Consultant Stroke hysician and Senior Geriatrician St. James s, National Clinical Lead in Stroke Medicine. Mr Tony Heffernan, Assistant Director of Nursing, HSE Mental Health Services. rof eter Kelly, Consultant Neurologist, Mater University Hospital. Dr Brian Maurer, Director of Cardiology St Vincent s University Hospital. Dr Regina McQuillan, alliative Medicine Consultant, St James s Hospital. Dr Sean Murphy, Consultant hysician in Geriatric Medicine, Midland Regional Hospital, Mullingar. Ms Annette Thompson, Clinical Nurse Specialist, Beaumont Hospital. Dr Joe Tracey, Director, National oisons Information Centre. Mr at O Riordan, Specialist in Emergency Management, HSE. rof eter Weedle, Adjunct rof of Clinical harmacy, National University of Ireland, Cork. Dr John Dowling, General ractitioner, Donegal SECIAL THANKS A special thanks to all the HECC team who were involved in this project from time to time, in particular Marion O Malley, rogramme Development Support Officer and Marie Ni Mhurchu, Client Services Manager, for their commitment to ensure the success of the project. 10

11 SECTION INTRODUCTION 2 - ATIENT ASSESSMENT rimary Survey Adult The development of Clinical ractice Guidelines (CGs) is a continuous process. The publication of the ILCOR Guidelines 2010 was the principle catalyst for updating these CGs. As research leads to evidence, and as practice evolves, guidelines are updated to offer the best available advice to those who care for the ill and injured in our pre-hospital environment. This 2012 edition offers current best practice guidance. The guidelines have expanded in number and scope with 60 CGs in total for Emergency Medical Technicians, covering such topics as ost Resuscitation Care for aediatric patients and End of Life DNR for the first time. The CGs continue to recognise the various levels of ractitioner (Emergency Medical Technician, aramedic and Advanced aramedic) and Responder (Cardiac First Response, Occupational First Aid and Emergency First Response) who offer care. The CGs cover these six levels, reflecting the fact that care is integrated. Each level of more advanced care is built on the care level preceding it, whether or not provided by the same person. For ease of reference, a version of the guidelines for each level of Responder and ractitioner is available on Feedback on the experience of using the guidelines in practice is essential for their ongoing development and refinement, therefore, your comments and suggestions are welcomed by HECC. The Medical Advisory Group believes these guidelines will assist ractitioners in delivering excellent pre-hospital care. Mr Cathal O Donnell Chair, Medical Advisory Group ( ) 11

12 SECTION IMLEMENTATION 2 - ATIENT & USE ASSESSMENT OF CLINICAL rimary RACTICE Survey GUIDELINES Adult Clinical ractice Guidelines (CGs) and the ractitioner CGs are guidelines for best practice and are not intended as a substitute for good clinical judgment. Unusual patient presentations make it impossible to develop a CG to match every possible clinical situation. The ractitioner decides if a CG should be applied based on patient assessment and the clinical impression. The ractitioner must work in the best interest of the patient within the scope of practice for his/her clinical level on the HECC Register. Consultation with fellow ractitioners and or medical practitioners in challenging clinical situations is strongly advised. The CGs herein may be implemented provided: 1 The ractitioner is in good standing on the HECC ractitioner s Register. 2 The ractitioner is acting on behalf of an organisation (paid or voluntary) that is approved by HECC to implement the CGs. 3 The ractitioner is authorised by the organisation on whose behalf he/she is acting to implement the specific CG. 4 The ractitioner has received training on - and is competent in - the skills and medications specified in the CG being utilized. The medication dose specified on the relevant CG shall be the definitive dose in relation to ractitioner administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the ractitioner to ensure that he/she is using the latest versions of CGs which are available on the HECC website Definitions Adult Child Infant Neonate aediatric patient a patient of 14 years or greater, unless specified on the CG. a patient between 1 and less than or equal to ( ) 13 years old, unless specified on the CG. a patient between 4 weeks and less than 1 year old, unless specified on the CG. a patient less than 4 weeks old, unless specified on the CG. any child, infant or neonate. 12

13 SECTION IMLEMENTATION 2 - ATIENT & USE ASSESSMENT OF CLINICAL rimary RACTICE Survey GUIDELINES Adult Care principles Care principles are goals of care that apply to all patients. Scene safety, standard precautions, patient assessment, primary and secondary surveys and the recording of interventions & medications on the atient Care Report (CR) are consistent principles throughout the guidelines and reflect the practice of ractitioners at work. Care principles are the foundations for risk management and the avoidance of error. Care rinciples 1 Ensure the safety of yourself, other emergency service personnel, your patients and the public: review all Ambulance Control Centre dispatch information. consider all environmental factors and approach a scene only when it is safe to do so. identify potential and actual hazards and take the necessary precautions. request assistance as required in a timely fashion, particularly for higher clinical levels. ensure the scene is as safe as is practicable. take standard infection control precautions. 2 Identify and manage life-threatening conditions: locate all patients. If the number of patients is greater than resources, ensure additional resources are sought. assess the patient s condition appropriately. prioritise and manage the most life-threatening conditions first. provide a situation report to Ambulance Control Centre as soon as possible after arrival on the scene as appropriate. 3 Ensure adequate ventilation and oxygenation. 4 Monitor and record patient s vital observations. 5 Optimise tissue perfusion. 6 Identify and manage other conditions. 7 rovide appropriate pain relief. 8 lace the patient in the appropriate posture according to the presenting condition. 9 Ensure the maintenance of normal body temperature (unless CG indicates otherwise). 13

14 SECTION IMLEMENTATION 2 - ATIENT & USE ASSESSMENT OF CLINICAL rimary RACTICE Survey GUIDELINES Adult 10 Maintain responsibility for patient care until handover to an appropriate ractitioner. Do not hand over responsibility for care of a patient to a ractitioner/responder who is less qualified or experienced unless the care required is within their scope of practice. 11 Arrange transport to an appropriate medical facility as necessary and in an appropriate time frame: On-scene times for life-threatening conditions, other than cardiac arrest, should not exceed 10 minutes. Following initial stabilisation other treatments should be commenced/ continued en-route. 12 rovide reassurance at all times. Completing a CR for each patient is paramount in the risk management process and users of the CGs must be committed to this process. CGs and the pre-hospital emergency care team The aim of pre-hospital emergency care is to provide a comprehensive and coordinated approach to patient care management, thus providing each patient with the most appropriate care in the most efficient time frame. In Ireland today, providers of emergency care are from a range of disciplines and include Responders (Cardiac First Response, Occupational First Aid and Emergency First Response) and ractitioners (Emergency Medical Technicians, aramedics, Advanced aramedics, Nurses and Doctors) from the statutory, private, auxiliary and voluntary services. CGs set a consistent standard of clinical practice within the field of pre-hospital emergency care. By reinforcing the role of the ractitioner, in the continuum of patient care, the chain of survival and the golden hour are supported in medical and trauma emergencies respectively. CGs guide the ractitioner in presenting to the acute hospital a patient who has been supported in the very early phase of injury/illness and in whom the danger of deterioration has lessened by early appropriate clinical care interventions. 14

15 SECTION IMLEMENTATION 2 - ATIENT & USE ASSESSMENT OF CLINICAL rimary RACTICE Survey GUIDELINES Adult CGs presume no intervention has been applied, nor medication administered, prior to the arrival of the ractitioner. In the event of another ractitioner or Responder initiating care during an acute episode, the ractitioner must be cognisant of interventions applied and medication doses already administered and act accordingly. In this care continuum, the duty of care is shared among all Responders/ ractitioners of whom each is accountable for his/her own actions. The most qualified Responder/ractitioner on the scene shall take the role of clinical leader. Explicit handover between Responders/ractitioners is essential and will eliminate confusion regarding the responsibility for care. In the absence of a more qualified ractitioner, the ractitioner providing care during transport shall be designated the clinical leader as soon as practical. Defibrillation policy The Medical Advisory Group has recommended the following pre-hospital defibrillation policy; Advanced aramedics should use manual defibrillation for all age groups. aramedics may consider use of manual defibrillation for all age groups. s and Responders shall use AED mode for all age groups. Using the 2012 Edition CGs The 2012 Edition CGs continue to be published in sections. Appendix 1, the Medication Formulary, is an important adjunct supporting decision-making by the ractitioner. Appendix 2, lists the care management and medications matrix for the six levels of ractitioner and Responder. Appendix 3, outlines important guidance for critical incident stress management (CISM) from the Ambulance Service CISM committee. Appendix 4, outlines changes to medications and skills as a result of updating to version 2 and the introduction of new CGs. Appendix 5, outlines the pre-hospital defibrillation position from HECC. 15

16 KEY/CODES EXLANATION Clinical ractice Guidelines for Emergency Medical Technician Codes explanation A Sequence step Emergency Medical Technician (Level 4) for which the CG pertains aramedic (Level 5) for which the CG pertains Advanced aramedic (Level 6) for which the CG pertains A sequence (skill) to be performed A parallel process Which may be carried out in parallel with other sequence steps A cyclical process in which a number of sequence steps are completed Emergency Medical Technician or lower clinical levels not permitted this route Mandatory sequence step A mandatory sequence (skill) to be performed Transport to an appropriate medical facility and maintain treatment en-route Consider treatment options A decision process The ractitioner must follow one route Given the clinical presentation consider the treatment option specified If no ALS available Instructions Transport to an appropriate medical facility and maintain treatment en-route, if having contacted Ambulance Control there is no ALS available An instruction box for information Reassess Reassess the patient following intervention Special instructions Special instructions Which the ractitioner must follow Request ALS Consider ALS Contact Ambulance Control and request Advanced Life Support (A or doctor) Consider requesting an ALS response, based on the clinical findings Special authorisation A skill or sequence that only pertains to aramedic or higher clinical levels Special authorisation This authorises the ractitioner to perform an intervention under specified conditions 4/5/6.4.1 Version 2, 07/11 4/5/6.x.y Version 2, mm/yy CG numbering system 4/5/6 = clinical levels to which the CG pertains x = section in CG manual, y = CG number in sequence mm/yy = month/year CG published Consider aramedic Consider requesting a aramedic response, based on the clinical findings Medication, dose & route Medication, dose & route Medication, dose & route A medication which may be administered by an or higher clinical level The medication name, dose and route is specified A medication which may be administered by a aramedic or higher clinical level The medication name, dose and route is specified A medication which may be administered by an Advanced aramedic The medication name, dose and route is specified xxx CG A direction to go to a specific CG following a decision process te: only go to the CGs that pertain to your clinical level Start from A clinical condition that may precipitate entry into the specific CG 16

17 CLINICAL SECTION 2 RACTICE - ATIENT GUIDELINES ASSESSMENT - INDEX rimary Survey Adult SECTION 2 ATIENT ASSESSMENT rimary Survey Medical Adult 19 rimary Survey Trauma Adult 20 Secondary Survey Medical Adult 21 Secondary Survey Trauma Adult 22 ain Management Adult 23 SECTION 3 RESIRATORY EMERGENCIES Advanced Airway Management Adult 24 Inadequate Respirations Adult 25 Exacerbation of COD 26 SECTION 4 MEDICAL EMERGENCIES Basic Life Support Adult 27 Basic Life Support aediatric 28 Foreign Body Airway Obstruction Adult 29 Foreign Body Airway Obstruction aediatric 30 VF or ulseless VT Adult 31 VF or ulseless VT aediatric 32 Symptomatic Bradycardia aediatric 33 Asystole Adult 34 ulseless Electrical Activity Adult 35 Asystole/EA aediatric 36 ost-resuscitation Care Adult 37 Recognition of Death Resuscitation not Indicated 38 Cardiac Chest ain Acute Coronary Syndrome 39 Symptomatic Bradycardia Adult 40 Allergic Reaction/Anaphylaxis Adult 41 Glycaemic Emergency Adult 42 Seizure/Convulsion Adult 43 Stroke 44 oisons Adult 45 Hypothermia 46 Epistaxis 47 Decompression Illness 48 Altered Level of Consciousness Adult 49 Behavioural Emergency 50 Mental Health Emergency 51 End of Life DNR 52 17

18 SECTION CLINICAL 2 RACTICE - ATIENT GUIDELINES ASSESSMENT - INDEX rimary Survey Adult SECTION 5 OBSTETRIC EMERGENCIES re-hospital Emergency Childbirth 53 Basic Life Support Neonate 54 SECTION 6 TRAUMA External Haemorrhage Adult 55 Shock from Blood Loss Adult 56 Spinal Immobilisation Adult 57 Burns Adult 58 Limb Injury Adult 59 Head Injury Adult 60 Submersion Incident 61 SECTION 7 AEDIATRIC EMERGENCIES rimary Survey Medical aediatric 62 rimary Survey Trauma aediatric 63 Secondary Survey aediatric 64 Inadequate Respirations aediatric 65 Stridor aediatric 66 Allergic Reaction/Anaphylaxis aediatric 67 Glycaemic Emergency aediatric 68 Seizure/Convulsion aediatric 69 External Haemorrhage aediatric 70 Shock from Blood Loss aediatric 71 ain Management aediatric 72 Spinal Immobilisation aediatric 73 Burns aediatric 74 ost Resuscitation Care aediatric 75 SECTION 8 RE-HOSITAL EMERGENCY CARE OERATIONS Major Emergency First ractitioners on Site 76 Major Emergency Operational Control 77 Triage Sieve 78 18

19 SECTION 2 - ATIENT ASSESSMENT 4/5/6.2.1 Version 2, 03/11 rimary Survey Medical Adult Medical issue The primary survey is focused on establishing the patient s clinical status and only applying interventions when they are essential to maintain life. It should be completed within one minute of arrival on scene. Take standard infection control precautions Consider pre-arrival information Scene safety Scene survey Scene situation Assess responsiveness A Airway patent & protected A ATIENT ASSESSMENT rimary Survey Medical - Adult Suction, OA NA Head tilt/ chin lift S2 B Adequate ventilation Consider Oxygen therapy C Adequate circulation AVU assessment Life threatening Clinical status decision n serious or life threat Serious not life threat Request ALS appropriate CG Consider ALS Secondary Survey CG Reference: ILCOR Guidelines

20 SECTION 2 - ATIENT ASSESSMENT 4/5/6.2.2 Version 2, 03/11 rimary Survey Trauma Adult ATIENT ASSESSMENT rimary Survey Trauma - Adult Trauma The primary survey is focused on establishing the patient s clinical status and only applying interventions when they are essential to maintain life. It should be completed within one minute of arrival on scene. Take standard infection control precautions Consider pre-arrival information Scene safety Scene survey Scene situation Control catastrophic external haemorrhage Mechanism of injury suggestive of spinal injury C-spine control A S2 Assess responsiveness Suction, OA NA Jaw thrust A Airway patent & protected B Adequate ventilation Consider Oxygen therapy C Adequate circulation AVU assessment Treat life threatening injuries only at this point Life threatening Clinical status decision n serious or life threat Maximum time on scene for life threatening trauma: 10 minutes Serious not life threat Request ALS appropriate CG Consider ALS Secondary Survey CG Reference: ILCOR Guidelines

21 SECTION 2 - ATIENT ASSESSMENT Version 2, 09/11 Markers identifying acutely unwell Cardiac chest pain Acute pain > 5 Secondary Survey Medical Adult rimary Survey Record vital signs atient acutely unwell Focused medical history of presenting complaint Request ATIENT ASSESSMENT Secondary Survey Medical - Adult appropriate CG Identify positive findings and initiate care management SAMLE history ALS S2 Check for medications carried or medical alert jewellery Consider aramedic Reference: Sanders, M. 2001, aramedic Textbook 2 nd Edition, Mosby Gleadle, J. 2003, History and Examination at a glance, Blackwell Science Rees, JE, 2003, Early Warning Scores, World Anaesthesia Issue 17, Article 10 21

22 SECTION 2 - ATIENT ASSESSMENT ATIENT ASSESSMENT Secondary Survey Trauma - Adult 05/ appropriate CG Identify positive findings and initiate care management Secondary Survey Trauma Adult rimary Survey Markers for multisystem trauma present Examination of obvious injuries Record vital signs SAMLE history Request ALS S2 Complete a head to toe survey as history dictates Check for medications carried or medical alert jewellery Consider aramedic Markers for multi-system trauma Systolic B < 90 Respiratory rate < 10 or > 29 Heart rate > 120 AVU = V, or U on scale Mechanism of Injury Reference: McSwain, N. et al, 2003, HTLS Basic and advanced prehospital trauma life support, 5 th Edition, Mosby 22

23 SECTION 2 - ATIENT ASSESSMENT 4/5/6.2.6 Version 2, 03/11 ain Management Adult ain A The general principle in pain management is to start at the bottom rung of the pain ladder, and then to climb the ladder if pain is still present. ractitioners, depending on his/her scope of practice, may make a clinical judgement and commence pain relief on a higher rung. or best achievable ain assessment Administer pain medication based on pain assessment and pain ladder recommendations Adequate relief of pain Analogue ain Scale 0 = no pain..10 = unbearable Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale ATIENT ASSESSMENT ain Management - Adult Go back to originating CG Reassess and move up the pain ladder if appropriate S2 Request ALS Severe pain ( 5 on pain scale) Morphine 2 mg IV and / or NitrousOxide & Oxygen, inh Repeat Morphine at not < 2 min intervals if indicated. Max 10 mg For musculoskeletal pain Max 16 mg Minor pain (2 to 3 on pain scale) Consider aramedic Moderate pain (3 to 4 on pain scale) aracetamol 1 g O aracetamol 1 g O and / or Ibuprofen 400 mg O and / or NitrousOxide & Oxygen, inh Consider Ondansetron 4 mg IV slowly or Cyclizine50mgIV slowly Consider other non pharmacological interventions HECC ain Ladder Special Authorisation: Registered Medical ractitioners may authorise the use of IM Morphine by aramedic or practitioners for a specific patient in an inaccessible location A Special Authorisation: Advanced aramedics are authorised to administer Morphine up to 10 mg IM if IV not accessible, the patient is cardiovascularly stable and no cardiac chest pain present Reference: World Health Organization, ain Ladder 23

24 SECTION 3 - RESIRATORY EMERGENCIES Advanced Airway Management Adult 03/11 CFR - A RESIRATORY EMERGENCIES Advanced Airway Management - Adult Adult Cardiac arrest BLS-Adult CG Minimum interruptions of chest compressions. Maximum hands off time 10 seconds. Able to ventilate Consider option of advanced airway Supraglottic Airway insertion Successful 2 nd attempt Supraglottic Airway insertion Consider FBAO Equipment list n-inflatable supraglottic airway S3 Maintain adequate ventilation and oxygenation throughout procedures Successful Revert to basic airway management Check supraglottic airway placement after each patient movement or if any patient deterioration Following successful Advanced Airway management:- i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute Continue ventilation and oxygenation appropriate CG Reference: ILCOR Guidelines

25 SECTION 3 - RESIRATORY EMERGENCIES Version 2, 03/11 Inadequate Respirations Adult Equipment list Volumizer to be used to administer Salbutamol Respiratory difficulties Assess and maintain airway Regard each emergency asthma call as for acute severe asthma until it is shown otherwise Inadequate rate or depth RR < 10 Request ALS Oxygen therapy Respiratory assessment Audible wheeze Request aramedic assistance RESIRATORY EMERGENCIES Inadequate Respirations - Adult ositive pressure ventilations Max 10 per minute Salbutamol, 2 puffs, (0.2 mg) metered aerosol S3 Reassess ECG & SpO2 monitoring Life threatening asthma Any one of the following in a patient with severe asthma; SpO2 < 92% Silent chest Cyanosis Feeble respiratory effort Bradycardia Arrhythmia Hypotension Exhaustion Confusion Unresponsive Acute severe asthma Any one of; Respiratory rate 25/ min Heart rate 110/ min Inability to complete sentences in one breath Moderate asthma exacerbation Increasing symptoms features of acute severe asthma Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline 25

26 SECTION 3 - RESIRATORY EMERGENCIES 05/ Exacerbation of COD Dyspnoea History of COD Oxygen Therapy 1. if O2 alert card issued follow directions. 2. if no O2 alert card, commence therapy at 28% 3. administer O2 titrated to SpO2 92% Oxygen therapy RESIRATORY EMERGENCIES Exacerbation of COD ECG & SpO2 monitor Request ALS Adequate respirations Inadequate Respirations CG S3 An exacerbation of COD is defined as; An event in the natural course of the disease characterised by a change in the patient s baseline dyspnoea, cough and/or sputum beyond day-today variability sufficient to warrant a change in management. (European Respiratory Society) 26

27 SECTION 4 - MEDICAL EMERGENCIES 4/5/6.4.1 Version 2, 06/11 Basic Life Support Adult A Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management Cardiac Arrest Request ALS Attach defibrillation pads Commence CR while defibrillator is being prepared only if 2 nd person available 30 Compressions : 2 ventilations. Oxygen therapy Chest compressions Rate: 100 to 120/ min Depth: at least 5 cm Ventilations Rate: 10/ min (1 every 6 sec) Volume: 500 to 600 ml A Change defibrillator to manual mode Consider changing defibrillator to manual mode Continue CR while defibrillator is charging Shockable VF or pulseless VT Give 1 shock Assess Rhythm Immediately resume CR x 2 minutes n - Shockable Asystole or EA Minimum interruptions of chest compressions. MEDICAL EMERGENCIES Basic Life Support - Adult Rhythm check * Maximum hands off time 10 seconds. S4 VF/ ulseless VT CG VF/ VT ROSC ost Resuscitation Care CG Asystole CG Asystole EA EA CG If an Implantable Cardioverter Defibrillator (ICD) is fitted in the patient treat as per CG. It is safe to touch a patient with an ICD fitted even if it is firing. * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines

28 SECTION 4 - MEDICAL EMERGENCIES 4/5/ /11 Basic Life Support aediatric ( 13 Years) Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management Cardiac arrest or pulse < 60 per minute with signs of poor perfusion Give 5 rescue ventilations Oxygen therapy A Request One rescuer CR 30 : 2 Two rescuer CR 15 : 2 Compressions : Ventilations ALS MEDICAL EMERGENCIES Basic Life Support - aediatric S4 Minimum interruptions of chest compressions. Maximum hands off time 10 seconds. A Continue CR while defibrillator is charging Change defibrillator to manual mode Consider changing defibrillator to manual mode Apply paediatric system AED pads Shockable VF or pulseless VT Give 1 shock Commence chest Compressions Continue CR (30:2) until defibrillator is attached < 8 years Assess Rhythm Apply adult defibrillation pads n - Shockable Asystole or EA Chest compressions Rate: 100 to 120/ min Depth: 1 /3 depth of chest Child; two hands Small child; one hand Infant (< 1); two fingers With two rescuer CR use two thumb-encircling hand chest compression for infants < 8 years use paediatric defibrillation system (if not available use adult pads) Immediately resume CR x 2 minutes Rhythm check * VF / ulseless VT CG VF/ VT Asystole / EA ROSC ost Resuscitation Care CG Asystole / EA CG * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines 2010 Infant AED It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior (front) and posterior (back), because of the infant s small size. 28

29 SECTION 4 - MEDICAL EMERGENCIES 4/ /08 Foreign Body Airway Obstruction Adult FBAO Are you choking? Request ALS One cycle of CR Effective One cycle of CR Severe (ineffective cough) Conscious Conscious 1 to 5 back blows followed by 1 to 5 abdominal thrusts as indicated Effective FBAO Severity Mild (effective cough) Encourage cough Adequate ventilations ositive pressure ventilations maximum 10 per minute Consider Oxygen therapy MEDICAL EMERGENCIES Foreign Body Airway Obstruction - Adult S4 Effective Oxygen therapy BLS Adult CG After each cycle of CR open mouth and look for object. If visible attempt once to remove it 29

30 SECTION 4 - MEDICAL EMERGENCIES MEDICAL EMERGENCIES Foreign Body Airway Obstruction - aediatric ( 13 years) 4/ /08 Request ALS Open mouth and look for object If visible one attempt to remove it Attempt 5 Rescue Breaths One cycle of CR Foreign Body Airway Obstruction aediatric ( 13 years) FBAO Severe (ineffective cough) Conscious Conscious 1 to 5 back blows followed by 1 to 5 thrusts (child abdominal thrusts) (infant chest thrusts) as indicated Are you choking? FBAO Severity Effective Mild (effective cough) Encourage cough Breathing adequately ositive pressure ventilations (12 to 20/ min) Consider Oxygen therapy S4 Effective One cycle of CR Effective Oxygen therapy BLS aediatric CG After each cycle of CR open mouth and look for object. If visible attempt once to remove it 30

31 SECTION 4 - MEDICAL EMERGENCIES 4/5/6.4.7 Version 2, 03/11 VF or ulseless VT Adult From BLS Adult CG VF or VT arrest A A Immediate IO access if IV not immediately accessible Refractory VF/VT post Epinephrine Amiodarone 300 mg (5 mg/kg) IV/ IO 2 nd dose (if required) Amiodarone 150 mg (2.5 mg/kg) IV/ IO ost Resuscitation Care CG ROSC Defibrillate EA CG Asystole CG EA Asystole If torsades de pointes, consider Magnesium Sulphate 2 g IV/IO Rhythm check * VF/VT NaCl IV/IO 500 ml (use as flush) Epinephrine (1:10 000) 1 mg IV/IO Every 3 to 5 minutes prn Initial Epinephrine between 2 nd and 4 th shock Advanced airway management Consider mechanical CR assist MEDICAL EMERGENCIES VF or ulseless VT - Adult Consider transport to ED if no change after 20 minutes resuscitation If no ALS available S4 With CR ongoing maximum hands off time 10 seconds Continue CR during charging Drive smoothly Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia Hypothermia Hypovolaemia Hypoxia Thrombosis pulmonary Tension pneumothorax Thrombus coronary Tamponade cardiac Toxins Trauma Mechanical CR device is the optimum care during transport Clinical leader to monitor quality of CR If Tricyclic Antidepressant Toxicity consider Sodium Bicarbonate 8.4% 50 ml IV * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines 2010 Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management A Consider use of waveform capnography A Special Authorisation: Advanced aramedics are authorised to substitute Amiodarone with a one off bolus of Lidocaine (1-1.5 mg/kg IV) if Amiodarone is not available 31

32 SECTION 4 - MEDICAL EMERGENCIES 4/5/6.4.8 Version 2, 06/11 VF or ulseless VT aediatric ( 13 years) MEDICAL EMERGENCIES VF or ulseless VT - aediatric ( 13 years) S4 From BLS Child CG A Immediate IO access if IV not immediately accessible ost Resuscitation Care CG Asystole / EA CG ROSC Asystole/EA Transport to ED if no change after 10 minutes resuscitation If no ALS available VF or VT arrest Rhythm check * VF/VT Defibrillate (4 joules/kg) Epinephrine (1:10 000), 0.01 mg/kg IV/IO Repeat every 3 to 5 minutes prn Initial Epinephrine between 2 nd and 4 th shock Refractory VF/VT post Epinephrine Amiodarone, 5 mg/kg, IV/IO A < 8 years use paediatric defibrillation system (if not available use adult pads) A Advanced airway management Check blood glucose Drive smoothly Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia Hypothermia Hypovolaemia Hypoxia Thrombosis pulmonary Tension pneumothorax Thrombus coronary Tamponade cardiac Toxins Trauma With CR ongoing maximum hands off time 10 seconds Continue CR during charging Clinical leader to monitor quality of CR * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Following successful Advanced Airway management:- i) Ventilate at 12 to 20 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute A Consider use of waveform capnography Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management Reference: ILCOR Guidelines

33 SECTION 4 - MEDICAL EMERGENCIES 4/5/6.4.9 Version 2, 07/11 Symptomatic Bradycardia aediatric ( 13 years) Signs of inadequate perfusion Tachycardia Diminished/absent peripheral pulses Tachypnoea Irritability/ confusion / ALoC Cool extremities, mottling Delayed capillary refill Check blood glucose Symptomatic Bradycardia Oxygen therapy ositive pressure ventilations (12 to 20/ min) Request ALS HR < 60 & signs of inadequate perfusion CR ECG & SpO2 monitoring NaCl (0.9%) 20 ml/kg IV/IO Reassess A Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IO Every 3 5 min prn A Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management Immediate IO access if IV not immediately accessible MEDICAL EMERGENCIES Symptomatic Bradycardia - aediatric ( 13 years) S4 ersistent bradycardia Consider advanced airway management if prolonged CR Continue CR If no ALS available Reference: International Liaison Committee on Resuscitation, 2010, art 6: aediatric basic and advanced life support, Resuscitation (2005) 67,

34 SECTION 4 - MEDICAL EMERGENCIES Version 2, 03/11 Asystole Adult From BLS Adult CG Asystole Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management ost Resuscitation Care CG ROSC EA CG EA Asystole MEDICAL EMERGENCIES Asystole - Adult VF / ulseless VT CG VF/VT Consider transport to ED if no change after 20 minutes resuscitation If no ALS available Rhythm check * Advanced airway management Consider mechanical CR assist S4 With CR ongoing maximum hands off time 10 seconds Drive smoothly Mechanical CR device is the optimum care during transport Clinical leader to monitor quality of CR * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines

35 SECTION 4 - MEDICAL EMERGENCIES 4/5/ Version 2, 03/11 From BLS Adult CG A Immediate IO access if IV not immediately accessible EA ulseless Electrical Activity Adult A Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management ost Resuscitation Care CG Asystole CG VF / ulseless VT CG ROSC Asystole VF/VT Consider transport to ED if no change after 20 minutes resuscitation If no ALS available Rhythm check * EA Epinephrine (1:10 000) 1 mg IV/ IO Every 3 to 5 minutes prn NaCl IV/IO 500 ml (use as flush) Advanced airway management Consider mechanical CR assist MEDICAL EMERGENCIES ulseless Electrical Activity - Adult S4 Drive smoothly Mechanical CR device is the optimum care during transport With CR ongoing maximum hands off time 10 seconds Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia Hypothermia Hypovolaemia Hypoxia Thrombosis pulmonary Tension pneumothorax Thrombus coronary Tamponade cardiac Toxins Trauma Clinical leader to monitor quality of CR If Tricyclic Antidepressant Toxicity consider Sodium Bicarbonate 8.4% 50 ml IV A Consider use of waveform capnography Consider fluid challenge NaCl 20 ml/kg IV/IO * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines

36 SECTION 4 - MEDICAL EMERGENCIES 4/5/ Version 2, 03/11 Asystole/EA aediatric ( 13 years) From BLS Child CG Asystole/ EA arrest A Immediate IO access if IV not immediately accessible A Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management MEDICAL EMERGENCIES Asystole/EA - aediatric ( 13 years) ost Resuscitation Care CG VF / ulseless VT CG ROSC VF/VT Transport to ED if no change after 10 minutes resuscitation If no ALS available Rhythm check * Asystole/ EA Epinephrine (1:10 000), 0.01 mg/kg IV/IO Repeat every 3 to 5 minutes prn A Advanced airway management Check blood glucose S4 With CR ongoing maximum hands off time 10 seconds Drive smoothly Clinical leader to monitor quality of CR Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia Hypothermia Hypovolaemia Hypoxia Thrombosis pulmonary Tension pneumothorax Thrombus coronary Tamponade cardiac Toxins Trauma Consider fluid challenge NaCl 20 ml/kg IV/IO Following successful Advanced Airway management:- i) Ventilate at 12 to 20 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute A Consider use of waveform capnography * +/- ulse check: pulse check after 2 minutes of CR if potentially perfusing rhythm Reference: ILCOR Guidelines

37 SECTION 4 - MEDICAL EMERGENCIES Version 2, 03/11 ost-resuscitation Care Adult Return of Spontaneous Circulation Maintain Oxygen therapy Titrate O2 to 94% - 98% Equipment list Cold packs Request ALS ositive pressure ventilations Max 10 per minute Conscious Adequate ventilation Recovery position Consider active cooling if unresponsive For active cooling place cold packs at arm pit, groin & abdomen MEDICAL EMERGENCIES ost-resuscitation Care - Adult Maintain patient at rest S4 ECG & SpO2 monitoring Monitor vital signs Check blood glucose Maintain care until handover to appropriate ractitioner If no ALS available Drive smoothly Reference: ILCOR Guidelines

38 SECTION 4 - MEDICAL EMERGENCIES /08 Recognition of Death Resuscitation not Indicated MEDICAL EMERGENCIES Recognition of Death - Resuscitation not Indicated S4 Definitive indicators of death: 1. Decomposition 2. Obvious rigor mortis 3. Obvious pooling (hypostasis) 4. Incineration 5. Decapitation 6. Injuries totally incompatible with life Apparent dead body Signs of Life Definitive indicators of Death Inform Ambulance Control It is inappropriate to commence resuscitation Complete all appropriate documentation Await arrival of appropriate ractitioner and / or Gardaí rimary survey CG 38

39 SECTION 4 - MEDICAL EMERGENCIES Version 2, 09/11 Cardiac Chest ain Acute Coronary Syndrome GTN, 0.4 mg SL Repeat to max of 1.2 mg SL prn Cardiac chest pain Oxygen therapy Request ALS Apply 3 lead ECG & SpO2 monitor Aspirin, 300 mg O Chest ain Monitor vital signs Oxygen therapy Maintain SpO2 between 94% to 98% (lower range if COD) Time critical commence transport to definitive care ASA MEDICAL EMERGENCIES Cardiac Chest ain - Acute Coronary Syndrome S4 39

40 SECTION 4 - MEDICAL EMERGENCIES 4/5/ /08 Symptomatic Bradycardia Adult Symptomatic Bradycardia Oxygen therapy A Request ALS MEDICAL EMERGENCIES Symptomatic Bradycardia - Adult ECG & SpO2 monitoring Atropine, 0.5 mg IV Repeat at 3 to 5 min intervals prn to max 3 mg 12 lead ECG Reassess S4 40

41 SECTION 4 - MEDICAL EMERGENCIES Version 2, 03/11 Allergic Reaction/Anaphylaxis Adult Allergic reaction Oxygen therapy Mild Moderate Severe/ anaphylaxis Monitor reaction Salbutamol 2 puffs (0.2 mg) metered aerosol Reassess ECG & SpO2 monitor Deteriorates Epinephrine administered pre arrival? (within 5 minutes) Consider subject to conditions above Epinephrine (1:1 000) 300 mcg Auto injection atient prescribed Epinephrine auto injection ECG & SpO2 monitor Request ALS Epinephrine (1:1 000) 300 mcg Auto injection MEDICAL EMERGENCIES Allergic Reaction/Anaphylaxis - Adult Consider aramedic Reassess S4 Mild Urticaria and or angio oedema Moderate Mild symptoms + simple bronchospasm Severe/ anaphylaxis Moderate symptoms + haemodynamic and or respiratory compromise 41

42 SECTION 4 - MEDICAL EMERGENCIES /08 Glycaemic Emergency Adult Abnormal blood glucose level < 4 mmol/l Blood Glucose 11 to 20 mmol/l A or V on AVU > 20 mmol/l MEDICAL EMERGENCIES Glycaemic Emergency - Adult Consider Glucose gel, g buccal or Sweetened drink Reassess Allow 5 minutes to elapse following administration of medication Glucagon 1 mg IM Consider ALS Reassess S4 Blood Glucose 4 mmol/l Consider ALS Repeat x 1 prn Glucose gel g buccal 42

43 SECTION 4 - MEDICAL EMERGENCIES Version 2, 07/11 Seizure/Convulsion Adult Consider other causes of seizures Meningitis Head injury Hypoglycaemia Eclampsia Fever oisons Alcohol/drug withdrawal Seizure / convulsion rotect from harm Oxygen therapy Seizing currently Seizure status ost seizure Glycaemic Emergency CG Request ALS Support head Check blood glucose Blood glucose < 4 mmol/l Consider ALS Alert Recovery position Airway management MEDICAL EMERGENCIES Seizure/Convulsion - Adult Reassess Check blood glucose S4 Still seizing Transport to ED if requested by Ambulance Control Glycaemic Emergency CG Blood glucose < 4 mmol/l Reassess 43

44 SECTION 4 - MEDICAL EMERGENCIES /08 Stroke Acute neurological symptoms Complete a FAST assessment Maintain airway Oxygen therapy Check blood glucose Oxygen therapy Maintain SpO2 between 94% to 98% (lower range if COD) MEDICAL EMERGENCIES Stroke Glycaemic Emergency CG BG < 4 or > 20 mmol/l ECG & SO2 monitoring Consider aramedic S4 Follow local protocol re notifying ED prior to arrival F facial weakness Can the patient smile?, Has their mouth or eye drooped? Which side? A arm weakness Can the patient raise both arms and maintain for 5 seconds? S speech problems Can the patient speak clearly and understand what you say? T time to transport now if positive FAST Reference: ILCOR Guidelines

45 SECTION 4 - MEDICAL EMERGENCIES 4/ /08 oisons Adult oison source Ingestion Inhalation Injection Absorption Corrosive Site burns Sips of water or milk Cool area Caution with oral intake Inadequate Respirations CG Adequate ventilations Consider decontamination prior to transportation Consider ALS oison type MEDICAL EMERGENCIES oisons - Adult araquat Other Alcohol S4 Do not give oxygen Oxygen therapy Check blood glucose Consider Oxygen therapy BG < 4 or > 20 mmol/l Glycaemic Emergency CG te: Inadequate respirations CG, authorises the administration of Naloxone IM for opiate overdose by aramedics Reference: Dr Joe Tracey, Director, National oison Information Centre 45