Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 2012

Guidelie Miistry of Health, NSW 73 Miller Street North Sydey NSW 2060 Locked Mail Bag 961 North Sydey NSW 2059 Telephoe (02) 9391 9000 Fax (02) 9391 9101 http://www.health.sw.gov.au/policies/ Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 2012 Documet Number GL2012_003 Publicatio date 10-Apr-2012 Fuctioal Sub group Cliical/ Patiet Services - Nursig ad Midwifery Cliical/ Patiet Services - Medical Treatmet Cliical/ Patiet Services - Critical care space space space Summary The itetio of these guidelies is to esure early appropriate maagemet of acute ad life threateig coditios, ad to relieve pai ad discomfort for patiets at hospitals where medical practitioers are ot immediately available. The guidelies reflect best cliical practice ad are ot madatory, however, they have bee adopted ad implemeted across the State sice 2004 providig essetial cliical support for rural emergecy cliicias. Replaces Doc. No. Rural Adult Emergecy Cliical Guidelies 3rd Editio [GL2010_003] Author Brach Statewide ad Rural Health Services ad Capital Plaig Brach cotact Sharo Low 9391 9484 Applies to Local Health Districts, Speciality Network Govered Statutory Health Corporatios, Board Govered Statutory Health Corporatios, Public Health System Support Divisio, Public Health Uits, Public Hospitals Audiece Nursig, Medical & Allied Health cliical staff, Emergecy Departmets Distributed to Public Health System, Divisios of Geeral Practice, Govermet Medical Officers, NSW Ambulace Service, Miistry of Health, Private Hospitals ad Day Procedure Cetres Review date 10-Apr-2017 Policy Maual Patiet Matters File No. H11/95743 Status Active Director-Geeral

PURPOSE GUIDELINE SUMMARY NSW RURAL ADULT EMERGENCY CLINICAL GUIDELINES VERSION 3.1, 3RD EDITION 2012 These guidelies are provided to assist early appropriate cliical maagemet of acute ad life threateig coditios, ad to relieve pai ad discomfort, for patiets at hospitals where medical officers are ot immediately available. The guidelies reflect best cliical practice ad have bee used extesively across the state sice 2004 to provide cliical support for rural emergecy cliicas. KEY PRINCIPLES Uderpiig these guidelies are the followig priciples: A graduated cliical respose is required depedig o the: o severity of the presetig emergecy coditio e.g. the cliical respose to patiets with mild to moderately severe asthma is differet to that for patiets with immediately life threateig asthma; o level of traiig ad expertise of the ursig staff who iitiate the maagemet of the patiet i.e. Registered Nurses with advaced cliical traiig will practice more advaced itervetios; o legal requiremets for urses who iitiate treatmet ad admiister medicatios based o medicatio stadig orders; o eed for flexibility to respod to iput from seior cliical staff ad medical officers to accommodate local circumstaces; The guidelies reflect evidece based best cliical practice ad expert cosesus opiio; Stadardisatio of iitial cliical maagemet of specific adult coditios; ad Aligmet with the priciples outlied i the First Lie Emergecy Care Course (FLECC) for Registered Nurses. Advaced Cliical Nurses have advaced kowledge ad skills; ad have bee deemed competet to carry out these advaced roles usig cotemporary assessmet ad ogoig credetialig processes. Where a Advaced Cliical Nurse utilises these guidelies: the desigated medical officer will be otified immediately; stadig medicatio stadig orders cotaied i these guidelies will be reviewed ad authorised by the desigated medical officer as soo as possible (withi 24 hours); ad the medical officer will coutersig the record of admiistratio o the patiets medicatio chart. A umber of appedices ad a formulary have bee icluded to complemet these guidelies. GL2012_003 Issue date: April 2012 Page 1 of 2

GUIDELINE SUMMARY NSW Health Pharmaceutical Services Brach has reviewed these guidelies ad has idicated that they are satisfactory for the cosideratio of the Local Health Districts Drug Committees for approval ad implemetatio as medicatio stadig orders, i terms of the criteria for stadig orders as specified i NSW Health Policy Directive, PD2007_077, Medicatio Hadlig i NSW Public Hospitals. These guidelies should be read i cojuctio with NSW Health Policy Directive PD2005_042 - Guidelies for Hospitals Seekig to Exted the Practice of Health Professioals: http://www.health.sw.gov.au/policies/pd/2005/pd2005_042.html REVISION HISTORY Versio Approved by Amedmet otes April 2012 A/Deputy Director-Geeral 3 rd Editio V3.1 2012. (GL2012_003) Strategy ad Resources Replaces GL2010_003 March 2010 (GL2010_003) May 2007 (GL2007_005) Deputy Director-Geeral Strategic Developmet Deputy Director-Geeral Strategic Developmet 1 st Editio 2004 Deputy Director-Geeral Strategic Developmet ATTACHMENTS 3 rd Editio 2009. Replaces GL2007_005: total revisio. 2 d Editio 2007. Replaced 1 st editio: total revisio. 2 d Editio V2 1 2007 issued August 2007 1. NSW Rural Adult Emergecy Cliical Guidelies Versio 3.1, 3rd Editio 2012 GL2012_003 Issue date: April 2012 Page 2 of 2

NSW Rural Adult Emergecy Cliical Guidelies NSW Rural Critical Care Taskforce 3rd Editio Versio 3.1

NSW MINISTRY OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.sw.gov.au This work is copyright. It may be reproduced i whole or i part for study traiig purposes subject to the iclusio of a ackowledgemet of the source. It may ot be reproduced for commercial usage or sale. Reproductio for purposes other tha those idicated above requires writte permissio from the NSW Miistry of Health. NSW Miistry of Health 2012 SHPN (SRSCP) 120005 ISBN 978 1 74187 691 8 Further copies of this documet ca be dowloaded from the NSW Health website www.health.sw.gov.au Revised February 2012

The NSW Rural Adult Emergecy Cliical Guidelies are to be implemeted for the emergecy maagemet of adult patiets oly. Aeromedical ad Medical Retrieval Service (AMRS) 1800 650 004 NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 1

Cotets Itroductio... 3 Abbreviatios... 5 1. Airway Emergecies... 7 Ucoscious Patiet... 8 Seizures... 10 Aaphylactic Reactio... 12 2. Breathig Emergecies... 15 Shortess of Breath with or without a History of Asthma... 16 Shortess of Breath with a History of Cardiac Disease... 20 Shortess of Breath with a History of Chroic Obstructive Pulmoary Disease... 22 3. Circulatory Emergecies... 25 Cardiorespiratory Arrest (Basic Life Support)... 26 Cardiorespiratory Arrest (Advaced Life Support)... 27 Compromisig Bradycardia... 29 Acute Coroary Sydrome with or without Associated Symptoms... 31 No-traumatic Shock... 34 Stroke icludig Trasiet Ischaemic Attack... 36 Severe Sepsis... 40 4. Disability Emergecies... 43 Meigococcal Disease... 44 5. Edocrie / Eveomatio Emergecies... 47 Hyperglycaemia with Severe Dehydratio... 48 Hypoglycaemia... 50 Sake / Spider Bite... 52 6. Trauma Emergecies... 55 Trauma... 56 Burs... 60 Drowig... 63 Head Ijury... 65 Isolated Severe Limb Ijury... 68 Ocular Ijuries... 70 7. Other Emergecies... 73 Abdomial/Loi/Flak Pai... 74 8. Formulary... 77 9. Appedices... 99 1. Rural ad Remote Emergecy Trolley Miimum Adult Requiremets... 100 2. Defibrillatio... 102 3. 12 Lead ECG Lead Placemet... 103 4. NSW Chest Pai Pathway... 104 5. Maagemet of Patiets with ST-segmet Elevatio Myocardial Ifarctio (STEMI)... 108 6. AVPU ad Glasgow Coma Scale (GCS)... 109 7. Pai Assessmet... 110 8. Abbey Pai Scale... 111 9. Sedatio Score/Scale... 112 10. Glass Tumbler Test....113 11. Sakebite Observatio Chart... 114 12. Trauma Triage Tool... 115 13A. Guidelies for whe to Apply Semi-rigid Cervical Collar....116 13B. Removal of Semi Rigid Cervical Collar without Radiographic Assessmet....117 14. Needle Thoracetesis for Decompressio of Tesio Peumothorax....118 15. Suggested Guidelies for a Neurovascular Assessmet... 120 16. Pelvic Bidig... 121 17. Bur Trasfer Flowchart... 122 18. Guidelie for Emergecy Departmet Documetatio... 126 19. Miimum Skill Set for Emergecy Departmet Staff... 127 20. Recommeded Blood Pathology Testig Available at the Poit of Care i Rural Facilities where a Emergecy Service is Provided... 128 PAGE 2 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Itroductio Emergecy Departmets (EDs) i rural ad remote New South Wales (NSW) face a umber of uique ad difficult challeges i tryig to deliver quality emergecy care ad achievig good patiet outcomes. I particular it ca be difficult for staff workig i rural ad remote EDs to acquire ad retai emergecy expertise. This may lead to iequalities i the stadards of emergecy care delivered i rural ad remote EDs. A key fuctio of the NSW Rural Critical Care Taskforce (RCCT) is to idetify ad develop ways to esure a more uiform quality of emergecy care i these EDs. Oe of the Taskforce s strategies led to the developmet, i 2004, of a set of Rural Emergecy Cliical Guidelies for Adults, which could be used by rural ad remote Registered Nurses (RNs) who have udergoe approved educatio ad credetialig. The itetio of the Guidelies is to esure early maagemet of immediately or immietly life threateig coditios, ad to relieve pai ad sufferig i patiets at sites where medical practitioers are ot immediately available. This is the fourth review of the documet i lie with chages to best practice; ad requests ad advice from ed users. The documet has bee developed with the followig desirable features: formattig which allows for graduated cliical resposes. These resposes vary depedig o: degree of severity of the presetig emergecy coditio. For example, the cliical respose to patiets with mild to moderately severe asthma is differet to that for patiets with immediately life threateig asthma. This type of graduated cliical respose has bee used quite successfully i ambulace service protocols for may years; level of traiig ad expertise of the ursig staff who are iitiatig maagemet of the patiet that is, formattig which allows for RNs with advaced traiig to practice more advaced itervetios. RNs without this advaced traiig ad credetialig caot perform the advaced itervetios. The use of shaded portios i the NSW Rural Adult Emergecy Cliical Guidelies idicates cliical itervetios that ca oly be iitiated by RNs who are recogised as Advaced Cliical Nurses. icorporatio of the various legal requiremets for urses who iitiate treatmet ad admiister medicatios based o medicatio stadig orders flexibility guidelies eed to be flexible eough to allow local iput from rural Medical Officers (MOs) ad RNs so that local practices ca be icorporated edorsemet by relevat committees ad divisios withi NSW Miistry of Health stadardisatio of the maagemet of specific adult coditios across rural NSW The NSW Rural Adult Emergecy Cliical Guidelies icorporate these features as well as the priciples outlied i the First Lie Emergecy Care Course (FLECC) for Registered Nurses ad the stadig orders developed by the Wollogog Hospital pilot site model of the Emergecy Departmet Work Practice Review (EDWPR). Special recogitio is made to the utilisatio of the template desiged ad developed by the EDWPR group. The Guidelies are also formatted to follow the geerally accepted Airway, Breathig, Circulatio (ABC) approach for maagig emergecy/critical care patiets. These Guidelies are largely based o expert cosesus opiio, supported by higher level evidece where available. The aims of the NSW Rural Adult Emergecy Cliical Guidelies are to: improve the emergecy care ad outcomes for patiets i the rural ad remote health care settigs of NSW; provide readily accessible ad user-friedly guidelies for cliicias providig emergecy care to patiets i rural ad remote areas of NSW; assist rural ad remote EDs i NSW achieve bechmarkig targets ad best practice stadards for patiets with emergecy presetatios; NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 3

address some of the curret professioal issues facig rural ad remote RNs by: providig a safe framework i which rural ad remote RNs ca iitiate maagemet ad care of emergecy patiets; recogisig ad formalisig the advaced role that may rural ad remote RNs curretly perform whe deliverig care to critically ill or ijured patiets presetig to Emergecy Departmets; providig a pathway by which credetialed RNs ca work toward cotiuig professioal developmet. Nursig staff usig these Guidelies are required to be appropriately educated, skilled ad credetialed. The shaded portios cotaied i the treatmet guidelies must oly be used by RNs who are recogised as Advaced Cliical Nurses. Advaced Cliical Nurses are those RNs who have advaced kowledge ad skills; ad have bee deemed competet to carry out these advaced roles usig cotemporary assessmet ad ogoig credetialig processes. A umber of appedices have bee icluded to complemet these Guidelies. Staff should familiarise themselves with both the Appedix ad Formulary sectios. Credetialig of Advaced Cliical Nurses (ACN) Registered Nurses ca be cosidered eligible to be credetialed for Advaced Cliical Nurse roles if: they have successfully completed a emergecy or critical care ursig course such as the FLEC Course/ Graduate Certificate/Graduate Diploma or higher degree i Emergecy Nursig; ad they ca demostrate recet ad ogoig kowledge ad experiece with maagig emergecy/critical care patiets. Credetialig will be obtaied ad maitaied by: completio of stadard competecy assessmets as recommeded by the Critical Care Network Committee i each Local Health District; the ACN maitaiig appropriate documetatio to allow review of the usage of these Guidelies. ACNs are required to be re-credetialed aually or accordig to idividual Local Health District policy. It will be the resposibility of the rural Local Health Districts through both their Critical Care Network Committee ad their Health Service Maagers to esure compliace with these requiremets. Implemetatio It is iteded: whe a Advaced Cliical Nurse utilises these Guidelies, a MO will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet; that ay medicatio stadig orders cotaied i these Guidelies will be siged ad authorised by a MO appoited by the Local Health District. This MO may be oe of those servicig the Emergecy Departmet/s usig these Guidelies; that MO review is required followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet as soo as possible (must be withi 24 hours). At the time of this review the MO must check ad coutersig the urse record of admiistratio o the medicatio chart. NSW Health Pharmaceutical Services Brach has reviewed these Guidelies ad have idicated that they are satisfactory for the cosideratio of the idividual Local Health District Drug Committees for approval ad implemetatio as medicatio stadig orders, i terms of the criteria for stadig orders as specified i NSW Health Policy Directive, PD2007_077, Medicatio Hadlig i NSW Public Hospitals. This documet should be read i cojuctio with the followig Policy Directive from NSW Miistry of Health: PD2005_042 Guidelies for Hospitals Seekig to Exted the Practice of Health Professioals. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 4 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Abbreviatios ABG Arterial Blood Gas mg Milligram ACN Advaced Cliical Nurse ml Millilitre ACS Acute Coroary Sydrome mmol/l Millimols per Litre AED Automatic/Automated Exteral Defibrillator MO Medical Officer AMI Acute Myocardial Ifarctio MRI Magetic Resoace Imagig ARC Australia Resuscitatio Coucil MSU Mid-Stream Urie AVPU Alert, Voice, Pai, Uresposive NGT Nasogastric tube BSA Body Surface Area O 2 Oxyge BGL Blood Glucose Level PEFR Peak Expiratory Flow Rate BiPAP Bi-level Positive Airway Pressure PPE Persoal protective equipmet bpm Beats per miute PoC Poit of Care CPAP Cotiuous Positive Airway Pressure POP Plaster of Paris CK Creatie kiase PO Per oral CNS Cetral Nervous System PR Per rectum coags Coagulatio Studies PV Per vagia CPR Cardiopulmoary Resuscitatio RN Registered Nurse CSF Cerebrospial fluid SBP Systolic Blood Pressure C-Spie Cervical spie SCI Subcutaeous ijectio CT Computed Tomography S/L Subligual DBP Diastolic Blood Pressure SOB Shortess of breath ECG Electrocardiograph SpO 2 Pulse oximetry saturatio ED Emergecy Departmet Stat Immediately ad oce oly ESR Erythrocyte Sedimetatio Rate STEMI ST segmet Elevatio Myocardial Ifarctio FBC Full Blood Cout TB Tuberculosis FLECC First Lie Emergecy Care Course TBSA Total body surface area g Gram TIAs Trasiet Ischaemic Attacks GCS Glasgow Coma Score/Scale U/A Urialysis GIT Gastroitestial tract UEC Urea Electrolytes Creatiie H 2 O Water UO Urie output Hb Haemoglobi VF Vetricular fibrillatio hcg Huma Chorioic Goadotropi VT Vetricular tachycardia ICU Itesive Care Uit IDC Idwellig catheter IM Itramuscular IO Itraosseous IV Itraveous Kg Kilogram L Litre LFT Liver Fuctio Test LHD Local Health District LMA Larygeal Mask Airway LOC Level of Cosciousess MDI Metered Dose Ihaler The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 5

The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 6 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 1 Airway Emergecies The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 7

Ucoscious Patiet Medical Officer must be otified immediately For Adults Oly Ucoscious Patiet The most commo error i the maagemet of a ucoscious patiet is iadequate maagemet of Airway, Breathig ad/or Circulatio. History Prompts Oset Evets mechaism of ijury Associated precedig symptoms Cliical Severity Prompts Glasgow Coma Score (GCS) less tha 9 Relevat past history, especially diabetes ad alcohol use Medicatio history, especially arcotic use Iability to maitai ow airway Allergies Assessmet Itervetio Positio Lie supie Airway Assess patecy Maitai airway patecy Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar (if there is a possibility of ijury) Breathig Respiratory rate ad effort SpO 2 Auscultatio Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Circulatio Ski temperature IV caulatio/pathology Pulse rate ad rhythm Capillary refill Blood pressure If SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 500 ml bolus Cardiac moitor Moitor vital sigs frequetly Disability AVPU/GCS + pupils Moitor LOC frequetly If GCS less tha 9 ad ot rapidly improvig, the patiet will require edotracheal itubatio by a MO to protect the airway from aspiratio Cosider LMA isertio if GCS equals 3 ad airway difficult to maitai Note: LMA does NOT protect the airway from aspiratio BGL Figer prick BGL If less tha 3 mmol/l ad ucoscious or cofused admiister IV 50% Glucose 50 ml or If o IV access admiister IM Glucago 1 mg Moitor figer prick BGL every 15 miutes util withi ormal limits Possible opiate overdose (characterised by pi-poit pupils ad hypovetilatio) If opiate overdose, give IM Naloxoe 800 micrograms ad IV Naloxoe 800 micrograms Measure ad test Pathology Temperature U/A Collect blood for FBC, UEC, (cosider group ad hold i trauma patiets) Fluid iput/output Electrocardiography Nil by mouth IV 0.9% Sodium Chloride 1000 ml at 125 ml per hour to maitai hydratio Fluid balace chart 12 lead ECG Specific treatmet Possible alcohol abuse If history of possible alcohol abuse give IM Thiamie 100 mg Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 8 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Ucoscious Patiet Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml bolus IV Stat 50% Glucose 50 ml IV Stat Glucago 1 mg (if IV access uavailable) IM Stat Naloxoe 800 micrograms IM Stat Naloxoe 800 micrograms IV Stat 0.9% Sodium Chloride 1000 ml IV 125 ml per hour to maitai hydratio Thiamie 100 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Be alert for acute opiate withdrawal after the admiistratio of Naloxoe. The half-life of Naloxoe is much shorter tha the opiate. Repeated doses of Naloxoe may be required. If IV access is uavailable, both doses of Naloxoe may be give IM, although it should be oted that this is ot ideal as the IM route will take loger to take effect. The admiistratio of Thiamie 100 mg is advocated i patiets suspected of havig hepatic ecephalopathy but its effect is rarely immediate ad delayed admiistratio will ot chage the course of the iitial resuscitatio. The old dogma that Thiamie should be withheld util hypoglycaemia is corrected to avoid precipitatig Wericke s ecephalopathy is ufouded. The absorptio of Thiamie is so much slower tha that of glucose, timig is irrelevat (Hew, 2004, p. 367). Cosider carbo dioxide retetio i ucoscious hypoxic patiets with a history of COPD, particularly if high flow oxyge has bee admiistered i trasit to the Emergecy Departmet. Refereces: Emergecy Life Support (ELS) Course Maual, 2005, 3 rd ed, ELS Course Ic., Tamworth. Fulde, G.W.O., (editor) 2004, Emergecy medicie the priciples of practice 4 th ed, Elsevier, Sydey. Hew, R. Altered Coscious State i Textbook of Adult Emergecy Medicie, 2004, Edited by Camero, P., Jeliek, G., Kelly, A., Murray, L, Brow, A., Heyworth, J., Elsevier, Sydey MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 9

Seizures Medical Officer must be otified immediately For Adults Oly Seizures Cliical Severity Prompts Rhythmical ivolutary jerkig (toic-cloic) Stiffeig of the body History Prompts Evets mechaism of ijury Associated symptoms; altered level of cosciousess, pale, sweaty, icotiece Cleched jaw Relevat past history Altered level of cosciousess Medicatio history Allergies Oset Assessmet Itervetio Positio Protect from further harm Do NOT restrai the patiet Lie supie or left lateral (after toic phase ad cloic movemets cease) Airway Assess patecy Maitai airway patecy (a asopharygeal airway is the recommeded adjuct uless cotra-idicated) Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar (if there is a possibility of ijury) Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Stop the seizures IV Midazolam 2.5 mg icremets slow ijectio every 1-2 miutes (to a total dose of 0.1 mg/kg) or if IV access uavailable: IM Midazolam 10 mg stat ad repeat (oce oly) after 5 miutes if required It may be difficult to adequately treat the patiet s airway ad breathig util the seizures have bee stopped. Oce this has occurred, it will be ecessary to reassess/ treat/maitai the patiet s airway ad breathig Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor Moitor vital sigs frequetly Disability AVPU/GCS + pupils BGL Moitor LOC frequetly Figer prick BGL If less tha 3 mmol/l admiister IV 50% Glucose 50 ml or IM Glucago 1 mg (if IV access uavailable) Moitor figer prick BGL every 15 miutes util withi ormal limits Measure ad test Pathology Temperature U/A Fluid itake/output Collect blood for FBC, UEC Nil by mouth Specific treatmet Possible alcohol abuse If history of possible alcohol abuse give IM Thiamie 100 mg Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 10 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Seizures Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Midazolam 2.5 mg icremets IV Slow ijectio every 1 2 miutes (to a total of 0.1 mg/kg) Midazolam 10 mg (if IV access uavailable) IM Stat ad repeat (oce oly) after 5 miutes if required 50% Glucose 50 ml IV Stat Glucago 1 mg (if IV access uavailable) IM Stat Thiamie 100 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Warig: respiratory ad cardiovascular depressio ca be severe after the admiistratio of Midazolam ad requires close moitorig ad treatmet. Observe for features of the seizure ad documet. Do ot attempt to put aythig betwee the teeth durig a seizure. Refereces: Fulde G.W.O., (editor) 2004, Emergecy medicie the priciples of practice 4 th ed, Elsevier, Sydey. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 11

Aaphylactic Reactio Medical Officer must be otified immediately For Adults Oly Aaphylactic Reactio Cliical Severity Prompts Aaphylaxis is likely whe ALL three criteria are met: sudde oset ad rapid progressio of symptoms life-threateig Airway ad/or Breathig ad/ or Circulatio problems are preset ski ad/or mucosal chages (flushig, urticaria, agioedema) Relevat History ad Assessmet Prompts Oset Exposure to kow allerge for the patiet Associated symptoms: respiratory distress, peripheral vasodilatio, hypotesio, urticaria, geeralised redess ad periorbital oedema Flushig, urticaria ad agioedema ca be abset i up to 20% of cases Gastroitestial symptoms: vomitig, abdomial pai, icotiece Relevat past history Medicatio history Allergies Assessmet Positio Itervetio Positio of comfort Cease/remove causative aget Airway Assess patecy Maitai airway patecy Breathig Circulatio Stridor Hoarse voice Respiratory rate ad effort SpO 2 Wheeze Ski temperature Pulse rate/rhythm Blood pressure Capillary refill Cardiac moitor Moitor vital sigs frequetly Disability AVPU/GCS + pupils Moitor LOC frequetly Measure ad test Fluid iput/output Fluid balace chart If stridor preset give IM Adrealie 0.5mg every 3-5 miutes (to a total of 2 mg) Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% If wheeze preset give Salbutamol 10 puffs of 100 microgram dose MDI + spacer IV caulatio If pulse rate greater tha 100 bpm, SBP less tha 90 mmhg ad capillary refill greater tha 2 secods give IV 0.9% Sodium Chloride 1000 ml bolus Specific treatmet No respose to IM Adrealie ad patiet presets sigs of cardiorespiratory collapse ** IV Adrealie 50 micrograms Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 12 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Aaphylactic Reactio Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Adrealie 0.5 mg IM Every 3-5 miutes to a total of 2 mg Salbutamol 10 puffs of 100 microgram dose Ihalatio Stat MDI + spacer ** Adrealie 50 micrograms IV Stat 0.9% Sodium Chloride 1000 ml bolus IV Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Systemic allergic reactios ca occur with urticaria, agioedema ad rhiitis, but are ot aaphylactic reactios as they are ot life-threateig. Death caused by aaphylactic reactio occurs most commoly i the first 45 miutes after the patiet has had cotact with a allerge. Adrealie is the most importat drug for the treatmet of a aaphylactic ad allergic reactio. **IV Adrealie 50 micrograms equates to 0.5 ml of 1:10,000 (10 ml) Adrealie. The best site for itramuscular (IM) Adrealie is the aterolateral aspect of the middle third of the thigh the eedle eeds to be log eough to esure that the Adrealie is ijected ito muscle (Soar et. al., 2008 p. 162). Refereces: Du, R. editor i chief; et. al.. 2003, The emergecy medicie maual, 3rd. ed, Veom Publishig Uit, West Beach Emergecy Life Support (ELS) Course Maual 3 d ed. 2005. ELS Course Ic., Tamworth MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> Soar J, Pumphrey R, Cat A, et. al.. for the Workig Group of the Resuscitatio Coucil (UK). 2008, Emergecy treatmet of aaphylactic reactios: Guidelies for health care providers, Resuscitatio, vol. 77, (2), o. 2 The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 13

PAGE 14 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 2 Breathig Emergecies NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 15

Shortess of Breath with or without a History of Asthma Medical Officer must be otified immediately For Adults Oly Shortess of Breath with or without a History of Asthma Cliical Severity Prompts Correspod with either mild, moderate or severe scale as described below History Prompts Oset Associated symptoms Relevat past history Medicatio history Trigger factors Past presetatio/s admissio/s (ED/ICU/itubatio) Allergies Cliical maifestatio of acute asthma ** Severe ad life threateig ** Moderate Mild Australasia Triage Scale (ATS) 1 2 3 Physical exhaustio Yes Paradoxical chest wall movemet may be preset Talks i Words Phrases Seteces Pulse rate Greater tha 120 bpm # 100-120 bpm Less tha 100 bpm Cetral cyaosis Likely to be preset May be preset Abset Wheeze itesity Ofte quiet/silet Moderate to loud Variable No No PEFR Less tha 50% predicted (or best if kow) or less tha 100 Litres/mi Pulse oximetry Less tha 90% cyaosis may be preset 50-75% predicted (or best if kow) Greater tha 75% predicted (or best if kow) Referece: Natioal Asthma Coucil, Australia, 2006, Asthma Maagemet Hadbook, p. 39. ** Ay of these features idicate the episode is severe. The absece of ay feature does ot exclude a severe attack. # Bradycardia may be see whe respiratory arrest is immiet. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 16 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Shortess of Breath with or without a History of Asthma Medical Officer must be otified immediately For Adults Oly Assessmet Positio Itervetio Sit patiet upright or positio of comfort Airway Assess patecy Maitai airway patecy Breathig If the patiet shows sigs of pre-arrest or asthma associated with aaphylaxis (exhibits decreasig LOC, icreasig cyaosis of lips/ mouth ad bradycardia) Respiratory rate ad effort SpO 2 Speech Use of accessory muscles Steral retractio Spirometry/PEFR (moderate ad mild asthma) Severe asthma If the patiet is pre-arrest or asthma associated with aaphylaxis give IM Adrealie 0.5 mg oe dose oly Assist vetilatio if required Apply O 2 to maitai SpO 2 above 95% 8-12 puffs Salbutamol 100 microgram MDI + spacer every 15-30 miutes. 4 puffs Ipratropium Bromide 20 microgram MDI + spacer stat If patiet caot ihale adequately to use a MDI ad spacer (severe asthma) Moderate asthma Mild asthma Salbutamol 5 mg ebule ad Ipratropium bromide 500 microgram ebule stat 8-12 puffs Salbutamol 100 microgram MDI + spacer every 1-4 hours 8-12 puffs Salbutamol 100 microgram MDI + spacer stat Circulatio Ski temperature IV caulatio for moderate ad severe asthma Pulse rate/rhythm Blood pressure Cardiac moitor Moitor vital sigs frequetly Electrocardiography 12 lead ECG Disability AVPU/GCS Moitor LOC frequetly Measure ad test Specific treatmet Temperature Spirometry Cotiuig respiratory distress For moderate ad severe asthma give IV Hydrocortisoe 200 mg or oral Predisoloe 50 mg (if IV access uavailable) Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 17

Shortess of Breath with or without a History of Asthma Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 8-15 litres/mi Ihalatio Cotiuous Adrealie 0.5 mg IM (pre-arrest circumstace) Stat Salbutamol 100 microgram per ihalatio MDI + spacer Ihalatio Severe: 8-12 puffs every 15-30 miutes Moderate: 8-12 puffs every 1-4 hours Mild: 8-12 puffs stat Salbutamol 5 mg Nebule Ihalatio Every 15-30 miutes (for patiets with severe asthma who caot ihale well eough to use MDI + spacer) Ipratropium Bromide 4 puffs of 20 microgram per Ihalatio Stat for severe cases ihalatio MDI + spacer Ipratropium Bromide 500 microgram Nebule Ihalatio Severe: stat (for patiets with severe asthma who caot ihale well eough to use MDI + spacer) Hydrocortisoe 200 mg IV Stat for moderate ad severe asthma Predisoloe 50 mg (if IV access Oral Stat for severe ad moderate asthma uavailable) 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 18 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Shortess of Breath with or without a History of Asthma Medical Officer must be otified immediately For Adults Oly Precautios ad Notes: There is substatial evidece that Ipratropium Bromide is of limited use i acute episodes of mild to moderate asthma. Ipratropium Bromide is ot ecessary i mild asthma ad optioal i moderate episodes. The use of short actig beta agoists by itermittet ihalatio via MDI ad spacer is ow recommeded i the maagemet of acute asthma, whether mild, moderate or severe. Delivery of short actig beta agoists via MDI ad spacer is equally effective as ebulisatio i patiets with moderate to severe acute asthma, other tha for those patiets with life-threateig asthma who caot ihale well eough to use a MDI + spacer (e.g. those requirig vetilatio). Cotiuous ebulisatio ad IV therapy are alteratives i severe asthma. However, adverse evets are more frequet. Use a ebuliser istead of MDI if the patiet caot ihale adequately. A 5 mg ebule of Salbutamol should be made up with 2 ml 0.9% Sodium Chloride. If available, give oxyge at a flow of 8-10 L/mi. A mouthpiece delivers cosiderably more drug to the lug tha a facemask. The best site for itramuscular (IM) Adrealie is the aterolateral aspect of the middle third of the thigh the eedle eeds to be log eough to esure that the Adrealie is ijected ito muscle (Soar et. al. 2008, p. 162). Refereces: Doherty, S. 2006, Emergecy care evidece i practice series: use of ipratropium bromide for acute asthma, Emergecy Care Commuity of Practice, Natioal Istitute of Cliical Studies, Melboure. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Natioal Asthma Coucil Australia, 2006, Asthma Maagemet Hadbook, revised ad updated, Natioal Asthma Coucil, Australia. NSW Health, 2007, PD2007_063 Ifectio Cotrol Policy, NSW Departmet of Health, North Sydey. Soar J, Pumphrey R, Cat A, et. al. for the Workig Group of the Resuscitatio Coucil (UK). 2008, Emergecy treatmet of aaphylactic reactios: Guidelies for health care providers, Resuscitatio, vol. 77(2), o. 2. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 19

Shortess of Breath with a History of Cardiac Disease Medical Officer must be otified immediately For Adults Oly Shortess of Breath with a History of Cardiac Disease Cliical Severity Prompts Severe respiratory distress with exhaustio Altered level of cosciousess History Prompts Oset Evets Associated symptoms pale, clammy, audible respiratory crepitatios, speakig i phrases or words Ability to talk i words oly Relevat past history Cetral cyaosis History of cardiac disease Audible respiratory crepitatios Medicatio history Allergies Assessmet Positio Itervetio Sit patiet upright Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Speech Auscultatio Assist vetilatio if required with positive pressure bag valve mask Apply O 2 via o re-breather mask at 15 L/mi, aim to maitai SpO 2 greater tha 95% Cosider CPAP/BiPAP if available Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure If SBP greater tha 90 mmhg give Glyceryl Triitrate S/L 300-600 micrograms or spray 1-2 sprays (400-800 micrograms) Repeat every 5 miutes if SBP greater tha 90 mmhg Audible respiratory crepitatios Audible respiratory crepitatios preset give IV Frusemide 40 mg Disability Cardiac moitor Electrocardiography AVPU/GCS BGL Moitor vital sigs frequetly 12 lead ECG Moitor LOC frequetly Figer prick BGL Measure ad Test Pathology Collect blood for FBC, UEC, cardiac markers ad ABG or veous blood gas (if available) Fluid iput/output U/A Fluid balace chart Restrict oral fluid itake Cosider IDC ad urie measuremets every hour Chest X-ray If available Specific Treatmet Cotiuig respiratory distress CPAP 10 cm H 2 0 if available ad SBP greater tha 100 mmhg ad SOB urelieved by other itervetios (i.e. Nitrates ad Frusemide) Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 20 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Shortess of Breath with a History of Cardiac Disease Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 15 litres/mi Ihalatio Cotiuous No re-breather mask Glyceryl Triitrate 300-600 micrograms S/L Stat ad the every 5 miutes (if SBP greater tha 90 mmhg) to a total of 3 tablets (1800 micrograms) Glyceryl Triitrate 1-2 sprays (400-800 micrograms) S/L Stat ad the every 5 miutes (if SBP greater tha 90 mmhg) to total of 4 sprays (1600 micrograms) Frusemide 40 mg IV Stat if audible respiratory crepitatios preset 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: DO NOT admiister Nitrates if patiet has take medicatios for treatmet of sexual dysfuctio e.g. Sildeafil (Viagra) i previous 24 hour period (profoud hypotesive effect). CPAP/BiPAP ca oly be used effectively whe the patiet has adequate respiratory effort. Systolic blood pressure less tha 90 mmhg with acute pulmoary oedema costitutes a diagosis of cardiogeic shock requirig emergecy circulatory assistace. Refereces: Lightfoot, D., 2004, Assessmet ad maagemet of acute pulmoary oedema i EDs, i Textbook of Adult Emergecy Medicie, 2 d ed, eds P. Camero, G. Jeliek, A. Kelly, L. Murray, A. Brow, J. Heyworth, Churchill Livigstoe, Sydey. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Natioal Heart Foudatio of Australia, 2006, Guidelies for the prevetio, detectio ad maagemet of chroic heart failure i Australia, November 2006. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 21

Shortess of Breath with a History of COPD Medical Officer must be otified immediately For Adults Oly Shortess of Breath with a History of Chroic Obstructive Pulmoary Disease Cliical Severity Prompts History of chroic obstructive pulmoary disease (emphysema, chroic brochitis) Severe respiratory distress with exhaustio Altered level of cosciousess Ability to talk i words oly History Prompts Oset Associated symptoms pale, sweaty, cyaosis Relevat past history chroic obstructive pulmoary disease Medicatio history Past presetatios/admissios (ED/ICU/itubatio) Allergies Cetral cyaosis Cofusio, lethargy or evidece of hypovetilatio Assessmet Positio Itervetio Sit patiet upright / positio of comfort Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Audible wheeze preset If patiet caot ihale adequately to use a MDI ad spacer (severe cases) Speech Use of accessory muscles Steral retractio Assist vetilatio if required Apply O 2 usig veturi mask start at 24%-28% to maitai SpO 2 90-95% 10 puffs Salbutamol 100 microgram MDI + spacer ad 4 puffs Ipratropium Bromide 20 microgram MDI + spacer Salbutamol 5mg ebule every 20 miutes if required ad Ipratropium bromide 500 microgram ebule stat Circulatio Ski temperature IV caulatio Pulse rate/rhythm Blood pressure Cardiac moitor Moitor vital sigs frequetly Disability AVPU/GCS Moitor LOC frequetly Measure ad test Temperature Electrocardiography Sputum Chest X-Ray Arterial blood gas or veous blood gas 12 lead ECG Obtai specime for microbiology If available If available Specific treatmet Cotiuig respiratory distress For moderate ad severe cases give IV Hydrocortisoe 200 mg or oral Predisoloe 50 mg (if IV access uavailable) CPAP/BiPAP Prepare equipmet if available Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 22 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Shortess of Breath with a History of COPD Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge Start at 24%-28% Ihalatio Veturi Mask Cotiuous Salbutamol 10 puffs of 100 microgram per Ihalatio Repeat every 20 miutes if required ihalatio MDI + spacer Salbutamol 5 mg Nebule Ihalatio Repeat every 20 miutes if required (for patiets who caot ihale well eough to use MDI + spacer) Ipratropium Bromide 4 puffs of 20 microgram MDI + spacer Ihalatio Stat Ipratropium Bromide 500 microgram Nebule Ihalatio Stat (for patiets who caot ihale well eough to use MDI + spacer) Hydrocortisoe 200 mg IV Stat Predisoloe 50 mg (if IV access uavailable) Oral Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Never withhold oxyge i severely dyspoeic patiets Metal status is a importat idicator of both worseig hypoxia ad hypercapia Be aware of sigs of hypercapia particularly decreasig LOC. Gas flow through medium cocetratio oxyge masks (e.g. Hudso) is iadequate whe the patiet is tachypoeic therefore these masks should ot be used. High flow oxyge should be avoided. Use a ebuliser istead of MDI if the patiet caot ihale adequately. A 5 mg ebule of Salbutamol should be made up with 2 ml 0.9% Sodium Chloride. Nebulised solutios are to be admiistered usig AIR. Refereces: Emergecy Life Support (ELS) Course Maual, 3rd ed. 2005, ELS Course Ic., Tamworth. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> Soar J., Pumphrey R., Cat A., et. al.. for the Workig Group of the Resuscitatio Coucil (UK). 2008, Emergecy treatmet of aaphylactic reactios: Guidelies for health care providers, Resuscitatio, vol. 77, (2), o. 2. The Australia Lug Foudatio, 2008, The COPD-X Pla: Australia ad New Zealad Guidelies for the Maagemet of Chroic Obstructive Pulmoary Disease versio 2.15 May 2008. (Edorsed by the Thoracic Society of Australia & New Zealad) NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 23

The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 24 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 3 Circulatory Emergecies The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 25

Basic Life Support Medical Officer must be otified immediately For Adults Oly Cardiorespiratory Arrest (Basic Life Support) Australia Resuscitatio Coucil, December 2010, Guidelie 8. Basic Life Support D R S A B C D Dagers? Resposive? Sed for help Ope Airway Normal Breathig? Start CPR 30 compressios : 2 breaths if uwillig / uable to perform rescue breaths cotiue chest compressios Attach Defibrillator (AED) as soo as available ad follow its prompts Cotiue CPR util resposiveess or ormal breathig retur December 2010 Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 26 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Advaced Life Support Medical Officer must be otified immediately For Adults Oly Cardiorespiratory Arrest (Advaced Life Support) Australia Resuscitatio Coucil, December 2010, Guidelie 11.2 Shockable Shock CPR for 2 miutes Advaced Life Support for Adults Start CPR 30 compressios: : 2 breaths Miimise Iterruptios Attach Defibrillator / Moitor Assess Retur of Spotaeous Curculatio? No Shockable CPR for 2 miutes Durig CPR Airway adjucts (LMA / ETT) Oxyge Waveform capography IV / IO access Pla actios before iterruptig compressios (e.g. charge maual defibrillator) Drugs Shockable * Adrealie 1 mg after 2 d shock (the every 2 d loop) * Amiodaroe 300 mg after 3 rd shock No Shockable * Adrealie 1 mg immediately (the every 2 d loop) Cosider ad Correct Hypoxia Hypovolaemia Hyper / hypokalaemia / metabolic disorders Hypothermia / hyperthermia Tesio peumothorax Tampoade Toxis Thrombosis (pulmoary / coroary) Post Resuscitatio Care Re-evaluate ABCDE 12 lead ECG Treat precipitatig causes Re-evaluate oxygeatio ad vetilatio Temperature cotrol (cool) Post Resuscitatio Care December 2010 Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 27

Advaced Life Support Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 15 litres/mi Ihalatio Cotiuous Adrealie 1 mg IV/IO Shockable rhythms- After 2d shock, the every 2d loop to a total of 3 mg No-shockable rhythms- immediately, the every 2d loop to a total of 3 mg Amiodaroe 300 mg IV/IO Stat after 3rd shock 0.9% Sodium Chloride 30 ml flush IV/IO As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: If stat dose of IV/IO Amiodaroe is effective ad retur of spotaeous circulatio has bee achieved the Amiodaroe ifusio is recommeded to follow. Refereces: Australia Ijectable Drugs Hadbook, 4 th editio. July 2008, The Society of Hospital Pharmacists of Australia. Australia Resuscitatio Coucil, 2010, Guidelie 11.2: Protocols for adult Advaced Life Support, ARC, Melboure. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 28 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Compromisig Bradycardia Medical Officer must be otified immediately For Adults Oly Compromisig Bradycardia Bradycardia must be cosidered i relatio to associated symptoms. Cliical Severity Prompts History Prompts Evets leadig to presetatio Sycope or seizure Chest pai oset (if ay) Bradycardia: less tha 40 beats per miute ad Associated symptoms: symptomatic i.e. plus oe or more of the followig: dyspoea - altered level of cosciousess sweatig - blood pressure: SBP less tha 90 mmhg pallor - chest pai fatigue - shortess of breath - sycope/dizziess - diaphoresis Relevat past history medicatio history allergies Assessmet Positio Itervetio Supie depedig o cliical status Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure If SBP less tha 90 mmhg give IV Atropie 0.5 mg icremets every 5 miutes (to total of 3mg) to maitai systolic blood pressure greater tha 90 mmhg Disability Cardiac moitor AVPU/GCS BGL Moitor vital sigs frequetly If o respose to Atropie MO to cosider exteral trasthoracic pacig (if available) Moitor LOC frequetly Figer prick BGL Measure ad test Electrocardiography 12 lead ECG (withi five miutes of arrival to ED) Pathology Collect blood for FBC, UEC, cardiac markers (where available) Fluid iput/output Fluid balace chart Nil by mouth Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 29

Compromisig Bradycardia Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Atropie 0.5 mg icremets to a total of 3mg IV Every 5 miutes titrated to maitai systolic blood pressure greater tha 90 mmhg 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Hypoxia ca cause bradycardia. Iferior myocardial ifarctio/ischaemia may lead to bradyarrhythmias. Symptomatic complete heart block will require pacig ad/or urget trasfer to defiitive care. Atropie may be ieffective i patiets who are o beta-blockers. Refereces: Brady W.J., Swart G., De Behke D.J., Joh Ma O., Aufderheide T. P. 1999, The efficacy of atropie i the treatmet of haemodyamically ustable bradycardia ad atrio-vetricular block: prehospital ad emergecy departmet cosideratios. Resuscitatio, vol. 41, o. 1, pp. 47-55. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Sodeck G.H., Domaovits H., Mero G., et. al.. 2007, Compromisig bradycardia: maagemet i the emergecy departmet Resuscitatio, vol. 73, o. 1, pp. 96-102. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 30 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Acute Coroary Sydrome Medical Officer must be otified immediately For Adults Oly Acute Coroary Sydrome (with or without associated symptoms) Cliical Severity Prompts Chest pai/discomfort heavy, cetral/left/right ad/ or associated symptoms Time pai lastig loger tha 5 miutes History Prompts Symptoms suggestive of myocardial ischaemia Provokes/Precipitates: what makes the pai worse? What were you doig whe you got the pai? Quality: what does the pai feel like? Describe the pai Regio: cetre of chest, retrosteral; Radiatio: arm(s)/back/jaw Severity: pai score 0-10 Time: oset of pai, pai lastig loger tha 5 miutes (refer to Appedix 7) Associated symptoms: ausea/vomitig sweatig shortess of breath palpitatios lethargy/fatigue Other: relevat past history risk factors: familial, diabetes, hyperlipidaemia, smokig, Aborigial & Torres Strait Islader medicatio history, icludig medicatios used for the treatmet of sexual dysfuctio e.g. Sildeafil (Viagra) allergies Commece NSW Chest Pai Pathway (Appedix 4) Assessmet Positio Itervetio Positio patiet upright/positio of comfort Airway Assess patecy Maitai airway patecy Breathig Circulatio Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor Electrocardiography Assist vetilatio if required Apply O 2 if SpO 2 less tha 93%** Aspiri 300 mg (chew) (if ot already give by Ambulace Officer) If pai preset, give Glyceryl Triitrate S/L 300-600 micrograms or Glyceryl Triitrate Spray S/L (400-800 micrograms) if SBP greater tha 90 mmhg, ca be repeated every 5 miutes Moitor vital sigs frequetly 12 lead ECG (withi 5 miutes of arrival to ED) IV caulatio/pathology If pai is preset, give IV Morphie 2.5 mg icremets every 5 miutes to a total 10 mg or IM Morphie (if IV access uavailable) 5-10 mg Assess suitability for fibriolysis (refer to Appedix 5) Disability AVPU/GCS BGL Moitor LOC frequetly Figer prick BGL Measure ad test Pathology Collect blood for (FBC, UEC, Tropoi where available) Fluid iput/output Moitor pai score If pai free after 30 Fluid balace chart Repeat 12 lead ECG miutes If pai returs at ay time Repeat 12 lead ECG Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 31

Acute Coroary Sydrome Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Apply if SpO 2 below 93% Aspiri 300 mg Oral (chew) Stat Glyceryl Triitrate 300-600 micrograms (½ -1 tablet) S/L Stat Every 5 miutes (if SBP greater tha 90 mmhg) to a total of 3 tablets (1800 micrograms) Glyceryl Triitrate spray Morphie Morphie 1-2 sprays (400-800 micrograms) 2.5 mg icremets (10 mg diluted with 9 ml 0.9% Sodium Chloride) 5-10 mg (if IV access uavailable) 0.9% Sodium Chloride 10 ml flush IV As required S/L IV IM Stat Every 5 miutes (if SBP greater tha 90 mmhg) to a total of 4 sprays (1600 micrograms) Every 5 miutes (ot to exceed a total of 10 mg) Stat (ot to exceed total of 10 mg) Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: **Oxyge therapy is idicated for patiets with hypoxia (SpO 2 less tha 93%) ad those with evidece of shock to correct tissue hypoxia. I the absece of hypoxia the beefits of oxyge therapy is ucertai ad i some cases oxyge therapy may be harmful (Chew et al 2011). Do NOT admiister Nitrates if patiet has take medicatios used for the treatmet of sexual dysfuctio e.g. Sildeafil (Viagra) i previous 24 hour period (profoud hypotesive effect). The diabetic, elderly, female or youg patiet may preset with atypical symptoms such as dyspoea, ausea, vomitig, palpitatios, sycope or cardiac arrest, o pai. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 32 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Acute Coroary Sydrome Medical Officer must be otified immediately For Adults Oly Refereces: Chew, D., Aroey, C., Aylward, P., Kelly, A-M., White, H.,Tidema, P., Waddell, J., Azadi, L., Wilso, A., Ruta, L. 2011. 2011 Addedum to the Guidelies for the Maagemet of Acute Coroary Sydrome. Heart, Lug & Circulatio, 20(8). Jowett N.I., Turer A.M., Cole A. ad Joes P.A., 2005, Modified electrode placemet must be recorded whe performig 12-lead electrocardiograms, Postgrad. Med. J. vol. 81, pp. 122-125. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Natioal Heart Foudatio of Australia & Cardiac Society of Australia ad New Zealad, 2006, Guidelies for the maagemet of acute coroary sydromes, The Medical Joural of Australia, vol. 184 o. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html>. Natioal Heart Foudatio, 2000, Reperfusio therapy for acute myocardial ifarctio. Rya T. J. ad Reeder G.S., 2009, Maagemet of suspected acute coroary sydrome i the emergecy departmet, viewed 19.01.2009, <http://www.uptodate.com/olie/cotet/topic.do?topickey=ad_emer/2821&selectedtitle=3`15 0&source=search_result>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 33

No-traumatic Shock Medical Officer must be otified immediately For Adults Oly No-traumatic Shock Tachycardia may ot occur i elderly patiets Patiets who are ormally hypertesive may require fluid resuscitatio prior to SBP less tha 90 mmhg sweaty capillary refill greater tha 2 secods History Prompts Oset Cliical Severity Prompts Tachycardia: (greater tha 100 beats per miute) Poor brai perfusio restlessess altered level of cosciousess Poor ski perfusio cold pale Evets: vomitig/diarrhoea, ifectio, pregacy, gastric/abdomial pai (If history of trauma refer to Trauma Guidelie) Relevat past history: palpitatios, light-headed, faitig Medicatio history Allergies Assessmet Itervetio Full PPE measures must be cosidered Positio Lie supie Airway Assess patecy Maitai airway patecy Breathig Circulatio Disability Measure ad test Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor AVPU/GCS + pupils BGL Primary Survey Secodary Survey Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% IV caulatio x 2/pathology If SBP less tha 90 mmhg give IV/IO 0.9% Sodium Chloride 500 ml bolus Moitor vital sigs frequetly Moitor LOC frequetly Figer prick BGL Repeat Commece Pathology Temperature U/A Fluid iput/output PV Loss Take blood for FBC, UEC, group ad hold (if required), veous blood gas, blood culture ad serum lactate Measure Hb if poit of care device (e.g. istat) is available Urie hcg (wome of childbearig age) Urie culture Fluid balace chart Nil by mouth Isert IDC measure ad record urie output every hour Moitor Electrocardiography 12 lead ECG Chest X-ray If available Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 34 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

No-traumatic Shock Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml IV/IO Stat (repeat oce oly if SBP remais less tha 90 mmhg) 0.9% Sodium Chloride 10 ml flush IV/IO As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Close moitorig of fluid iput ad output is essetial. Pregat wome (greater tha 20 weeks gestatio): require a left lateral tilt to reduce compressio of the Iferior Vea Cava hypotesio is a late sig of hypovolaemia greater volumes tha expected are required for resuscitatio. Refereces: Du R. et. al. (editor), 2000, The emergecy medicie maual, 2d ed, Veom Publishig Uit, West Beach. Emergecy Life Support (ELS) course maual, 3 d ed. 2005, ELS Course Ic., Tamworth. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Rose B.D. ad Madel J., Treatmet of severe hypovolaemia or hypovolaemic shock i adults, viewed 19.01.09, <http://uptodate.com/olie/cotet/topic.do?topickey=cc_medi/14949>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 35

Stroke icludig Trasiet Ischaemic Attack Medical Officer must be otified immediately For Adults Oly Stroke icludig Trasiet Ischaemic Attack Cliical Severity Prompts Facial weakess ca the perso smile? Is there mouth or eye droop? Arm weakess ca the perso raise both arms? Speech difficulty ca the perso speak clearly ad uderstad what you say? Time time of oset of symptoms ad duratio. History Prompts Oset Associated symptoms: Altered level of cosciousess, dizziess or loss of balace, loss of visio, blurred visio or decreased visio i oe or both eyes, headache, difficulty swallowig, altered or garbled speech, weakess or umbess i face or limbs, acute oset of cofusio Relevat past history cofirmed previous TIAs, diabetes, smoker, hypertesio, age 60 years or over Treat as a medical emergecy. Medicatio history especially diabetic medicatio ad aticoagulats such as warfari, aspiri, clopidogrel. Seizure medicatio. Alterative therapies Allergies Assessmet Positio Itervetio Positio head up 30 uless cotraidicated Airway Assess patecy Maitai airway patecy Breathig Circulatio Disability Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor Electrogradiograph AVPU/GCS + pupils BGL Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% IV caulatio/pathology If SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 500 ml Moitor vital sigs frequetly 12 lead ECG Moitor LOC frequetly Figer prick BGL less tha 3.5 mmol/l If ucoscious or cofused admiister IV 50% Glucose 50 ml or if IV access uavailable, admiister IM Glucago 1 mg Measure ad test Pathology Collect blood for (FBC, UEC, ESR, BGL, coags, veous blood gases) If temp greater tha 38.5 C take blood cultures Temperature Neurological Observatios Headache pai score (4-10) U/A Fluid iput/output Chest X-ray If greater tha 37.5 C give Paracetamol 500 mg - 1 g IV or Paracetamol 500 mg 1 g PR Moitor frequetly If headache pai score 4 10 give IV Morphie 2.5 mg icremets every 5 miutes to a total of 10 mg or IM Morphie 5 10 mg (if IV access uavailable) Full urialysis Fluid balace chart Nil by mouth cosider NGT If available The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 36 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Stroke icludig Trasiet Ischaemic Attack Medical Officer must be otified immediately For Adults Oly Specific treatmet Nausea/Vomitig If ausea/vomitig preset give IV or IM Metoclopramide 10 mg Hydratio Rapid iitial stroke scree (ROSIER Scale) ABCD 2 if TIA suspected Bedside swallow scree Possible alcohol abuse IV 0.9% Sodium Chloride 1000 ml (125 ml/hour to maitai hydratio) If score greater tha 0, trasfer for urget CT/MRI If greater tha 4, trasfer for urget CT/MRI Nil by mouth util bedside swallow scree atteded (withi 24 hours) If history of possible alcohol abuse give IM Thiamie 100 mg Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml (Circulatory support) IV Stat (repeat oce if SBP remais less tha 90 mmhg) 50% Glucose 50 ml IV Stat Glucago 1 mg (if IV access uavailable) IM Stat Paracetamol 500 mg 1g (If ot give IV) PR Stat Paracetamol 500 mg 1g (If ot give PR) IV Stat Morphie 2.5 mg icremets (10 mg IV Every 5 miutes (to a total of 10mg) diluted with 9 ml 0.9% Sodium Chloride) Morphie 5-10 mg (if IV access IM Stat (to a total of 10 mg) uavailable) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 1000 ml (maitai hydratio) IV 125 ml per hour Thiamie 100 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical officer review is required followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet as soo as possible (withi 24 hours). At the time of this review, the medical officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a advaced cliical urse uses these cliical guidelies, a medical officer will be otified, as early as practical, to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 37

Stroke icludig Trasiet Ischaemic Attack Medical Officer must be otified immediately For Adults Oly Precautios ad Notes: Body temperature icreases i up to 50% of patiets over the iitial 48 hours of stroke oset. The presece of fever has bee foud to correlate with poorer outcomes i stroke. Therefore atipyretics such as paracetamol or other fever-lowerig strategies are recommeded early i the maagemet of acute stroke, util body temperature is lowered to 37.5 C. Pai assessmet may require o-verbal assessmet (i.e Abbey scale Appedix 8) The ROSIER scale (p. 39) is the oly tool that has bee validated specifically for use i the ED followig triage. The ROSIER scale should be implemeted as stadard practice as part of the iitial assessmet i ED of all suspected stroke patiets. TIA ad mior stroke patiets are at high risk of subsequet stroke, with up to 10% sufferig a stroke withi the followig 48 hours. The ABCD 2 assessmet (p. 39) is the best, validated tool curretly available ad ca provide stratificatio iformatio to guide maagemet decisios. The ROSIER scale ad ABCD 2 assessmet are provided o page 39 Ideally all people with stroke should be trasferred to a hospital with a stroke uit (preferably withi three hours of stroke oset) for the beefit of thrombolysis where applicable. Patiets eed to be treated withi three hours of stroke oset. Patiets meetig criteria have up to a 4.5 hour timeframe from stroke symptom oset for thrombolysis admiistratio. A CT is required before the decisio to thrombolyse ca be made, so early trasfer is a priority. The admiistratio of thiamie 100 mg is advocated i patiets suspected of havig hepatic ecephalopathy but its effect is rarely immediate ad delayed admiistratio will ot chage the course of the iitial resuscitatio. The old dogma that thiamie should be withheld util hypoglycaemia is corrected to avoid precipitatig Wericke s ecephalopathy is ufouded. The absorptio of Thiamie is so much slower tha that of glucose, timig is irrelevat (Hew, 2004, p. 367). Refereces: ACT Now Expert report (2004): Improvig patiet maagemet ad outcomes i acute stroke: a coordiated approach. Australia Medicies Hadbook olie 2011 http://proxy7.use.hc.com.au/view.php?page=chapter3/ moographparacetamol.html#paracetamol <accessed February 2011> Australia Medicies Hadbook olie 2011 http://proxy7.use.hc.com.au/dbsearch.php?q=aspiri <accessed Feb 2011> Natioal istitute of cliical studies. 2009: Emergecy departmet stroke ad trasiet ischaemic attack care budle: Iformatio ad implemetatio package. Melboure: atioal Health ad Medical Research Coucil. Pages 15, 22. Natioal Stroke Foudatio 2010: Cliical Guidelies for stroke maagemet. Melboure Australia. Nor AM, Davis J, Se B, Shipsey D, et al 2005: The recogitio of stroke i the emergecy room (ROSIER) scale; developmet ad validatio of a stroke recogitio istrumet. Lacet Neurol Nov;4(11):727-34. Hew, R., 2004, Altered Coscious State i Textbook of adult emergecy medicie, eds Camero, P., Jeliek, G., Kelly, A., Murray, L., Brow, A., Heyworth, J., Elsevier, Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 38 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Stroke icludig Trasiet Ischaemic Attack Medical Officer must be otified immediately For Adults Oly ROSIER Scale Recogitio of Stroke i the Emergecy Room (ROSIER) Assessmet Symptom oset Date: / / Time: : GCS E= M= V= BP= / BGL= If BGL 3.5 mmol/l, treat urgetly ad reassess oce blood glucose ormal Date: / / Time: : Has there bee loss of cosciousess or sycope? Y (-1) o N (0) o Has there bee seizure activity? Y (-1) o N (0) o Is there a NEW ACUTE oset (or o awakeig from sleep) 1. Asymmetric facial weakess Y (+1) o N (0) o 2. Asymmetric arm weakess Y (+1) o N (0) o 3. Asymmetric leg weakess Y (+1) o N (0) o 4. Speech disturbace Y (+1) o N (0) o 5. Visual field defect Y (+1) o N (0) o Total score (-2 to +5) Provisioal diagosis Stroke o No-stroke (specify) o Note: Stroke is ulikely, but ot completely excluded if total scores are less tha or equal to 0. If score is greater tha 0 trasfer for urget CT/MRI Referece: Nor AM, Davis J, Se B, Shipsey D, et al (2005): The recogitio of stroke i the emergecy room (ROSIER) scale; developmet ad validatio of a stroke recogitio istrumet. Lacet Neurol Nov;4(11):727-34. ABCD 2 assessmet whe TIA suspected Assessmet Poits Score A Age: greater tha or equal to 60 years 1 poit B Blood pressure: greater tha or equal to 140/90 mmhg 1 poit C Cliical features: Uilateral weakess 2 poits Speech impairmet without weakess 1 poit D Duratio greater tha 60 miutes 2 poits Duratio 10 59 miutes 1 poit D Diabetes 1 poit Tool Iterpretatio Total Less tha or equal to 3 poits = Low risk Greater tha or equal to 4 poits = High risk If score is greater tha or equal to 4 poits trasfer for urget CT/MRI Referece: Natioal Stroke Foudatio 2010: Cliical Guidelies for stroke maagemet. Melboure Australia. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 39

Severe Sepsis Medical Officer must be otified immediately For Adults Oly Severe Sepsis Cliical Severity Prompts Immuocompromised patiet Abdome: pai, peritoism Chest: cough, shortess of breath Neuro: decreased metal alertess, eck stiffess headache. Idwellig medical device Recet surgery/ ivasive procedure History of fevers or rigors Red flags i ambulace hadover Ski: cellulitis, woud Urie: dysuria, frequecy, odour History Prompts Oset Recet overseas travel Relevat past history: diabetic, age Medicatio history Allergies Immediately call for assistace ad otify the Medical Officer ad Aeromedical ad Medical Retrieval Service (1800 650 004) Assessmet Positio Itervetio Positio of comfort Airway Assess patecy Maitai airway patecy Breathig Circulatio Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor Electrogradiograph Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% IV caulatio/pathology If SBP less tha 90 mmhg give IV/IO 0.9% Sodium Chloride 500 ml Moitor vital sigs frequetly 12 lead ECG Disability AVPU/GCS + pupils BGL DO NOT DELAY ANTIBIOTIC ADMINISTRATION Moitor LOC frequetly Figer prick BGL less tha 3.0 mmol/l ad coscious, admiister simple sugar or If ucoscious or cofused admiister IV 50% Glucose 50 ml or If IV access uavailable, admiister IM Glucago 1mg Figer prick BGL every 15 miutes util withi ormal limits ad the patiet metally alert Measure ad test Pathology If possible, take blood for FBC, UEC, LFT, coags, blood cultures x 2, veous blood gas Temperature U/A Fluid iput/output Chest X-ray If less tha 35.5 C apply warmig adjuctive measures. If greater tha 38.5 C give oral Paracetamol 500 mg 1 g Full urialysis Urie culture Fluid balace chart Isert IDC measure ad record urie output every hour If available The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 40 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Severe Sepsis Medical Officer must be otified immediately For Adults Oly Specific treatmet Hydratio itake IV 0.9% Sodium Chloride 1000 ml (125 ml/hour to maitai hydratio) Atibiotics IV/IO Flucloxacilli 2 g ad IV Getamici 7 mg/kg for first dose (maximum 640 mg) If allergic to peicilli give IV Vacomyci accordig to patiet s body weight Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/miute Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml IV/IO Stat (repeat oce if SBP remais less tha 90 mmhg) 50% Glucose 50 ml IV/IO Stat if BGL less tha 3.5 mmol/ L Glucago 1 mg (if IV access uavailable) IM Stat Paracetamol 500 mg - 1 g oral Stat 0.9% Sodium Chloride 1000 ml ( to maitai IV 125 ml/hour hydratio) Flucloxacilli 2 g dissolved i water for ijectio IV/IO 2 g i 50 ml 0.9% Sodium Chloride over at least 30 miutes Getamici 7 mg/kg (maximum 640 mg) IV 240 mg or less over 3-5 miutes More tha 240 mg over 30 miutes Some cetres may give up to 640 mg IV push over 3-5 miutes. Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 1000 ml (maitai hydratio) IV 125 ml per hour Thiamie 100 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Vacomyci (oly if patiet is allergic to peicilli) Loadig dose give accordig to patiet s actual body weight: Less tha 60 kg: 1 g 60-80 kg: 1.5 g 81-100 kg: 2 g Greater tha 100 kg: 2.5 g IV Admiister i 0.9% Sodium Chloride at a ifusio rate of o more tha 10 mg/miute The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 41

Severe Sepsis Medical Officer must be otified immediately For Adults Oly Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: IM atibiotic admiistratio is NOT preferred i this settig as superveig shock ad hypotesio may lead to failure of absorptio of the ijected atibiotic. Collectio of blood sample for culture should be attempted prior to admiistratio of atibiotics but should ot delay treatmet. IV Vacomyci is oly iitiated if the patiet is allergic to peicilli. IV Vacomyci must be ifused at a rate of o more tha 10 mg/miute. If the patiet is give Vacomyci, the Medical Officer must cofirm the patiet s real fuctio ad order a appropriate dose to be admiistered 12 hours after the loadig dose. Refereces: Agecy for Cliical Iovatio ad the Cliical Excellece Commissio. 2011. Sepsis Pathway. NSW Health. Agecy for Cliical Iovatio ad the Cliical Excellece Commissio. 2011. Sepsis Adult FIRST DOSE Empirical Itraveous Atibiotic Guidelie V1. NSW Health. etg Therapeutic Guidelies. Chapter 2. Revised Jue 2010. Ammeded October 2010. Therapeutic Guidelies Ltd. (www.tg.com.au) etg 3 March 2011. http://proxy9.use.hc.com.au/tgc/abg/708.htm#727id_gl The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 42 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 4 Disability Emergecies NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 43

Meigococcal Disease Medical Officer must be otified immediately For Adults Oly Meigococcal Disease: No-blachig Rash Cliical Severity Prompts Appearace of rapidly developig o-blachig petechial or purpuric rash (bruised haemorrhagic type/ does ot blach i.e. ski colour does ot fade uder pressure) which may oly be several lesios (refer Appedix 10 for Glass Tumbler Test) Associated symptoms iclude: headache, fever, vomitig, eck stiffess, photophobia ad drowsiess History Prompts Oset Evets bacterial meigitis suspected Associated symptoms: altered/abormal level of cosciousess, pallor, irritability (global sigs of meigeal irritatio) Relevat past history: cotact/associatio with perso/s recetly diagosed with meigococcal disease withi past 60 days immuosuppressio, recet head/eck ifectio Medicatio history Allergies Immediately call for assistace ad otify the Medical Officer ad Aeromedical ad Medical Retrieval Service (1800 650 004) Assessmet Itervetio Full PPE must be wor at all times Positio Completely udress Positio of comfort (icludig uderwear ad socks) Ispect all body surfaces/ folds/creases for rash Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure If SBP less tha 90 mmhg give IV/IO 0.9% Sodium Chloride 500 ml Disability Cardiac moitor 12 lead ECG AVPU/GCS + pupils BGL Moitor vital sigs frequetly As idicated DO NOT DELAY ANTIBIOTIC ADMINISTRATION Moitor LOC frequetly Figer prick BGL Measure ad test Pathology If possible, take blood for FBC, UEC, blood cultures Temperature U/A Fluid iput/output Nil by mouth Specific treatmet No blachig petechial/ purpuric rash If patiet weighs greater tha 65 kg give Dexamethasoe 10 mg IV/IO stat If less tha 65 kg give 0.15 mg per kg IV/IO stat ad IV/IO or IM Bezylpeicilli 1.2 g. If allergic to Bezylpeicilli give IV/IO or IM Ceftriaxoe 2 g Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 44 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Meigococcal Disease Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml IV/IO Stat (repeat oce if SBP remais less tha 90 mmhg) Dexamethasoe If patiet greater tha 65 kg give IV/IO Stat 10 mg Dexamethasoe If less tha 65 kg give 0.15 mg per kg Bezylpeicilli 1.2 g IV/IO/IM Stat Ceftriaxoe 2 g (if allergic to Bezylpeicilli) IV/IO/IM Stat 0.9% Sodium Chloride 10 ml flush IV/IO As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: IM atibiotic admiistratio is NOT preferred i this settig as superveig shock ad hypotesio may lead to failure of absorptio of the ijected atibiotic. Collectio of blood sample for culture should be attempted prior to admiistratio of atibiotics but should ot delay treatmet. Patiets presetig uwell with a blachig rash may progress to a o-blachig rash ad therefore require urget treatmet Refereces: Commuicable Diseases Network Australia, 2001, Guidelies for the early cliical ad public health maagemet of meigococcal disease i Australia, Commowealth Departmet of Health ad Aged Care, Caberra. etg Complete Therapeutic Guidelies Ltd. (www.tg.com.au) etg 26 November 2008, Revised Jue 2006. Viewed 8.02.09. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> va de Beek D., de Gas J., McItyre P., ad Prasad K., 2009, Corticosteroids for acute bacterial meigitis (Review), Issue 1, viewed 8.02.09, <http://www.thecochraelibrary.com>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 45

PAGE 46 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 5 Edocrie / Eveomatio Emergecies NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 47

Hyperglycaemia with Severe Dehydratio Medical Officer must be otified immediately For Adults Oly Hyperglycaemia with Severe Dehydratio Cliical Severity Prompts BGL greater tha 15 mmol/l Severe dehydratio Altered metal state Metabolic abormality e.g. ketoacidosis History Prompts Gradual oset of symptoms; icreased thirst, icreased urie output, dehydratio Associated symptoms; tachycardia, hypotesio, weight loss, cofusio, acetoe breath, Kussmaul s respiratios (deep sighig respiratios of metabolic acidosis), abdomial pai Relevat past history Medicatio history Evets leadig up to presetatio Allergies Assessmet Positio Itervetio Positio of comfort Airway Assess patecy Maitai airway patecy Breathig Circulatio Respiratory rate ad effort SpO 2 Ski temperature Ski turgor Mucous membraes Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor AVPU / GCS BGL Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% IV caulatio/pathology If sigs of dehydratio or if SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 500 ml bolus stat (repeat oce if sigs of dehydratio persist or SBP remais less tha 90 mmhg) Moitor vital sigs frequetly Disability Moitor LOC frequetly Figer prick BGL every 30 miutes Cosider isuli therapy but ot before a serum potassium is kow ad ot before advice from a Medical Officer Measure ad test Pathology Collect blood for FBC, UEC, BGL, ABGs/veous blood gas (if available) Temperature U/A Test for sugar ad ketoes Fluid iput/output Fluid balace chart Isert IDC measure ad record urie output every hour Electrocardiography 12 lead ECG Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 48 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Hyperglycaemia with Severe Dehydratio Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml IV Stat (repeat oce if sigs of dehydratio persist or SBP remais less tha 90 mmhg) 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Close moitorig of fluid iput ad output is essetial. Early maagemet priorities are to treat shock ad dehydratio. This is more importat iitially tha lowerig the blood glucose with isuli. Cosider isuli therapy but ot before a serum potassium is kow ad ot before advice from a medical officer. Refereces: Breer Z., 2006, Maagemet of hyperglycaemia emergecies, America Associatio of Critical Care Nurses, vol. 17, o.1, pp. 56-65. Frederick, S., ad Dazi, D., 2008, Metabolic emergecies, i eds Stoe C., ad Humphries R., Curret Diagosis ad Treatmet: Emergecy Medicie, 6 th ed, McGraw-Hill Compaies, New York. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Titialli J., Kele G., Ma O., ad Clie O., 2004, Emergecy medicie: a comprehesive study guide, 6 th ed, McGraw-Hill Compaies, New York. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 49

Hypoglycaemia Medical Officer must be otified immediately For Adults Oly Hypoglycaemia Ay patiet who presets with cofusio/covulsios/ coma should have hypoglycaemia cosidered as a cause. History Prompts Oset Associated symptoms: Cliical Severity Prompts BGL less tha 3 mmol/l Cofusio/seizure/coma cofusio, visual disturbaces, headache, dizziess, pallor Relevat past history Medicatio history Evets Allergies Assessmet Positio Itervetio Positio of comfort Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor Moitor vital sigs frequetly Disability AVPU/GCS BGL Moitor LOC frequetly Figer prick BGL less tha 3 mmol/l ad coscious admiister simple sugar or If ucoscious or cofused admiister IV 50% Glucose 50 ml or If IV access uavailable, admiister IM Glucago 1 mg Figer prick BGL every 15 miutes util withi ormal limits ad the patiet is metally alert Measure ad test Specific treatmet Pathology Temperature U/A Fluid iput/output Possible alcohol abuse Collect blood for FBC, UEC, BGL, ABGs/veous blood gas (if available) Fluid balace chart If history of possible alcohol abuse give IM Thiamie 100 mg Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 50 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Hypoglycaemia Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 50% Glucose 50 ml IV Stat Glucago 1 mg (if IV access uavailable) IM Stat Thiamie 100 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Examples of oral simple sugars are; sugar, sweets or soft drik (o-diabetic) or milk, ad these should be followed by a carbohydrate meal e.g. sadwiches or biscuits. Alcoholism is the leadig cause of Wericke s Ecephalopathy, which is a eurological sydrome associated with iadequate utritio, icludig a deficiecy i thiamie. The admiistratio of Thiamie 100 mg is advocated i patiets suspected of havig hepatic ecephalopathy but its effect is rarely immediate ad delayed admiistratio will ot chage the course of the iitial resuscitatio. The old dogma that Thiamie should be withheld util hypoglycaemia is corrected to avoid precipitatig Wericke s ecephalopathy is ufouded. The absorptio of Thiamie is so much slower tha that of glucose, timig is irrelevat (Hew, 2004, p. 367). Refereces: Doio M., Vega J., Miller J., ad Walsh M., 2007, Myths ad miscoceptios of Wericke s ecephalopathy: What every emergecy physicia should kow, Aals of Emergecy Medicie, vol. 50, o. 6, pp. 715-721. Frederick S., ad Dazi D., 2008, Metabolic Emergecies i eds Stoe C, ad Humphries R., Curret diagosis ad treatmet: Emergecy medicie, 6 th ed, McGraw-Hill Compaies, New York. Hew, R., 2004, Altered Coscious State i Textbook of adult emergecy medicie, eds Camero, P., Jeliek, G., Kelly, A., Murray, L., Brow, A., Heyworth, J., Elsevier, Sydey. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Titialli J., Kele G., Ma O., ad Clie O., 2004, Emergecy medicie: A comprehesive study guide, 6 th ed, McGraw-Hill Compaies, New York. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 51

Sake / Spider Bite Medical Officer must be otified immediately For Adults Oly Sake / Spider Bite Do NOT remove pressure immobilisatio badage. Cliical Severity Prompts Neurotoxic paralysis/diplopia/dysphagia Covulsios Abdomial pai, headache, ausea/vomitig History Prompts Evets time of bite, umber of bites, time ad type of first aid applied, pre-hospital treatmet, drug/alcohol itoxicatio, activity sice bite, bite site locatio/s Associated symptoms: weakess, paralysis, headache, ausea, vomitig, abdomial pai, altered level of coscious, severe localised pai (spider bite), localised sweatig, diaphoresis, excess salivatio, paiful lymph ode, ptosis Relevat past history/previous eveomatio or ativeom admiistratio Medicatio history Allergies Esure first aid measures have bee implemeted ad cosider early trasfer. Assessmet Positio Itervetio Positio of comfort / keep patiet immobile Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Circulatio First aid Apply pressure immobilisatio badage ad splitig to all victims of sake bite ad Fuel Web spider bite Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure If SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 500 ml Cardiac moitor Moitor vital sigs frequetly Disability AVPU /GCS + pupils Moitor LOC frequetly If GCS less tha 9 ad ot rapidly improvig, patiet may require edotracheal itubatio by a MO to protect the airway from aspiratio Cosider LMA isertio if GCS equals 3 ad airway difficult to maitai Note: LMA does NOT protect the airway from aspiratio Measure ad test Sigs of systemic sake eveomatio Pathology Temperature U/A Fluid iput/output Sigs of systemic eveomatio Electrocardiography Whole blood clottig time (i a glass tube) Collect blood for FBC, UEC, CK, coags, group ad hold Moitor Check for myoglobi Cosider IDC ad observe urie for myoglobi Isert IDC measure ad record urie output every hour Nil by mouth Fluid balace chart 12 lead ECG Specific Hydratio IV 0.9% Sodium Chloride 1000 ml (125 ml per hour) to maitai hydratio treatmet Systemic eveomatio Cosider appropriate ativeom Fuel web eveomatio Cosider IV Atropie 0.5 mg if bradycardic ad SBP less tha 90 mmhg Redback spider eveomatio Ice to bite site (do NOT apply pressure immobilisatio badage) Cosider Redback spider ativeom Nausea ad vomitig Immuisatio status If ausea or vomitig preset give IV or IM Metoclopramide 10 mg Cosider tetaus immuisatio e.g. IM Boostrix or ADT Booster 0.5 ml Documet assessmet fidigs, itervetios ad patiet s respose i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 52 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Sake / Spider Bite Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml (circulatio support) IV Stat (repeat oce if SBP remais less tha 90 mmhg) 0.9% Sodium Chloride 1000 ml (maitai hydratio) IV 125 ml per hour Atropie 0.5 mg IV Stat Metoclopramide 10 mg IV or IM Stat Boostrix or ADT Booster 0.5 ml IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Apply pressure immobilisatio badage at the same pressure as for spraied akle. Badage the whole limb from the armpit or groi to the digits. IM ijectios should be avoided (except Boostrix/ADT Booster) i sake bite victims because of coagulopathy. Whole blood clottig test may be performed to determie the legth of time blood takes to clot. It is performed by placig 10 ml of veous blood ito a glass test tube ad measurig the time take for the blood to clot. Normal time is less tha 10 miutes. A sakebite observatio chart is recommeded for recordig vital sigs ad specific sigs associated with sakebites/ eveomatio refer to Appedix 11. Refereces: MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. NSW Health, 2007, Sakebite ad spiderbite cliical maagemet guidelies, viewed 19.01.09, <http://www.health.sw. gov.au/policies/gl/2007/pdf/gl2007_006.pdf>. Stewart C., 2003, Sake bite i Australia: First aid ad eveomatio maagemet, Accidet ad emergecy ursig, vol. 11, o. 2, pp. 106-111. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 53

PAGE 54 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 6 Trauma Emergecies NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 55

Trauma Medical Officer must be otified immediately For Adults Oly Trauma Refer Trauma Triage Tool (Appedix 12). All trauma patiets should be treated as havig a spial ijury util prove otherwise. Immediately call for assistace ad otify the Medical Officer ad Aeromedical ad Medical Retrieval Service (AMRS) 1800 650 004. Cliical Severity Prompts History Prompts Vital sig abormalities: Evets: RR of less tha 10 or greater tha 29, SpO 2 less tha 90% o air, cyaosis or respiratory difficulty HR greater tha 120 bpm SBP less tha 90 mmhg or severe haemorrhage LOC is V, P or U o AVPU scale. Requires at least getle tactile stimulatio ad shout to rouse from decreasig level of cosciousess/gcs less tha or equal to 13 or paralysis/sesory deficit high risk mechaism of ijury type force ad time Relevat past history recet surgery Patiets takig aticoagulat therapy/ kow coagulopathy Medicatio history High risk mechaism of ijury Fastig status Types of ijuries especially multi-system ijuries Allergies The followig patiet groups are at greater risk ad require a high idex of suspicio for serious trauma: Patiets over the age of 65 years Pregat woma over 20 weeks gestatio Types of ijuries Peetratig to head, eck, chest, abdome, perieum or back Head use Head Ijury Guidelie page 65 Face severe facial ijury; ijury with potetial airway risk; severe haemorrhage Neck swellig, bruisig, hoarseess or stridor Chest severe pai, subcutaeous emphysema, paradoxical breathig, crush ijury Abdome severe pai, rigidity, distesio, restrait/abrasio/cotusio Pelvis severe pai, geital cotusios, vertical shear ad ope book fracture Spie weakess, sesory loss, visible deformity Limb vascular ijury with ischaemia of limb, crush ijury, fracture of 2 or more log boes, deglovig ijury, amputatio The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 56 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Trauma Medical Officer must be otified immediately For Adults Oly Assessmet Positio Itervetio Full PPE measures must be cosidered. Lie supie, depedig o cliical status Airway Assess patecy Maitai airway patecy (do NOT isert a aso-pharygeal airway if there is ay possibility of a fractured base of skull or asal boe fracture) Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar Breathig Respiratory rate ad effort. SpO 2 Assist vetilatio if required Apply O 2 via o-rebreather mask to maitai SpO 2 greater tha 95% Asymmetrical chest movemet, uilateral decreased breath souds, tracheal deviatio Tesio peumothorax requires immediate chest decompressio with a eedle thoracetesis (refer to Appedix 14) Ope suckig chest woud Cover with o-porous dressig taped o 3 sides oly remove immediately if respiratory status deteriorates Circulatio Exteral bleedig Cotrol exteral bleedig usig direct pressure/ elevatio/pressure dressig Iteral bleedig IV caulatio x 2 (large bore)/pathology Ivolve a surgeo as soo as possible Blood pressure Ski temperature Pulse rate/rhythm Capillary refill Cardiac moitor IV/IO Compoud Sodium Lactate (Hartmas) Solutio 200 ml bolus to maitai SBP 80-90 mmhg Moitor vital sigs frequetly Disability AVPU/GCS + Pupils Moitor GCS frequetly. If GCS less tha 9 ad ot rapidly improvig, patiet will require edotracheal itubatio by MO to protect the airway from aspiratio Cosider LMA isertio if GCS equals 3 ad airway difficult to maitai Note: LMA does NOT protect the airway from aspiratio BGL Figer prick BGL Measure ad test Primary Survey Secodary Survey Repeat Commece thorough head to toe assessmet icludig the patiet s back (log roll if at least 4 people are available) Idetified deficits go to specific treatmet sectio immediately Pai If pai score 4-10 give IV/IO Morphie 2.5 mg icremets every 5 miutes to a total of 10 mg or IM Morphie 5-10 mg to a total of 10 mg (if IV/IO access uavailable) Pathology Collect blood for FBC, UEC, group ad hold, formal blood alcohol (if required ad accredited to take), cosider beta hcg If available ABG/veous blood gas, base deficit, serum lactate Temperature Prevet hypothermia U/A Full urialysis ad uriary hcg (if required) Fluid iput/output Strict fluid balace chart Nil by mouth Isert IDC (uless cotraidicated); measure ad record urie output every hour Cosider gastric tube. Do NOT isert a aso-gastric tube if there is a possibility of a base of skull fracture or asal boe fracture Electrocardiography 12 lead ECG The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 57

Trauma Medical Officer must be otified immediately For Adults Oly Specific treatmet Assessmet Limb-threateig ijury (eurovascular compromise) Amputatios Abdomial Ijuries Suspected pelvic fracture Suspected fractured shaft of femur Ope fractures Impaled objects Fluid deficit Hydratio/itake Nausea & vomitig Immuisatio status Itervetio Neutral aligmet Split or plaster backslab Perform eurovascular limb observatios frequetly (refer to Appedix 15) Preserve amputated part: wrap i moist salie gauze. Seal i airtight plastic bag. Place sealed bag i a slurry of ice; keep ear patiet ad label bag with patiet s details accurately Cover exposed viscera with moist salie packs (avoid hypothermia) Stabilise with pelvic bidig or sheetig (refer to Appedix 16) Stabilise with tractio split. Perform eurovascular observatios pre ad post splitig Cover with salie pack; do ot repositio protrudig boe eds Stabilise object DO NOT remove IV/IO Compoud Sodium Lactate (Hartmas) Solutio 200 ml bolus as required to maitai SBP of 80-90 mmhg Nil by mouth IV/IO 0.9% Sodium Chloride 1000 ml (125 ml/hour to maitai hydratio) If ausea or vomitig preset give IV or IM Metoclopramide 10 mg Cosider tetaus immuisatio e.g. IM Boostrix or ADT Booster 0.5 ml Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 15 litres/mi Ihalatio Cotiuous No-rebreather mask Compoud Sodium Lactate (Hartmas) Solutio Morphie 200 ml (circulatio support) IV/IO Stat (repeat as required to maitai SBP of 80-90 mmhg) 2.5 mg icremets (10 mg diluted with 9 ml 0.9% Sodium Chloride) IV/IO Every 5 miutes (ot to exceed 10 mg) Morphie 5-10 mg (if IV/IO access uavailable) IM Stat (ot to exceed 10 mg i total) 0.9% Sodium Chloride 1000 ml (maitai hydratio) IV/IO 125 ml per hour Metoclopramide 10 mg IV or IM Stat Boostrix or ADT Booster 0.5 ml IM Stat 0.9% Sodium Chloride 10 ml flush IV/IO As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 58 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Trauma Medical Officer must be otified immediately For Adults Oly Precautios ad Notes: The list of ijuries idetified is ot exclusive of what might be preset. Be aware of distractig paiful ijuries that may mask other ad more serious ijuries. Some patiets who may be ormally hypertesive may require fluid resuscitatio prior to SBP less tha 90 mmhg. IV/IO Compoud Sodium Lactate (Hartmas) Solutio is the first choice for resuscitatio fluid i the hypovolaemic trauma patiet. IV/IO 0.9% Sodium Chloride may be used as a alterative; however large volumes may result i metabolic acidosis. Aggressive fluid resuscitatio results i icreased haemorrhage ad greater mortality. Smaller volumes of IV fluid boluses are recommeded. Prior to isertig i-dwellig catheter esure there is o blood at uriary meatus as this may idicate a urethral ijury ad this is a cotraidicatio to isertig a urethral catheter. Do ot isert asopharygeal airway or asogastric tube i patiets suspected of havig a fractured base of skull or asal boe fracture. Close moitorig of fluid iput ad output is essetial. Tachycardia may ot occur i athletes, elderly patiets, those takig beta blockig agets or those suspected of spial cord ijury. Be cautious i admiisterig Morphie if there is a altered level of cosciousess, respiratory compromise or SBP less tha 90 mmhg. Use of sedatio scores may be beeficial i this reassessmet. Refereces: Ambulace Service of NSW, 2008, Pre-hospital maagemet of major trauma. Trauma triage tool major trauma critieria (MIST) Protocol T1. America College of Surgeos Committee o Trauma, 2008, Shock i Advaced trauma life support course for doctors studet course maual, 8th ed, Uited States. Cai J.G., Smith C.E., 2001, Curret practices i fluid ad blood compoet therapy i trauma Semiars i aesthesia, vol. 20, o. 1, pp. 28-35. Curtis K., Ramsde C., ad Friedship J., 2007, Emergecy ad trauma ursig, Mosby, Sydey. Du R, et. a.l (editor), 2000, The emergecy medicie maual, 2 d ed, Veom Publishig Uit, West Beach. Dutto R.P., Mackezie C.F., Scalea T.M., 2002, Hypotesive resuscitatio durig active hemorrhage: impact o i-hospital mortality, Joural of trauma ijury, ifectio ad critical care, vol. 52, o. 6 pp. 1141-6. Emergecy Life Support (ELS) course maual, 2005, 3 d ed, ELS Course Ic., Tamworth. Emergecy Nurses Associatio, 2000, Trauma ursig core course provider maual, 5 th ed, Emergecy Nurses Associatio, USA. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> Nola J., 2001, Fluid resuscitatio for the trauma patiet, Resuscitatio, vol. 48, o. 1 pp. 57-69. Pascoe S., ad Lych J., 2007, Adult trauma cliical practice guidelies, maagemet of hypovolaemic shock i the trauma patiet, NSW Istitute of Trauma Ijury ad Maagemet, Sydey. Titialli J., Gabor M., Kele D., Stapczyski J., Ma O., Clie D., Emergecy medicie: A comprehesive study guide iteratioal, 6th ed, McGraw-Hill, New York The Neurosurgical Society of Australasia, 2000, The Maagemet of acute eurotrauma i rural ad remote locatios. A set of guidelies for the care of head ad spial ijuries, Royal Australasia College of Surgeos, Melboure The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 59

Burs Medical Officer must be otified immediately For Adults Oly Burs The bur surface is cooled with ruig water. Ideal water temperature is 15 C, with a rage of 8-25ºC for a miimum of 20 miutes; this is beeficial for the first three (3) hours oly o burs of less tha 10% TBSA. Prevet hypothermia. If the patiet has suffered chemical burs, esure staff are adequately protected from cotamiatio. Always brush dry chemicals off (use PPE) before applyig cool water. Cliical Severity Prompts Airway/facial/eck burs Burs to hads, feet, perieum Electrical burs icludig lightig ijuries Chemical burs Circumferetial burs of limbs or chest History Prompts Oset time of bur Evets: mechaism of ijury/exposure history of electrical/thermal/chemical/radiatio burs cofied space first aid measures defied Associated symptoms: cough, hoarse voice, sore throat, sooty sputum, stridor, eck/facial swellig, siged facial hair, cofusio Relevat past medical history Medicatio history Tetaus immuisatio status Allergies Assessmet Positio Itervetio Positio of comfort/cliical status Airway Breathig Circulatio Disability Measure ad test Assess patecy Evidece of airway bur: hoarse voice, stridor, sore throat, sooty sputum, eck / facial swellig Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Blisterig Cardiac moitor Electrocardiography Costrictive o-adhered clothig or jewellery AVPU/GCS + pupils BGL Primary survey Pai score (1-3) Pai score (4-10) Secodary survey Maitai airway patecy Cosider early edotracheal itubatio by MO Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar (if there is a possibility of ijury) Assist vetilatio if required Apply high flow O 2 usig a o-rebreather mask at 15 L/miute to all patiets except those with mior burs IV caulatio X 2 / pathology If SBP less tha 90 mmhg give IV/IO 0.9% Sodium Chloride 500 ml Moitor vital sigs frequetly 12 lead ECG if possible, (especially electrical burs ad lightig strikes) Remove Moitor LOC frequetly Figer prick BGL Repeat Oral Paadeie Forte (if ot il by mouth) 1-2 tablets for mior burs oly IV/IO Morphie 2.5 mg icremets every 5 miutes to a total of 10 mg or IM Morphie 5-10 mg (if IV/IO access uavailable) avoid burt areas Commece Calculate total body surface area burt (refer to Appedix 17) The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 60 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Burs Medical Officer must be otified immediately For Adults Oly Measure ad test Specific treatmet Assessmet Pathology Temperature Fluid iput/output Burs greater tha 15% TBSA U/A Liquid chemical Powder chemical Electrical/lightig strike/ haematuria/ haemoglobiuria/ rhabdomyolysis Circumferetial burs Bur wouds Nausea/vomitig Immuisatio status Itervetio Collect blood for FBC, UEC, (cosider group ad hold, myoglobi, ABG/veous blood gas) Avoid hypothermia Modified Parklad formula: i the first 24 hours post bur give IV/IO Compoud Sodium Lactate (Hartmas) Solutio 3-4 ml x kg body weight x % TBSA burt. Give 50% of total amout i first 8 hours from time of the bur, give the remaiig 50% over the ext 16 hrs Maitai UO at 0.5-1 ml/kg/hour Fluid balace chart Nil orally if burs greater tha 10-15% TBSA NGT if greater tha 20% TBSA burs ad ot cotraidicated For burs of more tha 20% TBSA, isert IDC measure ad record urie output every hour Observe urie for myoglobiuria or haemoglobiuria Copious water irrigatio Brush off prior to copious water irrigatio. Staff must use PPE Maitai UO greater tha 1-2 ml/kg/hour Elevate the affected limb Perform eurovascular observatios every 15 miutes If trasferrig withi 8 hours ad patiet stable, apply clig wrap to the burs If the face is burt paraffi oitmet should be applied If there is a delay i trasfer, woud maagemet should be i cosultatio with the bur surgeo who will receive the patiet. Do ot use Silver Sulphadiazie (SSD) cream without cosultig the tertiary Burs Service, ad do ot apply to the face If ausea/vomitig preset give IV or IM Metoclopramide 10 mg Cosider tetaus immuisatio e.g. IM Boostrix or ADT Booster 0.5 ml Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Compoud Sodium Lactate As per Modified Parklad IV/IO As per formula (Hartmas) Solutio formula (above) 0.9% Sodium Chloride 500 ml IV/IO Stat if SBP less tha 90 mmhg Paadeie Forte 1-2 tablets Oral Stat (oe dose oly) (Paracetamol 500 mg ad Codeie Phosphate 30 mg) Morphie 2.5 mg icremets IV/IO Every 5 miutes (to a total of 10 mg) (10 mg diluted with 9 ml 0.9% Sodium Chloride) Morphie 5-10 mg (if IV/IO access IM Stat (to a total of 10 mg) uavailable) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 ml flush IV/IO As required Boostrix or ADT Booster 0.5 ml IM Stat The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 61

Burs Medical Officer must be otified immediately For Adults Oly Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Cosult with burs specialist early. Prompt cosultatio is required for ay patiet with facial burs/ihalatio ijury to esure airway patecy is maitaied. Ay patiet sustaiig burs i a cofied space is susceptible to ihalatio ijury ad carbo mooxide poisoig. Do ot use ice or iced water to cool a bur. Maagemet of blisters is geerally guided by specialist cliicias or istitutioal prefereces. Patiets who require immediate cosultatio with a burs uit ad will likely require retrieval (refer to Appedix 17): full thickess burs greater tha 5% TBSA partial thickess burs greater tha 10% TBSA burs associated with ihalatioal ijury burs to face, hads, feet, geitalia, perieum ad major joits ay itubated patiet chemical burs electrical burs icludig lightig ijuries circumferetial burs of limbs or chest burs with cocomitat trauma burs i patiets with pre-existig medical coditios that could adversely affect patiet care ad outcome pregacy with cutaeous burs burs at the extremes of age e.g. frail elderly (NSW Health, GL2008_012, pp. 3-4) Hydrofluoric Acid burs early copious water irrigatio ad applicatio of Calcium Glucoate gel is recommeded. Cosult with a specialist early. Be cautious i admiisterig Morphie if there is a altered level of cosciousess, respiratory compromise or SBP less tha 90 mmhg. Use of sedatio scores may be beeficial i this reassessmet. Refer to NSW Severe Bur Ijury Trasfer Flow Chart; Bur Patiet Emergecy Assessmet & Maagemet Chart; Assessmet of % Total Body Surface Area (TBSA) ad Bur Distributio; Resuscitatio Fluids (Appedix 17). Refereces: Australia Resuscitatio Coucil, 2008, Guidelie 9.1.3 Burs, viewed 8.07.09, <http://www.resus.org.au/>. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> NSW Health, 2008, GL2008_012 Bur Trasfer Guidelies NSW Severe Bur Ijury Service, 2 d ed, NSW Departmet of Health, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 62 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Drowig Medical Officer must be otified immediately For Adults Oly Drowig Cliical Severity Prompts Altered level of cosciousess Wheezig Crepitatios Pik frothy sputum Tachycardia greater tha 100 beats per miute History Prompts I divig accidets or the ucoscious submersio victim, spial ad skull fractures must be cosidered Cosider: the possibility of associated drug ad/or alcohol use attempted self-harm sycope or seizure as a precipitatig evet alcohol or drug itake circulatory arrest Hypervetilatio before breath holdig uderwater Trauma (head/spial) Duratio of immersio Water temperature Time of accidet, time of rescue, time of first effective CPR Crepitatios, tachycardia, altered level of cosciousess, respiratory or cardiac arrest If respiratory ad/or cardiac arrest preset treat as per Cardiac Arrest Guidelie If history of trauma refer to Trauma Guidelie Assessmet Itervetio Positio Sit upright depedig o cliical status Positio supie if c-spie ijury is suspected Airway Assess patecy Maitai airway patecy Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar (if there is a possibility of ijury) Breathig Circulatio Respiratory rate ad effort SpO 2 Wheeze If patiet caot ihale adequately to use a MDI ad spacer Auscultatio Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac Moitor Electrocardiography Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% If SpO 2 falls below 95% with O2 cosult MO If wheeze preset give ihaled Salbutamol 6-12 puffs of 100 microgram MDI + spacer Salbutamol 5 mg ebule stat Cosider CPAP/BiPAP if available ad o associated trauma preset Cosider risk of peumothorax, especially if rapid ascet from sigificat depth Remove wet clothig cover with blakets, do NOT actively rewarm IV caulatio/pathology IV 0.9% Sodium Chloride 500 ml if SBP less tha 90 mmhg Moitor vital sigs frequetly 12 lead ECG Disability AVPU/GCS + pupils Moitor LOC frequetly If GCS less tha 9 ad ot rapidly improvig, patiet will require edotracheal itubatio by MO to protect the airway from aspiratio Cosider LMA isertio if GCS equals 3 ad airway difficult to maitai Note: LMA does NOT protect the airway from aspiratio BGL Figer prick BGL Measure ad test Pathology Collect blood for FBC, serum glucose, UEC, ABGs/veous blood gas if available Temperature U/A Fluid iput/output Chest X-ray Avoid hypothermia Fluid balace chart Nil by mouth Isert IDC measure ad record urie output every hour If available Specific treatmet Gastric distesio Do ot attempt to empty the stomach by exteral pressure Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 63

Drowig Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Salbutamol 6-12 puffs of 100 microgram dose MDI Ihalatio Stat + spacer Salbutamol 5 mg Nebule (if patiet uable to ihale Ihalatio Stat adequately usig MDI + spacer) 0.9% Sodium Chloride 500 ml IV Stat (repeat oce if SBP remais less tha 90 mmhg) 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: The ew defiitio of drowig icludes both cases of fatal ad o-fatal drowig. Drowig is the process of experiecig respiratory impairmet from submersio/immersio i liquid Drowig outcomes are classified as death, morbidity ad o morbidity (WHO, 2005). The World Health Orgaisatio (WHO) states that the terms wet, dry, active, passive, silet ad secodary drowig should o loger be used (WHO, 2005). Therefore a simple, comprehesive, ad iteratioally accepted defiitio of drowig has bee developed. Refereces: Australia Resuscitatio Coucil, 2005, Guidelie 9.3.2: Resuscitatio of the drowig victim, ARC, Melboure. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch> The America Heart Associatio, 2005, Guidelies for cardiopulmoary resuscitatio ad emergecy cardiovascular care, part 10.3: drowig, Circulatio, vol. 112, o. 24 Supplemet, pp. IV 133 IV 135. va Beeck E., Brache C.M., Szpilma D., Modell J.H. & Bieres J.J.L.M., 2005, A ew defiitio of drowig: towards documetatio ad prevetio of a global public health problem, Policy ad Practice, Bulleti of the World Health Orgaisatio, vol. 83, o. 11, pp. 853-856. World Health Orgaisatio, Departmet of Ijuries ad Violece Prevetio World Health Orgaisatio, 2003, Facts about ijuries: Drowig, viewed 14.06.09, <http://www.who.it/violece_ijury_prevetio/publicatios/other_ijury/e/ drowig_factsheet.pdf>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 64 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Head Ijury Medical Officer must be otified immediately For Adults Oly Head Ijury Cliical Severity Prompts GCS less tha 14 Loss of cosciousess with a history of trauma Visible deformities (fracture of skull or facial boes) Ecchymosis aroud eyes or ears CSF leak from ose or ears Iequality or o-reactivity of pupil/s SBP less tha 90 mmhg at ay time History Prompts Evets high risk mechaism of ijury Associated symptoms: headache, cofusio, irritability, memory loss, ausea, vomitig, dizziess, speech, motor ad/or visual disturbaces, seizure Relevat past history Medicatio history i.e. aticoagulats such as warfari, aspiri, clopidogrel Allergies Assessmet Positio Itervetio Positio head up 30 uless cotraidicated Airway Assess patecy Maitai airway patecy Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar Breathig Circulatio Disability Measure ad test Respiratory rate, effort, patter SpO 2 Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac moitor AVPU / GCS + Pupils BGL Assist vetilatio if required Apply high flow O 2 usig a o-rebreather mask at 15 L/miute to maitai SpO 2 greater tha 95% IV caulatio/pathology If SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 200 ml bolus Moitor vital sigs frequetly Moitor GCS frequetly If GCS 13 or less cosider retrieval/trasfer If GCS less tha 9 ad ot rapidly improvig, patiet will require edotracheal itubatio by MO to protect the airway from aspiratio Figer prick BGL Pathology Collect blood for FBC, UEC (cosider beta hcg ad blood alcohol levels - if accredited to take) Primary Survey Secodary Survey Temperature U/A Fluid iput/output Pai score (1-3) Pai score (4-10) Halo sig Repeat Commece Protect from hypo/hyperthermia Fluid balace chart Cosider IDC ad urie measuremets every hour Nil by mouth if decreasig level of cosciousess If pai score 1-3, ad GCS 14 or 15 ad patiet ot il by mouth, give oral Paracetamol 500 mg 1 g If pai score 4-10 give IV Morphie 2.5 mg icremets every 5 miutes to a total of 10 mg or IM Morphie 5-10 mg (if IV access uavailable) Specific treatmet Nausea/vomitig If ausea/vomitig preset give IV or IM Metoclopramide 10 mg Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 65

Head Ijury Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 200 ml bolus IV Stat (repeat oce if SBP remais less tha 90 mmhg) Paracetamol 500 mg - 1 g Oral Stat (oe dose oly) Morphie 2.5 mg icremets (10 mg IV Every 5 miutes (to a total of 10 mg) diluted with 9 ml 0.9% Sodium Chloride) Morphie 5-10 mg (if IV access IM Stat (to a total of 10 mg) uavailable) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Prevet secodary brai ijury. Hypotesio (i.e. SBP less tha 90 mmhg) is a poor progostic idicator. Do NOT isert a asopharygeal airway or asogastric tube i a patiet suspected of havig a fractured base of skull or asal boe fracture. If blood or fluid is draiig from the ose or ear suspect a fractured base of skull. A declie i the GCS of two or more poits must be cosidered sigificat. A MO must be cotacted immediately. The provisio of arcotic aalgesia is ot cotraidicated oce the life-savig surgical ad eurological evaluatio of the trauma patiet has bee performed. Be cautious i admiisterig Morphie if there is a altered level of cosciousess, respiratory compromise or SBP less tha 90 mmhg. Use of sedatio scores may be beeficial i this reassessmet. Note: ausea ad vomitig may be a sig of raised itracraial pressure. The halo sig is preset whe asal secretios o bed lie or dressigs form a halo. This occurs whe CSF, mixed with blood, spreads oto a absorbet surface. The darker blood chromatographically forms a rig aroud a lightlystaied cetre, formig a halo. Mixture of blood with tears or saliva ca give false-positives. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 66 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Head Ijury Medical Officer must be otified immediately For Adults Oly People o Warfari, Clopidogrel or aspiri (especially the elderly) who have a head ijury/trauma have a very high morbidity ad mortality. These patiets eed to be moitored very closely ad will require a CT sca, as they ca deterioriate very quickly. A MO must cosider the eed for a CT sca/further cosultatio, especially for high risk patiets ad patiets whose GCS is ot improvig, e.g. persistet GCS less tha 15 at 2 hours post ijury. Refereces: Du R., et. al. (eds), 2000, The emergecy medicie maual, 2 d ed, Veom Publishig Uit, West Beach. Emergecy Life Support (ELS) course maual, 2005, 3rd ed, ELS Course Ic., Tamworth. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. Natioal Health ad Medical Research Coucil, 2005, Acute pai maagemet: Scietific evidece, 2d ed, Commowealth of Australia, Caberra. Reed D., 2007, Adult trauma cliical practice guidelies, iitial maagemet of closed head ijury i adults, NSW Istitute of Trauma ad Ijury Maagemet, North Ryde. The Neurosurgical Society of Australasia, 2000, The maagemet of acute eurotrauma i rural ad remote locatios, The Royal Australasia College of Surgeos, Melboure. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 67

Isolated Severe Limb Ijury Medical Officer must be otified immediately For Adults Oly Isolated Severe Limb Ijury Cliical Severity Prompts Obvious deformity, swellig ad pai to limb Loss of sesatio ad pulse Ischaemia of limb History Prompts Oset Evets history of trauma, mechaism of ijury Associated symptoms; obvious deformity swellig to limb pai associated with the ijury Relevat past history Medicatio history Allergies Assessmet Positio Itervetio Positio of comfort/fuctio Airway Assess patecy Maitai airway patecy Breathig Circulatio Respiratory rate ad effort SpO 2 Exteral bleedig Ski temperature Pulse rate/rhythm Capillary refill Blood pressure Assist vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Cotrol exteral bleedig Record colour, warmth, sesatio, movemet ad pulses of affected limb (refer to Appedix 15) IV caulatio Moitor vital sigs frequetly Disability AVPU/GCS Moitor LOC frequetly Measure ad test Pai score (1-3) Pai score (4-10) If pai score 1-3 ad patiet ot il by mouth give oral Paadeie Forte 1-2 tablets If pai score 4-10 give IV Morphie 2.5 mg icremets every 5 miutes to a total of 10 mg or IM Morphie 5-10 mg (if IV access uavailable) Fluid iput/output Fluid balace chart Nil by mouth (util aaesthetic requiremet cofirmed) Neurovascular observatios Neutrally alig limb if possible. Assess both limbs frequetly as well as pre ad post splitig or plaster backslab X-Ray If available Specific treatmet Nausea/vomitig If ausea/vomitig preset give IV or IM Metoclopramide 10 mg Limb stabilisatio Immobilisatio/elevatio/ice/split/POP backslab Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 68 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Isolated Severe Limb Ijury Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous Paadeie Forte 1-2 tablets Oral Stat (Paracetamol 500 mg ad Codeie Phosphate 30 mg) Morphie 2.5 mg icremets (10 mg diluted with IV Every 5 miutes (ot to exceed 10 mg) 9 ml 0.9% Sodium Chloride) Morphie 5-10 mg (if IV access uavailable) IM Stat (ot to exceed 10 mg) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: Precautios ad Notes: Neurovascular limb observatios must also iclude the uaffected limb for compariso. Refer to Appedix 15 for suggested guidelies for a eurovascular assessmet. Compartmet sydrome is a limb threateig complicatio of limb ijury caused by icreased pressure. Be cautious i admiisterig Morphie if there is a altered level of cosciousess, respiratory compromise or SBP less tha 90 mmhg. Use of sedatio scores may be beeficial i this reassessmet. Refereces Curtis K., Ramsde C., & Friedship J., 2007, Emergecy ad trauma ursig, Mosby, Sydey. Du R., et. al. (ed), 2000, The emergecy medicie maual, 2d ed, Veom Publishig Uit, West Beach. MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 69

Ocular Ijuries Medical Officer must be otified immediately For Adults Oly Ocular Ijuries Some patiets who preset complaiig of eye flash burs may i fact have a coreal foreig body. Cliical Severity Prompts Ijury with loss of visual acuity Weldig i past 24 hours Exposure to sow or water glare i past 24 hours Chemical exposure or bur ijury to eye History Prompts Evets mechaism of ijury (e.g. drillig, high speed motor drillig without eye protectio) Associated symptoms; pai, redess, tearig, headache, loss of visio, type of foreig body (e.g. glass, dirt, orgaic, metal) Relevat past history Medicatio history Allergies Peetratig foreig body of the eye Assessmet Itervetio Positio Positio of comfort, but lie supie (if peetratig ijury or suspected retial detachmet) Airway Assess patecy Maitai airway patecy Stabilise the C-spie with i-lie immobilisatio ad apply a semi-rigid cervical collar (if associated history of trauma) Breathig Circulatio Respiratory rate ad effort SpO 2 Ski temperature Pulse rate/rhythm Blood pressure If other associated trauma, support vetilatio if required Apply O 2 to maitai SpO 2 greater tha 95% Moitor vital sigs frequetly Disability AVPU/GCS + pupils Moitor LOC frequetly Measure ad test Temperature Visual acuity Selle chart/figer cout/light perceptio assessmet ad pupillary respose Pai score (1-3) Pai score (4-10) If pai score 1-3 ad patiet ot il by mouth give oral Paadeie Forte 1-2 tablets If pai score 4-10 give IM Morphie 5-10 mg (10 mg i total) Specific treatmet Peetratig ijury Do ot remove foreig body. Stabilise foreig body Do ot apply eye pad or pressure to eye Cosider tetaus immuisatio e.g. IM Boostrix or ADT Booster 0.5 ml Coreal foreig bodies (e.g. dust, small orgaic matter) Chemical exposures Istil 0.4% Oxybuprocaie 2 drops per eye or 0.5% or 1% Amethocaie 2 drops per eye. Istil eye drops every 15-20 miutes durig irrigatio procedure If small amout of superficial dust or orgaic matter is preset, getly remove with a cotto bud which has bee moisteed with 0.9% Sodium Chloride. Getle irrigatio with a eutral fluid e.g. Compoud Sodium Lactate (Hartmas) solutio or 0.9% Sodium Chloride usig a IV blood pump givig set may be required if a umber of superficial dust particles are preset. If history of chemical exposure istil 0.4% Oxybuprocaie 2 drops per eye or 0.5% or 1% Amethocaie 2 drops per eye. Istil eye drops every 15-20 miutes durig irrigatio procedure Irrigate eye/s with copious amouts of a eutral fluid e.g. Compoud Sodium Lactate (Hartmas) Solutio or 0.9% Sodium Chloride usig a IV blood pump givig set for at least 30 miutes Cotiue irrigatio util ph is withi rage of 6.5 to 8.5 The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 70 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Ocular Ijuries Medical Officer must be otified immediately For Adults Oly Assessmet Itervetio Specific treatmet Flash burs If flash burs to eyes istil 0.4% Oxybuprocaie 2 drops per eye or 0.5% or 1% Amethocaie 2 drops per eye (oe dose oly) Suspected retial detachmet/hyphaema Fluid iput/output Nausea ad vomitig Coreal ijury Istruct patiet to observe strict bed rest, at least util reviewed by MO I aticipatio of surgical itervetio restrict the patiet to remai il by mouth If ausea/vomitig preset give IM Metoclopramide 10 mg Istil Fluorescei Sodium 1 drop affected eye/s oly, view ijury with cobalt blue light Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres / mi Ihalatio Cotiuous Compoud Sodium Lactate (Hartmas) Solutio 1000 ml Eye irrigatio Stat (repeat as required) 0.9% Sodium Chloride 1000 ml Eye irrigatio Stat (repeat as required) Paadeie Forte 1-2 tablets Oral Stat (Paracetamol 500 mg ad Codeie Phosphate 30 mg) Morphie 5-10 mg (ot to exceed total 10 mg) IM Stat 0.4% Oxybuprocaie drops 0.5% or 1% Amethocaie drops 2 drops per affected eye Topical Stat (every 15-20 miutes durig irrigatio procedure) or (Stat for flash burs) 2 drops per affected eye Topical Stat (every 15-20 miutes durig irrigatio procedure) or (Stat for flash burs) Metoclopramide 10 mg IM Stat Fluorescei Sodium 1 drop affected eye/s Topical Stat Boostrix or ADT Booster 0.5 ml IM Stat Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 71

Ocular Ijuries Medical Officer must be otified immediately For Adults Oly Precautios ad Notes: It is importat to test the visual acuity (VA) i ALL patiets with ocular trauma as it is a importat parameter ad is of medicolegal importace Chemical exposure: esure both the upper ad lower eyelids are everted durig irrigatio patiets with chemical exposure to the eyes should also be assessed for potetial aspiratio of chemicals ad subsequet airway obstructio esure the face ad other exposed areas are thoroughly washed with water. Coreal ijury/s: istil oe drop of Fluorescei Sodium to affected eye/s oly, view eye ijury with cobalt blue light from torch or ophthalmoscope soft cotact les/es MUST be removed prior to istillatio of Fluorescei Sodium drop/s Patiet with metallic foreig body/s i the eye require referral to MO. If ot (correctly) removed the metallic foreig body/s may lead to the formatio of rust rig/s. Do ot irrigate the eye/s if metallic foreig body is isitu Do ot sed patiet home with local aaesthetic eye drops Refereces: MIMS Olie <http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_ssearch>. NSW Departmet of Health, 2009, Eye Emergecy Maual: A Illustrated Guide, 2 d Ed, NSW Departmet of Health, North Sydey. Ramsde C., Curtis K., Seggie J., & Braybrooks L., 2007, Ocular emergecies, i Emergecy & trauma ursig, (eds) Curtis K., Ramsde C. & Friedship J., Mosby, Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 72 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 7 Other Emergecies NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 73

Abdomial/Loi/Flak Pai Medical Officer must be otified immediately For Adults Oly Abdomial/Loi/Flak Pai Note: A leakig abdomial aortic aeurysm ca mimic real colic i elderly patiets. Cliical Severity Prompts Pai to abdome/loi/flak Localised tederess to right upper or lower quadrat of abdome Rapid oset History Prompts Four immediately life threateig presetatios that require exclusio are; 1. Ruptured ectopic pregacy 2. Ruptured abdomial aortic aeurysm 3. Acute myocardial ifarctio 4. Ruptured splee Nature of Oset Associated symptoms ature of pai/radiatio ausea, vomitig diarrhoea/costipatio last mestrual period/symptoms of pregacy uriary symptoms weight loss Relevat past history Immuocompromised Medicatio history Evets mechaism of ijury (if trauma is ivolved) Allergies Assessmet Positio Itervetio Positio of comfort Airway Assess patecy Maitai airway patecy Breathig Respiratory rate ad effort SpO 2 Assist vetilatio if required Apply O 2 to maitai greater tha 95% Circulatio Ski temperature IV caulatio/pathology Pulse rate/rhythm Capillary refill Blood pressure If SBP less tha 90 mmhg give IV 0.9% Sodium Chloride 500 ml stat Cardiac moitor Moitor vital sigs frequetly Disability Measure ad test Specific treatmet AVPU / GCS BGL Abdomial assessmet Pai score (2-10) Pathology Temperature U/A Fluid iput/output Electrocardiography Hydratio / itake Moitor LOC frequetly Figer Prick BGL Look, liste ad feel If pai score 2-10 give IV Morphie 2.5 mg every 5 miutes to a total of 10 mg or IM Morphie 5-10 mg (if IV access uavailable) Collect blood for FBC, UEC, (cosider LFT s, serum amylase, coags, group ad hold) Urie hcg (if required), collect MSU Strai urie for calculi Fluid balace chart 12 Lead ECG Nil by mouth IV 0.9% Sodium Chloride 1000 ml at 125 ml per hour to maitai hydratio IM Prochlorperazie 12.5 mg Nausea ad vomitig Documet assessmet fidigs, itervetios ad resposes i the patiet s healthcare record The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 74 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Abdomial/Loi/Flak Pai Medical Officer must be otified immediately For Adults Oly Medicatio Stadig Orders Always check for allergies ad cotraidicatios. Drug Dose Route Frequecy Oxyge 6-15 litres/mi Ihalatio Cotiuous 0.9% Sodium Chloride 500 ml bolus IV Stat (repeat oce if SBP remais less tha 90 mmhg) Morphie 2.5 mg icremets (10 mg diluted with 9 ml 0.9% IV Every 5 miutes (to a total of 10 mg) Sodium Chloride) Morphie 5-10 mg (if IV access uavailable) IM Stat (to a total of 10 mg) 0.9% Sodium Chloride 1000 ml IV 125 ml per hour Prochlorperazie 12.5 mg IM Stat 0.9% Sodium Chloride 10 ml flush IV As required Medicatios withi this guidelie must be admiistered withi the cotext of the formulary. Medical Officer review is required as soo as possible (withi 24 hours) followig the admiistratio of a drug accordig to the stadig orders cotaied withi this documet. At the time of this review, the Medical Officer must check ad coutersig the urse s record of admiistratio o the medicatio chart. If a Advaced Cliical Nurse uses these Guidelies, a Medical Officer will be otified immediately to esure their early ivolvemet with the maagemet ad care of the patiet. Authorisig Medical Officer sigature: Name: Desigatio: Date: Drug Committee approval: Date: The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 75

Abdomial/Loi/Flak Pai Medical Officer must be otified immediately For Adults Oly Precautios ad Notes: Elderly patiets presetig with abdomial/loi/flak pai have a 14% mortality rate. Symptoms may be vague with a low tolerace for shock e.g. a SBP of 90 mmhg may be critical if previously hypertesive Patiets over the age of 65 years requirig opioids should be moitored frequetly, both for the effectiveess of the aalgesia ad the presece of adverse effects Opioid aalgesics ca be safely admiistered before full assessmet ad diagosis i acute abdomial pai, without icreasig the risk of errors i diagosis or treatmet Be cautious i admiisterig Morphie if there is a altered level of cosciousess, respiratory compromise or SBP less tha 90 mmhg. Use of sedatio scores may be beeficial i this reassessmet Metoclopramide hydrochloride should oly be used where bowel obstructio/perforatio has bee excluded Metoclopramide appears to be a more effective atiemetic tha prochlorperazie, but should ot be admiistered uless ordered by a Medical Officer Tachycardia may ot occur i patiets takig beta blockig agets. Refereces: Australia ad New Zealad College of Aaesthetists ad Faculty of Pai Medicie, 2010, Acute Pai Magemet: Scietific Evidece, 3rd ed. Gallager E.J., 2004, Acute abdomial pai, i Emergecy medicie: A comprehesive study guide, The McGraw-Hill Compaies Ic. Natioal Health ad Medical Research Coucil, Natioal Istitute of Cliical Studies, 2008, Pai medicatio for acute abdomial pai. A summary of best available evidece ad iformatio o curret cliical practice, Australia Govermet, Caberra. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 76 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

THE followig drug iformatio PERTAINS oly to the cotext specified i THIS NSW RURAL ADULT EMERGENCY CLINICAL GUIDELINES documet Formulary The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 77

Formulary Idex Adrealie...79 Amethocaie 0.5% or 1%...79 Amiodaroe...80 Aspiri...81 Atropie...81 Bezylpeicilli...82 Ceftriaxoe...82 Dexamethasoe...83 Fluorescei...83 Flucloxacilli...84 Frusemide...84 Getamici...85 Glucago...85 50% Glucose...86 Glyceryl Triitrate (tablet or spray)...87 Hydrocortisoe...88 Ipratropium Bromide (Atrovet)...88 Metoclopramide...89 Midazolam...89 Morphie...90 Naloxoe...91 Oxybuprocaie...91 Paracetamol...92 Paracetamol ad Codeie (Paadeie Forte)...92 Predisoloe...93 Prochlorperazie...93 Salbutamol (Vetoli)...94 Boostrix/ADT Booster...95 Thiamie (Vitami B-1)...96 0.9% Sodium Chloride...96 0.9% Sodium Chloride...97 Compoud Sodium Lactate (Hartmas Solutio)...98 Vacomyci...98 PAGE 78 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Pareteral Adreergic Agets Drug Name Adrealie Idicatios/Doses Cotraidicatios Iteractios Aaphylactic Reactio: 0.5 mg IM every 3-5 miutes (to a total of 2 mg); 50 micrograms IV stat if o respose to IM adrealie ad patiet presets sigs of cardiorespiratory collapse Shortess of breath with or without a history of asthma: 0.5 mg IM (pre-arrest circumstace or asthma associated with aaphylaxis) stat Cardiorespiratory Arrest (Advaced Life Support): Shockable rhythms: 1 mg IV/IO after the 2d shock ad the 1mg IV/IO every 2d loop to a total of 3 mg No-shockable rhythms: 1 mg IV/IO immediately ad the 1 mg IV/IO every 2d loop to a total of 3 mg Sympathomimetics cause additive effects; beta-blockers atagoise therapeutic effects of Adrealie; digoxi potetiates proarrhythmic effect of Adrealie; Tricyclic Atidepressats ad Moo Amie Oxidase Ihibitors potetiate cardiovascular effects of Adrealie Pregacy (Category A) Adrealie has bee give to a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Adrealie may delay the secod stage of labour by ihibitig cotractios of the uterus Precautios Adverse effects iclude cardiac ischaemia or dysrhythmias, fear, axiety, tremor, ad hypertesio with subarachoid haemorrhage; use with cautio i hypertesio, cardiovascular disease, ad cerebrovascular isufficiecy; pheothiazies ca cause a paradoxical decrease i BP commet as above Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio, http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/7-sectio-7?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter6/moographadrealie-02. html#adrealie-02 <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2826&product_ ame=adrealie+ijectio <accessed 22/12/08> Drug Category: Topical Ocular Aaesthetics Drug Name Amethocaie 0.5% or 1% Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Ocular Ijuries: 2 drops per affected eye, topical, stat to produce local aaesthesia i the eye. Ca be used every 15-20 miutes durig the irrigatio procedure. Stat oly for flash burs Documeted hypersesitivity. Not for use i cases with peetratig eye ijury Atagoises effect of sulfoamides ad amiosalicylic acid Amethocaie ot categorised May give rise to dermatitis i hypersesitive patiets. The aaesthetised eye should be protected from dust ad bacterial cotamiatio Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter11/moographamethocaie-02. html#amethocaie-02 <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=1515&product_ ame=miims+local+aaesthetics <accessed 22/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 79

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Atiarrhythmics Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Amiodaroe Cardiorespiratory Arrest (Advaced Life Support): 300 mg IV/IO stat after the 3rd shock for VF/VT cardiorespiratory arrest Documeted hypersesitivity; systemic lupus erythematosus, digitalis iduced dysrhythmias, torsade de poites, secod or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sius sydrome (without pacemaker) Icreases effect ad blood levels of theophyllie, quiidie, procaiamide, pheytoi, methotrexate, flecaiide, digoxi, cyclosporie, beta-blockers, ad aticoagulats; co admiistratio with calcium chael blockers may cause additive effects, further decreasig myocardial cotractility; cimetidie may icrease amiodaroe levels Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible. Avoid use 3 moths before ad durig pregacy; may cause thyroid dysfuctio ad bradycardia i the foetus Hypotesio (most commo adverse effect), bradycardia, ad AV block may occur. Phlebitis is a issue ad also icompatible with 0.9% Sodium Chloride Overly rapid admiistratio ca cause hypotesio Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/18-sectio-18?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter6/moographamiodaroe. html#amiodaroe <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=176&product_ ame=cordaroe+x+itraveous+ijectio <accessed 22/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 80 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Atiplatelet Agets Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Aspiri Acute Coroary Sydrome: 300 mg Oral (chew) stat (if ot already give by Ambulace Paramedics) Ihibits platelet aggregatio Documeted hypersesitivity; active upper GI bleed. Effects may decrease with atacids ad uriary alkaliisers; corticosteroids decrease salicylate serum levels; additive hypoprothrombiaemic effects ad icreased bleedig time may occur with coadmiistratio of aticoagulats; may atagoise uricosuric effects of probeecid ad icrease toxicity of pheytoi ad valproic acid Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible Avoid use i history of blood coagulatio defects, asthma, urticaria Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter7/moographaspiri-02. html#aspiri-02<accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=361&product_ ame=dispri <accessed 22/12/08> Drug Category: Aticholiergic Agets Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Atropie Compromisig Bradycardia: 0.5 mg IV icremets every 5 miutes (to a total of 3 mg) titrated to maitai SBP greater tha 90 mmhg Sake/spider Bite: (Systemic eveomatio) 0.5 mg IV stat if patiet bradycardic ad SBP less tha 90 mmhg Noe whe idicated for symptomatic bradycardia or asystole Noe for this idicatio Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Icreased risk of arrhythmias i IHD Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/32-sectio-32?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter6/moographatropie. html#atropie <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2163&product_ ame=atropie+sulfate+ijectio+bp <accessed 22/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 81

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: 8(a) Peicillis Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Bezylpeicilli Meigococcal Disease: No-blachig Rash 1.2 g IV/IO/IM Stat History of hypersesitivity reactios to beta-lactam atibiotics Itraveous solutios of Bezylpeicilli are physically icompatible with may other substaces icludig certai atihistamies, some other atibiotics, metaramiol tartrate, oradrealie acid tartrate, thiopetoe sodium ad pheytoi sodium Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Serious, ad occasioally fatal, hypersesitivity reactios (aaphylaxis) have bee reported i patiets receivig beta-lactam atibiotics Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/40-sectio-40?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter5/moographbezylpeicilli. html#bezylpeicilli<accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=846&product_ ame=bepe <accessed 22/12/08> Drug Category: 8(b) Cephalosporis Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Ceftriaxoe Meigococcal Disease: No-blachig Rash 2 g IV/IO/IM Stat (if allergy to peicilli) Allergy to cephalosporis Chlorampheicol Ceftriaxoe is icompatible with calcium; do ot give via calcium-cotaiig solutios i.e. do ot mix with Hartmas Category B1 Drugs that have bee take by oly a limited umber of pregat wome ad wome of childbearig age, without a icrease i the frequecy of malformatio or other direct or idirect harmful effects o the huma foetus havig bee observed. Studies i aimals have ot show evidece of a icreased occurrece of foetal damage Real, hepatic impairmet; impaired vitami K sythesis; prologed use; history of GIT disease (esp. colitis); pregacy, lactatio Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/56-sectio-56?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter5/moographceftriaxoe. html#ceftriaxoe<accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=7874&product_ ame=ceftriaxoe <accessed 22/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 82 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Corticosteroids Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Dexamethasoe Meigococcal disease: No-blachig rash if patiet greater tha 65 kg give 10 mg IV/IO stat If less tha 65 kg give 0.15 mg per kg IV/IO stat Kow hypersesitivity to dexamethasoe Rifampici, pheytoi ad barbiturates may reduce the plasma levels ad half-life of corticosteroids Oral cotraceptio Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed. Cosidered safe to use as o-treatmet may be more serious for the foetus ad ogoig pregacy Cirrhosis or hypothyroidism may ehace the effect of corticosteroids Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/83-sectio-83?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter14/moographdexamethasoe. html<accessed 05/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=679&product_ ame=dexmethsoe#precautios <accessed 05/03/09> Drug Category: Other Ophthalmic Medicatio Drug Name Fluorescei Idicatios/Doses Ocular Ijuries: istil oe drop to affected eye/s with excess beig washed away with sterile 0.9% Sodium Chloride solutio Fluorescei does ot stai a ormal corea, but coreal abrasios or ulcers are staied a bright gree ad foreig bodies are surrouded by a gree rig Cotraidicatios Kow hypersesitivity Iteractios Nil Pregacy Precautios Pseudomoas aerugiosa grows well i fluorescei sigle dose sterile solutios should be used whe usig this solutio to avoid ifectig already damaged eye/s. Fluorescei ca permaetly stai soft cotact leses remove leses before applyig the stai Modified from: Australia Medicies Hadbook 2008; http://proxy7.use.hc.com.au/appedices/appapp-additioal-drugs. html#fluorescei <accessed 06.02.2009> MIMS Olie 2008; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr _pi&product_ code=1618&product_ame=miims+stais <accessed 06.02.2009>. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 83

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Peicillis Ifectios ad Ifestatios Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Flucloxacilli Severe Sepsis: with o obvious source of ifectio ad patiet is immuocompromised 2 g IV/IO stat History of hypersesitivity reactios to peicillis ad other beta-lactam atibiotics Itraveous solutios of flucloxacilli are physically icompatible with may other substaces icludig may other atibiotics getamici, tobramyci ad vacomyci, ad meta clopramide,morphie sulphate, ad pethidie Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Serious, ad occasioally fatal, hypersetivity reactios (aaphylaxis) have bee reported i patiets receivig peicillis ad other beta-lactam atibiotics Modified from: Mims Olie, http://proxy36.use.hc.com.au/search/fullpi.aspx?modulename=product%20ifo&searchkeyword=flucloxa cilli+sodium+for+ijectio+(dbl)&previouspage=~/search/quicksearch.aspx&searchtype=&id=37670001_2 < accessed 30.09.11> Drug Category: 2(c) Diuretics Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Frusemide Shortess of Breath with History of Cardiac Disease: 40 mg IV stat if audible respiratory crepitatios preset Documeted hypersesitivity Severe sodium ad fluid depletio Treatmet with potassium-lowerig drugs, e.g. amphoterici, icreases risk of hypokalaemia; moitor potassium cocetratio Auria Iterferes with hypoglycaemic effect of atidiabetic agets cocurret amioglycosides cause auditory toxicity hearig loss of varyig degrees may occur; may icrease aticoagulat activity of warfari; icreased plasma lithium levels ad toxicity are possible Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible. Frusemide must ot be give durig pregacy uless there are compellig medical reasos. Treatmet durig pregacy requires moitorig of foetal growth Excessive diuresis may cause dehydratio, electrolyte imbalaces ad blood volume reductio with circulatory collapse ad possibly vascular thrombosis ad embolism, particularly i elderly patiets Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/131-sectio-131?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter6/moographfrusemide. html#frusemide<accessed 2/03/09> Mims Olie, http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=792&product_ ame=lasix <accessed 23/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 84 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Amioglycosides Ifectios ad Ifestatios Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Getamici Severe Sepsis: 7 mg/kg IV for oe dose (maximum 640 mg) Amioglycoside toxicity, history of sesitivity Getamyci is iactivated by peicillis ad cephalosporis ad should ot be mixed or give simultaeously. Should be admiistered by separate ifusio Category D Getamici kow to cross placeta. Evidece of selective uptake by the foetal kidey resultig i cellular damage. Thought to be reversible Real impairmet Modified from: Mims Olie, http://proxy36.use.hc.com.au/search/fullpi.aspx?modulename=product%20ifo&searchkeyword=getami ci&previouspage=~/search/quicksearch.aspx&searchtype=&id=8990001_2 < accessed 30.09.11> Drug Category: Glucose-elevatig Agets Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Glucago Ucoscious patiet: If IV access uavailable, 1 mg IM stat if BGL less tha 3.0 mmol/l ad patiet ucoscious or cofused Seizures: If IV access uavailable, 1 mg IM stat if BGL less tha 3.0 mmol/l Stroke icludig Trasiet Ischaemic Attack: If IV access uavailable- 1 mg IM stat if BGL less tha 3.5 mmol/l ad patiet ucoscious or cofused Severe Sepsis: If IV access uavailable- 1 mg IM stat if BGL less tha 3.0 mmol/l Hypoglycaemia: If IV access uavailable, 1 mg IM stat if BGL less tha 3.0 mmol/l ad patiet ucoscious or cofused Documeted hypersesitivity, phaeochromocytoma, isulioma, glucagooma May ehace effects of aticoagulats Category B2 Drugs that have bee take by oly a limited umber of pregat wome ad wome of childbearig age, without a icrease i the frequecy of malformatio or other direct or idirect harmful effects o the huma foetus havig bee observed. Studies i aimals are iadequate or may be lackig, but available data show o evidece of a icreased occurrece of foetal damage Effective i treatig hypoglycaemia oly if sufficiet liver glycoge preset, therefore glucago hydrochloride has virtually o effect o patiets i states of starvatio, adreal isufficiecy, or chroic hypoglycaemia or alcohol iduced hypoglycaemia Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/138-sectio-138?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter10/moographglucago. html#glucago <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2810&product_ ame=glucage <accessed 23/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 85

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Glucose Supplemet Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios 50% Glucose Ucoscious Patiet: 50 ml IV stat if BGL less tha 3.0 mmol/l ad patiet ucoscious or cofused Seizures: 50 ml IV stat if BGL less tha 3.0 mmol/l Stroke icludig Trasiet Ischaemic Attack: 50 ml IV stat if BGL less tha 3.5 mmol/l ad patiet ucoscious or cofused Severe Sepsis: 50 ml IV stat if BGL less tha 3.0 mmol/l ad patiet ucoscious or cofused Hypoglycaemia: 50 ml IV stat if BGL less tha 3.0 mmol/l ad patiet ucoscious or cofused Avoid i dehydrated patiets; diabetic (hyperglycaemic) coma Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed May cause ausea, moitor fluid balace, electrolyte cocetratios, ad acid-base balace closely; glucose admiistratio may produce vitami B-complex deficiecy; thrombophlebitis Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/139-sectio-139?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter10/ treathypoglycaemia.t.html#idxglucose:ihypoglycaemiaidx <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2741&product_ ame=glucose+ijectio+bp+50%25 <accessed 23/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 86 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Nitrates Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Glyceryl Triitrate (tablet or spray) Shortess of Breath with History of Cardiac Disease: 300-600 micrograms (½-1 tab) SL iitially, the every 5 miutes if SBP greater tha 90 mmhg to a total of 1800 micrograms or 1-2 sprays (400-800 micrograms) SL iitially, the every 5 miutes if SBP greater tha 90 mmhg to a total of 4 sprays (1600 micrograms) Acute Coroary Sydrome: 300-600 micrograms (½-1 tab) SL iitially, the every 5 miutes if SBP greater tha 90 mmhg to a total of 3 tablets (1800 micrograms) or 1-2 sprays (400-800 micrograms) SL iitially, the every 5 miutes if SBP greater tha 90 mmhg to a total of 4 sprays (1600 micrograms) Hypotesio; hypertrophic obstructive cardiomyopathy; cardiac tampoade; aortic or mitral steosis; cor pulmoale; marked aaemia; raised itracraial pressure; treatmet with phosphodiesterase 5 ihibitors (e.g. sildeafil Viagra); documeted hypersesitivity Severe hypotesio may occur with co admiistratio of phosphodiesterase 5 ihibitors (e.g. sildeafil) Viagra Category B2 Drugs that have bee take by oly a limited umber of pregat wome ad wome of childbearig age, without a icrease i the frequecy of malformatio or other direct or idirect harmful effects o the huma foetus havig bee observed. Studies i aimals are iadequate or may be lackig, but available data show o evidece of a icreased occurrece of foetal damage Adverse effects are mostly due to vasodilator effects. Cautio required i the presece of hypotesio. Medical officer should be cosulted prior to admiistratio i pregat patiets. Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter6/moographglyceryl-triitrate. html#glyceryl-triitrate <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=193&product_ ame=agiie <accessed 23/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 87

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Corticosteroids Drug Name Idicatios/Doses Cotraidicatios Iteractios Pregacy Precautios Hydrocortisoe Shortess of Breath with or without a History of Asthma: 200 mg IV (moderate ad severe asthma) stat Shortess of Breath with a History of Chroic Obstructive Pulmoary Disease: 200 mg IV (moderate ad severe cases) stat Ucotrolled ifectio, active peptic ulcer disease Thiazide diuretics may icrease the risk of hyperglycaemia caused by hydrocortisoe. Rifampici, pheytoi ad barbiturates may reduce the plasma levels ad half-life of corticosteroids. Decreases the efficacy of the followig medicatios; Aspiri, Isuli or oral atidiabetic agets Oral cotraceptio Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible Cirrhosis or hypothyroidism may ehace the effect of corticosteroids Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/147-sectio-147?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter14/moographhydrocortisoe. html#hydrocortisoe <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=689&product_ ame=solu%2dcortef <accessed 23/12/08> Drug Category: Brochodilators Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Ipratropium Bromide (Atrovet) Shortess of Breath with or Without a History of Asthma: 4 puffs of 20 microgram Metered Dose Ihaler (severe asthma) or 500 micrograms ebule (severe asthma) stat if patiet caot ihale adequately to use a MDI + spacer Shortess of Breath with History of Chroic Obstructive Pulmoary Disease: 4 puffs of 20 microgram Metered Dose Ihaler stat or 500 microgram ebule stat if patiet caot ihale adequately to use a MDI + spacer Documeted hypersesitivity to ipratropium Drugs with aticholiergic properties may icrease toxicity. Cardiovascular effects may icrease with Mooamie Oxidase Iihibitors, tricyclic atidepressats, ad sympathomimetic agets. Disodium cromoglycate with bezalkoium Cl Beta-Adreergics, xathies (additive). Check with Medical Officer before givig to patiet already receivig tiotropium Category B1 Drugs that have bee take by oly a limited umber of pregat wome ad wome of childbearig age, without a icrease i the frequecy of malformatio or other direct or idirect harmful effects o the huma foetus havig bee observed. Studies i aimals[1] have ot show evidece of a icreased occurrece of foetal damage Cautio i glaucoma (protect eyes if ebuliser i use), prostatic hypertrophy, ad hyperthyroidism, diabetes mellitus, ad cardiovascular disorders Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter19/moographipratropium. html#ipratropium<accessed 4/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=6818&product_ ame=atrovet+metered+aerosol+%28cfc%2dfree%29 <accessed 23/12/08> http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=1284&product_ame=atr ovet+nebulisig+solutio <accessed 23/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 88 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Atiemetics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Metoclopramide If ausea/vomitig preset: Sake / spider bite: 10 mg IV or IM stat Stroke icludig Trasiet Ischaemic attack: 10 mg IV or IM stat Trauma: 10 mg IV/IO or IM stat Burs: 10 mg IV/IO or IM stat Head Ijury: 10 mg IV or IM stat Isolated severe limb ijury: 10 mg IV or IM stat Ocular ijuries: 10 mg IM stat Documeted hypersesitivity. Patiets with history of dystoia / extrapyramidal reactios to medicatio. Extrapyramidal side effects (EPSE) more likely i patiets < 20 years of age Not to be used i presece of itestial obstructio Phaeochromocytoma May icrease sedative effects of other medicatio ad worse Parkiso s symptoms i patiets with Parkiso s Disease Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed. Cautio i history Parkiso disease; elderly more likely to experiece drowsiess Moderate ad Severe Real impairmet as EPSE are commo Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/196-sectio-196?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter12/moographmetoclopramide. html#metoclopramide <accessed 4/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=549&product_ ame=metoclopramide+ijectio <accessed 23/12/08> Drug Category: Axiolytics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Midazolam Seizures: 2.5 mg icremets IV slow ijectio every 1-2 miutes (to a total of 0.1 mg per kg) or If IV access uavailable, 10 mg IM stat ad repeat (oce oly) after 5 miutes if required Documeted hypersesitivity; pre-existig hypotesio. Rapid or bolus IV Sedative effects may be atagoized by theophyllies, alcohol; arcotics ad erythromyci may accetuate sedative effects due to decreased clearace Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible Respiratory depressio, apoea, cardiovascular depressio ad cardiac arrest are more likely after IV ijectio Cautio i cogestive heart failure, pulmoary disease, real impairmet, ad hepatic failure elimiate Midazolam slower Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/199-sectio-199?directory=3&itemid=8 <accessed 05/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter2/moographmidazolam.html <accessed 05/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=6104&product_ ame=midazolam+ijectio#precautios <accessed 05/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 89

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Aalgesics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Morphie Acute Coroary Sydrome: 2.5 mg icremets (to a total of 10 mg) IV every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Trauma (if pai score 4-10) 2.5 mg icremets (to a total of 10 mg) IV/IO every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Stroke icludig Trasiet Ischaemic attack (if pai score 4-10) 2.5 mg icremets (to a total of 10 mg) IV/IO every 5 miutes or 5 10 mg IM stat (to a total of 10 mg) Burs (if pai score 4-10) 2.5 mg icremets (to a total of 10 mg) IV/IO every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Head ijury (if pai score 4-10) 2.5 mg icremets (to a total of 10 mg) IV every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Isolated severe limb ijury (if pai score 4-10) 2.5 mg icremets (to a total of 10 mg) IV every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Ocular ijuries: 5-10mg IM stat (to a total of 10 mg) Abdomial/loi/flak pai (if pai score 2-10) 2.5 mg icremets (to a total of 10 mg) IV every 5 miutes or 5-10 mg IM stat (to a total of 10 mg) Documeted hypersesitivity; severe respiratory disease, coma Respiratory depressat ad sedative effects may be additive i the presece of other medicatio Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible. Cautio i hypotesio, ausea, vomitig, cautio i supravetricular tachycardias; has vagolytic actio ad may icrease vetricular respose rate Cautio i patiets with severe real, hepatic dysfuctio, may cause excessive sedatio or coma Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/ cotet/article/1-drug-moographs-a-z/202-sectio-202?directory=3&itemid=8 <accessed 06/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter3/moographmorphie. html#morphie <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=379&product_ ame=dbl+morphie+sulfate+ijectio+bp <accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 90 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Atidotes for Narcotic Agoists Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Naloxoe Ucoscious Patiet: 800 micrograms IM stat ad 800 micrograms IV stat Documeted hypersesitivity Decreases aalgesic effects of opioids. Effects of partial agoists eg bupreorphie, tramadol oly partially reversed by aloxoe. Category B1 Drugs that have bee take by oly a limited umber of pregat wome ad wome of childbearig age, without a icrease i the frequecy of malformatio or other direct or idirect harmful effects o the huma foetus havig bee observed. Studies i aimals[1] have ot show evidece of a icreased occurrece of foetal damage Cautio i cardiovascular disease; may precipitate withdrawal symptoms i patiets with opiate depedece. If patiets do ot respod to multiple dose of Naloxoe, cosider alterative causes of ucosciousess. Reversal of opioid effects may umask other toxicities i cases of igestio of multiple agets ad icrease the risk of seizures. Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/206-sectio-206?directory=3&itemid=8 <accessed 06/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter4/moographaloxoe. html#aloxoe <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2157&product_ ame=naloxoe+hydrochloride+ijectio <accessed 06/03/09> Drug Category: Topical Ocular Aaesthetics Drug Name Oxybuprocaie 0.4% Idicatios/Dose Ocular Ijuries: 2 drops per affected eye, topical, stat. To produce local aaesthesia i the eye. Ca be used every 15-20 miutes durig the irrigatio procedure. Stat oly for flash burs Cotraidicatios Documeted hypersesitivity. Not for use i cases with peetratig eye ijury. Cocomitat eye ifectio Iteractios Pregacy (Category D) Safety for use i pregacy has ot bee established. Miims, Oxybuprocaie eye drops should be used oly whe it is cosidered essetial by a doctor Precautios May give rise to dermatitis i hypersesitive patiets. The aaesthetised eye should be protected from dust ad bacterial cotamiatio. Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter11/moographoxybuprocaie. html#oxybuprocaie <accessed 2/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=7450&product_ ame=miims+beoxiate+%28oxybuprocaie%29 <accessed 22/12/08> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 91

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Aalgesics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Paracetamol Head ijury: 500 mg-1 g (1-2 tablets) oral stat if pai score 1-3 ad patiet ot il by mouth Stroke icludig Trasiet Ischaemic attack: 500 mg 1 g IV (Perfalga) if temperature greater tha 37.5 C or 500 mg 1 g (1-2 suppositories) per rectum if temperature greater tha 37.5 C Severe Sepsis: 500 mg 1 g (1-2 tablets) oral stat if temperature greater tha 38.5 C Documeted hypersesitivity patiet is il orally Aticoagulats; drugs affectig gastric emptyig; hepatic ezyme iducers icludig alcohol, aticovulsats Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Cautio i severe real or hepatic dysfuctio Max dose = 4g per day total Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter3/moographparacetamol. html#paracetamol <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=391&product_ ame=paadol <accessed 06/03/09> Drug Category: Aalgesics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Paracetamol ad Codeie (Paadeie Forte) (Paracetamol 500mg ad Codeie Phosphate 30mg) Burs: 1-2 tablets oral stat if pai score 1-3 ad patiet ot il by mouth Isolated Severe Limb Ijury: 1-2 tablets oral stat if pai score 1-3 ad patiet ot il by mouth Ocular Ijuries: 1-2 tablets oral stat if pai score 1-3 ad patiet ot il by mouth Documeted hypersesitivity Patiet il orally CNS depressats or tricyclic atidepressats icrease toxicity, drugs affectig gastric emptyig, sigificat respiratory disease, comatose patiets. Paracetamol may icrease chlorampheicol cocetratios Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Cautio i severe real or hepatic dysfuctio Max 4g per day total Paracetamol Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter3/moographparacetamol.html#id xpaadeieforteparacetamolacodeieidx <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=390&product_ ame=paadeie+forte <accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 92 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Corticosteroids Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Predisoloe Shortess of Breath with or without a History of Asthma: 50 mg oral stat (moderate ad severe asthma) if IV access uavailable Shortess of Breath with History of Chroic Obstructive Pulmoary Disease: 50 mg oral stat (severe ad moderate cases) if IV access uavailable Documeted Hypersesitivity to Predisoloe. Active Peptic ulcer; osteoporosis; psychoses, psychoeuroses; TB; systemic fugal ifectios Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Patiets who are immuosuppressed Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter14/moographpredisoepredisoloe.html#predisoe-predisoloe <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=2832&product_ ame=soloe accessed 06/03/09> Drug Category: Atiemetics Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Prochlorperazie Abdomial/loi/flak Pai: 12.5 mg IM stat if ausea/vomitig preset Documeted hypersesitivity Patiets with history of dystoia / extrapyramidal reactios to medicatio. Extrapyramidal Side Effects (EPSE) more likely i patiets less tha 20 years of age CNS depressio May icrease sedative effects of other medicatio ad worse Parkiso s symptoms i patiets with Parkiso s Disease Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible May worse symptoms of Parkiso s Disease; watch for hypotesio Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/248-sectio-248?directory=3&itemid=8 <accessed 06/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter12/moographprochlorperazie. html#prochlorperazie <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=553&product_ ame=stemetil <accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 93

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Ihaled Beta-agoists Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Salbutamol (Vetoli) Aaphylactic Reactio: Metered Dose Ihaler + spacer; 10 puffs of 100 microgram Metered Dose Ihaler stat if wheeze preset Shortess of Breath with or without a History of Asthma: Metered Dose Ihaler + spacer; 8-12 puffs of 100 microgram Metered Dose Ihaler every 15-30 miutes for severe asthma; 8-12 puffs of 100 microgram Metered Dose Ihaler every 1-4 hours for moderate asthma; 8-12 puffs of 100 microgram Metered Dose Ihaler stat for mild asthma 5 mg ebule every 15-30 miutes for patiets with severe asthma who caot ihale well eough to use MDI + spacer Shortess of Breath with History of Chroic Obstructive Pulmoary Disease: Metered Dose Ihaler + spacer; 10 puffs of 100 microgram dose Metered Dose Ihaler repeat every 20 miutes if required 5 mg ebule every 20 miutes if required (for patiets with severe cases who caot ihale well eough to use MDI + spacer) Drowig: Metered Dose Ihaler + spacer; 6-12 puffs of 100 microgram Metered Dose Ihaler stat if wheeze preset 5 mg ebule stat (for patiets who caot ihale well eough to use MDI + spacer) History of Hypersesitivity; Ca cause paradoxical brochospasm, allergic reactios May icrease cardiovascular effects of other sympathomimetics drugs Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed May cause tachycardia, ausea ad tremors. Cautio i patiets with coexistig cardiovascular disease. Hypokalaemia ca occur with high doses particularly i combiatio with other potassiumdepletig medicatios. Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter19/moographsalbutamol. html#salbutamol <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=4114&product_ ame=asmol+cfc%2dfree+ihaler <accessed 06/03/09> http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=1296&product_ame=vetol i+respirator+solutio+ad+nebules <accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 94 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Immue Ehacemet Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Diphtheria, tetaus +/-, pertussis (ADT Booster) (where ot available, Boostrix ca be used) Sake / spider Bite: 0.5 ml IM stat Trauma: 0.5 ml IM stat Burs: 0.5 ml IM stat Ocular Ijuries: 0.5 ml IM stat The oly absolute cotraidicatios to tetaus vaccie are: aaphylaxis followig a previous dose of the vaccie, or aaphylaxis followig ay vaccie compoet Immuosuppressio/ deficiecy patiets Category A ADT Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Category B2 Boostrix Adequate huma data o use durig pregacy ad adequate aimal reproductio studies are ot available. Therefore, Boostrix should be used durig pregacy oly whe clearly eeded ad the possible advatages outweigh the possible risks for the foetus. Whe protectio agaist tetaus is sought, cosideratio should be give to tetaus or combied diphtheria tetaus vaccies. As with all iactivated vaccies, oe does ot expect harm to the foetus. If a idividual has a tetaus-proe woud ad has previously had a severe adverse evet followig tetaus vacciatio, alterative measures, icludig the use of huma tetaus immuoglobuli, ca be cosidered. Modified from: The Australia Immuisatio Hadbook; http://www.immuise.health.gov.au/iteret/immuise/publishig.sf/cotet/ Hadbook-tetaus <accessed 06/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter20/moographdiphtheria-tetausvaccies.html#idxadtseediphtheriawithtetausvaccieidx <accessed 06/03/09> http://proxy7.use.hc.com.au/view.php?page=chapter20/moographdtp-vaccies.html#idxboostrixdtpvaccieidx <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=5686&product_ ame=boostrix# <accessed 06/03/09> http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=7766&product_ ame=adt+booster# <accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 95

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Vitami Supplemetatio Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Thiamie (Vitami B-1) Ucoscious patiet: 100 mg IM stat if history of possible alcohol abuse Seizures: 100 mg IM stat if history of possible alcohol abuse Stroke icludig Trasiet Iscahemic Attack: 100 mg IM stat if history of possible alcohol abuse Hypoglycaemia: 100 mg IM stat if history of possible alcohol abuse Previous hypersesitivity to pareteral admiistratio Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Hypersesitivity reactios ca occur followig pareteral admiistratio. Sudde oset or worseig of Wericke ecephalopathy, followig glucose, may occur i thiamie-deficiet patiets; admiister Modified from: Australia Ijectable Drugs Hadbook, Fourth Editio; http://proxy6.use.hc.com.au/aidh/idex.php/compoet/cotet/ article/1-drug-moographs-a-z/288-sectio-288?directory=3&itemid=8 <accessed 06/03/09> Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter4/moographthiamie. html#thiamie <accessed 06/03/09> Drug Category: Itraveous Fluids Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios 0.9% Sodium Chloride IV/IO caulae flush 10 ml 30 ml flush for resuscitatio (Cardiorespiratory Arrest) Medicatio dilutio e.g. Morphie Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Modified from: Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=4023&product_ ame=sodium+chloride+ijectio+0%2e9%25 < accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 96 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Itraveous Fluids Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios 0.9% Sodium Chloride Ucoscious Patiet: IV 500 ml bolus if SBP less tha 90 mmhg IV 1000 ml at 125 ml per hour to maitai hydratio Aaphylactic Reactio: IV 1000 ml bolus if pulse rate greater tha 100, SBP less tha 90 mmhg ad capillary refill greater tha 2 secods No-traumatic Shock: IV/IO 500 ml bolus if SBP Less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) Meigococcal Disease: o-blachig Rash IV/IO 500 ml bolus if SBP Less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) Stroke icludig Trasiet Ischaemic Attack: IV/IO 500 ml bolus if SBP Less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) IV 1000 ml at 125 ml per hour (to maitai hydratio) Severe Sepsis: IV/IO 500 ml bolus if SBP Less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) IV 1000 ml at 125 ml per hour (to maitai hydratio) Hyperglycaemia with Severe Dehydratio: IV 500 ml bolus if SBP less tha 90 mmhg or if sigs of dehydratio (repeat oce if sigs of dehydratio persist or SBP remais less tha 90 mmhg) Sake/spider Bite: IV 500 ml bolus if SBP Less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) IV 1000 ml at 125 ml per hour (to maitai hydratio) Trauma: IV/IO 1000 ml at 125 ml per hour (to maitai hydratio) Burs: IV/IO 500 ml bolus if SBP less tha 90 mmhg Drowig: IV 500 ml bolus if SBP less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) Head Ijury: IV 200 ml bolus if SBP less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) Ocular Ijuries: Topical for irrigatio of coreal foreig bodies ad chemical exposure (repeat as required) Abdomial/loi/flak Pai: IV 500 ml bolus if SBP less tha 90 mmhg (repeat oce if SBP remais less tha 90 mmhg) IV 1000 ml at 125 ml per hour (to maitai hydratio) Category A Drugs which have bee take by a large umber of pregat wome ad wome of childbearig age without ay prove icrease i the frequecy of malformatios or other direct or idirect harmful effects o the foetus havig bee observed Cogestive cardiac failure, severe real impairmet, sodium retetio Modified from: Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=3623&product_ ame=sodium+chloride+itraveous+ifusio+bp < accessed 06/03/09> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 97

Formulary Medical Officer must be otified immediately For Adults Oly Drug Category: Itraveous Fluids Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Compoud Sodium Lactate (Hartmas Solutio) Trauma: IV/IO 200 ml stat to maitai SBP 80-90 mmhg (repeat oce if required to maitai SBP 80-90 mmhg) Burs: IV/IO as per Modified Parklad formula Ocular ijuries: Topical for irrigatio of coreal foreig bodies ad chemical exposure (repeat as required) Cogestive heart failure or severe impairmet of real fuctio. Admiistered cocomitatly with potassium sparig diuretics ad agiotesi covertig ezyme (ACE) ihibitors. Simultaeous admiistratio of these drugs ca result i severe hyperkalaemia Category C Drugs that, owig to their pharmacological effects, have caused or may be suspected of causig harmful effects o the huma foetus or eoate without causig malformatios. These effects may be reversible Sodium retetio. Pregacy Modified from: Australia Medicies Hadbook; http://proxy7.use.hc.com.au/view.php?page=chapter7/tableelectrolytes-ifusiosolutios.tb.html#idxhartma????????scompoudsodiumlactateifusioidx <accessed 06/03/09> Mims Olie; http://proxy8.use.hc.com.au/ifmx-sapi/mims-data/?mival=2mims_abbr_pi&product_code=7704&product_ ame=compoud+sodium+lactate+%28hartma%27s+solutio%29+ijectio < accessed 06/03/09> Drug Category: Other atibiotics ad ati-ifectives Ifectios ad Ifestatios Drug Name Idicatios/Dose Cotraidicatios Iteractios Pregacy Precautios Vacomyci Severe Sepsis: Dose accordig to patiet s body weight if patiet is allergic to peicilli Kow hypersesitivity Do ot admiister IMI. Do ot ifuse as bolus or rapid ifusio as may cause profoud shock. If caula tissues vacomyci ca cause extravasatio. Use with cautio i elderly patiets ad patiets with impaired real fuctio. Vacomyci iteracts with may medicatios ad should be ifused aloe. Category B2. Not recommeded for lactatig wome. Real impairmet Modified from: MIMS olie, http://proxy36.use.hc.com.au/search/abbrpi.aspx?modulename=product%20ifo&searchkeyword=vaco myci&previouspage=~/search/quicksearch.aspx&searchtype=&id=9610001_2 < accessed 30.09.11> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 98 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SECTION 9 Appedices NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 99

APPENDIX 1: RURAL ad REMOTE EMERGENCY TROLLEY MINIMUM ADULT REQUIREMENTS Ideally the followig equipmet should be stored o a freely movig mobile trolley with IV pole. Airway ETT (cuffed) x 1 of each 6.0, 7.0, 7.5, 8.0, 8.5, & 9.0 mm Larygeal mask airway 4.0, 5.0 ad 6.0 Larygoscope Hadles with batteries x 2 Mackitosh (Curved) blades 3 ad 4 Oropharygeal rigid sucker Adult x 1 Oropharygeal airway 2, 3 & 4 Nasopharygeal airway 6.0 mm & 7.0 mm Itroducer/itubatig stylet Large & medium itroducer Bougie (gum elastic itroducer) Tape White cotto tape Other Magill forceps, lubricat satchels x 3, 10 ml syrige, scissors Breathig Self-iflatig 1500 ml resuscitatio bag with reservoir bag ad oxyge tubig Clear masks sizes: 3, 4 & 5 Y suctio catheters 12fg & 14fg Suctio tubig Disposable CO 2 idicator if capography ot available Dwell cath or 14g caula (8cm i legth) Circulatio Syriges 1 ml x 5; 2 ml x 5; 5 ml x 5; 10 ml x 10; 20 ml x 5; 1 x 50 ml Caula 14g, 16g, 20g, 22g, 18g, scalp vei eedle 23g, 25g 5 each of Needles x10 Blut drawig up 21g Itra-osseous Needle x 1 Needle-less system accessories As per LHD stock Givig sets Plai givig set x 2, blood pump givig set x 2, burette x1 Other 3 way taps x 5 miimal volume extesio tubig trasparet IV dressig x 5 adhesive tape x 1 touriquet atimicrobial swabs wipes x 10 The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 100 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Drugs/Fluids Size Amout Adrealie 1:10,000 1 mg i 10 ml Mii-jets x 3 Adrealie 1:1000 1 mg i 1 ml 10 Atropie 3 mg i total Glucose 5% 100 ml bag Glucose 10% 500 ml 1 Glucose 50% 50 ml 1 Sodium Chloride 0.9% 1000 ml 2 Sodium bicarboate 50 ml 1 Amiodaroe 150 mg i 3 ml ampoules 6 Calcium glucoate 10% 10% i 10 ml 2 Ligocaie 2% 100 mg 1 mii-jet Magesium Chloride 20% i 5 ml 2 Sodium Chloride 0.9% 10 ml 20 Naloxoe 400 micrograms/1 ml 4 Water for ijectio 10 ml 10 I fridge: Log actig euromuscular muscle blockig aget 5 Suxamethoium chloride 100 mg/2 ml 5 Other: Defibrillator Full oxyge cylider/source ECG electrodes Defib self-adhesive/gel pads x 2 packets Arrest documetatio form ad pe Sharps cotaier PPE Portable suctio NG tube Stethoscope Basic ad Advaced Life Support algorithm Scissors Drug additive labels The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 101

APPENDIX 2: DEFIBRILLATION Defibrillatio as soo as possible provides the best chace of survival i victims with VF or ucoscious VT. Defibrillatio works because it temporarily stus the myocardium with flow of electros, thus causig chages i membrae potetial, resultig i the depolarisatio of the cardiac cells. Depolarisatio stops the hyper-excitable areas of the myocardium from propagatig impulses. This, i tur, allows the sioatrial ode to resume its fuctio as the primary pacemaker of the heart, resultig i the ormal coordiated cotractile activity of the heart. Paddle/pad placemet Right parasteral area over the 2d itercostal space Midaxillary lie over the 6th itercostal space (Apex) Care should be take to esure that pads or electrodes are applied i accordace with maufacturer s istructios ad are ot i electrical cotact with each other. Precautios: Be aware of electrical hazards i the presece of water, metal fixtures, oxyge ad flammable substaces. War of impedig discharge by a stad clear commad; AVOID chargig the paddles uless they are placed o the victim s chest; AVOID placig the defibrillator paddles/pads over ECG electrodes (risk of burs or sparks), ECG leads (may melt), medicatio patches, a implated device (e.g. a pacemaker), a cetral lie isertio site; AVOID havig, or allowig ay perso to have, ay direct or idirect cotact with the victim durig defibrillatio (a shock may be received); AVOID havig the victim i cotact with metal fixtures e.g. bed rails (risk of bur); AVOID delivery of a shock with a gap betwee the paddles/pad ad chest wall (spark hazards); AVOID defibrillatig if victim, operator ad/or close bystader are situated i a explosive/flammable (e.g. petrol) eviromet; AVOID allowig oxyge from resuscitator to flow oto the victim s chest durig delivery of the shock (risk of fire). Factors that may cotribute to the resistace to flow of electros durig defibrillatio attempts. Mechaical causes of decreased defibrillatio success Physiological causes of decreased defibrillatio success Eergy selected Electrode size Chest wall diameter Electrode ski couplig material Number ad time iterval of previous shocks Electrode to chest cotact pressure Systemic acidosis Pre-existig cardiac disease Drug overdose Body temperature Legth of time without spotaeous circulatio Refereces: Australia Resuscitatio Coucil, 2010, Guidelie 11.4, Electrical therapy for adult advaced life support, ARC, Melboure. Bridy M.A., Burklow T.R., 2002, Uderstadig the ewer automated exteral defibrillator devices: electrophysiology, basicwaveforms, ad techology, Joural of Emergecy Nursig, Volume 28, o. 2, pp. 132-137. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 102 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 3: 12 LEAD ECG Procedure: Limb Lead Placemet The four limb leads are to be placed at the level of wrists ad akles as idicated i the diagram below. Ay variatio i limb lead placemet (e.g. amputee) is to be documeted o the 12 lead ECG, clearly specifyig the alterate limb lead placemets. Chest Lead Placemet V1 ad V2 sited at 4 th itercostal space o either side of the sterum. V3 sited betwee V2 ad V4. V4 sited at 5 th itercostal space, mid clavicular lie. V5 sited betwee V4 ad V6 / aterior axillary lie, lateral to V4. V6 sited at 5 th itercostal space, mid axillary lie, lateral to V4. Referece: Jowett N.I., Turer A.M., Cole A., ad Joes P. A., 2005, Modified electrode placemet must be recorded whe performig 12-lead electrocardiograms, Postgrad. Med. Joural, vol. 81, pp. 122-125. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 103

APPENDIX 4: NSW CHEST PAIN PATHWAY Facility: CHEST PAIN PATHWAY NON PRIMARY PCI SITE FAMILY NAME COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Date of Presetatio / / Time : Time of Symptom Oset: : CHEST PAIN or OTHER SYMPTOMS of MYOCARDIAL ISCHAEMIA (eg sweatig, sudde orthopea, sycope, dyspoea, epigastric discomfort, jaw pai, arm pai) Be aware: HIGH RISK ATYPICAL PRESENTATIONS (eg diabetes, real failure, female, elderly or Aborigial) TRIAGE CATEGORY 2 HIGH RISK Ay of the followig ACS symptoms are repetitive or prologed (> 10 mi) & still preset. Sycope History of chroic left vetricular systolic dysfuctio (especially if kow LVEF < 40%) OR curret cliical evidece of LVF. Previous PCI/CABG < 6 moths Diabetes + typical ACS symptoms Chroic real failure + typical ACS symptoms Haemodyamic compromise (sustaied SBP < 90 mmhg ad / or ew oset mitral regurgitatio) Elevated Tropoi (cosider haemolysis, real failure) Persistet or dyamic ECG chages of ST depressio 0.5 mm or ew T wave iversio 2 mm Trasiet ST elevatio ( 0.5 mm) i more tha two cotiguous leads Sustaied VT N N MRN GIVEN NAME MALE FEMALE D.O.B. / / ADDRESS LOCATION / WARD ECG & Vital Sigs, expert iterpretatio withi 10 miutes ST ELEVATION or (presumed ew) LBBB Cosider Aortic Dissectio (back pai, hypertesio, abset pulse, BP differece) Cosider Pulmoary Embolism (severe dyspoea, respiratory distress, low subscript O2 saturatio) Diagose NON ST ELEVATION ACUTE CORONARY SYNDROME (ACS) STRATIFY ACS RISK INTERMEDIATE RISK Ay of the followig ad o high risk features ACS symptoms withi 48 hrs that occurred at rest, or were repetitive or prologed (but curretly resolved) Previous PCI/CABG > 6 moths Kow coroary heart disease- Esp if prior AMI or kow coroary lesio > 50% steosis Two or more risk factors of: Hypertesio, family history, active smokig or hyperlipidaemia Chroic real failure (especially if kow GFR < 60 ml/mi) + atypical ACS symptoms Diabetes + atypical ACS symptoms Age > 65 years ECG is ot ormal ad has chaged from previous pai free ECG but does ot cotai high risk chages. Y M.O. All cases to be discussed with Seior Medical Officer Recommeded Maagemet o page 2 Geeral Maagemet Oxyge Aspiri IV Access Pai Relief Pathology icl Tropoi Chest X-ray Cosider Pericarditis (sharp chest pai, respiratory or positioal compoet) N Go immediately to STEMI MANAGEMENT (page 3) LOW RISK Ay of the followig ad o high or itermediate risk features Presetatio with cliical features cosistet with ACS without itermediate- risk or high-risk features. ECG Normal or uchaged from previous pai free ECG This tool is iteded as a guidelie for cliicias to provide quality patiet care. It is ot iteded, or should it replace, idividual cliical judgemet. Some patiets with co-morbidities or patiets ot suitable for ivasive ivestigatios may be appropriately maaged medically. NO WRITING Page 1 of 4 CHEST PAIN PATHWAY NON PRIMARY PCI SITE SMR080.071 Facility: CHEST PAIN NON PRIMA Cotraidicatios a Absolute cotraidicatios: Risk of bleedig - Active bleedig or bleedig d - Sigificat closed head or fa - Suspected aortic dissectio Risk of itracraial haemorr - Ay prior itracraial haemo - Ischaemic stroke withi 3 mo - Kow structural cerebral va - Kow maligat itracraia Relative cotraidicatios: Risk of bleedig - Curret use of aticoagulat - No-compressible vascular p - Recet major surgery (< 3 w - Traumatic or prologed (> 10 - Recet (withi 4 weeks) ite - Active peptic ulcer Risk of itracraial haemorr - History of chroic, severe, p - Severe ucotrolled hyperte - Ischaemic stroke more tha Other - Pregacy 1 Adapted from NHF/CSANZ G Cotraidicatios to Absolute - Recurret chest pai - Acute myocardial ifarctio, - High-risk ustable agia - Ucotrolled cardiac arrhyth - Symptomatic severe aortic s - Ucotrolled symptomatic he - Acute pulmoary embolus o - Acute myocarditis or pericard - Acute aortic dissectio Relative - Critical left mai coroary s - Moderate steotic valvular h - Electrolyte abormalities - Systolic hypertesio > 200 - Diastolic hypertesio > 100 - Tachyarrhythmias or bradyar - New oset atrial fibrillatio - Hypertrophic cardiomyopath - Metal or physical impair - High-degree atriovetricular - Restig ECG which will mak 2 Gibbos etal, Circulatio 10 Abbreviatios: ACS Acute Coroary Sydr ECG Electrocardiogram FMC First Medical Cotact LBBB Left Budle Brach B LVH Left Vetricular Hypert SMO Seior Medical officer NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.idd 1 The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 104 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

FAMILY NAME MRN GIVEN NAME MALE FEMALE SMRÊ(Îg Ä SMR080071 BINDING MARGIN - NO WRITING Facility: CHEST PAIN PATHWAY NON PRIMARY PCI SITE D.O.B. / / ADDRESS LOCATION / WARD M.O. COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Recommeded Further Maagemet Refer to drug protocols &/or Therapeutic Guidelies HIGH RISK ADMIT or TRANSFER Cotiuous cardiac moitorig & frequet vital sigs Repeat ECG immediately if symptoms recurs Repeat ECG 8 hrs post oset of symptoms Repeat Tropoi at 8 hrs if 1st sample egative * ECG/Tropoi review by medical officer Atiplatelet therapy Yes Discuss with cardiologist No } /SMO If o reaso Betablocker Yes No If o reaso Aticoagulat YES No If o reaso Symptomatic treatmet of ogoig pai/hypertesio IV GTN (titrate agaist pai & BP) IV Morphie Refer to omiated cardiologist for further maagemet INTERMEDIATE RISK RESTRATIFY Cotiuous cardiac moitorig & frequet vital sigs Repeat ECG immediately if symptoms recur Repeat ECG 8 hrs post oset of symptoms Repeat Tropoi at 8 hrs if 1st sample egative * ECG/Tropoi review by medical officer Refer for Exercise Stress Test ** if : No further chest pai/symptoms ad 2 egative Tropoi tests ad No ew ECG chages ad No cotraidicatios to stress test (page 4) Restratify to High Risk if: Recurret ischaemic chest pai or Positive Tropoi or New ECG chages or Positive stress test Restratify to Low Risk & Discharge if: Negative stress test or Stress test available withi 72 hrs** ad No further chest pai/symptoms Repeat ECG & vital sigs, if stable discharge NB: ** If stress test is ot available withi 72 hrs of discharge, treatmet pla should be guided by omiated SMO/Cardiologist LOW RISK DISCHARGE Regular vital sigs Repeat ECG immediately if symptoms recur Repeat ECG 8 hrs post oset of symptoms Repeat Tropoi at 8 hrs if 1st sample egative * ECG/Tropoi review by medical officer Restratify Risk if: Recurret ischaemic chest pai or Positive Tropoi or New ECG chages If low Risk ACS Discharge Follow up GP/LMO withi 3-5 days of D/C Cosider Specialist follow up Cosider discharge o Aspiri (discuss with SMO) Vital sigs prior to discharge If ulikely cardiac cause Cosider alterative diagosis Exit Pathway Facility STE CO INDIC REPE GE MAN ADM ANTITH TH CH REPE M 5. THR Te Body W Time a Pharmacological stress test or CT coroary agiography may be idicated *If a high sesitivity tropoi assay is used, the testig iterval may be reduced to 3 hours, provided the secod sample is take at least 6 hours after symptom oset. Dis Pri Or Re 120511 Medical Officer: Prit ame & sig Date Medical Officer Desigatio This tool is iteded as a guidelie for cliicias to provide quality patiet care. It is ot iteded, or should it replace, idividual cliical judgemet. Some patiets with co-morbidities or patiets ot suitable for ivasive ivestigatios may be appropriately maaged medically. NO WRITING Page 2 of 4 Medical O This tool judgeme NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.idd 2 The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 105

FAMILY NAME MRN FEMALE L HERE Facility: CHEST PAIN PATHWAY NON PRIMARY PCI SITE STEMI MANAGEMENT GIVEN NAME MALE FEMALE D.O.B. / / M.O. ADDRESS LOCATION / WARD COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE K ately if 1. CONFIRM INDICATIONS for REPERFUSION Chest pai > 30 mi ad < 12 hrs Persistet ST segmet elevatio of 1 mm i two or more cotiguous limb leads or ST segmet elevatio of 2 mm i two cotiguous chest leads or presumed ew LBBB patter Myocardial ifarct likely from history Time of diagostic ECG : st oset hrs if 1st 2. GENERAL MANAGEMENT Cardiac moitorig ECG IV Caula X 2 Routie bloods Oxyge Aalgesia Morphie Nitrates-Subligual or IV CXR Beta Blockers by chest 3. ADMINISTER ANTITHROMBOTIC THERAPY Cofirm admiistratio or give: Aspiri 300 mg (soluble) Clopidogrel 300-600 mg (or prasugrel &/or tirofiba) Eoxapari 30 mg IV the bd (or IV hepari or bivalirudi) 1 mg/kg subcut (Max 100 mg) Refer to local protocols &/or Therapeutic Guidelies ithi 3-5 4. CHOOSE REPERFUSION METHOD THROMBOLYSIS UNLESS Absolute or uacceptable relative cotraidicatios (see page 4) or Patiet does ot coset to thrombolysis or Documeted system for trasfer to PRIMARY PCI SITE i place ollow up SMO) scharge e diagosis 5. THROMBOLYSE Teecteplase / Reteplase Body Weight kg Dose Time admiistered : Discussed with cardiologist: Time : OR Trasfer to PRIMARY PCI SITE if appropriate (As per table below) Maximum Acceptable Delay from First Medical Cotact (FMC): Time sice symptom oset Acceptable delay from FMC to percutaeous itervetio < 1hours 60 miutes 1-3 hours 90 miutes 3-12 hours 120 miutes >12hours Not routiely recommeded from NHF/CSANZ Guidelies for the maagemet of acute coroary sydromes 2006 secod Discuss further maagemet immediately with omiated cardiologist Prioritise urgecy of trasfer with omiated cardiologist Orgaise trasfer to PCI-capable hospital (as per locally agreed protocol) Repeat ECG at 60 mis post thrombolytic al cliical medically. Medical Officer: Prit ame & sig Date Medical Officer Desigatio This tool is iteded as a guidelie for cliicias to provide quality patiet care. It is ot iteded, or should it replace, idividual cliical judgemet. Some patiets with co-morbidities or patiets ot suitable for ivasive ivestigatios may be appropriately maaged medically. Page 2 of 4 NO WRITING Page 3 of 4 12/05/2011 10:32:22 AM The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 106 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

EMALE ERE et opoi tis tory or ly T igh or ures rom CHEST PAIN PATHWAY NON PRIMARY PCI SITE SMR080.071 Facility: CHEST PAIN PATHWAY NON PRIMARY PCI SITE FAMILY NAME MRN GIVEN NAME MALE FEMALE D.O.B. / / ADDRESS LOCATION / WARD M.O. COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Cotraidicatios ad cautios for thrombolysis use i STEMI 1 Absolute cotraidicatios: Risk of bleedig - Active bleedig or bleedig diathesis (excludig meses) - Sigificat closed head or facial trauma withi 3 moths - Suspected aortic dissectio (icludig ew eurological symptoms) Risk of itracraial haemorrhage - Ay prior itracraial haemorrhage - Ischaemic stroke withi 3 moths - Kow structural cerebral vascular lesio (eg, arterioveous malformatio) - Kow maligat itracraial eoplasm (primary or metastatic) Relative cotraidicatios: Risk of bleedig - Curret use of aticoagulats: the higher the iteratioal ormalised ratio (INR), the higher the risk of bleedig - No-compressible vascular puctures - Recet major surgery (< 3 weeks) - Traumatic or prologed (> 10 miutes) cardiopulmoary resuscitatio - Recet (withi 4 weeks) iteral bleedig (eg, gastroitestial or uriary tract haemorrhage) - Active peptic ulcer Risk of itracraial haemorrhage - History of chroic, severe, poorly cotrolled hypertesio - Severe ucotrolled hypertesio o presetatio (> 180 mmhg systolic or > 110 mmhg diastolic) - Ischaemic stroke more tha 3 moths ago, demetia, or kow itracraial abormality ot covered i cotraidicatios Other - Pregacy 1 Adapted from NHF/CSANZ Guidelies for the maagemet of acute coroary sydromes 2006 Cotraidicatios to Exercise Testig (ACC/AHA Guidelies) 2 Absolute - Recurret chest pai - Acute myocardial ifarctio, withi 2 days - High-risk ustable agia - Ucotrolled cardiac arrhythmias causig symptoms or haemodyamic compromise - Symptomatic severe aortic steosis - Ucotrolled symptomatic heart failure - Acute pulmoary embolus or pulmoary ifarctio - Acute myocarditis or pericarditis - Acute aortic dissectio Relative - Critical left mai coroary steosis - Moderate steotic valvular heart disease - Electrolyte abormalities - Systolic hypertesio > 200 mmhg - Diastolic hypertesio > 100 mmhg - Tachyarrhythmias or bradyarrhythmias - New oset atrial fibrillatio - Hypertrophic cardiomyopathy ad other forms of outflow obstructio - Metal or physical impairmet leadig to the iability to exercise adequately - High-degree atriovetricular block - Restig ECG which will make EST iterpretatio difficult (eg LBBB, LVH with strai, Vetricular pacig, Vetricular preexcitatio.) 2 Gibbos etal, Circulatio 106:1883,2002 Abbreviatios: ACS Acute Coroary Sydrome CABG Coroary Artery Bypass Graft ECG Electrocardiogram EST Exercise Stress Test FMC First Medical Cotact GTN Glyceryl triitrate LBBB Left Budle Brach Block LVF Left Vetricular Failure l medically. LVH Left Vetricular Hypertrophy SMO Seior Medical officer PCI Percutaeous Coroary Itervetio STEMI ST Elevatio Myocardial Ifarctio ge 1 of 4 NO WRITING Page 4 of 4 BINDING MARGIN - NO WRITING SMRÊ(Îg Ä SMR080071 12/05/2011 10:32:22 AM The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 107

APPENDIX 5: MANAGEMENT of PATIENTS with ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION Patiets with STEMI who preset withi 12 hours of the oset of ischaemic symptoms should have a reperfusio strategy implemeted promptly. 12-lead ECG (at least oe of the followig ECG chages is madatory for thrombolysis) ST segmet elevatio of greater tha or equal to 1 mm i two or more cotiguous limb leads; ST segmet elevatio of greater tha or equal to 2 mm i two or more cotiguous chest leads; New left budle brach block (LBBB) patter (Note that LBBB is presumed ew uless there is evidece otherwise). Differetial diagoses must be cosidered by a Medical Officer: Aortic dissectio; Pericarditis; Pulmoary embolism Cotraidicatios* to be cosidered by a Medical Officer: Absolute Cotraidicatios: Active bleedig (excludig meses) Sigificat closed head or facial trauma (withi 3 moths) Suspected aortic dissectio Ay prior itracraial haemorrhage Ischaemic stroke withi 3 moths Kow structural cerebral vascular lesio Kow maligat itracraial eoplasm (primary or metastatic) Relative Cotraidicatios: Curret use of aticoagulats (the higher the INR, the greater the risk) No-compressible vascular pucture Recet major surgery (less tha 3 weeks) Pregacy Traumatic or prologed CPR loger tha 10 miutes Recet (withi 4 weeks) iteral bleedig Active peptic ulcer History of chroic, severe, poorly cotrolled hypertesio Ucotrolled hypertesio at time of presetatio SBP greater tha 180 mmhg or DBP greater tha 110 mmhg (should be treated prior to thrombolysis) Ischaemic stroke more tha 3 moths ago, demetia or kow itracraial abormality ot covered i cotraidicatios * May cotraidicatios are relative ad potetial beefits versus relative risks should always be cosidered. Referece: Natioal Heart Foudatio of Australia & Cardiac Society of Australia ad New Zealad, 2006, Guidelies for the maagemet of acute coroary sydromes, The Medical Joural of Australia, vol. 184, o. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 108 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 6: AVPU / GCS AVPU is a memoic used to obtai a rapid assessmet of a patiet s level of cosciousess. A Alert V Respods to vocal stimuli P Respods to Paiful Stimuli U Uresposive This observatio should also iclude assessig the pupillary reflexes. This rapid assessmet will detect oly gross eurological damage GCS Glasgow Coma Scale A quick, practical ad stadardised system for assessig the degree of coscious impairmet of the critically ill ad ijured. It ca also be used for predictig the duratio ad outcome for patiets with head ijuries. Three behavioural resposes are evaluated: Best Eye Opeig; Best Verbal Respose; ad Best Motor Respose. Each category has criteria ad umerical values are attached to each criterio. The highest score achievable is 15 ad the lowest score is 3. The Glasgow Coma Scale is used to moitor tred whe performig assessmets of level of cosciousess. A decreasig score is associated with eurological deterioratio. Best Eye Opeig Respose Eyes ope spotaeously 4 Eyes ope to voice 3 Eyes ope to paiful stimuli 2 No eye opeig 1 = 4 Best Verbal Respose Orietated to time place ad perso 5 Cofused 4 Iappropriate words 3 Icomprehesible Souds 2 No verbal respose 1 = 5 Best Motor Respose Obeys Commads 6 Localises to Paiful Stimuli 5 No purposeful respose to pai 4 Flexio to pai 3 Extesio to pai 2 No motor respose 1 = 6 Total = 15 A patiet with a GCS of less tha 9 ad ot rapidly improvig will require edotracheal itubatio by a Medical Officer to protect the patiet s airway from aspiratio. Referece: Healey C., Olser Turer M., Rogers F.B., Healey M.A., Glace L.G., Kilgo P.D, Shackford S.R. ad Meredith J.W., 2003, Improvig the Glasgow Coma Scale Score: Motor Score Aloe is a Better Predictor, The Joural of Trauma: Ijury, Ifectio, ad Critical Care, vol. 54, o. 4, pp. 671-680. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 109

APPENDIX 7: PAIN ASSESSMENT A umber of tools exist to assist cliicias i the assessmet of pai. A commoly used techique i the Emergecy Departmet is the PQRST memoic. FACTOR Provokes, Palliates, Precipitatig factors Quality Regio, Radiatio Severity, associated symptoms Time DESCRIPTION QUESTIONS What were you doig whe the pai occurred? What provoked the pai? What makes the pai better? What makes the pai worse? Have you had this type of pai before? What does the pai feel like? Ask the patiet to describe the pai i their words Where is the pai/show me where the pai is Does the pai radiate? If so, where? How severe is the pai? If you were to rate the pai o a scale from 0 to 10 with 0 beig o pai ad 10 beig the most severe pai you ca imagie, how would you rate your pai? Do you have ay other symptoms? Whe did the pai start? How log did it last? Does it come ad go? Referece: ENA & Newberry, 2003, Sheehy s Emergecy Nursig: Priciples ad Practice, 5th ed, Mosby. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 110 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 8: ABBEY PAIN SCALE The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 111

APPENDIX 9: SEDATION SCORE/SCALE Evidece idicates that a decrease i respiratory rate is a late ad ureliable idicator of respiratory depressio followig opioid admiistratio. Sedatio has bee foud to be a reliable early cliical idicator of respiratory depressio ad should be moitored followig opioid admiistratio usig a sedatio score. Sedatio Score Scale 0= Noe 1= Mild, occasioally drowsy, easy to rouse 2= Moderate, costatly or frequetly drowsy easy to rouse 3= Severe, somolet, difficult to rouse 4= Normal sleep The patiet is scored accordig to the scale above. The aim is to keep the sedatio score below 2 regardless of the route of opioid admiistratio. A sedatio score of 2 meas that the patiet is costatly drowsy or groggy but still easy to rouse e.g. they wake up easily but caot stay awake durig coversatio. Refereces: Lehe, Richard A., 2001, Pharmacology for Nursig Care, 4th ed, W.B. Sauders, Philadelphia. Natioal Health ad Medical Research Coucil, 1999, Acute Pai Maagemet: Scietific Evidece, Commowealth of Australia, Caberra. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 112 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 10: GLASS TUMBLER TEST A rash is commo with meigococcal ifectio it may be purpuric or petechial. Small red or purple spots develop at first ad may occur i groups aywhere o the body. They ofte grow to become blotchy ad look like little bruises. Oe or two may develop at first, ad the appear i differet parts of the body. The spots do ot fade whe pressed (ulike may other rashes). To check for this do the Tumbler Test. Place a clear glass tumbler firmly o oe of the spots or blotches ad see if you ca still see them through the glass. Note: it is harder to see o dark ski, so check paler areas. The rash is a sig of septicaemia. It may ot occur with meigitis aloe. Do NOT solely rely o the rash, as it may ot always occur or may occur late i the disease. Petechial Rash Petechiae result from tiy area of superficial bleedig ito the ski. They appear as roud, pipoit-sized spots that are ot raised. The colour varies from red to purple as they age ad gradually disappear. The rash does ot blach with pressure. Purpuric Rash Purpura are larger areas of bleedig ito the ski begiig as red areas that become purple ad later browish-yellow. The rash does ot blach with pressure. Referece: Meigococcal Educatio Ic., The Glass Test, viewed 10 August 2009, <http://www.meigococcal.org/the_rash.html> The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 113

APPENDIX 11: SNAKEBITE OBSERVATION CharT Sakebite Observatio Chart Patiet surame: Foreame: Date of birth: MRN umber: Date of bite Time of bite: Type of sake: Number of bites: Date: Time: Time after bite: GENERAL: Pulse rate: Blood pressure: Temperature: SPECIFIC: Regioal lymph ode tederess: Local bite site pai: Bite site swellig: Headache: Nausea: Vomitig: Abdomial pai: PARALYTIC SIGNS: Ptosis: Opthalmoplegia: Fixed dilated pupils: Dysarthria: Dysphalgia: Togue protrusio: Limb weakess: Respiratory weakess: Peak flow rate: MYOLYTIC SIGNS: Muscle pai: Myoglobiuria: COAGULOPATHY SIGNS: Persistat blood ooze: Haematuria: Active bleedig: RENAL: Urie output: LABORATORY KEY TESTS: INR/prothrombi time aptt Fibrioge XDP/FDP Platelet cout CK Creatiie Urea K+ ANTIVENOM: Type/amout/time: Reactio Referece: NSW Health, 2007, Sakebite ad Spiderbite Cliical Maagemet Guidelies, NSW Departmet of Health, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 114 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 12: TRAUMA TRIAGE TOOL M MECHANISM OF INJURY Blut Focal blut trauma to head or torso Trasport icidet: Death i same vehicle Itrusio ito occupat compartmet > 30 cm Steerig wheel deformity Patiet side impact Vehicle v. pedestria/cyclist/mbc Ejectio from vehicle Etrapmet with compressio Falls >3m or paediatrics twice the child s height High voltage ijury Crush ijury excludig figers/toes Ay rapid deceleratio mechaism that results i a large iertia chage at impact Patiets <16 or >65 years of age. Obstetric patiets >20 weeks gestatio, patiets o aticoagulats ad patiets with pre-existig disease are at greater risk ad require a high idex of suspicio for serious ijury. If i doubt, trasport to Trauma Cetre. Peetratig All peetratig ijury (excudig isolated ijury to hads or feet). AND/OR I INJURIES Head: Mior head ijury with loss of cosciousess, or amesic to evet with: 2 or more vomits or a seizure O aticoagulats Ope, depressed skull ad/or sigs of base of skull. A decreased LOC is due to traumatic ijury, util prove otherwise. Face: Ijury with potetial airway risk; severe haemorrhage. Neck: Swellig, bruisig, hoarseess, stridor. Chest: Severe pai, paradoxical breathig, restrait abrasio/cofusio. Abdome: Severe pai, rigidity, swellig, pelvic tederess, restrait/abrasio/cofusio. Limbs: 2 or more promial log boe, amputatio proximal to digits, ischaemia, deglovig ijury. Spial/Back: Visible deformity. Burs: Partial or full thickess burs. Adults >20%; Childre >10%, or burs ivolvig head/eck/face/hads/feet/groi or ihalatio ijury. All circumferetial burs or burs i a patiet with comorbidities or pregacy. AND/OR S SIGNS AND SYMPTOMS Airway: At risk, hoarseess, stridor. Breathig:RR <10 or >29, Sp0 2 < 90% o air, cyaosis or respiratory difficulty. Circulatio: HR >120, SBP <90 or severe haemorrhage. Disability: GCS 13 or paralysis/sesory deficit. Or ay worseig tred i ABCD. Paediatrics: Physiological chages are late idicators of serious ijury i a child who may lose 30% blood volume prior to ANY chages i vital sigs. The followig are a guide: 1st year 1 5 yrs 6-12 yrs HR >160 >140 >120 SBP <60 <70 <80 RR >60 >35 >30 T TRANSPORT If patiet meets Major Trauma Criteria, they are to be trasported to the highest level Trauma Cetre withi a 1-hour travel time or Aeromedical Retrieval Service advised. Trauma Triage Tool Major Trauma Criteria (MIST) Yes Yes Yes to ay Yes to ay Patiets 16 ad > 65 years of age who are ambulatory at the scee with ormal physiology ad mior or o apparet ijury. If i doubt, trasfer to Trauma Cetre IMMEDIATE AND URGENT TRANSPORT IMMEDIATE TRANSPORT URGENT TRANSPORT Yes No T RA U MA C O D E 3 M I S T Closest Hospital T R A U M A C E N T R E Referece: Ambulace Service of New South Wales, 2008, Trauma Triage Tool Major Trauma Criteria (MIST), Cliical Developmet Uit The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 115

APPENDIX 13a: GUIDELINES for whe to APPLY SEMI-RIGID CERVICAL COLLARS Stadard: All multi-trauma patiets or patiets with a head ijury will have a semi-rigid cervical collar applied. Patiets at risk for spial ijury will have a semi-rigid cervical collar applied as per the Caadia C-Spie rule. Patiets assessed ot to be at risk for spial ijury, will have a cervical collar removed. Caadia C-Spie Rule For alert (GCS 15) ad stable trauma patiets where cervical spie is a cocer. 1. Ay oe of the followig High Risk factors? Age 65 years or older Dagerous mechaism of ijury* Numbess or tiglig i extremities YES NO 2. Ay oe of the followig Low Risk factors which allows for safe assessmet of rage of motio? Ambulatory at ay time at the scee No midlie c-spie tederess Delayed oset of eck pai Simple rear-ed motor vehicle collisio Excludes: hit by bus or large truck, pushed ito ocomig traffic, hit by high speed vehicle more tha 100 km/hour YES 3. Patiet able to volutarily actively rotate eck 45º left ad right, regardless of pai? YES No C-spie immobilisatio required NO NO Apply semi-rigid cervical collar Immobilise C-spie Requires radiography * Dagerous mechaism of ijury Fall from more tha 3 feet/ 1 metre or 5 stairs Axial loadig to head e.g. divig, spear tackle MVC or MBC at high speed more tha 100 km/hr MVC rollover, ejectio Quadbike, motorised all-terrai vehicles Bicycle collisio Oce a cervical collar has bee applied, full spial precautios eed to be maitaied util the C-spie has bee cleared by cliical examiatio or radiographic assessmet. Cotraidicatios: peetratig eck ijury. This should be maaged with i-lie immobilisatio. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 116 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 13B: REMOVAL of SEMI-RIGID CERVICAL COLLAR without RADIOGRAPHIC ASSESSMENT Cervical spie clearace without radiographic assessmet ONLY applies to fully coscious patiets with a GCS 15. A Medical Officer makes the decisio for removal of a C-spie collar, after a thorough physical assessmet reveals the followig: NEXUS Criteria: Fully alert GCS 15 No midlie pai ad or tederess upo palpatio of the cervical spie No motor or sesory deficit e.g. weakess, umbess or parasthesia No distractig paiful ijury that may mask symptoms of a cervical ijury i.e. fracture, burs No evidece of alcohol ad/or drug igestio. If ALL of the NEXUS criteria are satisfied, cliical examiatio may the proceed. If a full rage of active movemet (45 degrees rotatio) ca be performed without pai, ad there is o evidece of: Bruisig, deformity or tederess o examiatio, Ijury above the clavicle. Medical coditio requirig extra cautio i.e. osteoporosis, rheumatoid arthritis The cervical spie ca be cliically cleared without radiographic imagig ad the cervical collar ca be removed. Refereces: Brehaut J.C., Stiell I.G., & Graham I.D., 2006, Will a ew cliical decisio rule be widely used? The case of the Caadia C-spie rule, Academic Emergecy Medicie, vol. 13, o. 4 p. 413. Rogers I., Ieraci S., 2006, Emergecy care evidece i practice series: Cervical spie x-rays i trauma. Emergecy Care Commuity of Practice, Natioal Istitute of Cliical Studies, Melboure. Stiell I.G., Clemet C.M., McKight R.D., Briso R., Schull M.J., Rowe B.H., Worthigto J.R., Eisehauer M.A., Cass D., Greeberg G., MacPhail I., Dreyer J., Lee J.S., Badiera G., Reardo M., Holroyd B., Lesiuk H., Wells G.A., 2003 The Caadia C-spie rule versus the NEXUS low-risk criteria i patiets with trauma, New Eglad Joural of Medicie, vol. 349, o. 26, pp. 2510-18. Stiell I.G., Lesiuk H., Wells G.A., McKight R.D., Briso R., Clemet C., Eisehauer M.A., Greeberg G.H., MacPhail I., Reardo M., Worthigto J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morriso L., Schull M., Laupacis A., 2001, Caadia CT head ad C-spie study group. The Caadia CT head rule study for patiets with mior head ijury: ratioale, objectives, ad methodology for phase I, Aals of Emergecy Medicie, vol. 38, o. 2, pp.160-69. Stiell I.G., Lesiuk H., Wells G.A., Coyle D., McKight R.D., Briso R., Clemet C., Eisehauer M.A., Greeberg G.H., Macphail I., Reardo M., Worthigto J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morriso L., Schull M., Laupacis A., 2001, Caadia CT head ad C-spie study group. Caadia CT head rule study for patiets with mior head ijury: methodology for phase II, Aals of Emergecy Medicie, vol. 38, o. 3, pp. 317-22. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 117

APPENDIX 14: NEEDLE THORACENTESIS for DECOMPRESSION OF TENSION Peumothorax Idicatio: a rapidly deterioratig haemodyamically ustable patiet who has a life-threateig tesio peumothorax. A tesio peumothorax is associated with the formatio of a oe-way valve at the poit of a rupture i the lug. Air becomes trapped i the pleural cavity betwee the chest wall ad the lug, ad builds up, puttig pressure o the lug ad keepig it from iflatig fully. The mediastium is shifted to the opposite side of the chest, decreasig veous retur ad compressig the opposite lug. Early sigs ad symptoms of a cliical tesio peumothorax: chest pai dyspoea axiety tachypoea tachycardia hyper-resoace of the chest wall o the affected side reduced chest movemet o the affected side dimiished chest souds o the affected side. Late sigs of a tesio peumothorax: decreased level of cosciousess tracheal deviatio away from the affected side hypotesio disteded eck veis cyaosis. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 118 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Procedural Steps for Needle Thoracetesis 1. Prepare Patiet Positio the patiet i upright positio (as tolerated) oly if a cervical spie ijury has bee excluded Apply O 2 via a o-rebreather face mask at 15 L/ miute 2. Clease the site with atimicrobial swab. 3. Isert a large bore IV caula (14 or 16 gauge), greater tha 8 cm i legth, ito the 2 d itercostal space just superior to the 3 rd rib, at a 90-degree agle ito the ski ad through the itercostal space (Figure b). Figure b Explai the procedure to the patiet, if coscious Expose the aterior chest Idetify ad locate ladmarks (o the affected side) see figures a ad b suprasteral otch midclavicular lie 2 d Itercostal space The 2 d itercostal space is foud by dividig the clavicle i half. From that halfway poit, palpate dow oe rib to the first space below that rib. This is the 2 d itercostal space (the space immediately after the clavicle is the 1 st itercostal space) (Figure a) Figure a 4. Pucture the parietal pleura. Remove the eedle from the catheter ad liste for a sudde escape of air, idicatig that the tesio peumothorax has bee relieved. 5. Leave the catheter i place. 6. Place the patiet i upright positio as tolerated (if C-spie ijuries have bee ruled out) to assist with respiratios. The patiet may remai supie if C-spie ijuries are suspected. 7. Cotiue to moitor the patiet ad reassess. N.B. A Medical Officer must ow isert a itercostal catheter. Referece: America College of Surgeos Committee o Trauma, 2008, Shock i Advaced Trauma Life Support Course for Doctors Studet Course Maual, 8 th ed, Uited States. Curtis K., Ramsde C., ad Friedship J., 2007, Emergecy ad trauma ursig, Mosby, Sydey. Operatioal Medicie, 2001, Field medical services school studet hadbook, < http://brookside press.org/products/ OperatioalMedicie/DATA/operatioalmed/Mauals/FMSS/NEEDLETHORO.CENTESISFMST0411.htm> Titialli J., Gabor M., Kele D., Stapczyski S., Ma J., ad Clie D., 2003, Emergecy medicie: A comprehesive study guide iteratioal editio, 6 th ed, McGraw-Hill, New York. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 119

APPENDIX 15: SUGGESTED GUIDELINES for a NEUROVASCULAR ASSESSMENT Begi assessmet by evaluatio of uijured limb first for ormal patiet baselie. Pulses Nerves Sesatio Motor Auxillary Auxillary Regimetal bade o upper arm Shoulder abductio Brachial Radial Web space betwee thumb ad idex figer Hyperexteded thumb or wrist Ular Media Pad of idex figer Thumb oppositio flex wrist Radial Ular Pad of little figer Abductio of figers Femoral Femoral Aterior of thigh Straight leg raise Popliteal Sciatic Lateral aspect of calf ad foot Hip extesio Aterior Tibialis Peroeal Deep Web space betwee first ad secod toes Dorsiflexio of foot Posterior Tibialis Tibial Heel of foot Platar flexio of foot Dorsalis Pedis Sub-Peroeal Dorsum of foot Foot eversio Referece: Tamworth Hospital Neurovascular Observatio Chart. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 120 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 16: PELVIC BINDING For rotatioally ustable pelvic fractures: Ope-book, Vertical Shear, Lateral Compressio type III or Combied Mechaism fractures. 1 Place folded bed sheet udereath the patiet betwee iliac crests ad greater trochaters. 2 With two trauma team members, cross the sheeet across the syphysis ad pull the sheet firmly so it tightly fits aroud ad stabilises the pelvis. 3 A third perso should clamp the sheet at the four poits show (away from laparotomy/agiograph access poits). Referece: Heetveld, M, 2007, The Maagemet of Haemodyamically Ustable Patiets with a Pelvic Fracture, NSW Istitute of Trauma ad Ijury Maagemet, Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 121

APPENDIX 17: BURN TRANSFER FLOWCHART Medical Retrieval Referral Mior Burs Meets Medical Retrieval Itubated patiets Head ad eck burs Burs >10% i childre or >20% i adults Burs with associated ihalatio Burs with sigificat comorbidities, e.g. trauma Electrical/chemical ijury Sigificat pre-existig medical disorder Circumferetial to limbs or chest compromisig circulatio or respiratio Needs referral but ot medical retrieval Burs >5% childre or >10% adults Burs to hads, feet, face, geitalia, perieum ad major joits Burs with a pre-existig medical coditio, e.g. diabetes Childre with suspected o-accidetal ijury ad adults with assault, selfiflicted ijury Pregacy (2d or 3rd trimester RNSH) Spial cord ijury RNSH Extremes of ages Mior burs are treated i cosultatio with the referrig doctor as a outpatiet, either locally (at origial place of care) or o referral to a ambulatory burs cliic for assessmet. Cotact: AMRS Adults 1800 650 004 NetS for childre up to 16th birthday 1300 362 500 The Childre s Hospital at Westmead Catchmet Area: All childre s referrals to the age of 15 i all areas of NSW. Cocord Repatriatio Geeral Hospital Catchmet Area: South-Easter Sydey/ Illawarra, Sydey West, Sydey South West, Greater Souther*, Greater Wester*, ACT Royal North Shore Hospital Catchmet Area: Sydey/Cetral Coast, Huter/New Eglad, North Coast* *Hospitals ear state border areas may refer to Burs Uits i adjoiig states. Cotact Burs Ambulatory Care: CHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h) Set up coferece call with receivig ICU/Bur Uit; facilitate commuicatio with primary referral site CHW ICU 99845 1171 CRGH ICU 99767 6404 RNSH ICU 99926 8640 CHW: Surgical Registrar o-call otified. Rig 9645 0000, the page Surgical Registrar CRGH: Burs Registrar o-call otified. Tel 9767 7111, the page Burs Registrar RNSH: Burs Registrar o-call otified. Tel: 9926 7111, the page Burs Registrar Not referred to service. AMRS/NETS will coordiate trasfer betweee primary hospital ad the receivig hospital. The o-call registrar will offer advice ad arrage a bed i liaiso with Bed Maagemet ad the Burs Uit. They are resposible for receivigthe patiet. The referrer will make the ambulace bookig. Referred to service. Ay issues or problems with these processes, or if further advice is required, the NSW Severe Bur Ijury Service Maager ca be cotacted o (02) 9926 5641 Referece: NSW Health, 2008, Bur Trasfer Guidelies NSW Severe Bur Ijury Service, 2d ed, NSW Departmet of Heath, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 122 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Referece: NSW Health, 2008, Bur Trasfer Guidelies NSW Severe Bur Ijury Service, 2d ed, NSW Departmet of Heath, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 123

Shade affected area Total % TBSA = NB: Fait erythema ot icluded i % TBSA assessmet NB: Difficult to accurately assess bur depth withi the first 24 48 hours post ijury. Referece: NSW Health, 2008, Bur Trasfer Guidelies NSW Severe Bur Ijury Service, 2d ed, NSW Departmet of Heath, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 124 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

Referece: NSW Health, 2008, Bur Trasfer Guidelies NSW Severe Bur Ijury Service, 2d ed, NSW Departmet of Heath, North Sydey. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 125

APPENDIX 18 GUIDELINE for EMERGENCY DEPARTMENT DOCUMENTATION Triage Documetatio Stadard 1. Date ad time of assessmet 6. Ay diagostic, first aid or treatmet measures iitiated 2. Chief presetig problem(s) 7. Assessmet ad treatmet area allocated 3. Relevat assessmet fidigs 8. Name of triage officer 4. Limited, relevat history 9. Re-triage category with time ad reaso (if applicable) 5. Iitial triage category allocated 10. Vital sigs should oly be measured at triage if required to estimate urgecy or if time permits (Australasia College for Emergecy Medicie ATS Guidelies Revised August 05) Primary Survey A Airway (& Cervical-Spie) B Breathig C Circulatio D Disability (eurological) Discomfort (pai assessmet) E Exposure & Eviromet History (source the patiet, caregiver or Ambulace Officer) Ogoig Assessmet Triage category 1 3 Record vital sigs at time of assessmet ad frequecy accordig to the patiet s cliical presetatio Triage category 4 Record vital sigs at time of assessmet ad at least oe further set prior to discharge or accordig to the patiet s cliical presetatio Triage category 5 Record vital sigs at time of assessmet ad relevat to presetatio Pla What pla has bee put i place for this patiet? Evaluatio Discharge Time of departure Destiatio Referrals Documetatio Patecy, airway oises, mechaism of ijury (spial, head, ihalatio ijury) airway adjucts (oro/asopharygeal/ LMA /ETT) Respiratory rate, rhythm ad depth, work of breathig, oxyge delivery device ad amout Ski colour, warmth ad diaphoresis, capillary refill, pulses, overt bleedig, IV caula (positio ad size) & fluids, (commece a fluid balace chart if fluids are admiistered) A alert V respods to voice P respods to paiful stimuli U uresposive Pupils size & reactio (PEARL) Pai assessmet ad score + BGL Head-to-toe or focused assessmet (idetified abormalities ad evirometal hazards durig exposure) M mechaism of ijury / illess I ijuries sustaied / illess progressio S sigs & symptoms T treatmet (pre presetatio) / trasport Documeted Observatios respiratory rate, oxyge saturatios (SpO 2) oxyge device, ad litres /miute pulse, blood pressure, temperature level of cosciousess GCS & pupils blood glucose level (BGL) pai score (0-10) ad assessmet ECG cardiac rhythm (if moitored) eurovascular observatios (if relevat) weight (if relevat) ay ivestigatios commeced /completed & outcome A allergies M medicatios (prescriptio, over the couter, herbal) P past medical / surgical history L last meal / last mestrual period / last immuisatio E evets leadig up to presetatio Documet i a cocise ad clear maer: procedures, itervetios, outcome & evaluatio chroologically stadig orders or guidelies if commeced otificatio who has bee told comply with legal reportig resposibilities Reassess patiet ad documet outcomes Documet discharge iformatio icludig ay istructios or educatio give to the patiet or family If patiet ot prepared to wait to be see documet advice give to the patiet or family Further madatory documetatio is required accordig to the patiet s cliical presetatio or if the patiet is admitted (i.e. alcohol/other drug use, smokig, ski itegrity ad falls screeig). The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 126 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

APPENDIX 19: EXAMPLE OF MINIMUM SKILL SET FOR EMERGENCY DEPARTMENT STAFF Skill Medical Officer Advaced Cliical Nurse (RN) RN EEN/EN Basic Life Support Essetial Essetial Essetial Essetial Airway Placemet of oropharygeal airway Essetial Essetial Essetial Essetial Oropharygeal suctio usig a rigid suctio device Essetial Essetial Essetial Essetial Two perso vetilatio usig a BVM before itubatio Essetial Essetial Essetial Desirable Assistace with edotracheal itubatio Essetial Essetial Essetial Desirable (e.g. cricoid pressure) Tracheal itubatio Desirable Not required Not required Not required Oe perso use of BVM after itubatio Essetial Essetial Essetial Desirable Tracheal suctio Essetial Essetial Desirable Not required Isertio of larygeal mask airway Essetial Desirable Not required Not required Maagemet of the difficult airway icludig surgical Desirable Not required Not required Not required cricothyroidotomy C-Spie Semi-rigid collar fittig e.g. Caadia C-spie rules Essetial Essetial Essetial Desirable Semi rigid collar removal decisio i.e. NEXUS Essetial Not required Not required Not required Spial Immobilisatio Essetial Essetial Essetial Essetial (Spial) log roll Essetial Essetial Essetial Essetial Breathig Delivery of o-ivasive oxyge therapy Essetial Essetial Essetial Essetial Needle decompressio of peumothorax Essetial Essetial Not required Not required Isertio of itercostal catheter Desirable Not required Not required Not required Circulatio Veepucture Essetial Essetial Desirable Desirable Blood alcohol sample collectio Essetial Essetial Desirable Not required Peripheral itraveous caulatio Essetial Essetial Desirable Not required Automated Exteral Defibrillatio (AED) Essetial Essetial Essetial Essetial Maual defibrillatio (i sites with maual defibrillator) Essetial Essetial Not required Not required Trascutaeous pacig (i sites with trascutaeous Desirable Desirable Not required Not required pacig capacity) Admiistratio of ALS protocol medicatios Essetial Essetial Not required Not required Blood sample by arterial pucture Desirable Desirable Not required Not required Recordig of 12 lead ECG Essetial Essetial Essetial Desirable 12 lead ECG iterpretatio of ACS Essetial Desirable Not required Not required Itraosseous eedle isertio Essetial Desirable Desirable Not required Isertio of Uriary Catheter Essetial Essetial Essetial Not required Disability Glasgow Coma Score ad pupillary respose Essetial Essetial Essetial Essetial Extras Triage Essetial Essetial Essetial Not required Primary ad secodary survey Essetial Essetial Essetial Desirable Nasogastric tube isertio Essetial Essetial Desirable Not required Splitig ad/or POP applicatio Essetial Essetial Desirable Not required Adapted from GMCT Guidelies for I-Hospital Cliical Emergecy Respose Systems for Medical Emergecies, October 2005. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1 NSW Health PAGE 127

APPENDIX 20: RECOMMENDED BLOOD PATHOLOGY TESTING AVAILABLE at the POINT OF CARE i RURAL FACILITIES WHERE a EMERGENCY SERVICE is provided The NSW Rural Critical Care Taskforce (RCCT) recogises that availability of specific blood pathology results at the poit of care is ecessary to assist i ad expedite effective diagosis, treatmet ad trasfer decisio-makig for patiets presetig to rural Emergecy Departmets, with appropriate mechaisms i place to support staff e.g. staff traiig, credetialig, ad calibratio. The followig blood pathology results are recommeded as the miimum stadard ecessary at the poit of care for rural facilities where a emergecy service is provided: 1. Blood gases (icludig sodium ad potassium levels) 2. Haemoglobi 3. Tropoi 4. INR These tests provide iformatio to escalate cocer ad add to the cliical assessmet picture for critically ill patiets. The shaded portios cotaied i the treatmet guidelies should oly be used by RNs who are recogised as Advaced Cliical Nurses. PAGE 128 NSW Health NSW Rural Adult Emergecy Cliical Guidelies 3rd Editio Versio 3.1

SHPN (SRSCP) 120005