Clinical Management Manual - Fair-Go

Transcription

ACT AMBULANCE SERVICE
CLINICAL MANAGEMENT MANUAL
POCKET EDITION
Fourth Edition – August 2007
1
Ver 4.1
08/07
CLINICAL MANAGEMENT GUIDELINES
Contents
PAGE NO.
Case Category
1
Patient Categories – Medical
2
Patient Categories – Trauma
3
Revised Trauma Score - Glasgow Coma Scale
4
ACTAS Approved Abbreviations
5
Clinical Management Guidelines
8
Rapid Sequence Induction Procedure
49
Drugs for Airway Management – Summary Sheet
53
ACTAS Pharmacology
56
Drug Dose Calculator
94
Medication Calculator
95
Drug Reference Key List
97
Patient Assessment – General Approach
105
Time Critical Guideline
106
Guideline for treatment of Agonal Trauma Patients
108
APGAR Score
110
Paediatric Reference Card
111
PEEP Values
112
Spinal Immobilisation Clearance Flowchart
113
Spinal Cord Injury
114
Differentiation of Wide Complex Tachycardias
115
Maximum QT Interval Chart
117
12 Lead Placement Chart
118
Acute Myocardial Infarction Table
119
Infarction Overview
120
Capnography
127
Wave Forms
129
Respiratory Status Assessment Chart
130
Burns Assessment Chart/ Rule of Nines
131
Paediatric Burns Assessment Chart
132
Normal Blood Values
133
External Pacing procedure
134
2
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Significant Contact Numbers
134
Motorola XTS 3000 Portable Radio - Duress Alarm Procedure
136
Hazchem Chart
137
Triage Flow Chart
140
Ambulance Roles at a Mass Casualty Incident (MCI)
141
3
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CASE CATEGORY
11
- Treatment and transport (usual case – default on data sheet)
12
- Ambulance not required (ANR)
13
- Treatment; no transport (mutual decision) (TNR)
14
- Patient refused treatment or transport (patient decision only)
21
- Back up other car – single patient
22
- Patient deceased – no resuscitation attempted
23
- Resuscitation ceased on scene
24
- Hoax call (apparent)
31
- Sports attendance
32
- Standby (public event / incident)
33
- Air Ambulance case
34
- Single Officer Response (transport by other vehicle)
41
- Transport of retrieval team (+/- patient)
42
- Aero-medical case - Primary
43
- Paramedic retrieval (no doctor)
44
- Medical retrieval (doctor)
1
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PATIENT CATEGORIES
Medical conditions
First three digits
Cerebral
001
002
003
004
005
006
007
008
009
Endocrine
041
042
048
Unconscious
Altered consciousness
Post unconsciousness
Seizures
Post seizure
CVA / Stroke
Headache
Other
Apparent Syncope
Obstetrics
051
052
053
056
057
058
Respiratory
011
Asthma – bronchiolitis
012
CAL
013
Acute LVF / pulmonary
oedema
014
Upper airway problems
015
Non-cardiac chest pain
016
Resp. tract infection
018
Other
019
Apparent hyperventilation
Cardiac
021
022
023
024
028
Abdominal
031
032
033
034
035
036
037
038
Hypoglycaemia
Hyperglycaemia
Other
Labour
Delivery prior to
ambulance arrival
Delivery by ambulance
officers
Bleeding
Complicated delivery
Other
Miscellaneous
061
Psychiatric
062
Generally unwell
063
Back Pain
064
Deceased patient
065
Routine transport
(Hosp.-hosp.; Air Amb)
066
Palliative care patients
068
Other
069
Emotional distress
Arrest
Chest pain
Arrhythmias
Chronic cardiac failure
Other
Location of patient (fourth digit)
1
2
3
4
5
6
7
8
9
Vomiting/nausea
Diarrhoea
Pain
Haematemesis / malaena
PV / gynae bleeding
PR Bleed
Suspected AAA
Other
2
-
Road / transport
Industrial / workplace
Private residence
Sports / recreation
Public place
School / education facility
Medical facility
Hotel/motel/paid lodgings
Other
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PATIENT CATEGORIES
Trauma Conditions
Mechanical – (first two digits)
Body area affected – (third digit)
11
12
21
22
23
31
32
33
34
35
1
2
3
4
5
6
7
8
9
0
Road vehicle
Other vehicles
Stabbing
Gunshot wound
Other penetrating injury
Fall between levels
Fall on one level
Fallen on patient
Crush
Other blunt trauma
Multiple
Head / neck
Spinal
Chest
Abdominal / pelvic
Upper limbs
Lower limbs
Other
NOF
Nil
Non-mechanical – (first two digits)
Location of patient –(fourth digit)
40
41
42
1
2
3
4
5
6
7
8
43
44
45
48
51
52
61
62
71
72
Electrical injuries
Injected poisoning
Ingested poisoning /
overdose
Inhaled poisoning
Absorbed poisoning
Burns / scalds
Other
Drowning / near drowning
Asphyxiation
Cold Syndromes
Heat Syndromes
Bites / stings
Allergy/anaphylaxis
9
3
- Road transport
- Industrial/workplace
- Private residence
- Sports/recreation
- Public place
- School/education facility
- Medical facility
- Hotel / motel / paid
lodgings
- Other
Ver 4.1
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REVISED TRAUMA SCORE (RTS)
Respiratory Rate
Systolic Blood Pressure
GCS
A
B
C
Rate
10-29
>29
6-9
1-5
0
Score
4
3
2
1
0
Pressure
>89
76-89
50-75
1-49
0
Score
4
3
2
1
0
GCS
13-15
9-12
6-8
4-5
3
Score
4
3
2
1
0
A+B+C = Revised Trauma Score
GLASGOW COMA SCALE
Eye Opening
INFANT
CHILD
ADULT
Spontaneous
To speech
To pain
Nil
Spontaneous
To command
To pain
Nil
Spontaneous
To command
To pain
Nil
4
3
2
1
BEST MOTOR RESPONSE
INFANT
CHILD
ADULT
Spontaneous
Withdraws from touch
Withdraws from pain
Flexion
Extension
No response
Obeys commands
Localises
Withdraws from pain
Flexion
Extension
No response
Obeys commands
Localises
Withdraws from pain
Flexion
Extension
No response
6
5
4
3
2
1
BEST VERBAL RESPONSE
INFANT
CHILD
ADULT
Coos, babbles, smiles
Irritable, crying
Cries, screams to pain
Moans, grunts
No response
Orientated
Confused
Inappropriate words
Incomprehensible
No response
Orientated
Confused
Inappropriate words
Incomprehensible
No response
4
Ver 4.1
5
4
3
2
1
08/07
ACT Ambulance Service
Approved Abbreviations
Only standard street name abbreviations,
those listed below and on the Patient
Care Record, in the context defined, are
permitted for use.
#
&
+, ++, +++
<
=
>
♀
♂
↑
↓
∆
fracture
and
to an increased degree
less than
equal to
greater than
female
male
increasing(ly)
decreasing(ly), continuing
disease
n/24
n/7
n/52
n /12
x(n)
Y/O
hours
days
weeks
months
number of times
years old
•/c
•/s
with
without
1˚HB
2˚HB
3˚HB
First Degree Heart Block
Second Degree Heart Block
Third Degree Heart Block
A
ACTAS
ACTES
ACTFB
AFP
AAA
AF
AFl
ALS
am
AMI
Asystole
A.C.T. Ambulance Service
A.C.T. Emergency Service
A.C.T. Fire Brigade
Australian Federal Police
Abdominal Aortic Aneurism
Atrial Fibrillation
Atrial Flutter
Advanced Life Support
morning
acute Myocardial Infarction
ANR
AO
Ambulance not required
Ambulance Officer
BBB
b.d.
BGL
BLS
BNO
BO
BP
BSL
Bundle Branch Block
twice a day
Blood Glucose Level
Basic Life Support
bowels not open
bowels Open
blood pressure
Blood Sugar Level
C/O
Ca.
CABG
Complains(ing) of
Cancer
Coronary Artery Bypass
Graft
Chronic Airways Limitation
(Chronic Obstructive
Airways Disease - COAD)
Calvary Hospital
Computerised Axial
Tomography
Congestive Cardiac Failure
Coronary Care Unit
centimetres
Central Nervous System
carbon monoxide
carbon dioxide
person deceased
Chest Pain
Continuous Positive
Airways Pressure
Cardio-Pulmonary
Resuscitation
Cerebro Spinal Fluid
Cerebro-Vascular Accident
CAL
Calv.
CAT
CCF
CCU
cm
CNS
CO
CO2
Code 5
CP
CPAP
B
B
CPR
CSF
CVA
DCCS
Dr.
Dx
5
Direct Current Counter
Shock
Doctor
diagnosis
Ver 4.1
08/07
EAR
ECC
ETT
Expired Air Resuscitation
External Cardiac
Compressions
Electro-Cardio Graph
Emergency Department
(Accident and Emergency
department)
expected date of
confinement
Electroencephalograph
Electro Mechanical
Dissociation
Ear Nose and Throat
Emergency Services
Agency
Endo-Tracheal Tube
GCS
GI
GP
Gx Px
Glasgow Coma Score
Gastro-Intestinal
General Practitioner
gravida No. para No.
Hb
HR
H/T
Hx
Haemoglobin
heart rate
hypertension
history
ICP
ICS
ICU
IGT
IH∆
IM
IMI
Inh
IO
IPPV
IU
IV
IVU
IVR
Intra-Cranial Pressure
Intercostal space
Intensive Care Unit
intra-gastric tube
Ischaemic Heart Disease
intra-muscular
intra-muscular injection
inhaled
intra-osseous
Intermittent Positive
Pressure Ventilation
International Unit
intravenous
intravenous unsuccessful
Idioventricular Rhythm
JR
JVP
Junctional Rhythm
Jugular Venous Pressure
KED
KTD
kg
km
kph
Kendrick Extrication Device
Kendrick Traction Device
kilogram
kilometre
kilometres per hour
ECG
ED
EDC
EEG
EMD
ENT
ESA
(L)
Lev.OC
LLQ
LMP
LOC
lpm
Ltr
LUQ
LVF
left
Level of Consciousness
Left Lower Quadrant
Last Menstrual Period
loss of consciousness
litres per minute
litre
Left Upper Quadrant
Left Ventricular Failure
Mane
MAP
MAST
morning
Mean Arterial Pressure
Medical Anti-Shock
Trousers
micrograms
Modified Chest Lead
milligram
millilitres
millimetres
milliMol
Magnetic Resonance
Imaging
Multiple Sclerosis
month
metre
mcg
MCL
mg
ml
mm
mMol
MRI
MS
Mth
mtr
Neb
NFR
NICU
NKA
No.
Nocte
NOF
N/S
nebule / nebulised
not for resuscitation
Neonatal Intensive Care
Unit
no known allergies
number
night
neck of Femur
normal Saline
O
O/A
Obs
O/E
O2
oral
on arrival
observations
on examination
oxygen
P
P
B
6
B
Ver 4.1
08/07
P
PA
PAC
PAO
PASG
PEA
PEARL
PEEP
PHx
PID
PJC
pulse
per axilla
Premature Atrial Contraction
Paramedic Ambulance
Officer
Pneumatic Anti Shock
Garment
Pulseless Electrical Activity
Pupils equal & reacting to
light
Posititve End Expiratory
Pressure
past history
Pelvic Inflammatory Disease
Premature Junctional
Contraction
pm
PR
prn
Pt
PU
PV
PVC
afternoon
per rectum
as required
patient
passed urine
per vagina
Premature Ventricular
Contraction
Q.I.D.
4 x times daily
(R)
RICE
right
Rest Ice Compression
Elevation
Right Lower Quadrant
range of movement
Rapid Sequence Induction
Road Traffic Accident
Right Upper Quadrant
Treatment
RLQ
ROM
RSI
RTA
RUQ
Rx
S/C
S/L
SB
SOB
SR
ST
SVT
subcutaneous
sublingual
Sinus Bradycardia
shortness of breath
Sinus Rhythm
Sinus Tachycardia
Supraventricular
Tachycardia
T or Temp
TCH
Tds
TKVO
TMC
TNR
temperature
The Canberra Hospital
three times a day
to keep vein open
threatened miscarriage
Transport Not Required
7
Tx
Transport
URTI
UTI
Upper Respiratory Tract
Infection
Urinary Tract Infection
V/S
VEB
VF
VT
vital signs
Ventricular Ectopic Beat
Ventricular Fibrillation
Ventricular Tachycardia
wt
weight
Ver 4.1
08/07
Clinical Management Guideline Index
01
General Care
20
Eye Injuries
02
Pain Management
21
Burns
03
Airway Management
22
Seizures
04
Cardiac Arrest
23
Stroke
05
Paediatric Cardiac Arrest
24
Near Drowning
06
Cardiac Arrhythmias
25
Diving Emergencies
07
Bradyarrhythmias
26
Obstetrical & Gynaecological
08
Tachycardias
09
Respiratory Distress
10
Diabetic Emergencies
11
Temperature Abnormalities
12
Upper Airway Obstruction
13
Abdominal Emergencies
14
Poor Perfusion / Hypotension /
Emergencies
Dehydration
15
27
Hyperkalaemia
28
Home Dialysis Emergencies
29
Allergic & Anaphylactic Reactions
30
Crush Syndrome
31
Electric Shock
32
Assault
33
Behavioural & Psychiatric
Emergencies
Decreased Level of
Consciousness
16
Chest Pain
17
Chest Injuries
18
Spinal Injuries
18a
Hypereflexia
19
Limb Injuries
34
C.B.R. Incident
35
Poisoning, Envenomation &
Overdose
8
36
Extended Care
37
Combative/Agitated Patients
38
Meningoccal Disease
Ver 4.1
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CLINICAL MANAGEMENT GUIDELINE 1
GENERAL CARE
Primary survey
Haemorrhage control
Posture
Oxygen therapy
NOTE: T R A N S P O R T I S T R E A T M E N T !
Identify time critical patients
- Actual - based on vital signs, pattern of injury; lack of
response to treatment.
- Potential - based on history; mechanism of injury.
Monitor & assess as required:
Note: time critical applies to both trauma and medical cases.
Observations.
ECG/12 Lead.
Blood glucose.
O2 saturations.
Temperature
Specific observations & examination
as per patient condition.
The following conditions warrant absolute minimum scene
times & urgent transport to hospital:
Cardiac arrest following penetrating trauma
(reference: Agonal Trauma Guideline).
Unrelieved upper airway obstruction.
Head injuries with significant deterioration in
levels of consciousness.
Chest injuries with respiratory deterioration.
Internal blood loss sufficient to cause significant hypotension.
Heatstroke.
Cardiac arrest in advanced pregnancy (gestation > 20/52)
Prolapsed umbilical cord, or complicated labour.
Continuing or worsening acute hypoxia, unresponsive to
treatment.
Generalised seizures, unresponsive to treatment.
Carbon monoxide poisoning with decreased level of
consciousness.
Treatment as required:
Cervical collar.
Bandaging.
Splinting.
PASG.
Temperature control.
Reassurance.
Cannulate as required – IV fluids as per
perfusion & hydration assessment.
Pain relief.
[List is not exclusive or exhaustive!]
Notify & transport to nearest appropriate
hospital.
9
NOTE: Time critical does not just mean rapid transport!
Ver 4.1 08/07
PAIN MANAGEMENT
General Care Guideline.
RELIEF OF PAIN & SUFFERING IS A PRIME GOAL OF AMBULANCE CARE.
Pain is what the patient says it is!
If possible, pharmacology should be directed at the
apparent underlying cause:
Pain assessment (PQRST).
Quantitate if possible.
GTN s/l for ischaemic chest pain.
Basic care is fundamental to pharmacological
management:
Methoxyflurane for mild - moderate pain; patients unable
to have narcotics; management of labour; often best for
paediatrics.
Reassurance.
Morphine for all other pain unless contra-indicated.
Posture.
Midazolam added to analgesia for musculo-skeletal pain.
Splinting.
Ketamine for pain management in selected patients.
Cooling of burns.
Ischaemic chest pain; limb pain; burns - aim for abolition
of pain.
Occlusive dressings.
Control of temperature
(especially the cold).
Undiagnosed conditions - aim for control of pain to a
bearable level of discomfort.
Gentle handling.
10
Ver 4.1
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AIRWAY MANAGEMENT
THE PRIMARY GOALS OF AIRWAY MANAGEMENT ARE:
OXYGENATION
VENTILATION
AIRWAY PROTECTION
in this order of priority.
Start basic – work up.
However - it is permissible to “leap-frog” steps if in your clinical judgement the patient’s condition warrants this.
Basic airway manoeuvres. - Posture, Suction, Oral airway, Nasal airway.
Mild sedation to permit basic airway management (midazolam).
“Cold” endotracheal intubation.
Rapid sequence induction:
- Suxamethonium / Midazolam*.
( Note: If patient has already had Midazolam for sedation do not give a repeat dose with
Suxamethonium or give a smaller dose.)
- Morphine / Midazolam if no relaxants, in selected patients.
Fall-back alternatives: - Failed Intubation Drill: Digital oral ETT placement*; LMA*; Surgical airway*.
Remember the primary goals! These will determine how aggressive your approach needs to be.
Always have a fall-back position. The end point is not necessarily placement of an endotracheal tube.
If an ETT is placed, confirmation of correct placement & maintenance of placement is imperative.
End Tidal CO2 is to be used.
- Use Cx collar to assist in maintaining ETT / LMA position.
There are to be multiple checks of ETT position, using multiple methods, by multiple people.
* TO BE IMPLEMENTED ONLY FOLLOWING APPROVED ACTAS TRAINING PROGRAMMES.
11
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ADULT CARDIAC ARREST
CPR.
IPPV – 100% O2
Monitor ECG
(a) – Ventricular Fibrillation/Tachycardia
(b) – Asystole
(c) – Pulseless Electrical Activity
Precordial thump if monitored & witnessed.
Shock
Cannulate
Adrenaline 1mg.
Shock
Intubate
Amiodarone 300 mg IV
Shock
Adrenaline
Shock
Adrenaline
Shock
In prolonged arrest - consider Sodium
Bicarbonate 0.5 mMol/kg
Shock
Check alternate leads /
lead selector.
Check aggressively for correctable causes:
Profound hypovolaemia.
Tension pneumothorax.
Continuing profound hypoxia.
Acidosis / Hyperkalaemia.
Gas trapping
Decision to transport.
Adrenaline every 2 minutes during transport.
Sodium Bicarbonate if prolonged transport.
Shock between medications.
Cannulate.
Atropine 2mg.
Adrenaline 1mg.
Intubate
Adrenaline
Adrenaline
In prolonged arrest – consider Sodium
Bicarbonate 0.5 mMol/kg.
Adrenaline
Adrenaline
Cannulate.
Atropine 2mg.
Adrenaline 1mg.
Intubate.
Adrenaline
Adrenaline
Adrenaline
Adrenaline
If Torsade: MgSO4 as 1st drug; no amiodarone.
Commence chest compressions on first patient contact; minimise any interruptions to chest compressions.
Consider PEEP.
Drug doses are to be followed by a minimum of 1 minute of CPR. If no failure, consider 5 - 10mls/kg IV N / saline during arrest management if
prolonged. IV drugs to be given via pump set. Elevate limbs following peripheral IV drug administration.
Post resuscitation - if pt is hypotensive, check for failure. If no failure, 5 - 10mls/kg N/saline. Repeat if patient responds.
Check patient’s temperature post resuscitation.
End Tidal CO2 may be an indicator of returning cardiac output.
12
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PAEDIATRIC CARDIAC ARREST
CPR.
(a) – Ventricular
Fibrillation/Tachycardia
Precordial thump if monitored & witnessed
Shock
2j / k
Cannulate / Intraosseous.
Adrenaline 0.01mg/kg.
Shock 4j/kg
Intubate
Amiodarone 5 mg/kg IV
Shock 4j/kg
Adrenaline
Shock 4j/kg
Adrenaline
Shock 4j/kg
In prolonged arrest – consider Sodium
Bicarbonate 0.5 mMol/kg
Shock 4j/kg
Transport.
Shock between medications.
If Torsade: MgSO4 as 1st drug; no amiodarone.
IPPV – 100% O2.
Monitor ECG
(b) – Asystole
(c) – Pulseless Electrical Activity
Check alternate leads.
Check for correctable causes:
Cannulate / Intraosseous.
Intubate.
If arrest cause not hypoxia consider –
Normal Saline 20 ml/kg.
Cannuate / Intraosseous.
Intubate.
If arrest cause not hypoxia consider –
Normal Saline 20 ml/kg.
Adrenaline.
Adrenaline.
Adrenaline.
Adrenaline.
Adrenaline.
Adrenaline.
Transport.
Transport.
Commence chest compressions on first patient contact; minimise any interruptions to chest compressions
Consider PEEP
Drug doses are to be followed by a minimum of 1 minute of CPR.
IGT for all arrested children.
Blood glucose level to be checked during paediatric resuscitation. Elevate limbs following peripheral IV drugs. Utilise pump set - watch total volume
in small children.
Post resuscitation - if pt is hypotensive, check for failure. If no failure, 5 - 10mls/kg N/saline. Repeat if patient responds.
Check temperature post resuscitation.
End Tidal CO2 may be an indicator of returning cardiac output.
13
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CARDIAC ARRHYTHMIAS
(a) - PACs / PVCs
(b) - Accelerated IVR
No specific treatment required.
No specific treatment required.
Monitor rhythm & patient condition.
Monitor rhythm & patient condition.
(c) - Bizarre
Rate & perfusion determines the type of
treatment.
-
Pulse is absent - treat as for cardiac
arrest (usually PEA)
-
Rate less than 50, perfusion poor – treat
as for bradyarrhythmias.
-
Rate is > than 150, regular, with wide
QRS complexes, patient significantly
compromised - treat as for VT.
-
Rate is > than 150, regular, with narrow
QRS complexes, patient symptomatic treat as for SVT.
If unable to decide which specific therapy is
required – general care; observe; prompt
transport.
14
Ver 4.1
08/07
BRADYARRHYTHMIAS
Consider treatment if rate below 50 in adults.
If poorly perfused or symptomatic:
-
Atropine 0.01 mg/kg.
If no LVF
- Consider IV fluid 5 - 10 ml/kg, prior to 2nd dose of Atropine
-
Repeat Atropine x 1 as required.
If perfusion remains poor:
-
Adrenaline infusion:
1 mg in 1000 mls Saline ( = 1mcg / ml)
Titrate to response. ( 20dpm = 1ml / min = 1 mcg / min)
Paediatric - use burette
-
Consider external pacing.*
* After completion of ACTAS approved training
15
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TACHYCARDIAS
General Care Guideline
(a) - Narrow QRS Complex
(b) - Wide QRS Complex
Consider: VT; SVT with aberrancy; rapid AF or AFl
with aberrancy.
Consider: Sinus tachycardia; SVT; AF; AFl; MAT.
Use 12 lead ECG.
Valsalva x 2.
Make differentiation: (12 lead ECG if time)
If SVT, AF or AFl - treat as per 8 (a)
If SVT:
If rapid, symptomatic VT:
Adenosine 6 mg IV.
Adenosine 12 mg IV if required.
Amiodarone 150 mg IV
No pulse: Treat as VF cardiac arrest
If rapid AF or AFl, refer to treatment algorithm:
Torsade de pointes: MgSO4 IV instead of amiodarone
Notify; Prompt transport to nearest appropriate hospital.
Notify; Prompt transport to nearest appropriate
hospital.
Paediatric doses: Adenosine: 0.05mg/kg; then 0.1mg/kg.
Amiodarone: 5mg/kg (to total 150mg)
Paediatric dose: Amiodarone: 5mg/kg
[IV Amiodarone - give over 10 mins via Springfusor. If extremely compromised in VT, may give over 5 mins by slow IV
injection.]
Consider pharmacological treatment if rate is above 150 in adults or 170 in children.
Consider IV fluids in all tachycardic patients if hypotensive, not in LVF & unresponsive to pharmacological management.
In any rapid rhythm (over 200), with patient unconscious and no pulse - shock.
16
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CLINICAL MANAGEMENT GUIDELINE 8 (continued)
TREATMENT ALGORITHM FOR RAPID ATRIAL FIBRILLATION OR FLUTTER
Establish diagnosis: ensure
No significant
compromise
Hypotension
Check for evidence of
LVF.
- Atrial fibrillation or flutter
- rapid rate ( > 150 )
- recent onset (reliably < 24 hours)
Ischaemic chest pain
Treat chest pain as
appropriate.
Pulmonary Oedema
Treat pulmonary oedema
as appropriate.
AF or AFl apparently
secondary to a cerebral
event
These patients will present
with a decreased LOC, &
may be hypotensive.
Observe
If none – treat with IV
fluids, 5 – 10 mls/kg.
Do NOT use Amiodarone
in these patients.
Treat rapid rate with
Amiodarone concurrently.
Treat rapid rate with
Amiodarone concurrently.
Check for evidence of
LVF.
If none – treat hypotension
with IV fluids, 5 – 10
mls/kg.
If LVF + hypotension –
treat cautiously with
Amiodarone.
Do NOT use Amiodarone
in these patients.
NB: Monitor BP closely –
combination of drug
treatments for pulmonary
oedema may cause
hypotension.
17
NB: Unconscious patients
post cardiac arrest in rapid
AF should be treated with
Amiodarone unless
otherwise contraindicated.
Ver 4.1
08/07
RESPIRATORY DISTRESS
(a) - Bronchospasm
(b) - Pulmonary oedema
Nebulised salbutamol + ipratropium.
Repeat salbutamol as required.
Add ipratropium to every second dose.
Significant hypoxia - nebulise with 100% O2.
- PEEP
If asthma, anaphylaxis or CAL:
Moderate to severe:
Hydrocortisone 200 mg IV / IM.
(Paed: 4 mg/kg to max. of 200mg)
Assist ventilation with IPPV + 100% O2 as required.
Add PEEP: 5 cm.
Increase by 5 cm as required.
If LVF:
Sitting legs dependent if possible.
Treat significant cardiac arrhythmias.
GTN S/L.
Frusemide:
On diuretics: 1 mg/ kg IV
Not on diuretics: 0.5 mg/kg IV.
May repeat dose after 10 - 15 mins
if still in severe distress.
Severe to life threatening bronchospasm
Adrenaline: Adult:
0.5 mg IM
Paediatric: 0.01 mg / kg IM (to 50 kgs)
Repeat IM dose x 1 as required.
If necessary: Adrenaline infusion:
1 mg in 1000 mls Saline ( = 1mcg / ml)
Titrate to response. ( 20dpm = 1ml / min = 1 mcg / min)
Morphine: 0.05 mg/kg IV.
May repeat dose after 10 mins if required.
Notify; Transport to nearest appropriate hospital.
[If wheezing as well, do not give nebulised
bronchodilators until after 1 dose of GTN or
Frusemide.
IV Frusemide & morphine - give slow over 2
minutes. If no IV, Frusemide may be given IM. ]
If patient critically ill, slow IV, up to 0.01 mg / kg, over 5 minutes.
Note: IV adrenaline in anaphylaxis & asthma should be used
very cautiously.
If IPPV required – slow rate; gentle, slow lateral chest
squeezes on exhalation.
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RESPIRATORY DISTRESS (continued)
(c) - Non specific respiratory distress
(d) – Hyperventilation due to anxiety.
Nebulised salbutamol + ipratropium.
Repeat salbutamol as required.
Add ipratropium to every second dose.
Check for pathological causes of
hyperventilation!!
O2 at low flow via Hudson mask.
Significant hypoxia - nebulise with 100% O2.
- PEEP
Monitor SaO2 and ECG
Remove source of anxiety if possible.
Reassurance.
Notify; Transport to nearest appropriate hospital
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DIABETIC EMERGENCIES
Check blood glucose level.
(a) - BGL < 4 mMol/l
(b) - BGL > 15 mMol/l
If symptomatic:
Oral glucose if conscious & laryngeal reflexes intact.
N / Saline IV – 10 ml / kg over contact time.
If decreased LOC:
Dextrose 50% - up to 0.5 ml / kg IV (0.25 g/kg)
If shocked & hypotensive: IV resuscitation.
Recheck BSL & LOC.
Repeat Dextrose dose if required.
Ensure oral intake of carbohydrate if patient is not
transported.
Glucagon IM if no IV available:
Patient wt > 20 kg: 1 IU.
Patient wt < 20 kg: 0.5 IU.
[IV dextrose always to be given into running line, over 5
minutes. Try to avoid post treatment hyperglycaemia.
Recovery may be slow if hypoglycaemia has been prolonged.
Paediatric pts: Dilute 50% with equal volume of 5% dextrose
or N/saline.]
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TEMPERATURE ABNORMALITIES
(a) - Heat abnormalities
(b) - Cold abnormalities
Check temperature
Check temperature
Exposure:
Minor heat syndromes:
Normal LOC; sweating;
core temp < approx 39.5oC.
Normal LOC; shivering;
core temp > approx 33.5oC.
More rapid warming is acceptable.
Warm oral fluids.
Gentle exercise if possible.
Gentle cooling.
Cease exertion.
Move patient to cool location.
Oral rehydration
- small sips.
IV rehydration if
- Nausea & vomiting;
- Significant dehydration;
- Multiple patients.
Hypothermia: Decreased LOC; no shivering;
core temp < approx 33oC.
Handle patient gently.
Remove wet clothing if sheltered; dry
patient off.
Wrap in warm blankets; then space blanket.
Heatstroke:
Decreased LOC; no sweating;
core temp > approx 40oC.
If IPPV – do not hyperventilate.
Rapid cooling; aggressive as possible.
IV resuscitation; cool fluids if possible.
Treat significant arrhythmias.
Check BGL.
Aggressively manage seizures or shivering.
If in VF: Shock
Cardiac drugs if core temperature > 32oC.
Do not cease resuscitation.
Notify; Urgent transport to nearest appropriate hospital.
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UPPER AIRWAY OBSTRUCTION
(a) - Foreign body
(b) - Swelling
Causes: croup / epiglottitis; insect sting; anaphylaxis;
trauma; oral / pharyngeal infection; burns.
Partial Obstruction:
Maximise oxygen therapy.
Encourage coughing.
Prompt transport.
Minimum intervention.
Complete obstruction:
Conscious patient:
Four modified chest thrusts;
if fails - Turn into lateral position. Four back blows.
If possible, position with head down to utilise gravity;
if fails - Repeat the sequence x 2;
if fails - Urgent transport – 100% oxygen
Unconscious patient:
Extricate foreign body with laryngoscope & Magill forceps;
if fails - Supine position - 4 modified chest thrusts;
if fails - Lateral position - 4 back blows;
if fails - Repeat sequence x 2;
if fails - Attempt intubation to push foreign body into (R) or (L)
main bronchus. (Insert tube as far as possible - use uncut
tube if possible).
Urgent transport - 100% oxygen. Notify
Consider surgical airway as last resort.
Maximise oxygenation.
Do not attempt close examination
of mouth / throat area.
Do not unnecessarily distress the patient.
Consider: Nebulised saline.
If severe obstruction: nebulised adrenaline:
wt > 10 kg - 5 mls Adrenaline 1:1000
wt < 10kg - 0.5ml/kg Adrenaline 1:1000
(Make volume up to 5 mls with saline, as required)
If insect sting or envenomation:
Consider IV / IM adrenaline.
If complete airway obstruction occurs - give 100% O2
and attempt I.P.P.V.
Urgent transport. Notify
Consider surgical airway as last resort.
Partial obstruction: prompt transport.
Obstruction relieved - provide oxygen therapy.
- prompt transport
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ABDOMINAL EMERGENCIES
Posture flat - knees may be flexed.
I.V. resuscitation as required.
Pain relief.
Cover open wounds with dry, sterile dressing; protruding viscera with saline
moistened sterile dressings.
If impaled object in situ - do not remove impaled object - move the patient with object in situ.
Notify: prompt transport to nearest appropriate hospital.
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POOR PERFUSION / HYPOTENSION / DEHYDRATION
Assess patient carefully to determine possible cause.
If dehydrated - N/saline IV.
( a ) Hypovolaemic
( c ) Distributive
( b ) Cardiogenic
( d ) Obstructive
High concentration O2.
If severely shocked &
uncompressible bleeding
lesion - early, rapid
transport.
Treat significant
arrhythmias.
Posture with care if
suspected spinal injuries.
If severely shocked early rapid transport.
Pain relief
IV fluids - keep BP 80 - 85 if
suspected spinal injuries.
IV fluids.
Adrenaline if suspected
anaphylaxis.
Decompress tension
pneumothorax.
Notify; prompt transport to
nearest appropriate hospital.
Notify; prompt transport
to nearest appropriate
hospital.
IV fluids to maintain
systolic BP 85 - 90.
Notify; prompt
transport to nearest
appropriate hospital.
Consider PASG if:
- severely shocked and
injuries are under suit;
OR
- there is a compressible
bleeding lesion.
Notify; prompt transport
to nearest appropriate
hospital.
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DECREASED LEVEL OF CONSCIOUSNESS
Assess patient carefully.
( a ) History of Trauma –
Head Injury
( b ) No history of Trauma
Cervical spine precautions.
Airway management guideline.
Check BGL.
Posture 10 - 15º head up.
If GCS below 12 – maintain:
Oxygen saturations > 95%
BP: 100 – 120 systolic.
Consider poisoning or O/D.
If GCS below 12 - maintain:
Oxygen saturations > 95%
BP: 100 – 120 systolic.
Notify; transport to nearest
appropriate hospital
Notify; transport to nearest appropriate
hospital.
( c ) Apparent syncope
Check thoroughly for more
significant causes, especially
in elderly patients.
Posture by perfusion or
comfort.
Check BGL
Consider 12 lead ECG
Notify; transport to nearest
appropriate hospital.
Evidence of a rapidly decreasing level of consciousness is a flag for time critical patient - minimal scene time & urgent
transport to hospital.
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CHEST PAIN / SUSPECTED ACUTE CORONARY SYNDROMES
Assess thoroughly for:
- possible Acute Coronary Syndromes (ACS)
- potentially life threatening other causes of chest pain.
Silent or atypical ACS presentations should be treated in the same manner as a typical presentation.
Possible Acute Coronary Syndrome
Monitor closely.
Pain assessed as probable non ACS
Assess for possible threat to life – noncardiac chest pain can kill!
12 lead ECG.
Aspirin.
GTN.
Metoclopramide.
If in any doubt – treat for ischaemic heart
disease.
Otherwise – manage as for undiagnosed
pain.
Pain management - aim to abolish pain or discomfort.
Prompt transport
Notify hospital AS EARLY AS POSSIBLE if AMI is
suspected.
Treat haemo-dynamically significant arrhythmias.
Prompt transport.
[Give aspirin, even if on regular slow release aspirin.
150mg dose if already on warfarin.
Watch for non-typical or silent presentations of ischaemic heart
disease, especially in females, elderly & patients with diabetes.
Aim to minimise scene time while still providing reassurance &
effective pain relief.]
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CHEST INJURIES
Pain relief as required.
Pneumothorax.
-
If suspected avoid coughing, Valsalva or IPPV.
Suspect tension pneumothorax in a patient with no air entry & significant
respiratory or cardio-vascular compromise.
-
Decompress tension as indicated.
Open chest wound
-
Cover, seal on 3 sides only, or use chest seal.
Flail chest
-
Stabilise the chest wall.
Posture patient with affected side down, or by manual pressure.
Avoid use of PASG.
Notify & transport to nearest appropriate hospital.
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SPINAL INJURIES
Instruct the patient to refrain from moving his head.
- Avoid flexion of the neck and rotation of the head.
- All other movements must be minimised.
- Maintain head in the neutral position.
Oxygen therapy
- 100 % if suspected cord lesion.
- I.P.P.V. If hypoventilating.
Posture supine and flat.
Cx collar
- Extricate with spine board or Kendrick Extrication Device
- Lift with board or scoop stretcher.
- DO NOT OVER-INFUSE
- Systolic blood pressure of 80 mm Hg is acceptable in high spinal injuries.
With suspected cord lesion - administer Metoclopramide 10 mg (adults only).
Insert IGT & urinary catheter prior to secondary, air or extended transports.
If transport is prolonged pressure area care is required.
Notify and transport patient to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 18a AUTONOMIC HYPERREFLEXIA
General care guideline
In established High Paraplegics or Quadriplegics assess the patient for Autonomic Hyperreflexia
The sudden onset of any of the following is significant.
- Sudden hypertension, (this may be in the normal range for the rest of the population); pounding headache, bradycardia,
flushing /blotching of skin; profuse sweating above level of lesion; skin pallor and piloerection below level; chills without fever;
nasal congestion, and blurred vision; shortness of breath, sense of apprehension or anxiety
Bladder:
Bowel:
Skin:
Other:
Causes
Distended due to blocked or kinked catheter, UTI, Bladder or kidney stones.
Constipation, faecal impaction, rectal irritation
Burns, pressure areas, tight clothing eg TED stockings.
Fractures, Distended stomach, labour, severe menstrual cramping.
Actions
-
Ask patient and carer if they suspect a cause
Elevate patient’s head and lower legs
Loosen any constrictive clothing
Check bladder drainage equipment for kinks or obstruction.
If found, initially drain 500mls, then a further 250 every 15
minutes until bladder is empty
- Monitor BP every 2-5 minutes
- Avoid pressing over bladder
Treatment
If the BP remains elevated (Ranging between 150-170mmHg). Commence treatment with:
IV Midazolam 0.05mg/kg, over one minute.
May be repeated once after 10 minutes if no fall in the BP. Give 0.1mg/Kg IM if unable to cannulate.
Midazolam should be given with extreme caution while constantly monitoring the patient’s vital signs.
NOTE: Treatment with Midazolam mandates transport to hospital.
Notify and transport to nearest hospital.
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LIMB INJURIES
Check arterial circulation in the limb.
If distal pulse absent
- gently realign fractured segments until pulse returns or alignment near normal.
Immobilise all fractures unless patient is otherwise time-critical.
Elevate if possible.
Do not attempt to reduce dislocations.
I.V. resuscitation where indicated.
Pain relief - add Midazolam as required.
- Ketamine as appropriate.
Partially severed limb - carefully protect; keep distal limb dry, wrapped and cool.
Completely severed limb:
Keep severed part dry, wrapped and cold.
Place in a dry sealed plastic bag, then place within another bag or bucket
filled with iced water at approx 4 deg C.
DO NOT immerse part in ice.
DO NOT attempt to clean or disinfect the severed part.
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EYE INJURIES
Ensure oxygenation.
Trauma:
Do not remove protruding foreign bodies.
If the eyeball is extruded, do not push it back into the socket.
If tolerated, transport patient lying flat.
The injured eye must be protected from rubbing, pressure. Use eye shield, or loosely taped eye patch.
Cover both eyes if patient tolerates this.
Severe eye injuries - administer Metoclopramide IV prior to transport (adults only).
Chemical Burns:
Irrigate immediately with copious quantities of water or saline for at least ten minutes.
The eyelids must be pulled apart to ensure the fluid washes the eye.
Scalds and Electrical Flash Burns:
No dressing is required, ice packs can be beneficial.
Foreign Bodies in Cornea:
Protect the eye with a shield or pad. Do not attempt to remove the foreign body.
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BURNS
If there is still heat left in the skin, cool with cold water. Utilise water-gel burns dressings.
Cover the burnt area with clean dressing/sheets.
If a limb is burnt, remove all rings, tight clothing, shoes; elevate the part.
Consider space blanket.
Check for upper airway obstruction, especially if the face is burnt.
(a) Hoarse voice
(b) Inspiratory stridor
(c) See-saw breathing
Treat bronchospasm or airway obstruction via relevant management guideline.
If decreased level of consciousness
- Suspect Carbon Monoxide poisoning (especially if burnt in a confined space).
- Administer 100% O2; consider PEEP.
Pain relief.
Cannulate
- N/Saline TKVO.
- 10ml / kg bolus as required.
- Maintenance fluid as required: N/Saline
1ml / kg / BSA / hr
5
since burn incident
Transport all smoke inhalation patients to hospital - delayed pulmonary oedema may occur.
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SEIZURES
Protect the patient from injury.
Blood glucose estimation early if no history of seizures.
Midazolam [ IM if no IV access ]
Treat any injuries secondary to the seizure.
Children with seizure and fever
- Remove excessive clothing
- Cool with tepid water
- Place cool cloths in axillae, groin, wrist and neck; change at 5 minute intervals
- Do not allow child to shiver
Notify and transport patient to nearest appropriate hospital
STROKE
Posture 10 - 15o head up.
Cannulate:
- blood glucose estimation.
- treat hypoglycaemia cautiously; avoid hyperglycaemia.
Treat seizures promptly & aggressively.
Minimise scene time.
NOTIFY HOSPITAL EARLY; prompt transport to nearest appropriate hospital
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NEAR DROWNING
Cardiac arrest - treat by specific guideline.
Highest concentration oxygen practical.
- Consider PEEP.
Cervical collar as required. IGT if possible.
Consider hypothermia / other related conditions.
Notify & transport.
Note: Late pulmonary oedema may occur.
* Transport is always required following near drowning episodes. *
DIVING EMERGENCIES
Consider the possibility of spinal injury!
Lie flat and keep flat, do not sit up!
If unconscious, assume possibility of air embolus - posture left lateral, with head down tilt.
Oxygen therapy: highest concentration practicable. Exclude pneumothorax.
Always dehydrated - rehydrate with N/Saline 10 mls / kg rapidly.
Ascertain dive profile (number and sequence of dives; time at depth; breathing mixtures;
decompression stops and any uncontrolled ascent.)
Remember to check dive partner.
Monitor symptom progression.
Pain relief - analgesics may mask symptom changes; aim for minimal analgesia.
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OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES
Unscheduled Normal Field Birth
Most important ambulance role in a field delivery is to appear calm!
Preferred management is birth at a hospital – but if birth is imminent, reassure the mother & help her to a comfortable position.
Ensure full history.
Oxygen.
Pain relief as required.
Provide support and guidance during birth of baby’s head while encouraging gentle “grunty” pushes or controlled breathing to ease
the head out slowly and gently. As the head is born have your hand close to the top of the baby’s head - you do not need to touch it
unless the woman gives an uncontrolled push and the baby would otherwise ‘shoot’ out (especially important if the baby is preterm <
37 weeks).
Observe for cord around the baby’s neck. If present the baby may be born through the loop of cord. If the cord is loose, it may be
slipped forward over the head, taking care not to stretch it or tear it. Rarely the cord is so tight that it stops the baby’s descent and in
this situation it may need to be clamped in two places and cut between the clamps. Great care is necessary not to injure the baby or
woman while doing this
Place the baby straight up on to the mother’s chest noting time of birth. Dry baby & maintain warmth by keeping the baby close to the
mother’s skin. Place warm blankets over the baby and mother.
Assess Apgar at 1 & 5 minutes.
Cord should not be cut routinely, but if necessary apply plastic clamp (x2) at 3cm from the umbilicus, milk the cord gently back from the
clamp 3cm, taking care not to pull on umbilicus. Apply plastic clamp (x2) then cut the cord using clean scissors.
Women in more advanced pregnancy (approx 20 + weeks gestation) are generally best treated / transported in left lateral position,
regardless of problem.
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OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES (continued)
P.V. Haemorrhage
Complicated Birth
Prolapsed cord:
Not pregnant / early pregnancy:
Posture in the knee chest position.
(often easier in the all fours knee chest position)
Oxygen 100%.
Advise hospital early.
Urgent transport.
Do not encourage pushing
Manage as per perfusion status.
Advanced pregnancy
(L) lateral position.
Do not attempt to massage the fundus of the
uterus.
Do not inflate abdominal chamber of PASG.
Breech presentation:
Normal, unassisted birth may not always be possible. Where possible, do
not encourage the woman to push but to breathe through contractions.
Transport urgently; notify hospital.
Once legs and body have been born, support baby’s body (do not apply
downward traction) as it hangs downward while waiting for the gentle, slow
birth of the head. Encourage the mother to ‘breathe’ her baby’s head out.
If head is not born with the next contraction, encourage her to push whilst
gently supporting the baby as it hangs downward.
Cardiac arrest in advanced pregnancy
Position with wedge under right hip to obtain
25-30 degree tilt.
Give fluid bolus early.
Urgent transport as soon as backup has
arrived.
If performing CPR, increase CPR compression
force due to the chest wall compliance
secondary to breast hypertrophy.
Other presentations:
Recognise!
Normal, unassisted delivery may not always be possible.
Urgent transport; notify hospital.
Ensure hospital is notified as early as possible
that patient is pregnant.
Women in more advanced pregnancy (approx 20 + weeks gestation) are generally best treated / transported in left lateral position,
regardless of problem.
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Ver 4.1
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HYPERKALAEMIA
Consider in these situations:
Renal failure / dialysis.
Crush syndrome, including situation of prolonged unconsciousness.
Occasionally – diabetic ketoacidosis.
ECG signs are unreliable; frequently do not follow expected progressions;
do not always show good correlation with serum K+ levels.
Monitor the ECG for signs of hyperkalaemia, which may include:
- Tall peaked T waves
- No P waves
- Wide QRS
- Sine wave pattern (VT)
- V.F / Asystole.
Arrhythmias, especially bradycardias, are common.
If ECG changes are present:
- Nebulised Salbutamol (continuous).
- Calcium Chloride 10 mg / kg I.V. over 2 minutes.
- Follow with: Sodium Bicarbonate 8.4% - 0.5mMol / kg IV over 2 minutes.
If changes persist after 10 – 15 minutes: - repeat Calcium & Sodium Bicarbonate x 1.
NB: Treatment is determined by pt presentation; ECG changes & clinical setting!
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HOME DIALYSIS EMERGENCIES
Possible problems:
Haemorrhage;
Hyperkalaemia;
Seizures;
Venous air embolism;
Haemolysis of the patient’s blood;
Myocardial Infarction
Remember that the patient or their family are a resource for management of the dialysis machine.
Remove the patient from the machine:
- A.C. Power
- Turn off at the wall;
- Blood lines
- Clamp both lines 30 cm from the arm;
- Cut both lines between clamps and the machine.
Utilise venous dialysis line if possible for IV access.
Venous air embolism is suspected if there is air in the venous return line.
Treat with 100 % oxygen; posture in the left lateral position with head down tilt 30 degrees.
Notify and transport to the nearest hospital
Note: true dialysis emergencies are rare. It is far more likely that a dialysis patient will require an
ambulance for conditions unrelated to dialysis. In this instance, avoid cannulating dialysis patients unless
the cannula is actually going to be used.
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ALLERGIC & ANAPHYLACTIC REACTIONS
Pressure immobilisation bandage / splint over the area of injection, sting or bite if appropriate.
Adrenaline is drug of choice for cases where there are potentially life-threatening signs
(hypotension; upper airway swelling; bronchospasm unresponsive to nebulised bronchodilators)
- IV use should be with caution.
- Consider use of IM adrenaline in the first instance.
- Infusion is the preferred method of IV administration.
Manage using guidelines for respiratory distress; hypotension; upper airways obstruction – as appropriate.
CRUSH SYNDROME
Rarely a problem with less than 45 minutes of compression of a significant muscle mass.
Acute volume loss on release is considered of greater clinical importance than hyperkalemia & acidosis.
Immediately prior to removal of the compressive force:
- consider use of arterial tourniquet to compressed limb.
- increase IV infusion rate.
- observe ECG .
Following removal of compressive force: release tourniquets carefully; check for ECG changes.
Treat as per Poor perfusion, Hyperkalemia, Limb Injuries guidelines.
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ELECTRIC SHOCK
DO NOT BECOME A VICTIM YOURSELF!
LOW VOLTAGE (<1000 Volts) - Appliance in house or main supply to house - pull out plug; pull
conductor away from patient; pull patient clear; switch off at mains.
METHOD: grasp clothes if dry; avoid contact with skin or conductor; use dry fibre rope or dry
blankets or similar non-conducting material.
HIGH VOLTAGE (>1000 Volts) - Request assistance from Electricity Authority. Use short steps to
approach a victim. Retreat immediately if tingling is felt.
Electrical burns usually cause greater tissue damage than the appearance of the skin surface
would suggest.
High Voltage - consider possible spinal injury.
Check for exit burn;
Treat other injuries as required.
Always transport.
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ASSAULT
Be aware of risks to yourself & others.
Ensure scene control & safety.
Attention to detail (such as full name, location, times; others present) is very important.
Treat injuries where indicated.
Specifically for sexual assault:
Be aware some patients may resent physical contact from carers;
Avoid any judgemental comments;
Articles of evidence, such as clothing must be taken with the patient (use a paper bag);
Discourage the patient from showering;
The patient should not be left alone at any time.
Do not give details of assault over the radio.
BEHAVIOURAL & PSYCHIATRIC EMERGENCIES
Identify yourself clearly. If concerned about your safety, or others, call police for assistance.
Be reassuring and non-judgemental when conversing with the patient.
Speak quietly - do not shout.
One officer should talk privately with the patient where possible.
Do not leave the patient alone.
Consider / exclude: hypoxia; hypoglycaemia; head injury; drug overdose; post-ictal state. Treat as appropriate.
Consider use of CMG 37 – Management of Combative or agitated patients.
Arrange for appropriate support services eg. CAT Team.
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C.B.R. INCIDENT
A CBR incident may be indicated by:
- Physical indicators, eg unusual pools of liquid, clouds or fogs, unusual colours, strange devices or
recent explosion.
- Medical signs and symptoms or unusual behaviour being displayed by many people.
- Dead birds or animals in the area.
STEP 123 is “Safety Trigger for Emergency Personnel” :
- 1 patient with cholinergic symptoms is suspicious, 2 patients indicate a CBR, 3 patients is a CBR.
PROTECT YOURSELF; DO NOT ENTER THE CONTAMINATED AREA IF THIS CAN BE DETERMINED.
If you find yourself in a contaminated area, cover nose and mouth with a damp cloth; take frequent shallow
breaths; don’t Taste, Eat, Smell, or Touch anything in the area; seek shielding if radioactivity is present;
leave the scene immediately and proceed to a safe upwind, uphill area; be aware of the possibility of
secondary devices.
Remain clear of the contaminated area (Designated HOT& WARM Zones) unless authorised to enter by the
incident commander. You must be equipped with appropriate personal protective equipment and suitable
training in its use. Only authorised and trained personnel will operate in the HOT& WARM Zones.
Decontaminate: Remove clothing and discard into special HAZMAT container.
Skin must be cleaned by thorough washing or preferably showering;
special attention to hair and parts of the body with opposing skin surfaces, e.g.: buttocks.
It is preferred that patients and personnel be decontaminated PRIOR to treatment.
Initial antidote can be administered prior to decontamination by suitably protected personnel.
Assist ventilation (Only if small number of casualties);
Obidoxime Combo-pen if a nerve agent is identified (cholinergic symptoms), if unavailable use Atropine.
Midazolam to treat seizure patients;
Treat associated injuries: Burns; Blast injuries; Fractures.
Ensure hospital is notified of possible contaminated patients.
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POISONING, ENVENOMATION & OVERDOSE
SPECIFIC AGENTS:
Opioids: Naloxone IM, followed by IV.
Tricyclic antidepressants: Watch for arrhythmias & seizures.
If either of above occurs - administer 0.5 mMol/kg Sodium Bicarbonate (treat seizures first with Midazolam
as per CMG 22)
Organo-phosphates: Take care not to become contaminated.
Consider possibility of other effected workers / occupants / first-aiders.
Where feasible - remove contaminated clothing, wash skin with soap & water. If cholinergic effects,
(salivation, sweating, nausea, bradycardia) administer: Atropine l.V. or IM. Repeat as required.
Ensure hospital is notified of contaminated patient.
Envenomation: Utilise pressure / immobilisation technique if appropriate.
Treat signs and symptoms as they arise eg. Cholinergic symptoms with some spider bites.
Identification - the creature should be brought to the hospital only if this can be done safely;
Do not rely on non-expert identification.
With positive identification of a Red Back Spider, pressure immobilisation is not required.
- Apply iced compresses (not directly to skin).
Carbon monoxide / smoke inhalation:
Beware of hazards - self-asphyxiation and / or explosion; remove patient from danger.
Treat according to Respiratory distress or Upper airway obstruction guideline.
100% oxygen if carbon monoxide suspected, consider PEEP.
Consider possibility of other effected workers / occupants / first-aiders
Any person who has suffered an inhalation injury of toxic substances is to be transported to hospital.
(Pulmonary oedema may be a late complication).
Urgent transport if decreased level of consciousness.
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EXTENDED CARE
This guideline will apply in the following circumstances:
- Where patient contact has, or is likely to, extend beyond
(approx) 60-90 minutes
- And the patient cannot be managed adequately within the
limits of existing guidelines and pharmacology;
ANALGESIA:
Morphine:
Following initial doses of Morphine, further doses of 0.05 mg/kg may
be given at 15 minute intervals, titrated against:
- Pain assessment
- History & presenting problem
- Perfusion status
- Level of consciousness & respiratory status
(no further doses if GCS is 13 or below, or if respiratory rate
drops below 10).
Intramuscular: same provisos as general pharmacology; 0.1mg/kg
dose; repeat after 30 minutes as required; thereafter at minimum of
90 minute intervals
It must be noted that the extended care guideline does not permit
Paramedics to extend their scope of practice to procedures, which
they have not been trained to perform.
I.V.FLUIDS:
Replacement:
Replacement of estimated or continuing losses with N/Saline
Aim for systolic BP of 90 mmHg.
Midazolam: Can repeat initial doses – as per morphine titration, with
care!
Maintenance:
N/Saline
- Baseline of 1 ml/kg/hr;
- Titrate to:
- Perfusion & hydration assessment
- Any continuing fluid losses
- Environmental conditions
- Urine output, if available (aim for 1 ml/kg/hr).
I.G. TUBE:
Consider placement in the following patients, if patient contact is
likely to be prolonged:
- cervical & thoracic spinal cord lesions
- burns patients, BSA over 20%
(esp. if respiratory involvement).
ANTIEMETIC:
Metoclopramide:
Further IV dose, after 3 – 4 hours.
May be given IM – repeat after 4 hours.
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MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS
CMG 37a – GENERAL AMBULANCE OPERATIONS
Elderly patients; known or suspected hypotension; general
debility: reduce dose – usually half.
Use in situations where the patient cannot be managed due to
agitation or combativeness.
Limb restraints are to be utilised in conjunction with
pharmacological restraint.
If concerned about safety call police for assistance.
Consider / exclude: hypoxia; hypoglycaemia; head injury;
drug overdose; post-ictal state
Treat as appropriate.
MENTAL HEALTH PATIENTS:
Speak quietly - do not shout. Do not leave the patient alone.
Attempt quiet reassurance in an attempt to persuade the patient
to accept treatment.
Wherever possible, obtain an Emergency Order for management of
mental health patients.
(AFP; medical practitioner; CAT Team)
If reassurance and persuasion are ineffective or
impractical, move to pharmacological management.
If not practical, proceed with pharmacological control if there is
concern for the welfare of the patient & / or others.
This should be a last resort:
Midazolam up 0.1mg / kg. Usually IM.
May repeat dose after 10 minutes if necessary.
Ensure adequate control of the limb and patient when
injecting.
Notify and transport patient to nearest appropriate hospital. PATIENTS
MANAGED WITH PHARMACOLOGICAL CONTROL MUST BE TRANSPORTED TO
HOSPITAL.
If agitated state thought to be due to psycho-stimulant use:
Midazolam up 0.2 mg/kg.
May repeat after 10 minutes if required.
45
NOTE: All patients managed with CMG 37 will require an incident report to
be submitted to the Clinical Services Section.
Ver 4.1
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CLINICAL MANAGEMENT GUIDELINES 37B
AERO-MEDICAL PATIENTS
A lower threshold for intervention with sedation applies to
patients who are transported by air.
In flight agitation & combativeness is to be managed
as a matter of urgency.
Inform the pilot in command.
Proceed immediately to pharmacological
management.
Do not use physical restraint alone, beyond the
time required to pharmacologically manage
the patient.
Identify and correct possible causes of agitation prior
to flight wherever possible.
Electrolyte imbalance, hypoxia, hypovolaemia,
hypoglycaemia, cold.
If still agitated – sedate prior to flight.
If unable to obtain agreement on sedation prior to
flight – advise pilot of your concerns.
If still no decision to sedate patient, & in your opinion
there is still an unacceptable risk – do not fly.
Advise all crew & ACTAS Duty Manager.
Duty Manager to discuss with Shock Trauma Service consultant.
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CLINICAL MANAGEMENT GUIDELINES 38
MENINGOCOCCAL DISEASE
Management
Prompt identification of meningococcal disease &
commencement of treatment out of hospital can be life saving.
A high index of suspicion is advisable, but only in critically ill
patients.
Ensure personal protection – gloves; mask; gown;
eye protection if airway care is being attended.
General care.
Consider meningococcal disease in the following
circumstances:
Ensure minimum scene time
Cannulate – 10 mls / kg Normal saline;
Repeat as required.
febrile illness &
sudden onset &
disturbed level of consciousness.
Ceftriaxone – 50 mg/kg IV or IM, to max 2g
+ / - haemorrhagic, purpuric or petechial rash;
Check BGL
+ / - tachycardia, hypotension, peripherally shut down.
Urgent transport
Other signs & symptoms often non-specific, especially in
young children.
Headache; photophobia; neck stiffness; vomiting; painful or
swollen joints; occ focal signs; seizures.
47
Note: deterioration is possible following antibiotic administration.
This would be unusual during average ambulance contact.
It will most likely be a decrease in LOC & / or BP.
Be prepared; manage with fluid.
If deterioration continues – consider adrenaline infusion.
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If Intubation is not successful the following “Failed Intubation Drill”
MUST BE FOLLOWED
Were vocal cords visualised during
Initial laryngoscopy
No
Yes
Insert OP airway and
ventilate with 100% o2
Check head /neck position
BURP manoeuvre
Objective confirmation
of tracheal placement
(ODD ETCo2)
Re-attempt intubation under direct
Vision, after suction or removal of
foreign body, as required
YES
No
Immediately remove ETT
and insert OP or NP airway
and re-ventilate with 100% O2
Continue management in
accordance with the
relevant CMG
DO NOT CONTINUE WITH FRUITLESS ATTEMPTS TO INTUBATE UNDER DIRECT VISION
Able to
oxygenate and
ventilate
Attempt digital placement
(on appropriate patients)
YES
If unsuccessful insert LMA
No
Able to oxygenate
and ventilate
CONSIDER
No
YES
CRICOTHYROTOMY
48
Continue management in
accordance with the
relevant CMG
Incident report to be
submitted
Ver 4.1
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RAPID SEQUENCE INDUCTION (RSI)
THIS IS A PROCEDURE OF LAST RESORT! EXPLORE ALL OTHER OPTIONS AND
ALTERNATIVES FIRST!
INDICATIONS
The unconscious patient with unequivocal, life threatening airway compromise and
clinical evidence of severe hypoxia.
OR
The unconscious patient with potential airway compromise where extrication
procedures will make it impossible to provide adequate airway control.
CONSIDERATIONS
The following essential considerations must be taken into account prior to utilisation
of this guideline.
Clinical Need
Airway compromise, clear & obvious
Glasgow Coma Score < 9
Hypoxia – Sats < 90% OR Centrally cyanosed
Time to Hospital (Should include Extrication, Load & Transport Time)
Patients who are not trapped or where extrication is not difficult, and are within 5-6 minutes
time to hospital, WOULD NOT be candidates for rapid sequence induction.
Assessment of the difficulty of Intubation
Based on Anatomical, Acquired and Situational Factors.
Confidence and experience of the operator.
Response to basic treatment
Try everything – posture, guedels, nasal, suction, O2, ventilation by mask etc.
Give basic options a chance to work.
Only proceed to rapid sequence induction if patient remains critical.
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Consequences and Outcomes
Worse case scenario:
Breathing patient with compromised airway;
becomes a can’t intubate, can’t ventilate scenario.
Fall back position
Do not continue with futile attempts to intubate.
Return to basics & re-ventilate.
Attempt placement with:
Digital placement
LMA
Surgical Airway as last resort.
PROCEDURE
Basic airway management.
Oxygenation – Aim for highest O2 saturations by most efficient method.
IV access – A fast flowing line that is reliable & secure.
A second line is sound insurance.
Most experienced operator to tube. Do not debate this issue - make a choice
and proceed!
This is not a teaching opportunity for intubation skills.
Prepare patient:
1.
Correct any hypotension / hypovolaemia
2.
Pre-oxygenate
3.
Monitor Patient, ECG / Oximetery
4.
Correct any bradycardia
5.
6.
Prepare and check equipment
This is vital and includes: Laryngoscope
Suction
ETT - syringe, ties etc.
LMA
Brief your assistant
7.
Check allergies
8.
Draw up drugs and check
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9.
Ask assistant to apply cricothyroid pressure
10.
Commence intubation
11.
Check tube position
Visualisation of tube between cords
Oesophageal detector device
Auscultation
Chest movement
Misting in the tube
EtCO2
Pulse oximetry
12.
Tie in securely.
DRUG SEQUENCE
Adult
Midazolam 0.05 mg/kg, Slow IV dose
Note: Watch BP !
Prior to Suxamethonium, if bradycardic rate < 50
Atropine 0.01 mg/kg, fast push.
Suxamethonium 1.5 mg/kg, over 30 – 60 seconds.
Post intubation to maintain tube and level of sedation,
Alternating dose of:
Midazolam up to 0.1mg / kg, slow IV dose
Morphine up to 0.05 mg /kg, slow IV dose
Note: Watch BP ! Suxamethonium causes bradycardia, if Pt is still bradycardic once ETT
is tied in, consider a dose of Atropine
Paediatric
Midazolam 0.05 mg/kg Slowly as possible
Note: Watch BP !
Atropine 0.01 mg/kg, fast push
Suxamethonium 1.5 mg/kg, over 30 – 60 seconds
Post intubation to maintain tube and level of sedation
Midazolam up to 0.1mg / kg, slow IV dose
Morphine up to 0.05 mg /kg, slow IV dose
Note: Watch BP !
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IF INTUBATION FAILS
Re-oxygenate / Re-ventilate patient – utilise basic techniques.
There is no second dose of Suxamethonium!
If intubation is still unsuccessful move to a fallback option – Failed intubation drill.
Digital Placement, LMA and Surgical Airway.
Consider urgent transport.
FOLLOW UP
1. All relevant details will be carefully documented on the PCR. This especially
applies to details concerning the need for sedation, the checks on correct
placement and the results of the procedure.
2. Incident Report to Clinical Support Section by fax that shift, the hard copy to be sent
via satchel. No Exceptions.
3. All pharmacologically facilitated Intubations will be subject to routine, mandatory
Medical Advisory Committee Review.
FINAL NOTE
As stated previously this is a procedure of last resort!
It is anticipated that this procedure will be utilised in only the most exceptional
circumstances.
The Clinical Advisory Committee will always support a decision not to use this procedure.
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DRUGS FOR AIRWAY MANAGEMENT - SUMMARY SHEET
SEDATION FOR BASIC AIRWAY MANAGEMENT:
Midazolam
Dose: up to 0.1 mg / kg l.V., slow IV dose.
( Note: If patient has already had Midazolam for sedation do not give a repeat dose
with Suxamethonium or give a smaller dose.)
RAPID SEQUENCE INDUCTION – Suxamethonium & Midazolam
Adult:
Midazolam 0.05 mg/kg, Slow IV dose.
Note: Check BP as soon as practical !
Prior to Suxamethonium, if bradycardic rate < 50
Atropine 0.01 mg/kg, fast push
Suxamethonium 1.5 mg/kg, over 30 – 60 seconds
Paediatric:
Midazolam 0.05 mg/kg Slow IV dose.
Note: Check BP as soon as practical !
Atropine 0.01 mg/kg, fast push.
Suxamethonium 1.5 mg/kg, over 30 – 60 seconds.
Note: Watch BP ! Suxamethonium causes bradycardia, if patient is still bradycardic
once ETT is tied in, consider a dose of Atropine
RAPID SEQUENCE INDUCTION – Morphine & Midazolam
Pre-infuse IV bolus of fluid, irrespective of BP.
Adults:
IF - normal size & weight & age < 75 & BP > 100
Morphine 10 mg IV, Midazolam 10 mg IV. Fast push.
IF - small adult or BP 70 – 100 or age ≥ 75
Morphine 5 mg IV, Midazolam 5 mg IV. Fast push.
IF - BP < 70
Morphine 2.5 mg IV, Midazolam 2.5 mg IV. Fast Push.
Flush dose with rapid IV fluid bolus.
Paediatrics:
Morphine 0.05 mg / kg mg IV, Midazolam 0.1 mg / kg mg IV.
If hypovolaemia suspected : give half calculated dose of each drug.
Flush dose with rapid IV fluid bolus.
Doses may be repeated x 1. (Prepare second doses)
POST INTUBATION - to maintain tube and level of sedation.
Midazolam up to 0.1mg / kg. Slow IV dose.
Morphine up to 0.05 mg /kg. Slow IV dose.
Note: Monitor BP closely !
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55
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A.C.T. AMBULANCE SERVICE
PHARMACOLOGY NOTES
INDEX
ACETYLSALICYLIC ACID (ASPIRIN)
KETAMINE
ADENOSINE
LIGNOCAINE
ADRENALINE
MAGNESIUM SULPHATE
AMIODARONE
METHOXYFLURANE (PENTHRANE)
ATROPINE SULPHATE
METOCLOPRAMIDE (MAXOLON)
CALCIUM CHLORIDE
MIDAZOLAM (HYPNOVEL)
CEFTRIAXONE
MORPHINE SULPHATE
DEXTROSE 5%
DEXTROSE 50%
NALOXONE (NARCAN)
NORMAL SALINE
FRUSEMIDE (LASIX)
OBIDOXIME
GLUCAGON
ONDANSETRON (ZOFRAN)
GLYCERYLTRINITRATE (ANGININE)
SALBUTAMOL (VENTOLIN)
HYDROCORTISONE
SODIUM BICARBONATE
IPRATROPIUM BROMIDE (ATROVENT)
SUXAMETHONIUM
Drug Calculator
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ACETYLSALICYLIC ACID
(ASPIRIN)
TYPE:
Nonsteroidal anti-inflammatory drug. [S.2]
PRESENTATION:
Tablet 300 mg.
ACTIONS:
1: Inhibits platelet function (up to 7 days).
2: Suppresses inflammation, reduces fever, relieves
pain.
Rapidly absorbed from stomach and small bowel.
USE:
Suspected Myocardial Ischaemia - reduces platelet
aggregation and limits clot development.
ADVERSE EFFECTS:
1:
2:
3:
Allergic reactions eg. asthma, angioneurotic
oedema, urticaria, rhinitis, shock.
CHECK FOR PREVIOUS REACTIONS.
Aggravation of bleeding tendencies.
Gastric irritation (unlikely with 1 tablet only).
CONTRA-INDICATIONS:
1: Known or suspected allergy to salicylates.
2: Known or suspected active bleeding.
3: Known bleeding tendency.
DOSE:
1 tablet (300mg)
- chewed and swallowed or
- dissolved in a small amount of water.
If on warfarin – ½ tablet (150mg) only.
Single dose only.
SPECIAL NOTE:
Administer even when patient is on slow release aspirin.
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ADENOSINE
(ADENOCOR)
TYPE:
Endogenous purine nucleoside, found in all body cells. [S.4]
PRESENTATION:
6 mg in 2 ml amps.
ACTIONS:
Causes transient inhibition of conduction in the heart,
especially in the A-V node.
Onset: 5 -10 seconds.
Duration: approx 10 seconds.
USES:
Treatment of Supra-ventricular Tachycardia.
Not for the treatment of Atrial Flutter or Fibrillation; however,
if mistakenly administered to patients in these arrhythmias,
the decrease in A-V conduction may unmask atrial activity.
ADVERSE EFFECTS:
Common, although transient & generally minor. Arrhythmias
at time of conversion - common ( up to 55% pts)
- includes PVCs, PACs, sinus brady, A-V blocks.
Transient flushing of the skin; mild dyspnoea; chest
tightness, nausea & headache. Feelings of apprehension &
fear.
CONTRA-INDICATIONS: 2° or 3° block.
Known hypersensitivity.
PRECAUTIONS:
Asthma - may exacerbate bronchospasm.
Pregnancy - use only if very poorly perfused.
Antagonised by: Theophylline
Potentiated by:
Dipyridamole (Persantin)
Carbamezapine (Carbium, Tegretol,
Teril)
DOSE:
Symptomatic adults only:
6 mg IV - rapid bolus (1 - 2 seconds).
- give into fast flowing pump set
If 1st dose unsuccessful, give 2nd dose
12 mg IV (2 minutes between doses)
Paediatric
2nd dose
SPECIAL NOTE:
:
:
0.05 mg / kg
0.1 mg / kg
Use only after unsuccessful Valsalva manoeuvrer x 2.
Record 12 lead ECG prior to use of Adenosine.
Rapid injection with a pump set increases likelihood of
success. Elevate limb if possible.
If successful conversion of arrhythmia - patient should be
transported to hospital - incidence of recurrence of
arrhythmia is quite high (10-15%).
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ADRENALINE
TYPE:
Naturally occurring catecholamine. [S.3]
PRESENTATION:
1:10000 - 1 mg in 10 mls - IMS Minijet
1:1000 - 1 mg in 1 ml
- ampoules
ACTIONS:
1.
2.
Peripheral vasoconstriction (α effect)
Increased rate of sinus node
Increased myocardial contractility
Increased AV conduction
Increased myocardial irritably (β1 effect)
Bronchodilatation
Vasodilatation of skeletal muscle (β2effect)
B
3.
B
B
B
Onset - IV: 30 secs;
IM: 30 - 90 secs
Max effect - IV: 3-5 mins;
IM: 4-10 mins
Endotracheal use: slightly longer times.
USES:
Ventricular fibrillation.
Asystole.
Pulseless Electrical Activity (PEA)
Anaphylaxis.
Severe - life threatening asthma.
Bradyarrhythmias resistant to Atropine.
Severe upper airway obstruction due to swelling.
ADVERSE EFFECTS:
Tachycardia.
Tachyarrhythmias.
Hypertension.
CONTRA-INDICATIONS: Known hypersensitivity.
PRECAUTIONS:
These apply to patients with cardiac output only:
- Care with patients with history of hypertension.
- Care with patients with history of ischaemic heart
disease.
- Give extremely slowly to patients on MAO Inhibitor
antidepressants (eg: Marplan, Parstelin, Marsilid,
Nardil, Parnate) Adrenaline may provoke a greatly
exaggerated response. Generally, patients on MAOIs
with cardiac output should receive no more than ¼
normal dose of adrenaline, titrated to response.
Continues over
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DOSE:
Cardiac Arrest
Adult:
1mg, IV fast push
Paediatric: 0.01mg/kg IV / IO fast push
Endotracheal if no IV or IO access.
No limit on number of doses in Cardiac Arrest
Anaphylaxis / Severe - life threatening asthma:
Adult:
0.5 mg IM
Paediatric: 0.01 mg / kg IM (to 50 kgs)
Repeat IM dose x 1 as required.
If required, IV Adrenaline by infusion:
1 mg in 1000 mls Saline ( = 1mcg/ml)
Titrate to response. (20 dpm = 1 ml / min = 1 mcg / min)
If patient critically ill, slow IV, up to 0.01 mg / kg, over 5
minutes.
Note: IV adrenaline in anaphylaxis & asthma should be used
very cautiously.
Bradyarrhythmias resistant to Atropine:
IV Adrenaline by infusion:
1 mg in 1000 mls Saline ( = 1mcg/ml)
Titrate to response. (20 dpm = 1ml/min = 1 mcg/min)
Severe upper airway swelling:
Adrenaline 1:1000:
wt > 10 kg - nebulise 5 mls Adrenaline 1:1000
wt < 10kg - nebulise 0.5ml/kg Adrenaline 1:1000 (make
volume up to 5 mls with saline, as required)
Single dose only.
SPECIAL NOTE: Adrenaline in 1000ml flask is to have medication label attached!
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AMIODARONE
(CORDARONE X)
TYPE:
Potent antiarrhythmic agent. [S.4]
PRESENTATION:
Ampoule 150 mg / 3 mls
ACTIONS:
Complex electrophysiological & pharmacological profile.
Prolongs the action potential duration; increases
refractoriness of all cardiac tissue.
Also blocks Na+ channels (Class I action).
Has some anti-adrenergic effects (Class II action).
Ca2+ blockade (Class IV).
Prolongs QT interval – reflects global prolongation of
repolarisation.
When given I.V., a significant effect is on AV node – causes
delay in nodal conduction.
Also effective for accessory pathway conduction.
P
P
P
P
USE:
Effective for both supraventricular & ventricular arrhythmias.
ACTAS use: to slow ventricular rate in AF and AFl.
Treat VT & VF.
ADVERSE EFFECTS:
IV: can cause vasodilatation & negative inotropic effects;
hypotension. (Dose & rate dependent.)
Occasionally may cause: - bradycardia ( esp in older pts).
- phlebitis.
- hot flushes / sweating.
CONTRA-INDICATIONS:
Cross sensitivity to Iodine.
DOSE:
VF: Adult: 300 mg IV push dose (over 30 – 60 seconds).
Paediatric: 5 mg / kg IV (to total 150mg).
Dilute to 10mls volume with 5% Dextrose.
VT, AF and AFl:
150 mg IV via Springfuser; (over 10 minutes, approx. 7 mls).
Paediatric: 5 mg / kg as above (to total 150mg).
(VT - If extremely compromised, may be given over 5 mins by
slow IV injection)
SPECIAL NOTE:
No repeat doses for either treatment regimen.
Needs to be administered in 5% Dextrose (incompatible with
saline)
Significant potential drug interactions: Following may
potentiate actions of amiodarone: digoxin; phenytoin
(Dilantin); β blockers; Ca2+ channel blockers; other antiarrhythmics.
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P
P
ATROPINE SULPHATE
TYPE:
Parasympathetic blocking agent [ S.4]
PRESENTATION:
1 mg in 10 mls - IMS Minijet
ACTIONS:
Large number of actions.
Those important in the pre hospital setting:
- Blocks the action of the vagus nerve on the heart.
- Increases the rate of the sinus node.
- Increases speed of conduction through the AV node.
- Reduces the amount of secretions from some glands:
(eg. tear & salivary glands).
Onset:
IV - 2 mins. Max effects - 5 mins
IM / ET- Slightly longer
USES:
- Bradyarrhythmias with poor perfusion
- Asystole / PEA
- Organophosphate poisoning / spider bite (to increase
heart rate & / or assist airway maintenance by reducing
excessive salivation)
- To prevent bradycardia with Suxamethonium use
ADVERSE EFFECTS:
Tachycardia; palpitations; blurred vision; dry mouth;
confusion, urinary retention; increased body temperature
(by reduction in sweating).
PRECAUTIONS:
DOSE:
Care needed in patients with Glaucoma.
Aim not to increase heart rate above 100 / min.
Bradyarrhythmias:
Adult: IV - 0.01 mg/kg – fast push
ET: - 0.01 mg/kg, if no immediate IV access.
Repeat x 1 as necessary
Paediatric:
Not used
Continues over
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Asystole / PEA:
Adult: 2mg IV / ET
Paediatric:
Not used
Organophosphate poisoning / cholinergic symptoms of spider
bite:
Adult / Paediatric: 0.01 mg/kg IV - repeat as required. No
upper limit on doses.
May be used IM in these circumstances, if IV access not
available or if there are multiple patients affected.
To prevent bradycardia with Suxamethonium use:
Adult / paediatric: 0.01 mg/kg IV, fast push
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CALCIUM CHLORIDE
TYPE:
Electrolyte - utilised in both electrical & mechanical
actions of the myocardium. [ No schedule]
PRESENTATION:
1 gm in 10 mls (10% solution) - IMS Minijet.
ACTIONS:
Opposes action of high serum potassium on the
myocardium.
Onset: IV: Several minutes.
Duration: 30 - 90 minutes.
USES:
Emergency treatment of hyperkalaemia.
ADVERSE EFFECTS:
Rare with nominated use.
- Tissue necrosis if extravasates from vein.
- Precipitates out in contact with bicarbonate.
CONTRA-INDICATIONS:
DOSE:
Adult / paediatric:
10 mg / kg IV, over 2 minutes.
Repeat x 1 as required.
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CEFTRIAXONE (ROCEPHIN)
TYPE:
3rd generation cephalosporin antibiotic. [S.4]
PRESENTATION:
Vial – 1g Ceftriaxone powder for reconstitution.
ACTIONS:
Broad spectrum antibiotic.
Especially effective against gram-negative bacteria
(eg Meningococcus).
Effective crossing of blood-brain barrier.
Half-life approx 8 hours.
USE:
Suspected meningococcal disease, in acutely ill patients.
ADVERSE EFFECTS:
Hypersensitivity reactions (not common)
Diarrhoea.
Skin rash.
PRECAUTIONS: Possibly 20% patients with penicillin allergy may be
sensitive to ceftriaxone.
CONTRA-INDICATIONS: Known sensitivity to cephalosporins.
DOSE:
50 mg/kg, to a total of 2g.
IV preferred. Can also be given IO.
Make up to 10 mls with water for injection; give slowly over 2 – 4 mins
May be administered IM; dilute a max dose of 1 g in 3mls 1% lignocaine
prior to administration.
Give two injections if dose is over 1 g (i.e. 3 mls volume).
SPECIAL NOTE:
An incident report should be submitted to Clinical Services if
Ceftriaxone is administered.
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DEXTROSE 5%
TYPE:
Isotonic dextrose solution;
contains 50 g Dextrose per 1 litre. [ No schedule]
PRESENTATION:
100 or 250 ml soft pack of 5% Dextrose.
ACTION:
Dextrose is metabolised rapidly when administered IV.
The water in which it was dissolved is distributed
throughout the body & has minimal effect on blood
volume.
USES:
To keep the vein patent, for the administration of drugs.
For dilution of Amiodarone prior to use.
(NB: Dextrose 5% is not used for the treatment of
hypoglycaemia).
ADVERSE EFFECTS:
Exercise care that the infusion does not run at more than
the recommended rate.
DOSE:
Intravenous infusion - 10 drops per minute (dpm) TKVO
Provides 10 ml / hr with standard giving set.
Run fully open for a few seconds to flush drugs.
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DEXTROSE 50%
TYPE:
Hypertonic dextrose solution;
contains 0.5 g Dextrose per ml. [ No schedule]
PRESENTATION:
50 ml - IMS Minijet (25 gm Dextrose).
ACTION:
Dextrose (glucose) is the main energy source for the body
cells, especially the brain.
Onset: IV 30 - 60 seconds.
USES:
Treat hypoglycaemia; following blood glucose
estimation - if BGL < 4, & patient unable to eat or drink.
ADVERSE EFFECTS
- Tissue necrosis if allowed to escape from the vein.
- Hyperglycaemia / hyperosmolality.
DOSE:
Up to 0.5 ml/kg IV (0.25 g/kg) slowly over 5 minutes
Continue to check patency of vein.
May repeat dose x 1 if level of consciousness or BGL has
not improved.
NOTE:
Patients who respond to 50% Dextrose should eat, to
prevent later development of further hypoglycaemia.
Recheck BGL following treatment.
Must be administered through a running IV line.
Paediatric use: dilute 50% dextrose with an equal amount
of 5% dextrose or normal saline.
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FRUSEMIDE
(LASIX)
TYPE:
Loop diuretic. [ S.4]
PRESENTATION:
80 mg in 8 mls - IMS Minijet
ACTIONS:
1.
Potent diuretic- produces increased urine
output within 5 - 10 minutes; lasts up to 3 hours
when given I V.
2.
Causes venous dilatation- decreases venous return.
Effect occurs within 5 minutes.
USES:
Acute Cardiogenic Pulmonary Oedema
- to decrease venous return and promote loss of fluid.
ADVERSE EFFECTS:
1.
2.
3.
If given too rapidly, may lead to hypotension.
If marked diuresis occurs, the resulting fluid
loss may lead to hypovolaemic shock,
especially in hypovolaemic patients.
Potassium loss may occur – may aggravate
arrhythmias. (esp. if previously hypokalaemic).
CONTRA-INDICATIONS: - Systolic BP < 90.
- Hypersensitivity. (Note – possible cross sensitivity to
sulphonamides).
DOSE
Adult:
On diuretics:
Not on diuretics:
1mg / kg IV over 2 mins.
0.5 mg / kg IV over 2 mins.
Initial dose may be repeated once after 10-15 mins if
respiratory distress is severe.
If severe pulmonary oedema & IV access not available:
Administer IM (in 2 separate sites if volume is greater
than 4 mls).
Paediatric: Not used.
68
Ver 4.1
08/07
GLUCAGON
TYPE:
Pancreatic hormone. [ S.4]
PRESENTATION:
Vial containing 1 International Unit of Glucagon, as dry
powder, with a syringe containing 1 ml of diluting solution.
ACTIONS:
Causes the liver to metabolise stores of glycogen to
Glucose, resulting in a rise in the blood glucose level. Only
effective if liver glycogen is available.
Onset: IM 5 - 20 mins.
USES:
Treatment of hypoglycaemia, BGL < 4 mMol / l, when oral
or intravenous glucose cannot be administered.
ADVERSE EFFECTS:
Very rarely occur.
Nausea and vomiting.
Very occasional hypersensitivity.
DOSE:
Adult:
1 International Unit (IU), IM.
Paediatric: wt < 20 kg (approx 5 yrs):
0.5 International Unit IM
wt > 20 kg: 1 International Unit IM.
Single dose only.
SPECIAL NOTE:
Patients who respond to Glucagon should eat, to prevent
later development of further hypoglycaemia.
Recheck BGL following treatment.
69
Ver 4.1
08/07
GLYCERYL TRINITRATE
(ANGININE)
TYPE:
Nitrate smooth muscle relaxant & vasodilator. {S.3]
PRESENTATION:
White 600 microgram sublingual tablets.
ACTIONS:
Arterial & venous vasodilatation.
Dilatation of collateral coronary vessels.
USES:
Relieve cardiac pain of ischaemic origin.
Relieve pulmonary oedema.
ADVERSE EFFECTS:
Hypotension.
Headache.
Flushing of skin.
Occasionally – bradycardia.
CONTRA-INDICATIONS:
Do not administer if systolic BP is < 90.
Do not administer if sildenafil (Viagra) or vardenafil
(Levitra) taken within 24 hours.
Following the last dose of tadalafil (Cialis), do not
administer within 4 to 5 days in the elderly and those with
renal impairment, or 3 to 4 days in all other patients.
DOSE:
Chest Pain:
1 tablet sublingual (600 mcg)
Repeat x 1 as necessary.
Acute cardiogenic pulmonary oedema:
1 tablet sublingual (600 mcg)
Not repeated.
90 > Systolic BP < 100, or patient who has not had
any nitrate medication previously - give 1/2 tablet
Repeat 1/2 tablet x 1 as necessary.
NOTE:
Tablet should fizz under tongue if it is still potent. Use tablets within 3
months of opening bottle. Container must be dated when opened.
70
Ver 4.1
08/07
HYDROCORTISONE (SODIUM SUCCINATE)
TYPE:
Adrenocortico-steroid. [S.4]
PRESENTATION:
100mg powder in 2ml vial.
Reconstitute with 2mls sterile water, Normal Saline or 5%
Dextrose.
ACTIONS:
Numerous & widespread.
ACTAS administration is for anti-inflammatory effect on
the airways.
USE:
Moderate to severe bronchospasm due to asthma,
anaphylaxis or chronic airways disease.
ADVERSE EFFECTS:
Nil significant with single use.
CONTRA-INDICATIONS:
DOSE:
Known previous reaction to corticosteroid.
Adult: 200 mg IV slow - over 2 minutes.
Paed: 4 mg / kg IV slow - over 2 minutes (to total 200mg).
May be administered IM.
SPECIAL NOTE:
Hydrocortisone is not a first line, priority drug in the
management of severe bronchospasm.
It is only to be given after aggressive oxygenation, inhaled
bronchodilators & (where necessary) adrenaline.
71
Ver 4.1
08/07
IPRATROPIUM BROMIDE
(ATROVENT)
TYPE:
Anticholinergic bronchodilator. [S. 4]
PRESENTATION:
Plastic “Nebule”:
1ml 250 mcg Ipratropium Bromide.
ACTIONS:
Bronchodilator.
Blocks vagal reflexes which mediate
bronchoconstriction.
Possibly more effective when used in combination
with salbutamol.
Onset: 3 – 5 mins.
Duration: 2 - 4 hours.
USES:
Bronchospasm from any cause; as an adjunct to
Salbutamol.
ADVERSE EFFECTS:
Rare with single use.
Occasionally - urine retention.
CONTRA-INDICATIONS:
PRECAUTIONS:
Care needed with use in patients with glaucoma.
DOSE:
Adult: 500 mcg - mixed with 1st, then 3rd and 5th
doses of salbutamol.
Paed: 250 mcg - mixed with 1st, then 3rd and 5th
doses of salbutamol.
72
Ver 4.1
08/07
KETAMINE HYDROCHLORIDE (KETLAR)
TYPE:
Dissociative anaesthetic agent. [S. 8]
PRESENTATION:
200mg in 2ml vial.
ACTIONS:
Complex, multiple actions.
Analgesic; sedative agent.
Marked amnesia
Has bronchodilating properties.
Does not tend to cause respiratory depression.
Does not tend to cause hypotension ( via sympathetic
stimulation.)
Onset of action is rapid: 1 – 2 minutes IV
3 – 5 minutes IM
USE:
Pain management, especially in patients who are hypotensive
or unable to have narcotics, & if no alternative available.
Particularly useful for trapped patients with limb injuries,
especially if BP is borderline for narcotics.
ADVERSE EFFECTS: Transient Laryngospasm
Hypersalivation
Emergence reactions.
Occ respiratory depression → apnoea
Hypotension occasionally if given rapidly to
a hypovolaemic patient.
Muscle twitching & purposeless movements.
PRECAUTIONS:
Use with care in patients where a rise in BP may be
hazardous (eg stroke, cerebral trauma)
Known glaucoma
Previous psychoses
Hyperthyroidism.
Elderly and paediatric patients.
Patients previously administered narcotics
CONTRA-INDICATIONS:
Known sensitivity.
Active cardiac disease (myocardial ischaemia, LVF,
uncontrolled hypertension.)
Children under 1 year old.
73
Ver 4.1
08/07
Continues over
DOSE:
See attached Dose Chart.
SPECIAL NOTE:
1. Patients who have received ketamine may still have a
significant awareness, despite an appearance of
unconsciousness.
2. Ketamine is a Drug of Dependence. Use must be
checked by both crewmembers.
3. Under the Drugs of Dependence Act, recording and
accounting for its use is a legal requirement.
4. The unused portion of the dose must be appropriately
disposed of & the disposal recorded.
5. If ketamine is administered, please submit an incident
report to Clinical Services.
74
Ver 4.1
08/07
KETAMINE DOSE CHART
DOSES:
Initial IV
Adult
Up to 1 mg/kg.
Increments of
up to 20 mg at
intervals of 30
– 60 seconds.
Elderly
(> 65 yrs)
Up to 1 mg/kg.
Increments of
up to 10 mg at
intervals of 30
– 60 seconds.
Paediatric Up to 1 mg/kg.
> 20 kg Increments of
up to 10 mg at
intervals of 30
– 60 seconds.
Paediatric Up to 1 mg/kg.
< 20 kg Increments of
up to 5 mg at
intervals of 30
– 60 seconds.
Repeat IV
After 5 – 10
minutes;
increments of
up to 20 mg as
before. No
upper limit.
After 5 – 10
minutes;
increments of
up to 10 mg as
before. No
upper limit.
After 5 – 10
minutes;
increments of
up to 10 mg as
before. No
upper limit.
After 5 – 10
minutes;
increments of
up to 5 mg as
before. No
upper limit.
Initial
IM
Repeat IM
1 mg/kg
After 5 – 10
minutes;
1 mg/kg
0.5
mg/kg
After 5 – 10
minutes;
0.5 mg/kg
0.5
mg/kg
After 5 – 10
minutes;
0.5 mg/kg
0.5
mg/kg
After 5 – 10
minutes;
0.5 mg/kg
Previous
opiates
IV: Up to
10mg
increments as
before.
IM: 0.5 mg/kg
IV: Up to 5
mg
increments as
before.
IM: 0.25
mg/kg
IV: Up to 5
mg
increments as
before.
IM: 0.25
mg/kg
IV: Up to 2.5
mg
increments as
before.
IM: 0.25
mg/kg
All IV doses to be given slowly, over 30 seconds.
Recommended dilutions:
Adult IV: 200mg diluted up to 10 ml; = 20mg / ml
Adult IM: 100 mg diluted up to 2 ml. Discard excess dose before IM use.
Elderly pt IV: 100 mg diluted up to 10 ml; = 10 mg / ml
Elderly pt IM: 100 mg diluted up to 2 ml. Discard excess dose before IM use
Children IV: 50 mg diluted to 10 ml; = 5 mg / ml
Children IM: 50 mg diluted to 2 mls. Discard excess dose before IM use.
75
Ver 4.1
08/07
LIGNOCAINE
TYPE:
Local anaesthetic.
Antiarrhythmic [S.4]
PRESENTATION:
50 mg in 5 mls - plastic ampoule.
ACTION:
Local anaesthetic effects.
Suppresses ventricular arrhythmias
Onset: S/C 1 – 4 mins. Max effect: 5 - 10 mins.
IV 1 - 3mins
USES:
1: Local anaesthesia prior to invasive procedures.
2: VT with cardiac output– in patients who cannot
have Amiodarone.
ADVERSE EFFECTS:
These effects are extremely unlikely in usual
subcutaneous doses, especially if the syringe is
continually aspirated.
More likely if given IV.
C.N.S. effects
- stimulation followed by
depression.
- drowsiness, agitation, muscle
twitching, seizures & coma.
Cardiac effects
- hypotension, bradycardia, heart
block, asystole.
CONTRA-INDICATIONS:
PRECAUTIONS:
Nil.
DOSE:
Local anaesthesia:
Adult and paediatric - up to 5 mls subcutaneous.
VT with cardiac output: 1mg/kg – slow IV
(over 2 minutes)
76
Ver 4.1
08/07
MAGNESIUM SULPHATE
TYPE:
Electrolyte solution [No schedule]
PRESENTATION:
50% solution (10 mMol) 2.5 gm in 5 ml vial
ACTION:
Magnesium is the 2nd most abundant intracellular
cation. Less than 1% is present in extracellular fluid.
Magnesium is involved in the processes regulating
sodium and potassium movement across cell
membranes. As such, it may promote myocardial
cell membrane stability.
USES:
Torsade de pointes (polymorphic VT)
(Often associated with prolonged QT interval)
ADVERSE EFFECTS:
Rare; more common if serum Mg is normal.
Respiratory depression; nausea & vomiting;
hypotension; confusion; bradycardia.
CONTRA-INDICATIONS:
AV block; renal failure; hepatic failure.
PRECAUTIONS:
Myaesthenia gravis.
DOSE:
Adults
Cardiac output: Dilute up to 10 mls with N/saline;
2.5 gm IV, over 3 – 5 minutes.
No cardiac output: 2.5 gm IV, over 30 - 60 seconds.
Paediatric: (unusual)
Dose is 50 mg/kg, to maximum of 2.5g.
Dilute to 10 mls = 250 mg/ml
Cardiac output:
give calculated dose IV over 3 – 5 minutes.
No cardiac output:
give calculated dose IV over 30 – 60 seconds
77
Ver 4.1
08/07
METHOXYFLURANE
(PENTHRANE)
TYPE:
PRESENTATION:
Volatile inhalation anaesthetic and analgesic agent.
[S.4]
3 ml bottle.
ACTION:
Central Nervous System depressant.
Onset 3 - 5 mins. Offset 3 – 5 mins.
USES:
For relief of pain of all origins.
ADVERSE EFFECTS:
Altered consciousness.
Renal dysfunction
} rare with once only
Jaundice
} ambulance use.
CONTRA-INDICATIONS:
Depressed level of consciousness.
PRECAUTIONS:
Renal disease.
Diabetes.
Antibiotic or barbiturate use.
Caution if patient cannot self-administer.
DOSE:
Up to 3 mls, self administered
Via Penthrox inhaler, with up to 8 l/m oxygen.
Dose should not exceed 6mls/day or 15mls/week
NOTE:
May be used with Midazolam for musculo-skeletal
pain.
78
Ver 4.1
08/07
METOCLOPRAMIDE (MAXOLON)
TYPE:
Antiemetic. [S.4]
PRESENTATION:
10 mg in 2 ml Ampoules.
ACTION:
Antiemetic - centrally acting on brain stem.
- increases gastric emptying.
Onset: 3-15 mins. (IV) Duration: 30 mins.
USES:
Prevent vomiting:
- when narcotic analgesic is to be administered.
- high spinal injury.
- serious eye injury
- suspected ischaemic chest pain.
Treat nausea & vomiting.
ADVERSE EFFECTS:
Uncommon with usual doses.
Occasionally
- drowsiness
- lethargy
- dry mouth
- oculogyric crisis, facial spasms,
speech difficulties.
Side effects may be more common in dehydrated
adolescents.
PRECAUTIONS:
Concomitant phenothiazide tranquilliser use – will
increase the likelihood of side effects.
CONTRA - INDICATIONS:
Previous reaction.
G.I. bleeding.
DOSE:
Adult dose: 10 mg lV over 2 mins
IM 10mg
Give prior to narcotic administration.
Single dose only.
Paed. dose: Not used.
79
Ver 4.1
08/07
MIDAZOLAM
(HYPNOVEL)
TYPE:
Anticonvulsant & sedative agent. [S.4]
PRESENTATION:
5 mg in 5 ml ampoules.
15 mg in 3 ml ampoules
ACTION:
1:
Anticonvulsant- reduces seizure activity.
2:
Minor tranquilliser.
3:
Muscle relaxant.
Onset (IV) 1 - 5 mins. Duration: 2 - 3 hours.
Onset (IM) 2 - 5 mins. Duration: ? 2 - 3 hours.
USES:
- Status epilepticus - in a patient who has
continual or prolonged seizures.
- Sedation to manage airway, RSI, sedation of a
previously intubated patient.
- Adjunct to analgesia for injuries where
significant muscle spasm is present.
- To manage agitated & combative patients.
- To manage autonomic hyper-reflexia.
ADVERSE EFFECTS:
Depression of level of consciousness - leading to:
respiratory depression.
loss of airway control.
Hypotension.
CONTRA-INDICATIONS
PRECAUTIONS
- haemodynamic instability
- respiratory depression
DOSE:
Seizures
Adult dose: Up to 0.1 mg / kg l.V., over 2 mins, until
fitting ceases.
Repeat if fitting continues or recurs.
Paed dose: Up to 0.1 mg / kg I.V., over 2 mins, until
fitting ceases.
Repeat if fitting continues or recurs.
I.M: 0.1 mg/kg. Repeat x1 after 10 mins as necessary.
continues over
80
Ver 4.1
08/07
Adjunct to analgesic use with muscle spasm:
Following 1 dose of Penthrane or 2 doses of Morphine, if
severe pain & muscle spasm are still present Up to 0.05 mg / kg I.V. over 2 mins.
Repeat x 1 as required
Further analgesic doses to be given with caution.
Mild sedation to facilitate basic airway management:
Up to 0.1mg/kg over 2 mins
When used with Morphine to sedate for airway
management in selected patients:
Adult: 10 mg I.V. rapid push
(adjusted for patient weight, age and BP).
Paed: 0.1 mg / kg rapid push.
When used with suxamethonium:
0.05mg / kg IV.
When used to manage a combative or agitated patient :
Up to 0.1mg / kg IV, until manageable.
May repeat as required to continue management.
IM: 0.1 mg/kg
If agitation & combativeness is thought due to
psychostimulant use:
Up to 0.2mg / kg IV, until manageable.
IM: 0.2 mg/kg
May repeat as required to continue management..
* Use 0.2mg/kg dose with caution.
All agitated patient management doses may be
reduced if there is known or suspected
hypotension or hypovolaemia; in frail or elderly
patients, or patients with general debility.
SPECIAL NOTE:
1: When administering lV for fitting, do not draw up total calculated
dose. Administer first 5 mg ampoule; wait briefly for response before
giving complete dose.
2: When using 0.2 mg/kg IM doses, the 15 mg / 3 ml formulation
should be used. Exercise caution that this is only used in these
circumstances.
3: Elderly patients may be especially sensitive to Midazolam, and
advanced age is often a better guide to dosing than weight.
81
Ver 4.1
08/07
MORPHINE SULPHATE
TYPE:
Narcotic Analgesic. [S.8]
PRESENTATION:
10 mg in 1 ml Ampoules.
ACTIONS:
1: Decreases pain perception and anxiety.
2: Vasodilatation.
Onset: (IV) 2 - 5 mins. Duration: 1 - 2 hours.
(IM) 5 + mins
Duration: 2 - 3 hours.
USES:
To relieve severe pain.
Acute pulmonary oedema.
RSI.
Sedation of a previously intubated patient.
ADVERSE EFFECTS:
Drowsiness.
Respiratory depression.
Hypotension.
Dependence.
Pin point pupils.
Bradycardia.
CONTRA-INDICATIONS:
Depressed level of consciousness (GCS 13 or
less)* Pain relief only.
Respiratory depression * Pain relief only.
BP < 70 mm Hg (pain relief).
BP < 90 mm Hg (pulmonary oedema).
Acute asthma attacks.
Pain management in labour.
PRECAUTIONS:
Elderly patients (may be sensitive).
Patients with COAD.
Hypovolaemic patients (hypovolaemia should be
corrected before Morphine administration).
Patients with systolic BP 70 – 90 (see below).
Children under 1 year.
82
Continues over
Ver 4.1 08/07
DOSE:
Dilute 10 mg ampoule to 10 mls volume with Normal
Saline 1 ml = 1 mg Morphine.
Pain relief:
Adult:
Up to 0.05 mg/kg lV, over 2 mins.
May be repeated at 5 min. intervals, until pain is
managed.
Paediatric: Up to 0.05 mg/kg IV, over 2 mins.
May be repeated at 5 min. intervals, until pain is
relieved. Use with caution under 1 yr of age.
Intramuscular administration:
Pain relief only.
- Not for chest pain if cardiac ischaemia suspected.
- No IV available.
- No hypotension.
- Patient contact estimated > than 20 mins
Dose: 0.1 mg / kg. Repeat x 1 after 30-45
mins as required.
Patient with pain; systolic BP 70 – 90:
- IV use only.
- hypovolaemic patients must be receiving fluids.
- up to half a calculated 0.05mg/kg dose, given
slowly.
- may be repeated as required, with great care, and
with an appropriate time interval between
doses, titrated to response.
- no further doses to be given if systolic BP drops 10
mmHg or more with half dose, even if it
remains above 70 (eg initial BP 85 mm;
following Morphine dose BP now 75 mm).
Continues over
83
Ver 4.1
08/07
Pulmonary Oedema:
0.05 mg/kg lV, over 2 mins.
May be repeated once after 10 mins, if required.
When used with Midazolam for RSI.
Adult: 10 mg IV rapid push
(dose adjusted for patient weight, age and BP).
Paed: 0.05 mg / kg rapid push.
To maintain sedation post intubation:
0.05 mg / kg lV, slow IV dose.
SPECIAL NOTES:
1. Morphine is a Drug of Dependence. Use must
be checked by both crew members.
2. Under the Drugs of Dependence Act,
recording and accounting for its use is a legal
requirement.
3. The unused portion of the dose must be
appropriately disposed of & the disposal
recorded.
4. Side effects may be reversed by use of
Naloxone, although it is desirable to avoid this
unless absolutely necessary.
5. Elderly patients may be especially sensitive to
Morphine, and advanced age is often a better
guide to dosing than weight.
84
Ver 4.1
08/07
NALOXONE
(NARCAN)
TYPE:
Narcotic antagonist. [S.4]
PRESENTATION:
0.4mg in 1 ml - IMS Minijet.
ACTION:
Reverses the effects of narcotic analgesics.
Onset: IV 1 - 2mins Duration: 30 - 45 mins.
IM: unknown; thought to be slightly longer onset &
duration than lV.
USES:
- Coma.
- Drug overdose and poisoning.
Use in situations where there is significant decrease in
level of consciousness; where there is hypoventilation,
and/or loss of protective reflexes; & where overdose of
narcotics cannot be positively excluded.
ADVERSE EFFECTS:
May precipitate acute withdrawal syndrome in narcotic
addicts.
Occasional aggressive behaviour following reversal.
CONTR-INDICATIONS: Known hypersensitivity
DOSE:
Adult: 0.4 mg IM, then
0.4mg lV, increments, fast push
May repeat IV dose x 3. (to max. 2 mg).
Paediatric: 0.01 mg / kg lV, fast push
Max paediatric dose: 3 doses.
All doses may be administered IM or IV as the situation
demands.
SPECIAL NOTE:
When used IV, effect may wear off rapidly, especially if
large dose of narcotic has been taken. An IM dose is
highly recommended if the patient is likely to refuse
transport.
Special care is needed if long acting agents are known or
suspected to have been used (eg. MS Contin; methadone)
In this case, give a larger IM dose and strongly encourage
transport to hospital.
85
Ver 4.1
08/07
NORMAL SALINE
TYPE:
Isotonic crystalloid solution of 0.9% Sodium chloride
solution. Contains 151mMol sodium & 151 mMol
chloride per litre. [No schedule]
PRESENTATION:
500 or 1000 mls of 0.9% Sodium Chloride solution
in collapsible plastic pack.
ACTON:
Plasma volume expander.
Also expands interstitial fluid volume.
Plasma volume effect is only temporary as most of
the Saline moves out of the blood vessels quite
quickly.
USES:
1.
Initial replacement fluid, in volume depleted or
dehydrated patients. Volume depletion may
be due to loss of blood, plasma or fluid and
electrolytes.
2.
Maintenance of hydration during prolonged
patient contact time.
3.
To keep vein open, as route for drugs.
ADVERSE EFFECTS:
Fluid overload.
DOSE:
IV resuscitation:
Adult:
10 ml / kg lV - then reassess patient.
Rate of administration, dependent on the condition
of patient. Aim to keep BP at about 90 mm systolic
No limit on amount, dependent on condition of
patient.
Paediatric:
10 ml / kg lV or IO - then reassess patient.
Paediatric cardiac arrest: 20 ml/kg.
TKVO:
Adult and paediatric:
10 drops per minute. (10 mls / hr with standard drip
set).
86
Ver 4.1
08/07
OBIDOXIME
TYPE:
Oxime. [No schedule]
PRESENTATION:
220 mg Obidoxime / 2 mg Atropine - auto injector.
ACTION:
Reactivating of inhibited acetylcholinesterase.
USES:
To treat super toxic organophosphate poisoning
(nerve agents) by relieving the symptoms of skeletal
neuromuscular blocking that occurs during a
cholinergic crisis.
Used in combination with atropine, as combination
auto-injector, or with atropine separately
administered.
ADVERSE EFFECTS:
Hypotension, menthol-like sensation, warm feeling
to the face, dull pain at site of injection. Multiple
doses can cause hepatic dysfunction.
DOSE:
Adult:
Up to 660 mg IM over 30 minutes.
Three doses via the auto-injector.
Paediatric: Single dose of 220 mg IM.
SPECIAL NOTE:
The preferred site for administration is the upper
thigh.
*
The auto injector needs to be held in place for 10
seconds when discharged to ensure the total dose
has been administered.
87
Ver 4.1
08/07
ONDANSETRON
(ZOFRAN)
TYPE:
Potent antinauseant & antiemetic. [S.4]
PRESENTATION:
Ampoule - 4mg / 2ml.
Wafers – 4mg.
ACTIONS:
Potent, highly selective histamine receptor
antagonist. Precise mode of action in control of
nausea & vomiting is not known. Likely to have
actions peripherally & in the CNS.
Maximum effect approx. 10 minutes following IV
administration.
Hepatic metabolism.
USE:
Pre-flight, for prevention or treatment of nausea &
vomiting.
PRECAUTIONS:
Not recommended in pregnancy.
ADVERSE EFFECTS:
Uncommon. Headache; flushing of skin; occ.
reaction at the site of IV injection; drowsiness;
anxiety & agitation; transient visual disturbances.
CONTRA-INDICATIONS:
DOSE:
Adult: 4 mg IV, slow over 2 minutes.
Paediatric: 0.1 mg / kg IV, slow over 2 minutes
(to total of 4mg).
May be administered IM if necessary.
May repeat x 1 if required, after approx 45 - 60
minutes.
Wafers:
4mg sublingual
May repeat x 1 if required, after approx 45 - 60
minutes.
SPECIAL NOTE:
Used only for patients and flight crew on the
helicopter.
88
Ver 4.1
08/07
SALBUTAMOL
(VENTOLIN)
TYPE:
Synthetic β2 receptor stimulant. [S.4]
PRESENTATION:
Plastic nebules: 5 mg in 2.5 mls nebuliser solution.
2.5 mg in 2.5 mls nebuliser solution.
ACTION:
Bronchodilatation.
Relaxation of involuntary muscle.
Moves K+ from extra-cellular to intra-cellular space.
B
P
B
P
Onset (neb): 5 mins
USES:
Max effect: 10-50 mins.
Bronchospasm from any cause.
Emergency treatment of suspected hyperkalaemia.
ADVERSE EFFECTS:
Rarely seen with usual nebulised therapeutic
doses:
- Tachycardia.
- Tremors.
- Hypotension.
CONTRA-INDICATIONS:
DOSE
Via nebuliser, with oxygen at 6 - 8 lpm.
Adult:
Paed:
5 mg nebule.
2.5 mg nebule.
Mod - severe bronchospasm; suspected
hyperkalaemia - give continuously.
SPECIAL NOTES:
With significant hypoxia, Salbutamol should be
administered with 100% oxygen.
89
Ver 4.1
08/07
SODIUM BICARBONATE
TYPE:
Hypertonic alkaline solution; 8.4% sodium bicarbonate
solution; contains 1 mMol / ml sodium & 1 mMol / ml
bicarbonate. [No schedule]
PRESENTATION:
50 ml Sodium Bicarbonate solution, IMS Minijet.
ACTIONS:
1.
2.
Neutralizes metabolic acidosis as a result of
cardiac arrest or poor perfusion.
Causes movement of K+ into cells – swaps with
H+ ions.
Onset: 30 - 60 seconds (IV).
USES:
To combat acidosis in prolonged cardiac arrest.
For emergency treatment of hyperkalaemia.
For treatment of arrhythmias and/or seizures in Tricyclic
overdosed patients.
To combat acidosis and hyperkalaemia in crush
syndrome.
ADVERSE EFFECTS:
Metabolic alkalosis.
High sodium content may lead to fluid overload & cardiac
failure.
Interacts with some other drugs - (esp. calcium &
adrenaline); always flush well through the line before &
after administration. Consider second line.
CONTRAINDICATIONS: Known hypersensitivity.
DOSE:
Adult & paediatric:
0.5 mMol / kg IV;
repeat x 1 as required
(fast push in cardiac arrest; over 2-5 mins for patients with
cardiac output).
90
Ver 4.1
08/07
SUXAMETHONIUM
TYPE:
Depolarising muscle relaxant. [S.4]
PRESENTATION:
Ampoules – 100mg / 2ml.
ACTIONS:
Acts like the neurotransmitter acetylcholine at the
neuromuscular junction. Persists for a period long
enough to exhaust the motor endplate by prolonged
depolarisation.
Onset: IV: approx 45 seconds.
Duration: IV: 5 – 7 minutes.
USE:
To facilitate airway management in selected patients
with a GCS of less than 9.
ADVERSE EFFECTS:
Bradycardia; potassium release; increased intraocular & intragastric pressure. Occasionally
prolonged paralysis. Has been associated with
malignant hyperthermia.
CONTRAINDICATIONS:
Previous reaction to suxamethonium.
Suspected hyperkalaemia.
PRECAUTIONS:
Elderly patients.
Neuromuscular disease.
Care with use in children.
Select patients carefully; always have a fallback
position!
DOSE:
1.5 mg / kg IV; over 30 – 60 secs.
SPECIAL NOTE:
To be used only following completion of the ACTAS
designated training programme.
Paediatric: give Atropine 0.01 mg / kg IV prior to
Suxamethonium.
Adults: if heart rate less than 50, give Atropine prior to
Suxamethonium.
Prior to administration, give Midazolam 0.05 mg / kg
IV.
Follow up with additional Midazolam after intubation.
91
Ver 4.1
08/07
92
Ver 4.1
08/07
93
Ver 4.1
08/07
DRUG DOSE CALCULATOR
DOSE
CALCULATION
NOTES
50 mg/kg
Dose = Weight x 50
nb: maximum 2 g for Ceftriaxone
& 2.5 g for magnesium
10 mg/kg
Dose = Weight x 10
5 mg/kg
Dose = Weight x 5
4 mg/kg
Dose = Weight x 4
1.5 mg/kg
Dose = Weight x 1.5
1mg/kg
Dose = Weight
1mMol/kg
0.5 mg/kg
0.5 ml/kg
1
Dose = Weight
2
0.25 mg/kg
Dose = Weight
4
0.1 mg/kg
Dose = Weight
10
0.05 mg/kg
Dose = Weight
20
0.01 mg/kg
Dose = Weight
100
94
Ver 4.1
08/07
A.C.T. AMBULANCE SERVICE – MEDICATION CALCULATOR
Wt (kg)
5
10
15
20
25
30
35
40
45
Adenosine 1st dose #
0.5mg
0.5mg
1mg
1mg
1.5mg
1.5mg
2mg
2mg
2.5mg
Adenosine 2nd dose #
0.5mg
1mg
1.5mg
2mg
2.5mg
3mg
3.5mg
4mg
4.5mg
Adrenaline
0.05mg
0.1mg
0.15mg
0.2mg
0.25mg
0.3mg
0.35mg
0.4mg
0.45mg
Amiodarone + output
25mg
50mg
75mg
100mg
125mg
150mg
150mg
150mg
150mg
Amiodarone no output
25mg
50mg
75mg
100mg
125mg
150mg
175mg
200mg
225mg
Atropine
0.05mg
0.1mg
0.15mg
0.2mg
0.25mg
0.3mg
0.35mg
0.4mg
0.45mg
Ceftriaxone & Magnesium
250mg
500mg
750mg
1g
1.25gm
1.5gm
1.75gm
2g
2g
Dextrose 50%
2.5ml
5ml
7.5ml
10ml
12.5ml
15ml
17.5ml
20ml
22.5ml
Frusemide
20mg
20mg
Frusemide + on diuretic
40mg
40mg
DRUG
Hydrocortisone
20mg #
40mg #
60mg #
80mg #
100mg #
120mg #
140mg #
160mg #
180mg #
Midazolam
0.5mg
1mg
1.5mg
2mg
2.5mg
3mg
3.5mg
4mg
4.5mg
Midazolam + morphine, methoxyflurane or
0.25mg
0.5mg
1mg
1mg
1.5mg
1.5mg
2mg
2mg
2.5mg
Morphine
0.5mg
0.5mg
1mg
1mg
1.5mg
1.5mg
2mg
2mg
2.5mg
Naloxone
0.1mg #
0.1mg #
0.2mg #
0.2mg #
0.3mg #
0.3mg #
0.4mg
0.4mg
0.4mg
5ml
7.5ml
10ml
12.5ml
15ml
17.5ml
20ml
22.5ml
15mg
20mg
30mg
40mg
45mg
50mg
60mg
65mg
suxamethonium
Sodium Bicarbonate 8.4%
Suxamethonium
2.5ml
5mg
# = paediatric only.
95
Ver 4.1
08/07
A.C.T. AMBULANCE SERVICE – MEDICATION CALCULATOR
Wt (kg)
DRUG
Adrenaline
50
60
70
80
90
100
110
120
130
0.5mg
0.6mg
0.7mg
0.8mg
0.9mg
1mg
1mg
1mg
1mg
150mg
above
30 kg
300mg
for all
adults
above
50kg
Amiodarone + output
Amiodarone no output
250mg #
275mg #
0.5mg
0.6mg
0.7mg
0.8mg
0.9mg
1mg
1mg
1mg
1mg
2g
2g
2g
2g
2g
2g
2g
2g
2g
Dextrose 50%
25ml
30ml
35ml
40ml
45ml
50ml
55ml *
60ml *
65ml *
Frusemide
25mg
30mg
35mg
40mg
45mg
50mg
55mg
60mg
65mg
Frusemide + on diuretic
50mg
60mg
70mg
80mg
90mg
100mg
110mg *
120mg *
130mg *
Atropine
Ceftriaxone
Hydrocortisone
200mg #
Midazolam
Midazolam + morphine, methoxyflurane
or suxamethonium
Morphine
2 0 0 m g
f o r
a d u l t s
5mg
6mg
7mg
8mg
9mg
10mg
11mg *
12mg *
13mg *
2.5mg
3mg
3.5mg
4mg
4.5mg
5mg
5.5mg *
6mg *
6.5mg *
2.5mg
3mg
3.5mg
4mg
4.5mg
5mg
5.5mg
6mg
6.5mg
2mg
in
5
doses
Naloxone
Sodium Bicarbonate 8.4%
25ml
30ml
35ml
40ml
45ml
50ml
55ml
Suxamethonium
75mg
90mg
100mg
120mg
130mg
150mg
150mg
# = paediatric only.
60ml
150mg
65ml
150mg
* = advisory doses only; rarely need to give more than 100kg dose.
96
Ver 4.1
08/07
DRUG REFERENCE KEY
There have been a significant number of both
additions & deletions from this list since it was last
compiled.
14B = Non Theophylline derivative
14C = Preventative aerosols
15 = Oral contraceptives
16 = Corticosteroids
17 = Diuretic (loop)
18 = Diuretic (potassium sparing)
19 = Diuretic (thiazide)
This listing covers medications that are commonly
prescribed in the community, as well as some that
may only be used in hospital. It is up to date as of
the beginning of 2006.
Every effort has been made to ensure accuracy however, it is possible transcription errors may have
occurred. Care should be taken not to rely totally on
this guide.
20 = Diuretic (thiazide analogue)
21 = Anti gout agents
22 = Histamine 2 antagonist
23 = Antilipid agents
24 = Hypnotics
It does not include street or illicit drugs.
25 = Hypoglycaemic agents
26 = Insulin preparations
27 = Sedatives
28 = Tranquillisers
29 = Vasodilator
Many drugs will have several numbers next to
them, as they are used in different clinical settings,
or may have these effects when taken in overdose.
It does not include antibacterial agents; cytotoxics
or immunomodifying agents. Generally, no drugs
given regularly by injection are included (exception insulins).
There are now a number of generic items on the
market, with the generic name + the company that
produces it as the drug name.
eg. Healthsense Captopril; Diltiazem BC.
The generic firms are:
BC;
Chem Mart;
DBL;
GenRx;
Healthsense;
Terry White Chemists;
1
2
3
4
5
30 = Antihistamines
31 = Analgesics
32 = Antipsychotic
33 = Angiotensin II antagonist
34 = Antiulcerant agents
35 = Benzodiazepine
36 = Migraine prophylaxis and therapy
37 = Anticonvulsant
38 = Bone & Calcium modifying agent
39 = Hormones
40 = Dementia agents
41 = CNS stimulants
42 = Anticholinergic type agents
43 = Glaucoma preparations
= Anabolic steroids
= Antianginal
= ACE inhibitors
= Antiarrhythmics
= Anticoagulants
Product Name
ABILIFY
ACCOLATE
ACCUPRIL
ACCURETIC
ACENORM
ACIMAX
ACLIN
ACT-3
ACTIFED
ACTION
ACTIPROFEN
ACTONEL
ACTOS
ACTRAPID
ADALAT
ADDOS
ADEFIN
AERODIOL
6 = Antidepressants
6A = 5HT uptake inhibitor
6B = MAO inhibitor
6C = Tetracyclic
6D = Tricyclic
7 = Antiemetics
8 = Antihypertensives
9 = Anti-inflamatory - non steroidal
10 = Antiparkinson agents
11 = Antiplatelet agents
12 = Beta blockers
13 = Calcium channel antagonists
14 = Bronchodilators
14A = Theophylline derivative
97
Serial Number
32
14
3,8
3,8
3,8
34
9,31
9,31
30
30
9
38
25
26
2,8,13
2,8,13
2,8
39
Ver 4.1
08/07
Product Name
AERON
AGGRASTAT
AGON SR
AIROMIR
AKINETON
ALDACTONE
ALDAZINE
ALDECIN
ALDOMET
ALEPAM
ALEVE
ALLEGRON
ALLERMAX
ALLOHEXAL
ALLOPURINOL BC
ALLORIN
ALLOSIG
ALODORM
ALPHAGAN
ALPHAPRESS
ALPHAPRIL
ALPRAX
ALPRAZOLAM
ALVESCO
AMARYL
AMFAMOX
AMIZIDE
AMPRACE
AMYTAL
ANAFRANIL
ANAGRAINE
ANAMORPH
ANAPROX
ANATENSOL
ANDRIOL
ANDROCUR
ANDRODERM
ANDRUMIN
ANGELIQ
ANGININE
ANGIOMAXIN
ANPEC
ANSELOL
ANTENEX
ANZEMET
APOVEN
APRESOLINE
APRINOX
ARATAC
ARAVA
AREDIA
ARICEPT
ARIMA
ARIPIPRAZOLE
ARIXTRA
AROPAX
ARSORB
ARTANE
ARTHREXIN
Serial Number
14B
5
2,8,13
14B
10, 42
8,18
28,32
16
8
28,35
9
6D
16
21
21
21
21
24,27,35
43
8,29
3, 8
27,28,35
27,28,35
16
25
22,34
8,18
3,8
24
6D
36
31
9,31,35
28,32
39
39
39
7
39
2,29
5
2,4,8,13
2,4,8,12
27,28,35
7
14B
8,29
8,19
4
9
38
40
6B
32
5
6A
2
10, 34, 42
9,21,31
Product Name
ARTHROTEC 50
ASASANTIN SR
ASIG
ASMOL
ASPALGIN
ASTRIX 100
ATACAND
ATEHEXAL
ATENOLOL BC
ATIVAN
ATROBEL
ATTENTA
AURORIX
AUSCAP
AUSCARD
AUSFAM
AUSGEM
AUSPRIL
AUSRAN
AVANDIA
AVANZA
AVAPRO
AVIL
AVOMINE
AXIT
AZOL
AZOPT
BARBLOC
BECLOFORTE
BECONASE
BECOTIDE
BENADRYL
BENZTROP
BEROTEC
BETAGAN
BETALOC
BETOPIC
BETOQUIN
BICOR
BIPHASIL
BONEFOS
BRENDA 35
BREVIBLOC
BREVINOR
BRICANYL
BROMOHEXAL
BROMOLACTIN
BRONDECON
BRUFEN
BUDAMAX
BUGESIC
BURINEX
BUSCOPAN
BUSPAR
BUTAMOL
CABESAR
CAFERGOT
CALCIJEX
CALCITRIOL
98
Serial Number
9
11, 5
3,8
14B
31
11, 5
33, 8
2,4, 8,12
2, 4, 8, 12
27,28,35
42
41
6B
6A
2,13
22, 34
23
3, 8
34
25
6
8,33
30
7
6A
39
43
2,4, 8,12
14C,16
16
14C,16
30
10,42
14B
43
2,4,8,12,36
43
43
12
15
38
15,39
4,12
15
14B
10
10
14A
9,31
16
9
17
42
28
14B
10
36
38
38
Ver 4.1
08/07
Product Name
CANDYL
CAPADEX
CAPOTEN
CAPTOHEXAL
CAPTOPRIL BC
CAPURATE
CARAFATE
CARBAMAZEPINE
CARDINORM
CARDIPRIN
CARDIZEM
CARDOL
CARTIA
CATAPRES
CELEBREX
CELESTONE
CELPRAM
CHLORPROMAZINE
CIALIS
CIMEHEXAL
CIMETIDINE BC
CIPRAMIL
CITRACAL
CITRIHEXAL
CLARAMAX
CLARATYNE
CLARINASE
CLEXANE
CLIMARA
CLIMEN
CLINORIL
CLOBEMIX
CLOMIPRAMINE
CLONAC
CLOPINE
CLOPIXOL
CLOPRAM
CLOZARIL
CODALGIN
CODAPANE
CODIPHEN
CODIS
CODOX
CODRAL FORTE
COGENTIN
COGNEX
COLESTID
COLGOUT
COMBIGAN
COMBIVENT
COMTAN
CONCORZ
CORAS
CORBETON
CORDARONE
CORDILOX
CORTATE
COSOPT
COUMADIN
Serial Number
9,31
31
3,8
3,8
3,8
21
34
32,37
4
11, 5
2,8,13
4,12
11, 5
8,36
9
16
6A
32,42
29
22,34
22, 34
6A
38
38
30
30
30
5
39
39
9,31
6B
6D
9
32
32
6D
32
31
31
31
31
31
31
10, 42
40
23
21
43
14B
10
6A
2,13
2,4,8,12
4
2,4,8,13
16
43
5
Product Name
COVERSYL
COZAAR
CROMESE
CRYSANAL
CYPRONE
CYPROSTAT
CYTOTEC
DANOCRINE
DAONIL
DAPA-TABS
MOCLOBEMIDE
DECA-DURABOLIN
DECANOATE
DEMAZIN
DEPO MEDROL
DEPO NISOLONE
DEPO PROVERA
DEPO RALOVERA
DEPTRAN
DERALIN
DERMESTRIL
DESERIL
DEXAMPHETAMINE
DEXAMETHSON
DIABEX
DIAFORMIN
DIAMICRON
DIAMOX
DIANE
DIAPRIDE
DIAZEPAM
DIBENYLINE
DICLOFENAC
DICLOHEXAL
DIDROCAL
DIDRONEL
DIGESIC
DIHYDERGOT
DILANTIN
DILATREND
DILAUDID
DILOSYN
DILTAHEXAL
DILTIAZEM BC
DILZEM
DIMETAPP
DIMIREL
DIMETRIOSE
DINAC
DINDEVAN
DITHIAZIDE
DITROPAN
DOLASED
DOLOBID
DOLAFORTE
DOLOXENE
DONNALIX
DONNATAB
DOTHEP
99
Serial Number
3,8
8,33
14C
9
39
39
34
39
25
8
6B
1
32
30
16
16
15
15
6D
2,4,8,12,36
39
36
41
16
25
25
25
37, 43
15, 39
25
35
29
9
9,31
38
38
31
36
37
12, 8
31
30
2,13
2, 13
2,13
30
25
39
9
5
19
42
31
9,31
31
31
42
7, 42
6D
Ver 4.1
08/07
Product Name
DOZILE
DRAMAMINE
DROLEPTAN
DUCENE
DUPHASTON
DURIDE
DUROGESIC
DURO-TOSS
DYMADON
DYNASTAT
EDRONAX
ECOTRIN
EFEXOR
ELDEPRYL
ELEMENDOS
ELEVA
ELMIRON
EMEND
ENAHEXAL
ENALAPRIL
ENDECRIN
ENDEP
ENDONE
ENIDIN
EPAC
EPHIDRINE HYDROC.
EPILIM
ERGODRYL
ESTALIS
ESTELLE 35 ED
ESTRACOMBI
ESTRADERM
ESTROFEM
EUTROXSIG
EVISTA
EXELON
FAMOHEXAL
FAMOTIDINE
FAVERIN
FEBRIDOL
FELDENE
FELODUR
FEMODEN
FEMOSTON
FEMTRAN
FENAC
FENAMINE
FEXO-TABS
FIBSOL
FIORINAL
FLECATAB
FLIXOTIDE
FLORINEF
FLUANXOL
FLUOHEXAL
FLUOXETINE BC
FLUOXETINE DBL
FORADILE
FORMET
Serial Number
27
7
32
27,28,35
39
2
31
30
31
9
6A
5,11,31
6A
10
37
6A
5
7
3, 8
3, 8
17
6D
31
43
14B
14B
32,37
36
39
39
39
39
39
39
38
40
34
34
6A
31
9,31
8,13
15
39
39
9,31
30
30
3, 8
31
4
14C16
16
32
6A
6A
6A
14B,14C
25
Product Name
FORTEO
FORTRAL
FOSAMAX
FRAGMIN
FRISIUM
FRUSEHEXAL
FRUSID
GABAHEXAL
GABAPENTIN
GABITRIL
GANTIN
GEMFIBROZIL BC
GEMHEXAL
GEMIFIBROMAX
GENORAL
GENOTROPIN
GENOX
GLIMEL
GLUCOBAY
GLUCOHEXAL
GLUCOMET
GLUCOPHAGE
GLYADE
GOPTEN
HALCION
HALDOL
HELIDAC
HEMINEURIN
HEPARIN
HEXAL DILAC
HUMALOG
HUMANOTROPE
HUMULIN
HYDOPA
HYDRENE
HYDROCORTISONE
HYGROTON
HYPNODORM
HYPURIN ISOPHANE
HYPURIN NEUTRAL
HYSONE
HYTRIN
IBUPROFEN
IKOREL
IMDUR DURULES
IMFLAC
IMIGRAN
IMPROVIL
IMOVANE
IMTRATE SR
INDAHEXAL
INDAPAMIDE
INDERAL
INDOCID
INSIG
INSOMN
INTAL
INZA
IOPIDINE
100
Serial Number
38,39
31
38
5
27,28,35
17
17
37
37
37
37
23
23
23
39
39
39
25
25
25
25
25
25
3,8
35
32
34
24,27
5
9
26
39
26
8
8,18,19
16
8,20
24,27,35
26
26
16
8
9
2
2
9
36
15
24, 27
2
8
8
2,4,8,12,36
9,21,31
8
24,27
14C
9,31
43
Ver 4.1
08/07
Product Name
IPRATRIN
IPRAVENT
ISCOVER
ISMELIN
ISOMONIT
ISOPTIN
ISOPTO CARBACHOL
ISOPTO CARPINE
ISORDIL
ISOSORBIDE MON.
JEZIL
JULIET 35
KALMA
KALURIL
KAPANOL
KARVEA
KARVEZIDE
KEPPRA
KINIDIN DURULES
KINSON
KLACID
KLIOGEST
KLIOVANCE
KONAKION
KOSTEO
KREDEX
KRIPTON
KWELLS
KYTRIL
LAMICTAL
LAMOGINE
LAMOTRIGINE
LANOXIN
LANTUS
LARGACTIL
LASIX
LEGOUT
LESCOL
LEVLEN ED
LEXAPRO
LEXOTAN
LIPAZIL
LIPEX
LIPIDIL
LIPITOR
LIPRACE
LIQUIGESIC CO
LISINOPRIL
LISODUR
LITHICARB
LIVIAL
LOCILAN
LOETTE
LOGICIN
LOGYNON
LONAVAR
LONITEN
LOPID
LOPRESOR
Serial Number
14B
14B
11, 5
29,31
2, 29
2,4,8,13
43
43
2,29
2
23
15, 39
27,28,35
8,18
31
8,33
8,33
37
4
10
34
39
39
5
38
8,12
10
7, 42
7
37
37
37
4
26
7,28,32, 40
8,17
21
23
15
6A
27,28,35
23
23
23
23
3,8
31
3,8
3,8
32
39
15
15
30
15
1
8
23
2,4,8,12,36
Product Name
LORASTYNE
LOSEC
LOVAN
LUMIGAN
LUMIN
LURSELLE
LUVOX
LYCINATE
MADOPAR
MAGICUL
MAOSIG
MAREVAN
MARVELON
MAXOLON
MAXOR
MEFIC
MEGACE
MELIPRAMINE
MELIZIDE
MELLERIL
MENOREST
MEPRAZOL
MERBENTYL
MERSYNDOL
METAMAX
METFORMIN BC
METHYLPHENIDATE
METOCLOPRAMIDE
METOHEXAL
METOPROLOL BC
MEXITIL
MIACALCIC
MICARDIS
MICROGYNON
MICROLUT
MICRONOR
MICROVAL
MIDAMOR
MINAX
MINIDIAB
MINIMS PILOCARP.
MINIPRESS
MINITRAN
MINULET
MIRENA
MIRTAZON
MIXTARD
MOBIC
MOBILIS
MODAVIGIL
MODECATE
MODURETIC
MOGADON
MOHEXAL
MONODUR DURULES
MONOFEME
MONOPLUS
MONOPREM
MONOPRIL
101
Serial Number
30
34
6A
43
6C
23
6A
2
10
22, 34
6B
5
15
7
34
9,31
39
6D
25
28,32
39
34
42
31
36
25
41
7
2,4,8,12,36
2,4,8,12,36
4
38
8,33
15
15
15
15
8,18
2,4,8,12,36
25
43
8
2,29
15
15, 39
6B
26
9
9,31
41
28,32
8,18,19
24,27,35
6B
2
15
3,8
39
3,8
Ver 4.1
08/07
Product Name
MONOTARD
MORPHALGIN
MOTILIUM
MOVELAT
MOVOX
MS CONTIN
MS MONO
MURELAX
MYSOLINE
NAPAMIDE
NAPROGESIC
NAPROSYN
NARAMIG
NARDIL
NASONEX
NATRILIX
NAVANE
NAVOBAN
NEO-MERCAZOLE
NEO-SYNEPHRINE
NEULACTIL
NEUTRAL PILOCARP.
NEURONTIN
NEXIUM
NICOTINIC ACID
NIDEM
NIFECARD
NIFEDIPINE BC
NIFEHEXAL
NIMOTOP
NITRO-DUR
NITROLINGUAL
NIZAC
NORDETTE
NORDITROPIN
NORFLEX
NORGESIC
NORIDAY
NORIMIN
NORINYL
NORMISON
NORVASC
NOTEN
NOVARAP
NOVNORM
NOVONORM
NOVOMIX
NOVORAPID
NUELIN
NUPENTIN
NUROFEN
NUROLASTS
NYEFAX
ODRIK
OGEN
OMEPRAL
OMNITROPE
OPTIMOL
ORAP
Serial Number
26
31
7
9
6B
31
31
27,28,35
37
8
9,31,36
9,31,36
36
6B
16
8
32
7
39
43
28,32
43
37
34
23
25
8,13
8,13
8,13
13
2,29
2,29
22,34
15
39
43
43
15
15
15
24,27,35
2,8,13
2,4,8,12
26
25
25
26
26
14A
37
9,31
9,31
8,13
3,8
39
34
39
43
28,32
Product Name
Serial Number
ORAP
28,32
ORGARAN
5
OROXINE
39
ORUDIS
9,31
ORUVAIL SR
9,31
OSPOLOT
37
OVESTIN
39
OXANDRIN
1
OXETINE
6A
OXIS
14B,14C
OXYCONTIN
31
OXYNORM
31
PAINSTOP
31
PALFIUM
31
PAMISOL
38
PANACORT
16
PANAFCORTELONE 16
PANAFEN PLUS
9
PANALGESIC
31
PANAMAX
31
PARACODIN
31
PARADEX
31
PARAHEXAL
31
PARALGIN
31
PARIET
34
PARLODEL
10
PARNATE
6B
PAXAM
35,37
PAXTINE
6A
PEETALIX
30
PENDINE
37
PEPCID
22,34
PEPCIDINE
22,34
PEPZAN
34
PERIACTIN
30,36
PERMAX
10
PERSANTIN
5,11,29
PEXSIG
2
PHENOBARBITONE 37
PHENERGAN
7,27,30
PHOSPHATE-SANDOZ 38
PHYSEPTONE
31
PILOCARPINE
43
PILOPT
43
PROPINE
43
PIROHEXAL
9,31
PIROXICAM
9
PLACIL
6D
PLAVIX
5,11
PLENDIL
8,13
POLARAMINE
30
PONSTAN
9,31
PRAMIN
7
PRASIG
8
PRATSIOL
8
PRAVACHOL
23
PRAZOHEXAL
8
PRAZOSIN BC
8
PREDMIX
16
102
Ver 4.1
08/07
Product Name
PREDSOLONE
PREGNYL
NYOGEL
PREMARIN
PREMIA 5
PRESOLOL
PRESSIN
PREXIGE
PRIMOBOLAN
PRIMOLUT
PRINIVIL
PRITOR
PROCID
PRO-BANTHINE
PROCUR
PRODEINE
PROGOUT
PROGYNOVA
PROLODONE
PROMETHAZINE
PRONESTYL
PROPYLTHIOURACIL
PROTAPHANE
PROTHIADEN
PROVERA
PROVEN
PROVIRON
PROXEN
PROZAC
PULMICORT
P.V. CARPINE
QUESTRAN LITE
QUILONUM SR
QVAR
RAFEN
RALOVERA
RAMACE
RANI
RANIHEXAL
RANITIDINE DBL
RANOXYL
REDIPRED
REFLUDAN
REGITINE
REMERON
REMINYL
RENITEC
REOPRO
RESPOCORT
RESTAVIT
RHINOCORT
RISPERDAL
RITALIN
RITHMIK
RIVOTRIL
ROCALTROL
ROSIG
RUBESAL
RYTHMODAN
Serial Number
16
39
43
39
39
8,12
8
31
1
39
3,8
8, 33
21
42
39
31
21
39
31
30
4
39
26
6D
39
9,31
39
9,31
6A
14C,16
43
23
32
14C,16
9,31
39
3,8
22,34
34
22,34
34
16
5
29
6A
40
3,8
5
16
27
16
32, 40
41
4
37
38
9,31
9
4
103
Product Name
SABRIL
SAIZEN
SANDOMIGRAN
SANDRENA
SEAZE
SELGENE
SEQUILAR ED
SERC
SERENACE
SEREPAX
SERETIDE
Serial Number
37
39
36
39
37
10
15
29,30
7,28,32
27,28,35
14B,14C
SEREVENT
SEROQUEL
SERTRALINE
SETACOL
SETAMOL
SIGMAXIN
SIGMETADINE
SIMVABELL
SIMVAHEXAL
SIMVAR
SIMVASTIN
SINEASE
SINEMET
SINEQUAN
SINGULAIR
SITRIOL
SKELID
SNUZAID
SODIUM OIDIDE
SOLAVERT
SOLIAN
SOLONE
SOLPRIN
SOMAC
SONE
SORBIDIN
SOTACOR
SOTAHEXAL
SOTALOL BC
SPIRACTIN
SPIRIVA
SPREN
STALEVO
STELAZINE
STEMETIL
STEMZINE
STILNOX
SURGAM
SURMONTIL
SUVULAN
SYMBICORT
SYMMETREL
SYNAREL
SYNPHASIC
TAGAMET
TALAM
TALOHEXAL
14B,14C
32
6A
42
31
4
22,34
23
23
23
23
30
10
6D
14
38
38
27
39
4, 12
32
16
5,11,31
34
16
2,29
4,12
4,12
4, 12
8,18
14C
11,31
10
7,28,32
7,32
7,32
24
9,31
6D
36
14C
10
39
15
22,34
6A
6A
Ver 4.1
08/07
Product Name
TAMBOCOR
TAZAC
TEGRETOL
TELFAST
TELNASE
TEMAZE
TEMGESIC
TEMTABS
TENOPT
TENORMIN
TENSIG
TENUATE
TERIL
TERTROXIN
TETRABENAZINE
TEVETEN
THEO-DUR
TICLID
TICLOPIDINE HEXAL
TILCOTIL
TILODENE
TIMOPTOL
TIMPILO
TOFRANIL
TOLVON
TOPACE
TOPAMAX
TOPROL
TORADOL
TRAMAL
TRANDATE
TRANSIDERM-NITRO
TRAVACALM
TRAVATAN
TRENTAL 400
TRI PROFEN
TRIFEME
TRILEPTAL
TRIPHASIL
TRIQUILAR
TRISEQUENS
TRITACE
TRUSOPT
TRYPTANOL
TYLENOL
ULCYTE
ULTRATARD
UNISOM
UREMIDE
UREX
VALIUM
VALLERGAN
VALPAM
VALPRO
VASOCARDOL CD
VASTIN
VEGANIN
VERACAPS
VIAGRA
Serial Number
4
22,34
32,37
30
16
24,27,35
31
24.27,35
43
2,4,8,12
2,4,8,12
45
32,37
39
43
8, 33
14
5,11
5,11
9
5,11
43
43
6D
6C
3, 8
35,37
12
9
31
8,12
2,29
7,42
43
11
9,31
15
37
15
15
39
3,8
43
6D
31
34
26
24,27
8,17
8,17
27,28,35
27,30
35
32,37
2,8,13, 33
23
31
2,8,13
29
Product Name
VIOXX
VISKEN
VOLTAREN
VYTORIN
XALACOM
XALATAN
XANAX
XYDEP
ZACTIN
ZADINE
ZANIDIP
ZANTAC
ZARONTIN
ZESTRIL
ZOCOR
ZOFRAN
ZOLOFT
ZOMIG
ZOTON
ZUMENON
ZYLOPRIM
ZYDOL
ZYPREXA
ZYRTEC
104
Serial Number
9
2,4,8,12
9,31
23
43
43
27,28,35
6A
6A
30
8, 13
22,34
37
3,8
23
7
6A
36
34
39
21
31
32
30
Ver 4.1
08/07
PATIENT ASSESSMENT
GENERAL APPROACH AND TREATMENT
Initial
Assessment
Danger
Response
Initial
Treatment
Alert. Voice. Pain.
Unconscious.
Secondary
Assessment
Secondary
Treatment
Formal GCS
Airway +
Cervical spine
care
Chin lift; head tilt;
jaw thrust.
Hold head still.
Suction; clear
airway.
Oral / nasal airway
Breathing
Look,
Listen,
Feel.
I.P.P.V.
Oxygen
Resp rate.
Pulse oximetry.
Breath sounds.
Pleural
decompression.
Stabilise flail
segment.
Circulation
Bleeding control.
Central pulse.
Skin signs
Cardiac
compressions
E.C.G. Monitor
D.C.C.S.
Cannula
Pulse rate.
B. P.
Analyse E.C.G.
I.V. Fluids
MAST
History
Of
event Patient.
Bystanders
Utilise bystanders
Full history.
Expose injuries.
Obtain
medications
Bring relatives
along.
B.G.L.
Formal drug
therapy.
Prepare for
transport.
Transport.
Notify hospital
Drugs
Transport
Call backup if
required.
Assess time critical
105
E.T.T.
Cx collar; KED
Board / scoop.
Ver 4.1
08/07
TIME CRITICAL PATIENT GUIDELINE
The following patients can be considered actually or potentially Time Critical. This
requires a minimum scene time, treatment en-route wherever possible, & prompt
transport to a designated Trauma Centre for trauma patients. This is a guideline
only, and does not represent a complete and exclusive list of time critical patients.
1:
TRAUMA PATIENTS
Vital signs (adults) [Actual time critical indicators]
Respiratory distress (rate > 29, or < 10 / minute) , or
altered L.O.C. (GCS < 13), or
hypotensive (sys BP < 90), and/or
revised trauma score < 12
Pattern of injury:
[Actual time critical indicators]
Penetrating injury – head; neck; torso; axilla, groin
Amputation above wrist or ankle
Fractures to 2 or more proximal long bones, or fractured pelvis
Suspected crush syndrome
Paralysis or significant weakness of limbs
“Significant” injury to single body region (eg, head, abdomen, chest)
or “lesser” injuries to 2 or more body regions
Burns - > 10% body surface; “special” areas (eg eyes, genitals);
Or respiratory tract involvement
106
Ver 4.1
08/07
Mechanism of injury: [Potential time critical indicators]
Motor vehicle
- high speed (> 60 kph), with significant intrusion into
passenger compartment
- rollover
- patient ejected from vehicle
- death / serious injury of another occupant
(- trapped, with actual extrication time > 20 minutes.)
Pedestrian
struck by a vehicle at > 30 kph
Pedal /
motorcyclist
impact speed > 30 kph
Other
2:
Fall > Twice patient height
Struck by object falling > 5 m (related to weight of object)
Explosion / blast
OTHER PATIENTS
chest pain suggestive of ischaemia
stroke
unrelieved upper airway obstruction
acute hypoxia,
unresponsive to treatment
aortic aneurysm or dissection
deteriorating L.O.C. (any cause)
worsening hypotension (any cause)
heatstroke or significant hypothermia
significant arrhythmias,
prolapsed umbilical cord or
complicated labour
generalised seizures,
carbon monoxide poisoning with
decreased L.O.C.
Cardiac arrest in advanced pregnancy (gestation > 20/52)
Modifying factors for all time critical patients:
- age < 5 yrs or > 60 yrs
- previous medical condition
- lack of response to current treatment.
107
Ver 4.1
08/07
GUIDELINES FOR THE RESUSCITATION OF ADULT AGONAL
TRAUMA PATIENTS
An Agonal trauma patient is described as a patient who presents on scene without cardiac
output, and there is some evidence that this has been for a short time only, (eg. witness
information; short response time; arrest in ambulance care).
It is acknowledged that the history of loss of cardiac output can be unreliable.
It is also assumed that there are no obvious, non-survivable injuries.
Be wary of situations where a cardiac event may have preceded the trauma event.
BLUNT TRAUMA
PENETRATING TRAUMA
1: Establish no cardiac output
1: Establish no cardiac output
•
If there are other patients on scene
with serious injuries & if there are not
sufficient resources to deal with all
patients, the agonal blunt trauma
patient is to be triaged out.
•
If there are other patients on scene
with serious injuries & if there are not
sufficient resources to deal with all
patients, the agonal penetrating
trauma patient is to be triaged out.
•
If other patients have minor injuries
or there are no other patients, then
the agonal trauma patient is to be
managed in the following manner.
•
If other patients have minor injuries
or there are no other patients, then
the agonal trauma patient is to be
managed in the following manner.
2: Determine if cardiac death has
occurred.
2: Determine if cardiac death has
occurred.
•
Monitor patient with leads.
•
Monitor patient with leads.
•
If a narrow complex electrical activity
with heart rate greater than 20 is
observed then cardiac death has not
occurred and attempts to resuscitate
the patient should be considered.
•
If a narrow complex electrical activity
with heart rate greater than 20 is
observed then cardiac death has not
occurred and attempts to resuscitate
the patient should be attempted.
•
If slow, wide complex rhythm, or
asystole, consider no resuscitation.
•
If slow, wide complex rhythm, or
asystole, consider resuscitation
3: Resuscitate rapidly (if possible
simultaneous procedures):
•
•
3: Resuscitate rapidly if possible
simultaneous procedures):
Cannulate; rapid infusion of greater
than 2 litres of crystalloid. (pump set)
•
108
Cannulate; rapid infusion of greater
than 2 litres of crystalloid. (pump set)
Ver 4.1
08/07
•
Secure definitive airway – ETT / LMA
Aggressive oxygenation
•
Secure definitive airway – ETT / LMA.
Aggressive oxygenation
•
If any doubt about air entry - chest
decompression with a large bore
cannula into the mid clavicular line
2nd intercostal space on affected
side/s.
•
If penetrating injury under the suit,
use PASG.
•
If chest penetration + any doubt
about air entry - chest decompression
with a large bore cannula into the mid
clavicular line 2nd intercostal space.
P
P
P
•
•
Drugs
4: If at this point no restoration of
cardiac output has occurred,
cessation of resuscitation should
be seriously considered.
P
Drugs
4: Facilitate urgent transport to
trauma centre. Ensure notification.
Agonal blunt trauma patients should not
generally be transported if active CPR
needs to be performed en route. The
likelihood that these patients will survive
from this point is effectively nil.
Transport of these patients may not be in
the best interest of staff and the community.
•
Continue active resuscitation.
•
If more than 15 minutes transport
time from trauma centre, go to
closest hospital.
•
If cardiac output restored, continue to
trauma centre.
Agonal penetrating trauma patients may be
considered for transport, as survival is
possible.
Exceptions:
- close to trauma centre.
- paramedic clinical judgement.
Exceptions:
- penetrating wounds to the head are to be
treated as for blunt agonal trauma.
- if more than 15 minutes transport time from
any hospital, & no cardiac output regained,
consider ceasing resuscitation.
- paramedic clinical judgement.
109
Ver 4.1
08/07
APGAR SCORE
SCORE
0
1
2
Colour
Blue / pale
Pink:
Extremities blue
Completely pink
Respiration
Absent
Slow: irregular
Good; crying
Heart Rate
Absent
Below 100
Above 100
Muscle Tone
Limp
Some flexion of extremities
Active motion
Reflex Irritability
No response
Grimace
Vigorous cry, cough,
sneeze
Assess Apgar at 1 & 5 minutes
110
Ver 4.1
08/07
A.C.T. AMBULANCE SERVICE - PAEDIATRIC REFERENCE CARD
Age
Weight
(kg)
Resps
Heart
Rate
Syst
BP
E.T.T.
size (mm)
Neonate
6 months
12 months
2 years
4 years
6 years
8 years
10 years
12 years
3.5
7
11
13
17
21
25
30
36
30 – 60
25 – 40
20 - 40
20 – 35
20 – 30
15 – 25
15 – 25
14 – 20
14 - 20
90 – 150
100 – 175
90 – 170
85 – 140
80 – 140
70 – 120
70 – 110
60 – 110
60 - 100
50 – 70
60 – 100
60 – 100
70 – 110
70 – 110
60 – 110
60 – 115
60 – 120
65 - 120
3
3.5
4
4.5
5
5.5
6
6.5
7
E.T.T.
Length
(cm)
14
14
14
14
16
17
19
20
21
Fluid
10ml / kg
Defib
2 j/ kg
Defib
4 j/ kg
35
70
110
130
160
200
250
280
380
5
20
20
30
30
50
50
50
100
20
30
50
50
50
100
100
100
150
All values are approximate only
Weight formula
Age < 9 years:
Age > 9 years
E.T.T. Size:
Age
Approx weight (kg) = (Age x 2) + 9
Approx weight (kg) = Age x 3
/4 + 4 = diameter in mm
Fluid resuscitation
10 ml / kg bolus - N/Saline
Thereafter – N/Saline bolus
DO NOT use pump set in children under 15 kg - use 3-way tap and syringe
Defibrillation
Rounded off to closest energy setting
References
- Paediatric Fluid Reference Card – Children’s Hospital of Pittsburgh
- Drug Doses in Paediatrics – Royal Children’s Hospital – Melbourne
111
Ver 4.1
08/07
PEEP VALUES
2.5 cm
5 cm
10 cm
15 cm
Infants (< 2 years age)
(minimum & maximum)
Cardiac arrest
Children >2 (min & max)
Intubated patients (not if suspected
Next level for:
- pulmonary oedema
- near drowning
- CO poisoning
- asthma (max)
- CAL (max)
Final level for:
- pulmonary oedema
- near drowning
- CO poisoning
raised ICP, and if sats > 90%)
Start level for:
- pulmonary oedema
- near drowning
- CO poisoning
- asthma
- CAL
only if still desaturated with
10cm.
if not responding to 5cm
112
Ver 4.1
08/07
ACT AMBULANCE SERVICE
SPINAL IMMOBILISATION CLEARANCE FLOWCHART
P
1: Patient mentation
Decreased level of consciousness?
No
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
Alcohol / drug impairment?
No
Loss of consciousness involved?
No
2: Subjective assessment
▪ Cervical
▪ Thoracic
No
▪
Numbness / tingling / weakness /
No
3: Objective assessment
▪ Cervical
▪ Lumbar spinal pain ?
No
Immobilise
burning sensation?
▪
▪ Thoracic
Yes ⇒⇒⇒⇒⇒⇒⇒
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
▪ Lumbar spinal tenderness ?
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
▪
Yes ⇒⇒⇒⇒⇒⇒⇒
Immobilise
Other painful injury or significant
distraction?
No
Pain with spine range of motion? #
P
No
P
MAY TRANSPORT WITHOUT SPINAL IMMOBILISATION
# Range of motion is only to be checked if all other criteria are negative!
NB: - Exercise care if a patient is seen very soon after the event.
- Recheck patient before clearing if not transporting.
- Your clinical judgement may be exercised to still utilise spinal immobilisation, even if the
algorithm clears the patient.
Pre-existing spinal disease and older age should increase the level of suspicion even with a clear process.
113
Ver 4.1
08/07
Spinal Cord Injury
It is vital to carry out motor and sensory examinations as the patient may have
motor damage without sensory damage and vice versa.
Sensory Examination
The level at which sensation is altered or absent is the level of injury.
Examine the patient with light touch and response to pain. Use the forehead as a
guide to what is normal sensation. When conducting the examination ensure you
check both upper limbs and hands and both lower limbs and feet.
T4 examination must be carried out in the mid-axillary line and not the midclavicular line as C2, C3 and C4 all provide sensation to the nipple line.
Motor Examination
Upper limb motor examination
1.
2.
3.
4.
Lower limb motor examination
Shrug shoulders C4
Bend the elbow C5
Push wrist back C6
Open/close hands C8
Flex hip
Extend knee
Pull foot up
Push foot down
L1 & L2
L3
L4
L5 & S1
For thoracic and abdominal motor examination look for activity of intercostal and
abdominal muscles.
Diagnosis of spinal cord injury in the unconscious patient
1. Look for diaphragmatic respiration. A quadriplegic has lost intercostal
muscles and relies on the diaphragm to breathe.
2. Flaccid limbs.
3. Loss of response to painful stimuli below the level of the lesion.
4. Loss of reflexes below the level of the lesion.
5. Erection in the unconscious male.
6. Low BP (Systolic less than 100) associated with a normal pulse or
bradycardia indicates that the patient MAY be a quadriplegic.
114
Ver 4.1
08/07
DIFERENTIATION OF WIDE COMPLEX TACHYCARDIAS.
The more of these present, greater the chance of VT.
If in doubt, treat as VT, especially if sick.
1: History of - Ischaemic heart disease
- Cardiac failure
- Cardiomyopathy
+ Increasing age.
2: Atrio-ventricular dissociation
3: Capture beats or fusion beats
4: Very wide QRS (> 0.14secs).
5: Bizarre or extreme axis = VT (a positive complex in AVR
strongly supports this).
6: Negative concordance across chest leads = VT
Positive concordance tends towards VT.
Non-concordance = 50:50.
7: V1
- monophasic R, or biphasic RS
- taller left (initial) peak on “rabbits ears” = VT;
- if second peak is taller = 50:50
- “fat” initial R wave (0.04 secs or >) lean towards VT.
8: V6 - monophasic QS or
- biphasic QR
- suggests VT.
9: Triphasic V1 & V6 = < 10% VT.
115
Ver 4.1
08/07
116
Ver 4.1
08/07
MAXIMUM Q – T INTERVALS
Heart Rate (per min)
300
250
214
187
166
150
136
125
115
107
100
93
88
83
78
75
71
68
65
62
60
57
55
52
51
50
48
46
45
43
42
41
40
39
38
37
36
35
34
33
32
31
30
Maximum Q-T Interval (sec)
(Females)
(Males)
.19
.21
.22
.24
.25
.27
.28
.29
.30
.31
.33
.34
.35
.36
.37
.38
.38
.39
.40
.41
.42
.43
.44
.44
.45
.46
.47
.48
.48
.49
.50
.50
.51
.52
.52
.53
.54
.55
.56
.56
.58
.58
.59
.19
.21
.23
.24
.26
.27
.29
.30
.31
.32
.33
.34
.35
.36
.37
.38
.39
.40
.41
.42
.43
.44
.45
.46
.46
.47
.48
.49
.49
.50
.51
.52
.52
.53
.54
.54
.55
.56
.57
.58
.59
.60
.61
117
Ver 4.1
08/07
12 Lead Placements
118
Ver 4.1
08/07
Acute Myocardial Infarction
ST elevation >1mthe limb leads and >2mm in the V leads in >2 consecutive
leads
•Myocardial injury presents as raised ST
•Commonly this is an acute ischaemic injury.
•Significant ST elevation >1mm in the limb leads and >2mm in the V leads
in >2 contiguous leads
•Infarction can present as pathological Q wave (older sign of full
thickness infarction - >= .04 wide; deeper than 25% of height of R
wave).
•Infarction may also present with T wave changes
inverted
large, “hyperacute”.
•ST depression may indicate myocardia ischaemia; occasionally myocardial
infarction.
•ECG changes + reliable or suspicious clinical story may indicate
myocardial ischaemia/infarction.
I
Lateral
aVR
V1 Septal
V4 Anterior
II Inferior
AVL Lateral
V2 Septal
V5 Lateral
III Inferior
AVF Inferior
V3 Anterior
V6 Lateral
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INFARCTION OVERVIEW
Site
Indicative Leads
Inferior
II, III, aVF
Septal
V1 - V2
Anterior
V3 – V4
Antero-septal
V1 – V4
Lateral
I, aVL, V6 (V5)
Antero-lateral
I, aVL, V3 – V6
R ventricular
V3R, V4R, (V1)
(usually seen with inferior changes)
Posterior
“Reciprocal” changes in anterior leads.
V8, V9. May be seen with inferior or
lateral changes.
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INFERIOR AMI
121
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ANTERO-SEPTAL AMI
122
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ANTERO-LATERAL AMI
123
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LATERAL AMI
124
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RIGHT BUNDLE BRANCH BLOCK
125
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LEFT BUNDLE BRANCH BLOCK
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CAPNOGRAPHY
USES OF CAPNOGRAPHY (ACTAS)
- Verify initial position of ETT
- Monitor continuing tracheal position of ETT.
- Assist in assessment of adequacy of chest compressions.
- Assist with confirmation of ROSC.
- Aid in determination of cessation of resuscitation efforts.
- Monitor effective IPPV in patients with critical CO2 requirements.
B
B
MONITORING PROCEDURE
Open CO2 connector door, connect Microstream tubing by turning clockwise.
(The monitor will sense the presence of the tubing and activate the ETCO2 function
automatically. Self-test, auto-zeroing and warm up may take up to 2 ½ minutes.)
B
B
B
B
B
B
- Connect the tubing to the patient
(Proximal to bacterial filter is preferred.)
- Display ETCO2 waveform on Channel 3.
B
B
B
B
- Adjust scale if required.
(Monitor is configured to “Autoscale”. This means that the monitor will over-select
the scale based on the measured ETCO2 measurement.)
B
B
B
B
The ETCO2 is displayed in mmHg. A respiratory rate is also displayed.
(No respiratory rate is displayed if the ETCO2 is less than 8mmHg. The waveform is
still valid.)
B
B
B
B
B
B
B
B
NOTE: Rapid altitude changes may cause the machine to attempt to purge the
tubing. If this occurs, disconnect the tubing briefly from the monitor, then reconnect.
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INTERPRETATION OF RESULTS
It is important to utilise the waveform to assist in interpretation of information, not
just relying on the numerical reading.
NOTE: PACO2 is generally 3 mmHg higher than ETCO2.
B
B
B
B
B
B
B
B
Critical values in critical patients:
Cardiac arrest: ETCO2 consistently above 15 mmHg seems to have some
positive correlation with ROSC.
B
B
B
B
Patients with acute intracranial pathology:
PA CO2 should be in range of 30 – 45 mmHg ∴
ETCO2 should be in range of 27 – 40 mmHg.
B
B
B
B
B
B
B
B
Documenting Results
Serial ETCO2 readings may be recorded in the appropriate section of the ACTAS PCR.
B
B
B
B
Waveform printouts (important for verification of ETT placement) may be attached to the
PCR from either a screen print or the code summary.
ETCO2 values will be included in the vital signs summary printout for later reference.
B
B
B
B
128
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Wave Forms
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RESPIRATORY STATUS ASSESSMENT
NORMAL
(#) RESPIRATORY DISTRESS
General
appearance
Calm, quiet, not anxious
Distressed, anxious, obviously fighting for breath,
exhausted. Decreased level of consciousness
Speech
Normal sentences, with no
difficulty.
Short sentences → phrases → words only →
none.
Respiratory Noises
Quiet, no noises.
Cough
Audible wheeze on exhalation;
“Crackly” moist sounds;
Inspiratory strider.
Chest auscultation
Quiet, no wheezes or
crackles
Wheeze: expiratory; occ inspiratory as well
Crackles fine → coarse;
bases → mid zone → full field
Silent chest – one side, or bilateral
Respiratory rate
Adults: 12 - 16 / minute
Kids: 15 – 25 / minute
Babies: 20 – 40 / minute
Tachypnoea - adults > 24 / min
- kids > 35 / min
- babies > 50 / min
Respiratory effort
Minimal apparent effort;
small chest / abdo
movement
Marked chest / abdo movement; use of accessory
muscles; intercostal recession; sternal retraction;
tracheal tug.
(NB - chest movement may be minimal with some
conditions)
Pulse rate
Adults: 60 - 80 / min
Kids: 80 –120
Babies: 100 - 140
(*)Tachycardia - adults > 100 / min
- kids > 130
- babies > 150
(heard without a
stethoscope)
(NB slow pulse rate late sign in severe cases)
Skin
Pink; normal.
Sweaty; sometimes pale
May be flushed
Cyanosis a late sign.
Conscious state
Alert; orientated.
Altered.
Oximetry
96% + on room air
90 – 95% on room air;
< 90% = serious hypoxia
NOTE: This assessment applies to patients with respiratory distress from any cause
(#)
(*)
Any of these features may indicate respiratory distress.
The more that are present, the greater the degree of respiratory distress.
Some patients, especially older patients, may be on medication that prevents
them from developing a tachycardia.
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RULE OF NINES FOR ADULTS
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Relative Percentage of Body Surface Area affected by Growth
AREA
Age 0
1
5
10
15
ADULT
A = ½ of head
9½
8½
6½
5½
4½
3½
B = ½ of one thigh
2¾
3¼
4
4½
4½
4¾
C = ½ of one leg
2½
2½
2¾
3
3¼
3½
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NORMAL BLOOD VALUES
Arterial Blood Gases
pH
PaO2
B
B
PaCO2
B
B
O2 content
B
B
CO2 content
B
B
7.36 - 7.44
85 - 100 mm Hg
36 - 44 mm Hg
20 - 21 vols%
48 - 50 vols%
Biochemistry:
Sodium
Potassium
Calcium
Magnesium
Bicarbonate
Creatinine
Urea
Glucose
134 – 146 mmol/l
3.4 – 5.0 mmol/l
2.25 – 2.65 mmol/l
0.7 – 1.1 mmol/l
22 – 28 mmol/l
50 – 120 mmol/l
3.0 – 8.0 mmol/l
3.9 – 6.2 mmol/l (fasting)
Haematology:
Haemoglobin
Haematocrit
Red cell count
White cell count
Platelet count
Male:
130 – 180 g/l
F/male:
120 – 160 g/l
Male:
42 – 52%
F/male:
37 – 48%
4.2 – 5.8 million
4.3 – 10.8 thousand
150 – 350 thousand.
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EXTERNAL PACING PROCEDURE
Indications:
Bradycardia with poor perfusion:
- unresponsive to atropine or IV fluids; or
- where IV access cannot be obtained.
[Preferred over adrenaline infusion for post cardiac arrest bradycardia.]
Procedure:
1:
Explain to patient and family
2:
Set up adrenaline infusion, if IV access obtained.
3:
Ensure ECG electrodes are well off the chest
4:
Prepare skin for pacing electrodes (clip - no shaving; no alcohol)
5:
Anterior electrode in approx V2 V3 12 lead position, horizontal.
(Avoid nipple, sternum & diaphragm)
6:
Posterior electrode at (L) vertebral edge, below bony prominence of
scapula, vertical.
7:
Set current at 0mA, demand mode, rate approx 50% over initial
B
B
B
B
bradycardia.
8:
Ensure pacer is sensing (markers on QRS complexes)
9:
Slowly increase current output in 5mA increments (use selector wheel)
until electrical capture occurs (rarely under 60mA)
10:
Ensure electrical capture (change in QRS; wide QRS; big T wave)
11:
Check mechanical capture (pulse; ↑ LOC; ↑ BP)
12:
Increase current output by 5mA over initial capture value.
13:
Ensure analgesia is provided.
14:
Continue to check electrical & mechanical capture.
15:
Adjust rate and current output as required
134
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Roof Hatch (Emergency Exits)
Off-side Window Emergency Exit
towards the rear (Driver’s side)
Access to Buses &
Coaches
Rear Window
Emergency Exit
(if fitted)
Rear-mounted
Engine
Batteries on other
side at REAR (on
most coaches or
buses, batteries are
near engine
External Emergency Release
valves or switches under
Bumper
Fuel Tank usually mounted here
for rear engine coach (for Mid or Front
engines, tank is towards rear
136
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…
137
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139
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140
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Ambulance Roles at a Mass Casualty Incident (MCI)
MCI = Greatest Good for Greatest Number
First Ambulance Crew on Scene
• Approach the incident with safety.
• Park the ambulance in a safe and upwind location.
• Wear all protective equipment as provided by ACTAS.
(eg: safety glasses, gloves, safety vest and helmet).
• Assess the situation and send a SITREP to the Ambulance
Commander or the ACTAS Communication Centre (if the Ambulance
Commander is not on scene).
• M - Message (I am notifying a major incident - standby for
SITREP)
• E - Exact location
• T - Type of incident
• H - Hazards (present and potential)
• A - Access to the area
• N - Number of casualties (actual or estimated)
• E - Emergency services (present or required)
• If greater than six (6) casualties, assume the roles of Triage Officer
and Transport Control Officer
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TRIAGE OFFICER
The Triage Officer role is undertaken by the most clinically
experienced intensive care paramedic on scene. They assume
responsibility for casualty triage, collection and clinical management
(patient care) at the incident site.
1. Initiate Triage by quickly assessing, prioritising and labelling
casualties (DRABC & move on)
2. Direct and control, supporting ambulance officers to casualties.
3. Maintain communications with the Ambulance Commander,
Transport Control Officer and Ambulance Officers.
4. Co-ordinate support provided from allied emergency services
and supporting agencies, in moving casualties from the incident
site, to the Casualty Collecting and Treatment Area.
5. At the Casualty Collecting Area, separate casualties into
distinct priority classification groups, to facilitate evacuation,
treatment and transport.
6. Patients with life-threatening injuries/illness should not be left
unattended, if at all possible.
7. Undertake continuing Triage of all casualties, to re-assess
priority of treatment and transport.
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TRANSPORT CONTROL OFFICE (TCO)
The TCO assumes responsibility for the establishment of the Casualty
Collecting Area (CCA), casualty evacuation and transport at the
incident site.
1. Determine the most appropriate access & egress routes &
vehicle staging area for ambulance vehicles and advise the
ComCen of these, for communication to other responding
resources
2. In consultation with the Triage Officer and Ambulance
Commander (if present), select a Casualty Collecting Area
(CCA) in a safe and upwind environment.
3. Select an Ambulance Marshalling Area, in a safe and upwind
environment, in close proximity to the Casualty Collecting Area.
4. Ensure all arriving ambulances are correctly positioned, that
keys are left in the vehicle ignition and the vehicle is configured
for two stretcher patients.
5. Prevent congestion at the Ambulance Loading Point by
ensuring that ONLY ONE VEHICLE is being loaded with
casualties, at any given time.
6. Record on the Casualty Movement Log, the number of
casualties transported, their priority and destination and the
ambulance vehicle identification number. Ensure that the
corner label from the triage tag is removed prior to the casualty
being loaded. (This task may be delegated to a support officer,
if available).
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7. Maintain communications with the Ambulance Commander and
Triage Officer.
Subsequent Ambulance Crews
• Approach the incident with safety.
• If transport control area is set up position ambulance or support
vehicle correctly in the marshalling area leaving keys in the ignition.
Once at the incident all warning devices should be switched off unless
otherwise directed
• Wear all protective equipment as provided by ACTAS.
(ie: safety glasses, gloves, safety vest and helmet).
• Report to the Ambulance Commander on arrival, for a SITREP and
tasking. If the Ambulance Commander is not on scene, report to the
Triage officer for tasking.
• If ambulance officers are tasked to transport casualties to hospital
they will:
• Transport casualties to the hospital or medical centre, nominated
by the TCO
• Advise the receiving Emergency Department by radio the number
of casualties being transport and the priority classification.
• Ensure that the receiving hospital or medical centre facilitates the
QUICK TURN AROUND of ambulance and support vehicles.
Report availability to Ambulance Liaison Officer at hospital ED (if present)
or ComCen for further tasking.
144
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Clinical Management Manual - Fair-Go

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