act ambulance service - Prehospital ambo guides

Transcription

act ambulance service - Prehospital ambo guides
ACT AMBULANCE SERVICE
CLINICAL MANAGEMENT MANUAL
POCKET EDITION
1
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CLINICAL MANAGEMENT GUIDELINES
Contents
PAGE NO.
Glasgow Coma Scale
1
ACTAS Approved Abbreviations
2
Clinical Management Guideline Index
5
Failed Intubation Drill procedure
55
Rapid Sequence Induction Procedure
56
Drugs for Airway Management – Summary Sheet
60
ACTAS Pharmacology Index
61
Drug Dose Calculator
101
Medication Calculator
102
Drug Reference Key List
104
Patient Assessment – General Approach
115
Time Critical Patient Guideline
116
Suicide Risk Assessment
118
Mental Health Status Assessment
119
Mental Competency Checklist
120
APGAR Score
121
Paediatric Reference Card
122
PEEP Values
123
Spinal Immobilisation flow chart
124
Spinal Cord Injury
125
Differentiation of Wide Complex Tachycardias
126
Maximum QT Interval Chart
128
12 Lead ECG Placement Chart
129
15 Lead ECG Placement Chart
130
STEMI Bypass Flow chart
131
STEMI Bypass Check List
132
Acute Myocardial Infarction Table
133
Infarction Overview
134
Capnography
144
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Wave Forms
146
Respiratory Status Assessment Chart
147
Burns Assessment Chart / Rule of Nines
148
Paediatric Burns Assessment Chart
149
Normal Blood Values
150
External Pacing procedure
151
Significant Contact Numbers
152
Motorola XTS 3000 Portable Radio - Duress Alarm Procedure
155
Hazchem Chart
157
Mass Casualty Triage Flow Chart
159
Ambulance Roles at a Mass Casualty Incident (MCI)
160
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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
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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
ACTSES
asystole
A.C.T. Ambulance Service
A.C.T. State Emergency
Service
A.C.T. Fire Brigade
Australian Federal Police
abdominal aortic aneurism
atrial fibrillation
atrial flutter
Advanced Life Support
morning
acute myocardial infarction
Ambulance not required
ACTFB
AFP
AAA
AF
AFl
ALS
am
AMI
ANR
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
CAL
complains(ing) of
Cancer
coronary artery bypass graft
Chronic Airflow Limitation
(Chronic Obstructive Airways
Disease – COAD;
Chronic Obstructive
Pulmonary Disease - COPD)
Calv.
CAT
Calvary Hospital
Computerised Axial
Tomography
CCF
CCU
cm
CNS
CO
CO2
Code 5
CP
CPAP
congestive cardiac failure
Coronary Care Unit
centimetres
central nervous system
Carbon Monoxide
Carbon Dioxide
person deceased
chest pain
continuous positive airways
pressure
CPR
Cardio-Pulmonary
Resuscitation
CSF
CVA
cerebrospinal fluid
cerebrovascular accident
DCCS
Direct Current Counter
Shock
doctor
diagnosis
Dr.
Dx
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EAR
ECC
ECG
ED
expired air resuscitation
external cardiac
compressions
electrocardiograph
Emergency Department
(Accident and Emergency
department)
EDC
expected date of
confinement
EEG
EMD
electroencephalograph
electromechanical
dissociation
ENT
ESA
Ear, Nose and Throat
Emergency Services
Agency
ETT
endotracheal tube
GCS
GI
GP
Gx Px
Glasgow Coma Score
gastrointestinal
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
intracranial pressure
intercostal space
Intensive Care Unit
intragastric tube
ischaemic heart disease
intramuscular
intramuscular injection
inhaled
intraosseous
intermittent positive
pressure ventilation
IU
IV
IVU
IVR
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
3
(L)
Lev.OC
LLQ
LMP
LOC
lpm
L
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
m
mane
MAP
mcg
mg
ml
mm
mMol
MRI
metre
morning
mean arterial pressure
microgram
milligram
millilitres
millimetres
milliMol
Magnetic Resonance
Imaging
MS
mth
MVA
Multiple Sclerosis
month
motor vehicle accident
neb
NFR
NGT
NICU
nebule / nebulised
not for resuscitation
nasogastric tube
Neonatal Intensive Care
Unit
NKA
No.
nocte
NOF
N/S
no known allergies
number
night
neck of femur
Normal Saline
O
O/A
obs
O/E
O2
oral
on arrival
observations
on examination
Oxygen
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P
PA
PAC
PEA
PEARL
pulse
per axilla
premature atrial contraction
pulseless electrical activity
pupils equal & reacting to
light
PEEP
positive end expiratory
pressure
PHx
PID
PJC
past history
pelvic inflammatory disease
premature junctional
contraction
pm
PO
PR
prn
pt
PU
PV
PVC
afternoon
per oral
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
RLQ
ROM
RSI
RTA
RTC
RUQ
Rx
right lower quadrant
range of movement
rapid sequence induction
road traffic accident
road traffic crash
right upper quadrant
treatment
S/C
S/L
SB
SOB
sPEEP
SR
ST
SVT
subcutaneous
sublingual
sinus bradycardia
shortness of breath
spontaneous PEEP
sinus rhythm
sinus tachycardia
supraventricular tachycardia
T or Temp
TCH
tds
TKVO
TMC
TNR
Tx
temperature
The Canberra Hospital
three times a day
to keep vein open
threatened miscarriage
transport not required
transport
4
URTI
upper respiratory tract
infection
UTI
urinary tract infection
V/S
VEB
VF
VT
vital signs
ventricular ectopic beat
ventricular fibrillation
ventricular tachycardia
wt
weight
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Clinical Management Guideline Index
01
General Care
23
Stroke
02
Pain Management
24
Near Drowning
03
Airway Management
25
Diving Emergencies
04
Cardiac Arrest
26
05
Paediatric Cardiac Arrest
Obstetrical & Gynaecological
Emergencies
27
Hyperkalaemia
06
Cardiac Arrhythmias
28
Home Dialysis Emergencies
07
Bradyarrhythmias
29
Allergic & Anaphylactic Reactions
08
Tachycardias
30
Crush Syndrome
09
Respiratory Distress
31
Electric Shock
10
Diabetic Emergencies
32
Assault
11
Temperature Abnormalities
33
12
Upper Airway Obstruction
Behavioural & Psychiatric
Emergencies
13
Abdominal Emergencies
34
C.B.R. Incident
14
Shock & Hypotension
35
Poisoning, Envenomation &
Overdose
15
Decreased Level of
Consciousness
36
Extended Care
16
Chest Pain / Suspected ACS
37
Combative / Agitated Patients
17
Chest Injuries
38
Meningococcal Disease
18
Spinal Injuries
39
Adult Agonal Trauma Patients
18a
Autonomic Hyperreflexia
40
Bariatric Patients (in development)
19
Limb Injuries
41
Headache (in development)
20
Eye Injuries
42
Back Pain (in development)
21
Burns
43
Dehydration (in development)
22
Seizures
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CLINICAL MANAGEMENT GUIDELINE 1
GENERAL CARE




Primary survey
Haemorrhage control
Posture
Oxygen therapy
NOTE:
TRANSPORT IS TREATMENT!
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:
Vital signs
ECG/12 - 15 Lead
Blood glucose
O2 saturations
Temperature
EtCO2
Specific observations & assessment
as per patient condition
NOTE: time-critical applies to both trauma and medical cases.
The following conditions warrant absolute minimum scene times
and urgent transport to hospital:



 Treatment as required:
Cervical collar
Bandaging
Splinting
Pelvic splint
Temperature control
Reassurance
Cannulate – IV fluids as
per perfusion & hydration assessment
Pain relief
Antiemetic








Notify and transport to nearest appropriate 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
(List is not exclusive or exhaustive!)
NOTE: time-critical does not just mean rapid transport!
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CLINICAL MANAGEMENT GUIDELINE 2
PAIN MANAGEMENT
General Care Guideline
RELIEF OF PAIN & SUFFERING IS A PRIME GOAL OF AMBULANCE CARE
GTN S/L for ischaemic chest pain.
Pain is what the patient says it is!
Always offer pain relief to the patient
Methoxyflurane for mild to moderate pain; patients
unable to have narcotics; management of labour; often
best for paediatrics.
Pain assessment (PQRST)
Quantitate if possible (scale & description)
Document on case sheet
Morphine Ischaemic chest pain and for all other pain
unless contraindicated.
Basic care is fundamental to pharmacological
management:
Midazolam small doses may be added to analgesia for
musculo-skeletal pain.






Reassurance
Posture
Splinting
Cooling of burns
Occlusive dressings
Control of temperature (especially the cold)
 Gentle handling
Ketamine for pain management in selected patients. May
be used with alternate small doses of Morphine.
ISCHAEMIC CHEST PAIN; LIMB PAIN; BURNS:
aim for abolition of pain

If possible, pharmacology should be directed at the
apparent underlying cause:
UNDIAGNOSED CONDITIONS:
aim for control of pain to a
bearable level of discomfort
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CLINICAL MANAGEMENT GUIDELINE 3
AIRWAY MANAGEMENT
General Care Guideline
THE PRIMARY GOALS OF AIRWAY MANAGEMENT ARE:
OXYGENATION
VENTILATION
AIRWAY PROTECTION
in this order of priority
Start basic and 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, nasopharyngeal airway.
Mild sedation to permit basic airway management (Midazolam).
“Cold” endotracheal intubation.
Rapid sequence induction:
 Suxamethonium / Midazolam*.
( NOTE: If the 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 patients with no suspected acute intracranial pathology.
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 cervical collar to assist in maintaining ETT/LMA position.
 There are to be multiple checks of ETT position, using multiple methods, by multiple people.
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CLINICAL MANAGEMENT GUIDELINE 4
ADULT CARDIAC ARREST
IPPV – 100% O2
Monitor ECG
(a) – Ventricular Fibrillation/Tachycardia
(b) – Asystole
(c) – Pulseless Electrical Activity
Precordial thump if monitored & witnessed
Check alternate leads /
lead selector
Check aggressively for correctable causes:
CPR
Shock
Cannulate
Adrenaline 1mg
Shock
Amiodarone 300 mg IV
Shock
Adrenaline
Shock
Adrenaline
Shock
Cannulate
Atropine 2mg + Adrenaline 1mg
Adrenaline
Adrenaline
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
Adrenaline
Adrenaline
Decision to transport
For refractory or persistent VF: consider MgSO4
For Torsades:
MgSO4 as the 1st drug; no Amiodarone
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
Intubate – when sufficient assistance
Adrenaline every 2 minutes during
transport





Profound hypovolaemia
Tension pneumothorax
Continuing profound hypoxia
Acidosis / Hyperkalaemia
Gas trapping
Cannulate
Atropine 2mg + Adrenaline 1mg
Adrenaline
Adrenaline
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
Adrenaline
Adrenaline
Decision to transport
Intubate – when sufficient assistance
Shock
Decision to transport
Intubate – when sufficient assistance
Adrenaline every 2 minutes during transport
Adrenaline every 2 minutes during transport
Shock between medications
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CLINICAL MANAGEMENT GUIDELINE 5
PAEDIATRIC CARDIAC ARREST
CPR
IPPV – 100% O2
Monitor ECG
(a) – Ventricular Fibrillation/Tachycardia
(b) – Asystole
(c) – Pulseless Electrical Activity
Precordial thump if monitored & witnessed
Check alternate leads
Check for correctable causes:
Shock 2 j/kg
Cannulate / Intraosseous
Cannulate / Intraosseous
Cannulate / Intraosseous
Adrenaline 0.01 mg/kg
Adrenaline 0.01 mg/kg
If hypoxia is not the apparent cause of
arrest: Normal Saline 20 ml/kg
If hypoxia is not the apparent cause of
arrest: Normal Saline 20 ml/kg
Adrenaline
Adrenaline
Adrenaline
Adrenaline
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
Adrenaline
Adrenaline
Adrenaline
Adrenaline
For Torsades:
MgSO4 as the 1st drug; no Amiodarone
Intubate – when sufficient assistance
Intubate – when sufficient assistance
In prolonged arrest – consider
Sodium Bicarbonate 0.5 mMol/kg
Shock 4 j/kg
Transport
Adrenaline 0.01 mg/kg
Shock 4 j/kg
Amiodarone 5 mg/kg IV
Shock 4 j/kg
Adrenaline
Shock 4 j/kg
Adrenaline
Shock 4 j/kg
Intubate – when sufficient assistance
Adrenaline every 2 minutes during
transport.
Transport
Adrenaline every 2 minutes during
transport.
Transport
Adrenaline every 2 minutes during transport.
Shock between medications.
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GENERAL RESUSCITATION CARE
This page has been intentionally left blank – insert to follow
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CLINICAL MANAGEMENT GUIDELINE 6
CARDIAC ARRHYTHMIAS
General Care Guideline
(a) - PACs / PVCs
(b) - Accelerated IVR
(c) - Bizarre
No specific treatment required
No specific treatment required
Monitor rhythm & patient condition
Monitor rhythm & patient condition
Rate & perfusion determines the type of
treatment.
Pulse is absent, with normal rate – treat as for
cardiac arrest (usually PEA)
Rate less than 50, poor perfusion – treat as
for bradyarrhythmias.
Rate greater than 150, regular, with wide QRS
complexes, and patient is significantly
compromised – treat as for VT.
Rate greater than 150, regular, with narrow
QRS complexes, and patient is symptomatic –
treat as for SVT.
If unable to decide which specific therapy is
required – general care; observe; prompt
transport.
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CLINICAL MANAGEMENT GUIDELINE 7
BRADYARRHYTHMIAS
General Care Guideline
Consider treatment if heart rate is less than 50 in adults
NOTE: Hypotension is an important determinant of perfusion status with Bradyarrhythmias
If poorly perfused or symptomatic:
Atropine 0.01 mg/kg
Check for signs of failure.
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 ml Normal Saline ( = 1mcg/ml)
Titrate to response. (20dpm = 1ml/min = 1 mcg/min)
Paediatric – use a burette
OR
external pacing, especially post cardiac arrest,
and sedation with Morphine and Midazolam as required
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CLINICAL MANAGEMENT GUIDELINE 8
TACHYCARDIAS
General Care Guideline
(a) Narrow QRS Complex
(b) Wide QRS Complex
Consider: Sinus tachycardia; SVT; AF; AFl; MAT
Consider: VT; SVT with aberrancy; rapid AF or AFl
with aberrancy.
Use 12 lead ECG
Make differentiation: (12 lead ECG if time)
If aberrant SVT, AF or AFl - treat as per 8(a)
Valsalva x 2
If SVT:
Adenosine 6 mg IV
Adenosine 12 mg IV, if required
If rapid, symptomatic VT:
Amiodarone 150 mg IV
No pulse: Treat as VF cardiac arrest
If rapid AF or AFl, refer to treatment algorithm:
Torsades de Pointes: MgSO4 IV instead of
Amiodarone
Notify and prompt transport to nearest appropriate hospital.
Notify and prompt transport to nearest appropriate
hospital.
IV Amiodarone – given over 10 minutes via Springfusor
(If the patient is extremely compromised and in VT, it may be given over 5 mins by slow IV injection
Consider pharmacological treatment if heart 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.
Any rapid rhythm (over 200), in an unconscious patient with no pulse  shock.
Paediatric doses:
Adenosine: 0.05 mg/kg; then 0.1 mg/kg
Amiodarone: 5 mg/kg (to a total of 150 mg)
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CLINICAL MANAGEMENT GUIDELINE 8 (continued)
TREATMENT ALGORITHM FOR RAPID ATRIAL FIBRILLATION OR FLUTTER
General Care Guideline
Establish diagnosis: ensure
- Atrial fibrillation or flutter
- rapid rate ( > 150 )
- recent onset (reliably < 24 hours)
No significant
compromise
Hypotension
Ischaemic chest pain
Pulmonary Oedema
Rapid AF or AFl apparently
secondary to an acute
cerebral event
Observe
Check for evidence of LVF
Treat chest pain as
appropriate
Treat pulmonary oedema
as appropriate
These patients will present
with a decreased LOC, &
may be hypotensive
If no LVF: treat with IV
fluids, 5 – 10 mls/kg
Check for evidence of LVF
Do NOT use Amiodarone
in these patients
If LVF + hypotension:
treat cautiously with
Amiodarone
Treat rapid rate with
Amiodarone concurrently
Treat rapid rate with
Amiodarone concurrently
If no LVF: treat hypotension
with IV fluids, 5 – 10 mls/kg
Do NOT use Amiodarone in
these patients.
NOTE: Monitor BP
closely – the combination
of drug treatments for
pulmonary oedema may
cause hypotension.
NOTE: Unconscious patients
post cardiac arrest in rapid
AF may be treated with
Amiodarone unless
otherwise contraindicated.
Allow several minutes for
rhythms to stabilise before
administering Amiodarone.
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CLINICAL MANAGEMENT GUIDELINE 9
RESPIRATORY DISTRESS
General Care Guideline
(a) Bronchospasm
(b) Pulmonary oedema
Mild to Moderate: Salbutamol and Ipratropium puffer with spacer
initially
Moderate to Severe:
 Nebulised Salbutamol + Ipratropium.
 Repeat Salbutamol as required.
 Add Ipratropium to every second dose as required.
 Significant hypoxia – nebulise with 100% O2 and PEEP.
 Hydrocortisone 200 mg IV / IM
 (Paed: 4 mg/kg to maximum of 200 mg)



Assist ventilation with IPPV + 100% O2 as required
Add PEEP: 5cm (THIS IS IMPORTANT)
Increase PEEP by 5 cm as required




If LVF:
Sit patient with legs dependent if possible
Treat significant cardiac arrhythmias
GTN S/L:
May be repeated x 1 after 5 minutes

Severe to life-threatening:
 Adrenaline: Adult:
0.5 mg IM
 Paediatric: 0.01 mg/kg IM (to 50 kg)
 Repeat IM dose x 1 as required
Adrenaline infusion:
 1 mg in 1000 mls Normal Saline ( = 1mcg/ml)
 Titrate to response. ( 20dpm = 1ml/min = 1 mcg/min)
 Paediatric – use burette
 If the patient is critically ill, slow IV, up to 0.01 mg/kg,no
faster than 50mcg/minute
Consider fluid bolus for patients with moderate to severe asthma.
Notify and transport to nearest appropriate hospital.

Morphine: 0.05 mg/kg IV (especially if using PEEP
and patient is distressed)
dose may be repeated after 10 minutes,if patient
remains in severe distress:



Frusemide:
On diuretics: 1 mg/kg IV
Not on diuretics: 0.5 mg/kg IV

If wheezing is present, do not give nebulised
bronchodilators until after the first two doses of GTN


If no IV, Frusemide may be given IM
If symptoms persist, may give third dose of GTN
Notify and transport to nearest appropriate hospital.
NOTE: IV Adrenaline in anaphylaxis & asthma should be used very cautiously.
If IPPV is required – use a slow rate with slow, gentle lateral chest squeezes on exhalation.
16
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CLINICAL MANAGEMENT GUIDELINE 9 (continued)
RESPIRATORY DISTRESS
General Care Guideline
(c) Non specific respiratory distress
(d) Hyperventilation due to anxiety.
Assess the patient carefully
Fully assess the patient for pathological causes of
hyperventilation.
Administer Salbutamol + Ipratropium
NOTE: Anxiety may accompany an underlying
pathological cause for hyperventilation.
Repeat Salbutamol - as required
Add Ipratropium to every second dose - as required
O2 at low flow rate via Hudson mask
Significant hypoxia - nebulise with 100% O2 PEEP
Monitor SaO2, ECG and check EtCO2
Remove source of anxiety if possible
Reassurance
Notify and transport to nearest appropriate hospital.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 10
DIABETIC EMERGENCIES
General Care Guideline
CHECK BLOOD GLUCOSE LEVEL:
(a) BGL < 4 mMol/L
(b) BGL > 15 mMol/L
If symptomatic:
Oral glucose, if conscious & laryngeal reflexes intact.
Normal Saline 10 ml/kg IV over contact time
If decreased LOC:
Glucose 10% – up to 2.5 ml/kg IV (0.25 g/kg)
If shocked & hypotensive: IV resuscitation
Notify and transport to nearest appropriate
hospital.
Re-check BGL & LOC.
Repeat Glucose 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
Notify and transport to nearest appropriate hospital.
NOTE: Recovery may be slow if hypoglycaemia has been prolonged.
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CLINICAL MANAGEMENT GUIDELINE 11
TEMPERATURE ABNORMALITIES
General Care Guideline
CHECK PATIENT‟S TEMPERATURE:
(a) Heat abnormalities
Minor heat syndromes:

Normal or transient disturbances in LOC;

sweating;

core temp < approx 39oC
Heatstroke:
Decreased LOC;
no sweating;
core temp > approx 39oC
Gentle cooling
Rapid cooling; aggressive as possible
Cease exertion
IV resuscitation; cool fluids if possible
Move patient to cool location
Treat significant arrhythmias
Oral rehydration: - allow small sips only
Check BGL
IV rehydration if:
Aggressively manage seizures or shivering
- nauseated &/or vomiting;
- significant dehydration;
- multiple patients.
Notify and transport to nearest appropriate hospital.
Notify and urgent transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 11 (continued)
TEMPERATURE ABNORMALITIES
General Care Guideline
(b) Cold abnormalities
Exposure:
 Normal LOC;
 shivering;
 core temp > approx 33.5oC
Hypothermia:
 Decreased LOC;
 no shivering;
 core temp < approx 33oC
More rapid warming is acceptable
Handle patient gently
Warm oral fluids
Remove wet clothing if sheltered; dry patient off
Gentle exercise if possible
Wrap in warm blankets; then space blanket
If IPPV – do not hyperventilate
If in VF:
Shock
Cardiac drugs if core temperature > 32oC
Do not cease resuscitation
Notify and transport to nearest appropriate hospital.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 12
UPPER AIRWAY OBSTRUCTION
General Care Guideline
(a) Foreign body
(b) Swelling
PARTIAL OBSTRUCTION:
 Maximise Oxygen therapy
 Encourage coughing
 Prompt transport
 Minimum intervention
Causes: croup / epiglottitis; insect sting; anaphylaxis;
trauma; oral / pharyngeal infection; burns.
COMPLETE OBSTRUCTION:
Conscious patient:
 Four modified chest thrusts;
 if fails  turn into lateral position. 4 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 (for children, use head down position, if
possible)
 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).
 Notify hospital and urgent transport – 100% Oxygen.
 Consider surgical airway as a last resort.
OBSTRUCTION RELIEVED: provide Oxygen therapy prompt transport
21
Maximise oxygenation
 Do not attempt close examination of mouth / throat
area
 Do not unnecessarily distress the patient
If severely obstructed: nebulised Adrenaline:
wt > 10 kg – 5 mls Adrenaline 1:1000
wt < 10kg – 0.5 ml/kg Adrenaline 1:1000
(Make volume up to 5 mls with Saline, as required)
If swelling is due to anaphylaxis or local insect sting:
IV / IM Adrenaline
For partial airway obstruction:
prompt transport
For complete airway obstruction:
give 100% O2 and attempt I.P.P.V.
notify hospital and urgent transport.
consider surgical airway as a last resort.
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CLINICAL MANAGEMENT GUIDELINE 13
ABDOMINAL EMERGENCIES
General Care Guideline
Posture flat – knees may be flexed.
IV resuscitation as required.
Pain relief.
Cover any open wounds with dry, sterile dressing; protruding viscera with
saline-moistened sterile dressings.
If an impaled object is in situ – do not remove it – move the patient with the object in situ.
Notify and prompt transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 14
SHOCK & HYPOTENSION
General Care Guideline
Assess the patient carefully to determine possible cause.
Consider assessment of postural changes
(a) Hypovolaemic
(b) Cardiogenic
High concentration O2
High concentration O2
High concentration O2
High concentration O2
If severely shocked, with
a non-compressible
bleeding lesion – early,
rapid transport
12 lead ECG
Adrenaline if suspected
anaphylaxis
Decompress tension
pneumothorax if
suspected
STEMI management
as indicated
IV fluids to maintain
adequate cerebral
perfusion
Treat significant
arrhythmias
(consider age,
co-morbidities & concurrent
injuries)
Pain relief
Consider pelvic splint
where appropriate
Notify and prompt
transport to nearest
appropriate hospital.
(c) Distributive
Posture with care if
suspected spinal injuries
(d) Obstructive
If severely shocked –
early, rapid transport
IV fluids
(keep BP no higher than
80 – 85 mmHg
if spinal injuries are suspected)
Assess for LVF
IV fluids with caution
Notify and prompt
transport to nearest
appropriate hospital.
Notify and prompt
transport to nearest
appropriate hospital.
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IV fluids
Notify and prompt
transport to nearest
appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 15
DECREASED LEVEL OF CONSCIOUSNESS
General Care Guideline
Assess the patient carefully
(a) History of trauma –
Head Injury
Cervical spine precautions
Airway management guideline
(b) No history of trauma
(c) Apparent syncope
Check BGL
Assess thoroughly for more
significant causes in all
patients
Posture 10 – 15º head up
Consider poisoning or O/D
If GCS below 12:
Check BGL
maintain O2 saturations > 95%
Consider cervical spine
precautions
BP 100 – 120 systolic
Airway management guideline
(MAP > 90)
Check BGL
Notify and transport to nearest
appropriate hospital.
If GCS below 12:
maintain O2 saturations > 95%
BP 100 – 120 systolic
(MAP > 90)
Notify and transport to nearest
appropriate hospital.
12 lead ECG if no obvious
alternate cause
Posture by perfusion or
comfort
Consider cervical spine
precautions
Notify and transport to nearest
appropriate hospital.
Evidence of a rapidly decreasing level of consciousness is a flag for a time-critical patient
– therefore, minimise scene time and transport urgently to hospital.
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CLINICAL MANAGEMENT GUIDELINE 16
CHEST PAIN / SUSPECTED ACUTE CORONARY SYNDROMES
General Care Guideline
Assess thoroughly for possible Acute Coronary Syndrome (ACS)
 i.e. 12 lead ECG
 if STEMI – initiate appropriate management without delay.
Possible Acute Coronary Syndrome
Pain assessed as probable non-ACS
Monitor closely
Assess for possible threat to life.
Utilise 12 lead ECG
12 lead ECG (15 lead as appropriate)
Aspirin
GTN
Antiemetic
Morphine
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 STEMI is
suspected*
Treat haemo-dynamically significant arrhythmias
Prompt transport
Give Aspirin, even if on regular slow-release Aspirin. Give a 150mg dose if already on Warfarin.
Watch for non-typical or silent presentations of ischaemic heart disease, especially in females, the elderly & patients with
diabetes.
Silent or atypical ACS presentations should be treated in the same manner as a typical presentation.
Aim to minimise scene time while still providing reassurance & effective pain relief.
*STEMI bypass procedure – notification, Heparin and Prasugrel / Clopidogrel
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CLINICAL MANAGEMENT GUIDELINE 17
CHEST INJURIES
General Care Guideline
IV resuscitation as required
Pain relief as required
Pneumothorax
 If suspected avoid coughing, Valsalva manoeuvres or IPPV
 Suspect a tension pneumothorax in a patient with diminished air entry &
significant respiratory or cardiovascular compromise.
Decompress tension as indicated
NOTE: diminished air entry may be an unreliable sign if the patient is
receiving positive pressure ventilation.
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
Effective pain relief
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 18
SPINAL INJURIES
General Care Guideline
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
 IPPV, if hypoventilating
Posture supine
Cervical Collar
 Extricate with spine board or Kendrick Extrication Device
 Lift with board or scoop stretcher
Do not routinely transport patients on the spine board/scoop stretcher.
Transportation on a spine board/scoop stretcher is only permissible where there is a short extrication
and travel time to hospital (no longer than 10 minutes).
If this occurs, ensure that the patient and board are restrained during transport.
IV resuscitation as required
 DO NOT OVER-INFUSE
 a systolic blood pressure of 80mmHg is acceptable in high spinal injuries
With suspected cord lesion - administer antiemetic
Insert IGT & urinary catheter prior to secondary, air or extended transports
If transport is prolonged, ensure pressure area care is attended
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 18a
AUTONOMIC HYPERREFLEXIA
This occurs in established High Paraplegics or Quadriplegics, therefore, assess the patient for Autonomic Hyperreflexia.
The sudden onset of any of the following is significant.




Sudden hypertension, (this may fall within the normal limits 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 of lesion; chills without fever; nasal congestion, blurred vision;
shortness of breath, sense of apprehension and/or anxiety.
Causes




Bladder:
Bowel:
Skin:
Other:
Distended due to blocked or kinked catheter, UTI, bladder or kidney stones.
Constipation, faecal impaction, rectal irritation.
Burns, pressure areas, tight clothing e.g. TED stockings.
Fractures, distended stomach, labour, severe menstrual cramping.
Actions
Ask patient and carer if they suspect a cause.
 Elevate patient‟s head and position with legs dependent, if possible.
 Loosen any constrictive clothing.
 Check bladder drainage equipment for kinks or obstruction:
 if found  drain 500mls initially, then a further 250mls every 15 minutes until the bladder is empty.
 Monitor BP every 2 – 5 minutes.
 Avoid pressing over the bladder.
Treatment
If the BP remains elevated (ranging between 150 – 170mmHg), commence treatment with:
 IV Midazolam 0.05 mg/kg, over one minute.
 This may be repeated once after 10 minutes if there is no fall in BP. Give 0.1 mg/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 appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 19
LIMB INJURIES
General Care Guideline
Check arterial circulation in the limb:
 If the distal pulse is absent gently re-align fractured segments until pulse returns or alignment is near
normal.
 Immobilise all fractures unless the patient is otherwise time-critical.
 Elevate the limb, if possible.
 Do not attempt to reduce dislocations.
IV resuscitation where indicated.
Pain relief
 Midazolam as required.
 Ketamine as appropriate.
Partially severed limb:
 carefully protect limb
 keep distal portion of 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 4oC.
 DO NOT immerse the part directly in ice.
 DO NOT attempt to clean or disinfect the severed part.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 20
EYE INJURIES
General Care Guideline
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 the patient lying flat.
The injured eye must be protected from rubbing pressure.
Use an eye shield, or a loosely taped eye patch.
Cover both eyes if the patient can tolerate this.
Severe eye injuries - administer IV antiemetic prior to transport.
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 completely over 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.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 21
BURNS
General Care Guideline
If there is still heat left in the skin, cool with cold water or saline. Watch for development of hypothermia. Utilise watergel burns dressings after cooling. Check & replace if they become warm.
Cover the burnt area with clean dressing/sheets.
If a limb is burnt, remove all rings, tight clothing, shoes, and elevate the part.
Consider space blanket.
Check for potential upper airway obstruction, especially if the face is burnt.
 Hoarse voice
 Inspiratory stridor
 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; with PEEP.
Pain relief
 IM Ketamine, if no IV access is available.
Cannulate Normal Saline for Adults with burn > 15% BSA; children > 10% BSA. (full or partial thickness)
 Adults: % BSA burned x wt (kg) in mls over 4 hours from time of burn.
 Children: 10 ml/kg.
If upper airway involvement is present – reduce fluids to ½ of what would otherwise be administered.
Transport suspected smoke inhalation patients to hospital as delayed pulmonary oedema may occur.
Notify and transport to nearest appropriate hospital. Prompt transport for any evidence of upper airway burns.
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CLINICAL MANAGEMENT GUIDELINE 22
SEIZURES
General Care Guideline
Protect the patient from injury.
Blood glucose estimation early, especially if no history of seizures.
Midazolam (IM if no IV access).
Treat any injuries secondary to the seizure.
Pregnant patient, no history of previous seizure activity – prompt treatment with 5mg MgSO4.
Children with seizure and or fever >38°C:
 Remove excessive clothing
 Cool with tepid water
 Place cool cloths in axillae, groin, wrist and neck; change as required
 Do not allow child to shiver
 Treat with Paracetamol 20 mg/kg or 15mg/kg if Paracetamol has been administered in the last 48
hours
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 23
STROKE
General Care Guideline
Posture 10 – 15o head up
 Airway management guideline
 Cannulate: - blood glucose estimation
 treat hypoglycaemia cautiously; avoid hyperglycaemia
 Treat seizures promptly & aggressively
 Minimise scene time
Notify hospital early and promptly transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 24
NEAR DROWNING
General Care Guideline
Cardiac arrest - treat by specific guideline.
 Use the highest concentration of Oxygen practicable.
 PEEP, if possible
 Cervical collar as required. IGT if possible.
 Consider hypothermia/other related conditions.
Notify and transport to nearest appropriate hospital.
NOTE: Late pulmonary oedema may occur.
* Transport is always required following near drowning episodes *
CLINICAL MANAGEMENT GUIDELINE 25
DIVING EMERGENCIES
General Care Guideline
Consider the possibility of spinal injury.
Lie flat and keep flat, do not sit up.
If unconscious, assume the possibility of an air embolus - posture left lateral, with a head-down tilt.
Oxygen therapy: highest concentration practicable. Exclude pneumothorax.
Patients are always dehydrated – re-hydrate with IV Normal Saline 10 ml/kg promptly.
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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CLINICAL MANAGEMENT GUIDELINE 26
OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES
General Care Guideline
Unscheduled Normal Field Birth
The most important ambulance role in a field delivery is to appear calm!
The 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 and maintain warmth by keeping the baby
close to the mother‟s skin. Place warm blankets over the baby and mother.
Assess the baby‟s Apgar score at 1 and 5 minutes after birth.
Cord should not be routinely cut 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 the umbilicus. Apply plastic clamp (x2) then cut the cord using clean scissors.
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Complicated Birth
P.V. Haemorrhage
Prolapsed cord:
Not pregnant / early pregnancy:
Posture in the knee to chest position
(often easier in the all fours knee to chest position)
100%Oxygen
Advise hospital early
Urgent transport
Do not encourage pushing
Manage as per perfusion status
Advanced pregnancy
Breech presentation:
Normal, unassisted birth may not always be possible.
Where possible, do not encourage the woman to push but to breathe
through her contractions.
Notify and urgently transport to hospital.
Once legs and body have been born, support the baby‟s body
as it hangs downward while waiting for the gentle, slow birth of the
head. (Do not apply downward traction). 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.
Manage as per perfusion status
Left lateral position
Do not attempt to massage the fundus of the uterus
Notify and prompt transport to nearest appropriate
hospital
Seizures due to eclampsia
5mg MgSO4 IV
Cardiac arrest in advanced pregnancy
Position with wedge under right hip to obtain
25 – 30o leftwards 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.
Ensure hospital is notified as early as possible that
the patient is pregnant.
Notify and urgently transport to nearest appropriate hospital.
Women in more advanced pregnancy (approx 20+ weeks gestation) are generally best treated/transported in
the left lateral position, regardless of the problem.
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CLINICAL MANAGEMENT GUIDELINE 27
HYPERKALAEMIA
General Care Guideline
Consider in these situations:
 Renal failure/dialysis
 Crush syndrome, including situations of prolonged unconsciousness
 Occasionally – diabetic ketoacidosis
ECG signs are unreliable, frequently do not follow expected progressions, and 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)
 VF / Asystole
Arrhythmias, especially bradycardias, are common.
If ECG changes are present:
 Nebulised Salbutamol (continuously).
 Calcium Chloride 10 mg/kg IV over 2 minutes.
 Follow with: Sodium Bicarbonate 8.4% – 0.5 mMol/kg IV over 2 minutes.
 If ECG changes persist after 10 – 15 minutes:
 repeat Calcium Chloride & Sodium Bicarbonate x 1
NOTE: Treatment is determined by patient presentation, ECG changes and the clinical setting.
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CLINICAL MANAGEMENT GUIDELINE 28
HOME DIALYSIS EMERGENCIES
Dialysis is a Renal Replacement Therapy used when kidney function no longer sustains life. The client is required to undergo treatment
on a regular basis (typically 3 times per week for 4 hours).
SOME IMPORTANT CONSIDERATIONS:
 Clients who are dialysed at home have undergone extensive training and maintain a record of their treatment.
 Use this and any further information provided by the patient and/or carer – they are very familiar with the process.
 Fistula access is the patient‟s life line. Vessels should be preserved for future fistula creation – therefore, ONLY
cannulate if necessary and use the cubital fossa or hand.
 Most calls to dialysis clients are not related to their dialysis.
REMOVE CLIENT FROM MACHINE BY:




Clamping machine blood lines (x2) and cannula (x2)
Unscrew lines from cannula. (Pump will stop and machine will alarm)
Do not turn machine off until client is removed
Use either cannula as access for fluid and medications (as both are sitting in an
arterialised vein)
 Attach giving set to cannula and administer IV fluid. Remember clients are often on
fluid restriction. 100 – 200 mls often resolves a hypotensive situation. Consult the
client‟s treatment record to ascertain usual BP
 Leave cannula in situ if time is an issue. However, reinforce with taping and protect
during transit, as these are metal needles and can cause damage to the vessels if
mishandled
 When removing cannulae, remember there is a high flow-in access
(1000 mls/minute) so use a protective mask and goggles. Moderate pressure is
needed on the exit site for 10 – 15 minutes
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CALLS TO CLIENTS ON DIALYSIS. Problems include:
1. Hypotensive episode:
This can occur due to excess fluid removal.
Assess the situation. If the client/helper can replace fluid, this is the best option.
 When the Paramedic is required to replace fluid:
 Place the client in the Trendelenberg position (supine with head lower than feet). Administer O2
 Remove client from machine
 Follow ACTAS Clinical Management Guideline for fluid replacement
2. Chest pain:
This may be caused by excess fluid removal during dialysis or other cardiac event.
 Stop dialysis and ask helper to return client‟s blood or remove client as above when necessary
 Use cannula as access. Withdraw 10mls of blood and discard before using cannula for blood-taking (to remove
saline in the line)
 Follow ACTAS Clinical Management Guideline for chest pain
3. Bleeding:
This may occur due to excess thinning of the blood due to Heparin used in dialysis. Heparin has half life of 92 minutes.
 Only light pressure on cannula site is required (10 – 15 minutes)
 DO NOT cut off the flow-in access as it will clot
 Use Diastop/Tip stop devices where available. Digital pressure is the best option
 DO NOT APPLY TIGHT BANDAGES
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4. Venous air embolism:
 Suspected if there is air in the venous return line.
 Stop treatment (stop machine by opening pump door)
 Treat with 100% Oxygen; posture in the left lateral position with a 30o head down tilt.
 Remove client from machine as above
5. Haemolysis:
Caused by damage to the blood cells due to an inappropriate dialysate (overheating, toxins such as Copper, Chloramines,
bleach, Formaldehyde).
Signs & Symptoms









chest pain/back pain
dyspnoea
localised burning and pain in access return site
the blood turns a characteristic port wine colour
Treatment
stop dialysis.
disconnect client.
give O2 if indicated.
check for arrhythmias, fluid volume replacement if indicated.
Reference:
Molzahn, A. E (2006) Contemporary Nephrology Nursing Principles and Practice. American Nephrology Nurses Association. New
Jersey
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CLINICAL MANAGEMENT GUIDELINE 29
ALLERGIC & ANAPHYLACTIC REACTIONS
General Care Guideline
Pressure immobilisation bandage / splint over the area of injection, sting or bite if appropriate.
Adrenaline is the drug of choice for cases where there are potentially life-threatening signs
(hypotension; upper airway swelling; bronchospasm unresponsive to nebulised bronchodilators)
 Consider the use of IM Adrenaline in the first instance
 IV use should be with caution
 If IV use is considered, a diluted infusion is the preferred method of administration.
 Manage, as appropriate, using ACTAS guidelines for respiratory distress; shock & hypotension; upper airway
obstruction.
 The fundamental principles are: O2 therapy; Adrenaline; IV fluids
*
CLINICAL MANAGEMENT GUIDELINE 30
CRUSH SYNDROME
General Care Guideline
This is rarely a problem with less than 45 minutes of compression of a significant muscle mass.
Acute volume loss on release is generally considered of greater clinical importance than hyperkalemia and acidosis.
Immediately prior to removal of the compressive force:
 consider the use of an arterial tourniquet to the compressed limb
 increase IV infusion rate
 observe ECG
 Following the removal of the compressive force: release the tourniquets carefully; check for ECG changes.
Manage, as appropriate, using ACTAS guidelines for shock & hypotension, hyperkalaemia, and limb injuries.
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CLINICAL MANAGEMENT GUIDELINE 31
ELECTRIC SHOCK
General Care Guideline
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.
High Voltage – consider possible spinal injury.
Check for exit burns.
Treat other injuries as required.
Electrical burns usually cause greater tissue damage than the appearance of the skin surface would suggest.
Therefore, always transport the patient to hospital.
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CLINICAL MANAGEMENT GUIDELINE 32
ASSAULT
General Care Guideline
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 the assault over the radio.
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CLINICAL MANAGEMENT GUIDELINE 33
BEHAVIOURAL & PSYCHIATRIC EMERGENCIES
General Care Guideline
Identify yourself clearly. If concerned about your safety, or others, call for police 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 e.g. CAT Team.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 34
C.B.R. INCIDENT
General Care Guideline
A CBR incident may be indicated by:
- Physical indicators: e.g. unusual pools of liquid, clouds or fogs, unusual colours, strange devices
or recent explosion.
- Medical signs and symptoms or unusual behaviour being displayed by a number of people.
- Dead birds or animals in the area.
STEP 123 is “Safety Trigger for Emergency Personnel”:
- one patient with cholinergic symptoms is suspicious,
- two patients indicate a CBR,
- three 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 your 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.
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CLINICAL MANAGEMENT GUIDELINE 34 (continued)
C.B.R. INCIDENT
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 (PPE) and have suitable training
in its use.
Only authorised and trained personnel will operate in the HOT& WARM zones.
To decontaminate:
 Remove clothing and discard into a special HAZMAT container;
 Skin must be cleaned by thorough washing or preferably showering;
 Pay special attention to hair and parts of the body with opposing skin surfaces, e.g. the 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.
Treatment:
 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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CLINICAL MANAGEMENT GUIDELINE 35
POISONING, ENVENOMATION & OVERDOSE
General Care Guideline
SPECIFIC AGENTS:
Opioids: IM Naloxone, followed by IV
Tricyclic antidepressants:
 Watch for arrhythmias, seizures and coma. If present:
- administer 0.5 mMol/kg Sodium Bicarbonate
- treat seizures first with Midazolam and tachyarrthymias with Magnesium Sulphate
Digoxin:
Treat tachyarrhythmias with Magnesium Sulphate.
Organophosphates:
 Take care not to become contaminated.
 Consider the possibility of other affected workers, occupants or first-aiders.
 Where feasible – remove contaminated clothing, and wash skin with soap and water.
 If cholinergic effects are present (salivation, sweating, nausea, bradycardia),
administer Atropine lV or IM. Repeat as required.
 Ensure hospital is notified of contaminated patient.
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CLINICAL MANAGEMENT GUIDELINE 35 (continued)
POISONING, ENVENOMATION & OVERDOSE
General Care Guideline
Envenomation:
 Utilise pressure/immobilisation technique if appropriate.
 Treat signs and symptoms as they arise e.g. Cholinergic symptoms with some spider bites.
 Identification – the creature should be brought to the hospital but only if this can be done
safely.
 DO NOT rely on non-expert identification.
 With the positive identification of a Red Back Spider, pressure immobilisation is not
required. Iced compresses should be applied to the area (but not directly onto the 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, with PEEP, if Carbon Monoxide is suspected
 Consider the possibility of other affected workers, occupants or 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)
 Urgently transport if there is a decreased level of consciousness
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CLINICAL MANAGEMENT GUIDELINE 36
EXTENDED CARE
This guideline will apply in the following circumstances:
where patient contact has, or is likely to, extend beyond
(approx) 60 – 90 minutes, andthe patient cannot be
managed adequately within the limits of existing guidelines
and pharmacology.
ANALGESIA:
Morphine:
Following initial doses of IV 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)
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.
IV FLUIDS:
IV Replacement:
Replacement of estimated or continuing losses with Normal
Saline.
Aim for systolic BP of 90 mmHg.
Intramuscular: same provisos as general pharmacology;
0.1mg/kg dose; repeat after 30 minutes as required;
thereafter at minimum of 90 minute intervals
IV Maintenance:
 Normal Saline
Midazolam:
Can repeat initial doses – as per Morphine titration,
with care!
 Baseline of 1 ml/kg/hr;
Titrated to:




Ketamine:
Follow Ketamine dose chart
Perfusion and hydration assessment
Any continuing fluid losses
Environmental conditions
Urine output, if available (aim for 1 ml/kg/hr).
Methoxyflurane:
6ml/day – 15ml/week
I.G. TUBE:
ANTIEMETIC:
Consider placement in the following patients, if patient
contact is likely to be prolonged:
 cervical & thoracic spinal cord lesions
Odansetron:
Further IV dose, after 3 to 4 hours.
May be given IM – repeat after 4 hours.
49
 burns patients, BSA over 20%b (especially if
there is respiratory tract involvement)
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CLINICAL MANAGEMENT GUIDELINE 37
MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS
CMG 37a – GENERAL AMBULANCE OPERATIONS
For use in situations where the patient cannot be managed due to agitation or combativeness.
If concerned about safety, call for police assistance.
Consider/exclude: hypoxia; hypoglycaemia; head injury; drug
overdose; post-ictal state; infection. Treat as appropriate.
Speak quietly - do not shout. Do not leave the patient alone.
Attempt quiet reassurance in an attempt to persuade the
patient to accept treatment.
Reduce the dose of Midazolam for elderly patients with:
 known or suspected hypotension;
 general debility - usually half the dose.
Limb restraints are to be utilised in conjunction with
pharmacological restraint.
MENTAL HEALTH PATIENTS:

If reassurance and persuasion are ineffective or impractical,
move to pharmacological management.
This should be a last resort:
Ensure adequate control of the limb and the patient.
Midazolam up to 0.1mg/kg. Usually IM.
May repeat dose after 10 minutes if necessary.
Wherever possible, obtain an Emergency Order for the
management of mental health patients.
(AFP; medical practitioner; CAT Team)
If not practical, proceed with pharmacological control if there
is genuine concern for the welfare of the patient and/or
others.
PATIENTS MANAGED WITH PHARMACOLOGICAL CONTROL MUST BE
If agitated state is thought to be due to psycho-stimulant use:
Midazolam up to 0.2 mg/kg.
May repeat after 10 minutes if required.
TRANSPORTED TO HOSPITAL
Monitoring once restrained and on O2:
ECG,
Temperature (watch for hypothermia),
O2 saturation,
EtCO2
NOTE
 Ensure thorough documentation on PCR
 All patients managed with CMG 37a will require an incident
report to be submitted to the Clinical Services Section.
Notify and transport to nearest appropriate hospital.
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CLINICAL MANAGEMENT GUIDELINE 37 (continued)
MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS
CMG 37b – AERO-MEDICAL PATIENTS
A lower threshold for intervention with sedation applies to
patients who are transported by air.
If unable to obtain agreement on sedation prior to flight, advise
pilot of your concerns.
Identify and correct possible causes of agitation prior to flight
wherever possible.
If still no decision to sedate patient and in your opinion there is
still an unacceptable risk, do not fly.






Advise all crew and ACTAS Duty Manager.
Electrolyte imbalance
Hypoxia
Hypovolaemia
Pain
Hypoglycaemia
Cold
Duty Manager to discuss with CRRS consultant.
If still agitated - sedate prior to flight.
In flight agitation and combativeness is to be managed as a
matter of urgency.
Note : All patients managed with CMG 37 will require an incident
report to be submitted to ACTAS Clinical Services
Inform the pilot in command.
Proceed immediately to pharmacological management.
Do not use physical restraint beyond the time required to
pharmacologically manage the patient.
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CLINICAL MANAGEMENT GUIDELINE 38
MENINGOCOCCAL DISEASE
Management
Prompt identification of meningococcal disease &
commencement of pre-hospital treatment can be
life-saving.
Ensure personal protection – gloves; mask; gown; and
eye protection, especially if airway care is being attended.
A high index of suspicion is advisable, but only in critically ill
patients.
 General care
Consider meningococcal disease in the following
circumstances:
 Cannulate – 10 ml/kg Normal Saline;
 Ensure minimum scene time
 Repeat as required.
febrile illness with
sudden onset &
disturbed level of consciousness.
 Ceftriaxone – 50 mg/kg IV or IM, to maximum of 2g
 Check BGL
+ / - haemorrhagic, purpuric or petechial rash;
 Urgent transport
+ / - tachycardia, hypotension, peripherally shut down.
Other signs & symptoms are often non-specific,
especially in young children. Such as:
NOTE:
headache; photophobia; neck stiffness; vomiting;
painful or swollen joints; focal signs; and seizures.
Deterioration is possible following antibiotic administration.
This would be unusual during average ambulance contact.
It will most likely be a decrease in LOC and/or BP.
Deterioration can be rapid
Be prepared; manage with IV fluid.
If deterioration continues – consider Adrenaline infusion.
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CLINICAL MANAGEMENT GUIDELINE 39
ADULT AGONAL TRAUMA PATIENTS
An agonal trauma patient is described as:
a trauma patient who presents on scene without cardiac output, and there is some
evidence that this has been for a short time only,(e.g. witness information; short response
time; arrest in ambulance care)
or
trauma patient immediately prior to arrest (faint central pulse, gasping/no respirations)
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
1: Establish no cardiac output
PENETRATING TRAUMA
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)
53
Cannulate; rapid infusion of greater
than 2 litres of crystalloid. (pump set)
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CLINICAL MANAGEMENT GUIDELINE 39 (continued)
ADULT AGONAL TRAUMA PATIENTS
BLUNT TRAUMAMA (continued)
PENETRATING TRAUMA (continued)

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 chest penetration + any doubt
about air entry - chest decompression
with a large bore cannula into the mid
clavicular line 2nd intercostal space.

Drugs
NOTE:
If IPPV is being performed, the
absence of air entry is an unreliable
sign of tension pneumothorax.

Drugs
4: If at this point no restoration of
cardiac output has occurred,
cessation of resuscitation should
be seriously considered.
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:
Exceptions:
- close to trauma centre
- penetrating wounds to the head are to be
treated as for blunt agonal trauma
- Paramedic clinical judgement
- if more than 15 minutes transport time from
any hospital, & no cardiac output regained,
consider ceasing resuscitation
- Paramedic clinical judgement
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CLINICAL MANAGEMENT GUIDELINE 40
BARIATRIC PATIENTS
CLINICAL MANAGEMENT GUIDELINE 41
HEADACHE
CLINICAL MANAGEMENT GUIDELINE 42
BACK PAIN
CLINICAL MANAGEMENT GUIDELINE 43
DEHYDRATION
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If intubation is not successful the following “Failed Intubation Drill”
MUST BE FOLLOWED
Were vocal cords visualised during
initial laryngoscopy?
Insert OP airway and
ventilate with 100% O2
Yes
No
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
No
Immediately remove ETT
and insert OP or NP airway
and re-ventilate with 100% O2
Yes
Continue management in
accordance with the
relevant CMG
DO NOT CONTINUE WITH FRUITLESS ATTEMPTS TO INTUBATE UNDER DIRECT VISION
Able to
oxygenate
and ventilate?
Yes
Attempt digital placement
(on appropriate patients)
If unsuccessful, insert LMA
No
Able to oxygenate
and ventilate?
CONSIDER
No
Yes
CRICOTHYROTOMY
56
Continue management in
accordance with the
relevant CMG
An incident report must be
submitted
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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 – Oxygen saturation < 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.
Consequences and outcomes
Worse case scenario:
 Breathing patient with compromised airway;
 becomes a “can‟t intubate, can‟t ventilate” scenario.
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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 a last resort.
Paediatrics – ONE attempt at endotracheal intubation only.
PROCEDURE
Basic airway management.
Oxygenation
 aim for the highest O2 saturations by the most efficient method.
IV access
 establish a fast flowing line that is reliable & secure.
 a second IV line is sound insurance.
The most experienced operator is 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
10 ml/kg Normal Saline unless in pulmonary oedema.
2. Pre-oxygenate
3. Monitor Patient; ECG / Oximetry
4.Correct any bradycardia
5. Prepare and check equipment
This is vital and includes:
 Laryngoscope
 Suction
 ETT - syringe, ties etc.
 LMA
 Surgical airway kit
6. Brief your assistant
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7. Check allergies
8. Draw up drugs and check
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 0.01mg/kg, fast push.
 Suxamethonium 1.5 mg/kg, over 30 – 60 seconds.
Post intubation to maintain tube and level of sedation,
Alternating doses 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 patient is still bradycardic once ETT is tied
in, consider a dose of Atropine.
Paediatric
 Midazolam 0.05 mg/kg As slowly as possible.
NOTE: Watch BP!
 Atropine 0.01mg/kg, fast push
 Suxamethonium 1.5 mg/kg, over 30 – 60 seconds
Post intubation to maintain tube and level of sedation alternating doses of:
 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 the patient – utilise basic techniques.
There is no second dose of Suxamethonium!
If intubation is still unsuccessful move to a fallback option, following the Failed Intubation
Drill procedure.
 Digital Placement
 LMA
 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 of the ETT and
the results of the procedure.
2. An Incident Report must be sent to the Clinical Support Section by the end of shift; the
hard copy is to be sent via satchel. There are no exceptions.
3. All pharmacologically facilitated intubations will be subject to routine, mandatory Clinical
Advisory Committee Review.
FINAL NOTE
As stated previously, this is a procedure of last resort!
It is anticipated that this procedure will only be utilised in the most exceptional of
circumstances.
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DRUGS FOR AIRWAY MANAGEMENT - SUMMARY SHEET
SEDATION FOR BASIC AIRWAY MANAGEMENT:
Midazolam Dose: up to 0.1 mg/kg, 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
- Reduce Midazolam dose if patient is over 60 or BP <100.
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 the patient is still
bradycardic once the ETT is tied in, consider a dose of Atropine.
SEDATE TO INTUBATE – Morphine & Midazolam:
Pre-infuse IV bolus of fluid, irrespective of BP
Adults:
IF - normal size & weight & age < 75 with a 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 IV, Midazolam 0.1 mg/kg IV
If hypovolaemia is suspected: give half the calculated dose of each drug.
Flush dose with rapid IV fluid bolus.
Doses may be repeated x 1. (Prepare the second doses)
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POST INTUBATION – to maintain ET tube and level of sedation:
Alternating doses of: Midazolam up to 0.1 mg/kg, slow IV dose
Morphine up to 0.05 mg/kg, slow IV dose
NOTE: Monitor BP closely
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A.C.T. AMBULANCE SERVICE
PHARMACOLOGY NOTES
INDEX
ACETYLSALICYLIC ACID (ASPIRIN)
ADENOSINE
ADRENALINE
AMIODARONE
ATROPINE SULPHATE
CALCIUM CHLORIDE
CEFTRIAXONE
CLOPIDOGREL
KETAMINE
LIGNOCAINE
MAGNESIUM SULPHATE
METHOXYFLURANE (PENTHRANE)
MIDAZOLAM (HYPNOVEL)
MORPHINE SULPHATE
NALOXONE (NARCAN)
NORMAL SALINE
OBIDOXIME
ONDANSETRON (ZOFRAN)
PARACETAMOL (PANDOL)
PRASUGREL (EFFIENT)
SALBUTAMOL (VENTOLIN)
SODIUM BICARBONATE
SUXAMETHONIUM
FRUSEMIDE (LASIX)
GLUCAGON
GLUCOSE 10%
GLYCERYLTRINITRATE (ANGININE)
HEPARIN
HYDROCORTISONE
INFLUENZA VACCINE
IPRATROPIUM BROMIDE (ATROVENT)
Drug Calculator
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ACETYLSALICYLIC ACID
(ASPIRIN)
TYPE:
Non-steroidal anti-inflammatory drug [S2]
PRESENTATION:
Tablet 300 mg
ACTIONS:
1. Inhibits platelet function (up to 7 days).
Suppresses inflammation, reduces fever, relieves
pain.
Rapidly absorbed from the stomach and small bowel.
USE:
Suspected Myocardial Ischaemia - reducing platelet
aggregation and limiting clot development.
ADVERSE EFFECTS:
Allergic reactions e.g. asthma, Angioneurotic
oedema, urticaria, rhinitis, shock.
CHECK FOR PREVIOUS REACTIONS
Aggravation of bleeding tendencies.
Gastric irritation (unlikely with 1 tablet only).
CONTRA-INDICATIONS:
Known or suspected allergy to Salicylates
Known or suspected active bleeding
Known bleeding tendency
Chest pain associated with psychostimulant OD
(due to an increased risk of cerebral haemorrhage)
DOSE:
1 tablet (300 mg)
chewed and swallowed, or dissolved in a small amount of
water.
½ tablet (150mg) if on warfarin
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 [S4]
PRESENTATION:
6 mg in 2ml ampoules
ACTION:
Causes transient inhibition of conduction in the heart,
especially in the A-V node.
Onset: 5 – 10 seconds - Duration: approx 10 seconds
USE:
Treatment of supraventricular 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 the time of conversion are common (up to
55% pts) - including 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° heart 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 a fast-flowing pump set
If 1st dose unsuccessful, give 2nd dose
12 mg IV (2 minutes between doses)
Paediatric:
2nd dose:
0.05 mg/kg
0.1 mg/kg
SPECIAL NOTE:
Use only after unsuccessful Valsalva manoeuvre x 2.
Record a 12 lead ECG prior to the use of Adenosine.
Rapid injection with a pump set increases the likelihood of success.
Elevate limb if possible.
Even if the arrhythmia is successfully converted – the patient should still be
transported to hospital as the incidence of recurrent arrhythmias is quite high
(10-15%).
If patient has previously had an unpleasant (fearful) experience with
Adenosine – consider a pre-dose of Midazolam 1 – 1.5mg IV.
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ADRENALINE
TYPE:
A naturally occurring catecholamine [S3]
PRESENTATION:
1:10000 - 1 mg in 10 ml
1:1000 - 1 mg in 1 ml
ACTIONS:
1. Peripheral vasoconstriction ( effect)
2. Increased rate of sinus node
3. Increased myocardial contractility
4. Increased AV conduction
5. Increased myocardial irritably (1 effect)
6. Bronchodilatation
7. Vasodilatation of skeletal muscle (2effect)
– IMS Mini-jet
– ampoules
Onset: 30 seconds IV;
IM:
Max effect: 3 – 5 minutes IV; IM:
30 – 90 seconds
4 – 10 minutes
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 (e.g.: Marplan, Parstelin, Marsilid,
Nardil, Parnate) as 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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ADRENALINE (cont)
DOSE:
Cardiac Arrest
Adult:
1 mg, IV fast push
Paediatric: 0.01 mg/kg IV / IO fast push
(If no IV or IO access, administer via endotracheal tube)
No limit on the number of doses in cardiac arrest
Anaphylaxis / Severe life-threatening asthma:
Adult:
0.5 mg IM
Paediatric: 0.01 mg/kg IM (to 50 kg)
Repeat IM dose x 1 as required
(The preferred IM site for anaphylaxis is the thigh)
If required, IV Adrenaline by infusion:1 mg in 1000 mls Normal
Saline ( = 1mcg/ml)Titrate to response (20 dpm = 1 ml/min =
1mcg/min)
Paediatric - use burette
If the patient is critically ill, slow IV, up to 0.01 mg/kg, no faster
than 50mcg/minute.
NOTE: IV Adrenaline in anaphylaxis & asthma should be used
very cautiously.
Bradyarrhythmias resistant to Atropine:
IV Adrenaline by infusion:
1 mg in 1000 mls Normal Saline ( = 1mcg/ml)
Titrate to response (20 dpm = 1ml/min = 1mcg/min)
Paediatric - use burette
Severe upper airway swelling:
Adrenaline 1:1000:
wt > 10 kg - nebulise 5 mls Adrenaline 1:1000
wt < 10 kg - nebulise 0.5 ml/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
TYPE:
PRESENTATION:
ACTIONS:
USE:
ADVERSE EFFECTS:
CONTRA-INDICATIONS:
DOSE:
Potent anti-arrhythmic agent [S4]
Ampoule 150 mg/3ml
Complex electrophysiological & pharmacological profile:
1. Prolongs the action potential duration; increases the
refractoriness of all cardiac tissue
2. Also blocks Na+ channels (Class I action)
3. Has some anti-adrenergic effects (Class II action)
Ca2+ blockade (Class IV)
4. Prolongs QT interval – reflects global prolongation of
repolarisation
5. When given IV, there is a significant effect on the AV
node which causes a delay in nodal conduction
6. Also effective for accessory pathway conduction
Effective for both supraventricular & ventricular arrhythmias
ACTAS USE: − to slow ventricular rate in AF and AFl
− to treat VT & VF
IV: can cause vasodilatation & negative inotropic effects;
hypotension. (dose & rate dependent)
Occasionally may cause:
1. Bradycardia ( especially in older pts)
2. Phlebitis3. Hot flushes / sweating
Known hypersensitivity
Cross sensitivity to Iodine
VF: Adult: 300 mg IV push dose (over 30 – 60 seconds)
Paediatric: 5 mg/kg IV
SPECIAL NOTE:
VT, AF and AFl:
150 mg IV via Springfuser (over 10 minutes, approx. 7 mls)
Paediatric: 5 mg/kg IV
(VT - If extremely compromised, may be given over 5 mins by
slow IV injection)
No repeat doses for either treatment regimen
Significant potential drug interactions:The following may
potentiate the actions of Amiodarone:
Digoxin; Phenytoin (Dilantin);  Blockers; Ca2+ Channel
Blockers; & other anti-arrhythmics.
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ATROPINE SULPHATE
TYPE:
Parasympathetic blocking agent [S4]
PRESENTATION:
1 mg in 10mls – IMS Mini-jet
ACTIONS:
Large number of actions.
Those important in the pre-hospital setting:
1. Blocks the action of the vagus nerve on the heart
2. Increases the rate of the sinus node
3. Increases speed of conduction through the AV node
4. Reduces the amount of secretions from some glands:
(e.g. tear & salivary glands).
Onset IV: 2 minutes
Max effect: 5 minutes
IM/ET – slightly longer
USES:
1. Bradyarrhythmias with poor perfusion
2. Asystole/PEA
3. Organophosphate poisoning/spider bite (to increase heart
rate irrespective of BP and/or assist airway
maintenance by reducing excessive salivation)
4. To prevent bradycardia with Suxamethonium use
ADVERSE EFFECTS:
tachycardia; palpitations; blurred vision; dry mouth;
confusion, urinary retention; increased body temperature
(by decreasing perspiration).
CONTRA-INDICATIONS: Known hypersensitivity
PRECAUTIONS:
Care needed in patients with Glaucoma
Aim not to increase heart rate above 100/minute
continues over
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ATROPINE SULPHATE (cont)
DOSE:
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
Asystole/PEA:
Adult: 2 mg IV/ET
Paediatric: Not used
Organophosphate poisoning/cholinergic symptoms of spider bite:
Adult/Paediatric: 0.01 mg/kg IV – fast push
Repeat as required. No upper limit on doses.
Continue use even if BP is not low.
May be used IM in these circumstances if IV access is not
available or if there are multiple patients affected.
To treat 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:
1g in 10mls (10% solution) – IMS Mini-jet
ACTION:
Opposes action of high serum Potassium on the
myocardium.
Onset: IV: Several minutes
Duration: 30 - 90 minutes
USES:
1. Emergency treatment of Hyperkalaemia
2. Prolonged hypotension, post Magnesium
administration, unresponsive to fluid
ADVERSE EFFECTS:
Rare with nominated use
1. Tissue necrosis if extravasates from vein
2. Precipitates out in contact with Bicarbonate
CONTRA-INDICATIONS:
Known hypersensitivity
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 [S4]
PRESENTATION:
Vial – 1g Ceftriaxone powder for reconstitution
ACTIONS:
1. Broad spectrum antibiotic
Especially effective against gram-negative bacteria
(e.g. Meningococcus)
2. Effective crossing of blood-brain barrier
USE:
Suspected meningococcal disease, in acutely ill patients
ADVERSE EFFECTS:
1. Hypersensitivity reactions (not common)
2. Diarrhoea
3. Skin rash
PRECAUTIONS:
It is possible that 20% patients with a Penicillin allergy
may be sensitive to Ceftriaxone.
CONTRA-INDICATIONS: Known sensitivity to cephalosporins
DOSE:
50 mg/kg, to a total of 2g
IV preferred. But can also be given IO
Make up to 10ml with water for injection; give slowly over
2 – 4 minutes
May be administered IM:
Dilute a maximum of 1g in 3mls of 1% Lignocaine prior to
administration.
Give two injections if dose is over 1g (i.e. over 3 mls
volume).
SPECIAL NOTE:
An incident report should be submitted to Clinical Services if
Ceftriaxone is administered.
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CLOPIDOGREL
(PLAVIX)
Potent inhibitor of platelet aggregation
TYPE:
Tablet – 75 mg
PRESENTATION:
A specific and potent inhibitor of platelet aggregation.
ACTION:
It does this by binding specifically and irreversibly to the
platelet P2RY12 purinergic receptor, inhibiting Adenosine
Diphosphate (ADP) mediated platelet activation and
aggregation.
Onset : >30 minutes
USE:
Patients with an acute ST elevation myocardial infarction
who meet the requirements for early percutaneous coronary
intervention (PCI) procedure.
ADVERSE EFFECTS:
1. Headache
2. Dizziness
3. Stomach disturbances/pain
4. Diarrhoea or constipation
CONTRA-INDICATIONS:
1. Known allergy
2. Known internal bleed within 6 months,
3. Current use of anticoagulants (excluding Aspirin or
Clopidogrel),
DOSE:
8 x 75 mg tablets (600 mg) – taken orally
Not to be dissolved but can be taken with water.
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GLUCOSE 10%
TYPE:
Hypertonic Glucose solution;
containing 0.1 g Dextrose per ml. [No schedule]
PRESENTATION:
Glucose – in 500ml plastic flask
ACTION:
Glucose is the main energy source for the body cells,
especially the brain.
Onset: 30 – 60 seconds
USE:
Treat hypoglycaemia; following blood glucose
estimation  if BGL < 4, & patient unable to eat or drink
ADVERSE EFFECTS
1. Tissue necrosis if allowed to escape from the vein
2. Hyperglycaemia/hyperosmolality
CONTRA-INDICATIONS: Known hypersensitivity
DOSE:
Up to 2.5 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 10% Glucose should eat to prevent later
development of further hypoglycaemia.
Re-check BGL following treatment.
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FRUSEMIDE
(LASIX)
TYPE:
Loop diuretic [S4]
PRESENTATION:
80 mg in 8ml – IMS Mini-jet
ACTIONS:
1.Potent diuretic
when given IV, Lasix increases
urine output within 5 – 10 minutes; and can last up to 3
hours
2. Causes venous dilatation – decreases venous
return. This effect occurs within 5 minutes.
USE:
Severe Acute Cardiogenic Pulmonary Oedema –
unresponsive to previous treatment – to decrease venous
return and promote loss of fluid.
ADVERSE EFFECTS:
1. If given too rapidly, may lead to hypotension.
2. If marked diuresis occurs, the resulting fluid loss may
lead to hypovolaemic shock, especially in hypovolaemic
patients.
3. Potassium loss may occur – may aggravate
arrhythmias (esp. if previously hypokalaemic).
CONTRA-INDICATIONS: 1. Systolic BP < 90mmHg
2. Hypersensitivity
(Note – possible cross-sensitivity to sulphonamides)
DOSE
Adult: On diuretics:
Adult Not on diuretics:
1 mg/kg IV over 2 minutes
0.5 mg/kg IV over 2 minutes
Single dose only
NOTE: If the patient is in severe pulmonary oedema & IV access is not available,
IM administration is acceptable. (use 2 separate sites if the volume is greater than
4mls).
Paediatric: Not used
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GLUCAGON
TYPE:
Pancreatic hormone [S4]
PRESENTATION:
Vial containing 1 International Unit of Glucagon, as a dry
powder, with a syringe containing 1 ml of diluting solution.
ACTION:
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 minutes
USE:
Treatment of hypoglycaemia, BGL < 4 mMol/L, when oral
or intravenous Glucose cannot be administered.
ADVERSE EFFECTS:
Very rare
1. Nausea and vomiting
2. Very occasional hypersensitivity
CONTRA-INDICATIONS: Known hypersensitivity
DOSE:
Adult:
1 International Unit (IU), IM
Paediatric: wt < 20kg (approx. 5 yrs):
0.5 International Unit IM
wt > 20kg: 1 International Unit IM
Single dose only
NOTE:
Patients who respond to Glucagon should eat, to prevent later
development of further hypoglycaemia.
Recheck BGL following treatment.
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GLYCERYL TRINITRATE
(ANGININE)
TYPE:
Nitrate smooth muscle relaxant and vasodilator [S3]
PRESENTATION:
White 600 mcg sublingual tablet
ACTIONS:
1. Arterial and venous vasodilatation
2. Dilatation of collateral coronary vessels
USES:
1. Relieve cardiac pain of ischaemic origin
2. Relieve pulmonary oedema
ADVERSE EFFECTS:
1. Hypotension
2. Headache
3. Flushing of skin
4. Occasionally – bradycardia
CONTRA-INDICATIONS:
1. Do not administer if systolic BP is < 90
2. Do not administer if HR < 50
3. Do not administer if Sildenafil (Viagra) or Vardenafil
(Levitra) have been taken within 24 hours
4. 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.
5. Known hypersensitivity
DOSE:
Chest Pain:
1 tablet sublingually (600 mcg)
Repeat x 1 as necessary
Acute Cardiogenic Pulmonary Oedema:
1 tablet sublingually (600 mcg)
Repeat x1 after approx 10 minutes if in severe respiratory
distress
If:
90 > Systolic BP < 100, or
the patient has not previously used any nitrate medication
give 1/2 tablet for either chest pain or APO
Repeat 1/2 tablet x 1 as necessary
NOTE:
Tablet should fizz under the tongue if it is still potent. Use tablets within 3 months of
opening bottle. The container MUST be dated when first opened.
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HEPARIN
TYPE:
Unfractionated Heparin anticoagulant
PRESENTATION:
Ampoule – 1 ml with 5000u Heparin
ACTIONS:
1. Inhibits blood clotting
2. Combines with antithrombin III, a naturally occurring
anti-clotting factor in plasma, and inhibits the conversion
of prothrombin to thrombin
3. It also interferes with the actions of other clotting factors
and with fibrin stabilising factor.
USE:
Patients with an acute ST elevation myocardial infarction
who meet the requirements for early percutaneous coronary
intervention (PCI)
ADVERSE EFFECTS:
1. Bleeding
2. Anaphylactoid reactions (rare)
3. Thrombocytopenia
CONTRA-INDICATIONS:
Use PCI checklist
PRECAUTIONS:
Use with care in patients with extensive history of allergies
DOSE:
Adults:
5000u IV, over 30 – 60 seconds
SPECIAL NOTE:
This treatment should not delay transport time to hospital
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HYDROCORTISONE (SODIUM SUCCINATE)
TYPE:
Adrenocorticosteroid [S4]
PRESENTATION:
100 mg powder in 2ml vial
Reconstitute with 2ml sterile water or Normal Saline
ACTIONS:
Numerous & widespread
ACTAS administration is for the anti-inflammatory effect
on the airways
USES:
1. Moderate to severe bronchospasm due to asthma,
anaphylaxis or chronic airways disease
2. Patients with a history of Addison‟s Disease who
present with a problem likely to precipitate a stress
response e.g. AMI, fractures, asthma, gastroenteritis.
ADVERSE EFFECTS:
Nil significant with single use
CONTRA-INDICATIONS: Known previous reaction to corticosteroids
DOSE:
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.
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INFLUENZA VACCINE
TYPE:
Influenza Virus Vaccine
PRESENTATION:
0.5 ml (pre-prepared syringe)
ACTION:
Provides antibody response and provides protection
against clinical illness. Because the influenza virus is
capable of significant changes in its antigenic behaviour
from time to time, protection is afforded by the vaccine,
limited to the strains from which the vaccine was prepared,
or closely related strains.
USE:
Prevention of Influenza virus, types A and B,
in appropriate population groups
ADVERSE EFFECTS:
Local reactions:
Swelling, redness, ecchymosis, induration,
tenderness/pain.
Systemic reactions:
Fever of short duration, malaise, shivering, tiredness,
headache, sweating, myalgia, arthralgia, and
lymphadenopathy. Allergic reactions have been reported.
CONTRA-INDICATIONS:
Should not be given to persons known
to be allergic to fowl proteins
(eggs, feathers or chicken meat)
PRECAUTIONS:
Caution should be exercised if the vaccine is to be given
to persons with an allergic condition such as asthma or
dermatitis.
DOSE:
Infants 6 months to 2 years
0.125 ml deep subcutaneous
Children 2 to 6 years
0.25 ml IMI
Adults and children over 6 years
0.5 ml IMI
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IPRATROPIUM BROMIDE
(ATROVENT)
TYPE:
Anticholinergic bronchodilator [S4]
PRESENTATION:
1 ml plastic nebule;
containing 250 mcg Ipratropium Bromide
ACTIONS:
1. Bronchodilator
2. Blocks vagal reflexes which mediate
bronchoconstriction
3. Possibly more effective when used in
combination with Salbutamol
3 – 5 minutes
2 – 4 hours
Onset:
Duration:
USE:
Bronchospasm from any cause; as an adjunct to
Salbutamol
ADVERSE EFFECTS:
Rare with single use
Occasionally – urine retention
CONTRA-INDICATIONS:
Known hypersensitivity
PRECAUTIONS:
Care needed with use in patients with glaucoma
DOSE:
Adult:
500 mcg – mixed with 1st, then 3rd and 5th doses of
Salbutamol
Paediatric:
250 mcg – mixed with 1st, then 3rd and 5th doses of
Salbutamol Use with MDI/Spacer
mild to moderate, no hypoxia and familiar with use
1. Adult >6 yrs 4 x 21mcg (4 puffs)
2. Child < 6 yrs 2 x 21mcg ( 2 puffs)
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KETAMINE HYDROCHLORIDE
(KETLAR)
TYPE:
Dissociative anaesthetic agent [S8]
PRESENTATION:
200 mg in 2ml vial
ACTIONS:
Complex, multiple actions:
1. Analgesic; sedative agent
2. Marked amnesia
3. Has bronchodilating properties
4. Does not tend to cause respiratory depression
5. Does not tend to cause hypotension
(via sympathetic stimulation)
Onset of action is rapid: 1 – 2 minutes IV
3 – 5 minutes IM
USES:
1. Pain management, especially in patients who are
hypotensive or unable to have narcotics, & if no
alternative is available.
2. Particularly useful for trapped patients with limb injuries,
especially if BP is borderline for narcotics.
3. Adjunct to Morphine, with alternating doses.
ADVERSE EFFECTS
1. Transient Laryngospasm
2. Hypersalivation
3. Emergence reactions
4. Muscle twitching & purposeless movements
5. Occasionally respiratory depression → apnoea
6. Occasionally hypotension if given rapidly to a
hypovolaemic patient
PRECAUTIONS:
1. Use with care in patients where a rise in BP may be
hazardous (e.g. stroke, cerebral trauma)
2. Known glaucoma
3. Previous psychoses
4. Hyperthyroidism
5. Elderly and paediatric patients
6. Patients previously administered narcotics
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KETAMINE HYDROCHLORIDE (cont)
CONTRA-INDICATIONS:
1. Known sensitivity
2. Active cardiac disease (myocardial ischaemia, LVF, uncontrolled hypertension.)
3. Children under 1 year old
DOSE:
See attached Dose Chart
NOTE: Ketamine can be used with alternating doses of Morphine.
SPECIAL NOTE:
Patients who have received Ketamine may still have a significant awareness,
despite an appearance of unconsciousness. They may be able to hear and have
some recall. Patients should be advised that they will experience
strange/unusual sensations.
Patients who become agitated may be managed with small repeat doses of
Midazolam.
Ketamine is a Drug of Dependence. Its use must be checked by both crew
members.
Under the Drugs of Dependence Act, recording and accounting for Ketamine use is
a legal requirement.
The unused portion of the dose must be appropriately disposed of & the disposal
recorded.
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KETAMINE DOSE CHART
DOSES:
Adult
Initial IV
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
> 20 kg Up to 1 mg/kg.
Increments of
up to 10 mg at
intervals of 30
– 60 seconds.
Paediatric
< 20 kg Up to 1 mg/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
1 mg/kg
0.5
mg/kg
0.5
mg/kg
0.5
mg/kg
Repeat IM
Previous
opiates
After 5 – 10
minutes;
1 mg/kg
IV: Up to
10 mg
increments as
before.
IM: 0.5 mg/kg
After 5 – 10
minutes;
0.5 mg/kg
IV: Up to
5 mg
increments as
before.
IM:
0.25 mg/kg
After 5 – 10
minutes;
0.5 mg/kg
IV: Up to
5 mg
increments as
before.
IM:
0.25 mg/kg
After 5 – 10
minutes;
0.5 mg/kg
IV: Up to
2.5 mg
increments as
before.
IM:
0.25 mg/kg
All IV doses are to be given slowly, over 30 seconds.
Recommended dilutions:
Adult IV: 200 mg diluted up to 10ml; = 20 mg/ml
Adult IM: 100 mg diluted up to 2ml. Discard excess dose before IM use.
Elderly pt IV: 100 mg diluted up to 10ml; = 10 mg/ml
Elderly pt IM: 100 mg diluted up to 2ml. Discard excess dose before IM use.
Children IV: 50 mg diluted to 10ml; = 5 mg/ml
Children IM: 50 mg diluted to 2ml. Discard excess dose before IM use.
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LIGNOCAINE
TYPE:
1. Local anaesthetic
2. Anti-arrhythmic [S4]
PRESENTATION:
50 mg in 5ml – plastic ampoule
ACTIONS:
1. Local anaesthetic effects
2. Suppresses ventricular arrhythmias
Onset S/C: 1 – 4 minutes
Max effect: 5 – 10 minutes
IV: 1 – 3mins
USES:
1. Local anaesthesia prior to invasive procedures
2. VT with cardiac output, in patients who cannot
have Amiodarone
3. First flush for IO in an aware patient
ADVERSE EFFECTS:
These effects are extremely unlikely in usual
subcutaneous doses, especially if the syringe is
continually aspirated.
More likely if given IV.
1. C.N.S. effects
stimulation followed by depression
drowsiness, agitation, muscle twitching,seizures &
coma
2. Cardiac effects
hypotension, bradycardia, heart block, asystole
CONTRA-INDICATIONS:
Known hypersensitivity
PRECAUTIONS:
Nil
DOSE:
Local anaesthesia:
Adult and Paediatric - up to 5mls subcutaneously
VT with cardiac output:
1 mg/kg – slow IV (over 2 minutes)
IO in an aware patient:
Adult:
2 - 4mls first flush
Paediatric: 1 - 2mls first flush
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MAGNESIUM SULPHATE
TYPE:
Electrolyte solution [No schedule]
PRESENTATION:
50% solution (10mMol) 2.5g in 5ml 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 and, as such, it may promote
myocardial cell membrane stability.
USES:
1. Torsades de pointes (polymorphic VT)
(Often associated with prolonged QT interval)
2. Refractory VF
3. Digoxin and Tricyclic antidepressant toxicity
4. Seizures due to eclampsia
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:
Adult:
Cardiac output:
Dilute up to 10mls with N/Saline;
2.5g IV, over 5 minutes
No cardiac output: 2.5g IV, over 30 – 60 seconds
Siezures due to Eclampsia: 5mg dilute up to 10ml IV
Paediatric: (unusual)
Dose is 50 mg/kg, to maximum of 2.5g
Dilute to 10mls = 250 mg/ml
Cardiac output:
give calculated dose IV over 3 – 5 minutes
No cardiac output:
give calculated dose IV over 30 – 60 seconds
SPECIAL NOTE: Prolonged hypotension post-Magnesium administration; if
unresponsive to fluids, patient may be treated with IV Calcium
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METHOXYFLURANE
(PENTHRANE)
TYPE:
Volatile inhalation anaesthetic and analgesic agent
[S4]
PRESENTATION:
3ml bottle
ACTION:
Central Nervous System depressant
Onset: 3 – 5 mins
Offset: 3 – 5 mins
USE:
For relief of pain of all origins
ADVERSE EFFECTS:
1. Altered consciousness
2. Renal dysfunction
} rare with once only
3. Jaundice
} Ambulance use
CONTRA-INDICATIONS:
1. Depressed level of consciousness
2. Known hypersensitivity
PRECAUTIONS:
1. Renal disease
2. Diabetes
3. Antibiotic or barbiturate use
4. Caution if patient unable to self-administer
DOSE:
Up to 3mls, self administered via
Penthrox inhaler, with up to 8 L/minute of Oxygen
Repeat x 1 as required
Dose should not exceed 6mls/day or 15mls/week
NOTE:
May be used with Midazolam for musculo-skeletal pain.
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METOCLOPRAMIDE (MAXOLON)
TYPE:
Antiemetic [S4]
PRESENTATION:
10 mg in 2ml ampoules
ACTION:
Antiemetic centrally acting on brain stem
increases gastric emptying
Onset: 3 – 15 minutes (IV)
Duration: 30 minutes
USES:
1. Prevent vomiting:
when narcotic analgesic is to be administered
2. High spinal injury
3. Serious eye injury
4. Suspected ischaemic chest pain
5. Treat nausea & vomiting
ADVERSE EFFECTS:
Uncommon with usual doses
Occasionally:
1. Drowsiness
2. Lethargy
3. Dry mouth
4. Oculogyric crisis, facial spasms
5. 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:
1. Previous reaction
2. G.I. bleeding
DOSE:
Adult dose:
10 mg lV over 2 minutes
IM 10 mg
Give prior to narcotic administration
Single dose only
Paediatric dose:
88
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MIDAZOLAM
(HYPNOVEL)
TYPE:
Anticonvulsant and sedative agent [S4]
PRESENTATION:
5 mg in 5ml ampoules
15 mg in 3ml ampoules
ACTIONS:
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:
1. Status epilepticus - in a patient who has
continual or prolonged seizures.
2. Sedation to manage airway, RSI, sedation of
a previously intubated patient.
3. Adjunct to analgesia for injuries
wheresignificant muscle spasm is present.
4. To manage agitated & combative patients.
5. To manage autonomic hyperreflexia.
6. Antiemetic (especially in paediatric patients).
ADVERSE EFFECTS:
Depression of level of consciousness - leading to:
1. Respiratory depression
2. Loss of airway control
3. Hypotension
CONTRA-INDICATIONS
Known hypersensitivity
PRECAUTIONS
1. Haemodynamic instability
2. Respiratory depression
DOSE:
Seizures:
Adult dose:
Up to 0.1 mg/kg lV, over 2 minutes, until fitting ceases.
Repeat if fitting continues or recurs.
Paediatric dose:
Up to 0.1 mg/kg IV, over 2 minutes, until fitting ceases.
Repeat if fitting continues or recurs.
I.M: 0.1 mg/kg
Repeat x 1 after 10 minutes as necessary.
continues over
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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 IV over 2 minutes
Repeat x 1 as required
Further analgesic doses are to be given with caution
Mild sedation to facilitate basic airway management:
Up to 0.1 mg/kg over 2 minutes
When used with Morphine to sedate for airway management in
selected patients:
Adult: 10 mg IV rapid push
(adjusted for patient weight, age and BP)
Paediatric: 0.1 mg/kg rapid push
Repeat x 1 as required
When used with Suxamethonium:
0.05 mg/kg IV
When used to manage a combative or agitated patient::
Up to 0.1 mg/kg IV, until manageable.
May repeat as required to continue management
IM: 0.1 mg/kg
May repeat as required to continue management
If agitation & combativeness is thought due to
psychostimulant use:
Up to 0.2 mg/kg IV, until manageable
May repeat as required to continue management
IM: 0.2 mg/kg *
May repeat as required to continue management
* Use 0.2 mg/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.
continues over
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When used to manage a patient with Autonomic Hyperreflexia:
After identifying causes and trying appropriate actions and if BP remains
elevated then:
IV: 0.05 mg/kg, over one minute,
May be repeated once after 10 minutes if no fall in BP
IM: 0.1 mg/kg
When used as an antiemetic:
0.05 mg/kg IV
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/3ml 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.
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MORPHINE SULPHATE
TYPE:
Narcotic analgesic [S8]
PRESENTATION:
10 mg in 1ml ampoule
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:
1. To relieve severe pain
2. Acute pulmonary oedema
3. RSI
4. Sedation of a previously intubated patient
5. Chest Pain
ADVERSE EFFECTS:
1. Nausea and vomiting
2. Drowsiness
3. Respiratory depression
4. Hypotension
5. Dependence
6. Pin point pupils
7. Bradycardia
CONTRA-INDICATIONS:
1. Depressed level of consciousness
(GCS 13 or less)* Pain relief only.
2. Respiratory depression * Pain relief only.
3. Known hypersensitivity
4. BP < 70mmHg (pain relief)
5. BP < 90mmHg (pulmonary oedema)
6. Acute asthma attacks
7. Pain management in labour
PRECAUTIONS:
1. Elderly patients (may be sensitive)
2. Patients with COAD
3. Hypovolaemic patients (hypovolaemia should be
corrected before Morphine administration)
4. Patients with systolic BP 70 – 90mmHg (see
below)
5. Children under 1 year
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DOSE:
Pain relief:
Adult:
Up to 0.05 mg/kg lV, over 2 minutes
May be repeated at 5 minute intervals, until pain is managed.
Paediatric: Up to 0.05 mg/kg IV, over 2 minutes
May be repeated at 5 minute intervals, until pain is relieved.
Use with caution under 1 yr of age.
Morphine administration can be used alternately with Ketamine.
Intramuscular administration:
Pain relief only.
Not for chest pain if cardiac ischaemia suspected
No IV available
No hypotension
Patient contact estimated > than 20 minutes
Dose: 0.1 mg/kg
Repeat x 1 after 30 – 45 minutes as required
Patient with pain; systolic BP of 70 – 90mmHg:
IV use only
hypovolaemic patients must be receiving fluids
up to half a calculated 0.05 mg/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
10mmHg or more with half dose, even if it remains above 70
(e.g. initial BP 85mmHg; following Morphine dose BP now 75
mmHg)
continues over
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Pulmonary Oedema:
0.05 mg/kg lV, over 2 minutes
May be repeated x 1 after 10 minutes, if required.
When used with Midazolam for RSI:
Adult:
10 mg IV rapid push
(dose adjusted for patient weight, age and BP).
Paediatric: 0.05 mg/kg rapid push
Repeat x 1 if required.
To maintain sedation post intubation:
0.05 mg/kg lV, slow IV dose
SPECIAL NOTE:
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.
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NALOXONE
(NARCAN)
TYPE:
Narcotic antagonist [S4]
PRESENTATION:
0.4 mg in 1ml – IMS Mini-jet
ACTION:
Reverses the effects of narcotic analgesics
Onset IV: 1 – 2 minutes
Duration: 30 – 45 minutes
IM: unknown; but thought to have a slightly longer onset
and duration than when given lV.
USES:
1. Coma
2. Drug overdose and poisoning
3.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:
1 May precipitate acute withdrawal syndrome in narcotic
addicts.
2. Occasional aggressive behaviour following reversal.
3. Nausea and vomiting.
CONTRA-INDICATIONS: Known hypersensitivity
DOSE:
Adult: 0.4 mg IM, then
0.4 mg lV increments, fast push
May repeat IV dose x 3 (to maximum of 2 mg)
Paediatric: 0.01 mg/kg lV, fast push
Maximum paediatric dose: 3 doses
All doses may be administered IM or IV as the situation demands.
SPECIAL NOTE:
When used IV, the effect may wear off rapidly, especially if a 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.
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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 1000mls of 0.9% Sodium Chloride solution
in a collapsible plastic flask.
ACTIONS:
1. Plasma volume expander
2. Also expands interstitial fluid volume
3. 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 IV route for drugs.
ADVERSE EFFECTS:
Fluid overload
DOSE:
IV fluid resuscitation:
Adult:
10 ml/kg lV – then reassess patient
Rate of administration is dependent on the condition of
patient. Aim to keep BP at about 90mmHg 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 (10ml/hr with a standard drip set).
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OBIDOXIME
TYPE:
Oxime [No schedule]
PRESENTATION:
220 mg Obidoxime/2 mg Atropine – auto injector
ACTION:
Reactivating inhibited acetylcholinesterase
USES:
1. To treat super toxic organophosphate poisoning
(nerve agents) by relieving the symptoms of
skeletal neuromuscular blocking that occurs
during a cholinergic crisis.
2. Used in combination with Atropine, as
combination auto-injector, or with Atropine
separately administered.
ADVERSE EFFECTS:
1. Hypotension, menthol-like sensation, warm
feeling to the face, dull pain at site of injection.
2. 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.
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ONDANSETRON
(ZOFRAN)
TYPE:
Potent anti-nauseant & antiemetic [S4]
PRESENTATION:
4 mg/2 ml ampoule
4 mg wafers
ACTIONS:
1. Potent, highly selective histamine receptor antagonist.
2. Precise mode of action in control of nausea & vomiting
is not known. Likely to have actions peripherally and in
the Central Nervous System.
3. Maximum effect is approximately 10 minutes following
IV administration.
4. Hepatic metabolism.
USE:
For the 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: Known hypersensitivity
DOSE:
Adult:
4 mg IV, slowly over 2 minutes
Paediatric: 0.1 mg/kg IV, slowly over 2 minutes
(to total of 4 mg).
May be administered IM if necessary.
May repeat x 1 if required, after approx. 10 minutes
Wafers:
4 mg sublingually
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PARACETAMOL
(PANADOL)
TYPE:
Simple analgesic / antipyretic
PRESENTATION:
48 mg/ml Colour Free Liquid
ACTIONS:
1. Antipyretic
2. Mild analgesic
USE:
Pyrexia in children who have had or may have a
febrile convulsion
(For ACTAS treatment, pyrexia is generally > 38o C)
PRECAUTIONS:
1. Impaired hepatic function
2. Impaired renal function
ADVERSE EFFECTS:
Rare – none of these side effects have been
confirmed or refuted as being linked to the casual use
of Paracetamol:
Dyspepsia, nausea, allergic and haematological
reactions
CONTRA-INDICATIONS:
1. Known or suspected allergy to Paracetamol
2. Previous Paracetamol dose in last 4 hours
3. Children who do not have a sufficient gag reflex to
swallow the measured dose
4. Not to be given to children < 1 month old
DOSE:
20 mg/kg given orally by 3ml syringe
SPECIAL NOTE:
It is envisaged that the administration of Panadol Liquid will be for children that are
post-ictal / post febrile convulsion, or who are likely to have a febrile convulsion and
are not responding to non-medical treatment.
Paracetamol does not necessarily prevent febrile convulsions.
Active cooling measure should still be carried out as well as checking for the reason for
pyrexia (URTI, Meningococcal disease).
As a general rule, if children are administered Paracetamol, they should not be left at
home.
Do not exeed 60mg/kg/24hours
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PRASUGREL
(EFFIENT)
TYPE:
Thienopyridine class inhibitor of platelet activation and
aggregation
PRESENTATION:
Tablet – 10 mg
ACTION:
Prasugrel is an inhibitor of platelet activation and
aggregation through the irreversible binding of its active
metabolite to the P2Y12 class of ADP receptors on platelets.
Peak concentration occurs approximately 30 minutes after
dosing.
USE:
Patients with an acute ST elevation myocardial infarction
who meet the requirements for early percutaneous coronary
intervention (PCI) procedure.
ADVERSE EFFECTS:
1. Purpura
2. Headache
3. Dizziness
4. Stomach disturbances/pain
5. Diarrhoea or constipation
CONTRA-INDICATIONS:
1. Hepatic failure
2. Pathologic bleeding
3. Any known or suspected CVA / TIA
4. Weight < 60kg
5. Age > 75
6. Current use of anticoagulants (excluding Aspirin or
Clopidogrel),
DOSE:
6 x 10 mg tablets (60 mg) – taken orally
Not to be dissolved but can be taken with water.
SPECIAL NOTE:
This treatment should not delay transport time to hospital
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SALBUTAMOL
TYPE:
(VENTOLIN)
Synthetic 2 receptor stimulant [S4]
PRESENTATION:
Plastic nebules:
5 mg in 2.5ml nebuliser solution
2.5 mg in 2.5ml nebuliser solution
ACTIONS:
1. Bronchodilatation
2. Relaxation of involuntary muscle
3. Moves K+ from extra-cellular to intra-cellular
space
Onset (neb): 5 minutes
Max effect: 10 – 50 minutes
USES:
1. Bronchospasm from any cause
2. Emergency treatment of suspected
hyperkalaemia
ADVERSE EFFECTS:
Rarely seen with usual nebulised therapeutic
doses:
1. Tachycardia
2. Tremors
3. Hypotension
CONTRA-INDICATIONS:
Known hypersensitivity
DOSE
Via nebuliser, with Oxygen at 6 – 8 L/minute
Adult:
Paed:
5 mg nebule
2.5 mg nebule
Use MDI/Spacer
mild to moderate, no hypoxia and familiar with use
Adult >6 yrs 10 x 100mcg (10 puffs)
Child < 6 yrs 5 x 100mcg ( 5 puffs)
With moderate to severe bronchospasm; or
suspected hyperkalaemia  give continuous
nebulised Salbutamol.
SPECIAL NOTE:
With significant hypoxia, Salbutamol should be
administered with 100% Oxygen.
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SODIUM BICARBONATE
TYPE:
Hypertonic alkaline solution; 8.4% Sodium Bicarbonate
solution; contains 1 mMol/ml Sodium & 1 mMol/ml
Bicarbonate. [No schedule]
PRESENTATION:
50ml Sodium Bicarbonate solution, IMS Mini-jet
ACTIONS:
1. Neutralizes metabolic acidosis as a result of cardiac
arrest or poor perfusion
2. Causes movement of K+ into cells – swaps with H+ ions
Onset: 30 – 60 seconds (IV)
USES:
1. To combat acidosis in prolonged cardiac arrest.
2. For emergency treatment of hyperkalaemia.
3. For treatment of arrhythmias, seizures or coma in
Tricyclic antidepressant and Digoxin overdose patients.
4. To combat acidosis and hyperkalaemia in crush
syndrome.
ADVERSE EFFECTS:
1. Metabolic alkalosis
2. High Sodium content may lead to fluid overload &
cardiac failure.
3. Interacts with some other drugs - (especially Calcium &
Adrenaline); always flush well through the line before &
after administration. Consider a second line.
CONTRAINDICATIONS: Known hypersensitivity
DOSE:
Adult & paediatric:
0.5 mMol/kg IV;
repeat x 1 as required
Given as a fast push in cardiac arrest; and
over 2 – 5 minutes to patients with a cardiac output.
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SUXAMETHONIUM
TYPE:
Depolarising muscle relaxant [S4]
PRESENTATION:
Ampoules – 100 mg/2ml
Acts like the neurotransmitter Acetylcholine at the
neuromuscular junction. Persists for a period long
enough to exhaust the motor endplate by prolonged
depolarisation.
ACTION:
Onset: IV: approx 45 seconds
Duration: IV: 5 – 7 minutes
To facilitate airway management in selected patients
with a GCS of less than 9
USE:
ADVERSE EFFECTS:
CONTRAINDICATIONS:
PRECAUTIONS:
Bradycardia; Potassium release; increased intraocular & intragastric pressure. Occasionally
prolonged paralysis. Has been associated with
malignant hyperthermia.
Previous reaction to Suxamethonium
Suspected hyperkalaemia
Elderly patients
Neuromuscular disease
Care with use in children
Select patients carefully; always have a fallback
position!
1.5 mg/kg IV; over 30 – 60 seconds
DOSE: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
(Bradycardia maybe a result of the head injury and raised ICP - thus
BP will be elevated. In this case there is no requirement for Atropine
regardless of the degree of bradycardia).
Prior to administration, give IV Midazolam 0.05 mg/kg
Follow up with additional Midazolam after intubation
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DRUG DOSE CALCULATOR
DOSE
50 mg/kg
CALCULATION
NOTES
Dose = Weight x 50
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
1 mg/kg
1 mMol/kg
Dose = Weight
1
0.5 mg/kg
0.5 ml/kg
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
104
Maximum dose of:
2g for Ceftriaxone, &
2.5g for Magnesium
NOTE:
Version 4.2
01/10
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
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.
15 = Oral contraceptives
16 = Corticosteroids
17 = Diuretic (loop)
18 = Diuretic (potassium sparing)
19 = Diuretic (thiazide)
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 immuno-modifying agents. Generally, no drugs
given regularly by injection are included (exception insulins).
30 = Antihistamines
31 = Analgesics
32 = Antipsychotic
33 = Angiotensin II antagonist
34 = Antiulcerant agents
There are now a number of generic items on the
market, with the generic name + the company that
produces it as the drug name.
e.g. Healthsense Captopril; Diltiazem BC.
The generic firms are:
BC;
Chem Mart;
DBL;
GenRx;
Healthsense;
Terry White Chemists;
1
2
3
4
5
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
44 = Weight Reducing Agents
= Anabolic steroids
= Antianginal
= ACE inhibitors
= Antiarrhythmics
= Anticoagulants
Product Name
ABILIFY
ACCOLATE
ACCUPRIL
ACCURETIC
ACENORM
ACIMAX
ACLIN
ACQUIN
ACT-3
ACTIFED
ACTION
ACTIPROFEN
ACTIQ
ACTONEL
ACTOS
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
105
Serial Number
32
14
3,8
3,8
3,8
34
9,31
3,8
9,31
30
30
9
31
38
25
Version 4.2
01/10
Product Name
ACTRAPID
ADALAT
ADDOS
ADEFIN
ADENOCOR
ADRONAT
ADVIL
AERODIOL
AERON
AGGRASTAT
AGON SR
AIROMIR
AKINETON
ALDACTONE
ALDAZINE
ALDOMET
ALENDROBELL
ALENDRONATE
ALEPAM
ALEVE
ALLEGRON
ALLERMAX
ALLOHEXAL
ALLOPURINOL BC
ALLORIN
ALLOSIG
ALODORM
ALPHAGAN
ALPHAPRESS
ALPHAPRIL
ALPRAX
ALPRAZOLAM
ALVESCO
AMARYL
AMFAMOX
AMISULPRIDE
AMIZIDE
ALMO
AMLOPIDINE
AMPRACE
AMYTAL
ANAFRANIL
ANAGRAINE
ANAMORPH
ANAPROX
ANATENSOL
ANDRIOL
ANDROCUR
Serial Number
26
2,8,13
2,8,13
2,8
4
Product Name
ANDRODERM
ANDRUMIN
ANGELIQ
ANGININE
ANGIOMAXIN
ANPEC
ANSELOL
ANTENEX
ANZEMET
APIDRA
APOVEN
APRESOLINE
APRINOX
ARATAC
ARAVA
AREDIA
ARICEPT
ARIMA
ARIPIPRAZOLE
ARIXTRA
AROPAX
ARTANE
ARTHREXIN
ARTHROTEC 50
ASASANTIN SR
ASIG
ASMOL
ASPALGIN
ASTRIX 100
ATACAND
ATEHEXAL
ATENOLOL BC
ATIVAN
ATROBEL
ATTENTA
AURORIX
AUSCAP
AUSCARD
AUSFAM
AUSGEM
38
9,31
39
14B
5
2,8,13
14B
10, 42
8,18
28,32
8
38
38
28,35
9
6D
16, 30
21
21
21
21
24,27,35
43
8,29
3, 8
27,28,35
27,28,35
16
25
22,34
32
8,18
13
13
3,8
24
6D
36
31
9,31,35
28,32
39
39
AUSPRIL
AUSRAN
AVANDAMET
AVANDIA
AVANZA
AVAPRO
AVIL
AVOMINE
106
Serial Number
39
7
39
2,29
5
2,4,8,13
2,4,8,12
27,28,35
7
26
14B
8,29
8,19
4
9
38
40
6B
32
5
6A
10, 34, 42
9,21,31
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
25
6
8,33
30
7
Version 4.2
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Product Name
AXIT
AYLIDE
AZOL
AZOPT
BARBLOC
BECLOFORTE
BECONASE
BECOTIDE
BENADRYL
BENZTROP
BEROTEC
BETAGAN
BETALOC
BETOPIC
BETOQUIN
BICOR
BIOGLAN
BIPHASIL
BONDRONAT
BONEFOS
BRENDA 35
BREVIBLOC
BREVINOR
BRICANYL
BROMOHEXAL
BROMOLACTIN
BRONDECON
BRUFEN
BUGESIC
BURINEX
BUSCOPAN
BUSPAR
BUTALGIN
BUTAMOL
BYETTA
CABESAR
CAFERGOT
CALCIJEX
CALCITRIOL
CADUET
CANDYL
CAPADEX
CAPOTEN
CAPTOHEXAL
CAPTOPRIL BC
CAPURATE
CARAFATE
Product Name
CARBAMAZEPINE
CARDINORM
CARDIPRIN
CARDIZEM
CARDOL
CARTIA
CATAPRES
CELEBREX
CELESTONE
CELICA
CELPRAM
CHOLSTAT
CHLORPROMAZINE
CIALIS
CIAZIL
CIMEHEXAL
CIMETIDINE BC
CIPRAMIL
CITALOBELL
CITALOPRAM
CITRACAL
CITRIHEXAL
CLARAMAX
CLARATYNE
CLARINASE
CLEXANE
CLIMARA
CLIMEN
CLINORIL
CLOBEMIX
CLOMIPRAMINE
CLONAC
CLOPINE
CLOPIXOL
CLOPRAM
CLOSYN
CLOZARIL
CODALGIN
CODAPANE
CODIPHEN
CODIS
CO-DIOVAN
CODOX
COGENTIN
COGNEX
COLESE
COLESTID
COLGOUT
Serial Number
6A
25
39
43
2,4, 8,12
14C,16
16
14C,16
30
10,42
14B
43
2,4,8,12,36
43
43
12
44
15
38
38
15,39
4,12
15
14B
10
10, 39
14A
9,31
9
17
42
28
9,31
14B
25
10
36
38
38
13
9,31
31
3,8
3,8
3,8
21
34
107
Serial Number
32,37
4
11, 5
2,8,13
4,12
11, 5
8,36
9
16
6A
6A
23
32,42
29
6A
22,34
22, 34
6A
6A
20
38
38
30
30
30
5
39
39
9,31
6B
6D
9
32
32
6D
32
32
31
31
31
31
3,8,33
31
10, 42
40
42
23
21
Version 4.2
01/10
Product Name
COLOFAC
COMBIGAN
COMBIVENT
COMTAN
CONCORZ
CORALAN
CORAS
CORBETON
CORDARONE
CORDILOX
CORTATE
COSOPT
COUMADIN
COVERSYL
COZAAR
CRESTOR
CROMESE
CRYSANAL
CYMBABLTA
CYPRONE
CYPROSTAT
CYPROHEXAL
CYTOTEC
DANOCRINE
DAONIL
DAPA-TABS
DECA-DURABOLIN
DECANOATE
DEMAZIN
DEPO DUR
DEPO MEDROL
DEPO NISOLONE
DEPO PROVERA
DEPO RALOVERA
DEPTRAN
DERALIN
DERMESTRIL
DESERIL
DEXAMPHETAMINE
DEXAMETHSON
DIABEX
DIAFORMIN
DIAMICRON
DIAMOX
DIANE
DIAPRIDE
DIAZEPAM
Product Name
DIBENYLINE
DICLOFENAC
DICLOHEXAL
DIDROCAL
DIDRONEL
DIGESIC
DIHYDERGOT
DILANTIN
DILASIG
DILATREND
DILAUDID
DILOSYN
DILTAHEXAL
DILTIAZEM BC
DILZEM
DIMETAPP
DIMIREL
DIMETRIOSE
DINAC
DINDEVAN
DIOVAN
DITHIAZIDE
DITROPAN
DOLAPRIL
DOLASED
DOLOBID
DOLAFORTE
DOLOXENE
DONNALIX
DONNATAB
DORMIZOL
DOTHEP
DOZILE
DRAMAMINE
DROLEPTAN
DUCENE
DUPHASTON
DURABOLIN
DURIDE
DUROGESIC
DUROMINE
DUROTRAM
DYMADON
DYNASTAT
EDECRIN
EDRONAX
ECOTRIN
EFEXOR
Serial Number
42
43
14B
10
6A
2
2,13
2,4,8,12
4
2,4,8,13
16
43
5
3,8
8,33
23
14C
9
6A
39
39
39
34
39
25
8
1
32
30
31
16
16
15
15
6D
2,4,8,12,36
39
36
41
16
25
25
25
37, 43
15, 39
25
35
108
Serial Number
29
9
9,31
38
38
31
36
37
8,12
12, 8
31
30
2,13
2, 13
2,13
30
25
39
9
5
33
19
42
3
31
9,31
31
31
42
7, 42
24
6D
27
7
32
27,28,35
39
1
2
31
44
31
31
9
8,17
6A
5,11,31
6A
Version 4.2
01/10
Product Name
ELDEPRYL
ELEMENDOS
ELEVA
ELMENDOS
EMETROL
ELMIRON
EMEND
ENAHEXAL
ENALABELL
ENALAPRIL
ENBREL
ENDECRIN
ENDEP
ENDONE
ENIDIN
EPAC
EPHIDRINE HYDROC.
EPILIM
ERGODRYL
ESIPRAM
ESTALIS
ESTELLE 35 ED
ESTRACOMBI
ESTRADERM
ESTRADOT
ESTROFEM
EUTROXSIG
EVISTA
EXELON
EXFORGE
EXOLISE
EXTINE
EZETROL
FAMOHEXAL
FAMOTIDINE
FAVERIN
FELDENE
FELODIL
FELODUR
FEMODEN
FEMOSTON
FEMTRAN
FENAC
FENAMINE
FEXAL
FEXO-TABS
FIBSOL
Product Name
FILPRIL
FIORINAL
FLECATAB
FLIXOTIDE
FLORINEF
FLUANXOL
FLUOHEXAL
FLUOXEBELL
FLUOXETINE BC
FLUOXETINE DBL
FORADILE
FORMET
FORTEO
FORTRAL
FOSAMAX
FOSPRIL
FOSINOPRIL
FRAGMIN
FRISIUM
FRUSEHEXAL
FRUSID
GABAHEXAL
GABAPENTIN
GABARAN
GABATINE
GABITRIL
GANTIN
GEMFIBROZIL BC
GEMHEXAL
GEMIFIBROMAX
GENORAL
GENOTROPIN
GENOX
GLIMEL
GLUCOBAY
GLUCOHEXAL
GLUCOMET
GLUCOPHAGE
GLUCOVANCE
GLYADE
GOPTEN
HALCION
HALDOL
HELIDAC
HEPARIN
HUMALOG
HUMANOTROPE
HUMIRA
Serial Number
10
37
6A
37
7
5
7
3, 8
3,8
3, 8
9
17
6D
31
43
14B
14B
32,37
36
6A
39
39
39
39
39
39
39
38
40
13,33
44
6A
23
34
34
6A
9,31
8,13
8,13
15
39
39
9,31
30
30
30
3, 8
109
Serial Number
3,8
31
4
14C16
16
32
6A
6A
6A
6A
14B,14C
25
38,39
31
38
3,8
3,8
5
27,28,35
17
17
37
37
37
37
37
37
23
23
23
39
39
39
25
25
25
25
25
25
25
3,8
35
32
34
5
26
39
9
Version 4.2
01/10
Product Name
HUMULIN
HYDOPA
HYDRENE
HYDROCORTISONE
HYFORIL
HYGROTON
HYPNODORM
HYPURIN ISOPHANE
HYPURIN NEUTRAL
HYSONE
HYTRIN
IBUPROFEN
IKOREL
IMDUR DURULES
IMFLAC
IMIGRAN
IMPROVIL
IMOVANE
IMREST
IMTRATE SR
INDAHEXAL
INDAPAMIDE
INDERAL
INDOCID
INDOPRIL
INSIG
INSOMN
INTEGRILIN
INTAL
INVEGA
INZA
IOPIDINE
IPRATRIN
IPRAVENT
ISCOVER
ISMELIN
ISOMONIT
ISOPTIN
ISOPTO CARBACHOL
ISOPTO CARPINE
ISORDIL
ISOSORBIDE MON.
JEZIL
JULIET 35
KALMA
KALURIL
KAPANOL
Product Name
KARVEA
KARVEZIDE
KEPPRA
KINIDIN DURULES
KINERET
KINSON
KLACID
KLIOGEST
KLIOVANCE
KONAKION
KOSTEO
KREDEX
KRIPTON
KWELLS
KYTRIL
LAMIDUS
LAMICTAL
LAMITRIN
LAMOGINE
LAMOTRIGINE
LANOXIN
LANTUS
LARGACTIL
LASIX
LEGOUT
LESCOL
LEVEMIR
LEVLEN ED
LEVOHEXAL
LEXAPRO
LEXOTAN
LIPAZIL
LIPEX
LIPIDIL
LIPITOR
LIPOSTAT
LIPRACE
LIPRACHOL
LIQUIGESIC CO
LISINOBELL
LISINOPRIL
LISINOTRUST
LISODUR
LITHICARB
LIVIAL
LOCILAN
LOETTE
LOGICIN
Serial Number
26
8
8,18,19
16
3,19
8,20
24,27,35
26
26
16
8
9
2
2
9
36
15
24, 27
24,27
2
8
8
2,4,8,12,36
9,21,31
3,8
8
24,27
11
14C
32
9,31
43
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
110
Serial Number
8,33
8,33
37
4
9
10
34
39
39
5
38
8,12
10
7, 42
7
37
37
37
37
37
4
26
7,28,32, 40
8,17
21
23
39
15
10
6A
27,28,35
23
23
23
23
23
3,8
23
31
3,8
3,8
3,8
3,8
32
39
15
15
30
Version 4.2
01/10
Product Name
LOGYNON
LONAVAR
LONITEN
LOPID
LOPRESOR
LORASTYNE
LOSEC
LOVAN
LUMIGAN
LUMIN
LURSELLE
LUVOX
LYCINATE
LYRICA
MADOPAR
MAGICUL
MAOSIG
MAREVAN
MARVELON
MAXOLON
MAXOR
MEDROXYHEXAL
MEFIC
MEGACE
MELIPRAMINE
MELIZIDE
MELLERIL
MELLIHEXAL
MELOXIBELL
MENOREST
MEPRAZOL
MERBENTYL
MERSYNDOL
METAMAX
METFORBELL
METFORMIN BC
METHYLPHENIDATE
METOCLOPRAMIDE
METOHEXAL
METOPROLOL BC
MEXITIL
MIACALCIC
MICARDIS
MICROGYNON
MICROLUT
MICRONOR
MICROVAL
Product Name
MIDAMOR
MINAX
MINIDIAB
MINIMS PILOCARP.
MINIPRESS
MINITRAN
MINULET
MIRENA
MIRTAZON
MIXTARD
MOBIC
MOBILIS
MOCLOBEMIDE
MODAVIGIL
MODECATE
MODURETIC
MOGADON
MOHEXAL
MONACE
MONODUR DURULES
MONOFEME
MONOPLUS
MONOPREM
MONOPRIL
MONOTARD
MORPHALGIN
MOTILIUM
MOVALIS
MOVELAT
MOVOX
MOXICAM
MS CONTIN
MS MONO
MURELAX
MYSOLINE
NAPAMIDE
NAPROGESIC
NAPROSYN
NARAMIG
NARDIL
NASONEX
NATRILIX
NAVANE
NAVOBAN
NEUPRO
NEO-MERCAZOLE
NEO-SYNEPHRINE
NEULACTIL
Serial Number
15
1
8
23
2,4,8,12,36
30
34
6A
43
6C
23
6A
2
37
10
22, 34
6B
5
15
7
34
15
9,31
39
6D
25
28,32
25
9
39
34
42
31
36
25
25
41
7
2,4,8,12,36
2,4,8,12,36
4
38
8,33
15
15
15
15
111
Serial Number
8,18
2,4,8,12,36
25
43
8
2,29
15
15, 39
6B
26
9
9,31
6B
41
28,32
8,18,19
24,27,35
6B
3
2
15
3,8
39
3,8
26
31
7
9
9
6B
9
31
31
27,28,35
37
8
9,31,36
9,31,36
36
6B
16
8
32
7
10
39
43
28,32
Version 4.2
01/10
Product Name
NEUTRAL PILOCARP.
NEURONTIN
NEXIUM
NICOTINIC ACID
NIDEM
NIFECARD
NIFEDIPINE BC
NIFEHEXAL
NIMOTOP
NITRO-DUR
NITROLINGUAL SPRAY
NITROSTAT
NIZAC
NORDETTE
NORDITROPIN
NORFLEX
NORGESIC
NORIDAY
NORIMIN
NORINYL
NORMISON
NORSPAN
NOLVADEX
NORVASC
NOTEN
NOVARAP
NOVNORM
NOVONORM
NOVOMIX
NOVORAPID
NUELIN
NUPENTIN
NUROFEN
NUROLASTS
NYEFAX
ODRIK
OGEN
OLMETEC
OMEPRAL
OMEPRAZOLE
OMNITROPE
ONDAZ
OPTIMOL
ORAP
ORAP
ORDINE
ORGARAN
Product Name
OROXINE
ORUDIS
ORUVAIL SR
OSPOLOT
OSSMAX
OVESTIN
OXANDRIN
OXETINE
OXIS
OXYCONTIN
OXYNORM
OZLODIP
PALFIUM
PAMACID
PAMISOL
PANACORT
PANAFCORTELONE
PANAFEN PLUS
PANALGESIC
PANAMAX
PARACODIN
PARADEX
PARAHEXAL
PARALGIN
PARIET
PARLODEL
PARNATE
PAROXETINE
PAXAM
PAXTINE
PEETALIX
PENDINE
PEPCID
PEPCIDINE
PEPZAN
PERIACTIN
PERINDO
PERINDOPRIL
PERIVASC
PERMAX
PERSANTIN
PEXSIG
PHENOBARBITONE
PHENERGAN
PHOSPHATE-SANDOZ
PHYSEPTONE
PHYSIOTENS
PILOCARPINE
Serial Number
43
37
34
23
25
8,13
8,13
8,13
13
2,29
2,29
2
22,34
15
39
43
43
15
15
15
24,27,35
31
39
2,8,13
2,4,8,12
26
25
25
26
26
14A
37
9,31
9,31
8,13
3,8
39
33
34
34
39
7
43
28,32
28,32
31
5
112
Serial Number
39
9,31
9,31
37
38
39
1
6A
14B,14C
31
31
2,8,13
31
34
38
16
16
9
31
31
31
31
31
31
34
10
6B
6A
35,37
6A
30
37
22,34
22,34
34
30,36
3,8
3,8
2,8,13
10
5,11,29
2
37
7,27,30
38
31
8
43
Version 4.2
01/10
Product Name
PILOPT
PROPINE
PIROHEXAL
PIROXICAM
PLACIL
PLAVIX
PLENDIL
POLARAMINE
PONSTAN
PRAMIN
PRASIG
PRATSIOL
PRAVACHOL
PRAVASTATIN
PRAZOHEXAL
PRAZOSIN BC
PREDMIX
PREDSOLONE
PREGNYL
PRESOLOL
NYOGEL
PREMARIN
PREMIA 5
PRESOLOL
PRESSIN
PREXIGE
PRILACE
PRIMOBOLAN
PRIMOLUT
PRINIVIL
PRITOR
PROCID
PRO-BANTHINE
PROBITOR
PROCUR
PRODEINE
PROGOUT
PROGYNOVA
PROLODONE
PROMETHAZINE
PRONESTYL
PROPYLTHIOURACIL
PROTAPHANE
PROTHIADEN
PROTOS
PROVERA
PROVEN
Product Name
PROVIRON
PROXEN
PROZAC
PULMICORT
P.V. CARPINE
PYRALIN
QUESTRAN LITE
QUILONUM SR
QUINAPRIL
QVAR
RAFEN
RALOVERA
RAMACE
RAMIPRIL
RANI
RANIHEXAL
RANSIM
RANITIDINE DBL
RANOXYL
RANZEPAM
RAPIFEN
REDIPRED
REDUCTIL
REFLUDAN
REGITINE
REMERON
REMINYL
RENITEC
REOPRO
RESPOCORT
RESTAVIT
RHINOCORT
RISPERDAL
RITALIN
RITHMIK
RIVOTRIL
ROCALTROL
ROSIG
RUBESAL
RYTHMODAN
SABRIL
SAIZEN
SANDOMIGRAN
SANDRENA
SEAZE
SELGENE
SEQUILAR ED
Serial Number
43
43
9,31
9
6D
5,11
8,13
30
9,31
7
8
8
23
23
8
8
16
16
39
8,12
43
39
39
8,12
8
31
2,3
1
39
3,8
8, 33
21
42
34
39
31
21
39
31
30
4
39
26
6D
38
39
9,31
113
Serial Number
39
9,31
6A
14C,16
43
9
23
32
3,8
14C,16
9,31
39
3,8
2,3
22,34
34
23
22,34
34
35
31
16
44
5
29
6A
40
3,8
5
16
27
16
32, 40
41
4
37
38
9,31
9
4
37
39
36
39
37
10
15
Version 4.2
01/10
Product Name
SERC
SERENACE
SEREPAX
SERETIDE
SEREVENT
SEROQUEL
SERTA
SERTRALINE
SERTATRUST
SETRONA
SETACOL
SETAMOL
SEVREDOL
SICAL
SIFROL
SIGMAXIN
SIGMETADINE
SIMVABELL
SIMVAHEXAL
SIMVAR
SIMVASTIN
SIMVATRUST
SINEASE
SINEMET
SINEQUAN
SINGULAIR
SITRIOL
SKELID
SNUZAID
SODIUM OIDIDE
SOLAVERT
SOLIAN
SOLONE
SOLPRIN
SOMAC
SOMIDEM
SONE
SORBIDIN
SOTACOR
SOTAHEXAL
SOTALOL BC
SPIRACTIN
SPIRIVA
SPREN
STALEVO
STELAZINE
STEMETIL
Product Name
STEMZINE
STILDEM
STILNOX
SUBLIMAZE
SUMAGRON
SUMATAB
SURGAM
SURMONTIL
SUSTANON
SUVULAN
SYMBICORT
SYMMETREL
SYNAREL
SYNPHASIC
TACIDINE
TAGAMET
TALAM
TALOHEXAL
TAMBOCOR
TARKA
TAZAC
TEGRETOL
TELFAST
TELNASE
TEMAZE
TEMGESIC
TEMTABS
TENOPT
TENORMIN
TENSIG
TENSODENINE
TENUATE
TERIL
TERTROXIN
TETRABENAZINE
TEVETEN
THEO-DUR
TICLID
TICLOPIDINE HEXAL
TILADE
TILCOTIL
TILODENE
TIMOPTOL
TIMPILO
TITRALAC
TOFRANIL
TOLERADE
TOLVON
Serial Number
29,30
7,28,32
27,28,35
14B,14C
14B,14C
32
6A
6A
6A
6A
42
31
31
38
10
4
22,34
23
23
23
23
23
30
10
6D
14
38
38
27
39
4, 12
32
16
5,11,31
34
24
16
2,29
4,12
4,12
4, 12
8,18
14C
11,31
10
7,28,32
7,32
114
Serial Number
7,32
24
24
31
36
36
9,31
6D
39
36
14C
10
39
15
34
22,34
6A
6A
4
2,4, 8,13
22,34
32,37
30
16
24,27,35
31
24.27,35
43
2,4,8,12
2,4,8,12
31
45
32,37
39
43
8, 33
14
5,11
5,11
14C
9
5,11
43
43
34
6D
6D
6C
Version 4.2
01/10
Product Name
TOPACE
TOPAMAX
TOPROL
TORADOL
TRAMAL
TRANALPHA
TRANDATE
TRANDOLAPRIL
TRANSIDERM-NITRO
TRAVACALM
TRAVATAN
TRYZAN
TRENTAL 400
TRI PROFEN
TRIASYN
TRIFEME
TRILEPTAL
TRIPHASIL
TRIQUILAR
TRISEQUENS
TRITACE
TRUSOPT
TRYPTANOL
TYLENOL
ULCAID
ULCYTE
ULTAC
ULTRATARD
UNISOM
UREMIDE
UREX
VALIUM
VALLERGAN
VALPAM
VALPRO
VASOCARDOL CD
VASTORAN
VASTIN
VEGANIN
VERACAPS
VIAGRA
VIOXX
VISKEN
VOLFAST
VOLTAREN
VOXAM
VYTORIN
Product Name
XALACOM
XALATAN
XANAX
XYDEP
XYLOCARD
XYVION
YASMIN
YAZ
ZACTIN
ZADINE
ZAMHEXAL
ZAN EXTRA
ZANIDIP
ZANTAC
ZARONTIN
ZELDOX
ZENICAL
ZESTRIL
ZIMSTAT
ZOCOR
ZOFRAN
ZOLOFT
ZOMIG
ZOLIBELL
ZOLPIDEM
ZOMETA
ZOTON
ZUMENON
ZYDEP
ZYLOPRIM
ZYDOL
ZYPREXA
Serial Number
3, 8
35,37
12
9
31
3,8
8,12
3,8
2,29
7,42
43
3,8
11
9,31
3,8,13
15
37
15
15
39
3,8
43
6D
31
34
34
34
26
24,27
8,17
8,17
27,28,35
27,30
35
32,37
2,8,13, 33
23
23
31
2,8,13
29
9
2,4,8,12
9,31
9,31
6A
23
115
Serial Number
43
43
27,28,35
6A
8
39
15
15
6A
30
27,28,35
3,8,13
8, 13
22,34
37
32
44
3,8
23
23
7
6A
36
24
24
38
34
39
6A
21
31
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PATIENT ASSESSMENT
GENERAL APPROACH AND TREATMENT
Initial
Assessment
Initial
Treatment
Secondary
Assessment
Secondary
Treatment
Alert
Danger
Response
Voice
Formal GCS
Pain
Unconscious
ETT
Chin lift;
head tilt;
jaw thrust;
Airway +
Cervical spine
care
Hold head still.
Suction;
Cervical collar
clear airway
KED
Oral / nasal airway
Board / scoop
Respiratory rate
Look,
Listen,
Feel.
Breathing
Circulation
I.P.P.V.
Pulse oximetry
Oxygen
Breath sounds
Control bleeding
Cardiac
compressions
Pulse rate
Central pulse
ECG Monitor
BP
Skin signs
D.C.C.S.
Analyse ECG
Pleural
decompression
Stabilise flail
segment
IV Fluids
Cannula
History
of:
Full history
Event
Patient
Bystanders
Utilise bystanders
Drugs
Transport
Expose injuries
Assess time critical
116
Bring relatives
along
Formal drug
therapy
BGL
Call backup if
required
Obtain
medications
Prepare for
transport
Transport
Notify hospital
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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 and 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 (systolic BP < 90mmHg), and/or
Revised Trauma Score < 12
Pattern of injury:
(Actual time critical indicators)
Penetrating injury – head; neck; torso; axilla, groin
Amputation above the wrist or ankle
Fractures to TWO or more proximal long bones, or a fractured pelvis
Suspected crush syndrome
Paralysis or significant weakness of limbs
“Significant” injury to single body region (e.g. head, abdomen, chest), or
“lesser” injuries to 2 or more body regions
Burns > 10% body surface; “special” areas
(e.g. eyes, genitals; or respiratory tract involvement)
continues over
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Mechanism of injury: (Potential time critical indicators)
2:
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
Fall > twice patient height
Struck by object falling > 5m (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. (from any cause)
worsening hypotension (from any cause)
heatstroke or significant hypothermia
significant arrhythmias,
unresponsive to treatment
prolapsed umbilical cord or
complicated labour
generalised seizures,
unresponsive to treatment
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 conditions
lack of response to current treatment
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GUIDE TO SUICIDE RISK ASSESSMENT
SUICIDE RISK QUESTIONS
MEANS:
Is the method available?
METHOD:
Is the method lethal?
Level of detail?
PLANS:
Rehearsals? Time/Date?
Place?
INTENT:
Plans to carry through?
Plans to actually die?
THOUGHTS:
Anxious Turmoil?
Worthlessness?
Hopelessness?
SUPPORTS:
Friends? Family?
Case Worker?
Social Worker?
HISTORY:
Personal/Family History?
Previous Attempts?
Other Illness?
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GUIDE TO MENTAL HEALTH STATUS ASSESSMENT
APPEARANCE
Grooming, Posture, Build, Clothing, Cleanliness
BEHAVIOUR
Eye Contact, Mannerisms, Gait, Activity Level
SPEECH
Rate, Volume, Pitch, Tone Flow, Pressure
MOOD
Emotion as described: Anxious, Depressed, Cheerful
AFFECT
Emotion as observed: Restrictive, Blunted, Labile
THOUGHT FORM
Amount, Rate, Derailment, Flight of ideas
THOUGHT CONTENT
Disturbance, Delusions, Suicidal, Obsessions
PERCEPTION
Illusions, Thought Insertion/Broadcasting, HallucinationsAuditory, Olfactory, Tactile, Visual or Gustatory
INSIGHT & JUDGEMENT
Cognition, understanding of illness, its causes & effect
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A.C.T. AMBULANCE SERVICE
MENTAL COMPETENCY ASSESSMENT – APPLICATION GUIDELINES
(For patients refusing Ambulance care or treatment where there is a known or suspected
medical condition causing concern)
1: Was patient assessed in accordance with
the ACTAS patient assessment standard?
(if not – document why)
YES / NO
2: Has the medical condition or concern
been fully explained to the patient, including
– level of concern; alternatives & options;
risks / consequences of their decision?
(if not – document why)
YES / NO
3: Does the patient acknowledge and
appear to comprehend the information given
to them?
YES / NO
(i.e. Are they able to repeat it back to you in
their own words?)
4: Is the patient able to accurately recall this
information when asked after a period of
time (approx 5 – 10 mins later)?
YES / NO
5: Does the patient communicate in a
consistent manner on the issues of the
medical condition, over the ambulance
contact time?
YES / NO
All yes = the patient is most likely to have the capacity to make an informed decision
1 x „No” = the patient may not be competent
2 or more “No” = a higher likelihood patient is not competent
(or they are uncooperative!)
FULLY DOCUMENT THE RESULTS OF THIS PROCESS!
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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 score at 1minute and 5 minutes after birth
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A.C.T. AMBULANCE SERVICE - PAEDIATRIC REFERENCE CARD
Age
Weight
(kg)
Resps
Heart
Rate
Systolic
BP
Neonate
6 months
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
12 months
2 years
4 years
6 years
8 years
10 years
12 years
E.T.T.
size
(mm)
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
E.T.T Length:
Age
/2 + 15 = length in cm
Fluid resuscitation
10 ml/kg bolus - Normal Saline
Thereafter – Normal 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
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PEEP VALUES
5 cm
10 cm
15 cm
Cardiac arrest for
adults, infants & children
Maximum level for infants &
children
Final level for:
Intubated patients
Next level for:
(not if suspected raised ICP,
and if O2 sats > 90%)
Start level for:
- pulmonary oedema
- near drowning
- CO poisoning
- asthma
- CAL
- pulmonary oedema
- near drowning
- CO poisoning
- asthma (max)
- CAL (max)
- pulmonary oedema
- near drowning
- CO poisoning
only if still desaturated with
10cm
if not responding to 5cm
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ACT AMBULANCE SERVICE
SPINAL IMMOBILISATION LOW RISK ASSESSMENT FLOWCHART
1: Patient mentation
Decreased level of consciousness?
No

Alcohol / drug impairment?
▪
Yes 
Immobilise
No

Loss of consciousness involved?
▪
Yes 
Immobilise
▪
Yes 
Immobilise
▪
Lumbar spinal pain?
▪
Yes 
No

2: Subjective assessment
▪ Cervical
▪ Thoracic
No

Numbness / tingling / weakness
No

3: Objective assessment
▪ Cervical
▪ Thoracic
Immobilise
or burning sensation?
▪
Yes 
Immobilise
▪ Lumbar spinal tenderness?
No

Other painful injury or significant
distraction?
▪
Yes 
Immobilise
No

Pain with spine range of motion? #
▪
Yes 
Immobilise
▪
Yes 
Immobilise
No

MAY TRANSPORT WITHOUT SPINAL IMMOBILISATION
# Range of motion is only to be checked if all other criteria are negative!

NOTE:Exercise care if a patient is seen very soon after the event.
- Significant distraction can be something other then a physical injury – e.g. significant injury to a
loved one or significant damage to car
- Recheck the patient before clearing, if not transporting.
Your clinical judgement may still be exercised to 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.
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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 the 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.
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DIFFERENTIATION 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
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128
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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)
(Males)
(Females)
.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
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12 Lead ECG Placement
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15 Lead ECG Placement
Post 12-lead ECG
1.
Locate V4R position:
 5th intercostal space;
 right side mid-clavicular line.
2.
Move V1 lead to V4R position
3.
Locate V8 position:
 in line with the anterior 5th intercostal space
 mid scapular line
4.
Move V5 lead to V8 position
5.
Locate V9 position:
 in line with V8 position
 left paraspinal border
6.
Move V6 lead to V9 position
7.
Acquire 15 lead ECG:
 Press “on”
 Insert the limb lead and the precordial lead attachments
into the main cable.
 Insert the cable connector into the green connector
on the monitor.
 Encourage the patient to remain as still as possible.
 Press 12 lead
 12 lead/age menu appears
 Select age
8.
Monitor will detect and print the 15 lead ECG
9.
Re-label the 3 altered leads on ECG strip
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A.C.T. Ambulance Service
STEMI Bypass Flow chart
1:
Identified STEMI patient by Intensive
Care Paramedic (ICP) via 12 lead
ECG and appropriate clinical evidence
2:
Transmit ECG to TCH ED with phone
number attached
3:
ECG to be reviewed by Admitting
Officer (AO)
4:
AO to call back transmitting phone
number within 5 minutes
5:
No call back from AO within 5
minutes....
Proceed to TCH;
Patient to be treated according
to STEMI by-pass guidelines
Complete check list!
6:
Confirmation from AO....
Proceed to TCH;
Patient to be treated according
to STEMI by-pass guidelines
7:
Unclear decision between AO
& ICP....
Proceed to TCH;
treat according to normal
ACTAS guidelines
Complete check list!
Complete check list!
8:
Ambulance to radio TCH ED to alert
them of STEMI patient and time to
hospital
9:
On arrival at TCH ED....
AO to review patient. Decision made
whether ACTAS takes patient straight to
catheter lab or offloads in ED.
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A.C.T. Ambulance Service
STEMI Bypass Check List
PATIENT DETAILS
Surname
Age
Given
name
Case
number
Date
INDICATIONS – if answer is NO or UNSURE to ANY of the
following, do NOT administer Heparin, Prasugrel or
Clopidogrel. Discuss with A/O
Symptoms less than 6 hours duration?
12 lead ECG, with ST elevation in 2 contiguous leads,
≥ 1 mm in limb leads, &/or ≥ 2 mm in chest leads?
Systolic BP less than 180mmHg?
Diastolic BP less than 110mmHg?
GCS = 15?
CONTRA-INDICATIONS for PRASUGREL
If yes - move to Clopidogrel
Known allergy to prasugrel
Age over 75 years
Weight under 60kg
ANY history of TIA / CVA (or unable to reliably ascertain)
CONTRAINDICATIONS for CLOPIDOGREL or HEPARIN
Known allergy to heparin or clopidogrel
Current use of anti coagulants (excluding aspirin or clopidogrel)
Pregnancy or delivery in last 2 weeks
Active pathologic bleeding of any origin
Severe renal or hepatic disease
Head injury or facial trauma in the last 3 months
Non compressible vascular punctures?
Clotting problem (haemophilia etc)?
Yes
No
Unsure
Yes
No
Unsure
Officer name:………………………………………. Signature:……………………….
Contra- indications may be relative rather than absolute. Discuss with Admitting
Officer during phone call back.
This completed form must be submitted with the review (2nd) copy of the ACTAS
PCR.
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Acute Myocardial Infarction
>1mthe limb leads and >2mm in the V leads in >2 consecutive leads
•
Acute 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 greater than 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 myocardial 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
Right ventricular
V3R, V4R, V5R, V6R
(usually seen with inferior changes)
Posterior
“Reciprocal” changes in anterior leads
Indicative changes
V 8, V 9
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INFERIOR AMI
136
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ANTERO-SEPTAL AMI
137
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ANTERO-LATERAL AMI
138
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LATERAL AMI
139
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RIGHT VENTRICULAR AMI
140
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POSTERIOR AMI
(1)
STANDARD 12 lead ECG
141
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POSTERIOR AMI
(2)
V7 – V9 LEADS
142
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RIGHT BUNDLE BRANCH BLOCK
143
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LEFT BUNDLE BRANCH BLOCK
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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
MONITORING PROCEDURE
1. 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)
2. Connect the tubing to the patient (proximal to bacterial filter is preferred)
3. Display ETCO2 waveform on Channel 3
4. Adjust scale if required
Monitor is configured to “Autoscale”. This means that the monitor will overselect the scale based on the measured ETCO2 measurement.
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).
NOTE: Rapid altitude changes may cause the machine to attempt to purge
the tubing. If this occurs, disconnect the tubing briefly from the monitor, and
then reconnect it.
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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.
Critical values in critical patients:
 Cardiac arrest: ETCO2 consistently above 15 mmHg seems to have
some positive correlation with ROSC.
Patients with acute intracranial pathology:
 PA CO2 should be in range of 30 – 45 mmHg 
 ETCO2 should be in range of 27 – 40 mmHg.
DOCUMENTATION OF RESULTS
 Serial ETCO2 readings may be recorded in the appropriate section of
the ACTAS PCR.
 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.
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Wave Forms
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RESPIRATORY STATUS AND PERFUSION 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
(heard without a
stethoscope)
Quiet, no noises
Cough
Audible wheeze on exhalation;
“Crackly” moist sounds;
Inspiratory stridor.
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
(NOTE: chest movement may be minimal with
some conditions)
Adults: 60 – 80 / min
Kids:
80 – 120
Babies: 100 – 140
(*)Tachycardia - adults > 100 / min
- kids > 130
- babies > 150
Respiratory Noises
Pulse rate
(slow pulse rate is a late sign in severe cases)
Skin
Pink; normal
Sweaty; sometimes pale
May be flushed
Cyanosis is 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 prevent
the development of 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
PaCO2
O2 content
CO2 content
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
Female:
120 – 160 g/l
Male:
42 – 52%
Female:
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.
(Pacing is preferred over an Adrenaline infusion for post cardiac arrest bradycardia).
Procedure:
1:
Explain procedure to the 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, horizontally
(Avoid the nipple, sternum & diaphragm)
6:
Posterior electrode at (L) vertebral edge, below bony prominence of
scapula, vertically
7:
Set current at 0mA, demand mode, rate approx 50% over initial
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:
14:
Ensure analgesia is provided (use alternating small doses of
Midazolam / Morphine)
Continue to check electrical and mechanical capture
15:
Adjust rate and current output as required
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ACCESS TO
BUSES &COACHES
Roof hatches
(emergency exits)
Off-side Window Emergency Exit
(towards rear on the Driver‟s side)
Rear Window
Emergency Exit
(if fitted)
Rear-mounted
engine
Batteries on other side
at REAR on most
coaches or buses,
Batteries are located
near the engine.
The fuel tank is usually mounted here
for rear engine coaches
(However, for mid or front engines, the
tank is towards the rear)
External Emergency
Release valves or
switches under bumper
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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 provided by ACTAS.
(e.g. 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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MCI = Greatest Good for Greatest Number
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 labeling 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, re-assessing the priority of
treatment and transport.
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MCI = Greatest Good for Greatest Number
TRANSPORT CONTROL OFFICER (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).
7. Maintain communications with the Ambulance Commander and Triage
Officer.
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SUBSEQUENT AMBULANCE CREWS
 Approach the incident with safety.
 If the transport control area is set up, position the ambulance or
support vehicle correctly in the marshalling area, leaving the keys
in the ignition.
Once at the incident, all warning devices should be switched off
unless otherwise directed
 Wear all protective equipment provided by ACTAS.
(i.e.: 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.
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