ACT AMBULANCE SERVICE

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1 ACT AMBULANCE SERVICE CLINICAL MANAGEMENT MANUAL POCKET EDITION Fourth Edition August

2 CLINICAL MANAGEMENT GUIDELINES Contents Case Category 1 Patient Categories Medical 2 Patient Categories Trauma 3 Revised Trauma Score - Glasgow Coma Scale 4 ACTAS Approved Abbreviations 5 Clinical Management Guidelines 8 PAGE NO. Rapid Sequence Induction Procedure 49 Drugs for Airway Management Summary Sheet 53 ACTAS Pharmacology 56 Drug Dose Calculator 94 Medication Calculator 95 Drug Reference Key List 97 Patient Assessment General Approach 105 Time Critical Guideline 106 Guideline for treatment of Agonal Trauma Patients 108 APGAR Score 110 Paediatric Reference Card 111 PEEP Values 112 Spinal Immobilisation Clearance Flowchart 113 Spinal Cord Injury 114 Differentiation of Wide Complex Tachycardias 115 Maximum QT Interval Chart Lead Placement Chart 118 Acute Myocardial Infarction Table 119 Infarction Overview 120 Capnography 127 Wave Forms 129 Respiratory Status Assessment Chart 130 Burns Assessment Chart/ Rule of Nines 131 Paediatric Burns Assessment Chart 132 Normal Blood Values 133 External Pacing procedure 134 2

3 Significant Contact Numbers 134 Motorola XTS 3000 Portable Radio - Duress Alarm Procedure 136 Hazchem Chart 137 Triage Flow Chart 140 Ambulance Roles at a Mass Casualty Incident (MCI) 141 3

4 CASE CATEGORY 11 - Treatment and transport (usual case default on data sheet) 12 - Ambulance not required (ANR) 13 - Treatment; no transport (mutual decision) (TNR) 14 - Patient refused treatment or transport (patient decision only) 21 - Back up other car single patient 22 - Patient deceased no resuscitation attempted 23 - Resuscitation ceased on scene 24 - Hoax call (apparent) 31 - Sports attendance 32 - Standby (public event / incident) 33 - Air Ambulance case 34 - Single Officer Response (transport by other vehicle) 41 - Transport of retrieval team (+/- patient) 42 - Aero-medical case - Primary 43 - Paramedic retrieval (no doctor) 44 - Medical retrieval (doctor) 1

5 PATIENT CATEGORIES Medical conditions First three digits Cerebral 001 Unconscious 002 Altered consciousness 003 Post unconsciousness 004 Seizures 005 Post seizure 006 CVA / Stroke 007 Headache 008 Other 009 Apparent Syncope Respiratory 011 Asthma bronchiolitis 012 CAL 013 Acute LVF / pulmonary oedema 014 Upper airway problems 015 Non-cardiac chest pain 016 Resp. tract infection 018 Other 019 Apparent hyperventilation Cardiac 021 Arrest 022 Chest pain 023 Arrhythmias 024 Chronic cardiac failure 028 Other Abdominal 031 Vomiting/nausea 032 Diarrhoea 033 Pain 034 Haematemesis / malaena 035 PV / gynae bleeding 036 PR Bleed 037 Suspected AAA 038 Other Endocrine 041 Hypoglycaemia 042 Hyperglycaemia 048 Other Obstetrics 051 Labour 052 Delivery prior to ambulance arrival 053 Delivery by ambulance officers 056 Bleeding 057 Complicated delivery 058 Other Miscellaneous 061 Psychiatric 062 Generally unwell 063 Back Pain 064 Deceased patient 065 Routine transport (Hosp.-hosp.; Air Amb) 066 Palliative care patients 068 Other 069 Emotional distress Location of patient (fourth digit) 1 - Road / transport 2 - Industrial / workplace 3 - Private residence 4 - Sports / recreation 5 - Public place 6 - School / education facility 7 - Medical facility 8 - Hotel/motel/paid lodgings 9 - Other 2

6 PATIENT CATEGORIES Trauma Conditions Mechanical (first two digits) 11 Road vehicle 12 Other vehicles 21 Stabbing 22 Gunshot wound 23 Other penetrating injury 31 Fall between levels 32 Fall on one level 33 Fallen on patient 34 Crush 35 Other blunt trauma Body area affected (third digit) 1 Multiple 2 Head / neck 3 Spinal 4 Chest 5 Abdominal / pelvic 6 Upper limbs 7 Lower limbs 8 Other 9 NOF 0 Nil Non-mechanical (first two digits) 40 Electrical injuries 41 Injected poisoning 42 Ingested poisoning / overdose 43 Inhaled poisoning 44 Absorbed poisoning 45 Burns / scalds 48 Other 51 Drowning / near drowning 52 Asphyxiation 61 Cold Syndromes 62 Heat Syndromes 71 Bites / stings 72 Allergy/anaphylaxis Location of patient (fourth digit) 1 - Road transport 2 - Industrial/workplace 3 - Private residence 4 - Sports/recreation 5 - Public place 6 - School/education facility 7 - Medical facility 8 - Hotel / motel / paid lodgings 9 - Other 3

7 REVISED TRAUMA SCORE (RTS) Respiratory Rate Systolic Blood Pressure GCS A B C Rate Score Pressure Score GCS Score > > A+B+C = Revised Trauma Score GLASGOW COMA SCALE Eye Opening INFANT CHILD ADULT Spontaneous To speech To pain Nil Spontaneous To command To pain Nil Spontaneous To command To pain Nil 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 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

8 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 hours n/7 days n/52 weeks n /12 months x(n) number of times Y/O years old /c /s with without ANR AO BBB b.d. BGL BLS BNO BO BP BSL C/O Ca. CABG CAL Calv. CAT CCF CCU cm CNS CO COB2B Code 5 CP CPAP CPR CSF CVA Ambulance not required Ambulance Officer Bundle Branch Block twice a day Blood Glucose Level Basic Life Support bowels not open bowels Open blood pressure Blood Sugar Level Complains(ing) of Cancer Coronary Artery Bypass Graft Chronic Airways Limitation (Chronic Obstructive Airways Disease - COAD) Calvary Hospital Computerised Axial Tomography Congestive Cardiac Failure Coronary Care Unit centimetres Central Nervous System carbon monoxide carbon dioxide person deceased Chest Pain Continuous Positive Airways Pressure Cardio-Pulmonary Resuscitation Cerebro Spinal Fluid Cerebro-Vascular Accident 1 HB 2 HB 3 HB First Degree Heart Block Second Degree Heart Block Third Degree Heart Block DCCS Dr. Dx Direct Current Counter Shock Doctor diagnosis A ACTAS ACTES ACTFB AFP AAA AF AFl ALS am AMI Asystole A.C.T. Ambulance Service A.C.T. Emergency Service A.C.T. Fire Brigade Australian Federal Police Abdominal Aortic Aneurism Atrial Fibrillation Atrial Flutter Advanced Life Support morning acute Myocardial Infarction 5

9 NP OB2B EAR ECC ECG ED EDC EEG EMD ENT ESA ETT GCS GI GP Gx Px Hb HR H/T Hx ICP ICS ICU IGT IH IM IMI Inh IO IPPV IU IV IVU IVR JR JVP KED KTD kg km kph Expired Air Resuscitation External Cardiac Compressions Electro-Cardio Graph Emergency Department (Accident and Emergency department) expected date of confinement Electroencephalograph Electro Mechanical Dissociation Ear Nose and Throat Emergency Services Agency Endo-Tracheal Tube Glasgow Coma Score Gastro-Intestinal General Practitioner gravida No. para No. Haemoglobin heart rate hypertension history Intra-Cranial Pressure Intercostal space Intensive Care Unit intra-gastric tube Ischaemic Heart Disease intra-muscular intra-muscular injection inhaled intra-osseous Intermittent Positive Pressure Ventilation International Unit intravenous intravenous unsuccessful Idioventricular Rhythm Junctional Rhythm Jugular Venous Pressure Kendrick Extrication Device Kendrick Traction Device kilogram kilometre kilometres per hour (L) left Lev.OC Level of Consciousness LLQ Left Lower Quadrant LMP Last Menstrual Period LOC loss of consciousness lpm litres per minute Ltr litre LUQ Left Upper Quadrant LVF Left Ventricular Failure Mane morning MAP Mean Arterial Pressure MAST Medical Anti-Shock Trousers mcg micrograms MCL Modified Chest Lead mg milligram ml millilitres mm millimetres mmol millimol MRI Magnetic Resonance Imaging MS Multiple Sclerosis Mth month mtr metre Neb nebule / nebulised NFR not for resuscitation NICU Neonatal Intensive Care Unit NKA no known allergies o P. number Nocte night NOF neck of Femur N/S normal Saline O O/A Obs O/E oral on arrival observations on examination oxygen 6

10 P PA PAC PAO PASG PEA PEARL PEEP PHx PID PJC pulse per axilla Premature Atrial Contraction Paramedic Ambulance Officer Pneumatic Anti Shock Garment Pulseless Electrical Activity Pupils equal & reacting to light Posititve End Expiratory Pressure past history Pelvic Inflammatory Disease Premature Junctional Contraction Tx URTI UTI V/S VEB VF VT wt Transport Upper Respiratory Tract Infection Urinary Tract Infection vital signs Ventricular Ectopic Beat Ventricular Fibrillation Ventricular Tachycardia weight pm PR prn Pt PU PV PVC afternoon per rectum as required patient passed urine per vagina Premature Ventricular Contraction Q.I.D. 4 x times daily (R) RICE RLQ ROM RSI RTA RUQ Rx right Rest Ice Compression Elevation Right Lower Quadrant range of movement Rapid Sequence Induction Road Traffic Accident Right Upper Quadrant Treatment S/C S/L SB SOB SR ST SVT subcutaneous sublingual Sinus Bradycardia shortness of breath Sinus Rhythm Sinus Tachycardia Supraventricular Tachycardia T or Temp TCH Tds TKVO TMC TNR temperature The Canberra Hospital three times a day to keep vein open threatened miscarriage Transport Not Required 7

11 Clinical Management Guideline Index 01 General Care 02 Pain Management 03 Airway Management 04 Cardiac Arrest 05 Paediatric Cardiac Arrest 06 Cardiac Arrhythmias 07 Bradyarrhythmias 08 Tachycardias 09 Respiratory Distress 10 Diabetic Emergencies 11 Temperature Abnormalities 12 Upper Airway Obstruction 13 Abdominal Emergencies 14 Poor Perfusion / Hypotension / Dehydration 15 Decreased Level of Consciousness 16 Chest Pain 17 Chest Injuries 18 Spinal Injuries 18a Hypereflexia 19 Limb Injuries 20 Eye Injuries 21 Burns 22 Seizures 23 Stroke 24 Near Drowning 25 Diving Emergencies 26 Obstetrical & Gynaecological Emergencies 27 Hyperkalaemia 28 Home Dialysis Emergencies 29 Allergic & Anaphylactic Reactions 30 Crush Syndrome 31 Electric Shock 32 Assault 33 Behavioural & Psychiatric Emergencies 34 C.B.R. Incident 35 Poisoning, Envenomation & Overdose 36 Extended Care 37 Combative/Agitated Patients 38 Meningoccal Disease 8

12 CLINICAL MANAGEMENT GUIDELINE 1 GENERAL CARE Primary survey Haemorrhage control Posture Oxygen therapy Monitor & assess as required: Observations. ECG/12 Lead. Blood glucose. O 2 saturations. Temperature Specific observations & examination as per patient condition. Treatment as required: Cervical collar. Bandaging. Splinting. PASG. Temperature control. Reassurance. Cannulate as required IV fluids as per perfusion & hydration assessment. Pain relief. Notify & transport to nearest appropriate hospital. 9 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. Note: time critical applies to both trauma and medical cases. The following conditions warrant absolute minimum scene times & urgent transport to hospital: Cardiac arrest following penetrating trauma (reference: Agonal Trauma Guideline). Unrelieved upper airway obstruction. Head injuries with significant deterioration in levels of consciousness. Chest injuries with respiratory deterioration. Internal blood loss sufficient to cause significant hypotension. Heatstroke. Cardiac arrest in advanced pregnancy (gestation > 20 / 52 ) Prolapsed umbilical cord, or complicated labour. Continuing or worsening acute hypoxia, unresponsive to treatment. Generalised seizures, unresponsive to treatment. Carbon monoxide poisoning with decreased level of consciousness. [List is not exclusive or exhaustive!] NOTE: Time critical does not just mean rapid transport!

13 CLINICAL MANAGEMENT GUIDELINE 2 PAIN MANAGEMENT General Care Guideline. RELIEF OF PAIN & SUFFERING IS A PRIME GOAL OF AMBULANCE CARE. Pain is what the patient says it is! Pain assessment (PQRST). Quantitate if possible. Basic care is fundamental to pharmacological management: Reassurance. Posture. Splinting. Cooling of burns. Occlusive dressings. Control of temperature (especially the cold). If possible, pharmacology should be directed at the apparent underlying cause: GTN s/l for ischaemic chest pain. Methoxyflurane for mild - moderate pain; patients unable to have narcotics; management of labour; often best for paediatrics. Morphine for all other pain unless contra-indicated. Midazolam added to analgesia for musculo-skeletal pain. Ketamine for pain management in selected patients. Ischaemic chest pain; limb pain; burns - aim for abolition of pain. Undiagnosed conditions - aim for control of pain to a bearable level of discomfort. Gentle handling. 10

14 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 work up. However - it is permissible to leap-frog steps if in your clinical judgement the patient s condition warrants this. Basic airway manoeuvres. - Posture, Suction, Oral airway, Nasal airway. Mild sedation to permit basic airway management (midazolam). Cold endotracheal intubation. Rapid sequence induction: - Suxamethonium / Midazolam*. ( Note: If patient has already had Midazolam for sedation do not give a repeat dose with Suxamethonium or give a smaller dose.) - Morphine / Midazolam if no relaxants, in selected patients. Fall-back alternatives: - Failed Intubation Drill: Digital oral ETT placement*; LMA*; Surgical airway*. Remember the primary goals! These will determine how aggressive your approach needs to be. Always have a fall-back position. The end point is not necessarily placement of an endotracheal tube. If an ETT is placed, confirmation of correct placement & maintenance of placement is imperative. End Tidal CO2 is to be used. - Use Cx collar to assist in maintaining ETT / LMA position. There are to be multiple checks of ETT position, using multiple methods, by multiple people. * TO BE IMPLEMENTED ONLY FOLLOWING APPROVED ACTAS TRAINING PROGRAMMES. 11

15 CLINICAL MANAGEMENT GUIDELINE 4 ADULT CARDIAC ARREST CPR. IPPV 100% O 2 Monitor ECG (a) Ventricular Fibrillation/Tachycardia (b) Asystole (c) Pulseless Electrical Activity Precordial thump if monitored & witnessed. Shock Cannulate Adrenaline 1mg. Shock Intubate Amiodarone 300 mg IV Shock Adrenaline Shock Adrenaline Shock In prolonged arrest - consider Sodium Bicarbonate 0.5 mmol/kg Shock Decision to transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. Shock between medications. Check alternate leads / lead selector. Cannulate. Atropine 2mg. Adrenaline 1mg. Intubate Adrenaline Adrenaline In prolonged arrest consider Sodium Bicarbonate 0.5 mmol/kg. Adrenaline Adrenaline Decision to transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. Check aggressively for correctable causes: Profound hypovolaemia. Tension pneumothorax. Continuing profound hypoxia. Acidosis / Hyperkalaemia. Gas trapping Cannulate. Atropine 2mg. Adrenaline 1mg. Intubate. Adrenaline Adrenaline In prolonged arrest - consider Sodium Bicarbonate 0.5 mmol/kg. Adrenaline Adrenaline Decision to transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. If Torsade: MgSO 4 as 1 st drug; no amiodarone. Commence chest compressions on first patient contact; minimise any interruptions to chest compressions. Consider PEEP. Drug doses are to be followed by a minimum of 1 minute of CPR. If no failure, consider 5-10mls/kg IV N / saline during arrest management if prolonged. IV drugs to be given via pump set. Elevate limbs following peripheral IV drug administration. Post resuscitation - if pt is hypotensive, check for failure. If no failure, 5-10mls/kg N/saline. Repeat if patient responds. Check patient s temperature post resuscitation. End Tidal CO 2 may be an indicator of returning cardiac output. 12

16 CLINICAL MANAGEMENT GUIDELINE 5 PAEDIATRIC CARDIAC ARREST CPR. IPPV 100% O 2. Monitor ECG (a) Ventricular Fibrillation/Tachycardia Precordial thump if monitored & witnessed Shock 2j / k Cannulate / Intraosseous. Adrenaline 0.01mg/kg. Shock 4j/kg Intubate Amiodarone 5 mg/kg IV Shock 4j/kg Adrenaline Shock 4j/kg Adrenaline Shock 4j/kg In prolonged arrest consider Sodium Bicarbonate 0.5 mmol/kg Shock 4j/kg Transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. Shock between medications. If Torsade: MgSO 4 as 1 st drug; no amiodarone. (b) Asystole Check alternate leads. Cannulate / Intraosseous. Adrenaline 0.01mg/kg. Intubate. If arrest cause not hypoxia consider Normal Saline 20 ml/kg. Adrenaline 0.01mg/kg. Adrenaline. In prolonged arrest - consider Sodium Bicarbonate 0.5 mmol/kg. Adrenaline. Adrenaline. Transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. (c) Pulseless Electrical Activity Check for correctable causes: Cannuate / Intraosseous. Adrenaline 0.01mg/kg. Intubate. If arrest cause not hypoxia consider Normal Saline 20 ml/kg. Adrenaline 0.01mg/kg. Adrenaline. In prolonged arrest - consider Sodium Bicarbonate 0.5 mmol/kg. Adrenaline. Adrenaline. Transport. Adrenaline every 2 minutes during transport. Sodium Bicarbonate if prolonged transport. Commence chest compressions on first patient contact; minimise any interruptions to chest compressions Consider PEEP Drug doses are to be followed by a minimum of 1 minute of CPR. IGT for all arrested children. Blood glucose level to be checked during paediatric resuscitation. Elevate limbs following peripheral IV drugs. Utilise pump set - watch total volume in small children. Post resuscitation - if pt is hypotensive, check for failure. If no failure, 5-10mls/kg N/saline. Repeat if patient responds. Check temperature post resuscitation. End Tidal CO 2 may be an indicator of returning cardiac output. 13

17 CLINICAL MANAGEMENT GUIDELINE 6 CARDIAC ARRHYTHMIAS General Care Guideline. (a) - PACs / PVCs (b) - Accelerated IVR (c) - Bizarre No specific treatment required. Monitor rhythm & patient condition. No specific treatment required. Monitor rhythm & patient condition. Rate & perfusion determines the type of treatment. - Pulse is absent - treat as for cardiac arrest (usually PEA) - Rate less than 50, perfusion poor treat as for bradyarrhythmias. - Rate is > than 150, regular, with wide QRS complexes, patient significantly compromised - treat as for VT. - Rate is > than 150, regular, with narrow QRS complexes, patient symptomatic - treat as for SVT. If unable to decide which specific therapy is required general care; observe; prompt transport. 14

18 CLINICAL MANAGEMENT GUIDELINE 7 BRADYARRHYTHMIAS General Care Guideline. Consider treatment if rate below 50 in adults. If poorly perfused or symptomatic: - Atropine 0.01 mg/kg. If no LVF - Consider IV fluid 5-10 ml/kg, prior to 2 nd dose of Atropine - Repeat Atropine x 1 as required. If perfusion remains poor: - Adrenaline infusion: 1 mg in 1000 mls Saline ( = 1mcg / ml) Titrate to response. ( 20dpm = 1ml / min = 1 mcg / min) Paediatric - use burette - Consider external pacing.* * After completion of ACTAS approved training 15

19 CLINICAL MANAGEMENT GUIDELINE 8 TACHYCARDIAS General Care Guideline (a) - Narrow QRS Complex Consider: Sinus tachycardia; SVT; AF; AFl; MAT. Use 12 lead ECG. Valsalva x 2. If SVT: (b) - Wide QRS Complex Consider: VT; SVT with aberrancy; rapid AF or AFl with aberrancy. Make differentiation: (12 lead ECG if time) If SVT, AF or AFl - treat as per 8 (a) If rapid, symptomatic VT: Adenosine 6 mg IV. Adenosine 12 mg IV if required. If rapid AF or AFl, refer to treatment algorithm: Notify; Prompt transport to nearest appropriate hospital. Paediatric doses: Adenosine: 0.05mg/kg; then 0.1mg/kg. Amiodarone: 5mg/kg (to total 150mg) Amiodarone 150 mg IV No pulse: Treat as VF cardiac arrest Torsade de pointes: MgSO 4 IV instead of amiodarone Notify; Prompt transport to nearest appropriate hospital. Paediatric dose: Amiodarone: 5mg/kg [IV Amiodarone - give over 10 mins via Springfusor. If extremely compromised in VT, may give over 5 mins by slow IV injection.] Consider pharmacological treatment if rate is above 150 in adults or 170 in children. Consider IV fluids in all tachycardic patients if hypotensive, not in LVF & unresponsive to pharmacological management. In any rapid rhythm (over 200), with patient unconscious and no pulse - shock. 16

20 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 AF or AFl apparently secondary to a cerebral event Observe Do NOT use Amiodarone in these patients. Check for evidence of LVF. If none treat with IV fluids, 5 10 mls/kg. If LVF + hypotension treat cautiously with Amiodarone. Treat chest pain as appropriate. Treat rapid rate with Amiodarone concurrently. Treat pulmonary oedema as appropriate. Treat rapid rate with Amiodarone concurrently. These patients will present with a decreased LOC, & may be hypotensive. Check for evidence of LVF. If none treat hypotension with IV fluids, 5 10 mls/kg. Do NOT use Amiodarone in these patients. NB: Monitor BP closely combination of drug treatments for pulmonary oedema may cause hypotension. NB: Unconscious patients post cardiac arrest in rapid AF should be treated with Amiodarone unless otherwise contraindicated. 17

21 CLINICAL MANAGEMENT GUIDELINE 9 RESPIRATORY DISTRESS General Care Guideline. (a) - Bronchospasm (b) - Pulmonary oedema Nebulised salbutamol + ipratropium. Repeat salbutamol as required. Add ipratropium to every second dose. Significant hypoxia - nebulise with 100% O 2. - PEEP If asthma, anaphylaxis or CAL: Moderate to severe: Hydrocortisone 200 mg IV / IM. (Paed: 4 mg/kg to max. of 200mg) Severe to life threatening bronchospasm Adrenaline: Adult: 0.5 mg IM Paediatric: 0.01 mg / kg IM (to 50 kgs) Repeat IM dose x 1 as required. If necessary: Adrenaline infusion: 1 mg in 1000 mls Saline ( = 1mcg / ml) Titrate to response. ( 20dpm = 1ml / min = 1 mcg / min) Paediatric - use burette If patient critically ill, slow IV, up to 0.01 mg / kg, over 5 minutes. Note: IV adrenaline in anaphylaxis & asthma should be used very cautiously. If IPPV required slow rate; gentle, slow lateral chest squeezes on exhalation. Notify; Transport to nearest appropriate hospital. 18 Assist ventilation with IPPV + 100% O 2 as required. Add PEEP: 5 cm. Increase by 5 cm as required. If LVF: Sitting legs dependent if possible. Treat significant cardiac arrhythmias. GTN S/L. Frusemide: On diuretics: 1 mg/ kg IV Not on diuretics: 0.5 mg/kg IV. May repeat dose after mins if still in severe distress. Morphine: 0.05 mg/kg IV. May repeat dose after 10 mins if required. Notify; Transport to nearest appropriate hospital. [If wheezing as well, do not give nebulised bronchodilators until after 1 dose of GTN or Frusemide. IV Frusemide & morphine - give slow over 2 minutes. If no IV, Frusemide may be given IM. ]

22 CLINICAL MANAGEMENT GUIDELINE 9 RESPIRATORY DISTRESS (continued) General Care Guideline. (c) - Non specific respiratory distress (d) Hyperventilation due to anxiety. Nebulised salbutamol + ipratropium. Repeat salbutamol as required. Add ipratropium to every second dose. Significant hypoxia - nebulise with 100% O 2. - PEEP Check for pathological causes of hyperventilation!! O 2 at low flow via Hudson mask. Monitor SaO 2 and ECG Remove source of anxiety if possible. Notify; Transport to nearest appropriate hospital Reassurance. Notify; Transport to nearest appropriate hospital. 19

23 CLINICAL MANAGEMENT GUIDELINE 10 DIABETIC EMERGENCIES General Care Guideline. Check blood glucose level. (a) - BGL < 4 mmol/l If symptomatic: Oral glucose if conscious & laryngeal reflexes intact. If decreased LOC: Dextrose 50% - up to 0.5 ml / kg IV (0.25 g/kg) Recheck BSL & LOC. Repeat Dextrose dose if required. (b) - BGL > 15 mmol/l N / Saline IV 10 ml / kg over contact time. If shocked & hypotensive: IV resuscitation. Notify; Transport to nearest appropriate hospital. 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; Transport to nearest appropriate hospital. [IV dextrose always to be given into running line, over 5 minutes. Try to avoid post treatment hyperglycaemia. Recovery may be slow if hypoglycaemia has been prolonged. Paediatric pts: Dilute 50% with equal volume of 5% dextrose or N/saline.] 20

24 CLINICAL MANAGEMENT GUIDELINE 11 TEMPERATURE ABNORMALITIES General Care Guideline. (a) - Heat abnormalities Check temperature Minor heat syndromes: Normal LOC; sweating; core temp < approx 39.5 o C. Gentle cooling. Cease exertion. Move patient to cool location. Oral rehydration IV rehydration if - small sips. - Nausea & vomiting; - Significant dehydration; - Multiple patients. Notify; Transport to nearest appropriate hospital. Heatstroke: Decreased LOC; no sweating; core temp > approx 40 o C. Rapid cooling; aggressive as possible. IV resuscitation; cool fluids if possible. Treat significant arrhythmias. Check BGL. Aggressively manage seizures or shivering. Notify; Urgent transport to nearest appropriate hospital. Exposure: (b) - Cold abnormalities Check temperature Normal LOC; shivering; core temp > approx 33.5 o C. More rapid warming is acceptable. Warm oral fluids. Gentle exercise if possible. Notify; Transport to nearest appropriate hospital. Hypothermia: Decreased LOC; no shivering; core temp < approx 33 o C. Handle patient gently. Remove wet clothing if sheltered; dry patient off. Wrap in warm blankets; then space blanket. If IPPV do not hyperventilate. If in VF: Shock Cardiac drugs if core temperature > 32 o C. Do not cease resuscitation. Notify; Transport to nearest appropriate hospital. 21

25 CLINICAL MANAGEMENT GUIDELINE 12 UPPER AIRWAY OBSTRUCTION General Care Guideline. Partial Obstruction: Maximise oxygen therapy. Encourage coughing. Prompt transport. Minimum intervention. (a) - Foreign body Complete obstruction: Conscious patient: Four modified chest thrusts; if fails - Turn into lateral position. Four back blows. If possible, position with head down to utilise gravity; if fails - Repeat the sequence x 2; if fails - Urgent transport 100% oxygen Unconscious patient: Extricate foreign body with laryngoscope & Magill forceps; if fails - Supine position - 4 modified chest thrusts; if fails - Lateral position - 4 back blows; if fails - Repeat sequence x 2; if fails - Attempt intubation to push foreign body into (R) or (L) main bronchus. (Insert tube as far as possible - use uncut tube if possible). Urgent transport - 100% oxygen. Notify Consider surgical airway as last resort. Obstruction relieved - provide oxygen therapy. - prompt transport (b) - Swelling Causes: croup / epiglottitis; insect sting; anaphylaxis; trauma; oral / pharyngeal infection; burns. Maximise oxygenation. Do not attempt close examination of mouth / throat area. Do not unnecessarily distress the patient. Consider: Nebulised saline. If severe obstruction: nebulised adrenaline: wt > 10 kg - 5 mls Adrenaline 1:1000 wt < 10kg - 0.5ml/kg Adrenaline 1:1000 (Make volume up to 5 mls with saline, as required) If insect sting or envenomation: Consider IV / IM adrenaline. If complete airway obstruction occurs - give 100% O 2 and attempt I.P.P.V. Urgent transport. Notify Consider surgical airway as last resort. Partial obstruction: prompt transport. 22

26 CLINICAL MANAGEMENT GUIDELINE 13 ABDOMINAL EMERGENCIES General Care Guideline. Posture flat - knees may be flexed. I.V. resuscitation as required. Pain relief. Cover open wounds with dry, sterile dressing; protruding viscera with saline moistened sterile dressings. If impaled object in situ - do not remove impaled object - move the patient with object in situ. Notify: prompt transport to nearest appropriate hospital. 23

27 CLINICAL MANAGEMENT GUIDELINE 14 POOR PERFUSION / HYPOTENSION / DEHYDRATION General Care Guideline. Assess patient carefully to determine possible cause. If dehydrated - N/saline IV. ( a ) Hypovolaemic ( b ) Cardiogenic ( c ) Distributive ( d ) Obstructive High concentration O 2. High concentration O 2. High concentration O 2. High concentration O 2. If severely shocked & uncompressible bleeding lesion - early, rapid transport. IV fluids to maintain systolic BP Consider PASG if: - severely shocked and injuries are under suit; OR - there is a compressible bleeding lesion. Treat significant arrhythmias. Pain relief Notify; prompt transport to nearest appropriate hospital. Posture with care if suspected spinal injuries. IV fluids - keep BP if suspected spinal injuries. Adrenaline if suspected anaphylaxis. Notify; prompt transport to nearest appropriate hospital. If severely shocked - early rapid transport. IV fluids. Decompress tension pneumothorax. Notify; prompt transport to nearest appropriate hospital. Notify; prompt transport to nearest appropriate hospital. 24

28 CLINICAL MANAGEMENT GUIDELINE 15 DECREASED LEVEL OF CONSCIOUSNESS General Care Guideline. Assess patient carefully. ( a ) History of Trauma Head Injury Cervical spine precautions. Airway management guideline. If GCS below 12 maintain: Oxygen saturations > 95% BP: systolic. ( b ) No history of Trauma Check BGL. Posture º head up. Consider poisoning or O/D. Airway management guideline. If GCS below 12 - maintain: Oxygen saturations > 95% BP: systolic. ( c ) Apparent syncope Check thoroughly for more significant causes, especially in elderly patients. Posture by perfusion or comfort. Check BGL Consider 12 lead ECG Notify; transport to nearest appropriate hospital Notify; transport to nearest appropriate hospital. Notify; transport to nearest appropriate hospital. Evidence of a rapidly decreasing level of consciousness is a flag for time critical patient - minimal scene time & urgent transport to hospital. 25

29 CLINICAL MANAGEMENT GUIDELINE 16 CHEST PAIN / SUSPECTED ACUTE CORONARY SYNDROMES General Care Guideline. Assess thoroughly for: - possible Acute Coronary Syndromes (ACS) - potentially life threatening other causes of chest pain. Silent or atypical ACS presentations should be treated in the same manner as a typical presentation. Monitor closely. 12 lead ECG. Aspirin. GTN. Metoclopramide. Possible Acute Coronary Syndrome Pain management - aim to abolish pain or discomfort. Notify hospital AS EARLY AS POSSIBLE if AMI is suspected. Pain assessed as probable non ACS Assess for possible threat to life noncardiac chest pain can kill! If in any doubt treat for ischaemic heart disease. Otherwise manage as for undiagnosed pain. Prompt transport Treat haemo-dynamically significant arrhythmias. Prompt transport. [Give aspirin, even if on regular slow release aspirin. 150mg dose if already on warfarin. Watch for non-typical or silent presentations of ischaemic heart disease, especially in females, elderly & patients with diabetes. Aim to minimise scene time while still providing reassurance & effective pain relief.] 26

30 I.V. resuscitation as required. Pain relief as required. Pneumothorax. CLINICAL MANAGEMENT GUIDELINE 17 CHEST INJURIES General Care Guideline. - If suspected avoid coughing, Valsalva or IPPV. Suspect tension pneumothorax in a patient with no air entry & significant respiratory or cardio-vascular compromise. - Decompress tension as indicated. Open chest wound Flail chest - Cover, seal on 3 sides only, or use chest seal. - Stabilise the chest wall. - Posture patient with affected side down, or by manual pressure. Avoid use of PASG. Notify & transport to nearest appropriate hospital. 27

31 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 % if suspected cord lesion. - I.P.P.V. If hypoventilating. Posture supine and flat. Cx collar - Extricate with spine board or Kendrick Extrication Device - Lift with board or scoop stretcher. I.V. resuscitation as required. - DO NOT OVER-INFUSE - Systolic blood pressure of 80 mm Hg is acceptable in high spinal injuries. With suspected cord lesion - administer Metoclopramide 10 mg (adults only). Insert IGT & urinary catheter prior to secondary, air or extended transports. If transport is prolonged pressure area care is required. Notify and transport patient to nearest appropriate hospital. 28

32 CLINICAL MANAGEMENT GUIDELINE 18a AUTONOMIC HYPERREFLEXIA General care guideline In established High Paraplegics or Quadriplegics assess the patient for Autonomic Hyperreflexia The sudden onset of any of the following is significant. - Sudden hypertension, (this may be in the normal range for the rest of the population); pounding headache, bradycardia, flushing /blotching of skin; profuse sweating above level of lesion; skin pallor and piloerection below level; chills without fever; nasal congestion, and blurred vision; shortness of breath, sense of apprehension or anxiety Causes Bladder: Distended due to blocked or kinked catheter, UTI, Bladder or kidney stones. Bowel: Constipation, faecal impaction, rectal irritation Skin: Burns, pressure areas, tight clothing eg TED stockings. Other: Fractures, Distended stomach, labour, severe menstrual cramping. Actions - Ask patient and carer if they suspect a cause - Elevate patient s head and lower legs - Loosen any constrictive clothing - Check bladder drainage equipment for kinks or obstruction. - If found, initially drain 500mls, then a further 250 every 15 minutes until bladder is empty - Monitor BP every 2-5 minutes - Avoid pressing over bladder Treatment If the BP remains elevated (Ranging between mmHg). Commence treatment with: IV Midazolam 0.05mg/kg, over one minute. May be repeated once after 10 minutes if no fall in the BP. Give 0.1mg/Kg IM if unable to cannulate. Midazolam should be given with extreme caution while constantly monitoring the patient s vital signs. NOTE: Treatment with Midazolam mandates transport to hospital. Notify and transport to nearest hospital. 29

33 CLINICAL MANAGEMENT GUIDELINE 19 LIMB INJURIES General Care Guideline. Check arterial circulation in the limb. If distal pulse absent - gently realign fractured segments until pulse returns or alignment near normal. Immobilise all fractures unless patient is otherwise time-critical. Elevate if possible. Do not attempt to reduce dislocations. I.V. resuscitation where indicated. Pain relief - add Midazolam as required. - Ketamine as appropriate. Partially severed limb - carefully protect; keep distal limb dry, wrapped and cool. Completely severed limb: Keep severed part dry, wrapped and cold. Place in a dry sealed plastic bag, then place within another bag or bucket filled with iced water at approx 4 deg C. DO NOT immerse part in ice. DO NOT attempt to clean or disinfect the severed part. Notify and transport patient to nearest appropriate hospital. 30

34 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 patient lying flat. The injured eye must be protected from rubbing, pressure. Use eye shield, or loosely taped eye patch. Cover both eyes if patient tolerates this. Severe eye injuries - administer Metoclopramide IV prior to transport (adults only). Chemical Burns: Irrigate immediately with copious quantities of water or saline for at least ten minutes. The eyelids must be pulled apart to ensure the fluid washes the eye. Scalds and Electrical Flash Burns: No dressing is required, ice packs can be beneficial. Foreign Bodies in Cornea: Protect the eye with a shield or pad. Do not attempt to remove the foreign body. Notify and transport patient to nearest appropriate hospital. 31

35 CLINICAL MANAGEMENT GUIDELINE 21 BURNS General Care Guideline. If there is still heat left in the skin, cool with cold water. Utilise water-gel burns dressings. Cover the burnt area with clean dressing/sheets. If a limb is burnt, remove all rings, tight clothing, shoes; elevate the part. Consider space blanket. Check for upper airway obstruction, especially if the face is burnt. (a) Hoarse voice (b) Inspiratory stridor (c) See-saw breathing Treat bronchospasm or airway obstruction via relevant management guideline. If decreased level of consciousness - Suspect Carbon Monoxide poisoning (especially if burnt in a confined space). - Administer 100% O 2 ; consider PEEP. Pain relief. Cannulate - N/Saline TKVO. - 10ml / kg bolus as required. - Maintenance fluid as required: N/Saline 1ml / kg / BSA / hr 5 since burn incident Transport all smoke inhalation patients to hospital - delayed pulmonary oedema may occur. Notify and transport patient to nearest appropriate hospital. 32

36 CLINICAL MANAGEMENT GUIDELINE 22 SEIZURES General Care Guideline. Protect the patient from injury. Blood glucose estimation early if no history of seizures. Midazolam [ IM if no IV access ] Treat any injuries secondary to the seizure. Children with seizure and fever - Remove excessive clothing - Cool with tepid water - Place cool cloths in axillae, groin, wrist and neck; change at 5 minute intervals - Do not allow child to shiver Notify and transport patient to nearest appropriate hospital CLINICAL MANAGEMENT GUIDELINE 23 STROKE General Care Guideline. Posture o head up. Airway management guideline. Cannulate: - blood glucose estimation. - treat hypoglycaemia cautiously; avoid hyperglycaemia. Treat seizures promptly & aggressively. Minimise scene time. NOTIFY HOSPITAL EARLY; prompt transport to nearest appropriate hospital 33

37 CLINICAL MANAGEMENT GUIDELINE 24 NEAR DROWNING General Care Guideline. Cardiac arrest - treat by specific guideline. Highest concentration oxygen practical. - Consider PEEP. Cervical collar as required. IGT if possible. Consider hypothermia / other related conditions. Notify & transport. Note: Late pulmonary oedema may occur. * Transport is always required following near drowning episodes. * 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 possibility of air embolus - posture left lateral, with head down tilt. Oxygen therapy: highest concentration practicable. Exclude pneumothorax. Always dehydrated - rehydrate with N/Saline 10 mls / kg rapidly. Ascertain dive profile (number and sequence of dives; time at depth; breathing mixtures; decompression stops and any uncontrolled ascent.) Remember to check dive partner. Monitor symptom progression. Pain relief - analgesics may mask symptom changes; aim for minimal analgesia. 34

38 CLINICAL MANAGEMENT GUIDELINE 26 OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES General Care Guideline. Unscheduled Normal Field Birth Most important ambulance role in a field delivery is to appear calm! Preferred management is birth at a hospital but if birth is imminent, reassure the mother & help her to a comfortable position. Ensure full history. Oxygen. Pain relief as required. Provide support and guidance during birth of baby s head while encouraging gentle grunty pushes or controlled breathing to ease the head out slowly and gently. As the head is born have your hand close to the top of the baby s head - you do not need to touch it unless the woman gives an uncontrolled push and the baby would otherwise shoot out (especially important if the baby is preterm < 37 weeks). Observe for cord around the baby s neck. If present the baby may be born through the loop of cord. If the cord is loose, it may be slipped forward over the head, taking care not to stretch it or tear it. Rarely the cord is so tight that it stops the baby s descent and in this situation it may need to be clamped in two places and cut between the clamps. Great care is necessary not to injure the baby or woman while doing this Place the baby straight up on to the mother s chest noting time of birth. Dry baby & maintain warmth by keeping the baby close to the mother s skin. Place warm blankets over the baby and mother. Assess Apgar at 1 & 5 minutes. Cord should not be cut routinely, but if necessary apply plastic clamp (x2) at 3cm from the umbilicus, milk the cord gently back from the clamp 3cm, taking care not to pull on umbilicus. Apply plastic clamp (x2) then cut the cord using clean scissors. Women in more advanced pregnancy (approx 20 + weeks gestation) are generally best treated / transported in left lateral position, regardless of problem. 35

39 CLINICAL MANAGEMENT GUIDELINE 26 OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES (continued) Complicated Birth P.V. Haemorrhage Prolapsed cord: Posture in the knee chest position. (often easier in the all fours knee chest position) Oxygen 100%. Advise hospital early. Urgent transport. Do not encourage pushing Breech presentation: Normal, unassisted birth may not always be possible. Where possible, do not encourage the woman to push but to breathe through contractions. Transport urgently; notify hospital. Once legs and body have been born, support baby s body (do not apply downward traction) as it hangs downward while waiting for the gentle, slow birth of the head. Encourage the mother to breathe her baby s head out. If head is not born with the next contraction, encourage her to push whilst gently supporting the baby as it hangs downward. Other presentations: Recognise! Normal, unassisted delivery may not always be possible. Urgent transport; notify hospital. Not pregnant / early pregnancy: Manage as per perfusion status. Advanced pregnancy (L) lateral position. Do not attempt to massage the fundus of the uterus. Do not inflate abdominal chamber of PASG. Cardiac arrest in advanced pregnancy Position with wedge under right hip to obtain degree tilt. Give fluid bolus early. Urgent transport as soon as backup has arrived. If performing CPR, increase CPR compression force due to the chest wall compliance secondary to breast hypertrophy. Ensure hospital is notified as early as possible that patient is pregnant. Women in more advanced pregnancy (approx 20 + weeks gestation) are generally best treated / transported in left lateral position, regardless of problem. 36

40 CLINICAL MANAGEMENT GUIDELINE 27 HYPERKALAEMIA General Care Guideline. Consider in these situations: Renal failure / dialysis. Crush syndrome, including situation of prolonged unconsciousness. Occasionally diabetic ketoacidosis. ECG signs are unreliable; frequently do not follow expected progressions; do not always show good correlation with serum K + levels. Monitor the ECG for signs of hyperkalaemia, which may include: - Tall peaked T waves - No P waves - Wide QRS - Sine wave pattern (VT) - V.F / Asystole. Arrhythmias, especially bradycardias, are common. If ECG changes are present: - Nebulised Salbutamol (continuous). - Calcium Chloride 10 mg / kg I.V. over 2 minutes. - Follow with: Sodium Bicarbonate 8.4% - 0.5mMol / kg IV over 2 minutes. If changes persist after minutes: - repeat Calcium & Sodium Bicarbonate x 1. NB: Treatment is determined by pt presentation; ECG changes & clinical setting! 37

41 Possible problems: Haemorrhage; Hyperkalaemia; Seizures; Venous air embolism; Haemolysis of the patient s blood; Myocardial Infarction CLINICAL MANAGEMENT GUIDELINE 28 HOME DIALYSIS EMERGENCIES General Care Guideline. Remember that the patient or their family are a resource for management of the dialysis machine. Remove the patient from the machine: - A.C. Power - Turn off at the wall; - Blood lines - Clamp both lines 30 cm from the arm; - Cut both lines between clamps and the machine. Utilise venous dialysis line if possible for IV access. Venous air embolism is suspected if there is air in the venous return line. Treat with 100 % oxygen; posture in the left lateral position with head down tilt 30 degrees. Notify and transport to the nearest hospital Note: true dialysis emergencies are rare. It is far more likely that a dialysis patient will require an ambulance for conditions unrelated to dialysis. In this instance, avoid cannulating dialysis patients unless the cannula is actually going to be used. 38

42 CLINICAL MANAGEMENT GUIDELINE 29 ALLERGIC & ANAPHYLACTIC REACTIONS Pressure immobilisation bandage / splint over the area of injection, sting or bite if appropriate. Adrenaline is drug of choice for cases where there are potentially life-threatening signs (hypotension; upper airway swelling; bronchospasm unresponsive to nebulised bronchodilators) - IV use should be with caution. - Consider use of IM adrenaline in the first instance. - Infusion is the preferred method of IV administration. Manage using guidelines for respiratory distress; hypotension; upper airways obstruction as appropriate. CLINICAL MANAGEMENT GUIDELINE 30 CRUSH SYNDROME General Care Guideline. Rarely a problem with less than 45 minutes of compression of a significant muscle mass. Acute volume loss on release is considered of greater clinical importance than hyperkalemia & acidosis. Immediately prior to removal of the compressive force: - consider use of arterial tourniquet to compressed limb. - increase IV infusion rate. - observe ECG. Following removal of compressive force: release tourniquets carefully; check for ECG changes. Treat as per Poor perfusion, Hyperkalemia, Limb Injuries guidelines. 39

43 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. Electrical burns usually cause greater tissue damage than the appearance of the skin surface would suggest. High Voltage - consider possible spinal injury. Check for exit burn; Treat other injuries as required. Always transport. 40

44 Be aware of risks to yourself & others. Ensure scene control & safety. CLINICAL MANAGEMENT GUIDELINE 32 ASSAULT General Care Guideline. Attention to detail (such as full name, location, times; others present) is very important. Treat injuries where indicated. Specifically for sexual assault: Be aware some patients may resent physical contact from carers; Avoid any judgemental comments; Articles of evidence, such as clothing must be taken with the patient (use a paper bag); Discourage the patient from showering; The patient should not be left alone at any time. Do not give details of assault over the radio. CLINICAL MANAGEMENT GUIDELINE 33 BEHAVIOURAL & PSYCHIATRIC EMERGENCIES General Care Guideline. Identify yourself clearly. If concerned about your safety, or others, call police for assistance. Be reassuring and non-judgemental when conversing with the patient. Speak quietly - do not shout. One officer should talk privately with the patient where possible. Do not leave the patient alone. Consider / exclude: hypoxia; hypoglycaemia; head injury; drug overdose; post-ictal state. Treat as appropriate. Consider use of CMG 37 Management of Combative or agitated patients. Arrange for appropriate support services eg. CAT Team. Notify and transport patient to nearest appropriate hospital. 41

45 CLINICAL MANAGEMENT GUIDELINE 34 C.B.R. INCIDENT General Care Guideline. A CBR incident may be indicated by: - Physical indicators, eg unusual pools of liquid, clouds or fogs, unusual colours, strange devices or recent explosion. - Medical signs and symptoms or unusual behaviour being displayed by many people. - Dead birds or animals in the area. STEP 123 is Safety Trigger for Emergency Personnel : - 1 patient with cholinergic symptoms is suspicious, 2 patients indicate a CBR, 3 patients is a CBR. PROTECT YOURSELF; DO NOT ENTER THE CONTAMINATED AREA IF THIS CAN BE DETERMINED. If you find yourself in a contaminated area, cover nose and mouth with a damp cloth; take frequent shallow breaths; don t Taste, Eat, Smell, or Touch anything in the area; seek shielding if radioactivity is present; leave the scene immediately and proceed to a safe upwind, uphill area; be aware of the possibility of secondary devices. Remain clear of the contaminated area (Designated HOT& WARM Zones) unless authorised to enter by the incident commander. You must be equipped with appropriate personal protective equipment and suitable training in its use. Only authorised and trained personnel will operate in the HOT& WARM Zones. Decontaminate: Remove clothing and discard into special HAZMAT container. Skin must be cleaned by thorough washing or preferably showering; special attention to hair and parts of the body with opposing skin surfaces, e.g.: buttocks. It is preferred that patients and personnel be decontaminated PRIOR to treatment. Initial antidote can be administered prior to decontamination by suitably protected personnel. Assist ventilation (Only if small number of casualties); Obidoxime Combo-pen if a nerve agent is identified (cholinergic symptoms), if unavailable use Atropine. Midazolam to treat seizure patients; Treat associated injuries: Burns; Blast injuries; Fractures. Ensure hospital is notified of possible contaminated patients. 42

46 CLINICAL MANAGEMENT GUIDELINE 35 POISONING, ENVENOMATION & OVERDOSE General Care Guideline. SPECIFIC AGENTS: Opioids: Naloxone IM, followed by IV. Tricyclic antidepressants: Watch for arrhythmias & seizures. If either of above occurs - administer 0.5 mmol/kg Sodium Bicarbonate (treat seizures first with Midazolam as per CMG 22) Organo-phosphates: Take care not to become contaminated. Consider possibility of other effected workers / occupants / first-aiders. Where feasible - remove contaminated clothing, wash skin with soap & water. If cholinergic effects, (salivation, sweating, nausea, bradycardia) administer: Atropine l.v. or IM. Repeat as required. Ensure hospital is notified of contaminated patient. Envenomation: Utilise pressure / immobilisation technique if appropriate. Treat signs and symptoms as they arise eg. Cholinergic symptoms with some spider bites. Identification - the creature should be brought to the hospital only if this can be done safely; Do not rely on non-expert identification. With positive identification of a Red Back Spider, pressure immobilisation is not required. - Apply iced compresses (not directly to skin). Carbon monoxide / smoke inhalation: Beware of hazards - self-asphyxiation and / or explosion; remove patient from danger. Treat according to Respiratory distress or Upper airway obstruction guideline. 100% oxygen if carbon monoxide suspected, consider PEEP. Consider possibility of other effected workers / occupants / first-aiders Any person who has suffered an inhalation injury of toxic substances is to be transported to hospital. (Pulmonary oedema may be a late complication). Urgent transport if decreased level of consciousness. 43

47 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) minutes - And the patient cannot be managed adequately within the limits of existing guidelines and pharmacology; It must be noted that the extended care guideline does not permit Paramedics to extend their scope of practice to procedures, which they have not been trained to perform. I.V.FLUIDS: Replacement: Replacement of estimated or continuing losses with N/Saline Aim for systolic BP of 90 mmhg. Maintenance: N/Saline - Baseline of 1 ml/kg/hr; - Titrate to: - Perfusion & hydration assessment - Any continuing fluid losses - Environmental conditions - Urine output, if available (aim for 1 ml/kg/hr). ANTIEMETIC: Metoclopramide: Further IV dose, after 3 4 hours. May be given IM repeat after 4 hours. ANALGESIA: Morphine: Following initial doses of Morphine, further doses of 0.05 mg/kg may be given at 15 minute intervals, titrated against: - Pain assessment - History & presenting problem - Perfusion status - Level of consciousness & respiratory status (no further doses if GCS is 13 or below, or if respiratory rate drops below 10). Intramuscular: same provisos as general pharmacology; 0.1mg/kg dose; repeat after 30 minutes as required; thereafter at minimum of 90 minute intervals Midazolam: Can repeat initial doses as per morphine titration, with care! I.G. TUBE: Consider placement in the following patients, if patient contact is likely to be prolonged: - cervical & thoracic spinal cord lesions - burns patients, BSA over 20% (esp. if respiratory involvement). 44

48 CLINICAL MANAGEMENT GUIDELINE 37 MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS CMG 37a GENERAL AMBULANCE OPERATIONS Use in situations where the patient cannot be managed due to agitation or combativeness. If concerned about safety call police for assistance. Consider / exclude: hypoxia; hypoglycaemia; head injury; drug overdose; post-ictal state 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. If reassurance and persuasion are ineffective or impractical, move to pharmacological management. This should be a last resort: Midazolam up 0.1mg / kg. Usually IM. May repeat dose after 10 minutes if necessary. Ensure adequate control of the limb and patient when injecting. Elderly patients; known or suspected hypotension; general debility: reduce dose usually half. Limb restraints are to be utilised in conjunction with pharmacological restraint. MENTAL HEALTH PATIENTS: Wherever possible, obtain an Emergency Order for management of mental health patients. (AFP; medical practitioner; CAT Team) If not practical, proceed with pharmacological control if there is concern for the welfare of the patient & / or others. Notify and transport patient to nearest appropriate hospital. PATIENTS MANAGED WITH PHARMACOLOGICAL CONTROL MUST BE TRANSPORTED TO HOSPITAL. If agitated state thought to be due to psycho-stimulant use: Midazolam up 0.2 mg/kg. May repeat after 10 minutes if required. NOTE: All patients managed with CMG 37 will require an incident report to be submitted to the Clinical Services Section. 45

49 CLINICAL MANAGEMENT GUIDELINES 37B AERO-MEDICAL PATIENTS A lower threshold for intervention with sedation applies to patients who are transported by air. In flight agitation & combativeness is to be managed as a matter of urgency. Identify and correct possible causes of agitation prior Inform the pilot in command. to flight wherever possible. Proceed immediately to pharmacological Electrolyte imbalance, hypoxia, hypovolaemia, management. hypoglycaemia, cold. Do not use physical restraint alone, beyond the If still agitated sedate prior to flight. time required to pharmacologically manage the patient. If unable to obtain agreement on sedation prior to flight advise pilot of your concerns. If still no decision to sedate patient, & in your opinion there is still an unacceptable risk do not fly. Advise all crew & ACTAS Duty Manager. Duty Manager to discuss with Shock Trauma Service consultant. 46

50 CLINICAL MANAGEMENT GUIDELINES 38 MENINGOCOCCAL DISEASE Prompt identification of meningococcal disease & commencement of treatment out of hospital can be life saving. A high index of suspicion is advisable, but only in critically ill patients. Consider meningococcal disease in the following circumstances: febrile illness & sudden onset & disturbed level of consciousness. + / - haemorrhagic, purpuric or petechial rash; + / - tachycardia, hypotension, peripherally shut down. Other signs & symptoms often non-specific, especially in young children. Headache; photophobia; neck stiffness; vomiting; painful or swollen joints; occ focal signs; seizures. Management Ensure personal protection gloves; mask; gown; eye protection if airway care is being attended. General care. Ensure minimum scene time Cannulate 10 mls / kg Normal saline; Repeat as required. Ceftriaxone 50 mg/kg IV or IM, to max 2g Check BGL Urgent transport Note: deterioration is possible following antibiotic administration. This would be unusual during average ambulance contact. It will most likely be a decrease in LOC & / or BP. Be prepared; manage with fluid. If deterioration continues consider adrenaline infusion. 47

51 If Intubation is not successful the following Failed Intubation Drill MUST BE FOLLOWED No Were vocal cords visualised during Initial laryngoscopy Yes Insert OP airway and ventilate with 100% o2 Check head /neck position BURP manoeuvre Re-attempt intubation under direct Vision, after suction or removal of foreign body, as required No Objective confirmation of tracheal placement (ODD ETCo2) YES Immediately remove ETT and insert OP or NP airway and re-ventilate with 100% O2 Continue management in accordance with the relevant CMG DO NOT CONTINUE WITH FRUITLESS ATTEMPTS TO INTUBATE UNDER DIRECT VISION Able to oxygenate and ventilate YES Attempt digital placement (on appropriate patients) If unsuccessful insert LMA No CONSIDER Able to oxygenate and ventilate CRICOTHYROTOMY No YES Continue management in accordance with the relevant CMG Incident report to be submitted 48

52 RAPID SEQUENCE INDUCTION (RSI) THIS IS A PROCEDURE OF LAST RESORT! EXPLORE ALL OTHER OPTIONS AND ALTERNATIVES FIRST! INDICATIONS The unconscious patient with unequivocal, life threatening airway compromise and clinical evidence of severe hypoxia. OR The unconscious patient with potential airway compromise where extrication procedures will make it impossible to provide adequate airway control. CONSIDERATIONS The following essential considerations must be taken into account prior to utilisation of this guideline. Clinical Need Airway compromise, clear & obvious Glasgow Coma Score < 9 Hypoxia Sats < 90% OR Centrally cyanosed Time to Hospital (Should include Extrication, Load & Transport Time) Patients who are not trapped or where extrication is not difficult, and are within 5-6 minutes time to hospital, WOULD NOT be candidates for rapid sequence induction. Assessment of the difficulty of Intubation Based on Anatomical, Acquired and Situational Factors. Confidence and experience of the operator. Response to basic treatment Try everything posture, guedels, nasal, suction, O 2, ventilation by mask etc. Give basic options a chance to work. Only proceed to rapid sequence induction if patient remains critical. 49

53 Consequences and Outcomes Worse case scenario: Breathing patient with compromised airway; becomes a can t intubate, can t ventilate scenario. Fall back position Do not continue with futile attempts to intubate. Return to basics & re-ventilate. Attempt placement with: Digital placement LMA Surgical Airway as last resort. PROCEDURE Basic airway management. Oxygenation Aim for highest O 2 saturations by most efficient method. IV access A fast flowing line that is reliable & secure. A second line is sound insurance. Most experienced operator to tube. Do not debate this issue - make a choice and proceed! This is not a teaching opportunity for intubation skills. Prepare patient: 1. Correct any hypotension / hypovolaemia 2. Pre-oxygenate 3. Monitor Patient, ECG / Oximetery 4. Correct any bradycardia 5. Prepare and check equipment This is vital and includes: Laryngoscope Suction ETT - syringe, ties etc. LMA 6. Brief your assistant 7. Check allergies 8. Draw up drugs and check 50

54 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 E t CO 2 Pulse oximetry 12. Tie in securely. DRUG SEQUENCE Adult Midazolam 0.05 mg/kg, Slow IV dose Note: Watch BP! Prior to Suxamethonium, if bradycardic rate < 50 Atropine 0.01 mg/kg, fast push. Suxamethonium 1.5 mg/kg, over seconds. Post intubation to maintain tube and level of sedation, Alternating dose of: Midazolam up to 0.1mg / kg, slow IV dose Morphine up to 0.05 mg /kg, slow IV dose Note: Watch BP! Suxamethonium causes bradycardia, if Pt is still bradycardic once ETT is tied in, consider a dose of Atropine Paediatric Midazolam 0.05 mg/kg Slowly as possible Note: Watch BP! Atropine 0.01 mg/kg, fast push Suxamethonium 1.5 mg/kg, over seconds Post intubation to maintain tube and level of sedation Alternating dose of: Midazolam up to 0.1mg / kg, slow IV dose Morphine up to 0.05 mg /kg, slow IV dose Note: Watch BP! 51

55 IF INTUBATION FAILS Re-oxygenate / Re-ventilate patient utilise basic techniques. There is no second dose of Suxamethonium! If intubation is still unsuccessful move to a fallback option Failed intubation drill. Digital Placement, LMA and Surgical Airway. Consider urgent transport. FOLLOW UP 1. All relevant details will be carefully documented on the PCR. This especially applies to details concerning the need for sedation, the checks on correct placement and the results of the procedure. 2. Incident Report to Clinical Support Section by fax that shift, the hard copy to be sent via satchel. No Exceptions. 3. All pharmacologically facilitated Intubations will be subject to routine, mandatory Medical Advisory Committee Review. FINAL NOTE As stated previously this is a procedure of last resort! It is anticipated that this procedure will be utilised in only the most exceptional circumstances. The Clinical Advisory Committee will always support a decision not to use this procedure. 52

56 DRUGS FOR AIRWAY MANAGEMENT - SUMMARY SHEET SEDATION FOR BASIC AIRWAY MANAGEMENT: Midazolam Dose: up to 0.1 mg / kg l.v., slow IV dose. ( Note: If patient has already had Midazolam for sedation do not give a repeat dose with Suxamethonium or give a smaller dose.) RAPID SEQUENCE INDUCTION Suxamethonium & Midazolam Adult: Midazolam 0.05 mg/kg, Slow IV dose. Note: Check BP as soon as practical! Prior to Suxamethonium, if bradycardic rate < 50 Atropine 0.01 mg/kg, fast push Suxamethonium 1.5 mg/kg, over 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 seconds. Note: Watch BP! Suxamethonium causes bradycardia, if patient is still bradycardic once ETT is tied in, consider a dose of Atropine RAPID SEQUENCE INDUCTION Morphine & Midazolam Pre-infuse IV bolus of fluid, irrespective of BP. Adults: IF - normal size & weight & age < 75 & BP > 100 Morphine 10 mg IV, Midazolam 10 mg IV. Fast push. IF - small adult or BP or age 75 Morphine 5 mg IV, Midazolam 5 mg IV. Fast push. IF - BP < 70 Morphine 2.5 mg IV, Midazolam 2.5 mg IV. Fast Push. Flush dose with rapid IV fluid bolus. Paediatrics: Morphine 0.05 mg / kg mg IV, Midazolam 0.1 mg / kg mg IV. If hypovolaemia suspected : give half calculated dose of each drug. Flush dose with rapid IV fluid bolus. Doses may be repeated x 1. (Prepare second doses) POST INTUBATION - to maintain tube and level of sedation. Alternating dose of: Midazolam up to 0.1mg / kg. Slow IV dose. Morphine up to 0.05 mg /kg. Slow IV dose. Note: Monitor BP closely! 53

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59 A.C.T. AMBULANCE SERVICE PHARMACOLOGY NOTES INDEX ACETYLSALICYLIC ACID (ASPIRIN) ADENOSINE ADRENALINE AMIODARONE ATROPINE SULPHATE CALCIUM CHLORIDE CEFTRIAXONE DEXTROSE 5% DEXTROSE 50% FRUSEMIDE (LASIX) GLUCAGON GLYCERYLTRINITRATE (ANGININE) HYDROCORTISONE IPRATROPIUM BROMIDE (ATROVENT) KETAMINE LIGNOCAINE MAGNESIUM SULPHATE METHOXYFLURANE (PENTHRANE) METOCLOPRAMIDE (MAXOLON) MIDAZOLAM (HYPNOVEL) MORPHINE SULPHATE NALOXONE (NARCAN) NORMAL SALINE OBIDOXIME ONDANSETRON (ZOFRAN) SALBUTAMOL (VENTOLIN) SODIUM BICARBONATE SUXAMETHONIUM Drug Calculator 56

60 ACETYLSALICYLIC ACID (ASPIRIN) TYPE: PRESENTATION: ACTIONS: Nonsteroidal anti-inflammatory drug. [S.2] Tablet 300 mg. 1: Inhibits platelet function (up to 7 days). 2: Suppresses inflammation, reduces fever, relieves pain. Rapidly absorbed from stomach and small bowel. USE: Suspected Myocardial Ischaemia - reduces platelet aggregation and limits clot development. ADVERSE EFFECTS: 1: Allergic reactions eg. asthma, angioneurotic oedema, urticaria, rhinitis, shock. CHECK FOR PREVIOUS REACTIONS. 2: Aggravation of bleeding tendencies. 3: Gastric irritation (unlikely with 1 tablet only). CONTRA-INDICATIONS: 1: Known or suspected allergy to salicylates. 2: Known or suspected active bleeding. 3: Known bleeding tendency. DOSE: 1 tablet (300mg) - chewed and swallowed or - dissolved in a small amount of water. If on warfarin ½ tablet (150mg) only. Single dose only. SPECIAL NOTE: Administer even when patient is on slow release aspirin. 57

61 ADENOSINE TYPE: PRESENTATION: ACTIONS: USES: ADVERSE EFFECTS: (ADENOCOR) Endogenous purine nucleoside, found in all body cells. [S.4] 6 mg in 2 ml amps. Causes transient inhibition of conduction in the heart, especially in the A-V node. Onset: 5-10 seconds. Duration: approx 10 seconds. Treatment of Supra-ventricular Tachycardia. Not for the treatment of Atrial Flutter or Fibrillation; however, if mistakenly administered to patients in these arrhythmias, the decrease in A-V conduction may unmask atrial activity. Common, although transient & generally minor. Arrhythmias at time of conversion - common ( up to 55% pts) - includes PVCs, PACs, sinus brady, A-V blocks. Transient flushing of the skin; mild dyspnoea; chest tightness, nausea & headache. Feelings of apprehension & fear. CONTRA-INDICATIONS: 2 or 3 block. Known hypersensitivity. PRECAUTIONS: DOSE: Asthma - may exacerbate bronchospasm. Pregnancy - use only if very poorly perfused. Antagonised by: Theophylline Potentiated by: Dipyridamole (Persantin) Carbamezapine (Carbium, Tegretol, Teril) Symptomatic adults only: 6 mg IV - rapid bolus (1-2 seconds). - give into fast flowing pump set If 1 st dose unsuccessful, give 2 nd dose 12 mg IV (2 minutes between doses) Paediatric : 0.05 mg / kg 2 nd dose : 0.1 mg / kg SPECIAL NOTE: Use only after unsuccessful Valsalva manoeuvrer x 2. Record 12 lead ECG prior to use of Adenosine. Rapid injection with a pump set increases likelihood of success. Elevate limb if possible. If successful conversion of arrhythmia - patient should be transported to hospital - incidence of recurrence of arrhythmia is quite high (10-15%). 58

62 effect) ADRENALINE TYPE: PRESENTATION: Naturally occurring catecholamine. [S.3] 1: mg in 10 mls - IMS Minijet 1: mg in 1 ml - ampoules ACTIONS: 1. Peripheral vasoconstriction (α effect) 2. Increased rate of sinus node Increased myocardial contractility Increased AV conduction Increased myocardial irritably (βb1b 3. Bronchodilatation Vasodilatation of skeletal muscle (βb2beffect) Onset - IV: 30 secs; IM: secs Max effect - IV: 3-5 mins; IM: 4-10 mins Endotracheal use: slightly longer times. USES: ADVERSE EFFECTS: Ventricular fibrillation. Asystole. Pulseless Electrical Activity (PEA) Anaphylaxis. Severe - life threatening asthma. Bradyarrhythmias resistant to Atropine. Severe upper airway obstruction due to swelling. Tachycardia. Tachyarrhythmias. Hypertension. CONTRA-INDICATIONS: Known hypersensitivity. PRECAUTIONS: These apply to patients with cardiac output only: - Care with patients with history of hypertension. - Care with patients with history of ischaemic heart disease. - Give extremely slowly to patients on MAO Inhibitor antidepressants (eg: Marplan, Parstelin, Marsilid, Nardil, Parnate) Adrenaline may provoke a greatly exaggerated response. Generally, patients on MAOIs with cardiac output should receive no more than ¼ normal dose of adrenaline, titrated to response. Continues over 59

63 DOSE: Cardiac Arrest Adult: 1mg, IV fast push Paediatric: 0.01mg/kg IV / IO fast push Endotracheal if no IV or IO access. No limit on number of doses in Cardiac Arrest Anaphylaxis / Severe - life threatening asthma: Adult: 0.5 mg IM Paediatric: 0.01 mg / kg IM (to 50 kgs) Repeat IM dose x 1 as required. If required, IV Adrenaline by infusion: 1 mg in 1000 mls Saline ( = 1mcg/ml) Titrate to response. (20 dpm = 1 ml / min = 1 mcg / min) Paediatric - use burette If patient critically ill, slow IV, up to 0.01 mg / kg, over 5 minutes. Note: IV adrenaline in anaphylaxis & asthma should be used very cautiously. Bradyarrhythmias resistant to Atropine: IV Adrenaline by infusion: 1 mg in 1000 mls Saline ( = 1mcg/ml) Titrate to response. (20 dpm = 1ml/min = 1 mcg/min) Paediatric - use burette Severe upper airway swelling: Adrenaline 1:1000: wt > 10 kg - nebulise 5 mls Adrenaline 1:1000 wt < 10kg - nebulise 0.5ml/kg Adrenaline 1:1000 (make volume up to 5 mls with saline, as required) Single dose only. SPECIAL NOTE: Adrenaline in 1000ml flask is to have medication label attached! 60

64 P blockade P channels P channel AMIODARONE (CORDARONE X) TYPE: PRESENTATION: ACTIONS: USE: ADVERSE EFFECTS: CONTRA-INDICATIONS: DOSE: Potent antiarrhythmic agent. [S.4] Ampoule 150 mg / 3 mls Complex electrophysiological & pharmacological profile. Prolongs the action potential duration; increases refractoriness of all cardiac tissue. + Also blocks NaP (Class I action). Has some anti-adrenergic effects (Class II action). 2+ CaP (Class IV). Prolongs QT interval reflects global prolongation of repolarisation. When given I.V., a significant effect is on AV node causes delay in nodal conduction. Also effective for accessory pathway conduction. Effective for both supraventricular & ventricular arrhythmias. ACTAS use: to slow ventricular rate in AF and AFl. Treat VT & VF. IV: can cause vasodilatation & negative inotropic effects; hypotension. (Dose & rate dependent.) Occasionally may cause: - bradycardia ( esp in older pts). - phlebitis. - hot flushes / sweating. Known hypersensitivity. Cross sensitivity to Iodine. VF: Adult: 300 mg IV push dose (over seconds). Paediatric: 5 mg / kg IV (to total 150mg). Dilute to 10mls volume with 5% Dextrose. VT, AF and AFl: 150 mg IV via Springfuser; (over 10 minutes, approx. 7 mls). Paediatric: 5 mg / kg as above (to total 150mg). (VT - If extremely compromised, may be given over 5 mins by slow IV injection) SPECIAL NOTE: No repeat doses for either treatment regimen. Needs to be administered in 5% Dextrose (incompatible with saline) Significant potential drug interactions: Following may potentiate actions of amiodarone: digoxin; phenytoin 2+ (Dilantin); β blockers; CaP blockers; other antiarrhythmics. 61

65 ATROPINE SULPHATE TYPE: PRESENTATION: ACTIONS: Parasympathetic blocking agent [ S.4] 1 mg in 10 mls - IMS Minijet Large number of actions. Those important in the pre hospital setting: - Blocks the action of the vagus nerve on the heart. - Increases the rate of the sinus node. - Increases speed of conduction through the AV node. - Reduces the amount of secretions from some glands: (eg. tear & salivary glands). Onset: IV - 2 mins. Max effects - 5 mins IM / ET- Slightly longer USES: ADVERSE EFFECTS: - Bradyarrhythmias with poor perfusion - Asystole / PEA - Organophosphate poisoning / spider bite (to increase heart rate & / or assist airway maintenance by reducing excessive salivation) - To prevent bradycardia with Suxamethonium use Tachycardia; palpitations; blurred vision; dry mouth; confusion, urinary retention; increased body temperature (by reduction in sweating). CONTRA-INDICATIONS: Known hypersensitivity. PRECAUTIONS: Care needed in patients with Glaucoma. Aim not to increase heart rate above 100 / min. DOSE: Bradyarrhythmias: Adult: IV mg/kg fast push ET: mg/kg, if no immediate IV access. Repeat x 1 as necessary Paediatric: Not used Continues over 62

66 Asystole / PEA: Adult: 2mg IV / ET Paediatric: Not used Organophosphate poisoning / cholinergic symptoms of spider bite: Adult / Paediatric: 0.01 mg/kg IV - repeat as required. No upper limit on doses. May be used IM in these circumstances, if IV access not available or if there are multiple patients affected. To prevent bradycardia with Suxamethonium use: Adult / paediatric: 0.01 mg/kg IV, fast push 63

67 CALCIUM CHLORIDE TYPE: PRESENTATION: ACTIONS: Electrolyte - utilised in both electrical & mechanical actions of the myocardium. [ No schedule] 1 gm in 10 mls (10% solution) - IMS Minijet. Opposes action of high serum potassium on the myocardium. Onset: IV: Several minutes. Duration: minutes. USES: Emergency treatment of hyperkalaemia. ADVERSE EFFECTS: Rare with nominated use. - Tissue necrosis if extravasates from vein. - Precipitates out in contact with bicarbonate. CONTRA-INDICATIONS: Known hypersensitivity. DOSE: Adult / paediatric: 10 mg / kg IV, over 2 minutes. Repeat x 1 as required. 64

68 CEFTRIAXONE (ROCEPHIN) TYPE: 3rd generation cephalosporin antibiotic. [S.4] PRESENTATION: Vial 1g Ceftriaxone powder for reconstitution. ACTIONS: Broad spectrum antibiotic. Especially effective against gram-negative bacteria (eg Meningococcus). Effective crossing of blood-brain barrier. Half-life approx 8 hours. USE: Suspected meningococcal disease, in acutely ill patients. ADVERSE EFFECTS: Hypersensitivity reactions (not common) Diarrhoea. Skin rash. PRECAUTIONS: Possibly 20% patients with penicillin allergy may be sensitive to ceftriaxone. CONTRA-INDICATIONS: Known sensitivity to cephalosporins. DOSE: 50 mg/kg, to a total of 2g. IV preferred. Can also be given IO. Make up to 10 mls with water for injection; give slowly over 2 4 mins May be administered IM; dilute a max dose of 1 g in 3mls 1% lignocaine prior to administration. Give two injections if dose is over 1 g (i.e. 3 mls volume). SPECIAL NOTE: An incident report should be submitted to Clinical Services if Ceftriaxone is administered. 65

69 DEXTROSE 5% TYPE: PRESENTATION: ACTION: USES: ADVERSE EFFECTS: Isotonic dextrose solution; contains 50 g Dextrose per 1 litre. [ No schedule] 100 or 250 ml soft pack of 5% Dextrose. Dextrose is metabolised rapidly when administered IV. The water in which it was dissolved is distributed throughout the body & has minimal effect on blood volume. To keep the vein patent, for the administration of drugs. For dilution of Amiodarone prior to use. (NB: Dextrose 5% is not used for the treatment of hypoglycaemia). Exercise care that the infusion does not run at more than the recommended rate. CONTRA-INDICATIONS: Known hypersensitivity. DOSE: Intravenous infusion - 10 drops per minute (dpm) TKVO Provides 10 ml / hr with standard giving set. Run fully open for a few seconds to flush drugs. 66

70 DEXTROSE 50% TYPE: PRESENTATION: ACTION: Hypertonic dextrose solution; contains 0.5 g Dextrose per ml. [ No schedule] 50 ml - IMS Minijet (25 gm Dextrose). Dextrose (glucose) is the main energy source for the body cells, especially the brain. Onset: IV seconds. USES: ADVERSE EFFECTS Treat hypoglycaemia; following blood glucose estimation - if BGL < 4, & patient unable to eat or drink. - Tissue necrosis if allowed to escape from the vein. - Hyperglycaemia / hyperosmolality. CONTRA-INDICATIONS: Known hypersensitivity. DOSE: Up to 0.5 ml/kg IV (0.25 g/kg) slowly over 5 minutes Continue to check patency of vein. May repeat dose x 1 if level of consciousness or BGL has not improved. NOTE: Patients who respond to 50% Dextrose should eat, to prevent later development of further hypoglycaemia. Recheck BGL following treatment. Must be administered through a running IV line. Paediatric use: dilute 50% dextrose with an equal amount of 5% dextrose or normal saline. 67

71 FRUSEMIDE TYPE: PRESENTATION: (LASIX) Loop diuretic. [ S.4] 80 mg in 8 mls - IMS Minijet ACTIONS: 1. Potent diuretic- produces increased urine output within 5-10 minutes; lasts up to 3 hours when given I V. 2. Causes venous dilatation- decreases venous return. Effect occurs within 5 minutes. USES: Acute Cardiogenic Pulmonary Oedema - to decrease venous return and promote loss of fluid. ADVERSE EFFECTS: 1. 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: - Systolic BP < Hypersensitivity. (Note possible cross sensitivity to sulphonamides). DOSE Adult: On diuretics: 1mg / kg IV over 2 mins. Not on diuretics: 0.5 mg / kg IV over 2 mins. Paediatric: Not used. Initial dose may be repeated once after mins if respiratory distress is severe. If severe pulmonary oedema & IV access not available: Administer IM (in 2 separate sites if volume is greater than 4 mls). 68

72 GLUCAGON TYPE: PRESENTATION: ACTIONS: Pancreatic hormone. [ S.4] Vial containing 1 International Unit of Glucagon, as dry powder, with a syringe containing 1 ml of diluting solution. Causes the liver to metabolise stores of glycogen to Glucose, resulting in a rise in the blood glucose level. Only effective if liver glycogen is available. Onset: IM 5-20 mins. USES: ADVERSE EFFECTS: Treatment of hypoglycaemia, BGL < 4 mmol / l, when oral or intravenous glucose cannot be administered. Very rarely occur. Nausea and vomiting. Very occasional hypersensitivity. CONTRA-INDICATIONS: Known hypersensitivity. DOSE: Adult: 1 International Unit (IU), IM. Paediatric: wt < 20 kg (approx 5 yrs): 0.5 International Unit IM wt > 20 kg: 1 International Unit IM. Single dose only. SPECIAL NOTE: Patients who respond to Glucagon should eat, to prevent later development of further hypoglycaemia. Recheck BGL following treatment. 69

73 GLYCERYL TRINITRATE (ANGININE) TYPE: PRESENTATION: ACTIONS: USES: ADVERSE EFFECTS: Nitrate smooth muscle relaxant & vasodilator. {S.3] White 600 microgram sublingual tablets. Arterial & venous vasodilatation. Dilatation of collateral coronary vessels. Relieve cardiac pain of ischaemic origin. Relieve pulmonary oedema. Hypotension. Headache. Flushing of skin. Occasionally bradycardia. CONTRA-INDICATIONS: Do not administer if systolic BP is < 90. Do not administer if sildenafil (Viagra) or vardenafil (Levitra) taken within 24 hours. Following the last dose of tadalafil (Cialis), do not administer within 4 to 5 days in the elderly and those with renal impairment, or 3 to 4 days in all other patients. Known hypersensitivity. DOSE: Chest Pain: 1 tablet sublingual (600 mcg) Repeat x 1 as necessary. Acute cardiogenic pulmonary oedema: 1 tablet sublingual (600 mcg) Not repeated. 90 > Systolic BP < 100, or patient who has not had any nitrate medication previously - give 1 / 2 tablet Repeat 1 / 2 tablet x 1 as necessary. NOTE: Tablet should fizz under tongue if it is still potent. Use tablets within 3 months of opening bottle. Container must be dated when opened. 70

74 HYDROCORTISONE (SODIUM SUCCINATE) TYPE: Adrenocortico-steroid. [S.4] PRESENTATION: 100mg powder in 2ml vial. Reconstitute with 2mls sterile water, Normal Saline or 5% Dextrose. ACTIONS: Numerous & widespread. ACTAS administration is for anti-inflammatory effect on the airways. USE: Moderate to severe bronchospasm due to asthma, anaphylaxis or chronic airways disease. ADVERSE EFFECTS: Nil significant with single use. CONTRA-INDICATIONS: Known previous reaction to corticosteroid. 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. 71

75 IPRATROPIUM BROMIDE (ATROVENT) TYPE: Anticholinergic bronchodilator. [S. 4] PRESENTATION: Plastic Nebule : 1ml 250 mcg Ipratropium Bromide. ACTIONS: Bronchodilator. Blocks vagal reflexes which mediate bronchoconstriction. Possibly more effective when used in combination with salbutamol. Onset: 3 5 mins. Duration: 2-4 hours. USES: ADVERSE EFFECTS: CONTRA-INDICATIONS: PRECAUTIONS: DOSE: Bronchospasm from any cause; as an adjunct to Salbutamol. Rare with single use. Occasionally - urine retention. Known hypersensitivity. Care needed with use in patients with glaucoma. Adult: 500 mcg - mixed with 1 st, then 3 rd and 5 th doses of salbutamol. Paed: 250 mcg - mixed with 1 st, then 3 rd and 5 th doses of salbutamol. 72

76 KETAMINE HYDROCHLORIDE (KETLAR) TYPE: Dissociative anaesthetic agent. [S. 8] PRESENTATION: ACTIONS: 200mg in 2ml vial. Complex, multiple actions. Analgesic; sedative agent. Marked amnesia Has bronchodilating properties. Does not tend to cause respiratory depression. Does not tend to cause hypotension ( via sympathetic stimulation.) Onset of action is rapid: 1 2 minutes IV 3 5 minutes IM USE: Pain management, especially in patients who are hypotensive or unable to have narcotics, & if no alternative available. Particularly useful for trapped patients with limb injuries, especially if BP is borderline for narcotics. ADVERSE EFFECTS: Transient Laryngospasm Hypersalivation Emergence reactions. Occ respiratory depression apnoea Hypotension occasionally if given rapidly to a hypovolaemic patient. Muscle twitching & purposeless movements. PRECAUTIONS: Use with care in patients where a rise in BP may be hazardous (eg stroke, cerebral trauma) Known glaucoma Previous psychoses Hyperthyroidism. Elderly and paediatric patients. Patients previously administered narcotics CONTRA-INDICATIONS: Known sensitivity. Active cardiac disease (myocardial ischaemia, LVF, uncontrolled hypertension.) Children under 1 year old. 73

77 Continues over DOSE: See attached Dose Chart. SPECIAL NOTE: 1. Patients who have received ketamine may still have a significant awareness, despite an appearance of unconsciousness. 2. Ketamine is a Drug of Dependence. Use must be checked by both crewmembers. 3. Under the Drugs of Dependence Act, recording and accounting for its use is a legal requirement. 4. The unused portion of the dose must be appropriately disposed of & the disposal recorded. 5. If ketamine is administered, please submit an incident report to Clinical Services. 74

78 KETAMINE DOSE CHART DOSES: Initial IV Repeat IV Initial IM Repeat IM Adult Up to 1 mg/kg. After 5 10 Increments of minutes; 1 mg/kg After 5 10 up to 20 mg at increments of minutes; intervals of 30 up to 20 mg as 1 mg/kg 60 seconds. before. No upper limit. Elderly (> 65 yrs) Paediatric > 20 kg Paediatric < 20 kg Up to 1 mg/kg. Increments of up to 10 mg at intervals of seconds. Up to 1 mg/kg. Increments of up to 10 mg at intervals of seconds. Up to 1 mg/kg. Increments of up to 5 mg at intervals of seconds. 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. 0.5 mg/kg 0.5 mg/kg 0.5 mg/kg After 5 10 minutes; 0.5 mg/kg After 5 10 minutes; 0.5 mg/kg After 5 10 minutes; 0.5 mg/kg Previous opiates IV: Up to 10mg increments as before. IM: 0.5 mg/kg IV: Up to 5 mg increments as before. IM: 0.25 mg/kg IV: Up to 5 mg increments as before. IM: 0.25 mg/kg IV: Up to 2.5 mg increments as before. IM: 0.25 mg/kg All IV doses to be given slowly, over 30 seconds. Recommended dilutions: Adult IV: 200mg diluted up to 10 ml; = 20mg / ml Adult IM: 100 mg diluted up to 2 ml. Discard excess dose before IM use. Elderly pt IV: 100 mg diluted up to 10 ml; = 10 mg / ml Elderly pt IM: 100 mg diluted up to 2 ml. Discard excess dose before IM use Children IV: 50 mg diluted to 10 ml; = 5 mg / ml Children IM: 50 mg diluted to 2 mls. Discard excess dose before IM use. 75

79 LIGNOCAINE TYPE: PRESENTATION: ACTION: Local anaesthetic. Antiarrhythmic [S.4] 50 mg in 5 mls - plastic ampoule. Local anaesthetic effects. Suppresses ventricular arrhythmias Onset: S/C 1 4 mins. Max effect: 5-10 mins. IV 1-3mins USES: 1: Local anaesthesia prior to invasive procedures. 2: VT with cardiac output in patients who cannot have Amiodarone. ADVERSE EFFECTS: These effects are extremely unlikely in usual subcutaneous doses, especially if the syringe is continually aspirated. More likely if given IV. C.N.S. effects Cardiac effects - stimulation followed by depression. - drowsiness, agitation, muscle twitching, seizures & coma. - hypotension, bradycardia, heart block, asystole. CONTRA-INDICATIONS: PRECAUTIONS: DOSE: Known hypersensitivity. Nil. Local anaesthesia: Adult and paediatric - up to 5 mls subcutaneous. VT with cardiac output: 1mg/kg slow IV (over 2 minutes) 76

80 MAGNESIUM SULPHATE TYPE: Electrolyte solution [No schedule] PRESENTATION: ACTION: 50% solution (10 mmol) 2.5 gm in 5 ml vial Magnesium is the 2 nd most abundant intracellular cation. Less than 1% is present in extracellular fluid. Magnesium is involved in the processes regulating sodium and potassium movement across cell membranes. As such, it may promote myocardial cell membrane stability. USES: Torsade de pointes (polymorphic VT) (Often associated with prolonged QT interval) ADVERSE EFFECTS: CONTRA-INDICATIONS: PRECAUTIONS: Rare; more common if serum Mg is normal. Respiratory depression; nausea & vomiting; hypotension; confusion; bradycardia. AV block; renal failure; hepatic failure. Myaesthenia gravis. DOSE: Adults Cardiac output: Dilute up to 10 mls with N/saline; 2.5 gm IV, over 3 5 minutes. No cardiac output: 2.5 gm IV, over seconds. Paediatric: (unusual) Dose is 50 mg/kg, to maximum of 2.5g. Dilute to 10 mls = 250 mg/ml Cardiac output: give calculated dose IV over 3 5 minutes. No cardiac output: give calculated dose IV over seconds 77

81 METHOXYFLURANE (PENTHRANE) TYPE: PRESENTATION: ACTION: USES: Volatile inhalation anaesthetic and analgesic agent. [S.4] 3 ml bottle. Central Nervous System depressant. Onset 3-5 mins. Offset 3 5 mins. For relief of pain of all origins. ADVERSE EFFECTS: Altered consciousness. Renal dysfunction Jaundice } rare with once only } ambulance use. CONTRA-INDICATIONS: PRECAUTIONS: DOSE: NOTE: Depressed level of consciousness. Known hypersensitivity. Renal disease. Diabetes. Antibiotic or barbiturate use. Caution if patient cannot self-administer. Up to 3 mls, self administered Via Penthrox inhaler, with up to 8 l/m oxygen. Repeat x 1 as required. Dose should not exceed 6mls/day or 15mls/week May be used with Midazolam for musculo-skeletal pain. 78

82 METOCLOPRAMIDE (MAXOLON) TYPE: PRESENTATION: ACTION: USES: Antiemetic. [S.4] 10 mg in 2 ml Ampoules. Antiemetic - centrally acting on brain stem. - increases gastric emptying. Onset: 3-15 mins. (IV) Duration: 30 mins. Prevent vomiting: - when narcotic analgesic is to be administered. - high spinal injury. - serious eye injury - suspected ischaemic chest pain. Treat nausea & vomiting. ADVERSE EFFECTS: PRECAUTIONS: CONTRA - INDICATIONS: DOSE: Uncommon with usual doses. Occasionally - drowsiness - lethargy - dry mouth - oculogyric crisis, facial spasms, speech difficulties. Side effects may be more common in dehydrated adolescents. Concomitant phenothiazide tranquilliser use will increase the likelihood of side effects. Previous reaction. G.I. bleeding. Adult dose: 10 mg lv over 2 mins IM 10mg Give prior to narcotic administration. Single dose only. Paed. dose: Not used. 79

83 MIDAZOLAM TYPE: (HYPNOVEL) Anticonvulsant & sedative agent. [S.4] PRESENTATION: 5 mg in 5 ml ampoules. 15 mg in 3 ml ampoules ACTION: 1: Anticonvulsant- reduces seizure activity. 2: Minor tranquilliser. 3: Muscle relaxant. Onset (IV) 1-5 mins. Duration: 2-3 hours. Onset (IM) 2-5 mins. Duration:? 2-3 hours. USES: - Status epilepticus - in a patient who has continual or prolonged seizures. - Sedation to manage airway, RSI, sedation of a previously intubated patient. - Adjunct to analgesia for injuries where significant muscle spasm is present. - To manage agitated & combative patients. - To manage autonomic hyper-reflexia. ADVERSE EFFECTS: Depression of level of consciousness - leading to: respiratory depression. loss of airway control. Hypotension. CONTRA-INDICATIONS Known hypersensitivity. PRECAUTIONS DOSE: - haemodynamic instability - respiratory depression Seizures Adult dose: Up to 0.1 mg / kg l.v., over 2 mins, until fitting ceases. Repeat if fitting continues or recurs. Paed dose: Up to 0.1 mg / kg I.V., over 2 mins, until fitting ceases. Repeat if fitting continues or recurs. I.M: 0.1 mg/kg. Repeat x1 after 10 mins as necessary. continues over 80

84 Adjunct to analgesic use with muscle spasm: Following 1 dose of Penthrane or 2 doses of Morphine, if severe pain & muscle spasm are still present - Up to 0.05 mg / kg I.V. over 2 mins. Repeat x 1 as required Further analgesic doses to be given with caution. Mild sedation to facilitate basic airway management: Up to 0.1mg/kg over 2 mins When used with Morphine to sedate for airway management in selected patients: Adult: 10 mg I.V. rapid push (adjusted for patient weight, age and BP). Paed: 0.1 mg / kg rapid push. Repeat x 1 as required. When used with suxamethonium: 0.05mg / kg IV. When used to manage a combative or agitated patient : Up to 0.1mg / kg IV, until manageable. May repeat as required to continue management. IM: 0.1 mg/kg May repeat as required to continue management. If agitation & combativeness is thought due to psychostimulant use: Up to 0.2mg / kg IV, until manageable. May repeat as required to continue management. IM: 0.2 mg/kg May repeat as required to continue management.. * Use 0.2mg/kg dose with caution. All agitated patient management doses may be reduced if there is known or suspected hypotension or hypovolaemia; in frail or elderly patients, or patients with general debility. SPECIAL NOTE: 1: When administering lv for fitting, do not draw up total calculated dose. Administer first 5 mg ampoule; wait briefly for response before giving complete dose. 2: When using 0.2 mg/kg IM doses, the 15 mg / 3 ml formulation should be used. Exercise caution that this is only used in these circumstances. 3: Elderly patients may be especially sensitive to Midazolam, and advanced age is often a better guide to dosing than weight. 81

85 MORPHINE SULPHATE TYPE: PRESENTATION: ACTIONS: USES: ADVERSE EFFECTS: CONTRA-INDICATIONS: PRECAUTIONS: Narcotic Analgesic. [S.8] 10 mg in 1 ml Ampoules. 1: Decreases pain perception and anxiety. 2: Vasodilatation. Onset: (IV) 2-5 mins. Duration: 1-2 hours. (IM) 5 + mins Duration: 2-3 hours. To relieve severe pain. Acute pulmonary oedema. RSI. Sedation of a previously intubated patient. Nausea and vomiting. Drowsiness. Respiratory depression. Hypotension. Dependence. Pin point pupils. Bradycardia. Depressed level of consciousness (GCS 13 or less)* Pain relief only. Respiratory depression * Pain relief only. Known hypersensitivity. BP < 70 mm Hg (pain relief). BP < 90 mm Hg (pulmonary oedema). Acute asthma attacks. Pain management in labour. Elderly patients (may be sensitive). Patients with COAD. Hypovolaemic patients (hypovolaemia should be corrected before Morphine administration). Patients with systolic BP (see below). Children under 1 year. 82 Continues over

86 DOSE: Dilute 10 mg ampoule to 10 mls volume with Normal Saline 1 ml = 1 mg Morphine. Pain relief: Adult: Up to 0.05 mg/kg lv, over 2 mins. May be repeated at 5 min. intervals, until pain is managed. Paediatric: Up to 0.05 mg/kg IV, over 2 mins. May be repeated at 5 min. intervals, until pain is relieved. Use with caution under 1 yr of age. Intramuscular administration: Pain relief only. - Not for chest pain if cardiac ischaemia suspected. - No IV available. - No hypotension. - Patient contact estimated > than 20 mins Dose: 0.1 mg / kg. Repeat x 1 after mins as required. Patient with pain; systolic BP 70 90: - IV use only. - hypovolaemic patients must be receiving fluids. - up to half a calculated 0.05mg/kg dose, given slowly. - may be repeated as required, with great care, and with an appropriate time interval between doses, titrated to response. - no further doses to be given if systolic BP drops 10 mmhg or more with half dose, even if it remains above 70 (eg initial BP 85 mm; following Morphine dose BP now 75 mm). Continues over 83

87 Pulmonary Oedema: 0.05 mg/kg lv, over 2 mins. May be repeated once after 10 mins, if required. When used with Midazolam for RSI. Adult: 10 mg IV rapid push (dose adjusted for patient weight, age and BP). Paed: 0.05 mg / kg rapid push. Repeat x 1 as required. To maintain sedation post intubation: 0.05 mg / kg lv, slow IV dose. SPECIAL NOTES: 1. Morphine is a Drug of Dependence. Use must be checked by both crew members. 2. Under the Drugs of Dependence Act, recording and accounting for its use is a legal requirement. 3. The unused portion of the dose must be appropriately disposed of & the disposal recorded. 4. Side effects may be reversed by use of Naloxone, although it is desirable to avoid this unless absolutely necessary. 5. Elderly patients may be especially sensitive to Morphine, and advanced age is often a better guide to dosing than weight. 84

88 NALOXONE TYPE: PRESENTATION: ACTION: USES: (NARCAN) Narcotic antagonist. [S.4] 0.4mg in 1 ml - IMS Minijet. Reverses the effects of narcotic analgesics. Onset: IV 1-2mins Duration: mins. IM: unknown; thought to be slightly longer onset & duration than lv. - Coma. - Drug overdose and poisoning. Use in situations where there is significant decrease in level of consciousness; where there is hypoventilation, and/or loss of protective reflexes; & where overdose of narcotics cannot be positively excluded. ADVERSE EFFECTS: May precipitate acute withdrawal syndrome in narcotic addicts. Occasional aggressive behaviour following reversal. Nausea and vomiting. CONTR-INDICATIONS: Known hypersensitivity DOSE: Adult: 0.4 mg IM, then 0.4mg lv, increments, fast push May repeat IV dose x 3. (to max. 2 mg). Paediatric: 0.01 mg / kg lv, fast push Max paediatric dose: 3 doses. All doses may be administered IM or IV as the situation demands. SPECIAL NOTE: When used IV, effect may wear off rapidly, especially if large dose of narcotic has been taken. An IM dose is highly recommended if the patient is likely to refuse transport. Special care is needed if long acting agents are known or suspected to have been used (eg. MS Contin; methadone) In this case, give a larger IM dose and strongly encourage transport to hospital. 85

89 NORMAL SALINE TYPE: PRESENTATION: ACTON: Isotonic crystalloid solution of 0.9% Sodium chloride solution. Contains 151mMol sodium & 151 mmol chloride per litre. [No schedule] 500 or 1000 mls of 0.9% Sodium Chloride solution in collapsible plastic pack. Plasma volume expander. Also expands interstitial fluid volume. Plasma volume effect is only temporary as most of the Saline moves out of the blood vessels quite quickly. USES: 1. Initial replacement fluid, in volume depleted or dehydrated patients. Volume depletion may be due to loss of blood, plasma or fluid and electrolytes. 2. Maintenance of hydration during prolonged patient contact time. 3. To keep vein open, as route for drugs. ADVERSE EFFECTS: Fluid overload. DOSE: IV resuscitation: Adult: 10 ml / kg lv - then reassess patient. Rate of administration, dependent on the condition of patient. Aim to keep BP at about 90 mm systolic No limit on amount, dependent on condition of patient. Paediatric: 10 ml / kg lv or IO - then reassess patient. Paediatric cardiac arrest: 20 ml/kg. TKVO: Adult and paediatric: 10 drops per minute. (10 mls / hr with standard drip set). 86

90 OBIDOXIME TYPE: PRESENTATION: ACTION: USES: Oxime. [No schedule] 220 mg Obidoxime / 2 mg Atropine - auto injector. Reactivating of inhibited acetylcholinesterase. To treat super toxic organophosphate poisoning (nerve agents) by relieving the symptoms of skeletal neuromuscular blocking that occurs during a cholinergic crisis. Used in combination with atropine, as combination auto-injector, or with atropine separately administered. ADVERSE EFFECTS: Hypotension, menthol-like sensation, warm feeling to the face, dull pain at site of injection. Multiple doses can cause hepatic dysfunction. DOSE: Adult: Up to 660 mg IM over 30 minutes. Three doses via the auto-injector. Paediatric: Single dose of 220 mg IM. SPECIAL NOTE: The preferred site for administration is the upper thigh. * The auto injector needs to be held in place for 10 seconds when discharged to ensure the total dose has been administered. 87

91 ONDANSETRON TYPE: PRESENTATION: ACTIONS: (ZOFRAN) Potent antinauseant & antiemetic. [S.4] Ampoule - 4mg / 2ml. Wafers 4mg. Potent, highly selective histamine receptor antagonist. Precise mode of action in control of nausea & vomiting is not known. Likely to have actions peripherally & in the CNS. Maximum effect approx. 10 minutes following IV administration. Hepatic metabolism. USE: PRECAUTIONS: Pre-flight, for prevention or treatment of nausea & vomiting. Not recommended in pregnancy. ADVERSE EFFECTS: Uncommon. Headache; flushing of skin; occ. reaction at the site of IV injection; drowsiness; anxiety & agitation; transient visual disturbances. CONTRA-INDICATIONS: DOSE: Known hypersensitivity. Adult: 4 mg IV, slow over 2 minutes. Paediatric: 0.1 mg / kg IV, slow over 2 minutes (to total of 4mg). May be administered IM if necessary. May repeat x 1 if required, after approx minutes. Wafers: 4mg sublingual May repeat x 1 if required, after approx minutes. SPECIAL NOTE: Used only for patients and flight crew on the helicopter. 88

92 P from receptor SALBUTAMOL TYPE: PRESENTATION: ACTION: (VENTOLIN) Synthetic βb2b stimulant. [S.4] Plastic nebules: 5 mg in 2.5 mls nebuliser solution. 2.5 mg in 2.5 mls nebuliser solution. Bronchodilatation. Relaxation of involuntary muscle. + Moves KP extra-cellular to intra-cellular space. Onset (neb): 5 mins Max effect: mins. USES: Bronchospasm from any cause. Emergency treatment of suspected hyperkalaemia. ADVERSE EFFECTS: CONTRA-INDICATIONS: DOSE Rarely seen with usual nebulised therapeutic doses: - Tachycardia. - Tremors. - Hypotension. Known hypersensitivity. Via nebuliser, with oxygen at 6-8 lpm. Adult: Paed: 5 mg nebule. 2.5 mg nebule. Mod - severe bronchospasm; suspected hyperkalaemia - give continuously. SPECIAL NOTES: With significant hypoxia, Salbutamol should be administered with 100% oxygen. 89

93 SODIUM BICARBONATE TYPE: PRESENTATION: Hypertonic alkaline solution; 8.4% sodium bicarbonate solution; contains 1 mmol / ml sodium & 1 mmol / ml bicarbonate. [No schedule] 50 ml Sodium Bicarbonate solution, IMS Minijet. 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: seconds (IV). USES: To combat acidosis in prolonged cardiac arrest. For emergency treatment of hyperkalaemia. For treatment of arrhythmias and/or seizures in Tricyclic overdosed patients. To combat acidosis and hyperkalaemia in crush syndrome. ADVERSE EFFECTS: Metabolic alkalosis. CONTRAINDICATIONS: Known hypersensitivity. High sodium content may lead to fluid overload & cardiac failure. Interacts with some other drugs - (esp. calcium & adrenaline); always flush well through the line before & after administration. Consider second line. DOSE: Adult & paediatric: 0.5 mmol / kg IV; repeat x 1 as required (fast push in cardiac arrest; over 2-5 mins for patients with cardiac output). 90

94 SUXAMETHONIUM TYPE: PRESENTATION: ACTIONS: Depolarising muscle relaxant. [S.4] Ampoules 100mg / 2ml. Acts like the neurotransmitter acetylcholine at the neuromuscular junction. Persists for a period long enough to exhaust the motor endplate by prolonged depolarisation. Onset: IV: approx 45 seconds. Duration: IV: 5 7 minutes. USE: ADVERSE EFFECTS: CONTRAINDICATIONS: PRECAUTIONS: DOSE: SPECIAL NOTE: To facilitate airway management in selected patients with a GCS of less than 9. 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 secs. To be used only following completion of the ACTAS designated training programme. Paediatric: give Atropine 0.01 mg / kg IV prior to Suxamethonium. Adults: if heart rate less than 50, give Atropine prior to Suxamethonium. Prior to administration, give Midazolam 0.05 mg / kg IV. Follow up with additional Midazolam after intubation. 91

95 92

96 93

97 DRUG DOSE CALCULATOR DOSE CALCULATION NOTES 50 mg/kg Dose = Weight x 50 nb: maximum 2 g for Ceftriaxone & 2.5 g for magnesium 10 mg/kg Dose = Weight x 10 5 mg/kg Dose = Weight x 5 4 mg/kg Dose = Weight x mg/kg Dose = Weight x 1.5 1mg/kg 1mMol/kg 0.5 mg/kg 0.5 ml/kg Dose = Weight 1 Dose = Weight mg/kg Dose = Weight mg/kg Dose = Weight mg/kg Dose = Weight mg/kg Dose = Weight

98 A.C.T. AMBULANCE SERVICE MEDICATION CALCULATOR Wt (kg) DRUG Adenosine 1 st dose # 0.5mg 0.5mg 1mg 1mg 1.5mg 1.5mg 2mg 2mg 2.5mg Adenosine 2 nd dose # Adrenaline Amiodarone + output 0.5mg 1mg 1.5mg 2mg 2.5mg 3mg 3.5mg 4mg 4.5mg 0.05mg 0.1mg 0.15mg 0.2mg 0.25mg 0.3mg 0.35mg 0.4mg 0.45mg 25mg 50mg 75mg 100mg 125mg 150mg 150mg 150mg 150mg Amiodarone no output 25mg 50mg 75mg 100mg 125mg 150mg 175mg 200mg 225mg Atropine 0.05mg 0.1mg 0.15mg 0.2mg 0.25mg 0.3mg 0.35mg 0.4mg 0.45mg Ceftriaxone & Magnesium 250mg 500mg 750mg 1g 1.25gm 1.5gm 1.75gm 2g 2g Dextrose 50% 2.5ml 5ml 7.5ml 10ml 12.5ml 15ml 17.5ml 20ml 22.5ml Frusemide 20mg 20mg Frusemide + on diuretic 40mg 40mg Hydrocortisone 20mg # 40mg # 60mg # 80mg # 100mg # 120mg # 140mg # 160mg # 180mg # Midazolam Midazolam + morphine, methoxyflurane or suxamethonium Morphine 0.5mg 1mg 1.5mg 2mg 2.5mg 3mg 3.5mg 4mg 4.5mg 0.25mg 0.5mg 1mg 1mg 1.5mg 1.5mg 2mg 2mg 2.5mg 0.5mg 0.5mg 1mg 1mg 1.5mg 1.5mg 2mg 2mg 2.5mg Naloxone 0.1mg # 0.1mg # 0.2mg # 0.2mg # 0.3mg # 0.3mg # 0.4mg 0.4mg 0.4mg Sodium Bicarbonate 8.4% Suxamethonium 2.5ml 5ml 7.5ml 10ml 12.5ml 15ml 17.5ml 20ml 22.5ml 5mg 15mg 20mg 30mg 40mg 45mg 50mg 60mg 65mg # = paediatric only. 95

99 A.C.T. AMBULANCE SERVICE MEDICATION CALCULATOR Wt (kg) DRUG Adrenaline 0.5mg 0.6mg 0.7mg 0.8mg 0.9mg 1mg 1mg 1mg 1mg Amiodarone + output 150mg above 30 kg Amiodarone no output 250mg # 275mg # 300mg for all adults above 50kg Atropine Ceftriaxone 0.5mg 0.6mg 0.7mg 0.8mg 0.9mg 1mg 1mg 1mg 1mg 2g 2g 2g 2g 2g 2g 2g 2g 2g Dextrose 50% 25ml 30ml 35ml 40ml 45ml 50ml 55ml * 60ml * 65ml * Frusemide 25mg 30mg 35mg 40mg 45mg 50mg 55mg 60mg 65mg Frusemide + on diuretic 50mg 60mg 70mg 80mg 90mg 100mg 110mg * 120mg * 130mg * Hydrocortisone 200mg # 200mg for adults Midazolam 5mg 6mg 7mg 8mg 9mg 10mg 11mg * 12mg * 13mg * Midazolam + morphine, methoxyflurane or suxamethonium 2.5mg 3mg 3.5mg 4mg 4.5mg 5mg 5.5mg * 6mg * 6.5mg * Morphine 2.5mg 3mg 3.5mg 4mg 4.5mg 5mg 5.5mg 6mg 6.5mg Naloxone 2mg in 5 doses Sodium Bicarbonate 8.4% 25ml 30ml 35ml 40ml 45ml 50ml 55ml 60ml 65ml Suxamethonium 75mg 90mg 100mg 120mg 130mg 150mg 150mg 150mg 150mg # = paediatric only. * = advisory doses only; rarely need to give more than 100kg dose. 96

100 DRUG REFERENCE KEY There have been a significant number of both additions & deletions from this list since it was last compiled. 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 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. It does not include street or illicit drugs. Many drugs will have several numbers next to them, as they are used in different clinical settings, or may have these effects when taken in overdose. It does not include antibacterial agents; cytotoxics or immunomodifying agents. Generally, no drugs given regularly by injection are included (exception - insulins). There are now a number of generic items on the market, with the generic name + the company that produces it as the drug name. eg. Healthsense Captopril; Diltiazem BC. The generic firms are: BC; Chem Mart; DBL; GenRx; Healthsense; Terry White Chemists; 1 = Anabolic steroids 2 = Antianginal 3 = ACE inhibitors 4 = Antiarrhythmics 5 = Anticoagulants 6 = Antidepressants 6A = 5HT uptake inhibitor 6B = MAO inhibitor 6C = Tetracyclic 6D = Tricyclic 7 = Antiemetics 8 = Antihypertensives 9 = Anti-inflamatory - non steroidal 10 = Antiparkinson agents 11 = Antiplatelet agents 12 = Beta blockers 13 = Calcium channel antagonists 14 = Bronchodilators 14A = Theophylline derivative 97 14B = Non Theophylline derivative 14C = Preventative aerosols 15 = Oral contraceptives 16 = Corticosteroids 17 = Diuretic (loop) 18 = Diuretic (potassium sparing) 19 = Diuretic (thiazide) 20 = Diuretic (thiazide analogue) 21 = Anti gout agents 22 = Histamine 2 antagonist 23 = Antilipid agents 24 = Hypnotics 25 = Hypoglycaemic agents 26 = Insulin preparations 27 = Sedatives 28 = Tranquillisers 29 = Vasodilator 30 = Antihistamines 31 = Analgesics 32 = Antipsychotic 33 = Angiotensin II antagonist 34 = Antiulcerant agents 35 = Benzodiazepine 36 = Migraine prophylaxis and therapy 37 = Anticonvulsant 38 = Bone & Calcium modifying agent 39 = Hormones 40 = Dementia agents 41 = CNS stimulants 42 = Anticholinergic type agents 43 = Glaucoma preparations Product Name Serial Number ABILIFY 32 ACCOLATE 14 ACCUPRIL 3,8 ACCURETIC 3,8 ACENORM 3,8 ACIMAX 34 ACLIN 9,31 ACT-3 9,31 ACTIFED 30 ACTION 30 ACTIPROFEN 9 ACTONEL 38 ACTOS 25 ACTRAPID 26 ADALAT 2,8,13 ADDOS 2,8,13 ADEFIN 2,8 AERODIOL 39

101 Product Name Serial Number AERON 14B AGGRASTAT 5 AGON SR 2,8,13 AIROMIR 14B AKINETON 10, 42 ALDACTONE 8,18 ALDAZINE 28,32 ALDECIN 16 ALDOMET 8 ALEPAM 28,35 ALEVE 9 ALLEGRON 6D ALLERMAX 16 ALLOHEXAL 21 ALLOPURINOL BC 21 ALLORIN 21 ALLOSIG 21 ALODORM 24,27,35 ALPHAGAN 43 ALPHAPRESS 8,29 ALPHAPRIL 3, 8 ALPRAX 27,28,35 ALPRAZOLAM 27,28,35 ALVESCO 16 AMARYL 25 AMFAMOX 22,34 AMIZIDE 8,18 AMPRACE 3,8 AMYTAL 24 ANAFRANIL 6D ANAGRAINE 36 ANAMORPH 31 ANAPROX 9,31,35 ANATENSOL 28,32 ANDRIOL 39 ANDROCUR 39 ANDRODERM 39 ANDRUMIN 7 ANGELIQ 39 ANGININE 2,29 ANGIOMAXIN 5 ANPEC 2,4,8,13 ANSELOL 2,4,8,12 ANTENEX 27,28,35 ANZEMET 7 APOVEN 14B APRESOLINE 8,29 APRINOX 8,19 ARATAC 4 ARAVA 9 AREDIA 38 ARICEPT 40 ARIMA 6B ARIPIPRAZOLE 32 ARIXTRA 5 AROPAX 6A ARSORB 2 ARTANE 10, 34, 42 ARTHREXIN 9,21,31 98 Product Name Serial Number ARTHROTEC 50 9 ASASANTIN SR 11, 5 ASIG 3,8 ASMOL 14B ASPALGIN 31 ASTRIX , 5 ATACAND 33, 8 ATEHEXAL 2,4, 8,12 ATENOLOL BC 2, 4, 8, 12 ATIVAN 27,28,35 ATROBEL 42 ATTENTA 41 AURORIX 6B AUSCAP 6A AUSCARD 2,13 AUSFAM 22, 34 AUSGEM 23 AUSPRIL 3, 8 AUSRAN 34 AVANDIA 25 AVANZA 6 AVAPRO 8,33 AVIL 30 AVOMINE 7 AXIT 6A AZOL 39 AZOPT 43 BARBLOC 2,4, 8,12 BECLOFORTE 14C,16 BECONASE 16 BECOTIDE 14C,16 BENADRYL 30 BENZTROP 10,42 BEROTEC 14B BETAGAN 43 BETALOC 2,4,8,12,36 BETOPIC 43 BETOQUIN 43 BICOR 12 BIPHASIL 15 BONEFOS 38 BRENDA 35 15,39 BREVIBLOC 4,12 BREVINOR 15 BRICANYL 14B BROMOHEXAL 10 BROMOLACTIN 10 BRONDECON 14A BRUFEN 9,31 BUDAMAX 16 BUGESIC 9 BURINEX 17 BUSCOPAN 42 BUSPAR 28 BUTAMOL 14B CABESAR 10 CAFERGOT 36 CALCIJEX 38 CALCITRIOL 38

102 Product Name Serial Number CANDYL 9,31 CAPADEX 31 CAPOTEN 3,8 CAPTOHEXAL 3,8 CAPTOPRIL BC 3,8 CAPURATE 21 CARAFATE 34 CARBAMAZEPINE 32,37 CARDINORM 4 CARDIPRIN 11, 5 CARDIZEM 2,8,13 CARDOL 4,12 CARTIA 11, 5 CATAPRES 8,36 CELEBREX 9 CELESTONE 16 CELPRAM 6A CHLORPROMAZINE 32,42 CIALIS 29 CIMEHEXAL 22,34 CIMETIDINE BC 22, 34 CIPRAMIL 6A CITRACAL 38 CITRIHEXAL 38 CLARAMAX 30 CLARATYNE 30 CLARINASE 30 CLEXANE 5 CLIMARA 39 CLIMEN 39 CLINORIL 9,31 CLOBEMIX 6B CLOMIPRAMINE 6D CLONAC 9 CLOPINE 32 CLOPIXOL 32 CLOPRAM 6D CLOZARIL 32 CODALGIN 31 CODAPANE 31 CODIPHEN 31 CODIS 31 CODOX 31 CODRAL FORTE 31 COGENTIN 10, 42 COGNEX 40 COLESTID 23 COLGOUT 21 COMBIGAN 43 COMBIVENT 14B COMTAN 10 CONCORZ 6A CORAS 2,13 CORBETON 2,4,8,12 CORDARONE 4 CORDILOX 2,4,8,13 CORTATE 16 COSOPT 43 COUMADIN 5 99 Product Name Serial Number COVERSYL 3,8 COZAAR 8,33 CROMESE 14C CRYSANAL 9 CYPRONE 39 CYPROSTAT 39 CYTOTEC 34 DANOCRINE 39 DAONIL 25 DAPA-TABS 8 MOCLOBEMIDE 6B DECA-DURABOLIN 1 DECANOATE 32 DEMAZIN 30 DEPO MEDROL 16 DEPO NISOLONE 16 DEPO PROVERA 15 DEPO RALOVERA 15 DEPTRAN 6D DERALIN 2,4,8,12,36 DERMESTRIL 39 DESERIL 36 DEXAMPHETAMINE 41 DEXAMETHSON 16 DIABEX 25 DIAFORMIN 25 DIAMICRON 25 DIAMOX 37, 43 DIANE 15, 39 DIAPRIDE 25 DIAZEPAM 35 DIBENYLINE 29 DICLOFENAC 9 DICLOHEXAL 9,31 DIDROCAL 38 DIDRONEL 38 DIGESIC 31 DIHYDERGOT 36 DILANTIN 37 DILATREND 12, 8 DILAUDID 31 DILOSYN 30 DILTAHEXAL 2,13 DILTIAZEM BC 2, 13 DILZEM 2,13 DIMETAPP 30 DIMIREL 25 DIMETRIOSE 39 DINAC 9 DINDEVAN 5 DITHIAZIDE 19 DITROPAN 42 DOLASED 31 DOLOBID 9,31 DOLAFORTE 31 DOLOXENE 31 DONNALIX 42 DONNATAB 7, 42 DOTHEP 6D

103 Product Name Serial Number DOZILE 27 DRAMAMINE 7 DROLEPTAN 32 DUCENE 27,28,35 DUPHASTON 39 DURIDE 2 DUROGESIC 31 DURO-TOSS 30 DYMADON 31 DYNASTAT 9 EDRONAX 6A ECOTRIN 5,11,31 EFEXOR 6A ELDEPRYL 10 ELEMENDOS 37 ELEVA 6A ELMIRON 5 EMEND 7 ENAHEXAL 3, 8 ENALAPRIL 3, 8 ENDECRIN 17 ENDEP 6D ENDONE 31 ENIDIN 43 EPAC 14B EPHIDRINE HYDROC. 14B EPILIM 32,37 ERGODRYL 36 ESTALIS 39 ESTELLE 35 ED 39 ESTRACOMBI 39 ESTRADERM 39 ESTROFEM 39 EUTROXSIG 39 EVISTA 38 EXELON 40 FAMOHEXAL 34 FAMOTIDINE 34 FAVERIN 6A FEBRIDOL 31 FELDENE 9,31 FELODUR 8,13 FEMODEN 15 FEMOSTON 39 FEMTRAN 39 FENAC 9,31 FENAMINE 30 FEXO-TABS 30 FIBSOL 3, 8 FIORINAL 31 FLECATAB 4 FLIXOTIDE 14C16 FLORINEF 16 FLUANXOL 32 FLUOHEXAL 6A FLUOXETINE BC 6A FLUOXETINE DBL 6A FORADILE 14B,14C FORMET Product Name Serial Number FORTEO 38,39 FORTRAL 31 FOSAMAX 38 FRAGMIN 5 FRISIUM 27,28,35 FRUSEHEXAL 17 FRUSID 17 GABAHEXAL 37 GABAPENTIN 37 GABITRIL 37 GANTIN 37 GEMFIBROZIL BC 23 GEMHEXAL 23 GEMIFIBROMAX 23 GENORAL 39 GENOTROPIN 39 GENOX 39 GLIMEL 25 GLUCOBAY 25 GLUCOHEXAL 25 GLUCOMET 25 GLUCOPHAGE 25 GLYADE 25 GOPTEN 3,8 HALCION 35 HALDOL 32 HELIDAC 34 HEMINEURIN 24,27 HEPARIN 5 HEXAL DILAC 9 HUMALOG 26 HUMANOTROPE 39 HUMULIN 26 HYDOPA 8 HYDRENE 8,18,19 HYDROCORTISONE 16 HYGROTON 8,20 HYPNODORM 24,27,35 HYPURIN ISOPHANE 26 HYPURIN NEUTRAL 26 HYSONE 16 HYTRIN 8 IBUPROFEN 9 IKOREL 2 IMDUR DURULES 2 IMFLAC 9 IMIGRAN 36 IMPROVIL 15 IMOVANE 24, 27 IMTRATE SR 2 INDAHEXAL 8 INDAPAMIDE 8 INDERAL 2,4,8,12,36 INDOCID 9,21,31 INSIG 8 INSOMN 24,27 INTAL 14C INZA 9,31 IOPIDINE 43

104 Product Name Serial Number IPRATRIN 14B IPRAVENT 14B ISCOVER 11, 5 ISMELIN 29,31 ISOMONIT 2, 29 ISOPTIN 2,4,8,13 ISOPTO CARBACHOL 43 ISOPTO CARPINE 43 ISORDIL 2,29 ISOSORBIDE MON. 2 JEZIL 23 JULIET 35 15, 39 KALMA 27,28,35 KALURIL 8,18 KAPANOL 31 KARVEA 8,33 KARVEZIDE 8,33 KEPPRA 37 KINIDIN DURULES 4 KINSON 10 KLACID 34 KLIOGEST 39 KLIOVANCE 39 KONAKION 5 KOSTEO 38 KREDEX 8,12 KRIPTON 10 KWELLS 7, 42 KYTRIL 7 LAMICTAL 37 LAMOGINE 37 LAMOTRIGINE 37 LANOXIN 4 LANTUS 26 LARGACTIL 7,28,32, 40 LASIX 8,17 LEGOUT 21 LESCOL 23 LEVLEN ED 15 LEXAPRO 6A LEXOTAN 27,28,35 LIPAZIL 23 LIPEX 23 LIPIDIL 23 LIPITOR 23 LIPRACE 3,8 LIQUIGESIC CO 31 LISINOPRIL 3,8 LISODUR 3,8 LITHICARB 32 LIVIAL 39 LOCILAN 15 LOETTE 15 LOGICIN 30 LOGYNON 15 LONAVAR 1 LONITEN 8 LOPID 23 LOPRESOR 2,4,8,12, Product Name Serial Number LORASTYNE 30 LOSEC 34 LOVAN 6A LUMIGAN 43 LUMIN 6C LURSELLE 23 LUVOX 6A LYCINATE 2 MADOPAR 10 MAGICUL 22, 34 MAOSIG 6B MAREVAN 5 MARVELON 15 MAXOLON 7 MAXOR 34 MEFIC 9,31 MEGACE 39 MELIPRAMINE 6D MELIZIDE 25 MELLERIL 28,32 MENOREST 39 MEPRAZOL 34 MERBENTYL 42 MERSYNDOL 31 METAMAX 36 METFORMIN BC 25 METHYLPHENIDATE 41 METOCLOPRAMIDE 7 METOHEXAL 2,4,8,12,36 METOPROLOL BC 2,4,8,12,36 MEXITIL 4 MIACALCIC 38 MICARDIS 8,33 MICROGYNON 15 MICROLUT 15 MICRONOR 15 MICROVAL 15 MIDAMOR 8,18 MINAX 2,4,8,12,36 MINIDIAB 25 MINIMS PILOCARP. 43 MINIPRESS 8 MINITRAN 2,29 MINULET 15 MIRENA 15, 39 MIRTAZON 6B MIXTARD 26 MOBIC 9 MOBILIS 9,31 MODAVIGIL 41 MODECATE 28,32 MODURETIC 8,18,19 MOGADON 24,27,35 MOHEXAL 6B MONODUR DURULES 2 MONOFEME 15 MONOPLUS 3,8 MONOPREM 39 MONOPRIL 3,8

105 Product Name Serial Number MONOTARD 26 MORPHALGIN 31 MOTILIUM 7 MOVELAT 9 MOVOX 6B MS CONTIN 31 MS MONO 31 MURELAX 27,28,35 MYSOLINE 37 NAPAMIDE 8 NAPROGESIC 9,31,36 NAPROSYN 9,31,36 NARAMIG 36 NARDIL 6B NASONEX 16 NATRILIX 8 NAVANE 32 NAVOBAN 7 NEO-MERCAZOLE 39 NEO-SYNEPHRINE 43 NEULACTIL 28,32 NEUTRAL PILOCARP. 43 NEURONTIN 37 NEXIUM 34 NICOTINIC ACID 23 NIDEM 25 NIFECARD 8,13 NIFEDIPINE BC 8,13 NIFEHEXAL 8,13 NIMOTOP 13 NITRO-DUR 2,29 NITROLINGUAL 2,29 NIZAC 22,34 NORDETTE 15 NORDITROPIN 39 NORFLEX 43 NORGESIC 43 NORIDAY 15 NORIMIN 15 NORINYL 15 NORMISON 24,27,35 NORVASC 2,8,13 NOTEN 2,4,8,12 NOVARAP 26 NOVNORM 25 NOVONORM 25 NOVOMIX 26 NOVORAPID 26 NUELIN 14A NUPENTIN 37 NUROFEN 9,31 NUROLASTS 9,31 NYEFAX 8,13 ODRIK 3,8 OGEN 39 OMEPRAL 34 OMNITROPE 39 OPTIMOL 43 ORAP 28, Product Name Serial Number ORAP 28,32 ORGARAN 5 OROXINE 39 ORUDIS 9,31 ORUVAIL SR 9,31 OSPOLOT 37 OVESTIN 39 OXANDRIN 1 OXETINE 6A OXIS 14B,14C OXYCONTIN 31 OXYNORM 31 PAINSTOP 31 PALFIUM 31 PAMISOL 38 PANACORT 16 PANAFCORTELONE 16 PANAFEN PLUS 9 PANALGESIC 31 PANAMAX 31 PARACODIN 31 PARADEX 31 PARAHEXAL 31 PARALGIN 31 PARIET 34 PARLODEL 10 PARNATE 6B PAXAM 35,37 PAXTINE 6A PEETALIX 30 PENDINE 37 PEPCID 22,34 PEPCIDINE 22,34 PEPZAN 34 PERIACTIN 30,36 PERMAX 10 PERSANTIN 5,11,29 PEXSIG 2 PHENOBARBITONE 37 PHENERGAN 7,27,30 PHOSPHATE-SANDOZ38 PHYSEPTONE 31 PILOCARPINE 43 PILOPT 43 PROPINE 43 PIROHEXAL 9,31 PIROXICAM 9 PLACIL 6D PLAVIX 5,11 PLENDIL 8,13 POLARAMINE 30 PONSTAN 9,31 PRAMIN 7 PRASIG 8 PRATSIOL 8 PRAVACHOL 23 PRAZOHEXAL 8 PRAZOSIN BC 8 PREDMIX 16

106 Product Name Serial Number PREDSOLONE 16 PREGNYL 39 NYOGEL 43 PREMARIN 39 PREMIA 5 39 PRESOLOL 8,12 PRESSIN 8 PREXIGE 31 PRIMOBOLAN 1 PRIMOLUT 39 PRINIVIL 3,8 PRITOR 8, 33 PROCID 21 PRO-BANTHINE 42 PROCUR 39 PRODEINE 31 PROGOUT 21 PROGYNOVA 39 PROLODONE 31 PROMETHAZINE 30 PRONESTYL 4 PROPYLTHIOURACIL 39 PROTAPHANE 26 PROTHIADEN 6D PROVERA 39 PROVEN 9,31 PROVIRON 39 PROXEN 9,31 PROZAC 6A PULMICORT 14C,16 P.V. CARPINE 43 QUESTRAN LITE 23 QUILONUM SR 32 QVAR 14C,16 RAFEN 9,31 RALOVERA 39 RAMACE 3,8 RANI 22,34 RANIHEXAL 34 RANITIDINE DBL 22,34 RANOXYL 34 REDIPRED 16 REFLUDAN 5 REGITINE 29 REMERON 6A REMINYL 40 RENITEC 3,8 REOPRO 5 RESPOCORT 16 RESTAVIT 27 RHINOCORT 16 RISPERDAL 32, 40 RITALIN 41 RITHMIK 4 RIVOTRIL 37 ROCALTROL 38 ROSIG 9,31 RUBESAL 9 RYTHMODAN Product Name Serial Number SABRIL 37 SAIZEN 39 SANDOMIGRAN 36 SANDRENA 39 SEAZE 37 SELGENE 10 SEQUILAR ED 15 SERC 29,30 SERENACE 7,28,32 SEREPAX 27,28,35 SERETIDE 14B,14C SEREVENT 14B,14C SEROQUEL 32 SERTRALINE 6A SETACOL 42 SETAMOL 31 SIGMAXIN 4 SIGMETADINE 22,34 SIMVABELL 23 SIMVAHEXAL 23 SIMVAR 23 SIMVASTIN 23 SINEASE 30 SINEMET 10 SINEQUAN 6D SINGULAIR 14 SITRIOL 38 SKELID 38 SNUZAID 27 SODIUM OIDIDE 39 SOLAVERT 4, 12 SOLIAN 32 SOLONE 16 SOLPRIN 5,11,31 SOMAC 34 SONE 16 SORBIDIN 2,29 SOTACOR 4,12 SOTAHEXAL 4,12 SOTALOL BC 4, 12 SPIRACTIN 8,18 SPIRIVA 14C SPREN 11,31 STALEVO 10 STELAZINE 7,28,32 STEMETIL 7,32 STEMZINE 7,32 STILNOX 24 SURGAM 9,31 SURMONTIL 6D SUVULAN 36 SYMBICORT 14C SYMMETREL 10 SYNAREL 39 SYNPHASIC 15 TAGAMET 22,34 TALAM 6A TALOHEXAL 6A

107 Product Name Serial Number TAMBOCOR 4 TAZAC 22,34 TEGRETOL 32,37 TELFAST 30 TELNASE 16 TEMAZE 24,27,35 TEMGESIC 31 TEMTABS 24.27,35 TENOPT 43 TENORMIN 2,4,8,12 TENSIG 2,4,8,12 TENUATE 45 TERIL 32,37 TERTROXIN 39 TETRABENAZINE 43 TEVETEN 8, 33 THEO-DUR 14 TICLID 5,11 TICLOPIDINE HEXAL 5,11 TILCOTIL 9 TILODENE 5,11 TIMOPTOL 43 TIMPILO 43 TOFRANIL 6D TOLVON 6C TOPACE 3, 8 TOPAMAX 35,37 TOPROL 12 TORADOL 9 TRAMAL 31 TRANDATE 8,12 TRANSIDERM-NITRO 2,29 TRAVACALM 7,42 TRAVATAN 43 TRENTAL TRI PROFEN 9,31 TRIFEME 15 TRILEPTAL 37 TRIPHASIL 15 TRIQUILAR 15 TRISEQUENS 39 TRITACE 3,8 TRUSOPT 43 TRYPTANOL 6D TYLENOL 31 ULCYTE 34 ULTRATARD 26 UNISOM 24,27 UREMIDE 8,17 UREX 8,17 VALIUM 27,28,35 VALLERGAN 27,30 VALPAM 35 VALPRO 32,37 VASOCARDOL CD 2,8,13, 33 VASTIN 23 VEGANIN 31 VERACAPS 2,8,13 VIAGRA Product Name Serial Number VIOXX 9 VISKEN 2,4,8,12 VOLTAREN 9,31 VYTORIN 23 XALACOM 43 XALATAN 43 XANAX 27,28,35 XYDEP 6A ZACTIN 6A ZADINE 30 ZANIDIP 8, 13 ZANTAC 22,34 ZARONTIN 37 ZESTRIL 3,8 ZOCOR 23 ZOFRAN 7 ZOLOFT 6A ZOMIG 36 ZOTON 34 ZUMENON 39 ZYLOPRIM 21 ZYDOL 31 ZYPREXA 32 ZYRTEC 30

108 PATIENT ASSESSMENT GENERAL APPROACH AND TREATMENT Initial Assessment Initial Treatment Secondary Assessment Secondary Treatment Danger Response Alert. Voice. Pain. Unconscious. Formal GCS Airway + Cervical spine care Chin lift; head tilt; jaw thrust. Hold head still. Suction; clear airway. Oral / nasal airway E.T.T. Cx collar; KED Board / scoop. Breathing Look, Listen, Feel. I.P.P.V. Oxygen Resp rate. Pulse oximetry. Breath sounds. Pleural decompression. Stabilise flail segment. Circulation Bleeding control. Central pulse. Skin signs Cardiac compressions E.C.G. Monitor D.C.C.S. Cannula Pulse rate. I.V. Fluids B. P. MAST Analyse E.C.G. History Of event - Patient. Bystanders Utilise bystanders Full history. Expose injuries. Obtain medications Bring relatives along. Drugs B.G.L. Formal drug therapy. Transport Call backup if required. Assess time critical Prepare for transport. Transport. Notify hospital 105

109 TIME CRITICAL PATIENT GUIDELINE The following patients can be considered actually or potentially Time Critical. This requires a minimum scene time, treatment en-route wherever possible, & prompt transport to a designated Trauma Centre for trauma patients. This is a guideline only, and does not represent a complete and exclusive list of time critical patients. 1: TRAUMA PATIENTS Vital signs (adults) [Actual time critical indicators] Respiratory distress (rate > 29, or < 10 / minute), or altered L.O.C. (GCS < 13), or hypotensive (sys BP < 90), and/or revised trauma score < 12 Pattern of injury: [Actual time critical indicators] Penetrating injury head; neck; torso; axilla, groin Amputation above wrist or ankle Fractures to 2 or more proximal long bones, or fractured pelvis Suspected crush syndrome Paralysis or significant weakness of limbs Significant injury to single body region (eg, head, abdomen, chest) or lesser injuries to 2 or more body regions Burns - > 10% body surface; special areas (eg eyes, genitals); Or respiratory tract involvement 106

110 Mechanism of injury: [Potential time critical indicators] Motor vehicle Pedestrian Pedal / motorcyclist Other - 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.) struck by a vehicle at > 30 kph impact speed > 30 kph Fall > Twice patient height Struck by object falling > 5 m (related to weight of object) Explosion / blast 2: OTHER PATIENTS chest pain suggestive of ischaemia unrelieved upper airway obstruction aortic aneurysm or dissection worsening hypotension (any cause) significant arrhythmias, unresponsive to treatment generalised seizures, unresponsive to treatment stroke acute hypoxia, unresponsive to treatment deteriorating L.O.C. (any cause) heatstroke or significant hypothermia prolapsed umbilical cord or complicated labour carbon monoxide poisoning with decreased L.O.C. Cardiac arrest in advanced pregnancy (gestation > 20 / 52 ) Modifying factors for all time critical patients: - age < 5 yrs or > 60 yrs - previous medical condition - lack of response to current treatment. 107

111 GUIDELINES FOR THE RESUSCITATION OF ADULT AGONAL TRAUMA PATIENTS An Agonal trauma patient is described as a patient who presents on scene without cardiac output, and there is some evidence that this has been for a short time only, (eg. witness information; short response time; arrest in ambulance care). It is acknowledged that the history of loss of cardiac output can be unreliable. It is also assumed that there are no obvious, non-survivable injuries. Be wary of situations where a cardiac event may have preceded the trauma event. BLUNT TRAUMA 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 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. 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 slow, wide complex rhythm, or asystole, consider no resuscitation. 3: Resuscitate rapidly (if possible simultaneous procedures): Cannulate; rapid infusion of greater than 2 litres of crystalloid. (pump set) 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 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. 2: Determine if cardiac death has occurred. 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 attempted. If slow, wide complex rhythm, or asystole, consider resuscitation 3: Resuscitate rapidly if possible simultaneous procedures): Cannulate; rapid infusion of greater than 2 litres of crystalloid. (pump set) 108

112 2P P intercostal P intercostal 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 nd space on affected side/s. Drugs Secure definitive airway ETT / LMA. Aggressive oxygenation If penetrating injury under the suit, use PASG. If chest penetration + any doubt about air entry - chest decompression with a large bore cannula into the mid nd clavicular line 2P space. Drugs 4: If at this point no restoration of cardiac output has occurred, cessation of resuscitation should be seriously considered. 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. 4: Facilitate urgent transport to trauma centre. Ensure notification. Continue active resuscitation. If more than 15 minutes transport time from trauma centre, go to closest hospital. If cardiac output restored, continue to trauma centre. Agonal penetrating trauma patients may be considered for transport, as survival is possible. Exceptions: - close to trauma centre. - paramedic clinical judgement. Exceptions: - penetrating wounds to the head are to be treated as for blunt agonal trauma. - if more than 15 minutes transport time from any hospital, & no cardiac output regained, consider ceasing resuscitation. - paramedic clinical judgement. 109

113 APGAR SCORE SCORE Colour Blue / pale Pink: Extremities blue Completely pink Respiration Absent Slow: irregular Good; crying Heart Rate Absent Below 100 Above 100 Muscle Tone Limp Some flexion of extremities Active motion Reflex Irritability No response Grimace Vigorous cry, cough, sneeze Assess Apgar at 1 & 5 minutes 110

114 A.C.T. AMBULANCE SERVICE - PAEDIATRIC REFERENCE CARD Age Weight Resps Heart Syst E.T.T. E.T.T. Fluid Defib Defib (kg) Rate BP size (mm) Length 10ml / kg 2 j/ kg 4 j/ kg (cm) Neonate months months years years years years years years All values are approximate only Weight formula E.T.T. Size: Age < 9 years: Approx weight (kg) = (Age x 2) + 9 Age > 9 years Approx weight (kg) = Age x 3 Age / = diameter in mm Fluid resuscitation 10 ml / kg bolus - N/Saline Thereafter N/Saline bolus DO NOT use pump set in children under 15 kg - use 3-way tap and syringe Defibrillation Rounded off to closest energy setting References - Paediatric Fluid Reference Card Children s Hospital of Pittsburgh - Drug Doses in Paediatrics Royal Children s Hospital Melbourne 111

115 PEEP VALUES 2.5 cm 5 cm 10 cm 15 cm Infants (< 2 years age) (minimum & maximum) Cardiac arrest Children >2 (min & max) Intubated patients (not if suspected raised ICP, and if sats > 90%) Start level for: - pulmonary oedema - near drowning - CO poisoning - asthma - CAL Next level for: - pulmonary oedema - near drowning - CO poisoning - asthma (max) - CAL (max) if not responding to 5cm Final level for: - pulmonary oedema - near drowning - CO poisoning only if still desaturated with 10cm. 112

116 P 1: Patient mentation ACT AMBULANCE SERVICE SPINAL IMMOBILISATION CLEARANCE FLOWCHARTP Decreased level of consciousness? No Alcohol / drug impairment? No Loss of consciousness involved? No Yes Immobilise Yes Immobilise Yes Immobilise 2: Subjective assessment Cervical Thoracic Lumbar spinal pain? No Numbness / tingling / weakness / No Yes Immobilise burning sensation? Yes Immobilise 3: Objective assessment Cervical Thoracic Lumbar spinal tenderness? No Other painful injury or significant distraction? No Pain with spine range of motion? P No # Yes Immobilise Yes Immobilise Yes Immobilise MAY TRANSPORT WITHOUT SPINAL IMMOBILISATION # Range of motion is only to be checked if all other criteria are negative! NB: - Exercise care if a patient is seen very soon after the event. - Recheck patient before clearing if not transporting. - Your clinical judgement may be exercised to still utilise spinal immobilisation, even if the algorithm clears the patient. Pre-existing spinal disease and older age should increase the level of suspicion even with a clear process. 113

117 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 Lower limb motor examination 1. Shrug shoulders C4 Flex hip L1 & L2 2. Bend the elbow C5 Extend knee L3 3. Push wrist back C6 Pull foot up L4 4. Open/close hands C8 Push foot down L5 & S1 For thoracic and abdominal motor examination look for activity of intercostal and abdominal muscles. Diagnosis of spinal cord injury in the unconscious patient 1. Look for diaphragmatic respiration. A quadriplegic has lost intercostal muscles and relies on the diaphragm to breathe. 2. Flaccid limbs. 3. Loss of response to painful stimuli below the level of the lesion. 4. Loss of reflexes below the level of the lesion. 5. Erection in the unconscious male. 6. Low BP (Systolic less than 100) associated with a normal pulse or bradycardia indicates that the patient MAY be a quadriplegic. 114

118 DIFERENTIATION OF WIDE COMPLEX TACHYCARDIAS. The more of these present, greater the chance of VT. If in doubt, treat as VT, especially if sick. 1: History of - Ischaemic heart disease - Cardiac failure - Cardiomyopathy + Increasing age. 2: Atrio-ventricular dissociation 3: Capture beats or fusion beats 4: Very wide QRS (> 0.14secs). 5: Bizarre or extreme axis = VT (a positive complex in AVR strongly supports this). 6: Negative concordance across chest leads = VT Positive concordance tends towards VT. Non-concordance = 50:50. 7: V 1 - 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 V 1 & V6 = < 10% VT. 115

119 116

120 117 MAXIMUM Q T INTERVALS Heart Rate (per min) Maximum Q-T Interval (sec) (Males) (Females)

121 12 Lead Placements 118

122 Acute Myocardial Infarction ST elevatio n >1mthe limb leads and >2mm in the V leads in >2 consecutive leads Myocardial injury presents as raised ST Commonly this is an acute ischaemic injury. Significant ST elevation >1mm in the limb leads and >2mm in the V leads in >2 contiguous leads Infarction can present as pathological Q wave (older sign of full thickness infarction - >=.04 wide; deeper than 25% of height of R wave). Infarction may also present with T wave changes - inverted - la rge, hyperacute. ST depression may indicate myocardia ischaemia; occasionally myocardial infarction. ECG changes + reliable or suspicious clinical story may indicate myocardial ischaemia/infarction. I Lateral avr V1 Septal V4 Anterior II Inferior AVL Lateral V2 Septal V5 Lateral III Inferior AVF Inferior V3 Anterior V6 Lateral 119

123 INFARCTION OVERVIEW Site Indicative Leads Inferior Septal II, III, avf V 1 - V 2 Anterior V 3 V 4 Antero-septal Lateral Antero-lateral R ventricular Posterior V 1 V 4 I, avl, V6 (V 5 ) I, avl, V3 V6 V 3 R, V 4 R, (V 1 ) (usually seen with inferior changes) Reciprocal changes in anterior leads. V 8, V 9. May be seen with inferior or lateral changes. 120

124 INFERIOR AMI 121

125 ANTERO-SEPTAL AMI 122

126 ANTERO-LATERAL AMI 123

127 LATERAL AMI 124

128 RIGHT BUNDLE BRANCH BLOCK 125

129 LEFT BUNDLE BRANC H BLOCK 126

130 CAPNOGRAPHY USES OF CAPNOGRAPHY (ACTAS) - Verify initial position of ETT - Monitor continuing tracheal position of ETT. - Assist in assessment of adequacy of chest compressions. - Assist with confirmation of ROSC. - Aid in determination of cessation of resuscitation efforts. - Monitor effective IPPV in patients with critical COB2B requirements. MONITORING PROCEDURE Open COB2B connector door, connect Microstream tubing by turning clockwise. (The monitor will sense the presence of the tubing and activate the EBTBCOB2B function automatically. Self-test, auto-zeroing and warm up may take up to 2 ½ minutes.) - Connect the tubing to the patient (Proximal to bacterial filter is preferred.) - Display EBTBCOB2B waveform on Channel 3. - Adjust scale if required. (Monitor is configured to Autoscale. This means that the monitor will over-select the scale based on the measured EBTBCOB2B measurement.) The EBTBCOB2B is displayed in mmhg. A respiratory rate is also displayed. (No respiratory rate is displayed if the EBTBCOB2B 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, then reconnect. 127

131 PBAB COB2B should INTERPRETATION OF RESULTS It is important to utilise the waveform to assist in interpretation of information, not just relying on the numerical reading. NOTE: PBABCOB2B is generally 3 mmhg higher than EBTBCOB2B. Critical values in critical patients: Cardiac arrest: EBTBCOB2B consistently above 15 mmhg seems to have some positive correlation with ROSC. Patients with acute intracranial pathology: should be in range of mmhg B EBTBCOB2 be in range of mmhg. Documenting Results Serial EBTBCOB2B 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. EBTBCOB2B values will be included in the vital signs summary printout for later reference. 128

132 Wave Forms 129

133 RESPIRATORY STATUS ASSESSMENT General appearance NORMAL Calm, quiet, not anxious (#) RESPIRATORY DISTRESS Distressed, anxious, obviously fighting for breath, exhausted. Decreased level of consciousness Speech Normal sentences, with no difficulty. Short sentences phrases words only none. Respiratory Noises (heard without a stethoscope) Quiet, no noises. Cough Audible wheeze on exhalation; Crackly moist sounds; Inspiratory strider. Chest auscultation Quiet, no wheezes or crackles Wheeze: expiratory; occ inspiratory as well Crackles fine coarse; bases mid zone full field Silent chest one side, or bilateral Respiratory rate Adults: / minute Kids: / minute Babies: / minute Tachypnoea - adults > 24 / min - kids > 35 / min - babies > 50 / min Respiratory effort Pulse rate Minimal apparent effort; small chest / abdo movement Adults: / min Kids: Babies: Marked chest / abdo movement; use of accessory muscles; intercostal recession; sternal retraction; tracheal tug. (NB - chest movement may be minimal with some conditions) (*)Tachycardia - adults > 100 / min - kids > babies > 150 (NB slow pulse rate late sign in severe cases) Skin Pink; normal. Sweaty; sometimes pale May be flushed Cyanosis a late sign. Conscious state Alert; orientated. Altered. Oximetry 96% + on room air 90 95% on room air; < 90% = serious hypoxia NOTE: This assessment applies to patients with respiratory distress from any cause (#) Any of these features may indicate respiratory distress. The more that are present, the greater the degree of respiratory distress. (*) Some patients, especially older patients, may be on medication that prevents them from developing a tachycardia. 130

134 RULE OF NINES FOR ADULTS 131

135 Relative Percentage of Body Surface Area affected by Growth AREA Age ADULT A = ½ of head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ 3 ½ B = ½ of one thigh 2 ¾ 3 ¼ 4 4 ½ 4 ½ 4 ¾ C = ½ of one leg 2 ½ 2 ½ 2 ¾ 3 3 ¼ 3 ½ 132

136 OB2B content NORMAL BLOOD VALUES Arterial Blood Gases ph PaOB2B mm Hg PaCOB2B mm Hg COB2B content vols% vols% Biochemistry: Sodium Potassium Calcium Magnesium Bicarbonate Creatinine Urea Glucose mmol/l mmol/l mmol/l mmol/l mmol/l mmol/l mmol/l mmol/l (fasting) Haematology: Haemoglobin Male: g/l F/male: g/l Haematocrit Male: 42 52% F/male: 37 48% Red cell count million White cell count thousand Platelet count thousand. 133

137 VB3B 12 EXTERNAL PACING PROCEDURE Indications: Bradycardia with poor perfusion: - unresponsive to atropine or IV fluids; or - where IV access cannot be obtained. [Preferred over adrenaline infusion for post cardiac arrest bradycardia.] Procedure: 1: Explain to patient and family 2: Set up adrenaline infusion, if IV access obtained. 3: Ensure ECG electrodes are well off the chest 4: Prepare skin for pacing electrodes (clip - no shaving; no alcohol) 5: Anterior electrode in approx VB2B lead position, horizontal. (Avoid nipple, sternum & diaphragm) 6: Posterior electrode at (L) vertebral edge, below bony prominence of scapula, vertical. 7: Set current at 0mA, demand mode, rate approx 50% over initial bradycardia. 8: Ensure pacer is sensing (markers on QRS complexes) 9: Slowly increase current output in 5mA increments (use selector wheel) until electrical capture occurs (rarely under 60mA) 10: Ensure electrical capture (change in QRS; wide QRS; big T wave) 11: Check mechanical capture (pulse; LOC; BP) 12: Increase current output by 5mA over initial capture value. 13: Ensure analgesia is provided. 14: Continue to check electrical & mechanical capture. 15: Adjust rate and current output as required 134

138 135

139 Roof Hatch (Emergency Exits) Off-side Window Emergency Exit towards the rear (Driver s side) Access to Buses & Coaches Rear Window Emergency Exit (if fitted) Rear-mounted Engine External Emergency Release Fuel Tank usually mounted here valves or switches under for rear engine coach (for Mid or Front Bumper engines, tank is towards rear Batteries on other side at REAR (on most coaches or buses, batteries are near engine 136

140 137

141

142 139