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Ambulance Victoria Clinical Practice Guidelines for Ambulance and MICA Paramedics © Ambulance Victoria 2014 2014 Edition - Update Clinical Practice Guidelines for Ambulance and MICA Paramedics Revised Edition July 2014 Ambulance Victoria Copyright © Ambulance Victoria 2014. This publication, either in whole or in part, may not be photocopied, lent, or reproduced in printed or electronic form without the written permission of Ambulance Victoria. Ambulance Victoria reserves the right to revoke any permission at any time. Inquiries should be directed to the Manager Corporate Communications. © Ambulance Victoria 2014 Ambulance Victoria 375 Manningham Road Doncaster, Victoria 3108 PO Box 2000 Doncaster, Victoria 3108 Disclaimer These Clinical Practice Guidelines (CPGs) have been approved for use by Ambulance Victoria (AV) Ambulance Paramedics and Mobile Intensive Care Ambulance (MICA) Paramedics by the AV Medical Advisory Committee. The content in these CPGs is for information and educational purposes only and is not intended to be relied on as a substitute for the provision of medical advice or treatment. These CPGs are provided in good faith without any express or implied warranty. AV, its agents, officers and employees accept no liability however arising for any loss or damage resulting from the use of these CPGs and any information and data or reliance placed on these CPGs. If you rely on the information in these CPGs you are responsible for ensuring by independent verification its accuracy, currency or completeness. National Library of Australia Cataloguing-in-Publication Data: Ambulance Victoria. Clinical Practice Guidelines / Ambulance Victoria. Revised ed. ISBN-13: 978-0-9806444-3-2 Includes index Bibliography First aid in injury and injury—Victoria—Handbooks, manuals, etc. Emergency medicine—Victoria—Handbooks, manuals, etc. Emergency medical technicians—Victoria. 616.025 Foreword The CPG 2014 Edition Update captures a series of recent guideline changes which have been approved by the AV Medical Advisory Committee. Many of these changes aim to strengthen AVs ongoing commitment to improve patient safety particularly in regards to medication safety. The changes include updates to the endotracheal intubation, seizure, agitated patient, asthma, anaphylaxis, and pain relief guidelines. In addition to these updated CPGs, there are two new guidelines; COPD and STEMI Management. In considering the evidence and expert clinician advice, the COPD CPG is now separated from the asthma CPG. This acknowledges the significant differences in aetiology between these two patient groups. The STEMI Management CPG has been also been added. This new CPG has been developed as a part of the Pre-hospital Thrombolysis Project which is currently being implemented throughout rural Victoria. Another change which you will notice is the change to care in relation to patient age. Emerging literature highlights the impact that frailty, rather than age, has upon patients’ ability to respond to health challenges and clinical care. The significance of frailty will increasingly be considered across AV CPGs including assessment notes and modified management options. © Ambulance Victoria 2014 All of the changes in this update are highlighted on the amendment summary at the back of the book. Every effort has been made to ensure the accuracy of these CPGs. They should be used with appropriate education and training. Angelia Dixon Medical Advisory Committee Chair Foreword iii © Ambulance Victoria 2014 Acknowledgements Members of the AV Clinical Practice Development Committee Additional Support Assoc Prof. Stephen Bernard Medical Adviser, AV Assoc Prof. Mark Fitzgerald Medical Adviser, AV Dr John Moloney Clinical Adviser, ARV Justin North-Coombes Paramedic representative Christopher Tang Paramedic representative Gavin Smith MICA Paramedic representative Daniel Cudini MICA Paramedic representative Ben Meadley AAV representative Tony GinisManager of Collaborative Emerg. Health Problems (acting) Greg GibsonClinical Support Manager (Metro West) Dianne Inglis Clinical Support Manager, Hume David Llewellyn Clinical Support Officer Jeff Kenneally Team Manager, MICA 13 Stephen BurgessClinical Education Development Manager Scott Bennetts Manager Clinical Effectiveness Paul Burke Clinical Practice Development Specialist Jodie D’Arcy Clinical Practice Development Officer Bill BargerManager Operational Quality and Improvement Dr Andrew Bacon Medical Adviser, AV Lavinia Cannon MICA Paramedic Mark Rewi MICA Paramedic Andrew McDonell Clinical Support Officer, Loddon Brion Rafferty Graduate Paramedic David Titler Graduate Paramedic Brendon Dunn ALS Paramedic Claire Mullett ALS Paramedic Toby Bugter MICA Paramedic Mike Gualano MICA Paramedic Tim Howes MICA Paramedic Brendan Kinderis MICA Paramedic Matthew Riddle MICA Paramedic Duncan Roney MICA Paramedic Glen Ward MICA Paramedic Mark Jones ALS Flight Paramedic Nick Roder MICA Flight Paramedic Brett Drummond Group Manager 5 (acting) Brandon Adams ALS Paramedic Damien D’Ambrosi MICA Paramedic James Marshall ALS Paramedic Yvonne Singer Victorian State Burns Program Co-ordinator, Alfred Hospital Prof. Russell GruenDirector, The National Trauma Research Institute Chas Spanti AV Business Manager And all AV paramedics involved in the consultation, design and implementation process Index Page iii iv v xiv xvi 1 151 253 283 297 353 © Ambulance Victoria 2014 Section Foreword Acknowledgements Index Guide to Abbreviations Graphic Guide Section One Adult Patient Section Two Paediatric Patient Section Three Obstetric Patient Section Four Newborn Patient Section Five Pharmacology Section Six Further Information Index v Index © Ambulance Victoria 2014 Title Section One Adult Patient SectionGuidelines One Adult Number Clinical Approach Oxygen Therapy CPG A0001 Clinical Approach CPG A0101 Perfusion Assessment CPG A0102 Respiratory Assessment CPG A0103 Conscious Assessment CPG A0104 Time Critical Guidelines CPG A0105 Mental Status Assessment CPG A0106 Cardiac Arrest Cardiac Arrest CPG A0201 ROSC Management CPG A0202 Withholding or Ceasing Resuscitation CPG A0203 Airway Management Laryngeal Mask Airway CPG A0301 Endotracheal Intubation CPG A0302 Failed Intubation Drill CPG A0303 Cricothyroidotomy CPG A0304 Cardiac Acute Coronary Syndromes CPG A0401 Bradycardia CPG A0402 Tachyarrhythmias CPG A0403 Supraventricular Tachyarrhythmias CPG A0403 Ventricular Tachycardia CPG A0404 Accelerated Idioventricular Rhythm CPG A0405 Pulmonary Oedema CPG A0406 Inadequate Perfusion (Cardiogenic Causes) CPG A0407 STEMI Management CPG A0408 Pain Relief Pain Relief CPG A0501 Page 1 5 8 10 11 12 17 19 22 25 30 32 46 47 50 54 56 58 60 62 64 66 68 76 CPG A0601 CPG A0602 82 88 CPG A0701 CPG A0702 CPG A0703 CPG A0704 CPG A0705 CPG A0706 CPG A0707 CPG A0708 CPG A0709 CPG A0710 CPG A0711 92 94 96 99 102 104 106 115 118 120 122 CPG A0801 CPG A0802 CPG A0803 CPG A0804 CPG A0805 CPG A0806 CPG A0807 126 129 132 134 136 140 142 CPG A0901 CPG A0902 146 148 © Ambulance Victoria 2014 Respiratory Asthma COPD Medical Nausea and Vomiting Hypoglycaemia Seizures Anaphylaxis Inadequate Perfusion (Non-cardiogenic / Non-hypovolaemic) Meningococcal Septicaemia Overdose Agitated Patient Organophosphate Poisoning Autonomic Dysreflexia Stroke / TIA Trauma Hypovolaemia Chest Injuries Traumatic Head Injury Spinal Injury Burns Fracture Management Diving Related Emergencies Environment Hypothermia / Cold Exposure Environmental Hyperthermia / Heat Stress Index Section One Adult vii Index Section One Adult Patient Section Two Guidelines Paediatric Title Number Paediatrics Normal Values CPG P0101 Perfusion Status Assessment CPG P0101 Respiratory Status Assessment CPG P0101 Conscious State Assessment CPG P0101 Paediatric Pain Assessment CPG P0101 Paediatric Charts CPG P0102 Time Critical Guidelines CPG P0105 Cardiac Arrest Cardiac Arrest (Paediatric) CPG P0201 Cardiac Arrest ROSC Management (Paediatric) CPG P0201 © Ambulance Victoria 2014 Airway Management Endotracheal Intubation (Paediatric) CPG P0301 Failed Intubation Drill (Paediatric) CPG P0302 Pain Relief Pain Relief (Paediatric) CPG P0501 Respiratory Upper Airway Obstruction (Paediatric) CPG P0601 Asthma (Paediatric) CPG P0602 Page 151 154 155 157 158 163 168 171 177 180 192 195 200 205 214 216 219 222 224 232 236 239 242 248 250 © Ambulance Victoria 2014 Medical Hypoglycaemia (Paediatric) CPG P0702 Seizures (Paediatric) CPG P0703 Anaphylaxis (Paediatric) CPG P0704 Meningococcal Septicaemia (Paediatric) CPG P0706 Overdose (Paediatric) CPG P0707 Organophosphate Poisoning (Paediatric) CPG P0709 Trauma Hypovolaemia (Paediatric) CPG P0801 Chest Injuries (Paediatric) CPG P0802 Burns (Paediatric) CPG P0803 Environment Hypothermia / Cold Exposure (Paediatric) CPG P0901 Environmental Hyperthermia / Heat Stress (Paediatric) CPG P0902 Index Section Two Paediatric ix Index Section One Adult Section Patient ThreeGuidelines Obstetric Title Number Obstetric Emergencies CPG O0101 Antepartum Haemorrhage CPG O0201 Pre-eclampsia / Eclampsia CPG O0202 © Ambulance Victoria 2014 Page 253 260 262 Normal Birth Breech / Compound Presentation (Imminent Birth) Preterm Labour Cord Prolapse Shoulder Dystocia CPG O0301 CPG O0302 CPG O0303 CPG O0304 CPG O0305 264 268 272 274 277 Primary Postpartum Haemorrhage CPG O0401 280 Index Title The Newborn Baby Number Page CPG N0101 283 Newborn Resuscitation Newborn Advanced Resuscitation CPG N0201 CPG N0202 288 294 Newborn Baby: APGAR Scoring System CPG N0301 296 © Ambulance Victoria 2014 Section One Adult Patient Section FourGuidelines Newborn Index Section Four Newborn xi © Ambulance Victoria 2014 Index Section One AdultFive Patient Guidelines Section Pharmacology Title Number Drug Presentation Adenosine CPG D032 Adrenaline CPG D002 Amiodarone CPG D003 Aspirin CPG D001 Atropine CPG D004 Ceftriaxone CPG D005 Dexamethasone CPG D007 Dextrose 5% CPG D008 Dextrose 10% CPG D009 Enoxaparin CPG D034 Fentanyl CPG D010 Frusemide CPG D011 Glucagon CPG D012 Glyceryl Trinitrate (GTN) CPG D013 Ipratropium Bromide CPG D014 Ketamine CPG D033 Lignocaine 1% (IM Administration) CPG D015 Lignocaine 1% (IO Administration) CPG D015A Methoxyflurane CPG D017 Metoclopramide CPG D018 Midazolam CPG D019 Misoprostol CPG D030 Morphine CPG:D020 Naloxone CPG D021 Normal Saline CPG D022 Oxytocin (Syntocinon) CPG D031 Pancuronium CPG D023 Prochlorperazine (Stemetil) CPG D024 Salbutamol CPG D025 Sodium Bicarbonate 8.4% CPG D026 Suxamethonium CPG D027 Tenecteplase CPG D035 Water for Injection CPG D029 Page 297 298 300 302 303 304 306 307 308 309 310 312 314 315 316 319 321 323 324 326 327 329 331 332 334 336 337 339 341 343 345 347 349 351 Index Title Alternative drug administration route OG / NG tube Interhospital transfers Sudden unexpected death of an infant or child Verbal de-escalation strategies IV fluid calculations Drug dilutions Peer Support Telephone Interpreting Service Summary of approved changes Page 353 354 356 360 362 362 363 365 366 367 © Ambulance Victoria 2014 Section Six Further Information Index Section Six Further Information xiii © Ambulance Victoria 2014 Guide to Abbreviations @ ‘At’ relating to time intervals between dose/action/intervention COPDChronic Obstructive Pulmonary Disease Hx ICP Intracranial pressure AAA Abdominal Aortic Aneurysm CPAP Continuous Positive Airway Pressure IFS Intubation Facilitated by Sedation ACS Acute Coronary Syndromes CPG Clinical Practice Guideline IHT Interhospital transfer ADLs Activities of Daily Living Intramuscular Atrial Fibrillation Cardiopulmonary Resuscitation Clinical Work Instruction IM AF CPR CWI IN Intranasal AIVR Accelerated Idioventricular Rhythm D5W 5% Dextrose IO Intraosseous ALS Advanced Life Support DBP Diastolic Blood Pressure AMI Acute Myocardial Infarction DCCS Direct Current Counter Shock IPPVIntermittent Positive Pressure Ventilation AP Ambulance Paramedic DCI Decompression Illness IU International Unit APH Antepartum haemorrhage DCR Direct Current Reversion IV Intravenous APO Acute Pulmonary Oedema DKA Diabetic Ketoacidosis J Joules ARV Adult Retrieval Victoria DM Duty Manager JVP Jugular Venous Pressure AV Ambulance Victoria dpm drops per minute KED Kendrick Extrication Device A-V Atrioventricular ECC External Cardiac Compression kg kilogram/s AVRT A-V re-entry tachycardia ECG Electrocardiogram L litre History AVNRT A-V nodal re-entry tachycardia EtCO2 End-tidal carbon dioxide LMA Laryngeal Mask Airway Ax Assessment ETT Endotracheal tube LOC Loss of Consciousness BGL Blood Glucose Level FG French Gauge LMO Local Medical Officer BLS Basic Life Support FHR Fetal Heart Rate L/min litres per minute BP Blood Pressure FRC Functional Residual Capacity LVF Left Ventricular Failure bpm beats per minute g gram/s MAO monoamine oxidase BVM Bag-Valve-Mask GCS Glasgow Coma Score max. maximum C/I Contraindication GIT Gastrointestinal Tract MCA Motor Car Accident CBR Chemical / Biological / Radiation GR Grade mcg microgram/s CCF Congestive Cardiac Failure GTN Glyceryl trinitrate mg milligram/s CNS Central Nervous System hr hour MI Myocardial Infarction C.O. Cardiac Output (L/min.) HR Heart Rate MICA Mobile Intensive Care Ambulance Guide to Abbreviations min minutes PIP mL millilitres PIPER Paediatric Infant Perinatal Emergency Retrieval SL Sublingual mL/hr millilitres per hour SOB Short of Breath mmHg millimetres of Mercury (Hg) pMDI mmol/L millimoles per litre PO Per oral SpO2Saturation of haemoglobin with O2 measured by Pulse Oximetry MOI PPH PPPH Postpartum Haemorrhage Primary Postpartum Haemorrhage S/S Signs/symptoms PSA Perfusion Status Assessment SV Stroke volume PPE Personal Protective Equipment SVT Supraventricular tachycardia PSV Pressure Support Ventilation Pt Patient PV Per Vagina QAP Qualified Ambulance Paramedic QRS QRS complex of ECG R & R Rest and Reassurance Mechanism of Injury MP MICA Paramedic MTS Major Trauma Service MV Minute Ventilation Mx Manage/Management NB Note well neb nebule NEPT Non Emergency Patient Transport NG Nasogastric NPA Nasopharyngeal Airway © Ambulance Victoria 2014 NSTEACSNon-ST Elevation Acute Coronary Syndromes Ventilation Peak Inspiratory Pressure Pressurised Metered Dose Inhaler ROSC Return of Spontaneous Circulation RSA Respiratory Status Assessment RSI Rapid Sequence Intubation STEMI ST Elevation Myocardial Infarction TBI Traumatic Brain Injury TBSA Total Burn Surface Area TCA Tricyclic Antidepressant temp Temperature TKVO To Keep Vein Open TPT Tension Pneumothorax Tx Transport UA Unstable Angina VF Ventricular Fibrillation vol Volume vs Versus O2 Oxygen OD Overdose ODD Oesophageal Detector Device OG Orogastric OPA Oropharyngeal Airway PCI Percutaneous Coronary Intervention PCR Patient Care Record Work of Breathing Pulmonary Embolus S RuralSelected AV Rural APs permitted to perform skill WOB PE WPW Wolf Parkinson White PEA Pulseless Electrical Activity SCI Spinal Cord Injury Wt Weight (kg) PEEP Positive End-Expiratory Pressure sec second x/60 x minutes e.g. 5/60 = 5 minutes PHx Past History SIMVSynchronous Intermittent Mandatory RTA Road Traffic Accident RUQ Right Upper Quadrant R/V Rendezvous Rx Treat/Treatment SA Sinoatrial SAH Sub-arachnoid Haemorrhage VSS Vital Signs Survey VT Tidal Volume VT Ventricular Tachycardia @ x/60 e.g. @ 5/60 = at 5 minutely intervals Guide to Abbreviations xv © Ambulance Victoria 2014 Graphic Guide Special Notes General Care • Information to support these CPGs and improve the user’s understanding of a concept. • Provides supporting information or care related to the CPGs. e.g. Infusion preparations. Graphic Guide ? Status 8 Assess / Consider • Presenting condition/signs and CPG A0101 Clinical Approach • More specific assessment criteria that may direct Rx pathway Action • Drug or intervention required for ALS / MICA Action • Unique drug or intervention required for MICA only or selected Rural ALS Stop • Either: - A contraindication exists -A high risk action follows -Care must be exercised to proceed -An immediate action is required © Ambulance Victoria 2014 ? Status Stop 8 Assess 8 Consider Action MICA Action Graphic Guide xvii © Ambulance Victoria 2014 This page intentionally left blank Version 2 - 04.06.14 Page 1 of 3 Oxygen Therapy CPG A0001 Introduction - This CPG should only be applied to adult Pts aged ≥ 16 years. Mx principles - O2 is a Rx for hypoxaemia, not breathlessness. O2 has not been shown to have any effect on the sensation of breathlessness in non-hypoxaemic Pts. - Rx is aimed at achieving normal or near normal SpO2 in acutely ill Pts. O2 should be administered to achieve a target SpO2 while continuously monitoring the Pt for any changes in condition. - O2 should not be administered routinely to Pts with normal SpO2. This includes those with stroke, ACS and arrhythmias. - In Pts who are acutely SOB, the administration of O2 should be prioritised before obtaining an O2 saturation reading. O2 can later be titrated to reach a desired target saturation range. - If pulse oximetry is not available or unreliable, provide an initial O2 dose of 2 - 6 L/min via nasal cannulae or 5 - 10 L/min via face mask until a reliable SpO2 reading can be obtained or symptoms resolve. Special circumstances - Early aggressive O2 administration may benefit Pts who develop critical illnesses and are haemodynamically unstable, such as cardiac arrest or resuscitation; major trauma / head injury; carbon monoxide poisoning; shock; severe sepsis; and anaphylaxis. In the first instance, O2 should be administered with the aim of achieving an SpO2 of 100%. Once the Pt is haemodynamically stable, O2 dose should be titrated to normal levels. © Ambulance Victoria 2014 - Pts with chronic hypoxaemia (e.g. COPD, neuromuscular disorders, class i, ii or iii obesity etc.) who develop critical illnesses as above should have the same initial aggressive O2 administration, pending the results of blood gas measurements. - COPD should be suspected in any patient over 40 years old who is: a smoker or ex-smoker, experiencing dyspnoea that is progressive, persistent and worse with exercise, has a chronic cough or chronic sputum production, has a family Hx of COPD. O'Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(SUPPL. 6):vi1-vi68. Oxygen Therapy CPG A0001 1 Version 2 - 04.06.14 Page 2 of 3 Oxygen Therapy Special Notes General Care • Pulse oximetry may be particularly unreliable in Pts with peripheral vascular disease, severe asthma, severe anaemia, cold extremities or peripherally 'shut down', severe hypotension and carbon monoxide poisoning. • O2 exchange is at its greatest in the upright position. Unless other clinical problems determine otherwise, the upright position is the preferred position when administering O2. • Pulse oximetry can be unreliable in the setting of severe hypoxaemia. An SpO2 reading below 80% increases the chance of being inaccurate. • Ensure the Pt's fingertips are clean of soil or nail polish. Both may affect the reliability of the pulse oximeter reading. The presence of nail infection may also cause falsely low readings. • All Pts with suspected carbon monoxide poisoning or pneumothorax should be given high dose O2 until arrival at hospital. These Pts who show no clinical evidence of breathlessness or hypoxaemia may still benefit from this practice. • Poisoning with substances other than carbon monoxide should be given O2 to maintain an SpO2 of 94-98%. Special circumstances occur in the setting of paraquat and bleomycin poisoning where the use of O2 therapy may prove detrimental to the Pt. The maintenance of prophylactic hypoxaemia in these Pts (SpO2 of 88-92%) is recommended. • Irrespective of SpO2 Pt VT should be assessed to ensure ventilation is adequate. © Ambulance Victoria 2014 CPG A0001 • Take due care with Pts who show evidence of anxiety/ panic disorders (e.g. hyperventilation syndrome). O2 is not required however no attempt should be made to retain CO2 (e.g. paper bag breathing). • All women with evidence of hypoxaemia who are more than 20 weeks pregnant should be Mx with left lateral tilt to improve cardiac output. • Face masks should not be used for flow rates < 5 L/min due to the risk of CO2 retention. • Nasal cannulae are likely to be just as effective with mouth-breathers. However, where nasal passages are congested or blocked, face masks should be used to deliver O2 therapy. Version 2 - 04.06.14 Page 3 of 3 Oxygen Therapy CPG A0001 ? Status Assess 8 • Evidence of hypoxaemia • Acute or chronic? • Breathlessness • Respiratory status • Assess and monitor SpO2 continuously • Consider causes of hypoxaemia ? Mild-moderate ? A dequate SpO2 hypoxaemia • SpO2 ≥ 94% ? Moderate-severe hypoxaemia ? Chronic hypoxaemia • SpO2 < 85 • COPD/pulmonary disease • SpO2 85 – 93% ✔ Action •No O2 required, reassure Pt • Neuromuscular disorders ✔ Action Critical illnesses, e.g. • T itrate O2 flow to SpO2 of 94 - 98% -Initial dose of 2 - 6 L/min via nasal cannulae -Consider simple face mask 5 - 10 L/min • Cardiac arrest or resuscitation High-concentration O2 may be • Major trauma/head injury harmful in the COPD Pt at risk of • Carbon monoxide poisoning hypercapnic respiratory failure • Shock • Severe sepsis • Anaphylaxis • Decompression illness © Ambulance Victoria 2014 • Status epilepticus • Obesity ✔ Action •Titrate O2 flow to SpO2 of 88 - 92% If no critical illness present -Initial dose of 2 - 6 L/min via nasal cannulae -Consider simple face mask 5 - 10 L/min ✔ Action • Initial Mx -Initial dose nonrebreather mask 10 - 15 L/min -If inadequate VT , consider BVM ventilation with 100% O2 •If Pt deteriorates or SpO2 remains < 88% -Rx as per Moderate-severe hypoxaemia • Once pt haemodynamically stable - Titrate O2 flow to SpO2 of 94 - 98% • If Pt deteriorates or SpO2 remains < 85% - BVM ventilation with 100% O2 -Consider LMA as per CPG A0301 Laryngeal Mask Airway -Consider ETT as per CPG A0302 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider Action MICA Action Oxygen Therapy CPG A0001 3 © Ambulance Victoria 2014 This page intentionally left blank Version 3 - 19-11-08 Page 1 of 3 Clinical Approach CPG A0101 The Clinical Approach is to be used to systematically assess all patients and to determine priorities of management. The only exception is when the need for immediate intervention is identified during the primary survey. Stop Primary survey / life threat status Standard precautions and PPE Dangers Response Airway – Consider potential for cervical spine injury Breathing – Assist ventilations if VT inadequate Circulation – CPR as required Haemorrhage – Control if life threatening Immediate Mx + Sitrep required (utilise ETHANE mnemonic) Rapport, rest and reassurance Position the Pt appropriately O2 Establish if refusal or limitation of Rx documented Apply assessment tools in order of relevance Determine need for Hx taking vs use of assessment tools © Ambulance Victoria 2014 Action Clinical Approach CPG A0101 5 Version 3 - 19-11-08 Page 2 of 3 Clinical Approach Assess History Hx of presenting complaint Pain - verbal analogue score Past medical Hx Medications Allergies Other information e.g. witnesses, doctor, Poisons Information etc. Assess © Ambulance Victoria 2014 Accurate Hx and assessment essential for problem recognition Hx should include assessment of mechanism of injury Vital signs survey GCS PSA RSA Pattern / mechanism of injury / medical condition Assess CPG A0101 Determine time criticality to Mx accordingly Accurate and thorough assessment in all Pts Secondary survey Head to toe assessment including evaluating pattern of injury SpO2 ECG - 12 lead if required Temp EtCO2 BGL - if required More detailed Hx Frailty status* Early recognition of time critical patient allows appropriate Mx, early request for further resources and timely Tx The frailty icon is used in CPGs to note where Mx may require adjustment in consideration of Pt frailty status. * Frailty does not necessarily correlate with advanced age. It is a complex syndrome with multiple contributing factors including age, baseline health, strength and endurance. Pts should be assessed as to where they may lie on the spectrum of frailty, and this should be considered when making treatment or transport decisions. Frail Pts are more vulnerable to complications of ill-health and CPGs may recommend consideration for adjusted treatment plans (including reduced drug doses) where appropriate. Version 3 - 19-11-08 Page 3 of 3 Clinical Approach CPG A0101 Determine Main Presenting Problem The combination of subjective (PHx, Hx, Meds) and objective (physical) data allows identification and prioritisation of clinical problems Confirm clinical reasoning with assessment data Action Further sitrep/resource requests as needed Consider time to hospital vs time to MICA support Tx to appropriate facility Mx clinical problems with appropriate CPG – Concurrent use of guidelines may be required in some situations IV access – if clinically indicated Reassess frequently and adapt Mx as appropriate Final assessment at destination/handover Action © Ambulance Victoria 2014 Provide MICA Mx in a timely manner Avoid unnecessary prehospital delays Clinical Approach CPG A0101 7 Version 2 - 01.09.03 Page 1 of 3 Perfusion Assessment Special Notes These observations and criteria need to be taken in context with: - The Pt’s presenting problem. - The Pt’s prescribed medications. - Repeated observations and the trends shown. - Response to Mx. BP alone does not determine perfusion status. • Perfusion definition The ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to meet their functional demands at that time and to effectively remove the associated metabolic waste products. • Perfusion assessment © Ambulance Victoria 2014 Other factors may affect the interpretation of the observations made, including: - cold or warm ambient temp. - anxiety. - any cause of altered consciousness. CPG A0102 Special Notes Version 2 - 01.09.03 Page 2 of 4 Perfusion Assessment CPG A0102 Perfusion status assessment Adequate perfusion Borderline perfusion Skin Pulse BP Conscious status Warm, pink, 60 – 100 bpm dry > 100 mmHg systolic Alert and orientated to time and place Cool, pale, 50 – 100 bpm clammy 80 – 100 mmHg systolic Alert and orientated to time and place Inadequate Cool, pale, < 50 bpm or > 100 bpm 60 – 80 mmHg perfusion clammy systolic Either alert and orientated to time and place or altered Extremely Cool, pale, < 50 bpm or > 110 bpm poor clammy perfusion < 60 mmHg systolic or unrecordable Altered or unconscious No perfusion Unrecordable Unconscious No palpable pulse © Ambulance Victoria 2014 Cool, pale, clammy Perfusion Assessment CPG A0102 9 Version 2 - 01.09.03 Page 3 of 4 Respiratory Assessment CPG A0103 © Ambulance Victoria 2014 Respiratory status assessment Normal Mild distress Moderate distress Severe distress (life threat) General appearance Calm, quiet Calm or mildly anxious Distressed or anxious Distressed, anxious, fighting to breathe, exhausted, catatonic Speech Clear and steady sentences Full sentences Short phrases only Words only or unable to speak Breath sounds and chest auscultation Usually quiet no wheeze Able to cough Able to cough Unable to cough Asthma: mild expiratory wheeze Asthma: expiratory wheeze, +/– inspiratory wheeze Asthma: expiratory wheeze +/– inspiratory wheeze, maybe no breath sounds (late) No crackles or scattered fine basal crackles, e.g. postural LVF: may be some fine crackles at bases LVF: crackles at bases to mid-zone LVF: fine crackles – full field, with possible wheeze Upper Airway Obstruction: Inspiratory stridor Respiratory rate 12 – 16 16 – 20 > 20 > 20 Bradypnoea (< 8) Respiratory rhythm Regular even cycles Asthma: may have slightly prolonged expiratory phase Asthma: prolonged expiratory phase Asthma: prolonged expiratory phase Breathing effort Normal chest movement Slight increase in normal chest movement Marked chest movement +/– use of accessory muscles Marked chest movement with accessory muscle use, intercostal retraction +/– tracheal tugging HR 60 – 100 bpm 60 – 100 bpm 100 – 120 bpm > 120 bpm Bradycardia late sign Skin Normal Normal Pale and sweaty Pale and sweaty, +/– cyanosis Conscious state Alert Alert May be altered Altered or unconscious Version 2 - 01.09.03 Page 4 of 4 Conscious Assessment CPG A0104 Glasgow Coma Score A. Eye opening Score Spontaneous 4 To voice 3 To pain 2 None 1 B. Verbal response A: Score Orientated 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 C. Motor response B: Score Obeys command 6 Localises to pain 5 Withdraws (pain) 4 Abnormal flexion (pain) 3 Extension (pain) 2 None 1 C: © Ambulance Victoria 2014 Total GCS (Max. score = 15) (A+B+C)= Conscious Assessment CPG A0104 11 Version 4 - 21.01.10 Page 1 of 7 Time Critical Guidelines Introduction The concept of the Time Critical Pt allows the recognition of the severity of a Pt’s condition or the likelihood of deterioration. This identification directs appropriate clinical Mx and the appropriate destination to improve outcome. Covered within the Time Critical Guidelines are: - Triage decisions for a Pt with major trauma - Triage decisions for a Pt with significant medical conditions - Requests for additional resources including MICA and Aeromedical services - Judicious scene time Mx (e.g. should not exceed 20 min for non-trapped major trauma Pt) - Appropriate receiving hospital and early notification It is important to note that the presence of time criticality does not infer a directive for speed of Tx, but rather the concept implies there be a “time consciousness” in the Mx of all aspects of Pt care and Tx. © Ambulance Victoria 2014 Time critical definitions Actual At the time the vital signs survey is taken, the Pt is in actual physiological distress. Emergent At the time the vital signs survey is taken, the Pt is not physiologically distressed but does have a pattern of injury or significant medical condition which is known to have a high probability of deteriorating to actual physiological distress. Potential At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no significant pattern of actual Injury/illness, but does have a mechanism of injury/illness known to have the potential to deteriorate to actual physiological distress. CPG A0105 Version 4 - 21.01.10 Page 2 of 7 Time Critical Guidelines CPG A0105 Trauma triage Pts meeting the criteria for major trauma should be triaged to the highest level of trauma care available within 45 min Tx time of the incident in accordance with Victorian State Trauma System requirements and AV policies and procedures. The receiving hospital must also be notified to ensure an appropriate reception team and facilities are available. Mechanism of injury (MOI) A Pt under the Trauma Triage Guidelines meets the criteria for major trauma if they have a combination of MOI and other co-morbidities constituting: •Systemic illness limiting normal activity / systemic illness constant threat to life. Examples include: - Poorly controlled hypertension - Obesity - Controlled or uncontrolled CCF - Symptomatic COPD - Ischaemic heart disease - Chronic renal failure or liver disease • Pregnancy • Age < 15 or > 55 Medical triage © Ambulance Victoria 2014 Pts meeting the time critical criteria for medical conditions are regarded as having, or potentially having, a clinical problem of major significance. These Pts are time critical and should be Tx to the nearest appropriate hospital. Time Critical Guidelines CPG A0105 13 ? Status Actual Time Critical Emergent Time Critical Vital signs are normal ? • Possible major trauma Assess vital signs 8 Assess pattern of injury 8 Action Vital signs not normal ? Action • Vital signs normal 8 Assess 8 Consider Action • Consider MICA / Aeromedical support within 45 min • Triage to highest level of trauma service Stop • Consider MICA / Aeromedical support within 45 min • Triage to highest level of trauma service Significant pattern of injury ? -fractured pelvis - fracture to two or more of the following: femur / tibia / humerus - major compound fracture or open dislocation -serious crush injury - burns > 20% or involving respiratory tract -suspected spinal cord injury • S pecific injuries - limb amputations / limb threatening injuries - injuries involving two or more of the above body regions • Blunt injuries - significant injury to a single region: head / chest / abdomen / axilla / groin •Penetrating injuries - head / neck / chest / abdomen / pelvis / axilla / groin • Any of the following: • May have pattern of injury • Any of the following: - Respiratory rate < 12 or > 24 - BP < 90 mmHg systolic - Pulse > 124 - GCS < 13 - SpO2 < 90% MICA Action Time Critical Guidelines (Trauma Triage) ? Status © Ambulance Victoria 2014 © Ambulance Victoria 2014 Potentially Time Critical No pattern of injury ? • Vital signs are normal • May have mechanism of Injury Assess mechanism of injury (MOI) 8 • Any of the following: - Ejection from vehicle - Motor / cyclist impact > 30 km/hr - Fall from height > 3 m - Struck on head by falling object > 3 m - Explosion - High speed MCA > 60 km/hr - Pedestrian impact - Prolonged extrication > 30 min 8 Assess co-morbidities No MOI ? ✔ CPG A0105 Not Time Critical • Vital signs are normal • No pattern of Injury Action Positive MOI and NO co-morbidities ? • Triage to nearest appropriate facility if required Positive MOI and co-morbidities ? • Vital signs are normal • No pattern of Injury • Any of the following: - Age > 55 - Pregnancy -Significant underlying medical condition • Vital signs are normal • No pattern of injury Action with notification • Triage to nearest appropriate facility Action within 45 min • Triage to highest level of trauma service Time Critical Guidelines CPG A0105 15 Actual Time Critical Emergent Time Critical ? Vital signs are normal • Possible medical time critical Status ? Assess vital signs 8 Assess medical condition 8 Action Vital signs not normal ? Action • Vital signs normal 8 Assess 8 Consider ✔ Action • Consider MICA / Aeromedical support with notification • Triage to nearest appropriate facility with notification Stop • Consider MICA / Aeromedical support • Triage to nearest appropriate facility Significant medical condition ? • Hypothermia or hyperthermia •Need for possible hyperbaric treatment e.g. acute decompression illness or cyanide poisoning • Medical symptoms / syndromes - ACS - Acute stroke - Severe sepsis, including suspected meningococcal disease - Possible AAA - Undiagnosed severe pain Any of the following: • May have significant medical condition •Any of the following: - Moderate or severe respiratory distress - Oxygen saturation < 90% room air / 93% supplemental O2 - < Adequate perfusion - GCS < 13 (unless normal for Pt) ✔ MICA Action Time Critical Guidelines (Medical) CPG A0105 ? Status © Ambulance Victoria 2014 Version 2 - 01.09.03 Page 1 of 1 Mental Status Assessment CPG A0106 Observations © Ambulance Victoria 2014 A mental status assessment is a systematic method used to evaluate a Pt’s mental function. In undertaking a mental status assessment, the main emphasis is on the person’s behaviour. This assessment is designed to provide Paramedics with a guide to the Pt’s behaviour, not to label or diagnose a Pt with a specific condition. 1. Appearance Neatness, cleanliness Pupils – size Extraocular movements 2. Behaviour Bizarre or inappropriate Threatening or violent Unusual motor activity, such as grimacing or tremors Impaired gait Psychomotor retardation or agitation 3. Speech Rate, volume, quantity, content 4. Mood Depressed, agitated, excited or irritable 5. Response Flat – unresponsive facial expression Appropriate/inappropriate 6. Perceptions Hallucinations 7. Thought content Delusions (i.e., false beliefs) Suicidal thoughts Overly concerned with body functions (e.g. bowels) 8 Thought flow Jumping irrationally from one thought to another 9. Concentration Poor ability to organise thoughts Short attention span Poor memory Impaired judgement Lack of insight Mental Status Assessment CPG A0106 17 © Ambulance Victoria 2014 This page intentionally left blank Version 5 - 08.06.11 Page 1 of 3 Cardiac Arrest CPG A0201 © Ambulance Victoria 2014 Principles of CPR CPR • It is assumed that CPR is commenced immediately and continued throughout cardiac arrest as required • Generic for all adult cardiac arrest conditions • Must not be interrupted for more than 10 sec during rhythm and pulse checks. If no pulse or unsure of pulse, recommence CPR immediately • Change operators every 2 min to improve CPR performance and reduce fatigue • Compression depth = 1/3 chest depth • Rhythm / pulse check every 2 min • Recommence compressions immediately post DCCS without performing a pulse check • This CPG contains the recommended joules for biphasic defibrillators used in manual mode. Modern defibrillators used in automatic mode will deliver acceptable pre-set joules. If using a monophasic device please refer to manufacturer instructions. Adjustment for temperature Ratios of compressions to ventilations Not intubated • 30 : 2 • Rate: approximately 100 compressions per min - Pause for ventilations • Withhold Sodium Bicarbonate 8.4% IV > 32˚C • Standard cardiac arrest CPG 30 - 32˚C • Double intervals between drug doses in this CPG • Normal DCCS intervals • Do not rewarm beyond 33oC if ROSC < 30˚C • Continue CPR and rewarming until temp > 30˚C • One DCCS shock only • One dose of Adrenaline • One dose of Amiodarone Intubated / LMA inserted • 15 : 1 • Rate: approximately 100 compressions per min - < 8 ventilations/min - No pause for ventilations Cardiac Arrest CPG A0201 19 Version 5 - 08-06-11 Page 2 of 3 Cardiac Arrest CPG A0201 First rhythm analysis should be conducted in AED mode. All subsequent analyses are at Paramedic discretion. Action • Immediately commence CPR 30 : 2. Change to 15 : 1 once airway secured with ETT/LMA ? VF/VT (pulseless) Action •Defibrillate single shock 200J Repeat DCCS every 2/60 if VF/VT © Ambulance Victoria 2014 persists ? PEA ? Asystole Identify and Rx causes Action - Hypoxia - Exsanguination - Asthma - TPT - Anaphylaxis - Upper airway obstruction •Confirm rhythm with printed ECG strip •Consider CPG A0203 Withholding or Ceasing Resuscitation ? VF/VT persists ? PEA persists ? Asystole persists Action Action Action •IV access / Normal Saline TKVO •IV access / Normal Saline TKVO •IV access / Normal Saline TKVO •Adrenaline 1 mg IV every 3/60 if no output •Adrenaline 1 mg IV every 3/60 if no output • Adrenaline 1 mg IV every 3/60 if no output • If no IV access Adrenaline 1 mg IO every 3/60 if no output • If no IV access Adrenaline 1 mg IO every 3/60 if no output • If no IV access Adrenaline 1 mg IO every 3/60 if no output ? VF/VT persists ? PEA persists ? Asystole persists Action Action Action •LMA •LMA •LMA • ETT • ETT • ETT •If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output •If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output •If unable to obtain IV or IO - Adrenaline 2 mg via ETT - Repeat every 3/60 if no output ? VF/VT persists ? PEA persists Action Action • Amiodarone 300 mg IV / IO • Normal Saline 20 mL/kg IV Amiodarone is C/I in confirmed or suspected TCA OD • or Normal Saline 20 mL/kg IO ? VF/VT persists Action •Repeat Amiodarone 150 mg IV / IO (max. combined dose 450 mg) © Ambulance Victoria 2014 Sodium Bicarbonate 8.4% may be administered earlier in the algorithm if hyperkalaemia suspected or in cardiac arrest secondary to TCA OD ? VF/VT persists ? PEA persists Asystole persists ? • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR Action Action Action • Sodium Bicarbonate 8.4% 50 mL IV / IO • Sodium Bicarbonate 8.4% 50 mL IV / IO • Sodium Bicarbonate 8.4% 50 mL IV / IO ? Outcome ? Outcome ? Outcome Action Action Action • If ROSC refer CPG A0202 • If ROSC refer CPG A0202 • If ROSC refer CPG A0202 • If no ROSC refer CPG A0203 • If no ROSC refer CPG A0203 • If no ROSC refer CPG A0203 If during CPR Pt gag reflex prevents ETT, a small dose of Midazolam (1-2 mg IV) may be administered to facilitate intubation. The use of sedation to either assist placement of, or to maintain placement of an LMA is C/I. ? Status Stop 8 Assess 8 Consider Cardiac Arrest CPG A0201 Action MICA Action 21 Version 4 - 20.09.06 Page 1 of 2 Cardiac Arrest (ROSC Management) Special Notes © Ambulance Victoria 2014 CPG A0407 Inadequate Perfusion (Cardiogenic Causes) CPG A0302 Endotracheal Intubation CPG A0406 Pulmonary Oedema CPG A0202 General Care Version 4 - 20.09.06 Page 2 of 2 Cardiac Arrest (ROSC Management) CPG A0202 ? Status • Post cardiac arrest - Return of spontaneous circulation (ROSC) ? Unintubated ? Perfusion Mx ? Therapeutic cooling ? Transport • GCS < 10 post ROSC Action • Pt intubated Action Action • Maintain BP > 120 mmHg or Pt’s usual BP (if known) • Collapse to ROSC > 10/60 • Appropriate receiving hospital • Collapse to ROSC > 10/60 -RSI as per CPG A0302 Endotracheal Intubation -Therapeutic cooling • Accurately assess HR during movement/loading to ensure output maintained throughout • Rx as per appropriate CPG if condition changes • Do not administer Amiodarone unless breakthrough VF/VT occurs • Temp > 34.5oC • Notify early • 12 lead ECG if available • No pulmonary oedema evident • Cardiac arrest not due to bleeding Action • Assess Pt temp • Sedation/paralysis - Midazolam 1 - 5 mg IV - Pancuronium 8 mg IV © Ambulance Victoria 2014 • Collapse to ROSC < 10/60 -No therapeutic cooling -RSI as per CPG A0302 Endotracheal Intubation if coma persists despite initial oxygenation and perfusion Mx • Normal Saline and Adrenaline to be used as required per CPG A0407 Inadequate Perfusion • Normal functional status (independent with ADLs) ? Status Stop 8 Assess 8 Consider Action MICA Action Cardiac Arrest (ROSC Management) CPG A0202 23 © Ambulance Victoria 2013 This page intentionally left blank Version 7 - 12.09.12 Page 1 of 4 © Ambulance Victoria 2014 Withholding or Ceasing Resuscitation CPG A0203 Special Notes Special Notes •Mass casualty incidents are in part characterised by the available resources being overwhelmed by larger Pt numbers. Where this is the case AV Emergency Management Unit provide trauma triage guidelines for Pt assessment that may differ significantly from guidelines used in other patient situations. • Prolonged cardiac arrest may be determined in two ways. The first is where there is clear evidence of decomposition / putrefaction, rigor mortis or morbid lividity. • Prolonged cardiac arrest may also be an adult presenting in asystole (verified with three monitoring leads over > 30 sec) with the interval between cardiac arrest onset i.e. collapse and arrival of the crew at the Pt > 10 min and where there are no compelling reasons to continue. • Compelling reasons to commence or continue resuscitation include: - suspected hypothermia - suspected drug OD - a child (< 18) - a family member requests continued effort - any signs of life observed including pupil reaction or agonal/ineffective gasping respiration - Pt in VF or VT. • Injuries incompatible with life are where there is no possibility of having survived i.e. decapitation, incineration and there are no signs of life. This is distinct from where it may be believed that there is no prospect for eventual survival due to injury severity. Traumatic cardiac arrest outcomes are poor but not futile. • Poor prognostic factors in cardiac arrest resuscitation include unwitnessed arrest, no prior bystander CPR and duration of cardiac arrest exceeding 30 min. • An Advanced Care Directive (ACD), which may include a Refusal of Treatment Certificate (ROTC) may be completed by an adult (≥ 18), an agent with enduring power of attorney or a Victorian Civil and Administrative Tribunal appointed guardian. • An ACD or ROTC may be sighted by attending Paramedics or they may accept in good faith the advice regarding the nature of these documents from those present at the scene. If there is any doubt about the application of a certificate the default position of resuscitation should be adopted. •A ROTC may only be completed in relation to a current condition. When ceasing or withholding resuscitative efforts in these circumstances the attending Paramedic must be satisfied that the Pt’s cardiac arrest is most likely due to this current condition. • A Paediatric Emergency Treatment Plan includes words to the effect that in the event of a significant deterioration or cardiac / respiratory arrest CPR is not to be commenced. It should be signed by the parent / guardian and treating doctor or medical team. •Paramedic crews must clearly record full details of the information given to them and the basis for their decision regrading resuscitation on the PCR. This is particularly important where a copy of the ROTC has not been sighted as it will serve if necessary as evidence of their good faith. •Under the Medical Treatment Act 1988 a person acting under the direction of a registered medical practitioner who, in good faith and in reliance on a ROTC, refuses to perform or continue medical Rx is not guilty of professional misconduct or guilty of an offence or liable in any civil proceedings because of the failure to perform or continue that Rx. Withholding or Ceasing Resuscitation CPG A0203 25 Version 7 - 12.09.12 Page 2 of 4 Withholding or Ceasing Resuscitation CPG A0203 ? Status • Absent signs of life • Do not attempt Pt Mx if there is risk to Paramedic safety Stop 8 Assess Signs of life evident • Response to stimuli • Spontaneous respiratory effort • Palpable carotid pulse If uncertain of life status, commence immediate resuscitation No signs of life evident Is this a mass casualty situation?•Pain may require IV • • Action • If Yes, refer applicable AV Emergency Response Plan • If No, continue Hx / assessment Is there no prospect of resuscitation? © Ambulance Victoria 2014 • Clear evidence of prolonged cardiac arrest or • Injuries incompatible with life or • Death declared by a doctor who is, or has been at the scene Action • If Yes, do not commence resuscitation and • Confirm the determinants of death are present and • Consider verification of death • If No, continue Hx / assessment One or more signs of life present Action • Mx as per appropriate CPG Version 7 - 12.09.12 Page 3 of 4 Withholding or Ceasing Resuscitation CPG A0203 Are there compelling reasons to withhold resuscitation?• P Adult (≥ 18) with an ACD or ROTC or Child (< 18) with a valid Emergency Treatment Plan to not commence resuscitation Action • If Yes, do not commence resuscitation • Confirm the determinants of death are present • Consider verification of death • If No, commence resuscitation All other presentations with no signs of life evident• P Action • Commence immediate resuscitation Cessation of resuscitation Adult (≥ 18) who, after 30 - 45/60 of ALS resuscitation (including DCCS / drug therapy) has nil ROSC, no signs of life including pupil reaction and agonal / gasping respiration and no compelling reason to continue Action • Cease resuscitation © Ambulance Victoria 2014 • Confirm the determinants of death are present • Consider Verification of Death Withholding or Ceasing Resuscitation CPG A0203 27 Version 7 - 12.09.12 Page 4 of 4 Withholding or Ceasing Resuscitation CPG A0203 Verification of death • Verification of Death refers to ‘establishing that a death has occurred after thorough clinical assessment of a body’. • Qualified Paramedics can provide verification if in the context of employment and if there is certainty of death. Providing verification of death is not mandatory for Paramedics. • Certification of death must still ultimately be provided by a Medical Practitioner as to cause of death. This falls outside the scope of verification of death. • Clinical assessment of a deceased person includes 6 clinical elements. These are the ‘determinants of death’: - No palpable carotid pulse. - No heart sounds heard for 2 min. - No breath sounds heard for 2 min. - Fixed (non responsive to light) and dilated pupils (may be varied from underlying eye illness). - No response to centralised stimulus (supraorbital pressure, mandibular pressure or sternal pressure). -No motor (withdrawal) response or facial grimace to painful stimulus (pinching inner aspect of elbow or nail bed pressure). N.B. ECG strip that shows asystole over 2 min is a seventh and optional finding that may be included. Ideally the determinants of death should be evaluated 5 - 10 min after cessation of resuscitation to ensure late ROSC does not occur. • The Verification of Death form should include all findings along with the full name of person (if known), location of death, estimated date and time of death (if known), name of the Paramedic conducting the assessment and if the treating doctor has been notified. • Police must be notified in cases of reportable or reviewable death with the attending crew remaining on scene until their arrival. SIDS are considered reportable. • A reportable death would include unexpected, unnatural or violent death, death following a medical procedure, death of a person held in custody or care (alcohol or mental health), a person otherwise under the auspice of the Mental Health Act but not in care or a person unknown. © Ambulance Victoria 2014 • A reviewable death is required following death of a child (< 18) where the death is the second or subsequent death of a child of the parent, guardian or foster parent. • The original Verification of Death form should be left with the deceased and the copy attached to the printed PCR. © Ambulance Victoria 2014 This page intentionally left blank 29 Version 2 - 20.09.06 Page 1 of 2 Laryngeal Mask Airway (LMA) Special Notes General Care • The LMA provides improved airway and ventilation Mx compared with a facemask and OPA. The LMA does not protect against aspiration, although studies have shown it to be as low as 3.5% with an LMA compared to 12.4% with a BVM. The LMA should therefore not be regarded as the equivalent of endotracheal intubation. • If insertion fails and ventilation is difficult or inadequate, check position of LMA cuff using a laryngoscope. If minor adjustment fails to correct the problem, remove the LMA inflated. Immediately insert an OPA / NPA and ventilate the Pt using a BVM. • The LMA forms a low pressure seal around the posterior perimeter of the larynx and when correctly inserted is seated superior to the oesophageal sphincter, thus enabling positive pressure ventilation via BVM or closed circuit resuscitator. Unconscious Pts who accept an OPA are generally suitable for insertion of an LMA. • Obese Pts have a naturally increased WOB. During assisted or intermittent positive pressure ventilation they will require higher airway pressures to inflate the lungs. They also have a higher incidence of hiatus hernia resulting in an increased likelihood of passive regurgitation of stomach contents. © Ambulance Victoria 2014 CPG A0301 • Only one attempt may be made to reinsert LMA. If insertion fails on the second attempt, do not delay returning to BVM using an OPA / NPA. • Do not over-inflate cuff. • The LMA may be used for the unconscious APO Pt. However, gentle assisted ventilation should be provided using a closed circuit resuscitator. • The LMA may be inserted in left or right lateral positions, or if entrapped, in a sitting position. Pts may be Mx in the lateral position when the LMA has been correctly inserted and taped in situ, using Transpore or Sleek, however, in general, it is recommended that Pts be Mx supine and carefully observed for aspiration. • If the conscious state of the Pt improves and there is an attempt to reject the LMA, remove the LMA with the cuff inflated. Version 2 - 20.09.06 Page 2 of 2 Laryngeal Mask Airway (LMA) 8 ? Status CPG A0301 LMA Size Chart • Unconscious Pt without gag reflex Portex • Ineffective ventilation with BVM / oxysaver and airway Mx (OPA / NPA) Size 3 Small adult 4 Normal adult 5 Larger adult • > 10/60 assisted ventilation required • Unable to intubate/difficult intubation Wt 30 - 50 kg 50 - 70 kg 70 - 140 kg Inflation 25 mL 35 mL 55 mL Size Wt 3 Small adult 30 - 50 kg 4 Normal adult 50 - 70 kg 5 Larger adult 70 - 140 kg Inflation 20 mL 30 mL 40 mL Unique Stop • Contraindications - Intact gag reflex or resistance to insertion - Strong jaw tone and/or trismus - Suspected epiglottitis or upper airway obstruction -The use of sedation to either assist placement of, or to maintain placement of an LMA is C/I i-gel quick reference guide i-gel size Pt weight guide* 1.0 2 – 5 kg 1.5 5 – 12 kg 2.0 10 – 25 kg 2.5 25 – 35 kg 3.0 30 – 60 kg 4.0 50 – 90 kg 5.0 90+ kg Max size of gastric tube N/A 10 12 12 12 12 14 *This is a guide only. Please ensure correct size is chosen corresponding to Pt airway size 8 Consider © Ambulance Victoria 2014 • Precautions - Inability to prepare the Pt in the sniffing position - Pts who require high airway pressures, e.g. advanced pregnancy, morbid obesity, decreased pulmonary compliance (stiff lungs due to pulmonary fibrosis) or increased airway resistance (severe asthma) - Pts ≤ 14 years due to enlarged tonsils - Significant volume of vomit in airway • Side effects - Correct placement of the LMA does not prevent passive regurgitation or gastric distension ? Status Stop 8 Assess 8 Consider Action MICA Action Laryngeal Mask Airway (LMA) CPG A0301 31 Version 6 - 04-06-14 Page 1 of 12 Endotracheal Intubation Guide Special Notes • The Medical Advisory Committee has authorised endotracheal intubation by MICA Paramedics in selected clinical situations • There are three intubation techniques available: - Unassisted endotracheal intubation - Intubation Facilitated by Sedation (IFS) - Rapid Sequence Intubation (RSI) The appropriate technique will vary according to the clinical setting and the scope of practice of the attending MICA Paramedic(s). • A MICA Paramedic operating alone may elect not to perform a drug-facilitated intubation until a second MICA Paramedic is present. • All intubations facilitated or maintained with drug therapy will be reviewed as part of AVs clinical governance processes. © Ambulance Victoria 2014 • The use of cricothyroidotomy is restricted to MICA Paramedics specifically credentialled in this skill as required by the Medical Advisory Committee. CPG A0302 General Care Version 6 - 04-06-14 Page 2 of 12 Endotracheal Intubation Guide CPG A0302 Status ? • Endotracheal intubation ? Primary indications ? Preparation ? Insertion of ETT • Cardiac arrest •GCS ≥ 10 & suspected airway burns (consult) • • IFS • RSI GCS < 10 due to: - Respiratory failure - Neurological injury - OD - Status Epilepticus - Hyperglycaemia with BGL reading “high” - Suspected airway burns (consult not required) ? Care and maintenance • Sedation • Sedation and paralysis © Ambulance Victoria 2014 • See CPG A0303 Failed Intubation Drill ? Drugs to facilitate intubation • Respiratory arrest ? Failed intubation ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation CPG A0302 33 Version 6 - 04-06-14 Page 3 of 12 Endotracheal Intubation Indications, Precautions, C/Is Special Notes Special Notes • Traumatic brain injury -RSI should be provided unless Pt is in cardiac arrest. This includes Pts with absent airway reflexes. -Midazolam should not be used to control combativeness prior to RSI in head injury. Judicious opioid pain relief should be administered. In the rare circumstance where combativeness is preventing preoxygenation, then all other preparations for the RSI should be undertaken and a small (20-40 mg) bolus of Ketamine may be given to enable preoxygenation. • Uncontrolled bleeding -In Pts with uncontrolled bleeding (e.g. ruptured AAA, ruptured ectopic pregnancy, penetrating truncal trauma, limb avulsion) ongoing bleeding may lead to poor cerebral perfusion and coma. -RSI in these Pts is potentially harmful. The sedation may drop BP further and the added scene time increases total blood loss. The appropriate Rx for these Pts is urgent Tx and immediate surgery. -RSI should NOT be undertaken in Pts who become unconscious when the coma is likely to be secondary to blood loss unless RSI is judged to be absolutely essential due to an unmanageably combative Pt or it is impractical to Tx unintubated. This applies to both air and road transport. -Airway Mx with BVM is to be maintained in conjunction with prompt Tx. Intubation (without drugs) should be considered if airway reflexes are lost, bearing in mind the risks of delay to definitive surgical care. • Status epilepticus -Status epilepticus refers to either ≥ 5/60 of continuous seizure activity OR multiple seizures without full recovery of normal conscious state between seizures. These Pts may require intubation if there is airway / ventilation compromise which is unable to be Mx using BVM and OPA / NPA. • Suspected TCA OD -Requiring hyperventilation for cardiac arrhythmia prevention or Mx. © Ambulance Victoria 2014 CPG A0302 • Overdose -The intent of the OD indication for RSI in the context of a difficult extrication is that the Pt be intubated at the scene to enable safer movement of the Pt. • Gag reflex during CPR -Rarely, patients develop a gag reflex during CPR. In this instance, judicious doses of Midazolam (1-2 mg IV) should be used to achieve sedation. • Severe hyperthermia -May result from drug OD, exertion (e.g. marathon running) or environmental exposure. If after 10/60 of active cooling Pt temp remains > 39.5oC and GCS < 10, then Pt should be intubated via RSI. • Severe hypothermia -Where possible intubation should be avoided in hypothermic Pts, due to the risk of provoking arrhythmias. • Severe pain -Severe pain Pts are those who are unable to be humanely managed with analgesia alone. Examples include mangled limb injuries, significant %TBSA burns, or Pts trapped in machinery/plant. Version 6 - 04.06.14 Page 4 of 12 Endotracheal Intubation Indications, Precautions, C/Is Unassisted Endotracheal Intubation IFS CPG A0302 RSI Indication ? Indication GCS < 10 ? Indication ? • Respiratory arrest • Hyperglycaemia with BGL reading “high” • Cardiac arrest • Frail or elderly respiratory failure - e.g. COPD or APO • GCS < 10 with - Traumatic Brain Injury (TBI) - Non-traumatic brain injury - CVA or sub-arachnoid haemorrhage - Hypoxic brain injury - Post hanging, near drowning or ROSC - Respiratory failure unless frail or elderly - Young asthmatic - Suspected airway burns - OD with any of: - Suspected TCA OD - Difficult extrication - Prolonged Tx time (>30/60) - SpO2 unable to be maintained > 90% - Severe hyperthermia - >39.5°C despite 10/60 of active cooling - Severe pain that is unable to be managed using analgesic agents - Status epilepticus • Absent airway reflexes •Pts with GCS < 10 and requiring intubation, but contraindicated for Suxamethonium and AAV support is unavailable. 8 General precautions •Time to intubation at hospital vs time to intubate at the scene 8 Specific precautions for IFS • As per general precautions, and •Poor baseline neurological functioning and major comorbidities •Anticipation of difficulty with BVM ventilation •Anticipation of a difficult intubation, e.g. obesity, short neck or facial trauma •Advanced Care Plan / Refusal of Medical Treatment document specifies “not for intubation” •In general if Tx time < 10/60, IFS should not be undertaken •In general, severe hypothermia Pts should receive basic airway Mx and be transported for rewarming. • GCS ≥ 10 with suspected airway burns (consult) Contraindications •Clinical situations where failed intubation drill is not possible • No functional electronic capnograph © Ambulance Victoria 2014 • Traumatic brain injury 8 Specific precautions for RSI • As per general precautions, and •In general if Tx time < 10/60, RSI should not be undertaken Contraindications CIs •Clinical situations where the failed intubation drill is not possible • No functional electronic capnograph • Any C/I to Suxamethonium ? Status Stop 8 Assess 8 Consider Action MICA Action •Coma due to uncontrolled bleeding, eg. penetrating trauma or suspected Endotracheal Intubation CPG ruptured A0302 aortic aneurysm 35 Endotracheal Intubation CPG A0302 © Ambulance Victoria 2014 This page intentionally left blank Version 6 - 04-06-14 Page 5 of 12 Endotracheal Intubation Preparation Unassisted Endotracheal Intubation IFS ? General preparation for intubation Preparation for IFS ? Action Action RSI ? Preparation for RSI Action •Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support • As per General preparation • As per General preparation •Pre-hydrate with Normal Saline 10 mL/kg IV bolus unless APO •Prehydrate with Normal Saline 10 mL/kg IV bolus • P re-oxygenate with high-flow O2 via nasal prongs, 100% O2 via BVM with 5 cm H2O PEEP valve and electronic capnograph attached •If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process •If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with intubation process • Draw up and label drugs as appropriate •Adrenaline not to be given in hypovolaemic shock •Ensure pulse oximeter and cardiac monitor are functional • © Ambulance Victoria 2014 CPG A0302 • Draw up and label drugs as appropriate Prepare equipment and assistance - Suction - ETT (plus one size smaller than predicted immediately available) with introducer - Ensure equipment for difficult or failed intubation is immediately available including bougie, LMA and cricothyroidotomy kit - Mark cricothyroid membrane as necessary - Brief assistant to provide cricoid pressure if required - If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck • Ensure functional and secure IV access ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation CPG A0302 37 Version 6 - 04.06.14 Page 6 of 12 Endotracheal Intubation Drugs Special Notes • In Pts with extremely poor perfusion, Rx with fluid therapy +/- Adrenaline infusion concurrently with IFS or RSI. In NTBI consider quarter doses of sedation for SBP < 80 mmHg. • In Pts with ROSC requiring RSI, adjust Fentanyl dose according to GCS and perfusion status, eg: © Ambulance Victoria 2014 -A ROSC Pt with GCS 3 and SBP 100 mmHg requires a smaller dose than the Pt with GCS 9 and SBP 160 mmHg CPG A0302 General Care Version 6 - 04.06.14 Page 7 of 12 Endotracheal Intubation Drugs Unassisted Endotracheal Intubation CPG A0302 IFS Adjusted sedation dose required Action • Proceed with intubation - no drugs required Half dose sedation required ? • SBP < 100 mmHg or frail/elderly Action • Fentanyl 50 mcg IV • Midazolam 0.05 mg/kg IV (max. 5 mg) Full dose sedation required ? • SBP ≥ 100 mmHg Action • Fentanyl 100 mcg IV • Midazolam 0.1 mg/kg IV (max. 10mg) Do not proceed if Pt C/I for Suxamethonium ? If unable to intubate due to excessive tone Action • Only if Pt is frail or elderly and being intubated for respiratory failure © Ambulance Victoria 2014 -Suxamethonium 1.5 mg/kg IV rounded up to nearest 25 mg (max. 150 mg) ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation CPG A0302 39 Endotracheal Intubation CPG A0302 © Ambulance Victoria 2014 This page intentionally left blank Version 6 - 04-06-14 Page 8 of 12 Endotracheal Intubation Drugs RSI - NTBI RSI - ROSC Adjusted sedation dose required djusted Fentanyl dose required A Commence Mx inadequate perfusion prior to RSI ? Half dose sedation required • SBP < 100 mmHg or frail/elderly RSI - Other Indications Action • If GCS ≥ 10 and suspected airway burns, consult with Alfred Hospital via AV Clinician for: - Ketamine 1.5 mg/kg IV (max. 200 mg) ? Sedation required Action Action • Fentanyl 50 mcg IV • Fentanyl 50 - 200 mcg IV • Midazolam 0.05 mg/kg IV (max. 5 mg) • If SBP < 80 mmHg consider: - Fentanyl 25 mcg IV and - Midazolam 1 mg IV If Fentanyl C/I, use Midazolam 1 - 5 mg IV as required - Midazolam 2.5 mg IV • If GCS < 10 (all other RSI indications) - Ketamine 1.5 mg/kg IV (max. 200 mg) Paralysing agent ? Action ? Full dose sedation required • SBP ≥ 100 mmHg ? Paralysing agent Action Action • Fentanyl 100 mcg IV • If Pt bradycardic at any stage - Atropine 600 mcg IV • Midazolam 0.1 mg/kg IV (max. 10mg) • If Pt bradycardic at any stage - Atropine 600 mcg IV • Suxamethonium 1.5 mg/kg IV round up to nearest 25 mg (max. 150 mg) • Suxamethonium 1.5 mg/kg IV rounded up to nearest 25 mg (max. 150 mg) ? Paralysing agent Action © Ambulance Victoria 2014 CPG A0302 ? Perfusion • If Pt bradycardic at any stage - Atropine 600 mcg IV Action • Suxamethonium 1.5 mg/kg IV rounded up to nearest 25 mg (max. 150 mg) • C ontinue perfusion Mx as per CPG A0202 Cardiac Arrest (ROSC Management) ? Perfusion Action Perfusion ? Action • Continue perfusion Mx as per relevant CPG Adrenaline infusion must not be administered to TBI Pts without consultation with a MTS • If SBP < 120 mmHg despite N/Saline 20 mL/ kg, administer Adrenaline infusion as per CPG A0407 to maintain SBP > 120 mmHg • If SBP > 160 mmHg administer Midazolam 0.1 mg/kg IV with target SBP 120 – 140 mmHg ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation CPG A0302 41 Version 6 - 04.06.14 Page 9 of 12 Endotracheal Intubation Insertion of ETT Insertion of Endotracheal Tube General Care of the Intubated Pt • Observe passage of ETT through cords, noting Australian Standard (AS) markings and grade of view. • Reconfirm tracheal placement using EtCO2 after every Pt movement. Disconnect and hold ETT during all transfers. • Inflate cuff. • Confirm tracheal placement by capnography – note that Pt in cardiac arrest may not have detectable EtCO2 initially. • If electronic capnography fails after intubation, use colourimetric capnometry. • Exclude right main bronchus intubation by auscultation of chest, including comparing air entry at the axillae. • If time permits, insert OG or NG tube, aspirate and connect to drainage bag. The OG route must be used in head or facial trauma. • Auscultate epigastrium to exclude gastric placement. • Note length at lips/teeth. • Note supplemental cues of correct placement, e.g. tube misting, bag movement in the spontaneously ventilating Pt, improved SpO2 and Pt colour. • Suction ETT and oropharynx in all Pts. • Ventilate using 100% O2 and tidal volume of 6-7 mL/ kg. Aim to maintain SpO2 > 95% and EtCO2 at 30 – 35 mmHg except: - Asthma, where a higher EtCO2 may be permitted, • Secure the ETT and insert a bite block if required. • If there is ANY doubt about tracheal placement the ETT must be removed. - TCA OD where the target EtCO2 is 20 – 25 mmHg, and - Hyperglycaemia with a BGL reading of “high”, where the EtCO2 should be maintained at the level detected immediately post intubation with a max of 25 mmHg. • If unable to intubate after ensuring correct technique, proceed to CPG A0303 Failed Intubation Drill. • PEEP © Ambulance Victoria 2014 CPG A0302 - Start with PEEP 5 cm H2O. In the setting of acute lung injury, if SpO2 remains <92% increase PEEP to 10 cm H2O • Document all checks and observations made to confirm correct ETT placement. Version 6 - 04.06.2014 Page 10 of 12 Endotracheal Intubation Insertion of ETT CPG A0302 8 Status Indications ? • Insertion / general care of ETT - Unassisted endotracheal intubation - IFS - RSI Insertion and checks of ETT ? Action •Confirm tracheal placement of ETT with capnography • Length at lips / teeth • Auscultate chest / epigastrium •Check for chest rise and fall, bag movement, SpO2, tube misting and Pt skin colour • Specific insertion instructions as per Insertion of ETT © Ambulance Victoria 2014 If there is ANY doubt about tracheal placement, the ETT must be removed ? Status Stop 8 Assess 8 Consider Action MICA Action General care / ventilation ? Action • ETT checks with each Pt movement • Provide circulatory support if hypotension present • Use colourimetric capnometry if capnograph fails • Suction ETT and oropharynx • Insert OG / NG tube •Ventilate via BVM or mechanical ventilator with PEEP 5-10 cm H2O, VT 6-7 mL/Kg, aiming for EtCO2 30-35 mmHg if appropriate to Pt condition •Monitor for signs of haemodynamic compromise and/or barotrauma that may occur secondary to higher levels of PEEP • Disconnect and hold ETT during transfers •Specific instructions as per General care of the Intubated Pt Endotracheal Intubation CPG A0302 43 Version 1 - 20.09.06Page Page 2 Version 6 - 04.06.2014 111ofof12 © Ambulance Victoria 2014 Xx Endotracheal Intubation Care and Mx of Intubated Pt CPG A0403 A0302 Special Notes General Care •For Pts who become hypotensive after intubation consider additional fluid and/or Adrenaline infusion according to clinical context. If hypotension persists consider reducing the sedation dose while closely monitoring the Pt for signs of under-sedation. •Not all Pts receiving drug facilitated intubation will require paralysis post intubation, e.g. status epilepticus, OD other than TCA. •Some Pts may require paralysis post intubation to control ventilation, e.g. asthma •TBI Pts require paralysis post intubation to prevent gagging and elevation in ICP. This should be administered prior to Suxamethonium wearing off, provided tracheal placement is confirmed and the ETT is secured. •NTBI Pts such as stroke or SAH do not routinely require paralysis post intubation. Only administer Pancuronium when sedation alone cannot maintain intubation. •Where a mechanical ventilator is available, longterm paralysis is indicated to minimise the risk of barotrauma and haemodynamic compromise. •In cases of status epilepticus (where long term paralysis is relatively contraindicated) use manual BVM ventilation instead of mechanical ventilation. • Infusion -Morphine 30 mg + Midazolam 30 mg in 30 mL D5W or N/Saline - 1 mL = 1 mg each drug - 1 mL/hr = 1 mg/hr •Fentanyl 300 mcg + Midazolam 30 mg in 30 mL D5W or N/Saline - 1 mL = 1 mg Midazolam + 10 mcg Fentanyl • Handover -The EtCO2 and respiratory wave-form immediately prior to Pt handover must be demonstrated to the receiving physician and documented on the ePCR. Paralysis is C/I in status epilepticus unless unavoidable for pt safety reasons. It is clinically preferred to use additional doses of Midazolam as required to allow monitoring of seizure activity. Consult with receiving hospital if considering paralysis in a seizing patient. Version Version 6 - 04.06.2014 1 - 20.09.06 Page Page 122ofof12 2 Xx Endotracheal Intubation Care and Mx of Intubated Pt 8 Status Indications ? 8 Consider • Intubated Pt • If Pt requires sedation or sedation and paralysis to maintain intubation and ventilation 8 Post intubation sedation ? Indications Post intubation paralysis 8 ? Indications • Restlessness / signs of under-sedation in the absence of other noxious stimuli - e.g. ETT too deep / irritating, occult pain • Prevention of shivering for Pts receiving therapeutic cooling • Signs of inadequate sedation • Where sedation alone is ineffective at maintaining intubation or allowing adequate ventilation / oxygenation Paralysed Pt - HR and BP trending up together - Lacrimation - Diaphoresis Non paralysed Pt - As per Paralysed - Cough / gag / movement •Morphine / Midazolam infusion 1 - 10 mL/hr IV, OR • Fentanyl / Midazolam infusion1 - 10 mL/hr IV - Administrator 0.5 mL - 5 mL IV boluses as required to maintain sedation © Ambulance Victoria 2014 • As prescribed for interhospital transfer • Reduction of metabolic heat production in hyperthermia Stop - Midazolam 0.5 mg - 5 mg IV as required, or - Midazolam / Morphine 0.5 mg - 5 mg IV each drug 8 Consider Action •The ETT must be secured and tracheal placement confirmed with electronic capnography •Paralysis is C/I for Pts in status epilepticus unless unavoidable for safety reasons ? Sedation and paralysis • Until sedation infusion established: 8 Assess • All Pts receiving paralysis MUST receive ongoing sedation Action Stop • Traumatic brain injury Sedation ? ? Status CPG A0302 A0403 MICA Action Action • Sedate as per Post intubation sedation • Pancuronium 8 mg IV -Repeat if evidence of returning muscular activity e.g. movement, coughing, gagging, chewing or curare cleft Endotracheal Intubation CPG A0302 45 Version 1 - 01.04.02 Page 1 of 1 Failed Intubation Drill CPG A0303 Failed Intubation Indications ? • Unable to see vocal cords during initial laryngoscopy Action • Insert OPA and ventilate with 100% O2 Action • Reattempt intubation using bougie with blind placement of ETT over bougie Yes • Objective confirmation of tracheal placement using EtCO2 Action 8 Consider • Continue Mx in accordance with relevant CPG No Action • Immediately remove ETT, insert OPA / NPA and ventilate with 100% O2 8 Consider Yes • Able to ventilate and oxygenate No Action • Insert LMA Yes Action • Cricothyroidotomy No • Able to ventilate and oxygenate Action © Ambulance Victoria 2014 8 Consider • If sedation / relaxant drugs administered allow these to wear off and Pt to resume normal respiration Version 3 - 01.11.05 Page 1 of 1 Cricothyroidotomy CPG A0304 8 ? Status • Unconscious Pt unable to be oxygenated and ventilated using BVM and OPA, NPA, LMA or ETT where: Stop •Contraindications - There are no C/Is when oxygenation and ventilation cannot occur with other techniques - RSI has been attempted but intubation has not been achieved - RSI is not authorised - Massive facial trauma is present and RSI is considered unsafe due to the inability to undertake the failed intubation drill - RSI is not possible due to lack of IV / IO access - Upper airway obstruction is present due to a pharyngeal or an impacted foreign body which is unable to be removed using manual techniques and Magill's forceps • Perform cricothyroidotomy using approved kit © Ambulance Victoria 2014 - Partial airway obstruction is present and Tx by Air Ambulance is required and expertise for alternative techniques is not available. Action ? Status Stop 8 Assess 8 Consider Action MICA Action Cricothyroidotomy CPG A0304 47 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 49 Version 1 - 20.09.06 Page 1 of 4 Acute Coronary Syndromes Special Notes • ACS is a spectrum of illnesses including: - UA - STEMI -NSTEACS •Not all Pts with ACS will present with pain, e.g. diabetic Pts, atypical presentations, elderly Pts. •The absence of ischaemic signs on the ECG does not exclude AMI. AMI is diagnosed by presenting Hx, serial ECGs and serial blood enzyme tests. •Suspected ACS related pain that has spontaneously resolved warrants investigation in hospital. •The goals of prehospital Mx in ACS are to facilitate timely reperfusion where available and resolve pain completely to reduce cardiac workload. •Pre-hospital thrombolysis management can only be initiated by accredited paramedics in approved regions of Victoria in accordance with CPG A0408 STEMI Management. © Ambulance Victoria 2014 •In patients who may be eligible for thrombolysis, invasive procedures should only be conducted according to clinical need and with the potential for increased bleeding risk in mind. CPG A0401 General Care Version 1 - 20.09.06 Page 2 of 4 Acute Coronary Syndromes CPG A0401 Status ? Consider 8 • ACS • Consider the spectrum of illnesses within ACS - UA - STEMI - NSTEACS ? ACS Mx ? Nausea / vomiting ? LVF ? Inadequate perfusion Action Action Action Action • General Principles of ACS Mx • See CPG A0701 Nausea and vomiting • See CPG A0406 Pulmonary Oedema • See CPG A0407 Inadequate Perfusion •CPG A0408 STEMI Management ? Arrhythmia Mx Action See CPG A0201 VF/VT (pulseless) CPG A0402 Bradycardia CPG A0403 Supraventricular Tachyarrhythmias CPG A0404 Ventricular Tachycardia CPG A0405 Accelerated Idioventricular Rhythm © Ambulance Victoria 2014 • ? Status Stop 8 Assess 8 Consider Action MICA Action Acute Coronary Syndromes CPG A0401 51 Version 1 - 20.09.06 Page 3 of 4 Acute Coronary Syndromes General Mx Principles Special Notes CPG A0401 General Care • GTN is a potent venodilator. It reduces C.O. via reduced venous return. • Signs of an inferior AMI include ST elevation in leads II and III. Bradycardia is not unusual in an inferior AMI due to the involvement of the right coronary artery and the SA and A-V nodes. • Nitrates are C/I in bradycardia (HR < 50 bpm) due to the Pt’s inability to compensate for a decrease in venous return by increasing HR to improve cardiac output. - C.O. = HR X SV © Ambulance Victoria 2014 • Where this CPG refers to GTN S/L, buccal administration can be substituted if required. The use of GTN is C/I in suspected inferior or right ventricular infarcts, as these Pts may not compensate for a drop in venous return. Version 1 - 20.09.06 Page 4 of 4 Acute Coronary Syndromes General Mx Principles Status ? 8 Assess requirement for: • ACS • Pain relief / nitrates CPG A0401 • Control of hypertension • Antiplatelet Rx ? Nitrates ? Antiplatelet Rx ? Pain Relief ✔ Action ✔ Action • • • Aspirin 300 mg oral ✔ Action BP > 110 mmHg - GTN 300 mcg S/L (no prev. admin.) or - GTN 600 mcg S/L If symptoms continue and BP remains > 110 mmHg - Repeat 300 - 600 mcg S/L @ 5/60 • Pain relief as per CPG A0501 Pain Relief - Rx until pain free • BP > 90 mmHg - GTN patch 50 mg (0.4 mg/hr) upper torso / arms - If BP falls < 90 mmHg, remove patch ? Hypertension +/- symptoms ✔ - SBP > 160 mmHg or - DBP > 100 mmHg • Control pain as per CPG A0501 Pain Relief © Ambulance Victoria 2014 • GTN 300 mcg S/L - Repeat 300 mcg @ 5/60 if hypertension persists ? Status Stop 8 Assess 8 Consider Action MICA Action Acute Coronary Syndromes CPG A0401 53 Version 6 - 16.12.10 Page 1 of 2 Bradycardia Special Notes General Care • Atropine is unlikely to be effective in complete heart block, however should still be administered. •Adrenaline Infusion - Adrenaline 3 mg added to make 50 mL with D5W or Normal Saline. • If side effects occur during Adrenaline infusion, cease infusion and recommence once side effects resolve titrating to Pt response. • If no increase in HR, pacing is likely to be required. • Notify appropriate hospital capable of managing a Pt likely to require pacing. • Bradycardia is technically defined as less than 60 bpm. In practical purposes many Pts will have a normal HR between 50 bpm and 60 bpm. Decisions to Rx should consider this and the more likely need to consider 50 bpm as the limiting point for Mx. © Ambulance Victoria 2014 CPG A0402 -1 mL/hr = 1 mcg/min •If no response from Adrenaline infusion @ 20 mcg/min, increasing infusion rate is unlikely to have additional chronotropic effects. Version 6 - 16.12.10 Page 2 of 2 Bradycardia CPG A0402 Assess 8 Status ? • Evidence of bradycardia • Perfusion status • Cardiac rhythm • Heart failure • Ischaemic chest pain ? Stable ? Unstable • Asymptomatic •Less than adequate perfusion • Adequate perfusion • HR > 20 bpm •Profound bradycardia (HR < 40 bpm) and full field APO - including acute STEMI and ischaemic chest pain •Runs of VT or ventricular escape rhythms Action ✔ •HR < 20 bpm • BLS ✔ Action •Rx as per Unstable if Pt deteriorates • Atropine 600 mcg IV -If no response @ 3 - 5/60 repeat 600 mcg (max. 1200 mcg) ? Adequate perfusion achieved ? Inadequate or extremely poor perfusion persists Action ✔ Action •Adrenaline infusion (3 mg/50 mL D5W / Normal Saline) commencing @ 5 mcg/min (5 mL/hr) • Continue current Mx • Tx © Ambulance Victoria 2014 - Increase by 5 mcg/min @ 2/60 until adequate perfusion/side effects (max. 20 mcg/min) - If syringe pump unavailable - Adrenaline 10 mcg IV - Repeat 10 mcg IV @ 2/60 until adequate perfusion / side effects •If poor perfusion persists Rx as per CPG A0407 Inadequate Perfusion Cardiogenic Causes ? Status Stop 8 Assess 8 Consider Action MICA Action Bradycardia CPG A0402 55 Tachyarrhythmias Special Notes © Ambulance Victoria 2014 This CPG contains the recommended joules for biphasic defibrillators used in manual mode. If using a monophasic device please refer to manufacturer instructions. CPG A0403 General Care Version 4 - 20.09.06 Page 1 of 1 Tachyarrhythmias CPG A0403 ? Status • Tachyarrhythmias QRS ≤ 0.12 sec ? • Rate > 100 bpm QRS > 0.12 sec ? • VT > 30 sec • • Rate > 100 bpm Absent or abnormal P waves - SVT (A-V nodal rhythms or AVRT) - AF, atrial flutter - Sinus tachycardia - Atrial tachycardia ? Adequate perfusion Action ? < Adequate perfusion / unstable Action • See CPG A0403 Supraventricular Tachyarrhythmias • See CPG A0403 Supraventricular Tachyarrhythmias • Generally regular • A-V dissociation / absence of P waves ? VT Action • See CPG A0404 Ventricular Tachycardia © Ambulance Victoria 2014 • Wide and bizarre ? Status Stop 8 Assess 8 Consider Action MICA Action Tachyarrhythmias CPG A0403 57 Version 5 – 12.09.12 Page 1 of 2 Supraventricular Tachyarrhythmias Special Notes • Symptomatic S/S - Rate related severe or persistent chest pain. - SOB with crackles. •A Pt eye opening to pain but not to voice commands would also be likely to be making incomprehensible sounds and making purposeful movements in response to pain. i.e. a GCS of 9 (E2, V2, M5). Sedation should be used cautiously in these Pts. • If Pt is unconscious or becomes unconscious at any time during Rx perform immediate synchronised cardioversion. •If the available device does not select 75 J, select nearest option up or down. •The effectiveness of the Pt’s respirations should be continuously monitored. •Atrial flutter and AF should not be treated under this CPG except if the Pt is rapidly deteriorating. •If wide complex QRS or unsure of diagnosis, Rx as for CPG A0404 Ventricular Tachycardia. © Ambulance Victoria 2014 •IV Adenosine should be administered through a large vein closer to the heart such as in the cubital fossa. CPG A0403 General Care • The valsalva manoeuvre is reserved exclusively for Pts with a BP ≥ 100 mmHg. • Where available a 12 lead ECG should be recorded prior to Mx unless the Pt requires immediate Rx. • Perform 3 lead ECG where 12 lead is unavailable. Valsalva instruction • Evidence suggests a greater reversion rate with an abdominal valsalva manoeuvre with the following 3 elements. 1. Position - supine. 2. Pressure - At least 40 mmHg for max. vagal tone. Best achieved with Pt blowing into a 10 mL syringe hard enough to move the plunger to create this pressure. 3. Duration - At least 15 sec if tolerated by Pt. Ref. G. Smith, A. Morgans and M. Boyle Emerg Med J 2009; 26: 8-10. doi: 10.1136 emj.2008.061572 • Expect transient ectopic activity for up to 30 sec. If present, administer O2 therapy until signs resolve. Ongoing arrhythmia should be Mx as per appropriate CPG. • Rx Pt symptomatically in accordance with appropriate CPG and Tx for further assessment and Rx. Version 5 – 12.09.12 Page 2 of 2 Supraventricular Tachyarrhythmias Status ? 8 • SVT (AVNRT or AVRT) • Perfusion status •Unstable – deteriorating rapidly SVT, AF, atrial flutter CPG A0403 Assess • Patient stability •Narrow complex tachycardia Stop • Exclude AF and atrial flutter ? SVT – Stable BP ≥ 100 • Synchronised cardioversion - Sedate Midazolam 2.5mg IV - Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not respond to verbal stimuli but does respond to pain - Cardioversion: DCCS 75 J single shock - If unsuccessful repeat DCCS using 150 J if required • Where available, record 12 Lead ECG prior to commencing Mx • Abdominal valsalva - Repeat x 2 @ 2/60 (Max. 3 attempts) © Ambulance Victoria 2014 Action Action • Where available, record 12 Lead ECG prior to commencing Mx • Adenosine 6 mg IV push If no reversion after 2/60 - Adenosine 12 mg IV push If no reversion after further 2/60 - Adenosine 12 mg IV push ? No reversion Unstable – deteriorating rapidly • Rapidly deteriorating • Altered conscious state • Includes AF, atrial flutter ? SVT - Unstable not rapidly deteriorating BP < 100 Action Reversion ? ? ? Reversion ? No reversion ? Loss of output Action • As per appropriate CPG Action Action Action Action • BLS •Mx as per SVT • BLS •O2 therapy if any ectopic activity is observed – unstable not rapidly deteriorating •O2 therapy if any ectopic activity is observed • Pain relief as per CPG A0501 Pain Relief ? Status Stop 8 Assess 8 Consider Action MICA Action • BLS Supraventricular Tachyarrhythmias CPG A0403 59 Version 6 - 06-09-10 Page 1 of 2 Ventricular Tachycardia (VT) Special Notes General Care • A Pt eye opening to pain but not to voice commands would also be likely to be making incomprehensible sounds and making purposeful movements in response to pain, i.e. a GCS of 9 (E2, V2, M5). Sedation should be used cautiously in these Pts. • ALS crews should considerer MICA R/V vs Tx to appropriate hospital as these Pts are dynamic and have a potential to deteriorate • The effectiveness of the Pt’s respirations should be continuously monitored © Ambulance Victoria 2014 CPG A0404 • Pt presenting symptomatic and poorly perfused is likely to require sync. cardioversion prior to Amiodarone administration. Version 6 - 06-09-10 Page 2 of 2 Ventricular Tachycardia (VT) ? Status CPG A0404 8 Assess • VT • Confirm VT - VT > 30 sec - Mostly regular - QRS > 0.12 sec - Rate > 100 bpm - A-V dissociation / absence of P waves ? Stable: Adequately perfused ? Unstable / Rapidly deteriorating ✔ Action ✔ Action • Amiodarone infusion 5mg/kg IV (max. 300mg) over 20/60 once only • Synchronised cardioversion - Sedate: Midazolam 2.5mg IV - Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not respond to verbal stimuli but does respond to pain - Cardioversion 150 J - If unsuccessful repeat using 150 J if required • Rx as per Unstable if Pt deteriorates Only dilute Amiodarone with D5W o not administer Amiodarone if suspected D TCA OD. Mx as per CPG A0707 Overdose: TCA ? Loss of output ✔ Action © Ambulance Victoria 2014 • As per appropriate CPG ? Reversion ✔ Action • Narrow complex - Amiodarone infusion as above (if not already established) • Other rhythms - Rx as per appropriate CPG ? Status Stop 8 Assess 8 Consider Action MICA Action Ventricular Tachycardia (VT) CPG A0404 61 Version 2 - 01.09.03 Page 1 of 2 Accelerated Idioventricular Rhythm (AIVR) Special Notes • AIVR is usually a benign rhythm but may be associated with AMI, reperfusion or drug toxicity. • Commonly seen in post cardiac arrest Pts. © Ambulance Victoria 2014 • May be associated with Adrenaline administration. General Care CPG A0405 Version 2 - 01.09.03 Page 2 of 2 Accelerated Idioventricular Rhythm (AIVR) ? Status 8 Assess • AIVR • Perfusion status ? < Adequate perfusion ? Adequate perfusion CPG A0405 ? No perfusion ✔ Action ✔ Action • Rx as per CPG A0201 Pulseless Electrical Activity • BLS • Tx ? Ventricular rate 60 - 100 bpm ? Ventricular rate > 100 bpm ✔ Action ✔ Action ✔ Action • Rx as per CPG A0402 Bradycardia •Normal Saline 250 mL IV bolus - Repeat 250 mL IV if perfusion status not improved • Rx as per CPG A0404 Ventricular Tachycardia © Ambulance Victoria 2014 ? Ventricular rate < 60 bpm ? Status Stop 8 Assess 8 Consider Accelerated Idioventricular Rhythm (AIVR) CPG A0405 Action MICA Action 63 Version 4 - 19-11-08 Page 1 of 2 Pulmonary Oedema Special Notes General Care • This CPG is primarily directed at cardiogenic pulmonary oedema, secondary to LVF or CCF. Other medical causes of pulmonary oedema should not be treated under this CPG. • Mx chest pain as per CPG A0401 Acute Coronary Syndromes. • Non-cardiac causes include: smoke inhalation / toxic gases, near drowning (aspiration) and anaphylaxis. In these cases pulmonary oedema is likely a result of altered permeability. These causes should be treated with O2 therapy and assisted ventilations and do not require nitrates. • Pts with pulmonary oedema presenting with a wheeze should only be Mx as per CPG A0601 Asthma if a PHx of bronchospasm can be confirmed. • Where this CPG refers to GTN S/L, buccal administration can be substituted if required. © Ambulance Victoria 2014 CPG A0406 • Frusemide should be used cautiously in the hypotensive Pt. • Avoid the use of Salbutamol in the setting of pulmonary oedema where possible. Version 4 - 19-11-08 Page 2 of 2 Pulmonary Oedema CPG A0406 Assess 8 ? Status • Consider causes: LVF / CCF, nutritional deficiency, liver disease, renal disease, fluid overload • Pulmonary oedema • Respiratory status Short of breath ? ? Not short of breath Action ✔ • BLS ? Full field crackles • If deteriorates, Rx as per SOB ✔ Action • GTN as per Basal / midzone crackles ? Basal / midzone crackles ✔ Action • BP > 110 mmHg - GTN 300 mcg S/L (no prev. admin.) or - GTN 600 mcg S/L - If BP > 110 mmHg and symptoms continue repeat 300 - 600 mcg S/L @ 5/60 • BP > 90 - GTN patch 50 mg (0.4 mg/hr) upper torso/arms • Remove GTN patch if BP decreases < 90 mmHg • Frusemide 20 - 40 mg IV • Frusemide 40 mg IV or Pt’s daily dose IV as a single dose (max. 100 mg) •If alert and anxious - Consider Morphine 1 - 2 mg IV ? No improvement or deteriorates • Suction if required - Provide assisted ventilation with 100% O2 if inadequate VT or RR • CPAP if available • Consider ETT as per CPG A0302 Endotracheal Intubation © Ambulance Victoria 2014 ? No improvement or deteriorates • Rx as for Full field crackles ? Status Stop 8 Assess 8 Consider Action MICA Action Pulmonary Oedema CPG A0406 65 Version 4 - 01.11.05 Page 1 of 2 Inadequate Perfusion Cardiogenic causes Special Notes General Care • Any IV infusions established under this CPG must be clearly labelled with the name and dose of any additive drugs and their dilution. • Adrenaline infusion > 50 mcg/min may be required to Mx these Pts. Ensure delivery system is fully operational (e.g. tube not kinked, IV patent) prior to increasing dose. • A Pt presenting with inadequate to extremely poor perfusion resulting from a cardiac event may not always have associated chest pain, e.g. silent MI, cardiomyopathy. • Pts presenting with suspected PE with inadequate to extremely poor perfusion should be Mx with this CPG. PE is not specifically a cardiac problem but may lead to cardiogenic shock due to an obstruction to venous return and the Pt may require fluid and Adrenaline therapy. © Ambulance Victoria 2014 CPG A0407 • Unstable Pts may require bolus Adrenaline concurrently with the infusion. • Adrenaline infusion - Adrenaline 3 mg added to make 50 mL with D5W or Normal Saline. - 1 mL/hr = 1 mcg/min Version 4 - 01.11.05 Page 2 of 2 Inadequate Perfusion Cardiogenic causes Status ? • Inadequate perfusion: cardiogenic causes • Mx other causes, e.g. arrhythmia, pain, hypovolaemia CPG A0407 Stop Assess 8 • Signs of pulmonary oedema (crackles) ? Crackles No crackles ? Action Action • Adrenaline infusion as per Inadequate or extremely poor perfusion • Normal Saline 250 mL IV -Repeat 250 mL IV if chest clear and inadequate or extremely poor perfusion persists Inadequate or extremely poor perfusion persists ? Action • Adrenaline infusion (3 mg/50mL D5W / Normal Saline) commencing @ 5 mcg/min (5 mL/hr) - Increase by 5 mcg/min @ 2/60 until adequate perfusion/side effects - If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min - If syringe pump unavailable: © Ambulance Victoria 2014 - Adrenaline 10 mcg IV - repeat 10 mcg @ 2/60 until adequate perfusion / side effects -If poor response - Adrenaline 50 - 100 mcg IV as required - NB. Doses > 100 mcg may be required • If chest clear continue Normal Saline 250 mL IV boluses up to 20 mL/kg ? Status Stop 8 Assess 8 Consider Action MICA Action Inadequate Perfusion Cardiogenic causes CPG A0407 67 Version 2 - 04.06.14 Page 1 of 7 STEMI Management Status ? •Confirm STEMI with onset < 6 hours •Symptom onset > 6 hours, notify ARV via the Clinician and Rx as per CPG A0401 Acute Coronary Syndromes CPG A0408 Stop 8 Assess • Inclusion criteria • Exclusion criteria • Precautions Stop •If Pt does not meet inclusion/exclusion criteria, Rx as per Urgent transport •If Pt meets any relative contraindications, consult with ARV prior to thrombolysis as dose may be adjusted (see Special Notes). ? Urgent transport •Symptom onset < 1 hour and PCI or Thrombolysis facility ≤ 30 min •Symptom onset 1-6 hours and PCI facility ≤ 1 hour, or if not available, Thrombolysis facility ≤ 30 min Action •Symptom onset < 1 hour and PCI or Thrombolysis facility > 30 min •Symptom onset 1 – 6 hours and PCI facility > 1 hour and Thrombolysis facility > 30 min Action • No thrombolysis • IV access x 2; Normal Saline TKVO •Refer to CPG A0401 Acute Coronary Syndromes •Analgesia and Aspirin as per CPG A0401 Acute Coronary Syndromes • Tx with hospital notification • Transmit 12 lead ECG to receiving hospital •Notify ARV via Clinician where secondary transfer may be required © Ambulance Victoria 2014 ? Urgent thrombolysis • Complete checklist and gain Pt consent •Enoxaparin 30mg IV followed 15/60 later by Enoxoparin 1 mg/kg SC (SC dose should not exceed 100 mg) • Tenecteplase IV bolus (see table in Special Notes) • Tx with hospital notification •Notify ARV via Clinician where secondary transfer may be required Version 1 - 20.09.06 Version 2 - 04.06.14 Page 2Pag7 of 7 STEMI Management Xx Thrombolysis inclusion criteria Patient MUST have ALL of the following to be considered for Thrombolysis •Symptoms started less than 6 hours ago •12 lead ECG shows ST Elevation ≥ 1mm in two contiguous limb leads (I, II, III, aVR, aVL, AVF) or ST Elevation ≥ 2mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6); or new LBBB pattern •Able to give informed consent Thrombolysis exclusion criteria Thrombolysis exclusion criteria (continued) •Traumatic or prolonged (>10 min) CPR •Acute pericarditis •Subacute bacterial endocarditis •History of CNS damage e.g. neoplasm, aneurysm, spinal surgery •New neurological symptoms •Significant closed head or facial trauma in past 3/12 Relative contraindications If the patient has any of the following risk factors, consult with ARV Coordinator: •Age ≥ 75 years* • Low body weight •Renal impairment • Dementia •History of stroke or TIA • Diabetes •Heart failure • Tachycardia •Pregnancy • Within 1/52 post-partum •Anaemia • Advanced liver disease • Blood pressure between 160 – 180 mmHg systolic • History of bleeding or known prolonged INR • Peripheral vascular disease • Administration of Enoxaparin 48 hours prior • Recent invasive procedures associated with bleeding such as femoral artery puncture, right heart catheterisation *If thrombolysis proceeds following consultation, note altered dose regimen for patients ≥75 years in special notes © Ambulance Victoria 2014 Patient CANNOT be given Thrombolysis if ANY of the following exclusion criteria apply: •Blood pressure: Systolic >180 mmHg; or Diastolic ≥110 mmHg •Known allergy or hypersensitivity to Tenecteplase or Gentamicin •Anticoagulant therapy e.g. Warfarin, Heparin, Dabigatran, Rivaroxaban, Apixaban •Glycoprotein IIb/IIIa inhibitors e.g. Abciximab, Eptifibatide, Tirofiban •Active bleeding or bleeding tendency (excluding menses) •GI bleeding within last 1/12 •Active peptic ulcer •Acute pancreatitis •Suspected aortic dissection •Non compressible vascular puncture •Recent major surgery (< 3/52) CPG A0408 A0403 ? Status Stop 8 Assess 8 Consider Action MICA Action STEMI Management CPG A0408 69 Version 2 - 04.06.14 Page 3 of 7 STEMI Management STEMI management care objective: Deliver timely and safe clinical and systems care which aim to restore coronary reperfusion. Patient destination •Following pre-hospital thrombolysis, Tx Pt to the closest emergency department, or if the Pt is stable, transport to a PCI centre where travel time is no greater than 90 minutes. •Where a Pt is Tx to the local emergency department or urgent care centre, notify ARV via the Clinician as soon as possible to ensure optimal opportunity to coordinate secondary transfer for potential PCI. •ARV is available to coordinate destination services, cardiology advice, and direct admissions to cardiology units on behalf of treating Paramedics. Special Notes •Thrombolysis considerations are complex, especially where precautions exist or physiological parameters are deranged. In these cases and where there are any clinical concern, consult with the ARV Co-ordinator via the Clinician. © Ambulance Victoria 2014 •Close monitoring is required in thrombolysis aftercare. This includes: frequent vital signs; serial ECGs; and monitoring of obvious and obscure sites of potential bleeding e.g. cannulation sites, PR, GI and mucous membranes (oral and conjunctival). CPG A0408 •Hypertensive patients can be reassessed following nitrate therapy and pain Mx as per CPG A0401 Acute Coronary Syndromes. If blood pressure subsequently falls within the relative contraindication criteria range (160 - 180 mmHg systolic), eligibility may be reassessed. •STEMI patients who have: failed thrombolysis; or who suffer complications; or who have pain onset > 6 hrs, should be managed symptomatically as per the relevant CPGs. Urgent ARV consult via the Clinician is also indicated to facilitate cardiology services. •A paraphrase of the consent statement is not permissible. The full statement must be read to every patient and signed where thrombolysis is indicated. Version 2 - 04.06.14 Page 4 of 7 STEMI Management CPG A0408 Tenecteplase body weight based dose table < 60 kg IV 30 mg - 6000 units (6 mL) 60 - 69 kg IV 35 mg - 7000 units (7 mL) 70 - 79 kg IV 40 mg - 8000 units (8 mL) 80 - 89 kg IV 45 mg - 9000 units (9 mL) ≥ 90 kg IV 50 mg - 10,000 units (10 mL) Age adjusted doses © Ambulance Victoria 2014 - Following consultation for patients ≥ 75 years - Tenecteplase dose should be halved - IV Enoxaparin should be omitted and only 0.75 mg/kg SC with a maximum of 75 mg SC Enoxaparin administered ? Status Stop 8 Assess 8 Consider Action MICA Action STEMI Management CPG A0408 71 Version 2 - 04.06.14 Page 5 of 7 STEMI Management – Additional resources CPG A0408 Ambulance VictoriaPre-Hospital Pre-Hospital Thrombolysis Thrombolysis Checklist Ambulance Victoria Check List This checklist and consent must be completed for all patients diagnosed with STEMI (NB. If the patient is excluded from thrombolysis, consent for medical record access is still required.) Exclusion Criteria Checklist Patient CANNOT be given Thrombolysis if ANY of the following exclusion criteria apply YES NO YES NO Is the patient’s Blood Pressure >180 mmHg systolic, or ≥110 mmHg diastolic? Is the patient allergic to Tenecteplase or Gentamicin? Is the patient currently being treated with any of the following anticoagulants: Warfarin, Heparin, Dabigatran, Rivaroxaban, Apixaban? Is the patient currently being treated with Glycoprotein IIb/IIIa inhibitors e.g. Abciximab, Eptifibatide, Tirofiban? Does the patient have any active bleeding or a bleeding tendency (excluding menses)? Has the patient had a GI bleed within the last month? Does the patient have a known active peptic ulcer? Does the patient have acute pancreatitis? Does the patient display any signs or symptoms of a suspected aortic dissection? Does the patient have a non-compressible vascular puncture? Has the patient undergone any recent major surgery (< 3/52)? In this presentation, has the patient received traumatic or prolonged (> 10 min) CPR? Does the patient have acute pericarditis? Does the patient have subacute bacterial endocarditis? Does the patient have a history of CNS damage (e.g. neoplasm, aneurysm, spinal surgery)? Does the patient display any new neurological symptoms such as decreased GCS, slurred speech, limb weakness, or severe headache? Has the patient experienced a significant closed head or facial trauma in past 3 months? If the patient answered “yes” to ANY Exclusion Criteria, do not give Thrombolysis Inclusion Criteria Checklist Patient can ONLY be given Thrombolysis if ALL of the following inclusion criteria apply Did the symptoms start less than 6 hours ago? Does the 12 Lead ECG show ST Elevation ≥ 1 mm in two contiguous limb leads (I, II, III, aVR, aVL, AVF) or ST Elevation ≥ 2 mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6); or a new LBBB? Is the patient able to give informed consent? If the patient answered “no” to ANY Inclusion Criteria, do not give Thrombolysis © Ambulance Victoria 2014 I, (service number) I have completed the above checklist Signature Date / Time AV Case number Version 2 - 04.06.14 Page 6 of 7 STEMI Management – Additional resources CPG A0408 Consent for Procedure This consent statement must be read to all patients, then signed prior to thrombolysis management “It is likely that you are having a heart attack and the best treatment available to you right now is a clot-dissolving drug called Tenecteplase. The sooner you receive this medication, the lower the risks of severe heart damage. Treatment at this stage saves the lives of about 1 in every 25 patients treated, however, these medications can cause serious side effects in a small minority of patients including serious bleeding. The biggest risk is stroke which affects about 1 patient in every 100 treated. Some patients also have allergic reactions and other effects that do not usually cause any major problems. The level of risk does vary from person to person depending on individual factors including past and current health issues, but the risks attached to this treatment are very much less than the likely benefit. Would you like me to give you the medication or have you decided not to have the medication but receive all other usual care?” I, Signature hereby consent to thrombolysis treatment. Date / Time Witness Consent for Medical Record Access We wish to follow your progress for quality improvement purposes and therefore request your permission to access your hospital record for information relating to this procedure. We may also contact you. Your information will be kept strictly confidential. I, hereby consent to Ambulance Victoria accessing my hospital record for information relating to this procedure and I agree to be contacted. I understand that I can withdraw this permission at any time. Date / Time Witness © Ambulance Victoria 2014 Signature ? Status Stop 8 Assess 8 Consider Action MICA Action STEMI Management CPG A0408 73 Version 2 - 04.06.14 Page 7 of 7 STEMI Management – References References Armstrong, PW, Gershlick, AH, Goldstein, P, Wilcox, R, Danays, T, Lambert, Y, Sulimov, V, Rosell Ortiz, F, Ostojic, M, Welsh, RC, Carvalho, AC, Nanas, J, Arntz, H-R, Halvorsen, S, Huber, K, Grajek, S, Fresco, C, Bluhmki, E, Regelin, A, Vandenberghe, K, Bogaerts, K & Van de Werf, F. 2013, Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction. New England Journal of Medicine, Vol. 368, no. 15, pp. 137987 Chew DP, Aroney CN,, Aylward PE, Kelly AM, White HD, Tideman PA, Waddell J, Azadi L, Wilson AJ & Ruta LAM. 2011; Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes (ACS) 2006. Heart, Lung and Circulation; 20:487-502. Naidoo R & Castle N. Prehospital thrombolysis: It’s all about time. In Lakshmanadoss U (2012) Novel strategies in ischemic heart disease, InTech, Durban. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand 2006. National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia, 2006;184, S1-S30. Taskforce on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van ‘t Hof A, Widimsky P & Zahger D. 2012. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. Vol 33, pp. 2569–2619 © Ambulance Victoria 2014 Drug notes information sourced from Australian Medicines Handbook and MIMS Online. CPG A0408 © Ambulance Victoria 2014 This page intentionally left blank 75 Version 8 - 04.06.14 Page 1 of 4 Pain Relief CPG A0501 Special Notes Special Notes • The preferred choice for non IV therapy is IN Fentanyl. • ALS Paramedics must consult prior to exceeding the 20 mg max. dose of Morphine and administer according to Pt need or the onset of adverse side effects. • The administration of Methoxyflurane and IN Fentanyl should not routinely occur in the same Pt. • The max. dose of Methoxyflurane is 6 mL per 24 hr period. • Be cautious of administering Fentanyl and Morphine to the same Pt. • If respiratory depression occurs due to opioid administration Mx as per CPG A0707 Overdose. • Headache should be Mx as per this CPG – Severe headache. • The effect of Morphine IM on pain relief is slow and variable. This route must be used as a last resort and strictly within indicated CPGs. • Opioid pain relief should not be administered during late second stage of labour. If opioids have been administered, Naloxone should not be administered to the newborn. Fentanyl IN preparation All adult doses must be prepared from 600 mcg/2 mL in a 1 mL syringe © Ambulance Victoria 2014 All doses include 0.1 mL to account for atomiser dead space — Doses have been rounded to the nearest 0.05 mL. All other adults Elderly or frail or weight ≤ 60 kg Initial dose 200 mcg 100 mcg Volume 0.75 mL 0.45 mL Subsequent dose 50 mcg 50 mcg Volume 0.25 mL 0.25 mL Subsequent dose 25 mcg 25 mcg Volume 0.2 mL 0.2 mL To administer Fentanyl, draw up desired vol according to dose table for the corresponding weight and age then atomise into Pt’s nostril. The max. amount to be atomised into any nostril is 1 mL. In some instances it may be appropriate to administer half of the vol into each nostril as optimal absorption occurs with volumes of 0.3 - 0.5 mL. This is also dependent on Pt compliance. Version 8 - 04.06.14 Page 2 of 4 Pain Relief CPG A0501 ? Status 8 Assess • Complaint of pain • Pain score > 2 • Determine requirement for IV vs non IV therapy ? Non IV therapy ? IV therapy • Pain likely to be controlled by non IV therapy or • Pain may require IV opioid and ongoing therapy • Unable to obtain IV Action Action If • If elderly or frail or weight ≤ 60kg: Fentanyl 100mcg IN -Repeat up to 50 mcg IN @ 5/60 titrated to pain or side effects (max. dose 200mcg) • All other adults: Fentanyl 200 mcg IN -Repeat up to 50 mcg IN @ 5/60 titrated to pain or side effects (max. dose 400mcg) If unable to administer IN Fentanyl • Methoxyflurane 3 mL - Repeat 3 mL if required (max. 6 mL) If pain not controlled by above Rx as per IV therapy • Morphine up to 5 mg IV -Repeat Morphine up to 5 mg IV @ 5/60 (max. 20 mg) titrated to pain or side effects • Unable to obtain IV access -> 60 kg : Morphine 10 mg IM -Repeat Morphine 5 mg IM after 15/60 (once only) if required - ≤ 60 kg : Morphine 0.1 mg/kg IM - Single dose only - consult for further dose • Morphine as above - no max. dose • If allergic or sensitive to Morphine - Fentanyl 25 - 50 mcg IV - Repeat Fentanyl 25 - 50 mcg IV @ 5/60 titrated to pain or side effects (max. 200 mcg) © Ambulance Victoria 2014 • Fentanyl as above - no max. dose ? Nausea Action • Rx as per CPG A0701 Nausea and Vomiting ? Status Stop 8 Assess 8 Consider Action MICA Action Pain Relief CPG A0501 77 Version 8 - 04.06.14 Page 3 of 4 Pain Relief Severe Headache Special Notes General Care • Non steroidal anti-inflammatory medications, as well as paracetamol and ibuprofen, in mild to moderate headache is acceptable for Pt self administration. • Many Pts who suffer migraines may already have a preset Rx plan in place. Most Pts will seek emergency care when such Rx has failed. Paramedics do not administer Aspirin for headache. • Opioids are of limited benefit in the Rx of migraine. Morphine may not be effective and may be associated with delayed recovery on occasions. It should only be used to Rx severe prolonged diagnosed headache where other measures have failed and where Tx to the treating facility is prolonged. © Ambulance Victoria 2014 CPG A0501 • Sudden onset severe headache, sometimes referred to as 'thunderclap' or 'worst in life', should prompt concern for serious intracranial pathology. Particular attention should be given to Pts whose headache intensity increases within secs to a min of onset. Other warning signs that may be suggestive of serious intracranial event include: - Abnormal neurological finding or atypical aura • Prochlorperazine is indicated for headache considered or diagnosed to be migraine irrespective of nausea and vomiting. - N ew onset headache in elderly Pts or those with a Hx of cancer - Altered level of consciousness or collapse • Paramedics do not diagnose headache. The term migraine may be used mistakenly to describe a severe headache. Headache Mx is usually dependant upon a diagnosis and tailored accordingly. Prehospital Mx seeks to provide interim relief until a more appropriate diagnosis and Mx can be provided. - Seizure activity - Fever and/or neck stiffness. • Prochlorperazine is unlikely to offer any clinical benefit for intracranial haemorrhage or SAH. It may be omitted in this case. Many such Pts will have signs of CNS depression in which case Prochlorperazine should not be administered. • Metoclopramide and Prochlorperazine should not be administered to the same Pt due to the increased risk of extrapyramidal reactions. • Metoclopramide may also be effective in the Mx of headache. Prochlorperazine is the preferred option for severe headache. • The Mx of severe dehydration where indicated may be of assistance in the Mx of severe headache. Version 8 - 04.06.14 Page 4 of 4 Pain Relief Severe Headache ? Status CPG A0501 Assess 8 • Severe headache: Pain score > 7 • Suspected cerebral bleed • Potential meningeal infection Stop If uncertain, Mx as suspected intracranial bleed as per CPG A0711 Suspected Stroke or TIA ? Severe Headache Action • Mx seizures as per CPG A0703 Continuous Seizures • If suspected meningococcal infection Mx as per CPG A0706 Meningococcal Septicaemia • In the first instance consider Mx all headache type and severity: - Methoxyflurane 3 mL - If effective, repeat 3 mL if required (max. 6 mL) - Prochlorperazine 12.5 mg IM •If after 15 min of above therapy and Pt still c/o severe pain (>7) and destination hospital remains > 15 min - Morphine 2.5 mg IV @ 5/60 titrated to pain or side effects (max. dose 20 mg) - Aim is to reduce pain to < 7 - If allergic or sensitive to Morphine administer Fentanyl 25 mcg IV @ 5/60 titrated to pain or side effects (max. dose 200 mcg) © Ambulance Victoria 2014 • If unable to obtain IV Access • If elderly or frail or weight ≤ 60 kg: Fentanyl 50 mcg IN - Repeat up to 25 mcg IN @ 5/60 titrated to pain or side effects (max. dose 100 mcg) • All other adults: Fentanyl 100 mcg IN ? Status Stop 8 Assess - Repeat up to 25 mcg IN @ 5/60 titrated to pain or side effects (max. dose 200 mcg) 8 Consider Action MICA Action Pain Relief CPG A0501 79 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 81 Version 16 - 20.09.06 04.06.14 Page 1 of 26 Xx Asthma CPG A0403 A0601 Status ? 8 Assess • Respiratory distress • Severity of asthma presentation Stop •This CPG should be read in conjunction with CPG A0001 Oxygen Therapy Conscious ? Mild / moderate / severe Unconscious / Becoming ? unconscious with poor / no ventilation Action Action • See CPG A0601 • See CPG A0601 No cardiac output ? Action • Loses C.O. See CPG A0601 © Ambulance Victoria 2014 • PEA as per CPG A0201 Cardiac Arrest Version 6 - 04.06.14 Page 2 of 6 Asthma CPG A0601 Special Notes General Care • Asthmatic Pts are dynamic and can show initial improvement with Rx then deteriorate rapidly. • Adrenaline infusion • Consider MICA support but do not delay Tx waiting for backup. • Despite hypoxaemia being a late sign of deterioration, pulse oximetry should be used throughout Pt contact (if available). - A drenaline 3 mg added to make 50 mL with D5W or Normal Saline - 1 mcg/min = 1 mL/hr - Dose: 2 - 15 mcg/min • An improvement in SpO2 may not be a sign of improvement in clinical condition. © Ambulance Victoria 2014 • Beware of Pt presenting with wheeze associated with heart failure and no asthma / COPD Hx. Asthma CPG A0601 83 Version 6 - 04.06.14 Page 3 of 6 Asthma CPG A0601 Status ? 8 Assess • Respiratory distress • Severity of distress • If Pt’s asthma Mx plan has been activated ? Mild or moderate ? Severe Action Action • Salbutamol pMDI and spacer - Deliver 4 - 12 doses @ 20/60 until resolution of symptoms - Pt to take 4 breaths for each dose •Salbutamol 10 mg (5 mL) and Ipratropium Bromide 500 mcg (2 mL) Nebulised -Repeat Salbutamol 5 mg (2.5 mL) Nebulised @ 5/60 if required • If pMDI spacer unavailable - Salbutamol 10 mg (5 mL) Nebulised -Repeat 5 mg (2.5 mL) Nebulised @ 5/60 if required • Dexamethasone 8 mg IV © Ambulance Victoria 2014 ? Inadequate response ? Adequate Response ? No Significant Response after 20/60 Action Action •Tx with continued reassessment • Rx as per Severe • No response to nebulised therapy • Speaking single words or acute life threat Action If unaccredited in IV Adrenaline therapy • Adrenaline 500 mcg IM (1 : 1,000) -Repeat 500 mcg IM @ 5 -10/60 (max. 1.5 mg) If no response to IM Adrenaline or Pt has inadequate ventilation • Adrenaline infusion IV 2 - 15 mcg/min (2 - 15 mL/hr) Version 6 - 04.06.14 Page 4 of 6 Asthma CPG A0601 Status ? • Unconscious / becomes unconscious - with poor or no ventilation but still with C.O. Pt requires immediate assisted ventilation 8 Action •Ventilate VT 6 - 7 mL/kg @ 5 - 8 ventilations/min • Moderately high respiratory pressures • Allow for prolonged expiratory phase Adequate response ? ? Inadequate response Action Action • Rx as per Severe respiratory distress • Rx as per Severe respiratory distress • Consider ETT as per CPG A0302 Endotracheal Intubation If Pt loses C.O. at any stage, see CPG A0601 © Ambulance Victoria 2014 ? Status Stop 8 Assess 8 Consider Action MICA Action Asthma CPG A0601 85 Version 6 - 04.06.14 Page 5 of 6 © Ambulance Victoria 2014 Asthma CPG A0601 Special Notes General Care • High EtCO2 levels should be anticipated in the intubated asthmatic patient and are considered safe. • TPT is very unlikely in the spontaneously ventilating Pt or Pts receiving IPPV via BVM. • Despite EtCO2 levels, Rx should not be adjusted and managing ventilation should be conscious of the effect of gas trapping when attempting to reduce EtCO2. • TPT may occur as a result of forceful IPPV via ETT. • Due to high intrathoracic pressure as a result of gas trapping, venous return is compromised and the patient may lose cardiac output. Apnoea allows the gas trapping to decrease. • Exclusion of bilateral TPT by chest decompression should only be considered if all the following criteria are present: • If there are clear signs of unilateral TPT then decompression of the affected side is indicated. 1. IPPV via ETT 2. Sudden loss of cardiac output 3. Rhythm = PEA 4. Nil response to 1 minute of apnoea + IV Adrenaline Version 6 - 04.06.14 Page 6 of 6 Asthma CPG A0601 ? Status • Pt loses C.O. -especially during assisted ventilation and bag becomes stiff Pt requires immediate intervention Action • Apnoea 1 min - Prepare for potential resuscitation ? Cardiac output returns Action ? Carotid pulse, no BP Action ? No return of output Action • Rx as per CPG A0601 • Adrenaline 50 mcg IV - Repeat 50 - 100 mcg IV @1/60 as required • Mx as per appropriate CPG A0201 Cardiac Arrest © Ambulance Victoria 2014 • Normal Saline 20 mL/kg IV ? Status Stop 8 Assess 8 Consider Action MICA Action Asthma CPG A0601 87 Version 1 - 04.06.14 Page 1 of 2 COPD Chronic Obstructive Pulmonary Disease Special Notes Special Notes COPD should be suspected in any Pt over 40 years old who has: Indications for CPAP • Smoking Hx (or ex-smoker) • Dyspnoea that is progressive, persistent and worse with exercise • Chronic cough • Chronic sputum production • Family Hx of COPD Exacerbation of pre-existing COPD can be defined as the following: © Ambulance Victoria 2014 • SpO2 of < 90% on room air (or < 95% on supplemental O2) Indications for the removal of prehospital CPAP •Ineffective - Cardiac / respiratory arrest - Mask intolerance / Pt agitation - Nil improvement after 1 hour of treatment •Vital Signs • Increased dyspnoea - HR <50 or SBP <90 mmHg • Increased cough - Loss of consciousness or GCS < 13 • Increased sputum production - Decreasing SpO2 • Complete removal of wheeze in these Pts may not be possible due to chronic airway disease CPG A0602 •Active risk to Pt - Loss of airway - Copious secretions - Active vomiting - Paramedic judgement of clinical deterioration Version 1 - 04.06.14 Page 2 of 2 COPD Chronic Obstructive Pulmonary Disease CPG A0602 Status ? • Exacerbation of COPD ? All exacerbation of COPD Action • Irrespective of severity - Salbutamol 10 mg + Ipratropium Bromide 500 mcg Nebulised • Dexamethasone 8 mg IV ? Adequate response ? Inadequate response after 10/60 Action Action • Titrate O2 flow to target SpO2 88 – 92% • If continuing severe respiratory distress and RR > 24 • Consider low flow O2 e.g. nasal prongs - CPAP (commence with 7.5 cm H2O) -Increase CPAP to 10 cm H2O @ 5 – 10/60 if no improvement in Pt condition - Reassess for signs of deteriorating respiratory status or ventilation failure ? Patient deteriorates Action • Provide assisted ventilation with 100% O2 if inadequate VT or RR © Ambulance Victoria 2014 • Consider ETT as per CPG A0302 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider Action MICA Action COPD Chronic Obstructive Pulmonary Disease CPG A0602 89 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 91 Version 2 - 16.12.10 Page 1 of 2 Nausea and Vomiting CPG A0701 Special Notes General Care • Prochlorperazine must only be administered via the IM route. • If there are no C/Is and the IV route is unobtainable with a long Tx time, then administer Metoclopramide IM. • If nausea and vomiting is being tolerated, basic care and Tx is the only required Rx. © Ambulance Victoria 2014 • Take care with Metoclopramide polyamp as it is similar to Ipratroprium Bromide and Atropine polyamps in appearance. Version 2 - 16.12.10 Page 2 of 2 Nausea and Vomiting CPG A0701 ? Status 8 Assess for: • Actual or potential for nausea and vomiting • Nausea and vomiting or • Potential spinal injury / eye trauma or • Potential motion sickness or • Vertigo Stop • Prochlorperazine must not be given IV •Metoclopramide and Prochlorperazine should not be administered in the same episode of Pt care without consultation ? Nausea and vomiting associated with: ? Prophylaxis for: - Cardiac chest pain - Iatrogenic secondary to opioid analgesia - Previous diagnosed migraine - Secondary to cytotoxic drugs or radiotherapy - Severe gastroenteritis Action • Metoclopramide 10 mg IV / IM - Repeat 10 mg IV / IM after 10/60 if symptoms persist (max. 20 mg) © Ambulance Victoria 2014 • If known allergy or C/I to Metoclopramide - Prochlorperazine 12.5 mg IM - Potential for motion sickness - Planned aeromedical evacuation ✔ Action • Prochlorperazine 12.5 mg IM ? Prophylaxis for: •Awake Pt (GCS 13 – 15) with potential spinal injuries who is immobilised on the stretcher • Eye trauma - e.g. penetrating eye injury, hyphema Action • Metoclopramide 10 mg IV / IM - Repeat 10 mg IV / IM after 10/60 if symptoms persist (max. 20 mg) ? Dehydrated ✔ Action • Mx as per CPG A0801 Hypovolaemia ? Status Stop 8 Assess 8 Consider Action MICA Action Nausea and Vomiting CPG A0701 93 Version 4 - 19.11.08 Page 1 of 2 Hypoglycaemia CPG A0702 Special Notes General Care • Pt may be aggressive during Mx. • If next meal is more than 20/60 away, encourage Pt to eat a long acting carbohydrate (e.g. sandwich, fruit, glass of milk) to sustain BGL until next meal. • Ensure IV is patent before administering Dextrose. Extravasation of Dextrose can cause tissue necrosis. • All IVs should be well flushed before and after Dextrose administration (minimum 10 mL Normal Saline). • Ensure sufficient advice on further Mx and follow-up if Pt refuses Tx. • If the Pt refuses Tx, repeat the advice for Tx using friend / relative assistance. If Pt still refuses Tx, document the refusal and leave Pt with a responsible third person and advise the third person of actions to take if symptoms recur and of the need to make early contact with LMO for follow up. • If inadequate response Tx without undue delay. • Maintain general care of unconscious Pt and ensure adequate airway and ventilation. • Further dose of Dextrose 10% may be required in some hypoglycaemic episodes. Consider consultation if BGL remains less than 4 mmol/L and unable to administer oral carbohydrates. © Ambulance Victoria 2014 • Continue initial Mx and Tx. Version 4 - 19.11.08 Page 2 of 2 Hypoglycaemia CPG A0702 Status ? • Evidence of probable hypoglycaemia - e.g. Hx diabetes, unconscious, pale, diaphoretic 8 Assess • BGL BGL > 4 mmol/L ? ? BGL < 4 mmol/L Responds to commands BGL < 4 mmol/L Does not respond to commands ? ✔ Action Action ✔ Action • Glucose 15 g oral • BLS • IV cannula in a large vein • Consider other causes of altered conscious state - e.g. stroke, seizure, hypovolaemia Adequate response ? • Confirm IV patency • Dextrose 10% 15 g (150 mL) IV - Normal Saline 10 mL flush • If unable to insert IV – Glucagon 1 IU IM ? Poor response ✔ Action ✔ Action • Consider Dextrose IV or Glucagon 1 IU IM © Ambulance Victoria 2014 • Consider Tx ? Status Stop 8 Assess 8 Consider Action MICA Action Adequate response ? - GCS 15 ? Inadequate response - GCS < 15 after 3/60 ✔ Action ✔ Action •Cease administration of IV Dextrose •Repeat Dextrose 10% 10g (100 mL) IV titrating to Pt conscious state - Normal Saline 10 mL flush Hypoglycaemia CPG A0702 95 Version 4 - 04.06.14 Page 1 of 2 Seizures Special Notes General Care • For the purposes of this CPG, Status Epilepticus (SE) refers to either ≥ 5/60 of continuous seizure activity OR multiple seizures without full recovery of consciousness (i.e. back to baseline) between seizures. • Ensure accurate dose calculation and confirm with other Paramedics on scene. • Generalised Convulsive Status Epilepticus (GCSE) is characterised by generalised tonic-clonic movements of the extremities with altered conscious state. • Subtle Status Epilepticus may develop from prolonged or uncontrolled GCSE and is characterised by coma and ongoing electrographical seizure activity with or without subtle convulsive movements (e.g. rhythmic muscle twitches or tonic eye deviation). Subtle SE is difficult to diagnose in the pre-hospital environment but should be considered in Pts who are witnessed to have generalised tonic-clonic convulsions initially and present with ongoing coma and no improvement in conscious state (with or without subtle convulsive movements). • Frequent errors in drug dosage administration occur within AV in this CPG. • Midazolam can have pronounced effects on BP, conscious state, ventilations and airway tone. • Calculate the dose each time as stock strength may change with manufacturer and familiarity may lead to errors. Seizures in Pregnancy • Consider eclampsia in pregnant Pts with no prior seizure history or have been diagnosed with pre-eclampsia. - Refer to CPG O0202 Pre-eclampsia / Eclampsia • For seizures other than GCSE, Midazolam may only be administered following consultation via the Clinician. - E clamptic seizures are rare (0.1% of all births) and usually self-limiting • Some Pts may be prescribed buccal / intranasal midazolam or rectal diazepam to manage seizures. • Midazolam crosses the placenta and administration in pregnant Pts may cause adverse effects to the baby. However GCSE is life-threatening to both mother and baby and Midazolam is therefore still indicated in this situation. • If a single seizure has spontaneously terminated continue with initial Mx and Tx. © Ambulance Victoria 2014 CPG A0703 • If Pt has a PHx of seizures and refuses Tx, they may be left in the care of a responsible third party. Advise the person of the actions to take for immediate continuing care if symptoms recur, and the importance of early contact with their primary care physician for follow-up. • Contact Paediatric Infant Perinatal Emergency Retrieval (PIPER) for advice via Clinician or on 1300 137 650. Version 4 - 04.06.14 Page 2 of 2 Seizures CPG A0703 Status ? Assess • Seizure activity •Evidence of Status Epilepticus (≥ 5/60 or ≥ 2 seizures without recovery) - GCSE or other SE (including subtle SE) •Consider other causes e.g. hypoglycaemia, hypoxia, head trauma, stroke / ICH, electrolyte disturbance, meningitis • Consider Pt’s own Mx plan and Rx already given ? Seizure activity ceased / Other SE / Subtle SE ? Generalised Convulsive SE Action Action • Monitor airway, ventilation, conscious state and BP • Mx airway and ventilation as required • If subtle SE suspected, consider time-critical Tx and consult for Midazolam • If airway patent, administer high-flow O2 as per CPG A0001 Oxygen Therapy • Midazolam 10 mg IM ? Seizure activity ceases Action • BLS © Ambulance Victoria 2014 • C ontinue to monitor airway, ventilation, conscious state and BP ? Seizure activity continues > 5/60 ? Seizure activity continues >10/60 ✔ Action • Midazolam 2 mg IV - Repeat Midazolam 2 mg IV @ 2 - 5/60 as required -Max. 6 mg IV (in addition to IM) ✔ Action • Consult for further doses • Consider ETT as per CPG A0302 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider - No IV access/no accreditation • Repeat Midazolam 10 mg IM once only • Consult for further doses •Continue to monitor airway, ventilation, conscious state and BP Pancuronium C/I unless unavoidable Action MICA Action Continuous Tonic-clonic Seizures CPG A0703 97 © Ambulance Victoria 2014 This page intentionally left blank Version 6 - 04.06.14 Page 1 of 3 Anaphylaxis Special Notes General Care • Signs of allergy include a range of cutaneous manifestations and/or a history of allergen exposure. This history can include food, bites/stings, medications or the allergen can be unknown. • Anaphylaxis can be difficult to identify. Cutaneous features are common though not mandatory. Irrespective of known allergen exposure, if 2 or more systemic manifestations are observed then anaphylaxis should be accepted. • Deaths from anaphylaxis are far more likely to be associated with delay in management rather than due to inadvertent administration of Adrenaline. • All Pts with suspected anaphylaxis must be advised that they should be transported to hospital regardless of the severity of their presentation or response to management. International guidelines recommend at least 4 hours of observation following treatment. • Different brands of self-administered adrenaline autoinjectors will deliver different doses of adrenaline. In the absence of Paramedic intervention, an auto-injector is an appropriate treatment. • Inhaled therapy may be of benefit in management of anaphylaxis though should always be secondary therapy. Salbutamol may be of use for persistent bronchospasm and Nebulised Adrenaline may be of use for persistent upper airway oedema and stridor. • Where poor perfusion persists despite initial Adrenaline therapy, large volumes of fluid may be extravasating. IV fluid therapy is indicated to support vasopressor administration. Preparation of Adrenaline infusion (syringe pump): - Adrenaline 3 mg added to make 50 mL with 5% Dextrose or Normal Saline 1 mL = 60 mcg 1 mL/hr = 1 mcg/min • In rare circumstances anaphylaxis can occur with symptoms in an isolated body system. If a Pt has hypotension following exposure to a known allergen for them consider treating as per anaphylaxis. • International guidelines recommend IM administration of Adrenaline to the anterolateral mid-thigh as the preferred site due to improved absorption. Whilst remaining alert to patient comfort and dignity issues, the mid-lateral thigh should be considered the preferred site of administration where possible. • IV Adrenaline should be reserved for the Pt who is extremely poorly perfused or facing impending cardiac arrest. • IV Adrenaline should be subsequent to IM Adrenaline in all cases with an initial IM therapy option selected for each anaphylaxis Pt regardless of presentation. • IV Adrenaline should preferably be administered via a syringe pump infusion where possible. © Ambulance Victoria 2014 CPG A0704 • For Pts persistently unresponsive to Adrenaline (especially if taking beta blocking medication) the administration of Glucagon 1-2 IU IM or IV can be considered under medical consultation. Glucagon administration must not delay further Adrenaline administration. Key reference: Simons FE, Ardusso L, Bilo M, Dimov V, Ebisawa M, El-Gamal Y, Ledford D, Lockey R, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong Y, and Worm M, “2012 Update: World Allergy Organisation Guidelines for the Assessment and Management of Anaphylaxis”, Current Opinion in Allergy and Clinical Immunology, 2012, 12:389-399 Anaphylaxis CPG A0704 99 Version 6 - 04.06.14 Page 2 of 3 Anaphylaxis ? Status CPG A0704 Stop • Suspected anaphylaxis • If Pt has Hx of anaphylaxis and has received Mx prior to arrival they MUST be Tx to hospital for observation and follow up 8 Assess • Sudden onset of illness (min to hrs) AND • Two or more of R.A.S.H. with or without confirmed antigen exposure: - R Respiratory distress (SOB, wheeze, cough, stridor) - A Abdominal symptoms (nausea, vomiting, diarrhoea, abdominal pain/cramps) - S Skin/mucosal symptoms (hives, welts, itch, flushing, angioedema, swollen lips/tongue) - H Hypotension (or altered conscious state) OR © Ambulance Victoria 2014 • Isolated hypotension (SBP < 90 mmHg) following exposure to known antigen ? No anaphylaxis ? Anaphylaxis / Severe allergic reaction Action Action • BLS • Monitor cardiac rhythm • Reassess for potential deterioration • Adrenaline 500 mcg IM (1:1,000) - Repeat 500 mcg IM @ 5/60 until satisfactory results or side effects occur - Small (≤60 kg), frail or elderly adults should be administered Adrenaline 300 mcg IM instead • Consider Tx for observation and further Mx ? Refusal of Transport • Provide O2 as per CPG A0001 Oxygen Therapy If Pt has had a possible anaphylactic reaction (irrespective of severity) then they should be offered Tx. If they refuse Tx then where possible they should be: • Advised of the risk and consequences of deterioration • Mx respiratory distress as indicated - Rx bronchospasm as per CPG A0601 Asthma - Consider nebulised Adrenaline for upper airway oedema as per CPG P0601 Upper Airway Obstruction • Left with a responsible third party • Consider fluid as per CPG A0801 Hypovolaemia • Given clear instructions on when to call back if required • Dexamethasone 8 mg IV • Advised to follow up with their LMO ? Irrespective of symptom resolution ? Inadequate Response Action • Extremely poor perfusion and/or • Tx • Impending cardiac arrest Action If • Reassess en route © Ambulance Victoria 2014 • Monitor for recurring symptoms • A drenaline as per CPG A0705 Inadequate Perfusion (Non-cardiogenic / Non-hypovolaemic) • Consider intubation • If intubated with no IV/IO access - Adrenaline 200 mcg via ETT @ 5/60 ? Status Stop 8 Assess 8 Consider Action MICA Action Anaphylaxis CPG A0704 101 Version 4 - 16-12-10 Page 1 of 2 Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic Special Notes General Care • Any infusions established under this CPG must be clearly labelled with the name and dose of any additive drugs and their dilution. • Adrenaline infusion > 50 mcg/min may be required to Mx these Pts. Ensure delivery system is fully operational (e.g. tube not kinked, IV patent) prior to increasing dose. • Sepsis criteria are relevant in the presence of an infection or severe clinical insult such as multi trauma leading to systemic inflammatory response syndrome (SIRS). 2 or more of: - Temp > 38ºC or < 36ºC - HR > 90 bpm - RR > 20/min - BP < 90 mmHg © Ambulance Victoria 2014 CPG A0705 • Unstable Pts may require bolus Adrenaline concurrently with the infusion. • Adrenaline infusion Adrenaline 3 mg added to make 50 mL with 5% Dextrose or Normal Saline 1 mL/hr = 1 mcg/min • If sepsis is suspected and prolonged Tx times exist (>1 hr) consider Ceftriaxone 1g IV (consult). Version 4 - 16-12-10 Page 2 of 2 Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic Status ? Assess 8 • Suspected sepsis • Perfusion status • Other causes of non-cardiogenic, non-hypovolaemic shock • Respiratory status CPG A0705 • Sepsis criteria • Other possible causes ? Inadequate or extremely poor perfusion Action •If sepsis is suspected and chest is clear and MICA is not immediately available: - Confirm request for MICA support - Normal Saline up to 20 mL/kg IV over 30 min • Normal Saline up to 20 mL/kg IV ? Adequate perfusion ? Inadequate or extremely poor perfusion persists Action Action • BLS • Adrenaline infusion (3 mg in 50 mL D5W/Normal Saline) commencing @ 5 mcg/min (5 mL/hr) • Tx - Increase by 5 mcg/min @ 2/60 until adequate perfusion or side effects © Ambulance Victoria 2014 - If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min - If syringe pump unavailable - Adrenaline 10 mcg IV - repeat 10 mcg @ 2/60 until adequate perfusion or side effects -If poor response - Adrenaline 50 - 100 mcg IV as required - Doses > 100 mcg may be required • If chest clear, continue Normal Saline 20 mL/kg IV boluses as per CPG A0801 Hypovolaemia Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A0705 ? Status Stop 8 Assess 8 Consider Action MICA Action 103 Version 3 - 01.11.05 Page 1 of 2 Meningococcal Septicaemia Special Notes General Care • Meningococcal septicaemia is transmitted by close personal exposure to airway secretions / droplets. Ceftriaxone preparation • Ensure face mask protection especially during intubation / suctioning. • Ensure medical follow up for staff post exposure. © Ambulance Victoria 2014 CPG A0706 •Dilute Ceftriaxone 1 g with 9.5 mL of Water for Injection and administer 1 g IV over approximately 2/60. • If unable to obtain IV access, or not accredited in IV cannulation, dilute Ceftriaxone 1 g with 3.5 mL 1% Lignocaine HCL and administer 1 g IM into the upper lateral thigh or other large muscle mass. Version 3 - 01.011.05 Page 2 of 2 Meningococcal Septicaemia CPG A0706 Status ? • Suspected meningococcal septicaemia PPE Confirm meningococcal septicaemia 8 • Typical purpuric rash • Septicaemia signs - Fever, rigor, joint and muscle pain - Cold hands and feet - Tachycardia, hypotension - Tachypnoea • Meningeal signs - Headache, photophobia, neck stiffness - Nausea and vomiting - Altered conscious state IV access ? ? No IV access Action © Ambulance Victoria 2014 • Ceftriaxone 1 g IV - Dilute with Water for Injection to make 10 mL - Administer slowly over 2/60 Action •If inadequate perfusion Rx as per CPG A0705 Inadequate Perfusion ? Status Stop 8 Assess 8 Consider Action - Unable to gain - Not IV accredited MICA Action • Ceftriaxone 1 g IM -Dilute with 3.5 mL 1% Lignocaine HCL to make 4 mL -Administer into upper lateral thigh or other large muscle mass Meningococcal Septicaemia CPG A0706 105 Version 2 - 20.09.06 Page 1 of 8 Overdose CPG A0707 General Care Special Notes •Provide supportive care (all cases) • If Pt still refuses Tx, after repeating the advice for Tx using friend / relative assistance, advise the Pt and responsible third person of follow-up, counselling facilities and actions to take for continuing care if symptoms recur. - Provide appropriate airway Mx and ventilatory support - If Pt is in an altered conscious state, assess BGL and if necessary Mx as per CPG A0801 Hypoglycaemia - If Pt is bradycardic with poor perfusion Mx as per CPG A0402 Bradycardia - If Pt is inadequately perfused, Mx as per appropriate CPG. - Assess Pt temp and Mx as per CPG A0901 Hypothermia / Cold Exposure, or CPG A0902 Environmental Hyperthermia / Heat Stress •Confirm clinical evidence of substance use or exposure - Identify which substance/s are involved and collect any packets if possible. - Identify by which route the substance/s have been taken (e.g. ingestion). - Establish the time the substance/s were taken. • For young persons, Paramedics should strongly encourage them to make contact with a responsible adult. • Paramedics should call the Police if, in their professional judgement, there appear to be factors that place the young Pt at increased risk, such as the Pt: -is subject to violence (e.g. from a parent, guardian or care giver) - is likely to be, or is in danger of sexual exploitation. In particular for children where: -the supply of drugs appears to be from a parent / guardian / care giver. -there is other evidence of child abuse / maltreatment or evidence of serious untreated injuries. • If the Pt claims to have taken an OD of a potentially life-threatening substance or as a suicide attempt then they must be Tx to hospital. Police assistance should be sought to facilitate this as required. • Documentation of refusal and actions taken must be recorded on the PCR. - Establish the amount of substance/s taken. © Ambulance Victoria 2014 - Establish what the substance/s were mixed with when taken (e.g. alcohol, water). - Establish if any Rx has been initiated prior to Ambulance arrival (e.g. induced vomiting). When dealing with cases of OD, if Paramedics are unfamiliar with a substance or unsure of the effects it may have, then consultation with Poisons Information should take place. They can be contacted via the Clinician, or on 13 11 26. Version 2 - 20.09.06 Page 2 of 8 Overdose CPG A0707 Status ? 8 Assess • Suspected OD • Substance/s involved Opioids ? TCA Antidepressants ? Sedatives ? Psychostimulants ? e.g. - - - - Heroin Morphine Codeine Other opioid preparations e.g. - Amitriptyline - Nortriptyline - Dothiepin e.g. - - - - e.g. - - - - Stop 8 Assess Cocaine Amphetamines Ecstacy PCP © Ambulance Victoria 2014 GHB Alcohol Benzodiazepines Volatile agents ? Status 8 Consider Action MICA Action Overdose CPG A0707 107 Version 2 - 20.09.06 Page 3 of 8 Overdose: Opioids CPG A0707 Special Notes General Care • Opioids may be in the form of IV preparations such as Heroin or Morphine and oral preparations such as Codeine, Endone, MS Contin. Some of these drugs also come as suppositories and topical patches. •If inadequate response after 10/60, the Pt is likely to require Tx without delay. • Not all opioid ODs are from IV administration of the drug. -Maintain general care of the unconscious Pt and ensure adequate airway and ventilation. -Consider other causes e.g. head injury, hypoglycaemia, polypharmaceutical OD. © Ambulance Victoria 2014 -Beware of Pt becoming aggressive. Version 2 - 20.09.06 Page 4 of 8 Overdose: Opioids CPG A0707 ? Status • Possible opioid OD Stop • Ensure personal / crew safety • Scene may have concealed syringes Assess evidence of opioid OD 8 - Altered conscious state - Respiratory depression - Substance involved - Exclude other causes (inc. no obvious head injury) - Pin point pupils - Track marks ? Opioid OD Action • Assist and maintain airway / ventilation • Naloxone 1.6 mg – 2 mg IM © Ambulance Victoria 2014 ? Adequate response ? Inadequate response after 10/60 Action Action • BLS • Naloxone 0.8 mg IM • Consider Tx • Consider airway Mx CPG A0301 Laryngeal Mask • Naloxone 0.8 mg IM/IV • Consider ETT as per CPG A0302 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: Opioids CPG A0707 109 Version 2 - 20.09.06 Page 5 of 8 Overdose: Tricyclic Antidepressants (TCA) CPG A0707 Special Notes Special Notes Signs and symptoms of TCA toxicity ECG changes • Mild to moderate OD - Drowsiness, confusion - Tachycardia - Slurred speech - Hyperreflexia - Ataxia - Mild hypertension - Dry mucus membranes - Respiratory depression ECG changes include prolonged PR, QRS and QT intervals associated with an increased risk of seizures if QRS > 0.10 sec and ventricular arrhythmias if QRS > 0.16 sec. How to measure a QT interval is shown below. • Severe toxicity (within 6 hr ingestion) - Coma - Respiratory depression / hypoventilation - Conduction delays - PVCs - SVT - VT - Hypotension - Seizures - ECG changes This could lead to aspiration, hyperthermia, rhabdomyolysis and APO. © Ambulance Victoria 2014 TCAs may be prescribed to Rx medical conditions other than depression (e.g. chronic pain). Version 2 - 20.09.06 Page 6 of 8 Overdose: Tricyclic Antidepressants (TCA) ? Status CPG A0707 Assess 8 • Possible TCA OD • Substance involved • Perfusion status • ECG criteria ? No toxicity ? Signs of TCA toxicity Action • BLS • Consider potential to develop signs of toxicity Any of the following - Less than adequate perfusion - QRS > 0.12 sec (> 0.16 sec indicates severe toxicity) - QT prolongation (> 1/2 R-R interval) Stop •Amiodarone is C/I in the setting of confirmed or suspected TCA OD Action • Sodium Bicarbonate 8.4% 100 mL IV given over 3/60 -Repeat 100 mL IV after 10/60 if signs of toxicity persist -Consult for further doses if signs of toxicity persist © Ambulance Victoria 2014 • Consider ETT as per CPG A0302 Endotracheal Intubation if signs of toxicity and GCS < 10 persist after initial Mx - Hyperventilate with 100% O2 - rate 20 - 24/min - EtCO2 target 20 - 25 mmHg if intubated ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: Tricyclic Antidepressants (TCA) CPG A0707 111 Version 2 - 20.09.06 Page 7 of 8 Overdose: Sedative Agents / Psychostimulants Special Notes • Hyperthermic psychostimulant OD © Ambulance Victoria 2014 In hyperthermic psychostimulant OD the trigger point for intervention in the Mx of agitation / aggression is lowered. Sedation should be initiated early to assist with cooling and avoid further increases in temp associated with agitation. CPG A0707 Version 2 - 20.09.06 Page 8 of 8 Overdose: Sedative Agents / Psychostimulants ? Status CPG A0707 Assess 8 • Sedative agents • Substance involved • Psychostimulants Stop •Ensure personal / crew safety Be aware of the potential for agitation / aggression / violence ? Sedative agents ? Psychostimulants Action Action • Pt may require airway Mx • Reduce stimuli by calming and controlling the Pt's environment • Mx agitation / aggression as per CPG A0708 •Mx seizures as per CPG A0703 Seizures The Agitated Patient •Mx cardiac chest pain as per CPG A0401 Acute Coronary Syndromes •Mx inadequate perfusion as per CPG A0705 • Mx temp as per CPG A0902 Hyperthermia / Inadequate Perfusion Heat Stress or A0901 Hypothermia / Cold exposure © Ambulance Victoria 2014 •Mx agitation / aggression as per CPG A0708 The Agitated Patient ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: Sedative Agents/Psychostimulants CPG A0707 113 © Ambulance Victoria 2014 This page intentionally left blank Version 3 - 04.06.14 Page 1 of 3 The Agitated Patient Special Notes General Care • This CPG applies to Pts who present with agitation or aggressive/violent behaviour. It may be used for those who are designated as Compulsory Patients under the Mental Health Act 2014; and also those who are in Police custody under Section 351 of the Mental Health Act 2014 (previously known as Section 10). • Paramedic safety is to be considered paramount at all times. Do not attempt any element of this CPG unless all necessary assistance is available. Hyperthermic psychostimulant OD • Sedation should be initiated early in hyperthermic Pts who have been using psychostimulants to assist with cooling and avoid further increases in temp secondary to agitation. Traumatic head injury • Bodily restraint using restraint straps may be used without the use of sedation in circumstances where the Pt will not sustain further harm by fighting against the restraints. • Restraint straps must be removed if there is any evidence of compromised Pt care. • The indications for the use of restraints, type of restraint and the time of application and removal must be recorded on the PCR. • In Pts with mild to moderate acute traumatic head injury (GCS 10 – 14), sedation can only be given after consultation with the Clinician. • In all cases where sedation is administered, supportive care should be provided as required including: Elderly / Frail Patients - Supplementary O2 as per CPG A0001 Oxygen Therapy • Elderly and/or frail Pts are particularly sensitive to the effects of benzodiazepines (including Midazolam). Aim to use the lowest dose possible and carefully monitor for side effects. • Elderly Pts can present with delirium, which is an acute and reversible change in cognitive function and distinct from dementia. Consider and exclude clinical causes as per CPG. © Ambulance Victoria 2014 CPG A0708 - Airway Mx - Perfusion Mx as per CPG A0705 Inadequate Perfusion (Non-cardiogenic / Non-hypovolaemic) - Temperature Mx as per CPG A0901 Hypothermia / Cold Exposure or CPG A0902 Environmental Hyperthermia / Heat Stress - Reassessment and Mx of clinical causes of agitation • The indications for the use of sedation must be clearly documented on the PCR. The Agitated Patient CPG A0708 115 Version 3 - 04.06.14 Page 2 of 3 The Agitated Patient Status ? CPG A0708 Stop • Agitated Pt • Observe for and Mx as appropriate - Hazards - Body fluids - Violence - Sharps - Clear egress - Reduce stimuli • Paramedic safety is paramount ? Agitated Pt ✔ Action • - Communicate with Pt Avoid confrontational behaviour Gain Pt co-operation for assessment Utilise verbal de-escalation strategies © Ambulance Victoria 2014 Assess / consider 8 • Assess and Mx clinical causes (as far as possible) - A Alcohol / drug intoxication - E Epilepsy (post-ictal) - I Insulin or other metabolic cause – hypo / hyperglycaemia, renal / liver failure - O Overdose / Oxygen (hypoxia) - U Underdose (including alcohol / drug withdrawal) - T Trauma (head trauma) Consult with Clinician prior to sedation - I Infection / sepsis - P Pain / Psychiatric condition - S Stroke / TIA • Also consider grief or extreme stress • There may be a combination of factors Able to Mx without restraint / sedation ? ✔ Action Requires restraint / sedation ? • Does not respond to verbal de-escalation • Mx causes as per appropriate CPG • Clinical causes have been excluded •Beware Pt condition may change and agitation increase requiring restraint / sedation • Pt risk to themselves or others - e.g. combative, agitated or aggressive Stop • Ensure sufficient physical assistance •Mild to moderate head injury GCS 10 - 14 (Mx pain, consult if sedation required) Action ✔ • Midazolam 5 - 10 mg IM - Use lower doses (2.5 - 5 mg IM) for elderly, frail, weight ≤ 60 kg, BP ≤ 100 mmHg or alcohol / drug involvement - If necessary, repeat @ 10/60 titrated to Pt response - Max. total dose 20 mg. Consult for further doses • Monitor airway, ventilation, conscious state and BP ✔ Action • Tx to appropriate destination • Apply restraint straps as required • Ensure sufficient assistance in transit • Midazolam 2.5 - 5 mg IV - Use lower doses (1 - 2 mg IV) for elderly, frail, weight ≤ 60 kg, BP ≤ 100 mmHg or alcohol / drug involvement - If necessary, repeat @ 5/60 titrated to Pt response • Provide early notification to receiving hospital © Ambulance Victoria 2014 •Consider Rx as per Requires restraint / sedation if Pt becomes agitated / aggressive - Max. total dose 30mg (IM + IV). Consult for further doses • IM injections may be indicated until IV access has been established ? Status Stop 8 Assess 8 Consider Action MICA Action The Agitated Patient CPG A0708 117 Version 4 - 01.11.05 Page 1 of 2 Organophosphate Poisoning Special Notes General Care •Notification to receiving hospital essential to allow for Pt isolation and decontamination. • Where possible, remove contaminated clothing and wash skin thoroughly with soap and water. • The key word to look for on the label is anticholinesterase. There are a vast number of organophosphates which are used not only commercially but also domestically. • If possible minimise the number of staff exposed. • Given potential contamination by a possible organophosphate, the container identifying trade and generic names should be identified and the Poisons Information Centre contacted for confirmation and advice (via Clinician or 13 11 26). © Ambulance Victoria 2014 CPG A0709 • Attempt to minimise transfers between vehicles. Version 4 - 01.11.05 Page 2 of 2 Organophosphate Poisoning CPG A0709 ? Status • Possible organophosphate exposure Stop • Avoid self contamination - wear PPE • Decontaminate Pt if possible 8 Confirm evidence of suspected poisoning • Cholinergic effects: salivation, bronchospasm, sweating, nausea or bradycardia • The key word to look for on the label is anticholinesterase + AND ? No excessive cholinergic effects Action 8 Evidence of excessive cholinergic effects • Salivation compromising the airway or bronchospasm and /or • Bradycardia with inadequate or extremely poor perfusion ? Excessive cholinergic effects Action • Tx to nearest appropriate hospital • Monitor for excessive cholinergic effects • Atropine 1200 mcg IV - Repeat 1200 mcg IV @ 5/60 until excessive cholinergic effects resolve • Consult with receiving hospital for further Mx if required © Ambulance Victoria 2014 •The use of Suxamethonium is C/I in Pts with suspected organophosphate poisoning ? Status Stop 8 Assess 8 Consider Action MICA Action Organophosphate Poisoning CPG A0709 119 Version 2 - 01.11.05 Page 1 of 2 Autonomic Dysreflexia Special Notes © Ambulance Victoria 2014 • Tx the Pt even if the symptoms are relieved as this presentation meets the criteria of autonomic dysreflexia, a medical emergency that requires identification of probable cause and Rx in hospital to prevent cerebrovascular catastrophe. CPG A0710 General Care Version 2 - 01.11.05 Page 2 of 2 Autonomic Dysreflexia CPG A0710 ? Status Confirm Autonomic Dysreflexia 8 • Possible autonomic dysreflexia • Previous spinal cord injury at T6 or above - Severe headache and/or - SBP > 160 mmHg Identify and Rx possible causes - remove the stimulus • If distended bladder (common), ensure indwelling catheter is not kinked • Mx pain, e.g. fractures, burns, labour ? If systolic BP remains > 160 mmHg Action • GTN 300 mcg S/L (no prev. admin) or GTN 600 mcg S/L ? Adequate response ? Inadequate response - BP remains > 160 mmHg Action Action • Tx to nearest appropriate hospital • Repeat initial dose of GTN @ 10/60 until either: - Symptoms resolve - Onset of side effects - BP < 160 mmHg © Ambulance Victoria 2014 • Tx to nearest appropriate hospital ? Status Stop 8 Assess 8 Consider Action MICA Action Autonomic Dysreflexia CPG A0710 121 Version 1 - 16.06.11 Page 1 of 2 © Ambulance Victoria 2014 Stroke / TIA CPG A0711 Special Notes General Care • Suspected stroke is a time critical emergency – early assessment and exclusion of stroke mimics is important • Symptom onset time is taken from when last seen symptom free (e.g. if wakes with symptoms then time Pt went to bed). • Rx times from symptom onset are: - thrombolysis – up to 4.5 hrs • Diagnosing and Mx stroke Pts with thrombolysis is a priority over seeking neurosurgical support. • Urgent secondary transfer of stroke Pts to a centre with Stroke Unit Care may be organised and involve the Clinician / AAV / ARV. • TIA can only be suspected if S/S completely resolve, otherwise Pt should be treated as a suspected stroke. • TIA is often a sign of an impending stroke – all TIAs should be conveyed to hospital for investigation. • Approximately 15% of strokes are intracranial haemorrhage (ICH). These Pts have potential for rapid deterioration. • Intracranial haemorrhage can be suspected where: - GCS < 10 and the Pt is not alert - The Pt complained of severe headache - Nausea and vomiting is present - Slow pulse and hypertension is noted - Pupil abnormalities are noted - Abnormal patterns of respiration are noted • MASS – Melbourne Ambulance Stroke Screen. Validated criteria used in prehospital stroke assessment. • Intubation by MICA Paramedics should be considered where there is difficulty maintaining adequate airway, oxygenation and ventilation. Intubation should not be considered as a mandatory practice in Mx of all these Pts. Time to hospital versus time to undertake the procedure should be considered. • Gagging should be avoided in the Mx of the non traumatic intracranial event Pt. The effect of gagging may vary in its detriment compared to the traumatic head injured Pt. • The use of longer acting muscle relaxants post intubation is not as essential in the suspected stroke Pt as it is with head trauma. Sedation alone is preferred unless gagging becomes problematic. They should not be used following evidence of seizure activity without significant head injury. • Anti-emetics have the potential to cause drowsiness. Their use must be balanced against a potential reduction in conscious state in these Pts. The use of Prochlorperazine is indicated as an analgesia adjunct for the Mx of severe headache. It is unlikely to have a beneficial effect for intracranial haemorrhage/SAH. • O2 therapy should be reserved for hypoxic Pts with an SpO2 < 94%. The use of routine O2 therapy is not recommended. Version 1 - 16.06.11 Page 2 of 2 Stroke / TIA CPG A0711 Status ? 8 Assess 8 Stroke Mimics • Suspected stroke or TIA •Symptom onset •Intoxication drug/ time alcohol 8 Co-morbidities • Middle ear disorder • Dementia • Migraine •Significant pre-existing • Stroke mimics • Hypo/hyperglycaemia • Subdural haematoma • Co-morbidities • Seizures • Sepsis • Brain tumour •Electrolyte • Syncope Action Action •In the setting of normal BGL, a finding of one or more of the •Provide analgesia as per CPG A0501 Pain Relief: Severe Headache ? Stroke signs and symptoms © Ambulance Victoria 2014 •BLS – maintain adequate airway and ventilation •Mx symptomatically – support affected limbs symptoms below is indicative of stroke: •Rx sustained seizure activity as per CPG A0703 Continuous Tonic – 8 Facial Droop Pt shows teeth or smiles Normal - both sides of face move equally Abnormal - one side of face does not move as well as the other Speech Normal - the Pt says the correct words, no slurring Abnormal - the Pt slurs words, says the wrong words, or is unable to speak or understand The Pt repeats “You can’t teach an old dog new tricks” disturbances ? Management ? Assess for MASS criteria Assessment findings ✔ 8 physical disability Hand grip Test as for GCS Normal - equal Abnormal - unilateral grip weakness Blood glucose Test for BGL Abnormal -if Normal BGL hypoglycemia Mx as per CPG A0702 Hypoglycemia clonic Seizures • If GCS < 10 consider ETT as per CPG A0302 Endotracheal Intubation ? Transport Action •Where Pt is unstable consider time to appropriate receiving hospital versus R/V with MICA / AAV. •If Pt is stable with no significant co-morbidities, onset time < 4.5 hr and Tx time < 1 hr – then transfer to the nearest hospital providing thrombolysis or stroke unit care and notify of pending arrival. •If Pt does not meet criteria above – then Tx to a closer centre preferably with stroke unit care / CT imaging. •If Pt deteriorates consider R/V with MICA / AAV ? Status Stop 8 Assess 8 Consider Action MICA Action Stroke / TIA CPG A0711 123 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 125 Version 6 - 16-12-10 Page 1 of 2 Hypovolaemia Special Notes •Titrate fluid administration to Pt response. •Aim for HR < 100 bpm and BP > 100 mmHg if perfusion is altered. •Consider establishing IV en route. Do not delay Tx for IV therapy. •Always consider TPT, particularly in the Pt with a chest injury not responding to fluid therapy and persistently hypotensive. CPG A0801 General Care •Haemorrhage from blunt trauma is not considered as ‘uncontrolled’ in the context of this CPG and should be Mx as defined within. •GI bleeding has potential to be ‘uncontrolled’ in the context of this CPG and should be considered as a modifying factor. •Excessive fluid should not be given if SCI is an isolated injury. •Clinical signs of significant dehydration include: - P ostural perfusion changes including tachycardia, hypotension or dizziness - Decreased sweating and urination - Poor skin turgor, dry mouth, dry tongue - Fatigue and altered consciousness - Evidence of poor fluid intake compared to fluid loss. •Dehydration in the hyperglycaemic Pt should be Mx using this CPG. © Ambulance Victoria 2014 Modifying factors • Complete spinal cord transection Rx as per CPG A0804 Spinal Injury - Pt with isolated neurogenic shock can be given up to Normal Saline 500 mL bolus to correct hypotension. No further fluid should be given if SCI is the sole injury. • Chest injury – Consider TPT Rx as per CPG A0802 Chest Injury • Penetrating trunk Injury, aortic aneurysm or uncontrolled haemorrhage. - Accept palpable carotid pulse and Tx immediately • GI haemorrhage – consider lesser volumes of fluid and accepting a blood pressure of 80 – 100 mmHg. Version 6 - 16-12-10 Page 2 of 2 Hypovolaemia CPG A0801 Status ? • Evidence of hypovolaemia • Identify and Mx - Haemorrhage, fractures, pain, TPT, hypoxia Stop 8 Assess • HR / BP • Consider modifying factors - SCI, chest injury, penetrating trunk injury, AAA, uncontrolled external haemorrhage, GI haemorrhage ? HR < 100 bpm; BP > 100 mmHg ? Isolated tachycardia ? Hypotension Action • HR > 100 bpm; BP > 100 mmHg • < 100 mmHg • F luid not required unless signs of significant dehydration Action Action • Normal Saline 20 mL/kg IV • Normal Saline 20 mL/kg IV ? If significantly dehydrated Action © Ambulance Victoria 2014 • N ormal Saline up to 20 mL/kg IV over 30 min ? HR > 100 bpm and/or BP < 100 mmHg ? HR < 100 bpm BP > 100 mmHg Action Action • Repeat Normal Saline 20 mL/kg ? HR < 100 bpm BP > 100 mmHg ? HR > 100 bpm and/or BP < 100 mmHg Action Action • No further fluid required • Insert second IV • No further fluid required • Repeat Normal Saline 20 mL/kg ? BP remains < 100 mmHg • After 40 mL/kg ? BP remains < 100 mmHg • After 40 mL/kg Action • Consult with MTS Action • Consult with MTS • If unavailable repeat Normal Saline 20 mL/kg IV • If unavailable repeat Normal Saline 20 mL/kg IV ? Status Stop 8 Assess 8 Consider Action MICA Action Hypovolaemia CPG A0801 127 Chest Injuries CPG A0802 © Ambulance Victoria 2014 This page intentionally left blank Version 4 - 01.11.05 Page 1 of 3 Chest Injuries CPG A0802 ? Status 8 Assess • • Respiratory status Chest injury - Traumatic - Spontaneous - Iatrogenic • Type of chest injury Action • Supplemental O2 if indicated • Pain relief as per CPG A0501 Pain Relief •Position Pt upright if possible unless perfusion is < adequate, altered conscious state, associated barotrauma or potential spinal injury ? Flail segment / rib fractures ? Open chest wound ? Pneumothorax Action Action • Signs of pneumothorax • May require ventilatory support if decreased VT • 3 sided sterile occlusive dressing Action © Ambulance Victoria 2014 • See CPG A0802 ? Status Stop 8 Assess 8 Consider Action MICA Action Chest Injuries CPG A0802 129 Version 4 - 01.11.05 Page 2 of 3 Chest Injuries CPG A0802 Special Notes General Care • In the setting of IPPV, equal air entry is NOT an exclusion criterion for TPT. • Tension Pneumothorax (TPT) - If some clinical signs of TPT are present and the Pt is deteriorating with decreasing conscious state and/ or poor perfusion, immediately decompress chest by inserting a long 14g cannula or intercostal catheter. • Chest injury Pts receiving IPPV have a high risk of developing a TPT. The solution for poor perfusion in this setting includes bilateral chest decompression. • Cardiac arrest Pts are at risk of developing chest injury during CPR. • Troubleshooting -Pt may re-tension as lung inflates if catheter kinks off. -Catheter may also clot off. Flush with sterile Normal Saline. • If a 14g cannula is used initially, it should be replaced with an intercostal catheter (if available) as soon as practicable. • Insertion site for cannula/intercostal catheter -Second intercostal space -Mid - clavicular line (avoiding medial placement) -Above rib below (avoiding neurovascular bundle) -Right angles to chest (towards body of vertebrae). - If air escapes, or air and blood bubble through the cannula / intercostal catheter, or no air / blood detected, leave in situ and secure. - If no air escapes but copious blood flows through the cannula / intercostal catheter then a major haemothorax is present. Remove, then cover the insertion site. • Needle test - If TPT suspected, but the assessment is not obvious, test for a TPT with a needle at least 45mm length (long 14/16 G) attached to Normal Saline filled syringe. - If needle test is suggestive of TPT, withdraw needle and immediately decompress chest. - If pneumocath not available, leave plastic cannula in situ refer to appropriate CWI. © Ambulance Victoria 2013 - If needle test is not suggestive of TPT, withdraw needle, cover insertion site with a clear adhesive dressing and circle the insertion site with a pen. - Be aware that a needle test for TPT can be prone to false readings and does not exclude TPT in all cases. Version 4 - 01.11.05 Page 3 of 3 Chest Injuries CPG A0802 Status ? Assess 8 • Pneumothorax - Simple - Tension • Criteria for simple vs tension pneumothorax ? Simple pneumothorax ? TPT • Any of the following: - Unequal breath sounds in spontaneously ventilating Pt - Low SpO2 on room air - Subcutaneous emphysema • Action • Continue BLS and supplemental O2 Action •Chest decompression as per General care (including accredited rural ALS) © Ambulance Victoria 2014 • Monitor closely for possible development of TPT Any of the following +/- signs of Simple pneumothorax: - Peak inspiratory pressure (ventilator) / stiff bag - EtCO2 - Poor perfusion or HR +/- BP - JVP - Conscious state in the awake Pt - Tracheal shift - Low SpO2 on supplemental O2 (late) ? Status Stop 8 Assess 8 Consider Action MICA Action Chest Injuries CPG A0802 131 Version 4 - 16-12-10 Page 1 of 2 Traumatic Head Injury Special Notes General Care •The Trauma Time Critical Guidelines require Pts with significant blunt trauma to a single region to be triaged to the highest level of care. • Dress open skull fractures / wounds with sterile combine soaked in sterile Normal Saline. • When assessing the pattern of injury, the Pt can be considered to have a significant blunt head injury in the setting of blunt head trauma with or without loss of consciousness / amnesia and GCS 13 - 15 with any of: - Any loss of consciousness exceeding 5/60. - Skull fracture (depressed, open or base of skull). - Vomiting more than once. - Neurological deficit. - Seizure. •Elderly Pts with standing height falls who meet no other time critical criteria but are on anti-coagulant, antiplatelet agents or have bleeding disorders should not be underestimated. Tx to an appropriate level of care. © Ambulance Victoria 2014 CPG A0803 • Maintain manual in-line neck stabilisation and apply cervical collar when convenient. If intubation is required, apply cervical collar after intubation. Attempt to minimise jugular vein compression. • Attempt to maintain normal temp. Version 4 - 16-12-10 Page 2 of 2 Traumatic Head Injury CPG A0803 ? Status Assess 8 • Traumatic head injury • Time critical head injury • Other head injury ? Airway ? Ventilation ? Perfusion ? General care Action Action Action Action •If airway patent and VT adequate (with trismus), do not insert NPA or OPA •Ensure adequate ventilation and VT of 10 mL/kg •Mx with Normal Saline as per CPG A0801 Hypovolaemia (unless in the setting of penetrating truncal trauma or uncontrolled overt bleeding) • Rx sustained seizure activity with Midazolam as per CPG A0703 Seizures •If airway not patent and gag is present, insert NPA and ventilate •Maintain SpO2 > 95% and Rx causes of hypoxia •If GCS < 10, regardless of airway reflexes, intubate as per CPG A0302 Endotracheal Intubation - RSI •Maintain EtCO2 at 30 - 35 mmHg Avoid hypo/ hypercapnia ? Status Stop 8 Assess 8 Consider •After 40 mL/kg reassess. If SBP < 100 mmHg, discuss ongoing resuscitation with the receiving Regional or Major Trauma Service while continuing to Tx •If consult is unavailable administer a further Normal Saline 20 mL/kg IV and reassess © Ambulance Victoria 2014 •If intubation is not possible / authorised and gag is absent insert LMA • Aim for SBP > 120 mmHg Action MICA Action • Measure BGL and rectify hypoglycaemia as per CPG A0702 Hypoglycaemia • Triage to highest level of care as per Time Critical Guidelines (Trauma Triage) • If Pt does not meet Time Critical Guidelines (Trauma Triage) criteria, triage Pt to next highest or appropriate level of trauma care Traumatic Head Injury CPG A0803 133 Version 3 - 15-12-10 Page 1 of 2 Spinal Injury Special Notes Special Notes • A cervical collar alone does not immobilise the cervical spine. If the neck needs immobilising then the whole spine needs immobilising. This may include the use of head rolls or other approved proprietary devices and the whole body immobilised on a spine board or ambulance stretcher in a manner that is appropriate for the presenting problem. A spine board must be restrained to the ambulance stretcher during Tx. • If a cervical collar is applied then it must be properly fitted and applied directly to the skin, not over clothing and not placing any pressure on the neck veins. • The head should not be independently restrained. • In Pts with a diseased vertebral column, a lesser mechanism of injury may result in SCI and should be Mx accordingly. • Spinal immobilisation with neutral alignment may not be possible in a Pt with a diseased vertebral column with associated anatomical deformity and should be modified accordingly e.g. position of comfort. • Spinal immobilisation is not without risk. Complications may include head and neck pain, detrimental effects on pulmonary function and subsequent neurological deficit (particularly in the elderly). © Ambulance Victoria 2014 CPG A0804 • Where there is no immediate risk to life and extrication is required then an extrication device (e.g. KED) should be considered. • Pts with a SCI may develop pressure areas within as little as 30 min following placement on a spine board and the duration on a spine board must be noted on the PCR. Effective padding should be applied to protect pressure areas. • For Tx times in excess of 60 min consideration should be given to removing the Pt from a spine board and appropriately securing them to the ambulance stretcher. • Pts with isolated neurogenic shock should be given a small fluid bolus (up to 500 mL Normal Saline IV) to correct hypotension. No further fluid should be given if SCI is the sole injury. • The Pt with multi trauma and SCI may not mount a sympathetic response to hypovolaemia. Fluid should be given based on estimated blood loss. Version 3 - 15-12-12 Page 2 of 2 Spinal Injury CPG A0804 ? Status Assess 8 • Potential or suspected spinal injury • Spinal column injury • Spinal cord injury ? If Pt meets major trauma criteria ? If Pt does not meet major trauma criteria Action • Has any mechanism of injury with potential to cause spinal injury • Mx airway as appropriate Action • Provide spinal immobilisation If any of the following present provide spinal immobilisation: •Administer pain relief as required as per • Increased injury risk - Age > 55 years -History of bone disease (e.g. osetoporosis, osteoarthritis, rheumatoid arthritis) or muscular weakness disease (e.g. muscular dystrophy) CPG A0501 Pain Relief • Mx hypovolaemia as per CPG A0801 Hypovolaemia •Tx without delay to an appropriate receiving hospital as per CPG A0105 Time Critical Guidelines (Trauma Triage) • Difficult Pt assessment -Unconsciousness or any acute or chronic altered conscious state (GCS < 15) or period of loss of consciousness - Drug or alcohol affected -Significant distracting injury e.g. extremity fracture or dislocation • Actual evidence of structural injury - Spinal column pain / bony tenderness • Actual evidence of spinal cord injury - Neurological deficit or changes - Mx as per emergent time critical trauma criteria © Ambulance Victoria 2014 •If none of the above present then spinal immobilisation / cervical collar not necessary ? Status Stop 8 Assess 8 Consider Action MICA Action If any doubt exists as to Hx or the above assessment, or if there is inability to adequately assess the Pt, provide spinal immobilisation. Clearance criteria within this CPG are not to be used for paediatric Pts. No paediatric Pt should be spinally cleared prehospital after major trauma. Apply all spinal care. Spinal Injury CPG A0804 135 Version 2 - 07.09.11 Page 1 of 3 Burns Special Notes General Care • All chemical burns should be irrigated for at least 20 min. Avoid flushing chemical onto uncontaminated areas. Burn cooling • Remove burnt clothing or that containing chemical hot liquid when safe to do so. Do not remove clothing that adheres to underlying tissue. Jewellery should be removed prior to swelling occurring. • Vol replacement is for the burn injury only. Mx other injuries accordingly including requirement for additional fluid. Electrical burns should receive fluid therapy to maintain adequate renal perfusion. • S/S of airway burns include: © Ambulance Victoria 2014 CPG A0805 - vidence of burns to upper torso, neck and face E Facial and upper airway oedema Sooty sputum Burns that have occurred in an enclosed space Singed facial hair (nasal hair, eyebrows, eyelashes, beards) - Respiratory distress (dyspnoea +/- wheeze and associated tachycardia, stridor) - Hypoxia (restlessness, irritability, cyanosis, decreased GCS). • Burn cooling should be for 20 min. Consider shorter periods for Pts with large TBSA where hypothermia may be induced. Cooling may be completed prior to Tx. Cooling provided prior to ambulance arrival should be included in the total cooling time. • Burn cooling should be with gentle running water that is between 5 - 15°C. Ice and ice water is not desirable. Similarly, dirty (i.e. dam) water should be avoided given the significant risk of infection. • If running water is not available, cooling may be commenced by immersing the affected area in still water. This water should be refreshed every few min to avoid it warming. • Maintaining normothermia is vital. Protect remainder of Pt from heat loss where possible • - Assess temp as soon as practicable and monitor - Cover the Pt with blankets etc. - Avoid Pt shivering. If clinically appropriate, elevation of the affected area in transit will assist in minimising burn wound oedema. Burn dressings • Cling wrap is an appropriate burn dressing. It should be applied longitudinally to allow for swelling. Cling wrap is the preferred burns dressing for all burns. • Water gel dressings (e.g. Burnaid™) may be considered as a cooling agent where no other cooling method exists. Cooling with water is the preferred method of cooling. After prescribed cooling times remove and replace with cling wrap dressing. Version 2 - 07.09.11 Page 2 of 3 Burns CPG A0805 Status ? 8 Assess mechanism of burn and burn injury • Evidence of burn injury • Airway injury • TBSA • Mechanism of burn injury • Severity of burn injury Stop • Ensure safety and removal from burn mechanism - Avoid chemical contamination or spreading to unaffected areas ? Initial burn Mx Action •Cool the burn, warm the Pt •Cool burn area – refer general care notes •Protect remainder of Pt from heat loss where possible •Provide analgesia as per CPG A0501 Pain Relief © Ambulance Victoria 2014 •Cover cooled burn area with appropriate dressing – refer General care notes ? All other burn presentations ? Partial or full thickness burns >15% BSA ? Suspected airway burns Action Action Action • BLS If TBSA is >15% For Pts with GCS up to 15 •Tx to appropriate facility •Normal Saline IV fluid replacement - % TBSA x Pt wt (kg) = vol (mL) - given over 2 hr from time of burn •Consider ETT as per CPG A0302 Endotracheal Intubation - Consult with Clinician - Use RSI method unless C/I • Tx to an appropriate facility ? Status Stop 8 Assess 8 Consider Action MICA Action Burns CPG A0805 137 Version 2 - 07.09.11 Page 3 of 3 Burns Special Notes Tx • Any burns involving the face, hands, feet, genitalia, major joints or circumferential burns of the chest or limbs or involving > 20% TBSA require assessment by a specialised burns service. For regional transfers this may be via secondary transfer. Metropolitan: • All burns Pts who meet the time critical trauma criteria should be Tx to the Alfred Hospital in preference if within 45 min. If > 45 min, Tx to nearest alternative highest level of trauma service. Rural: • Tx to highest designated trauma receiving centre within 45 min. • In all cases of prolonged Tx, consider alternative air Tx. © Ambulance Victoria 2014 • In all cases, appropriate consultations should occur and hospital notification provided CPG A0805 General Care Adult Rule of Nines expressed as a % of body surface area Note: Chest + Abdomen = 18% Front or 18% Back. Limbs are measured circumferentially. © Ambulance Victoria 2014 This page intentionally left blank 139 Version 1 - 01.11.05 Page 1 of 1 Fracture Management CPG A0806 Principles of fracture Mx General principles - Control external haemorrhage. - Support the injured area. - Immobilise the joint above and below the fracture. - Assess neurovascular status distal to the fracture before and after splinting • Provide pain relief and correct hypovolaemia as per appropriate CPGs. • Appropriate splinting can assist in pain reduction and arrest of haemorrhage Actions before and after splinting: - Realign long bone fractures in as close to normal position as possible. - Open fractures with exposed bone should be irrigated with a sterile isotonic solution prior to realignment and splinting. - If joints are involved there is an increased possibility of neurovascular impairment and reduction is not recommended. - Mx femoral shaft fractures and fractures of the upper 2/3 of the tibia and fibula with a traction splint unless there are distal dislocations or fractures. • In suspected fractures of the pelvis, the legs should be anatomically splinted together (to internally rotate the feet) and the pelvis splinted with a sheet wrap or other appropriate device. © Ambulance Victoria 2014 • Pts who meet the major trauma criteria are time critical but appropriate splinting should be considered part of essential prehospital Mx. © Ambulance Victoria 2014 This page intentionally left blank 141 Version 2 06-06-12 page 1 of 2 © Ambulance Victoria 2014 Diving Related Emergencies CPG A0807 Special Notes General Care • Pts with GCS < 15 and/or onset of symptoms < 10 - 15 min after surfacing, any seizure, LOC or altered conscious state have a higher probability of cerebral arterial gas embolism (CAGE) and are time critical. Consider air Tx for these Pts, preferably by helicopter at < 300 metres. • DCI S/S may include musculoskeletal pain, itching, any neurological changes or respiratory complaint • Specific Hx is important. This should include: – number of dives performed – surface interval between dives – max. depth(s) and bottom time(s) – type of ascent (controlled/rapid) – decompression or safety stops – breathing gas mixture used –level of exertion during and after dive –which symptoms presented and when first aid was provided. • It is essential that any divers computers and gauges from during the dive be Tx to the recompression facility. • This CPG is for Pts who have suffered a recent diving incident. Pts with a GCS of 15 who have been suffering symptoms for >12 - 24 hours before calling can be kept on a simple face mask but still need to be Tx to a recompression facility with their equipment. • At time of publication the only public recompression facility in Victoria is at the Alfred Hospital. There is also a facility at Royal Adelaide Hospital. • Primary goals for Pts with a diving related injury are allow nitrogen to off-gas, increase O2 delivery and rehydrate. • Removal of N2 can be best achieved by the highest O2 delivery system available. • Unconscious and intubated Pts must be ventilated using a BVM with 15 L of O2 if possible. A closed O2 delivery system is C/I for dysbaric patients. • Extended Tx times may require the oxy-saver to be connected to the D-cylinders via the adaptor hose. • Post immersion Pts can have isolated hypotension. Be aware of the potential for inadequate perfusion without hypovolaemia. Titrate fluid administration to Pt response. • Warming tissues can result in dissolved N2 undissolving. Pts < 32ºC should be warmed to that level to avoid arrhythmia risk • Any potential CAGE Pt must be kept supine or in the lateral position. The Pt should not be allowed to sit up or stand at any time. Pts who cannot be maintained in this position due to respiratory compromise may be kept semi-recumbent. • If there is an indication for opioid analgesia, then consult with the Alfred hospital before administration. Opioids may mask symptoms for the receiving physician when assessing potential recompression Rx. Prochlorperazine may also mask the symptom of vertigo. Version 2 06-06-12 page 2 of 2 Diving Related Emergencies ? Status CPG A0807 Assess 8 • Perfusion status •History of recent diving incident (SCUBA) • Respiratory status • GCS • S/S for DRE ? Stable (GCS = 15) • Symptomatic ? Unstable (GCS < 15) • Symptomatic with altered conscious state Action Action • Position Pt supine or lateral • Mx nausea as per CPG A0701 Nausea and Vomiting •Administer 100% O2 via oxy-saver regardless of respiratory status or SpO2 allowing expired air to exhaust. Maintain throughout regardless of any resolution of symptoms • Avoid rapid increases in body temp • Tx directly to a recompression chamber • Mx other signs and symptoms as per appropriate CPG • Mx as per Unstable (GCS < 15) if deterioration noted • Hydrate Pt as per Perfusion below • Mx as per GCS 15 •Be aware of the greater potential for chest injuries and Mx as per CPG A0802 Chest Injuries •Consider distance to a recompression chamber and the need for MICA and/or aeromedical Tx • Tx directly to a recompression chamber • Hydrate Pt as per Perfusion below • If GCS<10 manage as per CPG A0302 Endotracheal intubation as RSI Non Traumatic Brain Injury ? Perfusion • Dehydration • Less than adequate perfusion © Ambulance Victoria 2014 Action •If adequately perfused and chest clear administer Normal Saline 1000 mL over 15 - 20 min to rehydrate Pt. Continue Normal Saline @ 1000 mL every 4 hr •If less than adequate perfusion, titrate fluid administration to Pt response as per CPG A0801 Hypovolaemia • Do not use warmed fluid ? Status Stop 8 Assess 8 Consider Action MICA Action Diving Related Emergencies CPG A0807 143 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 145 Version 2 - 08.06.11 Page 1 of 2 Hypothermia / Cold Exposure Special Notes General Care •Hypothermia is insidious and rarely occurs in isolation. Where the Pt is in a group environment other members of the group should be carefully assessed for signs of hypothermia. • Shelter from wind in heated environment. •Arrhythmia in hypothermia is associated with temp below 33˚C. •Atrial arrhythmias, bradycardias or A-V blocks do not generally require Rx with anti-arrhythmic agents unless decompensated and resolve on rewarming. •Defibrillation and cardioactive drugs may not be effective at temp below 30˚C. VF may resolve spontaneously upon rewarming. •The onset and duration of drugs is prolonged in hypothermia and the interval between doses is therefore doubled, e.g. doses of Adrenaline become 6 minutely. © Ambulance Victoria 2014 CPG A0901 • Remove all damp or wet clothing. • Gently dry Pt with towels/blankets. • Wrap in warm sheet/blanket - cocoon. • Cover head with towel/blanket - hood. • Use thermal/space/plastic blankets above and below the Pt if available. • Only warm frostbite if no chance of refreezing prior to arrival at hospital. • Assess BGL if altered conscious state. Warmed fluid • Normal Saline warmed between 37 - 42˚C should be given to correct moderate/severe hypothermia and maintain perfusion if available. Fluid < 37˚C could be detrimental to Pt. Version 1 - 20.09.06 Page 2 of 2 Hypothermia / Cold Exposure CPG A0901 Status ? 8 Assess • Hypothermia • Mild hypothermia 32 - 35˚C • Moderate hypothermia 28 - 32˚C • Severe hypothermia < 28˚C • If alteration to cardiac arrest Mx required ? Cardiac arrest ? Non cardiac arrest • Moderate/severe hypothermia < 28 - 32˚C •Warmed Normal Saline 10 mL/kg IV ? > 32˚C Action • Avoid drug Mx of cardiac arrhythmias unless decompensated and until rewarming has commenced •Standard cardiac arrest CPG ? 30 - 32˚C Action • Double intervals between doses in relevant cardiac arrest CPG - Do not rewarm beyond 33˚C if ROSC ? < 30˚C Action • Continue CPR and rewarming until temp > 30˚C • One DCCS only • One dose of Adrenaline • One dose of Amiodarone •Withhold Sodium Bicarbonate 8.4% IV © Ambulance Victoria 2014 •Repeat Normal Saline 10 mL/kg IV (max. 40 mL/kg) to maintain perfusion ? Status Stop 8 Assess 8 Consider Action MICA Action Hypothermia / Cold Exposure CPG A0901 147 Version 3 - 20-12-09 Page 1 of 2 Environmental Hyperthermia Heat Stress Special Notes General Care • Pt body temp of < 40°C may usually be Mx with basic cooling techniques alone. • During cooling, the Pt should be monitored for the onset of shivering. Shivering may increase heat production and cooling measures should be adjusted to avoid its onset. • Be wary of fluid volumes in renal dialysis Pts causing fluid overload. Administer judicious increments with volumes not usually exceeding 10 mL/kg. • This CPG is not intended for the Mx of the febrile Pt due to infection. © Ambulance Victoria 2014 CPG A0902 • Gentle handling of the Pt is essential. Position flat or lateral and avoid head up position to avoid causing arrhythmias. Version 3 - 20-12-09 Page 2 of 2 Environmental Hyperthermia Heat Stress ? Status CPG A0902 Assess 8 • Hyperthermia / heat stress • Accurately assess temp • BGL if altered conscious state • Perfusion status and dehydration ? Requires active cooling Action • Cooling techniques - initiated and maintained until temp is < 38°C - Shelter / remove from heat source - Remove all clothing except underwear - Ensure airflow over Pt - Apply tepid water using spray bottle or wet towels • If significant dehydration or poor perfusion, Rx as per CPG A0801 Hypovolaemia • Provide initial Normal Saline 20 mL/kg IV and reassess VSS and temp -If Pt temp > 40°C use cool fluids if available (stored usually at < 8°C) • Continue to administer Normal Saline if Pt remains poorly perfused or significantly dehydrated -If cool fluids intiated, return to ambient temp once Pt temp is < 39°C • Rx low BGL as per CPG A0702 Hypoglycaemia • Airway and ventilation support with 100% O2 as required ? Adequate response Action • Severe cases - temp > 39.5˚C • BLS © Ambulance Victoria 2014 ? Assess • GCS < 10 • Tx Action • Consider ETT as per CPG A0302 Endotracheal Intubation • If intubated, sedation and paralysis essential to prevent shivering and reduce heat production ? Status Stop 8 Assess 8 Consider Action MICA Action Environmental Hyperthermia Heat Stress CPG A0902 149 © Ambulance Victoria 2014 This page intentionally left blank Version 5 - 20.09.06 Page 1 of 11 Paediatric CPG P0101 Special Notes Special Notes •For children up to the age of 14, drug doses are quoted on a dose per kg basis. The calculated dose is correct even if it exceeds the usual adult dose. • If the Mx recommended in these CPGs is not successful or if further guidance is required for ongoing Mx, consult with the senior medical staff of the Emergency Department or Intensive Care Unit at the Royal Children’s Hospital (RCH) or the receiving hospital, with a view to further Mx during Tx. •The body mass to body surface area ratio (body mass index) and the fat-carbohydrate-protein make-up of the child and developing young adolescent is different to that of an adult. •For specific Mx of the newborn refer to appropriate newborn guidelines. RCH Emergency Department RCH Intensive Care Unit (03) 9345 6153 (03) 9345 5211 5212/5213/6555 • AV radios are installed in the RCH Emergency Department, Intensive Care and Neonatal Intensive Care Units to allow direct ambulance communications for consultation and notification of arrival. These departments can be accessed via the AV Metro Clinician. Rural Paramedics may also access this facility using their portable radios if in the AV Metro radio coverage area. © Ambulance Victoria 2014 • Contact Paediatric Infant Perinatal Emergency Retrieval (PIPER), (formally known as NETS, PETS and PERS) any time via the Clinician or on 1300 137 650. Paediatric CPG P0101 151 Version 5 - 20.09.06 Page 2 of 11 Paediatric CPG P0101 Normal Values 1. Definitions Newborn from birth up to 24 hr Infant < 1 year Small child 1 – 8 years Large child 9 – 14 years 2. Paediatric weight calculation For children the doses of drugs, DCCS and fluid therapy are based on body weight. If the body weight is unknown, it can be estimated from the child’s age using the following: Newborn 3.5 kg 2 months 5 kg 5 months 7 kg 1 year 10 kg 1 – 9 years age x 2 + 8 kg 10 – 14 years age x 3.3 kg © Ambulance Victoria 2014 Refer to the paediatric tables for calculations of estimated body weight for specific ages. Version 5 - 20.09.06 Page 3 of 11 Paediatric CPG P0101 Normal Values 1. Normal blood volume Newborn – approximately 80 mL/kg Infant and child – approximately 70 mL/kg 2. Definition and observations Same as for adults – Refer to CPG A0102 Perfusion Assessment 3. Criteria a) Adequate perfusion Age HR BP Newborn 120 – 160 bpm N/A Infant 100 – 160 bpm > 70 mmHg systolic Small child 80 – 120 bpm > 80 mmHg systolic Large child 80 – 100 bpm > 90 mmHg systolic © Ambulance Victoria 2014 • Skin – warm, pink, dry • Conscious, alert, active Paediatric CPG P0101 153 Version 5 - 20.09.06 Page 4 of 11 Paediatric CPG P0101 Perfusion status assessment b) Inadequate Perfusion Age HR BP Newborn < 100 or > 170 bpm N/A Infant < 90 or > 170 bpm < 60 mmHg systolic Small child < 75 or > 130 bpm < 70 mmHg systolic Large child < 65 or > 100 bpm < 80 mmHg systolic • Skin – cool, pale, clammy, peripheral cyanosis • Altered conscious state, restless c) No Perfusion © Ambulance Victoria 2014 • • • • Absence of palpable pulses Skin – cool, pale Unrecordable blood pressure Unconscious Version 5 - 20.09.06 Page 5 of 11 Paediatric CPG P0101 Respiratory status assessment 1. Normal respiratory rates Newborn 40 – 60 breaths/min Infant 20 – 50 breaths/min Small child 20 – 35 breaths/min Large child 15 – 25 breaths/min 2. Definition and observations Same as for adults 3. Criteria a) Signs of respiratory distress include: • use of accessory muscles • grunting • pallor • wheezing • cyanosis (late sign) • chest wall retraction • abdominal protrusion. © Ambulance Victoria 2014 • tachypnoea Paediatric CPG P0101 155 Version 5 - 20.09.06 Page 6 of 11 Paediatric CPG P0101 Respiratory status assessment b) Signs of hypoxia include: Infants Children • pallor • restlessness • hypotension • tachypnoea • lethargy • tachycardia (bradycardia late sign) • apnoea • cyanosis. • bradycardia. c) CO2 retention is manifested by: • sweating (uncommon in infants) • hypertension • tachycardia • bounding pulse • pupillary dilatation • eventually leading to cardiovascular and central nervous system depression. © Ambulance Victoria 2014 Respiratory failure is common in the first two years of life. Small calibre airways are prone to obstruction. Respiratory distress may reflect dysfunction of other body systems, e.g. cardiac failure, abdominal distension or neurological problems. Version 5 - 20.09.06 Page 7 of 11 Paediatric CPG P0101 Conscious state assessment (Glasgow Coma Scale) Child ≤ 4 years Child > 4 years A. Eye opening Eye opening Score Spontaneous Reacts to speech Reacts to pain None B. Best verbal response 4 3 2 1 Score Appropriate words or social smile, fixes, follows Cries but consolable Persistently irritable Restless and agitated None C. Best motor response Spontaneous Localises to pain Withdraws from pain Abnormal flexion (pain) Extension response (pain) None 5 4 3 2 1 Score Spontaneous To voice To pain None 4 3 2 1 Best verbal response Score Orientated Confused Inappropriate words Incomprehensible sounds None 5 4 3 2 1 Score Best motor response Score 6 5 4 3 2 1 Obeys command Localises to pain Withdraws (pain) Abnormal flexion (pain) Extension (pain) None 6 5 4 3 2 1 ( A + B + C ) = (A+B+C)= © Ambulance Victoria 2014 Total GCS (max. score = 15) Paediatric CPG P0101 157 Version 5 - 20.09.06 Page 8 of 10 Paediatric Paediatric pain assessment Paediatric pain assessment should be appropriate to the developmental level of the child. Pain can be communicated by words, expressions and behaviour such as crying, guarding a body part or grimacing. Irrespective of the age of the Pt, pain should not be documented as “unable to rate” without some comment on signs, symptoms and/or behaviour to reflect that an assessment has occurred. The QUESTT principles of pain (Baker and Wong, 1987) may be helpful in assessing paediatric pain. Question the child Use pain rating scales Evaluate behaviour and physiological changes Secure parent’s involvement Take cause of pain into account Take action and evaluate results The following pain rating scales may be useful when assessing pain in children. FLACC Scale © Ambulance Victoria 2014 This is a behaviour scale that can be used for children less than 3 years of age or who are unable to communicate. Each of the five categories below is scored from 0 – 2 and the scores are added to get a total from 0 – 10. Behavioural pain scores need to be considered within the context of the child’s psychological status, anxiety and other environmental factors. CPG P0101 Version 5 - 20.09.06 Page 9 of 10 Paediatric CPG P0101 Paediatric pain assessment Face Legs Activity Cry Consolability 0 1 2 No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaw, quivering chin 0 1 2 Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up 0 1 2 Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking 0 1 2 No cry (awake or asleep) Moans or whimpers, occasional complaints Crying steadily, screams or sobs, frequent complaints 0 1 2 Content, relaxed Reassured by occasional touching, hugging, or being spoken to, distractible Difficult to console or comfort © Ambulance Victoria 2014 The FLACC is a behaviour pain assessment scale which is reproduced with permission of University of Michigan Health System and for clinical use by AV. © University of Michigan Paediatric CPG P0101 159 Version 5 - 20.09.06 Page 10 of 10 Paediatric CPG P0101 Paediatric pain assessment Wong – Baker Faces Pain Rating Scale This scale can be used with young children aged 3 years and older and may also be useful for adults and those from a non-English-speaking background. Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes their own pain and record the appropriate number. 0 NO HURT 2 HURTS LITTLE BIT 4 HURTS LITTLE MORE 6 HURTS EVEN MORE 8 HURTS WHOLE LOT 10 HURTS WORST From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. Verbal numerical rating scale © Ambulance Victoria 2014 This scale asks the Pt to rate their pain from “no pain” (0) to “worst pain possible” (10) and is suitable for use in children over 6 years of age who have an understanding of the concepts of rank and order. Avoid using numbers on this scale to prevent the Pt receiving cues. Some Pts are unable to use this scale with only verbal instructions but may be able to look at a number scale and point to the number that describes the intensity of their pain. Version 5 - 01.04.06 Page 1 of 6 Paediatric Charts CPG P0102 Paediatric Chart Age Weight 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg Resps Normal lower limit 40 20 20 20 20 20 20 20 20 20 20 15 15 15 15 15 15 /min Resps Normal upper limit 60 50 50 35 35 35 35 35 35 35 35 25 25 25 25 25 25 /min Pulse Pulse Pulse Pulse Inadequate perfusion < 100 < 90 < 90 < 75 < 75 < 75 < 75 < 75 < 75 < 75 < 75 < 65 < 65 < 65 < 65 < 65 < 65 /min Normal lower limit 120 100 100 80 80 80 80 80 80 80 80 80 80 80 80 80 80 /min Normal upper limit 160 160 160 120 120 120 120 120 120 120 120 100 100 100 100 100 100 /min Inadequate perfusion > 170 > 170 > 170 > 130 > 130 >130 > 130 > 130 > 130 > 130 > 130 > 100 > 100 > 100 > 100 > 100 > 100 /min SBP Normal lower limit NA > 70 > 70 > 80 > 80 SBP Inadequate perfusion NA < 60 < 60 < 70 < 70 < 70 < 70 < 70 < 70 < 70 < 70 < 80 < 80 < 80 < 80 < 80 < 80 mmHg ETT Internal diameter 3.5 3.5 3.5 4.0 4.5 5.0 5.0 5.5 5.5 6.0 6.0 6.5 6.5 7.0 7.0 7.5 7.5 mm ETT Length at lips 9.5 9.5 11 12 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 cm Naso/Orogastric Tube 8 12 12 12 12 12 12 14 14 14 14 14 14 14 14 14 14 FG Suction Catheter for ETT 6 6 8 8 8 8 8 8 8 8 10 10 10 10 10 10 10 FG 15 20 30 50 50 70 70 100 100 100 100 120 150 150 170 200 200 4 joules/kg > 80 > 80 > 80 > 80 > 80 > 90 > 90 > 90 > 90 > 90 > 90 mmHg © Ambulance Victoria 2014 DCCS (Biphasic) >80 Paediatric Charts CPG P0102 161 Version 5 - 01.04.06 Page 2 of 6 Paediatric Charts CPG P0102 Resuscitation drugs Age 0 Weight 3.5 Adrenaline 1:1,000 neb. Adrenaline 1:1,000 10 mcg/kg 2 6 Mth Mth 5 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg For all ages add 5 mL to nebuliser Adrenaline 1:1,000 mL 100 100 100 100 120 140 160 180 200 220 240 260 330 360 400 430 460 mcg use 1:10,000 0.1 0.12 0.14 0.16 0.18 0.2 0.22 0.24 0.26 0.33 0.36 0.4 0.43 0.46 mL mcg 35 50 70 100 120 140 160 180 200 220 240 260 330 360 400 430 460 1* 1* 1* 1* 4.6 mL 100 100 100 100 120 140 160 180 200 220 240 260 330 360 400 430 460 mcg 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 10 mL syringe 10 mcg/kg 0.35 0.5 35 1 mg/10 mL (1 mL = 10 mL) Adrenaline 1:1000 50 0.7 70 1 1.2 1.4 1.6 1.8 4.6 mL 100 120 140 160 180 200 220 240 260 330 360 400 430 460 2 mcg 1 mL syringe 100 mcg/kg 0.35 0.5 2.2 2.4 2.6 3.3 3.6 4 4.3 ETT Drug Dilution Volume Cardiac arrest (minimum dose 100 mcg) MICA anaphylaxis, asthma 10 mL syringe 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 350 500 700 1000 1200 1400 1600 1800 2000 2200 2400 2600 3300 3600 4000 4300 4600 Sodium Bicarbonate 8.4% MICA anaphylaxis, asthma 1 mL syringe 10 mcg/kg 1 mg/10 mL (1 mg = 10 mL) Adrenaline 1:10,000 ALS anaphylaxis, asthma 1 mL syringe 10 mcg/kg 1 mg/1 mL (1 mL = 1 mL) Adrenaline 1:10,000 Upr Airway oedema 0.1* 0.1* 0.1* 0.1* 0.12 0.14 0.16 0.18 0.2 0.22 0.24 0.26 0.33 0.36 0.4 0.43 0.46 1 mg/1 mL (1 mg = 1 mL) Guideline 1 mL 3 - 5 mL mL mcg Cardiac arrest (ETT dose) 5 - 10 mL 1 mL/kg 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 mL 2 mL/kg 7 10 14 20 24 28 32 36 40 44 48 52 66 72 80 86 92 mL Cardiac arrest TCA OD (2 mL/kg) 1.75 2.5 3.5 5 6 7 8 9 10 mL VF/ VT arrest 17.5 35 50 60 70 80 90 100 50 mL Minijet syringe Amiodarone 5 mg/kg 100 mg/10 mL (See across for dilution info) (10mg = 1mL) © Ambulance Victoria 2013 Amiodarone 5 mg/kg 25 mg Dilution info: Add 2 mL (100 mg) Amiodarone (from 150 mg in 3 mL ampoule) to 8 mL Dextrose in a 10 mL syringe Different dilution suggested for < 6 yr. 150 mg/3 mL (50 mg = 1 mL) Syringe Scales Different dilution suggested for > 6 yr. 4.6 mL 110 120 130 165 180 200 215 230 2.2 2.4 2.6 3.3 3.6 4 4.3 mg VF/ VT arrest 10 mL syringe 1 mL/0.01 mL increments 2.5 mL/0.1 mL increments 10 mL/0.2 mL increments 50 mL/1 mL increments *0.1 mL has been made a minimum vol to reduce dosage error. The minimum vol is sometimes different to the prescribed dose and should be recorded/handed over as the dose delivered. An example of the error that occurs in a vol less than 0.1 mL is as follows: required dose vol of 0.07 mL, 0.7 mL is prepared and the Pt incorrectly receives 10 × required dose. Version 5 - 01.04.06 Page 3 of 6 Paediatric Charts CPG P0102 Ceftriaxone and Dextrose Age Weight 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg 4 4 4 4 4 4 4 4 4 mL Ceftriaxone (IM) 50 mg/kg 0.7 1 1g diluted with 3.5 mL 1% Lignocaine 175 250 (1 mL = 250 mg) 1 mL syringe 1.4 2 2.4 2.8 3.2 3.6 350 500 600 700 800 900 1000 1000 1000 1000 1000 1000 1000 1000 1000 mg 2.5 mL syringe Guideline Meningococcal septicaemia 10 mL syringe Ceftriaxone (IV) 50 mg/kg 1.75 1 g diluted with 9.5 mL Water for Injection 175 (1 mL = 100 mg) 2.5 3.5 5 6 7 8 9 250 350 500 600 700 800 900 Dextrose 10% 10 10 10 10 10 10 10 10 10 mL 1000 1000 1000 1000 1000 1000 1000 1000 1000 mg Meningococcal septicaemia 10 mL syringe 3 mL/kg 10 15 21 30 36 42 48 54 60 66 72 78 99 108 120 129 138 mL 2 mL/kg 7 10 14 20 24 28 32 36 40 44 48 52 66 72 80 86 92 mL Hypoglycaemia Use a 50 mL syringe or infusion depending on volume to be delivered © Ambulance Victoria 2014 Drug dose errors can occur when calculations are required. All appropriate checking procedures should be followed including, where available 2 Paramedics independently confirming the required dose and vol and/or checking against approved AV reference material prior to administration. Paediatric Charts CPG P0102 163 © Ambulance Victoria 2014 This page intentionally left blank Version 5 - 01.04.06 Page 5 of 6 Paediatric Charts CPG P0102 Midazolam, Morphine and Naloxone 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs Weight 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg Fentanyl (IV) 2 mcg/kg 100 mcg/10 mL (1 mL = 10 mcg) 0.7 1 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mL 7 10 14 20 24 28 32 36 40 44 48 52 66 72 80 86 92 mcg Age Guideline Emergency sedation Add 2 mL (100 mcg) Fentanyl (from 100 mcg in 2 mL ampoule) to 8 mL Normal Saline in a 10 mL syringe Midazolam (IV) 0.1 mg/kg 0.35 15 mg/15 mL (1 mg = 1 mL) 0.35 0.5 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 mL 0.5 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 mg Add 3 mL (15 mg) Midazolam (from 15 mg in 3 mL ampoule) to 12 mL Normal Saline in a 20 mL syringe For induction doses, Add 3 mL (15 mg) Midazolam (from 15 mg in 3 mL ampoule) to 12 mL Normal Saline in a 20 mL syringe Morphine (IM) 10 mg/1 mL 0.1 mg/kg 0.035 0.05 0.07 0.1 0.35 1 0.5 0.7 0.12 0.14 0.16 0.18 1.2 1.4 1.6 0.2 1.8 2 0.22 0.24 0.26 0.33 0.36 2.2 2.4 2.6 3.3 3.6 0.4 4 see CPG P0301 0.43 0.46 mL 4.3 Post - ETT sedation 4.6 Pain relief mg 1 mL syringe CAUTION IM Morphine dose should never exceed 0.5mL Naloxone (IM) 400 mcg/1 mL 10 mcg/kg n/a 0.125 0.175 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.825 0.9 n/a 120 140 160 180 200 220 240 260 50 70 100 1 mL syringe 330 360 1 400 1.075 1.15 mL 430 460 Opioid overdose mcg 2.5 mL syr © Ambulance Victoria 2014 *0.1 mL has been made a minimum vol to reduce dosage error. The minimum vol is sometimes different to the prescribed dose and should be recorded/handed over as the dose delivered. An example of the error that occurs in a vol less than 0.1 mL is as follows: required dose vol of 0.07 mL, 0.7 mL is prepared and the Pt incorrectly receives 10 × required dose. Drug dose errors can occur when calculations are required. All appropriate checking procedures should be followed including, where available 2 Paramedics independently confirming the required dose and vol and/or checking against approved AV reference material prior to administration. Paediatric Charts CPG P0102 165 Version 5 - 01.04.06 Page 6 of 6 Paediatric Charts CPG P0102 Normal Saline, Salbutamol and Dexamethasone Age Weight Normal Saline 20 ml/kg 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg 70 100 140 200 240 280 320 360 400 440 480 520 660 720 800 860 920 mL Hypovolaemia, asthma, cardiac arrest, anaphylaxis Asthma Use a 50 mL syringe or infusion depending on volume to be delivered Salbutamol (IV) 500 mcg/1 mL dilute to 10 mL (1 mL=50 mcg) 5 mcg/kg 0.35 0.5 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 mL 17.5 25 35 50 60 70 80 90 100 110 120 130 165 180 200 215 230 mcg 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.65 1.8 2 2.15 25 30 35 40 45 50 55 60 65 82.5 90 2.5 mcg/kg 0.175 0.25 0.35 8.75 12.5 17.5 2.4 mL 100 107.5 115 mcg Salbutamol infusion 100 mcg/kg 0.35 0.5 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 Syringe pump 0.35 0.5 0.7 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 3.3 3.6 4 4.3 4.6 5 mg/5 mL take 100 mcg/kg and dilute Draw up in 2 mL syringe and add to 50 mL syringe Draw up in 10 mL syringe and add to 50 mL to 50 mL run @ 60 mL/hr (2 mcg/kg/min) Add 100 mcg/kg Salbutamol (from 5 mg/5 mL ampoule) to Normal Saline 50 mL and run at 60 mL/hr. (2 mcg/kg/min) mL Standard giving set 5 mg/5 mL take 200 mcg/kg 200 mcg/kg and dilute to 100 mL bag – run at 20 dpm Guideline 10 mL syringe Add 1 mL (500 mcg) Salbutamol to 9 mL Normal Saline in a 10 mL syringe Asthma mg 0.7 1 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mL 0.7 1 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mg Draw up in 10 mL syringe and add to 100 mL bag Add 200 mcg/kg Salbutamol (from 5 mg/5 mL ampoule) to Normal Saline 100 mL bag and run at 20 drops/min. Dexamethasone 8 mg in 2 mL 600 mcg/kg 0.52 0.75 1.05 1.5 1.8 2.1 2.4 2.7 3 3 3 3 3 3 3 3 3 mL 2.1 6 7.2 8.4 9.6 10.8 12 12 12 12 12 12 12 12 12 mg 3 © Ambulance Victoria 2014 1 mL syringe 4.2 2.5 mL syringe Asthma, anaphylaxis 5 mL syringe Drug dose errors can occur when calculations are required. All appropriate checking procedures should be followed including, where available 2 Paramedics independently confirming the required dose and vol and/or checking against approved AV reference material prior to administration. © Ambulance Victoria 2014 This page intentionally left blank 167 Respiratory rate BP HR Conscious state O2 saturation Skin Child 1 - 8 years < 40 or > 60 N/A < 100 or > 170 GCS < 15 N/A cold/pale/ clammy Newborn < 2 weeks Large Child 9 - 15 years < 20 or > 50 < 60 mmHg < 90 or > 170 GCS < 15 N/A cold/pale/ clammy Infant < 1 year Emergent Time Critical Vital signs are normal ? • May have pattern of injury • Any of the following: Assess pattern of injury 8 •Penetrating injuries - Head / Neck / Chest / Abdomen / Pelvis / Axilla / Groin • Blunt injuries - Significant injury to a single region: Head / Neck / Chest / Abdomen / Axilla / Groin - Injuries involving two or more of the above body regions • S pecific injuries - Limb amputations / limb threatening injuries -Suspected spinal cord injury - Burns > 20% or involving respiratory tract -Serious crush injury - Major compound fracture or open dislocation Significant pattern of injury ? • Vital signs normal Respiratory rate BP HR Conscious state O2 saturation Skin < 15 or > 25 < 80 mmHg < 65 or > 100 GCS < 15 < 90% cold/pale/ clammy - Fracture to two or more of the following: femur / tibia / humerus Vital signs not normal ? Action -Fractured pelvis Action 8 Assess 8 Consider Action • Consider MICA / Aeromedical support within 45 min • Triage to highest level of trauma service Stop • Consider MICA / Aeromedical support within 45 min • Triage to highest level of trauma service MICA Action <20 or >35 < 70 mmHg < 75 or > 130 GCS < 15 N/A cold/pale/ clammy Assess vital signs 8 Status ? • Possible major trauma Actual Time Critical Time Critical Guidelines (Trauma Triage) ? Status © Ambulance Victoria 2014 © Ambulance Victoria 2014 (Paediatric) Potentially Time Critical ? No Pattern of Injury • Vital signs are normal • May have mechanism of Injury 8 Assess Mechanism of Injury (MOI) • Any of the following: - Ejection from vehicle - Motor / cyclist impact > 30 km/hr - Fall from height > 3 m - Struck on head by falling object > 3 m - Explosion - High speed MCA > 60 km/hr - Vehicle rollover - Fatality in same vehicle - Pedestrian impact - Prolonged extrication > 30 min ? Positive MOI • Vital signs are normal • No pattern of injury Action within 45 min • Triage to highest level of trauma service ? ✔ No MOI CPG P0105 Not Time Critical • Vital signs are normal • No pattern of injury • Triage to nearest appropriate facility if required Action Time Critical Guidelines (Trauma Triage) (Paediatric) CPG A0105 169 © Ambulance Victoria 2014 This page intentionally left blank Version 6 - 16-06-11 Page 1 of 6 Cardiac Arrest (Paediatric) Causes and resuscitation principles Airway and breathing • Cardiac arrest in infants and children is most commonly caused by hypoxaemia, hypotension or both and should be suspected when the child or infant loses consciousness, appears pale or cyanosed or is apnoeic or pulseless. Examples of conditions causing cardiac arrest in infants and children are trauma, drowning, septicaemia, sudden infant death syndrome, asthma, upper airway obstruction and congenital abnormalities of the heart and lungs. • To assess an airway in an infant or child, the positioning and techniques are similar to those for an adult, with the exception that care should be taken to avoid over extension of the neck and head. • Infants and children most commonly arrest into severe bradycardia or asystole. VF may occur associated with congenital heart conditions or secondary to poisoning to cardioactive drugs and is often encountered during the course of resuscitation. Respiratory arrest may occur alone but if treated promptly may not progress to cardiac arrest. • Resuscitation is directed at adequate airway control, ventilation, chest compressions and Adrenaline. • The basic principles of paediatric life support are similar to those of adults. However, drug doses are usually related to body weight and some procedures need to be adapted for differences in paediatric anatomy. Older children may be treated as per adult CPGs but it should be noted that they do not have the same susceptibility to VF. © Ambulance Victoria 2014 CPG P0201 • For newborn resuscitation refer to CPG N0201 Newborn Resuscitation. • Signs of significant partial airway obstruction include: - noisy breathing - stridor or wheeze - neck and chest soft tissue retraction on inspiration. • Smaller children have a comparatively larger occiput causing natural flexion when supine. To position the head and neck to maintain an open airway: - Infants: Head and neck should be placed in the neutral position, avoiding additional neck flexion and head extension. This may require small padding beneath the shoulders rather than the head. - C hildren: Use neck flexion and head extension with caution in the younger child (up to 8 years of age). As the child gets older there will be less need to pad beneath the shoulders with the occiput and shoulders coming into the same line when supine. • If necessary, use chin lift or jaw thrust to clear the airway. The pharynx should be inspected with a laryngoscope and cleared of secretions using a Yankauer sucker. Magill's forceps may be needed to remove a foreign body. • If spontaneous ventilation is not present, an appropriate size OPA should be inserted and assisted ventilation should be commenced immediately. Effective airway control and adequate ventilation with O2 supplementation is the keystone of paediatric resuscitation. Cardiac Arrest (Paediatric) CPG P0201 171 Version 6 - 16-06-11 Page 2 of 6 © Ambulance Victoria 2014 Cardiac Arrest (Paediatric) CPG P0201 External cardiac compression (ECC) Rules of compressions to ventilations • Commence ECC if: • Infants and children - No palpable pulse (carotid, brachial or femoral) or Not intubated - HR < 60 bpm (infants) or 30 : 2 (single rescuer) - HR < 40 bpm (children). 15 : 2 (two rescuers) • Depth of compression / method of compression: Rate: Approximately 100 compressions/min -Approximately 1/3 the depth of the chest for all age groups. -Pause for ventilations Intubated / LMA inserted (MICA) -Approximately 50% of a compression cycle should be devoted to compression of the chest and 50% to relaxation. 3:1 for newborn Rate: Approximately 100 compressions/min -< 14 ventilations/min -no pause for ventilations Infant -Two fingers or two thumb technique. In the latter technique the hands encircle the chest and the thumbs compress the sternum. This is considered a more effective technique and is the preferred option for two rescuers. However care should be taken to avoid restricting chest expansion during inspiration. The two finger technique should be used by a single rescuer in order to minimise the transition time between ECC and ventilation. Also refer to CPG N0201 Newborn Resuscitation. Small child -One handed technique otherwise similar to that for adults Large child -Two handed technique similar to that for adults Version 6 - 16-06-11 Page 3 of 6 Cardiac Arrest (Paediatric) Principles of CPR Adjustment for temperature CPR > 32°C • It is assumed that CPR is commenced immediately and continued throughout the cardiac arrest as required. • Standard cardiac arrest CPG • Generic for all paediatric cardiac arrest conditions. • Double intervals of drug doses in relevant cardiac arrest CPG • Must not be interrupted for more than 10 sec during rhythm / pulse checks. If unsure of pulse, recommence CPR immediately. • Change operators every 2 min to improve CPR performance and to reduce fatigue. • Rhythm / pulse check every 2 min. • CPR recommenced immediately after defibrillation and after each pulse check as indicated. Defibrillation • An automated external defibrillator can be considered for use on children aged up to 8 years ONLY if an appropriate paediatric adaptor or in-built software provides the ability for age-appropriate rhythm recognition and joule delivery. This may vary from defibrillator to defibrillator. If unsure as to the settings on a particular machine, Paramedics are expected to use manual mode to analyse the rhythm and deliver a calculated 4 J/Kg shock if required. For age 9 and above, adult AED settings are appropriate. © Ambulance Victoria 2014 CPG P0201 30 – 32°C • Normal defibrillation intervals in relevant cardiac arrest CPG • Do not rewarm beyond 33°C if ROSC < 30°C • Continue CPR and rewarming until temp > 30°C • One DCCS only • One dose of Adrenaline • One dose of Amiodarone • Withhold Sodium Bicarbonate 8.4% IV • Paediatric defibrillation pads vary with device and therefore type should be determined before use. Paediatric pads usually have a maximum age / weight allowable for use and a change to adult pads is essential beyond that age / weight. Intraosseous (IO) insertion • If any delay in IV insertion (> 90 sec) insert an IO cannula. Cardiac Arrest (Paediatric) CPG P0201 173 Version 6 - 16-06-11 Page 4 of 6 Cardiac Arrest (Paediatric) CPG P0201 Where age appropriate, first rhythm analysis should be conducted in AED mode. All subsequent analyses are at Paramedic discretion. See special notes for further information. Action • Immediately commence CPR at appropriate ratio as specified ? VF/VT (pulseless) Action © Ambulance Victoria 2014 •Defibrillate single shock 4 J/kg - Repeat single shock 4 J/kg @ 2/60 intervals if VF/VT persists ? PEA ? Asystole/severe bradycardia persists Identify and Rx causes Action - Hypoxia - Exsanguination - Asthma - TPT - Anaphylaxis - Upper airway obstruction • Commence CPR if either: - Pulseless - HR < 60 (infants) - HR < 40 (children) •Confirm rhythm with printed ECG strip ? VF/VT persists ? PEA persists ? Asystole/severe bradycardia persists Action Action Action • IV access / Normal Saline TKVO • IV access / Normal Saline TKVO • IV access / Normal Saline TKVO • IO if delay in IV access • IO if delay in IV access • IO if delay in IV access •Adrenaline 10 mcg/kg IV or IO (minimum 100 mcg) - Repeat every 3/60 if no output •Adrenaline 10 mcg/kg IV or IO (minimum 100 mcg) - Repeat every 3/60 if no output •Adrenaline 10 mcg/kg IV or IO (minimum 100 mcg) - Repeat every 3/60 if no output ? VF/VT persists ? PEA persists ? Asystole/severe bradycardia persists Action Action Action • Intubate • Intubate • Intubate • If unable to obtain IV or IO - Adrenaline 100 mcg/kg via ETT • If unable to obtain IV or IO - Adrenaline 100 mcg/kg via ETT • If unable to obtain IV or IO - Adrenaline 100 mcg/kg via ETT • Change CPR ratio to 15 : 2 • Change CPR ratio to 15 : 2 • Change CPR ratio to 15 : 2 ? VF/VT persists Action • Amiodarone 5 mg/kg IV or IO Amiodarone is C/I in confirmed or suspected TCA OD ? VF/VT persists Action • Repeat Amiodarone 5 mg/kg IV or IO (max. 450 mg combined) Pulse present ? ? VF/VT persists ? PEA persists • Dehydration suspected Action •Severe bradycardia and inadequate perfusion Action • Normal Saline 20 mL/kg IV or IO Action © Ambulance Victoria 2014 • Normal Saline 20 mL/kg IV or IO • Normal Saline 20 mL/kg IV ? Asystole/severe bradycardia persists ? VF/VT persists ? PEA persists • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR Action Action Action • Sodium Bicarbonate 8.4% 1 mL/kg IV or IO • Sodium Bicarbonate 8.4% 1 mL/kg IV or IO • Sodium Bicarbonate 8.4% 1 mL/kg IV / IO ? ROSC ? ROSC ? ROSC Action Action Action • Rx as per ROSC Mx • Rx as per ROSC Mx • Rx as per ROSC Mx Sodium Bicarbonate 8.4% may be administered earlier in the algorithm if hyperkalaemia suspected or in cardiac arrest secondary to TCA OD ? Status Stop 8 Assess 8 Consider Action MICA Action Cardiac Arrest (Paediatric) CPG P0201 175 © Ambulance Victoria 2014 This page intentionally left blank Version 5 - 01.04.06 Page 6 of 6 Cardiac Arrest (Paediatric) CPG P0201 Status ? • Post cardiac arrest - ROSC Intubation/ventilation ? ? Perfusion Mx Tx ? Action Action Action •Consider ETT as per CPG P0301 Endotracheal Intubation (Paediatric) if not already intubated •Accurately assess pulse during movement/loading to ensure C.O maintained throughout • Appropriate receiving hospital • Notify early •Rx as per appropriate CPG if conditions changes •Maintain ETT as per P0301 Endotracheal Intubation (Paediatric) Do not administer Amiodarone unless breakthrough VF/VT occurs • Aim for EtCO2 30 - 35 mmHg © Ambulance Victoria 2014 • Ventilate VT 10 mL/kg ? Status Stop 8 Assess 8 Consider Action MICA Action Cardiac Arrest (Paediatric) CPG P0201 177 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 179 Version 4 - 19.11.08 Page 1 of 12 Endotracheal Intubation (Paediatric) Guide Special Notes • The Medical Advisory Committee has authorised paediatric endotracheal intubation by MICA Paramedics in selected Pts. • There are two intubation techniques available: - Intubation without drugs (unassisted endotracheal intubation) - IFS The appropriate technique will vary according to the clinical setting and a Paramedic’s authorised scope of practice. • A MICA Paramedic operating alone may elect not to use IFS until a second MICA Paramedic is present. © Ambulance Victoria 2014 • All intubations facilitated or maintained with drug therapy will be reviewed as part of AV's clinical governance processes. General Care CPG P0301 Version 4 - 19.11.08 Page 2 of 12 Endotracheal Intubation (Paediatric) Guide CPG P0301 Status ? • Endotracheal intubation ? Primary emergency indication ? Preparation ? Insertion of ETT • Respiratory arrest •See CPG P0302 Failed Intubation Drill • Cardiac arrest GCS < 10 due to: - respiratory failure - neurological injury - status epilepticus - DKA ? Drugs to facilitate intubation • IFS • RSI ? Care and maintenance • Sedation AAV only • Sedation and paralysis © Ambulance Victoria 2014 • ? Failed intubation ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation (Paediatric) CPG P0301 181 Version 4 - 19.11.08 Page 3 of 12 Endotracheal Intubation (Paediatric) Indications, Precautions, C/Is CPG P0301 Special Notes • Status epilepticus - A continuous or recurrent seizure of > 5/60 duration or no return of consciousness between episodes may require intubation where there is airway / ventilation compromise which is unable to be effectively Mx using BVM and OPA. • Neurological Injury © Ambulance Victoria 2014 - RSI should not be performed in the paediatric Pt except by AAV. General Care Version 4 - 19.11.08 Page 4 of 12 Endotracheal Intubation (Paediatric) Indications, Precautions, C/Is CPG P0301 Unassisted Endotracheal Intubation IFS ? Indication ? Indication GCS < 10 with intact airway reflexes • Respiratory arrest RSI • Respiratory failure - Unresponsive to non invasive ventilation and drug therapy • Cardiac arrest • Absent airway reflexes Contraindication • RSI not approved for use by road MICA Paramedics in paediatric Pts • DKA - DKA with BGL reading 'High' •Respiratory impairment post immersion / 8 General Precautions submersion • Time to intubation at hospital versus time to intubate at scene • •Brief cardiac arrest • Status epilepticus Advanced Care Plan in a Pt with severe pre-existing neurological disability specifies 'Not for Intubation' 8 Precautions for IFS • As per General precautions •Anticipation of difficulty with BVM ventilation • Anticipation of a difficult intubation, e.g. upper airway obstruction, facial trauma • In general if Tx time < 10/60 then no IFS Contraindication © Ambulance Victoria 2014 • Clinical situations where failed intubation drill would not be feasible such as upper airway obstruction • No functional electronic capnograph • Coma due to neurological injury (TBI, intracranial haemorrhage) ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation (Paediatric) CPG P0301 183 Version 4 - 19.11.08 Page 5 of 12 Endotracheal Intubation (Paediatric) Preparation Special Notes Age Special Notes Endotracheal tube size Length at lips 1 month 3.5 mm 9.5 cm 6 months 3.5 mm 11 cm 12 months 4 mm 12 cm Age/4 + 4 mm Age/2 + 12 cm > 12 months 1. Children under the age of 10 years should be intubated with an uncuffed ETT – the largest uncuffed ETT available is a size 6 mm. 2. If in doubt, refer to paediatric graph. The correct size ETT should allow a small leak around the ETT with positive pressure but not so great as to make ventilation inadequate. A closer fitting ETT may be necessary when ventilating stiff lungs, e.g. respiratory impairment post immersion / submersion. © Ambulance Victoria 2014 CPG P0301 ETT suction (Paediatric) This may be necessary to remove tracheal secretions or aspirated material: Suction catheter size ETT size 6 FG 3 - 3.5 mm ETT 8 FG 4 - 5.5 mm ETT 10 FG 6 mm ETT Version 4 - 19.11.08 Page 6 of 12 Endotracheal Intubation (Paediatric) Preparation Unassisted endotracheal intubation General preparation for intubation ? IFS RSI Preparation for IFS ? Action Action • Position Pt. If a cervical collar is fitted it should be opened while maintaining manual cervical support • As per General preparation for intubation • Pre-oxygenate with 100% O2 and electronic capnograph attached • If Pt hypotensive and/or tachycardic, follow relevant CPG in conjunction with the intubation process •Ensure pulse oximeter and cardiac monitor are functional CPG P0301 Contraindication • RSI not approved for use by road MICA Paramedics in paediatric Pts •Prehydrate with Normal Saline 10 mL/kg IV bolus unless APO • Draw up and label drugs as appropriate © Ambulance Victoria 2014 • Prepare equipment and assistance -Suction -ETT (plus one size smaller and one size larger than predicted immediately available) with introducer -ODD -Ensure equipment for a difficult / failed intubation is immediately available, including bougie, LMA, cricothyroidotomy kit - Mark cricothyroid membrane as necessary - Brief assistant to provide cricoid pressure, where appropriate - If suspected spinal injury, where possible a second assistant should be available to stabilise the head and neck • Ensure functional and secure IV access ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation (Paediatric) CPG P0301 185 Version 4 - 19.11.08 Page 7 of 12 Endotracheal Intubation (Paediatric) Drugs CPG P0301 IFS Drug Doses 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs Weight 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 Kg Fentanyl (IV) 2 mcg/kg 100 mcg/10 mL (10 mcg = 1 mL) 0.7 1.0 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mL 7 10 14 20 24 28 32 36 40 44 48 52 66 72 80 86 92 mcg Age Add 2 mL (100 mcg) Fentanyl (from 100 mcg in 2 mL ampoule) to 8 mL Normal Saline in a 10 mL syringe IFS Drug Doses 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs Weight 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 Kg Midazolam (IV) 0.2 mg/kg 15 mg/15 mL (10 mcg = 1 mL) 0.7 1 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mL 0.7 1 1.4 2 2.4 2.8 3.2 3.6 4 4.4 4.8 5.2 6.6 7.2 8 8.6 9.2 mg Age © Ambulance Victoria 2014 Add 3 mL (15 mg) Midazolam (from 15 mg in 3 mL ampoule) to 12 mL Normal Saline in a 20 mL syringe Version 4 - 19.11.08 Page 8 of 12 Endotracheal Intubation (Paediatric) Drugs Unassisted endotracheal intubation IFS CPG P0301 RSI Action Sedation required ? Contraindication • Proceed with intubation - no drugs required Action • RSI not approved for use by road MICA Paramedics in Paediatric Pts • Fentanyl 2 mcg/kg IV • Midazolam 0.2 mg/kg IV •If unable to administer Fentanyl Morphine 0.2 mg/kg IV If unable to intubate due to ? excessive tone Action • If GR 1 or 2 view but respiratory effort or airway reflexes are preventing intubation - Repeat same dose of sedation and reattempt intubation once only © Ambulance Victoria 2014 • If GR 3 or 4 view -P roceed to CPG P0302 Failed Intubation Drill ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation (Paediatric) CPG P0301 187 Version 4 - 19.11.08 Page 9 of 12 Endotracheal Intubation Insertion CPG P0301 Insertion of endotracheal tube General care of the intubated Pt • Observe passage of ETT through cords noting Australian Standard (AS) markings and GR of view. • Cervical collars should be placed on all intubated children over the age of 4 where practicable. • Check ETT position using ODD. • Re-confirm tracheal placement after every Pt movement using EtCO2. Disconnect and hold ETT during all transfers. • Inflate cuff (if applicable). • Confirm tracheal placement via capnometry. If capnography or colourimetric CO2 detection is negative (including Pts in cardiac arrest), the ETT must be removed. • If electronic capnography fails after intubation, use colourimetric capnometry. • Suction ETT and oropharynx in all Pts. • Exclude right main bronchus intubation by performing the cuff palpation (tracheal squash) test if applicable and by comparing air entry at the axillae. • Childrens stomachs are easily inflated. Insertion of an OG or NG tube may decrease splinting of the diaphragm and improve ventilation. • Note length of ETT at lips/teeth. • Secure the ETT and insert a bite block if required. • Ventilate using 100% O2 and VT of 10 mL/kg. Aim to maintain SpO2 > 95% and EtCO2 at 30-35 mmHg (except asthma where a higher EtCO2 may be permitted; TCA OD where the target is 20 - 25 mmHg; and DKA where the EtCO2 should be maintained at the level detected immediately post-intubation, with a max. of 25 mmHg). • If there is ANY doubt about tracheal placement the ETT must be removed. • Document all checks and observations made to confirm correct ETT placement. • Auscultate chest/epigastrium. • Note supplemental cues of correct placement (e.g. tube misting, bag movement in the spontaneously ventilating Pt, improved SpO2 and colour). • If unable to intubate after ensuring correct technique and problem solving then proceed to CPG P0302 Failed Intubation Drill. © Ambulance Victoria 2014 (Paediatric) Version 4 - 19.11.08 Page 10 of 12 Endotracheal Intubation Insertion (Paediatric) CPG P0301 8 ?Indications Status • Insertion/general care of ETT - Unassisted endotracheal intubation - IFS - RSI AAV ? Insertion and checks of ETT Action • ODD • Capnography – EtCO2 • Length lips / teeth General care / ventilation ? • Cuff palpation Action • Auscultate chest / epigastrium - Chest rise and fall, bag movement, SpO2, colour, tube misting • ETT checks with each Pt movement © Ambulance Victoria 2014 • Specific insertion instructions as per Insertion of endotracheal tube ? Status Stop • Provide circulatory support if hypotension present • Use colourimetric capnometry if capnography fails • Suction ETT and oropharynx • If capnography or colourimetricCO2 detection is negative (including Pts in cardiac arrest), the ETT must be removed. • Insert OG / NG tube • If there is ANY doubt about tracheal placement the ETT must be removed • Specific instructions as per General care of the intubated Pt 8 Assess 8 Consider Action MICA Action • Ventilate VT 10 mL/kg, EtCO2 30 - 35 mmHg if appropriate to Pt condition • Disconnect and hold ETT during transfers Endotracheal Intubation (Paediatric) CPG P0301 189 Version 4 - 19.11.08 Page 11 of 12 Endotracheal Intubation (Paediatric) Care and Mx of Intubated Pt CPG P0301 Special Notes General Care • For the Pt who becomes hypotensive after intubation, consider reducing the dose of sedation in association with additional fluid according to the clinical setting. • Morphine + Midazolam Infusion (Paediatric) - Morphine 15 mg + Midazolam 15 mg in 15 mL D5W or Normal Saline - 1 mL = 1 mg each drug - 0.1 mL = 0.1 mg each drug - 1 mL/hr = 1 mg/hr • Fentanyl + Midazolam Infusion (Paediatric) © Ambulance Victoria 2014 - Fentanyl 300 mcg + Midazolam 15 mg in 15 mL D5W or Normal Saline - 1 mL = 20 mcg Fentanyl + 1 mg Midazolam - 0.1 mL = 2 mcg Fentanyl + 0.1 mg Midazolam Version 4 - 19.11.08 Page 12 of 12 Endotracheal Intubation (Paediatric) Care and Mx of Intubated Pt CPG P0301 8 ? Status Indications 8 Consider • Intubated Pt • If Pt requires sedation or sedation / paralysis to maintain ETT and ventilation 8 ?Indications Post intubation sedation Indications Post intubation paralysis - consult only 8 ? • Restlessness / signs of under sedation in the absence of other noxious stimuli - e.g. ETT too deep / irritating, occult pain • Where sedation alone is ineffective at maintaining ETT or allowing adequate ventilation / oxygenation • As prescribed for interhospital transfer • Signs of inadequate sedation Non paralysed Pt - as per Paralysed Pt - cough / gag / movement Paralysed Pt - HR and BP trending up together - lacrimation - diaphoresis Stop • All Pts receiving paralysis MUST receive ongoing sedation • The ETT must be secured and tracheal placement re-confirmed with electronic capnography • C/I for Pt in status epilepticus Sedation ? Action Sedation and paralysis ? • Morphine / Midazolam infusion 0.1 - 0.2 mL/kg/hr IV - Repeat 0.1 mg/kg IV boluses as required Action • Sedate as per Post intubation sedation • Pancuronium 0.1 mg/kg IV - (consult only) - Repeat if evidence of returning muscular activity (movement, chewing, cough, gag, curare cleft) OR • Fentanyl / Midazolam infusion 0.1 - 0.2 mL/kg/hr IV © Ambulance Victoria 2014 • Until Morphine / Midazolam infusion established: - Midazolam 0.1 mg/kg IV as required or - Midazolam / Morphine 0.1 mg/kg IV each drug ? Status Stop 8 Assess 8 Consider Action MICA Action Endotracheal Intubation (Paediatric) CPG P0301 191 Version 1 - 19.11.08 Page 1 of 2 Failed Intubation Drill (Paediatric) Special Notes i-gel quick reference guide •Insert appropriate sized LMA where required. i-gel size Pt weight guide* 1.0 2 – 5 kg 1.5 5 – 12 kg 2.0 10 – 25 kg 2.5 25 – 35 kg 3.0 30 – 60 kg 4.0 50 – 90 kg 5.0 90+ kg Size Wt Inflation 1 < 5 kg < 6 mL 1.5 5 - 10 kg < 8 mL 2 10 - 20 kg < 12 mL 2.5 20 - 30 kg < 17 mL 3 30 - 50 kg Refer to CPG A0301 • Paediatric LMA insertion is for MICA only. • A 4.0 mm ID Minitracheotomy kit should be used for children over 12 years. • If cricothyroidotomy is required for children under the age of 12 years then needle cricothyroidotomy should be performed and jet ventilation administered. • The use of cricothyroidotomy without consultation is restricted to MICA Paramedics specifically accredited in this skill. © Ambulance Victoria 2014 CPG P0302 Max size of gastric tube N/A 10 12 12 12 12 14 *This is a guide only. Please ensure correct size is chosen corresponding to Pt airway size Version 1 - 19.11.08 Page 2 of 2 Failed Intubation Drill (Paediatric) CPG P0302 Indications Failed intubation ? • Unable to see vocal cords during initial laryngoscopy Action • Insert OPA and ventilate with 100% O2 Action • Reattempt intubation using bougie with blind placement of ETT over bougie 8 Consider Yes • Objective confirmation of tracheal placement using EtCO2 Action • Continue Mx in accordance with relevant CPG No Action • Immediately remove ETT, insert OPA and ventilate with 100% O2 8 Consider Yes • Able to ventilate and oxygenate No Action • Insert LMA © Ambulance Victoria 2014 8 Consider Yes • Able to ventilate and oxygenate Action No • If sedation drugs administered allow these to wear off and Pt to resume normal respiration Action • Cricothyroidotomy ? Status Stop 8 Assess 8 Consider Action MICA Action Failed Intubation Drill (Paediatric) CPG P0302 193 © Ambulance Victoria 2014 This page intentionally left blank Version 5 - 04.06.14 Page 1 of 3 Pain Relief (Paediatric) CPG P0501 Fentanyl Age Newborn / Infant <1 Small Child 1-8 Large Child 9 - 14 Yrs Weight < 10 10 - 24 ≥ 25 kg Fentanyl (IN) 100 mcg/2 mL (50 mcg=1 mL) N/A 0.6 1.1 mL N/A 25 50 mcg Guideline Analgesia All doses include 0.1 mL to account for atomiser dead space. © Ambulance Victoria 2014 Administer Fentanyl with caution in paediatric Pts and carefully monitor for side effects (excessive sedation, respiratory depression) In younger Pts (1-2 years) adequate analgesia may be attained with a single dose Consult with the RCH for Fentanyl doses in Pts < 10 kg (1 year) Pain Relief (Paediatric) CPG P0501 195 Version 5 - 04.06.14 Page 2 of 3 Pain Relief (Paediatric) Special Notes General Care • The max. dose of Methoxyflurane is 6 mL per 24 hr period. • IN Fentanyl must be drawn up from 100 mcg in 2 mL for children • If IV access is not available or delayed, consider IN Fentanyl and/or Methoxyflurane. • It is essential that the dose, vol and correct ampoule are double checked prior to administration. • Exercise caution if using Fentanyl and Morphine in combination. Smaller doses will be required. • To administer Fentanyl, draw up desired vol according to dose table for the corresponding weight and age then atomise into Pt's nostril. If Pt is compliant, divide dose between both nostrils to optimise absorption. • In younger Pts (1 - 2 years) adequate analgesia may be attained with a single dose of IN Fentanyl. Carefully monitor for side effects such as excessive sedation and respiratory depression. • Consult with the RCH for IN Fentanyl doses in Pts < 10 kg (1 year) • If respiratory depression occurs due to opioid administration, Mx as per CPG P0707 Overdose if required. • The analgesic effect of IM Morphine is slow and variable. This protocol must be used as a last resort and strictly within indicated CPG. • When administering IM Morphine, unless the Pt is heavier than their age-calculated weight, the max. increment given should not exceed 5 mg. © Ambulance Victoria 2014 CPG P0501 Version 5 - 04.06.14 Page 3 of 3 Pain Relief (Paediatric) CPG P0501 Status ? 8 Assess • Complaint of pain • Pain score > 2 • Determine requirement for non IV vs IV therapy If? Non IV therapy ? IV therapy • Pain likely to be controlled by non IV therapy • Pain may require IV opioid and ongoing therapy • Unaccredited for IV or unable to obtain IV Action Action • Consider Fentanyl IN and/or Methoxyflurane if appropriate • Fentanyl IN - Large child (≥ 25 kg) Fentanyl 50 mcg IN - Small child (10 - 24 kg) Fentanyl 25 mcg IN - Repeat same dose @ 5 - 10/60 titrated to pain or side effects (max. 3 doses) - Consult with the RCH for doses in children < 10 kg • Morphine 0.05 - 0.1 mg/kg IV - Repeat up to 0.05 mg/kg IV @ 5 - 10 / 60 - Titrated to obtain pain reduction to comfortable / tolerable level or side effects - Max. 0.2 mg/kg IV without consultation If unable to administer IN Fentanyl • Methoxyflurane 3 mL - Repeat 3 mL if required (max. 6 mL) © Ambulance Victoria 2014 • If pain not controlled by above and unable/not accredited to gain IV access: -Morphine 0.1 mg/kg IM -Single dose - consult with the RCH or the receiving hospital for further doses Prepare dose from Fentanyl 100 mcg/2 mL ? Status Stop 8 Assess 8 Consider ✔ Action ✔ MICA Action Pain Relief (Paediatric) CPG P0501 197 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 199 Upper Airway Obstruction (Paediatric) Special Notes © Ambulance Victoria 2014 Pts with suspected epiglottitis should be considered time critical. General Care CPG P0601 Version 4 - 08.06.11 Page 1 of 3 Upper Airway Obstruction (Paediatric) ? Status 8 Assess • Suspected upper airway obstruction • Identify possible cause CPG P0601 Partial obstruction ? Partial obstruction ? Croup ? ? Suspected epiglottitis • Effective cough • Ineffective cough Action Action Action • See CPG P0601 Action • •Use manual techniques as required: - Utilise gravity - Back slaps alternating with chest thrusts Passive techniques - Encourage cough - Utilise gravity - Maintain BLS Do not inspect airway • BLS • Tx • IF unconscious or becomes unconscious - Chest compressions - Suction - Magill's forceps - Forced ventilation • IF loss of C.O. - M x as per CPG P0201 Cardiac Arrest ack slap should not be used on B newborns © Ambulance Victoria 2014 ? Status Stop 8 Assess 8 Consider Action MICA Action Upper Airway Obstruction (Paediatric) CPG P0601 201 Version 4 - 08.06.11 Page 2 of 3 Upper Airway Obstruction Special Notes • Signs of severe croup - Agitation - Distress - Cyanosis - SpO2 of < 92% on air or decreasing SpO2 -Increased use of accessory muscles. • Reduction of cough / stridor and increasing lethargy may be a sign of worsening condition and needs to be assessed carefully. © Ambulance Victoria 2014 • Nebulised Adrenaline for croup is indicated for children presenting with some of the above signs of hypoxia or in a deteriorating condition. (Paediatric) General Care CPG P0601 Version 4 - 08.06.11 Page 3 of 3 Upper Airway Obstruction (Paediatric) ? Status 8 Assess • Croup / suspected croup • Respiratory distress CPG P0601 • Cough / stridor ? Mild / moderate ? Severe Action • • BLS • Rx as per Severe if Pt deteriorates Either: - Increasing respiratory distress - Increasing lethargy - Decreasing stridor Action • Adrenaline 5 mg/5 mL Nebulised (1:1,000) ? If improved ? If unimproved Action Action • Continue to monitor Pt •Repeat Adrenaline as above @ 5/60 intervals until improvement • Tx • Continue to monitor Pt © Ambulance Victoria 2014 • Tx ? Status Stop 8 Assess 8 Consider Action MICA Action Upper Airway Obstruction (Paediatric) CPG P0601 203 © Ambulance Victoria 2014 This page intentionally left blank Version 4 - 04.06.14 Page 1 of 7 Asthma (Paediatric) CPG P0602 ? Status Assess 8 • Respiratory distress • Severity of asthma presentation Mild or Moderate ? Severe ? ? Unconscious ? No cardiac output Action Action Action Action • See CPG P0602 • See CPG P0602 • See CPG P0602 • Loses C.O. See CPG P0602 © Ambulance Victoria 2014 • PEA as per CPG P0201 Cardiac Arrest ? Status Stop 8 Assess 8 Consider Action MICA Action Asthma (Paediatric) CPG P0602 205 Version 4 - 04.06.14 Page 2 of 7 Asthma (Paediatric) Special Notes General Care • Asthmatic Pts are dynamic and can show initial improvement with Rx then deteriorate rapidly. •Salbutamol infusion -100 mcg/kg Salbutamol added to make 50 mL D5W or Normal Saline -Administer @ 2 mcg/kg/min (60 mL/hr) • Consider MICA support but do not delay Tx waiting for back up. • Despite hypoxaemia being a late sign of deterioration, pulse oximetry should be used throughout Pt contact. • An improvement in SpO2 may not be a sign of improvement in clinical condition. • Paramedic assessment should consider any Rx prior to ambulance arrival, including whether or not the Pt has activated their asthma Mx plan. © Ambulance Victoria 2014 CPG P0602 Version 4 - 04.06.14 Page 3 of 7 Asthma (Paediatric) CPG P0602 Status ? 8 Assess • Respiratory distress • Severity of distress ? Mild or Moderate ? Severe Action Action • Salbutamol pMDI and spacer - ≥ 6 years Salbutamol 4-12 doses - < 6 years Salbutamol 2-6 doses - Pt to take 4 breaths for each dose • Salbutamol 10 mg (5 mL) and Ipratropium Bromide 250 mcg (1 mL) Nebulised -Repeat Salbutamol 5 mg (2.5 mL) Nebulised @ 5/60 if required • If pMDI spacer unavailable - Salbutamol 10 mg (5 mL) Nebulised - Repeat 5 mg (2.5 mL) @ 5/60 if required • Salbutamol 5 mcg/kg IV - Repeat 2.5 mcg/kg IV @ 2 - 3/60 if required (max. 10mcg/kg) • Dexamethasone 600 mcg/kg IV (max. 12 mg) ? Adequate response No significant response after 20/60 ? Action Action •Tx with continued reassessment • Rx as per Severe If unimproved •Salbutamol infusion 2 mcg/kg/min (60 mL/hr) © Ambulance Victoria 2014 •Repeat Salbutamol as necessary ? Status Stop 8 Assess 8 Consider Action MICA Action Asthma (Paediatric) CPG P0602 207 Version 4 - 04.06.14 Page 4 of 7 Asthma (Paediatric) Special Notes • High EtCO2 levels should be anticipated in the intubated asthmatic Pt. An EtCO2 level of 120 mmHg in this setting is considered safe and when Mx ventilation the Paramedic should be conscious of the effect of gas trapping when attempting to reduce EtCO2. © Ambulance Victoria 2014 • Extreme care must be taken with assisted ventilation as gas trapping and barotrauma occurs easily in asthmatic Pts with already high airway pressures. CPG P0602 General Care Version 4 - 04.06.14 Page 5 of 7 Asthma (Paediatric) CPG P0602 Status ? • Unconscious / becomes unconscious with poor or no ventilation but still with C.O. 8 Immediate action Pt requires immediate assisted ventilation • Ventilate @: Infant 15 - 20 ventilations/min, VT 10 mL/kg Small child 10 - 15 ventilations/min, VT 10 mL/kg Large child 8 - 12 ventilations/min, VT 10 mL/kg • Moderately high respiratory pressures • Allow for prolonged expiratory phase • Gentle lateral chest pressure during expiration Adequate response ? Inadequate response ? Action Action • Rx as per Severe respiratory distress • If unable to gain IV or unaccredited in IV Salbutamol - Adrenaline 10 mcg/kg IM (1:1,000) - Repeat @ 20/60 as required (max. 30 mcg/kg IM) • Rx as per Severe respiratory distress • Consider intubation per CPG P0301 Endotracheal Intubation • If unable to obtain IV or IO – Salbutamol 10 mcg/kg via ETT • Repeat Salbutamol 5 mcg/kg via ETT @ 2-3/60 if required (max. 20 mcg/kg ETT) © Ambulance Victoria 2014 ? Status Stop 8 Assess 8 Consider Action MICA Action If Pt loses C.O. at any stage see CPG P0602 Asthma (Paediatric) CPG P0602 209 Version 4 - 04.06.14 Page 6 of 7 Asthma (Paediatric) Special Notes • Consider potential for TPT and Mx. • Due to high intrathoracic pressure as a result of gas trapping, venous return is impaired and C.O. may be lost. Apnoea allows the gas trapping to decrease. © Ambulance Victoria 2014 • The Pt receiving APPV is at higher risk of this occurring and should be monitored closely. CPG P0602 General Care Version 4 - 04.06.14 Page 7 of 7 Asthma (Paediatric) CPG P0602 ? Status •Pt loses C.O. Pt requires immediate intervention Action • Apnoea 30 sec - Exclude TPT - Gentle lateral chest pressure - Prepare for potential resuscitation C.O. returns ? ? Carotid pulse, no BP ? No return of C.O. Action Action Action • Treat as per CPG A0602 • Adrenaline 10 mcg/kg IV - Repeat 10 mcg/kg IV @ 5/60 as required • Mx as per appropriate CPG © Ambulance Victoria 2014 • Normal Saline 20 mL/kg IV ? Status Stop 8 Assess 8 Consider Action MICA Action Asthma (Paediatric) CPG P0602 211 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 213 Version 2 - 19.11.08 Page 1 of 2 Hypoglycaemia (Paediatric) CPG P0702 Special Notes General Care • Pt may be aggressive during Mx. • If Pt’s next meal is more than 20/60 away, encourage the Pt to eat a long acting carbohydrate (e.g. sandwich, piece of fruit, glass of milk) to sustain BGL until next meal. • Ensure IV patent before administering Dextrose. Extravasation of Dextrose can cause tissue necrosis. • IV should be flushed well, both before and after Dextrose administration. • Ensure sufficient advice on further Mx and follow-up if Pt refuses Tx. • If adequate response, maintain initial Mx and Tx. • If the Pt refuses Tx, repeat the advice for Tx using friend / relative assistance. If Pt still refuses Tx, document the refusal and leave Pt with a responsible third person. Advise the third person of actions to take if symptoms recur and of the need to make early contact with LMO for follow up. • If inadequate response Tx without undue delay. • Maintain general care of unconscious Pt and ensure adequate airway and ventilation. • Further dose of Dextrose 10% may be required in some hypoglycaemic episodes. Consider consultation if BGL remains less than 4 mmol/L and unable to administer oral carbohydrates © Ambulance Victoria 2014 • Continue initial Mx and Tx. Version 2 - 19.11.08 Page 2 of 2 Hypoglycaemia (Paediatric) CPG P0702 ? Status • Evidence of probable hypoglycaemia - e.g. Hx diabetes, unconscious, pale, diaphoretic 8 Assess • BGL ? BGL > 4 mmol/L ? BGL < 4 mmol/L Responds to commands ? BGL < 4 mmol/L Does not respond to commands ✔ Action ✔ Action Action • Glucose 15 g Oral • BLS • If not accredited in IV Dextrose or no IV access - < 25 kg Glucagon 0.5 IU IM (0.5 mL) - > 25 kg Glucagon 1 IU IM (1 mL) • Consider other causes of altered conscious state - e.g. stroke, seizure, hypovolaemia • Dextrose 10% 3 mL/kg (300 mg/kg) IV - Normal Saline 10 mL IV flush • If unable to obtain IV access, Glucagon as above ? Adequate response ? Poor response ✔ Action ? Adequate response ? Inadequate response • GCS 15 • GCS < 15 after 3/60 • Consider Glucagon IM ✔ Action ✔ Action • Consider Dextrose IV • Cease Dextrose if still being given • Repeat Dextrose 10% 2 mL/kg (200 mg/kg) IV titrating to Pt conscious state ✔ Action © Ambulance Victoria 2014 • Consider Tx ? Status Stop 8 Assess 8 Consider Action MICA Action Hypoglycaemia (Paediatric) CPG P0702 215 Version 5 - 04.06.14 Page 1 of 2 Seizures (Paediatric) CPG P0703 Special Notes Special Notes • For the purposes of this CPG, Status Epilepticus (SE) refers to either ≥ 5/60 of continuous seizure activity OR multiple seizures without full recovery of consciousness (i.e. back to baseline) between seizures. • For seizures other than GCSE, Midazolam may only be administered following consultation via the Clinician. • Generalised Convulsive Status Epilepticus (GCSE) is characterised by generalised tonic-clonic movements of the extremities with altered conscious state. • If a single seizure has spontaneously terminated continue with initial Mx and Tx. • Some Pts may be prescribed buccal / intranasal midazolam or rectal diazepam to manage seizures. • If Pt has a PHx of seizures and refuses Tx, they may be left in the care of a responsible third party. Advise the person of the actions to take for immediate continuing care if symptoms recur, and the importance of early contact with their primary care physician for follow-up • Subtle Status Epilepticus may develop from prolonged or uncontrolled GCSE and is characterised by coma and ongoing electrographical seizure activity without any or with only subtle convulsive movements (e.g. rhythmic muscle twitches or tonic eye deviation). Subtle SE is difficult to diagnose in the pre-hospital environment but should be considered in Pts who are witnessed to have generalised tonic-clonic convulsions initially and present with ongoing coma with no improvement in conscious state (with or without subtle convulsive movements). Midazolam Dosage Chart Age Newborn Infant <1 Small Child 1-8 Large Child 9 - 14 Yrs Weight <5 5-9 10 - 24 ≥ 25 kg Midazolam (IM) 5 mg/1 mL (1 mg=0.2 mL) 0.1 0.2 0.5 1 mL 0.5 1 2.5 5 mg © Ambulance Victoria 2014 1 mL syringe Midazolam (IV) 15 mg/15 mL (1 mg=1 mL) 0.2 0.5 1 2 mL 0.2 0.5 1 2 mg Add 3 mL (15mg) Midazolam (from 15 mg in 3 mL ampoule) to 12 mL Normal Saline in a 20 mL syringe *0.1 mL has been made a minimum vol to reduce dosage error. The minimum vol is sometimes different to the prescribed dose and should be recorded/handed over as the dose delivered. An example of the error that occurs in a vol less than 0.1 mL is as follows: required dose vol of 0.07 mL, 0.7 mL is prepared and the Pt incorrectly receives 10 × required dose. Version 5 - 04.06.14 Page 2 of 2 Seizures (Paediatric) CPG P0703 Assess / manage Status ? • Evidence of Status Epilepticus (≥ 5/60 or ≥ 2 seizures without recovery) • Seizure activity - GCSE or other SE (including subtle SE) •Consider other causes e.g. hypoglycaemia, hypoxia, head trauma, stroke / ICH, electrolyte disturbance, meningitis • Consider Pt’s own Mx plan and Rx already given ? Seizure activity ceased / Other SE / Subtle SE ? Generalised Convulsive SE Action Action • BLS • Mx airway and ventilation as required • Continue to monitor airway, ventilation, conscious state and BP • If airway patent, administer high-flow O2 • If subtle SE suspected, consider time-critical transport to hospital and consult • Midazolam IM Clinician for Midazolam - Large child (≥ 25 kg) Midazolam 5 mg IM - Small child (10 - 24 kg) Midazolam 2.5 mg IM - Infant (5 - 9 kg) Midazolam 1 mg IM - Newborn (< 5 kg) Midazolam 0.5 mg IM • Continue to monitor airway, ventilation, conscious state and BP ? Seizure activity ceases Action ? Seizure activity continues > 5/60 • IV access © Ambulance Victoria 2014 ventilation, conscious state and BP Seizure activity continues > 10/60 Action • Midazolam IV • Continue to monitor airway, ? • No IV access/accreditation Action • BLS • Repeat original Midazolam IM - Large child Midazolam 2 mg IV - Small child Midazolam 1 mg IV - Infant Midazolam 0.5 mg IV - Newborn Midazolam 0.2 mg IV • Repeat original dose IV @ 2 - 5/60 as required dose once only • Consult for further doses •Continue to monitor airway, ventilation, conscious state and BP - Max. 3 IV doses (in addition to IM) • Consult for further doses •Consider intubation as per CPG P0301 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider Action Pancuronium C/I MICA Action Continuous Tonic-clonic Seizures (Paediatric) CPG P0703 217 © Ambulance Victoria 2014 This page intentionally left blank Version 61 - 04.06.14 20.09.06 Page 12 of 32 Anaphylaxis Xx (Paediatric) CPG P0704 A0403 Special Notes General Care • Signs of allergy include a range of cutaneous manifestations and/or a history of allergen exposure. This history can include food, bites/stings, medications or the allergen can be unknown. • Anaphylaxis can be difficult to identify. Cutaneous features are common though not mandatory. Irrespective of known allergen exposure, if 2 systemic manifestations are observed then anaphylaxis should be accepted. • In rare circumstances anaphylaxis can occur with symptoms in an isolated body system. If a Pt has hypotension relative to age (as per CPG P0101) following exposure to a known allergen for them consider treating as per anaphylaxis. • Deaths from anaphylaxis are far more likely to be associated with delay in management rather than due to inadvertent administration of Adrenaline. • International guidelines recommend IM administration of Adrenaline to the anterolateral mid-thigh as the preferred site due to improved absorption. Whilst remaining alert to patient comfort and dignity issues, the mid-lateral thigh should be considered the preferred site of administration where possible. • IV Adrenaline should be reserved for the Pt who is extremely poorly perfused or facing impending cardiac arrest. • IV Adrenaline should be subsequent to IM Adrenaline in all cases with an initial IM therapy option selected for each anaphylaxis Pt regardless of presentation. • IV Adrenaline should preferably be administered via a syringe pump infusion where possible. • For Pts persistently unresponsive to Adrenaline (especially if taking beta blocking medication) the administration of Glucagon 20-30 mcg / kg (max 1 mg) IV can be considered under consult. Glucagon administration must not delay further Adrenaline administration. • All Pts with suspected anaphylaxis must be advised that they should be transported to hospital regardless of the severity of their presentation or response to management. International guidelines recommend at least 4 hours of observation following treatment. • Different brands of self-administered adrenaline autoinjectors will deliver different doses of adrenaline. In the absence of Paramedic intervention, an auto-injector is an appropriate treatment. • Nebulised pharmacology may be of benefit in management of anaphylaxis though should always be secondary therapy. Salbutamol may be of use for persistent bronchospasm and Adrenaline may be of use for persistent upper airway oedema and stridor. • Where poor perfusion persists despite initial Adrenaline therapy, large volumes of fluid may be extravasating. IV fluid therapy is indicated to support vasopressor administration. Preparation of Adrenaline infusion (syringe pump): Adrenaline 300 mcg added to make 50 mL with 5% Dextrose or Normal Saline 1 mL = 6 mcg 1 mL/hr = 0.1 mcg/min © Ambulance Victoria 2014 At low flow rates in younger children an infusion may not be as effective as providing boluses. Clinical judgement should be applied to the most effective route of administration. Key reference: Simons FE, Ardusso L, Bilo M, Dimov V, Ebisawa M, El-Gamal Y, Ledford D, Lockey R, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong Y, and Worm M, “2012 Update: World Allergy Organisation Guidelines for the Assessment and Management of Anaphylaxis”, Current Opinion in Allergy and Clinical Immunology, 2012, 12:389-399 ? Status Stop 8 Assess 8 Consider Action MICA Action Anaphylaxis Xx CPG A0403 P0704 219 Version 16 - 20.09.06 04.06.14 Page 12 of 23 Xx Anaphylaxis (Paediatric) CPG A0403 P0704 ? Status Stop • Suspected anaphylaxis •If Pt has Hx of anaphylaxis and has received Mx prior to arrival they MUST be Tx to hospital for observation and follow up Assess • Sudden onset of illness (min to hrs) AND • Two or more of R.A.S.H.: - R Respiratory distress (SOB, wheeze, cough, stridor) - A Abdominal symptoms (nausea, vomiting, diarrhoea, abdo pain/cramps) - SSkin/mucosal symptoms (hives, welts, itch, flushing, angioedema, swollen lips/tongue) - H Hypotension (or altered conscious state) OR © Ambulance Victoria 2014 • Isolated hypotension (relative to age) with exposure to known antigen No anaphylaxis Anaphylaxis / Severe allergic reaction Action Action • BLS • Reassess for potential deterioration • Consider Tx for observation and further Mx • Monitor cardiac rhythm • Adrenaline 10 mcg/kg IM (1:1,000) - Repeat 10 mcg/kg IM @ 5/60 until satisfactory results or side effects occur • Provide high flow O2 • Mx respiratory distress as indicated - Rx bronchospasm as per CPG P0602 Asthma - Consider nebulised Adrenaline for upper airway oedema as per CPG P0601 Upper Airway Obstruction • Consider fluid as per CPG P0801 Hypovolaemia • Dexamethasone 600 mcg/kg IV (max. dose 12mg) Refusal of Transport Irrespective of symptom resolution If Pt has had a possible anaphylactic reaction (irrespective of severity) then they should be offered Tx. If they refuse Tx then where possible they should be: Action • Tx • Reassess en route • Monitor for recurring symptoms •Advised of the risk and consequences of deterioration • Left with a responsible 3rd party •Given clear instructions on when to call back if required • Advised to follow up with their LMO Inadequate Response • Extremely poor perfusion and/or • Impending cardiac arrest Action © Ambulance Victoria 2014 • If no IV access consider IO • Commence Adrenaline infusion @ 0.05 mcg/kg/min - If necessary titrate to effect up to a max. rate of 1 mcg/kg/min • If unable to establish infusion Adrenaline 10 mcg/kg IV/IO - Repeat 10 mcg/kg IV/IO @ 1/60 until adequate perfusion or side effects occur • Consider intubation. If intubated with no IV/IO access - Adrenaline 100 mcg/kg via ETT @ 5/60 ? Status Stop 8 Assess 8 Consider Action MICA Action Anaphylaxis CPG P0704 221 Version 4 1 - 20.09.06 Page 1 of 2 Xx Meningococcal Septicaemia CPG A0403 P0706 (Paediatric) Special Notes General Care • A typical purpuric rash may be subtle in some cases and present as a single ‘spot’ only. • Ceftriaxone preparation -Dilute Ceftriaxone 1 g with 9.5 mL of Water for Injection and administer 50 mg/kg IV over approximately 2 min (NB 1 mL = 100 mg). -If unable to obtain IV access, or not accredited in IV cannulation, dilute Ceftriaxone 1 g with 3.5 mL 1% Lignocaine HCL and administer 50 mg/kg IM into the upper lateral thigh (NB 1 mL = 250 mg). • The presence of rapid onset symptoms of sepsis +/rash may be a sign of meningococcal septicaemia. • Meningococcal is transmitted by close personal exposure to airway secretions / droplets. • Ensure face mask protection especially during intubation / suctioning. • Ensure medical follow up for staff post exposure. • Consider consultation where diagnosis is uncertain. Paediatric Chart Age Weight 0 2 Mth 6 Mth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Yrs 3.5 5 7 10 12 14 16 18 20 22 24 26 33 36 40 43 46 kg 1.4 2 2.4 2.8 3.2 3.6 4 4 4 4 4 4 4 4 4 mL 350 500 600 700 800 900 Ceftriaxone (IM) 50 mg/kg 0.7 1.0 1 g diluted with 3.5 mL 1% Lignocaine 175 250 (1 mL = 250 mg) 1 mL syringe © Ambulance Victoria 2014 Ceftriaxone (IV) 50 mg/kg 1.75 1 g diluted with 9.5 mL Water for Injection 175 (1 mL = 100 mg) 1000 1000 1000 1000 1000 1000 1000 1000 1000 mg 2.5 mL syringe 10 mL syringe 2.5 3.5 5 6 7 8 9 10 250 350 500 600 700 800 900 10 10 10 10 10 10 10 10 mL 1000 1000 1000 1000 1000 1000 1000 1000 1000 mg 10 mL syringe Version 4 1 - 20.09.06 Page 2 of 2 Xx Meningococcal Septicaemia (Paediatric) CPG A0403 P0706 Status ? • Possible meningococcal septicaemia PPE Confirm meningococcal septicaemia 8 • Typical purpuric rash • Septicaemia signs - Fever, rigor, joint and muscle pain - Cool hands and feet - Tachycardia, hypotension - Tachypnoea • Meningeal signs - Headache, photophobia, neck stiffness - Nausea and vomiting - Altered consciousness - Irritable or whimpering IV Access ? ? No IV Access Action © Ambulance Victoria 2014 • Ceftriaxone 50 mg/kg IV max. 1000 mg -Dilute 1000 mg to 10 mL with Water for Injection - Administer slowly over 2/60 ? Status Stop 8 Assess 8 Consider Action MICA Action - Unable to gain - Not IV accredited Action • Ceftriaxone 50 mg/kg IM max. 1000 mg -Dilute 1000 mg with 3.5 mL Lignocaine 1% - Administer into upper lateral thigh Meningococcal Septicaemia (Paediatric) Xx CPG A0403 P0706 223 Version 2 1 - 20.09.06 Page 1 of 8 2 Xx Overdose (Paediatric) General Care General Care • Provide supportive care (all cases) • Confirm clinical evidence of substance use or exposure - Identify which substance/s are involved and collect if possible. - Provide appropriate airway Mx and ventilatory support. - If Pt is in an altered conscious state, assess BGL and if necessary Mx as per CPG P0702 Hypoglycaemia (Paediatric). - Identify by which route the substance/s have been taken (e.g. ingestion). - If Pt is bradycardic with poor perfusion Mx as per CPG P0201 Bradycardia (Paediatric). - Establish the amount of substance/s taken. - If Pt is inadequately perfused, Mx as per CPG P0801 Hypovolaemia (Paediatric) in cases other than TCA OD. (e.g. alcohol, water)? - Assess Pt temp and Mx as per CPG P0901 Hypothermia / Cold exposure (Paediatric), or CPG P0902 Environmental Hyperthermia / Heat Stress (Paediatric). © Ambulance Victoria 2014 CPG A0403 P0707 - Establish the time the substance/s were taken. - What were the substance/s mixed with when taken - What Rx has been initiated prior to ambulance arrival (e.g. induced vomiting)? When dealing with cases of overdose, if paramedics are unfamiliar with a substance or unsure of the effects it may have, then consultation with Poisons Information should take place. They can be contacted via the Clinician, or on 13 11 26. Version 2 - 20.09.06 Page 2 of 8 Overdose (Paediatric) CPG P0707 Status ? 8 Assess • Suspected OD • Substance involved TCA Antidepressants ? Sedatives ? Psychostimulants ? e.g.- Heroin - Morphine - Codeine - Other opioid preparations e.g.- Amitriptyline - Nortriptyline - Dothepin e.g.- GHB - Alcohol - Benzodiazepines - Volatile agents e.g.- Cocaine - Amphetamines - Ecstacy - PCP © Ambulance Victoria 2014 ? Opioids ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose (Paediatric) CPG P0707 225 Version 2 - 20.09.06 Page 3 of 8 Overdose: Opioids (Paediatric) CPG P0707 Special Notes General Care • Opioids may be in the form of IV preparations such as Heroin or Morphine and oral preparations such as Codeine, Endone, MS Contin. Some of these drugs also come as suppositories and topical patches. •If inadequate response after 10/60 Pt is likely to require Tx without delay. • Not all opioid ODs are from IV administration of the drug. - Maintain general care of the unconscious Pt and ensure adequate airway and ventilation. - Consider other causes e.g. head injury, hypoglycaemia polypharmacy OD. © Ambulance Victoria 2014 - Beware of Pt becoming aggressive. Version 2 - 20.09.06 Page 4 of 8 Overdose: Opioids (Paediatric) ? Status CPG P0707 Stop • Ensure personal / crew safety • Possible opioid OD • Scene may have concealed syringes Assess evidence of opioid OD 8 - Altered conscious state - Respiratory depression - Substance involved - Pin point pupils - Track marks - Exclude other causes (e.g. obvious head injury) ? Opioid OD Action • Assist and maintain airway / ventilation • Naloxone 10 mcg/kg (max. 2 mg) IM ? Adequate response ? Inadequate response after 10/60 Action Action • BLS • Repeat Naloxone 10 mcg/kg (max. 2 mg) IM © Ambulance Victoria 2014 • Naloxone 10 mcg/kg (max. 2 mg) IM or IV • Consider airway Mx CPG P0301 Endotracheal Intubation ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: Opioids (Paediatric) CPG P0707 227 Version 2 - 20.09.06 Page 5 of 8 Overdose: Tricyclic Antidepressants (TCA) (Paediatric) Special Notes ECG changes ECG changes include prolonged PR, QRS and QT intervals associated with an increased risk of seizures if QRS > 0.10 sec and ventricular arrhythmias if QRS > 0.16 sec. © Ambulance Victoria 2014 How to measure a QT interval is shown below. General Care CPG P0707 Version 2 - 20.09.06 Page 6 of 8 Overdose: Tricyclic Antidepressants (TCA) (Paediatric) ? Status CPG P0707 Assess 8 • Possible TCA OD • Substance involved • Perfusion status • ECG criteria ? No toxicity ? Signs of TCA toxicity Action • BLS • Consider potential to develop signs of toxicity Any of the following: - Less than adequate perfusion - QRS > 0.12 sec (> 0.16 sec indicates severe toxicity) - QT prolongation (> 1/2 R-R interval) Stop •Amiodarone is C/I in the setting of confirmed or suspected TCA OD Action • Sodium Bicarbonate 8.4% 2 mL/kg IV over 3/60 - Repeat 2 mL/kg IV after 10/60 if signs of toxicity persist - Severe cases may require continuing doses - Consult RCH or receiving hospital © Ambulance Victoria 2014 •Consider ETT as per CPG P0301 Endotracheal Intubation - Hyperventilate relative to age with 100% O2 - EtCO2 target 20 - 25 mmHg if intubated ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: TCA (Paediatric) CPG P0707 229 Version 2 - 20.09.06 Page 7 of 8 Overdose: Sedative Agents/Psychostimulants (Paediatric) Special Notes Special Notes • For Pts who refuse Tx, repeat the advice for Tx using friend / relative assistance. If Pt still refuses Tx advise the Pt and responsible third person of follow up options, counselling services and actions to take for immediate continuing care if symptoms recur. • If Pt claims to have taken an OD of a potentially lifethreatening substance then they must be Tx to hospital. Police assistance should be sought to facilitate this as required. • For young persons, Paramedics should strongly encourage them to make contact with a responsible adult. • Paramedics should call the Police if in their professional judgement there appears to be factors that place the Pt at increased risk, such as: -Is subject to violence (e.g. from a parent, guardian or care giver). - Is likely to be, or is in danger of sexual exploitation. - In particular for children where: -The supply of drugs appears to be from a parent / guardian / care giver. -There is other evidence of child abuse / maltreatment or evidence of serious untreated injuries. © Ambulance Victoria 2014 CPG P0707 • Documentation of refusal and actions taken must be recorded on the PCR. • If the Police are contacted, they will notify Department of Human Services Child Protection if they believe the young person is in need of protection. • If a young person makes it known they are involved with DHS Child Protection and they give permission, an attempt should be made on their behalf to contact the young person’s Child Protection practitioner, Region or Child Protection After Hours Service (24 hours on 131 278) to advise of the ambulance attendance and Rx. The intent is to make arrangements for ongoing care for this Pt. Such contact is best made through the Clinician in the operations / communications centre. Version 2 - 20.09.06 Page 8 of 8 Overdose: Sedative Agents/Psychostimulants (Paediatric) ? Status CPG P0707 8 Assess • Sedative agents • Substances involved • Psychostimulants ? Sedative agents ? Psychostimulants Action Action • Be aware for potential for agitation / aggression particularly in GHB / volatile substance abuse • Be aware of potential for violent behaviour particularly with methamphetamines • Pt may require airway Mx • Reduce stimulus by calming and controlling Pt environment • Mx agitation / aggression as per CPG A0708 The Agitated Patient - Children up to 14 will be Mx in accordance with the adult CPG if sedation is required • Mx seizures as per CPG P0703 Seizures (Paediatric) • Mx temp as per CPG P0901 Hypothermia / Cold Exposure (Paediatric) or CPG P0902 Environmental Hyperthermia / Heat Stress (Paediatric) © Ambulance Victoria 2014 • Mx agitation / aggression as per CPG A0708 The Agitated Patient ? Status Stop 8 Assess 8 Consider Action MICA Action Overdose: Sedative Agents/Psychostimulants (Paediatric) CPG P0707 231 Version 3 - 01.11.05 Page 1 of 2 Organophosphate Poisoning (Paediatric) Special Notes General Care •Notification to receiving hospital essential to allow for Pt isolation. • Where possible, remove contaminated clothing and wash skin thoroughly with soap and water. • The key word to look for on the label is anticholinesterase. There are a vast number of organophosphates which are used not only commercially but also domestically. • Minimise the number of staff exposed. • If a potential contamination by a possible organophosphate has occurred, the container identifying trade and generic names should be located and the Poisons Information Centre contacted for confirmation and advice via the Clinician, or on 13 11 26. © Ambulance Victoria 2014 CPG P0709 • Attempt to minimise transfers between vehicles. Version 3 - 01.11.05 Page 2 of 2 Organophosphate Poisoning (Paediatric) CPG P0709 ? Status • Possible organophosphate exposure Stop • Avoid self contamination - wear PPE • Pt decontamination if possible 8 Confirm evidence of suspected poisoning • Cholinergic effects: salivation, bronchospasm, sweating, nausea or bradycardia + AND ? No excessive cholinergic effects Action 8 Evidence of excessive cholinergic effects • Salivation compromising the airway or bronchospasm and/or • Bradycardia with inadequate perfusion ? Excessive cholinergic effects Action • Tx to nearest appropriate hospital • Atropine 20 mcg/kg IV • Monitor for excessive cholinergic effects - Repeat 20 mcg/kg IV @ 5/60 until excessive cholinergic effects resolve • Consult with receiving hospital for further Mx if required © Ambulance Victoria 2014 The use of Suxamethonium is C/I in Pt with suspected organophosphate poisoning ? Status Stop 8 Assess 8 Consider Action MICA Action Organophosphate Poisoning (Paediatric) CPG P0709 233 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 235 Version 5 - 20.09.06 Page 1 of 2 Hypovolaemia (Paediatric) Special Notes CPG P0801 General Care •Modifying factors must be considered and Mx prior to aggressive fluid therapy. •Always consider TPT, particularly in the Pt with a chest injury, not responding to fluid therapy and persistently hypotensive. •Excessive fluid should not be given if SCI is an isolated injury. •If IV access is unable to be obtained and the Pt is obtunded, insert IO. •Pain relief as per CPG P0501 Pain Relief (Paediatric) Modifying factors • Pt with isolated neurogenic shock can be given up to 5 mL/kg Normal Saline IV bolus to correct hypotension • Chest injury - Consider TPT Rx as per CPG P0802 Chest Injury (Paediatric) © Ambulance Victoria 2014 • Penetrating trunk injury or uncontrolled haemorrhage - Accept palpable carotid pulse and Tx immediately. Consider IV access en route to hospital. Version 5 - 20.09.06 Page 2 of 2 Hypovolaemia (Paediatric) CPG P0801 Status ? Stop • Evidence of hypovolaemia • Identify and Mx: - Haemorrhage - Fractures - Pain - TPT - Hypoxia 8 Consider modifying factors / assess perfusion - - - - SCI chest injury penetrating trunk injury or uncontrolled haemorrhage ? Adequate perfusion ? Inadequate or no perfusion Action Action • Fluid not required • IV access - IO if unable to obtain • Normal Saline 20 mL/kg IV or IO © Ambulance Victoria 2014 ? Adequate response ? Inadequate response Action • No or inadequate improvement • No further fluid required Action • Repeat Normal Saline 20 mL/kg IV or IO - If after 40 mL/kg Pt remains < adequately perfused discuss ongoing Mx with RCH or receiving hospital ? Status Stop 8 Assess 8 Consider Action MICA Action Hypovolaemia (Paediatric) CPG P0801 237 © Ambulance Victoria 2014 This page intentionally left blank Version 4 - 01.11.05 Page 1 of 3 Chest Injuries (Paediatric) CPG P0802 ? Status 8 Assess • • Respiratory status Chest injury - traumatic - spontaneous - iatrogenic • Type of chest injury Action • Supplemental O2 • Pain relief as per CPG P0501 Pain Relief (Paediatric) • Position Pt upright if possible unless: - < adequate perfusion - altered consciousness - associated barotrauma or - potential spinal injury ? Flail segment/rib fractures ? Open chest wound ? Pneumothorax Action Action • Signs of pneumothorax • May require ventilatory support if decreased VT • 3-sided sterile occlusive dressing Action © Ambulance Victoria 2014 • See CPG P0802 ? Status Stop 8 Assess 8 Consider Action MICA Action Chest Injuries (Paediatric) CPG P0802 239 Version 4 - 01.11.05 Page 2 of 3 Chest Injuries (Paediatric) CPG P0802 Special Notes General Care • In IPPV setting, equal air entry is NOT an exclusion criteria for TPT. • TPT - If some clinical signs of TPT are present and the Pt is deteriorating with decreasing conscious state and/ or poor perfusion, immediately decompress chest by inserting a long 16G cannula. • Chest injury Pts receiving IPPV have a high risk of developing a TPT. Solution for poor perfusion in this setting includes bilateral chest decompression. • Cardiac arrest Pts are at risk of developing chest injury during CPR. • Trouble shooting -Pt may re-tension as lung inflates if catheter kinks off. -Catheter may also clot off. Flush with sterile Normal Saline. • Insertion site for cannula -Second intercostal space -Mid-clavicular line (avoiding medial placement) -Above rib below (avoiding neurovascular bundle) -Right angles to chest (towards body of vertebrae) - If air escapes, or air and blood bubble through the cannula, or no air/blood detected, leave in situ and secure. - If no air escapes but copious blood flows through the cannula then a major haemothorax is present. Remove, then cover the insertion site. • Needle test - If TPT suspected, but the assessment is not obvious, test for a TPT with a needle attached to Normal Saline filled syringe. - If needle test is suggestive of TPT, withdraw needle and immediately decompress chest. - If pneumocath not available, leave plastic cannula in situ, refer to appropriate CWI. © Ambulance Victoria 2014 - If needle test is not suggestive of TPT, withdraw needle, cover insertion site with a clear adhesive dressing and circle the insertion site with a pen. - Be aware that a needle test for TPT can be prone to false readings and does not exclude TPT in all cases. Version 4 - 01.11.05 Page 3 of 3 Chest Injuries (Paediatric) CPG P0802 Status ? 8 Assess • Pneumothorax - simple - tension • Criteria for simple pneumothorax vs TPT ? Simple pneumothorax ? TPT • • Any of the following: - Unequal breath sounds in spontaneously ventilating Pt - Low SpO2 on room air - Subcutaneous emphysema Action • Continue BLS and supplemental O2 • Monitor closely for possible development of TPT Any of the following +/- signs of Simple pneumothorax: - Peak inspiratory pressure (ventilator) / stiff bag - EtCO2 - Poor perfusion or HR +/- BP - JVP - Conscious state in the awake Pt - Tracheal shift - Low SpO2 on O2 (late) Action © Ambulance Victoria 2014 • Chest decompression as per General care ? Status Stop 8 Assess 8 Consider Action MICA Action Chest Injuries (Paediatric) CPG P0802 241 Version 2 - 07.09.11 Page 1 of 4 Burns (Paediatric) Special Notes General Care • All chemical burns should be irrigated for at least 20 min. Avoid flushing chemical onto uncontaminated areas. Burn cooling • Clothing burnt or containing hot liquid or chemical should be removed when safe to do so. Do not remove clothing that adheres to underlying tissue. Jewellery should be removed prior to swelling occurring. • Volume replacement is for burn injury only. Mx other injuries accordingly including requirement for additional fluid. Electrical burns should receive fluid therapy to maintain adequate renal perfusion. • Signs and symptoms of airway burns include: © Ambulance Victoria 2014 CPG P0803 - vidence of burns to upper torso, neck and face E Facial and upper airway oedema Sooty sputum Burns in an enclosed space Singed facial hair (nasal hair, eyebrows, eyelashes, beards etc.) - Respiratory distress (dyspnoea with wheeze present / absent and associated tachycardia, stridor) - Hypoxia (restlessness, irritability, cyanosis, decreased GCS). • Burn cooling should be for 20 min. Consider shorter periods in large TBSA burns where hypothermia may be induced. Cooling may be completed prior to Tx. Cooling provided prior to ambulance arrival should be included in the total cooling time. • Burn cooling should be with gentle running water that is between 5 – 15°C. Ice and ice water is not desirable. Similarly, dirty (i.e. dam) water should be avoided given the significant risk of infection introduction. • If running water is not available, cooling may be affected by immersion of affected area in still water. This water should be refreshed each few minutes to avoid it warming. • Maintaining normothermia is vital. Protect remainder of Pt from heat loss where possible: - Assess temp as soon as practicable and monitor. - Cover the Pt with blankets etc. - Avoid Pt shivering. • If clinically appropriate, elevation of the affected area in transit will assist in minimising burn wound oedema. Burn dressings • Cling wrap is an appropriate burn dressing. It should be applied longitudinally to allow for swelling. Cling wrap is the preferred burns dressing for all burns. • Water gel dressings (e.g. BurnaidTM) should not be used on any paediatric Pt due to risk of hypothermia and compromised peripheral perfusion. Version 2 - 07.09.11 Page 2 of 4 Burns (Paediatric) CPG P0803 Status ? 8 Assess mechanism of burn and burn injury • Evidence of burn injury • Airway injury • TBSA • Mechanism of burn injury • Severity of burn injury Stop • Ensure safety and removal from burn mechanism - Avoid chemical contamination or spreading to Pt's unaffected areas ? Initial burn Mx Action •Cool the burn, warm the Pt •Cool burn area – refer general care notes •Protect remainder of Pt from heat loss where possible •Provide analgesia as per CPG P0501 Pain Relief (Paediatric) © Ambulance Victoria 2014 •Cover cooled burn area with appropriate dressing – refer General care notes ? Status Stop ? All other burn presentations ? Partial or full thickness burns >15% BSA Action Action •Appropriate first aid • Tx to an appropriate facility • Tx to appropriate facility •Normal Saline IV fluid replacement - 3 x %TBSA x Pt weight (kg) = vol fluid (mL) - Given over 24 hr from time of burn -Administer half of the 24 hr fluid over the first 8 hr 8 Assess 8 Consider Action MICA Action Burns (Paediatric) CPG A0803 243 Version 2 - 07.09.11 Page 3 of 4 Burns (Paediatric) Special Notes Transport • Any burns involving the face, hands, feet, genitalia, major joints or circumferential burns of the chest or limbs or involving >20% TBSA require assessment by a specialised Burns Service. For regional transfers this may be via secondary transfer. Metropolitan: • All burns Pts who meet the time critical trauma criteria should be Tx to the Royal Children’s Hospital in preference if within 45 min. If > 45 min Tx to nearest alternative highest level of trauma service. Rural: • Tx to highest designated trauma receiving centre within 45 min. • In all cases of prolonged Tx, consider alternative air Tx. © Ambulance Victoria 2014 • In all cases, appropriate consultations should occur and hospital notification be provided. CPG P0803 General Care Version 2 - 07.09.11 Page 4 of 4 Burns (Paediatric) CPG P0803 Special Notes Paediatric-Adult Burns Assessment Ruler Expressed as a % of Total Body Surface Area 16 9 18 9 14 15 15 Chest + Abdomen = 18% Front or 18% Back Limbs are measured circumferentially Used with permission by the Victorian Burns Unit © Ambulance Victoria 2014 © 2007 Mike Fuery All rights reserved Burns (Paediatric) CPG P0803 245 © Ambulance Victoria 2014 This page intentionally left blank © Ambulance Victoria 2014 This page intentionally left blank 247 Version 1 - 20.09.06 Page 1 of 2 Hypothermia / Cold Exposure (Paediatric) Special Notes General Care •Hypothermia is insidious and rarely occurs in isolation. Where the Pt is in a group environment, other members of the group should be carefully assessed for signs of hypothermia. • Shelter from wind in heated environment •Arrhythmia in hypothermia is associated with temps below 33°C. •Atrial arrhythmias, bradycardia or A-V blocks generally resolve on rewarming. Rx with antiarrhythmic agents is usually not required unless decompensation has occurred. •Defibrillation and cardioactive drugs may not be effective at temps below 30°C. VF may resolve spontaneously upon re-warming. © Ambulance Victoria 2014 •The onset and duration of drugs is prolonged in hypothermia and the interval between doses is therefore doubled, e.g. doses of Adrenaline become 6 minutely. CPG P0901 • Remove all damp or wet clothing • Gently dry Pt with towels / blankets • Wrap in warm sheet / blanket - cocoon • Cover head with towel / blanket - hood • Use thermal / space / plastic blanket if available • Only warm frostbite if no chance of refreezing prior to arrival at hospital • Assess BGL if altered conscious state Warmed fluid • Normal Saline warmed between 37 - 42°C should be given to correct moderate / severe hypothermia and maintain perfusion (if available). Fluid < 37°C could be detrimental to Pt. Version 1 - 20.09.06 Page 2 of 2 Hypothermia / Cold Exposure (Paediatric) Status ? 8 Assess • Hypothermia • Mild hypothermia CPG P0901 32 - 35°C • Moderate hypothermia 28 - 32°C • Severe hypothermia < 28°C • If alteration to cardiac arrest Mx as required ? Non-cardiac arrest ? Cardiac arrest • Moderate / severe hypothermia < 28-32°C • N ormothermic Normal Saline 10 mL/kg IV - Repeat 10 mL/kg IV (max. 40 mL/kg) to maintain perfusion ? 30 - 32°C ? < 30°C Action Action Action • Standard cardiac arrest CPGs • D ouble intervals between doses in CPG P0201 Cardiac Arrest (Paediatric) - Do not rewarm beyond 33°C if ROSC • Continue CPR and rewarming until temp > 30°C • One DCCS only • One dose of Adrenaline • One dose of Amiodarone Withhold Sodium Bicarbonate IV © Ambulance Victoria 2014 • Avoid drug Mx of cardiac arrhythmia unless decompensated and until rewarming has commenced > 32°C ? ? Status Stop 8 Assess 8 Consider Action MICA Action Hypothermia/Cold Exposure (Paediatric) CPG P0901 249 Version 1 - 20.09.06 Page 1 of 2 Environmental Hyperthermia Special Notes Heat Stress (Paediatric) CPG P0902 General Care •Pt body temps of < 40 C may normally be Mx with basic cooling techniques alone. o •This CPG is not intended for the Mx of the febrile Pt due to infection. • During cooling, the Pt should be monitored for the onset of shivering. Shivering may increase heat production and cooling measures should be adjusted to avoid its onset. © Ambulance Victoria 2014 • Gentle Pt handling is essential. Position the Pt flat or lateral and avoid elevating the head to minimise the potential for an arrhythmia. Version 1 - 20.09.06 Page 2 of 2 Environmental Hyperthermia Heat Stress (Paediatric) CPG P0902 Assess 8 ? Status • Accurately assess temp • Hyperthermia/Heat stress • BGL if altered conscious state • Perfusion status ? Requires active cooling Action • Cooling techniques - initiated and maintained until temp is < 38°C - Shelter / remove from heat source - Ensure airflow over Pt - Remove all clothing except underwear - Apply tepid water using spray bottle or wet towels • Mx low BGL as per CPG P0702 Hypoglycaemia (Paediatric) • Airway and ventilation support with 100% O2 as required • Rx inadequate perfusion per CPG P0801 Hypovolaemia (Paediatric) - Cooled fluid preferable if available - If cool fluids initiated, return to ambient temp fluid once Pt temp is < 39oC ? Adequate response Action • Severe cases - temp > 39.5°C • BLS © Ambulance Victoria 2014 ? Poor response after 10/60 • GCS < 10 • Tx Action • Pt time critical, continue initial Mx ? Status Stop 8 Assess 8 Consider Action MICA Action Environmental Hyperthermia Heat Stress (Paediatric) CPG P0902 251 © Ambulance Victoria 2014 This page intentionally left blank Version 1 - 16.12.10 Page 1 of 6 Obstetric Emergencies ? Status Assess 8 • Pregnancy related CPG O0101 ? Other obstetric problem • Term Action • In labour • Trauma – as per appropriate CPG • Rupture of membranes • Cardiac arrest - as per CPG A0201 Cardiac Arrest • Presenting part on view • Baby born ? Birth not imminent ? Baby born Assess 8 ? Birth imminent Assess 8 Action • Complicated • Newborn care as per CPG N0201 Newborn Resuscitation • Complicated • Uncomplicated • Intra-partum care - Delivery as per CPG O0301 Normal Birth - PPPH as per CPG O0401 Primary Post Partum Haemorrhage • Uncomplicated ? Complicated ? Uncomplicated Action Action • Basic care • Mx as per CPG O0201 Ante-partum Haemorrhage •Pain relief as required as per CPG A0501 Pain Relief • Mx as per CPG O0202 Pre-eclampsia / Eclampsia • Continue to monitor • Tx © Ambulance Victoria 2014 ? Uncomplicated ? Complicated Action Action •Delivery as per CPG O0301 Normal Birth • Mx as per CPG O0302 Breech Presentation • Mx as per CPG O0303 Preterm Labour • Mx as per CPG O0304 Cord Prolapse • Mx as per CPG O0305 Shoulder Dystocia ? Status Stop 8 Assess 8 Consider Action MICA Action Obstetric Emergencies CPG O0101 253 Version 1 - 16.12.10 Page 2 of 6 Obstetric Emergencies: Definitions Definitions Term: > 37 weeks gestation Preterm: 24 – < 37 weeks gestation Show: Vaginal discharge of mucous and blood Spontaneous rupture of membranes: G ush of normally clear or pink coloured fluid. Can occur from prior to onset of labour until baby is born. Meconium stained amniotic fluid: Greenish / brown stained amniotic fluid First stage labour: O nset of regular painful contractions to full cervical dilatation (i.e. contractions every 2 - 20 min, 20 - 60 sec duration) Second stage labour: F ull cervical dilatation to birth of baby (typical duration Primipara 1 - 2 hr, Multipara 15 - 45 min) Imminent birth presentation: A ctive pushing / grunting Rectal pressure – urge to use bowels or bladder Anal pouting / bulging perineum Strong unstoppable urge to push Presenting part (baby's head) on view - crowning Mothers statement – “I am going to have the baby” © Ambulance Victoria 2014 Precipitate birth: U nusually rapid labour (less than 2 hr) with extremely quick birth. Rapid change in pressure from intrauterine life may cause cerebral irritation. CPG O0101 Version 1 - 16.12.10 Page 3 of 6 Obstetric Emergencies: Assessment CPG O0101 Assessment Focussed history In addition to routine history/examination Previous pregnancies •Any / number of previous pregnancies? •Prior caesarean sections / interventions? •Complications / problems with previous pregnancies? •Length of previous labours? Current pregnancy •How many weeks pregnant are you? •Are you expecting a singleton or multiple pregnancy? •Have your membranes ruptured? What was the colour of the amniotic fluid? •Are you having contractions? Assess frequency and duration. •Do you have an urge to push? •Have you felt fetal movements? More / less or same as normal? •Hospital interventions (if any)? •Do you anticipate any problems / complications (baby / mother)? •Have you had any antenatal care? •Any current complaints? vaginal bleeding / PV loss high BP pain trauma any other issues © Ambulance Victoria 2014 - - - - - Obstetric Emergencies: Assessment CPG O0101 255 Version 1 - 16.12.10 Page 4 of 6 Obstetric Emergencies: Physiological Parameters CPG O0101 Physiological parameters Cardiovascular BP inimal change – initial decrease in 1st and 2nd trimester, 3rd normal M SBP > 160 mmHg and DBP > 110 mmHg is significant HR by 15 – 20 bpm Cardiac output by 30 – 40% ECG Non specific ST changes, Q waves – III and AVF, atrial and ventricular ectopics SVR due to progesterone and blood volume Cardiac output 600 mL/min (at term). Placenta unable to auto regulate blood flow (Normal pregnancy HR 80 – 110 bpm) (Normal volume 6 – 7 L/min during pregnancy) Respiratory Respiratory rate by 15% (2 – 3 breaths/min) O2 demand by 15 - 20% Minute ventilation by 25 – 50% 11 – 19 L/min at term Tidal volume by 25 – 40% 8 – 10 mL/kg at term Arterial pH to 7.40 – 7.45 PaO2 by 10 mmHg PaCO2 27 – 32 mmHg 14 – 19 breaths/min at term 104 – 108 mmHg at term Haematological © Ambulance Victoria 2014 Blood volume (mL) 30 – 50% vol Haemoglobin (g/dL) 100 – 140 Haematocrit (%) 5,500 mL at term Red cell mass by 20 – 30% but is less than blood vol increase 32 – 42 (physiological anaemia) Plasma volume (mL) 30 – 50% Version 1 - 16.12.10 Page 5 of 6 Obstetric Emergencies: Basic care CPG O0101 Basic care As per Clinical Approach CPG A0101 with the following modifications: Position: (IF > 20 weeks pregnant) •A left lateral tilt can help to reduce aorta-caval compression and subsequent hypotension. •A 30o tilt can be achieved by placing a wedge (using blankets or pillows if required) under the Pt's right hip. This can significantly improve BP. •If Pt requires spinal immobilisation, then she should be packaged and tilted as an entire unit with a 15o tilt. Supplemental high flow O2: To counter physiological anaemia. IV access and fluid therapy: •Early IV access in emergencies. •High compensatory ability. Mother may lose up to 30 – 35% (2 L) circulating blood volume before showing signs of shock / hypotension. •Fetus may be compromised even when the mother appears stable. Stabilisation: •Assessment and resuscitation of the mother must take priority as ultimately the welfare of the fetus is optimised by providing the best available care to the mother. Triage: •Fetal morbidity and mortality can occur with seemingly minor blunt trauma. •All injured pregnant women should have an obstetric assessment due to risk of placental abruption. © Ambulance Victoria 2014 •Even minor injuries may be associated with complications such as feto-maternal haemorrhage. Contact Paediatric Infant Perinatal Emergency Retrieval (PIPER) 24/7 via Clinician or on 1300 137 650. Obstetric Emergencies: Basic care CPG O0101 257 Version 1 - 16.12.10 Page 6 of 6 Obstetric Emergencies: Destination hospital Obstetric Trauma Metropolitan: When Tx a baby born out of hospital or a woman in labour: Metropolitan: •All obstetric Pts who meet the time critical trauma criteria should be Tx to the Royal Melbourne Hospital in preference if within 45 min. If > 45 min Tx to nearest alternative highest level of trauma service. •Tx to a public hospital that has a Maternity Service bypassing hospitals that do not. -IF at term (>37 weeks gestation) and an uncomplicated labour is anticipated, then the default destination should be the hospital the patient is booked into whether public or private. -IF preterm and - between 32 - 37 weeks gestation consult with PIPER for advice re destination. - < 32 weeks gestation the receiving hospital should be the closest of the Royal Women's Hospital, Mercy Hospital for Women Heidelberg or Monash Clayton that have appropriate NICU facilities. © Ambulance Victoria 2014 Rural: •All pregnant women with complications of pregnancy / labour should be Tx to the closest Regional Base Hospital. If birth appears imminent: •Default to the closest hospital with a Maternity Service. CPG O0101 •Tx all patients > 24 weeks with any trauma of potential harm to the unborn child to the RMH. Rural: •Tx to highest designated trauma receiving centre within 45 min. •In all cases of prolonged Tx, consider alternative air Tx. • In all cases, appropriate consultation should occur with hospital notification provided. Severe medical complication Metropolitan •Tx all obstetric patients who meet the medical time critical criteria to the nearest major hospital capable of accepting obstetric patients including Royal Melbourne Hospital, Austin or Monash Clayton. Rural •Tx to nearest designated hospital capable of accepting time critical medical and obstetric patients. •In all cases of prolonged Tx, consider alternative air Tx. © Ambulance Victoria 2014 This page intentionally left blank 259 Version 1 - 16.12.10 Page 1 of 2 Antepartum Haemorrhage © Ambulance Victoria 2014 This page intentionally left blank CPG O0201 Version 1 - 16.12.10 Page 2 of 2 Antepartum Haemorrhage ? Status CPG O0201 Assess 8 • Antepartum haemorrhage • Perfusion status • External bleeding • Patient Hx • Abdominal pain • > 20 weeks gestation ? No clinical signs of altered perfusion • Antepartum haemorrhage ? Any clinical signs of altered perfusion • Internal bleeding may greatly exceed visible external bleeding Action • Signs of poor perfusion may present late and are always significant • Place Pt in left lateral tilt position Action • Tx to appropriate obstetric hospital • Place Pt in left lateral tilt position • Tx to appropriate obstetric hospital with notification in all cases • Fluid resuscitation as per CPG A0801 Hypovolaemia © Ambulance Victoria 2014 • Mx pain as per CPG A0501 Pain Relief ? Status Stop 8 Assess 8 Consider Action MICA Action Antepartum Haemorrhage CPG O0201 261 Version 1 - 16.12.10 Page 1 of 2 Pre-eclampsia / Eclampsia Special Notes Special Notes • Pre-eclampsia and eclampsia are time critical emergencies requiring early diagnosis, intervention and prompt Tx to reduce perinatal and maternal mortality. Inter hospital transfer • Mx of this condition may involve pharmacological control of hypertension, neurological instability and the prevention of seizures. This may include: • S/S of pre-eclampsia include: - headache - visual disturbances (flashing lights, shimmering) - nausea and/or vomiting - heartburn / epigastric or abdominal pain - hyper-reflexia. • Uterine pain and/or PV bleeding may signify abruption. • The most common cause of seizure in pregnancy is pre-existing epilepsy. New onset seizures in the latter half of pregnancy are most commonly eclampsia. • Seizures may occur during or post birth, usually within 48 hr of birth. • There are no reliable clinical indicators to predict eclampsia. • The only definitive Rx is birth of the baby. • Provide early hospital notification. Paediatric Infant Perinatal Emergency Retrieval (PIPER) for advice via Clinician or on 1300 137 650 © Ambulance Victoria 2014 CPG O0202 Nifedipine • Initial hospital dose is 10 mg oral, repeated after 30/60 if inadequate response. Consult with hospital staff to confirm Rx prior to Tx. MICA only IHT drugs Loading doses and infusions should be established prior to Tx. IV Magnesium Sulphate • Indicated for severe pre-eclampsia and for seizure prophylaxis. Infusion via a dedicated line and controlled infusion device with ECG monitoring in situ. A usual loading dose is 4 mg IV over 10 – 15 min or via IM with maintenance infusion usually at 1 g/hr (4 mmol/hr) until at least 24 hours post delivery or last seizure. IV Labetolol • Initial IV bolus of 20 mg given slowly over 2 min. This can be repeated every 10 min until optimal BP is achieved or max. dose of 300 mg delivered. Alternatively a 20 – 160 mg/hr infusion can follow the initial bolus titrated to achieve optimal BP. IV Hydralazine • Initial IV bolus (usually 5 – 10 mg) over 5 – 10 min. This can be repeated two more times at 30 min intervals. Maintenance infusion run at 5 mg/hr. Adjust rate to maintain BP between 140 - 160/90 - 100 mmHg. The BP should not fall below 140/80 mmHg as the placental circulation will have adapted to a higher BP. The severity of the disease will dictate the escort's scope of practice – MICA, AAV MICA, midwife / obstetrician escort, ARV. Version 1 - 16.12.10 Page 2 of 2 Pre-eclampsia / Eclampsia ? Status CPG O0202 Assess 8 • Pre-eclampsia • Hypertension • Eclampsia • Pre-eclampsia S/S • Seizure activity • Gestation > 20 weeks ? Normal BP ? Significant hypertension Action • Consider other causes of complaint Action • DBP 90 - 110 mmHg •Mx as per A0703 Continuous Tonic- ? Severe hypertension • Mx symptomatically ? Seizure activity - eclampsia • SBP 140 - 170 mmHg clonic Seizures • SBP > 170 mmHg &/or • Left lateral tilt position • DBP > 110 mmHg &/or • High flow O2 • RUQ abdominal pain Action ? Post seizure • Basic care Action • Left lateral tilt position •Assess for aspiration and Rx symptomatically •Mx precipitous delivery as per CPG O0301 Normal Birth © Ambulance Victoria 2014 •Mx placental abruption as per CPG O0201 Antepartum Haemorrhage ? Status Stop 8 Assess 8 Consider Action MICA Action Pre-eclampsia / Eclampsia CPG O0403 263 Version 1 - 16.12.10 Page 1 of 4 Normal Birth CPG O0301 © Ambulance Victoria 2014 This page intentionally left blank Version 1 - 16.12.10 Page 2 of 4 Normal Birth CPG O0301 ? Status Assess 8 • Imminent normal birth • Obstetric Hx • Labour progression Stop • Opioid analgesics are C/I in late second stage labour ? Normal birth – not imminent ? Imminent normal birth - preparation Action Action • Reassure • Reassure including cultural considerations • Monitor regularly for change • Prepare equipment for normal birth • Tx to obstetric facility using a left lateral tilt position • Provide a warm and clean environment • Provide analgesia as per CPG A0501 Pain Relief • Provide analgesia as per CPG A0501 Pain Relief ? Imminent normal birth - birth of head Action • As head advances, encourage the mother to push with each contraction •If head is birthing too fast, ask mother to pant with an open mouth during contractions instead © Ambulance Victoria 2014 •Place fingers on baby’s head to feel strength of descent of head •If precipitous, apply gentle backward and downward pressure to control sudden expulsion of the head ? Status Stop 8 Assess 8 Consider - Do not hold back forcibly Action MICA Action Normal Birth CPG O0301 265 Version 1 - 16.12.10 Page 3 of 4 Normal Birth CPG O0301 ? Imminent normal birth – umbilical cord check Action • Following the birth of the head, check for umbilical cord around neck: - If Loose, slip over baby’s head and check not wrapped around more than once. - If Tight, apply umbilical clamps and cut in between. ? Normal birth – head rotation Action • With the next contraction the head will turn to face one of the mother’s thighs (restitution) - Indicative of internal rotation of shoulders in preparation for birth of body ? Normal birth – birth of the shoulders and body Action • May be passive or guided birth •Hold baby’s head between hands and if required apply gentle downwards pressure to deliver the anterior (top) shoulder •Once the baby's anterior (top) shoulder is visible, if necessary to assist birth, apply gentle upward pressure to birth posterior (lower) shoulder – the body will follow quickly • Support the baby © Ambulance Victoria 2014 • Note time of birth • P lace baby skln to skin with mother on her chest to maintain warmth unless baby is not vigorous / requires resuscitation • Mx the vigorous newborn as per CPG N0101 Newborn Baby • Mx the non vigorous newborn as per CPG N0201 Newborn Resuscitation • If the body fails to deliver in < 60 sec after the head Mx as per CPG O0305 Shoulder Dystocia ? Normal birth – clamping and cutting the cord Action •If the newborn is vigorous, the cord can be cut at a convenient time over 1 – 3 min The cord should stop pulsing • If the newborn is non-vigorous and may require resuscitation, the cord may need to be cut earlier •Clamp twice, the first 10 cm from the baby then a second a further 5 cm •Cut between the two clamps ? Normal birth – birthing placenta (third stage) • Delivery of baby to placenta Action Passive (expectant) Mx • Allow placental separation to occur spontaneously without intervention • This may take from 15 min to 1 hr • Position mother sitting or squatting to allow gravity to assist expulsion • Breast feeding may assist separation or expulsion • Do not pull on cord – wait for signs of separation - lengthening of cord - uterus becomes rounded, firmer, smaller - trickle or gush of blood from vagina - cramping / contractions return • Placenta and membranes are birthed by maternal effort. Ask mother to give a little push •Use two hands to support and remove placenta using a twisting ‘see saw’ motion to ease membranes slowly out of the vagina • Note time of delivery of placenta © Ambulance Victoria 2014 • Place placenta and blood clots into a container and transfer • Inspect placenta and membranes for completeness • Inspect that fundus is firm, contracted and central • Continue to monitor fundus though do not massage once firm • If fundus is not firm or blood loss > 500 mL Mx as per CPG O0401 Post Partum Haemorrhage ? Status Stop 8 Assess 8 Consider Action MICA Action Normal Birth CPG O0301 267 Version 1 - 16.12.10 Page 1 of 4 Breech / Compound Presentation: (Imminent birth) Special Notes General Care Types of Breech Presentation During all breech labour • Keep mother informed of progress. Encourage mother to push hard with contractions. A B C A: Breech with extended legs (frank) – buttocks present first with flexed hips and legs extended on the abdomen. Most common = ½ of all breech presentations. B: Breech with flexed legs (complete) – buttocks present first with flexed hips and flexed knees. C:Footling – one or both feet present as neither hips nor knees are fully flexed. Feet are palpated lower than the buttocks. • It is normal for meconium to be passed as the baby’s buttocks are squeezed. • Cord prolapse is more common with breech presentation. • If a known breech and birth is not imminent, Tx to a booked obstetric unit with capacity for surgical intervention. Provide early hospital notification. © Ambulance Victoria 2014 CPG O0302 • Position mother with buttocks to bed edge with legs supported (lithotomy position) if on a stretcher or bed. Standing or squatting may be preferred by the mother and is more anatomically and physiologically sound though not suited to Tx or imminent birth. • Hands off approach encourages the baby to maintain a position of flexion, which simplifies birth. • Only touch to gently support – if too much stimulus the baby will extend flexed head. • Main force of birth is maternal effort. Do not attempt to pull baby out. The key is to allow the birth to occur spontaneously with minimal handling of the newborn. • Most additional manoeuvres are only required in the event of delay. • Prevent hypothermia by maintaining a warm environment. Use available resources e.g. warm towels or bubble wrap to wrap the baby if the body is exposed for an extended period. Cool air may stimulate breathing which is not desirable if the head remains unborn. Version 1 - 16.12.10 Page 2 of 4 Breech / Compound Presentation: (Imminent birth) ? Status CPG O0302 Assess 8 • Suspected breech birth • Stage of labour and birth imminent • Buttocks or both feet presenting first • One foot or hand / arm presenting first Stop • Opioid analgesics are C/I in late second stage labour • Do not attempt delivery of one foot or hand / arm presentation • Only proceed with delivery if birth is imminent ? One foot, hand or arm presenting ? Non imminent birth Action Action • General maternal care • Do not attempt to deliver • Tx to booked obstetric unit with notification • Tx urgently to an obstetric unit with notification • Consult with PIPER for advice ? Imminent breech birth – buttocks or both feet presenting Action © Ambulance Victoria 2014 • ? Status Stop 8 Assess 8 Consider Mx as per CPG O0301 Normal Birth except for: - Request urgent assistance - Reassure including cultural considerations - Prepare obstetrics equipment - Provide a warm and clean environment - Provide analgesia as per CPG A0501 Pain Relief - Allow the birth to occur spontaneously -Position mother with buttocks to bed edge and legs supported to allow gravity to assist - Do not touch baby as it emerges - Hands off the breech - The birth of buttocks / feet will occur slowly Action MICA Action Breech / Compound Presentation: (Imminent birth) CPG O0302 269 Version 1 - 16.12.10 Page 3 of 4 Breech / Compound Presentation: (Imminent birth) ? Buttocks first presentation – back upmost – delivery of body/legs Action • This is the most common presentation • Do not attempt to pull the baby out • Encourage mother to push hard with contractions • Feet and legs should spring free • Await further descent • Keep body warm by wrapping in a towel or bubble wrap if needed • The body will further descend to the clavicles and arms should swing free • Let baby hang until the nape of neck is visible • The baby should face downward • Assist birth of the head using modified Mauriceau Smellie Veit Manoeuvre ? Buttocks first presentation – back upmost – delivery of head Modified Mauriceau Smellie Veit Manoeuvre Action •Place the index and ring finger of non dominant hand on the baby’s shoulders and middle finger on the occiput to assist with flexion of the head © Ambulance Victoria 2014 •Place dominant hand under the baby to support the body, with ring and index fingers on the baby’s cheekbones •Slowly lift the baby straight up in a circle onto the mother’s abdomen, allowing the head to birth slowly • An assistant can aid flexion of head by applying direct pressure behind the pubic bone CPG O0302 ? Buttocks first presentation – back not uppermost Action • The baby’s back needs to remain uppermost • If legs delivered and back is not uppermost - Gently hold the baby by placing thumbs on bony sacrum with fingers around thighs. - Do not squeeze the abdomen - Rotate / turn baby uppermost between contractions taking care of baby’s spine - Take great care to never pull the baby ? Buttocks first presentation – legs don’t birth spontaneously Action • If extended legs (frank breech) - slip one hand along the leg of the baby lying anteriorly - place a finger behind the baby’s knee and deliver it by flexion and abduction ? Buttocks first presentation – arms don’t birth spontaneously Lovsett’s Manoeuvre Action •Hold baby by the sacrum •Turn baby 90 degrees so that one shoulder is in the antero-posterior diameter •Insert a finger into the brachial plexus and sweep the arm down over the baby’s chest •Turn baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter •Repeat the finger manoeuvre •Turn the baby 90 degrees again so that the back is uppermost •Await further descent © Ambulance Victoria 2014 •Do not pull or apply traction Contact PIPER via Clinician or on 1300 137 650 for advice ? Status Stop 8 Assess 8 Consider Action MICA Action Breech / Compound Presentation: (Imminent birth) CPG O0302 271 Version 1 - 16.12.10 Page 1 of 2 Preterm Labour CPG O0303 Special Notes Special Notes • There is a high possibility of abnormal presentation. Inter hospital transfer • Some women may be receiving tocolytics to suppress preterm labour. This may include pharmacotherapy including: • Tocolytics are drugs intended to suppress premature labour. They are C/I in the setting of massive maternal haemorrhage (APH) and pregnancy induced hypertension (pre-eclampsia / eclampsia). Nifedipine • Is the drug of choice. Initial dose of up to 20 mg orally given by hospital. Monitor for adverse reaction prior to Tx. Can repeat if contractions persist after 30 min. Ongoing monitoring of BP and pulse is required. GTN Patch 50 mg (0.4 mg/hr) transdermal • Placed on abdomen. A further 50 mg (0.4 mg/hr) patch may be added after 1 hr if contractions persist (max. dose 100 mg in 24 hrs). Paramedics may commence this therapy after appropriate consultation. • A 50mg Transiderm patch delivers 10 mg per 24 hr @ 0.4 mg/hr. Obstetric services may quote 10 mg patch instead of 50 mg as actual dose being delivered. IV Salbutamol • Infrequently used now. Any infusion must be regulated by a controlled delivery system. © Ambulance Victoria 2014 Contact PIPER via Clinician or on 1300 137 650 for advice Version 1 - 16.12.10 Page 2 of 2 Preterm Labour CPG O0303 ? Status Assess 8 • U terine contraction present @ 20 - 37 weeks ? Cord prolapse • Ruptured membranes Action • Check for cord prolapse • Mx as per CPG O0304 Cord Prolapse • Stage of labour ? Birth imminent ? Birth not imminent > 34 weeks ? Birth not imminent < 34 weeks Action Action Action • Consider other causes of complaint • Basic care • Mx symptomatically • Reassure •Consult for 50 mg GTN patch (0.4 mg/hr) applied to the abdomen © Ambulance Victoria 2014 •A further 50 mg GTN patch (0.4 mg/hr) may be added after 1 hr if contractions persist (max. 20 mg / 24 hr) ? Status Stop 8 Assess 8 Consider Action MICA Action Preterm Labour CPG O0303 273 Version 1 - 16.12.10 Page 1 of 2 Cord Prolapse Special Notes • This is a time critical emergency – early diagnosis, immediate intervention and prompt Tx to an appropriate facility are effective in reducing the perinatal mortality rate. • Notify the receiving hospital early. • In most instances caesarean section is the preferred method of birth, however if birth is imminent encourage mother to push – this ONLY applies when the presenting part is distending the perineum and the mother is pushing uncontrollably. Prepare for resuscitation of the newborn as per CPG N0201 Newborn Resuscitation. • Cord prolapse is usually associated with an unstable lie or malpresentation. • Cord handling should be kept to a minimum as this can lead to vasospasm or contraction of umbilical vessels. • Key history is important: time membranes ruptured, how long has the cord been visible, due date, fetal movement felt, onset of labour, contractions present, fetal presentation if known, PV bleeding. © Ambulance Victoria 2014 Contact PIPER via Clinician or on 1300 137 650 for advice CPG O0304 General Care Version 1 - 16.12.10 Page 2 of 2 Cord Prolapse CPG O0304 ? Status Assess 8 •Cord prolapse: umbilical cord visible at vulva with ruptured membranes • Cord visible at vulva • Ruptured membranes • Stage of labour ? Birth not imminent – Mx of mother ? Birth commencing Action Action •Position Pt on all fours with head down and buttocks up • Instruct mother to push • Provide explanation and reassurance • Prepare for newborn resuscitation • High flow O2 therapy • Mx as per CPG O0301 Normal Birth • Assist in delivery • Mx as per CPG N0201 Newborn Resuscitation ? Birth not imminent – Mx of cord Action • Minimise cord handling •Keep cord warm and moist. Use 2 fingers to gently place cord in vagina • If unsuccessful cover with warm saline packs (if possible) ? Birth not imminent – Mx of presenting part © Ambulance Victoria 2014 Action •If there is pressure on the cord by the presenting part insert fingers into vagina and push the presenting part (head) away from the cord • Maintain pressure until birth commences or advised to release ? Status Stop 8 Assess 8 Consider Action MICA Action Cord Prolapse CPG O0304 275 © Ambulance Victoria 2014 This page intentionally left blank Version 1 - 16.12.10 Page 1 of 3 Shoulder Dystocia Special Notes CPG O0305 General Care • This is a time critical situation. There is 5 - 7 min to deliver the baby due to compression of the cord against the pelvic rim. • Explain the situation to the mother to gain maximum co-operation. • It is important to note times of birth of head, timing of manoeuvres and delivery of body. • The newborn is likely to be compromised in this setting and require resuscitation. • During procedures, be prepared for a sudden release of resistance and be prepared to take hold of the baby. • The process of releasing the baby may cause injury, particularly clavicle fracture. Mx any such injury appropriately including arm immobilisation. • If these manoeuvres are not successful, consult with PIPER regarding when to abandon attempts to deliver and initiate Tx. © Ambulance Victoria 2014 Contact PIPER via Clinician or on 1300 137 650 for advice Shoulder Dystocia CPG O0305 277 Version 1 - 16.12.10 Page 2 of 3 Shoulder Dystocia ? Status CPG O0305 Assess 8 •Possible shoulder dystocia • Normal birthing procedure fails to accomplish delivery • Prolonged head-to-body delivery time (> 60 sec) • Difficulty with birth of face and chin • Baby’s head retracts against perineum (turtle sign) • Failure of baby’s head to restitute • Failure of shoulders to descend • Difficulty reaching neck when attempting to check for cord around neck • Baby’s head colour turns purple then black ? Prolonged head to body delivery time (> 60 sec) Action • Note time of birth of head • Request urgent additional assistance • Explain to mother and ask her to push with focused effort when required • Position mother with buttocks at bed edge • Apply gentle downward traction to deliver anterior shoulder ? Delivery accomplished - newborn © Ambulance Victoria 2014 Action ? Delivery accomplished mother ? Delivery not accomplished - after 30 - 60 sec Action •Mx as per CPG N0201 Newborn Resuscitation Action •Alternate the following sequence until baby is delivered • Basic care •Provide high flow O2 therapy •Assess for clavicle injury and immobilise if necessary • Reassure •Mx as per Delivery accomplished if successful at any time At no time attempt to rotate the baby’s head — rotate shoulders using pressure on the baby’s scapula instead ? Delivery not accomplished after 30 - 60 sec Action • Hyperflexion of maternal hips (McRobert’s manoeuvre) – knees to nipples -Place mother in a recumbent position -Hips to edge of bed enabling better access for gentle downward traction -Assist mother to grasp her knees and pull her knees / thighs back as far as possible onto her abdomen (use assistant to help achieve and maintain position) ? Delivery remains not accomplished after 30 - 60 sec Action • Suprapubic pressure whilst in McRobert’s position -Hands in CPR position behind symphysis pubis, at 45 degree angle along baby’s back (trying to rotate baby forward) -Apply 30 sec firm downward pressure, then 30 sec rocking motion to get shoulder out from under rim, at rate of approx 1 per sec. ? Delivery remains not accomplished after 30 - 60 sec Action •All Fours (Gaskin) manoeuvre -Rotate mother to all fours -Hold baby’s head and apply gentle downward traction – attempting to dis-impact and deliver the posterior shoulder (now uppermost) © Ambulance Victoria 2014 ? Delivery accomplished ? Delivery remains unaccomplished Action Action • Mx as above • Consult with PIPER regarding when to abandon manoeuvres and Tx • The newborn is likely to require resuscitation • If unable to consult, Tx with notification • Tx in McRobert’s manoeuvre position with 30º left lateral tilt ? Status Stop 8 Assess 8 Consider Action MICA Action Shoulder Dystocia CPG O0305 279 Version 1 - 16.12.10 Page 1 of 2 Primary Postpartum Haemorrhage (PPPH) Special Notes Special Notes • Massaging a fundus that is firm, central and contracted may interfere with normal placental post birth separation and worsen bleeding. Fundal massage should only be applied when the fundus is not firm. • Misoprostol is a synthetic prostaglandin which is licensed in Australia for prevention of gastric ulcers. However, because it can induce / augment uterine contractions it is used for inducing labour / abortion as well as to Rx haemorrhage after normal delivery. Its use in PPH is supported by tertiary maternity services in Victoria. Misoprostol is widely used in countries where there are no other medications available to control PPH. As its use in these circumstances is not licensed in Victoria, verbal consent must be obtained prior to administration and appropriate notation made. • The four Ts of PPPH are: - Tone (uterine atony) - Trauma (to genital structures) - Tissue (retention of placenta or membranes) - Thrombin (coagulopathy) The most common cause of PPPH is uterine atony. • An empty and contracted uterus does not bleed. • Higher risk Pts included multiple pregnancy, more than four pregnancies, past Hx of PPH, Hx of APH, large baby. • PPH can occur before or after the birth of the placenta. Contact Paediatric Infant Perinatal Emergency Retrieval (PIPER) via Clinician or on 1300 137 650 for advice © Ambulance Victoria 2014 CPG O0401 • There may be some risks / complications and side effects which may include nausea, diarrhoea or abdominal pain. In rare instances in women who have had a caesarean section, the uterine scar may rupture which would require surgery. • Side effects are unlikely for the dosage that will be given. • Misoprostol and Oxytocin can be given to the same Pt in the same episode of care. In the setting of PPPH, if Oxytocin is not immediately available then Misoprostol should be administered without delay. Version 1 - 16.12.10 Page 2 of 2 Primary Postpartum Haemorrhage (PPPH) ? Status CPG O0401 Assess 8 •PPPH (blood loss > 500 mL in first 24 hr from birth) • Fundus tone • Visible blood loss • Perineal / vaginal laceration ? Fundus firm ? Fundus not firm • Palpable firm, central and compacted fundus Action Action • Mx as per fundus firm • High flow O2 therapy • Massage fundus until firm and blood loss reduces • Analgesia as required as per CPG A0501 Pain Relief - Use a cupped hand • Mx perfusion as per CPG A0801 Hypovolaemia - Apply firm pressure in a circular motion • Mx any visible laceration with a dressing and firm pressure • Encourage mother to empty bladder if possible • Encourage baby to suckle breast ? Fundus remains not firm Action • Misoprostol 800 mcg Oral • Oxytocin 10 IU IM • Repeat Oxytocin 10 IU IM after 5 min if bleeding continues DO NOT ATTEMPT delivery of placenta due to risk of uterine inversion © Ambulance Victoria 2014 ? Intractable haemorrhage Action • ? Status Stop 8 Assess 8 Consider Action MICA Action Perform external abdominal aortic compression: - Locate point of compression just above the umbilicus and slightly to the left - Apply downward pressure with a closed fist directly through the abdominal wall -Effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied Primary Postpartum Haemorrhage (PPPH) CPG O0401 281 © Ambulance Victoria 2014 This page intentionally left blank Version 1 - 16.12.10 Page 1 of 4 The Newborn Baby: Definitions and Contacts CPG N0101 Newborn definition • 'Newborn' refers to the first min to hours post birth. For the purpose of resuscitation, AV accepts up to the first 24 hours from birth in the newborn definition. This is due to the adaptations of the respiratory and cardiovascular systems in this time. Preterm infant (24 - 37 completed weeks gestation) • Gestational age has an effect on the development of lung and pulmonary circulation and therefore influences how well these newborns establish effective respiration. • The primary focus in prehospital Mx is establishing and maintaining effective ventilation and preventing hypothermia. • Newborns > 32 and < 37 weeks gestation require Tx to a Level 2 Hospital (paediatrician and midwife staff on site 24/7). • Newborns < 32 weeks gestation or any infants who are intubated require Tx to a tertiary centre: Mercy Hospital for Women (MHW), Monash Medical Centre (MMC), Royal Women's Hospital (RWH) or Royal Children's Hospital (RCH). Consult with PIPER for an appropriate receiving hospital. • In rural Victoria, proceed to the nearest base hospital (or hospital with maternity services) and contact PIPER via the Clinician. Transport • Where available, MICA assistance should be sought early when preterm birth is considered a possibility. • Expeditious Tx to the nearest most appropriate hospital should occur without delay. © Ambulance Victoria 2014 Emergency contacts Paediatric Infant Perinatal Emergency Retrieval (PIPER) (formerly known as NETS, PETS and PERS) for all advice and assistance in newborn care and Mx contact via Clinician or 1300 137 650 The Newborn Baby: Definitions and Contacts CPG N0101 283 Version 1 - 16.12.10 Page 2 of 4 The Newborn Baby: Normal Values Weight: • Average full term weight = 3.5 kg Normal blood volume: • 80 mL/kg Heart rate: • 120 – 160 bpm • HR is the most important indicator for resuscitation. Respiration: • 40 – 60 breaths per min Skin: • Colour - may be dusky and peripherally cynanosed in the first few minutes after birth. Blue-ish / purple hand and feet are normal in the first 24 hr after birth and are not an indication for supplemental O2. • It may take 7 – 10 min post birth for SpO2 to reach > 90% and for colour to become centrally and peripherally pink. Conscious state: • Active motion, grimace and/or crying. Temperature: • Aim for normothermia (36.5 – 37.5ºC per axilla). • Newborns lose heat via the large surface area of the head and by evaporation from their wet bodies once outside the uterus. © Ambulance Victoria 2014 BGL: • 2.6 – 3.2 mmol/L CPG N0101 Version 1 - 16.12.10 Page 3 of 4 The Newborn Baby: General Care CPG N0101 Body temp: • Maintain normothermia (per axilla temperature of 36.5 – 37.5ºC). Place the newborn naked, skin to skin with the mother to maintain warmth and cover them both with warm blankets if the newborn is vigorous and not requiring ongoing resuscitation. • If resuscitation is required, place the newborn on a warm, flat surface, cover with bubble wrap and warm wraps. Place a woollen hat or the corner of a warm blanket on the newborn’s head to maintain warmth. • Following birth, preterm infants < 28 weeks gestation should be placed immediately (without drying body) into a polyethylene (Glad™ zip lock) bag with the head (dried) outside. If AV arrive after the birth, dry the infant, cover the head with a hat or the corner of a warm blanket and cover the body with bubble wrap and warm blankets. Cutting the cord: • Cutting the cord in the vigorous newborn is not urgent. Apply general care and cut the cord when it stops pulsating. © Ambulance Victoria 2014 • The cord must be cut in the non vigorous newborn earlier to allow effective resuscitation. This would usually be after initial basic tactile efforts and commencement of IPPV. The Newborn Baby: General Care CPG N0101 285 Version 1 - 16.12.10 Page 4 of 4 The Newborn Baby: Airway Position: • Place head and neck in a neutral position avoiding neck flexion and head extension. Suctioning: • The vigorous newborn does not require suctioning unless born through meconium stained amniotic fluid. They usually clear their own airway very effectively. • Newborns who are not vigorous at birth (not breathing and poor muscle tone) only require airway suctioning if born through meconium stained amniotic fluid or if the infant has obvious blood in the oropharynx. • The mouth should be suctioned followed by the nose. The newborn is a nasal breather and may gasp pharyngeal fluid if the nose is cleared first. • Intubation and suction of the trachea (if a person with the expertise to intubate is present) should follow where necessary in Mx of the non vigorous newborn. • Pharyngeal suctioning can cause laryngospasm and bradycardia through vagal stimulation, thus suctioning must be gentle and brief (5 – 6 sec) to avoid compromising the newborn further. © Ambulance Victoria 2014 • A 10 or 12 FG catheter is the recommended size for suctioning the oropharynx of a newborn. CPG N0101 © Ambulance Victoria 2013 This page intentionally left blank 287 Version 1 - 16.12.10 Page 1 of 6 Newborn Resuscitation: Advanced Airway CPG N0201 OPA: •size 00, 0 •May be useful if there is an airway abnormality or the infant's tongue is large and impeding effective BVM ventilation. •Not recommended for routine use in newborns with a normal airway as it can cause obstruction and vagal reactions. Laryngoscope blade: •Straight Miller blade. Size 1 for term. Size 00 preterm LMA: •Portex size 1 for newborn > 2000 g or 34 weeks gestation •Indicated for failed BVM and failed intubation. EtCO2: •An EtCO2 detector (Pedi- Cap™) is recommended to verify successful tracheal intubation in the newborn. •Paediatric EtCO2 is to be continuously monitored via the paediatric MRx attachment where available. ETT size mm Lip length (wt in kg + 6 cm) ETT suction catheter NG tube <1 kg or < 28 weeks ‘extremely preterm’ 2.5 6 – 7 cm 6 FG 6 FG 1 – 3 kg or 28 – 36 weeks ‘moderately preterm’ 3 8 – 9 cm 6 FG 8 FG > 3 kg or > 36 weeks ‘term or near term’ 3.5 9 – 1 0 cm 6 FG 8 FG Version 1 - 16.12.10 Page 2 of 6 Newborn Resuscitation: Ventilation CPG N0201 Ventilation: •The majority of newborns needing resuscitation at birth are apnoeic and bradycardic but rarely asystolic. Hypoxia eventually depresses respiratory drive and causes bradycardia. Effective ventilation is the key to newborn resuscitation. Pulmonary pressure changes are integral in effecting necessary fetal circulation changes. •Prompt improvement in HR > 100 bpm (assessed using a stethoscope over the apex of the heart) is the primary indicator of adequate ventilation. •Increased pressure may be required for initial breaths. Ventilation rate: •40 - 60 inflations per min. Tidal volume: •5 -10 mL/kg initially with room air. •If HR remains < 100 bpm after at least 30 sec of effective BVM ventilation on room air, supply high concentration O2. PEEP: •Where available use a 5 cm H2O PEEP valve attached to BVM during IPPV. •PEEP is important in improving lung vol and establishing and maintaining FRC particularly in preterm newborns. Newborn Resuscitation: Ventilation CPG N0201 289 Version 1 - 16.12.10 Page 3 of 6 Newborn Resuscitation: Circulation Chest compressions: •Chest compressions are rarely required unless the HR is below 60 bpm despite effective ventilation for at least 30 sec. •The first min of resuscitation should not compromise airway techniques and ventilation where the HR < 100 bpm. •If after 30 sec of effective BVM ventilation the HR remains < 60 bpm, compressions should be commenced. CPR: •3:1 compression:ventilation ratio. •Achieve 90 compressions and 30 ventilations per min with 0.5 sec pause in ventilation (120 events per min or two per sec). There is no pause post intubation. HR: •Reassess every 30 sec until HR > 60 bpm where compressions may be ceased. •Continue IPPV / APPV until HR >100 bpm and the newborn is breathing effectively. Cardiac monitor: •Attaching electrodes for routine cardiac monitoring of preterm newborns may result in damage to the fragile dermis of the skin. ECG electrode attachment should be reserved for emergency resuscitation circumstances. •Pulseless VT and/or VF are unlikely to be observed in the resuscitation of a newborn. Should these rhythms be observed defibrilate as for other age children using 4 J/kg at 2 min intervals as required. Pulse oximeter: •Where available, attach newborn O2 saturation probe to right hand (pre-ductal) to allow continuous evaluation of heart rate and SpO2. This negates need to stop chest compressions to evaluate the HR. CPG N0201 Version 1 - 16.12.10 Page 4 of 6 Newborn Resuscitation: Circulation CPG N0201 Compression method: Hand encircling 2 thumb method Alternative 2 finger method • The 2 thumb method is preferred in the 2 rescuer setting. • The 2 finger alternative preferred in single rescuer situations to minimise transition time. Compression Depth: • 1/3 depth of chest diameter. Newborn Resuscitation: Circulation CPG N0201 291 Version 1 - 16.12.10 Page 5 of 6 Newborn Resuscitation ? Status • Birthed CPG N0201 Assess 8 • Is the newborn crying or breathing? • Is the newborn moving? ? Breathing present – moving or crying • Vigorous newborn ? Not breathing – not moving or crying • Non-vigorous newborn Action Action • Routine care • Clear airway only if needed (see airway) • Dry (especially the head) • Stimulate by drying (then maintain warmth) • Keep warm (skin to skin with mother) • Place head and neck into a neutral position • Clear airway only if needed (see airway) • Assess HR, breathing, colour • Assess APGAR at 1 min and 5 min post birth Assess 8 By 30 sec • Is the newborn breathing? © Ambulance Victoria 2014 • Is the HR > 100 bpm? ? HR < 100 bpm and/or inadequate breathing Action ? HR > 100 bpm and breathing adequately Action • IPPV with room air @ 40 – 60 min until HR > 100 bpm and breathing adequately • Routine care • Continue to observe HR, breathing, colour, tone, activity • Reassess after 30 sec IPPV • If centrally cyanotic after 7 – 10 min post birth - Commence O2 @ 2 L/min via nasal cannula until pink Assess 8 By 60 sec • Evaluate HR and breathing ? HR > 100 bpm and breathing adequately Action • Cease IPPV • Observe HR, breathing, colour, tone and activity closely ? HR < 60 bpm and inadequate breathing Action • C ontinue IPPV @ 40 – 60 min until HR > 100 bpm and breathing adequately. Add supplemental high concentration O2 • Commence CPR @ 3:1 ratio aiming for 90 compressions and 30 ventilations per min • Continue to reassess after 30 sec IPPV • Continue to reassess after 30 sec CPR • IPPV with high-flow supplemental O2 Assess 8 By 90 sec © Ambulance Victoria 2014 ? HR 60 - 100 bpm and inadequate breathing Action • Evaluate HR and breathing ? HR > 100 bpm and breathing adequately ? HR 60 - 100 bpm and inadequate breathing Action Action Action • Cease IPPV and ECC • C ontinue IPPV @ 40 – 60 min until HR > 100 bpm and breathing adequately. Continue high concentration O2 • Continue CPR with supplemental O2 • Observe HR, breathing, colour, tone and activity closely • Continue to reassess after 30 sec IPPV • Cease high flow oxygen if centrally pink and/or SpO2 > 90% ? Status Stop 8 Assess 8 Consider Action MICA Action ? HR < 60 bpm • Mx as CPG N0202 Newborn Advanced Resuscitation • Continue to reassess @ 30 sec intervals Newborn Resuscitation CPG N0201 293 Version 1 - 16.12.10 Page 1 of 2 Newborn Advanced Resuscitation ? Asystole or severe bradycardia persists Action • Continue CPR if pulseless or HR < 60 bpm • Reassess every 30 sec ? Asystole or severe bradycardia persists Action • Adrenaline 10 mcg/kg IV or IO (minimum 100 mcg) repeated @ 3/60 intervals ? Asystole or severe bradycardia persists Action • Intubate • If unable to obtain above vascular access - Adrenaline 100 mcg/kg ETT ? Asystole or severe bradycardia persists Action • Normal Saline 10 – 20 mL/kg IV or IO © Ambulance Victoria 2014 - Repeat if necessary ? If pulse returns Action • At early opportunity, assess BGL • If BGL < 2.6 mmol/L, consult with PIPER for administration of 10% Dextrose or Glucagon CPG N0202 Version 1 - 16.12.09 Page 2 of 2 Newborn Advanced Resuscitation CPG N0202 Adrenaline 1:10,000: • 10 mcg/kg IV or IO (100 mcg/kg via ETT). • Do not use 1:1,000 unless diluted to 10 mL. Normal Saline: • 10 - 20 mL/kg IV or IO. Repeat if necessary. If BGL < 2.6 mmol/L: • Consult with PIPER for drug and dose administration advice for Mx using Dextrose 10% or Glucagon. Sodium Bicarbonate: • Not indicated / should not be administered. Atropine: • Not indicated / should not be administered. Naloxone: • Not indicated / should not be administered even in the setting of suspected opioid overdose. It can lead to acute withdrawal and seizures in the newborn. © Ambulance Victoria 2014 Sedation: • Not usually required to maintain ETT. Consult PIPER for further advice if necessary. Newborn Resuscitation CPG N0201 295 Version 1 - 16.12.10 Page 1 of 1 Newborn Baby: APGAR scoring system CPG N0301 APGAR scores should not be used as a guide for resuscitation. The time intervals used for resuscitation are contained elsewhere within this CPG. The APGAR score should be conducted 1 min after delivery and repeated 5/60 until APGAR score > 7. A score of: © Ambulance Victoria 2014 7 – 10 Satisfactory 4 – 6 Moderate depression and may need ongoing respiratory support (IPPV) 0 – 3 Newborn requiring ongoing resuscitation (including ETT and drug therapy) 0 points 1 point 2 points Appearance Blue, pale Body pink, extremities blue Totally pink Pulse Absent < 100 > 100 Grimace None Grimaces Cries Activity Limp Flexion of extremities Active motion Respiratory effort Absent Slow and weak Good strong cry Version 2 - 10.09.03 Page 1 of 1 Drug Presentation © Ambulance Victoria 2014 The pharmacology section of these CPGs has been specifically written to focus on the pharmacology relevant to selected medical emergencies. It is not intended that this section be seen as a standard text on pharmacology, therefore the content has been restricted to the context of prehospital practice. Presentation In many instances, drugs may be available in presentations other than those listed. This book indicates drug presentations that are currently available within AV. Pharmacology A statement is included as to the nature of the drug followed by a list of specific actions related to the prehospital use of that drug. Metabolism A statement has been included to indicate the fate of the particular drug within the body. Primary emergency indication The emergency situations in which the drug is primarily used within prehospital practice. The drug may have other indications within health care. Contraindications Absolute contraindications to the use of a particular drug are listed in this section. Precautions Relative contraindications or precautions to the use of a particular of a drug are listed in this section. Route of administration Most drugs can be administered by a variety of routes. This section lists only those routes of administration considered appropriate for use in prehospital practice. As a general principle, drugs should not be mixed in the same syringe or solution before administration. Side effects Common side effects attributed to the use of the drug are included in this section. Special notes In this section a variety of additional information has been included as background information. In particular, the time that the drug takes to have its effect. Drug Presentation CPG D000 297 Version 1 – 12.09.12 Page 1 of 2 Adenosine CPG D032 Presentation 6 mg in 2 mL glass ampoule Pharmacology A naturally occurring purine nucleoside found in all body cells Actions: - Slows conduction through the A-V node, resulting in termination of re-entry circuit activity within or including the A-V nodal pathway Metabolism By adenosine deaminase in red blood cells and vascular endothelium Primary emergency indication 1. AVNRT with adequate or inadequate perfusion but not deteriorating rapidly 2.AVRT and associated Wolff-Parkinson-White (WPW) or other accessory tract SVT with adequate or inadequate perfusion but not deteriorating rapidly Contraindications 1.Second degree or third degree A-V block (may produce prolonged sinus arrest / A-V blockade) 2. AF 3. Atrial flutter 4. Ventricular tachyarrhymias 5. Known hypersensitivity Precautions 1. Adenosine may provoke bronchospasm in the asthmatic Pt 2.Adenosine is antagonised by methylxanthines (e.g. caffeine or theophyllines). The drug may not be effective in Pts with large caffeine intake or those on high doses of theophylline medication © Ambulance Victoria 2014 Route of administration IV Version 1 – 12.09.12 Page 2 of 2 Adenosine Side effects CPG D032 Usually brief and transitory Transient arrhythmia (including asystole, bradycardia or ventricular ectopy) may be experienced following reversion Chest pain Dyspnoea Headache or dizziness Nausea Skin flushing denosine has a very short half life. It should be administered through an IV as close to A the heart as practicable, such as the cubital fossa Intravenous effects: Duration: < 10 sec © Ambulance Victoria 2014 Special notes Adenosine CPG D032 299 Version 5 - 04.06.14 Page 1 of 2 Adrenaline CPG D002 Presentation 1 mg in 1 mL glass ampoule (1:1,000) 1 mg in 10 mL glass ampoule (1:10,000) Pharmacology A naturally occurring alpha and beta-adrenergic stimulant © Ambulance Victoria 2014 Actions: - Increases HR by increasing SA node firing rate (Beta 1) - Increases conduction velocity through the A-V node (Beta 1) - Increases myocardial contractility (Beta 1) - Increases the irritability of the ventricles (Beta 1) - Causes bronchodilatation (Beta 2) - Causes peripheral vasoconstriction (Alpha) Metabolism By monoamine oxidase and other enzymes in the blood, liver and around nerve endings; excreted by the kidneys Primary emergency indications 1. 2. 3. 4. 5. Contraindication 1. Hypovolaemic shock without adequate fluid replacement Cardiac arrest - VF/VT, Asystole or PEA Inadequate perfusion (cardiogenic or non-cardiogenic/non-hypovolaemic) Bradycardia with poor perfusion Anaphylaxis Severe asthma - imminent life threat not responding to nebulised therapy, or unconscious with no BP 6. Croup Version 5 - 04.06.14 Page 2 of 2 Adrenaline Precautions CPG D002 Consider reduced doses for: 1. Elderly / frail Pts 2. Pts with cardiovascular disease 3. Pts on monoamine oxidase inhibitors © Ambulance Victoria 2014 4. Higher doses may be required for Pts on beta blockers Route of administration IV IM ETT Nebulised IV infusion IO Side effects Sinus tachycardia Supraventricular arrhythmias Ventricular arrhythmias Hypertension Pupillary dilatation May increase size of MI Feeling of anxiety/palpitations in the conscious Pt Special notes IV Adrenaline should be reserved for life threatening situations. IV effects: Onset: 30 sec Peak: 3 – 5 min Duration: 5 – 10 min IM effects: Onset: 30 – 90 sec Peak: 4 – 10 min Duration: 5 – 10 min Adrenaline CPG D002 301 Version 2 - 17.12.10 Page 1 of 1 Amiodarone CPG D003 Presentation 150 mg in 3 mL glass ampoule Pharmacology Class III anti-arrhythmic agent Metabolism By the liver Primary emergency indications 1. VF / pulseless VT refractory to cardioversion 2. Sustained or recurrent VT Contraindications 1. VF / pulseless VT refractory to cardioversion - Nil of significance in above indication © Ambulance Victoria 2014 2. VT - Inadequate perfusion - Pregnancy 3. TCA OD Precautions 1. Nil of significance in the above indications Route of administration IV Side effects Hypotension Bradycardia Special notes IV effects (bolus): Onset: 2 min Peak: 20 min Duration: 2 hr Amiodarone is incompatible with saline. Glucose 5% must be used as dilutant when preparing an IV infusion. An IV infusion of Amiodarone may be required during interhospital transfer. This will be prescribed by the referring physician and will normally be at a dose of 10 - 20 mg/kg run over 24 hr. Version 2 - 19.11.08 Page 1 of 1 Aspirin CPG D001 Presentation 300 mg chewable tablets 300 mg soluble or water dispersible tablets Pharmacology An analgesic, antipyretic, anti-inflammatory and antiplatelet aggregation agent © Ambulance Victoria 2014 Actions: - To minimise platelet aggregation and thrombus formation in order to retard the progression of coronary artery thrombosis in ACS - Inhibits synthesis of prostaglandins - anti-inflammatory actions Metabolism Converted to salicylate in the gut mucosa and liver; excreted mainly by the kidneys Primary emergency indication 1. ACS Contraindications 1. 2. 3. 4. 5. Precautions 1. Peptic ulcer 2. Asthma 3. Pts on anticoagulants Route of administration Oral Side effects Heartburn, nausea, gastrointestinal bleeding Increased bleeding time Hypersensitivity reactions Special notes Aspirin is C/I for use in acute febrile illness in children and adolescents The anti-platelet effects of Aspirin persist for the natural life of platelets. Onset: n/a Peak: n/a Duration: 8 - 10 days Hypersensitivity to aspirin / salicylates Actively bleeding peptic ulcers Bleeding disorders Suspected dissecting aortic aneurysm Chest pain associated with psychostimulant OD if SBP >160 mmHg Aspirin CPG D001 303 Version 4 - 20.09.06 Page 1 of 2 Atropine CPG D004 Presentation 0.6 mg in 1 mL polyamp 1.2 mg in 1 mL polyamp Pharmacology An anticholinergic agent. Actions: - inhibits the actions of acetylcholine on post-ganglionic cholinergic nerves at the neuro-effector site, e.g. as a vagal blocker and allows sympathetic effect to: - increase heart rate by increasing SA node firing rate - increase the conduction velocity through the A-V node © Ambulance Victoria 2014 - a ntidote to reverse the effects of cholinesterase inhibitors, (e.g. organophosphate insecticides) at the post-ganglionic neuro-effector sites of cholinergic nerves to: - reduce the excessive salivary, sweat, GIT and bronchial secretions; and - relax smooth muscles Metabolism By the liver; excreted mainly by the kidneys Primary emergency indication 1. Bradycardia with poor perfusion 2. Organophosphate poisoning with excessive cholinergic effects Contraindication 1. Nil of significance in the above indications Precautions 1. 2. 3. 4. Atrial flutter AF Do not increase HR above 100 bpm except in children under 6 years Glaucoma Version 4 - 20.09.06 Page 2 of 2 Atropine CPG D004 Route of administration IV ETT Side effects Tachycardia Palpitations Dry mouth Dilated pupils Visual blurring Retention of urine Confusion, restlessness (in large doses) Hot, dry skin (in large doses) Special notes IV effects: Onset: Peak: Duration: © Ambulance Victoria 2014 < 2 min < 5 min 2 - 6 hr Atropine CPG D004 305 Version 2 - 01.11.05 Page 1 of 1 © Ambulance Victoria 2014 Ceftriaxone CPG D005 Presentation 1 g sterile powder in a glass vial Pharmacology Cephalosporin antibiotic Metabolism Excreted unchanged in urine (33% - 67%) and in bile Primary emergency indication 1. Suspected meningococcal septicaemia 2. Severe sepsis (consult only) Contraindication 1. Allergy to Cephalosporin antibiotics Precautions 1. Allergy to Penicillin antibiotics Route of administration IV (preferred) IM (if IV access unavailable) Side effects Nausea Vomiting Skin rash Special notes Usual dose: adult 1 g, child 50 mg/kg (max. 1 g) Ceftriaxone IV must be made up to 10 mL using sterile water and dose administered over 2 min Ceftriaxone IM must be made up to 4 mL using 1% Lignocaine and dose administered in lateral upper thigh IM/IV effects: Onset: n/a Peak: n/a Duration: n/a Version 3 - 19.11.08 Page 1 of 1 © Ambulance Victoria 2014 Dexamethasone CPG D007 Presentation 8 mg in 2 mL glass vial Pharmacology A corticosteroid secreted by the adrenal cortex Actions: - Relieves inflammatory reactions - Provides immunosuppression Metabolism By the liver and other tissues; excreted predominantly by the kidneys Primary emergency indication 1.Bronchospasm associated with acute respiratory distress not responsive to nebulised Salbutamol 2. Anaphylaxis 3. Acute exacerbation of COPD Contraindication 1.Known hypersensitivity Precautions 1. Solutions which are not clear or are contaminated should be discarded Route of administration IV IM Side effects Nil of significance in the above indication Special notes Does not contain an antimicrobial agent, therefore use solution immediately and discard any residue IV effects: Onset: Peak: Duration: 30 - 60 min 2 hr 36 - 72 hr Dexamethasone CPG D007 307 Version 2 - 10.09.03 Page 1 of 1 Dextrose 5% CPG D008 Presentation 100 mL infusion soft pack Pharmacology An isotonic crystalloid solution Composition: - Sugar – 5% dextrose - Water Actions: - Provides a small source of energy - Supplies body water Metabolism Dextrose: - Broken down in most tissues - Stored in the liver and muscle as glycogen © Ambulance Victoria 2014 Water: - Excreted by the kidneys - Distributed throughout total body water, mainly in the extracellular fluid compartment Primary emergency indication 1. Vehicle for dilution and administration of IV emergency drugs Contraindication 1. Nil of significance in the above indication Precautions 1. Nil of significance in the above indication Route of administration IV infusion Side effects Nil of significance in the above indication Special notes IV half life: Approximately 20 ‑ 40 min Version 2 - 19.11.08 Page 1 of 1 © Ambulance Victoria 2014 Dextrose 10% CPG D009 Presentation 25 g in 250 mL infusion soft pack Pharmacology A slightly hypertonic crystalloid solution Composition: - Sugar ‑ 10% dextrose - Water Actions: - Provides a source of energy - Supplies body water Metabolism Dextrose: - Broken down in most tissues - Stored in liver and muscle as glycogen Water: - Excreted by the kidneys - Distributed throughout total body water, mainly in the extracellular fluid compartment Primary emergency indication 1.Diabetic hypoglycaemia (BGL analysis < 4 mmol/L) in Pts with an altered conscious state who are unable to self-administer oral glucose Contraindication 1. Nil of significance in the above indication Precautions 1. Nil of significance in the above indication Route of administration IV infusion Side effects Nil of significance in the above indication Special notes IV effects: Onset: Peak: Duration: 3 min n/a Depends on severity of hypoglycaemic episode Dextrose 10% CPG D009 309 Version 1 - 04.06.14 Page 1 of 2 Enoxaparin (Clexane) Presentation 100 mg in 1 mL pre-filled syringe with graduated markings (SC injection) 40 mg in 0.4 mL glass ampoule (IV bolus) Pharmacology Binds to and accelerates the action of antithrombin III which inactivates clotting factors IIa (thrombin) and Xa, inhibiting the conversion of prothrombin to thrombin Metabolism Metabolised by the liver Primary Emergency Indication 1. Acute STEMI Contraindication 1. Known allergy or hypersensitivity CPG D034 2. Active bleeding e.g. peptic ulcer, intracranial haemorrhage 3. Bleeding disorders 4. Severe hepatic impairment / disease © Ambulance Victoria 2014 5. Heparin-induced thrombocytopenia (HIT) Precautions 1. Renal impairment 2. If Pt ≥ 75yo, omit the initial IV bolus dose and only administer 0.75 mg/kg SC injection with a maximum 75 mg SC Route of Administration Enoxaparin 30 mg IV followed 15 min later by 1 mg/kg SC not exceeding 100 mg SC Version 1 - 04.06.14 Page 2 of 2 Enoxaparin (Clexane) Side Effects CPG D034 Bleeding Bruising Pain at injection site Hyperkalaemia Mild reversible thrombocytopenia Infrequent Transient elevation of liver aminotransferases Severe thrombocytopenia Rare Skin necrosis at injection site Osteoporosis with long term use Allergic reactions including urticaria and anaphylaxis Hypersensitivity reactions Special Notes STEMI - 12 lead ECG shows ST Elevation ≥ 1 mm in two contiguous limb leads (I, II, III, aVR, aVL, AVF) or ST Elevation ≥ 2mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6), new LBBB © Ambulance Victoria 2014 Onset: Within 3 hr Peak: 3 - 6 hr Duration: ≥ 12 hr Enoxaparin CPG D034 311 Version 2 - 01.11.05 Page 1 of 2 © Ambulance Victoria 2014 Fentanyl CPG D010 Presentation 100 mcg in 2 mL glass ampoule 200 mcg in 1mL glass vial (IN use only) 600 mcg in 2 mL glass vial (IN use only) Pharmacology A synthetic opioid analgesic Actions: CNS effects: - Depression – leading to analgesia - Respiratory depression – leading to apnoea - Dependence (addiction) Cardiovascular effects: - Decreases conduction velocity through the A-V node Metabolism By the liver; excreted by the kidneys Primary emergency indications 1. 2. 3. 4. Contraindication 1. Known hypersensitivity Precautions 1. 2. 3. 4. 5. 6. 7. Sedation to facilitate intubation Sedation to maintain intubation Drug facilitated intubation Analgesia – IV/IN Elderly/frail patients Impaired renal / hepatic function Respiratory depression, e.g. COPD Current asthma Pts on monoamine oxidase inhibitors Known addiction to opioids Rhinitis, rhinorrhea or facial trauma (IN route) Version 2 - 01.11.05 Page 2 of 2 Fentanyl CPG D010 Route of administration IV IN Side effects Respiratory depression Apnoea Rigidity of the diaphragm and intercostal muscles Bradycardia Special notes entanyl is a Schedule 8 drug under the Poisons Act and its use must be carefully F controlled with accountability and responsibility Respiratory depression can be reversed with Naloxone 100 mcg Fentanyl is equivalent in analgesic activity to 10 mg Morphine IV effects: Onset: Immediate Peak: < 5 min Duration: 30 - 60 min © Ambulance Victoria 2014 IN effects: Peak: 2 min Fentanyl CPG D010 313 Version 2 - 10.09.03 Page 1 of 1 Frusemide CPG D011 Presentation 40 mg in 4 mL glass ampoule Pharmacology A diuretic Actions: - Causes venous dilatation and reduces venous return - Promotes diuresis Metabolism Excreted by the kidneys Primary emergency indication 1. Acute LVF Contraindication 1. Nil of significance in the above indication Precautions 1. Hypotension Route of administration IV Side effects Hypotension Special notes The effect of vasopressor drugs will often be reduced after Rx with Frusemide. © Ambulance Victoria 2014 IV effects: Onset: 5 min Peak: 20 - 60 min Duration:2 - 3 hr Version 2 - 10.09.03 Page 1 of 1 Glucagon CPG D012 Presentation 1 mg (IU) in 1 mL hypokit Pharmacology A hormone normally secreted by the pancreas Actions: – Causes an increase in blood glucose concentration by converting stored liver glycogen to glucose Metabolism Mainly by the liver, also by the kidneys and in the plasma Primary emergency indication 1.Diabetic hypoglycaemia (BGL < 4 mmol/L) in Pts with an altered conscious state who are unable to self-administer oral glucose Contraindication 1. Nil of significance in the above indication Precautions 1. Nil of significance in the above indication Route of administration IM Side effects Nausea and vomiting (rare) Special notes Not all Pts will respond to Glucagon, e.g. those with inadequate glycogen stores in the liver (alcoholics, malnourished). © Ambulance Victoria 2014 IM effects: Onset: 5 min Peak: n/a Duration:25 min Glucagon CPG D012 315 Version 5 - 19.11.08 Page 1 of 3 Glyceryl Trinitrate (GTN) Presentation 0.6 mg tablets Transdermal GTN Patch (50 mg 0.4 mg/hr release) Pharmacology Principally, a vascular smooth muscle relaxant © Ambulance Victoria 2014 Actions: - Venous dilatation promotes venous pooling and reduces venous return to the heart (reduces preload) - Arterial dilatation reduces systemic vascular resistance and arterial pressure (reduces afterload) The effects of the above are: - Reduced myocardial O2 demand -Reduced systolic, diastolic and mean arterial blood pressure, whilst usually maintaining coronary perfusion pressure -Mild collateral coronary arterial dilatation may improve blood supply to ischaemic areas of myocardium -Mild tachycardia secondary to slight fall in blood pressure - Preterm labour: Uterine quiescence in pregnancy Metabolism By the liver Primary emergency indication 1. Chest pain with ACS 2. Acute LVF 3. Hypertension associated with ACS 4. Autonomic dysreflexia 5. Preterm labour (consult) CPG D013 Version 5 - 19.11.08 Page 2 of 3 © Ambulance Victoria 2014 Glyceryl Trinitrate (GTN) CPG D013 Contraindication 1. Known hypersensitivity 2. Systolic blood pressure < 110 mmHg tablet 3. Systolic blood pressure < 90 mmHg patch 4.Sildenafil Citrate (Viagra) or Vardenafil (Levitra) administration in the previous 24 hr or Tadalafil (Cialis) administration in the previous 4 days (PDE5 inhibitors) 5. Heart rate > 150 bpm 6. Bradycardia HR < 50 bpm (excluding autonomic dysreflexia) 7. VT 8. Inferior STEMI with systolic BP < 160 mmHg 9. Right ventricular MI Precautions 1. No previous administration 2. Elderly Pts 3. Recent MI 4. Concurrent use with other tocolytics Route of administration L S Buccal Transdermal Infusion (interhospital transfer only) Side effects achycardia T Hypotension Headache Skin flushing (uncommon) Bradycardia (occasionally) Glyceryl Trinitrate (GTN) CPG D013 317 Version 5 - 19.11.08 Page 3 of 3 Glyceryl Trinitrate (GTN) Special notes CPG D013 Storage: -GTN is susceptible to heat and moisture. Make sure that tablets are stored in their original light resistant, tightly sealed bottles. The foil pack of the patches should be intact. -Do not administer Pt’s own medication, as its storage may not have been in optimum conditions or it may have expired. -Tablet should be discarded and replaced after 1 month. -Patches should be discarded prior to use-by date. -Since both men and women can be prescribed Sildenafil Citrate (Viagra) or Vardenafil (Levitra) or Tadalafil (Cialis) all Pts should be asked if and when they last had the drug to determine if GTN is C/I. -Tadalafil (Cialis) may also be prescribed to men for Rx of benign prostatic hypertrophy. This is a new indication for the drug and may lead to an increased number of Pts under this Rx regimen. -GTN by IV infusion may be required for an interhospital transfer as per the treating doctor’s orders. Interhospital transfer: The IV dose is to be prescribed and signed by the referring hospital medical officer. Infusions usually run in the range of 5 mcg/min to 200 mcg/min and increased 3 - 5 mcg/min. © Ambulance Victoria 2014 S/L effects: Onset: Peak: Duration: 30 sec – 2 min 5 - 10 min 15 - 30 min Intravenous effects Onset: 30 sec – 1 min Peak: 3 - 5 min Duration: 15 - 30 min Transdermal effect Onset: Up to 30 min Peak: 2 hr Version 2 - 01.11.05 Page 1 of 2 Ipratropium Bromide Presentation 250 mcg in 1 mL nebule or polyamp Pharmacology Anticholinergic bronchodilator CPG D014 Actions: - Allows bronchodilatation by inhibiting cholinergic bronchomotor tone (i.e. blocks vagal reflexes which mediate bronchoconstriction) Excreted by the kidneys Primary emergency indication 1. Severe respiratory distress associated with bronchospasm Contraindication 1. Known hypersensitivity to Atropine or its derivatives Precautions 1. Glaucoma 2. Avoid contact with eyes Route of administration Nebulised (in combination with Salbutamol) Side effects Headache Nausea Dry mouth Skin rash Tachycardia (rare) Palpitations (rare) Acute angle closure glaucoma secondary to direct eye contact (rare) © Ambulance Victoria 2014 Metabolism Ipratropium Bromide CPG D014 319 Version 2 - 01.11.05 Page 2 of 2 Ipratropium Bromide Special notes There have been isolated reports of ocular complications (dilated pupils, increased intraocular pressure, acute angle glaucoma, eye pain) as a result of direct eye contact of Ipratropium Bromide formulations. The nebuliser mask must therefore be fitted properly during inhalation and care taken to avoid Ipratropium Bromide solution entering the eyes. Ipratropium Bromide must be nebulised in conjunction with Salbutamol and is to be administered as a single dose only. Onset: Peak Duration: © Ambulance Victoria 2014 CPG D014 3 - 5 min 1.5 - 2 hr 6 hr Version 1 - 04.06.14 Page 1 of 2 Ketamine CPG D033 Presentation 200 mg in 2 mL vial Pharmacology A rapid acting dissociative anaesthetic agent (primarily an NMDA receptor antagonist) © Ambulance Victoria 2014 Actions: - Produces a dissociative state characterised by: - a trance-like state with eyes open but not responsive - nystagmus - profound analgesia - normal pharyngeal and laryngeal reflexes - normal or slightly enhanced skeletal muscle tone - occasionally a transient and minimal respiratory depression Metabolism By the liver and excreted by the kidneys Primary emergency indication 1. Rapid sequence intubation 2. Intubation facilitated by sedation Contraindications 1. Known hypersensitivity 2. Severe hypertension (SBP > 180) Ketamine CPG D033 321 Version 1 - 04.06.14 Page 2 of 2 Ketamine Precautions CPG D033 1. Any condition where significant elevation of BP would be hazardous, e.g - Hypertension - CVA - Recent AMI - CCF 2. If being administered for analgesia, inject slowly over 1/60 to minimise risk of respiratory depression and hypertension Route of Administration IV IO Side Effects Cardiovascular Increase BP and HR CNS Respiratory depression or apnoea Emergence reactions (nightmares, restlessness, vivd dreams, confusion, hallucinations, irrational behaviour) Enhanced skeletal tone Nausea and vomiting Ocular Diplopia and nystagmus with slight increase in intraocular pressure © Ambulance Victoria 2014 Other Local pain at injection site Lacrimation Salivation Special Notes Onset: 30 sec Peak: 12 - 25 min Duration: N/A Version 5 - 01.04.06 Page 1 of 1 Lignocaine 1% (IM administration) Presentation 50 mg in 5 mL amp (1%) Pharmacology A local anaesthetic agent CPG D015 Actions: - Prevents initiation and transmission of nerve impulses causing local anaesthesia (1% solution) By the liver (90%) Excreted unchanged by the kidneys (10%) Primary emergency indication 1.Diluent for Ceftriaxone for IM administration in suspected meningococcal disease Contraindication 1.Known hypersensitivity Precautions 1.When using Lignocaine 1% as diluent for IM Ceftriaxone it is important to rule out inadvertent IV administration due to potential CNS complications Route of administration IM (1% solution with Ceftriaxone only) Side effects Nil – unless inadvertent IV administration Special notes IM effects: Onset: Rapid Peak: n/a Duration:1 - 1.5 hr © Ambulance Victoria 2014 Metabolism Lignocaine 1% (IM Administration) CPG D015 323 Version 1 - 08.09.10 Page 1 of 2 © Ambulance Victoria 2014 Lignocaine 1% (IO administration) Presentation 50 mg in 5 ml amp (1%) Pharmacology A local anaesthetic agent Actions: Prevents initiation and transmission of nerve impulses (local anaesthesia) Metabolism By the liver (90%) Excreted unchanged by the kidneys (10%) Primary emergency indication 1.To reduce the pain of IO drug and fluid administration in the responsive Pt Contraindication 1. Known hypersensitivity Precautions 1. Hypotension and poor perfusion 2. Chronic LVF 3. Liver disease Route of administration IO CPG D015A Version 1 - 08.09.10 Page 2 of 2 Lignocaine 1% (IO administration) Side effects CNS effects (common): - drowsiness - disorientation - decreased hearing - blurred vision - change or slurring of speech - twitching and agitation - convulsions Cardiovascular effects (uncommon): - hypotension - bradycardia - sinus arrest - A-V block Respiratory effects (uncommon): - difficulty in breathing - respiratory arrest Special notes IO effects Onset: Peak: Duration: CPG D015A © Ambulance Victoria 2014 1 – 4 min 5 – 10 min 20 min Lignocaine 1% (IO Administration) CPG D015A 325 Version 4 - 01.11.05 Page 1 of 1 © Ambulance Victoria 2014 Methoxyflurane CPG D017 Presentation 3 mL glass bottle Pharmacology Inhalational analgesic agent at low concentrations Metabolism Excreted mainly by the lungs By the liver Primary emergency indication 1. Pain relief Contraindication 1. Pre-existing renal disease / renal impairment 2. Concurrent use of tetracycline antibiotics 3. Exceeding total dose of 6 mL in a 24 hr period Precautions 1.The Penthrox™ inhaler must be hand-held by the Pt so that if unconsciousness occurs it will fall from the Pt’s face. Occasionally the operator may need to assist but must continuously assess the level of consciousness 2. Pre-eclampsia 3. Concurrent use with Oxytocin may cause hypotension Route of administration Self-administration under supervision using the hand held Penthrox™ Inhaler Side effects Drowsiness Decrease in blood pressure and bradycardia (rare) Exceeding the maximum total dose of 6 mL in a 24 hr period may lead to renal toxicity Special notes The maximum initial priming dose for Methoxyflurane is 3 mL. This will provide approximately 25 min of analgesia and may be followed by one further 3mL dose once the initial dose is exhausted if required. Analgesia commences after 8 - 10 breaths and lasts for approximately 3 - 5 min once discontinued. Do not administer in a confied space. Ensure adequate ventilation in ambulance. Version 5 - 17.12.10 Page 1 of 2 © Ambulance Victoria 2014 Metoclopramide CPG D018 Presentation 10 mg in 2 mL polyamp Pharmacology Antiemetic Actions: - Accelerates gastric emptying and peristalsis - Dopamine receptor antagonist Metabolism By the liver; excreted by the kidneys Primary emergency indication 1. Nausea / vomiting associated with - Chest pain / discomfort of a cardiac nature - Opioid administration for pain - Cytotoxic or radiotherapy - Previously diagnosed migraine - Severe gastroenteritis 2. Prophylaxis: - Awake spinal immobilised Pts - Eye trauma Contraindication 1. Children 2. Suspected bowel obstruction or perforation 3. Gastrointestinal haemorrhage Precautions 1. Undiagnosed abdominal pain 2. Adolescents (< 20 yrs) 3. Administer slowly over 1 min to minimise risk of extrapyramidal reactions Route of administration IV IM Metoclopramide CPG D018 327 Version 5 - 17.12.10 Page 2 of 2 Metoclopramide CPG D018 Side effects Drowsiness Lethargy Dry mouth Muscle tremor Extrapyramidal reactions (usually the dystonic type) Special notes Not effective for established motion sickness. Not effective for nausea prophylaxis in the setting of opioid administration. © Ambulance Victoria 2014 IV effects: Onset: 1 – 3 min Peak: n/a Duration:10 – 30 min IM effects: Onset: 10 – 15 min Peak: n/a Duration:1 – 2 hr Version 5 - 04.06.14 Page 1 of 2 Midazolam CPG D019 Presentation 5 mg in 1 mL glass ampoule 15 mg in 3 mL glass ampoule Pharmacology Short acting CNS depressant Actions: - Anxiolytic - Sedative - Anti-convulsant In the liver; excreted by the kidneys Primary emergency indication 1. Status epilepticus 2. Sedation to enable intubation (RSI / IFS) 3. Post intubation sedation 4. Sedation to enable synchronised cardioversion 5. Sedation in the agitated Pt (including Pts under the Mental Health Act 2014) 6. Sedation in psychostimulant OD Contraindications 1. Known hypersensitivity to benzodiazepines Precautions 1.Reduced doses may be required for the elderly/frail, Pts with chronic renal failure, CCF or shock 2.The CNS depressant effects of benzodiazepines are enhanced in the presence of narcotics and other tranquillisers including alcohol 3. Can cause severe respiratory depression in Pts with COPD 4. Pts with myasthenia gravis © Ambulance Victoria 2014 Metabolism Midazolam CPG D019 329 Version 5 - 04.06.14 Page 2 of 2 © Ambulance Victoria 2014 Midazolam CPG D019 Route of administration IM IV IV infusion Side effects Depressed level of consciousness Respiratory depression Loss of airway control Hypotension Special notes IM effects: Onset: Peak: Duration: 3 – 5 min 15 min 30 min IV effects: Onset: Peak: Duration: 1 – 3 min 10 min 20 min Version 1 - 17.12.10 Page 1 of 1 © Ambulance Victoria 2014 Misoprostol CPG D030 Presentation 200 mcg tablet Pharmacology A synthetic prostaglandin Actions: Enhances uterine contractions Metabolism Converted to active metabolite misoprostol acid in the blood Metabolised in the tissues and excreted by the kidneys Primary emergency indication 1. PPPH Contraindications 1. Allergy to prostaglandins 2. Exclude multiple pregnancy before drug administration Precautions 1. Hx of asthma Route of administration Oral Side effects Hyperpyrexia Shivering Abdominal pain Diarrhoea Special notes Side effects are more likely with > 600 mcg oral dose. Onset: 8 –10 min Peak: N/A Duration: 2 – 3 hr Misoprostol CPG D030 331 Version 5 - 20.09.06 Page 1 of 2 Morphine CPG D020 Presentation 10 mg in 1 mL glass ampoule Pharmacology An opioid analgesic Actions: CNS effects: - Depression (leading to analgesia) - Respiratory depression - Depression of cough reflex - Stimulation (changes of mood, euphoria or dysphoria, vomiting, pin-point pupils) - Dependence (addiction) © Ambulance Victoria 2014 Cardiovascular effects: - Vasodilatation - Decreases conduction velocity through the A-V Node Metabolism By the liver; excreted by the kidneys Primary emergency indication 1. Pain relief 2. Acute LVF with shortness of breath and full field crackles 3. Sedation to maintain intubation 4. Sedation to enable intubation 5. RSI Contraindications 1. Known hypersensitivity 2. Late second stage of labour Version 5 - 20.09.06 Page 2 of 2 Morphine CPG D020 Precautions 1. Elderly/frail patients 2. Hypotension 3. Respiratory depression 4. Current asthma 5. Respiratory tract burns 6. Known addiction to opioids 7. Acute alcoholism 8. Pts on monoamine oxidase inhibitors Route of administration IV IM IV infusion Side effects CNS effects: - Drowsiness - Respiratory depression - Euphoria - Nausea, vomiting - Addiction - Pin-point pupils Cardiovascular effects: - Hypotension - Bradycardia © Ambulance Victoria 2014 Special notes Morphine is a Schedule 8 drug under the Poisons Act and its use must be carefully controlled with accountability and responsibility. Side effects of Morphine can be reversed with Naloxone. Occasional wheals are seen in the line of the vein being used for IV injection. This is not an allergy, only a histamine release. IV effects: Onset: 2 – 5 min Peak: 10 min Duration: 1 – 2 hr IM effects: Onset: Peak: Duration: 10 – 30 min 30 – 60 min 1 – 2 hr Morphine CPG D020 333 Version 3 - 01.11.05 Page 1 of 2 Naloxone CPG D021 Presentation 0.4 mg in 1 mL glass ampoule 2 mg in 5 mL (prepared syringe) Pharmacology An opioid antagonist © Ambulance Victoria 2014 Action: - Prevents or reverses the effects of opioids Metabolism By the liver Primary emergency indication 1.Altered conscious state and respiratory depression secondary to administration of opioids or related drugs. Contraindications 1.Nil of significance in the above indication. Precautions 1.If Pt is known to be physically dependent on opioids, be prepared for a combative Pt after administration. 2. Neonates. Route of administration IM IV Side effects Symptoms of opioid withdrawal: - Sweating, goose flesh, tremor - Nausea and vomiting - Agitation - Dilatation of pupils, excessive lacrimation - Convulsions Version 3 - 01.11.05 Page 2 of 2 Naloxone Special notes CPG D021 The duration of action of Naloxone is often less than that of the opioid used, therefore repeated doses may be required. Naloxone reverses the effects of opioids with none of the actions produced by other opioid antagonists when no opioid is present in the body. (For example, it does not depress respiration or cause pupillary constriction). In the absence of opioids, Naloxone has no perceivable effects. Following an opioid associated cardiac arrest Naloxone should not be administered. Maintain assisted ventilation. Following head injury Naloxone should not be administered. Maintain assisted ventilation if required. IV effects: Onset: 1 – 3 min Peak: n/a Duration: 30 – 45 min © Ambulance Victoria 2014 IM effects: Onset: 1 – 3 min Peak: n/a Duration: 30 – 45 min Naloxone CPG D021 335 Version 3 - 19.11.08 Page 1 of 1 Normal Saline CPG D022 Presentation 10 mL polyamp 500 mL and 1000 mL infusion soft pack Pharmacology An isotonic crystalloid solution Composition: - Electrolytes (sodium and chloride in a similar concentration to that of extracellular fluid) Action: - Increases the vol of the intravascular compartment Metabolism Electrolytes: - Excreted by the kidneys © Ambulance Victoria 2014 Water: - Excreted by the kidneys - Distributed throughout total body water, mainly in the extracellular fluid compartment Primary emergency indication 1. As a replacement fluid in vol-depleted Pts 2.To expand intravascular vol in the non-cardiac, non-hypovolaemic hypotensive Pt e.g. anaphylaxis, burns, sepsis 3.As a fluid challenge in unresponsive, non-hypovolaemic, hypotensive Pts (other than LVF). e.g. PEA; asthma 4.Fluid for diluting and administering IV drugs 5. Fluid TKVO for IV administration of emergency drugs Contraindications 1. Nil of significance in the above indication Precautions 1. Consider modifying factors when administering for hypovolaemia Route of administration IV IO Side effects Nil of significance in the above indication Special notes IV half life: Approximately 30 – 60 min Version 3 - 01.11.05 Page 1 of 2 Oxytocin (Syntocinon) Presentation 10 units (IU) in 1 mL glass ampoule Pharmacology A synthetic oxytocic CPG D031 Action: Stimulates smooth muscle of the uterus producing contractions By the liver; excreted by the kidneys Primary emergency indication 1. PPPH Contraindications 1. Previous hypersensitivity 2. Severe toxaemia (pre-eclampsia) 3. Exclude multiple pregnancy before drug administration 4. Cord prolapse Precautions 1. If given IV may cause transient hypotension 2. Concurrent use with Methoxyflurane may cause hypotension Route of administration IM Side effects Uncommon via IM route: Tachycardia Bradycardia Nausea © Ambulance Victoria 2014 Metabolism Oxytocin (Syntocinon) CPG D031 337 Version 3 - 01.11.05 Page 2 of 2 Oxytocin (Syntocinon) Special notes Concomitant use with prostaglandins (Misoprostol) may potentiate uterotonic effect Must be stored between 2 - 8ºC © Ambulance Victoria 2014 IM effects: Onset: 2 – 4 min Peak: n/a Duration: 30 – 60 min CPG D031 Version 4 - 01.11.05 Page 1 of 2 Pancuronium CPG D023 Presentation 4 mg in 2 mL polyamp Pharmacology A non-depolarising neuromuscular blocking agent © Ambulance Victoria 2014 Actions: - Blocks transmission of impulses at the neuromuscular junction of striated muscles resulting in skeletal muscle paralysis - Due to weak vagolytic action, a slight rise in HR and mean arterial pressure may be expected Metabolism By the kidneys; excreted mainly unchanged in the urine Primary emergency indication 1. To maintain skeletal muscle paralysis and allow mechanical ventilation in intubated Pts following IFS, RSI or during interhospital transfer of ventilated Pts Contraindications 1.Pancuronium must not be given if continuous monitoring of Pt vital signs, including pulse oximetry and EtCO2 monitoring, is not available 2. Status epilepticus Precautions 1. Ensure patency of IV access 2. Sedatives must always be administered prior to Pancuronium 3. ETT placement, adequacy of ventilation, SpO2, EtCO2, HR and BP must be continuously monitored 4.Pts with myasthenia gravis should be given much smaller doses and monitored carefully due to the potential of increased degree of neuromuscular block 5. Care should be exercised in Pts with renal impairment Route of administration IV IO Pancuronium CPG D023 339 Version 4 - 01.11.05 Page 2 of 2 Pancuronium CPG D023 Side effects Slight increase in HR Slight increase in mean arterial pressure Localised reaction at injection site (rare) Special notes Allergic reactions such as urticaria, laryngeal oedema, bronchospasm and anaphylactic shock have been reported. Pancuronium infusions required during interhospital transfers are to be prescribed and signed by the referring hospital medical officer. The initial dose is usually 0.1 mg/kg. © Ambulance Victoria 2014 IV effects: Onset: 2 – 3 min Peak: 8 – 10 min Duration:35 – 45 min Version 2 - 17.12.10 Page 1 of 2 Prochlorperazine (Stemetil) Presentation 12.5 mg in 1 mL glass ampoule Pharmacology An anti-emetic CPG D024 Action: - Acts on several central neuro-transmitter systems Metabolised by the liver; excreted by the kidneys Primary emergency indication 1. Rx or prophylaxis of nausea / vomiting for - Motion sickness - Planned aeromedical evacuation - Known allergy or C/I to Metoclopramide administration - Headache irrespective of nausea / vomiting - Vertigo Contraindications 1. Circulatory collapse 2. CNS depression 3. Previous hypersensitivity 4. Children Precautions 1. Hypotension 2. Epilepsy 3. Pts affected by alcohol or on anti-depressants Route of administration IM © Ambulance Victoria 2014 Metabolism Prochlorperazine (Stemetil) CPG D024 341 Version 2 - 17.12.10 Page 2 of 2 © Ambulance Victoria 2014 Prochlorperazine (Stemetil) Side effects Drowsiness Blurred vision Hypotension Sinus tachycardia Skin rash Extrapyramidal reactions (usually the dystonic type) Special notes IM effect Onset: Peak: Duration: 20 min 40 min 6 hr CPG D024 Version 5 - 04.06.14 Page 1 of 2 Salbutamol CPG D025 Presentation 5 mg in 2.5 mL polyamp 500 mcg in 1 mL glass ampoule 5 mg in 5 mL glass ampoule pMDI (100 mcg per actuation) Pharmacology A synthetic beta adrenergic stimulant with primarily beta 2 effects © Ambulance Victoria 2014 Action: - Causes bronchodilatation Metabolism By the liver; excreted by the kidneys Primary emergency indication 1. Respiratory distress with suspected bronchospasm: - asthma - severe allergic reactions - COPD - smoke inhalation - oleoresin capsicum spray exposure Contraindications 1. IV Salbutamol is no longer indicated for adult Pts Precautions 1.Large doses of IV Salbutamol have been reported to cause intracellular metabolic acidosis Route of administration Nebulised IV IV Infusion ETT pMDI IO Salbutamol CPG D025 343 Version 5 - 04.06.14 Page 2 of 2 Salbutamol CPG D025 Side effects Sinus tachycardia Muscle tremor (common) Special notes IV Salbutamol has no advantage over nebulised Salbutamol provided that adequate ventilation is occurring. Salbutamol nebules / polyamps have a shelf life of one month after the wrapping is opened. The date of opening of the packaging should be recorded and the drug should be stored in an environment of < 30°C Although infrequently used, Salbutamol by IV infusion may be required during interhospital transfers of some women in premature labour The dose is to be prescribed and signed by the referring hospital medical officer Nebulised effects: Onset: 5 – 15 min Peak: n/a Duration: 15 – 50 min © Ambulance Victoria 2014 IV effects: Onset: Peak: Duration: 1 – 2 min n/a 30 – 60 min Version 4 - 20.09.06 Page 1 of 2 Sodium Bicarbonate 8.4% Presentation 50 mL prepared syringe 100 mL glass bottle Pharmacology A hypertonic crystalloid solution CPG D026 Composition: - Contains sodium and bicarbonate ions in a solution of high pH Action: - Raises pH Sodium: excreted by the kidneys Bicarbonate: excreted by the kidneys as bicarbonate ion and by the lungs as CO2 Primary emergency indication 1. Cardiac arrest, after 15 min of AV CPR 2. Symptomatic TCA OD Contraindications 1. Hypothermia < 30°C Precautions 1.Administration of Sodium Bicarbonate 8.4% must be accompanied by effective ventilation and ECC if required 2.Since Sodium Bicarbonate 8.4% causes tissue necrosis, care must be taken to avoid leakage of the drug into the tissues 3.Because of the high pH of this solution do not mix or flush any other drug or solution with Sodium Bicarbonate 8.4% Route of administration IV © Ambulance Victoria 2014 Metabolism Sodium Bicarbonate 8.4% CPG D026 345 Version 4 - 20.09.06 Page 2 of 2 © Ambulance Victoria 2014 Sodium Bicarbonate 8.4% Side effects Sodium overload may provoke pulmonary oedema Excessive doses of Sodium Bicarbonate 8.4%, especially without adequate ventilation and circulation, may cause an intracellular acidosis Special notes IV effects: Onset: 1 – 2 min Peak: n/a Duration:Depends on cause and Pt’s perfusion CPG D026 Version 5 - 04.06.14 Page 1 of 2 Suxamethonium CPG D027 Presentation 100 mg in 2 mL polyamp Pharmacology Depolarising neuromuscular blocking agent © Ambulance Victoria 2014 Actions: - Short acting muscular relaxant Metabolism Pseudo-cholinesterase in plasma Primary emergency indication 1. Complete muscle relaxation to allow endotracheal intubation Contraindications 1. 2. 3. 4. 5. 6. 7. 8. 9. Precautions 1. 2. 3. 4. 5. Route of administration IV IO Known hypersensitivity Upper airway obstruction Penetrating eye injury ECG signs of hyperkalaemia in conditions such as muscle necrosis and renal failure Burns > 24 hr post injury Organophosphate poisoning Ruptured AAA Known history of Suxamethonium apnoea Known history of malignant hyperthermia Liver disease Elderly Pts Crush injuries Pts who have not fasted Airway trauma Suxamethonium CPG D027 347 Version 5 - 04.06.14 Page 2 of 2 Suxamethonium CPG D027 Side effects Muscular fasciculation Increased intraocular pressure Increased intragastric pressure Elevated serum potassium levels Special notes Sedation is required prior to use Atropine 600 mcg should be administered prior to Suxamethonium administration in adult Pts with a HR < 60 Atropine 20 mcg/kg should be administered prior to Suxamethonium administration in children A second dose of Suxamethonium usually causes profound bradycardia Refrigeration of Suxamethonium is required - requires weekly rotation or disposal when not refrigerated © Ambulance Victoria 2014 Usual dosage: Adults: 1.5 mg/kg IV: (max. dose 150mg) IV effects: Onset: 20 - 40 sec Peak: 60 sec Duration: 4 - 6 min Version 1 - 04.06.14 Page 1 of 2 © Ambulance Victoria 2014 Tenecteplase (Metalyse) CPG D035 Presentation 50 mg in glass vial with weight marked and pre-filled syringe containing water for IV administration (must reconstitute all drug then discard unwanted amount according to weight) Pharmacology Fibrinolytic, a modified form of tissue plasminogen activator (tPA) that binds to fibrin and converts plasminogen to plasmin Metabolism Metabolised by the liver Primary Emergency Indication 1. Acute STEMI Contraindication (Exclusion criteria) 1. Blood pressure Systolic >180 mmHg; or Diastolic ≥110 mmHg 2. Known allergy or hypersensitivity to Tenecteplase or Gentamicin 3. Anticoagulant therapy e.g. Warfarin, Heparin, Dabigatran, Rivaroxaban, Apixaban 4. Glycoprotein IIb/IIIa inhibitors e.g. Abciximab, Eptifibatide, Tirofiban 5. Active bleeding or bleeding tendency (excluding menses) 6. GI bleeding within last 1/12 7. Active peptic ulcer 8. Acute pancreatitis 9. Suspected aortic dissection 10. Non compressible vascular puncture 11. Recent major surgery (< 3/52) 12. Traumatic or prolonged (>10 min) CPR 13. Acute pericarditis 14. Subacute bacterial endocarditis 15. History of CNS damage e.g. neoplasm, aneurysm, spinal surgery 16. New neurological symptoms 17. Significant closed head or facial trauma in past 3/12 Tenecteplase (Metalyse) CPG D035 349 Version 1 - 04.06.14 Page 2 of 2 Tenecteplase (Metalyse) Precautions (Relative contraindications) 1. Age ≥ 75 years 2. Low body weight 3. Renal impairment 4. Dementia 5.History of stroke or TIA 6. Diabetes 7. Heart failure 8. Tachycardia 9. Pregnancy 10.Within 1/52 post-partum CPG D035 11. Anaemia 12. Advanced liver disease 13.Blood pressure between 160 - 180 mmHg systolic 14. History of bleeding or known prolonged INR 15. Peripheral vascular disease 16. Administration of Enoxaparin 48 hours prior 17.Recent invasive procedures associated with bleeding such as femoral artery puncture, right heart catheterisation Route of Administration IV, using vial adapter on pre-prepared syringe, as single bolus over 10 seconds Side Effects Bleeding – including injection sites, ICH, internal bleeding Transient hypotension Infrequent - Allergic reactions including fever, chills, rash, nausea, headache, bronchospasm, vasculitis, nephritis and anaphylaxis Rare - Cholesterol embolism © Ambulance Victoria 2014 Special Notes STEMI - 12 lead ECG shows ST Elevation ≥ 1mm in two contiguous limb leads (I, II, III, aVR, aVL, AVF) or ST Elevation ≥ 2mm in two contiguous chest leads (V1, V2, V3, V4, V5, V6), new LBBB Weight optimised dosing improves efficacy and safety outcomes in drugs with narrow therapeutic index e.g. Fibrinolytics Other drugs which affect the clotting process may increase risk of bleeding associated with Tenecteplase. Version 3 - 01.11.05 Page 1 of 1 Water for Injection CPG D029 10 mL polyamp Pharmacology Water for injection is a clear, colourless, particle free, odourless and tasteless liquid. It is sterile, with a pH of 5.6 to 7.7 and contains no antimicrobial agents Metabolism Distributed throughout the body; excreted by the kidneys Primary emergency indication 1. Used to dissolve Ceftriaxone in preparation for IV injection Contraindications 1. Nil in the above indication Precautions 1. Nil in the above indication Route of administration IV Side effects Nil Special notes Nil © Ambulance Victoria 2014 Presentation Water for Injection CPG D029 351 © Ambulance Victoria 2014 This page intentionally left blank Version 2 - 04.06.14 Further Information Alternative drug administration route Intraosseous (IO) route Precautions • The use of the IO route is encouraged in all age groups (excluding preterm infants less than 1 kg) in circumstances when lifesaving drugs and/or fluid are required and IV access is delayed or not possible including: • Follow relevant CWI for IO device -Where ETT is indicated and sedation / paralysis pre or post ETT is required and timely IV access is not possible. • Necrosis of surrounding soft tissue due to extravasation -Cardiac arrest where there will be delay in gaining IV access. • IO insertion is usually not painful in the conscious Pt. It may on occasion be painful though to administer drugs / fluids through an IO cannula • The nominated sites for use in AV practice are the distal and proximal tibia. AAV can also use the proximal humerus (except for newborns). • Care should be taken not to inject air • Beware of extravasation Complications • Infection of bony tissue Local anaesthesia • If any part of the limb is traumatised or infected • If PT conscious, administer IO Lignocaine 1% local anaesthesia slowly prior to infusing drugs/fluid after needle confirmed patent • The proposed site cannot be adequately cleansed -Adult (>30 kg): 0.5 mg/kg (maximum 40 mg IO) • Osteogenesis imperfecta -Child (<30 kg): 0.5 mg/kg (maximum 20 mg IO) Contraindications © Ambulance Victoria 2014 Distal attempts into the same limb where an attempt has already been made should not occur Further Information 353 Further Information Alternative drug administration route (continued) ETT route • The ETT route is still an acceptable route for the administration for lifesaving drugs, however it is not considered as effective as IV or IO routes. Consequently, drug doses and volumes are modified accordingly. It is also not suitable for all prehospital drugs or fluid therapy. A more suitable drug administration route should be sought as soon as practicable. The IO route should be considered a first preference alternative option to the ETT route. Contraindications • Do not administer any other drugs via this route other than those listed below. Precautions • Administer as per relevant CWI. Where ETT size permits, drugs should be administered via a suction catheter inserted into the ETT and flushed with air to ensure drug delivery. © Ambulance Victoria 2014 • Ensure dilution of drug appropriate for age Age Individual dose volume Newborn and infants Up to 1 mL Small child Up to 5 mL Large child Up to 10 mL Adult = 10 mL Drugs via ETT route Adult Paediatric Adrenaline 2 x IV dose (= 2 mg) 10 x IV dose (= 0.1 mg/kg) 10 x IV dose (= 0.1 mg/kg) Salbutamol 2 x IV dose (= 10 mcg/kg initial / = 5 mcg/kg subsequent) Further Information OG / NG tube • The OG / NG tube may be inserted to relieve gastric distension in Pts from all age groups. • It is particularly important in the paediatric age group where ETTs are often uncuffed and air entering the stomach during ventilation may adversely affect diaphragmatic movement. © Ambulance Victoria 2014 • Neonate 10 FG < 4 years of age 12 FG ≥ 4 years of age 14 FG Further Information 355 Further Information 1. Interhospital transfers An interhospital transfer (secondary Tx) involves Pt Tx to a major centre or a specialised unit, which usually requires a timely response for best Pt outcome. The decision to transfer should be based on clinical assessment and clinical condition; availability of expertise and resources required in transit; and consideration of the risk involved in transferring the Pt. The specific level of resources will vary according to Pt condition and other factors. Use of Non-emergency Pt Tx (NEPT) providers - The NEPT service is not an emergency ambulance service. There is now regulation of the NEPT providers and further information is available on http://www.health.vic.gov.au/ nept Emergency transfers - This CPG is written from the perspective of emergency transfers. In more complex situations the Pt must be evaluated and determined to be stable by an appropriate retrieval/referral service medical practitioner in consultation with AV. The decision for appropriateness of transfer and escort requirements should entail a medically shared decision made between AV, the retrieval / referral service and the referring medical practitioner. Escorts - Accompanying practitioners (e.g. midwife / medical practitioner) and services may be required. The accompanying staff is to continue the maintenance of Pt care and responsibility as appropriate and work collaboratively with the Paramedic. The Paramedic crew is to coordinate the Tx and is to be actively involved in the overall Mx of the Pt. © Ambulance Victoria 2014 For unstable Pts and/or those with complex medical needs that may require a medical escort when one is not available, the sending medical practioner is to contact the AV Clinician and one of the specialist retrieval / referral services. In some instances where a medical escort is not available within a reasonable timeframe and the Pt’s condition may measurably deteriorate if transfer is delayed, a shared decision may be made by AV in conjunction with the sending medical practitioner and relevant retrieval / referral service as to the suitability of transfer with an ALS / MICA Paramedic. The medical practitioner or retrieval / referral service remains accountable for the final decision made. Further Information 1. Interhospital transfers (continued) Restraint of equipment and personnel - All personnel travelling in the ambulance must be capable of being seated and restrained by seatbelts in designated passenger seats. All items of equipment transported must be adequately restrained. The Paramedic is to ensure familiarity with the operation of the equipment they are to use prior to departure. Pharmacological agents / infusions - Paramedics should ensure that they are briefed and familiar with any medications that are being sent with the Pt for administration en route, including delivery devices. In general, interfacility medications that are outside the Paramedic’s scope of practice are not to be initiated en route. There may be circumstances (e.g. mental health Pts requiring regular doses of sedation) where Paramedics are required to continue a treatment plan during a transfer. This is acceptable under this guideline providing that the treatment plan is appropriately documented by the Medical Practitioner and that Paramedics are properly briefed. Responsibility and accountability - The referring hospital or medical practitioner is accountable for ensuring: -the appropriate level of care is provided, e.g. a medical escort if required; -a full handover on the Pt’s clinical status, current Mx and the potential events which may occur during Tx and their Mx; and -prescription of the dose and/or rate of an IV infusion and the relevant Rx guideline, including potential side effects and actions to instigate if a medical escort is not provided. Such prescription is to be written and signed by the Medical Practitioner on the AV PCR. The ALS / MICA Paramedic is to ensure that they are adequately briefed and prepared for the transfer and able to Mx the Pt’s clinical condition appropriately. If it is the judgement of the transferring Paramedic crew that the Pt’s requirements are outside of their scope or practice or level of expertise, the referer must be informed immediately. A suitably trained Paramedic (e.g. MICA or flight MICA Paramedic), or provision of an escort should be sought by contacting the AV Clinician. © Ambulance Victoria 2014 In any cases of doubt consultation and advice should be obtained from the Metro / Rural Clinician to ARV 1300 368 661. Further Information 357 Further Information 2. Interhospital transfer of the patient with ACS Pts with ACS, most commonly UA, STEMI or NSTEACS may be receiving drug infusion/s as part of their Rx regime such as GTN and/or Heparin and/or Tirofiban Hydrochloride. These infusions are to be administered by a controlled delivery infusion system. If the Pt is not classified as high risk these infusions can be Mx by an ALS Paramedic. Maintenance of pharmacological Rx for some Pts may include inotropic, vasopressor, and/or antiarrhythmic agents via an IV infusion as a part of their Mx. Some of these Pts may be safely transferred without a medical escort in the direct care of a MICA Paramedic (in the context of emergency transfers as specified in Part 1. Interhospital transfers introduction). As a general principle Pts receiving hospital based thrombolytic therapy should not be transferred until the full dose/s are completed due to the potential for significant adverse side effects. Once the thrombolytic therapy has been completed and the Pt is stable they may then undertake transfer. The level of care required in transit will be determined by the Pt’s condition. 3. Interhospital transfer of obstetric patient © Ambulance Victoria 2014 Refer to specific obstetric emergency CPG Further Information 4. Interhospital transfer of other Pts Pts may require IV fluids as part of their Mx during Tx. Some infusions may also contain additives. These infusions and additives must be considered in the context of the Pt’s total clinical status and Mx at that time. Many Pts can be safely Mx without a MICA or medical escort in the direct care of an ALS Paramedic. For example, Pts who are receiving infusions of crystalloid solutions, blood, opioids, chemotherapy drugs or additives (such as antibiotics or potassium chloride). These drugs must be delivered by a controlled delivery system and the infusion is to have been commenced prior to transfer. Pts with more complex drug therapy may be safely transferred without medical escort in the direct care of a MICA Paramedic in the context of emergency transfers (as specified in Part 1 Interhospital transfers introduction). For other Pts such as those intubated and ventilated and/or have invasive monitoring devices, the transfer is to be discussed with the Metro / Rural AV Clinician. Their consultation with ARV will consider Emergency transfers (as specified in Part 1). Contacts PH 1300 137 650 Adult Retrieval Victoria (ARV) PH 1300 368 661 © Ambulance Victoria 2014 Paediatric Infant Perinatal Emergency Retrieval (PIPER) (previously NETS, PETS and PERS) Further Information 359 Further Information Sudden unexpected death of an infant or child SIDS and Kids Victoria provides bereavement support to families following the sudden and unexpected death of a child from 20 weeks gestation to 6 years of age (up to 18 years of age in some country regions). SIDS and Kids Victoria has a 24-hour telephone service. Phone 1300 308 307 - Other children in the family may need time with their brother or sister. Even very young children can be included in the family’s grieving process right from the start. - Offer to telephone another family member, a friend or a doctor. It is helpful for the family to have the support of familiar and loving people. Initial response - Once the Police have completed their investigation, allow the parents to carry their child to the Ambulance and to nurse him or her during the journey to the hospital. This is an agreed protocol in cases of possible SIDS. - In the metropolitan area, Tx the child and the parents to the Emergency Department of the Royal Children’s Hospital, Monash Medical Centre or Frankston Hospital. This is an agreed protocol in cases of possible SIDS. - If you are attending the sudden and unexpected death of a baby or young child from a cause other than SIDS, consider providing the same opportunity to parents to be Tx with their child to the emergency department of a major hospital. You may need to gain permission from the State Coroner’s Office or from a member of the Victoria Police with the rank of Sergeant or above. - Attempt resuscitation and other life saving procedures if appropriate. Parents need to feel that everything possible was done for their child. - Depending on where you are in Victoria, notify the AV DM who will log the event and notify the Police to attend the scene. - Explain to the parents that the Police will attend to gather information for the Coroner and that this is necessary for all sudden and unexpected deaths, regardless of age. © Ambulance Victoria 2014 - Be generous with your time. Most parents wish to spend time with their child. If one parent is not present at the scene, consider waiting for him or her to arrive. Further Information Sudden unexpected death of an infant or child - - - Outside Melbourne, families’ needs should be treated individually. Consult with the State Coroner’s Office on (03) 9684 4790 (24 hours). Where possible the parents and infant should be taken to the nearest base hospital with an emergency department. Notify hospital to assist with reception. Encourage parents and the other children to accompany the child to hospital where they can spend time, with the support of nursing or social work staff, before taking leave of their child. Most hospital emergency departments have a private room for this purpose. Some parents may request to go to a different hospital, or stay at home or at the scene with the child until the arrival of the Coroner’s contracted funeral director. The individual needs and requests of the parents should be respected wherever possible, but the State Coroner’s Office must approve of these requests. Caring for parents Always use the child’s name unless parents indicate otherwise. - Avoid using clichés such as “At least you have your other children.” It is better to simply say “I’m so sorry your child has died” or “It must be awful for you.” There is no right way of grieving. Acknowledge and accept the feelings expressed by the parents. - Respect cultural mourning customs. - Do not take personally any anger expressed. - Do not be afraid to show your own emotions, but do not allow them to overwhelm the parents or detract from your ability to help. - Having gained the parents’ permission, please notify SIDS and Kids Victoria (1300 308 307 or (03) 8888 1600) of the child’s death. Remember to take care of yourself - The death of a baby or young child is extremely distressing for all involved. Do take a break if possible before returning to other duties. - You may need to talk about what you heard and saw, what you did or said and how you felt. If so, consider contacting Peer Support or the VACU psychologist via 1800 MANERS (1800 626 377). Reproduced from Emergency Responder’s Manual 3rd Edition. SIDS and Kids Victoria 2005. www.sidsandkids.org © Ambulance Victoria 2014 - - Further Information 361 Further Information Verbal de-escalation strategies - Listen to the Pt. - Use the Pt’s name to personalise the interaction. - Use open-ended questions. - Use calm, consistent, even tone of voice, even if Pt’s communication style becomes hostile or aggressive. - Avoid “no” language which may prompt an aggressive response, e.g. “I’m sorry, our policy doesn’t allow me to do that but I can offer you other assistance.” - Allow the Pt as much personal space as possible whilst maintaining control of the scene. - Avoid too much eye contact as this can increase fear in some paranoid Pts. IV fluid calculations Standard giving set: 20 drops = 1 mL Microdrip set: 60 microdrops = 1 mL Drops per minute = Drops per mL x volume time © Ambulance Victoria 2014 Volume to give = Strength required x volume Strength in stock Further Information Drug dilutions CPG A0401 Dilution Morphine increments Description Dilute Morphine 10 mg to 10 mL with 9 mL Normal Saline P0501 A0404 Amiodarone infusion Syringe Pump - Add Amiodarone 5 mg/kg (up to a max. 300 mg) to D5W to make up 50 mL. Run at a rate of 150 mL/hr (i.e. to be delivered over 20 min) Spring Loaded Infusion Device - Add Amiodarone 5 mg/kg up to 300 mcg (max. 6 mL of solution) to D5W to make up 10 mL. Use either 10 mL in 30 min or 10 mL in 15 min infusion device administration set depending on availability. (This runs over 30 or 15 min as closest available infusion rate option) A0402 Adrenaline infusion A0407 Adrenaline increments (10 mcg/mL) Adrenaline Infusions must be clearly labelled with the name and dose of the additive drug and time of commencement Dilute Adrenaline 1 mL of 1:10,000 to 10 mL with Normal Saline 9 mL (i.e. each 1 mL of resultant solution contains Adrenaline 10 mcg) Adrenaline increments (100 mcg/mL) Dilute 1 mL Adrenaline 1:1,000 solution to 10 mL with Normal Saline 9 mL (i.e. each 1 mL of resultant solution contains Adrenaline 100 mcg/mL) Morphine and Midazolam infusion Dilute Morphine 30 mg and Midazolam 30 mg diluted to 30 mL with Normal Saline (i.e. each 1 mL contains 1 mg Morphine and 1 mg Midazolam) A0705 A0402 A0407 Adult giving set - Add Amiodarone 5 mg/kg (max. 300mg) to D5W (100 mL) and run at 100 drops/min (delivered over 20 min) Dilute Adrenaline 3 mg to 50 mL with D5W/Normal Saline (i.e. each 1 mL of resultant solution contains Adrenaline 60 mcg) A0705 A0407 A0705 © Ambulance Victoria 2014 A0302 Further Information 363 Further Information Drug dilutions - Paediatric CPG P0704 Dilution Description Adrenaline infusion (Paed) Syringe pump Adrenaline 300 mcg added to make 50 mL with 5% Dextrose or Normal Saline 1 mL = 6 mcg 1 mL/hr = 0.1 mcg/min © Ambulance Victoria 2014 P0704 Salbutamol infusion (Paed) P0709 Atropine (Paed) P0201 Amiodarone (Paed) P0301 Fentanyl bolus (Paed) P0301 Midazolam bolus (Paed) P0301 Morphine and Midazolam infusion (Paed) At low flow rates in younger children an infusion may not be as effective as providing boluses. Clinical judgement should be applied to the most effective route of administration. Syringe pump Add 100 mcg/kg Salbutamol to D5W/Normal Saline solution to make 50 mL and run at 2 mcg/kg/min (60 mL/hr) Dilute 600 mcg Atropine 1 mL into Normal Saline 5 mL (i.e. each 1 mL contains 100 mcg) ≤ 6yrs: Add 2 mL (100 mg) Amiodarone (from 150 mg in 3 mL ampoule) to 8 mL D5W in a 10 mL syringe ≥ 6yrs: draw up 150 mg in 3 mL as required, no dilution Dilute 100 mcg Fentanyl to 10 mL with Normal Saline 8 mL to make a solution of 10 mcg/mL in one syringe Dilute 15 mg Midazolam with D5W/Normal Saline 12 mL to make 15 mL (i.e. each 1 mL contains 1 mg) Dilute 15 mg Morphine and 15 mg Midazolam to 15 mL with Normal Saline (i.e. each 1 mL contains 1 mg Morphine and 1 mg Midazolam) Further Information Peer Support Crisis counselling – Peer Support service Where staff are exposed to critical incidents or require psychological/emotional support, the following services are available within AV. Nominated Peer Support staff are rostered for contacts. All staff are encouraged to provide notification of critical incidents. - via email [email protected] - telephone 1800 MANERS (1800 626 377) - contact can be for peer support, VACU counselling line, emergency services chaplain, health safety and wellbeing (including workcover) and police statements/court attendance - Available to all employees, including CERT/ACO and immediate family members Additional support agencies - Paramedics and the public • Road Trauma Support Team: telephone 1300 367 797 (for members of the public) • Support After Suicide (03) 9427 9899 • Bereavement Counselling and Support Service (03) 9265 2111 • SIDS and Kids 1300 308 307 • Life Line 13 11 14 • Kids Help Line 1800 551 800 © Ambulance Victoria 2014 • Nurse-On-Call 1300 60 60 24 Further Information 365 Further Information Telephone Interpreting Service (TIS) Paramedics can access the TIS directly on the phone number below and by quoting client codes for AV. An Englishspeaking operator will request the language and dialect and connect the appropriate interpreter. There is no charge to the Pt. This service can be used to improve communication when there is a language barrier. For Pts who have limited comprehension of English, this service will assist to obtain a detailed Hx and perform thorough assessments. This also enables Paramedics to provide more culturally appropriate assistance to Pts from diverse backgrounds. Ambulance Priority Line 1300 655 010 Metro Paramedics to quote the Client Code number of C503484 Rural Paramedics to quote the Client Code number of C504815 Name of Paramedic may be requested by interpreter service operator Interpreter symbol The national interpreter symbol helps people from non-English-speaking backgrounds identify where they can get language assistance, including interpreters, when using government services. Launched in May 2006, the symbol makes it easier for Victorians with limited English skills to access a whole range of services including medical services, Police and emergency services. © Ambulance Victoria 2014 The interpreter symbol is displayed by government and government-funded services at places such as public hospitals, community health centres, local councils, Police stations, employment offices, migrant resource centres and housing offices. Further Information Summary of approved changes © Ambulance Victoria 2014 The following changes have been introduced since the 2012 edition of the CPGs and are inclusive of changes up until the June 2013 Medical Advisory Committee. CPG A0105 CPG title Time Critical Guidelines Amendment summary • Highest level of trauma care available within 45 minutes P0105 A0203 Withholding or Ceasing Resuscitation A0301 Laryngeal Mask Airway A0403 Supraventricular Tachyarrhythmias A0408 Inadequate Perfusion Secondary to Erectile Dysfunction Agents and GTN Administration • Clarification in Special Notes to include: - Mass casualty incidents - Compelling reasons to continue resuscitation - Injury severity and prospect of eventual survival • Development of algorithm inclusive of: - Mass casualty incidents - Prospect of resuscitation - Compelling reasons to withhold resuscitation - Other presentations - Cessation of resuscitation • Verification of death ideally occurs 5 – 10 minutes after cessation of resuscitation • Inclusion of i-gel quick reference guide • Precaution changed to include all paediatrics (≤14 years) • Removal of Verapamil and Metaraminol • Use of Fentanyl for sync cardioversion removed • Introduction of Adenosine for unstable not rapidly deteriorating patients • Valsalva approved for ALS Paramedics • Algorithm simplified to include treatment on one page • Guideline deleted due to low volume of use over review cycle A0501 Pain Relief • Fentanyl now first choice for pain relief for non-IV analgesia A0806 Fracture Management • Guideline reinstated A0807 Diving Related Emergencies • New guideline D032 Adenosine • New drug D006 Compound Sodium Lactate • Deleted D016 Metaraminol • Deleted D028 Verapamil • Deleted Further Information 367 Further Information Summary of approved changes © Ambulance Victoria 2014 The following changes have been introduced since the 2014 first edition of the CPGs and are inclusive of changes up until the June 2014 Medical Advisory Committee meeting. CPG A0001 CPG title Oxygen Therapy Amendment summary • Change COPD definition to align with CPG A0602 • Addition of status epilepticus as a “Critical Illness” A0101 A0302 Clinical Approach Endotracheal Intubation A0408 A0501 P0501 A0601 P0602 STEMI Management Pain Relief • Added description of frailty • Changed indications for RSI and IFS • Added coma due to uncontrolled bleeding as contraindication to RSI • Added pre-oxygenation using high-flow oxygen via nasal prongs • Changes to dose and choice of sedative agents (depending on indication) • Changes to BP management in Pts with NTBI • Deleted oesophageal detector device and squash test from CPG • New guideline • Changed IN Fentanyl dose modifier from age ≥ 60 to elderly / frail • Changed dose regimen for IN Fentanyl in paediatric Pts A0602 COPD Asthma • Changed adult and paediatric Salbutamol pMDI dose regimen • Replaced IV Salbutamol therapy with IV adrenaline therapy in adults • Deleted COPD component of CPG (now CPG A0602) • Removed lateral chest pressure for adults • Reduced tidal volumes for assisted ventilation in adults • Removed ETT doses of Salbutamol in adults • New guideline Further Information Summary of approved changes CPG title Seizures A0704 P0704 Anaphylaxis A0708 The Agitated Patient A0807 Diving Related Emergencies Amendment summary • Guideline renamed • Change in terminology from continuous seizures to status epilepticus • Defined treatment point for status epilepticus • Defined subtle status epilepticus • Added high-flow O2 therapy as initial Mx • Changed dose regimen of IM and IV Midazolam • Added special note for treating seizures in pregnant Pts • Modified diagnostic criteria for anaphylaxis • Changed IM Adrenaline doses • Added nebulised Adrenaline as adjunctive therapy • Added Adrenaline infusion therapy for adults and paediatric Pts • Amended guideline to reflect recent legislative changes to Mental Health Act • Removed restriction on sedation of Compulsory Patients • Changed requirement to consult with AV clinician prior to administering sedation to head-injured Pts • Changed dose regimen of IM and IV Midazolam • Added: Airway management option for GCS <10 © Ambulance Victoria 2014 CPG A0703 P0703 Reference Material 369 © Ambulance Victoria 2014
