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CLINICAL PROCEDURES AND GUIDELINES
FOREWORD
This is the pocket edition of the clinical procedures and guidelines,
developed for the ambulance sector of New Zealand. It is a summary of
the comprehensive version
These clinical procedures and guidelines are for use by Wellington Free
Ambulance (WFA) personnel, with current authority to practice, when
providing clinical care to patients on behalf of WFA. They have been
developed by the National Ambulance Sector Clinical Working Group
(NASCWG) and are issued to individual clinical personnel by the Medical
Director of Wellington Free Ambulance
These clinical procedures and guidelines expire at the beginning of 2016
at which time they will be formally updated and reissued.They remain the
intellectual property of the National Ambulance Sector Clinical Working
Group and may be recalled or updated at any time. Any persons other
than WFA personnel using these clinical procedures and guidelines do so
at their own risk. NASCWG and WFA will not be responsible for any
loss, damage or injury suffered by any person or persons as a result of, or
arising out of, the use of these clinical procedures and guidelines by
persons other than WFA personnel
NASCWG members at the time of publication
∙ Dr Andy Swain, Medical Director,Wellington Free Ambulance
∙ Mark Bailey, Clinical Effectiveness Manager,WFA
∙ Dr Alison Drewry, Director Defence Health, NZ Defence Force
∙ Dr Craig Ellis, Deputy Medical Director, St John
∙ Dr Tony Smith (Chair), Medical Director, St John
∙ Steve Mann, Clinical Education Delivery Manager, St John
Comments and enquiries
Clinical personnel should contact their appropriate Manager. Others
wishing to make formal comments or enquiries should contact
Chair of the National Ambulance Sector Clinical Working Group
c/o Ambulance New Zealand, PO Box 714,Wellington
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This is the CPG version control page. This page will be updated to
indicate which pages in the CPGs have been updated and which version
is the most current
Printerd pocket edition all pages are dated March 2014
Comprehensive and electronic versions all pages should be dated
December 2014
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1.2 AUTHORITY TO PRACTICE
Ambulance and Defence Force personnel cannot legally supply or
administer prescription medicines to patients unless they have authority
to practice, or they are Registered Health Practitioners with this ability
described within their scope of practice by their registering authority. In
addition, services restrict the use of some items of clinical equipment and
some clinical interventions to specific personnel
Authority to practice is the granting of authorisation to a specific person
to supply or administer prescription medicines to patients, or to use
specific items of clinical equipment, or to perform specific interventions
under the oversight of the medical director. All clinical care provided to
patients (beyond first aid) must comply with these clinical procedures
and guidelines. Personnel may not use these clinical procedures and
guidelines without individual authority to do so
Authority to practice is granted at a specified practice level (listed on
pages 14 and 15). Under each practice level is listed a delegated scope of
practice. A delegated scope of practice defines the medicines and
interventions that designated personnel may administer or use when
providing patient care. Ordinary interventions not formally described
within any delegated scope of practice can be performed by all personnel.
Colour bars to the left of treatment steps in each guideline serve as a
reminder of the minimum practice level for that intervention.These bars
correspond to colours in the top row of the table on pages 14 and 15
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2.1 GENERAL PRINCIPLES OF TREATMENT
Although not listed with each section, all patients require a primary and
secondary survey with appropriate intervention as required
Unless otherwise specified, the medicine doses and fluid volumes
described in these guidelines are for adults and children weighing 50kg or
more.
See the paediatric pages for paediatric dosing
All medicines have universal contraindications and as such they are not
repeatedly listed with each individual medicine. These are:
∙ Known allergy to the medicine or its constituents
∙ Pregnancy (particularly first trimester) is a relative contraindication
for most medicines and as such they should not be administered
unless there is a very strong indication to do so
Specific contraindications are listed in section 11 of this book, while
cautions are listed in the comprehensive edition. Most sections contain
alerts to some (generally not all) contraindications and cautions to assist
personnel
With the exception of sodium bicarbonate, drugs that are indicated for
IV administration may be administered IO if such access is available
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2.2 OXYGEN ADMINISTRATION
Few sections contain specific instructions on oxygen and clinical
judgement is required. Oxygen does not necessarily provide benefit and
should usually only be given if the patient has:
• An SpO2 less than 94% on air (exception – see CORD section) or
• Airway obstruction or
• Respiratory distress (exception – see CORD section) or
• Shock or
• Inability to obey commands from TBI or
• Smoke inhalation
Use the simplest device and lowest flow rates to achieve the desired
SpO2. If pulse oximetry is unreliable or unavailable, give oxygen as
appropriate based on the above bullet points
The oxygen flow rates to be used are:
• Nasal prongs 1-4 L/min
• Simple mask 6-8 L/min
• Nebulised mask 8 L/min
• Reservoir mask 10-15 L/min
• Manual ventilation bag 10-15 L/min
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2.4 STATUS CODES
Status codes are a numerical means of describing an assessment
of the severity of a patient’s condition
They are qualitative, require clinical judgement and are allocated to
patients after taking into account their illness or injuries, their vital
signs and the potential threat to their life
They are not altered by the mechanism of injury, the physical
environment (e.g. trapped or not trapped) or the age of the patient
Status
Status zero
Status one
Status two
Status three
Status four
Condition
Dead
Immediate threat to life
Potential threat to life
Unlikely threat to life
No threat to life
Triage tag
Black/white
Red
Orange
Green
Green
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All patients with head trauma causing loss of consciousness should be
advised that they need to be transported to the emergency department
for observation. Where a patient refuses transport the following advice
should be given to them and, wherever possible, to a responsible
accompanying adult
Problems could arise within the first 24 hours. Someone needs to be
with you during that time. You, or the person looking after you, must
phone 111 and ask for an ambulance if any of the following develop
• You have a headache that gets worse
• You are drowsy or difficult to wake up
• You have difficulty recognising people or places
• You have any vomiting
• You behave unusually or seem confused
• You have seizures or fits
• You have weak arms or legs, or are unsteady on your feet
• You have slurred speech
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10.1 PAEDIATRIC EQUIPMENT AND DRUG DOSE
For children, the dose of drugs, defibrillation energy, 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
Advanced Paediatric Life Support (APLS) formulae
Weight (kg)
• Under 1 year old
• 1 ­ 10 years old
• 11 ­ 14 years old
5
2 × (age in years + 4)
3 × age in years
For age 1 year and older, round patient weight (known or calculated) to
the nearest 10kg before using the tables in each CPG or on the following
pages
Endotracheal tube (ETT) size
• Newborn to 1 year
• 1 year and over
3 ­ 4 (uncuffed), 2 ­ 3 (cuffed)
(age in years / 4) + 4 (uncuffed)
(age in years / 4) + 3.5 (cuffed)
Endotracheal tube Length at Lips (LAL) (cm)
• Newborn
• Under 1 year
• 1 year and over
6 + weight in kg
ETT size × 3
(age in years / 2) + 12
Notes
• These formulae are a guide only, individual children may be lighter or
heavier than predicted by the APLS formulae.They may also require
a different ETT size, LAL, or defibrillation energy than that derived
from the formulae
• If drugs are administered, or a paediatric patient is intubated or
defibrillated, the patient's estimated/calculated weight must be
recorded together with drug dose(s), ETT size, LAL, energy settings,
etc.
• All children greater than 14 years or greater than 45kg can be given
adult doses
PAEDIATRIC DRUG DOSES
The following pages contain tables of paediatric drug doses.These tables
are provided to assist you in applying your knowledge and training.They
cannot incorporate all administration information, so a strong knowledge
of each drug is still required.They indicate the calculated dose for a given
patient weight, the concentration of solution that should be obtained, and
the volume that should be administered from that solution. For a
more detailed explanation consult the comprehensive edition
Drug administration errors have occurred where paramedics have
adminstered a listed volume "straight" rather than from the specified
concentration of solution. Entries that are highlighted red are drugs that
are frequently involved in administration errors
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10.2 OTHER PAEDIATRIC GUIDES
December 2014
Wong­Baker FACES pain scale
No hurt
Hurts
little bit
Hurts
Hurts
Hurts
little more even more whole lot
Hurts
worst
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The following is a summary of drug contraindications for quick
reference. For the complete standing orders, refer to the
comprehensive edition of the CPGs
ALL DRUGS: allergy and 1st trimester pregnancy
Drugs with no additional cautions are not listed
Amiodarone
Clopidogrel
• Known hypersensitivity or
allergy to iodine
• Pregnancy or lactation
• Severe liver impairment
• Active pathological bleeding
(e.g. peptic ulcer or
intracranial haemorrhage)
• Breast feeding
Aspirin
• Known hypersensitivity or
allergy to salicylates
• Recent gastric bleeding
• Pregnancy
• Children under 12 years old
Ceftriaxone
• Known hypersensitivity or
allergy to cephalosporins
• Consult if hypersensitivity or
allergy to penicillin
• Consult for children less than
1 year old
Entonox
• Decreased LOC
• Suspected pneumothorax
• Diagnosed bowel obstruction
• Scuba diving in the last 24hrs
Fentanyl
• Children under 1yr age
• Unable to obey commands
• Respiratory depression
(includes active or poorly
controlled asthma)
• Premature labour
• Myasthenia gravis
ALL DRUGS: allergy and 1st trimester pregnancy
Glucagon
Hydrocortisone
• Insulin- or glucagon-growing
tumours
• Premature infants
• Systemic fungal infections
Glyceryl trinitrate (GTN)
Ibuprofen
• Systolic BP less than
100mmHg
• HR less than 40 or greater
than 150bpm
• Erectile dysfunction
medications
• Known hypersensitivity to
ibuprofen and aspirin or other
nonsteroidal anti-inflammatory
drugs
• On anticoagulants i.e. warfarin
• Peptic ulcer or hiatus hernia
• Renal failure
• Third trimester pregnancy
Heparin
• Currently taking
anti-coagulants
Ipratropium bromide
• Known hypersensitivity or
allergy to atropine
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ALL DRUGS: allergy and 1st trimester pregnancy
Ketamine
Loratadine
• Patients where a significant
elevation of blood pressure
would constitute a risk
For analgesia
• Children under 1yr age
• Unable to obey commands
• Has active psychosis
• Cardiac chest pain
• Pregnant or breast feeding
• Children under 1yr age
• Taking erythromycin or
roxithromycin - check QTc
less than 500milliseconds
Magnesium sulphate
• Known hypermagnesaemia
Lignocaine
• Known hypersensitivity or
allergy to local anaesthetics
• Localised inflammation or
sepsis at the injection site,
or septicaemia
• Heart block (sinoatrial,
atrioventricular,
intraventricular)
• Serious CNS disease
(meningitis, cranial
haemorrhage)
Midazolam
• Hypersensitivity or allergy to
benzodiazepines
• GCS<10 for the agitated
patient
• Airway problems
• Myasthenia gravis
ALL DRUGS: allergy and 1st trimester pregnancy
Morphine sulphate
Oxytocin
• Acute severe asthma/CORD
Respiratory compromise or
depression (especially with
cyanosis)
• Premature infants or during
labour for the delivery of
premature infants
• Prolonged QT segment
Naloxone
• Newborns born to opiateabusers (may precipitate
withdrawal
Paracetamol
• Liver impairment
• Any drug overdose
• If patient has taken any other
medication containing
paracetamol within past
4hrs
Prednisone
• Active peptic ulcer
Ondansetron
• Less than 1year old
• Known contenital long QT
Oxygen
• CORD - more than 88% SpO2
Suxamethonium
• History or family history of
malignant hyperthermia
• Paraplegia/quadriplegia
• Muscle disorder
• Hyperkalaemia
• Significant healing burns
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ALL DRUGS: allergy and 1st trimester pregnancy
Tenecteplase
Ticagrelor
• Age > 75 years
• Stroke or head injury within
last 6 months
• Previous major surgery or GI
bleed within the last 2
months
• Recent trauma or surgery of
any form within the last 2
weeks (including extensive
CPR)
• Currently taking anticoagulant
• Severe uncontrolled
hypertension (systolic BP
greater than 200mmHg)
• Confirmed peptic ulcer
disease with symptoms in
the last 3 months
• History of intracranial
haemorrhage
• Active bleeding
• Severe hepatic impairment
Tramadol
• Known hypersensitivity to
tramadol or opioids
• MAOI inhibitors within last
14 days
• Epilepsy
• Acute Intoxication
Tranexamic Acid
• Subarachnoid haemorrhage
• Active intravascular clotting
e.g. DVT
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