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Chapter 21 Reference Tools Anaphylaxis Checklist Bakri Balloon Checklist Burr Hole Checklist Cardiac Arrest Checklist Central Line Checklist Defibrillation Checklist Emergency Delivery Checklist End-tidal CO2 Checklist EZ-IO Checklist Failed Intubation Checklist High Airway Pressure Checklist Hypoxia Checklist Needle Cricothyroidotomy Checklist Pericardiocentesis Checklist Perimortem C-section Checklist Rapid Sequence Intubation Checklist Status Epilepticus Checklist Surgical Cricothyroidotomy Checklist Tension Pneumothorax Checklist Thoracostomy Checklist Thoracotomy Checklist Vacuum Mattress Checklist Ventilator Failure Checklist Antidote Reference Common Induction Agents & Neuromuscular blockers Standard Retrieval Drug Kit Standard Retrieval Kit Set-up 1 2 CHAPTER 21 REFERENCE TOOLS Introduction to Reference Tools This section in particular has been developed to be accessible in the field. It contains recommendations for management of acute patient deterioration, troubleshooting equipment malfunction and checklists for more complex interventions. The reference tools not only enhance the text, but deliver core information to the retrievalist in the most comprehensive manner just when required. To be used in the primary retrieval setting, referral centre or during flight. We have structured the approach to dealing with a crisis into: Recognition - Symptoms & Signs - Inform - Consider Check Correct Communication Action - This enables the retrievalist to structure the approach to a crisis, inform the relevant personnel of the deterioration and correct the problem with suggested interventions. The aim of this section is to provide a uniform approach to complex patient deterioration, which is not dependent on the retrievalist’s environment. In addition there is a toxicology antidote reference guide, a précis of commonly used induction agents and neuromuscular blocker doses and effects, with a standard retrieval drug formulary and an example of a standard retrieval kit contents. RUNNING HEAD 1 Anaphylaxis checklist Recognition Symptoms & Signs: Urticaria Angioedema Stridor Tachypnoea Bronchospasm on auscultation & etCO2 trace Hypotension Gastrointestinal symptoms Communication Inform: Action Consider: Retrieval team Pilot & crewman Referral team Senior anaesthetist Coordinator Receiving centre Adrenaline 0.5ml of 1:1,000 I.M Adrenaline 5ml of 1:1,000 Nebulised Adrenaline infusion IV Hydrocortisone 100-200mg IV Fluid resuscitation if hypotension Salbutamol 5mg Nebulised 3 4 CHAPTER 21 REFERENCE TOOLS Bakri balloon Checklist Recognition Post partum haemorrhage Communication Retrieval Team Referral centre Obstetrician Coordinator Receiving centre Action Ensure uterus free of products by ultrasound Ensure foley catheter insertion for bladder drainage Trans-vaginal placement of balloon portion of catheter into uterus under ultrasound guidance Ensure balloon portion of catheter inserted past cervical canal Pre-measure 500ml of sterile fluid into jug Fill balloon with 500ml fluid using 50ml syringe Apply gentle traction to shaft of balloon to ensure contact between balloon & uterine wall when balloon full Secure to patient’s leg Pack vaginal canal with gauze to help stability of balloon Connect drainage tube to bakri balloon to monitor blood loss You may flush through this port in case of clot If balloon dislodges through cervix, deflate & re-position Balloon must be removed after 24hours RUNNING HEAD 1 Burr hole Checklist Recognition GCS <8 Extradural haematoma on CT scan Midline shift Unequal pupils Transfer not possible within appropriate timeframe Communication Retrieval team Coordinator Referral centre Receiving neurosurgeon Action Position patient appropriately-supine Ensure normocapnia or hypercapnia, normotensive, anticonvulsants, mannitol or hypertonic saline. Confirm haematoma on CT Mark patient shoulder corresponding to haematoma side Ensure CT scans are visible during procedure Burr hole must be over centre of haematoma Count down the number of slices from the top and multiply by slice thickness to calculate number of centimetres below the vertex the burr hole should be. Shave 5cm of hair over site that burr hole is to be made Mark a 3cm incision Clean area with chlorhexidine or betadine Drape sterile field Make an incision down to the bone Direct pressure to be applied to bleeding from superficial temporal artery Push the periosteum off the bone with a knife/swab Insert a self-retaining retractor Push down firmly with drill and start drilling keeping drill perpendicular to the skull. Ensure assistant is holding head still and ideally apply saline wash as you drill Keep going- DO NOT stop as this will disengage the clutch mechanism which can be difficult to re-engage manually Drill until the drill stops spinning 5 6 CHAPTER 21 REFERENCE TOOLS Use blunt hook to remove remaining bone fragments Extradural blood should now escape If the blood is subdural rather than extradural. Very carefully open the dura using a sharp hook to tent the dura up, and use a new sharp knife to incise in a cruciate manner. Subdural blood is likely to be more clotted and difficult to extrude than extradural. Manual removal of clot with forceps or gentle suction should be considered., but may damage brain and is unlikely to remove sufficient haematoma. If no blood is found either extra or sub durally, stop, check sider and check location of hole. Do not delay transfer. If fresh blood continues to ooze from wound don not try to tamponade. Leave retainer in place, diathermy skin edges, direct pressure. Adapted from : Reference Wilson MH, Wise, D, Davies G, Lockey D, Emergency burr holes how to do it Scan j trauma resus emerg med 20 2012 RUNNING HEAD 1 Cardiac Arrest Checklist Recognition Symptoms & Signs: Loss of consciousness Loss of pulse Apnoea Arrhythmia Hypoxia Hypotension Loss of etCO2 trace Communication Inform: Retrieval team Referral team Cardiac arrest team Pilot & Crewman Coordinator in timely manner Receiving unit in timely manner Family Action - Delegate tasks - Check pulse & confirm cardiac arrest - Immediate CPR - Early defibrillation - Early intubation - Check: - Oxygen supply - Endotracheal tube position & patency - Inotropic support is infusing via patent access - Monitoring is attached Correct: - Hypoxia See hypoxia checklist - Hypotension. IV crystalloid, blood or inotropes - Hypothermia. Active & passive rewarming: warm fluid, warming blankets, warm gases, urethral catheter, consider bypass or ECMO - Hypo/Hyper kalaemia, calcaemia, magnesaemia. VBG, ECG, replace or reduce. - Tension pneumothorax. needle thoracocentesis, thoracostomy, chest drain - Tamponade. Ultrasound, pericardiocentesis or thoracotomy 7 8 CHAPTER 21 REFERENCE TOOLS - Thromboembolism-thrombolysis Central line Checklist Recognition Inotrope support Difficult or additional IV access CVP monitoring Communication Retrieval team Referral team Pilot & crewman Coordinator Action Patient consent if appropriate Sterile procedure Ultrasound guided Cardiac monitored procedure Internal Jugular/Subclavian/Femoral insertion Lay equipment out in order on sterile field Ensure wire is withdrawn with cap removed Ensure central line is flushed with sterile saline prior to insertion Position patient & talk through procedure if awake Vein identified by landmarks Vein identified by ultrasound Site cleaned Sterile drapes Local anaesthetic infiltration Using seldinger technique: Large needle directed towards vein under ultrasound guidance Slowly advancing needle and aspirating When blood is withdrawn check that it looks venous, check it is not pulsatile & withdraw sample for blood gas to confirm Remove syringe Feed wire along needle to mark on guidewire Watch cardiac monitor to prevent ectopics or VT RUNNING HEAD 1 Remove needle over guidewire with care to leave guidewire in situ Make a single incison anterior to guidewire in skin Place dilator over guidewire & gently into skin, gently rotating Remove dilator Place central line over wire to 12-15cm mark Blood should ooze from distal port Remove wire without removing central line Remove blood for sampling & cultures Flush all ports of central line Close taps Close clips Secure in 2 places to skin with sutures Cover with sterile dressing Arrange CXR to check position & in case of pneumothoraces When position checked central may be used for infusions 9 10 CHAPTER 21 REFERENCE TOOLS Defibrillation Checklist Recognition Ventricular fibrillation Pulseless Ventricular Tachycardia Torsades de Pointes Consider risks & benefits in atrial or ventricular arrhythmia with cardiovascular compromise Communication Inform: Retrieval team Pilot & crewman Referral team Coordinator in a timely manner Action Check: Correct: Confirm cardiac arrest or compromise Consider precordial thump Start chest compressions Place defibrillation pads Attach to defibrillator Ensure no movement artefact, good contact & patient is dry Check defibrillator is reading via pads Confirm rhythm Synchronise defibrillator if patient compromised with pulse and consider sedation Charge Remove or reposition face mask oxygen, leave ventilator circuit Avoid contact with patient or equipment when shock delivered Shock 200J or incrementally from 100J if cardioversion Consider chemical cardioversion if electrical cardioversion fails RUNNING HEAD 1 Emergency Delivery Checklist Recognition Painful uterine contractions with cervical dilatation >3cm Rupture of membranes Communication Retrieval team Pilot & crewman Referral team Obstetrician Midwife Paediatrician Coordinator Receiving centre Action - Check observations - CTG if possible - Analgesia if possible - Request delivery pack st - 1 Stage - Onset of labour with uterine contractions until cervix is fully dilated at 10cm nd - 2 Stage - Head descends & rotates occiput up - Stand on patient’s right side - When the head crowns stop the patient pushing & ask them to take quick shallow breaths - This allows more control over delivery rate & prevents perineal tearing - Allow head to extend when delivered - Ensure cord is not around neck - If cord caught around neck try to remove gently or clamp & divide in situ - Anterior shoulder is delivered with assistance from mother pushing downward & backward traction of head may be required to assist anterior shoulder delivery - Posterior shoulder is delivered by lifting head upwards - Give 5units of oxytocin & 500mcg ergometrine IM - Give baby to mum rd - 3 Stage - The cord moves downwards with placenta apply gentle downwards traction & upwards pressure on uterus - If mother is rhesus negative then she requires Rhesus anti-D immunoglobulin 11 12 CHAPTER 21 REFERENCE TOOLS ETCO2 Checklist Recognition Change in waveform Rising etCO2 Falling etCO2 Communication Retrieval team Referral centre Coordinator Action etCO2 reflects Ventilation, Cardiac output, CO2 production Rising etCO2: Airway obstruction-check ETT patency position, length, cuff pressure, suction, ventilator circuit is in tact Hypoventilation-Increase rate, Increase tidal volume Bronchospasm-nebulisers, adrenaline, steroids Bronchial intubation-check CXR, auscultate Increased metabolic rate- Reduce temperature, exclude malignant hyperthermia Rebreathing CO2-check CO2 absorber & ventilator circuit Falling etCO2: Airway obstruction. check ETT patency, position, length, cuff pressure, suction Check circuit is in tact Hyperventilation. reduce rate, reduce tidal volume Reduced cardiac output. check pulse, fluid resuscitate, inotropic support Reduced metabolic rate. correct hypothermia, Cardiac arrest RUNNING HEAD 1 EZ-IO Checklist Recognition Inability to gain venous access in patient requiring emergent resuscitation Communication Retrieval team Referral centre Pilot & crewman Action Avoid long bone fracture or infection Identify appropriate site for insertion: Proximal Tibia. 2cm below patella & 2cm medial to tibial tuberosity Distal tibia. 3cm proximal to the medial malleolus on flat medial surface of bone Femur. 3cm above the mid-point of the distal femur Humerus. Ensuring patient has arm adducted and hand resting on abdomen. Insertion site is 1cm above greater tuberosity of humerus. This is felt by sliding hand along upper humerus until the greater tuberosity if palpated The 15mm needles should be used in paediatrics & 45mm needle in adults The needles magnetically attach & detach from the drill Sterile technique Consent patient if awake Use local anaesthetic Ensure limb is stabilized Needle should be inserted at 90 degrees to bone Allow adequate pressure to be exerted on skin Release trigger on drill when a “pop” is felt on entering medullary cavity Remove drill from needle by stabilizing needle and pulling back on drill Secure needle When needle is inserted unscrew cap Remove blood for testing Infuse drug or fluid at same dose for IV infusion Fluid or drug must be infused under pressure 13 14 CHAPTER 21 REFERENCE TOOLS Failed intubation Checklist Recognition Can’t intubate Can’t ventilate *Call for help EARLY* Communication Retrieval team Referral team Anaesthetist ENT surgeon General surgeon Coordinator in timely manner Action *Whether this is expected or unexpected call for help early *Start working down the list of alternative methods for intubation *Communication with team is essential & could be life-saving Check patient head position Use airway adjuncts Use 2 person technique 1 person to hold airway & other person to squeeze ambu-bag Attempt external larygngeal manipulation by laryngoscopist Use video-laryngoscope if not already Introduce bougie & feel for clicks of tracheal rings Use LMA Reverse non-depolarising muscle relaxant Needle or surgical cricothyroidotomy *See checklist* RUNNING HEAD 1 High Airway Pressure Checklist Recognition Rising peak inspiratory pressures >35cmH2O Communication Retrieval team Referral team Coordinator in a timely manner Action Mechanical obstruction to ventilation Check ETT position, patency, CXR, auscultate, suction, Ventilator failure. Hand ventilate with BVM to exclude mechanical failure and gas-trapping in asthma Clinical obstruction to ventilation Bronchospasm-nebs, adrenaline, low volume, low rate ARDS. High volume, increased rate Pulmonary oedema. Check PEEP, GTN Pneumothorax. Urgent decompression Obesity. Higher PIP may be necessary Inadequate sedation and/or paralysis Appropriately position patient 15 16 CHAPTER 21 REFERENCE TOOLS Hypoxia Checklist Recognition Tachypnoea Cyanosis Increased work of breathing Asymmetrical chest movement Deterioration in oxygen saturation Deterioration in etCO2 Communication Retrieval team Referral team Anaesthetist Coordinator in timely manner Receiving centre Action In awake patient: Sit patient up High flow oxygen Auscultate chest Treat bronchospasm, pulmonary oedema, pneumothorax CXR Arterial or venous blood gas *Consider RSI checklist* In intubated patient: Check oxygen source & supply Check inlet & outlet ventilator connections Check oxygen circuit is connected along length & is patent Check ETT position, patency, length, cuff pressure Suction ETT If ETT too low or too high withdraw or advance to 24cm at lips If there is a cuff leak replace ETT using a bougie Treat bronchospasm, pulmonary oedema, pneumothorax CXR RUNNING HEAD 1 Needle cricothyroidotomy Checklist Recognition Can’t intubate Can’t ventilate Intervene early Temporizing measure prior to surgical cricothyroidotomy Communication Retrieval team Referral centre Pilot & crewman Senior anaesthetist ENT/General surgeon Coordinator in timely manner Action Sterile procedure Identify thyroid cartilage & cricoid cartilage Secure cricoid cartilage with non-dominant hand Insertion of wide bore 14G cannula or needle into cricothyroid membrane that lies between these cartilages Needle must be inserted in midline and directed caudally Aspirate using syringe on needle Ensure needle inserted to appropriate depth. Too deep insertion will cause trauma to posterior tracheal wall Secure cannula Attach to oxygen source at 15L/minute with side hole in tubing Occlude side hole for 1 second every 5seconds to allow escape of CO2 Make arrangements for definitive airway insertion 17 18 CHAPTER 21 REFERENCE TOOLS Pericardiocentesis Checklist Recognition Tachycardia Tachypnoea Elevated JVP Muffled heart sounds Hypotension Cyanosis Pulsus paradoxus. A greater than 10mmHg systolic blood pressure drop on inspiration Cardiac arrest Communication Action Retrieval team Coordinator Pilot & Crewman Referral centre Trauma surgeon Discuss risks & benefits of procedure with above & patient Sterile technique Ultrasound guidance Position patient at 45degrees if awake Using needle & syringe from CVC kit Identify the xiphoid process Aim at 45degrees between the junction of the xiphoid process & left rib cage Direct the needle towards the tip of the left scapula Withdraw whilst advancing needle Watch monitor for current of injury as pericardial sac is penetrated. ECG changes imply the needle has penetrated the myocardium so withdraw. Pericardiocentesis is not indicated in those patients in cardiac arrest secondary to tamponade from trauma. *See thoracotomy* RUNNING HEAD 1 Perimortem c-section Checklist Recognition Cardiac arrest in pregnant mother The earlier the baby is removed the greater likelihood of survival If in doubt confirm pregnancy by ultrasound prior to c-section Communication Retrieval team Pilot & crewman Referral centre Obstetrician Coordinator Receiving centre Action Ongoing resuscitation of mother must occur in conjunction with c-section Standard c-section pack should be used but if not available skin prep, sterile drapes, scalpel, artery forceps or disposable cord clamp, scissors Paediatric team should be present to resuscitate baby Sub-umbilical midline skin incison if practitioner unfamiliar with procedure Separate rectus muscle Make incision into upper uterus using midline incision Insert catheter to drain bladder or aspirate if obstructing access Clamp cord Remove baby for resuscitation Remove placenta manually Ergometrine 0.25mg can be injected directly into myometrium to assist contractility Passive aortic compression can be applied at the level of the sacral promontory to assist with resuscitation efforts & minimise bleeding Compression clamps should be applied to uterus incision ankles & to uterine and abdominal incisions closed even if resuscitation is to be abandoned If maternal circulation is restored uterine contractility can be maintained and postpartum blood loss minimised by administering misoprostol 4 x 200mcg tablets rectally or infusion of oxytocin 40iu in 500ml hartmanns over 4hour 19 20 CHAPTER 21 REFERENCE TOOLS Rapid Sequence Intubation Checklist Recognition Respiratory Failure Reduced conscious level Retrieval purposes Communication Retrieval team Pilot & crewman Referral centre Coordinator Action The essentials of a safe RSI are: Consent patient if appropriate Communication with team Airway assessment “LEMON” Task allocation is essential: Airway operator Airway assistant Cricoid pressure Administering drugs Documenting procedure Monitoring observations If difficult airway anticipate call anaesthetist Airway Position patient-ear to sternal notch Manual-in-line stabilisation if required Optimise oxygenation by facemask or non-invasive ventilation or bag-valve mask ventilation Check PEEP valve on BVM Check airway adjuncts Nasal cannula with high flow oxygen Check suction Select Laryngoscope size 3 or 4 & check light source Check video laryngoscope & light source Select ETT & check cuff Ensure smaller & larger ETT available Check 10ml syringe Lubrication gel Choose stylet if required RUNNING HEAD 1 Select bougie with coude tip Select LMA Select Cricothyroidotomy kit Check with team Plan A, B & C Breathing Check oxygenation Review CXR Treat pneumothorax Circulation Monitoring. HR, Blood pressure, RR, Sats, etCO2 IV access. At least 2 ports, flushed & patent IV fluid. Running as bolus or flush or to keep vein open IV Drugs. Inotrope support if shocked or expected to deteriorate Arterial line Drugs Induction agent Muscle relaxant Sedation ready to start post intubation Inotropes or metaraminol in case of hypotension Everything Else Ask team if they understand Ask team if they have any concerns 21 22 CHAPTER 21 REFERENCE TOOLS Status Epilepticus Checklist Recognition Tonic clonic limb movements Saccidic eye movements Trismus Absences Seizure activity lasting >5minutes with no intervening neurological recovery Communication Retrieval team Pilot & crewman Referral team Action Consider: - Place patient in the recovery position - Diazepam PR 0.5mg/kg or IV 10mg - Lorazepam IV 4mg as alternative. Repeat after 10minutes if necessary - Midazolam IM, Buccal or Intranasal 0.15-0.3mg/kg or IV 12mg. - Phenytoin IV 15mg/kg Fosphenytoin 20mg/kg - Phenobarbitone 20mg/kg - RSI with Propofol or Thiopentone or midazolam Correct: - Hypoxia - Hypoglycaemia - Hyponatraemia - Thiamine & Pyridoxine deficiency - Eclampsia - Intracranial haemorrhage - Intracranial infection RUNNING HEAD 1 Surgical cricothyroidotomyChecklist Recognition Can’t intubate Can’t ventilate Intervene early Communication Retrieval team Referral centre Pilot & crewman Senior anaesthetist ENT/General surgeon Coordinator in timely manner Action - Here are 2 checklists for cricothyroidotomy depending on individual circumstances: - Minimal equipment procedure: - Sterile procedure - Identify thyroid cartilage & cricoid cartilage - Infiltrate with local anaesthetic if appropriate - Secure cricothyroid complex with non-dominant hand - Make vertical incision 1cm in length - Insert blunt end of scalpel & rotate 90 degrees to open up incision - Insert lubricated bougie only a few centimetres and direct distally - Insert a size 6.0mm endotracheal tube over the bougie - Inflate cuff - Connect to bag-valve mask & oxygen - Secure ETT - Open OR Seldinger technique: - Sterile procedure - Identify thyroid cartilage & cricoid cartilage - Infiltrate with local anaesthetic if appropriate 23 24 CHAPTER 21 REFERENCE TOOLS - Secure cricothyroid complex with non-dominant hand Make vertical incision 1cm in length OR Insert needle into cricothyroid membrane Use tracheal dilator to open cricothyroid membrane OR Using seldinger technique feed wire along needle Remove dilator and place tracheostomy tube OR make in -cision into cricothyroid membrane below wire insertion point Place dilator over wire & remove Place tracheostomy tube over wire Inflate cuff Secure tube Bag valve mask ventil Tension Pneumothorax Checklist Recognition Non-intubated Air hunger Hypoxia Tachpnoea Tachycardia Hypotension Cyanosis Intubated Decreased oxygen saturation Decreasing etCO2 Tracheal deviation Absent breath sounds Hyperresonance on percussion Communication Retrieval team Coordinator Pilot & crewman Referral centre Trauma surgeon Action - Consent patient & ensure sterility where possible - Bilateral or unilateral needle decompression in second interspace mid-clavicular line above the rib below using a 14g cannula - Follow-up with chest drain insertion or thoracostomy - Position patient appropriately - Clean chest wall with chlorhexidine or betadine - Ensure sterile field - Infiltrate chest wall with local anaesthetic ensure pleura is infiltrated - Consider conscious sedation in awake patient RUNNING HEAD 1 - - Make incision 2cm in 5th interspace anterior to mid-axillary line above the rib below Increase depth of incision. Greater force may need to be applied to breach parietal pleura and enter pleural cavity. Be mindful of underlying structures particularly in left sided drains Feed chest drain around posterior chest wall Attach drain to underwater seal and ensure bubbling, swinging and misting. & secure with sutures and dressing Thoracostomy Checklist Recognition Non-intubated Air hunger Hypoxia Tachpnoea Tachycardia Hypotension Cyanosis Intubated Dropping oxygen saturation Dropping etCO2 Tracheal deviation Absent breath sounds Hyperresonance on percussion Communication Action Retrieval team Coordinator Pilot & crewman Referral centre Trauma surgeon As initial treatment for tension pneumothorax or in place of chest drain insertion As for chest drain insertion but 2cm incision anterior to mid-axillary line should be extended to 5cm incision anteriorly 25 26 CHAPTER 21 REFERENCE TOOLS Thoracostomy is left open and can be examined in transit with a sterile gloved finger to remove any obstruction should tension recur Chest drain can be inserted at trauma centre or thoracotomy may be extended to clam-shell thoracotomy Thoracotomy Checklist Recognition Cardiac arrest in patient suffering penetrating chest trauma Communication Retrieval team Referral centre Pilot & crewman Receiving centre Trauma surgeon Action - Position patient supine - Sterile procedure - Ensure patient has good IV access and is receiving volume replacement with blood and crystalloid - Ensure airway is protected by intubation th - Thoracostomy incisions bilaterally anterior to 5 interspace midaxillary line to exclude tension pneumothoraces - Using a scalpel to join thoracostomies with a skin incision across the chest wall and below the nipples in the 5th interspace - Using sterile trauma scissors cut along this line into the chest wall until you reach the sternum on both sides of the chest. Use 2 fingers beneath the scissors to avoid damage to the lung tissue - Cut the fibrous tissue posterior to the sternum with a scalpel to allow the gigli saw to be passed beneath the sternum - Taking either end of the gigli saw with tension on the saw pull upwards whilst sawing though the sternum - With care because of sharp rib edges retract the rib cage such that the pericardium is visible. Allow an assistant to hold this in position for you - Take hold of the middle of the pericardial sac and tent it upwards and away from the heart - Cut a hole in the pericardial sac and extend up and down taking care not to damage the heart - The pericardial sac should now be reflected behind the heart - Scoop out any clot from the pericardial sac - Remove any penetrating object RUNNING HEAD 1 - - - Depending on wound size plug with gauze or a finger or place a foley catheter in wound or suture the hole in the myocardium with 0/0 non-absorbable monofilament Perform cardiac massage in upwards stroking manner with a hand behind the heart and one hand in front of the heart from bottom to top Ensure volume replacement is adequate It is possible to shock the heart out of VF using internal paddles or by closing rib cage but volume replacement is the key 27 28 CHAPTER 21 REFERENCE TOOLS Ventilator Failure Checklist Recognition Loss of display screen Loss of oxygen supply Communication Retrieval team Referral centre Closest healthcare facility or healthcare provider Coordinator may be able to facilitate liason with paramedic to provide replacement Action Bag-valve mask ventilation Ensure ventilator connected to oxygen supply & circuit Connect ventilator to power supply Ensure power supply on in vehicle Change power source Turn ventilator on & off Change rechargeable battery RUNNING HEAD 1 DRUG in OVERDOSE ANTIDOTE Benzodiazepine Beta-Blocker & Calcium channel Blocker Barbiturates Cyanide Digoxin Flumazenil 200mcg over 15seconds then 100mcg at 60 second intervals maximum dose 1mg IV OR 100-400mcg/hour as IV infusion High dose Insulin Euglycaemic Therapy Short acting INSULIN 0.5 IU/kg/hr -5 IU/kg/hr titrate to effect. Dextrose infusion at 0.5g/kg/hr using 20-50% Dextrose Check blood glucose & potassium Charcoal if <1hour Calcium gluconate 10ml of 10% IV OR Calcium chloride 20ml of 10% Glucagon 5-10mg IV but shortlived effect Atropine 500mcg up to 3mg IV Inotrope support Adrenaline or Noradrenaline Cardiac Pacing/IABP/ECMO Activated charcoal 50-100g oral suspension Alkalinization of urine Charcoal haemoperfusion Oxygen Charcoal <1hour 50-100g oral suspension Sodium thiosulphate 25ml of 50% over 10minutes IV Sodium nitrite 10ml of 3% over 5-20min IV Hydroxocobalamin(B12) 510g Dicobalt edetate 300mg over 1 minute IV in severe toxicity Charcoal <1hr 50-100g oral suspension 29 30 CHAPTER 21 REFERENCE TOOLS Ethylene Glycol Iron Lithium Local anaesthetic Methanol Sodium bicarbonate 8.4% 50100ml IV Insulin/dextrose if hyperkalaemia Insulin 50 IU in 50ml 5% dextrose titrate to normoglycaemia & normal potassium Atropine Cardiac Pacing Digibind 38mg IV as infusion Ethanol 12g/hr IV or Whisky/gin/vodka 125-150ml PO or NG or 8ml/kg of 10% ethanol IV Fomepizole Sodium bicarbonate 1mmol/kg IV Haemodialysis Desferrioxamine 15mg/kg/hr to maximum 80mg/kg in 24hrs IV Haemofiltration Intralipid 20% 1.5ml/kg over 1minute Follow-up with immediate infusion 0.25ml/kg/min. Rpt bolus every 3-5minutes up to 3ml/kg total dose until ROSC. Increase rate to 0.5ml/kg/min if BP declines. Max 8ml/kg Methaemoglobinaemia Organophosphate Ethanol 12g/hr IV or Whisky/gin/vodka 125-150ml PO or NG or 8ml/kg of 10% ethanol IV Fomepizole Folinic acid 1mg/kg max 50mg every 6hr for 48hr Sodium bicarbonate 1mmol/kg IV Haemodialysis Methylene blue 1-2mg/kg IV repeat after 30-60minutes if necessary Atropine 2mg IV until symp- RUNNING HEAD 1 Opiods Paracetamol Phenothiazine Salicylate Theophylline Tricyclic antidepressant toms subside Pralidoxime 30mg/kg over 510min IV repeat every 4-6hrs OR 8mg/kg/hr max 12g in 24hrs Naloxone 0.4-2mg if no response repeat at intervals of 23minutes to max 10mg IV or IM. Give half effective bolus dose over 1hour as IVI N-acetylcysteine 150mg/kg in 200ml 5%dextrose over 15min IV then, 50mg/kg in 500ml over 4hrs IV then, 100mg/kg in 1L over 16hr IV Methionine 2.5g followed by 3 further doses of 2.5g every 4hours PO (if NAC unavailable) Procyclidine 5-10mg IV or IM Benzatropine 1-2mg IV or IM Charcoal 50-100g PO Sodium bicarbonate 500ml of 1.26% every 1hr for 3hrs Haemodialysis Charcoal 50-100g PO Charcoal haemoperfusion Charcoal 50-100g PO Sodium bicarbonate 8.4% 50100ml & rpt if necessary Inotropes Intralipid 31 32 CHAPTER 21 REFERENCE TOOLS Common Induction Agents & Neuromuscular Blockers Induction Agent Adult dose Fentanyl 50-100mcg /kg IV 1.5mg/-2kg IV 4-10mg/kg IM Ketamine Midazolam Propofol 0.070.1mg/kg IV 1.52.5mg/kg IV 4mg/kg IV Thiopentone NonDepolarising neuromuscular blocker Paediatric dose Cautions 35mcg/kg IV 11.5mg/kg IV 3-4mg/kg IM >7yrs 0.15mg/kg HR RR Vt “wooden chest” 2.54mg/kg IV 2-7mg/kg IV BP, Vt, apnoea, ICP HRBPcerebral blood flow, bronchodilation BPHR apnoea BP, apnoea, ICPEEG Adult dose Paediatric dose Cautions 0.3-0.6mg/kg IV 0.3-0.6mg/kg Atracurium Bronchospasm 16min duration Pancuronium 0.05-0.1mg/kg IV 0.060.1mg/kg HR, BP 22min duration 0.06mg/kg IV 0.06mg/kg IV 0.08-0.1mg/kg IV 0.010.02mg/kg IV HR 17minutes duration 14-30minutes duration Rocuronium Vecuronium polarising neuromuscular blocker Suxamethonium Adult dose Paediatric dose 0.5-2mg/kg IV 1mg/kg IV Cautions serum K 5minutes duration RUNNING HEAD 1 33 Standard Retrieval Drug Kit Left Side Right Side DRUG DOSE AMOUN T DRUG DOSE AMOUN T Sodium Bicarbonate 4.2g / 50ml 2 Stemetil 12.5mg 2 Glucose 50% 25g / 50ml 1 Maxalon 10mg 2 Glucagon 1mg 1 Ondansetron IV 8mg 2 Hydrocortisone or Dexamethasone 250mg or 8mg 1 Ondansetron Wafer 4mg 4 Suxamethonium 100mg 2 Phenytoin 250mg 4 Propofol 200mg / 20ml 3 Nifedipine Oral 20mg 4 Pancuronium 4mg 4 Ventolin Obstetric 5mg / ml 1 Rocuronium 50mg 3 Lignocaine 1% 50mg / 5ml 2 Calcium Gluconate 2.2mm ol / 10ml 2 Adrenaline 1:1000 1mg / ml 10 34 CHAPTER 21 REFERENCE TOOLS Magnesium 10mmo l / 5ml (2.5g) 2 Ventolin 50mcg / ml 3 Ceftriaxone 1g 1 Metoprolol 5mg / 5ml 3 Aspirin 300mg 4 Naloxone 400mcg / ml 4 Amiodarone 150mg / 3ml 3 Noradrenaline 1:1000 2mg / 2ml 6 Aramine 10mg / 1ml 2 Verapamil 5mg / 2ml 2 Atropine 600mcg / 1ml 1 Atropine 1200mc g / 1ml 3 Lasix 40mg / 4ml 4 RUNNING HEAD 1 Standard Retrieval Kit Set-up BLUE BAG Bag Valve Mask with PEEP valve Braun Syringe pumps ET CO2 cable in black box RED BAG 1 Femoral arterial line 2 3 Long arrow radial arterial line 1 1 Pressure transducers 2 Test lung 1 Invasive monitoring cables (square & oval) 1 each Equipment checklist 1 CVC kit 2 Power leads for syringe pumps 3 Rapid infusor 2 NaCL 500ml 1 1 5% dextrose 100ml 1 1 IV Pump set 1 2 Basic airway kit Disposable ventilation circuit 2 Magills forceps – small 1 Invasive pressure Monitoring MULTI cable adaptor (NB. Handle with care) 1 Magills forceps – large 1 Suction catheters 10F 1 Top outer pocket Bougie Emergency pneumothorax kit Chest drainage kit bag End pocket 1 Oximax O2 sensor 2 Suction catheters 12F 1 Liquorice stick 1 ETT 6 1 Drager 90 degree angle connector 1 ETT 7 1 35 36 CHAPTER 21 REFERENCE TOOLS Penlite torch 1 End pocket 2 ETT 7.5 1 ETT 8 1 AA batteries for syringe pumps 1 packet Laryngoscope handle 1 Bacterial ETT filters 2 Long blade 1 Short blade 1 C size batteries 2 10ml syringe 1 Liquorice stick connector 1 Wee device 1 50ml Syringe – catheter tip 1 Transpore tape 1 Sleek tape 1 PROPAQ MONITOR Temperature probe 1 Trauma shears 1 Temperature cable 1 Hand sanitising gel 1 Monitor cables 1 Tube ties 2 ECG dots 1 bag Guedel size 3 (green) 1 O2 sat probe 1 Guedel size 4 (yellow) 1 O2 sat cable 1 Guedel size 5 (red) 1 Nasopharyngeal airway 6.5 & 7.5 1 each Nasogastric tube 16g 1 Lubricant 5 RUNNING HEAD 1 OPTIONAL EQUIPMENT Easy Cap II – CO2 detector Zoll Defibrillator Difficult Airway Kit Fast Trach intubating LMA size 4 Fast Trach intubating LMA size 5 ECG, NIB, Sats, RR Invasive temperature 1 1 1 Fast Trach ETT 6, 7 & 8 Cuffed emerg cricothyroidotomy kit Portex minitracheotomy kit 1 each External pacing Lubricant 5 iSTAT Pocket 1 End tidal CO2 Invasive pressure line 2 Biphasic defibrillator Measure: Na, K, iCa, Glucose, Hct, pH, pCO2, pO2 Calculate: Hb, TCO2, HCO3, BE, sO2 Vacuum Mattress Immobilisation of spinal patients Can be used to facilitate transport of intubated non spinal patients Transvenous pacing module 1 1 50ml syringes 3 Min volume extension tubing 3 Short arrow radial lines 2 Pocket 2 Trauma shears 1 Waste bag for dirty equip 2 Intra osseous needle 1 Molnar retention disc 1 BSL monitor 1 Pocket 3 Pressure bags 2 37 38 CHAPTER 21 REFERENCE TOOLS Space blankets 2 Pocket 4 BP cuff – thigh, regular, small 1 each
