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ACT AMBULANCE SERVICE CLINICAL MANAGEMENT MANUAL POCKET EDITION 1 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINES Contents PAGE NO. Glasgow Coma Scale 1 ACTAS Approved Abbreviations 2 Clinical Management Guideline Index 5 Failed Intubation Drill procedure 55 Rapid Sequence Induction Procedure 56 Drugs for Airway Management – Summary Sheet 60 ACTAS Pharmacology Index 61 Drug Dose Calculator 101 Medication Calculator 102 Drug Reference Key List 104 Patient Assessment – General Approach 115 Time Critical Patient Guideline 116 Suicide Risk Assessment 118 Mental Health Status Assessment 119 Mental Competency Checklist 120 APGAR Score 121 Paediatric Reference Card 122 PEEP Values 123 Spinal Immobilisation flow chart 124 Spinal Cord Injury 125 Differentiation of Wide Complex Tachycardias 126 Maximum QT Interval Chart 128 12 Lead ECG Placement Chart 129 15 Lead ECG Placement Chart 130 STEMI Bypass Flow chart 131 STEMI Bypass Check List 132 Acute Myocardial Infarction Table 133 Infarction Overview 134 Capnography 144 2 Version 4.2 01/10 Wave Forms 146 Respiratory Status Assessment Chart 147 Burns Assessment Chart / Rule of Nines 148 Paediatric Burns Assessment Chart 149 Normal Blood Values 150 External Pacing procedure 151 Significant Contact Numbers 152 Motorola XTS 3000 Portable Radio - Duress Alarm Procedure 155 Hazchem Chart 157 Mass Casualty Triage Flow Chart 159 Ambulance Roles at a Mass Casualty Incident (MCI) 160 3 Version 4.2 01/10 GLASGOW COMA SCALE EYE OPENING INFANT CHILD ADULT Spontaneous To speech To pain Nil Spontaneous To command To pain Nil Spontaneous To command To pain Nil 4 3 2 1 BEST MOTOR RESPONSE INFANT CHILD ADULT Spontaneous Withdraws from touch Withdraws from pain Flexion Extension No response Obeys commands Localises Withdraws from pain Flexion Extension No response Obeys commands Localises Withdraws from pain Flexion Extension No response 6 5 4 3 2 1 BEST VERBAL RESPONSE INFANT CHILD ADULT Coos, babbles, smiles Irritable, crying Cries, screams to pain Moans, grunts No response Orientated Confused Inappropriate words Incomprehensible No response Orientated Confused Inappropriate words Incomprehensible No response 1 Version 4.2 5 4 3 2 1 01/10 ACT Ambulance Service Approved Abbreviations Only standard street name abbreviations, those listed below and on the Patient Care Record, in the context defined, are permitted for use. # & +, ++, +++ < = > ♀ ♂ ∆ fracture and to an increased degree less than equal to greater than female male increasing(ly) decreasing(ly), continuing disease n/24 n/7 n/52 n/12 x (n) Y/O hours days weeks months number of times years old •/c •/s with without 1˚HB 2˚HB 3˚HB first degree heart block second degree heart block third degree heart block A ACTAS ACTSES asystole A.C.T. Ambulance Service A.C.T. State Emergency Service A.C.T. Fire Brigade Australian Federal Police abdominal aortic aneurism atrial fibrillation atrial flutter Advanced Life Support morning acute myocardial infarction Ambulance not required ACTFB AFP AAA AF AFl ALS am AMI ANR BBB b.d. BGL BLS BNO BO BP BSL bundle branch block twice a day blood glucose level Basic Life Support bowels not open bowels open blood pressure blood sugar level C/O Ca CABG CAL complains(ing) of Cancer coronary artery bypass graft Chronic Airflow Limitation (Chronic Obstructive Airways Disease – COAD; Chronic Obstructive Pulmonary Disease - COPD) Calv. CAT Calvary Hospital Computerised Axial Tomography CCF CCU cm CNS CO CO2 Code 5 CP CPAP congestive cardiac failure Coronary Care Unit centimetres central nervous system Carbon Monoxide Carbon Dioxide person deceased chest pain continuous positive airways pressure CPR Cardio-Pulmonary Resuscitation CSF CVA cerebrospinal fluid cerebrovascular accident DCCS Direct Current Counter Shock doctor diagnosis Dr. Dx 2 Version 4.2 01/10 EAR ECC ECG ED expired air resuscitation external cardiac compressions electrocardiograph Emergency Department (Accident and Emergency department) EDC expected date of confinement EEG EMD electroencephalograph electromechanical dissociation ENT ESA Ear, Nose and Throat Emergency Services Agency ETT endotracheal tube GCS GI GP Gx Px Glasgow Coma Score gastrointestinal general practitioner gravida No. para No. Hb HR H/T Hx haemoglobin heart rate hypertension history ICP ICS ICU IGT IH∆ IM IMI Inh. IO IPPV intracranial pressure intercostal space Intensive Care Unit intragastric tube ischaemic heart disease intramuscular intramuscular injection inhaled intraosseous intermittent positive pressure ventilation IU IV IVU IVR International Unit intravenous intravenous unsuccessful idioventricular rhythm JR JVP junctional rhythm jugular venous pressure KED KTD kg km kph Kendrick Extrication Device Kendrick Traction Device kilogram kilometre kilometres per hour 3 (L) Lev.OC LLQ LMP LOC lpm L LUQ LVF left level of consciousness left lower quadrant last menstrual period loss of consciousness litres per minute litre left upper quadrant left ventricular failure m mane MAP mcg mg ml mm mMol MRI metre morning mean arterial pressure microgram milligram millilitres millimetres milliMol Magnetic Resonance Imaging MS mth MVA Multiple Sclerosis month motor vehicle accident neb NFR NGT NICU nebule / nebulised not for resuscitation nasogastric tube Neonatal Intensive Care Unit NKA No. nocte NOF N/S no known allergies number night neck of femur Normal Saline O O/A obs O/E O2 oral on arrival observations on examination Oxygen Version 4.2 01/10 P PA PAC PEA PEARL pulse per axilla premature atrial contraction pulseless electrical activity pupils equal & reacting to light PEEP positive end expiratory pressure PHx PID PJC past history pelvic inflammatory disease premature junctional contraction pm PO PR prn pt PU PV PVC afternoon per oral per rectum as required patient passed urine per vagina premature ventricular contraction Q.I.D. 4 x times daily (R) RICE right rest, ice, compression & elevation RLQ ROM RSI RTA RTC RUQ Rx right lower quadrant range of movement rapid sequence induction road traffic accident road traffic crash right upper quadrant treatment S/C S/L SB SOB sPEEP SR ST SVT subcutaneous sublingual sinus bradycardia shortness of breath spontaneous PEEP sinus rhythm sinus tachycardia supraventricular tachycardia T or Temp TCH tds TKVO TMC TNR Tx temperature The Canberra Hospital three times a day to keep vein open threatened miscarriage transport not required transport 4 URTI upper respiratory tract infection UTI urinary tract infection V/S VEB VF VT vital signs ventricular ectopic beat ventricular fibrillation ventricular tachycardia wt weight Version 4.2 01/10 Clinical Management Guideline Index 01 General Care 23 Stroke 02 Pain Management 24 Near Drowning 03 Airway Management 25 Diving Emergencies 04 Cardiac Arrest 26 05 Paediatric Cardiac Arrest Obstetrical & Gynaecological Emergencies 27 Hyperkalaemia 06 Cardiac Arrhythmias 28 Home Dialysis Emergencies 07 Bradyarrhythmias 29 Allergic & Anaphylactic Reactions 08 Tachycardias 30 Crush Syndrome 09 Respiratory Distress 31 Electric Shock 10 Diabetic Emergencies 32 Assault 11 Temperature Abnormalities 33 12 Upper Airway Obstruction Behavioural & Psychiatric Emergencies 13 Abdominal Emergencies 34 C.B.R. Incident 14 Shock & Hypotension 35 Poisoning, Envenomation & Overdose 15 Decreased Level of Consciousness 36 Extended Care 16 Chest Pain / Suspected ACS 37 Combative / Agitated Patients 17 Chest Injuries 38 Meningococcal Disease 18 Spinal Injuries 39 Adult Agonal Trauma Patients 18a Autonomic Hyperreflexia 40 Bariatric Patients (in development) 19 Limb Injuries 41 Headache (in development) 20 Eye Injuries 42 Back Pain (in development) 21 Burns 43 Dehydration (in development) 22 Seizures 5 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 1 GENERAL CARE Primary survey Haemorrhage control Posture Oxygen therapy NOTE: TRANSPORT IS TREATMENT! Identify time-critical patients Actual – based on vital signs, pattern of injury; lack of response to treatment. Potential – based on history; mechanism of injury. Monitor & assess as required: Vital signs ECG/12 - 15 Lead Blood glucose O2 saturations Temperature EtCO2 Specific observations & assessment as per patient condition NOTE: time-critical applies to both trauma and medical cases. The following conditions warrant absolute minimum scene times and urgent transport to hospital: Treatment as required: Cervical collar Bandaging Splinting Pelvic splint Temperature control Reassurance Cannulate – IV fluids as per perfusion & hydration assessment Pain relief Antiemetic Notify and transport to nearest appropriate hospital. Cardiac arrest following penetrating trauma (reference: Agonal Trauma Guideline) Unrelieved upper airway obstruction Head injuries with significant deterioration in levels of consciousness Chest injuries with respiratory deterioration Internal blood loss sufficient to cause significant hypotension Heatstroke Cardiac arrest in advanced pregnancy (gestation > 20/52) Prolapsed umbilical cord, or complicated labour Continuing or worsening acute hypoxia, unresponsive to treatment Generalised seizures, unresponsive to treatment Carbon monoxide poisoning with decreased level of consciousness (List is not exclusive or exhaustive!) NOTE: time-critical does not just mean rapid transport! 6 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 2 PAIN MANAGEMENT General Care Guideline RELIEF OF PAIN & SUFFERING IS A PRIME GOAL OF AMBULANCE CARE GTN S/L for ischaemic chest pain. Pain is what the patient says it is! Always offer pain relief to the patient Methoxyflurane for mild to moderate pain; patients unable to have narcotics; management of labour; often best for paediatrics. Pain assessment (PQRST) Quantitate if possible (scale & description) Document on case sheet Morphine Ischaemic chest pain and for all other pain unless contraindicated. Basic care is fundamental to pharmacological management: Midazolam small doses may be added to analgesia for musculo-skeletal pain. Reassurance Posture Splinting Cooling of burns Occlusive dressings Control of temperature (especially the cold) Gentle handling Ketamine for pain management in selected patients. May be used with alternate small doses of Morphine. ISCHAEMIC CHEST PAIN; LIMB PAIN; BURNS: aim for abolition of pain If possible, pharmacology should be directed at the apparent underlying cause: UNDIAGNOSED CONDITIONS: aim for control of pain to a bearable level of discomfort 7 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 3 AIRWAY MANAGEMENT General Care Guideline THE PRIMARY GOALS OF AIRWAY MANAGEMENT ARE: OXYGENATION VENTILATION AIRWAY PROTECTION in this order of priority Start basic and work up. However, it is permissible to “leap-frog” steps if, in your clinical judgement, the patient‟s condition warrants this Basic airway manoeuvres – posture, suction, oral airway, nasopharyngeal airway. Mild sedation to permit basic airway management (Midazolam). “Cold” endotracheal intubation. Rapid sequence induction: Suxamethonium / Midazolam*. ( NOTE: If the patient has already had Midazolam for sedation do not give a repeat dose with Suxamethonium; or give a smaller dose.) Morphine / Midazolam if no relaxants, in patients with no suspected acute intracranial pathology. Fall-back alternatives: – Failed Intubation Drill: Digital oral ETT placement*; LMA*; Surgical airway* Remember the primary goals! These will determine how aggressive your approach needs to be. Always have a fall-back position. The end point is not necessarily placement of an endotracheal tube. If an ETT is placed, confirmation of correct placement & maintenance of placement is imperative. End Tidal CO2 is to be used. Use cervical collar to assist in maintaining ETT/LMA position. There are to be multiple checks of ETT position, using multiple methods, by multiple people. 8 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 4 ADULT CARDIAC ARREST IPPV – 100% O2 Monitor ECG (a) – Ventricular Fibrillation/Tachycardia (b) – Asystole (c) – Pulseless Electrical Activity Precordial thump if monitored & witnessed Check alternate leads / lead selector Check aggressively for correctable causes: CPR Shock Cannulate Adrenaline 1mg Shock Amiodarone 300 mg IV Shock Adrenaline Shock Adrenaline Shock Cannulate Atropine 2mg + Adrenaline 1mg Adrenaline Adrenaline In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg Adrenaline Adrenaline Decision to transport For refractory or persistent VF: consider MgSO4 For Torsades: MgSO4 as the 1st drug; no Amiodarone In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg Intubate – when sufficient assistance Adrenaline every 2 minutes during transport Profound hypovolaemia Tension pneumothorax Continuing profound hypoxia Acidosis / Hyperkalaemia Gas trapping Cannulate Atropine 2mg + Adrenaline 1mg Adrenaline Adrenaline In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg Adrenaline Adrenaline Decision to transport Intubate – when sufficient assistance Shock Decision to transport Intubate – when sufficient assistance Adrenaline every 2 minutes during transport Adrenaline every 2 minutes during transport Shock between medications 9 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 5 PAEDIATRIC CARDIAC ARREST CPR IPPV – 100% O2 Monitor ECG (a) – Ventricular Fibrillation/Tachycardia (b) – Asystole (c) – Pulseless Electrical Activity Precordial thump if monitored & witnessed Check alternate leads Check for correctable causes: Shock 2 j/kg Cannulate / Intraosseous Cannulate / Intraosseous Cannulate / Intraosseous Adrenaline 0.01 mg/kg Adrenaline 0.01 mg/kg If hypoxia is not the apparent cause of arrest: Normal Saline 20 ml/kg If hypoxia is not the apparent cause of arrest: Normal Saline 20 ml/kg Adrenaline Adrenaline Adrenaline Adrenaline In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg Adrenaline Adrenaline Adrenaline Adrenaline For Torsades: MgSO4 as the 1st drug; no Amiodarone Intubate – when sufficient assistance Intubate – when sufficient assistance In prolonged arrest – consider Sodium Bicarbonate 0.5 mMol/kg Shock 4 j/kg Transport Adrenaline 0.01 mg/kg Shock 4 j/kg Amiodarone 5 mg/kg IV Shock 4 j/kg Adrenaline Shock 4 j/kg Adrenaline Shock 4 j/kg Intubate – when sufficient assistance Adrenaline every 2 minutes during transport. Transport Adrenaline every 2 minutes during transport. Transport Adrenaline every 2 minutes during transport. Shock between medications. 10 Version 4.2 01/10 GENERAL RESUSCITATION CARE This page has been intentionally left blank – insert to follow 11 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 6 CARDIAC ARRHYTHMIAS General Care Guideline (a) - PACs / PVCs (b) - Accelerated IVR (c) - Bizarre No specific treatment required No specific treatment required Monitor rhythm & patient condition Monitor rhythm & patient condition Rate & perfusion determines the type of treatment. Pulse is absent, with normal rate – treat as for cardiac arrest (usually PEA) Rate less than 50, poor perfusion – treat as for bradyarrhythmias. Rate greater than 150, regular, with wide QRS complexes, and patient is significantly compromised – treat as for VT. Rate greater than 150, regular, with narrow QRS complexes, and patient is symptomatic – treat as for SVT. If unable to decide which specific therapy is required – general care; observe; prompt transport. 12 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 7 BRADYARRHYTHMIAS General Care Guideline Consider treatment if heart rate is less than 50 in adults NOTE: Hypotension is an important determinant of perfusion status with Bradyarrhythmias If poorly perfused or symptomatic: Atropine 0.01 mg/kg Check for signs of failure. If no LVF: Consider IV fluid 5 – 10 ml/kg, prior to 2nd dose of Atropine Repeat Atropine x 1 as required If perfusion remains poor Adrenaline infusion: 1 mg in 1000 ml Normal Saline ( = 1mcg/ml) Titrate to response. (20dpm = 1ml/min = 1 mcg/min) Paediatric – use a burette OR external pacing, especially post cardiac arrest, and sedation with Morphine and Midazolam as required 13 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 8 TACHYCARDIAS General Care Guideline (a) Narrow QRS Complex (b) Wide QRS Complex Consider: Sinus tachycardia; SVT; AF; AFl; MAT Consider: VT; SVT with aberrancy; rapid AF or AFl with aberrancy. Use 12 lead ECG Make differentiation: (12 lead ECG if time) If aberrant SVT, AF or AFl - treat as per 8(a) Valsalva x 2 If SVT: Adenosine 6 mg IV Adenosine 12 mg IV, if required If rapid, symptomatic VT: Amiodarone 150 mg IV No pulse: Treat as VF cardiac arrest If rapid AF or AFl, refer to treatment algorithm: Torsades de Pointes: MgSO4 IV instead of Amiodarone Notify and prompt transport to nearest appropriate hospital. Notify and prompt transport to nearest appropriate hospital. IV Amiodarone – given over 10 minutes via Springfusor (If the patient is extremely compromised and in VT, it may be given over 5 mins by slow IV injection Consider pharmacological treatment if heart rate is above 150 in adults or 170 in children. Consider IV fluids in all tachycardic patients if hypotensive, not in LVF & unresponsive to pharmacological management. Any rapid rhythm (over 200), in an unconscious patient with no pulse shock. Paediatric doses: Adenosine: 0.05 mg/kg; then 0.1 mg/kg Amiodarone: 5 mg/kg (to a total of 150 mg) continues over 14 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 8 (continued) TREATMENT ALGORITHM FOR RAPID ATRIAL FIBRILLATION OR FLUTTER General Care Guideline Establish diagnosis: ensure - Atrial fibrillation or flutter - rapid rate ( > 150 ) - recent onset (reliably < 24 hours) No significant compromise Hypotension Ischaemic chest pain Pulmonary Oedema Rapid AF or AFl apparently secondary to an acute cerebral event Observe Check for evidence of LVF Treat chest pain as appropriate Treat pulmonary oedema as appropriate These patients will present with a decreased LOC, & may be hypotensive If no LVF: treat with IV fluids, 5 – 10 mls/kg Check for evidence of LVF Do NOT use Amiodarone in these patients If LVF + hypotension: treat cautiously with Amiodarone Treat rapid rate with Amiodarone concurrently Treat rapid rate with Amiodarone concurrently If no LVF: treat hypotension with IV fluids, 5 – 10 mls/kg Do NOT use Amiodarone in these patients. NOTE: Monitor BP closely – the combination of drug treatments for pulmonary oedema may cause hypotension. NOTE: Unconscious patients post cardiac arrest in rapid AF may be treated with Amiodarone unless otherwise contraindicated. Allow several minutes for rhythms to stabilise before administering Amiodarone. 15 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 9 RESPIRATORY DISTRESS General Care Guideline (a) Bronchospasm (b) Pulmonary oedema Mild to Moderate: Salbutamol and Ipratropium puffer with spacer initially Moderate to Severe: Nebulised Salbutamol + Ipratropium. Repeat Salbutamol as required. Add Ipratropium to every second dose as required. Significant hypoxia – nebulise with 100% O2 and PEEP. Hydrocortisone 200 mg IV / IM (Paed: 4 mg/kg to maximum of 200 mg) Assist ventilation with IPPV + 100% O2 as required Add PEEP: 5cm (THIS IS IMPORTANT) Increase PEEP by 5 cm as required If LVF: Sit patient with legs dependent if possible Treat significant cardiac arrhythmias GTN S/L: May be repeated x 1 after 5 minutes Severe to life-threatening: Adrenaline: Adult: 0.5 mg IM Paediatric: 0.01 mg/kg IM (to 50 kg) Repeat IM dose x 1 as required Adrenaline infusion: 1 mg in 1000 mls Normal Saline ( = 1mcg/ml) Titrate to response. ( 20dpm = 1ml/min = 1 mcg/min) Paediatric – use burette If the patient is critically ill, slow IV, up to 0.01 mg/kg,no faster than 50mcg/minute Consider fluid bolus for patients with moderate to severe asthma. Notify and transport to nearest appropriate hospital. Morphine: 0.05 mg/kg IV (especially if using PEEP and patient is distressed) dose may be repeated after 10 minutes,if patient remains in severe distress: Frusemide: On diuretics: 1 mg/kg IV Not on diuretics: 0.5 mg/kg IV If wheezing is present, do not give nebulised bronchodilators until after the first two doses of GTN If no IV, Frusemide may be given IM If symptoms persist, may give third dose of GTN Notify and transport to nearest appropriate hospital. NOTE: IV Adrenaline in anaphylaxis & asthma should be used very cautiously. If IPPV is required – use a slow rate with slow, gentle lateral chest squeezes on exhalation. 16 continues over Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 9 (continued) RESPIRATORY DISTRESS General Care Guideline (c) Non specific respiratory distress (d) Hyperventilation due to anxiety. Assess the patient carefully Fully assess the patient for pathological causes of hyperventilation. Administer Salbutamol + Ipratropium NOTE: Anxiety may accompany an underlying pathological cause for hyperventilation. Repeat Salbutamol - as required Add Ipratropium to every second dose - as required O2 at low flow rate via Hudson mask Significant hypoxia - nebulise with 100% O2 PEEP Monitor SaO2, ECG and check EtCO2 Remove source of anxiety if possible Reassurance Notify and transport to nearest appropriate hospital. Notify and transport to nearest appropriate hospital. 17 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 10 DIABETIC EMERGENCIES General Care Guideline CHECK BLOOD GLUCOSE LEVEL: (a) BGL < 4 mMol/L (b) BGL > 15 mMol/L If symptomatic: Oral glucose, if conscious & laryngeal reflexes intact. Normal Saline 10 ml/kg IV over contact time If decreased LOC: Glucose 10% – up to 2.5 ml/kg IV (0.25 g/kg) If shocked & hypotensive: IV resuscitation Notify and transport to nearest appropriate hospital. Re-check BGL & LOC. Repeat Glucose dose if required. Ensure oral intake of carbohydrate if patient is not transported. Glucagon IM, if no IV available: Patient wt > 20 kg: 1 IU Patient wt < 20 kg: 0.5 IU Notify and transport to nearest appropriate hospital. NOTE: Recovery may be slow if hypoglycaemia has been prolonged. 18 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 11 TEMPERATURE ABNORMALITIES General Care Guideline CHECK PATIENT‟S TEMPERATURE: (a) Heat abnormalities Minor heat syndromes: Normal or transient disturbances in LOC; sweating; core temp < approx 39oC Heatstroke: Decreased LOC; no sweating; core temp > approx 39oC Gentle cooling Rapid cooling; aggressive as possible Cease exertion IV resuscitation; cool fluids if possible Move patient to cool location Treat significant arrhythmias Oral rehydration: - allow small sips only Check BGL IV rehydration if: Aggressively manage seizures or shivering - nauseated &/or vomiting; - significant dehydration; - multiple patients. Notify and transport to nearest appropriate hospital. Notify and urgent transport to nearest appropriate hospital. 19 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 11 (continued) TEMPERATURE ABNORMALITIES General Care Guideline (b) Cold abnormalities Exposure: Normal LOC; shivering; core temp > approx 33.5oC Hypothermia: Decreased LOC; no shivering; core temp < approx 33oC More rapid warming is acceptable Handle patient gently Warm oral fluids Remove wet clothing if sheltered; dry patient off Gentle exercise if possible Wrap in warm blankets; then space blanket If IPPV – do not hyperventilate If in VF: Shock Cardiac drugs if core temperature > 32oC Do not cease resuscitation Notify and transport to nearest appropriate hospital. Notify and transport to nearest appropriate hospital. 20 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 12 UPPER AIRWAY OBSTRUCTION General Care Guideline (a) Foreign body (b) Swelling PARTIAL OBSTRUCTION: Maximise Oxygen therapy Encourage coughing Prompt transport Minimum intervention Causes: croup / epiglottitis; insect sting; anaphylaxis; trauma; oral / pharyngeal infection; burns. COMPLETE OBSTRUCTION: Conscious patient: Four modified chest thrusts; if fails turn into lateral position. 4 back blows. if possible, position with head down to utilise gravity; if fails repeat the sequence x 2; if fails urgent transport – 100% Oxygen Unconscious patient: Extricate foreign body with laryngoscope & Magill forceps; if fails supine position (for children, use head down position, if possible) 4 modified chest thrusts; if fails lateral position – 4 back blows; if fails repeat sequence x 2; if fails attempt intubation to push foreign body into (R) or (L) main bronchus. (Insert tube as far as possible use uncut tube if possible). Notify hospital and urgent transport – 100% Oxygen. Consider surgical airway as a last resort. OBSTRUCTION RELIEVED: provide Oxygen therapy prompt transport 21 Maximise oxygenation Do not attempt close examination of mouth / throat area Do not unnecessarily distress the patient If severely obstructed: nebulised Adrenaline: wt > 10 kg – 5 mls Adrenaline 1:1000 wt < 10kg – 0.5 ml/kg Adrenaline 1:1000 (Make volume up to 5 mls with Saline, as required) If swelling is due to anaphylaxis or local insect sting: IV / IM Adrenaline For partial airway obstruction: prompt transport For complete airway obstruction: give 100% O2 and attempt I.P.P.V. notify hospital and urgent transport. consider surgical airway as a last resort. Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 13 ABDOMINAL EMERGENCIES General Care Guideline Posture flat – knees may be flexed. IV resuscitation as required. Pain relief. Cover any open wounds with dry, sterile dressing; protruding viscera with saline-moistened sterile dressings. If an impaled object is in situ – do not remove it – move the patient with the object in situ. Notify and prompt transport to nearest appropriate hospital. 22 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 14 SHOCK & HYPOTENSION General Care Guideline Assess the patient carefully to determine possible cause. Consider assessment of postural changes (a) Hypovolaemic (b) Cardiogenic High concentration O2 High concentration O2 High concentration O2 High concentration O2 If severely shocked, with a non-compressible bleeding lesion – early, rapid transport 12 lead ECG Adrenaline if suspected anaphylaxis Decompress tension pneumothorax if suspected STEMI management as indicated IV fluids to maintain adequate cerebral perfusion Treat significant arrhythmias (consider age, co-morbidities & concurrent injuries) Pain relief Consider pelvic splint where appropriate Notify and prompt transport to nearest appropriate hospital. (c) Distributive Posture with care if suspected spinal injuries (d) Obstructive If severely shocked – early, rapid transport IV fluids (keep BP no higher than 80 – 85 mmHg if spinal injuries are suspected) Assess for LVF IV fluids with caution Notify and prompt transport to nearest appropriate hospital. Notify and prompt transport to nearest appropriate hospital. 23 IV fluids Notify and prompt transport to nearest appropriate hospital. Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 15 DECREASED LEVEL OF CONSCIOUSNESS General Care Guideline Assess the patient carefully (a) History of trauma – Head Injury Cervical spine precautions Airway management guideline (b) No history of trauma (c) Apparent syncope Check BGL Assess thoroughly for more significant causes in all patients Posture 10 – 15º head up Consider poisoning or O/D If GCS below 12: Check BGL maintain O2 saturations > 95% Consider cervical spine precautions BP 100 – 120 systolic Airway management guideline (MAP > 90) Check BGL Notify and transport to nearest appropriate hospital. If GCS below 12: maintain O2 saturations > 95% BP 100 – 120 systolic (MAP > 90) Notify and transport to nearest appropriate hospital. 12 lead ECG if no obvious alternate cause Posture by perfusion or comfort Consider cervical spine precautions Notify and transport to nearest appropriate hospital. Evidence of a rapidly decreasing level of consciousness is a flag for a time-critical patient – therefore, minimise scene time and transport urgently to hospital. 24 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 16 CHEST PAIN / SUSPECTED ACUTE CORONARY SYNDROMES General Care Guideline Assess thoroughly for possible Acute Coronary Syndrome (ACS) i.e. 12 lead ECG if STEMI – initiate appropriate management without delay. Possible Acute Coronary Syndrome Pain assessed as probable non-ACS Monitor closely Assess for possible threat to life. Utilise 12 lead ECG 12 lead ECG (15 lead as appropriate) Aspirin GTN Antiemetic Morphine If in any doubt – treat for ischaemic heart disease Otherwise – manage as for undiagnosed pain Pain management - aim to abolish pain or discomfort Prompt transport Notify hospital AS EARLY AS POSSIBLE if STEMI is suspected* Treat haemo-dynamically significant arrhythmias Prompt transport Give Aspirin, even if on regular slow-release Aspirin. Give a 150mg dose if already on Warfarin. Watch for non-typical or silent presentations of ischaemic heart disease, especially in females, the elderly & patients with diabetes. Silent or atypical ACS presentations should be treated in the same manner as a typical presentation. Aim to minimise scene time while still providing reassurance & effective pain relief. *STEMI bypass procedure – notification, Heparin and Prasugrel / Clopidogrel 25 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 17 CHEST INJURIES General Care Guideline IV resuscitation as required Pain relief as required Pneumothorax If suspected avoid coughing, Valsalva manoeuvres or IPPV Suspect a tension pneumothorax in a patient with diminished air entry & significant respiratory or cardiovascular compromise. Decompress tension as indicated NOTE: diminished air entry may be an unreliable sign if the patient is receiving positive pressure ventilation. Open chest wound Cover, seal on 3 sides only, or use chest seal Flail chest Stabilise the chest wall Posture patient with affected side down, or by manual pressure Effective pain relief Notify and transport to nearest appropriate hospital. 26 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 18 SPINAL INJURIES General Care Guideline Instruct the patient to refrain from moving his head avoid flexion of the neck and rotation of the head all other movements must be minimised maintain head in the neutral position Oxygen therapy 100% if suspected cord lesion IPPV, if hypoventilating Posture supine Cervical Collar Extricate with spine board or Kendrick Extrication Device Lift with board or scoop stretcher Do not routinely transport patients on the spine board/scoop stretcher. Transportation on a spine board/scoop stretcher is only permissible where there is a short extrication and travel time to hospital (no longer than 10 minutes). If this occurs, ensure that the patient and board are restrained during transport. IV resuscitation as required DO NOT OVER-INFUSE a systolic blood pressure of 80mmHg is acceptable in high spinal injuries With suspected cord lesion - administer antiemetic Insert IGT & urinary catheter prior to secondary, air or extended transports If transport is prolonged, ensure pressure area care is attended Notify and transport to nearest appropriate hospital. 27 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 18a AUTONOMIC HYPERREFLEXIA This occurs in established High Paraplegics or Quadriplegics, therefore, assess the patient for Autonomic Hyperreflexia. The sudden onset of any of the following is significant. Sudden hypertension, (this may fall within the normal limits for the rest of the population); pounding headache, bradycardia, flushing/blotching of skin; profuse sweating above level of lesion; skin pallor and piloerection below level of lesion; chills without fever; nasal congestion, blurred vision; shortness of breath, sense of apprehension and/or anxiety. Causes Bladder: Bowel: Skin: Other: Distended due to blocked or kinked catheter, UTI, bladder or kidney stones. Constipation, faecal impaction, rectal irritation. Burns, pressure areas, tight clothing e.g. TED stockings. Fractures, distended stomach, labour, severe menstrual cramping. Actions Ask patient and carer if they suspect a cause. Elevate patient‟s head and position with legs dependent, if possible. Loosen any constrictive clothing. Check bladder drainage equipment for kinks or obstruction: if found drain 500mls initially, then a further 250mls every 15 minutes until the bladder is empty. Monitor BP every 2 – 5 minutes. Avoid pressing over the bladder. Treatment If the BP remains elevated (ranging between 150 – 170mmHg), commence treatment with: IV Midazolam 0.05 mg/kg, over one minute. This may be repeated once after 10 minutes if there is no fall in BP. Give 0.1 mg/kg IM if unable to cannulate. Midazolam should be given with extreme caution while constantly monitoring the patient‟s vital signs. NOTE: Treatment with Midazolam mandates transport to hospital. Notify and transport to nearest appropriate hospital. 28 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 19 LIMB INJURIES General Care Guideline Check arterial circulation in the limb: If the distal pulse is absent gently re-align fractured segments until pulse returns or alignment is near normal. Immobilise all fractures unless the patient is otherwise time-critical. Elevate the limb, if possible. Do not attempt to reduce dislocations. IV resuscitation where indicated. Pain relief Midazolam as required. Ketamine as appropriate. Partially severed limb: carefully protect limb keep distal portion of limb dry, wrapped and cool. Completely severed limb: Keep severed part dry, wrapped and cold. Place in a dry sealed plastic bag, then place within another bag or bucket filled with iced water at approx 4oC. DO NOT immerse the part directly in ice. DO NOT attempt to clean or disinfect the severed part. Notify and transport to nearest appropriate hospital. 29 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 20 EYE INJURIES General Care Guideline ENSURE OXYGENATION Trauma: Do not remove protruding foreign bodies. If the eyeball is extruded, do not push it back into the socket. If tolerated, transport the patient lying flat. The injured eye must be protected from rubbing pressure. Use an eye shield, or a loosely taped eye patch. Cover both eyes if the patient can tolerate this. Severe eye injuries - administer IV antiemetic prior to transport. Chemical Burns: Irrigate immediately with copious quantities of water or saline for at least ten minutes. The eyelids must be pulled apart to ensure the fluid washes completely over the eye. Scalds and Electrical Flash Burns: No dressing is required, ice packs can be beneficial. Foreign Bodies in Cornea: Protect the eye with a shield or pad. Do not attempt to remove the foreign body. Notify and transport to nearest appropriate hospital. 30 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 21 BURNS General Care Guideline If there is still heat left in the skin, cool with cold water or saline. Watch for development of hypothermia. Utilise watergel burns dressings after cooling. Check & replace if they become warm. Cover the burnt area with clean dressing/sheets. If a limb is burnt, remove all rings, tight clothing, shoes, and elevate the part. Consider space blanket. Check for potential upper airway obstruction, especially if the face is burnt. Hoarse voice Inspiratory stridor See-saw breathing Treat bronchospasm or airway obstruction via relevant management guideline. If decreased level of consciousness: Suspect Carbon Monoxide poisoning (especially if burnt in a confined space). Administer 100% O2; with PEEP. Pain relief IM Ketamine, if no IV access is available. Cannulate Normal Saline for Adults with burn > 15% BSA; children > 10% BSA. (full or partial thickness) Adults: % BSA burned x wt (kg) in mls over 4 hours from time of burn. Children: 10 ml/kg. If upper airway involvement is present – reduce fluids to ½ of what would otherwise be administered. Transport suspected smoke inhalation patients to hospital as delayed pulmonary oedema may occur. Notify and transport to nearest appropriate hospital. Prompt transport for any evidence of upper airway burns. 31 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 22 SEIZURES General Care Guideline Protect the patient from injury. Blood glucose estimation early, especially if no history of seizures. Midazolam (IM if no IV access). Treat any injuries secondary to the seizure. Pregnant patient, no history of previous seizure activity – prompt treatment with 5mg MgSO4. Children with seizure and or fever >38°C: Remove excessive clothing Cool with tepid water Place cool cloths in axillae, groin, wrist and neck; change as required Do not allow child to shiver Treat with Paracetamol 20 mg/kg or 15mg/kg if Paracetamol has been administered in the last 48 hours Notify and transport to nearest appropriate hospital. 32 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 23 STROKE General Care Guideline Posture 10 – 15o head up Airway management guideline Cannulate: - blood glucose estimation treat hypoglycaemia cautiously; avoid hyperglycaemia Treat seizures promptly & aggressively Minimise scene time Notify hospital early and promptly transport to nearest appropriate hospital. 33 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 24 NEAR DROWNING General Care Guideline Cardiac arrest - treat by specific guideline. Use the highest concentration of Oxygen practicable. PEEP, if possible Cervical collar as required. IGT if possible. Consider hypothermia/other related conditions. Notify and transport to nearest appropriate hospital. NOTE: Late pulmonary oedema may occur. * Transport is always required following near drowning episodes * CLINICAL MANAGEMENT GUIDELINE 25 DIVING EMERGENCIES General Care Guideline Consider the possibility of spinal injury. Lie flat and keep flat, do not sit up. If unconscious, assume the possibility of an air embolus - posture left lateral, with a head-down tilt. Oxygen therapy: highest concentration practicable. Exclude pneumothorax. Patients are always dehydrated – re-hydrate with IV Normal Saline 10 ml/kg promptly. Ascertain dive profile (number and sequence of dives; time at depth; breathing mixtures; decompression stops and any uncontrolled ascent.) Remember to check dive partner. Monitor symptom progression. Pain relief – analgesics may mask symptom changes; aim for minimal analgesia. 34 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 26 OBSTETRICAL & GYNAECOLOGICAL EMERGENCIES General Care Guideline Unscheduled Normal Field Birth The most important ambulance role in a field delivery is to appear calm! The preferred management is birth at a hospital – but if birth is imminent, reassure the mother & help her to a comfortable position. Ensure full history Oxygen Pain relief as required Provide support and guidance during birth of baby‟s head while encouraging gentle “grunty” pushes or controlled breathing to ease the head out slowly and gently. As the head is born have your hand close to the top of the baby‟s head – you do not need to touch it unless the woman gives an uncontrolled push and the baby would otherwise „shoot‟ out (especially important if the baby is preterm < 37 weeks). Observe for cord around the baby‟s neck. If present the baby may be born through the loop of cord. If the cord is loose, it may be slipped forward over the head, taking care not to stretch it or tear it. Rarely the cord is so tight that it stops the baby‟s descent and in this situation it may need to be clamped in two places and cut between the clamps. Great care is necessary not to injure the baby or woman while doing this. Place the baby straight up on to the mother‟s chest noting time of birth. Dry baby and maintain warmth by keeping the baby close to the mother‟s skin. Place warm blankets over the baby and mother. Assess the baby‟s Apgar score at 1 and 5 minutes after birth. Cord should not be routinely cut but, if necessary, apply plastic clamp (x2) at 3cm from the umbilicus, milk the cord gently back from the clamp 3cm, taking care not to pull on the umbilicus. Apply plastic clamp (x2) then cut the cord using clean scissors. continues over 35 Version 4.2 01/10 Complicated Birth P.V. Haemorrhage Prolapsed cord: Not pregnant / early pregnancy: Posture in the knee to chest position (often easier in the all fours knee to chest position) 100%Oxygen Advise hospital early Urgent transport Do not encourage pushing Manage as per perfusion status Advanced pregnancy Breech presentation: Normal, unassisted birth may not always be possible. Where possible, do not encourage the woman to push but to breathe through her contractions. Notify and urgently transport to hospital. Once legs and body have been born, support the baby‟s body as it hangs downward while waiting for the gentle, slow birth of the head. (Do not apply downward traction). Encourage the mother to „breathe‟ her baby‟s head out. If head is not born with the next contraction, encourage her to push whilst gently supporting the baby as it hangs downward. Manage as per perfusion status Left lateral position Do not attempt to massage the fundus of the uterus Notify and prompt transport to nearest appropriate hospital Seizures due to eclampsia 5mg MgSO4 IV Cardiac arrest in advanced pregnancy Position with wedge under right hip to obtain 25 – 30o leftwards tilt. Give fluid bolus early. Urgent transport as soon as backup has arrived. If performing CPR, increase CPR compression force due to the chest wall compliance secondary to breast hypertrophy. Other presentations: Recognise! Normal, unassisted delivery may not always be possible. Ensure hospital is notified as early as possible that the patient is pregnant. Notify and urgently transport to nearest appropriate hospital. Women in more advanced pregnancy (approx 20+ weeks gestation) are generally best treated/transported in the left lateral position, regardless of the problem. 36 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 27 HYPERKALAEMIA General Care Guideline Consider in these situations: Renal failure/dialysis Crush syndrome, including situations of prolonged unconsciousness Occasionally – diabetic ketoacidosis ECG signs are unreliable, frequently do not follow expected progressions, and do not always show good correlation with serum K+ levels. Monitor the ECG for signs of hyperkalaemia, which may include: Tall peaked T waves No P waves Wide QRS Sine wave pattern (VT) VF / Asystole Arrhythmias, especially bradycardias, are common. If ECG changes are present: Nebulised Salbutamol (continuously). Calcium Chloride 10 mg/kg IV over 2 minutes. Follow with: Sodium Bicarbonate 8.4% – 0.5 mMol/kg IV over 2 minutes. If ECG changes persist after 10 – 15 minutes: repeat Calcium Chloride & Sodium Bicarbonate x 1 NOTE: Treatment is determined by patient presentation, ECG changes and the clinical setting. 37 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 28 HOME DIALYSIS EMERGENCIES Dialysis is a Renal Replacement Therapy used when kidney function no longer sustains life. The client is required to undergo treatment on a regular basis (typically 3 times per week for 4 hours). SOME IMPORTANT CONSIDERATIONS: Clients who are dialysed at home have undergone extensive training and maintain a record of their treatment. Use this and any further information provided by the patient and/or carer – they are very familiar with the process. Fistula access is the patient‟s life line. Vessels should be preserved for future fistula creation – therefore, ONLY cannulate if necessary and use the cubital fossa or hand. Most calls to dialysis clients are not related to their dialysis. REMOVE CLIENT FROM MACHINE BY: Clamping machine blood lines (x2) and cannula (x2) Unscrew lines from cannula. (Pump will stop and machine will alarm) Do not turn machine off until client is removed Use either cannula as access for fluid and medications (as both are sitting in an arterialised vein) Attach giving set to cannula and administer IV fluid. Remember clients are often on fluid restriction. 100 – 200 mls often resolves a hypotensive situation. Consult the client‟s treatment record to ascertain usual BP Leave cannula in situ if time is an issue. However, reinforce with taping and protect during transit, as these are metal needles and can cause damage to the vessels if mishandled When removing cannulae, remember there is a high flow-in access (1000 mls/minute) so use a protective mask and goggles. Moderate pressure is needed on the exit site for 10 – 15 minutes 38 continues over Version 4.2 01/10 CALLS TO CLIENTS ON DIALYSIS. Problems include: 1. Hypotensive episode: This can occur due to excess fluid removal. Assess the situation. If the client/helper can replace fluid, this is the best option. When the Paramedic is required to replace fluid: Place the client in the Trendelenberg position (supine with head lower than feet). Administer O2 Remove client from machine Follow ACTAS Clinical Management Guideline for fluid replacement 2. Chest pain: This may be caused by excess fluid removal during dialysis or other cardiac event. Stop dialysis and ask helper to return client‟s blood or remove client as above when necessary Use cannula as access. Withdraw 10mls of blood and discard before using cannula for blood-taking (to remove saline in the line) Follow ACTAS Clinical Management Guideline for chest pain 3. Bleeding: This may occur due to excess thinning of the blood due to Heparin used in dialysis. Heparin has half life of 92 minutes. Only light pressure on cannula site is required (10 – 15 minutes) DO NOT cut off the flow-in access as it will clot Use Diastop/Tip stop devices where available. Digital pressure is the best option DO NOT APPLY TIGHT BANDAGES continues over 39 Version 4.2 01/10 4. Venous air embolism: Suspected if there is air in the venous return line. Stop treatment (stop machine by opening pump door) Treat with 100% Oxygen; posture in the left lateral position with a 30o head down tilt. Remove client from machine as above 5. Haemolysis: Caused by damage to the blood cells due to an inappropriate dialysate (overheating, toxins such as Copper, Chloramines, bleach, Formaldehyde). Signs & Symptoms chest pain/back pain dyspnoea localised burning and pain in access return site the blood turns a characteristic port wine colour Treatment stop dialysis. disconnect client. give O2 if indicated. check for arrhythmias, fluid volume replacement if indicated. Reference: Molzahn, A. E (2006) Contemporary Nephrology Nursing Principles and Practice. American Nephrology Nurses Association. New Jersey 40 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 29 ALLERGIC & ANAPHYLACTIC REACTIONS General Care Guideline Pressure immobilisation bandage / splint over the area of injection, sting or bite if appropriate. Adrenaline is the drug of choice for cases where there are potentially life-threatening signs (hypotension; upper airway swelling; bronchospasm unresponsive to nebulised bronchodilators) Consider the use of IM Adrenaline in the first instance IV use should be with caution If IV use is considered, a diluted infusion is the preferred method of administration. Manage, as appropriate, using ACTAS guidelines for respiratory distress; shock & hypotension; upper airway obstruction. The fundamental principles are: O2 therapy; Adrenaline; IV fluids * CLINICAL MANAGEMENT GUIDELINE 30 CRUSH SYNDROME General Care Guideline This is rarely a problem with less than 45 minutes of compression of a significant muscle mass. Acute volume loss on release is generally considered of greater clinical importance than hyperkalemia and acidosis. Immediately prior to removal of the compressive force: consider the use of an arterial tourniquet to the compressed limb increase IV infusion rate observe ECG Following the removal of the compressive force: release the tourniquets carefully; check for ECG changes. Manage, as appropriate, using ACTAS guidelines for shock & hypotension, hyperkalaemia, and limb injuries. 41 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 31 ELECTRIC SHOCK General Care Guideline DO NOT BECOME A VICTIM YOURSELF! LOW VOLTAGE (<1000 Volts) - Appliance in house or main supply to house - pull out plug; pull conductor away from patient; pull patient clear; switch off at mains. METHOD: grasp clothes if dry; avoid contact with skin or conductor; use dry fibre rope or dry blankets or similar non-conducting material. HIGH VOLTAGE (>1000 Volts) Request assistance from Electricity Authority. Use short steps to approach a victim. Retreat immediately if tingling is felt. High Voltage – consider possible spinal injury. Check for exit burns. Treat other injuries as required. Electrical burns usually cause greater tissue damage than the appearance of the skin surface would suggest. Therefore, always transport the patient to hospital. 42 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 32 ASSAULT General Care Guideline Be aware of risks to yourself & others. Ensure scene control & safety. Attention to detail (such as full name, location, times; others present) is very important. Treat injuries where indicated. Specifically for sexual assault: Be aware some patients may resent physical contact from carers; Avoid any judgemental comments; Articles of evidence, such as clothing must be taken with the patient (use a paper bag); Discourage the patient from showering; The patient should not be left alone at any time; Do not give details of the assault over the radio. 43 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 33 BEHAVIOURAL & PSYCHIATRIC EMERGENCIES General Care Guideline Identify yourself clearly. If concerned about your safety, or others, call for police assistance. Be reassuring and non-judgemental when conversing with the patient. Speak quietly – do not shout. One officer should talk privately with the patient where possible. Do not leave the patient alone. Consider / exclude: hypoxia hypoglycaemia head injury drug overdose post-ictal state Treat as appropriate. Consider use of CMG 37 – Management of combative or agitated patients. Arrange for appropriate support services e.g. CAT Team. Notify and transport to nearest appropriate hospital. 44 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 34 C.B.R. INCIDENT General Care Guideline A CBR incident may be indicated by: - Physical indicators: e.g. unusual pools of liquid, clouds or fogs, unusual colours, strange devices or recent explosion. - Medical signs and symptoms or unusual behaviour being displayed by a number of people. - Dead birds or animals in the area. STEP 123 is “Safety Trigger for Emergency Personnel”: - one patient with cholinergic symptoms is suspicious, - two patients indicate a CBR, - three patients is a CBR. PROTECT YOURSELF; DO NOT ENTER THE CONTAMINATED AREA IF THIS CAN BE DETERMINED. If you find yourself in a contaminated area: cover your nose and mouth with a damp cloth; take frequent shallow breaths; don‟t Taste, Eat, Smell, or Touch anything in the area; seek shielding if radioactivity is present; leave the scene immediately and proceed to a safe upwind, uphill area; be aware of the possibility of secondary devices. continues over 45 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 34 (continued) C.B.R. INCIDENT Remain clear of the contaminated area (Designated HOT& WARM zones) unless authorised to enter by the Incident Commander. You must be equipped with appropriate personal protective equipment (PPE) and have suitable training in its use. Only authorised and trained personnel will operate in the HOT& WARM zones. To decontaminate: Remove clothing and discard into a special HAZMAT container; Skin must be cleaned by thorough washing or preferably showering; Pay special attention to hair and parts of the body with opposing skin surfaces, e.g. the buttocks. It is preferred that patients and personnel be decontaminated PRIOR to treatment. Initial antidote can be administered prior to decontamination by suitably protected personnel. Treatment: Assist ventilation (only if small number of casualties); Obidoxime combo-pen if a nerve agent is identified (cholinergic symptoms), if unavailable, use Atropine. Midazolam to treat seizure patients; Treat associated injuries: burns; blast injuries; fractures. Ensure hospital is notified of possible contaminated patients. 46 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 35 POISONING, ENVENOMATION & OVERDOSE General Care Guideline SPECIFIC AGENTS: Opioids: IM Naloxone, followed by IV Tricyclic antidepressants: Watch for arrhythmias, seizures and coma. If present: - administer 0.5 mMol/kg Sodium Bicarbonate - treat seizures first with Midazolam and tachyarrthymias with Magnesium Sulphate Digoxin: Treat tachyarrhythmias with Magnesium Sulphate. Organophosphates: Take care not to become contaminated. Consider the possibility of other affected workers, occupants or first-aiders. Where feasible – remove contaminated clothing, and wash skin with soap and water. If cholinergic effects are present (salivation, sweating, nausea, bradycardia), administer Atropine lV or IM. Repeat as required. Ensure hospital is notified of contaminated patient. continues over 47 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 35 (continued) POISONING, ENVENOMATION & OVERDOSE General Care Guideline Envenomation: Utilise pressure/immobilisation technique if appropriate. Treat signs and symptoms as they arise e.g. Cholinergic symptoms with some spider bites. Identification – the creature should be brought to the hospital but only if this can be done safely. DO NOT rely on non-expert identification. With the positive identification of a Red Back Spider, pressure immobilisation is not required. Iced compresses should be applied to the area (but not directly onto the skin). Carbon monoxide / smoke inhalation: Beware of hazards – self-asphyxiation and/or explosion; remove patient from danger Treat according to respiratory distress or upper airway obstruction guideline 100% oxygen, with PEEP, if Carbon Monoxide is suspected Consider the possibility of other affected workers, occupants or first-aiders Any person who has suffered an inhalation injury of toxic substances is to be transported to hospital. (Pulmonary oedema may be a late complication) Urgently transport if there is a decreased level of consciousness 48 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 36 EXTENDED CARE This guideline will apply in the following circumstances: where patient contact has, or is likely to, extend beyond (approx) 60 – 90 minutes, andthe patient cannot be managed adequately within the limits of existing guidelines and pharmacology. ANALGESIA: Morphine: Following initial doses of IV Morphine, further doses of 0.05 mg/kg may be given at 15 minute intervals, titrated against: pain assessment history & presenting problem perfusion status level of consciousness & respiratory status (no further doses if GCS is 13 or below, or if respiratory rate drops below 10) It must be noted that the extended care guideline does not permit Paramedics to extend their scope of practice to procedures, which they have not been trained to perform. IV FLUIDS: IV Replacement: Replacement of estimated or continuing losses with Normal Saline. Aim for systolic BP of 90 mmHg. Intramuscular: same provisos as general pharmacology; 0.1mg/kg dose; repeat after 30 minutes as required; thereafter at minimum of 90 minute intervals IV Maintenance: Normal Saline Midazolam: Can repeat initial doses – as per Morphine titration, with care! Baseline of 1 ml/kg/hr; Titrated to: Ketamine: Follow Ketamine dose chart Perfusion and hydration assessment Any continuing fluid losses Environmental conditions Urine output, if available (aim for 1 ml/kg/hr). Methoxyflurane: 6ml/day – 15ml/week I.G. TUBE: ANTIEMETIC: Consider placement in the following patients, if patient contact is likely to be prolonged: cervical & thoracic spinal cord lesions Odansetron: Further IV dose, after 3 to 4 hours. May be given IM – repeat after 4 hours. 49 burns patients, BSA over 20%b (especially if there is respiratory tract involvement) Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 37 MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS CMG 37a – GENERAL AMBULANCE OPERATIONS For use in situations where the patient cannot be managed due to agitation or combativeness. If concerned about safety, call for police assistance. Consider/exclude: hypoxia; hypoglycaemia; head injury; drug overdose; post-ictal state; infection. Treat as appropriate. Speak quietly - do not shout. Do not leave the patient alone. Attempt quiet reassurance in an attempt to persuade the patient to accept treatment. Reduce the dose of Midazolam for elderly patients with: known or suspected hypotension; general debility - usually half the dose. Limb restraints are to be utilised in conjunction with pharmacological restraint. MENTAL HEALTH PATIENTS: If reassurance and persuasion are ineffective or impractical, move to pharmacological management. This should be a last resort: Ensure adequate control of the limb and the patient. Midazolam up to 0.1mg/kg. Usually IM. May repeat dose after 10 minutes if necessary. Wherever possible, obtain an Emergency Order for the management of mental health patients. (AFP; medical practitioner; CAT Team) If not practical, proceed with pharmacological control if there is genuine concern for the welfare of the patient and/or others. PATIENTS MANAGED WITH PHARMACOLOGICAL CONTROL MUST BE If agitated state is thought to be due to psycho-stimulant use: Midazolam up to 0.2 mg/kg. May repeat after 10 minutes if required. TRANSPORTED TO HOSPITAL Monitoring once restrained and on O2: ECG, Temperature (watch for hypothermia), O2 saturation, EtCO2 NOTE Ensure thorough documentation on PCR All patients managed with CMG 37a will require an incident report to be submitted to the Clinical Services Section. Notify and transport to nearest appropriate hospital. 50 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 37 (continued) MANAGEMENT OF COMBATIVE AND AGITATED PATIENTS CMG 37b – AERO-MEDICAL PATIENTS A lower threshold for intervention with sedation applies to patients who are transported by air. If unable to obtain agreement on sedation prior to flight, advise pilot of your concerns. Identify and correct possible causes of agitation prior to flight wherever possible. If still no decision to sedate patient and in your opinion there is still an unacceptable risk, do not fly. Advise all crew and ACTAS Duty Manager. Electrolyte imbalance Hypoxia Hypovolaemia Pain Hypoglycaemia Cold Duty Manager to discuss with CRRS consultant. If still agitated - sedate prior to flight. In flight agitation and combativeness is to be managed as a matter of urgency. Note : All patients managed with CMG 37 will require an incident report to be submitted to ACTAS Clinical Services Inform the pilot in command. Proceed immediately to pharmacological management. Do not use physical restraint beyond the time required to pharmacologically manage the patient. 51 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 38 MENINGOCOCCAL DISEASE Management Prompt identification of meningococcal disease & commencement of pre-hospital treatment can be life-saving. Ensure personal protection – gloves; mask; gown; and eye protection, especially if airway care is being attended. A high index of suspicion is advisable, but only in critically ill patients. General care Consider meningococcal disease in the following circumstances: Cannulate – 10 ml/kg Normal Saline; Ensure minimum scene time Repeat as required. febrile illness with sudden onset & disturbed level of consciousness. Ceftriaxone – 50 mg/kg IV or IM, to maximum of 2g Check BGL + / - haemorrhagic, purpuric or petechial rash; Urgent transport + / - tachycardia, hypotension, peripherally shut down. Other signs & symptoms are often non-specific, especially in young children. Such as: NOTE: headache; photophobia; neck stiffness; vomiting; painful or swollen joints; focal signs; and seizures. Deterioration is possible following antibiotic administration. This would be unusual during average ambulance contact. It will most likely be a decrease in LOC and/or BP. Deterioration can be rapid Be prepared; manage with IV fluid. If deterioration continues – consider Adrenaline infusion. 52 Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 39 ADULT AGONAL TRAUMA PATIENTS An agonal trauma patient is described as: a trauma patient who presents on scene without cardiac output, and there is some evidence that this has been for a short time only,(e.g. witness information; short response time; arrest in ambulance care) or trauma patient immediately prior to arrest (faint central pulse, gasping/no respirations) It is acknowledged that the history of loss of cardiac output can be unreliable. It is also assumed that there are no obvious, non-survivable injuries. Be wary of situations where a cardiac event may have preceded the trauma event. BLUNT TRAUMA 1: Establish no cardiac output PENETRATING TRAUMA 1: Establish no cardiac output If there are other patients on scene with serious injuries & if there are not sufficient resources to deal with all patients, the agonal blunt trauma patient is to be triaged out. If there are other patients on scene with serious injuries & if there are not sufficient resources to deal with all patients, the agonal penetrating trauma patient is to be triaged out. If other patients have minor injuries or there are no other patients, then the agonal trauma patient is to be managed in the following manner. If other patients have minor injuries or there are no other patients, then the agonal trauma patient is to be managed in the following manner. 2: Determine if cardiac death has occurred. 2: Determine if cardiac death has occurred. Monitor patient with leads. Monitor patient with leads. If a narrow complex electrical activity with heart rate greater than 20 is observed then cardiac death has not occurred and attempts to resuscitate the patient should be considered. If a narrow complex electrical activity with heart rate greater than 20 is observed then cardiac death has not occurred and attempts to resuscitate the patient should be attempted. If slow, wide complex rhythm, or asystole, consider no resuscitation. If slow, wide complex rhythm, or asystole, consider resuscitation 3: Resuscitate rapidly (if possible simultaneous procedures): 3: Resuscitate rapidly (if possible simultaneous procedures): Cannulate; rapid infusion of greater than 2 litres of crystalloid. (pump set) 53 Cannulate; rapid infusion of greater than 2 litres of crystalloid. (pump set) Version 4.2 01/10 CLINICAL MANAGEMENT GUIDELINE 39 (continued) ADULT AGONAL TRAUMA PATIENTS BLUNT TRAUMAMA (continued) PENETRATING TRAUMA (continued) Secure definitive airway – ETT / LMA Aggressive oxygenation Secure definitive airway – ETT/LMA Aggressive oxygenation If any doubt about air entry - chest decompression with a large bore cannula into the mid clavicular line 2nd intercostal space on affected side/s. If chest penetration + any doubt about air entry - chest decompression with a large bore cannula into the mid clavicular line 2nd intercostal space. Drugs NOTE: If IPPV is being performed, the absence of air entry is an unreliable sign of tension pneumothorax. Drugs 4: If at this point no restoration of cardiac output has occurred, cessation of resuscitation should be seriously considered. 4: Facilitate urgent transport to trauma centre. Ensure notification. Agonal blunt trauma patients should not generally be transported if active CPR needs to be performed en route. The likelihood that these patients will survive from this point is effectively nil. Transport of these patients may not be in the best interest of staff and the community. Continue active resuscitation. If more than 15 minutes transport time from trauma centre, go to closest hospital. If cardiac output restored, continue to trauma centre. Agonal penetrating trauma patients may be considered for transport, as survival is possible. Exceptions: Exceptions: - close to trauma centre - penetrating wounds to the head are to be treated as for blunt agonal trauma - Paramedic clinical judgement - if more than 15 minutes transport time from any hospital, & no cardiac output regained, consider ceasing resuscitation - Paramedic clinical judgement 54 Version 4.2 01/10 in development... CLINICAL MANAGEMENT GUIDELINE 40 BARIATRIC PATIENTS CLINICAL MANAGEMENT GUIDELINE 41 HEADACHE CLINICAL MANAGEMENT GUIDELINE 42 BACK PAIN CLINICAL MANAGEMENT GUIDELINE 43 DEHYDRATION 55 Version 4.2 01/10 If intubation is not successful the following “Failed Intubation Drill” MUST BE FOLLOWED Were vocal cords visualised during initial laryngoscopy? Insert OP airway and ventilate with 100% O2 Yes No Check head /neck position BURP manoeuvre Objective confirmation of tracheal placement (ODD, ETCO2) Re-attempt intubation under direct vision, after suction or removal of foreign body, as required No Immediately remove ETT and insert OP or NP airway and re-ventilate with 100% O2 Yes Continue management in accordance with the relevant CMG DO NOT CONTINUE WITH FRUITLESS ATTEMPTS TO INTUBATE UNDER DIRECT VISION Able to oxygenate and ventilate? Yes Attempt digital placement (on appropriate patients) If unsuccessful, insert LMA No Able to oxygenate and ventilate? CONSIDER No Yes CRICOTHYROTOMY 56 Continue management in accordance with the relevant CMG An incident report must be submitted Version 4.2 01/10 RAPID SEQUENCE INDUCTION (RSI) THIS IS A PROCEDURE OF LAST RESORT! EXPLORE ALL OTHER OPTIONS AND ALTERNATIVES FIRST! INDICATIONS The unconscious patient with unequivocal, life threatening airway compromise and clinical evidence of severe hypoxia. OR The unconscious patient with potential airway compromise where extrication procedures will make it impossible to provide adequate airway control. CONSIDERATIONS The following essential considerations must be taken into account prior to utilisation of this guideline. Clinical need airway compromise, clear & obvious Glasgow Coma Score < 9 hypoxia – Oxygen saturation < 90% OR centrally cyanosed time to hospital (should include extrication, load & transport time) Patients who are not trapped or where extrication is not difficult, and are within 5 – 6 minutes time to hospital, WOULD NOT be candidates for rapid sequence induction. Assessment of the difficulty of intubation Based on: anatomical, acquired and situational factors. confidence and experience of the operator. Response to basic treatment try everything – posture, guedels, nasal, suction, O2, ventilation by mask, etc. give basic options a chance to work. only proceed to rapid sequence induction if patient remains critical. Consequences and outcomes Worse case scenario: Breathing patient with compromised airway; becomes a “can‟t intubate, can‟t ventilate” scenario. continues over 57 Version 4.2 01/10 Fall back position Do not continue with futile attempts to intubate. Return to basics & re-ventilate. Attempt placement with: Digital placement LMA Surgical airway – as a last resort. Paediatrics – ONE attempt at endotracheal intubation only. PROCEDURE Basic airway management. Oxygenation aim for the highest O2 saturations by the most efficient method. IV access establish a fast flowing line that is reliable & secure. a second IV line is sound insurance. The most experienced operator is to tube. Do not debate this issue - make a choice and proceed! This is not a teaching opportunity for intubation skills. Prepare patient: 1. Correct any hypotension / hypovolaemia 10 ml/kg Normal Saline unless in pulmonary oedema. 2. Pre-oxygenate 3. Monitor Patient; ECG / Oximetry 4.Correct any bradycardia 5. Prepare and check equipment This is vital and includes: Laryngoscope Suction ETT - syringe, ties etc. LMA Surgical airway kit 6. Brief your assistant continues over 58 Version 4.2 01/10 7. Check allergies 8. Draw up drugs and check 9. Ask assistant to apply cricothyroid pressure 10. Commence intubation 11. Check tube position Visualisation of tube between cords Oesophageal detector device Auscultation Chest movement Misting in the tube EtCO2 Pulse oximetry 12. Tie in securely DRUG SEQUENCE Adult Midazolam 0.05 mg/kg, Slow IV dose NOTE: Watch BP! Prior to Suxamethonium, if bradycardic rate < 50 Atropine 0.01mg/kg, fast push. Suxamethonium 1.5 mg/kg, over 30 – 60 seconds. Post intubation to maintain tube and level of sedation, Alternating doses of: Midazolam up to 0.1mg/kg, slow IV dose Morphine up to 0.05 mg/kg, slow IV dose NOTE: Watch BP! Suxamethonium causes bradycardia, if patient is still bradycardic once ETT is tied in, consider a dose of Atropine. Paediatric Midazolam 0.05 mg/kg As slowly as possible. NOTE: Watch BP! Atropine 0.01mg/kg, fast push Suxamethonium 1.5 mg/kg, over 30 – 60 seconds Post intubation to maintain tube and level of sedation alternating doses of: Midazolam up to 0.1mg/kg, slow IV dose Morphine up to 0.05 mg/kg, slow IV dose NOTE: Watch BP! continues over 59 Version 4.2 01/10 IF INTUBATION FAILS Re-oxygenate / re-ventilate the patient – utilise basic techniques. There is no second dose of Suxamethonium! If intubation is still unsuccessful move to a fallback option, following the Failed Intubation Drill procedure. Digital Placement LMA Surgical Airway Consider urgent transport FOLLOW UP 1. All relevant details will be carefully documented on the PCR. This especially applies to details concerning the need for sedation, the checks on correct placement of the ETT and the results of the procedure. 2. An Incident Report must be sent to the Clinical Support Section by the end of shift; the hard copy is to be sent via satchel. There are no exceptions. 3. All pharmacologically facilitated intubations will be subject to routine, mandatory Clinical Advisory Committee Review. FINAL NOTE As stated previously, this is a procedure of last resort! It is anticipated that this procedure will only be utilised in the most exceptional of circumstances. 60 Version 4.2 01/10 DRUGS FOR AIRWAY MANAGEMENT - SUMMARY SHEET SEDATION FOR BASIC AIRWAY MANAGEMENT: Midazolam Dose: up to 0.1 mg/kg, slow IV dose. ( NOTE: If patient has already had Midazolam for sedation do not give a repeat dose with Suxamethonium; or give a smaller dose.) RAPID SEQUENCE INDUCTION – Suxamethonium & Midazolam: Adult: Midazolam 0.05 mg/kg, slow IV dose. NOTE: Check BP as soon as practical - Reduce Midazolam dose if patient is over 60 or BP <100. Prior to Suxamethonium, if bradycardic (rate < 50) Atropine 0.01 mg/kg, fast push Suxamethonium 1.5 mg/kg, over 30 – 60 seconds Paediatric: Midazolam 0.05 mg/kg, slow IV dose. NOTE: Check BP as soon as practical Atropine 0.01 mg/kg, fast push. Suxamethonium 1.5 mg/kg, over 30 – 60 seconds NOTE: Watch BP! Suxamethonium causes bradycardia, if the patient is still bradycardic once the ETT is tied in, consider a dose of Atropine. SEDATE TO INTUBATE – Morphine & Midazolam: Pre-infuse IV bolus of fluid, irrespective of BP Adults: IF - normal size & weight & age < 75 with a BP > 100 Morphine 10 mg IV, Midazolam 10 mg IV. Fast push. IF - small adult or BP 70 – 100 or age 75 Morphine 5 mg IV, Midazolam 5 mg IV. Fast push. IF - BP < 70 Morphine 2.5 mg IV, Midazolam 2.5 mg IV. Fast Push. Flush dose with rapid IV fluid bolus. Paediatrics: Morphine 0.05 mg/kg IV, Midazolam 0.1 mg/kg IV If hypovolaemia is suspected: give half the calculated dose of each drug. Flush dose with rapid IV fluid bolus. Doses may be repeated x 1. (Prepare the second doses) 61 Version 4.2 01/10 POST INTUBATION – to maintain ET tube and level of sedation: Alternating doses of: Midazolam up to 0.1 mg/kg, slow IV dose Morphine up to 0.05 mg/kg, slow IV dose NOTE: Monitor BP closely 62 Version 4.2 01/10 A.C.T. AMBULANCE SERVICE PHARMACOLOGY NOTES INDEX ACETYLSALICYLIC ACID (ASPIRIN) ADENOSINE ADRENALINE AMIODARONE ATROPINE SULPHATE CALCIUM CHLORIDE CEFTRIAXONE CLOPIDOGREL KETAMINE LIGNOCAINE MAGNESIUM SULPHATE METHOXYFLURANE (PENTHRANE) MIDAZOLAM (HYPNOVEL) MORPHINE SULPHATE NALOXONE (NARCAN) NORMAL SALINE OBIDOXIME ONDANSETRON (ZOFRAN) PARACETAMOL (PANDOL) PRASUGREL (EFFIENT) SALBUTAMOL (VENTOLIN) SODIUM BICARBONATE SUXAMETHONIUM FRUSEMIDE (LASIX) GLUCAGON GLUCOSE 10% GLYCERYLTRINITRATE (ANGININE) HEPARIN HYDROCORTISONE INFLUENZA VACCINE IPRATROPIUM BROMIDE (ATROVENT) Drug Calculator 63 Version 4.2 01/10 ACETYLSALICYLIC ACID (ASPIRIN) TYPE: Non-steroidal anti-inflammatory drug [S2] PRESENTATION: Tablet 300 mg ACTIONS: 1. Inhibits platelet function (up to 7 days). Suppresses inflammation, reduces fever, relieves pain. Rapidly absorbed from the stomach and small bowel. USE: Suspected Myocardial Ischaemia - reducing platelet aggregation and limiting clot development. ADVERSE EFFECTS: Allergic reactions e.g. asthma, Angioneurotic oedema, urticaria, rhinitis, shock. CHECK FOR PREVIOUS REACTIONS Aggravation of bleeding tendencies. Gastric irritation (unlikely with 1 tablet only). CONTRA-INDICATIONS: Known or suspected allergy to Salicylates Known or suspected active bleeding Known bleeding tendency Chest pain associated with psychostimulant OD (due to an increased risk of cerebral haemorrhage) DOSE: 1 tablet (300 mg) chewed and swallowed, or dissolved in a small amount of water. ½ tablet (150mg) if on warfarin Single dose only SPECIAL NOTE: Administer even when patient is on slow release Aspirin. 64 Version 4.2 01/10 ADENOSINE (ADENOCOR) TYPE: Endogenous purine nucleoside, found in all body cells [S4] PRESENTATION: 6 mg in 2ml ampoules ACTION: Causes transient inhibition of conduction in the heart, especially in the A-V node. Onset: 5 – 10 seconds - Duration: approx 10 seconds USE: Treatment of supraventricular tachycardia Not for the treatment of Atrial Flutter or Fibrillation; however, if mistakenly administered to patients in these arrhythmias, the decrease in A-V conduction may unmask atrial activity. ADVERSE EFFECTS: Common, although transient & generally minor. Arrhythmias at the time of conversion are common (up to 55% pts) - including PVCs, PACs, sinus brady, A-V blocks. Transient flushing of the skin; mild dyspnoea; chest tightness, nausea & headache, feelings of apprehension & fear. CONTRA-INDICATIONS: 2° or 3° heart block Known hypersensitivity PRECAUTIONS: Asthma - may exacerbate bronchospasm. Pregnancy - use only if very poorly perfused. Antagonised by: Theophylline Potentiated by: Dipyridamole (Persantin) Carbamezapine (Carbium, Tegretol, Teril) DOSE: Symptomatic adults only: 6 mg IV - rapid bolus (1 – 2 seconds) give into a fast-flowing pump set If 1st dose unsuccessful, give 2nd dose 12 mg IV (2 minutes between doses) Paediatric: 2nd dose: 0.05 mg/kg 0.1 mg/kg SPECIAL NOTE: Use only after unsuccessful Valsalva manoeuvre x 2. Record a 12 lead ECG prior to the use of Adenosine. Rapid injection with a pump set increases the likelihood of success. Elevate limb if possible. Even if the arrhythmia is successfully converted – the patient should still be transported to hospital as the incidence of recurrent arrhythmias is quite high (10-15%). If patient has previously had an unpleasant (fearful) experience with Adenosine – consider a pre-dose of Midazolam 1 – 1.5mg IV. 65 Version 4.2 01/10 ADRENALINE TYPE: A naturally occurring catecholamine [S3] PRESENTATION: 1:10000 - 1 mg in 10 ml 1:1000 - 1 mg in 1 ml ACTIONS: 1. Peripheral vasoconstriction ( effect) 2. Increased rate of sinus node 3. Increased myocardial contractility 4. Increased AV conduction 5. Increased myocardial irritably (1 effect) 6. Bronchodilatation 7. Vasodilatation of skeletal muscle (2effect) – IMS Mini-jet – ampoules Onset: 30 seconds IV; IM: Max effect: 3 – 5 minutes IV; IM: 30 – 90 seconds 4 – 10 minutes Endotracheal use: slightly longer times USES: Ventricular fibrillation Asystole Pulseless Electrical Activity (PEA) Anaphylaxis Severe life-threatening asthma Bradyarrhythmias resistant to Atropine Severe upper airway obstruction due to swelling ADVERSE EFFECTS: Tachycardia Tachyarrhythmias Hypertension CONTRA-INDICATIONS: Known hypersensitivity PRECAUTIONS: These apply to patients with cardiac output only: Care with patients with history of hypertension. Care with patients with history of ischaemic heart disease. Give extremely slowly to patients on MAO Inhibitor antidepressants (e.g.: Marplan, Parstelin, Marsilid, Nardil, Parnate) as Adrenaline may provoke a greatly exaggerated response. Generally, patients on MAOIs with cardiac output should receive no more than ¼ normal dose of adrenaline, titrated to response. continues over 66 Version 4.2 01/10 ADRENALINE (cont) DOSE: Cardiac Arrest Adult: 1 mg, IV fast push Paediatric: 0.01 mg/kg IV / IO fast push (If no IV or IO access, administer via endotracheal tube) No limit on the number of doses in cardiac arrest Anaphylaxis / Severe life-threatening asthma: Adult: 0.5 mg IM Paediatric: 0.01 mg/kg IM (to 50 kg) Repeat IM dose x 1 as required (The preferred IM site for anaphylaxis is the thigh) If required, IV Adrenaline by infusion:1 mg in 1000 mls Normal Saline ( = 1mcg/ml)Titrate to response (20 dpm = 1 ml/min = 1mcg/min) Paediatric - use burette If the patient is critically ill, slow IV, up to 0.01 mg/kg, no faster than 50mcg/minute. NOTE: IV Adrenaline in anaphylaxis & asthma should be used very cautiously. Bradyarrhythmias resistant to Atropine: IV Adrenaline by infusion: 1 mg in 1000 mls Normal Saline ( = 1mcg/ml) Titrate to response (20 dpm = 1ml/min = 1mcg/min) Paediatric - use burette Severe upper airway swelling: Adrenaline 1:1000: wt > 10 kg - nebulise 5 mls Adrenaline 1:1000 wt < 10 kg - nebulise 0.5 ml/kg Adrenaline 1:1000 (make volume up to 5 mls with saline, as required) Single dose only SPECIAL NOTE: Adrenaline in 1000ml flask is to have medication label attached! 67 Version 4.2 01/10 AMIODARONE TYPE: PRESENTATION: ACTIONS: USE: ADVERSE EFFECTS: CONTRA-INDICATIONS: DOSE: Potent anti-arrhythmic agent [S4] Ampoule 150 mg/3ml Complex electrophysiological & pharmacological profile: 1. Prolongs the action potential duration; increases the refractoriness of all cardiac tissue 2. Also blocks Na+ channels (Class I action) 3. Has some anti-adrenergic effects (Class II action) Ca2+ blockade (Class IV) 4. Prolongs QT interval – reflects global prolongation of repolarisation 5. When given IV, there is a significant effect on the AV node which causes a delay in nodal conduction 6. Also effective for accessory pathway conduction Effective for both supraventricular & ventricular arrhythmias ACTAS USE: − to slow ventricular rate in AF and AFl − to treat VT & VF IV: can cause vasodilatation & negative inotropic effects; hypotension. (dose & rate dependent) Occasionally may cause: 1. Bradycardia ( especially in older pts) 2. Phlebitis3. Hot flushes / sweating Known hypersensitivity Cross sensitivity to Iodine VF: Adult: 300 mg IV push dose (over 30 – 60 seconds) Paediatric: 5 mg/kg IV SPECIAL NOTE: VT, AF and AFl: 150 mg IV via Springfuser (over 10 minutes, approx. 7 mls) Paediatric: 5 mg/kg IV (VT - If extremely compromised, may be given over 5 mins by slow IV injection) No repeat doses for either treatment regimen Significant potential drug interactions:The following may potentiate the actions of Amiodarone: Digoxin; Phenytoin (Dilantin); Blockers; Ca2+ Channel Blockers; & other anti-arrhythmics. 68 Version 4.2 01/10 ATROPINE SULPHATE TYPE: Parasympathetic blocking agent [S4] PRESENTATION: 1 mg in 10mls – IMS Mini-jet ACTIONS: Large number of actions. Those important in the pre-hospital setting: 1. Blocks the action of the vagus nerve on the heart 2. Increases the rate of the sinus node 3. Increases speed of conduction through the AV node 4. Reduces the amount of secretions from some glands: (e.g. tear & salivary glands). Onset IV: 2 minutes Max effect: 5 minutes IM/ET – slightly longer USES: 1. Bradyarrhythmias with poor perfusion 2. Asystole/PEA 3. Organophosphate poisoning/spider bite (to increase heart rate irrespective of BP and/or assist airway maintenance by reducing excessive salivation) 4. To prevent bradycardia with Suxamethonium use ADVERSE EFFECTS: tachycardia; palpitations; blurred vision; dry mouth; confusion, urinary retention; increased body temperature (by decreasing perspiration). CONTRA-INDICATIONS: Known hypersensitivity PRECAUTIONS: Care needed in patients with Glaucoma Aim not to increase heart rate above 100/minute continues over 69 Version 4.2 01/10 ATROPINE SULPHATE (cont) DOSE: Bradyarrhythmias: Adult: IV - 0.01 mg/kg – fast push ET: 0.01 mg/kg, if no immediate IV access. Repeat x 1 as necessary Paediatric: Not used Asystole/PEA: Adult: 2 mg IV/ET Paediatric: Not used Organophosphate poisoning/cholinergic symptoms of spider bite: Adult/Paediatric: 0.01 mg/kg IV – fast push Repeat as required. No upper limit on doses. Continue use even if BP is not low. May be used IM in these circumstances if IV access is not available or if there are multiple patients affected. To treat bradycardia with Suxamethonium use: Adult/Paediatric: 0.01 mg/kg IV – fast push 70 Version 4.2 01/10 CALCIUM CHLORIDE TYPE: Electrolyte – utilised in both electrical & mechanical actions of the myocardium. [No schedule] PRESENTATION: 1g in 10mls (10% solution) – IMS Mini-jet ACTION: Opposes action of high serum Potassium on the myocardium. Onset: IV: Several minutes Duration: 30 - 90 minutes USES: 1. Emergency treatment of Hyperkalaemia 2. Prolonged hypotension, post Magnesium administration, unresponsive to fluid ADVERSE EFFECTS: Rare with nominated use 1. Tissue necrosis if extravasates from vein 2. Precipitates out in contact with Bicarbonate CONTRA-INDICATIONS: Known hypersensitivity DOSE: Adult/Paediatric: 10 mg/kg IV, over 2 minutes Repeat x 1 as required 71 Version 4.2 01/10 CEFTRIAXONE (ROCEPHIN) TYPE: 3rd generation cephalosporin antibiotic [S4] PRESENTATION: Vial – 1g Ceftriaxone powder for reconstitution ACTIONS: 1. Broad spectrum antibiotic Especially effective against gram-negative bacteria (e.g. Meningococcus) 2. Effective crossing of blood-brain barrier USE: Suspected meningococcal disease, in acutely ill patients ADVERSE EFFECTS: 1. Hypersensitivity reactions (not common) 2. Diarrhoea 3. Skin rash PRECAUTIONS: It is possible that 20% patients with a Penicillin allergy may be sensitive to Ceftriaxone. CONTRA-INDICATIONS: Known sensitivity to cephalosporins DOSE: 50 mg/kg, to a total of 2g IV preferred. But can also be given IO Make up to 10ml with water for injection; give slowly over 2 – 4 minutes May be administered IM: Dilute a maximum of 1g in 3mls of 1% Lignocaine prior to administration. Give two injections if dose is over 1g (i.e. over 3 mls volume). SPECIAL NOTE: An incident report should be submitted to Clinical Services if Ceftriaxone is administered. 72 Version 4.2 01/10 CLOPIDOGREL (PLAVIX) Potent inhibitor of platelet aggregation TYPE: Tablet – 75 mg PRESENTATION: A specific and potent inhibitor of platelet aggregation. ACTION: It does this by binding specifically and irreversibly to the platelet P2RY12 purinergic receptor, inhibiting Adenosine Diphosphate (ADP) mediated platelet activation and aggregation. Onset : >30 minutes USE: Patients with an acute ST elevation myocardial infarction who meet the requirements for early percutaneous coronary intervention (PCI) procedure. ADVERSE EFFECTS: 1. Headache 2. Dizziness 3. Stomach disturbances/pain 4. Diarrhoea or constipation CONTRA-INDICATIONS: 1. Known allergy 2. Known internal bleed within 6 months, 3. Current use of anticoagulants (excluding Aspirin or Clopidogrel), DOSE: 8 x 75 mg tablets (600 mg) – taken orally Not to be dissolved but can be taken with water. 73 Version 4.2 01/10 GLUCOSE 10% TYPE: Hypertonic Glucose solution; containing 0.1 g Dextrose per ml. [No schedule] PRESENTATION: Glucose – in 500ml plastic flask ACTION: Glucose is the main energy source for the body cells, especially the brain. Onset: 30 – 60 seconds USE: Treat hypoglycaemia; following blood glucose estimation if BGL < 4, & patient unable to eat or drink ADVERSE EFFECTS 1. Tissue necrosis if allowed to escape from the vein 2. Hyperglycaemia/hyperosmolality CONTRA-INDICATIONS: Known hypersensitivity DOSE: Up to 2.5 ml/kg IV (0.25 g/kg) slowly over 5 minutes Continue to check patency of vein May repeat dose x 1 if level of consciousness or BGL has not improved NOTE: Patients who respond to 10% Glucose should eat to prevent later development of further hypoglycaemia. Re-check BGL following treatment. 74 Version 4.2 01/10 FRUSEMIDE (LASIX) TYPE: Loop diuretic [S4] PRESENTATION: 80 mg in 8ml – IMS Mini-jet ACTIONS: 1.Potent diuretic when given IV, Lasix increases urine output within 5 – 10 minutes; and can last up to 3 hours 2. Causes venous dilatation – decreases venous return. This effect occurs within 5 minutes. USE: Severe Acute Cardiogenic Pulmonary Oedema – unresponsive to previous treatment – to decrease venous return and promote loss of fluid. ADVERSE EFFECTS: 1. If given too rapidly, may lead to hypotension. 2. If marked diuresis occurs, the resulting fluid loss may lead to hypovolaemic shock, especially in hypovolaemic patients. 3. Potassium loss may occur – may aggravate arrhythmias (esp. if previously hypokalaemic). CONTRA-INDICATIONS: 1. Systolic BP < 90mmHg 2. Hypersensitivity (Note – possible cross-sensitivity to sulphonamides) DOSE Adult: On diuretics: Adult Not on diuretics: 1 mg/kg IV over 2 minutes 0.5 mg/kg IV over 2 minutes Single dose only NOTE: If the patient is in severe pulmonary oedema & IV access is not available, IM administration is acceptable. (use 2 separate sites if the volume is greater than 4mls). Paediatric: Not used 75 Version 4.2 01/10 GLUCAGON TYPE: Pancreatic hormone [S4] PRESENTATION: Vial containing 1 International Unit of Glucagon, as a dry powder, with a syringe containing 1 ml of diluting solution. ACTION: Causes the liver to metabolise stores of glycogen to Glucose, resulting in a rise in the blood glucose level. Only effective if liver glycogen is available. Onset: IM 5 – 20 minutes USE: Treatment of hypoglycaemia, BGL < 4 mMol/L, when oral or intravenous Glucose cannot be administered. ADVERSE EFFECTS: Very rare 1. Nausea and vomiting 2. Very occasional hypersensitivity CONTRA-INDICATIONS: Known hypersensitivity DOSE: Adult: 1 International Unit (IU), IM Paediatric: wt < 20kg (approx. 5 yrs): 0.5 International Unit IM wt > 20kg: 1 International Unit IM Single dose only NOTE: Patients who respond to Glucagon should eat, to prevent later development of further hypoglycaemia. Recheck BGL following treatment. 76 Version 4.2 01/10 GLYCERYL TRINITRATE (ANGININE) TYPE: Nitrate smooth muscle relaxant and vasodilator [S3] PRESENTATION: White 600 mcg sublingual tablet ACTIONS: 1. Arterial and venous vasodilatation 2. Dilatation of collateral coronary vessels USES: 1. Relieve cardiac pain of ischaemic origin 2. Relieve pulmonary oedema ADVERSE EFFECTS: 1. Hypotension 2. Headache 3. Flushing of skin 4. Occasionally – bradycardia CONTRA-INDICATIONS: 1. Do not administer if systolic BP is < 90 2. Do not administer if HR < 50 3. Do not administer if Sildenafil (Viagra) or Vardenafil (Levitra) have been taken within 24 hours 4. Following the last dose of Tadalafil (Cialis), do not administer within 4 to 5 days in the elderly and those with renal impairment; or 3 to 4 days in all other patients. 5. Known hypersensitivity DOSE: Chest Pain: 1 tablet sublingually (600 mcg) Repeat x 1 as necessary Acute Cardiogenic Pulmonary Oedema: 1 tablet sublingually (600 mcg) Repeat x1 after approx 10 minutes if in severe respiratory distress If: 90 > Systolic BP < 100, or the patient has not previously used any nitrate medication give 1/2 tablet for either chest pain or APO Repeat 1/2 tablet x 1 as necessary NOTE: Tablet should fizz under the tongue if it is still potent. Use tablets within 3 months of opening bottle. The container MUST be dated when first opened. 77 Version 4.2 01/10 HEPARIN TYPE: Unfractionated Heparin anticoagulant PRESENTATION: Ampoule – 1 ml with 5000u Heparin ACTIONS: 1. Inhibits blood clotting 2. Combines with antithrombin III, a naturally occurring anti-clotting factor in plasma, and inhibits the conversion of prothrombin to thrombin 3. It also interferes with the actions of other clotting factors and with fibrin stabilising factor. USE: Patients with an acute ST elevation myocardial infarction who meet the requirements for early percutaneous coronary intervention (PCI) ADVERSE EFFECTS: 1. Bleeding 2. Anaphylactoid reactions (rare) 3. Thrombocytopenia CONTRA-INDICATIONS: Use PCI checklist PRECAUTIONS: Use with care in patients with extensive history of allergies DOSE: Adults: 5000u IV, over 30 – 60 seconds SPECIAL NOTE: This treatment should not delay transport time to hospital 78 Version 4.2 01/10 HYDROCORTISONE (SODIUM SUCCINATE) TYPE: Adrenocorticosteroid [S4] PRESENTATION: 100 mg powder in 2ml vial Reconstitute with 2ml sterile water or Normal Saline ACTIONS: Numerous & widespread ACTAS administration is for the anti-inflammatory effect on the airways USES: 1. Moderate to severe bronchospasm due to asthma, anaphylaxis or chronic airways disease 2. Patients with a history of Addison‟s Disease who present with a problem likely to precipitate a stress response e.g. AMI, fractures, asthma, gastroenteritis. ADVERSE EFFECTS: Nil significant with single use CONTRA-INDICATIONS: Known previous reaction to corticosteroids DOSE: Adult: 200 mg IV slow – over 2 minutes Paed: 4 mg/kg IV slow – over 2 minutes (to total 200mg) May be administered IM SPECIAL NOTE: Hydrocortisone is not a first-line priority drug in the management of severe bronchospasm. It is only to be given after aggressive oxygenation, inhaled bronchodilators & (where necessary) Adrenaline. 79 Version 4.2 01/10 INFLUENZA VACCINE TYPE: Influenza Virus Vaccine PRESENTATION: 0.5 ml (pre-prepared syringe) ACTION: Provides antibody response and provides protection against clinical illness. Because the influenza virus is capable of significant changes in its antigenic behaviour from time to time, protection is afforded by the vaccine, limited to the strains from which the vaccine was prepared, or closely related strains. USE: Prevention of Influenza virus, types A and B, in appropriate population groups ADVERSE EFFECTS: Local reactions: Swelling, redness, ecchymosis, induration, tenderness/pain. Systemic reactions: Fever of short duration, malaise, shivering, tiredness, headache, sweating, myalgia, arthralgia, and lymphadenopathy. Allergic reactions have been reported. CONTRA-INDICATIONS: Should not be given to persons known to be allergic to fowl proteins (eggs, feathers or chicken meat) PRECAUTIONS: Caution should be exercised if the vaccine is to be given to persons with an allergic condition such as asthma or dermatitis. DOSE: Infants 6 months to 2 years 0.125 ml deep subcutaneous Children 2 to 6 years 0.25 ml IMI Adults and children over 6 years 0.5 ml IMI 80 Version 4.2 01/10 IPRATROPIUM BROMIDE (ATROVENT) TYPE: Anticholinergic bronchodilator [S4] PRESENTATION: 1 ml plastic nebule; containing 250 mcg Ipratropium Bromide ACTIONS: 1. Bronchodilator 2. Blocks vagal reflexes which mediate bronchoconstriction 3. Possibly more effective when used in combination with Salbutamol 3 – 5 minutes 2 – 4 hours Onset: Duration: USE: Bronchospasm from any cause; as an adjunct to Salbutamol ADVERSE EFFECTS: Rare with single use Occasionally – urine retention CONTRA-INDICATIONS: Known hypersensitivity PRECAUTIONS: Care needed with use in patients with glaucoma DOSE: Adult: 500 mcg – mixed with 1st, then 3rd and 5th doses of Salbutamol Paediatric: 250 mcg – mixed with 1st, then 3rd and 5th doses of Salbutamol Use with MDI/Spacer mild to moderate, no hypoxia and familiar with use 1. Adult >6 yrs 4 x 21mcg (4 puffs) 2. Child < 6 yrs 2 x 21mcg ( 2 puffs) 81 Version 4.2 01/10 KETAMINE HYDROCHLORIDE (KETLAR) TYPE: Dissociative anaesthetic agent [S8] PRESENTATION: 200 mg in 2ml vial ACTIONS: Complex, multiple actions: 1. Analgesic; sedative agent 2. Marked amnesia 3. Has bronchodilating properties 4. Does not tend to cause respiratory depression 5. Does not tend to cause hypotension (via sympathetic stimulation) Onset of action is rapid: 1 – 2 minutes IV 3 – 5 minutes IM USES: 1. Pain management, especially in patients who are hypotensive or unable to have narcotics, & if no alternative is available. 2. Particularly useful for trapped patients with limb injuries, especially if BP is borderline for narcotics. 3. Adjunct to Morphine, with alternating doses. ADVERSE EFFECTS 1. Transient Laryngospasm 2. Hypersalivation 3. Emergence reactions 4. Muscle twitching & purposeless movements 5. Occasionally respiratory depression → apnoea 6. Occasionally hypotension if given rapidly to a hypovolaemic patient PRECAUTIONS: 1. Use with care in patients where a rise in BP may be hazardous (e.g. stroke, cerebral trauma) 2. Known glaucoma 3. Previous psychoses 4. Hyperthyroidism 5. Elderly and paediatric patients 6. Patients previously administered narcotics 82 Version 4.2 01/10 KETAMINE HYDROCHLORIDE (cont) CONTRA-INDICATIONS: 1. Known sensitivity 2. Active cardiac disease (myocardial ischaemia, LVF, uncontrolled hypertension.) 3. Children under 1 year old DOSE: See attached Dose Chart NOTE: Ketamine can be used with alternating doses of Morphine. SPECIAL NOTE: Patients who have received Ketamine may still have a significant awareness, despite an appearance of unconsciousness. They may be able to hear and have some recall. Patients should be advised that they will experience strange/unusual sensations. Patients who become agitated may be managed with small repeat doses of Midazolam. Ketamine is a Drug of Dependence. Its use must be checked by both crew members. Under the Drugs of Dependence Act, recording and accounting for Ketamine use is a legal requirement. The unused portion of the dose must be appropriately disposed of & the disposal recorded. 83 Version 4.2 01/10 KETAMINE DOSE CHART DOSES: Adult Initial IV Up to 1 mg/kg. Increments of up to 20 mg at intervals of 30 – 60 seconds. Elderly (> 65 yrs) Up to 1 mg/kg. Increments of up to 10 mg at intervals of 30 – 60 seconds. Paediatric > 20 kg Up to 1 mg/kg. Increments of up to 10 mg at intervals of 30 – 60 seconds. Paediatric < 20 kg Up to 1 mg/kg. Increments of up to 5 mg at intervals of 30 – 60 seconds. Repeat IV After 5 – 10 minutes; increments of up to 20 mg as before. No upper limit. After 5 – 10 minutes; increments of up to 10 mg as before. No upper limit. After 5 – 10 minutes; increments of up to 10 mg as before. No upper limit. After 5 – 10 minutes; increments of up to 5 mg as before. No upper limit. Initial IM 1 mg/kg 0.5 mg/kg 0.5 mg/kg 0.5 mg/kg Repeat IM Previous opiates After 5 – 10 minutes; 1 mg/kg IV: Up to 10 mg increments as before. IM: 0.5 mg/kg After 5 – 10 minutes; 0.5 mg/kg IV: Up to 5 mg increments as before. IM: 0.25 mg/kg After 5 – 10 minutes; 0.5 mg/kg IV: Up to 5 mg increments as before. IM: 0.25 mg/kg After 5 – 10 minutes; 0.5 mg/kg IV: Up to 2.5 mg increments as before. IM: 0.25 mg/kg All IV doses are to be given slowly, over 30 seconds. Recommended dilutions: Adult IV: 200 mg diluted up to 10ml; = 20 mg/ml Adult IM: 100 mg diluted up to 2ml. Discard excess dose before IM use. Elderly pt IV: 100 mg diluted up to 10ml; = 10 mg/ml Elderly pt IM: 100 mg diluted up to 2ml. Discard excess dose before IM use. Children IV: 50 mg diluted to 10ml; = 5 mg/ml Children IM: 50 mg diluted to 2ml. Discard excess dose before IM use. 84 Version 4.2 01/10 LIGNOCAINE TYPE: 1. Local anaesthetic 2. Anti-arrhythmic [S4] PRESENTATION: 50 mg in 5ml – plastic ampoule ACTIONS: 1. Local anaesthetic effects 2. Suppresses ventricular arrhythmias Onset S/C: 1 – 4 minutes Max effect: 5 – 10 minutes IV: 1 – 3mins USES: 1. Local anaesthesia prior to invasive procedures 2. VT with cardiac output, in patients who cannot have Amiodarone 3. First flush for IO in an aware patient ADVERSE EFFECTS: These effects are extremely unlikely in usual subcutaneous doses, especially if the syringe is continually aspirated. More likely if given IV. 1. C.N.S. effects stimulation followed by depression drowsiness, agitation, muscle twitching,seizures & coma 2. Cardiac effects hypotension, bradycardia, heart block, asystole CONTRA-INDICATIONS: Known hypersensitivity PRECAUTIONS: Nil DOSE: Local anaesthesia: Adult and Paediatric - up to 5mls subcutaneously VT with cardiac output: 1 mg/kg – slow IV (over 2 minutes) IO in an aware patient: Adult: 2 - 4mls first flush Paediatric: 1 - 2mls first flush 85 Version 4.2 01/10 MAGNESIUM SULPHATE TYPE: Electrolyte solution [No schedule] PRESENTATION: 50% solution (10mMol) 2.5g in 5ml vial ACTION: Magnesium is the 2nd most abundant intracellular cation. Less than 1% is present in extracellular fluid. Magnesium is involved in the processes regulating Sodium and Potassium movement across cell membranes and, as such, it may promote myocardial cell membrane stability. USES: 1. Torsades de pointes (polymorphic VT) (Often associated with prolonged QT interval) 2. Refractory VF 3. Digoxin and Tricyclic antidepressant toxicity 4. Seizures due to eclampsia ADVERSE EFFECTS: Rare; more common if serum Mg is normal. Respiratory depression; nausea & vomiting; hypotension; confusion; bradycardia. CONTRA-INDICATIONS: AV block; renal failure; hepatic failure PRECAUTIONS: Myaesthenia gravis DOSE: Adult: Cardiac output: Dilute up to 10mls with N/Saline; 2.5g IV, over 5 minutes No cardiac output: 2.5g IV, over 30 – 60 seconds Siezures due to Eclampsia: 5mg dilute up to 10ml IV Paediatric: (unusual) Dose is 50 mg/kg, to maximum of 2.5g Dilute to 10mls = 250 mg/ml Cardiac output: give calculated dose IV over 3 – 5 minutes No cardiac output: give calculated dose IV over 30 – 60 seconds SPECIAL NOTE: Prolonged hypotension post-Magnesium administration; if unresponsive to fluids, patient may be treated with IV Calcium 86 Version 4.2 01/10 METHOXYFLURANE (PENTHRANE) TYPE: Volatile inhalation anaesthetic and analgesic agent [S4] PRESENTATION: 3ml bottle ACTION: Central Nervous System depressant Onset: 3 – 5 mins Offset: 3 – 5 mins USE: For relief of pain of all origins ADVERSE EFFECTS: 1. Altered consciousness 2. Renal dysfunction } rare with once only 3. Jaundice } Ambulance use CONTRA-INDICATIONS: 1. Depressed level of consciousness 2. Known hypersensitivity PRECAUTIONS: 1. Renal disease 2. Diabetes 3. Antibiotic or barbiturate use 4. Caution if patient unable to self-administer DOSE: Up to 3mls, self administered via Penthrox inhaler, with up to 8 L/minute of Oxygen Repeat x 1 as required Dose should not exceed 6mls/day or 15mls/week NOTE: May be used with Midazolam for musculo-skeletal pain. 87 Version 4.2 01/10 METOCLOPRAMIDE (MAXOLON) TYPE: Antiemetic [S4] PRESENTATION: 10 mg in 2ml ampoules ACTION: Antiemetic centrally acting on brain stem increases gastric emptying Onset: 3 – 15 minutes (IV) Duration: 30 minutes USES: 1. Prevent vomiting: when narcotic analgesic is to be administered 2. High spinal injury 3. Serious eye injury 4. Suspected ischaemic chest pain 5. Treat nausea & vomiting ADVERSE EFFECTS: Uncommon with usual doses Occasionally: 1. Drowsiness 2. Lethargy 3. Dry mouth 4. Oculogyric crisis, facial spasms 5. Speech difficulties. Side effects may be more common in dehydrated adolescents. PRECAUTIONS: Concomitant phenothiazide tranquilliser use – will increase the likelihood of side effects. CONTRA-INDICATIONS: 1. Previous reaction 2. G.I. bleeding DOSE: Adult dose: 10 mg lV over 2 minutes IM 10 mg Give prior to narcotic administration Single dose only Paediatric dose: 88 Not used Version 4.2 01/10 MIDAZOLAM (HYPNOVEL) TYPE: Anticonvulsant and sedative agent [S4] PRESENTATION: 5 mg in 5ml ampoules 15 mg in 3ml ampoules ACTIONS: 1. Anticonvulsant – reduces seizure activity 2. Minor tranquilliser 3. Muscle relaxant Onset (IV) 1 – 5 mins Duration: 2 – 3 hours Onset (IM) 2 – 5 mins Duration: ? 2 – 3 hours USES: 1. Status epilepticus - in a patient who has continual or prolonged seizures. 2. Sedation to manage airway, RSI, sedation of a previously intubated patient. 3. Adjunct to analgesia for injuries wheresignificant muscle spasm is present. 4. To manage agitated & combative patients. 5. To manage autonomic hyperreflexia. 6. Antiemetic (especially in paediatric patients). ADVERSE EFFECTS: Depression of level of consciousness - leading to: 1. Respiratory depression 2. Loss of airway control 3. Hypotension CONTRA-INDICATIONS Known hypersensitivity PRECAUTIONS 1. Haemodynamic instability 2. Respiratory depression DOSE: Seizures: Adult dose: Up to 0.1 mg/kg lV, over 2 minutes, until fitting ceases. Repeat if fitting continues or recurs. Paediatric dose: Up to 0.1 mg/kg IV, over 2 minutes, until fitting ceases. Repeat if fitting continues or recurs. I.M: 0.1 mg/kg Repeat x 1 after 10 minutes as necessary. continues over 89 Version 4.2 01/10 Adjunct to analgesic use with muscle spasm: Following 1 dose of Penthrane or 2 doses of Morphine, if severe pain & muscle spasm are still present – Up to 0.05 mg/kg IV over 2 minutes Repeat x 1 as required Further analgesic doses are to be given with caution Mild sedation to facilitate basic airway management: Up to 0.1 mg/kg over 2 minutes When used with Morphine to sedate for airway management in selected patients: Adult: 10 mg IV rapid push (adjusted for patient weight, age and BP) Paediatric: 0.1 mg/kg rapid push Repeat x 1 as required When used with Suxamethonium: 0.05 mg/kg IV When used to manage a combative or agitated patient:: Up to 0.1 mg/kg IV, until manageable. May repeat as required to continue management IM: 0.1 mg/kg May repeat as required to continue management If agitation & combativeness is thought due to psychostimulant use: Up to 0.2 mg/kg IV, until manageable May repeat as required to continue management IM: 0.2 mg/kg * May repeat as required to continue management * Use 0.2 mg/kg dose with caution All agitated patient management doses may be reduced if there is known or suspected hypotension or hypovolaemia; in frail or elderly patients, or patients with general debility. continues over 90 Version 4.2 01/10 When used to manage a patient with Autonomic Hyperreflexia: After identifying causes and trying appropriate actions and if BP remains elevated then: IV: 0.05 mg/kg, over one minute, May be repeated once after 10 minutes if no fall in BP IM: 0.1 mg/kg When used as an antiemetic: 0.05 mg/kg IV SPECIAL NOTE: 1: When administering lV for fitting, do not draw up total calculated dose. Administer first 5 mg ampoule; wait briefly for response before giving complete dose. 2: When using 0.2 mg/kg IM doses, the 15 mg/3ml formulation should be used. Exercise caution that this is only used in these circumstances. 3: Elderly patients may be especially sensitive to Midazolam, and advanced age is often a better guide to dosing than weight. 91 Version 4.2 01/10 MORPHINE SULPHATE TYPE: Narcotic analgesic [S8] PRESENTATION: 10 mg in 1ml ampoule ACTIONS: 1. Decreases pain perception and anxiety 2. Vasodilatation Onset: (IV) 2 – 5 mins Duration: 1 – 2 hours (IM) 5+ mins Duration: 2 – 3 hours USES: 1. To relieve severe pain 2. Acute pulmonary oedema 3. RSI 4. Sedation of a previously intubated patient 5. Chest Pain ADVERSE EFFECTS: 1. Nausea and vomiting 2. Drowsiness 3. Respiratory depression 4. Hypotension 5. Dependence 6. Pin point pupils 7. Bradycardia CONTRA-INDICATIONS: 1. Depressed level of consciousness (GCS 13 or less)* Pain relief only. 2. Respiratory depression * Pain relief only. 3. Known hypersensitivity 4. BP < 70mmHg (pain relief) 5. BP < 90mmHg (pulmonary oedema) 6. Acute asthma attacks 7. Pain management in labour PRECAUTIONS: 1. Elderly patients (may be sensitive) 2. Patients with COAD 3. Hypovolaemic patients (hypovolaemia should be corrected before Morphine administration) 4. Patients with systolic BP 70 – 90mmHg (see below) 5. Children under 1 year 92 Version 4.2 01/10 DOSE: Pain relief: Adult: Up to 0.05 mg/kg lV, over 2 minutes May be repeated at 5 minute intervals, until pain is managed. Paediatric: Up to 0.05 mg/kg IV, over 2 minutes May be repeated at 5 minute intervals, until pain is relieved. Use with caution under 1 yr of age. Morphine administration can be used alternately with Ketamine. Intramuscular administration: Pain relief only. Not for chest pain if cardiac ischaemia suspected No IV available No hypotension Patient contact estimated > than 20 minutes Dose: 0.1 mg/kg Repeat x 1 after 30 – 45 minutes as required Patient with pain; systolic BP of 70 – 90mmHg: IV use only hypovolaemic patients must be receiving fluids up to half a calculated 0.05 mg/kg dose, given slowly may be repeated as required, with great care, and with an appropriate time interval between doses, titrated to response. no further doses to be given if systolic BP drops 10mmHg or more with half dose, even if it remains above 70 (e.g. initial BP 85mmHg; following Morphine dose BP now 75 mmHg) continues over 93 Version 4.2 01/10 Pulmonary Oedema: 0.05 mg/kg lV, over 2 minutes May be repeated x 1 after 10 minutes, if required. When used with Midazolam for RSI: Adult: 10 mg IV rapid push (dose adjusted for patient weight, age and BP). Paediatric: 0.05 mg/kg rapid push Repeat x 1 if required. To maintain sedation post intubation: 0.05 mg/kg lV, slow IV dose SPECIAL NOTE: 1. Morphine is a Drug of Dependence. Use must be checked by both crew members. 2. Under the Drugs of Dependence Act, recording and accounting for its use is a legal requirement. 3. The unused portion of the dose must be appropriately disposed of & the disposal recorded. 4. Side effects may be reversed by use of Naloxone, although it is desirable to avoid this unless absolutely necessary. 5. Elderly patients may be especially sensitive to Morphine, and advanced age is often a better guide to dosing than weight. 94 Version 4.2 01/10 NALOXONE (NARCAN) TYPE: Narcotic antagonist [S4] PRESENTATION: 0.4 mg in 1ml – IMS Mini-jet ACTION: Reverses the effects of narcotic analgesics Onset IV: 1 – 2 minutes Duration: 30 – 45 minutes IM: unknown; but thought to have a slightly longer onset and duration than when given lV. USES: 1. Coma 2. Drug overdose and poisoning 3.Use in situations where there is significant decrease in level of consciousness; where there is hypoventilation, and/or loss of protective reflexes; & where overdose of narcotics cannot be positively excluded. ADVERSE EFFECTS: 1 May precipitate acute withdrawal syndrome in narcotic addicts. 2. Occasional aggressive behaviour following reversal. 3. Nausea and vomiting. CONTRA-INDICATIONS: Known hypersensitivity DOSE: Adult: 0.4 mg IM, then 0.4 mg lV increments, fast push May repeat IV dose x 3 (to maximum of 2 mg) Paediatric: 0.01 mg/kg lV, fast push Maximum paediatric dose: 3 doses All doses may be administered IM or IV as the situation demands. SPECIAL NOTE: When used IV, the effect may wear off rapidly, especially if a large dose of narcotic has been taken. An IM dose is highly recommended if the patient is likely to refuse transport. Special care is needed if long-acting agents are known or suspected to have been used (eg. MS Contin; Methadone). In this case, give a larger IM dose and strongly encourage transport to hospital. 95 Version 4.2 01/10 NORMAL SALINE TYPE: Isotonic crystalloid solution of 0.9% Sodium Chloride solution. Contains 151mMol Sodium & 151 mMol Chloride per litre. [No schedule] PRESENTATION: 500 or 1000mls of 0.9% Sodium Chloride solution in a collapsible plastic flask. ACTIONS: 1. Plasma volume expander 2. Also expands interstitial fluid volume 3. Plasma volume effect is only temporary as most of the saline moves out of the blood vessels quite quickly USES: 1. Initial replacement fluid, in volume depleted or dehydrated patients. Volume depletion may be due to loss of blood, plasma or fluid and electrolytes. 2. Maintenance of hydration during prolonged patient contact time. 3. To keep vein open, as IV route for drugs. ADVERSE EFFECTS: Fluid overload DOSE: IV fluid resuscitation: Adult: 10 ml/kg lV – then reassess patient Rate of administration is dependent on the condition of patient. Aim to keep BP at about 90mmHg systolic No limit on amount, dependent on condition of patient. Paediatric: 10 ml/kg lV or IO – then reassess patient Paediatric cardiac arrest: 20 ml/kg TKVO: Adult and Paediatric: 10 drops per minute (10ml/hr with a standard drip set). 96 Version 4.2 01/10 OBIDOXIME TYPE: Oxime [No schedule] PRESENTATION: 220 mg Obidoxime/2 mg Atropine – auto injector ACTION: Reactivating inhibited acetylcholinesterase USES: 1. To treat super toxic organophosphate poisoning (nerve agents) by relieving the symptoms of skeletal neuromuscular blocking that occurs during a cholinergic crisis. 2. Used in combination with Atropine, as combination auto-injector, or with Atropine separately administered. ADVERSE EFFECTS: 1. Hypotension, menthol-like sensation, warm feeling to the face, dull pain at site of injection. 2. Multiple doses can cause hepatic dysfunction. DOSE: Adult: Up to 660 mg IM over 30 minutes (Three doses via the auto-injector) Paediatric: Single dose of 220 mg IM SPECIAL NOTE: The preferred site for administration is the upper thigh. The auto injector needs to be held in place for 10 seconds when discharged to ensure the total dose has been administered. 97 Version 4.2 01/10 ONDANSETRON (ZOFRAN) TYPE: Potent anti-nauseant & antiemetic [S4] PRESENTATION: 4 mg/2 ml ampoule 4 mg wafers ACTIONS: 1. Potent, highly selective histamine receptor antagonist. 2. Precise mode of action in control of nausea & vomiting is not known. Likely to have actions peripherally and in the Central Nervous System. 3. Maximum effect is approximately 10 minutes following IV administration. 4. Hepatic metabolism. USE: For the prevention or treatment of nausea & vomiting PRECAUTIONS: Not recommended in pregnancy ADVERSE EFFECTS: Uncommon Headache; flushing of skin; occ. reaction at the site of IV injection; drowsiness; anxiety & agitation; transient visual disturbances. CONTRA-INDICATIONS: Known hypersensitivity DOSE: Adult: 4 mg IV, slowly over 2 minutes Paediatric: 0.1 mg/kg IV, slowly over 2 minutes (to total of 4 mg). May be administered IM if necessary. May repeat x 1 if required, after approx. 10 minutes Wafers: 4 mg sublingually 98 Version 4.2 01/10 PARACETAMOL (PANADOL) TYPE: Simple analgesic / antipyretic PRESENTATION: 48 mg/ml Colour Free Liquid ACTIONS: 1. Antipyretic 2. Mild analgesic USE: Pyrexia in children who have had or may have a febrile convulsion (For ACTAS treatment, pyrexia is generally > 38o C) PRECAUTIONS: 1. Impaired hepatic function 2. Impaired renal function ADVERSE EFFECTS: Rare – none of these side effects have been confirmed or refuted as being linked to the casual use of Paracetamol: Dyspepsia, nausea, allergic and haematological reactions CONTRA-INDICATIONS: 1. Known or suspected allergy to Paracetamol 2. Previous Paracetamol dose in last 4 hours 3. Children who do not have a sufficient gag reflex to swallow the measured dose 4. Not to be given to children < 1 month old DOSE: 20 mg/kg given orally by 3ml syringe SPECIAL NOTE: It is envisaged that the administration of Panadol Liquid will be for children that are post-ictal / post febrile convulsion, or who are likely to have a febrile convulsion and are not responding to non-medical treatment. Paracetamol does not necessarily prevent febrile convulsions. Active cooling measure should still be carried out as well as checking for the reason for pyrexia (URTI, Meningococcal disease). As a general rule, if children are administered Paracetamol, they should not be left at home. Do not exeed 60mg/kg/24hours 99 Version 4.2 01/10 PRASUGREL (EFFIENT) TYPE: Thienopyridine class inhibitor of platelet activation and aggregation PRESENTATION: Tablet – 10 mg ACTION: Prasugrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the P2Y12 class of ADP receptors on platelets. Peak concentration occurs approximately 30 minutes after dosing. USE: Patients with an acute ST elevation myocardial infarction who meet the requirements for early percutaneous coronary intervention (PCI) procedure. ADVERSE EFFECTS: 1. Purpura 2. Headache 3. Dizziness 4. Stomach disturbances/pain 5. Diarrhoea or constipation CONTRA-INDICATIONS: 1. Hepatic failure 2. Pathologic bleeding 3. Any known or suspected CVA / TIA 4. Weight < 60kg 5. Age > 75 6. Current use of anticoagulants (excluding Aspirin or Clopidogrel), DOSE: 6 x 10 mg tablets (60 mg) – taken orally Not to be dissolved but can be taken with water. SPECIAL NOTE: This treatment should not delay transport time to hospital 100 Version 4.2 01/10 SALBUTAMOL TYPE: (VENTOLIN) Synthetic 2 receptor stimulant [S4] PRESENTATION: Plastic nebules: 5 mg in 2.5ml nebuliser solution 2.5 mg in 2.5ml nebuliser solution ACTIONS: 1. Bronchodilatation 2. Relaxation of involuntary muscle 3. Moves K+ from extra-cellular to intra-cellular space Onset (neb): 5 minutes Max effect: 10 – 50 minutes USES: 1. Bronchospasm from any cause 2. Emergency treatment of suspected hyperkalaemia ADVERSE EFFECTS: Rarely seen with usual nebulised therapeutic doses: 1. Tachycardia 2. Tremors 3. Hypotension CONTRA-INDICATIONS: Known hypersensitivity DOSE Via nebuliser, with Oxygen at 6 – 8 L/minute Adult: Paed: 5 mg nebule 2.5 mg nebule Use MDI/Spacer mild to moderate, no hypoxia and familiar with use Adult >6 yrs 10 x 100mcg (10 puffs) Child < 6 yrs 5 x 100mcg ( 5 puffs) With moderate to severe bronchospasm; or suspected hyperkalaemia give continuous nebulised Salbutamol. SPECIAL NOTE: With significant hypoxia, Salbutamol should be administered with 100% Oxygen. 101 Version 4.2 01/10 SODIUM BICARBONATE TYPE: Hypertonic alkaline solution; 8.4% Sodium Bicarbonate solution; contains 1 mMol/ml Sodium & 1 mMol/ml Bicarbonate. [No schedule] PRESENTATION: 50ml Sodium Bicarbonate solution, IMS Mini-jet ACTIONS: 1. Neutralizes metabolic acidosis as a result of cardiac arrest or poor perfusion 2. Causes movement of K+ into cells – swaps with H+ ions Onset: 30 – 60 seconds (IV) USES: 1. To combat acidosis in prolonged cardiac arrest. 2. For emergency treatment of hyperkalaemia. 3. For treatment of arrhythmias, seizures or coma in Tricyclic antidepressant and Digoxin overdose patients. 4. To combat acidosis and hyperkalaemia in crush syndrome. ADVERSE EFFECTS: 1. Metabolic alkalosis 2. High Sodium content may lead to fluid overload & cardiac failure. 3. Interacts with some other drugs - (especially Calcium & Adrenaline); always flush well through the line before & after administration. Consider a second line. CONTRAINDICATIONS: Known hypersensitivity DOSE: Adult & paediatric: 0.5 mMol/kg IV; repeat x 1 as required Given as a fast push in cardiac arrest; and over 2 – 5 minutes to patients with a cardiac output. 102 Version 4.2 01/10 SUXAMETHONIUM TYPE: Depolarising muscle relaxant [S4] PRESENTATION: Ampoules – 100 mg/2ml Acts like the neurotransmitter Acetylcholine at the neuromuscular junction. Persists for a period long enough to exhaust the motor endplate by prolonged depolarisation. ACTION: Onset: IV: approx 45 seconds Duration: IV: 5 – 7 minutes To facilitate airway management in selected patients with a GCS of less than 9 USE: ADVERSE EFFECTS: CONTRAINDICATIONS: PRECAUTIONS: Bradycardia; Potassium release; increased intraocular & intragastric pressure. Occasionally prolonged paralysis. Has been associated with malignant hyperthermia. Previous reaction to Suxamethonium Suspected hyperkalaemia Elderly patients Neuromuscular disease Care with use in children Select patients carefully; always have a fallback position! 1.5 mg/kg IV; over 30 – 60 seconds DOSE:SPECIAL NOTE: To be used only following completion of the ACTAS designated training programme. Paediatric: Give Atropine 0.01 mg/kg IV prior to Suxamethonium Adults: if heart rate less than 50, give Atropine prior to Suxamethonium (Bradycardia maybe a result of the head injury and raised ICP - thus BP will be elevated. In this case there is no requirement for Atropine regardless of the degree of bradycardia). Prior to administration, give IV Midazolam 0.05 mg/kg Follow up with additional Midazolam after intubation 103 Version 4.2 01/10 DRUG DOSE CALCULATOR DOSE 50 mg/kg CALCULATION NOTES Dose = Weight x 50 10 mg/kg Dose = Weight x 10 5 mg/kg Dose = Weight x 5 4 mg/kg Dose = Weight x 4 1.5 mg/kg Dose = Weight x 1.5 1 mg/kg 1 mMol/kg Dose = Weight 1 0.5 mg/kg 0.5 ml/kg Dose = Weight 2 0.25 mg/kg Dose = Weight 4 0.1 mg/kg Dose = Weight 10 0.05 mg/kg Dose = Weight 20 0.01 mg/kg Dose = Weight 100 104 Maximum dose of: 2g for Ceftriaxone, & 2.5g for Magnesium NOTE: Version 4.2 01/10 DRUG REFERENCE KEY There have been a significant number of both additions & deletions from this list since it was last compiled. 14B = Non Theophylline derivative 14C = Preventative aerosols This listing covers medications that are commonly prescribed in the community, as well as some that may only be used in hospital. It is up to date as of the beginning of 2006. 15 = Oral contraceptives 16 = Corticosteroids 17 = Diuretic (loop) 18 = Diuretic (potassium sparing) 19 = Diuretic (thiazide) Every effort has been made to ensure accuracy however, it is possible transcription errors may have occurred. Care should be taken not to rely totally on this guide. 20 = Diuretic (thiazide analogue) 21 = Anti gout agents 22 = Histamine 2 antagonist 23 = Antilipid agents 24 = Hypnotics It does not include street or illicit drugs. 25 = Hypoglycaemic agents 26 = Insulin preparations 27 = Sedatives 28 = Tranquillisers 29 = Vasodilator Many drugs will have several numbers next to them, as they are used in different clinical settings, or may have these effects when taken in overdose. It does not include antibacterial agents; cytotoxics or immuno-modifying agents. Generally, no drugs given regularly by injection are included (exception insulins). 30 = Antihistamines 31 = Analgesics 32 = Antipsychotic 33 = Angiotensin II antagonist 34 = Antiulcerant agents There are now a number of generic items on the market, with the generic name + the company that produces it as the drug name. e.g. Healthsense Captopril; Diltiazem BC. The generic firms are: BC; Chem Mart; DBL; GenRx; Healthsense; Terry White Chemists; 1 2 3 4 5 35 = Benzodiazepine 36 = Migraine prophylaxis and therapy 37 = Anticonvulsant 38 = Bone & Calcium modifying agent 39 = Hormones 40 = Dementia agents 41 = CNS stimulants 42 = Anticholinergic type agents 43 = Glaucoma preparations 44 = Weight Reducing Agents = Anabolic steroids = Antianginal = ACE inhibitors = Antiarrhythmics = Anticoagulants Product Name ABILIFY ACCOLATE ACCUPRIL ACCURETIC ACENORM ACIMAX ACLIN ACQUIN ACT-3 ACTIFED ACTION ACTIPROFEN ACTIQ ACTONEL ACTOS 6 = Antidepressants 6A = 5HT uptake inhibitor 6B = MAO inhibitor 6C = Tetracyclic 6D = Tricyclic 7 = Antiemetics 8 = Antihypertensives 9 = Anti-inflamatory - non steroidal 10 = Antiparkinson agents 11 = Antiplatelet agents 12 = Beta blockers 13 = Calcium channel antagonists 14 = Bronchodilators 14A = Theophylline derivative 105 Serial Number 32 14 3,8 3,8 3,8 34 9,31 3,8 9,31 30 30 9 31 38 25 Version 4.2 01/10 Product Name ACTRAPID ADALAT ADDOS ADEFIN ADENOCOR ADRONAT ADVIL AERODIOL AERON AGGRASTAT AGON SR AIROMIR AKINETON ALDACTONE ALDAZINE ALDOMET ALENDROBELL ALENDRONATE ALEPAM ALEVE ALLEGRON ALLERMAX ALLOHEXAL ALLOPURINOL BC ALLORIN ALLOSIG ALODORM ALPHAGAN ALPHAPRESS ALPHAPRIL ALPRAX ALPRAZOLAM ALVESCO AMARYL AMFAMOX AMISULPRIDE AMIZIDE ALMO AMLOPIDINE AMPRACE AMYTAL ANAFRANIL ANAGRAINE ANAMORPH ANAPROX ANATENSOL ANDRIOL ANDROCUR Serial Number 26 2,8,13 2,8,13 2,8 4 Product Name ANDRODERM ANDRUMIN ANGELIQ ANGININE ANGIOMAXIN ANPEC ANSELOL ANTENEX ANZEMET APIDRA APOVEN APRESOLINE APRINOX ARATAC ARAVA AREDIA ARICEPT ARIMA ARIPIPRAZOLE ARIXTRA AROPAX ARTANE ARTHREXIN ARTHROTEC 50 ASASANTIN SR ASIG ASMOL ASPALGIN ASTRIX 100 ATACAND ATEHEXAL ATENOLOL BC ATIVAN ATROBEL ATTENTA AURORIX AUSCAP AUSCARD AUSFAM AUSGEM 38 9,31 39 14B 5 2,8,13 14B 10, 42 8,18 28,32 8 38 38 28,35 9 6D 16, 30 21 21 21 21 24,27,35 43 8,29 3, 8 27,28,35 27,28,35 16 25 22,34 32 8,18 13 13 3,8 24 6D 36 31 9,31,35 28,32 39 39 AUSPRIL AUSRAN AVANDAMET AVANDIA AVANZA AVAPRO AVIL AVOMINE 106 Serial Number 39 7 39 2,29 5 2,4,8,13 2,4,8,12 27,28,35 7 26 14B 8,29 8,19 4 9 38 40 6B 32 5 6A 10, 34, 42 9,21,31 9 11, 5 3,8 14B 31 11, 5 33, 8 2,4, 8,12 2, 4, 8, 12 27,28,35 42 41 6B 6A 2,13 22, 34 23 3, 8 34 25 25 6 8,33 30 7 Version 4.2 01/10 Product Name AXIT AYLIDE AZOL AZOPT BARBLOC BECLOFORTE BECONASE BECOTIDE BENADRYL BENZTROP BEROTEC BETAGAN BETALOC BETOPIC BETOQUIN BICOR BIOGLAN BIPHASIL BONDRONAT BONEFOS BRENDA 35 BREVIBLOC BREVINOR BRICANYL BROMOHEXAL BROMOLACTIN BRONDECON BRUFEN BUGESIC BURINEX BUSCOPAN BUSPAR BUTALGIN BUTAMOL BYETTA CABESAR CAFERGOT CALCIJEX CALCITRIOL CADUET CANDYL CAPADEX CAPOTEN CAPTOHEXAL CAPTOPRIL BC CAPURATE CARAFATE Product Name CARBAMAZEPINE CARDINORM CARDIPRIN CARDIZEM CARDOL CARTIA CATAPRES CELEBREX CELESTONE CELICA CELPRAM CHOLSTAT CHLORPROMAZINE CIALIS CIAZIL CIMEHEXAL CIMETIDINE BC CIPRAMIL CITALOBELL CITALOPRAM CITRACAL CITRIHEXAL CLARAMAX CLARATYNE CLARINASE CLEXANE CLIMARA CLIMEN CLINORIL CLOBEMIX CLOMIPRAMINE CLONAC CLOPINE CLOPIXOL CLOPRAM CLOSYN CLOZARIL CODALGIN CODAPANE CODIPHEN CODIS CO-DIOVAN CODOX COGENTIN COGNEX COLESE COLESTID COLGOUT Serial Number 6A 25 39 43 2,4, 8,12 14C,16 16 14C,16 30 10,42 14B 43 2,4,8,12,36 43 43 12 44 15 38 38 15,39 4,12 15 14B 10 10, 39 14A 9,31 9 17 42 28 9,31 14B 25 10 36 38 38 13 9,31 31 3,8 3,8 3,8 21 34 107 Serial Number 32,37 4 11, 5 2,8,13 4,12 11, 5 8,36 9 16 6A 6A 23 32,42 29 6A 22,34 22, 34 6A 6A 20 38 38 30 30 30 5 39 39 9,31 6B 6D 9 32 32 6D 32 32 31 31 31 31 3,8,33 31 10, 42 40 42 23 21 Version 4.2 01/10 Product Name COLOFAC COMBIGAN COMBIVENT COMTAN CONCORZ CORALAN CORAS CORBETON CORDARONE CORDILOX CORTATE COSOPT COUMADIN COVERSYL COZAAR CRESTOR CROMESE CRYSANAL CYMBABLTA CYPRONE CYPROSTAT CYPROHEXAL CYTOTEC DANOCRINE DAONIL DAPA-TABS DECA-DURABOLIN DECANOATE DEMAZIN DEPO DUR DEPO MEDROL DEPO NISOLONE DEPO PROVERA DEPO RALOVERA DEPTRAN DERALIN DERMESTRIL DESERIL DEXAMPHETAMINE DEXAMETHSON DIABEX DIAFORMIN DIAMICRON DIAMOX DIANE DIAPRIDE DIAZEPAM Product Name DIBENYLINE DICLOFENAC DICLOHEXAL DIDROCAL DIDRONEL DIGESIC DIHYDERGOT DILANTIN DILASIG DILATREND DILAUDID DILOSYN DILTAHEXAL DILTIAZEM BC DILZEM DIMETAPP DIMIREL DIMETRIOSE DINAC DINDEVAN DIOVAN DITHIAZIDE DITROPAN DOLAPRIL DOLASED DOLOBID DOLAFORTE DOLOXENE DONNALIX DONNATAB DORMIZOL DOTHEP DOZILE DRAMAMINE DROLEPTAN DUCENE DUPHASTON DURABOLIN DURIDE DUROGESIC DUROMINE DUROTRAM DYMADON DYNASTAT EDECRIN EDRONAX ECOTRIN EFEXOR Serial Number 42 43 14B 10 6A 2 2,13 2,4,8,12 4 2,4,8,13 16 43 5 3,8 8,33 23 14C 9 6A 39 39 39 34 39 25 8 1 32 30 31 16 16 15 15 6D 2,4,8,12,36 39 36 41 16 25 25 25 37, 43 15, 39 25 35 108 Serial Number 29 9 9,31 38 38 31 36 37 8,12 12, 8 31 30 2,13 2, 13 2,13 30 25 39 9 5 33 19 42 3 31 9,31 31 31 42 7, 42 24 6D 27 7 32 27,28,35 39 1 2 31 44 31 31 9 8,17 6A 5,11,31 6A Version 4.2 01/10 Product Name ELDEPRYL ELEMENDOS ELEVA ELMENDOS EMETROL ELMIRON EMEND ENAHEXAL ENALABELL ENALAPRIL ENBREL ENDECRIN ENDEP ENDONE ENIDIN EPAC EPHIDRINE HYDROC. EPILIM ERGODRYL ESIPRAM ESTALIS ESTELLE 35 ED ESTRACOMBI ESTRADERM ESTRADOT ESTROFEM EUTROXSIG EVISTA EXELON EXFORGE EXOLISE EXTINE EZETROL FAMOHEXAL FAMOTIDINE FAVERIN FELDENE FELODIL FELODUR FEMODEN FEMOSTON FEMTRAN FENAC FENAMINE FEXAL FEXO-TABS FIBSOL Product Name FILPRIL FIORINAL FLECATAB FLIXOTIDE FLORINEF FLUANXOL FLUOHEXAL FLUOXEBELL FLUOXETINE BC FLUOXETINE DBL FORADILE FORMET FORTEO FORTRAL FOSAMAX FOSPRIL FOSINOPRIL FRAGMIN FRISIUM FRUSEHEXAL FRUSID GABAHEXAL GABAPENTIN GABARAN GABATINE GABITRIL GANTIN GEMFIBROZIL BC GEMHEXAL GEMIFIBROMAX GENORAL GENOTROPIN GENOX GLIMEL GLUCOBAY GLUCOHEXAL GLUCOMET GLUCOPHAGE GLUCOVANCE GLYADE GOPTEN HALCION HALDOL HELIDAC HEPARIN HUMALOG HUMANOTROPE HUMIRA Serial Number 10 37 6A 37 7 5 7 3, 8 3,8 3, 8 9 17 6D 31 43 14B 14B 32,37 36 6A 39 39 39 39 39 39 39 38 40 13,33 44 6A 23 34 34 6A 9,31 8,13 8,13 15 39 39 9,31 30 30 30 3, 8 109 Serial Number 3,8 31 4 14C16 16 32 6A 6A 6A 6A 14B,14C 25 38,39 31 38 3,8 3,8 5 27,28,35 17 17 37 37 37 37 37 37 23 23 23 39 39 39 25 25 25 25 25 25 25 3,8 35 32 34 5 26 39 9 Version 4.2 01/10 Product Name HUMULIN HYDOPA HYDRENE HYDROCORTISONE HYFORIL HYGROTON HYPNODORM HYPURIN ISOPHANE HYPURIN NEUTRAL HYSONE HYTRIN IBUPROFEN IKOREL IMDUR DURULES IMFLAC IMIGRAN IMPROVIL IMOVANE IMREST IMTRATE SR INDAHEXAL INDAPAMIDE INDERAL INDOCID INDOPRIL INSIG INSOMN INTEGRILIN INTAL INVEGA INZA IOPIDINE IPRATRIN IPRAVENT ISCOVER ISMELIN ISOMONIT ISOPTIN ISOPTO CARBACHOL ISOPTO CARPINE ISORDIL ISOSORBIDE MON. JEZIL JULIET 35 KALMA KALURIL KAPANOL Product Name KARVEA KARVEZIDE KEPPRA KINIDIN DURULES KINERET KINSON KLACID KLIOGEST KLIOVANCE KONAKION KOSTEO KREDEX KRIPTON KWELLS KYTRIL LAMIDUS LAMICTAL LAMITRIN LAMOGINE LAMOTRIGINE LANOXIN LANTUS LARGACTIL LASIX LEGOUT LESCOL LEVEMIR LEVLEN ED LEVOHEXAL LEXAPRO LEXOTAN LIPAZIL LIPEX LIPIDIL LIPITOR LIPOSTAT LIPRACE LIPRACHOL LIQUIGESIC CO LISINOBELL LISINOPRIL LISINOTRUST LISODUR LITHICARB LIVIAL LOCILAN LOETTE LOGICIN Serial Number 26 8 8,18,19 16 3,19 8,20 24,27,35 26 26 16 8 9 2 2 9 36 15 24, 27 24,27 2 8 8 2,4,8,12,36 9,21,31 3,8 8 24,27 11 14C 32 9,31 43 14B 14B 11, 5 29,31 2, 29 2,4,8,13 43 43 2,29 2 23 15, 39 27,28,35 8,18 31 110 Serial Number 8,33 8,33 37 4 9 10 34 39 39 5 38 8,12 10 7, 42 7 37 37 37 37 37 4 26 7,28,32, 40 8,17 21 23 39 15 10 6A 27,28,35 23 23 23 23 23 3,8 23 31 3,8 3,8 3,8 3,8 32 39 15 15 30 Version 4.2 01/10 Product Name LOGYNON LONAVAR LONITEN LOPID LOPRESOR LORASTYNE LOSEC LOVAN LUMIGAN LUMIN LURSELLE LUVOX LYCINATE LYRICA MADOPAR MAGICUL MAOSIG MAREVAN MARVELON MAXOLON MAXOR MEDROXYHEXAL MEFIC MEGACE MELIPRAMINE MELIZIDE MELLERIL MELLIHEXAL MELOXIBELL MENOREST MEPRAZOL MERBENTYL MERSYNDOL METAMAX METFORBELL METFORMIN BC METHYLPHENIDATE METOCLOPRAMIDE METOHEXAL METOPROLOL BC MEXITIL MIACALCIC MICARDIS MICROGYNON MICROLUT MICRONOR MICROVAL Product Name MIDAMOR MINAX MINIDIAB MINIMS PILOCARP. MINIPRESS MINITRAN MINULET MIRENA MIRTAZON MIXTARD MOBIC MOBILIS MOCLOBEMIDE MODAVIGIL MODECATE MODURETIC MOGADON MOHEXAL MONACE MONODUR DURULES MONOFEME MONOPLUS MONOPREM MONOPRIL MONOTARD MORPHALGIN MOTILIUM MOVALIS MOVELAT MOVOX MOXICAM MS CONTIN MS MONO MURELAX MYSOLINE NAPAMIDE NAPROGESIC NAPROSYN NARAMIG NARDIL NASONEX NATRILIX NAVANE NAVOBAN NEUPRO NEO-MERCAZOLE NEO-SYNEPHRINE NEULACTIL Serial Number 15 1 8 23 2,4,8,12,36 30 34 6A 43 6C 23 6A 2 37 10 22, 34 6B 5 15 7 34 15 9,31 39 6D 25 28,32 25 9 39 34 42 31 36 25 25 41 7 2,4,8,12,36 2,4,8,12,36 4 38 8,33 15 15 15 15 111 Serial Number 8,18 2,4,8,12,36 25 43 8 2,29 15 15, 39 6B 26 9 9,31 6B 41 28,32 8,18,19 24,27,35 6B 3 2 15 3,8 39 3,8 26 31 7 9 9 6B 9 31 31 27,28,35 37 8 9,31,36 9,31,36 36 6B 16 8 32 7 10 39 43 28,32 Version 4.2 01/10 Product Name NEUTRAL PILOCARP. NEURONTIN NEXIUM NICOTINIC ACID NIDEM NIFECARD NIFEDIPINE BC NIFEHEXAL NIMOTOP NITRO-DUR NITROLINGUAL SPRAY NITROSTAT NIZAC NORDETTE NORDITROPIN NORFLEX NORGESIC NORIDAY NORIMIN NORINYL NORMISON NORSPAN NOLVADEX NORVASC NOTEN NOVARAP NOVNORM NOVONORM NOVOMIX NOVORAPID NUELIN NUPENTIN NUROFEN NUROLASTS NYEFAX ODRIK OGEN OLMETEC OMEPRAL OMEPRAZOLE OMNITROPE ONDAZ OPTIMOL ORAP ORAP ORDINE ORGARAN Product Name OROXINE ORUDIS ORUVAIL SR OSPOLOT OSSMAX OVESTIN OXANDRIN OXETINE OXIS OXYCONTIN OXYNORM OZLODIP PALFIUM PAMACID PAMISOL PANACORT PANAFCORTELONE PANAFEN PLUS PANALGESIC PANAMAX PARACODIN PARADEX PARAHEXAL PARALGIN PARIET PARLODEL PARNATE PAROXETINE PAXAM PAXTINE PEETALIX PENDINE PEPCID PEPCIDINE PEPZAN PERIACTIN PERINDO PERINDOPRIL PERIVASC PERMAX PERSANTIN PEXSIG PHENOBARBITONE PHENERGAN PHOSPHATE-SANDOZ PHYSEPTONE PHYSIOTENS PILOCARPINE Serial Number 43 37 34 23 25 8,13 8,13 8,13 13 2,29 2,29 2 22,34 15 39 43 43 15 15 15 24,27,35 31 39 2,8,13 2,4,8,12 26 25 25 26 26 14A 37 9,31 9,31 8,13 3,8 39 33 34 34 39 7 43 28,32 28,32 31 5 112 Serial Number 39 9,31 9,31 37 38 39 1 6A 14B,14C 31 31 2,8,13 31 34 38 16 16 9 31 31 31 31 31 31 34 10 6B 6A 35,37 6A 30 37 22,34 22,34 34 30,36 3,8 3,8 2,8,13 10 5,11,29 2 37 7,27,30 38 31 8 43 Version 4.2 01/10 Product Name PILOPT PROPINE PIROHEXAL PIROXICAM PLACIL PLAVIX PLENDIL POLARAMINE PONSTAN PRAMIN PRASIG PRATSIOL PRAVACHOL PRAVASTATIN PRAZOHEXAL PRAZOSIN BC PREDMIX PREDSOLONE PREGNYL PRESOLOL NYOGEL PREMARIN PREMIA 5 PRESOLOL PRESSIN PREXIGE PRILACE PRIMOBOLAN PRIMOLUT PRINIVIL PRITOR PROCID PRO-BANTHINE PROBITOR PROCUR PRODEINE PROGOUT PROGYNOVA PROLODONE PROMETHAZINE PRONESTYL PROPYLTHIOURACIL PROTAPHANE PROTHIADEN PROTOS PROVERA PROVEN Product Name PROVIRON PROXEN PROZAC PULMICORT P.V. CARPINE PYRALIN QUESTRAN LITE QUILONUM SR QUINAPRIL QVAR RAFEN RALOVERA RAMACE RAMIPRIL RANI RANIHEXAL RANSIM RANITIDINE DBL RANOXYL RANZEPAM RAPIFEN REDIPRED REDUCTIL REFLUDAN REGITINE REMERON REMINYL RENITEC REOPRO RESPOCORT RESTAVIT RHINOCORT RISPERDAL RITALIN RITHMIK RIVOTRIL ROCALTROL ROSIG RUBESAL RYTHMODAN SABRIL SAIZEN SANDOMIGRAN SANDRENA SEAZE SELGENE SEQUILAR ED Serial Number 43 43 9,31 9 6D 5,11 8,13 30 9,31 7 8 8 23 23 8 8 16 16 39 8,12 43 39 39 8,12 8 31 2,3 1 39 3,8 8, 33 21 42 34 39 31 21 39 31 30 4 39 26 6D 38 39 9,31 113 Serial Number 39 9,31 6A 14C,16 43 9 23 32 3,8 14C,16 9,31 39 3,8 2,3 22,34 34 23 22,34 34 35 31 16 44 5 29 6A 40 3,8 5 16 27 16 32, 40 41 4 37 38 9,31 9 4 37 39 36 39 37 10 15 Version 4.2 01/10 Product Name SERC SERENACE SEREPAX SERETIDE SEREVENT SEROQUEL SERTA SERTRALINE SERTATRUST SETRONA SETACOL SETAMOL SEVREDOL SICAL SIFROL SIGMAXIN SIGMETADINE SIMVABELL SIMVAHEXAL SIMVAR SIMVASTIN SIMVATRUST SINEASE SINEMET SINEQUAN SINGULAIR SITRIOL SKELID SNUZAID SODIUM OIDIDE SOLAVERT SOLIAN SOLONE SOLPRIN SOMAC SOMIDEM SONE SORBIDIN SOTACOR SOTAHEXAL SOTALOL BC SPIRACTIN SPIRIVA SPREN STALEVO STELAZINE STEMETIL Product Name STEMZINE STILDEM STILNOX SUBLIMAZE SUMAGRON SUMATAB SURGAM SURMONTIL SUSTANON SUVULAN SYMBICORT SYMMETREL SYNAREL SYNPHASIC TACIDINE TAGAMET TALAM TALOHEXAL TAMBOCOR TARKA TAZAC TEGRETOL TELFAST TELNASE TEMAZE TEMGESIC TEMTABS TENOPT TENORMIN TENSIG TENSODENINE TENUATE TERIL TERTROXIN TETRABENAZINE TEVETEN THEO-DUR TICLID TICLOPIDINE HEXAL TILADE TILCOTIL TILODENE TIMOPTOL TIMPILO TITRALAC TOFRANIL TOLERADE TOLVON Serial Number 29,30 7,28,32 27,28,35 14B,14C 14B,14C 32 6A 6A 6A 6A 42 31 31 38 10 4 22,34 23 23 23 23 23 30 10 6D 14 38 38 27 39 4, 12 32 16 5,11,31 34 24 16 2,29 4,12 4,12 4, 12 8,18 14C 11,31 10 7,28,32 7,32 114 Serial Number 7,32 24 24 31 36 36 9,31 6D 39 36 14C 10 39 15 34 22,34 6A 6A 4 2,4, 8,13 22,34 32,37 30 16 24,27,35 31 24.27,35 43 2,4,8,12 2,4,8,12 31 45 32,37 39 43 8, 33 14 5,11 5,11 14C 9 5,11 43 43 34 6D 6D 6C Version 4.2 01/10 Product Name TOPACE TOPAMAX TOPROL TORADOL TRAMAL TRANALPHA TRANDATE TRANDOLAPRIL TRANSIDERM-NITRO TRAVACALM TRAVATAN TRYZAN TRENTAL 400 TRI PROFEN TRIASYN TRIFEME TRILEPTAL TRIPHASIL TRIQUILAR TRISEQUENS TRITACE TRUSOPT TRYPTANOL TYLENOL ULCAID ULCYTE ULTAC ULTRATARD UNISOM UREMIDE UREX VALIUM VALLERGAN VALPAM VALPRO VASOCARDOL CD VASTORAN VASTIN VEGANIN VERACAPS VIAGRA VIOXX VISKEN VOLFAST VOLTAREN VOXAM VYTORIN Product Name XALACOM XALATAN XANAX XYDEP XYLOCARD XYVION YASMIN YAZ ZACTIN ZADINE ZAMHEXAL ZAN EXTRA ZANIDIP ZANTAC ZARONTIN ZELDOX ZENICAL ZESTRIL ZIMSTAT ZOCOR ZOFRAN ZOLOFT ZOMIG ZOLIBELL ZOLPIDEM ZOMETA ZOTON ZUMENON ZYDEP ZYLOPRIM ZYDOL ZYPREXA Serial Number 3, 8 35,37 12 9 31 3,8 8,12 3,8 2,29 7,42 43 3,8 11 9,31 3,8,13 15 37 15 15 39 3,8 43 6D 31 34 34 34 26 24,27 8,17 8,17 27,28,35 27,30 35 32,37 2,8,13, 33 23 23 31 2,8,13 29 9 2,4,8,12 9,31 9,31 6A 23 115 Serial Number 43 43 27,28,35 6A 8 39 15 15 6A 30 27,28,35 3,8,13 8, 13 22,34 37 32 44 3,8 23 23 7 6A 36 24 24 38 34 39 6A 21 31 32 Version 4.2 01/10 PATIENT ASSESSMENT GENERAL APPROACH AND TREATMENT Initial Assessment Initial Treatment Secondary Assessment Secondary Treatment Alert Danger Response Voice Formal GCS Pain Unconscious ETT Chin lift; head tilt; jaw thrust; Airway + Cervical spine care Hold head still. Suction; Cervical collar clear airway KED Oral / nasal airway Board / scoop Respiratory rate Look, Listen, Feel. Breathing Circulation I.P.P.V. Pulse oximetry Oxygen Breath sounds Control bleeding Cardiac compressions Pulse rate Central pulse ECG Monitor BP Skin signs D.C.C.S. Analyse ECG Pleural decompression Stabilise flail segment IV Fluids Cannula History of: Full history Event Patient Bystanders Utilise bystanders Drugs Transport Expose injuries Assess time critical 116 Bring relatives along Formal drug therapy BGL Call backup if required Obtain medications Prepare for transport Transport Notify hospital Version 4.2 01/10 TIME CRITICAL PATIENT GUIDELINE The following patients can be considered actually or potentially Time Critical. This requires a minimum scene time, treatment en-route wherever possible and prompt transport to a designated Trauma Centre for trauma patients. This is a guideline only, and does not represent a complete and exclusive list of time critical patients. 1: TRAUMA PATIENTS Vital signs: adults (Actual time critical indicators) Respiratory distress (rate > 29, or < 10/minute), or Altered L.O.C. (GCS < 13), or Hypotensive (systolic BP < 90mmHg), and/or Revised Trauma Score < 12 Pattern of injury: (Actual time critical indicators) Penetrating injury – head; neck; torso; axilla, groin Amputation above the wrist or ankle Fractures to TWO or more proximal long bones, or a fractured pelvis Suspected crush syndrome Paralysis or significant weakness of limbs “Significant” injury to single body region (e.g. head, abdomen, chest), or “lesser” injuries to 2 or more body regions Burns > 10% body surface; “special” areas (e.g. eyes, genitals; or respiratory tract involvement) continues over 117 Version 4.2 01/10 Mechanism of injury: (Potential time critical indicators) 2: Motor vehicle - high speed (> 60 kph), with significant intrusion into passenger compartment - rollover - patient ejected from vehicle - death / serious injury of another occupant - trapped, with actual extrication time > 20 minutes. Pedestrian struck by a vehicle at > 30 kph Pedal / motorcyclist impact speed > 30 kph Other Fall > twice patient height Struck by object falling > 5m (related to weight of object) Explosion / blast OTHER PATIENTS chest pain suggestive of ischaemia stroke unrelieved upper airway obstruction acute hypoxia, unresponsive to treatment aortic aneurysm or dissection deteriorating L.O.C. (from any cause) worsening hypotension (from any cause) heatstroke or significant hypothermia significant arrhythmias, unresponsive to treatment prolapsed umbilical cord or complicated labour generalised seizures, unresponsive to treatment Carbon Monoxide poisoning with decreased L.O.C. Cardiac arrest in advanced pregnancy (gestation > 20/52) Modifying factors for all time critical patients: age < 5 yrs or > 60 yrs previous medical conditions lack of response to current treatment 118 Version 4.2 01/10 GUIDE TO SUICIDE RISK ASSESSMENT SUICIDE RISK QUESTIONS MEANS: Is the method available? METHOD: Is the method lethal? Level of detail? PLANS: Rehearsals? Time/Date? Place? INTENT: Plans to carry through? Plans to actually die? THOUGHTS: Anxious Turmoil? Worthlessness? Hopelessness? SUPPORTS: Friends? Family? Case Worker? Social Worker? HISTORY: Personal/Family History? Previous Attempts? Other Illness? 119 Version 4.2 01/10 GUIDE TO MENTAL HEALTH STATUS ASSESSMENT APPEARANCE Grooming, Posture, Build, Clothing, Cleanliness BEHAVIOUR Eye Contact, Mannerisms, Gait, Activity Level SPEECH Rate, Volume, Pitch, Tone Flow, Pressure MOOD Emotion as described: Anxious, Depressed, Cheerful AFFECT Emotion as observed: Restrictive, Blunted, Labile THOUGHT FORM Amount, Rate, Derailment, Flight of ideas THOUGHT CONTENT Disturbance, Delusions, Suicidal, Obsessions PERCEPTION Illusions, Thought Insertion/Broadcasting, HallucinationsAuditory, Olfactory, Tactile, Visual or Gustatory INSIGHT & JUDGEMENT Cognition, understanding of illness, its causes & effect 120 Version 4.2 01/10 A.C.T. AMBULANCE SERVICE MENTAL COMPETENCY ASSESSMENT – APPLICATION GUIDELINES (For patients refusing Ambulance care or treatment where there is a known or suspected medical condition causing concern) 1: Was patient assessed in accordance with the ACTAS patient assessment standard? (if not – document why) YES / NO 2: Has the medical condition or concern been fully explained to the patient, including – level of concern; alternatives & options; risks / consequences of their decision? (if not – document why) YES / NO 3: Does the patient acknowledge and appear to comprehend the information given to them? YES / NO (i.e. Are they able to repeat it back to you in their own words?) 4: Is the patient able to accurately recall this information when asked after a period of time (approx 5 – 10 mins later)? YES / NO 5: Does the patient communicate in a consistent manner on the issues of the medical condition, over the ambulance contact time? YES / NO All yes = the patient is most likely to have the capacity to make an informed decision 1 x „No” = the patient may not be competent 2 or more “No” = a higher likelihood patient is not competent (or they are uncooperative!) FULLY DOCUMENT THE RESULTS OF THIS PROCESS! 121 Version 4.2 01/10 APGAR SCORE SCORE 0 1 2 Colour Blue / pale Pink: Extremities blue Completely pink Respiration Absent Slow: irregular Good; crying Heart Rate Absent Below 100 Above 100 Muscle Tone Limp Some flexion of extremities Active motion Reflex Irritability No response Grimace Vigorous cry, cough, sneeze Assess Apgar score at 1minute and 5 minutes after birth 122 Version 4.2 01/10 A.C.T. AMBULANCE SERVICE - PAEDIATRIC REFERENCE CARD Age Weight (kg) Resps Heart Rate Systolic BP Neonate 6 months 3.5 7 11 13 17 21 25 30 36 30 – 60 25 – 40 20 – 40 20 – 35 20 – 30 15 – 25 15 – 25 14 – 20 14 – 20 90 – 150 100 – 175 90 – 170 85 – 140 80 – 140 70 – 120 70 – 110 60 – 110 60 - 100 50 – 70 60 – 100 60 – 100 70 – 110 70 – 110 60 – 110 60 – 115 60 – 120 65 – 120 12 months 2 years 4 years 6 years 8 years 10 years 12 years E.T.T. size (mm) 3 3.5 4 4.5 5 5.5 6 6.5 7 E.T.T. Length (cm) 14 14 14 14 16 17 19 20 21 Fluid 10ml/kg Defib 2 j/kg Defib 4 j/kg 35 70 110 130 160 200 250 280 380 5 20 20 30 30 50 50 50 100 20 30 50 50 50 100 100 100 150 All values are approximate only Weight formula Age < 9 years: Age > 9 years E.T.T. Size: Age Approx weight (kg) = (age x 2) + 9 Approx weight (kg) = age x 3 /4 + 4 = diameter in mm E.T.T Length: Age /2 + 15 = length in cm Fluid resuscitation 10 ml/kg bolus - Normal Saline Thereafter – Normal Saline bolus DO NOT use pump set in children under 15 kg - use 3-way tap and syringe Defibrillation Rounded off to closest energy setting References - Paediatric Fluid Reference Card – Children‟s Hospital of Pittsburgh - Drug Doses in Paediatrics – Royal Children‟s Hospital – Melbourne 123 Version 4.2 01/10 PEEP VALUES 5 cm 10 cm 15 cm Cardiac arrest for adults, infants & children Maximum level for infants & children Final level for: Intubated patients Next level for: (not if suspected raised ICP, and if O2 sats > 90%) Start level for: - pulmonary oedema - near drowning - CO poisoning - asthma - CAL - pulmonary oedema - near drowning - CO poisoning - asthma (max) - CAL (max) - pulmonary oedema - near drowning - CO poisoning only if still desaturated with 10cm if not responding to 5cm 124 Version 4.2 01/10 ACT AMBULANCE SERVICE SPINAL IMMOBILISATION LOW RISK ASSESSMENT FLOWCHART 1: Patient mentation Decreased level of consciousness? No Alcohol / drug impairment? ▪ Yes Immobilise No Loss of consciousness involved? ▪ Yes Immobilise ▪ Yes Immobilise ▪ Lumbar spinal pain? ▪ Yes No 2: Subjective assessment ▪ Cervical ▪ Thoracic No Numbness / tingling / weakness No 3: Objective assessment ▪ Cervical ▪ Thoracic Immobilise or burning sensation? ▪ Yes Immobilise ▪ Lumbar spinal tenderness? No Other painful injury or significant distraction? ▪ Yes Immobilise No Pain with spine range of motion? # ▪ Yes Immobilise ▪ Yes Immobilise No MAY TRANSPORT WITHOUT SPINAL IMMOBILISATION # Range of motion is only to be checked if all other criteria are negative! NOTE:Exercise care if a patient is seen very soon after the event. - Significant distraction can be something other then a physical injury – e.g. significant injury to a loved one or significant damage to car - Recheck the patient before clearing, if not transporting. Your clinical judgement may still be exercised to utilise spinal immobilisation, even if the algorithm clears the patient. Pre-existing spinal disease and older age should increase the level of suspicion even with a clear process. 125 Version 4.2 01/10 Spinal Cord Injury It is vital to carry out motor and sensory examinations as the patient may have motor damage without sensory damage and vice versa. Sensory Examination The level at which sensation is altered or absent is the level of injury. Examine the patient with light touch and response to pain. Use the forehead as a guide to what is normal sensation. When conducting the examination ensure you check both upper limbs and hands and both lower limbs and feet. T4 examination must be carried out in the mid-axillary line and not the midclavicular line as C2, C3 and C4 all provide sensation to the nipple line. Motor Examination Upper limb motor examination 1. 2. 3. 4. Lower limb motor examination Shrug shoulders C4 Bend the elbow C5 Push wrist back C6 Open/close hands C8 Flex hip Extend knee Pull foot up Push foot down L1 & L2 L3 L4 L5 & S1 For thoracic and abdominal motor examination, look for activity of the intercostal and abdominal muscles. Diagnosis of spinal cord injury in the unconscious patient 1. Look for diaphragmatic respiration. A quadriplegic has lost intercostal muscles and relies on the diaphragm to breathe. 2. Flaccid limbs. 3. Loss of response to painful stimuli below the level of the lesion. 4. Loss of reflexes below the level of the lesion. 5. Erection in the unconscious male. 6. Low BP (Systolic less than 100) associated with a normal pulse or bradycardia indicates that the patient MAY be a quadriplegic. 126 Version 4.2 01/10 DIFFERENTIATION OF WIDE COMPLEX TACHYCARDIAS. The more of these present, greater the chance of VT. If in doubt, treat as VT, especially if sick. 1: History of: - Ischaemic heart disease - Cardiac failure - Cardiomyopathy + increasing age 2: Atrio-ventricular dissociation 3: Capture beats or fusion beats 4: Very wide QRS (> 0.14secs) 5: Bizarre or extreme axis = VT (a positive complex in AVR strongly supports this) 6: Negative concordance across chest leads = VT Positive concordance tends towards VT Non-concordance = 50:50 7: V1 - monophasic R, or biphasic RS - taller left (initial) peak on “rabbits ears” = VT; - if second peak is taller = 50:50 - “fat” initial R wave (0.04 secs or >) lean towards VT 8: V6 - monophasic QS or - biphasic QR - suggests VT 9: Triphasic V1 & V6 = < 10% VT 127 Version 4.2 01/10 128 Version 4.2 01/10 MAXIMUM Q – T INTERVALS Heart Rate (per min) 300 250 214 187 166 150 136 125 115 107 100 93 88 83 78 75 71 68 65 62 60 57 55 52 51 50 48 46 45 43 42 41 40 39 38 37 36 35 34 33 32 31 30 Maximum Q-T Interval (sec) (Males) (Females) .19 .21 .22 .24 .25 .27 .28 .29 .30 .31 .33 .34 .35 .36 .37 .38 .38 .39 .40 .41 .42 .43 .44 .44 .45 .46 .47 .48 .48 .49 .50 .50 .51 .52 .52 .53 .54 .55 .56 .56 .58 .58 .59 .19 .21 .23 .24 .26 .27 .29 .30 .31 .32 .33 .34 .35 .36 .37 .38 .39 .40 .41 .42 .43 .44 .45 .46 .46 .47 .48 .49 .49 .50 .51 .52 .52 .53 .54 .54 .55 .56 .57 .58 .59 .60 .61 129 Version 4.2 01/10 12 Lead ECG Placement 130 Version 4.2 01/10 15 Lead ECG Placement Post 12-lead ECG 1. Locate V4R position: 5th intercostal space; right side mid-clavicular line. 2. Move V1 lead to V4R position 3. Locate V8 position: in line with the anterior 5th intercostal space mid scapular line 4. Move V5 lead to V8 position 5. Locate V9 position: in line with V8 position left paraspinal border 6. Move V6 lead to V9 position 7. Acquire 15 lead ECG: Press “on” Insert the limb lead and the precordial lead attachments into the main cable. Insert the cable connector into the green connector on the monitor. Encourage the patient to remain as still as possible. Press 12 lead 12 lead/age menu appears Select age 8. Monitor will detect and print the 15 lead ECG 9. Re-label the 3 altered leads on ECG strip 131 Version 4.2 01/10 A.C.T. Ambulance Service STEMI Bypass Flow chart 1: Identified STEMI patient by Intensive Care Paramedic (ICP) via 12 lead ECG and appropriate clinical evidence 2: Transmit ECG to TCH ED with phone number attached 3: ECG to be reviewed by Admitting Officer (AO) 4: AO to call back transmitting phone number within 5 minutes 5: No call back from AO within 5 minutes.... Proceed to TCH; Patient to be treated according to STEMI by-pass guidelines Complete check list! 6: Confirmation from AO.... Proceed to TCH; Patient to be treated according to STEMI by-pass guidelines 7: Unclear decision between AO & ICP.... Proceed to TCH; treat according to normal ACTAS guidelines Complete check list! Complete check list! 8: Ambulance to radio TCH ED to alert them of STEMI patient and time to hospital 9: On arrival at TCH ED.... AO to review patient. Decision made whether ACTAS takes patient straight to catheter lab or offloads in ED. 132 Version 4.2 01/10 A.C.T. Ambulance Service STEMI Bypass Check List PATIENT DETAILS Surname Age Given name Case number Date INDICATIONS – if answer is NO or UNSURE to ANY of the following, do NOT administer Heparin, Prasugrel or Clopidogrel. Discuss with A/O Symptoms less than 6 hours duration? 12 lead ECG, with ST elevation in 2 contiguous leads, ≥ 1 mm in limb leads, &/or ≥ 2 mm in chest leads? Systolic BP less than 180mmHg? Diastolic BP less than 110mmHg? GCS = 15? CONTRA-INDICATIONS for PRASUGREL If yes - move to Clopidogrel Known allergy to prasugrel Age over 75 years Weight under 60kg ANY history of TIA / CVA (or unable to reliably ascertain) CONTRAINDICATIONS for CLOPIDOGREL or HEPARIN Known allergy to heparin or clopidogrel Current use of anti coagulants (excluding aspirin or clopidogrel) Pregnancy or delivery in last 2 weeks Active pathologic bleeding of any origin Severe renal or hepatic disease Head injury or facial trauma in the last 3 months Non compressible vascular punctures? Clotting problem (haemophilia etc)? Yes No Unsure Yes No Unsure Officer name:………………………………………. Signature:………………………. Contra- indications may be relative rather than absolute. Discuss with Admitting Officer during phone call back. This completed form must be submitted with the review (2nd) copy of the ACTAS PCR. 133 Version 4.2 01/10 Acute Myocardial Infarction >1mthe limb leads and >2mm in the V leads in >2 consecutive leads • Acute Myocardial injury presents as raised ST • Commonly this is an acute ischaemic injury. • Significant ST elevation >1mm in the limb leads and >2mm in the V leads in greater than 2 contiguous leads • Infarction can present as pathological Q wave (older sign of full thickness infarction - >= .04 wide; deeper than 25% of height of R wave). • Infarction may also present with T wave changes inverted large, “hyperacute”. • ST depression may indicate myocardial ischaemia; occasionally myocardial infarction. • ECG changes + reliable or suspicious clinical story may indicate myocardial ischaemia/infarction. I Lateral aVR V1 Septal V4 Anterior II Inferior aVL Lateral V2 Septal V5 Lateral III Inferior aVF Inferior V3 Anterior V6 Lateral 134 Version 4.2 01/10 INFARCTION OVERVIEW SITE INDICATIVE LEADS Inferior II, III, aVF Septal V1 - V2 Anterior V3 – V4 Antero-septal V1 – V4 Lateral I, aVL, V6 (V5) Antero-lateral I, aVL, V3 – V6 Right ventricular V3R, V4R, V5R, V6R (usually seen with inferior changes) Posterior “Reciprocal” changes in anterior leads Indicative changes V 8, V 9 135 Version 4.2 01/10 INFERIOR AMI 136 Version 4.2 01/10 ANTERO-SEPTAL AMI 137 Version 4.2 01/10 ANTERO-LATERAL AMI 138 Version 4.2 01/10 LATERAL AMI 139 Version 4.2 01/10 RIGHT VENTRICULAR AMI 140 Version 4.2 01/10 POSTERIOR AMI (1) STANDARD 12 lead ECG 141 Version 4.2 01/10 POSTERIOR AMI (2) V7 – V9 LEADS 142 Version 4.2 01/10 RIGHT BUNDLE BRANCH BLOCK 143 Version 4.2 01/10 LEFT BUNDLE BRANCH BLOCK 144 Version 4.2 01/10 USES OF CAPNOGRAPHY (ACTAS) Verify initial position of ETT Monitor continuing tracheal position of ETT Assist in assessment of adequacy of chest compressions Assist with confirmation of ROSC Aid in determination of cessation of resuscitation efforts Monitor effective IPPV in patients with critical CO2 requirements MONITORING PROCEDURE 1. Open CO2 connector door, connect Microstream tubing by turning clockwise. (The monitor will sense the presence of the tubing and activate the ETCO2 function automatically. Self-test, auto-zeroing and warm up may take up to 2 ½ minutes) 2. Connect the tubing to the patient (proximal to bacterial filter is preferred) 3. Display ETCO2 waveform on Channel 3 4. Adjust scale if required Monitor is configured to “Autoscale”. This means that the monitor will overselect the scale based on the measured ETCO2 measurement. The ETCO2 is displayed in mmHg. A respiratory rate is also displayed. (No respiratory rate is displayed if the ETCO2 is less than 8mmHg. The waveform is still valid). NOTE: Rapid altitude changes may cause the machine to attempt to purge the tubing. If this occurs, disconnect the tubing briefly from the monitor, and then reconnect it. 145 Version 4.2 01/10 INTERPRETATION OF RESULTS It is important to utilise the waveform to assist in interpretation of information, not just relying on the numerical reading. NOTE: PACO2 is generally 3 mmHg higher than ETCO2. Critical values in critical patients: Cardiac arrest: ETCO2 consistently above 15 mmHg seems to have some positive correlation with ROSC. Patients with acute intracranial pathology: PA CO2 should be in range of 30 – 45 mmHg ETCO2 should be in range of 27 – 40 mmHg. DOCUMENTATION OF RESULTS Serial ETCO2 readings may be recorded in the appropriate section of the ACTAS PCR. Waveform printouts (important for verification of ETT placement) may be attached to the PCR from either a screen print or the code summary. ETCO2 values will be included in the vital signs summary printout for later reference. 146 Version 4.2 01/10 Wave Forms 147 Version 4.2 01/10 RESPIRATORY STATUS AND PERFUSION ASSESSMENT NORMAL RESPIRATORY DISTRESS (#) General appearance Calm, quiet, not anxious Distressed, anxious, obviously fighting for breath, exhausted. Decreased level of consciousness Speech Normal sentences, with no difficulty Short sentences phrases words only none (heard without a stethoscope) Quiet, no noises Cough Audible wheeze on exhalation; “Crackly” moist sounds; Inspiratory stridor. Chest auscultation Quiet, no wheezes or crackles Wheeze: expiratory; occ inspiratory as well Crackles fine coarse; bases mid zone full field Silent chest – one side, or bilateral Respiratory rate Adults: 12 – 16 / minute Kids: 15 – 25 / minute Babies: 20 – 40 / minute Tachypnoea - adults > 24 / min - kids > 35 / min - babies > 50 / min Respiratory effort Minimal apparent effort; small chest / abdo movement Marked chest / abdo movement; use of accessory muscles; intercostal recession; sternal retraction; tracheal tug (NOTE: chest movement may be minimal with some conditions) Adults: 60 – 80 / min Kids: 80 – 120 Babies: 100 – 140 (*)Tachycardia - adults > 100 / min - kids > 130 - babies > 150 Respiratory Noises Pulse rate (slow pulse rate is a late sign in severe cases) Skin Pink; normal Sweaty; sometimes pale May be flushed Cyanosis is a late sign Conscious state Alert; orientated Altered Oximetry 96% + on room air 90 – 95% on room air; < 90% = serious hypoxia NOTE: This assessment applies to patients with respiratory distress from any cause (#) Any of these features may indicate respiratory distress. The more that are present, the greater the degree of respiratory distress. (*) Some patients, especially older patients, may be on medication that prevent the development of tachycardia. 148 Version 4.2 01/10 RULE OF NINES FOR ADULTS 149 Version 4.2 01/10 Relative Percentage of Body Surface Area affected by Growth AREA Age 0 1 5 10 15 ADULT A = ½ of head 9½ 8½ 6½ 5½ 4½ 3½ B = ½ of one thigh 2¾ 3¼ 4 4½ 4½ 4¾ C = ½ of one leg 2½ 2½ 2¾ 3 3¼ 3½ 150 Version 4.2 01/10 NORMAL BLOOD VALUES Arterial Blood Gases: pH PaO2 PaCO2 O2 content CO2 content 7.36 - 7.44 85 - 100 mm Hg 36 - 44 mm Hg 20 - 21 vols% 48 - 50 vols% Biochemistry: Sodium Potassium Calcium Magnesium Bicarbonate Creatinine Urea Glucose 134 – 146 mMol/l 3.4 – 5.0 mMol/l 2.25 – 2.65 mMol/l 0.7 – 1.1 mMol/l 22 – 28 mMol/l 50 – 120 mMol/l 3.0 – 8.0 mMol/l 3.9 – 6.2 mMol/l (fasting) Haematology: Haemoglobin Haematocrit Red cell count White cell count Platelet count Male: 130 – 180 g/l Female: 120 – 160 g/l Male: 42 – 52% Female: 37 – 48% 4.2 – 5.8 million 4.3 – 10.8 thousand 150 – 350 thousand 151 Version 4.2 01/10 EXTERNAL PACING PROCEDURE Indications: Bradycardia with poor perfusion: - unresponsive to Atropine or IV fluids; or - where IV access cannot be obtained. (Pacing is preferred over an Adrenaline infusion for post cardiac arrest bradycardia). Procedure: 1: Explain procedure to the patient and family 2: Set up Adrenaline infusion, if IV access obtained 3: Ensure ECG electrodes are well off the chest 4: Prepare skin for pacing electrodes (clip - no shaving; no alcohol) 5: Anterior electrode in approx V2 V3 12 lead position, horizontally (Avoid the nipple, sternum & diaphragm) 6: Posterior electrode at (L) vertebral edge, below bony prominence of scapula, vertically 7: Set current at 0mA, demand mode, rate approx 50% over initial bradycardia 8: Ensure pacer is sensing (markers on QRS complexes) 9: Slowly increase current output in 5mA increments (use selector wheel) until electrical capture occurs (rarely under 60mA) 10: Ensure electrical capture (change in QRS; wide QRS; big T wave) 11: Check mechanical capture (pulse; ↑ LOC; ↑ BP) 12: Increase current output by 5mA over initial capture value 13: 14: Ensure analgesia is provided (use alternating small doses of Midazolam / Morphine) Continue to check electrical and mechanical capture 15: Adjust rate and current output as required 152 Version 4.2 01/10 153 Version 4.2 01/10 154 Version 4.2 01/10 155 Version 4.2 01/10 ACCESS TO BUSES &COACHES Roof hatches (emergency exits) Off-side Window Emergency Exit (towards rear on the Driver‟s side) Rear Window Emergency Exit (if fitted) Rear-mounted engine Batteries on other side at REAR on most coaches or buses, Batteries are located near the engine. The fuel tank is usually mounted here for rear engine coaches (However, for mid or front engines, the tank is towards the rear) External Emergency Release valves or switches under bumper 156 Version 4.2 01/10 157 Version 4.2 01/10 158 Version 4.2 01/10 159 Version 4.2 01/10 AMBULANCE ROLES AT A MASS CASUALTY INCIDENT (MCI) MCI = Greatest Good for Greatest Number FIRST AMBULANCE CREW ON SCENE Approach the incident with safety. Park the ambulance in a safe and upwind location. Wear all protective equipment provided by ACTAS. (e.g. safety glasses, gloves, safety vest and helmet) Assess the situation and send a SITREP to the Ambulance Commander or the ACTAS Communication Centre (if the Ambulance Commander is not on scene). M - Message (“I am notifying a major incident - standby for SITREP”) E - Exact location T - Type of incident H - Hazards (present and potential) A - Access to the area N - Number of casualties (actual or estimated) E - Emergency services (present or required) If greater than six (6) casualties, assume the roles of Triage Officer and Transport Control Officer 160 Version 4.2 01/10 MCI = Greatest Good for Greatest Number TRIAGE OFFICER The Triage Officer role is undertaken by the most clinically experienced Intensive Care Paramedic on scene. They assume responsibility for casualty triage, collection and clinical management (patient care) at the incident site. 1. Initiate Triage by quickly assessing, prioritising and labeling casualties (DRABC & move on). 2. Direct and control supporting Ambulance Officers to casualties. 3. Maintain communications with the Ambulance Commander, Transport Control Officer and Ambulance Officers. 4. Co-ordinate support provided from allied emergency services and supporting agencies, in moving casualties from the incident site, to the Casualty Collecting and Treatment Area. 5. At the Casualty Collecting Area, separate casualties into distinct priority classification groups, to facilitate evacuation, treatment and transport. 6. Patients with life-threatening injuries/illness should not be left unattended, if at all possible. 7. Undertake continuing Triage of all casualties, re-assessing the priority of treatment and transport. 161 Version 4.2 01/10 MCI = Greatest Good for Greatest Number TRANSPORT CONTROL OFFICER (TCO) The TCO assumes responsibility for the establishment of the Casualty Collecting Area (CCA), casualty evacuation and transport at the incident site. 1. Determine the most appropriate access & egress routes & vehicle staging area for ambulance vehicles and advise the ComCen of these, for communication to other responding resources. 2. In consultation with the Triage Officer and Ambulance Commander (if present), select a Casualty Collecting Area (CCA) in a safe and upwind environment. 3. Select an Ambulance Marshalling Area, in a safe and upwind environment, in close proximity to the Casualty Collecting Area. 4. Ensure all arriving ambulances are correctly positioned, that keys are left in the vehicle ignition and the vehicle is configured for two stretcher patients. 5. Prevent congestion at the Ambulance Loading Point by ensuring that ONLY ONE VEHICLE is being loaded with casualties, at any given time. 6. Record on the Casualty Movement Log, the number of casualties transported, their priority and destination and the ambulance vehicle identification number. Ensure that the corner label from the triage tag is removed prior to the casualty being loaded. (This task may be delegated to a support officer, if available). 7. Maintain communications with the Ambulance Commander and Triage Officer. 162 Version 4.2 01/10 MCI = Greatest Good for Greatest Number SUBSEQUENT AMBULANCE CREWS Approach the incident with safety. If the transport control area is set up, position the ambulance or support vehicle correctly in the marshalling area, leaving the keys in the ignition. Once at the incident, all warning devices should be switched off unless otherwise directed Wear all protective equipment provided by ACTAS. (i.e.: safety glasses, gloves, safety vest and helmet). Report to the Ambulance Commander on arrival for a SITREP and tasking. If the Ambulance Commander is not on scene, report to the Triage Officer for tasking. If ambulance officers are tasked to transport casualties to hospital they will: Transport casualties to the hospital or medical centre, nominated by the TCO Advise the receiving Emergency Department by radio the number of casualties being transport and the priority classification. Ensure that the receiving hospital or medical centre facilitates the QUICK TURN AROUND of ambulance and support vehicles. Report availability to Ambulance Liaison Officer at hospital ED (if present) or ComCen for further tasking. 163 Version 4.2 01/10
