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Guideline Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ space space Rural Adult Emergency Clinical Guidelines 3rd Edition Version 3.1 2012 space Document Number GL2012_003 Publication date 10-Apr-2012 Functional Sub group Clinical/ Patient Services - Nursing and Midwifery Clinical/ Patient Services - Medical Treatment Clinical/ Patient Services - Critical care Summary The intention of these guidelines is to ensure early appropriate management of acute and life threatening conditions, and to relieve pain and discomfort for patients at hospitals where medical practitioners are not immediately available. The guidelines reflect best clinical practice and are not mandatory, however, they have been adopted and implemented across the State since 2004 providing essential clinical support for rural emergency clinicians. Replaces Doc. No. Rural Adult Emergency Clinical Guidelines 3rd Edition [GL2010_003] Author Branch Statewide and Rural Health Services and Capital Planning Branch contact Sharon Lown 9391 9484 Applies to Local Health Districts, Speciality Network Governed Statutory Health Corporations, Board Governed Statutory Health Corporations, Public Health System Support Division, Public Health Units, Public Hospitals Audience Nursing, Medical & Allied Health clinical staff, Emergency Departments Distributed to Public Health System, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Ministry of Health, Private Hospitals and Day Procedure Centres Review date 10-Apr-2017 Policy Manual Patient Matters File No. H11/95743 Status Active Director-General GUIDELINE SUMMARY NSW RURAL ADULT EMERGENCY CLINICAL GUIDELINES VERSION 3.1, 3RD EDITION 2012 PURPOSE These guidelines are provided to assist early appropriate clinical management of acute and life threatening conditions, and to relieve pain and discomfort, for patients at hospitals where medical officers are not immediately available. The guidelines reflect best clinical practice and have been used extensively across the state since 2004 to provide clinical support for rural emergency clinicans. KEY PRINCIPLES Underpinning these guidelines are the following principles: • A ‘graduated’ clinical response is required depending on the: o severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma; o level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions; o legal requirements for nurses who initiate treatment and administer medications based on medication standing orders; o need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances; • • The guidelines reflect evidence based best clinical practice and expert consensus opinion; Standardisation of initial clinical management of specific adult conditions; and Alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses. Advanced Clinical Nurses have advanced knowledge and skills; and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines: • • • the designated medical officer will be notified immediately; standing medication standing orders contained in these guidelines will be reviewed and authorised by the designated medical officer as soon as possible (within 24 hours); and the medical officer will countersign the record of administration on the patients’ medication chart. A number of appendices and a formulary have been included to complement these guidelines. GL2012_003 Issue date: April 2012 Page 1 of 2 GUIDELINE SUMMARY NSW Health Pharmaceutical Services Branch has reviewed these guidelines and has indicated that they are satisfactory for the consideration of the Local Health Districts Drug Committees for approval and implementation as medication standing orders, in terms of the criteria for standing orders as specified in NSW Health Policy Directive, PD2007_077, Medication Handling in NSW Public Hospitals. These guidelines should be read in conjunction with NSW Health Policy Directive PD2005_042 - Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_042.html REVISION HISTORY Version April 2012 (GL2012_003) March 2010 (GL2010_003) Approved by A/Deputy Director-General Strategy and Resources Deputy Director-General Strategic Development Amendment notes rd 3 Edition V3.1 2012. Replaces GL2010_003 rd 3 Edition 2009. Replaces GL2007_005: total revision. May 2007 (GL2007_005) Deputy Director-General Strategic Development 2 Edition 2007. st Replaced 1 edition: total revision. nd 2 Edition V2 1 2007 issued August 2007 st 1 Edition 2004 nd Deputy Director-General Strategic Development ATTACHMENTS 1. NSW Rural Adult Emergency Clinical Guidelines – Version 3.1, 3rd Edition 2012 GL2012_003 Issue date: April 2012 Page 2 of 2 NSW Rural Adult Emergency Clinical Guidelines NSW Rural Critical Care Taskforce 3rd Edition – Version 3.1 NSW MINISTRY OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Ministry of Health. © NSW Ministry of Health 2012 SHPN (SRSCP) 120005 ISBN 978 1 74187 691 8 Further copies of this document can be downloaded from the NSW Health website www.health.nsw.gov.au Revised February 2012 The NSW Rural Adult Emergency Clinical Guidelines are to be implemented for the emergency management of adult patients only. Aeromedical and Medical Retrieval Service (AMRS) 1800 650 004 NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 1 Contents Introduction........................................................ 3 7. Other Emergencies................................... 73 Abbreviations..................................................... 5 1. Airway Emergencies................................... 7 Abdominal/Loin/Flank Pain.................................. 74 8. Formulary................................................... 77 Unconscious Patient.............................................. 8 Seizures............................................................... 10 Anaphylactic Reaction......................................... 12 9. Appendices ............................................... 99 2. Breathing Emergencies............................ 15 Shortness of Breath with or without a History of Asthma........................... 16 Shortness of Breath with a History of Cardiac Disease................................ 20 Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease............... 22 3. Circulatory Emergencies.......................... 25 Cardiorespiratory Arrest (Basic Life Support).............................................. 26 Cardiorespiratory Arrest (Advanced Life Support)...................................... 27 Compromising Bradycardia ................................. 29 Acute Coronary Syndrome with or without Associated Symptoms........................ 31 Non-traumatic Shock .......................................... 34 Stroke including Transient Ischaemic Attack........ 36 Severe Sepsis....................................................... 40 4. Disability Emergencies............................. 43 Meningococcal Disease....................................... 44 5. Endocrine / Envenomation Emergencies.............................................. 47 Hyperglycaemia with Severe Dehydration............ 48 Hypoglycaemia.................................................... 50 Snake / Spider Bite.............................................. 52 6. Trauma Emergencies................................ 55 Trauma............................................................... 56 Burns.................................................................. 60 Drowning ........................................................... 63 Head Injury.......................................................... 65 Isolated Severe Limb Injury.................................. 68 Ocular Injuries..................................................... 70 PAGE 2 1.Rural and Remote Emergency Trolley – Minimum Adult Requirements............... 100 2. Defibrillation............................................. 102 3. 12 Lead ECG Lead Placement................... 103 4. NSW Chest Pain Pathway.......................... 104 5. Management of Patients with ST-segment Elevation Myocardial Infarction (STEMI)..... 108 6. AVPU and Glasgow Coma Scale (GCS)...... 109 7. Pain Assessment....................................... 110 8. Abbey Pain Scale...................................... 111 9. Sedation Score/Scale................................. 112 10. Glass Tumbler Test .................................. .113 11. Snakebite Observation Chart ................... 114 12. Trauma Triage Tool .................................. 115 13A.Guidelines for when to Apply Semi-rigid Cervical Collar ........................................ .116 13B.Removal of Semi Rigid Cervical Collar without Radiographic Assessment ........... .117 14.Needle Thoracentesis for Decompression of Tension Pneumothorax ....................... .118 15. Suggested Guidelines for a Neurovascular Assessment ....................... 120 16. Pelvic Binding .......................................... 121 17.Burn Transfer Flowchart............................ 122 18. Guideline for Emergency Department Documentation......................................... 126 19. Minimum Skill Set for Emergency Department Staff...................................... 127 20. Recommended Blood Pathology Testing Available at the Point of Care in Rural Facilities where an Emergency Service is Provided.................................... 128 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Introduction Emergency Departments (EDs) in rural and remote New South Wales (NSW) face a number of unique and difficult challenges in trying to deliver quality emergency care and achieving good patient outcomes. In particular it can be difficult for staff working in rural and remote EDs to acquire and retain emergency expertise. This may lead to inequalities in the standards of emergency care delivered in rural and remote EDs. A key function of the NSW Rural Critical Care Taskforce (RCCT) is to identify and develop ways to ensure a more uniform quality of emergency care in these EDs. One of the Taskforce’s strategies led to the development, in 2004, of a set of Rural Emergency Clinical Guidelines for Adults, which could be used by rural and remote Registered Nurses (RNs) who have undergone approved education and credentialing. The intention of the Guidelines is to ensure early management of immediately or imminently life threatening conditions, and to relieve pain and suffering in patients at sites where medical practitioners are not immediately available. This is the fourth review of the document in line with changes to best practice; and requests and advice from end users. The document has been developed with the following desirable features: n formatting which allows for ‘graduated’ clinical responses. These responses vary depending on: – degree of severity of the presenting emergency condition. For example, the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma. This type of graduated clinical response has been used quite successfully in ambulance service protocols for many years; – level of training and expertise of the nursing staff who are initiating management of the patient – that is, formatting which allows for RNs with advanced training to practice more advanced interventions. RNs without this advanced training and credentialing cannot perform the advanced interventions. The use of shaded portions in the NSW Rural Adult Emergency Clinical Guidelines indicates clinical interventions that can only be initiated by RNs who are recognised as Advanced Clinical Nurses. n incorporation of the various legal requirements for nurses who initiate treatment and administer medications based on medication standing orders n flexibility – guidelines need to be flexible enough to allow local input from rural Medical Officers (MOs) and RNs so that local practices can be incorporated n endorsement by relevant committees and divisions within NSW Ministry of Health n standardisation of the management of specific adult conditions across rural NSW The NSW Rural Adult Emergency Clinical Guidelines incorporate these features as well as the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses and the standing orders developed by the Wollongong Hospital pilot site model of the Emergency Department Work Practice Review (EDWPR). Special recognition is made to the utilisation of the template designed and developed by the EDWPR group. The Guidelines are also formatted to follow the generally accepted Airway, Breathing, Circulation (ABC) approach for managing emergency/critical care patients. These Guidelines are largely based on expert consensus opinion, supported by higher level evidence where available. The aims of the NSW Rural Adult Emergency Clinical Guidelines are to: n improve the emergency care and outcomes for patients in the rural and remote health care settings of NSW; n provide readily accessible and user-friendly guidelines for clinicians providing emergency care to patients in rural and remote areas of NSW; n assist rural and remote EDs in NSW achieve benchmarking targets and best practice standards for patients with emergency presentations; NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 3 n address some of the current professional issues facing rural and remote RNs by: – providing a safe framework in which rural and remote RNs can initiate management and care of emergency patients; – recognising and formalising the advanced role that many rural and remote RNs currently perform when delivering care to critically ill or injured patients presenting to Emergency Departments; – providing a pathway by which credentialed RNs can work toward continuing professional development. Nursing staff using these Guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses. Advanced Clinical Nurses are those RNs who have advanced knowledge and skills; and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Credentialing will be obtained and maintained by: n completion of standard competency assessments as recommended by the Critical Care Network Committee in each Local Health District; n the ACN maintaining appropriate documentation to allow review of the usage of these Guidelines. ACNs are required to be re-credentialed annually or according to individual Local Health District policy. It will be the responsibility of the rural Local Health Districts through both their Critical Care Network Committee and their Health Service Managers to ensure compliance with these requirements. Implementation It is intended: n when an Advanced Clinical Nurse utilises these Guidelines, a MO will be notified immediately to ensure their early involvement with the management and care of the patient; n that any medication standing orders contained in these Guidelines will be signed and authorised by a MO appointed by the Local Health District. This MO may be one of those servicing the Emergency Department/s using these Guidelines; n that MO review is required following the administration of a drug according to the standing orders contained within this document as soon as possible (must be within 24 hours). At the time of this review the MO must check and countersign the nurse record of administration on the medication chart. A number of appendices have been included to complement these Guidelines. Staff should familiarise themselves with both the Appendix and Formulary sections. Credentialing of Advanced Clinical Nurses (ACN) Registered Nurses can be considered eligible to be credentialed for Advanced Clinical Nurse roles if: n n they have successfully completed an emergency or critical care nursing course such as the FLEC Course/ Graduate Certificate/Graduate Diploma or higher degree in Emergency Nursing; and they can demonstrate recent and ongoing knowledge and experience with managing emergency/critical care patients. NSW Health Pharmaceutical Services Branch has reviewed these Guidelines and have indicated that they are satisfactory for the consideration of the individual Local Health District Drug Committees for approval and implementation as medication standing orders, in terms of the criteria for standing orders as specified in NSW Health Policy Directive, PD2007_077, Medication Handling in NSW Public Hospitals. This document should be read in conjunction with the following Policy Directive from NSW Ministry of Health: n PD2005_042 – Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 4 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Abbreviations ABG Arterial Blood Gas mg Milligram ACN Advanced Clinical Nurse mL Millilitre ACS Acute Coronary Syndrome mmol/L Millimols per Litre AED Automatic/Automated External Defibrillator MO Medical Officer AMI Acute Myocardial Infarction MRI Magnetic Resonance Imaging ARC Australian Resuscitation Council MSU Mid-Stream Urine AVPU Alert, Voice, Pain, Unresponsive NGT Nasogastric tube BSA Body Surface Area O2 Oxygen BGL Blood Glucose Level PEFR Peak Expiratory Flow Rate BiPAP Bi-level Positive Airway Pressure PPE Personal protective equipment bpm Beats per minute PoC Point of Care CPAP Continuous Positive Airway Pressure POP Plaster of Paris CK Creatine kinase PO Per oral CNS Central Nervous System PR Per rectum coags Coagulation Studies PV Per vagina CPR Cardiopulmonary Resuscitation RN Registered Nurse CSF Cerebrospinal fluid SBP Systolic Blood Pressure C-Spine Cervical spine SCI Subcutaneous injection CT Computed Tomography S/L Sublingual DBP Diastolic Blood Pressure SOB Shortness of breath ECG Electrocardiograph SpO2 Pulse oximetry saturation ED Emergency Department Stat Immediately and once only ESR Erythrocyte Sedimentation Rate STEMI ST segment Elevation Myocardial Infarction FBC Full Blood Count TB Tuberculosis FLECC First Line Emergency Care Course TBSA Total body surface area g Gram TIAs Transient Ischaemic Attacks GCS Glasgow Coma Score/Scale U/A Urinalysis GIT Gastrointestinal tract UEC Urea Electrolytes Creatinine H2O Water UO Urine output Hb Haemoglobin VF Ventricular fibrillation hCG Human Chorionic Gonadotropin VT Ventricular tachycardia ICU Intensive Care Unit IDC Indwelling catheter IM Intramuscular IO Intraosseous IV Intravenous Kg Kilogram L Litre LFT Liver Function Test LHD Local Health District LMA Laryngeal Mask Airway LOC Level of Consciousness MDI Metered Dose Inhaler The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 5 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 6 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 1 Airway Emergencies The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 7 Unconscious Patient | Medical Officer must be notified immediately | For Adults Only Unconscious Patient History Prompts The most common error in the management of an unconscious patient is inadequate management of Airway, Breathing and/or Circulation. n Onset n Events – mechanism of injury n Associated preceding symptoms n Relevant past history, especially diabetes and alcohol use Clinical Severity Prompts n Glasgow Coma Score (GCS) less than 9 n Medication history, especially narcotic use n Inability to maintain own airway n Allergies Assessment Intervention Position Lie supine Airway Assess patency Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Breathing Respiratory rate and effort SpO2 Auscultation Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature IV cannulation/pathology Pulse – rate and rhythm Capillary refill Blood pressure Disability If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL bolus Cardiac monitor Monitor vital signs frequently AVPU/GCS + pupils Monitor LOC frequently If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration BGL Finger prick BGL If less than 3 mmol/L and unconscious or confused administer IV 50% Glucose 50 mL or If no IV access administer IM Glucagon 1 mg Monitor finger prick BGL every 15 minutes until within normal limits Measure and test Possible opiate overdose (characterised by pin-point pupils and hypoventilation) If opiate overdose, give IM Naloxone 800 micrograms and IV Naloxone 800 micrograms Pathology Temperature U/A Collect blood for FBC, UEC, (consider group and hold in trauma patients) Fluid input/output Nil by mouth IV 0.9% Sodium Chloride 1000 mL at 125 mL per hour to maintain hydration Electrocardiography Specific treatment Possible alcohol abuse Fluid balance chart 12 lead ECG If history of possible alcohol abuse give IM Thiamine 100 mg Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 8 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Unconscious Patient | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL bolus IV Stat 50% Glucose 50 mL IV Stat Glucagon 1 mg (if IV access unavailable) IM Stat Naloxone 800 micrograms IM Stat Naloxone 800 micrograms IV Stat 0.9% Sodium Chloride 1000 mL IV 125 mL per hour to maintain hydration Thiamine 100 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Be alert for acute opiate withdrawal after the administration of Naloxone. The half-life of Naloxone is much shorter than the opiate. Repeated doses of Naloxone may be required. n If IV access is unavailable, both doses of Naloxone may be given IM, although it should be noted that this is not ideal as the IM route will take longer to take effect. n ‘The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernicke’s encephalopathy is unfounded. The absorption of Thiamine is so much slower than that of glucose, timing is irrelevant’ (Hew, 2004, p. 367). n Consider carbon dioxide retention in unconscious hypoxic patients with a history of COPD, particularly if high flow oxygen has been administered in transit to the Emergency Department. References: Emergency Life Support (ELS) Course Manual, 2005, 3rd edn, ELS Course Inc., Tamworth. Fulde, G.W.O., (editor) 2004, Emergency medicine the principles of practice 4th edn, Elsevier, Sydney. Hew , R. Altered Conscious State in Textbook of Adult Emergency Medicine, 2004, Edited by Cameron, P., Jelinek, G., Kelly, A., Murray, L, Brown, A., Heyworth, J., Elsevier, Sydney MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 9 Seizures | Medical Officer must be notified immediately | For Adults Only Seizures History Prompts Clinical Severity Prompts n Events – mechanism of injury n Associated symptoms; n Rhythmical involuntary jerking (tonic-clonic) n Stiffening of the body n Clenched jaw n Relevant past history n Altered level of consciousness n Medication history n Allergies n Onset – altered level of consciousness, pale, sweaty, incontinence Assessment Intervention Position Protect from further harm Do NOT restrain the patient Lie supine or left lateral (after tonic phase and clonic movements cease) Airway Assess patency Maintain airway patency (a nasopharyngeal airway is the recommended adjunct unless contra-indicated) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Stop the seizures IV Midazolam 2.5 mg increments slow injection every 1-2 minutes (to a total dose of 0.1 mg/Kg) or if IV access unavailable: IM Midazolam 10 mg stat and repeat (once only) after 5 minutes if required It may be difficult to adequately treat the patient’s airway and breathing until the seizures have been stopped. Once this has occurred, it will be necessary to reassess/ treat/maintain the patient’s airway and breathing Circulation Disability Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure IV cannulation/pathology Cardiac monitor Monitor vital signs frequently AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL If less than 3 mmol/L administer IV 50% Glucose 50 mL or IM Glucagon 1 mg (if IV access unavailable) Monitor finger prick BGL every 15 minutes until within normal limits Measure and test Specific treatment Pathology Temperature U/A Collect blood for FBC, UEC Fluid intake/output Nil by mouth Possible alcohol abuse If history of possible alcohol abuse give IM Thiamine 100 mg Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 10 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Seizures | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Midazolam 2.5 mg increments IV Slow injection every 1–2 minutes (to a total of 0.1 mg/Kg) Midazolam 10 mg (if IV access unavailable) IM Stat and repeat (once only) after 5 minutes if required 50% Glucose 50 mL IV Stat Glucagon 1 mg (if IV access unavailable) IM Stat Thiamine 100 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Warning: respiratory and cardiovascular depression can be severe after the administration of Midazolam and requires close monitoring and treatment. n Observe for features of the seizure and document. n Do not attempt to put anything between the teeth during a seizure. References: Fulde G.W.O., (editor) 2004, Emergency medicine the principles of practice 4th edn, Elsevier, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 11 Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only Anaphylactic Reaction Relevant History and Assessment Prompts Clinical Severity Prompts n Anaphylaxis is likely when ALL three criteria are met: n Onset n Exposure to known allergen for the patient n Associated symptoms: – sudden onset and rapid progression of symptoms – respiratory distress, peripheral vasodilation, hypotension, urticaria, generalised redness and periorbital oedema – life-threatening Airway and/or Breathing and/ or Circulation problems are present – skin and/or mucosal changes (flushing, urticaria, angioedema) n Flushing, urticaria and angioedema can be absent in up to 20% of cases n Gastrointestinal symptoms: vomiting, abdominal pain, incontinence n Relevant past history n Medication history n Allergies Assessment Intervention Position Position of comfort Cease/remove causative agent Assess patency Maintain airway patency Stridor Hoarse voice If stridor present give IM Adrenaline 0.5mg every 3-5 minutes (to a total of 2 mg) Respiratory rate and effort SpO2 Wheeze Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Skin temperature Pulse – rate/rhythm Blood pressure Capillary refill IV cannulation If pulse rate greater than 100 bpm, SBP less than 90 mmHg and capillary refill greater than 2 seconds give IV 0.9% Sodium Chloride 1000 mL bolus Cardiac monitor Monitor vital signs frequently Disability AVPU/GCS + pupils Monitor LOC frequently Measure and test Fluid input/output Fluid balance chart Specific treatment No response to IM Adrenaline and patient presents signs of cardiorespiratory collapse ** IV Adrenaline 50 micrograms Airway Breathing Circulation If wheeze present give Salbutamol 10 puffs of 100 microgram dose MDI + spacer Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 12 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Adrenaline 0.5 mg IM Every 3-5 minutes to a total of 2 mg Salbutamol 10 puffs of 100 microgram dose MDI + spacer Inhalation Stat ** Adrenaline 50 micrograms IV Stat 0.9% Sodium Chloride 1000 mL bolus IV Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Systemic allergic reactions can occur with urticaria, angioedema and rhinitis, but are not anaphylactic reactions as they are not life-threatening. n Death caused by anaphylactic reaction occurs most commonly in the first 45 minutes after the patient has had contact with an allergen. n Adrenaline is the most important drug for the treatment of an anaphylactic and allergic reaction. n **IV Adrenaline 50 micrograms equates to 0.5 mL of 1:10,000 (10 mL) Adrenaline. n The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh – the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. al., 2008 p. 162). References: Dunn, R. editor in chief; et. al.. 2003, The emergency medicine manual, 3rd. edn, Venom Publishing Unit, West Beach Emergency Life Support (ELS) Course Manual 3nd edn. 2005. ELS Course Inc., Tamworth MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J, Pumphrey R, Cant A, et. al.. for the Working Group of the Resuscitation Council (UK). 2008, ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’, Resuscitation, vol. 77, (2), no. 2 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 13 PAGE 14 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 2 Breathing Emergencies NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 15 Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with or without a History of Asthma History Prompts Clinical Severity Prompts n Correspond with either mild, moderate or severe scale as described below n Onset n Associated symptoms n Relevant past history n Medication history n Trigger factors n Past presentation/s admission/s (ED/ICU/intubation) n Allergies Clinical manifestation of acute asthma ** Severe and life threatening ** Moderate Mild Australasian Triage Scale (ATS) 1 2 3 Physical exhaustion Yes Paradoxical chest wall movement may be present No No Talks in Words Phrases Sentences Pulse rate Greater than 120 bpm # 100-120 bpm Less than 100 bpm Central cyanosis Likely to be present May be present Absent Wheeze intensity Often quiet/silent Moderate to loud Variable PEFR Less than 50% predicted (or best if known) or less than 100 Litres/min 50-75% predicted (or best if known) Greater than 75% predicted (or best if known) Pulse oximetry Less than 90% cyanosis may be present Reference: National Asthma Council, Australia, 2006, Asthma Management Handbook, p. 39. ** Any of these features indicate the episode is severe. The absence of any feature does not exclude a severe attack. # Bradycardia may be seen when respiratory arrest is imminent. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 16 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Airway Breathing Circulation Assessment Intervention Position Sit patient upright or position of comfort Assess patency Maintain airway patency If the patient shows signs of pre-arrest or asthma associated with anaphylaxis (exhibits decreasing LOC, increasing cyanosis of lips/ mouth and bradycardia) If the patient is pre-arrest or asthma associated with anaphylaxis give IM Adrenaline 0.5 mg one dose only Respiratory rate and effort SpO2 Speech Use of accessory muscles Sternal retraction Spirometry/PEFR (moderate and mild asthma) Assist ventilation if required Apply O2 to maintain SpO2 above 95% Severe asthma 8-12 puffs Salbutamol 100 microgram MDI + spacer every 15-30 minutes. 4 puffs Ipratropium Bromide 20 microgram MDI + spacer stat If patient cannot inhale adequately to use an MDI and spacer (severe asthma) Salbutamol 5 mg nebule and Ipratropium bromide 500 microgram nebule stat Moderate asthma 8-12 puffs Salbutamol 100 microgram MDI + spacer every 1-4 hours Mild asthma 8-12 puffs Salbutamol 100 microgram MDI + spacer stat Skin temperature IV cannulation for moderate and severe asthma Pulse – rate/rhythm Blood pressure Cardiac monitor Monitor vital signs frequently Electrocardiography 12 lead ECG Disability AVPU/GCS Monitor LOC frequently Measure and test Temperature Spirometry Specific treatment Continuing respiratory distress For moderate and severe asthma give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable) Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 17 Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 8-15 litres/min Inhalation Continuous Adrenaline 0.5 mg IM (pre-arrest circumstance) Stat Salbutamol 100 microgram per inhalation MDI + spacer Inhalation Severe: 8-12 puffs every 15-30 minutes Moderate: 8-12 puffs every 1-4 hours Mild: 8-12 puffs stat Salbutamol 5 mg Nebule Inhalation Every 15-30 minutes (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Ipratropium Bromide 4 puffs of 20 microgram per inhalation MDI + spacer Inhalation Stat for severe cases Ipratropium Bromide 500 microgram Nebule Inhalation Severe: stat (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Hydrocortisone 200 mg IV Stat for moderate and severe asthma Prednisolone 50 mg (if IV access unavailable) Oral Stat for severe and moderate asthma 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 18 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n There is substantial evidence that Ipratropium Bromide is of limited use in acute episodes of mild to moderate asthma. Ipratropium Bromide is not necessary in mild asthma and optional in moderate episodes. n The use of short acting beta agonists by intermittent inhalation via MDI and spacer is now recommended in the management of acute asthma, whether mild, moderate or severe. n Delivery of short acting beta agonists via MDI and spacer is equally effective as nebulisation in patients with moderate to severe acute asthma, other than for those patients with life-threatening asthma who cannot inhale well enough to use an MDI + spacer (e.g. those requiring ventilation). n Continuous nebulisation and IV therapy are alternatives in severe asthma. However, adverse events are more frequent. n Use a nebuliser instead of MDI if the patient cannot inhale adequately. A 5 mg nebule of Salbutamol should be made up with 2 mL 0.9% Sodium Chloride. If available, give oxygen at a flow of 8-10 L/min. A mouthpiece delivers considerably more drug to the lung than a facemask. n The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh – the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. al. 2008, p. 162). References: Doherty, S. 2006, Emergency care evidence in practice series: use of ipratropium bromide for acute asthma, Emergency Care Community of Practice, National Institute of Clinical Studies, Melbourne. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Asthma Council Australia, 2006, Asthma Management Handbook, revised and updated, National Asthma Council, Australia. NSW Health, 2007, PD2007_063 Infection Control Policy, NSW Department of Health, North Sydney. Soar J, Pumphrey R, Cant A, et. al. for the Working Group of the Resuscitation Council (UK). 2008, ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’, Resuscitation, vol. 77(2), no. 2. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 19 Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with a History of Cardiac Disease Clinical Severity Prompts History Prompts n Onset n Events n Associated symptoms n Severe respiratory distress with exhaustion n Altered level of consciousness n Ability to talk in words only n Relevant past history n Central cyanosis n History of cardiac disease n Audible respiratory crepitations n Medication history n Allergies – pale, clammy, audible respiratory crepitations, speaking in phrases or words Assessment Intervention Position Sit patient upright Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Speech Auscultation Assist ventilation if required with positive pressure bag valve mask Apply O2 via non re-breather mask at 15 L/min, aim to maintain SpO2 greater than 95% Consider CPAP/BiPAP if available Circulation Skin temperature IV cannulation/pathology Pulse – rate/rhythm Capillary refill Blood pressure If SBP greater than 90 mmHg give Glyceryl Trinitrate S/L 300-600 micrograms or spray 1-2 sprays (400-800 micrograms) Repeat every 5 minutes if SBP greater than 90 mmHg Audible respiratory crepitations Audible respiratory crepitations present – give IV Frusemide 40 mg Cardiac monitor Electrocardiography Monitor vital signs frequently 12 lead ECG Disability AVPU/GCS BGL Monitor LOC frequently Finger prick BGL Measure and Test Pathology Collect blood for FBC, UEC, cardiac markers and ABG or venous blood gas (if available) Fluid input/output U/A Fluid balance chart Restrict oral fluid intake Consider IDC and urine measurements every hour Chest X-ray If available Continuing respiratory distress CPAP 10 cm H20 if available and SBP greater than 100 mmHg and SOB unrelieved by other interventions (i.e. Nitrates and Frusemide) Specific Treatment Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 20 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 15 litres/min Non re-breather mask Inhalation Continuous Glyceryl Trinitrate 300-600 micrograms S/L Stat and then every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Glyceryl Trinitrate 1-2 sprays (400-800 micrograms) S/L Stat and then every 5 minutes (if SBP greater than 90 mmHg) to total of 4 sprays (1600 micrograms) Frusemide 40 mg IV Stat if audible respiratory crepitations present 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n DO NOT administer Nitrates if patient has taken medications for treatment of sexual dysfunction e.g. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect). n CPAP/BiPAP can only be used effectively when the patient has adequate respiratory effort. n Systolic blood pressure less than 90 mmHg with acute pulmonary oedema constitutes a diagnosis of cardiogenic shock requiring emergency circulatory assistance. References: Lightfoot, D., 2004, ‘Assessment and management of acute pulmonary oedema in EDs’, in Textbook of Adult Emergency Medicine, 2nd edn, eds P. Cameron, G. Jelinek, A. Kelly, L. Murray, A. Brown, J. Heyworth, Churchill Livingstone, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Heart Foundation of Australia, 2006, Guidelines for the prevention, detection and management of chronic heart failure in Australia, November 2006. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 21 Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease Clinical Severity Prompts History Prompts n Onset n Associated symptoms – pale, sweaty, cyanosis n History of chronic obstructive pulmonary disease (emphysema, chronic bronchitis) Relevant past history – chronic obstructive pulmonary disease n Medication history n Severe respiratory distress with exhaustion n Past presentations/admissions (ED/ICU/intubation) n Altered level of consciousness n Allergies n Ability to talk in words only n Central cyanosis n Confusion, lethargy or evidence of hypoventilation n Assessment Intervention Position Sit patient upright / position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 using venturi mask start at 24%-28% to maintain SpO2 90-95% Audible wheeze present 10 puffs Salbutamol 100 microgram MDI + spacer and 4 puffs Ipratropium Bromide 20 microgram MDI + spacer If patient cannot inhale adequately to use an MDI and spacer (severe cases) Speech Use of accessory muscles Sternal retraction Salbutamol 5mg nebule every 20 minutes if required and Ipratropium bromide 500 microgram nebule stat Skin temperature IV cannulation Circulation Pulse – rate/rhythm Blood pressure Cardiac monitor Monitor vital signs frequently Disability AVPU/GCS Monitor LOC frequently Measure and test Temperature Specific treatment Electrocardiography 12 lead ECG Sputum Obtain specimen for microbiology Chest X-Ray Arterial blood gas or venous blood gas If available If available Continuing respiratory distress For moderate and severe cases give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable) CPAP/BiPAP Prepare equipment if available Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 22 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen Start at 24%-28% Inhalation Venturi Mask Continuous Salbutamol 10 puffs of 100 microgram per inhalation MDI + spacer Inhalation Repeat every 20 minutes if required Salbutamol 5 mg Nebule Inhalation Repeat every 20 minutes if required (for patients who cannot inhale well enough to use MDI + spacer) Ipratropium Bromide 4 puffs of 20 microgram MDI + spacer Inhalation Stat Ipratropium Bromide 500 microgram Nebule Inhalation Stat (for patients who cannot inhale well enough to use MDI + spacer) Hydrocortisone 200 mg IV Stat Prednisolone 50 mg (if IV access unavailable) Oral Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Never withhold oxygen in severely dyspnoeic patients n Mental status is an important indicator of both worsening hypoxia and hypercapnia n Be aware of signs of hypercapnia particularly decreasing LOC. n Gas flow through medium concentration oxygen masks (e.g. Hudson) is inadequate when the patient is tachypnoeic therefore these masks should not be used. High flow oxygen should be avoided. n Use a nebuliser instead of MDI if the patient cannot inhale adequately. A 5 mg nebule of Salbutamol should be made up with 2 mL 0.9% Sodium Chloride. n Nebulised solutions are to be administered using AIR. References: Emergency Life Support (ELS) Course Manual, 3rd edn. 2005, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J., Pumphrey R., Cant A., et. al.. for the Working Group of the Resuscitation Council (UK). 2008, ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’, Resuscitation, vol. 77, (2), no. 2. The Australian Lung Foundation, 2008, The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease version 2.15 May 2008. (Endorsed by the Thoracic Society of Australia & New Zealand) NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 23 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 24 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 3 Circulatory Emergencies The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 25 Basic Life Support | Medical Officer must be notified immediately | For Adults Only Cardiorespiratory Arrest (Basic Life Support) Australian Resuscitation Council, December 2010, Guideline 8. Basic Life Support D Dangers? R Responsive? S Send for help A Open Airway B Normal Breathing? C 30 compressions : 2 breaths D Start CPR if unwilling / unable to perform rescue breaths continue chest compressions Attach Defibrillator (AED) as soon as available and follow its prompts Continue CPR until responsiveness or normal breathing return December 2010 Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 26 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 for 2 minutes CPR Shock Shockable Post Resuscitation Care Return of Spontaneous Curculation? Assess Defibrillator / Monitor Attach 30 compressions compressions:: 22 breaths 30 breaths Minimise Interruptions Start CPR CPR for 2 minutes Non Shockable December 2010 Re-evaluate ABCDE 12 lead ECG Treat precipitating causes Re-evaluate oxygenation and ventilation Temperature control (cool) Post Resuscitation Care Hypoxia Hypovolaemia Hyper / hypokalaemia / metabolic disorders Hypothermia / hyperthermia Tension pneumothorax Tamponade Toxins Thrombosis (pulmonary / coronary) Consider and Correct During CPR Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO access Plan actions before interrupting compressions (e.g. charge manual defibrillator) Drugs Shockable * Adrenaline 1 mg after 2nd shock (then every 2nd loop) * Amiodarone 300 mg after 3rd shock Non Shockable * Adrenaline 1 mg immediately (then every 2nd loop) Advanced Life Support for Adults Advanced Life Support | Medical Officer must be notified immediately | For Adults Only Cardiorespiratory Arrest (Advanced Life Support) Australian Resuscitation Council, December 2010, Guideline 11.2 Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 27 Advanced Life Support | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 15 litres/min Inhalation Continuous Adrenaline 1 mg IV/IO Shockable rhythmsAfter 2nd shock, then every 2nd loop to a total of 3 mg Non-shockable rhythms- immediately, then every 2nd loop to a total of 3 mg Amiodarone 300 mg IV/IO Stat after 3rd shock 0.9% Sodium Chloride 30 mL flush IV/IO As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n If stat dose of IV/IO Amiodarone is effective and return of spontaneous circulation has been achieved then Amiodarone infusion is recommended to follow. References: Australian Injectable Drugs Handbook, 4th edition. July 2008, The Society of Hospital Pharmacists of Australia. Australian Resuscitation Council, 2010, Guideline 11.2: Protocols for adult Advanced Life Support, ARC, Melbourne. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 28 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only Compromising Bradycardia History Prompts Bradycardia must be considered in relation to associated symptoms. Events leading to presentation n Syncope or seizure Clinical Severity Prompts n Chest pain – onset (if any) n Associated symptoms: n Bradycardia: less than 40 beats per minute and symptomatic i.e. plus one or more of the following: –dyspnoea - altered level of consciousness –sweating - blood pressure: SBP less than 90 mmHg –pallor - chest pain –fatigue - shortness of breath n Relevant past history -syncope/dizziness – medication history -diaphoresis –allergies Assessment Intervention Position Supine depending on clinical status Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature IV cannulation/pathology Pulse – rate/rhythm Capillary refill Blood pressure If SBP less than 90 mmHg give IV Atropine 0.5 mg increments every 5 minutes (to total of 3mg) to maintain systolic blood pressure greater than 90 mmHg Cardiac monitor Monitor vital signs frequently If no response to Atropine MO to consider external transthoracic pacing (if available) Disability AVPU/GCS BGL Monitor LOC frequently Finger prick BGL Measure and test Electrocardiography 12 lead ECG (within five minutes of arrival to ED) Pathology Collect blood for FBC, UEC, cardiac markers (where available) Fluid input/output Fluid balance chart Nil by mouth Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 29 Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Atropine 0.5 mg increments to a total of 3mg IV Every 5 minutes titrated to maintain systolic blood pressure greater than 90 mmHg 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Hypoxia can cause bradycardia. n Inferior myocardial infarction/ischaemia may lead to bradyarrhythmias. n Symptomatic complete heart block will require pacing and/or urgent transfer to definitive care. n Atropine may be ineffective in patients who are on beta-blockers. References: Brady W.J., Swart G., De Behnke D.J., John Ma O., Aufderheide T. P. 1999, The efficacy of atropine in the treatment of haemodynamically unstable bradycardia and atrio-ventricular block: prehospital and emergency department considerations. Resuscitation, vol. 41, no. 1, pp. 47-55. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Sodeck G.H., Domanovits H., Meron G., et. al.. 2007, ‘Compromising bradycardia: management in the emergency department’ Resuscitation, vol. 73, no. 1, pp. 96-102. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 30 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only Acute Coronary Syndrome (with or without associated symptoms) – Severity: pain score 0-10 – Time: onset of pain, pain lasting longer than 5 minutes (refer to Appendix 7) n –nausea/vomiting Clinical Severity Prompts n n Associated symptoms: –sweating Chest pain/discomfort – heavy, central/left/right and/ or associated symptoms – shortness of breath –palpitations Time – pain lasting longer than 5 minutes –lethargy/fatigue History Prompts n n Other: Symptoms suggestive of myocardial ischaemia – relevant past history – Provokes/Precipitates: what makes the pain worse? What were you doing when you got the pain? – risk factors: familial, diabetes, hyperlipidaemia, smoking, Aboriginal & Torres Strait Islander – Quality: what does the pain feel like? Describe the pain – medication history, including medications used for the treatment of sexual dysfunction e.g. Sildenafil (Viagra) – Region: centre of chest, retrosternal; Radiation: arm(s)/back/jaw –allergies Commence NSW Chest Pain Pathway (Appendix 4) Assessment Intervention Position Position patient upright/position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 if SpO2 less than 93%** Circulation Skin temperature Pulse – rate/rhythm Capillary refill Aspirin 300 mg (chew) (if not already given by Ambulance Officer) Blood pressure Cardiac monitor If pain present, give Glyceryl Trinitrate S/L 300-600 micrograms or Glyceryl Trinitrate Spray S/L (400-800 micrograms) if SBP greater than 90 mmHg, can be repeated every 5 minutes Monitor vital signs frequently Electrocardiography 12 lead ECG (within 5 minutes of arrival to ED) IV cannulation/pathology If pain is present, give IV Morphine 2.5 mg increments every 5 minutes to a total 10 mg or IM Morphine (if IV access unavailable) 5-10 mg Assess suitability for fibrinolysis (refer to Appendix 5) Disability AVPU/GCS BGL Monitor LOC frequently Finger prick BGL Measure and test Pathology Collect blood for (FBC, UEC, Troponin where available) Fluid input/output Monitor pain score If pain free after 30 minutes Fluid balance chart If pain returns at any time Repeat 12 lead ECG Repeat 12 lead ECG Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 31 Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Apply if SpO2 below 93% Aspirin 300 mg Oral (chew) Stat Glyceryl Trinitrate 300-600 micrograms (½ -1 tablet) S/L Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Glyceryl Trinitrate spray 1-2 sprays (400-800 micrograms) S/L Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 4 sprays (1600 micrograms) Morphine 2.5 mg increments (10 mg diluted with 9 mL – 0.9% Sodium Chloride) IV Every 5 minutes (not to exceed a total of 10 mg) Morphine 5-10 mg (if IV access unavailable) IM Stat (not to exceed total of 10 mg) 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n **Oxygen therapy is indicated for patients with hypoxia (SpO2 less than 93%) and those with evidence of shock to correct tissue hypoxia. In the absence of hypoxia the benefits of oxygen therapy is uncertain and in some cases oxygen therapy may be harmful (Chew et al 2011). n Do NOT administer Nitrates if patient has taken medications used for the treatment of sexual dysfunction e.g. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect). n The diabetic, elderly, female or young patient may present with atypical symptoms such as dyspnoea, nausea, vomiting, palpitations, syncope or cardiac arrest, no pain. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 32 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only References: Chew, D., Aroney, C., Aylward, P., Kelly, A-M., White, H.,Tideman, P., Waddell, J., Azadi, L., Wilson, A., Ruta, L. 2011. 2011 Addendum to the Guidelines for the Management of Acute Coronary Syndrome. Heart, Lung & Circulation, 20(8). Jowett N.I., Turner A.M., Cole A. and Jones P.A., 2005, ‘Modified electrode placement must be recorded when performing 12-lead electrocardiograms’, Postgrad. Med. J. vol. 81, pp. 122-125. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand, 2006, ‘Guidelines for the management of acute coronary syndromes’, The Medical Journal of Australia, vol. 184 no. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html>. National Heart Foundation, 2000, Reperfusion therapy for acute myocardial infarction. Ryan T. J. and Reeder G.S., 2009, ‘Management of suspected acute coronary syndrome in the emergency department’, viewed 19.01.2009, <http://www.uptodate.com/online/content/topic.do?topicKey=ad_emer/2821&selectedTitle=3`15 0&source=search_result>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 33 Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only Non-traumatic Shock –sweaty – capillary refill greater than 2 seconds Tachycardia may not occur in elderly patients Patients who are normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg History Prompts n Onset Clinical Severity Prompts n Events: vomiting/diarrhoea, infection, pregnancy, gastric/abdominal pain (If history of trauma refer to Trauma Guideline) n Relevant past history: n Tachycardia: (greater than 100 beats per minute) n Poor brain perfusion –restlessness – palpitations, light-headed, fainting – altered level of consciousness n Poor skin perfusion n Medication history n Allergies –cold –pale Assessment Intervention Full PPE measures must be considered Position Lie supine Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation x 2/pathology Blood pressure If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL bolus Cardiac monitor Monitor vital signs frequently Disability AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL Measure and test Primary Survey Secondary Survey Repeat Commence Pathology Take blood for FBC, UEC, group and hold (if required), venous blood gas, blood culture and serum lactate Measure Hb if point of care device (e.g. iStat) is available Temperature U/A Urine hCG (women of childbearing age) Urine culture Fluid input/output Fluid balance chart Nil by mouth Insert IDC – measure and record urine output every hour PV Loss Monitor Electrocardiography 12 lead ECG Chest X-ray If available Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 34 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL IV/IO Stat (repeat once only if SBP remains less than 90 mmHg) 0.9% Sodium Chloride 10 mL flush IV/IO As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Close monitoring of fluid input and output is essential. n Pregnant women (greater than 20 weeks gestation): – require a left lateral tilt to reduce compression of the Inferior Vena Cava – hypotension is a late sign of hypovolaemia – greater volumes than expected are required for resuscitation. References: Dunn R. et. al. (editor), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Emergency Life Support (ELS) course manual, 3nd edn. 2005, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Rose B.D. and Mandel J., ‘Treatment of severe hypovolaemia or hypovolaemic shock in adults’, viewed 19.01.09, <http://uptodate.com/online/content/topic.do?topicKey=cc_medi/14949>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 35 Stroke including Transient Ischaemic Attack | Medical Officer must be notified immediately | For Adults Only Stroke including Transient Ischaemic Attack History Prompts Clinical Severity Prompts n Facial weakness – can the person smile? Is there mouth or eye droop ? n Arm weakness – can the person raise both arms? n Speech difficulty – can the person speak clearly and understand what you say? n Time – time of onset of symptoms and duration. Treat as a medical emergency. n Onset n Associated symptoms: – Altered level of consciousness, dizziness or loss of balance, loss of vision, blurred vision or decreased vision in one or both eyes, headache, difficulty swallowing, altered or garbled speech, weakness or numbness in face or limbs, acute onset of confusion n Relevant past history – confirmed previous TIAs, diabetes, smoker, hypertension, age 60 years or over n Medication history – especially diabetic medication and anticoagulants such as warfarin, aspirin, clopidogrel. Seizure medication. Alternative therapies n Allergies Assessment Intervention Position Position head up 30° unless contraindicated Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation/pathology Blood pressure If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL Disability Cardiac monitor Monitor vital signs frequently Electrogradiograph 12 lead ECG AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL less than 3.5 mmol/L If unconscious or confused administer IV 50% Glucose 50 mL or if IV access unavailable, administer IM Glucagon 1 mg Measure and test Pathology Collect blood for (FBC, UEC, ESR, BGL, coags, venous blood gases) If temp greater than 38.5°C take blood cultures Temperature If greater than 37.5°C give Paracetamol 500 mg - 1 g IV Neurological Observations Monitor frequently Headache pain score (4-10) If headache pain score 4 – 10 give IV Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5 – 10 mg (if IV access unavailable) U/A Full urinalysis Fluid input/output Fluid balance chart Nil by mouth – consider NGT Chest X-ray If available or Paracetamol 500 mg – 1 g PR The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 36 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Stroke including Transient Ischaemic Attack | Medical Officer must be notified immediately | For Adults Only Specific treatment Nausea/Vomiting If nausea/vomiting present give IV or IM Metoclopramide 10 mg Hydration IV 0.9% Sodium Chloride 1000 mL (125 mL/hour to maintain hydration) Rapid initial stroke screen (ROSIER Scale) If score greater than 0, transfer for urgent CT/MRI ABCD2 if TIA suspected If greater than 4, transfer for urgent CT/MRI Bedside swallow screen Nil by mouth until bedside swallow screen attended (within 24 hours) Possible alcohol abuse If history of possible alcohol abuse give IM Thiamine 100 mg Document assessment findings, interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL (Circulatory support) IV Stat (repeat once if SBP remains less than 90 mmHg) 50% Glucose 50 mL IV Stat Glucagon 1 mg (if IV access unavailable) IM Stat Paracetamol 500 mg – 1g (If not given IV) PR Stat Paracetamol 500 mg – 1g (If not given PR) IV Stat Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV Every 5 minutes (to a total of 10mg) Morphine 5-10 mg (if IV access unavailable) IM Stat (to a total of 10 mg) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 1000 mL (maintain hydration) IV 125 mL per hour Thiamine 100 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical officer review is required following the administration of a drug according to the standing orders contained within this document as soon as possible (within 24 hours). At the time of this review, the medical officer must check and countersign the nurse’s record of administration on the medication chart. n If an advanced clinical nurse uses these clinical guidelines, a medical officer will be notified, as early as practical, to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 37 Stroke including Transient Ischaemic Attack | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n Body temperature increases in up to 50% of patients over the initial 48 hours of stroke onset. The presence of fever has been found to correlate with poorer outcomes in stroke. Therefore antipyretics such as paracetamol or other fever-lowering strategies are recommended early in the management of acute stroke, until body temperature is lowered to 37.5°C. n Pain assessment may require non-verbal assessment (i.e Abbey scale Appendix 8) n The ROSIER scale (p. 39) is the only tool that has been validated specifically for use in the ED following triage. The ROSIER scale should be implemented as standard practice as part of the initial assessment in ED of all suspected stroke patients. n TIA and minor stroke patients are at high risk of subsequent stroke, with up to 10% suffering a stroke within the following 48 hours. The ABCD2 assessment (p. 39) is the best, validated tool currently available and can provide stratification information to guide management decisions. n The ROSIER scale and ABCD2 assessment are provided on page 39 n Ideally all people with stroke should be transferred to a hospital with a stroke unit (preferably within three hours of stroke onset) for the benefit of thrombolysis where applicable. Patients need to be treated within three hours of stroke onset. Patients meeting criteria have up to a 4.5 hour timeframe from stroke symptom onset for thrombolysis administration. A CT is required before the decision to thrombolyse can be made, so early transfer is a priority. n ‘The administration of thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. The old dogma that thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernicke’s encephalopathy is unfounded. The absorption of Thiamine is so much slower than that of glucose, timing is irrelevant’ (Hew, 2004, p. 367). References: ACT Now Expert report (2004): Improving patient management and outcomes in acute stroke: a coordinated approach. Australian Medicines Handbook online 2011 http://proxy7.use.hcn.com.au/view.php?page=chapter3/ monographparacetamol.html#paracetamol <accessed February 2011> Australian Medicines Handbook online 2011 http://proxy7.use.hcn.com.au/dbSearch.php?q=aspirin <accessed Feb 2011> National institute of clinical studies. 2009: Emergency department stroke and transient ischaemic attack care bundle: Information and implementation package. Melbourne: national Health and Medical Research Council. Pages 15, 22. National Stroke Foundation 2010: Clinical Guidelines for stroke management. Melbourne Australia. Nor AM, Davis J, Sen B, Shipsey D, et al 2005: The recognition of stroke in the emergency room (ROSIER) scale; development and validation of a stroke recognition instrument. Lancet Neurol Nov;4(11):727-34. Hew, R., 2004, ‘Altered Conscious State’ in Textbook of adult emergency medicine, eds Cameron, P., Jelinek, G., Kelly, A., Murray, L., Brown, A., Heyworth, J., Elsevier, Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 38 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Stroke including Transient Ischaemic Attack | Medical Officer must be notified immediately | For Adults Only ROSIER Scale Recognition of Stroke in the Emergency Room (ROSIER) // Time: : Date: // Time: : AssessmentDate: Symptom onset GCS E= _____ M= ______ V= ______ BP= ______ / ______ BGL= ______ If BGL 3.5 mmol/L, treat urgently and reassess once blood glucose normal Has there been loss of consciousness or syncope? Y (-1) o N (0) o Has there been seizure activity? Y (-1) o N (0) o 1. Asymmetric facial weakness Y (+1) o N (0) o 2. Asymmetric arm weakness Y (+1) o N (0) o 3. Asymmetric leg weakness Y (+1) o N (0) o 4. Speech disturbance Y (+1) o N (0) o 5. Visual field defect Y (+1) o N (0) o Total score _______ (-2 to +5) Is there a NEW ACUTE onset (or on awakening from sleep) Provisional diagnosis Stroke o Non-stroke (specify) o _____________________________________ Note: Stroke is unlikely, but not completely excluded if total scores are less than or equal to 0. If score is greater than 0 transfer for urgent CT/MRI Reference: Nor AM, Davis J, Sen B, Shipsey D, et al (2005): The recognition of stroke in the emergency room (ROSIER) scale; development and validation of a stroke recognition instrument. Lancet Neurol Nov;4(11):727-34. ABCD2 assessment when TIA suspected Assessment Points A Age: greater than or equal to 60 years 1 point B Blood pressure: greater than or equal to 140/90 mmHg 1 point C Clinical features: Unilateral weakness 2 points 1 point D D Speech impairment without weakness Duration greater than 60 minutes 2 points Duration 10 – 59 minutes 1 point Diabetes 1 point Score Tool Interpretation Total Less than or equal to 3 points = Low risk Greater than or equal to 4 points = High risk If score is greater than or equal to 4 points transfer for urgent CT/MRI Reference: National Stroke Foundation 2010: Clinical Guidelines for stroke management. Melbourne Australia. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 39 Severe Sepsis | Medical Officer must be notified immediately | For Adults Only Severe Sepsis Clinical Severity Prompts n Immunocompromised patient n Indwelling medical device n Recent surgery/ invasive procedure n History of fevers or rigors n Red flags in ambulance handover n Skin: cellulitis, wound n Urine: dysuria, frequency, odour n Abdomen: pain, peritonism n Chest: cough, shortness of breath n Neuro: decreased mental alertness, neck stiffness headache. History Prompts n Onset n Recent overseas travel n Relevant past history: diabetic, age n Medication history n Allergies Immediately call for assistance and notify the Medical Officer and Aeromedical and Medical Retrieval Service (1800 650 004) Assessment Intervention Position Position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation/pathology Blood pressure If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL Cardiac monitor Monitor vital signs frequently Electrogradiograph 12 lead ECG DO NOT DELAY ANTIBIOTIC ADMINISTRATION Disability AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL less than 3.0 mmol/L and conscious, administer simple sugar or If unconscious or confused administer IV 50% Glucose 50 mL or If IV access unavailable, administer IM Glucagon 1mg Finger prick BGL every 15 minutes until within normal limits and the patient mentally alert Measure and test Pathology If possible, take blood for FBC, UEC, LFT, coags, blood cultures x 2, venous blood gas Temperature If less than 35.5°C apply warming adjunctive measures. If greater than 38.5°C give oral Paracetamol 500 mg – 1 g U/A Full urinalysis Urine culture Fluid input/output Fluid balance chart Insert IDC – measure and record urine output every hour Chest X-ray If available The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 40 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Severe Sepsis | Medical Officer must be notified immediately | For Adults Only Specific treatment Hydration intake IV 0.9% Sodium Chloride 1000 mL (125 mL/hour to maintain hydration) Antibiotics IV/IO Flucloxacillin 2 g and IV Gentamicin 7 mg/kg for first dose (maximum 640 mg) If allergic to penicillin give IV Vancomycin according to patient’s body weight Document assessment findings, interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/minute Inhalation Continuous 0.9% Sodium Chloride 500 mL IV/IO Stat (repeat once if SBP remains less than 90 mmHg) 50% Glucose 50 mL IV/IO Stat if BGL less than 3.5 mmol/ L Glucagon 1 mg (if IV access unavailable) IM Stat Paracetamol 500 mg - 1 g oral Stat 0.9% Sodium Chloride 1000 mL ( to maintain hydration) IV 125 mL/hour Flucloxacillin 2 g dissolved in water for injection IV/IO 2 g in 50 mL 0.9% Sodium Chloride over at least 30 minutes Gentamicin 7 mg/kg (maximum 640 mg) IV 240 mg or less over 3-5 minutes More than 240 mg over 30 minutes Some centres may give up to 640 mg IV push over 3 -5 minutes. Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 1000 mL (maintain hydration) IV 125 mL per hour Thiamine 100 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Vancomycin (only if patient is allergic to penicillin) Loading dose given according to patient’s actual body weight: Less than 60 kg: 1 g 60-80 kg: 1.5 g 81-100 kg: 2 g Greater than 100 kg: 2.5 g IV Administer in 0.9% Sodium Chloride at an infusion rate of no more than 10 mg/minute The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 41 Severe Sepsis | Medical Officer must be notified immediately | For Adults Only Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n IM antibiotic administration is NOT preferred in this setting as supervening shock and hypotension may lead to failure of absorption of the injected antibiotic. n Collection of blood sample for culture should be attempted prior to administration of antibiotics but should not delay treatment. n IV Vancomycin is only initiated if the patient is allergic to penicillin. IV Vancomycin must be infused at a rate of no more than 10 mg/minute. n If the patient is given Vancomycin, the Medical Officer must confirm the patient’s renal function and order an appropriate dose to be administered 12 hours after the loading dose. References: Agency for Clinical Innovation and the Clinical Excellence Commission. 2011. Sepsis Pathway. NSW Health. Agency for Clinical Innovation and the Clinical Excellence Commission. 2011. Sepsis Adult FIRST DOSE Empirical Intravenous Antibiotic Guideline V1. NSW Health. eTG Therapeutic Guidelines. Chapter 2. Revised June 2010. Ammended October 2010. © Therapeutic Guidelines Ltd. (www.tg.com.au) etg 3 March 2011. http://proxy9.use.hcn.com.au/tgc/abg/708.htm#727ID_GL The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 42 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 4 Disability Emergencies NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 43 Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only Meningococcal Disease: Non-blanching Rash History Prompts Clinical Severity Prompts n n Appearance of rapidly developing non-blanching petechial or purpuric rash (bruised haemorrhagic type/ does not blanch i.e. skin colour does not fade under pressure) which may only be several lesions (refer Appendix 10 for Glass Tumbler Test) n Onset n Events – bacterial meningitis suspected n Associated symptoms: – altered/abnormal level of consciousness, pallor, irritability (global signs of meningeal irritation) n Relevant past history: – contact/association with person/s recently diagnosed with meningococcal disease within past 60 days Associated symptoms include: headache, fever, vomiting, neck stiffness, photophobia and drowsiness – immunosuppression, recent head/neck infection n Medication history n Allergies Immediately call for assistance and notify the Medical Officer and Aeromedical and Medical Retrieval Service (1800 650 004) Assessment Intervention Full PPE must be worn at all times Position Completely undress (including underwear and socks) Inspect all body surfaces/ folds/creases for rash Position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation/pathology Blood pressure If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL Cardiac monitor 12 lead ECG Monitor vital signs frequently As indicated DO NOT DELAY ANTIBIOTIC ADMINISTRATION Disability AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL Measure and test Pathology If possible, take blood for FBC, UEC, blood cultures Temperature U/A Specific treatment Fluid input/output Nil by mouth Non blanching petechial/ purpuric rash If patient weighs greater than 65 kg give Dexamethasone 10 mg IV/IO stat If less than 65 kg give 0.15 mg per kg IV/IO stat and IV/IO or IM Benzylpenicillin 1.2 g. If allergic to Benzylpenicillin give IV/IO or IM Ceftriaxone 2 g Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 44 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL IV/IO Stat (repeat once if SBP remains less than 90 mmHg) Dexamethasone If patient greater than 65 kg give 10 mg Dexamethasone If less than 65 kg give 0.15 mg per kg IV/IO Stat Benzylpenicillin 1.2 g IV/IO/IM Stat Ceftriaxone 2 g (if allergic to Benzylpenicillin) IV/IO/IM Stat 0.9% Sodium Chloride 10 mL flush IV/IO As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n IM antibiotic administration is NOT preferred in this setting as supervening shock and hypotension may lead to failure of absorption of the injected antibiotic. n Collection of blood sample for culture should be attempted prior to administration of antibiotics but should not delay treatment. n Patients presenting unwell with a blanching rash may progress to a non-blanching rash and therefore require urgent treatment References: Communicable Diseases Network Australia, 2001, Guidelines for the early clinical and public health management of meningococcal disease in Australia, Commonwealth Department of Health and Aged Care, Canberra. eTG Complete © Therapeutic Guidelines Ltd. (www.tg.com.au) etg 26 November 2008, Revised June 2006. Viewed 8.02.09. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> van de Beek D., de Gans J., McIntyre P., and Prasad K., 2009, ‘Corticosteroids for acute bacterial meningitis (Review)’, Issue 1, viewed 8.02.09, <http://www.thecochranelibrary.com>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 45 PAGE 46 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 5 Endocrine / Envenomation Emergencies NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 47 Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only Hyperglycaemia with Severe Dehydration History Prompts n Gradual onset of symptoms; – increased thirst, increased urine output, dehydration Clinical Severity Prompts n BGL greater than 15 mmol/L n Severe dehydration n Altered mental state n Metabolic abnormality e.g. ketoacidosis n Associated symptoms; – tachycardia, hypotension, weight loss, confusion, acetone breath, Kussmaul’s respirations (deep sighing respirations of metabolic acidosis), abdominal pain n Relevant past history n Medication history n Events leading up to presentation n Allergies Assessment Intervention Position Position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Skin turgor Mucous membranes Pulse – rate/rhythm IV cannulation/pathology If signs of dehydration or if SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL bolus stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) Capillary refill Blood pressure Cardiac monitor Monitor vital signs frequently Disability AVPU / GCS BGL Monitor LOC frequently Finger prick BGL every 30 minutes Consider insulin therapy but not before a serum potassium is known and not before advice from a Medical Officer Measure and test Pathology Collect blood for FBC, UEC, BGL, ABGs/venous blood gas (if available) Temperature U/A Fluid input/output Electrocardiography Test for sugar and ketones Fluid balance chart Insert IDC – measure and record urine output every hour 12 lead ECG Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 48 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL IV Stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Close monitoring of fluid input and output is essential. n Early management priorities are to treat shock and dehydration. This is more important initially than lowering the blood glucose with insulin. n Consider insulin therapy but not before a serum potassium is known and not before advice from a medical officer. References: Brenner Z., 2006, ‘Management of hyperglycaemia emergencies’, American Association of Critical Care Nurses, vol. 17, no.1, pp. 56-65. Frederick, S., and Danzi, D., 2008, ‘Metabolic emergencies’, in eds Stone C., and Humphries R., Current Diagnosis and Treatment: Emergency Medicine, 6th edn, McGraw-Hill Companies, New York. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Tintinalli J., Kelen G., Ma O., and Cline O., 2004, Emergency medicine: a comprehensive study guide, 6th edn, McGraw-Hill Companies, New York. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 49 Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only Hypoglycaemia History Prompts Any patient who presents with confusion/convulsions/ coma should have hypoglycaemia considered as a cause. n Onset n Associated symptoms: – confusion, visual disturbances, headache, dizziness, pallor Clinical Severity Prompts n BGL less than 3 mmol/L n Relevant past history n Confusion/seizure/coma n Medication history n Events n Allergies Assessment Intervention Position Position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature IV cannulation/pathology Pulse – rate/rhythm Capillary refill Blood pressure Disability Cardiac monitor Monitor vital signs frequently AVPU/GCS BGL Monitor LOC frequently Finger prick BGL less than 3 mmol/L and conscious administer simple sugar or If unconscious or confused administer IV 50% Glucose 50 mL or If IV access unavailable, administer IM Glucagon 1 mg Finger prick BGL every 15 minutes until within normal limits and the patient is mentally alert Measure and test Specific treatment Pathology Temperature U/A Collect blood for FBC, UEC, BGL, ABGs/venous blood gas (if available) Fluid input/output Fluid balance chart Possible alcohol abuse If history of possible alcohol abuse give IM Thiamine 100 mg Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 50 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 50% Glucose 50 mL IV Stat Glucagon 1 mg (if IV access unavailable) IM Stat Thiamine 100 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Examples of oral simple sugars are; sugar, sweets or soft drink (non-diabetic) or milk, and these should be followed by a carbohydrate meal e.g. sandwiches or biscuits. n Alcoholism is the leading cause of Wernicke’s Encephalopathy, which is a neurological syndrome associated with inadequate nutrition, including a deficiency in thiamine. n ‘The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernicke’s encephalopathy is unfounded. The absorption of Thiamine is so much slower than that of glucose, timing is irrelevant’ (Hew, 2004, p. 367). References: Donnino M., Vega J., Miller J., and Walsh M., 2007, ‘Myths and misconceptions of Wernicke’s encephalopathy: What every emergency physician should know’, Annals of Emergency Medicine, vol. 50, no. 6, pp. 715-721. Frederick S., and Danzi D., 2008, ‘Metabolic Emergencies’ in eds Stone C, and Humphries R., Current diagnosis and treatment: Emergency medicine, 6th edn, McGraw-Hill Companies, New York. Hew , R., 2004, ‘Altered Conscious State’ in Textbook of adult emergency medicine, eds Cameron, P., Jelinek, G., Kelly, A., Murray, L., Brown, A., Heyworth, J., Elsevier, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Tintinalli J., Kelen G., Ma O., and Cline O., 2004, Emergency medicine: A comprehensive study guide, 6th edn, McGraw-Hill Companies, New York. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 51 Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only Snake / Spider Bite n – weakness, paralysis, headache, nausea, vomiting, abdominal pain, altered level of conscious, severe localised pain (spider bite), localised sweating, diaphoresis, excess salivation, painful lymph node, ptosis Do NOT remove pressure immobilisation bandage. Clinical Severity Prompts n Neurotoxic paralysis/diplopia/dysphagia n Convulsions n Abdominal pain, headache, nausea/vomiting History Prompts n Events – time of bite, number of bites, time and type of first aid applied, pre-hospital treatment, drug/alcohol intoxication, activity since bite, bite site location/s Associated symptoms: n Relevant past history/previous envenomation or antivenom administration n Medication history n Allergies Ensure first aid measures have been implemented and consider early transfer. Assessment Intervention Position Position of comfort / keep patient immobile Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation First aid Apply pressure immobilisation bandage and splinting to all victims of snake bite and Funnel Web spider bite Skin temperature IV cannulation/pathology Pulse – rate/rhythm Capillary refill Disability Blood pressure If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL Cardiac monitor Monitor vital signs frequently AVPU /GCS + pupils Monitor LOC frequently If GCS less than 9 and not rapidly improving, patient may require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration Measure and test Specific treatment Signs of systemic snake envenomation Whole blood clotting time (in a glass tube) Pathology Collect blood for FBC, UEC, CK, coags, group and hold Temperature U/A Fluid input/output Signs of systemic envenomation Monitor Check for myoglobin Consider IDC and observe urine for myoglobin Insert IDC – measure and record urine output every hour Nil by mouth Fluid balance chart Electrocardiography 12 lead ECG Hydration IV 0.9% Sodium Chloride 1000 mL (125 mL per hour) to maintain hydration Systemic envenomation Consider appropriate antivenom Funnel web envenomation Consider IV Atropine 0.5 mg if bradycardic and SBP less than 90 mmHg Redback spider envenomation Ice to bite site (do NOT apply pressure immobilisation bandage) Consider Redback spider antivenom Nausea and vomiting Immunisation status If nausea or vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5 mL Document assessment findings, interventions and patient’s response in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 52 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL (circulation support) IV Stat (repeat once if SBP remains less than 90 mmHg) 0.9% Sodium Chloride 1000 mL (maintain hydration) IV 125 mL per hour Atropine 0.5 mg IV Stat Metoclopramide 10 mg IV or IM Stat Boostrix or ADT Booster 0.5 mL IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Apply pressure immobilisation bandage at the same pressure as for sprained ankle. Bandage the whole limb from the armpit or groin to the digits. n IM injections should be avoided (except Boostrix/ADT Booster) in snake bite victims because of coagulopathy. n Whole blood clotting test may be performed to determine the length of time blood takes to clot. It is performed by placing 10 mL of venous blood into a glass test tube and measuring the time taken for the blood to clot. Normal time is less than 10 minutes. n A snakebite observation chart is recommended for recording vital signs and specific signs associated with snakebites/ envenomation – refer to Appendix 11. References: MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. NSW Health, 2007, Snakebite and spiderbite clinical management guidelines, viewed 19.01.09, <http://www.health.nsw. gov.au/policies/gl/2007/pdf/GL2007_006.pdf>. Stewart C., 2003, ‘Snake bite in Australia: First aid and envenomation management’, Accident and emergency nursing, vol. 11, no. 2, pp. 106-111. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 53 PAGE 54 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 6 Trauma Emergencies NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 55 Trauma | Medical Officer must be notified immediately | For Adults Only Trauma Refer Trauma Triage Tool (Appendix 12). All trauma patients should be treated as having a spinal injury until proven otherwise. Immediately call for assistance and notify the Medical Officer and Aeromedical and Medical Retrieval Service (AMRS) 1800 650 004. Clinical Severity Prompts n Vital sign abnormalities: History Prompts n Events: – high risk mechanism of injury –type – force and time n Relevant past history – recent surgery – Patients taking anticoagulant therapy/ known coagulopathy n Medication history – RR of less than 10 or greater than 29, SpO2 less than 90% on air, cyanosis or respiratory difficulty – HR greater than 120 bpm – SBP less than 90 mmHg or severe haemorrhage – LOC is V, P or U on AVPU scale. Requires at least gentle tactile stimulation and ‘shout’ to rouse from decreasing level of consciousness/GCS less than or equal to 13 or paralysis/sensory deficit n High risk mechanism of injury n Fasting status n Types of injuries – especially multi-system injuries n Allergies n The following patient groups are at greater risk and require a high index of suspicion for serious trauma: – Patients over the age of 65 years – Pregnant woman over 20 weeks gestation Types of injuries Penetrating to head, neck, chest, abdomen, perineum or back Head use Head Injury Guideline page 65 Face severe facial injury; injury with potential airway risk; severe haemorrhage Neck swelling, bruising, hoarseness or stridor Chest severe pain, subcutaneous emphysema, paradoxical breathing, crush injury Abdomen severe pain, rigidity, distension, restraint/abrasion/contusion Pelvis severe pain, genital contusions, vertical shear and open book fracture Spine weakness, sensory loss, visible deformity Limb vascular injury with ischaemia of limb, crush injury, fracture of 2 or more long bones, degloving injury, amputation The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 56 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Trauma | Medical Officer must be notified immediately | For Adults Only Assessment Intervention Full PPE measures must be considered. Position Lie supine, depending on clinical status Airway Assess patency Maintain airway patency (do NOT insert a naso-pharyngeal airway if there is any possibility of a fractured base of skull or nasal bone fracture) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Breathing Respiratory rate and effort. SpO2 Assist ventilation if required Apply O2 via non-rebreather mask to maintain SpO2 greater than 95% Asymmetrical chest movement, unilateral decreased breath sounds, tracheal deviation Tension pneumothorax – requires immediate chest decompression with a needle thoracentesis (refer to Appendix 14) Open sucking chest wound Cover with non-porous dressing taped on 3 sides only – remove immediately if respiratory status deteriorates External bleeding Control external bleeding using direct pressure/ elevation/pressure dressing Internal bleeding IV cannulation x 2 (large bore)/pathology Circulation Involve a surgeon as soon as possible Disability Blood pressure Skin temperature Pulse – rate/rhythm Capillary refill IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus to maintain SBP 80-90 mmHg Cardiac monitor Monitor vital signs frequently AVPU/GCS + Pupils Monitor GCS frequently. If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration Measure and test BGL Finger prick BGL Primary Survey Secondary Survey Repeat Commence thorough head to toe assessment including the patient’s back (log roll if at least 4 people are available) Identified deficits – go to specific treatment section immediately Pain If pain score 4-10 give IV/IO Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg to a total of 10 mg (if IV/IO access unavailable) Pathology Collect blood for FBC, UEC, group and hold, formal blood alcohol (if required and accredited to take), consider beta hCG If available ABG/venous blood gas, base deficit, serum lactate Temperature Prevent hypothermia U/A Full urinalysis and urinary hCG (if required) Fluid input/output Strict fluid balance chart Nil by mouth Insert IDC (unless contraindicated); measure and record urine output every hour Consider gastric tube. Do NOT insert a naso-gastric tube if there is a possibility of a base of skull fracture or nasal bone fracture Electrocardiography 12 lead ECG The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 57 Trauma | Medical Officer must be notified immediately | For Adults Only Specific treatment Assessment Intervention Limb-threatening injury (neurovascular compromise) Neutral alignment Splint or plaster backslab Perform neurovascular limb observations frequently (refer to Appendix 15) Amputations Preserve amputated part: wrap in moist saline gauze. Seal in airtight plastic bag. Place sealed bag in a slurry of ice; keep near patient and label bag with patient’s details accurately Abdominal Injuries Suspected pelvic fracture Suspected fractured shaft of femur Open fractures Impaled objects Cover exposed viscera with moist saline packs (avoid hypothermia) Stabilise with pelvic binding or sheeting (refer to Appendix 16) Stabilise with traction splint. Perform neurovascular observations pre and post splinting Cover with saline pack; do not reposition protruding bone ends Stabilise object – DO NOT remove Fluid deficit IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus as required to maintain SBP of 80-90 mmHg Hydration/intake Nil by mouth IV/IO 0.9% Sodium Chloride 1000 mL (125 mL/hour to maintain hydration) Nausea & vomiting If nausea or vomiting present give IV or IM Metoclopramide 10 mg Immunisation status Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5 mL Document assessment findings, interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 15 litres/min Non-rebreather mask Inhalation Continuous Compound Sodium Lactate (Hartmanns) Solution 200 mL (circulation support) IV/IO Stat (repeat as required to maintain SBP of 80-90 mmHg) Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV/IO Every 5 minutes (not to exceed 10 mg) Morphine 5-10 mg (if IV/IO access unavailable) IM Stat (not to exceed 10 mg in total) 0.9% Sodium Chloride 1000 mL (maintain hydration) IV/IO 125 mL per hour Metoclopramide 10 mg IV or IM Stat Boostrix or ADT Booster 0.5 mL IM Stat 0.9% Sodium Chloride 10 mL flush IV/IO As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 58 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Trauma | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n The list of injuries identified is not exclusive of what might be present. n Be aware of distracting painful injuries that may mask other and more serious injuries. n Some patients who may be normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg. n IV/IO Compound Sodium Lactate (Hartmanns) Solution is the first choice for resuscitation fluid in the hypovolaemic trauma patient. IV/IO 0.9% Sodium Chloride may be used as an alternative; however large volumes may result in metabolic acidosis. n Aggressive fluid resuscitation results in increased haemorrhage and greater mortality. Smaller volumes of IV fluid boluses are recommended. n Prior to inserting in-dwelling catheter ensure there is no blood at urinary meatus as this may indicate a urethral injury and this is a contraindication to inserting a urethral catheter. n Do not insert nasopharyngeal airway or nasogastric tube in patients suspected of having a fractured base of skull or nasal bone fracture. n Close monitoring of fluid input and output is essential. n Tachycardia may not occur in athletes, elderly patients, those taking beta blocking agents or those suspected of spinal cord injury. n Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. References: Ambulance Service of NSW, 2008, ‘Pre-hospital management of major trauma’. Trauma triage tool – major trauma critieria (MIST) Protocol T1. American College of Surgeons Committee on Trauma, 2008, ‘Shock’ in Advanced trauma life support course for doctors – student course manual, 8th edn, United States. Cain J.G., Smith C.E., 2001, ‘Current practices in fluid and blood component therapy in trauma’ Seminars in anesthesia, vol. 20, no. 1, pp. 28-35. Curtis K., Ramsden C., and Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Dunn R, et. a.l (editor), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Dutton R.P., Mackenzie C.F., Scalea T.M., 2002, ‘Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality’, Journal of trauma – injury, infection and critical care, vol. 52, no. 6 pp. 1141-6. Emergency Life Support (ELS) course manual, 2005, 3nd edn, ELS Course Inc., Tamworth. Emergency Nurses Association, 2000, Trauma nursing core course – provider manual, 5th edn, Emergency Nurses Association, USA. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Nolan J., 2001, ‘Fluid resuscitation for the trauma patient’, Resuscitation, vol. 48, no. 1 pp. 57-69. Pascoe S., and Lynch J., 2007, Adult trauma clinical practice guidelines, management of hypovolaemic shock in the trauma patient, NSW Institute of Trauma Injury and Management, Sydney. Tintinalli J., Gabor M., Kelen D., Stapczynski J., Ma O., Cline D., Emergency medicine: A comprehensive study guide international, 6th edn, McGraw-Hill, New York The Neurosurgical Society of Australasia, 2000, The Management of acute neurotrauma in rural and remote locations. A set of guidelines for the care of head and spinal injuries, Royal Australasian College of Surgeons, Melbourne The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 59 Burns | Medical Officer must be notified immediately | For Adults Only Burns History Prompts The burn surface is cooled with running water. Ideal water temperature is 15°C, with a range of 8-25ºC for a minimum of 20 minutes; this is beneficial for the first three (3) hours only on burns of less than 10% TBSA. Prevent hypothermia. If the patient has suffered chemical burns, ensure staff are adequately protected from contamination. Always brush dry chemicals off (use PPE) before applying cool water. n Onset – time of burn n Events: – mechanism of injury/exposure – history of electrical/thermal/chemical/radiation burns – confined space – first aid measures – defined n Associated symptoms: – cough, hoarse voice, sore throat, sooty sputum, stridor, neck/facial swelling, singed facial hair, confusion n Relevant past medical history n Medication history n Tetanus immunisation status n Allergies Clinical Severity Prompts n Airway/facial/neck burns n Burns to hands, feet, perineum n Electrical burns including lightning injuries n Chemical burns n Circumferential burns of limbs or chest Assessment Intervention Position Position of comfort/clinical status Airway Assess patency Evidence of airway burn: hoarse voice, stridor, sore throat, sooty sputum, neck / facial swelling Maintain airway patency Consider early endotracheal intubation by MO Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15 L/minute to all patients except those with minor burns Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation X 2 / pathology Blood pressure If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL Blistering Cardiac monitor Monitor vital signs frequently Electrocardiography 12 lead ECG if possible, (especially electrical burns and lightning strikes) Constrictive non-adhered clothing or jewellery Remove Disability AVPU/GCS + pupils BGL Monitor LOC frequently Finger prick BGL Measure and test Primary survey Repeat Pain score (1-3) Oral Panadeine Forte (if not nil by mouth) 1-2 tablets for minor burns only Pain score (4-10) IV/IO Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV/IO access unavailable) – avoid burnt areas Secondary survey Commence Calculate total body surface area burnt (refer to Appendix 17) The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 60 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Burns | Medical Officer must be notified immediately | For Adults Only Measure and test Specific treatment Assessment Intervention Pathology Collect blood for FBC, UEC, (consider group and hold, myoglobin, ABG/venous blood gas) Temperature Avoid hypothermia Fluid input/output Burns greater than 15% TBSA Modified Parkland formula: in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmanns) Solution 3-4 mL x kg body weight x % TBSA burnt. Give 50% of total amount in first 8 hours from time of the burn, give the remaining 50% over the next 16 hrs U/A Maintain UO at 0.5-1 mL/kg/hour Fluid balance chart Nil orally if burns greater than 10-15% TBSA NGT if greater than 20% TBSA burns and not contraindicated For burns of more than 20% TBSA, insert IDC – measure and record urine output every hour Observe urine for myoglobinuria or haemoglobinuria Liquid chemical Powder chemical Electrical/lightning strike/ haematuria/ haemoglobinuria/ rhabdomyolysis Copious water irrigation Brush off prior to copious water irrigation. Staff must use PPE Maintain UO greater than 1-2 mL/kg/hour Circumferential burns Elevate the affected limb Perform neurovascular observations every 15 minutes Burn wounds If transferring within 8 hours and patient stable, apply cling wrap to the burns If the face is burnt paraffin ointment should be applied If there is a delay in transfer, wound management should be in consultation with the burn surgeon who will receive the patient. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary Burns Service, and do not apply to the face Nausea/vomiting Immunisation status If nausea/vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5 mL Document assessment findings, interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Compound Sodium Lactate (Hartmanns) Solution As per Modified Parkland formula (above) IV/IO As per formula 0.9% Sodium Chloride 500 mL IV/IO Stat if SBP less than 90 mmHg Panadeine Forte 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) Oral Stat (one dose only) Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV/IO Every 5 minutes (to a total of 10 mg) Morphine 5-10 mg (if IV/IO access unavailable) IM Stat (to a total of 10 mg) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 mL flush IV/IO As required Boostrix or ADT Booster 0.5 mL IM Stat The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 61 Burns | Medical Officer must be notified immediately | For Adults Only Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Consult with burns specialist early. n Prompt consultation is required for any patient with facial burns/inhalation injury to ensure airway patency is maintained. n Any patient sustaining burns in a confined space is susceptible to inhalation injury and carbon monoxide poisoning. n Do not use ice or iced water to cool a burn. n Management of blisters is generally guided by specialist clinicians or institutional preferences. n Patients who require immediate consultation with a burns unit and will likely require retrieval (refer to Appendix 17): – full thickness burns greater than 5% TBSA – partial thickness burns greater than 10% TBSA – burns associated with inhalational injury – burns to face, hands, feet, genitalia, perineum and major joints – any intubated patient – chemical burns – electrical burns including lightning injuries – circumferential burns of limbs or chest – burns with concomitant trauma – burns in patients with pre-existing medical conditions that could adversely affect patient care and outcome – pregnancy with cutaneous burns – burns at the extremes of age e.g. frail elderly (NSW Health, GL2008_012, pp. 3-4) n Hydrofluoric Acid burns – early copious water irrigation and application of Calcium Gluconate gel is recommended. Consult with a specialist early. n Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. n Refer to NSW Severe Burn Injury Transfer Flow Chart; Burn Patient Emergency Assessment & Management Chart; Assessment of % Total Body Surface Area (TBSA) and Burn Distribution; Resuscitation Fluids (Appendix 17). References: Australian Resuscitation Council, 2008, Guideline 9.1.3 Burns, viewed 8.07.09, <http://www.resus.org.au/>. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> NSW Health, 2008, GL2008_012 – Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Health, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 62 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Drowning | Medical Officer must be notified immediately | For Adults Only Drowning – syncope or seizure as a precipitating event – alcohol or drug intake – circulatory arrest Clinical Severity Prompts n Altered level of consciousness n Hyperventilation before breath holding underwater n Wheezing n Trauma (head/spinal) n Crepitations n Duration of immersion n Pink frothy sputum n Water temperature n Tachycardia – greater than 100 beats per minute n Time of accident, time of rescue, time of first effective CPR n Crepitations, tachycardia, altered level of consciousness, respiratory or cardiac arrest History Prompts n In diving accidents or the unconscious submersion victim, spinal and skull fractures must be considered n Consider: – the possibility of associated drug and/or alcohol use – attempted self-harm If respiratory and/or cardiac arrest present treat as per Cardiac Arrest Guideline If history of trauma refer to Trauma Guideline Assessment Intervention Position Sit upright depending on clinical status Position supine if c-spine injury is suspected Airway Assess patency Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% If SpO2 falls below 95% with O2 consult MO Wheeze If wheeze present give inhaled Salbutamol 6-12 puffs of 100 microgram MDI + spacer If patient cannot inhale adequately to use an MDI and spacer Salbutamol 5 mg nebule stat Consider CPAP/BiPAP if available and no associated trauma present Auscultation Consider risk of pneumothorax, especially if rapid ascent from significant depth Skin temperature Pulse – rate/rhythm Remove wet clothing – cover with blankets, do NOT actively rewarm Capillary refill Blood pressure IV cannulation/pathology IV 0.9% Sodium Chloride 500 mL if SBP less than 90 mmHg Cardiac Monitor Monitor vital signs frequently Electrocardiography 12 lead ECG AVPU/GCS + pupils Monitor LOC frequently If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Circulation Disability Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration Measure and test Specific treatment BGL Finger prick BGL Pathology Collect blood for FBC, serum glucose, UEC, ABGs/venous blood gas if available Temperature U/A Fluid input/output Avoid hypothermia Fluid balance chart Nil by mouth Insert IDC – measure and record urine output every hour Chest X-ray If available Gastric distension Do not attempt to empty the stomach by external pressure Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 63 Drowning | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Salbutamol 6-12 puffs of 100 microgram dose MDI + spacer Inhalation Stat Salbutamol 5 mg Nebule (if patient unable to inhale adequately using MDI + spacer) Inhalation Stat 0.9% Sodium Chloride 500 mL IV Stat (repeat once if SBP remains less than 90 mmHg) 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n The new definition of drowning includes both cases of fatal and non-fatal drowning. ‘Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid Drowning outcomes are classified as death, morbidity and no morbidity’ (WHO, 2005). The World Health Organisation (WHO) states that the terms wet, dry, active, passive, silent and secondary drowning should no longer be used (WHO, 2005). Therefore a simple, comprehensive, and internationally accepted definition of drowning has been developed. References: Australian Resuscitation Council, 2005, Guideline 9.3.2: Resuscitation of the drowning victim, ARC, Melbourne. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The American Heart Association, 2005, ‘Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 10.3: drowning’, Circulation, vol. 112, no. 24 Supplement, pp. IV 133 – IV 135. van Beeck E., Branche C.M., Szpilman D., Modell J.H. & Bierens J.J.L.M., 2005, A new definition of drowning: towards documentation and prevention of a global public health problem, Policy and Practice, Bulletin of the World Health Organisation, vol. 83, no. 11, pp. 853-856. World Health Organisation, Department of Injuries and Violence Prevention World Health Organisation, 2003, Facts about injuries: Drowning, viewed 14.06.09, <http://www.who.int/violence_injury_prevention/publications/other_injury/en/ drowning_factsheet.pdf>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 64 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Head Injury | Medical Officer must be notified immediately | For Adults Only Head Injury History Prompts Clinical Severity Prompts n Events – high risk mechanism of injury n Associated symptoms: n GCS less than 14 n Loss of consciousness with a history of trauma n Visible deformities (fracture of skull or facial bones) n Ecchymosis around eyes or ears n Relevant past history n CSF leak from nose or ears n n Inequality or non-reactivity of pupil/s Medication history i.e. anticoagulants such as warfarin, aspirin, clopidogrel SBP less than 90 mmHg at any time n n Allergies – headache, confusion, irritability, memory loss, nausea, vomiting, dizziness, speech, motor and/or visual disturbances, seizure Assessment Intervention Position Position head up 30° unless contraindicated Airway Assess patency Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Breathing Respiratory rate, effort, pattern SpO2 Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15 L/minute to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation/pathology Blood pressure If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 200 mL bolus Cardiac monitor Monitor vital signs frequently AVPU / GCS + Pupils Monitor GCS frequently If GCS 13 or less consider retrieval/transfer If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Finger prick BGL Disability BGL Measure and test Pathology Collect blood for FBC, UEC (consider beta hCG and blood alcohol levels if accredited to take) Primary Survey Secondary Survey Temperature U/A Fluid input/output Repeat Commence Protect from hypo/hyperthermia Fluid balance chart Consider IDC and urine measurements every hour Nil by mouth if decreasing level of consciousness Pain score (1- 3) If pain score 1-3, and GCS 14 or 15 and patient not nil by mouth, give oral Paracetamol 500 mg – 1 g If pain score 4-10 give IV Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV access unavailable) Pain score (4-10) Halo sign Specific treatment Nausea/vomiting If nausea/vomiting present give IV or IM Metoclopramide 10 mg Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 65 Head Injury | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 200 mL bolus IV Stat (repeat once if SBP remains less than 90 mmHg) Paracetamol 500 mg - 1 g Oral Stat (one dose only) Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV Every 5 minutes (to a total of 10 mg) Morphine 5-10 mg (if IV access unavailable) IM Stat (to a total of 10 mg) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Prevent secondary brain injury. n Hypotension (i.e. SBP less than 90 mmHg) is a poor prognostic indicator. n Do NOT insert a nasopharyngeal airway or nasogastric tube in a patient suspected of having a fractured base of skull or nasal bone fracture. n If blood or fluid is draining from the nose or ear suspect a fractured base of skull. n A decline in the GCS of two or more points must be considered significant. A MO must be contacted immediately. n The provision of narcotic analgesia is not contraindicated once the life-saving surgical and neurological evaluation of the trauma patient has been performed. n Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. n Note: nausea and vomiting may be a sign of raised intracranial pressure. n The halo sign is present when nasal secretions on bed linen or dressings form a halo. This occurs when CSF, mixed with blood, spreads onto an absorbent surface. The darker blood chromatographically forms a ring around a lightlystained centre, forming a halo. Mixture of blood with tears or saliva can give false-positives. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 66 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Head Injury | Medical Officer must be notified immediately | For Adults Only n People on Warfarin, Clopidogrel or aspirin (especially the elderly) who have a head injury/trauma have a very high morbidity and mortality. These patients need to be monitored very closely and will require a CT scan, as they can deterioriate very quickly. n A MO must consider the need for a CT scan/further consultation, especially for high risk patients and patients whose GCS is not improving, e.g. persistent GCS less than 15 at 2 hours post injury. References: Dunn R., et. al. (eds), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Emergency Life Support (ELS) course manual, 2005, 3rd edn, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Health and Medical Research Council, 2005, Acute pain management: Scientific evidence, 2nd edn, Commonwealth of Australia, Canberra. Reed D., 2007, Adult trauma clinical practice guidelines, initial management of closed head injury in adults, NSW Institute of Trauma and Injury Management, North Ryde. The Neurosurgical Society of Australasia, 2000, The management of acute neurotrauma in rural and remote locations, The Royal Australasian College of Surgeons, Melbourne. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 67 Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only Isolated Severe Limb Injury History Prompts Clinical Severity Prompts n Obvious deformity, swelling and pain to limb n Loss of sensation and pulse n Ischaemia of limb n Onset n Events – history of trauma, mechanism of injury n Associated symptoms; – obvious deformity – swelling to limb – pain associated with the injury n Relevant past history n Medication history n Allergies Assessment Intervention Position Position of comfort/function Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation External bleeding Skin temperature Pulse – rate/rhythm Control external bleeding Record colour, warmth, sensation, movement and pulses of affected limb (refer to Appendix 15) Capillary refill IV cannulation Blood pressure Monitor vital signs frequently Disability AVPU/GCS Monitor LOC frequently Measure and test Pain score (1-3) If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IV Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV access unavailable) Pain score (4-10) Specific treatment Fluid input/output Fluid balance chart Nil by mouth (until anaesthetic requirement confirmed) Neurovascular observations Neutrally align limb if possible. Assess both limbs frequently as well as pre and post splinting or plaster backslab X-Ray If available Nausea/vomiting If nausea/vomiting present give IV or IM Metoclopramide 10 mg Limb stabilisation Immobilisation/elevation/ice/splint/POP backslab Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 68 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous Panadeine Forte 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) Oral Stat Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV Every 5 minutes (not to exceed 10 mg) Morphine 5-10 mg (if IV access unavailable) IM Stat (not to exceed 10 mg) Metoclopramide 10 mg IV or IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: Precautions and Notes: n Neurovascular limb observations must also include the unaffected limb for comparison. n Refer to Appendix 15 for suggested guidelines for a neurovascular assessment. n Compartment syndrome is a limb threatening complication of limb injury caused by increased pressure. n Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. References Curtis K., Ramsden C., & Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Dunn R., et. al. (ed), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 69 Ocular Injuries | Medical Officer must be notified immediately | For Adults Only Ocular Injuries History Prompts Some patients who present complaining of eye flash burns may in fact have a corneal foreign body. n Events – mechanism of injury (e.g. drilling, high speed motor drilling without eye protection) n Associated symptoms; Clinical Severity Prompts – pain, redness, tearing, headache, loss of vision, type of foreign body (e.g. glass, dirt, organic, metal) n Injury with loss of visual acuity n Welding in past 24 hours n Relevant past history n Exposure to snow or water glare in past 24 hours n Medication history n Chemical exposure or burn injury to eye n Allergies n Penetrating foreign body of the eye Assessment Intervention Position Position of comfort, but lie supine (if penetrating injury or suspected retinal detachment) Airway Assess patency Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if associated history of trauma) Breathing Respiratory rate and effort SpO2 If other associated trauma, support ventilation if required Apply O2 to maintain SpO2 greater than 95% Circulation Skin temperature Pulse – rate/rhythm Blood pressure Monitor vital signs frequently Disability AVPU/GCS + pupils Monitor LOC frequently Measure and test Temperature Visual acuity Specific treatment Snellen chart/finger count/light perception assessment and pupillary response Pain score (1-3) Pain score (4-10) If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IM Morphine 5-10 mg (10 mg in total) Penetrating injury Do not remove foreign body. Stabilise foreign body Do not apply eye pad or pressure to eye Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5 mL Corneal foreign bodies (e.g. dust, small organic matter) Instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye. Instil eye drops every 15-20 minutes during irrigation procedure If small amount of superficial dust or organic matter is present, gently remove with a cotton bud which has been moistened with 0.9% Sodium Chloride. Gentle irrigation with a neutral fluid e.g. Compound Sodium Lactate (Hartmanns) solution or 0.9% Sodium Chloride using an IV blood pump giving set may be required if a number of superficial dust particles are present. Chemical exposures If history of chemical exposure instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye. Instil eye drops every 15-20 minutes during irrigation procedure Irrigate eye/s with copious amounts of a neutral fluid e.g. Compound Sodium Lactate (Hartmanns) Solution or 0.9% Sodium Chloride using an IV blood pump giving set for at least 30 minutes Continue irrigation until pH is within range of 6.5 to 8.5 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 70 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Ocular Injuries | Medical Officer must be notified immediately | For Adults Only Specific treatment Assessment Intervention Flash burns If flash burns to eyes instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye (one dose only) Suspected retinal detachment/hyphaema Fluid input/output Instruct patient to observe strict bed rest, at least until reviewed by MO In anticipation of surgical intervention restrict the patient to remain nil by mouth Nausea and vomiting If nausea/vomiting present give IM Metoclopramide 10 mg Corneal injury Instil Fluorescein Sodium 1 drop affected eye/s only, view injury with cobalt blue light Document assessment findings, interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres / min Inhalation Continuous Compound Sodium Lactate (Hartmanns) Solution 1000 mL Eye irrigation Stat (repeat as required) 0.9% Sodium Chloride 1000 mL Eye irrigation Stat (repeat as required) Panadeine Forte 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) Oral Stat Morphine 5-10 mg (not to exceed total 10 mg) IM Stat 0.4% Oxybuprocaine drops 2 drops per affected eye Topical Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) 0.5% or 1% Amethocaine drops 2 drops per affected eye Topical Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) Metoclopramide 10 mg IM Stat Fluorescein Sodium 1 drop affected eye/s Topical Stat Boostrix or ADT Booster 0.5 mL IM Stat Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 71 Ocular Injuries | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n It is important to test the visual acuity (VA) in ALL patients with ocular trauma as it is an important parameter and is of medicolegal importance n Chemical exposure: – ensure both the upper and lower eyelids are everted during irrigation – patients with chemical exposure to the eyes should also be assessed for potential aspiration of chemicals and subsequent airway obstruction – ensure the face and other exposed areas are thoroughly washed with water. n Corneal injury/s: – instil one drop of Fluorescein Sodium to affected eye/s only, view eye injury with cobalt blue light from torch or ophthalmoscope – soft contact lens/es MUST be removed prior to instillation of Fluorescein Sodium drop/s n Patient with metallic foreign body/s in the eye require referral to MO. If not (correctly) removed the metallic foreign body/s may lead to the formation of rust ring/s. Do not irrigate the eye/s if metallic foreign body is insitu n Do not send patient home with local anaesthetic eye drops References: MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. NSW Department of Health, 2009, Eye Emergency Manual: An Illustrated Guide, 2nd Edn, NSW Department of Health, North Sydney. Ramsden C., Curtis K., Seggie J., & Braybrooks L., 2007, ‘Ocular emergencies’, in Emergency & trauma nursing, (eds) Curtis K., Ramsden C. & Friendship J., Mosby, Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 72 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 7 Other Emergencies NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 73 Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only Abdominal/Loin/Flank Pain Note: A leaking abdominal aortic aneurysm can mimic renal colic in elderly patients. n Nature of Onset n Associated symptoms – nature of pain/radiation – nausea, vomiting Clinical Severity Prompts –diarrhoea/constipation – last menstrual period/symptoms of pregnancy n Pain to abdomen/loin/flank n Localised tenderness to right upper or lower quadrant of abdomen n Rapid onset History Prompts n Four immediately life threatening presentations that require exclusion are; 1. Ruptured ectopic pregnancy – urinary symptoms – weight loss n Relevant past history n Immunocompromised n Medication history n Events – mechanism of injury (if trauma is involved) n Allergies 2. Ruptured abdominal aortic aneurysm 3. Acute myocardial infarction 4. Ruptured spleen Assessment Intervention Position Position of comfort Airway Assess patency Maintain airway patency Breathing Respiratory rate and effort SpO2 Assist ventilation if required Apply O2 to maintain greater than 95% Circulation Skin temperature Pulse – rate/rhythm Capillary refill IV cannulation/pathology Blood pressure If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL stat Cardiac monitor Monitor vital signs frequently Disability AVPU / GCS BGL Monitor LOC frequently Finger Prick BGL Measure and test Abdominal assessment Look, listen and feel Pain score (2-10) If pain score 2-10 give IV Morphine 2.5 mg every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV access unavailable) Pathology Collect blood for FBC, UEC, (consider LFT’s, serum amylase, coags, group and hold) Temperature U/A Specific treatment Fluid input/output Urine hCG (if required), collect MSU Strain urine for calculi Fluid balance chart Electrocardiography 12 Lead ECG Hydration / intake Nil by mouth IV 0.9% Sodium Chloride 1000 mL at 125 mL per hour to maintain hydration Nausea and vomiting IM Prochlorperazine 12.5 mg Document assessment findings, interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 74 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Drug Dose Route Frequency Oxygen 6-15 litres/min Inhalation Continuous 0.9% Sodium Chloride 500 mL bolus IV Stat (repeat once if SBP remains less than 90 mmHg) Morphine 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) IV Every 5 minutes (to a total of 10 mg) Morphine 5-10 mg (if IV access unavailable) IM Stat (to a total of 10 mg) 0.9% Sodium Chloride 1000 mL IV 125 mL per hour Prochlorperazine 12.5 mg IM Stat 0.9% Sodium Chloride 10 mL flush IV As required Medications within this guideline must be administered within the context of the formulary. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Authorising Medical Officer signature: Name: Designation: Date: Drug Committee approval: Date: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 75 Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n Elderly patients presenting with abdominal/loin/flank pain have a 14% mortality rate. Symptoms may be vague with a low tolerance for shock e.g. a SBP of 90 mmHg may be critical if previously hypertensive n Patients over the age of 65 years requiring opioids should be monitored frequently, both for the effectiveness of the analgesia and the presence of adverse effects n Opioid analgesics can be safely administered before full assessment and diagnosis in acute abdominal pain, without increasing the risk of errors in diagnosis or treatment n Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment n Metoclopramide hydrochloride should only be used where bowel obstruction/perforation has been excluded n Metoclopramide appears to be a more effective antiemetic than prochlorperazine, but should not be administered unless ordered by a Medical Officer n Tachycardia may not occur in patients taking beta blocking agents. References: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2010, Acute Pain Magement: Scientific Evidence, 3rd edn. Gallager E.J., 2004, ‘Acute abdominal pain’, in Emergency medicine: A comprehensive study guide, The McGraw-Hill Companies Inc. National Health and Medical Research Council, National Institute of Clinical Studies, 2008, Pain medication for acute abdominal pain. A summary of best available evidence and information on current clinical practice, Australian Government, Canberra. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 76 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 The following drug information pertains only to the context specified in this NSW Rural ADULT Emergency Clinical Guidelines document Formulary The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 77 Formulary Index Adrenaline...................................................................79 Metoclopramide..........................................................89 Amethocaine 0.5% or 1%...........................................79 Midazolam...................................................................89 Amiodarone.................................................................80 Morphine.....................................................................90 Aspirin.........................................................................81 Naloxone.....................................................................91 Atropine......................................................................81 Oxybuprocaine.............................................................91 Benzylpenicillin............................................................82 Paracetamol.................................................................92 Ceftriaxone..................................................................82 Paracetamol and Codeine (Panadeine Forte).................92 Dexamethasone...........................................................83 Prednisolone................................................................93 Fluorescein...................................................................83 Prochlorperazine..........................................................93 Flucloxacillin.................................................................84 Salbutamol (Ventolin)...................................................94 Frusemide....................................................................84 Boostrix/ADT Booster...................................................95 Gentamicin..................................................................85 Thiamine (Vitamin B-1).................................................96 Glucagon.....................................................................85 0.9% Sodium Chloride................................................96 50% Glucose...............................................................86 0.9% Sodium Chloride................................................97 Glyceryl Trinitrate (tablet or spray)................................87 Compound Sodium Lactate (Hartmanns Solution)........98 Hydrocortisone............................................................88 Vancomycin.................................................................98 Ipratropium Bromide (Atrovent)...................................88 PAGE 78 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Parenteral Adrenergic Agents Drug Name Adrenaline Indications/Doses Anaphylactic Reaction: 0.5 mg IM every 3-5 minutes (to a total of 2 mg); 50 micrograms IV stat if no response to IM adrenaline and patient presents signs of cardiorespiratory collapse Shortness of breath with or without a history of asthma: 0.5 mg IM (pre-arrest circumstance or asthma associated with anaphylaxis) stat Cardiorespiratory Arrest (Advanced Life Support): – Shockable rhythms: 1 mg IV/IO after the 2nd shock and then 1mg IV/IO every 2nd loop to a total of 3 mg Non-shockable rhythms: 1 mg IV/IO immediately and then 1 mg IV/IO every 2nd loop to a total of 3 mg Contraindications Interactions Sympathomimetics cause additive effects; beta-blockers antagonise therapeutic effects of Adrenaline; digoxin potentiates proarrhythmic effect of Adrenaline; Tricyclic Antidepressants and Mono Amine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline Pregnancy (Category A) Adrenaline has been given to a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus Precautions Adverse effects include cardiac ischaemia or dysrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid haemorrhage; use with caution in hypertension, cardiovascular disease, and cerebrovascular insufficiency; phenothiazines can cause a paradoxical decrease in BP comment as above Modified from: Australian Injectable Drugs Handbook, Fourth Edition, http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/7-section-7?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographadrenaline-02. html#adrenaline-02 <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2826&product_ name=Adrenaline+Injection <accessed 22/12/08> Drug Category: Topical Ocular Anaesthetics Drug Name Amethocaine 0.5% or 1% Indications/Dose Ocular Injuries: 2 drops per affected eye, topical, stat to produce local anaesthesia in the eye. Can be used every 15-20 minutes during the irrigation procedure. Stat only for flash burns Contraindications Documented hypersensitivity. Not for use in cases with penetrating eye injury Interactions Antagonises effect of sulfonamides and aminosalicylic acid Pregnancy Amethocaine not categorised Precautions May give rise to dermatitis in hypersensitive patients. The anaesthetised eye should be protected from dust and bacterial contamination Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter11/monographamethocaine-02. html#amethocaine-02 <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1515&product_ name=Minims+Local+Anaesthetics <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 79 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Antiarrhythmics Drug Name Amiodarone Indications/Doses Cardiorespiratory Arrest (Advanced Life Support): 300 mg IV/IO stat after the 3rd shock for VF/VT cardiorespiratory arrest Contraindications Documented hypersensitivity; systemic lupus erythematosus, digitalis induced dysrhythmias, torsade de pointes, second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome (without pacemaker) Interactions Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecainide, digoxin, cyclosporine, beta-blockers, and anticoagulants; co administration with calcium channel blockers may cause additive effects, further decreasing myocardial contractility; cimetidine may increase amiodarone levels Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Avoid use 3 months before and during pregnancy; may cause thyroid dysfunction and bradycardia in the foetus Precautions Hypotension (most common adverse effect), bradycardia, and AV block may occur. Phlebitis is an issue and also incompatible with 0.9% Sodium Chloride Overly rapid administration can cause hypotension Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/18-section-18?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographamiodarone. html#amiodarone <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=176&product_ name=Cordarone+X+Intravenous+Injection <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 80 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Antiplatelet Agents Drug Name Aspirin Indications/Doses Acute Coronary Syndrome: 300 mg Oral (chew) stat (if not already given by Ambulance Paramedics) Inhibits platelet aggregation Contraindications Documented hypersensitivity; active upper GI bleed. Interactions Effects may decrease with antacids and urinary alkalinisers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinaemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonise uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Precautions Avoid use in history of blood coagulation defects, asthma, urticaria Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter7/monographaspirin-02. html#aspirin-02<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=361&product_ name=Disprin <accessed 22/12/08> Drug Category: Anticholinergic Agents Drug Name Atropine Indications/Doses Compromising Bradycardia: 0.5 mg IV increments every 5 minutes (to a total of 3 mg) titrated to maintain SBP greater than 90 mmHg Snake/spider Bite: (Systemic envenomation) 0.5 mg IV stat if patient bradycardic and SBP less than 90 mmHg Contraindications None when indicated for symptomatic bradycardia or asystole Interactions None for this indication Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Increased risk of arrhythmias in IHD Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/32-section-32?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographatropine. html#atropine <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2163&product_ name=Atropine+Sulfate+Injection+BP <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 81 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: 8(a) Penicillins Drug Name Benzylpenicillin Indications/Doses Meningococcal Disease: Non-blanching Rash – 1.2 g IV/IO/IM Stat Contraindications History of hypersensitivity reactions to beta-lactam antibiotics Interactions Intravenous solutions of Benzylpenicillin are physically incompatible with many other substances including certain antihistamines, some other antibiotics, metaraminol tartrate, noradrenaline acid tartrate, thiopentone sodium and phenytoin sodium Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Serious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/40-section-40?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter5/monographbenzylpenicillin. html#benzylpenicillin<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=846&product_ name=BenPen <accessed 22/12/08> Drug Category: 8(b) Cephalosporins Drug Name Ceftriaxone Indications/Doses Meningococcal Disease: Non-blanching Rash – 2 g IV/IO/IM Stat (if allergy to penicillin) Contraindications Allergy to cephalosporins Interactions Chloramphenicol Ceftriaxone is incompatible with calcium; do not give via calcium-containing solutions i.e. do not mix with Hartmanns Pregnancy Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals have not shown evidence of an increased occurrence of foetal damage Precautions Renal, hepatic impairment; impaired vitamin K synthesis; prolonged use; history of GIT disease (esp. colitis); pregnancy, lactation Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/56-section-56?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter5/monographceftriaxone. html#ceftriaxone<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7874&product_ name=Ceftriaxone <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 82 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Dexamethasone Indications/Doses Meningococcal disease: Non-blanching rash – if patient greater than 65 kg give 10 mg IV/IO stat If less than 65 kg give 0.15 mg per kg IV/IO stat Contraindications Known hypersensitivity to dexamethasone Interactions Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids Oral contraception Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed. Considered safe to use as non-treatment may be more serious for the foetus and ongoing pregnancy Precautions Cirrhosis or hypothyroidism may enhance the effect of corticosteroids Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/83-section-83?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographdexamethasone. html<accessed 05/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=679&product_ name=Dexmethsone#Precautions <accessed 05/03/09> Drug Category: Other Ophthalmic Medication Drug Name Fluorescein Indications/Doses Ocular Injuries: instil one drop to affected eye/s with excess being washed away with sterile 0.9% Sodium Chloride solution Fluorescein does not stain a normal cornea, but corneal abrasions or ulcers are stained a bright green and foreign bodies are surrounded by a green ring Contraindications Known hypersensitivity Interactions Nil Pregnancy Precautions Pseudomonas aeruginosa grows well in fluorescein – single dose sterile solutions should be used when using this solution to avoid infecting already damaged eye/s. Fluorescein can permanently stain soft contact lenses – remove lenses before applying the stain Modified from: Australian Medicines Handbook 2008; http://proxy7.use.hcn.com.au/appendices/appapp-additional-drugs. html#fluorescein <accessed 06.02.2009> MIMS Online 2008; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr _pi&product_ code=1618&product_name=Minims+Stains <accessed 06.02.2009>. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 83 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Penicillins – Infections and Infestations Drug Name Flucloxacillin Indications/Doses Severe Sepsis: with no obvious source of infection and patient is immunocompromised – 2 g IV/IO stat Contraindications History of hypersensitivity reactions to penicillins and other beta-lactam antibiotics Interactions Intravenous solutions of flucloxacillin are physically incompatible with many other substances including many other antibiotics – gentamicin, tobramycin and vancomycin, and meta clopramide,morphine sulphate, and pethidine Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Serious, and occasionally fatal, hypersentivity reactions (anaphylaxis) have been reported in patients receiving penicillins and other beta-lactam antibiotics Modified from: Mims Online, http://proxy36.use.hcn.com.au/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Flucloxa cillin+Sodium+for+Injection+(DBL)&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=37670001_2 < accessed 30.09.11> Drug Category: 2(c) Diuretics Drug Name Frusemide Indications/Doses Shortness of Breath with History of Cardiac Disease: 40 mg IV stat if audible respiratory crepitations present Contraindications Documented hypersensitivity Severe sodium and fluid depletion Treatment with potassium-lowering drugs, e.g. amphotericin, increases risk of hypokalaemia; monitor potassium concentration Anuria Interactions Interferes with hypoglycaemic effect of antidiabetic agents concurrent aminoglycosides cause auditory toxicity – hearing loss of varying degrees may occur; may increase anticoagulant activity of warfarin; increased plasma lithium levels and toxicity are possible Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Frusemide must not be given during pregnancy unless there are compelling medical reasons. Treatment during pregnancy requires monitoring of foetal growth Precautions Excessive diuresis may cause dehydration, electrolyte imbalances and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in elderly patients Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/131-section-131?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographfrusemide. html#frusemide<accessed 2/03/09> Mims Online, http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=792&product_ name=Lasix <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 84 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Aminoglycosides – Infections and Infestations Drug Name Gentamicin Indications/Doses Severe Sepsis: 7 mg/kg IV for one dose (maximum 640 mg) Contraindications Aminoglycoside toxicity, history of sensitivity Interactions Gentamycin is inactivated by penicillins and cephalosporins and should not be mixed or given simultaneously. Should be administered by separate infusion Pregnancy Category D Gentamicin known to cross placenta. Evidence of selective uptake by the foetal kidney resulting in cellular damage. Thought to be reversible Precautions Renal impairment Modified from: Mims Online, http://proxy36.use.hcn.com.au/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=gentami cin&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=8990001_2 < accessed 30.09.11> Drug Category: Glucose-elevating Agents Drug Name Glucagon Indications/Doses Unconscious patient: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L and patient unconscious or confused Seizures: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L Stroke including Transient Ischaemic Attack: If IV access unavailable- 1 mg IM stat if BGL less than 3.5 mmol/L and patient unconscious or confused Severe Sepsis: If IV access unavailable- 1 mg IM stat if BGL less than 3.0 mmol/L Hypoglycaemia: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L and patient unconscious or confused Contraindications Documented hypersensitivity, phaeochromocytoma, insulinoma, glucagonoma Interactions May enhance effects of anticoagulants Pregnancy Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of foetal damage Precautions Effective in treating hypoglycaemia only if sufficient liver glycogen present, therefore glucagon hydrochloride has virtually no effect on patients in states of starvation, adrenal insufficiency, or chronic hypoglycaemia or alcohol induced hypoglycaemia Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/138-section-138?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter10/monographglucagon. html#glucagon <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2810&product_ name=GlucaGen <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 85 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Glucose Supplement Drug Name 50% Glucose Indications/Doses Unconscious Patient: 50 mL IV stat if BGL less than 3.0 mmol/L and patient unconscious or confused Seizures: 50 mL IV stat if BGL less than 3.0 mmol/L Stroke including Transient Ischaemic Attack: 50 mL IV stat if BGL less than 3.5 mmol/L and patient unconscious or confused Severe Sepsis: 50 mL IV stat if BGL less than 3.0 mmol/L and patient unconscious or confused Hypoglycaemia: 50 mL IV stat if BGL less than 3.0 mmol/L and patient unconscious or confused Contraindications Avoid in dehydrated patients; diabetic (hyperglycaemic) coma Interactions Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions May cause nausea, monitor fluid balance, electrolyte concentrations, and acid-base balance closely; glucose administration may produce vitamin B-complex deficiency; thrombophlebitis Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/139-section-139?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter10/ treathypoglycaemia.t.html#idxglucose:inhypoglycaemiaidx <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2741&product_ name=Glucose+Injection+BP+50%25 <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 86 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Nitrates Drug Name Glyceryl Trinitrate (tablet or spray) Indications/Dose Shortness of Breath with History of Cardiac Disease: 300-600 micrograms (½-1 tab) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 1800 micrograms or n 1-2 sprays (400-800 micrograms) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms) Acute Coronary Syndrome: n 300-600 micrograms (½-1 tab) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 3 tablets (1800 micrograms) or n 1-2 sprays (400-800 micrograms) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms) n Contraindications Hypotension; hypertrophic obstructive cardiomyopathy; cardiac tamponade; aortic or mitral stenosis; cor pulmonale; marked anaemia; raised intracranial pressure; treatment with phosphodiesterase 5 inhibitors (e.g. sildenafil – Viagra); documented hypersensitivity Interactions Severe hypotension may occur with co administration of phosphodiesterase 5 inhibitors (e.g. sildenafil) – ‘Viagra’ Pregnancy Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of foetal damage Precautions Adverse effects are mostly due to vasodilator effects. Caution required in the presence of hypotension. Medical officer should be consulted prior to administration in pregnant patients. Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographglyceryl-trinitrate. html#glyceryl-trinitrate <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=193&product_ name=Anginine <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 87 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Hydrocortisone Indications/Doses Shortness of Breath with or without a History of Asthma: 200 mg IV (moderate and severe asthma) stat Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease: 200 mg IV (moderate and severe cases) stat Contraindications Uncontrolled infection, active peptic ulcer disease Interactions Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone. Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Decreases the efficacy of the following medications; Aspirin, Insulin or oral antidiabetic agents Oral contraception Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Precautions Cirrhosis or hypothyroidism may enhance the effect of corticosteroids Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/147-section-147?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographhydrocortisone. html#hydrocortisone <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=689&product_ name=Solu%2dCortef <accessed 23/12/08> Drug Category: Bronchodilators Drug Name Indications/Dose Ipratropium Bromide (Atrovent) Shortness of Breath with or Without a History of Asthma: 4 puffs of 20 microgram Metered Dose Inhaler (severe asthma) or n 500 micrograms nebule (severe asthma) stat if patient cannot inhale adequately to use an MDI + spacer Shortness of Breath with History of Chronic Obstructive Pulmonary Disease: n 4 puffs of 20 microgram Metered Dose Inhaler stat or n 500 microgram nebule stat if patient cannot inhale adequately to use an MDI + spacer n Contraindications Documented hypersensitivity to ipratropium Interactions Drugs with anticholinergic properties may increase toxicity. Cardiovascular effects may increase with Monoamine Oxidase Inihibitors, tricyclic antidepressants, and sympathomimetic agents. Disodium cromoglycate with benzalkonium Cl Beta-Adrenergics, xanthines (additive). Check with Medical Officer before giving to patient already receiving tiotropium Pregnancy Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Precautions Caution in glaucoma (protect eyes if nebuliser in use), prostatic hypertrophy, and hyperthyroidism, diabetes mellitus, and cardiovascular disorders Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter19/monographipratropium. html#ipratropium<accessed 4/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=6818&product_ name=Atrovent+Metered+Aerosol+%28CFC%2dfree%29 <accessed 23/12/08> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1284&product_name=Atr ovent+Nebulising+Solution <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 88 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Antiemetics Drug Name Metoclopramide Indications/Dose If nausea/vomiting present: Snake / spider bite: 10 mg IV or IM stat Stroke including Transient Ischaemic attack: 10 mg IV or IM stat Trauma: 10 mg IV/IO or IM stat Burns: 10 mg IV/IO or IM stat Head Injury: 10 mg IV or IM stat Isolated severe limb injury: 10 mg IV or IM stat Ocular injuries: 10 mg IM stat Contraindications Documented hypersensitivity. Patients with history of dystonia / extrapyramidal reactions to medication. Extrapyramidal side effects (EPSE) more likely in patients < 20 years of age Not to be used in presence of intestinal obstruction Phaeochromocytoma Interactions May increase sedative effects of other medication and worsen Parkinson’s symptoms in patients with Parkinson’s Disease Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed. Precautions Caution in history Parkinson disease; elderly more likely to experience drowsiness Moderate and Severe Renal impairment as EPSE are common Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/196-section-196?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter12/monographmetoclopramide. html#metoclopramide <accessed 4/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=549&product_ name=Metoclopramide+Injection <accessed 23/12/08> Drug Category: Anxiolytics Drug Name Indications/Dose Midazolam Seizures: 2.5 mg increments IV slow injection every 1-2 minutes (to a total of 0.1 mg per kg) or n If IV access unavailable, 10 mg IM stat and repeat (once only) after 5 minutes if required n Contraindications Documented hypersensitivity; pre-existing hypotension. Rapid or bolus IV Interactions Sedative effects may be antagonized by theophyllines, alcohol; narcotics and erythromycin may accentuate sedative effects due to decreased clearance Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Precautions Respiratory depression, apnoea, cardiovascular depression and cardiac arrest are more likely after IV injection Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure eliminate Midazolam slower Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/199-section-199?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter2/monographmidazolam.html <accessed 05/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=6104&product_ name=Midazolam+Injection#Precautions <accessed 05/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 89 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Analgesics Drug Name Morphine Indications/Dose Acute Coronary Syndrome: 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Trauma – (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Stroke including Transient Ischaemic attack – (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5 – 10 mg IM stat (to a total of 10 mg) Burns – (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Head injury – (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Isolated severe limb injury – (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Ocular injuries: n 5-10mg IM stat (to a total of 10 mg) Abdominal/loin/flank pain – (if pain score 2-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) n Contraindications Documented hypersensitivity; severe respiratory disease, coma Interactions Respiratory depressant and sedative effects may be additive in the presence of other medication Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Precautions Caution in hypotension, nausea, vomiting, caution in supraventricular tachycardias; has vagolytic action and may increase ventricular response rate Caution in patients with severe renal, hepatic dysfunction, may cause excessive sedation or coma Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/ content/article/1-drug-monographs-a-z/202-section-202?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographmorphine. html#morphine <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=379&product_ name=DBL+Morphine+Sulfate+Injection+BP <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 90 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Antidotes for Narcotic Agonists Drug Name Naloxone Indications/Dose Unconscious Patient: 800 micrograms IM stat and 800 micrograms IV stat Contraindications Documented hypersensitivity Interactions Decreases analgesic effects of opioids. Effects of partial agonists eg buprenorphine, tramadol only partially reversed by naloxone. Pregnancy Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Precautions Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence. If patients do not respond to multiple dose of Naloxone, consider alternative causes of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/206-section-206?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter4/monographnaloxone. html#naloxone <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2157&product_ name=Naloxone+Hydrochloride+Injection <accessed 06/03/09> Drug Category: Topical Ocular Anaesthetics Drug Name Oxybuprocaine 0.4% Indications/Dose Ocular Injuries: 2 drops per affected eye, topical, stat. To produce local anaesthesia in the eye. Can be used every 15-20 minutes during the irrigation procedure. Stat only for flash burns Contraindications Documented hypersensitivity. Not for use in cases with penetrating eye injury. Concomitant eye infection Interactions Pregnancy (Category D) Safety for use in pregnancy has not been established. Minims, Oxybuprocaine eye drops should be used only when it is considered essential by a doctor Precautions May give rise to dermatitis in hypersensitive patients. The anaesthetised eye should be protected from dust and bacterial contamination. Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter11/monographoxybuprocaine. html#oxybuprocaine <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7450&product_ name=Minims+Benoxinate+%28Oxybuprocaine%29 <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 91 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Analgesics Drug Name Paracetamol Indications/Dose Head injury: 500 mg-1 g (1-2 tablets) oral stat if pain score 1-3 and patient not nil by mouth Stroke including Transient Ischaemic attack: 500 mg – 1 g IV (Perfalgan) if temperature greater than 37.5°C or 500 mg – 1 g (1-2 suppositories) per rectum if temperature greater than 37.5°C Severe Sepsis: 500 mg – 1 g (1 -2 tablets) oral stat if temperature greater than 38.5°C Contraindications Documented hypersensitivity – patient is nil orally Interactions Anticoagulants; drugs affecting gastric emptying; hepatic enzyme inducers including alcohol, anticonvulsants Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Caution in severe renal or hepatic dysfunction Max dose = 4g per day total Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographparacetamol. html#paracetamol <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=391&product_ name=Panadol <accessed 06/03/09> Drug Category: Analgesics Drug Name Paracetamol and Codeine (Panadeine Forte) (Paracetamol 500mg and Codeine Phosphate 30mg) Indications/Dose Burns: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Isolated Severe Limb Injury: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Ocular Injuries: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Contraindications Documented hypersensitivity Patient nil orally Interactions CNS depressants or tricyclic antidepressants increase toxicity, drugs affecting gastric emptying, significant respiratory disease, comatose patients. Paracetamol may increase chloramphenicol concentrations Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Caution in severe renal or hepatic dysfunction Max 4g per day total Paracetamol Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographparacetamol.html#id xPanadeineForteparacetamolacodeineidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=390&product_ name=Panadeine+Forte <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 92 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Prednisolone Indications/Dose Shortness of Breath with or without a History of Asthma: 50 mg oral stat (moderate and severe asthma) if IV access unavailable Shortness of Breath with History of Chronic Obstructive Pulmonary Disease: 50 mg oral stat (severe and moderate cases) if IV access unavailable Contraindications Documented Hypersensitivity to Prednisolone. Active Peptic ulcer; osteoporosis; psychoses, psychoneuroses; TB; systemic fungal infections Interactions Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Patients who are immunosuppressed Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographprednisoneprednisolone.html#prednisone-prednisolone <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2832&product_ name=Solone accessed 06/03/09> Drug Category: Antiemetics Drug Name Prochlorperazine Indications/Dose Abdominal/loin/flank Pain: 12.5 mg IM stat if nausea/vomiting present Contraindications Documented hypersensitivity Patients with history of dystonia / extrapyramidal reactions to medication. Extrapyramidal Side Effects (EPSE) more likely in patients less than 20 years of age CNS depression Interactions May increase sedative effects of other medication and worsen Parkinson’s symptoms in patients with Parkinson’s Disease Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Precautions May worsen symptoms of Parkinson’s Disease; watch for hypotension Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/248-section-248?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter12/monographprochlorperazine. html#prochlorperazine <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=553&product_ name=Stemetil <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 93 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Inhaled Beta-agonists Drug Name Salbutamol (Ventolin) Indications/Dose Anaphylactic Reaction: Metered Dose Inhaler + spacer; 10 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present Shortness of Breath with or without a History of Asthma: n Metered Dose Inhaler + spacer; 8-12 puffs of 100 microgram Metered Dose Inhaler every 15-30 minutes for severe asthma; 8-12 puffs of 100 microgram Metered Dose Inhaler every 1-4 hours for moderate asthma; 8-12 puffs of 100 microgram Metered Dose Inhaler stat for mild asthma n 5 mg nebule every 15-30 minutes for patients with severe asthma who cannot inhale well enough to use MDI + spacer Shortness of Breath with History of Chronic Obstructive Pulmonary Disease: n Metered Dose Inhaler + spacer; 10 puffs of 100 microgram dose Metered Dose Inhaler repeat every 20 minutes if required n 5 mg nebule every 20 minutes if required (for patients with severe cases who cannot inhale well enough to use MDI + spacer) Drowning: n Metered Dose Inhaler + spacer; 6-12 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present n 5 mg nebule stat (for patients who cannot inhale well enough to use MDI + spacer) n Contraindications History of Hypersensitivity; Can cause paradoxical bronchospasm, allergic reactions Interactions May increase cardiovascular effects of other sympathomimetics drugs Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions May cause tachycardia, nausea and tremors. Caution in patients with coexisting cardiovascular disease. Hypokalaemia can occur with high doses particularly in combination with other potassiumdepleting medications. Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter19/monographsalbutamol. html#salbutamol <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=4114&product_ name=Asmol+CFC%2dfree+Inhaler <accessed 06/03/09> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1296&product_name=Ventol in+Respirator+Solution+and+Nebules <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 94 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Immune Enhancement Drug Name Diphtheria, tetanus +/-, pertussis (ADT Booster) (where not available, Boostrix can be used) Indications/Dose Snake / spider Bite: 0.5 mL IM stat Trauma: 0.5 mL IM stat Burns: 0.5 mL IM stat Ocular Injuries: 0.5 mL IM stat Contraindications The only absolute contraindications to tetanus vaccine are: anaphylaxis following a previous dose of the vaccine, or n anaphylaxis following any vaccine component n Interactions Immunosuppression/ deficiency patients Pregnancy Category A – ADT Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Category B2 – Boostrix Adequate human data on use during pregnancy and adequate animal reproduction studies are not available. Therefore, Boostrix should be used during pregnancy only when clearly needed and the possible advantages outweigh the possible risks for the foetus. When protection against tetanus is sought, consideration should be given to tetanus or combined diphtheria tetanus vaccines. As with all inactivated vaccines, one does not expect harm to the foetus. Precautions If an individual has a tetanus-prone wound and has previously had a severe adverse event following tetanus vaccination, alternative measures, including the use of human tetanus immunoglobulin, can be considered. Modified from: The Australian Immunisation Handbook; http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ Handbook-tetanus <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter20/monographdiphtheria-tetanusvaccines.html#idxADTseediphtheriawithtetanusvaccineidx <accessed 06/03/09> http://proxy7.use.hcn.com.au/view.php?page=chapter20/monographdtp-vaccines.html#idxBoostrixDTPvaccineidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=5686&product_ name=Boostrix# <accessed 06/03/09> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7766&product_ name=ADT+Booster# <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 95 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Vitamin Supplementation Drug Name Thiamine (Vitamin B-1) Indications/Dose Unconscious patient: 100 mg IM stat if history of possible alcohol abuse Seizures: 100 mg IM stat if history of possible alcohol abuse Stroke including Transient Iscahemic Attack: 100 mg IM stat if history of possible alcohol abuse Hypoglycaemia: 100 mg IM stat if history of possible alcohol abuse Contraindications Previous hypersensitivity to parenteral administration Interactions Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Hypersensitivity reactions can occur following parenteral administration. Sudden onset or worsening of Wernicke encephalopathy, following glucose, may occur in thiamine-deficient patients; administer Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/288-section-288?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter4/monographthiamine. html#thiamine <accessed 06/03/09> Drug Category: Intravenous Fluids Drug Name 0.9% Sodium Chloride Indications/Dose IV/IO cannulae flush – 10 mL 30 mL flush for resuscitation (Cardiorespiratory Arrest) Medication dilution e.g. Morphine Contraindications Interactions Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Modified from: Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=4023&product_ name=Sodium+Chloride+Injection+0%2e9%25 < accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 96 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Intravenous Fluids Drug Name 0.9% Sodium Chloride Indications/Dose Unconscious Patient: IV 500 mL bolus if SBP less than 90 mmHg n IV 1000 mL at 125 mL per hour to maintain hydration Anaphylactic Reaction: n IV 1000 mL bolus if pulse rate greater than 100, SBP less than 90 mmHg and capillary refill greater than 2 seconds Non-traumatic Shock: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Meningococcal Disease: non-blanching Rash – n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Stroke including Transient Ischaemic Attack: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125 mL per hour (to maintain hydration) Severe Sepsis: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125 mL per hour (to maintain hydration) Hyperglycaemia with Severe Dehydration: n IV 500 mL bolus if SBP less than 90 mmHg or if signs of dehydration (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) Snake/spider Bite: n IV 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125 mL per hour (to maintain hydration) Trauma: n IV/IO 1000 mL at 125 mL per hour (to maintain hydration) Burns: n IV/IO 500 mL bolus if SBP less than 90 mmHg Drowning: n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Head Injury: n IV 200 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Ocular Injuries: n Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) Abdominal/loin/flank Pain: n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125 mL per hour (to maintain hydration) n Contraindications Interactions Pregnancy Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Congestive cardiac failure, severe renal impairment, sodium retention Modified from: Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=3623&product_ name=Sodium+Chloride+Intravenous+Infusion+BP < accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 97 Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Intravenous Fluids Drug Name Compound Sodium Lactate (Hartmanns Solution) Indications/Dose Trauma: IV/IO 200 mL stat to maintain SBP 80-90 mmHg (repeat once if required to maintain SBP 80-90 mmHg) Burns: IV/IO as per Modified Parkland formula Ocular injuries: Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) Contraindications Congestive heart failure or severe impairment of renal function. Interactions Administered concomitantly with potassium sparing diuretics and angiotensin converting enzyme (ACE) inhibitors. Simultaneous administration of these drugs can result in severe hyperkalaemia Pregnancy Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Precautions Sodium retention. Pregnancy Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter7/tableelectrolytes-infusionsolutions.tb.html#idxHartmann????????scompoundsodiumlactateinfusionidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7704&product_ name=Compound+Sodium+Lactate+%28Hartmann%27s+Solution%29+Injection < accessed 06/03/09> Drug Category: Other antibiotics and anti-infectives – Infections and Infestations Drug Name Vancomycin Indications/Dose Severe Sepsis: Dose according to patient’s body weight if patient is allergic to penicillin Contraindications Known hypersensitivity Do not administer IMI. Do not infuse as bolus or rapid infusion as may cause profound shock. If cannula tissues vancomycin can cause extravasation. Use with caution in elderly patients and patients with impaired renal function. Interactions Vancomycin interacts with many medications and should be infused alone. Pregnancy Category B2. Not recommended for lactating women. Precautions Renal impairment Modified from: MIMS online, http://proxy36.use.hcn.com.au/Search/AbbrPI.aspx?ModuleName=Product%20Info&searchKeyword=vanco mycin&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=9610001_2 < accessed 30.09.11> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 98 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Section 9 Appendices NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 99 Appendix 1: Rural and Remote Emergency Trolley – Minimum Adult Requirements Ideally the following equipment should be stored on a freely moving mobile trolley with IV pole. Airway ETT (cuffed) x 1 of each 6.0, 7.0, 7.5, 8.0, 8.5, & 9.0 mm Laryngeal mask airway 4.0, 5.0 and 6.0 Laryngoscope Handles with batteries x 2 Mackintosh (Curved) blades 3 and 4 Oropharyngeal rigid sucker Adult x 1 Oropharyngeal airway 2, 3 & 4 Nasopharyngeal airway 6.0 mm & 7.0 mm Introducer/intubating stylet Large & medium introducer Bougie (gum elastic introducer) Tape White cotton tape Other Magill forceps, lubricant satchels x 3, 10 mL syringe, scissors Breathing Self-inflating 1500 mL resuscitation bag with reservoir bag and oxygen tubing Clear masks sizes: 3, 4 & 5 Y suction catheters 12fg & 14fg Suction tubing Disposable CO2 indicator if capnography not available Dwell cath or 14g cannula (8cm in length) Circulation Syringes 1 mL x 5; 2 mL x 5; 5 mL x 5; 10 mL x 10; 20 mL x 5; 1 x 50 mL Cannula 5 each of 14g, 16g , 20g , 22g , 18g , scalp vein needle 23g, 25g Needles x10 Blunt drawing up 21g Intra-osseous Needle x 1 Needle-less system accessories As per LHD stock Giving sets Plain giving set x 2, blood pump giving set x 2, burette x1 Other 3 way taps x 5 • minimal volume extension tubing • transparent IV dressing x 5 • adhesive tape x 1 • tourniquet • antimicrobial swabs wipes x 10 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 100 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Drugs/Fluids Size Amount Adrenaline 1:10,000 1 mg in 10 mL Mini-jets x 3 Adrenaline 1:1000 1 mg in 1 mL 10 Atropine 3 mg in total Glucose 5% 100 mL bag Glucose 10% 500 mL 1 Glucose 50% 50 mL 1 Sodium Chloride 0.9% 1000 mL 2 Sodium bicarbonate 50 mL 1 Amiodarone 150 mg in 3 mL ampoules 6 Calcium gluconate 10% 10% in 10 mL 2 Lignocaine 2% 100 mg 1 mini-jet Magnesium Chloride 20% in 5 mL 2 Sodium Chloride 0.9% 10 mL 20 Naloxone 400 micrograms/1 mL 4 Water for injection 10 mL 10 In fridge: Long acting neuromuscular muscle blocking agent 5 Suxamethonium chloride 100 mg/2 mL 5 Other: n Defibrillator n Full oxygen cylinder/source n ECG electrodes n Defib self-adhesive/gel pads x 2 packets n Arrest documentation form and pen n Sharps container n PPE n Portable suction n NG tube n Stethoscope n Basic and Advanced Life Support algorithm n Scissors n Drug additive labels The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 101 Appendix 2: Defibrillation Defibrillation as soon as possible provides the best chance of survival in victims with VF or unconscious VT. Defibrillation works because it temporarily stuns the myocardium with flow of electrons, thus causing changes in membrane potential, resulting in the depolarisation of the cardiac cells. Depolarisation stops the hyper-excitable areas of the myocardium from propagating impulses. This, in turn, allows the sinoatrial node to resume its function as the primary pacemaker of the heart, resulting in the normal coordinated contractile activity of the heart. Paddle/pad placement n Right parasternal area over the 2nd intercostal space n Midaxillary line over the 6th intercostal space (Apex) Care should be taken to ensure that pads or electrodes are applied in accordance with manufacturer’s instructions and are not in electrical contact with each other. Precautions: n Be aware of electrical hazards in the presence of water, metal fixtures, oxygen and flammable substances. Warn of impending discharge by a ‘stand clear’ command; n AVOID charging the paddles unless they are placed on the victim’s chest; n AVOID placing the defibrillator paddles/pads over ECG electrodes (risk of burns or sparks), ECG leads (may melt), medication patches, an implanted device (e.g. a pacemaker), a central line insertion site; n AVOID having, or allowing any person to have, any direct or indirect contact with the victim during defibrillation (a shock may be received); n AVOID having the victim in contact with metal fixtures e.g. bed rails (risk of burn); n AVOID delivery of a shock with a gap between the paddles/pad and chest wall (spark hazards); n AVOID defibrillating if victim, operator and/or close bystander are situated in an explosive/flammable (e.g. petrol) environment; n AVOID allowing oxygen from resuscitator to flow onto the victim’s chest during delivery of the shock (risk of fire). Factors that may contribute to the resistance to flow of electrons during defibrillation attempts. Mechanical causes of decreased defibrillation success Energy selected Electrode size Chest wall diameter Electrode skin coupling material Number and time interval of previous shocks Electrode to chest contact pressure Physiological causes of decreased defibrillation success Systemic acidosis Pre-existing cardiac disease Drug overdose Body temperature Length of time without spontaneous circulation References: Australian Resuscitation Council, 2010, Guideline 11.4, Electrical therapy for adult advanced life support, ARC, Melbourne. Bridy M.A., Burklow T.R., 2002, ‘Understanding the newer automated external defibrillator devices: electrophysiology, basicwaveforms, and technology’, Journal of Emergency Nursing, Volume 28, no. 2, pp. 132-137. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 102 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Appendix 3: 12 Lead ECG Procedure: Limb Lead Placement Chest Lead Placement The four limb leads are to be placed at the level of wrists and ankles as indicated in the diagram below. Any variation in limb lead placement (e.g. amputee) is to be documented on the 12 lead ECG, clearly specifying the alternate limb lead placements. V1 and V2 sited at 4th intercostal space on either side of the sternum. V3 sited between V2 and V4. V4 sited at 5th intercostal space, mid clavicular line. V5 sited between V4 and V6 / anterior axillary line, lateral to V4. V6 sited at 5th intercostal space, mid axillary line, lateral to V4. Reference: Jowett N.I., Turner A.M., Cole A., and Jones P. A., 2005, ‘Modified electrode placement must be recorded when performing 12-lead electrocardiograms’, Postgrad. Med. Journal, vol. 81, pp. 122-125. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 103 Appendix 4: NSW CHEST PAIN PATHWAY FAMILY NAME MRN GIVEN NAME MALE D.O.B. _______ / _______ / _______ Facility: FEMALE M.O. ADDRESS CHEST PAIN PATHWAY LOCATION / WARD NON PRIMARY PCI SITE Date of Presentation / CHEST PAIN or OTHER SYMPTOMS of MYOCARDIAL ISCHAEMIA COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE / Time £ ACS symptoms are repetitive or prolonged (> 10 min) & still present. £ Syncope £ History of chronic left ventricular systolic dysfunction (especially if known LVEF < 40%) OR current clinical evidence of LVF. £ Previous PCI/CABG < 6 months £ Diabetes + typical ACS symptoms £ Chronic renal failure + typical ACS symptoms £ Haemodynamic compromise (sustained SBP < 90 mmHg and / or new onset mitral regurgitation) Y Consider Pericarditis (sharp chest pain, respiratory or positional component) (back pain, hypertension, absent pulse, BP difference) Consider Pulmonary Embolism (severe dyspnoea, respiratory distress, low subscript O2 saturation) N N Diagnose NON ST ELEVATION ACUTE CORONARY SYNDROME (ACS) Go immediately to STEMI MANAGEMENT (page 3) STRATIFY ACS RISK INTERMEDIATE RISK Any of the following and no high risk features LOW RISK Any of the following and no high or intermediate risk features £ ACS symptoms within 48 hrs that £ Presentation with clinical features consistent with ACS without occurred at rest, or were repetitive or prolonged (but currently resolved) intermediate- risk or high-risk £ Previous PCI/CABG > 6 months features. £ Known coronary heart diseaseEsp if prior AMI or known coronary lesion > 50% stenosis £ Two or more risk factors of: Hypertension, family history, active smoking or hyperlipidaemia £ Chronic renal failure (especially if known GFR < 60 mL/min) + atypical ACS symptoms £ Diabetes + atypical ACS symptoms £ Age > 65 years All cases to be discussed with Senior Medical Officer Recommended Management on page 2 This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. NO WRITING Facility: CHEST PAIN NON PRIMA Contraindications an Absolute contraindications: Risk of bleeding - Active bleeding or bleeding d - Significant closed head or fa - Suspected aortic dissection Risk of intracranial haemorr - Any prior intracranial haemo - Ischaemic stroke within 3 mo - Known structural cerebral va - Known malignant intracrania Relative contraindications: Risk of bleeding - Current use of anticoagulant - Non-compressible vascular p - Recent major surgery (< 3 w - Traumatic or prolonged (> 10 - Recent (within 4 weeks) inte - Active peptic ulcer Risk of intracranial haemorr - History of chronic, severe, p - Severe uncontrolled hyperte - Ischaemic stroke more than Other - Pregnancy 1 Adapted from NHF/CSANZ G Contraindications to Absolute - Recurrent chest pain - Acute myocardial infarction, - High-risk unstable angina - Uncontrolled cardiac arrhyth - Symptomatic severe aortic s - Uncontrolled symptomatic he - Acute pulmonary embolus o - Acute myocarditis or pericard - Acute aortic dissection Relative - Critical left main coronary s - Moderate stenotic valvular h - Electrolyte abnormalities - Systolic hypertension > 200 - Diastolic hypertension > 100 - Tachyarrhythmias or bradyar - New onset atrial fibrillation - Hypertrophic cardiomyopath - Mental or physical impair - High-degree atrioventricular - Resting ECG which will mak 2 Gibbons etal, Circulation 10 Abbreviations: SMR080.071 £ Elevated Troponin (consider haemolysis, renal failure) £ Persistent or dynamic ECG changes of £ ECG is not normal and has changed £ ECG Normal or unchanged from l ST depression ≥ 0.5 mm or from previous pain free ECG but does previous pain free ECG not contain high risk changes. l new T wave inversion ≥ 2 mm £ Transient ST elevation (≥ 0.5 mm) in more than two contiguous leads £ Sustained VT CHEST PAIN PATHWAY NON PRIMARY PCI SITE Any of the following Oxygen Aspirin IV Access Pain Relief Pathology incl Troponin Chest X-ray Consider Aortic Dissection N : General Management ST ELEVATION or (presumed new) LBBB TRIAGE CATEGORY 2 HIGH RISK Time of Symptom Onset: ECG & Vital Signs, expert interpretation within 10 minutes (eg sweating, sudden orthopnea, syncope, dyspnoea, epigastric discomfort, jaw pain, arm pain) Be aware: HIGH RISK ATYPICAL PRESENTATIONS (eg diabetes, renal failure, female, elderly or Aboriginal) : ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ACS – Acute Coronary Syndr ECG – Electrocardiogram FMC – First Medical Contact LBBB – Left Bundle Branch B LVH – Left Ventricular Hypert SMO – Senior Medical officer Page 1 of 4 NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 1 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 104 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 FAMILY NAME MRN GIVEN NAME D.O.B. _______ / _______ / _______ Facility: MALE FEMALE M.O. Facility ADDRESS SMR080071 ¶SMRÊ(Îg|Ä CHEST PAIN PATHWAY LOCATION / WARD NON PRIMARY PCI SITE STE COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Recommended Further Management Refer to drug protocols &/or Therapeutic Guidelines HIGH RISK INTERMEDIATE RISK LOW RISK ADMIT or TRANSFER RESTRATIFY DISCHARGE CO INDIC REPE £ Continuous cardiac monitoring & frequent £ Regular vital signs vital signs £ Repeat ECG immediately if symptoms recur £ Repeat ECG immediately if symptoms £ Repeat ECG immediately if symptoms recur recurs £ Repeat ECG 8 hrs post onset £ Continuous cardiac monitoring & frequent vital signs £ Repeat ECG 8 hrs post onset of symptoms £ Repeat ECG 8 hrs post onset of symptoms £ Repeat Troponin at 8 hrs if 1st sample £ Repeat Troponin at 8 hrs if 1st sample negative * negative * £ ECG/Troponin review by medical officer £ ECG/Troponin review by medical officer BINDING MARGIN - NO WRITING Antiplatelet therapy £ Yes £ No } _______________________________ Betablocker £ Yes £ No If no reason______________________ _______________________________ Anticoagulant £ ECG/Troponin review by medical officer _______________________ Discuss with cardiologist /SMO If no reason______________________ GE MAN of symptoms £ Repeat Troponin at 8 hrs if 1st sample negative * Refer for Exercise Stress Test ** if : Restratify Risk if: £ No further chest pain/symptoms and £ Recurrent ischaemic chest pain or £ 2 negative Troponin tests and £ No new ECG changes and £ No contraindications to stress test (page 4) Restratify to High Risk if: £ Recurrent ischaemic chest pain or £ Positive Troponin or £ New ECG changes or £ Positive stress test £ YES £ No Restratify to Low Risk & Discharge if: If no reason______________________ £ Negative stress test or ________________________________ £ Stress test available within 72 hrs** and Symptomatic treatment of ongoing £ No further chest pain/symptoms £ Repeat ECG & vital signs, if stable pain/hypertension discharge £ IV GTN (titrate against pain & BP) NB: ** If stress test is not £ IV Morphine available within 72 hrs of £ Refer to nominated cardiologist discharge, treatment plan for further management should be guided by nominated SMO/Cardiologist ADM ANTITH TH £ Positive Troponin or £ New ECG changes If low Risk ACS CH REPE M £ Discharge £ Follow up GP/LMO within 3-5 days of D/C £ Consider Specialist follow up £ Consider discharge on Aspirin (discuss with SMO) 5. THR £ Vital signs prior to discharge Ten Body W If unlikely cardiac cause Consider alternative diagnosis Time a Exit Pathway Dis Pri Or Re Pharmacological stress test or CT coronary angiography may be indicated *If a high sensitivity troponin assay is used, the testing interval may be reduced to 3 hours, provided the second sample is taken at least 6 hours after symptom onset. 120511 Medical Officer: Print name & sign_____________________________________________ Date_____________ Medical Officer Designation______________________________________________________ Medical O This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. NO WRITING This tool judgemen Page 2 of 4 NSW HEALTH NON PRIMARY PCI SITE CP ASSESSMENT.indd 2 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 105 FAMILY NAME MRN GIVEN NAME FEMALE Facility: STEMI MANAGEMENT 1. CONFIRM INDICATIONS for REPERFUSION SK E iately if 2. GENERAL MANAGEMENT ost onset 8 hrs if 1st w by 3. ADMINISTER ANTITHROMBOTIC THERAPY _____ c chest FEMALE M.O. ADDRESS CHEST PAIN PATHWAY NON PRIMARY PCI SITE EL HERE MALE D.O.B. _______ / _______ / _______ LOCATION / WARD COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Time of diagnostic ECG Chest pain > 30 min and < 12 hrs Persistent ST segment elevation of ≥ 1 mm in two or more contiguous limb leads or ST segment elevation of ≥ 2 mm in two contiguous chest leads or presumed new LBBB pattern Myocardial infarct likely from history Cardiac monitoring Routine bloods Nitrates-Sublingual or IV ECG Oxygen CXR : IV Cannula X 2 Analgesia – Morphine Beta Blockers Confirm administration or give: Aspirin 300 mg (soluble) Clopidogrel 300 - 600 mg (or prasugrel &/or tirofiban) Enoxaparin 30 mg IV then bd (or IV heparin or bivalirudin) 1 mg/kg subcut (Max 100 mg) Refer to local protocols &/or Therapeutic Guidelines THROMBOLYSIS UNLESS 4. CHOOSE REPERFUSION METHOD within 3-5 follow up Absolute or unacceptable relative contraindications (see page 4) or Patient does not consent to thrombolysis or Documented system for transfer to PRIMARY PCI SITE in place Discussed with cardiologist: on SMO) 5. THROMBOLYSE ischarge Tenecteplase / Reteplase Body Weight _____kg Dose _____ se diagnosis Time administered : OR Time : Transfer to PRIMARY PCI SITE if appropriate (As per table below) Maximum Acceptable Delay from First Medical Contact (FMC): Time since symptom onset Acceptable delay from FMC to percutaneous intervention < 1hours 60 minutes 1-3 hours 90 minutes 3-12 hours 120 minutes >12hours Not routinely recommended from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006 Discuss further management immediately with nominated cardiologist Prioritise urgency of transfer with nominated cardiologist Organise transfer to PCI-capable hospital (as per locally agreed protocol) Repeat ECG at 60 mins post thrombolytic second ________ ________ Medical Officer: Print name & sign_____________________________________________ Date_____________ Medical Officer Designation______________________________________________________ ual clinical d medically. This tool is intended as a guideline for clinicians to provide quality patient care. It is not intended, nor should it replace, individual clinical judgement. Some patients with co-morbidities or patients not suitable for invasive investigations may be appropriately managed medically. Page 2 of 4 NO WRITING Page 3 of 4 12/05/2011 10:32:22 AM The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 106 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 FEMALE HERE ment roponin itis atory or NT tures k CHEST PAIN PATHWAY NON PRIMARY PCI SITE high or s GIVEN NAME D.O.B. _______ / _______ / _______ Facility: MALE FEMALE M.O. ADDRESS CHEST PAIN PATHWAY NON PRIMARY PCI SITE LOCATION / WARD COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE Contraindications and cautions for thrombolysis use in STEMI1 Absolute contraindications: Risk of bleeding - Active bleeding or bleeding diathesis (excluding menses) - Significant closed head or facial trauma within 3 months - Suspected aortic dissection (including new neurological symptoms) Risk of intracranial haemorrhage - Any prior intracranial haemorrhage - Ischaemic stroke within 3 months - Known structural cerebral vascular lesion (eg, arteriovenous malformation) - Known malignant intracranial neoplasm (primary or metastatic) Relative contraindications: Risk of bleeding - Current use of anticoagulants: the higher the international normalised ratio (INR), the higher the risk of bleeding - Non-compressible vascular punctures - Recent major surgery (< 3 weeks) - Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation - Recent (within 4 weeks) internal bleeding (eg, gastrointestinal or urinary tract haemorrhage) - Active peptic ulcer Risk of intracranial haemorrhage - History of chronic, severe, poorly controlled hypertension - Severe uncontrolled hypertension on presentation (> 180 mmHg systolic or > 110 mmHg diastolic) - Ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered in contraindications Other - Pregnancy 1 Adapted from NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006 Contraindications to Exercise Testing (ACC/AHA Guidelines)2 Absolute - Recurrent chest pain - Acute myocardial infarction, within 2 days - High-risk unstable angina - Uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise - Symptomatic severe aortic stenosis - Uncontrolled symptomatic heart failure - Acute pulmonary embolus or pulmonary infarction - Acute myocarditis or pericarditis - Acute aortic dissection Relative - Critical left main coronary stenosis - Electrolyte abnormalities - Systolic hypertension > 200 mmHg - Diastolic hypertension > 100 mmHg - Tachyarrhythmias or bradyarrhythmias - New onset atrial fibrillation ¶SMRÊ(Îg|Ä SMR080071 - Hypertrophic cardiomyopathy and other forms of outflow obstruction - Mental or physical impairment leading to the inability to exercise adequately - High-degree atrioventricular block - Resting ECG which will make EST interpretation difficult (eg LBBB, LVH with strain, Ventricular pacing, Ventricular preexcitation.) 2 Gibbons etal, Circulation 106:1883,2002 Abbreviations: SMR080.071 age 1 of 4 MRN - Moderate stenotic valvular heart disease from al d medically. FAMILY NAME BINDING MARGIN - NO WRITING ely ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ◆◆◆◆◆◆ ACS – Acute Coronary Syndrome CABG – Coronary Artery Bypass Graft ECG – Electrocardiogram EST – Exercise Stress Test FMC – First Medical Contact GTN – Glyceryl trinitrate LBBB – Left Bundle Branch Block LVF – Left Ventricular Failure LVH – Left Ventricular Hypertrophy PCI – Percutaneous Coronary Intervention SMO – Senior Medical officer STEMI – ST Elevation Myocardial Infarction NO WRITING Page 4 of 4 12/05/2011 10:32:22 AM The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 107 Appendix 5: Management of Patients with ST-segment elevation Myocardial Infarction Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have a reperfusion strategy implemented promptly. 12-lead ECG (at least one of the following ECG changes is mandatory for thrombolysis) n ST segment elevation of greater than or equal to 1 mm in two or more contiguous limb leads; n ST segment elevation of greater than or equal to 2 mm in two or more contiguous chest leads; n New left bundle branch block (LBBB) pattern (Note that LBBB is presumed new unless there is evidence otherwise). Differential diagnoses must be considered by a Medical Officer: n Aortic dissection; n Pericarditis; n Pulmonary embolism Contraindications* to be considered by a Medical Officer: Absolute Contraindications: n Active bleeding (excluding menses) n Significant closed head or facial trauma (within 3 months) n Suspected aortic dissection n Any prior intracranial haemorrhage n Ischaemic stroke within 3 months n Known structural cerebral vascular lesion n Known malignant intracranial neoplasm (primary or metastatic) Relative Contraindications: n Current use of anticoagulants (the higher the INR, the greater the risk) n Non-compressible vascular puncture n Recent major surgery (less than 3 weeks) n Pregnancy n Traumatic or prolonged CPR longer than 10 minutes n Recent (within 4 weeks) internal bleeding n Active peptic ulcer n History of chronic, severe, poorly controlled hypertension n Uncontrolled hypertension at time of presentation SBP greater than 180 mmHg or DBP greater than 110 mmHg (should be treated prior to thrombolysis) n Ischaemic stroke more than 3 months ago, dementia or known intracranial abnormality not covered in contraindications * Many contraindications are relative and potential benefits versus relative risks should always be considered. Reference: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand, 2006, ‘Guidelines for the management of acute coronary syndromes’, The Medical Journal of Australia, vol. 184, no. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 108 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Appendix 6: AVPU / GCS AVPU is a mnemonic used to obtain a rapid assessment of a patient’s level of consciousness. A – Alert V – Responds to vocal stimuli P – Responds to Painful Stimuli U – Unresponsive This observation should also include assessing the pupillary reflexes. This rapid assessment will detect only gross neurological damage GCS – Glasgow Coma Scale A quick, practical and standardised system for assessing the degree of conscious impairment of the critically ill and injured. It can also be used for predicting the duration and outcome for patients with head injuries. Three behavioural responses are evaluated: n Best Eye Opening; n Best Verbal Response; and n Best Motor Response. Each category has criteria and numerical values are attached to each criterion. The highest score achievable is 15 and the lowest score is 3. The Glasgow Coma Scale is used to monitor trend when performing assessments of level of consciousness. A decreasing score is associated with neurological deterioration. Best Eye Opening Response Eyes open spontaneously Eyes open to voice Eyes open to painful stimuli No eye opening 4 3 2 1=4 Best Verbal Response Orientated to time place and person Confused Inappropriate words Incomprehensible Sounds No verbal response Best Motor Response Obeys Commands Localises to Painful Stimuli Non purposeful response to pain Flexion to pain Extension to pain No motor response 5 4 3 2 1=5 6 5 4 3 2 1=6 Total = 15 A patient with a GCS of less than 9 and not rapidly improving will require endotracheal intubation by a Medical Officer to protect the patient’s airway from aspiration. Reference: Healey C., Olser Turner M., Rogers F.B., Healey M.A., Glance L.G., Kilgo P.D, Shackford S.R. and Meredith J.W., 2003, ‘Improving the Glasgow Coma Scale Score: Motor Score Alone is a Better Predictor’, The Journal of Trauma: Injury, Infection, and Critical Care, vol. 54, no. 4, pp. 671-680. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 109 Appendix 7: Pain Assessment A number of tools exist to assist clinicians in the assessment of pain. A commonly used technique in the Emergency Department is the PQRST mnemonic. FACTOR DESCRIPTION QUESTIONS Provokes, Palliates, Precipitating factors What were you doing when the pain occurred? What provoked the pain? What makes the pain better? What makes the pain worse? Have you had this type of pain before? Quality What does the pain feel like? Ask the patient to describe the pain in their words Region, Radiation Where is the pain/show me where the pain is Does the pain radiate? If so, where? Severity, associated symptoms How severe is the pain? If you were to rate the pain on a scale from 0 to 10 with 0 being no pain and 10 being the most severe pain you can imagine, how would you rate your pain? Do you have any other symptoms? Time When did the pain start? How long did it last? Does it come and go? Reference: ENA & Newberry, 2003, Sheehy’s Emergency Nursing: Principles and Practice, 5th edn, Mosby. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 110 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Appendix 8: Abbey Pain Scale The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 111 Appendix 9: SEDATION SCORE/SCALE Evidence indicates that a decrease in respiratory rate is a late and unreliable indicator of respiratory depression following opioid administration. Sedation has been found to be a reliable early clinical indicator of respiratory depression and should be monitored following opioid administration using a sedation score. Sedation Score Scale 0= None 1= Mild, occasionally drowsy, easy to rouse 2= Moderate, constantly or frequently drowsy easy to rouse 3= Severe, somnolent, difficult to rouse 4= Normal sleep The patient is scored according to the scale above. The aim is to keep the sedation score below 2 regardless of the route of opioid administration. A sedation score of 2 means that the patient is constantly drowsy or groggy but still easy to rouse – e.g. they wake up easily but cannot stay awake during conversation. References: Lehne, Richard A., 2001, Pharmacology for Nursing Care, 4th edn, W.B. Saunders, Philadelphia. National Health and Medical Research Council, 1999, Acute Pain Management: Scientific Evidence, Commonwealth of Australia, Canberra. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 112 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Appendix 10: Glass Tumbler Test A rash is common with meningococcal infection – it may be purpuric or petechial. Small red or purple spots develop at first and may occur in groups anywhere on the body. They often grow to become blotchy and look like little bruises. One or two may develop at first, and then appear in different parts of the body. The spots do not fade when pressed (unlike may other rashes). To check for this do the Tumbler Test. Place a clear glass tumbler firmly on one of the spots or blotches and see if you can still see them through the glass. Note: it is harder to see on dark skin, so check paler areas. The rash is a sign of septicaemia. It may not occur with meningitis alone. Do NOT solely rely on the rash, as it may not always occur or may occur late in the disease. Petechial Rash Petechiae result from tiny area of superficial bleeding into the skin. They appear as round, pinpoint-sized spots that are not raised. The colour varies from red to purple as they age and gradually disappear. The rash does not blanch with pressure. Purpuric Rash Purpura are larger areas of bleeding into the skin beginning as red areas that become purple and later brownish-yellow. The rash does not blanch with pressure. Reference: Meningococcal Education Inc., The Glass Test, viewed 10 August 2009, <http://www.meningococcal.org/the_rash.html> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 113 Appendix 11: SnakeBite Observation CharT Snakebite Observation Chart Patient surname: Forename: Date of birth: MRN number: Date of bite Time of bite: Type of snake: Number of bites: Date: Time: Time after bite: GENERAL: Pulse rate: Blood pressure: Temperature: SPECIFIC: Regional lymph node tenderness: Local bite site pain: Bite site swelling: Headache: Nausea: Vomiting: Abdominal pain: PARALYTIC SIGNS: Ptosis: Opthalmoplegia: Fixed dilated pupils: Dysarthria: Dysphalgia: Tongue protrusion: Limb weakness: Respiratory weakness: Peak flow rate: MYOLYTIC SIGNS: Muscle pain: Myoglobinuria: COAGULOPATHY SIGNS: Persistant blood ooze: Haematuria: Active bleeding: RENAL: Urine output: LABORATORY KEY TESTS: INR/prothrombin time aPTT Fibrinogen XDP/FDP Platelet count CK Creatinine Urea K+ ANTIVENOM: Type/amount/time: Reaction Reference: NSW Health, 2007, Snakebite and Spiderbite Clinical Management Guidelines, NSW Department of Health, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 114 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Transport incident: – Death in same vehicle – Intrusion into occupant compartment > 30 cm – Steering wheel deformity – Patient side impact – Vehicle v. pedestrian/cyclist/MBC – Ejection from vehicle – Entrapment with compression ■ ■ ■ ■ ■ Focal blunt trauma to head or torso Falls >3m or paediatrics twice the child’s height High voltage injury Crush injury excluding fingers/toes Any rapid deceleration mechanism that results in a large inertia change at impact INJURIES Paediatrics: Physiological changes are late indicators of serious injury in a child who may lose 30% blood volume prior to ANY changes in vital signs. The following are a guide: 1st year 1–5 yrs 6-12 yrs HR >160 >140 >120 SBP <60 <70 <80 RR >60 >35 >30 If patient meets Major Trauma Criteria, they are to be transported to the highest level Trauma Centre within a 1-hour travel time or Aeromedical Retrieval Service advised. T TRANSPORT Airway: At risk, hoarseness, stridor. Breathing:RR <10 or >29, Sp02 < 90% on air, cyanosis or respiratory difficulty. Circulation: HR >120, SBP <90 or severe haemorrhage. Disability: GCS ≤13 or paralysis/sensory deficit. Or any worsening trend in ABCD. AND/OR Yes Yes to any URGENT TRANSPORT IMMEDIATE TRANSPORT IMMEDIATE AND URGENT TRANSPORT Yes Yes to any Patients ≥16 and > 65 years of age who are ambulatory at the scene with normal physiology and minor or no apparent injury. If in doubt, transfer to Trauma Centre No Yes Closest Hospital Trauma Triage Tool — Major Trauma Criteria (MIST) TRAUMA S SIGNS AND SYMPTOMS Abdomen: Severe pain, rigidity, swelling, pelvic tenderness, restraint/abrasion/confusion. Limbs: 2 or more prominal long bone, amputation proximal to digits, ischaemia, degloving injury. Spinal/Back: Visible deformity. Burns: Partial or full thickness burns. Adults >20%; Children >10%, or burns involving head/neck/face/hands/feet/groin or inhalation injury. All circumferential burns or burns in a patient with comorbidities or pregnancy. AND/OR Head: Minor head injury with loss of consciousness, or amnesic to event with: ■ 2 or more vomits or a seizure ■ On anticoagulants Open, depressed skull and/or signs of base of skull. A decreased LOC is due to traumatic injury, until proven otherwise. Face: Injury with potential airway risk; severe haemorrhage. Neck: Swelling, bruising, hoarseness, stridor. Chest: Severe pain, paradoxical breathing, restraint abrasion/confusion. I Penetrating All penetrating injury (excuding isolated injury to hands or feet). Patients <16 or >65 years of age. Obstetric patients >20 weeks gestation, patients on anticoagulants and patients with pre-existing disease are at greater risk and require a high index of suspicion for serious injury. If in doubt, transport to Trauma Centre. ■ M MECHANISM OF INJURY Blunt Appendix 12: Trauma Triage Tool CENTRE TRAUMA CODE 3 MIST Reference: Ambulance Service of New South Wales, 2008, Trauma Triage Tool – Major Trauma Criteria (MIST), Clinical Development Unit The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 115 Appendix 13a: Guidelines for when to Apply Semi-Rigid Cervical Collars Standard: n All multi-trauma patients or patients with a head injury will have a semi-rigid cervical collar applied. n Patients at risk for spinal injury will have a semi-rigid cervical collar applied as per the Canadian C-Spine rule. n Patients assessed not to be at risk for spinal injury, will have a cervical collar removed. Canadian C-Spine Rule For alert (GCS 15) and stable trauma patients where cervical spine is a concern. 1. Any one of the following High Risk factors? n n n Age 65 years or older Dangerous mechanism of injury* Numbness or tingling in extremities YES NO 2. Any one of the following Low Risk factors which allows for safe assessment of range of motion? n Ambulatory at any time at the scene n No midline c-spine tenderness n Delayed onset of neck pain n Simple rear-end motor vehicle collision n NO n n Apply semi-rigid cervical collar Immobilise C-spine Requires radiography Excludes: hit by bus or large truck, pushed into oncoming traffic, hit by high speed vehicle more than 100 km/hour YES 3. Patient able to voluntarily actively rotate neck 45º left and right, regardless of pain? NO YES No C-spine immobilisation required * Dangerous mechanism of injury n Fall from more than 3 feet/ 1 metre or 5 stairs n Axial loading to head e.g. diving, spear tackle n MVC or MBC at high speed more than 100 km/hr n MVC rollover, ejection n Quadbike, motorised all-terrain vehicles n Bicycle collision Once a cervical collar has been applied, full spinal precautions need to be maintained until the C-spine has been cleared by clinical examination or radiographic assessment. Contraindications: penetrating neck injury. This should be managed with in-line immobilisation. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 116 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Appendix 13B: Removal of Semi-Rigid Cervical Collar without Radiographic Assessment Cervical spine clearance without radiographic assessment ONLY applies to fully conscious patients with a GCS 15. A Medical Officer makes the decision for removal of a C-spine collar, after a thorough physical assessment reveals the following: NEXUS Criteria: n Fully alert – GCS 15 n No midline pain and or tenderness upon palpation of the cervical spine n No motor or sensory deficit e.g. weakness, numbness or parasthesia n No distracting painful injury that may mask symptoms of a cervical injury i.e. fracture, burns n No evidence of alcohol and/or drug ingestion. If ALL of the NEXUS criteria are satisfied, clinical examination may then proceed. If a full range of active movement (45 degrees rotation) can be performed without pain, and there is no evidence of: n Bruising, deformity or tenderness on examination, n Injury above the clavicle. n Medical condition requiring extra caution i.e. osteoporosis, rheumatoid arthritis The cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. References: Brehaut J.C., Stiell I.G., & Graham I.D., 2006, ‘Will a new clinical decision rule be widely used? The case of the Canadian C-spine rule’, Academic Emergency Medicine, vol. 13, no. 4 p. 413. Rogers I., Ieraci S., 2006, ‘Emergency care evidence in practice series: Cervical spine x-rays in trauma’. Emergency Care Community of Practice, National Institute of Clinical Studies, Melbourne. Stiell I.G., Clement C.M., McKnight R.D., Brison R., Schull M.J., Rowe B.H., Worthington J.R., Eisenhauer M.A., Cass D., Greenberg G., MacPhail I., Dreyer J., Lee J.S., Bandiera G., Reardon M., Holroyd B., Lesiuk H., Wells G.A., 2003 ‘The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma’, New England Journal of Medicine, vol. 349, no. 26, pp. 2510-18. Stiell I.G., Lesiuk H., Wells G.A., McKnight R.D., Brison R., Clement C., Eisenhauer M.A., Greenberg G.H., MacPhail I., Reardon M., Worthington J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morrison L., Schull M., Laupacis A., 2001, ‘Canadian CT head and C-spine study group. The Canadian CT head rule study for patients with minor head injury: rationale, objectives, and methodology for phase I’, Annals of Emergency Medicine, vol. 38, no. 2, pp.160-69. Stiell I.G., Lesiuk H., Wells G.A., Coyle D., McKnight R.D., Brison R., Clement C., Eisenhauer M.A., Greenberg G.H., Macphail I., Reardon M., Worthington J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morrison L., Schull M., Laupacis A., 2001, ‘Canadian CT head and C-spine study group. Canadian CT head rule study for patients with minor head injury: methodology for phase II’, Annals of Emergency Medicine, vol. 38, no. 3, pp. 317-22. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 117 Appendix 14: Needle Thoracentesis for Decompression of Tension Pneumothorax Indication: a rapidly deteriorating haemodynamically unstable patient who has a life-threatening tension pneumothorax. A tension pneumothorax is associated with the formation of a one-way valve at the point of a rupture in the lung. Air becomes trapped in the pleural cavity between the chest wall and the lung, and builds up, putting pressure on the lung and keeping it from inflating fully. The mediastinum is shifted to the opposite side of the chest, decreasing venous return and compressing the opposite lung. Early signs and symptoms of a clinical tension pneumothorax: n chest pain n dyspnoea n anxiety n tachypnoea n tachycardia n hyper-resonance of the chest wall on the affected side n reduced chest movement on the affected side n diminished chest sounds on the affected side. Late signs of a tension pneumothorax: n decreased level of consciousness n tracheal deviation away from the affected side n hypotension n distended neck veins n cyanosis. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 118 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Procedural Steps for Needle Thoracentesis 2. Cleanse the site with antimicrobial swab. n Position the patient in upright position (as tolerated) only if a cervical spine injury has been excluded 3. Insert a large bore IV cannula (14 or 16 gauge), greater than 8 cm in length, into the 2nd intercostal space just superior to the 3rd rib, at a 90-degree angle into the skin and through the intercostal space (Figure b). n Apply O2 via a non-rebreather face mask at 15 L/ minute Figure b 1. Prepare Patient n Explain the procedure to the patient, if conscious n Expose the anterior chest n Identify and locate landmarks (on the affected side) – see figures a and b – suprasternal notch – midclavicular line –2nd Intercostal space The 2nd intercostal space is found by dividing the clavicle in half. From that halfway point, palpate down one rib to the first space below that rib. This is the 2nd intercostal space (the space immediately after the clavicle is the 1st intercostal space) (Figure a) Figure a 4. Puncture the parietal pleura. Remove the needle from the catheter and listen for a sudden escape of air, indicating that the tension pneumothorax has been relieved. 5. Leave the catheter in place. 6. Place the patient in upright position as tolerated (if C-spine injuries have been ruled out) to assist with respirations. The patient may remain supine if C-spine injuries are suspected. 7. Continue to monitor the patient and reassess. N.B. A Medical Officer must now insert an intercostal catheter. Reference: American College of Surgeons Committee on Trauma, 2008, ‘Shock’ in Advanced Trauma Life Support Course for Doctors – Student Course Manual, 8th edn, United States. Curtis K., Ramsden C., and Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Operational Medicine, 2001, Field medical services school student handbook, < http://brookside press.org/Products/ OperationalMedicine/DATA/operationalmed/Manuals/FMSS/NEEDLETHORO.CENTESISFMST0411.htm> Tintinalli J., Gabor M., Kelen D., Stapczynski S., Ma J., and Cline D., 2003, Emergency medicine: A comprehensive study guide international edition, 6th edn, McGraw-Hill, New York. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 119 APPENDIX 15: Suggested Guidelines for a Neurovascular Assessment Begin assessment by evaluation of uninjured limb first for normal patient baseline. Pulses Nerves Sensation Motor Auxillary Auxillary Regimental bade on upper arm Shoulder abduction Brachial Radial Web space between thumb and index finger Hyperextended thumb or wrist Ulnar Median Pad of index finger Thumb opposition – flex wrist Radial Ulnar Pad of little finger Abduction of fingers Femoral Femoral Anterior of thigh Straight leg raise Popliteal Sciatic Lateral aspect of calf and foot Hip extension Anterior Tibialis Peroneal Deep Web space between first and second toes Dorsiflexion of foot Posterior Tibialis Tibial Heel of foot Plantar flexion of foot Dorsalis Pedis Sub-Peroneal Dorsum of foot Foot eversion Reference: Tamworth Hospital Neurovascular Observation Chart. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 120 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 APPENDIX 16: PELVIC BINDING For rotationally unstable pelvic fractures: Open-book, Vertical Shear, Lateral Compression type III or Combined Mechanism fractures. 1 Place folded bed sheet underneath the patient between iliac crests and greater trochanters. 2 With two trauma team members, cross the sheeet across the synphysis and pull the sheet firmly so it tightly fits around and stabilises the pelvis. 3 A third person should clamp the sheet at the four points shown (away from laparotomy/angiograph access points). Reference: Heetveld, M, 2007, The Management of Haemodynamically Unstable Patients with a Pelvic Fracture, NSW Institute of Trauma and Injury Management, Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 121 APPENDIX 17: Burn TRANSFER FLOWCHART Medical Retrieval Referral Meets Medical Retrieval n n n n n n n n Intubated patients Head and neck burns Burns >10% in children or >20% in adults Burns with associated inhalation Burns with significant comorbidities, e.g. trauma Electrical/chemical injury Significant pre-existing medical disorder Circumferential to limbs or chest compromising circulation or respiration Needs referral but not medical retrieval Burns >5% children or >10% adults n Burns to hands, feet, face, genitalia, perineum and major joints n Burns with a pre-existing medical condition, e.g. diabetes n Children with suspected non-accidental injury and adults with assault, selfinflicted injury n Pregnancy (2nd or 3rd trimester RNSH) n Spinal cord injury RNSH n Extremes of ages n The Children’s Hospital at Westmead Catchment Area: All children’s referrals to the age of 15 in all areas of NSW. Contact: AMRS Adults 1800 650 004 n NETS for children up to 16th birthday 1300 362 500 n Minor Burns Concord Repatriation General Hospital Catchment Area: South-Eastern Sydney/ Illawarra, Sydney West, Sydney South West, Greater Southern*, Greater Western*, ACT Royal North Shore Hospital Catchment Area: Sydney/Central Coast, Hunter/New England, North Coast* Minor burns are treated in consultation with the referring doctor as an outpatient, either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment. Contact Burns Ambulatory Care: CHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h) *Hospitals near state border areas may refer to Burns Units in adjoining states. Set up conference call with receiving ICU/Burn Unit; facilitate communication with primary referral site CHW ICU 99845 1171 CRGH ICU 99767 6404 RNSH ICU 99926 8640 AMRS/NETS will coordinate transfer betweeen primary hospital and the receiving hospital. CHW: Surgical Registrar on-call notified. Ring 9645 0000, then page Surgical Registrar CRGH: Burns Registrar on-call notified. Tel 9767 7111, then page Burns Registrar RNSH: Burns Registrar on-call notified. Tel: 9926 7111, then page Burns Registrar Not referred to service. The on-call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receivingthe patient. The referrer will make the ambulance booking. Referred to service. Any issues or problems with these processes, or if further advice is required, the NSW Severe Burn Injury Service Manager can be contacted on (02) 9926 5641 Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 122 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 123 Shade affected area Total % TBSA = __________________ NB: Faint erythema not included in % TBSA assessment NB: Difficult to accurately assess burn depth within the first 24–48 hours post injury. Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 124 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 125 APPENDIX 18 Guideline for Emergency Department Documentation Triage Documentation Standard 1. Date and time of assessment 6. Any diagnostic, first aid or treatment measures initiated 2. Chief presenting problem(s) 7. Assessment and treatment area allocated 3. Relevant assessment findings 8. Name of triage officer 4. Limited, relevant history 9. Re-triage category with time and reason (if applicable) 5. Initial triage category allocated 10. Vital signs should only be measured at triage if required to estimate urgency or if time permits (Australasian College for Emergency Medicine – ATS Guidelines Revised August 05) Primary Survey Documentation A – Airway (& Cervical-Spine) Patency, airway noises, mechanism of injury (spinal, head, inhalation injury) airway adjuncts (oro/nasopharyngeal/ LMA /ETT) B – Breathing Respiratory rate, rhythm and depth, work of breathing, oxygen delivery device and amount C – Circulation Skin colour, warmth and diaphoresis, capillary refill, pulses, overt bleeding, IV cannula (position and size) & fluids, (commence a fluid balance chart if fluids are administered) D – Disability (neurological) – Discomfort (pain assessment) A – alert V – responds to voice P – responds to painful stimuli U – unresponsive E – Exposure & Environment Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure) History (source – the patient, caregiver or Ambulance Officer) M – mechanism of injury / illness I – injuries sustained / illness progression S – signs & symptoms T – treatment (pre presentation) / transport Ongoing Assessment Triage category 1–3 Record vital signs at time of assessment and frequency according to the patient’s clinical presentation Triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patient’s clinical presentation Triage category 5 Record vital signs at time of assessment and relevant to presentation Documented Observations – respiratory rate, oxygen saturations (SpO2) – oxygen device, and litres /minute – pulse, blood pressure, temperature – level of consciousness – GCS & pupils – blood glucose level (BGL) – pain score (0-10) and assessment – ECG – cardiac rhythm (if monitored) – neurovascular observations (if relevant) – weight (if relevant) – any investigations commenced /completed & outcome A – allergies M – medications (prescription, over the counter, herbal) P – past medical / surgical history L – last meal / last menstrual period / last immunisation E – events leading up to presentation Plan What plan has been put in place for this patient? Document in a concise and clear manner: n procedures, interventions, outcome & evaluation chronologically n standing orders or guidelines if commenced n notification – who has been told n comply with legal reporting responsibilities Evaluation Reassess patient and document outcomes Discharge Time of departure Destination Referrals n n Pupils size & reaction (PEARL) Pain assessment and score + BGL Document discharge information including any instructions or education given to the patient or family If patient not prepared to wait to be seen – document advice given to the patient or family Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (i.e. alcohol/other drug use, smoking, skin integrity and falls screening). The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 126 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 APPENDIX 19: EXAMPLE OF MINIMUM SKILL SET FOR EMERGENCY DEPARTMENT STAFF Skill Medical Officer Advanced Clinical Nurse (RN) RN EEN/EN Basic Life Support Essential Essential Essential Essential Airway Placement of oropharyngeal airway Essential Essential Essential Essential Oropharyngeal suction using a rigid suction device Essential Essential Essential Essential Two person ventilation using a BVM before intubation Essential Essential Essential Desirable Assistance with endotracheal intubation (e.g. cricoid pressure) Essential Essential Essential Desirable Tracheal intubation Desirable Not required Not required Not required One person use of BVM after intubation Essential Essential Essential Desirable Tracheal suction Essential Essential Desirable Not required Insertion of laryngeal mask airway Essential Desirable Not required Not required Management of the difficult airway including surgical cricothyroidotomy Desirable Not required Not required Not required Essential Essential Essential Desirable C-Spine Semi-rigid collar fitting e.g. Canadian C-spine rules Semi rigid collar removal decision i.e. NEXUS Essential Not required Not required Not required Spinal Immobilisation Essential Essential Essential Essential (Spinal) log roll Essential Essential Essential Essential Essential Essential Essential Essential Breathing Delivery of non-invasive oxygen therapy Needle decompression of pneumothorax Essential Essential Not required Not required Insertion of intercostal catheter Desirable Not required Not required Not required Venepuncture Essential Essential Desirable Desirable Blood alcohol sample collection Essential Essential Desirable Not required Circulation Peripheral intravenous cannulation Essential Essential Desirable Not required Automated External Defibrillation (AED) Essential Essential Essential Essential Manual defibrillation (in sites with manual defibrillator) Essential Essential Not required Not required Transcutaneous pacing (in sites with transcutaneous pacing capacity) Desirable Desirable Not required Not required Administration of ALS protocol medications Essential Essential Not required Not required Blood sample by arterial puncture Desirable Desirable Not required Not required Recording of 12 lead ECG Essential Essential Essential Desirable 12 lead ECG interpretation of ACS Essential Desirable Not required Not required Intraosseous needle insertion Essential Desirable Desirable Not required Insertion of Urinary Catheter Essential Essential Essential Not required Essential Essential Essential Essential Disability Glasgow Coma Score and pupillary response Extras Triage Essential Essential Essential Not required Primary and secondary survey Essential Essential Essential Desirable Nasogastric tube insertion Essential Essential Desirable Not required Splinting and/or POP application Essential Essential Desirable Not required Adapted from GMCT Guidelines for In-Hospital Clinical Emergency Response Systems for Medical Emergencies, October 2005. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 NSW Health PAGE 127 APPENDIX 20: Recommended Blood Pathology Testing Available at the Point of Care in Rural Facilities Where an Emergency Service is provided The NSW Rural Critical Care Taskforce (RCCT) recognises that availability of specific blood pathology results at the point of care is necessary to assist in and expedite effective diagnosis, treatment and transfer decision-making for patients presenting to rural Emergency Departments, with appropriate mechanisms in place to support staff e.g. staff training, credentialing, and calibration. The following blood pathology results are recommended as the minimum standard necessary at the point of care for rural facilities where an emergency service is provided: 1. Blood gases (including sodium and potassium levels) 2.Haemoglobin 3.Troponin 4.INR These tests provide information to escalate concern and add to the clinical assessment picture for critically ill patients. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as Advanced Clinical Nurses. PAGE 128 NSW Health NSW Rural Adult Emergency Clinical Guidelines 3rd Edition – Version 3.1 SHPN (SRSCP) 120005
