ST JOHN 2026

Adrenaline

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

INTRODUCTION

• A naturally occurring sympathomimetic agent

• Causes peripheral vasoconstriction

• Stimulation of cardiac conduction system causes increased contractions

• Causes bronchodilation and dilation of blood vessels in muscles

• IV/IO: Onset 30 seconds, peak 3-5 minutes, duration 5-10 minutes

• IM: Onset 30-90 seconds, peak 5-10 minutes, duration 5-10 minutes

DOSAGE: 1mg in 1ml (1:1000)

INDICATIONS

• Anaphylaxis

• Life-threatening asthma

• Severe croup

• Cardiac Arrest

• Post ROSC

• Haemorrhage control post cricothyroidotomy

CONTRAINDICATION

• There are no absolute contraindications for adrenaline

PRECAUTIONS / NOTES

• Ischaemic Heart Disease

. Hypertension

. Hypovolaemia

• Do not walk patient pre/post IM adrenaline administration in anaphylaxis - usually a minimum of 1 hour after 1 dose of Adrenaline and 4 hours if more than 1 dose of adrenaline given

. If given IV into a peripheral vein, follow each dose with a sodium chloride flush

MANAGEMENT

Cardiac Arrest

Adult:

1 mg IV/IO, repeat every 3-5 minutes as clinically indicated

Paediatric / Newborn:

10 microg/kg = 0.1 mL/kg of 1:10,000 adrenaline solution IV/IO, repeat every 3-5 minutes as clinically indicated.

Maximum bolus dose 1 mg (10 mL of 1:10,000 adrenaline solution).

Post-ROSC

Manage hypotension in Post-ROSC patients if BP is slow to rise:

The patient is considered hypotensive if Systolic BP is:

Adult: < 100mmHg

Paediatric: < 80mmHg

Titrate Adrenaline as required, to achieve and / or maintain the SBP requirements as listed above.

Adult:

50 microg (0.5 mL) every 3-5 min as required to maintain systolic blood pressure

Paediatric:

1 microg/kg every 3-5 min (maximum bolus 50 microg (0.5 mL)) to maintain systolic blood pressure

Life-threatening Asthma

Adult:

0.5 mg IM into lateral mid-thigh (0.5 mL of 1:1000), repeat every 5 minutes as clinically required

Paediatric > 1 month:

10 microg/kg IM into mid lateral thigh (0.01 ml of 1:1000) (maximum single dose of 0.5 mg or 0.5 mls), repeat every 5 mins as clinically required

Anaphylaxis

Adult:

• 0.5 mg IM into lateral mid-thigh (0.5 mL of 1:1000), repeat every 5 minutes as clinically required
  
  

• For impending or actual airway obstruction/stridor/angioedema unresponsive to 2 doses of IM adrenaline:

  • 5 mg (5 mL of undiluted 1:1000 adrenaline) nebulised, single dose only. Consult CSPSOC if further doses required.

  • The nebulised dose is in addition to ongoing IM doses to manage systemic anaphylaxis symptoms, continue IM adrenaline as required.

• Life threatening/peri-arrest* anaphylaxis refractory to 2 doses of IM adrenaline and fluid bolus: 10 microg (0.1 mL of 1:10000) IV/IO every minute as required. CSP consultation recommended prior to administration if possible. If 10 microg doses ineffective after 2 doses contact CSPSOC for higher dosing.

Paediatric > 1 month:

• 10 microg/kg IM into lateral mid-thigh (0.01 mL of 1:1000) (maximum single dose = 0.5 mg or 0.5 mL), repeat every 5 minutes as clinically required
  
  

• For impending or actual airway obstruction/stridor/angioedema unresponsive to 2 doses of IM adrenaline:

  • 5 mg (5 mL of undiluted 1:1000 adrenaline) nebulised, single dose only. Consult CSPSOC if further doses required.

  • The nebulised dose is in addition to ongoing IM doses to manage systemic anaphylaxis symptoms, continue IM adrenaline as required.

• Life threatening/peri-arrest* anaphylaxis refractory to 2 doses of IM adrenaline and fluid bolus: 0.2 microg/kg IV/IO (maximum single dose = 10 microg in 0.1 mL), every minute as required.

* For example: altered conscious state, extremely poor perfusion, systolic blood pressure <90mmHg

Croup

Infants (>1 month) / Paediatric:

• Nebulise 5 mg (5 mL of 1:1000) undiluted, repeat after 15 minutes if required (repeat once only, further doses require ASMA consult)

Haemorrhage control post cricothyroidotomy

• Soak gauze in 1:20,000 adrenaline solution (see preparation) and apply to cricothyroidotomy site using direct pressure.

Amiodorone

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Amiodarone

Introduction

Dosage: 150mg in a 3ml ampoule

Amiodarone is a Class III antidysrhythmic agent that prolongs the action potential duration and hence the refractory period of atrial, nodal and ventricular tissue. Thereby giving a very broad spectrum of activity

Antiarrhythmic. Decreases sinus node and junctional automaticity, slows AV and bypass conduction and prolongs refractory period of myocardial tissue¹

Immediate onset, peak <10min, duration 30-60mins

Indications

There is a national amiodarone shortage in Australia, if you do not have amiodarone available please revert to lignocaine as the primary anti-arrythmic.

Cardiac Arrest with persistent/shock resistant Ventricular Fibrillation/pulseless Ventricular Tachycardia, post 3rd shock(ANZCOR 2016).

Clinical Lead only: conscious VT (ASMA consult required)

Contraindications

. NO CONTRAINDICATIONS IN CARDIAC ARREST

. Not compatible with Saline (if infusion dose is advocated by a specifically authorised person)

For all other indications:

• Hypersensitivity to amiodarone 

• Second or third degree heart block, symptomatic bradycardia or sick sinus syndrome^1,3

• Polymorphic VT (including Torsade de Pointes)

Precautions / Notes

Heart failure

Thyroid dysfunction

Amiodarone is only indicated for shock resistant or recurrent VF / pulseless VT

Management

Cardiac Arrest

Adult:

= 300mg in 6ml IV/IO once only after 3rd shock

= Repeat dose of 150 mg in 3 ml may be administered after 5th shock

Paediatric / Infant:

= 5mg/kg IV/IO (up to a maximum of 300 mg) once only after 3rd shock

= Repeat 5 mg / kg IV/IO (to a maximum 150 mg) after 5th shock

Special Considerations:

Bradycardia

Hypotension

Polymorphic tachycardias

Nausea

Tremor

Dizziness

Paraesthesia

Headaches

Aspirin

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Introduction

Aspirin has the following pharmacological actions:

Analgesic

Antipyretic

Anti-inflammatory

Anti-platelet aggregation agent

Reduces mortality significantly in Acute Myocardial Infarction by minimising platelet aggregation and thrombus formation in order to retard the progression of coronary artery thrombosis.

Indications

Patients with suspected Acute Coronary Syndrome

Contraindications

Known hypersensitivity to aspirin / salicylates / NSAIDs

Children < 16 years of age.

Precautions / Notes

Actively bleeding peptic ulcers.

Suspected AAA.

Aspirin / salicylate-sensitive asthmatics

Management

300mg oral administration, preferably chewed.

Administered even if patient has taken aspirin that day or on anticoagulants (max of 300 mg)

Special Considerations

Heart burn, nausea, GI bleeding.

Increased bleeding time.

Anaphylactic reaction (some patients, especially asthmatics) exhibit notable sensitivity to aspirin, which may provoke various hypersensitivity / allergic reactions)

Atropine Sulphate

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Atropine Sulphate

Introduction

Dosage: 1.2mg in 1ml plastic vial

An anticholinergic agent that inhibits the action of acetylcholine on post ganglionic nerves at the neuroeffector site. This blocks vagal stimulation to allow the sympathetic response to increase pulse rate by increasing SA node firing rate, and increasing the conduction velocity through the AV node.

Competitively inhibits binding of acetylcholine to muscarinic receptors in the parasympathetic and central nervous systems

An antidote to reverse the effects of cholinesterase inhibitors such as seen with organophosphate poisoning.

Indications

Symptomatic Bradycardia, haemodynamically unstable due to the bradycardia and associated with poor signs of perfusion, including:

Cyanosis

Hypotension

Altered conscious state

Diaphoresis

Shortness of breath

Syncope

Organophosphate poisoning with cholinergic effects

Contraindications

Known hypersensitivity.

Patients with cardiac transplant.

Precautions / Notes

• Monitoring: HR, BP, RR, GCS. It is advisable that a 12 Lead ECG is conducted prior to medication administration to rule out Acute Myocardial Infarction (STEMI) and Third-degree atrioventricular (AV) block (atropine may not be effective). If in doubt transmit 12-lead ECG to CSP SOC to discuss or seek ASMA advice.

• Post ROSC bradycardia, isolated bradycardia or bradycardia linked to a traumatic cause does not indicate atropine. 

• Atropine treatment in patients with cardiac transplants is ineffective as vagus nerve is severed²

• Reversible paediatric bradycardia (hypoxia, vagal stimulation) should have primary causes addressed before administering atropine

• Caution in patients with Acute MI, (atropine may worsen ischemia and infarction)¹, Myasthenia Gravis² or severe inflammatory GI disease or GI obstruction²

• Organophosphate poisoning atropine treatment target end points: HR > 80 bpm, SBP > 80 mmHg, drying of respiratory secretions.

Management

Symptomatic Bradycardia

• IV/IO Injection

Adult: 600 MICROg (0.5 mL) as rapid IV push^2,5

• Repeat every 3 – 5 minutes if required¹

• Maximum total dose of 3 mg¹ (5 mL)

Paediatric: 20 MICROg/kg, Maximum 0.6 mg¹ (CCP ONLY or ASMA consult)

• Repeat once if required¹ 

Organophosphate poisoning

• IV/IO Injection

Adult: 1.2 mg initial dose^4,6

• Repeat dose every 5 minutes until atropinisation is evident (see Notes for target end points)

Paediatric: 20 MICROg/kg⁶

• Repeat dose every 5 minutes until atropinisation is evident (see Notes for target endpoints)

Adverse Effects and Complications

• Common Adverse Effects (dose dependant): dry mouth, tachycardia, blurred vision, photophobia, anxiety, delirium^1,6

Cophenylcaine

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Cophenylcaine

Introduction

Topical pump spray containing:

Lignocaine hydrochloride 50mg/ml

Phenylephrine 5mg/ml

A topical local anaesthetic and haemorrhage control agent for the relief of surface pain, nasal and oral bleeding.

Indications

Local pain: abrasions, small cuts and wounds

Relief of mild and moderate epistaxis

Post tonsillectomy haemorrhage

Intra-oral haemorrhage

Contraindications

Hypersensitivity to phenylephrine, lignocaine or other anaesthetics

Children <2yrs

Pregnancy

Precautions / Notes

Used with caution in patients with cardiovascular, hepatic and/or renal disease.

For oral use, nozzle inserted within the anterior 1/3 of mouth to avoid gag stimulation.

Each spray delivers 100 microlitres of fluid. The dose of lignocaine in each squirt is 5 mg and the dose of phenylephrine in each squirt is 0.5mg

Management

Adult:

Intranasal: Max 10 squirts (5 squirts per nostril)

Topically: Max 5 squirts

Oral use: 1 spray then pause, repeat if required to max. 5 sprays.

Paediatric:

Intranasal:

2-4 years: 1 squirt per nostril

4-8 years: 2 squirts per nostril

8-12 years: 3 squirts per nostril

Topically: Max 5 squirts

Oral use: 1 spray then pause, repeat if required to max. 5 sprays.

Maximum dosages should not be administered more than once in 24 hours.

Special Considerations

Oral administration may cause a transient bitter taste.

Pause between subsequent doses.

Droperidol

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

INTRODUCTION:

Droperidol is a neuroleptic, antipsychotic agent that acts on Alpha and Dopamine receptors, resulting in sedation

Onset of effect usually 3-5 mins both IM and IV

DOSAGE:

10 mg in 2 mls (5 mg in 5 mls)

IV/IO dosage: Dilute 10 mg in 2 mls with 8 mls NACL

INDICATION:

- Disturbed and Abnormal Behaviour (Generally RASS 1 ~ 3) where risk to safety is evident

- Dementia or frail patients where Olanzapine cannot be administered or is ineffective

CONTRAINDICATION:

• Known allergy

• Known Parkinson’s Disease

• Where Ketamine has been administered to sedate this episode

• Age < 6 years old

• Post-ictal Disturbed & Abnormal Behaviour

• Patients known or suspected to be pregnant

PRECAUTION / NOTES

Address organic causes for behavioural presentations at all times- eg. CVA, TBI, Hypoxia, Hypoglycaemia, etc

Post-ROSC agitation - consult ASMA / SOC CSP

Dementia patients - apply caution. Use lower doses

'Agitated or Excited Delirium', 'Acute Behavioural Disturbance' and 'Drug Induced Psychosis' are some alternative terms that may be used by other agencies

Sedation warnings

Sedation is HIGH RISK - must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)

Positive RASS score does not automatically infer a need to sedate

Age <16 years old - sedation should prompt a prior ASMA consult wherever practicable

Pregnant patients - STORC consult MUST be initiated prior to the decision to sedate in all cases where the patient is known or suspected to be pregnant. Transport of pregnant patients should be in the lateral position to prevent supine hypotension syndrome in any woman greater than 20 weeks gestation and to assist in managing airway secretions

ETOH / Intoxication - apply caution

Repeat & Maintenance doses - have a low threshold to consult with ASMA where repeat or maintenance doses are required

• Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)

• Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position

• Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required

• Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia

• RASS scores must be agreed and documented

• Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented

The final decision to sedate lies with the most senior clinician on scene

Administration limited to those with independent authority to practice per the  Medications Schedule

Adults < 70 years old: 

• IM (preferred route):

  • 5 mg in moderate to severe alcohol intoxication OR

  • 10 mg in nil to mild alcohol intoxication

• IV:

  • 2.5 - 5 mg titrate to effect

• Repeat as necessary every 15 mins to a maximum cumulative dose 20 mg/24 hrs (via all routes). Consider switch to IV Midazolam only if necessary after maximum dose reached.

Adults > 70 years of age or frail or with dementia:

• IM (preferred route):

  • 2.5 mg in moderate to severe alcohol intoxication OR

  • 5 mg in nil to mild alcohol intoxication

• IV:

  • 2.5 mg

• Repeat as necessary every 15 mins to a maximum cumulative dose 10 mg/24 hrs (via all routes). Consider switch to IV Midazolam  only if necessary after maximum dose reached.

Paediatrics 6-16 years old:

• IM (preferred route):

  • 0.2 mg/kg to a maximum of 5 mg

  • Repeat as necessary every 15 mins to a maximum cumulative dose 10 mg/24 hrs (via all routes).

• IV:

  • 0.2 mg/kg to a maximum of 5 mg 

  • Repeat as necessary every 30 mins to a maximum cumulative dose 10 mg/24 hrs (via all routes).

Adverse Effects and Complications

• Extrapyramidal effects / Dyskinesia

• Increased falls risk

• Hypotension

• Apply monitoring as soon as practicable

Fentanyl

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Introduction

A short acting synthetic narcotic analgesic

Dosage:

Fentanyl: 450mcg in 1.5ml (300mcg/ml); intra-nasal administration only

Fentanyl Citrate: 100mcg in 2ml ampoule (50mcg/ml); IV/IO only

Dilute 100mcg in 2ml with 8ml NaCl 0/9% to produce10mcg/1ml

Indications

Moderate to severe pain.

Acute Coronary Syndromes where GTN has been ineffective

Contraindications

Hypersensitivity to Fentanyl

Less than 1 year of age (IV / IO only)

Occluded nasal passages or epistaxis (intranasal only)

Precautions / Notes

Elderly patients

Respiratory depression: especially those at risk e.g. patients with severe COPD

Patients on MAO inhibitors

Caution in larger doses of women in active labour

Use of IV Ketamine as analgesic prior to minimum (age dependant) dose of IV Fentanyl requires ASMA authorisation:

Paediatric: 100mcg

Adult < 70 years old: 200mcg

Adult > 70 (or frail): 100mcg

Administer slowly and Cease administration prior to calculated dose if desired effect is obtained.

Patients under extended care (e.g. 'ramped' patients) who have already been administered pain relief should have careful consideration with regards to the dosages of fentanyl administered, titrating only to effect.

Management:

IV / IO Fentanyl Citrate: 100 mcg in 2 mls diluted into 100 mcg in 10 mls

Ramped patients must not have loading doses administered - maintenance doses (max 25mcg IV) to effect as required.

Ask the patient's age first prior to administering

Adult < 70 years old:

Pre-hospital loading dose: Titrate 1mcg/kg slow IV push (maximum single dose: 100mcg)

Subsequent dose: 25mcg to effect every 5 minutes

Adult > 70 years old or frail:

Pre-hospital loading dose: Titrate 0.5mcg/kg slow IV push (maximum single dose: 50mcg)

Subsequent dose: 25mcg to effect every 5 minutes titrated to effect

Paediatric:

Paediatric:

• Pre-hospital loading dose: titrate 0.5-1 microg/kg, slow push over 3-5 minutes (maximum single dose: 25 microg)

• Subsequent dose: 1 microg/kg (up to 25 microg) every 5 minutes, titrated to effecT

Subsequent IN dosages can be administered every 5-10minutes, titrated to effect for adult patients. FOR PAEDIATRIC PATIENTS SINGLE REPEAT DOSE ONLY (INITIAL + 1x REPEAT). CSPSCC consult required for multiple repeat doses for paediatric patients. 

ASMA consult required for paediatrics under 1 year old.

Adverse Effects and Complications

• Adopt a low threshold to engage with the ED team if pain remains difficult to control

• Drowsiness

• Nausea/vomiting

• Respiratory depression; monitor pulse oximetry for all patients having IV / IN Fentanyl

• Cardiovascular effects:

  • Bradycardia

  • Hypotension (rare)

Glucagon

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Glucagon

Introduction

A hyperglycaemic agent that converts stored liver glycogen to glucose to increase blood glucose concentration and decreasing GI motility.

Dosage: 1 mg / Hypokit = 1 mg / 1 ml

Onset 4-7 minutes, duration 10-30 minutes.

Indications

For demonstrated hypoglycaemia where oral glucose cannot be administered and IV access cannot be obtained in a safe and timely manner.

Altered conscious state in a known diabetic or of otherwise unknown cause where blood glucose level is below 4mmol/L.

Contraindications

Hypersensitivity.

Known pheochromocytoma, insulinoma, glucagonoma

Precautions / Notes

Glucagon is effective in treating hypoglycaemia only if sufficient liver glycogen is present (eg: it does not work on alcohol or anorexia induced hypoglycaemia).

Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.

Management

Intramuscular injection into deltoid muscle or mid-lateral thigh

Adult:

1 mg (1 mL) IM

Response to glucagon should occur in 10 minutes; if no response, give IV glucose

If unable to obtain IV access, repeat IM glucagon after 10 minutes if patient still has inadequate GCS and blood glucose level.

Paediatric:

< 25 kg: 0.5 mg (0.5 mL) IM

> 25kg: 1 mg (1 mL) IM

Single dose only

Special Considerations

Nausea/vomiting

Gastric pain

Transient rise of blood pressure for patients taking beta blockers.

Glucose 10%

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Glucose (Intravenous)

Introduction

A hypertonic crystalloid solution that provides a readily available source of energy (Glucose)

Dosage: 500 ml of 10% Glucose = 10 grams in 100 mls

Indications

Demonstrated hypoglycaemia where oral glucose administration is inappropriate in a:

Altered conscious state in known diabetic or of otherwise unknown cause where blood glucose level is below 4mmol/L.

Cardiac arrest, only if hypoglycaemia is suspected as a contributory cause of the arrest, not an early indication.

Contraindications:

Not to be used if there is no patent IV access

Precautions / Notes

Patients should ideally be cannulated with a large gauge cannula into a large vein, with patency confirmed with a free flowing bolus (>20ml) of 0.9% normal saline, before administering glucose 10% using a 20ml syringe via the injection port, titrated to effect. Administration via an IO should utilise a 20ml syringe and a three way tap.

High concentration of IV glucose may aggravate dehydration due to its hypertonicity whereby it draws water from the cells.

IV glucose is corrosive and IV patency must be ensured before administration.

Careful titration of glucose in head injured patients is vital as glucose leaking into CNS tissue will aggravate the injury, resulting in cerebral oedema.

Monitor blood glucose level carefully; beware of drop in level again after the patient has recovered.

Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.

IO administration is only as a last resort after all other avenues have been exhausted and the patient needs lifesaving glucose.

Do not wait on scene for glucose to take effect.

Management

Adult:

- 15 g (150 mL) IV

- If BGL < 4 mmol/L after 5-10 minutes, give 10 g (100 mL) IV titrating to effect

Paediatric:

• 2 mL/kg (0.20g/kg or 200mg/kg) up to 15 g (150 mL) IV/IO

• If BGL < 4 mmol/L after 5-10 minutes, repeat 2 mL/kg (0.20 g / kg or 200 mg/ kg) IV, titrating to effect

Newborn:

• 2 mL/kg (0.20 g/kg or 200 mg/kg)

• Repeat once only, if clinically indicated (BGL < 2 mmol/L)

Glucose Oral Gel

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Glucose Oral Gel

Introduction

Oral glucose (dextrose) for rapid response to mild hypoglycaemia

Onset 2-5 minutes, duration 12-25 minutes.

Dosage: 15 grams in tube

Indications

Demonstrated hypoglycaemia in:

- Altered conscious state in a known Diabetic.

- Altered conscious state of unknown medical cause, where blood glucose level is below 4mmol/L.

Contraindications

Nil

Precautions / Notes

Have patient's airway patent and in lateral position if unconscious.

Always consider patient's airway when administering gel.

Even if fully recovered, patients should be encouraged to be transported to a medical facility to ensure effective follow up and review.

Will liquefy over 30°C, however it is still useable.

Management

Adult:

Squeeze contents of tube (or as much as practical) into lower cheek pouch over gums/cheek and externally massage cheek.

Repeat after 10 minutes if still altered consciousness or deteriorating.

Child:

Administer small amounts of oral glucose gel into lower cheek pouch over gums/cheek and externally massage cheek.

Repeat after 10 minutes if still altered consciousness or deteriorating.

Do not delay transport.

Neonate/Infant:

Process for buccal administration of oral glucose gel:

Wearing a clean glove, gently dry the infant's buccal mucosa with gauze/pad.

Place a small amount of oral glucose gel onto gloved finger and gently massage into the infants buccal mucosa.

DO NOT administer the gel directly from the tube into the infants mouth.

Use only a portion of the tube, titrate to effect.

Repeat as necessary after 10 minutes if still altered consciousness or deteriorating.

Do not delay transport.

Special Considerations

Airway obstruction

Monitoring required post administration: Even if fully recovered, encourage patient to consume a long-acting complex carbohydrate (biscuit, bread) following oral glucose administration to prevent delayed hypoglycaemia.^2,

Glyceryl Trinitrate (GTN)

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Glyceryl Trinitrate (GTN)

Introduction

Nitrates cause the relaxation of vascular smooth muscle resulting in:

Vasodilation

Peripheral pooling and reduced venous return

Reduced left ventricular and diastolic pressure (preload)

Reduced systemic vascular resistance (afterload)

Reduced myocardial energy and oxygen requirements

Relaxes spasm of coronary arteries

Dosage: 0.4 mg of spray

Indications

Chest pain/discomfort of presumed cardiac origin not relieved by rest and reassurance with:

- Systolic BP > 90 mmHg; AND

- Heart rate is between 50-150 beats per minute.

Acute Cardiac Pulmonary Oedema with systolic BP >90 mmHg.

Autonomic Dysreflexia with systolic BP > 160 mmHg.

Suspected Irukandji Sting with systolic BP > 160mmHg.

Contraindications

Hypersensitivity

Hypotension < 90 mmHg

Ventricular Tachycardia (VT)

Recent use of medications used for sexual dysfunction or specific regular medication used in the treatment of pulmonary arterial hypertension (brand names below are not exhaustive):

Sildenafil (Viagra® / Revatio®), Vardenafil (Levitra®) or Avanafil (Spedra®) use in the previous 24 hours

Tadalafil (Cialis®) use in the previous 3 days

Riociguat (Adempas®) use in the previous 24 hours

Precautions / Notes

Nitrates are an early intervention and should not be delayed until on the stretcher or inside the ambulance.

Administer to the patient in a seated or semi-recumbent position.

Do not shake GTN bottle prior to administration.

Assess BP before every dose.

12 lead ECG prior to administering GTN in order to rule out Inferior MI's

Do not give this medication if patient was hypotensive at all throughout the patient assessment (even if treatment with fluid therapy)

Management

Cardiac Chest Pain

• 400 microg (1 spray) sublingually.

• If pain persists after 5 minutes and BP maintained, consider further sprays of GTN at 5 minute intervals

• Should the first 3 doses provide some relief but symptoms persist, continue with further doses at 5 minute intervals if no contraindications

Acute Cardiogenic Pulmonary Oedema

• 400 microg (1 spray) sublingually

• If BP maintained, consider further sprays of GTN at 5 minute intervals

• Should the first 3 doses provide some relief but symptoms persist, continue with further doses at 5 minute intervals if no contraindications

Autonomic Dysreflexia

• 400 microg (1 spray) sublingually.

• Repeat doses at 5 minute intervals until symptoms resolve or systolic BP < 160mmHg.

Suspected Irukandji Sting with systolic BP > 160mmHg

• 400 micrograms (1 spray) sublingually.

• Repeat doses at 5-minute intervals until symptoms resolve or systolic BP < 160mmHg.

Adverse Effects and Complications

Side effects:

• Hypotension (rare)

• Tachycardia

• Flushing

• Headache

• Dizziness

Heparin Sodium

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Heparin Sodium

Introduction

A naturally occurring anticoagulant which inhibits the clotting of blood by enhancing the rate at which antithrombin III neutralises thrombin and activated factor X (Xa).

• Anticoagulant.¹ Inactivates clotting factors IIa (thrombin) and Xa by binding to antithrombin III

Onset of action is immediate following IV administration.

Dosage: Ampoule of 5,000 international units (IU) in 5mL

Indications:

Patients with STEMI going directly to Cardiac Catheterisation Laboratory as per receiving hospital 12-lead ECG interpretation.

• Acute STEMI accepted for percutaneous Coronary Intervention (pCI) at a Cardiac Catheterisation Laboratory confirmed by receiving hospital 12-lead ECG interpretation⁴

Contraindications:

• Hypersensitivity to heparin or pork products³

• Uncontrolled active bleeding³ (excluding menses)^4,5

• Bleeding disorders (e.g. haemophillia, thrombocytopenia)^3,4

• History of Heparin Induced Thrombocytopenia (HIT)

• Patients under 18 years old⁶

Precautions / Notes

Haemorrhagic risks in case of possible trauma.

Management:

IV only: 5000IU / 5ml bolus dose flushed with NaCl 0.9%.

Special Considerations:

Haemorrhage

Hydrocortisone

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Hydrocortisone

Introduction

Corticosteroid

Onset of Action: 1 hour; Half-life: Variable; Duration of Action: 12 hours2,4

Dosage: 100 mg in 2 mls (powder for reconstitution)

Indications:

Adrenal crisis in patients with known adrenal insufficiency

Adults: Severe and Life-threatening Asthma exacerbations

Paediatrics: Life-threatening Asthma exacerbations

Contraindications:

Known hypersensitivity

Precautions / Notes:

Dosage to be given in line with patients own management plan or as below (Management) if no management plan available

Hydrocortisone should only be administered intravenously if IV access has already been established for other interventions or will need to be established for other interventions. IV access should not be established for the sole purpose of administering Hydrocortisone.

Preparation

Tap to ensure that powder is at base of vial and away from the central stopper2.

Place the Act-O-Vial on a flat, stable surface and hold with one hand6.

Press down firmly on the plastic activator with the palm of the other hand to force diluent into the lower compartment6

Gently mix the solution by turning the vial upside down a number of times. DO NOT SHAKE THE VIAL.6

Management

Dosage to be given should be in line with patients own management plan.

In the absence of patients own management plan the following dosages should be followed:

IM/IV injection:

Adult:

100 mg as a single dose1,4

Paediatric: 2-4 mg/kg

< 6 Months<7 kg25 mg (0.5mL)

6 months to 2 years8 - 12 kg50 mg (1mL)

3 - 10 years13 - 30 kg75 mg (1.5mL)

>10 years>30 kg100 mg (2mL)

Special Considerations:

Tachycardia

Intravenous Crystalloid Solutions (Normal Saline)

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Intravenous Crystalloid Solutions (Normal Saline)

Introduction

A sterile isotonic crystalloid solution

Dosages:

Normal saline (NaCl 0.9%) in 1000ml soft plastic bag

Normal saline (NaCl 0.9%) in 250ml soft plastic bag

10 ml plastic vial

Indications

Fluid replacement (volume expansion) for the treatment of shock, fluid loss, and cardiac arrest.

Contraindications

- Severe Pulmonary Oedema

Precautions / Notes

Adult patients with penetrating trauma, ectopic pregnancy or aortic aneurysm with hypotension and signs of impaired organ perfusion may benefit from permissive hypotension (systolic blood pressure of 70mmHg)

Fluid Therapy for shock, DKA & Hyperosmolar Hyperglycaemic State: Initial fluid therapy is directed toward expansion of the intravascular, interstitial, and intercellular volume, all of which are reduced in hyperglycaemic crises and restoration of renal perfusion.

Management

KVO

20 drops per minute (20 drops = 1ml)

Fluid Therapy for shock, DKA & Hyperosmolar Hyperglycaemic State[1])

Adult: 250ml boluses to a maximum total of 2000ml

Small adult/elderly: 250ml boluses up to maximum total of 1000ml

Paediatric: 10ml/kg over 5-10 minutes. Repeat once only

Cardiac Arrest

Adult / Paediatric: 20ml/kg bolus as a reversible cause of hypovolaemia

Newborn: 10ml/kg as a reversible cause of hypovolaemia

Post ROSC

Adult:

250ml boluses to a maximum total of 500ml with reassessment between each infusion

Paediatric:

10ml/kg, repeat once only with reassessment between each infusion (bolus max. 250ml)

Burns

Adult:

Apply modified Parkland Formula to patients that meet the following criteria:

Adults: > 15% TBSA

Paediatrics:

≥ 18 months and > 10% TBSA

OR

< 18 months and > 8% TBSA

Modified Parkland Formula:

2ml x %TBSA x weight of patient

50% of total amount over first 8 hours

50% of total amount over next

Ipratropium Bromide

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Ipratropium Bromide

Introduction

An anticholinergic bronchodilator. It inhibits the vagal reflexes that mediate bronchospasm.

Combined with a nebulised beta-2 agonist (Salbutamol), Ipratropium bromide produces significantly greater bronchodilation than a beta-2 agonist alone.

Dosage:

250mcg in 1ml nebule

Metered Dose Inhaler (MDI)20mcg per puff

Indications:

Severe bronchospasm:

Adult:

Severe to life-threatening asthma or COPD

Paediatric:

Severe to life-threatening asthma

Contraindications

- Hypersensitivity

Precautions / Notes

- Glaucoma

- Avoid contact with eyes.

Management

Adult:

Nebulised (combined with salbutamol):500 microg in 2 mL (x2 vial of 250 microg/mL)

= Dilute solution for nebulisation to 2-3ml with sodium chloride 0.9%

= Repeat nebulised dose every 20mins; maximum of 3 doses in 24 hours

Paediatric:

< 6 years

Nebulised dose:

Initial dose: 250 mcg in 1 ml

Repeat dose: Repeat 250 mcg in 1 ml every 20 mins (maximum of 3 nebulised dose)

Repeat dose: Single dose only

> 6 years old

Nebulised dose:

Initial dose: 500 mcg in 2 ml

Repeat dose: Repeat 500 mcg in 2 ml every 20 mins (maximum of 3 nebulised dose)

MDI puffer: 20 mcg per puff

Initial dose: 8 puff with 1 breath each

Repeat dose: Single dose only

Special Considerations

Headache.

Nausea.

Dry Mouth / Throat irritation

Skin rash.

Ketamine

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Mode of Action/Medication Class

• Rapid acting dissociative anaesthetic

• IM onset: 5-10 minutes

• IV onset: 1 minute

• Use of a sedative agent should never be considered routine. Have a high threshold to offer or administer.

 Indications

• IV: Second line agent for severe pain of traumatic origin post IV Fentanyl administration. ASMA consult needed if IV Fentanyl minimum dose (age dependent as per CPG) has not been given prior to IV Ketamine administration

• IM: First line agent for severe pain of traumatic origin should other means of administering pain medication not be available

• Combative Traumatic Brain Injury

Paramedic only

• (RASS 4) First line agent for severely disturbed or abnormal behaviour where there is an immediate risk to safety and rapid tranquilisation is required and no other sedative medications have already been administered to this patient

• Sedation in Pregnancy: First line agent if olanzapine not suitable for sedation in pregnancy

• CPR Induced Consciousness (CPRIC) where patient movement or other features are interfering with cardiac arrest management

 Contraindications

• Hypersensitivity

• Active cardiovascular disease including cardiac chest pain, heart failure, severe or poorly controlled hypertension

• Patients with delayed transfer of care (i.e. 'ramped')

• Non-pregnant Disturbed and abnormal behaviour that are clearly not RASS 4 or where other sedative agents have already been administered (ASMA authority required)

• Rapid Tranquilisation ONLY: Age < 16 years old

• Age < 1 years old

PRECAUTION / NOTES

• Caution in patients with stable psychiatric disorders such as Schizophrenia

• Caution in patients with hyperthyroidism or receiving thyroid replacement due to increased risk of hypertension and tachycardia

• Analgesia – IV Fentanyl minimum dose (age dependant as per CPG) should be given prior to IV Ketamine administration

• Analgesia for Non traumatic pain (IM / IV / IO) in opioid-dependent patients – consider SOC CSP consult

Sedation warnings

• Sedation is HIGH RISK – must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)

• Positive RASS score does not automatically infer a need to sedate

• Age <16 years old – sedation should prompt a prior ASMA consult wherever practicable

• Pregnant patients - STORC consult MUST be initiated prior to the decision to sedate in all cases where the patient is known or suspected to be pregnant. Transport of pregnant patients should be in the lateral position to prevent supine hypotension syndrome in any woman greater than 20 weeks gestation and to assist in managing airway secretions

• ETOH / Intoxication – apply caution

• Repeat & Maintenance doses – have a low threshold to consult with ASMA where repeat or maintenance doses are required

• Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)

• Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position

• Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required

• Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia

• RASS scores must be agreed and documented

• Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented

The final decision to sedate lies with the most senior clinician on scene

MANAGEMENT

Analgesia

For Prehospital use only

Adult:

• IM (pre-hospital only):

  • Initial dose: 1 mg/kg

  • Subsequent doses at 5 minute intervals – 0.5 mg/kg

  • Concentration: 200 mg/2 ml = 100 mg/ml

• IV/IO (pre-hospital only):

  • Initial dose: 5 - 20 mg titrated to effect over at least 1 minute

  • Subsequent doses at 5 minute intervals: 5 - 10 mg titrated to effect

Paediatric:

• IM (pre-hospital only):

  • Initial dose: 1 mg/kg;

  • Subsequent doses at 5 minute intervals: 0.5 mg/kg;

  • Concentration: 200 mg/2 ml = 100 mg/ml

• IV/IO (pre-hospital only):

  • 0.1 mg/kg administered over at least 1 minute and titrated to effect

  • Repeat at 5 minute intervals as required

Rapid Tranquilisation (RASS 4)

For Prehospital use only

Administration limited to those with independent authority to practice per the Medications Schedule

Adult 16 or over:

IM:

• Initial dose (agreed ideal body weight):

  • up to 2 mg/kg repeat if necessary to a maximum cumulative dose of 200 mg in moderate to severe alcohol intoxication OR

  • up to 4 mg/kg repeat if necessary to a maximum cumulative dose of 400 mg in nil to mild alcohol intoxication

Adequate sedation may be achieved with lower doses on a case-by-case basis

• IV access obtained as soon as practicable:

  • ASMA consult required where IV access is not achieved and further sedation required.

IV for maintenance of ketamine-induced sedation only:

• 0.5 mg/kg repeated every 5 - 10 minutes ONLY IF REQUIRED

Pregnant patients (STORC consult required):

IM

• Single dose (agreed ideal body weight):

  • Up to 4 mg/kg to a maximum dose of 400 mg

• If further sedation required, consider midazolam (IV only); if no IV access STORC consult required

• IV access to be obtained as soon as practicable:

  • STORC consult required where IV access is not achieved and further sedation required.

CPR Induced Consciousness (CPRIC)

IV/IO:

• 0.3 - 0.5 mg/kg, repeated once only at 5-10 minutes only if required

Combative Traumatic Brain Injury (TBI)

For Prehospital use only

IM:

• Initial dose: 2 mg/kg to a maximum of 200 mg (agreed ideal body weight)

• IV access obtained as soon as practicable

IV/IO:

• 0.5 mg/kg repeated every 5-10 minutes IF REQUIRED

Adverse Effects and Complications

• Blood pressure and pulse frequently elevated

• Random purposeless movements, muscle twitching and rash are common

• Hypersalivation

• Emergence reactions (10%)

• Transient laryngospasm

• Transient apnoea or respiratory depression

Lignocaine 1%

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Lignocaine 1%

Introduction:

Reversibly interrupt impulse conduction in peripheral nerves and stabilise excitable cell membranes by blocking Sodium Channels

Onset 1-2 minutes

Dosages: 20mg/2ml OR 50mg/5mL; (both 1%) in a plastic ampoule

Indications:

Local anaesthesia for:

IV cannulation

IO infusion

Suturing

Finger thoracostomy in the conscious patient

Cardiac Arrest:

INTERIM UPDATE - March 2025: Where Amiodarone unavailable, as a primary anti-arrhythmic for cardiac arrest with persistent or recurrent Ventricular Fibrillation/pulseless Ventricular Tachycardia, post 3rd shock.

If remaining in a shockable rythym with Lignocaine used as first-line agent, follow-up dose post 5th shock in line with ALS guidelines

Cardiac Arrest with persistent or recurrent Ventricular Fibrillation/pulseless Ventricular Tachycardia, refractory to defibrillation strategies and maximum dose of Amiodarone as per Cardiac Arrest CPG (Clinical exception required)

Contraindications:

- Hypersensitivity

Precautions / Notes:

Adverse drug reactions are rare when lignocaine is used as a local anaesthetic and is administered correctly.

Management

Local Anesthesia

Intradermal:

0.1mL

Intraosseous:

Small child: 10mg in 1mL

Small adult/large child: 20mg in 2mL

Adult: 40mg in 4mL

May be repeated at a second site if needed.

Finger Thoracostomy:

50mg in 5mL

Cardiac Arrest (Refractory VF/pVT)

INTERIM UPDATE DUE TO AMIODARONE SHORTAGE - March 2025:

Adult and paediatric dose: 1mg/kg (undiluted)

Clinical exception not required due to national amiodarone shortage

Normal guideline - IV/IO:

Adults: 1mg/kg (undiluted)

May be repeated once after 5 minutes if sufficient supply.

Clinical exception required

Special Considerations

Tinnitus, dizziness, anxiety, confusion, perioral numbness

Cardiovascular effects: Bradycardia, hypotension, dysrhythmias

CNS e

Methoxyflurane

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Methoxyflurane

Introduction

A halogenated ether that produces powerful modification of the awareness of pain with an associated light headed sensation.

6-8 breaths/ 1-2 min onset with maximum level after 2-4 minutes.

Dosage: 3 ml vial

Indications: Pain

Contraindications

Hypersensitivity to fluorinated anaesthetics

Children under 1 year of age

Patients who are unable to understand or co-operate including those affected by alcohol or illicit drugs

Patients with a severe head injury and altered state of consciousness

Patients susceptible to malignant hyperthermia1

Precautions / Notes:

Monitoring required: Monitor for over-sedation and apneoa, particularly in children under 5

Equipment required: Penthrox® Inhaler Device with charcoal filter attached

Renal impairment: renal toxicity in high doses. May worsen declining renal function.

Children under 5 may require assistance using the device1

Elderly: possible reduction in blood pressure or heart rate

Management:

Inhalation

Adult/Paediatric > 1 year old

3 mL vaporized in a Penthrox® Inhaler device1 inhaled intermittently to maintain adequate analgesia4

Repeat if necessary after 30 mins3 up to a total of 6 mL daily1,4

Maximum of 5 doses (15 mL) per week1

Not recommended to use on consecutive days

Special Considerations:

Lightheaded

Dizziness

Drowsy

Nausea

Malignant hyperthermia

Midazolam

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Midazolam

Introduction:

A water-soluble benzodiazepine that has anxiolytic, sedative and anticonvulsive characteristics. This is due to its bonding with receptors in the CNS; its action to increase the inhibitory effect of the g-aminobutyric acid (GABA) neurotransmitter on the GABA receptors and subsequent membrane threshold.

Midazolam is lipid-soluble in physiological pH and it reaches the CNS quickly.

Dosage: 15 mg in 3 mls

Indications:

Prolonged seizure activity - generalised seizure lasting ≥ 5 minutes OR recurrent / status seizure activity as per CPG

Focal seizure activity which is prolonged (≥ 5 minutes) and is associated with a GCS ≤ 12 as per CPG

ASMA consult required: Second-line IV agent for maintenance of sedation after Droperidol administration for Disturbed and/or Abnormal Behaviour

STORC consult required: Pregnant patients: Second-line IV agent for maintenance of sedation after Ketamine administration for Sedation in Pregnancy

Contraindications:

- Hypersensitivity

• Use of Midazolam for sedation after Ketamine requires ASMA authority (non-pregnant patient) orSTORC consult (pregnant patients)

Precautions / Notes:

Early monitoring as soon as practicable is required when administering midazolam; including SpO2, respiratory rate, pulse and blood pressure

SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops consistent with the Sedative Warnings section below.

Psychostimulants, in toxic levels can produce severe agitation and psychotic behaviour

Paediatric patients:

Intramuscular administrations should always be prepared in a 1mL IM syringe

Have a low threshold to consult with ASMA when repeat or maintenance doses are required for sedation

Management

DILUTION:

Midazolam for IV / IO Administration:

Draw up 15mg/3ml with 12ml normal saline to produce 15mg/15ml = 1mg/ml

OR

Draw up 10mg/2ml with 8ml normal saline to produce 10mg/10ml = 1mg/1ml

----------> Seizures

Adult < 70 years:

• IM

  • Initial dose: 5 mg 

  • Subsequent dose: 5 mg repeat once after 10 min if needed and no IV access.

• IV/IO

  • Initial dose: 2.5 - 5 mg

  • Subsequent dose: 2.5 mg every 5 min as needed to 15 mg max total.

Adult ≥ 70 years or frail:

• IM

  • Initial dose: 2.5 mg

  • Subsequent dose: 2.5 mg repeat once after 10 min if required and no IV access.

• IV/IO

  • Initial dose: 2.5 mg

  • Subsequent dose: 1 mg every 5 min as needed to 15 mg max total.

Paediatric:

• IM

  • Initial dose: 0.2 mg/kg (max single bolus 5 mg)

  • Subsequent dose: repeat initial dose once after 10 min if needed and no IV access.

• IV/IO

  • Initial dose: 0.1 mg/kg (max single bolus dose of 2.5 mg)

  • Subsequent dose: repeat initial dose as needed every 5 min to 10 mg max total.

The use of Midazolam in both adults and paediatric patients for other seizure types outside of CPG requires ASMA authority.

Maintenance of Sedation (IV Only)

Administration limited to those with independent authority to practice per the Medications Schedule.ASMA consult or STORC consult (for pregnant patients) consult must occur prior to administration

Adult < 70 years of age:

• IV

  • 1 - 2 mg, titrated to effect every 5 - 10 mins as required to a total max dose 5 mg

Adult ≥ 70 years or frail:

• IV

  • 0.5 - 1 mg, titrated to effect every 5 - 10 mins as required to a total max dose 5 mg

Paediatric (6-15 years of age):

• IV

  • 0.5 mg - 1 mg, titrated to effect every 5 - 10 mins as required to a total max dose 5 mg

Adverse Effects and Complications

• Respiratory depression

• Hypotension

• Anterograde and retrograde amnesia

• Myasthenia Gravis

Naloxone

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Naloxone

Introduction

Naloxone is a pure opioid antagonist that exerts its effect by competitive inhibition at the opioid receptor sites. It prevents or reverses the effects of opioids, including respiratory depression, sedation and hypotension. In the absence of opioids it exhibits essentially no pharmacological activity.

Dosage: 0.4 mg in 1 ml / TAKE HOME NALOXONE (1.8 mg naloxone)

Indications:

Reversal of respiratory depression in a suspected narcotic overdose.

Contraindications: Nil

Precautions / Notes:

- Polypharmacy overdose.

- Half-life of naloxone is < 1 hour; repeat doses may be required to maintain effect with longer acting opioids and those with active metabolites (e.g. methadone, diphenoxylate, codeine). Observe patients who respond to naloxone for 2-3 hours after administration for signs of re-narcotisation.

- Response to Naloxone is rapid; reconsider diagnosis if there is a failure to respond to 2 mg Naloxone.

- Patients may be aggressive post Naloxone and administration due to hypoxia. Scene safety and personal safety are paramount..

Management

Adult:

IM/IV/IO:

- 0.4-0.8 mg (400-800 microg) repeat dose every 2 minutes as required, titrated to clinical response to a maximum of 10 mg.

IN:

- One spray (1.8 mg) of Nyxoid® into nostril.

- Repeat at 2 minutes in opposite nostril if the patient does not respond.

Paediatric:

IM/IV/IO:

- 0.01 mg/kg (10 microg/kg, maximum dose 0.4 mg (400 microg), repeat every 2-3 minutes minutes as required, titrated to clinical response.

- If high suspicion of overdose, a 0.1 mg/kg (100 microg/kg) dose (maximum 2 mg) may be given following a lack of response to initial dose.

IN:

- One spray (1.8mg) of Nyxoid® into nostril.Repeat dose after 2 minutes if patient does not respond.

Special Considerations:

Withdrawal symptoms such as:

• Aggression

• Agitation

• Nausea/vomiting

• Dilated pupils and lacrimation

Take-Home-Naloxone (THN)

• Total dispensed amount (3.6 mg - 2x 1.8 mg Sprays + Box with Instructions)

• For patients that have required Naloxone, every attempt should be made to convince the 'at risk' patient to be transported to a healthcare facility.

• Where attempts prove futile, IN Naloxone - Nyxoid® could be left with the patient. This is to avoid the risk of opioid related respiratory depression due to the short half-life of Naloxone.

• In such circumstances please ensure to document leaving Nyxoid® with the person or a responsible other person in the PnT / ePCR.

• Due to our SASA requirements, clinicians cannot supply scheduled medicines to persons who are not St John WA patients.

Olanzepine

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Olanzepine

Introduction:

= Olanzapine is a second generation antipsychotic agent that acts on multiple receptors (incl. serotonin and dopamine receptors), resulting in sedation

= Onset of effect usually ~ 10 mins.

Indications:

= Disturbed and Abnormal Behaviour (RASS 1 ~ 2) where risk to safety is evident and the patient is able to tolerate or self-administer an oral wafer

= Preferred first line sedation agent in frail patients and those with Dementia

Contraindications:

= Known Allergy

= Known Parkinsons Disease

= < 6 years of age

Precautions / Notes:

= Sedation of any patient < 16 years of age -should prompt a prior ASMA consult wherever practicable.

= Organic causes such as suspected sepsis, traumatic brain injury or spontaneous intra-cranial event must be considered unlikely

= 'Agitated or Excited Delirium', 'Acute Behavioural Disturbance' and 'Drug Induced Psychosis' are some alternative terms that may be used by other agencies

= Effects may be amplified in patients with alcohol intoxication

= Oral dispersible tablet may be dissolved in water (may slightly delay onset of action but still preferable in non-emergent cases)

= Early monitoring as soon as practicable is required when administering Olanzapine; including SpO2, respiratory rate, pulse and blood pressure

= SpO2 and etCO2 monitoring must be applied whenever level of consciousness drops (~RASS < 0)

Management

Adults < 70 years old:

- Initial dose: 10mg

- Repeat once only after 15 mins if indicated to total maximum cumulative dose via all routes 20mg/24hrs.

Adults > 70 years old or frail:

- 5mg

- Repeat once only after 15 mins if indicated to total maximum cumulative dose via all routes 10mg/24hrs.

Paediatric 6 - 15 years old, > 40kg:

- 5 - 10mg

- Repeat once after 15mins if indicated to a total maximum cumulative dose via all routes 20mg

Ondansetron

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Ondansetron

Introduction:

= Anti-nauseant and anti-emetic

= Selective 5-HT3 receptor antagonist blocking serotonin centrally in the chemoreceptor trigger zone and peripherally on Vagus nerve terminals.

Dosage:

- 4 mg wafer

- 4 mg in 2 ml vial

Onset of action up to 30 minutes

Indications

- Moderate to severe nausea

- Active vomiting

- Prophylaxis for eye and spinal injuries

Contraindications

• Hypersensitivity to ondansetron

• Treatment with apomorphine: risk of severe hypotension and loss of conciousness²

• Paediatrics less than 2 years old

Precautions / Notes

Monitoring Required: ECG monitoring may be required for IV administration of high or repeated doses in patients with prolonged QT or risk factors for QT interval prolongation

Serotonin Syndrome: Risk of Serotonin Syndrome in concomitant use of other serotonergic drugs (e.g. SSRIs and SNRIs)

Hepatic Impairment: reduces clearance and prolongs half life

Phenylketonuria: wafers contain aspartame, administer with caution

Pregnancy, First Trimester: not recommended, seek advice from CSPSCC/STORC7

Children with gastroenteritis with diarrhoea as the prominent symptom: ondansetron may worsen diarrhoea3

Rapid injection may cause dizziness and transient visual disturbances.4

Management

Oral

Adult:

4 mg oral wafer.

If the patient remains symptomatic, a second dose may be given after 15 minutes.

Ensure that the total dose does not exceed 8 mg within an 8-hour period.

Paediatric (>4 years or >15kg):

4 mg oral wafer, not repeated

IM injection:

Adult:

4 mg IM injection

Can be repeated once if patient remains symptomatic after 15 minutes.

No further doses within 8 hrs of second dose

Paediatric (>2 years):

0.1 mg/kg up to 4 mg as a single dose, not repeated within 8 hrs

IV/IO injection

• Adult:

  • 4 mg over at least 30 secs but preferably 3-5 mins^1,4

  • If patient remains symptomatic a second dose may be given after 15 minutes¹.

  • No further doses within 8 hrs.

  • Note: Over 75 years: inject slowly as more susceptible to side effects¹. 

  Paediatric: (>2 years):

  • 0.1 mg/kg up to 4 mg as a single dose administered over 3-5 mins¹, not repeated within 8 hours^1,3

  • Note: IV ondansetron should only be given to patients unable to tolerate oral administration

Adverse Effects and Complications

Common Adverse Effects: constipation, headache, dizziness²

IV: blurred vision (transient visual disturbance with rapid IV administration⁴), dizziness, flushing

Monitoring required post administration: ECG changes following IV administration^1,4,5

Look alike, sound alike (LASA) medication: Olanzapine orally disintegrating tablet

Oxygen

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Oxygen

Introduction

Oxygen is a treatment for hypoxaemia and has not been shown to have any effect on breathlessness in non-hypoxaemic patients.

Indications

Adult:

Oxygen should be titrated to achieve oxygen saturations of between 94 - 98%, (or 88 - 92% for COPD patients).

Paediatric:

All paediatric patients with significant illness or injury should receive oxygen. Newborn resuscitation should ideally be commenced with room air for the first couple of breaths.

Contraindications

- Explosive or flammable environments

- Normoxia

Precautions / Notes:

If the target saturations cannot be maintained with the nasal cannula or medium concentration mask then change to a non-rebreather oxygen mask.

Oxygen increases the toxicity in paraquat poisoning, target saturations of 88-92%.

Remember that some conditions can affect SpO2 readings e.g. carbon monoxide poisoning and cold digits

Management

Mask: Nasal cannulae

FIO2: 24% - 35%

Flow Rate: 1-4 lpm

Mask: Simple face mask

FIO2: 40% - 60%

Flow Rate: 5-8 lpm

Mask: Non-rebreather mask

FIO2: 60% - 100%

Flow Rate: 10-15 lpm

Mask: Bag Valve Mask

FIO2: 100%

Flow Rate: 15 lpm

Special Considerations

Patients with acute episodes of COPD are at risk of developing carbon dioxide retention if they are given excessive supplemental oxygen. This can cause acidosis and subsequent organ dysfunction.

High oxygen concentrations can lead to increased production of reactive free radicals resulting in cellular damage. This may be responsible for the detrimental effects observed with the use of high flow oxygen in myocardial infarction and stroke.

Paracetamol

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Paracetamol (Acetaminophen)

Introduction:

Paracetamol is a p-aminophenol derivative that exhibits analgesic and antipyretic activity.

Delayed onset of action with peak effect via oral route achieved in ≥ 60 minutes.

Dosages:

500mg white tablets

Per oral liquid: 100mg/ml (2000mg/20ml) suspension

Indications:

= Mild to moderate pain (For example, headache, sprain/strain, toothache, etc.)

= As a component of a multimodal analgesic regime.

Contraindications:

- Known hypersensitivity to Paracetamol.

- Do not give if patient has had Paracetamol in the preceding 4 hours.

- Cannot exceed the maximum allowed single dose of 4 grams or exceed the maximum allowed paracetamol daily dose (24hrs).

Precautions / Notes:

There is no evidence that fever itself worsens the course of an illness. The primary goal should be to improve overall comfort.

SJA do not support the use of paracetamol in infants < 6 months.

20 ml Paracetamol suspension bottle is single patient use only. (Only used enteral syringe/dropper with suspension)

Management

Adult:

500mg tablet; oral administration of 500-1000mg (1-2 tablets)

Max single dose 1000mg

Max dose not to exceed 4000mg or 4 grams over a 24 hour period

Paediatric:

100mg/ml (oral suspension)

6 months - 12 years old: 15mg/kg

Repeat every 4 to 6 hours

Maximum daily dose is 60mg/kg in divided doses of 15mg/kg (not to exceed 4000mg), over a 24 hour period

Special Considerations

Nil known at therapeutic doses.

Prednisolone

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Prednisolone

Introduction

Synthetic glucocorticoid with anti-inflammatory effects

Peak effect within 1hr

Dosage: 25mg in 5mL suspension of Redipred

Indications:

Mild / Moderate croup

Severe croup after nebulised Adrenaline administration

Contraindications:

Known hypersensitivity to prednisolone or prednisone2

Vaccinations with "live" vaccines against common childhood illnesses within the last 48 hours, as this may result in severe attacks of these illnesses2 (MMR, Varicella (Chicken Pox), Yellow Fever, BCG, Rotavirus, Typhoid)

Precautions / Notes:

= 30ml Bottle is single patient use only

= Children who are on immunosuppressant drugs are more susceptible to infections than healthy children, e.g.: Chicken pox and measles

= Impaired immune responsiveness

Management

= 5 mg in 1 ml oral suspension

= Initial dose: Administer 1mg/kg to maximum single dose of 25mg in 5 mls

= Single dose only

Age: < 12 months

Weight: <10 kg

Dose: 10 mg in 2 mls

Age: 1-3 years old

Weight: 10-15 kg

Dose: 10 mg in 2 mls - 15 mg in 3 mls

Age: 4-5 years old

Weight: 15-20 kg

Dose: 15 mg in 3 mls - 20 mg in 4 mls

Age: 6-8 years old

Weight: 20-25 kg

Dose: 20 mg in 4 mls - 25 mg in 5 mls

Special Considerations:

= Side effects occur following prolonged use and are of little consequence in an emergency setting

= Vomiting

Salbutamol

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

Salbutamol Sulphate

Introduction:

= Short acting Beta 2 stimulant that causes relaxation of bronchial smooth muscle (bronchodilation).

= Initial effect 2-5 minutes maximum by 10 minutes.

Dosages:

Salbutamol nebules = 5mg in 2.5mL

Metered Dose Inhaler (MDI) = 100mcg per puff

Indications:

Bronchospasm and respiratory distress associated with wheeze:

Acute Bronchial Asthma

Bronchitis

Smoke inhalation

Severe allergic / anaphylactic reactions

Acute Pulmonary Oedema of non-cardiac origin

Salt Water Aspiration Syndrome (SCUBA divers)

Chronic Obstructive Pulmonary Disease (COPD)

Contraindications:

Known hypersensitivity to Salbutamol

Cardiogenic Pulmonary Oedema (?cardiac wheez: may cause flash pulmomary oedema, bronchodilation = spreads fluid / blood)

Age <12 months

Precautions / Notes

A spacer / MDI is the preferred route for Salbutamol administration where the patient presents with influenza like illness.

The use of a Metered Dose Inhaler (MDI) and spacer is equally as effective as nebulisation, in all asthma situations, where the patient is still able to adequately inhale.

Use of a nebuliser is recommended where the patient loses this ability.

Management:

MDI / Space chamber as per Clinical Skill

Adult/Child > 6 years:

4-12 puffs (400-1200 microg), repeat every 20 minutes (or sooner if needed) for the first hour

Paediatric < 6 years:

2-6 puffs (200-600 microg), repeat every 20 minutes (or sooner if needed) for the first hour

Using an MDI with spacer:

Press once firmly on the MDI to discharge 1 puff into the spacer

Instruct the patient to breathe in and out normally for 4 breaths

Repeat 1 puff at a time until the appropriate number of puffs have been taken

Repeat as clinically required as per dosing schedule above

Nebulised as per Clinical Skill:

Asthma

Adult/paediatric 6 years old or over:

5mg

Tranexamic Acid

INTRODUCTION:

DOSAGE:

INDICATION:

CONTRAINDICATION

PRECAUTION / NOTES

MANAGEMENT

SPECIAL CONSIDERATION

INTRODUCTION:

Antifibrinolytic

Tranexamic Acid (TXA) is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis (clot breakdown) by blocking the lysine binding site on plasminogen, competitively inhibiting the activation of plasminogen to plasmin.

Hepatic metabolism with renal excretion.

Onset: Within minutes

Duration: 17 hours

Half-life: 3 hours

DOSAGE: 1 gram in 10 ml (100 mg / mls)

INDICATION:

Significant trauma (< 3 hours) with signs of hypovolaemia or

Significant active haemorrhage that requires the use ofo Tourniquet/so Haemostatic/pressure dressing/s

Suspected head injury (< 3hours) with GCS motor score of 4 (withdrawing from pain) or below

Severe Primary or Secondary Post-Partum Haemorrhage (> 1000 mL) or PPH with signs of hypovolaemia (birth/bleed occurred < 3hrs)

Significant post-tonsillectomy haemorrhage

CONTRAINDICATION

Known hypersensitivity to Tranexamic Acid.

Injury time more than 3 hours (associated with increase in mortality).

PRECAUTION / NOTES

TXA administration in the traumatic patient in the metropolitan area should ordinarily prompt transport to a major trauma centre

Rapid administration may lead to hypotension and dizziness.

Give as early as possible post event. Survival benefit is reduced by 10% for every fifteen minute delay with no benefit seen after 3 hours

Address critical interventions (airway management, control of major haemorrhage etc.) before administration of tranexamic acid.

Tranexamic acid administration should not delay transfer, noting it may be administered en route.

Safety during pregnancy has not been demonstrated, but the balance of risk is such that it should be administered if the indications are met in life threatening circumstances

For pregnant women with antepartum haemorrhage, consult with STORC if maternal compromise or peri arrest is apparent.

• Subarachnoid haemorrhage; cerebral oedema or infarction may occur with IV administration²

• Pre-hospital administration of TXA for non-traumatic haemorrhage (excluding PPH or post-tonsillectomy haemorrhage) is not currently supported and should not occur. Examples of non-traumatic haemorrhage include GI bleeding from causes such as peptic ulcers, varices and malignancy⁶

Adult IV / IO:

• 1 g slowly over 10 minutes (Rapid administration may cause hypotension)

• SINGLE DOSE ONLY

Paediatric (<12 years) IV / IO:

• 15 mg/kg slowly over 10 minutes (max injection rate 50 mg/minute)

• SINGLE DOSE ONLY

Adverse Effects and Complications

Potential Adverse Effects: Hypotension (fast infusion rate), headache, dizziness^1,2

Intraosseous Access

Indication:

Contraindication:

Patient Factors:

Procedure:

Discontinue:

Indication:

Cannulation of the intraosseous space using EZ-IO:

****Cardiac arrest:

- First line cardiac arrest management for paediatrics

- Consideration for first line access in traumatic cardiac arrest

- Second line cardiac arrest management for adults following at least one failed intravenous (IV) access attempt.

All other circumstances:

- Where immediate medication administration is required following at least one failed intravenous (IV) access attempt when unable to administer via any other appropriate route.

Contraindication:

- Fracture to the targeted bone.

- IO within last 48 hours in the targeted bone.

- Inability to locate landmarks or excessive tissue.

- Prosthetic limb or joint (near insertion point).

- Patients with chlorhexidine sensitivity/allergy, use 10% povidone-iodine swab

Patient Factors:

- Existing trauma at the insertion site.

- Infection at the insertion site/in targeted bone.

- Use on limbs with possible proximal fractures.

-Previous orthopaedic procedure to targeted limb.

Procedure:

Prepare equipment required:

EZ-IO driver

Needle appropriate for patient and location

2% CHG 70% Alcohol swab OR

10% povidone-iodine swab

EZ-Stabiliser

EZ-Connect extension set (primed with saline)

10mL syringe

10mL normal saline for injection

Giving set

IV fluid

***Studies show that the humeral IO route is comparable to central venous drug delivery during CPR and should be selected in most non-paediatric cases. The tibial route is less effective and is de-emphisised.

***Select needle. This requires clinical judgement, taking into account the size of the bone and depth of overlying tissue. The following table is only a guide:

Pink = 15 mm = Minimal tissue (e.g. infant / paediatric tibia)

Blue = 25 mm = Minimal tissue (e.g. adult / paediatric tibia)

Yellow = 45 mm =Excessive tissue (e.g. humeral he

SITE SELECTION PROXIMAL HUMERUS

Place the patient's hand over the abdomen (elbow adducted and humerus internally rotated). Vasc - IO1

Palpate up the humerus (45° to the ground [the horizontal plane]) until you feel the surgical neck; the point at which you will begin to feel the 'ball' of the humerus.

Vasc - IO2

Palpate the insertion site 1 to 2cm above the surgical neck, into the greater tubercle ('ball' or humeral head).

Vasc - IO3

Once the insertion site has been prepared, insert the IO needle, angled slightly downwards and at 45° to the ground (horizontal plane)

SITE SELECTION: PROXIMAL TIBIA

*** Adult or Large Paediatric Patient

- Extend leg out straight.

- Palpate the tibial tuberosity. Locate the medial plateau site by moving two finger widths below the tibial tuberosity and then two finger widths medial along the flat aspect of the tibia.

- Insert needle 90° to bone.

*** Newborn, Infant or Paediatric Patient

- Extend leg out straight.

- Palpate the tibial tuberosity. Locate the medial plateau site by moving one finger width below the tibial tuberosity and then one finger width medially along the flat aspect of the tibia.

- Insert needle 90° to bone.

Direct Laryngoscopy & Magill Forceps

Indication:

Contraindication:

Patient Factors:

Procedure:

Discontinue:

Indication:

- To identify and remove a suspected foreign body from the hypopharynx that is preventing ventilation.

- In order to create a patent airway and an ability to achieve adequate ventilation

Contraindication:

- Conscious patient or Gag reflex intact

- Do not use Magill forceps if obstruction below the vocal cords.

- SpO2 reading of 90% and ventilation is achievable

- Suspected epiglottitis.

Patient Factors:

- Damage to upper respiratory tract, lips and teeth/dentures.

- Further impaction or crumbling of the foreign body

- Vagal stimulation

- Exacerbation of hypoxia / hypercapnia.

- Spinal injury

Procedure:

Prepare equipment required:

Laryngoscope

Magill forceps

Bag Valve Mask (BVM)

Oxygen Suction

*** Direct Laryngoscopy is a dynamic process that should start with properly positioning the patient in the Sniffing Position, but may require further position adjustment to achieve the required views.

In cardiac arrest due to foreign body airway obstruction, direct laryngoscopy & removal of foreign body MUST occur in conjunction with high quality chest compressions. Delayed ventilation (i.e. OPA/NPA with a non-rebreather mask) must NOT occur and ventilation must be commenced as soon as practicable.

Position the patient for optimal visualisation of the larynx (e.g sniff or pillow support)

Open patient's mouth by use of the cross finger technique, inspecting the oral cavity.

Suction if required

If the obstruction is visible and can be removed with the Magill forceps, proceed to Step 7.

Using left hand, place the laryngoscope blade into the right side of the patient's mouth, gently sweep the tongue to the left and position the blade midline in the mouth. Ensure any obstructions are not pushed further down the respiratory tract.

Advance the blade progressively down the tongue, exposing the obstructing o

Supraglottic Airway (SGA)

Indication:

Contraindication:

Patient Factors:

Procedure:

Discontinue:

Indication:

- To manage and maintain a compromised airway in the patient with absent pharyngeal and laryngeal reflexes.

Contraindication:

- Intact gag reflex

Patient Factors:

- Confirm LMA placement every time the patient is moved.

- Consider use of laryngoscope blade as tongue depressor in infants.

- Ensure the mask does not kink when advancing it into the patient's mouth.

Stabilise patient's head and neck to avoid flexion, rotation or traction.

- EtCO2 provides some analysis of ventilation and its use with SGA is advised.

- Utilise a 30:2 compression/ventilation regime during cardiac arrest when LMA is in use with LUCAS device.

Procedure:

Prepare equipment required:

i-gel®

Prepare equipment required:

Appropriate size i-gel®

BVM

Disposable catheter mount

Lubricant (NB: Back, both sides and tip)

Oxygen

Stethoscope

Airway support strap

Suction

EtCO2

Select i-gel® size:

Size Weight

3 30 - 60 kg

4 50 - 90 kg

Apply lubricant to posterior surface of i-gel®

Pre-oxygenate the patient

Ensure airway is clear.

Place patient's head in the 'sniffing' position using appropriate padding/ neutral position in suspected cervical spine trauma.

Push the mandible towards the thorax, insert the i-gel® into the patient's mouth (3) with the tip of the mask against the hard palate.

Glide the device as far as it will go along the hard palate until definitive resistance is felt.

Attach the catheter mount and EtCO2 to the i-gel®.

While stabilising the i-gel®, gently inflate the lungs to test for air entry and seal.

Auscultate chest to confirm placement.

Secure the i-gel® in a central position with securing strap.

The i-gel® forms a seal in the airway; this is referred to as a non-inflating cuff.

Discontinue:

- Ineffective ventilations (i.e.: adequate chest rise and fall) cannot be achieved. (Some air leakage can be expected)

Needle Thoracocentesis

Indication:

Contraindication:

Patient Factors:

Procedure:

Discontinue:

Indications:

Traumatic cardiac arrest with torso involvement

Contraindication:

- Patients not in cardiac arrest unless trained and authorised

- Consider ASMA consult in a patient with suspected tension pneumothorax and respiratory and/or haemodynamic compromise.

Patient Factors:

- Perform bilaterally in traumatic cardiac arrest

- A patient not in cardiac arrest can receive unilateral treatment on the affected side, with ASMA authorisation where applicable

- The site selected should be superior to the third rib to avoid trauma to intercostal blood vessels and nerves.

- Procedure can be repeated if tension pneumothorax redevelops.

- It is very difficult to detect breath sounds/chest rise and fall in Traumatic Cardiac Arrest, so tension pneumothorax should be assumed whenever there is trauma to the torso

- Use the angio cath 14g needle, as shorter cannulas are unlikely to penetrate into the plural space

Procedure:

All relevant infection control methods to be utilised.

Prepare equipment required:

Alcohol/betadine swab

Angio Cath 14g cannula**

10mL syringe & NaCl

Stethoscope

** Use an alternative size needle if the Angio-Cath is obviously too long for the anatomical features of the patient (e.g. younger / frail etc.)

Locate the specific landmark on the affected side: 2nd intercostal space, mid-clavicular line.

Clean the landmark site with an alcohol/betadine swab.

Connect the angio cath 14g cannula to the 10mL syringe.

Insert the needle at a 90° angle to the patient's chest wall.

While inserting the needle, aspirate the 10mL syringe. Resistance is felt until the cannula enters the pleural space and releases air and/or fluids.

Repeat procedure for opposing pleura.

Remove the needle leaving the cannula in place.

Re-evaluate the patient.

Auscultate the chest.

If found that the pneumothorax re-tensions:

Repeat

FOREIGN BODY AIRWAY OBSTRUCTION

Foreign Body Airway Obstruction

 Indications

• Clear the airway of a foreign body and maintain a patent airway in the conscious patient and when to commence CPR

 Procedure

Conscious patient with an effective cough/talking:

• Continuously reassure patient.

• Encourage coughing.

• Allow patient to be in a position of comfort.

• Do not encourage vomiting.

Conscious patient with an ineffective cough / not able to talk:

• If cough is ineffective, position patient so that gravity assists in the procedure:

  • Give up to 5 back blows:

    • Adult [Image 1]

    • Paediatric [Image 2]

    • Infant [Image 3]

  • Back blows are between the scapulae at a 90° angle to the patients back.

  • Check for dislodgement between each back blow.

• If still obstructed:

  • Perform up to 5 chest thrusts:

  • Adult [Image 4]

  • Paediatric [Image 5]

  • Infant [Image 6]

• Paediatrics and Adults can have chest thrusts performed in the sitting or standing position.

• Chest thrusts are sharper than CPR.

• Check for dislodgement between each chest thrust.

• If obstruction not dislodged and patient remains conscious, continue alternating 5 back blows with 5 chest thrusts until object dislodges.

Unconscious patient with an ineffective ventilations/breathing:

• Commence CPR as per Cardiac Arrest Guidelines.

Advanced Care (AP)

As per Primary Care

Unconscious

• If obstruction is visible above vocal chords – Follow Direct Laryngoscopy & Magill Forceps.

• If obstructions is below the vocal cords, consider Endotracheal Intubation (ETI) aiming for an intentional right main bronchus intubation, only if appropriately trained and authorised.

• Consider Cricothyrotomy (Vertical) if all methods and attempts are unsuccessful and patient is unconscious, and only appropriately trained and authorised. An immediate call to ASMA must occur.

Extended Care

As per Advanced Care and

Unconscious

• If obstructions is below the vocal cords, consider Endotracheal Intubation (ETI) aiming for an intentional right main bronchus intubation, only if appropriately trained and authorised.

1. 
   

 

• 
  

 

• 
  

 

• 
  

 

• 
  

 

• 
  

 Success

• Obstruction dislodged with effective ventilations achieved.

• Continue with patient assessment and subsequent management.

 Discontinue

• If patient becomes unconscious/unresponsive, follow Cardiac Arrest Clinical Practice Guideline.

CRICOTHYROTOMY

Cricothyrotomy (Vertical)

 Indications

• Cant Intubate, Cant Oxygenate (CICO) situation with decreasing SpO₂

• Primary airway attempt if ETT, supraglottic airway or BVM is not feasible (e.g. massive facial trauma or burns)

 Contraindications

• Children < 6 years of age

• Open tracheal injury

 Patient Factors & Considerations

• This procedure is largely tactile, and officers should not rely on vision alone as the surgical field may become obscured due to haemorrhage following incision.

• Misplacement is a risk of Cricothyrotomy¹:

  • As with endotracheal intubation, capnography is the gold standard for confirming correct ETT placement². Regular confirmation of clinically appropriate waveform capnography and ETCO2 is mandatory³.

  • Should capnography provide a consistent waveform with a max. reading of ≤10mmHg complete a DOPES check³.

  • Surgical emphysema developing around the neck indicates incorrect pre-tracheal insertion of ETT.

  • Asymmetrical chest movement may indicate ETT placement into the right bronchus².

• Check ETT placement whenever the patient is moved. As a rule, the officer ventilating is to control patient movements.

• Confirmatory checks should be done in a manner that minimises interruptions to chest compressions

• If no improvement in oxygenation after ongoing ventilation, consider possible misplacement

 Procedure

• Verbalise to your team that you are going to undertake a surgical airway

• Apply required Infection Prevention & Control measures as per policy

• Maintain oxygenation and ventilation with BVM or supraglottic device as best as possible

• Prepare the following equipment:

  • Bougie

  • Size 6 ETT

  • 10mL syringe

  • Alcohol/betadine swab

  • BVM

  • Cobbs connector

  • Disposable scalpel

  • Artery forceps

  • Oxygen

  • Suction

  • Tape

  • End Tidal CO₂ monitoring

• Prepare the neck with antiseptic solution

• Position patient with neck extended where possible

• Right handed individuals – stand on right side of patient; left-handed individuals stand on left side of patient

• With non-dominant (ND) hand, identify and stabilise the laryngeal cage with thumb and middle finger and, with the index finger, identify the landmarks of front of neck if possible (thyroid cartilage, cricoid cartilage and cricothyroid membrane) as per figure 1.

• If laryngeal landmarks are not identifiable, make a longitudinal incision at least 3-4cm in length through the skin and subcutaneous tissue. Stabilise your dominant hand on the sternum of the patient when making the incision.

• Separate soft tissue with either your fingers or artery forceps to identify underlying anatomical landmarks; specifically the cricothyroid membrane

• Lift the ND index finger and using the scalpel, make a horizontal incision using the SERT technique
  
  

  • Stab – with the blade facing you, insert it horizontally until resistance of back wall is felt

  • Extend – continue the incision as far as possible until resistance of side wall of cartilaginous cage felt

  • Reverse – turn the blade 180o and extend incision to opposite wall of cartilaginous cage

  • Twist – rotate the blade vertically to create a triangular hole beside scalpel’s blade

• Remove scalpel and dispose of safely.

• Insert pinkie finger of ND hand into the incision and ensure you can feel the tracheal walls

• Insert the bougie perpendicular to the alignment of the neck, along the pad of your pinkie finger, then rotate 90° to feed down the trachea to a depth of no more than 15cm (insertion further will eventually result in hold up in the small airways)

• Railroad a lubricated size 6.0 ETT over the bougie until the balloon is in the airway and is no longer visible (rotation of ETT may be required to pass through skin into airway to mitigate hold-up)

• Ensure ETT is held secure whilst balloon inflated and bougie removed

• Attach to bacterial filter, capnography, cobb's connecter and BVM

• Confirm placement with

  • Capnography reading with clinically appropriate waveform and amplitude, ongoing after 6 ventilations

  • Adequate and equal rise and fall of chest

  • Appropriate auscultation of the epigastrium and then left and right lung fields

• Assess the wound for haemorrhage and manage accordingly - consider Adrenaline-soaked gauze if indicated.

• Secure ETT with tape

• Document confirmatory checks, and time from declaring CICO to first ventilation (if possible)

 Success

• Capnography reading with clinically appropriate waveform and amplitude, ongoing after 6 ventilations

  WITH

• Adequate and equal rise and fall of chest

• Appropriate auscultation of the epigastrium and then left and right lung fields

Any of the above checks in the absence of appropriate capnography are NOT reliable indicators of correct ETT placement⁴. Checks should be documented.

VENTILATION EMERGENCY: DOPES

Ventilation Emergencies (DOPES)

 Indications

• To identify and rectify potential causes of ventilation problems in a sequential and structured manner.

 Patient Factors & Considerations

• Any ventilated patient MUST be escorted by either a doctor or nurse whom has sufficient knowledge of the operation of the ventilator and knows what to do in the case of ventilator malfunction.

• If an officer finds themselves in a situation where a ventilator malfunctions during a transfer, they may be required to assist with the checking procedure.

Critical points for Patient Care Record Form:

• Type of ventilator.

• Reason for ventilating patient.

• Patient’s main presenting problem and present condition.

• Care given before Officer’s arrival.

 Procedure

Checking for possible causes:

• Primary attendant (e.g. doctor/nurse) to check operation of ventilator

• Check ventilator tube for kinks.

• Check oxygen supply:

  • Connection to outlet.

  • Switch to spare 'D' size cylinder if required.

  • Oxygen supply tube can be connected to the outlet on the front of the Oxy-Viva in place of flow-meter.

• If unable to locate fault then ventilation will need to be provided manually using the Bag-Valve-Mask (BVM) connected to an oxygen supply flow-meter with regular oxygen tubing.

• If on a ventilator, the patient will have an advanced airway in-situ, such as an Endotracheal Tube (ETT) or Supraglottic Airway (SGA). Medical personnel will need to secure the advanced airway before transitioning to the BVM.

• Disconnect ventilator tubing from breathing tube and connect BVM using right-angled flexible connector if available.

• Ventilate patient at appropriate rate; a doctor/nurse MAY ventilate, or request the officer ventilates, at rate different to those listed in the ventilation clinical skill.

• Ensure that the doctor/nurse confirms that the advanced airway is still in-situ and ventilations are adequate.

• Contact receiving facility to advise of ventilator malfunction.

Transport Priority 1.

D

Displacement

• Look at airway device position, does it look displaced?

• Complete confirmatory checks per skill to verify placement

• Assess/consider ETT cuff inflation, depth, or oesophageal intubation.

• Check placement after any patient movement.

O

Obstruction

• Inability or severe resistance to ventilation is a very good indicator of obstruction.

• Clear Foreign Body Airway Obstruction

P

Pneumothorax

• Consider the signs and symptoms of pneumothorax/haemothorax.

• Consider ventilator settings.

E

Equipment Failure

• Consider failure of equipment starting from the oxygen cylinder straight through to the ETT and back again.

S

Secretions

• Thick mucus might obstruct ETT.

• Suction

 Success

• Restoration of effective ventilation/oxygenation

• Confirmed placement of advanced airway device per skill (if applicable)

Modified Valsalva Manoeuvre

Indications

• Patients requiring reversion of hemodynamically stable SVT (QRS interval <0.12 sec), confirmed by 12-lead analysis

Contraindications

• Recent or current acute myocardial infarction

• Severe coronary artery disease

• Haemodynamic instability (i.e. systolic BP below 90mmHg)

• Known glaucoma or retinal myopathy

Patient Factors & Considerations

• The following side effects might be experienced by the patient when performing the Modified Valsalva Manoeuvre:

  • Dizziness

  • Hypotension

  • Syncope

  • Tinnitus

  • Headache

• If patient is on the stretcher, procedure is only to be performed while stretcher is locked into ambulance or lowered to ground height.

Procedure

• All relevant infection control methods are to be utilised.

• Prepare equipment required:

  • 10mL syringe

  • Oxygen tubing

  • Sphygmomanometer

• Explain the procedure to the patient.

• Position patient in a semi-recumbent position.

• Ensure ECG monitor is attached, and that SVT has been confirmed with 12 Lead Analysis. Closely monitor all vital signs and 12-Lead ECG. Resuscitation equipment must be at hand as other arrhythmias may occur.

• Consider IV access prior to performing procedure.

---

• Patient position – Semi-recumbent

• Connect the sphygmomanometer to the oxygen tubing.

• Instruct the patient to take a deep breath in while placing the oxygen tubing in their mouth.

• Instruct the patient to blow into the tubing and attempt to reach 40mmHg, maintaining pressure for 15 seconds.

• Lower patient into a supine position with the legs raised (where possible) approx. 45 degrees (Trendelenburg position) for 15 secs.

• Return the patient to a semi-recumbent position for 45 seconds

• Re-assess 12 Lead ECG and all vital signs 

• If unsuccessful in the first instance the procedure can be repeated once.

If a sphygmomanometer is unavailable another method is to instruct the patient to try and blow the plunger of a 10mL syringe until movement is just seen for 15 seconds.

 

Success

• Termination of supraventricular tachycardia.

Discontinue

• After 2x attempts

• If the patient becomes hemodynamically unstable at any point (i.e. systolic BP below 90mmHg)

Pressure Immobilisation Technique (P.I.T)

Indications

• Bites and stings by the following creatures:

  • All Australian venomous snakes, including sea snakes.

  • Funnel Web spider.

  • Blue-ringed octopus.

  • Cone Shell.

 Contraindications

• Pressure Immobilization Technique (PIT) is not to be used on spider or insect bites (except the Funnel web spider).

 Patient Factors & Considerations

• The pressure immobilisation technique (PIT) retards the flow of lymph by which venoms gain access to the circulation. It has also been shown that there may be inactivation of certain venoms and venom components when the injected venom remains trapped in the tissues by the pressure bandage.

• The Snakebite Bandage (with continuous indicator) is the preferred bandage to achieve optimal compression with the Pressure Immobilisation Technique.

• In absence of the snakebite bandage, elastic bandages (10-15 cm wide) can be used and are preferred over crepe bandages. If neither are available, clothing or other material should be used.

• The bandage should be applied over existing clothing if possible.

• If the bite is not on the limb, firm direct pressure on the bite site may be useful.

 Procedure

• Resuscitation takes precedence over the PIT application, however PIT should be applied as soon as possible to minimise further venom flow.

• Apply a broad elasticated pressure bandage (10-15cm wide) over the bite site as soon as possible.

• A PIT BANDAGE SHOULD NEVER BE UTILISED AS A TORNIQUET, NOR SHOULD IT BE APPLIED TIGHT ENOUGH TO CREATE A TORNIQUET EFFECT.

• Where bandage is in situ and is found to be loose or ineffective: place a PIT bandage directly over top of any in situ bandage

• Apply a snakebite bandage, commencing at the distal end of the affected limb (i.e. fingers or toes of the bitten limb) and extending upwards, covering as much of the limb as possible.

• Apply enough tension to the snakebite bandages so that the continuous indicator forms a 1.5cm x 1.5cm square, rather than a rectangle in it's un-stretched state. This indicates that firm compression is achieved in the limb.

• If using elasticated bandages without the continuous compression indicator, the bandage should be firm and tight and you should be unable to easily slide a finger between the bandage and the skin. Application of this bandage should be a similar tightness as when bandaging a sprained joint. 

• Splint the limb.

• Keep the patient and the limb completely at rest.

• Assess arterial blood follow distal to pressure dressings via cap refill.

• If there is neurovascular compromise after applying the pressure dressing, it may be be necessary to take down the dressing and reapply not as tight.

Troubleshooting:

If the patient develops new onset of neurovascular compromise (such as a capillary refill time greater than three seconds on the affected limb) and/or pain that is disproportionate to the presenting injury, the patient may be at risk of developing compartment syndrome. If this occurs, contact CSPSOC/ASMA for advice before removing the bandage. DO NOT REMOVE PRIOR TO RECIEVING ADVICE FROM CSPSOC/ASMA.

Extrication post-Motor Vehicle Collision

Description

Patients involved in motor vehicle collisions will either:

• Self-extricate prior to emergency services arrival

• Self-extricate with instruction from emergency services

• Require manual extrication. These patients considered “entrapped"¹

Trapped patients are more likely to have time-critical injuries and are at increased risk of death² – entrapment time must be minimised.

 Indications

• Patients requiring extrication post motor vehicle collision

 Patient Factors & Considerations

• If a patient becomes time-critical at any point, extrication should be expedited

• If unable to assess time criticality, assume patient is time-critical until proven otherwise

• Clinical care should be limited to necessary interventions while a patient is entrapped, with consideration given to the benefit of the intervention vs the risk of prolonging entrapment time

• For self-extricating patients, minimise distance from the vehicle to the end point

 Procedure

• Approach scene with caution and assess for danger

• Perform a continuous dynamic risk assessment (hazards may change rapidly). Do not approach if unsafe to do so

• Perform necessary clinical interventions where required

• Instruct patients to self-extricate if they are:

  • Able to follow instructions AND

  • Able to safely mobilise (i.e. adequate baseline function and no injuries such as but not limited to femur or pelvic fractures that would hinder mobility)

• If the patient is unable to self-extricate, determine if they are time-critical (any immediate life threat present such as major haemorrhage, occluded airway, absent or ineffective breathing, decreased level of consciousness)

  • Time-critical patient: Perform immediate “emergency” extrication and remove patient as soon as is safely possible. Gentle handling should be employed where possible, however speed is prioritised.

• If the patient is not time-critical, develop a bespoke, patient centred extrication plan with the overarching goal being to appropriately minimise entrapment time

Clearly communicate extrication plan to other resources on scene, including verbalisation of patient conditions and desired timeframes for extrication.

 Success

• Patient extricated with entrapment time minimalised

 Discontinue

• If an initial extrication plan fails or is no longer appropriate, continue to communicate with other resources on scene (if present) to adapt the extrication plan

Additional Information

• Self-extrication, where indicated, is the fastest method of extrication and associated with the least movement of the cervical spine^1,3

• Spinal cord injuries caused by motor vehicle accidents are rare, and when present, are usually found in conjunction with other time-critical traumatic injuries²

• Basic hands-on assessments, such as palpation of pulses, evaluation of respiratory effort, and patient interaction is appropriate for the trapped patient⁴

• Monitoring equipment that interferes with or delays the extrication process should be avoided, unless the clinical insight they provide outweighs the potential for delay⁴

SPINAL MOTION RESTRICTION

Description

• Spinal motion restriction (SMR) refers to a spectrum of skills designed to decrease movement of the entire spinal column after injury

 Indications

• Patients requiring spinal motion restriction per Spinal Trauma guideline

 Contraindications

• Patients with isolated penetrating trauma (i.e. stab or gunshot wound to neck or torso with no blunt force involvement)¹

 Patient Factors & Considerations

• Spinal motion restriction (SMR) stabilises the head, neck and torso - not just the cervical spine

• SMR should be tailored to each patient and the available resources. SMR should not be prioritised over the management life-threatening conditions

• Forceful application of SMR that is not tolerated will not benefit the patient. Tailor SMR to patient comfort – take particular care to not exacerbate pre-existing conditions

Note:

• Safe work load of the extraction board: 220kg

• Safe work load of the scoop stretcher: 159kg

 Procedure

• Employ all infection control measures.

• Communicate with the patient:

  • Explain what SMR is and why it is being applied

• Minimise patient movement:

  • Instruct the patient to self-splint and avoid movement

  • Aim to minimise episodes of manual handling / patient movement

  • Avoid rough driving

  • Employ gentle patient handling

• Employ manual in-line stabilisation (MILS) 

  • This can be performed by clamping hands on the patient’s shoulders and using hands/forearms to stabilise the head and neck, maintaining alignment with the shoulders and torso

  • Remember: the rest of the body should also be stabilised

  • MILS may be withheld when a conscious patient is still (i.e. no driving or moving of the stretcher etc.) and able to self-splint

• Utilise Headblocks to minimise lateral movement of the head, if MILS is not feasible

  • The rest of the body should be secured to the same surface as the headblocks

  • Do not use if not tolerated by the patient

• Position the patient neutrally where tolerated, using padding to increase comfort.

  • Elderly patients and patients with pre-existing conditions (i.e. ankylosing spondylitis, kyphosis, osteoporosis, rheumatoid arthritis etc.) may require tailored positioning and padding due to anatomical differences^2,3

  • Do not force supine or uncomfortable positioning where this is not tolerated by the patient – consider the pre-injury body shape.

  • Patients with an acute traumatic brain injury or who are unable to tolerate neutral positioning may be positioned with a 30-degree tilt of the stretcher

  • Pregnant patients over 20 weeks gestation may be positioned with a left hip tilt to avoid aortocaval compression

• Apply a Lanyard as a visual reminder that c-spine has not been cleared

 Discontinue

• Discontinue if patient no longer tolerates spinal motion restriction

Additional Information

• Patients may self-extricate where able to mobilise safely and follow instruction to self-splint, per Extrication post motor vehicle collision skill

PELVIC SPLINT

Description

• Pelvic injuries can be life-threatening and require rapid identification and management

• Most pelvic injuries in younger patients are due to high-energy blunt trauma, although frail and older patients may sustain pelvic injuries from a low-energy mechanism¹

• Pelvic splinting may reduce blood loss and improve patient outcomes²

 Indications

Mechanism of injury suggestive of pelvic fracture, and ANY of the following

• Pain / tenderness / deformity of the pelvis or lower back OR

• Altered level of consciousness OR

• Distracting injuries OR

• Haemodynamic instability

 Contraindications

• Isolated neck of femur fractures

 Patient Factors & Considerations

• Physical examination in isolation cannot be relied on to detect pelvic fractures, especially among patients with distracting injuries and altered mental status³

• Patients too small for a T-POD® (generally this will be patients under 23kgs) should receive pelvic sheeting

• Pelvic binding should be considered as an urgent intervention and applied as soon as is practicable⁴

• Employ gentle patient handling and minimise movement (avoid log rolling)

• Patients with pelvic injuries are at increased risk of concurrent abdominal and/or thoracic injuries^5-7

 Procedure

T-POD®

• All relevant infection control methods to be utilised.

• Prepare equipment required:

  • T-POD®

  • Extrication board/scoop stretcher

  • Trauma shears

---

• Position patient supine

• MUST be applied direct to skin (or nothing more than light underwear)

• Slide the fabric belt under the patient legs and position accordingly

• The centreline of the binder must be at the level of the greater trochanters and symphysis pubis, NOT at the level of the iliac crests.

• Cut the T-POD to create a 15-20cm central gap

• Apply the pulley system to each side of the T-POD with the velcro

• Use the pull tab on the pulley system and slowly apply tension until adequate and/or anatomical alignment normalises

• Do NOT over-tension - the edges should not meet 

• Secure the pulley string around tabs and secure with velcro

• Ensure that two fingers can fit between the device and the patient and a gap remain

• Place padding between legs and bind the knees together. Bind ankles together with figure eight bandaging

• Record time of application if possible

Circumferential sheet method (for paediatric patient too small for T-POD®):

• All relevant infection control methods to be utilised.

• Prepare equipment required:

  • Sheet (folded to appropriate width for patient)

  • 2 x Clamps

• Place a folded sheet underneath the patient – the centreline should be at the level of the greater trochanters

• Two team members should cross the sheet across the pubic symphysis and pull the sheet firmly, without over tensioning

• Twist the ends together and secure with a clamp

• Place padding between legs and bind the knees together. Bind ankles together with figure eight bandaging

Slishman Traction Splint

Indications

• Immobilise Proximal 1/3 and mid-shaft femoral fractures.

• 
  

 Contraindications

• No reported contraindications

 Patient Factors & Considerations

• Assess distal neurovascular observations:

  • Pulse, Colour / Warmth / Movement / Sensation (CWMS)

• Compound fractures: being aware not to pull contaminates into the wound during traction

• Can be used in the presence of ankle/lower leg injury, amputation and pelvic injury.

• Procedure is under the control of the person applying manual traction.

• Unilateral fracture, second splint required for bilateral fractures.

• If TPOD being utilised, this needs to be applied before the Slishman traction splint 

 Procedure

Step 1: Attach Ankle Strap

• Remove the ankle strap and end cap from the pole.

• Unroll the ankle strap, wrap comfortably around the patient’s ankle with the end cap lateral and facing up to receive splint pole.

• Securing it with the large Velcro attachment area

• The ankle strap can be positioned proximal to the calf in lower limb injuries/amputation

Step 2: Attach Groin Strap

• Rest the female buckle on the patient’s anterior thigh.

• Slide the male end of the strap under and around the patient’s anterior thigh.

• Secure the groin strap with the female end and adjust the length if needed until comfortably secured.

Step 3: Apply Coarse Traction

• Release the lower black distal clamp and extend the distal pole.

• Insert distal pole it into ankle strap end cap.

• Apply coarse traction by extending the pole until resistance is felt, then tighten distal clamp.

Step 4: Apply Fine Traction

• Open the top red proximal clamp.

• Pull the traction cord that extends from the end of the pole until you have reached desired traction

• To reach desired traction, resistance on the cord will be felt and potentially a reduction in pain for the patient

• Tighten the red proximal clamp and release the traction cord

Step 5: Reassess and Monitor

• Reassess the patient’s CWMS and pain level

• Adjust traction as needed to minimize pain, while maintaining perfusion

• For rotational stability, attach mid leg strap to splint and wrap (one or both legs) below the knee. 

Additional information

• Manual traction should be maintained while setting up and applying the splint

• Prior to applying the splint, assess the patient’s circulation, sensory, and motor response and ensure you have all the components of the splint.

PERIPHERAL TOURNIQUET

Indications

• Uncontrolled, life-threatening limb haemorrhage

 Contraindications

• Haemorrhage that can be controlled using other haemorrhage control measures

 Patient Factors & Considerations

• Do not apply a peripheral tourniquet over the top of a wound or joint

 Procedure

• All relevant infection control methods are to be utilised.

• Expose injury and identify source of haemorrhage

---

• Slip the C-A-T® device under the affected extremity and feed the self adhering band through the friction adapter buckle.

• Position the C-A-T® device above the site of the uncontrolled haemorrhage leaving at least 5cm of uninjured skin between the C-A-T® and the wound site. Apply directly to skin surface and not over clothing if possible.

• Pull the free running end of the self-adhering band tight.

• Securely fasten self adhering band back onto itself.

• Twist the windlass rod until the bleeding is controlled^[1]. The tourniquet should be tight enough to stop all circulation to the injured limb and control the haemorrhage

• Lock the rod in place with the windlass clip and secure the windlass rod with the windlass strap^[2].

• Place a tourniquet sticker on the patient in a visible area and record the date and time the tourniquet was applied. This should also be recorded on the space provided on the tourniquet.

  • At the earliest practicable opportunity, if feasible, call CSPSCC so that notification can be passed to state trauma consultant

• Handover at hospital must include tourniquet location and application time. Do not cover with bandages or clothing.

 Success

• Haemorrhage from injured limb controlled

 Discontinue

Haemorrhage from injured limb has not ceased;

• Use the same procedure to place another peripheral tourniquet proximal to the first

• Simultaneous wound packing and/or direct pressure

• Priority 1 transport with prenotification and consideration of Major Trauma guidelines

WOUND PACKING

Indications

• Traumatic haemorrhage requiring packing that is not controlled by basic haemorrhage control measures such as direct pressure

 Contraindications

• Sucking chest wounds

• Eye wounds

• Airway wounds

• Wounds involving exposed organs (eg:bowel)

 Patient Factors & Considerations

• Wound packing carries risk of injury from exposed bone fragments. Apply caution.

• Wound packing should not delay peripheral tourniquet placement where immediately indicated

 Procedure

Preparation

• Appropriate PPE required

• Expose injury and identify source of bleeding

Procedure

• Apply direct firm pressure on source of haemorrhage whilst preparing QuikClot (if authorised) or appropriate material (i.e. gauze/crepe bandage)

• Pack chosen material directly into the wound at the source of haemorrhage (wound bed or vessel)

• Ensure wound is filled with chosen material, so that internal pressure is adequate to control haemorrhage

• Once the wound is firmly packed apply consistent pressure for at least 3 minutes or until bleeding stops

• Reassess for further haemorrhage

• Once haemorrhage has been controlled apply trauma/pressure bandage to maintain pressure, or continue to maintain direct pressure if needed

 Success

• Haemorrhage has been controlled

 Discontinue

Haemorrhage has not been controlled:

• Consider packing additional gauze/QuikClot into the cavity, increasing direct pressure and use of peripheral tourniquet if indicated

• Consider Priority 1 transport with prenotification as apporpriate and consideration of major trauma critieria

PRIORITIES OF MANAGEMENT (PRIMARY SURVEY)

DANGER: LOOK, LISTEN AND SMELL FOR ANY DANGER

RESPONSE: AVPU

- ALERT

- ALERT TO VOICE

- ALERT TO TOUCH / PAIN

- UNRESPONSIVE

** RAPID FIRST IMPRESSION OF THE PT (LOOK, POSTURAL TONE, SKIN, BREATHING)

** CONSIDER FOR BACK UP? (CREW / CSP / CCP)

** ASSESS FOR IMMEDIATE INTERVENTION FOR:

- C-SPINE CONSIDERATION FOR TRAUMA PATIENTS

- OBVIOUS CATASTROPHIC HAEMORRHAGE (TRAUMA = IMMEDIATE EXPOSURE AND A-E)

AIRWAY

IDENTIFY LIFE THREATENING FACTORS THAT MAY RESULT IN "AIRWAY OBSTRUCTION"

---------------------------------------------

DICL MNEMONIC

DIRECT TRAUMA TO THE UPPER AIRWAY AND SURROUNDING STRUCTURES

o MAXILO-FACIAL / LARYNGEAL / TRACHEAL INJURY / COMPRESSION INJURY DUE TO ANTERIOR NECK HAEMATOMA)

o INTRAORAL HAEMORRHAGE / EPISTAXIS

o SINGING OF FACE / HOARSE VOICE / SOOT IN THE SALIVA

-------------------------------------------------

- INCORRECT POSITIONING

o SUPINE POSITION ON UNCONSCIOUS / HYPERFLEXION OF THE INFANT DUE TO LARGE OCCIPUT

---------------------------------------

- CONTAMINATION OF THE AIRWAY DUE TO DEBRIS

o FOREIGN OBJECT, VOMIT, BLOOD, TEETH

----------------------------------------------

- LOSS OF PHARYNGEAL TONE

o UNCONSCIOUS DUE TO OD OF DRUGS OR ETOH

o DUE TO HEAD INJURY

------------------------------------------

FURTHER ASSESSMENT OF THE AIRWAY = "TWELVE C"

- TRISMUS / TRACHEAL DEVIATION

o SEIZURES, HEAD INJURY, OD

- WOUNDS

o INTRAORAL HAEMORRHAGE / TONSILLOCTOMY HAEMORRHAGE / EPISTAXIS

- EDEMA

o ANAPHYLAXIS

o BURNS

- LOUD

o STRIDOR

o COUGH

o GRUNTS

- VOMIT

- ESOPHAGEAL INJURY

o OESOPHAGEAL VARICES

o UNABLE TO SWALLOW EASILY

- CAROTID HAEMATOMA / SWELLING

o HANGING

AIRWAY CICO EVENT

Cricothyrotomy (Vertical)

Indications

Cant Intubate, Cant Oxygenate (CICO) situation with decreasing SpO2

Primary airway attempt if ETT, supraglottic airway or BVM is not feasible (e.g. massive facial trauma, anaphylaxis, ACE inhibitor angioedema or burns)

Contraindications:

Children < 6 years of age

Open tracheal injury

Procedure

Verbalise to your team that you are going to undertake a surgical airway

Apply required Infection Prevention & Control measures as per policy

Maintain oxygenation and ventilation with BVM or supraglottic device as best as possible

Prepare the following equipment:

Bougie / Size 6 ETT / 10mL syringe/ Alcohol/betadine swab / BVM / Cobbs connector / Disposable scalpel / Artery forceps / Oxygen / Suction Tape / End Tidal CO2 monitoring

BREATHING

ASSESS RESPIRATORY FUNCTION VIA "WEES"

** ANY DEVIATION TO RESPIRATORY FUNCTION = MUST AUSCULTATE

WHEEZING

RONCHI

CRACKLES

DIMINISHED

TRAUMA WITH THORACIC INVOLVEMENT

RESPIRATORY RATE / SPO2 / AUS / ETCO2 / POSITIONING

ASSESS RESPIRATORY FUNCTION VIA "WEES"

- WORK OF BREATHING

o RR / USE OF ACCESSORY MUSCLE / POSITIONING: TRIPOD

- EFFECTIVENESS OF BREATHING

o SPO2 / ETCO2

- EFFECTS OF INADEQUATE BREATHING

o PULSE RATE / MENTAL STATE

- SIGNS OF INJURY ON THORACIC SITE

o SEAT BELT MARKS

o TRAUMA WITH TORSO INVOLVEMENT

---------------------------------------------------

** ANY DEVIATION TO RESPIRATORY FUNCTION = MUST AUSCULTATE

WHEEZING: HIGH EXPIRATORY SOUND CAUSED BY OBSTRUCTION OF THE LOWER AIRWAYS = BRONCHOSPASM / EXCESSIVE MUCOUS PRODUCTION (MUCOUS PLUGGING) AND INFLAMMATION

- ANAPHYLAXIS: INSPIRATORY STRIDOR / TWO SYSTEMS INVOLVED (R.A.S.H)

- ASTHMA AND COPD: DYSPNOEA WITH CHEST TIGHTNESS / PRODUCTIVE COUGH

- CARDIAC WHEEZE = CHF (BACKFLOW OF BLOOD INTO THE PULMONARY CAPILLARIES (RARE)

OTHER CONDITIONS THAT INDUCE RESPIRATORY DISTRESS AND BRONCHOSPASM ASSOCIATED WITH A "WHEEZE":

- ACUTE BRONCHIAL ASTHMA

- BRONCHITIS

- EXACERBATION OF COPD

- ANAPHYLAXIS

- ACUTE PULMONARY OEDEMA OF NON CARDIAC ORIGIN

- SALT WATER ASPIRATION

- SMOKE INHALATION INJURY

-----------------------------------------------------------

RONCHI: LOW EXPIRATORY SOUND CAUSED BY EXCESSIVE MUCOUS PRODUCTION OR FLUID / TYPICALLY AT LOWER AIRWAY (BRONCHI) AND DESCRIBED AS A "SNORING" SOUND

- INFECTION (PNEUMONIA): FEVER / PRODUCTIVE COUGH (GREEN OR YELLOW SPUTUM) / TACHYPNOEA

- COPD: CHRONIC BRONCHITIS (BLUE BLOATER = PERIPHERAL OEDEMA / CLUBBING OF FINGERS) OR BRONCHIECTASIS: FREQUENT LUNG INFECTION DUE TO POOLING OF MUCOUS

- CYSTIC FIBROSIS: CHRONIC CONDITION CAUSED BY SCARRING TO THE LUNGS = INABILITY TO CLEAR MUCOUS

-----------------------------------------------------------

CRACKLES: OCCURS AT THE LEVEL OF THE ALVEOLI, RESPIRATORY DISTRESS THAT IS THE RESULT OF EXCESSIVE ACCUMULATION OF FLUI

CIRCULATION

PULSE / BP / ECG / SKIN

ASSESS THE CIRCULATORY STATE OF THE PATIENT VIA

- POSITION OF THE PATIENT (SITTING, STANDING OR LYING)

- PULSE (RADIAL / BRACHIAL / CAROTID)

o RATE, STRENGTH AND RHYTHM

- SKIN COLOUR / BLOOD PRESSURE / MENTAL STATE

CONSIDER FACTORS THAT MAY AFFECT PERFUSION OR SHOCK

- HYPOVOLAEMIA

o INTRINSIC: BURNS / INTERNAL BLEEDING

o EXTRINSIC: HAEMORRHAGE / DIARRHOEA / VOMITING

- CARDIOGENIC:

o INTRINSIC: ACUTE MYOCARDIAL INFARCTION / DYSRHYTHMIA

o EXTRINSIC: CARDIAC TAMPONADE / TENSION PNEUMOTHORAX / PULMONARY EMBOLISM

- DISTRIBUTIVE

o ANAPHYLACTIC

o SEPTIC

§ INCREASED CAPILLARY PERMEABILITY

§ WIDESPREAD VASODILATION

ANY PATIENT WITH A CHEST PAIN = 12LEADECG = 2Ps 5Ps M

ACS / ACUTE MYOCARDIAL INFARCTION: CRUSHING / RADIATING / DIAPHORETIC / DYSPNOEA / ACUTE ONSET

- FACTORS TO CONSIDER

o CARDIAC HX = STENTS / CABG / CAD

o DIABETES (NEUROPATHY = LESS PAIN)

o SMOKER

o AGE GREATER THAN 40

o OBESE

AORTIC DISSECTION + ANEURYSM: ACUTE ABDOMINAL PAIN (EPIGASTRIC), TEARING SENSATION, SIGNIFICANT ORTHOSTATIC HYPOTENSION

- ABDOMINAL PULSATING MASS

- HAEMODYNAMICALLY UNSTABLE

- ACUTE ONSET OF NEUROLOGICAL DEFICITS

PULMONARY EMBOLISM: SOB / HYPOXIA / DIMINISHED LUNG SOUNDS / 12LEADECG: LEAD I: LARGE S WAVE LEAD 2: FLIPPED T WAVE

- FACTORS TO CONSIDER:

o DVT: PITTING OEDEMA

o RECENT SURGERY, LONG PERIODS OF IMMOBILISATION, TRAVEL

o ORAL CONTRACEPTIVES

o CANCER PATIENTS OR CHEMOTHERAPY (HYPERCOAGULABLE STATE)

PERICARDITIS: MAY RESULT IN CARDIAC TAMPONADE

- CHEST PAIN EXACERBATES LEANING BACKWARDS, RELIEVED BY LEANING FORWARDS + FEVER

- SHARP STABBING PAIN

- 12LEADECG: SMILING ST ELEVATION AND PR DEPRESSION WIDESPREAD

o RISK FACTORS:

§ RECENT SURGERY

§ RECENT INFECTION (SEPSIS)

§ IV DRUG USE

SPONTANEOUS PNEUMOTHORAX: RESPIRATORY DISTRESS / HYPOXIA / JUGULAR VEIN DISTENSION / SUBCUTANEOUS EMPHYSE

DISABILITY

GCS / BSL / TEMPERATURE / PUPILS / FAST AND RACE / PAIN

ASSESS ALTERED MENTAL STATUS VIA 5S-NOTEE

WHAT CAN I HEAR, SEE OR SMELL (ENVIRONMENTAL CLUES) / AEIOUTIPS

- SUGAR:

o HYPOGLYCAEMIA

- persistent hypoglycaemia / pigmentation and hypotension = consider ADDISON'S DISEASE

o HYPERGLYCAEMIA (DKA and HHS = signs of dehydration and haemodynamic instability

- STROKE: FAST+ AND RACE (STROKE PATHWAY: FAST+ WITH <9 HOURS / INDEPENDENT WITH ADLS / BGL 4-22 MMOL

- SEIZURE: HX OF EPILEPSY / CAUSE OF SEIZURE (AEIOUTIPS) / POST ICTAL STATE = HYPOXIC BRAIN INSULT

- SEPSIS: EVIDENCE OF INFECTION FROM (CNS: MENINGITIS / ENCEPHALITIS / RESPIRATORY: TUBERCULOSIS, COVID AND PNEUMONIA / GI TRACT: GASTRO OR DIARRHOEA / RECENT SURGERY OR WOUND SITE / URINARY / UROSEPSIS (UTI) ) = FEVER / TACHYCARDIA / TACHYPNOEA / HYPOTENSION

- SYNCOPE: POSTURAL HYPOTENSION / FORCED BOWEL MOVEMENT OR CONSTIPATION / DEHYDRATION

- NARCAN: ABUSE OF ETOH OR DRUGS (OPIOIDS / GHB / ECSTASY) / STIMULANT OR DEPRESSANT / INTENTIONAL OR UNINTENTIONAL /

- OXYGEN: HYPOXIA / CARBON MONOXIDE POISONING / ANAEMIA

- TRAUMA: HEADSTRIKE / HAEMORRHAGE / BLUNT OR PENETRATING

- ENVIRONMENT: HEATSTROKE / BITES AND STINGS

- ELECTROLYTES: HYPERKALAEMIA OR HYPONATRAEMIA / METABOLIC IMBALANCES / ACID BASE IMBALANCES

**ADDISON'S DISEASE

Addison's disease is a rare disorder characterized by inadequate production of the steroid hormones cortisol and aldosterone by (adrenal cortex) due to autoimmune attacks to the adrenal cortex. Major symptoms include fatigue, gastrointestinal abnormalities, and changes in skin color (pigmentation).

Increased excretion of water and low blood pressure (hypotension) can lead to extremely low concentrations of water in the body (dehydration), persistent hypoglycaemia.

EXPOSURE

MEDICAL:

- URTICARIA, OEDEMA AND HIVES: ANAPHYLAXIS

- NON BLANCHING RASH + HAEMODYNAMICALLY UNSTABLE: MENINGOCOCCAL SEPTICAEMIA

TRAUMA

DCAP BTLS: DEFORMITY / CONTUSION / ABRASION / PENETRATING / BRUISING / TENDERNESS / LACERATION / SWELLING

ABDOMINAL: DISTENDED AND RIGID = INTRAABDOMINAL BLEEDING

ABNORMAL ABDOMINAL MASS: HERNIA

- FEVER AND SEPSIS: STRANGULATED HERNIA (WARM / HOT)

- PULSATING MASS, LOCALISED MAXIMAL PAIN AND REFERRED PAIN TO THE BACK: TRIPLE AAA

ABDOMINAL QUADRANTS:

- RIGHT UPPER QUADRANT: LIVER OR GALLBLADDER

- LEFT UPPER QUADRANT: STOMACH / SPLEEN / PANCREAS

- RIGHT LOWER QUADRANT: APPENDIX (BELLY BUTTON: EARLY ONSET / LATE ONSET: MCBURNEY'S POINT)

- LEFT LOWER QUADRANT: SIGMOID COLON (DIVERTICULITIS)

- SUPRAPUBIC AREA OR GROIN: INGUINAL HERNIA

ABDOMINAL PAIN WITH REFERRED LEFT SHOULDER TIP PAIN: SPLEEN INJURY (KEHR'S SIGN) OR RUPTURED ECTOPIC PREGNANCY

UPPER ABDOMINAL PAIN WITH REFERRED R) SHOULDER TIP PAIN AND RECENT DIET CHANGE: CHOLECYSTITIS OR CIRRHOSIS

SPINAL PAIN:

- SCIATICA LOWER BACK PAIN

o LOWER BACK PAIN

o BURNING / TINGLING PAIN THAT RADIATES DOWN TO THE LEGS

o NO ALTERATION ON MOVEMENT OR SENSATION

- CAUDA AQUINA: COMPRESSION OF THE SPINAL CORD

o ALTERED MOVEMENT OR SENSATION OF THE LOWER LIMBS

o UNABLE TO FLEX KNEES OR MOVE FEET

o SIGNIFICANT LOWER BACK PAIN

PATHOGENESIS OF ASTHMA

Asthma is characterised by ............... airways and ........................, leading to episodic, reversible .................... in response to a variety of stimuli

EXTRINSIC ASTHMA

Extrinsic asthma is a Type ...... ............................... reaction that is induced by an .................... ...................... / ........ mediated activation of mucosal .................. cells result in the release of ................... mediators and secondary mediators

The result of this is:

= bronchoconstriction by ................ and ................... reflex actions

= increased ..................... permeability

= increased ................... secretions

INTRINSIC ASTHMA

Intrinsic Asthma is initiated by a diverse ................ mechanism, including:

= ....................... infections

= drugs such as .............. and ................. .......................

= pollutants an

SPINAL TRAUMA

· Explain spinal cord injuries. Include common causes of SCI as per Major Trauma Guidelines

Two types of Spinal Injury

- .

- .

Types of Spinal Injury and their effects

- .

- .

- .

- .

- .

Two types of Spinal Injury

- . Primary Injury - occurs at the time of impact

- . Secondary Injury - occurs after primary injury due to a pathological cascade (e.g. swelling, movement of bone fragments)

Types of Spinal Injury, their mechanism and their effects

Cord concussion (temp disruption of function)

Cord contusion (bleeding, bruising to tissues of sc)

Cord compression (swelling and pressure)

Laceration (permanent loss of function)

Cord transection (complete/incomplete)

NEXUS CLINICAL DECISION RULE (CDR)

- If patient is not conscious =

- If the patient is conscious but not cooperative =

- If the patient is conscious and cooperative, but has neurological deficit =

CONSIDERING HIGH-RISK FACTORS (3)

NEXUS CDR CRITERIA (5)

- If patient is not conscious = apply semi rigid collar and immobilisation (or head blocks only with DAM)

- If the patient is conscious but not cooperative = apply manual in-line stabilisation / no semi rigid collar and apply lanyard if possible

- If the patient is conscious and cooperative, but has neurological deficit = apply semi rigid collar and immobilisation

CONSIDERING HIGH-RISK FACTORS (3)

- Patient is over the age of 65 years old

- Patient had a dangerous mechanism

- Patient has pre-existing spinal conditions

NEXUS CDR CRITERIA (5)

- altered mental status

- mid line tenderness

- distracting injury

- evidence of intoxication ETOH / drugs

- focal neurological deficit

· Explain stabilisation techniques and lanyard versus rigid collar as per CPGs

A lanyard is applied when NEXUS is not cleared but there are or aren't neurological symptoms. A semi rigid collar is used when NEXUS is not cleared and there are neurological symptoms.

· Describe two mechanisms of injury associated with abdominal trauma

Blunt

- Direct compression of the abdomen

- Fracture of solid organs e.g. spleen/liver

- Blowout of hollow organs e.g. intestines

Penetrating

- Direct trauma to organ and vasculature

o Projectile and fragments

- Projectile pathway not always obvious

What is Kehr's sign?

Left shoulder tip pain => spleen has been ruptured

· Explain what is meant by permissive hypotension and why it may be considered with abdominal trauma

Permissive hypotension is the act of maintaining a blood pressure lower than physiologic levels (SBP OF 70 MMHG) in a patient that has suffered from haemorrhagic blood loss from injuries such as severe penetrative trauma, aortic aneurysm or ectopic pregnancy.

The practice is employed to maintain adequate vasoconstriction, organ perfusion, and prevent an undesired coagulopathy during initial fluid resuscitation.

Define a burn, include the types/sourcesof burns

Burn is defined as direct injury from heat or caustic chemicals that results in an inflammatory response

Sources of damages of burns include:

- Thermal

- Electrical

- Chemical

- Radiation

The classification of the severity of burns

CAUSE

SKIN COLOUR

SKIN SURFACE

SENSATION

HEALING

SUPERFICIAL (FIRST DEGREE BURN)

CAUSE: sunburnt or minor flash

SKIN COLOUR: red

SKIN SURFACE: dry with no blisters

SENSATION: painful

PARTIAL THICKNESS (SECOND DEGREE)

CAUSE: hot liquids / flashes / flames

SKIN COLOUR: mottled red

SKIN SURFACE: blisters with weeping

SENSATION: Painful

FULL THICKNESS (THIRD DEGREE)

CAUSE: chemicals, electricity, flame

SKIN COLOUR: pearly white and translucent

SKIN SURFACE: dry with thrombosed blood vessels

SENSATION: anaesthetic

Explain signs of airway burns and possible complications

Signs and symptoms of airway burns:

- Sooty sputum

- Singed nasal hair and eyebrows

- Hoarse voice / Persistent cough

- Swelling of the airway

· Describe the types of Traumatic Brain Injuries including types of brain haemorrhages.

Also explain mechanism of coup/contracoup injuries

PRIMARY - AS A RESULT OF THE INITIAL FORCE

• Damage incurred as a direct consequence of the impact

• Neurones, axonal sheaths and blood vessels may be physically disrupted at the moment of impact, often with irreversible cell damage

• Injury to neural tissue:

- Focal cerebral contusions and lacerations (direct impact and contrecoup); and

- Diffuse axonal injury (shearing injury)

• Injury to intracranial blood vessels:

- Extradural haematoma

- Subdural haematoma

- Intracerebral haematoma

- Subarachnoid haemorrhage

SECONDARY - (AFTER THE PRIMARY INJURY)

• Represents further damage to central nervous system tissue by secondary insults, and adverse physiological events can occur minutes, hours, days after initial injury.

• These insults include hypotension, hypoxia, intracranial hypertension and seizures.

--------------------------------------------------

Secondary damage

• Ischemia from poor cerebral perfusion secondary to raised ICP:

- Expanding intracranial haematoma (exacerbated by coagulopathy); and

- Cerebral swelling/oedema

• Ischemia secondary to hypotension and anaemia:

- Haemorrhage with hypovolaemia or dilutional anaemia; and

------------------------------------------------------

A coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was hit

· Explain the signs and symptoms of Raised Intra-cranial Pressure. Include Monroe-Kellie Doctrine and Cushing's Triad and Posturing.

CUSHING'S TRIADS

- CUSHING'S TRIAD ARE THE THREE PRIMARY SIGNS THAT OFTEN INDICATE AN INCREASE IN INTRACRANIAL PRESSURE (ICP)

o INCREASED SYSTOLIC BP

o DECREASED PULSE

o DECREASED RESPIRATION

- SYMPTOMS OF INCREASED ICP ARE THE OPPOSITE OF SHOCK:

o DECREASED BP

o INCREASED PULSE

o INCREASED RESPIRATION

WHAT IS THE MONROE KELLIE DOCTRINE?

MONROE KELLIE DOCTRINE

When one compartment expands, another should reduce its volume or the ICP WILL INCREASE because the skull is a fixed space which maintains its components at equilibrium.

· Explain the importance of cerebral perfusion. Include the pre-hospital management of a patient with traumatic brain injury, 90 110 30 4 principles

>90% SPO2

>110 SBP

30 degree angle of patient positioning

>4 mmol BGL

all to maintain cerebral perfusion

· Explain signs and symptoms of snake bites.

Snake Bites:

- Puncture marks or not

- Headache

- Nausea and vomiting

- Swollen tender lymphatic glands

- Confusion

- Collapse

- Visual disturbances

- Drooping eyelids

- Difficulty swallowing, speaking, breathing

- Weakness or paralysis

- Respiratory weakness/arrest

- Seizures

Explain PIT as per CPG and explain why it is used.

Pressure Immobilisation Technique

Indications: all Australian venomous snakes, funnel web spider (eastern states), blue ringed octopus and cone shell snails.

Contraindications: not to be used on spider or insect bites (except funnel webs)

· Summarises bites and stings relevant to WA and their management as per CPGs

Tropical Jellyfish

Spray area liberally with vinegar for thirty seconds

If no vinegar remove the tentacles with gloved hand and immerse in sea water

Non-tropical jellyfish

Rinse in sea water and remove sting

Use hot water on the area for twenty minutes avoiding thermal burns

Venomous fish

Immerse area in as hot water as patient can tolerate

Ticks

Determine if patient has allergy to ticks if no history then remove tick immediately. If allergic to ticks leave the tick in place to avoid further envenomation.

Pulmonary Barotrauma

Clinical Presentation

Pulmonary Barotrauma: Injury produced as the result of volume increases in air-filled cavities expanding on ascent.

Clinical Presentation:

- Chest pain

- SOB

- Coughing

- Cyanosis

- Dysphagia

- Surgical emphysema around neck

- Decreased GCS

· Define Heat Stroke and Hypothermia. Explain their signs and symptoms and their management as per CPGs

Heat stroke is an excessive elevation of core body temperature above the normal range due to failure of thermoregulation

Heat stroke can be induced by:

Environmental factors, such as excessive heat absorption, hot and humid climates, excessive physical exertion

Intrinsic factors, such as metabolic reactions, drugs, infection

Management for HEAT STROKE and HYPOTHERMIA

When safe to do so, move the patient into a cool environment or shade.

Position patient supine if appropriate

Provide water to drink if fully conscious

Apply critical treatment points:

STRIP clothing off patient.

SOAK or spray the patient with tepid water.

FAN the patient to promote heat loss.

IMMERSE the patient in an ice bath if available. If unavailable, apply ice packs to neck, groin and armpits.

COVER the patient with wet cold cloths and continue to fan.

Consider delaying transport to ensure the patient is adequately cooled (approximately 15 minutes).

Continue cooling the patient during transport to hospital.

Hypothermia is defined as a core temperature below 35°C (3 levels)

Mild hypothermia (32-35°C)

Decreased respiratory rate

Lethargy

Weakness

Slurred speech

Ataxia

Shivering may cease

Moderate hypothermia (30-32°C):

Muscle rigidity

Poor reflexes

Dilated pupils

Hypotension

Bradycardia

Severe hypothermia (< 30°C)

Flaccid muscles

Fixed pupils

Arrhythmias

Cardiac arrest

Management for hypothermia

Management

When safe to do so, remove the patient from the cold environment

Position patient recumbent if appropriate or a position of comfort

Vitals

- Closely monitor patients temperature and BGL

- Consider O2 if indicated as per CPG

- Provide warm oral fluids to drink if fully conscious

- Remove wet and cold clothing

- Passively re-warm with blankets and warm surroundings (e.g. in-ambulance/vehicle heater)

- Consider vascular access

- Transport Priority 1 if patient time critical

ATOMIC assessment tool (chest injuries)

Airway obstruction

Tension pneumothorax

Open pneumothorax

Massive hemothorax

Intercostal disruption e.g flail chest

Cardiac tamponade

Cardiac Tamponade - Beck's Triad

1. Distant / Muffled Heart sounds

2. Jugular vein distension

3. Low blood pressure (hypotension)

Fernotrac Traction Splint

- Indications

- Contraindications

Indications: Immobilise femoral fractures.

Contraindications

· Ankle or foot fracture

· Fracture to the proximal third of the femur

· Neck of femur fracture

· Pelvic fracture

· Significant knee injury

· Supracondylar fracture of the distal end of the femur

Sager Traction Splint

- Indications

- Contraindications

Indications: Immobilise Proximal 1/3 and mid-shaft femoral fractures.

Contraindications:

· Ankle or foot fractures

· Neck of femur fractures

· Pelvic fracture

· Significant knee injuries

· Supracondylar fractures of the distal end of the femur.

· Under a clinical setting this should not be removed unless directed to by a doctor or senior clinician.

CROUP IN DEPTH

DEFINITION OF CROUP

Also known as ..............................., it is a type of ................... .................... that is usually caused by a ......................

The infection leads to .................. inside the ...................., which interferes with normal breathing

THIS PRODUCES THE CLASSIC SYMPTOMS OF (3) = which often worsens at .....................

CAUSE

Can be caused by a number of ............... including .................. and .................. virus

SIGNS AND SYMPTOMS

- Croup is characterised by a ............ ................. / ........................ / ......................... and .................. breathing which usually worsens at .........................

- Drooling or a very ................ appearrance may indicate other medical conditions, such as .........................

PATHOPHYSIOLOGY

The .................... infection that causes croup lea

DEFINITION OF CROUP

Croup, also known as laryngotracheobronchitis, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of "barking" cough, stridor, and a hoarse voice

CAUSE

Croup can be caused by a number of viruses including parainfluenza and influenza virus.

Signs and symptoms

Croup is characterized by a "barking" cough "), stridor, hoarseness, and difficulty breathing which usually worsens at night

Pathophysiology

The viral infection that causes croup leads to swelling of the larynx, trachea, and large bronchi due to infiltration of white blood cells

Swelling produces airway obstruction which, when significant, leads to dramatically increased work of breathing and the characteristic turbulent, noisy airflow known as stridor.

ASTHMA IN DEPTH

INTRODUCTION FOR ASTHMA

Asthma is a ......................., reversible, .................. disorder of ...................... airways. Asthma may be diagnosed any time after ........ years old (but typically diagnosed within ......... years old)

Asthma is usually detected by a persistent ............ ................., particularly at ..............., in the early .................... or with ................

It is usually accompanied with ................ ........................., ................. or ............................ and a ..................... (audible sound)

The narrowing of the airways from asthma is caused by ......................., extra .................. and ...........................

ASTHMA HAS 3 MAIN COMPONENTS

= ................ of the airway due to ...................

= associated .................. in the airway

= increased ...................... of airway secreti

Asthma is a chronic inflammatory disorder of the lower airways. Asthma may be diagnosed any time after one year of age

Asthma is usually detected by a persistent dry cough, particularly at night, in the early morning or with exercise.

It is usually accompanied with chest tightness, shortness of breath and a wheeze.

Narrowing of the airways is caused by inflammation, extra mucous and bronchoconstriction

It has three main components that can be characterised as follows:

= A narrowing of the airway due to bronchoconstriction.

= Associated swelling in the airway and,

= Increased production of airway secretions.

The airway can become obstructed due to this response

EXTRINSIC VS INTRINSIC ASTHMA

Extrinsic (outside cause)

Classic allergic asthma resulting in bronchospasm, increased mucous secretions, and increased vascular permeability.

Common in children, young adults.

· Seasonal in nature.

· Sudden brief attacks.

· Major component is bronchospasm.

· Good bronchodilator response.

Intrinsic (inherent cause)

Non-immune mechanisms such as respiratory infections, drugs such as aspirin and beta-blockers, pollutants, emotions and exercise.

· More common in older adults.

· No immunologic cause.

· Aspirin sensitivity / nasal polyps.

· May have poor bronchodilator response.

PERTINENT INFORMATION TO GATHER WITH ASTHMATIC PATIENT

= Associated "triggers"

= Duration of symptoms

= Medications including bronchodilators and steroids

Past episodes, hospital and ICU admissions

= Asthma plan

Chronic Obstructive Pulmonary Disorder (COPD)

Definition

COPD, is a term used to describe a set of ............... diseases that cause ............. problems, by blocking ............... and making it .................. to breathe.

Diseases associated with COPD include (4)

The two most common types of COPD include ................... ................. and ......................

Both are characterized by .............to the lungs that prevent proper ..............functioning.

Main clinical features include ........................................, ..................and a chronic ....................cough.

Chronic Obstructive Pulmonary Disorder (COPD)

Definition

Chronic obstructive pulmonary disease, or COPD, is a term used to describe a set of lung diseases that cause respiratory problems, by blocking airflow and making it hard to breathe.

Diseases associated with COPD include some forms of bronchiectasis, chronic asthma, emphysema, and chronic bronchitis

The two most common types of COPD include chronic bronchitis and emphysema.

Both are characterized by damage to the lungs that prevent proper respiratory functioning.

Main clinical features include shortness of breath, wheezing and a chronic phlegmy cough.

Definition of emphysema

Permanently enlarged/over-inflated alveolar due to the destruction of the alveolar walls.

Definition of chronic bronchitis

Hypersecretion of mucous and chronic productive cough for at least 3 months of the year for at least 2 consecutive years.

Definition of Bronchiectasis

Permanent distortion and dilation of bronchi and bronchioles.

PATHOPHYSIOLOGY OF EMPHYSEMA

In patients with COPD, exposure to cigarette smoke leads to the ..............of ...............walls and the permanent ................ ................. of ............... .................... spaces.

During exposure to cigarette smoke, ................and ................(white blood cells) gather in .......................

Excessive ..................to ................and .................leads to a breakdown of ................................ in the alveolar, the .......................of ..................walls and the loss of ....................tissue.

Breakdown of ............... .................leads to:

= Decrease ................. within the ....................

= ........... trapping

= Lung ............ ..................., which results in .............................

...................of ..................walls leads to:

= .....................airways

Loss

Emphysema:

In patients with COPD, exposure to cigarette smoke leads to the destruction of alveolar walls and the permanent over inflation of alveolar air spaces.

During exposure to cigarette smoke, neutrophils and macrophages (white blood cells) gather in alveoli.

Excessive exposure to neutrophils and macrophages leads to a breakdown of elastic fibres in the alveolar, the thickening of bronchial walls and the loss of pulmonary tissue.

Breakdown of elastic fibres leads to:

= Decrease recoil within the alveoli

= Air trapping

= Lung over inflation, which results in barrel chest

Thickening of bronchial walls leads to:

= Narrowed airways

Loss of pulmonary tissue leads to:

= Decreased gas exchange

= VQ (ventilation/perfusion) mismatch

PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS

Chronic Bronchitis:

Inhaled ..............(smoke) cause increase in ............presence, resulting in ................within the ..............wall.

Constant ................increases the ......... and ............... of ................cells and ................. glands.

This process leads to the ...............of ............. resulting in ................ to clear ...................

Impaired ...............function and increased ................production lead .................. .......................

Chronic Bronchitis:

Inhaled irritants (smoke) cause increase in neutrophil presence, resulting in inflammation within the bronchial wall.

Constant inflammation increases the size and number of goblet cells and mucous glands.

This process leads to the reduction of cilia resulting in inability to clear mucous.

Impaired ciliary function and increased mucous production lead narrowing airways.

PATHOPHYSIOLOGY OF BRONCHIEACTSIS

Often .................to other ..............disease or previous childhood .............. infections.

Recurrent airway ............... and ................... leads to deterioration in muscle and/or ............. fibres within ..............walls. resulting to the permanent .......................... of the bronchi and bronchioles

Widened ................ allow .................to pool.

Stagnant ..............provides excellent ............... for ....................to develop.

Bronchiectasis:

Often secondary to other respiratory disease or previous childhood chest infections.

Recurrent airway infection and inflammation leads to deterioration in muscle and/or elastic fibres within bronchial walls.

Widened bronchi allow mucous to pool.

Stagnant mucous provides excellent medium for bacteria to develop.

SIGNS AND SYMPTOMS OF EMPHYSEMA

Dyspnoea (shortness of breath)

Chronic non-productive cough = due to .......... trapping

Wheeze

Difficulty exhaling

Weakness on exertion

Barrel chest = due to increased ............. pressure and ............ trapping

............... lip breathing = maintain positive airway pressure

SIGNS AND SYMPTOMS OF CHRONIC BRONCHITIS

Dyspnoea (shortness of breath)

Constant productive cough

Wheeze

Chest pain, due to cough

Peripheral Oedema

SIGNS AND SYMPTOMS OF BRONCHIEACTISIS

Dyspnoea (shortness of breath)

Chronic cough

Up to 240ml of mucous production per day

Foul breath

Haemoptysis

Frequent lung infection

COPD patients and oxygen therapy (what happens with excessive O2 administration and the relevance of the Haldane Effect)

Patients with COPD optimise gas exchange due to hypoxic vasoconstriction. During excessive O2 administration, vasodilation occurs which moves blood to inadequately ventilated areas of the lungs. This results in reduced O2 absorption and increased CO2 retention.

The Haldane Effect

= If the pressure of oxygen in the blood is high, haemoglobin will release CO2 (normal in the lungs).

= If the pressure of oxygen in the blood is low, haemoglobin will bind to CO2 (normal in the tissue).

= During over oxygenation, the release of unbound CO2 will significantly increase.

= As the pressure of CO2 in the lungs will therefore be greater than O2 (which is abnormal due vasodilation), haemoglobin will bind to CO2 with greater affinity than O2 and subsequently reduce oxygenation.

Definition of Anaphylaxis

Anaphylaxis is any acute onset of hypotension, bronchospasm or upper airway obstruction where anaphylaxis is considered possible. Even if typical skin features are not present

OR

Any acute onset illness with typical skin features (urticarial rash or erythema/flushing and/or angioedema) PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms.

KEY TERMS: ANAPHYLAXIS and their definition

Antigen:

Antibody:

Immunoglobulin E (IgE):

Basophil:

Mast cell:

Antigen:

Substances (usually a protein) that enter your body and induce the formation of antibodies. These may sometimes referred to as allergens. A substance that is an allergen for one person may not be for another.

Antibody:

Neutralises antigens and removes them from the body.

Immunoglobulin E (IgE): Accounts for less than 1% of antibodies in normal serum. Responsible for immediate hypersensitivity reactions

Basophil:

A white blood cell that promotes inflammation

Mast cell:

Distributed amongst connective tissues (skin, lungs, GI tract which is where allergens are mostly likely to enter the body) . Filled with vasoactive amines (histamine, serotonin, leukotrienes).

Mast cells release amines as part of the inflammatory response.

They have a role in defending the body against parasites and they have receptors for IgE antibody on their surface.

This release is stimulated by antigens binding to IgE, injury (i.e. trauma) or chemical agents (e.g. toxins, or in some people, physical stresses such as exercise).

Antigens may enter your body via (4 routes)

Injection

Ingestion

Inhalation

Absorption

PATHOPHYSIOLOGY OF ANAPHYLAXIS

Anaphylaxis the most severe form of an .............. .................... /. Immediate allergic reactions are due to an interaction between ................................ antibodies and an .................(allergen) with a resulting release of ................from cells such as ................... and .............. cells.

.................will enter the ................ and trigger an ................... response which leads to the production of .................... (or ........................) which are designed to fight the invading .................. by ..................to them and causing ...................... of the cell.

This ........................ will cause a release of the chemicals that will fight the invading cells, such as .....................

· This normal antigen- antibody reaction is what protects the body from disease by activating the immune response.

Anaphylaxis the most severe form of an allergic reaction. Immediate allergic reactions are due to an interaction between Immunoglobulin-E (IgE) antibodies and an antigen (allergen) with a resulting release of chemicals from cells such as basophils and mast cells.

Antigens will enter the system and trigger an immune response which leads to the production of antibodies (or immunoglobulins) which are designed to fight the invading antigens by binding to them and causing degranulation of the cell.

This degranulation will cause a release of the chemicals that will fight the invading cells, such as histamine.

· This normal antigen- antibody reaction is what protects the body from disease by activating the immune response. The immune responses are normally protective, however they can become oversensitive and become directed toward harmless antigens to which we often are exposed; this response is known as an allergic response.

Mild to moderate allergic reactions

Mild to moderate allergic reactions

These reactions do not involve the circulatory or respiratory system. They usually occur minutes to 2 hours of exposure to an allergen.

Mild to moderate symptoms:

Hives or welts

Tingling mouth

Angioedema (swelling of lips, face, eyes)

Abdominal pain (this is a sign of anaphylaxis to medications and insect stings and bites)

Vomiting (this is a sign of anaphylaxis to medications and insect stings and bites)

What is anaphylaxis and its pathophysiology?

Anaphylaxis is usually ............... progressing and is an acute .................... reaction that can affect multiple ............... systems. It is a severe life threatening event which may impact one or more of the ...................... or ................... systems.

Anaphylaxis is caused by the ................... release of .................... mediators which results in a systemic ............... in capillary ..................., ............... muscle ................... and peripheral .......................

Allergic sensitisation occurs when an ................. enters the body and activates the ................... system response, leading to the production of .......... antibodies directed against that ....................

These ................... then remain ................... on the cells until another ...................to the antigen and are refe

Anaphylaxis is usually rapidly progressing and is an acute hypersensitivity reaction that can affect multiple organ systems. It is a severe life threatening event which may impact one or more of the cardiovascular or respiratory systems.

Anaphylaxis is caused by the widespread release of inflammatory mediators which results in a systemic increase in capillary permeability, smooth muscle contractility and peripheral vasodilation.

Allergic sensitisation occurs when an antigen enters the body and activates the immune system response, leading to the production of IgE antibodies directed against that antigen.

These antibodies then remain inactive on the cells until another exposure to the antigen and are referred to as antigen specific immunoglobulins.

When the antigen enters the body again, it binds to the IgE antibodies on mast cells and basophils. This interaction causes degranulation of the cell and the release of chemical mediators to fight the allergen.

These chemical mediators include:

histamines

leukotrienes

heparin

kinins

prostaglandins

thromboxanes

The physiological effects of inflammatory mediators of Anaphylaxis

An increase in the permeability of vessels

Causes dilation of capillaries and venules (causing flushing & angioedema)

Plasma leaks into interstitial space (decreases intravascular fluid volume and causes swelling)

Vasodilation further decreases cardiac preload, decreasing stroke volume and cardiac output (hypotension)

Contraction of smooth muscle in the GI tract and bronchial tree (associated with increases in gastric, nasal and lacrimal secretions and bronchospasm)

Signs and Symptoms of Anaphylaxis

Difficult/noisy breathing.

Swelling of tongue

Swelling/tightness in throat

Difficulty talking and/or hoarse voice

Wheeze or persistent cough.

Persistent dizziness and/or collapse

Change of consciousness

Hypotension

Pale and floppy (young children)

SMOKE INHALATION INJURY CPG

Introduction

Clinical Presentation

Smoke inhalation occurs when you breathe in harmful smoke particles and gases. Inhaling harmful smoke can inflame your lungs and airway, causing them to swell and block oxygen. This can lead to acute respiratory distress syndrome and respiratory failure.

Clinical Presentation

Altered Conscious State (note: may be delayed; may also present as changes in behaviour, neurological, or mental status.)

Cough

Shortness of breath Stridor Wheeze Hoarseness

Headache

Skin changes

Cyanosis - hypoxia

Bright red - carbon monoxide poisoning (very late sign)

Burns

Eye damage

Seizures

Soot in the nose or throat

Chest pain