1
Q
Amputations
A
- Basic care including haemorrhage control
- Indirect pressure such as arterial points
- Clinical support
- Arterial tourniquet in extreme circumstances when life-threatening haemorrhage unable to be controlled
- Seal the body part in a water tight bag and place in ice cooled water if possible
- Transport and notify
2
Q
Allergy (mild or moderate)
A
Skin rash or local allergic reaction
- Basic care
- Fexofenadine 180mg in adults
- Transport if required
3
Q
Anaphylaxis (adults)
A
Adults with severe hypotension, severe bronchospasm or respiratory distress due to angioedema
- Basic care
- IPPV with slow ventilation rates if required
- Clinical support
- Adrenaline 10mcg/kg IM to a max single dose of 500mcg. Repeated every 5m if required
- Saline 0.9% IV to maintain adequate BP
- Notify and transport
4
Q
Anaphylaxis (paeds)
A
Paediatrics with severe hypotension, severe bronchospasm or respiratory distress due to angioedema
- Basic care
- IPPV with slow ventilation rates as required
- Clinical support
- Adrenaline 10mcg/kg IM to a max single dose 500mcg. Repeated every 5m if required
- Transport and notify
5
Q
Mild Asthma - Adult
A
Talking in sentences, conscious, no physical exhaustion, no accessory muscle use, normal HR, normal to raised RR, expiratory wheeze, normal Sp02, no cyanosis
- Basic care and follow asthma management plan if required
- Salbutamol via MDI up to 1200mcg if required
- Repeat dose if required
- Consider GP referral
6
Q
Moderate Asthma - Adult
A
Talking phrases, conscious, no physical exhaustion, mild accessory muscle use, tachycardia, tachypnoea, moderate to loud wheeze inspiratory and expiratory, normal Sp02 (92-95% RA), no cyanosis
-Basic care and asthma management plan
-Salbutamol via MDI to achieve dose of 1200mcg
-Ipratropium via MDI to achieve dose of 160mcg
-Repeat salbutamol 1200mcg every 20m if patient fails to improve to a total of 3 doses
OR
-Salbutamol 5mg and Ipratropium 500mcg nebulised
-Repeat salbutamol every 20m to a total of 3 doses
-Oral prednisolone (if tolerated), 50mg, if no previous doses within last 24 hours
Fail to improve, esculate to severe asthma pathway
Transport to GP or hospital
7
Q
Severe Asthma - Adult
A
Speaking words, agitated/distressed, visibibly breathless/increased WOB, moderate accessory muscle use, tachycardia, tachypnoea, poor air movement, Sp02 90-94%, may have cyanosis, posturing, hyper inflated
- Basic care including high-flow 02
- Early clinical support
- Salbutamol 15mg and Ipratropium 500mcg neb, repeat salbutamol dose as required, add ipratropium every 20m up to 3 doses
- Oral prednisolone (if tolerated), 50mg, if no previous doses within last 24 hours
- No improvement or deterioration treat as life-threatening
- Transport and Notify
8
Q
Life-threaning Asthma - Adult
A
Unable to speak, drowsy/collapsed, exhausted, severe accessory muscle use or minimal due to tiring, tachycardia or bradycardia, poor respiratory effort or apnoea, low volume poor air movement, hypoxic Sp02 <90%, centrally cyanosed, posturing and hyper inflation
- Basic care including high flow 02
- Early clinical support
- Continuous salbutamol and ipratropium (every 20m, up to 3x doses) neb
- Fluid bolus 500mL IV
- Consider adrenaline 10mcg/kg IM, max of 500mcg
- No response to adrenaline consider repeat dose
- Transport and notify
9
Q
Asthma - Adults requiring IPPV
A
- Early clinical support
- Continuous nebulisation where possible
- IPPV with slow tidal volumes and slow ventilations to allow adequate chest deflation
- Fluid bolus 500mL IV
- Adrenaline , if no response consider repeat dose
- Transport and notify
10
Q
Mild Asthma - Paediatrics
A
Talking in sentences, conscious, no physical exhaustion, no accessory muscle use, normal HR, normal to raised RR, expiratory wheeze, normal Sp02, no cyanosis
- Basic care and asthma management plan
- < 6 years salbutamol via MDI up to 600mcg
- Consider use of resus mask for paeds <4 years who are unable to use spacer
- Repeat dose if required
- Transport
11
Q
Moderate Asthma - Paediatrics
A
Talking phrases, conscious, no physical exhaustion, mild accessory muscle use, tachycardia, tachypnoea, moderate to loud wheeze inspiratory and expiratory, normal Sp02 (92-95% RA), no cyanosis
- Basic care including high flow 02
- < 6 years - salbutamol via MDI 600mcg (6 puffs)
- < 6 years - ipratropium via MDI 80mcg (4 puffs)
- Repeat salbutamol every 20m with no improvement to a total of 3 doses
- < 6 years - salbutamol 2.5 mg and ipratropium 250mcg neb (add to saline to increase volume)
- Repeat salbumatol every 20m with no improvement up to 3 times
- Oral prednisolone 1mg/kg, max of 50mg provided no therapeutic doses in last 24 hours
- If pt fails to improve escalate to severe asthma guideline
- Transport
12
Q
Severe Asthma - Paediatrics
A
Speaking words, agitated/distressed, visibibly breathless/increased WOB, moderate accessory muscle use, tachycardia, tachypnoea, poor air movement, Sp02 90-94%, may have cyanosis, posturing, hyper inflated
- Basic care including high flow 02
- Early clinical support
- < 6 years - salbutamol 7.5mg and ipratropium 250mcg neb
- Oral prednisolone 1mg/kg, max of 50mg provided no therapeutic doses in last 24 hours
- With no improvement treat as life-threatening
- Transport and notify
13
Q
Life-threatning Asthma - Paediatrics
A
Unable to speak, drowsy/collapsed, exhausted, severe accessory muscle use or minimal due to tiring, tachycardia or bradycardia, poor respiratory effort or apnoea, low volume poor air movement, hypoxic Sp02 <90%, centrally cyanosed, posturing and hyper inflation
- Basic care including high-flow 02
- Early clinical support
- Salbutamol (continuous) and ipratropium (every 20m, up to 3x doses) neb
- Consider adrenaline 10mcg/kg IM to max dose of 500mcg
- If no response to adrenaline consider repeat dose
- Transport and notify
14
Q
Asthma - Paediatrics requiring IPPV
A
- Early clinical support
- Continuous nebulisation where possible
- IPPV with slow tidal volumes and slow ventilations to allow adequate chest deflation
- Adrenaline , if no response consider repeat dose
- Transport and notify
15
Q
Chemical Burns
A
- Local management plans or irrigate with cold running water for 20m where chemically appropriate
- Consider SOT
- Do not use hydrogel
16
Q
Thermal Burns
A
- Monitor patient closely for sings of airway compromise
- Cool with cold running water for up to 20 minutes - consider environmental conditions and ensure patient does not become hypothermic
- If no water is available apply a hydrogel dressing - for neonates max of 10 minutes, adults and paeds max of 20 minutes
- Once cooling/irrigation complete cover burns with cling wrap - remove hydrogel and continue cooling if required
- Saline 0.9% IV should aim to reestablish normovolaemia
- Transport and notify (RAH or WCH if possible)
17
Q
Acute Cardiogenic Pulmonary Oedema
A
- Basic Care
- Early clinical support
- Consider GTN if adequate BP, rate and rhythm appropriate, use of PDE-5 inhibitors - repeat every 5 minutes PRN
- Transport and notify
18
Q
COPD
A
-Basic care
-Initiate patient management plan where possible
-Titrate 02 to 88%-92% via nasal cannula
-Salbutamol via MDI to acheive dose of 1200mcg
-Ipratropium via MDI to achieve dose of 160mcg
-Repeat salbutamol every 20m to a max of 3 doses
If ineffective, or pt is unable to utilise MDI:
-Salbutamol (5mg) and ipratropium (500mcg) via neb
-Limit 02 exposure to 6 minutes where possible
-Nebs administered every 20m until clinical improvement is shown, up to a max of 3 doses
-Change to MDI asap
-Consider oral prednisolone 50mg, provided no therapeutic doses within last 24 hours
19
Q
Croup
A
Mild - moderate:
-Basic care
-Orla prednisolone 1mg/kg, max of 50mg
Severe respiratory distress or hypoxic:
- < 6 months administer 2.5mg adrenaline neb (made up to 5mL with normal saline), repeat PRN
- > 6 months administer 5mg/5mL adrenaline, repeat PRN
-Oral prednisolone 1mg/kg, max of 50mg
20
Q
Declaration of Life Extinct
A
For one full minute: -Nil heart sounds -Pulse -Respirations -Pupil react to light Leave iGel and IVs in place, circle with pen sites of attempted IVs or IM injections
21
Q
Envenomation - Snake
A
- Basic care
- Do not apply tourniquets or wash bite site
- Minimal patient exertion
- If on a limb apply pressure immobilisation
- Mark bite site
- Transport and notify
22
Q
Envenomation - Spiders
A
Redback:
-Basic care, apply ice, pain management, minimal patient exertion, transport
All other spiders:
-Basic care, minimal patient exertion, symptomatic management, transport
23
Q
Envenomation - Bee, Wasp, Ant
A
- Basic care including treatment of allery or anaphylaxis
- Minimal exertion
- Remove stinger using sidewards scraping motion
- Ice therapy
- Transport
24
Q
Envenomation - Marine
A
Blue-ringed octopus:
- Basic care with focus on ventilation due to paralysing effect of neurotoxin
- Minimal patient exertion
- Apply pressure immobilisation
- Clinical support
- Transport and notify
25
Falls
-Treat urgent medical issues and do not progress until safe to do so
-Perform mobility assessment
-Determining most appropriate lifting plan
-Once patient lifted complete comprehensive medical assessment
With medical cause, an injury, social concerns requiring further management or patient is on anticoags transport to hospital.
No clinical or social need to transport:
-complete falls screening: low risk = non urgent falls referral, high risk = urgent falls referral
If patient on ground for >1 hour, complete pressure injury risk assessment.
26
Fluid Resus in Medical Emergencies
-Basic care
Hypotension in setting of haemorrhagic hypovolaemia or obstructive shock:
-Balance rapid transport and scene time
-Adults: 0.9% saline IV to achieve a radial pulse and stable GCS
-Paediatrics: clinical support, consult for 0.9% saline IV
Symptomatic dehydration with hypotension:
-Clinical support and commence transport
-Initiate inactive cooling in hyperthermia (remove excess clothing, moisten skin and enhance evaporation, apply cold packs to ground and axilla)
-Consult for 0.9% saline IV
Relative hypovolaemia secondary to sepsis:
-Clinical support
-Consult for 0.9% saline IV
27
Hypoglycaemia - Adult
-If conscious state allows, consider oral carbs or glucose 15g
If ineffective or conscious state is not suitable select from:
-10% IV glucose titrated to the patients neuro function (100mL saline flush before and after)
-Glucagon 1mg IM
If the adult patient returns to normal functioning, patient may be left at home if:
-Consumed complex carbs
-Stable BGL achieved
-Been a previous stable diabetic
-Identifiable cause for episode can be identified
-Patient is in a suitable and stable environment
28
Hypoglycaemia - Paeds
- Clinical support
- If conscious state allows consider oral carbs or 15g glucose paste
- If oral carbs ineffective or conscious does not allow administer glucagon
- < 25kg IM 0.5mg
- >25kg IM 1mg
- If glucagon ineffective consult for IV glucose - flush line with saline to ensure patency, 2mL/kg of 10% glucose titrated to neuro function, followed by 1mL/kg saline flush
29
Ischaemic Chest Pain
-Basic care including 12L ECG
-Consider GTN SL (with adequate BP, rate and rhythm appropriate no use of PDE-5 inhibitors) repeat every 5m PRN
-Aspirin 300mg
If GTN and 02 does not resolve pain:
-IV cannula
-Consider clinical support for pain OR consult for 1-2.5mg IV morphine every 5m PRN
-Code STEMI if criteria met
30
Code STEMI Activation
```
Patient Criteria:
-Symptoms consistent with ACS and GCS 15
-Ongoing, unrelieved chest pain
-Symptom onset < 12 hours
-Travel time to hospital < 60 minutes
-2 serial ECG's with ST-elevation in 2 or more contiguous leads with normal QRS and no LBBB
Contraindications:
-Absence of chest pain
-Unstable patient
-STEMI in the setting of trauma or terminal phase of terminal illness
```
31
Meningococcal Septicaemia
-Basic care including appropriate PPE
-Clinical Support
If the patient is febrile with an altered conscious state, evidence of sepsis and acute onset of purpuric rash
Adults:
-IV benpen 2400mg OR
-IM benpen 2400mg as rescue
Paeds:
-IM benpen 60mg/kg max of 2400mg OR
-Patients >10 consult for IV 60mg/kg max of 2400mg
-Transport and notify
32
Narcotic OD
-Basic care with a focus on achieving adequate oxygenation
In adults naloxone doses titrated to spontaneous respirations:
-IV = 100mcg aliquots every 30-60s PRN
-IN = 120mcg aliquots every 30-60s PRN
-IM = 400mcg aliquots every 1-2m PRN
Paediatrics - naloxone doses are aimed for complete reversal:
-IM 400mcg PRN to max of 1600mcg
Newborns with respiratory depression due to long term maternal use should not be given naloxone, consult EOC.
33
Nausea and Vomiting
-Basic care
Adults:
Oral, IM or IV ondansetron 4mg, repeated once to maximum of 8mg
Paediatrics choose from:
-Oral ondansetron: 2mg (2-6) 4mg (6 and above)
-IM ondansetron 150mcg/kg to total dose of 4mg
-Consult (where IV is insitu or indicated for other treatment) for IV ondansetron 150mcg/kg max dose of 4mg
34
Pain Management - Adults
-Basic care including Sp02 and pain score monitoring
-Consider clinical support where pain is significant or likely difficult to control
-Oral paracetamol 1g as long as it hasnt been given in the last 4 hours
-IV paracetamol 1000mg/100mL over 10mins, followed by 100mL saline flush over 10mins
-Methoxyflurane 3mL, may be repeated once if required
If severe pain, stable GCS15 and systolic BP > 100:
-Fentanyl 25-50mcg IV slow push, repeated at 5 minute intervals to a maximum cumulative dose of 300mcg
-Fentanyl up to 200mcg IN, may be repeated once at a 5 minute interval, max cumulative dose of 400mcg
-If pain uncontrolled consider EOC consult
35
Pain Management - Paediatrics
-Basic care including Sp02 monitoring and use of FACES pain score
-Clinical support for significant pain
-Paracetamol 15mg/kg to a max dose of 1g, as long as it hasnt been given in the last 4 hours
-Methoxyflurane 3mL, repeated once if required
Patient over 1 years old with severe pain, GCS 15, with no signs of poor perfusion, CONSULT for:
-Fentanyl up to 1.5mcg/kg IN to a max single dose of 75mcg, may be repeated once after 5 minutes
-Fentanyl up to 0.5mcg/kg IV to a max single dose of 25mcg, may be repeated at 5 minute intervals, titrated to effect to a max cumulative dose of 2mcg/kg.
36
Seizures
-Basic care, consider existing seizure management plan
-Consider and manage treatable causes
If generalised seizure has persisted for >5 minutes:
-Midazolam 100mcg/kg IM to a max dose of 10mg (with no more than 5mL volume per injection site)
-Transport if seizure activity ceases, unless otherwise indicated in management plan
If generalised seizure activity re-occurs or continues 5 minutes after first dose of midazolam:
-Request clinical support
-Midazolam 100mcg/kg IM to a max dose of 10mg (with no more than 5mL volume per injection site)
*Midazolam may be administered immediately when there is a risk of physical injury, hypoxia or aspiration*
37
Severe Head Injury
- Basic care
- Clinical support
- In the absence of suspected spinal injury, consider maintaining posture of 30 degrees head elevation
- Ensure adequate 02
- For average size adults: 0.9% saline IV to maintain MAP of 90mmHg (or systolic BP of 120)
- Paediatrics: clinical support or consult for saline
- Transport and notify
38
Severe Hypothermia
-Basic care
Protect the patient from further heat loss via:
-Remove contact with cold surfaces and windy environments
-Remove wet clothing
-Dry the patient if wet
-Insulate with linen and space blanket
-Active warming should only be attempted in a controlled environment
-Minimise IV fluid administration to minimise after-drop and post-resus pulmonary complications
39
Spinal Injury - Adults (16 or above)
Provide Spinal Immobilisation if:
-Any significant distracting injuries
-Is under the influence of drugs or alcohol
-Has reduced GCS or is not cooperative
-Any thoracolumbar spinal pain
-Any new sensory or motor defecits
-Previous hx of spinal injury or disease
-Has priaprism
If the patient doesnt fit this criteria or has NO neck pain, immobilisation isnt necessary.
If the patient has neck pain apply Canadian C-Spine rule
If immoblisation is required choose from:
-Manual head stablisation
-Modified towel roll
-Vaccuum mattress
-Correctly fitting collar, given no deformities, ariway compromise or suspected increased ICP
For isolated suspected SCI with neurogenic shock:
-Aim to maintain normal temperature
-Request early clinical support
-Administer IV saline in 250mL alliquots to a max of 20mL/kg, aim for MAP >80mmHg
-Consult if treatment outcomes are not being met
40
Stroke
-Basic care including a ROSIER and BGL
Patient is NOT eligible for thrombolysis if:
-Onset of symptoms > 4 hours
-ROSIER score is negative
-the patient has diminished pre-morbid independent living
Patient IS eligible for thrombolysis if:
-ROSIER is positive
-the patient had a pre-morbid level of independent functioning
-arrival to receiving facility will be within 4 hours of symptom onset
-travel time to receiving facility is < 60 minutes
If transporting a patient eligible for thrombolysis:
-Confirm patient details with SDM and obtain their contact details
-Notify stroke co-ordinator at receiving facility (code stroke)
-Consider bilateral IV access with 18g cannula and 12L ECG as long as it does not delay transport time
41
Spinal Injury - Paediatrics (>16 years)
```
Provide immobilisation if any of these risk factors:
-Under the influence of drugs or alcohol
-Confused or uncooperative
-Reduced level of consciousness
-Focal neurology
-Neck pain or not moving their head
-Torso injury
-Diving injury
-High risk MVA
-Genetic disorder
If immobilisation is required choose an appropriate method
For isolated suspected SCI with neurogenic shock:
-Aim to maintain normal temperature
-Request early clinical support
-Administer IV saline in alliquots of 10mL/kg, up to 250mL
-Consider early consultation
```
42
Crush Syndrome
Anticipate crush syndrome when releasing compression of >60mins, affecting >18%TBSA crushed with large muscle mass.
-Consult with SAAS MO early via EOC
Precompression Release:
-Early clinical support and universal care
-Bilateral large bore cannula
-Patients >16yrs: IV saline in 250mL alliquots up to 20mL/kg, cease if signs of fluid overload
-Patients <16yrs: IV saline in in 10mL/kg alliquots (max of 250mL), up to 20mL/kg. Cease if signs of overload.
Post compression release:
-Prioritise early transport, minimise scene time
-Patients >16yrs: IV saline 250mL alliquots up to 20mL/kg, if ECG signs of hyperkalaemia present consutl MO for salbutamol neb
-Patients <16yrs: IV saline alliquots 10mL/kg (max of 250mL) up to 20ml/kg, if ECG signs of hyperkalaemia present consutl MO for salbutamol neb
43
Post-partum haemorrhage
-Universal care, early clinical support, MEDStar activate
-Temperature management (warm ambulance, remove wet clothes, insulate patient)
-Prioritise early transport and minimise scene time
-Assess and massage fundus, encourage pt to empty bladder
-Direct pressure to perineum to control external haem.
-Facilitate skin-skin contact of mother and baby if possible, encourage breast feeding if appropriate
-Large bore IV access above diaphragm if possible
TXA:
->16yrs confirmed primary PPH within 3 hours: TXA 1g slow IV push over 2-3mins
->16yrs confirmed secondary PPH consult MO
Fluid resuscitation - for patients not responding appropriately to verbal commands:
-Administer IV saline in 250mL alliquots until they respond
-Consult if it is likely to exceed 20mL/kg
External Abdominal Aortic Compression:
-If the haemorrhage is uncontrolled and the patient continues to deteriorate despite treatment
-Early GRN notification
44
Severe Haemorrhage
-Universal care, life support, early clinical support
-Haemorrhage control: direct and indirect pressure, arterial torniquet, immobilise fractures and splint pelvis, consider external abdominal aortic compression if subumbilical
-Temperature management: warm ambulance, remove wet clothing, apply blankets and space blankets
-Prioritise early transport and minimise scene time
-Large bore IV cannula, bilateral if possible
TXA:
-Traumatic cause (blunt or penetrating), within 3 hours of injury, patients >16yrs, BP of <90 OR HR >120, PATCH trial enrollement unavailable = 1g TXA IV slow push
-If non-traumatic cause of haemorrhage and signs of shock, consult EOC for TXA
FLUID RESUS:
-Patients >16yrs who are not responding appropriately to verbal commands: administer IV saline in 250mL alliquots until they begin to respond. Consult if likely to exceed 20mL/kg
-Patients <16yrs who are not responding appropriately to verbal commands: Administer IV saline in alliquots of 10mL/kg (up to 250mL) until they begin to respond appropriately. Consult if likely to exceed 20mL/kg
-Early GRN notification
Paramedic Practice
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