Paramedic CPGs December 07

Attach AED defibrillation pads Commence CPR while AED is being prepared only if 2nd person available

30 Compressions : 2 ventilations.

ShockableVF or pulseless VT

Non - ShockableAsystole or PEA

Basic Life Support - AdultCPG 1a

Assess Rhythm

Give 1 shock

VF/ VT

Cardiac Arrest

Version D 0.9 K

PEAAsystoleGo to CPG 3a(i)

Go to CPG 3a(ii)

Go to CPG 3a

From CPG 4a

Arrest witnessed by practitionerYes

Commence CPR30 Compressions : 2 ventilations.

Continue CPR for 2 minutesAttach AED defibrillation pads

No

EMT P

AP

ROSC Go to CPG 19

Rhythm check *

* =/- pulse check: Pulse check after 2 minutes of CPR if potentially perfusing rhythm

Immediately resume CPRx 2 minutes

Change defibrillator to manual mode

AP

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Request

ALS

Oxygen therapyOxygen therapy

Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management

Basic Life Support – Child (1 to 8 years)CPG 1b

Cardiac arrest

ShockableVF or pulseless VT

Non - ShockableAsystole or PEA

Assess Rhythm

Give 1 shock

Version D 0.10 K

One rescuer CPR 30 : 2Two rescuer CPR 15 : 2 compressions : Ventilations

Immediately resume CPRx 2 minutes

Switch to manual2 J/kg

Apply paediatric system AED pads

From CPG xx

Oxygen therapy

EMT P

AP

AP


Continue CPR for 2 minutes

Rhythm check *

VF/ VT

Asystole / PEA

Go to CPG xx

Go to CPG xx ROSC Go to

CPG xx


Request

ALS


Basic & Advanced Life Support – Infant (4 weeks to 1 year)CPG 1c

Cardiac arrest or

pulse < 60 per minute


Version D 0.9 K

Continue CPRAttach ECG monitor For two rescuer CPR use two

thumb-encircling hand chest compression

Assess Rhythm *VF or VT Asystole or PEA

Oxygen therapy

Immediate IO access if no IV in situContinue CPR

Epinephrine (1:10 000), 0.01 mg/kg IV/IORepeat every 3 to 5 min prn

Amiodarone, 5 mg/kg IV/IO

CPR for 2 minutes

Check blood glucose

One rescuer CPR 30 : 2Two rescuer CPR 15 : 2 compressions : Ventilations

EMT P

AP

Epinephrine1 mL/10 kg

Request

ALS

AP

CPR for 2 minutes

CPR for 2 minutes

Reassess Transport infant continuing CPR en-route


FromCPG xx


Basic & Advanced Life Support - NeonateCPG 1d

Yes

Term gestationAmniotic fluid clearBreathing or cryingGood muscle tone

Pink colour

Birth

Assess respirations, heart rate & colour Breathing, HR > 100 & Pink

Assess Heart Rate

Breathing well, HR > 100 & Pink

Version D 0.8 K

Provide warmthPosition; Clear airway if necessaryDry, stimulate, reposition

Breathing, HR > 100 but Cyanotic

Provide positive pressure ventilation for 30 sec

Apnoeic or HR < 100

Persistent Cyanosis

No, Pink

Yes

CPR (ratio 3:1) for 30 sec

Provide warmthDry baby

From CPG XX

No

Epinephrine (1:10 000) 0.01 mg/kg IV/ IOEvery 3 to 5 minutes prnConsider blood

glucose check

P AP

Give Supplementary O2

HR 60 to 100HR < 60

Assess Heart Rate

HR < 60

HR 60 to 100Breathing well, HR > 100 & Pink

If mother is IVDU consider

Or

Naloxone, 0.01 mg/kg IV

Naloxone, 0.01 mg/kg IM

Request

ALS

Consider

NaCl 0.9%, 10 mL/kg IV/IO


Foreign Body Airway Obstruction – AdultCPG 2a

Version D 0.5 K

One cycle of CPR

Conscious YesNo

one cycle of CPR

Yes

No

Encourage cough

No

Adequate ventilationsEffective

1 to 5 back blowsfollowed by

1 to 5 abdominal thrustsas indicated

No Yes

Ventilate

YesEffective

No

Yes

No

Was CPR, Abdominal

thrusts or O2 required

Consider discharge

into care of relative or

friend

Effective YesPersistent cough,

difficulty swallowing or sensation of object

in the throat

No

Yes

Consider

Oxygen therapy

EMT P

Conscious

Yes

No

Request

ALS

From CPG 1aFBAO

FBAO Severity

Severe(no cough)

Mild(cough present)

Are you choking?

Go to CPG xx

After each cycle of CPR open mouth and look for object

If visible attempt once to remove it

Foreign Body Airway obstruction – Paediatric (≤ 13 years)CPG 2b & 2c

Version D 0.8 K

ConsciousNo

Yes

YesEffective

One cycle of CPR

Open mouth and look for object

If visible one attempt to remove it

Attempt 5 Rescue Breaths

EMT P

Yes

Effective

1 to 5 back blows followed by 1 to 5 thrusts(child – abdominal thrusts)(infant – chest thrusts) as indicated

NoNo Conscious

Yes

Request

ALS

From CPG 1aFBAO

FBAO Severity

Severe(no cough)

Mild(cough present)

Are you choking?

Encourage cough

Breathing adequately

No

Consider

Oxygen therapy

Give rescue breaths

(10/ min)

Yes

After each cycle of CPR open mouth and look for object

If visible attempt once to remove it

Yes

one cycle of CPR

No

Effective

No

Go to CPG xx

VF or VT arrest

VF or Pulseless VT - Adult (> 8 years)CPG 3a

Epinephrine (1:10 000) 1 mg IV/ IOEvery 3 to 5 minutes prn

Amiodarone 300 mg (5 mg/kg) IV/ IO

Assess rhythm

Go to CPG 3a(i)Asystole

ROSC Go to CPG 19

No

No

No

No

No

Version D 0.10 K

No

Advanced airway management -

intubationAdvanced airway management –

LMA/LT

Consider mechanical CPR assist

Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute

If torsades de pointes, consider

Magnesium Sulphate 2 g IV

Amiodarone 150 mg (2.5 mg/kg) IV/ IO

Go to CPG xx

EMT P

AP

AP

P

CPR x 2 minutes

VF/VT

CPR x 2 minutes

Yes

3rd Shock

VF/VT

CPR x 2 minutes

Yes

4th Shock

VF/VT

CPR x 2 minutes

Yes

5th Shock

VF/VT

CPR x 2 minutes

Yes

6th Shock

Rhythm check *

Rhythm check *

Rhythm check *

Rhythm check *

VF/VT

Rhythm check *

2nd Shock

VF/VT


Yes

Rhythm check *

Consider causes and treat as appropriate:

Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma

Yes

PEA

FromCPG xx

If no ALS available

Immediate IO access if IV not immediately accessible

AP


Cardiac Arrest Asystole - AdultCPG 3a(i)

Asystole

Version D 0.10 K

Asystole No

Go to CPG 3a

P AP

Go to CPG 3b

No



LMA/ LT

AP



VF/VT

Go to CPG xxPEA

Go to CPG 19Rosc


CPR x 2 minutes

Rhythm check *

Atropine 3 mg IV/ IO CPR x 2 minutes

Yes

Asystole

Rhythm check *

CPR x 2 minutes

Yes

Rhythm check *

If persistent asystole for greater than 20 minutes

consider ceasing resuscitation




Consider ceasing resuscitation only if patient is NOT:

Hypothermicor

Cold water drowningor

Poisoningor

Overdoseor

Pregnantor

< 18 years

FromCPG xx


AP


Cardiac Arrest PEA -AdultCPG 3a(ii)

PEA

Version D 0.10 K

PEA

Yes

Atropine 1 mg IV/ IOEvery 3 to 5 minutes to 3 mg max

Yes



LMA/ LT



Go to CPG 3aVF/VT

Go to CPG xxAsystole

Go to CPG 19

EMT P

AP

AP

P


CPR x 2 minutes

CPR x 2 minutes

Rhythm check *

CPR x 2 minutes

Rate less than 60

If persistent PEA continue CPR

No



ROSC


FromCPG xx

Rhythm check *

If no ALS available

No


AP


Cardiac Arrest - Asystole - Decision Tree3b

Version D 0.6 K

Follow local protocol for

care of deceased

NoYes

From CPG 3a(i)Asystole

Patient is;Hypothermic orCold water drowning orPoisoning/ Overdose orPregnant or < 18 years

Confirm Asystolic Cardiac ArrestUnresponsiveNo signs of life; absence of central pulse and respiration

Confirm that (two minutes of CPR and no shock advised) x 3 are completed

Record two rhythm strips x 10 sec duration

Record on ECG stripsPCR NoPatient’s nameDate and time

Complete PCR and flag for mandatory clinical audit

Yes

Inform Ambulance Control

If present, inform next of kin

Emotional support for relatives should

be considered before leaving the scene

Consider ceasingresuscitation effortsNo

Resuscitation continuous for at least 20 minutes

P AP

Advanced Paramedics: continue to end of asystole algorithm and make clinical decision on ceasing resuscitation

AP

Unwitnessedarrest & no CPR prior

to arrival

Yes

No

Recognition of Death - Resuscitation not indicated3c

Version D 0.10 K

Signs of Life YesGo to

Primary survey

Inform Ambulance Control

Inform next of kin, if present

Follow local protocol for care

of deceased

Emotional support for relatives should

be considered before leaving the scene

It is inappropriate to commence resuscitation

Apparent dead body

Complete all appropriate

documentation

P AP

Recent & reliable written or verbal information from

family, caregivers or patient, stating that patient did not want

resuscitation

Yes

Yes

No

Definitive indicators of death:1. Decomposition2. Obvious rigor mortis3. Obvious pooling (hypostasis)4. Incineration5. Decapitation6. Injuries totally incompatible with life7. Unwitnessed traumatic cardiac arrest following blunt trauma

No

Consensus between caregiver and

practitioner on not resuscitating

No

Yes

Definite indicators of

DeathNo

Yes

No

End stage of terminal illness

CPR x 2 minutes Immediate IO access if IV not immediately accessible

2nd Shock (4 joules/Kg)

VF/VT

CPR x 2 minutes

3rd Shock (4 joules/Kg)

VF/VT

CPR x 2 minutes

4th Shock (4 joules/Kg)

VF/VT

CPR x 2 minutes


VF/VT

CPR x 2 minutes

Yes


No

No

No

No

VF/VT confirmed

Rhythm check *

Rhythm check *

Rhythm check *

Rhythm check *



VF or Pulseless VT – Child (1 to 8 years)CPG 3d (i)

Version D 0.8 K EMT P

AP

Epinephrine (1:10 000), 0.01 mg/kg IV/IORepeat every 3 to 5 minutes prn

Amiodarone, 5 mg/kg, IV/IO

Consider advanced airway management

- intubation

AP

Check blood glucose

Go to CPG xxAsystole/ PEA

ROSC Go to CPG xx


FromCPG xx


VF/VT

Rhythm check *

No

Yes

Yes

Yes

If no ALS availableYes

No

Asystole / PEA - Child (1 to ≤ 13 years)CPG 3d(ii)

Asystole/ PEA confirmed

Version D 0.8 K

Epinephrine (1:10 000) 0.01 mg/kg IV/IORepeat every 3 to 5 minutes prn


- intubation

Check blood glucose

EMT P

AP

AP

CPR x 2 minutes

Rhythm check *

If persistent Asystole / PEAcontinue CPR

Asystole or PEA

Yes Go to CPG xxVF/VT

ROSC Go to CPG xx





FromCPG xx


AP

Version D 0.7 K Traumatic Cardiac Arrest – AdultCPG 3e P AP

EMS Unwitnessed Traumatic Arrest

Apnoeic,Pulseless and

AsystolicNo

Yes

Blunt trauma

Yes

No

EMS Witnessed Traumatic Arrest

Patient respondsto resuscitation or

ALS provision within15 min

Go to appropriate

CPG

<18 yearsHypothermia

DrowningLightning strikeElectrical injury

No to all Request

ALS

Reference: Hopson, L et al, 2003, Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiac arrest, Position paper for National Association of EMS Physicians, Prehospital Emergency Care, Vol 7 p141-146

Low impact single vehicle

incident

No

Yes

Consider ceasing resuscitation No

Commence CPR and ALSYes to any

Rapid transport towards ALS

Yes

Take standard infection control precautions

Primary Survey Medical - AdultCPG 4a

Version D 0.6 K

Consider pre-arrival information

Scene safetyScene survey

Scene situation

No

Airway patent MaintainYesHead tilt/chin liftSuctionOPANPA

No

Pulse

Yes

Go to CPG 1a

Clinical status

AVPU assessment

Life threatening

Serious or Non serious

Go to CPG 5a

Airway obstructed No

Go to CPG 2a Yes

Assess responsiveness

ConsiderBreathing YesNo

Give 2 initial Ventilations

Oxygen therapy

Oxygen therapy

EMT P

AP

P

Go to appropriate

CPG

Adequate respirations No Go to

CPG xx

Yes

Request

ALS

Consider


Primary Survey Trauma - AdultCPG 4aVersion D 0.6 K



Scene situation

No

Airway patent MaintainYes

Breathing Yes

Jaw thrust(Head tilt/chin lift)SuctionOPANPA

No

No

Pulse

Yes

Give 2 initial Ventilations

Go to CPG 1a

Mechanism of injury suggestive of spinal injury

C-spine controlYesNo

AVPU assessment

Airway obstructed NoGo to

CPG 2a Yes

Arrest major external haemorrhage

Assess responsiveness

Oxygen therapy

Expose & check obvious injuries

Treat life threatening injuries only at this point

Oxygen therapy

EMT P

AP

P

Clinical statusLife threatening

Serious or Non serious

Go to CPG 5a

Go to appropriate

CPG


CPG xx

Yes

Request

ALS


Primary Survey Medical – Paediatric (≤ 13 Years)CPG 4b

Version D 0.8 K



Scene situation


Breathing Yes

Head tilt/ chin liftSuctionOPANPA (> 1year)

No

No

AVPU assessment


Go to CPG 2b Yes

Oxygen therapy

Work of BreathingAppearance

Circulation to skin

Paediatric Assessment Triangle


Sick child

Yes

No

Give 2 effectiveVentilations up

to 5 attempts

Oxygen therapy

EMT P

AP

P

P

Confirm Primary Survey findings

Pulse/ circulation

Yes

Go to CPG 1b

No Yes

Go to CPG 1c

No

> 1 year

Pulse < 60Yes

No

Go to CPG 5bClinical status

Life threatening or Serious Non serious

Go to appropriate

CPG

Request

ALS


CPG xx

Yes

Normal rates Age Pulse RespirationsInfant 100 – 160 30 – 60Toddler 90 – 150 24 – 40Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30


Primary Survey Trauma – Paediatric (≤ 13 years)CPG 4bVersion D 0.8 K



Scene situation


Breathing Yes

Jaw thrust(Head tilt/ chin lift)SuctionOPANPA (> 1 year)

No

No

Pulse/ circulation

Yes

Give 2 effectiveVentilations up

to 5 attempts

Go to CPG 1b

AVPU assessment

Go to CPG 5b


Go to CPG 2b Yes

Arrest major external haemorrhage

Oxygen therapy

Expose & check obvious injuries

Treat life threatening injuries only

Oxygen therapy

Work of BreathingAppearance

Circulation to skin



Sick child

Yes

No

Mechanism of injury suggestive of spinal injury

C-spine control

YesNo

No Yes

Go to CPG 1c No

EMT P

AP

P

Confirm Primary Survey findings

P

> 1 year

Pulse < 60Yes

No

Clinical statusLife threatening

or Serious Non seriousGo to

appropriate CPG

Request

ALS


CPG xx

Yes


Secondary Survey Trauma - adultCPG 5a (i)

Primary Survey

Version D 0.2 P AP

Markers for multi-system trauma

present

Markers for multi-system traumaGCS < 13Systolic BP < 90Respiratory rate < 10 or > 29Heart rate > 120Revised Trauma Score < 12Mechanism of Injury

No

Yes

Monitor and record vital signs

& GCS

SAMPLE history

Requires definitive

medical careYes

No

Examination of obvious injuries

Go toappropriate

CPG

Identify positive findings and initiate care

management

Reference: McSwain, N. et al, 2003, PHTLS Basic and advanced prehospital trauma life support, 5th Edition, Mosby

Revised Trauma ScoreVentilatory 10 – 29 4Rate > 29 3

6 – 9 2 1 – 5 1 0 0

Systolic BP > 89 476 – 89 350 – 75 2 1 – 49 1 no pulse 0

GCS 13 – 15 4 9 – 12 3 6 – 8 2 4 – 5 1 < 4 0

RTS = Total score

Request

ALS

Complete a detailed physical exam (head to toe survey) as history

dictates

Check for medications carried or medical

alert jewellery

Go to CPG xx

FromCPG xx

Secondary Survey Medical - adultCPG 5a (ii)

Primary Survey

Version D 0.2 P AP

Patient acutely unwell

No

Yes

SAMPLE history

Relevant family & social history

Requires definitive

medical careYes

No

Focused medical history of presenting

complaint

Go toappropriate

CPG


management

Reference: Sanders, M. 2001, Paramedic Textbook 2nd Edition, MosbyGleadle, J. 2003, History and Examination at a glance, Blackwell ScienceRees, JE, 2003, Early Warning Scores, World Anaesthesia Issue 17, Article 10

Request

ALS


alert jewellery

FromCPG xx

Go to CPG xx

Markers identifying acutely unwellCardiac chest painMEWS Score of ≥ 5Acute pain > 5

Examine body systems as appropriate

Record vital signs & GCS

Secondary Survey – Paediatric ( ≤13 years)CPG 5b

Primary Survey

Version D 0.3 P AP

FromCPG xx


Make appropriate contact with patient and or guardian

Use age appropriate language for patient

Identify presenting complaint and exact chronology from the time the

patient was last well

Observe both patient and guardian- do they relate normally to each other- is the guardian calm and not anxious- will patient separate from guardian- does the patient play and interact normally- is the patient distractible

Children and adolescents should always be examined with a

chaperone (usually a parent)

Head to toe examination(toe to head for younger children)

Observing for- pyrexia- rash- pain - tenderness- bruising- wounds- fractures- medical alert jewellery

Report findings as per Child Protection Guidelines to ED staff in a confidential manner

Check for normal patterns of- feeding- toilet- sleeping

Check vital signs

Reference:Miall, Lawrence et al, 2003, Paediatrics at a Glance, Blackwell Publishing

Go toappropriate

CPG


management

If non accidentalinjury or child abuse suspected

Check for current medications

Estimated weightAge x 2 + 9 Kg

Identify patient’s weight

Burns - AdultCPG 6a

Version D 0.6 K

Burn or Scald Cease contact with heat source

Isolatedsuperficial injury

(excluding FHFFP)Yes No

TBSA burn > 10% Yes

Commence local cooling of burn area

Monitor body temperature

Airway management

EMT P

AP

F: faceH: handsF: feet F: flexion pointsP: perineum


Consider humidifiedOxygen therapy

Appropriate history and burn

area ≤ 1%

Yes

No

Request

ALS

Inadequate respirations

Go to CPG A3Yes

NoMinimum 15 minutes cooling of area is recommended

Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114Sanders, M, 2001, Paramedic Textbook 2nd Edition, Mosby

Caution with the elderly, circumferential & electrical burns

Dressing/ covering of burn area

No

Hartmann’s Solution, 1000 mL, IV

> 25% TBSA and or time from

injury to ED > 1 hour

Yes

ConsiderHartmann’s Solution, 500 mL, IV

No

No

Pain > 2/10 Yes Go to CPG 13b Pain > 2/10Yes

Go to CPG xx

Inhalation and or facial injury

Paramedics are authorised to continue the established

infusion in the absence of an Advanced Paramedic or

Doctor during transportation

P


Remove burned clothing (unless stuck) & jewellery

Equipment listAcceptable dressingsBurns jel if < 10% TBSACling filmSterile dressingClean sheet

if > 10% TBSA

ECG & SpO2monitoring

Brush off powder & irrigate chemical burns

Follow local expert direction

Spinal Immobilisation - AdultCPG 7a

TraumaIndications for spinal immobilisation

Dangerous mechanism include;Fall ≥ 1 meter/ 5 stepsAxial load to headMVC > 100 km/hr, rollover or ejectionATV collisionBicycle collisionPedestrian v vehicle

Use clinical judgementIf in doubt, immobilise

Version D 0.4 K P AP

Equipment list

Extrication deviceLong boardVacuum mattressOrthopaedic stretcherRigid cervical collar

Low risk factorsSimple rear end MVC (excluding push into oncoming traffic or hit by bus or truck)No neck or back painAbsence of midline c-spine or back tenderness

Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms

Go to CPG xx

Consider treat & discharge

Immobilisation may not beindicated

Rapid extrication with long board and cervical collar

Patient in sitting position Yes

No

Life Threatening

Yes

No

Consider Vacuum mattress

Remove helmet(if worn)

Yes

Use extrication device

Load onto vacuum mattressor long board

Are all of the factors listed present;GCS = 15Communication effective with patientNo dangerous mechanism, distracting injury or penetrating traumaNo numbness or tingling in extremitiesPresence of low risk factors which allow safe assessment of range of motionPatient voluntarily able to actively rotate neck 45o left & right pain freePatient can walk pain free

Do not forcibly restrain a patient that is combatitive

Apply cervical collar

Isolated limb fracture

Limb Fractures - AdultCPG 8a

Version D 0.5

Consider need for pain relief

Provide manual stabilisation for fractured limb

Expose and examine limb

Check CSMs distal to fracture site

Reposition limb(two attempts)

CSMs intact

Yes

No

Recheck CSMs

Recheck CSMs

Go to CPG 13b

P AP

Apply appropriate

splinting device

Fracture mid shaft of femur

Apply traction splint

Yes No

Equipment list

Traction splintBox splintFrac strapsTriangular bandagesVacuum splintsLong boardOrthopaediac stretcher Dress open fractures

Pre- Hospital Emergency ChildbirthCPG 9a

Query labour

Take SAMPLE history

Patient in labour No

Yes

Birth imminent or travel time too long No

Position mother and prepare equipment for birth

Monitor vital signs and BP

Cord complicationYes

Go to CPG 9b

No

Breech birthYes

Go to CPG 9c

Support baby throughout delivery

Dry baby and check ABCs

Baby stable

Go to CPG 1d No

Clamp & cut cord Clamp cord at 10, 15 & 20 cm from babyCut cord between 15 and 20 cm clamps

Yes

Version D 0.4 K

Wrap baby and present to mother

Mother stable

Go to CPG 4a

No

Yes

If placenta delivers, bring to hospital with mother Reassess

P AP

Yes

No

Consider

Entonox

Contact GP / midwife/ medical team as required by local policy to come to scene or meet en route

If no progress with labour consider transporting patient

Request

ALSEquipment list

Cord ClampsBulb syringeTowelsSurgical glovesSurgical apronGauze swaps 10 x 10 cmUmbilical cord scissorsClinical waste bag

Umbilical Cord ComplicationsCPG 9bVersion D 0.5 K P AP

From CPG 9a

Cord complication

Cord around baby’s neck Prolapsed cord

Oxygen therapy

Attempt to slip the cord over the baby’s head

Successful

Go to CPG 9a

Yes

Clamp cord in two places and cut between both clamps

Ease the cord from around the neck

Cord rupture

Apply additional clamps to cord

Apply direct pressure with sterile dressing

Mother to adopt knee chest position

Hold presenting part off the cord using fingers

AP

Maintain cord temperature and moisture

Consider inserting an indwelling catheter into the bladder and run 500 mL of NaCl into the bladder and clamp catheter

AP

In labour &foetal heart beat

present

Consider

Nifedipine, 20 mg, PO

Contact GP / midwife/ medical team as required by local policy to come to scene or meet en route

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire TindallKatz Z et al, 1988, Management of labor with umbilical cord prolaps: A 5 year study. Obstet. Gynecol. 72(2): 278-281Duley, LMM, 2002, Clinical Guideline No 1(B), Tocolytic Drugs for women in preterm labour, Royal College of Obstetricians and gynaecologists

Request

ALS

No

Yes

No

Pre alert hospital as urgent caesarean section will be required

Breech birthCPG 9c

Version D 0.4 K P AP

From CPG 9a

Breech birth presentation

Oxygen therapy

Mother to adapt the lithotomy position

Support the baby as it emerges –avoid manipulation of the baby’s body

Nape of neck anteriorly visible at

vulva

Yes

No

Rotate baby’s legs in an ark in an upward direction as

contractions occur

Successful delivery after 5

contractionsYes

No

Go to CPG 9a

Place hand in the vagina with palm towards baby’s faceForm a V with fingers on each side of baby’s nose and gently push baby’s head away from vaginal wall

Await arrival of medical assistance

Contact GP / midwife/ medical team as required by local policy to come to scene

Grasp both baby’s ankles in other hand

Place one hand, palm up, onto baby’s face

P

Successful delivery

Yes

No

Go to CPG 9a No

Request

ALS

Consider

Entonox

Cardiac Chest Pain – Acute Coronary SyndromeCPG 10

Version D 0.9 K

Acute Coronary Syndrome

Apply monitoring leads, apply SPO2 monitor

Oxygen therapy

Aspirin 300 mg PO

Acquire & interpret 12 lead ECG

STEMISTEMI = ST elevation MI

Yes No

Primary PCI available within 60 min from 999 call

No

Yes

PCI = Percutaneous Coronary Intervention

Chest Pain

No

Yes

Symptoms ≤ 3 hoursYes No

Notify & transport to Primary PCI

facility

No

Contraindications for thrombolysis

ContraindicationsHaemorrhagic stroke or stroke of unknown origin at any timeIschemic stroke in preceding 6 months Central nervous system damage or neoplasmsRecent major trauma/ surgery/ head injury (within 3 weeks)Gastro-intestinal bleeding within the last monthActive peptic ulcerKnown bleeding disorderOral anticoagulant therapyAortic dissectionTransient ischemic attack in preceding 6 monthsPregnancy within 1 week post partumNon-compressible puncturesTraumatic resuscitationRefractory hypertension (sys BP > 180 mmHg)Advanced liver diseaseInfective endocarditis

Clopidogrel 300 mg PO

Indication for ThrombolysisPatient conscious, coherent and understands therapyPatient consent obtained< 75 yearsMI Symptoms 20 minutes to 6 hoursST elevation > 1 mm in two or more contiguous leads

P AP

Repeat Morphine at not < 2 min intervals if indicated.Max 10 mg

Consider

Morphine 2 mg IV

Cycilizine 50 mg IV slowly

Pain relief effective

No

Tenecteplase< 60 kg 30 mg60 – 70 kg 35 mg70 – 80 kg 40 mg80 – 90 kg 45 mg> 90 kg 50 mg

GTN 0.4 mg SLRepeat prn to max of 1.2 mg SL

Request

ALS

FromCPG xx

Yes

Reference: Reducing the Risk: A Strategic Approach, 2006, The Report of the Task Force on Sudden Cardiac Death

Followed by

Tenecteplase IV

Enoxaparin 30 mg IV

> 25 minutes from ED

Yes

Enoxaparin 1 mg/kg SC

Altered level of consciousness - AdultCPG 11aVersion D 0.5 K APP

V, P or U on AVPU scale

Head injury

Go to CPG xx

Go to CPG xx

Go to CPG xx

Go to CPG xx

AnaphylaxisGo to

CPG xx

Go to CPG xx

Go to CPG xx

Go to CPG xx

Go to CPG 18

Differential Diagnosis

ECG & SpO2 monitoring Calculate GCS

Go to CPG xx

Go to CPG xx

Check temperatureCheck pupillary size & responseCheck for skin rash

Go to CPG xx

Obtain SAMPLE history frompatient, relative or bystander

Check blood glucose

Maintain airway

Consider recovery position


alert jewellery

Go to CPG xx


Drowning

Septic shock

Poison

Glycaemic emergency

Post resuscitation

care

Bradycardia

Seizures

Hypothermia

Taser gun

Blood loss (shock)

Go to CPG 18 Stroke

Mental Health EmergencyCPG 12a

Version D 0.3 P

Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance vehicle

Behaviour abnormal

No

Yes

Reassure patientExplain what is happening at all times

Avoid confrontation

Patient agreesto travelNo

YesRequest- Gardaí- Medical Practitioner- Mental health team

Attempt verbal de-escalation

EMT

Hallucinations or Paranoia

RMP or RPNin attendance or have made arrangements for voluntary/

assisted admission

No

Yes

Transport patient to an Approved Centre

Reference; Reference Guide to the Mental Health Act 2001, Mental Health CommissionHSE Mental Health Services

RMP – Registered Medical PractitionerRPN – Registered Psychiatric Nurse

Request

ALS

Co-operate as appropriate with

medical or nursing team

Obtain a history from patient and or bystanders present as appropriate

No

Potential to harm self or

othersRequest control to inform Gardaí

Yes

If potential to harm self or othersensure minimum two people accompany patient in saloon of ambulance at all times

Behavioural emergencyCPG 12b

Version D 0.3 P

Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance vehicle

Behaviour abnormal

Obtain a history from patient and or bystanders present as appropriate

No

Reassure patientExplain what is happening at all times

Avoid confrontation

Patient agreesto travelNo

Yes

Request control to inform Gardaí and or Doctor

Attempt verbal de-escalation

EMT

Inform patient of potential consequences of treatment

refusal

Injury or illness potentially serious or likely to cause lasting

disability

YesOffer to treat and or

transport patient

No

Advise alternative care options and to call ambulance again if there is a

change of mind

Document refusal of treatment and or transport to ED

Is patient competent to

make informed decision

Yes

No

Await arrival of doctor or Gardaí

or receive implied consent

Treatment only

Yes

No

AP

Aid to Capacity Evaluation1. Patient verbalizes/ communicates understanding of clinical situation?2. Patient verbalizes/ communicates appreciation of applicable risk?3. Patient verbalizes/ communicates ability to make alternative plan of care?If no to any of the above consider Patient Incapacity

Potential to harm self or

othersRequest control to inform Gardaí

Yes

If potential to harm self or othersensure minimum two people accompany patient in saloon of ambulance at all times

Reference: HSE Mental Health Services

Pain management - AdultCPG 13b

Pain

Repeat Morphine at not < 2 min intervals if indicated.Max 10 mg

Analogue Pain Scale0 = no pain……..10 = unbearable


AP

Consider

Morphine, 2 mg, IV

Cycilizine, 50 mg IV slowly

Go back to

originatingCPG

Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale

And or

Paracetamol 1 g PO

Ibuprofen 400 mg PO

< 5 on pain scale

Yes

No

Nitrous Oxide & Oxygen, inhalation

Yes NoAdequate relief of pain

3 to 4 on pain scale -moderate

≥ 5 on pain scale -severe

Pain assessment

No

Request

ALS

If IV not accessible Morphine 10 mg IM

may be administered provided no cardiac chest pain present

AP

Registered Medical Practitioners may authorise the use of IM Morphine by Paramedic or EMT practitioners for patients in inaccessible locations

EMTP

Pain

Analogue Pain Scale0 = no pain……..10 = unbearable


AP

Go back to

originatingCPG

Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale

And or

< 6 on pain scale

Yes

No

Nitrous Oxide & Oxygen, inhalation

Yes NoAdequate relief of pain

2 to 5 on pain scale -moderate

≥ 6 on pain scale -severe

Pain assessment

No

Pain management – Paediatric (≤ 13)CPG 13b

Wong – Baker Faces for 3 years and older

Reference:From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of Paediatric Nursing, ed.6, St. Louis, 2001, p1301. Copyrighted by Mosby, Inc. Reprinted by permission.

Paracetamol 20 mg/kg PO

Ibuprofen 5 mg/kg PO

Consider

Repeat IV Morphine at not < 2 min intervals if indicated Max 0.15 mg/kg IV

Cycilizine, 0.7 mg/kg IV slowly

ORMorphine, 0.05 mg/kg, IV

Morphine, 0.1 mg/kg, PO

Request

ALS

Or

Or

Or

Glycaemic Emergency - AdultCPG 13e

Version D 0.9 K

Blood Glucose< 4 mmol/L

15 to 20 mmol/L

> 20 mmol/L

Glucagon 1 mg IM

Dextrose 10%, 250 mL IV infusionSodium Chloride 0.9% 1 L IV infusion

Reassess

Reassess

NoBlood Glucose > 4 & < 15 mmol/L

Yes

Allow 5 minutes to elapse following administration of

medication

No

P AP

Complete; After care Instructions – Diabetes and give a copy to the patient or carer

Glucose gel, 10-20 g buccal

Patient is fully alert and makes an informed decision

not to attend ED

Yes

Abnormal blood glucose

level


Go to CPG xx

Consider

ALS

Sweetened drink

Glycaemic Emergency – Paediatric (≤ 13)CPG 13e

Version D 0.8 K

Glucagon 0.5 mg IM Dextrose 10%, 5 mL/kg IV bolusRepeat x 1 prn

No Yes

Reassess

Blood Glucose< 3 mmol/L

Sodium Chloride 0.9% 20 mL/kg IV bolus

Yes

> 20 mmol/L

DehydrationNo

Abnormal blood glucose

level

P AP

ConsiderGlucose gel 5-10 g Buccal

Request

ALS

Reference: Dehydration- Paramedic Textbook 2nd E p 1229

Major Emergency (Major Incident) – First ambulance crewCPG 14a


AP



PPE (high visibility jacket and helmet) must be worn

Irish (Major Emergency) terminology in blackUK (Major Incident) terminology in blue

Practitioner 1 Practitioner 2(MIMMS trained)

Park at the scene as safety permits and in liaison with Fire & Garda if present

Leave blue lights on as vehicle acts as Forward Control Point pending the arrival of the Mobile Control Vehicle

Confirm arrival at scene with Ambulance Control and provide an initial visual report stating Major Emergency (Major Incident) Standby or Declared

Maintain communication with Practitioner 2

Leave the ignition keys in place and remain with vehicle

Carry out Communications Officer role until relieved

Carry out scene survey

Give situation report to ambulance control using METHANE message

Carry out HSE Controller of Operations (Ambulance Incident Officer) role until relieved

Liaise with Garda Controller of Operations (Police Incident Officer) and Local Authority Controller of Operations (Fire Incident Officer)

Select location for Holding Area (Ambulance Parking Point)

Set up key areas in conjunction with other Principle Response Agencies on site; - Site Control Point (Ambulance Control Point), - Casualty Clearing Station

METHANE messageM – Major Emergency declaration / standbyE – Exact location of the emergencyT – Type of incident (transport, chemical etc.)H – Hazards present and potentialA – Access / egress routesN – Number of casualties (injured or dead)E – Emergency services present and required

Possible Major Emergency

The first ambulance crew does not provide care or transport of patients as this interferes with their ability to liaise with other services, to assess the scene and to provide continuous information as the incident develops

The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

Major Emergency (Major Incident) – Operational ControlCPG 14b


APIrish (Major Emergency) terminology in blackUK (Major Incident) terminology in blue

Danger Area

Traffic Cordon

Inner Cordon

Outer Cordon

If Danger Area identified entry to Danger Area is controlled by a Senior

Fire Officer or an Garda Síochána

Entry to Outer Cordon (Silver area) is controlled by an Garda Síochána Entry to Inner Cordon (Bronze Area) is

limited to personnel providing emergency care and or rescuePersonal Protective Equipment required

Management structure for; Outer Cordon, Tactical Area (Silver Area)On-Site Co-ordinatorHSE Controller of Operations (Ambulance Incident Officer)Site Medical Officer (Medical Incident Officer)Local Authority Controller of Operations (Fire Incident Officer)Garda Controller of Operations (Police Incident Officer)

Management structure for; Inner Cordon, Operational Area (Bronze Area)Forward Ambulance Incident Officer (Forward Ambulance Incident Officer)Forward Medical Incident Officer (Forward Medical Incident Officer)Fire Service Incident Commander (Forward Fire Incident Officer)Garda Cordon Control Officer (Forward Police Incident Officer)

HSE CONTROLLER

LOCAL AUTHORITY

CONTROLLERGARDA

CONTROLLER

Casualty Clearing Station

Ambulance Loading

Point

Body Holding

Area HSE Holding

Area

Garda Holding

Area

LA Holding

Area

Site Control Point

Ref; A Framework for Major Emergency Management, 2006, Inter-Departmental Committee on Major Emergencies (Replaced by National steering Group on Major Emergency Management)


Other management functions for; Major Emergency siteCasualty Clearing OfficerTriage OfficerAmbulance Parking Point OfficerAmbulance Loading Point OfficerCommunications OfficerSafety Officer

One way ambulance circuit

Triage SieveCPG 14c

P

AP

EMT

Multiple casualty incident

Triage is a dynamic process

Version D 0.5 K

Can casualty walk

Is casualty breathing

Breathing now

Open airwayone attempt

Respiratory rate< 10 or > 29

Capillary refill > 2 secOr

Pulse > 120

No

NoYes

No

Priority 3(Delayed)

GREEN

Yes

DEADNo

Yes

Priority 1(Immediate)

RED

Yes

Yes

Priority 2(Urgent)

YELLOW

No


Triage SortCPG 14d P AP

Multiple casualty incident

10 – 29 / min> 29 / min6 – 9 / min1 – 5 / min

None≥ 90 mm Hg

76 – 89 mm Hg50 – 75 mm Hg1 – 49 mm Hg

No BP

Respiratory Rate

Systolic Blood Pressure

4321043210

Measured valueCardiopulmonary function Score

13 – 159 – 126 – 84 – 5

3

Glasgow Coma Score

43210

A

B

Insert score

C

Triage Revised Trauma Score A+B+C

RevisedTrauma Score

1 - 10

11

12

0

Triage is a dynamic process

Version D 0.4 K


SpontaneousTo VoiceTo PainNone

OrientedConfusedInappropriate wordsIncomprehensible sounds

Obeys commandsLocalises painWithdraw (pain)Flexion (pain)Extension (pain)None

4321

54321

654321

Eye Opening

Verbal Response

Motor Response

Glasgow Coma Score

Priority 3(Delayed)

GREEN

DEAD

Priority 1(Immediate)

RED

Priority 2(Urgent)

YELLOW

EpistaxisCPG 16

Version D 0.3 K P

AP

Medical

Apply digital pressure for 3 to 5 minutes

HypovolaemicYesGo to CPG xx

Advise patient to sit forward

Trauma From CPG 4a

Advise patient to breath through mouth only and not

to blow nose

EMT

FromCPG 4a

No

Haemorrhage controlledNo

Yes

Request

ALS

Consider

ALS

Version D 0.7 K Poisons - AdultCPG 17a

PEMT

Poison source

Ingestion Inhalation

CorrosiveYes

Sips of water or milk

Go to CPG A3

AbsorptionInjection

No

No Site burns

Cool area

YesNo

Yes

Poison type

Paraquat Other

Do not give oxygen

Adequate ventilations

Consider

Oxygen therapy

Request

ALS

FromCPG xx

Reference:Dr, Joe Tracey, Director, National Poison Information Centre

Consider decontamination prior to transportation

Caution with oral intake

Note:CPG A3, Inadequate respirations, authorises the administration of Naloxone IM for opiate overdose for Paramedics

Alcohol

Check blood glucose

NoBG

> 4 or > 15 mmol/L

Go to CPG xxYes

P

Version D 0.5 K APP

Positive FAST assessment

Yes

Oxygen therapy

Onset < 3 hours

SpecialisedStroke Unit available

Yes

No

No

No

Transport patient to hospital with

Specialised Stroke Unit (under local protocol)

Yes

Maintain airway

ReferenceProf R Boyle, 2006, Mending hearts and brains, Clinical case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHSAHA, 2005, Part 9 Adult Stroke, Circulation 2005; 112; 111-120A. Mohd Nor, et al, Agreement between ambulance paramedic- and physician- recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients, Stroke 004; 35;1355-1359Jeffrey L Saver, et al, Prehospital neuroprotective therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG) pilot trial, Stroke 2004; 35; 106-108

12 lead ECG

Obtain GCS

ECG & SPO2monitoring

Check blood glucose

StrokeCPG 18

acute neurolocical symptoms

F – facial weakness Can the patient smile?, Has their mouth or eye drooped? Which side?A – arm weakness Can the patient raise both arms and maintain for 5 seconds?S – speech problems Can the patient speak clearly and understand what you say?T – time to transport now if positive FAST

BG > 4 or > 15

mmol/L

Go to CPG xx Yes

No

Version D 0.5Post Resuscitation Care - Adult

CPG 19 AP

Return of Spontaneous

Circulation

Conscious Yes

No

Adequate ventilation

Yes

No

Ventilate at 10 to 12 per minute

Commence active cooling to target temperature of 32o C

Cold packs to arm pits, abdomen & groin

NaCl (4o C) 500 mL IVRepeat x 1 if required

Check blood glucose

Transport quietly and smoothly

P

Maintain patient at rest

Monitor vital signs

12 lead ECG

Equipment list

Low reading thermometerCold packs

Reference: ILCOR Guidelines 2005AHA Guidelines 2005, Part 7.5 Postresuscitation Support

Maintain Oxygen therapy



If Amiodarone used to convert VF/VT and persistent tachyarrhythmia Consider

Amiodarone, 1 mg/min, IV infusion

500 mL / 300 mg Amiodarone = 1.7 1 mg = 1.7 mL

IV giving set; X gtt = 1 mL X gtt x 1.7 mL = 1 mg/ min

NoYes

Atropine 0.5 mg IV

Symptomatic bradycardia

Monitor blood pressure and GCS

Request

ALS

Post VF/VT and unresponsive

Yes

No



Post Partum HaemorrhageCPG 20 P AP

2nd stage of labour complete

Mother is haemodynamically

unstableYes No

Oxygen therapy

External massage of the uterus

Syntometrine, 1 mL IM(if not already administered)

Version D 0.4 K

Go to CPG A13

Elevate lower limbs

Reassess

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

Check/ ask mother re multiple births prior to

administration of Syntometrine

Estimate blood loss

Request

ALS

Consider inserting a urinary

catheter

AP

Apply absorbent pad to perineum area

Haemorrhage in pregnancy prior to deliveryCPG 21

P APVersion D 0.3 K

Pregnancy ≥ 24 weeksAnti partum

haemorrhage

Patient is haemodynamically

unstableYes No

Go to CPG A13

Left lateral tilt

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

Apply absorbent pad to perineum area

Reassess

Request

ALS

Query pregnant< 24 weeks

Early pregnancy haemorrhage

Do not examine abdomen or vagina

Oxygen therapy

Version D 0.5 Conducted Electrical Weapon (Taser)CPG 25 APP

Taser gun used

Prior to touching the patient ensure that the Garda has disconnected the wires from the hand held unit

Cut wire connection proximal to barbs

Complete primary survey

Remove barbsClean and dress wounds

Go to appropriate

CPG

Patient care takes precedent over removal of barb

Barbs shall not be removed if they are embedded in the face, eye, neck, or groin

Monitor ECG & SpO2for minimum 15 minutes

Behavioural emergency

Go to appropriate

CPGYes

No

Reference:DSAC Sub-committee on the Medical Implications of Less-lethal Weapons 2004, Second statement on the medical implications of the use of the M26 Advanced Taser.United States Government Accountability Office, 2005, The use of Taser by selected law enforcement agenciesManitoba health Emergency Medical Services, 2007 Taser Dart Removal ProtocolAda County Paramedics, Idaho 2006 Taser Protocol

ConsiderOxygen therapy

Ensure Garda accompany patient at all times

Note:This CPG was developed in conjunction with Dr. Donal Collins, Chief Medical Officer, An Garda Síochána

Monitor GCS, temperature & vital signs

Monitor for signs of Excited Delirium

Head injury - AdultCPG 27

Head trauma

GCS < 12Yes No

Version D 0.2


P AP

Equipment list

Extrication deviceLong boardVacuum mattressOrthopaedic stretcherRigid cervical collarOxygen saturation monitor

LoC history No

Maintain Airway(Consider Advanced airway)

SeeCPG xx

Oxygen therapy

SpO2 & ECG monitoring


Transport to most appropriate ED according to

local protocol

SeeCPG xx

SeizuresGo to CPG xx

Yes

Secure to long board

Yes

No

Request

ALS

No

Blood glucose level < 4 mmol/L

Reference;Mc Swain, N, 2003, Pre Hospital Trauma Life Support 5th Edition, Mosby

GCS ≤ 8

10o head tilt

Yes

Control external haemorrhage

Maintain SBP > 120 mmHgSeeCPG xx

Consider cervical collar application

and long board use

Maintain in-line immobilisation

Revert to basic airway management

Advanced Airway Management - AdultCPG A1

Version D 0.6 K

Apnoea or special clinical considerations

Able to ventilate

Go to CPG 2a

Position for intubation restricted

Yes

Endotracheal intubation

No

Successful Yes

No

Successful Yes

No

2nd attempt Endotracheal

intubation

Successful YesNo

Successful Yes

No

Ensure CO2 detection device in ventilation

circuit

Continue ventilation and oxygenation

Check tube placement after each patient movement or if any patient

deterioration

Yes

No

P AP

AP

AP

Laryngeal Mask Airway or Laryngeal tube insertion

2nd attempt Laryngeal Mask Airway or Laryngeal tube insertion

Go to appropriate

CPG

Reference: International Liaison Committee on Resuscitation, 2005, Part 4: Advanced life support, Resuscitation (2005) 67, 213 – 247

Special clinical considerationsGCS = 3SpO2 < 92%RR ≤ 9BVM ineffective(All of the above must be present)

Maintain adequate ventilation and oxygenation throughout procedures

Consider

Inadequate Respirations – AdultCPG A3

Version D 0.10 K

Congestion / crepitations

Hx of CHF and features of pulmonary

oedema

Yes

GTN, 0.8 mg, SLRepeat x 1 prn

No

Frusemide, 40 mg, IV

Reassess

P AP

Silent chest, < 2 words per

breath or SpO2< 92%

Yes

Magnesium Sulphate 1.5 g IV infusion over 20 min

No


Assess and maintain airway

Oxygen therapy

OR

Salbutamol, 5 mg, nebuleRepeat x 1 at 15 minutes prn

Bronchospasm assessment

Mild /Moderate(2)

Severe(1)

Salbutamol, 4 puffs, metered aerosol

Repeat x 1 at 15 minutes prn

Salbutamol, 5 mg, nebuleRepeat x 1 at 15 minutes prn

Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline

Request

ALS

GCS = 3SpO2 < 92%

BVM ineffectiveRR ≤ 9

Yes

Life threatening asthmaAny one of the following in a patient with severe asthma;PEF < 33% best or predictedSpO2 < 92%Silent chestCyanosisFeeble respiratory effortBradycardiaArrhythmiaHypotensionExhaustionConfusionUnresponsive

Acute severe asthma (1)Any one of;PEF 33-50% best or predictedRespiratory rate ≥ 25/ minHeart rate ≥ 110/ minInability to complete sentences in one breath

Moderate asthma exacerbation (2)Increasing symptomsPEF > 50-75% best or predictedNo features of acute severe asthma

Respiratory assessment

Go to CPG xx

Consider


No

Inadequate rate or depthAsymmetrical movement

No

Tension Pneumothorax

suspected

Needle decompression

Yes

AP

No

Possible Hx of Narcotic overdose

Yes

Naloxone 0.4 mg IMRepeat x one prn

Naloxone 0.4 mg IV/IO/IMRepeat x one prn

Positive pressure ventilationsMax 10 per minute

Reassess

Symptomatic Bradycardia - AdultCPG A8

Version D 0.5 K P

AP

EMT

Symptomatic Bradycardia

Type II 2nd degree AV block or

3rd degree AV blockexcluded

Yes

Atropine, 0.5 mg IVRepeat at 3 to 5 min intervals prn to max 3 mg

Oxygen therapy


No

Request

ALS

12 lead ECGP

Atropine, 0.5 mg IV

Reassess

Version D 0.2 Septic Shock – Paediatric (≤ 13)CPG A54(ii) P AP

Septic shock

Oxygen therapy

Hartmann’s Solution 20 mL/kg IV/IO

Meningoccal disease

suspectedYes

No

Hartmann’s Solution, 20 mL/kg IV/IO aliquots to maintain palpable brachial pulse *

Benzylpenicillin IV/IO over 3 to 5 minutes or IM< 1 year 300 mg1 – 8 years 600 mg> 8 years 1 200 mg (1.2 g)

Request

ALS




P

* Radial pulse in older children

ECG & SpO2 monitoring

Check medication

with meningitis Foundation

Version D 0.2Shock from Blood Loss – Paediatric (≤ 13)

CPG A54(i) P AP

Haemorrhalogic shock

Patient trapped No

Yes

Oxygen therapy

Hartmann’s Solution 20 mL/kg IV/IO

Hartmann’s Solution, 20 mL/kg IV/IO aliquots to maintain palpable brachial pulse *

Continue fluid therapy until handover at ED




P

Request

ALS

Reference:American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Prefessionals, Jones and Bartlett.


Reassess

* Radial pulse in older children

Consider

Consider

Inadequate Respirations – Paediatric (≤ 13)CPG A56

Version D 0.4

Inadequate rate or depthAsymmetrical movement

No

P AP

Silent chest, < 2 words per breath, cannot feed or SpO2

< 92%

Yes

Ipratropium bromide 0.250 mg nebule & salbutamol (age

specific dose) nebule mixed

No


Assess and maintain airway

Oxygen therapy

ChestAuscultation

Regard each emergency asthma call as for acute severe asthma until it is shown otherwise

OR

Salbutamol < 5 years 2.5 mg nebule≥ 5 years 5 mg nebule

Repeat at 15 minutes prn

Bronchospasm assessment

Severe

Salbutamol, 2 puffs, metered aerosol


Mild /Moderate

Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline

Request

ALS

Tension Pneumothorax

suspected

Needle decompression

Yes

AP

No


Salbutamol < 5 years 2.5 mg nebule≥ 5 years 5 mg nebule


Life threatening asthmaAny one of the following in a patient with severe asthma;Silent chestCyanosisPoor respiratory effortHypotensionExhaustionConfusionUnresponsive

Acute severe asthmaAny one of;Inability to complete sentences in one breath or too breathless to talk or feedRespiratory rate > 30/ min for > 5 years old

> 50/ min for 2 to 5 years old

Heart rate > 120/ min for > 5 years old> 130/ min for 2 to 5 years old

Possible Hx of Narcotic overdose

Yes

Naloxone 0.01 mg/kg, IMRepeat x one prn

Naloxone 0.01 mg/kg, IV/IO/IMRepeat x one prn

Positive pressure ventilations– 12 to 20 per minute

Reassess

Assess & maintain airway

Humidified O2 – as high a concentration as tolerated

Do not distressTravel in position of comfort


Stridor – Paediatric (≤ 13)CPG 27

Version D 0.1 P

AP

EMT

Stridor

Oxygen therapy

Epinephrine administered pre arrival? (within 5

minutes)

Reoccurs / deteriorates /

no improvement

No

Deteriorates

Yes

No

Yes

No

Yes

Version D 0.4 KAnaphylaxis - Adult

CPG – A4

Moderate Severe

Epinephrine (1:1 000) 0.5 mg (500 mcg) IMRepeat at 5 minute intervals if no improvement

If bronchospasm consider nebulizer

Epinephrine (1:1 000) 0.5 mg (500 mcg) IM

Hartmann’s Solution 1 000 mL IV infusion

Repeat Hartmann’s Solution 1 000 mL IV infusion X 1 if indicated

Reassess

Salbutamol 5 mg nebule



Reassess

P AP

Request

ALS

AnaphylaxisOxygen therapy

Reassess

Mild

Monitor reaction

Mild anaphylaxisUrticaria and or angio oedema

Moderate anaphylaxisMild symptoms + simple bronchospasm

Severe anaphylaxisModerate symptoms + haemodynamic and or respiratory compromise

ECG & SpO2monitor

ECG & SpO2monitor

Request

ALS

Epinephrine administered pre arrival? (within 5

minutes)

No

Yes

Version D 0.6 K

Moderate Severe

P AP

Request

ALS

AnaphylaxisOxygen therapy

Mild

Monitor reaction

Anaphylaxis – Paediatric (≤ 13 years)CPG – A55

Epinephrine (1:1 000) IM< 6 months: 0.05 mg (50 mcg) IM6 months to 5 years: 0.125 mg (125 mcg) IM6 to 8 years: 0.25 mg (250 mcg) IM> 8 years: 0.5 mg (500 mcg) IM

Repeat Epinephrine at 5 minute intervals if no improvement

Hartmann’s Solution 20 mL/kg IV/IO bolus

Repeat Hartmann’s Solution 20 mL/kg IV/IO bolus X 1 if indicated

Epinephrine (1:1 000) IMSee age related doses above

Reoccurs / deteriorates /

no improvement

Deteriorates

No

Yes

Yes


Reassess

Salbutamol nebule< 5 yrs: 2.5 mg≥ 5 yrs: 5 mg


Salbutamol nebuleSee age related doses above

Reassess

No

Reassess

Mild anaphylaxisUrticaria and or angio oedema

Moderate anaphylaxisMild symptoms + simple bronchospasm

Severe anaphylaxisModerate symptoms + haemodynamic and or respiratory compromise

ECG & SpO2monitor

ECG & SpO2monitor

Inform rescue leader that the patient must not be released until IV fluids have commenced

Large bore x 2

Crush InjuryCPG 26

Version D 0.2 P AP

Patient trapped

Significant compression force

maintained NoCo-ordinate with

rescue personnel on release timing

NaCl 0.9% 20 mL/kg IV

Consider pain relief

Go to CPG xx


Prepare all required patient carrying devices and have on standby following extrication

Apply standard trauma care during and post extrication

Go to appropriate

CPG

Maintain AcBC

Oxygen therapy

Request

ALS

Reference:Crush Injury Syndrome (# 7102) Patient Care Policy, Alameda County EMS Agency (CA)Crush Injuries, Clinical Practice Manual, Queensland Ambulance Service

Consider Mobile Surgical Team (for amputation)

Yes

Version D 0.7 HypothermiaCPG 23

P

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human KineticsAHA, 2005, Part 10.4: Hypothermia, Circulation 2005:112;136-138Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170Pennington M, et al, 1994, Wilderness EMT, Wilderness EMS Institute

EMT

Query hypothermia

Immersion Yes

NoRemove patient horizontally from liquid

(Provided it is save to do so)

Protect patient from wind chill

Complete primary survey(Commence CPR if appropriate)

Remove wet clothing by cutting

Place patient in dry blankets/ sleeping bag with outer layer of insulation

Mild(Responsive)

Equipment list

Survival bagSpace blanketWarm air rebreather

Request

ALS

Moderate/ severe(Unresponsive)

Hypothermic patients should be handled gently & not permitted to walk

Pulse check for 30 to 45 seconds

Oxygen therapy Warmed O2if possible

Give hot sweet drinks

Members of rescue teams should have a clinical leader of at least EFR level

Hot packs to armpits & groin

Transport in head down positionHelicoptor: head forwardBoat: head aft

Check blood glucose


If Cardiac arrest follow CPGs but- no active re-warming

Seizure / convulsions – AdultCPG – A 11

Version D 0.8 K

Seizure / convulsion

Or

Diazepam, 10 mg PRRepeat by one prn Diazepam 5 mg IV

Repeat by one prn

No Yes

Seizure statusSeizing currently Post seizure

Check blood glucose

Patient is fully alert and makes an informed decision

not to attend EDNo

Protect from harm

Oxygen therapy

Anti convulsant medication

administered

No

Yes

Blood glucose < 4 or > 15 mmol/LYes

No

Go to CPG 13e

P AP

Midazolam 10 mg buccal

The patient;was not seizing on arrival

has history of seizureshas no injury

No

Yes

Consider other causes of seizures

MeningitisHead injuryHypoglycaemiaEclampsiaFever

Request

ALS

Reassess

Consider treat & discharge YesGo to

CPG xx

MAG decision requiredInternasal Midazolam?

Seizure / convulsions – Paediatric (≤ 13)CPG – A 57

Version D 0.11 K

Seizure / convulsion

Or

Diazepam PR< 3 years: 2.5 mg PR≥ 3 years: 5 mg PR

Repeat by one prn Diazepam 0.2 mg/kg IVRepeat by one prn

No Yes

Seizure statusSeizing currently Post seizure

Check blood glucose

Consider

Or

Paracetamol PR< 1 year: 60 mg PR1 – 3 years: 180 mg PR4 – 8 years: 360 mg PR

If pyrexial – cool child

Protect from harm

Oxygen therapy

Paracetamol, 20 mg/kg, PO

Blood glucose < 3 or > 20 mmol/LYes

No

Go to CPG 13e

P AP

Midazolam 0.5 mg/kg buccal

Request

ALS

Reassess

MAG decision requiredInternasal Midazolam?

Consider other causes of seizures

MeningitisHead injuryHypoglycaemiaEclampsiaFever

Symptomatic Bradycardia – PaediatricCPG A52

Version D 0.4 K P

AP

Symptomatic Bradycardia

Persistent bradycardia

Yes

Oxygen therapy

No

EMT

CPR

Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IOEvery 3 – 5 min prn

Continue CPR

Signs of poor perfusionUnresponsive or drowsyCold peripheriesDelayed capillary refill


if prolonged CPR

AP


Reference: International Liaison Committee on Resuscitation, 2005, Part 6: Paediatric basic and advanced life support, Resuscitation (2005) 67, 271 – 291

Ventilate

HR < 60

Yes

Hartmann’s Solution 20 mL/Kg IV/IO

No

Request

ALS

Reassess


AP

Version D 0.2 KShock from Blood Loss – Adult

CPG A13 (i) P AP

Hypovolaemia

Patient trapped No

Yes

Oxygen therapy

Hartmann’s Solution 500 mL IV

TraumaYes No

Head injury with GCS ≤ 8Yes No

Hartmann’s Solution, 250 mL IV aliquots to maintain SBP 120 mmHg

Hartmann’s Solution, 250 mL IV aliquots to maintain palpable radial

pulse (SBP 90 - 100 mmHg)






P

Request

ALS

Version D 0.3 K Septic Shock – AdultCPG A13 (ii) P AP

Hypovolaemia

Oxygen therapy


Meningitis suspected Yes

No


Benzylpenicillin, 1 200 mg IV/IMover 3 to 5 minutes

Request

ALS




P

Ensure appropriate PPE worn;Mask and goggles


Version D 0.5 K External Haemorrhage - AdultCPG 15a P

APOpen wound

Blood still flowing

No

Yes

PostureElevation

ExaminationPressure

Apply sterile dressing

Small superficial

wound

Significant blood loss

No

Yes

Advise to clean wound with soap & water and apply

fresh dressing

Yes

Go to CPG A13

EMT

Isolated wound& no relevant medical

historyNo

Yes

No

Haemorrhage controlled

No

Yes Apply additional dressing(s)

Haemorrhage controlledYes

No

Depress proximal pressure point

P


No

Apply tourniquetP


Go to CPG xx

EMT


Version D 0.5 K External Haemorrhage – Paediatric (≤13 years)CPG 15b P

APOpen wound

Blood still flowing?

No

Yes

PostureElevation

ExaminationPressure

Apply sterile dressing

EMT

Haemorrhage controlled

No

Yes Apply additional dressing(s)


No

Depress proximal pressure point

P


No

Apply tourniquetP

Small superficial

wound

Significant blood loss

No

Yes

Advise to clean wound with soap & water and apply

fresh dressing

Yes

Isolated wound& no relevant medical

historyNo

Yes

No


Go to CPG xx

Go to CPG A13

EMT


Treat & Discharge MedicalCPG 25 (i) APVersion D 0.2

FromCPG xx

Satisfactory treatment of

clinical condition

Zero on MEWS ScoreNo

Yes

Discharge into care of competent

person

Hypoglycaemia Seizure

Clinical impression

History of seizures

Yes

No

Patient competentor carer takes responsibility

Yes

No

No to any

If a patient expresses a wish to attend an Emergency Department then arrangements shall be made to transport him/her there

Aid to Capacity EvaluationPatient verbalizes/ communicates;1. understanding of clinical situation?2. appreciation of applicable risk?3. ability to make alternative plan of care?If no to any of the above consider Patient Incapacity

Yes to any

No to all

Reference: British Thoracic Society, 2005, British Guidelines on the Management of Acute AsthmaC O’Donnell, 2007, Hypoglycaemia Treat and Discharge Protocol

Complete; After care Instructions and give a copy to the patient or carer

P

Confirm the following;1. History of diabetes2. Latest blood glucose > 4.53. > 30 days since last episode

Confirm the following;1. On oral hypoglycaemics2. Glucagon administered

Yes to all

Yes to any

No to all

Confirm the following;1. Multiple seizures this episode2. Received Anticonvulsant3. In postictal state

Treat & Discharge - TraumaCPG 25 (ii) APVersion D 0.3

Minor injuryFromCPG xx

Yes to any

Closed wound Open woundBurn / scald

Injury type

No to all

Superficial Haematoma

Yes

No

Yes to any

No to all

Yes to any

P

If a patient expresses a wish to attend an Emergency Department then arrangements shall be made to transport him/her there

PatientCompetent orcarer takes

responsibility

Discharge into care of competent

person

No

Yes

Aid to Capacity EvaluationPatient verbalizes/ communicates;1. understanding of clinical situation?2. appreciation of applicable risk?3. ability to make alternative plan of care?If no to any of the above consider Patient Incapacity

Injury assessment;1. LoC experienced2. Joint mobility reduced3. CSMs not intact4. Pain score > 2/10

Zero on MEWS Score

Yes

No to all

Open wound assessment;1. Haemorrhage uncontrolled2. Punctured wound3. Suture(s) required4. Foreign body imbedded5. Wound requires debriding

Burn/ scald assessment;1. Skin broken2. Circumferential injury3. TBSA > 1%

No

Complete; After care Instructions and give a copy to the patient or carer

Spinal Immobilisation – Paediatric (≤ 13 years)CPG 7a (i)Version D 0.4 AP

Equipment listExtrication deviceLong boardPaediatric boardVacuum mattressOrthopaedic stretcherRigid cervical collar

Note: equipment must be age appropriate

TraumaIndications for spinal immobilisation

Immobilisation may not beindicated

Use clinical judgementIf in doubt, immobilise

Rapid extrication with long board/ peidi board and

cervical collar

Patient in sitting position Yes

No

Life Threatening

Yes

No


Remove helmet(if worn)

Low risk factorsSimple rear end MVC (excluding push into oncoming traffic or hit by bus or truck)No neck or back painAbsence of midline c-spine or back tenderness

Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms

Yes

Use extrication device

Patient in undamaged child seat

Load onto vacuum mattress, pedi board or long board

Yes

Immobilise in child seat

No

References;Viccellio, P, et al, 2001, A Prospective Multicentre Study of Cervical Spine Injury in Children, Pediatrics vol 108, e20Slack, S. & Clancy, M, 2004, Clearing the cervical spine of paediatric trauma patients, EMJ 21; 189-193

Paediatric spinal injury indicationsPedestrian v autoPassenger in high speed vehicle collisionEjection from vehicleSports/ playground injuriesFalls from a heightAxial load to head

Are all of the factors listed present;GCS = 15Communication effective with patientNo dangerous mechanism, distracting injury or penetrating traumaNo numbness or tingling in extremitiesPresence of low risk factors which allow safe assessment of range of motionPatient voluntarily able to actively rotate neck 45o left & right pain freePatient can walk pain free

Do not forcibly restrain a paediatric patient that is combatitive

P


Version D 0.2 Submersion incidentCPG 22

P

APSubmerged

in liquidRemove patient from liquid(Provided it is safe to do so)


Go to CPG xxYes

No

Oxygen therapy

SPO2 & ECG monitoring

Indicationsof respiratory

distressYes

Monitor Pulse, Respirations & BP

No

Patient is hypothermic Yes Go to

CPG xx

No

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human KineticsVerie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htmShepherd, S, 2005, Submersion Injury, Near Drowning, E Medicine, www.emedicine.com/emerg/topic744.htm AHA, 2005, Part 10.3: Drowning, Circulation 2005:112;133-135 Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances,Resuscitation (2005) 6751, S135-S170

Remove horizontally if possible(consider C-spine injury)

Do not delay on siteContinue algorithm en route

If bronchospasm consider


Check blood glucose

EMT

Complete primary survey(Commence CPR if appropriate)

Request

ALS

Spinal injury indicatorsHistory of;- diving- trauma- water slide use- alcohol intoxication

Ventilations may be commenced while the patient is still in water by trained rescuers

Transport to ED for investigation of secondary drowning insult

Higher pressure may be required for ventilation because of poor compliance resulting from pulmonary oedema

Decompression Illness (DCI)CPG 24

Version D 0.2 EMT P

APSCUBA diving

within 48 hoursComplete primary survey

(Commence CPR if appropriate)

Treat in supine position

100% O2

Oxygen therapy

Conscious No

Yes

Pain relief requiredYesGo to

CPG xxEntonox absolute contraindicated

No

Reference: The Primary Clinical Care Manual 3rd Edition, 2003, Queensland Health and the Royal flying doctor Service (Queensland Section)

Monitor ECG & SpO2


Transport is completed at an altitude of < 300 meters above incident site or aircraft pressurised equivalent to sea level

Request

ALS

Notify control of query DCI & alerthyperbaric unit

Maintain airway

Consider diving buddy as possible patient also

Transport dive computer and diving equipment with patient, if possible

Burns – Paediatric (≤13 years)CPG 6a (i)

Version D 0.4 K

Burn or Scald Cease contact with heat source

Isolatedsuperficial injury

(excluding FHFFP)Yes No

TBSA burn > 5% Yes


Monitor body temperature

Airway management

EMT P

AP

F: faceH: handsF: feet F: flexion pointsP: perineum


Consider humidifiedOxygen therapy

Appropriate history and burn

area ≤ 1%

Yes

No

Request

ALS


Go to CPG xxYes

No

Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114Sanders, M, 2001, Paramedic Textbook 2nd Edition, MosbyAmerican Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals, Jones & Bartlett

Caution with the very young, circumferential & electrical burns


No

Hartmann’s Solution IV10 – 14 years = 500 mL5 – 10 years = 250 mL

> 10% TBSA and or time from

injury to ED > 1 hour

Yes

No

No

Pain > 2/10 Yes Go to CPG 13b Pain > 2/10Yes

Go to CPG xx

Inhalation and or facial injury




P


Brush off powder & irrigate chemical burns

Follow local expert direction

Minimum 15 minutes cooling of area is recommended

Equipment listAcceptable dressingsBurns jel if < 10% TBSACling filmSterile dressingClean sheet

if > 10% TBSA

Remove burned clothing (unless stuck) & jewellery



AP

Documents

Paramedic CPGs December 07