CPG Review

Question 1

What is the adult dose of anaphylaxis? What is the repeat timeframe?

What does adrenaline come in?

How would you give the drug?

Answer 1

1. 10 microg per kilo up to a maximum of 500 microg. Repeat 5 minutely.
   eg. 40 kilo would be 400 microg.
2. Adrenaline comes as 1 in 1000 - 1mg in 1 ml
3. The drug is given neat.

Question 2

The dose for anaphylaxis for a 3 month old baby, is 50 microg. Explain how you would give this drug?

Answer 2

Draw up 9 ml of saline. Draw up 1000 microg in 1 ml solution of adrenaline. Now diluted, you have 100 microg per ml.

Get a second 1 ml syringe with a drawing needle. Draw up 100 microg in 1 ml. This makes 10 microg per ml.

Give a dose of .5 ml

Question 3

A patient has a mild oe moderate response to an allergen, the symptoms are:

• Skin rash
• Local allergic reaction

What is the appropriate treatment?

Answer 3

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Fexofenadine 180 mg orally
3. Transport if required.

Question 4

What is included in universal care and life support?

Answer 4

Primary Phase:

DRABC + S (send for help = Call for backup) + D (disability = AVPU) + E (exposure)

D - Danger

R- Response

** Control any life threatening haemorrhage immediately.

A- Airway -> Look for obvious obstructions, listen for evidence of airway compromise (Snorus respirations ect)

Correct immediately using:

• Posture
• Manual manouvres (head tilt, chin lift, jaw thrust).
• Suction
• Forceps + Laringoscope if indicated
• Airway devices with consideration of GCS / Gag reflex for aspiration risk.

B - Breathing -> Assess rate, assess WOB, asses depth of respiration. Ausciltate.

• Correct with posture, supplemental 02, PPV if indicated.

C -

• Check radial, if none, check brachial, if none, check corotid.
  2. Assess cap Refil centrally + Patient colour.

D - Disability

1. Assess patients GCS and note a score.

E - Exposure

1. Exposed the patient to identify injuries and management.
2. Ensure protection from the elements and management of temperature.

Secondary Phase:

• Hx
• Basic observations on call cases. Advanced or specialist observations where clinically indicated.
• Pain score
• Head to toe physical examinatino of any patient with low or high level trauma.
• Physical examination where clinically appropriate in medical presentations.
• Give special consideration to high risk groups (Paeds, barriatrics, non-english speaking patients, geriatric, co-morbid/complex ect.)
• Comply with ACDs, comply with all patient wishes, expecations and cultural norms where it is possible and reasonable to do so.

Question 5

What are the criteria for providing adrenaline in anaphylaxis?

Answer 5

TO be provided:

‘In adults with hypotension, severe bronchospasm, or respiratory distress due to angioedema. ‘

Question 6

What is the treatment protocol for ADULTS with anaphylaxis?

Answer 6

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
   - Call for backup-> ICPs can provide hydrocortisone, as well as adrenaline infusion (acctually harder to control exact dose and often less effective than intramuscular. Intramuscular works well due to enhanced endothelial cell permeability -»enhanced blood flow.
   - Intermittant positive pressure ventiation with slow rates if required (altered concious status, Unable to maintain an airway -> 10 breaths per minute a good starting point -> One breath every 6 seconds).
   - 10 microg per kilo dose of adrenaline IM in the thigh. Maximum dose is 500 microg. Repeat 5 minutely.
   - Note time of drug administration
   - Saline may be provided to ‘maintain adequate blood pressure’. Consider inadequate blood pressure to be a MAP of <65 -70. A fluid challenge would be indicated according to age and health status.
   - NOTIFY the recieving facility.

Question 7

What is the treatment protocol for PEDES with anaphylaxis?

Answer 7

The same as adult anaphylaxis EXCEPT

• Cannot give fluids

Question 8

A patient with ‘cardiogenic pulmonary oedema’ what is the treatment protocol?

Answer 8

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Early clinical support.

*** ICPs can offer: CPAP, GTN infusion (very effective).

• **Oxygen -> consider additional nasal spec on top of
  o2.

***Posture -> Have the patient lean forward and tripod to facilitate breathing

***ECG to assess rate and rhythm. Also to identify potential for cardiac compromise that may underpin the APO episode -> 12 lead is indicated to check for STEMI

2. ALL PRE GTN CHECKS:
   - Sys BP >100 mmHg + adequate concious state
   - No use of erectile dysfunction agents in last 24 - 48 hours —> Cialis (tadalafil), viagra, levitra (vardenafil), sildenafil.
   - Check allergies.
   - Make sure a 12-lead ECG is done to check for ‘adequate rate and rhythmn’ for providing GTN. Rhythmn should not be preload dependent (Rapid AF, SVT, Inferior STEMI, bradycardia, complete heart block (3rd degree, Bigeminy or trigeminy or quadgeminy).
3. Consider GTN 400 microg spray sublingual. Repeated 5 minutes PRN.
4. Note the time of drug administration.
5. Notify recieving hospital + Spine hospital.

Question 9

Which patients should be considered to have COPD?

Answer 9

The following criteria assume COPD:

1. Smoker over 50

WITH

2. History of chronic dyspnoea + exacerbated with mild exertion

OR

3. A chronic cough with sputum production.

Question 10

Should you give oxygen to a patient saturating at 80% who is known to be a c02 retainer?

Answer 10

Yes. ‘adequate oxygenation must be assured (88-92%) even if it leads to acute hypercapnia’.

Question 11

Why is a nuebuliser more effective for COPD patients?

Answer 11

There is no evidence that nebulisers are more effective. However, some patients with severe dysponea may have difficulty using the MDI effectively to achieve drug delivery.

In this case, nebulised medications may facilitate more effective treatment. It is common for severe COPD patients to have their own nebuliser that uses AIR instead of oxygen.

Question 12

What is a big downside to nebs in COPD patients?

Answer 12

We only have an OXYGEN driven nebuliser. This may exacerbate or potentiate acute hypercapnia. For this reason we have to reassess every 6 minutes.

Remove 02 if possible. However if sats remain <88%…we need to continue despite potential for hypercapnia.

Question 13

Every COPD patient should be treated as?

Answer 13

Potentially a C02 retainer, and provided oxygen between 88-92% Sp02 until blood gas analysis is completed.

Question 14

In COPD, what should determine hospital choice?

Answer 14

1. Any patient with a history of admission for respiratory illness should be transported to a spine hospital.
2. Any patient with COPD who is UNSTABLE should be taken to the NEAREST hospital to stabilise the patient.

Question 15

Treatment protocol for patients with moderate to severe COPD

AND

An exacerbation?

Answer 15

1. Seek a patient management plan if available and follow
2. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
3. Titrate oxygen delivery to 88-92% via NASAL cannula.
4. Support - Call for backup in COPD ‘If bronchodilator therapy is ineffective, adequate oxygenation cannot be achieved (02 less than 88-92%), or severe exacerbation of COPD is present’ - Call for ICP backup/CPAP + Rapid transport.

This means backup straight prior to treatment ONLY if the exacerbation is severe. Otherwise, treat, reassess, and then consider backup. CPAP is the primary value add from ICP, however BIPAP is superior and available at hospital.

5. Treatment via spacer + MDI.

• • Prime spacer (1 x 100 microg)
• • Salbutmol (1 puff (100 microg) + 4 inhalations) -> Provide full dose of 1200 microg.
• • Provide 8 puffs of ipratropium (20 microg per spray), provide the full dose of 160 microg.
• • Repeat salbutamol 20 minutes OR EARLIER if patient fails to improve. A total of 3 doses max. Do no repeat ipratropium.

6. NEB only to be used where SPACER is ‘Ineffective or the patient is unable to utilise the device to effect’.
7. Neb dose:

• *5 mg salbutamol + 500 microg ipraroptium via oxygen neb
• • Limit oxygen exposure to 6 minutes WHERE POSSIBLE.
• • Nebs of salbutamol + ipratropium given together/repeated every 20 minutes. Up to a maximum of 3 times.
• • Clinicans should be changing back to MDI + Spacer at the earliest opportunity (not oxygen driven).

8. Support - Call for backup in COPD ‘If bronchodilator therapy is ineffective, adequate oxygenation cannot be achieved (02 less than 88-92%), or severe exacerbation of COPD is present’ - Call for ICP backup/CPAP + Rapid transport.
9. Notify

Question 16

When should a neb be used in COPD, what is the adult dose?

Answer 16

1. Use a neb where ‘MDI has been ineffective OR the patient is unable to utilise the device to effect’
2. 5 mg of salbutamol nebulised with 8 litres of oxygen + 500 microg of ipatropium.
3. Limit excess oxygen and reassess every 6 minutes with a focus on Sp02, and the patient effect (hopefully an improvement in WOB).
4. Repeat of salbutamol and ipatropium can be administered every 20 minutes up to a maximum of 3 doses.
5. Change to an MDI at the first opporunity.
6. ‘If bronchodilator therapy is ineffective, adequate oxygenation cannot be achieved (02 less than 88-92%), or severe exacerbation of COPD is present’ - Call for ICP backup/CPAP + Rapid transport

Question 17

Explain fluid protocols for adults in asthma, anaphylaxis, obstructive shock and hypovolemia.

Answer 17

Asthma: Patients only receive fluid in LIFE THREATENING asthma and receive a 500 ml bolus/ fluid challenge. Presumably, more fluids would require a consult if required.

Anaphylaxis: fluid can be provided according to discresion to ‘maintain adequate blood pressure’. This is primarily if they have SYMPTOMS of poor perfusion such as poor cap refill, palor, dizziness ect. Lauren said she would probably start with 100 ml aliquots and reassess.

Obstructive shock and haemorrhagic hypovolaemia: comes under guideline of ‘fluid in medical emergencies’ prior to an arrest. Adults recieve fluid at a rate of discression ONLY until a radial pulse + stable GCS is achieved.

Question 18

How much fluid would you give for neurogenic shock? What is the criteria?

Answer 18

Criteria: For isolated traumatic spinal cord injury with signs and symptoms of neurogenic shock:

1. Aim to maintain normal temperature -> Utilise heat caps, vehicle heater, space blankets + normal blankets.
2. Consider SAAS Medical practitioner liason. Request bearly backup of ICP / Medstar as required.
3. In neurogenic shock we target MAP of 80 mmHg in adults. Administer saline .9% 250 ml aliquots (in patients >25 kg, aliquots should be 10ml per kilo otherwise). A maximum volume of fluid is 20 ml per kilo.
4. In pedes the same saline. 10 ml per kilo, up to a max of 20 ml per kilo. No MAP guidance is specified. Contact EOC medical practitioner for guidance.

Question 19

What is the treatment protocol for crushed patients?

Answer 19

1. Request clinical support + Universal care and life support
2. Remove the object as soon as possible, but only once prepared to manage subsequent hypotension (also consider other factors such as vac mat, ct6, pelvic binder). Hypotension is very rare in crush injuries less than 4-6 hours.
3. Large bore cannula access bilaterally if possible.

Question 20

What differs with pregnant patients as it pertains to hospital choice?

Answer 20

If it is TRAUMA involving a pregnant patient, Flinders is the only hospital that can treat both mum AND bubs. If it is MINOR than LMH is acceptable. Women’s and children’s will not want this patient.

Question 21

What amount of fluid do we give to a brown snake bite, when the patient BP is 80/60, but has a palpable radial pulse and stable GCS?

Answer 21

He may be in haemorrhagic shock, potentially due to DIC. However bending the CPG that far for giving fluid is incorrect. Consult for ECP to ask permission for fluids.

Question 22

Do all patients with head injuries get treated with the ‘severe head injury’ guideline?

Answer 22

No. Only patients with severe head injuries.

A severe head injury is when GCS IS LESS than 10

Question 23

What are key considerations in using hydrogel products in burn cases?

Answer 23

1. Hydrogel should not be used in chemical burns
2. Hydrogel is always a secondary option if running water is not available. Unless it’s an airway burn in which extrication is the priority, and hence hydrogel will be used as a primary cooling option.
3. You can only use hydrogel for 10 minutes on a pede. For an adult it is 20 minutes.
4. Hydrogel products need to be removed before application of cling wrap.
5. After cling wrap is applied, cooling can occur over the top with saline. Reassess temperature.

Question 24

What is the treatment for a patient with signs of airway burn?

Answer 24

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Do not forget as part of basic care -> Allergies, Past medical history, medications.
3. Consider MEDSTAR + ICP.

ICP can offer:

• Enhanced pain relief with ketamine
• Cricothyrotomy
• Escharaotomy (circumferential burns)

Medstar can offer:

• RSI
• Cricothyrotomy

2. Immediate extrication. NEAREST hospital.
3. You can SKIP all cooling for an airway burn. Cooling with burn-aid can occur en-route. Followup with glad wrap - loose. Can continue cooling with saline post glad wrap (over the top)
4. Pain relief - Consider withholding paracetamol if difficulty swallowing. Check swallow. Check BLOOD pressure to see if elligble for fentanyl. Fentanyl given 5 minutely. 50 microg doses likely.
5. Fluids -> calculate park-lands formula. We only give the first 50% of the park-lands total which can be given in the first 8 hours. The CPG Aim is to ‘re-establish and maintain normovolemia’.
6. Monitor for hypothermia. Reassessment of temperature is key.
7. For pedes consider transport to WHS for burns and for adults the RAH is the burn centre.

Question 25

What is park-lands formula?

Answer 25

(Percentage of total burn area x weight) x 4 (it’s x 4 because its 4 ml per kilo). Then divide by 2 for total given in 8 hour period.

Question 26

What hospital is appropriate for burns patients?

Answer 26

1. RAH for adults

2. Women and children for paediatrics and neonates.

Question 27

When would CPR be discontinued early in adults- what circumstances? What would be the minimum time-frame expected?

Answer 27

Consider:

• Pt wishes
• Past medical history + event history
• Cause -> Traumatic cause or persistent aysystole have a worse prognosis.
• Obtain consensus of all clinicians on scene.
• Minimum of 30 mins in all cases, with exclusion of traumatic or persistent aysystole which can be ceased after 10 minutes. These are all in the context of the aforementioned considerations.

Question 28

What are the four ‘simultaneous interventions’ that should be undertaken whilst doing an arrest?

Answer 28

1. Haemorrhage control -> consider pelvic binder, torniquet, Fracture management such as CT6.
2. Control the airway
3. Bilateral chest decompression (only in traumatic arrest).
4. Fluid resuscitation

Question 29

What is the guideline for fluid resuscitation in arrest? MEDICAL?

Answer 29

1. Only give fluid for a suspected HYPOVOLAEMIC or OBSTRUCTIVE cause of arrest.
2. Give in 500 ml aliquots.
3. Up to a max of 20ml/kg.
4. Consult if fluid above 20 ml/kilo needed.

Question 30

What is the guideline for fluid resuscitation in arrest? TRAUMATIC?

Answer 30

1. Can give without any rationale aside from a traumatic cause of arrest
2. No requirement for giving in 500 ml aliquots like in medical.
3. Give a ‘rapid infusion’ up to 20ml/kilo.

+

4. Can give an additional 10ml/kilo ‘if indicated’. Vital signs and clinical assessment suggestive that volume is benefiting the patient.

Question 31

What are the considerations before providing GTN in chest pain or APO?

Answer 31

1. ‘Adequate blood pressure’ ->
   - Consider a MAP above 65.
   - Consider a SBP > 100.
2. Appropriate rate and rhythm
   - Consider rate dependent rhythms such as uncontrolled AF
   - Consider preload dependent rhythms such as inferior infarcts with RV involvement.
3. No use of erectile dysfunction agents (PDE-5 inhibitors) within the last 48 hours.
4. No allergies

Question 32

What are the guidelines for providing lorazapam in mental health patients (Challenging behaviours CPG)?

What is the dose?

In what instance is droperidol or midazolam being provided?

Answer 32

1. Adults (> 16 years of age) can be given Loraz when they are able to cooperate and tolerate oral medication safely. The dose is 1-2mg oral.

‘Exhibit challenging behaviour that may benefit, and is ABLE to COOPERATE with oral medication’.

2. Children (>8 yrs and < 16 yrs old) may be eligible for Loraz with consult. Dose is 1 - 2 mg.
3. In patients in which verbal deescalation has failed, and unable to cooperate with oral medication -> request clinical support for droperidol. EOC clinican may also be engaged where ICP is unavailable.
4. When providing Droperidol.

• Nasal capnogrophy utilised. Trends recorded.
• BP post drug administration
• SAT scores pre and post administration.
• Sp02 trends and readings.

5. Patients under care and control should not be transported to a hospital with a sat score 2+. If lorazapam is unsuccessful and SAT elevated, request clinical support for IM/IV droperidol or IM/IV midazolam. If support unavailable the EOC clinican can be engaged.

Question 33

What is the guideline for treatment of croup?

Answer 33

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

Mild to moderate:

• Oral prednisolone 1 mg / kg up to a max of 50 mg.

*** Comes in: 25 mg per 5 ml

This works out to me 5 mg per ml. (25,000 microg / 5 ml = 5000 microg per ml).

Pedes: 13 kilogram 3 year old with croup. Dose will be 13 mg (1 mg per kilo). Sunrise over sunset. Strength required/stock strength x volume.

eg.

13 mg / 25 mg = .52

.52 * 5 ml = 2.6 ml dose

Check answer by taking dose (2.6 ml) x 5000 microg (prednisalone per ml of solution). eg. 2.6 * 5000 = 1300 microg. This is 13 mg, which is the desired dose.

Severe Respiratory Distress OR life threatening:

• < 6 months = administer 2.5 mg/2.5 ml) adrenaline nebulised. This NEEDS to be made up with 5 ml of saline. REPEAT PRN
• > 6 months = 5 mg/5ml nebulised. Repeat PRN.
• Oral prednisalone at standard 1 mg / kg dose for patients of all paediatric ages.

Question 34

What absent signs indicate declaration of life extinct?

Answer 34

1. No heart sounds - 1 full minute
2. No pulse - 1 full minute
3. No respirations - 1 full minute
4. No pupil reaction to light.

Question 35

When could you declare life extinct without having to meet the vital signs checklist?

Answer 35

1. Resuscitation is not appropriate due to meeting criteria for non-initiation of CPR eg. injuries incompatible with life.

Question 36

If doing a declaration of life extinct case, what needs to be documented on the case card?

Answer 36

1. Nil resps, heart sounds, pulse for one full minute + no pupil reaction.
2. Obvious death (note the circumstances)
3. Time of declaration of life extinct
4. The full name, signature and clinical qualification of the paramedic declaring
5. Document any trauma caused during clinical practice
6. Attach a print out of the ‘case summary’ from attachment of the MRx.
7. Add a signature directly to the hospital copy of the PCR
8. Leave the completed ‘hospital copy’ of the PCR and all clinical notes in the non-transport envelope with the attending SAPOL officer.

Question 37

Lets say a patient has been resuscitated, and ceasing CPR has been initiated. What is the protocol for lines in the patient ect.

Answer 37

1. Leave LMA in place + tube tie
2. Leave IV cannula in place, however remove IV lines and leave bung.
3. Circle in pen sites of transcutaneous procedures, such as failed IV attempts or IM drug administration sites.
4. Where it is not applicable for equipment markings to be left in situ or on the patient (ie. expected death in terminal illness), note the reasons for removal in the PCR.

Question 38

When do you give adrenaline in cardiac arrest? How much? What intervals?

Max dose?

Answer 38

1. Always give adrenaline regardless of shockable or non-shockable rhythm.
2. Give 1 mg IV
3. Interval is first dose ASAP. Second doses given every second round.

Question 39

What does amiodarone come in? When do you give amiodarone in cardiac arrest? How much? What intervals?

Max dose?

Answer 39

1. 150 mg in 3 ml.
2. Dose 300 mg – Slow push over 2 minutes (one cycle)
3. When: Refractory VF or VT (3 cycles of these rhythms).
4. Max dose 450 mg. Unsure if you actually give more however.

Question 40

Managing falls is quite self explanatory. Explain the basics of treatment/assessment?

Answer 40

1. Check for injury/secondary survey
2. Identify reason for falling. Medical vs Mechanical. Identify the TIME they have been on the floor. Identify if there was a head strike or LOC. Check recall of event.
3. Mobility assessment
4. Plan for removing off the floor - Is extrication assistance needed.
5. Basic Care/ Pain relief. Consider need to transport to hospital for pain relief.
6. Move Patient

Question 41

After you have stood or extricated a falls patients, what sort of referral processes ect. carry on from this point?

Answer 41

1. If no CLINICAL or SOCIAL need for transport:
   - For AMBULANT patients complete a falls screening score.

Low risk score = Non-urgent referral
High risk = Urgent referral

2. If the patient was on the ground for more than 1 HOUR. Give patient a pressure injury score ( A BRADEN score).

Follow advice on BRADEN score for steps after that.

Question 42

What fluids should be given for symptomatic dehydration? What is the treatment for dehydration?

Answer 42

If hyperthermia present:

• Remove excessive clothing
• Moisten skin and cool with a fan
• If available apply cold packs to groin and auxilla.
• Fluid: Can only be given in consult with EOC is clinical support unavailable

Question 43

What fluids can be given in Sepsis?

Answer 43

For relative hypovolaemia secondary to sepsis:

• Request clinical support
• If no support available then consult.

Question 44

What are the stepwise treatments of hypoglycemia in adults ?

Answer 44

1. Oral carbs first choice is concious status allows.
2. Glucose gel 15 grams
3. Select from:
   - Glucagon IM 1 mg. Glucagon comes in: 1 international unit – equivalent to 1 mg. Dose: Mix with 1 ml of water. This makes a dose of 1 mg per ml.
   - IV Glucose:
4. Gain IV Access + Flush to ensure patency
5. IV Glucose (10%) titrated to BGL and GCS.
6. 100 ml flush of IV saline following glucose dosage.

Question 45

What is the treatment protocol for pedes with a hypo?

Answer 45

1. Clinical Support
2. Oral carbs first choice is concious status allows.
3. Glucose gel 15 grams
4. Glucagon IM

Glucagon comes in: 1 international unit – equivalent to 1 mg. Dose: Mix with 1 ml of water. This makes a dose of 1 mg per ml.

• <25 kg provide .5 mg IM
• > 25 kg provide 1 mg IM
  5. If glucagon ineffective. Contact EOC clinican for IV glucose.
  6. Establish IV access. Flush to ensure patency
  7. IV Glucose 10% titrated to BGL and GCS.
  8. A 1 ml per kilo flush of saline following glucose.

Question 46

Can you leave a hypo patient at home? What would be the process?

Answer 46

1. Yes
   - Full neurological function restored
   - Complex carbs have been consumed
   - BGL within normal limits AND
   - has previously been a stable diabetic AND
   - and identifiable cause was identified

AND

• The patient resides in a suitable stable environment (think friends or family at home to monitor).

Question 47

What are the names of two common PDE-5 inhibitors?

Answer 47

Sildenafil and tadalafil

Question 48

What is the treatment under the ‘Chest Pain’ CPG?

Answer 48

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> Consider oxygenation if below 94% sats -> Posture -> ECG monitoring -> full set of obs. 12 lead ECG.
2. Consider signs of cardiogenic shock:

• Request clinical support. If clinical support present can bypass spoke hospital for spine. If not present, required to take patient to nearest ED (Liase with EOC if nessecary).
• Chest Pain
• Systolic BP < 90 mmHg
• Ischemic ECG changes (inverted T waves, Q waves, ST elevation, ST depression in 2 or more leads.)

3. If signs of shock evident:

• Clinical support
• IV access
• Posture (trundelenberg)
• Apply pads, prepare for deterioration.

4. If no signs of cardiogenic shock: Consider GTN administration considering ellgibility:

• Adequate BP (SBP > 100 or MAP > 65)
• Appropriate rate + rhythm
• No PDE-5 use of tildanafil or sildenafil within 24 hours. No use of vardenafil within 48 hours.
• No allergy

5. 400 mcg per spray every 5 minutes PRN.
6. 300 mg aspirin tablet
7. If pain unresolved, establish IV access.
8. If patient in severe pain, GCS 15 and Systolic BP >100 mmHG. Consult with eoc For 25 microg IV fentanyl. Up to max of 300 microg.
9. If the patient is NOT ellgible for code STEMI but has active chest pain, no pain on pallp or inspiration (pleuretic pain).

AND has hx of IHD. Including diabetes, Chronic renal failure, previous PCI, previous stent, previous CABG.

• Transport to PCI facility and bypass nearest ED.

** Public PCI Hospitals = FMC, RAH, LMH, TQEH.

** Private PCI Hospitals = Ashford, Flinders private, Wakefield.

9. If no response on code STEMI line, use a radio notification to request code STEMI.
10. If chest pain is resolved. Consider transport to nearest ED.

Question 49

From STEMI FLOWCHART:

• If you had a patient that was unstable, and did not meet the STEMI activation criteria, what would be the process?

Answer 49

1. Clinical support -> if unavailable -> EOC clinician
2. IV access
3. RESUS equipment ready and at hand. Consider drawing up drugs also.
4. Consider P2 to hospital + notification.

Question 50

What are contraindications for code STEMI?

Answer 50

1. Unstable patient
2. Absence of chest pain
3. STEMI in the setting of trauma
4. STEMI in the terminal phase of a terminal illness.
5. Required to be ST elevation in two contiguous leads, that does not mean V2 and v3. As they are different regions. Must be V3 + V4 for example.

Considerations:

• Dont soley rely on monitor. STEMI is based on STEMI criteria AND the patients presentation.
• Consider ST-Segmen mimics such as pericarditis
• If presentation is borderline. Sitll consider P2 transport and ED notification.

Question 51

What is the code STEMI activation criteria?

Answer 51

• Symptoms consistent with ACS
• Ongoing unrelieved chest pain
• GCS = 15
• Onset of symptoms < 12 hours
• Travel times to PCI facility < 60 minutes

+

The following features on two ECGs:

• ST elevation of at least 1 mm in 2 or more contiguous . chest leads
• ST elevation of at least 2 mm in 2 or more contiguous chest leads
• Normal QRS complex duration/width OR a RBBB present.

Question 52

What are the prerequisites for administering benzopenicilin in suspected meningococcal?

Answer 52

1. Febrile
2. Altered concious state
3. Evidence of sepsis AND
4. ACUTE onsent puperic rash.

Question 53

What is the SAAS standard dilution for naloxone?

Answer 53

Naloxone comes in: 400 mcg in 1 ml.

Add 3 ml of saline

makes 100 mcg per ml.

Adult dose IV: 100 microg aliquots, every 30-60 sec, PRN

OR

o Intranasal 120 microg aliquots, every 30-60 sec, PRN,

Adult IN dose: Works out to 40 mcg per .1 ml in a standard ampule. Dose IN is 120 mcg - so .3 ml needed + .1 ml to prime initial dose. .3 ml for every subsequent dose.

o IM 400 microg aliquots, every 1-2 min, PRN

Question 54

In what circumstances would there be non-initiation of CPR?

Answer 54

1. The patient has an advanced care directive, indicating that CPR is not desired
2. Obvious signs of death/Injuries incompatible with life - > decapitation, overwhelming incineration.
3. Patient is ->

• Asystolic
• No pulse
• No breathing
• Fixed dilated pupils
• No CPR 30 minutes prior to SAAS arrival.

4. CPR places crew at risk of significant environmental hazards.
5. Triaging in a multicasuality trauma determines that resources can be more usefully allocated.

Question 55

How do you define a newborn?

Answer 55

A baby born within the last 2 hours.

Question 56

Explain the overall flow of neonatal resus?

Answer 56

***Baby not crying, poor muscle tone:

• 30 seconds of dry and stimulate

***Baby STILL not crying and poor muscle tone:

• 30 seconds of IPPV (Just AIR) with a focus on chest wall movement. Rate 40-60

***Not breathing and crying effectively + HR is NOT above 100:

• 30 seconds of IPPV (just AIR) with a focus on chest wall movement. Rate 40-60

***If heart rate above 60 but not at healthy cut-off (HR > 100)

• IPPV with 100% oxygen + Sp02 to monitor parameters. Rate 40-60

*** If HR below 60

• Commence CPR at rate of 3:1. Two thumbs for compression method. No drugs / ALS.

Question 57

What is the principles of managing patients with envenomation?

Answer 57

The aim is to reduce effects of the venom, and symptomatically manage patients until definitive care.

Question 58

What is the guideline for snake bites in the ‘envenomation’ CPG?

Answer 58

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
   - Do NOT apply a torniquete OR wash the bite site. If a tornique is already applied, liase with EOC clinican for specific advise (The EOC clinican will contact toxinology services for specific guidance).
   - Apply a broad pressure bandage OVER the site of the bite.
   - THEN apply a second pressure immobilization bandage to cove as much of the limb as possible.
   - Use a splint (cardboard splint)
   - If bite is head or torso, use a simple dressing and bandage.
   - A vacum mat is ideal for transport if readily available.
   - Patient should be postured supine with head elevated 20 - 30 degrees.
   - IF snakebite is EXOTIC/NON-Aussie bite. Contact EOC to speak with toxicology service SA for specific advice.
   - NOTIFY hospital.

Question 59

What is the guideline for redback spider bites in the ‘envenomation’ CPG?

How about other unknown spiders or ‘big black’ spiders >2 cm in body length?

Answer 59

Red Backs:

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Minimal patient exertion
3. ICE the area if available.
4. Pain relief + notify.

Unknown Spiders:

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Identical treatment protocol to a snake bite. Pressure bandage + immobilise limb + minimise patient movement + vac mat + clinical support.
3. One key variable. If bitten >4 hours ago and no signs of funell web bite, unlikely to benefit from hospital and consider TNT.

Question 60

What is the guideline for bee and wasp stings in the ‘envenomation’ CPG?

Answer 60

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Treat for allergy or anaphylaxis if indicated
3. Ensure minimal patient exertion
4. For a bee sting - remove stinger with a scraping motion
5. Use ICE if available (to minimize swelling/pain).

Question 61

What is the guideline for blue ringed octopus stings in the ‘envenomation’ CPG?

Answer 61

1. Focus on VENTILATION due to the PARALYTIC effects of blue ringed octopi.
2. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
3. Compression bandage over the site of the bite
4. Second compression bandage covering as much of the limb as possible.
5. Vac mat + Notify the receiving facility
6. Consult with EOC to speak with a toxinology specialist for advice on treatment.

Question 62

Define a fall?

Answer 62

A fall is an event which results in a person inadvertently coming to rest on the ground. The mechanism varies as does the propensity for injury.

Question 63

What are the first steps in managing a fall?

Answer 63

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
   - Posture (supine is ideal so you can do a mobility assessment later)
   - temperature control (move them off a hard/cold surface if possible).
   - Secondary survey head to toe + backside -> Exclude any signs of injury. Consider C-spine.
   - Gathering a full and comprehensive history regarding the fall. including HOW LONG on the ground.
   - Medical history + meds
   - Treat any urgent medical issues/injuries -> Pain relief with checking for allergies.

Question 64

What are the secondary steps in managing a fall?

Answer 64

1. Perform a mobility assessment.
2. Determine the appropriate lifting plan, call for support if required.
3. Once the patient is extricated, reassess.
4. Assess SOCIAL issues. Is this environment safe? Is there supervision of the patient? Are they coping?

Patient goes to hospital if: Medical reason, social reason (not coping), or patient is on anticoagulants.

If no clinical or social need is found patient can be left at home.

Question 65

If you determine post a fall, that a patient could stay at home, what key steps do you take?

Answer 65

1. Falls risk assessment needs to be completed.

Low risk = Referral

High risk = Urgent referral.

2. Find out how long they have been on the ground. >1 hour demands a pressure injury screen.

Low risk - Provide advice

Advice =

• Keep active, small body shifts help.
• Regularly check for pressure injuries, and care for your skin
• Maintain good nutrition

Medium Risk - Provide advise PLUS:

• Reposition every 30 minutes.
• Ensure patient has fresh continent pads.
• Ensure they have dry clothes.

High Risk - All of the other advice PLUS

• Ask for prophylactic dressings from the sending facility
• Inquire about a pressure injury management plan.
• Use support surfaces (pillows, flat sheets?) to reduce pressure, friction, on at risk body areas.

Question 66

Describe the fluid volumes for all arrest scenarios -> Obstructive cause of arrest, Traumatic cause of arrest, and post-ROSC. Also decribe after how many mls you would reassess?

Answer 66

Normal arrest with obstructive cause:

• Only for patients with obstructive cause of arrest
• maximum fluid volume is 20 ml per kilo.
• Reassess every 500 ml aliquot.

Traumatic arrest:

• Only for patients with traumatic cause of arrest
• maximum fluid volume is Up to 30 ml per kilo
• Reassess every 500 ml aliquot.

Post Rosc:

• Only for patients with hypotension AND altered concious state.
• Give fluid until return of radial pulse or systolic >100.
• Reassess every 250 ml aliquot… checking for APO.
• If patient shows signs of APO, discontinue fluids.
• maximum fluid volume is 10 mls per kilo

Question 67

Can you apply the fluid resuscitation in medical emergencies when the cause is primarily a cardiac issue?

Answer 67

No you cannot apply the CPG to cardiac.

Question 68

What are the principles of the fluid resuscitation in medical emergencies CPG?

Answer 68

Fluids should be used to treat HYPOVOLEMIA (and NOT HYPOTENSION)…in conjunction with other treatments that include

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
   - Where possible, treatment of the underlying cause

The guideline addresses hypotension in the setting of:

***Haemorrhagic hypovolemia

***Obstructive shock states (This would be considered a medical form of hypovolemia because of the issue with blood delivery).

• Obstructive causes include tension pnemo, asthma (has it’s own guideline), PE, cardiac tamponade, aortic disection.

***Symptomatic Dehydration under consult. (Technically hypovolemia from fluid volume)

*** Relative hypovolemia secondary to SEPSIS, CAUSING or LIKELY to cause hypotension.

Question 69

Run through treatment under the fluid resuscitation in medical emergencies CPG, as it pertains to:

• Haemorrhagic hypovolemia (causing hypotension), and
• Obstructive shock (causing hypotension)?
• Explain this for adults + Pedes.

Answer 69

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Balance transport to definitive care and scene time.
3. Saline IV to achieve radial pulse + Stable GCS
4. Consult the EOC clinican if further management is required.

PEDES:

1. universal care and life support -> DRABC + SDE -> History -> Phx -> Medn ->Oxygenation -> Posture -> ECG monitoring -> full set of obs.
2. Balance transport to definitive care and scene time.
3. Request clinical support and COMMENCE transport. KEY, KEY, KEY.
   - If clinical support ‘not readily available’ consult the EOC clinician for permission to gain IV access + give saline.

Question 70

Run through treatment under the fluid resuscitation in medical emergencies CPG, as it pertains to:

• Symptomatic dehydration (causing HYPERthermia and/or hypotension)?

Answer 70

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. If hyperthermia present consider active cooling by:

**Exposure / removing excessive clothing

**Moisten skin to enhance evaporation (saline + air conditioning)

**If available, ICE/cold packs covered with a cloth in groin and axilla.

• IF clinical support not ‘readily available’, consult EOC clinician for saline IV.

Question 71

Run through treatment under the fluid resuscitation in medical emergencies CPG, as it pertains to:

• Relative hypovolaemia secondary to sepsis, causing or likely to cause hypotension

Answer 71

Indicated in ‘relative hypovolemia secondary to SEPSIS, CAUSING or LIKELY to cause hypotension’.

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. CLINICAL SUPPORT
3. If clinical support not ‘readily available’ (Not coming?), consult EOC clinician for saline IV and ADVICE for ongoing management,

Question 72

What is the mechanism that supports giving oxygen in shocked states?

Answer 72

Hypoperfusion occurs -> despite full sats, you can increase the pa02 of arterial blood -> despite the fact that o2 disolves POORLY in liquids compared to c02.

The 02 then moves via DIFFUSSION into the interstitium to improve supply of 02 to cells.

Question 73

What are the princples of anaphylaxis and allergy CPG?

Answer 73

• Anaphylactic and allergic reactions vary in severity
• Severe anaphylaxis OFTEN (not always) has hypotension, bronchospasm and angiooedema components.
• Treatment of anaphylaxis should focus on
  1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

** Oxygenation

**Posture

** Adrenaline

** Oral antihistamines should also be considered.

Question 74

In anaphylaxis and allergy CPG, how do you define a mild or moderate reaction. Constrast this with a severe reaction?

Answer 74

Mild to moderate = Skin rash or local allergic reaction.

Severe reaction -> ‘In adults with hypotension, severe bronchospasm, or respiratory distress due to angiooedema’.

Question 75

What are the principles of asthma in the SAAS ‘Asthma CPG’?

Answer 75

Two key concepts:

• Relief of bronchospasm with bronchodilators
• Reduction of inflammation with steroids (ICP + Definitive hospital care).
• If severe asthma occurs in the setting of anaphylaxis, early adrenaline is indicated and request clnical support early. ( In this case USE the anaphylaxis guideline. )
• In mild and moderate asthma MDI with spacers are proven to be at least AS effective as nebs.
• First line treatment for severe asthma is HIGH FLOW oxygen and NEBS with early backup and transport.
• ICPS can augment treatment in severe asthma, by providing magnesium and hydrocortisone.
• IM Adrenaline in asthma should be given in patients who
• • Are deteriorating
• • Are not improving
• To determine the correct treatment pathway in asthma you must use the definitions chart
• Follow any asthma care plan in place IF APPROPRIATE
• Asthma can occur in patients with NO HISTORY of asthma. Practicularly with chest infections OR smoke inhalation.
• Patients with severe or life-threatening asthma will need
• • Early clinical support
• • Specialist review at hospital, with an ICU unit (Spine hospital).
• In metro adelaide

** Any asthma patient given parenteral (IM adrenaline, steroids by an ICP, or magnesium via ICP) need to be taken to a spine hospital (Flinders, RAH, Lyell Mcewin, womens and childrens) or the QEH (which is a spoke hospital but ok in asthma according to the guideline).

** Unstable patients who require urgent medical assistance should be transported to the closest emergency department to stabalise the patient.

Question 76

In patients with Mild asthma, what is the treatment?

Answer 76

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Follow the patients asthma management plan
3. Salbutamol via a spacer:

• • Prime the space with one puff (1 x 100 microg)
• • Administer 100 micrograms + Inhale 4 times
• • Reassess (Unique to mild Asthma)
• *Repeat up to 1200 micrograms ONLY if required (no repeat -> Escalate to moderate if ineffective? Moderate asthma says you can provide salbutamol earlier than 20 minutes if they fail to improve -> dont fret about times.)

4. Consider GP referral if appropriate.

Question 77

In adult patients with moderate asthma, what is the treatment?

Answer 77

1. Basic Care
2. Follow the patients asthma management plan
3. Salbutamol and AFTERWARDS ipratropium via an MDI and spacer.

• • Prime the space with one puff (1 x 100 microg)
• • Administer 100 micrograms + Inhale 4 times and REPEAT every 4 inhalations to complete a full dose of 1200 microg.
• • This is to be followed by ipratropium 20 micrograms + 4 inhalations and repeat 8 TIMES to achieve total dose of 160 micrograms.

4. Salbutamol to be repeated 20 minutes later, or EARLIER if the patient ‘fails to improve’. No repeat on ipratropium.
5. If the patient fails to improve escalate to the severe asthma pathway.
6. Administer oral prednisolone 50 mg if tolerated and no previous therapeutic doses
   within past 24 hours. If patient improves consult with GP.
7. Transport as required to GP or hospital.

OR

1. Salbutamol 5 mg and 500 microg ipratropium nebulised
2. Repeat salbutamol every 20 minutes OR EARLIER if patient fails to improve. A TOTAL of 3 doses. Do not repeat ipratropium.
3. If the patient fails to improve escalate to the severe asthma pathway.
4. If patient improves consult with GP.
5. Transport as required to GP or hospital.

Question 78

In adult patients with severe asthma, what is the treatment?

Answer 78

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Provide high flow oxygen. No need to ask about asthma management plan.
3. Request EARLY clinical support
4. salbutamol 15 mg + Ipratropium 500 microg nebulised.
5. Repeat doses if required (You can repeat every 20 minutes both Salbutamol AND ipratropium. However, Escalate to life threatening is more likely- If the patient is not responding. IF they ARE responding, repeat dose may be indicated)
6. Administer oral prednisolone 50 mg if tolerated and no previous therapeutic doses within past 24 hours.
7. If no improvement, or patient deteriorates. Escalate to life threatening.
8. Notify recieving hospital.

Question 79

In adult patients with life threatening asthma, what is the treatment?

Answer 79

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Provide high flow oxygen. No need to ask about asthma management plan.
3. Request EARLY clinical support
4. Salbutamol 15 mg (continuous) + 500 microg ipratropium every 20 minutes.
5. 500 ml fluid bolus IV
6. Consider adrenaline 10 microg/kg. to a max single dose of 500 microgs.
7. If no response to adrenaline, repeat adrenaline.
8. Administer oral prednisolone 50 mg if tolerated and no previous therapeutic doses
   within past 24 hours.
9. Notify recieving facility.

Question 80

Treatment for Adult Asthma patients who require BVM?

Answer 80

1. Continuous nebs whenever possible. Remember you will need TWO oxygen bottles to achieve this. Consider a second one from the truck if logistically possible.
2. Request EARLY clinical support
3. 15 litre IPPV, with SMALL tidal volumes and SLOW ventilation rates allowing for adequate chest deflation.

** Patients should be very carefully ventilated to avoid barotrauma in hyper-inflated lungs with high airway pressures.

5. Fluid bolus 500 ml.
6. Consider adrenaline 10 microg/kg. to a max single dose of 500 microgs.
7. If no response to adrenaline, repeat adrenaline.
8. Notify hospital.

Question 81

What are the paediatric spine hospitals for pedes?

Answer 81

LMH, WCH, FMC

Question 82

What is the paediatric treatment for mild asthma?

Answer 82

For children over 6:

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Follow asthma management plan if appropriate
3. Prime the spacer (1 x 100 micrograms)
4. Salbutamol via a spacer:

• • Prime the space with one puff (1 x 100 microg)
• • Administer 100 micrograms + Inhale 4 times
• • Reassess after 600 microg (6 puffs)?
• *Repeat up to 1200 micrograms IF REQUIRED

4. Consider the resuscitation mask for pediatrics <4 who are unable to use a spacer
5. Consider GP referral and transsport to GP or hospital as appropriate.

For children UNDER 6:

• All the same except half dose of salbutamol.

** 6 puffs = 600 microgram max of salbutamol via a spacer.

• • Prime the space with one puff (1 x 100 microg)
• • Administer 100micrograms + Inhale 4 times each puff
• • Reassess after half dose (300 micrograms)
• *Repeat up to 600 micrograms if required

Question 83

What is the guideline for paediatrics with moderate asthma using an MDI/ SPACER.

Answer 83

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

Request EARLY support.

2. Unlike moderate for asthma in adults management plan is NOT indicated.
3. High flow oxygen -> if this is indicated consider nebulised salbutamol.
4. Preferred option is MDI via spacer:

Salbutamol:

• • Prime the space with one puff (1 x 100 microg)
• • Administer 100 micrograms + Inhale 4 times
• • > 6 yrs old -> Provide full dose of 1200 micrograms
• • If < 6 years old -> Provide full dose of 600 microg

***REPEAT salbutamol 20 minutely, do NOT repeat ipratropium. A max of 3 total doses.

Ipratropium:

• • > 6 yrs old = 160 micrograms (8 puffs of 20 micrograms)
• • < 6 years old = 80 micrograms (4 puffs of 20 micrograms).

4. Administer oral prednisolone 1 mg/kg to a max dose of 50 mg if tolerated and no previous
   therapeutic doses within past 24 hours
5. If no improvement, or the patient deteriorates, treat as life threatening (upgrade to the highest level and skip the other levels).
6. Transport to HOSPITAL.

Question 84

What is the guideline for paediatrics with moderate asthma using a nebuliser?

Answer 84

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Unlike moderate for asthma in adults management plan is NOT indicated.
3. High flow oxygen
4. Salbutamol and ipratropium nebulised:

• • > 6 years 5 mg salbutamol + 500 microg ipratropium.
• • < 6 years 2.5 mg salbutamol + 250 microg of ipratropium. (Half dose is 1.25 ml -> complicated)

***Salbutamol comes as 5 mg in 2.5 ml. To give half dose get 3 ml syringe with drawing needle. Draw 1.25 ml, place in neb.

*** Ipratropium comes as 500 microg in 1 ml. Use same 3 ml syringe to draw up .5 ml. Place in neb.

4. Repeat Salbutamol every 20 minutes or EARLIER if the patient does not improve. A total of 3 doses SALBUTAMOL. Do not repeat ipratropium.
5. If no improvement, upgrade to severe pathyway
6. • Administer oral prednisolone 1 mg/kg to a max dose of 50 mg if tolerated and no previous
   therapeutic doses within past 24 hours

Question 85

What is the guideline for paediatrics with severe asthma ?

Answer 85

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

Early clinical support

2. High flow oxygen.
3. Salbutamol and ipratropium nebulised:

• • > 6 years 15 mg salbutamol + 500 microg ipratropium.
• • < 6 years 7.5 mg salbutamol + 250 microg of ipratropium. (Half dose is 3.75 ml -> complicated)

***Salbutamol comes as 5 mg in 2.5 ml. To give half dose get 5 ml syringe with drawing needle. Half dose is 3.75 ml. Draw up 3 ml + and then just beneath 4th little line (4th line is 3.8 mls) that leads up to 4 mls.

*** Ipratropium comes as 500 microg in 1 ml. Use same 5 ml syringe to draw up .5 ml (half way between second and 3rd line (2nd line is .4, 3rd line is .6 mls) Place in neb.

4. If no improvement treat as life threatening. Does not talk about repeating doses in severe asthma. If not improving escalate to life threatening which is continuous salbutamol + 20 minutely ipratropium.
5. Administer oral prednisolone 1 mg/kg to a max dose of 50 mg if tolerated and no previous
   therapeutic doses within past 24 hours

Question 86

If there is a 5 ml syringe, and you are going from 2 ml to 3 mls, which has 5 little lines. How much is each little line in volume?

Answer 86

Each line is .2 ml (hard)

1st line -> 2.2 
2nd Line -> 2.4 
3rd Line -> 2.6 
4th Line -> 2.8 
5th Line -> 3 ml

Question 87

If there is a 3 ml syringe, and you are going from 2 ml to 2.5 mls, which has 5 little lines (3 ml syringes go up in half mls -> so 1 to 1.5, to 2, to 2.5, to 3). How much is each little line in volume?

Answer 87

Each line is .1 mls (easy)

1st line -> 2.1
2nd Line -> 2.2
3rd Line -> 2.3
4th Line ->  2.4
5th Line -> 2.5

Question 88

What is the guideline for paediatrics with life-threatening asthma ?

Answer 88

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

+

Early clinical support

2. High flow oxygen.
3. Salbutamol and ipratropium nebulised:

** Continuous salbutamol (no guidelines regarding dose/age). Ipratropium every 20 MINUTES.

4. Consider adrenaline at a dose of 10 microg per kilo. IM
5. If no response to adrenaline. Repeat dose of adrenaline IM.
6. Administer oral prednisolone 1 mg/kg to a max dose of 50 mg if tolerated and no previous
   therapeutic doses within past 24 hours

Question 89

What is the guideline for paediatrics requireing BVM?

Answer 89

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

+

Early clinical support

2. High flow oxygen.
3. Continuous nebulisation. Ipratropium every 20 minutes.
4. IPP with small volumes and slow ventilation rates to allow chest deflation. Key aim to avoid hyper inflation and barotrauma from high airway pressure.
5. IM adrenaline up to a max single dose of 500 microg.
6. No response to IM adrenaline -> repeat
7. Notify hospital.

Question 90

What are the principles for cardiogenic pulmonary oedema?

Answer 90

Acute cardiogenic pulmonary oedema is best treated by attention to

1. Posture
2. Oxygenation.

GTN is beneficial if there is adequate blood pressure. Assessment of adequate blood pressure should take into account:

• Systolic blood pressure
• Diastolic blood pressure (these two together is MAP -> cover it that way)
• Heart rate
• MAP
• Preload dependent rhythmns and posture.

Question 91

What are the principles in the COPD CPG?

Answer 91

Viral and bacterial respiratory infections are the cause of up to 79% of COPD exacerbations.

The remaining 30% are due to PE, Environmental polution, orhave an unknown cause.

The main symptoms associated with exacerbation are

• Increased dysponea
• Increased cough frequency
• Increased sputum production

MDI + Spacer same effectiveness as nebs, unless

• Severely dysponeic
• Low inspiratory flow rates

which causes difficulty in technique and flowing from technique, appropriate medication delivery. Nebs may be easier to use for these patients.

There is NO EVIDENCE to support the use of adrenaline for COPD exacerbation and it MAY BE HARMFUL.

COPD patients with moderate to severe exacerbation HAVE GREATER risk of hypercapnia + respiratory failure.

UNCONTROLLED oxygen exposure in these patients can lead to

• Respiratory acidosis
• Organ dysfunction
• Coma

This underpins recommendation of sp02 between 88-92%. Most patients should able to maintain 88-92% with a low fraction of inspired oxygen (Nasal specs at 4 litres). This means most COPD patients should need oxygen get nasal specs at up to 4 litres.

If nasal specs cannot maintain sats you must consider

• PE
• Pnemonia
• Acutre respiratory distress sydnrome
• Pulmonary oedema

Adequate oxygenation MUST be assured, even if it leads to acute hypercapnia - eg. If sats below 88%, despite 20 mins of oxygen keep going. May even need to increase oxygen to more 02 via a mask.

It is impossible to tell who will have hypercapnic respiratory failure, so SAAS recommends treating all moderate to severe COPD exacerbations as such, until bloods are done at hospital.

Within METRO:

• Any patient with previous ICU admission for respiratory illness should be transported to a spine hospital or TQEH if safe to do so.
• Unstable patients who require urgent medical assistance should be transported to the geographically closest ED to stablise the patient.

(My own addition)

ARDS: Acute respiratory distress syndrome (ARDS) is a diffuse lung injury that leads to a severe acute respiratory failure. ARDS will often lead to pulmonary oedema. It is a syndrome that occurs secondary to disease processes that increase memrane permeabliity, or cause damage to membranes. Such as SEPSIS, Severe pneumonia (same as sepsis), Aspiration (inhalation of vomit can cause inflammation and hence increased permeability+ vasodilation), or pulmonary hypertension. Pulmonary hypertension = chronic inflammation, vasocular damage and remodelling. Increase vasocular permeability.

Question 92

If completing a primary survey and getting no radial pulse, what is the next step?

Answer 92

1. Check brachial.

No brachial?

2. Check carotid.

Question 93

What are the principles of the ‘burns’ CPG?

Answer 93

Burns are best treated by

• Removal of the heat source
• Effective cooling/irrigation to reduce tissue damage and pain.
• Pain is likely to be significant and ongoing, pain relief should be an EARLY focus.

Use hydrogel when other cooling is not available. Hydrogel dressings can cause hypothermia and further tissue damage.

In the event of airway burn, airway management and urgent transport take precedent.

Question 94

What is the treatment protocol for thermal burns, in the saas ‘burns’ CPG?

Answer 94

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.

MULTIPLE temperatures taken to manage hypothermia.

Consider MEDSTAR + ICP.

ICP can offer:

• Enhanced pain relief with ketamine
• Cricothyrotomy

Medstar can offer:

• RSI
• Cricothyrotomy
• Escharaotomy (circumferential burns)

2. Monitor the patient closely for deterioration or signs of airway compromise.

• • Check change in voice quality
• • Check is tightness in throat
• • Check appearance for singes on face / eyebrows.
• • Check ability to swallow.

3. Cool with running water for 20 minutes.

Consider environmental conditions (Is it the middle of winter?) and make sure high risk people (elderly and young children) do not become hypothermic during cooling and irrigation.

** Mid-way through cooling, consider reassessing temperature (after 10 minutes of irrigation).

4. If no water is available, apply hydrogel dressing.

• • Neonates - Max time of 10 minutes
• • Adults and Paediatrics - Max time of 20 minutes

5. Once cooling + irrigation is completed, cover burns with cling wrap loosely.

• • Hydrogel must be removed prior to cling wrap
• • Cooling can occur over cling wrap (saline ect.).

5. Fluids can be given to ‘establish and maintain normovolemia).
6. Notify
7. Transport to WCH for pedes and neonates, and RAH for adults. Consider nearest ED for airway burns.

Question 95

How would you define a neonate?

Answer 95

A baby less than 1 month old.

Question 96

Explain how management varies for chemical burns?

Answer 96

The same as thermal burns except:

** Do not use hydrogel in chemical burns

** Consider specialist advice -> Contacting SOT’s.

** Provide 20 minutes of cooling ‘where chemically appropriate’ - Seek specialist advice before cooling.irrigating.

My Notes:

Water is contraindicated as a first aid measure in chemical burns caused by the heavy metals like sodium, potassium and calcium.They react violently and explosively with water to produce caustic hydroxide liberating much heat in its production and thus result in combination of thermal and chemical burn.

Question 97

What should be your ultimate mental checklist for giving any drug?

Answer 97

1. Check for allergies
2. Check for contraindications
3. Drug check the actual drug
4. Note the time of administration AND the dose on your notepad.
5. Set a timer for the next administration interval.

Question 98

What does naloxone come in? Give me the 3 doses for IM, IN and IV naloxone. Also, how it is prepared and administered.

Answer 98

Naloxone comes in 400 microg in 1 ml. All doses are PRN (Repeat doses as many times as required).

When giving IN you need to give neat. Each vial 40 microg per .1 of a ml. Dose for IN Naloxone is 120 microg. So .3 ml for 120 microg + .1ml to prime. so .4 ml is the dose every time for adults PRN.

IV: Mix 400 microg in 1 ml with 3 ml of saline. Makes 100 microg per ml. Dose is 100 microg IV PRN.

IM dose is 400 microg. Which is 1 ml neat given IM.

Pede doses:

Pedes ALWAYS receive IM naloxone.

<6 get half dose of 200 microg. This is .5 ml given IM and PRN.

> 6 receive same as adult dose which is 400 microg PRN.

Question 99

How do you prepare benzopenecillin, how is it given?

How much benzo is in each 1 ml?

Answer 99

In adult patients benzo can be given IM or IV.

In pede patients, benzo can be given IM only.

Prepare by taking 1.2 grams (1200 mg) and adding 3.2 ml of water, shaking and drawing up.

Benpen always works out as 300 mg per ml.

Question 100

What airway device largely shouldnt be used in head injury?

Answer 100

i-Gel.

Question 101

What are the principles of the amputation CPG?

Answer 101

The key aim of COMPLETE amputation is aimed at SALVAGING the limb for reattachment.

Partial amputations may result in significant haemorrhage.

Question 102

What is the treatment required for managing an amputation are per the amputation CPG?

Answer 102

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. You need to do both DIRECT pressure over the bleed AND indirect pressure over arterial pressure points to stop the bleeding
3. Early clinical support:

** ICP can offer intubation, possibly vasopresser support?

** Medstar can offer whole blood products.

4. Arterial torniques are only to be considered in extremis, where ‘life threatening haemorrhage is unable to be controlled DESPITE direct pressure’.
5. Place the torique as close as possible to the amputation site while STILL achieving haemorrhage control.
6. If the amputation is complete, seal the body part in a water tight bag, then get another bag filled with ice water if possible. The body part should NOT be placed in direct contact with ICE.
7. Notify.

Question 103

What are the principles listed in the croup CPG?

Answer 103

1. The aim of treatment is to reduce mucosal swelling of the airway through use of TOPICAL VASOCONTRICTORS (remember airway radius/diameter has a exponential effect on airway pressures required for respiration).
2. Because there is a risk of reoccurance for croup following adrenaline, ALL patients are to be transported to hospital. (This is relevant for pedes over 12 years old -> the only pedes that can be left at home).

Question 104

How do you make up benzopenecillin? What is the adult dose, and how much benzo is in each ml?

Answer 104

1. Make benzo by adding 3.2 ml of water. This makes a total volume of 4 ml per vial.
2. Each vial has 1.2 grams, which is 1200 mg per vial. The adult dose is 2400 mg, which is two whole vials (8 ml).
3. Benzo can be given IM or IV.
4. Once Benzo has been prepared, each ml has 300 mg in it.

Question 105

What are the principles for the ‘hypoglycemia’ CPG?

Answer 105

1. The best management is the LEAST invasive therapy, that improves BGL reading.
2. A BGL should be taken on ALL patients, PARTICULARLY children who have

• Altered concious state
• Trauma
• Seizures

Question 106

What is the treatment for ADULTS in the ‘hypoglycemia’ CPG?

Answer 106

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. If concious state allows (They can cough, and swallow -> Obeys commands). Give oral carbs OR 15 grams oral glucose paste.
3. If unconcious or experiencing a hypo seizure:

** Give glucose IV titrated to neurological function AND BGL.

** Reassess BGL - Avoid hyperglycemia (4-6 mmol range).

**100 ml flush BEFORE and AFTER glucose administration

4. If oral carbs are ineffective OR concious state is not suitable OR unable to gain IV access giver glucagon 1 mg IM ONLY. Not IV.
5. Consider transport. Not all hypo patients need to go to hospital. (Expand on this in another flash card).

Question 107

For adults in the ‘hypoglycemia’ CPG, what is the criteria for hospital transport?

Answer 107

1. If following therapy, adult returns to normal neuro function an ALTERNATIVE management plan can be considered (GP referral?).
2. This alternate plan should only be considered in patients who:
3. Consumed complex carbs
4. A stable BGL is attained (between 4 and 6). Avoiding hyperglycemia.
5. Has previously been a stable diabetic AND:
6. An identifyable cause for the episode is determined AND
7. The patient resides in a safe, stable environment
8. If decision made not to transport, it is desirable that:
   * Patient is supervised by someone, has family/roommate ect.
   * This observation is only until a follow up medical assessment can be booked - Think GP.
   * In ALL cases, this would be completed as a TNT.

Question 108

What is the treatment for PEDES in the ‘hypoglycemia’ CPG?

Answer 108

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. If concious state allows (They can cough, and swallow -> Obeys commands). Give oral carbs OR 15 grams oral glucose paste.
3. IF oral carbs ineffective OR concious state unsuitable consider glucagon IM.

• • < 8 yrs old .5 mg IM
• • > 8 years old adult dose of 1 mg IM.

4. If Glucagon is ineffective request clinical support for further management (IV glucose).
5. If clinical support is unavailable, consult with EOC clinican for requesting IV glucose.
6. Establish starting dose, which is 2 mls of glucose per kilo.
7. The starting dose is titrated against patient GCS and BGL.
8. Absolute max dose of 5ml per kilo.
9. FLUSH for pedes is 1 ml of saline per kilo, BEFORE and AFTER administration. Using a burette would be appropriate for this.
10. Transport

Question 109

Within code STEMI (in the ischemic chest pain CPG), what factors would make a patient considered ‘unstable?’

Answer 109

• Decreasing GCS
• Requiring ventilatory support (BVM)
• Inadequate MAP or BP
• Inappropriate HR or rhythm (think bigeminy -> every ‘other’ beat is a PVC)
• Trend of obs suggests deterioration
• Other concern -> Para disscression.

Question 110

What are the principles of the ischemic chest pain CPG?

Answer 110

1. Chest pain should be regarded as cardiac ischemia UNLESS there is an obvious alternate cause
2. Vasodilators are the primary treatment + supplemental oxygen to achieve >94% saturation.
3. Adequate BP should account for:

• • Systolic
• • Diastolic
• • HR
• • MAP
• • Preload dependent rhytmns
• *Posture

4. Morphine and GTN both have a PROFOUND effect on BP individually
5. Early PCI is associated with

• • Better patient outcomes
• • Reduced risk of compications

6. Early notification of PCI can reduce time to treatment in elligble patients.

Question 111

What are the principles in the ‘meningococcal Septicaemia’ CPG?

Answer 111

1. Early administration of antibiotics is associated with REDUCED mortality.
2. The greatest benefit in survival, is seen in patients with haemorrhagic complications (those with puperic rash)
3. Septic patients recieving parental (non-oral) antiobiotics (whether it be IV or IM) may experience sudden cardiovascular changes.
4. Cardiovascular changes are secondary to mass bacterial lysis causes by benzopenecillin. Patients must be monitored CLOSELY with ECG monitoring + basic care following ANY administration.
5. Each 1.2 gram benzylpenicillin is reconstituted with 3.2 ml of sterile water to make a 300 mg per ml solution.

Question 112

What is the treatment in the ‘meningococcal Septicaemia’ CPG?

Answer 112

1. Once identified IMMEDIATE withdrawl from scene for ‘DANGER’ in the primary survey. You must GOWN + GLOVES + Glasses + Respiratory mask.
2. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
3. Administered benzylpenecillin if patient is:

- Febrile 
\+
- Altered GCS
\+
- Evidence of sepsis accompanied by
\+ 
- Acute onset purperic rash

4. Consult before giving benzylpenicillin if the patients is :

- Febrile
\+
- Altered GCS
\+ 
- No rash
\+ 
- Clinical suspicion of meningococcal

5. Notify.

Question 113

Explain the principles of the ‘Metro emergency department destination triage’ CPG

Answer 113

1. Since transforming health, SAAS has a crucial role to deliver patients to the appropriate destination.
2. Patients likely to require admission to a specialist unit or department, should be transported to that hospital. This ensures minimal delays + reduces interhospital transports.
3. Transport decisions must be:

• Patient centred
• Safe
• Effective
• Efficient
• Equitable
• Support access to appropriate care

4. Unless otherwise operationally directed (diverts) or indicated by clinical documents (Pre-arranged intra-hospital transfer) the following destinations are warranted:
   - All patients to geographically closest ED
   - Unstable patients to geographically closest ED.
5. IF doubt about the appropriate destination, consult with:

• The relevant emergency department
• EOC clinican
• SDM

Question 114

Explain the treatment of the ‘Metro emergency department destination triage’ CPG?

Answer 114

1. Patients where NHS is the closest department, should be bypassed if:

• • Significant physiological abnormality is present.
    
    • In this case, request clinical support for bypass (call EOC clinican?)

**Respiratory issue requiring 02 (Anything <94% on RA).

** Any PEDE (<16 yrs old).

2. Organ transplant patients + Non-life threatening issue:

** Hospital where the care is being provided OR

** If no prior SA hospital management, go to RAH, FMC or WCH for PEDES.

3. Any patient requiring orthopedic surgery should go to a spine hospital or TQEH.

** PEDES go to FMC or WCH

** Any patient with ‘Isolated single Joint pain’ + Signs of infection + Temp >38 degrees -> Also go to Spine hospital or TQEH

4. Patients likely requiring cardiology admission if any of the following is found, go to TQEH or spine:

• • An implanted defib has discharged within 24 hours
• • Pacemaker ‘failed to capture’ meaning, there is a pacing spike and no atrial or ventricular complex (no P wave or QRS). WITHOUT physiological compromise.
• • Innappropriate discharges of pacemaker on ECG, identified by SAAS clinican

5. Spine hospital or TQEH if there are signs of cardiogenic shock, with the following criteria:

• • Cardiac chest pain AND
• • Ischemic changes on ECG (T wave inversion, Q waves deep, ST Elevation)
• • Hypotension with SBP < 90 mmHg.

6. Any patient requiring endocrinology admission, oncology admission goes to TQEH or spine:

• • Patients with insulin pumps
• • Jaundice + a physiological abnormality
• • Severe community aquired pneumonia with any two of the following
• Reduced GCS
• <90% sats on RA
• RR > 30
• SBP < 90 mmHg

7. Patients who may require surgergy go to TQEH or spine:

• • Abdo pain
• • PR bleeds + Emesis of blood
• • Necrotic limbs or infection in feet or toes of diabetics (may require vascular surgeon).

8. Obstetric admissions go to TQEH or Spine:

• • PV haemorrhage that is:
• > 20 weeks gestation
• < 20 weeks + a physiological abnormality
• <2 weeks post-delivery

** Advanced labour or delivery

Question 115

Princples of ‘Narcotic overdose’ CPG?

Answer 115

The primary aim is:

1. Re-establish an airway
2. Effective ventilation by:

• • 02 delivery
• • The minimum dose of naloxone via any route.

3. IV is the preferred route.
4. Pede doses are aimed at complete reversal
5. Transport to definitive care is the DESIRED end point. (This may support maintaining a lower GCS to hospital).

Question 116

What is the treatment for adults and pedes in the ‘Narcotic overdose CPG’?

Answer 116

CPG SAYS: Basic care with a focus on achieving adequate oxygenation (This is achieved with airway + 02 + naloxone).

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. In adults consider:

• Naloxone 100 microg IV
• Naloxone 120 microg IN
• Naloxone 400 microg IM

3. In PEDES consider:

• > 6 years old give Naloxone 400 microg IM
• < 6 years old give Naloxone 200 microg IM.
• MAX PEDE dose for ANY PEDE age is 1600 microg.
• 1600 microg is 4 doses for >6 yrs old (4x4=16) or 8 doses for <6 yrs old (2x 8=16)

4. In newborns with respiratory depression from maternal opiate use should NOT be given naloxone.
5. In newborns:

• • Continue basic care
• • Consult EOC clinican

6. In narcotic overdose clinical support is only indicated if therapy is inneffective.
7. Transport (may not need to notify)

Question 117

What are the principles in the ‘nausea and vomiting’ CPG?

Answer 117

Principle:

• N + V can indicate significant underlying illness
• Control may assist in comfort + safety of patient
• Ondansatron to be used with CAUTION in patients with

** Hx of dystonic reaction (spasmodic or sustained involuntary contractions of muscles)

**hypersensitivity to any seratonin receptor antagonists.

Question 118

What is the treatment in the ‘nausea and vomiting’ CPG?

Answer 118

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Ondansatron in adults

• IM 4 mg
• IV diluted with 5 ml saline. Slow push over 1 minute
• Repeat once if required to max dose of 8 mg.

3. Ondansatron in PEDES.
   - 100 microg per kg INTRAMUSCULAR. This is just like midazolam. So 27 kilo is 2.7 mg.
   - Because its IM, you would probably need to give it NEAT
   - You will probably HAVE to use sunrise over sunset for this one. Strength required/Stock strength x total volume in stock vial.
   - You can do the calculation with MG or with microg. Doesnt matter as long as both sunrise and sunset are the same units. Answer should always be a decimal/fraction.
   - Max dose for any pede is 4 mg (adult dose).

Question 119

What are the principles for the ‘non-initiation of CPR’ CPG?

Answer 119

• CPR may not be appropriate in some cardiac arrests PARTICULARLY in obvious or irratrievable deaths
• Where appropriate, the clinican should respect the patients end of life wishes if they are in the ‘terminal phase of a terminal illness’.

Question 120

What is the treatment for the ‘non-intiation of CPR’ CPG?

Answer 120

1. CPR may not be appropriate where:

** The patient has an ACD, or the patient has made their wishes known, or a subsitute decesion maker, or a perscribed relative, person responsible ect. makes the patient wishes known.

2. There are obvious signs of death:

** Rigor mortis (Caution in cases of hypothermia, lightning strike, or drowning -> They will look dead).

** Morbid lividity (Blood pooling)

• • Injuries incompatible with life:
• Decapitation
• Transection
• Incineration
• Overwhelming trauma

3. Patient is

**Asystolic
** Pulseless
** Not breathing
** Fixed dilated pupils
AND
** has been unresponsive for >30 minutes prior to SAAS arrival with no active CPR.

4. CPR places the crew at significant risk of injury due to environmental hazards
5. Triaging has determined a more appropriate use of resources (MCI).

Question 121

What are the principles of the pain management CPG?

Answer 121

1. Pain management should not rely only on meds. Consider also:

• • Reassurance
• • Posture
• • Temperature
• • Splinting

2. The goal is to reduce pain to a ‘tolerable level’ and NOT complete pain relief.
3. Caution in patients >60 yrs old, for any ‘parentally administered analgesic agent’.
4. Fentanyl is the preferred parental agent in severe pain. Doses are HIGHLY variable between individuals.
5. Dose intervals should take into account:

• • Patients presentation
• • Medication peak onset and effect (peak blood concentration for fentanyl 5-8 minutes).

6. Intranasal fentanyl is the preferred route for fentanyl in children.
7. Where more than 1 med is used, consider interactions between them (Paracetamol + fentanyl).

Question 122

What is the treatment for the ‘ Pain management CPG?’ for patients >16 yrs old?

Answer 122

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Basic care includes SP02 monitoring + Pain score. Also includes the wong-baker faces in paediatrics.
3. In patients >16 years old with ‘ongoing uncontrolled pain’:

• • ICP backup?
• • Paracetamol (1 gram oral) if not taken in last 4 hours.
• • Methoxyflurane 3 ml inhaled. Repeat once if required.

4. In ‘Severe pain’, Stable GCS of 15 (or patients normal GCS), with as systolic BP >100 mmHg:

• • Fentanyl 25 - 50 microg
• IV slow push (over no less than 1 minute).
• Repeat at 5 minute intervals as required
• Maximum dose is 300 microg

OR

• • Fentanyl IV up to 200 microg IN
• Each Fent IN comes as 250 microg. 25 microg per spray. 25 microg to prime. 25 microg usually discarded. 8 sprays = 200 microg.
• Repeat at 5 minute intervals as required
• Total dose is 400 microg (Two vials once you discard the 50 microg (Prime + one sprasy discarded).

5. Consider clinical support in ‘significant or unresolved pain’.
6. If pain uncontrolled, consult with EOC clinican
7. TRANSPORT ( I dont believe you can TNT).

Question 123

What is the treatment for the ‘ Pain management CPG?’ for patients <16 yrs old?

Answer 123

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Basic care includes SP02 monitoring + Pain score. Also includes the wong-baker faces in paediatrics.
3. In patients <16 years old with ‘ongoing uncontrolled pain’:

• • Clinical support in ALL cases of significant pain
• • Paracetamol at 15 mg per kilo (Maximum dose of 1 gram), provided no intake within 4 hours.
• • Methoxyflurane 3 ml inhaled. Repeat once if required.

4. If a patient >1 yr old, and has severe pain, stable GCS with ‘an absence of any signs of poor perfusion’:

** Consult with EOC clinican for:

• Fentanyl up to 1.5 microgram/kg intranasal with a MAX dose of 75 micrograms).
• Repeat 5 minutely if required
• Fentanyl up to .5 microgram/kg IV.
• Maximum SINGLE dose of 25 microg.
• Repeated at 5 minute intervals titrated to effect
• Maximum cummulative dose of 2 microg/kg.

5. If pain uncontrolled, consult with EOC clinican
6. TRANSPORT ( I dont believe you can TNT).

Question 124

What are the principles of the ‘seizure’ CPG?

Answer 124

1. Seizures are a symptom of underlying disease processes.
2. Identifyable causes should be TREATED as SOON as possible -> Hypoglycemia, Hypoxia, Trauma, Hypertermia ect.
3. Midazolam is a first-line therapy for generalised seizures when there is risk of:
   - Injury
   - Hypoxia
   - Aspiration
4. Second-line therapy should be considered EARLY in ALL cases where siezures have continued following the FIRST dose of midazolam.
5. Assessment AND management should take into consideration ANY existing seziure management plans
6. Following cessation of seizure:

** Stable patients who have a prolonged generalised seizure require specialist review at a health facility with an INPATIENT service.

These include: FMC, RAH, LMH, WCH.

Question 125

What is the treatment for the ‘Seizure’ CPG?

Answer 125

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Consider and MANAGE treatable causes:
   e. g. If patient is having a hypo seizure, provide IV glucose prior to giving midazolam.
3. Consider EXISTING seizure management plans
4. If seziure is GENERALISED and lasting >5 minutes:

• • .1 mg per kilo (100 microg per kilo) IM to a max of 10 mg. No more than 5 ml per injection site.
• • Transport to the closest ED if seizure activity ceases, unless otherwise indicated in medical management plan.

5. If generalised seizure is unresolved or reoccurs 5 minutes AFTER the first dose of midazolam

• • Request clinical support
• • Second dose of midaz.

6. Transport for further care:

** Patients with unresolved seziure activity must be taken to the nearest ED

** Within metro for seizures >5 minutes following the first dose of midazolam, and have ceased following a SECOND dose of midaz, transport to an age appropriate ED with neurological service (RAH, FMC, WCH, LMH).

** If the patient is unstable -> nearest ED.

** Consider further clinical support (Retrieval team) for specific causes (closed head injury) or where patient does not respond to treatment, or prolonged transport.

Question 126

What are the principles of the severe head injury CPG?

Answer 126

1. Primary goals are avoid:

• Hypotension
• Hypoxia

2. Hyperventilation should ONLY be considered in extreme circumstgances where there is EVIDENCE of cerebral herniation
3. Evidence of herniation is:
   - Irregular or decreased respirations (caused by impaired brainstem function)
   - Bradycardia
   - Systolic hypertension (widening pulse pressure)
4. Laryngoscopy or i-gel with INTACT gag reflex may increase ICP and precipitate ADVERSE outcomes.

Question 127

What is the treatment in the ‘severe head injury’ CPG?

Answer 127

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Request clinical support
3. In the absence of suspected spinal injury -> Consider 30 degree head posture.
4. Ensure adequate oxygenation
5. For an average sized adult -> Give saline for a MAP of at least 90 mmHg.
6. Pediatrics:

** IF clinical support unavailable, consult with EOC clinican for .9% saline.

7. TRANSPORT + notify.

Question 128

What are the treatment principles of severely hypothermic patients?

Answer 128

1. They may be extremely unstable.
2. Focus on:

• Gentle handling
• Preventing further heat loss
• Be aware standard treatments may be ineffective until warming has occured.

3. Normal clinical indicators of death are unreliable in the hypothermic partient!
4. In the absence of obvious signs of death, resus should be continued until core temperature can be assessed.

Question 129

What is the treatment for hypothermic patients?

Answer 129

1. Universal care and life support -> DRABC + SDE -> History -> Phx -> Medn -> consider oxygenation where appropriate -> Posture -> ECG monitoring -> full set of obs.
2. Reduce heat loss:
   * * Remove wet clothes
   * * Remove contaact with cold surfaces/wind ect.
   * * Dry patient if wet
   * * Insulate patient with blanket, space blanket, blanket.
   * * Consider blanker under patient.
3. Active warming should ONLY be attempted in a controlled environment.
4. Minimise IV fluid administrationto minimise thermal after-drop (Cold blood from peripheries to the core, causing decrease in core temperature). As well as minimising resuscitation pulmonary complications.
5. In hypothermic patients with no signs of life, and no palpable output -> COMMENCE CPR

Question 130

Discuss extrictation as discussed in the spinal injury CPG.

Answer 130

Controlled self-extrication ->Not appropriate if the meets the nexus criteria. Also inappropriate if the patient meets high risk factors in the canadian C-spine rule.

Explain to the patient if they develop any numbness of tingling. To stop, and to await controlled extrication.

Controlled extrication:

This option is for patient in whom self-extrication is innappropriate, but the patient is not time critical. Manual in-line stabilisation is ideal. A 2ndary option if this is impossible is the use of a C-spine colar.

Rapid extrication:

Patients whom are deemed time critical, or at risk of deterioration need to be extricated immediately, despite potential for secondary injury, in the interest of life preservation.