Guidelines Flashcards
Cardiac Arrest - Shockable
Commence CPR
Ratio 30:2
Defibrillate 200J Biphasic - repeat @ 2 mins
VF/VT Persists:
- Adrenaline 1mg IV Rpt: @ 4 min
- Amiorderone 300mg after 3rd shock
- Amiorderone 150mg after 5rd shock
Insert Igel
- CPR Ratio 15:1 uninterrupted
Reversible Causes (H’s and T’s)
Cardiac Arrest - Non-shockable
Commence CPR
Ratio 30:2
Do not shock - status check repeat @ 2 mins
Adrenaline 1mg IV Rpt: @ 4 min
PEA Persists
-20ml/kg Normal Saline
Insert Igel
- CPR Ratio 15:1 uninterrupted
Reversible Causes (H’s and T’s)
Cardiac Arrest - Hypothermic (>32, 30-32, <30)
> 32
Normal Management
30-32
Double dosage intervals
DO NOT warm above 33 with ROSC
<30 Continue CPR until warmed above 30* One shock only Single dose adrenaline Single dose amiodarone
Cardiac Arrest - Witnessed
Already monitored, and pads placed <20secs:
-If presenting in VF or VT, administer 3 quick successive defibrillation attempts without compressions
-Assess for rhythm changes and/or pulse after each attempt
- If 3rd shock is unsuccessful, manage as per medical cardiac arrest.
Cardiac Arrest - Traumatic Cause - Management
Catastrophic Haemorrhage
-Arterial Tourniquet
-Direct arterial compression
Airway Management
-Consider C spine
-SGA
-ICP ONLY ETT only if pt inadequate ventilation from SGA
Breathing Management
-IPPV with EtCO2 waveform
-Bilateral Chest Decompression
Circulation Management
-Pelvic Binder
-IV/IO Access
-Normal Saline 20mL/kg IV/IO
Cardiac compressions can occur simultaneously with the listed interventions only if it does not interfere with the treatment priorities and sufficient resources are available.
Cardiac Arrest - Traumatic -Reversible Causes
HOTT
Hypovolaemia
Oxygenation
Tension Pneumothorax
Tamponade (Cardiac)
Cardiac Arrest - Traumatic - Triad of Death
Hypothermia
Acidosis
Coagulopathy
Difficult Airway
Plan A:
Initial Intubation Attempt
Plan B & C:
Rescue Airway Strategies
Plan D:
Can’t Intubate, Can’t Oxygenate (CICO)
FONA:
Front of Neck Access
Foreign Body - Choking (Incomplete and Complete Obstruction)
ACDC
Airway
Cough
Delivery Back Blows
Chest Thrusts
Incomplete Obstruction:
Encourage Coughing
Transport
Complete Obstruction:
5x Back blows
5x Chest Thrusts
REPEAT until unconscious
Unconscious:
Manual Clearance
Laryngoscope and Magill’s
SGA
IPPV to forced ventilation
Loss of cardiac output - Commence CPR
ACS - Mx
FONA
Fentanyl (Pain Relief)
-Analgesia to reduce workload on the heart
Oxygen
-Normocytic therapy 94-98%
Nitrates
-0.4mg SL GTN @ 5 min if BP >100mmHg
Antiplatelet Rx
-Aspirin 300mg PO
Antiemetics if required:
Ondansatron
Note: Morphine delays Clopidogrel uptake
Bradycardia
BLS management
ICP ONLY Atropine
Tachycardia - Narrow Complex (SVT)
Asymptomatic:
- BLS
- 12 lead
- IV access
- Modified Valsalva Manoeuvre
- -Semi Recumbent
- -Pressure - syringe. Sudden Release
- -Supine - Legs up
Symptomatic:
- Modified Valsalva Manoeuvre
- No reversion - ICP Adenosine
Unstable:
ICP ONLY
Cardioversion
Adenosine
Tachycardia - Broad Complex
ICP MANAGEMENT ONLY
Torsarde de Pointes:
Mg Infusion
Stable:
Amiodarone
Unstable:
Caradioversion
AIVR - Accelerated Idioventricular Rhythm
Adequate Perfusion:
BLS
No Perfusion:
CPR - PEA
Inadequate Perfusion:
ICP MANAGEMENT ONLY
Pain Management - Mild
Consider NEED for pain relief.
Paracetamol 1000mg PO if not taken in past 4 hours.
-Not to be used to treat suspected ACS.
If not controlled or rapid relief required, elevate to moderate pain management.
Pain Management - Moderate
Consider paracetamol as per mild pain relief.
IV access Available:
- Morphine or Fentanyl IV as per severe pain.
- 0.05mg/kg MORP or 0.5mg/kg FENT
IV access unavailable or >10min delay: IN FENT up to 100mcg (total max dose 400mcg) or MXF 3ml (total max dose 6ml)
If unable to administer IN FENT or MXF:
0.1mg/kg IM Morphine or IM Fentanyl. (max single dose 10mg or 100mcg)
Rpt: Once after 20 mins.
Pain Management - Severe
IV access Available:
- Morphine or Fentanyl IV as per severe pain.
- 0.05mg/kg MOR or 0.5mg/kg FEN
- -max single dose 5g MOR, 50mcg FEN
- -Rpt: @ 5 mins.
- -max 20mg MOR or 200mcg FEN
If IV access unavailable:
As per moderate pain relief
Bronchoconstriction - Asthma - Mild/Moderate
Salbutamol pMDI
12 puffs @ 20 mins until symptoms resolve. (1200mcg)
If pMDI unavailable:
Salbutamol NEB 5mg in 2.5ml @ 5 mins as required.
No significant response after 20 mins, upgrade to Severe management.
Bronchoconstriction - Asthma - Severe
pMDI Salbutamol 12 x 100mcg spray @ 20 mins.
Consider repeat dose at 5-10mins
pMDI Ipratropium Bromide 8x 21mcg spray @ 20 mins.
(Burst therapy can repeat after 20 mins, max 3 burst doses.)
If spacer unavailable or not tolerated:
Salbutamol NEB 10mg in 5ml with Ipratropium Bromide 500mcg in 2ml
Repeat Salbutamol @ 5 mins.
Repeat IB @ 20 mins.
Consider Dexamethasone 8mg in 2ml IV/IM/PO
Further deterioration or no response: ICP ONLY Magnesium infusion
Bronchoconstriction - COPD
Salbutamol pMDI
-8 doses @ 10min interval
Ipratropium Bromide pMDI:
-4 doses at 10min interval
If pMDI unavailable or not tolerated:
Salbutamol 10mg in 5ml with Ipratropium Bromide 500mcg in 1ml NEB
Dexamethasone 8mg in 2ml IV/IM/PO
Altered Conscious State:
Assisted ventilation
Ventilate 5-8/min with 7ml/kg tidal volume
Allow prolonged expiratory phase
Gentle lateral chest pressure during expiration
Bronchoconstriction - Asthma - Life Threatening
Adrenaline 500mcg IM
Repeat @ 5 mins.
Salbutamol 10mg in 5ml with Ipratropium Bromide 500mcg in 1ml NEB
Normal Saline 20ml/kg
Dexamethasone 8mg in 2ml IV/IM/PO
ICP - Adrenaline Infusion 5mcg/min. Consider increasing dose 5mcg/min @ 2 min intervals
Magnesium 2.5g/5ml infusion
Bronchoconstriction - Asthma - Unconscious/Loss of Cardiac Output
Unconscious with Cardiac Output:
REQUIRES IMMEDIATE ASSISTED VENTILATIONS
IPPV with 100% O2 with a rate of 5-8/min
tidal Volume 7ml/kg
Moderately high respiratory pressure
Allow for prolonged expiration phase.
Lateral chest pressure if required.
Period of Apnoea for 1 min may be required due to gas trapping
Loss of Cardiac Output:
Commence Medical Cardiac Arrest
Nausea - Chest pain, Narcotics analgesia, Gastroenteritis, PMHx migraine
Metoclopramide 10mg IV/IM.
Rpt: Single @ 10mins
AND/OR
Ondansatron 4mg IV/IM
Rpt: Single @ 10mins
If dehydrated, manage as per Inadequate perfusion with hypovolaemia
Nausea - Prophylaxis Motion sickness, AMR
Prochlorperazine (Stemetil) 12.5mg IM
Ondansetron 4mg IV/IM
No repeat as per guidelines
Nausea - Prophylaxis for eye trauma, spinal injuries
Ondansetron 4mg IV/IM
Rpt: Once @ 10mins (max 8mg)
Nausea - Warnings
PROCHLORPERAZINE must not be given IV
Metoclopramide and Prochlorperazine must not be administered in the same episode of pt care.
Glycaemic Emergency - Hypoglycaemia
BGL <4mmol/L, responds to commands:
Glucose oral gel 15g
Poor response, consider IM Glucagon or IV glucose
BGL <4mmolL, doesn’t respond:
IV cannula in large vein. ENSURE IV PATENCY
Glucose 10% 15g (150ml) IV. Normal Saline flush.
If IV access unsuccessful:
IM Glucagon 1mg
Adequate response:
Cease glucose
Inadequate Response:
Rpt Glucose 10% 10g @ 5 mins. Normal saline flush.
BGL >4mmol/L
Consider other causes of altered conscious states. (AEIOUTIPS)
Seizures - Continuous or Recurrent Seizures
ENSURE CORRECT DOSAGES
Age <60yrs
Midazolam 0.1mg/kg IM (max single dose 10mg)
Continuous seizure after 10mins:
Rpt: Single IM Midaz 0.1mmg/kg
Age >60yrs
Midazolam 0.05mg/kg IM (max single dose 10mg)
Continuous Seizure after 10 mins:
Rpt: Single IM Midaz 0.05mg/kg
PAEDS:
Midaz 0.15mg/kg IM
Continuous Seizure after 10 mins:
Rpt: Single IM Midaz 0.15mg/kg
ICP ONLY
IV Midaz first line
Seizure activity after 5 mins, IV Midaz
Considerations: Protect Patient Airway and ventilations Other causes eg hypoglycaemia Patient's own management and Rx already given.
Anaphylaxis - Warnings
If pt Hx anaphylaxis and received treatment prior to AT arrival, pt MUST be transported to hospital for observation and follow up.
Anaphylaxis - Indications
RASH Respiratory Distress Abdominal symptoms Skin/mucosal symptoms Hypotension or Altered Conscious State
OR
Isolated hypotension/bronchospasm or upper airway obstruction with known antigen
OR
Single symptoms of R.A.S.H. with known contact with antigen and Hx anaphylaxis/severe allergic reaction
Inadequate perfusion - Non-cardiogenic/Non-hypovolaemic
FLUID MODIFYING FACTORS
Not for sepsis
Normal Saline 20ml/kg IV
ICP ONLY
Rpt 20ml/kg Normal Saline
Adrenaline Infusion
Additional 20ml/kg Normal Saline
Meningococcal Septicaemia
PPE
Evidence of septicaemia
-Typical purpuric rash
-Headache, fever, joint pain, ACS, hypotension, tachycardia
Ceftriaxone 2g IV
- Dilate each 1g in 10ml normal saline
- Administer slowly over 2 mins
Ceftriaxone 2g IM
- Dilute each 1g in 3.5ml Lignocaine HCl
- Multiple injection sites
Manage as per sepsis
Overdose - Narcotics (Partial and Complete)
ENSURE SAFETY - needles and sharps etc
Evidence of narcotics overdose (GCS <12 and RR <8
- Altered conscious state
- respiratory depression
- substances involved
- pin point pupils
- track marks
- exclude other causes eg head injury
Assist and maintain airway/ventilation (NPA preference)
-Consider LMA if ventilation >10mins
Partial
100mcg in 1ml IV naloxone @ 1 min (total max 2mg)
If no response after 1g, consider other causes and transport without delay.
Complete
800mcg IM Naloxone
Inadequate response - Rpt: 5 mins 800mcg naloxone IV/IM
Final repeat 400mcg (max total 2mg)
Overdose - TCA (amitriptyline)
Signs of TCA Toxicty:
- Inadequate perfusion
- Positive R wave >3mm in aVR,
- Prolonged QT intervals. (more than half R-R intervala)
- Wide QRS >0.12 indicated severe toxicity.
- QTc >500msec indicated toxicity
Management:
- ICP Backup
- Hyperventilate at 20-24/min, 100% O2
ICP ONLY
Sodium Bicarb infusion
Consider ET Tube
EtCO2 target 25-30
Overdose - Psychostimulants
Be safe. Monitor for aggressive behaviour Treat symptomatically -Acute Behavioural Disturbances -Seizures -Airway management -Chest pain as per ACS
Consider sedation if patient is hyperthermic
ABD - Acute Behavioural Disturbance
Sedation Assessment Tool (SAT) score
\+3 Aggressive \+2 Agitated \+1 Anxious 0 Normal -1 Rouse to voice -2 Rouse to pain -3 No response
SAFETY
Safety – self, partner, bystanders, pt
Aggression – be aware of triggers
Fix – organic causes, deescilate
Evaluate – assess patient, PSA, RSA, NSA, SAT
Tactical Communication – Listen, empathise, rapport
Yes to resources – TASPOL, oforms, ICP, mental health teams etc
SAT +1 Diazapam PO 10mg <60yrs 5mg >60yrs RPT: 60 mins
SAT +2 Droperidol IM 10mg if <60yrs or weight >50kg 5mg if >60yrs or <50kg RPT: Once after 15 mins (total max 20mg/10mg)
SAT +3 Droperidol IV 5mg RPT: 10 mins ICP ONLY Midazolam IV once only
IF UNRESPONSIVE TO DROPERIDOL:
ICP ONLY
Ketamine IM
IV midaz
Organophosphate Poisoning
Prenotification for patient is essential
Where possible, remove contaminated clothes and wash skin with soap and water.
Confirm evidence of suspected poisoning and excessive cholinergic effects
- Anticholinesterase on the label
- Salivation compromising airway or bronchospasm
- Bradycardia with inadequate perfusion
ICP ONLY
Atropine IV
Autonomic Dysreflexia
Pt Hx: Spinal chord injury T6 or superior
Severe headache
SBP <160
REMOVE STIMULUS
bladder distension
fractures, burns, pain, labour
If SBP >160 remains
GTN SL 0.4mg
RPT: @ 10 mins until symptoms resolve or BP <160
Trauma - Hypovolaemia
Consider Modifying Factors:
SCI, chest injury, trunk injury, AAA, uncontrolled haemorrhage
HR <100, BP >100,
Fluid not required
Either HR >100 OR BP <100
20ml/kg normal saline
ICP ONLY
RPT: 20ml/kg
Medical consult for further doses.
Trauma - Chest Injuries
Supplemental oxygen if required
Pain relief
Position pt upright if possible.
Flail Segment/Rib fractures:
Ventilatory Support
Splint to reduce paradoxal movement and further injury
Open Chest Wound:
3 sided dressing or chest seal
Pneumothorax
ICP ONLY
Needle decompression
Trauma - Severe Head Injuries
Fentanyl drug of choice for head injuries
AIRWAY:
If airway is patent and ventilation adequate, DO NOT insert NPA
OPA preferred in TBI
VENTILATION:
Maintain SpO2 >95%
Ventilate if required
Maintain EtCO2 35-40mmHg
PERFUSION:
Manage with normal saline as per inadequate perfusion.
General Care:
Treat sustained seizure activity with Midaz
Measure BGL and maintain normal levels
Trauma - Spinal Injury
Assess for major trauma guidelines
Meets Major Trauma Guidelines: Manage airway Provide spinal immobilisation Pain relief Immobilise and support fractures Manage hypovolaemia Transport without delay to major regional facility unless >60mins
NOT Major trauma guidelines: NEXUS 1 Age >60yrs 2 Hx bone disease 3 Unconscious or altered conscious state 4 Drug or alcohol affects 5 Significant distracting injury 6 Neuro or motor deficit 7 Spinal column pain/tenderness 8 If all of the above negative, and no pain on rotation 45* left and right, spinal immobilisation not necessary.
IF IN DOUBT, IMMOBILISE
Trauma - Burns
CAUTION - Airway burns, facial burns, hands, feet and genitals.
Rule of 9’s
Initial Management:
- Cool area. 20 mins. Running water if possible
- –Avoid overcooling
- Pain relief
- Cover with a dressing
- Monitor temperature
Partial or full thickness burns >10%
Normal saline 2ml/kg x TBSA over first 8 hours
Elevate burn if possible
Transport and pre-notify
Trauma - Fractures
Control external haemorrhage.
Support the injured area.
Immobilise the joint above and below fracture site.
Evaluate and record NVO distal to fracture site.
Pain relief and hypovolaemia management.
Realign long bone fractures as close to normal position as possible.
Open fractures with exposed bone should be irrigated with normal saline prior to realignment.
Femoral shaft fractures and 2/3 proximal tib/fib fractures should be managed with traction splint.
Pelvic fractures should have the legs splinted together, and pelvic splinting.
Trauma - Crush Syndrome
Definition: Compression injury >30mins
If less than 30 mins, or involves torso or head, remove crush immediately.
If >30 mins.
Establish IV and commence 500ml normal saline.
Pain relief
ICP ONLY
Widening QRS - Sodium Bicarb
Diving Emergency
MEDICAL CONSULT required to notify appropriate hospital.
Lay patient flat.
Antiemetics
Normal Saline 1000mL
Pain relief if required.
AVOID HIGH ALTITUDES
Decompression Sickness
0-36 hours post dive.
Ache, headache, SOB, rash, joint pain, seizure, paralysis, paraesthesia.
Hypothermia
Mild: 32-35
Moderate: 28-32
Severe: <28
Non Cardiac Arrest
Warm normal saline 10ml/kg IV
Repeat 10ml/kg (max 40ml/kg)
Hypothermic Cardiac Arrest
Alternative managment
Heat Stress
Accurately access temperature.
Cooling techniques: until temp <38*
- Remove from heat source
- Remove clothes except underwear
- Ensure airflow
- Apply tepid water using towels or spray bottles
AVOID SHIVERING as this may increase heat.
POOR RESPONSE AFTER 10 mins:
Transport without relay.
Obstetrics - Normal Birth
Positioning
APGAR 1, 5 and 10 mins if needed. Appearance Pulse Grimace Activity Resps
Obstetrics - PPH
> 600mls
Primary: First 24 hours
Secondary: 1 day to 6 weeks
Treat with inadequate perfusion with hypovolaemia
ICP ONLY
Medical consult for ergometrine
Obstetrics - Eclampsia
Pre-eclampsia: SBP >160mmHg DBP >90mmHg Peripheral/Generalised oedema GI disturbance
Eclampsia:
Hx preeclampsia
Seizure activity
Management: Preeclampsia: -Lateral position to avoid HTN -High flow O2 -Dark calm environment
Eclampsia
- ICP Backup
- If Mg infusion delay, manage as per seizures (0.1mg/kg IM MDZ)
ICP ONLY
Magnesium infusion
Paed - Pain Management
IN Fentanyl is first line agent for paediatric pain management
Consider MXF if unable to administer IN FEN. (procedural pain relief)
IM MOR is a last line agent.
Mild:
Paracetamol 15mg/kg PO
Moderate:
IN Fent
<25kg: 25mcg IN FEN
>25kg: 50mcg IN FEN
RPT: @ minimum 5 mins (consider longer) Total max 3x doses
Under 1 year (10kg) medical consult for pain relief.
Severe:
IM MOR 0.1mg/kg (max 5mg dose)
RPT: medical consult only
ICP:
IV MOR
IV FEN
KETAMINE
Paed - Upper airway Obstruction (Croup)
Mild/Moderate:
BLS
Severe:
Adrenaline 5mg in 5ml NEB
If no improvement:
RPT adrenaline 5mg/5ml NEB
ICP ONLY
Dexamethasone
Paed - Nausea
ICP ONLY
Ondansatron 0.1mg/kg IV/IM (max 4mg)
Ondansetron and Stemetil contraindicated <2yrs
Maxalon <8yrs contraindicated
Glycaemic Emergency - Hyperglycaemia
BGL >7mmmol/L
Pt unwell, requires medical assessment and treatment
BGL>12mmol/L
Normal saline bolus 250-500ml
If shocked, treat as per Inadequate Perfusion with hypovolaemia.
Anaphylaxis - Management
No anaphylaxis:
BLS
Monitor for deterioration.
Anaphylaxis: Monitor for arrhythmias Adrenaline 500mcg IM repeat @ 5 mins. Treat bronchospasm as per asthma Consider fluid resuscitation Consider NEB adrenaline 5mg/5ml for upper airway obstruction
PAEDS:
Adrenaline 10mcg/kg IM
Repeat @ 5 mins
Inadequate Response:
ICP ONLY
Adrenaline Infusion
Sepsis Management
qSOFA score <2 (HAT)
- Supplemental O2 if required
- Normal Saline
- -500ml bolus repeated until BP >100 (max 3L)
qSOFA >=2 As above including: -ICP Backup -Ceftriaxone 2g if transport >60min -Pre-notify
ICP ONLY
Adrenaline infusion
Trauma - Inadequate Perfusion - Fluid Modifying Factors
Spinal Cord Injury - Neurogenic shock given single 500ml bolus normal saline ONCE.
Chest injury - Consider tension pneumothorax. Treat as per chest injury.
Penetrating Trunk injury, suspected aortic aneurysm or uncontrolled haemorrhage (eg GI bleed) - Accept palpable carotid pulse with adequate conscious state and transport immediately.
Paed - Asthma
Mild/Moderate: 6 sprays (600mcg) @ 5 mins
5mg/2.5ml NEB Salbutamol if unable to use pMDI
Severe: Salbutamol MDI 6 sprays Ipratropium Bromide MDI: <6 yrs: 4 sprays >=6 yrs: 8 sprays
Salbutamol 5mg in 2.5ml NEB
Ipratropium Bromide 500mcg in 1 ml NEB
ICP ONLY
Mg infusion
Salbutamol IV
Dexamethasone IV/IM
Paed - Glycaemic Emergency - Hypoglycaemia
Responses to commands:
15g PO gel
Unresponsive:
Glucose 10% 5ml/kg
Unable to gain IV access:
<25kg - 0.5mg glucagon IM
>25kg - 1mg glucagon IM
ICP ONLY
RPT glucose 10% IV 5mg/kg
Paed - Seizures
Recurrent Seizures:
0.15mg/kg IM Midazolam
ICP ONLY: IV MDZ
If seizure continues after 10mins
RPT: original IM MDZ once
ICP ONLY
IV Midaz RPT after 5 mins
Intubation
Paed - Anaphylaxis
As per adult except:
Adrenaline 10mcg/kg IM
RPT: @ 5 mins
Consider nebulised adrenaline for upper airway swelling
ICP:
Consider IO access
Adrenaline infusion
Paed - Meningococcal Septicaemia
As per adult except:
Ceftriaxone Dose:
50mg/kg IV/IM (max 2g)
Manage as per Sepsis
Normal Saline 10mg/kg
RPT once after 15mins
Paed - Overdose - Narcotics
As per adult except:
No partial or complete
Naloxone Dose:
10mcg/kg IM (max 400mcg)
RPT: @ 10 mins
total max 2mg
