Paediatric Treatment/mental health Flashcards

Question

Sedation assessment - SAT assessment -1

Answer 1

Responsiveness - Asleep but rouses if name is called Speech - slurring or prominent slowing Sedation - none

Answer 2

Responsiveness - responds to physical stimulation Speech - few recognisable words Sedation - none

Answer 3

Responsiveness - no response to stimulation Speech - none Sedation - none

Answer 4

ACUTE BEHAVIOURAL DISTURBANCE Agitation, aggression or violent behaviour DANGERS Patient and paramedic safety is paramount Look for and manage as much as possible: - Clear egress - Sharps - ask the patient to empty their pockets and their bags/personal things - Potential violence - Body fluids - Environmental stimuli ASSESS Potential/correctable causes - Head injury - Unmet needs Establish - past history - Usual care plan SAT score ABLE TO MANAGE WITHOUT SEDATION OR RESTRAINT - continue verbal/environmental de-escalation strategies and transport to hospital - Manage as per requires restraint/sedation if level of agitation changes at any time - Consider consultation with TelePROMPT REQUIRES RESTRAINT/SEDATION Ensure sufficient physical assistance and planning before attempting interventions - Provide sedation as per agitation level/SAT score below - Aim for rousable drowsiness - Apply and remove restraints as appropriate to level of risk at that time MILD AGITATION (SAT SCORE +1) Cooperative and able to safety take an oral medication OLANZAPINE ODT oral: - 10mg repeat initial dose after 20 minutes if required (once only) OR - <60kg/frail/elderly/sedation from drugs of alcohol: 5mg repeat initial dose after 20 minutes if required (once only) MODERATE AGITATION (SAT SCORE +2) Very anxious/agitated/loud outburst DROPERIDOL IM/IV - 5-10mg repeat 5-10mg after 15 minutes if required (once only) OR - <60kg/frail/elderly/sedation from drugs of alcohol: 5mg repeat 5mg after 15 minutes if required (once only) OR MIDAZOLAM IM/IV (if droperidol contraindicated, known levy body dementia or Parkinson’s disease) MIDAZOLAM IM: - 5-10mg repeat 5-10mg after 10 minutes if required (once only) OR - 2.5-5mg (<60kg/frail/elderly/sedation from drugs of alcohol) repeat 2.5-5mg after 1- minutes if required (once only) MIDAZOLAM IV: - 2.5-5mg repeat 2.5-5mg at 5 minutes intervals, titrated to patient response OR - <60kg/frail/elderly/sedation from drugs of alcohol: 1-2mg repeat 1-2mg at 5 minutes intervals, titrated to patient response Midazolam max total dose 20mg (IM and IV) For suspected psychostimulant toxicity, consult receiving hospital for further Midazolam Droperidol ineffective after two doses: MIDAZOLAM IM: - 5-10mg repeat 5-10mg after 10 minutes if required (once only) OR - 2.5-5mg (<60kg/frail/elderly/sedation from drugs of alcohol) repeat 2.5-5mg after 1- minutes if required (once only) MIDAZOLAM IV: - 2.5-5mg repeat 2.5-5mg at 5 minutes intervals, titrated to patient response OR - <60kg/frail/elderly/sedation from drugs of alcohol: 1-2mg repeat 1-2mg at 5 minutes intervals, titrated to patient response Midazolam max total dose 20mg (IM and IV) For suspected psychostimulant toxicity, consult receiving hospital for further Midazolam SEVERE AGITATION (SAT score +3) Extraordinary and immediate risk KETAMINE IM: (consult AV medical advisor via AV clinician if patient remains agitated) - <60kg: 200mg - 60-90kg: 300mg - >90kg: 400mg KETAMINE IV: - 50-100mg REQUEST MICA POST - SEDATION Monitor the patient: - airway management (positions patient in lateral position) - Supplemental O2 (routine if sedated with ketamine) - Temperature management (hypo/hyperthermia) - Reassessment and management of clinical causes of acute behavioural disturbance - If sedated with ketamine manage hypersalivation (suctioning will be sufficient although if hypersalivation becomes to difficult to manage or airway is compromised treatment may include administration of atropine 600mcg IV/IM but only MICA can give it) Reassess and manage potential clinical causes IF HYPERTHERMIC/INCREASE MUSCLE TONE/SEIZURE ACTIVIST/ALCOHOL WITHDRAWAL: - Midazolam IM/IV (consult only) - MICA can due it with no consult If maintenance of sedation required, consider: OLANZAPINE ODT oral if cooperative: - 10mg repeat initial dose after 20 minutes if required (once only) OR - <60kg/frail/elderly/sedation from drugs of alcohol: 5mg repeat initial dose after 20 minutes if required (once only) OR DROPERIDOL IM/IV if unable to cooperate - 5-10mg repeat 5-10mg after 15 minutes if required (once only) OR - <60kg/frail/elderly/sedation from drugs of alcohol: 5mg repeat 5mg after 15 minutes if required (once only) OR MIDAZOLAM IM if Droperial contraindicated : - 5-10mg repeat 5-10mg after 10 minutes if required (once only) OR - 2.5-5mg (<60kg/frail/elderly/sedation from drugs of alcohol) repeat 2.5-5mg after 1- minutes if required (once only) MIDAZOLAM IV: - 2.5-5mg repeat 2.5-5mg at 5 minutes intervals, titrated to patient response OR - <60kg/frail/elderly/sedation from drugs of alcohol: 1-2mg repeat 1-2mg at 5 minutes intervals, titrated to patient response Midazolam max total dose 20mg (IM and IV) For suspected psychostimulant toxicity, consult the receiving hospital for further Midazolam NOTIFICATION - Physically or mechanically retrained - Escorted by police - Correct agitate (SAT >0) - Current altered conscious state (SAT <0)

Answer 5

Look for, listen to and ask about all the categories below The patient may be suffering from some of the following examples - remember verbal de-escalation strategies, active listening and calm/open language OBSERVE Initial approach When moving towards the patient, note when they open their eyes: - spontaneously on approach, - on verbal exchange, - in response to pain, or - no response. Safety - paramedic, patient and bystander safety is the first priority. Assess the scene for dangers (I.e. location, weapon). Obtain police support, early if required. Maintain vigilant reassessment of scene safety. Appearance (Determine whether the patient is alert, lethargic, obtunded, stuporous or comatose) - look for signs indicative or mental health issues or poor self-caring; uncleanliness, dishevelled, malnourished, sings of addiction (injection marks/nicotine stains) posture, pupil size and odour. Behaviour - patient may display; odd mannerisms, impaired gait, avoidance or overuse of eye contact, threatening or violent behaviour, unusual motor activity or activity level (i.e. wired or buzzing): buzzard/inappropriate responses to stimuli, pacing. Affect - observed to be; flat, depressed, agitated, excited, hostile, arguments, violent, irritable, morose, reactive, unbalanced, bizarre, withdrawn ect. LISTEN Orientation (person/ place/time) - Ask the patient what their name is, where they are, and what day, month and year this is. Speech - Take not of; rate, volume, quantity, tone, content, overly talkative, difficult to engage, tangential, flat, inflections ect. Thought process - may be altered, can be perceived by patient jumping irrationally between thoughts, sounding vague unsteady thought flow when communicating verbally Cognition - may be exhibiting signs if impairment such as; poor ability to organise thoughts, short attention span, poor memory, disorientation, impaired judgement, lack of insight DISCUSS Thought content - may be dominated by; delusion, obsessions, preoccupations, phobias, suicidal/depressed or homicidal thoughts, compulsions, superstitions Memory 1 - Ask the patient to remember three unrelated objects and repeat them back to you, e.g. apple, table, coin. Record how many trials it took for them to remember. Memory 2 - Ask the patient if they can remember the three objects that you asked them to remember earlier. Self-harm - as patient directly if they have attempted self-harm, sucked or are thinking/planning for those. Ask about previous attempts Perceptions - patient may be suffering from; hallucinations (ask specifically about auditory, visual and command hallucinations) disassociation i.e. ‘I feel detached from my body’, ‘my surroundings aren’t real’, ‘I am not in control of my actions’. Environment - risk factors include; lack of familial and social support, addiction or substance abuse, low socioeconomic status, life experience, recent stressors, sleeping problems or comorbidities (either physical or mental health conditions) Report - Accurately document/hand over findings. Accurate record-keeping and continuation of care.

Answer 6

Unconscious and not breathing normally History, mechanism of injury or injuries do not suggest traumatic cause of cardiac arrest ACTION - BVM ventilation (with OPA/NPA if required) - Apply multifunction electrode pads and perform pulse check PATIENT REMAINS UNRESPONSIVE - useless or HR <40 (child <12 years) or HR <60 (infant) VF/pulseless VT Prioritise High-performance CPR and timely defibrillation ACTION - defibrillate 4J/kg (max 20J) - Immediately recommence chest compressions MICA can give amiodarone IV and infusion Asystole/PEA/severe bradycardia Prioritise high-performance CPR ACTION - immediately recommence chest compressions PEA (consider reversible causes) - tension pneumothorax - upper airway obstruction - exsanguination - asthma - anaphylaxis - hypoxia FOR BOTH after the 2-minute cycle ALL CARDIAC ARREST PATIENTS ACTION - SGA (1 breathe every 6 seconds) MICA can do an ETT, give saline and adrenaline IV or Infusion

Answer 7

Face - no particular expression or smile Legs - normal position or relaxed Activity - lying quietly, normal position, moves easily Cry - No cry (awake or asleep) Consolability - content, relaxed

Answer 8

Face - occasional grimace or frown, withdrawn disinterested Legs - uneasy, restless, tense Activity - squirming, shifting back and forth, tense Cry - moans or whimpers, occasional complaints Consolability - reassured by occasional touching, hugging, or being spoken to, distractible

Answer 9

Face - frequent to constant frown, clenched jaw, quivering chin Legs - kicking or legs drawn up Activity - arched, rigid or jerking Cry - crying steadily, screams or sobs, frequent complaints Consolability - difficult to console or comfort

Answer 10

ALL PATIENTS WITH A CHEST INJURY - position sitting upright if possible - oxygen - pain relief PNEUMOTHORAX (open or closed) Mechanism - trauma - iatrogenic (relating to illness caused by medical examination or treatment) - spontaneous Signs - unequal breath sounds - subcutaneous emphysema - SpO2 <92% on room air ACTION - monitor closely for deterioration - do not occlude open pneumothorax - apply standard dressing if significant haemorrhage TENSION PNEUMOTHORAX (clinical deterioration AND suspected pneumothorax) - inadequate perfusion - increasing respiratory distress - SpO2 <92% despite oxygen - increased peak inspiration pressure/stiff bag - decreased ETCO2 MICA CAN DO - needle thoracostomy due to peri-arrest or when cardiac arrest is not imminent

Answer 11

Evidence of burn injury STOP Paramedic safety paramount - ensure safety and remove from the burn mechanism - avoid chemical contamination ASSESS THE MECHANISM OF BURN AND BURN INJURY - sings/symptoms of airway burns - mechanism of injury - the severity of the injury (%TBSA, estimated depth, other injuries, comorbidities) SUSPECTED AIRWAY BURNS If suspected airway burns, early involvement of senior airway expertise via AAV and/or PIPERn is essential PARTIAL OR FULL THICKNESS BURNS >10% TBSA - MICA can give saline ALL BURNS - treat pain per pain relief CPG - cool the burn for 20 mins and then warm the patient - apply the appropriate dressing - transport to the appropriate facility IF RESOURCES ALLOW MANAGE CONCURRENTLY

Answer 12

- get a supra-glottic airway in and start 15:1 If there is a second crew - gain IV access/normal saline TKVO - adrenaline 1mg IV repeat every 2nd cycle (or 4 minutes) flush all medication with 20-30mL normal saline Special circumstances Hypovolaemia/anaphylaxis/asthma: - normal slaine 20mL/kg IV

Answer 13

- PPE and check for danger - Conducting a dynamic risk assessment now and throughout this scenario - Will gain 360-degree access to the patient if possible - check for response verbal and pain - check for C spine damage - Airway - Breathing - Any pulse (circulation) and if any major haemorrhage - Fix airway/breathing before going to start CPR

Answer 14

- in cardiac arrest, start compressions 100-120 per minute, 5cm depth with a full chest recoil - call back up to confirm cardiac arrest - state ECG on screen and ask for agreement - continue compressions, everyone else clear - inspect the patient to check all clear - charging to 200 and move next to the person giving CPR, check ECG again and ask for agreement - tap the assistant's hand and say stop compressions (they need to reply with 'clear') - state ECG on screen and say shocking or disarm - continue compressions

Answer 15

- count to 15, 15-1 with nil pauses for ventilation - we are approaching the end of a 2-minute cycle - state ECG on screen and ask for agreement - continue compressions, everyone else clear - inspect the patient to check all clear - charging to 200 and move next to the person giving CPR, check ECG again and ask for agreement - tap the assistant's hand and say stoop compressions (they need to say 'clear') - state ECG on-screen and say shocking or disarm (if asystole/PEA) - continue compressions

Answer 16

- in cardiac arrest, start compressions 100-120 per minute, 5cm depth with a full chest recoil - call back up to confirm cardiac arrest - state ECG on screen and ask for agreement - continue compressions, everyone else clear - inspect the patient to check all clear - charging to 200 and move next to the person giving CPR, check ECG again and ask for agreement - tap the assistant's hand and say stop compressions (they need to reply with 'clear') - state ECG on screen and say shocking - continue compressions

Answer 17

- in cardiac arrest, start compressions 100-120 per minute, 5cm depth with a full chest recoil - call back up to confirm cardiac arrest - state ECG on screen and ask for agreement - continue compressions, everyone else clear - inspect the patient to check all clear - charging to 200 and move next to the person giving CPR, check ECG again and ask for agreement - find a CPR-generated pulse - tap the assistant's hand and say stop compressions (they need to reply with 'clear') - see if you can still feel a pulse if not disarm - continue compressions

Answer 18

- tension pneumothorax - upper airway obstruction - exsanguination - asthma - anaphylaxis - hypoxia

Answer 19

History, mechanism of injury or injuries DO NOT suggest medical causes of cardiac arrest MAJOR HAEMORRHAGE - prioritise control of major haemorrhage over all of the interventions Prioritise treatment of correctable causes of cardiac arrest over chest compressions and in order of clinical need ACTION - AIRWAY - ensure patent airway, oxygenation and ventilation - Supra-glottic airay ACTION - TENSION PNEUMOTHORAX - when accredited, decompress chest bilaterally ACTION - VOLUME REPLACEMENT - IV access - Normal saline 20mL/kg IV cardiac arrest persists despite addressing correctable causes ACTION - treat as per cardiac arrest CPG medical

Answer 20

HIGH RISK Any of: - moderate-severe TBI (GCA <13) - penetrating head injury High-risk features: - Any loss of consciousness exceeding 5 minutes - Skull fracture (depressed, open or base of the skull) - Vomiting more than once - Neurological deficit/pupil action or decreased GCS or spinal issues - Seizure - worsening signs and symptoms MANAGEMENT - airway management - breathing: ventilation/oxygenation - circulation: avoid hypotension if moderate-severe TBI suspected - supportive care TRANSPORT as per trauma triage MODERATE RISK Any of: - altered mental status (from baseline) dangerous mechanism of injury - motor/cyclist impact >30km/h - high-speed MCA >60km/h - pedestrian impact - ejection from the vehicle - fall from height >3m - struck on the head by an object falling >3m - explosion Amnesia ≥ 30mis Intoxication Age ≥65 coagulation/anticolagualtion/antiplatelt (not aspirin) MANAGMENT - transport (CT scene or observation required) - consider VVED if age and/or coagulopathy are the risk factors and no other concerning features LOW RISK - no high or moderate risk criteria - competent adult available to monitor patients for 4 hours Concussion symptoms - self-care (rest and reduce physical and cognitive activity like screen time, paracetamol for headache, do not drive or drink and be monitored for at least 4 hours) - safety netting (symptoms to look for like severe headache, repeated vomiting, confusion and agitation etc) - provide a health information sheet - GP follow-up (within 2-3 days) NO SYMPTOMS - safety netting - provide health information

Answer 21

Need to get a 12 lead on within 10 iminutes STOP request MICA early or aeromedical in suspected STEMI and provide early notification to hospital Adult: Antiplatelet treatment * Aspirin 300mg oral (presented in 300mg tablets) - if not already administered Pain relief (if required) * Glyceryl trinitrate 600mcg S/L (presented in 300mcg S/L) (300mcg if first time having GTN). Repeat 600mcg S/L (300mcg if first time having GTN) at 5 min intervals if required AND * Glyceryl trinitrate 50mg patch on upper arm or torso (presented in 50mg patch). Remove if BP falls under <100 If inadequate response or contraindicated for GTN DO NOT ADMINISTER PARACETAMOL OR KETAMINE IN SUSPECTED ACUTE CORONARY SYNDROME - follow pain relief guideline If IV access is available * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) If IV access is unavailable or delayed: * Fentanyl IN 200mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 400mcg (presented in 250mcg in 1mL) If other options are unavailable, unsuccessful or contraindicated: * Morphine IM 10mg with a 5mg repeat after 15 mins once only if required TRANSPORT STEMI * If onset <12 hours continue treatment as per STEMI management * if onset >12 hours transmit 12-lead ECG and provide hospital notification * notify ARV via clinician where the secondary transfer may be required NSTEMI/unstable angina - transport to the appropriate facility

Answer 22

Antiplatelet treatment * Aspirin 300mg oral (presented in 300mg tablets) - if not already administered Pain relief (if required) * Glyceryl trinitrate 300mcg S/L (presented in 300mcg S/L). Repeat 300mcg S/L at 5 min intervals if required AND * Glyceryl trinitrate 50mg patch on upper arm or torso (presented in 50mg patch). Remove if BP falls under <100 If inadequate response or contraindicated for GTN (patients who received GTN for the first time can be treated with Adult opioid doses) DO NOT ADMINISTER PARACETAMOL OR KETAMINE IN SUSPECTED ACUTE CORONARY SYNDROME If IV access is available * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) If IV access is unavailable or delayed: * Fentanyl IN 100mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 200mcg (presented in 250mcg in 1mL) If other options are unavailable, unsuccessful or contraindicated: * Morphine IM 0.1mg/kg once only TRANSPORT STEMI * If onset <12 hours continue treatment as per STEMI management * if onset >12 hours transmit 12-lead ECG and provide hospital notification * notify ARV via clinician where the secondary transfer may be required NSTEMI/unstable angina - transport to the appropriate facility

Answer 23

If you identify an acute infarct - Transmit ECG - Request MICA (ALS) - treat per ACS - Apply pads IF SYMPTOMS >12 HOURS, CONTINUE MANAGEMENT (Mx) PER ACS, TRANSPORT WITH NOTIFICATION TRANSPORT TIME TO PCI (Percutaneous coronary intervention) - - inclusion criteria - exclusion criteria - relative contraindications URGENT TRANSPORT TO PCI FACILITY - Time to PCI <1 hour OR - Does not meet all inclusion criteria OR - Meets one or more exclusion criteria STOP Paramedic should consult AV clinician if there is any uncertainty regarding the diagnosis of STEMI or thrombolysis ALS paramedics MUST consult AV clinician prior to administering Heparin - DO NOT DELAY ACTION - Continue Mx as per ACS - transport with hospital notification - Heparin IV bolus 4000 IU at 1-hour intervals (repeat Heparin IV bolus 1000 IU at 1-hour intervals) - Capture a repeat ECH 30 minutes before arrival and transmit to the receiving hospital with notification PREHOSPITAL THROMBOLYSIS - Time to pCI >1 hour AND - All inclusion criteria met AND - No exclusion criteria met STOP Paramedic should consult AV clinician if there is any uncertainty regarding the diagnosis of STEMI or thrombolysis ALS paramedics MUST consult AV clinician prior to administering Heparin - DO NOT DELAY ACTION - IV access x2 Normal saline TKVO - Complete the checklist and read the information statement to Pt - Tenecteplase IV bolus (table) - Heparin IV bolus 4000 IU at 1-hour intervals (repeat Heparin IV bolus 1000 IU at 1-hour intervals) - Transport with hospital notification - Transmit 12-lead ECG to receiving hospital - Capture a repeat ECG 30 minutes prior to arrival and transmit to the receiving hospital with notification

Answer 24

ASSESS FOR - nausea and vomiting OR - potential spinal injury - potential eye injury - potential motion sickness - vertigo STOP - prochlorperazine must not be given IV undifferentiated nausea and vomiting - Ondansetron 4mg ODT if tolerated with a repeat of 4mg after 5-10 mins if symptoms persist with a max dose of 8mg (presented in 4mg tablets) If the oral route is not tolerated or IV access is available: * Ondansetron 8mg IV with no repeat (presented in 8mg in 4mL) If Ondansetron is contraindicated/allergy: * Prochlorperazine 12.5mg IM with no repeat (presented in 12.5mg in 1mL) DEHYDRATED - less than adequate perfusion - consider normal saline IV (max, 40mL/kg) titrated to [patient response. Consult for further fluid and if unavailable repeat 20mL/kg IV *total of 60mL/kg) Adequate perfusion but significant dehydration - consider Normal saline 20mL/kg IV over 30 minutes VESTIBULAR NAUSEA - potential for motion sickness - planned aeromedical evacuation - vertigo If a patient is ≥ 21 years prochlorperazine 12.5mg IM (presented in 12.5mg in 1mL) If the patient <21 years of ondansetron as per nausea and vomiting PROPHYLAXIS FOR - awake patient with potential spinal injuries and immobilised - eye trauma e.g penetrating eye injury or hyphema ondansetron as per nausea and vomiting If known allergy to C/I to ondansetron and ≥ 21 prochlorperazine 12.5mg IM (presented in 12.5mg in 1mL)

Answer 25

Paracetamol 1000mg oral (presented in 500mg tablets)

Answer 26

Paracetamol 500mg oral

Answer 27

Paracetamol 1000mg oral (unless already administered) If IV access is available: * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) If IV access is unavailable or delayed: * Fentanyl IN 200mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 400mcg (presented in 250mcg in 1mL) OR * Ketamine IN 75mg initially, repeating 50mg doses at 20 min intervals as needed (presented in 200mg in 2mL) If other options are unavailable, unsuccessful or contraindicated: * Ketamine IN 75mg initially, repeating 50mg doses at 20 min intervals as needed (presented in 200mg in 2mL) initially if the minimal response to opioids OR * Morphine IM 10mg with a 5mg repeat after 15 mins once only if required For mild/moderate procedural pain: * Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles)

Answer 28

* Paracetamol 500mg oral (unless already administered) If IV access available: * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) If IV access unavailable or delayed: * Fentanyl IN 100mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 200mcg (presented in 250mcg in 1mL) OR * Ketamine IN 50mg initially, repeating 25mg doses at 20 min intervals as needed (presented in 200mg in 2mL) If other options unavailable, unsuccessful or contraindicated: * Ketamine IN 50mg initially, repeating 25mg doses at 20 min intervals as needed (presented in 200mg in 2mL)if minimal response to opioids OR * Morphine IM 0.1mg/kg once only For mild/moderate procedural pain: * Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles)

Answer 29

If IV access is available: * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) AND * Ketamine IN 75mg initially, repeating 50mg doses at 20 min intervals as needed (presented in 200mg in 2mL) - consult for ketamine IV if the pain remains severe following 2-3 doses (3-5 minutes between each medication to assess effectiveness) If IV access is unavailable or delayed: * Fentanyl IN 200mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 400mcg (presented in 250mcg in 1mL) AND/OR * Ketamine IN 75mg initially, repeating 50mg doses at 20 min intervals as needed (presented in 200mg in 2mL) AND/OR * Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles) AND/OR * Morphine IM 10mg with a 5mg repeat after 15 mins once only if required (only if opioid not already administered

Answer 30

If IV access available: * Morphine IV up to 5mg at 5 min intervals as required with a max dose of 20mg (presented in 10mg in 1mL) OR * Fentanyl IV up to 50mcg at 5 min intervals as required with a max dose of 200mcg (presented in 100mcg in 2mL) AND * Ketamine IN 50mg initially, repeating 25mg doses at 20 min intervals as needed (presented in 200mg in 2mL) - consult for ketamine IV if the pain remains severe following 2-3 doses (3-5 minutes between each medication to assess effectiveness) If IV access is unavailable or delayed: * Fentanyl IN 100mcg initially, repeating 50mcg doses at 5 min intervals as needed with a max dose of 200mcg (presented in 250mcg in 1mL) AND/OR * Ketamine IN 50mg initially, repeating 25mg doses at 20 min intervals as needed (presented in 200mg in 2mL) AND/OR * Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles) AND/OR * Morphine IM 0.1mg/kg once only (only if opioid not already administered

Answer 31

ALL PATIENT WITH A CHEST INJURY - position sitting upright if possible - oxygen - pain relief PNEUMOTHORAX Mechanism - trauma - iatrogenic - spontaneous Signs - unequal breath sounds - subcutaneous emphysema - Spo2 <92% on room air Ultrasound (if credentialed) - absent lung sliding - absent B lines - lung point MANAGEMENT - monitor closet for deterioration - do not occlude open pneumothorax - apply standard dressing if significant haemorrhage TENSION PNEUMOTHORAX (clinical deterioration AND suspected pneumothorax) - inadequate perfusion - increasing respiratory distress - SpO2 <92% despite oxygen - increased peak inspiratory pressure/stiff bag - decreased ECTO2 PERI-ARREST - response to pain or unresponsive (AVOP) AND BP <70: needle thoracotomy on the affected side MICA can do needle thoracotomy on all patients

Answer 32

Second intercostal space Mid-clavicular line Above the third rib Right angle to the chest Towards the spine The patient's right side should be decompressed first to minimise the risk of the needle puncturing the hear

Answer 33

Any mechanism of injury of traumatic injury with the potential to cause spinal cord injury (SCI) SUSPECTED SCI OR MAJOR TRAUMA - major trauma following blunt trauma to the head or trunk - neurological deficit ACTION - spinal immobilization - extricate on combi-carrier if necessary - consider propluactic antiemetic (anti nausea) - transport as per time-critical guidelines ISOLATED SPINAL CORD INJURY - nasal capnography - normal saline 5oomL. if BP <120mmHg OTHER TRAUM PATIENTS Increase injury risk - age ≥65 - history of vertebral disease/abnormalities Difficult assessment - altered conscious state - intoxication - significant distracting injury Evidence of structural injury - midline pain/tenderness on palpation Reduced neck range of motion - unable to rotate neck 45 degrees left and right CERVICAL SPINE NOT CLEARED ONE OR MORE criteria present ACTION - spinal immobilisation - extricate on combi-carrier if necessary consider self-extrication it patient this: - conscious and co-operative - not-intoxicated - not prevented by injury Consider prophylactic antiemetic

Answer 34

Motor function any weakness when asked to: - arms: grasp/pull/push - legs: push/plantar flex, pull/dorsiflex, leg raise Sensory function reduce or no sensation when applying light touch to the following: - Arm: light touch across the pal and back of the hand - Legs: light touch lateral side of the calcaneus OTHER - the patient should be questioned regarding numbness, tingling, burning or any other altered sensation, anywhere in the body - If ANY of the above criteria are present, the patient should be considered to have a neurological deficit and CANNOT be spinally cleared - the left arm and right sides should be tested simultaneously to compare strength between sides of the body

Answer 35

test for pain or restricted range of motion by asking the patient to: - turn their own head slowly to the left and right - approximately 45 degrees each way and stopping if they feel any pain or resistance DO NOT TUEN PATIENT'S HEAD FOR THEM

Answer 36

SIRS criteria: - <36 degrees OR >38 degrees - HR >90 - RR >20 SEPSIS signs and symptoms suggestive of infection - general: fever, chills, rigours, malaise (generally feeling discomfort, illness, or lack of well-being) - neurological altered mental status or actual deterioration in ADL's, headache, meningism (neck stiffness) - Respiratory: cough, dyspnoea - Abdominal: pain, rigidity, tenderness, guarding, swelling - Genitourinary: dysuria (discomfort, pain or burning when urinating), urinary frequency or urgency, haematuria (blood in the urine) - Skin: cellulitis, petechial rash, septic arthritis, infected wound of abscess RISK FACTORS - neutropenia, recent chemotherapy, or other immunocompromise - recent pneumonia, COPD - recent trauma/surgery/procedure or hospital stay in last 6 weeks - Indwelling medical devices (urinary catheter etc.) SHOCK MANAGEMENT - risk factors of (history of cardiac failure, chronic renal failure and elderly) - titrate normal saline to response MAX 100mL - All other patients titrate to response MAX. 2000mL SEPSIS Should be suspected where there is a known or suspected source of infection (+/- risk factors for Sepsis or SIRS criteria) and symbolic blood pressure <100mmHg Reduces max fluid dose - elderly/history of chronic renal failure/history of cardiac failure: 500Ml - all other patients: 1000mL Transport time >30 minutes: consult AV medical advisor via AC clinical for ceftriaxone 2g IV

Answer 37

Suspected exposure to agent associated with drug-induced hyperthermia - amphetamines - cocaine - lithium - MAO inhibitor - MDMA/ecstasy - PCP - SSRIs/SNRIs - tramadol PATIENTS MAY BE AGITATED - safety procedures per acute behaviour disturbance CPG MODERATE TOXICITY - Hyperthermia 38degrees - 39degrees AND - altered conscious state/agitation AND - tremor, increased muscle tone ACTION - escalate care/request MICA - sedate: midazolam (the acute behaviour doses) - cool - hydrate: normal saline 1000mL (risk of cardiac failure or elderly) - 2000ML SEVERE TOXICITY - Hyperthermia (≥ 39degrees) AND - altered conscious state/severe agitation AND - muscle rigidity, seizure activity ACTION First line - manage as per moderate toxicity (above) - severe agitation - sedate patient as per acute behavioural disturbance - prepare airway adjuncts and ventilation equipment MICA can consider intubation if there is an inadequate response or loss of airway

Answer 38

- If can get a supra-glottic airway do 1 breathe every 6 seconds (10 breathes per minute) - If only OPA in do a 15:2 stopping to allow for breaths MICA is only allowed to give adrenaline and other medication flush all medication with 20-30mL normal saline

Answer 39

It is established that death has occurred after a thorough clinical assessment of a body The 6 determinants of death - no palpable carotif pulse - no heart sounds hear for 2 minutes - no breath sounds heart for 2 minutes - fixed (non-responsive to light) and dilated pupils (may be varied from underlying eye illness) - no response to centralised stimulus (supraorbital pressure, mandibular pressure or sternal pressure) - no motor (withdrawal) response or facial grimace to a painful stimulus (pinching inner aspect of elbow or nail bed pressure) ECG strip that shows asystole over 2 minutes is a seventh and optional finding that may be included (should really be evaluated over 5-10 minutes after cessation of resuscitation to ensure late ROSC does not occur)

Answer 40

Prepare paramedic: - Don PPE, including eyewear, respiratory mask, and gloves. Self-Awareness: - Conscious of own beliefs, values, and identity. - Understand and be aware of emotional reactions, thoughts, and communication skills. Nominate who will lead the interaction - Allow time. - Do not rush Non-Verbal - Maintain an open and relaxed posture (by not crossing your arms, placing hands on hips or in pockets, finger wagging/prodding, or clenching fists) - Use culturally appropriate eye contact to show interest in the patient (Attempt to be at the patient’s eye level) - Explore the environment with your eyes to recognise patient’s interests, including cultural boundaries. - Respect the patient’s personal space (give at least two arms length, do not stand over the patient, minimise sudden movements) Prepare patient: - Introduce yourself and your role, explaining that you are hear to help (also introduce your partner and/or other services) - Ask for and use their preferred name (Consider enquiring about other cultural characteristics, such as: Aboriginal and/or Torres Strait Islander identity, Pro-nouns., Gender Identity) Prepare the environment - Remove bystanders and unnecessary staff - Consider the impact of sensory needs (lighting, noise, sensory items) - Keep exits clear and accessible - Remove potentially dangerous items - Make available food, drink, toilet, and bedding - Allow appropriate access to phone calls. - Consider nicotine therapy, or a replacement. Listening - Actively listen to observe, hear, and understand the patient, by using: (Verbal remarks, Facial expressions, Verbal encouragers (e.g. ‘uh-huh’, ‘go on’). - Use of silences to allow the patient to consider their responses. Clarification - Clarify to determine that the message being sent is what you are hearing or understanding. - Paraphrase to reflect/clarify what was said. Feedback - Interaction should: * Be respectful. * Thoughtful * Honest * In a friendly tone of voice. * Verbalise observed behaviour and information (e.g. you seem upset). * Concerned and interested tone of voice * Summarise overall points discussed. * Be centred on their needs. o Avoid personal information, views, or feelings. o Avoid threats, orders or advice. o Avoid arguing points. Questioning Questions should be: * Clear * Concise o Address only one topic. * Easily understood. o Use simple words * Open-ended. * Used to explore information. Find solutions Find solutions by: * Working together to compromise and problem-solve. * Being flexible * Offering realistic choices and options * Explain and give reasons for rules and decisions. * Ask “Is there anything I can do to help us work through this together?” * Apologise if the solution did not work as expected. Report Document and hand over procedure and responses

Answer 41

AEIOUTIPS A - alcohol (Confusion, Dysphasia, Unsteady Gait, Aggressive/Bizarre behaviour) - acidosis - arrhythmia - asthma (Difficulty breathing, Bronchospasm, Cough) - anaphylaxis (Difficulty breathing, Nausea, Vomiting, Diarrhoea, Rash - Hives, Urticaria, Hypotension) E - epilepsy (Seizure activity, Rapid onset, Urinary incontinence) I - infection/sepsis (Tachypnoea, Tachycardia, Diaphoresis, Hypotension) O - Overdose (Opioids) - Hypotensive, Bradycardia - pin point pupils - Overdose (Amphetamines) - Anxiety, Tachycardia, Diaphoresis, Seizure - dilated pupils U – underdose - uremia (Uremia is a buildup of toxins in your blood. It occurs when the kidneys stop filtering toxins out through your urine) - Confusion, Fatigue, Cramping in legs T - trauma (Perform a Head-Toe Secondary Survey) I – insulin hypoglycemia (Abnormal respiratory pattern. Pale, cold and clammy skin, Tachycardia) – insulin hyperglycemia (Increased respiratory rate, Polyuria, Polydipsia, Polyphagia, Dehydration) - Infarction (Diaphoretic, Anxious, Pale, Tachycardic, Hypotensive) P – pain (FLACC) – psychiatric/mental health (Bizarre Behaviour, Preform a Mental Status Assessment) – pregnancy S – stroke (Dysphasia, Unsteady Gait, Facial droop, Unequal hand grip strength) - TIA/syncope (fainting)

Answer 42

To determine TBI there could be any of the following - GCS = 13-15 - Mechanism of injury of blunt head/face trauma loss of consciousness and/or +/- amnesia - With the following 1 or more of: 5Heads - Any loss of consciousness exceeding 5 minutes - Skull fracture (depressed, open or base of the skull) - Vomiting more than once - Neurological deficit/pupil action or decreased GCS or spinal issues - Seizure

Answer 43

HEAD Overall looking for Lacerations/Deformity/Facial muscle/Asymmetry General crepitus, bony tenderness, subcutaneous emphysema (air under the skin) Irregular pupils (one really dilatated, bleeding – PEARL) Racoon eyes (base skull fracture) Bruising behind the ear (battle sign) – base skull fracture CFS fluid/if bleeding will be a yellow colour Halo sign – put cloths in ear and there may be blood in the centre and then yellow around the outside Teeth – broken/smashed/missing (run tongue around the mouth) – bleeding cuts in the mouth or swelling of the tongue Bleeding/cute/laceration Boggy mass – skull fracture La fate fractures/jaw (clench teeth and does it feel different) Nose fracture/ deformity, bleeding Headaches/amnesia/lightheaded/dizzie/tinnitus (ringing or buzzing in the ear)/photosensitivity Singed facial hairs for burns, soot and swelling/oedema (also look in the throat) NECK Deformity/laceration/raised JVP (jugular venous pressure – not easy to see) Bony tenderness, carotid pulse Tracheal deviation – tension pneumothorax (signs = sharp chest pain, increased respiratory rate, shortness of breath, decreased BP) Hoarseness voice (struggle to swallow) C spine deformity/pain – feel the c spine itself (increased bumpiness, bone out of line, tenderness/pain CHEST Expansion/laceration/deformity/accessory muscle movement/tenderness Paradoxical breathing (failed chest, rib fracture 3 ribs in 2 or more places) – due to the negative and positive pressure C3/C4/C5 nerves – control the diaphragm (also paradoxical breathing) Apply gentle pressure (spring the ribs) Check the sternum Look for fractures or dislocations Shallow breathing/diminish breathe sounds Subcut emphysema – air pockets under the skin (tension pneumothorax) Heart sounds, air entry and breath sounds, or additional sounds ABDOMEN laceration/bruising/distension (bloating and swelling) rigidity/guarding/grimacing Check-in quadrants – 4 (right and left upper and lower) The right upper – portion of the liver, gallbladder, right kidney, a small portion of the stomach, portions of the ascending and transverse colon, and parts of the small intestine Left upper – the left portion of the liver, the larger portion of the stomach, the pancreas, left kidney, spleen, portions of the transverse and descending colon, and parts of the small intestine Right lower – the cecum, appendix, part of the small intestines, the right female reproductive organs, and the right ureter Left lower – the majority of the small intestine, some of the large intestine, the left female reproductive organs, and the left ureter The liver and spleen are not hollow so are more likely to cause an issue Distension (pushed outwards) – due to fluid retention in the bladder/peritoneal cavity (can hold 5 litres) (contains the organs??) Roll motion to see whether it is soft or firm PELVIS Laceration/bruising/deformity Checking for alignment - shortening if the leg Checking for pain - light palpation Bony tenderness Lift leg to see if they can do that LIMBS Laceration/bruising/deformity Shortening Rotating Pain Open wounds Check movement – does it hurt Checking if not able to move a particular way Neurovascular status Check cap refill – checking blood supply to limbs No cap refill (single) = Compartment syndrome, clots No cap refill on both = may be an injury higher up, or there is a perfusion injury Check sensation, push-pull, sensation Compare limbs to each other BACK Laceration/deformity/bruising Bony tenderness Evidence of a bony step Subcutaneous emphysema Pain Check spine is in place