Paediatric Treatment/mental health

Question 1

PAEDIATRIC
Mild-moderate asthma
define and treatment

Answer 1

Severity classified as normal conscious state, some increased work of breathing, tachycardia, speaking in phrases/sentences.

Salbutamol pMDI with spacer at 20 min intervals, with 4 breaths per dose (100mcg per actuation)
* Small child (2-5 years old): 2-6 doses
* Medium child (6+ years old): 4-12 doses

Adequate response
* Transport with reassessment, repeat salbutamol as necessary

Inadequate response after 20 minutes
* Treat as severe asthma

Question 2

PAEDIATRIC
Severe asthma
define and treatment

Answer 2

Severity classified as agitated/distressed, markedly increased work of breathing, including accessory muscle use/retraction, tachycardia, and speaking in words.

Salbutamol nebulised repeated at 20 min intervals if required.
o Small child (2-4 years old): 2.5mg (1.25mL)
o Medium child (5-11 years old): 2.5mg-5mg (1.25mL-2.5mL)
o (12-15 years old): 5mg (2.5mL)

Ipratropium bromide single dose
o Small child (2-4 years old): 250mcg (1mL)
o Medium child (5-11 years old): 250mcg (1mL)
o (12-15 years old): 500mcg (2mL)

Question 3

PAEDIATRIC
Critical asthma
define and treatment

Answer 3

Severity is classified as altered conscious state, maximal work of breathing, marked tachycardia, unable to talk.

Salbutamol (all children 2-15 years) 10mg (5mL) nebulised. Repeat salbutamol at 5 min intervals if required

Ipratropium bromide nebulised
o Small/medium child (2-11 years): 250mcg (1mL)
o Adolescent (12-15 years): 500mcg (2mL)

If unable to gain IV or unaccredited in IV
Adrenaline 10mcg/kg (max 500mcg) IM repeated at 5-10 min intervals as required, with a max dose of 30mcg/kg (3 doses)

Dexamethasone 600mcg/kg oral with a max dose of 12mg

MICA ONLY
- give adrenaline IV or if not improved adrenaline infusion

Question 4

Pain
Mild pain (1-3/10)
Paediatric

Answer 4

Paracetamol oral if not already administered in the past 4 hours
- child <12 years 15mg/kg oral liquid (presented in 120mg in 5mL) (unless < 1 month)
- Adolescent (12 - 15 years) tablet
(<60kg: 500mg)
(≥ 60kg: 1000mg

If pain is not controlled or rapid pain relief is required consider treating it as moderate

Question 5

Pain
Moderate pain (4-6/10)
Paediatrics

Answer 5

Consider Paracetamol as per mild in combination with opioids (unless <1 month old)

Fentanyl IN
* Small child (10-17kg): 25mcg initial dose with 25mcg repeat at 5-10 min intervals (consult after 3 doses)
* Medium child (18-39kg): 25-50mcg initial dose with a 25-50mcg repeat at 5-10 min intervals (consult after 3 doses)
* Adolescent (≥ 40kg): 50-75mcg initial dose with 50-75mcg repeat at 5-10 min intervals (consult after 3 doses)
* CONSULT WITH V MEDICAL ADVISOR FOR DOSES IN CHILDREN <10KG

For mild/moderate procedural pain or unable to administer fentanyl IN:
* Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles)

Question 6

Pain
Severe pain (8-10/10)
Paediatrics

Answer 6

Fentanyl IN +/- Methoxyflurane as per moderate pain below (consult for further doses of fentanyl IN if required)
* Small child (10-17kg): 25mcg initial dose with 25mcg repeat at 5-10 min intervals (consult after 3 doses)
* Medium child (18-39kg): 25-50mcg initial dose with a 25-50mcg repeat at 5-10 min intervals (consult after 3 doses)
* Adolescent (≥ 40kg): 50-75mcg initial dose with 50-75mcg repeat at 5-10 min intervals (consult after 3 doses)
* CONSULT WITH V MEDICAL ADVISOR FOR DOSES IN CHILDREN <10KG

For mild/moderate procedural pain or unable to administer fentanyl IN:
* Methoxyflurane 3mL inhaled, 3mL repeat if required with a max dose of 6mL (presented in 3mL bottles)

If pain persists despite opioid therapy
Adolescent (12-15 years):
* Morphine 0.05-0.1 mg/kg IV (max 5mg), which can be repeated up to 0.05mg/kg at 5-10 minute intervals (Max dose 0.2 mg/kg without consultation - around 4 doses)
* Can give ketamine but to be done by MICA

For children <12 years old Ketamine IV and morphine IV can be given but by MICA

LAST RESORT
IM morphine 0.1mh/kg IM single dose if unable to administer IN and the IV route is unavailable
- unless the patient is heavier than their age-calculated weight, the maximum dose should not exceed 5mg

Question 7

Paediatric
Anaphylaxis

Answer 7

SUSPECTED ANAPHYLAXIS
* stop the trigger (cease infusion, remove food or wash exposed skin)
* ANY patient with anaphylaxis (including resolved or possible anaphylaxis) or any patient who has received adrenaline for any reason, MUST be transported to the hospital as per clinical flags/patient safety
* Patient required continuous monitoring as deterioration can occur suddenly

ANAPHYLAXIS CRITERIA
Sudden onset of symptoms (usually <30 min or up to 4 hours)
AND
Two or more of R.A.S.H. +/- confirmed exposure it antigen
* R respiratory distress
* A abdominal symptoms
* S skin/mucosal symptoms
* H hypotension
Isolated hypotension following exposure to a known antigen
OR
Isolated respiratory distress following exposure to known antigen

ACTION
Do not sit or walk the patient if possible
* adrenaline 10mcg/kg IM (max 500mcg) (1:1000), repeat @ 5 minute intervals,s as required
* Request MICA if risk factors OR not responsive to initial adrenaline
* Provide high flow O2
* MICA can give an adrenaline infusion

ADDITIONAL THERAPIES IN ORDER OF CLINICAL NEED
Always prioritise adrenaline doses
Airway oedema/stridor
- (adrenaline 5mg nebulised, have to consult for repeat doses if needed and notify receiving hospital)

Broncospasam
Salbutamol nebulised or pDMI - reparation at 20 minute intervals
- 12-15 yr (5mg or 4-12 doses)
- 6-11 yr (2.5 - 5mg or 4-12 doses)
- 2-5 yr (2.5mg or 2-6 doses)
Ipratropium bromide
- 12-15 yr (500mcg or 8 doses)
- 6-11 yr (250mcg or 8 doses)
- 2-5 yr (250mcg or 4 doses)
Dexamethasone (600mcg/kg IV/oral, Max 12mg (IV ROUTE MICA ONLY)

MICA ONLY Cardiovascular - hypotension despite initial adrenaline
- consider normal saline

Extremely poor perfusion OR impending cardiac arrest
MICA can give adrenaline IV/IO

Question 8

Paediatric
hypoglycaemia

Answer 8

Evidence of possible hypoglycaemia
- diabetic, altered conscious state, agitation, pale, diaphoretic

ASSESS
- BGL
- Conscious state assessment

BGL 4-11
Consider other causes
- stroke
- Seizures
- Hypovolaemia

BGL <4 responding to commands
- glucose 15g oral
If inadequate response retry 15 minutes
- considering repeated glucose 15g oral titrated to response (max 30g)
- OR glucagon IM
MICA can give dextrose IV

BGL <4 not responding to commands
If not accredited in IV dextrose or unable to obtain IV access
- <25kg glucagon 0.5 IU (0.5 mL) IM
- >or equal to 25kg glucagon 1 IU (1 mL) IM
MICA can put IV in big vein and give dextrose 10% and normal saline

Question 9

Hyperglycaemia
paediatrics

Answer 9

Evidence if possible hyperglycaemia
- confusion
- Dehydration
- Tachyponea
- Polydipsia (excessive thirst)
- Polyuria (Passing abnormally large amounts of urine)
- Kussmaul’s breathing (haracterized by rapid, deep breathing at a consistent pace)

ASSESS
- BGL
- Perfusion status assessment

BGL 4-11
Consider other causes
- dehydration
- sepsis
- metabolic disorders

BGL >11
Less than adequate perfusion AND clinical features of DKA/HHS
- confusion
- Dehydration
- Tachyponea
- Polydipsia
- Polyuria
- Kussmaul’s breathing
- History of diabetes
Consider antiemetic per nausea and vomiting CPG
MICA can give saline

Question 10

Meningococcal septeceamia

Answer 10

Possibly, make sure you are wearing full PPE even

Confirm meningococcal septicaemia
typical purpuric rash
Septicaemia signs
- fever, rigor, joint and muscle pain
- Cool hands and feet
- Tachycardia, hypotension
- Tachypnoea

Meningeal signs
- headache, photophobia, neck stiffness
- Nausea and vomiting
- Altered consciousness
- Irritable or whimpering

ACTION
Have IV access - MICA can only do, to give ceftriaxone IV

No IV access
- unable to gain (MICA ONLY)
- Not IV accredited (MICA ONLY)
Give certriazone 50mg/kg IM (MAX 1000mg)
- dilute 1000mg with 3.5mL lignocaine 1%
- Administer into upper lateral thigh

Question 11

Paediatric
nausea and vomiting

Answer 11

Actual or potential for nausea and vomiting
ASSESS
- nausea and vomiting OR
- Potential spinal injury
- Potential eye trauma

UNDIFFERENTIATED NAUSEA AND VOMITING:
Ondansetron ODT orally
- small child: 2mg
- Medium child: 4mg
- Adolescent: 4mg (repeat 4mg after 5-10min if symptoms persist - max 8mg ODT/IV or in combination)
- MICA only - if they can get IV in they can give ondansetron

PROPHYLAXIS FOR:
- awake patient GCS 13-15 with potential spinal injury and immobilised
- Eye trauma - penetrating eye injury or hyphema (when blood collects inside the front of the eye)
ACTION
Ondansetron ODT orally:
- Small child: 2mg
- Medium child: 4mg
- Adolescent: 4mg

Question 12

Peadiatrics
Overdose

Answer 12

OPIOID-NAIVE
Naloxone 10mcg/kg IM (max 800mcg)
- repeat once at 10 minutes if required
MICA only - naloxone IV

OPIOID DEPENDENT
Naloxone 1-2mcg/kg IM (max 100mcg)
- repeat once at 10 minutes if required
- MICA only - Naloxone IV

TRANSPORT
any of the following:
- unable to maintain airway
- SpO2 <92% on room air
- Age <16 or >65
- Suspected aspiration
- APO
- Incomplete response to two doses of Naloxone
- Suspected opioid other than heroin including synthetic opioids
- Pregnancy
Action we do
Transport & monitor
- vital signs
- SpO2
- Nasal capnography may be used

Or
Referral
All of:
- IV opioid only
- Normal vital signs including GCS 15
- SpO2 >or equal on room air
- Chest clear on auscultation
- Competent adult available to supervise for 4 hours
Actions we do
- non transport may be appropriate
- Supply intranasal Naloxone to family/friends where community pack available
- Consider referral to drug support service
Safety netting
- Avoid other sedating agents e.g. alcohol, benzodiazepines
- Local resources
- Provide opioid health information

Question 13

Paediatric
seizures

Answer 13

SEIZURE ACTIVITY - ASSESS/MANAGE
- evidence of status epilepticus (>equal to 5 minutes of or >equal to 2 seizures without recovery), with GCSE or other SE (including subtle SE)
- Consider other causes e.g. hypoglycaemia, hypoxia, head trauma, stroke/ICH, electrolyte disturbance, meningitis
- Consider p patients own management plan and prescribed medication already given

SEIZURE ACTIVITY CEASED/OTHER SE/SUBTLE SE
- BLS
- Continue to monitor airway, ventilation, conscious state and BP
- If subtle SE suspected, consider time-critical transport to hospital and consult clinician for Midazolam IM

GENERALISED CONVULSIVE SE
- manage airway and ventilation as required
- if airway patent, administer high-flow O
Midazolam
- adolescent (12-15): 5mg IM
- Medium child (5-11): 2.5-5mg IM
- Small child (1-4): 2.5mg IM
- small and large infant (<12 months)1mg IM
- Newborn (birth to 24 hours) 0.5mg
Conti use to monitor airway, ventilation, conscious state and BP

SEIZURE ACTIVITY CEASES
- BLS
- Continue to monitor airway, ventilation, conscious state and BP

SEIZURE ACTIVITY CONTINUES >5 MINUTES
MICA ONLY - get IV access and give Midazolam IV
- can endotracheal intubate if needed

SEIZURE ACTIVITY CONTINUES > 10 MINUTES
no IV access/accreditation
- Repeat original Midazolam IM dose once only
- Consult for further doses
- Continue to monitor airway, ventilation, conscious state and BP

Question 14

Paeditratics
Croup
MILD ASSESSMENT/TREATMENT

Answer 14

• behaviour: normal
• Stridor: none or only when active
• Respiratory rate: normal
• Accessory muscle use: none
• SpO2: >equal to 96%

Care
- DEXAMETHASONE:
150mcg/kg oral (max 12mg)
- Self care
- Safety netting
- Provide RCH croup factsheet

Disposition: self care

Question 15

Paeditratics
Croup
MODERATE ASSESSMENT/TREATMENT

Answer 15

• behaviour: intermittent mild agitation
• Stridor: intermittent at rest
• Respiratory rate: increased
• Accessory muscle use: moderate chest wall retraction
• SpO2: >equal to 96%

Care
- dexamethasone:
150mcg/kg oral (max 12mg)

Disposition: VED ambulance referral

Question 16

Paeditratics
Croup
SEVERE ASSESSMENT/TREAMENT

Answer 16

• behaviour: increasing agitation/drowsiness
• Stridor: persistent at rest/ decreasing (late sign)
• Respiratory rate: marked increase/decrease (late sign)
• Accessory muscle use: marked chest wall retraction
• SpO2: <96%

CARE
ADRENALINE:
(Adrenaline 5mg (5mL, 1:1000) nebulised at 5 minute intervals until improvements)
DEXAMETHASONE (high dose):
(Dexamethasone (high dose): 600mcg/kg oral (max 12mg

Disposition: transport

Question 17

DOSE TABLE
for croup mediction

Answer 17

Dexamethasone: 150mcg/kg oral (max 12mg)
Dexamethasone (high dose): 600mcg/kg oral (max 12mg)
Adrenaline 5mg (5mL, 1:1000) nebulised at 5 minute intervals until improvements

Question 18

Unconscious patient asthma paediatric

Answer 18

Unconscious/becomes unconscious with poor or no ventilation but still with cardio output

PATIENT REQUIRES ASSISTED VENTILATION
ACTION
Ventilate: Use ventilation sufficient to achieve rise and fall of the chest
- small child 12-15 ventilations/minute
- Medium child 10-14 ventilations/minute
- Adolescent 5-8 ventilations/minute
Moderately high respiratory pressures
Allow for prolonged expiratory phase
Gentle lateral chest pressure during expiration

ADEQUATE RESPONSE
Treat as per critical asthma

INADEQUATE RESPONSE
- treat as per critical asthma
- MICA can intubate
If patient loses cardiac output at any stage move to loss of cardiac output asthma CPG

Question 19

Loss of cardiac output asthma paediatric

Answer 19

Patient loses cardiac output

PATIENT REQUIRED IMMEDIATE INTERVENTION
Apnoea 30 seconds
- exclude TPT
- gentle lateral chest pressure
- Prepare for potential resuscitation

CARDIAC OUTPUT RETURNS
Treat as per unconscious asthma

CAROTID PULSE, NO BP
MICA can give adrenaline and normal saline IV

NO RETURN OF CARDIO OUTPUT
Manage per approximate cardiac arrest medical CPG

Question 20

Paediatrics upper airway obstruction

Answer 20

SUSPECTED UPPER AIRWAY OBSTRUCTION
- newborns: not recommend for this guideline. Use suctioning as per CPG newborn

ASSESS
Identify possible cause

PARTIAL OBSTRUCTION
Effective cough
ACTION
passive technique
- encourage cough
- Utilise gravity
- Maintain basic life support

PARTIAL OBSTRUCTION
Ineffective cough
ACTION
Use manual technique as required
- Utilise gravity
- Back slaps alternating with chest thrusts
IF unconscious or becomes unconscious
- chest compressions
- Suction
- Magill’s forceps
- Forced ventilation
IF loss cardiac output
- treat as per cardiac arrest

CROUP
- treat per CPG

SUSPECTED EPIGLOTTIS
Do not inspect airway
ACTION
- Basic life support
- Treatment

Question 21

Sedation assessment - SAT assessment
+3

Answer 21

Responsiveness
- combative, violent out of control

Speech
- continual loud outburst

Sedation agent
KETAMINE
IM
- <60kg: 200mg
- 60-90kg: 300mg
- >90kg: 400mg
IV
50-100mg

Make sure you put restraints on after you have sedated the patient
need to put restraints on patient - check cap refill to make sure not to tight
(also monitor patient airway, blood pressure, add high flow oxygen, call MICA and watch out for hypersalivation)

Question 22

Sedation assessment - SAT assessment
+2

Answer 22

Responsiveness
- very anxious and agitated

Speech
- loud outburst

Sedation agent
DROPERIDOL - IM/IV
- 5-10mg repeat 5-10mg after 15 minutes if required (once only) OR
- 5mg (<60kg/frail/elderly/sedation from drugs or alcohol) repeat 5mg after 15 minutes if required (once only)

Think about whether you need to use restraints after sedation (most likely will need to, to protect yourself and the patient, check cap refill when put on restraints so that it is not to tight)

Question 23

Sedation assessment - SAT assessment
+1

Answer 23

Responsiveness
- anxious/restless

Speech
- normal/talkative

Sedation agent
OLANZAPINE - ORAL
- 10mg repeat initial dose after 20 minutes if required (once only) OR
- 5mg (<60kg/frail/elderly/sedation from drugs of alcohol) repeat initial dose after 20 minutes if required (once only)

Question 24

Sedation assessment - SAT assessment
0

Answer 24

Responsiveness
- awake and calm/cooperative

Speech
- speaks normally

Sedation
- none

Question 25

Sedation assessment - SAT assessment
-1

Answer 25

Responsiveness
- Asleep but rouses if name is called

Speech
- slurring or prominent slowing

Sedation
- none

Question 26

Sedation assessment - SAT assessment
-2

Answer 26

Responsiveness
- responds to physical stimulation

Speech
- few recognisable words

Sedation
- none

Question 27

Sedation assessment - SAT assessment
-3

Answer 27

Responsiveness
- no response to stimulation

Speech
- none

Sedation
- none

Question 28

Acute Behavioural Disturnace

Answer 28

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)

Question 29

mental illness assessment

Answer 29

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.

Question 30

Cardiac arrest (Paediatric)

Answer 30

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

Question 31

Paediatric pain assessment (FLACC)
0 points

Answer 31

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

Question 32

Paediatric pain assessment (FLACC)
1 points

Answer 32

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

Question 33

Paediatric pain assessment (FLACC)
2 points

Answer 33

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

Question 34

Paediatrics
Chest injury

Answer 34

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

Question 35

Paediatric
burns

Answer 35

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

Question 36

Cardiac arrest - After the first 2-minute cycle what do you do
Adult

Answer 36

• 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

Question 37

CPR script part 1 (coming up to patient)
adult

Answer 37

• 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

Question 38

CPR script part 2 (start of cardiac arrest)
adult

Answer 38

• 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

Question 39

CPR script part 3 (continuation of compressions)
adult

Answer 39

• 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

Question 40

If pulseless (VF/VT) what do you do
script

Answer 40

• 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

Question 41

If PEA what do you do
script

Answer 41

• 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

Question 42

What is considered reversible causes for CPR

Answer 42

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

Question 43

Traumatic cardiac arrest
adult

Answer 43

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

Question 44

traumatic brain injury
adult

Answer 44

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

Question 45

ACS
adult

Answer 45

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

Question 46

ACS
Elderly

Answer 46

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

Question 47

STEMI

Answer 47

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

Question 48

Nausea and vomiting
adult

Answer 48

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)

Question 49

Pain
Mild pain (1-3/10)
Adults

Answer 49

Paracetamol 1000mg oral (presented in 500mg tablets)

Question 50

Elderly/frail/<60kg
Mild pain (1-3/10)

Answer 50

Paracetamol 500mg oral

Question 51

Pain
Moderate pain (4-6/10)
Adults

Answer 51

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)

Question 52

Pain
Moderate pain (4-6/10)
Elderly/frail/<60kg

Answer 52

• 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)

Question 53

Pain
Severe pain (7-10/10)
Adult

Answer 53

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

Question 54

Pain
Severe pain (7-10/10)
Elderly/Frail/<60kg

Answer 54

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

Question 55

Adult
Chest injury

Answer 55

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

Question 56

How to do a needle thoracotomy and which side does it go in and why

Answer 56

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

Question 57

Spinal injury
Adult

Answer 57

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

Question 58

Neurological examination or spinal clearance

Answer 58

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

Question 59

Neck range of motion to be spinally cleared
Adult

Answer 59

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

Question 60

Shock and SEPSIS criteria and SIRS criteria
Adults

Answer 60

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

Question 61

Drug-induced hyperthermia
Adult

Answer 61

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

Question 62

Cardiac arrest - After the first 2-minute cycle Paediatrics

Answer 62

• 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

Question 63

Verification of death

Answer 63

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)

Question 64

Verbal De-escalation

Answer 64

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

Question 65

Unconscious patient

Answer 65

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)

Question 66

5Heads

Answer 66

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

Question 67

Head-toe traumatised

Answer 67

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