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)
* 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
- 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

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)

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
MICA can do an ETT, give saline and adrenaline IV or Infusion

Question 31

Paediatric pain assessment
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
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
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
Major Trauma

Answer 34

Major Haemorrhage control

AIRWAY
- airway manoeuvres and positioning (OPA only if airway not patent)
- SGA if no gag reflex and prolonged ventilation is required
MICA an intubate

BREATHING
Oxygen
OR
Ventilate if required
- 6 - 8mL
RATE
- <3 months: 25
- 3-12 months: 25
- 1-4 years: 20
- 5-11 years: 16
- 12-15 years: 14
Suggested starting rats. Adjust to EtCO2 target
SPo2
- >95%
EtCO2
- 30-35 mmHg
MICA can consider chest decompression as per Chest Injury

CIRCULATION
First line
FLUID RESUSCITATION targeting adequate perfusion
- 12-15 years: HR(60-130) BP(90)
- 5-11 years: HR(80-140) BP(80)
- 1-4 years: HR(90-160) BP(70)
- 3-12 months: HR(100-180) BP(60)
- <3 months: HR(100-180) BP(50)
Normal saline IV *mac 40mL/kg) titrated to response
- consult AV medical advisor via AV clinician for further management if inadequate response
MICA can give a blood transfusion
PELVIC SPLINT (if blunt trauma to the pelvis or for all unconscious multi-trauma patients
CONSIDER OTHER CAUSES OF SHOCK (haemorrhage control, chest decompression, pelvic splint, ventilator strategy, anaphylaxis to medication)

SUPPORTIVE CARE
- warm the patient
- pain relief as required
- spinal immobilisation if required
- management of wounds/fractures
- seizures per CPG
- hypoglycaemia as per CPG
- pressure care

Question 35

Paediatrics
Chest injury

Answer 35

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 CTCO2
MICA CAN DO
- needle thoracostomy due to peri-arrest or when cardiac arrest is not imminent

Question 36

Paediatric
burns

Answer 36

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