SELECTED/EDITED SAAS ICP GUIDELINES 2018 (Modified) (16)

Question 1

ACUTE ADRENAL INSUFFICIENCY, ICP CPG

Answer 1

This life threatening condition is caused by acute CORTISOL (= Hydrocortisone) deficiency due to:

• loss of Pituitary drive (ACTH)
• Adreno-cortical failure (auto immune, TB, severe illness)
• Abrupt cessation of oral steroid therapy

It causes

• nausea/vomiting/abdo pain
• muscle pain and weakness
• hypovolaemia, hypoglycaemia and hyperkalemia, and may present with acute collapse (ADDISONIAN CRISIS)

Rx

• Address the ABCs, esp hypovolaemia and hypoglycaemia
• give NS 10ml/kg (max 3x) for hypotension
• give HYDROCORTISONE 100mg IV/IM/IO (kids 4mg/kg)

Question 2

AMPUTATION, ICP CPG

Answer 2

Address the ABCs, esp haemorrhage control via direct pressure, arterial pressure points, or, as a last resort, a close proximal TQ

• preserve the part for later re-implantation by sealing dry in a plastic bag floating in ice water (DO NOT place directly in ice water)

Question 3

ANAPHYLAXIS AND ALLERGY, ICP CPG

Answer 3

Address the ABCs, &

• If MILD - MODERATE (Allergy):
  
  • give NS IV KVO
  • consider FEXOFENADINE 180mg O
• If SEVERE (anaphylaxis):
  
  • give ADREN 500mcg IM stat (kids 10mcgkg), then if more needed:
    
    • repeat IMI 5/60 prn or
    • 50mcg IV prn, or
    • 500mcg in 500mls NS titrated
  • give NS IV for hypotension
  • give HYDROCORT 250mg IV (kids 4mg/kg IV/IO)
  • if IPPV reqd, use small, slow breaths

Question 4

AUTONOMIC DYSREFLEXIA, ICP CPG

Answer 4

Autonomic Dysreflexia = exaggerated SNS responses to normally benign stimuli, and can occur with cord injuries above T6, causing severe HT with seizures and ICH

Address the ABCs, and known causes (eg blocked catheter), then, for severe hypertension:

• give GTN* 400mcg SL 5/60 provided no focal signs of CVA & no Viagra etc in last 24-48h
• transport for further care

* this is the only SAAS guideline which uses GTN to manage HT

Question 5

BRADYCARDIA, ICP CPG (slightly modified from SAAS)

Answer 5

Address the ABCs, including hypoxia (particulary in children), IV access & 12 lead, then:

1. if PERFUSION ADEQUATE:
   
   • transport
2. if PERFUSION POOR:
   
   • give ATROPINE 600mcg IV prn (kids 20mcg/kg) max 3mg
   • consider ADREN infusion 500mcg/500ml NS titrated
   • consider transcutaneous pacing, with or without sedation.

Question 6

CARDIOGENIC PULMONARY OEDEMA (ACUTE), ICP CPG

Answer 6

Address the ABCs, including posture, oxygen & 12 lead ECG, then:

• give GTN 400mcg SL 5/60 prn provided BP adequate and no VIAGRA etc in last 24-48h, consider GTN infusion
• give CPAP 5-10 cm provided BP adequate

Question 7

EVENOMATION ICP CPG

Answer 7

Address the ABCs, consider analgesia, minimise exertion, and:

• For SNAKE bites:
  
  • do not wash the site*
  • apply a compression bandage to the site (mark it*) & a 2nd one to the whole limb
  • splint & elevate to reduce lymphatic flow
  • transport & ask the EOC ECP to notify the state duty TOXINOLOGIST via WCH switch
• For REDBACK BITES
  
  • apply ice
  • transport
• For ANT, BEE & WASP
  
  • consider anaphylaxis
  • remove sting by scraping sideways and apply ice
• For BLUE RING OCTOPUS BITES:
  
  • bandage and immobilise as per snake bite
  • prepare for IPPV as the toxin is a paralytic, & transport

* allows later use of venom detection kits

Question 8

HYPOGLYCAEMIA ICP CPG

Answer 8

BSL measurement is required for all patients with altered mental status, including trauma and seizure pts. If hypoglycaemic:

• give oral GLUCOSE if able, otherwise consider:
• GLUCAGON 1mg IMI (kids 0.5mg) or
• 10% D : 250mls IV (kids 10ml/kg)
• transport adults unless resolves fully, history known, consumes complex carbohydrates, and supports suitable, always transport kids

Question 9

OESOPHAGEAL SPASM, ICP CPG

Answer 9

Oesophageal spasm may be caused by reflux, drugs, vagal stimulation or food bolus, and may be treated with IV GLUCAGON provided cardiac ischaemia has been considered

• Address the ABCs, including 12 lead ECG
• give GLUCAGON 1mg IV*
• if unrelieved: give GTN 400mcg S/L provided BP adequate and no VIAGRA etc last 24-48h
• analgesia as reqd
• transport

* yes IV

Question 10

ORGANOPHOSPHATE POISONING, ICP CPG

Answer 10

Ensure crew safety, with PPE, HAZMAT support and mandatory SOT attendance*

• Address ABCs, strip and scrub
• give ATROPINE 1.2mg IV/IO/IM 5/60 until respiratory secretions normalise: large doses may be reqd
• transport

* SOTs carry ATROPINE/OBIDOXIME COMBIPENS which can displace Organophosphates from cholinesterase if given early, before the complex ‘ages’

Question 11

OVERDOSE ICP CPG (order mod from SAAS)

Answer 11

Address the ABCs, plus

1. for ADULT NARCOTIC OD: give NALOXONE titrated to return of respiration:
   
   • 100mcg IV/120 nasal/400 IMI prn
2. for PAEDIATRIC NARCOTIC OD: give NALOXONE titrated to full reversal:
   
   • <6y = 200mcg IV/IM prn (max 1600mcg)
   • >6y = 400mcg IV/IM prn (max 1600mcg)
3. for BRADYCARDIC/HYPOTENSIVE BETA/Ca CHANNEL BLOCKER OD:
   
   • ATROPINE 600mcg IV prn (max 3mg)
   • ADREN 50mcg IV prn, or 500/500 infusion titrated
   • GLUCAGON 1mg IV* prn
   • transcutaneous pacing

* yes, IV

Question 12

PAEDIATRIC CROUP, ICP CPG

Answer 12

• If significant, paediatric croup can be treated with NEB ADREN 5mg in 5mls, rpt prn, but transport then mandatory as recurrence likely

Question 13

SEPSIS, ICP CPG

Answer 13

patients with fever, altered mental state, hypoxia, hypotension and poor perfusion should be suspected of having severe sepsis & the sepsis protocol instituted:

• Address the ABCs and expedite transport
• If POORLY PERFUSED
  
  • give NS 10ml/kg IV or IO, prn x3
  • if no improvement, add ADREN infusion 500/500 IV/IO titrated
• If FEVER & ALTERED MENTAL STATUS, give BENZYL PEN for MENINGOCOCCUS
  
  • Infants = 600mg IV/IM/IO
  • Children = 1.2g
  • Adults = 2.4g

Question 14

SEVERE HYPOTHERMIA, ICP CPG

Answer 14

Diagnosis of death is difficult in severe hypothermia and resuscitation should generally be attempted unless obviously futile

• Address the ABCs, including ONE (only) defibrillation for VF: if unsuccessful, hold drugs & further shocks & transport under CPR*
• During transport:
  
  • handle gently: the myocardium can be very irritable
  • dry off and rug to prevent further heat loss but dont actively rewarm until in a controlled environment
  • restrict IVT to avoid further cooling and later pulmonary complications

* whereas VF is an indication for ECM, arguably even extreme bradycardia is not as it is an appropriate response to the reduced metabolic rate of hypothermia

Question 15

SVT, ICP CPG

Answer 15

Address the ABCs, including IV access and a 12 lead then:

• try VALSALVA*
• give ADENOSINE, 6/12/12mg IV (kids at 100/200/300 mcg/kg)
• if unsuccessful & deteriorating: consider SYNC CARDIOVERSION at 100 then 150J (kids 1 then 2J/kg)….with or without sedation

* eg blowing thru a syringe barrel

Question 16

VENTRICULAR TACHYCARDIA WITH A PULSE, ICP CPG (slightly simplified from SAAS)

Answer 16

address the ABCs, including IV access and a 12 lead, then:

• If in extremis: SYNC CARDIOVERSION at 100 then 150J (kids 1 then 2J/kg) with or without sedation, otherwise:
• give AMIODARONE 300mg slow IV (kids 5mg/kg)