Tassie Prep Flashcards
-What leads would you see elevation in with a inferior STEMI
- what artery is affected?
- How can you confirm RCA occlusion?
Leads II, III and AVF
The main artery affected would be the right coronary artery.
Less commonly the Left circumflex.
You can confirm RCA occlusion by moving V4 from L) side to right side (in same position) if there’s elevation this will confirm RCA occlusion.
Will All patients present with pain during a STEMI event?
Not all patients will present with pain during a STEMI event, some pt for example, Diabetic, Elderly and atypical presentations may not present with pain.
What is AT standard treatment for ACS
300mg Aspirin
400mcg of GTN at 5min intervals (if BP >100)
Pain relief
- Morphine 0.05mg/kg (max 5mg) per dose, total (max 20mg)
OR
Fentanyl 0.5mcg/kg (Max 50mcg) per dose. total (200mcg).
What are the criteria for SVT
Regular
Narrow QRS complex (<120ms)
Rate >100 (generally >140bpm)
Buried or Absent P waves
How does AT manage AVNRT and AVRT SVT?
Either Asymptomatic or symptomatic manage as per Abdominal modified Valsalva maneuver
ICP may give Adenosine, if ineffective and pt deteriorating then they may Sync Cardioversion.
What is the criteria for VT
Wide QRS > 120 ms (Generally >160ms)
Regular
> 100bpm
No P Waves
What are some unstable signs of VT
- Congestive cardiac failure
- BP <80
- GCS <13
Rapidly deteriorating
What are some signs of Severe Cardiogenic Pulmonary Oedema?
- Hypertension > 160 systolic
- Decreasing GCS
- Dyspnea
- Coarse Crackles on lungs
- Formulating
- Coughing
- Irritability
- Patient may also have pitting Oedema in legs (fluid overload), not all patients with this will be severe APO.
Why do patients respond to GTN with APO
GTN causes
- Venodilation which allows for venous pooling and reduces venous return (reduces preload)
- Ateriodilation reduces systemic vascular resistance and arterial pressure (reduces afterload).
These reduces the pressure in the heart, causing veneo and aterio- dilation, thus reducing hydrostatic pressure which allows for oncotic pressure to push fluid back out of interstitial spaces.
Why do patients with APO respond to CPAP?
CPAP works on both Cardiac and respiratory systems. CPAP increases intrathoracic pressure, which reduces preload by decreasing venous return.
CPAP lowers afterload by increasing the pressure gradient between the left ventricle and the extra-thoracic arteries.
Decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema.
Essentially it causes cardiac vasodilatation, reducing pressure in the heart, this also causes a reduction in hydrostatic pressure (allowing for oncotic pressure to overcome and push fluid out of the interstitial spaces.
Due to CPAP increasing pressure in the lungs it also assists in pushing fluid back out of the alveoli.
What is Tassie Ambulance Management for APO (basal/ Midzone Crackles)
Firstline
- Posture: sit patient upright
- If BP >100 systolic: GTN 400mcg at 5/60 intervals (no max)
Note: if nil improvement treat as per Full field crackles.
What is Tassie Ambulance Management for APO (full field Crackles)
Manage same as Basal/ Midzone crackles
- Provide positioning
- GTN at 400mcg if BP >100 systolic
- Call for ICP backup
ICP
- CPAP
- Potential GTN Infusion.
- Potential administration of frusemide.
Pain Management.
What are the specific indication to give Fentanyl over Morphine.
- Contraindication to Morphine
- Short Duration desirable.
- Hypotension
- Nausea and/ or vomiting.
Notes
Fentanyl should be a drug of choice for trauma pt who have inadequate perfusion.
What is the dosage of Morphine and Fentanyl in the pain management guideline.
Morphine IM or Subcut
- Up to 0.1mg/kg (max single dose 10mg) repeated once after 20 minutes if required.
Morphine IV/IO
- Up to 0.05mg/kg (max 5mg) to a total of 20mg.
Fentanyl IM or Subcut
- Up to 1mcg/kg (max single dose 100mcg) Repeated once after 20 minutes if required
Fentanyl IV/IO
- Up to 0.5 mcg (max of 50mcg/kg), repeat at 5/60 to a total of (200mcg) if required.
Consider reducing narcotic doses for what patient who
- > 65 years old
- Shocked patients
- Frail patients
- Cardiovascular compromised patients
- Underlying lung disease
- Metabolism disorders e.g (kidney or liver)
- Clinical decision making from paramedics.
How do Ambulance Tasmania clinically define Asthma
A combination of variable respiratory symptoms including
1. Wheezing
2 Shortness of breathe
3. Coughing
4. Chest tightness
Asthma is acute and reversible.
How does Ambulance Tasmania treat Mild to Moderate Asthma
Salbutamol pMDI with spacer
- Deliver 12 puffs at 20/60 intervals until resolution.
Or
Nebulize
Salbutamol 5mg in 2.5ml, repeat at 5/60 intervals if required.
How does Ambulance Tasmania treat Severe Asthma
Salbutamol pMDI with spacer
- Deliver 12 puffs at 5-10/60 intervals until resolution.
Ipratromium bromide pMDI with Spacer
- Deliver 8 doses at 20/60 (max 3 repeats)
If pMDI Spacer Unavailable
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat salbutamol
- 5mg in 2.5ml at 5/60 as required
Repeat Atrovent at
- 500mcg at 20/60 intervals (max 3 doses)
Dexamethasone
8mg in 2ml IV, IM or oral.
How does Ambulance Tasmania treat life threatening Asthma
Adrenaline IM
- 500mcg IM at 5/60 as required.
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat salbutamol
- 5mg in 2.5ml at 5/60 as required
Repeat Atrovent at
- 500mcg at 20/60 intervals (max 3 doses)
Dexamethasone
- 8mg in 2ml IV, IM or oral.
Normal Saline
- 20mls/kg
What is Ambulance Tasmania treatment for COPD
Salbutamol pMDI with spacer
- Deliver 8 puffs with 4 breaths repeat 10/60 as required
Ipratropium bromide pMDI with Spacer
- Deliver 4 doses and 4 breathes per dose at 10/60 as required
Or
Nebulize
Salbutamol 5mg in 2.5ml, repeat at 5/60 intervals if required.
If pMDI spacer unavaible or unable to tolerate
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat at 10 minute intervals as required
Dexamethasone
- 8mg in 2ml IV, IM or oral.
Oxygen therapy (nasal prongs)
- titrate to 88-92
If pt deteriorates
- Ventilate at 5-8 ventilations per minute at 7ml/kg.
-Allow for prolonged expiratory phase.
-Gentle lateral chest pressure if required.
Why do we give bronchodilators to patients in Resp distress
Bronchodilators primarily function by relaxing the smooth muscle surrounding the airways, which allows the airways to dilate (widen) and reduce resistance to airflow.
Beta-2 Adrenergic Agonists: Salbutamol
Mechanism: They activate beta-2 adrenergic receptors (beta-2 receptors) located on the smooth muscle cells of the bronchi.
When these receptors are activated by the drug, they stimulate adenylyl cyclase, an enzyme that increases the production of cyclic AMP (cAMP) within the smooth muscle cells.
The increased levels of cAMP activate protein kinase A which then lead to the relaxation of bronchial smooth muscle. This process ultimately dilates the airways and reduces airway resistance.
Atrovent
Mechanism: block the action of acetylcholine (ACh), a neurotransmitter released from parasympathetic nerve endings that typically stimulates muscarinic receptors (M1, M2, M3) on bronchial smooth muscle cells.
When acetylcholine binds to these receptors, it causes the smooth muscle to contract (bronchoconstriction).
By blocking muscarinic receptors, anticholinergics inhibit this bronchoconstrictor effect and promote bronchodilation.
How does Adrenaline Assist with life threatening airway presentations e.g Asthma
Beta-2 Adrenergic Receptor Stimulation:
Adrenaline primarily acts on beta-2 adrenergic receptors located on the smooth muscle cells of the bronchi and bronchioles.
When adrenaline binds to these receptors, it activates a cascade of events that leads to the relaxation of bronchial smooth muscle, causing bronchodilation (widening of the airways).
Vasoconstriction (Alpha-1 Receptor Activation):
-Adrenaline also stimulates alpha-1 adrenergic receptors, which are located on smooth muscle cells in blood vessels.
When these receptors are activated, it causes vasoconstriction, or the narrowing of blood vessels.
This effect is particularly helpful in reducing airway edema (swelling) that can occur during an asthma attack, as vasoconstriction decreases the permeability of blood vessels and limits the leakage of fluid into the tissues, which can worsen inflammation.
Inhibition of Inflammatory Mediators:
-Adrenaline has an indirect effect on inflammatory cells (such as mast cells, eosinophils, and neutrophils) in the airways. It can decrease the release of histamine and other pro-inflammatory mediators that contribute to airway inflammation and bronchoconstriction.
By reducing the release of these inflammatory substances, adrenaline helps to diminish the inflammatory response in the lungs.
Improvement of Mucociliary Clearance:
-Adrenaline can also enhance the function of the mucociliary escalator, the system that clears mucus from the airways. This helps remove excess mucus and reduces obstruction.
Whats the difference between coarse and fine crackles when listening to patients chests.
Fine Crackles:
Typically occur in rapid bursts or intermittent popping sounds during inspiration.
Timing:
Fine crackles are heard late in inspiration (end of the inspiratory phase).
Underlying Causes:
Fine crackles are usually a sign of fluid or inflammation in the alveoli and small airways.
They are often associated with conditions that involve interstitial lung disease, pulmonary fibrosis, or congestive heart failure (especially when there is fluid in the alveoli).
Other conditions include pneumonia, acute respiratory distress syndrome (ARDS), and atelectasis.
Clinical Significance:
- Coarse Crackles:
They have a bubbling, gurgling, or rattling quality.
Coarse crackles can be heard in both inspiration and expiration.
Timing:
Coarse crackles are typically heard early in inspiration but may also be audible during expiration, especially in more severe cases.
Underlying Causes:
Coarse crackles are commonly associated with the larger airways or bronchi and suggest more significant secretions in the airways or larger bronchi.
Common causes include bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), emphysema, and bronchiectasis.
They can also occur with severe pulmonary edema, where larger airways become filled with fluid.
Why is Glucagon used in Anaphylaxis for patient unresponsive to Adrenaline.
Glucagon can be used in the treatment of anaphylaxis when there is a severe or refractory case of hypotension (low blood pressure) that does not respond to adrenaline. Glucagon may be necessary in certain situations due to some patients taking beta-blockers
- Epinephrine Resistance in Beta-Blocked Patients
Beta-blockers (such as atenolol, metoprolol, or propranolol) are medications that block beta-1 and beta-2 adrenergic receptors, preventing the action of epinephrine and other catecholamines on the heart and smooth muscle. This can blunt the effectiveness of Adrenaline during anaphylaxis, especially in terms of its cardiovascular effects (e.g., increasing heart rate and blood pressure).
In such cases, glucagon becomes useful because it increases heart rate and cardiac output through beta-receptor-independent mechanisms. Specifically, glucagon activates the glucagon receptor, leading to an increase in cyclic AMP (cAMP) inside the cells, which stimulates the heart (positive inotropic and chronotropic effects) and improves vasoconstriction and blood pressure.
Glucagon’s Mechanism of Action in Anaphylaxis
-Glucagon acts on the glucagon receptor, which is distinct from the beta-adrenergic receptors that are typically targeted by adrenaline. This means that glucagon can work even in the presence of beta-blockers or when epinephrine’s effects are diminished or resistant.
Why do patients who have had an anaphylactic attack require transport to hospital and how long are they required to be monitored.
Patients are required to be monitored for at least 4 hours. This is due to patients re-presenting with signs and symptoms once adrenaline and other therapies wear off.
What is Ambulance Tasmania’s Treatment for Anaphylaxis.
Adrenaline
- 500mcg IM (repeat at 5/60) as required.
Consider Nebulized adrenaline as per Upper airway obstruction.
5mg Adrenaline Nebulized.
Further Mx as per Asthma
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat salbutamol
- 5mg in 2.5ml at 5/60 as required
Repeat Atrovent at
- 500mcg at 20/60 intervals (max 3 doses)
Dexamethasone
8mg in 2ml IV, IM or oral.
What does the RASH Criteria stand for?
How does the criteria work?
R- Respiratory Distress
- Short of breathe, Wheeze, cough or stridor
A- Abdominal
- Nausea, vomiting Diarrhea, abdominal pain or cramping
S- Skin
- Hives, rash, flushing, welts, angio-oedema, swollen lips or tounge.
H- Hypotension
- Hypotension or altered conscious state.
Pt needs to meet two or more of these symptoms with or without confirmed antigen exposure.
OR
Isolated hypotension <90mmhg, or isolated bronchospasm or isolated upper airway obstruction following likely exposure to antigen
OR
Any symptom of RASH in patient with known exposure to antigen with previous history of Anaphylaxis or severe allergic reactions to the same antigen.
What are the ECG Parameters including….
- What does small box represent
- What does one large box represent.
- PR interval
- QRS
- T waves
1 Small box = 0.04ms
1 Large box = 0.2
PR Interval = Between 0.12 -0.2ms (3- small squares)
QRS <0.12 (narrow, Less than 33 small sqaures) or > 0.12 Broad
T waves = Upright, none peaky or Inverted (not including V1 or lead III) for inverted.
What a normal PH range?
Which is acidosis and which is alkalosis.
PH ranges from 0-14
A normal blood PH range for a person is between 7.35-7.45
Acidosis is below 7.35
Alkalosis is above 7.45
Explain blood gas regulation through Bicarb and Respiratory regulation.
Blood Gas Regulation (Respiratory and Renal Systems)
The human body maintains its pH balance primarily through the bicarbonate buffer system and respiratory regulation:
Note: Hydrogen Ions are Acidic and come as a by product of metabolic waste.
During anaerobic respiration, when oxygen is scarce (e.g., during intense exercise), glucose is converted into lactic acid (lactate), which dissociates to release hydrogen ions.
Bicarbonate buffer system:
- In the blood, carbonic acid (H₂CO₃) dissociates into hydrogen ions (H⁺) and bicarbonate ions (HCO₃⁻). This helps buffer changes in pH. If the blood becomes too acidic, the kidneys can excrete excess hydrogen ions and retain bicarbonate ions to restore balance. If the blood becomes too alkaline, the kidneys can do the opposite.
Respiratory regulation:
The respiratory system helps control blood pH by adjusting the levels of carbon dioxide (CO₂). When CO₂ dissolves in the blood, it forms carbonic acid, which dissociates into hydrogen ions. Breathing rate can increase or decrease to help regulate CO₂ levels in the blood, and therefore control pH. Rapid breathing can help reduce CO₂ and raise pH (make the blood less acidic), while slow breathing can retain CO₂ and lower pH (make the blood more acidic).
The kidneys
play a critical role in maintaining long-term pH balance by excreting or retaining hydrogen ions and bicarbonate. The kidneys adjust the pH of the blood through a few key processes:
Excretion of Hydrogen Ions: The kidneys filter blood and remove hydrogen ions (H⁺) from the bloodstream, which are then excreted in urine. This process helps to lower blood acidity when there is an excess of hydrogen ions.
Reabsorption of Bicarbonate: The kidneys also reabsorb bicarbonate (HCO₃⁻) from the urine back into the blood. Bicarbonate acts as a buffer to neutralize excess hydrogen ions and raise the blood pH.
Ammonium Production: The kidneys also generate ammonium (NH₄⁺) from ammonia (NH₃), which helps to excrete excess hydrogen ions and further regulate pH.
CO2 +H2O↔H2CO3↔H+ + HCO3−
What is ETCO2 and how do paramedic utilize it in practice?
ETCO₂ stands for End-Tidal Carbon Dioxide, which is the concentration of carbon dioxide (CO₂) in the exhaled breath at the end of expiration. It is measured in millimeters of mercury (mmHg) or as a percentage.
Normal ETCO₂ levels range from 35–45 mmHg
Higher than 45 can indicate Respiratory acidosis. The higher the reading this indicates that there are high levels of Co2 during exhalation indicate acidosis.
Paramedic Practice.
Airway Management
- Confirmation of Endotracheal Tube (ETT) Placement:
After intubation, paramedics use ETCO₂ to confirm that the ETT is in the trachea and not the esophagus. A sustained ETCO₂ waveform indicates correct placement.
Continuous Monitoring: Ensures the tube remains in place during transport.
- Cardiac Arrest and CPR
- Effectiveness of Chest Compressions:
ETCO₂ levels reflect the quality of CPR. An ETCO₂ reading above 10 mmHg suggests effective chest compressions, while lower values indicate the need for improvement.
- Indicator of ROSC (Return of Spontaneous Circulation):
A sudden rise in ETCO₂ may signal that the heart has started beating again. - Respiratory Emergencies
- Assessing Ventilation:
Helps paramedics gauge the severity of conditions like asthma, COPD, or respiratory distress.
Rising ETCO₂ may indicate hypoventilation, while low levels suggest hyperventilation.
- Adjusting Ventilator Settings:
If a patient is on mechanical ventilation, ETCO₂ helps fine-tune the ventilator to maintain appropriate CO₂ levels. - Shock and Trauma
- Monitoring Perfusion:
Low ETCO₂ can indicate poor perfusion, which might occur in cases of shock or significant blood loss. - Sedation and Pain Management
- Monitoring Sedation Levels:
During procedural sedation, paramedics use ETCO₂ to monitor for respiratory depression and ensure patient safety.
What are some CPAP contraindications
(please note that CPAP isn’t currently available for use in AT guidelines, however could be utilized on consult)
Due to this, these are sourced from AV
- Cardiac Arrest
- Patient agitated or intolerance
- Nil improvement after 1 hour
- HR <50
- SBP <90
- GCS <13
- Decreasing SPO2
- Loss of airway control
- Copious airway secretions
- Active vomiting
- Paramedic judgement
What is Ambulance Tasmania Management of Mild, Moderate and severe Croup
Mild Croup
- Dexamethasone 0.15mg/kg (max 12mg) PO
- Review exclusion criteria and red flags
- Treat and refer, safety netting and GP appointment.
Moderate croup
- Dexamethasone 0.15mg/kg (max 12mg)
- Transport to ED
Severe Croup
- Consider ICP
- Dexamethasone 0.6mg/kg (max 12mg) PO, IM, IV.
- Adrenaline 5mg in 5ml Nebulized.
- Transport.
What are some clinical signs of Croup
- Fever with signs of systemic illness
- Irritability
- Inspiratory stridor (at rest or exertion)
- Feeling worse at night
- Barking cough and/ or Hoarse voice
- Total duration 3-7 days
Precipitated by URTI 1-2days prior to barking cough
How does Adrenaline and Dexamethasone help croup.
Adrenaline
- Adrenaline stimulates alpha-adrenergic receptors, leading to vasoconstriction in the subglottic mucosa. This reduces mucosal swelling and edema, quickly widening the airway.
Also stimulates beta-adrenergic receptors in the lungs:
Bronchodilation: Helps to improve airflow, although croup primarily involves the upper airway.
Dexamethasone
Corticosteroid: Dexamethasone works by reducing inflammation through inhibition of cytokine production and suppression of the inflammatory response.
Decreases subglottic Oedema and mucus production over time.
Unlike adrenaline, it addresses the underlying inflammatory process, providing more sustained relief.
How do Paramedics treat Hypoglycemia under Ambulance Tasmania Adult Guidelines.
If BGL <4 and responds to commands
- Glucose paste 15g
Inadequate response?
- Repeat dose of glucose paste.
- Glucagon.
Note
- If adequate response, insure patient eats substantial food within 30/60
Does not respond to commands or nil improvement from above
- IV Cannula (large vein) + confirm patency.
- Glucose 10% 15g in 150ml initial dose. (normal saline 10ml flush)
- If IV not attainable then Glucagon 1mg in 1ml
If inadequate response
- Repeat Glucose 10% 10g in 100ml IV
- Repeat this every 5 minutes until BGL >4.
How do Paramedics treat Hyperglycemia under Ambulance Tasmania Adult Guidelines.
ketones < 0.6
- Assess signs of dehydration.
- If nil Dehydration then consider referral pathway.
- If dehydration present treat as per below.
Ketones >0.06
- Transport to hospital for ongoing management.
If patient dehydrated (Tachycardic or hypotensive (HR >100 or BP <100))
- Manage as per Fluid guideline
- Normal saline 20ml/kg, Nil repeat.
Consider consult for further fluid if nil ICP Available and long transport times.
What is the normal range of ketones?
What are the different ranges and risk levels.
Normal range: <0.06
Mild to Mod: 0.06-3
Severe: >3
What are some exclusion criteria for Hyperglycemia when assessing referral pathways?
- Post hypoglycemia event and alone.
- Unable/ unwilling to eat.
- Pregnancy
- Moderate to Severe dehydration
- Nil pHx of Diabetes
- Steroids
- Chronic Alcoholics
- Ketones >0.06
How does Ambulance Tasmania treat Seizures?
Continuous or Recurrent seizures.
(More than one (without full recovery) or longer than 5 minutes)).
Age <60
- Midazolam 0.1mg/kg IM (Max 10mg) per dose.
Age >60
- Midazolam 0.05mg/kg (max 10mg) per dose
If nil improvement after 10/60
- Repeat Midazolam IM dose once only (Max 20mg total).
How do Benzodiazepines treat seizures?
They work by enhancing the activity of the gamma-aminobutyric acid (GABA) neurotransmitter in the brain.
GABA-A Receptor Modulation:
- Benzodiazepines bind to the GABA-A receptors in the central nervous system (CNS).
GABA is the brain’s primary inhibitory neurotransmitter, which reduces neuronal excitability.
When benzodiazepines bind to these receptors, they enhance the effect of GABA by increasing the frequency of chloride ion channel opening.
Hyperpolarization of Neurons:
The increased influx of chloride ions into neurons makes the inside of the cell more negative (hyperpolarized).
This reduces the likelihood that the neuron will fire (send an electrical signal), calming excessive brain activity during a seizure.
As per Ambulance Tasmania Seizure guideline, If a Patient has a pHx of Seizures and refuses transport to hospital, is this acceptable.
Yes, If a patient has a responsible third party present and able to watch the patient then they can be left at home. Crews should advise this person of actions to take if this event reoccurs and stress the importance of follow up with primary care physicians.
What is one consideration of using Midazolam?
Profound effects on Blood pressure potentially leading to hypotension.
- Reduced sympathetic output results in vasodilation (widening of blood vessels), decreasing systemic vascular resistance (SVR) and lowering blood pressure.
How does Ambulance Tasmania treat Meningococcal disease?
Apply PPE
Assess ABX criteria (any of below)
- Altered level of consciousness or
- Meningeal irritation (stiff neck. photophobia) or
- Non blanching petechial rash
ICP backup
Ceftriaxone 2mg IV, IO, IM. (regardless of Hospital transport time).
Treat as per sepsis.
How to prepare Ceftriaxone for IV Administration?
How to prepare for IM Administration?
Dilute each 1g of Ceftriaxone with 9.5mls of normal saline. This is required to be done twice as the dosage is 2g
Dilute 1g of ceftriaxone with 3.5mls of Lignocaine and administer into upper lateral thigh or butt cheek twice.
How does Ambulance Tasmania manage Narcotic ODs
- Assist and Maintain airway/ Ventilation.
Partial Reversal
- Naloxone 100mcg IV bolus every 60 seconds, titrated patient desired response (max 2mg)
Complete reversal
- Naloxone 800mcg IM
If inadequate response after 5 minutes
- Naloxone 800mcg IV, IM repeat at 400mcg IV, IM (max 2mg)
Note: If no response after 1mg consider other causes.
Also consider SGA for airway management.
What are some Narcotics
- Heroin
- Morphine / Fentanyl
- Codeine
- Methadone
- Endone
- MS Contin
- Pethidine
What is considered a Narcotic OD
What are some signs of OD
GCS < 12
Resp rate < 8
- Altered conscious state
- Resp Depression
- Pin point pupils
- Track marks
- Exclude other causes like head injury.
What are some signs and symptoms of Tricyclic OD
TCAs have Anticholinergic Effects
They also block sodium channels leading to ECG changes.
Mild to Moderate
- Drowsiness and confusion
- Tachycardia
- Slurred speech
- Hyperreflexia
- Ataxia ( loss of muscle control)
- Mild hypertension
- Dry mucus membranes
- Resp Depression
Severe Toxcicity
- Coma
- Resp Depression + Hypoventilation
- Conduction delays
- PVC, SVT, VT
- Hypotension
- Seizures
How does Ambulance Tasmania treat TCA OD
If patient has any of the following signs
1. Less than adequate perfusion
2. Positive R Wave (>3mm) in AVR
3. Progressively Widening QRS >0.12
4. QT Prolongation
5. QTc >500ms
What are the 4 Ts and Hs of a reversible cardiac Arrest.
Tension Pneumothorax
Thrombosis (coronary or Resp)
Tamponade (Fluid in pericardium)
Toxins (self posioniong)
Hypovolemia
Hypoxia
Hyperkalemia
Hypothermia
What are the 5HEDS Criteria
The 5 Heads criteria is used to determine a traumatic head injury.
5) Any loss of consciousness exceeding 5 minutes
H) Has skull fracture (depressed, open or base of skull)
E) Emesis more than once.
D) Deficit (Neurological)
S) Seizures.
How does Ambulance Tasmania manage Psychostimulant ODs
Main for of management for these OD is management under the Behavior guideline. These patients may require sedation if agitated
Other management strategies to consider are.
Chest pain as per ACS CPG
Seizures as per Seizure CPG
Hypo/Hyperthermia as per CPG
Do mental health patients have to be detained for the purposes of assessment prior to administration of sedation or restraint?
Yes
What are some conditions to consider when assessing a Behavioral case?
- Hypoglycemia
- Drug OD
- Hypoxia
- Post ictal
- Head injury
- Intercerberal Injury
- Acute psychiatric condition
What are some indicators that patients may/ will require sedation (3 considerations)
- Does not respond to verbal de-escalation
- Clinical causes have been excluded
- Patient is a risk to themselves or others
How does Ambulance Tasmania manage a SAT +1 Patient and how may they present.
SAT 1 patient will present with
- Anxious, pacing. agitated but still engaging
Management
- Diazepam 10mg oral
- > 60 years old 5mg
- Max total 40mg
- Can be repeated at 60 minute intervals
How does Ambulance Tasmania manage a SAT +2 or 3+ without IV present and how may they present.
SAT 2+ 3+ will present with moderate to high agitation with physical aggression imminent or present.
No IV
-Droperidol IM 10mg or 5mg (<50kg/ age >60)
- Repeat after 15 minutes if SAT score >0
- Max dose 20mg for normal adults or
- Max dose 10mg for <50kg or >60 age.
How does Ambulance Tasmania manage a SAT +2 or 3+ with IV present and how may they present.
SAT 2+ 3+ will present with moderate to high agitation with physical aggression imminent or present.
IV present
- 5mg Droperidol IV
- Repeat 5mg of Droperidol after 5/60 if patient SAT score >0
- Max dose 20mg for normal adult
- Max dose 10mg if <50kg or >60 age
What is the Patho of Autonomic Dysreflexia
AD requires a spinal cord injury above the T6 level, Lesion forms on spinal cord and disrupts the sympathetic system.
- The descending inhibitory pathways from the brain (which normally regulate sympathetic activity) cannot reach the spinal cord below the injury, leaving the sympathetic nervous system overactive.
- A noxious stimulus, often below the level of injury (such as a full bladder, bowel impaction, or skin irritation), triggers a massive sympathetic response. The body’s sympathetic nervous system responds by causing widespread vasoconstriction, which increases blood pressure.
Baroreceptor Reflex:
- The baroreceptors in the carotid sinus and aortic arch detect the high blood pressure and signal the brain to reduce heart rate and dilate blood vessels.
However, the disruption of the spinal cord prevents these signals from traveling effectively below the level of the injury, and as a result, the parasympathetic response (which would normally control heart rate and vascular tone) cannot counteract the excessive sympathetic activity.
This leads to unopposed vasoconstriction, continued elevation of blood pressure, and potentially bradycardia (a slow heart rate), which is characteristic of AD.
Clinical Manifestations:
Severe hypertension (systolic blood pressure can rise > 300 mmHg).
Bradycardia (heart rate can drop below 60 bpm).
Symptoms like headache, flushing, sweating above the level of injury, nasal congestion, and anxiety.
What are the 3 indicators of Autonomic Dysreflexia
- Injury T6 or above
- Severe headache
- Hypertension >160 systolic
How does Ambulance Tasmania treat Autonomic Dysreflexia
First Manage Stimulus
e.g.
- Unkink blocked catheter
- Manage pain for burns, fractures, labour
If BP remains > 160 systolic
- 400mcg of Sublingual GTN
If adequate respond, Tx to hospital
If inadequate response
- Repeat initial dose of GTN every 10/60 until
- Symptoms resolves
- BP <160
- Onset of Side effects.
What can precipitate a Automimic Dysreflexia episode.
6 Bs
Bladder (catheter blockage, distension, stones, infection, spasms)
Bowel (constipation, impaction)
Back passage (hemorrhoids, rectal issues, anal abscess, fissure)
Boils (skin lesions, infected ulcers)
Bones (fractures, dislocations)
What are some Stroke Mimics
(SIICK MESS)
S) Seizures
I) Inner ear disorder/
I) Intoxication (drug/alcohol)
C) Confusion (Hypo/Hyperglycemia)
K) Killer (Brain Tumor) / Subdural haematoma
M) Migraine
E) Electrolyte disturbance
S) Sepsis
S) Syncope
Modified FAST Assessment Tool
ACT FAST Assessment tool
How does Ambulance Tasmania sort e.g. (time frame, hospital, notifcation) and treat patients depending on Assessments.
If FAST Positive >24 hours or suspected TIA with full symptom resolution
- Tx closest hospital with stroke management
- Non urgent transport
FAST Positive <24 hours and ACTFAST Positive
- Hospital pre-notification
- Consider early AMR notification if > 60 minutes from RHH and stroke symptoms <6 hours
- IV 18g in large vein
- Urgent transport
FAST Positive <24 hours and ACT FAST Negative
- Pre notify stroke hospital
- IV access 18g in large vein
- Urgent transport
What is the patho of sepsis
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It results in widespread inflammation, immune system activation, and multi-organ failure. Sepsis can be triggered by any infection, including bacterial, viral, or fungal, but bacterial infections are the most common.
Mechanisms Involved in Sepsis:
Infection and Immune Activation:
Sepsis typically begins with an infection (e.g., pneumonia, urinary tract infection, or abdominal infection). Toxins release which activate the immune system and trigger an inflammatory response.
Systemic Inflammatory Response:
The release of inflammatory cytokines induces a systemic inflammatory response. This can lead to widespread vasodilation and increased capillary permeability, resulting in fluid leakage into tissues and contributing to hypotension.
This also leads to microvascular thrombosis, or small blood clots forming in the microcirculation, which can impair blood flow to vital organs.
Impaired Oxygen Delivery and Metabolic Dysfunction:
As blood vessels dilate and become more permeable, blood pressure drops (hypotension), and blood flow to organs becomes compromised.
Hypoperfusion (reduced blood supply) leads to hypoxia (lack of oxygen), causing cells to shift to anaerobic metabolism. This results in lactic acidosis, further impairing cellular function and worsening organ damage.
The combination of hypoxia, inflammation, and coagulation abnormalities leads to multi-organ failure (MOF). Commonly affected organs include the kidneys (acute kidney injury), lungs (acute respiratory distress syndrome), liver (hepatic dysfunction), and heart (cardiovascular collapse).
What Clinical signs/ risk factors of Sepsis as per Ambulance Tasmania.
The presence of one or more of these signs in conjunction with a history suggestive of infection should prompt the clinician to THINK SEPSIS.
- HR >90
- RR >22
- SBP < 100mmHg
- Temperature >38 or <36
- BGL >7 or elevated from baseline
- SpO2 <94% (or less than 88% in patients with COPD)
- New objective decrease in conscious state
- Impaired immunity (diabetes, steroids, chemotherapy)
- Decreased urination
- Petechial or non-blanching rash
What is qSOFA
Quick Sequential Organ Failure Assessment (qSOFA)
The qSOFA score identifies patients who are at risk of deterioration from sepsis – it does not diagnose sepsis.
qSOFA should be used to risk stratify patients and predict the need for antibiotic therapy in patients who already have a provisional diagnosis of sepsis, or to prompt the consideration of sepsis in the otherwise undifferentiated patient.
2 or more of HAT:
- Hypotension – SBP <100mmHg
- Altered conscious state – decreased from base level
- Tachypnoea – RR >22
What circumstance should paramedics give Antibiotics pre-hospitably
Antibiotics are only administered if the patient has a provisional diagnosis of sepsis with a positive qSOFA score AND the time to hospital is > 60 minutes.
Time to hospital is defined as the time from gaining IV access to triage handover in ED.
How does Ambulance Tasmania treat sepsis
qSOFA Score >2
- ICP backup
- O2, maintain above 94%
- Normal Saline 500mls, repeated until BP above 100systolic. Max (3L)
- Ceftriaxone 2g IV >60 minutes to ED
- Transport with notification
qSOFA score <2
- O2 to maintain >94%
- Normal saline 500mls
- If BP <100 continue 500ml bolus Max (3L)
Consider fluid overload when managing these patients with large amounts if fluids.
What are the Adult trauma red flags (Vital signs) in Ambulance Tasmania time critical guidelines
Any of the following
- Respiratory rate: <12 >24
- BP <90
- Pulse: <50 >120
- GCS <13
- Oxygen sats <90%
What are the Adult trauma red flags (Pattern of injury + MOI) in Ambulance Tasmania time critical guidelines
Any of the following
Penetrating injuries
- Head/ Neck/ Chest/ Abdomen/ Pelvis/ Axilla/ Groin
Blunt injuries
- Significant injury to a single region: Head/ Neck/ Chest/ Abdomen/ Pelvis/ Axilla/ Groin
- Injuries involving two or more of the above body regions.
Specific injuries
- Limb amputations, limb threatening injuries.
- Suspected spinal cord injuries
- Burns >20% or involving respiratory tract.
- Serious crush injury
- Major Compound fracture or open dislocation.
- Fracture of two or more of the following; Femur, Tibia or Humerus.
- Fractured Pelvis.
Mechanism of injury
- Ejection from vehicle
- Motor/ Cyclist impact >30km/hr
- Fall from height >3m
- Struck on head from falling object >3m
- Explosion
- Vehicle rollover
- Fatality in same car
- Pedestrian impact
- Prolonged Extrication
Comorbidities
- Age >60
- Pregnancy
- Significant medical condition
Note:
Patient is required to have a MOI + one or more comorbidity to meet trauma criteria.
What are the Adult medical red flags (Vital signs) in Ambulance Tasmania time critical guidelines
Any of the following
- Severe Respiratory distress
- Oxygen Saturations <90% on RA or 93% on oxygen (consider COPD patient)
- Inadequate perfusion
- GCS <13 (unless normal for patient)
- 12 Lead showing STEMI Patient
What are the Adult medical red flags (medical condition) in Ambulance Tasmania time critical guidelines
Any of the following
Medical symptoms/ syndromes
- Acute coronary syndrome
- Acute stroke
- Severe sepsis (include Meningococcal)
- Possible abdominal aortic aneurysm
- Undiagnosed severe pain
- Acute Asthma/ COPD with Moderate resp distress.
- Hypothermia or Hyperthermia
Note
- Notify communications for possible hyperbaric treatment e.g acute decompression illness or Cyanide poisoning.
What does AEIOUTIP used/stand for?
To assess altered level of consciousness.
A- Alcohol, Arrythmias,
E- Endocrine, Electrolyte
I- Insulin, Ingestion
O- Oxygen deficit, Overdose
U- Uremia or renal problems
T- Trauma or Temperature
I- Infection (sepsis)
P- Pain, Psychological
S- Stroke or Seizure
What is the Nexus Criteria
Is used to assess potential spinal injuries.
1) no posterior midline cervical tenderness;
2) no evidence of intoxication; 3) normal level of alertness (i.e. the patient is alert and oriented to person, place, time, and event);
4) no focal neurological deficit; and
5) no painful distracting injuries
What are some signs of a Haemorrhagic stoke.
Sudden headache (worst of their life)
Weakness or numbness: Sudden weakness or numbness in the face, arm, leg, or one side of the body
Vision problems: Double or blurry vision, or sudden trouble seeing in one or both eyes
Confusion/ irritability
Speech problems: Difficulty speaking or understanding speech.
Balance problems: Dizziness, loss of balance, or coordination
Other symptoms: Vomiting, nausea, seizures, loss of consciousness, neck stiffness, or passing out
What is Cushings triad
is a sign of symptoms that may indicate raised intercranial pressure
The three signs of Cushing’s triad are:
> Bradycardia: A low heart rate
Irregular respirations:
> Abnormal breathing patterns
> Widened pulse pressure: A large difference between systolic and diastolic blood pressure
What do we ventilate TCA ODs
> Respiratory Depression:
- TCAs can depress the central nervous system (CNS), potentially leading to hypoventilation or apnea. Assisted ventilation ensures adequate oxygenation and carbon dioxide elimination.
Acidosis Management:
> Acidosis
- TCA overdoses often cause metabolic acidosis, which can worsen TCA toxicity by increasing the proportion of the drug in its unbound, active form. Hyperventilation (inducing respiratory alkalosis) can be used as a temporary measure to counteract severe acidosis.
> Cardiac Arrhythmias:
TCAs block sodium channels, leading to prolonged QRS intervals and a risk of fatal arrhythmias. Adequate ventilation helps maintain oxygenation and acid-base balance, which can stabilize cardiac function.
Hypoxia Prevention:
Other Mx
> Sodium bicarbonate: To reverse acidosis and manage cardiac toxicity
> Activated charcoal: If the patient presents within a few hours of ingestion.
> Seizure management: With benzodiazepines.
What are the normal ranges of the following blood gases and what do any alteration in the ranges potentially mean.
- Lactate
> Normal Lactate: (0.5-2.2)
- Suggests adequate oxygen delivery and metabolic function.
> Mild Elevation (2–4 mmol/L):
- Early tissue hypoxia or metabolic stress (e.g., exercise, liver dysfunction, dehydration).
> Significant Elevation (> 4 mmol/L):
- Indicates severe hypoxia or impaired clearance (e.g., sepsis, shock, ischemia, or mitochondrial dysfunction).
What are the normal ranges of the following blood gases and what do any alteration in the ranges potentially mean.
- Hemoglobin
Men and Women generally differ slightly.
The normal range generally is around 12.1–17.2 for Men/ Women however may differ slightly
Reasons for Low readings
> Anemia
- Nutritional deficiency
- Blood loss (chronic or acute)
- Chronic kidney disease
- Bone marrow disorders
- Pregnancy
Reasons for high readings
- Dehydration
- High altitudes
- Lung/ heart disease.
- Smoking
Symptoms
Low Hemoglobin: Fatigue, weakness, pale skin, shortness of breath.
High Hemoglobin: Headache, dizziness, high blood pressure, risk of clotting.
What are the normal ranges of the following blood gases and what do any alteration in the ranges potentially mean.
- Pco2
Normal range is 35-45
> 45 = Acidosis
<35 = Alkalosis
High Pco₂ (Hypercapnia)
Causes:
- Hypoventilation (reduced breathing rate or depth):
- Chronic obstructive pulmonary disease (COPD)
- Respiratory muscle weakness (e.g., in neuromuscular diseases)
- Central nervous system depression (e.g., from sedatives or brainstem injury)
- Airway Obstruction: Asthma or choking.
Low Pco₂ (Hypocapnia)
- Hyperventilation (increased breathing rate or depth):
- Anxiety or panic attacks.
- Fever, sepsis, or
- pain.
- Artificial Ventilation:
- Excessive mechanical ventilation settings.
- Altitude: Hypoxia-induced hyperventilation at high altitudes.
What are the normal ranges of the following blood gases and what do any alteration in the ranges potentially mean.
- Hco3
The normal range for bicarbonate (HCO₃⁻) in the blood: 22–26 mmol/L
What HCO₃⁻ Reflects
Bicarbonate is a key component of the body’s buffering system, helping to maintain acid-base balance.
The normal range for bicarbonate (HCO₃⁻) in the blood is:
22–26 mEq/L (milliequivalents per liter)
Alternatively expressed as: 22–26 mmol/L
What HCO₃⁻ Reflects
Bicarbonate is a key component of the body’s buffering system, helping to maintain acid-base balance. It reflects the metabolic (kidney-regulated) component of acid-base status.
High HCO₃⁻ (Metabolic Alkalosis)
Causes:
Excess bicarbonate administration:
- Overuse of antacids or bicarbonate in treatment.
- Loss of acids:
- Prolonged vomiting or nasogastric suction (loss of stomach acid).
- Diuretic use (e.g., loop or thiazide diuretics).
- Hyperaldosteronism: Causes increased hydrogen ion loss in the kidneys.
Low HCO₃⁻ (Metabolic Acidosis)
Causes:
Increased acid production:
- Diabetic ketoacidosis.
- Lactic acidosis (e.g., in sepsis or shock).
- Toxin ingestion (e.g., methanol, ethylene glycol).
- Loss of bicarbonate:
- Diarrhea or pancreatic drainage.
-Kidney dysfunction:
Chronic kidney disease or renal tubular acidosis.
What is shock and what are the 5 types.
Shock is a life-threatening condition caused by inadequate perfusion of tissues, leading to cellular dysfunction and organ failure.
There are five major types of shock
- Hypovolemic
- Cardiogenic
- Distributive
- Obstructive
- Endocrine
What is Hypovolemic shock and what conditions should you consider?
Loss of blood or Fluids
Mechanism: Reduced blood volume → decreased venous return → decreased cardiac output → impaired tissue perfusion.
Examples
- Hemorrhage
- Severe Dehydration
- Burns
What is Cardiogenic shock and what conditions should you consider?
Failure of the heart to pump effectively.
Mechanism: Decreased cardiac output despite normal or high blood volume → inadequate tissue perfusion.
Examples:
- Myocardial infarction
- Severe heart failure,
- Arrhythmias
What is Distributive shock and what conditions should you consider?
Abnormal distribution of blood flow due to vasodilation or leaky blood vessels.
Mechanism: Vasodilation → decreased systemic vascular resistance (SVR) → inadequate blood pressure and perfusion.
Types:
> Septic Shock: Due to infection and systemic inflammation.
> Anaphylactic Shock: Severe allergic reaction causing vasodilation and fluid leakage.
> Neurogenic Shock: Spinal cord injury or nervous system damage causing loss of vascular tone.
What is Obstructive shock and what conditions should you consider?
Physical obstruction of blood flow.
Mechanism: Obstruction impedes venous return or cardiac output → reduced tissue perfusion.
Examples
- Pulmonary embolism
- Cardiac tamponade
- Tension pneumothorax.
What is Endocrine shock and what conditions should you consider?
Endocrine dysfunction leading to hemodynamic instability.
Mechanism: Hormonal imbalances impair vascular tone and fluid balance → reduced perfusion.
Examples:
- Addisonian crisis (adrenal insufficiency)
- Severe hypothyroidism (myxedema).
What are two factors that need to be considered when looking at the Inadequate perfusion guideline?
Heart Rate and Blood pressure.
When treating In adequate perfusion we are aiming for a blood pressure of >100 and a HR <100
Fluid can be given 20mls/kg for isolated Tachycardia or Hypotension.
Chest Injuries
What is something that should be considered in patients who aren’t responding to fluid with chest injuries?
Tension Pneumothorax
SCI
How should spinal cord patients be managed under the Inadequate fluid guideline who are suffering with Neurogenic shock.
500ml bolus of Normal Saline
- No further fluid should be administered in SCI is a sole injury in the setting of Hypotension.
Chest Injuries
Chest injuries
What does SMART AMBO mean and when should it be applied?
Smart Ambo is a acronym used for paramedics when wanting to locate a chest decompression.
S- Second intercostal space
M- Mid clavicular line
A- Above the rib below
R- Right Angle
T- Towards the spine
AMBO- Confirm with a second ambo.
Paramedics should ensure the right side is decompressed first to reduce the chances that paramedics will puncture the heart.
Chest Injuries
What are somethings paramedics can do to trouble shoot a kinked catheter
- Flush the catheter with normal saline
- If nil improvement paramedics can place another decompression needle laterally to the original.
Chest injuries
What is the management of chest injury patients.
Assess the type of chest injury
All chest injuries
- Supplemental O2
- Pain relief
- Position: upright if possible.
Flail segment
- May require ventilation support if decreased tidal
Open chest wound
- Three sided dressing
Pneumothorax
- Decompression.
Brain injury (severe)
What is the preferred opioid management for these patients.
Fentanyl
- Fast acting
- Less chance of Hypotension
- Doesn’t increase ICP
- Reduced risk of Histamine release which can increase ICP
Brain injury (severe)
What are some signs of raised ICP and what are some causes
Causes
- Stroke
- TBI
- Tumor
- Lesions
- Infections
Signs
- Headache
- Visual problems
- Nausea/ Vomiting
Late signs
- Hypertension
- Bradycardia
- Irregular Resps
Brain injury (severe)
What is the management of severe brain injuries
Airway
- Non patent airway + gag reflex present: insert NPA
- Insert SGA if nil options for tube, or other airways not effective and pt doesn’t have gag reflex
Ventilation
- 7ml/kg
- Maintain Spo2 > 95 and treat causes of hypoxia
- Maintain Etco2 35-40
Perfusion
- Manage with normal saline as per inadequate perfusion.
Brain injury (severe)
How to manage open skull fractures
Dress open skull fractures with sterile combine soaked in normal saline.
SCI
What is included in the Nexus Criteria (AIMSHUM)
If patient doesn’t meet Major trauma or passes neurological exam then paramedics should undergo NEXUS Assessment.
If patients meet any of the following paramedics should suspect SCI
A- Age >65
I- Intoxicated
M- Midline Tenderness on palpation
S- Significant distracting injury
H- Hx of bone disease
U- Unconscious/ altered GCS <15
M- (movement) rotate head 45 degrees left to right.
SCI
Neurological Exam
(Speed assessment)
Paramedics should assess the following, if patients fail any assessments then patients should be assumed to have some neurological deficit.
Motor function (any weakness)
- Arms: Push, pull, Grasp
- Legs: Push, pull, leg raise.
OR
Sensory function (reduced or no sensation)
- Arms: Palms/ back of hand
- Legs: Lateral aspect of heel
- Suprasternal notch
OR
Patients report any numbness, tingling, burning or any other altered sensation to any other part of their body
SCI
Can patients be encouraged to self extricate with suspected spinal injures
Patients can be encouraged to self extricate themselves if they’re conscious, cooperative, and not intoxicated.
A soft collar should be applied prior to patient self extricating
What patients shouldn’t be spinally cleared.
Paedi patients.
SCI
Management of
Suspected spinal cord injury or major trauma
- Manage Airway as appropriate
- Apply Collar
- Provide spinal motion restriction
- Pain relief
- Immobilize and support fracture
- Symptomatic and prophylactic management.
- Convey to MTC
What is the triad of Death?
The triad of death refers to 3 conditions you may see in trauma patients. The 3 condition can present worsening patient outcomes and increase the likelihood of mortality.
- Acidosis
- Coagulopathy (inability to clot)
- Hypothermia.
Burns
What are some things to consider when cooling a burn
- Use running water if possible
- Normal saline or wet gauze as substitute
- Avoid shivering
- Avoid ice or ice water.
- Ensure you re-evaluate pt temperature.
Burns
How do AT paramedics manage burns?
All burns
- Cool the burn for up to 20/60
- Apply Glad wrap to area (longitudinally)
- Pain relief
Partial or full thickness
- Normal saline IV (2mls/kg) x percentage of burn (over 8 hours)
What is Wallace rule of 9s
Crush Syndrome
What is crush syndrome
Crush syndrome, also known as traumatic rhabdomyolysis, is a severe medical condition caused by prolonged compression of muscle tissue. This compression leads to muscle cell damage and the release of intracellular contents into the bloodstream
Patho
Muscle Compression:
- Prolonged pressure on muscles disrupts blood flow (ischemia).
Lack of oxygen and nutrients causes muscle cell death.
Release of Intracellular Contents:
- Damaged muscle cells release potassium, myoglobin, and other toxic substances into the bloodstream.
Key substances released include:
- Myoglobin: Can cause kidney damage.
- Potassium: Can lead to life-threatening hyperkalemia.
Systemic Effects:
-Kidney Injury: Myoglobin precipitates in the kidneys, causing acute kidney injury (AKI).
- Metabolic Disturbances: Hyperkalemia, acidosis, and electrolyte imbalances can cause arrhythmias or cardiac arrest.
When can you move a compression injury
If compression injury <30 minutes or involving torso or head.
