Treatment

Question 1

ADULT
Mild-moderate asthma

Answer 1

Salbutamol pMDI with spacer 4-12 doses at 20 min intervals, with 4 breaths per dose (100mcg per actuation). Until the resolution of symptoms.

Adequate response
- Transport with reassessment
Inadequate response after 20 minutes
- Treat as severe asthma

Question 2

PAEDIATRIC
Mild-moderate asthma
define and treatment

Answer 2

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 3

ADULT
Severe asthma

Answer 3

Salbutamol 10mg (presented in 5mg in 2.5mL) and ipratropium bromide 500mcg (presented in 250mcg per 1mL) nebulised (nebuliser mask with oxygen at 8-10L/min)
* Repeat salbutamol 5mg (2.5mL) at 5 min intervals if required
* Dexamethasone 8mg oral or IV, if IV access is available (presented in 8mg in 2mL)

Inadequate response (no response to nebulised therapy, speaking single words or acute life threat)
* Adrenaline 500mcg IM (presented in 1mg in 1mL). Repeat adrenaline 500mcg after 5-10 min intervals with a max of 3 doses (1.5mL)
* Consult for IV adrenaline if still inadequate response to IM adrenaline

If no response to IM adrenaline, consult the clinician for IV adrenaline if thunderstorm asthma 20mcg at 2-minute intervals

Question 4

PAEDIATRIC
Severe asthma
define and treatment

Answer 4

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): 5oomcg (2mL)

Question 5

PAEDIATRIC
Critical asthma
define and treatment

Answer 5

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 250mcg (1mL) 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

Question 6

COPD

Answer 6

When treating COPD patients, titrate oxygen flow to stay between 88-92%, the normal range for a COPD patient. Consider low-flow oxygen (e.g nasal prongs) to stay in this range. Treat as regular severe hypoxaemia if SpO2 <85%.
Irrespective of severity

Salbutamol 10mg (presented in 5mg in 2.5mL) with ipratropium bromide 500mcg (presented in 250mcg in 1mL) nebulised.

Dexamethasone 8mg (presented in 8mg in 2mL) oral, or IV if access is available.

Question 7

Acute pulmonary Odeama

Answer 7

Signs of shortness of breathe and crackles

GTN:
600mcg SL if SBP >100mmHg
300mcg SL if pt has nor had it previously, borderline BP (<100) or small <60kg, or elderly/frail
@ 5/60 intervals, no max dose just till no pain or side effects

Transdermal patch 50mg (0.4mg p/h) upper torse or arm. Remove if SBP <100.

No improvements or full-field APO
CPAP 10cmH20
- suction and assisted ventilation if required

Question 8

ACS
adult

Answer 8

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 9

ACS
Elderly

Answer 9

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 10

STEMI

Answer 10

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 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 11

Nausea and vomiting

Answer 11

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 12

Pain
Mild pain (1-3/10)
Adults

Answer 12

Paracetamol 1000mg oral (presented in 500mg tablets)

Question 13

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

Answer 13

Paracetamol 500mg oral

Question 14

Pain
Mild pain (1-3/10)
Paediatric

Answer 14

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 15

Pain
Moderate pain (4-6/10)
Adults

Answer 15

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 16

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

Answer 16

• 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 17

Pain
Moderate pain (4-6/10)
Paediatrics

Answer 17

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

Fentanyl IN
o Small child (10-17kg): 25mcg initial dose with 25mcg repeat at 5-10 min intervals (consult after 3 doses)
o Medium child (18-39kg): 25-50mcg initial dose with a 25-50mcg repeat at 5-10 min intervals (consult after 3 doses)
o 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 18

Pain
Severe pain (8-10/10)
Adult

Answer 18

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 19

Pain
Severe pain (8-10/10)
Elderly/Frail/<60kg

Answer 19

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 20

Pain
Severe pain (8-10/10)
Paediatrics

Answer 20

Fentanyl IN +/- Methoxyflurane as per moderate pain below (consilt for further doses of fentanyl IN if required

o Small child (10-17kg): 25mcg initial dose with 25mcg repeat at 5-10 min intervals (consult after 3 doses)
o Medium child (18-39kg): 25-50mcg initial dose with a 25-50mcg repeat at 5-10 min intervals (consult after 3 doses)
o 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 (Mac dose 0.2 mg/kg without consultation)
Can give ketamine but to be done by MICA

Children <12 year old Ketamine IV and morphine IV can be given but by MICA

Question 21

Maternity focused assessment
Questions

Answer 21

PRODROME
- any reported complaints over the past (week/days) 1/52 – nil pain, PV bleeding, illness, infection or trauma

PREVIOUS PREGNANCIES
- any/number of previous pregnancies?
- prior caesarean sections/interventions?
- complications/problems with previous pregnancies?
- length of previous labours?

CURRENT PREGNANCIES
- How many weeks pregnant are you?
- are you expecting a singleton or multiple pregnancies?
- Have your membranes ruptured? What was the colour of the amniotic fluid?
- are you having contractions? Assess frequency and duration
- do you have an urge to push?
- have you felt fetal movement? more/less or same as normal?
- hospital interventions (if any)?
- do you anticipate any problems/complications (baby/mother)?
- have you had any antenatal care?
- any correct complaints? (vaginal bleeding/PV loss, high BP, pain, trauma, any other issues?

Question 22

Maternity focused assessment
reproductive (signs of going into labour)

Answer 22

Imminent Delivery
- Active pushing/grunting
- Rectal pressure (urge to use bowels or bladder)
- Anal pouting
- Bulging perineum
- Urge to push
- Crowning (presenting baby’s head)
- mother’s statement “I am going to have the baby”

Question 23

Maternity focused assessment
treatment

Answer 23

PREGNANCY-RELATED
Asses for
- gestation
- in labour
- rupture of membranes
- presenting part on view
- baby born

OTHER MATERNITY PROBLEM
Action
- trauma as per CPG
- cardiac arrest are per CPG

BIRTH NOT IMMINENT
complicated
- treat as antepartum haemorrhage (APH)
- treat as pre-eclampsia/eclampsia
uncomplicated
- basic care
- pain relief are required by CPG
- continue to monitor
- transport to hospital

BABY BORN
- newborn care ars per newborn resuscitation
Intrapartum care
- delivery as per normal birth CPG
- PPH as per primary post partum haemorrhage CPG

Question 24

Newborn resuscitation
what to do

Answer 24

Birthed, dried, skin to skin with mother
ASSESS
- Breathing
- muscle tone (flexed arms and legs)

BREATHING ADEQUATELY AND GOOD MUSCLE TONE
- vigorous newborn
manage as per the newborn baby’s CPG

APNOEIC OR GASPING OR NO MUSCLE TONE
- stimulate by drying (not more than 30 seconds)
- maintain warmth (blanket and beanie)
- place supine with head/neck in a neutral position with blanket under shoulders
- suction only if airway obstruction is suspected

ASSESS AGAIN
- breathing
- heart rate (auscultate or ECG)

HEART <100 AND/OR APNOEIC OR GASPING
- IPPV @ 40-60 per minute on room air
- pulse oximetry (right hand or right wrist)
- ECG monitoring if not already attached
- reassess after 30 seconds

ASSESS
- heart rate and breathing
- reassess every 30 seconds and change management accordingly

HR <60
CPR @3:1 ratio with oxygen (5 L/min)
- consult with PIPER for all infants with HR <60

HR 60-100
- IPPV @40-60 per minute
- ensure adequate mask seal, and airway position and increase ventilation pressure targeting chest rise
- if not increase in heart rate: IPPV with oxygen 5 L/min

HR >100, but SPO2 <90%
Breathing laboured
- IPPV at 4060 per minute
- titrate oxygen (1-5L/min) to meet target saturations
Breathing normally
- maintain warmth and treatment as per newborn baby CPG
- titrate oxygen 1-2 L/min via nasal cannula to meet target saturations
- discontinue oxygen where SpO2 >90%

Question 25

The newborn baby
What to do

Answer 25

birthed, dried, skin to skin with mother
ASSESS
- breathing
- muscle tone

APNOEIC OR GASPING OR NO MUSCLE TONE
Non-vigorous newborn
- manage as per newborn resuscitation CPG

BREATHING ADEQUATELY AND GOOD MUSCLE TONE
- continue to dry (especially the head)
- maintain warmth (skin-to-skin, blankets and beanie for the baby)
- routine suction is not recommended
- monitor HR (auscultation), breathing, tone and colour
- If vital signs deteriorate or the airway is obstructed at any stage, manage as per newborn resuscitation CPG

NORMAL NEWBORN: RESUSCITATION NOT REQUIRED
- cut the cord once the cord has stopped pulsating (approx 1-2 minutes) unless parental preference is to remain attached
- note APGAR when practicable

TRANSPORT
>36 weeks gestation, uncomplicated delivery, stable vital signs
- Tx to appropriate maternity service (pre-booked hospital)
32 - 36 weeks gestation AND stable vital signs
- Tx to a level 2 hospital (paediatrics and midwife on-site 24/7) in consultation with PIPER
<32 weeks gestation, or unstoppable vital signs
- Tx to tertiary centre in consultation with PIPER
Rural Victoria
- Tx to the nearest base hospital or hospital with maternity service and contact PIPER

Question 26

Normal birth
how to do

Answer 26

Imminent normal birth
- maternity history
- labour progression
Opioid analgesics are C/I in late second-stage labour

NORMAL BIRTH - NOT IMMINENT
- reassure
- monitor regularly for change
- Tx to the appropriate maternity service facility using a left lateral tilt position
- provide analgesia as per CPG

IMMINENT NORMAL BIRTH - PREPARATION
- reassure including cultural considerations
- prepare equipment for normal birth
- provide a warm and clean environment
- provide analgesia as per pain relief CPG

NORMAL BIRTH - BIRTH OF HEAD
- as the head advances, encourage the mother to push with each contraction
- if the head is birthing too fast, ask the mother to pant with an open mouth during contractions instead
- place fingers on baby’s head to feel the strength of descent of the head
- apply gentle pressure to the perineum to reduce the risk of perineal tears
- if precipitous (moving to fast), apply gentle backward and downward pressure to control sudden expulsion of the head - DO NOT HOLD BACK FORCIBLY
- not the time once the head is delivered

NORMAL BIRTH - UMBILICAL CORD CHECK
- following the birth of the head, check for an umbilical cord around the neck
- IF LOOSE and wrapped around the neck: slip over baby’s head with appropriate traction
- IF TIGHT: mother should be encouraged to push and if baby doe snot decent and cord still cannot be loosened, clamp and cut cord

NORMAL BIRTH - HEAD ROTATION
With the next contraction, the head will turn to face one of the mother thighs (restitution)
- this indicates internal rotation of the shoulders in preparation for the birth of the body

NORMAL BIRTH - BIRTH OF THE SHOULDERS AND BODY
- may be passive or guided
- hod baby’s head between hands and if required apply gentle downward pressure to deliver the anterior (top) shoulder
- once the baby’s anterior is visible, if necessary to assist the birth, apply gentle upward pressure to the birth posterior should - the body will follow quickly
- support the baby
- note time of birth
- place baby skin to skin with mother on her chest to maintain warmth unless the baby is not vigorous/requires resuscitation
- treat the vigorous baby as per newborn baby CPG
- treat the non-vigorous newborn as per newborn resuscitation CPG
- if the body fails to deliver in >60 seconds after the head, treat as per shoulder dystocia CPG
- following delivery of the baby, gently palpate the abdomen to ensure the second baby is not present

NORMAL BIRTH - CLAMPING AND CUTTING THE CORD
- There is no immediate urgency to cut the cord. Wait for the cord to stop pulsating, which commonly takes one to two minutes. Allow the birthing partner to cut the cord if they wish. Ideally, cord-cutting should be undertaken prior to extrication
- to cut the cord, apply the first clamp 10cm from the baby and the second clamp a further 5cm from the first, then cut between the two clamps
- for uncomplicated births, a parental birth preference where more and baby are transported to the hospital still attached is permissible (allowed)

NORMAL BIRTH - BIRTHING PACENA(THIRD STAGE)
Passive
- allow placental separation to occur spontaneously without intervention
- this may take from 15 minutes up to 1 hour
- position the mother sitting or squatting to alow gravity to assist expulsion
- breast-feeding may assist in separation or expulsion
DO NOT PULL ON CORD - WAIT FOR SIGNS OF SEPARATION (lengthening of cord - uterus becomes rounded, firmer, smaller - trickle of gush or blood from the vagina - cramping/contractions return)
- The placenta and membranes are birthed by maternal effort. ask mother to give a little push
- use two hands to support and remove the placenta using a twisting ‘see-saw’ motion to ease membranes slowly out of the vagina
- not time of delivery of placenta
- place placenta and blood clots into a container and transfer
- inspect placenta and membranes for completeness
- inspect the fundus is firm, contracted and central
- continue to monitor fundus though do not massage once firm
- if fundus is not firm or blood loss >500 mL treat as per primary postpartum haemorrhage CPG

Question 27

Primary postpartum haemorrhage (PPH)
how to treat

Answer 27

PPH - blood loss >500 mL in first 24 hours from birth
ASSESS
- fundus tone
- visible blood loss
- perineal/vaginal laceration

FUNDUS FIRM
Palpable firm, central and compacted fundus
- high flow O2 therapy
- analgesia as required as per pain relief CPG
BP <90 mmHg
- consider normal saline IV (max 40 mL/kg) titrated to patient response
- consult for further fluid, if consult unavailable repeat normal saline 20 mL/kg IV
Treat ant lacerations with a dressing and firm pressure

FUNDUS NOT FIRM
- treat as per fundus firm
- normally the fundus will not become firm and contracted until the placenta is delivered (avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs)
- massage fundus until firm and blood loss reduces (use a cupped hand and apply firm pressure in a circular motion)
- encourage the mother to empty her bladder if possible
- encourage baby to suckle breast

FUNDUS REMAINS FIRM
- oxytocin 10IU IM
- repeat oxytocin 10 IU IM after 5 minutes if bleeding continues
- tranexamic acid 1 gram In over 10 minutes
DO NOT ATTEMPT DELIVERY OF PLACENTA DUE TO RISK OF INTERNET INVERSION (the placenta fails to detach from the uterine wall, and pulls the uterus inside-out as it exits)

INTRACTABLE HAEMORRHAGE (nothing is working)
Perform external abdominal aortic compression
- locate point of compression just above the umbilicus and slightly to the left
- apply downward pressure with a closed fist directly through the abdominal wall
- effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied

Question 28

Antepartum Haemorrhage
what to do

Answer 28

Antepartum Haemorrhage
ASSESS
- perfusion status
- external bleeding
- Patient Hx
- Abdominal pain
- >20 week gestation

NO CLINICAL SIGNS OF ALTERED PERFUSION
Antepartum Haemorrhage
- place Pt in the left lateral position
- transfer to the appropriate obstetric hospital

ANY CLINICAL SIGNS OF ALTERED PERFUSION
Internal bleeding may greatly exceed visible external bleeding and signs of poor perfusion may present late and are always significant
- Place the patient in the left lateral tilt position
- Transport to the appropriate obstetric hospital with notification in all cases
LESS THAN ADEQUATE PERFUSION
- consider normal saline IV (max. 40 mL/kg) titrated to the patient’s response
- consult for further fluid, if consult unavailable repeat normal saline 20 mL/kg
Treat pain as per pain relief CPG

Question 29

Pre-eclampsia/eclampsia

Answer 29

ASSESS
- hypertension
- pre-eclampsia S/S
- seizure activity
- gestation >20 weeks

NORMAL BP
- consider other causes of complaint
- manage symptomatically

SIGNIFICANT HYPERTENSION
SBP 140-170 mmHg
DBP 90-110 mmHg
- basic care
- left lateral tilt

SEVERE HYPERTENSION
SBP >170 mmHg
DBP >110 mmHg
pre-eclampsia S&S
- consult with PIPER to manage hypertension

SEIZURE ACTIVITY - ECLAMPSIA
- treat as per seizures
- left lateral position
- high flow O2

POST SEIZURE
- assess for aspiration and treat symptomatically
- manage precipitous (possibly dangerous/fast) delivery as per normal birth CPG
- manage placental abruption as per antepartum haemorrhage CPG

Question 30

Breech birth
what to do

Answer 30

ASSESS
- stage of labour and birth imminent
- buttocks or both feet presenting first
- one foot or hand/arm presenting first
STOP
- opioid analgesia is C/I in second-stage labour
- do not attempt delivery of on foot or hand/arm presentation
- only proceed with delivery if birth is imminent

NON IMMINENT BIRTH
- general maternal care
- transport to booked appropriate maternity service unit with notification

ONE FOOT, HARD OR ARM PRESENTING
- do not attempt to deliver
- transport to an appropriate maternity service unit with notification
- consult with PIPER for advice

IMMINENT BREECH BIRTH - BUTTOCKS OR BOTH FEET PRESENTING
Manage as per normal birth CPG except for:
- request urgent assistance
- reassure including cultural considerations
- prepare obstetrics equipment
- provide a warm and clean environment
- provide analgesia as per pain relief CPG
- allow the birth to occur spontaneously
- position mother with buttocks to bed edge and legs supported to allow gravity to assist
- HANDS OFF THE BREECH
- the birth of the buttocks/feet will occur slowly

BUTTOCK FIRST PRESENTATION - BACK UPPERMOST -DELIVERY OF BODY/LEGS
- this is the most common presentation
- DO NOT ATTEMPT TO PULL THE BABY OUT
- encourage mother to push hard with contractions
- feet and legs should spring free
- await further decent
- keep the body warm by wrapping it in a towel or bubble wrap if needed
- the body will further descend to the clavicle and arms should swing free
- let baby’s hang until the nape of the neck is visible
- the baby should face downward
- assist the birth of the head using modified mauriceau smellie veit manoeuvre

BUTTOCK FIRST PRESENTATION - BACK UPPERMOST - DELIVERY OF HEAD MODIFIED MAURICEAU SMELLE VEIT MANOEUVRE
- place the index finger and ring finger of the non-dominant hand on the baby’s shoulders and the middle finger on the occiput to assist with flexion of the head
- place the dominant hand under the baby to support the body with the ring finger and index fingers don’t he baby’s cheekbones
- slowly lift the baby straight up in a circle onto the mother’s abdomen, allowing the head to birth slowly
- an assistant can aid flexion of the head by applying direct pressure behind the pubic bone

BUTTOCKS FIRST - BACK NOT UPPERMOST
- The baby’s back needs to remain uppermost
If legs are delivered and the back is not uppermost
- gently hold the baby by placing thumbs on bone sacrum with fingers around thighs
- DO NOT squeeze the abdomen
- rotate/turn baby uppermost between contractions taking care of baby’s spine
- take great care to NEVER pull the baby

BUTTOCKS FIRST PRESENTATION - LEGS DON’T BIRTH SPONTANEOUSLY
If extended legs (think Frank)
- slip one hand along the leg of the baby lying anteriorly
- place a finger behind the baby’s knee and deliver it by flexion and abduction

BUTTOCK’S FIRST PRESENTATION - ARMS DON’T BIRTH SPONTANEOUSLY LOVESETT’S MANOEUVRE
- hold the baby by the sacrum
- turn baby 90 degrees so that one shoulder is in the anterior-posterior diameter
- insert the finger into the brachial plexus and sweep the arm down over the baby’s chest
- turn baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter
- repeat the finger manoeuvre
- turn the baby 90 degrees again so that the back is uppermost
- await further descent
DO NOT PULL OR APPLY TRACTION

Question 31

Preterm labour
what to do

Answer 31

uterine contraction present @ 20 - 37 weeks
ASSESS
- ruptured membranes
- check for cord prolapse
- stage of labour

CORD PROLApSE
- manage as cord prolapse CPG

BIRTH IMMINENT
- consider other causes of complaint
- manage symptomatically

BIRTH NOT IMMINENT ≥ 34 WEEKS
- basic care
- reassure

BIRTH NOT IMMINENT <34 WEEKS
contraindications as per GTN medicine monograph including:
- bleeding in pregnancy
- BP <100 mmHg
50mg GTN patch (0.4 mg/hr) applied to the abdomen
- a further 50mg GTN patch *0.4 mg/hr) may be added after 1 hour if contractions persist (max 20 mg/24 hours)

Question 32

Cord prolapse
what to do

Answer 32

Umbilical cord visible at vulva with ruptured membranes
ASSESS
- cord visible at vulva
- ruptured membranes
- stage of labour

BIRTH COMMENCING
- instruct mother to push
- assist in delivery
- prepare for newborn resuscitation
- magage as normal birth CPG
- manage as per newborn resuscitation CPG

BIRTH NO IMMINENT - MANAGEMENT OF MOTHER
- position the patient semi-prone with hips elevated over folded towels
- provide explanation and reassurance
- high flow O2 therapy

BIRTH NOT IMMINENT - MANAGEMENT OF CORD
- minimise cord handling
- keep cord warm and moist. Use two fingers to gently place the cord in the vagina
- if unsuccessful cover with warm saline packs (if possible)

BIRTH NOT IMMINENT MANAGEMENT OF PRESENTING PART
- if there is pressure on the cord by the presenting part insert fingers into the vagina and push presenting part (head) away from the cord
- maintain pressure until birth commences or advised to release

Question 33

Shoulder dystocia
what to do

Answer 33

Possible shoulder dystocia
ASSESS
- normal birthing procedure fails to accomplish delivery
- prolonged hea to body delivery time >60 seconds
- difficulty with both face and chin
- baby’s head retracts against the perineum (turtle sign)
- failure of baby’s head to restitute
- failure of shoulders to descend
- difficulty reaching NECK when attempting to check for a cord around the neck
- baby’s head colour turns purple then black

PROLONGED HEAD-TO-BODY DELIVERY TIME >60 SECONDS
- note time of birth of head
- request urgent additional assistance
- explain to the mother and ask her to push with focused effect when required
- position mother with buttocks at bed edge
- apply gentle downward traction to deliver anterior shoulder

DELIVERY ACCOMPLISHED - NEWBORN
- manage per newborn resuscitation
- assess for clavicle injury and immobiliser if necessary

DELIVERY ACCOMPLISHED - MOTHER
- basic care
- reassure

DELIVERY NOT ACCOMPLISHED - AFTER 30-60 SECONDS
- alternate the following sequence until the baby is delivered
- manage as per delivery accomplished if successful at any time
AT NO TIME attempt to rotate the baby’s head - rotate shoulders using pressure on the baby’s scapula instead

DELIVERY NO ACCOMPLISHED AFTER 30-60 SECONDS
Hyperflexion of maternal hips (McRoberts manoeuvre) - knees to nipples
- place the mother in a recumbent position
- hips on the edge of the bed enabling better access for gentle downward traction
- assist the mother in grasping her knees and pulling her knees/thighs back as far as possible onto her abdomen (use the assistant to help achieve and maintain position)

DELIVERY REMAINS NOT ACCOMPLISHED AFTER 30 - 60 SECONDS
Suprabic pressure whilst in Mc Roberts position
- Hands in CPR position behind the pubis, at 45-degree angle along baby’s back (trying to rotate baby forward)
- Apply 30 seconds of firm downward pressure, then 30 seconds of rocking motion to get the shoulder out from under the rim, at a rate of approximately 1 per second

DELIVERY REMAINS NOT ACCOMPLISHED AFTER 30-60 SECONDS
All fours (Gaskin) manoeuvre
- rotate mother to all fours
- hold baby’s head and apply gentle downward traction - attempting to dis-impact and deliver the posterior shoulder (now uppermost)

DELIVERY ACCOMPLISHED
- manage as above
- the newborn. is likely to require resuscitation

DELIVERY REMAINS UNACCOMPLISHED
- consult with PIPER regarding when to abandon maneuvers and treatment
- if unable to consult, transport with notification
- transfer in McRoberts’s manoeuvre position with 30 degrees left later tilt

Question 34

Anaphylaxis
how to treat

Answer 34

Suspected anaphylaxis
STOP
- stop the trigger (eating the food, wash the exposed skin etc.)
- ANY pt with anaphylaxis (resolved/possible) must be transported to the hospital due to receiving adrenaline and clinical flags/pt safety CPG

CRITERIA
Sudden onset of symptoms, usually <30 min or up to 4 hours
AND
Two or more R.A.S.H. +/- confirmed exposure to antigen:
- R: respiratory distress
- A: abdominal symptoms
- S: skin/mucosal symptoms
- H: hypotension
OR
Isolated hypotension SBP <90 mmHg following exposure to a known antigen
OR
Isolated respiratory distress following exposure to known antigen

ANAPHYLAXIS/SEVERE ALLERGIC REACTION
Do not sit or walk the pt if possible
- adrenaline 500mcg IM (1:1000): repeat dose @ 5 minute intervals are required
- request MICA if risk factors OR not responsive to initial adrenaline
- Insert IV
- O2 per oxygen therapy; critical illness

ADDITIONAL THERAPIES (IN ORDER OF CLINICAL NEED)
Prioritise repeat adrenaline
- Airway oedema/stridor: Adrenaline 5mg nebulised (consult with a clinician for repeat dose if required and notify receiving hospital
- Bronchospasm: Salbutamol 5mg nebulised or pMDI 4-12 doses: repeat at 20-minute intervals if required
Ipratropium Brodmise 500 mcg nebulised or pMDI 8 doses
Dexamethasone 8 mg IV/oral
- Cardiovascular - hypotension (BP <90) despite initial adrenaline: normal saline IV (max. 40 mL/kg) titrated to response, consult if further fluid is required and if a consultant is unavailable repeat normal saline 20mL/kg IV
- Inadequate response to adrenaline with a history or heart failure OR taking beta blockers: glucagon 1mg IV/IM and repeat once @ 5 mins if required

Question 35

Seizure
how to treat

Answer 35

Seizure activity
ASSESS
- evidence of status epileptics (≥ 5 minutes or ≥ 2 seizures without recovery): GCSE (Generalized convulsive status epilepticus ) or other SE (status epilepticus) or subtle SE
- consider other causes (e.g. hypoglycaemia, hypoxia, head trauma, stroke/ICH, electrolyte disturbances, meningitis)
- consider pt own management plan and treatment already given

SEIZURE ACTIVITY CEASED/OTHER SE/SUBTLE SE
- monitor airway, ventilation, conscious state and BP
- if subtle SE is suspected, consider time-critical transport and consult for midazolam
- if pt has recovered fully consider treat and refer pathway as per treat and refer - seizures

GENERALISED CONVULSIVE SE
- manage airway and ventilation as required
- if the airway parent, administer high-flow O2 as per oxygen therapy CPG
- midazolam 10mg IM:
If small (< 60kg), frail or elderly pt should be administered 5 mg IM
repeat 5 mg IM once at 5 minute interval if required

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

NO RESPONSE AFTER 5 MINUTES
- only MICA can do something

NO RESPONSE AFTER 10 MINUTES
No IV access/no accreditation
- If pt had full dose initially (not small/frail/elderly) repeat midazolam 10mg IM once only - consult for further doses
- continue to monitor airway, ventilation, conscious state and BP

Question 36

Narrow complex tachycardia
how to treat

Answer 36

QRS <0.12 sec

STOP
- If the patient loses consciousness at any stage Mx with synchronised cardioversion in addition to cardiac arrest CPG (MICA only)
- Mx of sinus tachycardia should be directed at the underlying cause (e.g. hypovolemia, pain) and not treated using this CPH

STABLE - SVT (AENRT OR AVRT) - exclude AF and atrial flutter
SBP ≥90 mmHg
- record 12 lead ECG prior to commencing Mx
- Modified Valsalva or standard Valsalva (if manual handling or environmental concern) - repeat x2 @ 2-minute intervals (MAX 3 attempts)
MICA
Can give adenosine IV

STABLE - other rhythms
- Atrial flutter, Atrial fibrillation, multifocal atrial tachycardia
Use pain relief CPG

UNSTABLE AND RAPIDLY DETERIORATING
- Synchronised cardioversion with midazolam and fentanyl

Question 37

Bradycardia
how to treat

Answer 37

UNSTABLE
- less than adequate perfusion including acute STEMI and ischemia chest pain)
- profound bradycardia (HR < 40 bpm) and APO
- Runs of VT or ventricular escape rhythsm
- HR <40 bpm

MICA ONLY
- give atropine
- adrenaline infusion
And if incredibly poor perfusion
- Midazolam and fentynal

Question 38

Tachycardia wide complex

Answer 38

QRS ≥ 0.12 sec
If pt loses consciousness at any point Mx via cardiac arrest

MICA only
STABLE: VT OR UNCLEAR
- give amiodarone infusion if

UNSTABLE OR RAPIDLY DETERIORATING
- synchronised cardioversion with midazolam and fentanyl
- also amiodarone infusion if not fixefd

Question 39

Tenecteplase doses
weight

Answer 39

<60: 30mg, 6000IU, 6mL
60 - 69: 40mg, 7000IU, 7mL
70 - 79: 50mg, 8000IU, 8mL
80 - 89: 60mg, 9000IU, 9mL
90 - 100: 70mG, 10,000, 10mL

Question 40

APGAR

Answer 40

A- Appearance
- 0: blue/pale
- 1: pink body/blue extremities
- 2: totally pink

P - pulse
- 0: abstant
- 1: <100
- 2: >100

G - Grimice
- 0: none
- 1: grimace
- 2: cries

A - Activity
- 0: limp
- 1: extremity flexion
- 2: active motion

R - respiratory effect
- 0: none
- 1: weak/gasping/ineffective
- 2: strong cry

Question 41

Unconscious Asthma
how to treat

Answer 41

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

PATIENT REQUIRES IMMEDIATE ASSISTED VENTILATION
- ventilate 6-7 mL/kg @ 5 - ventilations/minute
- moderately high respiratory pressures
- allow for a prolonged expiratory phase

ADEQUATE RESPONSE
Treat it as severe asthma but remember that because they are not breathing for themselves, you will not be able to nebulise

So go straight to adrenaline and then dexamethasone:
* Dexamethasone 8mg oral or IV, if IV access is available (presented in 8mg in 2mL)

Inadequate response (no response to nebulised therapy, speaking single words or acute life threat)
* Adrenaline 500mcg IM (presented in 1mg in 1mL). Repeat adrenaline 500mcg after 5-10 min intervals with a max of 3 doses (1.5mL)
* Consult for IV adrenaline if still inadequate response to IM adrenaline

If no response to IM adrenaline, consult the clinician for IV adrenaline if thunderstorm asthma 20mcg at 2-minute intervals

Question 42

CPAP
Contraindications

Answer 42

• Inability to manage own airway (alter conscious state, active vomiting or excessive secretions)
• upper airway obstruction
• Hypoventilation (patient must have adequate spontaneous respirations)
• untreated tension pneumothorax (must be treated before considering CPAP)
• Haemodynamic instability (severe hypotension, ventricular arrhythmias - should all be treated before considering)
• Injuries that preclude mask application

Question 43

CPAP
precautions

Answer 43

• hypovolemia
• post chest decompression (closely monitor)
• COPD (monitor for deterioration)
• Hypotension

Question 44

CPAP
Indications for it to be removed

Answer 44

• Cardiac/respiratory arrest
• Pt agitation/intolerance
• No improvements after 1hr
• HR <50
• SBP <90
• GCS <13
• Decreasing SpO2
• Loss of airway control
• Copious secretion
• Active vomiting
• Paramedic judgement of Pt deterioration

Question 45

Valsalva Manoeuvre
Indications

Answer 45

• atrioventricular re-entry tachycardia (AVRT)
• AV node re-entry tachycardia (AVNRT)

Question 46

Valsalva Manoeuvre
contraindications

Answer 46

• systolic blood pressure <90 mmHg
• unstable or rapidly deteriorating patient
• atrial fibrillation or atria flutter

Question 47

Valsalva Manoeuvre
how to do

Answer 47

• Don PPE as required
• Attached to patient to cardiac monitor and position monitor so that it can be viewed by all paramedics
• get 10ml Syringe and open a new one and ensure the barrel is able to move freely in and out
• Reassure patient and explain the procedure
• Gain consent and check contraindications
• Consider inserting an intravenous cannula
• Position patient in the appropriate position (Modified Valsalva (Semi-Recumbent)
  Standard Valsalva (Supine Position))
• Hand the Syringe to the patient with barrel left pushed inward

MODIFIED VALSALVA
- position patient semi-recumbent
- press the snapshot button to record cardiac rhythm
- Encourage the patient to exhale forcefully into the syringe for approximately 15 seconds with enough pressure to push the syringe plunger outward, followed by normal breathing
- Immediately lay the patient flat and raise the patient’s legs to approximately 45 degrees for 15 seconds
- lower the patient’s legs and return them to a semi-recumbent position
- press end snapshot

STANDARD VALSALVA
- position the patient supine
- press snapshot button to record cardiac rhythm
- have the patient take one normal breathe and hold it
- encourage the patient to exhale forcefully into the syringe for approximately 15 seconds with enough pressure to push the syringe plunger outward, followed by normal breathing
- patient remains in supine position
- press end snapshot

Reassess the patient to confirm cardiac rhythm and reassess Pt vital signs

Question 48

Newborn resuscitation
what are we first assessing

Answer 48

Birthed, dried, skin to skin with mother
ASSESS
- Breathing
- muscle tone (flexed arms and legs)

Question 49

Newborn birth
what are we first assessing

Answer 49

birthed, dried, skin to skin with mother
ASSESS
- breathing
- muscle tone

Question 50

Normal birth
what are we first assessing

Answer 50

Imminent normal birth
- maternity history
- labour progression
Opioid analgesics are C/I in late second-stage labour

Question 51

Primary postpartum haemorrhage (PPH)
what are we first assessing

Answer 51

PPH - blood loss >500 mL in first 24 hours from birth
ASSESS
- fundus tone
- visible blood loss
- perineal/vaginal laceration

Question 52

Antepartum haemorrhage
what are we first assessing?

Answer 52

Antepartum Haemorrhage
ASSESS
- perfusion status
- external bleeding
- Patient Hx
- Abdominal pain
- >20 week gestation

Question 53

Pre-eclampsia/eclampsia
what are we first assessing

Answer 53

ASSESS
- hypertension
- pre-eclampsia S/S
- seizure activity
- gestation >20 weeks

Question 54

Breech birth
what are we first assessing

Answer 54

ASSESS
- stage of labour and birth imminent
- buttocks or both feet presenting first
- one foot or hand/arm presenting first
STOP
- opioid analgesia is C/I in second-stage labour
- do not attempt delivery of on foot or hand/arm presentation
- only proceed with delivery if birth is imminent

Question 55

Preterm labour
what are we first assessing

Answer 55

uterine contraction present @ 20 - 37 weeks
ASSESS
- ruptured membranes
- check for cord prolapse
- stage of labour

Question 56

Cord prolapse
what are we first assessing

Answer 56

Umbilical cord visible at vulva with ruptured membranes
ASSESS
- cord visible at vulva
- ruptured membranes
- stage of labour

Question 57

Shoulder dystocia
what are we first assessing

Answer 57

Possible shoulder dystocia
ASSESS
- normal birthing procedure fails to accomplish delivery
- prolonged head-to-body delivery time >60 seconds
- difficulty with birth of face and chin
- baby’s head retracts against the perineum (turtle sign)
- failure of baby’s head to restitute
- failure of shoulders to descend
- difficulty reaching NECK when attempting to check for a cord around the neck
- baby’s head colour turns purple then black