ST John Clinical Procedures 2009-2011

Clinical Procedures
20092011
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cLInIcAL ProcEdurES 2009 20
ForEWord These clinical procedures are for use by St John personnel, with current authority to practice at primary care level or above, when providing patient care on behalf of St John. They have been developed by the St John Clinical Management Group and are issued by Dr Tony Smith on their behalf.
These procedures expire at the end of September 2011 at which time they will be formally updated and reissued. They remain the intellectual property of St John and may be recalled or updated at any time. Any persons other than St John personnel using these procedures do so at their own risk. St John will not be responsible for any loss, damage or injury suffered by any person or persons as a result of, or arising out of, the use of these procedures by persons other than St John personnel.
Ian Civil Chair of the Clinical Governance Committee
Jaimes Wood Chief Executive
St John clinical Management Group Members at the time of publication Dr Tony Smith, Medical Director Tony Blaber, Operations Director Dr Muir Wallace, Medical Advisor, Midland Region Dr Craig Ellis, Medical Advisor, Central Region Dr David Richards, Medical Advisor, NRSI Dr John Chambers, Medical Advisor, Southern Region Norm Wilkinson, National Clinical Standards Manager Mark Deoki, Clinical Standards Manager, Northern Region Douglas Gallagher, Clinical Education Manager Mike Pudney, Clinical Standards Manager, Midland Region Cheryl desLandes, Clinical Standards Manager, Central Region Hank Bader, Clinical Standards Manager, NRSI Paul McNamara, Clinical Standards Manager, Southern Region comments and enquiries St John personnel should contact their Regional Clinical Standards Manager or Regional Medical Advisor. Others wishing to make formal comments or enquiries should contact: Dr Tony Smith Medical Director St John Private Bag 14902, Panmure, Auckland 1741, New Zealand tony.smith@stjohn.org.nz
Document Properties Title: CLINICAL PROCEDURES Issued by: Tony Smith, Medical Director Authorised by: Jaimes Wood, Chief Executive Issue No: 4 Doc Ref: CP Issue Date: Date for Review: November 2009 September 2011
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Section : Introduction 1.1 The primary survey 1.2 The secondary survey 1.3 Cervical spine immobilisation 1.4 Oxygen administration 1.5 PEEP valves 1.6 Non-transport Section 2: respiratory and cardiac 2.1 Asthma 2.2 Chronic obstructive airway disease 2.3 Cardiac arrest 2.4 Post cardiac arrest care 2.5 Cardiogenic shock 2.6 Dysrhythmias 2.7 Cardiogenic pulmonary edema 2.8 Cardiac chest pain 2.9 Post thrombolysis care Section : Shock and trauma 3.1 Hypovolaemic shock 3.2 Hypovolaemic shock from uncontrolled bleeding 3.3 Traumatic brain injury 3.4 Anaphylaxis 3.5 Burns Pg 10 Pg 11 Pg 13 Pg 15 Pg 17 Pg 18 Pg 23 Pg 26 Pg 27 Pg 40 Pg 41 Pg 43 Pg 47 Pg 49 Pg 51 Pg 52 Pg 54 Pg 56 Pg 58 Pg 61
Section : Altered consciousness 4.1 Hypoglycaemia 4.2 Hyperglycaemia 4.3 Seizures 4.4 Poisoning 4.5 The combative patient Section 5: Paediatrics 5.1 Paediatric vital signs 5.2 Paediatric drug doses 5.3 Croup 5.4 Newborn resuscitation Section 6: Miscellaneous 6.1 Pain relief 6.2 Nausea and vomiting 6.3 Rapid sequence intubation 6.4 Failed intubation drill 6.5 Intra-osseous drill 6.6 Obstetric problems 6.7 Diving emergencies 6.8 Palliative care 6.9 Status codes 6.10 Burn depth and area 6.11 Adult/child Glasgow Coma Score (GCS)
Pg 63 Pg 65 Pg 66 Pg 68 Pg 69 Pg 71 Pg 73 Pg 76 Pg 77 Pg 80 Pg 85 Pg 86 Pg 89 Pg 90 Pg 91 Pg 95 Pg 96 Pg 98 Pg 100 Pg 101
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PrActIcE LEVELS And dELEGAtEd ScoPES oF PrActIcE

St John personnel do not legally have the independent ability to supply or administer prescription medicines to patients, or to use certain pieces of clinical equipment. This legal ability is individually granted to personnel by a St John Medical Advisor, by a process of granting authority to practice (ATP). Personnel must not provide clinical care (beyond first aid) to patients without using these procedures and must not use these procedures, or wear practice level patches, without individual ATP. Off duty personnel who come across an incident are, for the purposes of using these procedures, immediately deemed to be on duty. ATP is granted at a particular practice level (listed below as headings). Under each practice level is listed a delegated scope of practice. A delegated scope of practice is the medicines and interventions that personnel may administer or use when providing patient care. These procedures contain some new additions to scopes of practice; personnel must not use these new additions until they have received official training and sign off in writing. Ordinary interventions not formally described within any scope of practice (for example automated defibrillation) can be performed by all personnel.
Primary care Entonox, methoxyflurane, aspirin, paracetamol. Ambulance officer (BLS) All of the above plus nasopharyngeal airways, nebulised salbutamol, GTN spray, IM glucagon, laryngeal mask airway, oral ondansetron, PEEP valves, tourniquets. Paramedic (BLS) All of the above plus manual defibrillation, synchronised cardioversion, IV cannulation, IV fluid administration, IV glucose, SC lignocaine for IV cannulation, 12 lead ECG acquisition. upskilled Paramedic (ILS) All of the above plus morphine, IV ondansetron, naloxone, nebulised adrenaline, IM adrenaline, IV adrenaline for cardiac arrest only. Advanced Paramedic (ALS) All of the above plus laryngoscopy, endotracheal intubation, capnography, cricothyroidotomy, chest decompression, intra-osseous needle access, adrenaline, atropine, frusemide, amiodarone, midazolam, ketamine, pacing, rapid sequence intubation* (*selected officers only).
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WHEn trEAtMEnt GIVEn dIFFErS FroM tHAt dEScrIBEd In tHESE ProcEdurES There are some circumstances where it is permissible to provide treatment that differs from that described in these procedures.
. Providing treatment that is neither described within these procedures nor within scope of practice (e.g. administration of insulin). There are three circumstances where this is permissible: A. When in direct communication with, and asked to do so by a St John Medical Advisor. The audit copy of the PRF must be sent to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs. B. When taking part in a clinical trial or feasibility trial overseen by a St John Medical Advisor. C. In specific circumstances for palliative care (see palliative care section). 2. Providing treatment that is described in these procedures, but is not within scope of practice (e.g. an ambulance officer giving IM adrenaline for anaphylaxis or a primary care officer giving salbutamol for asthma). There are three circumstances where this is permissible: A. When in direct communication with, and asked to do so by a St John Medical Advisor. The audit copy of the PRF must be sent to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs.
B. When in direct communication with, and asked to do so by a doctor other than a St John Medical Advisor. Under these circumstances all of the following criteria must be met: The doctor must be either present at the scene, or be the most senior doctor in the receiving department the patient will be transported to and The name and contact details of the doctor must be documented on the PRF and The treatments permissible are restricted to: nebulised salbutamol, sublingual GTN, IM glucagon, nebulised adrenaline or IM adrenaline and The audit copy of the PRF must be sent (along with a note describing the circumstances) to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs. C. When treatment is provided under the direct supervision of St John personnel. Under these circumstances all of the following criteria must be met: The person providing the treatment is enrolled in a course (or St John internship program) that upon completion will make them eligible to seek authority to practice at a level that would include the treatment and The person providing the treatment has been taught how to provide it and The person providing the supervision has the treatment within their scope of practice and takes responsibility for its provision.
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. Providing treatment that is not described in these procedures, but is within scope of practice (e.g. an ambulance officer giving salbutamol for hyperkalemia). There are two circumstances where this is permissible: A. An advanced paramedic may do so provided that the circumstances are exceptional and the audit copy of the PRF is sent (along with a note describing the circumstances) to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs. B. Personnel other than advanced paramedics may do so only when in direct communication with, and asked to do so by a doctor. A doctor may request personnel to provide treatment not described in these procedures, provided the request is consistent with good practice and the treatment is within their scope of practice, personnel may follow the request. If personnel are asked to provide treatment they think is inconsistent with good practice then they must decline the request. The name and contact details of the doctor must be recorded on the PRF, which must be sent (along with a note describing the circumstances) to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs. cLInIcAL trIALS St John is committed to improving clinical knowledge and patient outcomes by taking part in clinical trials. Such involvement in clinical trials improves the overall care that patients receive. Personnel are required to adhere to trial protocols and enter all eligible patients into clinical trials undertaken by St John.
. tHE PrIMArY SurVEY

The primary survey is a rapid assessment of immediate threats to life. The primary survey is important for all patients, not just those suffering from trauma. Any deterioration in the patients condition must prompt a reassessment of the primary survey looking for a cause. Airway: examine for and establish an adequate airway. Consider the possibility of cervical spine injury, but the airway takes priority. Breathing: examine for and establish adequate breathing. Look at and feel chest movement. circulation: examine for and establish adequate circulation. Feel pulse rate and strength, look at and feel peripheral perfusion/ capillary refill. Check for (and compress) external bleeding. disability: check the level of consciousness using AVPU or motor score of GCS. Consider immobilising the cervical spine if appropriate. Exposure, examination and environmental control: appropriately expose and examine the patient. Keep them warm.
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.2 tHE SEcondArY SurVEY

The secondary survey follows the primary survey. Do not conduct a detailed secondary survey if there are major abnormalities in the primary survey. central nervous System Record a GCS. Individually examine and record each component. Check the patient can talk normally, move their face and move and feel all four limbs. Look for unilateral weakness. Head and Face Look and feel for deformity, tenderness and bleeding. Look for pupil asymmetry and reaction to light. neck Look and feel for deformity and tenderness. Immobilise cervical spine if required and not already done. chest Look, feel and listen for symmetry of air entry, breath sounds, tenderness and crepitus. Abdomen and Pelvis Look and feel for tenderness or distension. Extremities Look and feel for wounds, fractures, colour, capillary refill, gross sensation and movement. Back Look and feel for tenderness and deformity.
FurtHEr rEcordInGS
Following the secondary survey, recheck and document the patients vital signs: Respiration rate including regularity and depth. Pulse rate including regularity and strength, peripheral perfusion and capillary refill time. Blood pressure. GCS. The completeness and frequency of vital sign recordings requires clinical judgement and must take into account patient condition, priorities, treatments and transport times. In general it is inappropriate to stop the ambulance to perform vital sign recordings and these should be performed enroute. Depending on the patients problem it is appropriate to record and document other parameters such as blood glucose, cardiac rhythm, 12 lead ECG, SpO2 etc. These should be re-recorded at clinically appropriate intervals and documented accordingly. Take and document an appropriate history. This should include mechanism of injury (if trauma), symptoms, prior events, medical history, medications and allergies. All treatments and interventions must be documented. Rhythm strips and 12 lead ECGs should be attached to the hospital and audit copy of the PRF.
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. cErVIcAL SPInE IMMoBILISAtIon

Consider the possibility of cervical spine injury in all patients suffering from trauma. High risk patients are those with injury secondary to road crash or significant fall (especially head first), and patients with pre-existing cervical spine abnormalities (e.g. ankylosing spondylitis or rheumatoid arthritis). Life threatening abnormalities within the primary survey always take priority over the cervical spine. Patients should have cervical spine immobilisation unless all of the following criteria are met: GCS 15, alert, cooperative and No neck or upper back tenderness on palpation or active movement and Normal peripheral sensation and movement and No painful or emotional distractions. These criteria may be used for children provided they are old enough to understand and cooperate with examination. Immobilising the cervical spine Immobilisation must not impair maintaining adequate airway, breathing and circulation. Place the patient supine in a well-fitted hard collar with the head in a neutral position (3-4 cm of flat pillow or folded towel behind the head). If the patient is placed on their side keep their spine in alignment.
Head blocks (or lateral padding) are not required as a routine. They should be considered if: significant movement (e.g. over rough terrain) is anticipated, or the patient is unconscious with normal airway and breathing, or if there are clinical signs of cervical spine injury. The head and shoulders must not be independently immobilised unless the entire body is also immobilised. Entire body immobilisation is not required as a routine but should be considered if significant movement (e.g. over rough terrain) is anticipated. Spine boards and other rigid flat boards are to be used as sliding or extrication devices only. Patients must not be transported on such boards. Devices such as the KED should not be used as a spinal immobilisation device in their own right. Their primary function is to keep alignment of the spine during extrication. KED should only be used in patients with a normal primary survey. Clinical judgement must be used for uncooperative patients. If attempts to immobilise the cervical spine result in the patient fighting then it is appropriate not to formally provide immobilisation if this approach minimises cervical spine movement. If significant respiratory distress is present gently sit the patient to 45 degrees, with a cervical collar in place and the spine in alignment.
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. oXYGEn AdMInIStrAtIon
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Few sections contain specific instructions on oxygen and clinical judgement is required. Oxygen does not necessarily provide benefit and should usually only be given if the patient has: An abnormal airway or Moderate or worse respiratory distress or Shock or Inability to obey commands as a result of an acutely depressed level of consciousness or Unrelieved cardiac chest pain or Smoke or toxic gas inhalation or An oxygen saturation <95% on air (unless they have COAD see COAD section). Use the simplest device and lowest flow of oxygen that will achieve the desired oxygen saturation, but do not spend time making multiple adjustments. Most patients will only require nasal prongs or an acute (ordinary) mask. Non-rebreather masks should be reserved for when higher levels of inspired oxygen are required and manual ventilation bags should be reserved for patients requiring assistance with their airway and/or breathing. If pulseoximetry is unreliable or unavailable then give oxygen as appropriate based on the above bullet points.
The oxygen flow rates to be used are: Nasal prongs 2-4 l/min. Acute (ordinary) mask 4-6 l/min. Nebulised drugs 8 l/min. Non-rebreather mask 6-8 l/min. Check that the valves are opening and closing correctly. The flow rate should be the minimum required to ensure that the reservoir bag does not fully deflate. Manual ventilation bag 8-10 l/min. Check that the valves are opening and closing correctly. The flow rate should be the minimum required to ensure that the reservoir bag does not fully deflate. The most common cause of a deflating reservoir bag is an excessive manual ventilation rate and/or an excessive tidal volume. commentary Oxygenation is not the same as ventilation. A patient can be well oxygenated but barely breathing and a patient can be breathing well but be poorly oxygenated. A pulseoximeter, providing it is working correctly, tells you how much oxygen is bound to haemoglobin as a percentage of maximum capacity, it does not tell you how well the patient is breathing. Pulseoximeters can be unreliable if the patient is cold, shocked, moving, shaking, has very dirty fingers, or has been exposed to carbon monoxide. Do not spend long periods of time trying to get a pulseoximeter reading and always look at the patient rather than the pulseoximeter.
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.5 PEEP VALVES
Attach a PEEP valve set to 10 to the manual ventilation bag if the patient is larger than 50kg and is status one with any of the following: Cardiogenic pulmonary edema or Receiving assisted ventilation or Receiving manual ventilation via mask, LMA or ETT. note: Patients with traumatic brain injury who are being ventilated should have PEEP set to 5. Patients receiving CPR should not have PEEP.

.6 non trAnSPort

Whenever personnel are called to a patient they must make three decisions: 1. Is treatment required? 2. Is transport to a medical facility required? 3. If transport is required, what form of transport is most appropriate? obligations of personnel Personnel must convey these decisions to the patient, as firm recommendations, along with an explanation of benefits, risks and alternatives. Personnel must: Fully assess the patient, including their competency. Take into account all available information, including non-clinical aspects such as social factors. Act in the patients best interest. Allow competent patients to decline recommendations. Insist on treatment and/or transport if it is in the best interest of an incompetent patient. Fully document assessment, interventions and recommendations. Contact a Doctor or Manager for advice if the situation is difficult.
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Transport must always be recommended if any of the following criteria are met: Personnel are unable to confidently exclude serious illness or injury or A treatment (medicine or IV fluid) or significant intervention has been administered (for exceptions, see below*) or There is significant abnormality in any physiological recording, including a temperature <36 or >38 degrees. *There are some situations where a treatment or significant intervention can be administered and then a recommendation made that transport not occur. They are restricted to the following: A doctor has been directly consulted with (at the time and by personnel dealing with the patient) and has decided that transport is not required. The name and contact details of the doctor must be recorded on the PRF. Paracetamol for minor discomfort, uncomplicated hypoglycaemia or epilepsy, and palliative care patients. Details are in the relevant sections. Assessing competency Patients meeting all of the following criteria can be deemed to be competent: They appear to understand information given to them and can recall this when asked and They appear to understand implications of their decisions and can recall these when asked and They communicate on these issues consistently.
If all of these criteria are not met, competency is in question and personnel must act in the best interest of the patient. Patients meeting any of the following criteria can be automatically deemed to be incompetent: Under the age of 16 years or Have attempted (or are expressing thoughts of ) self harm or Have short term memory loss. When a competent patient declines Competent patients have the right to decline recommendations made by personnel. In this setting personnel must: Explain the implications of their decision. Involve family, friends or GP when appropriate. Provide advice on what to do if they get worse. Read them the patient declined transport statement of the PRF. Ask them to sign the patient declined transport section of the PRF. Fully document assessment, interventions and recommendations. Provide them with the patient copy of the PRF. When the patient appears incompetent Personnel have the right to insist on treatment and/or transport if they believe this is in the best interest of an incompetent patient. The risk of treatment and/or transport against their will must be balanced against the risk of the illness or injury. In this setting personnel must: Encourage the patient to accept their recommendations. Involve family, friends or GP when appropriate.
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Utilise the help of Police if necessary, particularly when any form of physical restraint beyond simple measures is required. Fully document assessment, interventions and recommendations. When the patient is a child Parents (or guardians) have the right to decline recommendations on behalf of the child, but personnel must insist on treatment and/or transport if they believe the parents (or guardians) are placing the child at risk. transport by private means Not all patients requiring transport to a medical facility require transport in an ambulance. It is appropriate to recommend private transport provided all of the following criteria are met: The patient has not had any treatment (medicine or IV fluid), or significant intervention administered by personnel and The patient is very unlikely to require treatment or significant intervention during transport and A reasonable and appropriate alternative form of transport (for example private car or taxi) is available. When the patient or family insist on transport Competent patients have the right to decline recommendations, but patients and families do not have the right to insist on transport that personnel do not think is clinically indicated. If the insistence of the patient or family appears to be based upon genuine concern, and no other reasonable transport option is available, then the patient should be transported.
If the insistence of the patient or family appears to be based on maliciousness, convenience or petty concerns, then personnel may decline to transport the patient provided they: Explain the reasons for not providing transport and Fully document their involvement with the patient and family and Forward the audit copy of the patient report form for formal audit. When the patient or family insist on treatment but are declining transport These clinical procedures are based on the premise that patients receiving treatment will be transported. Treatment (medicine or IV fluid) should not be provided to a patient if they (or their family) are insisting on treatment but are declining transport, unless that treatment is required for a life threatening condition. documentation If it is not written down: it didnt occur. Comprehensive documentation must include: Details of patient assessment and findings. An assessment of the patients competence. All treatment and interventions provided. What was recommended and the reasons why. A summary of what was said to the patient and/or family. A summary of what the patient and/or family said. Why the patient was not transported. If the patient is not transported then the patient copy of the PRF must be given to them.
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RespiRatoRy and caRdiac

2.1 astHMa
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Mild to moderate asthma The patient is short of breath, but moving air and able to speak at least short sentences. They usually dont have significant chest or neck indrawing. Give 5 mg nebulised salbutamol. See commentary for use of MDIs with spacers. Gain IV access if not improving. Repeat nebulised salbutamol as required. severe to life threatening asthma The patient is very short of breath, not moving much air and unable to speak more than a few words. They usually have marked indrawing (unless exhausted) and may not have wheeze as they may not be moving enough air to create noise. Give continuous nebulised salbutamol. Give IM adrenaline. For adults: give 0.30.5 mg IM. Use a dose at the lower end if the patient is small, elderly or has myocardial ischemia. For children see paediatric drug dose table. Gain IV access. If the patient does not improve, repeat IM adrenaline using above doses after twenty minutes.
If the patient is status one give IV adrenaline (infusion preferred): a. For adults: place 1 mg adrenaline in a one litre bag of 0.9% NaCl (shake well and label) and give as an IV infusion. Start at two drops per second and adjust rate to patient condition or b. For adults: give 0.01 mg every 1-2 minutes as required. Reduce adrenaline dose if patient elderly, small or has myocardial ischemia. Adrenaline boluses must be drawn up from a one litre bag of 0.9% NaCl that has had 1 mg of adrenaline added to it (shake well and label). 10 ml of this solution will be 0.01 mg. For children see paediatric drug dose table. c. If you are unable to obtain IV access, IM adrenaline may be repeated every twenty minutes as required. If breathing becomes inadequate ventilate at a rate of 6/min (add PEEP of 10 if patient's weight is > 50kg). commentary Use this procedure if wheeze is present as a result of smoke or toxic gas inhalation. Insert IV cannulae into children only when necessary. Most children have a spacer. If their attack is mild to moderate consider allowing them to use their bronchodilator via spacer (commonly six to twelve puffs, one puff each minute, with six breaths to empty the spacer after each puff ) rather than giving them nebulised salbutamol.
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Children aged less than one year who are short of breath and wheezy have bronchiolitis and not asthma. Salbutamol does not have a role in bronchiolitis and should be rarely used in this setting. If however, the child is extremely wheezy salbutamol may be given provided oxygen administration is not compromised. Patients with a falling level of consciousness have a high chance of dying. Be aggressive with this group of patients. Adrenaline can make a patient tachyapneic and look or feel awful. It is important to differentiate this from a worsening of their asthma and not to automatically respond by giving more adrenaline. Heart failure may produce a wheeze that sounds like asthma.
2.2 cHRonic oBstRUctiVe aiRWay disease

Give oxygen if hypoxia is immediately life threatening or oxygen saturation is < 88% on air. Adjust oxygen flow to keep oxygen saturations 88-92%. Give 5 mg nebulised salbutamol and repeat as required. Turn oxygen flow rate down between nebules, to keep oxygen saturations 88-92%. commentary It is necessary to distinguish COAD from asthma because the two procedures are very different. Patients with asthma are usually less than 60 years of age and are symptom free between attacks. Patients with COAD are usually over 60 years of age and are not symptom free between attacks. There are a small number of patients whose carbon dioxide clearance is dependent on hypoxia. This is the reason we ask you to titrate oxygen flow to an oxygen saturation of 88-92%. Some of these patients will have a card or letter describing specific instructions for oxygen therapy, these patients are at very high risk of developing high carbon dioxide levels in response to oxygen exposure and the instructions should be followed. The first symptom of a rising carbon dioxide level is usually confusion followed by a falling level of consciousness. If this happens it is likely the patient has a rising carbon dioxide level assist their ventilation with a manual ventilation bag (with PEEP of 10) without added oxygen. Add oxygen only if life threatening hypoxia is present.
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2.3 caRdiac aRRest
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definitions A patient is in cardiac arrest when they are unconscious and have no palpable pulses or no signs of life. A witnessed cardiac arrest is one where the patient is seen or heard to collapse. A primary cardiac arrest is one where the arrest is either clearly due to a cardiac problem or there is no obvious cause. A secondary cardiac arrest is one where there is an obvious, noncardiac cause (e.g. asthma, drowning, trauma, poisoning). Return of spontaneous circulation (ROSC) is the presence of a palpable pulse, in the absence of ongoing CPR, for longer than sixty seconds. Attempted resuscitation is the performance of chest compressions or assisted ventilation by responding personnel or the delivery of a shock at anytime (including before ambulance arrival). deciding to commence resuscitation Resuscitation should begin unless there is a clear reason not to. Clear reasons not to include: Signs of rigor mortis or lividity. A clearly described advanced directive (or living will) not to receive resuscitation for cardiac arrest. Advanced directives do not have to be in writing and include clearly described verbal directives.
Clinical scenarios where resuscitation is either futile or not in the best interests of the patient e.g. unwitnessed cardiac arrest with asystole as initial rhythm, patients who are dying from cancer, and patients with severe end stage chronic medical conditions (e.g. end stage heart failure or end stage COAD) who are house bound. Competent patients have the right to decline treatment, including resuscitation. Family members do not have the right to either demand or decline resuscitation, but their opinion must be taken into consideration. If there is doubt regarding the appropriateness of a resuscitation attempt, then resuscitation should begin while further information is gained. There must be clear documentation regarding decisions made. prognosis of cardiac arrest There is no one factor that can be used to determine the prognosis of an individual cardiac arrest. Multiple factors must be taken into account:
poor prognosis
Secondary cardiac arrest Unwitnessed No bystander CPR Response time > 8 mins Initial rhythm asystole or PEA Total time in cardiac arrest > 20 mins
Better prognosis
Primary cardiac arrest Witnessed Bystander CPR Response time < 8 mins Initial rhythm VT or VF Total time in cardiac arrest < 20 mins
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deciding to stop resuscitation This requires clinical judgement on the likelihood of survival taking into account: The nature of the cardiac arrest Whether or not the cardiac arrest was witnessed Whether or not there was bystander CPR Response time The initial rhythm The total estimated time in cardiac arrest For personnel at ambulance officer or primary care level: in general resuscitation should continue until someone more senior arrives to take over. This is not always possible and if this is the case: If the arrest was not witnessed and no shock is advised, then the prognosis is very poor and it is appropriate to stop resuscitation if there are no signs of life within ten minutes of ambulance arrival. For other circumstances it is appropriate to stop resuscitation if there are no signs of life within twenty minutes of ambulance arrival. For personnel at paramedic level and above: in general it is appropriate to stop resuscitation at approximately 10-20 minutes of total cardiac arrest time in poor prognosis scenarios and approximately 30-40 minutes of total cardiac arrest time in good prognosis scenarios.
General principles of cardiac arrest If you witness a cardiac arrest, and a defibrillator is not attached, deliver a pre-cordial thump. Concentrate on chest compressions (100/min), ensure adequate depth, minimise pauses and perform uninterrupted compressions whenever possible. CPR compression to ventilation ratio is 30:2 for non-intubated patient. When performing 30:2 CPR, the person performing chest compressions must not stop if the person performing ventilation is not ready and must not stop for more than three seconds for ventilation. After a three second pause, chest compressions should be recommenced even if two breaths have not been delivered. If an ETT or LMA is in place, chest compressions should be continuous and the ventilation rate 8-10/min (not higher). CPR is performed for two minute cycles between rhythm checks. The person performing chest compressions should ideally change every 2 minutes (or earlier if tired). Personnel able to use defibrillators in manual mode should do so whenever possible. In manual mode, the defibrillator should be charged toward the end of the two-minute cycle of CPR, in order to minimise the time delay between stopping chest compressions and delivering a shock. If a shock is not required the charge should be dumped. Only perform a pulse check if the rhythm looks capable of producing cardiac output. If there is any doubt that a pulse is present, CPR should be performed.
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Defibrillators in advisory (automatic) mode should be used in children if a defibrillator in manual mode is not immediately available. All doses of IV drugs should be flushed with a minimum of 40 ml 0.9% NaCl, which may be delivered by a running line. If a patient has not achieved ROSC it is usually inappropriate to transport them to hospital. You must complete a cardiac arrest data form and attach it to a completed PRF if you have attempted resuscitation. tHe fiRst tWo MinUtes If the cardiac arrest is not witnessed by personnel with a defibrillator, two minutes of CPR (5 cycles of 30:2) will be performed prior to analysing the rhythm. It is however, acceptable for rhythm analysis to occur earlier if personnel think that resuscitation may be inappropriate. Here is a strongly suggested approach to these two minutes: 1. When no-one is present who can place an LMa One person performs chest compressions (30:2), but does not stop if the person performing the ventilation is not ready and does not stop for longer than three seconds for ventilation. The other person: During first cycle places airway and gets bag/mask ready. During second cycle attaches oxygen at 8l/min. During third cycle gets pads out and attaches to defibrillator. During fourth cycle attaches pads to chest. During fifth cycle turns defibrillator on and gets ready to push analyse.
2. When someone is present who can place an LMa One person performs continuous chest compressions, counting in their head to 200. The other person: Places and secures an LMA. Attaches bag, attaches oxygen at 8 l/min and ventilates at a rate of 8/min, but ventilation is not a priority at this stage. Attaches pads, turns on defibrillator and gets ready to either analyse in manual mode or push analyse in advisory mode at the end of 200 compressions. caRdiac aRRest WitH adVisoRy defiBRiLLatoR If arrest is not witnessed by personnel with defibrillator, perform two minutes of CPR (focusing on chest compressions) prior to turning defibrillator on. Follow the instructions noting that these may vary between defibrillators. If response time has been less than four minutes and bystander CPR has been in place, personnel should treat the cardiac arrest as if they have witnessed it. If arrest is witnessed by personnel with defibrillator, immediately attach and turn on defibrillator. Follow the instructions noting that these may vary between defibrillators. Perform continuous chest compressions whilst the defibrillator is being attached, if there is a second person to do this.
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Vf oR Vt WitH ManUaL defiBRiLLatoR
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cardiac arrest not witnessed by personnel with defibrillator Perform two minutes of CPR (focusing on chest compressions) before analysing rhythm. If response time has been less than four minutes and bystander CPR has been in place, personnel should treat the cardiac arrest as if they have witnessed it. Defibrillate once with maximum joules and immediately restart CPR without a rhythm check. Perform two minutes of CPR between rhythm checks. If still in VF or VT, continue to defibrillate using single shocks at maximum joules, immediately restarting CPR without a rhythm check after shocks. Intubate and gain IV access, but good CPR takes priority. If an LMA is in place and is working well, replacing it with an ETT is not a priority. In adults, give 1 mg adrenaline IV or 3 mg (diluted up to 10mls) ETT every four minutes. In adults, if in VF or VT at any time after the first dose of adrenaline, give 300 mg amiodarone IV, once only as a bolus. If patient is a child, defibrillate using 5J/kg (rounded up to nearest joule setting) and adjust drug doses according to paediatric drug dose table.
cardiac arrest witnessed by personnel with defibrillator Begin with immediate defibrillation using maximum joules. Perform continuous chest compressions whilst the defibrillator is being attached, if there is a second person to do this. Give up to three shocks, checking rhythm between shocks. Perform immediate CPR without a rhythm check after third shock. commentary Consider anterior/posterior placement of pads for patients who are paediatric, obese or in resistant VF or VT.
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asystoLe WitH ManUaL defiBRiLLatoR Begin with two minutes of CPR before analysing rhythm if arrest not witnessed by personnel with defibrillator. If response time has been less than four minutes and bystander CPR is in place, personnel should treat the cardiac arrest as if they have witnessed it. Intubate and gain IV access, but good CPR takes priority. If an LMA is in place and is working well, replacing it with an ETT is not a priority. In adults, give 1 mg adrenaline IV or 3 mg (diluted up to 10mls) ETT every four minutes. Perform two minutes of CPR between rhythm checks. If patient is a child, adjust drug doses according to paediatric drug dose table. commentary Confirm rhythm is asystole, check cables, leads, and amplitude. Exclude bradycardia, which can look like asystole at a glance. If rhythm is possibly fine VF, begin with VF procedure. Defibrillators in advisory mode will recognize low frequency VF as asystole; do not be concerned by this as low frequency VF will go into asystole when defibrillated. Asystole is the absence of a heart rhythm and reflects a dying heart. It is common to see slow bizarre complexes (<30/min) when a heart is dying; this is not PEA but is asystole. Survival from cardiac arrest with initial rhythm of asystole is rare and prolonged resuscitation attempts in this setting are inappropriate.
pULseLess eLectRicaL actiVity WitH ManUaL defiBRiLLatoR Begin with two minutes of CPR before analysing rhythm if arrest not witnessed by personnel with defibrillator. If response time has been less than four minutes and bystander CPR is in place, personnel should treat the cardiac arrest as if they have witnessed it. Examine patient to exclude immediately reversible causes and treat accordingly. Intubate and gain IV access, but good CPR takes priority. If an LMA is in place and is working well, replacing it with an ETT is not a priority. In adults, give 1 mg adrenaline IV or 3 mg (diluted up to 10mls) ETT every four minutes. Give 0.9% NaCl IV as a bolus. Give adults 1-2 litres and children 20-40 ml/kg. Perform two minutes of CPR between rhythm checks. If patient is a child, adjust drug doses according to paediatric drug dose table.
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commentary PEA occurs when a patient in cardiac arrest has a rhythm that should be associated with palpable cardiac output, but is not. It is a clinical condition, not an abnormal rhythm and is often secondary to a non-cardiac problem. Causes include hypovolaemia, hypoxia, tension pneumothorax, pulmonary embolism, cardiac tamponade and myocardial ischemia. The history of the cardiac arrest is very important to help determine what the cause may be. It is common for PEA to degenerate to asystole, during this process you often see slow bizarre complexes (< 30/min), this is asystole and not PEA. Survival from cardiac arrest with initial rhythm of PEA is low and prolonged resuscitation attempts in this setting are inappropriate.
caRdiac aRRest in speciaL sitUations cardiac arrest secondary to trauma A small number of patients have a primary cardiac arrest directly preceding their trauma. If you suspect this, then manage as a primary cardiac arrest. Cardiac arrest secondary to trauma has an extremely poor outcome and in most cases is due to severe hypovolaemia. It is appropriate to initiate a resuscitation attempt whilst immediately reversible causes (especially tension pneumothorax) are being sought and corrected, but unless quick ROSC occurs it is inappropriate to continue. Chest compressions are a low priority in this group of patients because the heart is usually empty. cardiac arrest secondary to asthma Focus on using a ventilation rate of only 6/min to avoid dynamic hyperinflation. Adrenaline has a high priority. cardiac arrest secondary to anaphylaxis IV adrenaline and IV fluid have a high priority. cardiac arrest secondary to asphyxiation Examples include drowning, hanging or SIDS. In this setting perform standard CPR but prioritise and focus on the ventilation aspect of CPR. cardiac arrest secondary to cyclic antidepressant poisoning Give adult patients 2-3 litres of 0.9% NaCl as a bolus as the cardiac toxicity may be reduced with a large dose of sodium ions.
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cardiac arrest and pregnancy In advanced pregnancy the uterus impedes venous return through the inferior vena cava in the supine position. Tilt the patient to their left or manually displace the uterus to the left to alleviate this. If you do not achieve quick ROSC and you are within ten minutes of a hospital capable of emergency caesarian section, consider transporting the mother with CPR enroute (focusing on good chest compressions), providing as much pre-hospital warning as possible. cardiac arrest secondary to hypothermia At very low temperatures (<30 degrees) patients are prone to VF and defibrillation and drugs may not work. Follow the procedures but if you do not achieve ROSC within three shocks and you consider the arrest is secondary to hypothermia, consider transporting the patient to hospital with CPR enroute. In this setting stop defibrillating, dont give any further drugs, focus on good chest compressions and obtain early advice from a medical specialist. cardiac arrest and implanted defibrillators/pacemakers Implanted defibrillators and pacemakers are usually in the soft tissue under the left clavicle. Standard procedures should be followed with the defibrillation pads placed as far away from the implanted defibrillator or pacemaker as possible.
2.4 post caRdiac aRRest caRe

If breathing adequately, give oxygen by non-rebreather mask. If not breathing adequately, ensure adequate airway and breathing but avoid hyperventilation. If intubated, ventilate to ETCO2 30-35 mmHg. If the patient has a poor airway and you cannot intubate them or if their GCS is persistently < 10, call for an advanced paramedic or doctor skilled at rapid sequence intubation (RSI) provided they can locate with you significantly faster than you can deliver the patient to hospital. Gain IV access if not already done. In adults: if intubated and restless give 1-2 mg of midazolam IV and repeat as required. Do not give midazolam to assist intubation. In adults: if they have had two (or more) VF or VT cardiac arrests with ROSC after each and no amiodarone has yet been given, give 150 mg of amiodarone IV slowly over 15-30 minutes. Use amiodarone with caution and slow rate of administration if hypotension present. If arrest was a primary arrest in an adult, then uncover them and do not attempt to warm them. Acquire 12 lead ECG provided this does not significantly delay treatment or transport, but this is not a priority. Transmit ECG if appropriate.
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2.5 caRdioGenic sHocK
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Give oxygen via non-rebreather mask. Determine and record cardiac rhythm, in particular look for VT and treat accordingly. Gain IV access. If dysrhythmia present, treat as per appropriate section, but use amiodarone with extreme caution. If cardiac chest pain and/or pulmonary edema present treat as per appropriate section, but use GTN and morphine with extreme caution. If systolic BP <100 mmHg give IV fluid provided patient has no shortness of breath, no significant crackles in the chest and the primary problem is not dysrhythmia. Give 500 1000 ml 0.9% NaCl IV as a bolus. Stop the fluid if they become short of breath. If they remain hypotensive, give a second IV fluid bolus with the same precautions. Acquire 12 lead ECG provided this does not significantly delay treatment or transport. Transmit ECG if appropriate. If you have a choice of hospital destinations discuss these with a medical specialist as the patient may benefit from going direct to a major hospital.
commentary Cardiogenic shock is caused by the heart being unable to pump adequately. The cause is usually an acute myocardial infarction, but other causes include pulmonary embolism, dysrhythmias (particularly VT) and cardiac tamponade. Typically patients are cold, pale and tachycardic with signs and symptoms of pulmonary edema. However, some patients will not develop pulmonary edema but will have an elevated jugular venous pressure and shock. This tends to occur with right ventricular infarcts, which are most commonly associated with inferior myocardial infarcts.
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2.6 dysRHytHMias
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introduction Dysrhythmias are divided into tachydysrhythmias and bradydysrhythmias. Patients with dysrhythmia are further divided into those who are compromised and those who are not. Compromise from a dysrhythmia can include cardiac chest pain, poor perfusion, hypotension and pulmonary edema. Treatment decisions are based mostly on the degree of compromise, rather than on the heart rate itself. BRadydysRHytHMias - adULts This procedure is for adults with bradydysrhythmia causing compromise. Bradydysrhythmia in children is usually due to hypoxia or hypovolemia and treating the underlying cause takes priority over drug therapy. Determine and record cardiac rhythm. If unconscious with heart rate < 30/min, treat as cardiac arrest even if pulse is palpable. Gain IV access and treat underlying cause if obvious. Acquire 12 lead ECG provided this does not significantly delay treatment or transport. Transmit ECG if appropriate. If heart rate < 50/min and patient compromised:
if rhythm narrow complex: e.g. sinus or nodal bradycardia, 1st or 2nd degree block 1. Give 0.6 mg atropine IV. If atropine responsive repeat as required. 2. If unresponsive to atropine give adrenaline. 3. If unresponsive to adrenaline initiate pacing.
if rhythm broad complex: e.g. 3rd degree block 1. Initiate pacing. 2. If unresponsive to pacing give adrenaline.
Pacing: pace at a rate of 70/min. If significant pain from pacing, give morphine and add low dose ketamine if required. Adrenaline (infusion is preferred): a. Place 1 mg adrenaline in a one litre bag of 0.9% NaCl (shake well and label) and give as an IV infusion. Start at two drops per second and adjust rate to patient condition or b. Give 0.01 mg every 1-2 minutes as required. Reduce adrenaline dose if patient elderly, small or has myocardial ischemia. Adrenaline boluses must be drawn up from a one litre bag of 0.9% NaCl that has had 1 mg of adrenaline added to it (shake well and label). 10 ml of this solution will be 0.01 mg
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tacHydysRHytHMias - adULts This procedure is for adults with: VT or Atrial fibrillation/flutter or supraventricular tachycardia causing significant cardiac compromise (particularly chest pain or pulmonary edema). Patients with these rhythms who are not significantly compromised should be transported without specific treatment. This procedure is not to be used for children under 15 years of age. If you have a symptomatic child, consult a medical specialist. Determine and record cardiac rhythm. If rhythm narrow complex and rate >150/min, try one valsalva manoeuvre. Gain IV access. If in VT (or rhythm is broad complex and rate >150/min) and they are significantly compromised: a. If patient cannot obey commands, cardiovert with 100J in synchronised mode. If no change cardiovert with 200J in synchronised mode. Do not continue to cardiovert if rhythm does not revert. If you cannot use a defibrillator in manual mode attach your defibrillator in advisory mode and follow the instructions. b. If patient can obey commands give 1-3 mg midazolam IV and cardiovert as above.
Acquire 12 lead ECG provided this does not significantly delay treatment or transport. Transmit ECG if appropriate. If in VT or tachydysrhythmia is persistently >130/min and causing significant compromise: give 150 mg amiodarone IV over 15-30 min provided you are more than 15 minutes from hospital. Use amiodarone with caution and reduce rate of administration if hypotension present. If tachydysrhythmia does not revert or slow down 15 min after finishing amiodarone, repeat using the same precautions. commentary It is important to differentiate sinus tachycardia from a tachydysrhythmia. Distinguishing between VT and SVT can be difficult if SVT is associated with bundle branch block (BBB). If the patient has a history of heart disease or is significantly compromised then it is most likely VT. If the patient has no history of heart disease or is not compromised it is most likely SVT. Atrial fibrillation, atrial flutter and supraventricular tachycardia do not usually cause hypotension. If a patient with one of these rhythms is hypotensive, it is likely that another process is going on, e.g. cardiogenic shock or septic shock. In such circumstances, amiodarone is relatively contraindicated and must be used with extreme caution. Amiodarone is preferably administered via an infusion using a 100 ml bag of 5% glucose (shake well and label).
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2.7 caRdioGenic pULMonaRy edeMa
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This procedure is for adults, if you have a child consult with a medical specialist. Determine and record cardiac rhythm. Give 0.4-0.8 mg GTN provided systolic BP >100 mmHg. Use with caution and reduce dose if patient elderly, small or hypotensive. Use extreme caution if drug for erectile dysfunction taken within last 24 hrs. Gain IV access. Repeat 0.40.8 mg GTN every 2-5 minutes if not improving, with same precautions as above. If respiratory distress is severe: apply manual ventilation bag with PEEP valve set to 10 and oxygen flow of 15 l/min, ensuring a tight seal with the mask. Allow the patient to spontaneously breathe unless ventilation is inadequate. Increase PEEP to 15 if the patient fails to improve. If not improving, give 40 mg frusemide IV provided systolic BP >100 mmHg, but if patient regularly takes frusemide give 80 mg IV with same precaution. Acquire 12 lead ECG provided this does not significantly delay treatment or transport. Transmit ECG if appropriate. IV morphine in 1 mg doses may be given for severe respiratory distress.
commentary Acute pulmonary edema is usually caused by myocardial ischemia. The best treatment is GTN. Morphine is not an effective treatment, but can be used to provide symptom relief from severe respiratory distress. Pulmonary edema may produce wheeze and patients with COAD may have heart failure as well. It can be very difficult to distinguish between the two, if you think both are present then treat for both. GTN may interact with drugs used for erectile dysfunction. Prolonged hypotension may occur if GTN is used in patients who have taken these drugs in the previous 24 hours. If in doubt, seek medical advice. Frusemide is most likely to be useful in patients with signs of ECF expansion or in patients those who are already on it.
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2.8 caRdiac cHest pain
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This procedure is for adults, if you have a child consult with a medical specialist. Give oxygen via nasal prongs. Determine and record cardiac rhythm. Give 0.4-0.8 mg GTN provided systolic BP >100 mmHg. Use with caution and reduce dose if patient elderly, small or hypotensive. Use extreme caution if drug for erectile dysfunction taken within last 24 hrs. Give 300 mg aspirin orally unless: 1. They have had 300 mg within the last hour or 2. They are known to be allergic to it or 3. They are an asthmatic with previous worsening of asthma after aspirin or non-steroidal anti-inflammatory drugs. Gain IV access. Acquire 12 lead ECG provided this does not significantly delay treatment or transport. Transmit if appropriate. If taking part in a thrombolysis program, use separate thrombolysis procedure if appropriate. If in a rural area where thrombolysis is provided by GPs, consult them early. Repeat GTN every 2-5 minutes if it relieves pain, but do not continue to use it if not. Repeated GTN is usually inappropriate if the chest pain is secondary to a tachydysrhythmia. If pain is significant, give morphine. Reduce dose if patient elderly, small or hypotensive.
commentary Some patients have atypical pain or discomfort, including face, jaw, neck or arm pain. Use this procedure if you strongly suspect such pain is due to myocardial ischemia. Some patients have silent myocardial ischemia without pain or discomfort - particularly diabetics and the elderly. They may present with any combination of - dysrhythmia, shortness of breath, fatigue, or light headedness. Use this procedure if you strongly suspect myocardial ischemia is the cause, provided there is objective evidence of myocardial ischemia on 12 lead ECG and there is no other obvious cause for their symptoms. In this circumstance only give repeated GTN if it is clearly associated with improvement. GTN may interact with drugs used for erectile dysfunction. Prolonged hypotension may occur if GTN is used in patients who have taken these drugs in the previous 24 hours. If in doubt, seek medical advice.
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2.9 post tHRoMBoLysis caRe
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This procedure is for patients who are being transported after thrombolysis for myocardial infarction. Give oxygen via nasal prongs. Monitor rhythm continuously and be prepared to treat cardiac arrest. If pain is significant, give morphine. Reduce dose if patient elderly, small or hypotensive. Measure blood pressure and pulse every 10 minutes. Watch closely for bleeding (particularly puncture sites). Seek early specialist medical advice for complications. Acquire 12 lead ECG after 60 min or if any significant change in condition. Do not transmit this ECG unless specifically asked to do so. commentary These patients have received a drug that accelerates breakdown of clots and are likely to have received heparin. Watch closely for bleeding and compress if appropriate. Bleeding can be internal which is why we ask for frequent recordings. Do not place additional IV lines unless necessary. If the patient has complications of their myocardial infarction (e.g. pulmonary edema, cardiac arrest), manage them using the appropriate section. If they have complications of their thrombolysis, particularly bleeding, seek urgent specialist medical advice. These patients must be transported in double-crewed ambulances.
3.1 hYPoVoLaEmIc Shock

Use this procedure if the patient has shock secondary to: a. Blunt trauma or b. Fluid loss (e.g. diarrhoea and vomiting) or c. Peripheral penetrating trauma where blood loss has been fully controlled or d. GI bleeding or e. Shock that does not obviously fit into another section. Gain large bore IV access. Give IV fluid if the patient has signs of poor perfusion. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. Note that there is a systolic BP target of 120 mmHg if the patient has TBI. Give further fluid boluses as required. Immobilise any fractures. In particular tightly wrap the pelvis (using sheet, KED or pelvic sling) and tie the knees together if shock is associated with a possible pelvic fracture. Do not spend longer than one or two minutes doing this. If the patient has trauma and hypovolaemic shock, transport them (whenever possible) direct to a hospital that regularly receives major trauma.
Shock and trauma
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Shock and trauma
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commentary Shock following blunt trauma is almost always caused by blood loss, but it is important to exclude tension pneumothorax. Occasionally shock in trauma patients can be due to spinal cord injury. Blood pressure is a poor guide to the level of shock. Fluid therapy should be titrated to perfusion, taking into account heart rate, pulse strength, capillary refill, pulse pressure, blood pressure and level of consciousness. Some patients may not become tachycardic despite being shocked e.g. if on a beta-blocker, if shock is end stage and the heart rate is falling, or ectopic pregnancy and miscarriage.
3.2 hYPoVoLaEmIc Shock From uncontroLLEd BLEEdInG

Use this procedure if the patient has shock due to: a. Penetrating truncal trauma or b. Leaking abdominal aortic aneurism or c. Peripheral penetrating trauma where blood loss has not been controlled or d. Bleeding associated with pregnancy (including ectopic). Compress any external bleeding. Apply a tourniquet if there is life threatening bleeding from a limb that is not controlled by conventional measures. Do not remove any penetrating objects. Cover sucking chest wounds with a sealed dressing e.g. a defibrillation pad. Load and treat enroute if the patient has shock. Gain large bore IV access. Only give IV fluid if profoundly shocked e.g. no radial pulse, a falling level of consciousness or unrecordable blood pressure. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. Give further fluid boluses only if they remain profoundly shocked. Give adults 250-500 ml and children 5-10 ml/kg.
Shock and trauma
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Shock and trauma
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If the patient has penetrating trauma and hypovolaemic shock, transport them (whenever possible) direct to a hospital that regularly receives major trauma. If you suspect the patient has a leaking abdominal aortic aneurism, transport them (whenever possible) direct to a hospital with vascular surgical facilities. commentary Mortality rates from shock associated with uncontrolled bleeding appear to be reduced if the patient is deliberately allowed to be hypotensive prior to operative control of the bleeding. This is why fluid is restricted in this group of patients to maintain the minimum blood pressure compatible with life. The most important aspects of prehospital management are to stop external bleeding and rapidly transport to hospital, providing most treatments enroute. Cover visible abdominal contents with cling film.
3.3 traumatIc BraIn InJurY

Use this procedure if the patient cannot obey commands and has a mechanism of injury suggesting TBI. Intubation is not a priority but if the patient is deeply unconscious with poor airway and/or breathing, intubate them but do not give sedation to facilitate intubation. Ventilate to ETCO2 of 30-35 mmHg. If the patient has a poor airway and you cannot intubate them or if their GCS is persistently < 10, call for an advanced paramedic or doctor skilled at rapid sequence intubation (RSI) provided they can locate with you significantly faster than you can deliver the patient to hospital. Gain large bore IV access and give IV fluid if the patient has a systolic BP < 120 mmHg. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. Give further fluid boluses as required. Transport them (whenever possible) direct to a hospital that regularly receives major trauma. If the patient is combative see combative patient section.
Shock and trauma
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Shock and trauma
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commentary The goal of managing TBI is the prevention of secondary brain injury such as hypoxia, hypotension, hypocarbia and hypercarbia. We have not specified a blood pressure target for children, here a blood pressure in the upper range of normal for that age should be the target. A brief seizure following TBI is relatively common (particularly in children) and does not require immediate treatment. Repeated or prolonged seizures should be treated as per the section on seizures.
3.4 anaPhYLaXIS
If the patient is status one or two, give IM adrenaline. In adults give 0.30.5 mg IM. Use a dose at the lower end if the patient is small, elderly or has myocardial ischemia. For children see paediatric drug dose table. See commentary if the patient has a preprescribed, preloaded adrenaline kit. If the patient has upper airway edema or swelling, give 5 mg nebulised adrenaline in addition to other treatment. This may be repeated every twenty minutes as required. Gain large bore IV access. Give IV fluid if the patient has signs of poor perfusion. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. Repeat as required. If the patient does not improve, repeat IM adrenaline using above doses after twenty minutes. If the patient remains status one give IV adrenaline (infusion preferred): a. For adults: place 1 mg adrenaline in a one litre bag of 0.9% NaCl (shake well and label) and give as an IV infusion. Start at two drops per second and adjust rate to patient condition or b. For adults: give 0.01 mg every 1-2 minutes as required. Reduce adrenaline dose if patient elderly, small or has myocardial ischemia. For children see paediatric drug dose table.
Shock and trauma
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Shock and trauma
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If the patient also has bronchospasm, use nebulised salbutamol in addition to other treatments, as per asthma section. If IV access cannot be obtained repeat the IM adrenaline dose every twenty minutes as required. commentary Adrenaline boluses must be drawn up from a one litre bag of 0.9% NaCl that has had 1 mg of adrenaline added to it (shake well and label). 10 ml of this solution will be 0.01 mg. Anaphylaxis is a life threatening allergic reaction. The patient can have shock, bronchospasm, rash, abdominal pain, diarrhoea, vomiting, generalised or focal edema, stridor, or any combination of these. Rash, itch and swelling alone is not an anaphylactic reaction and requires some of the systemic symptoms above to be considered anaphylaxis. The most important aspect of management is the early administration of adrenaline. Adrenaline administration can make a patient tachypneic and look or feel awful. It is important to differentiate this from a worsening of their anaphylaxis and not to automatically respond by giving more adrenaline. Some patients who are known to have anaphylaxis have a preloaded adrenaline syringe to be given IM in the event of anaphylaxis. Any person may administer this provided that the adrenaline has been prescribed for that patient and the patient is status one or status two. Use of this is not a substitute for appropriate back up.
If the patient is complaining of throat tightness in the absence of stridor or other signs of respiratory distress they do not automatically require adrenaline and the larger clinical picture should be considered. Isolated edema, especially of the mouth and face is commonly due to angioedema and not anaphylaxis. Angioedema is a condition that results in intermittent, unexpected and unpredictable swelling of the mouth and face, in the absence of systemic symptoms of anaphylaxis. This often occurs in patients taking aspirin or angiotensin converting enzyme inhibitors. In general these patients should be transported without any specific treatment. If the patient has stridor or significant respiratory distress then treat as for anaphylaxis.
Shock and trauma
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Shock and trauma

3.5 BurnS
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If the patient has been in an enclosed area or has possible smoke inhalation, give oxygen via non-rebreather mask if conscious or via manual ventilation bag if unconscious. If wheeze is present use salbutamol as per the asthma procedure. Cool burns for 20 minutes. This should be at the scene unless there are immediately life threatening injuries. If the burns are due to chemical exposure or explosion, all clothing must be removed (down to underwear) and the patient decontaminated. Cover burns with cling film. Avoid applying circumferentially and do not remove fluid that collects underneath. Gain large bore IV access and give IV fluid if the patient has signs of poor perfusion. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus. Repeat as required. Estimate burn area using the burn table in miscellaneous section. Give IV fluid if the burn area is > 15% and the patient has not yet received IV fluid. Give adults one litre of 0.9% NaCl as a bolus and a further one litre enroute. Give children 20 ml/kg of 0.9% NaCl as a bolus and a further 20 ml/kg enroute. If the burn area is >15% transport the patient, whenever possible, direct to a hospital that regularly receives large burns.
commentary Suspect airway burns if: a. There are burns to the mouth, lips or nose or b. There is hoarseness, or stridor or c. There is black sputum. Patients with airway burns must be transported to hospital immediately as early intubation may be required. Provide very early notification to the hospital of these patients. It is important to keep the patient warm: cool the burn but not the patient. Chemical burns to the eye are vision threatening. This is particularly the case with alkali. Irrigation should continue during transportation for at least thirty minutes.
Shock and trauma
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Altered consciousness
4.1 HYPoGlYcAeMiA
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If glucose < 4 mmol/l and the patient is symptomatic: a. If the patient is conscious and able to swallow give oral glucose or simple carbohydrate (e.g. sugar, jam, jellybeans or fruit juice). b. If the patient has an altered level of consciousness or cannot swallow, gain IV access and give glucose IV. For adults give 100 ml of 10% glucose, for children give 2 ml/kg of 10% glucose. c. If unable to gain IV access give IM glucagon. For adults and children > 30 kg give 1 mg, for smaller children give 0.5 mg. d. Repeat the glucose measurement after 10 minutes. Give further doses of IV glucose if required, but do not repeat IM glucagon. commentary Patients may receive treatment for hypoglycaemia and have a recommendation made to them that they do not need transport provided all of the following criteria are met: a. It is an isolated single episode and b. There is a clear and easily reversible cause (e.g. a missed meal) and c. It is not due to overdose (including accidental) of insulin or oral hypoglycaemics and d. It is not complicated by seizure or injury and e. The patient fully recovers to a GCS of 15 and is safe when walking and
f. The patient is given a complex carbohydrate to eat e.g. cheese or peanut butter sandwich and g. The patient has someone who can help look after them for the next few hours and h. They are instructed to measure their blood glucose level hourly for the next four to six hours. They may be initially hyperglycaemic following treatment they must be instructed not to treat this with insulin. Hypoglycaemia may then occur several hours later as the glucose is metabolised - this is why the complex carbohydrate is important.
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4.2 HYPerGlYcAeMiA
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If blood glucose > 20 mmol/l and the patient has either an altered level of consciousness or signs of poor perfusion, gain IV access and give fluid. For adults give one litre of 0.9% NaCl as a bolus and a further one litre enroute. For children give 20 ml/kg of 0.9% NaCl as a bolus and a further 20 ml/kg enroute. commentary This procedure is aimed at patients who may have diabetic ketoacidosis or a hyperglycaemic non-ketotic state. In both of these situations the primary problem is that the blood glucose has become high and the patient has become dehydrated because of salt and water loss in the urine. Diabetic ketoacidosis can present in a variety of ways including being non-specifically unwell and/or with abdominal pain and vomiting. Personnel should recommend transport for diabetic patients who are unwell, even if they do not have hyperglycaemia.
4.3 seiZures
Gain IV access. Measure blood glucose and treat accordingly. If the seizures are generalised and do not stop after several minutes or recur, give IV midazolam. Give adults 1-5 mg IV every 3-5 minutes, up to a maximum of 15 mg. If an IM dose was initially given, wait 10 minutes before giving a reduced IV dose. If you cannot gain IV access, give midazolam either IM or intranasal: a. IM dosing: give adults 5-10 mg IM and repeat once after 20 minutes if still seizing. b. Intranasal dosing: give adults 10-15 mg and repeat once after 20 minutes if still seizing. See commentary if the patient has pre-prescribed medicine. For children see paediatric drug dose table. The paediatric IV/IO dose may be given every 3-5 minutes to a maximum of three doses. The paediatric IM and intranasal dose may be repeated once after 20 minutes. If the patient is a febrile child then cool gently by removing their clothing.
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commentary IV midazolam must always be administered using 1 mg/ml solution. IM midazolam must always be administered using 5 mg/ml solution. Use a dose at the lower end of the ranges described if the patient is elderly, small or physiologically unstable. Some patients who have recurrent seizures have pre-prescribed PR or intranasal medicines (e.g. diazepam, midazolam). All personnel may administer such medicines provided that they have been prescribed for that patient and the seizures are prolonged. Use of this is not a substitute for appropriate back up. A recommendation that transport is not required may be made, even if the patient has received pre-prescribed medicine, provided all of the following criteria are met: a. They have known epilepsy and b. The seizure has not been complicated by injury and c. They have woken to obey commands (or recovered to their usual neurological state) and d. They can be left in the care of a competent adult.
4.4 PoisoninG
Measure blood glucose and treat accordingly. Gain IV access if the patient has abnormal vital signs. If opiate poisoning is suspected and the patient has an impaired level of consciousness or impaired breathing, give naloxone: a. Give adults 0.1-0.4 mg naloxone IV every 2-3 minutes as required. b. If you cannot gain IV access give 0.8 mg IM or 1.6 mg intranasal and repeat in 20 minutes if required. c. For children see paediatric drug dose table. If cyclic poisoning is suspected: a. Acquire a 12 lead ECG, provided this does not significantly delay treatment or transport. b. Give IV fluid if the patient is tachycardic or shows signs of poor perfusion. If the patient has a problem such as seizures or shock, refer to the appropriate section. commentary The management of poisoning is rarely poison specific and treatment should focus on supporting airway, breathing and circulation.
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4.5 tHe coMBAtiVe PAtient
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Look for and treat reversible causes. A reasonable attempt must be made to de-escalate the situation and calm the patient by talking to them. Utilize friends and/or family if appropriate. If the patient remains combative and there is imminent risk of serious harm to them or others, they may be sedated and/or restrained in order to allow safe treatment and transport. Sedation may be given if the patients age is > 10 and their motor score is > 5: a. Begin with IV morphine if the patient appears to be in pain. Give 2-5 mg morphine IV every 3-5 minutes. Use a dose at the lower end of the range if the patient is elderly, small, or physiologically unstable. If this is unsuccessful or they do not appear to be in pain, give midazolam. b. Give 1-2 mg midazolam IV every 3-5 minutes. If IV access cannot be obtained give 5-10 mg IM or 10-15 mg intranasal. Use a dose at the lower end of the range if the patient is elderly, small, or physiologically unstable. The IM or intranasal dose may be repeated once after 20 minutes if required.
commentary Always act in the best interests of the patient. A competent patient has the right to refuse treatment. Every patient is presumed competent unless you have reasonable grounds to believe they are not (see non-transport section for assessing competency). If you are unsure seek advice from a St John medical advisor or another medical specialist. Sedation and/or restraint carry risks which must be balanced against the risk of not treating or transporting the patient. Use only the minimum amount of sedation and/or restraint required to make the situation safe. If physical restraint is required then restrain hands and/or feet. Never restrain a patient face down and never restrain them with weight on their chest. All forms of physical restraint must be recorded on the PRF. Continually monitor airway, breathing, and level of consciousness. Monitor pulse, blood pressure and capillary refill (particularly in restrained limbs) if possible. Contact a St John medical advisor or another medical specialist for urgent advice if the situation is not easily brought under control.
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Paediatric
5.1 Paediatric VitaL SiGNS
Use the paediatric assessment triangle when assessing small children: Activity
(Movement, interaction, tone)
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Breathing
(Respiratory rate, work of breathing)
abnormal: Inactive, lethargic, abnormal or absent cry or speech, failure to interact with people or objects, floppy. Normal: Active, normal cry or speech, interacts with people and objects, good muscle tone.
abnormal: Tachypnea, nasal flaring, indrawing, use of accessory muscles, grunting.
a c
Normal: Normal, regular breathing without accessory muscle use or audible sounds.
Circulation
(Heart rate, perfusion)
abnormal: Tachycardia, mottled skin, pale, cold, slow capillary refill time. Normal: Normal heart rate, normal skin colour, warm, fast capillary refill time.
Tachypnea is a common presenting feature of shock. Tachycardia is a relatively non-specific sign and can be caused by fever, crying and pain. The circulation is best assessed by assessing perfusion. Blood pressure is not a very useful sign on its own, but the trend in combination with other signs is useful. GCS scoring in small children is difficult. Use AVPU and describe their activity. For older children, see GCS scoring in miscellaneous section. The normal values below are a broad guide only. Normal values table
Newborn 1 - 12 months 1 - 4 years 5 - 12 years > 12 years Heart rate 120 - 180 100 - 160 80 - 110 70 - 100 60 - 90 respiratory rate 30 - 60 20 - 50 20 - 40 15 - 30 12 - 16 BP (Syst) N/A >70 >80 >90 >100
Paediatric
72
Paediatric
5.2 Paediatric drUG dOSeS
73
For children, the doses of drugs, DC shocks and fluid therapy are based on weight. Where possible use known weight but if this is not known, estimate weight using (Age x 2)+10. Then round the weight of all children to the nearest of 5, 10, 20, 30, 40 or 50 kg and calculate doses accordingly. All children 50 kg and above can be given adult doses. IV/IO adrenaline in children must always be diluted. During cardiac arrest use 1/10,000, for all other circumstances use 1/1,000,000. To make up 1/10,000 adrenaline - take 1 ml of 1/1000 adrenaline containing 1 mg and draw up into a 10 ml syringe. Draw up an additional 9 ml of 0.9% NaCl to make a total of 10 ml. You now have 1/10,000 adrenaline containing 0.1 mg/ml. To make up 1/1,000,000 adrenaline take 1 ml of 1/1000 adrenaline containing 1 mg and place into a one litre bag of 0.9% NaCl. Shake well and label the bag. You now have 1/1,000,000 adrenaline containing 0.001 mg/ml. For drugs where there is a choice of dose range for adults (e.g. IM adrenaline, IV morphine, IV midazolam), the paediatric dose has been calculated using the upper limit of the dose range for adults. Consideration should be given to reducing the dose if the child is physiologically unstable or their weight has been significantly rounded up.
anaphylaxis and asthma

approximate age approximate weight Adrenaline IM (mg) Adrenaline IM (ml 1/1000) Adrenaline IV/IO (mg) Adrenaline IV/IO (ml 1/1,000,000) 3 mths 5 kg 0.05 mg N/A* 1 yr 10 kg 0.1 mg 0.1 ml 5 yr 20 kg 0.2 mg 0.2 ml 10 yr 30 kg 0.3 mg 0.3 ml 13 yr 40 kg 0.4 mg 0.4 ml
0.001 mg 0.002 mg 0.004 mg 0.006 mg 0.008 mg 1 ml 2 ml 4 ml 6 ml 8 ml
*Use 0.5 ml of 1/10,000 adrenaline.
cardiac arrest
approximate age approximate weight Defibrillation (J) Adrenaline IV/IO (mg) Adrenaline IV/IO (ml 1/10,000) Adrenaline ETT (mg) Adrenaline ETT* (ml 1/1000) Amiodarone IV/IO (mg) Amiodarone IV/IO (ml) 3 mths 5 kg 25 J 0.1 mg 1 ml 0.3 mg 0.3 ml 25 mg 0.5 ml 1 yr 10 kg 50 J 0.2 mg 2 ml 0.6 mg 0.6 ml 50 mg 1 ml 5 yr 20 kg 100 J 0.4 mg 4 ml 1.2 mg 1.2 ml 100 mg 2 ml 10 yr 30 kg 150 J 0.6 mg 6 ml 1.8 mg 1.8 ml 150 mg 3 ml 13 yr 40 kg 200 J 0.8 mg 8 ml 2.4 mg 2.4 ml 200 mg 4 ml
*Dilute ETT adrenaline before administration. Dilute up to 5 ml for children 5 years and under and 10 ml for children over 5 years.
Paediatric
74
Paediatric
Other drugs and fluids
approximate age approximate weight Glucagon IM (mg) Glucose 10% IV/IO (ml) Ketamine IV/IO (mg) Ketamine IM/oral (mg) Lignocaine 1% IO (ml) Midazolam IV/IO (seizures, mg) Midazolam IM (seizures, mg) Midazolam intranasal (seizures, mg) Morphine IV/IO (mg) Morphine IM (mg) Naloxone IV/IO (mg) Naloxone IM (mg) Ondansetron oral Ondansetron IV Paracetamol* (mg) 3 mths 5 kg 0.5 mg 10 ml N/A N/A N/A 0.5 mg 1 mg 1.5 mg 0.5 mg 1 mg 0.05 mg 0.1 mg N/A N/A 100 mg 1 yr 10 kg 0.5 mg 20 ml 2 mg 10 mg 1 ml 1 mg 2 mg 3 mg 1 mg 2 mg 0.1 mg 0.2 mg N/A N/A 200 mg 4 ml 200 ml 5 yr 20 kg 0.5 mg 40 ml 4 mg 20 mg 2 ml 2 mg 4 mg 6 mg 2 mg 4 mg 0.2 mg 0.4 mg 4 mg 2mg 400 mg 8 ml 400 ml 10 yr 30 kg 1 mg 60 ml 6 mg 30 mg 3 ml 3 mg 6 mg 9 mg 3 mg 6 mg 0.3 mg 0.6 mg 4 mg 3 mg 600 mg 12 ml 600 ml
75
13 yr 40 kg 1 mg 80 ml 8 mg 40 mg 4 ml 4 mg 8 mg 12 mg 4 mg 8 mg 0.4 mg 0.8 mg 4 mg 4 mg 800 mg 16 ml 800 ml
Paracetamol* (250mg/5ml) 2 ml 0.9% NaCl (20 ml/kg) 100 ml
*Always round the weight down rather than up for paracetamol dosing.
5.3 crOUP
If there is resting stridor or moderate to severe respiratory distress, give 5 mg nebulised adrenaline. Repeat nebulised adrenaline as required every twenty minutes. commentary Croup is a viral infection of the upper airway. It mostly occurs in children aged 3 months to 5 years. It is usually associated with a preceding viral illness and a loud barking cough. The patient may have a mild fever. The differential diagnosis includes foreign body airway obstruction, epiglottitis, tracheitis and pharyngeal abcess. Epiglottitis is a bacterial infection of the upper airway. It is now quite rare. It can occur at any age, including adults. It is not usually preceded by a viral illness. The patient will usually have a high fever and may want to sit forward and drool (the throat is too sore to swallow). With any form of upper airway obstruction calming and reassuring the patient (and the parents of a child) often helps. Allow the patient to adopt the position they want to. Nebulised adrenaline will not be harmful if the diagnosis turns out not to be croup.
Paediatric
76
Paediatric
5.4 NeWBOrN reSUScitatiON
77
The focus on newborn resuscitation is on supporting breathing. Assessment and interventions are based primarily on the babys breathing and heart rate. Request early back up and support from a hospital team if one is available and begin to transport as soon as possible.
if breathing is adequate and the heart rate is > 100/min dry the baby, do not give oxygen and keep it warm. Continue to monitor the heart rate. if breathing is inadequate and the heart rate is < 100/min ventilate with a manual ventilation bag at a rate of 40-60/min without added oxygen. Continually monitor the heart rate: if heart rate climbs to > 100/min
Dry the baby, keep them warm and do not give oxygen. Continually monitor breathing and heart rate, and be prepared to support breathing if required.
if the heart rate is 60 100/min

Focus on ventilation and continually monitor heart rate. If heart rate fails to improve continue to focus on ventilation and add oxygen. If no improvement place an LMA or ETT.
if the heart rate is < 60/min

Start CPR, but continue to focus on ventilation (with oxygen). Place an LMA or ETT. Gain IV or IO access and give adrenaline, but good CPR takes priority. Give a 20ml/kg bolus of 0.9% NaCl.
Measure blood glucose (heel prick) and treat accordingly. Dry the baby as soon as possible and keep them warm. Consider placing the body of premature newborns between two layers of cling film. commentary A crying and/or active baby requires no intervention and should stay with the mother. It is normal for a baby to have central blueness and a pulseoximeter saturation of 50-70% at the time of delivery and it is normal for the peripheries to remain blue for many minutes and the pulseoximeter saturation to be around 90% at five minutes. Oxygen administration during new born resuscitation appears to make outcomes worse. This is why oxygen is reserved for deterioration despite initial ventilation. Suctioning a babys mouth and nose before the body is delivered is not required unless there is a large amount of meconium visible around the mouth or nose. Ventilation takes priority over suctioning meconium. Lung inflation pressures for the initial breaths may be higher than that set on relief valves on manual ventilation bags. It is acceptable to close the relief valve for the first few breaths to aid expansion of the lungs.
Paediatric
78
Paediatric
79
Ventilation with a manual ventilation bag can result in distension of the stomach. If the abdomen is visibly distended, decompress the stomach by placing a small suction catheter into the stomach via the nose and applying suction. Do not spend a long time trying to do this if this is difficult. If you are required to clamp and cut the umbilical cord, leave at least 5cm of intact cord to facilitate later access to the cord vessels.
6.1 Pain RelieF

Pain is best relieved by an approach that combines multiple interventions e.g. reassurance, splinting, posture and pain relieving medicines. A combination of pain relieving medicines usually provides better pain relief than one medicine alone. Paracetamol Indicated for mild pain, or in addition to other measures for moderate pain. May be used if the patient is febrile. Not indicated for cardiac chest pain. Contraindicated if: a. Unable to obey commands or b. Unable to swallow or c. Any paracetamol has been taken within the last four hours or d. Paracetamol poisoning or e. Known allergy. Give large (>70kg) adults 1.5g and small (50-70kg) adults 1g. For children see paediatric drug dose table. A patient may be given paracetamol and have a recommendation made to them that they do not require non-transport, provided no other treatments are given and no compulsory criteria for recommending transport are met (see non-transport section).
Miscellaneous
80
Miscellaneous
81
entonox Indicated for moderate to severe pain. Contraindicated if: a. Unable to obey commands or b. Confirmed pneumothorax or c. Confirmed bowel obstruction or d. Patient has been SCUBA diving in the last 24 hrs or has a diving related emergency or e. Known allergy. Confirmed pneumothorax is a contraindication, but chest injuries are not, here you will need to monitor breathing and stop using entonox if breathing gets worse. In general only one form of inhalational pain relief (either entonox or methoxyflurane) should be used, but it is acceptable to swap from one to the other if there is a good indication to do so. Methoxyflurane Indicated for moderate to severe pain. Contraindicated if: a. Unable to obey commands or b. Known renal impairment (note: renal failure requiring dialysis, kidney stones and/or renal colic are not contraindications) or c. Known history or family history of malignant hyperthermia or d. Known allergy or e. They have received methoxyflurane within the last week.
Is relatively contraindicated in toxemia of pregnancy and in labour with known signs of foetal distress. Maximum dose for < 10 yrs is one dose (3ml) a day and for > 10yrs is two doses (6ml) a day. Administer one dose (3ml) at a time, always use with a charcoal filter and avoid adding oxygen to inhaler unless absolutely necessary. Place inhaler in a closed zip lock bag when not in use (may be reused by the same patient). Morphine Indicated for moderate to severe pain. Contraindicated if: a. Unable to obey commands (there is one exception to this, see combative patient section) or b. Known allergy. In adults: give 1-5 mg IV every 3-5 minutes. If you are unable to obtain IV access, give 5-10 mg IM, this may be repeated in 20 minutes if required. Use a dose at the lower end of the range if the patient is elderly, small or physiologically unstable. Do not use the IM route if shocked and avoid IM use in children if possible. For children see paediatric drug dose table. Self limiting histamine release is common after morphine administration and this is not allergy. Nausea and vomiting following morphine is not allergy. IV morphine must always be diluted to 1mg/ml in a 10 ml syringe.
Miscellaneous
82
Miscellaneous
83
Morphine and low dose midazolam Indicated when severe pain is unresponsive to usual pain relief and this severe pain is significantly impeding the ability to treat and/or transport the patient. It is not indicated for the relief of severe pain that is not impeding patient care. Contraindicated if: a. Age less than ten years or b. Unable to obey commands or c. Has abnormal airway, abnormal breathing or signs of shock or d. The patient is in a situation where personnel cannot intervene if the airway, breathing or circulation becomes abnormal or e. Ketamine has already been given. Give oxygen via nasal prongs or acute (ordinary) mask. Give morphine IV until the patient is gaining no further relief from morphine administration. Titrate very small doses of midazolam (e.g. 0.5-1 mg) IV every 3-5 minutes until adequate relief is obtained. The patient must be able to obey commands throughout the procedure, if they cannot, do not give any further midazolam.
Ketamine Indicated in severe pain, particularly musculoskeletal or burn pain. Is preferably used in combination with morphine. Contraindicated if: a. Age less than one year or b. Unable to obey commands or c. Has active psychosis or d. Has cardiac chest pain or e. Midazolam has already been given. Give oxygen via nasal prongs or acute (ordinary) mask. In adults: a. If morphine or IM ketamine already given, give 5-10 mg ketamine IV every 3-5 min. b. If morphine or IM ketamine has not been given, give 10-20 mg ketamine IV every 3-5 min. c. If unable to gain IV access, give 1 mg/kg ketamine (rounded off to nearest 10 kg) IM or oral, up to a maximum of 100 mg. This may be repeated after 20 minutes if required. Do not use IM route if shocked and avoid IM use in children if possible. d. Reduce the dose if the patient is elderly, small or physiologically unstable. For children, see paediatric drug dose table. Ketamine must be diluted to 2 mg/ml for IV use. Place 200 mg (2 ml) of ketamine in a 100 ml bag of 5% glucose (shake well and label).
Miscellaneous
84
Miscellaneous
6.2 nausea anD VoMiTinG
85
Ondansetron is indicated for the treatment of severe nausea and vomiting. Contraindicated if: a. Known allergy to ondansetron b. In first trimester of pregnancy. Dosing (oral is preferred): a. Give oral ondansetron unless vomiting is continuous. Give 8 mg oral for adults and 4 mg oral for children aged > 4 years. b. Give IV ondansetron if severe nausea and vomiting persists despite oral ondansetron, or if vomiting is continuous. Give 4 mg IV for adults and children > 40 kg. For smaller children see paediatric drug dose table.
6.3 RaPiD seQuence inTuBaTion (Rsi)

Indicated for patients with a GCS <10 with airway or ventilatory compromise. Absolute contraindications: a. Known history or family history of malignant hyperthermia or b. Paraplegics/quadriplegics or c. Any muscle disorder with long term weakness or d. Hyperkalemia strongly suspected or e. Electronic capnography unavailable or f. No dedicated suitable assistant (2nd AP preferred). Relative contraindications: a. Age < 5 or > 75 yrs or b. Age > 75 years with stroke or COAD as underlying cause or c. Predicted difficult airway or d. Less than 15 minutes to hospital or e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure. Preparation: a. Assess the patient for signs of difficult intubation. b. Prepare all equipment and brief assistant. c. Draw up and label drugs, ensure running IV line. d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP. e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag. If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.
Miscellaneous
86
Miscellaneous
87
Medicines: a. Give IV fentanyl over 1 minute, 2-3 minutes before induction. b. Regimen 1. For all patients with neurological cause for coma (e.g. TBI, stroke, post cardiac arrest) that do not have significant shock - give IV midazolam and IV suxamethonium. c. Regimen 2. For all other patients and particularly for those with shock give IV ketamine and IV suxamethonium. Intubate and confirm ETT position with capnography. If unable to intubate implement failed intubation drill. Give IV vecuronium once ETT confirmed in trachea. Ventilate to ETCO2 30-35 mmHg (exception life threatening asthma, ventilate at 6 breaths/min and ignore ETCO2). Give additional sedation (midazolam 1-3 mg and morphine 1-3 mg) and vecuronium as required.
Rsi Drug Dose Table

10kg 20kg 30kg 40kg 50kg 60kg 70kg 80kg 90kg 100+kg Fentanyl * (1 mcg/kg) Midazolam* (0.05 mg/kg) Ketamine (1.5 mg/kg) 10 20 30 40 50 60 70 80 90 100 mcg mcg mcg mcg mcg mcg mcg mcg mcg mcg 0.5 mg 15 mg 1 mg 30 mg 30 mg 2 mg 1.5 mg 45 mg 45 mg 3 mg 2 mg 60 mg 60 mg 4 mg 2.5 mg 75 mg 75 mg 5 mg 3 mg 90 mg 90 mg 6 mg 3.5 mg 100 mg 100 mg 7 mg 4 mg 120 mg 120 mg 8 mg 4.5 mg 140 mg 140 mg 9 mg 5 mg 150 mg 150 mg 10 mg
Suxamethonium 15 (1.5 mg/kg) mg Vecuronium (0.1 mg/kg) 1 mg
*Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg. Round the patients weight to the nearest 10 kg. Midazolam must be given using 1 mg/ml in a 5ml syringe. Ketamine must be diluted to 10 mg/ml in a 20ml syringe. Vecuronium must be diluted to 1 mg/ml in a 10ml syringe. Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe. Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.
Miscellaneous
88
Miscellaneous
6.4 FaileD inTuBaTion DRill
Able to visualize cords within 15 seconds or intubate within 30 seconds of laryngoscopy?
89
Manually ventilate (+/- OPA/NPA), ensure adequate oxygenation but do not hyperventilate
NO
YES
ONE retry with bougie (+/- dierent blade) with optimising position +/anterior tracheal pressure
Intubate accordingly
Immediate ETCO2 check is ETCO2 present?
YES
NO
Continue to ensure adequate oxygenation and ventilation
Remove ETT and insert LMA or OPA/NPA
Able to oxygenate and ventilate?
YES
NO
Perform cricothyroidotomy
6.5 inTRa-osseous DRill

Indicated for patients with a life threatening condition and a time critical need for IV drug or fluid therapy. Relatively contraindicated if: a. Infected skin over the insertion site or b. Fracture of the bone chosen for insertion or c. Orthopaedic metal in the bone chosen for insertion. Sites for placement: a. In patients > 40 kg use the 25mm needle in the proximal humerus or the proximal tibia. b. In patients < 40 kg use the 15mm needle in the proximal tibia. c. Use other insertion sites only in consultation with a Medical Advisor. Insertion technique: a. Clean the skin with an antimicrobial solution. b. Insert the needle to the correct depth. c. Aspirate and flush the needle with 10 ml 0.9% NaCl. d. Prime and attach the extension set. e. Secure the needle and extension set. f. Significant bone pain associated with fluid infusion may be alleviated with lignocaine. Give adults 5ml of 1% lignocaine. For children see paediatric drug dose table. Give lignocaine slowly over 1 min, waiting an additional 1 min before giving further fluid.
Miscellaneous
90
Miscellaneous
6.6 oBsTeTRic PRoBleMs
91
If the patient has a problem such as seizures or asthma, treat them as per the appropriate section. Pregnancy and trauma All pregnant patients over twenty weeks gestation with a mechanism of injury that involves acceleration/deceleration (e.g. road traffic crash or fall), or who have had direct abdominal or pelvic trauma, should have transport to a hospital with obstetric facilities firmly recommended, even if they appear uninjured. This is because of the risk of asymptomatic placental abruption. supine Hypotension The uterus can impede venous return through the inferior vena cava in the supine position. Tilt the patient to their left or manually displace the uterus to the left to alleviate this. antepartum Haemorrhage This is vaginal bleeding after twenty weeks gestation. All patients with antepartum haemorrhage should have transport recommended. If shock is present treat as uncontrolled bleeding. Premature labour If the patient is having regular contractions and the pregnancy is between 20 and 35 weeks gestation, transport immediately and give 5 mg nebulised salbutamol every 30 minutes. This is designed to delay delivery until the patient is in hospital.
normal delivery Allow the patient to adopt the position she wishes to. Support the babys head and shoulders as they appear without pulling on the baby or applying traction. Dry the baby and wrap in a clean dry towel. Keep them warm. Clamp and cut the cord (clamp 5cm from the baby). Allow the placenta to deliver on its own, without applying traction. This should happen in approximately 5-10 minutes, but may take up to 30 minutes. if the baby gets stuck If the babys head appears, but the body does not after two contractions with pushing: Get the patient to grab her knees, pull them to her chest and push as hard as she can with the next two contractions. If the above fails to deliver the baby, place the heel of your hand directly above the patients pubic bone and push slowly but firmly straight back toward the patients lower back. This is designed to reposition the babys shoulder, which is usually what is preventing delivery. If the above fails, transport urgently and seek urgent help and advice from a doctor or midwife. if the cord is wrapped around the neck This is quite common and is not an emergency. If the cord is loose and is easy to slip over the babys head, then do so. If you cannot slip it over the head, then leave it alone and continue with delivery.
Miscellaneous
92
Miscellaneous
93
Prolapsed umbilical cord and breech delivery Prolapsed umbilical cord is when the umbilical cord appears in the vagina ahead of the baby. Breech delivery is when the baby is coming out feet or buttocks first. Both risk the baby having poor blood supply from the cord being compressed and both require urgent delivery of the baby. Transport urgently and seek urgent help and advice from a doctor or midwife. Tell the patient not to push. Position her so that her hips are higher than her shoulders: either position her on her back with her hips on a pillow and the stretcher head down or position her on her elbows and knees with her head down on the stretcher. These manoeuvres are designed to take the weight of the baby off the cord and to delay delivery until expert help is available. If the baby appears in the vagina and the patient wants to push, allow delivery to occur. Retained placenta This is when the placenta has not been delivered within 30 minutes of the baby. Transport to hospital without delay. Be prepared to treat postpartum haemorrhage.
Postpartum haemorrhage This is abnormal bleeding (>500 ml) following delivery. Treat as uncontrolled bleeding. Transport urgently and seek urgent help and advice from a doctor or midwife. Compress any obvious bleeding site, e.g. a visible vaginal laceration. Encourage the baby to begin breast feeding or ask the patient or partner to stimulate both nipples by rolling them back and forth between their fingers and thumbs for approximately fifteen minutes. This is designed to release oxytocin to help the uterus contract. This is not a priority if it is difficult to achieve. Feel for the uterus and massage it firmly using two hands. If bleeding is severe and the patient is rapidly deteriorating perform bimanual compression of the uterus. Place one hand in the vagina (with the fingers extended), as far as you can with the palm up. Push upward with this hand toward the patients pubic bone. Place your other hand on the abdomen, feel for the uterus and push both hands firmly toward each other.
Miscellaneous
94
Miscellaneous
6.7 DiVinG eMeRGencies
95
Give oxygen via non-rebreather mask if conscious and via manual ventilation bag if unconscious. Position horizontal, either supine or lateral. Gain IV access and give one litre 0.9% NaCl as a bolus. Give another one litre enroute to hospital or recompression facility. Give analgesia if required but do not give entonox. If you have the potential for direct transport to a recompression facility phone them for advice: a. Auckland Naval Base, ph 0800 4337111 and ask for on call hyperbaric doctor. b. Christchurch Hospital, ph 03 3640640 and ask for on call hyperbaric doctor. Avoid transporting the patient at high altitudes (by road or air), as this may cause any gas bubbles to enlarge in size.
6.8 PalliaTiVe caRe

This procedure is written for patients who are receiving end of life care. It focuses on relief of symptoms and not on instituting treatments aimed at prolonging life. However, some patients under the care of palliative care teams or hospices are not at the very end of their lives. For these patients it may be appropriate to institute some life prolonging treatments and if there is any doubt medical advice should be sought. When treating patients receiving end of life care: It is appropriate to give treatments that are aimed at comfort and relief of symptoms e.g. relief of pain, anxiety or shortness of breath. It is inappropriate to give treatments that artificially prolong the process of dying e.g. CPR or assisted ventilation. Whenever possible follow the patients wishes regarding hospital admission (they may wish to die at home), taking into account the views of the family. If transport is required this should be to a hospice if at all possible, provided this is arranged by phone. Personnel may administer medicines and recommend the patient is not transported, provided this is consistent with adequate ongoing symptom control and they make contact with the patients palliative care personnel. This contact must be as soon as practical (preferably at the time) and must include why St John personnel were called and what they did for the patient.
Miscellaneous
96
Miscellaneous
97
Some patients are issued with medicines for self administration in the event of severe distress at the time of sudden deterioration. All St John personnel may administer such medicines, even if they are outside their scope of practice, provided all of the following criteria are met: a. There are clear written or phone instructions from palliative care personnel and b. The patient is in severe distress and c. No other suitable personnel are immediately available to administer the medicine and d. The audit copy of the PRF is sent (along with a note describing the circumstances) to the Regional Medical Advisor for audit. The person administering the treatment is responsible for ensuring this occurs.
6.9 sTaTus coDes

Status codes are a numerical means of describing an estimate of the severity of a patients condition. They are qualitative, require clinical judgement and are allocated to a patient after taking into account their illness or injuries, their vital signs and the potential threat to their life. They are not altered by the mechanism of injury, the physical environment (e.g. trapped or not trapped) or the age of the patient. The examples below are not an exhaustive list, but are indicative only. status Status zero Status one Status two Status three Status four condition Dead Critical problem Immediate threat to life Serious problem Potential threat to life Moderate problem Unlikely to threaten life Minor problem No threat to life Triage tag colour Black/white Red Orange/yellow Green Green
Miscellaneous
98
Miscellaneous
99
examples status one: obstructed airway or airway needing intervention, severe stridor, severe respiratory distress, shock unresponsive to fluid loading, multisystem trauma with abnormal vital signs, cardiac arrest or post cardiac arrest, cardiogenic shock, anterior ST elevation myocardial infarction on 12 lead ECG, status epilepticus, coma with GCS less than or equal to nine. status two: moderate stridor, moderate respiratory distress, shock responsive to fluid loading, multisystem trauma with normal or near normal vital signs, multiple long bone fractures, inferior ST elevation myocardial infarction on 12 lead ECG, cardiac chest pain unrelieved (or not significantly relieved) by oxygen and nitrates alone, abnormal level of consciousness with GCS 10-13, stroke with normal level of consciousness. status three: mild and improving stridor, mild and improving respiratory distress, isolated SVT with no other symptoms, cardiac chest pain relieved (or mostly relieved) by oxygen and nitrates alone, transient ischemic attack, isolated long bone fractures (including compound fractures), loss of consciousness with normal or near normal (GCS14-15) recovery. status four: isolated minor fractures, isolated hand injuries, strains and sprains, lacerations with controlled bleeding.
6.10 BuRn DePTH anD aRea

Superficial burns are red and painful like sunburn. Partial thickness burns have blisters, weep fluid and are painful. Full thickness burns are charred, white, leathery and usually painless. When calculating burn area: a. Do not include superficial burns. b. Cut a piece of paper the same size as the patients hand (including the fingers), which is approximately 1% of their body area, using this to estimate burn area. area Head and neck Right arm Left arm Front of trunk Back of trunk Right leg Left leg adult 9% 9% 9% 18% 18% 18% 18% child 15% 10% 10% 20% 20% 12% 12% infant 20% 10% 10% 20% 20% 10% 10%
Miscellaneous
100
Miscellaneous
101
6.11 aDulT/cHilD GlasGoW coMa scoRe

If the patient is staring blankly ahead score the eye component as 1. During generalised seizures score the GCS as 3. Do not estimate GCS. Individually assess and score each component. The motor score is the most important part of the GCS. In small children use the AVPU scale and the paediatric assessment triangle.
Best eye opening (e) Spontaneously To voice To pain None 4 3 2 1 Best verbal response (V) Orientated Mildly confused Very confused Moans or grunts None 5 4 3 2 1 Best motor response (M) Obeys commands Localises pain Withdraws from pain Flexion Extension None 6 5 4 3 2 1
noTes
Miscellaneous
102
Miscellaneous
noTes
103
noTes
Miscellaneous
104
Miscellaneous
noTes
105
noTes
Miscellaneous
106
Miscellaneous
noTes
107

ST John Clinical Procedures 2009-2011

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Clinical Procedures

Ian Civil Chair of the Clinical Governance Committee

Jaimes Wood Chief Executive

PrActIcE LEVELS And dELEGAtEd ScoPES oF PrActIcE

. tHE PrIMArY SurVEY

.6 non trAnSPort

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

2.2 cHRonic oBstRUctiVe aiRWay disease

RespiRatoRy and caRdiac

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RespiRatoRy and caRdiac

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RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

2.4 post caRdiac aRRest caRe

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

RespiRatoRy and caRdiac

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RespiRatoRy and caRdiac

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3.1 hYPoVoLaEmIc Shock

Shock and trauma

Shock and trauma

3.2 hYPoVoLaEmIc Shock From uncontroLLEd BLEEdInG

Shock and trauma

Shock and trauma

3.3 traumatIc BraIn InJurY

Shock and trauma

Shock and trauma

Shock and trauma

Shock and trauma

Shock and trauma

Shock and trauma

Shock and trauma

abnormal: Tachypnea, nasal flaring, indrawing, use of accessory muscles, grunting.

anaphylaxis and asthma

0.001 mg 0.002 mg 0.004 mg 0.006 mg 0.008 mg 1 ml 2 ml 4 ml 6 ml 8 ml

*Use 0.5 ml of 1/10,000 adrenaline.

Paracetamol* (250mg/5ml) 2 ml 0.9% NaCl (20 ml/kg) 100 ml

if the heart rate is 60 100/min

if the heart rate is < 60/min

6.1 Pain RelieF

6.3 RaPiD seQuence inTuBaTion (Rsi)

Rsi Drug Dose Table

Suxamethonium 15 (1.5 mg/kg) mg Vecuronium (0.1 mg/kg) 1 mg

. tHE PrIMArY SurVEY

.6 non trAnSPort