Contents - phecit.ie Practice Guidelines/2014... · 3-5Kg 6-7Kg 10-11Kg12-14Kg15-18Kg19-22Kg24-28Kg 30-36Kg. Notes 6. ASSESSMENT ASSESSMENT 8 Aid to patient decision-making capacity

ContentsMEDICATIONS Important Medication Information 68

A Amiodarone 70 Aspirin 72 Atropine 73

B Benzylpenicillin 74

C Clopidogrel 75 Cyclizine 76

D Dextrose 77 Diazepam 80

EEnoxaparin 83 Epinephrine 84

F Fentanyl 88 Furosemide 90

G Glucagon 91 GlucoseGel 92 GlycerylTrinitrate 93

H Hartmann’sSolution 94 Hydrocortisone 95

I Ibuprofen 98 IpratropiumBromide 100

L Lidocaine 101 Lorazepam 102

MMagnesiumSulphate 103 MidazolamSolution 104 Morphine 108

N Naloxone 112 Nifedipine 116 NitrousOxide&Oxygen 117

O Ondansetron 118 Oxygen 120

P Paracetamol 122

S Salbutamol 126 SodiumBicarbonate 127 SodiumChloride0.9% 128 Syntometrine 131

T Tenecteplase 132 Ticagrelor 134 TranexamicAcid 135

Commonly Prescribed Medications 136

HOSPITAL CONTACT NUMBERS & PCR CODES 146

2

ASSESSMENT 8 Aidtopatientdecision-makingcapacity 9 Asthmadecisions10 AVPU11 Burns-Adult12 GlasgowComaScale13 Hypothermia14 MIlocationandleadplacement15 ECGinterpretations16 PeakExpiratoryFlowRate-Adult23 Primarysurvey24 Spinalimmobilisationdecision25 StrokeFASTassessment26 Traumaassessment

PAEDIATRIC28 Burns-Paediatric29 Paediatricadvancedairwaysizes30 Paediatricanalgesiaoptions31 FLACCScale32 Wong-Bakerfaces33 Paediatricassessment34 Paediatricvalues35 PeakExpiratoryFlowRate-Paediatric36 WETFAGCalculations

MAJOR EMERGENCY40 Majoremergencyoperations 43 TriageSieve 44 TriageSort

MISCELLANEOUS46 EMSprioritydispatchprotocols49 HypodermicneedlesforIMinjection50 Oxygencylindercapacity51 Poisoncare54 RadioreportforED55 IMIST-AMBOHandoverPrototcol56 SafeAeromedicalHelicopterUsage59 Sepsis61 TreatandReferral

3

Field GuidePublished 2014

ThePre-HospitalEmergencyCareCouncil(PHECC)isanindependentstatutorybodywithresponsibilityforstandards,educationandtraininginpre-hospitalemergencycareinIreland.PHECC’sprimaryroleistoprotectthepublic.

Mission Statement The Pre-Hospital Emergency Care Council protects the public by independently specifying, reviewing, maintaining and monitoring standards of excellence for the delivery of quality pre-hospital emergency care for people in Ireland.

TheCouncilwasestablishedasabodycorporatebytheMinisterforHealthandChildrenbyStatutoryInstrumentNumber109of2000(EstablishmentOrder)whichwasamendedbyStatutoryInstrumentNumber575of2004(AmendmentOrder).TheseOrdersweremadeundertheHealth(CorporateBodies)Act,1961asamendedandtheHealth(MiscellaneousProvisions)Act2007.

Medications UpdatePleaserefertowww.phecc.ieortheFieldGuideSmartPhoneAppforup-to-datemedicationsinformation.

PHECC Field Guide for Practitioners 2014Project Leader: MrJohnLally,MSc,ICTSupportOfficer,PHECC.

Clinical Editor:MrBrianPower,MScinEMS,MBA,NQEMT-AP,ProgrammeDevelopmentOfficer,PHECC.

Published by:ThePre-HospitalEmergencyCareCouncilAbbeyMoatHouse,AbbeyStreet,Naas,CoKildare,IrelandPhone:+353(0)45882042Fax:+353(0)45882089Email:[email protected]:www.phecc.ieISBN:978-0-9562261-5-0

©Pre-HospitalEmergencyCareCouncil2014

Anypartofthispublicationmaybereproducedforeducationalpurposesandqualityimprovementprogrammessubjecttotheinclusionofanacknowledgementofthesource.Itmaynotbeusedforcommercialpurposes.

AcknowledgementOurthankstothePractitioners(PaulKelly,BrianO’Moore,DesmondWade,JasonMasterson,OmarFitzell,GregCookeandThomasBrady)whohelpedtodevelopthisguidebyparticipatingintheconsultationprocess.

4

5

IntroductionThisFieldGuideisnotasubstituteforthepublishedClinicalPracticeGuidelines(CPGs).ItisaquickreferencetohelpPractitionersinthefieldparticularlywithmedicationcalculationsandinfrequentclinicalencounters.Italsogivesvaluesforclinicalmeasurementsi.e.GCS.

ThisFieldGuidedoesnotauthoriseskillsormedicationadministration.PractitionersshouldonlypracticewithintheirscopeofpracticeandinaccordancewiththeirlevelonthePHECCRegister.

Therouteofadministrationshouldbeappropriatetothepatient’sclinicalpresentation.

Medications may be administered provided1. ThePractitionerisingoodstandingonthePHECCRegister.

2. ThePractitionercomplieswiththeCPGspublishedbyPHECC.

3. ThePractitionerisacting(paidorvoluntary)onbehalfofan organisationthatisaPHECClicencedCPGprovider.

4. ThePractitionerisprivileged,bytheorganisationonwhosebehalfhe/sheisacting,toadministerthemedication.

5. ThePractitionerhasreceivedtrainingon,andiscompetentin,theadministrationofthemedication.

6. ThemedicationsarelistedintheMedicinalProducts7th Schedule.

Paediatric values ThisguidehasadoptedtheBroselowtapecolourschemetoassistwithcalculations.

3-5Kg 6-7Kg 10-11Kg 12-14Kg 15-18Kg 19-22Kg 24-28Kg 30-36Kg

Notes

6

ASSESSMENT

ASSESSMENT 8 Aidtopatientdecision-makingcapacity 9 Asthmadecisions10 AVPU11 Burns-Adult12 GlasgowComaScale13 Hypothermia14 MIlocationandleadplacement15 ECGinterpretations16 PeakExpiratoryFlowRate-Adult23 Primarysurvey24 Spinalimmobilisationdecision25 StrokeFASTassessment26 Traumaassessment

8

Aid to patient decision-making capacity

1. Patientverbalises/communicatesunderstandingofclinicalsituation?

Yes

No

2. Patientverbalises/communicatesappreciationofapplicablerisk?

Yes

No

3. Patientverbalises/communicatesabilitytomakealternativeplanofcare?

Yes

No

If ‘yes’ to all of the above, the patient has demonstrated decision-making capacity and their decision must be respected.

If ‘no’ to any of the above, the patient is deemed not to possess current decision-making capacity.

Ifyouareconcernedaboutpatientwelfare,contactpatient’s

GP/relative/Gardaí.

Assmt

9

Asthma decisions

Life-threatening asthma PEFR<33%bestorpredicted.

Anyoneofthefollowinginapatientwithsevereasthma:

SpO2<92%.

Silentchest.

Cyanosis.

Feeblerespiratoryeffort.

Bradycardia.

Arrhythmia.

Hypotension.

Exhaustion.

Confusion.

Unresponsive.

Acute severe asthma Anyoneof:

PEFR33-50%bestorpredicted.

Respiratoryrate≥25/min.

Heartrate≥110/min.

Inabilitytocompletesentencesinonebreath.

Moderate asthma exacerbation PEFR>50-75%bestorpredicted.

Increasedsymptoms.

Nofeaturesofacutesevereasthma.

No indication for MgSO4 Consider MgSO4

AVPUThe definition of AVPU from a pre-hospital emergency care perspective is:

A = alert awake and interacting with the environment

V = response to voice not alert (as defined above) but responding to verbal stimuli

P = response to pain does not respond to voice but responds only to painful stimuli

U = unresponsive does not respond to any stimuli

10

Assmt

Assmt

11

9%

1%

9%9%

18% 18%

Front of trunk 18%

Back of trunk 18%

Adult

Burns – Adult Wallace’s Rule of Nines

Palm of patient’s hand = approximately 1% TBSA

Cooling time for burns 15 min. Chemical burns 20 min.

Adults:>10%TBSAconsiderIVinfusionofNaCl

>25%TBSAburnedand/ortimefrominjuryto

ED>1hour=IVinfusionofNaCl

Caution with burns gel if > 10% TBSA

Assmt

12

Glasgow Coma Scale

Adult & Child Infant

Eye Opening

Spontaneous 4 Spontaneous

Tovoice 3 Tovoice

Topain 2 Topain

Noresponse 1 Noresponse

Verbal Response

Orientated 5 Coos,babbles,smiles

Confused 4 Irritable,crying

Inappropriatewords 3 Cries/screamstopain

Incomprehensiblesounds 2 Moans,grunts


Motor Response

Obeyscommand 6 Spontaneous

Localisestopain 5 Withdrawsfromtouch

Withdrawsfrompain 4 Withdrawsfrompain

Abnormalflexion 3 Abnormalflexion

Extension 2 Extension


Assmt

13

Hypothermia

Temp Direction for cardiac arrest

Mild34-35.9oC

FollowCPGsbutnoactivere-warming

Moderate30-33.9oC

FollowCPGsbutdoublemedicationintervaluntiltemperature>34oCandnoactivere-warmingbeyond32oC

Severe<30oC

FollowCPGsbutlimitdefibrillationto3shocks,withholdmedicationsuntiltemperature>30oCandnoactivere-warmingbeyond32oC

Temp Direction for bradycardia

Mild34-35.9oC

FollowCPGs

Moderate30-33.9oC

FollowCPGsbutdonotuseAtropineuntiltemperature>34oC

Severe<30oC

FollowCPGsbutdonotuseAtropineuntiltemperature>34oC

Re-warming: NaCl at 40oC

Assmt

14

MI location and lead placement

I Lateral

aVR V1 Septal

V4 Anterior

II Inferior

aVL Lateral

V2 Septal

V5 Lateral

III Inferior

aVF Inferior

V3 Anterior

V6 Lateral

• V1 fourthintercostalspaceto therightofthesternum

• V2 fourthintercostalspaceto theleftofthesternum

• V3 directlybetweenV2&V4• V4 fifthintercostalspaceatleft

midclavicularline

• V5 levelwithleadV4atleftanterioraxillaryline

• V6 levelwithleadV5atleft midaxillaryline

• V4RFifthintercostelspaceat rightmidclavicularline. RightsidedECG

Angle of Louis

Assmt

15

Rate=No.ofRwavesin6secondsx10

No.oflargesquaresbetweenRwaves

1 2 3 4 5 6

Rate 300 150 100 75 60 50

NormalPRinterval=3to5smallsquares(0.12to0.2seconds)NormalQRSinterval<3smallsquares(0.12seconds)

STEMI definitionSTelevationintwoormorecontiguousleads(2mminleadsV2andV3,or1mminanyotherleads)ornewonsetLBBB.

ECG Interpretations

Assmt

16

Peak Expiratory Flow Rate – AdultNormal ValuesForusewithEU/EN13826scalePEFmetersonly

Adapted by Clement Clarke for use with EN13826 / EU scale peak flow meters from Nunn AJ Gregg I, Br Med J 1989:298;1068-70.

ActualPEFRx100=%bestPEFRPredictedPEFR

Female Peak Flow Rate (L/min)

Height 152 cm (5 ft) 160 cm (5 ft 3 in)

Age 100% 75% 100% 75%

15 385 289 394 295

20 409 307 419 314

25 422 316 433 325

30 427 320 437 328

35 425 319 436 327

40 420 315 431 323

45 412 309 422 316

50 401 301 411 308

55 389 292 399 299

60 376 282 385 289

65 362 272 371 278

70 348 261 356 267

75 334 250 342 256

80 320 240 327 245

85 306 229 313 235

17

Assmt


Height 167 cm (5 ft 6 in) 175 cm (5 ft 9 in)

Age 100% 75% 100% 75%

15 402 302 411 308

20 428 321 437 328

25 441 331 451 338

30 446 335 456 342

35 445 334 454 341

40 439 329 449 337

45 431 323 440 330

50 419 314 428 321

55 407 305 415 311

60 393 295 401 301

65 378 283 386 289

70 363 272 371 278

75 348 261 355 266

80 334 250 340 255

85 319 239 325 244

18

Assmt


Height 183 cm (6 ft)

Age 100% 75%

15 418 313

20 445 334

25 459 344

30 465 349

35 463 347

40 457 343

45 448 336

50 436 327

55 323 317

60 408 306

65 393 295

70 378 284

75 362 271

80 346 260

85 331 248

19

Assmt

Male Peak Flow Rate (L/min)

Height 160 cm (5 ft 3 in) 167 cm (5 ft 6 in)

Age 100% 75% 100% 75%

15 485 364 498 374

20 540 405 555 416

25 575 431 591 443

30 594 446 611 458

35 601 451 618 463

40 599 449 615 461

45 590 443 606 454

50 575 431 591 443

55 557 418 572 429

60 536 402 550 412

65 513 385 527 395

70 490 367 503 377

75 466 349 478 359

80 441 331 453 340

85 416 313 429 322

20

Assmt


Height 175 cm (5 ft 9 in) 183 cm (6 ft )

Age 100% 75% 100% 75%

15 511 383 524 393

20 571 428 586 439

25 608 456 624 468

30 628 471 645 484

35 636 477 653 490

40 633 475 650 488

45 623 467 640 480

50 608 456 624 468

55 588 441 603 452

60 566 425 581 436

65 542 407 556 417

70 517 388 530 398

75 491 368 503 377

80 465 349 477 358

85 440 330 451 338

Assmt

21

22

Assmt


Height 190 cm (6 ft 3 in)

Age 100% 75%

15 535 401

20 601 451

25 637 478

30 659 494

35 666 499

40 664 498

45 653 490

50 637 478

55 616 462

60 593 445

65 567 425

70 541 406

75 514 385

80 487 365

85 460 345

Source: HSE National Asthma Care Programme.

23

Primary survey

Primary Survey

Clinical status decision

Life threatening

Serious, not life threatening

Non-serious, or non-life threatening

CAcBC for trauma

CAB for medical

Control catastrophic haemorrhage

Scene safety Scene survey

Scene situation

Check responsiveness

Assmt

Assmt

24

Spinal immobilisation decision

1. Any dangerous mechanism?

•Fall≥1meter/5steps•Axialloadtohead•MVC>100Km/hour,rolloverorejectionfromvehicle•BicycleorATVcollision•Pedestrianvvehicle

2. Ensure patient is low risk

•Simplerear-endMVC(excludingpushintooncomingtrafficorhitbybusortruck)•Noneckorbackpain•Absenceofmidlinec-spineorbacktenderness

3. Ensure that all factors for spinal injury rule-out are present:

If in doubt, immobilise

I

M

M

O

B

I

L

I

S

E

If any

If not

If not

• GCS=15• Communicationeffectivewithpatient (notintoxicatedwithalcoholordrugs)• Nodangerousmechanism,distractinginjury ofpenetratingtrauma• Nonumbnessortinglinginextremities• Nomidlinepainortenderness• Patientvoluntaryabletoactivelyrotateneck 45degreesleftandright,painfree• Patientcanwalkpainfree

25

Stroke FAST assessmentF – Facial weakness •Canthepatientsmile? •Hasthemouthoraneyedrooped? •Whichside?

A – Arm weakness •Canthepatientraisebotharmsandmaintainfor5seconds?

S – Speech problems •Canthepatientspeakclearlyandunderstandwhatyousay?

T – Time when last normal •Onsetlessthan4.5hours

Don’t forget to check glucose!

RefertoFAST+inASHICEmessage.

Assmt

Assmt

Trauma Assessment

Cardiopulmonary function

Measured value

Score

Respiratory Rate(per min)

10-29 4

>29 3

6-9 2

1-5 1

None 0

Systolic Blood Pressure (mm Hg)

≥90 4

76-89 3

50-75 2

1-49 1

NoBP 0

Glasgow Coma Scale 13-15 4

9-12 3

6-8 2

4-5 1

3 0Triage revised trauma score<11=Lifethreatening11=Serious,notlifethreatening12=Non-seriousorlifethreatening

Markers for multi-system trauma GCS <13 HeartRate >120SystolicBP <90 RevisedTraumaScore <12RespiratoryRate<10or>29 MechanismofInjury

26

PAEDIATRIC

PAEDIATRIC28 Burns-Paediatric29 Paediatricadvancedairwaysizes30 Paediatricanalgesiaoptions31 FLACCScale32 Wong-Bakerfaces33 Paediatricassessment34 Paediatricvalues35 PeakExpiratoryFlowRate-Paediatric36 WETFAGCalculations

Burns – Paediatric Wallace’s Rule of Nines

Palm of patient’s hand = approximately 1% TBSA

Cooling time for burns 15 min. Chemical burns 20 min.

Paediatric (≥ 5 years): >10%TBSAburnedand/ortime

frominjurytoED>1hour=IVinfusionofNaCl

Caution with burns gel if > 10% TBSA

18%

9%9%

14%

14%

Front 18%Back 18%

Infant

28

Paed

Paediatric advanced airway sizes

Age ETT size LMA size I-gel size LTI size

2years 4.5mm 2 1.5 1

3years 4.5mm 2 2 2

4years 5mm 2 2 2

5years 5mm 2 2 2

6years 5.5mm 2.5 2 2

7years 5.5mm 2.5 2 2

8years 6mm 2.5 2 2

9years 6mm 2.5 2.5 2.5

10years 6.5mm 2.5 2.5 2.5

11years 6.5mm 3 3 2.5

12years 7mm 3 3 2.5

13years 7mm 3 3 2.5

14years 7.5mm 3 3 2.5

15years 7.5mm 4 3 3

1. Diameter of ET tube = diameter of patient’s little finger 2. ET size = (age / 4) + 4 29

Paed

Paediatric analgesia optionsNon-pharmacological ReassuranceDistractiontherapySplinting

The“PHECCpainladder”ismodelledontheWorldHealthOrganisationpainladderforpainrelief.

• Mild pain: OraladministrationofParacetamol.• Moderate pain: inhaledEntonox®and/oracombinationof ParacetamolandIbuprofen.• Severe pain: Morphine,Fentanyl and/orEntonoxuntil thepatient’spain istolerable.Thisthree-stepapproachtoadministeringtherightmedicationintherightdoseattherighttimeis80-90%effective.

Non-opioids Entonox®Paracetamoland/orIbuprofen

Opioids MorphinePOMorphineIVFentanylIN

30

Pain assessment:•<5yearsuseFLACCscale•5-7yearsuseWong-Bakerscale•≥8yearsuseanaloguepainscale

Paed

FLACC Scale (for less than 5 years)

0 1 2

Face Noparticularexpresionorsmile.

Occasionalgrimaceorfrown,withdrawn,disinterested.

Frequenttoconstantfrown,clenchedjaw,quiveringchin.

Legs Normalpositionorrelaxed.

Uneasy,restless,tense.

Kickingorlegsdrawnup.

Activity Lyingquietly,normalposition,moveseasily.

Squirming,tense,shiftingbackandforth,hesitanttomove,guarding.

Arched,rigidorjerking,fixedposition,rubbingofbodyparts.

Cry Nocrymoan(awakeorasleep).

Moansorwhimpers,occasionalcries,sighsorcomplaint.

Criessteadily,screams,sobs,moans,groans,frequentcomplaints.

Consolability Clam,content,relaxed,needsnoconsoling.

Reassuredbyhugging,talkingto,ordistracting.

Difficulttoconsoleorcomfort.

0 =No Pain

1 - 3 =Mild

4 - 6 =Moderate

7 - 10 =Severe

31

Paed

Wong-Baker faces Wong-Baker faces for 5 to 7 years Reference: From Wong D. L., Hockenberry-Eaton M., Wilson D., Wilkelstein M. L., Schwartz P.: Wong’s Essentials of Paediatric Nursing, ed 6, St. Louis, 2001, p1301.Copyrighted by Mosby, Inc. Reprinted by permission.

0 No Hurt

6 Hurts Even More

2 Hurts Little Bit

8 Hurts Whole Lot

4 Hurts Little More

10 Hurts Worse

32

Paed

Paediatric assessment Paediatric Assessment Triangle (PAT)

Characteristics of appearance

Features

Tone

Ishemovingorvigorouslyresistingexamination?Doeshehavegoodmuscletone?Orishelimp,listlessorflaccid?

Interactiveness

Howalertishe?Howreadilydoesaperson,objectorsounddistracthimordrawhisattention?

Consolability

Canhebeconsoledorcomfortedbythecaregiver?Orishiscryingandunrelievedbygentlereassurance?

Look/Gaze Doeshefixhisgazeonaface?Oristhereaglassy-eyedstare?

Speech/Cry Ishisspeechorcrystrongandspontaneous?Orisitweak,muffledorhoarse?

Work of breathing:Rate,nasalflaring,grunting&recession.

Circulation to skin:Capillaryrefill,palor,mottling&temperature.

Appe

aran

ce

Circulation to SkinW

ork of Breathing

33

Paed

Paediatric values Normal values

Age Pulse Respirations Sys BP

Infant(<1) 100-160 30-60

Toddler(1-3) 90-150 24-40 80-95

Pre-school(3-5) 80-140 22-34 80-100

Schoolage(>5) 70-120 18-30 90-110

Rememberimportanceofcuffsizeforbloodpressure:cuffwidth(2/3ofshouldertoelbowdistance)andcufflength(2/3oflimbcircumference).

Signs of inadequate perfusion •Coolextremities •Mottling•Delayedcapillaryrefill•Diminished/absentperipheralpulses•Tachycardia•Irritability/confusion/ALoC

Acute severe asthma Anyoneofthefollowing:Inabilitytocompletesentencesinonebreathortoobreathlesstotalkorfeed.

Respiratoryrate:>30/minfor>5yearsold >50/minfor2to5yearsold

Heartrate: >120/minfor>5yearsold >130/minfor2to5yearsold

34

Paed

Peak Expiratory Flow Rate - Paediatric

Age Predicted 75% 50% 33%

2years 90L/min 68L/min 45L/min 30L/min














Peak Expiratory Flow paediatric calculation: (Agex30)+30

35

Paed

5 yr 6 yr 7 yr 8 yr 9 yr 10 yr

W (Kg) 18 25 28 31 34 37

E (J) 72 100 112 124 136 148

T (mm) 5 5.5 5.5 6 6 6.5

10mL 180 250 280 310 340 370

20mL 360 500 560 620 680 740

mg 0.2 0.3 0.3 0.3 0.3 0.4

mL 1.8 2.5 2.8 3.1 3.4 3.7

G (mL) 90 125 140 155 170 185

WETFAG Calculations

36

Neo 6 mts 1 yr 2 yr 3 yr 4 yr

W (Kg) 3.5 6 10 12 14 16

E (J) 14 24 40 48 64 76

T (mm) 3 3.5 4 4.5 4.5 5

10mL 35 60 100 120 140 160

20mL contraindicated

120 200 240 280 320

mg 0.04 0.1 0.1 0.1 0.1 0.2

mL 0.4 0.6 1.0 1.2 1.4 1.6

G (mL) 17.5 30 50 60 70 80

A

F

A

F

Paed

11 yr 12 yr 13yr 14 yr 15yr

W (Kg) 40 43 46 49 52

E (J) 150 150 150 150 150

T (mm) 6.5 7.0 7.0 7.0 7.0

F 10mL 400 430 460 490 520

20mL 800 860 920 980 1,000

A mg 0.4 0.4 0.5 0.5 0.5

mL 4.0 4.3 4.6 4.9 5.2

G (mL) 200 215 230 245 250

W = weight(neo-3.5Kg,6months-6Kg, 1-5(agex2)+8,>5-(agex3)+7)E = energy(4J/Kg),(≥8years=150J)T = tubesize(age+4)/4F = fluids(20ml/Kg,neonate10ml/Kg)A = adrenaline(Epinephrine1:10,000)(0.01mg/Kg)G = glucose(5ml/Kg)

WETFAG Calculations....contd.

TheMedicalAdvisoryCommitteehasapprovedtheroundingofmedicationvolumestoonedecimalpoint.

37

F

A

Notes

38

MAJOR EMERGENCY

MAJOR EMERGENCY

40 Majoremergencyoperations 43 TriageSieve 44 TriageSort

Major Emergency Operations

First Practitioner on site

Practitioner 1:a) ParkatthesceneassafetypermitsandinliaisonwithFireand

Gardaifpresent.b) LeavebluelightsonasvehicleactsasforwardControlPoint

pendingthearrivaloftheMobileControlVehicle.c) ConfirmarrivalatscenewithAmbulanceControlandprovidean

initialvisualreportstating‘MajorEmergencyStandbyorDeclared’.d) MaintaincommunicationswithPractitioner2.e) Leavetheignitionkeyinplaceandremainwithvehicle.f) CarryoutCommunications Officerroleuntilrelieved.

Practitioner 2:a) Carryoutascenesurvey.b) GivesituationreporttoAmbulanceControlusingMETHANE

messageformat.c) CarryoutHSE Controller of Operationsroleuntilrelieved.d) LiaisewithGardaControllerofOperationsandLocalAuthority

ControllerofOperations.e) SelectlocationforHoldingArea.f) Setupkeyareasinconjunctionwithotherprincipleresponse

agenciesonsite:–SiteControlPoint–CasualtyClearingStation–AmbulanceParkingPoint

If first on scene do not provide care or transport as this will inhibit the early and orderly organisation of on-scene command. 40

Maj Emg

41

Major Emergency Operations (cont.)Site layout

Maj Emg

42

Major Emergency Operations (cont.)

The priority is to establish CSCATTT in that order C – Command&controlS – SafetyC – CommunicationsA – AssessmentT – TriageT – TreatmentT – Transport

METHANE message format M – MajoremergencydeclaredorstandbyE – ExactlocationT – TypeofincidentH – HazardsinvolvedA – AccesstoandfromincidentN – Numberofcasualties(estimatedorexact)E – Emergencyservicesonsite(orrequired)

Site organisation

Maj Emg

Triage Sieve

Triage is a dynamic process.

Multiple casualty incident

Cancasualtywalk?

Iscasualtybreathing?

Open airway

one attempt

Respiratoryrate<10or

>29?

Breathingnow?

Priority 3 (Delayed)

Green

Dead

Priority 1 (immediate)

Red

Priority 2 (Urgent)Yellow

NO

NO

NO

NO

YES

YES

YES

NO

43

Capillaryrefill>2secorPulse>120?

YESYES

Maj Emg

Triage Sort

RevisedTraumaScore

Priority 3 (Delayed)

Green

Dead

Priority 1 (immediate)

Red

Priority 2 (Urgent)Yellow

Triage is a dynamic process.

Cardiopulmonary function

Measured value

Score Insert score

RespiratoryRate 10–29/min>29/min6-9/min1-5/minNone

43210

A

SystolicBloodPressure

≥90mmHg76-89mmHg50-75mmHg1-49mmHg

NoBP

43210

B

GlasgowComaScale

13-159-126-84-53

43210

C

Triage Revised Trauma Score A+B+C

1-10

11

12

0

Multiple casualty incident

44

MISCELLANEOUS

46 EMSprioritydispatchprotocols49 HypodermicneedlesforIMinjection50 Oxygencylindercapacity51 Poisoncare54 RadioreportforED55 IMIST-AMBOHandoverPrototcol56 SafeAeromedicalHelicopterUsage59 Sepsis61 TreatandReferral

EMS Priority Dispatch Protocolsa) AMPDSisusedtoidentifyanappropriatechiefcomplaintcode

followingcallerinterrogationbythecalltakers.

b) Dispatchcrossreference(DCR)codesarefixedbyAMPDS andcannotbechangedastheyarelinkedtosoftwareandfield responderguide,etc.

c) AMPDShassixdesignatedresponselevels(Echo,Delta,Charlie,Bravo,AlphaandOmega),whicharelinkedtotheDCRcodes.

d) PHECCpublishedanEMSPriorityDispatchStandardwhich designatesanappropriateresponsetoeachofthesix responselevels.

e) TheresponseleveltoeachDCRcodeisagreedbyPHECC’sPriorityDispatchCommittee(PDC).

f) TheresponseforspecificDCRcodesmeetsIrishclinical standards.

g) Ambulancecontrol,whenactivatingaresponsetoanincident, willgivetheDCRcodeforinformationabouttheincidentto thePractitioners(de-emphasisingtheletterinthecode)and aPDC-agreedresponselevelofEcho,Delta,Charlie,Bravo, AlphaorOmega.

h) DCRcodesanddispatchlevelsareupdatedregularly.

46

EMS Priority Dispatch Protocols (cont.)Clinical Status

Code Description Essential Response

Response to Scene

1Life

threatening

Echo Lifethreatening–Cardiacorrespiratoryarrest

AmbulancewithminimumParamedic

Lightsandsiren

Delta Lifethreateningotherthancardiacorrespiratoryarrest

2Seriousnotlife

threatening

Charlie Seriousnotlifethreatening–immediate

Bravo Seriousnotlifethreatening–urgent

3Non-seriousornotlifethreatening

Alpha Non-seriousornotlifethreatening

AmbulancewithminimumEMT

Lightsand/orsirendiscretion

Omega Minorillnessorinjury

Continued overleaf...

Misc

47

Misc

EMS Priority Dispatch Protocols (cont.)1. AbdominalPain/Problems2. Allergies(Reactions)/

Envenomations(Stings,Bites)

3. AnimalBites/Attacks4. Assault/SexualAssault5. BackPain(Non-Traumatic

orNon-RecentTrauma)6. BreathingProblems7. Burns(Scalds)/Explosion

(Blast)8. CarbonMonoxide/

Inhalation/HAZCHEM/CBRN

9. CardiacorRespiratoryArrest/Death

10.ChestPain(Non-Traumatic)11.Choking12.Convulsions/Fitting13.DiabeticProblems14.Drowning(Near)/Diving/

ScubaAccident15.Electrocution/Lightning16.EyeProblems/Injuries17.Falls18.Headache19.HeartProblems/AICD20.Heat/ColdExposure21.Haemorrhage/Lacerations

22. InaccessibleIncident/OtherEntrapment(Non-Vehicle)

23.Overdose/Poisoning(Ingestion)

24.Pregnancy/Childbirth/Miscarriage

25.Psychiatric/AbnormalBehaviour/SuicideAttempt

26.SickPerson(SpecificDiagnosis)

27.Stab/Gunshot/PenetratingTrauma

28.Stroke(CVA)29.Traffic/Transportation

Incidents30.TraumaticInjuries(Specific)31.Unconscious/Fainting

(Near)32.UnknownProblem

(Collapse3rdParty)33.Transfer/Interfacility/

PalliativeCare34.ACN(AutomaticCrash

Notification)35.HealthCareProfessional

Admission36. InfluenzaPandemic37. EmergencyInterfacility

Transfer

48Please consult your Field Responder Guide for specific details.

Misc

Hypodermic needles for IM injection

Patient Needle length Deltoid

mm Inches Gauge

<1month 16 5/8 25G

Children 25 1 23G

Women<90Kg 25 1 23G

Women>90Kg 38 1½ 21G

Men60-118Kg 25 1 23G

Men>118Kg 38 1½ 21G

49

Misc

Oxygen cylinder capacity

D pin index cylinder – 340 litres

15L/min =22minutes

12L/min =28minutes

6L/min =56minutes

CD cylinder – 460 litres

15L/min =30minutes

12L/min =38minutes

6L/min =76minutes

F cylinder – 1,360 litres

15L/min =1hour30minutes

12L/min =1hour53minutes

6L/min =3hours46minutes

50

Poison careNational Poison Information Centre – 01 8092566 (APstoconsidercontacting“onlinemedicaladvice”atCUH)

Poison Symptoms Medication Tx

Tricyclic(antidepressants)

WideQRSorseizure(anticholinergic)

SodiumBicarbonate

Organophosphate Bradycardiaandsalivation(cholinergic)

Atropine

Opiate Inadequaterespirations Naloxone

Caution: Paraquat – Oxygen therapy only if SpO2 < 92%.

Common Tricyclic (antidepressant) Medications

Medication Trade name

Clomipramine Anafranil

Dosulepin Prothiaden

Lofepramine Gamanil

Medication Trade name

Trazodone Molipaxin

Dothiepin Dothep

Trimipramine Surmontil

51

Misc

Misc

Poison care (cont.)ToxidromesToxidromesareclinicalsyndromesforthesuccessfulrecognitionofpoisoningpatterns.

Opiates ToxidromeMorphine,Heroin,Codeine(Solpadol),Distalgesic

Neurological Coma,seizures

Pupils Pinpoint(miosis)

Pulse Bradycardia

BP Hypotension

Respirations Depressed

Temperature Hypothermia

GI Constipation

Sympathomimetic Toxidrome (fightorflight)Cocaine,Amphetamines,MDMA,Ephedrine

Neurological Excitation,hallucinations,seizures

Pupils Dilated

Pulse Tachycardia,arrhythmias

BP Hypertension

Skin Warmandsweaty

Temperature Hyperthermia

GI Increasedbowelsounds

52

Misc

Poison care (cont.)Cholinergic ToxidromeOrganiphosphates(insecticides),Mushrooms

Neurological Confusion,drowsiness,coma,muscleweakness,twitching

Pupils Pinpointed(miosis)

Pulse Bradycardia/Tachycardia

Skin Sweating

Respirations Depression,bronchospasm

GI Salivation,Lacrimation,Urination,Defaecation,Gastricupset,Emesis(SLUDGE)

Anticholinergic Toxidrome(Hotasahare,dryasabone,redasabeetrootandmadasahatter).Antihistamines,Antidepressants,Phenothiazines,Mushroom,Plants

Neurological Agitated,fits,hallucinationsordrowsiness,hypertonia

Pupils Dilated

Pulse Tachycardia,arrhythmias

BP Hypertension

Skin Flushed,hotanddry

Temperature Hyperthermic

GI/GU Urinaryretention,drymouth

53

Misc

54

Radio Report for Emergency Dept.

WhenpatientsrequireurgentmedicalattentiononarrivalattheEDitisessentialthatanappropriatepatientreportprecedestheirarrival.

Thereportneedstobeclearandconciseyettransferallrelevantinformation.

ItisgoodpracticetoidentifyyourclinicallevelwhencommunicatingwiththeED.

TherecommendedformatisASHICE.

A — Ageofpatient S — Sexofpatient H — Historyofevent I — Illness/injury C — Condition(vitalsigns&reasonforpre-alerting) E — Estimatedtimeofarrival

Misc

55

IMIST-AMBO Handover Protocol

Misc

Safe Aeromedical Helicopter Usage

TherearecurrentlytwoservicesinIrelandprovidingaeromedicaltransport,theEAS(EmergencyAeromedicalService)andtheIrishCoastGuard.

Differentaircraftareoperatedbyeachorganisation.Regardlessofthetype,thesamesafetyprecautionsmustbeadheredto.

Requesting a Helicopter: Shouldyourequirehelicopterevacuation,yourrequestshouldgotoambulancecontrol,whowillliaisewiththeNACC(NationalAeromedicalCoordinationCentre).Anaccuratepatientlocationisvitalingettingthehelicoptertoyourlocationwithminimaldelay.IfyouhaveelectedtobeginyourjourneytohospitalbyroaditisnottoolatetorequestahelicopterandtheNACCwillprovidearendezvouspointforyoutomeetthehelicopter.

Helicopter is on the way:Thepatientmustremainintheambulancewiththedoorsclosed.Ideallyyouwillhavethepatientonacarryingsheetwhichwillaidswiftloadingofthepatientontothehelicopter.Althoughitisnotyourresponsibilitytopreparealandingsite,itishelpfultoknowwhatthehelicoptercrewwillbelookingforusingthis5pointchecklist:1.Aflatareaapproximatelythesizeofhalfafootballfie (atleast50mx50m).2.Nowirescrossingthelandingarea.3.Noobviouswiresimpedingtheflightpath.4.TheLZmustbefreeoflivestockandpeople.

56

57

Safe Aeromedical Helicopter Usage...contd.

5. Ifyougetachance,walktheareaandcollectFOD (ForeignObjectDebris)suchastrafficcones,clothing,rubbish anythingthatcanbeblownupinthehelicopter’sstrong downwashandcauseahazardtothehelicopterorthose around.

Confirmthe5pointchecklistwithambulancecontrol.Sportsfieldsoftenmakeideallandingsites.

The landing:Thehelicoptercrewwillgenerallylandintowind.Whileitislandingmakesurenociviliansapproachthelandingarea.Ifsafetyandsecurityiscompromisedthecrewwillnotland.Neverapproachahelicopterunlesssignalledbythecrewtodoso.

Loading the patient:TheAPorCrewmanwillcometoyouanddecidewhethertheaircraftwillshutdownorarotors-runningloadingwilltakeplace.Ifarotors-runningloadingistotakeplacethereareanumberofhazardstoconsider.ListentothebriefgiventoyoubytheAP/Crewmanandadheretoalldirectionsinrelationtosafety,PPEetc.

Take-Off:Clinicalpersonnelshouldremainatthelandingzonefor5minutesafterthehelicopterhastakenoff,thiswayifthehelicopterdevelopsatechnicalfaultearlyintheflightthecrewcanreturntotheLZandoffloadthepatienttoyou.

Safe Aeromedical Helicopter Usage...contd.Thefollowinggraphicillustrateskeysafetypointswhenoperatingwithhelicopters.

58

Sepsis

SIRS (Systemic inflammatory response syndrome):Theclincialsyndromethatresultsfromaderegulatedinflammatoryresponseortoanon-infectionsinsult.

Sepsis:SIRSthatissecondarytoinfectionthathasbeendisagnosedclinically.

Severe Sepsis:Sepsisplusatleastonesignofhypoperfusionororgandysfunctionthatisnewandnotexplainedbyotherknownetiologyoforgandysfunction.

Septic Shock:Severesepsisassociatedwithrefractoryhypotension(BP<90/60mmHg)despiteadequatefluidresuscitationand/orserumlactatelevel≥4.0mmol/L.

59

Sepsis identification tool

60

61

Treat and Referral

This means treating the patient according to current CPGs and then, once the patient is stabilised and meets the specific criteria, referring the patient to care other than the Emergency Department.

Clinical care pathway options

Clinical Care Pathways Rationale

CP1TreatandtransporttoanEmergencyDepartment.

SomeissuehasemergedduringpatientcarethatindicatethatEDisthemostappropriateclinicalcarepathway.Thiscouldincludethepatient’schangeofmind.

CP2Treat and referral for follow up care within 2 hours (arranged with local practitioner).

Thepatient,intheopinionoftheParamedicorAdvancedParamedic,doesnotrequireimmediatemedicalcare,howevertheyshouldbereviewedwithinapproximately2hours.TheParamedicorAdvancedParamedicmustarrangeanappointmentwiththelocalclinicalservicestoseethepatientwithinthistimeframe.IfanappointmentcannotbeobtainedthepatientmustbetransportedtoED.

Treat and Referral....contd.

Clinical care pathway options...contd

Clinical Care Pathways Rationale

CP3Treat and referral for follow up care within 48 hours or as soon as practicable.

The patient, having been stabilised, is advised to attend for follow up care within 48 hours. This care can be to a GP or a specialist clinic. The Paramedic or Advanced Paramedic bears no responsibility for a patient not adhering to the follow up advice.

CP4

Treat and referral to self-care with aftercare instructions.

Theissueissominorthatfurthercareisnotrecommended.Thismayresultfroma3rdpartycalling999withoutindentifyingtheseverityofthepatient.

62


Generic patient inclusion for Treat and Referral(T&R) clinical pathway Yes/No

1. ≥ 18 years and < 60 years. Yes/No

2. Not pregnant. Yes/No

3. Social support available. Yes/No

4. Demonstrates capacity and willing to engage. Yes/No

5. Reliable history. Yes/No

6. Vital signs within normal range (following care). Yes/No

7. Compliant with treatment, including own medications. Yes/No

8. Clinical status of “non-serious or non-life threat” (following care). Yes/No

9. Absence of self-inflicted injury or assault. Yes/No

10. No observed significant co-morbidity. Yes/No

11. 1st call for same condition within 30 days. Yes/No

12. Registered with a general practitioner. Yes/No

If yes to all generic patient inclusion criteria, proceed to specific exclusion criteria.

63


Clinical care pathway options...contd

Vital Sign Normal range

Respiratoryrate 12-20

SpO2 ≥96%

Inspired air Roomair

Systolic BP 111-150

Pulse 51-90

AVPU (CNS response) Alert

Temperature (°C) 36-37.5

64

Treat and Referral....contd.Specific patient exclusion for T&R following hypoglycaemia Yes/No

1. 1st ever hypoglycaemic event. Yes/No

2. < 30 days since last episode. Yes/No

3. Unable or unwilling to eat. Yes/No

4. Latest blood glucose < 4 mmol/L (after care). Yes/No

5. No serial improvement in blood glucose. Yes/No

6. On oral hypoglycaemics (sulphyonylurea tablets in particular). Yes/No

7. Recent medication change or additional medications prescribed (within 30 days). Yes/No

8. Seizures associated with hypoglycaemia. Yes/No

9. Insulin or oral hypoglycaemics overdose. Yes/No

65

Treat and Referral....contd.Specific patient exclusion for T&R following isolated seizure Yes/No

1. First seizure. Yes/No

2. Anti convulsant administered. Yes/No

3. Concurrent acute illness (including abnormal temperature). Yes/No

4. History of multi seizure presentation. Yes/No

5. History of recent head injury. Yes/No

6. Increased frequency of seizure. Yes/No

7. Seizure involving submersion or injury. Yes/No

8. Seizure type or pattern differing to usual presentation. Yes/No

9. Suspicion of overdose / ingestion / aspiration. Yes/No

10. Un-witnessed seizure. Yes/No

11. Two or more seizures within 24 hours. Yes/No

12. Glucose < 4 mmol/L. Yes/No

13. Recent medication change or additional medications prescribed (within 30 days). Yes/No

66

MEDICATIONS

MEDICATIONS Important Medication Information 68

A Amiodarone 70 Aspirin 72 Atropine 73

B Benzylpenicillin 74

C Clopidogrel 75 Cyclizine 76

D Dextrose 77 Diazepam 80

EEnoxaparin 83 Epinephrine 84

F Fentanyl 88 Furosemide 90

G Glucagon 91 GlucoseGel 92 GlycerylTrinitrate 93

H Hartmann’sSolution 94 Hydrocortisone 95

I Ibuprofen 98 IpratropiumBromide 100

L Lidocaine 101 Lorazepam 102

MMagnesiumSulphate 103 MidazolamSolution 104 Morphine 108

N Naloxone 112 Nifedipine 116 NitrousOxide&Oxygen 117

O Ondansetron 118 Oxygen 120

P Paracetamol 122

S Salbutamol 126 SodiumBicarbonate 127 SodiumChloride0.9% 128 Syntometrine 131

T Tenecteplase 132 Ticagrelor 134 TranexamicAcid 135

Commonly Prescribed Medications 136

Important medication information Thefollowingpagescontainquickreferencesformedications.Calculationsforpaediatric doses are based on a specific concentrationofthemedication,asoutlinedonthetopofeachpage.

Theformulaforestimatingweightis

neonate: 3.5 Kg

6 months: 6 Kg

1-5 years: (age in years x 2) + 8 Kg

> 5 years: (age in years x 3) + 7 Kg.

ToconvertlbstoKg,dividelbsby2.2.

Volumesareroundeduptothenearest0.1mL.

Wherecalculationsexceedtheadultdosetheadultdoseapplies.

If other concentrations of the medication are used these specific calculations do not apply, and the Practitioner is required to make the calculations by other means.

Want (mg)

Simple Version

Have (mg)x Vol (mL) = Vol to Administer (mL)

Dose Required (mg)

Formula for medication calculation

Dose in Container (mg)x Vol of Solution (mL) = Vol to Administer (mL)

68

Notes

69

A - D

A - D

Medications

Amiodarone

Indications: Ventricularfibrillation(VF),ventriculartachycardia(VT),symptomatictachycardia(>150)

Adult dose: VF/VT:5mg/KgIV/IO(loadingdoseforcardiacarrest:300mgand150mgsupplementarydose).

Symptomatictachycardia:150mgIV(in100mLD5W).

Paediatric dose: VF/VT:5mg/KgIV/IO.

Contraindications: KnownhypersensitivitytoIodine,KSAR.

Side effects: Inflammationofperipheralveins,BradycardiaandAVconductingabnormalities.

Additional information: Ifdiluted,mixwithDextrose5%.MaybeflushedwithNaCl

Forcardiacarrestdonotdilute,administerdirectlyfollowed

byaflush.

Drawupveryslowly.

70

71

Amiodarone calculations

Paediatric dose: 5mg/Kg

Concentration: 300mg/10mL

Age Weight mg mL

Neonate 3.5Kg 17.5mg 0.6mL

6months 6Kg 30mg 1.0mL

1year 10Kg 50mg 1.7mL

2years 12Kg 60mg 2.0mL














A - D

A - D

Aspirin

Indications: CardiacchestpainorsuspectedMyocardialInfarction(MI).

Adult dose: 300mgtabletPO.

Paediatric dose: Contraindicated.

Contraindications: Activesymptomaticgastrointestinal(GI)ulcer,bleedingdisorder(e.g.haemophilia),KSAR,patients<16years.

Side effects: Epigastricpainanddiscomfort,bronchospasm,gastrointestinalhaemorrhage.

Additional information: Aspirin300mgisindicatedforcardiacchestpainregardlessifpatienthastakenanticoagulantsorisalreadyonAspirin.IfthepatienthasswallowedanAspirin(entericcoated)preparationwithoutchewingit,thepatientshouldberegardedasnothavingtakenanyAspirin;administer300mgPO.

72

A - D

Atropine

Indications: Symptomaticbradycardia,Cholinergicpoisonwithbradycardiaandsalivation.

Adult dose: Cholinergicpoisonwithbradycardiaandsalivation:1mgIV.Repeatat5minintervalstoensureminimalsalivarysecretions.

SymptomaticBradycardia:0.6mg(600mcg)IV.Repeatat

3-5minintervalstoMax3mg.

Paediatric dose: Notindicated.

Contraindications: KSAR,post-cardiactransplantation.

Side effects: Tachycardia,drymouth,dilatedpupils.

Additional information: Accidentalexposuretoeyescausesblurredvision.

73

Benzylpenicillin

Indications: Severesepsis-Adult.

Suspectedorconfirmedmeningococcalsepsis-Paediatric.

Adult dose: 1,200mgIV/IO/IM.

Paediatric dose: <1yr:300mgIV/IO/IM.

1-8yrs:600mgIV/IO/IM.

>8yrs:1,200mgIV/IO/IM.

Contraindications: KSAR.

Side effects: Gastrointestinaldisturbances,hypersensitivityreactions.

Additional information: AlsocalledPenicillinG.

74

A - D

Clopidogrel

Indications: STElevationMyocardialInfarction(STEMI)ifpatientisnotsuitableforPPCI.

Adult dose: 300mgPO.

≥75years:75mgPO.


Contraindications: KSAR,activepathologicalbleeding,severeliverimpairment.

Side effects: Abdominalpain,dyspepsia,diarrhoea.

Additional information:Ifapatienthasbeenloadedwithananti-plateletmedication(otherthanAspirin),priortothearrivalofthepractitioner,thepatientshouldnotbeadministeredClopidogrel.

75

A - D

A - D

76

Cyclizine

Indications: Management,preventionandtreatmentofnauseaandvomiting.

Adult dose: 50mgslowIV/IO/IM.



Side effects: Tachycardia,drymouthandsedation.

A - D

77

Dextrose 5% solution

Indications: UseasadilutantforAmiodaroneinfusion

Adult dose: DiluteappropriatedoseofAmiodaronein100mLor500mL.



Side effects: NecrosisoftissuearoundIVaccess.

Additional Information: ParamedicsareauthorisedtocontinuetheestablishedinfusionintheabsenceofanAdvancedParamedicordoctorduringtransportation.

A - D

78

Dextrose 10% solution

Indications: Hypoglycaemicemergency.Bloodglucose<4mmol/L.

Adult dose: 250mLIV/IOinfusion(repeatx1prn).

Paediatric dose: 5mL/KgIV/IO(repeatx1prn).


Side effects: NecrosisoftissuearoundIVaccess.

Additional information: AlsocalledGlucose.

Cannulapatencywillreducetheeffectoftissuenecrosis.

A - D

79

Dextrose 10% calculations

Paediatric dose: 500mg/Kg(5mL/Kg)

Concentration:50g/500mL

Age Weight g mL

Neonate 3.5Kg 1.75g 17.5mL

6months 6Kg 3g 30mL

1year 10Kg 5g 50mL

2years 12Kg 6g 60mL

3years 14Kg 7g 70mL

4years 16Kg 8g 80mL

5years 18Kg 9g 90mL

6years 25Kg 12.5g 125mL

7years 28Kg 14g 140mL









A - D

Diazepam IV

Indications: Seizure.

Adult dose: 5mgIV/IO(repeatx1prn).

Paediatric dose: 0.1mg/KgIV/IO(repeatx1prn).

Contraindications: Respiratorydepression,KSAR,shock,depressedvitalsignsoralcoholrelatedALoC.

Side effects: Hypotension,respiratorydepression,drowsinessandlight-headedness(thenextday).

Additional information: DiazepamIV/IOshouldbetitratedtoeffect.

ThemaximumdoseofDiazepamincludesthatadministeredbycarerpriortoarrivalofPractitioner.

80

A - D

Diazepam IV calculations

Paediatric dose: 0.1mg/Kg

Concentration:10mg/2mL

Age Weight mg mL


6months 6Kg 0.6mg 0.1mL

1year 10Kg 1.0mg 0.2mL

2years 12Kg 1.2mg 0.2mL














81

A - D

Diazepam Rectal Solution

Indications: Seizure.

Adult dose: 10mgPR(repeatx1prn).Max20mgPR.

Paediatric dose: <3years:2.5mgPR.

3-7years:5mgPR.

≥8years:10mgPR.

Repeatallx1after5minsifseizurepersistsorreoccurs.

Contraindications: Respiratorydepression,KSAR,shock,depressedvitalsignsoralcoholrelatedALoC.

Side effects: Hypotension,respiratorydepression,drowsinessandlight-headedness(thenextday).

Additional information: Beawareofmodestyofpatient.

Shouldbeadministeredinthepresenceofa2ndperson.

Eggandsoyaproteinsareusedinthemanufactureofdiazepamrectalsolution;allergiestotheseproteinsmaybeencountered.

ThemaximumdoseofDiazepamincludesthatadministeredbycarerpriortoarrivalofPractitioner.

82

83

Enoxaparin sodium solution

Indications: AcuteST-segmentElevationMyocardialInfarction(STEMI)immediatelyfollowingtheadministrationofathrombolyticagent.

Adult dose: 30mgIVbolus(>75years:0.75mg/KgSC).


Contraindications: Activemajorbleedingdisordersandconditionswithahighriskofuncontrolledhaemorrhage,includingrecenthaemorrhagicstrokeorsubduralhaematoma;injaundice;activegastricorduodenalulceration;hiatalulceration;threatenedabortion,orretinopathy,hypersensitivitytoEnoxaparinorotherLowMolecularWeightHeparins,KSAR.

Side effects: Pain,haematomaandmildlocalirritationmayfollowthesubcutaneousinjection.

Additional Information: Donotstoreabove25degreesCelsius.Donotrefrigerateorfreeze.MedicalPractitioners:Duetothesignificantincreasedriskofintra-cerebralbleedforpatientsaged>75yearsDONOTadministerIVEnoxaparin.Enoxaparin0.75mg/KgSC(Max75mgSC)istherecommendeddoseandroute.

E - H

Epinephrine (1:10,000)

Indications: Cardiacarrest.

Paediatricbradycardiaunresponsivetoothermeasures.

Adult dose: Cardiacarrest:1mgIV/IO(repeat3-5minprn).

Paediatric dose: Cardiacarrest:0.01mg/Kg(0.1mL/Kg)IV/IO(repeat3-5minprn).

Bradycardia:0.01mg/Kg(0.1mL/Kg)IV/IO(repeatevery3-5minsprn).


Side effects: Innon-cardiacarrestpatients:palpitations,tachyarrhythmias,hypertension.

Additional information: N.B.Doublecheckconcentrationsonpackbeforeuse.

84

E - H

E - H

Epinephrine (1:10,000) calculations


Concentration:1mg/10mL

Age Weight mg mL


















85

E - H

Epinephrine (1:1,000)

Indications: Severeanaphylaxis.

Adult dose: 0.5mgIM(0.5mL).

EMT(andEFRassistpatient)0.3mg(Autoinjector).

All:repeatevery5minutesprn.

Paediatric dose: <6months:0.05mgIM(0.05mL)

6monthsto5years:0.125mgIM(0.13mL)

6to8years:0.25mgIM(0.25mL)

>8years:0.5mgIM(0.5mL)

EMT(andEFRassistpatient):

6months<10years:0.15mg(Autoinjector)

≥10years:0.3mg(Autoinjector)

All:repeatevery5minutesprn.

Contraindications: Nil.

Side effects: Palpitations,tachyarrthymias,hypertension,angina-likesymptoms.

Additional information: N.B.Doublechecktheconcentrationonpackbeforeuse.

86

Notes

E - H

87

E - H

Fentanyl

Indications: Acuteseverepaininpatients≥1yearold.

Adult dose: 0.1mgIN.(repeatx1after10minutesifseverepainpersists).

Paediatric dose: 0.0015mg/Kg(1.5mcg/Kg)IN.(repeatx1after10minutesifseverepainpersists.)

Contraindications: KnownFentanylhypersensitivity,alteredlevelofconsciousness,bilateraloccludednasalpassage,nasaltrauma,Epistaxis,Hypovolaemia.

Side effects: Sedation,Nausea,Vomiting,Respiratorydepression.

Additional information: CautionifpatienthastransdermalFentanylpatch.

Includeanadditional0.1mL,toallowfordeadspaceinMAD,inthecalculatedvolumerequired.

Administer50%volumeineachnostrilifmorethan1mL.

88

89

Fentanyl IN calculations (inclusive of 0.1 mL for MAD)Paediatric dose: 0.0015mg/KgConcentration:0.1mg/2mL

Age Weight mg mL

Neonate 3.5Kg

6months 6Kg
















Contraindicated

Contraindicated

E - H

Furosemide injection

Indications: Pulmonaryoedema.

Adult dose: 40mgslowIV.


Contraindications: Pregnancy,hypokalaemia,KSAR.

Side effects: Headache,dizziness,hypotension,arrhythmias,transientdeafness,diarrhoea,nauseaandvomiting.

Additional information: Protectfromlight.

90

E - H

91

Glucagon

Indications: HypoglycaemiainpatientsunabletotakeoralglucoseorunabletogainIVaccess,withabloodglucoselevel<4mmol/L.

Adult dose: 1mgIM.

Paediatric dose: ≤8years:0.5mgIM.

>8years:1mgIM.

Contraindications: Phaechromocytoma,KSAR.

Side effects: Rare:maycausehypotension,dizziness,headache,nauseaandvomiting.

Additional information: Maybeineffectiveinpatientswithlowstoredglycogene.g.prioruseinprevious24hours,alcoholicpatientswithliverdisease.

Storeinrefrigerator.

Protectfromlight.

E - H

E - H

92

Glucose Gel

Indications: Hypoglycaemia,bloodglucose<4mmol/L.

Adult dose: 10-20gbuccal.

Repeatprn.

Paediatric dose: ≤8years:5-10gbuccal.

>8years:10-20gbuccal.

Repeatprn.


Side effects: Maycausevomitinginpatientsunder5ifadministeredtooquickly.

Additional information: Glucosegelwillmaintainglucoselevelsonceraisedbutshouldbeusedsecondarytodextrosetoreversehypoglycaemia.

Proceed with caution: Patientswithairwaycompromise.Alteredlevelofconsciousness.

93

Glyceryl Trinitrate

Indications: Angina,suspectedMyocardialInfarction(MI),AdvancedParamedicandParamedic-pulmonaryoedema.

Adult dose: AnginaorMI:0.4mgsublingual

(repeat3-5minprn,toMax1.2mg).

Pulmonaryoedema:0.8mgsublingual(repeatx1prn).


Contraindications: SBP<90mmHg,Viagraorotherphosphodiesterasetype5inhibitors(Sildenafil,TadalafilandVardenafil)usedwithinprevious24hours,KSAR.

Side effects: Headache,transienthypotension,flushing,dizziness.

Additional information: Ifthepumpisneworhasnotbeenusedforaweekormore,thefirstsprayshouldbereleasedintotheair.

E - H

94

Hartmann’s Solution

Indications: WhenNaClisunavailableitmaybesubstitutedwithHartmann’sSolutionIV/IO,exceptforcrushinjuries,burns,renalfailureandhyperglycaemia.

Adult dose: SeeNaCl.

Paediatric dose: SeeNaCl.


Side effects: Ifadministeredinlargeamountsmaycauseoedema.

Additional information: Observecautionwithpatientswithhistoryofheartfailure.AlsocalledSodiumLactateIntravenousSolutionorCompoundRingerLactateSolutionforInjection.Warmfluidspriortoadministrationifpossible.

E - H

Hydrocortisone

Indications: Severeorrecurrentanaphylacticreactions.AsthmarefractorytoSalbutamolandIpratropiumBromide.ExacerbationofCOPD(AP).

Adrenalinsufficiency(P).

Adult dose: AnaphylacticreactionandexacerbationofCOPD(AP):200mgIV(infusionin100mLNaCl)orIM.Asthma(AP):100mgIV(infusionin100mLNaCl).Adrenalinsufficiency(P&AP):100mgIV(infusionin100mLNaCl)orIM.

Paediatric dose: Anaphylacticreaction(AP):<1year:25mgIV(infusionin100mLNaCl)orIM.1to5years:50mgIV(infusionin100mLNaCl)orIM.>5years:100mgIV(infusionin100mLNaCl)orIM.

Asthma(AP):

<1year:25mgIV(infusionin100mLNaCl).

1to5years:50mgIV(infusionin100mLNaCl).

>5years:100mgIV(infusionin100mLNaCl).Adrenalinsufficiency(P&AP):6monthsto≤5years:50mgIV(AP)(infusionin100mLNaCl)orIM(P).>5years:100mgIV(AP)(infusionin100mLNaCl)orIM(P).

95

E - H

Hydrocortisone ...contd

Contraindications: Nomajorcontraindicationsinacutemanagementofanaphylaxis.

Side effects: CCF,hypertension,abdominaldistension,vertigo,headache,nausea,malaise,hiccups.

Additional information: Intramuscularinjectionshouldavoidthedeltoidareabecauseofthepossibilityoftissueatrophy.

Dosageshouldnotbelessthan25mg.

IVisthepreferredrouteforadrenalcrisis.

96

E - H

97

Notes

I - N

I - NI - N

Ibuprofen

Indications: Mildtomoderatepain.

Adult dose: 400mgPO.

Paediatric dose: 10mg/KgPO.

Contraindications: Notsuitableforchildrenunder3months,patientwithhistoryofasthmaexacerbatedbyAspirin,pregnancy,pepticulcerdisease,KSAR.

Side effects: Skinrashes,gastrointestinalintoleranceandbleeding.

Additional information: IfIbuprofenadministeredinprevious6hours,adjustthedosedownwardbytheamountgivenbyothersourcesresultinginamaximumof10mg/Kg.

Cautionwithsignificantburnsorpoorperfusionduetoriskofkidneyfailure.

CautionifconcurrentNSAIDsuse.

98

I - N

Ibuprofen (Brufen Syrup) calculations



Age Weight mg mL

Neonate 3.5Kg Contraindicated

















99

I - N

I - N

Ipratropium Bromide

Indications: AcutemoderateasthmaorexacerbationofCOPDnotrespondingtoinitialSalbutamoldose.

Adult dose: 0.5mgNEB.

Paediatric dose: <12years:0.25mgNEB.

≥12years:0.5mgNEB.


Side effects: Transientdrymouth,blurredvision,tachycardia,headache.

100

Lidocaine

Indications: WhenAmiodaroneisunavailableitmaybesubstitutedwithLidocaineforVF/VTarrests.

Adult dose: 1-1.5mg/KgIV/IO(Max:3mg/Kg).


Contraindications: Nocontraindicationsforcardiacarrest.

Side effects: Drowsiness,dizziness,twitching,paraesthesia,convulsions,bradycardia,respiratorydepression.

Additional information: LidocainemaynotbeadministeredifAmiodaronehasbeenadministered.

101

I - N

I - N

Lorazepam

Indications: Combativewithhallucinationsorparanoiaandrisktoselforothers.

Adult dose: 2mgPO.


Contraindications: Historyofsensitivitytobenzodiazepines,severehepaticorpulmonaryinsufficiency,suspectedsignificantalcoholand/orsedativesingested,KSAR.

Side effects: Drowsiness,confusion,headache,dizziness,blurredvisionandnausea/vomiting.

Onrareoccasions–hypotension,hypertension.

102

I - N

Magnesium Sulphate Injection

Indications: Torsadesdepointes,persistentbronchospasm,seizureassociatedwitheclampsia.

Adult dose: Pulselesstorsadesdepoints:2gIV/IO.

Torsadesdepointes:2gIV(infusionin100mLNaCl).

Persistentbronchospasm:2gIV(infusionin100mLNaCl).

Seizureassociatedwithpre-eclampsia:4gIV(infusionin100mLNaCl).


Contraindications: Noneincardiacarrest,KSAR.

Side effects: Decreaseddeep-tendonreflexes,respiratorydepression,bradycardia,hypothermia.

103

I - N

Indications: Seizures,combativewithhallucinationsorparanoiaandrisktoselforothers.

Adult dose: Seizureorcombativepatient:2.5mgIV/IO(AP)or5mgIMor10mgbuccalor5mgintranasal(P&AP).(repeatx1prn).Paramedic:IM,buccalorINonly.

Paediatric dose: Seizure:<1year:2.5mgbuccal1yearto<5years:5mgbuccal5yearsto<10years:7.5mgbuccal≥10years:10mgbuccal.or0.2mg/Kgintranasalor0.1mg/KgIV/IO.(repeatx1prn).Paramedic:buccalorINonly.

Contraindications: Shock,depressedvitalsignsoralcohol-relatedALoC,respiratorydepression,KSAR.

Side effects: Respiratorydepression,headache,hypotension,drowsiness.

Additional information: MidazolamIVshouldbetitratedtoeffect.Ensureoxygenandresuscitationequipmentareavailablepriortoadministration.Nomorethantwodosesbypractitioners.Practitionersshouldtakeintoaccountthedoseadministeredbycarerspriortoarrivalofpractitioner.Contraindications,otherthanKSAR,refertononseizingpatients.

Midazolam Solution

104

105

Midazolam IN calculations (inclusive of 0.1 mL for MAD)

Paediatric dose: 0.2mg/KgIntranasal


Age Weight mg mL


















I - N

I - N

106

Midazolam IV calculationsPaediatric dose: 0.1mg/KgIV/IO


Age Weight mg mL


















I - N

107

Notes

I - N

Morphine

Indications: Adult:Severepain(≥7onpainscale)

Paediatric:Severepain(≥7onpainscale)

Adult dose: 2mgIV/IO(repeatatnot<2minintervalsprntomax10mg,orformusculoskeletalpainmax16mg).

Upto10mgIM(ifnotcardiacchestpainandnoIVaccess).

Paediatric dose: 0.3mg/KgPO(max10mg)

0.05mg/KgIV/IO(repeatatnot<2minintervalsprntomax

0.1mg/Kg).

Contraindications: PO<1year,KSAR,labourpains,acuterespiratorydepression,acuteintoxication,systolicBP<90mmHg.

Side effects: Respiratorydepression,drowsiness,nauseaandvomiting,constipation.

Additional information: Usewithextremecautionparticularlywithelderly/young.Cautionwithacuterespiratorydistress.CautionwithreducedGCS.Notrecommendedforheadache.N.B.ControlledunderMisuseofDrugsAct(1977,1984).

108

I - N

109

Morphine calculations (dilute in 9 mL NaCl)

Paediatric dose: 0.05mg/KgIV/IO


Age Weight mg Dose


















I - N

Morphine calculations (Oromorph)

Paediatric dose: 0.3mg/KgPO


Age Weight mg Dose


6months 6Kg Contraindicated
















110

I - N

111

Notes

Naloxone

Indications: Inadequaterespirationsand/orALoCfollowingknownorsuspectednarcoticoverdose.

Adult dose: 0.4mgIV/IO(AP)0.4mgIM/SC(P)0.8mgIN(EMT)All:Repeatafter3minprntomax2mg.

Paediatric dose: 0.01mg/KgIV/IO(AP)0.01mg/KgIM/SC(P)0.02mg/KgIN(EMT)All:Repeatprntomaintainopioidreversaltomax0.1mg/Kgor2mg.


Side effects: Acutereversalofnarcoticeffectrangingfromnauseaandvomitingtoagitationandseizures.

Additional information: Usewithcautioninpregnancy.Administerwithcautiontopatientswhohavetakenlargedoseofnarcoticsorarephysicallydependent.Rapidreversalwillprecipitateacutewithdrawalsyndrome.Preparetodealwithaggressivepatients.

112

I - N

113

Naloxone IV/IO calculations

Paediatric dose:

0.01mg/KgIV/IO(AP)

Concentration: 0.4mg/1mL

Age Weight mg Dose


















I - N

114

Naloxone IN calculations (inclusive of 0.1 mL for MAD)Paediatric dose: 0.02mg/KgIN(EMT)


Age Weight mg Dose


















I - N

115

Naloxone IM/SC calculations

Paediatric dose:

IM/SC0.01mg/Kg(AP,P)


Age Weight mg Dose


















I - N

I - N

116

Nifedipine

Indications: Prolapsedcord.

Adult dose:20mgPO.


Contraindications: Hypotension,KSAR.

Side effects: Hypotension,headache,bradycardia,nausea&vomiting

Additional information: ClosemonitoringofmaternalpulseandBPisrequiredandcontinuousfoetalmonitoringshouldbecarriedoutifpossible.

O - T

117

Nitrous Oxide 50% & Oxygen 50%

Indications: Painrelief.

Adult dose: Self-administereduntilpainrelieved.

Paediatric dose: Self-administereduntilpainrelieved.

Contraindications: ALoC,chestinjury/pneumothorax,shock,recentscubadive,decompressionsickness,intestinalobstruction,inhalationinjury,carbonmonoxidepoisoning,KSAR.

Side effects: Disinhibition,decreasedlevelsofconsciousness,lightheadedness.

Additional information: Donotuseifpatientunabletounderstandinstructions.Incoldtemperatureswarmcylinderandinverttoensuremixofgases.AdvancedParamedicsmayusediscretionwithminorchestinjuries.Brandname:Entonox®.Hasanaddictiveproperty.CautionwhenusingEntonoxforgreaterthanonehourforSickleCellCrisis.

O - T

O - TO - T

118

Ondansetron

Indications: Management,preventionandtreatmentofnauseaandvomiting.

Adult dose:4mgslowIV.

Paediatric dose: 0.1mg/KgIVslowlytoMaxof4mg.


Side effects: Headache,sensationofwarmth,flushing,hiccups.

O - TO - T

119

Ondansetron calculations



Age Weight mg mL


















O - TO - T

120

Oxygen

Adult dose: CardiacandrespiratoryarrestorSickleCellCrisis:100%.Lifethreatsidentifiedduringprimarysurvey:100%untilareliableSpO2measurementobtainedthentitrateO2toachieveSpO2of94%-98%.ForpatientswithacuteexacerbationofCOPD,administerO2titratetoachieveSpO292%orasspecifiedonCOPDOxygenAlertCard.AllotheracutemedicalandtraumatitrateO2toachieveSpO294%-98%.

Paediatric dose: CardiacandrespiratoryarrestorSickleCellCrisis:100%.

Lifethreatsidentifiedduringprimarysurvey:100%untilareliableSpO2measurementobtainedthentitrateO2toachieveSpO2of96%-98%.

AllotheracutemedicalandtraumatitrateO2toachieveSpO2of96%-98%.

Contraindications: Bleomycinlunginjury.

Side effects: ProlongeduseofO2withchronicCOPDpatientsmayleadtoreductioninventilationstimulus.

Indications: Absence/inadequateventilationfollowinganacutemedicalortraumaticevent.

SpO2<94%adultsand<96%paediatrics,SpO2<92%forpatientswithacuteexacerbationofCOPD.

O - T

121

Oxygen ...contd

Additional information: AwrittenrecordmustbemadeofwhatOxygentherapyisgiventoeverypatient.

DocumentationrecordingoximetrymeasurementsshouldstatewhetherthepatientisbreathingairoraspecifieddoseofsupplementalOxygen.

ConsiderhumidifierifOxygentherapyforpaediatricpatientsis>30minuteduration.

Cautionwithparaquatpoisoning,administerOxygenifSpO2<92%.

Avoidnakedflames,powerfuloxidisingagent.

Paracetamol

Indications: Pyrexia,minorormoderatepain(1-6onpainscale)foradultandpaediatricpatients.

Adult dose: 1gPO.

Paediatric dose: >1month<1year:90mgPR(AP).

1-3years:180mgPR(AP).

4-8years:360mgPR(AP).

20mg/KgPO(AP,P&EMT).

Contraindications: KSAR,chronicliverdisease,<1monthold.

Side effects: Nil.

Additional information: ParacetamoliscontainedinParacetamolSuspensionandotherover-the-counterdrugs.

Consultwithparent/guardianinrelationtomedicationpriortoarrivalonscene.

ForPRuse,beawareofmodestyofpatient,shouldbeadministeredinpresenceofa2ndperson.

IfParacetamoladministeredinprevious4hours,adjustthedosedownwardbytheamountgivenbyothersourcesresultinginamaximumof20mg/Kg.

O - T

122

123

Paracetamol (Calpol) calculations



Age Weight mg mL


















O - T

Paracetamol 6+

Indications: Pyrexia,minorormoderatepain(1-6onpainscale)foradultandpaediatricpatients.

Adult dose: 1gPO

Paediatric dose: 20mg/KgPO(AP,PandEMT).

Contraindications: KSAR,chronicliverdisease,<1monthold.

Side effects: Nil.

Additional information: ParacetamoliscontainedinParacetamolSuspensionandotherover-the-counterdrugs.

Consultwithparent/guardianinrelationtomedicationpriortoarrivalonscene.

IfParacetamoladministeredinprevious4hours,adjustthedosedownwardbytheamountgivenbyothersourcesresultinginamaximumof20mg/Kg.

124

O - T

Paracetamol 6+ (Calpol) calculations



Age Weight mg mL


















125

O - T

126

Salbutamol

Indications: Bronchospasm,ExacerbationofCOPD,Respiratorydistressfollowingsubmersionincident.

Adult dose: 5mgNEB(or0.1mgmeteredaerosolsprayx5).

(repeatat5minprn).

Paediatric dose: <5years:2.5mgNEB(or0.1mgmeteredaerosolsprayx3).

≥5years:5mgNEB(or0.1mgmeteredaerosolsprayx5).

(repeatat5minprn).


Side effects: Tachycardia,tremors,tachyarrhythmias,highdosesmaycausehypokalaemia.

Additional information:ItismoreefficienttouseavolumizerinconjunctionwithanaerosolinhalerwhenadministeringSalbutamol.

IfanOxygendrivennebuliserisusedtoadministerSalbutamolforapatientwithacuteexacerbationofCOPDitshouldbelimitedto6minutesmaximum.

O - T

127

Sodium Bicarbonate

Indications: WidecomplexQRSarrhythmiasand/orseizuresfollowingTricyclicantidepressant(TCA)overdose,cardiacarrestfollowingTricyclicoverdose,cardiacarrestfollowingharnessinducedsuspensiontrauma.

Adult dose:1mEq/Kg(1mL/Kg8.4%solution).Max50mEq(50mL8.4%).



Side effects: Nilwhenusedforemergencies.

O - T

128

Sodium Chloride 0.9%

Indications:

IV/IOfluidforpre-hospitalemergencycare.

Adult dose: Keepveinopen(KVO)ormedicationflushforcardiacarrestprn.

Crushinjury,suspensiontrauma,PEAorAsystole:20mL/KgIV/IOinfusion.

Hypothermia:250mLIV/IOinfusion(warmedto40degreesCelsiusapprox),repeattomax1L.

#neckoffemur,sepsis,symptomaticbradycardia:250mLIVinfusion.

Decompressionillness,sepsiswithpoorperfusion:500mLIV/IOinfusion.

Shockfrombloodloss:500mLIV/IOinfusion.Repeatinaliquotsof250mLprntomaintainsystolicBPof90–100mmHg,120mmHg(headinjuryGCS≤8).

Burns:>25%TBSAand/or1hourfromtimeofinjurytoED,1,000mLIV/IOinfusion.>10%TBSAconsider500mLIV/IOinfusion

Adrenalinsufficiency,glycaemicemergency,heat-relatedemergency,SickleCellCrisis:1,000mLIV/IOinfusion.

Anaphylaxis:1,000mLIV/IOinfusion,repeatx1prn.

Post-resuscitationcare:1,000mLIV/IOinfusion(at4degreesCelsiusapprox).Ifpersistenthypotension,maintainSysBP>90mmHg.

O - T

O - T

129

Sodium Chloride 0.9% ....contd

Paediatric dose: Keepveinopen(KVO)ormedicationflushforcardiacarrestprn.Glycaemicemergency,neonatalresuscitation,SickleCellCrisis:10mL/KgIV/IOinfusion.Hypothermia:10mL/KgIV/IOinfusion(warmedto40degreesCelsiusapprox),repeatx1prn.Haemorrhagicshock:10mL/KgIV/IO,repeatprnifsignsofinadequateperfusion.Anaphylaxis:20mL/KgIV/IOinfusion,repeatx1prn.Adrenalinsufficiency,crushinjury,septicshock,suspensiontrauma,symptomaticbradycardia,Asystole/PEA:20mL/KgIV/IOinfusion.Post-resuscitationcare:20mL/KgIV/IOinfusionifpersistentpoorperfusion.Burns:>10%TBSAand/or>1hourfromtimeofinjurytoED:5–10years:250mLIV/IO.>10years:500mLIV/IO.

Contraindications:

KSAR.

Side Effects:

Excessivevolumereplacementmayleadtoheartfailure.

Additional information:

NaClistheIV/IOfluidofchoiceforpre-hospitalemergencycare.

ForKVOuse500mLpackonly.

130

Sodium Chloride 0.9% calculations

Paediatric dose: 20mL/Kg

Haemorrhagic shock & neonate: 10mL/Kg

Age Weight 10 mL/Kg 20 mL/Kg

Neonate 3.5Kg 35mL Contraindicated

6months 6Kg 60 120

1year 10Kg 100 200

2years 12Kg 120 240

3years 14Kg 140 280

4years 16Kg 160 320

5years 18Kg 180 360

6years 25Kg 250 500

7years 28Kg 280 560

8years 31Kg 310 620

9years 34Kg 340 680

10years 37Kg 370 740

11years 40Kg 400 800

12years 43Kg 430 860

13years 46Kg 460 920

14years 49Kg 490 980

15years 52Kg 520 1040

O - T

131

Syntometrine

Indications: Controlofpostpartumhaemorrhage.

Adult dose:1mLIM.


Contraindications: Severekidney,liverorcardiacdysfunction,sepsis,KSAR.

Side effects: Nauseaandvomiting,abdominalpain,headache,dizziness,cardiacarrhythmias.

Additional information: Ensurethatasecondfoetusisnotintheuteruspriortoadministration.

O - T

Tenecteplase

Indications: Patientconscious,coherentandunderstandstherapy.

Patientconsentobtained.

ConfirmedSTEMI.

PatientnotsuitableforPPCIfromatimeorclinicalperspective.

Adult dose:<60Kg:30mg(6mL).

≥60<70Kg:35mg(7mL).

≥70<80Kg:40mg(8mL).

≥80<90Kg:45mg(9mL).

≥90Kg:50mg(10mL).

Paediatric dose:Notindicated.

132

O - T

133

O - T

Tenecteplase ....contd

Contraindications: Haemorrhagicstrokeorstrokeofunknownoriginatanytime.Ischaemicstrokeinprevious6months.Centralnervoussystemdamageorneoplasms.Recentmajortrauma/surgery/headinjury(within3weeks).Gastro-intestinalbleedingwithinthelastmonth.Activepepticulcer.Knownbleedingdisorder.Oralanticoagulanttherapy.Aorticdissection.Transientischaemicattackinpreceding6months.Pregnancyandwithinoneweekpost-partum.Non-compressiblepunctures.Traumaticresuscitation.Refractoryhypertension(SysBP>180mmHg).Advancedliverdisease.Infectiveendocarditis.

Side effects: Haemorrhagepredominantlysuperficialattheinjectionsite,ecchymosesareobservedcommonlybutusuallydonotrequireanyspecificaction,stroke(includingintracranialbleeding)andotherseriousbleedingepisodes.

Additional Information:Enoxaparinshouldbeusedasantithromboticadjunctivetherapy.

Ticagrelor

Indications: IdentificationofSTElevationMyocardialInfarction(STEMI)iftransportingtoPPCIcentre.

Adult dose:Loadingdoseof180mgPO.


Contraindications: Hypersensitivitytotheactivesubstance(Ticagrelor)ortoanyoftheexcipients,activepathologicalbleeding,historyofintracranialhaemorrhage,moderatetoseverehepaticimpairment.

Side effects: Dyspnoea,epistaxis,gastrointestinalhaemorrhage,subcutaneousordermalbleeding,bruisingandproceduralsitehaemorrhage.

Otherundesirableeffectsincludeintracranialbleeding,elevationsofserumcreatinineanduricacidlevels.ConsultSmPCforafulllistofundesirableeffects.

Additional information: Specialauthorisation:AdvancedParamedicsandParamedicsareauthorisedtoadministerTicagrelor180mgPOfollowingidentificationofSTEMIandmedicalpractitionerinstruction.

Ifapatienthasbeenloadedwithananti-plateletmedication(otherthanAspirin),priortothearrivalofthepractitioner,thepatientshouldnothaveTicagreloradministered.

134

O - T

Tranexamic Acid

Indications: Suspectedsignificantinternalorexternalhaemorrhageassociatedwithtrauma.

Adult Dose: 1gIV/IO(infusionin100mLNaCl).

Paediatric Dose: Notindicated.

Contraindications: Hypersensitivitytotheactivesubstanceortoanyoftheexcipients,acutevenousorarterialthrombosis,historyofconvulsions,severehepaticimpairment.

Side Effects: Diarrhoea,vomiting,nausea.Otherundesirableeffectsincludevisualdisturbance,impairedcolouredvision,dizzinessandheadache.

Additional Information: Cautionwithheadinjury.

135

O - T

Commonly prescribed medications

Brand name Generic name Indication

Bata-adalat Atenolol Hypertension

Betnovatecream Betamethasone Inflammatoryskindisorder

Bisocor Bisoprolol Angina/heartfailure

Citalopram Citalopram Depression

ClarithromycinRanbaxy

Clarithromycin Infection(nopenicillin)

CentylK Bendroflumethazide Hypertension

Coversyl Perindopril Anti-hypertensive

Cozaar LozartanPotassium

Heartfailure

Crestor Rosuvastatin Hypercholesterolemia

Deltacortril Prednisolone Suppressionofinflammatorydisorders

Diamicron Gliclazide Diabetes

Diovan Valsartan Heartfailure

Dona Glucosamine Jointpain

Fastumgel Ketoprofen Osteoarthritis

Flagyl Metronidazole Anaerobicbacteria

Glucophage MetforminHydrochloride

DiabetesMellitus

Istin Amlodipine Hypertension

COMMONLY PRESCRIBED MEDICATIONS

136

Commonly prescribed medications ...contd


Lamictal Lamotrigine Seizurecontrol

Lexapro Escitalopram Depression

Lipitor Atorvastatin Hypercholesterolemia

Lipostat PravastatinSodium

Hyperlipidaemias

Losamel Omeprazole Duodenalulcer

Motilium Demperidone Anti-emetic

Nexium Esomeprazole Gastricoversecretionofhydrochloricacid

Omnexel Tamsulosin Benignprostatichypertrophy

Serc Betahistine Vertigo,tinnitus

Stilnoct Zolpidem Insomnia

Tritrace Ramipril Hypertension

Vibramycin Doxycycline Infection

Xanax Alprazolam Anxiety

Zimovane Zopiclone Insomnia

Zoton Lansoprazole Gastricoversecretionofhydrochloricacid

Zydol Tramadol Pain

137



138

Commonly prescribed anti-eplileptic medications


Ativan Lorazepam Add-onforallseizuretypes.Rescueuse.

Buccolam Midazolam Prolongedseizure.

Diamox Acetazolamide Hasaspecificroleintreatingepilepsyassociatedwithmenstruation.Itcanalsobeusewithotheranti-epilepticsfortonic-clonicandpartialseizures.

Epanutin Phenytoin Allformsofepilepsyexceptabsenceseizures.Serumlevelmonitoringessential.

Epilim

Epilimchrono

Epilimchronoshere

Episenta

SodiumValporate

Allformsofepilepsy.

Epistatusbuccal Midazolam Prolongedorclustersofallseizuretypes.

Rescueuse.

StatusEpilepticus.

139

Commonly prescribed anti-eplileptic medications ...contd


Felbatol Felbamate Addonforallseizuretypeswhichhavefailedallotheranti-epilepticdruguses.Usedunderstrictspecialistsupervision.

Frisium Clobazam Addonforallseizuretypes.

Generalisedtonic-clonicandpartialseizuresbuttolerancefrequentlydevelops.

Gabitril Tiagabine Addontreatmentforartialseizureswithorwithoutsecondarygeneralisationnotsatisfactorilycontrolledwithotheranti-epilepticmedication.

Inovelon Rufinamide AddontreatmentofseizuresinLennox-Gastauntsyndrome.




Keppra Levetiracetam Mono-therapyandadd-ontreatmentofpartialseizureswithorwithoutsecondarygeneralisationandforadd-ontherapyofmyoclonicseizures.

Lamictal Lamotrigine Mono-therapyandadd-ontreatmentofpartialseizuresandprimaryandsecondarilygeneralisedtonic-clonicseizures;seizuresassociatedwithLennox-Gastautsyndrome;mono-therapyoftypicalabsenceseizuresinchildren.

Lyrica Pregabalin Add-ontherapyforpartialseizureswithorwithoutsecondarygeneralisation.

Mysoline Primidone Allformsofepilepsyexceptabsenceseizures.


140



Rivotril Clonazepam Add-onforallseizuretypes.

Partialseizures,absencesandmyoclonicjerks.

Sabril Vigabatrin Initiatedandsupervisedbyappropriatespecialist,addontreatmentofpartialseizureswithorwithoutsecondarygeneralisationnotsafisfactorilycontrolledwithotheranti-epilepticdrugs;mono-therapyformanagementofinfantilespasms(West’ssyndrome).

Tegretol

TegretolRetard

Metformin

Carbamazepine

Partialandsecondarygeneralisedtonic-clonicseizures,primarygeneralisedtonic-clonicseizures.

141


142



Topamax Topiramate Mono-therapyandadd-ontreatmentofgeneralisedtonic-clonicseizuresorpartialseizureswithorwithoutsecondarygeneralisation;add-ontreatmentofseizuresinLennox-Gastautsyndrome.

Trileptal Oxcarbazepine Mono-therapyandadd-ontreatmentofpartialseizureswithorwithoutsecondarygeneralisedtonic-clonicseizures.

Vimpat Lacosamide Add-ontherapyinthetreatmentofpartial-onsetseizureswithorwithoutsecondarygeneralisation.




Zarontin

Emeside

Ethosuximide Typicalabsenceseizures;itmayalsobeusedinatypicalabsenceseizures.Rarelyusedformyoclonicseizures.

Zebinix Eslicarbazepine Add-ontreatmentinadultswithpartialseizures,withorwithoutsecondarygeneralisation.

Zonergan Zonisamide Add-ontreatmentfordrug-resistantpartialseizureswithorwithoutsecondarygeneralisation.

143


144

Commonly prescribed diabetes medications


Biguanides

Glucophage Metformin Ithelpstostoptheliverproducingnewglucose.

Thiazolidlinediones (glitazones)

Actos Pioglitazone Reducesthebody’sresistancetoinsulinallowingittoworkmoreeffectivelyatimprovingbloodglucosecontrol.

Sulfonlyure as

Amaryl Glimepiride Sulfonylureasworkbystimulatingthepancreastoreleasemoreinsulin.

Daonil Gilbenclamide

Diamicron

DiamicronMRGilclazide

Glibenese

MinodiabGilpizide

Tolbutamide Tolbutamide


Commonly prescribed diabetes medications ...contd


Alpha glu cosidase inhibitors

Acarbose Glucobay Theyworkbyslowingdownthedigestionofcarbohydratesfoundinstarchyfoods.

Miglitol Glyset

Prandial glucose regulator

Prandin Repaglinide Theystimulatethepancreaticbetacellstoproducemoreinsulinforthebody–similartoSulphonylureas.

Starlix Nateglinide

DPP-4 inhib itors

Januvia Sitagliptin Theyhelpstimulatetheproductionofinsulinwhenitisneededandreducetheproductionofglucagonbytheliverwhenitisnotneeded.

Galvus Vildagliptin

Onglyza Saxagliptin

145


Hospital contact numbers & PCR codes

Hospital Main Line ED PCR Code

Armagh

CraigavonAreaHospital

(048)38334444 (048)38332006 CAH

Cavan

CavanGeneralHospital

(049)4376000 (049)4376607 CGH

Clare

MidWesternRegionalHospital-Ennis

(065)6824464 (065)6863121 ERH

Cork

BantryGeneralHospital

(027)50133 (027)52929

BGH

CorkUniversityHospital

(021)4922000 (021)4920232 CUH

CorkUniversityMaternityHospital

(021)4920500 (021)4920598 CUMH

MallowGeneralHospital

(022)21251 (022)52506

MLGH

MercyHospitalCork (021)4271971 (021)4935241 MUH

SouthInfirmaryVictoriaHospitalCork

(021)4926100 n/a SIVH

146

HOSPITAL CONTACT NUMBERS & PCR CODES


Derry

AthnagelvinHospital (048)71345171 (048)71611379 AHD

Donegal

LetterkennyGeneralHospital

(074)9125888 (074)9123595

LGH

Down

DaisyHillHospital,Newry

(048)30835000 (048)30832406

DHH

Dublin

AMNCH(Tallaght)–Adult

(01)4142000

(01)4143601 AMNA

AMNCH(Tallaght)–Paediatric

(01)4142000 (01)4143510 AMNC

BeaumontHospital (01)8093000 (01)8092714 BHD

ConnollyHospitalBlanchardstown

(01)8213844

(01)6466250 CHD

CoombeWomen’sHospital

(01)4085200

(01)4085531 CWH

MaterMisericordiaeHospital

(01)8032000 (01)8032651

MMH

NationalChildren’sHospital(TempleSt)

(01)8784200 (01)8784829

TCH

147



Dublin (cont.)

NationalMaternityHospital,HollesSt

(01)6373100 n/a NMH

OurLady’sHospitalforSickChildren,Crumlin

(01)4096100

(01)4096346(01)4096326

OLHC

RotundaHospital (01)8171700 n/a RMH

RoyalVictoriaEyeandEarHospital

(01)6644600 (01)6343648 RVH

StJames’sHospital (01)4103000 (01)4162775 SJH

StMichael’s,DunLaoghaire

(01)2806901 (01)6639828 SMH

StVincent’sUniversityHospital

(01)2214000 (01)2214358 SVH

Fermanagh

ErneHospital,Enniskillen

(048)66382000

n/a EHE

Galway

PortiunculaHospital,Ballinasloe

(0909)648200

(0909)648248

PHB

UniversityHospitalGalway

(091)524222 (091)544556 UHG

148


149


Kerry

KerryGeneral (066)7184000 (066)7184395 KgH

Kildare

NaasGeneralHospital (045)849500 (045)849909 NGH

Kilkenny

StLuke’sGeneralHospital

(056)7785000 (056)7785403 SLK

Laois

MidlandRegionalHospital,Portlaoise

(057)8621364

(057)8696028 PMR

Limerick

LimerickMaternityHospital(StMunchin’s)

(061)327455

n/a

LRMH

MidwesternRegionalHospital

(061)482219 (061)482120 LRH

StJohn’sHospitalLimerick

(061)462222 (061)462130 SJHL



Louth

OurLadyofLourdesHospital

(041)9837601 (041)9832321 OLOL

Mayo

MayoGeneralHospital

(094)9021733 (094)9042377 MOGH

Offaly

TullamoreGeneralHospital

(057)9321501

(057)9328021

TMR

Sligo

SligoGeneralHospital

(071)9171111

(071)9174506 SGH

Tipperary

MidwesternRegionalHospital,Nenagh

(067)31491

(067)42311

NRH

SouthTipperaryGeneralHospital,Clonmel

(052)6177000

(052)6177042

STGH

150


151


Waterford

WaterfordRegionalHospital

(051)848000 (051)842445 WRH

Westmeath

MidlandRegionalHospital-Mullingar

(044)9340221

(044)9394121 MMR

Wexford

WexfordGeneralHospital

(053)9153000

(053)9153313

WGH


152

Notes

153

Notes

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il S

izes

1mm

2mm

3mm

4mm

5mm

6mm

7mm

8mm

9mm

cm 1

2 3

4 5

6 7

8 9

10 11

12

Ruler

Documents

Contents - phecit.ie Practice Guidelines/2014... · 3-5Kg 6-7Kg 10-11Kg12-14Kg15-18Kg19-22Kg24-28Kg 30-36Kg. Notes 6. ASSESSMENT ASSESSMENT 8 Aid to patient decision-making capacity