Attach AED defibrillation pads Commence CPR while AED is being prepared only if 2nd person available
30 Compressions : 2 ventilations.
ShockableVF or pulseless VT
Non - ShockableAsystole or PEA
Basic Life Support - AdultCPG 1a
Assess Rhythm
Give 1 shock
VF/ VT
Cardiac Arrest
Version D 0.9 K
PEAAsystoleGo to CPG 3a(i)
Go to CPG 3a(ii)
Go to CPG 3a
From CPG 4a
Arrest witnessed by practitionerYes
Commence CPR30 Compressions : 2 ventilations.
Continue CPR for 2 minutesAttach AED defibrillation pads
No
EMT P
AP
ROSC Go to CPG 19
Rhythm check *
* =/- pulse check: Pulse check after 2 minutes of CPR if potentially perfusing rhythm
Immediately resume CPRx 2 minutes
Change defibrillator to manual mode
AP
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
Request
ALS
Oxygen therapyOxygen therapy
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Basic Life Support – Child (1 to 8 years)CPG 1b
Cardiac arrest
ShockableVF or pulseless VT
Non - ShockableAsystole or PEA
Assess Rhythm
Give 1 shock
Version D 0.10 K
One rescuer CPR 30 : 2Two rescuer CPR 15 : 2 compressions : Ventilations
Immediately resume CPRx 2 minutes
Switch to manual2 J/kg
Apply paediatric system AED pads
From CPG xx
Oxygen therapy
EMT P
AP
AP
Commence CPR30 Compressions : 2 ventilations.
Continue CPR for 2 minutes
Rhythm check *
VF/ VT
Asystole / PEA
Go to CPG xx
Go to CPG xx ROSC Go to
CPG xx
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
Request
ALS
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Basic & Advanced Life Support – Infant (4 weeks to 1 year)CPG 1c
Cardiac arrest or
pulse < 60 per minute
Commence CPR30 Compressions : 2 ventilations.
Version D 0.9 K
Continue CPRAttach ECG monitor For two rescuer CPR use two
thumb-encircling hand chest compression
Assess Rhythm *VF or VT Asystole or PEA
Oxygen therapy
Immediate IO access if no IV in situContinue CPR
Epinephrine (1:10 000), 0.01 mg/kg IV/IORepeat every 3 to 5 min prn
Amiodarone, 5 mg/kg IV/IO
CPR for 2 minutes
Check blood glucose
One rescuer CPR 30 : 2Two rescuer CPR 15 : 2 compressions : Ventilations
EMT P
AP
Epinephrine1 mL/10 kg
Request
ALS
AP
CPR for 2 minutes
CPR for 2 minutes
Reassess Transport infant continuing CPR en-route
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
FromCPG xx
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Basic & Advanced Life Support - NeonateCPG 1d
Yes
Term gestationAmniotic fluid clearBreathing or cryingGood muscle tone
Pink colour
Birth
Assess respirations, heart rate & colour Breathing, HR > 100 & Pink
Assess Heart Rate
Breathing well, HR > 100 & Pink
Version D 0.8 K
Provide warmthPosition; Clear airway if necessaryDry, stimulate, reposition
Breathing, HR > 100 but Cyanotic
Provide positive pressure ventilation for 30 sec
Apnoeic or HR < 100
Persistent Cyanosis
No, Pink
Yes
CPR (ratio 3:1) for 30 sec
Provide warmthDry baby
From CPG XX
No
Epinephrine (1:10 000) 0.01 mg/kg IV/ IOEvery 3 to 5 minutes prnConsider blood
glucose check
P AP
Give Supplementary O2
HR 60 to 100HR < 60
Assess Heart Rate
HR < 60
HR 60 to 100Breathing well, HR > 100 & Pink
If mother is IVDU consider
Or
Naloxone, 0.01 mg/kg IV
Naloxone, 0.01 mg/kg IM
Request
ALS
Consider
NaCl 0.9%, 10 mL/kg IV/IO
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Foreign Body Airway Obstruction – AdultCPG 2a
Version D 0.5 K
One cycle of CPR
Conscious YesNo
one cycle of CPR
Yes
No
Encourage cough
No
Adequate ventilationsEffective
1 to 5 back blowsfollowed by
1 to 5 abdominal thrustsas indicated
No Yes
Ventilate
YesEffective
No
Yes
No
Was CPR, Abdominal
thrusts or O2 required
Consider discharge
into care of relative or
friend
Effective YesPersistent cough,
difficulty swallowing or sensation of object
in the throat
No
Yes
Consider
Oxygen therapy
EMT P
Conscious
Yes
No
Request
ALS
From CPG 1aFBAO
FBAO Severity
Severe(no cough)
Mild(cough present)
Are you choking?
Go to CPG xx
After each cycle of CPR open mouth and look for object
If visible attempt once to remove it
Foreign Body Airway obstruction – Paediatric (≤ 13 years)CPG 2b & 2c
Version D 0.8 K
ConsciousNo
Yes
YesEffective
One cycle of CPR
Open mouth and look for object
If visible one attempt to remove it
Attempt 5 Rescue Breaths
EMT P
Yes
Effective
1 to 5 back blows followed by 1 to 5 thrusts(child – abdominal thrusts)(infant – chest thrusts) as indicated
NoNo Conscious
Yes
Request
ALS
From CPG 1aFBAO
FBAO Severity
Severe(no cough)
Mild(cough present)
Are you choking?
Encourage cough
Breathing adequately
No
Consider
Oxygen therapy
Give rescue breaths
(10/ min)
Yes
After each cycle of CPR open mouth and look for object
If visible attempt once to remove it
Yes
one cycle of CPR
No
Effective
No
Go to CPG xx
VF or VT arrest
VF or Pulseless VT - Adult (> 8 years)CPG 3a
Epinephrine (1:10 000) 1 mg IV/ IOEvery 3 to 5 minutes prn
Amiodarone 300 mg (5 mg/kg) IV/ IO
Assess rhythm
Go to CPG 3a(i)Asystole
ROSC Go to CPG 19
No
No
No
No
No
Version D 0.10 K
No
Advanced airway management -
intubationAdvanced airway management –
LMA/LT
Consider mechanical CPR assist
Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute
If torsades de pointes, consider
Magnesium Sulphate 2 g IV
Amiodarone 150 mg (2.5 mg/kg) IV/ IO
Go to CPG xx
EMT P
AP
AP
P
CPR x 2 minutes
VF/VT
CPR x 2 minutes
Yes
3rd Shock
VF/VT
CPR x 2 minutes
Yes
4th Shock
VF/VT
CPR x 2 minutes
Yes
5th Shock
VF/VT
CPR x 2 minutes
Yes
6th Shock
Rhythm check *
Rhythm check *
Rhythm check *
Rhythm check *
VF/VT
Rhythm check *
2nd Shock
VF/VT
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
Yes
Rhythm check *
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
Yes
PEA
FromCPG xx
If no ALS available
Immediate IO access if IV not immediately accessible
AP
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Cardiac Arrest Asystole - AdultCPG 3a(i)
Asystole
Version D 0.10 K
Asystole No
Go to CPG 3a
P AP
Go to CPG 3b
No
Advanced airway management -
intubationAdvanced airway management –
LMA/ LT
AP
Consider mechanical CPR assist
Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute
VF/VT
Go to CPG xxPEA
Go to CPG 19Rosc
Epinephrine (1:10 000) 1 mg IV/ IOEvery 3 to 5 minutes prn
CPR x 2 minutes
Rhythm check *
Atropine 3 mg IV/ IO CPR x 2 minutes
Yes
Asystole
Rhythm check *
CPR x 2 minutes
Yes
Rhythm check *
If persistent asystole for greater than 20 minutes
consider ceasing resuscitation
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
Consider ceasing resuscitation only if patient is NOT:
Hypothermicor
Cold water drowningor
Poisoningor
Overdoseor
Pregnantor
< 18 years
FromCPG xx
Immediate IO access if IV not immediately accessible
AP
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Cardiac Arrest PEA -AdultCPG 3a(ii)
PEA
Version D 0.10 K
PEA
Yes
Atropine 1 mg IV/ IOEvery 3 to 5 minutes to 3 mg max
Yes
Advanced airway management -
intubationAdvanced airway management –
LMA/ LT
Consider mechanical CPR assist
Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute
Go to CPG 3aVF/VT
Go to CPG xxAsystole
Go to CPG 19
EMT P
AP
AP
P
Epinephrine (1:10 000) 1 mg IV/ IOEvery 3 to 5 minutes prn
CPR x 2 minutes
CPR x 2 minutes
Rhythm check *
CPR x 2 minutes
Rate less than 60
If persistent PEA continue CPR
No
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
ROSC
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
FromCPG xx
Rhythm check *
If no ALS available
No
Immediate IO access if IV not immediately accessible
AP
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
Cardiac Arrest - Asystole - Decision Tree3b
Version D 0.6 K
Follow local protocol for
care of deceased
NoYes
From CPG 3a(i)Asystole
Patient is;Hypothermic orCold water drowning orPoisoning/ Overdose orPregnant or < 18 years
Confirm Asystolic Cardiac ArrestUnresponsiveNo signs of life; absence of central pulse and respiration
Confirm that (two minutes of CPR and no shock advised) x 3 are completed
Record two rhythm strips x 10 sec duration
Record on ECG stripsPCR NoPatient’s nameDate and time
Complete PCR and flag for mandatory clinical audit
Yes
Inform Ambulance Control
If present, inform next of kin
Emotional support for relatives should
be considered before leaving the scene
Consider ceasingresuscitation effortsNo
Resuscitation continuous for at least 20 minutes
P AP
Advanced Paramedics: continue to end of asystole algorithm and make clinical decision on ceasing resuscitation
AP
Unwitnessedarrest & no CPR prior
to arrival
Yes
No
Recognition of Death - Resuscitation not indicated3c
Version D 0.10 K
Signs of Life YesGo to
Primary survey
Inform Ambulance Control
Inform next of kin, if present
Follow local protocol for care
of deceased
Emotional support for relatives should
be considered before leaving the scene
It is inappropriate to commence resuscitation
Apparent dead body
Complete all appropriate
documentation
P AP
Recent & reliable written or verbal information from
family, caregivers or patient, stating that patient did not want
resuscitation
Yes
Yes
No
Definitive indicators of death:1. Decomposition2. Obvious rigor mortis3. Obvious pooling (hypostasis)4. Incineration5. Decapitation6. Injuries totally incompatible with life7. Unwitnessed traumatic cardiac arrest following blunt trauma
No
Consensus between caregiver and
practitioner on not resuscitating
No
Yes
Definite indicators of
DeathNo
Yes
No
End stage of terminal illness
CPR x 2 minutes Immediate IO access if IV not immediately accessible
2nd Shock (4 joules/Kg)
VF/VT
CPR x 2 minutes
3rd Shock (4 joules/Kg)
VF/VT
CPR x 2 minutes
4th Shock (4 joules/Kg)
VF/VT
CPR x 2 minutes
5th Shock (4 joules/Kg)
VF/VT
CPR x 2 minutes
Yes
6th Shock (4 joules/Kg)
No
No
No
No
VF/VT confirmed
Rhythm check *
Rhythm check *
Rhythm check *
Rhythm check *
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
VF or Pulseless VT – Child (1 to 8 years)CPG 3d (i)
Version D 0.8 K EMT P
AP
Epinephrine (1:10 000), 0.01 mg/kg IV/IORepeat every 3 to 5 minutes prn
Amiodarone, 5 mg/kg, IV/IO
Consider advanced airway management
- intubation
AP
Check blood glucose
Go to CPG xxAsystole/ PEA
ROSC Go to CPG xx
Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute
FromCPG xx
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
VF/VT
Rhythm check *
No
Yes
Yes
Yes
If no ALS availableYes
No
Asystole / PEA - Child (1 to ≤ 13 years)CPG 3d(ii)
Asystole/ PEA confirmed
Version D 0.8 K
Epinephrine (1:10 000) 0.01 mg/kg IV/IORepeat every 3 to 5 minutes prn
Consider advanced airway management
- intubation
Check blood glucose
EMT P
AP
AP
CPR x 2 minutes
Rhythm check *
If persistent Asystole / PEAcontinue CPR
Asystole or PEA
Yes Go to CPG xxVF/VT
ROSC Go to CPG xx
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
Following successful Advanced Airway management:-i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 per minute
* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm
FromCPG xx
Immediate IO access if IV not immediately accessible
AP
Version D 0.7 K Traumatic Cardiac Arrest – AdultCPG 3e P AP
EMS Unwitnessed Traumatic Arrest
Apnoeic,Pulseless and
AsystolicNo
Yes
Blunt trauma
Yes
No
EMS Witnessed Traumatic Arrest
Patient respondsto resuscitation or
ALS provision within15 min
Go to appropriate
CPG
<18 yearsHypothermia
DrowningLightning strikeElectrical injury
No to all Request
ALS
Reference: Hopson, L et al, 2003, Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiac arrest, Position paper for National Association of EMS Physicians, Prehospital Emergency Care, Vol 7 p141-146
Low impact single vehicle
incident
No
Yes
Consider ceasing resuscitation No
Commence CPR and ALSYes to any
Rapid transport towards ALS
Yes
Take standard infection control precautions
Primary Survey Medical - AdultCPG 4a
Version D 0.6 K
Consider pre-arrival information
Scene safetyScene survey
Scene situation
No
Airway patent MaintainYesHead tilt/chin liftSuctionOPANPA
No
Pulse
Yes
Go to CPG 1a
Clinical status
AVPU assessment
Life threatening
Serious or Non serious
Go to CPG 5a
Airway obstructed No
Go to CPG 2a Yes
Assess responsiveness
ConsiderBreathing YesNo
Give 2 initial Ventilations
Oxygen therapy
Oxygen therapy
EMT P
AP
P
Go to appropriate
CPG
Adequate respirations No Go to
CPG xx
Yes
Request
ALS
Consider
Take standard infection control precautions
Primary Survey Trauma - AdultCPG 4aVersion D 0.6 K
Consider pre-arrival information
Scene safetyScene survey
Scene situation
No
Airway patent MaintainYes
Breathing Yes
Jaw thrust(Head tilt/chin lift)SuctionOPANPA
No
No
Pulse
Yes
Give 2 initial Ventilations
Go to CPG 1a
Mechanism of injury suggestive of spinal injury
C-spine controlYesNo
AVPU assessment
Airway obstructed NoGo to
CPG 2a Yes
Arrest major external haemorrhage
Assess responsiveness
Oxygen therapy
Expose & check obvious injuries
Treat life threatening injuries only at this point
Oxygen therapy
EMT P
AP
P
Clinical statusLife threatening
Serious or Non serious
Go to CPG 5a
Go to appropriate
CPG
Adequate respirations No Go to
CPG xx
Yes
Request
ALS
Take standard infection control precautions
Primary Survey Medical – Paediatric (≤ 13 Years)CPG 4b
Version D 0.8 K
Consider pre-arrival information
Scene safetyScene survey
Scene situation
Airway patent MaintainYes
Breathing Yes
Head tilt/ chin liftSuctionOPANPA (> 1year)
No
No
AVPU assessment
Airway obstructed No
Go to CPG 2b Yes
Oxygen therapy
Work of BreathingAppearance
Circulation to skin
Paediatric Assessment Triangle
Paediatric Assessment Triangle
Sick child
Yes
No
Give 2 effectiveVentilations up
to 5 attempts
Oxygen therapy
EMT P
AP
P
P
Confirm Primary Survey findings
Pulse/ circulation
Yes
Go to CPG 1b
No Yes
Go to CPG 1c
No
> 1 year
Pulse < 60Yes
No
Go to CPG 5bClinical status
Life threatening or Serious Non serious
Go to appropriate
CPG
Request
ALS
Adequate respirations No Go to
CPG xx
Yes
Normal rates Age Pulse RespirationsInfant 100 – 160 30 – 60Toddler 90 – 150 24 – 40Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30
Take standard infection control precautions
Primary Survey Trauma – Paediatric (≤ 13 years)CPG 4bVersion D 0.8 K
Consider pre-arrival information
Scene safetyScene survey
Scene situation
Airway patent MaintainYes
Breathing Yes
Jaw thrust(Head tilt/ chin lift)SuctionOPANPA (> 1 year)
No
No
Pulse/ circulation
Yes
Give 2 effectiveVentilations up
to 5 attempts
Go to CPG 1b
AVPU assessment
Go to CPG 5b
Airway obstructed No
Go to CPG 2b Yes
Arrest major external haemorrhage
Oxygen therapy
Expose & check obvious injuries
Treat life threatening injuries only
Oxygen therapy
Work of BreathingAppearance
Circulation to skin
Paediatric Assessment Triangle
Paediatric Assessment Triangle
Sick child
Yes
No
Mechanism of injury suggestive of spinal injury
C-spine control
YesNo
No Yes
Go to CPG 1c No
EMT P
AP
P
Confirm Primary Survey findings
P
> 1 year
Pulse < 60Yes
No
Clinical statusLife threatening
or Serious Non seriousGo to
appropriate CPG
Request
ALS
Adequate respirations No Go to
CPG xx
Yes
Normal rates Age Pulse RespirationsInfant 100 – 160 30 – 60Toddler 90 – 150 24 – 40Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30
Secondary Survey Trauma - adultCPG 5a (i)
Primary Survey
Version D 0.2 P AP
Markers for multi-system trauma
present
Markers for multi-system traumaGCS < 13Systolic BP < 90Respiratory rate < 10 or > 29Heart rate > 120Revised Trauma Score < 12Mechanism of Injury
No
Yes
Monitor and record vital signs
& GCS
SAMPLE history
Requires definitive
medical careYes
No
Examination of obvious injuries
Go toappropriate
CPG
Identify positive findings and initiate care
management
Reference: McSwain, N. et al, 2003, PHTLS Basic and advanced prehospital trauma life support, 5th Edition, Mosby
Revised Trauma ScoreVentilatory 10 – 29 4Rate > 29 3
6 – 9 2 1 – 5 1 0 0
Systolic BP > 89 476 – 89 350 – 75 2 1 – 49 1 no pulse 0
GCS 13 – 15 4 9 – 12 3 6 – 8 2 4 – 5 1 < 4 0
RTS = Total score
Request
ALS
Complete a detailed physical exam (head to toe survey) as history
dictates
Check for medications carried or medical
alert jewellery
Go to CPG xx
FromCPG xx
Secondary Survey Medical - adultCPG 5a (ii)
Primary Survey
Version D 0.2 P AP
Patient acutely unwell
No
Yes
SAMPLE history
Relevant family & social history
Requires definitive
medical careYes
No
Focused medical history of presenting
complaint
Go toappropriate
CPG
Identify positive findings and initiate care
management
Reference: Sanders, M. 2001, Paramedic Textbook 2nd Edition, MosbyGleadle, J. 2003, History and Examination at a glance, Blackwell ScienceRees, JE, 2003, Early Warning Scores, World Anaesthesia Issue 17, Article 10
Request
ALS
Check for medications carried or medical
alert jewellery
FromCPG xx
Go to CPG xx
Markers identifying acutely unwellCardiac chest painMEWS Score of ≥ 5Acute pain > 5
Examine body systems as appropriate
Record vital signs & GCS
Secondary Survey – Paediatric ( ≤13 years)CPG 5b
Primary Survey
Version D 0.3 P AP
FromCPG xx
Normal rates Age Pulse RespirationsInfant 100 – 160 30 – 60Toddler 90 – 150 24 – 40Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30
Make appropriate contact with patient and or guardian
Use age appropriate language for patient
Identify presenting complaint and exact chronology from the time the
patient was last well
Observe both patient and guardian- do they relate normally to each other- is the guardian calm and not anxious- will patient separate from guardian- does the patient play and interact normally- is the patient distractible
Children and adolescents should always be examined with a
chaperone (usually a parent)
Head to toe examination(toe to head for younger children)
Observing for- pyrexia- rash- pain - tenderness- bruising- wounds- fractures- medical alert jewellery
Report findings as per Child Protection Guidelines to ED staff in a confidential manner
Check for normal patterns of- feeding- toilet- sleeping
Check vital signs
Reference:Miall, Lawrence et al, 2003, Paediatrics at a Glance, Blackwell Publishing
Go toappropriate
CPG
Identify positive findings and initiate care
management
If non accidentalinjury or child abuse suspected
Check for current medications
Estimated weightAge x 2 + 9 Kg
Identify patient’s weight
Burns - AdultCPG 6a
Version D 0.6 K
Burn or Scald Cease contact with heat source
Isolatedsuperficial injury
(excluding FHFFP)Yes No
TBSA burn > 10% Yes
Commence local cooling of burn area
Monitor body temperature
Airway management
EMT P
AP
F: faceH: handsF: feet F: flexion pointsP: perineum
Commence local cooling of burn area
Consider humidifiedOxygen therapy
Appropriate history and burn
area ≤ 1%
Yes
No
Request
ALS
Inadequate respirations
Go to CPG A3Yes
NoMinimum 15 minutes cooling of area is recommended
Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114Sanders, M, 2001, Paramedic Textbook 2nd Edition, Mosby
Caution with the elderly, circumferential & electrical burns
Dressing/ covering of burn area
No
Hartmann’s Solution, 1000 mL, IV
> 25% TBSA and or time from
injury to ED > 1 hour
Yes
ConsiderHartmann’s Solution, 500 mL, IV
No
No
Pain > 2/10 Yes Go to CPG 13b Pain > 2/10Yes
Go to CPG xx
Inhalation and or facial injury
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
Dressing/ covering of burn area
Remove burned clothing (unless stuck) & jewellery
Equipment listAcceptable dressingsBurns jel if < 10% TBSACling filmSterile dressingClean sheet
if > 10% TBSA
ECG & SpO2monitoring
Brush off powder & irrigate chemical burns
Follow local expert direction
Spinal Immobilisation - AdultCPG 7a
TraumaIndications for spinal immobilisation
Dangerous mechanism include;Fall ≥ 1 meter/ 5 stepsAxial load to headMVC > 100 km/hr, rollover or ejectionATV collisionBicycle collisionPedestrian v vehicle
Use clinical judgementIf in doubt, immobilise
Version D 0.4 K P AP
Equipment list
Extrication deviceLong boardVacuum mattressOrthopaedic stretcherRigid cervical collar
Low risk factorsSimple rear end MVC (excluding push into oncoming traffic or hit by bus or truck)No neck or back painAbsence of midline c-spine or back tenderness
Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms
Go to CPG xx
Consider treat & discharge
Immobilisation may not beindicated
Rapid extrication with long board and cervical collar
Patient in sitting position Yes
No
Life Threatening
Yes
No
Consider Vacuum mattress
Remove helmet(if worn)
Yes
Use extrication device
Load onto vacuum mattressor long board
Are all of the factors listed present;GCS = 15Communication effective with patientNo dangerous mechanism, distracting injury or penetrating traumaNo numbness or tingling in extremitiesPresence of low risk factors which allow safe assessment of range of motionPatient voluntarily able to actively rotate neck 45o left & right pain freePatient can walk pain free
Do not forcibly restrain a patient that is combatitive
Apply cervical collar
Isolated limb fracture
Limb Fractures - AdultCPG 8a
Version D 0.5
Consider need for pain relief
Provide manual stabilisation for fractured limb
Expose and examine limb
Check CSMs distal to fracture site
Reposition limb(two attempts)
CSMs intact
Yes
No
Recheck CSMs
Recheck CSMs
Go to CPG 13b
P AP
Apply appropriate
splinting device
Fracture mid shaft of femur
Apply traction splint
Yes No
Equipment list
Traction splintBox splintFrac strapsTriangular bandagesVacuum splintsLong boardOrthopaediac stretcher Dress open fractures
Pre- Hospital Emergency ChildbirthCPG 9a
Query labour
Take SAMPLE history
Patient in labour No
Yes
Birth imminent or travel time too long No
Position mother and prepare equipment for birth
Monitor vital signs and BP
Cord complicationYes
Go to CPG 9b
No
Breech birthYes
Go to CPG 9c
Support baby throughout delivery
Dry baby and check ABCs
Baby stable
Go to CPG 1d No
Clamp & cut cord Clamp cord at 10, 15 & 20 cm from babyCut cord between 15 and 20 cm clamps
Yes
Version D 0.4 K
Wrap baby and present to mother
Mother stable
Go to CPG 4a
No
Yes
If placenta delivers, bring to hospital with mother Reassess
P AP
Yes
No
Consider
Entonox
Contact GP / midwife/ medical team as required by local policy to come to scene or meet en route
If no progress with labour consider transporting patient
Request
ALSEquipment list
Cord ClampsBulb syringeTowelsSurgical glovesSurgical apronGauze swaps 10 x 10 cmUmbilical cord scissorsClinical waste bag
Umbilical Cord ComplicationsCPG 9bVersion D 0.5 K P AP
From CPG 9a
Cord complication
Cord around baby’s neck Prolapsed cord
Oxygen therapy
Attempt to slip the cord over the baby’s head
Successful
Go to CPG 9a
Yes
Clamp cord in two places and cut between both clamps
Ease the cord from around the neck
Cord rupture
Apply additional clamps to cord
Apply direct pressure with sterile dressing
Mother to adopt knee chest position
Hold presenting part off the cord using fingers
AP
Maintain cord temperature and moisture
Consider inserting an indwelling catheter into the bladder and run 500 mL of NaCl into the bladder and clamp catheter
AP
In labour &foetal heart beat
present
Consider
Nifedipine, 20 mg, PO
Contact GP / midwife/ medical team as required by local policy to come to scene or meet en route
Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire TindallKatz Z et al, 1988, Management of labor with umbilical cord prolaps: A 5 year study. Obstet. Gynecol. 72(2): 278-281Duley, LMM, 2002, Clinical Guideline No 1(B), Tocolytic Drugs for women in preterm labour, Royal College of Obstetricians and gynaecologists
Request
ALS
No
Yes
No
Pre alert hospital as urgent caesarean section will be required
Breech birthCPG 9c
Version D 0.4 K P AP
From CPG 9a
Breech birth presentation
Oxygen therapy
Mother to adapt the lithotomy position
Support the baby as it emerges –avoid manipulation of the baby’s body
Nape of neck anteriorly visible at
vulva
Yes
No
Rotate baby’s legs in an ark in an upward direction as
contractions occur
Successful delivery after 5
contractionsYes
No
Go to CPG 9a
Place hand in the vagina with palm towards baby’s faceForm a V with fingers on each side of baby’s nose and gently push baby’s head away from vaginal wall
Await arrival of medical assistance
Contact GP / midwife/ medical team as required by local policy to come to scene
Grasp both baby’s ankles in other hand
Place one hand, palm up, onto baby’s face
P
Successful delivery
Yes
No
Go to CPG 9a No
Request
ALS
Consider
Entonox
Cardiac Chest Pain – Acute Coronary SyndromeCPG 10
Version D 0.9 K
Acute Coronary Syndrome
Apply monitoring leads, apply SPO2 monitor
Oxygen therapy
Aspirin 300 mg PO
Acquire & interpret 12 lead ECG
STEMISTEMI = ST elevation MI
Yes No
Primary PCI available within 60 min from 999 call
No
Yes
PCI = Percutaneous Coronary Intervention
Chest Pain
No
Yes
Symptoms ≤ 3 hoursYes No
Notify & transport to Primary PCI
facility
No
Contraindications for thrombolysis
ContraindicationsHaemorrhagic stroke or stroke of unknown origin at any timeIschemic stroke in preceding 6 months Central nervous system damage or neoplasmsRecent major trauma/ surgery/ head injury (within 3 weeks)Gastro-intestinal bleeding within the last monthActive peptic ulcerKnown bleeding disorderOral anticoagulant therapyAortic dissectionTransient ischemic attack in preceding 6 monthsPregnancy within 1 week post partumNon-compressible puncturesTraumatic resuscitationRefractory hypertension (sys BP > 180 mmHg)Advanced liver diseaseInfective endocarditis
Clopidogrel 300 mg PO
Indication for ThrombolysisPatient conscious, coherent and understands therapyPatient consent obtained< 75 yearsMI Symptoms 20 minutes to 6 hoursST elevation > 1 mm in two or more contiguous leads
P AP
Repeat Morphine at not < 2 min intervals if indicated.Max 10 mg
Consider
Morphine 2 mg IV
Cycilizine 50 mg IV slowly
Pain relief effective
No
Tenecteplase< 60 kg 30 mg60 – 70 kg 35 mg70 – 80 kg 40 mg80 – 90 kg 45 mg> 90 kg 50 mg
GTN 0.4 mg SLRepeat prn to max of 1.2 mg SL
Request
ALS
FromCPG xx
Yes
Reference: Reducing the Risk: A Strategic Approach, 2006, The Report of the Task Force on Sudden Cardiac Death
Followed by
Tenecteplase IV
Enoxaparin 30 mg IV
> 25 minutes from ED
Yes
Enoxaparin 1 mg/kg SC
Altered level of consciousness - AdultCPG 11aVersion D 0.5 K APP
V, P or U on AVPU scale
Head injury
Go to CPG xx
Go to CPG xx
Go to CPG xx
Go to CPG xx
AnaphylaxisGo to
CPG xx
Go to CPG xx
Go to CPG xx
Go to CPG xx
Go to CPG 18
Differential Diagnosis
ECG & SpO2 monitoring Calculate GCS
Go to CPG xx
Go to CPG xx
Check temperatureCheck pupillary size & responseCheck for skin rash
Go to CPG xx
Obtain SAMPLE history frompatient, relative or bystander
Check blood glucose
Maintain airway
Consider recovery position
Check for medications carried or medical
alert jewellery
Go to CPG xx
Inadequate respirations
Drowning
Septic shock
Poison
Glycaemic emergency
Post resuscitation
care
Bradycardia
Seizures
Hypothermia
Taser gun
Blood loss (shock)
Go to CPG 18 Stroke
Mental Health EmergencyCPG 12a
Version D 0.3 P
Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance vehicle
Behaviour abnormal
No
Yes
Reassure patientExplain what is happening at all times
Avoid confrontation
Patient agreesto travelNo
YesRequest- Gardaí- Medical Practitioner- Mental health team
Attempt verbal de-escalation
EMT
Hallucinations or Paranoia
RMP or RPNin attendance or have made arrangements for voluntary/
assisted admission
No
Yes
Transport patient to an Approved Centre
Reference; Reference Guide to the Mental Health Act 2001, Mental Health CommissionHSE Mental Health Services
RMP – Registered Medical PractitionerRPN – Registered Psychiatric Nurse
Request
ALS
Co-operate as appropriate with
medical or nursing team
Obtain a history from patient and or bystanders present as appropriate
No
Potential to harm self or
othersRequest control to inform Gardaí
Yes
If potential to harm self or othersensure minimum two people accompany patient in saloon of ambulance at all times
Behavioural emergencyCPG 12b
Version D 0.3 P
Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance vehicle
Behaviour abnormal
Obtain a history from patient and or bystanders present as appropriate
No
Reassure patientExplain what is happening at all times
Avoid confrontation
Patient agreesto travelNo
Yes
Request control to inform Gardaí and or Doctor
Attempt verbal de-escalation
EMT
Inform patient of potential consequences of treatment
refusal
Injury or illness potentially serious or likely to cause lasting
disability
YesOffer to treat and or
transport patient
No
Advise alternative care options and to call ambulance again if there is a
change of mind
Document refusal of treatment and or transport to ED
Is patient competent to
make informed decision
Yes
No
Await arrival of doctor or Gardaí
or receive implied consent
Treatment only
Yes
No
AP
Aid to Capacity Evaluation1. Patient verbalizes/ communicates understanding of clinical situation?2. Patient verbalizes/ communicates appreciation of applicable risk?3. Patient verbalizes/ communicates ability to make alternative plan of care?If no to any of the above consider Patient Incapacity
Potential to harm self or
othersRequest control to inform Gardaí
Yes
If potential to harm self or othersensure minimum two people accompany patient in saloon of ambulance at all times
Reference: HSE Mental Health Services
Pain management - AdultCPG 13b
Pain
Repeat Morphine at not < 2 min intervals if indicated.Max 10 mg
Analogue Pain Scale0 = no pain……..10 = unbearable
Version D 0.11 K EMT P
AP
Consider
Morphine, 2 mg, IV
Cycilizine, 50 mg IV slowly
Go back to
originatingCPG
Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale
And or
Paracetamol 1 g PO
Ibuprofen 400 mg PO
< 5 on pain scale
Yes
No
Nitrous Oxide & Oxygen, inhalation
Yes NoAdequate relief of pain
3 to 4 on pain scale -moderate
≥ 5 on pain scale -severe
Pain assessment
No
Request
ALS
If IV not accessible Morphine 10 mg IM
may be administered provided no cardiac chest pain present
AP
Registered Medical Practitioners may authorise the use of IM Morphine by Paramedic or EMT practitioners for patients in inaccessible locations
EMTP
Pain
Analogue Pain Scale0 = no pain……..10 = unbearable
Version D 0.9 K EMT P
AP
Go back to
originatingCPG
Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale
And or
< 6 on pain scale
Yes
No
Nitrous Oxide & Oxygen, inhalation
Yes NoAdequate relief of pain
2 to 5 on pain scale -moderate
≥ 6 on pain scale -severe
Pain assessment
No
Pain management – Paediatric (≤ 13)CPG 13b
Wong – Baker Faces for 3 years and older
Reference:From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of Paediatric Nursing, ed.6, St. Louis, 2001, p1301. Copyrighted by Mosby, Inc. Reprinted by permission.
Paracetamol 20 mg/kg PO
Ibuprofen 5 mg/kg PO
Consider
Repeat IV Morphine at not < 2 min intervals if indicated Max 0.15 mg/kg IV
Cycilizine, 0.7 mg/kg IV slowly
ORMorphine, 0.05 mg/kg, IV
Morphine, 0.1 mg/kg, PO
Request
ALS
Or
Or
Or
Glycaemic Emergency - AdultCPG 13e
Version D 0.9 K
Blood Glucose< 4 mmol/L
15 to 20 mmol/L
> 20 mmol/L
Glucagon 1 mg IM
Dextrose 10%, 250 mL IV infusionSodium Chloride 0.9% 1 L IV infusion
Reassess
Reassess
NoBlood Glucose > 4 & < 15 mmol/L
Yes
Allow 5 minutes to elapse following administration of
medication
No
P AP
Complete; After care Instructions – Diabetes and give a copy to the patient or carer
Glucose gel, 10-20 g buccal
Patient is fully alert and makes an informed decision
not to attend ED
Yes
Abnormal blood glucose
level
Consider treat & discharge
Go to CPG xx
Consider
ALS
Sweetened drink
Glycaemic Emergency – Paediatric (≤ 13)CPG 13e
Version D 0.8 K
Glucagon 0.5 mg IM Dextrose 10%, 5 mL/kg IV bolusRepeat x 1 prn
No Yes
Reassess
Blood Glucose< 3 mmol/L
Sodium Chloride 0.9% 20 mL/kg IV bolus
Yes
> 20 mmol/L
DehydrationNo
Abnormal blood glucose
level
P AP
ConsiderGlucose gel 5-10 g Buccal
Request
ALS
Reference: Dehydration- Paramedic Textbook 2nd E p 1229
Major Emergency (Major Incident) – First ambulance crewCPG 14a
Version D 0.4 K EMT P
AP
Take standard infection control precautions
Consider pre-arrival information
PPE (high visibility jacket and helmet) must be worn
Irish (Major Emergency) terminology in blackUK (Major Incident) terminology in blue
Practitioner 1 Practitioner 2(MIMMS trained)
Park at the scene as safety permits and in liaison with Fire & Garda if present
Leave blue lights on as vehicle acts as Forward Control Point pending the arrival of the Mobile Control Vehicle
Confirm arrival at scene with Ambulance Control and provide an initial visual report stating Major Emergency (Major Incident) Standby or Declared
Maintain communication with Practitioner 2
Leave the ignition keys in place and remain with vehicle
Carry out Communications Officer role until relieved
Carry out scene survey
Give situation report to ambulance control using METHANE message
Carry out HSE Controller of Operations (Ambulance Incident Officer) role until relieved
Liaise with Garda Controller of Operations (Police Incident Officer) and Local Authority Controller of Operations (Fire Incident Officer)
Select location for Holding Area (Ambulance Parking Point)
Set up key areas in conjunction with other Principle Response Agencies on site; - Site Control Point (Ambulance Control Point), - Casualty Clearing Station
METHANE messageM – Major Emergency declaration / standbyE – Exact location of the emergencyT – Type of incident (transport, chemical etc.)H – Hazards present and potentialA – Access / egress routesN – Number of casualties (injured or dead)E – Emergency services present and required
Possible Major Emergency
The first ambulance crew does not provide care or transport of patients as this interferes with their ability to liaise with other services, to assess the scene and to provide continuous information as the incident develops
The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK
Major Emergency (Major Incident) – Operational ControlCPG 14b
Version D 0.6 K EMT P
APIrish (Major Emergency) terminology in blackUK (Major Incident) terminology in blue
Danger Area
Traffic Cordon
Inner Cordon
Outer Cordon
If Danger Area identified entry to Danger Area is controlled by a Senior
Fire Officer or an Garda Síochána
Entry to Outer Cordon (Silver area) is controlled by an Garda Síochána Entry to Inner Cordon (Bronze Area) is
limited to personnel providing emergency care and or rescuePersonal Protective Equipment required
Management structure for; Outer Cordon, Tactical Area (Silver Area)On-Site Co-ordinatorHSE Controller of Operations (Ambulance Incident Officer)Site Medical Officer (Medical Incident Officer)Local Authority Controller of Operations (Fire Incident Officer)Garda Controller of Operations (Police Incident Officer)
Management structure for; Inner Cordon, Operational Area (Bronze Area)Forward Ambulance Incident Officer (Forward Ambulance Incident Officer)Forward Medical Incident Officer (Forward Medical Incident Officer)Fire Service Incident Commander (Forward Fire Incident Officer)Garda Cordon Control Officer (Forward Police Incident Officer)
HSE CONTROLLER
LOCAL AUTHORITY
CONTROLLERGARDA
CONTROLLER
Casualty Clearing Station
Ambulance Loading
Point
Body Holding
Area HSE Holding
Area
Garda Holding
Area
LA Holding
Area
Site Control Point
Ref; A Framework for Major Emergency Management, 2006, Inter-Departmental Committee on Major Emergencies (Replaced by National steering Group on Major Emergency Management)
The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK
Other management functions for; Major Emergency siteCasualty Clearing OfficerTriage OfficerAmbulance Parking Point OfficerAmbulance Loading Point OfficerCommunications OfficerSafety Officer
One way ambulance circuit
Triage SieveCPG 14c
P
AP
EMT
Multiple casualty incident
Triage is a dynamic process
Version D 0.5 K
Can casualty walk
Is casualty breathing
Breathing now
Open airwayone attempt
Respiratory rate< 10 or > 29
Capillary refill > 2 secOr
Pulse > 120
No
NoYes
No
Priority 3(Delayed)
GREEN
Yes
DEADNo
Yes
Priority 1(Immediate)
RED
Yes
Yes
Priority 2(Urgent)
YELLOW
No
The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK
Triage SortCPG 14d P AP
Multiple casualty incident
10 – 29 / min> 29 / min6 – 9 / min1 – 5 / min
None≥ 90 mm Hg
76 – 89 mm Hg50 – 75 mm Hg1 – 49 mm Hg
No BP
Respiratory Rate
Systolic Blood Pressure
4321043210
Measured valueCardiopulmonary function Score
13 – 159 – 126 – 84 – 5
3
Glasgow Coma Score
43210
A
B
Insert score
C
Triage Revised Trauma Score A+B+C
RevisedTrauma Score
1 - 10
11
12
0
Triage is a dynamic process
Version D 0.4 K
The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK
SpontaneousTo VoiceTo PainNone
OrientedConfusedInappropriate wordsIncomprehensible sounds
Obeys commandsLocalises painWithdraw (pain)Flexion (pain)Extension (pain)None
4321
54321
654321
Eye Opening
Verbal Response
Motor Response
Glasgow Coma Score
Priority 3(Delayed)
GREEN
DEAD
Priority 1(Immediate)
RED
Priority 2(Urgent)
YELLOW
EpistaxisCPG 16
Version D 0.3 K P
AP
Medical
Apply digital pressure for 3 to 5 minutes
HypovolaemicYesGo to CPG xx
Advise patient to sit forward
Trauma From CPG 4a
Advise patient to breath through mouth only and not
to blow nose
EMT
FromCPG 4a
No
Haemorrhage controlledNo
Yes
Request
ALS
Consider
ALS
Version D 0.7 K Poisons - AdultCPG 17a
PEMT
Poison source
Ingestion Inhalation
CorrosiveYes
Sips of water or milk
Go to CPG A3
AbsorptionInjection
No
No Site burns
Cool area
YesNo
Yes
Poison type
Paraquat Other
Do not give oxygen
Adequate ventilations
Consider
Oxygen therapy
Request
ALS
FromCPG xx
Reference:Dr, Joe Tracey, Director, National Poison Information Centre
Consider decontamination prior to transportation
Caution with oral intake
Note:CPG A3, Inadequate respirations, authorises the administration of Naloxone IM for opiate overdose for Paramedics
Alcohol
Check blood glucose
NoBG
> 4 or > 15 mmol/L
Go to CPG xxYes
P
Version D 0.5 K APP
Positive FAST assessment
Yes
Oxygen therapy
Onset < 3 hours
SpecialisedStroke Unit available
Yes
No
No
No
Transport patient to hospital with
Specialised Stroke Unit (under local protocol)
Yes
Maintain airway
ReferenceProf R Boyle, 2006, Mending hearts and brains, Clinical case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHSAHA, 2005, Part 9 Adult Stroke, Circulation 2005; 112; 111-120A. Mohd Nor, et al, Agreement between ambulance paramedic- and physician- recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients, Stroke 004; 35;1355-1359Jeffrey L Saver, et al, Prehospital neuroprotective therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG) pilot trial, Stroke 2004; 35; 106-108
12 lead ECG
Obtain GCS
ECG & SPO2monitoring
Check blood glucose
StrokeCPG 18
acute neurolocical symptoms
F – facial weakness Can the patient smile?, Has their mouth or eye drooped? Which side?A – arm weakness Can the patient raise both arms and maintain for 5 seconds?S – speech problems Can the patient speak clearly and understand what you say?T – time to transport now if positive FAST
BG > 4 or > 15
mmol/L
Go to CPG xx Yes
No
Version D 0.5Post Resuscitation Care - Adult
CPG 19 AP
Return of Spontaneous
Circulation
Conscious Yes
No
Adequate ventilation
Yes
No
Ventilate at 10 to 12 per minute
Commence active cooling to target temperature of 32o C
Cold packs to arm pits, abdomen & groin
NaCl (4o C) 500 mL IVRepeat x 1 if required
Check blood glucose
Transport quietly and smoothly
P
Maintain patient at rest
Monitor vital signs
12 lead ECG
Equipment list
Low reading thermometerCold packs
Reference: ILCOR Guidelines 2005AHA Guidelines 2005, Part 7.5 Postresuscitation Support
Maintain Oxygen therapy
Consider causes and treat as appropriate:
Hydrogen ion acidosisHyper/ hypokalaemiaHypothermiaHypovolaemiaHypoxiaThrombosis – pulmonaryTension pneumothoraxThrombus – coronaryTamponade – cardiacToxinsTrauma
If Amiodarone used to convert VF/VT and persistent tachyarrhythmia Consider
Amiodarone, 1 mg/min, IV infusion
500 mL / 300 mg Amiodarone = 1.7 1 mg = 1.7 mL
IV giving set; X gtt = 1 mL X gtt x 1.7 mL = 1 mg/ min
NoYes
Atropine 0.5 mg IV
Symptomatic bradycardia
Monitor blood pressure and GCS
Request
ALS
Post VF/VT and unresponsive
Yes
No
Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac arrest management
ECG & SpO2monitoring
Post Partum HaemorrhageCPG 20 P AP
2nd stage of labour complete
Mother is haemodynamically
unstableYes No
Oxygen therapy
External massage of the uterus
Syntometrine, 1 mL IM(if not already administered)
Version D 0.4 K
Go to CPG A13
Elevate lower limbs
Reassess
Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall
Check/ ask mother re multiple births prior to
administration of Syntometrine
Estimate blood loss
Request
ALS
Consider inserting a urinary
catheter
AP
Apply absorbent pad to perineum area
Haemorrhage in pregnancy prior to deliveryCPG 21
P APVersion D 0.3 K
Pregnancy ≥ 24 weeksAnti partum
haemorrhage
Patient is haemodynamically
unstableYes No
Go to CPG A13
Left lateral tilt
Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall
Apply absorbent pad to perineum area
Reassess
Request
ALS
Query pregnant< 24 weeks
Early pregnancy haemorrhage
Do not examine abdomen or vagina
Oxygen therapy
Version D 0.5 Conducted Electrical Weapon (Taser)CPG 25 APP
Taser gun used
Prior to touching the patient ensure that the Garda has disconnected the wires from the hand held unit
Cut wire connection proximal to barbs
Complete primary survey
Remove barbsClean and dress wounds
Go to appropriate
CPG
Patient care takes precedent over removal of barb
Barbs shall not be removed if they are embedded in the face, eye, neck, or groin
Monitor ECG & SpO2for minimum 15 minutes
Behavioural emergency
Go to appropriate
CPGYes
No
Reference:DSAC Sub-committee on the Medical Implications of Less-lethal Weapons 2004, Second statement on the medical implications of the use of the M26 Advanced Taser.United States Government Accountability Office, 2005, The use of Taser by selected law enforcement agenciesManitoba health Emergency Medical Services, 2007 Taser Dart Removal ProtocolAda County Paramedics, Idaho 2006 Taser Protocol
ConsiderOxygen therapy
Ensure Garda accompany patient at all times
Note:This CPG was developed in conjunction with Dr. Donal Collins, Chief Medical Officer, An Garda Síochána
Monitor GCS, temperature & vital signs
Monitor for signs of Excited Delirium
Head injury - AdultCPG 27
Head trauma
GCS < 12Yes No
Version D 0.2
Consider Vacuum mattress
P AP
Equipment list
Extrication deviceLong boardVacuum mattressOrthopaedic stretcherRigid cervical collarOxygen saturation monitor
LoC history No
Maintain Airway(Consider Advanced airway)
SeeCPG xx
Oxygen therapy
SpO2 & ECG monitoring
Apply cervical collar
Transport to most appropriate ED according to
local protocol
SeeCPG xx
SeizuresGo to CPG xx
Yes
Secure to long board
Yes
No
Request
ALS
No
Blood glucose level < 4 mmol/L
Reference;Mc Swain, N, 2003, Pre Hospital Trauma Life Support 5th Edition, Mosby
GCS ≤ 8
10o head tilt
Yes
Control external haemorrhage
Maintain SBP > 120 mmHgSeeCPG xx
Consider cervical collar application
and long board use
Maintain in-line immobilisation
Revert to basic airway management
Advanced Airway Management - AdultCPG A1
Version D 0.6 K
Apnoea or special clinical considerations
Able to ventilate
Go to CPG 2a
Position for intubation restricted
Yes
Endotracheal intubation
No
Successful Yes
No
Successful Yes
No
2nd attempt Endotracheal
intubation
Successful YesNo
Successful Yes
No
Ensure CO2 detection device in ventilation
circuit
Continue ventilation and oxygenation
Check tube placement after each patient movement or if any patient
deterioration
Yes
No
P AP
AP
AP
Laryngeal Mask Airway or Laryngeal tube insertion
2nd attempt Laryngeal Mask Airway or Laryngeal tube insertion
Go to appropriate
CPG
Reference: International Liaison Committee on Resuscitation, 2005, Part 4: Advanced life support, Resuscitation (2005) 67, 213 – 247
Special clinical considerationsGCS = 3SpO2 < 92%RR ≤ 9BVM ineffective(All of the above must be present)
Maintain adequate ventilation and oxygenation throughout procedures
Consider
Inadequate Respirations – AdultCPG A3
Version D 0.10 K
Congestion / crepitations
Hx of CHF and features of pulmonary
oedema
Yes
GTN, 0.8 mg, SLRepeat x 1 prn
No
Frusemide, 40 mg, IV
Reassess
P AP
Silent chest, < 2 words per
breath or SpO2< 92%
Yes
Magnesium Sulphate 1.5 g IV infusion over 20 min
No
Inadequate respirations
Assess and maintain airway
Oxygen therapy
OR
Salbutamol, 5 mg, nebuleRepeat x 1 at 15 minutes prn
Bronchospasm assessment
Mild /Moderate(2)
Severe(1)
Salbutamol, 4 puffs, metered aerosol
Repeat x 1 at 15 minutes prn
Salbutamol, 5 mg, nebuleRepeat x 1 at 15 minutes prn
Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline
Request
ALS
GCS = 3SpO2 < 92%
BVM ineffectiveRR ≤ 9
Yes
Life threatening asthmaAny one of the following in a patient with severe asthma;PEF < 33% best or predictedSpO2 < 92%Silent chestCyanosisFeeble respiratory effortBradycardiaArrhythmiaHypotensionExhaustionConfusionUnresponsive
Acute severe asthma (1)Any one of;PEF 33-50% best or predictedRespiratory rate ≥ 25/ minHeart rate ≥ 110/ minInability to complete sentences in one breath
Moderate asthma exacerbation (2)Increasing symptomsPEF > 50-75% best or predictedNo features of acute severe asthma
Respiratory assessment
Go to CPG xx
Consider
ECG & SpO2monitoring
No
Inadequate rate or depthAsymmetrical movement
No
Tension Pneumothorax
suspected
Needle decompression
Yes
AP
No
Possible Hx of Narcotic overdose
Yes
Naloxone 0.4 mg IMRepeat x one prn
Naloxone 0.4 mg IV/IO/IMRepeat x one prn
Positive pressure ventilationsMax 10 per minute
Reassess
Symptomatic Bradycardia - AdultCPG A8
Version D 0.5 K P
AP
EMT
Symptomatic Bradycardia
Type II 2nd degree AV block or
3rd degree AV blockexcluded
Yes
Atropine, 0.5 mg IVRepeat at 3 to 5 min intervals prn to max 3 mg
Oxygen therapy
ECG & SPO2monitoring
No
Request
ALS
12 lead ECGP
Atropine, 0.5 mg IV
Reassess
Version D 0.2 Septic Shock – Paediatric (≤ 13)CPG A54(ii) P AP
Septic shock
Oxygen therapy
Hartmann’s Solution 20 mL/kg IV/IO
Meningoccal disease
suspectedYes
No
Hartmann’s Solution, 20 mL/kg IV/IO aliquots to maintain palpable brachial pulse *
Benzylpenicillin IV/IO over 3 to 5 minutes or IM< 1 year 300 mg1 – 8 years 600 mg> 8 years 1 200 mg (1.2 g)
Request
ALS
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
* Radial pulse in older children
ECG & SpO2 monitoring
Check medication
with meningitis Foundation
Version D 0.2Shock from Blood Loss – Paediatric (≤ 13)
CPG A54(i) P AP
Haemorrhalogic shock
Patient trapped No
Yes
Oxygen therapy
Hartmann’s Solution 20 mL/kg IV/IO
Hartmann’s Solution, 20 mL/kg IV/IO aliquots to maintain palpable brachial pulse *
Continue fluid therapy until handover at ED
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
Request
ALS
Reference:American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Prefessionals, Jones and Bartlett.
ECG & SpO2 monitoring
Reassess
* Radial pulse in older children
Consider
Consider
Inadequate Respirations – Paediatric (≤ 13)CPG A56
Version D 0.4
Inadequate rate or depthAsymmetrical movement
No
P AP
Silent chest, < 2 words per breath, cannot feed or SpO2
< 92%
Yes
Ipratropium bromide 0.250 mg nebule & salbutamol (age
specific dose) nebule mixed
No
Inadequate respirations
Assess and maintain airway
Oxygen therapy
ChestAuscultation
Regard each emergency asthma call as for acute severe asthma until it is shown otherwise
OR
Salbutamol < 5 years 2.5 mg nebule≥ 5 years 5 mg nebule
Repeat at 15 minutes prn
Bronchospasm assessment
Severe
Salbutamol, 2 puffs, metered aerosol
Repeat x 1 at 15 minutes prn
Mild /Moderate
Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline
Request
ALS
Tension Pneumothorax
suspected
Needle decompression
Yes
AP
No
ECG & SpO2monitoring
Salbutamol < 5 years 2.5 mg nebule≥ 5 years 5 mg nebule
Repeat x 1 at 15 minutes prn
Life threatening asthmaAny one of the following in a patient with severe asthma;Silent chestCyanosisPoor respiratory effortHypotensionExhaustionConfusionUnresponsive
Acute severe asthmaAny one of;Inability to complete sentences in one breath or too breathless to talk or feedRespiratory rate > 30/ min for > 5 years old
> 50/ min for 2 to 5 years old
Heart rate > 120/ min for > 5 years old> 130/ min for 2 to 5 years old
Possible Hx of Narcotic overdose
Yes
Naloxone 0.01 mg/kg, IMRepeat x one prn
Naloxone 0.01 mg/kg, IV/IO/IMRepeat x one prn
Positive pressure ventilations– 12 to 20 per minute
Reassess
Assess & maintain airway
Humidified O2 – as high a concentration as tolerated
Do not distressTravel in position of comfort
ECG & SpO2monitoring
Stridor – Paediatric (≤ 13)CPG 27
Version D 0.1 P
AP
EMT
Stridor
Oxygen therapy
Epinephrine administered pre arrival? (within 5
minutes)
Reoccurs / deteriorates /
no improvement
No
Deteriorates
Yes
No
Yes
No
Yes
Version D 0.4 KAnaphylaxis - Adult
CPG – A4
Moderate Severe
Epinephrine (1:1 000) 0.5 mg (500 mcg) IMRepeat at 5 minute intervals if no improvement
If bronchospasm consider nebulizer
Epinephrine (1:1 000) 0.5 mg (500 mcg) IM
Hartmann’s Solution 1 000 mL IV infusion
Repeat Hartmann’s Solution 1 000 mL IV infusion X 1 if indicated
Reassess
Salbutamol 5 mg nebule
If bronchospasm consider nebulizer
Salbutamol 5 mg nebule
Reassess
P AP
Request
ALS
AnaphylaxisOxygen therapy
Reassess
Mild
Monitor reaction
Mild anaphylaxisUrticaria and or angio oedema
Moderate anaphylaxisMild symptoms + simple bronchospasm
Severe anaphylaxisModerate symptoms + haemodynamic and or respiratory compromise
ECG & SpO2monitor
ECG & SpO2monitor
Request
ALS
Epinephrine administered pre arrival? (within 5
minutes)
No
Yes
Version D 0.6 K
Moderate Severe
P AP
Request
ALS
AnaphylaxisOxygen therapy
Mild
Monitor reaction
Anaphylaxis – Paediatric (≤ 13 years)CPG – A55
Epinephrine (1:1 000) IM< 6 months: 0.05 mg (50 mcg) IM6 months to 5 years: 0.125 mg (125 mcg) IM6 to 8 years: 0.25 mg (250 mcg) IM> 8 years: 0.5 mg (500 mcg) IM
Repeat Epinephrine at 5 minute intervals if no improvement
Hartmann’s Solution 20 mL/kg IV/IO bolus
Repeat Hartmann’s Solution 20 mL/kg IV/IO bolus X 1 if indicated
Epinephrine (1:1 000) IMSee age related doses above
Reoccurs / deteriorates /
no improvement
Deteriorates
No
Yes
Yes
If bronchospasm consider nebulizer
Reassess
Salbutamol nebule< 5 yrs: 2.5 mg≥ 5 yrs: 5 mg
If bronchospasm consider nebulizer
Salbutamol nebuleSee age related doses above
Reassess
No
Reassess
Mild anaphylaxisUrticaria and or angio oedema
Moderate anaphylaxisMild symptoms + simple bronchospasm
Severe anaphylaxisModerate symptoms + haemodynamic and or respiratory compromise
ECG & SpO2monitor
ECG & SpO2monitor
Inform rescue leader that the patient must not be released until IV fluids have commenced
Large bore x 2
Crush InjuryCPG 26
Version D 0.2 P AP
Patient trapped
Significant compression force
maintained NoCo-ordinate with
rescue personnel on release timing
NaCl 0.9% 20 mL/kg IV
Consider pain relief
Go to CPG xx
ECG & SPO2monitoring
Prepare all required patient carrying devices and have on standby following extrication
Apply standard trauma care during and post extrication
Go to appropriate
CPG
Maintain AcBC
Oxygen therapy
Request
ALS
Reference:Crush Injury Syndrome (# 7102) Patient Care Policy, Alameda County EMS Agency (CA)Crush Injuries, Clinical Practice Manual, Queensland Ambulance Service
Consider Mobile Surgical Team (for amputation)
Yes
Version D 0.7 HypothermiaCPG 23
P
Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human KineticsAHA, 2005, Part 10.4: Hypothermia, Circulation 2005:112;136-138Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170Pennington M, et al, 1994, Wilderness EMT, Wilderness EMS Institute
EMT
Query hypothermia
Immersion Yes
NoRemove patient horizontally from liquid
(Provided it is save to do so)
Protect patient from wind chill
Complete primary survey(Commence CPR if appropriate)
Remove wet clothing by cutting
Place patient in dry blankets/ sleeping bag with outer layer of insulation
Mild(Responsive)
Equipment list
Survival bagSpace blanketWarm air rebreather
Request
ALS
Moderate/ severe(Unresponsive)
Hypothermic patients should be handled gently & not permitted to walk
Pulse check for 30 to 45 seconds
Oxygen therapy Warmed O2if possible
Give hot sweet drinks
Members of rescue teams should have a clinical leader of at least EFR level
Hot packs to armpits & groin
Transport in head down positionHelicoptor: head forwardBoat: head aft
Check blood glucose
ECG & SpO2 monitoring
If Cardiac arrest follow CPGs but- no active re-warming
Seizure / convulsions – AdultCPG – A 11
Version D 0.8 K
Seizure / convulsion
Or
Diazepam, 10 mg PRRepeat by one prn Diazepam 5 mg IV
Repeat by one prn
No Yes
Seizure statusSeizing currently Post seizure
Check blood glucose
Patient is fully alert and makes an informed decision
not to attend EDNo
Protect from harm
Oxygen therapy
Anti convulsant medication
administered
No
Yes
Blood glucose < 4 or > 15 mmol/LYes
No
Go to CPG 13e
P AP
Midazolam 10 mg buccal
The patient;was not seizing on arrival
has history of seizureshas no injury
No
Yes
Consider other causes of seizures
MeningitisHead injuryHypoglycaemiaEclampsiaFever
Request
ALS
Reassess
Consider treat & discharge YesGo to
CPG xx
MAG decision requiredInternasal Midazolam?
Seizure / convulsions – Paediatric (≤ 13)CPG – A 57
Version D 0.11 K
Seizure / convulsion
Or
Diazepam PR< 3 years: 2.5 mg PR≥ 3 years: 5 mg PR
Repeat by one prn Diazepam 0.2 mg/kg IVRepeat by one prn
No Yes
Seizure statusSeizing currently Post seizure
Check blood glucose
Consider
Or
Paracetamol PR< 1 year: 60 mg PR1 – 3 years: 180 mg PR4 – 8 years: 360 mg PR
If pyrexial – cool child
Protect from harm
Oxygen therapy
Paracetamol, 20 mg/kg, PO
Blood glucose < 3 or > 20 mmol/LYes
No
Go to CPG 13e
P AP
Midazolam 0.5 mg/kg buccal
Request
ALS
Reassess
MAG decision requiredInternasal Midazolam?
Consider other causes of seizures
MeningitisHead injuryHypoglycaemiaEclampsiaFever
Symptomatic Bradycardia – PaediatricCPG A52
Version D 0.4 K P
AP
Symptomatic Bradycardia
Persistent bradycardia
Yes
Oxygen therapy
No
EMT
CPR
Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IOEvery 3 – 5 min prn
Continue CPR
Signs of poor perfusionUnresponsive or drowsyCold peripheriesDelayed capillary refill
Consider advanced airway management
if prolonged CPR
AP
ECG & SPO2monitoring
Reference: International Liaison Committee on Resuscitation, 2005, Part 6: Paediatric basic and advanced life support, Resuscitation (2005) 67, 271 – 291
Ventilate
HR < 60
Yes
Hartmann’s Solution 20 mL/Kg IV/IO
No
Request
ALS
Reassess
Immediate IO access if IV not immediately accessible
AP
Version D 0.2 KShock from Blood Loss – Adult
CPG A13 (i) P AP
Hypovolaemia
Patient trapped No
Yes
Oxygen therapy
Hartmann’s Solution 500 mL IV
TraumaYes No
Head injury with GCS ≤ 8Yes No
Hartmann’s Solution, 250 mL IV aliquots to maintain SBP 120 mmHg
Hartmann’s Solution, 250 mL IV aliquots to maintain palpable radial
pulse (SBP 90 - 100 mmHg)
Hartmann’s Solution, 250 mL IV aliquots to maintain SBP 100 mmHg
Continue fluid therapy until handover at ED
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
Request
ALS
Version D 0.3 K Septic Shock – AdultCPG A13 (ii) P AP
Hypovolaemia
Oxygen therapy
Hartmann’s Solution 500 mL IV
Meningitis suspected Yes
No
Hartmann’s Solution, 250 mL IV aliquots to maintain SBP 100 mmHg
Benzylpenicillin, 1 200 mg IV/IMover 3 to 5 minutes
Request
ALS
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
Ensure appropriate PPE worn;Mask and goggles
Continue fluid therapy until handover at ED
Version D 0.5 K External Haemorrhage - AdultCPG 15a P
APOpen wound
Blood still flowing
No
Yes
PostureElevation
ExaminationPressure
Apply sterile dressing
Small superficial
wound
Significant blood loss
No
Yes
Advise to clean wound with soap & water and apply
fresh dressing
Yes
Go to CPG A13
EMT
Isolated wound& no relevant medical
historyNo
Yes
No
Haemorrhage controlled
No
Yes Apply additional dressing(s)
Haemorrhage controlledYes
No
Depress proximal pressure point
P
Haemorrhage controlledYes
No
Apply tourniquetP
Consider treat & discharge
Go to CPG xx
EMT
ConsiderOxygen therapy
Version D 0.5 K External Haemorrhage – Paediatric (≤13 years)CPG 15b P
APOpen wound
Blood still flowing?
No
Yes
PostureElevation
ExaminationPressure
Apply sterile dressing
EMT
Haemorrhage controlled
No
Yes Apply additional dressing(s)
Haemorrhage controlledYes
No
Depress proximal pressure point
P
Haemorrhage controlledYes
No
Apply tourniquetP
Small superficial
wound
Significant blood loss
No
Yes
Advise to clean wound with soap & water and apply
fresh dressing
Yes
Isolated wound& no relevant medical
historyNo
Yes
No
Consider treat & discharge
Go to CPG xx
Go to CPG A13
EMT
ConsiderOxygen therapy
Treat & Discharge MedicalCPG 25 (i) APVersion D 0.2
FromCPG xx
Satisfactory treatment of
clinical condition
Zero on MEWS ScoreNo
Yes
Discharge into care of competent
person
Hypoglycaemia Seizure
Clinical impression
History of seizures
Yes
No
Patient competentor carer takes responsibility
Yes
No
No to any
If a patient expresses a wish to attend an Emergency Department then arrangements shall be made to transport him/her there
Aid to Capacity EvaluationPatient verbalizes/ communicates;1. understanding of clinical situation?2. appreciation of applicable risk?3. ability to make alternative plan of care?If no to any of the above consider Patient Incapacity
Yes to any
No to all
Reference: British Thoracic Society, 2005, British Guidelines on the Management of Acute AsthmaC O’Donnell, 2007, Hypoglycaemia Treat and Discharge Protocol
Complete; After care Instructions and give a copy to the patient or carer
P
Confirm the following;1. History of diabetes2. Latest blood glucose > 4.53. > 30 days since last episode
Confirm the following;1. On oral hypoglycaemics2. Glucagon administered
Yes to all
Yes to any
No to all
Confirm the following;1. Multiple seizures this episode2. Received Anticonvulsant3. In postictal state
Treat & Discharge - TraumaCPG 25 (ii) APVersion D 0.3
Minor injuryFromCPG xx
Yes to any
Closed wound Open woundBurn / scald
Injury type
No to all
Superficial Haematoma
Yes
No
Yes to any
No to all
Yes to any
P
If a patient expresses a wish to attend an Emergency Department then arrangements shall be made to transport him/her there
PatientCompetent orcarer takes
responsibility
Discharge into care of competent
person
No
Yes
Aid to Capacity EvaluationPatient verbalizes/ communicates;1. understanding of clinical situation?2. appreciation of applicable risk?3. ability to make alternative plan of care?If no to any of the above consider Patient Incapacity
Injury assessment;1. LoC experienced2. Joint mobility reduced3. CSMs not intact4. Pain score > 2/10
Zero on MEWS Score
Yes
No to all
Open wound assessment;1. Haemorrhage uncontrolled2. Punctured wound3. Suture(s) required4. Foreign body imbedded5. Wound requires debriding
Burn/ scald assessment;1. Skin broken2. Circumferential injury3. TBSA > 1%
No
Complete; After care Instructions and give a copy to the patient or carer
Spinal Immobilisation – Paediatric (≤ 13 years)CPG 7a (i)Version D 0.4 AP
Equipment listExtrication deviceLong boardPaediatric boardVacuum mattressOrthopaedic stretcherRigid cervical collar
Note: equipment must be age appropriate
TraumaIndications for spinal immobilisation
Immobilisation may not beindicated
Use clinical judgementIf in doubt, immobilise
Rapid extrication with long board/ peidi board and
cervical collar
Patient in sitting position Yes
No
Life Threatening
Yes
No
Consider Vacuum mattress
Remove helmet(if worn)
Low risk factorsSimple rear end MVC (excluding push into oncoming traffic or hit by bus or truck)No neck or back painAbsence of midline c-spine or back tenderness
Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms
Yes
Use extrication device
Patient in undamaged child seat
Load onto vacuum mattress, pedi board or long board
Yes
Immobilise in child seat
No
References;Viccellio, P, et al, 2001, A Prospective Multicentre Study of Cervical Spine Injury in Children, Pediatrics vol 108, e20Slack, S. & Clancy, M, 2004, Clearing the cervical spine of paediatric trauma patients, EMJ 21; 189-193
Paediatric spinal injury indicationsPedestrian v autoPassenger in high speed vehicle collisionEjection from vehicleSports/ playground injuriesFalls from a heightAxial load to head
Are all of the factors listed present;GCS = 15Communication effective with patientNo dangerous mechanism, distracting injury or penetrating traumaNo numbness or tingling in extremitiesPresence of low risk factors which allow safe assessment of range of motionPatient voluntarily able to actively rotate neck 45o left & right pain freePatient can walk pain free
Do not forcibly restrain a paediatric patient that is combatitive
P
Apply cervical collar
Version D 0.2 Submersion incidentCPG 22
P
APSubmerged
in liquidRemove patient from liquid(Provided it is safe to do so)
Inadequate respirations
Go to CPG xxYes
No
Oxygen therapy
SPO2 & ECG monitoring
Indicationsof respiratory
distressYes
Monitor Pulse, Respirations & BP
No
Patient is hypothermic Yes Go to
CPG xx
No
Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human KineticsVerie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htmShepherd, S, 2005, Submersion Injury, Near Drowning, E Medicine, www.emedicine.com/emerg/topic744.htm AHA, 2005, Part 10.3: Drowning, Circulation 2005:112;133-135 Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances,Resuscitation (2005) 6751, S135-S170
Remove horizontally if possible(consider C-spine injury)
Do not delay on siteContinue algorithm en route
If bronchospasm consider
Salbutamol 5 mg nebule
Check blood glucose
EMT
Complete primary survey(Commence CPR if appropriate)
Request
ALS
Spinal injury indicatorsHistory of;- diving- trauma- water slide use- alcohol intoxication
Ventilations may be commenced while the patient is still in water by trained rescuers
Transport to ED for investigation of secondary drowning insult
Higher pressure may be required for ventilation because of poor compliance resulting from pulmonary oedema
Decompression Illness (DCI)CPG 24
Version D 0.2 EMT P
APSCUBA diving
within 48 hoursComplete primary survey
(Commence CPR if appropriate)
Treat in supine position
100% O2
Oxygen therapy
Conscious No
Yes
Pain relief requiredYesGo to
CPG xxEntonox absolute contraindicated
No
Reference: The Primary Clinical Care Manual 3rd Edition, 2003, Queensland Health and the Royal flying doctor Service (Queensland Section)
Monitor ECG & SpO2
Hartmann’s Solution 500 mL IV
Transport is completed at an altitude of < 300 meters above incident site or aircraft pressurised equivalent to sea level
Request
ALS
Notify control of query DCI & alerthyperbaric unit
Maintain airway
Consider diving buddy as possible patient also
Transport dive computer and diving equipment with patient, if possible
Burns – Paediatric (≤13 years)CPG 6a (i)
Version D 0.4 K
Burn or Scald Cease contact with heat source
Isolatedsuperficial injury
(excluding FHFFP)Yes No
TBSA burn > 5% Yes
Commence local cooling of burn area
Monitor body temperature
Airway management
EMT P
AP
F: faceH: handsF: feet F: flexion pointsP: perineum
Commence local cooling of burn area
Consider humidifiedOxygen therapy
Appropriate history and burn
area ≤ 1%
Yes
No
Request
ALS
Inadequate respirations
Go to CPG xxYes
No
Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114Sanders, M, 2001, Paramedic Textbook 2nd Edition, MosbyAmerican Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals, Jones & Bartlett
Caution with the very young, circumferential & electrical burns
Dressing/ covering of burn area
No
Hartmann’s Solution IV10 – 14 years = 500 mL5 – 10 years = 250 mL
> 10% TBSA and or time from
injury to ED > 1 hour
Yes
No
No
Pain > 2/10 Yes Go to CPG 13b Pain > 2/10Yes
Go to CPG xx
Inhalation and or facial injury
Paramedics are authorised to continue the established
infusion in the absence of an Advanced Paramedic or
Doctor during transportation
P
Dressing/ covering of burn area
Brush off powder & irrigate chemical burns
Follow local expert direction
Minimum 15 minutes cooling of area is recommended
Equipment listAcceptable dressingsBurns jel if < 10% TBSACling filmSterile dressingClean sheet
if > 10% TBSA
Remove burned clothing (unless stuck) & jewellery
ECG & SpO2monitoring
Immediate IO access if IV not immediately accessible
AP