Adult CPG WM - 0

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Oxygen Therapy CPG A0001
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Introduction
- This CPG should only be applied to adult Pts aged ≥ 16 years.
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Mx principles
- O2 is a Rx for hypoxaemia, not breathlessness. O2 has not been shown to have any effect on the sensation of
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breathlessness in non-hypoxaemic Pts.
- Rx is aimed at achieving normal or near normal SpO2 in acutely ill Pts. O2 should be administered to achieve a target SpO2
while continuously monitoring the Pt for any changes in condition.
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- O2 should not be administered routinely to Pts with normal SpO2. This includes those with stroke, ACS and arrhythmias.
- In Pts who are acutely SOB, the administration of O2 should be prioritised before obtaining an O2 saturation reading. O2
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can later be titrated to reach a desired target saturation range.
- If pulse oximetry is not available or unreliable, provide an initial O2 dose of 2 - 6 L/min via nasal cannulae or 5 - 10 L/min
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via face mask until a reliable SpO2 reading can be obtained.
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Special circumstances
- Early aggressive O2 administration may benefit Pts who develop critical illnesses and are haemodynamically unstable,
such as cardiac arrest or resuscitation; major trauma / head injury; carbon monoxide poisoning; shock; severe sepsis; and
anaphylaxis. In the first instance, O2 should be administered with the aim of achieving an SpO2 of 100%. Once the Pt is
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haemodynamically stable, O2 dose should be titrated to normal levels.

- Pts with chronic hypoxaemia (e.g. COPD, neuromuscular disorders, class i, ii or iii obesity etc.) who develop critical illnesses
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as above should have the same initial aggressive O2 administration, pending the results of blood gas measurements.
- If a diagnosis of COPD is unknown, it should be assumed in any Pt who is > 50 years and are long-term smokers or
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ex-smokers with a Hx of long standing breathlessness on minor exertion. Pts with COPD may also use terms such as
chronic bronchitis and emphysema to describe their condition but sometimes mistakenly use asthma.
© Ambulance Victoria 2013
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O'Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(SUPPL. 6):vi1-vi68.
Oxygen Therapy CPG A0001 1

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Special Notes General Care
• Pulse oximetry may be particularly unreliable in Pts with • O2 exchange is at its greatest in the upright position.
peripheral vascular disease, severe asthma, severe Unless other clinical problems determine otherwise,
anaemia, cold extremities or peripherally 'shut down', the upright position is the preferred position when
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severe hypotension and carbon monoxide poisoning. administering O2.
• Pulse oximetry can be unreliable in the setting of severe • Ensure the Pt's fingertips are clean of soil or nail polish.
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hypoxaemia. An SpO2 reading below 80% increases the Both may affect the reliability of the pulse oximeter
chance of being inaccurate. reading. The presence of nail infection may also cause
• All Pts with suspected carbon monoxide poisoning falsely low readings.
or pneumothorax should be given high dose O2 until • Take due care with Pts who show evidence of anxiety/
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arrival at hospital. Pts who show no clinical evidence of panic disorders (e.g. hyperventilation syndrome). O2 is
breathlessness or hypoxaemia may still benefit from this not required however no attempt should be made to
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practice. retain CO2 (e.g. paper bag breathing).
• Poisoning with substances other than carbon monoxide • All women with evidence of hypoxaemia who are more
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should be given O2 to maintain an SpO2 of 94-98%. than 20 weeks pregnant should be Mx with left lateral
Special circumstances occur in the setting of paraquat tilt to improve output.
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and bleomycin poisoning where the use of O2 therapy • Face masks should not be used for flow rates < 5 L/min
may prove detrimental to the Pt. The maintenance of due to the risk of CO2 retention.
prophylactic hypoxaemia in these Pts (SpO2 of 88-92%)
• Nasal cannulae are likely to be just as effective with
is recommended.
mouth-breathers. However, where nasal passages are
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• Irrespective of SpO2 Pt VT should be assessed to congested or blocked, face masks should be used to
ensure ventilation is adequate. deliver O2 therapy.
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? Status 8 Assess
• Evidence of hypoxaemia • Acute or chronic?
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• Breathlessness • Respiratory status
• Assess and monitor SpO2 continuously
• Consider causes of hypoxaemia
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dequate SpO2 ? Mild-moderate ? Moderate-severe hypoxaemia ? Chronic hypoxaemia
hypoxaemia • SpO2 < 85 • COPD/pulmonary disease
• SpO2 ≥ 94%
✔ Action • SpO2 85 – 93% • Neuromuscular disorders
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• No O2 required, ✔ Action  Critical illnesses, e.g. • Obesity
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reassure Pt • T
itrate O2 flow to SpO2 • Cardiac arrest or resuscitation High-concentration O2 may be
of 94 - 98% • Major trauma/head injury harmful in the COPD Pt at risk of
- Initial dose of 2 - 6 L/min
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• Carbon monoxide poisoning hypercapnic respiratory failure
via nasal cannulae
• Shock ✔ Action
- Consider simple face
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• Severe sepsis
mask 5 - 10 L/min • Titrate O2 flow to SpO2 of 88 - 92%
• Anaphylaxis
If no critical illness present
• Decompression illness - Initial dose of 2 - 6 L/min via
✔ Action nasal cannulae
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• Initial Mx - Consider simple face mask

- Initial dose nonrebreather mask 5 - 10 L/min
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10 - 15 L/min • If Pt deteriorates or SpO2

- If inadequate VT , consider BVM remains < 88%
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ventilation with 100% O2 - Rx as per Moderate-severe

• Once pt haemodynamically stable hypoxaemia
- Titrate O2 flow to SpO2 of 94 - 98%

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• If Pt deteriorates or SpO2 remains < 85%

- BVM ventilation with 100% O2
- Consider LMA as per CPG A0301
Laryngeal Mask Airway
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- Consider ETT as per CPG A0302

Endotracheal Intubation
Oxygen Therapy CPG A0001 3

? Status Stop 8 Assess 8 Consider  Action  MICA Action
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Clinical Approach CPG A0101
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This Clinical Approach is to be applied to all Pts as a basic level of care. There is an assumption in each CPG
that this is the minimum level of care that the Pt will receive prior to the application of CPG.
The exception to this rule is the Pt in immediate life threat that requires intervention during the Primary survey.
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Stop Primary survey / life threat status
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Standard precautions and PPE Immediate Mx + Sitrep
Dangers required (utilise ETHANE
mnemonic)
Response
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Airway – Consider potential for cervical spine injury
Breathing – Assist ventilations if VT inadequate
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Circulation – CPR as required
Haemorrhage – Control if life threatening
Action
N
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Rapport, rest and reassurance Apply assessment tools in
Position the Pt appropriately order of relevance
O2 Determine need for Hx taking
vs use of assessment tools
Establish if refusal or limitation of Rx documented
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Clinical Approach CPG A0101 5

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Assess History
Hx of presenting complaint Accurate Hx and assessment

Pain - verbal analogue score essential for problem
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Past medical Hx recognition
Medications Hx should include assessment
Allergies of mechanism of injury
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Other information e.g. witnesses, doctor, Poisons
Information etc.
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Assess Vital signs survey
GCS Determine time criticality to

PSA
RSA
N Mx accordingly
Accurate and thorough
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assessment in all Pts
Pattern / mechanism of injury / medical condition
Assess Secondary survey

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Head to toe assessment including evaluating pattern Early recognition of time

of injury critical patient allows
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SpO2 appropriate Mx, early request

ECG - 12 lead if required for further resources and
Temp timely Tx
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EtCO2
BGL - if required
More detailed Hx
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Determine Main Presenting Problem
The combination of subjective (PHx, Hx, Meds) and Confirm clinical reasoning with
objective (physical) data allows identification and assessment data
prioritisation of clinical problems
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Action
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Further sitrep/resource requests as needed
Consider time to hospital vs time to MICA support
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Tx to appropriate facility
Mx clinical problems with appropriate CPG – multiple
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CPGs may be required
IV access – if clinically indicated
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Reassess frequently and adapt Mx as appropriate
Final assessment at destination/handover
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Action
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Provide MICA Mx in a timely manner

Avoid unnecessary prehospital delays
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Clinical Approach CPG A0101 7

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Perfusion Assessment CPG A0102
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Special Notes Special Notes
These observations and criteria need to be taken in
context with:
- The Pt’s presenting problem.
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- The Pt’s prescribed meds.
- Repeated observations and the trends shown.
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- Response to Mx.
BP alone does not determine perfusion status.
• Perfusion definition
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The ability of the cardiovascular system to provide
tissues with an adequate oxygenated blood supply
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to meet their functional demands at that time and to
effectively remove the associated metabolic waste
products.
• Perfusion assessment
Other factors may affect the interpretation of the
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observations made, including:
- cold or warm ambient temp.
- anxiety.
- any cause of altered consciousness.
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Perfusion Assessment CPG A0102
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Perfusion status assessment
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Skin Pulse BP Conscious status
Adequate Warm, pink, 60 – 100 bpm > 100 mmHg Alert and orientated
perfusion dry systolic to time and place
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Borderline Cool, pale, 50 – 100 bpm 80 – 100 mmHg Alert and orientated
perfusion clammy systolic to time and place
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Inadequate Cool, pale, < 50 bpm or > 100 bpm 60 – 80 mmHg Either alert and orientated
perfusion clammy systolic to time and place
or altered
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Extremely Cool, pale, < 50 bpm or > 110 bpm < 60 mmHg Altered or
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poor clammy systolic or unconscious
perfusion unrecordable
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No perfusion Cool, pale, No palpable Unrecordable Unconscious
clammy pulse
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Perfusion Assessment CPG A0102 9

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Respiratory Assessment CPG A0103
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Respiratory status assessment
Normal Mild distress Moderate distress Severe distress (life threat)
General appearance Calm, quiet Calm or mildly anxious Distressed or anxious Distressed, anxious, fighting to
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breathe, exhausted, catatonic
Speech Clear and steady Full sentences Short phrases only Words only or unable to speak
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sentences
Breath sounds Usually quiet Able to cough Able to cough Unable to cough
and no wheeze
chest auscultation Asthma: mild expiratory Asthma: expiratory Asthma: expiratory wheeze +/–
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wheeze wheeze, +/– inspiratory inspiratory wheeze, maybe no
wheeze breath sounds (late)
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No crackles or LVF: may be some fine LVF: crackles at bases - LVF: fine crackles – full field, with
scattered fine basal crackles at bases to mid-zone possible wheeze
crackles,
e.g. postural
N Upper Airway Obstruction:
Inspiratory stridor
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Respiratory rate 12 – 16 16 – 20 > 20 > 20
Bradypnoea (< 8)
Respiratory rhythm Regular even cycles Asthma: may have slightly Asthma: prolonged Asthma: prolonged expiratory
prolonged expiratory expiratory phase phase
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phase
Breathing effort Normal chest Slight increase in normal Marked chest movement Marked chest movement with
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movement chest movement +/– use of accessory accessory muscle use, intercostal
muscles retraction +/– tracheal tugging
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HR 60 – 100 bpm 60 – 100 bpm 100 – 120 bpm > 120 bpm
Bradycardia late sign
Skin Normal Normal Pale and sweaty Pale and sweaty, +/– cyanosis
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Conscious state Alert Alert May be altered Altered or unconscious

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Conscious Assessment CPG A0104
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Glasgow Coma Score
A. Eye opening Score
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Spontaneous 4
To voice 3
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To pain 2
None 1 A:
B. Verbal response Score
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Orientated 5
Confused 4
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Inappropriate words 3
Incomprehensible sounds 2
None
C. Motor response
N 1 B:
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Score
Obeys command 6
Localises to pain 5
Withdraws (pain) 4
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Abnormal flexion (pain) 3

Extension (pain) 2
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None 1 C:
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Total GCS (Max. score = 15)

(A+B+C)=
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Conscious Assessment CPG A0104 11

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Time Critical Guidelines CPG A0105
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Introduction
The concept of the Time Critical Pt allows the recognition of the severity of a Pt’s condition or the likelihood of
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deterioration. This identification directs appropriate clinical Mx and the appropriate destination to improve outcome.
Covered within the Time Critical Guidelines are:
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- Triage decisions for a Pt with major trauma
- Triage decisions for a Pt with significant medical conditions
- Requests for additional resources including MICA and Aeromedical services
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- Judicious scene time Mx (e.g. should not exceed 20 min for non-trapped major trauma Pt)
- Appropriate receiving hospital and early notification
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It is important to note that the presence of time criticality does not infer a directive for speed of Tx, but rather the
concept implies there be a “time consciousness” in the Mx of all aspects of Pt care and Tx.
Time critical definitions

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Actual At the time the vital signs survey is taken, the Pt is in actual physiological distress.
Emergent At the time the vital signs survey is taken, the Pt is not physiologically distressed but does have
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a pattern of injury or significant medical condition which is known to have a high probability of
deteriorating to actual physiological distress.
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Potential At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no
significant pattern of actual Injury/illness, but does have a mechanism of injury/illness known to have
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the potential to deteriorate to actual physiological distress.

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Time Critical Guidelines CPG A0105
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Trauma triage
Pts meeting the criteria for major trauma should be triaged to the highest level of trauma care available within
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45 min Tx time of the incident in accordance with Victorian State Trauma System requirements and AV policies and
procedures.
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The receiving hospital must also be notified to ensure an appropriate reception team and facilities are available.
Mechanism of injury (MOI)
A Pt under the Trauma Triage Guidelines meets the criteria for major trauma if they have a combination of MOI and
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other co-morbidities constituting:
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• Systemic illness limiting normal activity / systemic illness constant threat to life. Examples include:
- Poorly controlled hypertension
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- Obesity
- Controlled or uncontrolled CCF
- Symptomatic COPD
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- Ischaemic heart disease
- Chronic renal failure or liver disease
• Pregnancy
• Age < 15 or > 55
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Medical triage
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Pts meeting the time critical criteria for medical conditions are regarded as having, or potentially having, a clinical
problem of major significance. These Pts are time critical and should be Tx to the nearest appropriate hospital.
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Time Critical Guidelines CPG A0105 13

Time Critical Guidelines (Trauma Triage)
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? Status
• Possible major trauma
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8 Assess vital signs
• Any of the following:
- Respiratory rate < 12 or > 24
? Vital signs are normal

• May have pattern of injury
- BP < 90 mmHg systolic C
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- Pulse > 124
8 Assess pattern of injury
- GCS < 13 • Any of the following:
- SpO2 < 90% • Penetrating injuries
- head / neck / chest / abdomen / pelvis /
axilla / groin
E • Blunt injuries
- significant injury to a single region:
C head / chest / abdomen / axilla / groin
- injuries involving two or more of the above body
N • S
regions
pecific injuries
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- limb amputations / limb threatening injuries
- suspected spinal cord injury
- burns > 20% or involving respiratory tract
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- serious crush injury
- major compound fracture or open dislocation
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- fracture to two or more of the following:
femur / tibia / humerus
- fractured pelvis
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? Significant pattern of injury
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? Vital signs not normal • Vital signs normal
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 Action  Action
• Triage to highest level of trauma service • Triage to highest level of trauma service
within 45 min within 45 min
• Consider MICA / Aeromedical support • Consider MICA / Aeromedical support
CPG A0105
IA Potentially Time Critical Not Time Critical
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? No pattern of injury
• Vital signs are normal
• May have mechanism of Injury
8 Assess mechanism of injury (MOI)
E ? No MOI
✔
-
-
Ejection from vehicle
Motor / cyclist impact > 30 km/hr
C • No pattern of Injury
 Action
-
-
-
Fall from height > 3 m

Struck on head by falling object > 3 m
Explosion
N• Triage to nearest appropriate facility if required
-
-
-
High speed MCA > 60 km/hr

Pedestrian impact
Prolonged extrication > 30 min LA
8 Assess co-morbidities
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- Age > 55
B
- Pregnancy
- Significant underlying medical condition
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? Positive MOI and co-morbidities
? Positive MOI and NO co-morbidities
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• No pattern of injury • No pattern of Injury
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• Triage to highest level of trauma service • Triage to nearest appropriate facility
within 45 min with notification
Time Critical Guidelines CPG A0105 15
Time Critical Guidelines (Medical) CPG A0105
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? Status
• Possible medical time critical
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8 Assess vital signs
- Moderate or severe respiratory distress
? Vital signs are normal

• May have significant medical condition
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- Oxygen saturation < 90% room air / 93%
8 Assess medical condition
supplemental O2
- < Adequate perfusion Any of the following:
- GCS < 13 (unless normal for Pt) • Medical symptoms / syndromes
- ACS
E - Acute stroke
- Severe sepsis, including suspected
meningococcal disease
C - Possible AAA
- Undiagnosed severe pain
N • Need for possible hyperbaric treatment e.g.
acute decompression illness or cyanide
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poisoning
• Hypothermia or hyperthermia
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B
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? Significant medical condition
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? Vital signs not normal • Vital signs normal
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• Triage to nearest appropriate facility • Triage to nearest appropriate facility
with notification with notification
• Consider MICA / Aeromedical support • Consider MICA / Aeromedical support
? Status Stop 8 Assess 8 Consider ✔ Action ✔ MICA Action
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Mental Status Assessment CPG A0106
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Observations
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A mental status assessment is a systematic method used to evaluate a Pt’s mental function. In undertaking a
mental status assessment, the main emphasis is on the person’s behaviour. This assessment is designed to
provide Paramedics with a guide to the Pt’s behaviour, not to label or diagnose a Pt with a specific condition.
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1. Appearance Neatness, cleanliness
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Pupils – size
Extraocular movements
2. Behaviour Bizarre or inappropriate
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Threatening or violent
Unusual motor activity, such as grimacing or tremors
Impaired gait
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Psychomotor retardation or agitation
N
3. Speech Rate, volume, quantity, content
4. Mood Depressed, agitated, excited or irritable
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5. Response Flat – unresponsive facial expression
Appropriate/inappropriate
6. Perceptions Hallucinations
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7. Thought content Delusions (i.e., false beliefs)

Suicidal thoughts
Overly concerned with body functions (e.g. bowels)
B
8 Thought flow Jumping irrationally from one thought to another

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9. Concentration Poor ability to organise thoughts

Short attention span
Poor memory
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Impaired judgement
Lack of insight
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Mental Status Assessment CPG A0106 17

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Cardiac Arrest CPG A0201
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Principles of CPR
CPR Adjustment for temperature

• It is assumed that CPR is commenced immediately and > 32˚C
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continued throughout cardiac arrest as required
• Standard cardiac arrest CPG
• Generic for all adult cardiac arrest conditions
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• Must not be interrupted for more than 10 sec during rhythm and
30 - 32˚C
pulse checks. If no pulse or unsure of pulse, recommence
• Double intervals between drug doses
CPR immediately
in this CPG
• Change operators every 2 min to improve CPR performance
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• Normal DCCS intervals
and reduce fatigue • Do not rewarm beyond 33oC if ROSC
• Compression depth = 1/3 chest depth
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• Rhythm / pulse check every 2 min < 30˚C
• Recommence compressions immediately post DCCS without
N
• Continue CPR and rewarming
performing a pulse check
until temp > 30˚C
• This CPG contains the recommended joules for biphasic
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• One DCCS shock only
defibrillators used in manual mode. Modern defibrillators used in
automatic mode will deliver acceptable pre-set joules. If using a • One dose of Adrenaline
monophasic device please refer to manufacturer instructions. • One dose of Amiodarone
Ratios of compressions to ventilations • Withhold Sodium Bicarbonate 8.4% IV
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Not intubated
• 30 : 2
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• Rate: approximately 100 compressions per min

- Pause for ventilations
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Intubated / LMA inserted

• 15 : 1
• Rate: approximately 100 compressions per min

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- < 8 ventilations/min
- No pause for ventilations
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Cardiac Arrest CPG A0201 19

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Cardiac Arrest CPG A0201
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First rhythm analysis should be conducted in AED mode. All subsequent analyses are at Paramedic discretion.
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 Action
• Immediately commence CPR 30 : 2. Change to 15 : 1 once airway secured with ETT/LMA
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? VF/VT (pulseless) ? PEA ? Asystole
 Action Identify and Rx causes  Action
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• Defibrillate single shock 200J - Hypoxia • Confirm rhythm with printed ECG strip
Repeat DCCS every 2/60 if VF/VT - Exsanguination • Consider CPG A0203 Withholding or
- Asthma Ceasing Resuscitation
persists
- TPT
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- Anaphylaxis
- Upper airway obstruction
C
? VF/VT persists ? PEA persists ? Asystole persists
N  Action
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• IV access / Normal Saline TKVO • IV access / Normal Saline TKVO • IV access / Normal Saline TKVO
• Adrenaline 1 mg IV every 3/60 if no output • Adrenaline 1 mg IV every 3/60 if no output • Adrenaline 1 mg IV every 3/60 if no output
• If no IV access Adrenaline 1 mg IO • If no IV access Adrenaline 1 mg IO • If no IV access Adrenaline 1 mg IO
every 3/60 if no output every 3/60 if no output every 3/60 if no output
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B
? VF/VT persists ? PEA persists ? Asystole persists

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 Action  Action  Action

• LMA • LMA • LMA
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• ETT • ETT • ETT

• If unable to obtain IV or IO • If unable to obtain IV or IO • If unable to obtain IV or IO
- Adrenaline 2 mg via ETT - Adrenaline 2 mg via ETT - Adrenaline 2 mg via ETT
- Repeat every 3/60 if no output - Repeat every 3/60 if no output - Repeat every 3/60 if no output
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? VF/VT persists ? PEA persists
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• Amiodarone 300 mg IV / IO • Normal Saline 20 mL/kg IV
Amiodarone is C/I in confirmed or • OR Normal Saline 20 mL/kg IO
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suspected TCA OD
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? VF/VT persists
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 Action
• Repeat Amiodarone 150 mg IV / IO
(max. combined dose 450 mg)
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Sodium Bicarbonate 8.4% may be administered earlier in the algorithm if hyperkalaemia suspected or in cardiac arrest secondary to TCA OD
? VF/VT persists
N
? PEA persists ? Asystole persists
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• After 15/60 Paramedic CPR • After 15/60 Paramedic CPR • After 15/60 Paramedic CPR
• Sodium Bicarbonate 8.4% • Sodium Bicarbonate 8.4% • Sodium Bicarbonate 8.4%
50 mL IV / IO 50 mL IV / IO 50 mL IV / IO
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B
? Outcome ? Outcome ? Outcome

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• If ROSC refer CPG A0202 • If ROSC refer CPG A0202 • If ROSC refer CPG A0202
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• If no ROSC refer CPG A0203 • If no ROSC refer CPG A0203 • If no ROSC refer CPG A0203
If during CPR Pt gag reflex prevents ETT, a small dose of Midazolam (1-2 mg IV) may be administered to facilitate intubation.
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The use of sedation to either assist placement of, or to maintain placement of an LMA is C/I.
Cardiac Arrest CPG A0201 21

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Cardiac Arrest (ROSC Management) CPG A0202
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CPG A0407 Inadequate Perfusion (Cardiogenic • Therapeutic hypothermia
Causes) Ensure fluid is < 8oC prior to administration.
CPG A0302 Endotracheal Intubation
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CPG A0406 Pulmonary Oedema
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N
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Cardiac Arrest (ROSC Management) CPG A0202
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? Status
• Post cardiac arrest
- Return of spontaneous circulation (ROSC)
C
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? Unintubated ? Perfusion Mx ? Therapeutic cooling ? Transport
• GCS < 10 post ROSC  Action • Pt intubated  Action
 Action • Maintain BP > 120 mmHg • Collapse to ROSC > 10/60 • Appropriate receiving
or Pt’s usual BP (if known) hospital
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• Collapse to ROSC > 10/60 • Normal functional status
- RSI as per CPG • Normal Saline and (independent with ADLs) • Notify early
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A0302 Endotracheal Adrenaline to be used as • Temp > 34.5oC • 12 lead ECG if available
Intubation required per CPG A0407
• No pulmonary oedema
- Therapeutic cooling Inadequate Perfusion
N
evident
• Collapse to ROSC < 10/60 • Accurately assess HR
• Cardiac arrest not due to
- No therapeutic cooling during movement/loading
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bleeding
- RSI as per CPG to ensure output
A0302 Endotracheal maintained throughout
Intubation if coma  Action
• Rx as per appropriate
persists despite initial CPG if condition • Assess Pt temp
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oxygenation and changes • Sedation/paralysis

perfusion Mx - Midazolam 1 - 5 mg IV
B
• Do not administer
- Pancuronium 8 mg IV
Amiodarone unless
breakthrough VF/VT • Rapid infusion cold
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occurs Normal Saline up to

2000 mL IV if available
- Cease if APO occurs

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and Rx as per CPG

A0406 Pulmonary
Oedema
- Maintain temp range
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32 - 34°C
Cardiac Arrest (ROSC Management) CPG A0202 23

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Withholding or Ceasing Resuscitation CPG A0203
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• Mass casualty incidents are in part characterised by • An Advanced Care Directive (ACD), which may include
the available resources being overwhelmed by larger a Refusal of Treatment Certificate (ROTC) may be
Pt numbers. Where this is the case AV Emergency completed by an adult (≥ 18), an agent with enduring
Management Unit provide trauma triage guidelines power of attorney or a Victorian Civil and Administrative
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for Pt assessment that may differ significantly from Tribunal appointed guardian.
guidelines used in other patient situations. • An ACD or ROTC may be sighted by attending
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• Prolonged cardiac arrest may be determined in two Paramedics or they may accept in good faith the advice
ways. The first is where there is clear evidence of of those present at the scene. If there is any doubt
decomposition / putrefaction, rigor mortis or morbid about the application of a certificate the default position
lividity. of resuscitation should be adopted.
E
• Prolonged cardiac arrest may also be an adult • A ROTC may only be completed in relation to a current
presenting in asystole (verified with three monitoring condition. When ceasing or withholding resuscitative
leads over > 30 sec) with the interval between cardiac efforts in these circumstances the attending Paramedic
C
arrest onset i.e. collapse and arrival of the crew at the must be satisfied that the Pt’s cardiac arrest is most
Pt > 10 min and where there are no compelling reasons likely due to this current condition.
N
to continue. • A Paediatric Emergency Treatment Plan includes
• Compelling reasons to commence or continue words to the effect that in the event of a significant
resuscitation include: deterioration or cardiac / respiratory arrest CPR is not
LA
- suspected hypothermia to be commenced. It should be signed by the parent /
- suspected drug OD guardian and treating doctor or medical team.
- a child (< 18) • Paramedic crews must clearly record full details of
- a family member requests continued effort the information given to them and the basis for their
- any signs of life observed including pupil reaction or decision regrading resuscitation on the PCR. This
U
agonal/ineffective gasping respiration is particularly important where a copy of the ROTC

- Pt in VF or VT. has not been sighted as it will serve if necessary as
B
• Injuries incompatible with life are where there is evidence of their good faith.
no possibility of having survived i.e. decapitation, • Under the Medical Treatment Act 1988 a person acting
incineration and there are no signs of life. This is under the direction of a registered medical practitioner
M
distinct from where it may be believed that there is no who, in good faith and in reliance on a ROTC, refuses
prospect for eventual survival due to injury severity. to perform or continue medical Rx is not guilty of
Traumatic cardiac arrest outcomes are poor but not professional misconduct or guilty of an offence or
)A
futile. liable in any civil proceedings because of the failure to

• Poor prognostic factors in cardiac arrest resuscitation perform or continue that Rx.
include unwitnessed arrest, no prior bystander CPR
and duration of cardiac arrest exceeding 30 min.
(C
Withholding or Ceasing Resuscitation CPG A0203 25

IA
R
? Status Stop
TO
• Absent signs of life • Do not attempt Pt Mx if there is risk to Paramedic safety
8 Assess
Signs of life evident
C
• Response to stimuli One or more signs of life present
• Spontaneous respiratory effort  Action
VI
• Palpable carotid pulse • Mx as per appropriate CPG
If uncertain of life status, commence immediate
resuscitation
E
No signs of life evident
C
Is this a mass casualty situation?• Pain may require IV • •
 Action
N
LA
• If Yes, refer applicable AV Emergency Response Plan
• If No, continue Hx / assessment
U
Is there no prospect of resuscitation?

• Clear evidence of prolonged cardiac arrest or
B
• Injuries incompatible with life or

• Death declared by a doctor who is, or has been at the
scene
M
 Action
)A
• If Yes, do not commence resuscitation and

• Confirm the determinants of death are present and
• Consider verification of death
• If No, continue Hx / assessment
(C
IA
R
Are there compelling reasons to withhold resuscitation?• P
TO
Adult (≥ 18) with an ACD or ROTC or
Child (< 18) with a valid Emergency Treatment Plan to not
commence resuscitation
C
 Action
• If Yes, do not commence resuscitation
VI
• Confirm the determinants of death are present
• Consider verification of death
• If No, commence resuscitation
E
C
All other presentations with no signs of life evident• P
 Action
N
• Commence immediate resuscitation
LA
Cessation of resuscitation
Adult (≥ 18) who, after 30 - 45/60 of ALS resuscitation (including DCCS /
drug therapy) has nil ROSC, no signs of life including pupil reaction and
U
agonal / gasping respiration and no compelling reason to continue

B
 Action
• Cease resuscitation
M
• Confirm the determinants of death are present

• Consider Verification of Death
)A
(C
Withholding or Ceasing Resuscitation CPG A0203 27

IA
R
TO
Verification of death
• Verification of Death refers to ‘establishing that a death has occurred after thorough clinical assessment of a body’.
• Qualified Paramedics can provide verification if in the context of employment and if there is certainty of death. Providing verification of death is
not mandatory for Paramedics.
C
• Certification of death must still ultimately be provided by a Medical Practitioner as to cause of death. This falls outside the scope of verification of
death.
VI
• Clinical assessment of a deceased person includes 6 clinical elements. These are the ‘determinants of death’:
- No palpable carotid pulse.
- No heart sounds heard for 2 min.
E
- No breath sounds heard for 2 min.
C
- Fixed (non responsive to light) and dilated pupils (may be varied from underlying eye illness).
- No response to centralised stimulus (supraorbital pressure, mandibular pressure or sternal pressure).
N
- No motor (withdrawal) response or facial grimace to painful stimulus (pinching inner aspect of elbow or nail bed pressure).
N.B. ECG strip that shows asystole over 2 min is a seventh and optional finding that may be included.
LA
Ideally the determinants of death should be evaluated 5 - 10 min after cessation of resuscitation to ensure late ROSC does not occur.
• The Verification of Death form should include all findings along with the full name of person (if known), location of death, estimated date and time
of death (if known), name of the Paramedic conducting the assessment and if the treating doctor has been notified.
• Police must be notified in cases of reportable or reviewable death with the attending crew remaining on scene until their arrival. SIDS are
U
considered reportable.
• A reportable death would include unexpected, unnatural or violent death, death following a medical procedure, death of a person held in
B
custody or care (alcohol or mental health), a person otherwise under the auspice of the Mental Health Act but not in care or a person unknown.
• A reviewable death is required following death of a child (< 18) where the death is the second or subsequent death of a child of the parent,
M
guardian or foster parent.

• The original Verification of Death form should be left with the deceased and the copy attached to the printed PCR.
)A
(C
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
29
IA
IA
Laryngeal Mask Airway (LMA) CPG A0301
R
TO
• The LMA provides improved airway and ventilation • If insertion fails and ventilation is difficult or inadequate,
Mx compared with a facemask and OPA. The LMA check position of LMA cuff using a laryngoscope. If
does not protect against aspiration, although studies minor adjustment fails to correct the problem, remove
C
have shown it to be as low as 3.5% with an LMA the LMA inflated. Immediately insert an OPA / NPA
compared to 12.4% with a BVM. The LMA should and ventilate the Pt using a BVM.
VI
therefore not be regarded as the equivalent of • Only one attempt may be made to reinsert LMA. If
endotracheal intubation. insertion fails on the second attempt, do not delay
• The LMA forms a low pressure seal around the returning to BVM using an OPA / NPA.
posterior perimeter of the larynx and when correctly • Do not over-inflate cuff.
E
inserted is seated superior to the oesophageal
• The LMA may be used for the unconscious APO
sphincter, thus enabling positive pressure ventilation
C
Pt. However, gentle assisted ventilation should be
via BVM or closed circuit resuscitator. Unconscious
provided using a closed circuit resuscitator.
Pts who accept an OPA are generally suitable for
N
insertion of an LMA. • The LMA may be inserted in left or right lateral
positions, or if entrapped, in a sitting position. Pts may
• Obese Pts have a naturally increased WOB. During
be Mx in the lateral position when the LMA has been
LA
assisted or intermittent positive pressure ventilation
correctly inserted and taped in situ, using Transpore or
they will require higher airway pressures to inflate the
Sleek, however, in general, it is recommended that Pts
lungs. They also have a higher incidence of hiatus
be Mx supine and carefully observed for aspiration.
hernia resulting in an increased likelihood of passive
regurgitation of stomach contents. • If the conscious state of the Pt improves and there is
U
an attempt to reject the LMA, remove the LMA with

the cuff inflated.
B
M
)A
(C
IA
Laryngeal Mask Airway (LMA) CPG A0301
R
? Status
8 LMA Size Chart
TO
• Unconscious Pt without gag reflex Portex
• Ineffective ventilation with BVM / oxysaver and airway Size Wt Inflation
Mx (OPA / NPA) 3 Small adult 30 - 50 kg 25 mL
• > 10/60 assisted ventilation required 4 Normal adult 50 - 70 kg 35 mL
5 Larger adult 70 - 140 kg 55 mL
C
• Unable to intubate/difficult intubation
Unique
VI
Size Wt Inflation
Stop 3 Small adult 30 - 50 kg 20 mL
• Contraindications 4 Normal adult 50 - 70 kg 30 mL
- Intact gag reflex or resistance to insertion 5 Larger adult 70 - 140 kg 40 mL
E
- Strong jaw tone and/or trismus
- Suspected epiglottitis or upper airway obstruction
i-gel quick reference guide
C
- The use of sedation to either assist placement of, or
to maintain placement of an LMA is C/I i-gel size Pt weight guide* Max size
of gastric tube
N 1.0
1.5
2 – 5 kg
5 – 12 kg
N/A
10
LA
2.0 10 – 25 kg 12
2.5 25 – 35 kg 12
3.0 30 – 60 kg 12
4.0 50 – 90 kg 12
5.0 90+ kg 14
U
*This is a guide only. Please ensure correct size is chosen corresponding

to Pt airway size
B
8 Consider
• Precautions
M
- Inability to prepare the Pt in the sniffing position

- Pts who require high airway pressures, e.g. advanced pregnancy, morbid obesity, decreased pulmonary
)A
compliance (stiff lungs due to pulmonary fibrosis) or increased airway resistance (severe asthma)
- Pts ≤ 14 years due to enlarged tonsils
- Significant volume of vomit in airway
• Side effects
(C
- Correct placement of the LMA does not prevent passive regurgitation or gastric distension
Laryngeal Mask Airway (LMA) CPG A0301 31

Version 5 - 08-06-11 Page 1 of 11
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Endotracheal Intubation Guide CPG A0302
R
TO
• The Medical Advisory Committee has authorised

endotracheal intubation by MICA Paramedics in
selected Pts.
C
• There are three intubation techniques available:
VI
- Intubation without drugs (unassisted endotracheal
intubation)
- Intubation facilitated by sedation (IFS)
- Rapid sequence intubation (RSI)
E
The appropriate technique will vary according to the
clinical setting and a Paramedic’s authorised scope of
C
practice.
• A MICA Paramedic operating alone may elect not
to use IFS or RSI until a second MICA Paramedic is
present.
N
LA
• All intubations facilitated or maintained with drug
therapy will be reviewed as part of AV's clinical
governance processes.
• The use of cricothyroidotomy is restricted to AV MICA
U
Paramedics specifically accredited in this skill by the

Medical Advisory Committee.
B
M
)A
(C
Version 5 - 08-06-11 Page 2 of 11
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Endotracheal Intubation Guide CPG A0302
R
TO
? Status
• Endotracheal intubation
C
VI
? Primary indications ? Preparation ? Insertion of ETT ? Failed intubation
• Respiratory arrest • See CPG A0303
• Cardiac arrest ? Drugs to facilitate intubation Failed Intubation
Drill
E
• GCS < 10 due to: • IFS
- Respiratory failure • RSI ? Care and maintenance
C
- Neurological injury
- OD • Sedation
- Status epilepticus • Sedation and paralysis
N
- DKA
LA
U
B
M
)A
(C
Endotracheal Intubation CPG A0302 33

Version 5 - 08-06-11 Page 3 of 11
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Endotracheal Intubation Indications, Precautions, C/Is CPG A0302
R
TO
• Primary neurological injury • Uncontrolled bleeding

- RSI should be provided unless Pt is in cardiac arrest. - In Pts with uncontrolled bleeding (e.g. ruptured AAA,
ruptured ectopic pregnancy, penetrating truncal
C
This includes Pts with absent airway reflexes.
trauma, intra-abdominal trauma, limb avulsion),
- Midazolam should not be used to control
ongoing bleeding may lead to poor cerebral perfusion
VI
combativeness prior to RSI in head injury.
and coma.
Judicious pain relief with opioids should be used. If
combativeness is preventing preoxygenation (this is - RSI in these Pts is potentially harmful. The sedation
rare), then once all preparations have been made for may drop BP further and the added scene time
increases total blood loss. The appropriate Rx for
E
RSI the Fentanyl should be given. This should settle
the Pt sufficiently to enable preoxygenation for 2 - 3 these Pts is urgent Tx and immediate surgery.
C
min, then the Midazolam and Suxamethonium - RSI should NOT be undertaken in Pts who become
should be given and the Pt intubated. unconscious when the coma is likely to be secondary
to blood loss, unless RSI is judged to be absolutely
N
• Status epilepticus
essential (unmanageably combative and/or impractical
- A continuous or recurrent seizure of 10 min duration to Tx unintubated). This applies to Pts being Tx both
LA
or no return of consciousness between episodes may by road and air Ambulance.
require intubation where there is airway / ventilation
- Airway Mx with BVM is to be maintained in conjunction
compromise which is unable to be effectively Mx
with prompt Tx. Intubation (without drugs) should be
using BVM and OPA / NPA.
considered if airway reflexes are lost, bearing in mind
U
• Suspected TCA OD the risks of delay to definitive surgical care.

- Requiring hyperventilation for cardiac arrhythmia • Severe hyperthermia
B
prevention or Mx.
- May result from drug OD or heat exposure. If after
• Overdose 10/60 of active cooling Pt temp remains > 39.5°C and
M
- The intent of the OD (difficult extrication) indication GCS < 10, then Pt should be intubated with RSI.
for RSI is for the Pt to be intubated at the scene to
)A
enable safer extrication.

(C
Version 5 - 08-06-11 Page 4 of 11
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Endotracheal Intubation Indications, Precautions, C/Is CPG A0302
R
TO
Unassisted Endotracheal Intubation IFS RSI
? Indication ? Indication GCS < 10 ? Indication GCS < 10
• Respiratory arrest • Respiratory failure • Traumatic brain injury (TBI)
• Cardiac arrest - Unresponsive to non-invasive • Non-traumatic brain injury
C
ventilation and drug therapy - Stroke / subarachnoid haemorrhage
• Absent airway reflexes
• DKA • Hypoxic brain injury
VI
- DKA with BGL reading 'high' - Post-hanging, near drowning
- ROSC as per CPG A0202 Cardiac Arrest
• OD with any of:
E
8 General precautions - Suspected TCA OD
• Time to intubation at hospital vs - Difficult extrication
C
time to intubate at scene 8 Precautions for IFS - Prolonged Tx time (> 30/60)
- SpO2 unable to be maintained > 90%
• Poor baseline neurological • As per General precautions
N
function and major co-morbidities • Severe hyperthermia
• Anticipation of difficulty with BVM
- > 39.5°C despite 10/60 of active cooling
• Advanced Care Plan / Refusal ventilation
LA
of Medical Treatment document • Status epilepticus
• Anticipation of a difficult intubation,
specifies “not for intubation” e.g. obesity, short neck or • Suspected airway burns consult only
facial trauma
• In general if Tx time < 10/60
U
then no IFS
8 Precautions for RSI
B
• As per General precautions IFS

Contraindications • In general if Tx time < 10/60 then no RSI
M
• Clinical situations where failed intubation

drill would not be feasible
Contraindications CIs
• No functional electronic capnograph

)A
• As per first two C/I IFS

• Pts indicated for RSI
• Any C/I to Suxamethonium
• Coma due to uncontrolled bleeding
(C

IA
Endotracheal Intubation Preparation CPG A0302
R
TO
C
VI
E
C
N
LA
U
B
M
)A
(C
Version 5 - 08-06-11 Page 5 of 11
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Endotracheal Intubation Preparation CPG A0302
R
TO
? General preparation for intubation ? Preparation for IFS ? Preparation for RSI
 Action
 Action
 Action
C
• Position Pt. If a cervical collar is fitted • As per General preparation for intubation • As per General preparation for intubation
it should be opened while maintaining • Pre-hydrate with Normal Saline • Pre-hydrate with Normal Saline
VI
manual cervical support 10 mL/kg IV bolus unless APO 10 mL/kg IV bolus
• Pre-oxygenate with 100% O2 • If Pt hypotensive and/or tachycardic, • If Pt hypotensive and/or tachycardic,
and electronic capnograph attached follow relevant CPG in conjunction with follow relevant CPG in conjunction with
• Ensure pulse oximeter and cardiac the intubation process the intubation process
E
monitor are functional • Draw up and label drugs as appropriate • Adrenaline not to be given in
hypovolaemic shock
C
• Prepare equipment and assistance
- Suction • Draw up and label drugs as appropriate
- ETT (plus one size smaller than
N
predicted immediately available) with
introducer
LA
- ODD
- Ensure equipment for a difficult / failed
intubation is immediately available,
including bougie, LMA,
U
cricothyroidotomy kit
- Mark cricothyroid membrane as
necessary
B
- Brief assistant to provide cricoid

pressure, where appropriate
M
- If suspected spinal injury, where

possible a second assistant should be
available to stabilise the head and neck

)A
• Ensure functional and secure IV access

(C

Version 5 - 08-06-11 Page 6 of 11
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Endotracheal Intubation Drugs CPG A0302
R
TO
Special Notes Dosage RSI
• Sedation doses for RSI are based on initial Age < 60 Dose
observations. This is especially important in BP < 80 mmHg 1/4 or 1/2 Fentanyl
multi-trauma with TBI. Initial fluid challenges may Midazolam 1 mg
C
resolve tachycardia and/or hypotension, however the BP 80 - 100 mmHg Half
Pt is still at risk of cardiovascular compromise and
BP > 100 mmHg, HR > 100 bpm (TBI only) Half
VI
the BP must be strenuously supported. Half doses
(or less) of sedation are required in this situation. BP > 100, HR > 100 bpm (all other) Full
• In Pts with extremely poor perfusion, Rx with fluid Age ≥ 60

therapy +/- Adrenaline infusion concurrently with
E
BP < 80 mmHg 1/4 or 1/2 Fentanyl
IFS or RSI. Consider quarter doses of sedation.
Midazolam 1 mg
C
• Frail, elderly or hypotensive Pts have prolonged BP > 80 mmHg Half
circulation times. Allow for this when giving a second
N
dose of sedation during IFS.
Dosage IFS
LA
Age < 60 Dose
BP < 100 mmHg Half
BP > 100 mmHg Full
U
Age ≥ 60 Half dose for all

B
M
)A
(C
Version 5 - 08-06-11 Page 7 of 11
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Endotracheal Intubation Drugs CPG A0302
R
TO
 Action Adjusted sedation dose required Adjusted sedation dose required
• Proceed with intubation
- no drugs required ? Half dose sedation required ? Reduced dose sedation required if either:
C
• BP < 100 mmHg and/or age ≥ 60 • BP < 80 mmHg
• BP 80 - 100 mmHg
VI
 Action
• HR > 100 mmHg (TBI only)
• Fentanyl 50 mcg IV
• Age ≥ 60
• Midazolam 0.05 mg/kg IV (max. 5 mg)
 Action
E
? Full dose sedation required
C
- If BP < 80 mmHg consider
• BP > 100 mmHg and age < 60
Fentanyl 25 mcg IV
 Action
N
• Fentanyl 100 mcg IV • Midazolam 0.05 mg/kg IV (max. 5 mg)
- If BP < 80 mmHg give Midazolam 1 mg IV
• Midazolam 0.1 mg/kg IV (max. 10mg)
LA
? Full dose sedation required

? If unable to intubate due to • BP > 100 mmHg and age < 60
excessive tone
 Action
U
 Action
• If GR 1 or 2 view but respiratory effort or
B
• Midazolam 0.1 mg/kg IV (max. 10 mg)

airway reflexes are preventing intubation
- R
epeat same dose of sedation and
? Paralysing agent
M
reattempt intubation once only

 Action
• If GR 3 or 4 view
• If Pt bradycardic at any stage

)A
- Refer to CPG A0303 Failed Intubation

Drill - Atropine 600 mcg IV
• Suxamethonium 1.5 mg/kg IV
round up to nearest 25 mg (max. 150 mg)
(C

Version 5 - 08-06-11 Page 8 of 11
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Endotracheal Intubation Insertion of ETT CPG A0302
R
TO
Insertion of Endotracheal Tube General Care of the Intubated Pt
• Observe passage of ETT through cords noting • Reconfirm tracheal placement using EtCO2 after every
Australian Standard (AS) markings and grade of view. Pt movement. Disconnect and hold ETT during all
• Check ETT position using ODD. transfers.
C
• Inflate cuff. • If electronic capnography fails after intubation, use
colourimetric capnometry.
VI
• Confirm tracheal placement via capnography (NB: Pt in
cardiac arrest may not have CO2 initially detectable). • Suction ETT and oropharynx in all Pts.
• Exclude right main bronchus intubation by performing • If time permits, insert OG or NG tube, aspirate and
the cuff palpation (tracheal squash) test and by connect to drainage bag. The OG route must be
E
comparing air entry at the axillae. used in head or facial trauma.
• Note length of ETT at lips/teeth. • Ventilate using 100% O2 and tidal volume of 10 mL/
C
kg. Aim to maintain SpO2 > 95% and EtCO2 at
• Auscultate chest / epigastrium.
30 - 35 mmHg (except asthma / COPD where a
• Note supplemental cues of correct placement (e.g. tube higher EtCO2 may be permitted, TCA OD where
N
misting, bag movement in the spontaneously ventilating the target is 20 - 25 mmHg and DKA where the
Pt, improved O2 saturation and colour). EtCO2 should be maintained at the level detected
LA
• Secure the ETT and insert a bite block if required. immediately post-intubation, with a max. of 25
• If there is ANY doubt about tracheal placement, mmHg).
the ETT must be removed. • Document all checks and observations made to
• If unable to intubate after ensuring correct technique confirm correct ETT placement.
U
proceed to CPG A0303 Failed Intubation Drill.

B
M
)A
(C
Version 5 - 08-06-11 Page 9 of 11
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Endotracheal Intubation Insertion of ETT CPG A0302
R
TO
? Status
8 Indications
• Insertion / general care of ETT
- Unassisted endotracheal intubation
- IFS
C
- RSI
VI
? Insertion and checks of ETT
E
 Action
• ODD ? General care / ventilation
C
• Capnography - EtCO2  Action
• Length lips / teeth • ETT checks with each Pt movement
• Cuff palpation
• Auscultate chest / epigastrium
N • Provide circulatory support if hypotension present
LA
• Use colourimetric capnometry if capnography fails
- Chest rise and fall, bag movement, SpO2,
• Suction ETT and oropharynx
colour, tube misting
• Specific insertion instructions as per Insertion • Insert OG / NG tube
of ETT • Ventilate VT 10 mL/kg, EtCO2 30 - 35 mmHg
U
if appropriate to Pt condition
• If there is ANY doubt about tracheal
placement, the ETT must be removed • Disconnect and hold ETT during transfers
B
• Specific instructions as per General care

of the intubated Pt
M
)A
(C

Version 5 - 08-06-11 Page 10 of 11
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Endotracheal Intubation Care and Mx of Intubated Pt CPG A0302
R
TO
• For Pts who become hypotensive after intubation, • Infusion
consider reducing the dose of sedation, in association - Morphine 30 mg + Midazolam 30 mg in 30 mL
with additional fluid +/- Adrenaline infusion according D5W or Normal Saline
C
to the clinical setting. - 1 mL = 1 mg each drug
• Not all Pts receiving RSI will require paralysis post - 1 mL/hr = 1 mg/hr
VI
intubation, e.g. continuous convulsions, OD other than • Fentanyl 300 mcg + Midazolam 30 mg in 30 mL
TCA. D5W or Normal Saline
• Some Pts receiving IFS may require paralysis post - 1 mL = 1 mg Midazolam + 10 mcg Fentanyl
intubation to control ventilation e.g. asthmatic Pt.
E
• Handover
• TBI Pts require paralysis post intubation to prevent
- The EtCO2 and respiratory wave form immediately
C
gagging and elevation in ICP. Ideally this should be
prior to Pt handover must be demonstrated to the
given before the Suxamethonium wears off, provided
receiving physician and documented on the PCR.
tracheal placement is confirmed and the ETT is
secured.
• Non traumatic brain injured Pts i.e. stroke, SAH, do not
N
LA
routinely require paralysis post intubation. Administer
where sedation alone cannot maintain intubation.
U
B
M
)A
Paralysis is C/I in status epilepticus, where clinical monitoring of seizure activity is required. Use additional doses of
Midazolam as required.
(C
Version 5 - 08-06-11 Page 11 of 11
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Endotracheal Intubation Care and Mx of Intubated Pt CPG A0302
R
TO
8
? Status
Indications 8 Consider
• Intubated Pt • If Pt requires sedation or sedation and paralysis to maintain intubation and ventilation
C
8 Post intubation sedation
? Indications ? Post
8 intubation paralysis
Indications
VI
• Restlessness / signs of under-sedation in the absence of • Prevention of shivering for Pts receiving therapeutic cooling
other noxious stimuli • Primary neurological Pts
- e.g. ETT too deep / irritating, occult pain
• Where sedation alone is ineffective at maintaining intubation or
• Signs of inadequate sedation
E
allowing adequate ventilation / oxygenation
Paralysed Pt Non paralysed Pt • As prescribed for interhospital transfer
- HR and BP trending up together - As per Paralysed
C
- Lacrimation - Cough / gag / movement • Reduction of metabolic heat production in hyperthermia
- Diaphoresis
N

Stop
? Sedation • All Pts receiving paralysis MUST receive ongoing sedation
LA
Action
 • The ETT must be secured and tracheal placement reconfirmed with
• Morphine / Midazolam infusion 1 - 10 mL/hr IV electronic capnography
- 0.5 mg - 5 mg IV boluses as required • C/I for Pt in status epilepticus

U
• Until Morphine / Midazolam infusion established:

- Midazolam 0.5 mg - 5 mg IV as required or ? Sedation and paralysis
B
- Midazolam / Morphine 0.5 mg - 5 mg IV each drug Action


OR
M
• Sedate as per Post intubation sedation

• Fentanyl / Midazolam infusion 1 - 10 mL/hr • Pancuronium 8 mg IV
- Repeat if evidence of returning muscular activity

)A
(movement, chewing, cough, gag, curare cleft)

(C

IA
Failed Intubation Drill CPG A0303
R
? Failed Intubation
Indications
TO
• Unable to see vocal cords during initial laryngoscopy

Action

• Insert OPA and ventilate with 100% O2
C

VI
Action

• Reattempt intubation using bougie with blind placement
of ETT over bougie
E

8 Consider Yes Action

C 
• Objective confirmation of tracheal placement using EtCO2 • Continue Mx in accordance with relevant CPG
No

Action

N
• Immediately remove ETT, insert OPA / NPA and ventilate with 100% O2
LA

8 Consider Yes
• Able to ventilate and oxygenate
U
No

Action

B
• Insert LMA
M

8 Consider Yes
• Able to ventilate and oxygenate

)A
 
Action


No
Action
 • If sedation / relaxant drugs administered allow these to

• Cricothyroidotomy wear off and Pt to resume normal respiration

(C
IA
Cricothyroidotomy CPG A0304
R
TO
? Status
8 Stop
• Unconscious Pt unable to be oxygenated and • Contraindications

ventilated using BVM and OPA, NPA, LMA or ETT - There are no C/Is when oxygenation and ventilation
where: cannot occur with other techniques
C
- RSI has been attempted but intubation has not
been achieved
VI
- RSI is not authorised
- Massive facial trauma is present and RSI is
considered unsafe due to the inability to undertake
E
the failed intubation drill
- RSI is not possible due to lack of IV / IO access
C
- Upper airway obstruction is present due to a
pharyngeal or an impacted foreign body which is
N
unable to be removed using manual techniques and
Magill's forceps  Action
LA
- Partial airway obstruction is present and Tx by Air • Perform cricothyroidotomy using approved kit
Ambulance is required and expertise for alternative
techniques is not available.
U
B
M
)A
(C
Cricothyroidotomy CPG A0304 45

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
47
IA
IA
Acute Coronary Syndromes CPG A0401
R
TO
• ACS is a spectrum of illnesses including:
- UA
- STEMI
C
- NSTEACS
• Not all Pts with ACS will present with pain, e.g. diabetic
VI
Pts, atypical presentations, elderly Pts.
• The absence of ischaemic signs on the ECG does not
exclude AMI. AMI is diagnosed by presenting Hx, serial
ECGs and serial blood enzyme tests.
E
• Suspected ACS related pain that has spontaneously
C
resolved warrants investigation in hospital.
• The goals of prehospital Mx in ACS are to facilitate
N
timely reperfusion where available and resolve pain
completely to reduce cardiac workload.
LA
• In patients who may be eligible for thrombolysis,
invasive procedures should only be conducted
according to clinical need and with the potential for
increased bleeding risk in mind.
U
• Current evidence suggests Tx to a PCI-enabled facility

improves Pt outcomes in STEMI Tx time < 90 min.
B
M
)A
(C
IA
Acute Coronary Syndromes CPG A0401
R
TO
? Status 8 Consider
• ACS • Consider the spectrum of
- UA illnesses within ACS
- STEMI
C
- NSTEACS
VI
E
? ACS Mx ?
Nausea / vomiting ? LVF ? Inadequate perfusion
 Action  Action  Action  Action
C
• General Principles • See CPG A0701 • See CPG A0406 • See CPG A0407
of ACS Mx Nausea and vomiting Pulmonary Oedema Inadequate Perfusion
N ? Arrhythmia Mx
LA
 Action
• See
CPG A0201 VF/VT (pulseless)
U
CPG A0402 Bradycardia

CPG A0403 Supraventricular Tachyarrhythmias
CPG A0404 Ventricular Tachycardia
B
CPG A0405 Accelerated Idioventricular Rhythm

M
)A
(C
Acute Coronary Syndromes CPG A0401 49

IA
Acute Coronary Syndromes General Mx Principles CPG A0401
R
TO
• GTN is a potent venodilator. It reduces C.O. via
reduced venous return.
• Signs of an inferior AMI include ST elevation in leads II
C
and III. Bradycardia is not unusual in an inferior AMI due
to the involvement of the right coronary artery and the
VI
SA and A-V nodes.
• Nitrates are C/I in bradycardia (HR < 50 bpm) due
to the Pt’s inability to compensate for a decrease in
venous return by increasing HR to improve cardiac
E
output.
- C.O. = HR X SV
C
• Where this CPG refers to GTN S/L, buccal
administration can be substituted if required.
N
LA
U
B
M
)A
The use of GTN is C/I in suspected inferior or right ventricular infarcts, as these Pts may not compensate for a drop in venous return.
(C
IA
Acute Coronary Syndromes General Mx Principles CPG A0401
R
TO
? Status 8 Assess requirement for:
• ACS • Pain relief / nitrates
• Control of hypertension
C
• Antiplatelet Rx
VI
? Antiplatelet Rx ? Nitrates ? Pain Relief
Action
✔ Action
✔ Action
✔
E
• Aspirin 300 mg oral • BP > 110 mmHg • Pain relief as per CPG A0501
- GTN 300 mcg S/L (no prev. admin.) or Pain Relief
C
- GTN 600 mcg S/L - Rx until pain free
• If symptoms continue and BP remains > 110 mmHg
- Repeat 300 - 600 mcg S/L @ 5/60
N
• BP > 90 mmHg
- GTN patch 50 mg (0.4 mg/hr) upper torso / arms
LA
- If BP falls < 90 mmHg, remove patch
? Hypertension +/- symptoms

U
✔ - SBP > 160 mmHg or

- DBP > 100 mmHg
B
• Control pain as per CPG A0501 Pain Relief

M
• GTN 300 mcg S/L

- Repeat 300 mcg @ 5/60 if hypertension persists
)A
(C
Acute Coronary Syndromes CPG A0401 51

IA
Bradycardia CPG A0402
R
TO
• Atropine is unlikely to be effective in complete heart • Adrenaline Infusion
block, however should still be administered. - Adrenaline 3 mg added to make 50 mL with
• If side effects occur during Adrenaline infusion, cease D5W or Normal Saline.
C
infusion and recommence once side effects resolve - 1 mL/hr = 1 mcg/min
titrating to Pt response. • If no response from Adrenaline infusion @
VI
• If no increase in HR, pacing is likely to be required. 20 mcg/min, increasing infusion rate is unlikely to
• Notify appropriate hospital capable of managing a Pt have additional chronotropic effects.
likely to require pacing.
E
• Bradycardia is technically defined as less than 60 bpm.
In practical purposes many Pts will have a normal HR
C
between 50 bpm and 60 bpm. Decisions to Rx should
consider this and the more likely need to consider 50
bpm as the limiting point for Mx.
N
LA
U
B
M
)A
(C
IA
Bradycardia CPG A0402
R
? Status 8 Assess
TO
• Evidence of bradycardia • Perfusion status
• Cardiac rhythm
• Heart failure
• Ischaemic chest pain
C
VI
? Stable ? Unstable
• Asymptomatic • Less than adequate perfusion
• Adequate perfusion - including acute STEMI and ischaemic chest pain
E
• HR > 20 bpm • Profound bradycardia (HR < 40 bpm) and full field APO
C
✔ Action • Runs of VT or ventricular escape rhythms
• BLS • HR < 20 bpm
N
• Rx as per Unstable if Pt ✔ Action
deteriorates • Atropine 600 mcg IV
LA
- If no response @ 3 - 5/60 repeat 600 mcg
(max. 1200 mcg)
U
? Adequate perfusion achieved ? Inadequate or extremely poor perfusion persists

✔ Action  Action
B
• Continue current Mx • Adrenaline infusion (3 mg/50 mL D5W / Normal Saline)

commencing @ 5 mcg/min (5 mL/hr)
M
• Tx
- Increase by 5 mcg/min @ 2/60 until adequate perfusion/side
effects (max. 20 mcg/min)
)A
- If syringe pump unavailable

- Adrenaline 10 mcg IV
- Repeat 10 mcg IV @ 2/60 until adequate perfusion / side effects
• If poor perfusion persists Rx as per CPG A0407 Inadequate
(C
Perfusion Cardiogenic Causes
Bradycardia CPG A0402 53

IA
Tachyarrhythmias CPG A0403
R
TO
This CPG contains the recommended joules for biphasic
defibrillators used in manual mode. If using a monophasic
device please refer to manufacturer instructions.
C
VI
E
C
N
LA
U
B
M
)A
(C
IA
Tachyarrhythmias CPG A0403
R
TO
? Status
• Tachyarrhythmias
C
VI
? QRS ≤ 0.12 sec QRS > 0.12 sec
?
• Rate > 100 bpm • VT > 30 sec
• Absent or abnormal P waves • Rate > 100 bpm
- SVT (A-V nodal rhythms or AVRT)
E
• Wide and bizarre
- AF, atrial flutter • Generally regular
C
- Sinus tachycardia
• A-V dissociation / absence of P waves
- Atrial tachycardia
N
LA
? Adequate perfusion ? < Adequate perfusion / unstable ? VT
• See CPG A0403 Supraventricular • See CPG A0403 Supraventricular • See CPG A0404 Ventricular
U
Tachyarrhythmias Tachyarrhythmias Tachycardia

B
M
)A
(C
Tachyarrhythmias CPG A0403 55

Version 5 – 12.09.12 Page 1 of 2
IA
Supraventricular Tachyarrhythmias CPG A0403
R
TO
• Symptomatic S/S • The valsalva manoeuvre is reserved exclusively for Pts
- Rate related severe or persistent chest pain. with a BP ≥ 100 mmHg.
- SOB with crackles.
C
• Where available a 12 lead ECG should be recorded prior
• A Pt eye opening to pain but not to voice commands to Mx unless the Pt requires immediate Rx.
would also be likely to be making incomprehensible
VI
• Perform 3 lead ECG where 12 lead is unavailable.
sounds and making purposeful movements in response
to pain. i.e. a GCS of 9 (E2, V2, M5). Sedation should Valsalva instruction
be used cautiously in these Pts. • Evidence suggests a greater reversion rate with an
abdominal valsalva manoeuvre with the following 3
• If Pt is unconscious or becomes unconscious at any
E
elements.
time during Rx perform immediate synchronised
cardioversion. 1. Position
C
- supine.
• If the available device does not select 75 J, select
2. Pressure
nearest option up or down.
N
- At least 40 mmHg for max. vagal tone. Best
• The effectiveness of the Pt’s respirations should be achieved with Pt blowing into a 10 mL syringe
continuously monitored. hard enough to move the plunger to create this
LA
• Atrial flutter and AF should not be treated under this pressure.
CPG except if the Pt is rapidly deteriorating. 3. Duration
• If wide complex QRS or unsure of diagnosis, Rx as for - At least 15 sec if tolerated by Pt.
CPG A0404 Ventricular Tachycardia. Ref. G. Smith, A. Morgans and M. Boyle Emerg Med J 2009; 26: 8-10.
U
doi: 10.1136 emj.2008.061572

• IV Adenosine should be administered through
• Expect transient ectopic activity for up to 30 sec. If
a large vein closer to the heart such as in the
B
present, administer O2 therapy until signs resolve.

cubital fossa.
Ongoing arrhythmia should be Mx as per appropriate
M
CPG.
• Rx Pt symptomatically in accordance with appropriate
CPG and Tx for further assessment and Rx.

)A
(C
Version 5 – 12.09.12 Page 2 of 2
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Supraventricular Tachyarrhythmias CPG A0403
R
? Status 8 Assess
TO
• SVT (AVNRT or AVRT) • Perfusion status
• Unstable – deteriorating rapidly • Patient stability
SVT, AF, atrial flutter • Narrow complex tachycardia
C
VI
Stop
• Exclude AF and atrial flutter
? Unstable – deteriorating rapidly
E
• Rapidly deteriorating
• Altered conscious state
C
? SVT – Stable BP ≥ 100 ? SVT - Unstable not rapidly
• Includes AF, atrial flutter
 Action deteriorating BP < 100
N
Action

• Where available, record 12  Action • Synchronised cardioversion
Lead ECG prior to
LA
• Where available, record 12 Lead - Sedate Midazolam 2.5mg IV
commencing Mx ECG prior to commencing - Repeat Midazolam 2.5mg IV @ 2/60 until
• Abdominal valsalva Mx Pt does not respond to verbal stimuli but
- Repeat x 2 @ 2/60 • Adenosine 6 mg IV push does respond to pain
U
If no reversion after 2/60 - Cardioversion: DCCS 75 J single shock

- Adenosine 12 mg IV push - If unsuccessful repeat DCCS using 150 J if
If no reversion after further 2/60
B
required
- Adenosine 12 mg IV push
M
? Reversion ? No reversion ? Reversion ? No reversion ? Loss of output

)A
 Action  Action  Action  Action  Action

• BLS • Mx as per SVT • BLS • Pain relief as per CPG A0501 • As per appropriate
• O2 therapy if any – unstable not rapidly • O2 therapy if any Pain Relief CPG
(C
ectopic activity is deteriorating ectopic activity is • BLS

observed observed
Supraventricular Tachyarrhythmias CPG A0403 57

IA
Ventricular Tachycardia (VT) CPG A0404
R
TO
• A Pt eye opening to pain but not to voice commands • ALS crews should considerer MICA R/V vs Tx to
would also be likely to be making incomprehensible appropriate hospital as these Pts are dynamic and have
sounds and making purposeful movements in response a potential to deteriorate
C
to pain, i.e. a GCS of 9 (E2, V2, M5). Sedation should • Pt presenting symptomatic and poorly perfused is likely
be used cautiously in these Pts. to require sync. cardioversion prior to Amiodarone
VI
• The effectiveness of the Pt’s respirations should be administration.
continuously monitored
• Amiodarone and Fentanyl have the potential
to interact adversely. Concurrent administration
E
should be avoided. If Fentanyl has already been
administered, monitor the Pt closely when administering
C
Amiodarone.
N
LA
U
B
M
)A
(C
IA
Ventricular Tachycardia (VT) CPG A0404
R
TO
? Status 8 Assess
• VT • Confirm VT
- VT > 30 sec
- Mostly regular
C
- QRS > 0.12 sec
- Rate > 100 bpm
VI
- A-V dissociation / absence of P waves
E
? Stable: Adequately perfused ? Unstable / Rapidly deteriorating
C
Action
✔ Action
✔
• Amiodarone infusion 5mg/kg IV • Synchronised cardioversion
N
(max. 300mg) over 20/60 once only - Sedate: Midazolam 2.5mg IV
• Rx as per Unstable if Pt deteriorates - Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not respond
to verbal stimuli but does respond to pain
LA
Only dilute Amiodarone with D5W
- Cardioversion 150 J
o not administer Amiodarone if suspected
D - If unsuccessful repeat using 150 J if required
TCA OD. Mx as per CPG A0707 Overdose:
TCA
U
B
? Loss of output ? Reversion

✔ Action Action
✔
M
• As per appropriate CPG • Narrow complex

- Amiodarone infusion as above
)A
(if not already established)

• Other rhythms
- Rx as per appropriate CPG
(C
Ventricular Tachycardia (VT) CPG A0404 59

IA
Accelerated Idioventricular Rhythm (AIVR) CPG A0405
R
TO
• AIVR is usually a benign rhythm but may be associated
with AMI, reperfusion or drug toxicity.
• Commonly seen in post cardiac arrest Pts.
C
• May be associated with Adrenaline administration.
VI
E
C
N
LA
U
B
M
)A
(C
IA
Accelerated Idioventricular Rhythm (AIVR) CPG A0405
R
TO
? Status 8 Assess
• AIVR • Perfusion status
C
VI
? Adequate perfusion ? < Adequate perfusion ? No perfusion
Action
✔ Action
✔
• BLS • Rx as per CPG A0201
Pulseless Electrical Activity
E
• Tx
C
? Ventricular rate < 60 bpm
✔ Action ✔ Action
N
? Ventricular rate 60 - 100 bpm ? Ventricular rate > 100 bpm
✔ Action
LA
• Rx as per CPG A0402 • Normal Saline 250 mL IV • Rx as per CPG A0404
Bradycardia bolus Ventricular Tachycardia
- Repeat 250 mL IV if perfusion
status not improved
U
B
M
)A
(C
Accelerated Idioventricular Rhythm (AIVR) CPG A0405 61

IA
Pulmonary Oedema CPG A0406
R
TO
• This CPG is primarily directed at cardiogenic pulmonary • Mx chest pain as per CPG A0401 Acute Coronary
oedema, secondary to LVF or CCF. Other medical Syndromes.
causes of pulmonary oedema should not be treated • Frusemide should be used cautiously in the
C
under this CPG. hypotensive Pt.
• Non-medical causes include: smoke inhalation / • Pts with pulmonary oedema presenting with a wheeze
VI
toxic gases, near drowning (aspiration) and anaphylaxis. should only be Mx as per CPG A0601 Asthma
In these cases pulmonary oedema is likely a result of if a PHx of bronchospasm can be confirmed.
altered permeability. These causes should be treated
• Avoid the use of Salbutamol in the setting of
with O2 therapy and assisted ventilations and do not
E
pulmonary oedema where possible.
require nitrates.
• Where this CPG refers to GTN S/L, buccal
C
administration can be substituted if required.
N
LA
U
B
M
)A
(C
IA
Pulmonary Oedema CPG A0406
R
TO
? Status 8 Assess
• Pulmonary oedema • Consider causes: LVF / CCF, nutritional deficiency, liver disease, renal disease, fluid overload
• Respiratory status
C
? Not short of breath ? Short of breath
VI
✔ Action
• BLS
• If deteriorates, Rx as ? Full field crackles
per SOB
E
✔ Action
• GTN as per Basal / midzone crackles
C
? Basal / midzone crackles • Frusemide 40 mg IV or Pt’s daily dose IV as
✔
Action a single dose (max. 100 mg)
• BP > 110 mmHg
N
- GTN 300 mcg S/L (no prev. admin.) or
• If alert and anxious
- Consider Morphine 1 - 2 mg IV
LA
- GTN 600 mcg S/L
- If BP > 110 mmHg and symptoms continue
repeat 300 - 600 mcg S/L @ 5/60 ? No improvement or deteriorates
• BP > 90 • Suction if required
U
- GTN patch 50 mg (0.4 mg/hr) upper torso/arms - Provide assisted ventilation with 100% O2
• Remove GTN patch if BP decreases < 90 if inadequate VT or RR
B
mmHg • CPAP if available

• Frusemide 20 - 40 mg IV
M
• Consider ETT as per CPG A0302

?
No improvement or deteriorates
)A
• Rx as for Full field crackles

(C
Pulmonary Oedema CPG A0406 63

IA
Inadequate Perfusion Cardiogenic causes CPG A0407
R
TO
• Any IV infusions established under this CPG must be • Adrenaline infusion > 50 mcg/min may be required
clearly labelled with the name and dose of any additive to Mx these Pts. Ensure delivery system is fully
drugs and their dilution. operational (e.g. tube not kinked, IV patent) prior to
C
• A Pt presenting with inadequate to extremely poor increasing dose.
perfusion resulting from a cardiac event may not • Unstable Pts may require bolus Adrenaline
VI
always have associated chest pain, e.g. silent MI, concurrently with the infusion.
cardiomyopathy. • Adrenaline infusion
• Pts presenting with suspected PE with inadequate to - Adrenaline 3 mg added to make 50 mL with D5W
extremely poor perfusion should be Mx with this CPG.
E
or Normal Saline.
PE is not specifically a cardiac problem but may lead
- 1 mL/hr = 1 mcg/min
to cardiogenic shock due to an obstruction to venous
C
return and the Pt may require fluid and Adrenaline
therapy.
N
LA
U
B
M
)A
(C
IA
Inadequate Perfusion Cardiogenic causes CPG A0407
R
TO
? Status Stop
• Inadequate perfusion: cardiogenic causes • Mx other causes, e.g. arrhythmia, pain, hypovolaemia
8 Assess
C
• Signs of pulmonary oedema (crackles)
VI
? Crackles ? No crackles
E
• Adrenaline infusion as per • Normal Saline 250 mL IV
C
Inadequate or extremely poor - Repeat 250 mL IV if chest clear and inadequate or extremely poor
perfusion perfusion persists
? Inadequate or extremely poor perfusion persists

N
LA
 Action
• Adrenaline infusion (3 mg/50mL D5W / Normal Saline) commencing @ 5 mcg/min (5 mL/hr)
- Increase by 5 mcg/min @ 2/60 until adequate perfusion/side effects
U
- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min
- If syringe pump unavailable:
B
- repeat 10 mcg @ 2/60 until adequate perfusion / side effects
M
- If poor response

- Adrenaline 50 - 100 mcg IV as required
- NB. Doses > 100 mcg may be required

)A
• If chest clear continue Normal Saline 250 mL IV boluses up to 20 mL/kg

(C
Inadequate Perfusion Cardiogenic causes CPG A0407 65

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
67
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Pain Relief CPG A0501
R
TO
• The preferred choice for non IV therapy is IN • ALS Paramedics must consult prior to exceeding the
Fentanyl. 20 mg max. dose of Morphine and administer according
• The administration of Methoxyflurane and IN to Pt need or the onset of adverse side effects.
Fentanyl should not routinely occur in the same Pt. • The effect of Morphine IM on pain relief is slow and
C
• The max. dose of Methoxyflurane is 6 mL per 24 hr variable. This route must be used as a last resort and
period. strictly within indicated CPGs.
• Be cautious of administering Fentanyl and Morphine
VI
• Opioid pain relief should not be administered during
to the same Pt.
late second stage of labour. If opioids have been
• If respiratory depression occurs due to opioid administered, Naloxone should not be administered to
administration Mx as per CPG A0707 Overdose.
the newborn.
E
• Headache should be Mx as per this CPG – Severe
headache.
C
Fentanyl IN preparation
N
LA
All adult doses must be prepared from 600 mcg/2 mL in a 1 mL syringe To administer Fentanyl, draw up desired vol
according to dose table for the corresponding
All doses include 0.1 mL to account for atomiser dead space —
weight and age then atomise into Pt’s nostril.
Doses have been rounded to the nearest 0.05 mL.
The max. amount to be atomised into any
U
Age < 60 and Age ≥ 60 and/or nostril is 1 mL. In some instances it may be
Wt > 60 kg Wt ≤ 60 kg appropriate to administer half of the vol into
each nostril as optimal absorption occurs with
B
Initial dose 200 mcg 100 mcg

volumes of 0.3 - 0.5 mL. This is also dependent
Volume 0.75 mL 0.45 mL on Pt compliance.
M
Subsequent dose 50 mcg 50 mcg

Volume 0.25 mL 0.25 mL

)A
Subsequent dose 25 mcg 25 mcg

Volume 0.2 mL 0.2 mL
(C
IA
Pain Relief CPG A0501
R
TO
? Status 8 Assess
• Complaint of pain • Pain score > 2
• Determine requirement for IV vs non IV therapy
C
VI
? Non IV therapy ? IV therapy
• Pain likely to be controlled by non IV therapy or • Pain may require IV opioid and ongoing therapy
• Unable to obtain IV  Action
If Action
E
• Morphine up to 5 mg IV
• Fentanyl IN - Repeat Morphine up to 5 mg IV @ 5/60 (max. 20
C
- If age < 60 and > 60kg : Fentanyl 200 mcg IN mg) titrated to pain or side effects
- Repeat up to 50 mcg IN @ 5/60 titrated to pain or • Unable to obtain IV access
N
side effects (max. dose 400 mcg) - > 60 kg : Morphine 10 mg IM
- If age ≥ 60 and/or ≤ 60 kg : Fentanyl 100 mcg IN - Repeat Morphine 5 mg IM after 15/60 (once only)
- Repeat up to 50 mcg IN @ 5/60 titrated to pain or
LA
if required
side effects (max. dose 200 mcg) - ≤ 60 kg : Morphine 0.1 mg/kg IM
If unable to administer IN Fentanyl - Single dose only - consult for further dose
• Methoxyflurane 3 mL • Morphine as above - no max. dose
U
- Repeat 3 mL if required (max. 6 mL)

• If allergic or sensitive to Morphine
If pain not controlled by above Rx as per IV therapy
- Fentanyl 25 - 50 mcg IV
B
- Repeat Fentanyl 25 - 50 mcg IV @ 5/60 titrated

to pain or side effects (max. 200 mcg)
M
• Fentanyl as above - no max. dose

)A
? Nausea
 Action
• Rx as per CPG A0701 Nausea and Vomiting
(C
Pain Relief CPG A0501 69

Version 7 - 29-02-12 Page 3 of 44
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Pain Relief Severe Headache CPG A0501
R
TO
• Non steroidal anti-inflammatory medications, as well • Many Pts who suffer migraines may already have a pre-
as paracetamol and ibuprofen, in mild to moderate set Rx plan in place. Most Pts will seek emergency care
headache is acceptable for Pt self administration. when such Rx has failed.
C
Paramedics do not administer Aspirin for • Sudden onset severe headache, sometimes referred
headache. to as 'thunderclap' or 'worst in life', should prompt
VI
• Opioids are of limited benefit in the Rx of migraine. concern for serious intracranial pathology. Particular
Morphine may not be effective and may be associated attention should be given to Pts whose headache
with delayed recovery on occasions. It should only intensity increases within secs to a min of onset.
be used to Rx severe prolonged diagnosed headache Other warning signs that may be suggestive of serious
E
where other measures have failed and where Tx to the intracranial event include:
treating facility is prolonged. - Abnormal neurological finding or atypical aura
C
• Prochlorperazine is indicated for headache - N
ew onset headache in elderly Pts or those with a Hx
considered or diagnosed to be migraine irrespective of of cancer
nausea and vomiting.
• Paramedics do not diagnose headache. The term
N - Altered level of consciousness or collapse
- Seizure activity
LA
migraine may be used mistakenly to describe a severe
- Fever and/or neck stiffness.
headache. Headache Mx is usually dependant upon
a diagnosis and tailored accordingly. Prehospital Mx • Metoclopramide may also be effective in the Mx of
seeks to provide interim relief until a more appropriate headache. Prochlorperazine is the preferred option
U
diagnosis and Mx can be provided. for severe headache.

• Prochlorperazine is unlikely to offer any clinical benefit • Metoclopramide and Prochlorperazine should not
B
for intracranial haemorrhage or SAH. It may be omitted be administered to the same Pt due to the increased
in this case. Many such Pts will have signs of CNS risk of extrapyramidal reactions.
M
depression in which case Prochlorperazine should • The Mx of severe dehydration where indicated may be
not be administered. of assistance in the Mx of severe headache.
)A
(C
IA
Pain Relief Severe Headache CPG A0501
R
? Status 8 Assess
TO
• Severe headache: Pain score > 7 • Suspected cerebral bleed
• Potential meningeal infection
Stop
C
If uncertain, Mx as suspected intracranial bleed as per
VI
CPG A0711 Suspected Stroke or TIA
? Severe Headache
E
 Action
• Mx seizures as per CPG A0703 Continuous Seizures
C
• If suspected meningococcal infection Mx as per CPG A0706 Meningococcal Septicaemia
• In the first instance consider Mx all headache type and severity:
- Methoxyflurane 3 mL
N
- If effective, repeat 3 mL if required (max. 6 mL)
LA
- Prochlorperazine 12.5 mg IM
• If after 15 min of above therapy and Pt still c/o severe pain (>7) and destination
hospital remains > 15 min
U
- Morphine 2.5 mg IV @ 5/60 titrated to pain or side effects (max. dose 20 mg)
- Aim is to reduce pain to < 7
B
- If allergic or sensitive to Morphine administer Fentanyl 25 mcg IV @ 5/60 titrated to pain or
side effects (max. dose 200 mcg)
M
• If unable to obtain IV Access

• If age < 60 and > 60 kg: Fentanyl 100 mcg IN

)A
- Repeat up to 25 mcg IN @ 5/60 titrated to pain or side effects (max. dose 200 mcg)
• If age ≥ 60 and/or ≤ 60 kg: Fentanyl 50 mcg IN
- Repeat up to 25 mcg IN @ 5/60 titrated to pain or side effects (max. dose 100 mcg)
(C
Pain Relief CPG A0501 71

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
IA
Asthma CPG A0601
R
TO
? Status 8 Assess
• Respiratory distress • Severity of asthma / COPD presentation
Stop
C
• This CPG should be read in conjunction
VI
with CPG A0001 Oxygen Therapy
E
? Mild / moderate / severe ? Exacerbation of COPD ? Unconscious ? No cardiac output
C
• See CPG A0601 • See CPG A0601 • See CPG A0601 • Loses C.O.
N
See CPG A0601
• PEA as per CPG A0201
LA
Cardiac Arrest
U
B
M
)A
(C
Asthma CPG A0601 73

IA
Asthma CPG A0601
R
TO
• Asthmatic Pts are dynamic and can show initial • Salbutamol infusion
improvement with Rx then deteriorate rapidly. - Salbutamol 1 mg added to make 50 mL with
• Consider MICA support but do not delay Tx waiting for D5W or Normal Saline.
C
backup. - 15 mcg/min = 45 mL/hr
• Despite hypoxaemia being a late sign of deterioration,
VI
pulse oximetry should be used throughout Pt contact (if
available).
• An improvement in SpO2 may not be a sign of
E
improvement in clinical condition.
• Beware of Pt presenting with wheeze associated with
C
heart failure and no asthma / COPD Hx.
N
LA
U
B
M
)A
(C
IA
Asthma CPG A0601
R
TO
? Status 8 Assess
• Respiratory distress • Severity of distress
• If Pt’s asthma Mx plan has been activated
C
VI
? Mild or moderate ? Severe
• Salbutamol pMDI and spacer • Salbutamol 10 mg (5 mL) and Ipratropium
- Deliver 4 doses @ 4/60 until resolution of symptoms Bromide 500 mcg (2 mL) Nebulised
E
- Pt to take 4 breaths for each dose - Repeat Salbutamol 5 mg (2.5 mL)
Nebulised @ 5/60 if required
C
• If pMDI spacer unavailable
- Salbutamol 10 mg (5 mL) Nebulised
- Repeat 5 mg (2.5 mL) Nebulised @ 5/60 if required
N
• Salbutamol 250 mcg IV
- Repeat 125 mcg IV @ 5/60 if required
(max. 500 mcg)
LA
• Dexamethasone 8 mg IV
? Adequate Response ? No Significant Response after 10/60 If unimproved
 Action  Action • Salbutamol infusion IV @ 15 mcg/min
U
(45 mL/hr)
• Tx with continued • Rx as per Severe
reassessment
B
M
)A
(C
Asthma CPG A0601 75

IA
COPD Chronic Obstructive Pulmonary Disease CPG A0601
R
TO
C
VI
E
C
N
LA
U
B
M
)A
(C
IA
COPD Chronic Obstructive Pulmonary Disease CPG A0601
R
TO
? Status
• Exacerbation of COPD
? All exacerbations of COPD
C
 Action
VI
• If Severe
- Rx as per appropriate section of CPG A0601 Asthma
• Irrespective of severity
- Salbutamol 10 mg + Ipratropium Bromide 500 mcg Nebulised
E
C
? Adequate response
 Action
N ? Inadequate response
 Action
LA
• Titrate O2 flow to target SpO2 90% • Continue Mx as per CPG A0601 Asthma
- Consider low flow O2, e.g. nasal prongs O2
U
B
M
)A
(C
COPD CPG A0601 77

IA
Asthma CPG A0601
R
TO
• High EtCO2 levels should be anticipated in the intubated
asthmatic Pt. EtCO2 levels of 120 mmHg in this setting
are considered safe and Paramedics Mx ventilation
C
should be conscious of the effect of gas trapping when
attempting to reduce EtCO2.
VI
• Extreme care must be taken with assisted ventilation as
gas trapping and barotrauma occurs easily in asthmatic
Pts with already high airway pressures.
E
C
N
LA
U
B
M
)A
(C
IA
Asthma CPG A0601
R
TO
? Status
• Unconscious / becomes unconscious
- with poor or no ventilation but still with Pt requires immediate assisted ventilation
C.O.
8 Action
C
• Ventilate VT 10 mL/kg @ 5 - 8 ventilations/min
VI
• Moderately high respiratory pressures
• Allow for prolonged expiratory phase
• Gentle lateral chest pressure during expiration if required
E
C
? Adequate response ? Inadequate response
• Rx as per Severe respiratory distress
N • If unable to gain IV or unaccredited in IV Salbutamol

- Adrenaline 300 mcg IM (1 : 1,000)
LA
- Repeat 300 mcg IM @ 20/60 as required (max. 900 mcg IM)
• Rx as per Severe respiratory distress
• Consider ETT as per CPG A0302 Endotracheal Intubation
U
• If unable to obtain IV or IO
B
- Salbutamol 2 x IV / IO dose via ETT

If Pt loses C.O. at any stage, see CPG A0601
M
)A
(C
Asthma CPG A0601 79

IA
Asthma CPG A0601
R
TO
• Consider potential for TPT and Mx.
• High intrathoracic pressures result from gas trapping,
decreasing venous return, leading to loss of C.O.
C
Apnoea allows the gas trapping to decrease.
VI
E
C
N
LA
U
B
M
)A
(C
IA
Asthma CPG A0601
R
TO
? Status
• Pt loses C.O.
- especially during assisted ventilation and
bag becomes stiff
C
VI
Pt requires immediate intervention
 Action
• Apnoea 1 min
- Exclude TPT
E
- Gentle lateral chest pressure
- Prepare for potential resuscitation
C
? Cardiac output returns
N
? Carotid pulse, no BP ? No return of output
LA
• Rx as per CPG A0601 • Adrenaline 50 mcg IV • Mx as per appropriate CPG
- Repeat 50 - 100 mcg IV @1/60 as required A0201 Cardiac Arrest
U
• Normal Saline 20 mL/kg IV

B
M
)A
(C
Asthma CPG A0601 81

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
83
IA
IA
Nausea and Vomiting CPG A0701
R
TO
• Prochlorperazine must only be administered via the • If there are no C/Is and the IV route is unobtainable with
IM route. a long Tx time, then administer Metoclopramide IM.
• If nausea and vomiting is being tolerated, basic care
C
and Tx is the only required Rx.
• Take care with Metoclopramide polyamp as it is
VI
similar to Ipratroprium Bromide and Atropine
polyamps in appearance.
E
C
N
LA
U
B
M
)A
(C
IA
Nausea and Vomiting CPG A0701
R
? Status 8 Assess for:
TO
• Actual or potential for nausea • Nausea and vomiting or
and vomiting • Potential spinal injury / eye trauma or
• Potential motion sickness or
• Vertigo
C
VI
Stop
• Prochlorperazine must not be given IV
• Metoclopramide and Prochlorperazine should not be administered
E
in the same episode of Pt care without consultation
C
? Nausea and vomiting associated with: ? Prophylaxis for: ? Prophylaxis for:
-
-
Cardiac chest pain
Iatrogenic secondary to opioid analgesia
N - Potential for motion sickness
- Planned aeromedical evacuation
• Awake Pt (GCS 13 – 15) with
potential spinal injuries who
LA
- Previous diagnosed migraine ✔ is immobilised on the stretcher
Action
- Secondary to cytotoxic drugs or radiotherapy • Eye trauma
• Prochlorperazine 12.5 mg IM
- Severe gastroenteritis - e.g. penetrating eye injury,
hyphema
U
Action

• Metoclopramide 10 mg IV / IM Action

B
- Repeat 10 mg IV / IM after 10/60 if symptoms • Metoclopramide 10 mg IV / IM

persist (max. 20 mg) - Repeat 10 mg IV / IM after
M
• If known allergy or C/I to 10/60 if symptoms persist

Metoclopramide (max. 20 mg)
- Prochlorperazine 12.5 mg IM
)A
? Dehydrated
Action
✔
(C
• Mx as per CPG A0801 Hypovolaemia
Nausea and Vomiting CPG A0701 85

IA
Hypoglycaemia CPG A0702
R
TO
• Pt may be aggressive during Mx. • If next meal is more than 20/60 away, encourage Pt
• Ensure IV is patent before administering Dextrose. to eat a long acting carbohydrate (e.g. sandwich, fruit,
Extravasation of Dextrose can cause tissue necrosis. glass of milk) to sustain BGL until next meal.
C
• All IVs should be well flushed before and after Dextrose • If the Pt refuses Tx, repeat the advice for Tx using
administration (minimum 10 mL Normal Saline). friend / relative assistance. If Pt still refuses Tx, document
VI
the refusal and leave Pt with a responsible third
• Ensure sufficient advice on further Mx and follow-up if
person and advise the third person of actions to take if
Pt refuses Tx.
symptoms recur and of the need to make early contact
with LMO for follow up.
E
• If inadequate response Tx without undue delay.
C
• Maintain general care of unconscious Pt and ensure
adequate airway and ventilation.
• Further dose of Dextrose 10% may be required in
N some hypoglycaemic episodes. Consider consultation

if BGL remains less than 4 mmol/L and unable to
LA
administer oral carbohydrates
• Continue initial Mx and Tx.
U
B
M
)A
(C
IA
Hypoglycaemia CPG A0702
R
TO
? Status
• Evidence of probable hypoglycaemia 8 Assess
- e.g. Hx diabetes, unconscious, pale, diaphoretic
• BGL
C
VI

?
BGL > 4 mmol/L ? BGL < 4 mmol/L Responds to commands ? BGL < 4 mmol/L Does not respond to commands
E
✔
Action ✔ Action  Action
• BLS • Glucose 15 g oral • IV cannula in a large vein
C
• Consider other causes of • Confirm IV patency
altered conscious state • Dextrose 10% 15 g (150 mL) IV
N
- e.g. stroke, seizure, - Normal Saline 10 mL flush
hypovolaemia
• If unable to insert IV – Glucagon 1 IU IM
LA
U
?
Adequate response ? Poor response ? Adequate response ? Inadequate response
Action
✔ Action
✔ - GCS 15 - GCS < 15 after 3/60
B
• Consider Tx • Consider Dextrose IV or ✔ Action ✔ Action

Glucagon 1 IU IM
M
• Cease administration of • Repeat Dextrose 10%

IV Dextrose 10g (100 mL) IV titrating
to Pt conscious state
)A
- Normal Saline 10 mL
flush
(C
Hypoglycaemia CPG A0702 87

IA
Continuous Tonic-clonic Seizures CPG A0703
R
TO
• For seizures other than generalised tonic-clonic seizures, • Frequent errors in drug dosage administration occur
Midazolam may only be administered following medical within AV in this CPG.
consultation. • Ensure accurate dose calculation and confirm with
C
• Seizures may not always present with tonic-clonic other Paramedics on scene.
limb activity, e.g. unconsciousness with flicking eye • Midazolam can have pronounced effects on BP,
VI
movements (nystagmus) may indicate ongoing seizure conscious state, ventilations and airway tone.
activity.
• Calculate the dose each time as stock strength may
• If a single seizure has spontaneously terminated continue change with manufacturer and familiarity may lead to
with initial Mx and Tx.
E
errors.
• If Pt has a PHx of seizures and refuses Tx, leave them in
C
the care of a responsible third party. Advise the person
of the actions to take for immediate continuing care if
symptoms recur and the importance of early contact Adult Dos Calculation for Midazolam IM
N
with their primary care physician for follow-up.
Strength required
x Stock volume
Stock strength
LA
e.g. 80 kg Pt @ 0.1 mg/kg = 8 mg Stock strength 15 mg/3 mL
8 mg x 3mL same as 8 mg x 2 mL
15 mg 10 mg
U
= 8 mg x 1mL = 0.8 x 2 mL
5 mg
Dose required = 1.6 mL = 1.6 mL

B
M
)A
(C
IA
Continuous Tonic-clonic Seizures CPG A0703
R
TO
? Status Assess

• Continuous tonic-clonic seizures • Protect Pt
• Continuously monitor airway and ventilation - assist as
required
C
• Consider other causes e.g. hypoglycaemia
• Consider Pt’s own Mx plan and Rx already given
VI
? Continuous tonic-clonic seizure
E
Ensure accurate dosage - 1/2 dose for age ≥ 60 years
C
✔ Action
• Age ≥ 60 - Midazolam 0.05mg/kg IM (max. single dose 5mg)
N
• Age < 60 - Midazolam 0.1mg/kg IM (max. single dose 10mg)
LA
? Seizure activity ceases ? Seizure activity continues > 5/60 ? Seizure activity continues >10/60
 Action Action
✔ - No IV access/no accreditation
U
• BLS • Midazolam 0.05 mg/kg IV ✔ Action

• Monitor airway and BP - Repeat 0.05 mg/kg IV @ 2 - 5/60 as required • Repeat original Midazolam IM
B
- Max. combined dose IM + IV 0.25 mg/kg dose once only

• Consult for further doses • Consult for further doses
M
• Consider ETT as per CPG A0302 Endotracheal

Intubation
)A
Pancuronium C/I
(C
Continuous Tonic-clonic Seizures CPG A0703 89

IA
Anaphylaxis CPG A0704
R
TO
• All Pts with suspected anaphylaxis must be Tx to
hospital regardless of the severity of their presentation or
response to Mx.
C
• Angio-oedema (vascular oedema) leads to increased
tissue fluid, presenting as swelling, upper airway
VI
obstruction (throat tightness), orbital oedema and other
systemic signs of swelling.
• Identify Hx of exposure to substances known to cause
anaphylactic reaction, e.g.
E
- recent insect bite
- medications
C
- exposure to food known to cause anaphylactic reaction
and presenting with evidence of systemic involvement.
N
• Research indicates most deaths from anaphylaxis
occurred after a delay in administration of Adrenaline.
LA
• Absence of an obvious trigger does not exclude
anaphylaxis.
U
B
M
)A
(C
IA
Anaphylaxis CPG A0704
R
TO
? Status
• Evidence of anaphylaxis
• Hx of exposure to antigen
C
8 Assess for systemic involvement
+ 8 Assess physiological distress
VI
• Angio-oedema or • Respiratory distress / bronchospasm or
• Urticaria or Plus at least one • Less than adequate perfusion or
of these
• GIT disturbance • Altered conscious state
E
C
? Mild ? Moderate ? Severe
• No physiological distress • Borderline to inadequate perfusion • Extremely poor perfusion
N
• Local allergic reaction • Mild to moderate respiratory distress • Severe respiratory distress
e.g. red rash, itchiness • Altered conscious state • Unconscious
LA
• BLS • Monitor Pt for cardiac arrhythmias • Rx as per Moderate
• Adrenaline 300 mcg IM (1 : 1,000) • Adrenaline 50 mcg IV (1 : 10,000)
U
- Repeat 300 mcg IM @ 5/60 until - Repeat 50 - 100 mcg IV @ 1/60 until
satisfactory results or side effects occur satisfactory results or side effects occur
B
• Rx bronchospasm as per A0601 Asthma • IV fluid as per CPG A0801 Hypovolaemia

• Consider fluid as per CPG A0801 • Dexamethasone 8 mg IV
M
Hypovolaemia • If no IV access Rx as per Moderate

• If no IV access consider IO
)A
• If intubated
- Adrenaline 200 mcg via ETT @ 5/60
(C
Anaphylaxis CPG A0704 91

IA
Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A0705
R
TO
• Any infusions established under this CPG must be • Adrenaline infusion > 50 mcg/min may be required
clearly labelled with the name and dose of any additive to Mx these Pts. Ensure delivery system is fully
drugs and their dilution. operational (e.g. tube not kinked, IV patent) prior to
C
• Sepsis criteria are relevant in the presence of an increasing dose.
infection or severe clinical insult such as multi trauma • Unstable Pts may require bolus Adrenaline
VI
leading to systemic inflammatory response syndrome concurrently with the infusion.
(SIRS). • Adrenaline infusion
2 or more of: Adrenaline 3 mg added to make 50 mL with 5%
- Temp > 38ºC or < 36ºC
E
Dextrose or Normal Saline
- HR > 90 bpm
1 mL/hr = 1 mcg/min
- RR > 20/min
C
- BP < 90 mmHg • If sepsis is suspected and prolonged Tx times exist (>1
hr) consider Ceftriaxone 1g IV (consult).
N
LA
U
B
M
)A
(C
IA
Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic CPG A0705
R
TO
? Status 8 Assess
• Suspected sepsis • Perfusion status
• Other causes of non-cardiogenic, • Respiratory status
non-hypovolaemic shock • Sepsis criteria
C
• Other possible causes
VI
? Inadequate or extremely poor perfusion
 Action
E
• If sepsis is suspected and chest is clear and MICA is not
immediately available:
C
- Confirm request for MICA support
- Normal Saline up to 20 mL/kg IV over 30 min
N
• Normal Saline up to 20 mL/kg IV
LA
? Adequate perfusion ? Inadequate or extremely poor perfusion persists
U
• BLS • Adrenaline infusion (3 mg in 50 mL D5W/Normal Saline) commencing @ 5 mcg/min (5 mL/hr)

• Tx - Increase by 5 mcg/min @ 2/60 until adequate perfusion or side effects
B
- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50 mcg/min
- If syringe pump unavailable
M
- repeat 10 mcg @ 2/60 until adequate perfusion or side effects
)A
- If poor response

- Adrenaline 50 - 100 mcg IV as required
- Doses > 100 mcg may be required
• If chest clear, continue Normal Saline 20 mL/kg IV boluses as per CPG A0801 Hypovolaemia
(C
Inadequate Perfusion
Non-cardiogenic / Non-hypovolaemic CPG A0705
93
IA
Meningococcal Septicaemia CPG A0706
R
TO
• Meningococcal septicaemia is transmitted by close Ceftriaxone preparation
personal exposure to airway secretions / droplets. • Dilute Ceftriaxone 1 g with 9.5 mL of Water for
• Ensure face mask protection especially during Injection and administer 1 g IV over approximately
C
intubation / suctioning. 2/60.
• Ensure medical follow up for staff post exposure. • If unable to obtain IV access, or not accredited in
VI
IV cannulation, dilute Ceftriaxone 1 g with 3.5 mL 1%
Lignocaine HCL and administer 1 g IM into the upper
lateral thigh or other large muscle mass.
E
C
N
LA
U
B
M
)A
(C
Version 3 - 01.011.05 Page 2 of 2
IA
Meningococcal Septicaemia CPG A0706
R
TO
? Status
• Suspected meningococcal septicaemia
PPE
C
VI
8 Confirm meningococcal septicaemia
• Typical purpuric rash
• Septicaemia signs
- Fever, rigor, joint and muscle pain
E
- Cold hands and feet
- Tachycardia, hypotension
C
- Tachypnoea
• Meningeal signs
N
- Headache, photophobia, neck stiffness
- Nausea and vomiting
LA
- Altered conscious state
U
? IV access ? No IV access
 Action - Unable to gain
B
• Ceftriaxone 1 g IV - Not IV accredited

- Dilute with Water for Injection to  Action
M
make 10 mL
- Administer slowly over 2/60 • Ceftriaxone 1 g IM
- Dilute with 3.5 mL 1% Lignocaine HCL to

)A
• If inadequate perfusion Rx as per

make 4 mL
CPG A0705 Inadequate Perfusion
- Administer into upper lateral thigh or other
large muscle mass
(C
Meningococcal Septicaemia CPG A0706 95

IA
Overdose CPG A0707
R
General Care Special Notes
• If Pt still refuses Tx, after repeating the advice for Tx using friend /
TO
• Provide supportive care (all cases)
- Provide appropriate airway Mx and ventilatory support relative assistance, advise the Pt and responsible third person of
follow-up, counselling facilities and actions to take for continuing
- If Pt is in an altered conscious state, assess care if symptoms recur.
BGL and if necessary Mx as per • For young persons, Paramedics should strongly encourage them to
C
CPG A0801 Hypoglycaemia make contact with a responsible adult.
- If Pt is bradycardic with poor perfusion Mx as • Paramedics should call the Police if, in their professional
VI
per CPG A0402 Bradycardia judgement, there appear to be factors that place the Pt at
- If Pt is inadequately perfused, Mx as per appropriate increased risk, such as the Pt:
CPG. - is subject to violence (e.g. from a parent, guardian or care giver)
- is likely to be, or is in danger of sexual exploitation.
- Assess Pt temp and Mx as per
E
CPG A0901 Hypothermia / Cold Exposure, or In particular for children where:
CPG A0902 Environmental Hyperthermia / - the supply of drugs appears to be from a parent / guardian / care
C
Heat Stress giver.
- there is other evidence of child abuse / maltreatment or evidence
• Confirm clinical evidence of substance use or exposure of serious untreated injuries.
N
- Identify which substance/s are involved and collect • If the Pt claims to have taken an OD of a potentially life-threatening
any packets if possible. substance or as a suicide attempt then they must be Tx to hospital.
LA
- Identify by which route the substance/s have been Police assistance should be sought to facilitate this as required.
taken (e.g. ingestion). • Documentation of refusal and actions taken must be recorded on
- Establish the time the substance/s were taken. the PCR.
- Establish the amount of substance/s taken.

U
- Establish what the substance/s were mixed with when

taken (e.g. alcohol, water).
B
- Establish if any Rx has been initiated prior to

Ambulance arrival (e.g. induced vomiting).
M
)A
When dealing with cases of OD, if Paramedics are unfamiliar with a substance or unsure of the effects it may have, then
consultation with Poisons Information should take place. They can be contacted via the Clinician, or on 13 11 26.
(C
IA
Overdose CPG A0707
R
TO
? Status 8 Assess
• Suspected OD • Substance/s involved
C
VI
? Opioids ? TCA Antidepressants ? Sedatives ? Psychostimulants
e.g. - Heroin e.g. - Amitriptyline e.g. - GHB e.g. - Cocaine
- Morphine - Nortriptyline - Alcohol - Amphetamines
- Codeine - Dothiepin - Benzodiazepines - Ecstacy
E
- Other opioid - Volatile agents - PCP
preparations
C
N
LA
U
B
M
)A
(C
Overdose CPG A0707 97

IA
Overdose: Opioids CPG A0707
R
TO
• Opioids may be in the form of IV preparations such • If inadequate response after 10/60, the Pt is likely to
as Heroin or Morphine and oral preparations such as require Tx without delay.
Codeine, Endone, MS Contin. Some of these drugs - Maintain general care of the unconscious Pt and
C
also come as suppositories and topical patches. ensure adequate airway and ventilation.
• Not all opioid ODs are from IV administration of - Consider other causes e.g. head injury,
VI
the drug. hypoglycaemia, polypharmaceutical OD.
- Beware of Pt becoming aggressive.
E
C
N
LA
U
B
M
)A
(C
IA
Overdose: Opioids CPG A0707
R
TO
? Status Stop
• Possible opioid OD • Ensure personal / crew safety
• Scene may have concealed syringes
C
8 Assess evidence of opioid OD
VI
- Altered conscious state
- Respiratory depression
- Substance involved
E
- Exclude other causes (inc. no obvious head injury)
- Pin point pupils
C
- Track marks
N
? Opioid OD
LA
 Action
• Assist and maintain airway / ventilation
• Naloxone 1.6 mg – 2 mg IM
U
B
? Adequate response ? Inadequate response after 10/60

M
• BLS • Naloxone 0.8 mg IM

• Consider Tx • Consider airway Mx CPG A0301 Laryngeal Mask
)A
• Naloxone 0.8 mg IM/IV

• Consider ETT as per CPG A0302 Endotracheal
Intubation
(C
Overdose: Opioids CPG A0707 99

IA
Overdose: Tricyclic Antidepressants (TCA) CPG A0707
R
TO
Signs and symptoms of TCA toxicity ECG changes
• Mild to moderate OD ECG changes include prolonged PR, QRS and QT intervals
- Drowsiness, confusion associated with an increased risk of seizures if QRS > 0.10
C
- Tachycardia sec and ventricular arrhythmias if QRS > 0.16 sec.
- Slurred speech
VI
- Hyperreflexia How to measure a QT interval is shown below.
- Ataxia
- Mild hypertension
- Dry mucus membranes
E
- Respiratory depression
• Severe toxicity (within 6 hr ingestion)
C
- Coma
- Respiratory depression / hypoventilation
N
- Conduction delays
- PVCs
LA
- SVT
- VT
- Hypotension
- Seizures
U
- ECG changes
This could lead to aspiration, hyperthermia,

B
rhabdomyolysis and APO.

TCAs may be prescribed to Rx medical conditions other
M
than depression (e.g. chronic pain).

)A
(C
IA
Overdose: Tricyclic Antidepressants (TCA) CPG A0707
R
TO
? Status 8 Assess
• Possible TCA OD • Substance involved
• Perfusion status
• ECG criteria
C
VI
? No toxicity ? Signs of TCA toxicity
 Action Any of the following
- Less than adequate perfusion
E
• BLS
- QRS > 0.12 sec (> 0.16 sec indicates severe toxicity)
• Consider potential to develop signs of toxicity
- QT prolongation (> 1/2 R-R interval)
C
Stop
N • Amiodarone is C/I in the setting of confirmed or suspected

TCA OD
LA
 Action
• Sodium Bicarbonate 8.4% 100 mL IV given over 3/60
- Repeat 100 mL IV after 10/60 if signs of toxicity persist
U
- Consult for further doses if signs of toxicity persist

• Consider ETT as per CPG A0302 Endotracheal Intubation if
B
signs of toxicity and GCS < 10 persist after

initial Mx
- Hyperventilate with 100% O2 - rate 20 - 24/min
M
- EtCO2 target 20 - 25 mmHg if intubated

)A
(C
Overdose: Tricyclic Antidepressants (TCA) CPG A0707 101

IA
Overdose: Sedative Agents / Psychostimulants CPG A0707
R
TO
Special Notes
• Hyperthermic psychostimulant OD
In hyperthermic psychostimulant OD the trigger point
for intervention in the Mx of agitation / aggression is
C
lowered. Sedation should be initiated early to assist
with cooling and avoid further increases in temp
VI
associated with agitation.
E
C
N
LA
U
B
M
)A
(C
IA
Overdose: Sedative Agents / Psychostimulants CPG A0707
R
TO
? Status 8 Assess
• Sedative agents • Substance involved
• Psychostimulants
C
Stop
• Ensure personal / crew safety
VI
Be aware of the potential for agitation /
aggression / violence
E
? Sedative agents ? Psychostimulants
C
N
• Pt may require airway Mx • Reduce stimuli by calming and controlling the Pt's environment
• Mx agitation / aggression as per CPG A0708 • Mx seizures as per CPG A0703 Continuous
LA
The Agitated Patient Tonic-clonic Seizures
• Mx inadequate perfusion as per CPG A0705 • Mx cardiac chest pain as per CPG A0401 Acute
Coronary Syndromes
Inadequate Perfusion
• Mx temp as per CPG A0902 Hyperthermia /
U
Heat Stress or A0901 Hypothermia / Cold exposure

• Mx agitation / aggression as per CPG A0708 The
B
Agitated Patient
M
)A
(C
Overdose: Sedative Agents/Psychostimulants CPG A0707 103

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
IA
The Agitated Patient CPG A0708
R
TO
• This CPG does not apply to Pts who have been • Paramedic safety is to be considered paramount at all
recommended for Tx under the Mental Health Act. times. Do not attempt any element of this CPG unless all
If sedation is required in these circumstances then necessary assistance is available.
C
the Act requires that this only be administered by a • Provide supportive care in all cases where sedation
prescribed Medical Practitioner or Registered Nurse. administered.
VI
• This CPG is appropriate for Pts under Section 10 of the • Provide airway Mx appropriate to the clinical condition,
Mental Health Act. administer O2 to all Pts and assist ventilation as required.
• The indications for the use of sedation and/or restraint • If less than adequate perfusion Mx as per CPG A0705
must be clearly documented on the PCR.
E
Inadequate Perfusion (Non-cardiogenic / Non-
• Mechanical restraint may also be utilised without the hypovolaemic).
C
use of sedation in circumstances where the Pt will not • Continue to assess Pt temp and Mx as per CPG A0902
sustain further harm by fighting against the restraints. Environmental Hyperthermia / Heat Stress or CPG
• Mechanical restraints must be removed if there is
N
A0901 Hypothermia / Cold Injury.
any indication that the restraint is compromising the • If not already completed, ensure that all possible
provision of supportive care. clinical causes of agitation are assessed and Mx by the
LA
• The type of restraint used and its time of application appropriate CPG.
and/or removal must be clearly documented on the Traumatic head injury
PCR. • In Pts with mild to moderate acute traumatic head injury
Hyperthermic psychostimulant OD (GCS 10 - 14), sedation cannot be given without
U
• Sedation should be initiated early in hyperthermic Pts medical consultation with a Major or Regional Trauma
who have been using psychostimulants to assist with Service.
B
cooling and avoid further increases in temp secondary

to agitation.
M
)A
(C
The Agitated Patient CPG A0708 105

IA
The Agitated Patient CPG A0708
R
? Status Stop
TO
• Agitated Pt • Observe for and Mx as appropriate
- Hazards - Body fluids
- Violence - Sharps
- Clear egress - Reduce stimuli
C
• Paramedic safety is paramount
VI
? Agitated Pt
✔ Action
• Communicate with Pt
E
- Avoid confrontational behaviour
- Gain Pt co-operation for assessment
C
- Utilise verbal de-escalation strategies
8 Assess / consider
N
LA
• Assess and Mx clinical causes (as far as possible)
- Hypoglycaemia
- Hypoxia
- Post-ictal
U
- Drug intoxication (initiate sedation early in hyperthermic psychostimulant OD)

- Drug withdrawal
B
- Intracerebral pathology
- Mild to moderate acute traumatic head injury (consult with MTS for sedation)
- Acute psychiatric condition
M
- Pain
)A
(C
IA
R
? Able to Mx without restraint / sedation ? Requires restraint / sedation
✔ Action • Does not respond to verbal de-escalation
TO
• Mx causes as per appropriate CPG • Clinical causes have been excluded
• Beware Pt condition may change and agitation • Pt risk to themselves or others
increase requiring restraint / sedation - e.g. combative, agitated or aggressive
C
Stop
VI
• Ensure Pt is not recommended under the Mental Health Act
- Sedation by Paramedics is not permitted within the Mental
Health Act for these Pts
• Ensure sufficient physical assistance
E
• Reduced sedation dose for age / BP
• Mild to moderate head injury GCS 10 - 14 (Mx pain, consult if
C
sedation required)
N ✔ Action
LA
• Age ≥ 60 or BP ≤ 100 mmHg
- Midazolam 0.05 mg/kg IM (max. 5 mg per dose)
✔ Action - Repeat initial dose @ 10/60 IM (max. 4 doses) as required
• Tx to appropriate destination • Age < 60 and BP > 100 mmHg
U
• Ensure sufficient assistance in transit - Midazolam 0.05 - 0.1 mg/kg IM (max. 10 mg per dose)
• Provide early notification to receiving hospital - Repeat initial dose @ 10/60 IM (max. 4 doses) as required
B
• Consider Rx as per Requires restraint / sedation • Apply mechanical restraint devices if required
if Pt becomes agitated / aggressive • Above doses may be given IV and repeated @ 5/60 as required
M
• IM injections may be indicated until IV access has been established

)A
(C
The Agitated Patient CPG A0708 107

IA
Organophosphate Poisoning CPG A0709
R
TO
• Notification to receiving hospital essential to allow for • Where possible, remove contaminated clothing and
Pt isolation and decontamination. wash skin thoroughly with soap and water.
• The key word to look for on the label is • If possible minimise the number of staff exposed.
C
anticholinesterase. There are a vast number • Attempt to minimise transfers between vehicles.
of organophosphates which are used not only
VI
commercially but also domestically.
• Given potential contamination by a possible
organophosphate, the container identifying trade and
generic names should be identified and the Poisons
E
Information Centre contacted for confirmation and
advice (via Clinician or 13 11 26).
C
N
LA
U
B
M
)A
(C
IA
Organophosphate Poisoning CPG A0709
R
TO
? Status
• Possible organophosphate exposure
C
Stop
• Avoid self contamination - wear PPE
VI
• Decontaminate Pt if possible
E
8 Confirm evidence of suspected poisoning 8 Evidence of excessive cholinergic effects
• Cholinergic effects: salivation, bronchospasm, • Salivation compromising the airway or
C
sweating, nausea or bradycardia bronchospasm and /or
• The key word to look for on the label is Plus • Bradycardia with inadequate or extremely
N
anticholinesterase poor perfusion
LA
? No excessive cholinergic effects ? Excessive cholinergic effects
U
• Tx to nearest appropriate hospital • Atropine 1200 mcg IV

• Monitor for excessive cholinergic effects - Repeat 1200 mcg IV @ 5/60 until excessive cholinergic effects resolve
B
• Consult with receiving hospital for further Mx if required
• The use of Suxamethonium is C/I in Pts with suspected

M
organophosphate poisoning
)A
(C
Organophosphate Poisoning CPG A0709 109

IA
Autonomic Dysreflexia CPG A0710
R
TO
• Tx the Pt even if the symptoms are relieved as this
presentation meets the criteria of autonomic dysreflexia,
a medical emergency that requires identification
C
of probable cause and Rx in hospital to prevent
cerebrovascular catastrophe.
VI
E
C
N
LA
U
B
M
)A
(C
IA
Autonomic Dysreflexia CPG A0710
R
TO
? Status 8 Confirm Autonomic Dysreflexia
• Possible autonomic dysreflexia • Previous spinal cord injury at T6 or above
- Severe headache and/or
- SBP > 160 mmHg
C
VI
Identify and Rx possible causes - remove the stimulus
• If distended bladder (common), ensure indwelling catheter is not kinked
• Mx pain, e.g. fractures, burns, labour
E
? If systolic BP remains > 160 mmHg
C
 Action
• GTN 300 mcg S/L (no prev. admin) or
N
GTN 600 mcg S/L
LA
? Adequate response ? Inadequate response - BP remains > 160 mmHg
U
• Tx to nearest appropriate hospital • Repeat initial dose of GTN @ 10/60 until either:
- Symptoms resolve
B
- Onset of side effects

- BP < 160 mmHg
M
• Tx to nearest appropriate hospital

)A
(C
Autonomic Dysreflexia CPG A0710 111

IA
Stroke / TIA CPG A0711
R
TO
• Suspected stroke is a time critical emergency – early • Intubation by MICA Paramedics should be considered
assessment and exclusion of stroke mimics is important where there is difficulty maintaining adequate airway,
• Symptom onset time is taken from when last seen oxygenation and ventilation. Intubation should not be
C
symptom free (e.g. if wakes with symptoms then time considered as a mandatory practice in Mx of all these
Pt went to bed). Pts. Time to hospital versus time to undertake the
VI
• Rx times from symptom onset are: procedure should be considered.
- thrombolysis – up to 4.5 hrs • Gagging should be avoided in the Mx of the non
• Diagnosing and Mx stroke Pts with thrombolysis is a traumatic intracranial event Pt. The effect of gagging
priority over seeking neurosurgical support. may vary in its detriment compared to the traumatic
E
• Urgent secondary transfer of stroke Pts to a centre with head injured Pt.
Stroke Unit Care may be organised and involve the • The use of longer acting muscle relaxants post
C
Clinician / AAV / ARV. intubation is not as essential in the suspected stroke Pt
• TIA can only be suspected if S/S completely resolve, as it is with head trauma. Sedation alone is preferred
N
otherwise Pt should be treated as a suspected stroke. unless gagging becomes problematic. They should not
• TIA is often a sign of an impending stroke – all TIAs be used following evidence of seizure activity without
should be conveyed to hospital for investigation.
LA
significant head injury.
• Approximately 15% of strokes are intracranial • Anti-emetics have the potential to cause drowsiness.
haemorrhage (ICH). These Pts have potential for rapid Their use must be balanced against a potential
deterioration.
reduction in conscious state in these Pts. The use of
• Intracranial haemorrhage can be suspected where:
U
Prochlorperazine is indicated as an analgesia adjunct

- GCS < 10 and the Pt is not alert for the Mx of severe headache. It is unlikely to have a
- The Pt complained of severe headache beneficial effect for intracranial haemorrhage/SAH.
B
- Nausea and vomiting is present • O2 therapy should be reserved for hypoxic Pts with
- Slow pulse and hypertension is noted an SpO2 < 94%. The use of routine O2 therapy is not
M
- Pupil abnormalities are noted recommended.

- Abnormal patterns of respiration are noted
)A
• MASS – Melbourne Ambulance Stroke Screen.

Validated criteria used in prehospital stroke assessment.
(C
IA
Stroke / TIA CPG A0711
R
? Status 8 Assess 8 Stroke Mimics 8 Co-morbidities
TO
• Suspected stroke or TIA • Symptom onset • Intoxication drug/ • Middle ear disorder • Dementia
time alcohol • Migraine • Significant pre-existing
• Stroke mimics • Hypo/hyperglycaemia • Subdural haematoma physical disability
• Co-morbidities • Seizures • Sepsis
C
• Brain tumour • Electrolyte
VI
• Syncope disturbances
? Assess for MASS criteria ? Management

 Action
E
 Action
• In the setting of normal BGL, a finding of one or more of the • BLS – maintain adequate airway and ventilation
C
symptoms below is indicative of stroke: • Mx symptomatically – support affected limbs
• Provide analgesia as per CPG A0501 Pain Relief: Severe Headache
? Stroke signs and symptoms
N
Assessment findings
✔ • Rx sustained seizure activity as per CPG A0703 Continuous Tonic –
8 8
clonic Seizures
LA
Facial Droop Pt shows teeth Normal - both Abnormal - one side
or smiles sides of face of face does not move • If GCS < 10 consider ETT as per CPG A0302 Endotracheal Intubation
move equally as well as the other
Speech The Pt repeats Normal - the Abnormal - the Pt slurs
U
“You can’t Pt says the words, says the wrong ? Transport

teach an old correct words, words, or is unable to  Action
B
dog new tricks” no slurring speak or understand

• Where Pt is unstable consider time to appropriate receiving hospital versus
Hand grip Test as for GCS Normal - equal Abnormal - unilateral
R/V with MICA / AAV.
M
grip weakness
• If Pt is stable with no significant co-morbidities, onset time < 4.5
Blood Test for BGL Abnormal -if Normal BGL
hr and Tx time < 1 hr – then transfer to the nearest hospital providing

)A
glucose hypoglycemia
Mx as per thrombolysis or stroke unit care and notify of pending arrival.
CPG A0702 • If Pt does not meet criteria above – then Tx to a closer
Hypoglycemia
centre preferably with stroke unit care / CT imaging.
(C
• If Pt deteriorates consider R/V with MICA / AAV
Stroke / TIA CPG A0711 113

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
115
IA
IA
Hypovolaemia CPG A0801
R
TO
• Titrate fluid administration to Pt response. • Haemorrhage from blunt trauma is not considered as
• Aim for HR < 100 bpm and BP > 100 mmHg if perfusion ‘uncontrolled’ in the context of this CPG and should be
is altered. Mx as defined within.
C
• Consider establishing IV en route. Do not delay Tx for • GI bleeding has potential to be ‘uncontrolled’ in the
IV therapy. context of this CPG and should be considered as a
VI
• Always consider TPT, particularly in the Pt with a chest modifying factor.
injury not responding to fluid therapy and persistently
hypotensive.
E
• Excessive fluid should not be given if SCI is an isolated
injury.
C
• Clinical signs of significant dehydration include:
- P
ostural perfusion changes including tachycardia,
hypotension or dizziness
- Decreased sweating and urination
N
LA
- Poor skin turgor, dry mouth, dry tongue
- Fatigue and altered consciousness
- Evidence of poor fluid intake compared to fluid loss.
• Dehydration in the hyperglycaemic Pt should be Mx using
U
this CPG.
B
Modifying factors
M
• Complete spinal cord transection Rx as per CPG A0804 Spinal Injury

- Pt with isolated neurogenic shock can be given up to Normal Saline 500 mL bolus to correct hypotension.
No further fluid should be given if SCI is the sole injury.
)A
• Chest injury – Consider TPT Rx as per CPG A0802 Chest Injury

• Penetrating trunk Injury, aortic aneurysm or uncontrolled haemorrhage.
- Accept palpable carotid pulse and Tx immediately
(C
• GI haemorrhage – consider lesser volumes of fluid and accepting a blood pressure of 80 – 100 mmHg.
IA
Hypovolaemia CPG A0801
R
? Status Stop
TO
• Evidence of hypovolaemia • Identify and Mx
- Haemorrhage, fractures, pain, TPT, hypoxia
8 Assess
C
• HR / BP
VI
• Consider modifying factors
- SCI, chest injury, penetrating trunk injury, AAA, uncontrolled external haemorrhage, GI haemorrhage
E
? HR < 100 bpm; BP > 100 mmHg ? Isolated tachycardia ? Hypotension
 Action • HR > 100 bpm; BP > 100 mmHg • < 100 mmHg
C
• F
luid not required unless signs  Action  Action
of significant dehydration • Normal Saline 20 mL/kg IV • Normal Saline 20 mL/kg IV
? If significantly dehydrated
N
LA
 Action
• N
ormal Saline up to 20 mL/kg ? HR < 100 bpm ? HR > 100 bpm and/or
IV over 30 min BP > 100 mmHg BP < 100 mmHg
U
? HR > 100 bpm and/or • No further fluid required • Insert second IV
B
? HR < 100 bpm BP < 100 mmHg • Repeat Normal Saline 20 mL/kg
BP > 100 mmHg
M
 Action
 Action • Repeat Normal Saline 20 mL/kg ? BP remains < 100 mmHg
• No further fluid required • After 40 mL/kg

)A
? BP remains < 100 mmHg  Action

• After 40 mL/kg
• Consult with MTS
 Action • If unavailable repeat
(C
• Consult with MTS Normal Saline 20 mL/kg IV

• If unavailable repeat Normal Saline 20 mL/kg IV
8 Assess 8 Consider
Hypovolaemia CPG A0801 117
? Status Stop  Action  MICA Action
IA
Chest Injuries CPG A0802
R
TO
C
VI
E
C
N
LA
U
B
M
)A
(C
IA
R
TO
? Status 8 Assess
• Chest injury • Respiratory status
- Traumatic • Type of chest injury
- Spontaneous
C
- Iatrogenic
 Action
VI
• Supplemental O2 if indicated
• Pain relief as per CPG A0501 Pain Relief
• Position Pt upright if possible unless perfusion is
< adequate, altered conscious state, associated
E
barotrauma or potential spinal injury
C
? Flail segment / rib fractures
N
? Open chest wound ? Pneumothorax
LA
 Action  Action • Signs of pneumothorax
• May require ventilatory support • 3 sided sterile occlusive dressing  Action
if decreased VT • See CPG A0802
U
B
M
)A
(C
Chest Injuries CPG A0802 119

IA
R
TO
• In the setting of IPPV, equal air entry is NOT an exclusion • Tension Pneumothorax (TPT)
criterion for TPT. - If some clinical signs of TPT are present and the Pt is
• Chest injury Pts receiving IPPV have a high risk of deteriorating with decreasing conscious state and/
C
developing a TPT. The solution for poor perfusion in this or poor perfusion, immediately decompress chest by
setting includes bilateral chest decompression. inserting a long 14g cannula or intercostal catheter.
VI
• Cardiac arrest Pts are at risk of developing chest injury - If air escapes, or air and blood bubble through
during CPR. the cannula / intercostal catheter, or no air / blood
detected, leave in situ and secure.
• Troubleshooting
- If no air escapes but copious blood flows through
E
- Pt may re-tension as lung inflates if catheter kinks off.
- Catheter may also clot off. Flush with sterile Normal the cannula / intercostal catheter then a major
haemothorax is present. Remove, then cover the
C
Saline.
insertion site.
• If a 14g cannula is used initially, it should be replaced
with an intercostal catheter (if available) as soon as • Needle test
N
practicable. - If TPT suspected, but the assessment is not obvious,
test for a TPT with a needle at least 45mm length (long
• Insertion site for cannula/intercostal catheter
LA
14/16 G) attached to Normal Saline filled syringe.
- Second intercostal space
- Mid - clavicular line (avoiding medial placement) - If needle test is suggestive of TPT, withdraw needle and
- Above rib below (avoiding neurovascular bundle) immediately decompress chest.
- Right angles to chest (towards body of vertebrae). - If pneumocath not available, leave plastic cannula
U
in situ refer to appropriate CWI.

- If needle test is not suggestive of TPT, withdraw needle,
B
cover insertion site with a clear adhesive dressing and

circle the insertion site with a pen.
M
- Be aware that a needle test for TPT can be prone to

false readings and does not exclude TPT in all cases.
)A
(C
IA
R
TO
? Status 8 Assess
• Pneumothorax • Criteria for simple vs tension
- Simple pneumothorax
- Tension
C
VI
? Simple pneumothorax
? TPT
• Any of the following: • Any of the following +/- signs of Simple pneumothorax:
- Unequal breath sounds in -  Peak inspiratory pressure (ventilator) / stiff bag
E
spontaneously ventilating Pt -  EtCO2
- Low SpO2 on room air - Poor perfusion or  HR +/-  BP
C
- Subcutaneous emphysema -  JVP
-  Conscious state in the awake Pt
N
- Tracheal shift
 Action
- Low SpO2 on supplemental O2 (late)
• Continue BLS and supplemental O2
LA
• Monitor closely for possible development  Action
of TPT • Chest decompression as per General care (including
accredited rural ALS)
U
B
M
)A
(C
Chest Injuries CPG A0802 121

IA
Traumatic Head Injury CPG A0803
R
TO
• The Trauma Time Critical Guidelines require Pts with • Dress open skull fractures / wounds with sterile combine
significant blunt trauma to a single region to be triaged soaked in sterile Normal Saline.
to the highest level of care. • Maintain manual in-line neck stabilisation and apply
C
• When assessing the pattern of injury, the Pt can be cervical collar when convenient. If intubation is required,
considered to have a significant blunt head injury in apply cervical collar after intubation. Attempt to minimise
VI
the setting of blunt head trauma with or without loss of jugular vein compression.
consciousness / amnesia and GCS 13 - 15 with any of: • Attempt to maintain normal temp.
- Any loss of consciousness exceeding 5/60.
- Skull fracture (depressed, open or base of skull).
E
- Vomiting more than once.
- Neurological deficit.
C
- Seizure.
• Elderly Pts with standing height falls who meet no
N
other time critical criteria but are on anti-coagulant,
antiplatelet agents or have bleeding disorders should
LA
not be underestimated. Tx to an appropriate level of
care.
U
B
M
)A
(C
IA
Traumatic Head Injury CPG A0803
R
TO
? Status 8 Assess
• Traumatic head injury • Time critical head injury
• Other head injury
C
VI
? Airway ? Ventilation ? Perfusion ? General care
• If airway patent and VT • Ensure adequate • Mx with Normal Saline as per • Rx sustained seizure
adequate (with trismus), ventilation and CPG A0801 Hypovolaemia activity with Midazolam
E
do not insert NPA VT of 10 mL/kg (unless in the setting of as per CPG A0703
penetrating truncal trauma or Continuous Tonic –
C
• If airway not patent and • Maintain SpO2
gag is present, insert > 95% and uncontrolled overt bleeding) Clonic Seizures
NPA and ventilate Rx causes of • Aim for SBP > 120 mmHg • Measure BGL and
N
• If GCS < 10, regardless hypoxia • After 40 mL/kg reassess. If rectify hypoglycaemia
of airway reflexes, • Maintain SBP < 100 mmHg, discuss as per CPG A0702
LA
intubate as per CPG EtCO2 at 30 ongoing resuscitation with the Hypoglycaemia
A0302 Endotracheal - 35 mmHg receiving Regional or Major • Triage to highest level
Intubation - RSI Avoid hypo/ Trauma Service while continuing of care as per Time
• If intubation is not hypercapnia to Tx Critical Guidelines
U
possible / authorised • If consult is unavailable (Trauma Triage)

and gag is absent insert administer a further Normal • If Pt does not meet
B
LMA Saline 20 mL/kg IV and Time Critical

reassess Guidelines (Trauma
M
Triage) criteria, triage

Pt to next highest or
appropriate level of
)A
trauma care
(C
Traumatic Head Injury CPG A0803 123

IA
Spinal Injury CPG A0804
R
TO
• A cervical collar alone does not immobilise the cervical • If a cervical collar is applied then it must be properly
spine. If the neck needs immobilising then the whole fitted and applied directly to the skin, not over clothing
spine needs immobilising. This may include the use and not placing any pressure on the neck veins.
C
of head rolls or other approved proprietary devices • Where there is no immediate risk to life and extrication
and the whole body immobilised on a spine board or is required then an extrication device (e.g. KED) should
VI
ambulance stretcher in a manner that is appropriate be considered.
for the presenting problem. A spine board must be
• Pts with a SCI may develop pressure areas within as
restrained to the ambulance stretcher during Tx.
little as 30 min following placement on a spine board
• The head should not be independently restrained. and the duration on a spine board must be noted on
E
• In Pts with a diseased vertebral column, a lesser the PCR. Effective padding should be applied to protect
mechanism of injury may result in SCI and should be pressure areas.
C
Mx accordingly. • For Tx times in excess of 60 min consideration should
• Spinal immobilisation with neutral alignment may not be given to removing the Pt from a spine board and
N
be possible in a Pt with a diseased vertebral column appropriately securing them to the ambulance stretcher.
with associated anatomical deformity and should be • Pts with isolated neurogenic shock should be given a
LA
modified accordingly e.g. position of comfort. small fluid bolus (up to 500 mL Normal Saline IV) to
• Spinal immobilisation is not without risk. Complications correct hypotension. No further fluid should be given if
may include head and neck pain, detrimental effects on SCI is the sole injury.
pulmonary function and subsequent neurological deficit • The Pt with multi trauma and SCI may not mount a
U
(particularly in the elderly). sympathetic response to hypovolaemia. Fluid should be

given based on estimated blood loss.
B
M
)A
(C
IA
Spinal Injury CPG A0804
R
? Status 8 Assess
TO
• Potential or suspected spinal injury • Spinal column injury
• Spinal cord injury
C
? If Pt meets major trauma criteria ? If Pt does not meet major trauma criteria
VI
 Action • Has any mechanism of injury with potential to cause spinal injury
• Mx airway as appropriate  Action
• Provide spinal immobilisation If any of the following present provide spinal immobilisation:
E
• Administer pain relief as required as per • Increased injury risk
CPG A0501 Pain Relief - Age > 55 years
C
- History of bone disease (e.g. osetoporosis, osteoarthritis,
• Mx hypovolaemia as per CPG A0801 Hypovolaemia
rheumatoid arthritis) or muscular weakness disease (e.g.
• Tx without delay to an appropriate receiving hospital as muscular dystrophy)
N
per CPG A0105 Time Critical Guidelines (Trauma
• Difficult Pt assessment
Triage)
- Unconsciousness or any acute or chronic altered conscious
LA
state (GCS < 15) or period of loss of consciousness
- Drug or alcohol affected
- Significant distracting injury e.g. extremity fracture or dislocation
• Actual evidence of structural injury
U
- Spinal column pain / bony tenderness

• Actual evidence of spinal cord injury
B
- Neurological deficit or changes

- Mx as per emergent time critical trauma criteria
M
• If none of the above present then spinal immobilisation /

cervical collar not necessary
)A
If any doubt exists as to Hx or the above assessment, or if

there is inability to adequately assess the Pt, provide spinal
immobilisation.
Clearance criteria within this CPG are not to be used for
(C
paediatric Pts. No paediatric Pt should be spinally cleared

prehospital after major trauma. Apply all spinal care.
Spinal Injury CPG A0804 125

IA
Burns CPG A0805
R
TO
• All chemical burns should be irrigated for at least 20 Burn cooling
min. Avoid flushing chemical onto uncontaminated • Burn cooling should be for 20 min. Consider shorter
areas. periods for Pts with large TBSA where hypothermia
C
• Remove burnt clothing or that containing chemical may be induced. Cooling may be completed prior to Tx.
hot liquid when safe to do so. Do not remove clothing Cooling provided prior to ambulance arrival should be
VI
that adheres to underlying tissue. Jewellery should be included in the total cooling time.
removed prior to swelling occurring. • Burn cooling should be with gentle running water that
• Vol replacement is for the burn injury only. Mx other is between 5 - 15°C. Ice and ice water is not desirable.
injuries accordingly including requirement for additional Similarly, dirty (i.e. dam) water should be avoided given
E
fluid. Electrical burns should receive fluid therapy to the significant risk of infection.
maintain adequate renal perfusion.
C
• If running water is not available, cooling may be
• S/S of airway burns include: commenced by immersing the affected area in still water.
- vidence of burns to upper torso, neck and face
E This water should be refreshed every few min to avoid it
N
- Facial and upper airway oedema warming.
- Sooty sputum • Maintaining normothermia is vital. Protect remainder of
LA
- Burns that have occurred in an enclosed space Pt from heat loss where possible
- Singed facial hair (nasal hair, eyebrows, eyelashes, - Assess temp as soon as practicable and monitor
beards) - Cover the Pt with blankets etc.
- Respiratory distress (dyspnoea +/- wheeze and - Avoid Pt shivering.
U
associated tachycardia, stridor) • If clinically appropriate, elevation of the affected area in

- Hypoxia (restlessness, irritability, cyanosis, transit will assist in minimising burn wound oedema.
B
decreased GCS).
Burn dressings
• Cling wrap is an appropriate burn dressing. It should be
M
applied longitudinally to allow for swelling. Cling wrap is

the preferred burns dressing for all burns.
• Water gel dressings (e.g. Burnaid™) may be considered

)A
as a cooling agent where no other cooling method

exists. Cooling with water is the preferred method of
cooling. After prescribed cooling times remove and
replace with cling wrap dressing.
(C
IA
Burns CPG A0805
R
TO
? Status 8 Assess mechanism of burn and burn injury
• Evidence of burn injury • Airway injury
• TBSA
C
• Mechanism of burn injury
• Severity of burn injury
VI
Stop
• Ensure safety and removal from burn mechanism
- Avoid chemical contamination or spreading to unaffected areas
E
C
? Initial burn Mx
 Action
N
• Cool the burn, warm the Pt
• Cool burn area – refer general care notes
LA
• Protect remainder of Pt from heat loss where possible
• Provide analgesia as per CPG A0501 Pain Relief
• Cover cooled burn area with appropriate dressing – refer General care notes
U
B
? All other burn presentations ? Partial or full thickness burns >15% BSA ? Suspected airway burns
M

• BLS If TBSA is >15% For Pts with GCS up to 15
• Tx to appropriate facility • Consider ETT as per CPG A0302 Endotracheal

)A
• Normal Saline IV fluid replacement

- % TBSA x Pt wt (kg) = vol (mL) Intubation
- given over 2 hr from time of burn - Consult with Clinician
- Use RSI method unless C/I
• Tx to an appropriate facility
(C
Burns CPG A0805 127

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Burns CPG A0805
R
TO
Tx Adult Rule of Nines
• Any burns involving the face, hands, feet, genitalia, expressed as a % of body surface area
major joints or circumferential burns of the chest or
C
Note: Chest + Abdomen = 18% Front or 18% Back.
limbs or involving > 20% TBSA require assessment by Limbs are measured circumferentially.
a specialised burns service. For regional transfers this
VI
may be via secondary transfer.
Metropolitan:
• All burns Pts who meet the time critical trauma criteria
E
should be Tx to the Alfred Hospital in preference if
within 45 min. If > 45 min, Tx to nearest alternative
C
highest level of trauma service.
Rural:
N
• Tx to highest designated trauma receiving centre within
45 min.
LA
• In all cases of prolonged Tx, consider alternative air Tx.
• In all cases, appropriate consultations should
occur and hospital notification provided
U
B
M
)A
(C
(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
129
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Fracture Management CPG A0806
R
TO
Principles of fracture Mx
General principles
- Control external haemorrhage.
C
- Support the injured area.
- Immobilise the joint above and below the fracture.
VI
- Assess neurovascular status distal to the fracture before and after splinting
• Provide pain relief and correct hypovolaemia as per appropriate CPGs.
• Appropriate splinting can assist in pain reduction and arrest of haemorrhage
E
Actions before and after splinting:
- Realign long bone fractures in as close to normal position as possible.
C
- Open fractures with exposed bone should be irrigated with a sterile isotonic solution prior to realignment and
splinting.
N
- If joints are involved there is an increased possibility of neurovascular impairment and reduction is not recommended.
LA
- Mx femoral shaft fractures and fractures of the upper 2/3 of the tibia and fibula with a traction splint unless there are
distal dislocations or fractures.
• In suspected fractures of the pelvis, the legs should be anatomically splinted together (to internally rotate the feet) and the
pelvis splinted with a sheet wrap or other appropriate device.
U
• Pts who meet the major trauma criteria are time critical but appropriate splinting should be considered part of essential
prehospital Mx.
B
M
)A
(C
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)A
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B
U
LA
N
C
E
VI
C
TO
R
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Version 1 30-11-11 page 2 of 2
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Diving Related Emergencies CPG A0807
R
TO
• Pts with GCS < 15 and/or onset of symptoms • Primary goals for Pts with a diving related injury are
< 10 - 15 min after surfacing, any seizure, LOC or allow nitrogen to off-gas, increase O2 delivery and
altered conscious state have a higher probability of rehydrate.
cerebral arterial gas embolism (CAGE) and are time • Removal of N2 can be best achieved by the highest O2
C
critical. Consider air Tx for these Pts, preferably by delivery system available. Ideally for conscious Pts this
helicopter at < 300 metres. can be done using the oxy-saver allowing expired air to
VI
• DCI S/S may include musculoskeletal pain, itching, any vent to the atmosphere.
neurological changes or respiratory complaint • Unconscious and intubated Pts must be ventilated
• Specific Hx is important. This should include: using a BVM with 15 L of O2 if possible. A closed O2
– number of dives performed delivery system is C/I for dysbaric patients.
E
– surface interval between dives • Extended Tx times may require the oxy-saver to be
– max. depth(s) and bottom time(s) connected to the D-cylinders via the adaptor hose.
C
– type of ascent (controlled/rapid) • Post immersion Pts can have isolated hypotension.
– decompression or safety stops Be aware of the potential for inadequate perfusion
N
– breathing gas mixture used without hypovolaemia. Titrate fluid administration to Pt
– level of exertion during and after dive response.
– which symptoms presented and when first aid was
LA
• Warming tissues can result in dissolved N2 un-
provided. dissolving. Pts < 32ºC should be warmed to that level
• It is essential that any divers computers and gauges to avoid arrhythmia risk
from during the dive be Tx to the recompression facility. • Any potential CAGE Pt must be kept supine or in the
• This CPG is for Pts who have suffered a recent diving lateral position. The Pt should not be allowed to sit up
U
incident. Pts with a GCS of 15 who have been suffering or stand at any time. Pts who cannot be maintained
symptoms for >12 - 24 hours before calling can be in this position due to respiratory compromise may be
B
kept on a simple face mask but still need to be Tx to a kept semi-recumbent.

recompression facility with their equipment. • If there is an indication for opioid analgesia, then
M
• At time of publication the only public recompression consult with the Alfred hospital before administration.
facility in Victoria is at the Alfred Hospital. There is also a Opioids may mask symptoms for the receiving
facility at Royal Adelaide Hospital.
physician when assessing potential recompression Rx.

)A
Prochlorperazine may also mask the symptom of

vertigo.
(C
Version 1 30-11-11 page 1 of 2
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Diving Related Emergencies CPG A0807
R
? Status 8 Assess
• History of recent diving incident • Perfusion status
TO
(SCUBA) • Respiratory status
• GCS
• S/S for DRE
C
VI
? Stable (GCS = 15) ? Unstable (GCS < 15)
• Symptomatic • Symptomatic with altered conscious state
E
• Position Pt supine or lateral • Mx as per GCS 15
• Mx nausea as per CPG A0701 Nausea and Vomiting • Be aware of the greater potential for chest injuries and Mx as per
C
• Administer 100% O2 via oxy-saver regardless of respiratory status or CPG A0802 Chest Injuries
SpO2 allowing expired air to exhaust. Maintain throughout regardless • Mx as per CPG A0803 Severe Traumatic Head Injury
N
of any resolution of symptoms • Consider distance to a recompression chamber and the need for
• Avoid rapid increases in body temp MICA and/or aeromedical Tx
LA
• Tx directly to a recompression chamber • Tx directly to a recompression chamber
• Mx other signs and symptoms as per appropriate CPG • Hydrate Pt as per Perfusion below
• Mx as per Unstable (GCS < 15) if deterioration noted
• Hydrate Pt as per Perfusion below
U
B
? Perfusion
• Dehydration
M
• Less than adequate perfusion

 Action
)A
• If adequately perfused and chest clear administer Normal Saline

1000 mL over 15 - 20 min to rehydrate Pt. Continue Normal
Saline @ 1000 mL every 4 hr
• If less than adequate perfusion, titrate fluid administration to Pt
(C
response as per CPG A0801 Hypovolaemia

• Do not use warmed fluid
Diving Related Emergencies CPG A0807 133

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)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA
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)A
M
B
U
LA
N
C
E
VI
C
TO
R
135
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Hypothermia / Cold Exposure CPG A0901
R
TO
• Hypothermia is insidious and rarely occurs in isolation. • Shelter from wind in heated environment.
Where the Pt is in a group environment other members • Remove all damp or wet clothing.
of the group should be carefully assessed for signs of
C
• Gently dry Pt with towels/blankets.
hypothermia.
• Wrap in warm sheet/blanket - cocoon.
• Arrhythmia in hypothermia is associated with temp
VI
below 33˚C. • Cover head with towel/blanket - hood.
• Atrial arrhythmias, bradycardias or A-V blocks do not • Use thermal/space/plastic blankets above and below
generally require Rx with anti-arrhythmic agents unless the Pt if available.
decompensated and resolve on rewarming. • Only warm frostbite if no chance of refreezing prior to
E
• Defibrillation and cardioactive drugs may not be arrival at hospital.
effective at temp below 30˚C. VF may resolve
C
• Assess BGL if altered conscious state.
spontaneously upon rewarming.
• The onset and duration of drugs is prolonged in Warmed fluid
N
hypothermia and the interval between doses is • Normal Saline warmed between 37 - 42˚C should
therefore doubled, e.g. doses of Adrenaline become 6 be given to correct moderate/severe hypothermia and
LA
minutely. maintain perfusion if available. Fluid < 37˚C could be
detrimental to Pt.
U
B
M
)A
(C
IA
Hypothermia / Cold Exposure CPG A0901
R
TO
? Status 8 Assess
• Hypothermia • Mild hypothermia 32 - 35˚C
• Moderate hypothermia 28 - 32˚C
• Severe hypothermia < 28˚C
C
• If alteration to cardiac arrest Mx required
VI
? Non cardiac arrest ? Cardiac arrest
E
• Moderate/severe hypothermia < 28 - 32˚C
• Warmed Normal Saline 10 mL/kg IV
C
• Repeat Normal Saline 10 mL/kg IV ? > 32˚C ? 30 - 32˚C ? < 30˚C
(max. 40 mL/kg) to maintain perfusion
N
• Avoid drug Mx of cardiac arrhythmias • Standard cardiac • Double intervals • Continue CPR and rewarming
unless decompensated and until arrest CPG between doses in until temp > 30˚C
LA
rewarming has commenced relevant cardiac • One DCCS only
arrest CPG
• One dose of Adrenaline
- Do not rewarm
beyond 33˚C if • One dose of Amiodarone
U
ROSC
• Withhold Sodium Bicarbonate
8.4% IV
B
M
)A
(C
Hypothermia / Cold Exposure CPG A0901 137

IA
Environmental Hyperthermia Heat Stress CPG A0902
R
TO
• Pt body temp of < 40°C may usually be Mx with basic • During cooling, the Pt should be monitored for the
cooling techniques alone. onset of shivering. Shivering may increase heat
• Be wary of fluid volumes in renal dialysis Pts causing production and cooling measures should be adjusted
C
fluid overload. Administer judicious increments with to avoid its onset.
volumes not usually exceeding 10 mL/kg. • Gentle handling of the Pt is essential. Position flat or
VI
• This CPG is not intended for the Mx of the febrile Pt lateral and avoid head up position to avoid causing
due to infection. arrhythmias.
E
C
N
LA
U
B
M
)A
(C
IA
Environmental Hyperthermia Heat Stress CPG A0902
R
? Status 8 Assess
TO
• Hyperthermia / heat stress • Accurately assess temp
• BGL if altered conscious state
• Perfusion status and dehydration
C
? Requires active cooling
VI
 Action
• Cooling techniques - initiated and maintained until temp is < 38°C
- Shelter / remove from heat source - Remove all clothing except underwear
- Ensure airflow over Pt - Apply tepid water using spray bottle or wet towels
E
• If significant dehydration or poor perfusion, Rx as per CPG A0801 Hypovolaemia
• Provide initial Normal Saline 20 mL/kg IV and reassess VSS and temp
C
- If Pt temp > 40°C use cool fluids if available (stored usually at < 8°C)
• Continue to administer Normal Saline if Pt remains poorly perfused or significantly dehydrated
N
- If cool fluids intiated, return to ambient temp once Pt temp is < 39°C
• Rx low BGL as per CPG A0702 Hypoglycaemia
LA
• Airway and ventilation support with 100% O2 as required
U
B
? Adequate response ? Assess

 Action • Severe cases - temp > 39.5˚C
M
• BLS • GCS < 10

• Tx  Action
)A
• Consider ETT as per CPG A0302

• If intubated, sedation and paralysis essential to
(C
prevent shivering and reduce heat production
Environmental Hyperthermia Heat Stress CPG A0902 139

(C
)A
M
B
U
LA
N
C
E
VI
C
TO
R
IA

Adult CPG WM - 0

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Version 1 - 08.06.

haemodynamically stable, O2 dose should be titrated to normal levels.

Oxygen Therapy CPG A0001 1

• Initial Mx - Consider simple face mask

10 - 15 L/min • If Pt deteriorates or SpO2

ventilation with 100% O2 - Rx as per Moderate-severe

- Titrate O2 flow to SpO2 of 94 - 98%

• If Pt deteriorates or SpO2 remains < 85%

- Consider ETT as per CPG A0302

Oxygen Therapy CPG A0001 3

Clinical Approach CPG A0101 5

Hx of presenting complaint Accurate Hx and assessment

GCS Determine time criticality to

Assess Secondary survey

Head to toe assessment including evaluating pattern Early recognition of time

SpO2 appropriate Mx, early request

Provide MICA Mx in a timely manner

Clinical Approach CPG A0101 7

Perfusion Assessment CPG A0102 9

Conscious state Alert Alert May be altered Altered or unconscious

A. Eye opening Score

Abnormal flexion (pain) 3

Total GCS (Max. score = 15)

Conscious Assessment CPG A0104 11

Time critical definitions

the potential to deteriorate to actual physiological distress.

Time Critical Guidelines CPG A0105 13

? Vital signs are normal

Fall from height > 3 m

High speed MCA > 60 km/hr

? Vital signs are normal

7. Thought content Delusions (i.e., false beliefs)

8 Thought flow Jumping irrationally from one thought to another

9. Concentration Poor ability to organise thoughts

Mental Status Assessment CPG A0106 17

CPR Adjustment for temperature

• Rate: approximately 100 compressions per min

Intubated / LMA inserted

• Rate: approximately 100 compressions per min

Cardiac Arrest CPG A0201 19

? VF/VT persists ? PEA persists ? Asystole persists

 Action  Action  Action

• ETT • ETT • ETT

? Outcome ? Outcome ? Outcome

 Action  Action  Action

Cardiac Arrest CPG A0201 21

oxygenation and changes • Sedation/paralysis

occurs Normal Saline up to

- Cease if APO occurs

and Rx as per CPG

Cardiac Arrest (ROSC Management) CPG A0202 23

agonal/ineffective gasping respiration is particularly important where a copy of the ROTC

futile. liable in any civil proceedings because of the failure to

Withholding or Ceasing Resuscitation CPG A0203 25

Is there no prospect of resuscitation?

• Injuries incompatible with life or

• If Yes, do not commence resuscitation and

agonal / gasping respiration and no compelling reason to continue

• Confirm the determinants of death are present

Withholding or Ceasing Resuscitation CPG A0203 27

guardian or foster parent.

an attempt to reject the LMA, remove the LMA with

• Initial Mx - Consider simple face mask

10 - 15 L/min • If Pt deteriorates or SpO2

ventilation with 100% O2 - Rx as per Moderate-severe

- Consider ETT as per CPG A0302

- Cease if APO occurs

- Refer to CPG A0303 Failed Intubation

- Repeat if evidence of returning muscular activity

• Current evidence suggests Tx to a PCI-enabled facility

• Continue current Mx • Adrenaline infusion (3 mg/50 mL D5W / Normal Saline)