Guideline

Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/

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Rural Adult Emergency Clinical Guidelines 3rd Edition
space Document Number GL2010_003 Publication date 03-Mar-2010 Functional Sub group Clinical/ Patient Services - Nursing and Midwifery Clinical/ Patient Services - Medical Treatment Clinical/ Patient Services - Critical care Summary The intention of these guidelines is to ensure early appropriate management of acute and life threatening conditions, and to relieve pain and discomfort for patients at hospitals where medical practitioners are not immediately available. The guidelines reflect best clinical practice and are not mandatory, however, they have been adopted and implemented across the State since 2004 providing essential clinical support for rural emergency clinicians. NOTE: On 13 January 2012 an amendment was made to correct an error to the dose for Isolated severe limb injury listed on page 82. Replaces Doc. No. Rural Emergency Clinical Guidelines for Adults - 2nd Edition 2007 Version 2.1 - NSW [GL2007_005] Author Branch Statewide and Rural Health Services and Capital Planning Branch contact Brett Abbenbroek 9391 9526 Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Public Health System Support Division, Public Health Units, Public Hospitals Audience Nursing, Medical & Allied Health clinical staff, and all Emergency Departments Distributed to Public Health System, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Ministry of Health, Private Hospitals and Day Procedure Centres Review date 03-Mar-2012 Policy Manual Patient Matters File No. 97/1749-10
Director-General

Status Active

GUIDELINE SUMMARY

RURAL ADULT EMERGENCY CLINICAL GUIDELINES 3RD EDITION PURPOSE
These guidelines are provided to assist early appropriate clinical management of acute and life threatening conditions, and to relieve pain and discomfort, for patients at hospitals where medical officers are not immediately available. The guidleines reflect best clinical practice and have been used extensively across the state since 2004 to provide clinical support for rural emergency clinicans.

KEY PRINCIPLES
Underpinning these guidelines are the following principles:  A ‘graduated’ clinical response is required depending on the: o severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma; o level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions; o legal requirements for nurses who initiate treatment and administer medications based on medication standing orders; o need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances;    The guidelines reflect evidence based best clinical practice and expert consensus opinion; Standardisation of initial clinical management of specific adult conditions; and Alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses.

USE OF THE GUIDELINE
These guidelines are to be used for adults only and have been formatted to follow the generally accepted Airway, Breathing and Circulation (ABC) approach for managing emergency/critically ill patients. Nursing staff using these Guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by Registered Nurses who are recognised as Advanced Clinical Nurses.

GL2010_003

Issue date: March 2010

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GUIDELINE SUMMARY

Advanced Clinical Nurses have advanced knowledge and skills; and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines:    the designated medical officer will be notified immediately; standing medication standing orders contained in these guidelines will be reviewed and authorised by the designated medical officer as soon as possible (within 24 hours); and the medical officer will countersign the record of administration on the patients’ medication chart.

A number of appendices and a formulary have been included to complement these guidelines. NSW Health Pharmaceutical Services Branch has reviewed these guidelines and has indicated that they are satisfactory for the consideration of the local Area Health Service Drug Committees for approval and implementation as medication standing orders, in terms of the criteria for standing orders as specified in NSW Health Policy Directive, PD2007_077 - Medication Handling in NSW Public Hospitals. These guidelines should be read in conjunction with NSW Health Policy Directive PD2005_042 - Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_042.html

REVISION HISTORY
Version 3rd Edition (GL2010_003) 2ndEdition 2007 (GL2007_005) 1st Edition 2004 Approved by Deputy Director-General Strategic Development Deputy Director-General Strategic Development Deputy Director-General Strategic Development Amendment notes Rescinds GL2007_005: total revision. Replaced 1st edition: total revision.

ATTACHMENTS
1. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

GL2010_003

Issue date: March 2010

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NSW Rural Adult Emergency Clinical Guidelines NSW Rural Critical Care Taskforce – 3rd Edition .

au This work is copyright. Reproduction for purposes other than those indicated above requires written permission from the NSW Department of Health.gov. (02) 9391 9900 www.nsw. It may not be reproduced for commercial usage or sale.health. © NSW Department of Health 2010 SHPN (SSD) 090220 ISBN 978-1-74187-347-4 For further copies of this document please contact: Better Health Centre – Publications Warehouse PO Box 672 North Ryde BC. NSW 2113 Tel. (02) 9391 9101 TTY.au February 2010 . (02) 9887 5450 Fax. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source.health.gov.nsw. (02) 9391 9000 Fax. (02) 9887 5452 Further copies of this document can be downloaded from the NSW Health website www.NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel.

The NSW Rural Adult Emergency Clinical Guidelines are to be implemented for the emergency management of adult patients only. Aeromedical and Medical Retrieval Service (AMRS) 1800 650 004 NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 1 .

........................ Suggested Guidelines for a Neurovascular Assessment .................... 15 Shortness of Breath with or without a History of Asthma . appendices ....57 Isolated Severe Limb Injury .......107 14.............. 113 17................... trauma emergencies ..............................................92 2..................... 7 Unconscious Patient .................12 9.................................. 114 18...................................... 47 Trauma .............. 36 endocrine / envenomation emergencies .............108 15... 8 Seizures... .... 5 1.16 Shortness of Breath with a History of Cardiac Disease ..................................................... Guidelines for when to Apply Semi-rigid Cervical Collar ....................................... Burn Transfer Flowchart . ............. Other emergencies .. Guideline for Emergency Department Documentation ..........99 2...............................103 11b....................................... 62 7....................Removal of Semi-rigid Cervical Collar without Radiographic Assessment ......26 Cardiorespiratory Arrest (Advanced Life Support)....... airway emergencies .......................100 9.................................29 Acute Coronary Syndrome with or without Associated Symptoms . Circulatory emergencies ....................... 44 6.................. 3 abbreviations .............102 11a............................................ 40 Hypoglycaemia ............................................ 48 Burns .............. . 8............................................ 12 Lead ECG Lead Placement .95 4........................................................................................... 5.. Recommended Blood Pathology Testing Available at the Point of Care in Rural Facilities where an Emergency Service is Provided .............. Management of Patients with ST-segment Elevation Myocardial Infarction (STEMI).........................................................................................................................55 Head Injury .............10 Anaphylactic Reaction ........................ ..............97 6......................Contents Introduction ................. Minimum Skill Set for Emergency Department Staff ....... ........................................31 Non-traumatic Shock .......... 66 Formulary ..........................52 Drowning ................................101 10...........33 4...... 39 Hyperglycaemia with Severe Dehydration ............... 110 16...................... 91 1..................... 116 3.... Breathing emergencies.................... Disability emergencies .. Pelvic Binding ............................... 35 Meningococcal Disease .................42 Snake / Spider Bite........... Defibrillation ............ Sedation Score/Scale ....................... 65 Abdominal/Loin/Flank Pain .. Needle Thoracentesis for Decompression of Tension Pneumothorax ..............20 Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease .................109 Burn Patient Emergency Assessment & Management Chart .................................................... Glass Tumbler Test .................. AVPU and Glasgow Coma Scale (GCS) ....................... Pain Assessment ............................................................................98 7.... Rural and Remote Emergency Trolley – Minimum Requirements ............................................ Snakebite Observation Chart ......................... 22 8..........104 12............ 94 3............................ 60 Ocular Injuries ..........................................................27 Compromising Bradycardia ............ Trauma Triage Tool .................................................................................................................. 69 PAGE 2 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .......... 25 Cardiorespiratory Arrest (Basic Life Support) ......................105 13...... 96 5.............. Burn Injury Referral/Retrieval Criteria Checklist............

Special recognition is made to the utilisation of the template designed and developed by the EDWPR group. In particular it can be difficult for staff working in rural and remote EDs to acquire and retain emergency expertise. in 2004. For example. The intention of the Guidelines is to ensure early management of immediately or imminently life threatening conditions. supported by higher level evidence where available. the use of shaded portions in the NSW Rural Adult Emergency Clinical improve the emergency care and outcomes for patients in the rural and remote health care settings of NSW.Introduction Emergency Departments (EDs) in rural and remote New South Wales (NSW) face a number of unique and difficult challenges in trying to deliver quality emergency care and achieving good patient outcomes. assist rural and remote EDs in NSW achieve benchmarking targets and best practice standards for patients with emergency presentations. The document has been developed with the following desirable features: n Guidelines indicates clinical interventions that can only be initiated by RNs who are recognised as Advanced Clinical Nurses. and requests and advice from end users. – level of training and expertise of the nursing staff who are initiating management of the patient – that is. These Guidelines are largely based on expert consensus opinion. The Guidelines are also formatted to follow the generally accepted Airway. n incorporation of the various legal requirements for nurses who initiate treatment and administer medications based on medication standing orders flexibility – guidelines need to be flexible enough to allow local input from rural Medical Officers (MOs) and RNs so that local practices can be incorporated endorsement by relevant committees and divisions within NSW Health standardisation of the management of specific adult conditions across rural NSW n n n The NSW Rural Adult Emergency Clinical Guidelines incorporate these features as well as the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses and the standing orders developed by the Wollongong Hospital pilot site model of the Emergency Department Work Practice Review (EDWPR). formatting which allows for RNs with advanced training to practice more advanced interventions. Circulation (ABC) approach for managing emergency/critical care patients. and to relieve pain and suffering in patients at sites where medical practitioners are not immediately available. which could be used by rural and remote Registered Nurses (RNs) who have undergone approved education and credentialing. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma. This type of graduated clinical response has been used quite successfully in ambulance service protocols for many years. The aims of the NSW Rural Adult Emergency Clinical Guidelines are to: n formatting which allows for ‘graduated’ clinical responses. These responses vary depending on: – degree of severity of the presenting emergency condition. This is the third total revision of the document in line with changes to best practice. This may lead to inequalities in the standards of emergency care delivered in rural and remote EDs. One of the Taskforce’s strategies led to the development. Breathing. RNs without this advanced training and credentialing cannot perform the advanced interventions. of a set of Rural Emergency Clinical Guidelines for Adults. provide readily accessible and user-friendly guidelines for clinicians providing emergency care to patients in rural and remote areas of NSW. A key function of the NSW Rural Critical Care Taskforce (RCCT) is to identify and develop ways to ensure a more uniform quality of emergency care in these EDs. n n NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 3 .

A number of appendices have been included to complement these Guidelines. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses. This MO may be one of those servicing the Emergency Department/s using these Guidelines. skilled and credentialed. n NSW Health Pharmaceutical Services Branch has reviewed these Guidelines and have indicated that they are satisfactory for the consideration of the local Area Health Service Drug Committees for approval and implementation as medication standing orders. It will be the responsibility of the rural Area Health Services through both their Critical Care Network Committee and their Health Service Managers to ensure compliance with these requirements. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Staff should familiarise themselves with both the Appendix and Formulary sections. Advanced Clinical Nurses are those RNs who have advanced knowledge and skills. – recognising and formalising the advanced role that many rural and remote RNs currently perform when delivering care to critically ill or injured patients presenting to Emergency Departments. Nursing staff using these Guidelines are required to be appropriately educated. This document should be read in conjunction with the following Policy Directive from NSW Health: n PD2005_042 – Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals. a MO will be notified immediately to ensure their early involvement with the management and care of the patient. At the time of this review the MO must check and countersign the nurse record of administration on the medication chart. that MO review is required following the administration of a drug according to the standing orders contained within this document as soon as possible (must be within 24 hours). Medication Handling in NSW Public Hospitals. Implementation It is intended: n when an Advanced Clinical Nurse utilises these Guidelines. and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. n Credentialing of advanced Clinical Nurses (aCN) Registered Nurses can be considered eligible to be credentialed for Advanced Clinical Nurse roles if: n n they have successfully completed an advanced or critical care nursing course such as the FLEC Course/ Graduate Certificate/Graduate Diploma in Emergency.n address some of the current professional issues facing rural and remote RNs by: – providing a safe framework in which rural and remote RNs can initiate management and care of emergency patients. the ACN maintaining appropriate documentation to allow review of the usage of these Guidelines. that any medication standing orders contained in these Guidelines will be signed and authorised by a MO appointed by the Area Health Service. Credentialing will be obtained and maintained by: n completion of standard competency assessments as recommended by the Critical Care Network Committee in each Area Health Service. in terms of the criteria for standing orders as specified in NSW Health Policy Directive. n Advanced Clinical Nurses are required to be recredentialed annually or according to local Area Health Service policy. PAGE 4 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . PD2007_077. – providing a pathway by which credentialed RNs can work toward continuing professional development. and they can demonstrate recent and ongoing knowledge and experience with managing emergency/critical care patients.

NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 5 . Voice. Unresponsive Body Surface Area Blood Glucose Level Bi-level Positive Airway Pressure Beats per minute Continuous Positive Airway Pressure Creatine kinase Cardiopulmonary Resuscitation Cerebrospinal fluid Cervical spine Computed Tomography Diastolic Blood Pressure Electrocardiograph Emergency Department Full Blood Count First Line Emergency Care Course Glasgow Coma Score/Scale Gastrointestinal tract Human Chorionic Gonadotropin Intensive Care Unit Indwelling catheter Intramuscular Intraosseous Intravenous Kilogram L LFT LMA LOC MDI mg mL mmol/L MO NGT O2 PEFR PPE PoC POP PO PR PV RN SBP SCI S/L SOB SpO2 Stat STEMI TBSA U/A UEC UO VF VT Litre Liver Function Test Laryngeal Mask Airway Level of Consciousness Metered Dose Inhaler Milligram Millilitre Millimols per Litre Medical Officer Nasogastric tube Oxygen Peak Expiratory Flow Rate Personal protective equipment Point of Care Plaster of Paris Per oral Per rectum Per vagina Registered Nurse Systolic Blood Pressure Subcutaneous injection Sublingual Shortness of breath Pulse oximetry saturation Immediately and once only ST segment Elevation Myocardial Infarction Total body surface area Urinalysis Urea Electrolytes Creatinine Urine output Ventricular fibrillation Ventricular tachycardia The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Pain.abbreviations ABG ACN ACS AED AHS AMI ARC AVPU BSA BGL BiPAP bpm CPAP CK CPR CSF C-Spine CT DBP ECG ED FBC FLECC GCS GIT hCG ICU IDC IM IO IV Kg Arterial Blood Gas Advanced Clinical Nurse Acute Coronary Syndrome Automatic/Automated External Defibrillator Area Health Service Acute Myocardial Infarction Australian Resuscitation Council Alert.

PAGE 6 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

SECTION 1 Airway Emergencies The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 7 .

9% Sodium Chloride 500 mL bolus Monitor vital signs frequently Monitor LOC frequently If GCS less than 9 and not rapidly improving. (consider group and hold in trauma patients) Nil by mouth IV 0. History Prompts n n n n n n Onset Events – mechanism of injury Associated preceding symptoms Relevant past history. Breathing and/or Circulation. especially diabetes and alcohol use Medication history. PAGE 8 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . the patient will require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration Disability AVPU/GCS + pupils BGL Finger prick BGL If less than 3 mmol/L and unconscious or confused administer IV 50% Glucose 50 mL or If no IV access administer IM Glucagon 1 mg Monitor finger prick BGL every 15 minutes until within normal limits Possible opiate overdose (characterised by pin-point pupils and hypoventilation) Measure and test Pathology Temperature U/A Fluid input/output If opiate overdose. especially narcotic use Allergies Clinical Severity Prompts n n Glasgow Coma Score (GCS) less than 9 Inability to maintain own airway assessment Position airway Assess patency Intervention Lie supine Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology Breathing Respiratory rate and effort SpO2 Auscultation Skin temperature Pulse – rate and rhythm Capillary refill Blood pressure Cardiac monitor Circulation If SBP less than 90 mmHg give IV 0. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. give IM Naloxone 800 micrograms and IV Naloxone 800 micrograms Collect blood for FBC.Unconscious Patient | Medical Officer must be notified immediately | For Adults Only Unconscious Patient The most common error in the management of an unconscious patient is inadequate management of Airway. UEC.9% Sodium Chloride 1000mL at 125mL per hour to maintain hydration Fluid balance chart 12 lead ECG If history of possible alcohol abuse give IM Thiamine 100 mg Electrocardiography Specific treatment Possible alcohol abuse Document assessment findings.

O.. Hew .use.. p. A. timing is irrelevant’ (Hew. 367). Tamworth. Drug Oxygen 0.com. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernicke’s encephalopathy is unfounded.9% Sodium Chloride Thiamine 0. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document..hcn. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Be alert for acute opiate withdrawal after the administration of Naloxone. particularly if high flow oxygen has been administered in transit to the Emergency Department. R. Kelly. Murray. Brown. The half-life of Naloxone is much shorter than the opiate.. Sydney. At the time of this review.W. If an Advanced Clinical Nurse uses these Guidelines. both doses of Naloxone may be given IM.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Elsevier. P. G. although it should be noted that this is not ideal as the IM route will take longer to take effect.. Altered Conscious State in Textbook of Adult Emergency Medicine. ELS Course Inc. Fulde. Consider carbon dioxide retention in unconscious hypoxic patients with a history of COPD. L. J. The absorption of Thiamine is so much slower than that of glucose.Unconscious Patient | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Emergency medicine the principles of practice 4th edn. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 9 . Jelinek. If IV access is unavailable. 2004. (editor) 2004. A. G.9% Sodium Chloride Dose 6-15 litres/min 500 mL bolus 50 mL 1 mg (if IV access unavailable) 800 micrograms 800 micrograms 1000 mL 100 mg 10 mL flush Route Inhalation IV IV IM IM IV IV IM IV Frequency Continuous Stat Stat Stat Stat Stat 125mL per hour to maintain hydration Stat As required Medications within this guideline must be administered within the context of the formulary.9% Sodium Chloride 50% Glucose Glucagon Naloxone Naloxone 0. 3rd edn. Sydney MIMS Online <http://proxy8... n n n References: Emergency Life Support (ELS) Course Manual. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. 2004. Repeated doses of Naloxone may be required. Heyworth. Edited by Cameron. ‘The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. Elsevier. 2005.

it will be necessary to reassess/ treat/maintain the patient’s airway and breathing Circulation Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU/GCS + pupils BGL IV cannulation/pathology Monitor vital signs frequently Monitor LOC frequently Finger prick BGL If less than 3 mmol/L administer IV 50% Glucose 50 mL or IM Glucagon 1 mg (if IV access unavailable) Monitor finger prick BGL every 15 minutes until within normal limits Measure and test Pathology Temperature U/A Fluid intake/output Collect blood for FBC. PAGE 10 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .Seizures | Medical Officer must be notified immediately | For Adults Only Seizures Clinical Severity Prompts n n n n History Prompts n n Events – mechanism of injury Associated symptoms. UEC Nil by mouth If history of possible alcohol abuse give IM Thiamine 100 mg Specific treatment Possible alcohol abuse Document assessment findings. Once this has occurred. – altered level of consciousness. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. pale. sweaty.1 mg/Kg) or if IV access unavailable: IM Midazolam 10 mg stat and repeat (once only) after 5 minutes if required It may be difficult to adequately treat the patient’s airway and breathing until the seizures have been stopped.5 mg increments slow injection every 1-2 minutes (to a total dose of 0. incontinence Rhythmical involuntary jerking (tonic-clonic) Stiffening of the body Clenched jaw Altered level of consciousness n n n n Relevant past history Medication history Allergies Onset assessment Position Intervention Protect from further harm Do NOt restrain the patient Lie supine or left lateral (after tonic phase and clonic movements cease) Maintain airway patency (a nasopharyngeal airway is the recommended adjunct unless contra-indicated) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Stop the seizures airway Assess patency Breathing Respiratory rate and effort SpO2 IV Midazolam 2.

com. At the time of this review. Observe for features of the seizure and document. If an Advanced Clinical Nurse uses these Guidelines. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 11 . Do not attempt to put anything between the teeth during a seizure.1 mg/Kg) Stat and repeat (once only) after 5 minutes if required Stat Stat Stat As required Medications within this guideline must be administered within the context of the formulary..O. (editor) 2004. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. Drug Oxygen Midazolam Midazolam 50% Glucose Glucagon Thiamine 0. Sydney.W. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. Elsevier. n n References: Fulde G.Seizures | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications.use.9% Sodium Chloride Dose 6-15 litres/min 2.hcn.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Warning: respiratory and cardiovascular depression can be severe after the administration of Midazolam and requires close monitoring and treatment.5 mg increments 10 mg (if IV access unavailable) 50 mL 1 mg (if IV access unavailable) 100 mg 10 mL flush Route Inhalation IV IM IV IM IM IV Frequency Continuous Slow injection every 1–2 minutes (to a total of 0. Emergency medicine the principles of practice 4th edn. MIMS Online <http://proxy8.

urticaria and angioedema can be absent in up to 20% of cases Gastrointestinal symptoms: vomiting. abdominal pain. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. generalised redness and periorbital oedema Anaphylaxis is likely when all three criteria are met: – sudden onset and rapid progression of symptoms – life-threatening Airway and/or Breathing and/ or Circulation problems are present – skin and/or mucosal changes (flushing. peripheral vasodilation. urticaria. incontinence Relevant past history Medication history Allergies n n n n assessment Position Assess patency Stridor Hoarse voice Breathing Respiratory rate and effort SpO2 Wheeze Skin temperature Pulse – rate/rhythm Blood pressure Capillary refill Cardiac monitor Disability Measure and test Specific treatment AVPU/GCS + pupils Fluid input/output No response to IM Adrenaline and patient presents signs of cardiorespiratory collapse Intervention Position of comfort Cease/remove causative agent Maintain airway patency If stridor present give IM Adrenaline 0. PAGE 12 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . urticaria.9% Sodium Chloride 1000 mL bolus Monitor vital signs frequently Monitor LOC frequently Fluid balance chart ** IV Adrenaline 50 micrograms airway Circulation Document assessment findings.Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only anaphylactic Reaction Clinical Severity Prompts n Relevant History and assessment Prompts n n n Onset Exposure to known allergen for the patient Associated symptoms: – respiratory distress. angioedema) n Flushing.5mg every 3-5 minutes (to a total of 2 mg) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% If wheeze present give Salbutamol 10 puffs of 100 microgram dose MDI + spacer IV cannulation If pulse rate greater than 100 bpm. SBP less than 90 mmHg and capillary refill greater than 2 seconds give IV 0. hypotension.

editor in chief. West Beach Emergency Life Support (ELS) Course Manual 3nd edn. 3rd.5 mL of 1:10. but are not anaphylactic reactions as they are not life-threatening. al. n n n n References: Dunn. 162).use. 2008. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Systemic allergic reactions can occur with urticaria.5 mg 10 puffs of 100 microgram dose MDI + spacer 50 micrograms 1. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Venom Publishing Unit. Pumphrey R. 2008 p. al. 2005.Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Tamworth MIMS Online <http://proxy8. **IV Adrenaline 50 micrograms equates to 0.000 (10mL) Adrenaline.. Drug Oxygen Adrenaline Salbutamol ** Adrenaline 0. et.. 2 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh – the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. al. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. no.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 13 . vol. Adrenaline is the most important drug for the treatment of an anaphylactic and allergic reaction. Death caused by anaphylactic reaction occurs most commonly in the first 45 minutes after the patient has had contact with an allergen.. (2). Cant A. for the Working Group of the Resuscitation Council (UK). 77. If an Advanced Clinical Nurse uses these Guidelines. ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’.com. The emergency medicine manual. angioedema and rhinitis. et.000 mL bolus 10 mL flush Route Inhalation IM Inhalation IV IV IV Frequency Continuous Every 3-5 minutes to a total of 2 mg Stat Stat Stat As required Medications within this guideline must be administered within the context of the formulary.. Resuscitation. R. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.9% Sodium Chloride Dose 6-15 litres/min 0. 2003. At the time of this review. edn. ELS Course Inc.hcn.9% Sodium Chloride 0.

PAGE 14 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

SECTION 2 Breathing Emergencies NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 15 .

moderate or severe scale as described below Clinical manifestation of acute asthma ** Severe and life threatening ** australasian triage Scale (atS) Physical exhaustion talks in Pulse rate Central cyanosis Wheeze intensity PeFR Pulse oximetry 1 Yes Paradoxical chest wall movement may be present Words Greater than 120 bpm # Likely to be present Often quiet/silent Less than 50% predicted (or best if known) or less than 100 Litres/min Less than 90% cyanosis may be present Moderate 2 No Mild 3 No Phrases 100-120 bpm May be present Moderate to loud 50-75% predicted (or best if known) Sentences Less than 100 bpm Absent Variable Greater than 75% predicted (or best if known) Reference: National Asthma Council. Australia. p. # Bradycardia may be seen when respiratory arrest is imminent. 39. 2006. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. PAGE 16 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . The absence of any feature does not exclude a severe attack.Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with or without a History of asthma Clinical Severity Prompts n History Prompts n n n n n n n Onset Associated symptoms Relevant past history Medication history Trigger factors Past presentation/s admission/s (ED/ICU/intubation) Allergies Correspond with either mild. Asthma Management Handbook. ** Any of these features indicate the episode is severe.

5mg one dose only Assist ventilation if required Apply O2 to maintain SpO2 above 95% 8-12 puffs Salbutamol 100 microgram MDI + spacer every 15-30 minutes. 4 puffs Ipratropium Bromide 20 microgram MDI + spacer stat Salbutamol 5mg nebule and Ipratropium bromide 500 microgram nebule stat 8-12 puffs Salbutamol 100 microgram MDI + spacer every 1-4 hours 8-12 puffs Salbutamol 100 microgram MDI + spacer stat IV cannulation for moderate and severe asthma If patient cannot inhale adequately to use an MDI and spacer (severe asthma) Moderate asthma Mild asthma Circulation Skin temperature Pulse – rate/rhythm Blood pressure Cardiac monitor Electrocardiography Disability Measure and test Specific treatment AVPU/GCS Temperature Spirometry Continuing respiratory distress Monitor vital signs frequently 12 lead ECG Monitor LOC frequently For moderate and severe asthma give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable) Document assessment findings. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 17 . interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. increasing cyanosis of lips/ mouth and bradycardia) Breathing Respiratory rate and effort SpO2 Speech Use of accessory muscles Sternal retraction Spirometry/PEFR (moderate and mild asthma) Severe asthma Intervention Sit patient upright or position of comfort Maintain airway patency If the patient is pre-arrest or asthma associated with anaphylaxis give IM Adrenaline 0.Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only assessment Position airway Assess patency If the patient shows signs of pre-arrest or asthma associated with anaphylaxis (exhibits decreasing LOC.

Drug Oxygen Adrenaline Salbutamol Dose 8-15 litres/min 0.5 mg 100 microgram per inhalation MDI + spacer 5mg Nebule Route Inhalation IM (pre-arrest circumstance) Inhalation Frequency Continuous Stat Severe: 8-12 puffs every 15-30 minutes Moderate: 8-12 puffs every 1-4 hours Mild: 8-12 puffs stat Every 15-30 minutes (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Stat for severe cases Severe: stat (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Stat for moderate and severe asthma Stat for severe and moderate asthma As required Salbutamol Inhalation Ipratropium Bromide Ipratropium Bromide Hydrocortisone Prednisolone 0.Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. At the time of this review. If an Advanced Clinical Nurse uses these Guidelines.9% Sodium Chloride 4 puffs of 20 microgram per inhalation MDI + spacer 500 microgram Nebule 200 mg 50 mg (if IV access unavailable) 10 mL flush Inhalation Inhalation IV Oral IV Medications within this guideline must be administered within the context of the formulary. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. PAGE 18 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document.

2006.9% Sodium Chloride.com. National Asthma Council Australia. NSW Health. Australia.use. revised and updated. Asthma Management Handbook. al. 77(2). Pumphrey R. give oxygen at a flow of 8-10 L/min. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh – the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. Use a nebuliser instead of MDI if the patient cannot inhale adequately. 2008.hcn.Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n There is substantial evidence that Ipratropium Bromide is of limited use in acute episodes of mild to moderate asthma. A 5 mg nebule of Salbutamol should be made up with 2 mL 0. 2006.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. p. other than for those patients with life-threatening asthma who cannot inhale well enough to use an MDI + spacer (e. A mouthpiece delivers considerably more drug to the lung than a facemask. for the Working Group of the Resuscitation Council (UK). 2007. MIMS Online <http://proxy8. North Sydney. 2. Emergency Care Community of Practice. Cant A. S. Delivery of short acting beta agonists via MDI and spacer is equally effective as nebulisation in patients with moderate to severe acute asthma. The use of short acting beta agonists by intermittent inhalation via MDI and spacer is now recommended in the management of acute asthma. 2008. moderate or severe. al. Emergency care evidence in practice series: use of ipratropium bromide for acute asthma. NSW Department of Health. ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’.g. adverse events are more frequent. et. However. PD2007_063 Infection Control Policy. vol. whether mild. Soar J. Resuscitation. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 19 . If available. no. National Institute of Clinical Studies. Continuous nebulisation and IV therapy are alternatives in severe asthma. those requiring ventilation). n n n n n References: Doherty. Ipratropium Bromide is not necessary in mild asthma and optional in moderate episodes. 162). Melbourne. National Asthma Council.

interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Nitrates and Frusemide) Audible respiratory crepitations Cardiac monitor Electrocardiography Disability Measure and test AVPU/GCS BGL Pathology Fluid input/output U/A Chest X-ray Specific treatment Continuing respiratory distress Document assessment findings. UEC. clammy. speaking in phrases or words Severe respiratory distress with exhaustion Altered level of consciousness Ability to talk in words only Central cyanosis Audible respiratory crepitations n n n n Relevant past history History of cardiac disease Medication history Allergies assessment Position airway Breathing Assess patency Respiratory rate and effort SpO2 Speech Auscultation Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Intervention Sit patient upright Maintain airway patency Assist ventilation if required with positive pressure bag valve mask Apply O2 via non re-breather mask at 15 L/min. audible respiratory crepitations. PAGE 20 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with a History of Cardiac Disease Clinical Severity Prompts n n n n n History Prompts n n n Onset Events Associated symptoms – pale.e. aim to maintain SpO2 greater than 95% Consider CPAP/BiPAP if available IV cannulation/pathology Circulation If SBP greater than 90 mmHg give Glyceryl Trinitrate S/L 300-600 micrograms or spray 1-2 sprays (400-800 micrograms) Repeat every 5 minutes if SBP greater than 90 mmHg Audible respiratory crepitations present – give IV Frusemide 40 mg Monitor vital signs frequently 12 lead ECG Monitor LOC frequently Finger prick BGL Collect blood for FBC. cardiac markers and ABG or venous blood gas (if available) Fluid balance chart Restrict oral fluid intake Consider IDC and urine measurements every hour If available CPAP 10 cm H20 if available and SBP greater than 100 mmHg and SOB unrelieved by other interventions (i.

in Textbook of Adult Emergency Medicine. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. ‘Assessment and management of acute pulmonary oedema in EDs’.Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Jelinek. Sydney. eds P.9% Sodium Chloride IV IV Medications within this guideline must be administered within the context of the formulary. detection and management of chronic heart failure in Australia. A. D. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 21 .. CPAP/BiPAP can only be used effectively when the patient has adequate respiratory effort.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. n n References: Lightfoot. Brown. If an Advanced Clinical Nurse uses these Guidelines. A. Murray. Churchill Livingstone. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.hcn. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect).com.use. MIMS Online <http://proxy8. At the time of this review. Guidelines for the prevention. 2004. National Heart Foundation of Australia. Cameron. Systolic blood pressure less than 90 mmHg with acute pulmonary oedema constitutes a diagnosis of cardiogenic shock requiring emergency circulatory assistance. J. Heyworth. 2nd edn. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: DO NOT administer Nitrates if patient has taken medications for treatment of sexual dysfunction e. G. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. L.g. 2006. November 2006. Kelly. Drug Oxygen Glyceryl Trinitrate Dose 15 litres/min Non re-breather mask 300-600 micrograms Route Inhalation S/L Frequency Continuous Stat and then every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Stat and then every 5 minutes (if SBP greater than 90 mmHg) to total of 4 sprays (1600 micrograms) Stat if audible respiratory crepitations present As required Glyceryl Trinitrate 1-2 sprays (400-800 micrograms) 40 mg 10 mL flush S/L Frusemide 0.

chronic bronchitis) Severe respiratory distress with exhaustion Altered level of consciousness Ability to talk in words only Central cyanosis Confusion. PAGE 22 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . cyanosis n History of chronic obstructive pulmonary disease (emphysema. lethargy or evidence of hypoventilation Relevant past history – chronic obstructive pulmonary disease Medication history Past presentations/admissions (ED/ICU/intubation) Allergies n n n n n n n n assessment Position airway Breathing Assess patency Respiratory rate and effort SpO2 Audible wheeze present If patient cannot inhale adequately to use an MDI and spacer (severe cases) Speech Use of accessory muscles Sternal retraction Circulation Skin temperature Pulse – rate/rhythm Blood pressure Cardiac monitor Disability Measure and test AVPU/GCS Temperature Electrocardiography Sputum Chest X-Ray Arterial blood gas or venous blood gas Specific treatment Continuing respiratory distress CPAP/BiPAP Intervention Sit patient upright / position of comfort Maintain airway patency Assist ventilation if required Apply O2 using venturi mask start at 24%-28% to maintain SpO2 90-95% 10 puffs Salbutamol 100 microgram MDI + spacer and 4 puffs Ipratropium Bromide 20 microgram MDI + spacer Salbutamol 5mg nebule every 20 minutes if required and Ipratropium bromide 500 microgram nebule stat IV cannulation Monitor vital signs frequently Monitor LOC frequently 12 lead ECG Obtain specimen for microbiology If available If available For moderate and severe cases give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable) Prepare equipment if available Document assessment findings.Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease Clinical Severity Prompts n History Prompts n n Onset Associated symptoms – pale. sweaty. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. et.. A 5 mg nebule of Salbutamol should be made up with 2 mL 0. Resuscitation.. (Endorsed by the Thoracic Society of Australia & New Zealand) NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 23 . Cant A. ELS Course Inc. ‘Emergency treatment of anaphylactic reactions: Guidelines for health care providers’.9% Sodium Chloride. High flow oxygen should be avoided. 77. n n References: Emergency Life Support (ELS) Course Manual..use. If an Advanced Clinical Nurse uses these Guidelines. 2008. MIMS Online <http://proxy8. for the Working Group of the Resuscitation Council (UK). Drug Oxygen Salbutamol Salbutamol Dose Start at 24%-28% 10 puffs of 100 microgram per inhalation MDI + spacer 5 mg Nebule Route Inhalation Venturi Mask Inhalation Inhalation Frequency Continuous Repeat every 20 minutes if required Repeat every 20 minutes if required (for patients who cannot inhale well enough to use MDI + spacer) Stat Stat (for patients who cannot inhale well enough to use MDI + spacer) Stat Stat As required Ipratropium Bromide Ipratropium Bromide Hydrocortisone Prednisolone 0. Tamworth. no.15 May 2008.Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n n n Designation: Date: Never withhold oxygen in severely dyspnoeic patients Mental status is an important indicator of both worsening hypoxia and hypercapnia Be aware of signs of hypercapnia particularly decreasing LOC.com. The Australian Lung Foundation. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J. Pumphrey R. Gas flow through medium concentration oxygen masks (e. At the time of this review. The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease version 2. Use a nebuliser instead of MDI if the patient cannot inhale adequately. 3nd edn.hcn. (2). 2008. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. 2005. vol.g..9% Sodium Chloride 4 puffs of 20 microgram MDI + spacer 500 microgram Nebule 200 mg 50 mg (if IV access unavailable) 10 mL flush Inhalation Inhalation IV Oral IV Medications within this guideline must be administered within the context of the formulary. Nebulised solutions are to be administered using aIR. al. 2. Hudson) is inadequate when the patient is tachypnoeic therefore these masks should not be used.

PAGE 24 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

SECTION 3 Circulatory Emergencies The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 25 .

Not Moving AED = Automated External Defibrillator Australian Resuscitation Council Document assessment findings. Not Breathing Normally. February 2006. Basic Life Support Flow Chart D R A B C D Check for DANGER Hazards / Risks / Safety? RESPONSIVE? (Unconscious?) If not.Basic Life Support | Medical Officer must be notified immediately | For Adults Only Cardiorespiratory arrest (Basic life Support) Australian Resuscitation Council. Unresponsive. PAGE 26 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Guideline 7. call for help Call 000 / Resuscitation Team Open AIRWAY Look for signs of life Give 2 initial BREATHS if not breathing normally Give 30 chest COMPRESSIONS (almost 2 compressions per second) followed by 2 breaths Attach AED as soon as available and follow its prompts Continue CPR until qualified personnel arrive or signs of life return NO SIGN OF LIFE = Unconscious.

these should be single shocks. n n n Australian Resuscitation Council Document assessment findings.Advanced Life Support | Medical Officer must be notified immediately | For Adults Only Cardiorespiratory arrest (advanced life Support) Australian Resuscitation Council.NaHCO3 1 mmol/kg Atropine (1-3 mg) + Pacing (for asystole & severe bradycardia) n n CORRECT REVERSIBLE CAUSES n n Immediate CPR 2 minutes n n Immediate CPR 2 minutes n n n n CONSIDER n n NOTE: 1. Guideline 11.2 Adult Cardiorespiratory Arrest Precordial Thump for witnessed / monitored arrest BLS Algorithm (if appropriate) Attach Defib – monitor Assess rhythm / pulse Shockable VF / Pulseless VT Non-Shockable PEA / Asystole During CPR IF NOT ALREADY DONE Attempt Defibrillation1 One Shock Manual Biphasic 200J2 Manual Monophasic 360J n Check electrode / paddle position & contact Attempt / verify / secure IV access Give adrenaline 1mg & repeat every 3 minutes Hypoxaemia Hypovolaemia Hypo/hyperthermia Hypo/hyperkalaemia & other metabolic disorders Tamponade Tension pneumothorax Toxins / Poisons / Drugs Thrombosis .Lignocaine 1-1.Amiodarone 300 mg . 2. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 27 . interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.Magnesium 5 mmol Electrolytes . For witnessed arrest. when using a manual defibrillator. Default biphasic energy.Pulmonary / coronary Advanced airway Antiarrhythmic . give up to 3 stacked shocks at first defibrillation attempt. February 2006. If further shocks are required.5 mg/kg .Potassium 5 mmol Buffer .

n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: If stat dose of IV/IOI Amiodarone or Lignocaine is effective and return of spontaneous circulation has been achieved then Amiodarone or Lignocaine infusion is recommended to follow.5 mg/Kg 30 mL flush Route Inhalation IV/IO IV/IO IV/IO IV/IO IV/IO Frequency Continuous Every 3 minutes to a total of 3 mg Stat over 1-2 minutes Every 3-5 minutes to a total of 3mg Stat As required Medications within this guideline must be administered within the context of the formulary. Drug Oxygen Adrenaline Amiodarone Atropine Lignocaine 0.2: Protocols for adult Advanced Life Support. Australian Resuscitation Council. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. 2006. 4th edition. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. If an Advanced Clinical Nurse uses these Guidelines. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. n References: Australian Injectable Drugs Handbook. July 2008. At the time of this review. Guideline 11. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. sodium bicarbonate and pacing cannot be initiated by an ACN.Advanced Life Support | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Magnesium.9% Sodium Chloride Dose 15 litres/min 1 mg 300 mg (dilute with 5% Dextrose 10-20 mL) 1 mg 1-1. Melbourne. PAGE 28 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . The Society of Hospital Pharmacists of Australia. potassium. ARC.

e. UEC. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. plus one or more of the following: altered level of consciousness blood pressure: SBP less than 90 mmHg chest pain shortness of breath syncope/dizziness diaphoresis n Relevant past history – medication history – allergies assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Intervention Supine depending on clinical status Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology If SBP less than 90 mmHg give IV Atropine 0.5 mg increments every 5 minutes (to total of 3mg) to maintain systolic blood pressure greater than 90 mmHg Monitor vital signs frequently If no response to Atropine MO to consider external transthoracic pacing (if available) Monitor LOC frequently Finger prick BGL 12 lead ECG (within five minutes of arrival to ED) Collect blood for FBC.Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only Compromising Bradycardia Bradycardia must be considered in relation to associated symptoms. History Prompts events leading to presentation n n n Syncope or seizure Clinical Severity Prompts n Chest pain – onset (if any) Associated symptoms: – dyspnoea – sweating – pallor – fatigue Bradycardia: less than 40 beats per minute and symptomatic i. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 29 . cardiac markers (where available) Fluid balance chart Nil by mouth Cardiac monitor Disability Measure and test AVPU/GCS BGL Electrocardiography Pathology Fluid input/output Document assessment findings.

41. 1999. Drug Oxygen Atropine Dose 6-15 litres/min 0. Symptomatic complete heart block will require pacing and/or urgent transfer to definitive care. The efficacy of atropine in the treatment of haemodynamically unstable bradycardia and atrio-ventricular block: prehospital and emergency department considerations.J. Swart G. no. MIMS Online <http://proxy8. P.9% Sodium Chloride 10 mL flush IV Medications within this guideline must be administered within the context of the formulary. Sodeck G.. If an Advanced Clinical Nurse uses these Guidelines. At the time of this review. Inferior myocardial infarction/ischaemia may lead to bradyarrhythmias.. Resuscitation.5 mg increments to a total of 3mg Route Inhalation IV Frequency Continuous Every 5 minutes titrated to maintain systolic blood pressure greater than 90 mmHg As required 0. 47-55. 2007. Aufderheide T...H. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. ‘Compromising bradycardia: management in the emergency department’ Resuscitation.. 1. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. et. References: Brady W.com.use.. al.. De Behnke D.J.hcn. vol. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. no. 96-102. pp. vol. Atropine may be ineffective in patients who are on beta-blockers. 1. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. John Ma O.Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Meron G. 73.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Domanovits H. pp. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n n n Designation: Date: Hypoxia can cause bradycardia. PAGE 30 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition ..

diabetes. central/left/right and/ or associated symptoms Time – pain lasting longer than 5 minutes n n History Prompts n Other: – relevant past history – risk factors: familial. retrosternal. UEC. smoking. Sildenafil (Viagra) – allergies Symptoms suggestive of myocardial ischaemia – Provokes/Precipitates: what makes the pain worse? What were you doing when you got the pain? – Quality: what does the pain feel like? Describe the pain – Region: centre of chest. hyperlipidaemia.5 mg increments every 5 minutes to a total 10 mg or IM Morphine (if IV access unavailable) 5-10 mg Assess suitability for fibrinolysis (refer to Appendix 4) Disability Measure and test AVPU/GCS BGL Pathology Fluid input/output Monitor pain score If pain free after 30 minutes If pain returns at any time Monitor LOC frequently Finger prick BGL Collect blood for (FBC. including medications used for the treatment of sexual dysfunction e. can be repeated every 5 minutes Monitor vital signs frequently 12 lead ECG (within 5 minutes of arrival to ED) IV cannulation/pathology If pain is present. cardiac markers where available) Fluid balance chart Repeat 12 lead ECG Repeat 12 lead ECG Document assessment findings. pain lasting longer than 5 minutes (refer to Appendix 6) n Associated symptoms: – nausea/vomiting – sweating – shortness of breath – palpitations – lethargy/fatigue Chest pain/discomfort – heavy. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Radiation: arm(s)/back/jaw assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Intervention Position patient upright/position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Aspirin 300 mg (chew) (if not already given by Ambulance Officer) Cardiac monitor Electrocardiography If pain present. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 31 .g. give Glyceryl Trinitrate S/L 300-600 micrograms or Glyceryl Trinitrate Spray S/L (400-800 micrograms) if SBP greater than 90 mmHg. give IV Morphine 2.Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only acute Coronary Syndrome (with or without associated symptoms) Clinical Severity Prompts n – Severity: pain score 0-10 – time: onset of pain. Aboriginal & Torres Strait Islander – medication history.

n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Do NOt administer Nitrates if patient has taken medications used for the treatment of sexual dysfunction e. viewed 19. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Reperfusion therapy for acute myocardial infarction. vol.01. 81. 184 no. 2005. 122-125. and Jones P. 2009. the diabetic. elderly. female or young patient may present with atypical symptoms such as dyspnoea.S.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mL flush IV Morphine 0. J. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect).01. vomiting. and Reeder G. J. <http://www. National Heart Foundation. no pain. 8 S1-S32.use.Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. Ryan T. Drug Oxygen Aspirin Glyceryl Trinitrate Dose 6-15 litres/min 300 mg 300-600 micrograms (½ -1 tablet) Route Inhalation Oral (chew) S/L Frequency Continuous Stat Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 4 sprays (1600 micrograms) Every 5 minutes (not to exceed a total of 10mg) Stat (not to exceed total of 10 mg) As required Glyceryl Trinitrate spray 1-2 sprays (400-800 micrograms) S/L Morphine 2.hcn. <http://www.com. 2000.M.2009.. vol. Turner A. viewed 19. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document.I.5 mg increments (10 mg diluted with 9 mL – 0.mja.com. ‘Modified electrode placement must be recorded when performing 12-lead electrocardiograms’. If an Advanced Clinical Nurse uses these Guidelines. PAGE 32 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .do?topicKey=ad_emer/2821&selectedTitle=3`15 0&source=search_result>. At the time of this review. MIMS Online <http://proxy8. ‘Management of suspected acute coronary syndrome in the emergency department’. nausea.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. ‘Guidelines for the management of acute coronary syndromes’.com/online/content/topic. palpitations.au/public/issues/184_08_170406/suppl_170406_fm.g. Med. syncope or cardiac arrest. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. Postgrad.9% Sodium Chloride IM IV Medications within this guideline must be administered within the context of the formulary.. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.A.. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. 2006.09. n References: Jowett N.html>.uptodate. The Medical Journal of Australia. pp. Cole A..

g. group and hold (if required) Venous blood gas and Blood culture Measure Hb if point of care device (e. iStat) is available Urine hCG (women of childbearing age) Urine culture Fluid balance chart Nil by mouth Insert IDC – measure and record urine output every hour Monitor 12 lead ECG If available Temperature U/A Fluid input/output PV Loss Electrocardiography Chest X-ray Document assessment findings. gastric/abdominal pain (If history of trauma refer to Trauma Guideline) Relevant past history: – palpitations. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 33 . UEC. infection. Lie supine Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation x 2/pathology If SBP less than 90 mmHg give IV/IO 0.Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only Non-traumatic Shock Tachycardia may not occur in elderly patients Patients who are normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg History Prompts n n Onset Events: vomiting/diarrhoea. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. light-headed.9% Sodium Chloride 500 mL bolus Monitor vital signs frequently Monitor LOC frequently Finger prick BGL Repeat Commence Take blood for FBC. fainting Clinical Severity Prompts n n n Tachycardia: (greater than 100 beats per minute) Poor brain perfusion – restlessness – altered level of consciousness n n Medication history Allergies n Poor skin perfusion – cold – pale – sweaty – capillary refill greater than 2 seconds assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability Measure and test AVPU/GCS + pupils BGL Primary Survey Secondary Survey Pathology Intervention Full PPe measures must be considered. pregnancy.

West Beach. ELS Course Inc.use. 2000.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.09. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n Designation: Date: Close monitoring of fluid input and output is essential.. At the time of this review. If an Advanced Clinical Nurse uses these Guidelines. Pregnant women (greater than 20 weeks gestation) – require a left lateral tilt to reduce compression of the Inferior Vena Cava – hypotension is a late sign of hypovolaemia – greater volumes than expected are required for resuscitation. 3nd edn. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. The emergency medicine manual. Rose B. 2nd edn. PAGE 34 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. ‘Treatment of severe hypovolaemia or hypovolaemic shock in adults’.hcn.9% Sodium Chloride Dose 6-15 litres/min 500 mL 10 mL flush Route Inhalation IV/IO IV/IO Frequency Continuous Stat (repeat once only if SBP remains less than 90 mmHg) As required Medications within this guideline must be administered within the context of the formulary. Emergency Life Support (ELS) course manual. and Mandel J. al.Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications.01. viewed 19.9% Sodium Chloride 0.com. <http://uptodate. References: Dunn R. Drug Oxygen 0. Venom Publishing Unit. Tamworth. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document.. (editor). et. 2005. MIMS Online <http://proxy8.com/online/content/topic.D.do?topicKey=cc_medi/14949>.

SECTION 4 Disability Emergencies NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 35 .

irritability (global signs of meningeal irritation) Appearance of rapidly developing non-blanching petechial or purpuric rash (bruised haemorrhagic type/ does not blanch i.e. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. fever. neck stiffness. vomiting. photophobia and drowsiness n Relevant past history: – contact/association with person/s recently diagnosed with meningococcal disease within past 60 days – immunosuppression. pallor. If allergic to Benzylpenicillin give IV/IO or IM Ceftriaxone 2 g Intervention Full PPe must be worn at all times. Position of comfort airway Breathing Circulation Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology If SBP less than 90 mmHg give IV/IO 0. UEC.Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only Meningococcal Disease: Non-blanching Rash Clinical Severity Prompts n History Prompts n n n Onset Events – bacterial meningitis suspected Associated symptoms: – altered/abnormal level of consciousness.2g.15 mg per kg IV/IO stat and IV/IO or IM Benzylpenicillin 1. take blood for FBC. blood cultures DO NOt DelaY aNtIBIOtIC aDMINIStRatION Document assessment findings.9% Sodium Chloride 500 mL Monitor vital signs frequently As indicated Monitor LOC frequently Finger prick BGL If possible. recent head/neck infection Medication history Allergies n n n Immediately call for assistance and notify the Medical Officer and Aeromedical and Medical Retrieval Service (1800 650 004) assessment Position Completely undress (including underwear and socks) Inspect all body surfaces/ folds/creases for rash Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor 12 lead ECG Disability Measure and test AVPU/GCS + pupils BGL Pathology Temperature U/A Fluid input/output Specific treatment Non blanching petechial/ purpuric rash Nil by mouth If patient weighs greater than 65 kg give Dexamethasone 10mg IV/IO stat If less than 65 kg give 0. skin colour does not fade under pressure) which may only be several lesions (refer Appendix 7 for Glass Tumbler Test) Associated symptoms include: headache. PAGE 36 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

viewed 8.thecochranelibrary. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Commonwealth Department of Health and Aged Care.2 g 2 g (if allergic to Benzylpenicillin) 10 mL flush Route Inhalation IV/IO IV/IO Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Stat Benzylpenicillin Ceftriaxone 0.09.tg.9% Sodium Chloride IV/IO/IM IV/IO/IM IV/IO Stat Stat As required Medications within this guideline must be administered within the context of the formulary.02. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 37 .com. At the time of this review. Issue 1. and Prasad K. MIMS Online <http://proxy8.Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. Collection of blood sample for culture should be attempted prior to administration of antibiotics but should not delay treatment. ‘Corticosteroids for acute bacterial meningitis (Review)’..com.. McIntyre P. Canberra. Patients presenting unwell with a blanching rash may progress to a non-blanching rash and therefore require urgent treatment n n References: Communicable Diseases Network Australia.15 mg per kg 1. 2009. Guidelines for the early clinical and public health management of meningococcal disease in Australia. If an Advanced Clinical Nurse uses these Guidelines.9% Sodium Chloride Dexamethasone Dose 6-15 litres/min 500 mL If patient greater than 65 kg give 10mg Dexamethasone If less than 65 kg give 0. Revised June 2006.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> van de Beek D. 2001.. de Gans J. Viewed 8.09.02. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: IM antibiotic administration is NOT preferred in this setting as supervening shock and hypotension may lead to failure of absorption of the injected antibiotic. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.. (www. <http://www.com>.use. Drug Oxygen 0.hcn. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.au) etg 26 November 2008. eTG Complete © Therapeutic Guidelines Ltd.

PAGE 38 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

SECTION 5 Endocrine / Envenomation Emergencies NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 39 .

acetone breath. – increased thirst. Kussmaul’s respirations (deep sighing respirations of metabolic acidosis). weight loss. UEC. confusion. increased urine output. – tachycardia.Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only Hyperglycaemia with Severe Dehydration Clinical Severity Prompts n n n n History Prompts n Gradual onset of symptoms.9% Sodium Chloride 500mL bolus stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) Monitor vital signs frequently Monitor LOC frequently Finger prick BGL every 30 minutes Consider insulin therapy but not before a serum potassium is known and not before advice from a Medical Officer Collect blood for FBC. BGL. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. dehydration n Associated symptoms. abdominal pain BGL greater than 15mmol/L Severe dehydration Altered mental state Metabolic abnormality e. hypotension. ABGs/venous blood gas (if available) Test for sugar and ketones Fluid balance chart Insert IDC – measure and record urine output every hour 12 lead ECG Measure and test Pathology Temperature U/A Fluid input/output Electrocardiography Document assessment findings. ketoacidosis n n n n Relevant past history Medication history Events leading up to presentation Allergies assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Skin turgor Mucous membranes Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU / GCS BGL Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology If signs of dehydration or if SBP less than 90 mmHg give IV 0.g. PAGE 40 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. 17.. no. Drug Oxygen 0. At the time of this review. Early management priorities are to treat shock and dehydration. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. 2004.use.9% Sodium Chloride 10 mL flush IV Medications within this guideline must be administered within the context of the formulary. Kelen G. Current Diagnosis and Treatment: Emergency Medicine. pp. McGraw-Hill Companies. in eds Stone C. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. S. New York.Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications.9% Sodium Chloride Dose 6-15 litres/min 500 mL Route Inhalation IV Frequency Continuous Stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) As required 0. References: Brenner Z. and Cline O..... D.. American Association of Critical Care Nurses. If an Advanced Clinical Nurse uses these Guidelines. n Consider insulin therapy but not before a serum potassium is known and not before advice from a medical officer. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n Designation: Date: Close monitoring of fluid input and output is essential. 6th edn. McGraw-Hill Companies. 2006. ‘Metabolic emergencies’. This is more important initially than lowering the blood glucose with insulin. 2008. and Danzi. 6th edn.. New York.1.hcn. Emergency medicine: a comprehensive study guide. and Humphries R. vol. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Frederick. MIMS Online <http://proxy8. ‘Management of hyperglycaemia emergencies’. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Tintinalli J.. Ma O. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 41 .com.. 56-65.

administer IM Glucagon 1 mg Finger prick BGL every 15 minutes until within normal limits and the patient is mentally alert Measure and test Pathology Temperature U/A Fluid input/output Possible alcohol abuse Collect blood for FBC. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. UEC. visual disturbances. PAGE 42 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . BGL. History Prompts n n Onset Associated symptoms: – confusion. headache. pallor Clinical Severity Prompts n n BGL less than 3 mmol/L Confusion/seizure/coma n n n n Relevant past history Medication history Events Allergies assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU/GCS BGL Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology Monitor vital signs frequently Monitor LOC frequently Finger prick BGL less than 3 mmol/L and conscious administer simple sugar or If unconscious or confused administer IV 50% Glucose 50 mL or If IV access unavailable. dizziness.Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only Hypoglycaemia Any patient who presents with confusion/convulsions/ coma should have hypoglycaemia considered as a cause. ABGs/venous blood gas (if available) Fluid balance chart If history of possible alcohol abuse give IM Thiamine 100 mg Specific treatment Document assessment findings.

Jelinek. J. Current diagnosis and treatment: Emergency medicine.. Sydney.... and Cline O. 2008. Ma O. ‘Metabolic Emergencies’ in eds Stone C.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Annals of Emergency Medicine. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Examples of oral simple sugars are. Murray.. Alcoholism is the leading cause of Wernicke’s Encephalopathy. Vega J. including a deficiency in thiamine.. 6.. 2004.Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications.g. 367). 2004. 50. L. and these should be followed by a carbohydrate meal e.. and Humphries R. New York. and Walsh M. pp. Elsevier. Drug Oxygen 50% Glucose Glucagon Thiamine 0. no..hcn. Brown. Heyworth...com. Frederick S.. and Danzi D. Tintinalli J. McGraw-Hill Companies. 6th edn. 2007. p. P. n n References: Donnino M. vol. If an Advanced Clinical Nurse uses these Guidelines.9% Sodium Chloride Dose 6-15 litres/min 50 mL 1 mg (if IV access unavailable) 100 mg 10 mL flush Route Inhalation IV IM IM IV Frequency Continuous Stat Stat Stat As required Medications within this guideline must be administered within the context of the formulary. A.. New York. Kelen G. which is a neurological syndrome associated with inadequate nutrition.. G. ‘Myths and misconceptions of Wernicke’s encephalopathy: What every emergency physician should know’. Hew . A. R. ‘The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. sandwiches or biscuits.. sweets or soft drink (non-diabetic) or milk. Miller J. 2004.. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. 715-721. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 43 . n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. sugar. eds Cameron. McGraw-Hill Companies.. MIMS Online <http://proxy8. ‘Altered Conscious State’ in Textbook of adult emergency medicine. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernicke’s encephalopathy is unfounded..use. timing is irrelevant’ (Hew. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. At the time of this review. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. 6th edn. The absorption of Thiamine is so much slower than that of glucose. Emergency medicine: A comprehensive study guide. Kelly.

pre-hospital treatment. severe localised pain (spider bite). bite site location/s assessment Position Intervention ensure first aid measures have been implemented and consider early transfer. number of bites. vomiting. group and hold Monitor Check for myoglobin Consider IDC and observe urine for myoglobin Insert IDC – measure and record urine output every hour Nil by mouth Fluid balance chart 12 lead ECG IV 0. patient may require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration Disability AVPU /GCS + pupils Measure and test Signs of systemic snake envenomation Pathology Temperature U/A Fluid input/output Signs of systemic envenomation Electrocardiography Whole blood clotting time (in a glass tube) Collect blood for FBC. drug/alcohol intoxication. diaphoresis. headache.Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only Snake / Spider Bite Do NOt remove pressure immobilisation bandage. PAGE 44 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .g. paralysis. excess salivation. UEC. altered level of conscious. IM Boostrix or ADT Booster 0. painful lymph node.5 mL Specific treatment Hydration Systemic envenomation Funnel web envenomation Redback spider envenomation Nausea and vomiting Immunisation status Document assessment findings.9% Sodium Chloride 500 mL Monitor vital signs frequently Monitor LOC frequently If GCS less than 9 and not rapidly improving. interventions and patient’s response in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. nausea/vomiting n n n Relevant past history/previous envenomation or antivenom administration Medication history Allergies History Prompts n Events – time of bite.5 mg if bradycardic and SBP less than 90 mmHg Ice to bite site (do NOT apply pressure immobilisation bandage) Consider Redback spider antivenom If nausea or vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e. coags. abdominal pain. localised sweating.9% Sodium Chloride 1000 mL (125 mL per hour) to maintain hydration Consider appropriate antivenom Consider IV Atropine 0. ptosis Clinical Severity Prompts n n n Neurotoxic paralysis/diplopia/dysphagia Convulsions Abdominal pain. time and type of first aid applied. CK. n Associated symptoms: – weakness. activity since bite. nausea. headache. Position of comfort / keep patient immobile Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Apply pressure immobilisation bandage and splinting to all victims of snake bite and Funnel Web spider bite IV cannulation/pathology airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 First aid Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor If SBP less than 90 mmHg give IV 0.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.5 mg 10 mg 0. 2. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 45 . <http://www. 106-111. gov. viewed 19. 2007. NSW Health. vol..pdf>. n n n References: MIMS Online <http://proxy8. Accident and emergency nursing.9% Sodium Chloride Dose 6-15 litres/min 500 mL (circulation support) 1000 mL (maintain hydration) 0. IM injections should be avoided (except Boostrix/ADT Booster) in snake bite victims because of coagulopathy. 2003.09.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Normal time is less than 10 minutes. Stewart C. Snakebite and spiderbite clinical management guidelines. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: Apply pressure immobilisation bandage at the same pressure as for sprained ankle. A snakebite observation chart is recommended for recording vital signs and specific signs associated with snakebites/ envenomation – refer to Appendix 9. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.9% Sodium Chloride Atropine Metoclopramide Boostrix or ADT Booster 0. pp.hcn. ‘Snake bite in Australia: First aid and envenomation management’. At the time of this review.Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.nsw.9% Sodium Chloride 0. Drug Oxygen 0.au/policies/gl/2007/pdf/GL2007_006. If an Advanced Clinical Nurse uses these Guidelines. Bandage the whole limb from the armpit or groin to the digits. It is performed by placing 10 mL of venous blood into a glass test tube and measuring the time taken for the blood to clot. 11.com.use.health.01. Whole blood clotting test may be performed to determine the length of time blood takes to clot. no.5 mL 10 mL flush Route Inhalation IV IV IV IV or IM IM IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) 125mL per hour Stat Stat Stat As required Medications within this guideline must be administered within the context of the formulary.

PAGE 46 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

SECTION 6 Trauma Emergencies NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 47 .

Clinical Severity Prompts n History Prompts n Vital sign abnormalities: – RR of less than 10 or greater than 29. restraint/abrasion/contusion severe pain. crush injury. perineum or back use Head Injury Guideline page 57 severe facial injury. subcutaneous emphysema. bruising. hoarseness or stridor severe pain. genital contusions. visible deformity vascular injury with ischaemia of limb. cyanosis or respiratory difficulty – HR greater than 120 bpm – SBP less than 90 mmHg or severe haemorrhage – LOC is V. amputation The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. P or U on AVPU scale. injury with potential airway risk. degloving injury. vertical shear and open book fracture weakness. Immediately call for assistance and notify the Medical Officer and aeromedical and Medical Retrieval Service (aMRS) 1800 650 004. SpO2 less than 90% on air. severe haemorrhage swelling. distension. sensory loss. PAGE 48 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . crush injury severe pain. paradoxical breathing. abdomen. chest. Requires at least gentle tactile stimulation and ‘shout’ to rouse from decreasing level of consciousness/GCS less than or equal to 13 or paralysis/sensory deficit Events: – high risk mechanism of injury – type – force and time Relevant past history – recent surgery – Patients taking anticoagulant therapy/ known coagulopathy Medication history Fasting status Allergies The following patient groups are at greater risk and require a high index of suspicion for serious trauma: – Patients over the age of 65 years – Pregnant woman over 20 weeks gestation n n n n n n n High risk mechanism of injury Types of injuries – especially multi-system injuries types of injuries Penetrating Head Face Neck Chest Abdomen Pelvis Spine Limb to head. fracture of 2 or more long bones. all trauma patients should be treated as having a spinal injury until proven otherwise.Trauma | Medical Officer must be notified immediately | For Adults Only trauma Refer trauma triage tool (appendix 10). neck. rigidity.

formal blood alcohol (if required and accredited to take). consider beta hCG If available ABG/venous blood gas. patient will require endotracheal intubation by MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration Disability AVPU/GCS + Pupils BGL Measure and test Primary Survey Secondary Survey Finger prick BGL Repeat Commence thorough head to toe assessment including the patient’s back (log roll if at least 4 people are available) Identified deficits – go to specific treatment section immediately If pain score 4-10 give IV/IO Morphine 2. group and hold. measure and record urine output every hour Consider gastric tube. Lie supine. Do NOt insert a naso-gastric tube if there is a possibility of a base of skull fracture or nasal bone fracture 12 lead ECG Pain Pathology Temperature U/A Fluid input/output Electrocardiography The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. SpO2 Asymmetrical chest movement. tracheal deviation Open sucking chest wound Cover with non-porous dressing taped on 3 sides only – remove immediately if respiratory status deteriorates Control external bleeding using direct pressure/ elevation/pressure dressing IV cannulation x 2 (large bore)/pathology Involve a surgeon as soon as possible IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus to maintain SBP 80-90 mmHg Circulation External bleeding Internal bleeding Blood pressure Skin temperature Pulse – rate/rhythm Capillary refill Cardiac monitor Monitor vital signs frequently Monitor GCS frequently.5 mg increments every 5 mins to a total of 10 mg or IM Morphine 5-10 mg to a total of 10mg (if IV/IO access unavailable) Collect blood for FBC. depending on clinical status Maintain airway patency (do NOt insert a naso-pharyngeal airway if there is any possibility of a fractured base of skull or nasal bone fracture) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Assist ventilation if required Apply O2 via non-rebreather mask to maintain SpO2 greater than 95% Tension pneumothorax – requires immediate chest decompression with a needle thoracentesis (refer to Appendix 12) Breathing Respiratory rate and effort. serum lactate Prevent hypothermia Full urinalysis and urinary hCG (if required) Strict fluid balance chart Nil by mouth Insert IDC (unless contraindicated). base deficit. UEC.Trauma | Medical Officer must be notified immediately | For Adults Only assessment Position airway Assess patency Intervention Full PPe measures must be considered. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 49 . unilateral decreased breath sounds. If GCS less than 9 and not rapidly improving.

9% Sodium Chloride Dose 15 litres/min Non-rebreather mask 200 mL (circulation support) 2.5 mg increments (10 mg diluted with 9 mL 0. keep near patient and label bag with patient’s details accurately Cover exposed viscera with moist saline packs (avoid hypothermia) Stabilise with pelvic binding or sheeting (refer to Appendix 14) Stabilise with traction splint. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution Morphine Morphine 0.Trauma | Medical Officer must be notified immediately | For Adults Only assessment Specific treatment Limb-threatening injury (neurovascular compromise) Amputations Intervention Neutral alignment Splint or plaster backslab Perform neurovascular limb observations frequently (refer to Appendix 13) Preserve amputated part: wrap in moist saline gauze.9% Sodium Chloride 1000mL (125 mL/hour to maintain hydration) If nausea or vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.5mL Abdominal Injuries Suspected pelvic fracture Suspected fractured shaft of femur Open fractures Impaled objects Fluid deficit Hydration/intake Nausea & vomiting Immunisation status Document assessment findings. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. Place sealed bag in a slurry of ice. At the time of this review. IM Boostrix or ADT Booster 0. If an Advanced Clinical Nurse uses these Guidelines.5 mL 10 mL flush Route Inhalation IV/IO IV/IO IM IV/IO IV or IM IM IV/IO Frequency Continuous Stat (repeat as required to maintain SBP of 80-90 mmHg) Every 5 minutes (not to exceed 10 mg) Stat (not to exceed 10mg in total) 125 mL per hour Stat Stat As required Medications within this guideline must be administered within the context of the formulary. Perform neurovascular observations pre and post splinting Cover with saline pack. do not reposition protruding bone ends Stabilise object – DO NOt remove IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus as required to maintain SBP of 80-90 mmHg Nil by mouth IV/IO 0.9% Sodium Chloride) 5-10 mg (if IV/IO access unavailable) 1000 mL (maintain hydration) 10 mg 0. interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. Seal in airtight plastic bag.g. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.9% Sodium Chloride Metoclopramide Boostrix or ADT Booster 0. PAGE 50 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

no. Be cautious in administering Morphine if there is an altered level of consciousness.com. Do not insert nasopharyngeal airway or nasogastric tube in patients suspected of having a fractured base of skull or nasal bone fracture. New York The Neurosurgical Society of Australasia.. 1. vol.. West Beach... ‘Fluid resuscitation for the trauma patient’. The emergency medicine manual. IV/IO 0. NSW Institute of Trauma Injury and Management. et. Smaller volumes of IV fluid boluses are recommended. The Management of acute neurotrauma in rural and remote locations..hcn. those taking beta blocking agents or those suspected of spinal cord injury. a. 6 pp. no.. Emergency and trauma nursing. Dutton R. 2005. 6th edn. elderly patients. 2000. 52.E. McGraw-Hill.. 2000.. ‘Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality’. Emergency Life Support (ELS) course manual. 2007. ‘Shock’ in Advanced trauma life support course for doctors – student course manual. Tachycardia may not occur in athletes. Cain J. pp. ELS Course Inc. 1 pp. IV/IO Compound Sodium Lactate (Hartmanns) Solution is the first choice for resuscitation fluid in the hypovolaemic trauma patient.Trauma | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n n n n The list of injuries identified is not exclusive of what might be present. Royal Australasian College of Surgeons. ‘Current practices in fluid and blood component therapy in trauma’ Seminars in anesthesia. Venom Publishing Unit.P. 48. United States. infection and critical care. Cline D. Prior to inserting in-dwelling catheter ensure there is no blood at urinary meatus as this may indicate a urethral injury and this is a contraindication to inserting a urethral catheter. Tintinalli J. 2008. Trauma nursing core course – provider manual. 2002.. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 51 . management of hypovolaemic shock in the trauma patient. Pascoe S. Curtis K. 2000. Trauma triage tool – major trauma critieria (MIST) Protocol T1. American College of Surgeons Committee on Trauma. respiratory compromise or SBP less than 90 mmHg. Emergency medicine: A comprehensive study guide international. Tamworth. 2007. 8th edn. A set of guidelines for the care of head and spinal injuries. Ma O. Kelen D. 1141-6. ‘Pre-hospital management of major trauma’.M. vol. Smith C. MIMS Online <http://proxy8. and Lynch J. 57-69. 2001. 5th edn. Ramsden C. 2001. 3nd edn. Sydney. 20. and Friendship J. Scalea T. 28-35. Aggressive fluid resuscitation results in increased haemorrhage and greater mortality.l (editor).. USA. vol.G... Some patients who may be normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. 2008. n n n n n n References: Ambulance Service of NSW.use.9% Sodium Chloride may be used as an alternative. Adult trauma clinical practice guidelines.F. Close monitoring of fluid input and output is essential... Mackenzie C.. Dunn R.. 2nd edn. Resuscitation. Emergency Nurses Association. Stapczynski J. Gabor M. Melbourne The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Be aware of distracting painful injuries that may mask other and more serious injuries. no.. Mosby. Sydney. however large volumes may result in metabolic acidosis.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Nolan J.. Journal of trauma – injury. Emergency Nurses Association.

confusion Relevant past medical history Medication history Tetanus immunisation status Allergies n Clinical Severity Prompts n n n n n Airway/facial/neck burns Burns to hands. with a range of 8-25ºC for a minimum of 20 minutes.9% Sodium Chloride 500 mL Monitor vital signs frequently 12 lead ECG if possible. perineum Electrical burns including lightning injuries Chemical burns Circumferential burns of limbs or chest assessment Position n n n n Intervention Position of comfort/clinical status Maintain airway patency Consider early endotracheal intubation by MO Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15L/minute to all patients except those with minor burns IV cannulation X 2 / pathology airway Assess patency Evidence of airway burn: hoarse voice. sooty sputum. Ideal water temperature is 15°C. feet. this is beneficial for the first three (3) hours only on burns of less than 10% TBSA.Burns | Medical Officer must be notified immediately | For Adults Only Burns The burn surface is cooled with running water. singed facial hair. neck / facial swelling Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Blistering Cardiac monitor Electrocardiography Constrictive non-adhered clothing or jewellery Breathing Circulation If SBP less than 90 mmHg give IV/IO 0. (especially electrical burns and lightning strikes) Remove Monitor LOC frequently Finger prick BGL Repeat Oral Panadeine Forte (if not nil by mouth) 1-2 tablets for minor burns only IV/IO Morphine 2. ensure staff are adequately protected from contamination. sore throat.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV/IO access unavailable) – avoid burnt areas Commence Calculate total body surface area burnt (refer to Appendix 15) Disability Measure and test AVPU/GCS + pupils BGL Primary survey Pain score (1-3) Pain score (4-10) Secondary survey The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. stridor. sore throat. Prevent hypothermia. neck/facial swelling. Always brush dry chemicals off (use PPE) before applying cool water. sooty sputum. If the patient has suffered chemical burns. stridor. hoarse voice. History Prompts n n Onset – time of burn Events: – mechanism of injury/exposure – history of electrical/thermal/chemical/radiation burns – confined space – first aid measures – defined Associated symptoms: – cough. PAGE 52 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

wound management should be in consultation with the burn surgeon who will receive the patient.9% Sodium Chloride Panadeine Forte Dose 6-15 litres/min As per Modified Parkland formula (above) 500 mL 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 2.9% Sodium Chloride) 5-10 mg (if IV/IO access unavailable) 10 mg 10 mL flush 0. Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution 0.g. (consider group and hold. give the remaining 50% over the next 16 hrs Maintain UO at 0. UEC. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 53 . myoglobin.5 mL Route Inhalation IV/IO IV/IO Oral Frequency Continuous As per formula Stat if SBP less than 90 mmHg Stat (one dose only) Morphine IV/IO Every 5 minutes (to a total of 10 mg) Morphine Metoclopramide 0.5-1 mL/kg/hour Fluid balance chart Nil orally if burns greater than 10-15% TBSA NGT if greater than 20% TBSA burns and not contraindicated For burns of more than 20% TBSA.9% Sodium Chloride Boostrix or ADT Booster IM IV or IM IV/IO IM Stat (to a total of 10 mg) Stat As required Stat The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.Burns | Medical Officer must be notified immediately | For Adults Only assessment Measure and test Pathology Temperature Fluid input/output Burns greater than 15% TBSA Intervention Collect blood for FBC. Give 50% of total amount in first 8 hours from time of the burn. Staff must use PPE Maintain UO greater than 1-2 mL/kg/hour U/A Specific treatment Liquid chemical Powder chemical Electrical/lightning strike/ haematuria/ haemoglobinuria/ rhabdomyolysis Circumferential burns Burn wounds Elevate the affected limb Perform neurovascular observations every 15 minutes If transferring within 8 hours and patient stable. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary Burns Service. and do not apply to the face If nausea/vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.5mL Nausea/vomiting Immunisation status Document assessment findings. IM Boostrix or ADT Booster 0. ABG/venous blood gas) Avoid hypothermia Modified Parkland formula: in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmanns) Solution 3-4 mL x kg body weight x % TBSA burnt. apply cling wrap to the burns If the face is burnt paraffin ointment should be applied If there is a delay in transfer. interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications. insert IDC – measure and record urine output every hour Observe urine for myoglobinuria or haemoglobinuria Copious water irrigation Brush off prior to copious water irrigation.5 mg increments (10 mg diluted with 9 mL 0.

GL2008_012 – Burn Transfer Guidelines – NSW Severe Burn Injury Service. 3-4) n Hydrofluoric Acid burns – early copious water irrigation and application of Calcium Gluconate gel is recommended. perineum and major joints – any intubated patient – chemical burns – electrical burns including lightning injuries – circumferential burns of limbs or chest – burns with concomitant trauma – burns in patients with pre-existing medical conditions that could adversely affect patient care and outcome – pregnancy with cutaneous burns – burns at the extremes of age e.com. Consult with a specialist early. Management of blisters is generally guided by specialist clinicians or institutional preferences. 2008.org.hcn. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.use.Burns | Medical Officer must be notified immediately | For Adults Only Medications within this guideline must be administered within the context of the formulary. North Sydney. <http://www. Refer to NSW Severe Burn Injury Transfer Flow Chart.5 Burns.07. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n n n n n Designation: Date: Consult with burns specialist early. MIMS Online <http://proxy8.resus. PAGE 54 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . If an Advanced Clinical Nurse uses these Guidelines. Any patient sustaining burns in a confined space is susceptible to inhalation injury and carbon monoxide poisoning. Prompt consultation is required for any patient with facial burns/inhalation injury to ensure airway patency is maintained. feet. NSW Department of Health. Do not use ice or iced water to cool a burn. 2008. Patients who require immediate consultation with a burns unit and will likely require retrieval (refer to Appendix 15): – full thickness burns greater than 5% TBSA – partial thickness burns greater than 10% TBSA – burns associated with inhalational injury – burns to face. Resuscitation Fluids (Appendix 15). a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Use of sedation scores may be beneficial in this reassessment. Burn Patient Emergency Assessment & Management Chart. n n References: Australian Resuscitation Council. viewed 8. frail elderly (NSW Health.au/>. Guideline 8. respiratory compromise or SBP less than 90 mmHg. genitalia. 2nd edn. At the time of this review.09. pp. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. hands. GL2008_012. Assessment of % Total Body Surface Area (TBSA) and Burn Distribution. Be cautious in administering Morphine if there is an altered level of consciousness.g.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> NSW Health.

especially if rapid ascent from significant depth Remove wet clothing – cover with blankets. ABGs/venous blood gas if available Avoid hypothermia Fluid balance chart Nil by mouth Insert IDC – measure and record urine output every hour If available Do not attempt to empty the stomach by external pressure Document assessment findings. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 55 . tachycardia. patient will require endotracheal intubation by MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration airway Assess patency Breathing Respiratory rate and effort SpO2 Wheeze If patient cannot inhale adequately to use an MDI and spacer Auscultation Circulation Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac Monitor Electrocardiography Disability AVPU/GCS + pupils BGL Measure and test Pathology Temperature U/A Fluid input/output Chest X-ray Specific treatment Gastric distension Finger prick BGL Collect blood for FBC.9% Sodium Chloride 500mL if SBP less than 90 mmHg Monitor vital signs frequently 12 lead ECG Monitor LOC frequently If GCS less than 9 and not rapidly improving. UEC. time of first effective CPR Crepitations.Drowning | Medical Officer must be notified immediately | For Adults Only Drowning Clinical Severity Prompts n n n n n – syncope or seizure as a precipitating event – alcohol or drug intake – circulatory arrest n n n n n Altered level of consciousness Wheezing Crepitations Pink frothy sputum Tachycardia – greater than 100 beats per minute Hyperventilation before breath holding underwater Trauma (head/spinal) Duration of immersion Water temperature Time of accident. time of rescue. spinal and skull fractures must be considered Consider: – the possibility of associated drug and/or alcohol use – attempted self-harm assessment Position Intervention n If respiratory and/or cardiac arrest present treat as per Cardiac arrest Guideline If history of trauma refer to trauma Guideline Sit upright depending on clinical status Position supine if c-spine injury is suspected Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% If SpO2 falls below 95% with O2 consult MO If wheeze present give inhaled Salbutamol 6-12 puffs of 100 microgram MDI + spacer Salbutamol 5mg nebule stat Consider CPAP/BiPAP if available and no associated trauma present Consider risk of pneumothorax. serum glucose. do NOt actively rewarm IV cannulation/pathology IV 0. altered level of consciousness. respiratory or cardiac arrest History Prompts n n In diving accidents or the unconscious submersion victim. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

pp.. passive. Therefore a simple. ARC.3: drowning’. Modell J.7: Resuscitation of the drowning victim.com. 11.who.9% Sodium Chloride Dose 6-15 litres/min 6-12 puffs of 100 microgram dose MDI + spacer 5 mg Nebule (if patient unable to inhale adequately using MDI + spacer) 500 mL 10 mL flush Route Inhalation Inhalation Inhalation IV IV Frequency Continuous Stat Stat Stat (repeat once if SBP remains less than 90 mmHg) As required Medications within this guideline must be administered within the context of the formulary. The World Health Organisation (WHO) states that the terms wet.int/violence_injury_prevention/publications/other_injury/en/ drowning_factsheet. 853-856. 2005. PAGE 56 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . 2005). 2005.hcn. vol.M. silent and secondary drowning should no longer be used (WHO. Policy and Practice.09.use.. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n Designation: Date: The new definition of drowning includes both cases of fatal and non-fatal drowning. no. A new definition of drowning: towards documentation and prevention of a global public health problem.Drowning | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. At the time of this review. morbidity and no morbidity’ (WHO. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart.06.M. Drug Oxygen Salbutamol Salbutamol 0. ‘Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid Drowning outcomes are classified as death. Circulation.L. active. part 10. dry..9% Sodium Chloride 0. ‘Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. and internationally accepted definition of drowning has been developed. 2005). Guideline 8. MIMS Online <http://proxy8. 83. 24 Supplement. <http://www.J. viewed 14. Szpilman D.. vol. 112. no. van Beeck E. & Bierens J. pp.pdf>. IV 133 – IV 135.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The American Heart Association. Bulletin of the World Health Organisation. References: Australian Resuscitation Council. Branche C.H. Department of Injuries and Violence Prevention World Health Organisation. World Health Organisation. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. comprehensive. Melbourne. 2005. Facts about injuries: Drowning. 2003. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. If an Advanced Clinical Nurse uses these Guidelines.

anticoagulants such as warfarin. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 57 . speech.3) Pain score (4-10) Halo sign Specific treatment Nausea/vomiting Document assessment findings. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. give oral Paracetamol 500mg – 1g If pain score 4-10 give IV Morphine 2. pattern SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Circulation If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 200 mL bolus Monitor vital signs frequently Monitor GCS frequently If GCS 13 or less consider retrieval/transfer If GCS less than 9 and not rapidly improving. irritability. and GCS 14 or 15 and patient not nil by mouth. effort. confusion. memory loss. motor and/or visual disturbances.e. aspirin. dizziness.Head Injury | Medical Officer must be notified immediately | For Adults Only Head Injury Clinical Severity Prompts n n n n n n n History Prompts n n Events – high risk mechanism of injury Associated symptoms: – headache. vomiting. nausea. seizure GCS less than 14 Loss of consciousness with a history of trauma Visible deformities (fracture of skull or facial bones) Ecchymosis around eyes or ears CSF leak from nose or ears Inequality or non-reactivity of pupil/s SBP less than 90 mmHg at any time assessment Position Intervention n n n Relevant past history Medication history i. UEC (consider beta hCG and blood alcohol levels if accredited to take) Repeat Commence Protect from hypo/hyperthermia Fluid balance chart Consider IDC and urine measurements every hour Nil by mouth if decreasing level of consciousness If pain score 1-3. patient will require endotracheal intubation by MO to protect the airway from aspiration Finger prick BGL Collect blood for FBC. clopidogrel Allergies Position head up 30° unless contraindicated Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15L/minute to maintain SpO2 greater than 95% IV cannulation/pathology airway Assess patency Breathing Respiratory rate.5mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10mg (if IV access unavailable) If nausea/vomiting present give IV or IM Metoclopramide 10 mg Disability AVPU / GCS + Pupils BGL Measure and test Pathology Primary Survey Secondary Survey Temperature U/A Fluid input/output Pain score (1.

Note: nausea and vomiting may be a sign of raised intracranial pressure.9% Sodium Chloride IM IV or IM IV Stat (to a total of 10 mg) Stat As required Medications within this guideline must be administered within the context of the formulary. At the time of this review. Drug Oxygen 0. The provision of narcotic analgesia is not contraindicated once the life-saving surgical and neurological evaluation of the trauma patient has been performed. Hypotension (i. respiratory compromise or SBP less than 90 mmHg. SBP less than 90 mmHg) is a poor prognostic indicator. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. forming a halo. Do NOT insert a nasopharyngeal airway or nasogastric tube in a patient suspected of having a fractured base of skull or nasal bone fracture.Head Injury | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications. PAGE 58 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . A MO must be contacted immediately. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. Be cautious in administering Morphine if there is an altered level of consciousness.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mg 10 mL flush Route Inhalation IV Oral IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Stat (one dose only) Every 5 minutes (to a total of 10 mg) Morphine Metoclopramide 0. If an Advanced Clinical Nurse uses these Guidelines.9% Sodium Chloride Paracetamol Morphine Dose 6-15 litres/min 200 mL bolus 500 mg .1 g 2. The halo sign is present when nasal secretions on bed linen or dressings form a halo. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. spreads onto an absorbent surface.e. If blood or fluid is draining from the nose or ear suspect a fractured base of skull. This occurs when CSF. Mixture of blood with tears or saliva can give false-positives. The darker blood chromatographically forms a ring around a lightlystained centre. n n n n n n The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. mixed with blood. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n n Designation: Date: Prevent secondary brain injury. Use of sedation scores may be beneficial in this reassessment. A decline in the GCS of two or more points must be considered significant.

Venom Publishing Unit. North Ryde. n References: Dunn R. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 59 . 3nd edn.use.g. 2nd edn. ELS Course Inc. persistent GCS less than 15 at 2 hours post injury.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. initial management of closed head injury in adults. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Canberra. e. The management of acute neurotrauma in rural and remote locations. et. Commonwealth of Australia. These patients need to be monitored very closely and will require a CT scan.com. 2005. 2000.Head Injury | Medical Officer must be notified immediately | For Adults Only n People on Warfarin. West Beach.hcn. Clopidogrel or aspirin (especially the elderly) who have a head injury/trauma have a very high morbidity and mortality.. especially for high risk patients and patients whose GCS is not improving. NSW Institute of Trauma and Injury Management. National Health and Medical Research Council. Acute pain management: Scientific evidence. 2005. 2007. The Neurosurgical Society of Australasia. 2000. Adult trauma clinical practice guidelines. MIMS Online <http://proxy8.. al. (eds). 2nd edn. Tamworth. Melbourne. as they can deterioriate very quickly. Reed D. Emergency Life Support (ELS) course manual. The emergency medicine manual. The Royal Australasian College of Surgeons.. A MO must consider the need for a CT scan/further consultation.

– obvious deformity – swelling to limb – pain associated with the injury Obvious deformity. sensation. warmth. PAGE 60 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . movement and pulses of affected limb (refer to Appendix 13) IV cannulation Monitor vital signs frequently Monitor LOC frequently If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IV Morphine 2.Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only Isolated Severe limb Injury Clinical Severity Prompts n n n History Prompts n n n Onset Events – history of trauma. swelling and pain to limb Loss of sensation and pulse Ischaemia of limb n n n Relevant past history Medication history Allergies assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 External bleeding Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Disability Measure and test AVPU/GCS Pain score (1-3) Pain score (4-10) Intervention Position of comfort/function Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Control external bleeding Record colour. interventions and responses in the patient’s healthcare record The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Assess both limbs frequently as well as pre and post splinting or plaster backslab If available If nausea/vomiting present give IV or IM Metoclopramide 10 mg Immobilisation/elevation/ice/splint/POP backslab Fluid input/output Neurovascular observations X-Ray Specific treatment Nausea/vomiting Limb stabilisation Document assessment findings. mechanism of injury Associated symptoms.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV access unavailable) Fluid balance chart Nil by mouth (until anaesthetic requirement confirmed) Neutrally align limb if possible.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. 2007. al. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. References Curtis K. 2000.. West Beach. If an Advanced Clinical Nurse uses these Guidelines. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes: n n n n Designation: Date: Neurovascular limb observations must also include the unaffected limb for comparison. Refer to Appendix 13 for suggested guidelines for a neurovascular assessment.Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only Medication Standing Orders Always check for allergies and contraindications.hcn... Mosby. Drug Oxygen Panadeine Forte Dose 6-15 litres/min 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 2. Compartment syndrome is a limb threatening complication of limb injury caused by increased pressure. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. MIMS Online <http://proxy8. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 61 . n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. Venom Publishing Unit. Dunn R.. Ramsden C. & Friendship J. et. Use of sedation scores may be beneficial in this reassessment.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride IV IM IV or IM IV Every 5 minutes (not to exceed 10 mg) Stat (not to exceed 10 mg) Stat As required Medications within this guideline must be administered within the context of the formulary. Emergency and trauma nursing. 2nd edn.com. The emergency medicine manual. At the time of this review.use. respiratory compromise or SBP less than 90 mmHg. Sydney.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mg 10 mL flush Route Inhalation Oral Frequency Continuous Stat Morphine Morphine Metoclopramide 0.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. (ed). Be cautious in administering Morphine if there is an altered level of consciousness.

5 The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. support ventilation if required Apply O2 to maintain SpO2 greater than 95% Monitor vital signs frequently Monitor LOC frequently Snellen chart/finger count/light perception assessment and pupillary response If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IM Morphine 5-10 mg (10mg in total) Do not remove foreign body.Ocular Injuries | Medical Officer must be notified immediately | For Adults Only Ocular Injuries Some patients who present complaining of eye flash burns may in fact have a corneal foreign body. IM Boostrix or ADT Booster 0. but lie supine (if penetrating injury or suspected retinal detachment) Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if associated history of trauma) If other associated trauma. Stabilise foreign body Do not apply eye pad or pressure to eye Consider tetanus immunisation e. type of foreign body (e.9% Sodium Chloride using an IV blood pump giving set for at least 30 minutes Continue irrigation until pH is within range of 6.4% Oxybuprocaine 2 drops per eye or 0.9% Sodium Chloride using an IV blood pump giving set may be required if a number of superficial dust particles are present.5% or 1% Amethocaine 2 drops per eye.4% Oxybuprocaine 2 drops per eye or 0.g. Gentle irrigation with a neutral fluid e. headache.g.5mL Instil 0. dirt. high speed motor drilling without eye protection) Associated symptoms. drilling. dust.g.g. History Prompts n Events – mechanism of injury (e.9% Sodium Chloride. PAGE 62 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . – pain. small organic matter) Chemical exposures If history of chemical exposure instil 0. metal) n Clinical Severity Prompts n n n n n Injury with loss of visual acuity Welding in past 24 hours Exposure to snow or water glare in past 24 hours Chemical exposure or burn injury to eye Penetrating foreign body of the eye assessment Position Intervention n n n Relevant past history Medication history Allergies Position of comfort.5 to 8.5% or 1% Amethocaine 2 drops per eye. organic. Instil eye drops every 15-20 minutes during irrigation procedure Irrigate eye/s with copious amounts of a neutral fluid e. Instil eye drops every 15-20 minutes during irrigation procedure If small amount of superficial dust or organic matter is present. Compound Sodium Lactate (Hartmanns) solution or 0. loss of vision. tearing.g. glass.g. Compound Sodium Lactate (Hartmanns) Solution or 0. gently remove with a cotton bud which has been moistened with 0. airway Assess patency Breathing Circulation Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Blood pressure AVPU/GCS + pupils Temperature Visual acuity Pain score (1-3) Pain score (4-10) Disability Measure and test Specific treatment Penetrating injury Corneal foreign bodies (e. redness.

view injury with cobalt blue light Document assessment findings. n Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation: The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.9% Sodium Chloride Panadeine Forte Dose 6-15 litres / min 1000 mL 1000 mL 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 5-10 mg (not to exceed total 10mg) 2 drops per affected eye 2 drops per affected eye Route Inhalation Eye irrigation Eye irrigation Oral Frequency Continuous Stat (repeat as required) Stat (repeat as required) Stat Morphine 0. a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 63 . If an Advanced Clinical Nurse uses these Guidelines.5% or 1% Amethocaine drops Metoclopramide Fluorescein Sodium Boostrix or ADT Booster IM Topical Topical Stat Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) Stat Stat Stat 10 mg 1 drop affected eye/s 0. At the time of this review. n Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. at least until reviewed by MO In anticipation of surgical intervention restrict the patient to remain nil by mouth If nausea/vomiting present give IM Metoclopramide 10 mg Instil Fluorescein Sodium 1 drop affected eye/s only.5% or 1% Amethocaine 2 drops per eye (one dose only) Instruct patient to observe strict bed rest. Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution 0.5 mL IM Topical IM Medications within this guideline must be administered within the context of the formulary. interventions and responses in the patient’s healthcare record Medication Standing Orders Always check for allergies and contraindications.Ocular Injuries | Medical Officer must be notified immediately | For Adults Only assessment Specific treatment Flash burns Suspected retinal detachment/hyphaema Fluid input/output Nausea and vomiting Corneal injury Intervention If flash burns to eyes instil 0.4% Oxybuprocaine 2 drops per eye or 0.4% Oxybuprocaine drops 0.

Curtis K. 2nd Edn... NSW Department of Health. Mosby. & Friendship J.. NSW Department of Health.hcn. Corneal injury/s: – instil one drop of Fluorescein Sodium to affected eye/s only. Sydney. 2009. Ramsden C. Seggie J. PAGE 64 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . ‘Ocular emergencies’. in Emergency & trauma nursing. 2007. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Ramsden C. North Sydney. & Braybrooks L. Do not irrigate the eye/s if metallic foreign body is insitu Do not send patient home with local anaesthetic eye drops n n n n References: MIMS Online <http://proxy8.com. view eye injury with cobalt blue light from torch or ophthalmoscope – soft contact lens/es MUST be removed prior to instillation of Fluorescein Sodium drop/s Patient with metallic foreign body/s in the eye require referral to MO.. If not (correctly) removed the metallic foreign body/s may lead to the formation of rust ring/s. (eds) Curtis K.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>.Ocular Injuries | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n It is important to test the visual acuity (VA) in ALL patients with ocular trauma as it is an important parameter and is of medicolegal importance Chemical exposure: – ensure both the upper and lower eyelids are everted during irrigation – patients with chemical exposure to the eyes should also be assessed for potential aspiration of chemicals and subsequent airway obstruction – ensure the face and other exposed areas are thoroughly washed with water..use. Eye Emergency Manual: An Illustrated Guide..

SECTION 7

Other Emergencies

NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH

PAGE 65

Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only

abdominal/loin/Flank Pain
Note: A leaking abdominal aortic aneurysm can mimic renal colic in elderly patients.

n n

Nature of Onset Associated symptoms – nature of pain/radiation – nausea, vomiting – diarrhoea/constipation – last menstrual period/symptoms of pregnancy – urinary symptoms – weight loss Relevant past history Immunocompromised Medication history Events – mechanism of injury (if trauma is involved) Allergies

Clinical Severity Prompts
n n

Pain to abdomen/loin/flank Localised tenderness to right upper or lower quadrant of abdomen Rapid onset
n n

n

History Prompts
n

n n n

Four immediately life threatening presentations that require exclusion are; 1. Ruptured ectopic pregnancy 2. Ruptured abdominal aortic aneurysm 3. Acute myocardial infarction 4. Ruptured spleen

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse – rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability Measure and test AVPU / GCS BGL Abdominal assessment Pain score (2-10)

Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain greater than 95% IV cannulation/pathology

If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL stat Monitor vital signs frequently Monitor LOC frequently Finger Prick BGL Look, listen and feel If pain score 2-10 give IV Morphine 2.5 mg every 5 minutes to a total of 10mg or IM Morphine 5-10 mg (if IV access unavailable) Collect blood for FBC, UEC, (consider LFT’s, serum amylase, coags, group and hold) Urine hCG (if required), collect MSU Strain urine for calculi Fluid balance chart 12 Lead ECG Nil by mouth IV 0.9% Sodium Chloride 1000 mL at 125 mL per hour to maintain hydration IM Prochlorperazine 12.5 mg

Pathology Temperature U/A Fluid input/output Electrocardiography Specific treatment Hydration / intake Nausea and vomiting

Document assessment findings, interventions and responses in the patient’s healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 66 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition

Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders Always check for allergies and contraindications.
Drug Oxygen 0.9% Sodium Chloride Morphine Dose 6-15 litres/min 500 mL bolus 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 1000 mL 12.5 mg 10 mL flush Route Inhalation IV IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Every 5 minutes (to a total of 10 mg) Stat (to a total of 10mg) 125 mL per hour Stat As required

Morphine 0.9% Sodium Chloride Prochlorperazine 0.9% Sodium Chloride

IM IV IM IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurse’s record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

n

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation:

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 67

Pain medication for acute abdominal pain.g. 2nd edn. Acute pain management: Scientific evidence.J. n n n n n n References: Gallager E.Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only Precautions and Notes: n Elderly patients presenting with abdominal/loin/flank pain have a 14% mortality rate. respiratory compromise or SBP less than 90 mmHg. Australian Government. in Emergency medicine: A comprehensive study guide. National Health and Medical Research Council. Use of sedation scores may be beneficial in this reassessment Metoclopramide hydrochloride should only be used where bowel obstruction/perforation has been excluded Metoclopramide appears to be a more effective antiemetic than prochlorperazine. National Institute of Clinical Studies. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. but should not be administered unless ordered by a Medical Officer Tachycardia may not occur in patients taking beta blocking agents. a SBP of 90 mmHg may be critical if previously hypertensive Patients over the age of 65 years requiring opioids should be monitored frequently. A summary of best available evidence and information on current clinical practice. The McGraw-Hill Companies Inc. both for the effectiveness of the analgesia and the presence of adverse effects Opioid analgesics can be safely administered before full assessment and diagnosis in acute abdominal pain.. The Australian and New Zealand College of Anaesthetists. ‘Acute abdominal pain’. Symptoms may be vague with a low tolerance for shock e. Canberra. without increasing the risk of errors in diagnosis or treatment Be cautious in administering Morphine if there is an altered level of consciousness. 2008. 2005. 2004. PAGE 68 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .

NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 69 .THE FOLLOWING DRUG INFORMATION PERTAINS ONLY TO THE CONTEXT SPECIFIED IN THIS NSW RURAL ADULT EMERGENCY CLINICAL ADULT GUIDELINES DOCUMENT Formulary The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

.....................................................................................................................................................................................................................................................................................................................................................................................................................................................71 Amiodarone....................................................................................77 Glyceryl Trinitrate (tablet or spray)..............................................................................................................83 Oxybuprocaine..............................................................................................................75 Frusemide ..................................84 Paracetamol and Codeine (Panadeine Forte)....................................................................................................................................................................................................................85 Salbutamol sulphate (Ventolin).................................................................................................. ........................................................................88 0.................................................................................81 Midazolam hydrochloride.........................................................................................................................................................................................................................................................................................................................74 Dexamethasone .......................................................................................................................................................................................76 50% Glucose ............................................................................................84 Prednisolone ...................................90 PAGE 70 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition ........................................................9% Sodium Chloride ....... ..................................................................................................................................72 Aspirin .......................................................................................................88 0..........................................................................................................................86 Boostrix/ADT Booster .........................................................................................................................................................................................5% or 1% .................................................................................................................................................85 Prochlorperazine ...............................................................................74 Ceftriaxone ...............................................Formulary Index Adrenaline ...........................................................................................................................................................................................................................76 Glucagon ...................................................................................................................................................................................................................................73 Atropine ................................75 Fluoescein sodium..................................................................................................................................................78 Ipratropium Bromide (Atrovent)......................................................................................73 Benzylpenicillin ...............................................................................................................................................................................................................................................79 Lignocaine Hydrochloride ....................................................................................................................................................................................................................................77 Hydrocortisone ..................................................................................................71 Amethocaine 0..80 Metoclopramide ......................................................................................................................................89 Compound Sodium Lactate (Hartmanns Solution) .....................................................................................83 Paracetamol .....................................................................................................................9% Sodium Chloride .......................................................................................................................................................87 Thiamine (Vitamin B-1).................................................................................................81 Morphine....82 Naloxone ........................................................................................................................

http://proxy7.au/view.hcn.use. and hypertension with subarachnoid haemorrhage. Can be used every 15-20 minutes during the irrigation procedure.hcn. and cerebrovascular insufficiency.au/view. Not for use in cases with penetrating eye injury Antagonises effect of sulfonamides and aminosalicylic acid Amethocaine not categorised May give rise to dermatitis in hypersensitive patients.5 mg IM (every 3-5 minutes) to a total of 2mg. The anaesthetised eye should be protected from dust and bacterial contamination Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook. fear. http://proxy7.php?page=chapter6/monographadrenaline-02. Stat only for flash burns Documented hypersensitivity.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2826&product_ name=Adrenaline+Injection <accessed 22/12/08> Drug Category: topical Ocular anaesthetics Drug Name Indications/Dose amethocaine 0.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1515&product_ name=Minims+Local+Anaesthetics <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.hcn. phenothiazines can cause a paradoxical decrease in BP comment as above Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook. anxiety. tremor. html#amethocaine-02 <accessed 2/03/09> Mims Online. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 71 .use. Tricyclic Antidepressants and Mono Amine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline (Category a) Adrenaline has been given to a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus Adverse effects include cardiac ischaemia or dysrhythmias.use.hcn. 50 micrograms IV stat if no response to IM adrenaline and patient presents signs of cardiorespiratory collapse Shortness of breath with or without a history of asthma: 0.com. http://proxy6. Fourth Edition.5 mg IM (pre-arrest circumstance or asthma associated with anaphylaxis) stat Cardiorespiratory arrest (advanced life Support): 1 mg IV/IO every 3 minutes to a total of 3 mg Sympathomimetics cause additive effects.com.php/component/content/ article/1-drug-monographs-a-z/7-section-7?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.au/aidh/index.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Parenteral adrenergic agents Drug Name Indications/Doses adrenaline anaphylactic reaction: 0. html#adrenaline-02 <accessed 2/03/09> Mims Online. http://proxy8.5% or 1% Ocular injuries: 2 drops per affected eye.com. stat to produce local anaesthesia in the eye.com.hcn. cardiovascular disease. beta-blockers antagonise therapeutic effects of Adrenaline. use with caution in hypertension. topical.php?page=chapter11/monographamethocaine-02. http://proxy8. digoxin potentiates proarrhythmic effect of Adrenaline.com.use.

further decreasing myocardial contractility.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=176&product_n ame=Cordarone+X+Intravenous+Injection <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.use. digoxin. http://proxy8. flecainide. phenytoin. http://proxy6.hcn.com. Phlebitis is an issue and also incompatible with 0.hcn.php/component/content/ article/1-drug-monographs-a-z/18-section-18?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.hcn. digitalis induced dysrhythmias. second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome (without pacemaker) Increases effect and blood levels of theophylline.au/aidh/index.com. and anticoagulants. Avoid use 3 months before and during pregnancy.9% Sodium Chloride Overly rapid administration can cause hypotension Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook. cyclosporine. systemic lupus erythematosus. owing to their pharmacological effects.php?page=chapter6/monographamiodarone. torsade de pointes. methotrexate. PAGE 72 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . http://proxy7.use. cimetidine may increase amiodarone levels Category C Drugs that. These effects may be reversible.com. and AV block may occur. beta-blockers. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. html#amiodarone <accessed 2/03/09> Mims Online. bradycardia. Fourth Edition.use. may cause thyroid dysfunction and bradycardia in the foetus Hypotension (most common adverse effect).au/view. quinidine. co administration with calcium channel blockers may cause additive effects. procainamide.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: antiarrhythmics Drug Name Indications/Doses amiodarone Cardiorespiratory arrest (advanced life Support): 300 mg IV/IO over 1-2 mins stat (Dilute with 10-20mL 5% Glucose) for VF/VT cardiorespiratory arrest when defibrillation and adrenaline have failed Contraindications Documented hypersensitivity.

use.use. http://proxy8. urticaria Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook.com. html#atropine <accessed 2/03/09> Mims Online. active upper GI bleed.com. asthma.com. corticosteroids decrease salicylate serum levels.hcn.au/view.use. additive hypoprothrombinaemic effects and increased bleeding time may occur with coadministration of anticoagulants.hcn.5 mg IV increments every 5 minutes (to a total of 3mg) titrated to maintain SBP greater than 90 mmHg Snake/spider bite: (Systemic envenomation) 0.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=361&product_ name=Disprin <accessed 22/12/08> Drug Category: anticholinergic agents Drug Name Indications/Doses atropine Cardiorespiratory arrest (advanced life Support): 1 mg IV/IO every 3-5 minutes to a total of 3 mg Compromising Bradycardia: 0.au/aidh/index.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: antiplatelet agents Drug Name Indications/Doses aspirin acute Coronary Syndrome: 300 mg Oral (chew) stat (if not already given by Ambulance Officers) Inhibits platelet aggregation Documented hypersensitivity.php?page=chapter6/monographatropine.5 mg IV stat if patient bradycardic and SBP less than 90 mmHg None when indicated for symptomatic bradycardia or asystole None for this indication Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Increased risk of arrhythmias in IHD Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.use. owing to their pharmacological effects. These effects may be reversible Avoid use in history of blood coagulation defects.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2163&product_ name=Atropine+Sulfate+Injection+BP <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.hcn.au/view. http://proxy6. Fourth Edition. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 73 .com.hcn. may antagonise uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid Category C Drugs that. http://proxy7.use. http://proxy7. Effects may decrease with antacids and urinary alkalinisers.php?page=chapter7/monographaspirin-02.hcn.php/component/content/ article/1-drug-monographs-a-z/32-section-32?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.com. html#aspirin-02<accessed 2/03/09> Mims Online. http://proxy8.

without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. lactation Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.com.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: 8(a) Penicillins Drug Name Indications/Doses Contraindications Interactions Benzylpenicillin Meningococcal disease: Non-blanching rash: 1. http://proxy6.use.au/aidh/index. colitis). hepatic impairment. hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.php?page=chapter5/monographceftriaxone.au/view.e.hcn.hcn. http://proxy7. history of GI disease (esp. and occasionally fatal. Fourth Edition.php/component/content/ article/1-drug-monographs-a-z/56-section-56?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. prolonged use.com. thiopentone sodium and phenytoin sodium Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Serious. http://proxy8. http://proxy6.com. PAGE 74 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . http://proxy8.use. some other antibiotics.hcn. html#benzylpenicillin<accessed 2/03/09> Mims Online.hcn.com. http://proxy7. impaired vitamin K synthesis.use.use.hcn.com.php/component/content/ article/1-drug-monographs-a-z/40-section-40?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.hcn. do not give via calcium-containing solutions i.2g IV/IO/IM Stat History of hypersensitivity reactions to beta-lactam antibiotics Intravenous solutions of Benzylpenicillin are physically incompatible with many other substances including certain antihistamines. noradrenaline acid tartrate.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=846&product_ name=BenPen <accessed 22/12/08> Drug Category: 8(b) Cephalosporins Drug Name Indications/Doses Contraindications Interactions Ceftriaxone Meningococcal disease: Non-blanching rash: 2g IV/IO/IM Stat (if allergy to penicillin) Allergy to cephalosporins Chloramphenicol Ceftriaxone is incompatible with calcium. Studies in animals have not shown evidence of an increased occurrence of foetal damage Renal.use. pregnancy.use.php?page=chapter5/monographbenzylpenicillin.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7874&product_ name=Ceftriaxone <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.au/view. metaraminol tartrate. Fourth Edition.com. do not mix with Hartmanns Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age.au/aidh/index. html#ceftriaxone<accessed 2/03/09> Mims Online.

Considered safe to use as non-treatment may be more serious for the foetus and ongoing pregnancy Cirrhosis or hypothyroidism may enhance the effect of corticosteroids Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.hcn.use.use. http://proxy6.02.hcn.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=679&product_ name=Dexmethsone#Precautions <accessed 05/03/09> Drug Category: Other Ophthalmic Medication Drug Name Indications/Doses Fluorescein Sodium Ocular injuries: instil one drop to affected eye/s with excess being washed away with sterile saline solution Fluorescein does not stain a normal cornea.com.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Indications/Doses Dexamethasone Meningococcal disease: Non-blanching rash – if patient greater than 65 kg give 10mg IV/IO stat If less than 65 kg give 0.com.2009> MIMS Online 2008.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr _pi&product_ code=1618&product_name=Minims+Stains <accessed 06.02. http://proxy7.hcn. html#fluorescein <accessed 06.com. http://proxy7.au/appendices/appapp-additional-drugs. phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids Oral contraception Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed.hcn.use. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 75 .au/view.2009>.hcn.au/aidh/index.com. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.php?page=chapter14/monographdexamethasone. Fluorescein can permanently stain soft contact lenses – remove lenses before applying the stain Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook 2008.use. http://proxy8. but corneal abrasions or ulcers are stained a bright green and foreign bodies are surrounded by a green ring Known hypersensitivity Nil Pseudomonas aeruginosa grows well in fluorescein – single dose sterile solutions should be used when using this solution to avoid infecting already damaged eye/s.php/component/content/ article/1-drug-monographs-a-z/83-section-83?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.use. html<accessed 05/03/09> Mims Online.15 mg per kg IV/IO stat Known hypersensitivity to dexamethasone Rifampicin. Fourth Edition. http://proxy8.com.

use.use. therefore glucagon hydrochloride has virtually no effect on patients in states of starvation.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: 2(c) Diuretics Drug Name Indications/Doses Contraindications Frusemide Shortness of breath with history of cardiac disease: 40 mg IV stat if audible respiratory crepitations present Documented hypersensitivity Severe sodium and fluid depletion Treatment with potassium-lowering drugs. These effects may be reversible.com.php?page=chapter10/monographglucagon. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations.0 mmol/L Hypoglycaemia: If IV access unavailable. http://proxy8.hcn.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=792&product_ name=Lasix <accessed 23/12/08> Drug Category: Glucose-elevating agents Drug Name Indications/Doses Glucagon Unconscious patient: If IV access unavailable.use.hcn. 1 mg IM stat if BGL less than 3.php/component/content/ article/1-drug-monographs-a-z/131-section-131?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. amphotericin. increased plasma lithium levels and toxicity are possible Category C Drugs that. html#frusemide<accessed 2/03/09> Mims Online. http://proxy7. PAGE 76 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . http://proxy7. glucagonoma May enhance effects of anticoagulants Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age. monitor potassium concentration Anuria Interferes with hypoglycaemic effect of antidiabetic agents concurrent aminoglycosides cause auditory toxicity – hearing loss of varying degrees may occur. insulinoma. adrenal insufficiency. e. Frusemide must not be given during pregnancy unless there are compelling medical reasons. http://proxy6. Fourth Edition. but available data show no evidence of an increased occurrence of foetal damage Effective in treating hypoglycaemia only if sufficient liver glycogen present. phaeochromocytoma. owing to their pharmacological effects.au/view. Fourth Edition. particularly in elderly patients Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.use.com. electrolyte imbalances and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism. http://proxy6.use.com.hcn.0 mmol/L and patient unconscious or confused Seizures: If IV access unavailable.hcn. 1 mg IM stat if BGL less than 3.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2810&product_name=GlucaGen <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. may increase anticoagulant activity of warfarin.com. Treatment during pregnancy requires monitoring of foetal growth Excessive diuresis may cause dehydration. Studies in animals are inadequate or may be lacking.g.com.use.au/aidh/index. increases risk of hypokalaemia.com. html#glucagon <accessed 2/03/09> Mims Online.au/aidh/index.au/view. without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. http://proxy8.php/component/content/ article/1-drug-monographs-a-z/138-section-138?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. 1 mg IM stat if BGL less than 3.hcn.php?page=chapter6/monographfrusemide. or chronic hypoglycaemia or alcohol induced hypoglycaemia Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.0 mmol/L and patient unconscious or confused Documented hypersensitivity.hcn.

com. raised intracranial pressure.au/aidh/index.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Glucose Supplement Drug Name Indications/Doses 50% Glucose Unconscious Patient: 50 mL IV stat if BGL less than 3.use.hcn. then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms) n Contraindications Hypotension. cor pulmonale.hcn. Caution required in the presence of hypotension.hcn.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=193&product_ name=Anginine <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. thrombophlebitis Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook. marked anaemia. treatment with phosphodiesterase 5 inhibitors (e.php/component/content/ article/1-drug-monographs-a-z/139-section-139?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. http://proxy6. monitor fluid balance.t.php?page=chapter10/ treathypoglycaemia. then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms) acute Coronary Syndrome: n 300-600 micrograms (½-1 tab) SL initially.use.com. http://proxy7. then every 5 minutes if SBP greater than 90 mmHg to a total of 1800 micrograms or n 1-2 sprays (400-800 micrograms) SL initially. Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook. html#glyceryl-trinitrate <accessed 2/03/09> Mims Online.hcn. Fourth Edition. http://proxy8.use. then every 5 minutes if SBP greater than 90 mmHg to a total of 3 tablets (1800 micrograms) or n 1-2 sprays (400-800 micrograms) SL initially.use. but available data show no evidence of an increased occurrence of foetal damage Adverse effects are mostly due to vasodilator effects. sildenafil – Viagra).com.hcn. hypertrophic obstructive cardiomyopathy.com.html#idxglucose:inhypoglycaemiaidx <accessed 2/03/09> Mims Online.au/view. sildenafil) – ‘Viagra’ Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2741&product_name=Glucose+Injection+BP+50%25 <accessed 23/12/08> Drug Category: Nitrates Drug Name Indications/Dose Glyceryl trinitrate (tablet or spray) Shortness of breath with history of cardiac disease: 300-600 micrograms (½-1 tab) SL initially. electrolyte concentrations.g.com.g.php?page=chapter6/monographglyceryl-trinitrate.au/view. http://proxy8. aortic or mitral stenosis. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 77 .0 mmol/L Hypoglycaemia: 50 mL IV stat if BGL less than 3. documented hypersensitivity Severe hypotension may occur with co administration of phosphodiesterase 5 inhibitors (e. Studies in animals are inadequate or may be lacking.0 mmol/L and patient unconscious or confused Avoid in dehydrated patients.use. cardiac tamponade. glucose administration may produce vitamin B-complex deficiency. Medical officer should be consulted prior to administration in pregnant patients. diabetic (hyperglycaemic) coma Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed May cause nausea. http://proxy7.0 mmol/L and patient unconscious or confused Seizures: 50 mL IV stat if BGL less than 3. and acid-base balance closely.

use.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=689&product_ name=Solu%2dCortef <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.php?page=chapter14/monographhydrocortisone.php/component/content/ article/1-drug-monographs-a-z/147-section-147?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. http://proxy8. http://proxy6. owing to their pharmacological effects.au/view. Aspirin. html#hydrocortisone <accessed 2/03/09> Mims Online.au/aidh/index. Decreases the efficacy of the following medications. active peptic ulcer disease Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Indications/Doses Hydrocortisone Shortness of breath with or without a history of asthma: 200 mg IV (moderate and severe asthma) stat Shortness of breath with a history of chronic obstructive pulmonary disease: 200 mg IV (moderate and severe cases) stat Uncontrolled infection.com. Fourth Edition.hcn. PAGE 78 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .use. Insulin or oral antidiabetic agents Oral contraception Category C Drugs that.com.com.hcn. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. http://proxy7. phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Rifampicin.hcn. These effects may be reversible Cirrhosis or hypothyroidism may enhance the effect of corticosteroids Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.

Check with Medical Officer before giving to patient already receiving tiotropium Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age.use.php?page=chapter19/monographipratropium. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Caution in glaucoma (protect eyes if nebuliser in use). tricyclic antidepressants.hcn. diabetes mellitus. http://proxy8. Cardiovascular effects may increase with Monoamine Oxidase Inihibitors. Disodium cromoglycate with benzalkonium Cl Beta-Adrenergics. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 79 . prostatic hypertrophy. html#ipratropium<accessed 4/03/09> Mims Online. without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed.use.com.com. and sympathomimetic agents.au/view.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=6818&product_name=Atrovent+Metered+Aerosol+%28CFC%2dfree%29 <accessed 23/12/08> http://proxy8. http://proxy7.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Bronchodilators Drug Name Indications/Dose Ipratropium Bromide (atrovent) Shortness of breath with or without a history of asthma: 4 puffs of 20 microgram Metered Dose Inhaler (severe asthma) or n 500 micrograms nebule (severe asthma) stat if patient cannot inhale adequately to use an MDI + spacer Shortness of breath with history of chronic obstructive pulmonary disease: n 4 puffs of 20 microgram Metered Dose Inhaler stat or n 500 microgram nebule stat if patient cannot inhale adequately to use an MDI + spacer n Contraindications Interactions Documented hypersensitivity to ipratropium Drugs with anticholinergic properties may increase toxicity. xanthines (additive).hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1284&product_name=Atr ovent+Nebulising+Solution <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.use. and cardiovascular disorders Pregnancy Precautions Modified from: Australian Medicines Handbook. and hyperthyroidism.hcn.

Co-administration with cimetidine or beta-blockers increases toxicity of lignocaine. Caution hepatic disease.com. co administration may increase effects of suxamethonium. http://proxy7.au/view. http://proxy6.com. html#lignocaine-02 <accessed 4/03/09> Mims Online. Fourth Edition.use. high concentrations can cause seizures and AV-conduction abnormalities Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.php?page=chapter6/monographlignocaine-02.hcn. Heart block 2nd or 3rd degree.php/component/content/ article/1-drug-monographs-a-z/181-section-181?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. may increase risk of CNS severe respiratory depression and cardiac adverse effects in elderly patients.hcn. amiodarone. Documented hypersensitivity to lignocaine or other local anaesthetics. PAGE 80 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . beta-blockers .5mg/Kg IV/IO stat for VF/VT cardiorespiratory arrest when defibrillation.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: antiarrhythmics Drug Name Indications/Dose Contraindications lignocaine Hydrochloride Cardiorespiratory arrest (advanced life Support): 1-1. Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed . adrenaline and amiodarone have failed Non VF/VT arrest.au/aidh/index. http://proxy8. other antiarrhythmics incl.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=1910&product_name=Lignocaine+Injection <accessed 23/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.use.

au/aidh/index. apnoea. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 81 . html#metoclopramide <accessed 4/03/09> Mims Online. http://proxy7.hcn.use. Fourth Edition. Respiratory depression. Precautions Modified from: Australian Injectable Drugs Handbook.5 mg increments IV slow injection every 1-2 minutes (to a total of 0. 10 mg IM stat and repeat (once only) after 5 minutes if required n Contraindications Interactions Pregnancy Documented hypersensitivity. http://proxy6.com.com. http://proxy6. narcotics and erythromycin may accentuate sedative effects due to decreased clearance Category C Drugs that.php/component/content/ article/1-drug-monographs-a-z/199-section-199?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook. http://proxy8.au/view.use.au/aidh/index.use.php/component/content/ article/1-drug-monographs-a-z/196-section-196?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook.use.hcn. renal impairment.1 mg per kg) or n If IV access unavailable. Rapid or bolus IVI Sedative effects may be antagonized by theophyllines.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: antiemetics Drug Name Indications/Dose Metoclopramide If nausea/vomiting present: Snake / spider bite: 10 mg IV or IM stat trauma: 10 mg IV/IO or IM stat Burns: 10 mg IV/IO or IM stat Head Injury: 10 mg IV or IM stat Isolated severe limb injury: 10 mg IV or IM stat Ocular injuries: 10 mg IM stat Documented hypersensitivity.use. pulmonary disease. Fourth Edition.php?page=chapter12/monographmetoclopramide. pre-existing hypotension.com. Caution in congestive heart failure. Caution in history Parkinson disease. http://proxy7. Patients with history of dystonia / extrapyramidal reactions to medication. These effects may be reversible. cardiovascular depression and cardiac arrest are more likely after IV injection. elderly more likely to experience drowsiness Moderate and Severe Renal impairment as EPSE are common Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.hcn.php?page=chapter2/monographmidazolam.html <accessed 05/03/09> Mims Online.au/view. owing to their pharmacological effects.com. and hepatic failure eliminate Midazolam slower.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=549&product_ name=Metoclopramide+Injection <accessed 23/12/08> Drug Category: anxiolytics Drug Name Indications/Dose Midazolam hydrochloride Seizures: 2.hcn. alcohol.hcn.com. http://proxy8. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=6104&product_name=Midazolam+Injection#Precautions <accessed 05/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.com. Extrapyramidal side effects (EPSE) more likely in patients < 20 years of age Not to be used in presence of intestinal obstruction Phaeochromocytoma May increase sedative effects of other medication and worsen Parkinson’s symptoms in patients with Parkinson’s Disease Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed.hcn.

http://proxy8.hcn.com. hepatic dysfunction.com. Fourth Edition.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-100 mg IM stat (to a total of 10 mg) Ocular injuries: n 5-10mg IM stat (to a total of 10 mg) abdominal/loin/flank pain – (if pain score 2-10) n 2. coma Respiratory depressant and sedative effects may be additive in the presence of other medication Category C Drugs that. has vagolytic action and may increase ventricular response rate Caution in patients with severe renal. caution in supraventricular tachycardias.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=379&product_ name=DBL+Morphine+Sulfate+Injection+BP <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. owing to their pharmacological effects. may cause excessive sedation or coma Precautions Modified from: Australian Injectable Drugs Handbook.php?page=chapter3/monographmorphine.php/component/ content/article/1-drug-monographs-a-z/202-section-202?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook. Caution in hypotension.hcn.hcn.com. PAGE 82 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . html#morphine <accessed 06/03/09> Mims Online. severe respiratory disease.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: analgesics Drug Name Indications/Dose Morphine acute Coronary Syndrome: 2. http://proxy6.au/view.au/aidh/index.use.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) n Contraindications Interactions Pregnancy Documented hypersensitivity.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Head injury – (if pain score 4-10) n 2.use.use. These effects may be reversible.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) trauma – (if pain score 4-10) n 2. http://proxy7.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Burns – (if pain score 4-10) n 2. vomiting. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Isolated severe limb injury – (if pain score 4-10) n 2. nausea.

Effects of partial agonists eg buprenorphine.com. Concomitant eye infection Precautions Modified from: Australian Medicines Handbook. Not for use in cases with penetrating eye injury.hcn. may precipitate withdrawal symptoms in patients with opiate dependence.use. Oxybuprocaine eye drops should be used only when it is considered essential by a doctor May give rise to dermatitis in hypersensitive patients. To produce local anaesthesia in the eye. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Caution in cardiovascular disease. Precautions Modified from: Australian Injectable Drugs Handbook.au/aidh/index.use.php?page=chapter11/monographoxybuprocaine. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 83 . stat. html#naloxone <accessed 06/03/09> Mims Online. Can be used every 15-20 minutes during the irrigation procedure.com. If patients do not respond to multiple dose of Naloxone.use.php?page=chapter4/monographnaloxone.hcn. Stat only for flash burns Documented hypersensitivity. http://proxy8. http://proxy6. http://proxy7. consider alternative causes of unconsciousness.php/component/content/ article/1-drug-monographs-a-z/206-section-206?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook. Minims.au/view.4% Ocular injuries: 2 drops per affected eye.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=7450&product_name=Minims+Benoxinate+%28Oxybuprocaine%29 <accessed 22/12/08> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.hcn.au/view.com. without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Oxybuprocaine 0.use. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures. html#oxybuprocaine <accessed 2/03/09> Mims Online. Fourth Edition. topical. http://proxy8. http://proxy7.use.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: antidotes for Narcotic agonists Drug Name Indications/Dose Contraindications Interactions Pregnancy Naloxone Unconscious patient: 800 micrograms IM stat and 800 micrograms IV stat Documented hypersensitivity Decreases analgesic effects of opioids. Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age.hcn.com.hcn. The anaesthetised eye should be protected from dust and bacterial contamination.com. tramadol only partially reversed by naloxone.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2157&product_name=Naloxone+Hydrochloride+Injection <accessed 06/03/09> Drug Category: topical Ocular anaesthetics Drug Name Indications/Dose Contraindications Interactions Pregnancy (Category D) Safety for use in pregnancy has not been established.

php?page=chapter3/monographparacetamol.hcn.hcn. http://proxy8.com. PAGE 84 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .hcn.use.com. http://proxy7.au/view. significant respiratory disease. drugs affecting gastric emptying. drugs affecting gastric emptying. anticonvulsants Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Caution in severe renal or hepatic dysfunction Max dose = 4g per day total Precautions Modified from: Australian Medicines Handbook.use. http://proxy7.use.au/view.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=390&product_ name=Panadeine+Forte <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.com.use. Paracetamol may increase chloramphenicol concentrations Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Caution in severe renal or hepatic dysfunction Max 4g per day total paracetamol Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook. comatose patients.html#id xPanadeineForteparacetamolacodeineidx <accessed 06/03/09> Mims Online. http://proxy8. html#paracetamol <accessed 06/03/09> Mims Online.php?page=chapter3/monographparacetamol. hepatic enzyme inducers including alcohol.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: analgesics Drug Name Indications/Dose Contraindications Interactions Pregnancy Paracetamol Head injury: 500 mg-1 g (1-2 tablets) oral stat if pain score 1-3 and patient not nil by mouth Documented hypersensitivity – patient is nil orally Anticoagulants.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=391&product_ name=Panadol <accessed 06/03/09> Drug Category: analgesics Drug Name Indications/Dose Paracetamol and Codeine (Panadeine Forte) (Paracetamol 500mg and Codeine Phosphate 30mg) Burns: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Isolated severe limb injury: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Ocular injuries: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Documented hypersensitivity Patient nil orally CNS depressants or tricyclic antidepressants increase toxicity.com.hcn.

hcn. http://proxy6.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Corticosteroids Drug Name Indications/Dose Prednisolone Shortness of breath with or without a history of asthma: 50 mg oral stat (moderate and severe asthma) if IV access unavailable Shortness of breath with history of chronic obstructive pulmonary disease: 50 mg oral stat (severe and moderate cases) if IV access unavailable Documented Hypersensitivity to Prednisolone.hcn. psychoneuroses.use.au/view.hcn.5 mg IM stat if nausea/vomiting present Documented hypersensitivity Patients with history of dystonia / extrapyramidal reactions to medication.use.com. These effects may be reversible May worsen symptoms of Parkinson’s Disease.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2832&product_name=Solone accessed 06/03/09> Drug Category: antiemetics Drug Name Indications/Dose Contraindications Prochlorperazine abdominal/loin/flank pain: 12.com. osteoporosis.com. Fourth Edition.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=553&product_ name=Stemetil <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.hcn.com.php/component/content/ article/1-drug-monographs-a-z/248-section-248?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook. owing to their pharmacological effects. TB. Extrapyramidal Side Effects (EPSE) more likely in patients < 20 years of age CNS depression May increase sedative effects of other medication and worsen Parkinson’s symptoms in patients with Parkinson’s Disease Category C Drugs that. http://proxy7. psychoses. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations.html#prednisone-prednisolone <accessed 06/03/09> Mims Online. Active Peptic ulcer.use. http://proxy8. http://proxy8.hcn.au/aidh/index.php?page=chapter12/monographprochlorperazine. watch for hypotension Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook. systemic fungal infections Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Patients who are immunosuppressed Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook.php?page=chapter14/monographprednisoneprednisolone. http://proxy7. html#prochlorperazine <accessed 06/03/09> Mims Online.use. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 85 .au/view.com.

allergic reactions May increase cardiovascular effects of other sympathomimetics drugs Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed May cause tachycardia. http://proxy7. html#salbutamol <accessed 06/03/09> Mims Online. 8-12 puffs of 100 microgram Metered Dose Inhaler every 15-30 minutes for severe asthma. 10 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present Shortness of breath with or without a history of asthma: n Metered Dose Inhaler + spacer.hcn. PAGE 86 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . Caution in patients with coexisting cardiovascular disease. 8-12 puffs of 100 microgram Metered Dose Inhaler every 1-4 hours for moderate asthma.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1296&product_name=Ventol in+Respirator+Solution+and+Nebules <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.com.com. 6-12 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present n 5 mg nebule stat (for patients who cannot inhale well enough to use MDI + spacer) n Contraindications Interactions Pregnancy History of Hypersensitivity.hcn.use. Precautions Modified from: Australian Medicines Handbook.php?page=chapter19/monographsalbutamol. 10 puffs of 100 microgram dose Metered Dose Inhaler repeat every 20 minutes if required n 5 mg nebule every 20 minutes if required (for patients with severe cases who cannot inhale well enough to use MDI + spacer) Drowning: n Metered Dose Inhaler + spacer. http://proxy8.au/view. Hypokalaemia can occur with high doses particularly in combination with other potassiumdepleting medications. nausea and tremors.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=4114&product_name=Asmol+CFC%2dfree+Inhaler <accessed 06/03/09> http://proxy8.hcn. 8-12 puffs of 100 microgram Metered Dose Inhaler stat for mild asthma n 5 mg nebule every 15-30 minutes for patients with severe asthma who cannot inhale well enough to use MDI + spacer Shortness of Breath with history of chronic obstructive pulmonary disease: n Metered Dose Inhaler + spacer.use.com. Can cause paradoxical bronchospasm.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Inhaled Beta-agonists Drug Name Indications/Dose Salbutamol sulphate (Ventolin) anaphylactic reaction: Metered Dose Inhaler + spacer.

Boostrix can be used) Snake / spider bite: 0.com.com.com.nsf/Content/ Handbook-tetanus <accessed 06/03/09> Australian Medicines Handbook.5 mL IM stat Ocular Injuries: 0.au/view.use.hcn.au/internet/immunise/publishing.5 mL IM stat The only absolute contraindications to tetanus vaccine are: anaphylaxis following a previous dose of the vaccine. http://proxy7. consideration should be given to tetanus or combined diphtheria tetanus vaccines.immunise. or n anaphylaxis following any vaccine component n Contraindications Interactions Pregnancy Immunosuppression/ deficiency patients Category a – aDt Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Category B2 – Boostrix Adequate human data on use during pregnancy and adequate animal reproduction studies are not available.hcn.gov. http://www.use.hcn. tetanus +/-.health. pertussis (aDt Booster) (where not available. alternative measures. http://proxy8.au/view.hcn. Precautions Modified from: The Australian Immunisation Handbook.use.use. including the use of human tetanus immunoglobulin. If an individual has a tetanus-prone wound and has previously had a severe adverse event following tetanus vaccination.php?page=chapter20/monographdtp-vaccines.5 mL IM stat Burns: 0.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=5686&product_name=Boostrix# <accessed 06/03/09> http://proxy8.com. one does not expect harm to the foetus.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7766&product_ name=ADT+Booster# <accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. As with all inactivated vaccines.html#idxBoostrixDTPvaccineidx <accessed 06/03/09> Mims Online. When protection against tetanus is sought.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Immune enhancement Drug Name Indications/Dose Diphtheria.html#idxADTseediphtheriawithtetanusvaccineidx <accessed 06/03/09> http://proxy7. Therefore. can be considered. Boostrix should be used during pregnancy only when clearly needed and the possible advantages outweigh the possible risks for the foetus. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 87 .5 mL IM stat trauma: 0.php?page=chapter20/monographdiphtheria-tetanusvaccines.

au/view.hcn. administer Contraindications Interactions Pregnancy Precautions Modified from: Australian Injectable Drugs Handbook.com. html#thiamine <accessed 06/03/09> Drug Category: Intravenous Fluids Drug Name Indications/Dose 0.use. PAGE 88 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .use.hcn.php?page=chapter4/monographthiamine.au/aidh/index.com.9% Sodium Chloride IV/IO cannulae flush – 10 mL 30 mL flush for resuscitation (Cardiorespiratory Arrest) Medication dilution e. Morphine Contraindications Interactions Pregnancy Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Precautions Modified from: Mims Online. may occur in thiamine-deficient patients. http://proxy6.com. Fourth Edition. Sudden onset or worsening of Wernicke encephalopathy.g.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=4023&product_name=Sodium+Chloride+Injection+0%2e9%25 < accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.php/component/content/ article/1-drug-monographs-a-z/288-section-288?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook.hcn. following glucose.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Vitamin Supplementation Drug Name Indications/Dose thiamine (Vitamin B-1) Unconscious patient: 100 mg IM stat if history of possible alcohol abuse Seizures: 100 mg IM stat if history of possible alcohol abuse Hypoglycaemia: 100 mg IM stat if history of possible alcohol abuse Previous hypersensitivity to parenteral administration Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Hypersensitivity reactions can occur following parenteral administration. http://proxy7. http://proxy8.use.

Sodium retention Precautions Modified from: Mims Online.use.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=3623&product_name=Sodium+Chloride+Intravenous+Infusion+BP < accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. http://proxy8.9% Sodium Chloride Unconscious patient: IV 500 mL bolus if SBP less than 90 mmHg n IV 1000 mL at 125mL per hour to maintain hydration anaphylactic reaction: n IV 1000 mL bolus if pulse rate greater than 100. Severe renal impairment. SBP less than 90 mmHg and capillary refill greater than 2 seconds Non-traumatic shock: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Meningococcal disease: non-blanching rash: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Hyperglycaemia with severe dehydration: n IV 500 mL bolus if SBP less than 90 mmHg or if signs of dehydration (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) Snake/spider bite: n IV 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125mL per hour (to maintain hydration) trauma: n IV/IO 1000 mL at 125mL per hour (to maintain hydration) Burns: IV/IO 500 mL bolus if SBP less than 90 mmHg Drowning : n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Head injury: n IV 200 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Ocular injuries: n Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) abdominal/loin/flank pain: n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125mL per hour (to maintain hydration) n Contraindications Interactions Pregnancy Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Congestive cardiac failure. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 89 .hcn.com.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Intravenous Fluids Drug Name Indications/Dose 0.

hcn.Formulary | Medical Officer must be notified immediately | For Adults Only Drug Category: Intravenous Fluids Drug Name Indications/Dose Compound Sodium lactate (Hartmanns Solution) trauma: IV/IO 200 mL stat to maintain SBP 80-90 mmHg (repeat once if required to maintain SBP 80-90 mmHg) Burns: IV/IO as per Modified Parkland formula Ocular injuries: Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) Congestive heart failure or severe impairment of renal function.tb.use. owing to their pharmacological effects.com. These effects may be reversible Na retention. PAGE 90 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition .au/view. Simultaneous administration of these drugs can result in severe hyperkalaemia Category C Drugs that. Administered concomitantly with potassium sparing diuretics and angiotensin converting enzyme (ACE) inhibitors.use. http://proxy7. Pregnancy Contraindications Interactions Pregnancy Precautions Modified from: Australian Medicines Handbook.hcn. http://proxy8.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=7704&product_name=Compound+Sodium+Lactate+%28Hartmann%27s+Solution%29+Injection < accessed 06/03/09> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.com.html#idxHartmann????????scompoundsodiumlactateinfusionidx <accessed 06/03/09> Mims Online.php?page=chapter7/tableelectrolytes-infusionsolutions. have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations.

SECTION 9

Appendices

NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH

PAGE 91

APPENDIX 1: RURAL AND REMOTE EMERGENCY TROLLEY – MINIMUM ADULT REqUIREMENTS
Ideally the following equipment should be stored on a freely moving mobile trolley with IV pole.
airway ETT (cuffed) x 1 of each Laryngeal mask airway Laryngoscope Oropharyngeal rigid sucker Oropharyngeal airway Nasopharyngeal airway Introducer/intubating stylet Tape Other Breathing Self-inflating 1500mL resuscitation bag with reservoir bag and oxygen tubing Clear masks sizes: 3, 4 & 5 Y suction catheters 12fg & 14fg Suction tubing Disposable CO2 indicator if capnography not available Dwell cath or 14g cannula (8cm in length) 6.0, 7.0, 7.5, 8.0, 8.5, & 9.0 mm 4.0, 5.0 and 6.0 Handles with batteries x 2 Mackintosh (Curved) blades 3 and 4 Adult x 1 2, 3 & 4 6.0 mm & 7.0 mm Large & medium introducer Bougie (gum elastic introducer) White cotton tape Magill forceps, lubricant satchels x 3, 10 mL syringe, scissors

Circulation
Syringes Cannula 5 each of Needles x10 Intra-osseous Needle-less system accessories Giving sets Other 1 mL x 5; 2 mL x 5; 5 mL x 5; 10 mL x 10; 20 mL x 5; 1 x 50 mL 14g, 16g , 20g , 22g , 18g , scalp vein needle 23g, 25g Blunt drawing up 21g Needle x 1 As per AHS stock Plain giving set x 2, blood pump giving set x 2, burette x1 3 way taps x 5 • minimal volume extension tubing • transparent IV dressing x 5 • adhesive tape x 1 • tourniquet • antimicrobial swabs wipes x 10

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 92 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition

Drugs/Fluids Adrenaline 1:10,000 Adrenaline 1:1000 Atropine Glucose 5% Glucose 10% Glucose 50% Sodium Chloride 0.9% Lignocaine 2% Sodium bicarbonate Amiodarone Calcium gluconate 10% Magnesium Chloride Sodium Chloride 0.9% Naloxone Water for injection In fridge: Long acting neuromuscular muscle blocking agent Suxamethonium chloride

Size 1mg in 10mL 1mg in 1mL 3 mg in total 100mL bag 500 mL 50 mL 1000 mL 100 mg 50 mL 150 mg in 3mL ampoules 10% in 10 mL 20% in 5 mL 10 mL 400 micrograms/1mL 10 mL 5 100 mg/2mL

amount Mini-jets x 3 10

1 1 2 1 Minijet 1 6 2 2 20 4 10

5

Other:
n n n n n n n n n n n n n

Defibrillator Full oxygen cylinder/source ECG electrodes Defib self-adhesive/gel pads x 2 packets Arrest documentation form and pen Sharps container PPE Portable suction NG tube Stethoscope Basic and Advanced Life Support algorithm Scissors Drug additive labels

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 93

AVOID having.. no. 2006. AVOID defibrillating if victim. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Warn of impending discharge by a ‘stand clear’ command. operator and/or close bystander are situated in an explosive/flammable (e. Guideline 11. resulting in the normal coordinated contractile activity of the heart. an implanted device (e. thus causing changes in membrane potential.. bed rails (risk of burn). ECG leads (may melt). medication patches. Defibrillation works because it temporarily stuns the myocardium with flow of electrons.g. oxygen and flammable substances. allows the sinoatrial node to resume its function as the primary pacemaker of the heart. Paddle/pad placement n n Right parasternal area over the 2nd intercostal space Midaxillary line over the 6th intercostal space (Apex) Care should be taken to ensure that pads or electrodes are applied in accordance with manufacturer’s instructions and are not in electrical contact with each other. PAGE 94 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . AVOID delivery of a shock with a gap between the paddles/pad and chest wall (spark hazards). any direct or indirect contact with the victim during defibrillation (a shock may be received). Bridy M. petrol) environment. basicwaveforms. n n n n n n n Factors that may contribute to the resistance to flow of electrons during defibrillation attempts. Precautions: n Be aware of electrical hazards in the presence of water. AVOID allowing oxygen from resuscitator to flow onto the victim’s chest during delivery of the shock (risk of fire). ‘Understanding the newer automated external defibrillator devices: electrophysiology. 2002. a central line insertion site. Burklow T. metal fixtures. AVOID placing the defibrillator paddles/pads over ECG electrodes (risk of burns or sparks). AVOID charging the paddles unless they are placed on the victim’s chest.APPENDIX 2: DEFIBRILLATION Defibrillation as soon as possible provides the best chance of survival in victims with VF or unconscious VT. Journal of Emergency Nursing. This. Depolarisation stops the hyper-excitable areas of the myocardium from propagating impulses.g. Mechanical causes of decreased defibrillation success Energy selected Electrode size Chest wall diameter Electrode skin coupling material Number and time interval of previous shocks Electrode to chest contact pressure Systemic acidosis Pre-existing cardiac disease Drug overdose Body temperature Length of time without spontaneous circulation Physiological causes of decreased defibrillation success References: Australian Resuscitation Council. Volume 28. AVOID having the victim in contact with metal fixtures e. ARC. pp. 2.g. Melbourne. or allowing any person to have.R. 132-137.5: Electrical therapy for adult advanced life support.A. resulting in the depolarisation of the cardiac cells. in turn. a pacemaker). and technology’.

Chest lead Placement V1 and V2 sited at 4th intercostal space on either side of the sternum. V5 sited between V4 and V6 / anterior axillary line.. mid clavicular line.. lateral to V4. V4 sited at 5th intercostal space. Turner A. amputee) is to be documented on the 12 lead ECG. Any variation in limb lead placement (e. Med. Postgrad.. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 95 . lateral to V4. clearly specifying the alternate limb lead placements. Cole A. Journal.I. Reference: Jowett N. V6 sited at 5th intercostal space. A.M. ‘Modified electrode placement must be recorded when performing 12-lead electrocardiograms’. 81. V3 sited between V2 and V4.APPENDIX 3: 12 LEAD ECG Procedure: limb lead Placement The four limb leads are to be placed at the level of wrists and ankles as indicated in the diagram below. pp. 122-125. vol. 2005.. and Jones P. mid axillary line. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.g.

Reference: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand.APPENDIX 4: MANAGEMENT OF PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have a reperfusion strategy implemented promptly. dementia or known intracranial abnormality not covered in contraindications n * Many contraindications are relative and potential benefits versus relative risks should always be considered. PAGE 96 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . ST segment elevation of greater than or equal to 2 mm in two or more contiguous chest leads. Differential diagnoses must be considered by a Medical Officer: n n n Aortic dissection. The Medical Journal of Australia. 2006. vol. poorly controlled hypertension Uncontrolled hypertension at time of presentation SBP greater than 180 mmHg or DBP greater than 110 mmHg (should be treated prior to thrombolysis) Ischaemic stroke more than 3 months ago. 184. viewed 19. New left bundle branch block (LBBB) pattern (Note that LBBB is presumed new unless there is evidence otherwise). Pericarditis.01. no.mja. Pulmonary embolism Contraindications* to be considered by a Medical Officer: Absolute Contraindications: n n n n n n n Active bleeding (excluding menses) Significant closed head or facial trauma (within 3 months) Suspected aortic dissection Any prior intracranial haemorrhage Ischaemic stroke within 3 months Known structural cerebral vascular lesion Known malignant intracranial neoplasm (primary or metastatic) Relative Contraindications: n n n n n n n n n Current use of anticoagulants (the higher the INR. ‘Guidelines for the management of acute coronary syndromes’. 12-lead eCG (at least one of the following eCG changes is mandatory for thrombolysis) n n n ST segment elevation of greater than or equal to 1 mm in two or more contiguous limb leads.au/public/issues/184_08_170406/suppl_170406_fm.html> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.09. <http://www.com. the greater the risk) Non-compressible vascular puncture Recent major surgery (less than 3 weeks) Pregnancy Traumatic or prolonged CPR longer than 10 minutes Recent (within 4 weeks) internal bleeding Active peptic ulcer History of chronic. severe. 8 S1-S32.

The highest score achievable is 15 and the lowest score is 3. and Critical Care.D. practical and standardised system for assessing the degree of conscious impairment of the critically ill and injured. 2003. Reference: Healey C. 4. Best Verbal Response.. pp. Each category has criteria and numerical values are attached to each criterion. Rogers F. Healey M.B.R. Kilgo P. vol.G. no.A.. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 97 .APPENDIX 5: AVPU / GCS AVPU is a mnemonic used to obtain a rapid assessment of a patient’s level of consciousness. The Glasgow Coma Scale is used to monitor trend when performing assessments of level of consciousness. ‘Improving the Glasgow Coma Scale Score: Motor Score Alone is a Better Predictor’. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.W. Glance L. Infection... It can also be used for predicting the duration and outcome for patients with head injuries.. 671-680.. A decreasing score is associated with neurological deterioration. The Journal of Trauma: Injury. a – Alert V – Responds to vocal stimuli P – Responds to Painful Stimuli U – Unresponsive This observation should also include assessing the pupillary reflexes. Olser Turner M. Three behavioural responses are evaluated: n n n Best Eye Opening. and Meredith J. and Best Motor Response. Best eye Opening Response Eyes open spontaneously Eyes open to voice Eyes open to painful stimuli No eye opening Best Verbal Response Orientated to time place and person Confused Inappropriate words Incomprehensible Sounds No verbal response Best Motor Response Obeys Commands Localises to Painful Stimuli Non purposeful response to pain Flexion to pain Extension to pain No motor response 4 3 2 1=4 5 4 3 2 1=5 6 5 4 3 2 1=6 Total = 15 a patient with a GCS of less than 9 and not rapidly improving will require endotracheal intubation by a Medical Officer to protect the patient’s airway from aspiration. Shackford S. 54. This rapid assessment will detect only gross neurological damage GCS – Glasgow Coma Scale A quick.

associated symptoms time Reference: ENA & Newberry. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Precipitating factors DESCRIPTION QUESTIONS What were you doing when the pain occurred? What provoked the pain? What makes the pain better? What makes the pain worse? Have you had this type of pain before? What does the pain feel like? Ask the patient to describe the pain in their words Where is the pain/show me where the pain is Does the pain radiate? If so.APPENDIX 6: PAIN ASSESSMENT A number of tools exist to assist clinicians in the assessment of pain. 2003. how would you rate your pain? Do you have any other symptoms? When did the pain start? How long did it last? Does it come and go? Quality Region. Sheehy’s Emergency Nursing: Principles and Practice. where? How severe is the pain? If you were to rate the pain on a scale from 0 to 10 with 0 being no pain and 10 being the most severe pain you can imagine. A commonly used technique in the Emergency Department is the PQRSt mnemonic. Mosby. Radiation Severity. Palliates. PAGE 98 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . FACTOR Provokes. 5th edn.

APPENDIX 7: SEDATION SCORE/SCALE Evidence indicates that a decrease in respiratory rate is a late and unreliable indicator of respiratory depression following opioid administration. 1999. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. 2001. occasionally drowsy. they wake up easily but cannot stay awake during conversation. Canberra. Commonwealth of Australia. Saunders. W. A sedation score of 2 means that the patient is constantly drowsy or groggy but still easy to rouse – e.. 4th edn. Sedation has been found to be a reliable early clinical indicator of respiratory depression and should be monitored following opioid administration using a sedation score. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 99 . difficult to rouse 4= Normal sleep The patient is scored according to the scale above. References: Lehne. The aim is to keep the sedation score below 2 regardless of the route of opioid administration. Richard A. Acute Pain Management: Scientific Evidence. Sedation Score Scale 0= None 1= Mild. easy to rouse 2= Moderate.B.g. Pharmacology for Nursing Care. somnolent. Philadelphia. National Health and Medical Research Council. constantly or frequently drowsy easy to rouse 3= Severe.

so check paler areas. Place a clear glass tumbler firmly on one of the spots or blotches and see if you can still see them through the glass. Small red or purple spots develop at first and may occur in groups anywhere on the body. They appear as round. The spots do not fade when pressed (unlike may other rashes). The rash does not blanch with pressure.meningococcal. To check for this do the tumbler test. The rash is a sign of septicaemia. viewed 10 August 2009. <http://www. Note: it is harder to see on dark skin. The rash does not blanch with pressure.html> The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. They often grow to become blotchy and look like little bruises. One or two may develop at first. Purpuric Rash Purpura are larger areas of bleeding into the skin beginning as red areas that become purple and later brownish-yellow.APPENDIX 8: GLASS TUMBLER TEST A rash is common with meningococcal infection – it may be purpuric or petechial. pinpoint-sized spots that are not raised. The colour varies from red to purple as they age and gradually disappear.. Petechial Rash Petechiae result from tiny area of superficial bleeding into the skin. PAGE 100 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . It may not occur with meningitis alone. Reference: Meningococcal Education Inc. Do NOt solely rely on the rash. as it may not always occur or may occur late in the disease. The Glass Test. and then appear in different parts of the body.org/the_rash.

North Sydney. 2007.APPENDIX 9: SNAKEBITE OBSERVATION CHART Snakebite Observation Chart Patient surname: Forename: Date of birth: MRN number: Date: Time: Time after bite: GENERAL: Pulse rate: Blood pressure: Temperature: SPECIFIC: Regional lymph node tenderness: Local bite site pain: Bite site swelling: Headache: Nausea: Vomiting: Abdominal pain: PARALYTIC SIGNS: Ptosis: Opthalmoplegia: Fixed dilated pupils: Dysarthria: Dysphalgia: Tongue protrusion: Limb weakness: Respiratory weakness: Peak flow rate: MYOLYTIC SIGNS: Muscle pain: Myoglobinuria: COAGULOPATHY SIGNS: Persistant blood ooze: Haematuria: Active bleeding: RENAL: Urine output: LABORATORY KEY TESTS: INR/prothrombin time aPTT Fibrinogen XDP/FDP Platelet count CK Creatinine Urea K+ ANTIVENOM: Type/amount/time: Reaction Date of bite Time of bite: Type of snake: Number of bites: Reference: NSW Health. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. NSW Department of Health. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 101 . Snakebite and Spiderbite Clinical Management Guidelines.

pelvic tenderness. All circumferential burns or burns in a patient with comorbidities or pregnancy. Or any worsening trend in ABCD. paradoxical breathing. patients on anticoagulants and patients with pre-existing disease are at greater risk and require a high index of suspicion for serious injury. Patients ≥16 and > 65 years of age who are ambulatory at the scene with normal physiology and minor or no apparent injury. Paediatrics: Physiological changes are late indicators of serious injury in a child who may lose 30% blood volume prior to ANY changes in vital signs. A decreased LOC is due to traumatic injury. Clinical Development Unit Yes to any IMMEDIATE TRANSPORT The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. stridor. S SIGNS AND SYMPTOMS Airway: At risk. bruising. transport to Trauma Centre. restraint abrasion/confusion. Spinal/Back: Visible deformity. The following are a guide: 1st year 1–5 yrs 6-12 yrs HR >160 >140 >120 SBP <60 <70 <80 RR >60 >35 >30 Yes to any URGENT TRANSPORT T T TRANSPORT If patient meets Major Trauma Criteria. depressed skull and/or signs of base of skull. degloving injury. Breathing:RR <10 or >29. cyanosis or respiratory difficulty. or burns involving head/neck/face/hands/feet/groin or inhalation injury. Circulation: HR >120. severe haemorrhage. If in doubt. Limbs: 2 or more prominal long bone. amputation proximal to digits. rigidity. stridor. AND/OR Yes IMMEDIATE AND URGENT TRANSPORT APPENDIX 10: TRAUMA TRIAGE TOOL I INJURIES Ambulance Service of New South Wales.M MECHANISM OF INJURY ■ ■ Trauma Triage Tool — Major Trauma Criteria (MIST) Yes Closest Hospital PAGE 102 ■ ■ ■ Reference: Focal blunt trauma to head or torso Falls >3m or paediatrics twice the child’s height High voltage injury Crush injury excluding fingers/toes Any rapid deceleration mechanism that results in a large inertia change at impact Blunt ■ Yes No Transport incident: – Death in same vehicle – Intrusion into occupant compartment > 30 cm – Steering wheel deformity – Patient side impact – Vehicle v. NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition Head: Minor head injury with loss of consciousness. Adults >20%. SBP <90 or severe haemorrhage. ischaemia. until proven otherwise. Trauma Triage Tool – Major Trauma Criteria (MIST). pedestrian/cyclist/MBC – Ejection from vehicle – Entrapment with compression Patients <16 or >65 years of age. Obstetric patients >20 weeks gestation. Disability: GCS ≤13 or paralysis/sensory deficit. swelling. Sp02 < 90% on air. Children >10%. Neck: Swelling. Chest: Severe pain. AND/OR Abdomen: Severe pain. . transfer to Trauma Centre T R A U M A U C O D E 3 M I T N S R E E C A M A R T Penetrating All penetrating injury (excuding isolated injury to hands or feet). hoarseness. Face: Injury with potential airway risk. or amnesic to event with: ■ 2 or more vomits or a seizure ■ On anticoagulants Open. they are to be transported to the highest level Trauma Centre within a 1-hour travel time or Aeromedical Retrieval Service advised. hoarseness. 2008. If in doubt. restraint/abrasion/confusion. Burns: Partial or full thickness burns.

Canadian C-Spine Rule For alert (GCS 15) and stable trauma patients where cervical spine is a concern. full spinal precautions need to be maintained until the C-spine has been cleared by clinical examination or radiographic assessment. will have a cervical collar removed. pushed into oncoming traffic. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 103 . spear tackle n MVC or MBC at high speed more than 100 km/hr n MVC rollover. ejection n Quadbike. motorised all-terrain vehicles n Bicycle collision Once a cervical collar has been applied. regardless of pain? YES NO No C-spine immobilisation required * Dangerous mechanism of injury n Fall from more than 3 feet/ 1 metre or 5 stairs n Axial loading to head e. Any one of the following High Risk factors? n Age 65 years or older n Dangerous mechanism of injury* n Numbness or tingling in extremities NO YES 2.APPENDIX 11A: GUIDELINES FOR WHEN TO APPLY SEMI-RIGID CERVICAL COLLARS Standard: n n n All multi-trauma patients or patients with a head injury will have a semi-rigid cervical collar applied. Patients at risk for spinal injury will have a semi-rigid cervical collar applied as per the Canadian C-Spine rule. 1. Any one of the following Low Risk factors which allows for safe assessment of range of motion? n Ambulatory at any time at the scene n No midline c-spine tenderness n Delayed onset of neck pain n Simple rear-end motor vehicle collision Excludes: hit by bus or large truck.g. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Patient able to voluntarily actively rotate neck 45º left and right. diving. Contraindications: penetrating neck injury. hit by high speed vehicle more than 100 km/hour n NO n n Apply semi-rigid cervical collar Immobilise C-spine Requires radiography YES 3. Patients assessed not to be at risk for spinal injury. This should be managed with in-line immobilisation.

D. Brison R.. Rowe B. rheumatoid arthritis The cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. Reardon M.... Cass D. MacPhail I.. vol. 4 p. Ieraci S. 349. Laupacis A. Macphail I...g.. no. Wells G.. after a thorough physical assessment reveals the following: NeXUS Criteria: n n n n n Fully alert – GCS 15 No midline pain and or tenderness upon palpation of the cervical spine No motor or sensory deficit e... vol. ‘Will a new clinical decision rule be widely used? The case of the Canadian C-spine rule’. Brison R. Laupacis A..G.. objectives... pp. Verbeek R.D. Verbeek R.A. 2006. fracture.. Emergency Care Community of Practice. Stiell I.. McKnight R.... pp. Clement C. If all of the NEXUS criteria are satisfied...e.. vol.R. Dreyer J.e. Holroyd B. 2001.. Melbourne.. Brison R. Eisenhauer M.A.. 38... ‘Emergency care evidence in practice series: Cervical spine x-rays in trauma’.. Rowe B.H.G. 3. Reardon M... 2. Wells G. New England Journal of Medicine. 26. 2001.. 2510-18. burns No evidence of alcohol and/or drug ingestion. Medical condition requiring extra caution i. Stiell I.A. Worthington J. Dreyer J.J. no.A... Morrison L.A. Stiell I. Worthington J.G. Lesiuk H. MacPhail I.....G... ‘Canadian CT head and C-spine study group. clinical examination may then proceed. Dreyer J. Morrison L.. 13. Clement C.H... no. Cass D. 413. Lesiuk H.. 317-22. Holroyd B. Schull M. McKnight R. Schull M.. no. vol. PAGE 104 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . 2006. National Institute of Clinical Studies.D.M. Eisenhauer M.. Rowe B.. McKnight R.D. Eisenhauer M. 38.160-69. and methodology for phase I’.. weakness. Greenberg G.C. & Graham I.. Schull M... Holroyd B..APPENDIX 11B: REMOVAL OF SEMI-RIGID CERVICAL COLLAR WITHOUT RADIOGRAPHIC ASSESSMENT Cervical spine clearance without radiographic assessment ONlY applies to fully conscious patients with a GCS 15. and there is no evidence of: n n n Bruising. Bandiera G. Academic Emergency Medicine.. 2003 ‘The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma’.A. If a full range of active movement (45 degrees rotation) can be performed without pain. References: Brehaut J. Wells G. numbness or parasthesia No distracting painful injury that may mask symptoms of a cervical injury i. Annals of Emergency Medicine. Rogers I. Clement C. Annals of Emergency Medicine...S. Lee J. Cass D.H.. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Worthington J. A Medical Officer makes the decision for removal of a C-spine collar.. Canadian CT head rule study for patients with minor head injury: methodology for phase II’.. Greenberg G. Stiell I. deformity or tenderness on examination.. Coyle D.. Greenberg G. Lesiuk H. ‘Canadian CT head and C-spine study group. Reardon M. osteoporosis. The Canadian CT head rule study for patients with minor head injury: rationale. pp.. Injury above the clavicle..

early signs and symptoms of a clinical tension pneumothorax: n n n n n n n n chest pain dyspnoea anxiety tachypnoea tachycardia hyper-resonance of the chest wall on the affected side reduced chest movement on the affected side diminished chest sounds on the affected side. A tension pneumothorax is associated with the formation of a one-way valve at the point of a rupture in the lung. decreasing venous return and compressing the opposite lung. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 105 . Air becomes trapped in the pleural cavity between the chest wall and the lung. putting pressure on the lung and keeping it from inflating fully.APPENDIX 12: NEEDLE THORACENTESIS FOR DECOMPRESSION OF TENSION PNEUMOTHORAX Indication: a rapidly deteriorating haemodynamically unstable patient who has a life-threatening tension pneumothorax. and builds up. late signs of a tension pneumothorax: n n n n n decreased level of consciousness tracheal deviation away from the affected side hypotension distended neck veins cyanosis. The mediastinum is shifted to the opposite side of the chest.

Puncture the parietal pleura. Curtis K. Place the patient in upright position as tolerated (if C-spine injuries have been ruled out) to assist with respirations. PAGE 106 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . Kelen D. at a 90-degree angle into the skin and through the intercostal space (Figure b). Gabor M. The patient may remain supine if C-spine injuries are suspected. ‘Shock’ in Advanced Trauma Life Support Course for Doctors – Student Course Manual.htm> Tintinalli J. 7.org/Products/ OperationalMedicine/DATA/operationalmed/Manuals/FMSS/NEEDLETHORO. Field medical services school student handbook. greater than 8 cm in length. Remove the needle from the catheter and listen for a sudden escape of air. 3. N.. 5. Cleanse the site with antimicrobial swab.CENTESISFMST0411... Reference: American College of Surgeons Committee on Trauma. 8th edn. into the 2nd intercostal space just superior to the 3rd rib. and Cline D. A Medical Officer must now insert an intercostal catheter. Sydney. palpate down one rib to the first space below that rib. McGraw-Hill.. From that halfway point. Prepare Patient n 2.. 2001. Insert a large bore IV cannula (14 or 16 gauge).. if conscious Expose the anterior chest Identify and locate landmarks (on the affected side) – see figures a and b – suprasternal notch – midclavicular line – 2nd Intercostal space The 2nd intercostal space is found by dividing the clavicle in half. 2007. 2003. indicating that the tension pneumothorax has been relieved. and Friendship J. Leave the catheter in place.Procedural Steps for Needle thoracentesis 1.. This is the 2nd intercostal space (the space immediately after the clavicle is the 1st intercostal space) (Figure a) n n n n Figure a 4. 2008. < http://brookside press.. Ma J. 6th edn. United States. 6. New York.. Emergency and trauma nursing. Emergency medicine: A comprehensive study guide international edition. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Mosby. Operational Medicine. Figure b Position the patient in upright position (as tolerated) only if a cervical spine injury has been excluded Apply O2 via a non-rebreather face mask at 15 L/ minute Explain the procedure to the patient. Stapczynski S. Continue to monitor the patient and reassess.B. Ramsden C.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Pulses Auxillary Brachial Ulnar Radial Femoral Popliteal Anterior Tibialis Posterior Tibialis Dorsalis Pedis Nerves Auxillary Radial Median Ulnar Femoral Sciatic Peroneal Deep Tibial Sub-Peroneal Sensation Regimental bade on upper arm Web space between thumb and index finger Pad of index finger Pad of little finger Anterior of thigh Lateral aspect of calf and foot Web space between first and second toes Heel of foot Dorsum of foot Motor Shoulder abduction Hyperextended thumb or wrist Thumb opposition – flex wrist Abduction of fingers Straight leg raise Hip extension Dorsiflexion of foot Plantar flexion of foot Foot eversion Reference: Tamworth Hospital Neurovascular Observation Chart. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 107 .APPENDIX 13: SUGGESTED GUIDELINES FOR A NEUROVASCULAR ASSESSMENT Begin assessment by evaluation of uninjured limb first for normal patient baseline.

APPENDIX 14: PELVIC BINDING
For rotationally unstable pelvic fractures: Open-book, Vertical Shear, lateral Compression type III or Combined Mechanism fractures.

1
Place folded bed sheet underneath the patient between iliac crests and greater trochanters.

2
With two trauma team members, cross the sheeet across the synphysis and pull the sheet firmly so it tightly fits around and stabilises the pelvis.

3
a third person should clamp the sheet at the four points shown (away from laparotomy/angiograph access points).

Reference: Heetveld, M, 2007, The Management of Haemodynamically Unstable Patients with a Pelvic Fracture, NSW Institute of Trauma and Injury Management, Sydney.
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 108 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition

APPENDIX 15: BURN TRANSFER FLOWCHART
Medical Retrieval Meets Medical Retrieval
n n n n n n n n

Referral Needs referral but not medical retrieval Burns >5% children or >10% adults n Burns to hands, feet, face, genitalia, perineum and major joints n Burns with a pre-existing medical condition, e.g. diabetes n Children with suspected non-accidental injury and adults with assault, selfinflicted injury n Pregnancy (2nd or 3rd trimester RNSH) n Spinal cord injury RNSH n Extremes of ages
n

Minor Burns

Intubated patients Head and neck burns Burns >10% in children or >20% in adults Burns with associated inhalation Burns with significant comorbidities, e.g. trauma Electrical/chemical injury Significant pre-existing medical disorder Circumferential to limbs or chest compromising circulation or respiration

Minor burns are treated in consultation with the referring doctor as an outpatient, either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment.

the Children’s Hospital at Westmead Catchment area: All children’s referrals to the age of 15 in all areas of NSW. Contact: aMRS adults 1800 650 004 n NetS for children up to 16th birthday 1300 362 500
n

Concord Repatriation General Hospital Catchment area: South-Eastern Sydney/ Illawarra, Sydney West, Sydney South West, Greater Southern*, Greater Western*, ACT Royal North Shore Hospital Catchment area: Sydney/Central Coast, Hunter/New England, North Coast* *Hospitals near state border areas may refer to Burns Units in adjoining states.

Contact Burns ambulatory Care: CHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h)

Set up conference call with receiving ICU/Burn Unit; facilitate communication with primary referral site CHW ICU CRGH ICU RNSH ICU 99845 1171 99767 6404 99926 8640

CHW: Surgical Registrar on-call notified. Ring 9645 0000, then page Surgical Registrar CRGH: Burns Registrar on-call notified. Tel 9767 7111, then page Burns Registrar RNSH: Burns Registrar on-call notified. Tel: 9926 7111, then page Burns Registrar

Not referred to service.

AMRS/NETS will coordinate transfer betweeen primary hospital and the receiving hospital.

The on-call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receivingthe patient. The referrer will make the ambulance booking.

Referred to service.

Any issues or problems with these processes, or if further advice is required, the NSW Severe Burn Injury Service Manager can be contacted on (02) 9926 5641 Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 109

Reference: NSW Health, 2008, Burn Transfer Guidelines – NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 110 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition

NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 111 . North Sydney. NSW Department of Heath. Burn Transfer Guidelines – NSW Severe Burn Injury Service. 2008.Shade affected area Total % TBSA = __________________ NB: Faint erythema not included in % TBSA assessment NB: Difficult to accurately assess burn depth within the first 24–48 hours post injury. Reference: NSW Health. 2nd edn. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

Reference: NSW Health. 2nd edn. North Sydney. Burn Transfer Guidelines – NSW Severe Burn Injury Service. PAGE 112 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . NSW Department of Heath. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. 2008.

mechanism of injury (spinal. and litres /minute – pulse. warmth and diaphoresis. interventions. IV cannula (position and size) & fluids. Assessment and treatment area allocated 8. rhythm and depth. overt bleeding. blood pressure. Chief presenting problem(s) 3. oxygen saturations (SpO2) – oxygen device. (commence a fluid balance chart if fluids are administered) a – alert V – responds to voice P – responds to painful stimuli U – unresponsive Pupils size & reaction (PEARL) Pain assessment and score + BGL e – exposure & environment History (source – the patient. smoking. Initial triage category allocated 6. herbal) P – past medical / surgical history l – last meal / last menstrual period / last immunisation e – events leading up to presentation Document in a concise and clear manner: n procedures. caregiver or Ambulance Officer) Ongoing assessment triage category 1–3 Record vital signs at time of assessment and frequency according to the patient’s clinical presentation triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patient’s clinical presentation triage category 5 Record vital signs at time of assessment and relevant to presentation Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure) M – mechanism of injury / illness I – injuries sustained / illness progression S – signs & symptoms t – treatment (pre presentation) / transport Documented Observations – respiratory rate. alcohol/other drug use. head. oxygen delivery device and amount Skin colour. pulses. Name of triage officer 9. Vital signs should only be measured at triage if required to estimate urgency or if time permits (Australasian College for Emergency Medicine – ATS Guidelines Revised August 05) Primary Survey a – airway (& Cervical-Spine) B – Breathing C – Circulation D – Disability (neurological) – Discomfort (pain assessment) Documentation Patency. over the counter. skin integrity and falls screening). relevant history 5.APPENDIX 16 GUIDELINE FOR EMERGENCY DEPARTMENT DOCUMENTATION triage Documentation Standard 1. airway noises. capillary refill. work of breathing. outcome & evaluation chronologically n standing orders or guidelines if commenced n notification – who has been told n comply with legal reporting responsibilities Reassess patient and document outcomes n n Plan What plan has been put in place for this patient? evaluation Discharge Time of departure Destination Referrals Document discharge information including any instructions or education given to the patient or family If patient not prepared to wait to be seen – document advice given to the patient or family Further mandatory documentation is required according to the patient’s clinical presentation or if the patient is admitted (i. Date and time of assessment 2. first aid or treatment measures initiated 7. Re-triage category with time and reason (if applicable) 10. temperature – level of consciousness – GCS & pupils – blood glucose level (BGL) – pain score (0-10) and assessment – ECG – cardiac rhythm (if monitored) – neurovascular observations (if relevant) – weight (if relevant) – any investigations commenced /completed & outcome a – allergies M – medications (prescription. Limited. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses. Relevant assessment findings 4. inhalation injury) airway adjuncts (oro/nasopharyngeal/ LMA /ETT) Respiratory rate.e. Any diagnostic. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 113 .

APPENDIX 17: EXAMPLE OF MINIMUM SKILL SET FOR EMERGENCY DEPARTMENT STAFF Skill Basic Life Support airway Placement of oropharyngeal airway Oropharyngeal suction using a rigid suction device Two person ventilation using a BVM before intubation Assistance with endotracheal intubation (e.e.g. NEXUS Spinal Immobilisation (Spinal) log roll Breathing Delivery of non-invasive oxygen therapy Needle decompression of pneumothorax Insertion of intercostal catheter Circulation Venepuncture Blood alcohol sample collection Peripheral intravenous cannulation Automated External Defibrillation (AED) Manual defibrillation (in sites with manual defibrillator) Transcutaneous pacing (in sites with transcutaneous pacing capacity) Administration of ALS protocol medications Blood sample by arterial puncture Recording of 12 lead ECG 12 lead ECG interpretation of ACS Intraosseous needle insertion Insertion of Urinary Catheter Essential Essential Essential Essential Essential Desirable Essential Desirable Essential Essential Essential Essential Essential Essential Essential Essential Essential Desirable Essential Desirable Essential Desirable Desirable Essential Desirable Desirable Desirable Essential Not required Not required Not required Not required Essential Not required Desirable Essential Desirable Not required Not required Essential Not required Not required Not required Not required Desirable Not required Not required Not required Essential Essential Desirable Essential Essential Not required Essential Not required Not required Essential Not required Not required Essential Essential Essential Essential Essential Not required Essential Essential Essential Not required Essential Essential Desirable Not required Essential Essential Essential Essential Essential Essential Desirable Essential Essential Essential Desirable Essential Essential Essential Essential Not required Essential Essential Desirable Not required Essential Essential Essential Essential Not required Essential Desirable Not required Not required Essential Essential Desirable Desirable Not required Desirable Not required Not required Not required Medical Officer Essential advanced Clinical Nurse (RN) Essential RN Essential eeN/eN Essential The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.g. PAGE 114 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . Canadian C-spine rules Semi rigid collar removal decision i. cricoid pressure) Tracheal intubation One person use of BVM after intubation Tracheal suction Insertion of laryngeal mask airway Management of the difficult airway including surgical cricothyroidotomy C-Spine Semi-rigid collar fitting e.

Skill Disability Glasgow Coma Score and pupillary response extras Triage Primary and secondary survey Nasogastric tube insertion Splinting and/or POP application Medical Officer advanced Clinical Nurse (RN) RN eeN/eN Essential Essential Essential Essential Essential Essential Essential Essential Essential Essential Essential Essential Essential Essential Desirable Desirable Not required Desirable Not required Not required Adapted from GMCT Guidelines for In-Hospital Clinical Emergency Response Systems for Medical Emergencies. NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition NSW HealtH PAGE 115 . October 2005. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

PAGE 116 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines – 3rd Edition . Blood gases (including sodium and potassium levels) 2. The following blood pathology results are recommended as the minimum standard necessary at the point of care for rural facilities where an emergency service is provided: 1. treatment and transfer decision-making for patients presenting to rural Emergency Departments. credentialing. Troponin 4.APPENDIX 18: RECOMMENDED BLOOD PATHOLOGY TESTING AVAILABLE AT THE POINT OF CARE IN RURAL FACILITIES WHERE AN EMERGENCY SERVICE IS PROVIDED The NSW Rural Critical Care Taskforce (RCCT) recognises that availability of specific blood pathology results at the point of care is necessary to assist in and expedite effective diagnosis. Haemoglobin 3.g. staff training. with appropriate mechanisms in place to support staff e. and calibration. INR These tests provide information to escalate concern and add to the clinical assessment picture for critically ill patients. The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

.

SHPN (SSD) 090220 .