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Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES - 2014 Edition

Responder Emergency First Responder - Basic Tactical Emergency Care

October 2014 1 Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES - 2014 Edition

PHECC Clinical Practice Guidelines First Edition 2001 Second Edition 2004 Third Edition 2009 Third Edition Version 2 2011 Fourth Edition April 2012 Fifth Edition July 2014

Published by:

Pre-Hospital Emergency Care Council Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland Phone: + 353 (0)45 882042 Fax: + 353 (0)45 882089 Email: [email protected] Web: www.phecc.ie

ISBN 978-0-9929363-0-3 © Pre-Hospital Emergency Care Council 2014

Permission is hereby granted to redistribute this document, in whole or part, for educational, non-commercial purposes providing that the content is not altered and that the Pre-Hospital Emergency Care Council (PHECC) is appropriately credited for the work. Written permission from PHECC is required for all other uses. Please contact the author: [email protected]

October 2014 2 Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES - 2014 Edition

TABLE OF CONTENTS

FOREWORD ...... 4 ACCEPTED ABBREVIATIONS ...... 5 ACKNOWLEDGEMENTS ...... 7 INTRODUCTION ...... 9 IMPLEMENTATION AND USE OF CLINICAL PRACTICE GUIDELINES ...... 10

CLINICAL PRACTICE GUIDELINES

INDEX ...... 12 KEY/CODES EXPLANATION ...... 13 SECTION 1 CARE PRINCIPLES ...... 14 SECTION 2 PATIENT ASSESSMENT ...... 16 SECTION 3 RESPIRATORY EMERGENCIES ...... 19 SECTION 4 MEDICAL EMERGENCIES ...... 22 SECTION 5 OBSTETRIC EMERGENCIES ...... 37 SECTION 6 TRAUMA ...... 38 SECTION 7 PAEDIATRIC EMERGENCIES ...... 45

Appendix 1 - Medication Formulary ...... 53 Appendix 2 – Medications & Skills Matrix ...... 62 Appendix 3 – Critical Incident Stress Management ...... 69 Appendix 4 – Pre-Hospital Defibrillation Position Paper ...... 71

October 2014 3 Clinical Practice Guidelines

FOREWORD

The role of the Pre-Hospital Emergency Care Council (PHECC) is to protect the public by independently specifying, reviewing, maintaining and monitoring standards of excellence for the delivery of quality pre-hospital emergency care for people in Ireland. The contents of this clinical publication are fundamental to how we achieve this goal. Clinical Practice Guidelines have been developed for responders and practitioners to aid them in providing world-class pre-hospital emergency care to people in Ireland. I would like to thank the members of the Medical Advisory Committee, chaired by Dr Mick Molloy for their efforts and expertise in developing these guidelines. The council acknowledge the work of the PHECC Executive in researching and compiling these Guidelines, in particular Mr Brian Power, Programme Development Officer. I also commend the many responders and practitioners whose ongoing feedback has led to the improvement and creation of many of the Guidelines herein. The publication of these Guidelines builds on the legacy of previous publications and marks yet another important milestone in the development of care delivered by responders and practitioners throughout Ireland. Despite the difficulties faced by responders and licensed service providers, I am proud that they continue to develop their skills and knowledge to provide safer and more effective patient care.

______Mr Tom Mooney, Chair, Pre-Hospital Emergency Care Council

October 2014 4 Clinical Practice Guidelines

ACCEPTED ABBREVIATIONS

Accepted abbreviations Advanced ...... AP ...... ALS Airway, Breathing & Circulation ...... ABC All Terrain Vehicle ...... ATV Altered Level of Consciousness ...... ALoC Automated External Defibrillator...... AED ...... BVM ...... BLS Blood Glucose ...... BG Blood Pressure ...... BP Basic Tactical Emergency Care ...... BTEC

Carbon Dioxide ...... CO2 Cardiopulmonary Resuscitation ...... CPR Cervical Spine ...... C-spine Chronic Obstructive Pulmonary Disease ...... COPD Clinical Practice Guideline ...... CPG Degree ...... o Degrees Centigrade ...... oC

Dextrose 10% in water ...... D10W Drop (gutta) ...... gtt Electrocardiogram ...... ECG Emergency Department ...... ED Emergency Medical Technician ...... EMT Endotracheal Tube ...... ETT Foreign Body Airway Obstruction ...... FBAO Fracture ...... # General Practitioner ...... GP Glasgow Coma Scale ...... GCS Gram ...... g Milligram ...... mg Millilitre ...... mL

October 2014 5 Clinical Practice Guidelines

ACCEPTED ABBREVIATIONS (contd)

Millimole ...... mmol Minute ...... min Modified Early Warning Score...... MEWS Motor Vehicle Collision ...... MVC Myocardial Infarction ...... MI ...... NPA Milliequivalent ...... mEq Millimetres of mercury ...... mmHg Nebulised ...... NEB Negative decadic logarithm of the H+ ion concentration ...... pH Orally (per os) ...... PO Oropharyngeal airway ...... OPA

Oxygen ...... O2 Paramedic ...... P Peak Expiratory Flow ...... PEF Per rectum ...... PR Percutaneous Coronary Intervention ...... PCI Personal Protective Equipment ...... PPE Pulseless Electrical Activity ...... PEA Respiration rate ...... RR Return of Spontaneous Circulation ...... ROSC Revised Trauma Score ...... RTS

Saturation of arterial oxygen ...... SpO2 ST Elevation Myocardial Infarction ...... STEMI Subcutaneous ...... SC Sublingual ...... SL Systolic Blood Pressure ...... SBP . Therefore ...... Total body surface area ...... TBSA Ventricular Fibrillation...... VF Ventricular Tachycardia...... VT When necessary (pro re nata) ...... prn

October 2014 6 Clinical Practice Guidelines

ACKNOWLEDGEMENTS

The process of developing CPGs has been long and detailed. Mr Thomas Keane, Paramedic, Member of Council The quality of the finished product is due to the painstaking work of many people, who through their expertise and review Mr Shane Knox, Education Manager, National Ambulance of the literature, ensured a world-class publication. Service College Col Gerard Kerr, Director, the Defence Forces Medical Corps PROJECT LEADER & EDITOR Mr Declan Lonergan, Advanced Paramedic, Education & Competency Assurance Manager, HSE National Mr Brian Power, Programme Development Officer, PHECC. Ambulance Service Mr Seamus McAllister, Divisional Training Officer, Northern INITIAL CLINICAL REVIEW Ireland Ambulance Service Dr David McManus, Medical Director, Northern Ireland Dr Geoff King, Director, PHECC. Ambulance Service Ms Pauline Dempsey, Programme Development Officer, Dr David Menzies, Consultant in Emergency Medicine, Clinical PHECC. Lead, Emergency Medical Science, University College Ms Jacqueline Egan, Programme Development Officer, PHECC. Dublin Mr Shane Mooney, Advanced Paramedic, Chair of Quality and Safety Committee MEDICAL ADVISORY COMMITTEE Mr Joseph Mooney, Emergency Medical Technician, Dr Mick Molloy, (Chair) Consultant in Emergency Medicine Representative from the PHECC register Dr Niamh Collins, (Vice Chair) Consultant in Emergency Mr David O’Connor, Advanced Paramedic, representative from Medicine, Connolly Hospital Blanchardstown the PHECC register Prof Gerard Bury, Professor of General Practice, University Dr Peter O’Connor, Consultant in Emergency Medicine, College Dublin Medical Advisor Dublin Fire Brigade Dr Seamus Clarke, General Practitioner, representing the Irish Mr Cathal O’Donnell, Consultant in Emergency Medicine, College of General Practitioners Medical Director, HSE National Ambulance Service Mr Jack Collins, Emergency Medical Technician, Mr Kenneth O’Dwyer, Advanced Paramedic, representative Representative from the PHECC register from the PHECC register Prof Stephen Cusack, Consultant in Emergency Medicine, Mr Martin O’Reilly, Advanced Paramedic, District Officer Cork University Hospital Dublin Fire Brigade A/Prof Conor Deasy, Consultant in Emergency Medicine, Mr Rory Prevett, Paramedic, representative from the PHECC Cork University Hospital, Deputy Medical Director HSE register National Ambulance Service Dr Neil Reddy, Medical Director, Code Blue Mr Michael Dineen, Paramedic, Vice Chair of Council Mr Derek Rooney, Paramedic, representative from the PHECC Mr David Hennelly, Advanced Paramedic, Clinical register Development Manager, National Ambulance Service Ms Valerie Small, Advanced Nurse Practitioner, Chair of Mr Macartan Hughes, Advanced Paramedic, Head of Education and Standards Committee. Education & Competency Assurance, HSE National Ambulance Service Dr Sean Walsh, Consultant in Paediatric Emergency Medicine, Our Lady’s Hospital for Sick Children, Crumlin Mr David Irwin, Advanced Paramedic, representative from the Irish College of

October 2014 7 Clinical Practice Guidelines

ACKNOWLEDGEMENTS

EXTERNAL CONTRIBUTORS Mr Kevin Reddington, Advanced Paramedic Ms Diane Brady, CNM II, Delivery Suite, Castlebar Hospital. Ms Barbara Shinners, Emergency Medical Technician Mr Ray Brady, Advanced Paramedic Dr Dermott Smith, Consultant Endocrinologist Mr Joseph Browne, Advanced Paramedic Dr Alan Watts, Register in Emergency Medicine Dr Ronan Collins, Director of Stroke Services, Age Related Health Prof Peter Weedle, Adjunct Prof of Clinical Pharmacy, National Care, Adelaide & Meath Hospital, Tallaght. University of Ireland, Cork. Mr Denis Daly, Advanced Paramedic Mr Brendan Whelan, Advanced Paramedic Mr Jonathan Daly, Emergency Medical Technician Dr Zelie Gaffney Daly, General Practitioner SPECIAL THANKS

Prof Kieran Daly, Consultant Cardiologist, University Hospital HSE National Clinical Programme for Acute Coronary Syndrome Galway HSE National Asthma Programme Mr Mark Dixon, Advanced Paramedic HSE National Diabetes Programme Dr Colin Doherty, Neurology Consultant HSE National Clinical Programme for Emergency Medicine Mr Michael Donnellan, Advanced Paramedic HSE National Clinical Programme for Epilepsy Dr John Dowling, General Practitioner, Donegal HSE National Clinical Programme for Paediatrics and Mr Damien Gaumont, Advanced Paramedic Neonatology Dr Una Geary, Consultant in Emergency Medicine Dr David Janes, General Practitioner A special thanks to all the PHECC team who were involved in this project. In particular Ms Deirdre Borland for her dedication Mr Lawrence Kenna, Advanced Paramedic in bringing this project to fruition. Mr Paul Lambert, Advanced Paramedic Dr George Little, Consultant in Emergency Medicine EXTERNAL CLINICAL PROOFREADING Mr Christy Lynch, Advanced Paramedic Ms Sheila Bourke, EFR Dr Pat Manning, Respiratory Consultant Ms Miriam Lahart, EFR Dr Adrian Murphy, Specialist Register in Emergency Medicine Dr Regina McQuillan, Palliative Care Consultant, St Francis Hospice, Raheney Prof. Alf Nickolson, Consultant Paediatrician Dr Susan O’Connell, Consultant Paediatrician Mr Paul O’Driscoll, Advanced Paramedic Ms Helen O’Shaughnessy, Advanced Paramedic Mr Tom O’Shaughnessy, Advanced Paramedic Dr Michael Power, Consultant Anaesthetist

Mr Colin Pugh, Paramedic

October 2014 8 Clinical Practice Guidelines

INTRODUCTION

Clinical Practice Guidelines for pre-hospital care are under constant review as practices change, new therapies and medications are introduced, and as more pre-hospital clinical pathways are introduced such as Code STEMI and code stroke which are both leading to significant improved outcomes for patients. A measure of how far the process has developed can be gained from comparing the 29 Standard Operating Procedures for pre-hospital care in existence prior to the inception of the Pre-Hospital Emergency Care Council and the now more than 319 guidelines and growing. The 2014 guidelines include such new developments as the use of intranasal fentanyl for advanced paramedics and harness induced suspension trauma for both practitioners and responders. Clinical Practice Guidelines recognise that practitioners and responders provide care to the same patients but to different skill levels and utilising additional pharmaceutical interventions depending on the practitioner level. This edition of the guidelines has introduced some new concepts such as the basic tactical emergency care standard at EFR and EMT level for appropriately employed individuals. As ever feedback on the guidelines from end users or interested parties is always welcomed and may be directed to the Director of PHECC or the Medical Advisory Committee who review each and every one of the guidelines before they are approved by the Council.

______Dr Mick Molloy, Chair, Medical Advisory Committee.

October 2014 9 Clinical Practice Guidelines

IMPLEMENTATION

Clinical Practice Guidelines (CPGs) and the responder CPGs are guidelines for best practice and are not intended as a substitute for good clinical judgment. Unusual patient presentations make it impossible to develop a CPG to match every possible clinical situation. The responder decides if a CPG should be applied based on patient assessment and the clinical impression. The responder must work in the best interest of the patient within the scope of practice for his/her clinical level. Consultation with fellow responders and/or practitioners in challenging clinical situations is strongly advised.

The CPGs herein may be implemented provided: 1 The responder maintains current certification as outlined in PHECC’s Education & Training Standard. 2 The responder is authorised, by the organisation on whose behalf he/she is acting, to implement the specific CPG. 3 The responder has received training on, and is competent in, the skills and medications specified in the CPG being utilised.

The medication dose specified on the relevant CPG shall be the definitive dose in relation to responder administration of medications. The onus rests on the responder to ensure that he/she is using the latest version of CPGs which are available on the PHECC website www.phecc.ie

Definitions

Adult A patient of 16 years or greater, unless specified on the CPG.

Child A patient between 1 and less than or equal to (≤) 15 years old, unless specified on the CPG

Infant A patient between 4 weeks and less than 1 year old, unless specified on the CPG

Neonate A patient less than 4 weeks old, unless specified on the CPG

Paediatric patient Any child, infant or neonate

Care principles are goals of care that apply to all patients. The PHECC care principles for responders are outlined in Section 1.

Completing an ACR/CFRR for each patient is paramount in the risk management process and users of the CPGs must commit to this process.

Minor injuries Responders must adhere to their individual organisational protocols for treat and discharge/referral of patients with minor injuries.

October 2014 10 Clinical Practice Guidelines

IMPLEMENTATION

CPGs and the pre-hospital emergency care team The aim of pre-hospital emergency care is to provide a comprehensive and coordinated approach to patient care management, thus providing each patient with the most appropriate care in the most efficient time frame. In Ireland today, the provision of emergency care comes from a range of disciplines and includes Responders (Cardiac First Responders, First Aid Responders and Emergency First Responders) and practitioners (Emergency Medical Technicians, Paramedics, Advanced Paramedics, Nurses and Doctors) from the statutory, private, auxiliary and voluntary services. CPGs set a consistent standard of clinical practice within the field of pre-hospital emergency care. By reinforcing the role of the responder, in the continuum of patient care, the chain of survival and the golden hour are supported in medical and traumatic emergencies respectively. CPGs guide the responder in presenting to a practitioner a patient who has been supported in the very early phase of injury/ illness and in whom the danger of deterioration has lessened by early appropriate clinical care interventions. The CPGs presume no intervention has been applied, nor medication administered, prior to the arrival of the responder. In the event of another practitioner or responder initiating care during an acute episode, the responder must be cognisant of interventions applied and medication doses already administered and act accordingly. In this care continuum, the duty of care is shared among all responders/practitioners of whom each is accountable for his/her own actions. The most qualified responder/practitioner on the scene shall take the role of clinical leader. Explicit handover between responders/practitioners is essential and will eliminate confusion regarding the responsibility for care.

Emergency First Response- Basic Tactical Emergency Care (EFR-BTEC) EFR-BTEC is a new education and training standard published in 2014. Persons certified at EFR-BTEC learn EFR and the additional knowledge and skill set for providing pre-hospital emergency care in hostile or austere environments. Entry to this course is restricted to people who have the potential to provide emergency first response in hostile or austere environments and who are working or volunteering on behalf of a Licensed CPG Provider with specific approval for BTEC provision.

First Aid Response First Aid Response (FAR) is a new education and training standard published in 2014. This standard offers training and certification to individuals and groups who require a first aid skill set including cardiac first response. This standard is designed to meet basic first aid and basic life support (BLS) requirements that a certified person, known as a “First Aid Responder”, may encounter in their normal daily activities.

Defibrillation Policy The Medical Advisory Committee has recommended the following pre-hospital defibrillation policy; • Advanced Paramedics should use manual defibrillation for all age groups. • Paramedics may consider use of manual defibrillation for all age groups. • EMTs and responders shall use AED mode for all age groups.

October 2014 11 Clinical Practice Guidelines

INDEX EMERGENCY FIRST RESPONDER - BTEC CPGs

SECTION 1 CARE PRINCIPLES ...... 14 SECTION 2 PATIENT ASSESSMENT ...... 16 Primary Survey – Adult ...... 16 Secondary Survey Medical – Adult ...... 17 Secondary Survey Trauma – Adult ...... 18 SECTION 3 RESPIRATORY EMERGENCIES ...... 19 Advanced - Adult ...... 19 Abnormal Work of Breathing – Adult ...... 20 Asthma - Adult ...... 21 SECTION 4 MEDICAL EMERGENCIES ...... 22 Basic Life Support – Adult ...... 22 Foreign Body Airway Obstruction – Adult ...... 23 Post-Resuscitation Care – Adult ...... 24 Recognition of Death – Resuscitation not Indicated ...... 25 Cardiac Chest Pain - Acute Coronary Syndrome ...... 26 Altered Level of Consciousness – Adult ...... 27 Anaphylaxis – Adult ...... 28 Decompression Illness (DCI) ...... 29 Fainting ...... 30 Glycaemic Emergency – Adult ...... 31 Heat Related Illness ...... 32 Hypothermia ...... 33 Poisons ...... 34 Seizure/Convulsion – Adult ...... 35 Stroke ...... 36 SECTION 5 OBSTETRIC EMERGENCIES ...... 37 Pre-Hospital Emergency Childbirth ...... 37 SECTION 6 TRAUMA ...... 38 Burns ...... 38 External Haemorrhage ...... 39 Harness Induced Suspension Trauma ...... 40 Heat-Related Emergency ...... 41 Limb Injury ...... 42 Spinal Immobilisation – Adult ...... 43 Submersion Incident ...... 44 SECTION 7 PAEDIATRIC EMERGENCIES ...... 45 Primary Survey – Paediatric ...... 45 Abnormal Work of Breathing - Paediatric ...... 46 Asthma - Paediatric ...... 47 Basic Life Support – Paediatric ...... 48 Foreign Body Airway Obstruction – Paediatric ...... 49 Anaphylaxis – Paediatric ...... 50 Seizure/Convulsion – Paediatric ...... 51 Spinal Immobilisation – Paediatric ...... 52

October 2014 12 Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES for EMERGENCYClinical Practice FIRST Guidelines RESPONDER - BTEC for (CODES EXPLANATION) Emergency First Response Codes explanation

A parallel process Which may be carried out in parallel CFR Cardiac First Responder (Level 1) for which the CPG pertains with other sequence steps

First Aid Responder A cyclical process in which a number FAR (Level 2) for which the CPG pertains of sequence steps are completed

Emergency First Responder An EFR who has completed Basic Tactical EFR EFR (Level 3) for which the CPG pertains Emergency Care training and has been BTEC privileged to operate in adverse conditions

Sequence step A sequence (skill) to be performed First Aid Responder or lower clinical FAR levels not permitted this route Mandatory sequence step A mandatory sequence (skill) to be performed

Ring ambulance control Instructions An instruction box for information

Request Request an AED from local area Special instructions AED Special instructions Which the Responder must follow

A decision process EFR A skill or sequence that only pertains The Responder must follow one route to EFR or higher clinical levels

Given the clinical Special authorisation Special This authorises the Responder to perform Consider treatment presentation consider authorisation options the treatment option an intervention under specified conditions specified

xyz Finding following clinical assessment, Reassess the patient Reassess leading to treatment modalities following intervention

1/2/3.4.1 CPG numbering system Version 2, 07/11 1/2/3 = clinical levels to which the CPG pertains 1/2/3.x.y x = section in CPG manual, y = CPG number in sequence Version 2, mm/yy mm/yy = month/year CPG published

A medication which may be administered by a CFR or higher clinical level Medication, dose & route The medication name, dose and route is specified

Medication, dose & route A medication which may be administered by an EFR or higher clinical level The medication name, dose and route is specified

Go to xxx A direction to go to a specific CPG following a decision process CPG Note: only go to the CPGs that pertain to your clinical level

Start from A clinical condition that may precipitate entry into the specific CPG

October 2014 13 Clinical Practice Guidelines

SECTION 1 CARE PRINCIPLES

Care principles and responders Care principles are goals of care that apply to all patients. Scene safety, standard precautions, patient assessment, primary and secondary surveys and the recording of interventions and medications on the Ambulatory Care Report (ACR) or the Cardiac First Response Report (CFRR) are consistent principles throughout the guidelines and reflect the practice of responders. Care principles are the foundations for risk management and the avoidance of error.

PHECC Care Principles

1 Ensure the safety of yourself, other emergency service personnel, your patients and the public:

• Review all pre-arrival information.

• Consider all environmental factors and approach a scene only when it is safe to do so.

• Identify potential and actual hazards and take the necessary precautions.

• Liaise with other emergency services on scene.

• Request assistance as required in a timely fashion, particularly for higher clinical levels.

• Ensure the scene is as safe as is practicable.

• Take standard infection control precautions.

2 Call for help early: • Ring 999/112 using the RED card process, or • Obtain practitioner help on scene through pre-determined processes.

3 Seek consent prior to initiating care: • Patients have the right to determine what happens to them and their bodies. • For patients presenting as P or U on the AVPU scale implied consent applies. • Patients may refuse assessment, care and/or transport.

4 Identify and manage life-threatening conditions: • Locate all patients. If the number of patients is greater than resources, ensure additional resources are sought. • Assess the patient’s condition appropriately.

• Prioritise and manage the most life-threatening conditions first. • Provide a situation report to Ambulance Control Centre (112/999) using the RED card process as soon as possible after arrival on the scene.

October 2014 14 Clinical Practice Guidelines

SECTION 1 CARE PRINCIPLES

5 Ensure adequate Airway, Breathing and Circulation: • Ensure airway is open. • Commence CPR if breathing is not present. • If the patient has abnormal work of breathing ensure 999/112 is called early.

6 Control all external haemorrhage.

7 Identify and manage other conditions.

8 Place the patient in the appropriate posture according to the presenting condition.

9 Ensure the maintenance of normal body temperature (unless a CPG indicates otherwise).

10 Provide reassurance at all times.

11 Monitor and record patient’s vital observations.

12 Maintain responsibility for patient care until handover to an appropriate responder/practitioner.

13 Complete patient care records following an interaction with a patient.

14 Identify the clinical leader on scene.

October 2014 15 Clinical Practice Guidelines

SECTION 2 PATIENT ASSESSMENT

3.2.3T Version 3, 01/13 Primary Survey - Adult EFR BTEC

Take standard infection control precautions

Consider pre-arrival information

Scene safety Scene survey Scene situation

Control catastrophic external haemorrhage

Mechanism of C-spine injury suggestive Yes No control of spinal injury

Special Authorisation: EFRs having completed Assess responsiveness Unresponsive EFR the BTEC course may be 999 / 112 privileged by a licensed Responsive CPG provider to insert an NPA on its behalf

Request AED

Suction, Head tilt/chin lift, OPA No Airway patent Yes Maintain Jaw thrust NPA

Go to Airway FBAO Yes No obstructed CPG

Go to BLS Breathing Consider CPG No

Yes

Treat life-threatening injuries only at this point RED Card Information and sequence required by Ambulance Control when requesting an emergency ambulance response: Pulse, Respiration & 1 Phone number you are calling from AVPU assessment 2 Location of incident 3 Chief complaint 4 Number of patients Consider expose & examine Normal rates 5 Age (approximate) Pulse: 60 – 100 6 Gender Respirations: 12 – 20 7 Conscious? Yes/no Formulate RED card 8 Breathing normally? Yes/no information If over 35 years – Chest Pain? Yes/no If trauma – Severe bleeding? Yes/no 999 / 112 (if not already called

Appropriate Practitioner Registered Medical Practitioner Go to Maintain care Registered Nurse appropriate until handover Registered Advanced Paramedic CPG to appropriate Registered Paramedic Reference: ILCOR Guidelines 2010 Practitioner Registered EMT October 2014 16 Clinical Practice Guidelines

SECTION 2 PATIENT ASSESSMENT

2/3.2.4 Version 1, 05/08 Secondary Survey Medical – Adult FAR EFR 2/3.2.4 Version 1, 05/08 Secondary Survey Medical – Adult OFAFAR EFR Primary OFA Survey Primary Survey Record vital signs

Record vital signs Markers identifying acutely unwell Cardiac chest pain MarkersSystolic BP identifying < 90 mmHg acutely unwell Patient acutely Yes CardiacRespiratory chest rate pain < 10 or > 29 unwell AVPU = P or U on scale Systolic BP < 90 mmHg Patient acutely Acute pain > 5 Yes Respiratory rate < 10 or > 29 unwell AVPU = P or U on scale No Acute pain > 5 No Focused medical history of presenting Focusedcomplaint medical history of presenting complaint Go to Identify positive findings appropriate and initiate care SAMPLE history GoCPG to Identifymanagement positive findings appropriate and initiate care SAMPLE history CPG management Check for medications carried or medical Checkalert for jewellery medications carried or medical alert jewellery

Formulate RED card information Formulate RED card information 999 / 112

999 / 112 Maintain care until handover toMaintain appropriate care untilPractitioner handover to appropriate Practitioner Go to appropriate GoCPG to appropriate CPG

RED Card Information and sequence required by Ambulance Control Analogue Pain Scale when requesting an emergencyRED Card ambulance response: 0 = no pain……..10 = unbearable 1 Phone number you are calling from Information and sequence required by Ambulance Control Analogue Pain Scale 2 Location of incident when requesting an emergency ambulance response: 0 = no pain……..10 = unbearable 13 PhoneChief complaint number you are calling from 24 NumberLocation ofof patientsincident Appropriate Practitioner 35 AgeChief (approximate) complaint Registered Medical Practitioner 46 NumberGender of patients Registered Nurse 57 AgeConscious? (approximate) Yes/no Appropriate Practitioner Registered Advanced Paramedic 68 BreathingGender normally? Yes/no Registered Medical Practitioner Registered Paramedic 7 Conscious? Yes/no Registered Nurse Registered EMT 8If Breathingover 35 years normally? – Chest Pain? Yes/no Registered Advanced Paramedic If trauma – Severe bleeding? Yes/no Registered Paramedic If over 35 years – Chest Pain? Yes/no Registered EMT If trauma – Severe bleeding? Yes/no Reference: Bergeron, D, et al, 2001, First Responder 6th Edition, Brady Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps Reference: Bergeron, D, et al, 2001, First Responder 6th Edition, Brady Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps October 2014 17 Clinical Practice Guidelines

SECTION 2 PATIENT ASSESSMENT

2/3.2.5 Version 1, 05/08 Secondary Survey Trauma – Adult FAR EFR 2/3.2.5 Version 1, 05/08 Secondary Survey Trauma – Adult OFAFAR EFR Primary Survey OFA Primary Survey Follow Obvious minor organisational Yes injury protocolsFollow for Obvious minor organisationalminor injuries Yes injuryNo protocols for minor injuries No Examination of obvious injuries Examination of obvious injuries Record vital signs

Record vital signs Go to Identify positive findings SAMPLE history appropriate and initiate care GoCPG to Identifymanagement positive findings SAMPLE history appropriate and initiate care Complete a head to toe CPG management survey as history dictates Complete a head to toe survey as history dictates Check for medications carried or medical Checkalert for jewellery medications carried or medical alert jewellery Formulate RED card information Formulate RED card information 999 / 112

999 / 112 Maintain care until handover toMaintain appropriate care untilPractitioner handover to appropriate Practitioner

RED Card Information and sequence required by Ambulance Control when requesting an emergencyRED Card ambulance response: 1Information Phone number and yousequence are calling required from by Ambulance Control 2 Locationwhen requesting of incident an emergency ambulance response: 3 Chief complaint 1 Phone number you are calling from Appropriate Practitioner 4 Number of patients 2 Location of incident Registered Medical Practitioner 35 AgeChief (approximate) complaint AppropriateRegistered Nurse Practitioner 46 NumberGender of patients Registered MedicalAdvanced Practitioner Paramedic 57 AgeConscious? (approximate) Yes/no Registered NurseParamedic 68 BreathingGender normally? Yes/no Registered EMTAdvanced Paramedic 7 Conscious? Yes/no Registered Paramedic If8 Breathingover 35 years normally? – Chest Pain? Yes/no If trauma – Severe bleeding? Yes/no Registered EMT If over 35 years – Chest Pain? Yes/no If trauma – Severe bleeding? Yes/no

Reference: Bergeron, D, et al, 2001, First Responder 6th Edition, Brady Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps Reference: Bergeron, D, et al, 2001, First Responder 6th Edition, Brady Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps October 2014 18 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES

1/3.3.1T Version 2, 07/13 Advanced Airway Management – Adult CFR - A EFR BTEC Adult Cardiac arrest

Able to Consider No ventilate FBAO

Yes

Go to Consider option BLS-Adult No of advanced CPG airway

Yes

Equipment list

Supraglottic Airway Non-inflatable supraglottic airway Minimum interruptions of insertion chest compressions.

Maximum hands off time 10 seconds. Successful Yes

No

2nd attempt Supraglottic Airway insertion

Maintain adequate ventilation and Successful Yes oxygenation throughout procedures No

Check supraglottic airway Revert to basic airway placement after each patient management movement or if any patient deterioration

Following successful Advanced Airway management:- i) Ventilate at 8 to 10 per minute. Continue ventilation and oxygenation ii) Unsynchronised chest compressions continuous at 100 to 120 per minute

Go to appropriate CPG

Reference: ILCOR Guidelines 2010

October 2014 19 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES

2/3.3.2 Version 2, 05/14 Abnormal Work of Breathing – Adult FAR EFR

Respiratory OFA difficulties 999 / 112

EFR Consider SpO2

Oxygen therapy 100% O2 initially to patients with abnormal WoB, airway difficulties, cyanosis or ALoC or SPO2 < 94% Position patient

Airway Yes compromised

No Go to BLS CPG

Respiratory rate < 10 with Yes cyanosis or ALoC

No

Respiratory assessment

Cough Audible Wheeze Other

History of Fever/ chills Consider , cardiac/ Check cardiac history Known Signs of neurological/ systemic No No asthma Allergy illness, pain or psychological upset Yes Yes

FAR Go to Anaphylaxis CPG

Go to Asthma CPG

Maintain care until handover to appropriate Practitioner

October 2014 20 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES

3.3.4 Version 1, 11/13 Asthma – Adult EFR

Wheeze/ 999 / 112 bronchospasm

History of No All asthma incidents are treated as Asthma an emergency until proven otherwise

Yes

Prescribed Salbutamol No previously

Yes

Assist patient to administer own inhailer Salbutamol, 2 puffs, (0.2 mg) metered aerosol

Repeat up to 5 times if no improvement Reassess

Oxygen therapy

Maintain care until handover to appropriate Practitioner

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management of Asthma, a national clinical guideline

October 2014 21 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.1 Version 3, 06/11 Basic Life Support – Adult CFR FAR

EFR OFA

Collapse

999 / 112 Responsive Yes Patient

No

Shout for help Request AED

Open Airway Not breathing normally? i.e. only gasping Minimum interruptions of chest compressions.

999 / 112 Maximum hands off time 10 seconds.

Commence chest Compressions CFR-A Suction Continue CPR (30:2) until AED is attached or patient Chest compressions OPA EFR starts to move Rate: 100 to 120/ min CFR-A Oxygen therapy Depth: at least 5 cm

Ventilations Rate: 10/ min Apply AED pads Volume: 500 to 600 mL

AED Assesses Rhythm

CFR-A Shock advised No Shock advised Consider insertion Continue of non-inflatable CPR while supraglottic airway, AED is however do not Give 1 charging delay 1st shock or shock stop CPR Breathing normally?

Immediately resume CPR Immediately resume CPR 30 compressions: 2 breaths 30 compressions: 2 breaths x 2 minutes (5 cycles) x 2 minutes (5 cycles)

Go to Post Resuscitation Care CPG

Continue CPR until an If an Implantable Cardioverter appropriate Practitioner Defibrillator (ICD) is fitted in takes over or patient starts the patient treat as per CPG. to move It is safe to touch a patient If unable to ventilate perform with an ICD fitted even if it is compression only CPR firing.

Reference: ILCOR Guidelines 2010

October 2014 22 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.2 Version 3, 03/11 Foreign Body Airway Obstruction – Adult CFR FAR EFR OFA

Are you FBAO choking?

Severe FBAO Mild (ineffective cough) Severity (effective cough)

No Conscious Yes Encourage cough

1 to 5 back blows

No Effective Yes

1 to 5 abdominal thrusts (or chest thrusts for obese or pregnant patients)

No Effective Yes

If patient becomes unresponsive

Open Airway

999 / 112

One cycle of CPR

Effective Yes

No CFR-A Consider Oxygen therapy Go to BLS Adult After each cycle of CPR open CPG mouth and look for object. If visible attempt once to remove it 999 / 112

Maintain care until handover to appropiate Practitioner

ILCOR Guidelines 2010: Chest thrusts, back blows, or abdominal thrusts are effective for relieving FBAO in conscious adults and children > 1 year of age

October 2014 23 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.7 Version 3, 03/11 Post-Resuscitation Care CFR FAR

EFR OFA

Return normal spontaneous If registered healthcare professional, breathing and pulse oximetry available, titrate oxygen to maintain SpO2; CFR-A Maintain Adult: 94% to 98% Oxygen therapy Paediatric: 96% to 98%

999 / 112 if not already contacted

Conscious Yes

No

Recovery position (if no trauma)

Maintain patient at rest

OFA Monitor vital signs

Maintain care until handover to appropriate Practitioner

Special Authorisation: CFR-As, linked to EMS, may be authorised to For active cooling place actively cool unresponsive patients following return cold packs in arm pits, of spontaneous circulation (ROSC) groin & abdomen

Reference: ILCOR Guidelines 2010

October 2014 24 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.9 Version 2, 05/08 Recognition of Death – Resuscitation not Indicated CFR FAR

EFR OFA

Apparent dead body

Go to BLS Signs of Life Yes CPG

No

Definitive indicators of No Death

Yes Definitive indicators of death: 1. Decomposition 2. Obvious rigor mortis 3. Obvious pooling (hypostasis) 4. Incineration It is inappropriate to 5. Decapitation commence resuscitation 6. Injuries totally incompatible with life

999 / 112 Inform Ambulance Control

Complete all appropriate documentation

Await arrival of appropriate Practitioner and / or Gardaí

October 2014 25 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.10 CFR FAR Version 2, 03/11 Cardiac Chest Pain – Acute Coronary Syndrome

EFR OFA

Cardiac chest pain

999 / 112 if not already contacted

CFR-A If registered healthcare professional, Oxygen therapy and pulse oximetry available, titrate oxygen to maintain SpO2; Adult: 94% to 98%

Aspirin, 300 mg PO

Chest pain Yes ongoing

Patient No prescribed No GTN

Yes

Assist patient to administer GTN 0.4 mg SL

Monitor vital signs

Maintain care until handover to appropiate Practitioner

Reference: ILCOR Guidelines 2010 October 2014 26 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.14 Version 1, 05/08 Altered Level of Consciousness – Adult FAR EFR

OFA

V, P or U on AVPU scale 999 / 112

Maintain airway

Trauma Yes

No Consider Cervical Spine

Airway No maintained

Yes Recovery Position

Complete a FAST assessment

Obtain SAMPLE history from patient, relative or bystander

Check for medications carried or medical alert jewellery

Maintain care until handover to appropriate Practitioner

F – facial weakness Can the patient smile?, Has their mouth or eye drooped? A – arm weakness Can the patient raise both arms? S – speech problems Can the patient speak clearly and understand what you say? T – time to call 999 / 112 (if positive FAST)

October 2014 27 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.15 FAR EFR Version 1, 12/11 Anaphylaxis – Adult OFA Anaphylaxis Anaphylaxis is a life-threatening Patient’s name condition identified by the 999/ 112 following criteria: Responder’s name • Sudden onset and rapid progression of symptoms Doctor’s name • Difficulty breathing Oxygen therapy • Diminished consciousness • Red, blotchy skin

Collapsed No Yes state Place in semi- Lie flat with recumbent position legs raised

Breathing No Yes difficulty Patient prescribed Yes Epinephrine auto injection

Assist patient to administer own Epinephrine (1:1 000) 300 mcg IM No Patient Auto injection Yes prescribed Salbutamol Assist patient to administer No Salbutamol 2 puffs (0.2 mg) metered aerosol

Reassess

Monitor vital signs

Maintain care until handover to • Exposure to a known allergen for appropriate the patient reinforces the diagnosis Practitioner of anaphylaxis Be aware that: • Skin or mouth/ tongue changes alone are not a sign of an anaphylactic reaction • There may also be vomiting, abdominal pain or incontinence

Special Authorisation: Special Authorisation: Responders who have received training Responders who have received training and are authorised by a Medical and are authorised by a Medical Practitioner for a named patient may Practitioner for a named patient may administer Salbutamol via an aerosol administer Epinephrine via an auto measured dose. injector.

Reference: Immunisation Guidelines for Ireland 2008 RCPI, ILCOR Guidelines 2010 October 2014 28 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

3.4.16 Version 1, 05/08 Decompression Illness (DCI) EFR

SCUBA diving within 48 hours Complete primary survey (Commence CPR if appropriate) Consider diving buddy as possible patient also Treat in supine position

Oxygen therapy

100% O2

Ensure Ambulance Control is notified 999 / 112

Conscious No

Maintain airway Yes

Maintain care until handover to appropiate Practitioner

Transport dive computer Transport is completed at and diving equipment an altitude of < 300 metres with patient, if possible above incident site or aircraft pressurised equivalent to sea level

Reference: The Primary Clinical Care Manual 3rd Edition, 2003, Queensland Health and the Royal Flying Doctor Service (Queensland Section)

October 2014 29 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.18 Version 1, 02/14 Fainting FAR EFR

Apparent OFA faint Check Airway and Breathing (A & B)

Call 999 / 112

A or B issue Go to BLS Yes identified CPG

No

Check for obvious injuries (Primary survey)

Go to Haemorrhage Yes Haemorrhage identified CPG

No

Ensure patient is lying down

Elevate lower limbs (higher than body)

Prevent chilling

Monitor vital signs

Encourage patient to gradually return to sitting position

Go to Check for underlying medical If yes appropriate conditions CPG

Maintain care until handover to appropriate Practitioner

Advise patient to attend a medical practitioner regardless of how simple the faint may appear

Schoenwetter, David J. Fainting/ Syncope, Emergency Medicine

October 2014 30 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.19 FAR EFR Version2/3.4.19 1, 05/08 Glycaemic Emergency – Adult Version 1, 05/08 Glycaemic Emergency – Adult FAR EFR OFA OFA Known diabetic with confusionKnown ordiabetic altered with levels confusionof consciousness or altered levels of consciousness 999 / 112 999 / 112

A or V on No AVPUA or V scale on No AVPU scale Yes Yes

Sweetened drink Recovery position SweetenedOr drink Recovery position Or Glucose gel, 10-20 g buccal Glucose gel, 10-20 g buccal

Allow 5 minutes to elapse following administrationAllow 5 minutes of tosweetened elapse following drink or administrationGlucose of sweetened gel drink or Glucose gel

Reassess Reassess

Improvement No Improvementin condition No in condition Yes Yes

Maintain careMaintain until handovercare until to handoverappropriate to Practitionerappropriate Practitioner

Reference: Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps Reference: Mohun J, 2003, First Aid Manual 8th Edition, Irish Red Cross & Order of Malta Ambulance Corps October 2014 31 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.20 Version 1, 02/12 Heat-Related Illnesses FAR EFR 2/3.4.20 Version 1, 02/12 Heat-Related Illnesses OFAFAR EFR

Collapse from heat- OFA related condition Collapse from heat- related condition Remove/ protect from hot 999 / 112 environment (providingRemove/ itprotect is safe from to do hot so) 999 / 112 environment (providing it is safe to do so)

Yes Conscious No

Yes Conscious No Exercise-related dehydration should be treated with oral fluids. Give cool fluids to Recovery position Exercise-related(caution with over dehydration hydration with drink (maintain airway) shouldwater) be treated with oral fluids. Give cool fluids to Recovery position (caution with over hydration with drink (maintain airway) water)

Cooling may be achieved by: Cool patient Removing clothing CoolingFanning may be achieved by: Cool patient RemovingTepid sponging clothing Fanning Tepid sponging

Monitor vital signs

Monitor vital signs

Maintain care until handoverMaintain to appropriatecare until handoverPractitioner to appropriate Practitioner

Reference: ILCOR Guidelines 2010 RFDS, 2009, Primary Clinical Care Manual Reference: ILCOR Guidelines 2010 RFDS, 2009, Primary Clinical Care Manual October 2014 32 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

3.4.21 EFR Version 2, 05/14 Hypothermia FAR 3.4.21 EFR Version 2, 05/14 Hypothermia OFAFAR

Query OFA hypothermia Query hypothermia Immersion Yes

Remove patient horizontally from liquid Members of rescue teams ImmersionNo Yes should have a clinical (Provided it is safe to do so) leader of at least EFR level Remove patient horizontally from liquid Members of rescue teams No should have a clinical (Provided it is safe to do so) leader of at least EFR level Protect patient from wind chill

Protect patient from wind chill Pulse check for Complete primary survey 30 to 45 seconds (Commence CPR if appropriate) Pulse check for Hypothermic patients Complete primary survey 30 to 45 seconds should be handled gently (Commence CPR if appropriate) Hypothermic& not permitted patients to walk should be handled gently Ensure Ambulance control is & not permitted to walk informed 999 / 112 Ensure Ambulance control is informed 999 / 112

Remove wet clothing by cutting

Remove wet clothing by cutting Place patient in dry blankets/ sleeping bag with outer layer of insulation Place patient in dry blankets/ sleeping bag with outer layer of insulation

Yes Alert and able to swallow

Yes Alert and able Give hot sweet to swallowNo drinks Give hot sweet No drinks

If Cardiac Arrest follow CPGs but - no active re-warming If Cardiac Arrest follow CPGs but - no active re-warming EFR Hot packs to armpits & groin EFR Hot packs to armpits & groin Equipment list Maintain Survival bag Equipment list care until Transport in head down position Space blanket Helicopter: head forward handoverMaintain to Hot pack Boat: head aft Survival bag appropiatecare until Transport in head down position Space blanket handoverPractitioner to Helicopter: head forward Hot pack appropiate Boat: head aft Practitioner

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics AHA, 2005, Part 10.4: Hypothermia, Circulation 2005:112;136-138 Reference: Golden,Soar, J etF &al, Tipton 2005, M,European 2002, Es Resuscitationsentials of Sea Council Survival, Guidelines Human foKineticsr Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, ResuscitationAHA, 2005, Part (2005) 10.4: 6751, Hypothermia, S135-S170 Circulation 2005:112;136-138 PenningtonSoar, J et al, M, 2005, et al, European 1994, Wilderness Resuscitation EMT, Council Wilderness Guidelines EMS Institute for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170 Pennington M, et al, 1994, Wilderness EMT, Wilderness EMS Institute October 2014 33 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.22 Version 1, 12/11 Poisons FAR EFR OFA Poisoning

Scene safety is paramount 999/ 112

Poison source

Inhalation, ingestion or injection Absorption

No Site burns Yes

Cleanse/ clear/ For decontamination decontaminate follow local protocol

Consider Always be No A on AVPU Oxygen therapy cognisant of Airway, Recovery Yes Breathing Position and Circulation issues following poison Monitor vital signs

Maintain poison source package for inspection by EMS

Maintain care until handover to appropriate Practitioner

If suspected tablet overdose locate tablet container and hand it over to appropriate practitioner

Reference: ILCOR Guidelines 2010

October 2014 34 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

2/3.4.23 Version 2, 07/11 Seizure/Convulsion – Adult FAR EFR

OFA

Seizure / convulsion

Consider other causes Protect from harm of seizures Meningitis Head injury 999 / 112 Hypoglycaemia Eclampsia Fever Poisons Alcohol/drug withdrawal Oxygen therapy

Seizing currently Seizure status Post seizure

Support head Alert Yes

No

Recovery position

Airway management

Reassess

Maintain care until handover to appropriate Practitioner

October 2014 35 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

1/2/3.4.28 Version 2, 03/11 Stroke CFR FAR

EFR OFA

Acute neurological symptoms

Complete a FAST assessment

999 or 112

Maintain airway

If registered healthcare professional, CFR-A Oxygen therapy and pulse oximetry available, titrate oxygen to maintain SpO2; Adult: 94% to 98% Maintain care until handover to appropriate Practitioner

F – facial weakness Can the patient smile?, Has their mouth or eye drooped? Which side? A – arm weakness Can the patient raise both arms and maintain for 5 seconds? S – speech problems Can the patient speak clearly and understand what you say? T – time to call 999 / 112 now if FAST positive

Reference: ILCOR Guidelines 2010

October 2014 36 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

3.5.1 Version 1, 05/08 Pre-Hospital Emergency Childbirth EFR

Query labour

999 or 112

Take SAMPLE history

Patient in No labour

Yes

Position mother

Monitor vital signs

Birth Complications Yes

No

Support baby throughout delivery

Dry baby and check ABCs

Go to BLS Baby Paediatric No stable CPG Yes

Wrap baby to maintain temperature

Go to Primary No Mother Survey stable CPG Yes

If placenta delivers, retain for inspection

Maintain Reassess care until handover to appropriate Practitioner

October 2014 37 Clinical Practice Guidelines

SECTION 6 TRAUMA

2/3.6.1 Version 2, 10/11 Burns FAR EFR

OFA Burn or Cease contact with heat source Scald

F: face H: hands F: feet F: flexion points Isolated P: perineum Yes superficial injury No 999 / 112 (excluding FHFFP)

Inhalation and or Yes facial injury

No Minimum 15 minutes cooling Airway management of area is recommended. Caution with hypothermia Go to Abnormal Respiratory Yes work of distress breathing CPG No

Caution - blisters Consider humidified should be left intact Oxygen therapy

Commence local Brush off powder & irrigate Commence local cooling of burn area chemical burns cooling of burn area Follow local expert direction

Remove burnt clothing (unless stuck) & jewellery Dressing/ covering of burn area

Dressing/ covering of burn area

Pain > 2/10 Yes Equipment list Acceptable dressings No Burns gel (caution for > 10% TBSA) Cling film Sterile dressing Clean sheet Appropriate history and burn No area ≤ 1%

Yes Prevent chilling (monitor body temperature)

Ensure ambulance control Caution with the elderly, very young, has been notified circumferential & electrical burns

Maintain Follow care until organisational handover to protocols for appropriate minor injuries Practitioner

Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114 Sanders, M, 2001, Paramedic Textbook 2nd Edition, Mosby ILCOR Guidelines 2010 October 2014 38 Clinical Practice Guidelines

SECTION 6 TRAUMA

3.6.1T Version 3, 02/14 External Haemorrhage EFR 3.6.1T BTEC Version 3, 02/14 External Haemorrhage EFR Posture BTEC Open Elevation Active bleeding Yes wound ExaminationPosture Open ElevationPressure Active bleeding Yes wound No Examination Pressure No Catastrophic No Yes EFR haemorrhage Special Authorisation: Catastrophic No Yes EFRs having completed the haemorrhage Consider BTEC techniques EFR BTEC course may be Special Authorisation: Apply tourniquet Apply a dressing EFRsprivileged having by completed a licensed the service provider to apply a Considerif limb injury BTEC techniquesimpregnated with BTEC course may be haemostatic agent privilegedtourniquet byand/or a licensed use a Apply tourniquet Apply a dressing servicehaemostatic provider impregnated to apply a if limb injury impregnated with tourniquetdressing onand/or its behalf use a haemostatic agent haemostatic impregnated 999 / 112 dressing on its behalf Apply sterile dressing 999 / 112 Apply sterile dressing

Haemorrhage No controlled Haemorrhage No controlledYes Apply additional pressure dressing(s) Yes Apply additional pressure dressing(s)

Monitor vital signs

Monitor vital signs 999 / 112 Clinical signs Yes of shock 999 / 112 Clinical signs Yes of shockNo Prevent chilling and elevate lower limbs (if possible) No Prevent chilling and elevate lower limbs (if possible)

Consider Oxygen therapy Consider Oxygen therapy Equipment list

Sterile dressing (various sizes) Maintain Crepe bandage (variousEquipment sizes) list care until handover to SterileConforming dressing bandage (various (various sizes) sizes) Maintain Triangular bandage appropriatecare until Crepe bandage (various sizes) Practitioner ConformingDressing impregnated bandage (various with haemostatic sizes) agent handover to Triangular bandage appropriate Dressing impregnated with haemostatic agent Practitioner

Reference: ILCOR Guidelines 2010, Reference:Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037 ILCOR Guidelines 2010, Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037 October 2014 39 Clinical Practice Guidelines

SECTION 6 TRAUMA

2/3.6.4 Version 2, 05/14 Harness Induced Suspension Trauma OFA EFR 2/3.6.4 Version 2, 05/14 Harness Induced Suspension Trauma OFA EFR This CPG does not Fall arrested by authorise rescue This CPG does not harness/rope by untrained Fall arrested by authorise rescue personnel harness/rope by untrained Caution personnel Caution 999 / 112

999 / 112 Personal safety of the ResponderPersonal Patient still Consider removing a harness safetyis of the No paramount suspended suspended person from Responder Consider removing a harness is Patient still suspension in the direction of No Yes paramount suspended gravitysuspended i.e. downwards, person from so as suspension in the direction of Advise patientYes to move to avoid further negative If circulation is compromised legs (to encourage hydrostaticgravity i.e. downwards, force, however so as remove the harness when Adviseblood flow patient back to to move the thisto avoid measure further should negative not the patient is safely lowered If circulation is compromised legs (toheart) encourage otherwisehydrostatic delay force, rescue. however removeto the ground the harness when blood flow back to the this measure should not the patient is safely lowered Elevate heart)lower limbs if otherwise delay rescue. to the ground possible during rescue Elevate lower limbs if possible during rescue Place patient in a horizontal position as soon as practically Place patientpossible in a horizontal position as soon as practically possible Monitor vital signs

Monitor vital signs

Oxygen therapy

Oxygen therapy

Go to appropriate GoCPG to appropriate CPG

Patients must be transported to ED Patientsfollowing must suspension be transportedtrauma regardless to ED of followinginjury status suspension trauma regardless of Symptoms of pre-syncope injury status light-headedness nauseaSymptoms of pre-syncope sensationslight-headedness of flushing tinglingnausea or numbness of the arms or legs anxietysensations of flushing visualtingling disturbance or numbness of the arms or legs aanxiety feeling of about to faint visual disturbance a feeling of about to faint

Reference: Adish A et al, 2009, Evidence-based review of the current guidance on first aid measures for suspension trauma, Health and Safety Executive (UK) Research Reference:report RR708 AdishAustralian A et Resuscitational, 2009, Evidence-based Council, 2009, review Guideline of the 9.current1.5 Harness guidance Suspension on first aid Tr measuresauma first foraid suspemanagement.nsion trauma, Health and Safety Executive (UK) Research reportThomassen RR708 O et al, Does the horizontal position increase risk of rescue death following suspension trauma?, Emerg Med J 2009;26:896-898 doi:10.1136/ emj.2008.064931Australian Resuscitation Council, 2009, Guideline 9.1.5 Harness Suspension Trauma first aid management. Thomassen O et al, Does the horizontal position increase risk of rescue death following suspension trauma?, Emerg Med J 2009;26:896-898 doi:10.1136/ emj.2008.064931 October 2014 40 Clinical Practice Guidelines

SECTION 6 TRAUMA

2/3.6.6 Version 2, 05/14 Heat-Related Emergency FAR EFR 2/3.6.6 Version 2, 05/14 Heat-Related Emergency OFAFAR EFR Collapse from heat- related condition OFA Collapse from heat- related condition Remove/ protect from hot 999 / 112 environment (providing it is safe to do so) Remove/ protect from hot 999 / 112 environment (providing it is safe to do so) Alert Yes and able to No swallow Alert Yes Exercise-related dehydration and able to No should be treated with oral fluids. Give cool fluids to swallow Recovery position (caution with over hydration with drink (maintain airway) Exercise-related dehydration water) should be treated with oral fluids. Give cool fluids to Recovery position (caution with over hydration with drink (maintain airway) water)

Cooling may be achieved by: Cool patient Removing clothing Fanning Cooling may be achieved by: Tepid sponging Cool patient Removing clothing Fanning Tepid sponging

Monitor vital signs

Monitor vital signs

Maintain care until handover to Maintain appropriate care until Practitioner handover to appropriate Practitioner

Reference: ILCOR Guidelines 2010 RFDS, 2009, Primary Clinical Care Manual Reference: ILCOR Guidelines 2010 RFDS, 2009, Primary Clinical Care Manual October 2014 41 Clinical Practice Guidelines

SECTION 6 TRAUMA

3.6.7T Version 3, 02/14 Limb Injury EFR BTEC Limb injury

Expose and examine limb

Equipment list

Dressings Dress open wounds Triangular bandages Splinting devices Compression bandages Ice packs Go to Pelvic splinting device Haemorrhage No Haemorrhage controlled Control CPG

Yes

Provide manual stabilisation for injured limb

EFR Check CSMs distal to injury site

Injury type

999 / 112 Fracture Soft tissue injury Dislocation

Rest Apply appropriate Splint/support Ice splinting device in position Compression /sling found Elevation

EFR Recheck CSMs

Maintain care until handover to appropriate Practitioner

EFR Special Authorisation: EFRs having completed the BTEC course may be privileged by a licensed service provider to apply a pelvic splinting device on its behalf

October 2014 42 Clinical Practice Guidelines

SECTION 6 TRAUMA

2/3.6.9 Version 1, 05/08 Spinal Immobilisation – Adult FAR EFR

OFA

Trauma Indications for spinal If in doubt, immobilisation Do not forcibly restrain a patient that is combative treat as spinal injury

999 / 112

Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms Neurological symptoms Reduction in feeling in an area Equipment list Reduction in movement in a limb Pins and needles Rigid cervical collar Stabilise cervical spine Paralysis

EFR Remove helmet (if worn)

EFR Apply cervical collar

Maintain care until handover to appropriate Practitioner

EFR

Special Authorisation: EFRs may extricate a patient on a long board in the absence of a Practitioner if; 1 an unstable environment prohibits the attendance of a Practitioner, or 2 while awaiting the arrival of a Practitioner the patient requires rapid extrication to initiate emergency care

October 2014 43 Clinical Practice Guidelines

SECTION 6 TRAUMA

1/2/3.6.10 Version 2, 05/08 Submersion Incident CFR OFA 1/2/3.6.10 Submersion Incident CFR OFA Version 2, 05/08 Submerged EFR in liquid Submerged EFR in liquid Spinal injury indicators History of; Remove patient from liquid Ensure Ambulance Control is informed 999 / 112 Spinal- diving injury indicators (Provided it is safe to do so) History- trauma of; Remove patient from liquid Ensure Ambulance Control is - waterdiving slide use (Provided it is safe to do so) informed 999 / 112 - traumaalcohol intoxication - water slide use Remove horizontally if possible - alcohol intoxication (consider C-spine injury) Request AED Ventilations may be Remove horizontally if possible Request commenced while the (consider C-spine injury) AED Ventilationspatient is still may in water be commencedby trained rescuers while the patient is still in water by trained rescuers Unresponsive Go to BLS Yes & not breathing CPG Unresponsive Go to BLS Yes & not breathing CPG No

No Oxygen therapy Higher pressure may be required for ventilation because of poor Oxygen therapy Higher pressure may be Monitor requiredcompliance for resultingventilation from Respirations becausepulmonary of oedemapoor & Pulse compliance resulting from OFA Monitor Respirations pulmonary oedema & Pulse OFA Go to Patient is Yes Hypothermia hypothermic GoCPG to Patient is Yes Hypothermia hypothermic No CPG

No Maintain care until handoverMaintain to appropriatecare until handoverPractitioner to appropriate Practitioner

Transportation to Emergency Department is required for investigationTransportation ofto secondary Emergency drowningDepartment insult is required for investigation of secondary drowning insult

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics Verie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htm Reference: Golden,Shepherd, F & S, Tipton 2005, M, Submersion 2002, Essentials Injury, Nearof Sea Drowni Survival,ng, EHuman Medicine, Kinetics www.emedicine.com/emerg/topic744.htm Verie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htm Shepherd, S, 2005, Submersion Injury, Near Drowning, E Medicine, www.emedicine.com/emerg/topic744.htm October 2014 44 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

3.7.3 Version 3, 12/13 Primary Survey – Paediatric (≤ 15 years) EFR

Trauma Take standard infection control precautions

Consider pre-arrival information

Scene safety Scene survey Scene situation

Control catastrophic external haemorrhage

Mechanism of C-spine injury suggestive Yes No control of spinal injury

Assess responsiveness

Suction, Head tilt/chin lift, No Airway patent Yes Maintain OPA Jaw thrust

Go to Airway FBAO Yes No obstructed CPG

Normal rates Go to BLS Age Pulse Respirations Infant 100 – 160 30 – 60 Paediatric No Breathing Toddler 90 – 150 24 – 40 CPG Pre school 80 – 140 22 – 34 Yes School age 70 – 120 18 – 30

Consider Oxygen therapy RED Card Information and sequence required by Ambulance Control when requesting an emergency ambulance response: 1 Phone number you are calling from Formulate RED card 2 Location of incident information 3 Chief complaint 4 Number of patients 999 / 112 5 Age (approximate) 6 Gender 7 Conscious? Yes/no 8 Breathing normally? Yes/no Consider expose & examine If over 35 years – Chest Pain? Yes/no If trauma – Severe bleeding? Yes/no Pulse, Respiration & AVPU assessment

Appropriate Practitioner Maintain Registered Medical Practitioner care until Go to Registered Nurse handover to appropriate Registered Advanced Paramedic appropiate CPG Registered Paramedic Practitioner Registered EMT

Reference: ILCOR Guidelines 2010, American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals

October 2014 45 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

2/3.7.11 Version 2, 05/14 Abnormal Work of Breathing – Paediatric (≤ 15 years) FAR EFR

Respiratory OFA difficulties 999 / 112

EFR Consider SpO2

Oxygen therapy 100% O2 initially to patients with abnormal WoB, airway difficulties, cyanosis or ALoC or SPO2 < 96% Position patient

Airway Yes compromised

No Go to BLS CPG

Respiratory rate < 10 with Yes cyanosis or ALoC

No

Respiratory assessment

Cough Audible Wheeze Other

History of Fever/ chills Consider shock, cardiac/ Check cardiac history Known Signs of neurological/ systemic No No asthma Allergy illness, pain or psychological upset Yes Yes

Go to FAR Anaphylaxis CPG

Go to Asthma CPG

Maintain care until handover to appropriate Practitioner

October 2014 46 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

3.7.12 Version 1, 11/13 Asthma – Paediatric (≤ 15 years) EFR

Wheeze/ 999 / 112 bronchospasm

History of No All asthma incidents are treated as Asthma an emergency until shown otherwise

Yes

Prescribed Salbutamol No previously

Yes

Assist patient to administer own inhailer Salbutamol, 2 puffs, If no improvement repeat; (0.2 mg) metered aerosol for ≤ 6 year olds up to 3 times, for > 6 year olds up to 5 times, as required

Reassess

Oxygen therapy

Maintain care until handover to appropriate Practitioner

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management of Asthma, a national clinical guideline

October 2014 47 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

1/2/3.7.20 Version 5, 12/13 Basic Life Support – Paediatric (≤ 15 Years) CFR FAR

EFR OFA

Collapse

999 / 112 Responsive Yes Patient

No

Shout for help Request AED

Open Airway Not breathing normally i.e. only gasping

Chest compressions CFR-A Suction Rate: 100 to 120/ min Commence chest Compressions 1 OPA Depth: /3 depth of chest EFR Continue CPR (30:2) for approximately 2 minutes Child; two hands CFR-A Oxygen therapy Small child; one hand Infant (< 1); two fingers

999 / 112

For < 8 years use paediatric Apply AED pads defibrillation system (if not available use adult pads)

AED Assesses Rhythm

Continue CPR while Shock advised No Shock advised AED is charging

Give 1 Minimum shock Breathing normally? interruptions of chest Immediately resume CPR Immediately resume CPR compressions. 30 compressions: 2 breaths 30 compressions: 2 breaths x 2 minutes (5 cycles) x 2 minutes (5 cycles) Maximum hands Go to Post off time 10 Resuscitation seconds. Care CPG Continue CPR until an appropriate Practitioner takes over or patient starts to move If unable to ventilate perform compression only CPR Infant AED It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior (front) and posterior (back), because of the infant’s small size. Reference: ILCOR Guidelines 2010 October 2014 48 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

1/2/3.7.21 FAR Version 4, 12/13 Foreign Body Airway Obstruction – Paediatric (≤ 15 years) CFR

EFR OFA

Are you FBAO choking?

Severe FBAO Mild (ineffective cough) Severity (effective cough)

No Conscious Yes

Encourage cough

1 to 5 back blows

No Effective Yes

1 to 5 thrusts (child – abdominal thrusts) (infant – chest thrusts)

No Effective Yes

If patient becomes unresponsive

Open Airway

999 / 112

one cycle of CPR

Effective Yes

CFR-A No Consider Oxygen therapy Go to BLS Paediatric CPG 999 /112

Maintain care until After each cycle of CPR open handover to mouth and look for object. appropiate If visible attempt once to remove it Practitioner

ILCOR Guidelines 2010: Chest thrusts, back blows, or abdominal thrusts are effective for relieving FBAO in conscious adults and children > 1 year of age

October 2014 49 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

2/3.7.31 FAR EFR Version 2, 12/13 Anaphylaxis – Paediatric (≤ 15 years) OFA Anaphylaxis

Patient’s name 999/ 112 Anaphylaxis is a life threatening condition identified by the Responder’s name following criteria: Doctor’s name • Sudden onset and rapid progression of symptoms Oxygen therapy • Difficulty breathing • Diminished consciousness • Red, blotchy skin

Collapsed No Yes state Place in semi- Lie flat with recumbent position legs raised

Breathing No Yes Patient prescribed difficulty Yes Epinephrine auto injection

Assist patient to administer own Epinephrine (1: 1 000) IM No Patient 6 mts to < 10 yrs 0.15 mg (auto injector) Yes prescribed ≥ 10 yrs 0.3 mg (auto injector) Salbutamol Assist patient to administer No Salbutamol 2 puffs (0.2 mg) metered aerosol

Reassess

Monitor vital signs

Maintain care until handover to appropriate • Exposure to a known allergen for Practitioner the patient reinforces the diagnosis of anaphylaxis Be aware that: • Skin or mouth/ tongue changes alone are not a sign of an anaphylactic reaction • There may also be vomiting, abdominal pain or incontinence

Special Authorisation: Special Authorisation: Responders who have received training Responders who have received training and are authorised by a Medical and are authorised by a Medical Practitioner for a named patient may Practitioner for a named patient may administer Salbutamol via an aerosol administer Epinephrine via an auto measured dose. injector.

Reference: Immunisation Guidelines for Ireland 2008 RCPI, ILCOR Guidelines 2010 October 2014 50 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

2/3.7.33 Version 3, 12/13 Seizure/Convulsion – Paediatric (≤ 15 years) FAR EFR OFA

Seizure / convulsion

Consider other causes of seizures Protect from harm Meningitis Head injury Hypoglycaemia 999 / 112 Fever Poisons Alcohol/drug withdrawal

Oxygen therapy

Seizing currently Seizure status Post seizure

Support head Alert Yes

No

Recovery position

Airway management

If pyrexial – cool child

Reassess

Maintain care until handover to appropriate Practitioner

October 2014 51 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

3.7.52 EFR Version 2, 12/13 Spinal Immobilisation – Paediatric (≤ 15 years)

Paediatric spinal injury indications include Trauma Pedestrian v auto Indications for spinal Passenger in high speed vehicle collision If in doubt, immobilisation Ejection from vehicle treat as Sports/ playground injuries Falls from a height spinal injury Axial load to head

999 / 112

Return head to neutral position unless on Do not forcibly restrain a movement there is Increase in patient that is combative Pain, Resistance or Neurological symptoms

Equipment list Rigid cervical collar

Note: equipment must be Neurological symptoms Stabilise cervical spine age appropriate Reduction in feeling in an area Reduction in movement in a limb Pins and needles Remove helmet Paralysis (if worn)

Apply cervical collar

Patient in undamaged No child seat

Yes

Immobilise in child seat

Maintain care until handover to appropriate Practitioner

EFR

Special Authorisation: EFRs may extricate a patient on a long board in the absence of a Practitioner if; 1 an unstable environment prohibits the attendance of a Practitioner, or 2 while awaiting the arrival of a Practitioner the patient requires rapid extrication to initiate emergency care

References; Viccellio, P, et al, 2001, A Prospective Multicentre Study of Cervical Spine Injury in Children, Pediatrics vol 108, e20 Slack, S. & Clancy, M, 2004, Clearing the cervical spine of paediatric trauma patients, EMJ 21; 189-193

October 2014 52 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

The medication formulary is published by the Pre-Hospital Emergency Care Council (PHECC) to support Emergency First Responder - BTEC to be competent in the use of medications permitted under Clinical Practice Guidelines (CPGs).

The Medication Formulary is recommended by the Medical Advisory Committee (MAC) prior to publication by Council.

The medications herein may be administered provided:

1 The Emergency First Responder - BTEC complies with the CPGs published by PHECC. 2 The Emergency First Responder is acting on behalf of an organisation (paid or voluntary) that is a PHECC licensed CPG provider. 3 The Emergency First Responder - BTEC is privileged, by the organisation on whose behalf he/she is acting, to administer the medications. 4 The Emergency First Responder - BTEC has received training on, and is competent in, the administration of the medication.

The context for administration of the medications listed here is outlined in the CPGs. Every effort has been made to ensure accuracy of the medication doses herein. The dose specified on the relevant CPG shall be the definitive dose in relation to Emergency First Responder - BTEC administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the Emergency First Responder - BTEC to ensure that he/she is using the latest versions of CPGs which are available on the PHECC website www.phecc.ie

All medication doses for patients ≤ 15 years shall be calculated on a weight basis unless an age-related dose is specified for that medication.

The route of administration should be appropriate to the patients clinical presentation. IO access is authorised for Advanced Paramedics for life threatening emergencies (or under medical direction).

The dose for paediatric patients may never exceed the adult dose.

Paediatric weight estimations acceptable to PHECC are:

Neonate 3.5 Kg

Six months 6 Kg

One to five years (age x 2) + 8 Kg

Greater than 5 years (age x 3) + 7 Kg

Reviewed on behalf of PHECC by Prof Peter Weedle, Adjunct Professor of Clinical Pharmacy, School of Pharmacy, University College Cork.

This edition contains 6 medications for Emergency First Responder - BTEC.

October 2014 53 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL: Amendments to the 2012 Edition

The paediatric age range has been increased to reflect the HSE National Clinical Programme for Paediatrics and Neonatology age profile:

A paediatric patient is defined as a patient up to the eve of his/her 16th birthday (≤ 15 years).

Oxygen HEADING ADD DELETE

Contraindications Paraquat poisoning

Indications Sickle Cell Disease - 100%

Additional Information Caution with paraquat poisoning, administer oxygen if SpO2 < 92%

Please visit www.phecc.ie for the latest edition/version.

October 2014 54 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY (Adult ≥ 16 and Paediatric ≤ 15 unless otherwise stated) CLINICAL LEVEL:

LIST OF MEDICATIONS

Aspirin ...... 56 Epinephrine (1:1000) ...... 57 Glucose gel ...... 58 Glyceryl Trinitrate (GTN) ...... 59 Oxygen ...... 60 Salbutamol ...... 61

October 2014 55 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Aspirin

Class Platelet aggregation inhibitor.

Descriptions Anti-inflammatory agent and an inhibitor of platelet function. Useful agent in the treatment of various thromboembolic diseases such as acute myocardial infarction.

Presentation 300 mg dispersible tablet.

Administration Orally (PO) - dispersed in water, or to be chewed - if not dispersible form. (CPG: 5/6.4.10, 4.4.10, 1/2/3.4.10).

Indications Cardiac chest pain or suspected Myocardial Infarction.

Contraindications Active symptomatic gastrointestinal (GI) ulcer. Bleeding disorder (e.g. haemophilia). Known severe adverse reaction. Patients < 16 years old.

Usual Dosages Adult: 300 mg tablet.

Paediatric: Contraindicated.

Pharmacology/Action Antithrombotic Inhibits the formation of thromboxane A2, which stimulates platelet aggregation and artery constriction. This reduces clot/thrombus formation in an MI.

Side effects Epigastric pain and discomfort. Bronchospasm. Gastrointestinal haemorrhage.

Long-term effects Generally mild and infrequent but incidence of gastro-intestinal irritation with slight asymptomatic blood loss, increased bleeding time, bronchospasm and skin reaction in hypersensitive patients.

Additional information Aspirin 300 mg is indicated for cardiac chest pain regardless if patient is on anticoagulants or is already on aspirin.

If the patient has swallowed an aspirin (enteric coated) preparation without chewing it, the patient should be regarded as not having taken any aspirin; administer 300 mg PO.

October 2014 56 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Epinephrine (1:1,000)

Class Sympathetic agonist

Description Naturally occurring catecholamine. It is a potent alpha and beta adrenergic stimulant; however, its effect on beta receptors is more profound.

Presentation Pre-filled syringe, ampoule or Auto injector (for EMT use) 1 mg/1 mL (1:1,000)

Administration Intramuscular (IM) (CPG: 5/6.4.15, 4.4.15, 2/3.4.16, 5/6.7.31, 4.7.31, 2/3.7.31)

Indications Severe anaphylaxis

Contraindications None known

Usual Dosages Adult: 0.5 mg (500 mcg) IM (0.5 mL of 1: 1,000) EMT & (EFR assist patient) 0.3 mg (Auto injector) Repeat every 5 minutes prn

Paediatric: < 6 months: 0.05 mg (50 mcg) IM (0.05 mL of 1:1 000) 6 months to 5 years: 0.125 mg (125 mcg) IM (0.13 mL of 1:1 000) 6 to 8 years: 0.25 mg (250 mcg) IM (0.25 mL of 1:1 000) > 8 years: 0.5 mg (500 mcg) IM (0.5 mL of 1:1 000) EMT & (EFR assist patient): 6 months < 10 years: 0.15 mg (Auto injector) ≥ 10 years: 0.3 mg (Auto injector) Repeat every 5 minutes prn

Pharmacology/Action Alpha and beta adrenergic stimulant Reversal of laryngeal oedema & bronchospasm in anaphylaxis Antagonises the effects of histamine

Side effects Palpitations Tachyarrhythmias Hypertension Angina-like symptoms

Additional information N.B. Double check the concentration on pack before use

October 2014 57 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Glucose gel

Class Antihypoglycaemic.

Description Synthetic glucose paste.

Presentation Glucose gel in a tube or sachet.

Administration Buccal administration: Administer gel to the inside of the patient’s cheek and gently massage the outside of the cheek. (CPG: 5/6.4.19, 4.4.19, 2/3.4.19, 5/6.7.32, 4.7.32)

Indications Hypoglycaemia. Blood glucose < 4 mmol/L. EFR – Known diabetic with confusion or altered levels of consciousness.

Contraindications Known severe adverse reaction.

Usual Dosages Adult: 10 – 20 g buccal. Repeat prn.

Paediatric: ≤ 8 years; 5 – 10 g buccal. > 8 years: 10 – 20 g buccal. Repeat prn.

Pharmacology/Action Increases blood glucose levels.

Side effects May cause vomiting in patients under the age of five if administered too quickly.

Additional information Glucose gel will maintain glucose levels once raised but should be used secondary to Dextrose to reverse hypoglycaemia.

Proceed with caution: Patients with airway compromise. Altered level of consciousness.

October 2014 58 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Glyceryl Trinitrate (GTN)

Class Nitrate.

Description Special preparation of Glyceryl trinitrate in an aerosol form that delivers precisely 0.4 mg of Glyceryl trinitrate per spray.

Presentation Aerosol spray: metered dose 0.4 mg (400 mcg).

Administration Sublingual (SL): Hold the pump spray vertically with the valve head uppermost. Place as close to the mouth as possible and spray under the tongue. The mouth should be closed after each dose. (CPG: 5/6.3.5, 4.4.10, 5/6.4.10).

Indications Angina. Suspected Myocardial Infarction (MI). EFRs may assist with administration. Advanced Paramedic and Paramedic - Pulmonary oedema.

Contraindications SBP < 90 mmHg. Viagra or other phosphodiesterase type 5 inhibitors (Sildenafil, Tadalafil and Vardenafil) used within previous 24 hours. Known severe adverse reaction.

Usual Dosages Adult: Angina or MI: 0.4 mg (400 mcg) Sublingual. Repeat at 3-5 min intervals, Max: 1.2 mg. EFRs 0.4 mg sublingual max. Pulmonary oedema; 0.8 mg (800 mcg) sublingual. Repeat x 1.

Paediatric: Not indicated.

Pharmacology/Action Vasodilator Releases nitric oxide which acts as a vasodilator. Dilates coronary arteries particularly if in spasm increasing blood flow to myocardium. Dilates systemic veins reducing venous return to the heart (pre load) and thus reduces the heart’s workload. Reduces BP.

Side effects Headache. Transient Hypotension. Flushing. Dizziness.

Additional information If the pump is new or has not been used for a week or more, the first spray should be released into the air.

October 2014 59 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Oxygen

Class Gas.

Description Odourless, tasteless, colourless gas necessary for life.

Presentation D, E or F cylinders, coloured black with white shoulders. CD cylinder; white cylinder. Medical gas.

Administration Inhalation via: High concentration reservoir (non-rebreather) mask. Simple face mask. Venturi mask. Tracheostomy mask. Nasal cannulae. Bag Valve Mask. (CPG: Oxygen is used extensively throughout the CPGs)

Indications Absent/inadequate ventilation following an acute medical or traumatic event. SpO2 < 94% adults and < 96% paediatrics. SpO2 < 92% for patients with acute exacerbation of COPD.

Contraindications Bleomycin lung injury.

Usual Dosages Adult: Cardiac and respiratory arrest and Sickle Cell Crisis; 100%. Life threats identified during primary survey; 100% until a reliableSpO 2 measurement obtained then titrate O2 to achieve SpO2 of 94% - 98%. For patients with acute exacerbation of COPD, administer O2 titrate to achieve SpO2 92% or as specified on COPD Oxygen Alert Card. All other acute medical and trauma titrate O2 to achieve SpO2 94% -98%.

Paediatric: Cardiac and respiratory arrest; 100%. Life threats identified during primary survey; 100% until a reliableSpO 2 measurement obtained then titrate O2 to achieve SpO2 of 96% - 98%. All other acute medical and trauma titrate O2 to achieve SpO2 of 96% - 98%.

Pharmacology/Action Oxygenation of tissue/organs.

Side effects Prolonged use of O2 with chronic COPD patients may lead to reduction in ventilation stimulus.

A written record must be made of what oxygen therapy is given to every patient. Additional information Documentation recording oximetry measurements should state whether the patient is breathing air or a specified dose of supplemental oxygen. Consider humidifier if oxygen therapy for paediatric patients is > 30 minute duration. Caution with paraquat poisoning, administer oxygen if SpO2 < 92% Avoid naked flames, powerful oxidising agent.

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APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL:

Medication Salbutamol

Class Sympathetic agonist.

Description Sympathomimetic that is selective for beta-2 adrenergic receptors.

Presentation Nebule 2.5 mg in 2.5 mL. Nebule 5 mg in 2.5 mL. Aerosol inhaler: metered dose 0.1 mg (100 mcg).

Administration Nebuliser (NEB). Inhalation via aerosol inhaler. (CPG: 4/5/6.3.3, 4/5/6.3.4, 3.3.4, 5/6.4.15, 4.4.15, 2/3.4.16, 4/5/6.6.10, 4/5/6.7.12, 3.7.12, 5/6.7.31, 4.7.31, 2/3.7.31).

Indications Bronchospasm. Exacerbation of COPD. Respiratory distress following submersion incident.

Contraindications Known severe adverse reaction.

Usual Dosages Adult: 5 mg NEB (or 0.1 mg metered aerosol spray x 5) Repeat at 5 min prn. (EFRs: 0.1 mg metered aerosol spray x 2).

Paediatric: < 5 yrs - 2.5 mg NEB (or 0.1 mg metered aerosol spray x 3). ≥ 5 yrs - 5 mg NEB (or 0.1 mg metered aerosol spray x 5). Repeat at 5 min prn. (EFRs: 0.1 mg metered aerosol spray x 2).

Pharmacology/Action Beta-2 agonist. Bronchodilation. Relaxation of smooth muscle.

Side effects Tachycardia. Tremors. Tachyarrhythmias. High doses may cause hypokalaemia.

Additional information It is more efficient to use a volumizer in conjunction with an aerosol inhaler when administering Salbutamol. If an oxygen driven nebuliser is used to administer Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum.

October 2014 61 Clinical Practice Guidelines

APPENDIX 2 MEDICATIONS & SKILLS MATRIX NEW FOR 2014

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Burns care P P P P P Soft tissue injury P P P P P SpO2 monitoring P Move and secure a patient to a P paediatric board Ibuprofen PO P Salbutamol Nebule P Subcutaneous injection P P Naloxone IN P P P Pain assessment P P P Haemostatic agent P P P End Tidal CO2 monitoring P Hydrocortisone IM P Ipratropium Bromide Nebule P CPAP / BiPAP P P Naloxone SC P P Nasal pack P P Ticagrelor P P Treat and referral P P Tranexamic Acid P

CARE MANAGEMENT INCLUDING THE ADMINISTRATION OF MEDICATIONS AS PER LEVEL OF TRAINING AND DIVISION ON THE PHECC REGISTER AND RESPONDER LEVELS.

Pre-Hospital responders and practitioners shall only provide care management including medication administration for which they have received specific training. Practioners must be privileged by a licensed CPG provider to administer specific medications and perform specific clinical interventions. KEY

P = Authorised under PHECC CPGs

URMPIO = Authorised under PHECC CPGs under registered medical practitioner’s instructions only

APO = Authorised under PHECC CPGs to assist practitioners only (when applied to EMT, to assist Paramedic or higher clinical levels)

SA = Authorised subject to special authorisation as per CPG

BTEC = Authorised subject to Basic Tactical Emergency Care rules

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATIONS

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Aspirin PO P P P P P P P Oxygen P P P P P Glucose Gel Buccal P P P P GTN SL PSA P P P Salbutamol Aerosol PSA P P P Epinephrine (1:1,000) auto injector PSA P P P Glucagon IM P P P Nitrous oxide & Oxygen (Entonox©) P P P Naloxone IN P P P Paracetamol PO P P P Ibuprofen PO P P P Salbutamol nebule P P P Morphine IM URMPIO URMPIO PSA Clopidogrel PO P P Epinephrine (1: 1,000) IM P P Hydrocortisone IM P P Ipratropium Bromide Nebule P P Midazolam IM/Buccal/IN P P Naloxone IM/SC P P Ticagrelor P P Dextrose 10% IV PSA P Hartmann’s Solution IV/IO PSA P Sodium Chloride 0.9% IV/IO PSA P Amiodarone IV/IO P Atropine IV/IO P Benzylpenicillin IM/IV/IO P Cyclizine IV P Diazepam IV/PR P Epinephrine (1:10,000) IV/IO P Fentanyl IN P Furosemide IV/IM P Hydrocortisone IV P Lorazepam PO P Magnesium Sulphate IV P Midazolam IV P

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATIONS (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Morphine IV/PO P Naloxone IV/IO P Nifedipine PO P Ondansetron IV P Paracetamol PR P Sodium Bicarbonate IV/ IO P Syntometrine IM P Tranexamic Acid P Enoxaparin IV/SC PSA Lidocaine IV PSA Tenecteplase IV PSA

AIRWAY & BREATHING MANAGEMENT

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

FBAO management P P P P P P P Head tilt chin lift P P P P P P P Pocket mask P P P P P P P Recovery position P P P P P P P Non rebreather mask P P P P P OPA P P P P P Suctioning P P P P P Venturi mask P P P P P SpO2 monitoring PSA P P P P Jaw Thrust P P P P Nasal cannula P P P P P BVM P PSA P P P NPA BTEC BTEC P P Supraglottic airway adult (uncuffed) P P P P Oxygen humidification P P P Supraglottic airway adult (cuffed) PSA P P CPAP / BiPAP P P Non-invasive ventilation device P P Peak Expiratory Flow P P

October 2014 64 Clinical Practice Guidelines

APPENDIX 2 MEDICATIONS & SKILLS MATRIX AIRWAY & BREATHING MANAGEMENT (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

End Tidal CO2 monitoring P P Supraglottic airway paediatric PSA P Endotracheal intubation P Laryngoscopy and Magill forceps P Needle cricothyrotomy P Needle thoracocentesis P

CARDIAC

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

AED adult & paediatric P P P P P P P CPR adult, child & infant P P P P P P P Recognise death and resuscitation P P P P P P P not indicated Targeted temperature management PSA P P P CPR newly born P P P ECG monitoring (lead II) P P P Mechanical assist CPR device P P P 12 lead ECG P P Cease resuscitation - adult P P Manual defibrillation P P

HAEMORRHAGE CONTROL

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Direct pressure P P P P P Nose bleed P P P P P Haemostatic agent P P P Tourniquet use BTEC BTEC P P Nasal pack P P Pressure points P P

October 2014 65 Clinical Practice Guidelines

APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATION ADMINISTRATION

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Oral P P P P P P P Buccal route P P P P Per aerosol (inhaler) + spacer PSA P P P Sublingual PSA P P P Intramuscular injection P P P Intranasal P P P Per nebuliser P P P Subcutaneous injection P P P IV & IO Infusion maintenance PSA P Infusion calculations P Intraosseous injection/infusion P Intravenous injection/infusion P Per rectum P

TRAUMA CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Burns care P P P P P Cervical spine manual stabilisation P P P P P Application of a sling P P P P P Soft tissue injury P P P P P Cervical collar application P P P P Helmet stabilisation/removal P P P P Splinting device application to upper P P P P limb Move and secure patient to a long PSA P P P board Rapid Extraction PSA P P P Log roll APO P P P Move patient with a carrying sheet APO P P P Move patient with an orthopaedic APO P P P stretcher Splinting device application to lower APO P P P limb Secure and move a patient with an APO APO P P extrication device

October 2014 66 Clinical Practice Guidelines

APPENDIX 2 MEDICATIONS & SKILLS MATRIX TRAUMA (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Pelvic Splinting device BTEC P P P Move and secure patient into a BTEC P P P vacuum mattress Active re-warming P P P Move and secure a patient to a P P P paediatric board Traction splint application APO P P Spinal Injury Decision P P Taser gun barb removal P P Reduction dislocated patella P

OTHER

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Assist in the normal delivery of a APO P P P baby De-escalation and breakaway skills P P P Glucometry P P P Broselow tape P P Delivery Complications P P External massage of uterus P P Intraosseous cannulation P Intravenous cannulation P Urinary catheterisation P

PATIENT ASSESSMENT

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Assess responsiveness P P P P P P P Check breathing P P P P P P P FAST assessment P P P P P P P Capillary refill P P P P P AVPU P P P P P Breathing & pulse rate P P P P P

October 2014 67 Clinical Practice Guidelines

APPENDIX 2 MEDICATIONS & SKILLS MATRIX PATIENT ASSESSMENT (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Primary survey P P P P P SAMPLE history P P P P P Secondary survey P P P P P CSM assessment P P P P Rule of Nines P P P P Assess pupils P P P P Blood pressure PSA P P P Capacity evaluation P P P Do Not Attempt Resuscitation P P P Paediatric Assessment Triangle P P P Pain assessment P P P Patient Clinical Status P P P Pre-hospital Early Warning Score P P P Pulse check (cardiac arrest) PSA P P P Temperature OC P P P sieve P P P Chest auscultation P P GCS P P Treat and referral P P Triage sort P P

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APPENDIX 3 CRITICAL INCIDENT STRESS MANAGEMENT

Your Psychological Well-Being

As a Responder it is extremely important for your psychological well-being that you do not expect to save every critically ill or injured patient that you treat. For a patient who is not in hospital, whether they survive a cardiac arrest or multiple trauma depends on a number of factors including any other medical condition the patient has. Your aim should be to perform your interventions well and to administer the appropriate medications within your scope of practice. However sometimes you may encounter a situation which is highly stressful for you, giving rise to Critical Incident Stress (CIS). A critical incident is an incident or event which may overwhelm or threaten to overwhelm our normal coping responses. As a result of this we can experience CIS.

SYMPTOMS OF CIS INCLUDE SOME OR ALL OF THE FOLLOWING:

Examples of physical symptoms: Examples of psychological symptoms: • Feeling hot and flushed, sweating a lot • Feeling overwhelmed • Dry mouth, churning stomach • Loss of motivation • Diarrhoea and digestive problems • Dreading going to work • Needing to urinate often • Becoming withdrawn • Muscle tension • Racing thoughts • Restlessness, tiredness, sleep difficulties, headaches • Confusion • Increased drinking or smoking • Not looking after yourself properly • Overeating, or loss of appetite • Difficulty making decisions • Loss of interest in sex • Poor concentration • Racing heart, breathlessness and rapid breathing • Poor memory • Anger • Anxiety • Depression

Post-Traumatic Stress Reactions

Normally the symptoms of Critical Incident Stress subside within a few weeks or less. Sometimes however, they may persist and develop into a post-traumatic stress reaction and you may also experience emotional reactions.

Anger at the injustice and senselessness of it all.

Sadness and depression caused by an awareness of how little can be done for people who are severely injured and dying, sense of a shortened future, poor concentration, not being able to remember things as well as before.

Guilt caused by believing that you should have been able to do more or that you could have acted differently.

Fear of ‘breaking down’ or ‘losing control’, not having done all you could have done, being blamed for something or a similar event happening to you or your loved ones.

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APPENDIX 3 CRITICAL INCIDENT STRESS MANAGEMENT

Avoiding the scene of the trauma or anything that reminds you of it.

Intrusive thoughts in the form of memories or flashbacks which cause distress and the same emotions as you felt at the time.

Irritability outbursts of anger, being easily startled and constantly being on guard for threats.

Feeling numb leading to a loss of your normal range of feelings, for example, being unable to show affection, feeling detached from others.

EXPERIENCING SIGNS OF EXCESSIVE STRESS If the range of physical, emotional and behavioural signs and symptoms already mentioned do not reduce over time (for example, after two weeks), it is important that you get support and help.

Where to find help?

Your own CPG approved organisation will have a CISM support network or system. We recommend that you contact them for help and advice. (i.e. your peer support worker/coordinator/staff support officer).

• For a self-help guide, please go to www.cismnetworkireland.ie • The NAS CISM/ CISM Network published a booklet called ‘Critical Incident Stress Management for Emergency Personnel’. It can be purchased by emailing [email protected] • The NAS CISM committee in partnership with PHECC developed an eLearning CISM Stress Awareness Training (SAT) module. It can be accessed by all PHECC registered practitioners using their PHECC eLearning username and password. In due course PHECC will launch a CISM SAT module for non-PHECC registered personnel. • See a health professional who specialises in traumatic stress.

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APPENDIX 4 PRE-HOSPITAL DEFIBRILLATION POSITION PAPER

Defibrillation is a lifesaving intervention for victims of sudden cardiac arrest (SCA). Defibrillation in isolation is unlikely to reverse SCA unless it is integrated into the chain of survival. The chain of survival should not be regarded as a linear process with each link as a separate entity but once commenced with ‘early access’ the other links, other than ‘post return of spontaneous circulation (ROSC) care’, should be operated in parallel subject to the number of people and clinical skills available.

Cardiac arrest management process

ILCOR guidelines 2010 identified that without ongoing CPR, survival with good neurological function from SCA is highly unlikely. Defibrillators in AED mode can take up to 30 seconds between analysing and charging during which time no CPR is typically being performed. The position below is outlined to ensure maximum resuscitation efficiency and safety.

Position 1. Defibrillation mode 1.1 Advanced paramedics, and health care professionals whose scope of practice permits, should use defibrillators in manual mode for all age groups. 1.2 Paramedics may consider using defibrillators in manual mode for all age groups. 1.3 EMTs and responders shall use defibrillators in AED mode for all age groups.

2. Hands off time (time when chest compressions are stopped) 2.1 Minimise hands off time, absolute maximum 10 seconds. 2.2 Rhythm and/or pulse checks in manual mode should take no more than 5 to 10 seconds and CPR should be recommenced immediately. 2.3 When defibrillators are charging CPR should be ongoing and only stopped for the time it takes to press the defibrillation button and recommenced immediately without reference to rhythm or pulse checks. 2.4 It is necessary to stop CPR to enable some AEDs to analyse the rhythm. Unfortunately this time frame is not standard with all AEDs. As soon as the analysing phase is completed and the charging phase has begun CPR should be recommenced.

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APPENDIX 4 PRE-HOSPITAL DEFIBRILLATION POSITION PAPER

3 Energy 3.1 Biphasic defibrillation is the method of choice. 3.2 Biphasic truncated exponential (BTE) waveform energy commencing at 150 to 200 joules shall be used. 3.3 If unsuccessful the energy on second and subsequent shocks shall be as per manufacturer of defibrillator instructions. 3.4 Monophasic defibrillators currently in use, although not as effective as biphasic defibrillators, may continue to be used until they reach the end of their lifespan.

4 Safety 4.1 For the short number of seconds while a patient is being defibrillated no person should be in contact with the patient. 4.2 The person pressing the defibrillation button is responsible for defibrillation safety. 4.3 Defibrillation pads should be used as opposed to defibrillation paddles for pre-hospital defibrillation.

5 Defibrillation pad placement 5.1 The right defibrillation pad should be placed mid clavicular directly under the right clavicle. 5.2 The left defibrillation pad should be placed mid-axillary with the top border directly under the left nipple. 5.3 If a pacemaker or Implantable Cardioverter Defibrillator (ICD) is fitted, defibrillator pads should be placed at least 8 cm away from these devices. This may result in anterior and posterior pad placement which is acceptable.

6 Paediatric defibrillation 6.1 Paediatric defibrillation refers to patients less than 8 years of age. 6.2 Manual defibrillator energy shall commence and continue with 4 joules/Kg. 6.3 AEDs should use paediatric energy attenuator systems. 6.4 If a paediatric energy attenuator system is not available an adult AED may be used. 6.5 It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior and posterior, because of the infant’s small size.

7 Implantable Cardioverter Defibrillator (ICD) 7.1 If an Implantable Cardioverter Defibrillator (ICD) is fitted in the patient, treat as per CPG. It is safe to touch a patient with an ICD fitted even if it is firing.

8 Cardioversion 8.1 Advanced paramedics are authorised to use synchronised cardioversion for unresponsive patients with a tachycardia greater than 150.

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Published by: Pre-Hospital Emergency Care Council Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland. Phone: + 353 (0)45 882042 Fax: + 353 (0)45 882089 P Email: [email protected] Web: www.phecc.ie Emergency First Responder - EMT Basic Tactical Emergency Care