CLINICAL PRACTICE GUIDELINES for Pre-Hospital Emergency Care

CLINICAL PRACTICE GUIDELINES For Pre-Hospital Emergency Care

2012 Version

CFR

OFA

EFR

EMERGENCY MEDICAL TECHNICIAN EMT

AP CLINICAL PRACTICE GUIDELINES - Published 2012 The Pre-Hospital Emergency Care Council (PHECC) is an independent statutory body with responsibility for standards, education and training in the field of pre-hospital emergency care in Ireland. PHECC’s primary role is to protect the public.

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

The Council was established as a body corporate by the Minister for Health and Children by Statutory Instrument Number 109 of 2000 (Establishment Order) which was amended by Statutory Instrument Number 575 of 2004 (Amendment Order). These Orders were made under the Health (Corporate Bodies) Act, 1961 as amended and the Health (Miscellaneous Provisions) Act 2007. CLINICAL PRACTICE GUIDELINES - 2012 Version

Practitioner

Emergency Medical Technician PHECC Clinical Practice Guidelines First Edition 2001 Second Edition 2004 Third Edition 2009 Third Edition Version 2 2011 2012 Edition April 2012

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 978-0-9571028-2-8

Any part of this publication may be reproduced for educational purposes and quality improvement programmes subject to the inclusion of an acknowledgement of the source. It may not be used for commercial purposes. TABLE OF CONTENTS

PREFACE

FOREWORD ...... 6

ACCEPTED ABBREVIATIONS ...... 7

ACKNOWLEDGEMENTS ...... 9

INTRODUCTION ...... 11

IMPLEMENTATION AND USE OF CLINICAL PRACTICE GUIDELINES . . . . .12

CLINICAL PRACTICE GUIDELINES

KEY/CODES EXPLANATION ...... 16

CLINICAL PRACTICE GUIDELINES - INDEX ...... 17

SECTION 2 PATIENT ASSESSMENT ...... 19

SECTION 3 RESPIRATORY EMERGENCIES ...... 24

SECTION 4 MEDICAL EMERGENCIES ...... 27

SECTION 5 OBSTETRIC EMERGENCIES ...... 53

SECTION 6 TRAUMA ...... 55

SECTION 7 PAEDIATRIC EMERGENCIES ...... 62

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS ...... 76

Appendix 1 - Medication Formulary ...... 79

Appendix 2 – Medications & Skills Matrix ...... 92

Appendix 3 – Critical Incident Stress Management ...... 99

Appendix 4 – CPG Updates for Emergency Medical Technicians . . .102

Appendix 5 – Pre-hospital defibrillation position paper...... 103

PHECC Clinical Practice Guidelines - Emergency Medical Technician 5 FOREWORD

It is my pleasure to write the foreword to this PHECC Clinical Handbook comprising Clinical Practice Guidelines (CPGs) and Medication Formulary. There are now 236 CPGs in all, to guide integrated care across the six levels of Responder and Practitioner. My understanding is that it is a world first to have a Cardiac First Responder using guidance from the same integrated set as all levels of Responders and Practitioners up to Advanced Paramedic. We have come a long way since the publication of the first set of guidelines numbering 35 in 2001, and applying to EMTs only at the time. I was appointed Chair in June 2008 to what is essentially the second Council since PHECC was established in 2000.

I pay great tribute to the hard work of the previous Medical Advisory Group chaired by Mark Doyle, in developing these CPGs with oversight from the Clinical Care Committee chaired by Sean Creamer, and guidance and authority of the first Council chaired by Paul Robinson. The development and publication of CPGs is an important part of PHECC’s main functions which are:

1. To ensure training institutions and course content in First Response and Emergency Medical Technology reflect contemporary best practice. 2. To ensure pre-hospital emergency care Responders and Practitioners achieve and maintain competency at the appropriate performance standard. 3. To sponsor and promote the implementation of best practice guidelines in pre-hospital emergency care. 4. To source, sponsor and promote relevant research to guide Council in the development of pre-hospital emergency care in Ireland. 5. To recommend other pre-hospital emergency care standards as appropriate. 6. To establish and maintain a register of pre-hospital emergency care practitioners. 7. To recognise those pre-hospital emergency care providers which undertake to implement the clinical practice guidelines.

The CPGs, in conjunction with relevant ongoing training and review of practice, are fundamental to achieve best practice in pre-hospital emergency care. I welcome this revised Clinical Handbook and look forward to the contribution Responders and Practitioners will make with its guidance.

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

6 PHECC Clinical Practice Guidelines - Emergency Medical Technician ACCEPTED ABBREVIATIONS

Advanced Paramedic AP Advanced Life Support ALS Airway, breathing & circulation ABC All terrain vehicle ATV Altered level of consciousness ALoC Automated External Defibrillator AED Bag Valve Mask BVM Basic Life Support BLS Blood Glucose BG Blood Pressure BP

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 Greater than > Greater than or equal to ≥ Heart rate HR History Hx Impedance Threshold Device ITD Inhalation Inh Intramuscular IM Intranasal IN Intraosseous IO Intravenous IV Keep vein open KVO Kilogram Kg Less than < PHECC Clinical Practice Guidelines - Emergency Medical Technician 7 ACCEPTED ABBREVIATIONS (Cont.)

Less than or equal to ≤ Litre L Maximum Max Microgram mcg Milligram mg Millilitre mL Millimole mmol Minute min Modified Early Warning Score MEWS Motor vehicle collision MVC Myocardial infarction MI Nasopharyngeal airway 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

8 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTIONACKNOWLEDGEMENTS 2 - PATIENT ASSESSMENT Primary Survey – Adult

The process of developing CPGs has been Mr Michael Garry, Paramedic, Chair of long and detailed. The quality of the Accreditation Committee finished product is due to the painstaking Mr Macartan Hughes, Advanced Paramedic, Head of Education & Competency work of many people, who through their Assurance, HSE National Ambulance Service expertise and review of the literature, Mr Lawrence Kenna, Advanced Paramedic, ensured a world-class publication. Education & Competency Assurance Manager, HSE National Ambulance Service PROJECT LEADER & EDITOR Mr Paul Lambert, Advanced Paramedic, Mr Brian Power, Programme Development Station Officer Dublin Fire Brigade Officer, PHECC. Mr Declan Lonergan, Advanced Paramedic, Education & Competency Assurance INITIAL CLINICAL REVIEW Manager, HSE National Ambulance Service Dr Geoff King, Director, PHECC. Mr Paul Meehan, Regional Training Officer, Ms Pauline Dempsey, Programme Northern Ireland Ambulance Service Development Officer, PHECC. Dr David Menzies, Medical Director AP Ms Jacqueline Egan, Programme Development programme NASC/UCD Officer, PHECC. Dr David McManus, Medical Director, Northern Ireland Ambulance Service MEDICAL ADVISORY GROUP Dr Peter O’Connor, Consultant in Emergency Dr Zelie Gaffney, (Chair) General Practitioner Medicine, Medical Advisor Dublin Fire Dr David Janes, (Vice Chair) General Brigade Practitioner Mr Cathal O’Donnell, Consultant in Emergency Prof Gerard Bury, Professor of General Medicine, Medical Director HSE National Practitioner University College Dublin Ambulance Service Dr Niamh Collins, Locum Consultant in Mr John O’Donnell, Consultant in Emergency Emergency Medicine, St James’s Hospital Medicine, Area Medical Advisor, National Prof Stephen Cusack, Consultant in Ambulance Service West Emergency Medicine, Area Medical Advisor, Mr Frank O’Malley, Paramedic, Chair of Clinical National Ambulance Service South Care Committee Mr Mark Doyle, Consultant in Emergency Mr Martin O’Reilly, Advanced Paramedic, Medicine, Deputy Medical Director HSE District Officer Dublin Fire Brigade National Ambulance Service Dr Sean O’Rourke, Consultant in Emergency Mr Conor Egleston, Consultant in Emergency Medicine, Area Medical Advisor, National Medicine, Our lady of Lourdes Hospital, Ambulance Service North Leinster Drogheda

PHECC Clinical Practice Guidelines - Emergency Medical Technician 9 SECTIONACKNOWLEDGEMENTS 2 - PATIENT ASSESSMENT Primary Survey – Adult

Ms Valerie Small, Nurse Practitioner, St Mr Tony Heffernan, Assistant Director of James’s Hospital, Vice Chair Council Nursing, HSE Mental Health Services. Dr Sean Walsh, Consultant in Paediatric Prof Peter Kelly, Consultant Neurologist, Emergency Medicine, Our Lady’s Hospital Mater University Hospital. for Sick Children Crumlin Dr Brian Maurer, Director of Cardiology St Mr Brendan Whelan, Advanced Paramedic, Vincent’s University Hospital. Education & Competency Assurance Dr Regina McQuillan, Palliative Medicine Manager, HSE National Ambulance Service Consultant, St James’s Hospital. Dr Sean Murphy, Consultant Physician in EXTERNAL CONTRIBUTORS Geriatric Medicine, Midland Regional Hospital, Mr Fergal Hickey, Consultant in Emergency Mullingar. Medicine, Sligo General Hospital Ms Annette Thompson, Clinical Nurse Mr George Little, Consultant in Emergency Specialist, Beaumont Hospital. Medicine, Naas Hospital Dr Joe Tracey, Director, National Poisons Mr Richard Lynch, Consultant in Emergency Information Centre. Medicine, Midlands Regional Hospital Mr Pat O’Riordan, Specialist in Emergency Mulingar Management, HSE. Ms Celena Barrett, Chief Fire Officer, Kildare Prof Peter Weedle, Adjunct Prof of Clinical County Fire Service. Pharmacy, National University of Ireland, Ms Diane Brady, CNM II, Delivery Suite, Cork. Castlebar Hospital. Dr John Dowling, General Practitioner, Dr Donal Collins, Chief Medical Officer, An Donegal Garda Síochána. Dr Ronan Collins, Director of Stroke Services, SPECIAL THANKS Age Related Health Care, Adelaide & Meath A special thanks to all the PHECC team Hospital, Tallaght. who were involved in this project from Dr Peter Crean, Consultant Cardiologist, St. time to time, in particular Marion O’Malley, James’s Hospital. Programme Development Support Officer Prof Kieran Daly, Consultant Cardiologist, and Marie Ni Mhurchu, Client Services University Hospital Galway Manager, for their commitment to ensure the Dr Mark Delargy, Consultant in success of the project. Rehabilitation, National Rehabilitation Centre. Dr Joseph Harbison, Lead Consultant Stroke Physician and Senior Geriatrician St. James’s, National Clinical Lead in Stroke Medicine.

10 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTIONINTRODUCTION 2 - PATIENT ASSESSMENT Primary Survey – Adult

The development of Clinical Practice Guidelines (CPGs) is a continuous process. The publication of the ILCOR Guidelines 2010 was the principle catalyst for updating these CPGs. As research leads to evidence, and as practice evolves, guidelines are updated to offer the best available advice to those who care for the ill and injured in our pre-hospital environment.

This 2012 edition offers current best practice guidance. The guidelines have expanded in number and scope – with 60 CPGs in total for Emergency Medical Technicians, covering such topics as Post Resuscitation Care for Paediatric patients and End of Life – DNR for the first time. The CPGs continue to recognise the various levels of Practitioner (Emergency Medical Technician, Paramedic and Advanced Paramedic) and Responder (Cardiac First Response, Occupational First Aid and Emergency First Response) who offer care.

The CPGs cover these six levels, reflecting the fact that care is integrated. Each level of more advanced care is built on the care level preceding it, whether or not provided by the same person. For ease of reference, a version of the guidelines for each level of Responder and Practitioner is available on www.phecc.ie Feedback on the experience of using the guidelines in practice is essential for their ongoing development and refinement, therefore, your comments and suggestions are welcomed by PHECC. The Medical Advisory Group believes these guidelines will assist Practitioners in delivering excellent pre-hospital care.

______Mr Cathal O’Donnell Chair, Medical Advisory Group (2008-2010)

PHECC Clinical Practice Guidelines - Emergency Medical Technician 11 SECTIONIMPLEMENTATION 2 - PATIENT & USE ASSESSMENT OF CLINICAL Primary PRACTICE Survey GUIDELINES– Adult

Clinical Practice Guidelines (CPGs) and the Practitioner 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 Practitioner decides if a CPG should be applied based on patient assessment and the clinical impression. The Practitioner must work in the best interest of the patient within the scope of practice for his/her clinical level on the PHECC Register. Consultation with fellow Practitioners and or medical practitioners in challenging clinical situations is strongly advised.

The CPGs herein may be implemented provided: 1 The Practitioner is in good standing on the PHECC Practitioner’s Register. 2 The Practitioner is acting on behalf of an organisation (paid or voluntary) that is approved by PHECC to implement the CPGs. 3 The Practitioner is authorised by the organisation on whose behalf he/she is acting to implement the specific CPG. 4 The Practitioner has received training on - and is competent in - the skills and medications specified in the CPG being utilized.

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

Definitions Adult a patient of 14 years or greater, unless specified on the CPG. Child a patient between 1 and less than or equal to (≤) 13 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.

12 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTIONIMPLEMENTATION 2 - PATIENT & USE ASSESSMENT OF CLINICAL Primary PRACTICE Survey GUIDELINES– Adult

Care principles 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 & medications on the Patient Care Report (PCR) are consistent principles throughout the guidelines and reflect the practice of Practitioners at work. Care principles are the foundations for risk management and the avoidance of error.

Care Principles 1 Ensure the safety of yourself, other emergency service personnel, your patients and the public: • review all Ambulance Control Centre dispatch 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. • 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 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 as soon as possible after arrival on the scene as appropriate. 3 Ensure adequate ventilation and oxygenation. 4 Monitor and record patient’s vital observations. 5 Optimise tissue perfusion. 6 Identify and manage other conditions. 7 Provide appropriate pain relief. 8 Place the patient in the appropriate posture according to the presenting condition. 9 Ensure the maintenance of normal body temperature (unless CPG indicates otherwise).

PHECC Clinical Practice Guidelines - Emergency Medical Technician 13 SECTIONIMPLEMENTATION 2 - PATIENT & USE ASSESSMENT OF CLINICAL Primary PRACTICE Survey GUIDELINES– Adult

10 Maintain responsibility for patient care until handover to an appropriate Practitioner. Do not hand over responsibility for care of a patient to a Practitioner/Responder who is less qualified or experienced unless the care required is within their scope of practice. 11 Arrange transport to an appropriate medical facility as necessary and in an appropriate time frame: • On-scene times for life-threatening conditions, other than cardiac arrest, should not exceed 10 minutes. • Following initial stabilisation other treatments should be commenced/ continued en-route. 12 Provide reassurance at all times.

Completing a PCR for each patient is paramount in the risk management process and users of the CPGs must be committed to this process.

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, providers of emergency care are from a range of disciplines and include Responders (Cardiac First Response, Occupational First Aid and Emergency First Response) 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 Practitioner, in the continuum of patient care, the chain of survival and the golden hour are supported in medical and trauma emergencies respectively.

CPGs guide the Practitioner in presenting to the acute hospital 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.

14 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTIONIMPLEMENTATION 2 - PATIENT & USE ASSESSMENT OF CLINICAL Primary PRACTICE Survey GUIDELINES– Adult

CPGs presume no intervention has been applied, nor medication administered, prior to the arrival of the Practitioner. In the event of another Practitioner or Responder initiating care during an acute episode, the Practitioner 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.

In the absence of a more qualified Practitioner, the Practitioner providing care during transport shall be designated the clinical leader as soon as practical.

Defibrillation policy The Medical Advisory Group 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.

Using the 2012 Edition CPGs The 2012 Edition CPGs continue to be published in sections. • Appendix 1, the Medication Formulary, is an important adjunct supporting decision-making by the Practitioner. • Appendix 2, lists the care management and medications matrix for the six levels of Practitioner and Responder. • Appendix 3, outlines important guidance for critical incident stress management (CISM) from the Ambulance Service CISM committee. • Appendix 4, outlines changes to medications and skills as a result of updating to version 2 and the introduction of new CPGs. • Appendix 5, outlines the pre-hospital defibrillation position from PHECC.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 15 KEY/CODES EXPLANATION

Clinical Practice Guidelines for Emergency Medical Technician Codes explanation

Emergency Medical Technician EMT A parallel process (Level 4) for which the CPG pertains Which may be carried out in parallel with other sequence steps Paramedic P (Level 5) for which the CPG pertains A cyclical process in which a number Advanced Paramedic of sequence steps are completed AP (Level 6) for which the CPG pertains Emergency Medical Technician or lower clinical levels not permitted this Sequence step A sequence (skill) to be performed EMT route

Mandatory Transport to an appropriate medical A mandatory sequence (skill) to be performed sequence step facility and maintain treatment en-route

Transport to an appropriate medical A decision process If no ALS available facility and maintain treatment en-route, if The Practitioner must follow one route having contacted Ambulance Control there is no ALS available Given the clinical presentation Consider treatment Instructions options consider the treatment option An instruction box for information specified

Special Special instructions Reassess the patient instructions Which the Practitioner must follow Reassess following intervention

P A skill or sequence that only pertains Request Contact Ambulance Control and request to Paramedic or higher clinical levels ALS Advanced Life Support (AP or doctor) Special authorisation Special This authorises the Practitioner to Consider Consider requesting an ALS response, authorisation perform an intervention under specified ALS based on the clinical findings conditions

4/5/6.4.1 CPG numbering system Consider requesting a Version 2, 07/11 Consider Paramedic response, based on 4/5/6 = clinical levels to which the CPG pertains Paramedic 4/5/6.x.y x = section in CPG manual, y = CPG number in sequence the clinical findings Version 2, mm/yy mm/yy = month/year CPG published

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

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

Medication, dose & route A medication which may be administered by an Advanced Paramedic 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

16 PHECC Clinical Practice Guidelines - Emergency Medical Technician CLINICALSECTION 2PRACTICE - PATIENT GUIDELINES ASSESSMENT - INDEX Primary Survey – Adult

SECTION 2 PATIENT ASSESSMENT Primary Survey Medical – Adult 19 Primary Survey Trauma – Adult 20 Secondary Survey Medical – Adult 21 Secondary Survey Trauma – Adult 22 Pain Management – Adult 23

SECTION 3 RESPIRATORY EMERGENCIES Advanced Airway Management – Adult 24 Inadequate Respirations – Adult 25 Exacerbation of COPD 26

SECTION 4 MEDICAL EMERGENCIES Basic Life Support – Adult 27 Basic Life Support – Paediatric 28 Foreign Body Airway Obstruction – Adult 29 Foreign Body Airway Obstruction – Paediatric 30 VF or Pulseless VT – Adult 31 VF or Pulseless VT – Paediatric 32 Symptomatic Bradycardia – Paediatric 33 Asystole – Adult 34 Pulseless Electrical Activity – Adult 35 Asystole/PEA – Paediatric 36 Post-Resuscitation Care – Adult 37 Recognition of Death – Resuscitation not Indicated 38 Cardiac Chest Pain – Acute Coronary Syndrome 39 Symptomatic Bradycardia – Adult 40 Allergic Reaction/Anaphylaxis – Adult 41 Glycaemic Emergency – Adult 42 Seizure/Convulsion – Adult 43 Stroke 44 Poisons – Adult 45 Hypothermia 46 Epistaxis 47 Decompression Illness 48 Altered Level of Consciousness – Adult 49 Behavioural Emergency 50 Mental Health Emergency 51 End of Life – DNR 52

PHECC Clinical Practice Guidelines - Emergency Medical Technician 17 SECTIONCLINICAL 2PRACTICE - PATIENT GUIDELINES ASSESSMENT - INDEX Primary Survey – Adult

SECTION 5 OBSTETRIC EMERGENCIES Pre-Hospital Emergency Childbirth 53 Basic Life Support – Neonate 54

SECTION 6 TRAUMA External Haemorrhage – Adult 55 Shock from Blood Loss – Adult 56 Spinal Immobilisation – Adult 57 Burns – Adult 58 Limb Injury – Adult 59 Head Injury – Adult 60 Submersion Incident 61

SECTION 7 PAEDIATRIC EMERGENCIES Primary Survey Medical – Paediatric 62 Primary Survey Trauma – Paediatric 63 Secondary Survey – Paediatric 64 Inadequate Respirations – Paediatric 65 Stridor – Paediatric 66 Allergic Reaction/Anaphylaxis – Paediatric 67 Glycaemic Emergency – Paediatric 68 Seizure/Convulsion – Paediatric 69 External Haemorrhage – Paediatric 70 Shock from Blood Loss – Paediatric 71 Pain Management – Paediatric 72 Spinal Immobilisation – Paediatric 73 Burns – Paediatric 74 Post Resuscitation Care – Paediatric 75

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS Major Emergency – First Practitioners on Site 76 Major Emergency – Operational Control 77 Triage Sieve 78

18 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 2 - PATIENT ASSESSMENT

4/5/6.2.1 Version 2, 03/11 Primary Survey Medical – Adult EMT P

AP Medical Take standard infection control precautions issue

The primary survey is focused on establishing the patient’s clinical status Consider pre-arrival information and only applying interventions when they are essential to maintain life. It should be completed within one Scene safety minute of arrival on scene. Scene survey Scene situation

Assess responsiveness

A No Airway patent & ASSESSMENT PATIENT Primary Survey Medical - Adult protected

Suction, Head tilt/ Yes OPA chin lift S2 P NPA

B Consider No Adequate Oxygen therapy ventilation

Yes

C No Adequate circulation

Yes

AVPU assessment

Life Non serious Clinical status decision threatening or life threat

Serious not life threat

Go to Request Go to Consider Secondary appropriate Survey ALS CPG ALS CPG

Reference: ILCOR Guidelines 2010

PHECC Clinical Practice Guidelines - Emergency Medical Technician 19 SECTION 2 - PATIENT ASSESSMENT

4/5/6.2.2 Primary Survey Trauma – Adult EMT P Version 2, 03/11

Trauma Take standard infection control precautions AP

Consider pre-arrival information The primary survey is focused on establishing the patient’s clinical status and only applying interventions when Scene safety they are essential to maintain life. Scene survey It should be completed within one Scene situation minute of arrival on scene.

Control catastrophic external haemorrhage

Mechanism of C-spine No injury suggestive Yes control of spinal injury PATIENT ASSESSMENT PATIENT - Adult Primary Survey Trauma

Assess responsiveness S2

A No Airway patent & protected Suction, OPA Jaw thrust Yes P NPA

B Consider No Adequate Oxygen therapy ventilation

Yes

C No Adequate circulation

Yes

AVPU assessment

Treat life threatening injuries only at this point

Life Non serious Clinical status decision threatening or life threat

Maximum time on Serious not scene for life threatening life threat trauma: ≤ 10 minutes

Go to Request Go to Consider Secondary appropriate Survey ALS CPG ALS CPG

Reference: ILCOR Guidelines 2010

20 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 2 - PATIENT ASSESSMENT

4.2.4 Version 2, 09/11 Secondary Survey Medical – Adult EMT

Primary Survey

Record vital signs

Patient acutely Markers identifying acutely unwell Yes Cardiac chest pain unwell Acute pain > 5

Focused medical history of presenting complaint Request ASSESSMENT PATIENT Secondary Survey Medical - Adult

Go to Identify positive findings ALS appropriate and initiate care SAMPLE history CPG management S2

Check for medications carried or medical alert jewellery

Consider Paramedic

Reference: Sanders, M. 2001, Paramedic Textbook 2nd Edition, Mosby Gleadle, J. 2003, History and Examination at a glance, Blackwell Science Rees, JE, 2003, Early Warning Scores, World Anaesthesia Issue 17, Article 10

PHECC Clinical Practice Guidelines - Emergency Medical Technician 21 SECTION 2 - PATIENT ASSESSMENT

4.2.5 Secondary Survey Trauma – Adult EMT 05/08

Primary Survey

Markers for multi- system trauma Yes present

Examination of obvious injuries

Record vital signs Request

Go to Identify positive findings ALS SAMPLE history PATIENT ASSESSMENT PATIENT - Adult Secondary Survey Trauma appropriate and initiate care CPG management

Complete a head to toe S2 survey as history dictates

Check for medications carried or medical alert jewellery

Consider Paramedic

Markers for multi-system trauma Systolic BP < 90 Respiratory rate < 10 or > 29 Heart rate > 120 AVPU = V, P or U on scale Mechanism of Injury

Reference: McSwain, N. et al, 2003, PHTLS Basic and advanced prehospital trauma life support, 5th Edition, Mosby

22 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 2 - PATIENT ASSESSMENT

4/5/6.2.6 Version 2, 03/11 Pain Management – Adult EMT P

AP Pain

Analogue Pain Scale 0 = no pain……..10 = unbearable The general principle in pain management is to start at the bottom rung of the pain ladder, and then to Pain assessment climb the ladder if pain is still present. Practitioners, depending on his/her scope of practice, may make a clinical Administer pain medication based on judgement and commence Decisions to give analgesia must pain relief on a higher rung. pain assessment and pain ladder recommendations be based on clinical assessment and not directly on a linear scale

Adequate relief

Yes or best achievable ASSESSMENT PATIENT Management - Adult Pain of pain

Go back Reassess and move S2 to up the pain ladder if originating appropriate CPG

Repeat Morphine at Request not < 2 min intervals if indicated. IV ALS 2 mg Max 10 mg rphine Mo For musculoskeletal Severe pain pain Max 16 mg (≥ 5 on pain scale) or and / , ygen & Ox xide us O Nitro inh

Consider O Paramedic 1 g P amol racet Pa r nd / o Moderate pain a g PO 0 m r n 40 nside mg IV (3 to 4 on pain scale) rofe Co tron 4 Ibup danse On owly r sl / o or and g IV , 50 m ygen clizine & Ox Cy ly xide slow us O Nitro inh ions g PO vent mol 1 nter aceta cal i Minor pain Par ologi rmac (2 to 3 on pain scale) pha on er er n Ladd oth Pain ider ECC Cons PH

AP EMT Special Authorisation: Special Authorisation: Registered Medical Practitioners may authorise the Advanced Paramedics are authorised to administer Morphine P use of IM Morphine by Paramedic or EMT practitioners up to 10 mg IM if IV not accessible, the patient is cardio- for a specific patient in an inaccessible location vascularly stable and no cardiac chest pain present

Reference: World Health Organization, Pain Ladder

PHECC Clinical Practice Guidelines - Emergency Medical Technician 23 SECTION 3 - RESPIRATORY EMERGENCIES

4.3.1 03/11 Advanced Airway Management – Adult CFR - A EMT

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

2nd attempt Supraglottic Airway insertion RESPIRATORY EMERGENCIES RESPIRATORY Advanced Airway Management - Adult

Maintain adequate ventilation and Successful Yes S3 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:- Continue ventilation and oxygenation i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute

Go to appropriate CPG

Reference: ILCOR Guidelines 2010

24 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 3 - RESPIRATORY EMERGENCIES

4.3.2 Version 2, 03/11 Inadequate Respirations – Adult EMT

Equipment list Respiratory Volumizer to be difficulties used to administer Salbutamol Regard each emergency asthma call Assess and maintain airway as for acute severe asthma until it is shown otherwise

Oxygen therapy

Respiratory assessment

Inadequate rate or depth RR < 10 Audible No wheeze

Yes Request

ALS Request Paramedic assistance RESPIRATORY EMERGENCIES RESPIRATORY - Adult Inadequate Respirations

Salbutamol, 2 puffs, Positive pressure ventilations (0.2 mg) metered aerosol Max 10 per minute S3

Reassess

ECG & SpO2 monitoring

Acute severe asthma Life threatening asthma Any one of; Any one of the following in a patient with severe asthma; Respiratory rate ≥ 25/ min SpO2 < 92% Heart rate ≥ 110/ min Silent chest Inability to complete sentences in one breath Cyanosis Feeble respiratory effort Bradycardia Arrhythmia Hypotension Exhaustion Moderate asthma exacerbation Confusion Increasing symptoms Unresponsive No features of acute severe asthma

Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline

PHECC Clinical Practice Guidelines - Emergency Medical Technician 25 SECTION 3 - RESPIRATORY EMERGENCIES

4.3.3 05/09 Exacerbation of COPD EMT

Dyspnoea

History of No COPD

Yes

Oxygen Therapy 1. if O2 alert card issued follow directions. Oxygen therapy 2. if no O2 alert card, commence therapy at 28% 3. administer O2 titrated to SpO2 92%

Go to ECG & SpO2 Inadequate monitor Respirations CPG

Request

ALS

Adequate

RESPIRATORY EMERGENCIES RESPIRATORY Exacerbation of COPD No respirations

Yes S3

An exacerbation of COPD is defined as; An event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough and/or sputum beyond day-today variability sufficient to warrant a change in management. (European Respiratory Society)

26 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.1 Version 2, 06/11 Basic Life Support – Adult EMT P

Cardiac Initiate mobilisation of 3 to 4 Arrest practitioners / responders on site to assist with cardiac arrest management Request

ALS

Chest compressions Rate: 100 to 120/ min Attach defibrillation pads Depth: at least 5 cm Commence CPR while defibrillator is being prepared only if 2nd person available 30 Compressions : 2 ventilations. Oxygen therapy Ventilations Rate: 10/ min (1 every 6 sec) Volume: 500 to 600 mL

AP Change defibrillator to manual mode Shockable Assess Non - Shockable VF or pulseless VT Rhythm Asystole or PEA P Consider changing defibrillator to manual mode Give 1 shock

Continue CPR while defibrillator is charging Minimum interruptions of Immediately resume CPR chest compressions.

x 2 minutes MEDICAL EMERGENCIES Basic Life Support - Adult

Maximum hands off time 10 seconds.

Rhythm check * S4

Go to VF/ Go to Post Pulseless VT VF/ VT ROSC Resuscitation CPG Care CPG

Go to Go to PEA Asystole Asystole PEA CPG CPG

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.

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

PHECC Clinical Practice Guidelines - Emergency Medical Technician 27 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.4 06/11 Basic Life Support – Paediatric (≤ 13 Years) EMT P

AP Cardiac arrest or Initiate mobilisation of 3 to 4 practitioners / responders pulse < 60 per minute with signs of poor perfusion on site to assist with cardiac arrest management Give 5 rescue ventilations Oxygen therapy

One rescuer CPR 30 : 2 Two rescuer CPR 15 : 2 Request Compressions : Ventilations

ALS

Chest compressions Minimum interruptions of Rate: 100 to 120/ min 1 chest compressions. Depth: /3 depth of chest Commence chest Compressions Child; two hands Continue CPR (30:2) until defibrillator is attached Small child; one hand Maximum hands off time Infant (< 1); two fingers 10 seconds.

With two rescuer CPR use two thumb-encircling hand Yes < 8 years No chest compression for infants

AP Change defibrillator to manual mode < 8 years use paediatric Apply paediatric system Apply adult defibrillation defibrillation system P Consider changing AED pads pads (if not available use adult pads) defibrillator to manual mode

Assess Non - Shockable MEDICAL EMERGENCIES Basic Life Support - Paediatric Shockable Continue VF or pulseless VT Rhythm Asystole or PEA CPR while defibrillator is charging S4 Give 1 shock

Immediately resume CPR x 2 minutes

Rhythm check *

Go to VF / Go to Post Pulseless VT VF/ VT ROSC Resuscitation CPG Care CPG

Asystole / PEA

Go to Asystole / PEA CPG

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 * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm 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), Reference: ILCOR Guidelines 2010 because of the infant’s small size.

28 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5.4.5 EMT P 05/08 Foreign Body Airway Obstruction – Adult

Are you FBAO choking?

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

No Conscious Yes Encourage cough

1 to 5 back blows followed by 1 to 5 abdominal thrusts as indicated

Yes Request Adequate No Conscious No Effective Yes Yes ventilations ALS

Positive pressure One cycle of CPR ventilations maximum 10 per minute

Consider Effective Yes Oxygen therapy

No MEDICAL EMERGENCIES Body Airway Obstruction - Adult Foreign

One cycle of CPR S4

Effective Yes

No Oxygen therapy

Go to BLS Adult CPG

After each cycle of CPR open mouth and look for object. If visible attempt once to remove it

PHECC Clinical Practice Guidelines - Emergency Medical Technician 29 SECTION 4 - MEDICAL EMERGENCIES

4/5.4.6 EMT P 05/08 Foreign Body Airway Obstruction – Paediatric (≤ 13 years)

Are you

13 years) FBAO choking? ≤

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

No Conscious Yes

1 to 5 back blows followed by 1 to 5 thrusts Encourage cough (child – abdominal thrusts) (infant – chest thrusts) as indicated Yes

Request Breathing No Conscious No Effective Yes Yes adequately ALS

No Open mouth and look for object If visible one attempt to Positive pressure remove it ventilations (12 to 20/ min)

Attempt 5 Rescue Breaths Consider

Oxygen therapy

One cycle of CPR MEDICAL EMERGENCIES ( Body Airway Obstruction - Paediatric Foreign

Effective Yes S4 No

One cycle of CPR

Effective Yes

No Oxygen therapy

Go to BLS Paediatric CPG

After each cycle of CPR open mouth and look for object. If visible attempt once to remove it

30 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.7 EMT P Version 2, 03/11 VF or Pulseless VT – Adult

AP From BLS VF or VT Adult CPG arrest

Refractory VF/VT post Epinephrine AP Amiodarone 300 mg (5 mg/kg) IV/ IO

Immediate IO access if IV nd 2 dose (if required) not immediately accessible Amiodarone 150 mg (2.5 mg/kg) IV/ IO

Go to Post Resuscitation ROSC Care CPG

Defibrillate Yes

Go to PEA No PEA CPG VF/VT

Advanced airway management NaCl IV/IO 500 mL Go to (use as flush) Asystole Asystole Rhythm Consider CPG check * mechanical Epinephrine (1:10 000) 1 mg IV/IO CPR assist Every 3 to 5 minutes prn

If torsades de pointes, consider Initial Epinephrine Magnesium Sulphate 2 g IV/IO between 2nd and 4th shock MEDICAL EMERGENCIES VF or Pulseless VT - Adult Consider transport to ED if no change after 20 minutes resuscitation

If no ALS available S4

With CPR ongoing maximum hands off time 10 seconds Continue CPR during charging

Mechanical CPR device is the optimum care during transport Drive smoothly Initiate mobilisation of 3 to 4 practitioners / responders Consider causes and treat as Clinical leader to on site to assist with cardiac appropriate: monitor quality arrest management Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Hypovolaemia Consider use Hypoxia of waveform Thrombosis – pulmonary capnography Tension pneumothorax Thrombus – coronary Tamponade – cardiac If Tricyclic Antidepressant Toxicity consider AP Special Authorisation: Toxins Sodium Bicarbonate 8.4% 50 mL IV Trauma Advanced Paramedics are authorised to substitute Amiodarone with a one off bolus * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm of Lidocaine (1-1.5 mg/Kg IV) if Amiodarone is not available Reference: ILCOR Guidelines 2010

PHECC Clinical Practice Guidelines - Emergency Medical Technician 31 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.8 Version 2, 06/11 VF or Pulseless VT – Paediatric (≤ 13 years) EMT P

AP From BLS VF or VT Child arrest CPG < 8 years use paediatric defibrillation system (if not available use adult pads) AP Immediate IO access if IV not immediately accessible Refractory VF/VT post Epinephrine

Amiodarone, 5 mg/kg, IV/IO 13 years) ≤

Go to Post Resuscitation ROSC Defibrillate Care CPG Yes (4 joules/Kg)

No VF/VT

Go to AP Asystole / Asystole/PEA Advanced airway PEA CPG management

Rhythm Check blood glucose check * Epinephrine (1:10 000), 0.01 mg/kg IV/IO Repeat every 3 to 5 minutes prn

Initial Epinephrine between 2nd and 4th shock

MEDICAL EMERGENCIES ( VF or Pulseless VT - Paediatric Transport to ED if no change after 10 minutes resuscitation If no ALS available S4

With CPR ongoing maximum hands off time 10 seconds Continue CPR during charging Drive smoothly Following successful Advanced Airway management:- i) Ventilate at 12 to 20 per minute. ii) Unsynchronised chest Clinical leader to compressions continuous at 100 Consider causes and treat as monitor quality appropriate: to 120 per minute Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Consider use Hypovolaemia of waveform Hypoxia capnography Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Tamponade – cardiac Initiate mobilisation of 3 to 4 Toxins practitioners / responders Trauma on site to assist with cardiac arrest management * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

32 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.9 Version 2, 07/11 Symptomatic Bradycardia – Paediatric (≤ 13 years) EMT P

AP Symptomatic Bradycardia

Signs of inadequate perfusion Oxygen therapy Tachycardia Initiate mobilisation of 3 to 4

Diminished/absent peripheral pulses practitioners / responders 13 years) Positive pressure

Tachypnoea on site to assist with cardiac ≤ Irritability/ confusion / ALoC ventilations arrest management Cool extremities, mottling (12 to 20/ min) Delayed capillary refill

Request AP ALS Immediate IO access if IV not immediately accessible

HR < 60 & signs of No inadequate perfusion

Yes

CPR

ECG & SpO2 monitoring

NaCl (0.9%) 20 mL/Kg IV/IO MEDICAL EMERGENCIES ( - Paediatric Symptomatic Bradycardia

Check blood glucose Reassess S4 Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IO Every 3 – 5 min prn

Persistent No bradycardia

P Yes Consider advanced airway management if prolonged CPR Continue CPR

If no ALS available

Reference: International Liaison Committee on Resuscitation, 2010, Part 6: Paediatric basic and advanced life support, Resuscitation (2005) 67, 271 – 291

PHECC Clinical Practice Guidelines - Emergency Medical Technician 33 SECTION 4 - MEDICAL EMERGENCIES

4.4.10 Version 2, 03/11 Asystole – Adult EMT

From BLS Adult Asystole Initiate mobilisation of 3 to 4 CPG practitioners / responders on site to assist with cardiac arrest management

Go to Post Resuscitation ROSC Care CPG

Yes

Go to PEA No PEA CPG Asystole

Advanced airway Go to VF / management Pulseless VT VF/VT Rhythm CPG check * Consider mechanical CPR assist

Consider transport to ED if no change after 20 minutes resuscitation

If no ALS available MEDICAL EMERGENCIES Asystole - Adult

S4 With CPR ongoing maximum hands off time 10 seconds

Mechanical CPR device is the optimum care during transport Drive smoothly Clinical leader to monitor quality of CPR

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

34 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.11 Version 2, 03/11 Pulseless Electrical Activity – Adult EMT P

AP From BLS Adult PEA CPG Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac AP arrest management Immediate IO access if IV not immediately accessible

Go to Post Resuscitation ROSC Care CPG

Yes

Go to Asystole Asystole No PEA CPG

Advanced airway management Go to VF / Rhythm Pulseless VT VF/VT Epinephrine (1:10 000) 1 mg IV/ IO Consider CPG check * Every 3 to 5 minutes prn mechanical CPR assist

NaCl IV/IO 500 mL (use as flush) MEDICAL EMERGENCIES Pulseless Electrical Activity - Adult Consider transport to ED if no change after 20 minutes resuscitation If no ALS available S4

With CPR ongoing maximum hands off time

Mechanical CPR device is 10 seconds the optimum care during transport Drive smoothly

Clinical leader to Consider causes and treat as appropriate: monitor quality Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Consider use Hypovolaemia of waveform Hypoxia capnography Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Consider fluid challenge Tamponade – cardiac If Tricyclic Antidepressant Toxicity consider Toxins NaCl 20 mL/Kg IV/IO Trauma Sodium Bicarbonate 8.4% 50 mL IV

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

PHECC Clinical Practice Guidelines - Emergency Medical Technician 35 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.12 Version 2, 03/11 Asystole/PEA – Paediatric ( ≤ 13 years) EMT P

AP From BLS Asystole/ PEA Child CPG arrest Initiate mobilisation of 3 to 4 practitioners / responders AP on site to assist with cardiac arrest management Immediate IO access if IV not immediately accessible

Go to Post Resuscitation ROSC Care CPG Yes Asystole/ 13 years) No PEA ≤

Go to VF / Pulseless VT VF/VT AP CPG Rhythm Advanced airway check * Epinephrine (1:10 000), 0.01 mg/kg IV/IO management Repeat every 3 to 5 minutes prn Check blood glucose

Transport to ED if no change after 10 minutes resuscitation If no ALS available MEDICAL EMERGENCIES ( Asystole/PEA - Paediatric

S4 With CPR ongoing maximum hands off time 10 seconds Drive smoothly

Clinical leader to monitor quality of CPR

Consider causes and treat as appropriate: Following successful Advanced Hydrogen ion acidosis Airway management:- Hyper/ hypokalaemia i) Ventilate at 12 to 20 per minute. Hypothermia ii) Unsynchronised chest Hypovolaemia compressions continuous at 100 Hypoxia to 120 per minute Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Consider fluid challenge Tamponade – cardiac AP Toxins NaCl 20 mL/Kg IV/IO Consider use Trauma of waveform capnography

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

36 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4.4.14 Version 2, 03/11 Post-Resuscitation Care – Adult EMT

Return of Spontaneous Circulation Maintain Titrate O2 to Oxygen therapy 94% - 98%

Equipment list Request Cold packs ALS

Conscious Yes

Adequate No ventilation

Yes

Positive pressure ventilations Max 10 per minute Recovery position

For active cooling place Consider active cold packs at arm pit, cooling if groin & abdomen unresponsive MEDICAL EMERGENCIES - Adult Care Post-Resuscitation

Maintain patient at rest S4

ECG & SpO2 monitoring

Monitor vital signs

Check blood glucose

Maintain care until handover to appropriate Practitioner

If no ALS available

Drive smoothly

Reference: ILCOR Guidelines 2010

PHECC Clinical Practice Guidelines - Emergency Medical Technician 37 SECTION 4 - MEDICAL EMERGENCIES

4.4.15 05/08 Recognition of Death – Resuscitation not Indicated EMT

Apparent dead body

Go to Primary Signs of Life Yes survey CPG No

Definitive indicators of No Death Definitive indicators of death: 1. Decomposition Yes 2. Obvious rigor mortis 3. Obvious pooling (hypostasis) 4. Incineration 5. Decapitation 6. Injuries totally incompatible with life It is inappropriate to commence resuscitation

Inform Ambulance Control

Complete all appropriate documentation

Await arrival of

MEDICAL EMERGENCIES Recognition of Death - Resuscitation not Indicated appropriate Practitioner and / or Gardaí S4

38 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4.4.16 Version 2, 09/11 Cardiac Chest Pain – Acute Coronary Syndrome EMT

Cardiac chest pain

Oxygen therapy Oxygen therapy Maintain SpO2 between 94% to 98% (lower range if COPD) Request

ALS

Apply 3 lead ECG & SpO2 monitor

Aspirin, 300 mg PO

Yes Chest Pain

Time critical No commence transport to GTN, 0.4 mg SL definitive care ASAP Repeat to max of 1.2 mg SL prn

Monitor vital signs MEDICAL EMERGENCIES Syndrome - Acute Coronary Chest Pain Cardiac

PHECC Clinical Practice Guidelines - Emergency Medical Technician 39 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.17 05/08 Symptomatic Bradycardia – Adult EMT P

AP Symptomatic Bradycardia Oxygen therapy

Request

ALS

ECG & SpO2 monitoring

Atropine, 0.5 mg IV Repeat at 3 to 5 min intervals prn to max 3 mg

P 12 lead ECG

Reassess MEDICAL EMERGENCIES - Adult Symptomatic Bradycardia

40 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4.4.18 Version 2, 03/11 Allergic Reaction/Anaphylaxis – Adult EMT

Allergic reaction

Oxygen therapy

Severe/ Moderate Mild anaphylaxis

Epinephrine administered pre No arrival? (within 5 minutes)

Salbutamol 2 puffs Yes Patient prescribed (0.2 mg) metered aerosol Monitor Epinephrine auto Yes reaction injection

No Reassess Epinephrine (1:1 000) 300 mcg Auto injection

ECG & SpO2 monitor

Consider subject to conditions above Request Deteriorates Yes Epinephrine (1:1 000) 300 mcg Auto injection ALS

No MEDICAL EMERGENCIES Reaction/Anaphylaxis - Adult Allergic Consider Paramedic Reassess S4

Severe/ anaphylaxis Mild Moderate Moderate symptoms + Urticaria and or angio Mild symptoms + simple haemodynamic and or oedema bronchospasm respiratory compromise

PHECC Clinical Practice Guidelines - Emergency Medical Technician 41 SECTION 4 - MEDICAL EMERGENCIES

4.4.19 05/08 Glycaemic Emergency – Adult EMT

Abnormal blood glucose level

< 4 mmol/L Blood Glucose 11 to 20 mmol/L

A or V Yes No on AVPU > 20 mmol/L

Consider Glucagon 1 mg IM Glucose gel, 10 - 20 g buccal or Sweetened drink

Consider

Reassess ALS

Allow 5 minutes to elapse following administration of medication

Reassess MEDICAL EMERGENCIES - Adult Glycaemic Emergency

Blood Glucose Yes ≥ 4 mmol/L

S4 No

Consider Repeat x 1 prn

ALS Glucose gel 10-20 g buccal

42 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4.4.20 EMT Version 2, 07/11 Seizure/Convulsion – Adult

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

Seizing currently Seizure status Post seizure

Request Consider

ALS ALS

Support head Alert Yes

No Check blood glucose

Recovery position Go to Glycaemic Blood glucose Yes Emergency < 4 mmol/L CPG Airway management MEDICAL EMERGENCIES - Adult Seizure/Convulsion No

Reassess Check blood glucose S4

Still seizing No

Yes Go to Glycaemic Blood glucose Yes Emergency < 4 mmol/L Transport to ED if requested by CPG Ambulance Control No

Reassess

PHECC Clinical Practice Guidelines - Emergency Medical Technician 43 SECTION 4 - MEDICAL EMERGENCIES

4.4.22 05/08 Stroke EMT

Acute neurological symptoms

Complete a FAST assessment

Maintain airway

Oxygen therapy Oxygen therapy Maintain SpO2 between 94% to 98% (lower range if COPD) Check blood glucose

Go to BG Glycaemic Yes < 4 or > 20 Emergency mmol/L CPG No

ECG & SPO2 monitoring

Consider Paramedic MEDICAL EMERGENCIES Stroke

Follow local protocol re S4 notifying ED prior to arrival

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

Reference: ILCOR Guidelines 2010

44 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5.4.23 05/08 Poisons – Adult EMT P

Poison source

Ingestion Inhalation Injection Absorption

Yes Corrosive No No Site burns Yes

Sips of water or milk Cool area

Go to Caution with Consider decontamination Inadequate Adequate oral intake No prior to transportation Respirations ventilations CPG Yes

Consider

ALS

Poison type MEDICAL EMERGENCIES - Adult Poisons

Paraquat Other Alcohol S4

Do not give Check blood Oxygen therapy oxygen glucose

Go to Consider BG Glycaemic No < 4 or > 20 Yes Oxygen therapy Emergency mmol/L CPG

P Note: Inadequate respirations CPG, authorises the administration of Naloxone IM for opiate overdose by Paramedics

Reference: Dr Joe Tracey, Director, National Poison Information Centre

PHECC Clinical Practice Guidelines - Emergency Medical Technician 45 SECTION 4 - MEDICAL EMERGENCIES

4/5.4.24 05/08 Hypothermia EMT P

Query hypothermia

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

Protect patient from wind chill

Complete primary survey Pulse check for (Commence CPR if appropriate) 30 to 45 seconds

Oxygen therapy Warmed O2 Hypothermic patients if possible should be handled gently & not permitted to walk Remove wet clothing by cutting

Place patient in dry blankets/ sleeping bag with outer layer of insulation

ECG & SpO2 monitoring

Mild Moderate/ severe (Responsive) (Unresponsive)

Request MEDICAL EMERGENCIES Hypothermia Give hot sweet drinks ALS S4

If Cardiac Arrest follow CPGs but - no active re-warming

Hot packs to armpits & groin

Check blood glucose Equipment list

Survival bag Transport in head down position Space blanket Helicopter: head forward Warm air rebreather Boat: head aft

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics AHA, 2005, Part 10.4: Hypothermia, Circulation 2005:112;136-138 Soar, J et al, 2005, European Resuscitation Council Guidelines 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

46 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.25 05/08 Epistaxis EMT P

Primary Primary Survey Medical Trauma Survey Medical Trauma

Advise patient to sit forward

Apply digital pressure for 3 to 5 minutes

Advise patient to breath through mouth only and not to blow nose

Go to Request Shock Yes Hypovolaemic CPG ALS

Haemorrhage No controlled

Yes Consider

ALS MEDICAL EMERGENCIES Epistaxis

PHECC Clinical Practice Guidelines - Emergency Medical Technician 47 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.26 Version 2, 07/11 Decompression Illness (DCI) EMT P

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

Oxygen therapy

100% O2

Request

ALS

Conscious No

Maintain Airway, Yes Breathing & Circulation

Go to Entonox absolutely Pain relief Pain Mgt. Yes contraindicated required CPG

AP Go to MEDICAL EMERGENCIES Illness (DCI) Decompression Nausea & Yes Nausea Vomiting CPG S4 No

Monitor ECG & SpO2

NaCl (0.9%) 500 mL IV/IO

Notify control of query DCI & alert ED

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

Special Authorisation: P Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

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

48 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4.4.27 05/08 Altered Level of Consciousness – Adult EMT

V, P or U on AVPU scale Maintain airway

No Trauma Yes

Consider Recovery Position Cervical Spine

P or U on Yes AVPU scale

Request Consider Paramedic ALS

Obtain SAMPLE history from patient, relative or bystander

ECG & SP02 monitoring MEDICAL EMERGENCIES Level of Consciousness - Adult Altered

Check temperature Check pupillary size & response Go to Symptomatic Go to Anaphylaxis Check for skin rash S4 CPG Bradycardia CPG

Check for medications carried or medical Glycaemic Go to Go to Submersion alert jewellery emergency CPG CPG incident

Check blood glucose Go to Shock from Go to Head injury CPG blood loss CPG

Differential Diagnosis Go to Inadequate Go to Hypothermia CPG respirations CPG

Post Go to Go to Poison resuscitation CPG CPG care

Go to Go to Seizures Stroke CPG CPG

PHECC Clinical Practice Guidelines - Emergency Medical Technician 49 SECTION 4 - MEDICAL EMERGENCIES

4/5/6.4.28 05/08 Behavioural Emergency EMT P

Behaviour AP abnormal Obtain a history from patient and or bystanders present as appropriate Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance Indications of Go to vehicle medical cause of Yes appropriate illness CPG

Potential Yes to harm self or others Request control No to inform Gardaí

Reassure patient Explain what is happening at all times If potential to harm self or others Avoid confrontation ensure minimum two people accompany patient in saloon of ambulance at all times Attempt verbal de-escalation

Patient agrees No to travel

Injury or illness Yes potentially serious or No MEDICAL EMERGENCIES Emergency Behavioural likely to cause lasting disability Offer to treat and or S4 Yes transport patient Inform patient of potential consequences of treatment refusal Treatment only No

Request control Yes to inform Gardaí and or Doctor

Is patient competent to No make informed decision Aid to Capacity Evaluation 1. Patient verbalizes/ communicates Yes understanding of clinical situation? 2. Patient verbalizes/ communicates appreciation of applicable risk? Await arrival of doctor or Advise alternative care options and 3. Patient verbalizes/ communicates Gardaí to call ambulance again if there is a ability to make alternative plan of care? change of mind or If no to any of the above consider receive implied consent Patient Incapacity

Document refusal of treatment and or transport to ED

Reference: HSE Mental Health Services

50 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 4 - MEDICAL EMERGENCIES

4/5.4.29 05/08 Mental Health Emergency EMT P

Behaviour abnormal with previous RMP – Registered Medical Practitioner RPN – Registered Psychiatric Nurse psychiatric history

RMP or RPN Practitioners may not in attendance or have made compel a patient to Yes arrangements for voluntary/ accompany them or assisted admission prevent a patient from leaving an ambulance vehicle No

Co-operate as Obtain a history from patient and or appropriate with If potential to harm self or others bystanders present as appropriate medical or nursing ensure minimum two people team accompany patient in saloon of ambulance at all times Potential Yes to harm self or Transport patient to an others Approved Centre Request control No to inform Gardaí

Reassure patient Explain what is happening at all times Avoid confrontation

Attempt verbal de-escalation MEDICAL EMERGENCIES Mental Health Emergency

Combative with hallucinations Yes or Paranoia & risk to self or others S4 Request No ALS

Patient agrees No to travel

Yes Request as appropriate - Gardaí Aid to Capacity Evaluation - Medical Practitioner 1. Patient verbalizes/ communicates - Mental health team understanding of clinical situation? 2. Patient verbalizes/ communicates appreciation of applicable risk? 3. Patient verbalizes/ communicates ability to make alternative plan of care? If no to any of the above consider Patient Incapacity

Reference; Reference Guide to the Mental Health Act 2001, Mental Health Commission HSE Mental Health Services

PHECC Clinical Practice Guidelines - Emergency Medical Technician 51 SECTION 4 - MEDICAL EMERGENCIES

4.4.31 06/10 End of Life – DNR EMT

End stage Patient becomes terminal acutely unwell illness

The dying patient, along Respiratory Yes with his/her family, is viewed distress as a single unit of care Basic airway maintenance No

Oxygen therapy

Confirm and agree Recent & procedure with reliable written clinical staff in the instruction from patient’s No event of a death in doctor stating that the transit patient is not for resuscitation Go to Primary Yes survey CPG

Agreement between caregivers present and Practitioners No not to resuscitate

Yes

It is inappropriate to commence resuscitation MEDICAL EMERGENCIES End of Life - DNT

Inform Ambulance S4 Control

Yes Pulse present Appropriate Practitioner Provide supportive care until handover Registered Medical Practitioner No Registered Nurse to appropriate Registered Advanced Paramedic Practitioner Registered Paramedic Registered EMT Consult with Ambulance Follow local Control re; ‘location to protocol for care transport patient / of deceased deceased’

Complete all appropriate documentation

Emotional support Keep next of kin for relatives should informed, if be considered before present leaving the scene

52 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 5 - OBSTETRIC EMERGENCIES

4.5.1 05/08 Pre-Hospital Emergency Childbirth EMT

Query labour

Take SAMPLE history

Patient in No labour

Yes

Birth imminent or No travel time too long

Yes

Request Ambulance Control to contact GP / Request midwife/ medical team as required by local policy to come to scene or meet en route ALS

Consider Position mother Entonox

Monitor vital signs and BP

Birth Yes Complications

Support baby throughout delivery

Dry baby and check ABCs OBSTETRIC EMERGENCIES Childbirth Emergency Pre-Hospital Go to BLS Baby No Neonate stable CPG Yes S5

Wrap baby to maintain temperature

Go to Primary Mother No Survey stable CPG Yes

If placenta delivers, retain for inspection

Reassess Rendezvous with Paramedic, Advanced Paramedic, midwife or doctor en-route to hospital

PHECC Clinical Practice Guidelines - Emergency Medical Technician 53 SECTION 5 - OBSTETRIC EMERGENCIES

4.5.2 EMT 05/08 Basic Life Support – Neonate (< 4 weeks)

From Initiate mobilisation of 3 to 4 Childbirth Birth practitioners / responders CPG on site to assist with cardiac arrest management

Term gestation Amniotic fluid clear Yes < 4 weeks old Breathing or crying Good muscle tone

Request

ALS

Provide warmth Provide warmth Position; Clear airway if necessary Dry baby Dry, stimulate, reposition

Assess respirations, heart rate & colour Breathing, HR > 100

Not breathing or HR < 100 Breathing, HR > 100 but Cyanotic

Give Supplementary O2

OBSTETRIC EMERGENCIES Basic Life Support - Neonate (< 4 weeks) Persistent No Cyanosis

S5 Yes

Provide positive pressure ventilation for 30 sec

Assess Heart HR < 60 HR 60 to 100 Rate

CPR for 30 sec Breathing well, HR > 100 (Ratio 3 : 1)

Wrap baby well and give to mother Observe baby Contact Ambulance Control If HR < 60 continue CPR (3 : 1 ratio), for direction on transport checking HR every 30 sec, until appropriate Practitioner takes over or HR > 60

54 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 6 - TRAUMA

4/5/6.6.1 05/08 External Haemorrhage – Adult EMT P

Open AP wound

Yes Active bleeding

Posture No Elevation Examination Pressure

Apply sterile dressing

Consider Oxygen therapy

Haemorrhage No controlled

Apply additional Yes dressing(s)

Haemorrhage Yes controlled

No P Depress proximal pressure point

Haemorrhage Yes controlled

No P Apply tourniquet

Go to Significant Yes Shock blood loss CPG

No TRAUMA External Haemorrhage - Adult

PHECC Clinical Practice Guidelines - Emergency Medical Technician 55 SECTION 6 - TRAUMA

4.6.2 05/08 Shock from Blood Loss – Adult EMT

Signs of poor perfusion

Control external haemorrhage

Oxygen therapy

Request

ALS

SpO2 & ECG monitor

Signs of poor perfusion Tachycardia Diminished/absent peripheral pulses Tachypnea Irritability/ confusion / ALoC Cool, pale & moist skin Delayed capillary refill TRAUMA Blood Loss - Adult Shock from

56 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 6 - TRAUMA

4.6.3 Spinal Immobilisation – Adult 05/08 EMT

Trauma Indications for spinal immobilisation Do not forcibly restrain a If in doubt, patient that is combatitive treat as spinal injury Return head to neutral position unless on movement there is Increase in Pain, Resistance or Neurological symptoms

Stabilise cervical spine

Consider Paramedic

Remove helmet (if worn)

Equipment list Long board Vacuum mattress Life Orthopaediac stretcher Yes No Threatening Rigid cervical collar

Apply cervical collar

Patient in Yes No sitting position

Prepare extrication Rapid extrication with long device for use board and cervical collar Follow direction of Paramedic, Advanced Paramedic or doctor

Load onto vacuum mattress/ long board TRAUMA Spinal Immobilisation - Adult

Consider Vacuum mattress S6

Dangerous mechanism include; Fall ≥ 1 meter/ 5 steps Axial load to head MVC > 100 km/hr, rollover or ejection ATV collision Bicycle collision Pedestrian v vehicle

PHECC Clinical Practice Guidelines - Emergency Medical Technician 57 SECTION 6 - TRAUMA

4/5/6.6.4 Version 2, 07/11 Burns – Adult EMT P

AP Burn or Cease contact with heat source Scald

Inhalation and/or facial Yes injury Should cool for another Airway management 10 minutes during No packaging and transfer Go to Respiratory Yes Inadequate distress Respirations CPG No

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

Remove burned clothing & jewellery (unless stuck) Equipment list Acceptable dressings Burns gel (caution for > 10% TBSA) Dressing/ covering Cling film of burn area Sterile dressing Clean sheet Go to Pain Mgt. Yes Pain > 2/10 CPG No

F: face Caution with the elderly, H: hands Isolated superficial injury circumferential & electrical burns F: feet Yes No F: flexion points (excluding FHFFP) P: perineum

Request TBSA burn No Yes > 10% ALS

ECG & SpO2 monitoring

> 25% TBSA and or time from No Yes injury to ED TRAUMA Burns - Adult > 1 hour Consider NaCl (0.9%), 500 mL, IV/IO NaCl (0.9%), 1000 mL, IV/IO S6

Monitor body temperature

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

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

58 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 6 - TRAUMA

4/5/6.6.5 Version 3, 02/12 Limb Injury – Adult EMT P

AP Limb injury

Consider Go to Establish need for pain relief Pain Mgt. ALS CPG

Expose and examine limb

Equipment list Traction splint Dress open wounds Box splint Frac straps Triangular bandages Vacuum splints Provide manual stabilisation for Long board injured limb Orthopaedic stretcher Cold packs Elastic bandages Pelvic splinting device Check CSMs distal to injury site

Injury type

Fracture mid shaft Fracture Soft tissue injury Dislocation of femur

Isolated lateral Yes dislocation of patella

P Rest AP Apply Splint/support Reduce Apply traction Ice appropriate in position dislocation and splint Compression splinting device found apply splint Elevation

Recheck CSMs TRAUMA Limb Injury - Adult

For a limb threatening injury treat as an emergency and pre alert ED S6

Contraindications for application of traction splint 1 # pelvis 2 # knee 3 Partial amputation 4 Injuries to lower third of lower leg 5 Hip injury that prohibits normal alignment

Reference: An algorithm guiding the evaluation and treatment of acute primary patellar dislocations, Mehta VM et al. Sports Med Arthrosc. 2007 Jun;15(2):78-81

PHECC Clinical Practice Guidelines - Emergency Medical Technician 59 SECTION 6 - TRAUMA

4.6.6 05/08 Head Injury – Adult EMT

Head trauma Maintain Airway

Equipment list Oxygen therapy

Extrication device Long board Control external haemorrhage Vacuum mattress Orthopaedic stretcher Rigid cervical collar Maintain in-line immobilisation

P or U on Yes No AVPU

Request Consider Paramedic ALS

Apply cervical collar

Secure to long board

SpO2 & ECG monitoring

See Glycaemic Check blood glucose Emergency CPG

Seizures No

Yes

Go to Seizures / Consider Vacuum Convulsions mattress CPG TRAUMA Head Injury - Adult

Reference; Mc Swain, N, 2003, Pre Hospital Trauma Life Support 5th Edition, Mosby

60 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 6 - TRAUMA

4/5/6.6.7 05/08 Submersion Incident EMT P

AP Submerged Request in liquid ALS Remove patient from liquid (Provided it is safe to do so)

Remove horizontally if possible (consider C-spine injury) Spinal injury indicators History of; Ventilations may be - diving commenced while the - trauma Complete primary survey patient is still in water - water slide use (Commence CPR if appropriate) by trained rescuers - alcohol intoxication

Go to Inadequate Inadequate Yes respirations Respirations CPG No Higher pressure may be Oxygen therapy required for ventilation because of poor compliance resulting from

SpO2 & ECG monitoring pulmonary oedema

Indications Yes of respiratory distress

Monitor Pulse, If bronchospasm consider Respirations & BP Salbutamol ≥ 5 years 5 mg NEB < 5 years 2.5 mg NEB Go to Patient is Yes Hypothermia hypothermic CPG

Check blood glucose

Do not delay on site Transport to ED for Continue algorithm en route investigation of

secondary drowning TRAUMA Incident Submersion insult S6

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 Shepherd, S, 2005, Submersion Injury, Near Drowning, E Medicine, www.emedicine.com/emerg/topic744.htm AHA, 2005, Part 10.3: Drowning, Circulation 2005:112;133-135 Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170

PHECC Clinical Practice Guidelines - Emergency Medical Technician 61 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.1 Version 3, 03/12 Primary Survey Medical – Paediatric (≤ 13 Years) EMT P

AP Medical Take standard infection control precautions issue

Consider pre-arrival information The primary survey is focused on establishing the patient’s clinical status and only applying interventions when they are essential to maintain life. Scene safety It should be completed within one Scene survey Paediatric Assessment Triangle minute of arrival on scene. Scene situation

Paediatric Assessment Triangle

Work of Appearance Breathing

Suction, A Head tilt/ OPA No Airway patent & Circulation chin lift to skin P NPA protected Ref: Pediatric Education for Prehospital Professionals Yes

Give 5 B Consider Ventilations No Adequate Oxygen therapy ventilation Oxygen therapy Yes 13 years) ≤

C Pulse < 60 & signs Yes of poor perfusion

AVPU assessment

Go to Life Non serious Secondary Clinical status decision threatening or life threat Survey CPG Serious not life threat

If child protection concerns are present Request

ALS Report findings as per

PAEDIATRIC EMERGENCIES PAEDIATRIC ( Primary Survey Medical - Paediatric Children First guidelines to ED staff and line manager in a confidential manner Go to appropriate S7 CPG Normal ranges Age Pulse Respirations Infant 100 – 160 30 – 60 Toddler 90 – 150 24 – 40 Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30

Reference: ILCOR Guidelines 2010, American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals Department of Children and Youth Affairs, 2011, Children First: National Guidance for the protection and Welfare of Children

62 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.2 Primary Survey Trauma – Paediatric (≤ 13 years) Version 3, 03/12 EMT P

Trauma Take standard infection control precautions AP

Consider pre-arrival information Paediatric Assessment Triangle The primary survey is focused on establishing the patient’s clinical status Scene safety and only applying interventions when Scene survey they are essential to maintain life. Scene situation It should be completed within one minute of arrival on scene. Work of Appearance Breathing Paediatric Assessment Triangle

Circulation Control catastrophic to skin external haemorrhage Ref: Pediatric Education for Prehospital Professionals

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

Suction, A Jaw thrust OPA No Airway patent & (Head tilt/ chin lift) P NPA(> 1 year) protected Yes

Give 5 B Consider 13 years) Ventilations No ≤ Adequate Oxygen therapy ventilation Oxygen therapy Yes

C Pulse < 60 & signs Yes of poor perfusion

No If child protection concerns AVPU assessment are present

Expose & check obvious injuries Report findings as per Children First guidelines to ED staff and line manager in a confidential manner Treat life threatening injuries only

Go to Life Non serious Secondary EMERGENCIES PAEDIATRIC ( - Paediatric Primary Survey Trauma Clinical status decision threatening or life threat Survey CPG Serious not S7 life threat Go to Request Normal ranges appropriate Age Pulse Respirations CPG ALS Infant 100 – 160 30 – 60 Toddler 90 – 150 24 – 40 Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30 Reference: ILCOR Guidelines 2010, American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals Department of Children and Youth Affairs, 2011, Children First: National Guidance for the protection and Welfare of Children

PHECC Clinical Practice Guidelines - Emergency Medical Technician 63 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.4 Version 2, 03/12 Secondary Survey – Paediatric ( ≤ 13 years) EMT P

AP Primary Survey

Make appropriate contact Use age appropriate with patient and or guardian language for patient if possible

Identify presenting complaint and exact chronology from the time the patient was last well Children and adolescents should Check for normal patterns of always be examined with a chaperone - feeding (usually a parent) where possible - toilet - sleeping - interaction with guardian

Estimated weight Identify patient’s weight (Age x 3) + 7 Kg

Head to toe examination Go to Identify positive findings Observing for appropriate and initiate care - pyrexia CPG management - rash - pain - tenderness - bruising - wounds - fractures - medical alert jewellery

Normal ranges Age Pulse Respirations Re-check vital Infant 100 – 160 30 – 60 signs Toddler 90 – 150 24 – 40 13 years) 13 years) Pre school 80 – 140 22 – 34 ≤ School age 70 – 120 18 – 30 Check for current medications

If child protection concerns PAEDIATRIC EMERGENCIES PAEDIATRIC ( Secondary Survey - Paediatric are present

S7 Report findings as per Children First guidelines to ED staff and line manager in a confidential manner

Reference: Miall, Lawrence et al, 2003, Paediatrics at a Glance, Blackwell Publishing Department of Children and Youth Affairs, 2011, Children First: National Guidance for the protection and Welfare of Children Luscombe, M et al 2010, BMJ, Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weightﾼ3(age)+7’

64 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.5 Version 2, 03/11 Inadequate Respirations – Paediatric (≤ 13 years) EMT

Inadequate respirations Equipment list Volumizer to be Regard each emergency asthma call used to administer Assess and maintain airway as for acute severe asthma until it is Salbutamol shown otherwise

Do not distress Permit child to adopt position of comfort

Go to Consider FBAO FBAO CPG

Oxygen therapy

Unresponsive patient with Audible a falling respiratory rate No wheeze

Yes Request

ALS Request Paramedic assistance

Positive pressure ventilations 13 years)

12 to 20 per minute ≤ Salbutamol, 2 puffs, (0.2 mg) metered aerosol

Reassess

ECG & SpO2 monitoring

Moderate asthma exacerbation (2)

Increasing symptoms No features of acute severe asthma

Life threatening asthma Acute severe asthma Any one of the following in a patient with severe asthma; Any one of; Silent chest Inability to complete sentences in one breath or too PAEDIATRIC EMERGENCIES PAEDIATRIC ( - Paediatric Inadequate Respirations Cyanosis breathless to talk or feed Poor respiratory effort Respiratory rate > 30/ min for > 5 years old Hypotension > 50/ min for 2 to 5 years old Exhaustion Confusion Heart rate > 120/ min for > 5 years old S7 Unresponsive > 130/ min for 2 to 5 years old

Reference: British Thoracic Society, 2005, British Guidelines on the Management of Asthma, a national clinical guideline

PHECC Clinical Practice Guidelines - Emergency Medical Technician 65 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.6 05/08 Stridor – Paediatric (≤ 13 years) EMT P

AP Stridor

Consider FBAO

Assess & maintain airway

Croup or epiglottitis Yes suspected

No Do not insert anything into the mouth

Do not distress Transport in position of comfort

Humidified O2 – as high a concentration as tolerated Oxygen therapy

ECG & SpO2 monitoring 13 years) 13 years) ≤ PAEDIATRIC EMERGENCIES PAEDIATRIC ( Stridor - Paediatric

66 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.8 Version 2, 03/11 Allergic Reaction/Anaphylaxis – Paediatric (≤ 13 years) EMT

Allergic reaction Oxygen therapy

Severe/ Moderate Mild anaphylaxis

Epinephrine administered pre No Salbutamol 2 puffs arrival? (within 5 (0.2 mg) metered aerosol minutes)

Yes Patient prescribed Epinephrine auto Yes injection

No Epinephrine (1: 1 000) Monitor Reassess 6 mts to < 10 yrs use junior auto injector reaction ≥ 10 yrs use auto injector

ECG & SpO2 monitor ECG & SpO2 monitor 13 years) 13 years)

Consider subject to conditions above ≤ Epinephrine (1: 1 000) Request Deteriorates Yes 6 mts to < 10 yrs use junior auto injector ≥ 10 yrs use auto injector ALS No

Consider Reassess Paramedic PAEDIATRIC EMERGENCIES PAEDIATRIC ( Reaction/Anaphylaxis - Paediatric Allergic

Severe Mild Moderate Moderate symptoms + Urticaria and or angio Mild symptoms + simple haemodynamic and or S7 oedema bronchospasm respiratory compromise

PHECC Clinical Practice Guidelines - Emergency Medical Technician 67 SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.9 05/08 Glycaemic Emergency – Paediatric (≤ 13 years) EMT

Abnormal blood glucose level

< 4 mmol/L Blood Glucose > 10 mmol/L

A or V Yes No on AVPU Consider Glucose gel, 5-10 g buccal or Glucagon > 8 years 1 mg IM Sweetened drink ≤ 8 years 0.5 mg IM

Reassess

Yes Patient alert No

Request 13 years) 13 years)

≤ ALS PAEDIATRIC EMERGENCIES PAEDIATRIC ( - Paediatric Glycaemic Emergency

68 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.10 Version 2, 07/11 Seizure/Convulsion – Paediatric (≤ 13 years) EMT

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

Seizing currently Seizure status Post seizure

Consider Request ALS ALS

Support head Alert Yes

No Check blood glucose

Recovery position Go to Glycaemic Blood glucose Yes Emergency < 4 mmol/L CPG Airway No management 13 years) 13 years)

Reassess ≤ If pyrexial – cool child

Consider Still seizing No Paracetamol, 20 mg/kg, PO

Yes

Check blood glucose

Transport to ED if requested by Ambulance Control Go to Glycaemic Blood glucose Yes Emergency < 4 mmol/L CPG No

Reassess PAEDIATRIC EMERGENCIES PAEDIATRIC ( - Paediatric Seizure/Convulsion

PHECC Clinical Practice Guidelines - Emergency Medical Technician 69 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.11 05/08 External Haemorrhage – Paediatric (≤ 13 years) EMT P

Open wound

Yes Active bleeding

Posture No Elevation Examination Pressure

Apply sterile dressing

Consider Oxygen therapy

Haemorrhage No controlled

Apply additional Yes dressing(s)

13 years) 13 years) Haemorrhage

≤ Yes controlled

No P Depress proximal pressure point

Haemorrhage Yes controlled

No P Apply tourniquet

Go to Significant Yes Shock blood loss CPG

No PAEDIATRIC EMERGENCIES PAEDIATRIC ( External Haemorrhage - Paediatric

70 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.13 05/08 Shock from Blood Loss – Paediatric (≤ 13 years) EMT

Shock

Oxygen therapy

Control external haemorrhage

Request

ALS

SpO2 & ECG monitor 13 years) 13 years)

Signs of inadequate perfusion ≤ Tachycardia Diminished/absent peripheral pulses Tachypnea Irritability/ confusion / ALoC Cool extremities, mottling Delayed capillary refill PAEDIATRIC EMERGENCIES PAEDIATRIC ( Blood Loss - Paediatric Shock from

PHECC Clinical Practice Guidelines - Emergency Medical Technician 71 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.14 Version 2, 03/11 Pain Management – Paediatric (≤ 13 years) EMT P

AP Pain

Analogue Pain Scale The general principle in pain Pain assessment 0 = no pain……..10 = unbearable management is to start at the bottom rung of the pain ladder, and then to climb the ladder if pain is still present. Administer pain medication based on Practitioners, depending on his/ pain assessment and pain ladder her scope of practice, may recommendations make a clinical judgement and commence pain relief on a higher rung. Decisions to give analgesia must Yes or best achievable Adequate relief be based on clinical assessment of pain and not directly on a linear scale

No Go back to Reassess and move originating up the pain ladder if CPG appropriate

Morphine PO g PO for > 1 year Request mg/K ne 0.3 old only orphi mg M ax 10 ALS M or Severe pain Repeat Morphine (≥ 6 on pain scale) V IV at not < 2 min g/Kg I .05 m hine 0 intervals prn to Morp 0 mg Max 1 Max: 0.1 mg/kg IV

O /Kg P 13 years) 13 years) 0 mg or mol 2 nd / ≤ ceta a , Consider Para or ygen Consider d / & Ox an g PO xide ParamedicParamedic g/K us O 10 m Nitro inh rofen Ibup Moderate pain r sider g (3 to 5 on pain scale) d / o Con mg/K an n 0.1 nsetro mg) Onda ax 4 , wly (M ygen IV slo & Ox xide us O Nitro inh

O /Kg P 0 mg ns mol 2 ntio aceta erve Par al int Minor pain ologic rmac pha der (2 to 3 on pain scale) on n Lad er n c Pai oth diatri ider C Pae Cons PHEC

Wong – Baker Faces for 3 years and older PAEDIATRIC EMERGENCIES PAEDIATRIC ( Management - Paediatric Pain

S7 2 4 6 8 10 0 HURTS HURTS HURTS HURTS HURTS NO HURT LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST

Reference: From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of Paediatric Nursing, ed.6, St. Louis, 2001, p1301. Copyrighted by Mosby, Inc. Reprinted by permission.

Reference: World Health Organization, Pain Ladder 72 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.15 05/08 Spinal Immobilisation – Paediatric (≤ 13 years) EMT

Trauma Return head to neutral position unless on Indications for spinal movement there is Increase in If in doubt, immobilisation Pain, Resistance or Neurological symptoms treat as spinal injury

Stabilise cervical spine

Do not forcibly restrain Consider a paediatric patient that Paramedic is combatitive

Remove helmet (if worn)

Equipment list Life Yes Long board Threatening Vacuum mattress Orthopaediac stretcher No Rigid cervical collar

Note: equipment must be Rapid extrication with long Apply cervical collar age appropriate board and cervical collar

Patient in Yes No sitting position

Patient in Yes undamaged No 13 years) child seat ≤

Prepare extrication Immobilise in device for use the child seat Follow direction of Paramedic, Advanced Paramedic or doctor

Load onto vacuum mattress/ long board/ paediatric board

Consider Vacuum mattress PAEDIATRIC EMERGENCIES PAEDIATRIC ( Spinal Immobilisation - Paediatric Paediatric spinal injury indications include Pedestrian v auto Passenger in high speed vehicle collision Ejection from vehicle Sports/ playground injuries S7 Falls from a height Axial load to head

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

PHECC Clinical Practice Guidelines - Emergency Medical Technician 73 SECTION 7 - PAEDIATRIC EMERGENCIES

4/5/6.7.16 EMT P Version 2, 07/11 Burns – Paediatric (≤ 13 years)

AP Burn or Cease contact with heat source Scald

Inhalation and/or facial Yes injury Should cool for another Airway management 10 minutes during No packaging and transfer Go to Respiratory Yes Inadequate distress Respirations CPG No

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

Remove burned clothing & jewellery (unless stuck) Equipment list Acceptable dressings Dressing/ covering Burns gel (caution for > 10% TBSA) of burn area Cling film Sterile dressing Clean sheet Go to Pain Mgt. Yes Pain > 2/10 CPG No

Isolated F: face superficial injury Caution with the very young, No H: hands (excluding FHFFP) circumferential & electrical burns F: feet F: flexion points P: perineum Yes Request TBSA burn No Yes > 5% ALS

ECG & SpO2 monitoring

13 years) 13 years) > 10% TBSA

≤ and time from injury No to ED > 1 hour

Yes

NaCl (0.9%), IV/IO > 10 years = 500 mL 5 ≤ 10 years = 250 mL

Monitor body temperature PAEDIATRIC EMERGENCIES PAEDIATRIC ( Burns - Paediatric Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of S7 an Advanced Paramedic or Doctor during transportation

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

74 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 7 - PAEDIATRIC EMERGENCIES

4.7.17 03/11 Post-Resuscitation Care – Paediatric EMT

Return of Spontaneous Circulation Maintain Titrate O2 to Equipment list Oxygen therapy 96% - 98%

Cold packs

Request

ALS

Conscious Yes

Adequate No ventilation

Yes

Positive pressure ventilations Max 12 to 20 per minute Recovery position

Consider active For active cooling place cooling if cold packs at arm pit, unresponsive groin & abdomen

Maintain patient at rest

ECG & SpO2 monitoring

Monitor vital signs

Check blood glucose

Maintain care until handover to appropriate Practitioner

If no ALS available

Drive EMERGENCIES PAEDIATRIC - Paediatric Resuscitation Care Post smoothly

Reference: ILCOR Guidelines 2010 S7

PHECC Clinical Practice Guidelines - Emergency Medical Technician 75 SECTION 8 - PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.1 05/08 Major Emergency (Major Incident) – First Practitioners on site EMT P

Irish (Major Emergency) terminology in black UK (Major Incident) terminology in blue

Possible Major Emergency

Take standard infection control precautions

Consider pre-arrival information

PPE (high visibility jacket and helmet) must be worn

Practitioner 2 Practitioner 1 (Ideally MIMMS trained)

Park at the scene as safety permits and in liaison with Fire & Garda Carry out scene survey if present Give situation report to Ambulance Control using METHANE message Leave blue lights on as vehicle acts as Forward Control Point pending the arrival of the Mobile Control Vehicle Carry out HSE Controller of Operations (Ambulance Incident Officer) role until relieved Confirm arrival at scene with Ambulance Control and provide an initial visual report stating Major Emergency (Major Incident) Liaise with Garda Controller of Operations (Police Incident Officer) Standby or Declared and Local Authority Controller of Operations (Fire Incident Officer)

Maintain communication with Practitioner 2 Select location for Holding Area (Ambulance Parking Point)

Leave the ignition keys in place and remain with vehicle Set up key areas in conjunction with other Principle Response Agencies on site; Carry out Communications Officer role until relieved - Site Control Point (Ambulance Control Point), - Casualty Clearing Station

METHANE message If single Practitioner is first on site M – Major Emergency declaration / standby combine both roles until additional E – Exact location of the emergency Practitioners arrive T – Type of incident (transport, chemical etc.) H – Hazards present and potential A – Access / egress routes N – Number of casualties (injured or dead) E – Emergency services present and required

The first ambulance crew does not provide care or transport of patients as this interferes with their ability to liaise with other services, to assess the scene and to provide PRE-HOSPITAL EMERGENCY CARE OPERATIONS PRE-HOSPITAL on site Practitioners - First Major Emergency continuous information as the incident develops S8

The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

76 PHECC Clinical Practice Guidelines - Emergency Medical Technician SECTION 8 - PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.2 05/08 Major Emergency (Major Incident) – Operational Control EMT P

AP Irish (Major Emergency) terminology in black UK (Major Incident) terminology in blue If Danger Area identified entry to Danger Area is controlled by a Senior Traffic Cordon Fire Officer or an Garda Síochána

Outer Cordon

Inner Cordon

Danger Area

Body Casualty Site Control Holding Clearing Point Area Station HSE Garda LA Holding Holding Holding Ambulance Area Area Area Loading Point

Entry to Outer Cordon (Silver area) One way ambulance circuit Entry to Inner Cordon (Bronze Area) is is controlled by an Garda Síochána limited to personnel providing emergency care and or rescue Personal Protective Equipment required

Management structure for; Management structure for; Outer Cordon, Tactical Area (Silver Area) Inner Cordon, Operational Area (Bronze Area) On-Site Co-ordinator Forward Ambulance Incident Officer (Forward Ambulance Incident Officer) HSE Controller of Operations (Ambulance Incident Officer) Forward Medical Incident Officer (Forward Medical Incident Officer) Site Medical Officer (Medical Incident Officer) Fire Service Incident Commander (Forward Fire Incident Officer) Local Authority Controller of Operations (Fire Incident Officer) Garda Cordon Control Officer (Forward Police Incident Officer) Garda Controller of Operations (Police Incident Officer)

Other management functions for; Major Emergency site Casualty Clearing Officer Triage Officer Ambulance Parking Point Officer Ambulance Loading Point Officer Communications Officer Safety Officer

LOCAL AUTHORITY HSE GARDA CONTROLLER CONTROLLER CONTROLLER PRE-HOSPITAL EMERGENCY CARE OPERATIONS PRE-HOSPITAL Control - Operational Major Emergency

Reference: A Framework for Major Emergency Management, 2006, Inter-Departmental Committee on Major Emergencies (Replaced by National steering Group on Major Emergency Management) S8

The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

PHECC Clinical Practice Guidelines - Emergency Medical Technician 77 SECTION 8 - PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.3 05/08 Triage Sieve EMT P

AP Multiple casualty incident

Priority 3 Can casualty (Delayed) Yes walk GREEN No

Is casualty Yes No breathing

Open airway one attempt

Breathing now No DEAD

Yes

Respiratory rate Yes < 10 or > 29 Priority 1 No (Immediate)

RED Capillary refill > 2 sec Or Yes Pulse > 120

No Priority 2 (Urgent)

YELLOW

Triage is a dynamic process PRE-HOSPITAL EMERGENCY CARE OPERATIONS PRE-HOSPITAL Sieve Triage

The principles and terminology of Major Incident Medical management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

78 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 1 - MEDICATION FORMULARY

The Medication Formulary is published by the Pre-Hospital Emergency Care Council (PHECC) to enable pre-hospital emergency care Practitioners to be competent in the use of medications permitted under SI 512 of 2008 schedule 7. This is a summary document only and Practitioners are advised to consult with official publications to obtain detailed information about the medications used.

The Medication Formulary is recommended by the Medical Advisory Group (MAG) and ratified by the Clinical Care Committee (CCC) prior to publication by Council.

The medications herein may be administered provided: 1 The Practitioner is in good standing on the 4 The Practitioner is authorised, by the PHECC Practitioner’s Register. organisation on whose behalf he/she is 2 The Practitioner complies with the Clinical acting, to administer the medications. Practice Guidelines (CPGs) published by 5 The Practitioner has received training on, PHECC. and is competent in, the administration of 3 The Practitioner is acting on behalf of an the medication. organisation (paid or voluntary) that is 6 The medications are listed on the Medicinal approved by PHECC to implement the CPGs. Products Schedule 7. 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 Practitioner administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the Practitioner to ensure that he/she is using the latest versions of CPGs which are available on the PHECC website www.phecc.ie Sodium Chloride 0.9% (NaCl) is the IV/IO fluid of choice for pre-hospital emergency care.

All medication doses for patients (≤ 13 years) shall be calculated on a weight basis unless an age related dose is specified for that medication. THE DOSE FOR PAEDIATRIC PATIENTS MAY NEVER EXCEED THE ADULT DOSE. Paediatric weight calculations acceptable to PHECC are; • (age x 3) + 7 Kg • Length based resuscitation tape (Broselow® or approved equivalent) Reviewed on behalf of PHECC by Prof Peter Weedle, Adjunct Professor of Clinical Pharmacy, School of Pharmacy, University College Cork. This version contains 9 medications for EMT level. Please visit www.phecc.ie for the latest edition/version.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 79 APPENDIX 1 - MEDICATION FORMULARY

AMENDEMENTS TO THE 2012 EDITION INCLUDE:

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

Oxygen Heading Add Delete

Indications SpO2 < 94% adults & < 96% paediatrics SpO2 < 97% Usual Adult: Life threats identified during primary survey; Adult: via BVM,

dosages 100% until a reliable SpO2 measurement obtained Pneumothorax;

then titrate O2 to achieve SpO2 of 94% - 98%. 100 % via high

All other acute medical and trauma titrate O2 to concentration

achieve SpO2 94% -98%. reservoir mask. All other acute Paediatric: Life threats identified during primary medical and trauma

survey; 100% until a reliable SpO2 measurement titrate to SpO2 >

obtained then titrate O2 to achieve SpO2 of 96% - 97%. 98%. Paediatric: via BVM,

All other acute medical and trauma titrate O2 to All other acute

achieve SpO2 of 96% - 98%. medical and trauma titrate to SpO2 > 97%. Additional If an oxygen driven nebuliser is used to administer information Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum.

80 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 1 - MEDICATION FORMULARY

Paracetamol Heading Add Delete Indications Minor or moderate pain (2 – 6 on pain scale) for moderate pain (2 – adult and paediatric patients 6 on pain scale)

Contra Chronic liver disease Paracetamol given indications in previous 4 hours Additional If Paracetamol administered in previous 4 hours, information adjust the dose downward by the amount given by other sources resulting in a maximum of 20 mg/Kg

Salbutamol Heading Add Delete Additional If an oxygen driven nebulizer is used to administer information Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum

PHECC Clinical Practice Guidelines - Emergency Medical Technician 81 APPENDIX 1 - MEDICATION FORMULARY

Index of medication formulary (Adult ≥ 14 and Paediatric ≤ 13 unless otherwise stated)

Aspirin 83 Epinephrine (1:1000) 84 Glucagon 85 Glucose gel 86 Glyceryl Trinitrate 87 Nitrous Oxide 50% & Oxygen 50% 88 Oxygen 89 Paracetamol 90 Salbutamol 91

82 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 1 - MEDICATION FORMULARY

CLINICAL LEVEL: CFR OFA EFR EMT P AP

DRUG NAME ASPIRIN Class Platelet aggregator 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 soluble tablet. Administration Orally (PO) - dispersedIf soluble in- dispersewater – ifin solublewater, or to be chewed, if not soluble. if not soluble - to be chewed. (CPG: 5/6.4.16, 4.4.16, 1/2/3.4.16). Indications Cardiac chest pain or suspected Myocardial Infarction. Contra-Indications 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: Not indicated. Pharmacology/ Antithrombotic.

Action 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 side Generally mild and infrequent but high incidence of gastro- effects intestinal irritation with slight asymptomatic blood loss, increased bleeding time, bronchospasm and skin reaction in hypersensitive patients. Additional Aspirin 300 mg is indicated for cardiac chest pain regardless if information patient has taken anti coagulants or is already on aspirin. One 300 mg tablet in 24 hours. 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.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 83 APPENDIX 1 - MEDICATION FORMULARY

CFR CLINICALOFA LEVEL:EFR EMT P AP

DRUG NAME EPINEPHRINE (1:1 000) Class Sympathetic agonist. Descriptions 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: 5/6.4.18, 5/6.7.8, 4.4.18, 4.7.8). Indications Severe anaphylaxis. Contra-Indications None known. Usual Dosages Adult: 0.5 mg (500 mcg) IM (0.5 mL of 1: 1 000). EMT use auto injector (0.3 mg). Repeat every 5 minutes if indicated. 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: for 6 months <10 years use EpiPen® Jr (0.15 mg). for ≥ 10 years use auto injector (0.3 mg). Repeat every 5 minutes if indicated. Pharmacology/Action Alpha and beta adrenergic stimulant. Reversal of laryngeal oedema & bronchospasm in anaphylaxis. Antagonises the effects of histamine. Side effects Palpitations. Tachyarrthymias. Hypertension. Angina like symptoms. Additional N.B. Double check the concentration on pack before use. information

84 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 1 - MEDICATION FORMULARY

CFR OCLINICALFA LEVEL:EFR EMT P AP

DRUG NAME GLUCAGON Class Hormone and antihypoglycaemic. Descriptions Glucagon is a protein secreted by the alpha cells of the islets of Langerhans in the pancreas. It is used to increase the blood glucose level in cases of hypoglycaemia in which an IV cannot be immediately placed. Presentation 1 mg vial powder and solution for reconstitution (1 mL). Administration Intramuscular (IM). (CPG: 5/6.4.19, 5/6.7.9, 4.4.19, 4.7.9). Indications Hypoglycaemia in patients unable to take oral glucose or unable to gain IV access with a blood glucose level < 4 mmol/L. Contra-Indications Known severe adverse reaction. Phaechromocytoma. Usual Dosages Adult: 1 mg IM. Paediatric: ≤ 8 years 0.5 mg (500 mcg) IM. >8 years 1 mg IM. Pharmacology/Action Glycogenolysis. Increases plasma glucose by mobilising glycogen stored in the liver. Side effects Rare, may cause hypotension, dizziness, headache, nausea and vomiting. Additional May be ineffective in patients with low stored glycogen e.g. information prior use in previous 24 hours, alcoholic patients with liver disease. Protect from light.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 85 APPENDIX 1 - MEDICATION FORMULARY

CLINICALCFR LEVEL:OFA EFR EMT P AP

DRUG NAME GLUCOSE GEL Class Antihypoglycaemic. Descriptions 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, 5/6.7.9, 4.4.19, 4.7.9, 2/3.4.19). Indications Hypoglycaemia. Blood Glucose < 4 mmol/L. EFR: Known diabetic with confusion or altered levels of consciousness. Contra-Indications 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 or Glucagon to reverse hypoglycaemia. Proceed with caution: - patients with airway compromise. - altered level of consciousness.

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CLINICALCFR LEVEL:OFA EFR EMT P AP

DRUG NAME GLYCERYL TRINITRATE (GTN) Class Nitrate. Descriptions 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: 5/6.3.2, 5/6.4.16, 4.4.16, 1/2/3.4.16). Indications Angina. Suspected Myocardial Infarction (MI). EFR: may assist with administration. Advanced Paramedic and Paramedic: Pulmonary oedema. Contra- SBP < 90 mmHg. Indications Viagra or other phosphodiesterase type 5 inhibitors (Sildenafil, Tadalafil and Vardenafil) used within previous 24 hr. 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. EFR: 0.4 mg sublingual max. Pulmonary oedema; 0.8 mg (800 mcg) sublingual. Repeat x 1. Paediatric: Not indicated. Pharmacology/ Vasodilator. Action 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 workload. Reduces BP. Side effects Headache, Transient Hypotension, Flushing, Dizziness. Additional If the pump is new or it has not been used for a week or more the information first spray should be released into the air.

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CFR OCLINICALFA LEVEL:EFR EMT P AP

DRUG NAME NITROUS OXIDE 50% AND OXYGEN 50% (ENTONOX®) Class Analgesic. Descriptions Potent analgesic gas contains a mixture of both nitrous oxide and oxygen. Presentation Cylinder, coloured blue with white and blue triangles on cylinder shoulders. Medical gas: 50% Nitrous Oxide & 50% Oxygen. Administration Self administered. Inhalation by demand valve with face-mask or mouthpiece. (CPG: 4/5/6.2.6, 4/5/6.7.14, 5/6.5.1, 5/6.56, 4.5.1). Indications Pain relief. Contra- Altered level of consciousness. Indications Chest Injury/pneumothorax. Shock. Recent scuba dive. Decompression sickness. Intestinal obstruction. Inhalation Injury. Carbon monoxide (CO) poisoning. Known severe adverse reaction. Usual Dosages Adult: Self-administered until pain relieved. Paediatric: Self-administered until pain relieved. Pharmacology/ Analgesic agent gas: Action - CNS depressant. - pain relief. Side effects Disinhibition. Decreased level of consciousness. Light headedness. Additional Do not use if patient unable to understand instructions. information In cold temperatures warm cylinder and invert to ensure mix of gases. Advanced Paramedics may use discretion with minor chest injuries. Brand name: Entonox®. Has an addictive property.

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CliniCal level: CFR - A EFR EMT P AP

MediCation Oxygen Class Gas. descriptions 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. Contra-indications Paraquat poisoning & Bleomycin lung injury. Usual dosages Adult: Cardiac and respiratory arrest: 100%.

Life threats identified during primary survey: 100% until a reliable SpO2

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 reliable SpO2

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/ Oxygenation of tissue/organs. action

Side effects Prolonged use of O2 with chronic COPD patients may lead to reduction in ventilation stimulus. additional A written record must be made of what oxygen therapy is given to every information patient. 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. Avoid naked flames, powerful oxidising agent.

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CliniCal level: EMT P AP

MediCation Paracetamol Class Analgesic and antipyretic. descriptions Paracetamol is used to reduce pain and body temperature. Presentation Rectal suppository 180 mg and 60 mg. Suspension 120 mg in 5 mL. 500 mg tablet. administration Per Rectum (PR). Orally (PO). (CPG: 4/5/6.2.6, 5/6.7.10, 4/5/6.7.14, 4.7.10). indications Pyrexia following seizure for paediatric patients. advanced Paramedics may administer Paracetamol, in the absence of a seizure for the current episode, provided the paediatric patient is pyrexial and has a previous history of febrile convulsions. Minor or moderate pain (2 - 6 on pain scale) for adult and paediatric patients. Contra-indications Known severe adverse reaction. Chronic liver disease. Usual dosages adult: 1 g PO. Paediatric: Pr (AP Only) Po < 1 year - 60 mg PR. 20 mg/Kg PO. 1-3 years - 180 mg PR. 4-8 years - 360 mg PR. Pharmacology/action Analgesic – central prostaglandin inhibitor. Antipyretic – prevents the hypothalamus from synthesising prostaglandin E, inhibiting the body temperature from rising further. Side effects None. long term side effects Long term use at high dosage or over dosage can cause liver damage and less frequently renal damage. additional information Note: Paracetamol is contained in Paracetamol Suspension and other over the counter drugs. Consult with parent/guardian in relation to medication prior to arrival on scene. For PR use be aware of modesty of patient, should be administered in presence of a 2nd person. If Paracetamol administered in previous 4 hours, adjust the dose downward by the amount given by other sources resulting in a maximum of 20 mg/Kg.

90 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 1 - MEDICATION FORMULARY

CLINICALCFR LEVEL:OFA EFR EMT P AP

DRUG NAME SALBUTAMOL Class Sympathetic agonist. Descriptions Sympathomimetic that is selective for beta-two 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. Advanced Paramedics may repeat Salbutamol x 3. (CPG: 5/6.3.2, 5/6.3.3, 5/6.4.18, 4/5/6.6.7, 5/6.7.5, 5/6.7.8, 4.3.2, 4.4.18, 4.7.5, 4.7.8, 3.3.2, 3.7.5). Indications Bronchospasm. Exacerbation of COPD. Respiratory distress following submersion incident. Contra-Indications Known severe adverse reaction. Usual Dosages Adult: 5 mg NEB. Repeat at 5 min prn (APs x 3 and Ps x 1). EMT & EFR: 0.1 mg metered aerosol spray x 2. Paediatric: < 5 yrs - 2.5 mg NEB. ≥ 5 yrs - 5 mg NEB. Repeat at 5 min prn (APs x 3 and Ps x 1). EMT & EFR: 0.1 mg metered aerosol spray x 2. Pharmacology/ Beta 2 agonist. Action Bronchodilation. Relaxation of smooth muscle. Side effects Tachycardia. Tremors. Tachyarrthymias. Long-term side High doses may cause hypokalaemia. effects Additional It is more efficient to use a volumizer in conjunction with an aerosol information inhaler when administering Salbutamol. If an oxygen driven nebulizer is used to administer Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum

PHECC Clinical Practice Guidelines - Emergency Medical Technician 91 APPENDIX 2 - MEDICATION & SKILLS MATRIX

NEW FOR 2012:

Clopidogrel PSA Pelvic splinting device P P 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.

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) PSA Authorised subject to special authorisation as per CPG

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Medication Aspirin PO P P P P P P P Oxygen P P P P P Glucose Gel Buccal PSA P P P GTN SL PSA P P P Salbutamol Aerosol PSA P P P Epinephrine (1:1,000) auto P P P injector Glucagon IM P P P Nitrous oxide & Oxygen P P P (Entonox ®) Paracetamol PO P P P

92 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 2 - MEDICATION & SKILLS MATRIX

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Medication Morphine IM URMPIO URMPIO PSA Epinephrine P P (1: 1,000) IM Ibuprofen PO P P Midazolam IM/Buccal/IN P P Naloxone IM P P Salbutamol nebule P P Clopidogrel PO PSA 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 Enoxaparin IV/SC P Epinephrine (1:10,000) IV/IO P Furosemide IV/IM P Hydrocortisone IV/IM P Ipratropium bromide Nebule P Lorazepam PO P Magnesium Sulphate IV P Midazolam IV P Morphine IV/PO P Naloxone IV/IO P Nifedipine PO P Ondansetron IV P Paracetamol PR P Sodium Bicarbonate IV/ IO P

PHECC Clinical Practice Guidelines - Emergency Medical Technician 93 APPENDIX 2 - MEDICATION & SKILLS MATRIX

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Medication Syntometrine IM P Tenecteplase IV P Lidocaine IV PSA

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Airway & Breathing Management 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 Jaw Thrust P P P P BVM P PSA P P P Nasal cannula P P P P Supraglottic airway adult P P P P

SpO2 monitoring PSA P P P Cricoid pressure P P P Oxygen humidification P P P Flow restricted oxygen P P powered ventilation device NPA P P Peak Expiratory flow P P

End Tidal CO2 monitoring P Endotracheal intubation P

94 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 2 - MEDICATION & SKILLS MATRIX

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Laryngoscopy and Magill P forceps Supraglottic airway child P Nasogastric tube P Needle cricothyrotomy P Needle thoracocentesis P Cardiac AED adult & paediatric P P P P P P P CPR adult, child & infant P P P P P P P Emotional support P P P P P P P Recognise death and P P P P P P P resuscitation not indicated 2-rescuer CPR P P P P Active cooling 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 P P Manual defibrillation P P Haemorrhage control Direct pressure P P P P P Nose bleed P P P P P Pressure points P P Tourniquet use P P Medication administration Oral P P P P P P P Buccal route PSA P P P Per aerosol PSA P P P

PHECC Clinical Practice Guidelines - Emergency Medical Technician 95 APPENDIX 2 - MEDICATION & SKILLS MATRIX

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Sublingual PSA P P P Intramuscular injection P P P Per nebuliser P P Intranasal P P IV & IO Infusion PSA P maintenance Infusion calculations P Intraosseous injection/ P infusion Intravenous injection/ P infusion Per rectum P Subcutaneous injection P Trauma Cervical spine manual P P P P P stabilisation Application of a sling P P P P P Cervical collar application P P P P Helmet stabilisation/ P P P P removal Splinting device application P P P P to upper limb Move and secure patient to PSA P P P a long board Rapid Extraction PSA P P P Log roll APO P P P Move patient with a APO P P P carrying sheet Move patient with an APO P P P orthopaedic stretcher Splinting device application APO P P P to lower limb

96 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 2 - MEDICATION & SKILLS MATRIX

CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A Secure and move a patient APO APO P P with an extrication device Active P P P re-warming Move and secure patient P P P into a vacuum mattress Pelvic Splinting device P P P Traction splint application APO P P Move and secure a patient P P to a paediatric board Spinal Injury Decision P P Taser gun barb removal P P Other Assist in the normal APO P P P delivery of a baby De-escalation and P P P breakaway skills Glucometry P P P Broselow tape P P Delivery Complications P P External massage of uterus P P Intraosseous cannulisation P Intravenous cannulisation P Urinary catheterisation P Patient assessment 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 AVPU P P P P P Breathing & pulse rate P P P P P Primary survey P P P P P

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CFR CFR OFA EFR EMT P AP CLINICAL LEVEL – C – A SAMPLE history P P P P P Secondary survey P P P P P Capillary refill P P P P CSM assessment P P P P Rule of Nines P P P P Pulse check (cardiac arrest) PSA P P P Assess pupils P P P Blood pressure P P P Capacity evaluation P P P Do Not Resuscitate P P P Pre-hospital Early Warning P P P Score Paediatric Assessment P P P Triangle Patient Clinical Status P P P Temperature 0C P P P Triage sieve P P P Chest auscultation P P GCS P P Revised Trauma Score P P Triage sort P P

98 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 3 - CRITICAL INCIDENT STRESS MANAGEMENT

CRITICAL INCIDENT STRESS AWARENESS

Your psychological well being As a Practitioner/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. You are successful as a Practitioner/Responder if you follow your CPGs well. 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 • Becoming withdrawn • Needing to urinate often • Racing thoughts • Muscle tension • Confusion • Restlessness, tiredness, sleep • Not looking after yourself properly difficulties, headaches • Difficulty making decisions • Increased drinking or smoking • Poor concentration • Overeating, or loss of appetite • Poor memory • Loss of interest in sex • Anger • Racing heart, breathlessness and • Anxiety rapid breathing • Depression

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Post-traumatic stress reactions

Normally the symptoms listed above 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 the following 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. 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.

100 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 3 - CRITICAL INCIDENT STRESS MANAGEMENT

Where to find help?

• Your own CPG approved organisation will have a support network or system. We recommend that you contact them for help and advice.

• Speak to your GP.

• See a private counsellor who has specialised in traumatic stress. (You can get names and contact numbers for these counsellors from your local co- ordinator or from the www.cism.ie).

• For a self-help guide, please go to the website: www.cism.ie

• The National Ambulance Service CISM committee has recently published a booklet called ‘Critical Incident Stress Management for Emergency Personnel’ and you can buy it by emailing [email protected].

We would like to thank the National Ambulance Service CISM Committee for their help in preparing this section.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 101 APPENDIX 4 - CPG UPDATES FOR EMERGENCY MEDICAL TECHNICIAN

CPG updates for Emergency Medical Technician – April 2012

A policy decision has been made to publish new an update clinical practice guidelines in April and October each year.

Updated CPGs from the previous version. CPGs The principal differences are: CPG 4.4.22 • A typographical error indicated to go to ‘Hypoglycaemia’ Stroke CPG, which has been corrected to ‘Glycaemic Emergency’ CPG. CPG 4/5/6.6.5 • CPG 4.6.5 Limb Fractures – Adult has been renamed Limb Limb Injury – Adult Injury – Adult to broaden the scope of the CPG. • The CPG now deals with fractures, soft tissue injuries and dislocations. • Pain relief has been changed from ‘consider’ to ‘establish need for’ • There is now a requirement to pre-alert the Emergency Department for limb threatening injuries. • A pelvic splinting device is now authorised for use by EMTs CPG 4/5/6.7.1 • Children First Guidelines requirements have been added Primary Survey Medical to this CPG.. – Paediatric CPG 4/5/6.7.2 • Children First Guidelines requirements have been added Primary Survey Trauma – to this CPG. Paediatric

New CPGs introduced into this version include New CPGs The new skills and medications incorporated into the CPG are: CPG 4/5/6.7.4 • This CPG outlines the progress through the secondary Secondary Survey – survey for a paediatric patient. Paediatric • Children First Guidelines requirements have been included in this CPG.

102 PHECC Clinical Practice Guidelines - Emergency Medical Technician APPENDIX 5 - PRE-HOSPITAL DEFIBRILLATION

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

Early Access

Early Early Early CPR Debrillation ALS

Post ROSC Care

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.

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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.

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.

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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.

PHECC Clinical Practice Guidelines - Emergency Medical Technician 105

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