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BLANK CPG GUIDE

2012 Edition

Andrew Osborn

PERFUSION STATUS ASSESSMENT:


Skin

Pulse

BP

GCS

Adequate
Perfusion
Borderline
Perfusion
Inadequate
Perfusion
Extremely Poor
Perfusion
No Perfusion

RESPIRATORY STATUS ASSESSMENT:


Normal
General
Appearance
Speech
Breath Sounds
and Chest
Auscultation
Respiratory
Rate
Respiratory
Rhythm
Breathing Effort

Mild Distress

Moderate
Distress

Severe
Distress

Normal

Mild Distress

Moderate
Distress

Severe
Distress

Pulse Rate
Skin
Conscious
State
GLASCOW COMA SCORE:
Eyes Opening:
4
3
2
1
Verbal Response:
5
4
3
2
1
Motor Response:
6
5
4
3
2

TIME CRITICAL GUIDELINES:


Definitions:
Actual:

Emergent:

Potential:

Mechanism of Injury (MOI)


A patient will be time critical if they have a combination of a MOI and other comorbidities constituting:
Systemic illness limiting normal activity / Systemic illness constant threat to life.

Pregnancy

Age <15 or >55

Medical Triage: These patients are time critical to the nearest appropriate hospital.

TRAUMA TIME CRITICAL GUIDELINES:


Actual Time Critical
VITAL SIGNS

VITAL SIGNS

Respiratory Rate
Blood Pressure
Pulse
GCS
Oxygen Saturations
Emergent Time Critical
Pattern of Injury
Penetrating Injuries

Blunt Injuries

Specific Injuries

1
2
3
4
5
6
7

Potentially Time Critical


Mechanism of Injury

Co-Morbidities

POTENTIAL OR SUSPECTED SPINAL INJURY


Clearance Criteria (if not meeting major trauma criteria)
1
2
3
4
5
6
7

TRAUMA TIME CRITICAL GUIDELINES (Paediatric)


Actual Time Critical
VITAL SIGNS

Newborn <2 weeks

Infant < 1 years

Child
1-8 years

Respiratory
Rate
Blood Pressure
Pulse
GCS
SpO2
Skin

Emergent Time Critical


Pattern of Injury
Penetrating Injuries

Blunt Injuries

Specific Injuries

1
2
3
4
5
6
7

Child
9-15 years

Potentially Time Critical (Paediatric)


Mechanism of Injury

MEDICAL TIME CRITICAL GUIDELINES


Actual Time Critical

Emergent Time Critical


Medical Symptoms/Syndromes
-

MENTAL STATUS ASSESSMENT


1
2
3
4
5
6
7
8
9

STROKE ASSESSMENT

Normal

Facial Droop

Pt smiles or shows teeth

Speech

You cant teach an old


dog new tricks

Hand Grip

As GCS

Blood Glucose

As BSL
Stroke Mimics

Abnormal

Stroke Mimics

Consider Co-Morbidities and time of onset in time criticality

OXYGEN USE IN EMERGENCY PRESENTATIONS


Oxygen is a treatment for hypoxaemia, not breathlessness. The guideline aims to achieve
normal or near-normal oxygen saturations in acutely ill patients.

Withhold O2 in

Administer O2 for critical illnesses


1
2
3
4
5
6
- Initial Management

- Once Pt Stable

- If Pt Deteriorates or SpO2 <85%

Conditions with chronic hypoxaemia who develop above critical illnesses as above should
have the same initial aggressive oxygen administration.
Chronic Hypoxaemia

Titrate SpO2 to

CARDIAC ARREST
Ratio
Not Intubated

Ratio:
Rate:

Intubated / LMA

Ratio:
Rate:

Temperature Adjustment
> 32 degrees
30 - 32 degrees

< 30 degrees

Unconscious Pulseless VT/VF


Action

Amount

Interval

Defibrillation
Adrenaline
Amiodarone
Sodium Bicarbonate
Normal Saline
Pulseless Electrical Activity (PEA)
Causes:
Action

Amount

Interval

Amount

Interval

Defibrillation
Adrenaline
Atropine
Sodium Bicarbonate
Normal Saline
Asystole
Action
Adrenaline

Action
Atropine
Sodium Bicarbonate
Normal Saline

Amount

Interval

WITHHOLDING AND/OR CEASING PRE-HOSPITAL RESUSCITATION


Circumstances where resuscitation efforts may be withheld

Circumstances where resuscitation efforts may be ceased

Laryngeal Mask Airway (LMA)


Indications
1
2
3
4
Contraindications
1
2
3
4
Precautions
1
2
3
4
Side Effects

LMA Sizing Chart


Portex

Size
3
4
5

Weight

Inflation

ACUTE CORONARY SYNDROME


Nitrates
Drug

Amount

Frequency

Drug

Amount

Frequency

Drug

Amount

Frequency

Amount

Frequency

Amount

Frequency

Antiplatelet Rx

Pain Relief

ACUTE PULMONARY OEDEMA


Nitrates
Drug

Pain Relief if chest pain


Drug

Consider antiplatelet drugs if pt has cardiac chest pain

PAIN RELIEF
Drug

Amount

Frequency

Methoxyflurane
Morphine IV
Morphine IM

Fentanyl IV
Fentanyl IN

RESPIRATORY
ASTHMA
Mild or Moderate
Drug

Amount

Frequency

No significant response treat as severe after 10/60 of treatment


Severe
Drug

Amount

Frequency

If patient unconscious/becomes unconscious with poor ventilation but still CO

If inadequate response:
Drug

If patient loses cardiac output

COPD

Amount

Frequency

All exacerbation of COPD treat as severe asthma.


Target O2 flow to 88-92%
----------- Arrest
----------- ROSC

NAUSEA AND VOMITING


Indications

Drug

Amount

Frequency

HYPOGLYCAEMIA
BSL < 4 responds to
commands

Drug

BSL < 4 does not respond to commands

Amount

Frequency

Drug

Amount

Frequency

CONTINUOUS TONIC-CLONIC SEIZURES


Drug

Age

Amount

Frequency

ANAPHYLAXIS
Status - Evidence of anaphylaxis/anaphylactoid - Exposure to foreign antigen
Assess for systemic Involvement

Drug

Assess physiological distress

Amount

Frequency

SEPSIS / SIRS
VSS 2 or more of

Then

MENINGOCOCCAL SEPTICAEMIA
Confirmed by

IV Access
Drug

Amount

Frequency

Dilution: ............................................................................
No IV Access
Drug

Amount

Dilution: .............................................................................

Frequency

NARCOTIC OVERDOSE
Evidence of narcotic overdose
-

Then
Drug

Unless:

Amount

Frequency

THE AGITATED PATIENT


Assess and Manage Clinical Causes
-

Drug

Age

BP

Amount

Frequency

AUTONOMIC DYSREFLEXIA
Confirm

Identify and treat possible causes - if BP remains > 160


Drug

Amount

Frequency

Repeat GTN @ 10/60 until


- ..................................................................... - .....................................................................
- .....................................................................

SEVERE HEADACHE

Pain score > 7


-

- If after 15/60 of therapy and pain score still > 7 and destination hospital remains > 7
-

INADEQUATE PERFUSION associated with Hypovolaemia


AIM
VSS

Normal Saline

Maximum

VSS normal (signs of significant


dehydration)

Modifying Factors

Amount given

CHEST INJURIES
Open Chest Wound

Rx -

Flail Segment/Rib Fracture

Rx -

SEVERE TRAUMATIC HEAD INJURY


Open Skull Fracture/Wound

Rx -

Sustained Seizures

Rx -

Normal Saline IV

Rx - AIM -

Hypoglycaemia

Rx -

SEVERE TRAUMATIC HEAD INJURY


5 HEDS
-

5HEDS-

SPINAL COLUMN INJURY (SCI) MANAGEMENT


HAS POSITIVE MECHANISM OF INJURY
If any of the following present then provide spinal immobilisation
1
2
3
4
5
6
7
MUST NOT BE USED FOR PAEDIATRICS

BURNS
9%
9%
9%
9%
9%
9%
9%
9%
9%
9%
9%
1%

Assess burn injury SIGNS OF AIRWAY BURNS


-

BURN MANAGEMENT

Partial or Full Thickness Burns >15%

APPEARANCE
Superficial
Partial
Full thickness

HYPOTHERMIA / COLD EXPOSURE


-Arrhythmias commonly occur in temperatures below 33 degrees.
-Defibrillation & cardioactive drugs may not be effective at temperatures below 30 degrees.
-Warmed fluid between 37-42 degrees should be administered to correct hypothermia and
maintain perfusion. Fluid <37 degrees can be detrimental to the patient.
Mild Hypothermia
Moderate Hypothermia
Severe Hypothermia

Non-Cardiac Arrest
Moderate to Severe
Hypothermia Management

ENVIRONMENTAL HYPERTHERMIA (Heat Stress)


Cooling Techniques

PAEDIATRIC PATIENT
WEIGHT
Newborn
5 months
1 year
1-9 years
10-14 years
DEFINITIONS
Newborn
Infant
Young Child
Older Child
NORMAL BLOOD VOLUME
Newborn
Infant and Child

ADEQUATE PERFUSION
Pulse

Blood Pressure

Newborn
Infant
Small Child
Large Child
Skin Consciousness -

Warm, Pink, Dry


Alert & Active

INADEQUATE PERFUSION
Pulse

Blood Pressure

Newborn
Infant
Small Child
Large Child
Skin Consciousness -

Cool, Pale, Clammy, Peripheral Cyanosis


Altered, Restless

NO PERFUSION
- Absence of palpable pulses
- Skin - Cool, Pale
- Unrecordable blood pressure
- Unconscious
NORMAL RESPIRATORY RATES
Newborn
Infant
Small Child
Large Child
SIGNS OF RESPIRATORY DISTRESS

SIGNS OF HYPOXIA INCLUDE


Infant

CARBON DIOXIDE RETENTION IS MANIFESTED BY

Children

PAEDIATRIC GCS
CHILD < 4

CHILD > 4

Eyes Opening
4

Verbal Response

Motor Response

APGAR SCORE
0
Appearance
Pulse
Grimace

Activity
Respiratory Effort
7-10 Satisfactory
4-6 Moderate depression and may need respiratory support
0-3 Newborn requiring resuscitation

CARDIAC ARREST (Paediatric)


Newborn
Not Intubated

Ratio:
Rate:

Intubated / LMA

Ratio:
Rate:

Infants and Children


Not Intubated

Ratio:
Rate:

Intubated / LMA

Ratio:
Rate:

Commence ECC if either:


- No palpable pulse (carotid, brachial or femoral)
- HR < 60 infants
- HR < 40 children
Unconscious Pulseless VT/VF
Action
Defibrillation

Amount

Interval

PEA
- Manage causes and continue resuscitation
Asystole
- Manage causes and continue resuscitation

PAIN RELIEF
Drug
Methoxyflurane
Fentanyl IN
Morphine IM

Amount

Frequency

RESPIRATORY (Paediatric)
UPPER AIRWAY OBSTRUCTION
Partial Obstruction

Complete Obstruction

SUSPECTED EPIGLOTTITIS

CROUP
Severe

and/or

and/or

3
then:

Drug

Amount

Frequency

ASTHMA (Paediatric)
Mild or Moderate
Drug

Amount

Frequency

No significant response treat as severe after 10/60 of treatment


Severe
Drug

Amount

Frequency

If patient unconscious/becomes unconscious with poor ventilation but still CO


Infant:
Small Child:
Large Child:
Allowing:
If inadequate response:
Drug

If patient loses cardiac output

Amount

Frequency

HYPOGLYCAEMIA (Paediatric)
BSL < 4 responds to
commands

Drug

BSL < 4 does not respond to commands

Weight

Amount

Frequency

Frequency

Max Dose

CONTINUOUS TONIC-CLONIC SEIZURES


Drug

Amount

ANAPHYLAXIS
Status - Evidence of anaphylaxis/anaphylactoid - Exposure to foreign antigen
Assess for systemic Involvement

Drug

Assess physiological distress

Amount

Frequency

MENINGOCOCCAL SEPTICAEMIA
Confirmed by

No IV Access
Drug

Amount

Frequency

Dilution: .............................................................................
Administered into: ...............................................................

NARCOTIC OVERDOSE (Paediatric)


Evidence of narcotic overdose
-

Then
Drug

Unless:

Amount

Frequency

Max Dose

THE AGITATED PATIENT (as per adult guideline)


Drug

Amount

Frequency

Max Doses

OBSTETRIC EMERGENCIES
Term
Pre Term
Show
Spontaneous Rupture of
Membranes
Merconium Stained Liquor
First Stage Labour

Second Stage Labour

Imminent Birth Presentation

Precipitate Birth

ASSESSMENT

OBSTETRIC EMERGENCY MANAGEMENT


Basic Care

ANTEPARTUM HAEMORRHAGE
Assess:
No clinical signs of altered perfusion

Any clinical signs of altered perfusion

PRE-ECLAMPSIS / ECLAMPSIA
Signs and Symptoms
-

Assess

Significant Hypertension
-

Severe Hypertension
-

Manage with

NORMAL BIRTH DELIVERY (Imminent)


Preperation

Birth of head

Umbilical cord check


If loose If tight Head rotation
Birth of the head and shoulders

Clamping and cutting the cord

Birthing placenta

BREECH / COMPOUND PRESENTATION (Imminent Birth)


Stage of labour and birth imminent
Buttocks or both feet presenting first
One foot or hand/arm presenting first
DO NOT ATTEMPT DELIVERY OF ONLY PROCEED IF One foot, hand or arm presenting

Buttocks or both feet presenting

Back upmost delivery of body/legs

Back upmost delivery of head Modified Mauriceau Smellie Veit Manourvre

Breech Buttocks first presentation back not uppermost

Buttocks first presentation legs dont birth spontaneously


Buttocks first presentation arms dont birth spontaneously Lovsetts Manoeuvre

PRE-TERM LABOUR
Birth Imminent > 34 weeks

Birth Imminent < 34 weeks

CORD PROLAPSE (umbilical cord visible at vulva with ruptured membranes)


Assess: Birth Not Imminent Management of Mother

Birth Not Imminent Management of Cord

Birth Not Imminent Management of Presenting Part

Birth Commencing

Manage as Normal Birth


Manage as Newborn Resuscitation

SHOULDER DYSTOCIA
Shoulder dystocia is a specific case of dystocia whereby after the delivery of the head, the
anterior shoulder of the infant cannot pass below the pubic symphysis, or requires
significant manipulation to pass below the pubic symphysis. It is diagnosed when the
shoulders fail to deliver shortly after the fetal head. In shoulder dystocia, it is the chin that
presses against the walls of the perineum. Shoulder dystocia is an obstetrical emergency,
and fetal demise can occur if the infant is not delivered, due to compression of the
umbilical cord within the birth canal.
- Contact PERS 1300 137 650 via clinician
- Time critical 5-7 minutes to deliver baby due to compression of the cord against
the pelvic rim
- Explain the situation to the mother to gain maximum co-operation
- Important to note time of birth of head, timing of manoeuvres and delivery of the
body
- The newborn is likely to be compromised and require resuscitation
- During procedures be prepared for a sudden release of resistance and delivery of
baby
- The process of release may cause a clavicle fracture Rx as per fracture Rx
Prolonged head to body delivery time (>60 sec)

Delivery not accomplished After 30 60 sec


Alternate the following sequences until baby delivered

AT NO TIME ATTEMPT TO ROTATE THE BABYS HEAD ROTATE SHOULDERS


USING PRESSURE ON THE BABYS SCAPULA INSTEAD
Delivery not accomplished After 30 60 sec
Hyperflexion of maternal hips (McRoberts Manoeuvre) knees to nipples
-

Delivery not accomplished After 30 60 sec


Suprapubic pressure whilst in McRoberts position
-

Delivery remains not accomplished After 30 60 sec


All Fours (Gaskin) Manoeuvre
-

Delivery remains unaccomplished

Delivery accomplished

PRIMARY POSTPARTUM HAEMORRHAGE (PPPH)


Status - >
Assess

mls in first 24 hours from birth


-

Fundus firm Palpable firm, central and compacted fundus

Fundus not firm

Then:

Drug

Intractable Haemorrhage
-

Dose

Frequency

NEWBORN
Resuscitation
Cord cutting in the vigorous newborn is not urgent. General care and cut cord when
it has stopped pulsating.
Cord cutting in the non-vigorous newborn is required earlier to allow effective
resuscitation. This would usually be after initial basic tactile efforts and commencement
of IPPV.
If resuscitation is required, provide warming for newborn during resuscitation,
covering with bubble wrap and place a woolen hat on the newborns head.
Preterm newborns (<28 weeks) should be placed immediately, without drying into a
polyethylene bag with the head (dried) outside and then placed against the mother and
covered with warm blankets.
The vigorous newborn does not require suctioning unless born through merconium
stained amniotic fluid and is showing signs of respiratory difficulty.
Newborns who are not vigorous at birth only require suctioning if born through
merconium stained amniotic fluid
The mouth should be suctioned followed by the nose.
A 10 or 12 FG catheter is the usual ssize for suctioning the newborn.

BREATHING PRESENT MOVING OR CRYING (Vigorous newborn)

By 30 seconds
NOT BREATHING NOT MOVING OR CRYING (Non-Vigorous newborn)

Assess

- Is the baby breathing


- Is the HR > 100

HR >100 and breathing adequately

HR <100 and inadequate breathing

Reasess after 60 seconds


HR 60 100 and inadequate breathing

HR < 60 and inadequate breathing

Reassess after 90 seconds


HR > 100 and breathing adequately

HR < 60

Continue to reassess at 30 second intervals

ASPIRIN
Presentation
Pharmacology

Metabolism
Indications
Contraindications

1
2
3
4
5

Precautions

1
2
3

Route
Side Effects

1
2
3

Special Notes
Onset Times
Onset

Peak

Duration

ADRENALINE

Presentation
Pharmacology
Metabolism
Indications

1
2
3
4
5
6
7

Contraindications

Precautions

1
2
3
4

Route
Side Effects

2
3
4
5
6
7
Special Notes
Onset Times
IM
Onset

Peak

Duration

Onset

Peak

Duration

IV

CEFTRIAXONE
Presentation
Pharmacology
Metabolism
Indications

1
2

Contraindications

Precautions

Route
Side Effects

1
2

Special Notes

DEXTROSE
Presentation
Pharmacology
Metabolism
Indications
Contraindications
Precautions
Route
Side Effects
Onset Times
Onset

Peak

Duration

FENTANYL
Presentation

Pharmacology
CNS CVS
Metabolism
Indications
Contraindications

1
2
3
4

Precautions

1
2
3
4
5
6
7
8

Route
Side Effects

1
2
3

Presentation

/
4

Onset Times
IN
Onset

Peak

Duration

Onset

Peak

Duration

IV

GLUCAGON
Presentation
Pharmacology
Metabolism
Indications

Contraindications
Precautions
Route
Side Effects

Onset Times
Onset

Peak

Duration

GLYCERYL TRINITRATE
Presentation

Pharmacology
The effects of above are to:
-

Metabolism
Indications

1
2
3
4

Contraindications

1
2
3
4
5
6
7
8

9
Precautions

1
2
3

Route
Side Effects

1
2
3
4
5

Onset Times
Buccal
Onset

Peak

Duration

Peak

Duration

Transdermal
Onset

ATROVENT
Presentation
Pharmacology

Metabolism
Indications

Contraindications

Precautions

1
2

Route
Side Effects

1
2
3
4
5
6
7

Special Notes
Onset Times
Onset

Peak

Duration

LIGNOCAINE
Presentation
Pharmacology

Metabolism
Indications

Contraindications
Precautions

Route
Side Effects
Onset Times
Onset

Peak

Duration

METHOXYFLURANE
Presentation
Pharmacology
Metabolism
Indications

Contraindications

1
2
3

Precautions

1
2

Route
Side Effects

1
2
3

Onset Times
Onset

Peak

Duration

METOCLOPRAMIDE
Presentation
Pharmacology
Metabolism
Indications

1
-

Contraindications

1
2
3

Precautions

Route
Side Effects

1
2
3
4
5

Onset Times
IM

Onset

Peak

Duration

Onset

Peak

Duration

IV

MIDAZOLAM
Presentation
Pharmacology
Metabolism
Indications

1
2
3
4

Contraindications

Precautions

1
2
3
4

Route
Side Effects

1
2

3
4
Onset Times
IM
Onset

Peak

Duration

MORPHINE
Presentation
Pharmacology
CNS CVS

Metabolism
Indications

Contraindications

1
2

Precautions

1
2
3
4
5
6
7
8

Route
Side Effects

1
2

3
4
5
6
7
8
Special Notes

Onset Times
IM
Onset

Peak

Duration

Onset

Peak

Duration

IV

NALOXONE
Presentation

Pharmacology
Metabolism
Indications

Contraindications
Precautions

1
2

Route
Side Effects

1
2
3
4
5

Special Notes

Cardiac Arrest Head Injury Neonates -

Onset Times
IM
Onset

Peak

Duration

NORMAL SALINE
Presentation
Pharmacology
Metabolism
Indications

1
2
3
4
5

Contraindications
Precautions
Route
Side Effects
Special Notes

PROCHLORPERAZINE
Presentation
Pharmacology
Metabolism
Indications

1
-

Contraindications

1
2
3
4

Precautions

1
2
3

Route
Side Effects

1
2
3
4
5
6

Onset Times
Onset

Peak

Duration

SALBUTAMOL
Presentation
Pharmacology
Metabolism
Indications

1
-

Contraindications
Precautions

1
2

Route
Side Effects

1
2

Special Notes
Onset Times
Onset

Peak

Duration

WATER FOR INJECTION


Presentation
Pharmacology

Metabolism
Indications
Contraindications
Precautions
Route
Side Effects