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Pr ac
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October 2014 Edition

Paramedic
Clinical Practice Guidelines

CLINICAL PRACTICE
GUIDELINES - 2014 Edition

Practitioner
Paramedic

October 2014 1
Clinical Practice Guidelines

CLINICAL PRACTICE
GUIDELINES - 2014 Edition

PHECC Clinical Practice Guidelines

First Edition 2001

Second Edition 2004

Third Edition 2009

Third Edition Version 2 2011

Fourth Edition April 2012

Fifth Edition July 2014

Published by:

Pre-Hospital Emergency Care Council

Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland

Phone: + 353 (0)45 882042

Fax: + 353 (0)45 882089

Email: info@phecc.ie

Web: www.phecc.ie

ISBN 978-0-9571028-8-0

© Pre-Hospital Emergency Care Council 2014

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

October 2014 2
Clinical Practice Guidelines

CLINICAL PRACTICE
GUIDELINES - 2014 Edition

TABLE OF CONTENTS

FOREWORD ............................................................................................................... 4

ACCEPTED ABBREVIATIONS ................................................................................. 5

ACKNOWLEDGEMENTS ......................................................................................... 7

INTRODUCTION ........................................................................................................
9

IMPLEMENTATION AND USE OF CLINICAL PRACTICE GUIDELINES .......... 10

CLINICAL PRACTICE GUIDELINES

INDEX ....................................................................................................................... 12

KEY/CODES EXPLANATION ..................................................................................

14

SECTION 1 CARE PRINCIPLES ............................................................................. 15

SECTION 2 PATIENT ASSESSMENT ....................................................................

16

SECTION 3 RESPIRATORY EMERGENCIES ........................................................ 21

SECTION 4 MEDICAL EMERGENCIES ................................................................

26

SECTION 5 OBSTETRIC EMERGENCIES ............................................................. 53

SECTION 6 TRAUMA .............................................................................................. 59

SECTION 7 PAEDIATRIC EMERGENCIES ........................................................... 70

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS .................... 95

SECTION 9 TREAT & REFERRAL ......................................................................... 100

Appendix 1 - Medication Formulary .............................................................. 103

Appendix 2 – Medications & Skills Matrix ................................................... 130

Appendix 3 – Critical Incident Stress Management .................................. 137

Appendix 4 – CPG Updates for Paramedics .................................................. 139

Appendix 5 – Pre-Hospital Defibrillation Position Paper .......................... 147

October 2014 3
Clinical Practice Guidelines

FOREWORD

The role of the Pre-Hospital Emergency Care Council (PHECC) is to protect the public by
independently specifying, reviewing, maintaining and monitoring standards of excellence for the
delivery of quality pre-hospital emergency care for people in Ireland. The contents of this clinical
publication are fundamental to how we achieve this goal.

Clinical Practice Guidelines have been developed for responders and practitioners to aid them in
providing world-class pre-hospital emergency care to people in Ireland.

I would like to thank the members of the Medical Advisory Committee, chaired by Dr Mick Molloy
for their efforts and expertise in developing these guidelines. The council acknowledge the work of
the PHECC Executive in researching and compiling these Guidelines, in particular Mr Brian Power,
Programme Development Officer. I also commend the many responders and practitioners whose ongoing feedback has led to
the improvement and creation of many of the Guidelines herein.

The publication of these Guidelines builds on the legacy of previous publications and marks yet another important milestone
in the development of care delivered by responders and practitioners throughout Ireland. Despite the difficulties faced by
responders and licensed service providers, I am proud that they continue to develop their skills and knowledge to provide
safer and more effective patient care.

__________________

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

October 2014 4
Clinical Practice Guidelines

ACCEPTED ABBREVIATIONS

Accepted abbreviations
Advanced 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
Basic Tactical Emergency Care ................................................................................. BTEC
Carbon Dioxide .............................................................................................................. CO2
Cardiopulmonary Resuscitation ............................................................................... CPR
Cervical Spine ................................................................................................................ C-spine
Chronic Obstructive Pulmonary Disease ................................................................ COPD
Clinical Practice Guideline ......................................................................................... CPG
Degree .............................................................................................................................. o
Degrees Centigrade ...................................................................................................... oC
Dextrose 10% in water ............................................................................................... D10W
Drop (gutta) .................................................................................................................... gtt
Electrocardiogram ........................................................................................................ ECG
Emergency Department ............................................................................................... ED
Emergency Medical Technician ................................................................................ EMT
Endotracheal Tube ........................................................................................................ ETT
Foreign Body Airway Obstruction ............................................................................ FBAO
Fracture ........................................................................................................................... #
General Practitioner .................................................................................................... GP
Glasgow Coma Scale ................................................................................................... GCS
Gram ................................................................................................................................ g
Milligram ........................................................................................................................ mg
Millilitre .......................................................................................................................... mL

October 2014 5
Clinical Practice Guidelines

ACCEPTED ABBREVIATIONS
(contd)

Millimole ........................................................................................................................ mmol

Minute ........................................................................................................................... min
Modified Early Warning Score ................................................................................ MEWS
Motor Vehicle Collision ............................................................................................. MVC
Myocardial Infarction ............................................................................................... MI
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

October 2014 6
Clinical Practice Guidelines

ACKNOWLEDGEMENTS

The process of developing CPGs has been long and detailed. Mr Thomas Keane, Paramedic, Member of Council
The quality of the finished product is due to the painstaking
work of many people, who through their expertise and review Mr Shane Knox, Education Manager, National Ambulance
of the literature, ensured a world-class publication. Service College

Col Gerard Kerr, Director, the Defence Forces Medical Corps

PROJECT LEADER & EDITOR Mr Declan Lonergan, Advanced Paramedic, Education &
Competency Assurance Manager, HSE National
Mr Brian Power, Programme Development Officer, PHECC. Ambulance Service

Mr Seamus McAllister, Divisional Training Officer, Northern

Ireland Ambulance Service
INITIAL CLINICAL REVIEW
Dr David McManus, Medical Director, Northern Ireland
Dr Geoff King, Director, PHECC. Ambulance Service
Ms Pauline Dempsey, Programme Development Officer, Dr David Menzies, Consultant in Emergency Medicine, Clinical
PHECC. Lead, Emergency Medical Science, University College
Ms Jacqueline Egan, Programme Development Officer, PHECC. Dublin

Mr Shane Mooney, Advanced Paramedic, Chair of Quality and

Safety Committee
MEDICAL ADVISORY COMMITTEE
Mr Joseph Mooney, Emergency Medical Technician,
Dr Mick Molloy, (Chair) Consultant in Emergency Medicine Representative from the PHECC register

Dr Niamh Collins, (Vice Chair) Consultant in Emergency Mr David O’Connor, Advanced Paramedic, representative from
Medicine, Connolly Hospital Blanchardstown the PHECC register

Prof Gerard Bury, Professor of General Practice, University Dr Peter O’Connor, Consultant in Emergency Medicine,
College Dublin Medical Advisor Dublin Fire Brigade

Dr Seamus Clarke, General Practitioner, representing the Irish Mr Cathal O’Donnell, Consultant in Emergency Medicine,
College of General Practitioners Medical Director, HSE National Ambulance Service

Mr Jack Collins, Emergency Medical Technician, Mr Kenneth O’Dwyer, Advanced Paramedic, representative
Representative from the PHECC register from the PHECC register

Prof Stephen Cusack, Consultant in Emergency Medicine, Mr Martin O’Reilly, Advanced Paramedic, District Officer
Cork University Hospital Dublin Fire Brigade

A/Prof Conor Deasy, Consultant in Emergency Medicine, Mr Rory Prevett, Paramedic, representative from the PHECC
Cork University Hospital, Deputy Medical Director HSE register
National Ambulance Service
Dr Neil Reddy, Medical Director, Code Blue
Mr Michael Dineen, Paramedic, Vice Chair of Council
Mr Derek Rooney, Paramedic, representative from the PHECC
Mr David Hennelly, Advanced Paramedic, Clinical register
Development Manager, National Ambulance Service
Ms Valerie Small, Advanced Nurse Practitioner, Chair of
Mr Macartan Hughes, Advanced Paramedic, Head of Education and Standards Committee.
Education & Competency Assurance, HSE National
Ambulance Service Dr Sean Walsh, Consultant in Paediatric Emergency Medicine,
Our Lady’s Hospital for Sick Children, Crumlin
Mr David Irwin, Advanced Paramedic, representative from the
Irish College of Paramedics

October 2014 7
Clinical Practice Guidelines

ACKNOWLEDGEMENTS

EXTERNAL CONTRIBUTORS Mr Kevin Reddington, Advanced Paramedic

Ms Diane Brady, CNM II, Delivery Suite, Castlebar Hospital. Ms Barbara Shinners, Emergency Medical Technician

Mr Ray Brady, Advanced Paramedic Dr Dermott Smith, Consultant Endocrinologist

Mr Joseph Browne, Advanced Paramedic Dr Alan Watts, Register in Emergency Medicine

Dr Ronan Collins, Director of Stroke Services, Age Related Health Prof Peter Weedle, Adjunct Prof of Clinical Pharmacy, National
Care, Adelaide & Meath Hospital, Tallaght. University of Ireland, Cork.

Mr Denis Daly, Advanced Paramedic Mr Brendan Whelan, Advanced Paramedic

Mr Jonathan Daly, Emergency Medical Technician

Dr Zelie Gaffney Daly, General Practitioner SPECIAL THANKS

Prof Kieran Daly, Consultant Cardiologist, University Hospital HSE National Clinical Programme for Acute Coronary Syndrome
Galway HSE National Asthma Programme
Mr Mark Dixon, Advanced Paramedic HSE National Diabetes Programme
Dr Colin Doherty, Neurology Consultant HSE National Clinical Programme for Emergency Medicine
Mr Michael Donnellan, Advanced Paramedic HSE National Clinical Programme for Epilepsy
Dr John Dowling, General Practitioner, Donegal HSE National Clinical Programme for Paediatrics and
Mr Damien Gaumont, Advanced Paramedic Neonatology

Dr Una Geary, Consultant in Emergency Medicine

Dr David Janes, General Practitioner A special thanks to all the PHECC team who were involved in
this project. In particular Ms Deirdre Borland for her dedication
Mr Lawrence Kenna, Advanced Paramedic in bringing this project to fruition.
Mr Paul Lambert, Advanced Paramedic

Dr George Little, Consultant in Emergency Medicine EXTERNAL CLINICAL PROOFREADING

Mr Christy Lynch, Advanced Paramedic Mr Michael Murphy, Paramedic
Dr Pat Manning, Respiratory Consultant Mr Austin Florish, Paramedic
Dr Adrian Murphy, Specialist Register in Emergency Medicine

Dr Regina McQuillan, Palliative Care Consultant, St Francis

Hospice, Raheney

Prof. Alf Nickolson, Consultant Paediatrician

Dr Susan O’Connell, Consultant Paediatrician

Mr Paul O’Driscoll, Advanced Paramedic

Ms Helen O’Shaughnessy, Advanced Paramedic

Mr Tom O’Shaughnessy, Advanced Paramedic

Dr Michael Power, Consultant Anaesthetist

Mr Colin Pugh, Paramedic

October 2014 8
Clinical Practice Guidelines

INTRODUCTION

Clinical Practice Guidelines for pre-hospital care are under constant review as practices change,
new therapies and medications are introduced, and as more pre-hospital clinical pathways are
introduced such as Code STEMI and code stroke which are both leading to significant improved
outcomes for patients. A measure of how far the process has developed can be gained from
comparing the 29 Standard Operating Procedures for pre-hospital care in existence prior to the
inception of the Pre-Hospital Emergency Care Council and the now more than 319 guidelines and
growing.

The 2014 guidelines include such new developments as the use of intranasal fentanyl for advanced
paramedics and harness induced suspension trauma for both practitioners and responders.

Clinical Practice Guidelines recognise that practitioners and responders provide care to the same patients but to different skill
levels and utilising additional pharmaceutical interventions depending on the practitioner level.

This edition of the guidelines has introduced some new concepts such as the basic tactical emergency care standard at EFR
and EMT level for appropriately employed individuals. As ever feedback on the guidelines from end users or interested parties
is always welcomed and may be directed to the Director of PHECC or the Medical Advisory Committee who review each and
every one of the guidelines before they are approved by the Council.

__________________

Dr Mick Molloy, Chair, Medical Advisory Committee.

Feedback on the CPGs may be given through the centre for Pre-hospital Research www.ul.ie/cpr/forum

October 2014 9
Clinical Practice Guidelines

IMPLEMENTATION

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 a licensed CPG provider (paid or voluntary).

3 The practitioner is privileged by the licensed CPG provider 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
utilised.

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 16 years or greater, unless specified on the CPG.

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

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

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

Paediatric patient Any child, infant or neonate

CPGs and the pre-hospital emergency care team

The aim of pre-hospital emergency care is to provide a comprehensive and coordinated approach to patient care management,
thus providing each patient with the most appropriate care in the most efficient time frame.

In Ireland today, the provision of emergency care comes from a range of disciplines and includes responders (Cardiac First
Responders, First Aid Responders and Emergency First Responders) and practitioners (Emergency Medical Technicians,
Paramedics, Advanced Paramedics, Nurses and Doctors) from the statutory, private, auxiliary and voluntary services.

October 2014 10
Clinical Practice Guidelines

IMPLEMENTATION

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
traumatic 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.

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.

Emergency Medical Technician - Basic Tactical Emergency Care (EMT-BTEC)

EMT-BTEC certifies registered EMTs with additional knowledge and skill set for providing pre-hospital emergency care in
hostile or austere environments. EMT-BTEC training is restricted to EMTs who have the potential to provide emergency care
in hostile or austere environments and who are working or volunteering on behalf of a Licensed CPG Provider with specific
approval for BTEC provision.

Emergency First Response - Basic Tactical Emergency Care (EFR-BTEC)

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

First Aid Response

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

Defibrillation Policy
The Medical Advisory Committee has recommended the following pre-hospital defibrillation policy;

• Advanced Paramedics should use manual defibrillation for all age groups.

• Paramedics may consider use of manual defibrillation for all age groups.

• EMTs and responders shall use AED mode for all age groups.

October 2014 11
Clinical Practice Guidelines

INDEX
PARAMEDIC CPGs

SECTION 1 CARE PRINCIPLES ........................................................................15

SECTION 2 PATIENT ASSESSMENT ............................................................ 16
Primary Survey Medical – Adult ........................................................................ 16
Primary Survey Trauma – Adult ......................................................................... 17
Secondary Survey Medical – Adult ................................................................... 18
Secondary Survey Trauma – Adult .................................................................... 19
Pain Management – Adult .................................................................................. 20

SECTION 3 RESPIRATORY EMERGENCIES .............................................. 2

1
Advanced Airway Management – Adult ......................................................... 21
Inadequate Ventilations – Adult ....................................................................... 22
Exacerbation of COPD .......................................................................................... 23
Asthma - Adult ...................................................................................................... 24
Acute Pulmonary Oedema - Adult ................................................................... 25
SECTION 4 MEDICAL EMERGENCIES ....................................................... 26
Basic Life Support – Adult .................................................................................. 26
Foreign Body Airway Obstruction – Adult ..................................................... 27
VF or Pulseless VT – Adult .................................................................................. 28
Asystole – Adult .................................................................................................... 29
Asystole – Decision Tree ..................................................................................... 30
Pulseless Electrical Activity – Adult ................................................................ 31
Post-Resuscitation Care – Adult ...................................................................... 32
End of Life - DNR .................................................................................................. 33
Recognition of Death – Resuscitation not Indicated ................................. 34
Acute Coronary Syndrome .................................................................................. 35
Symptomatic Bradycardia – Adult ................................................................... 36
Tachycardia - Adult .............................................................................................. 37
Adrenial Insufficiency - Adult ........................................................................... 38
Altered Level of Consciousness – Adult .......................................................... 39
Allergic Reaction/Anaphylaxis – Adult ........................................................... 40
Decompression Illness (DCI) .............................................................................. 41
Epistaxis ................................................................................................................... 42
Glycaemic Emergency – Adult ........................................................................... 43
Hypothermia ........................................................................................................... 44
Poisons – Adult ...................................................................................................... 45
Seizure/Convulsion – Adult ................................................................................ 46
Sepsis – Adult ......................................................................................................... 47
Shock from Blood Loss (non-trauma) – Adult .............................................. 48
Sickle Cell Crisis - Adult ...................................................................................... 49
Stroke ........................................................................................................................ 50
Mental Health Emergency .................................................................................. 51
Behavioural Emergency ....................................................................................... 52

SECTION 5 OBSTETRIC EMERGENCIES ................................................... 53

Pre-Hospital Emergency Childbirth ................................................................. 53
Basic and Advanced Life Support – Neonate ................................................ 54
Haemorrhage in Pregnancy Prior to Delivery ................................................ 55
Postpartum Haemorrhage ................................................................................... 56
Umbilical Cord Complications ........................................................................... 57
Breech Birth ............................................................................................................ 58

October 2014 12
Clinical Practice Guidelines

INDEX
PARAMEDIC CPGs

SECTION 6 TRAUMA ....................................................................................... 59

Burns – Adult ......................................................................................................... 59
Crush Injury ............................................................................................................ 60
External Haemorrhage – Adult ......................................................................... 61
Harness Induced Suspension Trauma ............................................................. 62
Head Injury – Adult ............................................................................................. 63
Heat-Related Emergency .................................................................................... 64
Limb Injury – Adult .............................................................................................. 65
Shock from Blood Loss (trauma)– Adult ........................................................ 66
Spinal Immobilisation – Adult .......................................................................... 67
Submersion Incident ............................................................................................ 68
Traumatic Cardiac Arrest – Adult .................................................................... 69

SECTION 7 PAEDIATRIC EMERGENCIES ................................................. 70

Primary Survey Medical – Paediatric .............................................................. 70
Primary Survey Trauma – Paediatric ............................................................... 71
Secondary Survey – Paediatric ......................................................................... 72
Pain Management – Paediatric ........................................................................ 73
Advanced Airway Management – Paediatric ≥ 8 ...................................... 74
Inadequate Ventilations – Paediatric ............................................................. 75
Asthma - Paediatric ............................................................................................ 76
Stridor – Paediatric ............................................................................................. 77
Basic Life Support – Paediatric ........................................................................ 78
Foreign Body Airway Obstruction – Paediatric ............................................ 79
VF or Pulseless VT – Paediatric ......................................................................... 80
Asystole/PEA – Paediatric .................................................................................. 81
Symptomatic Bradycardia – Paediatric .......................................................... 82
Post Resuscitation Care - Paediatric ............................................................... 83
Adrenial Insufficiency - Paediatric .................................................................. 84
Allergic Reaction/Anaphylaxis – Paediatric .................................................. 85
Glycaemic Emergency – Paediatric ................................................................. 86
Seizure/Convulsion – Paediatric ....................................................................... 87
Septic Shock – Paediatric ................................................................................... 88
Pyrexia - Paediatric .............................................................................................. 89
Sickle Cell Crisis - Paediatric ............................................................................. 90
External Haemorrhage – Paediatric ................................................................. 91
Shock from Blood Loss – Paediatric ................................................................. 92
Spinal Immobilisation – Paediatric .................................................................. 93
Burns – Paediatric ................................................................................................. 94

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS ....... 95

Major Emergency – First Practitioners on site .............................................. 95
Major Emergency – Operational Control ........................................................ 96
Triage Sieve .............................................................................................................. 97
Triage Sort ................................................................................................................ 98
Conducted Electrical Weapon (Taser) ............................................................... 99

SECTION 9 TREAT & REFERRAL ................................................................. 100

Clinical Care Pathway Decision - T & R ......................................................... 100
Hypoglycaemia - T & R ....................................................................................... 101
Isolated Seizure - T & R ...................................................................................... 102

October 2014 13
Clinical Practice Guidelines

CLINICAL PRACTICE
GUIDELINES for PARAMEDIC
Clinical Practice Guidelines
for
(CODES EXPLANATION) Paramedic
Codes explanation
Emergency Medical Technician An EMT who has completed Basic Tactical
EMT EMT
(Level 4) for which the CPG pertains Emergency Care training and has been
BTEC privileged to operate in adverse conditions
Paramedic
A parallel process
P (Level 5) for which the CPG pertains
Which may be carried out in parallel
Advanced Paramedic with other sequence steps
AP (Level 6) for which the CPG pertains
A cyclical process in which a number
Medical Practitioner of sequence steps are completed
MP (Level 7) for which the CPG pertains
P Paramedic or lower clinical levels not
Sequence step A sequence (skill) to be performed permitted this route

Mandatory A mandatory sequence (skill) to be performed Transport to an appropriate medical

sequence step
facility and maintain treatment en-route

A decision process If no ALS available Transport to an appropriate medical

The Practitioner must follow one route facility and maintain treatment en-route, if
having contacted Ambulance Control
Given the clinical presentation
Consider treatment there is no ALS available
options consider the treatment option
specified Instructions An instruction box for information
xyz Finding following clinical assessment,
leading to treatment modalities
Special Special instructions
Reassess the patient instructions Which the Practitioner must follow
Reassess
following intervention

AP A skill or sequence that only

Request pertains to Advanced Paramedic
Contact Ambulance Control and request
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
Consider requesting a
Consider
4/5/6.4.1 CPG numbering system Paramedic response, based on
Paramedic
Version 2, 07/11
4/5/6 = clinical levels to which the CPG pertains the clinical findings
4/5/6.x.y x = section in CPG manual, y = CPG number in sequence Consider
Version 2, mm/yy
mm/yy = month/year CPG published Medical Consider medical oversight
Oversight

A medication which may be administered by an EMT or higher clinical level

Medication, dose & route
The medication name, dose and route is specified

Medication, dose & route A medication which may be administered by 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
A direction to go to a specific CPG following a decision process
Go to xxx
CPG Note: only go to the CPGs that pertain to your clinical level

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

October 2014 14
Clinical Practice Guidelines

SECTION 1
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 and medications on the Patient Care Report (PCR) or the Ambulatory Care
Report (ACR) are consistent principles throughout the guidelines and reflect the practice of practitioners. Care principles are
the foundations for risk management and the avoidance of error.

PHECC Care Principles

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

2 Seek consent prior to initiating interventions and/or administering medications.

3 Identify and manage life-threatening conditions.

4 Ensure adequate ventilation and oxygenation.

5 Optimise tissue perfusion.

6 Provide appropriate pain relief.

7 Identify and manage other conditions.

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

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

10 Provide reassurance at all times.

11 Monitor and record patient’s vital observations.

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

13 Arrange transport to an appropriate medical facility as necessary and in an appropriate time frame.

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

15 Identify the clinical leader on scene; this shall be the most qualified practitioner on scene. In the absence of a more
qualified practitioner, the practitioner providing care during transport shall be designated the clinical leader as soon
as practical.

October 2014 15
Clinical Practice Guidelines

SECTION 2
PATIENT ASSESSMENT

4/5/6.2.1
Version 3, 02/14 Primary Survey Medical – Adult EMT P
BTEC
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 &
protected

Suction, Yes
Head tilt/
OPA
chin lift
NPA
P

B Consider
EMT
Special Authorisation: No Adequate Oxygen therapy
EMTs having completed ventilation
the BTEC course may be
privileged by a licensed Yes
CPG provider to insert an
NPA on its behalf
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

October 2014 16
Clinical Practice Guidelines

SECTION 2
PATIENT ASSESSMENT

4/5/6.2.2
Version 3, 02/14 Primary Survey Trauma – Adult EMT P
BTEC
AP
Trauma Take standard infection control precautions

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

Assess responsiveness

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

EMT B Consider
Special Authorisation: No Adequate
EMTs having completed Oxygen therapy
ventilation
the BTEC course may be
privileged by a licensed Yes
CPG provider to insert an
NPA on its behalf
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

October 2014 17
Clinical Practice Guidelines

SECTION 2
PATIENT ASSESSMENT
5/6.2.4
Version 2, 09/11 Secondary Survey Medical – Adult P AP
5/6.2.4
Version 2, 09/11 Secondary Survey Medical – Adult P AP

Primary
Survey
Primary
Survey Record vital signs
& GCS
Record vital signs
& GCS

Patient acutely
Markers identifying acutely unwell Yes
unwell
Cardiac chest pain Patient acutely
Markers identifying acutely unwell Yes
Acute pain >5 unwell
Cardiac chest pain No
Acute pain > 5
No
Focused medical
history of presenting
Focused medical
complaint
history of presenting
complaint
SAMPLE history

SAMPLE history
Request
Relevant family &
social history Request
ALS
Go to Identify positive findings
Relevant family &
appropriate and initiate care
social history ALS
Go
CPGto Identify positive findings
management
appropriate and initiate care Check for medications
CPG management carried or medical
Check forjewellery
alert medications
carried or medical
alert jewellery

Examine body systems as

appropriate
Examine body systems as
appropriate

Reference: Sanders, M. 2001, Paramedic Textbook 2nd Edition, Mosby

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

October 2014 18
Clinical Practice Guidelines

SECTION 2
PATIENT ASSESSMENT
5/6.2.5
Version 2, 01/13 Secondary Survey Trauma – Adult P AP
5/6.2.5
Version 2, 01/13 Secondary Survey Trauma – Adult P AP

Primary
Survey
Primary
Survey
Markers for multi-
system trauma Yes
Markers for multi-
present
system trauma Yes
present
No
No
Examination of ECG & SpO2
obvious injuries monitoring
Examination of ECG & SpO2
obvious injuries monitoring
Monitor and
record vital signs
Monitor and
& GCS
record vital signs
& GCS
Request
Go to Identify positive findings SAMPLE history
Request
appropriate and initiate care ALS
Go to Identify positive findings SAMPLE history
CPG management ALS
appropriate and initiate care
CPG management Complete a detailed
physical exam (head to
Complete a detailed
toe survey) as history
physical exam (head to
dictates
toe survey) as history
dictates

Check for medications

carried or medical
Check for medications
alert jewellery
carried or medical
alert jewellery

Consider repeat
primary survey
Consider repeat
primary survey
Markers for multi-system trauma
GCS < 13
Markers for multi-system trauma
Systolic BP < 90
GCS < 13
Respiratory rate < 10 or > 29
Systolic BP < 90
Heart rate > 120
Respiratory rate < 10 or > 29
Revised Trauma Score < 12
Heart rate > 120
Mechanism of Injury
Revised Trauma Score < 12
Mechanism of Injury

Revised Trauma Score

Respiratory 10 – 29 4
Revised Trauma Score
Rate > 29 3
Respiratory 10 – 29 4
6–9 2
Rate > 29 3
1–5 1
6–9 2
0 0
1–5 1
Systolic BP ≥ 90 4
0 0
76 – 89 3
Systolic BP ≥ 90 4
50 – 75 2
76 – 89 3
1 – 49 1
50 – 75 2
no BP 0
1 – 49 1
GCS 13 – 15 4
no BP 0
9 – 12 3
GCS 13 – 15 4
6–8 2
9 – 12 3
4–5 1
6–8 2
3 0
4–5 1
RTS = Total score
3 0
RTS = Total score

Reference: McSwain, N. et al, 2011, PHTLS Prehospital Trauma Life Support, 7th Edition, Mosby
Reference: McSwain, N. et al, 2011, PHTLS Prehospital Trauma Life Support, 7th Edition, Mosby

October 2014 19
Clinical Practice Guidelines

SECTION 2
PATIENT ASSESSMENT

4/5/6.2.6
Version 4, 02/14 Pain Management – Adult EMT P

AP
Pain

Analogue Pain Scale

Pain assessment 0 = no pain……..10 = unbearable
Practitioners, depending on
his/her scope of practice,
may make a clinical
judgement and commence
pain relief on a higher rung Administer pain medication based on
of the pain ladder. pain assessment and pain ladder
recommendations

Adequate relief
Yes or best achievable
of pain

No

Go back Reassess and move

to up the pain ladder if
originating appropriate
CPG

Repeat Fentanyl
mg IN IN, once only, at
nyl 0.1 prn
Request Fenta t x1
not < 10 min after
Re p e a initial dose.
ALS or
and /
Severe pain IV
ine 2 mg Repeat Morphine at
(≥ 7 on pain scale) Morph not < 2 min intervals
if indicated.
Max 10 mg
or For musculoskeletal
and / pain Max 16 mg
,
x y gen
e&O
Consider s Oxid h
PO Nitrou in
Paramedic ol 1 g
cetam
Para or
Moderate pain and / PO
40 0 mg ider g IV
(4 to 6 on pain scale) ro fe n Cons setron 4 m
Ibup n
Onda slowly
or
and / or
mg IV
x y gen
, ine 50
e&O Cycliz lowly
s
s Oxid h
Nitrou in
s
ntion
ol 1 g
PO
a l inte r v e
cetam c
Mild pain Para ologi
- p h a rmac
(1 to 3 on pain scale) n
er n o dder
ns id er oth CC P
ain La
Co P H E

Decisions to give analgesia must

be based on clinical assessment
and not directly on a linear scale

Special Authorisation:
AP APs are authorised to administer Morphine, up to 10 mg
IM, if IV not accessible, the patient is cardiovascularly
stable and no cardiac chest pain present

Reference: World Health Organization, Pain Ladder

October 2014 20
Clinical Practice Guidelines

SECTION 3
RESPIRATORY EMERGENCIES

5/6.3.1
Version 3, 03/14 Advanced Airway Management – Adult P AP

Apnoea or special
clinical considerations

Special clinical considerations

Ventilations Consider
GCS = 3 No
maintained FBAO
SpO2 < 92%
RR ≤ 9
BVM ineffective Yes
(All of the above must be present)

Supraglottic airway insertion Paramedic: Maximum two attempts at supraglottic

airway insertion.
or Advanced paramedic: Maximum two attempts at
AP ETT and maximum two attempts at supraglottic
Endotracheal intubation airway insertion (either as primary device or
rescue from failed ETT)

Successful Yes

Maintain adequate No
ventilation and
oxygenation throughout
procedures Ensure CO2 detection
Revert to basic airway
device in ventilation
management
circuit

Check placement of advanced

airway after each patient movement
or if any patient deterioration

Minimum interruptions of
chest compressions. Continue ventilation and oxygenation

Maximum hands off time AP

Consider use
10 seconds. of waveform
Go to capnography
appropriate
CPG

Following successful Advanced

Airway management:-
i) Ventilate at 8 to 10 per minute.
ii) Unsynchronised chest
compressions continuous at 100
to 120 per minute

Reference: ILCOR Guidelines 2010

October 2014 21
Clinical Practice Guidelines

SECTION 3
RESPIRATORY EMERGENCIES

4/5/6.3.2
Version 2, 05/14 Inadequate Ventilations – Adult EMT P

AP
Airway Go to
Respiratory
patent & No Airway
difficulty protected CPG

Yes
P
Consider
Check SpO2 Raised ETCO2 + reduced SpO2:
ETCO2
Consider assisted ventilation

Raised ETCO2 + normal SpO2:

100% O2 initially unless Oxygen therapy Encourage deep breaths
patient has known COPD
Titrate O2 to standard as
clinical condition improves
Request

ALS

Patient assessment

Consider positive pressure ventilations

(Max 10 per minute)

Brain insult Respiratory failure Substance intake Other

Go to Respiratory assessment Consider pain, posture &

Go to Go to
Head neuromuscular disorders
Stroke Poison
injury
CPG CPG
CPG

Bronchospasm/ Asymmetrical
Crepitations Other
known asthma breath sounds

Go to Go to Go to Go to Consider shock, cardiac/

Asthma Allergy/ COPD EMT Sepsis neurological/ systemic
CPG Anaphylaxis CPG CPG illness, pain or
CPG psychological upset

Go to
Consider collapse,
APO CPG
consolidation & fluid

Tension
Yes Pneumothorax No
suspected
AP
Needle
decompression

October 2014 22
Clinical Practice Guidelines

SECTION 3
RESPIRATORY EMERGENCIES
4/5/6.3.3
Version 2, 02/14 Exacerbation of COPD EMT P

4/5/6.3.3 AP
Version 2, 02/14 Dyspnoea Exacerbation of COPD EMT P

AP
History of
Dyspnoea No
COPD

Yes of
History
No
Oxygen Therapy COPD
1. if O2 alert card issued follow directions. Oxygen therapy
2. if no O2 alert card, commence therapy at 28% Yes
3. administer O2 titrated to SpO2 92%
Oxygen Therapy
1. if O2 alert card issued follow directions. Oxygen therapy
2. if no O2 alert card, commence therapy at 28% ECG & SpO2
3. administer O2 titrated to SpO2 92% monitor

ECG & SpO2

P monitor
Measure Peak
Expiratory Flow
P
Measure Peak
Expiratory Flow
Salbutamol 5 mg NEB

Salbutamol 5 mg NEB
PEF < 50%
No
predicted
Go to
PEFYes
< 50% Inadequate
No Ventilations
predicted
CPG
Go to
Request Inadequate
Yes
Ventilations
ALS CPG
Request

Ipratropium bromide
ALS 0.5 mg NEB
& salbutamol 5 mg NEB mixed

Ipratropium bromide 0.5 mg NEB

& salbutamol 5 mg NEB mixed
Deteriorates
No
/unstable

Yes
Deteriorates
No
/unstable
Hydrocortisone 200 mg IV
(in 100 mLYes
NaCl) or IM

Hydrocortisone 200 mg IV
(in 100 mL NaCl) or IM

Adequate
No
respirations

Yes
Adequate
No
respirations

Yes

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-to-
day variability sufficient to warrant a change in management. (European Respiratory Society)
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-to-
day variability sufficient to warrant a change in management. (European Respiratory Society)

October 2014 23
Clinical Practice Guidelines

SECTION 3
RESPIRATORY EMERGENCIES

4/5/6.3.4
Version 2, 05/14 Asthma – Adult EMT P

Asthma/ AP
bronchospasm
Assess and maintain airway

Respiratory assessment

Salbutamol, 5 mg, NEB

Mild Asthma OR
Salbutamol If no improvement Salbutamol
(0.1 mg) metered aerosol aerosol, 0.1 mg may be repeated
up to 5 times as required

Resolved/
Yes
improved

No

ECG & SpO2 monitoring

Oxygen therapy

Request

ALS

Salbutamol, 5 mg, NEB

OR
Moderate Asthma Ipratropium bromide 0.5 mg
NEB & salbutamol 5 mg NEB
mixed

Resolved/
Yes
improved

No

Salbutamol, 5 mg, NEB

Resolved/
Yes
improved

No

Hydrocortisone, 100 mg slow IV

Severe Asthma (infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB

Resolved/
Yes
improved

No

Life-threatening Consider
Asthma Magnesium Sulphate 2 g IV
(infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB

Every 5 minutes prn

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management
of Asthma, a national clinical guideline
October 2014 24
Clinical Practice Guidelines

SECTION 3
RESPIRATORY EMERGENCIES

5/6.3.5
Version 1, 12/13 Acute Pulmonary Oedema – Adult P AP

Respiratory distress
with Congestion /
crepitations
Oxygen therapy

SpO2, ECG & BP

monitoring

Go to
12 Lead ECG STEMI
ACS CPG

Go to
Pulmonary Inadequate
No
oedema Respirations
CPG
Yes

GTN, 0.8 mg, SL

Repeat x 1 prn

Reassess

Meets criteria
No
for CPAP

Yes

Apply Continuous Positive Airway Oxygen

Pressure (CPAP) device Adequate flow to drive CPAP

Systemic fluid
Yes
retention

Furosemide, 40 mg, IV No

Bradycardia Yes
Criteria for CPAP Atropine, 0.6 mg IV
Clinical signs of APO No Repeat to Max 3 mg prn
RR > 25 per min
SpO2 < 90%

Exclusion Criteria
COPD / Asthma
Inability to sit up
Pneumothorax
Need for immediate intubation
SBP < 100 mmHg / cardiovascular collapse CPAP
Life-threatening arrythmia Commence with 5 cm H2O
Reduced GCS (AVPU < V) Titrate up to 10 cm H2O as tolerated
Unable to tolerate CPAP Monitor clinical response
Vomiting Titrate O2 to maintain SpO2 > 95%

Reference: Williams, B et al 2013, When Pressure is Positive: A Literature Review of the Prehospital Use of Continuous Positive Airway Pressure. Prehosp
Disaster med, 1-10.
October 2014 25
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

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

AP

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
x 2 minutes
chest compressions.

Maximum hands off time

10 seconds.

Rhythm check *

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

October 2014 26
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5.4.2 EMT P
Version 1, 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

No

Positive pressure
One cycle of CPR ventilations
maximum 10 per minute

Consider
Effective Yes
Oxygen therapy

No

One cycle of CPR

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

October 2014 27
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.3 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
2nd 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 CPG
PEA No VF/VT

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

Consider transport to
ED if no change after 20
minutes resuscitation

If no ALS available

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 If Tricyclic Antidepressant Toxicity or
Tamponade – cardiac harness induced suspension trauma consider AP
Toxins Special Authorisation:
Sodium Bicarbonate (8.4%) 1 mEq/Kg IV/IO
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

October 2014 28
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.4
Version 2, 03/11 Asystole – Adult P AP

From BLS
Adult Asystole Initiate mobilisation of 3 to 4
CPG 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
PEA CPG
PEA No Asystole

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

NaCl IV/IO 500 mL

Following 10 minutes (use as flush)
of asystole
Go to
Asystole
decision
CPG

With CPR ongoing maximum

hands off time 10 seconds

Clinical leader to
monitor quality
of CPR

Consider causes and treat as

appropriate:
Hydrogen ion acidosis
Hyper/ hypokalaemia AP
Hypothermia Consider use
Hypovolaemia of waveform
capnography
Hypoxia
Thrombosis – pulmonary
Tension pneumothorax
Thrombus – coronary If Tricyclic Antidepressant Toxicity or Consider fluid challenge
Tamponade – cardiac harness induced suspension trauma consider
Toxins NaCl 20 mL/Kg IV/IO
Sodium Bicarbonate (8.4%) 1 mEq/Kg IV/IO
Trauma

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

Reference: ILCOR Guidelines 2010

October 2014 29
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.5
P AP
Version 1, 05/08 Asystole - Decision Tree

From From
Asystole – Traumatic
Adult
Asystole Cardiac
CPG Arrest
CPG

Traumatic
Patient is;
Cardiac Arrest
Hypothermic or
Cold water drowning or
Yes No
Poisoning/ Overdose or
Pregnant or
< 18 years
Witnessed
arrest & CPR prior to Yes
arrival of EMS

Resuscitation continuous for

No at least 20 minutes in asystole

Confirm Asystolic Cardiac Arrest

Unresponsive
No signs of life; absence of central pulse and respiration

Confirm that (two minutes of CPR and

no shock advised) x 3 are completed

Consider ceasing
No resuscitation efforts

Yes

Record two rhythm strips

x 10 sec duration

Record on ECG strips

PCR No
Patient’s name
Date and time

Continue
BLS & or ALS Inform Ambulance
Control

Emotional support
If present, inform for relatives should
If no ALS available next of kin be considered before
leaving the scene

Complete PCR and flag for

mandatory clinical audit

Follow local
protocol for
care of
deceased

October 2014 30
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.6
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 /
Pulseless VT
Rhythm Consider
VF/VT Epinephrine (1:10 000) 1 mg IV/ IO
CPG check * Every 3 to 5 minutes prn mechanical
CPR assist

NaCl IV/IO 500 mL

(use as flush)

Consider transport to
ED if no change after 20
minutes resuscitation

If no ALS available

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 If Tricyclic Antidepressant Toxicity or
Tamponade – cardiac harness induced suspension trauma consider Consider fluid challenge
Toxins NaCl 20 mL/Kg IV/IO
Trauma Sodium Bicarbonate (8.4%) 1 mEq/Kg IV/IO

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

Reference: ILCOR Guidelines 2010

October 2014 31
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES
5/6.4.7
Version 3, 11/13 Post-Resuscitation Care – Adult P AP

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

ALS

Initiate mobilisation of 3 to 4
practitioners / responders
Adequate on site to assist with cardiac
No arrest management
ventilation
Positive pressure ventilations
Max 10 per minute Yes

Avoid
12 lead ECG hyperthermia

Go to
Yes STEMI
ACS CPG
No

Maintain patient at rest

If persistent hypotensive consider
NaCl (0.9%) IV/IO
ECG & SpO2
monitoring to maintain Sys BP > 90 mmHg

Monitor blood pressure

and GCS

Symptomatic
Bradycardia Ventricular Tachycardia
arrhythmia
Atropine 0.6 mg IV/IO Consider
Repeat at 3 to 5 min intervals prn Amiodarone, 150 mg IV/IO infusion
to max 3 mg No (in 100 mL D5W)

Check blood glucose

Consider causes and treat as

appropriate:
Hydrogen ion acidosis
Unresponsive No Hyper/ hypokalaemia
Hypothermia
Hypovolaemia
Yes Hypoxia
Thrombosis – pulmonary
Tension pneumothorax
Equipment list Commence cooling
Thrombus – coronary
(Target 32o to 34o C)
Tamponade – cardiac
Cold packs
Toxins
Trauma
NaCl (4o C approx) 1 L IV/IO
Repeat x 1 if required

Monitor vital signs

When ALS available

consider transporting to
primary PCI facility
(follow local protocol)

Reference: ILCOR Guidelines 2010

October 2014 32
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.8 P
End of Life – DNR AP
Version 1, 06/10

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

A planned ambulance
transport is a scheduled
Planned discharge to home or an
Confirm and agree Yes ambulance No interfacility patient transport
procedure with transport
clinical staff in the
event of a death in
transit Recent & Recent &
reliable written reliable evidence from a
instruction from patient’s clinical source stating that No
No
doctor stating that the the patient is not for
patient is not for resuscitation
resuscitation
Go to Go to
Primary Primary
Survey Yes Yes Survey
CPG CPG

Agreement
between caregivers
present and Practitioners No
not to
resuscitate

Yes

It is inappropriate to
commence resuscitation

Inform Ambulance
Control

Yes Pulse present

Appropriate Practitioner Provide supportive
Registered Medical Practitioner care until handover
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

October 2014 33
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.9
Version 2, 06/11 Recognition of Death – Resuscitation not Indicated P AP

Apparent
dead body

Signs of Life Yes

No Go to
Primary
survey
CPG

Definitive
indicators of No
Death
Yes

It is inappropriate to
commence resuscitation

Inform Ambulance
Control

Complete all
appropriate
documentation

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

Follow local
protocol for care
of deceased

Definitive indicators of death:

1. Decomposition
2. Obvious rigor mortis
3. Obvious pooling (hypostasis)
4. Incineration
5. Decapitation
6. Injuries totally incompatible with life
7. Unwitnessed traumatic cardiac arrest following
blunt trauma (see CPG 5/6.6.11)

October 2014 34
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES
5/6.4.10
5/6.4.10
Version 6, 02/14
Acute Coronary Syndrome P AP
Version 6, 02/14
Acute Coronary Syndrome P AP
Acute Coronary MP
Acute Coronary
Syndrome MP
Syndrome Oxygen therapy
Oxygen therapy Oxygen therapy
STEMI:
Request Maintain therapy
Oxygen SpO2 between
ST elevation in two or more
STEMI: 94% to 98%
Maintain SpO2 between
contiguous
ST elevationleads (2or
in two mm in leads
more Request
ALS (lower
94% torange
98% if COPD)
V2 and V3, leads
contiguous or 1 mm in any
(2 mm other
in leads
leads) (lower range if COPD)
V2 andorV3,
LBBB
or 1 with
mm clinical
in any other ALS
symptoms of AMI.
leads) or LBBB with clinical
symptoms of AMI. Apply 3 lead ECG &
SpO
Apply monitor
3 2lead ECG &
MP
SpO2 monitor
MPIndication for Thrombolysis
Aspirin 300 mg PO
Indication for Thrombolysis
1. Patient conscious, coherent and understands therapy
2.
1. Patient consent obtained
conscious, coherent and understands therapy Aspirin 300 mg PO
3. Less than
2. Patient 75 years
consent old
obtained
4.
3. MI Symptoms
Less > 20 Min
than 75 years old & ≤ 6 hours No Chest Pain Yes
5. MI
4. Confirmed
SymptomsSTEMI
> 20 Min & ≤ 6 hours No Chest Pain Yes
6.
5. Time to PPCI
Confirmed centre > 90 minutes of STEMI
STEMI GTN 0.4 mg SL
confirmation
6. Time to PPCI on 12 lead
centre > 90ECG
minutes of STEMI Repeat prn
GTNto0.4
max
mgofSL
1.2 mg SL
7. No contraindications
confirmation present
on 12 lead ECG Repeat prn to max of 1.2 mg SL
7. No contraindications present
Acquire & interpret Pain relief
Yes
12 lead
Acquire ECG
& interpret effective
Pain relief
Yes
12 lead ECG effective
No
No
No STEMI
No STEMI Go to Pain
Yes Mgt.toCPG
Go Pain
Yes Mgt. CPG

Time to PPCI
CentreTime
< 90 to
min of STEMI Discuss with
PPCI Yes PPCIwith
Discuss
Centre < 90 min ofon
identification STEMI
12 lead ECG Yes Physician
PPCI
identification on
12 lead ECG Physician

No
No

Clopidogrel, 300 mg, PO

Ticagrelor 180 mg PO
(≥ 75 years, 300
Clopidogrel, 75 mg
mg,PO)
PO
Ticagrelor 180 mg PO
(≥ 75 years, 75 mg PO)

Pre-hospital
No thrombolysis
Pre-hospital
No available
thrombolysis
available
Yes
Yes

Tenecteplase IV
MP
Tenecteplase
Followed by IV
MP
Patients age > 75 years do not give Followed
Enoxaparin 30by
mg IV
Patients age > but
IV Enoxaparin 75 years doEnoxaparin
rather not give (> 75 Yrs:Enoxaparin
Enoxaparin300.75
mg mg/Kg
IV SC)
IV Enoxaparin
0.75mg/kg but rather
SC (max 75 mgEnoxaparin
SC) (> 75 Yrs: Enoxaparin 0.75 mg/Kg SC)
0.75mg/kg SC (max 75 mg SC)

Time critical Transport to

Tenecteplase commence transport to
Time critical Transport
Primary PCI to
< 60 kg 30 mg
Tenecteplase nearest appropriate
commence transport to Primary
facilityPCI
6060
< – 70
kg kg 35
30 mg
mg hospital
nearest ASAP
appropriate
70
60 –
– 80
70 kg
kg 40
35 mg
mg
facility
hospital ASAP
80 – 90 kg 45 mg
70 – 80 kg 40 mg
>
8090 kg kg 45
– 90 50 mg
mg
> 90 kg 50 mg

Reference: HSE ACS Programme 2013, ILCOR Guidelines 2010, ECS Guidelines 2010
Reference: HSE ACS Programme 2013, ILCOR Guidelines 2010, ECS Guidelines 2010

October 2014 35
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.11
Version 2, 02/14 Symptomatic Bradycardia – Adult EMT P

AP
Symptomatic
Bradycardia
Oxygen therapy

Symptomatic includes;
Acute altered mental status Request
Ischemic chest discomfort
Acute heart failure ALS
Hypotension
Signs of shock

ECG & SpO2

monitoring

Atropine, 0.6 mg IV
Titrate Atropine to
Repeat at 3 to 5 min intervals prn to max 3 mg
effect (HR > 60)

P
12 lead ECG

NaCl (0.9%) 250 mL IV infusion

(Repeat x one prn)

Reassess

Reference: ILCOR guidelines 2010

October 2014 36
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.12
Version 1, 02/14 Tachycardia – Adult P AP

Tachycardia
ECG and SpO2
monitoring

Oxygen therapy

Request
Acquire 12 lead ECG
ALS

No HR > 150 /min

Yes Persistent tachyarrhythmia causing any of;

- Hypotension
- Acutely altered mental status
No Symptomatic - Signs of shock
- Ischaemic chest discomfort
- Acute heart failure
Yes

No Unstable Yes

QRS Complex

Narrow Broad

Irregular Regular Regular Irregular

AP Torsades de
V Fib
Consider cardioversion pointes
Narrow regular = 50 J
(synch on) if unresponsive

Go to VF/
Pulseless Yes
VT CPG
Amiodarone 150 mg IV No
infusion (in 100 mL D5W)

Yes Converted
QRS Complex
No
Magnesium Sulphate 2 g IV
Narrow Broad infusion (in 100 mL NaCl)

Regular Irregular Regular

AP
Consider if VT likely Consider cardioversion
Valsalva /
Amiodarone 150 mg IV Broad regular = 100 J
vagal
infusion (in 100 mL D5W) (synch on) if unresponsive
Manoeuvre

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

Reference: ILCOR Guidelines 2010

October 2014 37
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.13
Version 1, 12/13 Adrenal Insufficiency – Adult P AP

Diagnosed with Addison’s

disease or Adrenal insufficiency
Recent
illness or No
injury
Yes

Check blood glucose

SBP < 90
No
mmHg

Yes

Request

ALS

Consider
Hydrocortisone 100 mg IM Hydrocortisone 100 mg IV
if IV not available (in 100 mL NaCl)

Reassess

NaCl (0.9%) 1 L IV infusion

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

Reference:

October 2014 38
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.14
Version 1, 05/08 Altered Level of Consciousness – Adult P AP

V, P or U on
AVPU scale

Maintain airway

No Trauma Yes

Consider Consider
recovery position Cervical Spine

Obtain SAMPLE history from

patient, relative or bystander

ECG & SpO2 monitoring

Calculate GCS

Check temperature
Check pupillary size & response
Check for skin rash
Go to Shock from Go to
Anaphylaxis
CPG blood loss CPG
Check for medications
carried or medical
alert jewellery
Submersion Go to
Go to Symptomatic incident CPG
CPG Bradycardia
Check blood glucose

Go to Glycaemic Go to
Head injury
CPG emergency CPG

Differential
Diagnosis
Go to Inadequate Go to
Hypothermia
CPG respirations CPG

Go to Post
Poison Go to
CPG resuscitation
CPG
care

Go to Go to
Seizures Septic shock
CPG CPG

Go to Go to
Stroke Taser gun
CPG CPG

October 2014 39
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.15
Version 2, 07/11 Allergic Reaction/Anaphylaxis – Adult P AP

Allergic
reaction
Oxygen therapy

Severe/
Mild Moderate
Anaphylaxis

Epinephrine
administered pre No
arrival? (within 5
minutes)

Epinephrine (1:1 000) 0.5 mg (500 mcg) IM

Yes Repeat at 5 minute intervals if no improvement
Monitor
reaction

Request

ALS

Reassess

If bronchospasm consider
nebuliser Recurs / deteriorates /
No
no improvement
Salbutamol 5 mg NEB

Yes
Reassess

ECG & SpO2 ECG & SpO2

monitor monitor

Request
Deteriorates Yes Epinephrine (1:1 000) 0.5 mg (500 mcg) IM
ALS

No NaCl (0.9%) 1 L IV/IO infusion

Repeat by one prn

If bronchospasm consider
nebuliser
Salbutamol 5 mg NEB

Severe or
recurrent reactions
Yes
and or patients with
asthma
Hydrocortisone 200 mg IV
(in 100 mL NaCl) or IM
No

Mild
Urticaria and or angio
oedema Special Authorisation:
Paramedics are authorised to continue
Severe/ anaphylaxis P the established infusion in the absence
Moderate Moderate symptoms + of an Advanced Paramedic or Doctor
Mild symptoms + simple haemodynamic and or
bronchospasm respiratory compromise during transportation

October 2014 40
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.16
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

No

AP Go to
Nausea &
Yes Nausea
Vomiting
CPG
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)

October 2014 41
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.17
Version 2, 01/13 Epistaxis EMT P

AP

Primary Primary
Survey Medical Trauma Survey
Medical Trauma

Advise patient to
sit forward

Apply digital pressure for

15 minutes
Equipment list

Proprietary nasal
Advise patient to breathe
pack
through mouth only and not
to blow nose

Haemorrhage
No
controlled

Consider Yes

ALS

P
Consider insertion
of a proprietary
nasal pack

Request Go to
Hypovolaemic Yes Shock
ALS CPG

No

Reference: Management of Acute Epistaxis 2011, Ola Bamimore, MD; Chief Editor: Steven C Dronen, MD, http://emedicine.medscape.com/article/764719-
overview#showall

October 2014 42
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.19
Version 1, 05/08 Glycaemic Emergency – Adult P AP

Abnormal
blood glucose
level

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

Dextrose 10% 250 mL IV/IO infusion

> 20 mmol/L
Or
Glucagon 1 mg IM
Or
Glucose gel 10-20 g buccal Consider

Or ALS
Sweetened drink

Reassess NaCl (0.9%) 1 L IV/IO infusion

Allow 5 minutes to elapse

following administration of
medication
Reassess

Blood Glucose
No
< 4 mmol/L

Yes

Consider

ALS

Repeat if indicated
Dextrose 10%, 250 mL IV/IO infusion
Or
Glucose gel 10-20 g buccal

Reassess

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

October 2014 43
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.21
Version 2, 06/13 Hypothermia P AP

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

Pulse check for

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

Hypothermic patients
should be handled gently Remove wet clothing by cutting
& not permitted to walk

Equipment list
Place patient in dry blankets/ sleeping
bag with outer layer of insulation Low reading thermometer
Survival bag
Space blanket
Hot pack
ECG & SpO2 monitoring

Check and record core temperature

Mild Moderate Severe

34 – 35.9oC 30 – 33.9oC < 30oC

Give hot sweet

drinks

If Cardiac Arrest
Follow CPGs but; Follow CPGs but;
Follow CPGs but
- double medication interval until temperature > 34oC - limit defibrillation to three shocks
- no active re-warming
- no active re-warming beyond 32oC - withhold medications until temperature > 30oC
- no active re-warming beyond 32oC

Unresponsive Yes
Consider
No advanced airway

If Bradycardiac

Follow CPGs but;

- do not use Atropine until temperature > 34oC

NaCl warmed to 40oC approx Warm fluids to be

Adult: 250 mL IV, Repeat prn to max 1 L administered over
Paediatric: 10 mL/Kg IV, Repeat prn x 1 30 minutes

Hot packs to Check blood Transport in head down position

armpits & groin glucose Helicopter: head forward
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

October 2014 44
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES
4/5.4.22
Version 3, 02/14 Poisons – Adult EMT P
4/5.4.22
Version 3, 02/14 Poisons – Adult EMT P
Poison
source
Poison
source Ingested
Yes corrosive
Ingested
Caution with Sips of water Yes
No
corrosive
oral intake or milk
Caution with Sips of water
No
oral intake or milk

Consider

Consider
ALS

ALS

Poison type

Poison type

Paraquat Other Alcohol Opiate

Paraquat Other Alcohol Opiate

With Paraquat Check blood

glucose
poisoning do not Check blood
With Paraquat
administer oxygen glucose
poisoning do not
unless SpO2 < 92% BG
administer oxygen
No < 4 or > 20
unless SpO2 < 92% BG
mmol/L
No < 4 or > 20
Yes
mmol/L

Yes
Go to
Glycaemic
Go to
Emergency
Glycaemic
CPG
Emergency
CPG
Adequate
Yes
ventilations
Adequate
Yes
Consider ventilations
No
Oxygen therapy
Consider No
Oxygen therapy Naloxone 0.8 mg IN
(Repeat x one prn)
NaloxoneOr0.8 mg IN
(Repeat0.4
Naloxone x one
mg prn)
IM/SC
(Repeat Or
x one prn)
ECG & SpO2
Naloxone 0.4 mg IM/SC
monitoring
(Repeat x one prn)
ECG & SpO2
monitoring
Go to
Inadequate
Go to
Ventilations
Inadequate
CPG
Ventilations
CPG

Reference:
ILCOR Guidelines 2010
Reference:
Boyer, E, 2012, Management of Opioid Analgesic Overdose, N Engl J Med 2012;367:146-55.DOI: 10.1056/NEJMra1202561
ILCOR Guidelines 2010
Boyer, E, 2012, Management of Opioid Analgesic Overdose, N Engl J Med 2012;367:146-55.DOI: 10.1056/NEJMra1202561

October 2014 45
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.23 P AP
Version 3, 02/14 Seizure/Convulsion – Adult

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

Request Consider

ALS ALS

No Yes
IV access

Midazolam 2.5 mg IV/IO

Repeat by one prn
Or
Midazolam 10 mg buccal Diazepam 5 mg IV/IO
Repeat by one prn Repeat by one prn
Or
Midazolam 5 mg IN
Repeat by one prn
Or Check blood glucose
Midazolam 5 mg IM
Repeat by one prn
Or
Diazepam, 10 mg PR
Repeat by one prn

Go to
Blood glucose Glycaemic
Yes
< 4 or > 20 mmol/L Emergency
Maximum two doses of CPG
anticonvulsant medication
by Practitioner regardless
of route No

Reassess

If pre-Eclampsia/ Eclampsia
consider
Magnesium Sulphate, 4 g IV
(infusion in 100 mL NaCl)

Reference: Tukur, J. and Z. Muhammad (2010). "Management of eclampsia at AKTH: before and after magnesium sulphate." Niger J Med 19(1): 104-107

October 2014 46
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.24
Version 3, 02/14 Sepsis – Adult EMT P

AP
Patient unwell
Signs of Systemic Inflammatory Response Syndrome (SIRS)
- Temperature < 36 or > 38.3oC
- Heart rate > 90
If temperature > 38oC consider - Respiratory rate > 20 No
- Acutely confused
Paracetamol, 1 g PO - Glucose > 7.7 (not diabetic)
Has the patient two or more signs (SIRS)
Yes

Could this be a severe infection?

For example
If meningitis suspected
- Pneumonia
ensure appropriate
- Meningitis/ meningococcal disease
PPE is worn;
- UTI
No Mask and goggles
- Abdominal pain or distension
- Indwelling medical device
- Cellulitis/ septic arthritis/ infected wound
- Chemotherapy < 6 weeks
- Recent organ transplant
Yes

ECG & SpO2

monitoring

Oxygen therapy

Commence with 100% O2.

Caution with patients with
COPD Request

ALS

Benzylpenicillin, 1,200 mg slow IV or IM

Signs of poor Signs of shock/ poor perfusion

Yes
perfusion Mottled/ cold peripheries
Central capillary refill > 2 sec
SBP < 90 mmHg
No
Purpuric rash
Absent radial pulse
NaCl 0.9%, 500 mL IV/IO NaCl 0.9%, 250 mL, IV/IO

If Sys BP < 100 mmHg

consider aliquots

NaCl 0.9%, 250 mL, IV/IO

Pre alert ED
if severe
sepsis

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

October 2014 47
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

5/6.4.25
Version 1, 12/13 Shock from Blood Loss (non-trauma) – Adult P AP

Clinical signs
of shock
Control external haemorrhage

Oxygen therapy

Request

ALS

NaCl (0.9%), 500 mL IV/IO

Reassess

NaCl (0.9%), 250 mL IV/IO aliquots

to maintain palpable radial pulse
(SBP 90 - 100 mmHg)

SpO2 and ECG

monitoring

Continue fluid therapy until

handover at ED

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

October 2014 48
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES
4/5/6.4.27
Version 1, 12/13 Sickle Cell Crisis - Adult EMT P
4/5/6.4.27
Version 1, 12/13 Sickle Cell Crisis - Adult EMT AP P
Sickle Cell crisis
AP
Sickle Cell crisis 100% O2
Oxygen therapy

Oxygen therapy 100% O2

Pain
Go to
management Yes
Pain CPG
required
Pain
Go to
management
No Yes
Pain CPG
required

No

Go to
Elevated
Sepsis Yes
temperature
CPG
Go to
Elevated
Sepsis Yes No
temperature
CPG

No
Consider patient’s If patient is cold ensure that he/she is
care plan warmed to normal temperature

Consider patient’s If patient is cold ensure that he/she is

care plan warmed to normal temperature

Encourage oral fluids

Encourage oral fluids

Dehydration
& unable to take oral No
fluids
Dehydration
& unable to take oral No
Yes
fluids

Yes
Request

ALS
Request

ALS
NaCl (0.9%) 1 L IV infusion

NaCl (0.9%) 1 L IV infusion

SpO2 & ECG
monitor

SpO2 & ECG

monitor

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

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

October 2014 49
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES
5/6.4.28
5/6.4.28
Version 2, 07/11 Stroke P AP
Version 2, 07/11 Stroke P AP

Acute neurological
Acute neurological
symptoms
symptoms

Obtain GCS
Obtain GCS

Positive FAST
Positive FAST No
assessment No
assessment

Yes
Yes

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

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

ECG & SpO2

ECG & SpO2
monitoring
monitoring

Onset < 4.5

Onset < 4.5 No
hours No
hours

Yes
Yes

Specialised
Specialised
Stroke Unit No
Stroke Unit
available No
available
Yes
Yes

Transport patient to
Transport patient
hospital with to
hospital with Unit Follow local protocol re
Specialised Stroke Follow local
Specialised notifying ED protocol re
prior to arrival
(under localStroke Unit
protocol) notifying ED prior to arrival
(under local protocol)

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

Reference
Reference
ILCOR Guidelines 2010
ILCOR Guidelines
Prof R Boyle, 2006,2010
Mending hearts and brains, Clinical case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHS
Prof
AHA,R2005,
Boyle, 2006,
Part Mending
9 Adult hearts
Stroke, and brains,
Circulation 2005;Clinical case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHS
112; 111-120
AHA, 2005, Part 9 Adult
A. Mohd Nor, et al, Agreement Stroke,between
Circulation 2005; 112;
ambulance 111-120 and physician- recorded neurological signs with Face Arm Speech Test (FAST) in
paramedic-
A. Mohd
acute Nor,patients,
stroke et al, Agreement between
Stroke 004; ambulance paramedic- and physician- recorded neurological signs with Face Arm Speech Test (FAST) in
35;1355-1359
acute stroke
Jeffrey patients,
L Saver, Stroke 004; neuroprotective
et al, Prehospital 35;1355-1359 therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG)
Jeffrey
pilot L Saver,
trial, Stroke et al, Prehospital
2004; 35; 106-108neuroprotective therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG)
pilot trial,Hacke
Werner StrokeMD,
2004; 35;2008,
et al, 106-108
Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke, N Engl J Med 2008; 359:1317-29
Werner Hacke MD, et al, 2008, Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke, N Engl J Med 2008; 359:1317-29

October 2014 50
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5.4.29
Version 1, 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

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

Patient agrees
No
to travel

Yes
Request as appropriate
- Gardaí Aid to Capacity Evaluation
- Medical Practitioner 1. Patient verbalises/ communicates
- Mental health team understanding of clinical situation?
2. Patient verbalises/ communicates
appreciation of applicable risk?
3. Patient verbalises/ 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

October 2014 51
Clinical Practice Guidelines

SECTION 4
MEDICAL EMERGENCIES

4/5/6.4.30
Version 1, 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

No

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
likely to cause lasting
disability
Offer to treat and or
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

Yes

Aid to Capacity Evaluation

Await arrival of doctor or Advise alternative care options and 1. Patient verbalises/ communicates
Gardaí to call ambulance again if there is a understanding of clinical situation?
or change of mind 2. Patient verbalises/ communicates
receive implied consent appreciation of applicable risk?
3. Patient verbalises/ communicates
ability to make alternative plan of care?
Document refusal of treatment
If no to any of the above consider
and or transport to ED
Patient Incapacity

Reference: HSE Mental Health Services

October 2014 52
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES

5/6.5.1
Version 2, 03/11 Pre-Hospital Emergency Childbirth P AP

Query labour

Take SAMPLE history

If no progress with
labour consider Patient in
No
transporting patient labour

Yes

Birth
imminent or
No
travel time too
long

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

ALS
Equipment list
Cord Clamps
Bulb syringe
Position mother and prepare Towels
equipment for birth Surgical gloves
Surgical apron
Consider Gauze swaps 10 x 10 cm
Nitrous Oxide Umbilical cord scissors
Monitor vital signs and BP
& Oxygen Clinical waste bag
Neonatal BVM
Polythene bag
Go to
Umbilical
Cord
Cord Yes
complication
Complications
CPG
No

Go to
Breech
Breech Birth Yes
birth
CPG
No

Support baby
throughout delivery

No Gestation Yes
< 28 weeks

Dry baby and Cover newborn in

check ABCs polythene wrap/bag up to
neck without drying first

Go to BLS &
ALS Baby
No
Neonate stable
CPG
Yes
Wait at least one
Clamp & cut cord minute post birth
then clamp cord at
10, 15 & 20 cm from
Wrap baby and
baby
present to mother
Cut cord between 15
and 20 cm clamps
Go to
No Mother
Primary
stable
Survey CPG
Yes

If placenta delivers, bring to

Reassess
hospital with mother
Reference: ILCOR Guidelines 2010

October 2014 53
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES

5/6.5.2
Version 2, 03/11 Basic & Advanced Life Support – Neonate (< 4 weeks) P AP

From
Gestation
Childbirth Birth < 28 weeks
No Initiate mobilisation of 3 to 4
CPG practitioners / responders
on site to assist with cardiac
Yes
Term arrest management
gestation
< 4 Weeks old Cover newborn in Amniotic fluid clear
polythene wrap/bag up to Yes
Breathing or crying
neck without drying first Good muscle
tone
No

Provide warmth Provide warmth Dry baby

Position; Clear airway Position; Clear airway Provide warmth
(if necessary) (if necessary)
Stimulate, reposition Dry, stimulate, reposition

Request

ALS

Assess
CPR 3 : 1 respirations,
Breathing, HR > 100 & Pink
Compressions : Ventilations Apnoeic or HR < 100 heart rate &
Use two thumbs encircling colour
technique when two
practitioners present Breathing, HR > 100 but Cyanotic

Give Supplementary O2

Persistent
No
Cyanosis

Yes

Provide positive pressure ventilation for 30 sec

Assess
HR < 60 HR 60 to 100
Heart Rate

CPR (ratio 3:1) for 30 sec

Breathing well, HR > 100

Assess
HR 60 to 100 Breathing well, HR > 100
Heart Rate

HR < 60

Consider blood Continue CPR

glucose check
Epinephrine (1:10 000) 0.01 mg/kg IV/ IO
Every 3 to 5 minutes prn
Consider pulse
oximetry
If mother is opiate user consider
Naloxone, 0.01 mg/kg IV/IO
Or
Naloxone, 0.01 mg/kg IM

Consider
NaCl (0.9%), 10 mL/kg IV/IO

Reference: ILCOR Guidelines 2010

October 2014 54
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES

5/6.5.3
Version 1, 05/08 Haemorrhage in Pregnancy Prior to Delivery P AP

Query pregnant Pregnancy

< 24 weeks ≥ 24 weeks
Early pregnancy Antepartum
haemorrhage haemorrhage

Left lateral tilt

Do not examine
abdomen or vagina

Apply absorbent pad to perineum

area

Oxygen therapy

Patient is
Yes haemodynamically No
unstable

Request

ALS

Reassess

Go to
Shock
CPG

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

October 2014 55
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES

5/6.5.4
05/08 Postpartum Haemorrhage P AP

2nd stage of
labour complete

Apply absorbent pad to perineum

area

Estimate
blood loss
Oxygen therapy

Syntometrine, 1 mL IM
(if not already administered)

Mother is
Yes haemodynamically No
unstable

Request

ALS

External massage of the uterus

Check/ ask mother re

Reassess
multiple births prior to Elevate lower limbs
administration of
Syntometrine

AP Consider
inserting a urinary
catheter

Go to
Shock
CPG

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

October 2014 56
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES
5/6.5.5
Version5/6.5.5
1, 05/08 Umbilical Cord Complications P AP
Version 1, 05/08 Umbilical Cord Complications P AP

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

Oxygen therapy
Oxygen therapy

Cord around
baby’s neck Cord rupture Prolapsed cord
Cord around
baby’s neck Cord rupture Prolapsed cord

Apply additional
Attempt to slip the cord Mother to adopt
clampsadditional
Apply to cord
over the to
Attempt baby’s head
slip the cord knee chest
Mother position
to adopt
clamps to cord
over the baby’s head knee chest position
Apply direct pressure
with sterile AP
Yes Successful Apply directdressing
pressure Hold presenting part off
with sterile dressing AP the cord
Hold using fingers
presenting part off
Yes Successful
the cord using fingers
No
No Maintain cord temperature
Clamp cord in two places and and moisture
Maintain cord temperature
cut between
Clamp cord inboth
twoclamps
places and and moisture
cut between both clamps

AP Consider inserting an indwelling catheter

Ease the cord from into the bladder and
around the neck AP Consider inserting anrun 500 mLcatheter
indwelling of NaCl
Ease the cord from into the
into the bladder
bladder and
and run
clamp
500catheter
mL of NaCl
around the neck into the bladder and clamp catheter

Go to
Childbirth
Go to In labour No
CPG
Childbirth No
In labour
CPG
Yes
Yes

Consider
Consider
Nifedipine, 20 mg, PO
Nifedipine, 20 mg, PO

For prolapsed cord pre-alert

hospital as emergency
For prolapsed caesarean
cord pre-alert
section
hospital will be required
as emergency caesarean
section will be required

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall
Katz Z BR,
Reference: Sweet, et al,2000,
1988,Mayes’
Management of labor
Midwifery, with umbilical
12th Edition, cord
Bailleire prolaps: A 5 year study. Obstet. Gynecol. 72(2): 278-281
Tindall
Duley,
Katz Z LMM, 2002,Management
et al, 1988, Clinical Guideline No with
of labor 1(B),umbilical
Tocolyticcord
Drugs for women
prolapse: in preterm
A 5 year study. labour,
Obstet.Royal College
Gynecol. of Obstetricians
72(2): 278-281 and gynaecologists
Duley, LMM, 2002, Clinical Guideline No 1(B), Tocolytic Drugs for women in preterm labour, Royal College of Obstetricians and Gynaecologists

October 2014 57
Clinical Practice Guidelines

SECTION 5
OBSTETRIC EMERGENCIES

5/6.5.6
Version 1, 05/08 Breech Birth P AP

Breech birth
presentation

Request Request Ambulance Control to contact GP /

midwife/ medical team as required by local policy
ALS to come to scene or meet en route

Oxygen therapy

Mother to adapt the lithotomy position

Support the baby as it emerges –

avoid manipulation of the baby’s body

Yes Successful
No
delivery

No

Nape of neck
anteriorly visible at No
vulva
Go to
Consider Childbirth Yes
Nitrous Oxide CPG
& Oxygen
Place one hand, palm up, onto
baby’s face

Grasp both baby’s ankles in other

hand

Rotate baby’s legs in an arc

in an upward direction as
contractions occur

Successful
Yes delivery after 5
contractions

No

Place hand in the vagina with palm towards baby’s face

Form a V with fingers on each side of baby’s nose and
gently push baby’s head away from vaginal wall

October 2014 58
Clinical Practice Guidelines

SECTION 6
TRAUMA

4/5/6.6.1
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.
Caution with hypothermia Go to
Respiratory Yes Inadequate
distress Ventilations
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
Isolated Caution with the elderly,
H: hands
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
> 1 hour
Consider
NaCl (0.9%), 500 mL, IV/IO NaCl (0.9%), 1000 mL, IV/IO

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

October 2014 59
Clinical Practice Guidelines

SECTION 6
TRAUMA

5/6.6.2
Version 1, 05/08 Crush Injury P AP

Request
Patient
trapped ALS
AcBC
Maintain AcBC Airway
cervical spine
Breathing
Oxygen therapy Circulation

Significant
Co-ordinate with compression force No
rescue personnel on maintained
release timing
Yes

Consider Mobile Surgical Team

(for amputation)

IV access
Large bore x 2

Go to
Consider
Pain Mgt.
pain relief
CPG

NaCl (0.9%) 20 mL/Kg IV/IO

Prepare all required patient

carrying devices and have on
standby following extrication ECG & SPO2
monitoring

If possible commence IV fluids prior to release

Apply standard trauma care

during and post extrication

Go to
appropriate
CPG

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

Reference:
Crush Injury Syndrome (# 7102) Patient Care Policy, Alameda County EMS Agency (CA)
Crush Injuries, Clinical Practice Manual, Queensland Ambulance Service

October 2014 60
Clinical Practice Guidelines

SECTION 6
TRAUMA
4/5/6.6.3 P
4/5/6.6.3 External Haemorrhage – Adult EMT P
Version 3, 02/14
Version 3, 02/14
External Haemorrhage – Adult EMT
BTEC AP
Open BTEC AP
Open
wound
wound
Catastrophic
Active bleeding Yes Catastrophic Yes
Active bleeding Yes haemorrhage Yes
haemorrhage

No No
No No Posture
Posture P
Elevation P
Elevation Apply tourniquet if
Examination Apply tourniquet
Examination limb injury if Request
Pressure limb injury Request
Pressure
ALS
consider applying a dressing ALS
consider applying
impregnated a dressing
with haemostatic agent
impregnated with haemostatic agent

Posture EMT Special Authorisation:

Posture
Elevation EMT Special Authorisation:
Elevation EMTs, having completed the
Examination EMTs, having completed
Examination BTEC course, may be the
Pressure BTEC course, may be
Pressure privileged by a licensed CPG
privileged by a licensed CPG
provider to apply a tourniquet
provider on
to apply a
its behalf tourniquet
on its behalf

Apply sterile dressing

Apply sterile dressing

Consider
Consider
Oxygen therapy
Oxygen therapy

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

Haemorrhage
Yes Haemorrhage
Yes controlled
controlled

No
No
P
P Depress proximal
Depress proximal
pressure point
pressure point

Haemorrhage
Yes Haemorrhage
Yes controlled
controlled

No
No
P
P
Apply tourniquet
Equipment list Apply tourniquet
Equipment list
Sterile dressing (various sizes)
Sterile bandage
Crepe dressing (various
(various sizes)
sizes)
Crepe bandage (various sizes)sizes) Go to
Conforming bandage (various Significant Go to
Conforming bandage (various sizes) Significant Yes Shock
Triangular bandage blood loss Yes Shock
Triangular bandage blood loss CPG
Trauma tourniquet CPG
Trauma
Dressingtourniquet
impregnated with haemostatic agent No
Dressing impregnated with haemostatic agent No

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

October 2014 61
Clinical Practice Guidelines

SECTION 6
TRAUMA

4/5/6.6.4
Version 2, 05/14 Harness Induced Suspension Trauma EMT P

AP
This CPG does not Fall arrested by
authorise rescue harness/rope
by untrained
personnel Caution
Patient still
No
suspended

Yes
Personal
safety of the Advise patient to move Consider removing a harness
Practitioner legs to encourage
is suspended person from
venous return
paramount suspension in the direction of
gravity i.e. downwards, so as
Elevate lower limbs if to avoid further negative
possible during rescue
hydrostatic force, however
this measure should not
otherwise delay rescue.
If circulation is compromised Request
remove the harness when
the patient is safely lowered ALS
to the ground

Place patient in a horizontal

position as soon as practically If adult cardiac arrest following rescue consider
possible Sodium Bicarbonate (8.4%) 50 mEq IV/IO

Monitor BP, SpO2 and ECG

Oxygen therapy
to maintain SpO2 > 94%

NaCl (0.9%) 20 mg/Kg aliquots IV

to maintain Sys BP > 90 mmHg

Go to
appropriate
CPG

Patients must be
transported to ED
following suspension
trauma regardless of
injury status

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

Reference:
Adish A et al, 2009, Evidence-based review of the current guidance on first aid measures for suspension trauma, Health and Safety Executive (UK) Research
report RR708
Australian Resuscitation Council, 2009, Guideline 9.1.5 Harness Suspension Trauma first aid management.
Thomassen O et al, Does the horizontal position increase risk of rescue death following suspension trauma?, Emerg Med J 2009;26:896-898 doi:10.1136/
emj.2008.064931

October 2014 62
Clinical Practice Guidelines

SECTION 6
TRAUMA
5/6.6.5
Version5/6.6.5
2, 01/13 Head Injury – Adult P AP
Version 2, 01/13 Head Injury – Adult P AP
See
Maintain Airway Advanced
See
Head trauma (Consider Advanced
Maintain Airwayairway) Airway
Advanced
Head trauma (Consider Advanced airway) CPG
Airway
CPG
Oxygen therapy
Oxygen therapy
Control external haemorrhage
Control external haemorrhage

Maintain in-line immobilisation

Maintain in-line immobilisation
See
Consider spinal Spinal
See
injuryspinal
Consider injury
Spinal
injury CPG
injury
CPG
SpO2 & ECG
monitoring
SpO 2 & ECG
monitoring

Request
No GCS ≤ 12 Yes Request
No GCS ≤ 12 Yes ALS
ALS

No GCS ≤ 8
No GCS ≤ 8
Yes
Yes
Minimise increases in See
Intra Cranial
Minimise Pressure
increases in Pain
SeeMgt
Intra
Pain Cranial Pressure
Management CPG
Pain Mgt
Pain Management CPG
Control nausea & vomiting
See
Control
10 nausea
o upward head& tilt
vomiting N&V
See
10 o upward head tilt
Check collar tension CPG
N&V
Check collar tension CPG

With head injury maintain SBP: See

with head
GCS ≤ 8 atmaintain
120 mmHg Avoid hypotension Shock
See
With injury SBP: CPG
with GCS ≤
with GCS >88 at
at 90
120– mmHg
100 mmHg Avoid hypotension Shock
with GCS > 8 at 90 – 100 mmHg CPG

See
Glycaemic
See
Check blood glucose
Emergency
Glycaemic
Check blood glucose CPG
Emergency
CPG
See
Seizures
See /
Patient seizing
Convulsions
Seizures /
Patient seizing CPG
Convulsions
CPG
Consider Vacuum
mattress
Consider Vacuum
mattress

Equipment list
Equipment list
Extrication device
Long boarddevice
Extrication
Vacuum
Long boardmattress
Orthopaedic stretcher
Vacuum mattress
Rigid cervicalstretcher
Orthopaedic collar
Rigid cervical collar

Reference;
Mc Swain, N, 2011, PHTLS Prehospital Trauma Life Support 7th Edition, Mosby
Reference;
Mc Swain, N, 2011, PHTLS Prehospital Trauma Life Support 7th Edition, Mosby

October 2014 63
Clinical Practice Guidelines

SECTION 6
TRAUMA

4/5/6.6.6
Version 1, 12/13 Heat-Related Emergency – Adult EMT P

AP
Collapse from heat-
related condition

Remove/ protect from hot

environment
(providing it is safe to do so)

Yes Alert No

Mild Hyperthermia
(heat stress) Give cool fluids to
Maintain airway
drink

Check blood
Exercise-related dehydration glucose
should be treated with oral fluids.
(caution with over hydration with
water)
Cool patient Do not over cool
Cooling may be achieved by:
Removing clothing
Fanning
Moderate SpO2 & ECG Tepid sponging
Hyperthermia monitor Ice packs
(Heat exhaustion)

Consider

ALS

Severe
Consider
Hyperthermia
(Heat stroke) > 40oC NaCl (0.9%) 1 L IV

Elevate oedematous limbs

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

Reference: ILCOR Guidelines 2010,

European Resuscitation Guidelines 2010.
RFDS, 2011, Primary Clinical Care Manual

October 2014 64
Clinical Practice Guidelines

SECTION 6
TRAUMA

4/5/6.6.7
Version 4, 02/14 Limb Injury – Adult EMT P

Limb injury AP

Consider
Go to
Establish need for pain relief
Pain CPG
ALS

Expose and examine limb

Dress open wounds

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

Injury
type

Fracture Fractured femur Soft tissue injury Dislocation

Isolated lateral
Neck of Mid shaft Yes
Other dislocation of patella
femur of femur

No
Request
> 20 min Consider
Yes
to facility Paramedic
ALS
No

Consider
NaCl (0.9%), 250 mL IV

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

Recheck CSMs

Contraindications for application of traction splint

1 # pelvis
2 # knee
3 Partial amputation For a limb-threatening injury
4 Injuries to lower third of lower leg treat as an emergency and
5 Hip injury that prohibits normal alignment pre alert ED

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

October 2014 65
Clinical Practice Guidelines

SECTION 6
TRAUMA

5/6.6.8
Version 3, 12/13 Shock from Blood Loss (trauma) – Adult P AP

Clinical signs
of shock
Control external haemorrhage

Oxygen therapy

Request

ALS

Patient trapped No

Yes

NaCl (0.9%), 500 mL IV/IO

Suspected
significant
No
With polytrauma internal/ external
consider application haemorrhage
of a pelvic splint
Yes

Tranexamic acid 1 g IV/IO

(in 100 mL NaCl)

Head injury
Yes No
with GCS ≤ 8

NaCl (0.9%), 250 mL IV/IO aliquots

NaCl (0.9%), 250 mL IV/IO aliquots
to maintain palpable radial pulse
to maintain SBP 120 mmHg
(SBP 90 - 100 mmHg)

Maintain normo-temperature

Continue fluid therapy until

handover at ED

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

Reference: Gruen, R. L. and M. C. Reade (2012). "Administer tranexamic acid early to injured patients at risk of substantial bleeding." BMJ 345: e7133

October 2014 66
Clinical Practice Guidelines

SECTION 6
TRAUMA
5/6.6.9
Version 2, 07/11 Spinal Immobilisation – Adult P AP
5/6.6.9
Version 2, 07/11 Spinal Immobilisation – Adult P AP
Trauma
Initial indications for Use clinical
Trauma
spinal immobilisation Do not forcibly restrain a
judgement
Initial indications for patient that is combative Use
Do not forcibly restrain a If in clinical
doubt,
spinal immobilisation judgement
Return head to neutral position unless on patient that is combative immobilise
movement there is Increase in If in doubt,
Pain,
ReturnResistance or Neurological
head to neutral symptoms
position unless on immobilise
movement there is Increase in
Pain, Resistance or Neurological symptoms
Remove helmet
(if worn)
Remove helmet
(if worn) Dangerous mechanism include;
Neck or Fall ≥ 1 meter/ 5 steps
back pain or Axial load to mechanism
Dangerous head include;
No MVC
Fall ≥ >1 100 km/hr,
metre/ rollover or ejection
5 steps
midline
Neckspinal
or
tenderness
back pain or ATV
Axial collision
load to head
No Bicycle
MVC > 100 collision
km/hr, rollover or ejection
midline spinal
tenderness
Yes Pedestrian
ATV collision v vehicle
Dangerous Bicycle collision
mechanism of Pedestrian v vehicle
Yes injury or significant
Dangerous No
distractingof
mechanism
injury
injury or significant No
distracting
Are all of the factors listed present;
injury
Yes
GCS = 15
Communication effective
Are all of the factors (notpresent;
listed intoxicated with alcohol or drugs)
Yes Yes
Absence
GCS = 15of numbness, tingling or weakness in extremities
Presence of low risk factors which
Communication effective (not intoxicatedallow safe
withassessment of range of motion
alcohol or drugs)
Patient
Absencevoluntarily able to
of numbness, rotateorneck
tingling 45o leftin
weakness & extremities
right without pain Yes
Patient can
Presence ofwalk without
low risk painwhich allow safe assessment of range of motion
factors
Patient voluntarily able to rotate neckNo 45o left & right without pain
Patient can walk without pain
No

Life Immobilisation
Yes Threatening No may not be
Life indicated
Immobilisation
Yes Threatening NoApply cervical collar may not be
indicated
Apply cervical collar

Rapid extrication with long Patient in

Yes Go to
board and cervical collar sitting position appropriate
Rapid extrication with long Patient in
Yes CPG
Go to
board and cervical collar sittingNo
position Use extrication device appropriate
CPG
No Use extrication device

Load onto vacuum mattress

or long board
Load onto vacuum mattress
or long board Low risk factors
Simple rear end MVC
Consider Vacuum (excluding push into
Low risk factors
mattress oncoming
Simple reartraffic
end or hit by
MVC
Consider Vacuum bus or truck)
(excluding push into
mattress oncoming traffic or hit by
bus or truck)

Equipment list
Extrication devicelist
Equipment
Long board
Vacuum mattress
Extrication device
Orthopaedic
Long board stretcher
Rigid
Vacuumcervical collar
mattress
Orthopaedic stretcher
Rigid cervical collar
Reference: Vaillancourt, Christian et al, 2009, Ann Emerg Med. 2009 Nov; 54(5): 663-671.e1. Ppub 2009 Apr 24

Reference: Vaillancourt, Christian et al, 2009, Ann Emerg Med. 2009 Nov; 54(5): 663-671.e1. Ppub 2009 Apr 24

October 2014 67
Clinical Practice Guidelines

SECTION 6
TRAUMA

4/5/6.6.10
Version 2, 02/14 Submersion Incident EMT P

Request AP
Submerged
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
Ventilations may be
History of;
commenced while the
Complete primary survey - diving
patient is still in water
(Commence CPR if appropriate) - trauma
by trained rescuers
- water slide use
- alcohol intoxication
Go to
Adequate Inadequate
No
ventilations Ventilations
CPG
Yes
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

No

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

No

Check blood glucose

Do not delay on site Transport to ED for

Continue algorithm en route investigation of
secondary drowning
insult

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics
Verie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htm
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

October 2014 68
Clinical Practice Guidelines

SECTION 6
TRAUMA

5/6.6.11
Version 1, 05/08
Traumatic Cardiac Arrest – Adult P AP

EMS Unwitnessed EMS Witnessed

Traumatic Arrest Traumatic Arrest

Go to Apnoeic,
appropriate No Pulseless and
CPG Asystolic

Yes

Blunt trauma No

Yes

<18 years
Hypothermia
Commence
Drowning Yes to any
Lightning strike
CPR and ALS
Electrical injury

No to all
Request

ALS

Low energy
Yes
incident

Rapid transport towards ALS

No

Patient
responds
No to BLS or ALS Yes
provision within
15 min

Consider ceasing
resuscitation

Go to Go to
Recognition Asystole
of Death Decision
CPG Tree CPG

Reference: Hopson, L et al, 2003, Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiac arrest, Position paper for National
Association of EMS Physicians, Prehospital Emergency Care, Vol 7 p141-146

October 2014 69
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

4/5/6.7.1
Version 4, 12/13
Primary Survey Medical – Paediatric (≤ 15 Years) EMT P

AP
Medical
Take standard infection control precautions
issue

Consider pre-arrival information

The primary survey is focused on
establishing the patien t’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/ Circulation
OPA No Airway patent &
chin lift to skin
NPA protected
P
Ref: Pediatric Education for Prehospital Professionals
Yes

Give 5 B Consider
Ventilations No Adequate
Oxygen therapy
ventilation
Oxygen therapy
Yes

C
Pulse < 60 & signs
Yes
of poor
perfusion

No

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
Children First guidelines to
ED staff and line manager in a
confidential manner
Go to
appropriate
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 Firs t: National Guidance for the Protection and Welfare of Children

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PAEDIATRIC EMERGENCIES

4/5/6.7.2 Primary Survey Trauma – Paediatric (≤ 15 years)

Version 4, 12/13
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)
NPA(> 1 year) protected
P
Yes

Give 5 B Consider
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
Clinical status decision
threatening or life threat Survey
CPG

Serious not
life threat Normal ranges
Go to Request Age Pulse Respirations
appropriate Infant 100 – 160 30 – 60
CPG ALS 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

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PAEDIATRIC EMERGENCIES
4/5/6.7.4
Version 3, 12/13
Secondary Survey – Paediatric ( ≤ 15 years) EMT P
4/5/6.7.4
Version 3, 12/13
Secondary Survey – Paediatric ( ≤ 15 years) EMT P
AP
Primary AP
Survey
Primary
Survey
Make appropriate contact
Use age appropriate
with patient and or guardian
language for patient
if possible contact
Make appropriate
Use age appropriate
with patient and or guardian
language for patient
if possible
Identify presenting complaint and
exact chronology from the time the
patient
Identify was last wellcomplaint and
presenting Children and adolescents should
Check for normal from
exact chronology patterns
the of
time the always be examined with a chaperone
patient was -last
feeding
well (usually
Childrenaand
parent) where possible
adolescents should
- toiletpatterns of
Check for normal always be examined with a chaperone
- sleeping
feeding (usually a parent) where possible
- interaction
toilet with guardian
- sleeping
- interaction with guardian
Estimated weight
Neonate = 3.5 Kg
Identify patient’s weight Six monthsEstimated
= 6 Kg weight
One to five
Neonate years
= 3.5 Kg= (age x 2) + 8 Kg
Identify patient’s weight Greater than 5
Six months = 6 Kgyears = (age x 3) + 7 Kg
Head to toe examination One to five years = (age x 2) + 8 Kg
Go to Identify positive findings Greater than 5 years = (age x 3) + 7 Kg
Observing for
appropriate and initiate care
Head-to pyrexia
toe examination
CPG
Go to management
Identify positive findings
- rash
Observing for
appropriate and initiate care
- pain
pyrexia
CPG management
- tenderness
rash
- bruising
pain
- wounds
tenderness
- fractures
bruising
- medical
wounds alert jewellery
- fractures
- medical alert jewellery Normal ranges
Age Pulse Respirations
Re-check vital Infant 100 – 160
Normal ranges 30 – 60
signs Toddler
Age 90 – 150 Respirations
Pulse 24 – 40
Recheck vital Pre school 100
Infant 80 – 140
160 22
30 – 34
60
signs School
Toddlerage 90
70 – 150
120 18 – 40
24 30
Check for current Pre school 80 – 140 22 – 34
medications School age 70 – 120 18 – 30
Check for current
medications

If child protection concerns

are present
If child protection concerns
are present

Report findings as per

Children First guidelines to
ED stafffindings
Report and lineas
manager
per in a
confidential manner
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
Reference: of Children and Youth Affairs, 2011, Children First: National Guidance for the protection and Welfare of Children
Miall, Lawrence
Luscombe, M et et
al al, 2003,
2010, Paediatrics
BMJ, at a Glance,
Weight estimation Blackwell Publishing
in paediatrics: a comparison of the APLS formula and the formula ‘Weightﾼ3(age)+7’
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’
October 2014 72
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PAEDIATRIC EMERGENCIES

4/5/6.7.5
Version 6, 02/14 Pain Management – Paediatric (≤ 15 years) EMT P

AP
Pain
Pain assessment recommendation
< 5 years use FLACC scale
Pain assessment
Practitioners, depending on his/ 5 – 7 years use Wong Baker scale
her scope of practice, may ≥ 8 years use analogue pain scale
make a clinical judgement and
commence pain relief on a
Administer pain medication based on Analogue Pain Scale
higher rung of the pain ladder.
pain assessment and pain ladder 0 = no pain……..10 = unbearable
recommendations

Yes or best achievable Adequate relief

of pain

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

g/Kg IN
015 m
nyl 0.0 g/Kg)
Fenta c Fentanyl IN &
Request (1.5 m 1 prn Morphine PO
tx
Repea
or for ≥ 1 year
ALS And / PO old only
mg/Kg
ine 0.3 mg
Severe pain Morph 1 0
Ma x
(≥ 7 on pain scale)
or
Repeat Fentanyl
g IV IN, once only, at
5 mg/K
ine 0.0 g not < 10 min after
Morph x 0.1 mg/K
O Ma initial dose.
gP
mg/K or
cetam
ol 20 and /
Para or y gen
,
Consider
and / PO
Oxide
& Ox Repeat Morphine
Paramedic g/Kg s
10 m Nitrou inh IV at not < 2 min
rofen
Ibup intervals prn to
Moderate pain Max: 0.1 mg/kg IV
or ider
(4 to 6 on pain scale) and / Cons g/Kg
0.1 m )
s etron g
Onda n
(M ax4m
, wly
y gen IV slo
& Ox
s Oxide
Nitrou inh

O
/Kg P ns
cetam
ol 2 0 mg
terv entio
Mild pain
P ar a
log ical in
maco
(1 to 3 on pain scale) non -phar in Lad
der

i de r other ediatr
ic Pa
Cons C P a
P HE C

Decisions to give analgesia must

be based on clinical assessment
and not directly on a linear scale

Reference: World Health Organization, Pain Ladder

October 2014 73
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SECTION 7
PAEDIATRIC EMERGENCIES

5.7.10
Version 1, 03/14 Advanced Airway Management – Paediatric (≥ 8 years) P

Prolonged
CPR

Ventilations Consider
No
maintained FBAO

Yes

Minimum interruptions of
chest compressions. Supraglottic airway insertion

Maximum hands off time

10 seconds.

Successful Yes

No

Ensure CO2 detection

Revert to basic airway
Maintain adequate device in ventilation
management
circuit
ventilation and
oxygenation throughout
procedures Check placement of advanced
airway after each patient movement
or if any patient deterioration

Continue ventilation and oxygenation

Go to
appropriate
CPG

Following successful Advanced Airway

management:-
i) Ventilate at 12 to 20 per minute.
ii) Unsynchronised chest compressions
continuous at 100 to 120 per minute

Reference: ILCOR Guidelines 2010,

Paediatric basic and advanced life support

October 2014 74
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PAEDIATRIC EMERGENCIES

4/5/6.7.11
Inadequate Ventilations – Paediatric (≤ 15 years) EMT P
Version 3, 03/14

AP
Airway Go to
Respiratory
patent & No Airway
difficulty protected CPG

Yes
P
Consider
Check SpO2 Raised ETCO2 + reduced SpO2:
ETCO2
Consider assisted ventilation

Raised ETCO2 + normal SpO2:

100% O2 initially Oxygen therapy Encourage deep breaths
Titrate O2 to standard as
clinical condition improves

Request

ALS

Patient assessment

Consider positive pressure ventilations

(12 to 20 per minute) via BVM

Brain insult Respiratory failure Substance intake Other

If suspected narcotic OD Consider

Go to Respiratory assessment Naloxone, 0.01 mg/Kg IV/IO Consider pain, posture &
Head neuromuscular disorders
injury Or
CPG Naloxone, 0.01 mg/Kg IM/SC

Or
Naloxone, 0.02 mg/Kg IN

Bronchospasm/ Asymmetrical
Crepitations Other
known asthma breath sounds

Go to Go to Consider shock, cardiac/

Go to neurological/ systemic
Asthma Anaphylaxis Sepsis
CPG CPG illness, pain or
CPG psychological upset

Consider collapse,
consolidation & fluid

Tension
Yes Pneumothorax No
suspected
AP
Needle
decompression

Repeat Naloxone prn to

Max 0.1 mg/Kg or 2 mg

October 2014 75
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PAEDIATRIC EMERGENCIES

4/5/6.7.12
Version 2, 05/14 Asthma – Paediatric (≤ 15 years) EMT P

Asthma/ AP
bronchospasm
Assess and maintain airway

Respiratory assessment

< 5 years Salbutamol 2.5 mg NEB

≥ 5 years Salbutamol 5 mg, NEB
If no improvement Salbutamol
Mild Asthma OR aerosol, 0.1 mg may be repeated;
Salbutamol for < 5 year olds up to 3 times,
(0.1 mg) metered aerosol for ≥ 5 year olds up to 5 times,
as required

Resolved/
Yes
improved

No

ECG & SpO2 monitoring

Oxygen therapy

Request

ALS

< 5 years Salbutamol 2.5 mg NEB

≥ 5 years Salbutamol 5 mg, NEB
OR
Ipratropium bromide
Moderate Asthma
< 12 years 0.25 mg NEB
≥ 12 years 0.5 mg NEB
& age specific Salbutamol NEB mixed

Resolved/
Yes
improved

No

Salbutamol, age-specific dose,

NEB

Resolved/
Yes
improved

No

Hydrocortisone (in 100 mL NaCl)

Severe Asthma < 1 year 25 mg IV
1 – 5 years 50 mg IV
> 5 years 100 mg IV

Salbutamol, age-specific dose,

NEB

Resolved/
Yes
improved

No

Salbutamol, age-specific dose, NEB

Life-threatening
Every 5 minutes prn
Asthma

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

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PAEDIATRIC EMERGENCIES

4/5/6.7.13
Version 2, 12/13 Stridor – Paediatric (≤ 15 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

October 2014 77
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PAEDIATRIC EMERGENCIES

4/5/6.7.20
Version 2, 12/13 Basic Life Support – Paediatric (≤ 15 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
< 8 years use paediatric
Oxygen therapy defibrillation system
(if not available use adult pads)

Request

ALS One rescuer CPR 30 : 2

Two rescuer CPR 15 : 2
Compressions : Ventilations
Minimum interruptions of
chest compressions.
Commence chest Compressions
Continue CPR (30:2) until defibrillator is attached Chest compressions
Maximum hands off time Rate: 100 to 120/ min
Depth: 1/3 depth of chest
10 seconds.
Child; two hands
Small child; one hand
Infant (< 1); two fingers
Yes < 8 years No

With two rescuer CPR use

AP Change defibrillator to two thumb-encircling hand
manual mode chest compression for infants
Apply paediatric system Apply adult defibrillation
P Consider changing AED pads pads
defibrillator to
manual mode

Shockable Assess Non - Shockable

Continue VF or pulseless VT Rhythm Asystole or PEA
CPR while
defibrillator
is charging
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.

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PAEDIATRIC EMERGENCIES

4/5.7.21 EMT P
Version 2, 12/13 Foreign Body Airway Obstruction – Paediatric (≤ 15 years)

Are you
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
No No Breathing
Conscious 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

Effective Yes

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

October 2014 79
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PAEDIATRIC EMERGENCIES

4/5/6.7.22
Version 3, 12/13 VF or Pulseless VT – Paediatric (≤ 15 years) EMT P

AP
From BLS
VF or VT
Paediatric
CPG arrest
< 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

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

Transport to ED if no change
after 10 minutes resuscitation
If no ALS available

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 to 120 per minute
appropriate:
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

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PAEDIATRIC EMERGENCIES

4/5/6.7.23
Version 3, 12/13 Asystole/PEA – Paediatric ( ≤ 15 years) EMT P

AP
From BLS
Asystole/ PEA
Paediatric
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/
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

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 (0.9%) 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

October 2014 81
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PAEDIATRIC EMERGENCIES

4/5/6.7.24
Version 3, 10/13 Symptomatic Bradycardia – Paediatric (≤ 15 years) EMT P

AP
Symptomatic
Bradycardia
Oxygen therapy

Initiate mobilisation of 3 to 4
practitioners / responders
Yes Hypoxia on site to assist with cardiac
arrest management
Consider positive No
pressure ventilations
(12 to 20/ min)
Collective signs of inadequate perfusion
Tachypnoea
Diminished/absent peripheral pulses
Delayed capillary refill
Cool extremities, mottling AP
Unresponsive Request
Immediate IO access if IV
ALS not immediately accessible

Unresponsive
Signs of Inadequate
No
perfusion &
HR < 60

Yes

CPR

ECG & SpO2

monitoring

NaCl (0.9%) 20 mL/Kg IV/IO

Check blood glucose

Reassess

Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IO

Every 3 – 5 min prn

Persistent
No
bradycardia

Yes

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

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PAEDIATRIC EMERGENCIES

5/6.7.25
Version 2, 12/13 Post-Resuscitation Care – Paediatric (≤ 15 years) P AP

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

Request

ALS

Initiate mobilisation of 3 to 4
practitioners / responders
Unresponsive No on site to assist with cardiac
arrest management
Yes

Adequate
No
ventilation
Positive pressure ventilations
Max 12 to 20 per minute Yes For active cooling place
cold packs at arm pit,
groin & abdomen

Commence active cooling

Maintain patient at rest

ECG & SpO2

monitoring

Monitor blood pressure

and GCS

Check blood glucose

Monitor vital signs

Transport
quietly and
smoothly

Consider causes and treat as

appropriate:
Hydrogen ion acidosis
Hyper/ hypokalaemia
Hypothermia If persistent poor perfusion
Hypovolaemia consider
Hypoxia NaCl (0.9%) 20 mL/Kg IV/IO
Thrombosis – pulmonary
Tension pneumothorax
Thrombus – coronary
Tamponade – cardiac
Equipment list
Toxins
Trauma Cold packs

Reference: ILCOR Guidelines 2010

October 2014 83
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SECTION 7
PAEDIATRIC EMERGENCIES
5/6.7.30
Version 1, 12/13 Adrenal Insufficiency – Paediatric (≤ 15 years) P AP

5/6.7.30
Version 1, 12/13 Adrenal Insufficiency – Paediatric (≤ 15 years) P AP
Diagnosed with Addison’s
disease or Adrenal insufficiency
Diagnosed with Addison’s
disease or Adrenal insufficiency Recent
illness or No
injury
Recent
Yes or
illness No
injury

Yes
Check blood glucose

Check blood glucose

Poor perfusion No

Poor Yes
perfusion No

Yes
Request

ALS
Request
Consider
ALS
Hydrocortisone IV
Hydrocortisone IM (in 100 mL NaCl)
6 mth ≤ 5 years: 50 mg 6 mth ≤ 5 years: 50 mg
Consider
> 5 years: 100 mg > 5Hydrocortisone
years: 100IVmg
Hydrocortisone IM (in 100 mL NaCl)
if6IV not available
mth ≤ 5 years: 50 mg 6 mth ≤ 5 years: 50 mg
> 5 years: 100 mg > 5 years: 100 mg
if IV not available Reassess

Reassess

NaCl (0.9%) 20 mL/Kg IV

NaCl (0.9%) 20 mL/Kg IV

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

Reference: Antal, Z. and P. Zhou (2009). "Addison disease." Pediatr Rev 30(12): 491-493

Reference: Antal, Z. and P. Zhou (2009). "Addison disease." Pediatr Rev 30(12): 491-493

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PAEDIATRIC EMERGENCIES

5/6.7.31
Version 3, 12/13 Allergic Reaction/Anaphylaxis – Paediatric (≤ 15 years) P AP

Allergic
reaction
Oxygen therapy
Severe/
Mild Moderate
Anaphylaxis

Epinephrine
administered pre No
arrival? (within 5
minutes) Epinephrine (1:1 000) IM
< 6 months: 0.05 mg (50 mcg) IM
6 months to 5 years: 0.125 mg (125 mcg) IM
Yes
6 to 8 years: 0.25 mg (250 mcg) IM
Monitor > 8 years: 0.5 mg (500 mcg) IM
reaction

Request Repeat Epinephrine

Salbutamol NEB may be substituted with at 5 minute intervals
Salbutamol aerosol 0.1 mg. ALS if no improvement
If no improvement Salbutamol may be repeated;
for < 5 year olds up to 3 times,
for ≥ 5 year olds up to 5 times,
prn Reassess

If bronchospasm consider
nebuliser Reoccurs /
Salbutamol NEB No deteriorates /
< 5 yrs: 2.5 mg no improvement
5 yrs: 5 mg

Yes

Reassess

ECG & SpO2 ECG & SpO2

monitor monitor

Request
Epinephrine (1:1 000) IM
Deteriorates Yes
See age-related doses above
ALS
No NaCl (0.9%), 20 mL/Kg IV/IO bolus
Repeat by one prn

If bronchospasm consider
nebuliser
Salbutamol NEB
See age-related doses above

Severe or
recurrent reactions
Yes
and or patients with
Hydrocortisone asthma
(infusion in 100 mL NaCl)
< 1 yr 25 mg IV or IM No
1-5 yrs 50 mg IV or IM
> 5 yrs 100 mg IV or IM

Mild
Urticaria and or angio
oedema
Special Authorisation:
Paramedics are authorised to continue
P the established infusion in the absence
Severe Moderate
Moderate symptoms + Mild symptoms + simple of an Advanced Paramedic or Doctor
haemodynamic and or bronchospasm during transportation
respiratory compromise

October 2014 85
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PAEDIATRIC EMERGENCIES

5/6.7.32
Version 3, 12/13 Glycaemic Emergency – Paediatric (≤ 15 years) P AP

Abnormal
blood glucose
level

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

Consider
Glucose gel > 20 mmol/L
≤ 8 years 5-10 g Buccal
> 8 years 10-20 g Buccal

Request

ALS

No Yes

IV access

Glucagon
≤ 8 years 0.5 mg IM Dextrose 10% 5 mL/Kg IV/IO bolus
> 8 years 1 mg IM Repeat x 1 prn

Consider
Reassess No Dehydration
ALS
Yes

NaCl (0.9%) 10 mL/Kg IV/IO bolus

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

Reference: Dehydration- Paramedic Textbook 2nd E p 1229

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PAEDIATRIC EMERGENCIES

5/6.7.33
Version 3, 02/14 Seizure/Convulsion – Paediatric (≤ 15 years) P AP

Seizure / convulsion

Consider other causes

of seizures Protect from harm
Meningitis
Head injury
Hypoglycaemia Oxygen therapy
Fever
Poisons
Alcohol/drug withdrawal

Seizing currently Seizure status Post seizure

Request Consider

ALS ALS

No Yes

IV access
Midazolam 0.1 mg/Kg IV/IO
Midazolam buccal Repeat by one prn
< 1 year: 2.5 mg Or
1 year to < 5 years; 5 mg
5 years to < 10 years: 7.5 mg Diazepam 0.1 mg/Kg IV/IO
≥ 10 years: 10 mg Repeat by one prn
Repeat by one prn

Or
Midazolam 0.2 mg/Kg IN
Repeat by one prn

Or Go to
Diazepam PR
Pyrexia Yes Pyrexia
< 3 years: 2.5 mg PR
CPG
3 to 7 years: 5 mg PR
≥ 8 years: 10 mg PR No
Repeat by one prn

Check blood glucose

Maximum two doses of
anticonvulsant medication
by Practitioner regardless
of route
Do not exceed adult dose Reassess

October 2014 87
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

5/6.7.34
Version 3, 12/13 Septic Shock – Paediatric (≤ 15 years) P AP

Clinical signs
of shock

Oxygen therapy

Request

ALS

NaCl (0.9%), 20 mL/Kg IV/IO

Meningococcal
Ensure appropriate PPE worn; Yes
disease suspected
Mask and goggles

No
Benzylpenicillin IV/IO over 3 to 5 minutes or IM
< 1 year 300 mg
1 – 8 years 600 mg
> 8 years 1 200 mg (1.2 g)

NaCl (0.9%), 20 mL/Kg IV/IO aliquots

if signs of inadequate perfusion

ECG & SpO2 monitoring

Signs of inadequate perfusion

A: (not directly affected)
B: Increased respiratory rate (without increased effort)
C: Tachycardia
Diminished/absent peripheral pulses
Delayed capillary refill
D: Irritability/ confusion / ALoC
E: Cool extremities, mottling

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

October 2014 88
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

4/5/6.7.35
Version 1, 12/13 Pyrexia – Paediatric (≤ 15 years) EMT P

AP
Child with elevated
temperature
Remove/ protect from hot
environment
(providing it is safe to do so)

Yes Alert No

Recovery position
Give cool fluids to (maintain airway)
drink
Check blood
glucose

Cool patient

≥ 38oC
temperature with
Yes
signs of distress
or pain
Paracetamol, 20 mg/Kg PO
Or
Paracetamol
> 1 mth < 1 year: 90 mg PR
1 to 3 years: 180 mg PR No
4 to 8 years: 360 mg PR

Consider

ALS

Go to
Query
Septic
Yes severe
Shock
Sepsis
CPG

No

SpO2 & ECG

monitor

Reference: ILCOR Guidelines 2010

RFDS, 2011, Primary Clinical Care Manual

October 2014 89
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

4/5/6.7.36
Version 1, 12/13 Sickle Cell Crisis – Paediatric (≤ 15 years) EMT P

AP
Sickle Cell crisis
Oxygen therapy 100% O2

Pain
Go to
management Yes
Pain CPG
required

No

Go to
Elevated
Pyrexia Yes
temperature
CPG
No

If patient is cold ensure that he/she is

warmed to normal temperature

Consider patient’s Encourage oral fluids

care plan

Dehydration
& unable to take oral No
fluids

Yes

Request

ALS

NaCl (0.9%) 10 mL/Kg IV

SpO2 & ECG

monitor

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

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

October 2014 90
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES
4/5/6.7.50
Version 3, 02/14 External Haemorrhage – Paediatric (≤ 15 years) EMT P
4/5/6.7.50
Version 3, 02/14 External Haemorrhage – Paediatric (≤ 15 years) EMT
BTEC P
Open AP
wound BTEC
Open AP
wound
Catastrophic
Active bleeding Yes Yes
haemorrhage
Catastrophic
Active bleeding Yes Yes
haemorrhage
No No
Posture P
No No Elevation
Posture Apply tourniquet if
Examination Plimb injury Request
Elevation
Pressure Apply tourniquet if
Examination
limb injury Request
ALS
Pressure
Consider applying a dressing
impregnated with haemostatic agent ALS
Consider applying a dressing
impregnated with haemostatic agent

Posture EMT Special Authorisation:

Elevation
Posture EMT EMTs having completed the
Examination Special
Elevation BTEC Authorisation:
course may be
Pressure EMTs having
Examination privileged by acompleted the
licensed CPG
BTECtocourse
provider apply may be
a tourniquet
Pressure
privilegedon
byits
a licensed
behalf CPG
provider to apply a tourniquet
on its behalf

Apply sterile dressing

Apply sterile dressing

Consider
Oxygen therapy
Consider
Oxygen therapy

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

Haemorrhage
Yes
controlled
Haemorrhage
Yes
controlled
No
P No
Depress proximal
P pressure point
Depress proximal
pressure point

Haemorrhage
Yes
controlled
Haemorrhage
Yes
controlled
No
P No
Apply tourniquet
Equipment list P
Sterile dressingEquipment
(various sizes) Apply tourniquet
list
Crepe bandage (various sizes)
Sterile dressing (various sizes) Go to
Conforming bandage (various sizes) Significant
Crepe bandage (various sizes) Yes Shock
Triangular bandage blood loss Go to
Conforming bandage (various sizes) Significant CPG
Trauma tourniquet Yes Shock
Triangular bandage
Dressing impregnated with haemostatic agent blood loss
No CPG
Trauma tourniquet
Dressing impregnated with haemostatic agent No

Reference:
ILCOR Guidelines 2010,
Reference:
Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037
ILCOR Guidelines 2010,
Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037
October 2014 91
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

5/6.7.51
Version 3, 12/13 Shock from Blood Loss – Paediatric (≤ 15 years) P AP

Clinical signs
of shock

Control external haemorrhage

Oxygen therapy

Request

ALS

Patient trapped No

Yes

NaCl (0.9%) 10 mL/Kg IV/IO

Reassess

NaCl (0.9%), 10 mL/Kg IV/IO aliquots

if signs of inadequate perfusion

Continue fluid therapy until

handover at ED

ECG & SpO2 monitoring

Signs of inadequate perfusion

A: (not directly affected)
B: Increased respiratory rate (without increased effort)
C: Tachycardia
Diminished/absent peripheral pulses
Delayed capillary refill
D: Irritability/ confusion / ALoC
E: Cool extremities, mottling

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

Reference:
American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Prefessionals, Jones and Bartlett.

October 2014 92
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

5/6.7.52
Version 3, 12/13 Spinal Immobilisation – Paediatric (≤ 15 years) P AP

Trauma
Initial indications for Use clinical
spinal immobilisation judgement
If in doubt,
Return head to neutral position unless on immobilise
movement there is Increase in Do not forcibly restrain a
Pain, Resistance or Neurological symptoms patient that is combative

Remove helmet
(if worn)

Dangerous mechanism include;

Neck or Fall ≥ 1 metre/ 5 steps
back pain or Axial load to head
No MVC > 100 km/hr, rollover or ejection
midline spinal
tenderness ATV collision
Bicycle collision
Yes Pedestrian v vehicle
Dangerous
mechanism of
injury or significant No
distracting
injury
Are all of the factors listed present;
Yes
GCS = 15
Communication effective (not intoxicated with alcohol or drugs)
Absence of numbness, tingling or weakness in extremities Yes
Presence of low risk factors which allow safe assessment of range of motion
Patient voluntarily able to rotate neck 45o left & right without pain
Patient can walk without pain
No

Life Immobilisation
Yes No
Threatening may not be
indicated
Apply cervical collar

Patient in Go to
Yes
sitting position appropriate
CPG
Patient in
No No undamaged Yes
Rapid extrication with long
board/ paediatric board and child seat
cervical collar
Use extrication device Immobilise in child seat

Load onto vacuum mattress,

paediatric board or long
board

Consider Vacuum
mattress

Low risk factors

Simple rear end MVC Equipment list
(excluding push into
oncoming traffic or hit by Extrication device
bus or truck) Long board
Vacuum mattress
Orthopaedic stretcher
References; Rigid cervical collar
Viccellio, P, et al, 2001, A Prospective Multicentre Study of Cervical Spine Injury in Children, Pediatrics vol 108, e20
Slack, S. & Clancy, M, 2004, Clearing the cervical spine of paediatric trauma patients, EMJ 21; 189-193

October 2014 93
Clinical Practice Guidelines

SECTION 7
PAEDIATRIC EMERGENCIES

4/5/6.7.53
Version 3, 12/13 Burns – Paediatric (≤ 15 years) EMT P

Burn or AP
Cease contact with heat source
Scald

Inhalation
and/or facial Yes
Should cool for another injury
10 minutes during Airway management
packaging and transfer. No
Caution with hypothermia
Go to
Respiratory Yes Inadequate
distress Ventilations
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
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,
H: hands No circumferential & electrical burns
(excluding FHFFP)
F: feet
F: flexion points
P: perineum
Yes
Request
TBSA burn
No Yes
> 5%
ALS

ECG & SpO2

monitoring

> 10% TBSA

and/or time from
No
injury to ED
> 1 hour

Yes

NaCl (0.9%), IV/IO

5 to 10 years = 250 mL
> 10 years = 500 mL

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

October 2014 94
Clinical Practice Guidelines

SECTION 8
PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.1
Version 2, 01/13 Major Emergency (Major Incident) – First Practitioners on site EMT P

AP
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 conjunction with Fire & Carry out scene survey
Garda 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 Principal Response
Agencies on site;
Carry out Communications Officer role until relieved - Site Control Point (Ambulance Control Point),
- Casualty Clearing Station
- Ambulance loading point
- On site co-ordination centre

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
continuous information as the
incident develops

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

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

October 2014 95
Clinical Practice Guidelines

SECTION 8
PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.2
Version 2, 01/13 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
Fire Officer or an Garda Síochána
Traffic Cordon

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 is controlled by an Garda Síochána
Entry to Inner Cordon (Bronze Area) is
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
Please note that Controller of Casualty Clearing Officer
Operations may be other than Triage Officer
ambulance or fire officers, depending Ambulance Parking Point Officer
on the nature of the emergency Ambulance Loading Point Officer
Communications Officer
Safety Officer

LOCAL AUTHORITY HSE GARDA

CONTROLLER CONTROLLER CONTROLLER

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

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

October 2014 96
Clinical Practice Guidelines

SECTION 8
PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.3
Version 1, 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

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

October 2014 97
Clinical Practice Guidelines

SECTION 8
PRE-HOSPITAL EMERGENCY CARE OPERATIONS

5/6.8.4
Version 1, 05/08 Triage Sort P AP

Multiple casualty
incident

Triage is a
dynamic
Cardiopulmonary function Measured value Score Insert score process
10 – 29 / min 4
> 29 / min 3
Respiratory Rate 6 – 9 / min 2 A
1 – 5 / min 1
None 0
≥ 90 mm Hg 4
76 – 89 mm Hg 3
Systolic Blood
50 – 75 mm Hg 2 B
Pressure
1 – 49 mm Hg 1
No BP 0
13 – 15 4
9 – 12 3
Glasgow Coma Scale 6–8 2 C
4–5 1
3 0
Triage Revised Trauma Score A+B+C
Priority 1
(Immediate)
1 - 10
RED

Priority 2
(Urgent)
11
YELLOW
Revised
Trauma
Score
Priority 3
12 (Delayed)

GREEN

Spontaneous 4
Eye Opening
To Voice 3 0 DEAD
To Pain 2
None 1

Oriented 5
Confused 4
Verbal
Inappropriate words 3
Response
Incomprehensible sounds 2
None 1
Obeys commands 6
Localises pain 5
Motor Withdraw (pain) 4
Response Flexion (pain) 3
Extension (pain) 2
None 1
Glasgow Coma Scale

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

October 2014 98
Clinical Practice Guidelines

SECTION 8
PRE-HOSPITAL EMERGENCY CARE OPERATIONS
5/6.8.5
Version 1, 05/08 Conducted Electrical Weapon (Taser) P AP
5/6.8.5
Version 1, 05/08 Conducted Electrical Weapon (Taser) P AP

Prior to touching the patient ensure

Taser
that the Garda has disconnected
gun used Prior to touching the patient ensure
Taser the wires from the hand held unit
that the Garda has disconnected
gun used
the wires from the hand held unit
Go to
Complete
appropriate
primary survey
Go
CPGto
Complete
appropriate
primary survey
CPG
Cut wire connection proximal
to barbs
Cut wire connection proximal
to barbs

Monitor ECG & SpO2

for minimum 15 minutes
Monitor ECG & SpO2
for minimum 15 minutes
Go to
Behavioural Yes Behavioural
emergency Go to
emergency
Behavioural Yes Behavioural
CPG
emergency
No emergency
CPG
No
Patient care takes precedent Remove barbs Barbs should not be removed if
over removal of barb Clean and dress wounds they are embedded in the face,
Patient care takes precedent Remove barbs Barbsneck,
should not be removed if
eye, or groin
over removal of barb Clean and dress wounds they are embedded in the face,
eye, neck, or groin
Monitor GCS, temperature
& vital signs
Monitor GCS, temperature
& vital signs

Monitor for signs of

Excited Delirium
Monitor for signs of
Excited Delirium

Consider
Oxygen therapy
Consider
Oxygen therapy

Ensure Garda accompany

patient at all times
Ensure Garda accompanies
patient at all times

Note:
This CPG was developed in conjunction with
Note:
the Chief Medical Officer, An Garda Síochána
This CPG was developed in conjunction with
the Chief Medical Officer, An Garda Síochána

Reference:
DSAC Sub-committee on the Medical Implications of Less-lethal Weapons 2004, Second statement on the medical implications of the use of the M26
Reference:Taser.
Advanced
DSAC Sub-committee
United on the
States Government Medical Implications
Accountability of Less-lethal
Office, 2005, The use ofWeapons
Taser by2004, Second
selected statement onagencies
law enforcement the medical implications of the use of the M26
Advancedhealth
Manitoba Taser.Emergency Medical Services, 2007 Taser Dart Removal Protocol
United States Government Accountability Office, 2005, The use of Taser by selected law enforcement agencies
Manitoba Health Emergency Medical Services, 2007 Taser Dart Removal Protocol

October 2014 99
Clinical Practice Guidelines

SECTION 9
TREAT & REFERRAL

5/6.9.1 Clinical Care Pathway Decision – Treat & Referral

Version 2, 01/13 P AP

From
Non serious or
relevant
CPGs non life threat

Administer specific treatment Patient

responds to No
& provide patient with the Generic patient inclusion
opportunity to recover/ intervention(s)
1. ≥ 18 years & ≤ 60 years.
respond 2. Not pregnant.
Yes
3. Social support available.
4. Demonstrates capacity and willing to engage.
Conduct complete patient assessment 5. Reliable history.
Focused history
6. Vital signs within normal range (following care).
Systematic physical examination
7. Compliant with treatment, including own
medications.
8. Clinical status of ‘Non serious or non life threat
All generic (following care).
inclusion criteria No 9. Absence of self-inflicted injury or assault.
present 10. No observed significant relevant co-morbidity.
11. 1st call for same condition within 30 days.
Yes 12. Registered with general practitioner.
If in any doubt about generic inclusions the
practitioner should transport to ED
Practitioner
satisfied with non No
ED care

Yes

CPG If medical practitioner is present;

for treat & referral follow direction on transport
No decision
available for
condition Transport to ED

Yes

An
adult carer,
both capable &
No
willing to accept
responsibility,
available
Yes

Explain clinical pathway options to Vital sign Normal range

patient and carer Respiratory Rate 12 – 20
SpO2 ≥ 96%
Inspired O2 Room air
Patient & Systolic BP 111 - 150
carer accepts non No Pulse (BPM) 51 - 90
ED care
AVPU/CNS Response Alert

Yes Temperature (oC) 36 – 37.5

Go to Clinical Care Pathway options

appropriate CP1 Treat & Transport to an Emergency Department
T&R CPG
CP2 Treat & Referral for follow-up care within 2 hours
(arranged with local practitioner)
CP3 Treat & Referral for follow-up care within 48 hours or
as soon as practicable
CP4 Treat & Referral to self-care with after-care instructions

Reference: Ambulance Service of NSW, 2008, CARE Clinical Pathways

HSE Acute Medicine Programme, 2011, Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical
Deterioration

October 2014 100

Clinical Practice Guidelines

SECTION 9
TREAT & REFERRAL
5/6.9.2
Version 2, 01/13 Hypoglycaemia – Treat & Referral P AP
5/6.9.2
Version 2, 01/13 Hypoglycaemia – Treat & Referral P AP
From
Clinical Previously
Pathway
From diagnosed with Specific Hypoglycaemic exclusion
Decision
Clinical Previously
diabetes 1. First ever hypoglycaemic episode.
CPG
Pathway diagnosed with Specific
2. Hypoglycaemic
< 30 days exclusion
since last episode.
Decision diabetes 1. First ever
3. Unable or hypoglycaemic
unwilling to eat.episode.
CPG 2. < 30 days since last episode.
4. Latest blood glucose < 4.0 mmol/L (after treatment).
3. Unable
5. No serialorimprovement
unwilling to eat.
of blood glucose.
Exclusions 4. Latest
6. On oralblood glucose < 4.0
hypoglycaemics mmol/L (aftertablets
(sulphonylurea treatment).
in
Yes
present 5. particular).
No serial improvement of blood glucose.
Yes
Exclusions 6. Recent
7. On oral medication
hypoglycaemics
change or additional tablets in
(sulphonylurea
present particular).
No medications prescribed (within 30 days).
7.
8. Recent
Seizure medication change
in association or additional
with hypoglycaemia
No medications
9. Insulin or oralprescribed (within overdose
hypoglycaemics 30 days).
Seizure
8. in
If in association
any doubt about 1 with hypoglycaemia
to 9 above the practitioner
or oral hypoglycaemics
9. Insulintransport
should to ED overdose
If in any doubt about 1 to 9 above the practitioner
should transport to ED

CP 1 CP 2 CP 3 CP 4

CP 1 CP 2 CP 3 CP 4
Transport Immediate 48 hours Self-care

Transport Immediate 48 hours Self-care

1. Complete after-care Instructions and give a copy to the patient or carer

2. Complete the PCR and mark for Clinical Audit
1. Complete after-care Instructions and give a copy to the patient or carer
2. Complete the PCR and mark for Clinical Audit

Ensure patient takes in both quick

(lucozade, fruit juice or sweets) and
Ensure patient(bread,
longer-acting takes in bothbiscuit)
toast, quick
(lucozade, fruit juice or sweets) and
carbohydrates
longer-acting (bread, toast, biscuit)
carbohydrates
If the patient expresses a
Flush line with 10 mL
NaCl following removal wish to attend an Emergency
If the patientthen
Department expresses a
of 10%line
Flush Dextrose
with 10 mL
infusion
NaCl following removal wish to attend shall
arrangements an Emergency
be made
of 10% Dextrose Department
to transport then
him/her there
infusion arrangements shall be made
to transport him/her there

Reference: HSE Diabetes Programme, 2012.

Ambulance Service of NSW, 2008, CARE Clinical Pathways
Reference: O’Donnell C, 2007,
HSE Diabetes Hypoglycaemia
Programme, 2012. Treat and Discharge Protocol (unpublished)
Carter A, et alService
Ambulance 2002, Transport
of NSW, Refusal
2008,by Hypoglycaemic
CARE Patients after On-scene Intravenous Dextrose, Academic Emergency medicine, Vol. 9, No. 8:p855-857
Clinical Pathways
O’Donnell C, 2007, Hypoglycaemia Treat and Discharge Protocol (unpublished)
Carter A, et al 2002, Transport Refusal by Hypoglycaemic Patients after On-scene Intravenous Dextrose, Academic Emergency medicine, Vol. 9, No. 8:p855-857

October 2014 101

Clinical Practice Guidelines

SECTION 9
TREAT & REFERRAL
5/6.9.3
Version 2, 01/13 Isolated seizure – Treat & Referral P AP

5/6.9.3
Version 2, 01/13 Isolated seizure – Treat & Referral P AP
From
Clinical Specific seizure exclusion
Pathway Known epileptic 1. First seizure.
From
Decision 2. Anticonvulsant administered.
Clinical Specific seizure exclusion
CPG 3. Concurrent acute illness (including abnormal
Pathway Known epileptic 1. First seizure.
temperature).
Decision 2. Anticonvulsant administered.
4. History of multi seizure presentations.
CPG 3. Concurrent acute illness (including abnormal
5. History of recent head injury.
temperature).
Exclusions 6. Increased frequency of seizures.
Yes 4. History of multi seizure presentations.
present 7. Seizure involving submersion or injury.
5. History of recent head injury.
8. Seizure type or pattern differing to usual presentation.
Exclusions 6. Increased frequency of seizures.
Yes No 9. Suspicion of overdose / ingestion / aspiration.
present 7. Seizure involving submersion or injury.
10. Unwitnessed seizure.
8. Seizure type or pattern differing to usual presentation.
11. Two or more seizures within 24 hours.
No 9. Suspicion of overdose / ingestion / aspiration.
12. Glucose < 4 mmol/L.
10. Unwitnessed seizure.
13. Recent medication change or additional medications
11. Two or more seizures within 24 hours.
prescribed (within 30 days).
12. Glucose < 4 mmol/L.
If in any doubt about 1 to 13 above the practitioner
13. Recent medication change or additional medications
should transport to ED
prescribed (within 30 days).
If in any doubt about 1 to 13 above the practitioner
should transport to ED
CP 1 CP 2 CP 3 CP 4

CP 1
Transport CP 2
Immediate 48CP 3
hours CP 4
Self-care

Transport Immediate 48 hours Self-care

1. Complete after-care Instructions and give a copy to the patient or carer

2. Complete the PCR and mark for Clinical Audit

1. Complete after-care Instructions and give a copy to the patient or carer

2. Complete the PCR and mark for Clinical Audit

Isolated seizure:
Lasting < 5 minutes
Similar to previous events
Isolated seizure:
Lasting < 5 minutes
Similar to previous events

If the patient expresses a

wish to attend an Emergency
Department then
If the patient expresses a
arrangements shall be made
wish to attend an Emergency
to transport him/her there
Department then
arrangements shall be made
to transport him/her there

Reference: HSE Epilepsy Programme 2012

Ambulance Service of NSW, 2008, CARE Clinical Pathways
NICHOLL, J. S. 1999. Prehospital management of the seizure patient. Emerg Med Serv, 28, 71-5.
Simonson, H and Pelberg, A, 1993, Unnecessary Emergency Transport and Care of Grand Mal Seizures, American Journal of Medical Quality, Vol 8, No 2, p53-55.
Reference: Mechem,
HSE Epilepsy
CC etProgramme 2012
al, 2001, Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation, Academy of Emergency Medicine, Mar;8(3):231-6
Ambulance Service of NSW, 2008, CARE Clinical Pathways
NICHOLL, J. S. 1999. Prehospital management of the seizure patient. Emerg Med Serv, 28, 71-5.
Simonson, H and Pelberg, A, 1993, Unnecessary Emergency Transport and Care of Grand Mal Seizures, American Journal of Medical Quality, Vol 8, No 2, p53-55.
Mechem, CC et al, 2001, Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation, Academy of Emergency Medicine, Mar;8(3):231-6

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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 the Medicinal Products 7th Schedule (SI 300 of
2014). 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 Committee (MAC) prior to publication by Council.

The medications herein may be administered provided:

1 The practitioner is in good standing on the PHECC practitioner’s Register.

2 The practitioner complies with the Clinical Practice Guidelines (CPGs) published by PHECC.
3 The practitioner is acting on behalf of an organisation (paid or voluntary) that is a PHECC licensed CPG provider.
4 The practitioner is privileged, by the organisation on whose behalf he/she is acting, to administer the medications.
5 The practitioner has received training on, and is competent in, the administration of the medication.
6 The medications are listed on the Medicinal Products 7th Schedule.

The context for administration of the medications listed here is outlined in the CPGs.

Every effort has been made to ensure accuracy of the medication doses herein. The dose specified on the relevant CPG shall be
the definitive dose in relation to 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.

Water for injection shall be used when diluting medications, however if not available NaCl (0.9%) may be used if not
contraindicated.

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

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

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

Paediatric weight estimations acceptable to PHECC are:

Neonate 3.5 Kg

Six months 6 Kg

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

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

Reviewed on behalf of PHECC by Prof Peter Weedle, Adjunct Professor of Clinical Pharmacy, School of Pharmacy, University
College Cork.
This version contains 17 medications.

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Amendments to the 2012 Edition

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

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

Water for injection shall be used when diluting medications, however if not available NaCl (0.9%) may be used if not
contraindicated.

The paediatric weight estimation formulae have been modified.

New Medications introduced;

• Hydrocortisone
• Ticagrelor

Clopidogrel
HEADING ADD DELETE

Indications ST Elevation Myocardial Infarction (STEMI) if the patient is Identification of ST Elevation

not suitable for PPCI Myocardial Infarction (STEMI)

Usual Dosages 300 mg PO 600 mg PO

≥ 75 years > 75 years

Additional information Paramedics are authorised to

administer Clopidogrel PO
following identification of
STEMI and medical practitioner
instruction

Epinephrine (1:1,000)
HEADING ADD DELETE

Usual Dosages Auto-injector EpiPen® Jr

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Ibuprofen
HEADING ADD DELETE

Clinical Level

Presentation 400 mg tablet

Description It is an anti-inflammatory analgesic It is used to reduce mild to

moderate pain

Additional information Caution with significant burns or poor perfusion due to risk
of kidney failure
Caution if concurrent NSAIDs use

Ipratropium Bromide
HEADING ADD DELETE

Clinical Level

Administration CPG: 4/5/6.3.3, 4/5/6.3.4, 4/5/6.7.18 CPG: 5/6.3.2, 5/6.7.5

Usual Dosages Paediatric Paediatric

< 12 years: 0.25 mg NEB 0.25 mg NEB
≥ 12 years: 0.5 mg NEB

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MEDICATION FORMULARY

Midazolam Solution
HEADING ADD DELETE

Administration 2.5 mg in 0.5 mL pre-filled syringe

5 mg in 1 mL pre-filled syringe
7.5 mg in 1.5 mL pre-filled syringe
10 mg in 2 mL pre-filled syringe

Indications Combative with hallucinations or paranoia and risk to self Psychostimulant overdose
or others Hallucinations or paranoia

Usual Dosages Seizure: Paediatric:

< 1 year: 2.5 mg buccal Seizure: 0.5 mg/Kg buccal
1 year to < 5 years: 5 mg buccal Psychostimulant overdose: 2.5
mg IV or 5 mg IM (Repeat x 2
5 years to < 10 years: 7.5 mg buccal
prn)
≥ 10 years: 10 mg buccal
Hallucinations or paranoia:
5 mg IV/IM

Additional information No more than two doses by practitioners. Practitioners should The maximum dose of
take into account the dose administered by caregivers prior Midazolam includes that
to arrival of practitioner. administered by caregiver prior
to arrival of Practitioner

Naloxone
HEADING ADD DELETE

Clinical level

Administration Intranasal (IN). CPG: 5/6.3.2, 5/6.7.5

CPG: 6.4.23, 4/5.4.23, 4/5/6.7.5

Indications Inadequate respiration and/or ALoC following known or Respiratory rate < 10 secondary
suspected narcotic overdose to known or suspected narcotic
overdose

Usual Dosages Adult: 0.8 mg (800 mcg) IN (EMT) (Paramedic repeats by one prn)
Paediatric: 0.02 mg/Kg (20 mcg/Kg) IN (EMT)

Nitrous Oxide 50% and Oxygen 50% (Entonox®)

HEADING ADD DELETE

Additional information Caution when using Entonox for greater than one hour for
Sickle Cell Crisis

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Oxygen
HEADING ADD DELETE

Contraindications Paraquat poisoning

Indications Sickle Cell Disease - 100%

Additional Information Caution with paraquat poisoning, administer oxygen

if SpO2 < 92%

Paracetamol
HEADING ADD DELETE

Presentation 250 mg in 5 mL

Indications Pyrexia 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.

Contraindications < 1 month old

Usual Dosages > 1 month < 1 year - 90 mg PR < 1 year - 60 mg PR

Salbutamol
HEADING ADD DELETE

Administration Advanced Paramedics may

repeat Salbutamol x 3

Usual Dosages Adult: Adult:

.. (or 0.1 mg metered aerosol spray x 5) Repeat at 5 min prn (APs x 3
Repeat at 5 min prn and Ps x 1)

(EFRs: 0.1 mg metered aerosol spray x 2) (EMTs & EFRs: 0.1 mg metered
aerosol spray x 2)

Paediatric: Paediatric:

< 5 yrs…(or 0.1 mg metered aerosol spray x 3) Repeat at 5 min prn (APs x 3
and Ps x 1)
≥ 5 yrs…(or 0.1 mg metered aerosol spray x 5)
(EMTs & EFRs: 0.1 mg metered
Repeat at 5 min prn aerosol spray x 2)
(EFRs: 0.1 mg metered aerosol spray x 2)

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Sodium Chloride 0.9%

HEADING ADD DELETE

Usual Dosages Adult: Adult:

Suspension Trauma, PEA or Asystole: 20 mL/Kg IV/IO Post-resuscitation care: 500 mL
infusion IV/IO infusion
Adrenal insufficiency: 1,000 mL IV/IO infusion
Heat-Related Emergency: 1,000 mL IV/IO infusion Shock; 500 mL IV/IO infusion
Hypothermia, Sepsis, # neck of femur and Bradycardia: Repeat in aliquots of 250 mL
…Repeat to max 1 L prn to maintain systolic BP of;
Post-resuscitation care: 1,000 mL IV/IO infusion 100 mmHg (hypovolaemia or
Shock from blood loss; … to maintain systolic BP of septic).
90 – 100 mmHg
Sickle Cell Crisis: 1,000 mL IV/IO infusion 90 – 100 mmHg (head injury
# neck of femur, sepsis: 250 mL IV infusion GCS > 8)
Sepsis with poor perfusion: 500 mL IV/IO infusion
Post partum haemorrhage; 1,000 mL IV/IO infusion Paediatric:
Glycaemic emergency: 20 mL/
Paediatric: Kg IV/IO infusion
Glycaemic emergency: 10 mL/Kg IV/IO infusion
Hypothermia: 10 mL/Kg IV/IO infusion ... Repeat prn x 1 Hypothermia: 20 mL/Kg IV/IO
Adrenal insufficiency, Septic shock, Symptomatic infusion
Bradycardia, Asystole/PEA: 20 mL/Kg IV/IO infusion
Burns: …. > 1 hour ….. Shock: 20 mL/Kg IV/IO infusion

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

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MEDICATION FORMULARY
CLINICAL LEVEL:
LIST OF MEDICATIONS
Aspirin ........................................................................................................ 110
Clopidogrel .............................................................................................. 111
Epinephrine 1mg/1ml (1:1000) .......................................................... 112
Glucagon .................................................................................................. 113
Glucose gel .............................................................................................. 114
Glyceryl Trinitrate (GTN) ...................................................................... 115
Hydrocortisone ....................................................................................... 116
Ibuprofen .................................................................................................. 118
Ipratropium Bromide ............................................................................ 119
Midazolam Solution .............................................................................. 121
Naloxone .................................................................................................. 122
Nitrous Oxide 50% and Oxygen 50% (Entonox®) ...................... 123
Oxygen ...................................................................................................... 124
Paracetamol ............................................................................................ 125
Salbutamol .............................................................................................. 126
Sodium Chloride 0.9% (NaCl) ............................................................ 128
Ticagrelor ................................................................................................. 129

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MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Aspirin

Class Platelet aggregation inhibitor

Descriptions Anti-inflammatory agent and an inhibitor of platelet function

Useful agent in the treatment of various thromboembolic diseases such as acute myocardial
infarction

Presentation 300 mg dispersible tablet

Administration Orally (PO) - dispersed in water, or to be chewed - if not dispersible form

(CPG: 5/6.4.10, 4.4.10, 1/2/3.4.10)

Indications Cardiac chest pain or suspected Myocardial Infarction

Contraindications Active symptomatic gastrointestinal (GI) ulcer

Bleeding disorder (e.g. haemophilia)
Known severe adverse reaction
Patients < 16 years old

Usual Dosages Adult: 300 mg tablet

Paediatric: Contraindicated

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

Side effects Epigastric pain and discomfort

Bronchospasm
Gastrointestinal haemorrhage

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

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

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

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CLINICAL LEVEL:

Medication Clopidogrel

Class Platelet aggregation inhibitor

Description An inhibitor of platelet function

Presentation 300 mg tablet

75 mg tablet

Administration Orally (PO)

(CPG: 5/6.4.10)

Indications ST Elevation Myocardial Infarction (STEMI) if the patient is not suitable for PPCI

Contraindications Known severe adverse reaction

Active pathological bleeding
Severe liver impairment

Usual Dosages Adult: 300 mg PO

≥ 75 years; 75 mg PO

Paediatric: Not indicated

Pharmacology/Action Clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet
receptor, and the subsequent ADP-mediated activation of the GPIIb/IIIa complex, thereby
inhibiting platelet aggregation. Biotransformation of Clopidogrel is necessary to produce
inhibition of platelet aggregation. Clopidogrel acts by irreversibly modifying the platelet ADP
receptor.

Side effects Abdominal pain

Dyspepsia
Diarrhoea

Additional information If a patient has been loaded with an anti-platelet medication (other than Aspirin), prior to the
arrival of the practitioner, the patient should not have Clopidogrel administered.

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CLINICAL LEVEL:

Medication Epinephrine (1:1,000)

Class Sympathetic agonist

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

Presentation Pre-filled syringe, ampoule or Auto injector (for EMT use)

1 mg/1 mL (1:1,000)

Administration Intramuscular (IM)

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

Indications Severe anaphylaxis

Contraindications None known

Usual Dosages Adult: 0.5 mg (500 mcg) IM (0.5 mL of 1: 1,000)

EMT & (EFR assist patient) 0.3 mg (Auto injector)
Repeat every 5 minutes prn

Paediatric: < 6 months: 0.05 mg (50 mcg) IM (0.05 mL of 1:1 000)

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

Pharmacology/Action Alpha and beta adrenergic stimulant

Reversal of laryngeal oedema & bronchospasm in anaphylaxis
Antagonises the effects of histamine

Side effects Palpitations

Tachyarrhythmias
Hypertension
Angina-like symptoms

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

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CLINICAL LEVEL:

Medication Glucagon

Class Hormone and Antihypoglycaemic

Description 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, 4.4.19, 5/6.7.32, 4.7.32)

Indications Hypoglycaemia in patients unable to take oral glucose or unable to gain IV access, with a
blood glucose level < 4 mmol/L.

Contraindications Known severe adverse reaction

Phaeochromocytoma

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 & vomiting.

Additional information May be ineffective in patients with low stored glycogen e.g. prior use in previous 24 hours,
alcoholic patients with liver disease.

Store in refrigerator
Protect from light

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CLINICAL LEVEL:

Medication Glucose gel

Class Antihypoglycaemic

Description Synthetic glucose paste

Presentation Glucose gel in a tube or sachet

Administration Buccal administration:

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

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

Contraindications Known severe adverse reaction

Usual Dosages Adult: 10 – 20 g buccal

Repeat prn

Paediatric: ≤ 8 years; 5 – 10 g buccal

> 8 years: 10 – 20 g buccal
Repeat prn

Pharmacology/Action Increases blood glucose levels

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

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

Proceed with caution:

Patients with airway compromise
Altered level of consciousness

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CLINICAL LEVEL:

Medication Glyceryl Trinitrate (GTN)

Class Nitrate

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

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

Administration Sublingual (SL):

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

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

Contraindications SBP < 90 mmHg

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

Usual Dosages Adult: Angina or MI: 0.4 mg (400 mcg) Sublingual

Repeat at 3-5 min intervals, Max: 1.2 mg
(EFRs 0.4 mg sublingual max, assist patient)
Pulmonary oedema; 0.8 mg (800 mcg) sublingual
Repeat x 1

Paediatric: Not indicated

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

Side effects Headache

Transient Hypotension
Flushing
Dizziness

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

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CLINICAL LEVEL:

Medication Hydrocortisone

Class Corticosteroid and anti-inflammatory

Description Hydrocortisone is a potent corticosteroid with anti-inflammatory properties

Presentation Powder and solvent for solution for injection or infusion.

Vial containing off-white powder and vial containing water for injections.
Prepare the solution aseptically by adding not more than 2 mL of Sterile Water for Injections
to the contents of one 100 mg vial, shake and withdraw for use.

Administration Intravenous (IV) infusion

Intramuscular (IM)
The preferred route for initial emergency use is intravenous
(CPG: 4/5/6.3.3, 4/5/6.3.4, 5/6.4.13, 5/6.4.15, 4/5/6.7.12, 5/6.7.30, 5/6.7.31)

Indications Severe or recurrent anaphylactic reactions

Asthma refractory to Salbutamol and Ipratropium Bromide
Exacerbation of COPD (Advanced Paramedic)
Adrenal insufficiency (Paramedic)

Contraindications No major contraindications in acute management of anaphylaxis

Usual Dosages Adult: Anaphylactic reaction and Exacerbation of COPD (AP):

200 mg IV (infusion in 100 mL NaCl) or IM
Asthma (AP):
100 mg IV (infusion in 100 mL NaCl)
Adrenal insufficiency (P & AP):
100 mg IV (infusion in 100 mL NaCl) or IM

Paediatric: Anaphylactic reaction (AP);

< 1 year 25 mg IV (infusion in 100 mL NaCl) or IM
1 to 5 years 50 mg IV (infusion in 100 mL NaCl) or IM
> 5 years 100 mg IV (infusion in 100 mL NaCl) or IM
Paediatric: Asthma (AP);
< 1 year 25 mg IV (infusion in 100 mL NaCl)
1 to 5 years 50 mg IV (infusion in 100 mL NaCl)
> 5 years 100 mg IV (infusion in 100 mL NaCl)
Adrenal insufficiency (P & AP);
6 mths to ≤ 5 years: 50 mg IV (AP) (infusion in 100 mL NaCl) or IM (P)
> 5 years : 100 mg IV (AP) (infusion in 100 mL NaCl) or IM (P)

Pharmacology/Action Potent anti-inflammatory properties and inhibits many substances that cause inflammation

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MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Hydrocortisone

Side effects CCF, hypertension, abdominal distension, vertigo, headache, nausea, malaise and hiccups

Long-term side effects Adrenal cortical atrophy develops during prolonged therapy and may persist for months after
stopping treatment

Additional information Intramuscular injection should avoid the deltoid area because of the possibility of tissue
atrophy.
Dosage should not be less than 25 mg.

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CLINICAL LEVEL:

Medication Ibuprofen

Class Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Description It is an anti-inflammatory analgesic

Presentation Suspension 100 mg in 5 mL

200 mg tablet, 400 mg tablet

Administration Orally (PO)

(CPG: 4/5/6.2.6, 4/5/6.7.5)

Indications Mild to moderate pain

Contraindications Not suitable for children under 3 months

Patient with history of asthma exacerbated by aspirin
Pregnancy
Peptic ulcer disease
Known severe adverse reaction

Usual Dosages Adult: 400 mg PO

Paediatric: 10 mg/Kg PO

Pharmacology/Action Suppresses prostaglandins, which cause pain via the inhibition of cyclooxygenase (COX).
Prostaglandins are released by cell damage and inflammation.

Side effects Skin rashes, gastrointestinal intolerance and bleeding

Long-term side effects Occasionally gastrointestinal bleeding and ulceration occurs.

May also cause acute renal failure, interstitial nephritis and NSAID-associated nephropathy.

Additional information If Ibuprofen administered in previous 6 hours, adjust the dose downward by the amount given
by other sources resulting in a maximum of 10 mg/Kg.
Caution with significant burns or poor perfusion due to risk of kidney failure.
Caution if concurrent NSAIDs use.

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CLINICAL LEVEL:

Medication Ipratropium Bromide

Class Anticholinergic

Description It is a parasympatholytic bronchodilator that is chemically related to atropine.

Presentation Nebuliser Solution 0.25 mg (250 micrograms) in 1 mL

Administration Nebulised (NEB) mixed with age-specific dose of Salbutamol

(CPG: 4/5/6.3.3, 4/5/6.3.4, 4/5/6.7.12)

Indications Acute moderate asthma or exacerbation of COPD not responding to initial Salbutamol dose.

Contraindications Known severe adverse reaction

Usual Dosages Adult: 0.5 mg NEB

Paediatric: < 12 years: 0.25 mg NEB

≥ 12 years: 0.5 mg NEB

Pharmacology/Action It blocks muscarinic receptors associated with parasympathetic stimulation of the bronchial
air passageways. This results in bronchial dilation and reduced bronchial secretions.

Side effects Transient dry mouth, blurred vision, tachycardia and headache.

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CLINICAL LEVEL:

Medication Midazolam Solution

Class Benzodiazepine

Description It is a potent sedative agent. Clinical experience has shown Midazolam to be 3 to 4 times
more potent per mg as Diazepam.

Presentation Ampoule 10 mg in 2 mL or ampoule 10 mg in 5 mL.

Buccal liquid 50 mg in 5 mL.
Pre-filled syringe 2.5 mg in 0.5 mL.
Pre-filled syringe 5 mg in 1 mL.
Pre-filled syringe 7.5 mg in 1.5 mL.
Pre-filled syringe 10 mg in 2 mL.
Pre-filled syringe 10 mg in 1 mL.

Administration Intravenous (IV).

Intraosseous (IO).
Intramuscular (IM).
Buccal.
Intranasal (IN) (50% in each nostril).
(CPG: 5/6.4.23, 6.4.29, 5/6.7.33).

Indications Seizures.
Combative with hallucinations or paranoia and risk to self or others.

Contraindications Shock.
Depressed vital signs or alcohol-related altered level of consciousness.
Respiratory depression.
Known severe adverse reaction.

Usual Dosages Adults: Seizure or combative patient.

2.5 mg IV/IO (AP) or 5 mg IM or 10mg buccal or 5 mg intranasal (P & AP)
(Repeat x 1 prn)
Paramedic: IM, buccal or IN only.

Paediatric: Seizure:
< 1year: 2.5 mg buccal
1 year to < 5 years: 5 mg buccal
5 years to < 10 years: 7.5 mg buccal
≥ 10 years: 10 mg buccal
or
0.2 mg/Kg intranasal or 0.1 mg/Kg IV/IO
(Repeat x 1 prn)
Paramedic: buccal or IN only

Pharmacology/Action It affects the activity of a chemical that transmits impulses across nerve synapses called
Gamma-AminoButyric Acid (GABA). GABA is an inhibitory neurotransmitter. Midazolam works

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CLINICAL LEVEL:

Medication Midazolam Solution (contd)

by increasing the effects of GABA at these receptors.

Side effects Respiratory depression, headache, hypotension & drowsiness

Additional information Midazolam IV should be titrated to effect.

Ensure oxygen and resuscitation equipment are available prior to administration.
No more than two doses by practitioners.
Practitioners should take into account the dose administered by carers prior to arrival of
practitioner.
Contraindications, other that KSAR, refer to non seizing patients.

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CLINICAL LEVEL:

Medication Naloxone

Class Narcotic antagonist

Description Effective in management and reversal of overdoses caused by narcotics or synthetic narcotic
agents.

Presentation Ampoules 0.4 mg in 1 mL (400 mcg /1 mL) or pre-loaded syringe

Administration Intravenous (IV)

Intramuscular (IM)
Subcutaneous (SC)
Intraosseous (IO)
Intranasal (IN)
(CPG: 6.4.22, 4/5.4.22, 5/6.5.2, 4/5/6.7.11)

Indications Inadequate respiration and/or ALoC following known or suspected narcotic overdose.

Contraindications Known severe adverse reaction

Usual Dosages Adult: 0.4 mg (400 mcg) IV/IO (AP)

0.4 mg (400 mcg) IM or SC (P)
0.8 mg (800 mcg) IN (EMT)
Repeat after 3 min prn to a Max 2 mg

Paediatric: 0.01 mg/Kg (10 mcg/Kg) IV/IO (AP)

0.01 mg/Kg (10 mcg/Kg) IM/SC (P)
0.02 mg/Kg (20 mcg/Kg) IN (EMT)
Repeat dose prn to maintain opioid reversal to Max 0.1 mg/Kg or 2 mg

Pharmacology/Action Narcotic antagonist

Reverse the respiratory depression and analgesic effect of narcotics

Side effects Acute reversal of narcotic effect ranging from nausea & vomiting to agitation and seizures.

Additional information Use with caution in pregnancy.

Administer with caution to patients who have taken large dose of narcotics or are physically
dependent.
Rapid reversal will precipitate acute withdrawal syndrome.
Prepare to deal with aggressive patients.

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Nitrous Oxide 50% and Oxygen 50% (Entonox®)

Class Analgesic

Description 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, 5/6.5.1, 4.5.1, 5/6.5.6, 4/5/6.7.5)

Indications Pain relief

Contraindications Altered level of consciousness

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/Action Analgesic agent gas:

- CNS depressant
- Pain relief

Side effects Disinhibition

Decreased level of consciousness
Lightheadedness

Additional information Do not use if patient unable to understand instructions.

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.
Caution when using Entonox for greater than one hour for Sickle Cell Crisis.

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Oxygen

Class Gas

Description Odourless, tasteless, colourless gas necessary for life.

Presentation D, E or F cylinders, coloured black with white shoulders.

CD cylinder; white cylinder
Medical gas

Administration Inhalation via:

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

Indications Absent/inadequate ventilation following an acute medical or traumatic event

SpO2 < 94% adults and < 96% paediatrics
SpO2 < 92% for patients with acute exacerbation of COPD

Contraindications Bleomycin lung injury

Usual Dosages Adult: Cardiac and respiratory arrest or Sickle Cell Crisis; 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 or Sickle Cell Crisis; 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/Action Oxygenation of tissue/organs

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

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

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Paracetamol

Class Analgesic and antipyretic

Description Paracetamol is used to reduce pain and body temperature

Presentation Rectal suppository 180 mg, 90 mg and 60 mg

Suspension 120 mg in 5 mL or 250 mg in 5 mL
500 mg tablet

Administration Per Rectum (PR)

Orally (PO)
(CPG: 4/5/6.2.6, 4/5/6.4.24, 4/5/6.7.5, 4/5/6.7.35)

Indications Pyrexia
Minor or moderate pain (1 - 6 on pain scale) for adult and paediatric patients

Contraindications Known severe adverse reaction

Chronic liver disease
< 1 month old

Usual Dosages Adult: 1 g PO

Paediatric: PR (AP) PO (AP, P & EMT)

> 1 mth < 1 year - 90 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.

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Salbutamol

Class Sympathetic agonist

Description Sympathomimetic that is selective for beta-2 adrenergic receptors

Presentation Nebule 2.5 mg in 2.5 mL

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

Administration Nebuliser (NEB)

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

Indications Bronchospasm
Exacerbation of COPD
Respiratory distress following submersion incident

Contraindications Known severe adverse reaction

Usual Dosages Adult: 5 mg NEB (or 0.1 mg metered aerosol spray x 5)

Repeat at 5 min prn
(EFRs: 0.1 mg metered aerosol spray x 5, assist patient)

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

Pharmacology/Action Beta-2 agonist

Bronchodilation
Relaxation of smooth muscle

Side effects Tachycardia

Tremors
Tachyarrhythmias
High doses may cause hypokalaemia

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

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Sodium Chloride 0.9% (NaCl)

Class Isotonic crystalloid solution

Description Solution of sodium and chloride, also known as normal saline (NaCl)

Presentation Soft pack for infusion 100 mL, 500 mL & 1,000 mL
Ampoules 10 mL

Administration Intravenous (IV) infusion, Intravenous (IV) flush, Intraosseous (IO)

Paramedic: maintain infusion once commenced
(CPG: Sodium Chloride 0.9% is used extensively throughout the CPGs)

Indications IV/IO fluid for pre-hospital emergency care

Contraindications Known severe adverse reaction

Usual Dosages ADULT

Keep vein open (KVO) or medication flush for cardiac arrest prn

Crush injury, Suspension Trauma, PEA or Asystole:

20 mL/Kg IV/IO infusion

Hypothermia: 250 mL IV/IO infusion (warmed to 40oC approx) Repeat to max 1 L

# neck of femur, sepsis, symptomatic bradycardia:

250 mL IV infusion

Decompression illness, sepsis with poor perfusion;

500 mL IV/IO infusion

Shock from blood loss;

500 mL IV/IO infusion. Repeat in aliquots of 250 mL prn to maintain systolic BP
of;
90 – 100 mmHg
120 mmHg (head injury GCS ≤ 8)

Burns; > 25% TBSA and/or 1 hour from time of injury to ED, 1000 mL IV/IO infusion
> 10% TBSA consider 500 mL IV/IO infusion

Adrenal insufficiency, Glycaemic emergency, Heat-related Emergency, Sickle Cell Crisis;

1,000 mL IV/IO infusion

Anaphylaxis:
1,000 mL IV/IO infusion, repeat x one prn

Post-resuscitation care:
1,000 mL IV/IO infusion (at 4oC approx). If persistent hypotension maintain
Sys BP > 90 mmHg

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Sodium Chloride 0.9% (NaCl) (contd)

PAEDIATRIC
Keep vein open (KVO) or medication flush for cardiac arrest prn

Glycaemic emergency, Neonatal resuscitation, Sickle Cell Crisis:

10 mL/Kg IV/IO infusion

Hypothermia: 10 mL/Kg IV/IO infusion (warmed to 40oC approx). Repeat prn x 1

Haemorrhagic shock;
10 mL/Kg IV/IO, repeat prn if signs of inadequate perfusion

Anaphylaxis; 20 mL/Kg IV/IO infusion, repeat x one prn

Adrenal insufficiency, Crush injury, Septic shock, Suspension Trauma, Symptomatic

Bradycardia, Asysotol/PEA:
20 mL/Kg IV/IO infusion

Post-resuscitation care:
20 mL/Kg IV/IO infusion if persistent poor perfusion

Burns: > 10% TBSA and/or > 1 hour from time of injury to ED:
5 – 10 years: 250 mL IV/IO
> 10 years: 500 mL IV/IO

Pharmacology/Action Isotonic crystalloid solution

Fluid replacement

Side effects Excessive volume replacement may lead to heart failure

Additional information NaCl is the IV/IO fluid of choice for pre-hospital emergency care

For KVO use 500 mL pack only

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APPENDIX 1
MEDICATION FORMULARY
CLINICAL LEVEL:

Medication Ticagrelor

Class Platelet aggregation inhibitor

Description An inhibitor of platelet function

Presentation 90 mg tablets

Administration Orally (PO)

(CPG: 5/6.4.10)

Indications Identification of ST Elevation Myocardial Infarction (STEMI) if transporting to PPCI centre

Contraindications Hypersensitivity to the active substance (Ticagrelor) or to any of the excipients

Active pathological bleeding
History of intracranial haemorrhage
Moderate to severe hepatic impairment

Usual Dosages Adult: Loading dose 180 mg PO

Paediatric: Not indicated

Pharmacology/Action Ticagrelor is a selective adenosine diphosphate (ADP) receptor antagonist acting on the P2Y12
ADP-receptor that can prevent ADP-mediated platelet activation and aggregation. Ticagrelor
is orally active, and reversibly interacts with the platelet P2Y12 ADP-receptor. Ticagrelor does
not interact with the ADP binding site itself, but interacts with platelet P2Y12 ADP-receptor
to prevent signal transduction.

Side effects Common: Dyspnoea, epistaxis, gastrointestinal haemorrhage, subcutaneous or dermal

bleeding, bruising and procedural site haemorrhage.

Other undesirable effects include intracranial bleeding, elevations of serum creatinine and
uric acid levels. Consult SmPC for a full list of undesirable effects.

Additional information Special authorisation:

Advanced paramedics and paramedics are authorised to administer Ticagrelor 180 mg PO
following identification of STEMI and medical practitioner instruction.
If a patient has been loaded with an anti-platelet medication (other than aspirin), prior to the
arrival of the practitioner, the patient should not have Ticagrelor administered.

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
NEW FOR 2014
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

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

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

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

KEY
P = Authorised under PHECC CPGs

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

APO = Authorised under PHECC CPGs to assist practitioners only

(when applied to EMT, to assist Paramedic or higher clinical levels)

SA = Authorised subject to special authorisation as per CPG

BTEC = Authorised subject to Basic Tactical Emergency Care rules

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
MEDICATIONS
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

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

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
MEDICATIONS (contd)
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

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

AIRWAY & BREATHING MANAGEMENT

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

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

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
AIRWAY & BREATHING MANAGEMENT (contd)
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

End Tidal CO2 monitoring P P

Supraglottic airway paediatric PSA P
Endotracheal intubation P
Laryngoscopy and Magill forceps P
Needle cricothyrotomy P
Needle thoracocentesis P

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

AED adult & paediatric P P P P P P P

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

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

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

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
MEDICATION ADMINISTRATION
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

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

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

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

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
TRAUMA (contd)
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Pelvic Splinting device BTEC P P P

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

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

Assist in the normal delivery of a APO P P P

baby
De-escalation and breakaway skills P P P
Glucometry P P P
Broselow tape P P
Delivery Complications P P
External massage of uterus P P
Intraosseous cannulation P
Intravenous cannulation P
Urinary catheterisation P

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

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

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APPENDIX 2
MEDICATIONS & SKILLS MATRIX
PATIENT ASSESSMENT (contd)
CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

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

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APPENDIX 3
CRITICAL INCIDENT STRESS MANAGEMENT

Your Psychological Well-Being

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

SYMPTOMS OF CIS INCLUDE SOME OR ALL OF THE FOLLOWING:

Examples of physical symptoms: Examples of psychological symptoms:

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

Post-Traumatic Stress Reactions

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

Anger at the injustice and senselessness of it all.

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

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

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

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APPENDIX 3
CRITICAL INCIDENT STRESS MANAGEMENT

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

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

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

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

EXPERIENCING SIGNS OF EXCESSIVE STRESS

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

Where to find help?

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

• For a self-help guide, please go to www.cismnetworkireland.ie

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

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPG updates 2014

For administrative purposes the numbering system on some CPGs has been changed.

The paediatric age range has been extended to reflect the new national paediatric age (≤ 15 years), as outlined by The National
Clinical Programme for Paediatrics and Neonatology.

CPGs that have content changes are outlined below.

Updated CPGs from the 2012 version.

CPGs The principal differences are Theory Skills

CPG 4/5/6.2.1 EMTs, who have completed the BTEC course, may be privileged by a . P x
Primary Survey Medical – licensed CPG provider to insert an NPA following appropriate training.
Adult
CPG 4/5/6.2.2 EMTs, who have completed the BTEC course, may be privileged by a P x
Primary Survey Trauma – licensed CPG provider to insert an NPA following appropriate training.
Adult
CPG 5/6.2.5 ECG & SpO2 monitoring inserted on multi-system trauma arm. P x
Secondary Survey Trauma –
Adult Add ‘consider repeat primary survey’. P x
CPG 4/5/6.2.6 Delete ‘Minor pain (2 to 3 on pain scale)’ replace with ‘Mild pain P x
Pain Management – Adult (1 to 3 on pain scale)’

Change Moderate pain to ‘4 to 6 on the pain scale’ P x

Change Severe pain to ‘≥ 7 on the pain scale’ P x

Add Fentanyl IN for advanced paramedic practice P x

Add Ibuprofen PO for EMT practice P x

CPG 5/6.3.1 The age range from 8 years has been replaced by standard adult range. P x
Advanced Airway
Management – Adult It is now explicit that following two unsuccessful attempts at intubation P x
an AP may attempt insertion of a supraglottic airway.
CPG 4/5/6.3.2 This CPG replaces Inadequate Respirations – Adult (5/6.3.2 and 4.3.2) P x
Inadequate Ventilations – incorporating all three practitioner levels in one CPG.
Adult
This CPG outlines generic care for all patients with inadequate P x
ventilation and then offers pathways for specific clinical issues.

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills

CPG 4/5/6.3.3 This CPG incorporates all three practitioner levels in one CPG replacing P x
Exacerbation of COPD 4.3.3 at EMT level.

Peak expiratory flow measurement is now within the scope of practice P P

for paramedics.

Salbutamol Neb is now within the scope of practice for EMTs. P x

Ipratropium bromide Neb is now within the scope of practice for P P

paramedics.
CPG 5/6.4.10 Thrombolysis has been removed from the scope of practice for advanced P x
Acute Coronary Syndrome paramedics.

Ticagrelor is now within the scope of practice for paramedics and P P

advanced paramedics.

The dose for Clopidogrel has been reduced from 600 mg to 300 mg. P x

The indication for Clopidogrel has been changed; it is now indicated for P x
patients with confirmed STEMI who are not transported to a PPCI centre.
CPG 4/5/6.4.11 The dose of Atropine has been increased from 0.5 mg to 0.6 mg. P x
Symptomatic Bradycardia –
Adult Add ‘NaCL infusion 250 mL (repeat by one)’ P x

Insert information box; ‘Titrate Atropine to effect (HR > 60)’ P x

CPG 4/5/6.4.17 Digital pressure has been increased to 15 minutes. P x
Epistaxis
The insertion of a proprietary nasal pack is now within the scope of P P
practice for paramedics and advanced paramedics.
CPG 5/6.4.21 Paramedic has been included in this CPG. P x
Hypothermia
Warmed O2 has been removed. P x

Mild hypothermia is now defined as 34 – 35.9oC. P x

Moderate hypothermia is now defined as 30 – 33.9oC. P x

Paediatric dose for NaCl has been reduced from 20 mL/Kg to 10 mL/Kg. P x

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills

CPG 4/5.4.22 The methods of introduction of a poison have been removed. P x

Poisons – Adult
Naloxone has been added to this CPG for opiate induced poison. P x

Naloxone IN is now within the scope of practice for EMTs and P x

paramedics.

The absolute contraindication for O2 has been removed following P x

paraquat poisoning.
CPG 5/6.4.23 Magnesium sulphate may be considered by advanced paramedics to P x
Seizure/Convulsion – Adult manage a pre-eclampsia patient who is seizing.
CPG 4/5/6.4.24 This CPG replaces Septic Shock - Adult. P x
Sepsis – Adult
It authorises the administration of Paracetamol for pyrexic patients. P x

It authorises the administration, by advanced paramedics, of P x

Benzylpenicillin for severe sepsis.

Advanced paramedics may consider additional aliquots of NaCl to P x

maintain systolic BP > 100 mmHg.
CPG 4/5/6.6.1 Add ‘Caution with hypothermia’ P x
Burns – Adult
CPG 4/5/6.6.3 This CPG has been updated to reflect the importance of managing P x
External Haemorrhage – catastrophic haemorrhage immediately.
Adult
Dressings impregnated with haemostatic agents are now within the P P
scope of practice for EMTs, paramedics and advanced paramedics.

EMTs, who have completed the BTEC course, may be privileged by a P x

licensed CPG provider to apply a tourniquet.

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills

CPG 5/6.6.5 LoC history has been replaced with ‘consider spinal injury’ P x
Head Injury – Adult
Collar and long board have been replaced with ‘see Spinal injury CPG’ to P x
avoid repetition.

A ‘GCS of < 12’ has been replaced with a ‘GCS of ≤ 12’ P x

An emphasis has been placed on minimising Intra Cranial Pressure; using P x

pain management, control of nausea & vomiting, 10o upward head tilt
and ensuring that the collar is not too tight.

‘Maintain SBP > 120 mmHg’ has been replaced with ‘avoid hypotension’ P x

‘Transport to most appropriate ED according to local protocol’ has been P x

deleted
CPG 4/5/6.6.7 Fractured neck of femur has been included. P x
Limb Injury – Adult
With a fractured neck of femur, if the transport time to ED is > 20 P x
minutes, ALS should be requested.

With a fractured neck of femur advanced paramedics should consider P x

NaCl infusion.
CPG 5/6.6.8 This CPG has been renamed from ‘Shock from Blood Loss – Adult’. P x
Shock from Blood Loss
(trauma) – Adult Add; with polytrauma consider application of a pelvic splint. P x

Change ‘Trauma’ to ‘Suspected significant internal/ external P x

haemorrhage’

Tranexamic acid is now within the scope of practice for advanced P x

paramedics.
CPG 4/5/6.6.10 Salbutamol is now within the scope of practice for EMTs. P x
Submersion Incident
CPG 4/5/6.7.4 The estimated weight formula has been updated; P x
Secondary Survey – Neonate = 3.5 Kg
Paediatric Six months = 6 Kg
One to five years = (age x 2) + 8 Kg
Greater than 5 years = (age x 3) + 7 Kg

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills

CPG 4/5/6.7.5 Pain assessment recommendations; P P
Pain Management – < 5 years use FLACC scale
Paediatric 5 – 7 years use Wong Baker scale
≥ 8 years use analogue pain scale

Delete ‘Minor pain (2 to 3 on pain scale)’ replace with ‘Mild pain (1 to 3 P x

on pain scale)’

Change Moderate pain to ‘4 to 6 on the pain scale’ P x

Change Severe pain to ‘≥ 7 on the pain scale’ P x

Fentanyl IN is now within the scope of practice for advanced paramedics. P x

Ibuprofen PO is now within the scope of practice for EMTs. P x

CPG 4/5/6.7.11 This CPG replaces Inadequate Respirations – Paediatric (5/6.7.5 and P x
Inadequate Ventilations – 4.7.5) incorporating all three practitioner levels in one CPG.
Paediatric
This CPG outlines generic care for all patients with inadequate P x
ventilation and then offers pathways for specific clinical issues.

Naloxone IN is now within the scope of practice for EMTs, paramedics P P

and advanced paramedics.

CPG 4/5/6.7.24 ‘The routine ventilations’ has been changed to ‘ventilations if hypoxic’. P x
Symptomatic Bradycardia –
Paediatric Unresponsive has been added as a criteria for CPR P x

Consider advanced airway management if prolonged CPR has been P x

removed.
CPG 5/6.7.32 The dose of NaCl has been reduced from 20 mL/Kg to 10 mL/Kg. P x
Glycaemic Emergency –
Paediatric
CPG 5/6.7.33 The dose of Midazolam buccal has been changed from weight based to P P
Seizure/ Convulsion – age based.
Paediatric
CPG 4/5/6.7.50 This CPG has been updated to reflect the importance of managing P x
External Haemorrhage – catastrophic haemorrhage immediately.
Paediatric
Dressings impregnated with haemostatic agents are now within the P P
scope of practice for EMTs, paramedics and advanced paramedics.

EMTs, who have completed the BTEC course, may be privileged by a P x

licensed CPG provider to apply a tourniquet.

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills

CPG 4/5/6.7.53 Add ‘Caution with hypothermia’ P x

Burns – Paediatric
4/5/6.8.1 Add ‘ambulance loading point’ P x
Major Emergency –
First Practitioners on site Add ‘On site co-ordination centre’ P x
4/5/6.8.2 Add information box ‘Controller of Operations may be other than P x
Major Emergency – ambulance or fire officers, depending on nature of emergency’
Operational Control

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

New CPGs

New CPGs The new skills and medications incorporated in the CPG are: Theory Skills

CPG 4/5/6.3.4 This CPG outlines the care for a patient with an acute asthma episode. P x
Asthma – Adult
CPG 5/6.3.5 This CPG outlines the care for a patient with an acute pulmonary P P
Acute Pulmonary Oedema oedema episode.
CPG 5/6.4.12 This CPG outlines the care for a patient with a tachycardia episode. P x
Tachycardia – Adult
CPG 5/6.4.13 This CPG outlines the care for a patient with an adrenal crisis. P P
Adrenal Insufficiency – Adult
CPG 5/6.4.25 This CPG outlines the care for a patient with non traumatic blood loss. P x
Shock from Blood Loss
(non-trauma) – Adult
CPG 4/5/6.4.27 This CPG outlines the care for a patient with a sickle cell crisis. P x
Sickle Cell Crisis – Adult
CPG 4/5/6.6.4 This CPG outlines, in particular, the correct posture for patients following P x
Harness Induced harness induced suspension trauma.
Suspension Trauma
CPG 4/5/6.6.6 This CPG outlines the care for a patient with a heat-related emergency. P x
Heat Related Emergency –
Adult
CPG 5.7.10 This CPG outlines the advanced airway management for a paediatric P x
Advanced Airway Manage- patient ≥ 8 years old.
ment – Paediatric (≥ 8 years)
CPG 4/5/6.7.12 This CPG outlines the care for a paediatric patient with an acute asthma P x
Asthma – Paediatric episode.
CPG 5/6.7.30 This CPG outlines the care for a paediatric patient with an adrenal crisis. P P
Adrenal Insufficiency –
Paediatric
CPG 4/5/6.7.35 This CPG outlines the care for a paediatric patient with a pyrexia P x
Pyrexia – Paediatric episode.
CPG 4/5/6.7.36 This CPG outlines the care for a paediatric patient with a sickle cell crisis. P x
Sickle Cell Crisis –
Paediatric
CPG 5/6.9.1 This CPG outlines the inclusion process to select patients for a clinical P x
Clinical Care Pathway care pathway other than ED care.
Decision – Treat & Referral

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APPENDIX 4
CPG UPDATES FOR PARAMEDICS

New CPGs The new skills and medications incorporated in the CPG are: Theory Skills

CPG 5/6.9.2 This CPG outlines the exclusion process to select patients following a P x
Hypoglycaemia – hypoglycaemic event for a clinical care pathway other than ED care.
Treat & Referral
CPG 5/6.9.3 This CPG outlines the exclusion process to select patients following an P x
Isolated Seizure – Treat & isolated seizure for a clinical care pathway other than ED care.
Referral

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APPENDIX 5
PRE-HOSPITAL DEFIBRILLATION POSITION PAPER

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

Cardiac arrest management process

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

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

2. Hands off time (time when chest compressions are stopped)

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

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APPENDIX 5
PRE-HOSPITAL DEFIBRILLATION POSITION PAPER

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

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

5 Defibrillation pad placement

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

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

7 Implantable Cardioverter Defibrillator (ICD)

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

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

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Published by:
Pre-Hospital Emergency Care Council
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Naas, Co Kildare, Ireland.
Phone: + 353 (0)45 882042
Fax: + 353 (0)45 882089
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Paramedic