x01 - CPG - ADULT Web 0

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Version 1 - 08.06.11 Page 1 of 3
Oxygen Use in Emergency Presentations
CPG A0001
Introduction
- The Oxygen Use in Emergency Presentations guideline has been introduced after a comprehensive and thorough
review of the evidence-based medical literature investigating oxygen therapy in emergency settings.**
- This guideline is intended for use by Ambulance and MICA Paramedics where a reliable oxygen saturation reading (or
pulse oximetry reading, SpO2) is available.
- This guideline should only be applied to adult Pts aged 16 years old.
Management Principles
- Oxygen is a treatment for hypoxaemia, not breathlessness. Oxygen has not been shown to have any effect on the
sensation of breathlessness in non-hypoxaemic Pts.
- This guideline aims to achieve normal or near normal oxygen saturations in acutely ill Pts. Oxygen should be prescribed to
achieve a target oxygen saturation, while continuously monitoring the Pt for any changes in condition.
- Oxygen should not be administered routinely to Pts with normal oxygen saturations. This includes those with stroke,
acute coronary syndromes and arrhythmias.
- In Pts who are acutely short of breath, the administration of oxygen should be prioritised before obtaining an oxygen
saturation reading. Oxygen can later be titrated to reach a desired target saturation range.
- If pulse oximetry is not available or unreliable, provide an initial oxygen dose of 2-6l/min via nasal cannulae or 5-10l/min
via face mask until a reliable oxygen saturation reading can be obtained.
Special Circumstances
- Early aggressive oxygen administration may benefit Pts who develop critical illnesses and are haemodynamically unstable,
such as: 1) Cardiac Arrest or Resuscitation; 2) Major Trauma/Head Injury; 3) Carbon Monoxide Poisoning; 4) Shock;
5) Severe Sepsis, and; 6) Anaphylaxis. In the first instance, oxygen should be administered with the aim of achieving an
SpO2 of 100%. Once the Pt is haemodynamically stable, oxygen dose should be titrated to normal levels.
- Pts with chronic hypoxaemia (e.g. COPD, neuromuscular disorders, morbid obesity etc.) who develop critical illnesses as
above should have the same initial aggressive oxygen administration, pending the results of blood gas measurements.
- If a diagnosis of COPD is unknown, it should be assumed in any Pt who is > 50 years of age and are long-term smokers or
ex-smokers with a history of longstanding breathlessness on minor exertion. Pts with COPD may also use terms such as
chronic bronchitis and emphysema to describe their condition but sometimes mistakenly use asthma.
** O'Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(SUPPL. 6):vi1-vi68.
Oxygen Use in Emergency Presentations CPG A0001
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CPG A0001
Special Notes
General Care
Pulse oximetry may be particularly unreliable in Pts with

peripheral vascular disease, severe asthma, severe
anaemia, cold extremities or peripherally shut down,
severe hypotension, and carbon monoxide poisoning.
Oxygen exchange is at its greatest in the upright

position. Unless other clinical problems determine
otherwise, the upright position is the preferred position
when administering oxygen.
Pulse oximetry can be unreliable in the setting of severe

hypoxaemia. An oxygen saturation reading below 80%
increases the chance of being inaccurate.
Ensure the Pts fingertips are clean of soil or nail polish.

Both may affect the reliability of the pulse oximeter
reading. The presence of onychomycosis may also
cause falsely low readings.
All Pts with suspected carbon monoxide poisoning or

pneumothorax should be given high dose oxygen until
arrival at hospital. Pts who show no clinical evidence of
breathlessness or hypoxaemia may still benefit from this
practice.
Poisoning with substances other than carbon monoxide

should be given oxygen to maintain an SpO2 of 9498%. Special circumstances occur in the setting of
paraquat and bleomycin poisoning where the use of
oxygen therapy may prove detrimental to the Pt. The
maintenance of prophylactic hypoxaemia in these Pts
(SpO2 of 88-92%) is recommended.
Take due care with Pts who show evidence of anxiety/

panic disorders (e.g. Hyperventilation Syndrome).
Oxygen is not required however no attempt should be
made to retain carbon dioxide (e.g. paper bag breathing).
All women with evidence of hypoxaemia who are more
than 20 weeks pregnant should be managed with left
lateral tilt to improve cardiac output.
Some Pts may experience dryness of the nasal mucosa

if oxygen flow delivery exceeds 4l/min via nasal cannulae.
Face masks should not be used for flow rates < 5l/min,
due to the risk of carbon dioxide retention.
Nasal cannulae are likely to be just as effective with
mouth-breathers. However, where nasal passages are
congested or blocked, face masks should be used to
deliver oxygen therapy.
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? Status
Assess
8
Evidence of hypoxaemia
Acute or chronic?
Breathlessness
Respiratory status
CPG A0001
Assess & monitor SpO2 continuously

Consider causes of hypoxaemia
? Mild-Moderate
? Normal Oxygen
? Moderate-Severe Hypoxaemia
SpO2 < 85
Hypoxaemia
Saturation
SpO2 = 85 93%
SpO2 94
? Chronic Hypoxaemia
COPD/Pulmonary Disease
OR
Neuromuscular disorders
Action
Action
? Critical Illnesses
No O2 Required,
Reassure Pt
Titrate O2 flow to SpO2

of 94-98%
- Initial dose of 2-6l/min.
via nasal cannulae
- Consider simple face
mask 5-10l/min.
Cardiac Arrest or Resuscitation
High-concentration O2 may be
Major Trauma/Head Injury
harmful in the COPD Pt at risk of
Carbon Monoxide Poisoning
hypercapnic respiratory failure
Morbid Obesity
Shock
Action
Severe Sepsis
Titrate O2 flow to SpO2 of 88-92%
Anaphylaxis
Action
Initial management
- Initial dose nonrebreather mask 10-15l/min.
- If inadequate VT, consider BVM ventilation
with 100% O2
Once Pt stable
- Titrate O2 flow to SpO2 of 94-98%
If Pt deteriorates or SpO2 remains < 85%

- BVM ventilation with 100% O2
- Consider LMA as per CPG A0301
Laryngeal Mask Airway

? Status
Stop
8 Assess
8 Consider
Action
MICA Action
if no critical illness present

- Initial dose of 2-6l/min. via nasal
cannulae
- Consider simple face mask
5-10l/min
If Pt deteriorates or SpO2

remains < 88%
- Treat as per Moderate-Severe
Hypoxaemia
- Consider ETT as per CPG A0302

Endotracheal Intubation
Oxygen Use in Emergency Presentations CPG A0001
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Version 3 - 19-11-08 Page 1 of 3
Clinical Approach
Stop
CPG A0101
Primary Survey / Life Threat Status
Standard Precautions: Gloves, goggles, PPE,

mask, vest
Dangers
Response
Airway Cervical spine immobilization if required
Breathing Assist ventilations if VT inadequate
Circulation Commence CPR if required
Haemorrhage Control life threatening haemorrhage
Immediate Mx + Sitrep
required (Utilise ETHANE
mnemonic)
Rapport, Rest and Reassurance

Posture / Position of comfort
Oxygen as required (e.g. hypoxia, respiratory distress)
Establish if Refusal of Treatment documented
In order of clinical need

If clinically applicable,
assess Hx prior to
physical contact with Pt
e.g. VSS, applying monitor,
exposing chest
Action
Assess
History
Brief clinical Hx
Event prior to Ambulance call
Past medical Hx
Pain Verbal analogue score
Medications
Allergies
Other information sources i.e. witnesses, poisons
information, doctor.
Accurate Hx + assessment
essential for problem
recognition
Clinical Approach CPG A0101
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Clinical Approach
Assess
CPG A0101
Vital Sign Survey
GCS
PSA
RSA
Pattern / mechanism of injury / medical condition
Determine time criticality to

Mx accordingly
Accurate body system
assessment in all Pts
Assessment Tools / Secondary Survey

Secondary Survey
SpO2
Monitor/ECG (12 lead if available)
Temp
EtCO2
More detailed Hx
BGL - Blood Glucose Level
Thorough physical
examination
- Head to toe
- Inspection, palpation,
auscultation
The combination of subjective (PHx, Hx, Meds) and

objective (physical) data allows identification of
clinical problems
Multiple problems may be identified and prioritised to
provide treatment order
Some overlap in treatment may address multiple
problems
The treatment of one clinical problem should ideally
not compromise the treatment of other problems
identified
Confirm clinical reasoning

with assessment data
Determine Main
Presenting Problem
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Clinical Approach
CPG A0101
Action
Further Sitrep / Resource requirements as required

Consider time to hospital vs time to R/V with MICA
Paramedic
IV access if required
Specific treatment - appropriate CPG applied to
Mx clinical problems
Transport to appropriate facility
Reassess frequently and adapt Mx as appropriate
Final assessment at destination/handover
Action
Provide MICA therapies in the most timely manner

without causing unnecessary pre-hospital delays
This Clinical Approach is to be applied to all Pts as a basic level of care. There is an assumption in each CPG
that this is the minimum level of care that the Pt will receive prior to the application of the Guideline.
The exception to this rule is the Pt in immediate life threat that requires intervention during the Primary Survey.
Clinical Approach CPG A0101
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Perfusion and Respiratory Assessment

Special Notes
Special Notes
These observations and criteria need to be taken in

context with:
- The Pts presenting problem
- The Pts prescribed medication
- Repeated observations and the trends shown
- Response to management.
Respiratory Assessment
Perfusion Definition

The ability of the cardiovascular system to provide

tissues with an adequate blood supply to meet their
functional demands at that time and to effectively
remove the associated metabolic waste products.
Perfusion Assessment

Other factors may affect the interpretation of the

observations made, e.g., the environment, both cold
and warm ambient temp. may affect skin signs; anxiety
may affect pulse rate; and the many causes of altered
conscious state or unconsciousness. Other conditions
may affect conscious state observations such as poor
cerebral perfusion, respiratory hypoxia, head injuries,
hypoglycaemia and drug overdoses.
The Perfusion Status Assessment table represents a

graded progression from adequate to no perfusion.
CPG A0102
The Respiratory Status Assessment table represents

a graded progression from normal to severe
respiratory status.
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Perfusion Status Assessment

Adequate
Perfusion

Borderline
Perfusion
Skin
Pulse
CPG A0102
BP
Conscious Status
Warm, pink,
60 100/min
dry
> 100mmHg
systolic
Alert and orientated

in time and place
Cool, pale,
50 100/min
clammy
80 100mmHg
systolic
Alert and orientated

in time and place
Inadequate
Cool, pale,
< 50/min, or
60 80mmHg
Perfusion
clammy
> 100/min
systolic

Either alert and orientated

in time and place
or altered
Extremely
Cool, pale,
< 50/min, or

Poor
clammy
> 110/min
Perfusion
< 60mmHg
systolic or
unrecordable
Altered or
unconscious
No Perfusion

Unrecordable
Unconscious
Cool, pale,
clammy
Absence of
palpable pulse
Perfusion Criteria CPG A0102
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Respiratory Status Assessment

Normal
CPG A0103
Mild Distress
Moderate Distress
Severe Distress (Life Threat)
General Appearance Calm, quiet
Calm or mildly anxious
Distressed or anxious
Distressed, anxious, fighting to

breathe, exhausted, catatonic
Speech
Full sentences
Short phrases only
Words only or unable to speak
Able to cough
Able to cough
Unable to cough
Asthma: mild expiratory

wheeze
Asthma: expiratory
wheeze, +/ inspiratory
wheeze
Asthma: expiratory wheeze +/

inspiratory wheeze, maybe no
breath sounds (late).
LVF: may be some fine

crackles at bases
LVF: crackles at bases to mid-zone
Respiratory Rate
No crackles or
scattered fine basal
crackles,
e.g. postural
12 16
16 20
> 20
Respiratory Rhythm
Regular even cycles
Asthma: prolonged
expiratory phase
Breathing Effort
Normal chest
movement
Asthma: may be slightly

prolonged expiratory
phase
Slight increase in normal
chest movement
LVF: fine crackles full field, with

possible wheeze
Upper Airway Obstruction:
Inspiratory stridor
> 20
Bradypnoea (< 8)
Asthma: prolonged expiratory
phase
Pulse Rate
60 100
60 100
Marked chest movement

+/ use of accessory
muscles.
100 120
Marked chest movement with

accessory muscles, intercostal
retraction +/ tracheal tugging
> 120, bradycardia late sign
Skin
Normal
Normal
Pale and sweaty
Pale and sweaty, +/ cyanosis
Conscious State
Alert
Alert
May be altered
Altered or unconscious
Breath Sounds
And
Chest Auscultation
Clear and steady

sentences
Usually quiet
no wheeze
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Conscious State Assessment
CPG A0104
Glasgow Coma Score

A. Eye Opening
Score
Spontaneous
To Voice
To Pain
None
B. Verbal Response
A:
Score
Orientated
Confused
Inappropriate words
Incomprehensible sounds
None
C. Motor Response
B:
Score
Obeys Command
Localises to pain
Withdraws (pain)
Flexion (pain)
Extension (pain)
None
C:
Total GCS (Max. Score = 15)
(A+B+C)=
Conscious State Assessment CPG A0104
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Time
Critical Guidelines
Introduction
The concept of the Time Critical Pt allows the recognition of the severity of a Pts condition or the likelihood of
deterioration. This identification directs appropriate clinical management and the appropriate destination to improve
outcome. Covered within the Time Critical Guidelines are:
-
Triage decisions for a Pt with Major Trauma
Triage decisions for a Pt with significant Medical Conditions
Requests for additional resources including MICA Paramedic and Aeromedical services
Judicious scene time management (e.g. should not exceed 20min. for non-trapped major trauma Pt)
Appropriate receiving hospital and early notification
It is important to note that the presence of time criticality does not infer a directive for speed of transport, but rather
the concept implies there be a Time Consciousness in the management of all aspects of Pt care and transport.
Time Critical Definitions
Actual
At the time the vital signs survey is taken, the Pt is in actual physiological distress.
Emergent
At the time the vital signs survey is taken, the Pt is not physiologically distressed but does have
a Pattern of Injury or Significant Medical Condition which is known to have a high probability of
deteriorating to actual physiological distress.
Potential
At the time the vital signs survey is taken, the Pt is not physiologically distressed and there is no
significant Pattern of actual Injury/Illness, but does have a Mechanism of Injury/Illness known to
have the potential to deteriorate to actual physiological distress.
CPG A0105
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Time
Critical Guidelines
CPG A0105
Trauma Triage
Pts meeting the criteria for Major Trauma should be triaged to the highest level of Trauma care available within
30min. transport time of the incident in accordance with Victorian State Trauma System requirements and AV
policies and procedures.
The receiving hospital must also be notified to ensure an appropriate reception team and facilities are available.
Mechanism of Injury (MOI)
A Pt under the Trauma Triage Guidelines meets the criteria for Major Trauma if they have a combination of MOI and
other Co-morbidities constituting:
Systemic illness limiting normal activity / Systemic illness constant threat to life. Examples include:
- Poorly controlled hypertension
- Morbid obesity
- Controlled or uncontrolled Congestive Cardiac Failure
- Symptomatic COPD
- Ischaemic heart disease
- Chronic renal failure or liver disease
Pregnancy
Age < 15 or > 55
Medical Triage
Pts meeting the time critical criteria for Medical conditions are regarded as having, or potentially having, a clinical
problem of major significance. These Pts are time critical to the nearest appropriate hospital.
Time Critical Guidelines CPG A0105
13
? Status
? Status
Actual Time Critical
Possible major trauma
Assess Vital Signs

8
Emergent Time Critical
Vital Signs are normal

?
May have Pattern of Injury
Assess Pattern of Injury

8
Any of the following:
Significant Pattern of Injury

?
Vital Signs normal

- Respiratory Rate < 12 or > 24
- BP < 90 mmHg systolic
- Pulse > 124
- GCS < 13
- Oxygen saturation < 90%
Penetrating Injuries
- Head / Neck / Chest / Abdomen / Pelvis /
Axilla / Groin
Blunt Injuries
- Significant injury to a single region:
Head / Chest / Abdomen / Axilla / Groin
- Injuries involving two or more of the above body

regions
S
pecific Injuries
- Limb amputations / limb threatening injuries
- Suspected spinal cord injury
- Burns > 20% or involving respiratory tract
- Serious crush injury
- Major compound fracture or open dislocation
- Fracture to two or more of the following:

Femur / Tibia / Humerus
?
Vital Signs not normal
Action
- Fractured pelvis
Action
8 Assess
8 Consider
Action
Consider MICA / Aeromedical support
within 30min.
Triage to highest level of trauma service
Stop
within 30min.
MICA Action
Trauma Triage Time Critical Guidelines
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Potentially Time Critical
?
No Pattern of Injury

May have Mechanism of Injury
Assess Mechanism of Injury (MOI)

8

- Ejection from vehicle
- Motor/cyclist impact > 30km/h
- Fall from height > 3m
- Struck on head by falling object > 3m
- Explosion
- High speed MCA > 60km/h
- Pedestrian impact
- Prolonged extrication > 30min.
Assess Co-morbidities
8
No MOI
CPG A0105
Not Time Critical

Action
?
Positive MOI and NO Co-morbidities
Triage to nearest appropriate facility if required
?
Positive MOI and Co-morbidities


- Age > 55
- Pregnancy
- Significant underlying medical condition

Action
with notification
Triage to nearest appropriate facility
Action
within 30min.
Trauma Time Critical Guidelines CPG A0105
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? Status
Respiratory Rate
BP
Pulse
Conscious State
O2 saturation
Skin
Respiratory Rate
BP
Pulse
Conscious State
O2 saturation
Skin
Child
1 - 8 years
< 40 or > 60
N/A
< 100 or > 170
GCS < 15
N/A
cold/pale/
clammy
Newborn
< 2 weeks
< 15 or > 25
< 80mmHg
<65 or > 100
GCS < 15
< 90%
cold/pale/
clammy
Large Child
9 - 15 years
< 20 or > 50
< 60mmHg
< 90 or > 170
GCS < 15
N/A
cold/pale/
clammy
Infant
< 1 year

?
May have Pattern of Injury
Assess Pattern of Injury

8
Penetrating Injuries
- Head / Neck / Chest / Abdomen / Pelvis /
Axilla / Groin
Blunt Injuries
- Significant injury to a single region:
Head / Neck / Chest / Abdomen / Axilla / Groin
- Injuries involving two or more of the above body

regions
S
pecific Injuries
- Limb amputations / limb threatening injuries
- Suspected spinal cord injury
- Burns > 20% or involving respiratory tract
- Serious crush injury
- Major compound fracture or open dislocation
- Fracture to two or more of the following:

Femur / Tibia / Humerus
- Fractured pelvis
Vital Signs normal
?
Significant Pattern of Injury
Action
?
Action
8 Assess
8 Consider
Action
within 30min.
Stop
within 30min.
MICA Action
< 20 > 35
< 70mmHg
< 75 or > 130
GCS < 15
N/A
cold/pale/
clammy
Assess Vital Signs

8
Possible major trauma
Status
?
Trauma Triage Time Critical Guidelines
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(Paediatric)
Potentially Time Critical
?

May have Mechanism of Injury
Assess Mechanism of Injury (MOI)

8

- Ejection from vehicle
- Motor/cyclist impact > 30km/h
- Fall from height > 3m
- Struck on head by falling object > 3m
- Explosion
- High speed MCA > 60km/h
- Vehicle rollover
- Fatality in same vehicle
- Pedestrian impact
- Prolonged extrication > 30min.
?
Positive MOI

Action
within 30min.
No MOI
CPG A0105
Not Time Critical

Action
Triage to nearest appropriate facility if required
Trauma Time Critical Guidelines (Paediatric) CPG A0105
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? Status
?
Status
Possible Medical time critical
?
May have Significant Medical Condition
Assess Vital Signs

8
Assess Medical Condition

8
Medical Symptoms / Syndromes

- Acute Coronary Syndrome
- Acute stroke
- Severe sepsis, including suspected
meningococcal disease
- Possible Abdominal Aortic Aneurysm
- Undiagnosed severe pain
Need for possible hyperbaric treatment e.g.

acute decompression illness or cyanide
poisoning
Hypothermia or Hyperthermia
Action
Vital Signs normal
?
Significant Medical Condition
Action
8 Assess
8 Consider
Action
with notification
with notification
Stop
?

- Moderate or Severe Respiratory Distress
- Oxygen saturation < 90% Room Air / 93%
supplemental O2
- < Adequate Perfusion
- GCS < 13 (unless normal for Pt)
MICA Action
Medical Time Critical Guidelines CPG A0105
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Mental
Status Assessment
CPG A0106
Observations
A mental status assessment is a systematic method used to evaluate a Pts mental function. In undertaking a
mental status assessment, the main emphasis is on the persons behaviour. This assessment is designed to
provide Paramedics with a guide to the Pts behaviour, not to label or diagnose a Pt with a specific condition.
1. Appearance
2. Behaviour
Neatness, cleanliness
Pupils size
Extraocular movements
Bizarre or inappropriate
Threatening or violent
Unusual motor activity, such as grimacing or tremors
Impaired gait
Psychomotor retardation or agitation
3. Speech
Rate, volume, quantity, content
4. Mood
Depressed, agitated, excited or irritable
5. Response
Flat unresponsive facial expression

Appropriate/inappropriate
6. Perceptions
Hallucinations
7. Thought content
Delusions (i.e., false beliefs)

Suicidal thoughts
Overly concerned with body functions (eg. Bowels)
8 Thought flow
Jumping irrationally from one thought to another
9. Concentration
Poor ability to organise thoughts

Short attention span
Poor memory
Impaired judgement
Lack of insight
Mental Status Assessment CPG A0106
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Cardiac
Arrest
CPG A0201
Principles of CPR
CPR
Assumption that CPR is commenced immediately and
continued throughout cardiac arrest as required
Generic for all adult cardiac arrest conditions
Must not be interrupted for more than 10 sec. during

rhythmand pulse checks. If unsure of pulse, recommence
CPRimmediately
Change operators every 2min. to improve CPR performance

and reduce fatigue
Compression depth is 1/3 of the chest depth
Adjustment for temperature

> 32C
Standard Cardiac Arrest Guidelines

30 - 32C
Double dosage intervals in relevant

cardiac arrest Guideline
Normal defibrillation intervals in relevant

cardiac arrest Guideline
Do not rewarm beyond 33C if ROSC
Rhythm/Pulse check every 2min
CPR recommended immediately after defibrillation and pulse

check
Ratios of compressions to ventilations
Not intubated
30 : 2
Rate: Approximately 100 compressions per min.
- Pause for ventilations
Intubated / LMA inserted
15 : 1
Rate: Approximately 100 compressions per min.
- < 8 ventilations/min.
- No pause for ventilations
< 30C
Continue CPR and rewarming

until temp. > 30C
One defibrillation shock only
One dose of Adrenaline
One dose of Amiodarone
Withhold NaHCO3 8.4% IV
Cardiac Arrest CPG A0201
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Cardiac Arrest
CPG A0201
Action
Immediately commence CPR 30 : 2
? Unconscious/Pulseless VF/VT
? Pulseless Electrical Activity (PEA)
? Asystole persists
Action
Identify and Rx causes
Action
Defibrillate Single shock 200J

Biphasic (360J Monophasic)

- Repeat single shock @ 2/60 intervals

if VF/VT persists
- Hypoxia
- Anaphylaxis
- Asthma
- Exsanguination
- Upper airway obstruction
- Tension pneumothorax
Confirm rhythm on 3 leads and with

printed ECG strip.
? VF/VT persists
? PEA persists
? Asystole persists
Action
Action
Action
IV access / Normal Saline TKVO
Adrenaline 1mg IV
- Repeat every @3/60 if no output
Adrenaline 1mg IV
Adrenaline 1mg IV
Consider IO if delay in IV access

Adrenaline 1mg IO

Adrenaline 1mg IO

Adrenaline 1mg IO
? VF/VT persists
? PEA persists
? Asystole persists
Action
Action
Action
Insert LMA
Insert LMA
Insert LMA
Change CPR ratio to 15 : 1
Intubate
Intubate
Intubate
If unable to obtain IV or IO

- Adrenaline 2mg via ETT


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? VF/VT persists
? PEA persists
Action
Action
Amiodarone 5mg/kg IV / IO
Normal Saline 20ml/kg IV
Amiodarone is contraindicated in
confirmed or suspected Tricyclic
antidepressant medication OD
OR Normal Saline 20ml/kg IO
? VF/VT persists
Action
Repeat Amiodarone 150mg IV / IO

(max. combined dose 450mg)
? VF/VT persists
PEA persists
?
Asystole persists
?
After 15/60 Paramedic CPR
Action
Action
Action
Sodium Bicarbonate 8.4%

50ml IV / IO

50ml IV / IO

50ml IV / IO
? Outcome
? Outcome
? Outcome
Action
Action
Action
If ROSC treat as per CPG A0202
If no ROSC refer CPG A0203
Sodium Bicarbonate may be administered earlier in the algorithm if hyperkalaemia suspected or in cardiac arrest secondary to TCA overdose
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Cardiac Arrest CPG A0201
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Cardiac Arrest (ROSC Management)
CPG A0202
Special Notes
General Care
CPG A0407 Inadequate Perfusion (Cardiogenic

Causes)
CPG A0302 Endotracheal Intubation
CPG A0406 Pulmonary Oedema
Therapeutic Hypothermia
Ensure fluid is < 8 degrees prior to administration.
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Cardiac Arrest (ROSC Management)
CPG A0202
Status
?
Post cardiac arrest

- Return of spontaneous circulation (ROSC)
?
Unintubated
?
Perfusion management
?
Therapeutic cooling
?
Transport
GCS < 10 post ROSC
Action
Pt intubated
Action
Action
Maintain BP > 120 or Pts

usual BP (if known)
Collapse to ROSC > 10/60
Appropriate receiving
hospital
Collapse to ROSC > 10/60

- RSI as per CPG A0302
- Therapeutic cooling
Collapse to ROSC < 10/60

- No therapeutic cooling
- RSI as per CPG A0302
if coma persists despite
initial oxygenation and
perfusion Mx
Normal Saline and

Adrenaline to be used as
required per CPG A0407

Accurately assess pulse

during movement/loading
to ensure output
maintained throughout
Rx as per appropriate
Guideline if condition
changes

Do not administer
Amiodarone unless
breakthrough VF/VT
occurs
Normal functional status

(independent with ADLs)
Temp. > 34.5
Stop
8 Assess
8 Consider
Action
MICA Action
12 lead ECG if available
No pulmonary oedema
evident
Cardiac arrest not due to

bleeding
Action
Assess Pt temp.
Sedation/paralysis
- Midazolam 1-5mg IV
- Pancuronium 8mg IV

? Status
Notify early
Rapid infusion cold

Normal Saline up to
2000ml IV if available
- Cease if APO occurs
and Rx as per CPG
A0406
- maintain temp.range
32-34C
Cardiac Arrest (ROSC Management) CPG A0202
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Withholding and/or Ceasing Pre-hospital resuscitation
CPG A0203
Special Notes
Special Notes
A Refusal of Treatment Certificate may be completed by:

- a person aged 18 years or older;
- an agent, where a person aged 18 years or older has
completed an Enduring Power of Attorney (Medical
Treatment)
- a guardian appointed by the Victorian Civil and
Administrative Tribunal (VCAT).
A Refusal of Treatment Certificate may be sighted by
the attending Ambulance crew, or they may accept in
good faith the advice of those present at the scene. If
there is any doubt about the application of a certificate
the default position of resuscitation should be adopted.
Ambulance crews must clearly record full details of

the information given to them and the basis for their
decision regarding resuscitation on the PCR. This is
particularly important in circumstances where a copy
of the Refusal of Treatment Certificate has not been
sighted as it will serve if necessary as evidence of their
good faith.
A Refusal of Treatment Certificate may only be

completed in relation to a current condition. When
ceasing or withholding resuscitative efforts in these
circumstances the attending Ambulance or MICA
Paramedic needs to be satisfied that the Pts cardiac
arrest is most likely due to this current condition.
Under the Medical Treatment Act 1988 a person

acting under the direction of a Registered Medical
Practitioner who, in good faith and in reliance on a
Refusal of Treatment Certificate, refuses to perform or
continue medical treatment is not guilty of professional
misconduct or guilty of an offence or liable in any
civil proceedings because of the failure to perform or
continue that treatment.
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Withholding
and/or Ceasing Pre-hospital resuscitation
CPG A0203
Circumstances where resuscitation efforts may be withheld

- Likely risk to Paramedic health and safety
- Clear evidence of prolonged cardiac arrest (e.g. rigor mortis, decomposition, postmortem lividity)
- Injuries incompatible with life (e.g. decapitation)
- Inadequate resources to deal with all Pts (e.g. multi-casualty incidents)

- Death declared by Medical Officer who is, or has been, at the scene
- An adult (18 years or older), where a Refusal of Treatment Certificate has been completed for a current
condition which most likely caused the cardiac arrest
- A child (< 18 years), for whom there is an emergency management plan that states words to the effect in
the event of a significant deterioration or cardiac/respiratory arrest cardiopulmonary resuscitation is not to be
commenced. It should be signed by the parent/guardian and treating doctor/medical team
- An adult (18 years or older) whose initial cardiac rhythm is asystole (over a minimum 30 sec. period),
provided the time interval between the onset of cardiac arrest, i.e. collapse, and arrival of the crew at the Pt
has exceeded 10min. and there are no compelling reasons to continue, such as suspected hypothermia,
suspected drug overdose, a child (< 18 years) or family/bystander requests continued efforts
Circumstances where resuscitation efforts may be ceased
- An adult (18 years or older) who, after 30min. of Advanced Life Support resuscitation (including advanced
airway management, defibrillation and/or Adrenaline) has no return of spontaneous circulation, is not in VF or
VT, has no other signs of life present such as gasps or pupil reaction and hypothermia or drug overdose are
not suspected.
Withholding and/or Ceasing Pre-hospital resuscitation CPG A0203
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Withholding and/or Ceasing Pre-hospital resuscitation
CPG A0203
Verification of death
Verification of death refers to establishing that a death has occurred after thorough clinical assessment of a body
Qualified paramedics can provide verification if in the context of employment and if there is certainty of death.
Providing verification of death is not mandatory for paramedics.
Certification of death must still ultimately be provided by a Medical Practitioner as to cause of death. This falls
outside the scope of verification of death.
Clinical Assessment of a Deceased Person includes 7 clinical elements
- No palpable carotid pulse
- No heart sounds heard for 2 minutes
- No breath sounds heard for 2 minutes
- Fixed (non responsive to light) and dilated pupils (may be varied from underlying eye illness)
- No response to centralised stimulus (supraorbital pressure, mandibular pressure or sternal rub)
- No motor (withdrawal) response or facial grimace to painful stimulus (pinching inner aspect of elbow or
nail bed pressure)
- ECG strip shows asystole
The verification of death form should include all findings along with the full name of person (if known), location of
death, estimated date and time of death (if known), name of the paramedic conducting the assessment and if
the treating doctor has been notified.
Police must be notified in cases of reportable or reviewable death with the attending crew remaining on scene
until their arrival. SIDS are considered reportable.
A reportable death would include unexpected, unnatural or violent death, death following a medical procedure,
death of a person held in custody or care (alcohol or mental health), a person otherwise under the auspice of the
Mental Health Act but not in care or a person unknown.
A reviewable death is required following death of a child (<18) where the death is the second or subsequent
death of a child of the parent, guardian or foster parent.
The original verification of death form should be left with the deceased and the copy attached to a printed PCR.
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Laryngeal Mask Airway (LMA)
CPG A0301
Special Notes
General Care
The LMA provides improved airway and ventilation

Mx compared with a facemask and OPA. The LMA
does not protect against aspiration, although studies
have shown it to be as low as 3.5% with an LMA
compared to 12.4% with a Bag Valve Mask (BVM).
The LMA should therefore not be regarded as
the equivalent of endotracheal intubation.
If insertion fails and ventilation is difficult or inadequate,

check position of LMA cuff using a laryngoscope. If
minor adjustment fails to correct the problem, remove
the LMA inflated. Immediately insert an OPA/NPA and
ventilate the Pt using a BVM.
The LMA forms a low pressure seal around the

posterior perimeter of the larynx and when correctly
inserted is seated superior to the oesophageal
sphincter thus enabling positive pressure ventilation
via BVM or closed circuit resuscitator. Unconscious
Pts who accept an OPA are generally suitable for
insertion of an LMA.
Pt with morbid obesity have a naturally increased

work of breathing and during assisted or intermittent
positive pressure ventilation require higher pressures
to inflate the lungs. They also have a higher
incidence of hiatus hernia resulting in an increased
likelihood of passive regurgitation of stomach
contents.
Only one attempt may be made to reinsert LMA.

If insertion fails on the 2nd attempt, do not delay
returning to BVM using an OPA/NPA.
Do not over-inflate cuff.
The LMA may be used for the unconscious APO

Pt. However, gentle assisted ventilation should be
provided using a closed circuit resuscitator.
The LMA may be inserted in left or right lateral

positions or if entrapped, in a sitting position. Pts
may be managed in the lateral position when the
LMA has been correctly inserted and taped in situ,
using Transpore or Sleek, however, in general, it is
recommended that Pts be Mx supine and carefully
observed for aspiration.
If the conscious state of the Pt improves and there is

an attempt to reject the LMA, remove the LMA with
the cuff inflated.
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Laryngeal Mask Airway (LMA)

8
? Status
CPG A0301
LMA Size Chart
Unconscious Pt without gag reflex
Portex
Ineffective ventilation with BVM/oxysaver and airway

Mx (OPA/NPA)
Size
3 Small Adult
4 Normal Adult
5 Larger Adult
>10/60 assisted ventilation required
Unable to intubate/difficult intubation
Wt
30 - 50kg
50 - 70kg
70kg - 140kg
Inflation
25 ml
35 ml
55 ml
Size
Wt
3 Small Adult
30 - 50kg
4 Normal Adult 50 - 70kg
5 Larger Adult 70kg - 140kg
Inflation
20 ml
30 ml
40 ml
Unique
Stop
Contraindications
- Intact gag reflex or resistance to insertion
- Strong jaw tone + trismus
- Suspected epiglottitis or upper airway obstruction
- Do not intentionally provide sedation to insert or
maintain insertion of LMA
8
Consider
Precautions
- Inability to prepare the Pt in the sniffing position
- Pts who require high airway pressures, e.g. advanced pregnancy, morbid obesity, decreased pulmonary
compliance (stiff lungs due to pulmonary fibrosis) or increased airway resistance (severe asthma)
- Pts < 14 years of age due to enlarged tonsils
- Significant volume of vomit in airway
Side Effects
- Correct placement of the LMA does not prevent passive regurgitation or gastric distension
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Laryngeal Mask Airway (LMA) CPG A0301
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Version 5 - 08-06-11 Page 1 of 11
Endotracheal Intubation Guide

Special Notes
The Medical Standards Committee has authorised

endotracheal intubation by MICA Paramedics in
selected Pts.
There are three intubation techniques available:

- Intubation without drugs (Unassisted Endotracheal

Intubation)
- Intubation Facilitated by Sedation (IFS)
- Rapid Sequence Intubation (RSI)
The appropriate technique will vary according to the

clinical setting and a Paramedics authorised scope of
practice.
A MICA Paramedic operating alone may elect not

to use IFS or RSI until a second MICA Paramedic is
present.
All intubations facilitated or maintained with drug
therapy will be reviewed as part of AV Clinical
governance processes.
The use of cricothyroidotomy is restricted to AV MICA

Paramedics specifically accredited in this skill by the
Medical Standards Committee.
CPG A0302
General Care
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Version 5 - 08-06-11 Page 2 of 11
Endotracheal Intubation Guide
CPG A0302
Status
?
Endotracheal intubation
? Primary indications
? Preparation
? Insertion of ETT
? Failed intubation
Respiratory arrest
See CPG A0303
? Drugs to facilitate intubation
Cardiac arrest

? Status
GCS < 10 due to:

- Respiratory failure
- Neurological injury
- Overdose
- Status epilepticus
- DKA
Stop
8 Assess
Intubation Facilitated by Sedation (IFS)

Rapid Sequence Intubation (RSI)
? Care and maintenance

Sedation
Sedation and paralysis
8 Consider
Action
MICA Action
Endotracheal Intubation CPG A0302
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Version 5 - 08-06-11 Page 3 of 11
Endotracheal Intubation Indications, Precautions, C/Is
CPG A0302
Special Notes
Special Notes
Primary Neurological Injury
Uncontrolled bleeding
- RSI should be provided unless Pt is in cardiac arrest.

This includes Pts with absent airway reflexes.
- Midazolam should not be used to control

combativeness prior to RSI in head injury.
Judicious pain relief with narcotic should be used.
If combativeness is preventing preoxygenation (this
is rare), then once all preparations have been made
for RSI the Fentanyl should be given. This should
settle the Pt sufficiently to enable preoxygenation for
2-3min., then the Midazolam and Suxamethonium
should be given and the Pt intubated.
- In Pts with uncontrolled bleeding (e.g. ruptured AAA,

ruptured ectopic pregnancy, penetrating truncal
trauma, intra-abdominal trauma, limb avulsion),
ongoing bleeding may lead to poor cerebral
perfusion and coma.
- RSI in these Pts is potentially harmful. The

sedation may drop blood pressure further and
the added scene time increases total blood loss.
The appropriate treatment for these Pts is urgent
transport and immediate surgery.
- RSI should NOT be undertaken in Pts who

become unconscious when the coma is likely to be
secondary to blood loss, unless RSI is judged to
be absolutely essential (unmanageably combative
and / or impractical to transport unintubated). This
applies to Pts being transported both by road and air
Ambulance.
- Airway management with BVM is to be maintained in

conjunction with prompt transport. Intubation (without
drugs) should be considered if airway reflexes are
lost, bearing in mind the risks of delay to definitive
surgical care.
Status epilepticus

- A continuous or recurrent seizure of 10min. duration

or no return of consciousness between episodes may
require intubation where there is airway/ventilation
compromise which is unable to be effectively
managed using BVM and OPA/NPA.
Suspected tricyclic antidepressant O/D

- Requiring hyperventilation for cardiac arrhythmia

prevention or management.
Overdose

- The intent of the OD (difficult extrication) indication

for RSI is for the Pt to be intubated at the scene to
enable safer extrication.
Severe hyperthermia

- May result from drug OD or heat exposure. If after

10/60 of active cooling Pt temp. remains > 39.5C
and GCS < 10, then Pt should be intubated with RSI.
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Version 5 - 08-06-11 Page 4 of 11
Endotracheal Intubation Indications, Precautions, C/Is

Unassisted Endotracheal Intubation
IFS
RSI
Indication
?
?
Indication GCS < 10
Indication GCS < 10

?
Respiratory arrest
Respiratory failure
- Unresponsive to non-invasive
ventilation and drug therapy
Traumatic brain injury (TBI)
DKA
- Diabetic Ketoacidosis with BGL
reading High
Hypoxic brain injury

- Post-hanging, near drowning
- ROSC as per CPG A0202 Cardiac Arrest
Cardiac arrest
Absent airway reflexes
8
General Precautions
Time to intubation at hospital

versus time to intubate at scene
8
Precautions for IFS
As per General Precautions
Poor baseline neurological

function and major co-morbidities
Anticipation of difficulty with BVM

ventilation
Advanced Care Plan / Refusal

of Medical Treatment document
specifies Not for Intubation
Anticipation of a difficult intubation,

e.g. morbid obesity, short neck or
facial trauma
In general if transport time < 10/60
then no IFS

Contraindication (CIs)
Clinical situations where failed intubation

drill would not be feasible
No functional electronic capnograph
Pts indicated for RSI
? Status
CPG A0302
Stop
8 Assess
8 Consider
Action
MICA Action
Non-traumatic brain injury

- Stroke/Subarachnoid haemorrhage
Overdose with any of:

- Suspected tricyclic antidepressant O/D
- Difficult extrication
- Prolonged transport time (>30/60)
- O2 sat. unable to be maintained > 90%
Severe hyperthermia
- > 39.5C despite 10/60 of management
Status epilepticus
Suspected airway burns consult only
8
Precautions for RSI
As per General Precautions IFS
In general if transport time < 10/60 then no RSI

Contraindication (CIs)
As per first two Contraindications IFS
Any contraindications to Suxamethonium

Coma due to uncontrolled bleeding
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Endotracheal Intubation Preparation
Special Notes
General Care
CPG A0302
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Version 5 - 08-06-11 Page 5 of 11
Endotracheal Intubation Preparation

IFS
General preparation for intubation

?
Action
Preparation for IFS

?
Action
CPG A0302
RSI
? Preparation for RSI
Action
Position Pt. If a cervical collar is fitted

it should be opened while maintaining
manual cervical support
As per General preparation for intubation
As per General preparation for intubation
Pre-hydrate with Normal Saline fluid

bolus 10 ml/kg IV unless APO
Pre-hydrate with Normal Saline fluid

bolus 10 ml/kg IV
Pre-oxygenate with 100% O2

and electronic capnograph attached
If Pt hypotensive and/or tachycardic,

follow relevant CPG in conjunction with
the intubation process
If Pt hypotensive and/or tachycardic,

follow relevant CPG in conjunction with
the intubation process
Draw up and label drugs as appropriate
Adrenaline not to be given in

Hypovolaemic shock
Ensure pulse oximeter and cardiac

monitor are functional

Prepare equipment and assistance

- Suction
- ETT (plus one size smaller than
predicted immediately available) with
introducer
- Oesophageal Detector Device (ODD).
- Ensure equipment for a difficult / failed
intubation is immediately available,
including bougie, LMA,
cricothyroidotomy kit
- Mark cricothyroid membrane as
necessary
- Brief assistant to provide cricoid
pressure, where appropriate
- If suspected spinal injury, where
possible a second assistant should be
available to stabilise the head and neck
Draw up and label drugs as appropriate
Ensure functional and secure IV access
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
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Version 5 - 08-06-11 Page 6 of 11
Endotracheal Intubation Drugs

Special Notes
Sedation doses for RSI are based on initial

observations. This is especially important in
multi-trauma with TBI. Initial fluid challenges may
resolve tachycardia and/or hypotension, however the
Pt is still at risk of cardiovascular compromise and
the blood pressure must be strenuously supported.
Half doses (or less) of sedation are required in this
situation.
In Pts with extremely poor perfusion, treat with fluid
therapy +/- Adrenaline infusion concurrently with
IFS or RSI. Consider quarter doses of sedation.
Frail, elderly or hypotensive Pts have prolonged

circulation times. Allow for this when giving a second
dose of sedation during IFS.
CPG A0302
Dosage RSI
Age < 60
BP < 80

Dose
1/4 or 1/2 Fentanyl

Midazolam 1mg
BP 80 - 100
Half
BP > 100, HR > 100 (TBI only)
Half
BP > 100 , HR > 100 (all other)
Full
Age > 60
BP < 80

BP > 80
1/4 or 1/2 Fentanyl

Midazolam 1mg
Half
Dosage IFS
Age < 60
Dose
BP < 100
Half
BP > 100
Full
Age > 60
Half dose for all
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Version 5 - 08-06-11 Page 7 of 11
Endotracheal Intubation Drugs

IFS
CPG A0302
RSI
Action
Adjusted sedation dose required
Proceed with intubation

- no drugs required
Half dose sedation required

?
Reduced dose sedation required if either:

?
BP < 100 and / or age > 60
BP < 80
BP 80 - 100
HR > 100 (TBI only)
Action
Fentanyl 50mcg IV
Midazolam 0.05mg/kg IV (max. 5mg)
Adjusted sedation dose required
Age > 60
Action
Full dose sedation required

?
BP > 100 and age < 60
Action
Fentanyl 100mcg IV
If unable to intubate due to

?
excessive tone
Action
If GR 1 or 2 view but respiratory effort or

airway reflexes are preventing intubation
- R
epeat same dose of sedation and
reattempt intubation once only
If GR 3 or 4 view
- Proceed to Failed Intubation Drill
Fentanyl 50mcg IV
- If BP < 80mmHg consider 25mcg

- If BP < 80mmmmHg give Midazolam
1mg IV
Full dose sedation required

?
BP > 100 and age < 60
Action
Fentanyl 100mcg IV
Paralysing agent
?
Action
If Pt bradycardic at any stage

- Atropine 600mcg IV
Suxamethonium 1.5mg/kg IV
round up to nearest 25mg (max. 150mg)
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
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Version 5 - 08-06-11 Page 8 of 11
Endotracheal Intubation Insertion of ETT
CPG A0302
Insertion of Endotracheal Tube
General Care of the Intubated Pt
Observe passage of ETT through cords noting AS

standard markings and grade of view.
Reconfirm tracheal placement using EtCO2 after every

Pt movement. Disconnect and hold ETT during all
transfers.
Check ETT position using Oesophageal Detector

Device (ODD).
Inflate cuff.
Confirm tracheal placement via capnography (note: Pt

in cardiac arrest may not have CO2 initially detectable).
Exclude right main bronchus intubation by performing
the cuff palpation (tracheal squash) test and by
comparing air entry at the axillae.
If electronic capnography fails after intubation, use

colourimetric capnometry.
Suction ETT and oropharynx in all Pts.
If time permits, insert orogastric or nasogastric tube,

aspirate and connect to drainage bag. The orogastric
route must be used in head or facial trauma.
Secure the ETT and insert a bite block if required.
Ventilate using 100% oxygen and tidal volume

of 10 ml/kg. Aim to maintain SpO2 > 95% and
EtCO2 at 30 - 35mmHg (except asthma / COPD
where a higher EtCO2 may be permitted, tricyclic
OD where the target is 20 - 25mmHg, and DKA
where the EtCO2 should be maintained at the level
detected immediately post-intubation, with a max. of
25mmHg).
If there is ANY doubt about tracheal placement,

the ETT must be removed.
Document all checks and observations made to

confirm correct ETT placement.
Note length of ETT at lips/teeth.

Auscultate chest / epigastrium.
Note supplemental cues of correct placement (e.g.

tube misting, bag movement in the spontaneously
ventilating Pt, improved oxygen saturation and colour).
If unable to intubate after ensuring correct technique

and problem solving then proceed to Failed
Intubation Drill.
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Version 5 - 08-06-11 Page 9 of 11
Endotracheal Intubation Insertion of ETT
CPG A0302
8
Status
Indications
?
Insertion / General care of ETT

- Unassisted Endotracheal Intubation

- IFS

- RSI

? Insertion and checks of ETT
Action
ODD
? General care / ventilation
Capnography - EtCO2
Action
Length lips/teeth
ETT checks with each Pt movement
Cuff Palpation
Provide circulatory support if hypotension present
Auscultate chest/epigastrium
- Chest rise and fall, bag movement, SpO2,
colour, tube misting
Use colourimetric capnometry if capnography fails
Specific insertion instructions as per Insertion

of Endotracheal Tube
If there is ANY doubt about tracheal

placement, the ETT must be removed
Suction ETT and oropharynx

Insert OG/NG tube
Ventilate VT 10ml / per kg, EtCO2 30 - 35mmHg

if appropriate to Pt condition
Disconnect and hold ETT during transfers
Specific instructions as per General Care
of the Intubated Pt
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
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Version 5 - 08-06-11 Page 10 of 11
Endotracheal Intubation Care and Mx. of Intubated Pt

Special Notes
General Care
For Pts who become hypotensive after intubation,

consider reducing the dose of sedation, in association
with additional fluid +/- Adrenaline infusion according
to the clinical setting.
Infusion
Not all Pts receiving RSI will require paralysis post

intubation, e.g. continuous convulsions, OD other than
tricyclic.
Some Pts receiving IFS may require paralysis post
intubation to control ventilation e.g. asthmatic Pt.
Traumatic Brain injured Pts require paralysis
post intubation to prevent gagging and elevation
in ICP. Ideally this should be given before the
Suxamethonium wears off, provided tracheal
placement is confirmed and the tube is secured.
Non traumatic brain injured Pts i.e. stroke, SAH. do not

routinely require paralysis post intubation. Administer
where sedation alone cannot maintain intubation.
Paralysis is C/I in status epilepticus, where clinical
monitoring of seizure activity is required. Use additional
doses of Midazolam as required.
CPG A0302
- Morphine 30mg + Midazolam 30mg/30ml D5W or

Normal Saline
- 1ml = 1mg each drug
- 1ml/hr = 1mg/hr
Handover
- The EtCO2 and respiratory wave form immediately

prior to Pt handover must be demonstrated to the
receiving physician and documented on the PCR.
Fentanyl 300mcg + Midazolam 30mg/30ml D5W or

Normal Saline
- 1ml = 1mg Midazolam + 10mcg Fentanyl
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Version 5 - 08-06-11 Page 11 of 11
Endotracheal Intubation Care and Mx. of Intubated Pt

8
Status
Indications
?
Intubated Pt
Does Pt require sedation or sedation / paralysis to maintain intubation and ventilation
CPG A0302
Consider
8
? Post
Intubation Sedation
Indications
Post
Intubation Paralysis
?
Indications
8
Restlessness / signs of under sedation in the absence of

other noxious stimuli
- e.g. ETT too deep / irritating, occult pain
Prevention of shivering for Pts receiving therapeutic cooling
Signs of inadequate sedation

Non Paralysed Pt
- As per Paralysed
- Cough/gag/movement

Paralysed Pt
- HR and BP trending up together
- Tearing
- Diaphoresis
Primary Neurological Pts
Where sedation alone is ineffective at maintaining intubation or

allowing adequate ventilation / oxygenation
As prescribed for interhospital transfer
Reduction of metabolic heat production in hyperthermia
Sedation
?
Stop
All Pts receiving paralysis MUST receive ongoing sedation
Action
Morphine/Midazolam infusion 1 - 10ml/hr IV
The ETT must be secured and tracheal placement reconfirmed with

electronic capnography
C/I for Pt in Status epilepticus
- 0.5mg - 5mg IV boluses as required
Until Morphine/Midazolam infusion established:

- Midazolam 0.5mg - 5mg IV as required or
- Midazolam/Morphine 0.5mg - 5mg IV each drug
OR alternatively
Sedation and Paralysis

?
Sedate as per Post Intubation Sedation
Fentanyl/Midazolan infusion 1 - 10ml/hr
? Status
Stop
8 Assess
Action
8 Consider
Action
Pancuronium 8mg IV
- Repeat if evidence of returning muscular activity
(movement, chewing, cough, gag, curare cleft)
MICA Action
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Failed Intubation Drill
CPG A0303
Intubation
? Failed
Indications
Unable to see vocal cords during initial laryngoscopy
Action
Insert OP Airway and ventilate with 100% O2
Action
Reattempt intubation using bougie with blind placement

of ETT over bougie
Yes
8
Consider
Objective confirmation of tracheal placement using EtCO2
Action
Continue Management in accordance with relevant CPG
No
Action
Immediately remove ETT, insert OPA/NPA and ventilate with 100% O2
Yes
8
Consider
Able to ventilate and oxygenate
No
Action
Insert LMA
Yes
8
Consider
Able to ventilate and oxygenate
No
Action
Cricothyroidotomy
Action
If sedation /relaxant drugs administered allow these to

wear off and Pt to resume normal respiration
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Cricothyroidotomy
CPG A0304
8
? Status
Unconscious Pt unable to be oxygenated and

ventilated using Bag and Mask, OP / NP airway, LMA
or ETT where:
- RSI has been attempted but intubation has not
been achieved
Stop
Contraindications
- Nil in circumstances where oxygenation and

ventilation are not possible using alternative
techniques.
- RSI is not authorised
- Massive facial trauma is present and RSI is

considered unsafe due to the inability to undertake
the failed intubation drill
- RSI is not possible due to lack of intravenous
access
- Upper airway obstruction is present due to a

pharyngeal or an impacted foreign body which is
unable to be removed using manual techniques and
Magill forceps
Action
Perform Cricothyroidotomy using approved kit.
- Partial airway obstruction is present and transport

by Air Ambulance is required and expertise for
alternative techniques are not available.
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Cricothyroidotomy CPG A0304
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Acute Coronary Syndrome

Special Notes

Acute Coronary Syndrome (ACS) is a spectrum of

illnesses including:
- Unstable Angina
- Non-ST Elevation Myocardial Infarction (NSTEMI)
- ST-Elevation Myocardial Infarction (STEMI)
Not all Pts with ACS will present with pain, e.g. diabetic
Pts, atypical presentations, elderly Pts.
The absence of ischaemic signs on the ECG does not
exclude AMI. AMI is diagnosed by presenting history,
serial ECGs and serial blood enzyme tests
Suspected ACS related pain that has spontaneously
resolved warrants investigation in hospital.
The goal of management in ACS is to resolve pain
completely if safe to do so. This reduces cardiac
workload.
The IM route of administration is relatively

contraindicated in ACS if Pt is eligible for thrombolysis.
Current evidence suggests transport to a PCI-enabled
facility improves Pt outcomes in STEMI transport
time < 90mins.
CPG A0401
General Care
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Acute Coronary Syndrome
CPG A0401
Status
?
Consider
8
Acute Coronary Syndrome (ACS)
Consider the spectrum of

illnesses within ACS
- UA
- NSTEMI
- STEMI
?
ACS Mx
?
Nausea/Vomiting
?
LVF
?
Inadequate Perfusion
Action
Action
Action
Action
General Principles
of ACS Mx
See CPG A0701
See CPG A0406
See CPG A0407
?
Arrhythmia Mx
Action
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
See
CPG A0201 VF / Pulseless VT
CPG A0402 Bradycardia
CPG A0403 Supraventricular Tachyarrhythmias
CPG A0404 Ventricular Tachycardia
CPG A0405 Accelerated Idioventricular Rhythm
Acute Coronary Syndrome CPG A0401
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Acute Coronary Syndrome General Management Principles

Special Notes
GTN is a potent venodilator that can decrease venous

return therefore decreasing right ventricular (RV) filling
and fibre stretch with a reduction in cardiac output.
The use of GTN is contraindicated in Inferior and RV
infarcts.
Up to 50% of Inferior AMIs have RV involvement and
cannot compensate to a drop in venous return due to
myocardial insufficiency.
Signs of an Inferior AMI include ST elevation in leads II

and III. Bradycardia is not unusual in an Inferior AMI due
to the involvement of the right coronary artery and the
SA / AV nodes.
Nitrates are C/I in bradycardia (HR < 50) due to the
Pts inability to compensate to a decrease in venous
return by increasing HR to improve cardiac output.
- C.O. = HR x SV
General Care
CPG A0401
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Acute Coronary Syndrome General Management Principles

Status
?
Assess requirement for:

8
ACS
Pain relief/nitrates
CPG A0401
Control of hypertension
Antiplatelet Rx
? Nitrates
? Antiplatelet Rx
Action
Action
Aspirin 300mg oral
BP > 110
- GTN 300mcg S/L/Buccal (no prev. admin.) or
- GTN 600mcg S/L/Buccal
If symptoms continue and BP remains > 110
- Repeat 300 - 600mcg S/L/ Buccal @ 5/60
? Pain Relief
Action
Pain relief as per CPG A0501

Pain Relief
- Rx until pain free
BP > 90
- GTN Patch 50mg (0.4mg/hr) upper torso / arms

- If BP falls < 90, remove patch
? Hypertension +/- symptoms
- Systolic BP > 160 or

- Diastolic BP > 100
Control pain as per CPG A0501 Pain Relief
GTN 300 mcg S/L/Buccal

- Repeat 300mcg @ 5/60 if hypertension persists
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Acute Coronary Syndrome CPG A0401
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Bradycardia
CPG A0402
Special Notes
General Care
Atropine is unlikely to be effective in complete heart

block.
Adrenaline Infusion
- 3mg Adrenaline added to make 50ml with
D5W or Normal Saline.
If side effects occur during Adrenaline infusion, cease

infusion and recommence once side effects resolve
titrating to Pt response.
If no increase in HR, pacing is likely to be required.
Notify appropriate hospital capable of managing a Pt

likely to require pacing.
Bradycardia is technically defined as less than 60 bpm.
In practical purposes many Pts will have a normal heart
rate between 50 and 60. Decisions to treat should
consider this and the more likely need to consider 50 as
the limiting point for management.
- 1ml/hr = 1mcg/min
If no response from Adrenaline infusion @ 20mcg/min.,

increasing infusion rate is unlikely to have additional
chronotropic effects.
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Bradycardia
CPG A0402
8
Assess
?
Status
Perfusion status
Evidence of Bradycardia
Cardiac rhythm
Heart failure
Ischemic chest pain
? Stable
? Unstable
Asymptomatic
Less than adequate perfusion
Adequate Perfusion
HR > 20
Profound bradycardia (HR < 40) and full field APO
- including acute STEMI and ischemic chest pain
Runs of VT or ventricular escape rhythms

Action
HR < 20
BLS
Rx as per < Adequate

perfusion if Pt deteriorates

Action

Atropine 600mcg IV
- If no response after 3 - 5/60
- Repeat 600mcg IV
? Adequate Perfusion achieved
?
Inadequate or Extremely Poor Perfusion persists

Action
Action
Continue current management
Adrenaline Infusion (3mg/50ml D5W/Normal Saline)

commencing @ 5mcg/min. (5ml/hr)
Transport
- Increase by 5mcg/min. @ 2/60 until adequate perfusion/side

effects (max. 20mcg/min.)
- If syringe pump unavailable/malfunction

- Adrenaline 10mcg IV
- repeat 10mcg IV @ 2/60 until adequate perfusion/side effects
If poor perfusion persists treat as per CPG A0407 Inadequate

Perfusion Cardiogenic Causes
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Bradycardia CPG A0402
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Tachyarrhythmias - Adult
Special Notes
CPG A0403
General Care
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Tachyarrhythmias - Adult
CPG A0403
Status
?
Tachyarrhythmias
? Status
?
QRS < 0.12 sec
?
QRS > 0.12 sec
Rate > 100
VT > 30 sec
Rate > 100
Absent or abnormal p waves

- SVT (AV nodal rhythms or AVRT)
- Atrial fibrillation / flutter
- Sinus tachycardia
- Atrial tachycardia
Wide and bizarre

Generally regular
AV dissociation / absence of p waves
? Adequate Perfusion
? < Adequate Perfusion / Unstable
Action
Action
? Ventricular Tachycardia
Action
See CPG A0403 SVT
See CPG A0403 SVT
See CPG A0404 VT
Stop
8 Assess
8 Consider
Action
MICA Action
Tachyarrhythmias - Adult CPG A0403
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Supraventricular Tachyarrhythmias (SVT)

Special Notes
Symptomatic
CPG A0403
General Care
signs and symptoms
- Rate related severe or persistent chest pain

- Shortness of breath with crackles
Valsalva instruction
- Evidence suggests a greater reversion rate with an
abdominal valsalva manoeuvre with the following
3 elements.
1. Position
- Supine
2. Pressure
- At least 40mmHg for max. vagal tone. Best achieved
with Pt blowing into a 10ml syringe hard enough to
move the plunger to create this pressure.
3. Duration
- At least 15sec. if tolerated by Pt
Ref. G Smith, A Morgans, and M Boyle

Emerg Med J 2009; 26: 8-10. doi:10.1136
emj.2008.061572
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CPG A0403
Status
?
SVT
? Adequate perfusion
BP > 100
? Asymptomatic
? Symptomatic
Action
Action
Abdominal valsalva
manoeuvre
Abdominal valsalva
manoeuvre
Action
BLS
? Reversion
If Pt deteriorates, Rx as
per Symptomatic or
< Adequate Perfusion
Action
BLS
No Reversion
If > 30/60 transport time and SOB with

crackles or chest pain
Action
Verapamil 5mg IV given over 1/60

- Repeat 1mg IV @ 1/60 until either:
- Arrhythmia reversion
- BP < 100
- max. 10mg IV
Verapamil is C/I for Pt on Beta blockers
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Supraventricular Tachyarrhythmias (SVT) CPG A0403
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CPG A0403
Special Notes
General Care
A Pt eye opening to pain but not to voice commands

would also be likely to be making incomprehensible
sounds and making purposeful movements in response
to pain. i.e. a GCS of 9, (E2, V2, M5). Sedation should
be used cautiously in these Pts.
If wide complex QRS or unsure of diagnosis treat as for

CPG A0404 Ventricular Tachycardia.
The effectiveness of the Pts respirations should be

continuously monitored.
Treat Pt symptomatically in accordance with appropriate

Guideline and transport for further assessment and
treatment.
If Pt is unconscious or becomes unconscious at any
time during treatment, perform immediate synchronised
cardioversion.
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CPG A0403
Status
?
SVT (AV nodal rhythms or AVRT) or Unstable / rapidly deteriorating, SVT, AF, Atrial Flutter
? < Adequate perfusion
? Unstable
SVT (AV nodal rhythms or AVRT)
Rapidly deteriorating, altered conscious state

(includes SVT, AF, Atrial Flutter)
BP < 100
? Symptomatic
? Unstable / rapidly deteriorating
Action
Action
Abdominal valsalva manoeuvre
? Reversion
? No reversion
Action
If > 30/60 transport time and

SOB with crackles or chest pain
BLS
Synchronised cardioversion
- Sedate: Fentanyl 25 mcg IV single dose only +
Midazolam 2.5mg IV
- Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not
respond to verbal stimuli but does respond to pain
- Cardioversion: Biphasic 75J (Monophasic 100J)
- If unsuccessful repeat using Biphasic 150J (Monophasic
200J then 360J) if required
Action
?
Metaraminol 0.5mg IV given over 1/60

- Repeat 0.5mg IV @ 2/60 until either:
- Arrhythmia reversion
- BP > 100
- max. 5mg IV delivered
If BP increases to > 100

- Consider Verapamil as per Adequate Perfusion
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
? Loss of output
Action
As per appropriate CPG
? Reversion
Action
BLS
Supraventricular Tachyarrhythmias (SVT) CPG A0403
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Ventricular Tachycardia (VT)
CPG A0404
Special Notes
General Care
A Pt eye opening to pain but not to voice commands

would also be likely to be making incomprehensible
sounds and making purposeful movements in response
to pain, i.e. a GCS of 9 (E2, V2, M5). Sedation should
be used cautiously in these Pts.
ALS / QAP crews should considerer MICA R/V vs

transport to appropriate hospital as these Pts are
dynamic and have a potential to deteriorate
The effectiveness of the Pts respirations should be

continuously monitored
Amiodarone and Fentanyl have the potential

to interact adversely. Concurrent administration
should be avoided. If Fentanyl has already been
administered, monitor the Pt closely when administering
Amiodarone.
Pt presenting symptomatic and poorly perfused is likely

to require sync. Cardioversion prior to Amiodarone
administration.
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Ventricular Tachycardia (VT)
CPG A0404
? Status
Assess
8
Ventricular Tachycardia
Confirm Ventricular Tachycardia

- VT > 30sec.
- QRS > 0.12sec. - Rate > 100
- Mostly regular
- A-V dissociation / absence of p waves
? Stable: Adequately perfused
? Unstable / Rapidly Deteriorating
Action
Action
Amiodarone infusion 5mg/kg IV

(max. 300mg) over 20/60 once only
Synchronised cardioversion
- Sedate: Midazolam 2.5mg IV
- Repeat Midazolam 2.5mg IV @ 2/60 until Pt does not respond
to verbal stimuli but does respond to pain
- Cardioversion: Biphasic 150J (Monophasic 200J)
- If unsuccessful repeat using Biphasic 150J (Monophasic 360J)
if required

Rx as per Unstable if Pt deteriorates
Only dilute Amiodarone with D5W
Do not administer Amiodarone if suspected

Tricyclic Antidepressant Medication
Overdose. Manage as per CPG A0707
Management of Overdose: TCA
? Loss of output
Action
As per appropriate CPG
? Reversion
Action
Narrow complex
- Amiodarone infusion as above

(if not already running)
Other rhythms
- Rx as per appropriate CPG
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Ventricular Tachycardia (VT) CPG A0404
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Accelerated Idioventricular Rhythm (AIVR)

Special Notes
AIVR is usually a benign rhythm but may be associated

with AMI, reperfusion or drug toxicity.
Commonly seen in post cardiac arrest Pts.
May be associated with Adrenaline administration.
General Care
CPG A0405
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Accelerated Idioventricular Rhythm (AIVR)

? Status
Assess
8
AIVR
Perfusion status
? Adequate Perfusion
? < Adequate Perfusion
? No Perfusion
Action
Action
Rx as per CPG A0201

Pulseless Electrical Activity
BLS
Transport
? Status
CPG A0405
? Ventricular rate < 60
? Ventricular rate 60-100
? Ventricular rate > 100
Action
Action
Action
Rx as per CPG A0402

Bradycardia
Normal Saline 250ml IV bolus

- Repeat 250ml IV if perfusion

status not improved
Rx as per CPG A0404

Ventricular Tachycardia
Stop
8 Assess
8 Consider
Action
MICA Action
Accelerated Idioventricular Rhythm (AIVR) CPG A0405
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Pulmonary Oedema
CPG A0406
Special Notes
General Care
This Guideline is primarily directed at cardiogenic

pulmonary oedema, secondary to LVF or CCF. Other
medical causes of pulmonary oedema should not be
treated under this Guideline.
Manage chest pain as per CPG A0401 Acute

Coronary Syndrome.
Non-medical causes include: smoke inhalation/toxic

gases, near drowning (aspiration) and anaphylaxis.
Pulmonary oedema is likely a result of altered
permeability. These causes should be treated with
oxygen therapy and assisted ventilations and do not
require nitrates.
Frusemide should be used cautiously in the

hypotensive Pt.
Pts with pulmonary oedema presenting with a wheeze

should only be managed as per CPG A0601 Asthma
if a history of bronchospasm can be confirmed.
Avoid the use of Salbutamol in the setting of
pulmonary oedema where possible.
Remove GTN patch if BP decreases < 90.
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Pulmonary Oedema
CPG A0406
8
Assess
Status
?
Pulmonary Oedema
Consider causes: LVF/CCF, nutritional deficiency, liver disease, renal disease, fluid overload
Respiratory status
Short of Breath
?
? Not Short of Breath

Action
BLS
If deteriorates, treat as
for Short of Breath
? Full Field Crackles
Action
GTN as per Basal/Midzone Crackles
? Basal/Midzone Crackles
Action
BP > 110
- GTN 300mcg S/L/Buccal (no prev. admin.) or
- GTN 600mcg S/L/Buccal

- If BP > 110 and symptoms continue repeat

300 - 600mcg S/L/ Buccal @ 5/60
BP > 90
- GTN Patch 50mg (0.4mg/hr) upper torso/arms
Frusemide 20 - 40mg IV
Frusemide 40mg IV or Pts daily dose IV as

a single dose (max. 100mg)
If alert and anxious
- Consider Morphine 12mg IV
? No improvement or deteriorates
Suction if required

- Provide assisted ventilation with 100% Oxygen
if inadequate VT or VR
CPAP if available
No
improvement or deteriorates
?
Treat as for Full Field Crackles
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Intubate if necessary as per CPG A0302

Pulmonary Oedema CPG A0406
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Inadequate Perfusion Cardiogenic causes
CPG A0407
Special Notes
General Care
Any intravenous infusions established under this

Guideline must be clearly labelled with the name and
dose of any additive drugs and their dilution.
Adrenaline infusion > 50mcg/min. may be required

to manage these Pts. Ensure delivery system is fully
operational (e.g. tube not kinked, IV patent) prior to
increasing dose.
A Pt presenting with inadequate to extremely poor

perfusion resulting from a cardiac event may not always
have associated chest pain, e.g. silent myocardial
infarction, cardiomyopathy.
Pts presenting with suspected pulmonary embolus
with inadequate to extremely poor perfusion should
be managed with this Guideline. Pulmonary embolus
is not specifically a cardiac problem but may lead to
cardiogenic shock due to an obstruction to venous
return and the Pt may require fluid and Adrenaline
therapy.
Unstable Pts may require bolus Adrenaline

concurrently with the infusion.
Adrenaline infusion
- 3mg Adrenaline added to make 50ml with D5W or

Normal Saline.
- 1ml/hr = 1mcg/min
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Inadequate Perfusion Cardiogenic causes

Status
?
Inadequate perfusion: cardiogenic causes
Manage other causes, e.g. arrhythmia, pain, hypovolaemia
CPG A0407
Stop
Assess
Signs of pulmonary oedema (crackles)
? Crackles
?
No Crackles
Action
Action
Adrenaline infusion as per

Inadequate or Extremely Poor
Perfusion
Normal Saline 250ml IV

- Repeat 250ml IV if chest clear and Inadequate or Extremely Poor Perfusion
persists
?
Action
Adrenaline infusion (3mg/50ml D5W/Normal Saline) commencing @ 5mcg/min. (5ml/hr)

- Increase by 5mcg/min. @ 2/60 until adequate perfusion/side effects

- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50mcg/min
- If syringe pump unavailable/malfunction:
- repeat 10mcg @ 2/60 until adequate perfusion/side effects
- If poor response
- Adrenaline 50 - 100mcg IV as required
- NB. Doses > 100mcg may be required
If chest clear continue Normal Saline 250ml IV boluses up to 20ml/kg
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Inadequate Perfusion Cardiogenic causes CPG A0407
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Secondary to Erectile Dysfunction Agents
and GTN Administration
Special Notes
Erectile Dysfunction agents for the purposes of this

Guideline are PDE5 inhibitors such as Viagra, Cialis
and Levitra.
The combination of these drugs with GTN can
cause a dramatic drop in BP.
General Care
CPG A0408
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Secondary to Erectile Dysfunction Agents
and GTN Administration
CPG A0408
Status
?
8
Assess / Consider
Concurrent use of erectile

dysfunction agents and Glyceryl
Trinitrate
Perfusion status
Exclude / Rx other causes, e.g. hypovolaemia, arrhythmia, pain
?
Action
Metaraminol 0.5mg IV given over 1/60

- Repeat 0.5mg IV @ 2/60 until either:
- BP > 100
- max. 5mg IV is given
If BP has not responded to max. dose, discuss Mx with

receiving hospital
? Status
Stop
8 Assess
8 Consider
Action
Inadequate Perfusion Secondary to Erectile Dysfunction Agents

and GTN Administration CPG A0408
MICA Action
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Pain Relief
CPG A0501
Special Notes
Special Notes
The max. dose of Methoxyflurane is 6ml per 24hr.

period
ALS Paramedics must consult prior to exceeding the

20mg max. dose of Morphine and administer according
to Pt need or the onset of adverse side effects.
Be cautious of using Fentanyl and Morphine in

combination. Smaller doses will be required
The effect of Morphine IM on pain relief is slow and

variable. This route must be used as a last resort and
strictly within indicated Guidelines.
If respiratory depression occurs due to narcotic

administration manage as per CPG A0707
Management of Overdose
Narcotic pain relief should not be administered during

late second stage of labour. If narcotics have been
administered, Naloxone should not be administered to
the newborn.
Headache should be managed as per this guideline

severe headache.
Fentanyl IN preparation
All Adult doses must be prepared from 600mcg/2ml in a 1ml syringe
All doses include 0.1ml to account for atomiser dead space

Doses have been rounded to the nearest 0.5ml.
Age < 60 and
Wt. > 60kg
Age > 60 and/or

Wt.< 60kg
Initial dose
200mcg
100mcg
Volume
0.75ml
0.45ml
Subsequent dose
50mcg
50mcg
Volume
0.25ml
0.25ml
Subsequent dose
25mcg
25mcg
Volume
0.2ml
0.2ml
To administer Fentanyl, draw up desired

volume according to dose table for the
corresponding weight and age then atomise
into Pts nostril.
The max. amount to be atomised into any

nostril is 1ml. In some instances it may be
appropriate to administer half of the volume into
each nostril as optimal absorption occurs with
volumes of 0.3 - 0.5ml. This is also dependent
on Pt compliance.
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Pain Relief
CPG A0501
Status
?
Assess
8
Complaint of pain
Pain score > 2
Determine requirement for non IV therapy vs IV
? Non IV therapy
? IV therapy
Pain likely to be controlled by non IV therapy or
Pain may require IV narcotic and ongoing therapy
Unable to obtain IV
Action
If

Action
Consider Methoxyflurane and/or Fentanyl IN if

appropriate or while establishing IV access
Methoxyflurane 3ml
- Repeat 3ml if required (max. 6ml)
Fentanyl IN
- If age < 60 and > 60kg : Fentanyl 200mcg IN
- Repeat up to 50mcg IN @ 5/60 titrated to pain or
side effects (max. dose 400mcg)
- If age > 60 and/or < 60kg : Fentanyl 100mcg IN
- Repeat up to 50mcg IN @ 5/60 titrated to pain or
If pain not controlled by above Rx as per IV therapy
Morphine up to 5mg IV
- Repeat up to 5mg IV @ 5/60 (max. 20mg) titrated
topain or side effects
Unable to obtain IV access

- > 60kg : Morphine 10mg IM
- Repeat 5mg IM after 15/60 (once only) if required
- < 60kg : Morphine 0.1mg/kg IM
- Single dose only - consult for further dose
Morphine as above - no max. dose
If allergic to Morphine
- Fentanyl 25 - 50mcg IV
- Repeat Fentanyl 25 - 50mcg IV @ 5/60 titrated
topain or side effects (max. 200mcg)
Fentanyl as above - no max. dose
? Nausea
Action
Rx as per CPG A0701 Nausea and Vomiting
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Pain Relief CPG A0501
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Pain Relief Severe Headache
CPG A0501
Special Notes
General Care
Non steroidal anti-inflammatory medication, including

paracetamol and ibuprofen, in mild to moderate
headache is acceptable for Pt self administration.
Many Pts who suffer migraines may already have a

pre-set treatment plan in place. Most Pts will seek
emergency care when such treatments have failed.
Paramedics do not administer Aspirin for

headache.
Opioids are of limited benefit in the treatment of

migraine. Morphine may not be effective and may
be associated with delayed recovery on occasions.
It should only be used to treat severe prolonged
diagnosed headache where other measures have failed
and where transport to the treating facility is prolonged.
Sudden onset severe headache, sometimes referred

to as thunderclap or worst in life, should prompt
concern for serious intracranial pathology. Particular
attention should be given to Pts whose headache
severity reaches maximal intensity within seconds to
a minute of onset. Other warning signs that may be
suggestive of serious intracranial event include:

- Abnormal neurological finding or atypical aura
Prochlorperazine is indicated for headache

considered or diagnosed to be migraine irrespective of
nausea and vomiting
- N
ew onset headache in elderly Pts or those with a
history of cancer
- Altered level of consciousness or collapse
Paramedics do not diagnose headache. The term

migraine may be used mistakenly to describe a
severe headache. Headache management is usually
dependant upon a diagnosis and tailored accordingly.
Pre-hospital management seeks to provide interim relief
until a more appropriate diagnosis and management
can be provided.
- Seizure activity
- Fever and/or neck stiffness.
Stemetil is unlikely to offer any clinical benefit for

intracranial haemorrhage or SAH. It may be omitted
in this case. Many such Pts will have signs of CNS
depression in which case Stemetil should not be
administered.
Metoclopramide may also be effective in the

management of headache. Prochlorperazine is the
preferred option for severe headache.
Metoclopramide and Prochlorperazine should not

be administered to the same Pt due to the increased
risk of extrapyramidal reactions.
The management of severe dehydration where

indicated may be of assistance in the management of
severe headache.
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Pain Relief Severe Headache

? Status
CPG A0501
Assess
8
Severe Headache: Pain Score > 7
Suspected cerebral bleed
Potential Meningeal Infection
Stop
If uncertain, manage as suspected intracranial bleed as per

CPG A0711 Suspected Stroke or TIA
? Severe Headache
Action
Manage seizures as per CPG A0703 Continuous Seizures
If suspected Meningococcal infection manage as per CPG A0706 Meningococcal Septicaemia

In the first instance consider managing all headache:
- Methoxyflurane 3ml
- If effective, repeat 3ml if required (max. 6ml)

- Stemetil 12.5 mg IMI
If after 15 minutes of above therapy and Pt still c/o severe pain (>7) and destination
hospital remains >15 minutes

- Morphine 2.5mg IV @ 5/60 titrated to pain or side effects (max. dose 20mg).
- Aim is to reduce pain to < 7.
- If allergic or sensitive to Morphine administer Fentanyl 25 mcg IV @ 5/60 titrated to pain or
If unable to obtain IV Access
If age < 60 and > 60kg: Fentanyl 100mcg IN

- Repeat up to 25mcg IN @ 5/60 titrated to pain or side effects (max. dose 200mcg)
If age > 60 and/or < 60kg: Fentanyl 50mcg IN

? Status
Stop
8 Assess
- Repeat up to 25mcg IN @ 5/60 titrated to pain or side effects (max. dose 100mcg)
8 Consider
Action
MICA Action
Pain Relief CPG A0501
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Asthma
CPG A0601
Status
?
8
Assess
Respiratory distress
Severity of Asthma / COPD presentation
Stop
This guideline should be read in conjunction

with CPG A0001 Oxygen Use in Emergency
Presentations
?
Mild/Moderate/Severe
Action
?
Exacerbation of COPD
Action
?
Unconscious
Action
?
No cardiac output
Action
See CPG A0601
See CPG A0601
See CPG A0601
Loses cardiac output

See CPG A0601
PEA as per CPG A0201
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Asthma CPG A0601
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Asthma
CPG A0601
Special Notes
General Care
Asthmatic Pts are dynamic and can show initial

improvement with treatment then deteriorate rapidly.
Salbutamol infusion
Consider MICA support but do not delay transport

waiting for backup.
Despite hypoxaemia being a late sign of deterioration,

pulse oximetry should be used throughout Pt contact (if
available).
An improvement in SpO2 may not be a sign of
improvement in clinical condition.
Beware of Pt presenting wheeze associated with heart

failure and no asthma / COPD Hx.
pMDI = Pressurised Metered Dose Inhaler
- 1mg Salbutamol added to make 50ml with

D5W or Normal Saline.
- 15mcg/min. = 45ml/hr
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Asthma
CPG A0601
Status
?
8
Assess
Respiratory distress
Severity of distress
If Pts asthma Mx plan has been activated
? Mild or Moderate
?
Severe
Action
Action
Salbutamol pMDI and spacer

- Deliver 4 puffs @ 4/60 until resolution of symptoms
- Pt to take 4 breaths for each puff
If pMDI spacer unavailable
- Salbutamol 10mg (5ml) Nebulised
- Repeat 5mg (2.5ml) Nebulised @ 5/60 if required
Salbutamol 10mg (5ml) and Ipratropium

Bromide 500mcg (2ml) Nebulised
- Repeat Salbutamol 5mg (2.5ml)
Nebulised @ 5/60 if required
Salbutamol 250mcg IV
- Repeat 125mcg IV @ 5/60 if required
(max. 500mcg)
Dexamethasone 8mg IV
? Status
? Adequate Response
?
No Significant Response after 10/60
Action
Action
Transport with continued

reassessment
Rx as per Severe
Stop
8 Assess
8 Consider
Action
MICA Action
If unimproved
Salbutamol infusion IV @ 15mcg/min.
(45ml/hr)
Asthma CPG A0601
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COPD Chronic Obstructive Pulmonary Disease
Special Notes
General Care
CPG A0601
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COPD Chronic Obstructive Pulmonary Disease
CPG A0601
?
Status
Exacerbation of COPD
?
All exacerbations of COPD
Action
If Severe
- Treat as per appropriate section of CPG A0601 Asthma
Irrespective of severity
- Salbutamol 10mg + Ipratropium Bromide 500mcg Nebulised
? Status
?
Adequate response
Action
?
Inadequate response
Action
Titrate O2 flow to target SpO2 90%

- Consider low flow O2, e.g. Nasal Prong O2
Continue Mx as per CPG A0601 Asthma
Stop
8 Assess
8 Consider
Action
MICA Action
COPD CPG A0601
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Asthma
Special Notes
High EtCO2 levels should be anticipated in the intubated

asthmatic Pt. EtCO2 levels of 120mmHg in this setting
is considered safe, and managing ventilation should be
conscious of the effect of gas trapping when attempting
to reduce EtCO2.
Extreme care must be taken with assisted ventilation as
gas trapping and barotrauma occurs easily in asthmatic
Pts with already high airway pressures.
CPG A0601
General Care
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Asthma
CPG A0601
Status
?
Unconscious / Becomes Unconscious

- with poor or no ventilation but still with
cardiac output
Pt requires immediate assisted ventilation
8
Action
Ventilate @ 5 - 8 ventilations/min., VT 10ml/kg
Moderately high respiratory pressures

Allow for prolonged expiratory phase
Gentle lateral chest pressure during expiration if required
Adequate Response
?
Inadequate Response
?
Action
Action
Rx as per Severe Respiratory Distress
If unable to gain IV or unaccredited in IV Salbutamol

- Adrenaline 300mcg IM (1 : 1,000)
- Repeat 300mcg IM @ 20/60 as required (max. 900mcg IM)
Rx as per Severe Respiratory Distress
Consider intubation per CPG A0302 Endotracheal Intubation

? Status
Stop
8 Assess
8 Consider
Action
MICA Action
- Salbutamol 2x IV/IO dose via ETT
If Pt loses output at any stage, see CPG A0601
Asthma CPG A0601
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Asthma
Special Notes
Consider potential for tension pneumothorax and Mx.
Due to high intrathoracic pressure due to gas trapping,

venous return is lost and Pt may lose cardiac output.
Apnoea allows the gas trapping to decrease.
CPG A0601
General Care
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Asthma
CPG A0601
?
Status
Pt loses cardiac output

- especially during assisted ventilation and
bag becomes stiff
Pt requires immediate intervention
Action
Apnoea 1 min
- Exclude tension pneumothorax
- Gentle lateral chest pressure
- Prepare for potential resuscitation
?
Cardiac output returns
Action
?
Carotid pulse, no BP
Action
?
No return of output
Action
Treat as per CPG A0601
Adrenaline 50mcg IV
- Repeat 50 - 100mcg IV @1/60 as required
Mx as per appropriate Guideline
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Asthma CPG A0601
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Nausea and Vomiting
CPG A0701
Special Notes
General Care
Prochlorperazine must only be administered via the

IM route.
If there are no contraindications and the IV route is

unobtainable with a long transport time, then administer
Metoclopramide IM.
If nausea and vomiting tolerated, basic care and
transport is the only required treatment
Take care with Metoclopramide Polyamp as it is

similar to Ipratroprium Bromide and Atropine
Polyamps in appearance.
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Nausea and Vomiting
CPG A0701
Status
?
Assess for:
8
Actual or potential for nausea

and vomiting
Nausea and vomiting or
Spinal cord injury / Eye trauma or

Potential motion sickness
Vertigo
Stop
Prochlorperazine must not be given IV
Metoclopramide and Prochlorperazine should not be administered

in the same episode of Pt care without consultation
? Nausea and vomiting associated with:

? Prophylaxis for:
- Cardiac chest pain

- Latrogenic secondary to narcotic analgesia
- Previous diagnosed migraine
- Secondary to cytotoxic drugs or radiotherapy
- Severe gastroenteritis
Action
Metoclopramide 10mg IV/IM

- Repeat 10mg IV/IM after 10/60 if symptoms

persist (max. 20mg)
If known allergy/contraindication to
Metoclopramide
- Prochlorperazine 12.5mg IM
- Potential for motion sickness

- Planned aeromedical evacuation
- Vertigo
Action
Prochlorperazine 12.5mg IM
? Prophylaxis for:
Awake Pt (GCS 13 15) with

suspected spinal injuries who
are immobilized on the stretcher
Eye trauma
- e.g. penetrating eye injury,
hyphema
Action
Metoclopramide 10mg IV/IM

- Repeat 10mg IV/IM after
10/60 if symptoms persist
(max. 20mg)
? If dehydrated
Action
Manage as per CPG A0801 Hypovolaemia
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Nausea and Vomiting CPG A0701
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Hypoglycaemia
CPG A0702
Special Notes
General Care
Pt may be aggressive during management.
If Pts next meal more than 20min. away, encourage the

Pt to eat a long acting carbohydrate (e.g. sandwich,
piece of fruit, glass of milk) to sustain BGL to next meal.
Ensure IV patent before administering Dextrose.

Extravasation of Dextrose can cause tissue necrosis.
Ensure sufficient advice on further management and
follow-up if Pt refuses transport.
All IVs should be flushed well before and after
Dextrose administration.
If adequate response, maintain initial Mx and transport.
If the Pt refuses transport, repeat the advice for transport

using friend/relative assistance. If Pt still refuses
transport, document the refusal, and leave Pt with a
responsible third person and advise the third person of
actions to take if symptoms re-occur and of the need to
make early contact with LMO for follow up.
If inadequate response transport without undue delay.
Maintain general care of unconscious Pt and ensure
adequate airway and ventilation.
Further dose of Dextrose 10% may be required in

some Hypoglycaemic episodes. Consider consultation
if BGL remains less than 4 mmol/L and unable to
administer oral carbohydrates
Continue initial Mx and transport.
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Hypoglycaemia
CPG A0702
Status
?
Evidence of probable Hypoglycaemia
- e.g. Hx diabetes, unconscious, pale, diaphoretic

?
BGL > 4
Action
Assess
8
BGL
? BGL < 4 Responds to commands
BGL < 4 Does not respond to commands

?

Action
Action
Glucose 15g Oral
BLS
IV cannula in a large vein
Consider other causes of

altered conscious state
- e.g. stroke, seizure,

hypovolaemia
?
Adequate response
If unable to insert IV

Glucagon 1 iu IM
8 Assess
Consider Dextrose IV or
Glucagon 1 iu IM
8 Consider
Action
?
Adequate response
Action
Consider transport
Stop
Dextrose 10% 15g (150ml) IV

- Normal Saline 10ml flush
? Poor response
Action
? Status
Confirm IV patency
MICA Action
- GCS 15
?
Inadequate response
- GCS < 15 after 3/60
Action
Action
Cease Dextrose if still

being given
Repeat Dextrose 10%

10g (100ml) IV titrating
to Pt conscious state
- Normal Saline 10ml
flush
Hypoglycaemia CPG A0702
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Continuous Tonic-Clonic Seizures
CPG A0703
Special Notes
General Care
For seizures other than generalised tonic-clonic seizures,

Midazolam may only be administered following medical
consultation.
Frequent errors in drug dosage administration occur

within AV in this Guideline.
Seizures may not always present with tonic-clonic

limb activity, e.g. unconsciousness with flicking eye
movements (nystagmus) may indicate ongoing seizure
activity.
If a single seizure has spontaneously terminated continue

with initial management and transport.
If Pt has a past history of seizures and refuses transport,

leave them in the care of a responsible third party.
Advise the person of the actions to take for immediate
continuing care if symptoms reoccur, and the importance
of early contact with their primary care physician for
follow-up.
Ensure accurate dose calculation and confirm with

other Paramedics on scene.
Midazolam can have pronounced effects on BP,
conscious state and airway tone.
Calculate the dose each time as stock strength may

change with manufacturer and familiarity may lead to
errors.
Adult Dosage Calculation for Midazolam IM

Strength required
Stock strength
x Stock volume
e.g. 80kg Pt @ 0.1mg/kg = 8mg

8mg
x 3ml
15mg
Dose required
8mg
x 1ml
5mg
= 1.6ml
Stock strength 15mg/3ml
same as
8mg
x 2ml
10mg
0.8
1.6ml
x 2ml
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Continuous Tonic-Clonic Seizures

Status
?
CPG A0703
Assess
/ Manage
Continuous recurrent seizures
Protect Pt
Consider other causes e.g. hypoglycaemia
Continuously monitor airway

and ventilation - assist as required
Consider Pts own management

plan and treatment already given
? Continuous Tonic-Clonic Seizure
Ensure accurate dosage - 1/2 dose for age > 60 yr
Action
Age > 60 - Midazolam 0.05mg/kg IM (max. single dose 5mg)
Age < 60 - Midazolam 0.1mg/kg IM (max. single dose 10mg)
? Seizure activity ceases
? Seizure activity continues > 5/60
? Seizure activity continues >10/60
Action
- IV access / accreditation
- No IV access / no accreditation
BLS
Action
Monitor airway and BP
Midazolam 0.05mg/kg IV
- Repeat 0.05mg/kg IV @ 2 - 5/60 as required
- max. combined dose IM + IV 0.25mg/kg
Repeat original Midazolam IM

dose once only
Consult for further doses
Monitor airway and BP

Action
Consult for further doses
Consider intubation as per CPG A0302

? Status
Stop
8 Assess
8 Consider
Pancuronium contraindicated
Action
MICA Action
Continuous Tonic-Clonic Seizures CPG A0703
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Anaphylaxis
Special Notes
All Pts with suspected anaphylaxis must be transported

to hospital regardless of the severity of their presentation
or response to management.
Angio-oedema (vascular oedema) leads to increased
tissue fluid, presenting as swelling, upper airway
obstruction (throat tightness), orbital oedema and other
systemic signs of swelling.
Identify history of exposure to substances known
to cause anaphylactic reaction, e.g. recent insect
bite, medications, exposure to food known to cause
anaphylactic reaction and presenting with evidence of
systemic involvement.
Research indicates most deaths from anaphylaxis

occurred with a delay in administration of Adrenaline
in severe reactions.
CPG A0704
General Care
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Anaphylaxis
CPG A0704
? Status
Evidence of anaphylaxis
Exposure to foreign antigen
Assess for Systemic Involvement

8
Angio-oedema or
Urticaria or
Plus at least one

of these
GIT disturbance
? Mild
Respiratory distress / bronchospasm or

Less than Adequate Perfusion or
Altered Conscious State
? Moderate
? Severe
No Physiological Distress
< Borderline to Inadequate Perfusion
Extremely Poor Perfusion
Local allergic reaction

e.g. red rash / itchy
Action
Action
Monitor Pt for cardiac arrhythmias
Treat as per Moderate
Adrenaline 300mcg IM (1 : 1,000)

- Repeat 300mcg IM @ 5/60 until
satisfactory results or side effects occur
Adrenaline 50 mcg IV (1 : 10,000)

- Repeat 50 - 100 mcg IV @ 1/60 until
satisfactory results or side effects occur
Treat bronchospasm as per A0601 Asthma
IV fluid as per CPG A0801 Hypovolaemia
Consider fluid as per CPG A0801

Hypovolaemia
Action
BLS
? Status
Assess Physiological Distress

8
Stop
8 Assess
8 Consider
Action
MICA Action
If no IV access Rx as per Moderate

If no IV access consider IO
If intubated
- Adrenaline 200mcg via ETT @ 5/60
Anaphylaxis CPG A0704
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Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic
CPG A0705
Special Notes
General Care
Any infusions established under this guideline must be

clearly labelled with the name and dose of any additive
drugs and their dilution
Adrenaline infusion > 50mcg/min may be required

to manage these Pts. Ensure delivery system is fully
operational (e.g. tube not kinked, IV patent) prior to
increasing dose.
Sepsis Criteria are relevant in the presence of an

infection or severe clinical insult such as multi trauma
leading to SIRS (Systemic Inflammatory Response
Syndrome).
2 or more of:
- Temp > 38 or < 36
- HR > 90
- RR > 20
- BP < 90
Unstable Pts may require bolus Adrenaline concurrently

with the infusion.
Adrenaline infusion

3mg Adrenaline added to make 50ml with 5%

Dextrose or Normal Saline
1ml/hr = 1mcg/min
If sepsis suspected and prolonged transport times exist

(>1 hour) consider Ceftriaxone 1g IV (consult)
Dexamethasone is no longer indicated in the
management of the Pt with sepsis
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Inadequate Perfusion Non-cardiogenic / Non-hypovolaemic
CPG A0705
8
Assess
Status
?
Suspected Sepsis
Perfusion status
Other causes of non-cardiogenic,

non-hypovolaemic shock
Respiratory status
Sepsis criteria
Other possible causes
?
Inadequate or Extremely poor perfusion
Action
If sepsis is suspected and chest is clear and MICA is not

immediately available:

- Confirm request for MICA support
- Normal Saline up to 20ml/kg IV over 30 mins.
Normal Saline up to 20ml/kg IV
?
Adequately Perfusion
?
Action
Action
BLS
Adrenaline infusion (3mg/50ml D5W/Normal Saline) commencing @ 5mcg/min. (5ml/hr)
Transport
- Increase by 5mcg/min. @ 2/60 until adequate perfusion or side effects
- If poor perfusion persists, reassess Pt and delivery system prior to increasing rate beyond 50mcg/min
- If syringe pump unavailable/malfunction
- repeat 10mcg @ 2/60 until adequate perfusion or side effects
- If poor response
- Adrenaline 50 - 100mcg IV as required
- NB. Doses > 100mcg may be required
If chest clear, continue Normal Saline 20ml/kg IV boluses as per CPG A0801 Hypovolaemia
Non-cardiogenic / Non-hypovolaemic CPG A0705
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
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Version 3 - 01.011.05 Page 1 of 2
Meningococcal Septicaemia
CPG A0706
Special Notes
General Care
Meningococcal is transmitted by close personal

exposure to airway secretions/droplets.
Ceftriaxone preparation
Ensure face mask protection especially during

intubation/suctioning.
Ensure medical follow up for staff post exposure.
Dilute Ceftriaxone 1g with 9.5ml of water for

injection and administer 1g IV over approximately
2/60.
If unable to obtain IV access, or not accredited in

IV cannulation, dilute Ceftriaxone 1g with 3.5ml 1%
Lignocaine HCL and administer 1g IM into the upper
lateral thigh or other large muscle mass.
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Version 3 - 01.011.05 Page 2 of 2
Meningococcal Septicaemia
CPG A0706
Status
?
Suspected meningococcal septicaemia

PPE
Confirm Meningococcal Septicaemia

8
Typical purpuric rash

Septicaemia signs
- Fever, rigor, joint and muscle pain
- Cold hands and feet
- Tachycardia, hypotension
- Tachypnea
Meningeal signs
- Headache, photophobia, neck stiffness
- Nausea and vomiting
- Altered consciousness
?
IV Access
?
No IV Access
Action
Ceftriaxone 1g IV
- Dilute with water for injection to
make 10ml
- Administer slowly over 2/60
? Status
Stop
8 Assess
8 Consider
- Unable to gain
- Not IV accredited
Action
Ceftriaxone 1g IM
- Dilute with 3.5ml 1% Lignocaine HCL to
make 4ml
- Administer into upper lateral thigh or other
large muscle mass
Action
MICA Action
Meningococcal Septicaemia CPG A0706
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Drug Overdose
CPG A0707
General Care
General Care
Provide Supportive Care (all cases)
Confirm clinical evidence of substance use or exposure
- Provide appropriate airway management and

ventilatory support
- Identify which substance/s are involved and collect if

possible.
- If Pt is in an altered conscious state, assess

BGL and if necessary manage as per
CPG A0801 Hypoglycaemia
- Identify by which route the substance/s had been

taken (e.g. ingestion).
- If Pt is bradycardic with poor perfusion manage as

per CPG A0402 Bradycardia
- Establish the amount of substance/s taken.
- If Pt is inadequately perfused, manage as per

CPG A0801 Hypovolaemia
- Assess Pt temp. and manage as per

CPG A0901 Hypothermia / Cold Exposure, or
CPG A0902 Environmental Hyperthermia /
Heat Stress
- Establish the time the substance/s were taken.
- What were the substance/s mixed with when taken

(e.g.: alcohol, water)?
- What treatment has been initiated prior to Ambulance

arrival (e.g. induced vomiting)?
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Drug Overdose
? Status
CPG A0707
Status
?
8
Assess
Suspected overdose
Substance involved
?
Narcotics
?
TCA Antidepressants
?
Sedatives
?
Psychostimulants
e.g. -
-
-
-

e.g. - Amitriptyline
- Nortriptyline
- Dothiepin
e.g. -
-
-
-
e.g. -
-
-
-
Stop
Heroin
Morphine
Codeine
Other narcotic
preparations
8 Assess
8 Consider
Action
MICA Action
GHB
Alcohol
Benzodiazepines
Volatile agents
Cocaine
Amphetamines
Ecstacy
PCP
Drug Overdose CPG A0707 101
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Overdose: Narcotics
CPG A0707
Special Notes
General Care
Narcotics may be in the form of IV preparations such

as Heroin or Morphine and oral preparations such as
Codeine, Endone, MS Contin. Some of these drugs
also come as suppositories.
If inadequate response after 10/60, Pt is likely to require

transport without delay.
Not all narcotic overdoses are from IV administration of

the drug.
- Maintain general care of the unconscious Pt and

ensure adequate airway and ventilation.
- Consider other causes e.g. head injury,
hypoglycaemia polypharmacy overdose.
- Beware of Pt becoming aggressive.
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Overdose: Narcotics
? Status
CPG A0707
Possible narcotic overdose
Stop
Ensure personal / crew safety
Scene may have concealed syringes
Assess evidence of narcotic overdose

8

- Altered conscious state

- Pin point pupils
- Respiratory depression
- Track marks
- Substance involved
- Exclude other causes (inc. no obvious head injury)
? Narcotic overdose
Action
Assist and maintain airway/ventilation

Naloxone 1.6mg 2mg IM
? Adequate response
? Inadequate response after 10/60
Action
Action
BLS
Naloxone 0.8 mg IM
Consider transport
Consider airway Mx CPG A0301 Laryngeal Mask

Naloxone 0.8 mg IM or IV
Consider airway Mx
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Overdose: Narcotics CPG A0707 103
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Overdose: Tricyclic Antidepressants (TCA)
CPG A0707
Special Notes
Special Notes
Signs and Symptoms of TCA Toxicity
ECG changes
Mild to moderate OD
- Drowsiness, confusion
- Tachycardia
- Slurred speech
- Hyperreflexia
- Ataxia
- Mild hypertension
- Dry mucus membranes
- Respiratory depression
ECG changes include prolonged PR, QRS and QT intervals

associated with an increased risk of seizures if QRS > 0.10
sec. and ventricular arrhythmias if QRS > 0.16 sec.
How to measure a QT interval is shown below.
Severe toxicity (within 6hr. ingestion)

- Coma
- Respiratory depression/hypoventilation
- Conduction delays
- Premature Ventricular Contractions (PVCs)
- SVT
- VT
- Hypotension
- Seizures
- ECG changes
This could lead to aspiration, hyperthermia,

rhabdomyolysis and acute pulmonary oedema.
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Overdose: Tricyclic Antidepressants (TCA)

? Status
CPG A0707
Assess
8
Possible TCA overdose
Substance involved
Perfusion status
ECG criteria
? No toxicity
? Signs of TCA toxicity
Action
BLS
Consider potential to develop signs of toxicity
Any of the following

- Less than adequate perfusion
- QRS > 0.12 sec. (> 0.16 sec. indicates severe toxicity)
- QT prolongation (> 1/2 R-R interval)
Stop
Amiodarone is contraindicated in the setting of confirmed or

suspected Tricyclic antidepressant medication overdose
Action
Sodium Bicarbonate 8.4% 100ml IV given over 3/60

- Repeat 100ml IV after 10/60 if signs of toxicity persist
- Severe cases may require continuing doses - Consult
Consider Intubation as per CPG A0302 Endotracheal

Intubation if signs of toxicity and GCS < 10 persist after
initial Mx
- Hyperventilate with 100% O2 - rate 20 - 24bpm
- EtCO2 target 20-25mmHg if intubated
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Overdose: Tricyclic Antidepressants (TCA) CPG A0707 105
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Overdose: Sedative Agents/Psychostimulants
CPG A0707
Special Notes
Special Notes
If Pt still refuses transport after repeating the advice for

transport using friend/relative assistance, advise the Pt
and responsible third person of follow-up, counselling
facilities and actions to take for continuing care if
symptoms reoccur.
If a young person makes it known they are involved

with DHS Child Protection and they give permission,
an attempt should be made on their behalf to contact
the young persons Child Protection practitioner,
Region or Child Protection After Hours Service (24hr.
on 131 278) to advise of the Ambulance attendance
and treatment. The intent is to make arrangements
for ongoing care for this Pt. Such contact is best
made through the senior clinician in operations/
communication centre.
For young persons, Paramedics should strongly

encourage them to make contact with a responsible
adult.
Paramedics should call the Police if in their professional

judgement there appears to be factors that place the Pt
at increased risk, such as:
- is subject to violence (e.g. from a parent, guardian or
care giver)
- is likely to be, or is in danger of sexual exploitation

In particular for children where:
- the supply of drugs appears to be from a parent/

guardian/care giver.
- there is other evidence of child abuse/maltreatment

or evidence of serious untreated injuries.
If Pt claims to have taken an overdose of a potentially

life-threatening substance then they must be
transported to hospital. Police assistance should be
sought to facilitate this as required.
Documentation of refusal and actions taken must be
recorded on the PCR.
In such situations if the Police are contacted, they

will notify Department of Human Services Child
Protection if they believe the young person is in need
of protection.
Hyperthermic psychostimulant OD

In hyperthermic psychostimulant OD the trigger point

for intervention in the Mx of agitation/aggression is
lowered. Sedation should be initiated early to assist
with cooling and avoid further increases in temp.
associated with agitation.
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Overdose: Sedative Agents/Psychostimulants

? Status
CPG A0707
Assess
8
Sedative agents
Substance involved
Psychostimulants
? Sedative agents
? Psychostimulants
Action
Action
Be aware for potential for agitation / aggression

particularly in GHB / volatile substance abuse
Be aware of potential for violent behaviour, particularly with

Methamphetamines
Pt may require airway management
Reduce stimulus by calming and controlling Pt environment
Manage agitation / aggression as per CPG A0708
Manage seizures as per CPG A0703 Continuous

Tonic-Clonic Seizures
The Agitated Patient
Manage cardiac chest pain as per CPG A0401 Acute

Coronary Syndrome
Manage temp. as per CPG A0902 Hyperthermia/

Heat Stress or A0901 Hypothermia / Cold exposure
Manage agitation / aggression as per CPG A0708 The

Agitated Patient
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Overdose: Sedative Agents/Psychostimulants CPG A0707 107
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CPG A0708
Special Notes
General Care
This Guideline does not apply to Pts who have been

recommended for transport under the Mental Health
Act. If sedation is required in these circumstances then
the Act requires that this only be administered by a
prescribed Medical Practitioner or Registered Nurse.
Paramedic safety is to be considered paramount at all

times. Do not attempt any element of this Guideline
unless all necessary assistance is available.
This Guideline is appropriate for Pts under section 10

ofthe Mental Health Act.
Provide airway management appropriate to the clinical

condition, administer oxygen to all Pts and assist
ventilation as required.
The indications for the use of sedation and/or restraint

must be clearly documented on the PCR.
Mechanical restraint may also be utilised without the
use of sedation in circumstances where the Pt will not
sustain further harm by fighting against the restraints.
Mechanical restraints must be removed if there is
any indication that the restraint is compromising the
provision of supportive care.
The type of restraint used and its time of application

and/or removal must be clearly documented on the
PCR.
Hyperthermia
Sedation should be initiated early in hyperthermic Pts
who have been using psychostimulants to assist with
cooling and avoid further increases in temp. secondary
to agitation.
Provide supportive care in all cases where sedation

administered.
If less than adequate perfusion manage as per CPG

A0705 Inadequate Perfusion (Non-cardiogenic /
Non-hypovolaemic).
Continue to assess Pt temp. and manage as per CPG

A0902 Environmental Hyperthermia / Heat Stress,
or CPG A0901 Hypothermia / Cold Injury.
If not already completed, ensure that all possible clinical

causes of agitation are assessed and managed by the
appropriate Guideline.
Head Injury
In Pts with mild to moderate head injury (GCS 10 - 14),
sedation cannot be given without medical consultation
with a Major or Regional Trauma Service.
The Agitated Patient CPG A0708 109
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Status
?
CPG A0708
Stop
Agitated Pt
Observe for and manage as appropriate

- Hazards
- Body fluids
- Violence
- Sharps
- Clear egress
- Reduce stimuli
- Paramedic safety is paramount
Agitated Pt
?
Action

Communicate with Pt
- Avoid confrontational behaviour
- Gain Pt co-operation for assessment
- Utilise verbal de-escalation strategies
8
Assess/Consider
Assess and manage clinical causes (as far as possible)

- Hypoglycaemia
- Drug withdrawal
- Hypoxia
- Intracerebral pathology
- Post-ictal
- Mild to moderate head injury
- Drug intoxication (consult with MTS for sedation)
(initiate sedation early
- Acute psychiatric condition
in hyperthermic
psychostimulant Pt)
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Able to Mx without restraint/sedation
?

Action
Requires restraint/sedation
?
Does not respond to verbal de-escalation
Mx cause as appropriate
Clinical causes have been excluded
Continue to treat cause of agitation
Pt risk to themselves or others

- e.g. combative, agitated or aggressive
Beware Pt condition may change and agitation

increase requiring restraint/sedation
Stop
Ensure Pt is not recommended under the Mental Health Act

- Sedation by Paramedics is contraindicated for these Pts
Ensure sufficient physical assistance
Reduced sedation dose for age / BP
Mild to moderate head injury GCS 10 - 14 (consult for sedation)

Action
Age > 60 or BP < 100

- Midazolam 0.05mg/kg IM (max. 5mg per dose)

- Repeat initial dose @ 10/60 IM (max. 4 doses) as required
Age < 60 and BP > 100
- Midazolam 0.05 - 0.1mg/kg IM (max. 10mg per dose)

- Repeat initial dose @ 10/60 IM (max. 4 doses) as required

Action
Transport to appropriate destination
Ensure sufficient assistance in transit
Provide early notification to receiving hospital
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Apply mechanical restraint devices if required
Above doses may be given IV and repeated @ 5/60 as required

IM injections may be indicated until IV access has been established
The Agitated Patient CPG A0708 111
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Organophosphate Poisoning
CPG A0709
Special Notes
General Care
Notification to receiving hospital essential to allow for

Pt isolation.
Where possible, remove contaminated clothing and

wash skin thoroughly with soap and water.
The key word to look for on the label is

anticholinesterase. There are a vast number of
organophosphates which are used not only used
commercially but also domestically.
If possible minimise the number of staff exposed.
If a potential contamination by a possible

organophosphate has occurred, the container
identifying trade and generic names should be identified
and the Poisons Information Centre contacted for
confirmation and advice.
Attempt to minimise transfers between vehicles.
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CPG A0709
? Status
Possible organophosphate exposure

Stop
Avoid self contamination - wear PPE

Pt decontamination if possible
Confirm evidence of suspected poisoning

8
Cholinergic effects: salivation, bronchospasm,

sweating, nausea or bradycardia
+
Plus
The key word to look for on the label is

anticholinesterase
? No excessive cholinergic effects

Action
8 Evidence of excessive cholinergic effects

Salivation compromising the airway or
bronchospasm and /or
Bradycardia with Inadequate or Extremely

Poor Perfusion
? Excessive cholinergic effects
Action
Transport to nearest appropriate hospital
Monitor for excessive cholinergic effects
Atropine 1200mcg IV
- Repeat 1200mcg IV @ 5/10 until excessive cholinergic effects resolve
Consult with receiving hospital for further management if required
The use of Suxamethonium is contraindicated in Pts with suspected

? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Organophosphate Poisoning CPG A0709 113
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Autonomic Dysreflexia
Special Notes
Transport the Pt even if the symptoms are relieved

as this presentation meets the criteria of Autonomic
Dysreflexia, a medical emergency that requires
identification of probable cause and treatment in
hospital to prevent cerebrovascular catastrophe.
CPG A0710
General Care
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Autonomic Dysreflexia
CPG A0710
? Status
Confirm Autonomic Dysreflexia

8
Possible autonomic dysreflexia
Previous spinal cord injury at T6 or above

- Severe headache
- Systolic BP > 160
Identify & treat possible causes - remove the stimulus
If distended bladder (common), ensure indwelling catheter is not kinked

Manage pain, e.g. fractures, burns, labour
? If systolic BP remains > 160
Action
GTN 300mcg S/L/Buccal (nil prev. admin.) or

GTN 600mcg S/L/Buccal
? Adequate response
? Inadequate response - BP remains > 160
Action
Action
Repeat initial dose of GTN @ 10/60 until either:

- Symptoms resolve
- Onset of side effects
- BP < 160
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Autonomic Dysreflexia CPG A0710 115
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Suspected Stroke or TIA
CPG A0711
Special Notes
General Care
Suspected stroke is a time critical emergency early

assessment and exclusion of stroke mimics is important
Symptom onset time is taken from when last seen
symptom free (e.g. if wakes with symptoms then time
Pt went to bed)
Treatment times from symptom onset are:
- thrombolysis up to 4.5 hrs
Diagnosing and managing stroke Pts with thrombolysis
is a priority over seeking neurosurgical support.
Urgent secondary transfer of stroke Pts to a centre
with Stroke Unit Caremay be organized and involve
theClinician, AAV / ARV
TIA can only be suspected if signs/symptoms
completely resolve, otherwise Pt should be treated as a
suspected stroke.
TIA is often a sign of a impending stroke all TIAs
should be conveyed to hospital for investigation.
Approximately 15% of strokes are intracranial
haemorrhage (ICH). These Pts have potential for rapid
deterioration.
Intracranial haemorrhage can be suspected where:
- GCS < 10 and the Pt is not alert
- The Pt complained of severe headache
- Nausea and vomiting is present
- Slow pulse and hypertension is noted
- Pupil abnormalities are noted
- Abnormal patterns of respiration are noted
MASS Melbourne Ambulance Stroke Screen.
Validated criteria used in prehospital stroke assessment.
Intubation by MICA paramedics should be considered

where there is difficulty maintaining adequate airway,
oxygenation and ventilation. Intubation should not be
considered as a mandatory practice in management of
all these Pts. Time to hospital versus time to undertake
the procedure should be considered.
Gagging should be avoided in the management of
the non traumatic intra-cranial event Pt. The effect of
gagging may vary in its detriment compared to the
traumatic head injured Pt.
The use of longer acting muscle relaxants post

intubation is not as essential in the suspected stroke Pt
as it is with head trauma. Sedation alone is preferred
unless gagging becomes problematic. They should not
be used following evidence of seizure activity without
significant head injury.
Anti-emetics have the potential to cause drowsiness.

Their use must be balanced against a potential
reduction in conscious state in these Pts. The use of
Stemetil is indicated as an analgesia adjunct for the
management.of severe headache. It is unlikely to have a
beneficial effect for intracranial haemorrhage/SAH.
Oxygen therapy should be reserved for hypoxic Pts with
a SpO2 <95%. The use of routine oxygen therapy is not
recommended.
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Suspected Stroke or TIA
CPG A0711
Status
?
8
Assess
8
Stroke Mimics
Suspected stroke or TIA
Symptom onset
Intoxication drug/
time
alcohol
8
Co-morbidities
Middle ear disorder
Dementia
Migraine
Significant pre-existing
Stroke Mimics
Hypo/hyperglycaemia
Subdural haematoma
Co-morbidities
Seizures
Sepsis
Brain tumour
Electrolyte
Syncope
Action
Action
In the setting of normal BGL, a finding of one or more of the
Provide analgesia as per CPG A0501 Pain Relief: Severe Headache
? Stroke signs and symptoms

Facial Droop Pt shows teeth
or smiles
Speech
Hand grip
Blood
glucose
The Pt repeats
You cant
teach an old
dog new tricks
Treat sustained seizure activity as per CPG A0703 Continuous Tonic
Normal - both
sides of face
move equally
Abnormal - one side

of face does not move
as well as the other
Normal - the
Pt says the
correct words,
no slurring
Abnormal - the Pt slurs

words, says the wrong
words, or is unable to
speak or understand
Test as for GCS Normal - equal Abnormal - unilateral

grip
weakness
Test for BGL
BLS maintain adequate airway and ventilation
Manage symptomatically support affected limbs
symptoms below is indicative of stroke;

Findings
disturbances
? Management
? Assess for MASS criteria
Assessment
physical disability
Abnormal -if
Normal BGL
hypoglycemia
manage as per
CPG A0702
Hypoglycemia
Clonic Seizures
If GCS < 10 consider intubation as per CPG A0302 Endotracheal

intubation
? Transport
Action
Where Pt is unstable consider time to appropriate receiving hospital versus

rendezvous with MICA / AAV.
If Pt is stable with no significant co-morbidities, onset time <4.5
hours and transport time <one hour then transfer to the nearest hospital
providing thrombolysis or strokeunit care and notify of pending arrival.
If Pt does not meet criteria above then transport to a closer

centre preferably with stroke unit care / CT imaging.
If Pt deteriorates consider rendezvous with MICA / AAV
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Suspected Stroke or TIA CPG A0711 117
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Hypovolaemia
Special Notes
Titrate fluid administration to Pt response
Aim for HR < 100, BP > 100 if VSS altered
Consider establishing IV en route. Do not delay

transport for IV therapy.
Always consider tension pneumothorax, particularly

in the Pt with a chest injury not responding to fluid
therapy and persistently hypotensive
CPG A0801
General Care
Haemorrhage from Blunt trauma is not considered as

uncontrolled in the context of this guideline and should
be managed as defined within.
GI bleeding has potential to be uncontrolled in the
context of this guideline and should be considered as a
modifying factor.
Excessive fluid should not be given if spinal cord injury

is an isolated injury.
Clinical signs of significant dehydration include:
- Postural perfusion changes including tachycardia,

hypotension or dizziness
- Decreased sweating and urination
- Poor skin turgor, dry mouth, dry tongue

- Fatigue and altered consciousness
- Evidence of poor fluid intake compared to fluid loss

Dehydration in the hyperglycaemic Pt should be
managed under this guideline
Modifying factors
Complete spinal cord transection Rx as per CPG A0804 Spinal Injury

- P
t with isolated neurogenic shock can be given up to 500ml Normal Saline bolus to correct hypotension.
No further fluid should be given if SCI is the sole injury.
Chest injury Consider tension pneumothorax Rx as per CPG A0802 Chest Injury
Penetrating Trunk Injury, aortic aneurysm or uncontrolled haemorrhage.
- Accept palpable carotid pulse and transport immediately
GI bleeding consider lesser volumes of fluid and accepting a blood pressure of 80 100mmHg.
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Hypovolaemia
CPG A0801
Status
?
Evidence of hypovolaemia
Identify and manage:

- Haemorrhage, fractures, pain, tension pneumothorax, hypoxia
Stop
8
Assess
HR / BP
Consider modifying factors
- SCI, chest injury, penetrating trunk injury, AAA, uncontrolled external haemorrhage
? HR<100 BP>100
? Isolated Tachycardia
? Hypotension
Action
HR > 100 BP > 100
BP < 100
Fluid not required unless signs
Action
Action
of significant dehydration
? If significantly dehydrated
Action
Normal Saline up to 20ml/kg IV

over 30 minutes
? BP>100 HR<100
? BP<100 and/or HR>100
Action
Action
No further fluid required
Insert second IV
Repeat Normal Saline 20ml/kg
? If HR<100 BP>100
? HR>100 and/or BP<100

Action
Action
Repeat Normal Saline 20ml/kg
? BP remains < 100
No further fluid required
After 40ml/kg
? BP remains < 100
Action
After 40ml/kg
Consult with MTS
Action
If unavailable repeat
Consult with MTS
If unavailable repeat Normal Saline 20ml/kg IV
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Inadequate Perfusion Associated with Hypovolaemia CPG A0801 121
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Chest Injuries
Special Notes
CPG A0802
General Care
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Chest Injuries
CPG A0802
Status
?
8
Assess
Respiratory status
Chest injury
- Traumatic
- Spontaneous
- Iatrogenic
Type of chest injury
Action
Supplemental oxygen
Pain relief as per CPG A0501 Pain Relief

? Status
Position Pt upright if possible unless

perfusion is < adequate, altered
consciousness, associated barotrauma
or potential spinal injury
? Flail segment/Rib fractures
? Open chest wound
Action
Action
Signs of pneumothorax
May require ventilatory support

if decreased VT
3 sided sterile occlusive dressing
Action
Stop
8 Assess
8 Consider
? Pneumothorax
See CPG A0802
Action
MICA Action
Chest Injuries CPG A0802 123
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Chest Injuries
CPG A0802
Special Notes
General Care
In IPPV setting, equal air entry is NOT an exclusion

criteria for TPT.
Tension Pneumothorax (TPT)

- If some clinical signs of TPT are present and the Pt is
deteriorating with decreasing conscious state and/
or poor perfusion, immediately decompress chest by
inserting a long 14G cannula or Intercostal Catheter.
Chest injury Pts receiving IPPV have a high risk of

developing a TPT. Solution for poor perfusion in this
setting includes bilateral chest decompression.
Cardiac arrest Pts are at risk of developing chest injury

during CPR.
Troubleshooting
- Pt may re-tension as lung inflates if catheter kinks off.
- Catheter may also clot off. Flush with sterile Normal
Saline.
If a 14G Cannula is used initially, it should be replaced
with an intercostal catheter (if available) as soon as
practicable.

Insertion site for cannula/intercostal catheter

- Second intercostal space
- Mid clavicular line (avoiding medial placement)
- Above rib below (avoiding neurovascular bundle)
- Right angles to chest (towards body of vertebrae)
- If air escapes, or air and blood bubble through the

cannula/intercostal catheter, or no air/blood detected,
leave insitu and secure.
- If no air escapes but copious blood flows through the

cannula/intercostal Catheter then a major haemothorax
is present. Remove, then cover the insertion site.
Needle Test
- If TPT suspected, but the assessment is not obvious,
test for a TPT with a needle at least 45mm length (long
14/16G) attached to Normal Saline filled syringe.
- If needle test is suggestive of TPT, withdraw needle and

immediately decompress chest.
- If pneumocath not available, leave plastic cannula
in situ refer to appropriate CWI.
- If needle test is not suggestive of TPT, withdraw needle,

cover insertion site with a clear adhesive dressing and
circle the insertion site with a pen
- Be aware that a needle test for TPT can be prone to
false readings and does not exclude TPT in all cases.
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Chest Injuries
CPG A0802
Status
?
8
Assess
Pneumothorax
- Simple
- Tension
Criteria for Simple vs Tension

Pneumothorax
? Simple pneumothorax
? Tension pneumothorax (TPT)


- Unequal breath sounds in
spontaneously ventilating Pt
- Low SpO2 on room air
- Subcutaneous emphysema
Action
Continue BLS and supplemental O2
Monitor closely for possible development

of TPT
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Any of the following +/- signs of Simple Pneumothorax:

- Peak inspiratory pressure (ventilator) / stiff bag
- EtCO2
- Poor Perfusion or HR +/- BP
- Jugular Venous Pressure (JVP)
- Conscious state in the awake Pt
- Tracheal shift
- Low SpO2 on supplemental O2 (late)
Action
Chest decompression as per General Care S-Rural
Chest Injuries CPG A0802 125
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Traumatic Head Injury
CPG A0803
Special Notes
General Care
The Trauma Time Critical Guidelines require Pts with

Significant Blunt Trauma to a Single region to be triaged
to the highest level of care.
Dress open skull fractures/wounds with sterile combine

soaked in sterile Normal Saline 0.9%.
A Significant Blunt Trauma Head Injury can be

described as the following:
Blunt Head Trauma with or without Loss of

Consciousness/Amnesia and GCS 13 15 with any of:

ny Loss of Consciousness exceeding 5 Minutes

A
Skull Fracture (Depressed, Open or Base of Skull)
Vomiting more than once
Neurological Deficit
Seizure
Elderly Pts with standing height falls who meet no

other time critical criteria but are on anti-coagulant,
antiplatelet agents or have bleeding disorders should
not be underestimated. Transport to an appropriate
level of care.
Maintain manual in-line neck stabilisation and apply

cervical collar when convenient. If intubation is required,
apply cervical collar after intubation. Attempt to minimise
jugular vein compression.
Attempt to maintain normal temp.
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Traumatic Head Injury
CPG A0803
Status
?
Assess
8
Traumatic head injury
Time Critical Head Injury

Other Head Injury
?
Airway
Action
?
Ventilation
Action
?
Perfusion
Action
?
General Care
Action
If airway patent and VT

adequate (with trismus),
do not insert NPA
Ensure adequate
ventilation and
VT of 10ml/kg
If airway not patent and

gag is present, insert
NPA and ventilate
Maintain SpO2
> 95% and
treat causes of
hypoxia
Manage with Normal

Saline as per CPG A0801
Hypovolaemia (unless in the
setting of penetrating truncal
trauma or uncontrolled overt
bleeding)
Treat sustained seizure

activity with Midazolam
as per CPG A0703
Continuous Tonic
Clonic Seizures
If GCS < 10, regardless

of airway reflexes,
intubate as per CPG
A0302 Endotracheal
Intubation - RSI
Maintain EtCO2
at 30 - 35mmHg
Avoid hypo/
hypercapnia
If intubation is not

possible/ authorised and
gag is absent insert LMA
? Status
Stop
8 Assess
8 Consider
Aim for systolic BP > 120
After 40ml/kg reassess. If

systolic BP < 100, discuss
ongoing resuscitation with the
receiving Regional or Major
Trauma Service while continuing
to transport
If consult is unavailable
administer a further Normal
Saline 20ml/kg IV and
reassess
Action
MICA Action
Measure BGL and

rectify hypoglycaemia
as per CPG A0702
Hypoglycaemia
Triage to highest
level of care as per
Trauma Time Critical
Guidelines
If Pt does not meet

Trauma Time Critical
Guidelines criteria,
Triage Pt to next highest
or appropriate level of
trauma care
Severe Traumatic Head Injury CPG A0803 127
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Spinal Injury
CPG A0804
Special Notes
Special Notes
A cervical collar alone does not immobilise the cervical

spine. If the neck needs immobilising then the whole
spine needs immobilising. This may include the use
of head rolls or other approved proprietary devices
and the whole body immobilised on a spine board or
ambulance stretcher in a manner that is appropriate
for the presenting problem. A spine board must be
restrained to the ambulance stretcher during transport,
If a cervical collar is applied then it must be properly

fitted and applied directly to the skin, not over clothing
and not placing any pressure on the neck veins.
The head should not be independently restrained
In Pts with a diseased vertebral column, a lesser

mechanism of injury may result in SCI and should be
managed accordingly
Spinal immobilisation with neutral alignment may not
be possible in a Pt with a diseased vertebral column
with associated anatomical deformity and should be
modified accordingly e.g. position of comfort.
Spinal immobilisation is not without risk. Complications

may include head and neck pain, detrimental effects on
pulmonary function and subsequent neurological deficit
(particularly in the elderly).
Where there is no immediate risk to life and extrication

is required than an extrication device (e.g. KED) should
be considered.
Pts with a SCI may develop pressure areas within as

little as 30 min. following placement on a spine board
and the duration on a spine board must be noted on
the PCR. Effective padding should be applied to protect
pressure areas.
For transport times in excess of 60 min. consideration
should be given to removing the Pt from a spine board
and appropriately securing them to the ambulance
stretcher.
Pts with isolated neurogenic shock should be given a
small fluid bolus (up to 500ml Normal Saline IV) to
correct hypotension. No further fluid should be given if
SCI is the sole injury.
The Pt with multi trauma and SCI may not mount a

sympathetic response to hypovolaemia. Fluid should be
given based on estimated blood loss.
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Spinal Injury
CPG A0804
? Status
Assess
8
Potential or suspected spinal injury
Spinal column injury

Spinal cord injury
? If Pt Meets Major Trauma Criteria
? If Pt does not meet major trauma criteria
Action
Has any mechanism of injury with potential to cause spinal injury
Manage airway as appropriate
Action
Provide spinal immobilisation
If any of the following present provide spinal immobilisation
Administer pain relief as required as per
Increased Injury Risk

- Age > 55 years
- History of bone disease (e.g. osetoporosis, osteoarthritis,
rheumatoid arthritis or muscular weakness disease
(e.g. muscular dystrophy)
CPG A0501 Pain Relief
Manage hypovolaemia as per CPG A0801

Hypovolaemia
Transport without delay to an appropriate receiving
hospital in accordance with Trauma Triage Guidelines
Difficult Pt assessment
- Unconsciousness or any acute or chronic altered conscious
state (GCS<15) or period of loss of consciousness
- Drug or alcohol affected
- Significant distracting injury e.g. extremity fracture or dislocation
Actual evidence of structural injury
- Spinal column pain/bony tenderness
Actual evidence of spinal cord injury

- Neurological deficit or changes
- Manage as per emergent time critical trauma criteria
If none of the above present then spinal immobilization/

cervical collar not necessary
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
If any doubt exists as to history or the above assessment,

or if there is inability to adequately assess the Pt, provide
spinal immobilisation.
Clearance criteria within this guideline are not to be used for

paediatric Pts. No paediatric Pt should be spinally cleared
pre-hospital after major trauma. Apply all spinal care.
Spinal Injury CPG A0804 129
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Adult Burns
CPG A0805
Special Notes
General Care
All chemical burns should be irrigated for at least 20

min. Avoid flushing chemical onto uncontaminated
areas.
Burn Cooling
Remove clothing burnt or containing chemical or hot

liquid when safe to do so. Do not remove clothing
that adheres to underlying tissue. Jewellery should be
removed prior to swelling occuring
Volume replacement is for burn injury only. Manage
other injuries accordingly including requirement for
additional fluid. Electrical burns should receive fluid
therapy to maintain adequate renal perfusion.
Signs and symptoms of airway burns include:

vidence of burns to upper torso, neck and face

E
Facial and upper airway oedema
Sooty sputum
Burns occurring in an enclosed space
Singed facial hair (nasal hair, eyebrows, eyelashes,
beards)
- Respiratory distress (dyspnoea with wheeze present/
absent and associated tachycardia, stridor)
- Hypoxia (restlessness, irritability, cyanosis,
decreasedGCS)
Burn cooling should be for 20 min. Consider shorter

periods in large BSA burns where hypothermia may be
induced. Cooling may be completed prior to transport.
Cooling provided prior to ambulance arrival should be
included in the total cooling time.
Burn cooling should be with gentle running water that
is between 515C. Ice and ice water is not desirable.
Similarly, dirty (i.e. dam) water should be avoided given
the significant risk of infection introduction.
If running water is not available, cooling may be affected

by immersion of affected area in still water. This water
should be refreshed each few minutes to avoid it warming.
Maintaining normothermia is vital. Protect remainder of
Pt from heat loss where possible

- Assess temperature as soon as practicable and monitor

- Cover the Pt with blankets etc.
- Avoid Pt shivering.
Burn Dressings
Cling wrap is an appropriate burn dressing. It should be
applied longitudinally to allow for swelling. Cling wrap is
the preferred burns dressing for all burns.
Water gel dressings (e.g. Burnaid) may be considered

as a cooling agent where no other cooling method
exists. Cooling with water is the preferred method of
cooling. After prescribed cooling times remove and
replace with clingwrap dressing.
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Adult Burns
CPG A0805
Status
?
8
Assess mechanism of burn and burn injury
Evidence of burn injury
Airway injury
Mechanism of burn injury
Body surface area burnt
Severity of burn injury
Stop
Ensure safety and removal from burn mechanism

- Avoid chemical contamination or spreading to Pt unaffected areas
? Initial burn management
Action
Cool the burn, warm the Pt
Cool burn area refer general care notes
Protect remainder of patient from heat loss where possible

Provide analgesia as per CPG A0501 Pain Relief
Cover cooled burn area with appropriate dressing refer general care notes
? All other burn presentations
? Partial or full thickness burns >15% BSA
? Suspected airway burns
Action
Action
Action
Appropriate first aid
If total BSA is >15%
For Pts with GCS up to 15
Transport to appropriate facility
Normal Saline IV fluid replacement

- % burn surface area x pt. weight (kg) =
vol fluid (mls)
- given over 2 hours from time of burn
Consider intubation as per Endotracheal

Intubation CPG A0302
- Consult with Clinician
- Use RSI method unless contraindicated
Transport to an appropriate facility
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Adult Burns CPG A0805 131
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Adult Burns
Special Notes
CPG A0805
General Care
Transport
Any burns involving the face, hands, feet, genitalia,

major joints or circumferential burns of the chest or
limbs or involving >20% BSA require assessment by
a specialised Burns Service. For regional transfers this
may be via secondary transfer
Metropolitan:
All burns Pts who meet the time critical trauma
criteria should be transported to the Alfred Hospital in
preference if within 30 min. IF > 30 min. transport to
nearest alternative highest level of trauma service.
Rural:
Transport to highest designated trauma receiving centre
within 30 min.
In all cases of prolonged transport, consider alternative
air transport
In all cases, appropriate consultations should
occur andhospital notification provided
Adult Rule of Nines
expressed as a % of body surface area
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133
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Hypothermia/Cold Exposure
CPG A0901
Special Notes
General Care
Hypothermia is insidious and rarely occurs in isolation.

Where the Pt is in a group environment other members
of the group should be carefully assessed for signs of
hypothermia.
Shelter from wind in heated environment.
Arrhythmia in hypothermia is associated with

temp. below 33C.
Atrial arrhythmias, bradycardia, or atrioventricular block

do not generally require treatment with anti-arrhythmic
agents unless decompensated, and resolve on
rewarming.
Defibrillation and cardioactive drugs may not be
effective at temp. below 30C. VF may resolve
spontaneously upon rewarming.
The onset and duration of drugs is prolonged in

hypothermia and the interval between doses is
therefore doubled, for example doses of Adrenaline
become 6 minutely.
Remove all damp or wet clothing.
Gently dry Pt with towels / blankets.
Wrap in warm sheet / blanket - cocoon.

Cover head with towel / blanket - hood.
Use thermal / space / plastic blanket if available.
Only warm frostbite if no chance of refreezing prior to

arrival at hospital.
Assess BGL if altered conscious state.
Warmed fluid
Normal Saline warmed between 37 - 42C should be
given to correct moderate / severe hypothermia and
maintain perfusion if available. Fluid < 37C could be
detrimental to Pt.
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Hypothermia/Cold Exposure
CPG A0901
Status
?
Assess
8
Hypothermia
Mild Hypothermia
32 - 35C
Moderate Hypothermia 28 - 32C

Severe Hypothermia
< 28C
If alteration to Cardiac Arrest Mx required
? Non cardiac arrest
? Cardiac Arrest
Moderate/Severe Hypothermia < 28 - 32C
Warmed Normal Saline 10ml/kg IV

- Repeat 10ml/kg IV (max. 40ml/kg)
to maintain perfusion
Avoid drug Mx of cardiac arrhythmia
unless decompensated and until
rewarming has commenced
?
> 32C
Action
Standard Cardiac
Arrest Guidelines
? 30 - 32C
Action
Double dosage
intervals in
relevant cardiac
arrest Guideline
- Do not rewarm
beyond 33C if
ROSC
?
< 30C
Action
Continue CPR and rewarming

until temp. > 30C
One defibrillation shock only
One dose of Adrenaline
One dose of Atropine

One dose of Amiodarone
Withhold NaHCO3 8.4% IV
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Hypothermia/Cold Exposure CPG A0901 135
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Environmental Hyperthermia Heat Stress
CPG A0902
Special Notes
General Care
Pt body temperatures of < 40C, can normally be

managed with basic cooling techniques alone
During cooling, the Pt should be monitored for the

onset of shivering. Shivering may increase heat
production and cooling measures should be adjusted
to avoid its onset.
Be wary of fluid volumes in renal dialysis Pts causing

fluid overload. Administer judicious increments with
volumes not usually exceeding 10 ml/kg.
This guideline is not intended for the management the

febrile Pt due to infection.
Gentle handling of the Pt is essential. Position flat or

lateral and avoid head up position to avoid causing
arrhythmias.
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Environmental Hyperthermia Heat Stress

? Status
CPG A0902
Assess
8
Hyperthermia / Heat stress
Accurately assess temperature

BGL if altered conscious state
Perfusion status & dehydration
? Requires active cooling

Action
Cooling techniques - initiated and maintained until temp. is < 38C

- Shelter / remove from heat source
- Remove all clothing except underwear
- Ensure airflow over Pt
- Apply tepid water using spray bottle or wet towels
If significant dehydration or poor perfusion, treat as per CPG A0801 Hypovolaemia
Provide initial Normal Saline 20ml/kg IV and reassess VSS and temp
- If Pt. temp > 40C use cool fluids if available (stored usually at < 8C)
Continue to administer Normal Saline if pt remains poorly perfused or significantly dehydrated

- If cool fluids intiated, return to ambient temp once Pt temp is < 39C
Treat low BGL as per CPG A0801 Hypoglycaemia
Airway and ventilation support with 100% O2 as required
? Adequate response
Action
? Assess
Severe cases - Temp. > 39.5C
BLS
GCS < 10
Transport
Action
Consider intubation as per CPG A0302

If intubated, sedation and paralysis essential to

prevent shivering and reduce heat production
? Status
Stop
8 Assess
8 Consider
Action
MICA Action
Environmental Hyperthermia Heat Stress CPG A0902 137
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Oxygen Use in Emergency Presentations

Oxygen Use in Emergency Presentations CPG A0001

Oxygen Use in Emergency Presentations

Pulse oximetry may be particularly unreliable in Pts with

Oxygen exchange is at its greatest in the upright

Pulse oximetry can be unreliable in the setting of severe

Ensure the Pts fingertips are clean of soil or nail polish.

All Pts with suspected carbon monoxide poisoning or

Poisoning with substances other than carbon monoxide

Take due care with Pts who show evidence of anxiety/

Some Pts may experience dryness of the nasal mucosa

Oxygen Use in Emergency Presentations

Assess & monitor SpO2 continuously

Titrate O2 flow to SpO2

Cardiac Arrest or Resuscitation

Major Trauma/Head Injury

harmful in the COPD Pt at risk of

Carbon Monoxide Poisoning

hypercapnic respiratory failure

Titrate O2 flow to SpO2 of 88-92%

If Pt deteriorates or SpO2 remains < 85%

if no critical illness present

If Pt deteriorates or SpO2

- Consider ETT as per CPG A0302

Oxygen Use in Emergency Presentations CPG A0001

Primary Survey / Life Threat Status

Standard Precautions: Gloves, goggles, PPE,

Rapport, Rest and Reassurance

In order of clinical need

Clinical Approach CPG A0101

Vital Sign Survey

Determine time criticality to

Assessment Tools / Secondary Survey

The combination of subjective (PHx, Hx, Meds) and

Confirm clinical reasoning

Further Sitrep / Resource requirements as required

Provide MICA therapies in the most timely manner

Clinical Approach CPG A0101

Perfusion and Respiratory Assessment

These observations and criteria need to be taken in

The ability of the cardiovascular system to provide

Other factors may affect the interpretation of the

The Perfusion Status Assessment table represents a

The Respiratory Status Assessment table represents

Perfusion Status Assessment

Alert and orientated

Alert and orientated

Either alert and orientated

Perfusion Criteria CPG A0102

Respiratory Status Assessment

Severe Distress (Life Threat)

General Appearance Calm, quiet

Calm or mildly anxious

Distressed, anxious, fighting to

Short phrases only

Words only or unable to speak

Asthma: mild expiratory

Asthma: expiratory wheeze +/

LVF: may be some fine

LVF: crackles at bases to mid-zone

Regular even cycles

Asthma: may be slightly

Titrate O2 flow to SpO2

Titrate O2 flow to SpO2 of 88-92%

If Pt deteriorates or SpO2

- Consider ETT as per CPG A0302

- Suspected spinal cord injury

- Burns > 20% or involving respiratory tract

- Serious crush injury

- Major compound fracture or open dislocation

- Fracture to two or more of the following:

- Suspected spinal cord injury

- Burns > 20% or involving respiratory tract

- Serious crush injury

- Major compound fracture or open dislocation

- Fracture to two or more of the following: