Cpg 2013 pocket clinical

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CLINICAL PRACTICE GUIDELINES FOREWORD

This is the pocket edition of the clinical practice guidelines, developed for the ambulance sector of New Zealand. It is a summary of the comprehensive version

These clinical practice guidelines expire at the beginning of 2016 at which time they will be formally updated and reissued. They remain the intellectual property of the National Ambulance Sector Clinical Working Group and may be recalled or updated at any time. Any persons other than WFA personnel using these clinical practice guidelines do so at their own risk. NASCWG and WFA will not be responsible for any loss, damage or injury suffered by any person or persons as a result of, or arising out of, the use of these clinical practice guidelines by persons other than WFA personnel

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These clinical practice guidelines are for use by Wellington Free Ambulance (WFA) personnel, with current authority to practice, when providing clinical care to patients on behalf of WFA. They have been developed by the National Ambulance Sector Clinical Working Group (NASCWG) and are issued to individual clinical personnel by the Medical Director of Wellington Free Ambulance

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NASCWG members at the time of publication ∙ Dr Andy Swain, Medical Director,Wellington Free Ambulance ∙ Mark Bailey, Clinical Effectiveness Manager,WFA ∙ Dr Alison Drewry, Director Defence Health, NZ Defence Force ∙ Dr Craig Ellis, Deputy Medical Director, St John ∙ Dr Tony Smith (Chair), Medical Director, St John ∙ Steve Mann, Clinical Education Delivery Manager, St John

Comments and enquiries Clinical personnel should contact their appropriate Manager. Others wishing to make formal comments or enquiries should contact Chair of the National Ambulance Sector Clinical Working Group c/o Ambulance New Zealand, PO Box 714,Wellington

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CPG VERSION CONTROL - MARCH 2014 ISSUE This is the CPG version control page. This page will be updated to indicate which pages in the CPGs have been updated and which version is the most current All pages should be dated March 2014

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1.2 AUTHORITY TO PRACTICE Ambulance and Defence Force personnel cannot legally supply or administer prescription medicines to patients unless they have authority to practice, or they are Registered Health Practitioners with this ability described within their scope of practice by their registering authority. In addition, services restrict the use of some items of clinical equipment and some clinical interventions to specific personnel Authority to practice is the granting of authorisation to a specific person to supply or administer prescription medicines to patients, or to use specific items of clinical equipment, or to perform specific interventions under the oversight of the medical director. All clinical care provided to patients (beyond first aid) must comply with these clinical practice guidelines. Personnel may not use these clinical practice guidelines without individual authority to do so Authority to practice is granted at a specified practice level (listed on pages 14 and 15). Under each practice level is listed a delegated scope of practice. A delegated scope of practice defines the medicines and interventions that designated personnel may administer or use when providing patient care. Ordinary interventions not formally described within any delegated scope of practice can be performed by all personnel.

Colour bars to the left of treatment steps in each guideline serve as a reminder of the minimum practice level for that intervention.These bars correspond to colours in the top row of the table on pages 14 and 15 Page 13

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2.1 GENERAL PRINCIPLES OF TREATMENT

Although not listed with each section, all patients require a primary and secondary survey with appropriate intervention as required Unless otherwise specified, the medicine doses and fluid volumes described in these guidelines are for adults and children weighing 50kg or more.

See the paediatric pages for paediatric dosing All medicines have universal contraindications and as such they are not repeatedly listed with each individual medicine. These are: ∙ Known allergy to the medicine or its constituents ∙ Pregnancy (particularly first trimester) is a relative contraindication for most medicines and as such they should not be administered unless there is a very strong indication to do so Specific contraindications are listed in section 11 of this book, while cautions are listed in the comprehensive edition. Most sections contain alerts to some (generally not all) contraindications and cautions to assist personnel With the exception of sodium bicarbonate, drugs that are indicated for IV administration may be administered IO if such access is available

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2.2 OXYGEN ADMINISTRATION

Few sections contain specific instructions on oxygen and clinical judgement is required. Oxygen does not necessarily provide benefit and should usually only be given if the patient has: • An SpO2 less than 94% on air (exception – see CORD section) or • Airway obstruction or • Respiratory distress (exception – see CORD section) or • Shock or • Inability to obey commands from TBI or • Smoke inhalation

The oxygen flow rates to be used are: • Nasal prongs 1-4 L/min • Simple mask 6-8 L/min • Nebulised mask 8 L/min • Reservoir mask 10-15 L/min • Manual ventilation bag 10-15 L/min

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Use the simplest device and lowest flow rates to achieve the desired SpO2. If pulse oximetry is unreliable or unavailable, give oxygen as appropriate based on the above bullet points

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2.4 STATUS CODES Status codes are a numerical means of describing an assessment of the severity of a patient’s condition They are qualitative, require clinical judgement and are allocated to patients after taking into account their illness or injuries, their vital signs and the potential threat to their life

Status Status zero Status one Status two Status three Status four

Condition Dead Immediate threat to life Potential threat to life Unlikely threat to life No threat to life

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Triage tag Black/white Red Orange Green Green

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They are not altered by the mechanism of injury, the physical environment (e.g. trapped or not trapped) or the age of the patient

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All patients with head trauma causing loss of consciousness should be advised that they need to be transported to the emergency department for observation. Where a patient refuses transport the following advice should be given to them and, wherever possible, to a responsible accompanying adult Problems could arise within the first 24 hours. Someone needs to be with you during that time. You, or the person looking after you, must phone 111 and ask for an ambulance if any of the following develop • You have a headache that gets worse • You are drowsy or difficult to wake up • You have difficulty recognising people or places • You have any vomiting • You behave unusually or seem confused • You have seizures or fits • You have weak arms or legs, or are unsteady on your feet • You have slurred speech

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10.1 PAEDIATRIC EQUIPMENT AND DRUG DOSE For children, the dose of drugs, defibrillation energy, and fluid therapy are based on body weight. If the body weight is unknown, it can be estimated from the child’s age using the following Advanced Paediatric Life Support (APLS) formulae

Weight (kg) • Under 1 year old • 1 ­ 10 years old • 11 ­ 14 years old

5 2 × (age in years + 4) 3 × age in years

For age 1 year and older, round patient weight (known or calculated) to the nearest 10kg before using the tables in each CPG or on the following pages

• Newborn to 1 year • 1 year and over

3­4 (age in years / 4) + 4

Endotracheal tube Length at Lips (LAL) (cm) • Newborn • Under 1 year • 1 year and over

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6 + weight in kg ETT size × 3 (age in years / 2) + 12

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Endotracheal tube (ETT) size

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Notes • These formulae are a guide only, individual children may be lighter or heavier than predicted by the APLS formulae.They may also require a different ETT size, LAL, or defibrillation energy than that derived from the formulae • If drugs are administered, or a paediatric patient is intubated or defibrillated, the patient's estimated/calculated weight must be recorded together with drug dose(s), ETT size, LAL, energy settings, etc. • All children greater than 14 years or 42kg can be given adult doses PAEDIATRIC DRUG DOSES The following pages contain tables of paediatric drug doses.These tables are provided to assist you in applying your knowledge and training.They cannot incorporate all administration information, so a strong knowledge of each drug is still required.They indicate the calculated dose for a given patient weight, the concentration of solution that should be obtained, and the volume that should be administered from that solution. For a more detailed explanation consult the comprehensive edition Drug administration errors have occurred where paramedics have adminstered a listed volume "straight" rather than from the specified concentration of solution. Entries that are highlighted red are drugs that are frequently involved in administration errors

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10.2 OTHER PAEDIATRIC GUIDES

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Wong足Baker FACES pain scale

No hurt

Hurts little bit

Hurts Hurts Hurts little more even more whole lot

Hurts worst

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The following is a summary of drug contraindications for quick reference. For the complete standing orders, refer to the comprehensive edition of the CPGs ALL DRUGS: allergy and 1st trimester pregnancy Drugs with no additional cautions are not listed

Amiodarone

• Known hypersensitivity or allergy to iodine • Pregnancy or lactation • Known hypersensitivity or allergy to salicylates • Recent gastric bleeding • Pregnancy • Children under 12 years old

Clopidogrel

• Severe liver impairment • Active pathological bleeding (e.g. peptic ulcer or intracranial haemorrhage) • Breast feeding

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• Decreased LOC • Suspected pneumothorax • Diagnosed bowel obstruction • Scuba diving in the last 24hrs

Fentanyl

• Children under 1yr age • Unable to obey commands • Respiratory depression (includes active or poorly controlled asthma) • Premature labour • Myasthenia gravis

Glucagon

• Insulin- or glucagon-growing tumours

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Aspirin

Entonox

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ALL DRUGS: allergy and 1st trimester pregnancy

Glyceryl trinitrate (GTN) • Systolic BP less than 100mmHg • HR less than 40 or greater than 150bpm

Heparin

• Older than 75 years • Stroke or head injury within last 6 months • Previous major surgery or GI bleed within the last 2 months • Recent trauma or surgery of any form within the last 2 weeks (including extensive CPR) • Currently taking anticoagulant • Severe uncontrolled hypertension (systolic BP greater than 200mmHg) • Confirmed peptic ulcer disease with symptoms in the last 3 months

Hydrocortisone

• Premature infants • Systemic fungal infections

Ibuprofen

• Known hypersensitivity to ibuprofen and aspirin or other nonsteroidal anti-inflammatory drugs • On anticoagulants i.e. warfarin • Peptic ulcer or hiatus hernia • Renal failure

Ipratropium bromide

• Known hypersensitivity or allergy to atropine

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ALL DRUGS: allergy and 1st trimester pregnancy

Ketamine

• Patients where a significant elevation of blood pressure would constitute a risk For analgesia • Children under 1yr age • Unable to obey commands • Has active psychosis

• Known hypersensitivity or allergy to local anaesthetics • Localised inflammation or sepsis at the injection site, or septicaemia • Heart block (sinoatrial, atrioventricular, intraventricular) • Serious CNS disease (meningitis, cranial haemorrhage)

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• Pregnant or breast feeding • Children under 1yr age • Taking erythromycin or roxithromycin - check QTc less than 500milliseconds

Magnesium sulphate

• Known hypermagnesaemia

Midazolam

• Hypersensitivity or allergy to benzodiazepines • GCS<10 for the agitated patient • Airway problems • Myasthenia gravis

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Lignocaine

Loratadine

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ALL DRUGS: allergy and 1st trimester pregnancy

Morphine sulphate

• Acute severe asthma/CORD • Respiratory compromise or depression (especially with cyanosis) • Premature infants or during labour for the delivery of premature infants

Naloxone

• Newborns born to opiateabusers (may precipitate withdrawal)

Oxygen

• CORD - more than 88% SpO2

Oxytocin

Paracetamol

• Liver impairment • Any drug overdose • If patient has taken any other medication containing paracetamol within past 4hrs

Prednisone • Peptic ulcer

Suxamethonium

• History or family history of malignant hyperthermia • Paraplegia/quadriplegia • Muscle disorder • Hyperkalaemia • Significant healing burns

• Prolonged QT segment

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ALL DRUGS: allergy and 1st trimester pregnancy

• Age > 75 years • Stroke or head injury within last 6 months • Previous major surgery or GI bleed within the last 2 months • Recent trauma or surgery of any form within the last 2 weeks (including extensive CPR) • Currently taking anticoagulant • Severe uncontrolled hypertension (systolic BP greater than 200mmHg) • Confirmed peptic ulcer disease with symptoms in the last 3 months

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Ticagrelor

• History of intracranial haemorrhage • Active bleeding • Severe hepatic impairment

Tramadol

• Known hypersensitivity to tramadol or opioids • MAOI inhibitors within last 14 days • Epilepsy

Tranexamic Acid

• Subarachnoid haemorrhage • Active intravascular clotting e.g. DVT

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Tenecteplase

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