Non-Emergency Patient Transport Clinical Practice Protocols 2024 PDF

------------------------------------------------------------- Non-emergency patient transport clinical practice protocols 2024 edition ------------------------------------------------------------- +-----------------------------------------------------------------------+ | Non-emergency patien...

------------------------------------------------------------- Non-emergency patient transport clinical practice protocols 2024 edition ------------------------------------------------------------- +-----------------------------------------------------------------------+ | Non-emergency patient transport clinical practice protocols | | | | 2024 edition | | | | Date of issue: August 2024 | | | | Next revision due: 30 June 2025 | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ | To receive this document in another format [email the Non-Emergency | | Patient Transport and First Aid Services | | team](mailto:[email protected]) | | \. | | | | Authorised and published by the Victorian Government, 1 Treasury | | Place, Melbourne. | | | | © State of Victoria, Australia, Department of Health, August 2024. | | | | ISBN/ISSN 978-1-76131-151-2 (online/PDF/Word) | | | | Available at the [NEPT legislation and Clinical Practice Protocols | | webpage](https://www.health.vic.gov.au/patient-care/nept-legislation- | | and-clinical-practice-protocols) | | \ | +-----------------------------------------------------------------------+ | | +-----------------------------------------------------------------------+ Contents {#contents.TOCheadingreport} ======== [Purpose 8](#purpose) [2024 edition -- review overview 8](#edition-review-overview) [Guide to using the CPPs 9](#guide-to-using-the-cpps) ['Memory items' and 'checklist items' 9](#memory-items-and-checklist-items) [Paediatric and maternity/obstetric patients 9](#paediatric-and-maternityobstetric-patients) [Inter-facility transport (IFT) management -- including high-acuity services 10](#inter-facility-transport-ift-management-including-high-acuity-services) [Limitation of treatment and patient review 10](#limitation-of-treatment-and-patient-review) [Administering medicines not included in scope of practice 10](#administering-medicines-not-included-in-scope-of-practice) [Scope of practice 11](#scope-of-practice) [Assessment tools 15](#assessment-tools) [NEPT perfusion status assessment (PSA) -- adult 15](#nept-perfusion-status-assessment-psa-adult) [NEPT respiratory status assessment (RSA) -- adult 15](#nept-respiratory-status-assessment-rsa-adult) [Not suitable for NEPT and escalation of care 18](#not-suitable-for-nept-and-escalation-of-care) [Pain assessment tools 20](#pain-assessment-tools) [Paediatric assessment triangle 21](#paediatric-assessment-triangle) [Acceptable paediatric VSS 22](#acceptable-paediatric-vss) [Paediatric definitions and weight guide 22](#paediatric-definitions-and-weight-guide) [Glasgow coma scale (adult) 24](#glasgow-coma-scale-adult) [Glasgow coma scale (paediatric) 24](#glasgow-coma-scale-paediatric) [AVPU scale 25](#avpu-scale) [Time critical guidelines 26](#time-critical-guidelines) [Sedation assessment tool (SAT score) 28](#sedation-assessment-tool-sat-score) [Mental status assessment (MSA) 29](#mental-status-assessment-msa) [CPP001: Clinical approach to assessment -- unplanned medical presentation 30](#cpp001-clinical-approach-to-assessment-unplanned-medical-presentation) [CPP002: Clinical approach to assessment -- unplanned major trauma presentation 32](#cpp002-clinical-approach-to-assessment-unplanned-major-trauma-presentation) [CPP003: Clinical approach to inter-facility transport 33](#cpp003-clinical-approach-to-inter-facility-transport) [CPP004: Cardiac arrest -- adult 35](#cpp004-cardiac-arrest-adult) [Signs of life 35](#signs-of-life) [High-quality CPR principles 35](#high-quality-cpr-principles) [Compression ratio: 35](#compression-ratio) [Defibrillation pad placement 35](#defibrillation-pad-placement) [General notes 35](#general-notes) [CPP005: Cardiac arrest -- paediatric 38](#cpp005-cardiac-arrest-paediatric) [Signs of life 38](#signs-of-life-1) [High-quality CPR principles 38](#high-quality-cpr-principles-1) [Compression ratio, rate and technique 38](#compression-ratio-rate-and-technique) [Defibrillation pad placement 38](#defibrillation-pad-placement-1) [General notes 39](#general-notes-1) [Hypothermic cardiac arrest \< 30°C 39](#hypothermic-cardiac-arrest-30c-1) [CPP006: Clinical escalation 40](#cpp006-clinical-escalation) [CPP007: Oxygen therapy 41](#cpp007-oxygen-therapy) [CPP008: Narrow complex tachycardia (NCT) 43](#cpp008-narrow-complex-tachycardia-nct) [CPP009: Wide complex tachycardia (WCT) 45](#cpp009-wide-complex-tachycardia-wct) [CPP010: Bradycardia 47](#cpp010-bradycardia) [CPP011: Sepsis recognition and escalation 49](#cpp011-sepsis-recognition-and-escalation) [CPP012: Undifferentiated shock 51](#cpp012-undifferentiated-shock) [CPP013: Cardiogenic shock 54](#cpp013-cardiogenic-shock) [CPP014: Acute cardiogenic pulmonary oedema (ACPO) 56](#cpp014-acute-cardiogenic-pulmonary-oedema-acpo) [CPP015: Stroke 58](#cpp015-stroke) [CPP016: Headache 60](#cpp016-headache) [CPP017: Seizures 61](#cpp017-seizures) [CPP018: Asthma -- adult 63](#cpp018-asthma-adult) [Thunderstorm asthma 65](#thunderstorm-asthma) [CPP019: Asthma -- paediatric 66](#cpp019-asthma-paediatric) [CPP020: Chronic obstructive pulmonary disease (COPD) exacerbation 68](#cpp020-chronic-obstructive-pulmonary-disease-copd-exacerbation) [CPP021: Anaphylaxis: adult 70](#cpp021-anaphylaxis-adult) [Recognition of anaphylaxis (RASH criteria) 70](#recognition-of-anaphylaxis-rash-criteria) [CPP022: Anaphylaxis -- paediatric 72](#cpp022-anaphylaxis-paediatric) [CPP023: Acute coronary syndrome -- cardiac chest pain 74](#cpp023-acute-coronary-syndrome-cardiac-chest-pain) [CPP024: Hypoglycaemia 76](#cpp024-hypoglycaemia) [CPP025: Hyperglycaemia 78](#cpp025-hyperglycaemia) [CPP026: Nausea and vomiting 79](#cpp026-nausea-and-vomiting) [CPP027: Foreign body airway obstruction (FBAO) 80](#cpp027-foreign-body-airway-obstruction-fbao) [CPP028: Laryngectomy and tracheostomy care 82](#cpp028-laryngectomy-and-tracheostomy-care) [CPP029: Pain relief 84](#cpp029-pain-relief) [Pain assessment 84](#pain-assessment) [Non-pharmacological management 84](#non-pharmacological-management) [Chronic pain 84](#chronic-pain) [General notes 84](#general-notes-2) [CPP030: Burns 86](#cpp030-burns) [CPP031: Fractures or dislocations 88](#cpp031-fractures-or-dislocations) [CPP032: Traumatic head injury 89](#cpp032-traumatic-head-injury) [CPP033: Potential spinal injury 90](#cpp033-potential-spinal-injury) [Appendix 1: Abbreviations and definitions 92](#appendix-1-abbreviations-and-definitions) [Appendix 2: Withholding or ceasing resuscitation 94](#appendix-2-withholding-or-ceasing-resuscitation) [Withholding resuscitation 94](#withholding-resuscitation) [Ceasing resuscitation 94](#ceasing-resuscitation) [Appendix 3: Advance care directives and end-of-life care 95](#appendix-3-advance-care-directives-and-end-of-life-care) [Advance care directive (ACD) 95](#advance-care-directive-acd) [Appendix 4: Mental health patients 98](#appendix-4-mental-health-patients) [Key message 98](#key-message) [Appendix 5: 'Double-loading' (low acuity only) 100](#appendix-5-double-loading-low-acuity-only) [Appendix 6: Minimum equipment list 101](#appendix-6-minimum-equipment-list) [Appendix 7: Prolonged transport 103](#appendix-7-prolonged-transport) [Pressure injuries 103](#pressure-injuries) [Appendix 8: Medication pharmacology reference material 105](#appendix-8-medication-pharmacology-reference-material) [Adrenaline 106](#adrenaline) [Amiodarone 108](#amiodarone) [Aspirin 109](#aspirin) [Atropine 110](#atropine) [Glucagon 111](#glucagon) [Glucose paste 112](#glucose-paste) [Glyceryl Trinitrate (GTN) 113](#glyceryl-trinitrate-gtn) [Nitrous Oxide (Entonox®) 115](#nitrous-oxide-entonox) [Ipratropium Bromide 116](#ipratropium-bromide) [Methoxyflurane 118](#methoxyflurane) [Metaraminol 120](#metaraminol) [Ondansetron 121](#ondansetron) [Paracetamol 122](#paracetamol) [Salbutamol 123](#salbutamol) Purpose ======= The purpose of the Non-emergency patient transport clinical practice protocols *(the CPPs)* is to provide practice requirements, treatment recommendations and minimum equipment levels to licensed non-emergency patient transport (NEPT) providers when assessing, managing and transporting patients. In accordance with the *Non-Emergency Patient Transport and First Aid Services Act 2003* (the Act) and the Non-Emergency Patient Transport Regulations 2016 (the Regulations), the *CPPs* set out additional practices that NEPT providers must follow. These additional requirements assist licensed NEPT providers, health services and other organisations to make decisions about the use of NEPT services for patients with a variety of clinical conditions and in a range of acuities. The NEPT CPPs do not dictate management for every condition or diagnosis (with some exceptions such as anaphylaxis) that NEPT is likely to provide transport services for, rather the CPPs provide direction for management of symptoms that may present as complications during service delivery. 2024 edition -- review overview ------------------------------- The 2024 edition of the NEPT CPPs has been developed within the scope and terms of reference of the Clinical Practice Protocol Assessment Committee (CPPAC) from the Department of Health. Consultation has been sought from a wide range of sources including NEPT providers, workforce, the Office of the Clinical Chiefs (Safer Care Victoria), Ambulance Victoria and industrial relations bodies. Subject matter expertise (SME) advice has been sought where required for specific protocols. Clinical scope of practice has been aligned and clarified for different levels of NEPT crew members (PTO, ATA, EN, RN, CCRN) and licence holders should consider these different levels when considering service delivery requirements. Effort has been made to ensure that treatment recommendations contained within the CPPs are best practice for NEPT service delivery at time of publication. This review sought to: - ensure best-practice treatment pathways are recommended - clarify and prescribe minimum equipment standards required - where appropriate, update the scope of practice for NEPT workforce to align with current training - update to reflect legislative changes. This review did not seek to: - substantially alter the characteristics of NEPT service delivery - provide new workforce options for the NEPT sector - substantially alter scope of service for NEPT workforce. Where medicines are included with doses it is because they have received [secretarial approval](https://www.health.vic.gov.au/drugs-and-poisons/medicines-and-poisons-secretary-approvals) \ for independent possession and administration by NEPT providers or are likely to be approved for purchase and possession under a revised secretarial approval. Please consider medicines available for purchase, possession and administration by a NEPT service when planning management. Refer to minimum equipment list on page 102 for details on suggested medication stockholding levels. Guide to using the CPPs ----------------------- Where treatment recommendations are provided within a protocol, it includes all levels of NEPT crew members and clinical scope of practice. NEPT licence holders have a responsibility to ensure processes are in place to support NEPT crew members to familiarise themselves with and not exceed their credentialled and defined scope of practice, detailed on page 13, when delivering patient care. For any condition described in the CPPs, the NEPT crew members must consider their scope prior to initiating the recommended treatment. This is a departure from previously formatted iterations of the CPPs, which contained different coloured boxes used to indicate different levels of NEPT crew member. Where a skill, procedure or medicine is accredited for use by a NEPT crew member, this refers to independent initiation. This does not prevent a NEPT crew member undertaking a procedure, skill or administering a medication which they may reasonably be expected to be proficient to perform under the direct supervision and/or authorisation of an appropriately credentialled, registered health practitioner. NEPT crew members are reminded of the responsibility and availability of seeking clinical consult in case of a need to operate outside credentialled scope of practice including consultation with the Ambulance Victoria (AV) Clinician, NEPT provider clinician, and any applicable registered health practitioner involved in a patient's care at either a sending or receiving facility. It is acknowledged that the information provided in the protocols has been selected for the relevance to licensed NEPT providers and may not be suitable for use in other clinical situations. References to management options and medications including use, contraindications, side effects and dose ranges are specific to the types of conditions seen by licensed NEPT providers and may differ from other reference material available. Where applicable management and pharmacology have been aligned to AV's clinical practice guidelines (CPGs) where any variance would cause confusion or a delay in escalation or transition in care. 'Memory items' and 'checklist items' ------------------------------------ NEPT crew members rarely action the majority of the CPPs. Therefore, there is **no expectation** that the NEPT CPPs should be committed to memory verbatim. NEPT crew members should consider the items that are required to be 'memory actions' requiring immediate attention to preserve life and refer to the CPPs for guidance on specific management options. Memory items -- are designed to give a trained response to certain situations. This will be from training received through foundational formal pre-employment education. Checklist items -- are tasks that should be completed once memory items are completed and will be the continuation of management. The CPPs should be referred to when completing these items. **Example:** A patient is apnoeic - - Memory item is to follow the primary survey and provide IPPV - Checklist items are the continuation in the applicable CPP, including check of tidal volume and ventilation rates as appropriate and trouble-shooting the cause of apnoea. Paediatric and maternity/obstetric patients ------------------------------------------- The majority of patients treated and transported by NEPT services are adult patients. Paediatric or maternity patient being transported are likely to be clinically well for the duration of a transport. As such, doses for medicines have been included within generic management of some conditions (for example, anaphylaxis) where it is possible that NEPT services will encounter paediatric patients and where intervention is likely and/or required to preserve life. For further information beyond the material in the CPP on how to manage paediatric or maternity patients in an emergency (including childbirth), contact the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service on 1300 137 650. Inter-facility transport (IFT) management -- including high-acuity services --------------------------------------------------------------------------- Not every condition or deterioration management option will be presented in the CPPs. Where applicable, any management initiated by a sending facility in the case of IFT should be adhered to and a plan developed prior to departure in case of deterioration. These plans may conflict with the CPPs. Where there is conflict, the sending facility / agreed medical plan takes precedence over the CPPs where it is reasonable and in the best interest of the patient. If NEPT crew members are uncertain about the management plan initiated by a sending facility, contact the provider or AV clinician. Where there is uncertainty or a final determination cannot be reached, further advice may be obtained by contacting the relevant retrieval service: - ARV -- 1300 368 661 - PIPER -- 1300 137 650 Limitation of treatment and patient review ------------------------------------------ NEPT providers should conduct patient care reviews as detailed within the regulations utilising the structure of the clinical oversight committee. Following an adverse outcome or significant presentation requiring management under these CPPs this should be conducted within the 'just-culture' framework. Further information on conducting patient reviews can be found through [Safer Care Victoria (SCV)](https://www.safercare.vic.gov.au/support-and-training/review-and-response) \ The department does not imply any responsibility on the part of NEPT crew members to undertake any treatment or management option that they have not been authorised for or are unable to reasonably perform due to circumstances out of control of the individual crew member. Administering medicines not included in scope of practice --------------------------------------------------------- In the event patients are being transferred with medicines between hospitals/health facilities which fall outside the scope of practice contained within **table 1** arrangement should be made to ensure that these medicines are dispensed. For a medicine to be dispensed to a patient it must be labelled by a relevant prescribing health practitioner in accordance with Appendix L of the poisons standard (the SUSMP). Once a medicine has been dispensed any carer of a patient (including a NEPT crew-member) may assist in the administration of the medicine. Note that currently only Registered Nurses working as crew members for NEPT services may administer medication based off an order (not prescribed to the specific patient) from a prescribing health practitioner. Scope of practice ================= Table 1. Scope of practice for NEPT crew members Protocol or skill PTO EN ATA RN RN CC ---------------------------------------------------------------------- ----- ---- ----- ---- ------- Cardiac arrest defibrillation - AED ü ü ü ü ü defibrillation - Manual TE TE TE ü Oropharyngeal airway ü ü ü ü ü Nasopharyngeal airway TE ü ü ü Supra-Glottic airway TE ü TE ü Bag Valve Mask Ventilation ü ü ü ü ü IV cannulation TE ü Adrenaline (IV) ü Amiodarone (IV) ü **Narrow complex tachycardias** Assist patient to perform Valsalva if part of own regular management TE ü **Wide complex tachycardia** Amiodarone (IV infusion) TE ***Bradycardia*** Atropine TE ***Undifferentiated shock*** IV fluid (normal Saline) TE ü Metaraminol IV TE ***Cardiogenic shock*** Supportive care (positioning) ü ü ü ü ü Adrenaline infusion TE **Anaphylaxis (adult and paediatric)** Adrenaline (via auto injector) (IM) ü ü ü ü ü Adrenaline 1:1000 drawn from ampoule (IM) TE TE ü ü Normal Saline bolus doses TE ü Glucagon for refractory anaphylaxis ü TE ü ü Adrenaline via Neb for stridor TE ü ü ü Salbutamol (pMDI) ü ü ü ü ü Salbutamol (Neb) TE ü ü ü Ipratropium Bromide (Atrovent) (pMDI) ü ü ü ü Ipratropium Bromide (Atrovent) (Neb) TE ü ü ü Adrenaline IV bolus ü **Breathing difficulties (hypoxia management)** Oxygen saturation monitoring ü ü ü ü ü Oxygen (nasal prongs/face mask) ü ü ü ü ü Titrated oxygen care based on oxygen saturation ü ü ü ü ü Bag Valve Mask Ventilation ü ü ü ü ü **Asthma (adult and paediatric)** Salbutamol (pMDI) ü ü ü ü ü Salbutamol (Neb) TE ü ü ü Ipratropium Bromide (Atrovent) (pMDI) ü ü ü ü Ipratropium Bromide (Atrovent) (Neb) TE ü ü ü Adrenaline (1:1000) IMI TE TE ü ü Adrenaline (auto-injector) ü ü ü ü ü **COPD exacerbation** Salbutamol (pMDI) ü ü ü ü ü Salbutamol (Neb) TE ü ü ü Ipratropium Bromide (Atrovent) (pMDI) ü ü ü ü Ipratropium Bromide (Atrovent) (Neb) TE ü ü ü **Laryngectomy/tracheostomy care** Transport of non-recent insertion (no complications forecast) ü ü ü ü ü Transport of recent (\>5 days) insertion ü Suction/oxygenation ü ü ü ü ü **Acute cardiogenic pulmonary oedema** Glyceryl Trinitrate (S/L) ü ü ü ü Oxygen therapy ü ü ü ü ü **Choking** Back blows/chest thrusts ü ü ü ü ü Laryngoscopy/Magills forceps TE **Acute coronary syndrome** 3 lead ECG monitoring ü ü ü ü 12 Lead ECG acquisition (not diagnostic) ü ü ü ü Aspirin (oral) ü ü ü ü ü GTN (sublingual) ü ü ü ü **Hypoglycaemia** Glucose paste (oral) ü ü ü ü ü BGL ü ü ü ü ü Glucagon (IM) TE ü ü ü Dextrose 10% ü **Nausea and vomiting** Ondansetron (oral) ü ü ü ü Ondansetron IV/IM ü ü **Fracture management** Anatomical splinting ü ü ü ü ü Traction splints TE TE ü TE ü Pelvic splinting ü ü ü ü ü **Pain management** Ice/warm pack ü ü ü ü ü Formable splint ü ü ü ü ü Anatomical splint ü ü ü ü ü Paracetamol (oral) ü ü ü ü ü Methoxyflurane (inhaled) ü ü ü ü Entonox (inhaled) ü ü ü ü **Spinal injuries** C-collar ü ü ü ü ü Prophylactic ondansetron TE ü ü ü **Major trauma management** Arterial tourniquets ü ü ü ü ü Pressure dressings ü ü ü ü ü **Maintenance of medication administration** Narcotic infusion (s/c) TE TE ü ü ü IV Crystalloid TE ü ü ü GTN infusion TE ü ü ü Heparin infusion TE ü ü ü Blood products TE ü ü ü IV Crystalloid with potassium added TE ü ü ü Antibiotic infusion maintenance TE ü ü ü Narcotic infusion (IV) ü ü Other vasoactive medications (e.g. inotropes) ü Anti-arrhythmic medications ü **Other treatments** Capped CVC for low acuity patients ü ü ü ü ü PICC that is not in active use ü ü ü ü ü TPN via PICC TE ü ü ü Bladder washout TE TE ü ü Chemotherapy infusion TE TE TE TE CVC infusion (including TPN) ü ü ICC TE ü Insulin infusion ü ü IV cannula insertion TE ü Arterial line monitoring (not insertion) ü Intra-aortic balloon pump management ü Pacing wire management (not insertion) ü **Transport Acuity** Low acuity (IFT) ü ü ü ü ü Low acuity (unplanned ambulance) ü ü ü ü ü Medium acuity (IFT) ü ü ü ü Medium acuity (unplanned ambulance) TE ü TE ü High acuity (IFT only) ü ### Assessment tools ================ NEPT perfusion status assessment (PSA) -- adult ----------------------------------------------- Perfusion relates to the ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to meet the functional demands at that time, and to effectively remove the associated metabolic waste products. It is important to not view perfusion as an isolated vital sign (for example BP), rather the picture the patient presents as a collection of vital signs. It is important to contextualise perfusion with the patients presenting condition and any significant past medical history. Table 2. NEPT PSA +-----------+-----------+-----------+-----------+-----------+-----------+ | | Skin | Pulse | BP | Conscious | Capillary | | | | | | state | refill | +===========+===========+===========+===========+===========+===========+ | **Adequat | Warm, | 60-100 | \> 100 | Alert | Central | | e | pink, dry | BPM | systolic | | and | | perfusion | | | | | distal\ | | ** | | | | | \< 2 | | | | | | | seconds | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Borderl | Warm, | 50-100 | 80-100 | Alert | Central | | ine | pink, | BPM | systolic | | \< 2 | | perfusion | dry/cool, | | | | seconds | | ** | pale, | | | | | | | clammy | | | | Distal \> | | | | | | | 2 seconds | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Inadequ | Cool, | \< 50 | 60-80 | Alert or | Central | | ate | pale, | BPM\ | systolic | altered | \< 2 | | perfusion | clammy | or\ | | | seconds | | ** | | \> 100 | | | or \> 2 | | | | BPM | | | seconds | | | | | | | | | | | | | | Distal \> | | | | | | | 2 seconds | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Extreme | Cool, | \< 50 | \< 60 | Altered | Central | | ly | pale, | BPM\ | systolic | or | \> 2 | | poor | clammy | or\ | or | unconscio | seconds | | perfusion | | \> 110 | unrecorda | us | | | ** | | BPM | ble | | Distal \> | | | | | | | 2 seconds | +-----------+-----------+-----------+-----------+-----------+-----------+ | **No | Cyanotic, | No | Unrecorda | Unrecorda | Extremely | | perfusion | cool, | palpable | ble | ble | delayed | | ** | pale, | pulse | | | central | | | clammy | | | | and | | | | | | | distal | | | | | | | refill or | | | | | | | none | +-----------+-----------+-----------+-----------+-----------+-----------+ NEPT respiratory status assessment (RSA) -- adult ------------------------------------------------- Respiratory status refers to the movement of air in and out of the lungs (ventilation -- V) and the exchange of carbon dioxide (CO~2~) and oxygen (O~2~) at the alveolar level (perfusion -- Q). This means that respiratory effort measures two important components -- the physical effort of moving air in and out of the lungs and the effectiveness of gas exchange within the lungs. It is important to consider these two components when assessing respiratory status as some conditions which require oxygen or ventilation support may not have any adventitious sounds on auscultation -- for example, pulmonary embolus or cystic fibrosis. No single sign or symptom constitutes the respiratory status of a patient. Signs and symptoms referred to in table 3 should be considered when they directly correlate to a patient's respiratory function, for example somebody who is mildly anxious in isolation with no respiratory component does not automatically have mild respiratory distress. Likewise, a patient who is obviously fighting to breathe but does not have an easily measured respiratory rate may be critical. Some general and accepted respiratory values and markers correlating to an assessment of the respiratory status of a patient are summarised in table 3. Table 3 relates only to an otherwise well person and should be assessed against the normal respiratory status of the patient. For example, a patient with Chronic Obstructive Pulmonary Disease (COPD) may present with scattered wheezing as their 'normal' respiratory status however persistent wheeze could indicate a deterioration or acute presentation of their condition. Table 3. NEPT RSA +-----------+-----------+-----------+-----------+-----------+-----------+ | | No | Mild | Moderate | Severe | Critical | | | respirato | distress | distress | distress | | | | ry | | | | | | | distress | | | | | +===========+===========+===========+===========+===========+===========+ | General | Calm or | Mildly | Distresse | Distresse | Fighting | | appearanc | quiet | anxious | d | d, | to | | e | | | or | anxious | breathe, | | | | | anxious | | catatonic | +-----------+-----------+-----------+-----------+-----------+-----------+ | Speech | Clear and | Full | Short | Words | Unable to | | | steady | sentences | phrases | only | speak or | | | sentences | | | | single | | | | | | | word or | | | | | | | grunting | +-----------+-----------+-----------+-----------+-----------+-----------+ | Breath | *Bronchos | Able to | Able to | Unable to | Unable to | | sounds | pasm:* | cough | cough | cough | cough | | and | Usually | | | | | | auscultat | quiet | *Bronchos | *Bronchos | *Bronchos | *Bronchos | | ion | with no | pasm:* | pasm:* | pasm:* | pasm:* | | | wheeze | Mild | expirator | expirator | Little to | | | | expirator | y | y | not air | | | *Oedema:* | y | wheeze | and | movement | | | No | wheeze | +/- | inspirato | -- | | | crackles | | inspirato | ry | 'silent | | | or | *Oedema:* | ry | wheeze | chest'. | | | scattered | crackles | wheeze | | | | | fine | at base | | *Oedema:* | *Oedema:* | | | crackles | of lungs | *Oedema:* | crackles | Full | | | | | crackles | full-fiel | field | | | | | at base | d | crackles | | | | | to | +/- | +/- | | | | | mid-zone | possible | possible | | | | | | wheeze | wheeze OR | | | | | | | little to | | | | | | | no air | | | | | | | movement | +-----------+-----------+-----------+-----------+-----------+-----------+ | Respirato | 12-16 | 16-20 | \> 20 | \> 20 | \> 30 or | | ry | | | | | \< 8 | | rate | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | Respirato | Regular | Slight | *Bronchos | *Bronchos | *Bronchos | | ry | even | increase | pasm:* | pasm:* | pasm:* | | rhythm | cycles | in normal | prolonged | Prolonged | Prolonged | | | | chest | expirator | expirator | expirator | | | | movement | y | y | y | | | | | phase | phase | phase | | | | | | | | | | | | *Oedema:* | *Oedema:* | *Oedema:* | | | | | short | short | short | | | | | sharp | sharp | sharp | | | | | breaths | breaths | breaths | +-----------+-----------+-----------+-----------+-----------+-----------+ | Work of | Normal | Slight | Marked | Marked | Marked | | breathing | chest | increase | chest | chest | chest | | | movement | in normal | movement | movement | movement | | | | effort | +/- use | with | with | | | | | of | accessory | accessory | | | | | accessory | muscle | muscle | | | | | muscles | use, | use, | | | | | | intercost | intercost | | | | | | al | al | | | | | | retractio | retractio | | | | | | n | n | | | | | | +/- | +/- | | | | | | tracheal | tracheal | | | | | | tugging | tugging | | | | | | | | | | | | | | Or | | | | | | | | | | | | | | Reduced | | | | | | | respirato | | | | | | | ry | | | | | | | effort | | | | | | | due to | | | | | | | fatigue | +-----------+-----------+-----------+-----------+-----------+-----------+ | Heart | 60-100 | 60-100 | 100-120 | \> 120 | \> 120 or | | Rate | | | | | bradycard | | | | | | | ic | | | | | | | (late | | | | | | | stage) | +-----------+-----------+-----------+-----------+-----------+-----------+ | Skin | Normal | Normal | Pale and | Pale and | Pale and | | | | | sweaty | sweaty | sweaty, | | | | | | +/- | periphera | | | | | | cyanosis | l | | | | | | | cyanosis | | | | | | | may be | | | | | | | central | | | | | | | cyanosis | | | | | | | (late | | | | | | | sign) | +-----------+-----------+-----------+-----------+-----------+-----------+ | Conscious | Alert | Alert | May be | Altered | Altered | | state | | | altered | | or | | | | | | | catatonic | | | | | | | (no | | | | | | | purposefu | | | | | | | l | | | | | | | movements | | | | | | | or | | | | | | | interacti | | | | | | | on) | +-----------+-----------+-----------+-----------+-----------+-----------+ Not suitable for NEPT and escalation of care -------------------------------------------- It is a requirement of the regulations that NEPT providers do not transport a patient if their condition is time critical or is likely to become time critical during transport. Table 4 summarises vital signs survey (VSS) that may indicate a person is not suitable for NEPT. When considering the physiological parameters in table 4 they should be contextualised against the patient's normal physiological state and likelihood of deterioration and expected clinical trajectory. For example: - A small frame patient may have a 'normal' BP of 90/50, where the NEPT crew member can be reasonably satisfied that no other aspect of perfusion is compromised and this is normal for the patient. - A patient who has just completed a dialysis appointment may present with mild hypotension and this has been considered by the health practitioner administering dialysis. NEPT transport may then be authorised following clinical advice or assessment by a person authorised to assess the patient as being haemodynamically stable for transport. Specifically, person's authorised to assess the patient must be either a registered medical practitioner, registered nurse or registered paramedic. NEPT services must take reasonable steps to clarify a patient's physiological status and suitability for transport prior to the arrival of a NEPT crew. During IFT the patient must meet the requirements outlined in table 4 and have a plan and medicines provided prior to transport to allow to manage reasonably predictable deterioration (for example, order and supply of vasopressors). Consideration should be given to optimising patient presentation and VSS at the sending facility prior to commencing transport and contact with ARV established. NEPT crew members should be aware that they may be directed to transport a patient outside of these parameters by a medical practitioner, registered nurse or registered paramedic working within the AV communications centre when it is necessary to avoid the possibility of a patient dying or suffering an adverse event were the patient required to wait for alternative transport. Table 4. Not suitable for NEPT +-----------------+-----------------+-----------------+-----------------+ | NEPT transport | Acuity | | | | criteria | | | | +=================+=================+=================+=================+ | | Low | Medium | High | +-----------------+-----------------+-----------------+-----------------+ | Heart rate | \< 60 | \< 50 (with no | \< 45 (with no | | | | other signs of | other signs of | | | \>100 | altered | altered | | | | perfusion) | perfusion) | | | | | | | | | \> 110 | \> 120 | +-----------------+-----------------+-----------------+-----------------+ | Systolic blood | \< 100 | \< 100 | \< 90 | | pressure | | | | | | | | Or | | | | | | | | | | MAP \< 60 | +-----------------+-----------------+-----------------+-----------------+ | GCS | Any reduction | Reduction in | Reduction in | | | to normal GCS | GCS \> 2 points | GCS \> 2 points | | | | from patient's | from patient's | | | | normal baseline | normal baseline | | | | conscious state | conscious state | | | | | (excluding | | | | | mechanically | | | | | ventilated | | | | | patient with | | | | | escort) | +-----------------+-----------------+-----------------+-----------------+ | Respiratory | \< Normal | Mild | Mild | | status | respiratory | respiratory | respiratory | | | status | distress that | distress that | | | | does not | does not | | | | respond to | respond to | | | | management | management | | | | | | | | | OR | OR | | | | | | | | | Moderate, | Moderate, | | | | severe, | severe, | | | | critical | critical | | | | respiratory | respiratory | | | | distress | distress | | | | | (excluding | | | | | patient well | | | | | established on | | | | | NIV with | | | | | escort) | +-----------------+-----------------+-----------------+-----------------+ | Cardiac Chest | Not within 2 | Not within 2 | Not within 2 | | pain | hours of | hours of | hours of | | | transport | transport | transport | +-----------------+-----------------+-----------------+-----------------+ | Major trauma | Not by NEPT | Not by NEPT | Not by NEPT | | | | | | | (as described | | | | | in major trauma | | | | | criteria) | | | | +-----------------+-----------------+-----------------+-----------------+ | Acute stroke | Not by NEPT | Not routinely | Not routinely | | symptoms | | by NEPT unless | by NEPT unless | | | | outside of | outside of | | | | stroke | stroke | | | | treatment | treatment | | | | window or not | window or not | | | | for acute | for acute | | | | management. | management | +-----------------+-----------------+-----------------+-----------------+ | Severe acute | Not by NEPT | Not by NEPT | Not by NEPT | | abdominal pain | | | | | (no diagnosis) | | | | +-----------------+-----------------+-----------------+-----------------+ | Pain unable to | Escalate care | Escalate care | Escalate care | | be controlled | | | | | by NEPT | | | | +-----------------+-----------------+-----------------+-----------------+ | Clinical | SAT Score \>0 | SAT score \> +1 | SAT score \> +1 | | agitation | | | | | | SAT score \ 120 - RR \< 10 or \> 30 - Systolic BP \< 90mmHg - SPO~2~ \< 90% - If ≥ 16 years - GCS \ 20% TBSA (\> 10% if ≤ 15 years old or suspected respiratory tract burns) - High voltage (\>1000 volts) burn injury - Serious crush injury - Major compound fracture or open dislocation - Fracture to 2 or more femur/tibia/humerus - Fractured pelvis. Assess the above and if present in combination with the following high-risk criteria, manage as major trauma. #### Mechanism of injury - Motor/cyclist impact \> 30kph - High speed MCA - Pedestrian impact - Ejection from vehicle - Prolonged extrication - Fall from height \> 3m - Struck on head by object falling \> 3m - Explosion. #### Co-morbidities - Age \< 12 or \> 55, OR - Pregnant, OR - Significant underlying medical condition. Sedation assessment tool (SAT score) ------------------------------------ Occasions may arise where NEPT services are engaged to transport an agitated patient or a patient suffering from an acute mental health episode. The SAT score should be used as a guide to determine whether transport is able to be facilitated by NEPT services. See Appendix 4: Information about the transport of mental health patients by NEPT services for further information. Undifferentiated agitation (that is, not linked to a known mental health condition or past history of behaviour) is unlikely to be NEPT suitable and should prompt concern as this may be due to physiological distress, and care should be escalated. NEPT crew members should conduct a risk assessment prior to transport and escalate concerns if there is a reasonable belief that transport cannot be safely undertaken. The administration of sedation is not authorised for NEPT, however NEPT may transport patients who have received sedation. Table 7. Sedation assessment tool Score Responsiveness Speech --------------------------------- -------------------------------------- ------------------------------- +3 Combative, violent out of control Continual loud outbursts +2 Very anxious and agitated Loud outbursts +1 (medium-high acuity cut-off) Anxious or restless Normal or talkative 0 (low-acuity cut-off) Awake, and calm or cooperative Speaks normally -1 (medium-high acuity cut-off) Asleep, but rouses if name is called Slurring or prominent slowing -2 Responds to physical stimulation Few recognisable words -3 No response to stimulation Nil Mental status assessment (MSA) ------------------------------ Look for, listen to and ask about all categories below. The patient may be suffering from some of the following Remember verbal de-escalation strategies, active listening and calm/open body language. Table 8. Mental Status assessment tool +-----------------------+-----------------------+-----------------------+ | ### Observe | ### Listen | ### Discuss | +=======================+=======================+=======================+ | #### Safety | #### Speech | #### Thought content | | | | | | NEPT crew member, | Take note of rate, | May be dominated by | | patient and bystander | volume, quantity, | delusions, | | safety first is | tone, content, | obsessions, | | priority. Assess the | excessive talking, | preoccupations, | | scene for dangers, | difficulty engaging, | phobias, | | that is, location or | tangential, flat, | suicidal/depressed or | | weapon. Obtain police | inflections et | homicidal thoughts, | | support early if | cetera. | compulsions or | | required. Maintain | | superstitions. | | vigilant reassessment | | | | of scene safety. | | | +-----------------------+-----------------------+-----------------------+ | #### Appearance | #### Thought process | #### Self-harm | | | | | | Look for signs of | May be altered, can | Ask patient directly | | indicative of mental | be perceived by | if they have | | health issues or poor | patient jumping | attempted self-harm, | | self-caring; | irrationally between | suicide or are | | uncleanliness, | thoughts, sounding | thinking about or | | dishevelled, | vague, unsteady | planning these. Ask | | malnourished, signs | through-flow when | about previous | | of addiction | communicating | attempts. | | (injection marks or | verbally. | | | nicotine stains), | | | | posture, pupil size | | | | or odour. | | | +-----------------------+-----------------------+-----------------------+ | #### Behaviour | #### Cognition | #### Perceptions | | | | | | Patient may display | May be exhibiting | Patient may be | | odd mannerisms, | signs of impairment | suffering from | | impaired gait, | such as poor ability | hallucinations (ask | | avoidance or overuse | to organise thoughts, | specifically about | | of eye contact, | short attention span, | auditory, visual and | | threatening or | poor memory, | command | | violent behaviour, | disorientation, | hallucinations), | | unusual motor | impaired judgement or | disassociation, that | | activity or activity | lack of insight. | is, 'I feel detached | | level (that is, wired | | from my body', 'my | | or buzzing), bizarre | | surroundings aren't | | or inappropriate | | real' or 'I am not in | | responses to stimuli, | | control of my | | or pacing. | | actions'. | +-----------------------+-----------------------+-----------------------+ | #### Affect | ### | #### Environment | | | | | | Observed to be flat, | | Risk factors include | | depressed, agitated, | | lack of familial and | | excited, hostile, | | social support, | | argumentative, | | addiction or | | violent, irritable, | | substance abuse, low | | morose, reactive, | | socio-economic | | unbalanced, bizarre, | | status, life | | withdrawn, et cetera. | | experiences, recent | | | | stressors, sleeping | | | | problems or | | | | comorbidities (either | | | | physical or mental | | | | health conditions). | +-----------------------+-----------------------+-----------------------+ #### CPP001: Clinical approach to assessment -- unplanned medical presentation ========================================================================= Generally, unplanned events will present following calls to the emergency phone line (Triple Zero '000'), State health emergency management plan (SHEMP -- replaced SHERP) activations, or incidentally when conducting other NEPT duties. This approach should also be applied by NEPT crew members when conducting an IFT and the patient presents with an unexpected deterioration or with a different complaint or condition than the IFT was originally requested for. Where NEPT crew members suspect a significant underlying condition or are concerned with patient presentation regardless of patient VSS, refer to CPP006 Clinical escalation. NEPT crew members should be suspicious of signs and symptoms that cannot be explained. Figure 2. Clinical approach to assessment unplanned medical presentation  CPP002: Clinical approach to assessment -- unplanned major trauma presentation ============================================================================== Trauma presentations should be assessed in the first instance with these considerations before moving on to injury specific assessment and management. The priorities listed below are the priorities in managing immediate life threat in major trauma and are a departure from traditional order of 'ABC'. Figure 3. Clinical approach to assessment unplanned major trauma presentation CPP003: Clinical approach to inter-facility transport ===================================================== Inter-facility transport (IFT) is defined as the transport of patients between healthcare facilities. IFT is a crucial part of today\'s healthcare system that allows facilities to transfer patients needing specialised assessment or care that cannot be adequately provided at their current health facility. Prior to conducting an IFT, NEPT crew members should ascertain the exact clinical condition of the patient and determine the potential for deterioration prior to commencing transport. Refer to Table 4 'not suitable for NEPT' to determine patient eligibility for transport. During the IFT, NEPT crew members are required to reassess the patient appropriately, and clearly document any changes in the patient's condition or any interventions that have been undertaken. At a minimum, a set of VSS must be obtained within 30 minutes prior to transfer from a sending facility. Additional sets of VSS should be recorded as required and with respect to patient acuity. Patients receiving active management should receive 15-minutely VSS or more frequently as dictated by patient condition. Minimum observations include: - GCS or AVPU - RSA - PSA - SPO~2~ - Pain assessment (where appropriate) - BGL (where appropriate) - Temperature (where appropriate). The following checklist table may be completed as a memory aid by NEPT crew members prior to transport commencing. Table 9. Checklist for completion prior to transport +-----------------+-----------------+-----------------+-----------------+ | Item | Yes | No | N/A | +=================+=================+=================+=================+ | Handover | | | | | provided and | | | | | transfer | | | | | paperwork | | | | | provided | | | | | | | | | | - Confirm | | | | | receiving | | | | | facility | | | | +-----------------+-----------------+-----------------+-----------------+ | Is the patient | | | | | time critical | | | | | or likely to | | | | | become time | | | | | critical during | | | | | transfer? | | | | | | | | | | If yes, | | | | | transfer is not | | | | | suitable for | | | | | NEPT | | | | +-----------------+-----------------+-----------------+-----------------+ | Has the patient | | | | | experienced | | | | | cardiac related | | | | | chest pain in | | | | | the\ | | | | | 2 hours prior | | | | | to transfer? | | | | | | | | | | If yes, | | | | | transfer is not | | | | | suitable for | | | | | NEPT | | | | +-----------------+-----------------+-----------------+-----------------+ | Has the patient | | | | | been assessed | | | | | by a registered | | | | | paramedic, | | | | | registered | | | | | nurse or | | | | | registered | | | | | medical | | | | | practitioner as | | | | | being | | | | | haemodynamicall | | | | | y | | | | | stable for the | | | | | duration of the | | | | | transfer? | | | | | | | | | | - If no, | | | | | transfer is | | | | | not | | | | | suitable | | | | | for NEPT | | | | | | | | | | Gain details of | | | | | authorising | | | | | health | | | | | practitioner | | | | +-----------------+-----------------+-----------------+-----------------+ | Advanced care | | | | | directive | | | | | provided (where | | | | | an ACD exists) | | | | +-----------------+-----------------+-----------------+-----------------+ | Plan for | | | | | clinical | | | | | management/dete | | | | | rioration | | | | | agreed upon and | | | | | ongoing | | | | | management | | | | | identified | | | | | | | | | | - Frequency | | | | | of VSS | | | | | stipulated | | | | | | | | | | - Clinical | | | | | trajectory | | | | | | | | | | - Infusion | | | | | doses | | | | | established | | | | | | | | | | - Medication | | | | | and other | | | | | care | | | | | required | | | | | PRN during | | | | | transfer | | | | | established | | | | | | | | | | - Pressure | | | | | injury | | | | | assessment | | | | | or | | | | | prevention | | | | | plan | | | | +-----------------+-----------------+-----------------+-----------------+ | Does patient | | | | | acuity at time | | | | | of dispatch | | | | | match patient | | | | | acuity at time | | | | | of transfer? | | | | | | | | | | If no, and | | | | | patient acuity | | | | | not within | | | | | scope of NEPT | | | | | crew, transfer | | | | | is not suitable | | | | | for NEPT | | | | +-----------------+-----------------+-----------------+-----------------+ | Is patient | | | | | ready for | | | | | transfer? | | | | | | | | | | - Toileted | | | | | | | | | | - Hydrated | | | | | | | | | | - Fed | | | | | | | | | | - Analgesia | | | | | provided | | | | | (if | | | | | applicable) | | | | | | | | | | - Sedation | | | | | provided | | | | | (if | | | | | applicable) | | | | +-----------------+-----------------+-----------------+-----------------+ | Confirm three | | | | | (3) points of | | | | | patient | | | | | identification, | | | | | for example: | | | | | | | | | | - Medical ID | | | | | bracelet | | | | | | | | | | - Health care | | | | | record | | | | | | | | | | - Patient | | | | | stating | | | | | name and | | | | | identifying | | | | | features | | | | +-----------------+-----------------+-----------------+-----------------+ | Is all required | | | | | equipment for | | | | | transport | | | | | present, for | | | | | example (as | | | | | applicable): | | | | | | | | | | - Cardiac | | | | | monitoring | | | | | | | | | | - NIBP | | | | | | | | | | - SPO~2~ | | | | | | | | | | - BGL | | | | | | | | | | - ETCO~2~ | | | | | | | | | | - Infusion | | | | | pump(s) | | | | | | | | | | - Arterial | | | | | line | | | | | established | | | | | | | | | | - IDC in situ | | | | +-----------------+-----------------+-----------------+-----------------+ | Have all | | | | | medications | | | | | required for | | | | | transport been | | | | | prepared and | | | | | supplied? | | | | +-----------------+-----------------+-----------------+-----------------+ | Have all | | | | | medications or | | | | | prescriptions | | | | | required for | | | | | ongoing care | | | | | been provided | | | | | and included as | | | | | part of | | | | | handover | | | | | documentation? | | | | +-----------------+-----------------+-----------------+-----------------+ | Have all | | | | | patient | | | | | belongings been | | | | | accounted for | | | | | and are they | | | | | able to be | | | | | transported? | | | | +-----------------+-----------------+-----------------+-----------------+ | Is patient | | | | | aware of the | | | | | reasons for | | | | | transfer and do | | | | | they consent to | | | | | the transfer | | | | | (where | | | | | appropriate)? | | | | +-----------------+-----------------+-----------------+-----------------+ Table 9. Post transport checklist Item Yes No N/A ---------------------------------------------------------------------------------------------------- ----- ---- ----- Has verbal handover been provided to receiving facility? Has a patient care record been completed? Has a patient care record been provided to receiving facility (medium-high acuity only)? Have patient belongings, medication and clinical notes been transferred to the receiving facility? CPP004: ­Cardiac arrest -- adult ================================ Signs of life ------------- Any patient who is unconscious and not breathing normally (for example, gasping, agonal breathing) should be presumed to be in cardiac arrest. Palpation of a pulse is unreliable, if any doubt exists as to the presence of a pulse, chest compressions must be commenced. High-quality CPR principles --------------------------- - Rate: 100-120 compressions per minute - Depth: ≥ 5 cm, allow for full recoil - Ventilation duration: 1 second per ventilation (aiming to see rise and fall of the chest) - Two-minute rotations of compressor - Minimise interruptions to chest compressions (including while pad placement occurs) - Optimal defibrillation pad positioning - Resume compressions immediately after defibrillation or disarm/no shock delivered. Compression ratio: ------------------ ### No SGA (OP/NPA/BVM) - 30 compressions : 2 ventilations - Pause for ventilations. ### SGA or ETT in situ - 15 compressions : 1 ventilation - 6-8 ventilations per minute - No pause for ventilations. Defibrillation pad placement ---------------------------- Optimal defibrillation pad positioning ensures transmyocardial current density is maximised when defibrillation occurs. - Apex pad is positioned on the left, at the mid axillary line, 6th intercostal space - Sternal pad rolled on laterally from right sternal margin on the patient's right chest, under the right clavicle and above the right nipple. General notes ------------- - For the purposes of the protocols, an automatic external defibrillator (AED) is regarded as being the same as a semi‑automatic external defibrillator (SAED) - High-quality ECC and defibrillation are the cornerstone of resuscitation -- this must be prioritised over all other interventions - If CPR is commenced, escalation of care **CPP006** is required as early as practicable. ### Hypothermic cardiac arrest \< 30°C - The primary goal is to prevent further heat loss prior to ROSC or transport - significant improvement in temperature from prehospital intervention is unlikely - Double the interval for Adrenaline and Amiodarone dose. ### Traumatic cardiac arrest Where trauma is the suspected cause of cardiac arrest prioritise control of major haemorrhage over all other interventions. Follow management within CPP002 Clinical approach to assessment - unplanned major trauma presentation. ### Withholding or ceasing resuscitation Refer to Appendix 2: Withholding or ceasing resuscitation. Figure 4. Cardiac arrest algorithm  CPP005: Cardiac arrest -- paediatric ==================================== This guideline applies to patients \ 21-35 % 1-6 L/min Simple face mask (Hudson mask) 40-60% 6-8 L/min Non-rebreather mask (NRB) \> 60% 10-15 L/min Bag valve mask (BVM) 100% (with good seal) 15 L/min or enough to inflate reservoir bag Nebuliser mask (NEB) 40-50% 8 L/min Figure 6. Oxygen administration guidance  CPP008: Narrow complex tachycardia (NCT) ======================================== Typically, tachyarrhythmias will present to high acuity services undertaking cardiac-related IFT, however may present as an incidental finding. Where there is an agreed management plan or medical order, in the case of a tachyarrhythmia this takes precedence over the management options presented below. Narrow complex tachycardias (NCT) present when a pacemaker site above the ventricles is firing abnormally. NCT ECG strips will have differences depending on the rhythm but share the characteristic of having a QRS complex \< 0.12s and a rate \> 100. NCT are generally divided into the following types which may be identifiable by NEPT crew members. - Sinus tachycardia (STach) - (Rapid) atrial fibrillation (R-AF) - Paroxysmal supraventricular tachycardia (PSVT/SVT) - Atrial flutter (AFlutter) - Atrial tachycardia - Junctional tachycardia. NEPT crew members should be suspicious of unexplained sinus tachycardias as this may be a sign of physiological distress. Some common medicines that may be provided by sending health services to high acuity NEPT services include: - Adenosine - Calcium channel blockers (for example, diltiazem or verapamil) - Beta blockers (for example, metoprolol or sotolol) - Anti-arrhythmic medicines (for example, amiodarone or flecainide). Synchronised cardioversion is not to be authorised for routine use by NEPT crew members. Figure 7. Management of NCT CPP009: Wide complex tachycardia (WCT) ====================================== NEPT providers are not authorised to routinely commence transfer of a patient with a current WCT at time of transfer from a facility, however situations may arise where a WCT presents during the course of transport. WCT is defined as: - Lasting \> 30 seconds - Rate \> 100 - QRS \> 0.12 seconds - Regular - AV dissociation or absence of P waves. WCT may present for a number of reasons, including: - cardiomyopathy - acidosis - coronary artery disease - drug toxicity - Hyperkalaemia. In the out-of-hospital environment without access to further diagnostic facilities a WCT should always be presumed to be a ventricular tachycardia (VT) and managed with anti-arrhythmics unless specifically planned for (for example, transfer of a patient with known hyperkalaemia). All WCT should be managed with a high degree of caution and with the assumption of deterioration regardless of perfusion status at time of presentation. The majority of NEPT services will not require the management options contained within this protocol. Management of WCT will be an infrequent occurrence and therefore clinical consult as part of escalation is strongly recommended. Figure 8. Management of WCT  CPP010: Bradycardia =================== Bradycardia may be defined as a heart rate \< 60 bpm however many people may have a heart rate between 50-60 bpm in their day-to-day lives. Escalation of care and decision to transport should be guided by the 'not suitable for NEPT' criteria. The management indicated within this protocol relates to an unplanned presentation of symptomatic bradycardia during transport. Unstable symptomatic bradycardia requiring intervention is defined as the following: - Less than adequate perfusion (for example hypotension or altered mentation) - HR \< 20 regardless of overall perfusion status - Persistent ventricular escape rhythms or runs of VT in between bradycardia. Note that atropine may not be effective in the case of a complete or 2^nd^ degree type II heart block, however, should still be administered. Occasionally high acuity NEPT may be required to transport patients who are undergoing investigation for bradycardia who have active management. Common medication infusions which may be encountered include: - Isoprenaline - Dopamine - Adrenaline (epinephrine). External transcutaneous pacing is not routinely authorised for use by NEPT crew members. The majority of NEPT services will not require the management options contained within this protocol. Management of symptomatic bradycardia will be an infrequent occurrence and therefore clinical consult as part of escalation is strongly recommended. Figure 9. Management of bradycardia CPP011: Sepsis recognition and escalation ========================================= Sepsis is a condition which spans a clinical continuum with a complex series of interactions of inflammatory responses and microvascular injury which ultimately may lead to a state of septic shock and is one of the leading causes of preventable death worldwide. NEPT services are often the transport means for vulnerable members of the community with the potential for any infective process to progress into sepsis. The following are some risk factors for infection progressing to sepsis: - Elderly patients - Compromised immune system including patients undergoing chemotherapy treatment - Chronic kidney or liver disease - Admission to hospital for a significant length - Recent antibiotic administrations - Invasive devices, for example an in-dwelling catheter (IDC). For this reason, an NEPT specific sepsis recognition and escalation pathway has been developed to assist NEPT crew members to identify and escalate care. While management options may be limited in NEPT services, early identification and escalation of care is aimed at preventing severe complications of sepsis. Criteria have been developed based on a modified systemic inflammatory response syndrome SIRS criteria and a modified sepsis related organ failure (qSOFA) criteria with the recognition that blood analysis, in particular blood lactate and white cell count (WCC), is not feasible in the NEPT environment. Figure 10. Sepsis recognition and management  CPP012: Undifferentiated shock ============================== NEPT crew members may encounter patients who are in a state of shock as an incidental finding during the course of unplanned NEPT activities, such as when responding to cases generated by Triple Zero '000' or SHEMP activations or as an acute deterioration during IFT. Shock can be defined as a state of cellular and tissue hypoxia due to either reduced oxygen delivery, increased oxygen consumption, inadequate oxygen utilization or a combination of these processes. It is important to consider a patient's overall perfusion status when determining shock. The most visible marker of shock is profound hypotension and for this reason may be the decision point to initiate intervention. Overall perfusion status should be established using the perfusion status assessment table 2. Shock is divided into different types based on the cause. Table 12 lists the types of shock and common examples: Table 12. Shock types +-----------------------------------+-----------------------------------+ | Shock type | Example cause(s) | +===================================+===================================+ | Obstructive shock\ | - Tension pneumothorax | | (unlikely during NEPT service | | | delivery) | - Haemothorax | | | | | | - Cardiac tamponade | +-----------------------------------+-----------------------------------+ | Cardiogenic shock | - Acute myocardial Infarction | | | | | | - Tachyarrhythmias | | | | | | - Bradyarrhythmias | +-----------------------------------+-----------------------------------+ | Distributive shock | - Sepsis | | | | | | - Anaphylaxis | | | | | | - Neurogenic shock | +-----------------------------------+-----------------------------------+ | Hypovolaemic shock\ | - Lack of blood volume | | (unlikely during NEPT service | (haemorrhage) | | delivery) | | | | - Lack of systemic volume\ | | | (vomiting, diarrhoea, burns) | +-----------------------------------+-----------------------------------+ NEPT crew members should consider management of specific conditions relevant, which may\ lead to a shocked state, and manage these as per the applicable CPP, For example: - Anaphylaxis should prioritise management with adrenaline (epinephrine) according to\ CPP020 Anaphylaxis - Bradycardia should prioritise management to increase heart rate according to CPP010 Bradycardia - Tachyarrthymias should prioritise a decrease in heart rate according to CPP008 Narrow complex tachycardia or CPP009 Wide complex tachycardia - Cardiogenic shock associated with ACS should be managed according to CPP013 Cardiogenic shock. NEPT high acuity services may transport patients who have a condition that would lead to a shocked state provided that these patients are not expected to deteriorate enroute and are stable at time of transfer. Prior to departure from the sending facility a plan for deterioration needs to be agreed upon with a medication order and infusion schedule prepared. Some common vasopressors: - Noradrenaline (norepinephrine) - Adrenaline (epinephrine) - Metaraminol - Vasopressin - Dopamine - Phenylephrine - Dobutamine. Management options presented below represent management of an undifferentiated acute shock state and/or following initial unsuccessful management of a presumed cause for which no other management option is presented. The majority of NEPT services will not require the management options contained within this protocol. Management of undifferentiated shock will be an infrequent occurrence and therefore clinical consult as part of escalation is strongly recommended. Figure 11. Management of undifferentiated shock CPP013: Cardiogenic shock ------------------------- Cardiogenic shock can be defined as a shock state (SBP \ - Isolated hypotension (SBP \< 90mmHg) following exposure to a *known* antigen, - Isolated respiratory distress following exposure to a *known* antigen. Where doubt exists about the diagnosis of anaphylaxis in the absence of any definitive other differential diagnosis, manage as per anaphylaxis and escalate care early. Anaphylaxis management is centred around early intervention with IMI adrenaline. Other considerations should follow and not interrupt regular IMI adrenaline doses. **\ ** Figure 18. Management of anaphylaxis - adult CPP022: Anaphylaxis -- paediatric ================================= The background information, recognition (RASH+ criteria) and management goals of anaphylaxis are broadly similar to the adult population. Below is a modified protocol for paediatric anaphylaxis: #### Recognition of anaphylaxis (RASH criteria) Anaphylaxis can be reasonably suspected using the following criteria ('RASH +'): - Sudden onset of symptoms (usually \< 30 min or up to 4 hours) AND - Two or more of RASH. If two or more symptoms, consider differential diagnosis. If nothing obvious or easy to confirm, manage as anaphylaxis. - R: Respiratory distress - A: Abdominal symptoms (vomiting, nausea, diarrhoea) - S: Skin or mucosal symptoms (rash, discolouration or mucous secretion) - H: Hypotension (SBP \< 90) OR - Isolated hypotension (SBP \< 90mmHg) following exposure to a known antigen OR - Isolated respiratory distress following exposure to a known antigen. Where doubt exists about the diagnosis of anaphylaxis in the absence of any definitive other differential diagnosis, manage as per anaphylaxis and escalate care early. Anaphylaxis management is centred around early intervention with IMI adrenaline. Other considerations should follow and not interrupt regular IMI adrenaline doses. Contact PIPER on 1300 137 650 for guidance for ongoing management. Clearly state position and that the call is coming from a NEPT service. **\ ** Figure 19. Management of anaphylaxis - paediatric **\ ** CPP023: Acute coronary syndrome -- cardiac chest pain ===================================================== Acute coronary syndrome (ACS) can be defined as a group of diseases in which blood flow to the heart is decreased. Specifically, ACS that this protocol applies to include: - ST-elevation myocardial Infarction (STEMI) - non-ST elevation acute coronary syndrome (NSTEAC), including non-ST elevation myocardial infarction (NSTEMI) and unstable angina - persistently increasing angina without definitive evidence of myonecrosis (heart muscle damage). For the purposes of NEPT service delivery, the presence of suspicious acute central chest pain or epigastric pain which cannot be explained by other definitive diagnosis, should lead NEPT crew members to suspect ACS and manage accordingly. Some other symptoms of concern include: - nausea or vomiting - diaphoresis - ECG abnormalities - pain radiating to jaw or back - pain in chest or epigastric region that is described as aching, pressure, tightness or burning - dyspnoea. The goal of NEPT management of ACS is to reduce platelet aggregation through the administration of aspirin, rapid clinical escalation, a reduction in myocardial workload by reducing hypertension with GTN, and pain relief. In the case of ACS, the complete removal of pain is unlikely. The goal of analgesia should be to provide a level of pain relief which the patient considers mild. 12-lead ECGs may be acquired by NEPT services where there is capacity and appropriate equipment. Where a suspicious ECG is identified, this should be communicated as part of clinical escalation. Management of associated symptoms (for example, nausea and vomiting, pain relief, acute cardiogenic pulmonary oedema) should be conducted as per the appropriate CPP. Figure 20. Management of acute coronary syndrome  **\ ** CPP024: Hypoglycaemia ===================== Hypoglycaemia is defined as blood glucose level (BGL) concentration less than 4 mmol/L. Signs and symptoms of hypoglycaemia may not occur until levels lower than this and may include: - altered level of consciousness (or unconscious) - agitation - dizziness - increased appetite - sweating. Hypoglycaemia is usually found in patients who have diabetes and are undergoing management with insulin, meglitinides and sulfonylureas. Accidental overdoses of medication (usually relative to the amount of energy intake the person is consuming) are the most common cause of hypoglycaemic episodes. Hypoglycaemia may also be found in certain patient cohorts who are not diabetics including: - alcoholic patients - patient with critical illness or trauma - patients suffering from counter-regulatory hormone deficiencies - patients with some cancers. Hypoglycaemia management is aimed toward correcting the low BGL and supportive care including airway security (if required). It is important to note that glucagon may not be effective in patients who have low stores of glycogen, including: - frail or elderly - people on low