Clinical Practice Guidelines ALS and MICA Paramedics PDF

Clinical Practice Guidelines ALS and MICA Paramedics Version 3.12.14 Exported 15/10/2024 About This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. © Ambulance Victoria 2019 These clinical practice guideli...

Clinical Practice Guidelines ALS and MICA Paramedics Version 3.12.14 Exported 15/10/2024 About This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. © Ambulance Victoria 2019 These clinical practice guidelines, protocols, work instructions and tools (‘the work’) have been developed and are owned by Ambulance Victoria, with the exception of content provided by third parties and other excluded material identified below. An online version of the work can be accessed from https://cpg.ambulance.vic.gov.au With the exception of: Ambulance Victoria’s branding, logos and trademarks; other trademarks, logos and coats of arms; and content supplied by third parties, images supplied by third parties. The work is available under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Licensees can copy and distribute the material for non-commercial purposes only. If you remix, transform or build upon the material you may not distribute the modified material. To view a copy of this licence visit the Creative Commons website using the following link: https://creativecommons.org/licenses/by-nc-nd/4.0/legalcode Use of the work under the above Creative Commons License requires you to attribute the work in any reasonable manner requested by Ambulance Victoria, but not in a way that suggests Ambulance Victoria endorses you or your use of the work. The following is provided to enable you to meet your obligation under the Creative Commons License. Material used ‘as supplied’ Source: ‘Clinical Practice Guidelines for Ambulance and MICA Paramedics’, Ambulance Victoria, 2019. Available under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Derivative material for internal use only Based on ‘Clinical Practice Guidelines for Ambulance and MICA Paramedics’, Ambulance Victoria, 2019, as amended by [insert name]. The original resource is available under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. An online version of the original resourced can be accessed from https://cpg.ambulance.vic.gov.au. Third Party Copyright In some cases, a third party may hold copyright in material presented in this work. Their permission may be required to use that material. About Page 1 1 This is an uncontrolled document, it is the reader’s responsibility to ensure currency. About Enquiries Enquiries in relation to these guidelines can be emailed to: [email protected] DISCLAIMER These clinical practice guidelines, protocols, work instructions and tools are expressly intended for use by Ambulance Victoria paramedics and first responders when performing duties and delivering ambulance services for, and on behalf of, Ambulance Victoria. Other users: The content of this work is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Ambulance Victoria does not represent or warrant that the content of this work is accurate, reliable, up-to-date, complete or that the information contained in this work is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant or complete and where appropriate, seek independent professional advice. To the maximum extent permitted by law, Ambulance Victoria excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on this work or any information contained in this work (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with this work or its use). This work provides links to external websites. Ambulance Victoria does not control and accepts no liability for the content of those websites or for any direct, special, indirect, incidental, consequential, punitive, exemplary, or other loss, cost, damage or expense arising from use or reliance on those websites. Ambulance Victoria does not endorse any external website and does not warrant that they are accurate, authentic, reliable, up-to-date, relevant or complete. Your use of any external website is governed by the terms of that website. The provision of a link to an external website does not authorise you to reproduce, adapt, modify, communicate or in any way deal with the material on that site. If this work contains links to your website and you have any objection to such links, please contact Ambulance Victoria at: [email protected] Developed by Media4Learning: www.media4learning.co.nz About Page 2 2 This is an uncontrolled document, it is the reader’s responsibility to ensure currency.  Clinical Approach CPG A0101 Care Objective To ensure all patients receive a structured and comprehensive assessment of their health status that leads to their healthcare needs being addressed. Intended patient group All patients This CPG represents a minimum standard of assessment. If a full assessment is not completed or is deemed unnecessary the rationale MUST be documented. Pre-arrival Biases & human factors Cognitive bias and human factors have a significant impact on decision making and should be considered and discussed frequently throughout the entire process of patient care. Early diagnostic closure based on dispatch information presents a particular risk to patient safety. Patients from marginalised populations are at greater risk of harm from unconscious bias. These risks include low socioeconomic status, culturally and linguistically diverse, Aboriginal or Torres Strait Islander, substance affected, have a mental health related presentation or behaviours of concern. Human factors and their potential impact on patient care should be considered and acknowledged prior to arrival and throughout patient assessment: — Hungry — Angry — Late — Tired — Stressed Assessment Information on the patient’s health status is collected in a structured, reproducible and comprehensive way. Assessment is a cyclic process. Certain information may need to be prioritised upon initial assessment in high acuity patients or where urgent care is required (e.g. extreme pain). Where this is the case, a second or third cycle should involve more thorough and complete information collection. Rapid assessment Immediate impression based on the presence of altered conscious state, increased work of breathing and obvious skin signs (e.g. diaphoresis, cyanosis) that informs: — The need for a formal primary survey — This is an uncontrolled document, it is the reader's responsibility to ensure currency. 3 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 1 of 7  Clinical Approach CPG A0101 — The urgency with which the patient should be assessed and the need for simultaneous collection of information Primary survey If a patient deteriorates the default position should be to return to the primary survey for reassessment. Exposure: Refers to both exposing the patient for assessment (e.g. to locate possible major haemorrhage) and exposure to environmental conditions. Patient dignity should be maintained as much as possible while managing the risk of potential life-threatening conditions. Prevent hypothermia following exposure. History of the presenting illness Avoid interrupting or redirecting the patient where possible during initial history taking. Appears well / non-serious complaint: Avoid concurrent vital signs and other assessment elements where possible to allow for uninterrupted, thorough history taking. Appears unwell / serious complaint: Concurrent assessment as required (e.g. 12 lead ECG in chest pain, SpO2 in acute SOB). Accountability and responsibilities All paramedics at scene are accountable for ensuring the patient receives appropriate and safe care. Where two paramedics attend a case, both should be present for assessment if possible to allow for shared decision making. Attendant 1: Assess the patient directly, taking the lead in history taking and physical examination. Attendant 2: Observes assessment and scene with minimal cognitive load, collects information and identifies missed information, errors or opportunities. Vital signs & adjuncts BSL must be measured in patients with: — Altered conscious state — History of diabetes — Medical patients with undifferentiated acute illness Physical examination Focussed examination: found in specific CPGs indicated for particular complaints (e.g. ACT- FAST/MASS, AEIOUTIPS, Spinal neurological examination, etc.) General physical examination: Any other physical assessment informed by the paramedic’s evolving understanding of the patient’s presenting illness Social / Environmental factors May present a range of hazards and health risks which influence their care plan as much as the diagnosis or clinical problems. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 4 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 2 of 7  Clinical Approach CPG A0101 Diagnosis Information related to the patient’s presentation is subjected to a process of critical analysis to identify and define the patient’s healthcare needs. Diagnosis: Any clinically useful characterisation of the patient’s health status that leads to a care plan that meets the patient’s needs. This includes a likely underlying pathology and/or a simple statement of clinical problems to be addressed. All stages of the diagnostic process should be discussed between AV staff and with the patient / family where possible and appropriate. Risk The identification of risk and the subsequent escalation of care is more important than a precise diagnosis and allows for safe decision making where there is diagnostic uncertainty (this is expected to be frequent). Initial assessment captures a single moment in time. The patient’s trajectory or expected clinical course should be considered despite an unremarkable initial assessment. Differential Diagnosis Diagnostic uncertainty is common and should be acknowledged. Where the underlying cause is uncertain, a care plan may be based on clinical problems (e.g. hypotension) and/or risks (e.g. elderly and frail). Clinical judgement Clinical judgement is a subjective process to establish the most appropriate and accurate characterisation of the patient’s condition that leads to a safe and effective care plan. — Most appropriate diagnosis based on a balance of the urgency and likelihood of possible conditions — A hierarchy of clinical problems requiring management — The risks to patient safety Expert consultation and/or the escalation of care (e.g. transport) is recommended where clinical judgement does not lead to a satisfactory diagnosis, clinical problem and risk profile (e.g. staff on scene cannot agree). Care pathway A care plan that addresses the patient’s needs is developed, applied and evaluated. Treatment: Apply the appropriate CPG, CWI, direct care (e.g. wound dressing) or the patient’s own care plan as required (e.g. palliative patients, medically prescribed crisis medications) Escalation of care Escalation of care should occur as soon as possible after recognition of deterioration. This may This is an uncontrolled document, it is the reader's responsibility to ensure currency. 5 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 3 of 7  Clinical Approach CPG A0101 include transport to ED or specialist facility, MICA, HEMS, PIPER, expert consultation, etc. Family members / carers may be able to identify deterioration earlier in the patient’s course. Family / carer concern should be considered in decisions relating to escalation of care. Care can be escalated at any stage and for any reason at the judgement of the paramedic. Referral A referral resource containing a summary of the assessment, care plan, safety netting and referral instructions MUST be provided and explained to the patient in all instances of non-transport including refusal. Safety netting: A plan to address unexpected but possible adverse events or deterioration. Apply the concept of safety netting in all patients who are not transported to hospital. A patient treated with the intention of referral away from ED must be reassessed prior to departure. If the patient has deteriorated or has not responded to treatment as expected, then revise the care plan and transport them to ED. Access to care In order to be safe and effective, the care plan must be feasible and the patient must have access to the resources necessary to enact the plan. The following barriers should be considered: — Socio-economic status & health literacy — Logistic issues (e.g. opening times, transport) — Patient’s location in relation to health services — Linguistic or cultural barriers — Disability related barriers Reassessment 15-minutely VSS reassessment is the minimum standard. Where it is impossible or clinically unnecessary, the rationale MUST be documented. Where a patient is considered unwell or deteriorates, reassessment should be performed more frequently and care escalated as appropriate. Reassessment should include: — SpO2, HR, BP, RR, GCS and any other observation that was initially found to be abnormal (e.g. haemorrhage, pain, SOB) — The efficacy and safety of any treatments (e.g. tourniquets, CPAP, splint, thoracostomies, ETT) This is an uncontrolled document, it is the reader's responsibility to ensure currency. 6 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 4 of 7  Clinical Approach CPG A0101 Transfer of care Continuity of care is supported through a seamless and safe transfer of care. Where the patient is referred into the community, the effective transfer of information from paramedics to other healthcare professionals is as important as handover in an ED. Attempt to make direct contact with the healthcare professional and include relevant information regarding the patient’s presentation in the referral resource. Avoid the transmission of bias to other healthcare professional by the use of biased language at handover or in documentation. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 7 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 5 of 7  Clinical Approach CPG A0101 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 8 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 6 of 7  Clinical Approach CPG A0101 Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/CPG Clin approach_consent and capacity_clin flags.pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 9 Version 5.0.0 - 13/02/2020 Exported 14/10/2024 Clinical Approach CPG A0101 Page 7 of 7  Major Incidents CPG F0026 First resource to any major incident 1. Adopt Roles - Triage Officer (most experienced) and Transport Officer 2. SITREP 3. Triage 1 Adopt Roles Triage Officer Transport Officer Most experienced staff member assumes scene Supports and follows directions of the Triage leadership role Officer Put on Triage Officer vest Put on Transport Officer vest Assume scene leadership (direct the Follow directions of the Triage Officer Transport Officer) Assess scene safety Assess scene safety Triage patients (SmartPac triage cards) as Do initial scene walkthrough and scene directed by the Triage Officer size-up to inform a SitRep (≤15 min) Provide clinical care as directed by the Triage patients (SmartPac triage cards) or Triage officer direct Transport Officer to triage patients Coordinate access and egress Establish scene layout - Casualty Clearing Point and, Loading Point, Holding Point Maintain Casualty Movement Log for all patients Direct newly arrived resources to patients Supervise Casualty Clearing Point Regular SitReps Coordinate transport vehicles and briefs Handover / Report to Incident Health responding crews (access; egress; safety) Commander when established 2 SitRep E xact location of incident T ype of incident H azards at scene A ccess/Egress to/from scene N umber of patients (based on priority) E mergency Services at scene and required This is an uncontrolled document, it is the reader's responsibility to ensure currency. 10 Version 1.1.0 - 15/10/2024 Exported 14/10/2024 Major Incidents CPG F0026 Page 1 of 5  Major Incidents CPG F0026 3 Triage Triage - Sieve Use Sieve for initial triage and whenever time / resources restrict detailed assessment. Triage Sort When sufficient time and resources are available, a more detailed secondary triage using the Sort method. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 11 Version 1.1.0 - 15/10/2024 Exported 14/10/2024 Major Incidents CPG F0026 Page 2 of 5  Major Incidents CPG F0026 General Notes This information is a summary of the AV Emergency Response Plan which provides a framework for the management of major incidents across AV. Safety When approaching an incident, personnel must: — Undertake a Dynamic Risk Assessment — Be aware of the Safety Zones (hot, warm, cold zones) — This is an uncontrolled document, it is the reader's responsibility to ensure currency. 12 Version 1.1.0 - 15/10/2024 Exported 14/10/2024 Major Incidents CPG F0026 Page 3 of 5  Major Incidents CPG F0026 — Limit or mitigate exposure to risks and hazards Actual or potential High Threat Environment (e.g. Active Armed Offender) — If you don’t believe it is safe, then don’t enter. — Request Police immediately, with clear information — If suspected after entry, retreat and activate duress alarm immediately. Offer limited assistance to others where it is safe to do so. Incident Health Commander (IHC) Role The IHC will received handover from the Triage Officer once at scene and assumes command including the coordination of AV resources. AV staff attending the scene must follow the directions of the IHC who is the strategic leader at scene. IHC tasks include: — Put on Health Commander vest — Reviewing scene safety and the need for a Safety Officer — Ensure Triage and Transport Officers are in place — Assess the scene (patients; geography; complexity) — ETHANE SITREPs 20 weeks gestation) Push the uterus to the left side to minimise aorto-caval compression (manual uterine displacement). — If this is not feasible, consider tilting the patient to the left. Where mCPR is available, consult early with the AV Medical Advisor and PIPER via the AV Clinician for consideration of transport for resuscitative hysterotomy. Notify hospital as soon as possible once the decision to transport is made. Manual uterine displacement procedure Manual displacement of the uterus is challenging and requires one person dedicated to this task throughout the arrest. The purpose is to relieve aorto-caval compression and improve cardiac output. Positioned to left of patient (A): Use two hands to cup and lift the uterus to the left Positioned to right of patient (B): Use one hand to push the uterus up and to the left This is an uncontrolled document, it is the reader's responsibility to ensure currency. 72 Version 8.0.0 - 15/10/2024 Exported 14/10/2024 Medical Cardiac Arrest CPG A0201-1 Page 9 of 12  Medical Cardiac Arrest CPG A0201-1 Image: Manual uterine displacement2 Consider tilting the patient to the left (approx. 15°- 30°) if manual uterine displacement is not feasible, however this may negatively impact the effectiveness of chest compressions. Implantable devices Permanent pacemaker — Apply ECG electrodes when time / resources permit without interrupting HP-CPR. More information Pacing spikes may be mistaken for QRS complexes despite the patient being in a shockable rhythm. Applying ECG electrodes and viewing alternative leads can assist in differentiating pacing spikes from QRS complexes. Ventricular assist devices (VAD) — Anterior-posterior pad placement if possible: — Apex pad: Left anterior chest wall, halfway between the xiphoid process and the left nipple. — Sternal pad: To the left of the spine and below the scapula. — Do not disconnect the pump. — Contact the Alfred Hospital Heart Failure Registrar or Consultant via the AV Clinician as soon as possible. — Patients with a VAD do not generally have a palpable pulse. Pulse checks cannot be used to diagnose cardiac arrest or ROSC. Interfering CPR-induced consciousness (CPRIC) The primary aim of management is to gain control of patient symptoms as soon as possible to recommence HP-CPR. Where any of the following are present: — Interference with CPR — Gag reflex is present preventing adequate oxygenation / ventilation or SGA / ETT insertion — Suspected awareness / pain / combative movements interrupting resuscitation Administer: — Ketamine 50 – 100 mg IV every 1-2 minutes (no max. dose). — No IV access: Ketamine 200 mg IM (single dose). — Consider Rocuronium 150 mg IV to facilitate intubation if unable to provide adequate oxygenation / ventilation following at least 1.5 mg / kg IV Ketamine. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 73 Version 8.0.0 - 15/10/2024 Exported 14/10/2024 Medical Cardiac Arrest CPG A0201-1 Page 10 of 12  Medical Cardiac Arrest CPG A0201-1 Consider the patient’s weight and severity of symptoms to determine ketamine dose. Cardiac arrest secondary to hypothermia < 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, amiodarone and lignocaine doses. ROSC is unlikely to be achieved if more than 3 shocks are required while the patient remains severely hypothermic - consider AAV or mCPR for transport. Where these resources are not available, continue DCCS as per standard cardiac arrest. For patients in cardiac arrest where hypothermia is clearly the cause, mCPR to hospital may be appropriate. Consult the AV Medical Advisor via the Clinician for management advice. Tension pneumothorax Where tension pneumothorax is considered to be the cause of cardiac arrest, in either medical or traumatic arrest, decompress the chest bilaterally. Clinically significant pneumothorax as a result of chest compressions is very unusual and chest decompression should not be routine in medical cardiac arrest. Point of care ultrasound should be used if credentialled to confirm absence of lung sliding before attempting chest decompression. Hyperkalaemia Indiscriminate use of calcium in cardiac arrest is associated with harm.3, 4 A hyperkalaemic cause of arrest should only be considered if: — The potassium level has been measured and is known to be elevated (>6 mmol/L) or — Hyperkalaemia is very strongly suspected (typically only patients with renal failure / dialysis or following a significant crush injury). Outside of these settings, the use of calcium will cause more harm than any benefit obtained. Flush with 10 mL normal saline between administration of calcium gluconate and sodium bicarbonate. Hypovolaemia / anaphylaxis / asthma In PEA arrest where hypovolaemia, anaphylaxis or asthma is suspected or the patient has a rhythm that may be fluid responsive, administer normal saline 1000 – 2000 mL IV. Hypoglycaemia Measure BGL after all other management is established. Manage hypoglycaemia as per CPG A0702 Hypoglycaemia. More information Hypoglycaemia in cardiac arrest is rare. However, BGL should be measured and hypoglycaemia treated. It is important that measurement of BGL does not interrupt other more important management in any way. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 74 Version 8.0.0 - 15/10/2024 Exported 14/10/2024 Medical Cardiac Arrest CPG A0201-1 Page 11 of 12  Medical Cardiac Arrest CPG A0201-1 Intra-arrest thrombolysis Consult AV Medical Advisor via the AV Clinician for thrombolysis as per CPG A0408 STEMI Management if the patient experiences a witnessed arrest due to a known or strongly suspected PE. Thrombolysis should only be considered if there are sufficient resources at the scene to continue HP- CPR for up to 60 minutes post administration of thrombolysis. Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/MAC Paper - Medical Cardiac Arrest 2024.pdf References 1. Soar J, Maconochie I, Wyckoff MH, Olasveengen TM, Singletary EM, Greif R, et al. 2019 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation. 2019;140(24):e826-e80. 2. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_Suppl_2):S366-S468. 3. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out- of-hospital cardiac arrest: a randomized clinical trial. Jama. 2021;326(22):2268-76. 4. Padrao EMH, Bustos B, Mahesh A, de Almeida Castro M, Randhawa R, Dipollina CJ, et al. Calcium use during cardiac arrest: A systematic review. Resuscitation Plus. 2022;12:100315. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 75 Version 8.0.0 - 15/10/2024 Exported 14/10/2024 Medical Cardiac Arrest CPG A0201-1 Page 12 of 12  Traumatic Cardiac Arrest CPG A0201-2 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 76 Version 7.0.0 - 15/10/2024 Exported 14/10/2024 Traumatic Cardiac Arrest CPG A0201-2 Page 1 of 5  Traumatic Cardiac Arrest CPG A0201-2 Care Objectives Major haemorrhage control over all other interventions Management of correctable causes in order of clinical need: — Hypoxia — Tension pneumothorax — Hypovolaemia Standard cardiac arrest management concurrent to addressing correctable causes (if resources permit) General Notes Intended patient group Patients aged ≥ 16 years in traumatic cardiac arrest Consider medical cause: In cases where the history, mechanism or injuries are inconsistent with traumatic cardiac arrest, or patient is in VF / VT. If any doubt exists as to the cause of arrest, treat as per CPG A0201-1 Medical Cardiac Arrest. More information The Traumatic Cardiac Arrest CPG should be applied only when the cause of cardiac arrest is clearly traumatic. Medical cardiac arrest may lead to incidents with the potential to cause injury (e.g. slow speed MVA, standing height fall). If these patients receive traumatic cardiac arrest care, it may delay defibrillation and chest compressions. Strongly suspect a medical cause of arrest where the MOI and history do not suggest the potential for severe injuries. Management The potential causes of cardiac arrest should be managed in order of clinical need. Treating correctable causes should be prioritised over standard cardiac arrest care (chest compressions and adrenaline). More information Undifferentiated trauma vs obvious cause Uncertain cause: in the absence of a clear cause, or where it is probable there are multiple causes, it is reasonable to apply all interventions in the CPG in the order presented (i.e. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 77 Version 7.0.0 - 15/10/2024 Exported 14/10/2024 Traumatic Cardiac Arrest CPG A0201-2 Page 2 of 5  Traumatic Cardiac Arrest CPG A0201-2 haemorrhage control, airway, breathing, circulation). This is likely to be the most common type of traumatic arrest. If resources permit, multiple interventions should be performed concurrently including standard cardiac arrest care. Obvious causes: Where there is a clear etiology (e.g. amputation), it is not mandatory to provide all interventions in this CPG (e.g. chest decompression). In cases of witnessed traumatic arrest, prioritise treatment to address the most likely cause first. If there is any doubt as to the cause, all interventions should be provided. Standard medical arrest Chest compressions are not likely to be effective in the setting of hypoxia, tension pneumothorax and severe hypovolaemia. As such they are not the priority. However, there is no requirement that standard cardiac arrest care be delayed until correctable causes have been addressed. Ideally, haemorrhage control, airway management, chest decompression, fluid resuscitation, chest compressions and adrenaline should be delivered simultaneously. Where clear signs of prolonged cardiac arrest are present or continued resuscitation may be futile, consider CPG A0203 Withholding or Ceasing Resuscitation. Major haemorrhage Control of major haemorrhage is the absolute priority in all circumstances. It can be achieved with: — Arterial tourniquets — Haemostatic dressings / wound packing — Direct pressure Undifferentiated blunt trauma: A pelvic splint should be applied after other interventions. Where pelvic fracture is clearly contributing to cardiac arrest, a pelvic splint may be applied earlier. Blood components Where available, Packed Red Blood Cells (PRBC) are preferred for fluid resuscitation over normal saline. MICA paramedics credentialed in blood component administration may administer PRBC. Legal minor: PRBC must only be administered to a child < 18 years if: — A parent / legal guardian can be contacted and the parent / legal guardian consents to the administration of a blood transfusion. OR — A medical doctor approves administration (preferably AV Medical Advisor via the AV Clinician or RCH) Religious objection: PRBC must not be administered to a patient with a known religious objection to blood transfusion (e.g. Jehovah’s Witness) and who refuses consent. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 78 Version 7.0.0 - 15/10/2024 Exported 14/10/2024 Traumatic Cardiac Arrest CPG A0201-2 Page 3 of 5  Traumatic Cardiac Arrest CPG A0201-2 Chest decompression Finger thoracostomy is the preferred method for chest decompression (where credentialed). Perform needle thoracostomy if finger thoracostomy is delayed or not available. Ultrasound Where all correctible causes have been addressed, focused assessment with sonography for trauma may be considered (where credentialled) to: — Assess cardiac wall motion and identify patients with a low flow state (low cardiac output). — Assess for cardiac tamponade. — Ensure correctible causes have been adequately managed (e.g. tension pneumothorax). Perfusion assessment ETCO2 can be used as a surrogate marker for cardiac output and may assist in identifying patients with a low flow state. Return of Spontaneous Circulation Where ROSC is achieved, manage the patient as per CPG A0810 Major Trauma. Special circumstances Penetrating truncal trauma and PEA Where a Major Trauma Service is within 20 minutes from loss of vital signs: — Immediately transport Signal 1 with early notification. — Do not stop to manage the patient if they lose vital signs en-route to hospital. Provide an updated notification to hospital and continue Signal 1. — Only perform limited interventions: haemorrhage control, basic airway management (+/- SGA) and chest decompression. — Chest compressions are not required during transport. — Do not delay for MICA, mCPR, IV or ETT insertion. More information In-hospital resuscitative thoracotomy is a priority over standard traumatic cardiac arrest management if it can be performed within 20 minutes of loss of vital signs. It can: Release tension pneumothorax Provide surgical relief of cardiac tamponade Allow direct control of intrathoracic haemorrhage Severe crush injury This is an uncontrolled document, it is the reader's responsibility to ensure currency. 79 Version 7.0.0 - 15/10/2024 Exported 14/10/2024 Traumatic Cardiac Arrest CPG A0201-2 Page 4 of 5  Traumatic Cardiac Arrest CPG A0201-2 In the setting of cardiac arrest due to severe crush injury, manage as per CPG A0201 Medical Cardiac Arrest - “Hyperkalaemia”: — Calcium gluconate 10% 6.6 mmol (3 g) IV (slow push) — Sodium bicarbonate 8.4% 100 mL IV Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/MAC Paper - Traumatic Cardiac Arrest 2024.pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 80 Version 7.0.0 - 15/10/2024 Exported 14/10/2024 Traumatic Cardiac Arrest CPG A0201-2 Page 5 of 5  ROSC Management CPG A0202 General Notes Excessive fluid administration during the intra-arrest and post-ROSC period may be detrimental. Judicious administration of fluid may be especially important in VF/ VT. The total volume of fluid administered during cardiac arrest and post-ROSC management, including RSI, should not exceed 20 mL/kg unless correcting suspected hypovolaemia. Where the cause of arrest is unclear, paramedics should assume a cardiac cause and transport to a PCI capable facility where possible. Where resources allow and other priorities have been addressed, BGL should be measured post ROSC and hypoglycaemia treated as per CPG A0702 Hypoglycaemia. The extremely combative patient Severe post-ROSC agitation / combativeness that is obstructing further care (e.g. oxygenation and ventilation in preparation for RSI) may be sedated using the following dose regimen: — Ketamine 50 – 100 mg IV every 1-2 minutes (no max. dose). — No IV access: Ketamine 200 mg IM (single dose). — Consider the patient’s weight and severity of symptoms to determine dose. — Consider a half dose if the patient is shocked. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 81 Version 5.2.0 - 15/10/2024 Exported 14/10/2024 ROSC Management CPG A0202 Page 1 of 2  ROSC Management CPG A0202 Flowchart Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/CPRIC and Agitation post-ROSC MAC Feb 2021.pdf https://av-digital-cpg.web.app/assets/pdf/MAC/MAC CPG A0203 Return of Spontaneous Circulation (ROSC) NOV 2016.pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 82 Version 5.2.0 - 15/10/2024 Exported 14/10/2024 ROSC Management CPG A0202 Page 2 of 2  Withholding or Ceasing Resuscitation CPG A0203-1 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 83 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 1 of 6  Withholding or Ceasing Resuscitation CPG A0203-1 Care Objectives Identify patients who will not benefit from resuscitation or where there is a legal requirement to withhold resuscitation Provide guidance for the cessation of resuscitation following an unsuccessful resuscitation attempt Intended patient group Patients aged ≥ 16 years presenting in medical or traumatic cardiac arrest General Notes Withholding resuscitation Where it is unclear whether to withhold resuscitation, commence resuscitation while continuing to gather information through history taking, reviewing medical documentation (if available), and visual observations. Obvious death Obvious death is characterised by any of the following: — Injuries where survival is impossible (e.g. decapitation, incineration, cranial destruction, hemicorporectomy) — Rigor mortis — Postmortem lividity — Putrefaction / decomposition — Death that has been declared by a doctor who is or was at the scene Advance Care Directives Paramedics have a legal obligation and duty of care to act in accordance with an Advance Care This is an uncontrolled document, it is the reader's responsibility to ensure currency. 84 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 2 of 6  Withholding or Ceasing Resuscitation CPG A0203-1 Directive (ACD) or the decisions of a medical treatment decision maker. A paramedic may provide or withhold treatment based upon the patient’s wishes as recorded on an ACD that is sighted by them, or paramedics may accept, in good faith, the advice from those present at the scene of the patient’s wishes and that this supporting documentation exists. A patient's ACD must be followed even where the emergency is not directly related to a pre-existing illness. If the person’s wishes are unknown or there is doubt about the documentation or its existence, paramedics are to provide routine care. Please note: The law permits provision of medical treatment in an emergency (e.g. resuscitation), without consent, to a person who does not have decision-making capacity. Emergency treatment should not be delayed while searching for an ACD (or a medical treatment decision maker), but a health practitioner must comply with a known ACD. Except in circumstances where: — The ACD instructs a health care professional to provide medically futile or unethical treatment, or — The ACD instructs a health care professional to take action(s) that would go against their code of conduct, or — The ACD cannot be readily and confidently understood and applied by the health care professional. For more information, see The Victorian Office of the Public Advocate’s A clinicians guide to medical decision making and CPG A0111 Consent and Capacity Medical treatment decision maker The medical treatment decision maker should be determined as per CPG A0111 Consent and Capacity. Prolonged cardiac arrest Less than 1% of patients presenting to paramedics in an asystolic or agonal rhythm survive to hospital discharge. Resuscitation should only be commenced on this patient cohort if they have received prior defibrillation or are known to have a bystander witnessed collapse AND paramedics begin resuscitative attempts within 10 minutes of that collapse, or a paramedic witnessed arrest. Bystander CPR and/or normal temperature is not associated with increased survival in patients with asystolic or agonal rhythms and is not a compelling reason to commence or continue resuscitation. Patients who initially present to AV in asystole following traumatic cardiac arrest not witnessed by paramedics have a 0% survival rate. Commencing resuscitation is not indicated. Initial presenting rhythm “Initial presenting rhythm” refers to the results of the first rhythm analysis conducted on the patient, regardless of provider (i.e. including public access defibrillation, EMR, etc.). If a patient has received defibrillation prior to AV arrival, the patient is assumed to have presented in VF / VT. Where patients present with Pulseless Electrical Activity (PEA), a heart rate < 20 is considered to be an agonal rhythm. The duration of resuscitation should be based on the initial rhythm rather than the rhythm the patient This is an uncontrolled document, it is the reader's responsibility to ensure currency. 85 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 3 of 6  Withholding or Ceasing Resuscitation CPG A0203-1 is presenting in at the time of deciding to cease resuscitation. Expected death Patients who are at or near end-of-life are unlikely to benefit from resuscitation or life prolonging measures. In this patient cohort the risk of potential harm and suffering outweighs any chances of meaningful survival. Withhold resuscitation where the death was expected due to the progression of a specific, advanced incurable disease. There will often be a period of deterioration in the days or weeks leading up to death. Some patients may not have an ACD in place or the family may be unsure of the details. Consider consulting the AV Medical Advisor via the AV Clinician if there is uncertainty around the decision to withhold resuscitation (e.g. there are differences of opinion in a family around the patient’s treatment). Patients with significant functional decline and frailty or severe, life limiting co-morbidities may not meet the criteria for expected death or other criteria to withhold resuscitation. — In this circumstance, early cessation of resuscitation may be considered in consultation with the AV Medical Advisor via the AV Clinician. This is considered separately to frail patients where a medical treatment decision maker is available at scene to make an informed decision on behalf of the patient. More information Patients with significant frailty or severe comorbidity rarely recover from cardiac arrest. This includes patients who are dependent on others for personal care (frailty score ≥ 7) or comorbidities such as severe COPD, chronic renal failure, advanced dementia. Current health legislation and AV policy support health practitioners, including paramedics, in not offering or administering medically futile or non-beneficial treatments. However, these decisions are often complex and challenging and it is appropriate to continue resuscitative efforts while information is collected and consultation with the AV Medical Advisor occurs. While most patients with significant comorbidities will not have the physiological reserve to recover from resuscitation, some patients may benefit from resuscitation such as a patient with renal failure who is receiving dialysis awaiting kidney transplant. Voluntary Assisted Dying In Victoria, patients with a terminal diagnosis may choose to undertake Voluntary Assisted Dying (VAD). The medication used leads to deep sedation and respiratory depression. In most patients, death from respiratory depression occurs within one hour after oral ingestion. Where AV attends a patient who is actively involved in a VAD case, it is important to note: — There will be a documented instructional Advance Care Directive for "no resuscitation". — This is an uncontrolled document, it is the reader's responsibility to ensure currency. 86 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 4 of 6  Withholding or Ceasing Resuscitation CPG A0203-1 — Family members or other health professionals (including paramedics) are not permitted to assist in the administration of the VAD medicine. — Attending paramedics are not to administer active clinical therapy or resuscitation such as oxygen therapy, assisted ventilation or IV drug / fluid administration. — Supportive care such as positioning and other comfort measures are encouraged. If the dying process is prolonged, paramedics / remote area nurses are encouraged to contact the VAD care navigator or patient’s specialist VAD doctor. If this is unsuccessful, please contact the patient’s palliative care team. For more information see the Victorian Department of Health’s Voluntary Assisted Dying website. Mass casualty incidents Mass casualty incidents are in part characterised by the available resources being overwhelmed by larger patient numbers. Where this is the case, the AV Emergency Management Unit provides guidance (CPG F0026) for patient assessment that may differ significantly from guidelines used in other situations. Aeromedical Resuscitation efforts may be ceased during Air Ambulance transport when cardiac arrest occurs in the setting of severe injury, a quickly reversible cause for the cardiac arrest has been excluded (i.e. pneumothorax, cardiac arrhythmia) and it is not practical to continue chest compressions to hospital. Communicating death, dying and comfort care If it is safe and appropriate to do so, you may offer to support a family member in viewing resuscitation efforts before they are discontinued. More information Studies have shown that some people benefit from witnessing resuscitative efforts on their loved one. If someone elects to watch the resuscitation efforts, it is essential to pre-brief them and outline the expectation of how the scene looks, how the patient looks (they will not look like themself, they will appear deceased, they may have tubes and machinery attached to them) prior to them witnessing the resuscitation. Ensure all team members are aware that a family member will be viewing the resuscitation. Once the decision to withhold or cease resuscitation is made, the priority should be providing comfort care to the patient and their family. Paramedics should consult with relevant stakeholders such as family, palliative care services, VVED, and/or the AV Medical Advisor regarding further steps in providing comfort care through the dying process. Principles that can be used to communicate when a death has occurred include: — Speak slowly, clearly and concisely. — Clump information together in 1-3 sentences and leave a pause in between to help the receiver process the news. — Use the D- words to convey death “Death” “Dying” “Die” “Dead”. Avoid phrases such as This is an uncontrolled document, it is the reader's responsibility to ensure currency. 87 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 5 of 6  Withholding or Ceasing Resuscitation CPG A0203-1 “passed away” or “your loss”. — Content may need to be repeated several times — Use a non-judgemental approach as people may respond with a range of reactions. — Provide practical guidance on next steps AV staff can use the Palliative Care Advice Service (PCAS) for advice and support in navigating both expected and unexpected deaths. PCAS can also provide grief counselling to the family both whilst AV is on scene and at a later time. The SPIKES communication framework provides a helpful approach to conversations around death and dying. Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/MAC paper - Withholding or Ceasing Resuscitation (Adult) 2.2.pdf CPG Walkthrough Video - Withholding or Ceasing Resuscitation This is an uncontrolled document, it is the reader's responsibility to ensure currency. 88 Version 9.0.0 - 15/10/2024 Exported 14/10/2024 Withholding or Ceasing Resuscitation CPG A0203-1 Page 6 of 6  Verification of Death CPG A0203-2 Verification of death Verification of Death refers to ‘establishing that a death has occurred after thorough clinical assessment of a body’. Registered 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 6 clinical elements. These are the ‘determinants of death’: — 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 pressure). — No motor (withdrawal) response or facial grimace to painful stimulus (pinching inner aspect of elbow or nail bed pressure). N.B. ECG strip that shows asystole over 2 minutes is a seventh and optional finding that may be included. Ideally the determinants of death should be evaluated 5 - 10 minutes after cessation of resuscitation to ensure late ROSC does not occur. 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. Cases of 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 and Wellbeing Act but not in care or a person unknown. A reviewable death is required following death of a child (< 18 years) 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 the printed PCR. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 89 Version 8.2.0 - 18/12/2023 Exported 14/10/2024 Verification of Death CPG A0203-2 Page 1 of 1  Supra-Glottic Airway (SGA) CPG A0301 General Notes A supra-glottic airway (SGA) provides improved airway and ventilation management compared to a bag-valve-mask and OPA. It does not offer the same level of protection against aspiration as intubation, however is it often quicker and easier to insert and may be an appropriate initial method of managing the airway. If an SGA is placed, the insertion of an orogastric tube may provide benefit in decompressing the stomach and allowing drainage of gastric contents. In the setting of cardiac arrest, insertion of an orogastric tube must not delay or interfere with higher priority actions such as uninterrupted compressions or defibrillation. Patients who require higher airway pressures e.g. pregnancy, morbid obesity, decreased pulmonary compliance (pulmonary fibrosis) or increased airway resistance (severe asthma) should be carefully monitored to ensure effective ventilation is being achieved and passive regurgitation avoided. If an SGA is inserted, ventilation proves difficult or inadequate and trouble-shooting fails to correct the issue, consider removing the SGA if ventilation is possible through another airway management plan. Three attempts in total at SGA insertion are permitted irrespective of skill-set (ALS, MICA, MFP). If difficulty is encountered in the placement of an SGA, problem solving aimed at improving the chance of success should occur prior to subsequent attempts. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 90 Version 3.1.0 - 21/09/2020 Exported 14/10/2024 Supra-Glottic Airway (SGA) CPG A0301 Page 1 of 2  Supra-Glottic Airway (SGA) CPG A0301 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 91 Version 3.1.0 - 21/09/2020 Exported 14/10/2024 Supra-Glottic Airway (SGA) CPG A0301 Page 2 of 2  Endotracheal Intubation CPG A0302 Care Objectives Ensure safe and effective airway management throughout entire episode of care. General Notes Intended patient group Patient ≥ 12 years of age. Risk-benefit analysis A dynamic risk-benefit analysis is required for every prehospital intubation and should include evaluation of any precautions alongside the clinical context. Prehospital RSI may cause patient harm. Minimising scene times should be prioritised over the decision to perform prehospital RSI. Physiological derangement refractory to or requiring significant resuscitation, such as hypotension, hypoxia and/or metabolic acidosis may be exacerbated by RSI and precipitate cardiac arrest. In rural and regional areas RSI may be undertaken or withheld by single-responder MICA Paramedics following consideration of risk-benefit analysis. Rapid Sequence Intubation (RSI) Medication Ketamine is the preferred sedation induction agent for all RSI unless contraindicated by BP > 180 mmHg in the setting of NTBI. Fentanyl and Midazolam dosage should be based on assessment of cardiovascular and frailty status at the time of RSI. Patients with traumatic brain injury should receive hemodynamic support via Normal Saline 10 mL/kg during preparation for RSI, however administration must not delay RSI. Calculated Ketamine and Rocuronium doses should be rounded up to the nearest 10 mg. Avoid Fentanyl administration in the setting of serotonin syndrome/hyperthermia. Delayed Sequence Intubation (DSI) This pathway is intended for patients with respiratory failure and/or combativeness preventing pre- oxygenation. In these cases, optimisation of oxygen saturation is the goal prior to paralytic administration (as opposed to normalisation). The only sedation medication approved for DSI is Ketamine. It should be administered via slow IV push to preserve airway reflexes and maintain respiratory rate. Capnography The recording of pre- and post-intubation capnography is necessary to accurately describe the This is an uncontrolled document, it is the reader's responsibility to ensure currency. 92 Version 7.3.0 - 15/10/2024 Exported 14/10/2024 Endotracheal Intubation CPG A0302 Page 1 of 5  Endotracheal Intubation CPG A0302 therapeutic effect of ETT placement. Post-intubation capnography is essential for confirmation of tracheal placement and must be noted by all paramedics. If there is any doubt about tracheal placement the ETT must be immediately removed. A Zoll and an EMMA capnograph (or a second Zoll as a last resort) must both be connected and functional prior to all intubations. Following intubation, if a waveform / reading is lost on one device, immediately check the other capnograph. Waveform remains on second capnograph: — Leave ETT in situ — Troubleshoot faulty capnograph Waveform lost on both devices: — Immediately remove ETT — CPG A0303 Difficult airway guideline Trouble shooting should include: — Check airway circuit for kinks and check monitor connections — Remove PEEP valve — Change disposable capnography sensor — Connect new capnograph (if immediately available) — Ensure the BVM pop-off valve is set to ‘override’ (valve closed). The extremely combative patient Pre-RSI combativeness in TBI should be managed judiciously with analgesia as per CPG A0501 / P0501 Pain Relief. In rare cases, IM or IV Ketamine may be required for control of a combative patient who endangers crew and prevents full assessment. The hypertensive patient In the absence of any precautions, Ketamine may be considered in the setting of severe hypertension BP > 180mmHg (e.g. asthma or severe pain aetiology such as burns). Ketamine is the ideal agent for RSI in patients with burns. Expect high BP in this patient group and manage with aggressive opioid analgesia prior to RSI. If BP remains > 180mmHg, RSI with Ketamine is still appropriate. Unassisted intubation Unassisted intubation is permitted in patients with a GCS of 3 where there are no airway reflexes present, excluding TBI / NTBI. Unassisted intubation is permitted in the setting of pre- and peri-arrest multi-trauma with TBI and no airway reflexes, however transport unintubated is preferred. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 93 Version 7.3.0 - 15/10/2024 Exported 14/10/2024 Endotracheal Intubation CPG A0302 Page 2 of 5  Endotracheal Intubation CPG A0302 In this cohort, gentle laryngoscopy should be undertaken during intubation attempts and suction prepared. ETI should be abandoned if airway reflexes interfere with laryngoscopy or intubation. Unassisted intubation is not a shortcut. Prepare and anticipate the need for rapid post ETT sedation and paralysis. Flowchart - Indications & Preparation This is an uncontrolled document, it is the reader's responsibility to ensure currency. 94 Version 7.3.0 - 15/10/2024 Exported 14/10/2024 Endotracheal Intubation CPG A0302 Page 3 of 5  Endotracheal Intubation CPG A0302 Flowchart - Procedure Related Resources https://av-digital-cpg.web.app/assets/pdf/MAC/Endotracheal intubation (adult) MAC Paper.FINAL.pdf https://av-digital-cpg.web.app/assets/pdf/MAC/MAC CPG A0501-1 Hypersalivation management post ketamine (atropine).pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 95 Version 7.3.0 - 15/10/2024 Exported 14/10/2024 Endotracheal Intubation CPG A0302 Page 4 of 5  Endotracheal Intubation CPG A0302 This is an uncontrolled document, it is the reader's responsibility to ensure currency. 96 Version 7.3.0 - 15/10/2024 Exported 14/10/2024 Endotracheal Intubation CPG A0302 Page 5 of 5  Difficult Airway Guideline CPG A0303 General Notes Guideline Principles This guideline applies to all patients (≥ 12 years of age) undergoing medication assisted intubation. However, the principles may also be applied to unassisted intubation. Oxygenation A critical desaturation threshold should be identified by the team. For the adequately oxygenated patient this may be defined as < 90%. In difficult to oxygenate patients this will be lower, but a critical threshold should still be verbalized. Rescue airway strategies should be used at any time during the procedure to correct critical desaturation. Crew Resource Management RSI is a team-based procedure. Team roles, anticipated challenges and airway plan must be verbalized prior to commencement. Difficulties encountered during the procedure must be communicated to the team to ensure a shared awareness and prompt corrective actions. Plan A: OPTIMISED First intubation attempt First pass intubation is the key objective of this guideline. The strategy of ‘Head-Scope-Throat’ is a rapid analysis of intubation difficulties and appropriate equipment selection. ‘Head-Scope-Throat’ should be performed when difficulties are encountered and/or between first and second attempt. Equipment selection is based on paramedic preference and clinical context (i.e. anatomy, airway complications). However it is recommended that Plan A should include the use of a bougie. Plan B: ALTERNATIVE second intubation attempt A second intubation attempt must involve an alternative strategy that corrects identified issues. Alternative strategies should include the bougie and/or video laryngoscope if not previously utilized. Paramedics should in general abide by the limitation of two intubation attempts. However a third attempt may be appropriate in the setting of: — Oxygen saturations can be maintained — There is an identified corrective intubation strategy (E.g. technique issues, airway visibility, insufficient ramping, equipment failure, etc.) Plan C: Rescue Airway Strategy If intubation is unsuccessful following two attempts, rescue airway strategies must be implemented with the key objective of achieving adequate oxygenation. The preferred airway rescue strategy is the SGA. However there may be clinical circumstances where reverting to two-handed BVM combined with basic airway adjuncts is appropriate. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 97 Version 3.0.1 - 1/9/2023 Exported 14/10/2024 Difficult Airway Guideline CPG A0303 Page 1 of 2  Difficult Airway Guideline CPG A0303 Plan D: Can’t Intubate Cant Oxygenate A can’t intubate, can’t oxygenate (CICO) situation is a life-threatening emergency that requires cricothyroidotomy. While rare, in critical desaturation where the patient is deemed to be at immediate risk of arrest, moving directly to Plan D may be appropriate. Cricothyroidotomy is a primary airway method when intubation is deemed impossible, and other airway techniques (i.e. SGA and BVM) are not possible or ineffective. Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 98 Version 3.0.1 - 1/9/2023 Exported 14/10/2024 Difficult Airway Guideline CPG A0303 Page 2 of 2  Airway Maintenance CPG A0305 Care Objectives Optimise sedation +/- paralysis Optimise ventilation parameters using lung protective strategies General Notes Intended patient group Patients aged ≥ 12 years requiring airway maintenance Indications Post intubation paralysis is indicated: — In all primary neurological patients — Where sedation alone is ineffective at maintaining intubation or allowing adequate ventilation/oxygenation — To prevent shivering in patients being therapeutically cooled — To facilitate mechanical ventilation Status epilepticus Status epilepticus patients may require intubation (including paralysis) if there are airway or ventilation compromise which is not able to be managed using BVM and OPA/NPA. Paralysis is never to be used with the intent of terminating the seizure. This patient group may require high doses of Midazolam (bolus/independent infusion) post intubation. Rates in excess of 20 mg/hr may be necessary to ensure effective control. Normal saline and inotropes/vasopressors may be used as per CPG A0705 Shock. Non-traumatic brain injury Bolus Fentanyl (25 – 50 mcgs) and Midazolam (2.5 – 5 mg) may be administered to achieve SBP < 140 mmHg post-intubation. Normal Saline and inotropes/vasopressors may be used to achieve SBP > 120 mmHg as per CPG A0705 Shock. Sedation Patients should be routinely given a loading dose of sedation prior to commencement of the infusion to ensure a therapeutic level is achieved rapidly. 1 – 15 mL/hr is a suggested range only and some patient cohorts will exceed this e.g. high pain and high GCS prior to ETT. Consider running independent opioid and Midazolam infusions to allow differing analgesic and sedation doses for specific presentations (e.g. pain-producing pathology/injuries, status epilepticus, etc.). This is an uncontrolled document, it is the reader's responsibility to ensure currency. 99 Version 1.4.0 - 15/10/2024 Exported 14/10/2024 Airway Maintenance CPG A0305 Page 1 of 4  Airway Maintenance CPG A0305 Signs of inadequate sedation include cough, gag or patient movement, HR and BP trending up together, lacrimation, diaphoresis, and salivation. Paralysis All patients who are paralysed require ongoing sedation. Rocuronium infusions should be prepared with 100 mg in a 10 mL syringe. Where access to infusion pumps are limited, preference should be for sedation and inotrope infusion not paralysis. General care Insert bite block (non-paralysed patients) Suction ETT and oropharynx Gastric decompression Consider disconnecting ETT circuit during transfer if clinically appropriate Reconfirm tracheal placement following each movement Monitor ETCO2 using both the Zoll waveform capnography and EMMA capnograph. Position patient in a 30° head-up semi-recumbent position if clinically appropriate Check cuff pressure and ensure 20 – 30 cmH2O Maintain normothermia unless otherwise indicated Monitor temperature using oesophageal probe where available Undertake the Critical IHT Checklist to ensure comprehensive patient care post intubation Mechanical Ventilation Adult Mechanical Ventilation Calculator This is an uncontrolled document, it is the reader's responsibility to ensure currency. 100 Version 1.4.0 - 15/10/2024 Exported 14/10/2024 Airway Maintenance CPG A0305 Page 2 of 4  Airway Maintenance CPG A0305 This is an uncontrolled document, it is the reader's responsibility to ensure currency. 101 Version 1.4.0 - 15/10/2024 Exported 14/10/2024 Airway Maintenance CPG A0305 Page 3 of 4  Airway Maintenance CPG A0305 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 102 Version 1.4.0 - 15/10/2024 Exported 14/10/2024 Airway Maintenance CPG A0305 Page 4 of 4  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Flowchart This is an uncontrolled document, it is the reader's responsibility to ensure currency. 103 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 1 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 This is an uncontrolled document, it is the reader's responsibility to ensure currency. 104 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 2 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Care Objectives Secretion clearance Establish airway (stoma) patency Oxygenation +/- ventilation via the stoma Intended patient group All patients with a tracheostomy or laryngectomy Pathophysiology Tracheostomy A stoma is created through the neck to the trachea to form an airway below the larynx. The larynx remains intact. Tracheostomy patients can breathe through their stoma and potentially their mouth / nose to some extent. A tracheostomy tube +/- inner tube may be present. Laryngectomy Patients with a laryngectomy cannot be oxygenated, ventilated or intubated via the mouth. A stoma is created through the neck to the trachea to form an airway, however the larynx is completely removed. The trachea is only connected to the neck and stoma. Airflow from the mouth and nose into the trachea is impossible. Patients with a laryngectomy cannot be oxygenated, ventilated or intubated via the mouth. Usually, a tube will not be in situ. Other devices such as laryngeal buttons, heat-moisture exchangers (HME) or tracheo-oesophageal puncture (‘TOP’) speaking valves may be present. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 105 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 3 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Further information on tracheostomies, laryngectomies and tube types Tracheostomy A tracheostomy stoma is a surgical opening in the neck and trachea. The larynx remains intact. A tracheostomy tube +/- inner tube may be inserted. Tracheostomy tube may or may not have a cuff and / or an above-cuff suction port. Tracheostomy patients potentially have two airways: they can breathe through their stoma and mouth / nose. Although the reason for the tracheostomy is that the mouth /nose airway is not enough to sustain life. Tracheostomy tubes: There are many different brands and tubes available usually held in situ by tape around the neck. The tube is usually made with a polyvinyl chloride (PVC), silicone, or polyurethane but some people with tracheostomies in the community may still have silver tubes. Single lumen: Outer tube only. Holds tracheostomy open. Double lumen: Outer tube within which sits a disposable inner/reusable tube (cannula). The inner tube can be easily removed for cleaning. Cuffed tracheostomy tube with inner cannula This is an uncontrolled document, it is the reader's responsibility to ensure currency. 106 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 4 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Uncuffed tracheostomy tube with inner cannula Uncuffed or Cuffed: A cuff is a balloon attached to the base of a tracheostomy tube. Cuffed tubes are typically used for the mechanically ventilated patient, or for patient who cannot swallow. Cuffed tubes prevent air from escaping and aspiration. A cuff needs to be deflated whilst speaking valves are in-situ. Uncuffed tubes will in generally be sized to allow air to escape into the upper airway above the tracheostomy tube The outer flange of the tracheostomy tube will have information regarding type and size. This is an uncontrolled document, it is the reader's responsibility to ensure currency. 107 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 5 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Uncuffed tracheostomy tube with speaking value (Passe Muir) This is an uncontrolled document, it is the reader's responsibility to ensure currency. 108 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 6 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Uncuffed tracheostomy tube This is an uncontrolled document, it is the reader's responsibility to ensure currency. 109 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 7 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Inner cannula Swedish nose (HME for tracheostomy tubes) Fenestrated: Fenestrated tracheostomy tubes have holes or an opening that allow for movement of air into the larynx. When a speaking device (Passy Muir Valve) is placed on the end of a fenestrated tube, speech can be generated. Laryngectomies Laryngectomy patients also have a surgical opening in their neck and trachea, but unlike tracheostomy patient’s, they have had their larynx removed. Their oropharynx is completely detached from their trachea. They only have an airway via their tracheal stoma. Typically, a tracheostomy tube will not be in situ. Devices such as laryngeal buttons, Buchanan bibs, Voice prosthesis (not always visable as they are internal and on the posterior wall of the trachea) and HME (heat moisture exchangers) baseplates and filters could be insitu. Buchanan Bib This is an uncontrolled document, it is the reader's responsibility to ensure currency. 110 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 8 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Assessment Tube or stoma occlusion Noisy breathing Blood / tissue / secretions around the stoma or tracheotomy tube if present Increased work of breathing (e.g. accessory muscle use, tracheal tugging) Agitation, tachypnoea, diaphoresis, pallor, hypoxia Other complications A stomal review by a nurse consultant or other specialist may be required if any of the following are identified: red mucosa, granulated tissue, pain, bleeding, strong odour, exudate or swelling. Management Patients and carers will frequently be familiar with the management of tracheostomy / laryngectomy emergencies. Consider their advice and follow any action plans that may be present. Oxygen The default route of oxygenation and ventilation in all patients should be the stoma. Oxygen via the stoma: Initially it may be hard to establish whether the patient has a laryngectomy or tracheostomy. Providing oxygen via both routes is recommended where the patient’s history is uncertain. However, oxygen via the stoma is the priority as it is appropriate for both laryngectomy and tracheostomy patients. Oxygen via the mouth: If two sources of oxygen are available, a second mask should be added to the patient’s face as some tracheostomy patients may benefit from oxygenation via a partially patent upper airway, especially if their tracheostomy is totally blocked. Supplemental oxygen should be administered if required as per CPG A0001 Oxygen therapy while the patient is being assessed and in between interventions such as suctioning. Suction Adult: 10-12 FG Y catheter Paediatric: catheter size no more than half of the diameter of the tracheostomy or stoma. Procedure: Insert (> 10 cm) → apply continuous suction → slowly withdraw (< 10 seconds) (depth of insertion should be at least the length of the tracheostomy tube if present) Full procedure: CWI/OPS/193 Suction This is an uncontrolled document, it is the reader's responsibility to ensure currency. 111 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 9 of 10  Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 The patency of the tracheostomy tube or stoma should be established by removing potentially blocked devices and passing a suction catheter. Only remove devices as required to pass a suction catheter (e.g. a cap, cover, speaking valve, HME filter and the inner tube of a dual lumen tube if it is present). Other devices such as the outer tracheostomy tube or laryngectomy tube (if present) should not be removed at this stage. Do not attempt to remove tracheoesophageal puncture valves / voice prosthesis embedded in the posterior tracheal wall. Suction catheter can be passed: suction as required. Frequent repeat suctioning may be required if there are copious secretions. Consider other causes for respiratory distress if the stoma/tube is patent. If the patient improves following the removal of a blocked inner tube, it can be flushed with normal saline and reinserted if required (e.g. to facilitate reattaching the patient to a ventilator or a BVM). Unable to pass suction catheter The stoma or tube is likely to be totally blocked. If a tracheostomy tube is present, the tube may be displaced. If the tracheostomy tube has a cuff, deflating the cuff without removing the tube may partially correct the displacement and allow for spontaneous ventilation and oxygenation. Suction may be required following deflation as secretions collected above the cuff may be released into the lower airways. No improvement / deterioration If unable to pass a suction catheter and cuff deflation has not led to improvement, the tracheostomy tube (if present) must be removed. Further attempts at troubleshooting are unlikely to be successful. Apnoeic / cardiac arrest Ventilation / intubation should be attempted via the stoma. When ventilating through the stoma, assess for significant air leak through the mouth. If this is present the upper airway may be patent to some extent. BVM ventilation via the stoma is unlikely to be successful. Paramedics should attempt to cover the stoma with an occlusive dressing to achieve an airtight seal and manage the patient via the upper airway. Related Resources Ventilation via the stoma CPG Walkthrough Video -Tracheostomy / laryngectomy airway emergencies https://av-digital-cpg.web.app/assets/pdf/MAC/MAC Paper - Tracheostomy and laryngectomy emergencies - March 2021.pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 112 Version 1.1.0 - 16/11/2022 Exported 14/10/2024 Tracheostomy / Laryngectomy Airway Emergencies CPG A0306 Page 10 of 10  Acute Coronary Syndromes CPG A0401 Care Objectives Rapid identification of STEMI to facilitate timely reperfusion (PCI or PHT) is the primary goal of prehospital management. Provision of antiplatelet rx (aspirin). Reduce cardiac workload by treating associated symptoms (e.g. nausea, pain). General Notes The spectrum of ACS encompasses unstable angina, non ST-elevation ACS (NSTEACS) and ST- elevation myocardial infarction (STEMI). Not all patients with ACS will present with pain (e.g. elderly, female, diabetes history, atypical presentations). The absence of ischaemic signs on the ECG does not exclude AMI. AMI is diagnosed by presenting history, serial ECGs and serial enzyme tests. Suspected ACS-related pain that has spontaneously resolved warrants investigation in hospital. In patients who may be eligible for thrombolysis, invasive procedures should only be conducted according to clinical need and with the potential for increased bleeding risk in mind. Hyperoxaemia has been shown to be detrimental in patients with STEMI. Routine oxygen administration is not required in ACS and should only be provided as per CPG A0001 Oxygen Therapy. If a lower dose of aspirin has been administered prior to AV arrival, it is reasonable for paramedics to supplement the dose to as close to 300 mg as possible. Nitrates are C/I in bradycardia (HR < 50 bpm) due to the patient’s inability to compensate for a decrease in venous return by increasing HR to improve cardiac output. C.O. = HR x SV Where this CPG refers to GTN S/L, buccal administration can be substituted if required. Pain – treat with nitrates and if unresolved, treat with opioids as per CPG A0501 Pain relief. The intent of analgesia in ACS is to make the patient comfortable. Getting the patient completely pain- free is not always possible and in some cases may be detrimental if excessive opioid doses are required to achieve it. Nausea/vomiting – treat as per CPG A0701 Nausea and vomiting LVF – treat as per CPG A0406 Acute Pulmonary Oedema Inadequate Perfusion – treat as per CPG A0407 Inadequate Perfusion Dysrhythmias – see appropriate CPG Chest pain following mRNA vaccine Some patients may experience chest pain 1 – 10 days following mRNA vaccine (Pfizer or Moderna). This is This is an uncontrolled document, it is the reader's responsibility to ensure currency. 113 Version 2.1.0 - 18/12/2023 Exported 14/10/2024 Acute Coronary Syndromes CPG A0401 Page 1 of 4  Acute Coronary Syndromes CPG A0401 more common amongst males 12 – 29 years of age. It usually self resolves within 24-48 hours and is not typically associated with more serious adverse outcomes. However, other serious underlying causes such as pulmonary embolism and myocardial infarction should be considered. Severe myocarditis is very rare but has been reported following mRNA vaccine. These patients will present with ECG changes and other concerning symptoms that would prompt transport regardless of cause. There is no need to specifically identify severe myocarditis. Patients with low pre-existing cardiovascular risk and no other concerning aspects to their presentation should be referred to their GP for assessment within 24 hours and do not need to be assessed in an emergency department. Myocarditis or pericarditis following mRNA vaccines can be identified following investigations by a GP. This pathway should NOT be applied to COVID positive patients. Chest pain (< 10 days following mRNA vaccine) AND Age < 35 Non-ischaemic chest pain ≤ 1 cardiovascular risk factors Normal vital signs Normal 12-Lead ECG No other serious symptoms No Hx of coronary artery disease No PHx PE / thromboembolic events Refer to GP (24 hrs) Provide patient with copy of ECG for GP Provide safety netting information Cardiovascular risk factors Current smoker Diabetes This is an uncontrolled document, it is the reader's responsibility to ensure currency. 114 Version 2.1.0 - 18/12/2023 Exported 14/10/2024 Acute Coronary Syndromes CPG A0401 Page 2 of 4  Acute Coronary Syndromes CPG A0401 Hypertension Hypercholesterolaemia Family Hx of premature coronary artery disease Flowchart Related Resources Heart Foundation Resources for Health Professionals Cardiac Clinical Network (SCV) https://av-digital-cpg.web.app/assets/pdf/MAC/MAC Nov 2016 CPG A0401 Acute Coronary Syndrome.pdf https://av-digital-cpg.web.app/assets/pdf/MAC/Glyceryl Trinitrate MAC March 2021.pdf This is an uncontrolled document, it is the reader's responsibility to ensure currency. 115 Version 2.1.0 - 18/12/2023 Exported 14/10/2024 Acute Coronary Syndromes CPG A0401 Page 3 of 4  Acute Coronary Syndromes CPG A0401 This is an uncontrolled document, it is the reader's responsibility to ensure currency. 116 Version 2.1.0 - 18/12/2023 Exported 14/10/2024 Acute Coronary Syndromes CPG A0401 Page 4 of 4  Bradycardia CPG A0402 Care Objectives To increase heart rate where bradycardia is causing haemodynamic compromise, heart failure or life threatening arrhythmia. General Notes Atropine is unlikely to be effective in 2nd degree type II (Mobitz II) and 3rd degree (complete) heart block, however, it should still be administered. Where the patient initially responds adequately to two doses of Atropine however the effect is not sustained, repeat Atropine 600 mcg doses as required (total maximum of 3000 mcg). Atropine is ineffective and potentially harmful in patients who have had cardiac transplant. Atropine should be used with caution in myocardial infarction as increased heart rate may worsen ischemia. Titrate Adrenaline to patient response. If no increase in HR after 10 mcg/min, pacing should be commenced. If side effects occur during Adrenaline infusion, cease infusion and recommence once side effects resolve or proceed to pacing. Adrenaline Infusion — Adrenaline 3 mg added to make 50 mL with D5W or Normal Saline