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Guideline

Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/

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Rural Adult Emergency Clinical Guidelines 3rd Edition


space Document Number GL2010_003 Publication date 03-Mar-2010 Functional Sub group Clinical/ Patient Services - Nursing and Midwifery Clinical/ Patient Services - Medical Treatment Clinical/ Patient Services - Critical care Summary The intention of these guidelines is to ensure early appropriate management of acute and life threatening conditions, and to relieve pain and discomfort for patients at hospitals where medical practitioners are not immediately available. The guidelines reflect best clinical practice and are not mandatory, however, they have been adopted and implemented across the State since 2004 providing essential clinical support for rural emergency clinicians. NOTE: On 13 January 2012 an amendment was made to correct an error to the dose for Isolated severe limb injury listed on page 82. Replaces Doc. No. Rural Emergency Clinical Guidelines for Adults - 2nd Edition 2007 Version 2.1 - NSW [GL2007_005] Author Branch Statewide and Rural Health Services and Capital Planning Branch contact Brett Abbenbroek 9391 9526 Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Public Health System Support Division, Public Health Units, Public Hospitals Audience Nursing, Medical & Allied Health clinical staff, and all Emergency Departments Distributed to Public Health System, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, Ministry of Health, Private Hospitals and Day Procedure Centres Review date 03-Mar-2012 Policy Manual Patient Matters File No. 97/1749-10
Director-General

Status Active

GUIDELINE SUMMARY

RURAL ADULT EMERGENCY CLINICAL GUIDELINES 3RD EDITION PURPOSE


These guidelines are provided to assist early appropriate clinical management of acute and life threatening conditions, and to relieve pain and discomfort, for patients at hospitals where medical officers are not immediately available. The guidleines reflect best clinical practice and have been used extensively across the state since 2004 to provide clinical support for rural emergency clinicans.

KEY PRINCIPLES
Underpinning these guidelines are the following principles: A graduated clinical response is required depending on the: o severity of the presenting emergency condition e.g. the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma; o level of training and expertise of the nursing staff who initiate the management of the patient i.e. Registered Nurses with advanced clinical training will practice more advanced interventions; o legal requirements for nurses who initiate treatment and administer medications based on medication standing orders; o need for flexibility to respond to input from senior clinical staff and medical officers to accommodate local circumstances; The guidelines reflect evidence based best clinical practice and expert consensus opinion; Standardisation of initial clinical management of specific adult conditions; and Alignment with the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses.

USE OF THE GUIDELINE


These guidelines are to be used for adults only and have been formatted to follow the generally accepted Airway, Breathing and Circulation (ABC) approach for managing emergency/critically ill patients. Nursing staff using these Guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by Registered Nurses who are recognised as Advanced Clinical Nurses.

GL2010_003

Issue date: March 2010

Page 1 of 2

GUIDELINE SUMMARY

Advanced Clinical Nurses have advanced knowledge and skills; and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. Where an Advanced Clinical Nurse utilises these guidelines: the designated medical officer will be notified immediately; standing medication standing orders contained in these guidelines will be reviewed and authorised by the designated medical officer as soon as possible (within 24 hours); and the medical officer will countersign the record of administration on the patients medication chart.

A number of appendices and a formulary have been included to complement these guidelines. NSW Health Pharmaceutical Services Branch has reviewed these guidelines and has indicated that they are satisfactory for the consideration of the local Area Health Service Drug Committees for approval and implementation as medication standing orders, in terms of the criteria for standing orders as specified in NSW Health Policy Directive, PD2007_077 - Medication Handling in NSW Public Hospitals. These guidelines should be read in conjunction with NSW Health Policy Directive PD2005_042 - Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals: http://www.health.nsw.gov.au/policies/PD/2005/PD2005_042.html

REVISION HISTORY
Version 3rd Edition (GL2010_003) 2ndEdition 2007 (GL2007_005) 1st Edition 2004 Approved by Deputy Director-General Strategic Development Deputy Director-General Strategic Development Deputy Director-General Strategic Development Amendment notes Rescinds GL2007_005: total revision. Replaced 1st edition: total revision.

ATTACHMENTS
1. NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

GL2010_003

Issue date: March 2010

Page 2 of 2

NSW Rural Adult Emergency Clinical Guidelines


NSW Rural Critical Care Taskforce 3rd Edition

NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Department of Health. NSW Department of Health 2010 SHPN (SSD) 090220 ISBN 978-1-74187-347-4 For further copies of this document please contact: Better Health Centre Publications Warehouse PO Box 672 North Ryde BC, NSW 2113 Tel. (02) 9887 5450 Fax. (02) 9887 5452 Further copies of this document can be downloaded from the NSW Health website www.health.nsw.gov.au February 2010

The NSW Rural Adult Emergency Clinical Guidelines are to be implemented for the emergency management of adult patients only.

Aeromedical and Medical Retrieval Service (AMRS) 1800 650 004

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 1

Contents

Introduction ....................................................... 3 abbreviations .................................................... 5 1. airway emergencies .................................. 7


Unconscious Patient ............................................. 8 Seizures...............................................................10 Anaphylactic Reaction .........................................12

9.

appendices .............................................. 91
1. Rural and Remote Emergency Trolley Minimum Requirements ..............................92 2. Defibrillation ................................................. 94 3. 12 Lead ECG Lead Placement .........................95 4. Management of Patients with ST-segment Elevation Myocardial Infarction (STEMI). ........ 96 5. AVPU and Glasgow Coma Scale (GCS) ...........97 6. Pain Assessment ............................................98 7. Sedation Score/Scale ......................................99

2.

Breathing emergencies............................ 15
Shortness of Breath with or without a History of Asthma ...........................16 Shortness of Breath with a History of Cardiac Disease ................................20 Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease .............. 22

8. Glass Tumbler Test ..................................... .100 9. Snakebite Observation Chart .......................101 10. Trauma Triage Tool ......................................102 11a. Guidelines for when to Apply Semi-rigid Cervical Collar ........................... .103 11b.Removal of Semi-rigid Cervical Collar without Radiographic Assessment .............. .104 12. Needle Thoracentesis for Decompression of Tension Pneumothorax .......................... .105 13. Suggested Guidelines for a Neurovascular Assessment ..........................107 14. Pelvic Binding ..............................................108 15. Burn Injury Referral/Retrieval Criteria Checklist; Burn Transfer Flowchart ...............109 Burn Patient Emergency Assessment & Management Chart .................................... 110 16. Guideline for Emergency Department Documentation ............................................ 113 17. Minimum Skill Set for Emergency Department Staff ......................................... 114 18. Recommended Blood Pathology Testing Available at the Point of Care in Rural Facilities where an Emergency Service is Provided ...... 116

3.

Circulatory emergencies ......................... 25


Cardiorespiratory Arrest (Basic Life Support) ..............................................26 Cardiorespiratory Arrest (Advanced Life Support)........................................27 Compromising Bradycardia .................................29 Acute Coronary Syndrome with or without Associated Symptoms ........................31 Non-traumatic Shock ..........................................33

4. 5.

Disability emergencies ............................ 35


Meningococcal Disease ...................................... 36

endocrine / envenomation emergencies ............................................. 39


Hyperglycaemia with Severe Dehydration ........... 40 Hypoglycaemia ....................................................42 Snake / Spider Bite.............................................. 44

6.

trauma emergencies ............................... 47


Trauma ............................................................... 48 Burns ..................................................................52 Drowning ...........................................................55 Head Injury .........................................................57 Isolated Severe Limb Injury ................................. 60 Ocular Injuries .................................................... 62

7. 8.

Other emergencies .................................. 65


Abdominal/Loin/Flank Pain ................................. 66

Formulary .................................................. 69

PAGE 2

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Introduction

Emergency Departments (EDs) in rural and remote New South Wales (NSW) face a number of unique and difficult challenges in trying to deliver quality emergency care and achieving good patient outcomes. In particular it can be difficult for staff working in rural and remote EDs to acquire and retain emergency expertise. This may lead to inequalities in the standards of emergency care delivered in rural and remote EDs. A key function of the NSW Rural Critical Care Taskforce (RCCT) is to identify and develop ways to ensure a more uniform quality of emergency care in these EDs. One of the Taskforces strategies led to the development, in 2004, of a set of Rural Emergency Clinical Guidelines for Adults, which could be used by rural and remote Registered Nurses (RNs) who have undergone approved education and credentialing. The intention of the Guidelines is to ensure early management of immediately or imminently life threatening conditions, and to relieve pain and suffering in patients at sites where medical practitioners are not immediately available. This is the third total revision of the document in line with changes to best practice; and requests and advice from end users. The document has been developed with the following desirable features:
n

Guidelines indicates clinical interventions that can only be initiated by RNs who are recognised as Advanced Clinical Nurses.
n

incorporation of the various legal requirements for nurses who initiate treatment and administer medications based on medication standing orders flexibility guidelines need to be flexible enough to allow local input from rural Medical Officers (MOs) and RNs so that local practices can be incorporated endorsement by relevant committees and divisions within NSW Health standardisation of the management of specific adult conditions across rural NSW

The NSW Rural Adult Emergency Clinical Guidelines incorporate these features as well as the principles outlined in the First Line Emergency Care Course (FLECC) for Registered Nurses and the standing orders developed by the Wollongong Hospital pilot site model of the Emergency Department Work Practice Review (EDWPR). Special recognition is made to the utilisation of the template designed and developed by the EDWPR group. The Guidelines are also formatted to follow the generally accepted Airway, Breathing, Circulation (ABC) approach for managing emergency/critical care patients. These Guidelines are largely based on expert consensus opinion, supported by higher level evidence where available. The aims of the NSW Rural Adult Emergency Clinical Guidelines are to:
n

formatting which allows for graduated clinical responses. These responses vary depending on: degree of severity of the presenting emergency condition. For example, the clinical response to patients with mild to moderately severe asthma is different to that for patients with immediately life threatening asthma. This type of graduated clinical response has been used quite successfully in ambulance service protocols for many years; level of training and expertise of the nursing staff who are initiating management of the patient that is, formatting which allows for RNs with advanced training to practice more advanced interventions. RNs without this advanced training and credentialing cannot perform the advanced interventions. the use of shaded portions in the NSW Rural Adult Emergency Clinical

improve the emergency care and outcomes for patients in the rural and remote health care settings of NSW; provide readily accessible and user-friendly guidelines for clinicians providing emergency care to patients in rural and remote areas of NSW; assist rural and remote EDs in NSW achieve benchmarking targets and best practice standards for patients with emergency presentations;

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 3

address some of the current professional issues facing rural and remote RNs by: providing a safe framework in which rural and remote RNs can initiate management and care of emergency patients; recognising and formalising the advanced role that many rural and remote RNs currently perform when delivering care to critically ill or injured patients presenting to Emergency Departments; providing a pathway by which credentialed RNs can work toward continuing professional development.

Credentialing will be obtained and maintained by:


n

completion of standard competency assessments as recommended by the Critical Care Network Committee in each Area Health Service; the ACN maintaining appropriate documentation to allow review of the usage of these Guidelines.

Advanced Clinical Nurses are required to be recredentialed annually or according to local Area Health Service policy. It will be the responsibility of the rural Area Health Services through both their Critical Care Network Committee and their Health Service Managers to ensure compliance with these requirements.

Nursing staff using these Guidelines are required to be appropriately educated, skilled and credentialed. The shaded portions contained in the treatment guidelines must only be used by RNs who are recognised as Advanced Clinical Nurses. Advanced Clinical Nurses are those RNs who have advanced knowledge and skills; and have been deemed competent to carry out these advanced roles using contemporary assessment and ongoing credentialing processes. A number of appendices have been included to complement these Guidelines. Staff should familiarise themselves with both the Appendix and Formulary sections.

Implementation
It is intended:
n

when an Advanced Clinical Nurse utilises these Guidelines, a MO will be notified immediately to ensure their early involvement with the management and care of the patient; that any medication standing orders contained in these Guidelines will be signed and authorised by a MO appointed by the Area Health Service. This MO may be one of those servicing the Emergency Department/s using these Guidelines; that MO review is required following the administration of a drug according to the standing orders contained within this document as soon as possible (must be within 24 hours). At the time of this review the MO must check and countersign the nurse record of administration on the medication chart.

Credentialing of advanced Clinical Nurses (aCN)


Registered Nurses can be considered eligible to be credentialed for Advanced Clinical Nurse roles if:
n

they have successfully completed an advanced or critical care nursing course such as the FLEC Course/ Graduate Certificate/Graduate Diploma in Emergency; and they can demonstrate recent and ongoing knowledge and experience with managing emergency/critical care patients.

NSW Health Pharmaceutical Services Branch has reviewed these Guidelines and have indicated that they are satisfactory for the consideration of the local Area Health Service Drug Committees for approval and implementation as medication standing orders, in terms of the criteria for standing orders as specified in NSW Health Policy Directive, PD2007_077, Medication Handling in NSW Public Hospitals. This document should be read in conjunction with the following Policy Directive from NSW Health:
n

PD2005_042 Guidelines for Hospitals Seeking to Extend the Practice of Health Professionals.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 4 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

abbreviations
ABG ACN ACS AED AHS AMI ARC AVPU BSA BGL BiPAP bpm CPAP CK CPR CSF C-Spine CT DBP ECG ED FBC FLECC GCS GIT hCG ICU IDC IM IO IV Kg Arterial Blood Gas Advanced Clinical Nurse Acute Coronary Syndrome Automatic/Automated External Defibrillator Area Health Service Acute Myocardial Infarction Australian Resuscitation Council Alert, Voice, Pain, Unresponsive Body Surface Area Blood Glucose Level Bi-level Positive Airway Pressure Beats per minute Continuous Positive Airway Pressure Creatine kinase Cardiopulmonary Resuscitation Cerebrospinal fluid Cervical spine Computed Tomography Diastolic Blood Pressure Electrocardiograph Emergency Department Full Blood Count First Line Emergency Care Course Glasgow Coma Score/Scale Gastrointestinal tract Human Chorionic Gonadotropin Intensive Care Unit Indwelling catheter Intramuscular Intraosseous Intravenous Kilogram L LFT LMA LOC MDI mg mL mmol/L MO NGT O2 PEFR PPE PoC POP PO PR PV RN SBP SCI S/L SOB SpO2 Stat STEMI TBSA U/A UEC UO VF VT Litre Liver Function Test Laryngeal Mask Airway Level of Consciousness Metered Dose Inhaler Milligram Millilitre Millimols per Litre Medical Officer Nasogastric tube Oxygen Peak Expiratory Flow Rate Personal protective equipment Point of Care Plaster of Paris Per oral Per rectum Per vagina Registered Nurse Systolic Blood Pressure Subcutaneous injection Sublingual Shortness of breath Pulse oximetry saturation Immediately and once only ST segment Elevation Myocardial Infarction Total body surface area Urinalysis Urea Electrolytes Creatinine Urine output Ventricular fibrillation Ventricular tachycardia

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 5

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 6 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 1

Airway Emergencies

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 7

Unconscious Patient | Medical Officer must be notified immediately | For Adults Only

Unconscious Patient
The most common error in the management of an unconscious patient is inadequate management of Airway, Breathing and/or Circulation.

History Prompts
n n n n n n

Onset
Events mechanism of injury Associated preceding symptoms Relevant past history, especially diabetes and alcohol use Medication history, especially narcotic use Allergies

Clinical Severity Prompts


n n

Glasgow Coma Score (GCS) less than 9 Inability to maintain own airway

assessment Position airway Assess patency

Intervention Lie supine Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology

Breathing

Respiratory rate and effort SpO2 Auscultation Skin temperature Pulse rate and rhythm Capillary refill Blood pressure Cardiac monitor

Circulation

If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL bolus Monitor vital signs frequently Monitor LOC frequently If GCS less than 9 and not rapidly improving, the patient will require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration

Disability

AVPU/GCS + pupils

BGL

Finger prick BGL If less than 3 mmol/L and unconscious or confused administer IV 50% Glucose 50 mL or If no IV access administer IM Glucagon 1 mg Monitor finger prick BGL every 15 minutes until within normal limits

Possible opiate overdose (characterised by pin-point pupils and hypoventilation) Measure and test Pathology Temperature U/A Fluid input/output

If opiate overdose, give IM Naloxone 800 micrograms and IV Naloxone 800 micrograms Collect blood for FBC, UEC, (consider group and hold in trauma patients)

Nil by mouth IV 0.9% Sodium Chloride 1000mL at 125mL per hour to maintain hydration Fluid balance chart 12 lead ECG If history of possible alcohol abuse give IM Thiamine 100 mg

Electrocardiography Specific treatment Possible alcohol abuse

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 8 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Unconscious Patient | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen 0.9% Sodium Chloride 50% Glucose Glucagon Naloxone Naloxone 0.9% Sodium Chloride Thiamine 0.9% Sodium Chloride Dose 6-15 litres/min 500 mL bolus 50 mL 1 mg (if IV access unavailable) 800 micrograms 800 micrograms 1000 mL 100 mg 10 mL flush Route Inhalation IV IV IM IM IV IV IM IV Frequency Continuous Stat Stat Stat Stat Stat 125mL per hour to maintain hydration Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Be alert for acute opiate withdrawal after the administration of Naloxone. The half-life of Naloxone is much shorter than the opiate. Repeated doses of Naloxone may be required. If IV access is unavailable, both doses of Naloxone may be given IM, although it should be noted that this is not ideal as the IM route will take longer to take effect. The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernickes encephalopathy is unfounded. The absorption of Thiamine is so much slower than that of glucose, timing is irrelevant (Hew, 2004, p. 367). Consider carbon dioxide retention in unconscious hypoxic patients with a history of COPD, particularly if high flow oxygen has been administered in transit to the Emergency Department.

References:
Emergency Life Support (ELS) Course Manual, 2005, 3rd edn, ELS Course Inc., Tamworth. Fulde, G.W.O., (editor) 2004, Emergency medicine the principles of practice 4th edn, Elsevier, Sydney. Hew , R. Altered Conscious State in Textbook of Adult Emergency Medicine, 2004, Edited by Cameron, P., Jelinek, G., Kelly, A., Murray, L, Brown, A., Heyworth, J., Elsevier, Sydney MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 9

Seizures | Medical Officer must be notified immediately | For Adults Only

Seizures
Clinical Severity Prompts
n n n n

History Prompts
n n

Events mechanism of injury Associated symptoms; altered level of consciousness, pale, sweaty, incontinence

Rhythmical involuntary jerking (tonic-clonic) Stiffening of the body Clenched jaw Altered level of consciousness
n n n n

Relevant past history Medication history Allergies Onset

assessment Position

Intervention Protect from further harm Do NOt restrain the patient Lie supine or left lateral (after tonic phase and clonic movements cease) Maintain airway patency (a nasopharyngeal airway is the recommended adjunct unless contra-indicated) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Stop the seizures

airway

Assess patency

Breathing

Respiratory rate and effort SpO2

IV Midazolam 2.5 mg increments slow injection every 1-2 minutes (to a total dose of 0.1 mg/Kg) or if IV access unavailable: IM Midazolam 10 mg stat and repeat (once only) after 5 minutes if required

It may be difficult to adequately treat the patients airway and breathing until the seizures have been stopped. Once this has occurred, it will be necessary to reassess/ treat/maintain the patients airway and breathing
Circulation Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU/GCS + pupils BGL IV cannulation/pathology

Monitor vital signs frequently Monitor LOC frequently Finger prick BGL If less than 3 mmol/L administer IV 50% Glucose 50 mL or IM Glucagon 1 mg (if IV access unavailable) Monitor finger prick BGL every 15 minutes until within normal limits

Measure and test

Pathology Temperature U/A Fluid intake/output

Collect blood for FBC, UEC

Nil by mouth If history of possible alcohol abuse give IM Thiamine 100 mg

Specific treatment

Possible alcohol abuse

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 10 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Seizures | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen Midazolam Midazolam 50% Glucose Glucagon Thiamine 0.9% Sodium Chloride Dose 6-15 litres/min 2.5 mg increments 10 mg (if IV access unavailable) 50 mL 1 mg (if IV access unavailable) 100 mg 10 mL flush Route Inhalation IV IM IV IM IM IV Frequency Continuous Slow injection every 12 minutes (to a total of 0.1 mg/Kg) Stat and repeat (once only) after 5 minutes if required Stat Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Warning: respiratory and cardiovascular depression can be severe after the administration of Midazolam and requires close monitoring and treatment. Observe for features of the seizure and document. Do not attempt to put anything between the teeth during a seizure.

n n

References:
Fulde G.W.O., (editor) 2004, Emergency medicine the principles of practice 4th edn, Elsevier, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 11

Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only

anaphylactic Reaction
Clinical Severity Prompts
n

Relevant History and assessment Prompts


n n n

Onset Exposure to known allergen for the patient


Associated symptoms: respiratory distress, peripheral vasodilation, hypotension, urticaria, generalised redness and periorbital oedema

Anaphylaxis is likely when all three criteria are met: sudden onset and rapid progression of symptoms life-threatening Airway and/or Breathing and/ or Circulation problems are present skin and/or mucosal changes (flushing, urticaria, angioedema)

Flushing, urticaria and angioedema can be absent in up to 20% of cases Gastrointestinal symptoms: vomiting, abdominal pain, incontinence Relevant past history Medication history Allergies

n n n

assessment Position Assess patency Stridor Hoarse voice Breathing Respiratory rate and effort SpO2 Wheeze Skin temperature Pulse rate/rhythm Blood pressure Capillary refill Cardiac monitor Disability Measure and test Specific treatment AVPU/GCS + pupils Fluid input/output No response to IM Adrenaline and patient presents signs of cardiorespiratory collapse

Intervention Position of comfort Cease/remove causative agent Maintain airway patency If stridor present give IM Adrenaline 0.5mg every 3-5 minutes (to a total of 2 mg) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% If wheeze present give Salbutamol 10 puffs of 100 microgram dose MDI + spacer IV cannulation If pulse rate greater than 100 bpm, SBP less than 90 mmHg and capillary refill greater than 2 seconds give IV 0.9% Sodium Chloride 1000 mL bolus Monitor vital signs frequently Monitor LOC frequently Fluid balance chart ** IV Adrenaline 50 micrograms

airway

Circulation

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 12 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Anaphylactic Reaction | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen Adrenaline Salbutamol ** Adrenaline 0.9% Sodium Chloride 0.9% Sodium Chloride Dose 6-15 litres/min 0.5 mg 10 puffs of 100 microgram dose MDI + spacer 50 micrograms 1,000 mL bolus 10 mL flush Route Inhalation IM Inhalation IV IV IV Frequency Continuous Every 3-5 minutes to a total of 2 mg Stat Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Systemic allergic reactions can occur with urticaria, angioedema and rhinitis, but are not anaphylactic reactions as they are not life-threatening. Death caused by anaphylactic reaction occurs most commonly in the first 45 minutes after the patient has had contact with an allergen. Adrenaline is the most important drug for the treatment of an anaphylactic and allergic reaction. **IV Adrenaline 50 micrograms equates to 0.5 mL of 1:10,000 (10mL) Adrenaline. The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. al., 2008 p. 162).

n n n

References:
Dunn, R. editor in chief; et. al.. 2003, The emergency medicine manual, 3rd. edn, Venom Publishing Unit, West Beach Emergency Life Support (ELS) Course Manual 3nd edn. 2005. ELS Course Inc., Tamworth MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J, Pumphrey R, Cant A, et. al.. for the Working Group of the Resuscitation Council (UK). 2008, Emergency treatment of anaphylactic reactions: Guidelines for health care providers, Resuscitation, vol. 77, (2), no. 2

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 13

PAGE 14

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 2

Breathing Emergencies

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 15

Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only

Shortness of Breath with or without a History of asthma


Clinical Severity Prompts
n

History Prompts
n n n n n n n

Onset
Associated symptoms Relevant past history Medication history Trigger factors Past presentation/s admission/s (ED/ICU/intubation) Allergies

Correspond with either mild, moderate or severe scale as described below

Clinical manifestation of acute asthma


** Severe and life threatening ** australasian triage Scale (atS) Physical exhaustion talks in Pulse rate Central cyanosis Wheeze intensity PeFR Pulse oximetry 1 Yes Paradoxical chest wall movement may be present Words Greater than 120 bpm # Likely to be present Often quiet/silent Less than 50% predicted (or best if known) or less than 100 Litres/min Less than 90% cyanosis may be present Moderate 2 No Mild 3 No

Phrases 100-120 bpm May be present Moderate to loud 50-75% predicted (or best if known)

Sentences Less than 100 bpm Absent Variable Greater than 75% predicted (or best if known)

Reference: National Asthma Council, Australia, 2006, Asthma Management Handbook, p. 39. ** Any of these features indicate the episode is severe. The absence of any feature does not exclude a severe attack. # Bradycardia may be seen when respiratory arrest is imminent.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 16 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only

assessment Position airway Assess patency If the patient shows signs of pre-arrest or asthma associated with anaphylaxis (exhibits decreasing LOC, increasing cyanosis of lips/ mouth and bradycardia) Breathing Respiratory rate and effort SpO2 Speech Use of accessory muscles Sternal retraction Spirometry/PEFR (moderate and mild asthma) Severe asthma

Intervention Sit patient upright or position of comfort Maintain airway patency If the patient is pre-arrest or asthma associated with anaphylaxis give IM Adrenaline 0.5mg one dose only

Assist ventilation if required Apply O2 to maintain SpO2 above 95%

8-12 puffs Salbutamol 100 microgram MDI + spacer every 15-30 minutes. 4 puffs Ipratropium Bromide 20 microgram MDI + spacer stat Salbutamol 5mg nebule and Ipratropium bromide 500 microgram nebule stat 8-12 puffs Salbutamol 100 microgram MDI + spacer every 1-4 hours 8-12 puffs Salbutamol 100 microgram MDI + spacer stat IV cannulation for moderate and severe asthma

If patient cannot inhale adequately to use an MDI and spacer (severe asthma) Moderate asthma Mild asthma Circulation Skin temperature Pulse rate/rhythm Blood pressure Cardiac monitor Electrocardiography Disability Measure and test Specific treatment AVPU/GCS Temperature Spirometry Continuing respiratory distress

Monitor vital signs frequently 12 lead ECG Monitor LOC frequently

For moderate and severe asthma give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable)

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 17

Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen Adrenaline Salbutamol Dose 8-15 litres/min 0.5 mg 100 microgram per inhalation MDI + spacer 5mg Nebule Route Inhalation IM (pre-arrest circumstance) Inhalation Frequency Continuous Stat Severe: 8-12 puffs every 15-30 minutes Moderate: 8-12 puffs every 1-4 hours Mild: 8-12 puffs stat Every 15-30 minutes (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Stat for severe cases Severe: stat (for patients with severe asthma who cannot inhale well enough to use MDI + spacer) Stat for moderate and severe asthma Stat for severe and moderate asthma As required

Salbutamol

Inhalation

Ipratropium Bromide Ipratropium Bromide Hydrocortisone Prednisolone 0.9% Sodium Chloride

4 puffs of 20 microgram per inhalation MDI + spacer 500 microgram Nebule 200 mg 50 mg (if IV access unavailable) 10 mL flush

Inhalation Inhalation IV Oral IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation:

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 18 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Shortness of Breath with or without a History of Asthma | Medical Officer must be notified immediately | For Adults Only

Precautions and Notes:


n

There is substantial evidence that Ipratropium Bromide is of limited use in acute episodes of mild to moderate asthma. Ipratropium Bromide is not necessary in mild asthma and optional in moderate episodes. The use of short acting beta agonists by intermittent inhalation via MDI and spacer is now recommended in the management of acute asthma, whether mild, moderate or severe. Delivery of short acting beta agonists via MDI and spacer is equally effective as nebulisation in patients with moderate to severe acute asthma, other than for those patients with life-threatening asthma who cannot inhale well enough to use an MDI + spacer (e.g. those requiring ventilation). Continuous nebulisation and IV therapy are alternatives in severe asthma. However, adverse events are more frequent. Use a nebuliser instead of MDI if the patient cannot inhale adequately. A 5 mg nebule of Salbutamol should be made up with 2 mL 0.9% Sodium Chloride. If available, give oxygen at a flow of 8-10 L/min. A mouthpiece delivers considerably more drug to the lung than a facemask. The best site for intramuscular (IM) Adrenaline is the anterolateral aspect of the middle third of the thigh the needle needs to be long enough to ensure that the Adrenaline is injected into muscle (Soar et. al. 2008, p. 162).

n n

References:
Doherty, S. 2006, Emergency care evidence in practice series: use of ipratropium bromide for acute asthma, Emergency Care Community of Practice, National Institute of Clinical Studies, Melbourne. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Asthma Council Australia, 2006, Asthma Management Handbook, revised and updated, National Asthma Council, Australia. NSW Health, 2007, PD2007_063 Infection Control Policy, NSW Department of Health, North Sydney. Soar J, Pumphrey R, Cant A, et. al. for the Working Group of the Resuscitation Council (UK). 2008, Emergency treatment of anaphylactic reactions: Guidelines for health care providers, Resuscitation, vol. 77(2), no. 2.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 19

Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only

Shortness of Breath with a History of Cardiac Disease


Clinical Severity Prompts
n n n n n

History Prompts
n n n

Onset
Events Associated symptoms pale, clammy, audible respiratory crepitations, speaking in phrases or words

Severe respiratory distress with exhaustion Altered level of consciousness Ability to talk in words only Central cyanosis Audible respiratory crepitations
n n n n

Relevant past history History of cardiac disease Medication history Allergies

assessment Position airway Breathing Assess patency Respiratory rate and effort SpO2 Speech Auscultation Skin temperature Pulse rate/rhythm Capillary refill Blood pressure

Intervention Sit patient upright Maintain airway patency Assist ventilation if required with positive pressure bag valve mask Apply O2 via non re-breather mask at 15 L/min, aim to maintain SpO2 greater than 95% Consider CPAP/BiPAP if available IV cannulation/pathology

Circulation

If SBP greater than 90 mmHg give Glyceryl Trinitrate S/L 300-600 micrograms or spray 1-2 sprays (400-800 micrograms) Repeat every 5 minutes if SBP greater than 90 mmHg Audible respiratory crepitations present give IV Frusemide 40 mg Monitor vital signs frequently 12 lead ECG Monitor LOC frequently Finger prick BGL Collect blood for FBC, UEC, cardiac markers and ABG or venous blood gas (if available) Fluid balance chart Restrict oral fluid intake Consider IDC and urine measurements every hour If available CPAP 10 cm H20 if available and SBP greater than 100 mmHg and SOB unrelieved by other interventions (i.e. Nitrates and Frusemide)

Audible respiratory crepitations Cardiac monitor Electrocardiography Disability Measure and test AVPU/GCS BGL Pathology Fluid input/output U/A Chest X-ray Specific treatment Continuing respiratory distress

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 20 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Shortness of Breath with a History of Cardiac Disease | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen Glyceryl Trinitrate Dose 15 litres/min Non re-breather mask 300-600 micrograms Route Inhalation S/L Frequency Continuous Stat and then every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Stat and then every 5 minutes (if SBP greater than 90 mmHg) to total of 4 sprays (1600 micrograms) Stat if audible respiratory crepitations present As required

Glyceryl Trinitrate

1-2 sprays (400-800 micrograms) 40 mg 10 mL flush

S/L

Frusemide 0.9% Sodium Chloride

IV IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

DO NOT administer Nitrates if patient has taken medications for treatment of sexual dysfunction e.g. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect). CPAP/BiPAP can only be used effectively when the patient has adequate respiratory effort. Systolic blood pressure less than 90 mmHg with acute pulmonary oedema constitutes a diagnosis of cardiogenic shock requiring emergency circulatory assistance.

n n

References:
Lightfoot, D., 2004, Assessment and management of acute pulmonary oedema in EDs, in Textbook of Adult Emergency Medicine, 2nd edn, eds P. Cameron, G. Jelinek, A. Kelly, L. Murray, A. Brown, J. Heyworth, Churchill Livingstone, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Heart Foundation of Australia, 2006, Guidelines for the prevention, detection and management of chronic heart failure in Australia, November 2006.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 21

Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only

Shortness of Breath with a History of Chronic Obstructive Pulmonary Disease


Clinical Severity Prompts
n

History Prompts
n n

Onset
Associated symptoms pale, sweaty, cyanosis

History of chronic obstructive pulmonary disease (emphysema, chronic bronchitis) Severe respiratory distress with exhaustion Altered level of consciousness Ability to talk in words only Central cyanosis Confusion, lethargy or evidence of hypoventilation

Relevant past history chronic obstructive pulmonary disease Medication history Past presentations/admissions (ED/ICU/intubation) Allergies

n n n

n n n n n

assessment Position airway Breathing Assess patency Respiratory rate and effort SpO2 Audible wheeze present If patient cannot inhale adequately to use an MDI and spacer (severe cases) Speech Use of accessory muscles Sternal retraction Circulation Skin temperature Pulse rate/rhythm Blood pressure Cardiac monitor Disability Measure and test AVPU/GCS Temperature Electrocardiography Sputum Chest X-Ray Arterial blood gas or venous blood gas Specific treatment Continuing respiratory distress CPAP/BiPAP

Intervention Sit patient upright / position of comfort Maintain airway patency Assist ventilation if required Apply O2 using venturi mask start at 24%-28% to maintain SpO2 90-95% 10 puffs Salbutamol 100 microgram MDI + spacer and 4 puffs Ipratropium Bromide 20 microgram MDI + spacer Salbutamol 5mg nebule every 20 minutes if required and Ipratropium bromide 500 microgram nebule stat

IV cannulation

Monitor vital signs frequently Monitor LOC frequently

12 lead ECG Obtain specimen for microbiology If available If available

For moderate and severe cases give IV Hydrocortisone 200 mg or oral Prednisolone 50 mg (if IV access unavailable) Prepare equipment if available

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 22 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Shortness of Breath with a History of COPD | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen Salbutamol Salbutamol Dose Start at 24%-28% 10 puffs of 100 microgram per inhalation MDI + spacer 5 mg Nebule Route Inhalation Venturi Mask Inhalation Inhalation Frequency Continuous Repeat every 20 minutes if required Repeat every 20 minutes if required (for patients who cannot inhale well enough to use MDI + spacer) Stat Stat (for patients who cannot inhale well enough to use MDI + spacer) Stat Stat As required

Ipratropium Bromide Ipratropium Bromide Hydrocortisone Prednisolone 0.9% Sodium Chloride

4 puffs of 20 microgram MDI + spacer 500 microgram Nebule 200 mg 50 mg (if IV access unavailable) 10 mL flush

Inhalation Inhalation IV Oral IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n n n

Designation:

Date:

Never withhold oxygen in severely dyspnoeic patients Mental status is an important indicator of both worsening hypoxia and hypercapnia Be aware of signs of hypercapnia particularly decreasing LOC. Gas flow through medium concentration oxygen masks (e.g. Hudson) is inadequate when the patient is tachypnoeic therefore these masks should not be used. High flow oxygen should be avoided. Use a nebuliser instead of MDI if the patient cannot inhale adequately. A 5 mg nebule of Salbutamol should be made up with 2 mL 0.9% Sodium Chloride. Nebulised solutions are to be administered using aIR.

References:
Emergency Life Support (ELS) Course Manual, 3nd edn. 2005, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Soar J., Pumphrey R., Cant A., et. al.. for the Working Group of the Resuscitation Council (UK). 2008, Emergency treatment of anaphylactic reactions: Guidelines for health care providers, Resuscitation, vol. 77, (2), no. 2. The Australian Lung Foundation, 2008, The COPD-X Plan: Australian and New Zealand Guidelines for the Management of Chronic Obstructive Pulmonary Disease version 2.15 May 2008. (Endorsed by the Thoracic Society of Australia & New Zealand)
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 23

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 24 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 3

Circulatory Emergencies

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 25

Basic Life Support | Medical Officer must be notified immediately | For Adults Only

Cardiorespiratory arrest (Basic life Support)


Australian Resuscitation Council, February 2006, Guideline 7.

Basic Life Support Flow Chart

D R A B C D

Check for DANGER

Hazards / Risks / Safety?


RESPONSIVE? (Unconscious?)

If not, call for help Call 000 / Resuscitation Team


Open AIRWAY Look for signs of life

Give 2 initial BREATHS if not breathing normally

Give 30 chest COMPRESSIONS (almost 2 compressions per second) followed by 2 breaths

Attach AED as soon as available and follow its prompts

Continue CPR until qualified personnel arrive or signs of life return NO SIGN OF LIFE = Unconscious, Unresponsive, Not Breathing Normally, Not Moving
AED = Automated External Defibrillator

Australian Resuscitation Council

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 26 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Advanced Life Support | Medical Officer must be notified immediately | For Adults Only

Cardiorespiratory arrest (advanced life Support)


Australian Resuscitation Council, February 2006, Guideline 11.2

Adult Cardiorespiratory Arrest


Precordial Thump
for witnessed / monitored arrest

BLS Algorithm (if appropriate) Attach Defib monitor Assess rhythm / pulse

Shockable
VF / Pulseless VT

Non-Shockable
PEA / Asystole

During CPR
IF NOT ALREADY DONE

Attempt Defibrillation1 One Shock


Manual Biphasic 200J2 Manual Monophasic 360J

Check electrode / paddle position & contact Attempt / verify / secure IV access Give adrenaline 1mg & repeat every 3 minutes Hypoxaemia Hypovolaemia Hypo/hyperthermia Hypo/hyperkalaemia & other metabolic disorders Tamponade Tension pneumothorax Toxins / Poisons / Drugs Thrombosis - Pulmonary / coronary Advanced airway Antiarrhythmic - Amiodarone 300 mg - Lignocaine 1-1.5 mg/kg - Magnesium 5 mmol Electrolytes - Potassium 5 mmol Buffer - NaHCO3 1 mmol/kg Atropine (1-3 mg) + Pacing (for asystole & severe bradycardia)

n n

CORRECT REVERSIBLE CAUSES


n n

Immediate CPR
2 minutes

n n

Immediate CPR
2 minutes

n n n n

CONSIDER
n n

NOTE: 1. For witnessed arrest, when using a manual defibrillator, give up to 3 stacked shocks at first defibrillation attempt. If further shocks are required, these should be single shocks. 2. Default biphasic energy.

Australian Resuscitation Council

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 27

Advanced Life Support | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen Adrenaline Amiodarone Atropine Lignocaine 0.9% Sodium Chloride Dose 15 litres/min 1 mg 300 mg (dilute with 5% Dextrose 10-20 mL) 1 mg 1-1.5 mg/Kg 30 mL flush Route Inhalation IV/IO IV/IO IV/IO IV/IO IV/IO Frequency Continuous Every 3 minutes to a total of 3 mg Stat over 1-2 minutes Every 3-5 minutes to a total of 3mg Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

If stat dose of IV/IOI Amiodarone or Lignocaine is effective and return of spontaneous circulation has been achieved then Amiodarone or Lignocaine infusion is recommended to follow. Magnesium, potassium, sodium bicarbonate and pacing cannot be initiated by an ACN.

References:
Australian Injectable Drugs Handbook, 4th edition. July 2008, The Society of Hospital Pharmacists of Australia. Australian Resuscitation Council, 2006, Guideline 11.2: Protocols for adult Advanced Life Support, ARC, Melbourne.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 28 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only

Compromising Bradycardia
Bradycardia must be considered in relation to associated symptoms.

History Prompts
events leading to presentation
n n n

Syncope or seizure

Clinical Severity Prompts


n

Chest pain onset (if any) Associated symptoms:


dyspnoea sweating pallor fatigue

Bradycardia: less than 40 beats per minute and symptomatic i.e. plus one or more of the following: altered level of consciousness blood pressure: SBP less than 90 mmHg chest pain shortness of breath syncope/dizziness diaphoresis

Relevant past history medication history allergies

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure

Intervention Supine depending on clinical status Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology

If SBP less than 90 mmHg give IV Atropine 0.5 mg increments every 5 minutes (to total of 3mg) to maintain systolic blood pressure greater than 90 mmHg Monitor vital signs frequently If no response to Atropine MO to consider external transthoracic pacing (if available) Monitor LOC frequently Finger prick BGL 12 lead ECG (within five minutes of arrival to ED) Collect blood for FBC, UEC, cardiac markers (where available) Fluid balance chart Nil by mouth

Cardiac monitor

Disability Measure and test

AVPU/GCS BGL Electrocardiography Pathology Fluid input/output

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 29

Compromising Bradycardia | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen Atropine Dose 6-15 litres/min 0.5 mg increments to a total of 3mg Route Inhalation IV Frequency Continuous Every 5 minutes titrated to maintain systolic blood pressure greater than 90 mmHg As required

0.9% Sodium Chloride

10 mL flush

IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n n n

Designation:

Date:

Hypoxia can cause bradycardia. Inferior myocardial infarction/ischaemia may lead to bradyarrhythmias. Symptomatic complete heart block will require pacing and/or urgent transfer to definitive care. Atropine may be ineffective in patients who are on beta-blockers.

References:
Brady W.J., Swart G., De Behnke D.J., John Ma O., Aufderheide T. P. 1999, The efficacy of atropine in the treatment of haemodynamically unstable bradycardia and atrio-ventricular block: prehospital and emergency department considerations. Resuscitation, vol. 41, no. 1, pp. 47-55. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Sodeck G.H., Domanovits H., Meron G., et. al.. 2007, Compromising bradycardia: management in the emergency department Resuscitation, vol. 73, no. 1, pp. 96-102.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 30 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only

acute Coronary Syndrome (with or without associated symptoms)


Clinical Severity Prompts
n

Severity: pain score 0-10 time: onset of pain, pain lasting longer than 5 minutes (refer to Appendix 6)
n

Associated symptoms: nausea/vomiting sweating shortness of breath palpitations lethargy/fatigue

Chest pain/discomfort heavy, central/left/right and/ or associated symptoms Time pain lasting longer than 5 minutes
n

History Prompts
n

Other: relevant past history risk factors: familial, diabetes, hyperlipidaemia, smoking, Aboriginal & Torres Strait Islander medication history, including medications used for the treatment of sexual dysfunction e.g. Sildenafil (Viagra) allergies

Symptoms suggestive of myocardial ischaemia Provokes/Precipitates: what makes the pain worse? What were you doing when you got the pain? Quality: what does the pain feel like? Describe the pain Region: centre of chest, retrosternal; Radiation: arm(s)/back/jaw

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure

Intervention Position patient upright/position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Aspirin 300 mg (chew) (if not already given by Ambulance Officer)

Cardiac monitor Electrocardiography

If pain present, give Glyceryl Trinitrate S/L 300-600 micrograms or Glyceryl Trinitrate Spray S/L (400-800 micrograms) if SBP greater than 90 mmHg, can be repeated every 5 minutes Monitor vital signs frequently 12 lead ECG (within 5 minutes of arrival to ED) IV cannulation/pathology If pain is present, give IV Morphine 2.5 mg increments every 5 minutes to a total 10 mg or IM Morphine (if IV access unavailable) 5-10 mg Assess suitability for fibrinolysis (refer to Appendix 4)

Disability Measure and test

AVPU/GCS BGL Pathology Fluid input/output Monitor pain score If pain free after 30 minutes If pain returns at any time

Monitor LOC frequently Finger prick BGL Collect blood for (FBC, UEC, cardiac markers where available) Fluid balance chart Repeat 12 lead ECG Repeat 12 lead ECG

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 31

Acute Coronary Syndrome | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen Aspirin Glyceryl Trinitrate Dose 6-15 litres/min 300 mg 300-600 micrograms ( -1 tablet) Route Inhalation Oral (chew) S/L Frequency Continuous Stat Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 3 tablets (1800 micrograms) Stat Every 5 minutes (if SBP greater than 90 mmHg) to a total of 4 sprays (1600 micrograms) Every 5 minutes (not to exceed a total of 10mg) Stat (not to exceed total of 10 mg) As required

Glyceryl Trinitrate spray

1-2 sprays (400-800 micrograms)

S/L

Morphine

2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mL flush

IV

Morphine 0.9% Sodium Chloride

IM IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Do NOt administer Nitrates if patient has taken medications used for the treatment of sexual dysfunction e.g. Sildenafil (Viagra) in previous 24 hour period (profound hypotensive effect). the diabetic, elderly, female or young patient may present with atypical symptoms such as dyspnoea, nausea, vomiting, palpitations, syncope or cardiac arrest, no pain.

References: Jowett N.I., Turner A.M., Cole A. and Jones P.A., 2005, Modified electrode placement must be recorded when performing 12-lead electrocardiograms, Postgrad. Med. J. vol. 81, pp. 122-125. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand, 2006, Guidelines for the management of acute coronary syndromes, The Medical Journal of Australia, vol. 184 no. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html>. National Heart Foundation, 2000, Reperfusion therapy for acute myocardial infarction. Ryan T. J. and Reeder G.S., 2009, Management of suspected acute coronary syndrome in the emergency department, viewed 19.01.2009, <http://www.uptodate.com/online/content/topic.do?topicKey=ad_emer/2821&selectedTitle=3`15 0&source=search_result>.
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 32 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only

Non-traumatic Shock
Tachycardia may not occur in elderly patients Patients who are normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg

History Prompts
n n

Onset Events: vomiting/diarrhoea, infection, pregnancy, gastric/abdominal pain (If history of trauma refer to Trauma Guideline) Relevant past history: palpitations, light-headed, fainting

Clinical Severity Prompts


n n

Tachycardia: (greater than 100 beats per minute) Poor brain perfusion restlessness altered level of consciousness
n n

Medication history Allergies

Poor skin perfusion cold pale sweaty capillary refill greater than 2 seconds

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability Measure and test AVPU/GCS + pupils BGL Primary Survey Secondary Survey Pathology

Intervention

Full PPe measures must be considered.


Lie supine Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation x 2/pathology

If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL bolus Monitor vital signs frequently Monitor LOC frequently Finger prick BGL Repeat Commence Take blood for FBC, UEC, group and hold (if required) Venous blood gas and Blood culture Measure Hb if point of care device (e.g. iStat) is available Urine hCG (women of childbearing age) Urine culture Fluid balance chart Nil by mouth Insert IDC measure and record urine output every hour Monitor 12 lead ECG If available

Temperature U/A Fluid input/output

PV Loss Electrocardiography Chest X-ray

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 33

Non-traumatic Shock | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride 0.9% Sodium Chloride Dose 6-15 litres/min 500 mL 10 mL flush Route Inhalation IV/IO IV/IO Frequency Continuous Stat (repeat once only if SBP remains less than 90 mmHg) As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n

Designation:

Date:

Close monitoring of fluid input and output is essential. Pregnant women (greater than 20 weeks gestation) require a left lateral tilt to reduce compression of the Inferior Vena Cava hypotension is a late sign of hypovolaemia greater volumes than expected are required for resuscitation.

References:
Dunn R. et. al. (editor), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Emergency Life Support (ELS) course manual, 3nd edn. 2005, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Rose B.D. and Mandel J., Treatment of severe hypovolaemia or hypovolaemic shock in adults, viewed 19.01.09, <http://uptodate.com/online/content/topic.do?topicKey=cc_medi/14949>.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 34 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 4

Disability Emergencies

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 35

Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only

Meningococcal Disease: Non-blanching Rash


Clinical Severity Prompts
n

History Prompts
n n n

Onset Events bacterial meningitis suspected Associated symptoms: altered/abnormal level of consciousness, pallor, irritability (global signs of meningeal irritation)

Appearance of rapidly developing non-blanching petechial or purpuric rash (bruised haemorrhagic type/ does not blanch i.e. skin colour does not fade under pressure) which may only be several lesions (refer Appendix 7 for Glass Tumbler Test) Associated symptoms include: headache, fever, vomiting, neck stiffness, photophobia and drowsiness

Relevant past history: contact/association with person/s recently diagnosed with meningococcal disease within past 60 days immunosuppression, recent head/neck infection Medication history Allergies

n n

Immediately call for assistance and notify the Medical Officer and Aeromedical and Medical Retrieval Service (1800 650 004)
assessment Position Completely undress (including underwear and socks) Inspect all body surfaces/ folds/creases for rash Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor 12 lead ECG Disability Measure and test AVPU/GCS + pupils BGL Pathology Temperature U/A Fluid input/output Specific treatment Non blanching petechial/ purpuric rash Nil by mouth If patient weighs greater than 65 kg give Dexamethasone 10mg IV/IO stat If less than 65 kg give 0.15 mg per kg IV/IO stat and IV/IO or IM Benzylpenicillin 1.2g. If allergic to Benzylpenicillin give IV/IO or IM Ceftriaxone 2 g Intervention

Full PPe must be worn at all times.


Position of comfort

airway Breathing Circulation

Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology

If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL Monitor vital signs frequently As indicated Monitor LOC frequently Finger prick BGL If possible, take blood for FBC, UEC, blood cultures

DO NOt DelaY aNtIBIOtIC aDMINIStRatION

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 36 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Meningococcal Disease | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride Dexamethasone Dose 6-15 litres/min 500 mL If patient greater than 65 kg give 10mg Dexamethasone If less than 65 kg give 0.15 mg per kg 1.2 g 2 g (if allergic to Benzylpenicillin) 10 mL flush Route Inhalation IV/IO IV/IO Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Stat

Benzylpenicillin Ceftriaxone 0.9% Sodium Chloride

IV/IO/IM IV/IO/IM IV/IO

Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

IM antibiotic administration is NOT preferred in this setting as supervening shock and hypotension may lead to failure of absorption of the injected antibiotic. Collection of blood sample for culture should be attempted prior to administration of antibiotics but should not delay treatment. Patients presenting unwell with a blanching rash may progress to a non-blanching rash and therefore require urgent treatment

References: Communicable Diseases Network Australia, 2001, Guidelines for the early clinical and public health management of meningococcal disease in Australia, Commonwealth Department of Health and Aged Care, Canberra. eTG Complete Therapeutic Guidelines Ltd. (www.tg.com.au) etg 26 November 2008, Revised June 2006. Viewed 8.02.09. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> van de Beek D., de Gans J., McIntyre P., and Prasad K., 2009, Corticosteroids for acute bacterial meningitis (Review), Issue 1, viewed 8.02.09, <http://www.thecochranelibrary.com>.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 37

PAGE 38

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 5

Endocrine / Envenomation Emergencies

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 39

Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only

Hyperglycaemia with Severe Dehydration


Clinical Severity Prompts
n n n n

History Prompts
n

Gradual onset of symptoms; increased thirst, increased urine output, dehydration

Associated symptoms; tachycardia, hypotension, weight loss, confusion, acetone breath, Kussmauls respirations (deep sighing respirations of metabolic acidosis), abdominal pain

BGL greater than 15mmol/L Severe dehydration Altered mental state Metabolic abnormality e.g. ketoacidosis
n n n n

Relevant past history Medication history Events leading up to presentation Allergies

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Skin turgor Mucous membranes Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU / GCS BGL

Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology If signs of dehydration or if SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500mL bolus stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg)

Monitor vital signs frequently Monitor LOC frequently Finger prick BGL every 30 minutes Consider insulin therapy but not before a serum potassium is known and not before advice from a Medical Officer Collect blood for FBC, UEC, BGL, ABGs/venous blood gas (if available) Test for sugar and ketones Fluid balance chart Insert IDC measure and record urine output every hour 12 lead ECG

Measure and test

Pathology Temperature U/A Fluid input/output Electrocardiography

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 40 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Hyperglycaemia with Severe Dehydration | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride Dose 6-15 litres/min 500 mL Route Inhalation IV Frequency Continuous Stat (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) As required

0.9% Sodium Chloride

10 mL flush

IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n

Designation:

Date:

Close monitoring of fluid input and output is essential. Early management priorities are to treat shock and dehydration. This is more important initially than lowering the blood glucose with insulin.

Consider insulin therapy but not before a serum potassium is known and not before advice from a medical officer.

References:
Brenner Z., 2006, Management of hyperglycaemia emergencies, American Association of Critical Care Nurses, vol. 17, no.1, pp. 56-65. Frederick, S., and Danzi, D., 2008, Metabolic emergencies, in eds Stone C., and Humphries R., Current Diagnosis and Treatment: Emergency Medicine, 6th edn, McGraw-Hill Companies, New York. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Tintinalli J., Kelen G., Ma O., and Cline O., 2004, Emergency medicine: a comprehensive study guide, 6th edn, McGraw-Hill Companies, New York.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 41

Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only

Hypoglycaemia
Any patient who presents with confusion/convulsions/ coma should have hypoglycaemia considered as a cause.

History Prompts
n n

Onset Associated symptoms: confusion, visual disturbances, headache, dizziness, pallor

Clinical Severity Prompts


n n

BGL less than 3 mmol/L Confusion/seizure/coma

n n n n

Relevant past history Medication history Events Allergies

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability AVPU/GCS BGL

Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% IV cannulation/pathology

Monitor vital signs frequently Monitor LOC frequently Finger prick BGL less than 3 mmol/L and conscious administer simple sugar or If unconscious or confused administer IV 50% Glucose 50 mL or If IV access unavailable, administer IM Glucagon 1 mg Finger prick BGL every 15 minutes until within normal limits and the patient is mentally alert

Measure and test

Pathology Temperature U/A Fluid input/output Possible alcohol abuse

Collect blood for FBC, UEC, BGL, ABGs/venous blood gas (if available)

Fluid balance chart If history of possible alcohol abuse give IM Thiamine 100 mg

Specific treatment

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 42 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Hypoglycaemia | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders


Always check for allergies and contraindications.
Drug Oxygen 50% Glucose Glucagon Thiamine 0.9% Sodium Chloride Dose 6-15 litres/min 50 mL 1 mg (if IV access unavailable) 100 mg 10 mL flush Route Inhalation IV IM IM IV Frequency Continuous Stat Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Examples of oral simple sugars are; sugar, sweets or soft drink (non-diabetic) or milk, and these should be followed by a carbohydrate meal e.g. sandwiches or biscuits. Alcoholism is the leading cause of Wernickes Encephalopathy, which is a neurological syndrome associated with inadequate nutrition, including a deficiency in thiamine. The administration of Thiamine 100 mg is advocated in patients suspected of having hepatic encephalopathy but its effect is rarely immediate and delayed administration will not change the course of the initial resuscitation. The old dogma that Thiamine should be withheld until hypoglycaemia is corrected to avoid precipitating Wernickes encephalopathy is unfounded. The absorption of Thiamine is so much slower than that of glucose, timing is irrelevant (Hew, 2004, p. 367).

References: Donnino M., Vega J., Miller J., and Walsh M., 2007, Myths and misconceptions of Wernickes encephalopathy: What every emergency physician should know, Annals of Emergency Medicine, vol. 50, no. 6, pp. 715-721. Frederick S., and Danzi D., 2008, Metabolic Emergencies in eds Stone C, and Humphries R., Current diagnosis and treatment: Emergency medicine, 6th edn, McGraw-Hill Companies, New York. Hew , R., 2004, Altered Conscious State in Textbook of adult emergency medicine, eds Cameron, P., Jelinek, G., Kelly, A., Murray, L., Brown, A., Heyworth, J., Elsevier, Sydney. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. Tintinalli J., Kelen G., Ma O., and Cline O., 2004, Emergency medicine: A comprehensive study guide, 6th edn, McGraw-Hill Companies, New York.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 43

Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only

Snake / Spider Bite


Do NOt remove pressure immobilisation bandage.

Associated symptoms: weakness, paralysis, headache, nausea, vomiting, abdominal pain, altered level of conscious, severe localised pain (spider bite), localised sweating, diaphoresis, excess salivation, painful lymph node, ptosis

Clinical Severity Prompts


n n n

Neurotoxic paralysis/diplopia/dysphagia Convulsions Abdominal pain, headache, nausea/vomiting


n n n

Relevant past history/previous envenomation or antivenom administration Medication history Allergies

History Prompts
n

Events time of bite, number of bites, time and type of first aid applied, pre-hospital treatment, drug/alcohol intoxication, activity since bite, bite site location/s
assessment Position Intervention

ensure first aid measures have been implemented and consider early transfer.

Position of comfort / keep patient immobile Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Apply pressure immobilisation bandage and splinting to all victims of snake bite and Funnel Web spider bite IV cannulation/pathology

airway Breathing Circulation

Assess patency Respiratory rate and effort SpO2 First aid Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor

If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL Monitor vital signs frequently Monitor LOC frequently If GCS less than 9 and not rapidly improving, patient may require endotracheal intubation by a MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration

Disability

AVPU /GCS + pupils

Measure and test

Signs of systemic snake envenomation Pathology Temperature U/A Fluid input/output Signs of systemic envenomation Electrocardiography

Whole blood clotting time (in a glass tube) Collect blood for FBC, UEC, CK, coags, group and hold Monitor Check for myoglobin Consider IDC and observe urine for myoglobin Insert IDC measure and record urine output every hour Nil by mouth Fluid balance chart 12 lead ECG IV 0.9% Sodium Chloride 1000 mL (125 mL per hour) to maintain hydration Consider appropriate antivenom Consider IV Atropine 0.5 mg if bradycardic and SBP less than 90 mmHg Ice to bite site (do NOT apply pressure immobilisation bandage) Consider Redback spider antivenom If nausea or vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5 mL

Specific treatment

Hydration Systemic envenomation Funnel web envenomation Redback spider envenomation Nausea and vomiting Immunisation status

Document assessment findings, interventions and patients response in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 44 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Snake / Spider Bite | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride 0.9% Sodium Chloride Atropine Metoclopramide Boostrix or ADT Booster 0.9% Sodium Chloride Dose 6-15 litres/min 500 mL (circulation support) 1000 mL (maintain hydration) 0.5 mg 10 mg 0.5 mL 10 mL flush Route Inhalation IV IV IV IV or IM IM IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) 125mL per hour Stat Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

Apply pressure immobilisation bandage at the same pressure as for sprained ankle. Bandage the whole limb from the armpit or groin to the digits. IM injections should be avoided (except Boostrix/ADT Booster) in snake bite victims because of coagulopathy. Whole blood clotting test may be performed to determine the length of time blood takes to clot. It is performed by placing 10 mL of venous blood into a glass test tube and measuring the time taken for the blood to clot. Normal time is less than 10 minutes. A snakebite observation chart is recommended for recording vital signs and specific signs associated with snakebites/ envenomation refer to Appendix 9.

n n

References: MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. NSW Health, 2007, Snakebite and spiderbite clinical management guidelines, viewed 19.01.09, <http://www.health.nsw. gov.au/policies/gl/2007/pdf/GL2007_006.pdf>. Stewart C., 2003, Snake bite in Australia: First aid and envenomation management, Accident and emergency nursing, vol. 11, no. 2, pp. 106-111.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 45

PAGE 46

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 6

Trauma Emergencies

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 47

Trauma | Medical Officer must be notified immediately | For Adults Only

trauma
Refer trauma triage tool (appendix 10). all trauma patients should be treated as having a spinal injury until proven otherwise. Immediately call for assistance and notify the Medical Officer and aeromedical and Medical Retrieval Service (aMRS) 1800 650 004.

Clinical Severity Prompts


n

History Prompts
n

Vital sign abnormalities: RR of less than 10 or greater than 29, SpO2 less than 90% on air, cyanosis or respiratory difficulty HR greater than 120 bpm SBP less than 90 mmHg or severe haemorrhage LOC is V, P or U on AVPU scale. Requires at least gentle tactile stimulation and shout to rouse from decreasing level of consciousness/GCS less than or equal to 13 or paralysis/sensory deficit

Events: high risk mechanism of injury type force and time Relevant past history recent surgery Patients taking anticoagulant therapy/ known coagulopathy Medication history Fasting status Allergies The following patient groups are at greater risk and require a high index of suspicion for serious trauma: Patients over the age of 65 years Pregnant woman over 20 weeks gestation

n n n n

n n

High risk mechanism of injury Types of injuries especially multi-system injuries

types of injuries
Penetrating Head Face Neck Chest Abdomen Pelvis Spine Limb to head, neck, chest, abdomen, perineum or back use Head Injury Guideline page 57 severe facial injury; injury with potential airway risk; severe haemorrhage swelling, bruising, hoarseness or stridor severe pain, subcutaneous emphysema, paradoxical breathing, crush injury severe pain, rigidity, distension, restraint/abrasion/contusion severe pain, genital contusions, vertical shear and open book fracture weakness, sensory loss, visible deformity vascular injury with ischaemia of limb, crush injury, fracture of 2 or more long bones, degloving injury, amputation

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 48 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Trauma | Medical Officer must be notified immediately | For Adults Only

assessment Position airway Assess patency

Intervention Full PPe measures must be considered. Lie supine, depending on clinical status Maintain airway patency (do NOt insert a naso-pharyngeal airway if there is any possibility of a fractured base of skull or nasal bone fracture) Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Assist ventilation if required Apply O2 via non-rebreather mask to maintain SpO2 greater than 95% Tension pneumothorax requires immediate chest decompression with a needle thoracentesis (refer to Appendix 12)

Breathing

Respiratory rate and effort. SpO2 Asymmetrical chest movement, unilateral decreased breath sounds, tracheal deviation Open sucking chest wound

Cover with non-porous dressing taped on 3 sides only remove immediately if respiratory status deteriorates Control external bleeding using direct pressure/ elevation/pressure dressing IV cannulation x 2 (large bore)/pathology Involve a surgeon as soon as possible IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus to maintain SBP 80-90 mmHg

Circulation

External bleeding Internal bleeding Blood pressure Skin temperature Pulse rate/rhythm Capillary refill Cardiac monitor

Monitor vital signs frequently Monitor GCS frequently. If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOt protect the airway from aspiration

Disability

AVPU/GCS + Pupils

BGL Measure and test Primary Survey Secondary Survey

Finger prick BGL Repeat Commence thorough head to toe assessment including the patients back (log roll if at least 4 people are available) Identified deficits go to specific treatment section immediately If pain score 4-10 give IV/IO Morphine 2.5 mg increments every 5 mins to a total of 10 mg or IM Morphine 5-10 mg to a total of 10mg (if IV/IO access unavailable) Collect blood for FBC, UEC, group and hold, formal blood alcohol (if required and accredited to take), consider beta hCG If available ABG/venous blood gas, base deficit, serum lactate Prevent hypothermia Full urinalysis and urinary hCG (if required) Strict fluid balance chart Nil by mouth Insert IDC (unless contraindicated); measure and record urine output every hour Consider gastric tube. Do NOt insert a naso-gastric tube if there is a possibility of a base of skull fracture or nasal bone fracture 12 lead ECG

Pain

Pathology

Temperature U/A Fluid input/output

Electrocardiography

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 49

Trauma | Medical Officer must be notified immediately | For Adults Only

assessment Specific treatment Limb-threatening injury (neurovascular compromise) Amputations

Intervention Neutral alignment Splint or plaster backslab Perform neurovascular limb observations frequently (refer to Appendix 13) Preserve amputated part: wrap in moist saline gauze. Seal in airtight plastic bag. Place sealed bag in a slurry of ice; keep near patient and label bag with patients details accurately Cover exposed viscera with moist saline packs (avoid hypothermia) Stabilise with pelvic binding or sheeting (refer to Appendix 14) Stabilise with traction splint. Perform neurovascular observations pre and post splinting Cover with saline pack; do not reposition protruding bone ends Stabilise object DO NOt remove IV/IO Compound Sodium Lactate (Hartmanns) Solution 200 mL bolus as required to maintain SBP of 80-90 mmHg Nil by mouth IV/IO 0.9% Sodium Chloride 1000mL (125 mL/hour to maintain hydration) If nausea or vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5mL

Abdominal Injuries Suspected pelvic fracture Suspected fractured shaft of femur Open fractures Impaled objects Fluid deficit Hydration/intake Nausea & vomiting Immunisation status

Document assessment findings, interventions and responses in the patients healthcare record

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution Morphine Morphine 0.9% Sodium Chloride Metoclopramide Boostrix or ADT Booster 0.9% Sodium Chloride Dose 15 litres/min Non-rebreather mask 200 mL (circulation support) 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV/IO access unavailable) 1000 mL (maintain hydration) 10 mg 0.5 mL 10 mL flush Route Inhalation IV/IO IV/IO IM IV/IO IV or IM IM IV/IO Frequency Continuous Stat (repeat as required to maintain SBP of 80-90 mmHg) Every 5 minutes (not to exceed 10 mg) Stat (not to exceed 10mg in total) 125 mL per hour Stat Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation:

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 50 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Trauma | Medical Officer must be notified immediately | For Adults Only

Precautions and Notes:


n n n n

The list of injuries identified is not exclusive of what might be present. Be aware of distracting painful injuries that may mask other and more serious injuries. Some patients who may be normally hypertensive may require fluid resuscitation prior to SBP less than 90 mmHg. IV/IO Compound Sodium Lactate (Hartmanns) Solution is the first choice for resuscitation fluid in the hypovolaemic trauma patient. IV/IO 0.9% Sodium Chloride may be used as an alternative; however large volumes may result in metabolic acidosis. Aggressive fluid resuscitation results in increased haemorrhage and greater mortality. Smaller volumes of IV fluid boluses are recommended. Prior to inserting in-dwelling catheter ensure there is no blood at urinary meatus as this may indicate a urethral injury and this is a contraindication to inserting a urethral catheter. Do not insert nasopharyngeal airway or nasogastric tube in patients suspected of having a fractured base of skull or nasal bone fracture. Close monitoring of fluid input and output is essential. Tachycardia may not occur in athletes, elderly patients, those taking beta blocking agents or those suspected of spinal cord injury. Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment.

n n

References:
Ambulance Service of NSW, 2008, Pre-hospital management of major trauma. Trauma triage tool major trauma critieria (MIST) Protocol T1. American College of Surgeons Committee on Trauma, 2008, Shock in Advanced trauma life support course for doctors student course manual, 8th edn, United States. Cain J.G., Smith C.E., 2001, Current practices in fluid and blood component therapy in trauma Seminars in anesthesia, vol. 20, no. 1, pp. 28-35. Curtis K., Ramsden C., and Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Dunn R, et. a.l (editor), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Dutton R.P., Mackenzie C.F., Scalea T.M., 2002, Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality, Journal of trauma injury, infection and critical care, vol. 52, no. 6 pp. 1141-6. Emergency Life Support (ELS) course manual, 2005, 3nd edn, ELS Course Inc., Tamworth. Emergency Nurses Association, 2000, Trauma nursing core course provider manual, 5th edn, Emergency Nurses Association, USA. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> Nolan J., 2001, Fluid resuscitation for the trauma patient, Resuscitation, vol. 48, no. 1 pp. 57-69. Pascoe S., and Lynch J., 2007, Adult trauma clinical practice guidelines, management of hypovolaemic shock in the trauma patient, NSW Institute of Trauma Injury and Management, Sydney. Tintinalli J., Gabor M., Kelen D., Stapczynski J., Ma O., Cline D., Emergency medicine: A comprehensive study guide international, 6th edn, McGraw-Hill, New York The Neurosurgical Society of Australasia, 2000, The Management of acute neurotrauma in rural and remote locations. A set of guidelines for the care of head and spinal injuries, Royal Australasian College of Surgeons, Melbourne

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 51

Burns | Medical Officer must be notified immediately | For Adults Only

Burns
The burn surface is cooled with running water. Ideal water temperature is 15C, with a range of 8-25C for a minimum of 20 minutes; this is beneficial for the first three (3) hours only on burns of less than 10% TBSA. Prevent hypothermia. If the patient has suffered chemical burns, ensure staff are adequately protected from contamination. Always brush dry chemicals off (use PPE) before applying cool water.

History Prompts
n n

Onset time of burn Events: mechanism of injury/exposure history of electrical/thermal/chemical/radiation burns confined space first aid measures defined Associated symptoms: cough, hoarse voice, sore throat, sooty sputum, stridor, neck/facial swelling, singed facial hair, confusion Relevant past medical history Medication history Tetanus immunisation status Allergies

Clinical Severity Prompts


n n n n n

Airway/facial/neck burns Burns to hands, feet, perineum Electrical burns including lightning injuries Chemical burns Circumferential burns of limbs or chest
assessment Position

n n n n

Intervention Position of comfort/clinical status Maintain airway patency Consider early endotracheal intubation by MO Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15L/minute to all patients except those with minor burns IV cannulation X 2 / pathology

airway

Assess patency Evidence of airway burn: hoarse voice, stridor, sore throat, sooty sputum, neck / facial swelling Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Blistering Cardiac monitor Electrocardiography Constrictive non-adhered clothing or jewellery

Breathing

Circulation

If SBP less than 90 mmHg give IV/IO 0.9% Sodium Chloride 500 mL Monitor vital signs frequently 12 lead ECG if possible, (especially electrical burns and lightning strikes) Remove Monitor LOC frequently Finger prick BGL Repeat Oral Panadeine Forte (if not nil by mouth) 1-2 tablets for minor burns only IV/IO Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV/IO access unavailable) avoid burnt areas Commence Calculate total body surface area burnt (refer to Appendix 15)

Disability Measure and test

AVPU/GCS + pupils BGL Primary survey Pain score (1-3) Pain score (4-10)

Secondary survey

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 52 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Burns | Medical Officer must be notified immediately | For Adults Only

assessment Measure and test Pathology Temperature Fluid input/output Burns greater than 15% TBSA

Intervention Collect blood for FBC, UEC, (consider group and hold, myoglobin, ABG/venous blood gas) Avoid hypothermia Modified Parkland formula: in the first 24 hours post burn give IV/IO Compound Sodium Lactate (Hartmanns) Solution 3-4 mL x kg body weight x % TBSA burnt. Give 50% of total amount in first 8 hours from time of the burn, give the remaining 50% over the next 16 hrs Maintain UO at 0.5-1 mL/kg/hour Fluid balance chart Nil orally if burns greater than 10-15% TBSA NGT if greater than 20% TBSA burns and not contraindicated For burns of more than 20% TBSA, insert IDC measure and record urine output every hour Observe urine for myoglobinuria or haemoglobinuria Copious water irrigation Brush off prior to copious water irrigation. Staff must use PPE Maintain UO greater than 1-2 mL/kg/hour

U/A

Specific treatment

Liquid chemical Powder chemical Electrical/lightning strike/ haematuria/ haemoglobinuria/ rhabdomyolysis Circumferential burns Burn wounds

Elevate the affected limb Perform neurovascular observations every 15 minutes If transferring within 8 hours and patient stable, apply cling wrap to the burns If the face is burnt paraffin ointment should be applied If there is a delay in transfer, wound management should be in consultation with the burn surgeon who will receive the patient. Do not use Silver Sulphadiazine (SSD) cream without consulting the tertiary Burns Service, and do not apply to the face If nausea/vomiting present give IV or IM Metoclopramide 10 mg Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5mL

Nausea/vomiting Immunisation status

Document assessment findings, interventions and responses in the patients healthcare record

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution 0.9% Sodium Chloride Panadeine Forte Dose 6-15 litres/min As per Modified Parkland formula (above) 500 mL 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV/IO access unavailable) 10 mg 10 mL flush 0.5 mL Route Inhalation IV/IO IV/IO Oral Frequency Continuous As per formula Stat if SBP less than 90 mmHg Stat (one dose only)

Morphine

IV/IO

Every 5 minutes (to a total of 10 mg)

Morphine Metoclopramide 0.9% Sodium Chloride Boostrix or ADT Booster

IM IV or IM IV/IO IM

Stat (to a total of 10 mg) Stat As required Stat

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 53

Burns | Medical Officer must be notified immediately | For Adults Only

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n n n n n

Designation:

Date:

Consult with burns specialist early. Prompt consultation is required for any patient with facial burns/inhalation injury to ensure airway patency is maintained. Any patient sustaining burns in a confined space is susceptible to inhalation injury and carbon monoxide poisoning. Do not use ice or iced water to cool a burn. Management of blisters is generally guided by specialist clinicians or institutional preferences. Patients who require immediate consultation with a burns unit and will likely require retrieval (refer to Appendix 15): full thickness burns greater than 5% TBSA partial thickness burns greater than 10% TBSA burns associated with inhalational injury burns to face, hands, feet, genitalia, perineum and major joints any intubated patient chemical burns electrical burns including lightning injuries circumferential burns of limbs or chest burns with concomitant trauma burns in patients with pre-existing medical conditions that could adversely affect patient care and outcome pregnancy with cutaneous burns burns at the extremes of age e.g. frail elderly (NSW Health, GL2008_012, pp. 3-4)

Hydrofluoric Acid burns early copious water irrigation and application of Calcium Gluconate gel is recommended. Consult with a specialist early. Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. Refer to NSW Severe Burn Injury Transfer Flow Chart; Burn Patient Emergency Assessment & Management Chart; Assessment of % Total Body Surface Area (TBSA) and Burn Distribution; Resuscitation Fluids (Appendix 15).

References:
Australian Resuscitation Council, 2008, Guideline 8.5 Burns, viewed 8.07.09, <http://www.resus.org.au/>. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> NSW Health, 2008, GL2008_012 Burn Transfer Guidelines NSW Severe Burn Injury Service, 2nd edn, NSW Department of Health, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 54 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Drowning | Medical Officer must be notified immediately | For Adults Only

Drowning
Clinical Severity Prompts
n n n n n

syncope or seizure as a precipitating event alcohol or drug intake circulatory arrest


n n n n n

Altered level of consciousness Wheezing Crepitations Pink frothy sputum Tachycardia greater than 100 beats per minute

Hyperventilation before breath holding underwater Trauma (head/spinal) Duration of immersion Water temperature Time of accident, time of rescue, time of first effective CPR Crepitations, tachycardia, altered level of consciousness, respiratory or cardiac arrest

History Prompts
n

In diving accidents or the unconscious submersion victim, spinal and skull fractures must be considered Consider: the possibility of associated drug and/or alcohol use attempted self-harm
assessment Position Intervention

If respiratory and/or cardiac arrest present treat as per Cardiac arrest Guideline If history of trauma refer to trauma Guideline

Sit upright depending on clinical status Position supine if c-spine injury is suspected Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if there is a possibility of injury) Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% If SpO2 falls below 95% with O2 consult MO If wheeze present give inhaled Salbutamol 6-12 puffs of 100 microgram MDI + spacer Salbutamol 5mg nebule stat Consider CPAP/BiPAP if available and no associated trauma present Consider risk of pneumothorax, especially if rapid ascent from significant depth Remove wet clothing cover with blankets, do NOt actively rewarm IV cannulation/pathology IV 0.9% Sodium Chloride 500mL if SBP less than 90 mmHg Monitor vital signs frequently 12 lead ECG Monitor LOC frequently If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Consider LMA insertion if GCS equals 3 and airway difficult to maintain Note: LMA does NOT protect the airway from aspiration

airway

Assess patency

Breathing

Respiratory rate and effort SpO2 Wheeze If patient cannot inhale adequately to use an MDI and spacer Auscultation

Circulation

Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac Monitor Electrocardiography

Disability

AVPU/GCS + pupils

BGL Measure and test Pathology Temperature U/A Fluid input/output Chest X-ray Specific treatment Gastric distension

Finger prick BGL Collect blood for FBC, serum glucose, UEC, ABGs/venous blood gas if available Avoid hypothermia Fluid balance chart Nil by mouth Insert IDC measure and record urine output every hour If available Do not attempt to empty the stomach by external pressure

Document assessment findings, interventions and responses in the patients healthcare record
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 55

Drowning | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen Salbutamol Salbutamol 0.9% Sodium Chloride 0.9% Sodium Chloride Dose 6-15 litres/min 6-12 puffs of 100 microgram dose MDI + spacer 5 mg Nebule (if patient unable to inhale adequately using MDI + spacer) 500 mL 10 mL flush Route Inhalation Inhalation Inhalation IV IV Frequency Continuous Stat Stat Stat (repeat once if SBP remains less than 90 mmHg) As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n

Designation:

Date:

The new definition of drowning includes both cases of fatal and non-fatal drowning. Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid Drowning outcomes are classified as death, morbidity and no morbidity (WHO, 2005). The World Health Organisation (WHO) states that the terms wet, dry, active, passive, silent and secondary drowning should no longer be used (WHO, 2005). Therefore a simple, comprehensive, and internationally accepted definition of drowning has been developed.

References:
Australian Resuscitation Council, 2005, Guideline 8.7: Resuscitation of the drowning victim, ARC, Melbourne. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch> The American Heart Association, 2005, Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 10.3: drowning, Circulation, vol. 112, no. 24 Supplement, pp. IV 133 IV 135. van Beeck E., Branche C.M., Szpilman D., Modell J.H. & Bierens J.J.L.M., 2005, A new definition of drowning: towards documentation and prevention of a global public health problem, Policy and Practice, Bulletin of the World Health Organisation, vol. 83, no. 11, pp. 853-856. World Health Organisation, Department of Injuries and Violence Prevention World Health Organisation, 2003, Facts about injuries: Drowning, viewed 14.06.09, <http://www.who.int/violence_injury_prevention/publications/other_injury/en/ drowning_factsheet.pdf>.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 56 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Head Injury | Medical Officer must be notified immediately | For Adults Only

Head Injury
Clinical Severity Prompts
n n n n n n n

History Prompts
n n

Events high risk mechanism of injury Associated symptoms: headache, confusion, irritability, memory loss, nausea, vomiting, dizziness, speech, motor and/or visual disturbances, seizure

GCS less than 14 Loss of consciousness with a history of trauma Visible deformities (fracture of skull or facial bones) Ecchymosis around eyes or ears CSF leak from nose or ears Inequality or non-reactivity of pupil/s SBP less than 90 mmHg at any time
assessment Position Intervention
n n n

Relevant past history Medication history i.e. anticoagulants such as warfarin, aspirin, clopidogrel Allergies

Position head up 30 unless contraindicated Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar Assist ventilation if required Apply high flow O2 using a non-rebreather mask at 15L/minute to maintain SpO2 greater than 95% IV cannulation/pathology

airway

Assess patency

Breathing

Respiratory rate, effort, pattern SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor

Circulation

If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 200 mL bolus Monitor vital signs frequently Monitor GCS frequently If GCS 13 or less consider retrieval/transfer If GCS less than 9 and not rapidly improving, patient will require endotracheal intubation by MO to protect the airway from aspiration Finger prick BGL Collect blood for FBC, UEC (consider beta hCG and blood alcohol levels if accredited to take) Repeat Commence Protect from hypo/hyperthermia Fluid balance chart Consider IDC and urine measurements every hour Nil by mouth if decreasing level of consciousness If pain score 1-3, and GCS 14 or 15 and patient not nil by mouth, give oral Paracetamol 500mg 1g If pain score 4-10 give IV Morphine 2.5mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10mg (if IV access unavailable) If nausea/vomiting present give IV or IM Metoclopramide 10 mg

Disability

AVPU / GCS + Pupils

BGL Measure and test Pathology Primary Survey Secondary Survey Temperature U/A Fluid input/output Pain score (1- 3) Pain score (4-10) Halo sign Specific treatment Nausea/vomiting

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 57

Head Injury | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride Paracetamol Morphine Dose 6-15 litres/min 200 mL bolus 500 mg - 1 g 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mg 10 mL flush Route Inhalation IV Oral IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Stat (one dose only) Every 5 minutes (to a total of 10 mg)

Morphine Metoclopramide 0.9% Sodium Chloride

IM IV or IM IV

Stat (to a total of 10 mg) Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n n

Designation:

Date:

Prevent secondary brain injury. Hypotension (i.e. SBP less than 90 mmHg) is a poor prognostic indicator. Do NOT insert a nasopharyngeal airway or nasogastric tube in a patient suspected of having a fractured base of skull or nasal bone fracture. If blood or fluid is draining from the nose or ear suspect a fractured base of skull. A decline in the GCS of two or more points must be considered significant. A MO must be contacted immediately. The provision of narcotic analgesia is not contraindicated once the life-saving surgical and neurological evaluation of the trauma patient has been performed. Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment. Note: nausea and vomiting may be a sign of raised intracranial pressure. The halo sign is present when nasal secretions on bed linen or dressings form a halo. This occurs when CSF, mixed with blood, spreads onto an absorbent surface. The darker blood chromatographically forms a ring around a lightlystained centre, forming a halo. Mixture of blood with tears or saliva can give false-positives.

n n n

n n

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 58 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Head Injury | Medical Officer must be notified immediately | For Adults Only

People on Warfarin, Clopidogrel or aspirin (especially the elderly) who have a head injury/trauma have a very high morbidity and mortality. These patients need to be monitored very closely and will require a CT scan, as they can deterioriate very quickly. A MO must consider the need for a CT scan/further consultation, especially for high risk patients and patients whose GCS is not improving, e.g. persistent GCS less than 15 at 2 hours post injury.

References:
Dunn R., et. al. (eds), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. Emergency Life Support (ELS) course manual, 2005, 3nd edn, ELS Course Inc., Tamworth. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. National Health and Medical Research Council, 2005, Acute pain management: Scientific evidence, 2nd edn, Commonwealth of Australia, Canberra. Reed D., 2007, Adult trauma clinical practice guidelines, initial management of closed head injury in adults, NSW Institute of Trauma and Injury Management, North Ryde. The Neurosurgical Society of Australasia, 2000, The management of acute neurotrauma in rural and remote locations, The Royal Australasian College of Surgeons, Melbourne.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 59

Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only

Isolated Severe limb Injury


Clinical Severity Prompts
n n n

History Prompts
n n n

Onset Events history of trauma, mechanism of injury Associated symptoms; obvious deformity swelling to limb pain associated with the injury

Obvious deformity, swelling and pain to limb Loss of sensation and pulse Ischaemia of limb

n n n

Relevant past history Medication history Allergies

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 External bleeding Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Disability Measure and test AVPU/GCS Pain score (1-3) Pain score (4-10)

Intervention Position of comfort/function Maintain airway patency Assist ventilation if required Apply O2 to maintain SpO2 greater than 95% Control external bleeding Record colour, warmth, sensation, movement and pulses of affected limb (refer to Appendix 13) IV cannulation Monitor vital signs frequently Monitor LOC frequently If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IV Morphine 2.5 mg increments every 5 minutes to a total of 10 mg or IM Morphine 5-10 mg (if IV access unavailable) Fluid balance chart Nil by mouth (until anaesthetic requirement confirmed) Neutrally align limb if possible. Assess both limbs frequently as well as pre and post splinting or plaster backslab If available If nausea/vomiting present give IV or IM Metoclopramide 10 mg Immobilisation/elevation/ice/splint/POP backslab

Fluid input/output Neurovascular observations X-Ray Specific treatment Nausea/vomiting Limb stabilisation

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 60 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Isolated Severe Limb Injury | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders

Always check for allergies and contraindications.


Drug Oxygen Panadeine Forte Dose 6-15 litres/min 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 10 mg 10 mL flush Route Inhalation Oral Frequency Continuous Stat

Morphine Morphine Metoclopramide 0.9% Sodium Chloride

IV IM IV or IM IV

Every 5 minutes (not to exceed 10 mg) Stat (not to exceed 10 mg) Stat As required

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Precautions and Notes:
n n n n

Designation:

Date:

Neurovascular limb observations must also include the unaffected limb for comparison. Refer to Appendix 13 for suggested guidelines for a neurovascular assessment. Compartment syndrome is a limb threatening complication of limb injury caused by increased pressure. Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment.

References
Curtis K., Ramsden C., & Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Dunn R., et. al. (ed), 2000, The emergency medicine manual, 2nd edn, Venom Publishing Unit, West Beach. MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 61

Ocular Injuries | Medical Officer must be notified immediately | For Adults Only

Ocular Injuries
Some patients who present complaining of eye flash burns may in fact have a corneal foreign body.

History Prompts
n

Events mechanism of injury (e.g. drilling, high speed motor drilling without eye protection) Associated symptoms; pain, redness, tearing, headache, loss of vision, type of foreign body (e.g. glass, dirt, organic, metal)

Clinical Severity Prompts


n n n n n

Injury with loss of visual acuity Welding in past 24 hours Exposure to snow or water glare in past 24 hours Chemical exposure or burn injury to eye Penetrating foreign body of the eye
assessment Position Intervention
n n n

Relevant past history Medication history Allergies

Position of comfort, but lie supine (if penetrating injury or suspected retinal detachment) Maintain airway patency Stabilise the C-spine with in-line immobilisation and apply a semi-rigid cervical collar (if associated history of trauma) If other associated trauma, support ventilation if required Apply O2 to maintain SpO2 greater than 95% Monitor vital signs frequently Monitor LOC frequently Snellen chart/finger count/light perception assessment and pupillary response If pain score 1-3 and patient not nil by mouth give oral Panadeine Forte 1-2 tablets If pain score 4-10 give IM Morphine 5-10 mg (10mg in total) Do not remove foreign body. Stabilise foreign body Do not apply eye pad or pressure to eye Consider tetanus immunisation e.g. IM Boostrix or ADT Booster 0.5mL Instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye. Instil eye drops every 15-20 minutes during irrigation procedure If small amount of superficial dust or organic matter is present, gently remove with a cotton bud which has been moistened with 0.9% Sodium Chloride. Gentle irrigation with a neutral fluid e.g. Compound Sodium Lactate (Hartmanns) solution or 0.9% Sodium Chloride using an IV blood pump giving set may be required if a number of superficial dust particles are present.

airway

Assess patency

Breathing Circulation

Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Blood pressure AVPU/GCS + pupils Temperature Visual acuity Pain score (1-3) Pain score (4-10)

Disability Measure and test

Specific treatment

Penetrating injury

Corneal foreign bodies (e.g. dust, small organic matter)

Chemical exposures

If history of chemical exposure instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye. Instil eye drops every 15-20 minutes during irrigation procedure Irrigate eye/s with copious amounts of a neutral fluid e.g. Compound Sodium Lactate (Hartmanns) Solution or 0.9% Sodium Chloride using an IV blood pump giving set for at least 30 minutes Continue irrigation until pH is within range of 6.5 to 8.5

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 62 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Ocular Injuries | Medical Officer must be notified immediately | For Adults Only

assessment Specific treatment Flash burns Suspected retinal detachment/hyphaema Fluid input/output Nausea and vomiting Corneal injury

Intervention If flash burns to eyes instil 0.4% Oxybuprocaine 2 drops per eye or 0.5% or 1% Amethocaine 2 drops per eye (one dose only) Instruct patient to observe strict bed rest, at least until reviewed by MO In anticipation of surgical intervention restrict the patient to remain nil by mouth If nausea/vomiting present give IM Metoclopramide 10 mg Instil Fluorescein Sodium 1 drop affected eye/s only, view injury with cobalt blue light

Document assessment findings, interventions and responses in the patients healthcare record

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen Compound Sodium Lactate (Hartmanns) Solution 0.9% Sodium Chloride Panadeine Forte Dose 6-15 litres / min 1000 mL 1000 mL 1-2 tablets (Paracetamol 500 mg and Codeine Phosphate 30 mg) 5-10 mg (not to exceed total 10mg) 2 drops per affected eye 2 drops per affected eye Route Inhalation Eye irrigation Eye irrigation Oral Frequency Continuous Stat (repeat as required) Stat (repeat as required) Stat

Morphine 0.4% Oxybuprocaine drops 0.5% or 1% Amethocaine drops Metoclopramide Fluorescein Sodium Boostrix or ADT Booster

IM Topical Topical

Stat Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) Stat (every 15-20 minutes during irrigation procedure) or (Stat for flash burns) Stat Stat Stat

10 mg 1 drop affected eye/s 0.5 mL

IM Topical IM

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation:

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 63

Ocular Injuries | Medical Officer must be notified immediately | For Adults Only

Precautions and Notes:


n

It is important to test the visual acuity (VA) in ALL patients with ocular trauma as it is an important parameter and is of medicolegal importance Chemical exposure: ensure both the upper and lower eyelids are everted during irrigation patients with chemical exposure to the eyes should also be assessed for potential aspiration of chemicals and subsequent airway obstruction ensure the face and other exposed areas are thoroughly washed with water. Corneal injury/s: instil one drop of Fluorescein Sodium to affected eye/s only, view eye injury with cobalt blue light from torch or ophthalmoscope soft contact lens/es MUST be removed prior to instillation of Fluorescein Sodium drop/s Patient with metallic foreign body/s in the eye require referral to MO. If not (correctly) removed the metallic foreign body/s may lead to the formation of rust ring/s. Do not irrigate the eye/s if metallic foreign body is insitu Do not send patient home with local anaesthetic eye drops

References:
MIMS Online <http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_ssearch>. NSW Department of Health, 2009, Eye Emergency Manual: An Illustrated Guide, 2nd Edn, NSW Department of Health, North Sydney. Ramsden C., Curtis K., Seggie J., & Braybrooks L., 2007, Ocular emergencies, in Emergency & trauma nursing, (eds) Curtis K., Ramsden C. & Friendship J., Mosby, Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 64 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 7

Other Emergencies

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 65

Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only

abdominal/loin/Flank Pain
Note: A leaking abdominal aortic aneurysm can mimic renal colic in elderly patients.

n n

Nature of Onset Associated symptoms nature of pain/radiation nausea, vomiting diarrhoea/constipation last menstrual period/symptoms of pregnancy urinary symptoms weight loss Relevant past history Immunocompromised Medication history Events mechanism of injury (if trauma is involved) Allergies

Clinical Severity Prompts


n n

Pain to abdomen/loin/flank Localised tenderness to right upper or lower quadrant of abdomen Rapid onset
n n

History Prompts
n

n n n

Four immediately life threatening presentations that require exclusion are; 1. Ruptured ectopic pregnancy 2. Ruptured abdominal aortic aneurysm 3. Acute myocardial infarction 4. Ruptured spleen

assessment Position airway Breathing Circulation Assess patency Respiratory rate and effort SpO2 Skin temperature Pulse rate/rhythm Capillary refill Blood pressure Cardiac monitor Disability Measure and test AVPU / GCS BGL Abdominal assessment Pain score (2-10)

Intervention Position of comfort Maintain airway patency Assist ventilation if required Apply O2 to maintain greater than 95% IV cannulation/pathology

If SBP less than 90 mmHg give IV 0.9% Sodium Chloride 500 mL stat Monitor vital signs frequently Monitor LOC frequently Finger Prick BGL Look, listen and feel If pain score 2-10 give IV Morphine 2.5 mg every 5 minutes to a total of 10mg or IM Morphine 5-10 mg (if IV access unavailable) Collect blood for FBC, UEC, (consider LFTs, serum amylase, coags, group and hold) Urine hCG (if required), collect MSU Strain urine for calculi Fluid balance chart 12 Lead ECG Nil by mouth IV 0.9% Sodium Chloride 1000 mL at 125 mL per hour to maintain hydration IM Prochlorperazine 12.5 mg

Pathology Temperature U/A Fluid input/output Electrocardiography Specific treatment Hydration / intake Nausea and vomiting

Document assessment findings, interventions and responses in the patients healthcare record

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 66 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only

Medication Standing Orders Always check for allergies and contraindications.


Drug Oxygen 0.9% Sodium Chloride Morphine Dose 6-15 litres/min 500 mL bolus 2.5 mg increments (10 mg diluted with 9 mL 0.9% Sodium Chloride) 5-10 mg (if IV access unavailable) 1000 mL 12.5 mg 10 mL flush Route Inhalation IV IV Frequency Continuous Stat (repeat once if SBP remains less than 90 mmHg) Every 5 minutes (to a total of 10 mg) Stat (to a total of 10mg) 125 mL per hour Stat As required

Morphine 0.9% Sodium Chloride Prochlorperazine 0.9% Sodium Chloride

IM IV IM IV

Medications within this guideline must be administered within the context of the formulary.
n

Medical Officer review is required as soon as possible (within 24 hours) following the administration of a drug according to the standing orders contained within this document. At the time of this review, the Medical Officer must check and countersign the nurses record of administration on the medication chart. If an Advanced Clinical Nurse uses these Guidelines, a Medical Officer will be notified immediately to ensure their early involvement with the management and care of the patient.

Authorising Medical Officer signature: Name: Date: Drug Committee approval: Date: Designation:

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 67

Abdominal/Loin/Flank Pain | Medical Officer must be notified immediately | For Adults Only

Precautions and Notes:


n

Elderly patients presenting with abdominal/loin/flank pain have a 14% mortality rate. Symptoms may be vague with a low tolerance for shock e.g. a SBP of 90 mmHg may be critical if previously hypertensive Patients over the age of 65 years requiring opioids should be monitored frequently, both for the effectiveness of the analgesia and the presence of adverse effects Opioid analgesics can be safely administered before full assessment and diagnosis in acute abdominal pain, without increasing the risk of errors in diagnosis or treatment Be cautious in administering Morphine if there is an altered level of consciousness, respiratory compromise or SBP less than 90 mmHg. Use of sedation scores may be beneficial in this reassessment Metoclopramide hydrochloride should only be used where bowel obstruction/perforation has been excluded Metoclopramide appears to be a more effective antiemetic than prochlorperazine, but should not be administered unless ordered by a Medical Officer Tachycardia may not occur in patients taking beta blocking agents.

n n

References:
Gallager E.J., 2004, Acute abdominal pain, in Emergency medicine: A comprehensive study guide, The McGraw-Hill Companies Inc. National Health and Medical Research Council, National Institute of Clinical Studies, 2008, Pain medication for acute abdominal pain. A summary of best available evidence and information on current clinical practice, Australian Government, Canberra. The Australian and New Zealand College of Anaesthetists, 2005, Acute pain management: Scientific evidence, 2nd edn.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 68 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

THE FOLLOWING DRUG INFORMATION PERTAINS ONLY TO THE CONTEXT SPECIFIED IN THIS NSW RURAL ADULT EMERGENCY CLINICAL ADULT GUIDELINES DOCUMENT

Formulary

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 69

Formulary Index

Adrenaline .....................................................................................................................................................................71 Amethocaine 0.5% or 1% .............................................................................................................................................71 Amiodarone...................................................................................................................................................................72 Aspirin ...........................................................................................................................................................................73 Atropine ........................................................................................................................................................................73 Benzylpenicillin ..............................................................................................................................................................74 Ceftriaxone ....................................................................................................................................................................74 Dexamethasone .............................................................................................................................................................75 Fluoescein sodium..........................................................................................................................................................75 Frusemide ......................................................................................................................................................................76 Glucagon .......................................................................................................................................................................76 50% Glucose .................................................................................................................................................................77 Glyceryl Trinitrate (tablet or spray). .................................................................................................................................77 Hydrocortisone ..............................................................................................................................................................78 Ipratropium Bromide (Atrovent). ....................................................................................................................................79 Lignocaine Hydrochloride ...............................................................................................................................................80 Metoclopramide ............................................................................................................................................................81 Midazolam hydrochloride...............................................................................................................................................81 Morphine.......................................................................................................................................................................82 Naloxone .......................................................................................................................................................................83 Oxybuprocaine...............................................................................................................................................................83 Paracetamol ...................................................................................................................................................................84 Paracetamol and Codeine (Panadeine Forte)...................................................................................................................84 Prednisolone ..................................................................................................................................................................85 Prochlorperazine ............................................................................................................................................................85 Salbutamol sulphate (Ventolin).......................................................................................................................................86 Boostrix/ADT Booster .....................................................................................................................................................87 Thiamine (Vitamin B-1)...................................................................................................................................................88 0.9% Sodium Chloride ..................................................................................................................................................88 0.9% Sodium Chloride ..................................................................................................................................................89 Compound Sodium Lactate (Hartmanns Solution) ..........................................................................................................90

PAGE 70

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Parenteral adrenergic agents


Drug Name Indications/Doses adrenaline anaphylactic reaction: 0.5 mg IM (every 3-5 minutes) to a total of 2mg; 50 micrograms IV stat if no response to IM adrenaline and patient presents signs of cardiorespiratory collapse Shortness of breath with or without a history of asthma: 0.5 mg IM (pre-arrest circumstance or asthma associated with anaphylaxis) stat Cardiorespiratory arrest (advanced life Support): 1 mg IV/IO every 3 minutes to a total of 3 mg Sympathomimetics cause additive effects; beta-blockers antagonise therapeutic effects of Adrenaline; digoxin potentiates proarrhythmic effect of Adrenaline; Tricyclic Antidepressants and Mono Amine Oxidase Inhibitors potentiate cardiovascular effects of Adrenaline (Category a) Adrenaline has been given to a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Adrenaline may delay the second stage of labour by inhibiting contractions of the uterus Adverse effects include cardiac ischaemia or dysrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid haemorrhage; use with caution in hypertension, cardiovascular disease, and cerebrovascular insufficiency; phenothiazines can cause a paradoxical decrease in BP comment as above

Contraindications Interactions

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition, http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/7-section-7?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographadrenaline-02. html#adrenaline-02 <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2826&product_ name=Adrenaline+Injection <accessed 22/12/08>

Drug Category: topical Ocular anaesthetics


Drug Name Indications/Dose amethocaine 0.5% or 1% Ocular injuries: 2 drops per affected eye, topical, stat to produce local anaesthesia in the eye. Can be used every 15-20 minutes during the irrigation procedure. Stat only for flash burns Documented hypersensitivity. Not for use in cases with penetrating eye injury Antagonises effect of sulfonamides and aminosalicylic acid Amethocaine not categorised May give rise to dermatitis in hypersensitive patients. The anaesthetised eye should be protected from dust and bacterial contamination

Contraindications Interactions Pregnancy Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter11/monographamethocaine-02. html#amethocaine-02 <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1515&product_ name=Minims+Local+Anaesthetics <accessed 22/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 71

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: antiarrhythmics


Drug Name Indications/Doses amiodarone

Cardiorespiratory arrest (advanced life Support): 300 mg IV/IO over 1-2 mins stat (Dilute
with 10-20mL 5% Glucose) for VF/VT cardiorespiratory arrest when defibrillation and adrenaline have failed

Contraindications

Documented hypersensitivity; systemic lupus erythematosus, digitalis induced dysrhythmias, torsade de pointes, second or third degree heart block (without pacemaker) symptomatic bradycardia (without pacemaker) or sick sinus syndrome (without pacemaker) Increases effect and blood levels of theophylline, quinidine, procainamide, phenytoin, methotrexate, flecainide, digoxin, cyclosporine, beta-blockers, and anticoagulants; co administration with calcium channel blockers may cause additive effects, further decreasing myocardial contractility; cimetidine may increase amiodarone levels Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Avoid use 3 months before and during pregnancy; may cause thyroid dysfunction and bradycardia in the foetus Hypotension (most common adverse effect), bradycardia, and AV block may occur. Phlebitis is an issue and also incompatible with 0.9% Sodium Chloride Overly rapid administration can cause hypotension

Interactions

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/18-section-18?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographamiodarone. html#amiodarone <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=176&product_n ame=Cordarone+X+Intravenous+Injection <accessed 22/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 72 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: antiplatelet agents


Drug Name Indications/Doses aspirin acute Coronary Syndrome: 300 mg Oral (chew) stat (if not already given by Ambulance Officers) Inhibits platelet aggregation Documented hypersensitivity; active upper GI bleed. Effects may decrease with antacids and urinary alkalinisers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinaemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonise uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Avoid use in history of blood coagulation defects, asthma, urticaria

Contraindications Interactions

Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter7/monographaspirin-02. html#aspirin-02<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=361&product_ name=Disprin <accessed 22/12/08>

Drug Category: anticholinergic agents


Drug Name Indications/Doses atropine Cardiorespiratory arrest (advanced life Support): 1 mg IV/IO every 3-5 minutes to a total of 3 mg Compromising Bradycardia: 0.5 mg IV increments every 5 minutes (to a total of 3mg) titrated to maintain SBP greater than 90 mmHg Snake/spider bite: (Systemic envenomation) 0.5 mg IV stat if patient bradycardic and SBP less than 90 mmHg None when indicated for symptomatic bradycardia or asystole None for this indication Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Increased risk of arrhythmias in IHD

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/32-section-32?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographatropine. html#atropine <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=2163&product_ name=Atropine+Sulfate+Injection+BP <accessed 22/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 73

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: 8(a) Penicillins


Drug Name Indications/Doses Contraindications Interactions Benzylpenicillin Meningococcal disease: Non-blanching rash: 1.2g IV/IO/IM Stat History of hypersensitivity reactions to beta-lactam antibiotics Intravenous solutions of Benzylpenicillin are physically incompatible with many other substances including certain antihistamines, some other antibiotics, metaraminol tartrate, noradrenaline acid tartrate, thiopentone sodium and phenytoin sodium Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Serious, and occasionally fatal, hypersensitivity reactions (anaphylaxis) have been reported in patients receiving beta-lactam antibiotics

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/40-section-40?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter5/monographbenzylpenicillin. html#benzylpenicillin<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=846&product_ name=BenPen <accessed 22/12/08>

Drug Category: 8(b) Cephalosporins


Drug Name Indications/Doses Contraindications Interactions Ceftriaxone Meningococcal disease: Non-blanching rash: 2g IV/IO/IM Stat (if allergy to penicillin) Allergy to cephalosporins Chloramphenicol Ceftriaxone is incompatible with calcium; do not give via calcium-containing solutions i.e. do not mix with Hartmanns Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals have not shown evidence of an increased occurrence of foetal damage Renal, hepatic impairment; impaired vitamin K synthesis; prolonged use; history of GI disease (esp. colitis); pregnancy, lactation

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/56-section-56?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter5/monographceftriaxone. html#ceftriaxone<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7874&product_ name=Ceftriaxone <accessed 22/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 74 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Corticosteroids


Drug Name Indications/Doses Dexamethasone Meningococcal disease: Non-blanching rash if patient greater than 65 kg give 10mg IV/IO stat If less than 65 kg give 0.15 mg per kg IV/IO stat Known hypersensitivity to dexamethasone Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids Oral contraception Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed. Considered safe to use as non-treatment may be more serious for the foetus and ongoing pregnancy Cirrhosis or hypothyroidism may enhance the effect of corticosteroids

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/83-section-83?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographdexamethasone. html<accessed 05/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=679&product_ name=Dexmethsone#Precautions <accessed 05/03/09>

Drug Category: Other Ophthalmic Medication


Drug Name Indications/Doses Fluorescein Sodium Ocular injuries: instil one drop to affected eye/s with excess being washed away with sterile saline solution Fluorescein does not stain a normal cornea, but corneal abrasions or ulcers are stained a bright green and foreign bodies are surrounded by a green ring Known hypersensitivity Nil Pseudomonas aeruginosa grows well in fluorescein single dose sterile solutions should be used when using this solution to avoid infecting already damaged eye/s. Fluorescein can permanently stain soft contact lenses remove lenses before applying the stain

Contraindications Interactions Pregnancy Precautions

Modified from: Australian Medicines Handbook 2008; http://proxy7.use.hcn.com.au/appendices/appapp-additional-drugs. html#fluorescein <accessed 06.02.2009> MIMS Online 2008; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr _pi&product_ code=1618&product_name=Minims+Stains <accessed 06.02.2009>.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 75

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: 2(c) Diuretics


Drug Name Indications/Doses Contraindications Frusemide Shortness of breath with history of cardiac disease: 40 mg IV stat if audible respiratory crepitations present Documented hypersensitivity Severe sodium and fluid depletion Treatment with potassium-lowering drugs, e.g. amphotericin, increases risk of hypokalaemia; monitor potassium concentration Anuria Interferes with hypoglycaemic effect of antidiabetic agents concurrent aminoglycosides cause auditory toxicity hearing loss of varying degrees may occur; may increase anticoagulant activity of warfarin; increased plasma lithium levels and toxicity are possible Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Frusemide must not be given during pregnancy unless there are compelling medical reasons. Treatment during pregnancy requires monitoring of foetal growth Excessive diuresis may cause dehydration, electrolyte imbalances and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in elderly patients

Interactions

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/131-section-131?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographfrusemide. html#frusemide<accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=792&product_ name=Lasix <accessed 23/12/08>

Drug Category: Glucose-elevating agents


Drug Name Indications/Doses Glucagon Unconscious patient: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L and patient unconscious or confused Seizures: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L Hypoglycaemia: If IV access unavailable, 1 mg IM stat if BGL less than 3.0 mmol/L and patient unconscious or confused Documented hypersensitivity, phaeochromocytoma, insulinoma, glucagonoma May enhance effects of anticoagulants Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of foetal damage Effective in treating hypoglycaemia only if sufficient liver glycogen present, therefore glucagon hydrochloride has virtually no effect on patients in states of starvation, adrenal insufficiency, or chronic hypoglycaemia or alcohol induced hypoglycaemia

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/138-section-138?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter10/monographglucagon. html#glucagon <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2810&product_name=GlucaGen <accessed 23/12/08>
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 76 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Glucose Supplement


Drug Name Indications/Doses 50% Glucose Unconscious Patient: 50 mL IV stat if BGL less than 3.0 mmol/L and patient unconscious or confused Seizures: 50 mL IV stat if BGL less than 3.0 mmol/L Hypoglycaemia: 50 mL IV stat if BGL less than 3.0 mmol/L and patient unconscious or confused Avoid in dehydrated patients; diabetic (hyperglycaemic) coma Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed May cause nausea, monitor fluid balance, electrolyte concentrations, and acid-base balance closely; glucose administration may produce vitamin B-complex deficiency; thrombophlebitis

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/139-section-139?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter10/ treathypoglycaemia.t.html#idxglucose:inhypoglycaemiaidx <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2741&product_name=Glucose+Injection+BP+50%25 <accessed 23/12/08>

Drug Category: Nitrates


Drug Name Indications/Dose Glyceryl trinitrate (tablet or spray) Shortness of breath with history of cardiac disease: 300-600 micrograms (-1 tab) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 1800 micrograms or n 1-2 sprays (400-800 micrograms) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms) acute Coronary Syndrome: n 300-600 micrograms (-1 tab) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 3 tablets (1800 micrograms) or n 1-2 sprays (400-800 micrograms) SL initially, then every 5 minutes if SBP greater than 90 mmHg to a total of 4 sprays (1600 micrograms)
n

Contraindications

Hypotension; hypertrophic obstructive cardiomyopathy; cardiac tamponade; aortic or mitral stenosis; cor pulmonale; marked anaemia; raised intracranial pressure; treatment with phosphodiesterase 5 inhibitors (e.g. sildenafil Viagra); documented hypersensitivity Severe hypotension may occur with co administration of phosphodiesterase 5 inhibitors (e.g. sildenafil) Viagra Category B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of foetal damage Adverse effects are mostly due to vasodilator effects. Caution required in the presence of hypotension. Medical officer should be consulted prior to administration in pregnant patients.

Interactions Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographglyceryl-trinitrate. html#glyceryl-trinitrate <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=193&product_ name=Anginine <accessed 23/12/08>
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 77

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Corticosteroids


Drug Name Indications/Doses Hydrocortisone Shortness of breath with or without a history of asthma: 200 mg IV (moderate and severe asthma) stat Shortness of breath with a history of chronic obstructive pulmonary disease: 200 mg IV (moderate and severe cases) stat Uncontrolled infection, active peptic ulcer disease Thiazide diuretics may increase the risk of hyperglycaemia caused by hydrocortisone. Rifampicin, phenytoin and barbiturates may reduce the plasma levels and half-life of corticosteroids. Decreases the efficacy of the following medications; Aspirin, Insulin or oral antidiabetic agents Oral contraception Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Cirrhosis or hypothyroidism may enhance the effect of corticosteroids

Contraindications Interactions

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/147-section-147?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographhydrocortisone. html#hydrocortisone <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=689&product_ name=Solu%2dCortef <accessed 23/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 78 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Bronchodilators


Drug Name Indications/Dose Ipratropium Bromide (atrovent) Shortness of breath with or without a history of asthma: 4 puffs of 20 microgram Metered Dose Inhaler (severe asthma) or n 500 micrograms nebule (severe asthma) stat if patient cannot inhale adequately to use an MDI + spacer Shortness of breath with history of chronic obstructive pulmonary disease: n 4 puffs of 20 microgram Metered Dose Inhaler stat or n 500 microgram nebule stat if patient cannot inhale adequately to use an MDI + spacer
n

Contraindications Interactions

Documented hypersensitivity to ipratropium Drugs with anticholinergic properties may increase toxicity. Cardiovascular effects may increase with Monoamine Oxidase Inihibitors, tricyclic antidepressants, and sympathomimetic agents. Disodium cromoglycate with benzalkonium Cl Beta-Adrenergics, xanthines (additive). Check with Medical Officer before giving to patient already receiving tiotropium Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Caution in glaucoma (protect eyes if nebuliser in use), prostatic hypertrophy, and hyperthyroidism, diabetes mellitus, and cardiovascular disorders

Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter19/monographipratropium. html#ipratropium<accessed 4/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=6818&product_name=Atrovent+Metered+Aerosol+%28CFC%2dfree%29 <accessed 23/12/08> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1284&product_name=Atr ovent+Nebulising+Solution <accessed 23/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 79

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: antiarrhythmics


Drug Name Indications/Dose Contraindications lignocaine Hydrochloride Cardiorespiratory arrest (advanced life Support): 1-1.5mg/Kg IV/IO stat for VF/VT cardiorespiratory arrest when defibrillation, adrenaline and amiodarone have failed Non VF/VT arrest. Documented hypersensitivity to lignocaine or other local anaesthetics. Heart block 2nd or 3rd degree. Co-administration with cimetidine or beta-blockers increases toxicity of lignocaine; co administration may increase effects of suxamethonium, other antiarrhythmics incl. amiodarone; beta-blockers . Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed . Caution hepatic disease, may increase risk of CNS severe respiratory depression and cardiac adverse effects in elderly patients; high concentrations can cause seizures and AV-conduction abnormalities

Interactions

Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/181-section-181?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter6/monographlignocaine-02. html#lignocaine-02 <accessed 4/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=1910&product_name=Lignocaine+Injection <accessed 23/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 80 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: antiemetics


Drug Name Indications/Dose Metoclopramide If nausea/vomiting present: Snake / spider bite: 10 mg IV or IM stat trauma: 10 mg IV/IO or IM stat Burns: 10 mg IV/IO or IM stat Head Injury: 10 mg IV or IM stat Isolated severe limb injury: 10 mg IV or IM stat Ocular injuries: 10 mg IM stat Documented hypersensitivity. Patients with history of dystonia / extrapyramidal reactions to medication. Extrapyramidal side effects (EPSE) more likely in patients < 20 years of age Not to be used in presence of intestinal obstruction Phaeochromocytoma May increase sedative effects of other medication and worsen Parkinsons symptoms in patients with Parkinsons Disease Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed. Caution in history Parkinson disease; elderly more likely to experience drowsiness Moderate and Severe Renal impairment as EPSE are common

Contraindications

Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/196-section-196?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter12/monographmetoclopramide. html#metoclopramide <accessed 4/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=549&product_ name=Metoclopramide+Injection <accessed 23/12/08>

Drug Category: anxiolytics


Drug Name Indications/Dose Midazolam hydrochloride Seizures: 2.5 mg increments IV slow injection every 1-2 minutes (to a total of 0.1 mg per kg) or n If IV access unavailable, 10 mg IM stat and repeat (once only) after 5 minutes if required
n

Contraindications Interactions Pregnancy

Documented hypersensitivity; pre-existing hypotension. Rapid or bolus IVI Sedative effects may be antagonized by theophyllines, alcohol; narcotics and erythromycin may accentuate sedative effects due to decreased clearance Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Respiratory depression, apnoea, cardiovascular depression and cardiac arrest are more likely after IV injection. Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure eliminate Midazolam slower.

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/199-section-199?directory=3&Itemid=8 <accessed 05/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter2/monographmidazolam.html <accessed 05/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=6104&product_name=Midazolam+Injection#Precautions <accessed 05/03/09>
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 81

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: analgesics


Drug Name Indications/Dose Morphine acute Coronary Syndrome: 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) trauma (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Burns (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV/IO every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Head injury (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg) Isolated severe limb injury (if pain score 4-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-100 mg IM stat (to a total of 10 mg) Ocular injuries: n 5-10mg IM stat (to a total of 10 mg) abdominal/loin/flank pain (if pain score 2-10) n 2.5 mg increments (to a total of 10 mg) IV every 5 minutes or n 5-10 mg IM stat (to a total of 10 mg)
n

Contraindications Interactions Pregnancy

Documented hypersensitivity; severe respiratory disease, coma Respiratory depressant and sedative effects may be additive in the presence of other medication Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. Caution in hypotension, nausea, vomiting, caution in supraventricular tachycardias; has vagolytic action and may increase ventricular response rate Caution in patients with severe renal, hepatic dysfunction, may cause excessive sedation or coma

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/

content/article/1-drug-monographs-a-z/202-section-202?directory=3&Itemid=8 <accessed 06/03/09>


Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographmorphine. html#morphine <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=379&product_ name=DBL+Morphine+Sulfate+Injection+BP <accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 82 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: antidotes for Narcotic agonists


Drug Name Indications/Dose Contraindications Interactions Pregnancy Naloxone Unconscious patient: 800 micrograms IM stat and 800 micrograms IV stat Documented hypersensitivity Decreases analgesic effects of opioids. Effects of partial agonists eg buprenorphine, tramadol only partially reversed by naloxone. Category B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus having been observed. Studies in animals[1] have not shown evidence of an increased occurrence of foetal damage Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients with opiate dependence. If patients do not respond to multiple dose of Naloxone, consider alternative causes of unconsciousness. Reversal of opioid effects may unmask other toxicities in cases of ingestion of multiple agents and increase the risk of seizures.

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/206-section-206?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter4/monographnaloxone. html#naloxone <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2157&product_name=Naloxone+Hydrochloride+Injection <accessed 06/03/09>

Drug Category: topical Ocular anaesthetics


Drug Name Indications/Dose Contraindications Interactions Pregnancy (Category D) Safety for use in pregnancy has not been established. Minims, Oxybuprocaine eye drops should be used only when it is considered essential by a doctor May give rise to dermatitis in hypersensitive patients. The anaesthetised eye should be protected from dust and bacterial contamination. Oxybuprocaine 0.4% Ocular injuries: 2 drops per affected eye, topical, stat. To produce local anaesthesia in the eye. Can be used every 15-20 minutes during the irrigation procedure. Stat only for flash burns Documented hypersensitivity. Not for use in cases with penetrating eye injury. Concomitant eye infection

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter11/monographoxybuprocaine. html#oxybuprocaine <accessed 2/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=7450&product_name=Minims+Benoxinate+%28Oxybuprocaine%29 <accessed 22/12/08>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 83

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: analgesics


Drug Name Indications/Dose Contraindications Interactions Pregnancy Paracetamol Head injury: 500 mg-1 g (1-2 tablets) oral stat if pain score 1-3 and patient not nil by mouth Documented hypersensitivity patient is nil orally Anticoagulants; drugs affecting gastric emptying; hepatic enzyme inducers including alcohol, anticonvulsants Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Caution in severe renal or hepatic dysfunction Max dose = 4g per day total

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographparacetamol. html#paracetamol <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=391&product_ name=Panadol <accessed 06/03/09>

Drug Category: analgesics


Drug Name Indications/Dose Paracetamol and Codeine (Panadeine Forte) (Paracetamol 500mg and Codeine Phosphate 30mg) Burns: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Isolated severe limb injury: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Ocular injuries: 1-2 tablets oral stat if pain score 1-3 and patient not nil by mouth Documented hypersensitivity Patient nil orally CNS depressants or tricyclic antidepressants increase toxicity, drugs affecting gastric emptying, significant respiratory disease, comatose patients. Paracetamol may increase chloramphenicol concentrations Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Caution in severe renal or hepatic dysfunction Max 4g per day total paracetamol

Contraindications Interactions

Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter3/monographparacetamol.html#id xPanadeineForteparacetamolacodeineidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=390&product_ name=Panadeine+Forte <accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 84 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Corticosteroids


Drug Name Indications/Dose Prednisolone Shortness of breath with or without a history of asthma: 50 mg oral stat (moderate and severe asthma) if IV access unavailable Shortness of breath with history of chronic obstructive pulmonary disease: 50 mg oral stat (severe and moderate cases) if IV access unavailable Documented Hypersensitivity to Prednisolone. Active Peptic ulcer; osteoporosis; psychoses, psychoneuroses; TB; systemic fungal infections Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Patients who are immunosuppressed

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter14/monographprednisoneprednisolone.html#prednisone-prednisolone <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=2832&product_name=Solone accessed 06/03/09>

Drug Category: antiemetics


Drug Name Indications/Dose Contraindications Prochlorperazine abdominal/loin/flank pain: 12.5 mg IM stat if nausea/vomiting present Documented hypersensitivity Patients with history of dystonia / extrapyramidal reactions to medication. Extrapyramidal Side Effects (EPSE) more likely in patients < 20 years of age CNS depression May increase sedative effects of other medication and worsen Parkinsons symptoms in patients with Parkinsons Disease Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible May worsen symptoms of Parkinsons Disease; watch for hypotension

Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/248-section-248?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter12/monographprochlorperazine. html#prochlorperazine <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=553&product_ name=Stemetil <accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 85

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Inhaled Beta-agonists


Drug Name Indications/Dose Salbutamol sulphate (Ventolin) anaphylactic reaction: Metered Dose Inhaler + spacer; 10 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present Shortness of breath with or without a history of asthma: n Metered Dose Inhaler + spacer; 8-12 puffs of 100 microgram Metered Dose Inhaler every 15-30 minutes for severe asthma; 8-12 puffs of 100 microgram Metered Dose Inhaler every 1-4 hours for moderate asthma; 8-12 puffs of 100 microgram Metered Dose Inhaler stat for mild asthma n 5 mg nebule every 15-30 minutes for patients with severe asthma who cannot inhale well enough to use MDI + spacer Shortness of Breath with history of chronic obstructive pulmonary disease: n Metered Dose Inhaler + spacer; 10 puffs of 100 microgram dose Metered Dose Inhaler repeat every 20 minutes if required n 5 mg nebule every 20 minutes if required (for patients with severe cases who cannot inhale well enough to use MDI + spacer) Drowning: n Metered Dose Inhaler + spacer; 6-12 puffs of 100 microgram Metered Dose Inhaler stat if wheeze present n 5 mg nebule stat (for patients who cannot inhale well enough to use MDI + spacer)
n

Contraindications Interactions Pregnancy

History of Hypersensitivity; Can cause paradoxical bronchospasm, allergic reactions May increase cardiovascular effects of other sympathomimetics drugs Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed May cause tachycardia, nausea and tremors. Caution in patients with coexisting cardiovascular disease. Hypokalaemia can occur with high doses particularly in combination with other potassiumdepleting medications.

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter19/monographsalbutamol. html#salbutamol <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=4114&product_name=Asmol+CFC%2dfree+Inhaler <accessed 06/03/09> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=1296&product_name=Ventol in+Respirator+Solution+and+Nebules <accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 86 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Immune enhancement


Drug Name Indications/Dose Diphtheria, tetanus +/-, pertussis (aDt Booster) (where not available, Boostrix can be used) Snake / spider bite: 0.5 mL IM stat trauma: 0.5 mL IM stat Burns: 0.5 mL IM stat Ocular Injuries: 0.5 mL IM stat The only absolute contraindications to tetanus vaccine are: anaphylaxis following a previous dose of the vaccine, or n anaphylaxis following any vaccine component
n

Contraindications

Interactions Pregnancy

Immunosuppression/ deficiency patients Category a aDt Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Category B2 Boostrix Adequate human data on use during pregnancy and adequate animal reproduction studies are not available. Therefore, Boostrix should be used during pregnancy only when clearly needed and the possible advantages outweigh the possible risks for the foetus. When protection against tetanus is sought, consideration should be given to tetanus or combined diphtheria tetanus vaccines. As with all inactivated vaccines, one does not expect harm to the foetus. If an individual has a tetanus-prone wound and has previously had a severe adverse event following tetanus vaccination, alternative measures, including the use of human tetanus immunoglobulin, can be considered.

Precautions

Modified from: The Australian Immunisation Handbook; http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ Handbook-tetanus <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter20/monographdiphtheria-tetanusvaccines.html#idxADTseediphtheriawithtetanusvaccineidx <accessed 06/03/09> http://proxy7.use.hcn.com.au/view.php?page=chapter20/monographdtp-vaccines.html#idxBoostrixDTPvaccineidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=5686&product_name=Boostrix# <accessed 06/03/09> http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=7766&product_ name=ADT+Booster# <accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 87

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Vitamin Supplementation


Drug Name Indications/Dose thiamine (Vitamin B-1) Unconscious patient: 100 mg IM stat if history of possible alcohol abuse Seizures: 100 mg IM stat if history of possible alcohol abuse Hypoglycaemia: 100 mg IM stat if history of possible alcohol abuse Previous hypersensitivity to parenteral administration Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Hypersensitivity reactions can occur following parenteral administration. Sudden onset or worsening of Wernicke encephalopathy, following glucose, may occur in thiamine-deficient patients; administer

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Injectable Drugs Handbook, Fourth Edition; http://proxy6.use.hcn.com.au/aidh/index.php/component/content/ article/1-drug-monographs-a-z/288-section-288?directory=3&Itemid=8 <accessed 06/03/09> Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter4/monographthiamine. html#thiamine <accessed 06/03/09>

Drug Category: Intravenous Fluids


Drug Name Indications/Dose 0.9% Sodium Chloride IV/IO cannulae flush 10 mL 30 mL flush for resuscitation (Cardiorespiratory Arrest) Medication dilution e.g. Morphine

Contraindications Interactions Pregnancy Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed

Precautions

Modified from: Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=4023&product_name=Sodium+Chloride+Injection+0%2e9%25 < accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 88 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Intravenous Fluids


Drug Name Indications/Dose 0.9% Sodium Chloride Unconscious patient: IV 500 mL bolus if SBP less than 90 mmHg n IV 1000 mL at 125mL per hour to maintain hydration anaphylactic reaction: n IV 1000 mL bolus if pulse rate greater than 100, SBP less than 90 mmHg and capillary refill greater than 2 seconds Non-traumatic shock: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Meningococcal disease: non-blanching rash: n IV/IO 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Hyperglycaemia with severe dehydration: n IV 500 mL bolus if SBP less than 90 mmHg or if signs of dehydration (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg) Snake/spider bite: n IV 500 mL bolus if SBP Less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125mL per hour (to maintain hydration) trauma: n IV/IO 1000 mL at 125mL per hour (to maintain hydration) Burns: IV/IO 500 mL bolus if SBP less than 90 mmHg Drowning : n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Head injury: n IV 200 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) Ocular injuries: n Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) abdominal/loin/flank pain: n IV 500 mL bolus if SBP less than 90 mmHg (repeat once if SBP remains less than 90 mmHg) n IV 1000 mL at 125mL per hour (to maintain hydration)
n

Contraindications Interactions Pregnancy Category a Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus having been observed Congestive cardiac failure, Severe renal impairment, Sodium retention

Precautions

Modified from: Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=3623&product_name=Sodium+Chloride+Intravenous+Infusion+BP < accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 89

Formulary | Medical Officer must be notified immediately | For Adults Only

Drug Category: Intravenous Fluids


Drug Name Indications/Dose Compound Sodium lactate (Hartmanns Solution) trauma: IV/IO 200 mL stat to maintain SBP 80-90 mmHg (repeat once if required to maintain SBP 80-90 mmHg) Burns: IV/IO as per Modified Parkland formula Ocular injuries: Topical for irrigation of corneal foreign bodies and chemical exposure (repeat as required) Congestive heart failure or severe impairment of renal function. Administered concomitantly with potassium sparing diuretics and angiotensin converting enzyme (ACE) inhibitors. Simultaneous administration of these drugs can result in severe hyperkalaemia Category C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible Na retention. Pregnancy

Contraindications Interactions Pregnancy

Precautions

Modified from: Australian Medicines Handbook; http://proxy7.use.hcn.com.au/view.php?page=chapter7/tableelectrolytes-infusionsolutions.tb.html#idxHartmann????????scompoundsodiumlactateinfusionidx <accessed 06/03/09> Mims Online; http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_ code=7704&product_name=Compound+Sodium+Lactate+%28Hartmann%27s+Solution%29+Injection < accessed 06/03/09>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 90 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

SECTION 9

Appendices

NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH

PAGE 91

APPENDIX 1: RURAL AND REMOTE EMERGENCY TROLLEY MINIMUM ADULT REqUIREMENTS


Ideally the following equipment should be stored on a freely moving mobile trolley with IV pole.
airway ETT (cuffed) x 1 of each Laryngeal mask airway Laryngoscope Oropharyngeal rigid sucker Oropharyngeal airway Nasopharyngeal airway Introducer/intubating stylet Tape Other Breathing Self-inflating 1500mL resuscitation bag with reservoir bag and oxygen tubing Clear masks sizes: 3, 4 & 5 Y suction catheters 12fg & 14fg Suction tubing Disposable CO2 indicator if capnography not available Dwell cath or 14g cannula (8cm in length) 6.0, 7.0, 7.5, 8.0, 8.5, & 9.0 mm 4.0, 5.0 and 6.0 Handles with batteries x 2 Mackintosh (Curved) blades 3 and 4 Adult x 1 2, 3 & 4 6.0 mm & 7.0 mm Large & medium introducer Bougie (gum elastic introducer) White cotton tape Magill forceps, lubricant satchels x 3, 10 mL syringe, scissors

Circulation
Syringes Cannula 5 each of Needles x10 Intra-osseous Needle-less system accessories Giving sets Other 1 mL x 5; 2 mL x 5; 5 mL x 5; 10 mL x 10; 20 mL x 5; 1 x 50 mL 14g, 16g , 20g , 22g , 18g , scalp vein needle 23g, 25g Blunt drawing up 21g Needle x 1 As per AHS stock Plain giving set x 2, blood pump giving set x 2, burette x1 3 way taps x 5 minimal volume extension tubing transparent IV dressing x 5 adhesive tape x 1 tourniquet antimicrobial swabs wipes x 10

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 92 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Drugs/Fluids Adrenaline 1:10,000 Adrenaline 1:1000 Atropine Glucose 5% Glucose 10% Glucose 50% Sodium Chloride 0.9% Lignocaine 2% Sodium bicarbonate Amiodarone Calcium gluconate 10% Magnesium Chloride Sodium Chloride 0.9% Naloxone Water for injection In fridge: Long acting neuromuscular muscle blocking agent Suxamethonium chloride

Size 1mg in 10mL 1mg in 1mL 3 mg in total 100mL bag 500 mL 50 mL 1000 mL 100 mg 50 mL 150 mg in 3mL ampoules 10% in 10 mL 20% in 5 mL 10 mL 400 micrograms/1mL 10 mL 5 100 mg/2mL

amount Mini-jets x 3 10

1 1 2 1 Minijet 1 6 2 2 20 4 10

Other:
n n n n n n n n n n n n n

Defibrillator Full oxygen cylinder/source ECG electrodes Defib self-adhesive/gel pads x 2 packets Arrest documentation form and pen Sharps container PPE Portable suction NG tube Stethoscope Basic and Advanced Life Support algorithm Scissors Drug additive labels

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 93

APPENDIX 2: DEFIBRILLATION
Defibrillation as soon as possible provides the best chance of survival in victims with VF or unconscious VT. Defibrillation works because it temporarily stuns the myocardium with flow of electrons, thus causing changes in membrane potential, resulting in the depolarisation of the cardiac cells. Depolarisation stops the hyper-excitable areas of the myocardium from propagating impulses. This, in turn, allows the sinoatrial node to resume its function as the primary pacemaker of the heart, resulting in the normal coordinated contractile activity of the heart.

Paddle/pad placement
n n

Right parasternal area over the 2nd intercostal space Midaxillary line over the 6th intercostal space (Apex)

Care should be taken to ensure that pads or electrodes are applied in accordance with manufacturers instructions and are not in electrical contact with each other.

Precautions:
n

Be aware of electrical hazards in the presence of water, metal fixtures, oxygen and flammable substances. Warn of impending discharge by a stand clear command; AVOID charging the paddles unless they are placed on the victims chest; AVOID placing the defibrillator paddles/pads over ECG electrodes (risk of burns or sparks), ECG leads (may melt), medication patches, an implanted device (e.g. a pacemaker), a central line insertion site; AVOID having, or allowing any person to have, any direct or indirect contact with the victim during defibrillation (a shock may be received); AVOID having the victim in contact with metal fixtures e.g. bed rails (risk of burn); AVOID delivery of a shock with a gap between the paddles/pad and chest wall (spark hazards); AVOID defibrillating if victim, operator and/or close bystander are situated in an explosive/flammable (e.g. petrol) environment; AVOID allowing oxygen from resuscitator to flow onto the victims chest during delivery of the shock (risk of fire).

n n

n n n

Factors that may contribute to the resistance to flow of electrons during defibrillation attempts. Mechanical causes of decreased defibrillation success Energy selected Electrode size Chest wall diameter Electrode skin coupling material Number and time interval of previous shocks Electrode to chest contact pressure Systemic acidosis Pre-existing cardiac disease Drug overdose Body temperature Length of time without spontaneous circulation

Physiological causes of decreased defibrillation success

References: Australian Resuscitation Council, 2006, Guideline 11.5: Electrical therapy for adult advanced life support, ARC, Melbourne. Bridy M.A., Burklow T.R., 2002, Understanding the newer automated external defibrillator devices: electrophysiology, basicwaveforms, and technology, Journal of Emergency Nursing, Volume 28, no. 2, pp. 132-137.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 94 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 3: 12 LEAD ECG


Procedure:
limb lead Placement The four limb leads are to be placed at the level of wrists and ankles as indicated in the diagram below. Any variation in limb lead placement (e.g. amputee) is to be documented on the 12 lead ECG, clearly specifying the alternate limb lead placements. Chest lead Placement V1 and V2 sited at 4th intercostal space on either side of the sternum. V3 sited between V2 and V4. V4 sited at 5th intercostal space, mid clavicular line. V5 sited between V4 and V6 / anterior axillary line, lateral to V4. V6 sited at 5th intercostal space, mid axillary line, lateral to V4.

Reference: Jowett N.I., Turner A.M., Cole A., and Jones P. A., 2005, Modified electrode placement must be recorded when performing 12-lead electrocardiograms, Postgrad. Med. Journal, vol. 81, pp. 122-125.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 95

APPENDIX 4: MANAGEMENT OF PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION


Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have a reperfusion strategy implemented promptly. 12-lead eCG (at least one of the following eCG changes is mandatory for thrombolysis)
n n n

ST segment elevation of greater than or equal to 1 mm in two or more contiguous limb leads; ST segment elevation of greater than or equal to 2 mm in two or more contiguous chest leads; New left bundle branch block (LBBB) pattern (Note that LBBB is presumed new unless there is evidence otherwise).

Differential diagnoses must be considered by a Medical Officer:


n n n

Aortic dissection; Pericarditis; Pulmonary embolism

Contraindications* to be considered by a Medical Officer: Absolute Contraindications:


n n n n n n n

Active bleeding (excluding menses) Significant closed head or facial trauma (within 3 months) Suspected aortic dissection Any prior intracranial haemorrhage Ischaemic stroke within 3 months Known structural cerebral vascular lesion Known malignant intracranial neoplasm (primary or metastatic)

Relative Contraindications:
n n n n n n n n n

Current use of anticoagulants (the higher the INR, the greater the risk) Non-compressible vascular puncture Recent major surgery (less than 3 weeks) Pregnancy Traumatic or prolonged CPR longer than 10 minutes Recent (within 4 weeks) internal bleeding Active peptic ulcer History of chronic, severe, poorly controlled hypertension Uncontrolled hypertension at time of presentation SBP greater than 180 mmHg or DBP greater than 110 mmHg (should be treated prior to thrombolysis) Ischaemic stroke more than 3 months ago, dementia or known intracranial abnormality not covered in contraindications

* Many contraindications are relative and potential benefits versus relative risks should always be considered. Reference: National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand, 2006, Guidelines for the management of acute coronary syndromes, The Medical Journal of Australia, vol. 184, no. 8 S1-S32, viewed 19.01.09, <http://www.mja.com.au/public/issues/184_08_170406/suppl_170406_fm.html>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 96 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 5: AVPU / GCS


AVPU is a mnemonic used to obtain a rapid assessment of a patients level of consciousness. a Alert V Responds to vocal stimuli P Responds to Painful Stimuli U Unresponsive This observation should also include assessing the pupillary reflexes. This rapid assessment will detect only gross neurological damage

GCS Glasgow Coma Scale


A quick, practical and standardised system for assessing the degree of conscious impairment of the critically ill and injured. It can also be used for predicting the duration and outcome for patients with head injuries. Three behavioural responses are evaluated:
n n n

Best Eye Opening; Best Verbal Response; and Best Motor Response.

Each category has criteria and numerical values are attached to each criterion. The highest score achievable is 15 and the lowest score is 3. The Glasgow Coma Scale is used to monitor trend when performing assessments of level of consciousness. A decreasing score is associated with neurological deterioration. Best eye Opening Response Eyes open spontaneously Eyes open to voice Eyes open to painful stimuli No eye opening Best Verbal Response Orientated to time place and person Confused Inappropriate words Incomprehensible Sounds No verbal response Best Motor Response Obeys Commands Localises to Painful Stimuli Non purposeful response to pain Flexion to pain Extension to pain No motor response 4 3 2 1=4 5 4 3 2 1=5 6 5 4 3 2 1=6 Total = 15

a patient with a GCS of less than 9 and not rapidly improving will require endotracheal intubation by a Medical Officer to protect the patients airway from aspiration. Reference: Healey C., Olser Turner M., Rogers F.B., Healey M.A., Glance L.G., Kilgo P.D, Shackford S.R. and Meredith J.W., 2003, Improving the Glasgow Coma Scale Score: Motor Score Alone is a Better Predictor, The Journal of Trauma: Injury, Infection, and Critical Care, vol. 54, no. 4, pp. 671-680.
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 97

APPENDIX 6: PAIN ASSESSMENT


A number of tools exist to assist clinicians in the assessment of pain. A commonly used technique in the Emergency Department is the PQRSt mnemonic.
FACTOR Provokes, Palliates, Precipitating factors DESCRIPTION QUESTIONS What were you doing when the pain occurred? What provoked the pain? What makes the pain better? What makes the pain worse? Have you had this type of pain before? What does the pain feel like? Ask the patient to describe the pain in their words Where is the pain/show me where the pain is Does the pain radiate? If so, where? How severe is the pain? If you were to rate the pain on a scale from 0 to 10 with 0 being no pain and 10 being the most severe pain you can imagine, how would you rate your pain? Do you have any other symptoms? When did the pain start? How long did it last? Does it come and go?

Quality Region, Radiation Severity, associated symptoms

time

Reference: ENA & Newberry, 2003, Sheehys Emergency Nursing: Principles and Practice, 5th edn, Mosby.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 98 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 7: SEDATION SCORE/SCALE


Evidence indicates that a decrease in respiratory rate is a late and unreliable indicator of respiratory depression following opioid administration. Sedation has been found to be a reliable early clinical indicator of respiratory depression and should be monitored following opioid administration using a sedation score. Sedation Score Scale 0= None 1= Mild, occasionally drowsy, easy to rouse 2= Moderate, constantly or frequently drowsy easy to rouse 3= Severe, somnolent, difficult to rouse 4= Normal sleep The patient is scored according to the scale above. The aim is to keep the sedation score below 2 regardless of the route of opioid administration. A sedation score of 2 means that the patient is constantly drowsy or groggy but still easy to rouse e.g. they wake up easily but cannot stay awake during conversation. References: Lehne, Richard A., 2001, Pharmacology for Nursing Care, 4th edn, W.B. Saunders, Philadelphia. National Health and Medical Research Council, 1999, Acute Pain Management: Scientific Evidence, Commonwealth of Australia, Canberra.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 99

APPENDIX 8: GLASS TUMBLER TEST


A rash is common with meningococcal infection it may be purpuric or petechial. Small red or purple spots develop at first and may occur in groups anywhere on the body. They often grow to become blotchy and look like little bruises. One or two may develop at first, and then appear in different parts of the body. The spots do not fade when pressed (unlike may other rashes). To check for this do the tumbler test. Place a clear glass tumbler firmly on one of the spots or blotches and see if you can still see them through the glass. Note: it is harder to see on dark skin, so check paler areas. The rash is a sign of septicaemia. It may not occur with meningitis alone. Do NOt solely rely on the rash, as it may not always occur or may occur late in the disease. Petechial Rash Petechiae result from tiny area of superficial bleeding into the skin. They appear as round, pinpoint-sized spots that are not raised. The colour varies from red to purple as they age and gradually disappear. The rash does not blanch with pressure. Purpuric Rash Purpura are larger areas of bleeding into the skin beginning as red areas that become purple and later brownish-yellow. The rash does not blanch with pressure. Reference: Meningococcal Education Inc., The Glass Test, viewed 10 August 2009, <http://www.meningococcal.org/the_rash.html>

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 100 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 9: SNAKEBITE OBSERVATION CHART


Snakebite Observation Chart
Patient surname: Forename: Date of birth: MRN number: Date: Time: Time after bite: GENERAL: Pulse rate: Blood pressure: Temperature: SPECIFIC: Regional lymph node tenderness: Local bite site pain: Bite site swelling: Headache: Nausea: Vomiting: Abdominal pain: PARALYTIC SIGNS: Ptosis: Opthalmoplegia: Fixed dilated pupils: Dysarthria: Dysphalgia: Tongue protrusion: Limb weakness: Respiratory weakness: Peak flow rate: MYOLYTIC SIGNS: Muscle pain: Myoglobinuria: COAGULOPATHY SIGNS: Persistant blood ooze: Haematuria: Active bleeding: RENAL: Urine output: LABORATORY KEY TESTS: INR/prothrombin time aPTT Fibrinogen XDP/FDP Platelet count CK Creatinine Urea K+ ANTIVENOM: Type/amount/time: Reaction Date of bite Time of bite: Type of snake: Number of bites:

Reference: NSW Health, 2007, Snakebite and Spiderbite Clinical Management Guidelines, NSW Department of Health, North Sydney.
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 101

M MECHANISM OF INJURY

Trauma Triage Tool Major Trauma Criteria (MIST)


Yes Closest Hospital

PAGE 102

Reference:
Focal blunt trauma to head or torso Falls >3m or paediatrics twice the childs height High voltage injury Crush injury excluding fingers/toes Any rapid deceleration mechanism that results in a large inertia change at impact

Blunt

Yes No

Transport incident: Death in same vehicle Intrusion into occupant compartment > 30 cm Steering wheel deformity Patient side impact Vehicle v. pedestrian/cyclist/MBC Ejection from vehicle Entrapment with compression

Patients <16 or >65 years of age. Obstetric patients >20 weeks gestation, patients on anticoagulants and patients with pre-existing disease are at greater risk and require a high index of suspicion for serious injury. If in doubt, transport to Trauma Centre.

Patients 16 and > 65 years of age who are ambulatory at the scene with normal physiology and minor or no apparent injury. If in doubt, transfer to Trauma Centre

T R A U M A U C O D E 3 M I T N S R E E C A M A R T

Penetrating All penetrating injury (excuding isolated injury to hands or feet). AND/OR

Yes

IMMEDIATE AND URGENT TRANSPORT

APPENDIX 10: TRAUMA TRIAGE TOOL

INJURIES

Ambulance Service of New South Wales, 2008, Trauma Triage Tool Major Trauma Criteria (MIST), Clinical Development Unit
Yes to any
IMMEDIATE TRANSPORT

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.

NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Head: Minor head injury with loss of consciousness, or amnesic to event with: 2 or more vomits or a seizure On anticoagulants Open, depressed skull and/or signs of base of skull. A decreased LOC is due to traumatic injury, until proven otherwise. Face: Injury with potential airway risk; severe haemorrhage. Neck: Swelling, bruising, hoarseness, stridor. Chest: Severe pain, paradoxical breathing, restraint abrasion/confusion. AND/OR

Abdomen: Severe pain, rigidity, swelling, pelvic tenderness, restraint/abrasion/confusion. Limbs: 2 or more prominal long bone, amputation proximal to digits, ischaemia, degloving injury. Spinal/Back: Visible deformity. Burns: Partial or full thickness burns. Adults >20%; Children >10%, or burns involving head/neck/face/hands/feet/groin or inhalation injury. All circumferential burns or burns in a patient with comorbidities or pregnancy.

S SIGNS AND SYMPTOMS

Airway: At risk, hoarseness, stridor. Breathing:RR <10 or >29, Sp02 < 90% on air, cyanosis or respiratory difficulty. Circulation: HR >120, SBP <90 or severe haemorrhage. Disability: GCS 13 or paralysis/sensory deficit. Or any worsening trend in ABCD. Paediatrics: Physiological changes are late indicators of serious injury in a child who may lose 30% blood volume prior to ANY changes in vital signs. The following are a guide: 1st year 15 yrs 6-12 yrs HR >160 >140 >120 SBP <60 <70 <80 RR >60 >35 >30

Yes to any

URGENT TRANSPORT

T TRANSPORT

If patient meets Major Trauma Criteria, they are to be transported to the highest level Trauma Centre within a 1-hour travel time or Aeromedical Retrieval Service advised.

APPENDIX 11A: GUIDELINES FOR WHEN TO APPLY SEMI-RIGID CERVICAL COLLARS


Standard:
n n n

All multi-trauma patients or patients with a head injury will have a semi-rigid cervical collar applied. Patients at risk for spinal injury will have a semi-rigid cervical collar applied as per the Canadian C-Spine rule. Patients assessed not to be at risk for spinal injury, will have a cervical collar removed.

Canadian C-Spine Rule For alert (GCS 15) and stable trauma patients where cervical spine is a concern. 1. Any one of the following High Risk factors? n Age 65 years or older n Dangerous mechanism of injury* n Numbness or tingling in extremities NO

YES

2. Any one of the following Low Risk factors which allows for safe assessment of range of motion? n Ambulatory at any time at the scene n No midline c-spine tenderness n Delayed onset of neck pain n Simple rear-end motor vehicle collision
Excludes: hit by bus or large truck, pushed into oncoming traffic, hit by high speed vehicle more than 100 km/hour

NO

n n

Apply semi-rigid cervical collar Immobilise C-spine Requires radiography

YES

3. Patient able to voluntarily actively rotate neck 45 left and right, regardless of pain? YES

NO

No C-spine immobilisation required

* Dangerous mechanism of injury n Fall from more than 3 feet/ 1 metre or 5 stairs n Axial loading to head e.g. diving, spear tackle n MVC or MBC at high speed more than 100 km/hr n MVC rollover, ejection n Quadbike, motorised all-terrain vehicles n Bicycle collision

Once a cervical collar has been applied, full spinal precautions need to be maintained until the C-spine has been cleared by clinical examination or radiographic assessment. Contraindications: penetrating neck injury. This should be managed with in-line immobilisation.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 103

APPENDIX 11B: REMOVAL OF SEMI-RIGID CERVICAL COLLAR WITHOUT RADIOGRAPHIC ASSESSMENT


Cervical spine clearance without radiographic assessment ONlY applies to fully conscious patients with a GCS 15. A Medical Officer makes the decision for removal of a C-spine collar, after a thorough physical assessment reveals the following:

NeXUS Criteria:
n n n n n

Fully alert GCS 15 No midline pain and or tenderness upon palpation of the cervical spine No motor or sensory deficit e.g. weakness, numbness or parasthesia No distracting painful injury that may mask symptoms of a cervical injury i.e. fracture, burns No evidence of alcohol and/or drug ingestion.

If all of the NEXUS criteria are satisfied, clinical examination may then proceed. If a full range of active movement (45 degrees rotation) can be performed without pain, and there is no evidence of:
n n n

Bruising, deformity or tenderness on examination, Injury above the clavicle. Medical condition requiring extra caution i.e. osteoporosis, rheumatoid arthritis

The cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. References: Brehaut J.C., Stiell I.G., & Graham I.D., 2006, Will a new clinical decision rule be widely used? The case of the Canadian C-spine rule, Academic Emergency Medicine, vol. 13, no. 4 p. 413. Rogers I., Ieraci S., 2006, Emergency care evidence in practice series: Cervical spine x-rays in trauma. Emergency Care Community of Practice, National Institute of Clinical Studies, Melbourne. Stiell I.G., Clement C.M., McKnight R.D., Brison R., Schull M.J., Rowe B.H., Worthington J.R., Eisenhauer M.A., Cass D., Greenberg G., MacPhail I., Dreyer J., Lee J.S., Bandiera G., Reardon M., Holroyd B., Lesiuk H., Wells G.A., 2003 The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma, New England Journal of Medicine, vol. 349, no. 26, pp. 2510-18. Stiell I.G., Lesiuk H., Wells G.A., McKnight R.D., Brison R., Clement C., Eisenhauer M.A., Greenberg G.H., MacPhail I., Reardon M., Worthington J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morrison L., Schull M., Laupacis A., 2001, Canadian CT head and C-spine study group. The Canadian CT head rule study for patients with minor head injury: rationale, objectives, and methodology for phase I, Annals of Emergency Medicine, vol. 38, no. 2, pp.160-69. Stiell I.G., Lesiuk H., Wells G.A., Coyle D., McKnight R.D., Brison R., Clement C., Eisenhauer M.A., Greenberg G.H., Macphail I., Reardon M., Worthington J., Verbeek R., Rowe B., Cass D., Dreyer J., Holroyd B., Morrison L., Schull M., Laupacis A., 2001, Canadian CT head and C-spine study group. Canadian CT head rule study for patients with minor head injury: methodology for phase II, Annals of Emergency Medicine, vol. 38, no. 3, pp. 317-22.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 104 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 12: NEEDLE THORACENTESIS FOR DECOMPRESSION OF TENSION PNEUMOTHORAX


Indication: a rapidly deteriorating haemodynamically unstable patient who has a life-threatening tension pneumothorax. A tension pneumothorax is associated with the formation of a one-way valve at the point of a rupture in the lung. Air becomes trapped in the pleural cavity between the chest wall and the lung, and builds up, putting pressure on the lung and keeping it from inflating fully. The mediastinum is shifted to the opposite side of the chest, decreasing venous return and compressing the opposite lung. early signs and symptoms of a clinical tension pneumothorax:
n n n n n n n n

chest pain dyspnoea anxiety tachypnoea tachycardia hyper-resonance of the chest wall on the affected side reduced chest movement on the affected side diminished chest sounds on the affected side.

late signs of a tension pneumothorax:


n n n n n

decreased level of consciousness tracheal deviation away from the affected side hypotension distended neck veins cyanosis.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 105

Procedural Steps for Needle thoracentesis 1. Prepare Patient


n

2. Cleanse the site with antimicrobial swab. 3. Insert a large bore IV cannula (14 or 16 gauge), greater than 8 cm in length, into the 2nd intercostal space just superior to the 3rd rib, at a 90-degree angle into the skin and through the intercostal space (Figure b). Figure b

Position the patient in upright position (as tolerated) only if a cervical spine injury has been excluded Apply O2 via a non-rebreather face mask at 15 L/ minute Explain the procedure to the patient, if conscious Expose the anterior chest Identify and locate landmarks (on the affected side) see figures a and b suprasternal notch midclavicular line 2nd Intercostal space The 2nd intercostal space is found by dividing the clavicle in half. From that halfway point, palpate down one rib to the first space below that rib. This is the 2nd intercostal space (the space immediately after the clavicle is the 1st intercostal space) (Figure a)

n n n

Figure a

4. Puncture the parietal pleura. Remove the needle from the catheter and listen for a sudden escape of air, indicating that the tension pneumothorax has been relieved. 5. Leave the catheter in place. 6. Place the patient in upright position as tolerated (if C-spine injuries have been ruled out) to assist with respirations. The patient may remain supine if C-spine injuries are suspected. 7. Continue to monitor the patient and reassess.

N.B. A Medical Officer must now insert


an intercostal catheter.

Reference: American College of Surgeons Committee on Trauma, 2008, Shock in Advanced Trauma Life Support Course for Doctors Student Course Manual, 8th edn, United States. Curtis K., Ramsden C., and Friendship J., 2007, Emergency and trauma nursing, Mosby, Sydney. Operational Medicine, 2001, Field medical services school student handbook, < http://brookside press.org/Products/ OperationalMedicine/DATA/operationalmed/Manuals/FMSS/NEEDLETHORO.CENTESISFMST0411.htm> Tintinalli J., Gabor M., Kelen D., Stapczynski S., Ma J., and Cline D., 2003, Emergency medicine: A comprehensive study guide international edition, 6th edn, McGraw-Hill, New York.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 106 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 13: SUGGESTED GUIDELINES FOR A NEUROVASCULAR ASSESSMENT


Begin assessment by evaluation of uninjured limb first for normal patient baseline.
Pulses Auxillary Brachial Ulnar Radial Femoral Popliteal Anterior Tibialis Posterior Tibialis Dorsalis Pedis Nerves Auxillary Radial Median Ulnar Femoral Sciatic Peroneal Deep Tibial Sub-Peroneal Sensation Regimental bade on upper arm Web space between thumb and index finger Pad of index finger Pad of little finger Anterior of thigh Lateral aspect of calf and foot Web space between first and second toes Heel of foot Dorsum of foot Motor Shoulder abduction Hyperextended thumb or wrist Thumb opposition flex wrist Abduction of fingers Straight leg raise Hip extension Dorsiflexion of foot Plantar flexion of foot Foot eversion

Reference: Tamworth Hospital Neurovascular Observation Chart.


The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 107

APPENDIX 14: PELVIC BINDING


For rotationally unstable pelvic fractures: Open-book, Vertical Shear, lateral Compression type III or Combined Mechanism fractures.

1
Place folded bed sheet underneath the patient between iliac crests and greater trochanters.

2
With two trauma team members, cross the sheeet across the synphysis and pull the sheet firmly so it tightly fits around and stabilises the pelvis.

3
a third person should clamp the sheet at the four points shown (away from laparotomy/angiograph access points).

Reference: Heetveld, M, 2007, The Management of Haemodynamically Unstable Patients with a Pelvic Fracture, NSW Institute of Trauma and Injury Management, Sydney.
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 108 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 15: BURN TRANSFER FLOWCHART


Medical Retrieval Meets Medical Retrieval
n n n n n n n n

Referral Needs referral but not medical retrieval Burns >5% children or >10% adults n Burns to hands, feet, face, genitalia, perineum and major joints n Burns with a pre-existing medical condition, e.g. diabetes n Children with suspected non-accidental injury and adults with assault, selfinflicted injury n Pregnancy (2nd or 3rd trimester RNSH) n Spinal cord injury RNSH n Extremes of ages
n

Minor Burns

Intubated patients Head and neck burns Burns >10% in children or >20% in adults Burns with associated inhalation Burns with significant comorbidities, e.g. trauma Electrical/chemical injury Significant pre-existing medical disorder Circumferential to limbs or chest compromising circulation or respiration

Minor burns are treated in consultation with the referring doctor as an outpatient, either locally (at original place of care) or on referral to an ambulatory burns clinic for assessment.

the Childrens Hospital at Westmead Catchment area: All childrens referrals to the age of 15 in all areas of NSW. Contact: aMRS adults 1800 650 004 n NetS for children up to 16th birthday 1300 362 500
n

Concord Repatriation General Hospital Catchment area: South-Eastern Sydney/ Illawarra, Sydney West, Sydney South West, Greater Southern*, Greater Western*, ACT Royal North Shore Hospital Catchment area: Sydney/Central Coast, Hunter/New England, North Coast* *Hospitals near state border areas may refer to Burns Units in adjoining states.

Contact Burns ambulatory Care: CHW: 9845 1850 (b/h) 9845 1114 (a/h) CRGH: 9767 7775 (b/h) 9767 7776 (a/h) RNSH: 9926 7988 (b/h) 9926 8941 (a/h)

Set up conference call with receiving ICU/Burn Unit; facilitate communication with primary referral site CHW ICU CRGH ICU RNSH ICU 99845 1171 99767 6404 99926 8640

CHW: Surgical Registrar on-call notified. Ring 9645 0000, then page Surgical Registrar CRGH: Burns Registrar on-call notified. Tel 9767 7111, then page Burns Registrar RNSH: Burns Registrar on-call notified. Tel: 9926 7111, then page Burns Registrar

Not referred to service.

AMRS/NETS will coordinate transfer betweeen primary hospital and the receiving hospital.

The on-call registrar will offer advice and arrange a bed in liaison with Bed Management and the Burns Unit. They are responsible for receivingthe patient. The referrer will make the ambulance booking.

Referred to service.

Any issues or problems with these processes, or if further advice is required, the NSW Severe Burn Injury Service Manager can be contacted on (02) 9926 5641 Reference: NSW Health, 2008, Burn Transfer Guidelines NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 109

Reference: NSW Health, 2008, Burn Transfer Guidelines NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

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PAGE 110 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Shade affected area

Total % TBSA = __________________

NB: Faint erythema not included in % TBSA assessment NB: Difficult to accurately assess burn depth within the first 2448 hours post injury.

Reference:
NSW Health, 2008, Burn Transfer Guidelines NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 111

Reference:
NSW Health, 2008, Burn Transfer Guidelines NSW Severe Burn Injury Service, 2nd edn, NSW Department of Heath, North Sydney.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 112 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

APPENDIX 16 GUIDELINE FOR EMERGENCY DEPARTMENT DOCUMENTATION


triage Documentation Standard
1. Date and time of assessment 2. Chief presenting problem(s) 3. Relevant assessment findings 4. Limited, relevant history 5. Initial triage category allocated 6. Any diagnostic, first aid or treatment measures initiated 7. Assessment and treatment area allocated 8. Name of triage officer 9. Re-triage category with time and reason (if applicable) 10. Vital signs should only be measured at triage if required to estimate urgency or if time permits

(Australasian College for Emergency Medicine ATS Guidelines Revised August 05) Primary Survey a airway (& Cervical-Spine) B Breathing C Circulation D Disability (neurological) Discomfort (pain assessment) Documentation Patency, airway noises, mechanism of injury (spinal, head, inhalation injury) airway adjuncts (oro/nasopharyngeal/ LMA /ETT) Respiratory rate, rhythm and depth, work of breathing, oxygen delivery device and amount Skin colour, warmth and diaphoresis, capillary refill, pulses, overt bleeding, IV cannula (position and size) & fluids, (commence a fluid balance chart if fluids are administered) a alert V responds to voice P responds to painful stimuli U unresponsive Pupils size & reaction (PEARL) Pain assessment and score + BGL

e exposure & environment History (source the patient, caregiver or Ambulance Officer) Ongoing assessment triage category 13 Record vital signs at time of assessment and frequency according to the patients clinical presentation triage category 4 Record vital signs at time of assessment and at least one further set prior to discharge or according to the patients clinical presentation triage category 5 Record vital signs at time of assessment and relevant to presentation

Head-to-toe or focused assessment (identified abnormalities and environmental hazards during exposure) M mechanism of injury / illness I injuries sustained / illness progression S signs & symptoms t treatment (pre presentation) / transport Documented Observations respiratory rate, oxygen saturations (SpO2) oxygen device, and litres /minute pulse, blood pressure, temperature level of consciousness GCS & pupils blood glucose level (BGL) pain score (0-10) and assessment ECG cardiac rhythm (if monitored) neurovascular observations (if relevant) weight (if relevant) any investigations commenced /completed & outcome a allergies M medications (prescription, over the counter, herbal) P past medical / surgical history l last meal / last menstrual period / last immunisation e events leading up to presentation Document in a concise and clear manner: n procedures, interventions, outcome & evaluation chronologically n standing orders or guidelines if commenced n notification who has been told n comply with legal reporting responsibilities Reassess patient and document outcomes
n n

Plan What plan has been put in place for this patient?

evaluation Discharge Time of departure Destination Referrals

Document discharge information including any instructions or education given to the patient or family If patient not prepared to wait to be seen document advice given to the patient or family

Further mandatory documentation is required according to the patients clinical presentation or if the patient is admitted (i.e. alcohol/other drug use, smoking, skin integrity and falls screening).
The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 113

APPENDIX 17: EXAMPLE OF MINIMUM SKILL SET FOR EMERGENCY DEPARTMENT STAFF
Skill Basic Life Support airway Placement of oropharyngeal airway Oropharyngeal suction using a rigid suction device Two person ventilation using a BVM before intubation Assistance with endotracheal intubation (e.g. cricoid pressure) Tracheal intubation One person use of BVM after intubation Tracheal suction Insertion of laryngeal mask airway Management of the difficult airway including surgical cricothyroidotomy C-Spine Semi-rigid collar fitting e.g. Canadian C-spine rules Semi rigid collar removal decision i.e. NEXUS Spinal Immobilisation (Spinal) log roll Breathing Delivery of non-invasive oxygen therapy Needle decompression of pneumothorax Insertion of intercostal catheter Circulation Venepuncture Blood alcohol sample collection Peripheral intravenous cannulation Automated External Defibrillation (AED) Manual defibrillation (in sites with manual defibrillator) Transcutaneous pacing (in sites with transcutaneous pacing capacity) Administration of ALS protocol medications Blood sample by arterial puncture Recording of 12 lead ECG 12 lead ECG interpretation of ACS Intraosseous needle insertion Insertion of Urinary Catheter Essential Essential Essential Essential Essential Desirable Essential Desirable Essential Essential Essential Essential Essential Essential Essential Essential Essential Desirable Essential Desirable Essential Desirable Desirable Essential Desirable Desirable Desirable Essential Not required Not required Not required Not required Essential Not required Desirable Essential Desirable Not required Not required Essential Not required Not required Not required Not required Desirable Not required Not required Not required Essential Essential Desirable Essential Essential Not required Essential Not required Not required Essential Not required Not required Essential Essential Essential Essential Essential Not required Essential Essential Essential Not required Essential Essential Desirable Not required Essential Essential Essential Essential Essential Essential Desirable Essential Essential Essential Desirable Essential Essential Essential Essential Not required Essential Essential Desirable Not required Essential Essential Essential Essential Not required Essential Desirable Not required Not required Essential Essential Desirable Desirable Not required Desirable Not required Not required Not required Medical Officer Essential advanced Clinical Nurse (RN) Essential RN Essential eeN/eN Essential

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 114 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

Skill Disability Glasgow Coma Score and pupillary response extras Triage Primary and secondary survey Nasogastric tube insertion Splinting and/or POP application

Medical Officer

advanced Clinical Nurse (RN)

RN

eeN/eN

Essential

Essential

Essential

Essential

Essential Essential Essential Essential

Essential Essential Essential Essential

Essential Essential Desirable Desirable

Not required Desirable Not required Not required

Adapted from GMCT Guidelines for In-Hospital Clinical Emergency Response Systems for Medical Emergencies, October 2005.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
NSW Rural Adult Emergency Clinical Guidelines 3rd Edition NSW HealtH PAGE 115

APPENDIX 18: RECOMMENDED BLOOD PATHOLOGY TESTING AVAILABLE AT THE POINT OF CARE IN RURAL FACILITIES WHERE AN EMERGENCY SERVICE IS PROVIDED
The NSW Rural Critical Care Taskforce (RCCT) recognises that availability of specific blood pathology results at the point of care is necessary to assist in and expedite effective diagnosis, treatment and transfer decision-making for patients presenting to rural Emergency Departments, with appropriate mechanisms in place to support staff e.g. staff training, credentialing, and calibration. The following blood pathology results are recommended as the minimum standard necessary at the point of care for rural facilities where an emergency service is provided: 1. Blood gases (including sodium and potassium levels) 2. Haemoglobin 3. Troponin 4. INR These tests provide information to escalate concern and add to the clinical assessment picture for critically ill patients.

The shaded portions contained in the treatment guidelines should only be used by RNs who are recognised as advanced Clinical Nurses.
PAGE 116 NSW HealtH NSW Rural Adult Emergency Clinical Guidelines 3rd Edition

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