Clinical Procedures and Guidelines

1 ICLINICAL Procedures AND Guidelines 2019-22 Clinical Procedures and GuidelinesComprehensive edition2019 2022 Clinical Procedures and Guidelines - Comprehensive EditionIssued by: Dr Tony Smith, Medical DirectorIssue No: 8 Document No: CDT508 Authorised by: Norma Lane, Director of Clinical OperationsIssue date: June 2019 Expiry date: February 2022 St John New Zealand, 2019 Except as provided by the Copyright Act 1994, no part of this publication may be reproduced or stored in a retrieval system in any form or by any means without the prior written permission of the copyright Procedures AND Guidelines 2019-22 Introduction These are the Clinical Procedures and Guidelines (CPGs), incorporating standing orders for use of personnel within the New Zealand emergency ambulance sector. These CPGs are for the use of St John personnel with current authority to practise, when providing Clinical care to patients on behalf of St John.

2 These CPGs have been developed by the National Ambulance Sector Clinical Working Group and are issued to individual Clinical personnel by Dr Tony Smith, the Medical Director for St CPGs will be reviewed at the end of 2020 and 2021, with updates being issued at that time if required. These CPGs expire at the end of February 2022 at which time they will be formally updated and reissued. They remain the intellectual property of the National Ambulance Sector Clinical Working Group and may be recalled or updated at any time. Any persons other than St John personnel using these CPGs do so at their own risk. Neither St John nor the National Ambulance Sector Clinical Working Group will be responsible for any loss, damage or injury suffered by any person as a result of, or arising out of, the use of these CPGs by persons other than authorised St John personnel. National Ambulance Sector Clinical Working Group Members Pete Collins, Patient Safety Manager, Wellington Free AmbulanceDr Craig Ellis, Deputy Medical Director, St JohnHannah MacLeod, Clinical Innovation and Learning Manager, St JohnDaniel Ohs, Assistant Director of Operations - Clinical Practice, St John Dr Tony Smith (Chair), Medical Director, St John Adam Stevenson, Intensive Care Paramedic, Wellington Free AmbulanceDr Andy Swain, Medical Director, Wellington Free AmbulanceComments and enquiriesPersonnel should send an email to Others wishing to make formal comments or enquiries should contact Dr Tony Smith at Dr Tony SmithMedical DirectorDr Ian CivilChair of the Clinical Governance CommitteeivCLINICAL Procedures AND Guidelines 2019-22 Contents1.

3 General treatment principles Authority to practise and practice levels General principles Providing treatment that differs from that authorised in these CPGs Analgesia Advance directives and advance care plans Patient competency Calling the Clinical Desk Personnel on the Clinical Desk providing advice Crew resource management Handover Informed consent Initial management of a major incident End of life care Verification of death Oxygen administration Status codes Requesting a helicopter Treatment and referral decisions Vital signs Documentation The primary and secondary survey 682: Respiratory Asthma Chronic obstructive pulmonary disease (COPD) Foreign body airway obstruction Positive end expiratory pressure (PEEP) Stridor Croup 923: Cardiac Assessment for myocardial ischaemia Myocardial ischaemia ST elevation myocardial infarction (STEMI) Fibrinolytic therapy Inter-hospital transfer of patients with STEMI Cardiogenic pulmonary oedema Determining the level of cardiovascular compromise Ventricular tachycardia Supraventricular tachycardia Atrial fibrillation or atrial flutter Cardioversion checklist Bradycardia Cardiogenic shock Cardiac arrest 143 Cardiac arrest in special situations Treatment following return of spontaneous circulation 1564.

4 Shock and trauma Shock Major trauma triage Anaphylaxis Burns Crush injury Hypovolaemia from uncontrolled bleeding Hypovolaemia from controlled bleeding Hypovolaemia from fluid loss concussion and minor traumatic brain injury Severe traumatic brain injury Limb and/or soft tissue injuries Patella dislocation Shoulder dislocation Digit dislocation Other dislocations Spinal cord injury Cervical spine immobilisation 222vCLINICAL Procedures AND Guidelines Tension pneumothorax Amputation Eye injuries Wounds 2435: Altered consciousness/metabolic Agitated delirium Hyperglycaemia Hypoglycaemia Poisoning from gases Poisoning from medicines Poisoning from recreational drugs Poisoning from miscellaneous causes Seizures 2746: Infection Assessing for sepsis Sepsis Meningococcal septicaemia Cellulitis Chest infection Influenza Lower urinary tract infection (UTI) Sore throat Infectious disease precautions 3027: Paediatrics Special considerations in young children Paediatric equipment and drug doses Neonatal resuscitation 3268: Pregnancy Antepartum haemorrhage Postpartum haemorrhage Pregnancy and birth 3389: Intubation and ventilation The principles of intubation and ventilation Preparation for RSI checklist Rapid sequence intubation (RSI) RSI checklist Failed intubation drill Post intubation Mechanical ventilation 35710: Mental Health Mental health conditions Assessing mental status Attempted and/or threatened suicide Non-suicidal self-harm Psychological wellness 37111.

5 Environmental Drowning SCUBA diving emergencies Hyperthermia Hypothermia 38212: Miscellaneous Autonomic dysreflexia Blocked urinary catheter Epistaxis Minor allergy Nausea and/or vomiting Stroke Transient ischaemic attack Inter-hospital transfer for stroke clot retrieval (SCR) Special considerations in the elderly Obesity Patients with existing vascular access 415viCLINICAL Procedures AND Guidelines 2019-2213: Flag tables Making recommendations using the flag tables Abdominal pain Falls Fever in patients aged under five years Fever in patients aged five years and over Headache Non-traumatic lumbar back pain Syncope Vertigo 44014: Medicines Medicines Adenosine Adrenaline Amiodarone Amoxicillin/clavulanic acid Aspirin Atropine Calcium chloride Ceftriaxone Clopidogrel Droperidol Enoxaparin Fentanyl Gentamicin Glucagon Glucose gel Glyceryl trinitrate (GTN) spray Glyceryl trinitrate (GTN)

6 Patch Heparin Hydrocortisone Ibuprofen Ipratropium Ketamine Labetalol 1% lignocaine Loratadine Magnesium sulphate Metaraminol Methoxyflurane Metoprolol Midazolam Naloxone Olanzapine Ondansetron Oxytocin Paracetamol Prednisone and prednisolone Promethazine Rocuronium ropivacaine Salbutamol sodium bicarbonate Suxamethonium Tenecteplase Tramadol Tranexamic acid Valproate Authority to practise and practice levelsAmbulance personnel cannot legally supply or administer prescription medicines to patients unless they have authority to practise, or they are a registered health practitioner with the ability to supply or administer prescription medicines described within their scope of practice. In addition, services restrict the use of some items of Clinical equipment and the performance of some Clinical Procedures to personnel at specified practice levels.

7 Authority to practise is the authorisation of a person to use these CPGs by the ambulance service Medical Director. Personnel may not use these CPGs without authority to practise. Authority to practise is granted at a specified practice level and the practice levels are listed in the table. Each practice level has a delegated scope of practice that defines the medicines and interventions that personnel may administer or perform when treating patients. Interventions that are not described within the delegated scopes of practice (for example automated defibrillation) may be provided by all personnel. 1: General treatment principlesCLINICAL Procedures AND Guidelines 2019-222 SkillEMTP aramedicICPA drenaline IN, IM, nebulised and topical Aspirin PO Glucagon IM GTN SL and patch Ibuprofen PO Ipratropium nebulised Laryngeal mask airway Laryngoscopy (airway obstruction) Loratadine PO Methoxyflurane inhaled Ondansetron IM Paracetamol PO Prednisolone PO Prednisone PO PEEP Salbutamol nebulised Tramadol PO Adrenaline IV (cardiac arrest only) Amiodarone IV (cardiac arrest only) Amoxicillin/clavulanic acid IV Ceftriaxone IM and IV Clopidogrel PO CPAP Droperidol IM and IV Enoxaparin SC Fentanyl IN, IM and IV Gentamicin IV Glucose IV Heparin IV IO access IV cannulation Ketamine IM, PO and IV (analgesia only) 1% lignocaine SC and IO Manual defibrillation Midazolam IM (seizures and agitated delirium only)

8 Clinical Procedures AND Guidelines 2019-223 SkillEMTP aramedicICPM idazolam IV (seizures only) Naloxone IM and IV Olanzapine PO Ondansetron IV Oxytocin IM sodium chloride IV Synchronised cardioversion Tenecteplase IV Tranexamic acid IV Valproate IV Adenosine IV Adrenaline (all routes) Amiodarone IV Atropine IV Calcium chloride IV Chest decompression (needle) Cricothyroidotomy Endotracheal intubation Fascia iliaca block Finger thoracostomy GTN IV infusion Hydrocortisone IV Ketamine (analgesia and dissociation) Labetalol IV Magnesium IV Metaraminol IV Metoprolol IV Midazolam IV Pacing Promethazine IV Rocuronium IV ropivacaine SC % sodium bicarbonate IV Suxamethonium IV (RSI endorsed personnel only) Clinical Procedures AND Guidelines General principlesStanding orders These CPGs incorporate standing orders and personnel are required to adhere to them. Use of these standing orders does not require the Medical Director to countersign each use.

9 However, use will be subject to the audit process within St John and Wellington Free Ambulance. The words must and should appear throughout the CPGs. The word must means that personnel are always required to follow this instruction. The word should means that personnel are required to follow the instruction unless there is a good Clinical reason not to. Some personnel have an expanded delegated scope of practice, for example personnel involved in providing urgent or extended community care. Such personnel are provided with additional CPGs which supersede these CPGs in specific circumstances. General principles of treatment Although not listed in each section, all patients require a primary and secondary survey with appropriate intervention as required. Unless specified otherwise, all medicine doses and fluid volumes in these CPGs are for adults, and children whose weight has been rounded to 50 kg or more.

10 See the paediatric drug dose section for children whose weight has been rounded to less than or equal to 40 kg. For the purposes of these CPGs a patient is an adult if they are aged greater than or equal to 16 years. Alternative care pathways Alternative care pathways (also known as right care pathways) are being developed, piloted and introduced in different areas of the country. The general principle behind alternative care pathways is to meet the healthcare needs of the patient in the most effective and efficient way possible. Where alternative care pathways have been formally introduced, the treatment and referral principles within them supersede those within these trials St John and Wellington Free Ambulance are committed to improving Clinical knowledge and patient outcomes by taking part in Clinical trials. Such involvement in Clinical trials improves the overall care that patients receive.