Pocket Paramedic

2013
By Jason Houghton

A collaboration of useful guidelines

In a quick reference pocket book;
tailored for pre-hospital care.

PocketParamedic.org
contact@PocketParamedic.org

Pocket Paramedic
2013
An elegant solution to a simple problem
A collaboration of useful guidelines in a quick
reference pocket book tailored for pre-hospital
care.
This handy pocket book resulted from my quest to
consolidate the most relevant and useful
guidance into a single source; something that can
be carried in your pocket at all times - whenever
you may need it.
Pocket Paramedic is 100% non-profit. Sold at cost.
Hopefully, this will mean more people can benefit
from it.
Download the FREE electronic edition from:
PocketParamedic.org
I hope you find it useful.

Jason Houghton - Paramedic

contact@pocketparamedic.org

Contents
Adults
Algorithms and Charts
Paediatrics
Algorithms and Charts
Obstetrics
Useful Information and Charts
Equipment
Instructions and Guidance
Assessment & History Taking
Aid memoirs, Acronyms and Diagnosis
Trauma & Medical Emergencies
Useful Information and Charts
Anatomy
Diagrams and Terminology
ECG & ETCO2 Interpretation
Examples and Explanations
Major Incidents
Acronyms and Plan of Action
Infection Prevention & Control
Useful Information
Key Contacts
Phone Numbers
Notes
Extra Space
References
Credits and Information Sources

4
19
32
37
45

53
62
68
77
91
96
97
99
3

Adults
Algorithms and Charts

Adult Basic Life Support

Adult Advanced Life Support
Adult Cardiac Arrest

5
6
7

Adult Bradycardia

Adult Tachycardia (With Pulse)

Adult Chocking Treatment

10

In Hospital Resuscitation

11

AED Algorithm

12

Adult Glasgow Coma Scale

13

Adult Normal Ranges & Drug Dosages

14

Normal Peak Flow Readings

15

Normal Peak Flow Readings Chart - Men

16

Normal Peak Flow Readings Chart - Women

17

Adult Analgesic Ladder

18

Adults

Adult Basic Life Support 10

Adults

Adult Advanced Life Support 10

Adults

Adult Cardiac Arrest 10

Adults

Adult Bradycardia 10

Adult Tachycardia (With Pulse) 10

Adults

Adults

Adult Choking Treatment 10

10

Adults

In Hospital Resuscitation 10

11

Adults

AED Algorithm 10

12

Adult Glasgow Coma Scale

4

Opens Eyes Spontaneously

Opens Eyes in Response to Voice

Opens Eyes in Response to Painful Stimuli

Does Not Open Eyes

Adults

Eyes

Verbal
5

Oriented, Converses Normally

Confused, Disoriented

Utters Inappropriate Words

Incomprehensible Sounds

Makes No Sounds

Motor
6

Obeys Commands

Localizes Painful Stimuli

Flexion / Withdrawal to Painful Stimuli

3
2
1

Abnormal Flexion to Painful Stimuli (Decorticate)

Extension to Painful Stimuli (Decerebrate)
Makes No Movements
13

Adults

Adult Normal Ranges & Dosages

Parameter

Unit

Value

Heart Rate

BPM

60 - 100

Respiratory Rate

BPM

12 - 19

SpO2

95

BP Systolic

mmHg

100 - 170

BP Diastolic

mmHg

60 - 80

Blood Glucose (BM)

mmol/L

5 - 10.9

st

Joules

200

nd

Joules

300

rd

Energy 3 Shock

Joules

360

Adrenaline 1:10000

mg (ml)

1 (10)

Amiodarone

mg (ml)

300 (10)

Amiodarone (Refractory VF/VT)

mg (ml)

150 (5)

Energy 1 Shock
Energy 2 Shock

14

Normal Peak Flow Readings 8

Adults

EU/EN13826 PEF Meters Only

15

16

Normal Peak Flow Readings Chart - Men 8

Adults

Adults

Normal Peak Flow Readings Chart - Women 8

17

Adult Analgesic Ladder

Adults

(12 Years and Older)

Pain Score

Medical Pain

Trauma,
Orthopaedic,
Musculoskeletal &
Soft tissue Pain

03
Mild
Pain

Consider Entonox
+/Ibuprofen 400MG

Consider Entonox
+/Ibuprofen 400MG

46
Moderate Pain

Consider Entonox
+/Morphine
2.5 to 5mg
(Max 20mg)

Consider Entonox
+/Ibuprofen 400MG

7 10
Severe
Pain

Consider Entonox
+/Morphine
2.5 to 5mg
(Max 20mg)

Consider Entonox
+/Ibuprofen 400MG
+/Morphine
2.5 to 5mg
(Max 20mg)

For Cardiac Related Chest Pain

Morphine Should be Considered in the First Instance

18

Paediatrics
Paediatric Basic Life Support
Paediatric Advanced Life Support
Paediatric Cardiac Arrest

20
21
22

Newborn Advanced Life Support

23

Paediatric Chocking Treatment

24

Paediatric Glasgow Coma Scale

25

Paediatric Arrest Calculations

26

Paediatric Normal Ranges & Arrest Dosages

27

Normal Peak Flow Readings Chart - Paediatric

28

Pain Assessment Faces

29

FLACC Scale Pain Assessment

30

Paediatric Analgesic Ladder

31

19

Paediatrics

Paediatric Basic Life Support 10

20

Paediatrics

Paediatric Advanced Life Support 10

21

Paediatrics

Paediatric Cardiac Arrest 10

22

Paediatrics

Newborn Life Support 10

23

Paediatrics

Paediatric Choking Treatment 10

24

Paediatric Glasgow Coma Scale

4

Opens Eyes Spontaneously

Opens Eyes in Response to Speech

Opens Eyes in Response to Painful Stimuli

Does Not Open Eyes

Paediatrics

Eyes

Verbal
5

Smiles, Orients to Sounds, Objects, Interacts

Cries but Consolable, Inappropriate Interactions

Inconsistently Inconsolable, Moaning

Inconsolable, Agitated

No Verbal Response

Motor
6

Infant Moves Spontaneously or Purposefully

Infant Withdraws from Touch

Infant Withdraws from Pain

Abnormal Flexion to Pain for Infant (Decorticate)

Extension to Pain (Decerebrate)

No motor response
25

Paediatric Arrest Calculations 10

Resuscitation Council UK 2010

Paediatrics

WEIGHT
Age
0 12 Months
1 5 Years
6 12 Years

Formula
Weight (kg) = (Age in Months x 0.5) + 4
Weight (kg) = (Age in Years x 2) + 8
Weight (kg) = (Age in Years x 3) + 7

ENERGY
Age
0 12 Years

Formula
Joules = Weight (kg) x 4j

TUBE SIZE
Age
Pre Term
Neonates

Formula
2.5mm
3 3.5mm
Internal diameter (mm) = (Age/4) + 4
Length (cm) = (Age/2) + 12

1 10 Years

FLUID
Type
Medical
Trauma
Concealed Haem

Formula (0 12 Years)
Bolus (ml) = Weight (kg) x 20ml
Bolus (ml) = Weight (kg) x 10ml
Bolus (ml) = Weight (kg) x 5ml

ADRENALINE

AMIODARONE

Formula (1:10,000) (0 12 Years)

Formula (300mg in 10ml) (0 12 Years)

Dose (mcg) =
Weight (kg) x 10mcg (0.1ml)

Dose (mg) = Weight (kg) x 5mg

Then mls = Dose (mg) / 30)

GLUCOSE
Age
0 12 Years
26

Formula
Dose (ml) 10% Glucose = Weight (kg) x 2ml

Paediatrics
HR
(BPM)
110-160
110-160
110-160
110-160
110-160
110-150
100-150
95-140
95-140
95-140
80-120
80-120
80-120
80-120
80-120
80-120
80-120

RR
(PM)
30-40
30-40
30-40
30-40
30-40
25-35
25-35
25-30
25-30
25-30
20-25
20-25
20-25
20-25
20-25
20-25
20-25

BP
Weight Energy Tube Fluids Adrenaline
(Systolic) (kg) (Joules) (mm) (ml) (ml) (mcg)
70-90
4
20
3
80
0.40 (40)
70-90
4.5
20
3
90
0.45 (45)
70-90
5.5
25
3.5
110
0.55 (55)
70-90
7
40
4
140
0.70 (70)
70-90
8.5
40
4
170
0.85 (85)
80-95
10
40
4.5
200
1.0 (100)
80-95
11
50
4.5
220
1.1 (110)
80-100
12
50
5
240
1.2 (120)
80-100
14
60
5
280
1.4 (140)
80-100
16
70
5
320
1.6 (160)
90-100
18
80
5.5
360
1.8 (180)
80-110
25
80
6
500
2.5 (250)
90-110
28
100
6
560
2.8 (280)
90-110
31
100
6.5
620
3.1 (310)
90-110
34
120
6.5
680
3.4 (340)
90-110
37
130
7
740
3.7 (370)
90-110
40
140
7
800
4.0 (400)

Amiodarone Glucose
(ml) (mg)
(ml)
0.67 (20)
8
0.75 (22.5)
9
0.92 (27.5)
11
1.17 (35)
14
1.42 (42.5)
17
1.67 (50)
20
1.83 (55)
22
2.00 (60)
24
2.30 (70)
28
2.66 (80)
32
3.00 (90)
36
4.20 (125)
50
4.67 (140)
56
5.12 (155)
62
5.67 (170)
68
6.17 (185)
74
6.67 (200)
80

Paediatric Normal Ranges & Arrest Drug Dosages 2013

Age
Birth
1M
3M
6M
9M
12 M
18 M
2 Yr
3 Yr
4 Yr
5 Yr
6 Yr
7 Yr
8 Yr
9 Yr
10 Yr
11 Yr

27

28

Normal Peak Flow Chart - Paediatrics 8

Paediatrics

Paediatric Pain Assessment Faces

29

Paediatrics

30
Kicking, or legs drawn up

Arched, rigid or jerking

Crying steadily, screams or

sobs, frequent complaints
Difficult to console or
comfort

Uneasy, restless, tense

Squirming, shifting back and

forth, tense
Moans or whimpers;
occasional complaint

Reassured by occasional
touching, hugging or being
talked to, distractible

Normal position or relaxed

Lying quietly, normal

position, moves easily

No cry (awake or asleep)

Content, relaxed

Activity

Cry

Consolability

Frequent to constant
quivering chin, clenched jaw

Legs

Occasional grimace or frown,

withdrawn, uninterested

No particular expression or
smile

Face

Criteria

Paediatric Non-Verbal Pain Assessment Tool

FLACC Scale

Paediatrics

Paediatric Analgesic Ladder

Pain Score

Medical Pain

Trauma,
Orthopaedic,
Musculoskeletal &
Soft tissue Pain

03
Mild
Pain

Consider Entonox
+/Ibuprofen &/or
Paracetamol

Consider Entonox
+/Ibuprofen &/or
Paracetamol

46
Moderate
Pain

Consider Entonox
+/Morphine

Consider Entonox
+/Ibuprofen &/or
Paracetamol

Consider Entonox
+/Morphine

Consider Entonox
+/Ibuprofen &/or
Paracetamol
+/Morphine

7 10
Severe
Pain

Paediatrics

(Under 12 Years)

For Cardiac Related Chest Pain

Morphine Should be Considered in the First Instance

31

Obstetrics
Algorithms and Charts

32

APGAR Score for Newborns

Mechanics of Normal Birth

33
34

Shoulder Dystocia

35

Breech Birth Delivery

36

APGAR Score for Newborns

1

Blue or Pale All Over

Blue at Extremities, Body Pink

No Cyanosis, Body and Extremities Pink

Obstetrics

Appearance

Pulse
1

Absent

<100

100

Grimace
1

No Response to Stimulation

Grimace/Feeble Cry when Stimulated

Cry or Pull Away when Stimulated

Activity
1

None

Some Flexion

Flexed Arms and Legs that Resist Extension

Respiration
1

Absent

Weak, Irregular, Gasping

Strong, Lusty Cry

33

Obstetrics

Mechanics of Normal Birth 5

34

Obstetrics

Shoulder Dystocia 4

The McRoberts' manoeuvre is a procedure performed to

release a baby's impacted shoulder during shoulder
dystocia. The mother's legs are held back in a flexed
position and pulled to her chest to further open the
pelvis and allow the baby's shoulder to be released. At
the same time suprapubic pressure is applied to the
mother's lower abdomen over the pubic bone.
35

Obstetrics

Breech Birth Delivery 5

36

Equipment
Instructions and Guidance
Laerdal Suction Unit
ParaPAC Operation

38
39

Fitting a Collar

40

Fitting a Donway

41

Fitting a Donway Continued

42

Fitting a KED

43

Fitting a KED Continued

44

37

Equipment

Laerdal Suction Unit 6

Procedure for Daily Test.

1
2
3

5
6
7
8
9

38

Ensure that tubing is unwound and un-occluded

Ensure the suction catheter adapter is removed from the
holder (if applicable)
Ensure the canister lid, T-bar, angled connector and tubing
are securely fastened.
To run the test, press and hold the test button while setting
the operating switch to 500+mmHg. Do not release the test
button until a minimum of 2 seconds after the operating
switch has been set to 500mmHg. The test will start
immediately.
As soon as LED 2 from the bottom of the battery status
indicator comes on (takes approximately 1 second) fully
occlude the patient suction tubing until all 4 LEDs have
illuminated and LED 1 lights up again.
Keep the tubing blocked while LED 2, 3 and 4 lights up.
Release the tubing when LED 1 comes on again.
Evaluate the test results.
After evaluating the test results, turn the operating switch to
0 to exit the device test.

ParaPAC Operation 11

39

Equipment

40

Fitting a Cervical Collar

Equipment

Fitting a Donway 9

41

Equipment

42

Fitting a Donway Continued

Equipment

Fitting a KED 9

43

Equipment

44

Fitting a KED Continued

Equipment

Assessment & History Taking

Aid memoirs, Acronyms and Diagnosis
Patient Assessment Triangle
Body Assessment - DCAPBTLS

46
47

Neurological Assessment - 5Ps

47

Chest Assessment - TWELVEFLAPS

48

Chest Assessment ATOMFC

49

Chest Trauma

49

Chest Pain - History Taking

50

Abdominal Pain - History Taking

51

Abdominal Pain Locations

52

45

Patient Assessment Triangle

Assessment

Airway &
Appearance

Breathing
Effort

Circulation/Skin

General Impression (First View of Patient)

Normal
Abnormal
Normal cry or speech. Responds
to parents or to environmental
A stimuli such as lights, keys, or
toys. Good muscle tone. Moves
extremities well.

Abnormal or absent cry or speech.

Decreased response to parents or
environmental stimuli. Floppy or rigid
muscle tone or not moving.

Breathing appears regular

without excessive respiratory
B muscle effort or audible
respiratory sounds.

Increased/excessive (nasal flaring,

retractions or abdominal muscle use)
or decreased/absent respiratory
effort or noisy breathing.

Colour appears normal for racial

C group of child. No significant

bleeding.

Cyanosis, mottling, paleness/pallor or

obvious significant bleeding.

Initial Assessment (Primary Survey)

Normal
Abnormal
Clear and maintainable. Alert on

A AVPU scale.

Easy, quiet respirations.

B Respiratory rate within normal

range. No central cyanosis.
Colour normal. Capillary refill at
palms, soles, forehead or central
C body 2 sec. Strong peripheral
and central pulses with regular
rhythm.

46

Obstruction to airflow. Gurgling,

stridor or noisy breathing. Verbal,
Pain or Unresponsive on AVPU scale.
Presence of retractions, nasal flaring,
stridor, wheezes, grunting, gasping or
gurgling. Respiratory rate outside
normal range. Central cyanosis.
Cyanosis, mottling, or pallor. Absent
or weak peripheral or central pulses;
Pulse or systolic BP outside normal
range; Capillary refill > 2 sec with
other abnormal findings.

Assessment

Body Assessment
DCAPBTLS
D

Deformity

Contusions

Abrasions

Penetrations

Burns

Tenderness

Lacerations

Swelling

Body Assessment
5Ps
P

Pain

Paralysis (Movement)

Paraesthesia (Sensation)

Pulses and Capillary Refill

Pallor (Skin Colour and Temperature)

Swelling

47

Assessment

Chest Assessment
TWELVEFLAPS

48

Tracheal deviation (Is it central?)

Wounds / Bleeding (Check the neck, must be

sealed to prevent air embolus / haemorrhage)

Emphysema (Surgical, may indicate tension

pneumothorax)

Laryngeal Injury (Is there crepitus, indicating

injury?)

Veins (Distended?, if so may indicate a tension

pneumothorax or cardiac tamponade)

Expose & Examine the thorax

Feel (Flail segments, wounds, symmetrical

expansion, crepitus, fractures)

Look (Equal rise and fall, paradoxical breathing,

bruising, wounds)

Auscultation (Equal sounds, absent, diminished,

added sounds?)

Percussion (Dullness, hyper-resonance,

symmetry)

Search sides and back

Assessment

Chest Assessment
ATOMFC
A

Airway obstruction (Tongue, trauma, foreign

object, vomit etc)

Tension Pneumothorax

Open sucking wound (Open Pneumothroax)

Massive Haemorrhage (Haemothroax)

Flail Chest

Cardiac Tamponade

Chest Trauma
Differential Diagnosis
Condition

Chest
Expansion

Trachea

Percussion

Pneumothorax Decreased Unchanged Resonant

Tension
Hyper
Pneumothorax expanded

Deviated
Hyper
away from
Resonant
tension

Possibly
reduced

Undeviated Dullness

Collapse /
consolidation

Reduced

May
deviate
towards
collapse

Pleural effusion

Possibly
reduced

Undeviated Dullness

Haemothorax

Breath
Sounds
Reduced
Absent of
affected
side
Reduced or
absent

Reduced or
May be dull bronchial
breathing
Reduced or
absent

49

Assessment

Chest Pain - History Taking

SOCRATES
S
O

C
R

50

Site - Where is the pain or discomfort? Can you point to the

area with one finger?
Onset - What were you doing when the pain first started?
What do you think may have caused this pain or discomfort?
Character - Can you describe the type of pain? Is it: dull ache,
sharp, stabbing, cramping, tearing, tightness, crushing,
burning? Is it there all the time or does it in waves?
Radiating - Does the pain stay in one place or does it radiate?
Does it follow a certain pattern?
Associated Symptoms - Pale, clammy, dyspnoea,
tachypnoea, SOB, dizzy, syncope, lethargy, confusion,
vomiting,
haemoptysis,
productive
cough,
fever,
haematemesis, pulse abnormalities, impending doom. Have
you had a recent cough or been vomiting? When did you last
eat? Have you had any difficulty swallowing?
Time - How long have you had the pain? Has it been there
ever since? Have you ever had a similar episode like this
before?
Exacerbate / Relieve - Does anything ease the pain?
(Analgesia, patient positioning, resting. Does anything make
the pain worse? (Walking, leaning forward, lying down,
coughing, movement, inhalation or expiration.
Severity - If you were to score the pain out of 10, 1 being no
pain and 10 being the worst imaginable, what would you
score it?
Previous History - Recent trauma, chest infection or
coughing, asthma, angina, COPD, heart failure, dyspepsia,
dysphagia,
Risk Factors - Family history, smoker, overweight, heavy
drinker,
sedentary
life
style,
hypertension,
hypercholesterolemia, long travel / pregnancy, diabetes.

Abdominal Pain - History Taking

S
O
C
R

Assessment

SOCRATES
Site - Where is the pain or discomfort? Can you point to the area
with one finger?
Onset - What were you doing when the pain first started? What
do you think may have caused this pain or discomfort?
Character - Can you describe the type of pain? Is it: dull ache,
sharp, stabbing, cramping, tearing, tightness, crushing, burning?
Is it there all the time or does it in waves?
Radiating - Does the pain stay in one place or does it radiate?
Does it follow a certain pattern?
Associated Symptoms - Pale, clammy, dyspnoea, tachypnoea,
SOB, dizzy, syncope, lethargy, confusion, nausea, vomiting,
diarrhoea? Have you noticed anything abnormal when passing
water? For example: Increased or reduced frequency, dark or off
colour urine. Does it have a strong odour, burning sensation?
Have you noticed anything abnormal when passing a bowel
motion? Increased or reduced frequency, pain, loose or hard
stools, dark coloured or bright red.
Time - How long have you had the pain? Has it been there ever
since? Have you ever had a similar episode like this before?
Exacerbate / Relieve - Does anything ease the pain? (Analgesia,
patient positioning, resting, applying pressure, passing wind or
bowel motion?) Does anything make the pain worse? (Lying
down, coughing, movement, inhalation, expiration, palpation,
passing water or bowel motion?)
Severity - If you were to score the pain out of 10, 1 being no pain
and 10 being the worst imaginable, what would you score it?
Birth Bearing Age - Any chance you could be pregnant? Are there
any changes to your menstruation cycle: early, late, abnormal
colour, odours, increased pain? Have you had any vaginal
discharge?
Previous History - Recent trauma, chest infection or coughing,
asthma, angina, COPD, heart failure, dyspepsia, dysphagia,
Risk Factors - Family history, overweight, heavy drinker,
sedentary life style, hypertension, hypercholesterolemia, long
travel / pregnancy, diabetes.

51

Assessment

Abdominal Pain Locations 1

52

Trauma & Medical Emergencies

Useful Information and Charts
Rule of Nines
Submersion/Immersion Drowning
Key Points - Submersion/Immersion

54
55
55

Shock Comparison

56

Stages of Shock

57

Catastrophic Haemorrhage Tourniquet

58

Removing a Helmet

59

Fitting a Triangular Bandage

60

Routes of Drug Administration

61

53

Trauma & Medical

Rule of Nines
Paediatric & Adult

54

Trauma & Medical

Submersion/Immersion Drowning
The pulse may be extremely slow if hypothermia is
present, and external cardiac compression may be
required. Bradycardia often responds to improved
ventilation and oxygenation. Drugs such as adrenaline
and atropine are less effective in HYPOTHERMIA, and
must not be repeatedly used. These drugs may pool in
the static circulation of the drowned casualty, and then,
after re-warming and circulation has been restored, act
as a dangerous bolus of drug as they are circulated.
In hypothermic cardiac arrest, defibrillation will be
unsuccessful where the core temperature remains low.
At 28C the ventricle may spontaneously fibrillate.
Defibrillation may not succeed until the core
temperature rises above 30-32C.

Key Points Submersion/Immersion

Ensure own personal safety

Successful resuscitations have occurred after prolonged

submersion/immersion.
Near drowning is often associated with hypothermia.
Special considerations in cardiac arrest treatment in the
presence of hypothermia.

Severe complications may develop several hours after

submersion/immersion.
55

56

<2 Seconds

<2 Seconds

Anaphylactic

Neurogenic
----

<2 Seconds

Septic

Cap Refill

>2 Seconds

BP

Cardiogenic

HR

Hypovolaemia

RR
>2 Seconds

Type

Shock Comparison
Pale
Clammy
Sweaty
Pale
Clammy
Sweaty
Flushed
Hot
Sweaty
Flushed
Hot
Sweaty
Flushed
Hot
Sweaty

Skin

Trauma & Medical

Stage

15 - 30%

<15%

Blood Loss

1500 2000

750 - 1500

750

ml

Trauma & Medical

2

30 - 40%

>2000

Extreme Tachycardia & Tachypnoea,

Weak Pulse, Decreased LOC & Systolic
BP <70, Skin is Sweaty, Cool and Pallor

Normal Blood Pressure & Resp Rate,

Slight Pallor & Anxiety
Tachycardia, Increased Resp Rate &
Diastolic Pressure, Narrow Pulse
Pressure, Sweating, Mildly Anxious/
Restless
Marked Tachycardia >120 bpm &
Tachypnoea >30 bpm, Decreased
Systolic Pressure, Altered Mental
Status, Sweating, Cool & Pale Skin

Signs and Symptoms

Stages of Shock

>40%

57

58

Catastrophic Haemorrhage Tourniquet 9

Trauma & Medical

Removing a Helmet 9

59

Trauma & Medical

60

Fitting a Triangular Bandage

Trauma & Medical

9

Code

Route

Description

BUC

Buccal

Administration directed toward the

cheek, from within the mouth.

ET

Endotracheal

Administration down the ET tube.

IM

Intramuscular

Administration within a muscle.

INH

Inhaled

Administration by breathing.

IO

Intraosseous

Administration within the bone

marrow.

IV

Intravenus

Administration within or into a vein

or veins.

NASAL

Nasal

Administration to the nose;

administered by way of the nose.

NEB

Nebulised

Administration in the form of mist.

PO

Oral

Administration to or by way of the

mouth.

PR

Rectal

Administration to the rectum.

SC

Subcutaneous

Administration beneath the skin;

hypodermic.

SL

Sublingual

Administration beneath the

tongue.

TOPIC

topical

Administration to a particular spot

on the outer surface of the body.

Trauma & Medical

Routes of Drug Administration

61

Anatomy
Diagrams and Terminology

62

Palpable Pulse Locations

Bones - General

63
64

Bones Spinal Colum

65

Anatomical Terms of Location

66

Patient Positioning

67

Anatomy

Palpable Pulse Locations

63

Anatomy

Bones - General

64

Anatomy

Bones Spinal Colum

65

Anatomy

Anatomical Terms of Location

66

Term

Definition

Anterior
Posterior
Dorsal
Ventral
Lateral (Left)
Lateral (Right)
Medial (Left/
Right)
Proximal
Distal

From front (Anterior) to back

(Posterior).
From top (Dorsal) to bottom
opposite end of body (Ventral).

From left to right side of the body.

From centre of organism to one or
other side
from tip of an appendage (distal) to
where it joins the body (proximal)

Anatomy

Patient Positioning 7

67

ECG & ETCO2 Interpretation

Examples and Explanations

68

ECG Lead Placement

Normal ECG
ECG Assessment Guide

69
70
71

ECG Arrhythmias 1

72

ECG Arrhythmias 2

73

ECG Arrhythmias 3

74

ECG Arrhythmias 4

75

Interpretation of ETCO2 Waveform

76

ECG & ETCO2

ECG Lead Placements 9

69

ECG & ETCO2

Normal ECG 3

I Lateral

aVR

V1 Septal

V4 Anterior

II Inferior

aVL Lateral

V2 Septal

V5 Lateral

III Inferior

aVF Inferior

V3 Anterior

V6 Lateral

Interval
PR Interval
QRS Complex
QT Interval
70

Time in Seconds
0.12 to 0.22
0.08 to 0.12
0.35 to 0.42

ECG Assessment Guide 3

Description

ECG & ETCO2

Point
What is the rhythm? Regular, Irregular
What is the Rate?

Fast, Normal, Slow

Are there P Waves

Present?

YES - Atrial Foci

NO - Junctional or Ventricle Foci

Are all the P Waves

the Same?

YES - Then Same Foci

No - Then Different Foci

Is there a P Wave
before each QRS?

YES - Atrial Foci

NO - Junctional or Ventricle Foci

Is there a QRS after

every P Wave?

NO - Ventricular Standstill or Possible Heart Block

Is the P-R Interval

Normal?

YES - 0.12 to 0.20 Seconds (3-5 small squares)

NO - If >0.0 seconds its First Degree Heart Block

Is the QRS Normal?

YES - 0.04 to 0.12 secconds (1-3 small squares)

NO Bundle Branch Block

Is the ST Segment
Isoelectric?

If Elevated its Myocardial Infarction

If Depressed its Ischemia or Angina

Is the T Wave
Normal?

YES 3 Times the Height of the P Wave

NO Inverted?

71

ECG & ETCO2

ECG Arrhythmias 1 3
Normal Sinus

1st Degree
Heart Block

2nd Degree
Heart Block
Type 1
Missing QRS Complex
2nd Degree
Heart Block
Type 2
Multiple Missing QRS Complexes
3rd Degree
Heart Block
72

ECG & ETCO2

ECG Arrhythmias 2 3
Atrial
Fibrillation

Atrial Flutter

Asystole

Bundle Branch
(Determine
Left/Right from
12 Lead)

Sinus
Bradycardia

73

ECG & ETCO2

ECG Arrhythmias 3 3
Idioventricular
Rhythm

Junctional
Rhythm

Multifocal
Premature
Ventricular
Contraction

Premature
Atrial
Contraction
Compensatory Pause

Paced Rhythm

74

ECG & ETCO2

ECG Arrhythmias 4 3
Premature
Junctional
Contraction

Compensatory Pause
Super
Ventricular
Tachycardia

Unifocal
Premature
Ventricular
Contraction

Ventricular
Fibrillation

Ventricular
Tachycardia

75

ECG & ETCO2

Interpretation of ETCO2 Waveform

Sudden loss of
waveform, ETCO
near zero.
ET Tube,
disconnected,
dislodged, kinked or
obstructed.
Loss of circulatory
function.
Decreasing ETCO
with loss of plateau.
ET tube cuff leak or
deflated cuff
ET tube in
hypopharynx
Partial obstruction

CPR Assessment.
Attempt to maintain
minimum of
10mmHg

Sudden Increase in
ETCO2.
Return of
spontaneous
circulation

76

Major Incidents
Acronyms and Plan of Action
Approach - Think STEP 123
Approach - Scene Assessment - CSCATTT

78
78

Dynamic Operational Risk Assessment

79

Plan of Action - SitRep - METHANE

80

Plan of Action - Briefing Structure - IIMARC

80

Primary Triage

81

Triage Categories

82

Pre-Alert - ASHICE

83

Handover - Trauma MIST

84

Handover Medical MIST

84

EH20 Escape Hood

85

NAAK Presentation

86

NAAK Indications

87

NAAK Directions for Use

88

Electronic Personal Dosimeter (EPD)

89

EPD Alarm Descriptions

90

77

Major Incidents

Approach
Think STEP 123
S

Safety

Triggers for

Emergency

Personnel

Casualty, approach using normal procedures

Casualties, approach with caution, consider all

options

Casualties or more, without obvious cause, do

not approach scene

Scene Assessment - CSCATTT

78

Command and Control

Safety

Communication

Assessment

Triage

Treatment

Transport

Major Incidents

Dynamic Operational Risk Assessment

A dynamic risk assessment is undertaken and applied to
tasks or situations that are in the main unforeseeable or
unpredictable or during which the circumstances,
environment or behaviour of the patient or those at
scene may be subject to rapid change.

79

Major Incidents

Plan of Action
Situation Report to Control - METHANE
M

Major Incident Standby or Declared

Extraction Location

Type of Incident

Hazards (Present and Potential)

Access (Egress)

Number of Casualties

Emergency Services (On Scene or Required)

Briefing Structure - IIMARC

80

Information Overview of incident, location,

what is involved and when it happened

Intention What are we going to do

Method How are we going to achieve it

Administration What records are required

Risks DORA, hazards, Minimising them and

contingency plans

Talk groups, mobile phones, de-brief

arrangements

Major Incidents

Primary Triage

81

Major Incidents

Triage Categories

82

Tag Colour

Definition

EXPECTANT
/ DEAD

Victim unlikely to survive given severity

of injuries, level of available care, or
both.
Palliative care and pain relief should be
provided

Priority 1

Victim can be helped by immediate

intervention and transport
Required medical attention within
minutes for survival (up to 60)
Includes compromises to patients
Airway, Breathing, Circulation

Priority 2

Victims transport can be delayed

Includes serious and potentially life
threatening injuries, but status not
expected to deteriorate significantly
over several hours

Priority 3

Victim with relatively minor injuries

Unlikely to deteriorate over days
May be able to assist in own care
Walking wounded

Major Incidents

Pre-Alert
ASHICE
A

Age

Sex

History

Illness / Injuries / Intervention

Condition HR, RR, SpO2 Air / O2, BP, BM,
Temp, GCS, ECG.
Estimated Time of Arrival

C
E

RED

Cardiac Arrest.
Peri-Arrest.
Any patient eliciting MTC outcome
using Major Trauma Pathfinder.
Currently fitting.
GCS 12 or less.
PPCI.

AMBER

Cardiac chest pain

New Stroke (regardless of symptom
time).
Any other clinical concern.

83

Major Incidents

Handover
Trauma - MIST
M

Mechanism of Injury

Injuries

Signs (Vitals)

Treatment

Medical - MIST
M

84

Medical History (PMH/Allergies)

Illnesses (PC/HPC)

Signs (Vitals)

Treatment

Major Incidents

EH20 Escape Hood 2

For use when the crew believe that they have been
potentially exposed to a form of hazardous
contamination. One size fits all. It will provide 20
minutes of respiratory protection to escape the scene.

85

Major Incidents

NAAK Presentation
Services carry a supply of 10 packs of Nerve Agent
Antidote Kits on every Emergency ambulance for selfadministration by the crew in the event of accidental
exposure to nerve agents.

They consist of 2 prefilled automatic intramuscular

injection devices linked by a plastic clip and housed in a
foam pouch. Atropen containing 2.0mg of Atropine and
a Combopen containing 600mg Pralidoxime Chloride.

86

Major Incidents

NAAK Indications
The Nerve Agent Antidote Kit (NAAK) should be selfadministered or assisted by their crew mate if they are
incapacitated on occasions where they suspect that they
have been accidentally exposed to nerve agents such as
Organo Phosphates (deliberate or accidental release),
and are suffering the effects listed below.
Clinical Diagnosis:
History of exposure
Miosis
Respiratory distress
Bronchorrhoea
Depressed level of consciousness
Bronchospasm
Muscle Twitching
Convulsion
Including one or more of the following:
Bronchorrhoea
Bronchospasm
Severe Bradycardia (<40 bpm)
User may experience the following side effects:
Impairment of psychomotor function
Disorientation
Loss visual accommodation
Photophobia
Transient bradycardia then tachycardia

Palpitations
Arrhythmias
CNS depression
Circulatory/respiratory failure

87

Major Incidents

NAAK Directions for Use

Remove Pen No 1 marked ATROPINE from
the plastic holder this removes the safety
cap and extreme care must be taken.

1
Place the GREEN cap of the auto injector
against the upper quadrant of the thigh
making sure that that it is clear of anything
in the trouser pocket. Press hard until the
injector functions, count to ten slowly and
then withdraw. Bend the needle on any
hard surface until it breaks off. Record time
of administration.

2
Remove Pen No 2 marked PRALIDOXIME
from the plastic holder this removes the
safety cap and extreme care must be
taken.

4
88

Place the BLACK cap of the auto injector

against the upper quadrant of the thigh
making sure that that it is clear of anything
in the trouser pocket. Press hard until the
injector functions, count to ten slowly and
then withdraw. Bend the needle on a hard
surface until it snaps off. Record time of
administration. Hold both injectors in your
hand until help arrives.

Major Incidents

Electronic Personal Dosimeter (EPD)

An Electronic Personal Dosimeter (EPD) is a small pager sized
device that will monitor for the presence of ionising radiation.
It is designed to allow for normal every day background levels
of radiation, but should it detect a rise in levels of radiation in
the vicinity of the wearer it will activate an internal audible
alarm to alert the wearer to look at the display and take action
according to the reading and the perceived local
circumstances.

Default Screen
This example shows the Dose Rate
on the display screen in microSieverts/hour (Sv/h).

Test Display Screen

At the beginning of every shift the
wearer
should
perform
a
confidence test. From the default
display screen press and hold the
operating button until TEST is
displayed.

Confidence Test Display

Double press the operating button
to initiate the confidence test,
which confirms operation of visual
display and the visual and audible
alarms. The display screen will
show all icons at once, the audible
alarm will sound and the visual
indicator will flash.

89

Major Incidents

EPD Alarm Descriptions

Alert

Description

Low Battery
Warning

There is a low battery warning, which is an

intermittent slow tone. This indicated there is
about ten hours battery life left. This will be
the most common warning heard (the data in
the EPD will be stored for about a month
without a battery).
The first tone or Primary Alert Signal is an
intermittent double fast chirp and the LED
will illuminate RED and indicates the presence
of a level of radiation just above background.
This tone will also sound whenever the
battery is replaced and is a function of the
auto test process. It also acts as a reminder of
the alerts for the wearer. The user should be
aware of this facility and is NOT to change
batteries at incident sites. The Primary Alert
Signal should be the only activation alarm the
wearer will ever hear whilst performing their
duties, the most common will be the low
battery warning.
The second tone, the Secondary Alert Signal is
a slow two-tone alarm and indicated a level of
radiation approximately equivalent to that
received annually by normal means. Under
normal circumstances where this level of
radiation is present, Ambulance staff will not
be deployed forward to assist casualties.
The third alert tone, the Tertiary Alert Signal
is a continuous single high tone. This tone
indicated that the wearer has been exposed
to a potentially significant or high dose.

Alarm 1
Primary Alert
Signal

Alarm 2
Secondary
Alert Signal

Alarm 3
Tertiary Alert
Signal

90

Infection Prevention & Control

Useful Information
Mops and Buckets
Hand Washing Technique

92
93

Hand Hygiene

94

Protective Clothing

94

Sharp/Splash Injury Procedure

95

91

Infection Control

Mops and Buckets

Mops and their corresponding colour coded buckets

must not be interchanged. If any mop becomes
contaminated with blood or body fluids, then the
head should be discarded as clinical waste and a
replacement fitted immediately. All mop heads
should be routinely replaced every month.
92

Good and efficient hand hygiene is the single most important

factor in the prevention and control of the spread of infection.
Second to hand washing, consistent use of barrier methods,
especially wearing gloves, is the most important step in
preventing cross-contamination of staff and patients.

Infection Control

Hand Washing Technique 12

93

Infection Control

Hand Hygiene 12
Use the hand washing technique:

Protective Clothing

94

Circumstance/Activity

Appropriate PPE

Circumstance/Activity
Appropriate PPE

Circumstance/Activity
Appropriate PPE

Exposure to blood/body
fluids anticipated, but low
risk of splashing.

Wear gloves, plastic apron

and sleeve protectors.

Wear gloves, plastic apron

and sleeve protectors.

Wear gloves, plastic apron

and sleeve protectors.

Infection Control

Sharp/Splash Injury Procedure

Inoculation/blood splash injuries include any sharp
object that pierces the skin, bites or any other exposure
to blood or body fluids.
Bleed it Apply pressure, but DO NOT suck the wound.
Wash it Wash with soap under warm running water for
2 minutes.
Dry it Do not scrub the injury or pat it dry.
Dress it Cover the injury with a dressing.
For splashes to the eyes Irrigate with saline or water.
For splashes to the mouth Rinse with copious amounts
of water and wash your face.
Donor Identify and document the source of the
inoculation injury include: Name, DOB and home address
if possible.
Inform Contact EOC and inform them of the situation.
Attend Go to the nearest Emergency Department
without delay.
Report it Report the incident to occupational health as
soon as possible. Telephone your local Occupational
health service. Write Numbers Below:

95

Key Contacts
Phone Numbers and Addresses

96

Notes

97

Notes

98

References and Credits

1. Ansari, P (2012) Acute Abdominal Pain [Online] URL: http://
www.merckmanuals.com/professional/gastrointestinal_disorders/
acute_abdomen_and_surgical_gastroenterology/
acute_abdominal_pain.html
2. Avon Protection Systems (2011) EH20 Data Sheet, Melksham/England: Avon
Protection Systems.
3. Evans, S (2004) A Guide Through the Maze of ECGs, 3rd Edition, Somerset/
England: Association of Professional Ambulance Personnel.
4. Fikac, L (2000) Shoulder Dystocia [Online] URL: http://
www.capefearvalley.com/outreach/outreach/peapods/obemergencies/
shoulderdystocia.htm
5. Kochenour, N (1997) The Mechanism of Normal Labor [Online] URL: http://
library.med.utah.edu/kw/human_reprod/lectures/physiology_labor/#2
6. Laerdal (2013) Laerdal Suction Unit: Instruction Manual, Kent/England:
Laerdal Medical Limited
7. Medtrng (2012) Postures and Direction of Movement [Online] URL: http://
www.medtrng.com/posturesdirection.htm
8. Peak Flow (2004) Mini-Wright Peak Flow Meter: Predictive Normal Values
(Nomogram, EU scale), Essex/England: Clement Clarke International.
9. Queensland Ambulance Service (2011) Clinical Practice Manual [Online] URL:
http://www.ambulance.qld.gov.au/medical/CPM.asp
10. Resuscitation Council UK (2010) Resuscitation Guidelines 2010, London/
England: RCUK.
11. Smiths Medical (2008) Emergency Transport and Ventilation [Online] URL:
http://www.smiths-medical.com/Upload/products/product_relateddocs/
EmergencyTransport.pdf
12. World Health Organisation (2009) Clean Care is Safer Care: Clean Your
Hands, Geneva/Switzerland: WHO.

99

Handover

A collaboration of useful guidelines in a quick

reference pocket book tailored for prehospital care.
This handy pocket book resulted from my quest
to consolidate the most relevant and useful
guidance into a single source; something that
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Download the FREE electronic edition from:
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