ELSI Core Manual April 2012

EMERGENCY CARE MANUAL
Core Information
2nd Edition
For the emergency management of seriously ill patients in

isolated locations where access to equipment, drugs,
communications and transport is limited.
Adapted with permission from the Emergency Life Support Inc. Course Manual
Copyright 2012 Emergency Life Support (ELS) Course Inc.

All rights reserved, including the right to reproduce this manual or any parts thereof, unless written
permission has been obtained from the Emergency Life Support (ELS) Course Inc. Committee of Management
Emergency Life Support (ELS) Course Inc. 2012

This page has been deliberately left blank.
Emergency Life Support (ELS) Course Inc. 2012

TABLE OF CONTENTS
Introduction .............................................................................................................................................3
Acknowledgments ..................................................................................................................................3
Emergency Management of the Seriously Ill Patient
Summary .................................................................................................................................................4
Details ......................................................................................................................................................5
Triage .......................................................................................................................................................5
Initial Stabilisation ..................................................................................................................................8
Positioning of the Patient ......................................................................................................9
Airway .................................................................................................................................10
Assessment ...........................................................................................................10
Treatment ...............................................................................................................11
Basic Measures ........................................................................................11
Simple Airway Opening Manoeuvres ........................................................12
Airway Opening Devices ...........................................................................13
Laryngeal Mask Airways ........................................................................14
First Aid for Foreign Body Obstruction ......................................................15
Stabilising C spine ...................................................................................19
Breathing .............................................................................................................................20
Assessment ...........................................................................................................20
Treatment ...............................................................................................................22
Use of a Bag-Valve-Mask .........................................................................22
Teaching Family/Carers to hand ventilate................................................23
Oxygen Therapy .......................................................................................24
Giving bronchodilators ............................................................................ 27
Needle Thoracostomy ...............................................................................28
Circulation ...........................................................................................................................29
CPR - Basic ...........................................................................................................30
CPR - Advanced ....................................................................................................31
Intraosseous Needle Insertion ..................................................................33
Priming of pump IV Giving Set .................................................................34
Disability ..............................................................................................................................35
Pupils .....................................................................................................................35
Glasgow Coma Score ............................................................................................35
Airway Protection ...................................................................................................36
Measure ..............................................................................................................................37
Monitor ................................................................................................................................37
Reassess ............................................................................................................................37
Emergency Life Support (ELS) Course Inc. - 2012 1

Seizures
Background ...................................................................................................39
Treatment.......................................................................................................40
Asthma
Background ...................................................................................................44
Treatment.......................................................................................................45
Overdose / Poisoning
Background ...................................................................................................48
Treatment.......................................................................................................51
Snake Bite
Background ...................................................................................................56
Treatment.......................................................................................................57
Post Partum Haemorrhage

Background ...................................................................................................62
Treatment...................................................................................................... 64
Appendices
Glasgow Coma Scale .......................................................................................................... .... 68
AVPU Scale .............................................................................................................................69
The Golden Rules of Intubation ................................................................................................ 70
Cormack-Lehane Laryngoscopy Grades .................................................................................. 71
Mallampati Classification .......................................................................................................... 72
The Approach to the undifferentiated case of shock ................................................................ 73
Triage of the Sick Child ............................................................................................................ 74
Paediatric Resuscitation Guide ................................................................................................ 75
Paediatric Parameters..............................................................................................................77
Empiric Antibiotics for Emergency Management......................................................................78
Emergency Anti-malarial Treatment.........................................................................................78
Oxygen Cylinder Size and how long they will last....................................................................79
Additional Skills
Femoral vein Cannulation ......................................................................................................... 80
Intercostal Catheter (Chest Tube) insertion ............................................................................. 81
Limb Pressure and Immobilisation ........................................................................................... 84
Needle Cricothyroidotomy/Transtracheal Jet insufflation ......................................................... 85
Surgical Cricothyroidotomy....................................................................................................... 87
2 Emergency Life Support (ELS) Course Inc. - 2012

INTRODUCTION
This manual is designed to be used by health care workers delivering emergency care in isolated
environments that have limited access to equipment, drugs, communications and transport.
The purpose of this manual is to describe a systematic approach that can be used to initiate the
emergency management of seriously ill patients.
The manual will also provide an outline of the basic knowledge and skills needed to apply this approach.
The principles outlined in this manual are based on those taught in the Australasian Emergency Life
Support (ELS) Course.
This manual does not specifically cover trauma management although many of the principles outlined are
applicable.
ACKNOWLEDGMENTS
Some of the diagrams, tables and guidelines used in this manual have been adapted from the following
documents/sites:
The Royal Flying Doctor Service of Australia

and The Queensland Government
www.fotosearch.com
Drug Doses, Frank Shann
APLS 4th Edition
NSW Child Health Network, Paediatric Resuscitation Card
Broselow Tape
Editors 2nd Edition:
Andrew Bezzina, MB BS, DipRACOG, FACEM

Senior Staff Specialist, Emergency Medicine, Shoalhaven District Memorial Hospital, New South
Wales, VMO Emergency Physician Tamworth Regional Referral Hospital, VMO Emergency
Physician, Bowral District Hospital, VMO, Intensive Care Unit, Figtree Private Hospital.
Phil Hungerford, MB BS, FACEM

Director, Critical Care Services, Tamworth Base Hospital, New South Wales. Medical
Consultant, New England Critical Care Network, New South Wales
John Kennedy MB BS, FACEM,

Staff Specialist and Director of Emergency Medicine Training, Emergency Department, Royal
North Shore Hospital.
EMERGENCY MANAGEMENT OF THE SERIOUSLY
ILL PATIENT- SUMMARY:
1. TRIAGE
- seriously ill patients should be placed in an area with access to maximum
available resuscitation equipment and to the most skilled clinicians
- immediately commence the following:
2. INITIAL STABILISATION
- simultaneous assessment and treatment of abnormalities as they are found.
POSITION THE PATIENT - optimally for the clinical circumstance.

AIRWAY
Keep patent using airway opening manoeuvres and suction if necessary.
If there is any likelihood of cervical spine injury, perform in-line immobilisation followed
by the application of a hard cervical collar.
BREATHING
Assess the respiratory rate, pattern and effort. If inadequate, assist ventilation mouth to
mouth, mouth to mask or by using a bag-valve-mask attached to oxygen.
Administer oxygen.
Auscultate the chest.
If a tension pneumothorax is suspected decompress it with a needle thoracostomy
CIRCULATION
Assess for the presence of cardiac output
- An absence of breathing presumes an absence of cardiac output.
- If breathing present palpate the femoral or carotid arteries (adults), or brachial artery /
apex beat (children).
a) No cardiac output found - immediately commence Basic Cardiac Life Support

N.B. if in an isolated environment with no rapid access to intensive care facilities and patient has no
evidence of cardiac output (No heart sounds, No respiratory effort, No movement). Further intervention
will be futile and it is appropriate to cease resuscitation efforts.
b) Cardiac output found
o Measure PR, BP and capillary refill.
o Insert an IV cannula.
o If the patient is in shock, give IV fluids as appropriate.
o Attach to a cardiac monitor if available, assess the rhythm, and correct any
immediately life-threatening rhythm disturbances.
DISABILITY
Measure the Glasgow Coma Score (GCS) or assess the AVPU response and record a pupil
response. If the GCS 8 or the AVPU response is P or U then the airway is at risk from
aspiration. If local resources allow and you have adequate skill and support then consider
endotracheal Intubation for airway protection. If not - use non invasive methods e.g. posture.
MEASURE
Temperature and if available, a fingerprick blood sugar. If hypoglycaemia is found, give 0.25 -
1g/kg of IV dextrose and then remeasure the fingerprick blood sugar level. If IV access is not
available then high concentration glucose drinks can be administered orally if the patient is
conscious or via a nasogastric tube if they are not.
MONITOR
P, BP, and if available ECG, SaO2
REASSESS
Repeat the above steps and treat any further abnormalities that may have developed.

EMERGENCY MANAGEMENT OF THE SERIOUSLY
ILL PATIENT - DETAILS:
__________________________________________________________________
1. TRIAGE
Triage means to sort. To triage patients in an emergency setting involves sorting these patients to
prioritise their degree of urgency (How quickly should they be seen?).
Generally this implies that patients who are more seriously ill will be seen and treated before patients who
are less seriously ill.
However, in some situations where staff and resources are overwhelmed by the number of seriously ill
patients requiring treatment simultaneously, a situation of reverse triage exists. The most severely
injured/ill are unlikely to survive because of resource constraints so less urgent patients are treated first to
enable the most good to be done for the greatest number.
Various systems have been used in many centres in the developing world and are often modifications of
developed world triage designed to suit local conditions.
e.g. at the Queen Elizabeth Central Hospital, Blantyre, Malawi (triage for sick children):
Triage Categories Action required
EMERGENCY Need immediate emergency treatment Call for help and bring
the patient to emergency area
PRIORITY Need assessment and rapid attention move to the front of the
queue
NON-URGENT Patient can wait their turn in queue
EMERGENCY SIGNS - if any are positive, the patient is severely ill or injured.
AIRWAY AND BREATHING

Appears obstructed or central cyanosis or severe respiratory distress
ASSESS AND TREAT
CIRCULATION (SHOCK or heavy BLEEDING)

Weak or fast pulse or cap refill > 3 seconds or heavy bleeding or severe trauma
ASSESS AND TREAT
CONSCIOUSNESS/CONVULSING
Altered consciousness or convulsing
ASSESS AND TREAT

PAIN from LIFE-THREATENING CAUSE
Severe abdominal pain and abdomen hard on

palpation
Severe headache and stiff neck
Trauma to head/neck
New onset chest pain
Major burn
Snakebite
PRIORITY SIGNS
If screening the patient for emergency signs is negative then assess for priority signs.
Any problems with breathing

Violent behaviour toward self or others or very agitated
Very pale
Very weak/ill
Recent fainting
Bleeding (coughing up blood , vomiting blood, bleeding in stool/faeces or moderate
bleeding from injury or nosebleed)
Fracture or dislocation (broken bone)
Burns
Animal bites (from suspected poisonous or rabid or sick animal)
Frequent diarrhoea (>5 loose stools per day)
Problems with vision
New loss of function (not able to move parts of body)
Rape/abuse (this should always be considered as a possibility)
Very bad red rash with skin peeling or involvement of eyes/mouth
These patients should be moved to the front of the queue
NON-URGENT PATIENTS
If the patient has no emergency signs and no priority signs, they can wait their turn in the queue

In Australia and New Zealand the Australasian College for Emergency Medicine (ACEM) promotes a
Triage Scale which can be used in Emergency Departments with on-site medical staff.
This scale has five levels of acuity:
TRIAGE CATEGORY TREATMENT ACUITY

ASSIGNED TO DESCRIPTION (maximum waiting time to
THE PATIENT be seen)
1 Immediately life threatening See immediately
Imminently life threatening
or
Important time critical interventions required
2 or 10 minutes
Patient is in severe pain
Potentially life threatening
3 or 30 minutes
Situational urgency
Potentially serious
4 or 60 minutes
Significant complexity or severity
Less urgent
5 or 2 hours
Clinico-administrative problem
Seriously ill patients are usually assigned a triage category of either 1 or 2.
This scale is not designed to be used in Emergency Departments where there is no on-site medical
staffing.
The specifics of any triage system used are less important than the overall concept. That is, that the
early prioritisation of the urgency of treatment of patients prevents delays which may be harmful to these
patients.
The two components of Emergency Department triage decisions are:
1. Ensuring that patients have medical intervention within an appropriate time frame.
and
2. Ensuring that patients are managed in an area with appropriate monitoring and equipment

2. INITIAL STABILISATION
SIMULTANEOUS ASSESSMENT AND TREATMENT
During this stage seriously ill patients have their basic life functions and vital signs assessed and treated
simultaneously.
This is done in a sequence that prioritises potentially life-threatening events into an order of acuity and
thus determines the order in which they must be assessed and treated. This implies, for example, that
hypoglycaemia is not as immediately life threatening as an obstructed airway and therefore that the
obstructed airway must be dealt with first.
In this initial stabilisation stage, when an abnormality is identified, the sequence should stop and the
abnormality be treated before the sequence recommences. For example, if the patients breathing is
identified as being inadequate, then this should be treated before the circulatory status is assessed and
treated.
As a corollary, if the patient deteriorates at any time, then the sequence must be started again from the
beginning.
The components of the initial stabilisation stage are:
Positioning of the Patient as appropriate to the clinical circumstance
Airway simultaneous assessment and treatment
Breathing simultaneous assessment and treatment
Circulation simultaneous assessment and treatment
Disability simultaneous assessment and treatment
Measure the patients temperature and blood sugar level
Monitor the patient appropriately
Reassess
These components are dealt with in detail on the following pages.

POSITIONING OF THE PATIENT
In certain circumstances appropriate positioning of the patient can greatly enhance their management.
Examples:
1. An Unconscious Patient
During active assessment and treatment of the airway, an unconscious patient should be
placed on their back with the operator standing behind the patients head. Unconscious
patients who are being recovered can be positioned head down and in the left lateral position, with
their neck flexed and head extended (however, if cervical spine injury is suspected, do not move the
neck). This recovery position prevents the tongue from falling back over their airway. Also, if the
patient vomits whilst in this position, it is more likely that the vomitus will run out the mouth rather than
back down the airway.
2. A Dyspnoeic Patient
A patient who is dyspnoeic will often prefer to sit upright. There can be good physiological reasons
for this. It enables optimal use of accessory muscles of respiration and in the case of pulmonary
oedema, helps reduce pulmonary shunting. Managing these patients in the upright position can
reduce their hypoxia as well as get their maximal co-operation.
3. A Child with Partial Upper Airway Obstruction

The optimal position for these children is sitting upright on their parents lap. The sitting position
allows the child to hold their head and neck in such a way as to maintain the patency of their airway.
Also, being on their parents lap can have a calming effect on a frightened child in an environment
that can be quite threatening to them. This can decrease the risk of converting a partial upper airway
obstruction to a complete obstruction.
4. A Patient with Shock

The supine position is desirable for these patients. It allows for the most efficient use of the
cardiovascular compensatory mechanism and hence, the best perfusion of the vital organs. The use
of Trendelenburg (feet elevated above the level of the head) is controversial and has not been shown
to make a difference to patient outcome or to improve physiological parameters.
5. A Patient with a Head Injury

Unless significant shock or spinal injury is present, these patients should be positioned with the head
O
elevated at 30 to the horizontal. This may reduce the patients intracranial pressure.
6. A Patient with Facial Trauma or Partial Upper Airway Obstruction from any
Cause
If the patient is conscious and does not have a significant cervical spine injury, self-posturing (eg.
sitting up and leaning forwards) can help maintain their airway patency. In the setting of facial trauma
this helps stop any facial structures from falling backwards and occluding the airway and will also stop
blood running down the airway.
7. A Pregnant Patient in their Third Trimester

In the third trimester of pregnancy, lying flat can cause supine hypotension from inferior vena caval
compression. To prevent this, place a wedge under the right flank or place the patient in the left
lateral position. If the patient has suspected spinal injuries, then appropriate precautions will be
required.

AIRWAY simultaneous assessment and treatment
Airway management is of paramount importance in any clinical setting. It must always be assessed first
and if any compromise or potential compromise is found, then this must be dealt with as a first priority.
An airway must be:
1. Patent (ie. not obstructed)

A patent airway is an absolute first priority for any patient. An obstructed airway can be actual (i.e.
partially or completely obstructed) or potential (e.g. airway burns which may result in progressive
obstruction over the following hours).
2. Protected from Aspiration

This is a relative priority. It does not take priority over the initial assessment and treatment of a
patients breathing and circulation.
Cervical spine protection is regarded as being part of airway assessment and

treatment BUT keeping the airway patent has first priority
Assessment of the Airway

Assessment usually involves examination before history as the majority of cases of airway compromise
(actual or potential) are evident by simple observation.
SIGNS OF COMPLETE OBSTRUCTION

no air movement present (patient wont be able to breathe, speak, cry or cough)
until the patient loses consciousness they will demonstrate:
agitation
extreme respiratory distress with extensive use of the accessory muscles of respiration
gripping at their own throat
paradoxical breathing i.e. the abdomen moves inwards while the chest expands during
attempted inspiration
cyanosis
rapid deterioration and loss of consciousness which is followed shortly afterwards by
respiratory and then cardiac arrest
SIGNS OF PARTIAL OBSTRUCTION

some air movement present
stridor
self- posturing if the patient is conscious (e.g. sitting up and leaning forward)
respiratory distress with coughing (often weak or ineffective), wheezing, and use of the accessory
muscles of respiration
respiratory cyanosis whilst breathing room air (but this is a late sign of partial upper airway
obstruction)
SIGNS OF POTENTIAL OBSTRUCTION

normal air movement
none of the features for partial or complete obstruction
swollen face, swollen tongue, sore throat, external neck trauma, circumferential neck burns,
sooty sputum, burnt mouth / tongue / nasal hairs, history of fire or explosion in an enclosed space

Treatment of the Airway
This is a staged process.
Basic Measures Patient Positioning / Suction

Simple Airway Opening Manoeuvres
Airway Opening Devices
First Aid for Foreign Body Obstruction
1. Basic Measures
Patient Position - the ideal position for a patient whilst theyre having their airway treated
varies depending on such factors as:-
Is the patient unconscious? If so, then whilst the airway is being actively assessed and treated,
place the patient on their back. If the airway is not being actively treated and the patient is being
recovered, then the recovery position can be used (patient on their left side, head down).
Is the airway partially obstructed? If so, allow self-posturing in conscious patients.
Suction of the airway to clear secretions, blood or other fluids.
Airway Suction
Theory
Obstruction of the airway can occur from pooling of secretions, blood, vomit or other debris in the
airway. Perform suctioning of the airway with an appropriate size sucker and in conjunction with
airway opening manoeuvres.
Technique
a) Ensure that suction tubing is attached to the suction outlet, via a suction bottle for collection
of secretions / vomitus.
b) Tubing should be large bore, to facilitate the passage of blood or vomitus.
c) The sucker should be a rigid, surgical sucker with large bore openings.
d) In conjunction with basic airway opening manoeuvres, gently insert the sucker into the
pharynx and mouth and remove secretions. It may be necessary to clear the tip of the sucker
to remove large particulate matter.
e) The placement of an oropharyngeal airway will prevent the patient biting down on the sucker
if this is a problem.
f) In patients with clenched teeth, the airway can be suctioned with the aid of a flexible sucker
passed down a nasopharyngeal airway.

2. Simple Airway Opening Manoeuvres - performed with the patient supine
Head Tilt
This is contraindicated in cases of potential or actual cervical spine injury.
This manoeuvre is performed from a position behind the patients head.
Placing the head in the sniffing position, i.e. the neck flexed and the head extended.
Great care must be taken in small children to avoid hyper-extension of the head as this may
occlude the airway. In adults, a small pillow under the occiput will help maintain flexion of the
neck. Children do not need this pillow because of their relatively large occiputs.
Head Tilt
and
Chin Lift
Chin Lift
Grip the chin by placing your thumb below the lower lip, slightly retracting it, and your fingers on
the underside of the chin. With this pistol grip pull the mandible forwards and upwards. This
lifts the tongue anteriorly away from the posterior wall of the pharynx. This is the method of
choice in suspected cervical spine injury.
With children, be careful to press on the mandible and not on the sub-mandibular tissue as this
can cause airway obstruction.
Jaw Thrust
Place your hands either side of the head with the little fingers behind the angles of the mandible.
Then lift the mandible forward, which lifts the tongue away from the posterior wall of the pharynx.
None of these simple airway-opening manoeuvres will protect the airway from aspiration.

3. Airway Opening Devices
Oropharyngeal Airway
Guedel-type airways are quite simple to insert. The correct size is that where the length from
flange to tip reaches from the incisors to the angle of the mandible. An average adult will take a
size 3. In adults it is inserted into the mouth upside down then rotated through 180 degrees on
reaching the oropharynx. In children it is inserted in the position of function (a tongue depressor
may be used to hold the tongue clear) as the rotation manoeuvre may tear the soft palate.
Advantages
easy
effective
safe
cheap
Disadvantages
doesnt protect the airway from aspiration
if the patient is conscious they will gag, which may lead to coughing, straining and vomiting
Complications
incorrect placement causing airway occlusion
trauma
vomiting and aspiration

Nasopharyngeal
This artificial airway is softer than the Guedel-type and it is passed posteriorly along the floor of
the nose into the pharynx. The correct size is that with a length from flange to tip adequate to
reach from the nares to the angle of the mandible. It must be lubricated pre-insertion.
Advantages
can be used in the patient with a clenched jaw
less gagging than with a Guedel-type airway
dont need to negotiate the tongue
Disadvantages
more difficult to insert
cannot use if possible fracture to base of skull, eg. where there are facial fractures
may cause nasal haemorrhage
Complications
as for Guedel-type with the addition of intracranial placement in the setting of fractured base
of skull
Laryngeal Mask Airway

Introduction
The Laryngeal Mask Airway (LMA) is an airway device that functions somewhere between an
oropharyngeal (Guedel) airway and an endotracheal tube. Various types of LMA are available.
LMAs are frequently used both in routine anaesthetic practice and as a rescue emergency airway and
ventilation device.
A LMA cannot be inserted unless the patient is deeply unconscious or has been anaesthetised.
Indications
Cant make or keep the airway patent with standard airway opening manoeuvres and devices
(see flowchart below)
Unconscious patients who cannot be ventilated with a bag/mask e.g. severe face trauma
Patients where an attempt at intubation has failed.
Contra-indications
Unable to open mouth
Awake patient
Active vomiting.
Note: LMAs usually provide a stable & patent airway but do NOT protect against aspiration

Placement
Select the right-sized LMA (typically size 3-4 for a female, 4-5 for a male). Check the cuff and
valve for leaks
Deflate the cuff so it folds back from the aperture and apply water-soluble lubricant on the back of
it.
Position the patient in the 'sniffing' position unless C-spine injury suspected
Holding the LMA like a pencil, with the distal opening facing forwards, insert the tip into the
patient's mouth. Using your index finger, advance the mask over the hard palate then the soft
palate and as far as possible into the laryngo-pharynx. To complete the manoeuvre, hold the tube
of the LMA and push it further into the airway until resistance is felt.
Inflate the cuff without holding the tube. Slight outward movement will occur as the mask
'centres'.
Confirm a patent airway, secure the LMA with tape and insert a bite block, e.g. a Guedel airway.
Complications
Aspiration, cough/gag if the patient is too awake

Local trauma

4. First Aid for a Foreign Body in the Upper Airway
FOR COMPLETE OBSTRUCTION
The aim of these first aid procedures is to increase intra thoracic pressure to dislodge or move the
foreign body in the airway.
If the Patient is Conscious, a number of different techniques may be used:

For Adults
a) Give four back blows between the shoulder blades with the heel of your hand.
and / or
b) Give four axillary compressions with your hands high up in the patients axillae.
and / or
c) Perform Heimlich manoeuvre
For Children
a) Place the child across your knees, face down, and give four back blows between the
shoulder blades.
and / or
b) Give four axillary compressions with your hands high in the childs axillae.
If the Patient is Unconscious:

a) Try basic airway opening manoeuvres e.g. suction, head positioning, Oropharyngeal
(Guedel-type) airway, nasopharyngeal airway.
b) If this is unsuccessful, attempt direct laryngoscopy without the use of a muscle relaxant. If a
foreign body is seen, remove it using suction or Magill's forceps (or equivalent).
IS THE PATIENT MAKING RESPIRATORY EFFORT?
Yes: Give O2 if available. Ongoing respiratory effort suggests that the foreign body
has moved and that the obstruction may have either resolved or been converted
to a partial obstruction.
No: Attempt ventilation with bag valve mask if equipment available or if not try
Mouth-to-Mask / Mouth-to-Mouth.
i. Can Ventilate: Suggests obstruction has moved and has been

converted to a partial obstruction
ii. Cant ventilate: Still obstructed
1. Repeat cycle
2. Consider examination of lower airway with
laryngoscopy
3. Consider oxygenation with transtracheal jet
insufflation
4. Consider a surgical airway

FOR PARTIAL OBSTRUCTION
Partial obstruction implies that the patient is moving enough air to maintain oxygen delivery to vital
organs. Incorrect intervention e.g. use of the first aid measures mentioned above may, convert a
partial obstruction to a complete obstruction.
Give oxygen if available
Summon help from the doctor most experienced in airway management
DO NOT give the patient sedating or paralysing drugs, and do not perform direct
laryngoscopy. This may convert a partial obstruction to a complete obstruction.
Assemble appropriate equipment and drugs eg. suction, bag-valve-mask, intubation drugs
and equipment, a difficult intubation tray (if available), and a surgical airway setup.
The patient will require an examination of the airway under anaesthetic by a doctor with the appropriate
skills and training.

Stabilising the Cervical Spine
Every patient with a suspected spinal injury should be immobilized until spine can
be cleared clinically or with an X-ray. It is important to document all exams and
findings.
Who to immobilize:
Every unconscious trauma patient
Every conscious trauma patient with head, face OR neck injury AND who has any of:
altered mentation, appears intoxicated, has posterior midline cervical spine tenderness,
a painful distracting injury or focal neurological signs.
How to immobilize cervical spine:

Keep the patient lying on a flat and firm (not hard) surface
Prevent the neck from moving with locally available materials (towel rolls, newspaper,
sandbags, or
bags of IV fluids) or cervical collar if available
If patient vomits, turn whole patient on their side, keeping head in line with the body
Keep someone with patient at all times to watch the airway
How to immobilize thoracic and lumbar spine:

Keep patient on a flat and firm (not hard) surface
If need to move patient use log roll technique
How to determine whether to discontinue cervical spine immobilization:

Patient must be conscious with NO altered mental state and NO evidence of intoxication and
they have NO significantly painful injuries elsewhere THEN check for
Posterior neck pain at rest
Tenderness with palpation of posterior cervical spine
Sensory or motor deficit
If patient has NONE of these symptoms ask them to move neck.

If no pain or neurological signs on active range of motion, spine is clear.
If patient cannot be cleared clinically, patient should remain immobilized until their cervical
spine is cleared with an X-ray
Ideally three X-ray views are needed to clear the cervical spine (lateral, AP, open mouth
odontoid)
The most important view is the lateral X-ray. An adequate lateral X-ray must view to C7/T1.

BREATHING simultaneous assessment and treatment
Assessment of Breathing
This requires assessment of the:
respiratory rate
adequacy of the respiratory effort
pattern of respiration (eg. paradoxical breathing or a flail chest)
auscultatory findings of the chest
pulse oximetry reading (where available)
These clinical signs must be taken in the context of the clinical picture. They must be interpreted as a
package, rather than individually. Some important considerations are:
1. Respiratory Rate
There is significant variability between patients e.g. the normal respiratory rate for a 3 week old
neonate is significantly different to that of a 60 year old adult.
2. Respiratory Effort
The presence of respiratory compromise is usually evident from the end of the bed by observing
signs such as posture (tripoding) intercostal and subcostal recession, tracheal tug or accessory
muscle use in addition to the rate estimate from above.
3. Respiratory Pattern
This likewise can be an end of the bed assessment of the pattern of chest movement that may
diagnose significant pathology evident as e.g. paradoxical breathing (abdomen moves down with
inspiration but the chest moves in rather than expanding), chest wall splinting, and asymmetrical
chest movements.
4. Cyanosis is an unreliable sign of hypoxaemia and varies with:

skin pigmentation
haemoglobin level
ambient light
skin perfusion
5. Auscultate the Chest

Check that the trachea is midline and that air entry is present on both sides of the chest. Note any
added sounds.
Subsequent steps are dependent on the availability of equipment.
6. Oxygen Saturation is assessed by pulse oximetry. It must be assessed in context and its
limitations understood. The pulse oximeter will display:
oxygen saturation
pulse rate
pulse volume
Pulse volume is displayed as a plethysmographic waveform and is subject to more error than the
oxygen saturation reading. Alarms are usually present for low saturations and for pulse rate upper
and lower limits. The accuracy for oxygen saturation is +2%, but only in the 70% - 100% range.

The saturation is not the same as the partial pressure of oxygen and there is not a linear relationship
between the two. The relationship is described by the haemoglobin-oxygen dissociation curve and
this in turn is not a constant as it is affected by:
temperature
pH
PCO2
2, 3 DPG levels in the red blood cells
Approximate correlations are:

75% sat. = PaO2 40 mm.Hg
90% sat. = PaO2 60 mm.Hg
Factors influencing pulse oximetry readings are:
Signal Interference
shivering, movement, high intensity light from another source
Decreased Light Transmission

dirty skin, dark nail polish
(pigments eg. bilirubin, do not affect the reading)
Decreased Signal Volume

e.g. poor peripheral perfusion from shock or hypothermia
Abnormal Haemoglobin
carboxyhaemoglobin (causes an overestimation of saturation)
anaemia (especially at levels < 50g/L)
Others
intravenous dyes
Pulse Oximetry
Theory
Pulse oximetry provides a non-invasive method of assessing a patients oxygenation. Equipment
consists of a probe, containing two light sources and a photodetector. The probe connects to a
monitor that contains a microprocessor and displays oxygen saturation, pulse rate and pulse volume
(as a plethysmographic wave form). The light sources emit red and infra-red light across a vascular
bed e.g. a fingertip, which is then detected by the photodetector.
Oxyhaemoglobin and reduced haemoglobin have different absorption characteristics for the two
different light wavelengths and the ratio of these differences is used to calculate the SaO2.
Technique
a) Choose the sensor / probe. Infants require adhesive probes, usually on the feet / toes.
b) Clean the area chosen for the sensor, with an alcohol wipe, to remove any dirt. Remove any
fingernail or toenail polish if these are the sites to be used.
c) Connect the sensor via the cable to the pulse oximeter monitor. Check there is a pulse waveform
and pulse rate readout.
d) Check the oxygen saturation reading and adjust oxygen therapy according to required oxygen
saturations.
e) Set alarms for:

High and Low level SaO2
High and Low pulse rate

Treatment of Breathing
IF RESPIRATORY RATE OR EFFORT ARE INADEQUATE, ASSIST VENTILATION WITH A BAG-
VALVE-MASK ATTACHED TO OXYGEN (if available)
IF NO BAG VALVE MASK AVAILABLE THEN AN ALTERNATIVE WOULD BE MOUTH -TO- MASK
OR MOUTH-TO-MOUTH VENTILATION
Use of a Bag-Valve-Mask
Theory
The indication for the use of a bag-valve-mask is when the patients respiratory rate or effort are
inadequate and require assistance.
The bag-valve-mask system usually consists of:
A clear facemask which fits over the patients nose and mouth
A self-filling bag with an inlet for oxygen and an attached oxygen reservoir bag
A valve connection between the bag and the mask that allows one-way movement of oxygen
from the bag to the patient via the mask, and a separate valve that allows venting of exhaled
gas to the atmosphere.
Sometimes a pop-off valve is part of the connection between the bag and mask, which is pre-set to
open at a certain pressure. This is designed to prevent barotrauma to the patients lungs - it is best,
however, to avoid over-inflation of the patients lungs and not rely on this safeguard valve. A tidal
volume of 7-10ml/kg, or enough to make the chest rise, is adequate.
Technique
1. Ensure cervical spine protection if needed, using in-line immobilisation or a hard collar.
2. Use basic airway manoeuvres to open the airway. Suction the airway if necessary.
3. Ensure the equipment is properly assembled, ie:

the clear facemask is the correct size and gives a good seal over the face and nose
the valve connection is correctly fitted and checked to be working
the self-inflating bag is attached to oxygen at 15L/min and the reservoir bag is filled with
oxygen
4. Standing at the head of the patient, place the clear facemask over their mouth and nose, ensuring
a tight seal around the mask, particularly over the bridge of the nose and the chin. Hold the mask
in place with one hand using your thumb and index finger to hold the mask on, with the remaining
fingers along the mandible supporting the jaw. The patient is then ventilated by squeezing the
bag.
5. Alternatively, two people can use the equipment. One person uses both hands to hold on the
mask and support the jaw, whilst an assistant ventilates by squeezing the bag. This is
recommended for inexperienced operators.

Preparing the family or other caregivers for using a bag to ventilate a
patient who has been intubated ( LMA or Endotracheal Tube )
(Adapted from WHO district clinician manual)
Overaggressive assisted ventilation can cause serious harm to a patients lungs

and even lead to death. It is critical that the family understands the proper
technique, the need for continuous bagging and when to call for help.
It is also critical the family do not attempt to feed the ventilated patient
Demonstrate how to use the bag then watch them do it. Advise the caregivers as follows -
What to do:
If you are not sure, ask for help from the HEO, nurse or doctor.
Hold the bag in one hand and depress a 2 L bag to about 1/3 of its volume
Give one breath over about one second - give about 10 breaths/minute in adults.
Make sure that after each breath, the patient completely exhales before giving the next breath.
Watch to make sure that the chest is rising and falling evenly. The patients abdomen should not
be expanding.
If the patient is breathing on their own, deliver breaths in time with the patients own inhalation.
Do not deliver a breath as the patient exhales.
It should be easy to compress the bag and you should feel minimal resistance. If you feel
resistance ask for help from the nurse or doctor.
Demonstrate how to suction secretions and vomit
When to call for help:

Call immediately for help if:
The patient is turning blue or if the patients oximeter reading falls below 90% (for
patients monitored with a pulse oximeter)
The patient is waking up and biting on the tube, or trying to pull the tube out of his or her
mouth.
It becomes hard to compress the bag or you feel increased resistance
You hear gurgling noise when you give a breath or the tube is filling with secretions.
The patients stomach seems to be filling with air or is expanding
When you touch the patients skin it feels like it is full of air and crackles under your
fingers
You must take a break, and there is no one to relieve you
If you must take a break, make sure that someone takes over for you and the patient is always
being ventilated.
If the patient is vomiting
Call for help. Stop ventilating the patient for a short period of time while you
suction or manually remove all vomit.
If there is no concern for a spinal injury, turn the patients head to the side, to get
as much vomit out as possible. Resume ventilation when the vomiting has
stopped and as much vomit as possible has been removed from the airway.

Give Oxygen
There are several options for the method of oxygen administration and the one chosen is dependent
on the needs of the individual patient and the available equipment. Delivery methods can be
classified as:
Oxygen concentrators
100% Oxygen Systems
Variable Performance Systems
1. Oxygen Concentrators
How does an oxygen concentrator work?

An oxygen concentrator separates the oxygen from the nitrogen in air and increases the
proportion of oxygen from about 21% to about 90%. There are four filters within the oxygen
concentrator through which the air passes, which get rid of bacteria and dust. The air is forced
under pressure through a molecular sieve (usually containing zeolite) which binds the nitrogen.
Oxygen then passes through to a reservoir where it is available for use by patients. There are
two identical canisters, alternately filling with nitrogen and then emptying when the pressure is
released, so that the production of oxygen is continuous.
WHO/UNICEF machine standards

An International Standard (ISO) already exists for small concentrators, relating mainly to safety in
use. To reach the WHO/UNICEF standard, the machine must first meet the ISO standard and, in
addition to this:
It must be capable of functioning in adverse circumstances, including:

ambient temperature of up to 40C
relative humidity up to 100%
unstable mains voltage
excessively dusty environment
It must pass military standard shock, vibration, and corrosion tests.
It must be incapable of delivering an output oxygen concentration of less than 70%.
Every machine must be supplied with a comprehensive service manual.
Every machine must be supplied with 2 years of replacement spares.
Limitations of the machines

When high humidity is combined with high temperatures the concentration of oxygen may
be reduced to 70%.
Low voltage may cause the machine to overheat because the motor is running
inefficiently. A voltage regulator should be used in these circumstances.
When a flow-splitter is being used, the total flow must not be more than 4 litres per
minute, or the oxygen concentration will decrease.
In the ambient air at high altitudes, the oxygen flow may be reduced to 80% at 4000
metres, but this should not cause serious difficulties in most cases.
If there is a power failure, the oxygen reservoir inside the machine will last only 2-3
minutes. Oxygen cylinders are recommended as a back up oxygen supply system in
case of power failure.
Using the machine

There is now a small range of models that are consistent with WHO specifications for district
hospitals. These have flow rates of 5-8 litres per minute of 90%-95% oxygen from a 300-375
watts mains or a back-up generator.
If the oxygen source is used for more than one patient, a flow splitter, 0.5 and 1.0 litre / minute
nozzles, blanking plugs and flow indicators, together with additional tubing (and humidifiers) are
required.

Flow-splitters (necessary for delivery of oxygen to more than one patient) are now available in at
least two models on the market, and the cost for this attachment is now less than when flow-
splitters need to be manufactured as a special item.
One of the higher flow rate models has two main outlets, allowing eight patients at any time to
receive oxygen at 1 litre per minute (using two four-way flow splitters). Flow models of 8 litres
were designed for nebulizing beta-2 agonist bronchodilators (eg. salbutamol) for patients with
asthma, but these models may be useful in hospitals where eight patients can be nursed in a
high-dependency area.
Non-crush plastic tubing for oxygen delivery is required. If a nasopharyngeal catheter is used, a
bubble humidifier is needed.
The concentrator may work 24 hours a day, every day, as long as daily maintenance procedures
are carried out. Typically, all that is required is that the user washes a coarse filter each day and
replaces three other filters at varying times during the year.
2. 100% Oxygen Systems
These are most commonly non-rebreathing circuits employing a reservoir oxygen bag.
For example:
Self-refilling circuits eg. Laerdal or Air Viva bags with an attached reservoir bag or
Soft reservoir bags attached to a Hudson type mask
Ensure that the oxygen flow is enough to keep the reservoir bag inflated at all times.
3. Variable Performance Systems
The delivered oxygen concentration of these systems falls as the respiratory rate, tidal volume,
and peak inspiratory flow rate rise. Options are:
Nasal cannulae
Standard Hudson type mask
Nasal Prongs
Deliver oxygen at concentrations of 22-40%. Flow rates of >4L / minute are not well
tolerated due to drying of the nasal mucosa.
Not recommended in dyspnoeic adults due to their small nasopharyngeal reservoir and
greater proportion of mouth breathing.
Tend to be more efficient in children.

Standard Hudson Type Mask
At flow rates of 6-14L / minute delivers oxygen at concentrations of 35-60%. Adding a
reservoir bag to these masks (the non-rebreather mask) allows an increase in delivered
oxygen to as high as 90%. This is further improved if a second oxygen supply to the
mask is used allowing delivery of 30L / minute.
Procedure
Titrate oxygen using clinical picture (colour/ respiratory rate and pattern) and if available,
pulse oximetry
If the patient is critically ill , go straight to 10-15 litres via a non-rebreather mask
If the patient is not critically ill, start at low flow rates and gradually increase according to
the patients response.(see below)
Recheck the patient in 15 minutes and measure the oxygen saturation.
Positive pressure
Some patients may still be hypoxic despite maximal oxygen flow
Positive pressure with non-invasive ventilation (CPAP) or mechanical ventilation with
PEEP may improve oxygenation in these patients, but is not available in many facilities.
Response to drop in oxygen saturation or increasing respiratory rate on oxygen

Increase flow rate if possible
Check to make sure oxygen supply and all equipment is working properly.
Check that the cylinder still has sufficient oxygen
Check that oxygen is flowing out of the prongs or face mask (hold the end close to your
hand and you will feel the airflow)
Check that there are no leaks in the connections or oxygen tubing.
Exclude new acute pathology in the patient e.g. pneumothorax, pleural effusion, heart
failure, poisoning
If wheezing, give salbutamol

Giving Bronchodilators
Salbutamol by metered-dose inhaler

100 mcg/puff; 200 puffs/inhaler
Use spacer and/or mask depending if patient not able to coordinate breathing and inhaler
If MILD WHEEZING:
2 puffs every 20 minutes x 3 times then 2 puffs every 3 to 6 hours
If MODERATE or SEVERE WHEEZING
Give salbutamol, either continuous nebulizers or prime spacer with 5 puffs then give 2 puffs
via spacer every 2 minutes
Salbutamol by nebulizer
5 mg in 5 ml solution if patient weighs more than 20 kg (give 2.5 mg in 2.5 ml
solution if less than 20 kg)
Place in nebulizer
Connect to oxygen if available
Give every 10-20 minutes or, if severe, give continuously (refill chamber every 5 to 6 minutes)
How to make spacer from plastic bottle

Use a clean plastic 300500 ml bottle. (Clean monthly and prime with 10 puffs
after each cleaning, before using for treatment).Remove the cap from the bottle.
Remove the inhaler cap and trace the shape of the opening of the inhaler on the
base of the bottle, directly opposite the mouth of the bottle.
Cut an opening into the base of the bottle exactly (or slightly smaller) than the
size traced with a heated paperclip. (An alternative is to make a slit in the side
of the bottle and place the puffer through the hole)
Insert the inhaler into the spacer to check the size.
For severe attacks or if the patient cannot co-operate, cut off the bottom and use
as a mask.

Needle Thoracostomy
Indications
Needle thoracostomy is performed to provide emergency decompression of a tension pneumothorax.
It is a temporising measure only. It should be immediately followed by the insertion of an
intercostal catheter.
Tension pneumothorax is a time critical emergency and it is a clinical diagnosis.
Clinical signs of a tension pneumothorax are those of:
1. The Pneumothorax
Respiratory distress
Pleuritic chest pain on the affected side
Hyper-resonant percussion note and decreased or absent breath sounds on the affected side.
Dilated neck veins
Subcutaneous emphysema may be present.
2. Mediastinal displacement
Trachea deviated to the side opposite the pneumothorax
Displaced apex beat to the side opposite the pneumothorax
and
3. Circulatory Compromise
Tachycardia
Poor peripheral perfusion
Hypotension
Cardiac arrest (usually pulseless electrical activity)
Technique
Landmarks
Second intercostal space, mid-clavicular line. The second intercostal space is best found by feeling
for the prominence of the angle of Louis, which is where the second rib articulates with the sternum.
Procedure
Insert a large bore cannula through the second intercostal space in the mid-clavicular line. After
feeling the loss of resistance on passing into the pneumothorax, remove the stylet. A rush of air
usually follows as the pneumothorax is decompressed.
Secure the catheter with tape.
Formal intercostal catheter placement must follow as these cannulae can easily be displaced or
kinked.

CIRCULATION simultaneous assessment and treatment
1. Assess for the presence of cardiac output

by first considering whether the patient is breathing. If not breathing then manage as if pulseless and
progress as below. If breathing then palpate the femoral or carotid arteries (adults), or brachial artery
/ apex beat (children).
If the patient is pulseless, commence basic cardiopulmonary resuscitation:
Cardiopulmonary Resuscitation - Basic
D Check for danger
R Responsiveness? - Shake and Shout
Call for help if unresponsive
Position on hard, flat surface
A Airway clear and open
B Establish whether breathing
If not breathing, give 2 initial breaths
C Give 30 chest compressions (almost 2 compressions / sec) followed by 2 breaths
D Attach Defibrillator if available and use as

appropriate to rhythm
Continue CPR (30 compressions: 2 breaths)

Cardiopulmonary Resuscitation - Basic
AGE Less than 1 year 1 to 7 years 8 years to adult
Ventilation Blow until chest rises Blow until chest rises Blow until chest rises
volume
Sternal compression Lower sternum Lower sternum Lower sternum

site
Each cycle should be
50% compression,
50% relaxation
Compression 2 or 3 fingers Heal of one hand Heels of both hands

delivery
1 1 1
Compression depth /3 A-P chest diameter /3 A-P chest diameter /3 A-P chest diameter
Compression rate 100 per minute 100 per minute 100 per minute
Compression / 1 operator 30:2 1 operator 30:2

30:2
Ventilation ratio 2 operators 15:2 2 operators 15:2

Cardiopulmonary Resuscitation - Advanced
Cardiac Arrest
Basic Life Support
Attach cardiac monitor/defibrillator
Assess
rhythm
Shockable Not
DEFIBRILLATE CPR immediately for 2 mins

Monophasic 360J Yes
Biphasic 200J
AED: device specific
During CPR:
Check electrode/paddle position
and contact
Intravenous access
CPR immediately for 2 mins Adrenaline 1 mg IVI-repeat every 3
mins
Consider atropine 1-3 mg IVI +
pacing for asystole or severe
No
bradycardia.
Assess rhythm shockable?
Yes
DEFIBRILLATE Assess rhythm shockable?

Monophasic 360J
Biphasic 200J
Resume CPR immediately for 2 mins No

During CPR:
Intravenous access
Adrenaline 1 mg IVI
Repeat every 3 mins
No If asystole/PEA go back to asystole/PEA algorithm

Assess rhythm shockable? If return of spontaneous circulation, begin postresuscitation care
Yes During CPR

IPPV ( + ETT) with 100% O2 (avoid hyperventilation)
DEFIBRILLATE Assess rhythm every 2 mins
Monophasic 360J For witnessed arrest, when using manual defibrillator, give up to 3 stacked shocks at first
Biphasic 200J defibrillation attempt
Correct reversible causes:
Hypovolaemia
Hypoxia
Hypo/hyperkalaemia & other metabolic disorders
Hypoglycaemia
Hypo/hyperthermia
Resume CPR for 2 mins Tamponade - pericardial
During CPR, give Amiodarone 300 Tension pneumothorax
mg IVI once, then consider additional Thrombosis pulmonary/coronary
150 mg once or Toxins/poisons/drugs
Lignocaine 1-1.5 mg/kg IVI, then 0.5 NaHCO3 only if hyperkalaemia, arrest > 15 mins or OD tricyclics
mg/kg IV, max 3 doses or 3 mg/kg Ca chloride 10 ml of 10% only in OD Ca channel blockers, hypocalcaemia or hyperkalaemia
Magnesium 1-2gIVI only for torsades de pointes

If breathing and a pulse is palpable:
2. Measure the Pulse Rate (PR)
3. Measure the Blood Pressure (BP) using an appropriate sized cuff (ie. a cuff big
2
enough to cover /3 of the upper arm).
Assessing what is a normal PR and BP in the paediatric population is dependent on the childs
age.
In adults, hypotension is a relative term eg. an elderly person whose usual BP is

190
/100 will be
120
relatively hypotensive with a BP of /80.
4. Measure the Capillary Refill time in the finger tips. This should be <2 second.
Additional parameters which can be used to assess the adequacy of circulation over time are
urinary output and mental state.
Subsequent steps are dependent on the availability of equipment
5. Attach the Patient to an ECG Monitor and determine the cardiac rhythm.
If the rhythm is found to be life threatening, then immediate treatment is required.
6. Insert an IV Cannula
A large gauge cannula (14G or 16G in adults) is required for rapid fluid resuscitation.
If insertion is difficult in children consider using an intraosseous needle (see below)
7. If Hypovolaemic Shock is Present, Commence Rapid Fluid

Resuscitation via a pump giving set. Commence with 10-20ml/kg of colloid or isotonic
crystalloid, and then reassess the PR, BP, and capillary refill.
If shock persists repeat the IV colloid or isotonic crystalloid bolus of 10-20ml/kg.

Intraosseous Needle Insertion
Theory
Intraosseous access can be used to administer fluids, blood or drugs ie. most things that can be
given intravenously can be given through an intraosseous needle.
Fluids and drugs that are given into the medullary cavity of a long bone are rapidly taken up into
the venous sinuses and enter the venous circulation.
Indications
A child younger than 5 years needing resuscitation, when intravenous access is not achieved in 3-5
minutes.
Contraindications
Infection over the insertion site.
Possible fracture of the chosen bone.
Congenital bony disorders e.g. osteogenesis imperfecta.
Site
The preferred site is the flat surface of the upper medial part of the tibia, 2cm below the tibial
tuberoscity.
Other possible sites include:
medial malleolus
femoral condyle
iliac crest
i
Equipment
Intraosseous needle. Alternatively, if a purpose made intraosseous needle is not available, a
spinal needle with stylette or a bone marrow needle can be used.
Dressing pack
Local anaesthetic
Syringe
Giving set
Technique
Advise the parents of the procedure.
Find the insertion site:

flat surface of the upper medial aspect of tibia, 2cm below tibial tuberoscity
medial malleolus
femoral condyle
iliac crest
Disinfect the skin.
Use local anaesthetic in the awake patient.
Needle insertion with a twisting motion and firm pressure.

The needle is directed slightly caudal to prevent injury to the bone growth plate.
There is a give or loss of resistance when the needle passes through the cortex and enters the
marrow cavity.
Inject fluid with syringe to check position. There should be little or no swelling of the
subcutaneous tissue as fluid is infused.
If you are unhappy with the position and need to re-site the cannula, use another bone, NOT a
different site in the same bone. Extravasation of drugs / fluids can occur from the initial breach if
the same bone is used.
Fluid or drugs can be given through the intraosseous needle either as a bolus or via a giving set.
The needle should be removed as soon as secure intravenous access is obtained. Twenty-four
hours is the maximum time for an intraosseous needle to remain in situ.
Complications
With short term use, complications are rare, but include:
malplacement into subcutaneous tissues which can lead to compartment syndromes
fracture of bone
injury to bone growth plate
local infection of bone or skin
Priming of a Pump IV Giving Set
Theory
In the setting of shock, fluids cannot be adequately or reliably infused using gravity alone. Pump
sets are used to rapidly infuse fluids in this setting.
For interhospital transfer of patients, where motion and lack of height mean gravity drips are
unreliable, pump sets can be used.
Description
A pump set is an intravenous infusion set that has a compressible chamber and a one-way valve in
the line.
Technique
To prime a pump set:
Turn flow regulator on IV line off.
Connect set to bag of intravenous fluid.
Prime the drop chamber by squeezing gently.
Invert the pump chamber. Turn the drip on.
Keep the pump chamber inverted until it fills completely.
Let fluid flow through the rest of the IV line.
With manual compression of the chamber, large volumes of fluid can be given quickly.

DISABILITY simultaneous assessment and treatment
Pupils
Test pupil size, equality, and reaction using a bright light.
Beware of previous eye injury, eye surgery or previous use of eye drops, all of which can give
misleading pupil responses.
A single, dilated, unreactive pupil is of critical significance in the setting of head injury or coma. It
may represent an expanding intracranial collection usually on the same side.
During CPR fixed dilated pupils are not a reason to discontinue CPR.
Glasgow Coma Score

An altered level of consciousness from any cause is best described using an objective scale, such as the
Glasgow Coma Score (GCS). Avoid non-specific terms e.g. stuporose or semi-conscious.
ADULT MODIFIED FOR CHILDREN

Finding Score Finding Score
Eye Opening: Eye Opening:
Spontaneous 4 Spontaneous 4
To speech 3 To speech 3
To pain 2 To pain 2
None 1 None 1
Best Verbal Response: Best Verbal Response:
Orientated 5 Coos, babbles 5
Confused 4 Irritable, cries 4
Inappropriate words 3 Cries to pain 3
Incomprehensible sounds 2 Moans or groans to pain 2
None 1 None 1
Best Motor Response: Best Motor Response:
Obeys commands 6 Normal spontaneous movement 6
Localises pain 5 Withdraws to touch 5
Withdraws to pain 4 Withdraws to pain 4
Abnormal flexion to pain 3 Abnormal flexion to pain 3
Abnormal extension to pain 2 Abnormal extension to pain 2
None 1 None 1
Painful stimuli should be applied to each limb and then centrally and the best response recorded.
When spinal injury is present, assess the patients reaction to pain above the level of the lesion e.g.
supraorbital pressure may cause only facial grimacing in a quadriplegic patient.
NOTE:
A patient can have a normal GCS of 15, but still have focal neurological signs.
A patient can have a normal GCS of 15, but still have a clouded conscious state.
This clouding of consciousness can be further quantified by using a more extensive mental state
examination.
AVPU scale
This is an abbreviated version of the Glasgow Coma Score:
A alert
V responds to voice
P responds to pain
U unresponsive
An AVPU score of P or U is equivalent to a GCS 8

Airway Protection
An airway is unprotected from aspiration when the normal protective reflexes are absent. This is most
commonly associated with a decreased level of consciousness. A Glasgow Coma Score of < 8 or an
AVPU of P or U is usually associated with an unprotected airway.
Signs of an airway unprotected from aspiration
GCS 8 (or AVPU of P or U)

absent gag / cough reflex
Protection of the airway is achieved by

o Posture
The patient may be placed head down and in the left lateral position if there are no concerns about a
possible cervical spine injury. A sucker should be kept nearby (if available).
o Endotracheal Intubation
Definitive airway protection is achieved by placing a cuffed endotracheal tube. However, this requires
the availability of specialised skills and equipment.

MEASURE
o Measure the patients temperature and finger-prick blood sugar level (BSL).
o These measurements can sometimes be the key to the diagnosis e.g. refractory seizures
caused by low BSL, or coma from hypothermia.
o If low BSL is present, it requires immediate treatment with 1g/kg of IV dextrose. In
children this is usually given as a 10% solution and in adults as a 50% solution. If IV
access or IV dextrose solutions are not available then high concentration glucose drinks
can be administered orally if the patient is conscious or via a nasogastric tube if not.
o Then re-measure the fingerprick BSL to ensure that the hypoglycaemia has resolved.
Patients who may be thiamine deficient (eg. alcoholics) require 100mg thiamine IV
(mixed in 10ml of saline) to be given immediately after the IV dextrose to prevent the
onset of an acute Wernickes Encephalopathy.
o There are various different methods for measuring a patients temperature and these
vary in their degree of accuracy and invasiveness.
o Oral, axillary, and rectal temperature measurement all have different degrees of accuracy
and different indications for their use. If the temperature measurement is of significant
importance, the rectal temperature is the most accurate.
o Of particular note are patients who are peripherally vasoconstricted, and whose
temperature measured peripherally may be falsely low.
o If significant hyperthermia or hypothermia is detected, commence cooling or heating
measures
MONITOR
If the equipment is available once the patient is stable it is important that they have ongoing monitoring of
their pulse, blood pressure, and if available ECG, SaO2 to detect any deterioration of their condition.
This process can be aided by the use of machines with alarms.
REASSESS
Before moving on to the next stage of the patients emergency management, it is important to go back to
the beginning of the initial stabilisation stage and run through each step, looking for any change in the
patients condition, and treating any new abnormalities which have developed. It is also important to note
that if the sequence has stopped at any point between Airway and Monitor then reassessment should
occur at that point commencing at airway again.

3. DIRECTED HISTORY AND EXAMINATION
Focus on the patients immediate illness.

Take a history and perform an examination on the organ system or systems which are involved with the
current problem.
4. COMMENCE SPECIFIC TREATMENTS
There may be other treatments which are time critical and which have not already occurred in the initial
stabilisation phase.
For example the administration of antibiotics to a septicaemic patient.
5. ONGOING CARE AND PATIENT HANDOVER
This can be a difficult and time consuming stage of the emergency management of a seriously ill patient.
The important elements of this stage are good communication with the staff that will be responsible for
the ongoing management of the patient and vigilance concerning repeated assessment of the patients
condition.

SEIZURES
Background Information
DEFINITION
Status Epilepticus is generally defined as:
A seizure lasting for more than 5 to 10 minutes.

OR
Two or more seizures without recovery of consciousness in between.
CAUSES
Similar list of causes to those of the Unconscious Patient. Status Epilepticus is most common in
infants and in adults over 60.
Some of the common age related associations are:
NEONATES: birth trauma, infections (malaria) and hypoglycaemia
CHILDREN: head trauma, fever, idiopathic epilepsy and congenital

lesions, CNS infections (malaria)
YOUNG ADULTS: sub-therapeutic anti-epileptic drug levels in known

epileptics, head trauma, alcohol withdrawal, drug
toxicity, malaria
MIDDLE AGE / ELDERLY: Cerebrovascular disease, alcohol withdrawal, malaria,

CNS tumour or trauma, cardiac disease, sub-therapeutic
anti-epileptic levels
CLINICAL FEATURES
These may be a combination of the features of:
1. THE CONDITION
Can have convulsive features (eg. clonic / tonic) or non-convulsive features (eg. petit mal
and psychomotor). In children beware of the subtle signs of ongoing convulsive seizures
(e.g. unresponsiveness with the eyes rolled back or deviated to one side, and without
twitching in the arms or legs).
2. THE CAUSE
For example, CNS infection (malaria) or trauma.
3. THE COMPLICATIONS OF THE SEIZURE

For example head trauma, musculoskeletal trauma, rhabdomyolysis, hyperthermia,
hypoglycaemia, hypoxia, aspiration pneumonia.
IMPORTANT POINTS
1. Repeated or prolonged seizures can cause brain damage from hypoxia,
hyperthermia, hypoglycaemia and lactic acidosis.
2. Status Epilepticus has average 22% mortality at 30 days and this is highest in the elderly.

SEIZURES
Treatment
TRIAGE
Place the patient in an area with access to maximum available resuscitation equipment.
Call for help.
Immediately commence their initial stabilisation.
INITIAL STABILISATION
1. POSITION PATIENT - lying flat in the left lateral position, unless the airway is being actively
treated, in which case place the patient on their back.
2. AIRWAY - keep patent:
While the seizure is in progress:

Do not force anything into the patients mouth. Try simple airway opening
manoeuvres, such as head tilt, chin lift, jaw thrust, and gentle airway suction. If
available, try inserting a Guedel-type airway or if the jaw is clenched, a
nasopharyngeal airway.
If there is a possibility that the cervical spine has been injured, provide in-line
immobilisation until the seizure has stopped and the airway has been made patent.
If available apply a hard cervical collar.
3. BREATHING
Assess the respiratory rate and effort. Respiratory effort is often inadequate during
the seizure and in the immediate post-ictal period and may require assistance. If the
equipment is available then use a bag-valve-mask attached to oxygen. If not then
mouth to mask may be feasible.
Check for cyanosis, respiratory rate and adequacy of chest movements. If not
requiring assisted ventilation, administer oxygen via a facemask.
Listen to the chest.
4. STOP THE SEIZURE
This is a key component of Airway and Breathing management.
A INITIAL SEIZURE CONTROL
BENZODIAZEPINES
Potent, rapid, usually act within 5 minutes.
Administer IV doses slowly to minimise respiratory depression effect.
Midazolam - IV dose - 0.05-0.1mg/kg (adult 3-7mg) boluses. Repeat to a

maximum of 20mg. Can be used IMI/ Intranasal/ Sublingual - useful if
difficult to establish IV access. Duration of action 15-30 minutes.
OR
Diazepam IV dose - 0.1-0.2mg/kg. Can be repeated twice. Duration of
action 15-30 minutes. Rectal (diazepam 0.5mg/kg) can be used. Do not
use IMI (erratic absorption and causes sterile abscesses).

B MAINTENANCE OF SEIZURE CONTROL AND PROPHYLAXIS
Consider using when:

seizures are ongoing, i.e. Status Epilepticus.
seizures are expected to be ongoing, eg. associated with head injury.
patient is to be paralyzed and ventilated (masks the presence of
seizures).
PHENYTOIN
Onset of action 20 minutes.
Usually given after control of seizures with benzodiazepines.

Loading dose 15-20mg/kg (even if already taking phenytoin) at
50mg/min. usually given after control of seizures with benzodiazepines.
Mix in 100ml of saline and give at no greater than 50mg/min.
(1mg/kg/min. in children) as hypotension may result.
Dont mix with dextrose as precipitation will occur.
OTHER DRUGS
Phenobarbitone 10-20mg/kg IV - onset of action 10-20 minutes.
Dilute 1:10 in saline or dextrose. Give at no greater than

50mg/min. (1mg/kg/min. in children) to avoid respiratory
depression.
Paraldehyde 0.4ml/kg (mixed with an equal volume of olive or mineral

oil) PR or 0.2ml/kg Deep IM (can be repeated but no further doses for
48 hours as has a variable half life.
If a plastic syringe used it must be administered immediately on drawing up
as paraldehyde will dissolve certain types of plastic.
5. REASSESS AIRWAY AND BREATHING

Repeat the airway opening manoeuvres above. Continue to assist ventilation if
required.
6. CIRCULATION
Measure PR, BP and capillary refill.
Attach to a cardiac monitor if available and assess the rhythm. Correct any
Insert an IV cannula if this hasnt already occurred.
If shock is present, give 10-20ml/kg of colloid or crystalloid rapidly through an IV pump
set.
7. DISABILITY - measure the Glasgow Coma Score and record pupil response. Consider
(where the equipment and skills are available) endotracheal intubation if Glasgow
Coma Score <8 and not rapidly improving. This is to protect the airway from aspiration.
There is often a transient decreased level of consciousness in these patients from a
combination of the post-ictal state and the effects of the anticonvulsant drugs that have been
given.
8. MEASURE - temperature and fingerprick BSL.
9. IF HYPOGLYCAEMIA IS PRESENT GIVE 50% dextrose 50ml IV (1ml/kg in children) and

recheck the fingerprick BSL.
If the patient is likely to be thiamine deficient (e.g. alcoholics) give thiamine, 100mg made up
to 10mls with saline IV.
10. MONITOR (IF AVAILABLE) Pulse Rate and rhythm, Respiratory Rate and pattern, BP.
11. REASSESS

DIRECTED HISTORY AND EXAMINATION
ASK ABOUT Event:
history from anyone available (witnesses, family, friends)
onset, description of seizures, duration, associated trauma
Symptoms:
prior to the seizure (e.g. fever, headache, personality change)
Past History:
previous seizure history
chronic illnesses
diabetes
drug ingestion history
LOOK FOR Subtle signs of ongoing seizures, especially in children

(e.g. unresponsiveness with the eyes rolled back or deviated to
one side, without twitching in the arms or legs).
Cause eg. Evidence of malaria, fever, neck stiffness, trauma, stroke,

drug/alcohol ingestion.
Complications e.g. head trauma, musculoskeletal trauma,

rhabdomyolysis, hyperthermia, hypoglycaemia, hypoxia, aspiration
pneumonia.
PERFORM A 12 lead ECG (if available) and urinalysis
TESTS Guided by the suspected cause and available tests
SPECIFIC TREATMENT
1. Antibiotics if meningitis is a possibility. May be given prior to lumbar puncture
2. Further IV glucose for hypoglycaemia.
3. Anti-malarials where malaria likely.
4. Specific antidotes if poisoning is suspected.
5. Treat specific complications (e.g. cool the patient if hyperthermic, give IV fluids for
dehydration or rhabdomyolysis).

ONGOING CARE
All patients who present with status epilepticus will require frequent and careful reassessment and
readjustment of their treatment.
If available, this should occur in a centre capable of ICU level care.
IMPORTANT POINTS
1. Stop the seizure as soon as possible.
2. Seizure control can be considered as part of the treatment of the airway and
breathing. The airway and breathing are difficult to treat whilst seizures are occurring
and need reassessment and treatment when the seizures have stopped.
3. Treat reversible causes e.g. hypoglycaemia.
4. Look for possible complications.

IMMEDIATELY LIFE THREATENING ASTHMA
AND SEVERE ASTHMA
DEFINITION
Asthma is a condition characterised by bronchial hyper-responsiveness and inflammation.
Immediately life threatening asthma is where respiratory arrest is imminent.
Severe asthma is not yet immediately life threatening, but may soon become so without
immediate treatment.
CLINICAL FEATURES
1. Signs of immediately life threatening asthma:
Extreme respiratory distress with marked dyspnoea, and use of the accessory
muscles of respiration.
silent chest
exhaustion
inability to speak
mental obtundation
relative bradycardia (a very late and ominous sign)
cyanosis
2. Signs of severe asthma:

respiratory distress with marked dyspnoea, wheeze, and use of the accessory
muscles of respiration
able to speak in single words only
PR > 120, SaO2 < 92% (on air)
3. The diagnosis is usually obvious, but occasionally upper airway obstruction, inhaled foreign
body, or left ventricular failure can mimic asthma.
4. Occasionally, acute deterioration in previously stable asthma can be due to other processes,
especially pneumothorax. The role of a chest X-ray in acute severe asthma is only to
exclude pneumothorax.
IMPORTANT POINTS
Left ventricular failure can mimic asthma.

IMMEDIATELY LIFE THREATENING ASTHMA
AND SEVERE ASTHMA
Treatment
TRIAGE
Place the patient in an area with access to maximum available resuscitation equipment. Call for help and
immediately commence their initial stabilisation.
1. POSITION PATIENT sitting up.
2. AIRWAY - keep patent.
3. BREATHING
Assess the respiratory rate and effort.
IF IN IMMINENT DANGER OF RESPIRATORY ARREST

(decreased level of consciousness, exhaustion, inability to speak)
Assist ventilation with a bag-valve-mask attached to oxygen.

Give:
Adrenaline 1:1,000 0.5mg (0.01mg/kg) IMI. Repeat in 5 minutes if the

patients condition has not improved.
OR
Adrenaline 1:10,000 1-5ml IVI over 5 minutes then an IV infusion of 0.1-
1.0g/kg/min.
Put 6mg in 100ml 5% dextrose - commence at 10ml/hr. This will give a

starting dose of 600g/hr or 0.16g/kg/min. for a 60kg adult.
AND
Enlist the help of the most senior clinician available.
Measure (if available) SaO2.

Check for signs of tension pneumothorax. If these are present, treat immediately with
a needle thoracostomy on the affected side.
IF NOT IN IMMINENT DANGER OF RESPIRATORY ARREST
GIVE NEBULISED SALBUTAMOL 5mg (1ml) and IPRATROPIUM 0.5mg (1ml) with the
nebuliser preferably driven by oxygen at 6L/min.
4. CIRCULATION
Measure PR, BP, capillary refill.
Attach to a cardiac monitor and assess the rhythm.
Insert an IV cannula.
5. DISABILITY - measure the Glasgow Coma Score and record a pupil response.
6. MEASURE - temperature, fingerprick BSL.
7. MONITOR (IF AVAILABLE) - BP, SaO2, ECG.
8. REASSESS

ASK ABOUT Event:
precipitating factors
duration and onset of current attack
treatment given so far and response to this
Symptoms:
cough
dyspnoea
wheeze
Past History:
normal medications and compliance
steroid usage
MEASURE PEFR can be measured but should not be used in distressed patients.
No particular measures are of use in the acute management.
TESTS Dont delay commencing treatment by performing tests

Chest X-ray - to exclude pneumothorax.
SPECIFIC TREATMENT
1. Continue nebuliser therapy according to response and side effects, rather than weight or
age of patient. Maximal therapy would be salbutamol 5mg (1ml) diluted with 3ml normal
saline given continuously (ie. refilled about every 5 minutes or earlier if empty) with
ipratropium (500g) added every 20 minutes.
2. If unresponsive to nebulizer therapy, give IV salbutamol at 5g/kg loading dose over 5-

10 minutes followed by an infusion at 5-20g/kg/hr.
Mix 10mg salbutamol in 500ml normal saline. An initial infusion rate of 25ml/hr will
give a dose of 8g/kg/hr for a 60kg adult.
Note: Intravenous salbutamol comes in different strength solutions and is

DIFFERENT to nebuliser solution. Check the information on the ampoules carefully.
Cardiac monitoring is necessary if available, although tachycardia rarely limits the

dose of salbutamol. Hypokalaemia is a common side effect of IV salbutamol and
may need treatment.
3. Hydrocortisone 2-4mg/kg IV up to a maximum of 200mg every 6 hours is necessary to

treat the airway inflammatory process.
4. Adrenaline infusion - use in acutely ill patients not responding to the above measures or
where salbutamol IV formulation is not available:
- see previous page for dosage and administration.

nd
5. Aminophylline can be used first line if salbutamol is not available or 2 line when other
therapies have failed.
6. Unlike most other forms of respiratory failure, intubation and ventilation should be regarded
as a last resort. It is technically difficult and associated with a high incidence of
complications (especially barotrauma as well as hypotension from air trapping) and a
significant mortality (10-30%).
7. Intubation and mechanical ventilation are indicated for apnoea, coma and end stage
clinical exhaustion. This should be performed by the clinician most experienced in airway
management.

Techniques of ventilation using low tidal volumes, low respiratory rates (e.g. 4-8/min.), long
expiratory times, and which result in higher PaCO 2 levels, reduce the risk of barotrauma and air
trapping.
1
Large volumes of IV fluid are often needed after intubation to treat hypotension (e.g. /2 - 1 litre of
colloid or crystalloid). Any mechanically ventilated asthmatic who deteriorates suddenly should
be presumed to have a tension pneumothorax until proven otherwise.
ONGOING CARE
1. All patients who present with the signs of immediately life threatening asthma or severe
asthma will require frequent and careful reassessment and readjustment of their treatment
2. If available, this should occur in a centre capable of ICU level care.
3. If signs resolve quickly with treatment and PEFR returns to > 60% of predicted, patients can
be admitted to a general ward.
IMPORTANT POINTS
1. Intubation and ventilation are regarded as a last resort. If required, it will

require involving the most senior available clinician preferably one with
anaesthetics / ICU skills and experience.
2. Treat promptly and aggressively.
3. If in doubt about severity, it is best to err on the side of caution and over-
treat the patient.

POISONING / DRUG OVERDOSE EMERGENCIES
Background information
1. Paediatric accidental ingestions comprise a significant number of poisonings. The

commonest age range is 1 to 5 years, with a peak at 2 years. Most poisonings in this age
group are non-drug eg. cleaning agents, cosmetics, plants, pesticides, and hydrocarbons.
2. The commonest drug ingestions in all age groups combined are chloroquine, kerosene, iron,
paracetamol, aspirin, and amoxycillin.
3. Recreational drug and alcohol overdose are commonest in adolescents and young adults.
4. Alcohol is a co-ingestant in a high percentage of adult overdoses. Methyl alcohol ingestion is

particularly dangerous.
5. Parasuicide / suicide attempts have the highest incidence in adolescent females.
6. Death rates from the various drug categories have a similar distribution to the frequencies of
drug ingestion.
7. In an alert patient the history of drug ingestion is generally reliable. The exceptions are
patients in Police custody, recreational drug users and those with high suicide intent.

CLINICAL FEATURES
The clinical features will vary, depending on the type of substance ingested. Many substances
will produce a recognisable symptom complex or toxidrome
COMMON TOXIDROMES
Toxidrome Symptoms Sources (Partial List)

Anticholinergic Dry skin, hyperthermia, thirst, Antihistamines, Phenothiazines
dysphagia, tachycardia, urinary Plants - Datura Lily, Belladonna
retention, dilated pupils, delirium, Mushrooms - certain species
hallucinations, seizures, confusion, Scopolamine, Atropine
behavioural disturbances, Tricyclic antidepressants
vasodilatation, respiratory failure,
cardiovascular collapse
Cholinergic Muscarinic (DUMBELS) Organophosphate insecticides
Defaecation, urination, miosis, Carbamate insecticides
bradycardia, emesis, lacrimation, Pilocarpine
increased secretions Mushrooms (certain species)
Nicotinic Betel nut
Tachycardia, hypertension, muscle
fasciculations, paralysis
Sympathomimetic CNS excitation, convulsions, Theophylline, caffeine,
hypertension, tachycardia amphetamines, cocaine,
ephedrine
Narcotic CNS depression, hypotension, Heroin, pethidine, morphine,
hypoventilation, miosis codeine, lomotil
Extrapyramidal Oculogyric crisis, rigidity, tremor, Phenothiazines, Butyrophenones
torticollis, opisthotonos
Haemoglobinopathies Headache, nausea, vomiting, Carbon monoxide
fatigue, respiratory distress, altered Methaemoglobin
level of consciousness
Metal fume fever Chills, fever, nausea, vomiting, Fumes of copper, iron, brass,
headache, fatigue, respiratory mercury etc. (metal oxides).
distress, muscular pain
Serotonin syndrome: Confusion, agitation, anxiety, SSRI anti-depressants, often at
a combination of an sweating, hyperthermia, therapeutic doses but in
acute organic brain myoclonus, hyperreflexia, rigidity, combination with serotinergic
syndrome, autonomic tremor. Other symptoms may drugs eg. pethidine,
dysfunction and include coma, seizures, blood
neuromuscular pressure changes, abdominal pain,
hyperactivity diarrhoea, mydriasis, shivering,
nystagmus

IMPORTANT POINTS
1. Suspect poisoning / overdose in any patient with an altered level of
consciousness.
2. Mixed ingestions are common, especially those involving alcohol.
3. The history of ingestion is generally reliable in an alert patient.
4. Always consider substances which patients may not think are harmful
eg. paracetamol, chloroquine.
5. Recognisable toxidromes may help identify the ingested substance.
6. Always consider the possibility of multiple drug ingestions, especially with

alcohol.

POISONING / DRUG OVERDOSE EMERGENCIES
Treatment
TRIAGE
Call for help.
1. POSITION PATIENT - supine if hypotension is present.
2. AIRWAY - keep patent - airway management is the cornerstone of the management of

patients with poisoning and drug overdose.
3. BREATHING
Assess the respiratory rate and effort. If inadequate, assist ventilation with a bag-
valve-mask attached to oxygen.
Measure Respiratory Rate and Pattern and (if available) SaO2. If < 95% and not
requiring assisted ventilation, administer oxygen via a facemask.
4. CIRCULATION
Attach to a cardiac monitor if available and assess the rhythm. Correct any
Take blood (if testing is locally available) for FBC, electrolytes and BSL.
If the patient has shock, give 10-20ml/kg of colloid or crystalloid rapidly through an IV
pump set.
5. DISABILITY - measure the Glasgow Coma Score and record a pupil response. If the GCS
is < 8 and not rapidly improving, consider endotracheal intubation to protect the
airway from aspiration. Beware of the poisoned patient who has ingested a substance with
sedative properties. These patients may rapidly lose consciousness and their airway
protective reflexes and then be at risk of aspiration. If narcotic overdose is suspected
because of the presence of pinpoint pupils, give 2-4mg IV of naloxone (0.1mg/kg in
children to a maximum of 2mg).
7. IF LOW BSL IS PRESENT - give 1ml/kg of 50% dextrose IV and recheck the fingerprick
BSL. Add thiamine 100mg IV / IM stat if chronic alcohol abuse is suspected.
8. MONITOR (IF AVAILABLE) - SaO2, BP, ECG.
9. PERFORM - 12 lead ECG, urinalysis.
10. REASSESS

ASK ABOUT Event:
from anyone available (patient, family, friends, witnesses)
time, amount and type of ingestion
treatment so far
history of events leading to the presentation (eg. social /
psychiatric stresses, child abuse / non-supervision / access to
medications)
NOTE: All patients who have attempted self harm should be

specifically assessed as to the degree of their suicidal intent.
Symptoms:
consistent with a toxidrome
Past History:
allergies
current medications
co-existing medical illnesses
psychiatric / social history
LOOK FOR 1. Specific toxidromes (see above)
2. Evidence of associated injuries eg:

head injury
rhabdomyolysis or compression syndromes if the patient has
been lying unconscious for a long period
pulmonary aspiration
IV needle tracks (should alert to the possibility of associated
HIV disease)
sepsis and signs of immunocompromise
TESTS (if available acute interventions will rarely be determined by blood drug levels)
1. For the Overdose:

Consider urgent serum drug level(s) if the history is
suggestive, the ingested drug can be measured and there is a
specific antidote or treatment strategy e.g. paracetamol, iron.
(Do not measure paracetamol levels until 4 hours
after the ingestion).
2. For the Complications:

CPK if rhabdomyolysis is a possibility
LFTs and coagulation profile if liver damage is a possibility
Chest X-ray for pulmonary aspiration
3. For Associated Injuries:

Head CT scan if there is a possibility of trauma.
Cervical spine X-ray if there is the possibility of trauma.

SPECIFIC TREATMENT
1. DECONTAMINATION
i) Use Personal Protective Equipment.

ii) Remove contaminated clothing.
iii) Wash skin and irrigate the patients eyes if contaminated.
iv) Gastro-intestinal decontamination (Options are dependent on equipment availability).
a) Emesis - There is no evidence that vomiting reduces absorption of the

poison, and it may increase the risk of aspiration. In particular, vomiting
should not be induced following ingestion of corrosives and
hydrocarbons, as it increases the risk of complications. It may have a
role in remote centres when the ingestion is within 1 hour, when no other
therapies are available (such as activated charcoal), and when the risks
of forced emesis are outweighed by the potential benefits of getting rid of
the poison.
b) Gastric Lavage There is a very limited role for gastric lavage

Gastric lavage is rarely required, and should only be considered if a life-
threatening amount of a substance that cannot be removed effectively by
other means (for example, iron), has been ingested within the
last hour. Gastric lavage is clearly unnecessary if the risk of toxicity is
small, or if the patient presents too late. The main risk is pulmonary
aspiration of stomach contents and trauma to the uncooperative patient.
Lavage should not be administered following ingestion of corrosives
since it is likely to increase the risk of perforation of the oesophagus and
stomach. It should also be avoided following ingestion of hydrocarbons
because of the risk of aspiration
The prerequisites for gastric lavage are:
Consent of the patient
Patient is conscious and able to protect the airway or intubated
Patient should have been adequately resuscitated and should
have a stable cardiovascular status
Gastric lavage should be performed by a qualified doctor and the
procedure MUST be explained to the patient. The patients pulse and
blood pressure should be monitored throughout the procedure.
Never use force to introduce the tube. Place the patient on left lateral
position and with the head tilted down. Insert a NG tube (36 to 40 French
gauge or 30 English gauge in adults and 24 to 28 French gauge in
children), introduce 200 to 300ml (10ml/Kg in children) of normal saline
0
or water (preferably warmed to 38 C, avoid water in children to prevent
hyponatraemia). Then remove the volume introduced before giving
further fluid.
If the patient becomes restless or if the blood pressure drops, abandon
the procedure. Give a dose of activated charcoal (50g) to an adult and
1mg/Kg to a child after the lavage (see below).
Activated charcoal may be useful in the first few hours after
ingestion for some poisons
Activated charcoal acts by adsorbing the poison and preventing it from
being absorbed.
Note: it is ineffective against alkalis, acids, heavy metals, iron, lithium,
toxic alcohols, and glycols and hydrocarbons such as kerosene. In the
case of hydrocarbons, charcoal may increase the risk of vomiting and
therefore aspiration. Activated charcoal should also not be given to
patients with ileus.

How to prepare activated charcoal
Mix 10 grams of charcoal with 100200 ml water
For adolescents and adults: give 10 gram doses every 20 minutes up to maximum 50 grams
(Children: give 5 grams every 20 minutes up to maximum 15 grams or 1 gram/kg whichever is
lower);
Can be administered via a nasogastric tube if the airway is protected and the patient is compliant.
Multiple doses (0.5g/kg 4 hourly) considered in overdoses such as

theophylline, carbamazepine, dapsone, digoxin, quinine, phenobarbital.
a) Whole Bowel Irrigation - achieved by using isotonic bowel preparation

solutions (eg. polyethylene glycol - Golytely or Glycoprep).
Indications:
ingestion of a sustained release preparation
ingestion of a substance not adsorbed by charcoal (iron)
Administer orally or via nasogastric tube and continue until effluent is clear.
Rate is 2L/hr for adults or 500ml/hr for children.
2. ANTIDOTES
Some poisons have specific antidotes. Commonly used antidotes are:
Poison Antidote
Carbon monoxide Oxygen
Narcotics Naloxone
Paracetamol N-Acetylcysteine
Organophosphates Atropine / pralidoxime
Iron Desferrioxamine
Beta Blockers Glucagon
Calcium channel blockers Calcium
Hydrofluoric acid Calcium
Benzodiazepines Flumazenil
Methaemoglobinaemia Methylene Blue
ONGOING CARE
All patients who present with poisoning or drug overdose, will require frequent and careful reassessment
until the signs of toxicity have resolved and there is no longer any risk to the patients airway, breathing,
or circulation.
1. Admit / transfer patients who:
require ongoing medical monitoring.
remain symptomatic from poisoning / drug overdose.
require ongoing antidote treatment or drug elimination therapy.
require ongoing psychiatric or social care.
2. For patients who dont require admission:
Non-intentional Ingestions (usually children)

Discharge home with appropriate counselling regarding safe storage and dispensing
of medicines and poisons.
Intentional Ingestions
Recreational ingestion - discharge home with follow-up drug and alcohol counselling.

IMPORTANT POINTS
1. The most common error in the management of poisoning / drug overdose
patients is inadequate management of the airway, breathing and circulation.
2. Emesis is no longer a standard part of the in-hospital management of

poisonings /overdoses
3. Gastric lavage is of no use in the majority of poisonings /overdoses.
4. Activated charcoal is most effective if given within an hour of drug ingestion.
5. All patients who have attempted self harm should be specifically assessed
as to the degree of their suicidal intent.

SNAKE BITE
BACKGROUND
PNG has several species of extremely venomous snakes and the incidence of snake bite in some
areas is as high as anywhere in the world. Snake envenomation is a cause of significant morbidity
and mortality in PNG.
Snake venom spreads by flow in the lymphatics. First aid using pressure immobilisation bandaging
restricts venom movement.
Definitive treatment is with antivenom.
CAUSES/CLINICAL SETTINGS
1. Snake bite and envenomation is common in PNG
2. The commonest snakes causing serious envenomation are the Papuan Taipan and the Death
Adder, but several other species are also implicated.
3. Victims of snake bite in PNG often present late and critically unwell.
4. Most bites are on the extremities and are therefore suitable for Pressure Immobilisation
Bandaging.
5. Antivenom is often hard to source and is expensive.
CLINICAL FEATURES
1. Patients showing signs of envenomation after snake bite should be treated with antivenom. In
the absence of antivenom, paralysis due to death adder envenomation can be treated with
neostigmine.
2. The major effects of PNG snake venoms are neurotoxicity and coagulopathy.
Rhabdomyolysis may also occur. Different snakes have different effects eg. Papuan
Taipan causes coagulopathy,neurotoxicity and rhabdomyolysis. Death Adders cause
neurotoxicity only.
3. Coagulopathy typically develops in the first few hours.
4. Neurotoxic effects tend to occur after the coagulopathy, usually beginning as cranial nerve
palsies (diplopia, facial and bulbar palsies with difficulty talking and swallowing) and then
descending limb and respiratory weakness.
5. Patients suspected of snakebite should have a 20 minute Whole Blood Clotting Test (20WBCT)
performed on presentation and at least once more 6 hours later. They should also be continually
assessed for signs of neurotoxicity, paying particular attention to signs of ptosis, ocular palsy
and difficulty swallowing and talking.

IMPORTANT POINTS
1. Envenomation after snake bite is common in PNG
2. The major systemic effects of envenomation by PNG snakes are coagulopathy,

neurotoxicity and rhabdomyolysis.
3. Most snake bites are on the extremities and can be treated initially with the pressure
immobilisation technique.
4. The 20WBCT is a simple and reliable test for coagulopathy in snake bite victims

SNAKE BITE
Treatment
TRIAGE
Call for help.
1. POSITION - of comfort, unless the patient requires active airway management, in which case
place the patient on their back.
3. BREATHING
Assess the respiratory rate and effort. If inadequate (from neurotoxicity causing profound
weakness), assist ventilation.
Administer Oxygen
Auscultate the chest.
4. CIRCULATION
Attach to a cardiac monitor if available and assess the rhythm.
Administer FIRST-AID using the pressure immobilisation technique. The principle is
to obstruct lymphatic flow and to inactivate the muscle pump. Do not cut, wash or apply
chemicals to the bite site. Put a clean pad over the bite site. Apply a crepe bandage
starting distally, and then moving proximally to cover the entire limb. Apply at the same
pressure as for an ankle sprain. Immobilize the limb with a splint and immobilize the
patient.
KEEP BANDAGE / SPLINT IN PLACE until antivenom and resuscitation equipment are
available and an IV line is in place.
Perform a 20WBCT using 10mls of whole blood in a clean glass bottle or tube. Allow to
stand for 20 minutes without being shaken, tilted or disturbed. At 20 minutes, tilt to one
side and observe whether clot is formed. Failure to clot confirms envenomation.
If the patient is very unstable do not wait for tests or results before commencing
antivenom. In these patients, immediately give poly-valent antivenom. Administer
the antivenom according to the instructions on the packet insert.
DO NOT REMOVE THE BANDAGE AT THIS STAGE.
5. DISABILITY - measure the Glasgow Coma Score and record a pupil response. If the GCS is
< 8, consider endotracheal intubation to protect the airway from aspiration. The airway
may also need protection if the patient has trouble swallowing (eg saliva) or talking due to
paralysis.
7. MONITOR BP. ECG and SaO2 if available.
8. REASSESS

ASK ABOUT Event:
time since bite
size of snake (envenomation less likely with very small snakes)
number of bites (multiple bites = severe envenomation)
type of first aid applied
treatment so far
alcohol intoxication (significant envenomation is more likely)
activity since bite
Symptoms:
of systemic envenomation (headache, nausea, vomiting, bleeding,
visual disturbance, difficulty speaking or swallowing, difficulty breathing,
limb weakness)
rate of onset (rapid onset correlates with significant envenomation)
Past History:
previous bites and anti-venom use, horse serum allergy, tetanus
immunisation status, other allergies, medications, general health
LOOK FOR
Bite site - may look like multiple scratches. (Dont remove the
bandage - cut a window in the bandage).
Bleeding at bite site or venipuncture sites, cranial nerve signs, motor
weakness.
MEASURE
Perform dipstick urinalysis (looking for blood from a coagulopathy and

myoglobin from rhabdomyolysis).
TESTS
The 20WBCT is the most important test to determine if there is
coagulopathy. If it is positive (blood fails to clot) it confirms
envenomation. If negative, the patient should still be observed and the
test repeated in 6 hours.
VDK may be useful if monovalent antivenom is available.
SPECIFIC TREATMENT
If the patient is very unstable: - leave the bandage in place
1. GIVE ANTIVENOM - read the instructions on the packet insert.

Polyvalent or monovalent? For the very unstable or dying patient, immediately give
polyvalent. If the snake is reliably identified or there is a positive VDK test and
monovalent is available it can be considered.
Is a pre-med. necessary? Yes. Use adrenaline 0.25mg sci in all patients receiving
antivenom. Consider steroids +/- antihistamines in those at high risk of allergic reactions.
What dose in children? The same as in adults.
2. IDENTIFY THE SNAKE

Dead snake if expert available.
Venom Detection Kit (if available, takes about /2 hour to complete the test).
1
3. SEEK ADVICE
PMGH

4. SUPPORTIVE TREATMENT
IV fluids, tetanus prophylaxis, ongoing coagulopathy is an indication for more
antivenom.
5. CONSIDER REMOVING BANDAGE only when the patient is clinically stable. In the initially
unstable patient this will usually only be once they have started receiving antivenom. If the
patient becomes clinically unstable or collapses after removal of the pressure immobilization
bandage, it should be replaced until more antivenom has been administered and clinical stability
is restored.
6. CONTINUE TO OBSERVE
Ensure coagulopathy is resolving with repeat 20WBCT after 6hours and other signs of
envenomation are improving. Consider further antivenom. In the absence of antivenom,
paralysis due to death adder envenomation can be treated with neostigmine.
The patient is clinically stable but has signs of coagulopathy, paralysis, or rhabdomyolysis
1. GIVE ANTIVENOM (see above). Polyvalent unless snake reliably identified or VDK positive.
2. CONSIDER REMOVING BANDAGE only when the patient is clinically stable. In the initially
unstable patient this will usually only be once they have started receiving antivenom. If the
patient becomes clinically unstable or collapses after removal of the pressure immobilization
bandage, it should be replaced until more antivenom has been administered and clinical stability
is restored.
3. CONTINUE TO OBSERVE:
Ensure coagulopathy (see above) is resolving and other signs of envenomation are improving.
Consider further antivenom. In the absence of antivenom, death adder envenomation can be
treated with neostigmine.
If patient has no signs of coagulopathy, paralysis or other signs of envenomation.
1. REMOVE THE BANDAGE and observe for symptoms or signs of systemic envenomation.
Reapply bandage if the patient becomes clinically unstable.
2. CONTINUE TO OBSERVE for signs of envenomation and repeat 20WBCT at 6 hours.
ONGOING CARE
1. Observe any patient with probable snake bite for 6-12 hours and perform 20WBCT at
presentation and at 6 hours.
2. If the patient is to be transferred leave the bandage and splint in place:

Take care to attend the airway, breathing and circulation during transport as all can be
compromised in the snake envenomation patient.

IMPORTANT POINTS
1. Don't remove the first aid bandage unless antivenom is available and an IV line
is in place.
2. Children require the same dose of antivenom as adults.
3. Probable snakebite victims should be observed for signs of envenomation for at least 6-
12 hours and have 20WBCT at presentation and at 6 hours
4. If snakebite victims require transfer to another facility for antivenom attention should be
paid to the airway, breathing and circulation during transport.
5. Paralysis due to Death Adder envenomation can be treated with neostigmine in the
absence of antivenom.

POST PARTUM HAEMORRHAGE
DEFINITION
Occurs in 20 - 30% of pregnancies and accounts for about 25% of maternal deaths.
PRIMARY - occurring within the first 24 hours post partum.
SECONDARY - bleeding greater than normal lochial loss occurring more than 24 hours post
partum and up to 6 weeks.
CAUSES
1. PRIMARY
Atonic uterus
Retained placenta or membranes
Uterine, cervical, or vaginal tears
2. SECONDARY
Infection (endometritis)
often present
usually anaerobes / streptococci / enterococci
Subinvolution
Others
lacerations eg. vagina, cervical
carcinoma of the cervix
choriocarcinoma
coitus
haematological disorders
placental polyps
Uncertain
in 50%

CLINICAL FEATURES
1. HISTORY
Primary Post Partum Haemorrhage

previous post partum haemorrhage
precipitous delivery
instruments used at delivery e.g. forceps or ventouse
ragged placenta or membranes noted at delivery giving a clinical suspicion of
retained placenta or partially retained placenta
Secondary Post Partum Haemorrhage

ragged placenta or membranes noted at delivery giving a clinical suspicion of
retained placenta or partially retained placenta
blood loss varies from an amount equivalent to normal menstruation to torrential
may have offensive and / or persistently red lochia
usually occurs 5-15 days post partum
fever (not always)
2. EXAMINATION
Primary Post Partum Haemorrhage

evidence of hypovolaemia
evidence of retained placenta, vaginal tear, cervical tear
Secondary Post Partum Haemorrhage

fever (not always)
offensive lochia
boggy, tender uterus of larger size than expected for stage of post partum (this is
not always present)
IMPORTANT POINTS
Primary post partum haemorrhage can be torrential and can be immediately

life-threatening.

POST PARTUM HAEMORRHAGE
Treatment
TRIAGE
Call for help.
1. POSITION PATIENT - lying flat.
3. BREATHING
Assess the respiratory rate and effort:

o If inadequate, assist ventilation with the maximal means available, preferably a
bag-valve-mask attached to oxygen.
o If not requiring assisted ventilation, administer maximal oxygen via a facemask.
4. CIRCULATION

Where available, attach to a cardiac monitor and assess the rhythm.
Insert 16G IV cannulae x 2.
Take blood for blood count, blood cultures, cross match (if testing and blood is
available).
Give Oxytocin 10 units IM/IV.
IF THE PATIENT IS SHOCKED:
Give 10-20ml/kg of N/Saline rapidly through an IV pump set.

If shock persists give a further bolus 10 20 ml/kg N/Saline and consider :
Ways to control haemorrhage
Blood transfusion if shock persists after the second bolus N/Saline
Get help early
1. CONTROL HAEMORRHAGE
2. Attempt to control haemorrhage by locating the source:
3. For Vaginal tears / Cervical tear
Apply sterile pad /pressure to obvious bleed point, put legs together.
Wait 5 minutes.
Repair with sutures to achieve haemostasis.
4. For bleeding from above the Cervical Os :
Consider getting help early (most senior Obstetric clinician available)

Empty the Bladder (Catheterise if necessary)

a) PLACENTA NOT DELIVERED:
Palpate Uterus
If Uterus hard, deliver placenta with controlled cord traction.
If Uterus soft give further Oxytocin 10units IV/IM.

Massage the uterus until it is hard.
Attempt to deliver the Placenta with controlled cord traction.
If unsuccessful and bleeding continues, remove placenta manually.
If unable to deliver or remove the Placenta, seek urgent help.

Consider: Oxytocin 40 units in 1000mls N/Saline over 30-60 minutes.
b) PLACENTA IS DELIVERED:
Placenta incomplete (or unavailable for inspection)

Remove placental fragments.
If unable to deliver or remove the Placenta, seek urgent help.

Consider: Oxytocin 40 units in 1000mls N/Saline over 30-60 minutes.
Placenta complete:
Massage the Uterus to express any clots.
If Uterus remains soft give Oxytocin 10 units IM/IV.
Continue massaging Uterus until it is hard.
OTHER OPTIONS
MECHANICAL Compression
Uterine massage
Bimanual compression
Aortic compression
CHEMICAL
Oxytocin 10 units IV or IM stat. Then 40 units in 1000mls N/Saline

over 30-60 minutes.
OR
Ergometrine 0.5mg IV stat.
OR
Misoprostol 600mcg Sublingual.
OPERATIVE
Senior clinical obstetric staff must be involved early. Haemorrhage
control may involve a range of interventions, from simple suturing to
total hysterectomy.
5. MEASURE BSL / Temperature.
6. MONITOR - ECG, SaO2, BP, and PV loss.
7. REASSESS Focus on PR, BP and PV loss.

IF THE PATIENT IS NOT SHOCKED:
5. MEASURE BSL / Temperature.
6. MONITOR - PR, BP, and PV loss.
7. REASSESS

ASK ABOUT EVENT:
Time since delivery

Heavy Bleeding is defined as:
o Pad/ Cloth soaked < 5 minutes
o Constant trickling of blood
o Bleeding > 250 mls since delivery
o Delivery out of hospital and still bleeding
Volume loss (pad usage, patients estimate, symptoms of
hypovolaemia)
Fever, pain
Offensive or persistently red lochia
Previous PPH
Multiparity
DELIVERY:
Traumatic, use of instruments

Incomplete placenta or membranes
LOOK FOR
Vaginal examination for nature and volume of loss,
Products in the os, tenderness and size of uterus.
Take cervical and vaginal swabs for microculture.
SPECIFIC TREATMENT
1. Antibiotics to cover:
Aerobic and anaerobic Streptococci sp.

Anaerobes
Occasionally Staphylococcus sp. or Mycoplasma hominis
Eg. Ampicillin 1g every 8 hours IV (if not allergic)

AND
Metronidazole 500g every 12 hours IV
CONSIDER
Gentamycin 5mg/kg
2. Consideration of Curettage.
3. Analgesia - small increments of IV narcotics.
Eg. Morphine 2.5mg increments IV titrated to pain

FURTHER CONSIDERATIONS
1. Adequate support for the baby if maternal admission is required.
2. Ultrasound if available may be useful in identifying presence and volume of retained
placenta.
ONGOING CARE
1. Admit all primary post-partum haemorrhages.
2. Secondary haemorrhages can be discharged if:
Lochia less than normal menstruation

Vital signs normal
No tenderness nor bogginess of uterus
Adequate access to hospital
No social imperative to admit eg. failure to cope with baby
3. Consider retrieval/ High Dependency options if large volume blood loss.
IMPORTANT POINTS
Heavy postpartum bleeding is ANY ONE of the following:

Pad/ Cloth soaked < 5 minutes
Constant trickling of blood
Bleeding > 250 mls since delivery
Delivery out of hospital and still bleeding
For unstable patients with a primary post partum haemorrhage, the control of
the haemorrhage may need to be a combination of mechanical, chemical
and operative measures.

APPENDICES
GLASGOW COMA SCALE
Spontaneous 4
EYE To speech 3
OPENING To pain 2
None 1
Orientated 5
BEST Confused 4
VERBAL Inappropriate words 3
RESPONSE Incomprehensible sounds 2
None 1
Obeys commands 6
BEST Localises pain 5
MOTOR Withdraws to pain 4
RESPONSE Abnormal flexion to pain 3
Abnormal extension to 2
pain
None 1

AVPU Scale
The AVPU scale is a quick way of assessing a patients level of consciousness. It relates to the
level of stimulus required to get a response of any type (Eyes, Motor or Voice) from a patient.
A (Alert) = Alert fully awake (not necessarily

orientated)
V (Voice) = Not alert but responds in some way to

verbal stimuli
P (Pain) = Not alert, no response to voice but

responds to painful stimuli.
U (Unresponsive) = No response to any stimulus.

THE GOLDEN RULES OF INTUBATION
1. You dont need an ET tube in place

to keep an airway patent or to
oxygenate a patient.
2. Dont give a paralysing drug to a

patient unless you are sure you will
be able to ventilate and oxygenate
them if the intubation is
unsuccessful.
3. All intubations are difficult for

inexperienced operators.
4. Have a back-up plan ready for

failed intubation before attempting
intubation.

CORMACK-LEHANE
LARYNGOSCOPY GRADES
Grade I - Glottis can be fully seen.
Grade II - Glottis can be partly exposed only (anterior commissure cannot be seen)
Grade III - Glottis cannot be seen (corniculate cartilages only can be seen)
Grade IV - Neither glottis nor corniculate cartilages can be seen.

MALLAMPATI CLASSIFICATION
Class I - faucial pillars, soft palate, uvula visible= likely CL grade 1 view of
larynx
Class II - faucial pillars, soft palate visible.

- uvula masked by base of tongue.
Class III - soft palate only visible.
Class IV - soft palate not visible. = likely CL grade 3 or 4 view of larynx.

An approach to a patient who has shock and
where the cause isnt immediately obvious
BACKGROUND:
If a patient has shock, the cause is usually apparent after considering the clinical setting, the vital
signs, and the patient history.
However, in some patients this is not the case.
Also, some patients can have more than one cause of shock coexisting.
However, in practical terms, it is useful to consider such situations with the following simple questions and
interventions:
a) Volume loss?
i) Any bleeding points?

If yes - control bleeding or arrange for the bleeding to be controlled (call a surgeon).
rd
If no - assess for non-bleeding fluid losses V and D, 3 space losses eg. pancreatitis, polyuria.
ii) Volume replacement IV access and fluids.
If not volume loss..

b) Pump malfunction?
Look for evidence of cardiogenic shock / PE / tension pneumothorax in the clinical context (chest
pain, SOB, abnormal ECG, LVF, clinical signs or context of pneumothorax, etc.)
If so then
i) Fluid bolus (IV access and fluid bolus - unless in obvious acute pulmonary oedema).
ii) Relieve obstructions (release tension pneumothorax / fibrinolytics for PE)
iii) Improve contractility and output inotropes / vasopressors.
If not pump malfunction..

c) Vasodilatation?
Sepsis or Anaphylaxis can cause this.

The clinical context should give clues to which of these is the cause.
However, irrespective of which, the approach is -

i) Fill the vascular space (IV access and fluid bolus)
ii) Support cardiac function inotropes / vasopressors
iii) Decrease vasodilatation vasopressors
In anaphylaxis Adrenaline as inotrope and vasopressor
In sepsis - Noradrenaline
iv) Treat the cause Anaphylaxis antihistamines H1/H2, Steroids
- Sepsis antibiotics (time critical), drain pus if there is any, debride
necrotic material if there is any.
If its none of the above is it shock? Consider neurogenic shock.

Triage of the Sick Child
A Arousal, Alertness, Activity
B Breathing Difficulty
(rate, effort, grunting)
C Colour (pallor)
and
Circulatory impairment
(mottling, capillary return, pulse,
BP)
D Decreased Drinking
(< half the usual amount in the last
24 hours)
and
Decreased output
(< 4 wet nappies in the last 24 hours
for infants).
PAEDIATRIC RESUSCITATION GUIDE
IMPORTANT The following table provides approximate estimates for equipment sizes
and drug doses, based on age and weight. It is particularly useful when
pre-notification occurs so that all team members can refer to it. ALWAYS
check actual age and weight on arrival. Similar information can be found
or checked using the Broselow Tape, the NETS Calculator, the NSW Child
Health Network Paediatric Resuscitation Cards or Frank Shanns Drug
Doses book.
PATIENT NAME
AGE (years)
WEIGHT (kg)
Estimating weight by age:
Neonate = 3kg nb. Estimates good for
Six months = 7kg pre-notification.
Twelve months = 11kg Check actual weight or
Broselow weight
Age < 9 years = 2 x age + 9
Age > 9 years = 3 x age
AIRWAY WITH C-SPINE CONTROL

Guedels = incisor to angle of jaw
Nasopharyngeal = nares to tragus
NG / OG / ETT sucker size = 2 x ETT
Laryngeal Mask size 0 5 kg 1
5 10kg 1.5
10 20kg 2
> 20kg 2.5
Uncuffed ETT size* = age/4 + 4
Oral ETT length at lips* = age/2 + 12
Nasal ETT length at nares = age/2 + 15
* if age < 1 year ETT size Oral length
Neonate 3 9
Six months 3.5 10
Twelve months 4 11
BREATHING WITH OXYGEN
hand ventilate if less than 20kg
chest tube (ICC) = 4 x ETT
paediatric circuit required
CIRCULATION WITH BLEEDING
CONTROL
stop bleeding with direct pressure / splints
fluid bolus = 20ml / kg N/Saline
packed cells bolus = 10-20 ml/kg
Adrenaline = 0.1ml/kg of l in 10,000
DC shock = 2 / 4 joules per kg
urinary catheter (IDC) = 2 x ETT

DISABILITY WITH D. E. F. G.
Check AVPU and bedside blood sugar
Dextrose dose = 5ml/kg of 10% dextrose
EXPOSURE WITH ENVIRONMENT
CONTROL
Check temperature & expose / log roll
Paracetamol bolus 20mg / kg PO/PR
Overhead heater
BASIC RSI DRUGS
Oxygen 15L NRB O2
Atropine 20 microgram / kg (min. 100 max 600)
Thiopentone 1 - 3mg / kg (higher doses only if stable)
Suxamethonium 1.5 - 2mg / kg
Vecuronium 0.1mg / kg
Morphine infusion 50mg in 50mls NS start at 0.05
0.1mg/kg/hr
Midazolam infusion 50mg in 50mls NS start at 0.05 -
0.1mg/kg/hr
BASIC ANALGESIA
Paracetamol - 20mg/kg PO/PR bolus
- 10-15mg/kg q 4hr
- maximum 90mg/kg/day short-term
Paracetamol/codeine in 120mg/5mg in 5ml
- 0.6ml / kg
- calculated on paracetamol dose
Morphine - 0.1mg/kg IVI / IO divided doses every 5min
- avoid if < 3 months
BASIC ANTIBIOTICS (severe infection)
Ceftriaxone 100mg/kg (max 2g) daily
Penicillin 60mg/kg(max 1.8g) q 4hr
BASIC ANTI-SEIZURE
Midazolam 0.1 0.15mg/kg IV/IMI /IO
Midazolam 0.5mg/kg buccal
Phenytoin 20mg/kg (max 1g) over 30 mins in NS
Phenobarb 20mg/kg (max 1g) over 30 mins in NS
References *Drug Doses, Frank Shann

th
* APLS 4 Edition
* NSW Child Health Network, Paediatric Resuscitation Card
* Broselow Tape

PAEDIATRIC PARAMETERS
NORMAL VALUES
Age Weight Heart Rate Respiratory Rate BP Systolic
(kg) (per min) (per min) (mm Hg)
Premature 1 145 <40 42 + 10
Newborn 2-3 125 60 + 10
1 month 4 120 24-35 80 + 16
6 months 7 130 89 + 29
1 year 10 130 20-30 96 + 30
2-3 years 12-14 120 99 + 25
4-5 years 16-18 100 99 + 20
6-8 years 20-26 100 12-25 105 + 13
10-12 years 32-42 75 112 + 19
>14 years 50 70 12-18 120 + 20
PROCEDURAL VALUES
ET Tube
Age Weight Laryngo- ID+ Length at Suction Chest Urinary NG Tube

(kg) scopy (mm) Nose Catheter Tube Catheter
Blade (cm) (Fr) (Fr)
Premature 1 0 2.5 10 6 10 5 (feeding)

Newborn 1-2 1 3 11 6-8 10-12
Newborn 2-3 3 12 3.5-5 Fr
1 month 4 3.5 13 8 feeding 5-8 (feeding)
6 months 7 3.5 14 tube
1 year 10 1 4 15 8-10 16-20 8
2-3 years 12-14 4.5 16 10 20-24
4-5 years 16-18 2 5-6 17 20-28 10
6-8 years 20-26 6-6.5 18
10-12 32-42 2-3 7 20 12 28-32 8-14 Fr 10-12
years
>14 years 50 3 7.5-8.5 24 32-42 Foley >12

Empiric IV/IM antibiotics for emergency management.
Note:
If the above antibiotics are not available, Chloramphenicol may be an alternative in some
circumstances.
Intravenous dose = 1 g (adult) or (child) 20- 25 mg/kg up to 1g, 6-hourly.
Emergency antimalarial treatment.

ADDITIONAL SKILLS
Femoral Vein Cannulation.
Indications.
When attempted cannulation of other veins has been unsuccessful.
Contraindications.
Ambulatory patient (Ambulation increases the risk of catheter fracture and migration.)
Venous injury (known or suspected) at the level of the femoral veins or proximally (ie, iliac veins
or inferior vena cava)
Distortion of anatomy due to local injury or deformity

Absence of a clearly palpable femoral artery
Procedure
Feel for the femoral artery in the groin at the mid-inguinal point (midway between pubic symphysis and
anterior superior iliac spine in line with mid-clavicular line). The femoral vein lies 1cm below and 1 cm
medial to artery at this point. Insert the needle at this point at an angle of 20-30 to the skin, and advance
in the direction of the patients head, maintaining negative pressure on the syringe until the vein is
entered and blood is aspirated

Chest tube (Intercostal Catheter) insertion
Indications:
pneumothorax:
o Tension
o pneumothoraces require immediate needle decompression followed by chest tube Small
pneumothoraces (rim of air less than 3 cm between lung and chest wall) may resolve
spontaneously or require only simple aspiration.
o Any intubated patient with a pneumothorax will require a chest tube.
haemothorax
haemopneumothorax
acute empyema.
Contraindications:
no absolute contraindications if placed emergently (e.g. in a patient with tension pneumothorax).
Equipment:
sterile gloves and sterile towels or drapes
antiseptic
lignocaine with adrenaline, 5-10 ml syringe, 23-25 gauge needle
scalpel
curved forceps/clamp
chest tube and underwater-seal drainage system, or one-way valve device and drainage bag
suture material (0 or 1-0 sutures required to anchor tube), needle driver, large curved artery
forceps
dressing material.
Procedure:
1. Some patients may require sedation and large amounts of analgesia for this procedure, as it can
be quite painful.
2. Position the patient lying face up with arm of the involved side raised over their head. If the
patient is unable to lie down due to respiratory distress, they may sit up in a bed or chair.
Supplemental oxygen may be helpful.
3. Choose the site, usually the fifth or sixth intercostal space at the midaxillary line. In order to avoid
damage to vital organs, you should stay within the triangle of safety defined inferiorly by the
nipple line in men or the base of the breast in women, anteriorly by the border of the pectoralis
major muscle, and posteriorly by the latissumus dorsi muscle. The apex of the triangle should be
just below the axilla.
4. Caution should be exercised throughout the procedure as broken ribs can easily pierce your
gloves. Double-gloving can help prevent this.
5. Prepare the skin with antiseptic.
6. Using lignocaine, infiltrate the skin and muscle. Note the length of needle needed to enter the
pleural cavity; this may be useful later when you are inserting the drain.

7. Aspirate fluid from the chest cavity to confirm your diagnosis.
8. Make a 3-4 cm horizontal incision just above the rib to avoid damaging the vessels under the
lower part of the rib.
9. Use more lignocaine to anaesthetize the intercostal tissues and pleura at the site of insertion.
10. Use blunt dissection to penetrate through the intercostal tissue to the pleura: insert the closed
clamp over the top of the rib and once past, open and spread to dissect, slowly enlarging the
opening and proceeding inward. This will eventually create a tunnel through which the tube may
be inserted.
11. A finger must be inserted into the tunnel to confirm that it has penetrated through to the pleural
space. Sweep the finger around to make sure you cannot feel the liver or spleen.
12. Use the same forceps to grasp the tube at its tip and introduce it into the chest. Never use a
sharp instrument to introduce the tube. For pneumothorax, angle the tube up; for pleural effusion,
angle down and towards the back. Be sure to insert the tube far enough that all drainage holes
are inside the pleural space.

13. Close the incision with interrupted skin sutures, using one stitch to anchor the tube. This can be
done by leaving the ends of that suture very long and wrapping and tying the ends firmly around
the tube several times. Leave an additional suture untied adjacent to the tube for closing the
wound after the tube is removed. Apply a gauze dressing. Further secure the tube with adhesive
tape.
14. Connect the tube to the underwater-seal drainage system and mark the initial level of fluid in the
drainage bottle. Alternatively, a one-way valve device and drainage bag may be used.
15. Routine administration of antibiotics to prevent infection is not necessary; however there may be
some benefit in the setting of penetrating chest injuries.
Aftercare and removal:

Place a pair of large artery forceps by the bedside for clamping the tube when changing the
bottle. The drainage system is patent if the fluid level swings freely with changes in the
intrapleural pressure. Persistent bubbling over several days suggests a bronchopleural fistula and
is an indication for referral.
Change the connecting tube and the bottle at least once every 48 hours, replacing them with
sterile equivalents.
If there is no drainage for 12 hours, despite your milking the tube, clamp the tube for a further
six hours and X-ray the chest. If the lung is satisfactorily expanded, the clamped tube can then be
removed.
To remove the tube, carefully remove the dressing. Paracetamol given beforehand will reduce
discomfort during the procedure. Clean the skin with antiseptic. Hold the edges of the wound
together with fingers and thumb over gauze while cutting the skin stitch that is anchoring the tube.
Ask the patient to inhale and valsalva, and withdraw the tube rapidly as an assistant ties the
previously loose stitch.
Complications:
re-expansion pulmonary oedema (this may be prevented by draining less than 1.5 L of fluid at
once)
chest tube malposition, e.g. subcutaneous placement
lung parenchyma perforation/laceration
diaphragmatic perforation
recurrent pneumothorax
empyema.

Limb pressure immobilization following a snakebite
Indications:
Bites by cobras, king cobras, kraits, sea snakes, taipans, and other elapids may lead, on rare
occasions, to the rapid development of life-threatening respiratory paralysis. This paralysis might
be delayed by slowing down the absorption of venom from the site of the bite.
Contraindications:
viper bites may increase local effects of necrotic venom.
Equipment:
bandage
material for rigid splint.
Procedure:
1. Ideally, an elasticized, stretchy, crepe bandage, approximately 10 cm wide and at least 4.5
metres long should be used. If that it not available, any long strips of material can be used.
2. The bandage is bound firmly around the entire bitten limb, starting distally around the fingers or
toes and moving proximally. The limb should then be splinted and the patient kept still.
3. The bandage is bound as tightly as for a sprained ankle, but not so tightly that the peripheral
pulse (radial, posterior tibial, dorsalis pedis) is occluded or that a finger cannot be slipped
between its layers.
Complications:
release of a tight tourniquet or compression bandage may result in the dramatic development of
severe systemic envenoming.

NEEDLE CRICOTHYROIDOTOMY / TRANSTRACHEAL JET INSUFFLATION
This is a technique for achieving oxygenation. It does not provide adequate ventilation.
It is not possible to ventilate a patient with a self-inflating bag attached to a needle
cricothyroid-otomy. Its main role is to buy time in which to attempt a surgical airway big
enough to ventilate the patient through.
It is a temporary emergency surgical airway, which is especially useful in children < 8

years whose airways are too small for other types of surgical airway. It is most
commonly used in severe maxillofacial trauma, but can also be used in the setting of an
upper airway obstruction from any cause.
Technique
Inform the patient / parents if possible.
Local anaesthesia using 1% lignocaine with adrenaline. This is infiltrated into the skin
overlying the cricothyroid membrane and on down to the membrane itself. Aspiration
of air will confirm the needles passage beyond the membrane and into the trachea.
With a 5ml syringe attached to the cannula and aspirating as you go, advance the
cannula tip through the inferior part of the cricothyroid membrane aiming caudally.
When air is aspirated freely, advance 1 to 2mm further, stop and slide the cannula
sheath off the needle while holding the needle still. Remove the needle, leaving the
cannula sheath in place.
A 3-way stopcock or Y connector is used to connect the cannula to oxygen tubing,
which is in turn connected to the oxygen source.
In adults, the oxygen flow rate is set at 15 L/min.
In children the flow rate is initially set at the childs age in years.
Oxygenation occurs by occluding the open end of the stopcock or Y-connector or 1
second. If this does not cause the chest to rise, the oxygen flow rate should be
increased by increments of 1 litre/min and the effects of the 1-second inspiration
reassessed.
Exhalation is passive by unblocking the Y-connector or stopcock for 4 seconds.

This can usually occur even in situations of partial airway obstruction. However, if this
is not occurring as evidenced by the chest wall not falling again, then additional
needles may need to be placed through the cricothyroid membrane to allow
exhalation.
The patients neck should be observed for swelling from injection of gas into the
tissues.
Secure the cannula to the neck.
Arrange for a formal tracheostomy.
NOTE: Sometimes direct puncture of the trachea (ie. below the level of the cricothyroid
membrane) is required if the patient is a very young baby (which makes palpation
of the cricothyroid membrane impossible) or if a foreign body is thought to be
below the level of the cricoid ring.
Complications
Malposition
subcutaneous emphysema
haemorrhage
Injury to nearby structures
vocal cords
cricoid cartilage
trachea
carotid arteries
vagal / recurrent laryngeal nerves
jugular veins
oesophagus
Barotrauma
especially in infants or in patients with complete upper airway obstruction
Infection

Advantages
Less complications than other surgical airways
Easier than other surgical airways
Requires minimal surgical skills
Can be used in young children
Disadvantages
Does not provide a definitive airway
Does not provide adequate ventilation
Exposes the lungs to potentially high pressure

CRICOTHYROIDOTOMY - Surgical
Indications:
When endotracheal intubation has failed and the patient cant be ventilated with a bag-valve-
mask (face or laryngeal)
When the face and/or airway are severely traumatised or burnt and other measures to keep the
airway patent have failed or are not possible or appropriate
Relative Contraindications:
Inexperienced operator
Combative patient
Overlying infection
Distorted local anatomy
Bleeding disorder
Complications Surgical Cricothyroidotomy

Malposition
subcutaneous emphysema
haemorrhage
injury to nearby structures (as above)
Haemorrhage
Failure and resultant hypoxia
Infection

Advantages Surgical Cricothyroidotomy
Provides a definitive and stable airway useable for any application
Simpler and safer than a tracheostomy
Rapid
Disadvantages of Surgical Cricothyroidotomy

Landmarks are often difficult in the clinical settings in which it is needed
Needs some degree of surgical skill
Is not recommended in a child < 8 years old (cricothyroidotomy with tracheal jet
insufflation are recommended for these patients)

ELSI Core Manual April 2012

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EMERGENCY CARE MANUAL

For the emergency management of seriously ill patients in

Copyright 2012 Emergency Life Support (ELS) Course Inc.

Emergency Life Support (ELS) Course Inc. 2012

Emergency Life Support (ELS) Course Inc. 2012

Emergency Management of the Seriously Ill Patient

Initial Stabilisation ..................................................................................................................................8

Positioning of the Patient ......................................................................................................9

Emergency Life Support (ELS) Course Inc. - 2012 1

Post Partum Haemorrhage

Glasgow Coma Scale .......................................................................................................... .... 68

AVPU Scale .............................................................................................................................69

The Golden Rules of Intubation ................................................................................................ 70

Cormack-Lehane Laryngoscopy Grades .................................................................................. 71

Mallampati Classification .......................................................................................................... 72

The Approach to the undifferentiated case of shock ................................................................ 73

Triage of the Sick Child ............................................................................................................ 74

Paediatric Resuscitation Guide ................................................................................................ 75

Empiric Antibiotics for Emergency Management......................................................................78

Emergency Anti-malarial Treatment.........................................................................................78

Oxygen Cylinder Size and how long they will last....................................................................79

Femoral vein Cannulation ......................................................................................................... 80

Intercostal Catheter (Chest Tube) insertion ............................................................................. 81

Limb Pressure and Immobilisation ........................................................................................... 84

Needle Cricothyroidotomy/Transtracheal Jet insufflation ......................................................... 85

2 Emergency Life Support (ELS) Course Inc. - 2012

The Royal Flying Doctor Service of Australia

Drug Doses, Frank Shann

APLS 4th Edition

NSW Child Health Network, Paediatric Resuscitation Card

Editors 2nd Edition:

Andrew Bezzina, MB BS, DipRACOG, FACEM

Phil Hungerford, MB BS, FACEM

John Kennedy MB BS, FACEM,

POSITION THE PATIENT - optimally for the clinical circumstance.

a) No cardiac output found - immediately commence Basic Cardiac Life Support

4 Emergency Life Support (ELS) Course Inc. - 2012

Triage Categories Action required

AIRWAY AND BREATHING

ASSESS AND TREAT

CIRCULATION (SHOCK or heavy BLEEDING)

ASSESS AND TREAT

ASSESS AND TREAT

Emergency Life Support (ELS) Course Inc. - 2012 5

Severe abdominal pain and abdomen hard on

Any problems with breathing

These patients should be moved to the front of the queue

6 Emergency Life Support (ELS) Course Inc. - 2012

This scale has five levels of acuity:

TRIAGE CATEGORY TREATMENT ACUITY

Seriously ill patients are usually assigned a triage category of either 1 or 2.

The two components of Emergency Department triage decisions are:

Emergency Life Support (ELS) Course Inc. - 2012 7

The components of the initial stabilisation stage are:

Positioning of the Patient as appropriate to the clinical circumstance

Airway simultaneous assessment and treatment

Breathing simultaneous assessment and treatment

Circulation simultaneous assessment and treatment

Disability simultaneous assessment and treatment

Measure the patients temperature and blood sugar level

Monitor the patient appropriately

These components are dealt with in detail on the following pages.

8 Emergency Life Support (ELS) Course Inc. - 2012

3. A Child with Partial Upper Airway Obstruction