adult emergency response guidelines - · pdf filethe adult emergency response guidelines is a...

AAdduulltt EEmmeerrggeennccyy RReessppoonnssee GGuuiiddeelliinneess Instructions & Abbreviations

Standing Orders Policy

DRS ABCD – Basic Life Support Flow Chart

Rapid Assessment Guide for Emergency Response

Dyspnoea & Cyanosis

Disorganised Speech / Behaviour

Coma / Altered Level of Consciousness

Acute Asthma

Acute Dystonic Reaction

Anaphylaxis

Chest Pain

Haemorrhage / Hypovolemia

Hypoglycaemia

Meningococcal Disease

Opioid Overdose

Status Epilepticus

Stab Wounds

Suicide Attempt

2

Version Control The Adult Emergency Response Guidelines is a version controlled

document. Version status, amendments and the distribution list are

given below

1. BUILD STATUS:

Version Date Author/s/Editor

Reason Sections

1 2003 Clinical and Nursing Services

Original

2 2009 Clinical and Nursing Services

Review All

Amended 2010 Clinical and Nursing Services

Update to Midazolam Standing Order

Status Epilepticus


Update of DRS ABCD from Australian Resuscitation Council

DR ABCD


Update to Benzylpenicillin (Sodium) Standing Order

Meningococcal


Removal of Hartmanns Solution from Standing Orders

Haemorrhage/ Hypovolemia


Removal of Hartmanns Solution from Standing Orders

Stab Wound


Updated as per PD2011_037 NSW Chest Pain Pathway

Chest Pain

3

2. DISTRIBUTION:

Copy No Version Issue Date Issued To

2 February 2011

All Justice Health Emergency Response Equipment Packs

4

IInnttrroodduuccttiioonn

The Emergency Response Guidelines have been developed to guide the clinical practice of nurses working in Justice Health and Forensic Mental Health Network. It is important to note that the Emergency Response Guidelines contain information that has been assessed as being pertinent to the Correctional Environment. The Emergency Response Guidelines have been developed for Registered Nurses to assist in the assessment, management and referral process for general emergency situations. Information contained has been developed in accordance with the Justice Health and Forensic Mental Health Network Adult Standing Orders.

The Emergency Response Guidelines have been developed in consultation with the Primary Health Clinical Stream. Every effort has been made to ensure that the information contained in the package meets evidence based best practice standards.

The Emergency Response Guidelines are to be placed in both the Airway Management Backpack and the First Aid Bag in each Health Centre for reference when attending to an Emergency response situation.

For information related to medications, Registered Nurses should refer to the MIMS, for verification of indications, dosages and possible side effects of medications administered.

This document is a formal publication of Justice Health and Forensic Mental Health Network; all rights are reserved by the organisation. The document may, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. Justice Health and Forensic Mental Health Network PO Box 150 Matraville NSW 2036 Version 2.0 - 2009

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REFERENCES

Australian Resuscitation Council Guidelines www.resus.org.au

Diabetes Australia www.diabetesaustralia.com.au

Heart Foundation www.heartfoundation.com.au

National Asthma Council Australia. Asthma Management Handbook, 2006. www.asthmafoundation.com.au

Expert advice was provided by:

Prince of Wales Hospital, Emergency Staff Specialist, Dr Kenneth Abraham

Ambulance Service of NSW, Senior Medical Adviser / Director of Research, Associate Professor Paul M Middleton, RGN MBBS FRCS (Eng) Dip IMCRCS (Ed) FCEM FACEM

Further information

Inquiries pertaining to Adult Standing Orders contained in these guidelines should be directed to the Chief Pharmacist on (02) 9700 3088

Inquiries pertaining to clinical information or formatting contained in these guidelines should be directed to the Project Officer C&NS (02) 9700 3024

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EEmmeerrggeennccyy RReessppoonnssee GGuuiiddeelliinneess

The Emergency Response Guidelines contains key Emergency Response situations that are clearly identified by a colour coding system identified on the front page of the Emergency Response Guidelines and the corresponding colour coded tab at the right hand side of the folder.

An algorithm is presented on the first page of each of the identified sections with pertinent information regarding the Justice Health and Forensic Mental Health Network Standing Orders and Nurse Initiated Medications.

All health care professionals should ensure that they are familiar with the information contained in the Justice Health and Forensic Mental Health Network Adult Standing Orders, as the algorithms are a supplement to guide care in an emergency situation. They do not provide education regarding the aetiology of the illness or disease.

The Primary Survey should be carried out in all Emergency Response situations prior to the management of the identified emergency. This assessment should proceed quickly, within 1-2 minutes. Nothing should interrupt this assessment except treatment of airway obstruction or cardiac arrest.

Patients who require active resuscitation, are assessed as medically unstable or have sustained a significant injury should be transferred to hospital. Appropriate medical advice is to be obtained by telephone in cases where the condition of the patient is serious or in cases where the condition of the patient is beyond the scope of practice and expertise of the health care professional to manage.

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AAbbbbrreevviiaattiioonnss

ABCD Airway, Breathing, Compression and Defibrillation

BGL Blood Glucose Level

BP Blood Pressure

COPD Chronic Obstructive Pulmonary Disease

CPR Cardiopulmonary Resuscitation

EAR Expired Air Resuscitation

ECG Electrocardiograph

GCS Glasgow Coma Scale

LOC Level of Consciousness

IMI Intramuscular Injection

MO Medical Officer

NIM Nurse Initiated Medication

NRM Non Re-breathing Mask

PEF Peak Expiratory Flow (Peak Flow)

PO Per Oral

PRN As required

R.R. Respiratory Rate

Sp O2 Oxygen Saturation

SCI Sub-Cutaneous Injection

SO Standing Order

8

ADULT STANDING ORDERS PREFACE

A specific prescriber should provide the majority of clinical care to a specific individual patient. However, the NSW Health Department Policy Directive, PD2007_077, Medication Handling in NSW Public Hospitals – October 2007, section 5.2 - Standing Orders, authorises the development of protocols for medications, which may be supplied or administered by a registered nurse to a patient with an identified clinical condition without a medical officer’s authorisation, provided appropriate written protocols for its use are also developed.

Justice Health and Forensic Mental Health Network Standing Orders provide authorisation for Registered Nursing staff to administer medication in defined situations to individual patients without a prior written order by a medical practitioner on a medication chart.

Standing Orders apply to persons over the age of eighteen years and in the adult correction facilities, and are not to be utilised in the Adolescent Healthcare Centres.

Standing Orders apply to life saving situations and when access to medical officer is not possible and is not to be utilised for routine day to day requirement.

Each Standing Order has been approved for use by the Justice Health and Forensic Mental Health Network Drugs and Therapeutics Committee (D&TC) and is in the form of a written instruction, signed and dated by the Chief Executive. Standing Orders are reviewed every year by the D&TC.

OBJECTIVES

Standing Orders have been developed for the administration of medication in life saving or other specific situations within Justice Health and Forensic Mental Health Network.

OUTCOMES

• Appropriate and timely response to identified life threatening and other medical situations that can occur when medical officers are not available.

• Best practice in health management of identified medical situations occurring within the constraints of the environment.

• Improved patient care and individual patient outcomes.

• Reduction of adverse incidents or severity of consequences of the incident.

• High quality treatment and care, which is evident through timely intervention for, identified medical concerns.

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DOCUMENTATION

When a Registered Nurse administers medication/s according to one of these Standing Orders they must be recorded in black ink on a Justice Health and

Forensic Mental Health Network Standing Order medication chart (in-patient and out-patient) and a note made in the patient’s medical record explaining the rationale for use.

Whenever a Registered Nurse uses a Standing Order a Medical Officer must

be contacted within 24 hours to provide advice on treatment. This communication along with any treatment advice or changes to a patient’s management plan must be documented in the patient’s medical record. The date and time of the discussion with the Medical Officer must be noted on the

Standing Order medication chart and in the patient’s medical record.

A Medical Officer must check this record and confirm it in writing within 7 days of initiating treatment (reference therapeutic act verbal medication order requirement).

A Medical Officer must review the use of a Standing Order applied more than 3 times in a four-week period.

It is the responsibility of the NUM or NIC to establish a system and to arrange for the Medical Officers of their ward or healthcare centre to perform this function.

Refer also the Justice Health and Forensic Mental Health Network Medication Guidelines, Sections 6.19 Standing Orders and 6.20 Emergency Telephone Orders.

The Justice Health and Forensic Mental Health Network Standing Orders are available on the Justice Health and Forensic Mental Health Network Intranet: Procedures / Policies > Medications > Adult Standing Orders.

The Airway Management Backpack and First Aid Bag as well

as AED (if available) should be taken to all Emergency

situations. The Backpack and First Aid Bag should be carried

in the correct manner.

13

Check for DANGER

Hazards / Risks / Safety?

Check for RESPONSE

(If unresponsive)

Open the AIRWAY

Normal BREATHING?

(If not breathing / abnormal

breathing)

Give 30 chest COMPRESSIONS

(almost 2 compressions per

second) followed by 2 breaths

then continue

Attach AUTOMATED EXTERNAL

DEFIBRILLATOR (AED) as soon

as available and follow prompts

Call Ambulance and notify

Emergency Department

Discuss with MO on call, if the patient is breathing and normal cardiac

rhythm has returned, further assess causation of incident – Give O2 15L/min

via a non re-breathing mask.

Refer to Dyspnoea and Cyanosis Algorithm if altered breathing patterns

(Refer to: Adult Standing Orders and Nurse Initiated Medications)

Organise transfer to hospital if indicated

Suction with V-Vac suction

device if required and

clear airway

Chin lift / jaw thrust while

maintaining spinal

precautions

If spinal injury is

suspected, apply stiff

neck collar and

maintain spinal

precautions

*When using

bag valve

device, it is

recommended

for use with two

operators.

Attach pocket

mask without

filter to Bag

valve device for

more secure

connection

DRS ABCD – Basic Life Support Flowchart

D

R

B

C

D

A

SEND for help – ring 000S

Consider

Continue CPR until responsiveness or

normal breathing return

LOOK

LISTEN

FEEL

11

14

DDeeffiibbrriillllaattiioonn • An Automated Electronic Device (AED) is a portable device that

monitors the heart.

• The AED’s computer assesses the patient’s heart rhythm and prompts the rescuer to provide the correct treatment, guiding the rescuer at every stage.

• The AED will prompt the user to deliver a shock to the patient only when the patient is in a shockable rhythm. It will not allow the operator to shock the patient unless the patient is in a shockable rhythm.

• Voice prompts guide the user throughout the emergency including CPR coaching via audible prompts.

• For every minute defibrillation is delayed the patients chance of survival decreases by 10%.

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RReessppoonnssee

PRIMARY SURVEY SECONDARY SURVEY

A AIRWAY HEAD TO TOE - head, neck, neurological, B BREATHING chest, abdominal, pelvis and limbs C CIRCULATION FRONT TO BACK D DISABILITY

E EXPOSURE

ANY PATIENT WITH A SIGNIFICANT HEAD INJURY ALSO HAS A CERVICAL SPINAL INJURY

UNTIL PROVEN OTHERWISE

CAUSE OF COMA A ALCOHOL, ASPHYXIA GLASGOW COMA SCALE

E EPILEPSY

I INSULIN (OVER / UNDERDOSE) EYE OPENING POINTS

O OVERDOSE NONE 1

U URAEMIA TO PAINFUL STIMULUS 2

T TRAUMA TO VERBAL STIMULUS 3

I INFECTION SPONTANEOUS 4

P PSYCHIATRIC BEST VERBAL RESPONSE POINTS

S STROKE / SHOCK NONE 1

INCOMPREHENSIBLE SOUND 2

SAMPLE HISTORY INAPPROPRIATE WORDS 3

CONFUSED 4

S SYMPTOMS ORIENTATED 5

A ALLERGIES BEST MOTOR RESPONSE POINTS

M MEDICATIONS NONE 1

P PREVIOUS INJURY ABNORMAL EXTENSION 2

L LAST MEAL ABNORMAL FLEXION 3

E EVENT LEADING TO INCIDENT WITHDRAWS FROM PAIN 4

LOCALISES PAIN 5

PAIN ASSESSMENT OBEYS COMMAND 6

P PAIN

Q QUALITY

POISONS INFORMATION CENTRE PHONE: 13 11 26

R REGION/RADIATION

S SEVERITY

T TIME

Refer to the following JH&FMHN Policies: Policy N

o 1.010 Access to inmates – Emergencies

Policy No 1.032 Admission to Public Hospitals – Emergency

Policy No 1.020 Administration of Medications

Policy No 5.040 Emergency, First Aid

Policy No 5.070 Infection Control

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AABBCCDDEE –– PPrriimmaarryy SSuurrvveeyy Mobilise resources quickly and designate one person to each of the following:

• Take charge of the assessment process

• Begin resuscitation interventions as required

• Make phone calls

Prior to proceeding with assistance ensure personal safety, assess for any signs of danger:

• Other patients in the vicinity are secured (DCS)

• Blood or fluids

• Electricity

• Unstable foundations

• Don gloves, goggles and face mask

• Apply a gown if necessary

• Sharp objects, place any sharp objects into a sharps container

The primary survey is a prioritised assessment and treatment of life-threatening injuries which is approached in an orderly fashion and should take no more than 2-5 minutes to complete.

A for airway management and cervical spine protection

B for breathing and ventilation

C for circulation and haemorrhage control

D for disability: Neurological status

E for exposure / environmental control: completely expose patient

Airway management and cervical spine protection

• Attempt to elicit a response from the patient

• Give an audible command e.g. ‘Can you hear me?’

• Giving a tactile stimulus e.g. grasp the casualty’s hands and say ‘if you can hear me squeeze my hands and let them go’

• Ask patient what happened. If the person can answer, you have valuable information about patency of the airway and level of consciousness

• Make a brief assessment of the patient’s level of consciousness (conscious/altered level of consciousness/unconscious)

• Facial or mandibular, tracheal / laryngeal injuries

• Oxygen

• Keep cervical spine in neutral position while managing airway if you suspect a cervical spine injury (cervical spine injuries should be suspected in all patients with a blunt injury above the clavicle)

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• Use backward head tilt/chin lift (head and neck slightly extended and line from chin to jaw angle perpendicular to the floor-do not use if cervical spine injury suspected) or jaw thrust (place 2-3 fingers under each side of lower jaw angle and lift jaw upward and outward) manoeuvres to open airway. Ensure that the tongue does not fall back into pharynx and obstruct the airway

• Insert an oropharyngeal airway if patient is unconscious and it is clinically indicated. Measure from the corner of the mouth to the tip of the ear lobe for size required. Insert with end uppermost, turning the Guedel airway 180 degrees when you reach the soft palate.

Signs of airway obstruction may include but are not limited to:

• Snoring or gurgling

• Stridor or abnormal breath sounds

• Agitation (hypoxia)

• Using the accessory muscles of ventilation/paradoxical

• Chest movements

• Cyanosis

Attempt to elicit a verbal response from patient

• Look for blood, vomitus or foreign objects

• Use V-Vac to assist in clearing the patients airway

Breathing

Look and feel for movement

• Your ear is placed close to the mouth of the patient with the head turned looking for chest wall movement.

• Ascertain if the patient is breathing?

• If the patient is not breathing immediately commence EAR. Give 2 ‘rescue breaths’ with a bag valve device or with the pocket facemask.

• Ensure that the chest is rising with each inhalation.

• Ensure effective head tilt to allow for exhalation.

If the patient is breathing spontaneously, ensure the patient is breathing effectively and check respiratory effort and use of accessory muscles (look, listen and feel).

Assist ventilation if breathing is not effective with the mask and bag valve device.

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• Ventilate with oxygen using a mask and bag valve device at 12 breaths/min

• Ensure ventilations are performed with a slow inspiratory flow rate to reduce the incidence of gastric distension, regurgitation and aspiration.

If patient is breathing spontaneously (12-18 breaths/min), improve oxygenation of vital tissues - Give oxygen at 15 L/min by non re-breathing mask; maintain oxygen saturation > 98%

• Ensure effective ventilations are being achieved

• If ventilation is ineffective due to possible airway obstruction, reassess the airway and attempt to clear the obstruction.

• Inspect chest for crepitus and open wounds

Circulation

‘Shock’ is defined as inadequate tissue perfusion and tissue oxygenation. In the trauma patient it is most often due to hypovolaemia. The diagnosis of shock is based on clinical findings: hypotension, tachycardia, tachypnoea, as well as hypothermia, pallor, cool extremities, decreased capillary refill and decreased urine production.

There are different types of shock including:

Haemorrhagic (hypovolaemic) shock: Due to acute loss of blood or fluids. The amount of blood loss after trauma is often poorly assessed and in blunt trauma is usually underestimated. Remember:

• Large volumes of blood may be hidden in the peritoneal and pleural cavities

• Femoral shaft fracture may lose up to 2 litres of blood

• Pelvic fracture often lose in excess of 2 litres of blood

Cardiogenic shock: Due to inadequate heart function.

This may be from:

• Myocardial contusion (bruising)

• Cardiac tamponade

• Tension pneumothorax (preventing blood returning to heart)

• Penetrating wound of the heart

• Myocardial infarction

Neurogenic shock: Due to the loss of sympathetic tone, usually resulting from spinal cord injury, with the classical presentation of hypotension without reflex tachycardia or skin vasoconstriction.

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Septic shock: Rare in early phase of trauma but is a common cause of late

death (via multi-organ failure) in the weeks following injury. Common in untreated or unrecognised infections, often seen in penetrating abdominal injury and burns patients.

Haemorrhage Control

• Identify and control external bleeding, this should be performed by a second rescuer if the patient is requiring CPR

• Apply direct pressure and dressings to external bleeding

• If the wound continues to bleed apply a further dressing over the original dressing. Never remove the original dressing

• If a foreign object or knife is protruding from the wound, do not remove, stabilise the object. (Refer to: Stab Wound Algorithm)

Tourniquets should not be used; they can cause reperfusion syndromes and add to primary injury.

Disability

Rapid neurological assessment (is patient awake, vocally responsive to pain or unconscious)

• A – awake

• V – verbal response

• P – painful response

• U – unresponsive

System at this stage is clear and quick.

If time allows a Glasgow Coma Scale could be used.

Any change in level of consciousness or depreciation in the GCS should prompt a return to the beginning of primary survey.

Exposure

Expose patient entirely to allow global assessment. If the patient is suspected of having a neck or spinal injury, in-line immobilisation is important. Patient privacy must be considered.

20

Dyspnoea and Cyanosis Algorithm

Conduct Primary Survey – ABCDE

(Refer to: Adult Standing Orders

Asthma, Anaphylaxis, Opioid

overdose)

Record BP, PR, RR, Temp, BGL,

Sp O2

Administer O2 15L via non re-breathing

mask

Has the patient sustained a chest

injury?

Cover any chest wounds with three-

sided dressing

Is the trachea midline?

Reassess Circulation:

Quality, location rate

Is Carotid Pulse present?

Position patient in comfortable

position and maintain cervical spine

precautions

Is the patient post-ictal?

Place in recovery position

Assess Neurological Status

Is asthma suspected?

Go to: Asthma Algorithm

Is Anaphylaxis suspected?

Go to: Anaphylaxis Algorithm

Is Dyspnoea and Cyanosis due to other

causes?

Consider: Exacerbation of COPD, opioid

overdose, smoke inhalation, aspiration,

pulmonary oedema, etc and discuss with

Medical Officer

Suspect tension pneumothorax

Call ambulance, requires urgent transfer to

hospital

No

No

Further assess causation of

incident – Give O2 15 L/min

Discuss with MO

If symptoms do

not improve then

call Ambulance

000

Commence CPR

(30 compressions then 2 breaths)

Administer 2 breaths

(with high flow O2, using mask and

*bag valve device)

Call Ambulance and notify Emergency

Department

Insert Guedal airway (Measuring from

tip of ear to corner of mouth)

No

If spinal injury suspected apply stiff neck

collar, observe cervical spine precautions

*When using bag valve device, it is

recommended for use with two operators.

Attach pocket mask without filter bag to

device for more secure connection.

Yes

Yes

Yes

19

21

Disorganised Speech / Behaviour Algorithm


Indications: required for patients with acute disturbance of speech or behaviour

Record BP, PR, RR, Temp, BGL, Sp O2

Assess: BP, PR, RR, Temp, BGL, Sp O2, AVPUAdminister O2 15L/min via

non-re-breathing mask.

Is BGL < 4 mmol/L?

Refer to: Hypoglycaemia Algorithm

Administer O2 15L/min via non

re-breathing mask

Insert IV Cannula

Assess GCS

Discuss with MO

Transfer to hospital for assessment

Face, Arm and Speech Test (FAST)

Suspect stroke if any of the following are abnormal

A) Facial movements

Ask patient to smile or show teeth. Look for

asymmetry – unequal smile or grimace or obvious

facial asymmetry

B) Arm movements

Lift the patient’s arm together to 90O if sitting, or 45

O

if supine. Ask patient to hold that position for 5 sec

and then let go it is abnormal if one drifts down or

falls more rapidly

C) Speech impairment

Look for new disturbances in speech. Look for

slurred speech and word-finding difficulties. Ask the

patient to name common nearby objects such as a

cup, chair, key and pen.

If there is a severe visual disturbance, place an

object in the patients hand and ask them to name it.

Possible drug induced behavioural

change

If patient is unconscious or

very drowsy refer to Opioid

overdose algorithm

Has patient

received a recent

head injury?

Assess GCS, cognitive function,

perceptual disturbances and

complete the FAST

Fluctuating LOC?

Perform Mental State Examination

Appearance / behaviour

Rate & content of speech

Form and content of thought

Mood & affect

Perceptual abnormalities

Insight & judgement

Refer to: Coma / altered

level of consciousness

algorithm

Administer O2

15L/min via non

re-breathing mask.

Call Ambulance

No

Yes

No

Discuss patient with Psychiatrist

or Medical Officer

Yes

No Yes

Yes

No

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Coma / Altered Level of Consciousness Algorithm

Administer O2 15L/min via non-breathing

mask

Assess blood glucose level

Is the Blood Glucose Level less than

4 mmol/L?

Is alteration in level of

consciousness (LOC) due to

possible overdose?

Is alteration in LOC due to head

injury, cardiac or unknown cause?

Hypoglycaemia

Go to: Hypoglycaemia Algorithm

(Refer to: Adult Standing Order,

Hypoglycaemia)

Opioid overdose

Go to: Opioid Overdose Algorithm

(Refer to: Standing Order: Opioid

Overdose)

Contact on call Medical Officer

Notify Emergency Department of

transfer.

No

No

Yes

Yes

Yes

A – Alcohol, asphyxia

E – Epilepsy

I – Insulin (overdose / underdose)

O – Overdose

U - Uraemia

T – Trauma

I – Infection

P – Psychiatric

S – Stroke, shock, seizures

POSSIBLE CAUSES OF COMA


(Refer to: Standing Orders: Hypoglycaemia, Anaphylaxis, Opioid overdose)

Record BP, PR, RR, Temp, BGL, Sp O2

Organise urgent transfer to hospital

Administer O2 at 15 L/min via non

re-breathing mask

Regularly assess:

Respiratory rate, radial pulse rate,

blood pressure and level of

consciousness (GCS)

Monitor:

Airway, Breathing and Circulation

23

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CCoonnsscciioouussnneessss Non Pharmacologic Interventions • Assess and stabilise ABCDE including cervical spine

• Insert oropharyngeal airway (size is determine by measuring from the edge of the patients mouth to the ear lobe)

• Place in recovery position, unless there are contraindications such as a suspected cervical spine fracture. (If the patient is already in the recovery position then you should attempt to manage the patient in this position provided they do not require active resuscitation)

• Check Blood Glucose Level (BGL) - If BGL < 4 mmol/L, assume hypoglycaemia

• NB. Unstable diabetics with a normally high blood glucose level can experience the symptoms of hypoglycaemia > 4 mmol/L.

Pharmacologic Interventions If BGL < 4 mmol/L:

• Administer 1mg glucagon IMI

• Check BGL after 10 minutes, if BGL remains below 4 mmol/L administer a second dose of 1mg glucagon IMI.

If BGL > 4mmol/L:

• Suspect opioid overdose

Give Naloxone (Narcan) (D class drug), initially 2mg IMI or SCI; repeat every 2-3 minutes if necessary to a maximum dose of 10 mgs. The routine use of naloxone for patients without evidence of opioid intoxication should be considered for patients who present with an altered level of consciousness where the cause is unknown. If you are unsure, discuss with a physician before administering. Monitor vital signs, including pulse oximetry (if available)

• Obtain a brief history focusing on the presenting problem. Try to clarify the cause of the incident

• In particular, determine if person has had any recent illness, fever, rash, vomiting or trauma or has the patient been diagnosed with a chronic illness

• Attempt to ascertain if the patient has experienced any recent symptoms of illness or substance withdrawal which could be linked to the current presentation.

Observations in the secondary survey should attempt to uncover signs of infection, trauma, or toxic or metabolic derangements. Signs suggestive of drug overdose should be sought.

Adjuvant Therapy

• Give oxygen (15 L / min) via a non-re-breather mask; keep oxygen saturation > 97%.

24

Acute Asthma Algorithm


(Refer to: Adult Standing Order Acute Asthma)

Record: BP, PR, RR, Temp, BGL, Sp O2

Assess Asthma Severity

Mild

Talks in sentences

Pulse < 100/min

Variable wheeze

PEF > 75% predicted

(or best if known)

Sp O2 over 97%

Moderate

Talks in phrases

Pulse 100-120/min

Moderate to loud wheeze

PEF 50-75% predicted (or

best if known)

Sp O2 between 95-97%

Severe and life threatening

Tallks in words

Pulse > 120/min

Often quiet wheeze

Altered LOC

Physical exhaustion

PEF <50% predicted (or best if known)

or less than 100 L/min

Sp O2 less than 95%

(Do not attempt PEF if patient

is cyanosed)

5mg nebulised

salbutamol +2.5 mls

saline with O2 8L/min

Repeat dose 4th hourly

monitoring changes in

severity

5mg nebulised

salbutamol +2.5 mls

saline, 3 nebs over one

hour and 500mcg

Ipratropium Bromide 4th

hourly with continuous O2

8L/min

Regularly monitor for

changes in severity

5mg Nebulised Salbutamol

+2.5mls saline continuously and

500mcg Ipratropium Bromide 2nd

hourly with Continuous O2

15L/min

Requires continuous monitoring

Urgently transfer patient to

hospital.

Inform Medical Officer

Refer to MO and issue patient with

salbutamol puffer if required.

Advise patient to notify Health

Centre staff if symptoms return

25

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

ACUTE ASTHMA

SALBUTAMOL

Asthma can be life threatening. Spirometry is the lung function test of choice for diagnosing asthma and for assessing asthma control in response to treatment. Perform spirometry and/or peak expiratory (PEF) measurement as soon as possible to gain an objective measure of airflow limitation. Severe asthma should receive continuous oxygen at 15L/min. Oxygen therapy may be associated with respiratory depression and arrest in patients with chronic CO2 retention, particularly those with Chronic Obstructive Pulmonary Disease (COPD).

Drug Name SALBUTAMOL

Common Brand Names Ventolin inhaler or Nebules

Strength 100mcg / dose 200 doses inhaler 2.5 mg and 5 mg solution

Dose For the inhaler use 1-2 inhalations, repeat every 3-6 hours if necessary

For the Nebules use 5mg in normal saline every 3-6 hours for mild and 1-4 hours for moderate asthma or every 15 minutes for severe asthma with oxygen at 8L/min

Administration / Route Inhalation via metered dose Inhaler (MDI) with volumatic inhaler device (spacer device for metered dose inhalers, if available) or nebuliser for the Nebules

FOR MODERATE ASTHMA THAT IS NOT RESPONSIVE TO THERAPY AND FOR SEVERE ASTHMA, CONTACT THE AMBULANCE SERVICE of NSW FOR EMERGENCY TRANSFER TO HOSPITAL AND INFORM THE LOCAL MEDICAL OFFICER OR CMO ON CALL.

26

Initial assessment of acute asthma in adults

Findings Mild Moderate *Severe & life threatening

Physical exhaustion Talks in Pulse rate Pulsus paradoxus Wheeze intensity Peak Expiry Flow (PEF) Forced Expiratory Volume (FEV1)

No Sentences < 100 Not palpable Variable More than 75% predicted (or best if known) More than 75% predicted

No Phrases 100-120/min May be palpable Moderate to loud 50 - 75% predicted (or best if known) 50-75% predicted

Yes Paradoxical chest wall movement may be present Words More than 120/min Palpable Often quiet Less than 50% predicted (or best if known) or less than 100 L per min Less than 50% predicted or less than 1L

INDICATIONS

Relief of acute bronchospasm (acute asthma).

4X4X4 FIRST AID PLAN

Inhaler with Spacer

• Shake inhaler and insert mouthpiece into spacer.

• Place spacer mouthpiece in person’s mouth and fire 1 puff.

• Ask the person to breathe in and out normally for about 4 breaths.

• Repeat in quick succession until 4 puffs have been given.

Inhaler without Spacer

• Shake inhaler

• Place mouthpiece in person’s mouth. Fire 1 puff as the person inhales slowly and steadily

• Ask the person to hold that breath for 4 seconds, then take 4 normal breaths

• Repeat until 4 puffs have been given.

(National Asthma Council Australia, 2006)

27

CONTRAINDICATIONS

Known allergy to main ingredient or preservatives.

DRUG INTERACTIONS

Beta-Blockers; other sympathomimetics, beta-adrenergic stimulants; ipratropium bromide; xanthines; steroids; diuretics; digitalis.

ADVERSE EFFECTS

Hypokalaemia, arrhythmias; tremor; tachycardia, palpitations; headache; hypotension; nausea; sensation of warmth; nervousness.

DOCUMENTATION

• Physical Observations including: pulse, blood pressure, respiratory rate, spirometry (if available) or PEF (if able), oxygen saturation, physical assessment

• Document medication on Standing Order chart.

The nurse must record the administration in black ink on the Standing Order medication chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

Landau, P. (Ed) (1999). The Medical Officer’s Handbook. Sydney: Westmead Hospital (accessed August 2007).

MIMS Online

Available at: http:// www.ciap.health.nsw.gov.au [accessed August 2007].

National Asthma Council Australia, Asthma Management Handbook, 2006.

28

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

ACUTE ASTHMA

IPRATROPIUM BROMIDE (ATROVENT)


Drug Name IPRATROPIUM BROMIDE

Common Brand Names Atrovent, Ipratrin, DBL Ipratropium (Nebuliser Solution)

Strength 250cmg/ml and 500mcg/ml nebules

Dose Mild asthma: nil indicated

Moderate asthma: 500mcg 4th hourly Severe asthma:500mcg by nebuliser driven by oxygen (at least 8L/min) every 2-4 hours

To be used with salbutamol in moderate to severe asthma.

Do not use ipratropium bromide alone for immediate relief of symptoms.

Administration / Route Nebulised with oxygen and salbutamol at > 8L/min

FOR MODERATE ASTHMA THAT IS NOT RESPONSIVE TO THERAPY AND FOR SEVERE ASTHMA, CONTACT THE AMBULANCE SERVICE of NSW FOR EMERGENCY TRANSFER TO HOSPITAL AND INFORM THE LOCAL MEDICAL OFFICER OR CMO ON CALL

29


Findings Mild Moderate *Severe & life threatening




Yes Paradoxical chest wall movement may be present Words More than 120/min Palpable Often quiet Less than 50% predicted (or best if known) or less than 100 L per min Less than 50% predicted or less than 1L

INDICATION

Relief of moderate asthma attacks.

CONTRAINDICATIONS

Known allergy, hypersensitivity to soya lecithin or related foods (soya beans, peanuts), atropine hypersensitivity.

PRECAUTIONS

Closed angle glaucoma, prostatic hyperplasia, urinary retention, avoid contact with eyes.

DRUG INTERACTIONS

• Xanthines

• Beta-mimetics (especially if there is a risk of glaucoma).

30

ADVERSE EFFECTS

• Care is recommended during pregnancy and lactation (Category B1)

• Headache; nausea; dry mouth; throat irritation; cough; anticholinergic effects; GI motility disturbances; acute angle closure glaucoma (following direct eye contact); rash; angioedema; urticaria; paradoxical bronchoconstriction; allergic reaction

• Avoid contact with eyes.

DOCUMENTATION



The nurse must record the administration in black ink on the Standing Order medication chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

Landau, P. (Ed) (1999). The Medical Officer’s Handbook. Sydney: Westmead Hospital (accessed August 2007).

MIMS Online. Available at: http:// www.ciap.health.nsw.gov.au (accessed August 2007).


31

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

ACUTE ASTHMA

PREDNISOLONE


This Standing Order is for a single initial dose of oral steroid until the on call doctor is contacted. It should be used following initial treatment with nebulised salbutamol and ipratropium bromide (atrovent).

Drug Name PREDNISOLONE

Common Brand Names Solone, Panafcortelone

Strength 5mg tablets/25mg tablets

Dose Mild asthma: nil indicated

Moderate asthma: 50mg orally

Severe asthma:50mg orally

Administration / Route Orally. To be taken with food to minimise GI upset

This Standing Order is for a single dose only. Ring on call doctor following administration for advice regarding acute asthma

management.

FOR MODERATE ASTHMA THAT IS NOT RESPONSIVE TO THERAPY, AND FOR SEVERE ASTHMA, CONTACT THE AMBULANCE SERVICE OF NSW FOR EMERGENCY TRANSFER TO HOSPITAL AND INFORM THE LOCAL MEDICAL OFFICER OR CMO ON CALL.

32


Findings Mild Moderate Severe & life threatening




Yes. Paradoxical chest wall movement may be present Words More than 120/min Palpable Often quiet Less than 50% predicted (or best if known) or less than 100 L per min Less than 50% predicted or less than 1L

INDICATION

Antiinflammatory in asthma exacerbation

CONTRAINDICATIONS

• Known allergy

• Uncontrolled infections

• Peptic ulcer; osteoporosis; psychoses, psychoneuroses; TB

• Uncontrolled infections (bacterial and viral).

PRECAUTIONS

Diabetes, infection, stress, peptic ulcer, fresh intestinal anastomoses, cirrhosis, hypothyroidism, ulcerative colitis, osteoporosis, elderly, active TB, ocular herpes simplex, diverticulitis.

33

DRUG INTERACTIONS

Antacids; oral hypoglycaemics; insulin; digitalis glycosides; diuretics; barbiturates; phenytoin; rifampicin; potassium supplements; ritodrine; Na+ containing drugs or food; somatrem, somatropin; vaccines, immunisations; troleandomycin; ketaconazole; aspirin; oral anticoagulants; cyclosporine; phenobarbitone.

ADVERSE EFFECTS

Fluid retention; dyspepsia; oedema; metabolic disturbances; hypertension; hyperglycaemia, delayed wound healing; peptic ulcer; mental, neurological changes; Cushingoid states; muscle weakness.

DOCUMENTATION



The nurse must record the administration in ink on the Standing Order medication chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

Landau, P. (Ed) (1999). The Medical Officer’s Handbook. Sydney: Westmead Hospital. (accessed August 2007)



34

Acute Dsytonic Reaction Algorithm

Conduct Primary Survey – ABCDE – Reassure the patient

(Refer to: Adult Standing Order, Acute Dystonic Reaction)

Indications – oculogyric crisis, torticollis or retrocollis, trismus, opisthotonos, laryngeal spasm

Assess type and severity of dystonia

Administer 2mg benztropine (Cogentin) IMI

Assess temperature, pulse, blood pressure, respiratory rate, Sp O2, level of consciousness

Assess response to benztropine

Severe dystonia (potential

for airway compromise)

Discuss with psychiatrist

Repeat benztropine 2 mg

IMI after 30 minutes.

Reassess vital signs,

monitor respirations

Maximum of 4 mg

benztropine in 24 hours

Mild dystonia

Discuss with Psychiatrist on

call

Repeat benztropine 2mg

IMI after 30 minuutes if

dystonia persists

Maximum 4mg benztropine

in 24 hours Assess for signs of injury

and differential diagnosis,

check BGL.

Discuss with psychiatrist

or Medical Officer

(If dystonia is due to

metoclopramide

(Maxalon), cease

treatment immediately.

If dystonia is due to

Neuroleptic Malignant

Syndrome, discuss with

Psychiatrist)

Patient is febrile, confused

and has muscle rigidity?No

Assess differential diagnosis.

Assess mental status

??? Neuroleptic Malignant

Syndrome in patients taking

neuroleptic medication.

Also suspect serotonin syndrome

for patients on antidepressants.

Ring psychiatrist or Medical Officer

Transfer to hospital for further assessment

Continue O2 > 8L/min

Yes

No

If dsystonia persists, assess severity

35

MENTAL HEALTH

CLINICAL STREAM

STANDING ORDERS

ACUTE DYSTONIC REACTION

BENZTROPINE

Acute dystonic reactions are caused mainly by antipsychotic medication and occur most commonly with high potency antipsychotics (e.g. haloperidol). These adverse effects can be extremely distressing. Acute dystonic reactions are a medical emergency. Symptoms include oculogyric crisis (‘look-ups’), torticollis, trismus, opisthotonos and laryngeal spasm. They generally develop within hours to days of administration of antipsychotic medication and affect the face, neck and trunk. In an emergency situation where respiratory compromise or arrest occurs, follow resuscitation procedures.

Drug Name BENZTROPINE

Common Brand Names Cogentin

Strength 2mg/2ml ampoule

Dose 2mg IMI maximum of 4mg in 24 hours

Administration / Route Intramuscular injection. If the patient does not improve in another 20-30 minutes, the drug should be administered again.

• Check patients treatment sheets for current medication orders, i.e., is the patient already on a regular order of benztropine or any other antiparkinsonian medication either as an ongoing or as a PRN medication

• Reassure and keep the patient calm and provide supplementary oxygen if required. If there is respiratory compromise follow resuscitation procedures

• Request Medical Officer to asses or review the patient and their medication as soon as possible. To preclude the reappearance of symptoms it is advised that a medical officer prescribe oral anticholinergic medication for 2-3 days after the onset of the acute dystonic reaction

• Observe and remain with the patient following administration.

36

INDICATIONS

Acute dystonic reaction causing severe distress, or moderate distress lasting 45 to 60 minutes, as evidenced by oculogyric crisis (‘look-ups’), torticollis or retrocollis (spasm of the neck muscles), trismus (‘lock-jaw’, spasm of tongue and floor of mouth), opisthotonos / tardive dyskinesia (spasm/arching of the back), laryngeal spasm (difficulty swallowing, talking or breathing).

CONTRAINDICATIONS

Known allergy or hypersensitivity.

PRECAUTIONS

Tardive dyskinesia, prostatic hyperplasia, psychoses, tachycardia, high doses, narrow angle glaucoma, symptoms that are only causing moderate distress (in this case, monitor the patient and/or contact the on call medical officer.

ADVERSE EFFECTS

Anticholinergic effects, tachycardia, disorientation, hyperthermia (use with caution in hot weather), GI upset, blurred vision, urinary retention, dysuria, bowel obstruction, may aggravate tardive dyskinesia, idiosyncratic reactions (abnormal behaviour, confusion, hallucinations), headache, dizziness, drowsiness, numbness of fingers, cramps, memory problems and muscle weakness.

DRUG INTERACTIONS

Benztropine may decrease the effects of:

• Haloperidol and phenothiazines (chlorpromazine) – decreases the antipsychotic effect therefore increasing psychotic symptomatology.

The following drugs may increase the effects of benztropine:

• Amantidine (antiparkinsonian medication) may increase confusion and hallucinations

• MAOI type A inhibitor (Moclobemide) intensifies the effect of the benztropine

• Tricyclic antidepressants – adds to eye effects, increases internal eye pressure (dangerous in glaucoma)

• Levodopa – possible reduction in levodopa efficacy

• Clozapine, phenothiazine and haloperidol– can cause increased risk of elevated temperatures, neurological adverse effects and bowel obstructions (paralytic ileus) and

• Serum levels of Digoxin are increased.

37

DOCUMENTATION

Physical observations including:

• Pulse, blood pressure, respiratory rate, and physical assessment.

• Type and severity of dystonic reaction symptoms

• Current mental state in medical record


The nurse must record the administration in black ink on the Standing Order Treatment chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

Drugdex Drug Evaluations. Available at: http:// www.ciap.health.nsw.gov.au (accessed August 2007).


38

Anaphylaxis Algorithm


(Refer to: Adult Standing Order Anaphylaxis

Indications: +/- itching, rash, widespread vasodilatation and

extravasations (swelling), acute allergic reaction with shortness of

breath, facial swelling, oral cavity swelling, shock, cardiac

arrhythmia, respiratory compromise, hypotension

NB

Please ensure that this is

the correct clinical

diagnosis before

proceeding with drug

administration. If in doubt

about diagnosis, seek

advice from the on call

medical officer.

Assess Severity of reaction and differential diagnosis

If anaphylaxis is severe immediately organise transfer to hospital

Administer continuous O2 15L/min via non re-breathing mask

Mild allergic

reaction

Sensations of

warmth

Itching

Rash

Moderate allergic

reaction

Erythematous

Urticarial rash

Oedema of face,

neck, soft tissues

Severe reaction / Anaphylaxis

Hypotention (shock)

Angioedema

- Oedema of face, neck, soft

tissues

Bronchospasm

- Dyspnoea, Wheeze Cough

Cyanosis

- Shortness of breath

Laryngeal oedema

- Laryngeal stridor, hoarseness

Urticarial rash -

- Wheals

- Pruritus

Arrhythmia, weak pulse

Observe for

changes in

severity

Discuss with MO

on call

0.5 ml Adrenaline

1:1000 (0.5mg) IMI

Observe for changes

in severity

Discuss with MO on

call and organise

transfer to hospital

Administer 0.5 ml Adrenaline

(1:1000 0.5mg) IMI

Administer continuous O2 > 8L/

min

Call Ambulance and transfer

patient to hospital

Assess for signs of hypotension

or respiratory distress

Discuss with MO on call

Laryngeal oedema

Administer 5mg (5mls 1:1000)

nebulised adrenaline with continuous

O2 > 8L/min

Bronchospasm

2.5-5mg nebulised salbutamol

1ml normal saline PRN with O2 > 8L/min

Hypotension systolic BP < 100 mmHg

Rapid fluid resuscitation, normal

saline stat

See Haemorrhage / hypovolaemia

algorithm

Signs of re

spira

tory distre

ss?

39

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

ANAPHYLAXIS

ADRENALINE

An anaphylactic reaction is an immediate (type 1 IgE mediated) systemic allergic reaction to allergens including drugs e.g. penicillin, and insect toxins, e.g. bee stings. It is characterized by widespread vasodilatation and extravasations of fluid from the vascular compartment into the body's tissues, especially into the head, neck and chest, and at times the tongue. When severe, such a reaction is called anaphylaxis. A severe anaphylactoid reaction is a life-threatening emergency. As in all medical emergencies; initial management should be ABC of resuscitation, namely: Airway, Breathing and Circulation. All patients with anaphylaxis should be transferred out to hospital for medical assessment.

Drug Name ADRENALINE

Common Brand Names Adrenaline 1:1000

Strength 1mg/1ml ampoule

Dose 0.5mL IMI

Administration / Route Intramuscular injection

• If there has been little or no response to the initial dose of adrenaline, this may be repeated at 20 minute intervals depending on the response of the patient and the severity of the condition.

• Adrenaline must be used at the first suspicion of anaphylaxis. It is safe and effective, and can be life saving. Withholding adrenaline due to concerns of adverse effects can result in death of the patient.

• Establish at least one, preferably two IV lines 18g or larger cannula.

• All efforts should be made to insert 2 large bore IV cannula (18g or larger) and to commence Normal Saline.

If there is hypotension replace fluid rapidly i.e. open IV line valves fully.

40

INDICATIONS

Following clinical recognition of anaphylactic reaction:

• Early

o sensations of warmth, itching, especially in the axillae and groins.or at point of exposure

• Progressive

o erythematous or urticarial rash

o oedema of face, neck, soft tissues

• Severe

o hypotension (shock) bronchospasm (wheezing)

o laryngeal oedema (dyspnoea, stridor, aphonia, drooling)

o arrhythmia, cardiac arrest.

PRECAUTIONS

High doses, cardiovascular, cerebrovascular, lung disorders including asthma, Parkinsonism, prostatic hypertrophy.

CONTRAINDICATIONS

N.B. In anaphylaxis, ALL contraindications are relative.

• Known allergy or hypersensitivity

• Hyperthyroidism; hypertension; ischaemic heart disease; diabetes; glaucoma; cardiac dilatation; arrhythmias; cerebral arteriosclerosis

• Obstetrics when maternal BP > 130/80 mmHg

• Shock (other than anaphylactic)

• Organic brain damage.

DRUG INTERACTIONS

Sympathomimetics; vasodilators; tricyclic antidepressants; antihistamines; thyroid hormones; halothane, cyclopropane, trichloroethylene; MAOIs, hypoglycaemics.

ADVERSE EFFECTS

Anxiety; restlessness; tachycardia; tremor; weakness; dizziness; headache; dyspnoea; cold extremities; pallor; sweating; nausea, vomiting; flushing; disorientation; impaired memory; psychosis; ventricular fibrillation; severe hypertension.

41

OTHER MEASURES IN THE TREATMENT OF ANAPHYLAXIS

1. The ABC's of resuscitation - Airway, Breathing and Circulation

2. Cease administration of any suspected medication or diagnostic material immediately

3. Administer oxygen by facemask at 15 L/minute

4. Call for an ambulance and a Medical Officer. If unstable, transfer to hospital

5. Bronchospasm may be relieved or improved by giving nebulised salbutamol (2.5-5mg solution) and Normal Saline 1:1 ml prn

6. Try to reassure the patient

7. Nebulised adrenaline 5 ml of 1:1000 solution (1 mg/1ml) may be tried in laryngeal oedema

8. Observe vital signs frequently and, if available, monitor ECG.

DOCUMENTATION

• Physical Observations including: pulse, blood pressure, respiratory rate, oxygen saturations and physical assessment in patient notes

• Type and severity of anaphylactic symptoms


The nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

Drugdex Drug Evaluations. Available at: http:// www.ciap.health.nsw.gov.au (accessed August 2007).

42

Chest Pain Algorithm


(Refer to: Adult Standing Order, chest pain)

Chest Pain / Angina / Possible Acute Myocardial Ischaemia / Infarction

Symptoms e.g. sweating, sudden orthopnea, syncope, dyspnoea, epigastric discomfort, jaw

pain, arm pain

Be aware: High risk atypical presentations (e.g. diabetes, renal failure, female, elderly or

Aboriginal

Administer O2 at 15L/min via a non-re-breathing mask.

∗ Assess: temperature, pulse, blood pressure, respiratory rate, pulse oximetry.

∗ Assess for signs of shock

∗ Patients who are cool and tachycardic should be considered as being in hypovolaemic

shock until proven otherwise

Is systolic BP > 90mmHG

Give ½ - 1 tablet GTN

(Anginine) sublingually.

Continue O2 therapy.

Call Ambulance

Give 300mg *Aspirin PO

Continue O2 therapy

Give further ½ to 1 tablet GTN

(Anginine) sublingually, only if

systolic BP remains > 90mnHg

repeat every 3-5 mins (max 3

tablets) Continue O2 therapy

Pain relieved?

Notify Medical Officer and

NUM or AHNM

Insert 16-14g IV cannula

Notify Emergency Department

If possible perform ECG and send

a copy with patient and a copy of

previous ECG’s (if any)

Regularly assess changes in vital signs

Airway, Breathing and Circulation.

Transfer to hospital for further assessment if

ECG changes apparent

Pain relieved?

Give 300 mg *Aspirin PO

If possible perform ECG

Discuss with Medical Officer

Reassess vital

signs

ECG abnormal

Discuss with Medical

Officer regarding further

action

Yes No

No

Yes

No

Yes

No

Yes \ Unsure

*Contraindicated if history of allergy to aspirin, active Gastro-intestinal bleed or taking warfarin

NOTE: If patient has a supply of GTN (Anginine), always replace 43

43

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

CHEST PAIN

GLYCERYL TRINITRATE

CONTACT MEDICAL OFFICER URGENTLY IF PAIN PERSISTS FOR MORE THAN 15 MINUTES OR TRANSFER TO LOCAL CASUALTY IF ANY SUSPICION OF A MYOCARDIAL INFARCT. REMEMBER ABORIGINAL MALES MAY HAVE HEART ATTACKS IN THEIR EARLY TWENTIES AND THE ISCHAEMIC PAIN MIGHT BE IN ATYPICAL LOCATIONS.

Angina is the paroxysmal pain caused by transient myocardial ischaemia. The pain occurs when the oxygen demands of the myocardial tissues exceed the ability of the coronary vessels to supply the affected area with enough blood to meet the oxygen needs of the myocardial tissues.

Atherosclerosis of the coronary arteries, vasospasm of the coronary arteries or a combination of these two factors can be the causation. Investigations in clinical practice provide limited supporting evidence for Angina, as a resting ECG can show no cardiac changes, unless there is a history of coronary artery disease.

If an arrhythmia is present organise immediate transfer of the patient to hospital.

THE FIRST-AID MANAGEMENT of CHEST PAIN consists of:

1. Maintenance of the airway,

2. Oxygen at 10 to 15 L/min and

3. Administration of Anginine.

Drug Name GLYCERYL TRINITRATE / GTN

Common Brand Names Anginine

Strength 600mcg

Dose 600mcg sublingually (half a tablet in the elderly initially).

Repeat every 3-5 minutes if unresolved.

Administration / Route PO

• Sit/lie patient down as GTN may cause dizziness.

• Ensure blood pressure is checked prior to administration and continuing monitoring and observations after administration.

• The advice of a Medical Officer must

44

always be sought, as soon as practicable, regarding further management. The patient should be transferred to hospital if the pain persists after 2 tablets over 10 minutes.

• Advise patient not to swallow the tablet and to place the tablet under the tongue or in the cheek and allow it to dissolve.

• Advise patient to spit tablet out once the pain has been relieved.

INDICATIONS

Chest Pain of suspected cardiac origin (Angina or Myocardial Infarction). The most characteristic features of Acute Myocardial Infarction are:

1. Angina of severe, sustained or unusual intensity

2. Any ischaemic chest pain which does not abate with rest

3. Any angina with a drop in blood pressure or onset of an irregular pulse

4. Sudden onset of central chest pain which may or may not radiate to the neck, jaw, arms or back.

The most characteristic features of classic angina are:

1. Retrosternal or banding chest pain precipitated by physical or emotional exertion

2. Pain is relieved by rest

3. Pain or discomfort may be felt alternatively or additionally in the arms, epigastrium, jaw or back.

Atypical Angina can present as pain in the jaw, neck, shoulders, arm or epigastric region.

Other associated features that may be present in acute myocardial infarction or Angina include:

• Dyspnoea

• Nausea

• Diaphoresis

• Palpitations

• Faintness

CONTRAINDICATIONS

• Blood Pressure <90 mmHg

• Cerebral Haemorrhage

• Head Injury

• Hyper tropic Obstructive Cardiomyopathy

45

DRUG INTERACTIONS

Alcohol, Antihypertensives, Levodopa, Opioid analgesics, Hydralazine, Calcium channel blockers, Minoxidil, Prazosin, Sympathomimetics, Sildenafil, Tadalafil, tricyclic antidepressants.

ADVERSE EFFECTS

• Vascular headache

• Flushing

• Tachycardia

• Dizziness

• Hypotension

• Syncope

• GI upset

• Restlessness

OBSERVATIONS

• Pulse

• Temperature

• Blood pressure

• Respiratory rate

• Oxygen saturation

• Listen to chest for air entry and wheeze

• ECG

DOCUMENTATION

• Document clinical reason for administration in patient’s notes

• Monitor and document physical observations including: Pulse, blood pressure, oxygen saturations, respiratory rate and ECG.

The registered nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES


46

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

CHEST PAIN

ASPIRIN

Aspirin commenced within 24 hours of the onset of an acute MI can be effective in reducing the overall mortality from acute MI, reduces non-fatal re-infarction and reduces nonfatal stroke.

Drug Name ASPIRIN

Common Brand Names Solprin, Disprin

Strength 300mg tabs

Dose 300mg dissolved in 100mls water STAT

Administration / Route PO with food

• Caution should be used when administering to patients with active gastric bleeding or Asthma

• Contraindicated in patients with known hypersensitivity to Aspirin

INDICATIONS

Aspirin is standard therapy for all patients with pain suggestive of acute MI to prevent coronary re-thrombosis and reducing the incidence of mortality

CONTRAINDICATIONS

Known allergy or hypersensitivity to aspirin or NSAIDS. Active peptic ulcer, bleeding tendency, severe hepatic dysfunction, third trimester of pregnancy.

DRUG INTERACTIONS

Anticoagulants, hypoglycaemics, uricosurics, methotrexate, NSAIDs, antacids, frusemide.

47

ADVERSE EFFECTS

Gastro Intestinal irritation, increased bleeding time, sensitivity, rashes, urticaria, heartburn, nausea and vomiting.

DOCUMENTATION

• Document clinical reason for administration in patient’s notes.

• Monitor and document physical observations including: Pulse, blood pressure, oxygen saturations, respiratory rate and ECG.

The registered nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted within 24 hours for ongoing management and this must be documented in the patient’s medical record.

REFERENCES


48

Haemorrhage / Hypovolemia Algorithm


Assess severity of haemorrhage / shock

(Refer to: Adult Standing Order Hypovolemia))

Control any external

bleeding, apply pressure

dressing. Stabilise and

penetrating objects

Early Shock (compensated)

Loss of 15% to 25% of blood volume

η Tachycardia, postural drop in BP,

narrowed pulse pressure, pallor,

thirst, diaphoresis, delayed

capillary refill time > 3 secs,

anxiety, restlessness

Late Shock (uncompensated)

Loss of > 30% to 45% of blood volume

η Hypotension, tachycardia,

delayed capillary refill time > 3

secs, cool/cold peripheries

altered level of consciousness

η Administer O2 > 15 litres via non

re-breathing mask

η Control external bleeding and

stabilise any penetrating objects,

if present

η Insert two large bore IV cannulas

(14-16g)

η Administer normal saline 500mls

over 30 minutes

η Call an Ambulance

η Administer O2 15 litres via non re-

breathing mask

η Control external bleeding and

stabilise any penetrating objects,

if present

η Insert two large bore IV cannulas

(14-16g)

η Commence IV normal saline 1

litre stat, (titrate to aim for heart

rate <100bpm, systolic blood

pressure > 90 mmHg)

η Assess neurological status and

regularly evaluate Airway,

Breathing and CirculationAssess severity and location of injury if

hypovolaemia is secondary to injury.

Stabilise any pelvic or long bone

fractures

Organise transfer to hospital

Notify Emergency Department

Notify Medical Officer and NUM and AHNM

49

49

Sodium Chloride is a fluid replacement in severe blood loss – more than 500mLs (approximate area equal to surface of a hospital towel). Sodium Chloride is infused to a patient with the use of a wide bore cannula. This procedure can only be undertaken by nursing staff accredited in inserting a cannula (does not include scalp vein needle). Normal Saline is an intravenous solution intended for restoring hydration.

DRUG NAME: NORMAL SALINE COMMON BRAND NAMES: Baxter STRENGTH: Normal Saline (0.9%) DOSE: The dose of Normal Saline is dependant upon the

age, weight and clinical condition of the patient as well as laboratory determinations. Parenteral drug products should be inspected visually for particulate matter and discolouration prior to administration. Additives may not be compatible.

ADMINISTRATION/ROUTE: Intravenous infusion via cannula. Titrate to aim for heart rate <100bpm and systolic blood pressure >90mm Hg

INDICATIONS:

• Intravenous fluid replacement

• Metabolic acidosis

• Restoring, maintaining NaCl; 3% (hypertonic)

• Severe NaCl depletion CONTRAINDICATIONS:

• Congestive Cardiac Failure

PRIMARY HEALTH CLINICAL STREAM

STANDING ORDERS

HYPOVOLEMIA

NORMAL SALINE 0.9%

(Sodium Chloride)

50

• Severe renal impairment

• Oedema with Na retention

• Raised, normal or slightly decreased electrolyte levels PRECAUTIONS: The intravenous administration of Normal Saline can cause fluid and/or solute overload resulting in dilution of serum electrolyte concentrations, over hydration, congested states or pulmonary oedema. The risk of dilution is inversely proportional to the electrolyte concentration of the infusion. The effect of the normal saline component on patients with metabolic or respiratory alkalosis should be monitored closely. Normal Saline should be administered with extreme caution. DRUG INTERACTIONS: Normal Saline should not be administered simultaneously with blood preparations through the same administration set because of possibility of coagulation. These products should not be administered concomitantly with potassium sparing diuretics and angiotension converting enzymes (ACE) inhibitors. Simultaneous administration of these drugs can result in severe hyperkalaemia. ADVERSE EFFECTS: Allergic reactions or anaphylactic/anaphyloid symptoms such as localised or general urticaria, skin rash and erythema and itching/pruritis; skin swelling, peri orbital, facial and/or laryngeal oedema (Quincke’s oedema); chest tightness, chest pain with tachycardia or bradycardia; nasal congestion, coughing, sneezing, bronchospasm and/or difficulty breathing have been reported during administration of Normal Saline. Adverse reactions may occur due to the solution of the technique of administration including fever response or infection at the site of injection. Prolonged intravenous infusion of this type of product may cause venous thrombosis or phlebitis extending from the site of injection, extravasation and hypovolaemia. If an adverse reaction does occur, discontinue the infusion and evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examiniation if deemed necessary.

51

OVERDOSE: Symptoms of overdosage with intravenous solutions are related to disturbed electrolyte levels and fluid imbalance. Symptoms indicative of overdose include shortness of breath, peripheral oedema, nausea, vomiting and diarrhoea, abdominal cramps, weakness, paraesthesia, paralysis, mental confusion, tachycardia and other cardiac abnormalities. Overdose requires immediate clinical assessment, cessation or slowing of intravenous fluids, laboratory assessment of electrolyte levels, calculation of fluid balance, electrocardiogram (ECG) monitoring and commencement of appropriate supportive treatment. DOCUMENTATION:

• Document observations, including Glasgow Coma Score in patients’ notes.

• Document response to treatment The nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record. REFERENCES: MIMS Online. Available at http://www.ciap.health.nsw.gov.au

52

Hypoglycaemia Algorithm


(Refer to: Adult Standing Order Hypoglycaemia)

Indications – deteriorating level of consciousness or coma especially in known diabetic

patients, low BGL <4mmol/L)

Administer O2 15 L/min. Check BGL < 4mmol/L)

Altered level of Consciousness?

Talking normally (swallow reflex present)?

Give oral glucose drink

Reassess Blood Glucose Levels and

Glasgow Coma Scale.

Follow the Justice Health Hypoglycaemia

Action Plan (See over page)

Altered level of consciousness?

Assess neurological status and regularly

evaluate Airway, Breathing and Circulation

Assess causation of hypoglycaemic episode.

If concerned, ring Medical Officer and/or

organise transfer to hospital.

Observe and regularly check BGL for 4 hours

Contact MO for advice re ongoing management

Consider opioid

overdose if BGL

not < 4mmol/l

(Refer to Opioid

overdose

algorithm)

1mg glucagon hypokit SCI

Assess response

(post glucagon vomiting is not

unusual)

Responsive to Glucagon?

Administer 50mls of 50%

Dextrose

IVI

Rate of infusion should not exceed

0.5g/kg/hr to avoid glycosuria

Reassess response

Arrange emergency transfer to

hospital

Yes

No

No

No

Yes

Yes

Yes

No

53

HHyyppooggllyyccaaeemmiiaa AAccttiioonn PPllaann What is hypoglycaemia?

Hypoglycaemia (also called a ‘hypo’ or low blood glucose) is when blood glucose level has dropped too low. Usually this occurs when the level falls below 4 mmol/L although this can vary. While people taking certain tablets for their diabetes can experience hypoglycaemia, it is more common in people who inject insulin.

What are the main causes of hypoglycaemia?

Delaying or missing a meal Not eating enough carbohydrate

Unplanned physical activity More strenuous exercise than normal

Drinking alcohol Too much insulin or tablets

What are the symptoms?

(symptoms vary from person to person)

Weakness, trembling or shaking

Sweating

Light headedness Headache

Dizziness Lack of concentration / behaviour change

Tearful / crying Irritability

Hunger Numbness around the lips and fingers

If you feel any of these symptoms, test your blood glucose level. If you are not able to do this, treat as a hypo.

How is a “hypo” treated?

Have some quick acting carbohydrate:

• 3 glucose tablets.

Plus (only 1 of the following) longer acting carbohydrate:

• 1 small can baked beans OR 6 small dry biscuits in sealed pack OR 1/2 sandwich OR 1 glass milk or soy drink OR 1 piece of fruit OR 2-3 pieces of dried apricots, figs or other dried fruit OR 1

small tub of low fat yogurt.

Wait 10-15 minutes. Retest your blood glucose - if it isn't rising, repeat treatment with a quick acting carbohydrate as described above. If your next meal is more than 20 minutes away, eat some longer acting carbohydrate.

Two hypo kits will be issued. The Hypo Kit should only be used in the event of a hypo. Go to the clinic for replacement Hypo Kit if the kit is used for a hypo or if the “use by date” on the rations has expired.

Adapted from Diabetes Australia resources,

accessed from

www.diabetesaustralia.com.au

54

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

HYPOGLYCAEMIA

GLUCAGON

Nursing staff may use IM glucagon and IV dextrose for severe hypoglycaemia under the provisions of this policy.

Be mindful of other causes of unconsciousness e.g. narcotic overdose.

Drug Name GLUCAGON HYDROCHLORIDE

Common Brand Names Glucagen Hypokit, Glucagen

Strength 1mg Injection

Dose 1mg SC, IM or IVI

Administration / Route Subcutaneous, intramuscular or intravenous injection

If possible check blood glucose and if less than 4mmol / litre then:

• If conscious with adequate swallowing reflex give a glucose drink or jelly beans.

• If level of consciousness is deteriorating or if unconscious, give Glucagon SC, IMI or IVI.

• Administer IV Dextrose as per Standing Order.

Give oral carbohydrates when patient has responded to prevent recurrent hypoglycaemia.

INDICATIONS

If hypoglycaemia is suspected in a known diabetic or level of consciousness is deteriorating.

CONTRAINDICATIONS

• Known allergy or hypersensitivity

• Phaeochromocytoma

• Insulinoma

• Glucagonoma

55

PRECAUTIONS

Fasting, adrenal insufficiency, chronic alcohol induced hypoglycaemia.

DRUG INTERACTIONS

• Warfarin

• Beta-blockers

• Insulin (antagonise glucagon)

• Secondary hypoglycaemia

ADVERSE EFFECTS

• Nausea and/or vomiting

• Secondary hypoglycaemia

DOCUMENTATION

• Document observations, including Glasgow Coma Score (GCS) and BGL in patient’s notes

• Document response to treatment.


REFERENCES


56

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

HYPOGLYCAEMIA

DEXTROSE

Nursing staff may use IM glucagon and IV dextrose for severe hypoglycaemia under the provisions of this policy.

Be mindful of other causes of unconsciousness e.g. narcotic overdose.

In an emergency situation e.g. respiratory compromise or arrest, follow resuscitation procedures.

Administration of 50mg Thiamine IMI may be necessary to prevent the precipitation of acute Wernicke’s encephalopathy in patients with alcohol dependency and should be administered prior to the administration of Glucose.

Drug Name 50% GLUCOSE

Common Brand Names 50% Dextrose, 50% Glucose BP Injection

Strength 50ml Mini-jet Injection

Dose 50ml of 50% Glucose IVI. Rate of infusion should not exceed 0.5g/kg/hr to avoid glycosuria.

Administration / Route Intravenous injection ONLY.

• If conscious with adequate swallowing reflex give 10-20g of glucose orally.

• If level of consciousness is deteriorating or if unconscious, give IMI, IVI or SC glucagon.

• If comatose or patient’s level of consciousness does not improve administer IV Dextrose as per Standing Order.

• If comatose, cannulate using 21g scalp vein set and administer 50 mls of 50% Dextrose intravenously. Flush cannula with 10 mls of normal saline 0.9% intravenously.

• If patient remains unconscious, contact medical officer and urgently transfer to a local hospital.

• As patient recovers, contact medical officer for further treatment.

• NB: extra care should be taken to avoid local site tissue necrosis

57

INDICATIONS

• If hypoglycaemia is suspected in a known diabetic or otherwise level of consciousness is deteriorating

• Comatose patient

CONTRAINDICATIONS

• Diabetic (hyperglycaemic) coma

• Anuria

• Intraspinal / intracranial haemorrhage

• Dehydrated delirium tremors

• Corn (maize) allergy

• High ischaemic stroke risk

• Glucose – galactose malabsorption syndrome

DRUG INTERACTIONS

Corticosteroids, check compatibility of additives.

ADVERSE EFFECTS

• Tissue necrosis if extravasations from vein occurs

• May aggravate brain damage in head injuries and strokes

• Fluid, electrolyte, acid-base disturbances

• Injection site reactions

• Vitamin B deficiency

• Anaphylaxis

• Flushing

• May precipitate Wernicke's encephalopathy in alcoholics with Thiamine deficiency.

DOCUMENTATION

• Document observations, including Glasgow Coma Score (GCS) and BGL in patient’s notes.

• Document response to treatment.


REFERENCES


58

Meningococcal Disease Algorithm


Ensure Differential Diagnosis assessed

(Refer to: Adult Standing Order Suspected Cases of Meningococcal Disease)

Suspected case of meningococcal disease (Droplet precautions: gloves and mask)

PATIENT with sudden onset of:

ν Fever, prostration

ν Nausea, vomiting

ν +/- Rash (e.g. petechial, purpuric, maculopapular) – check patient’s body carefully

ν +/- Headache, drowsiness, with or without neck stiffness

ν Irritability, confusion, seizures, photophobia

Suspect bacterial sepsis

ν Arrange immediate transfer to hospital by Ambulance

ν Discuss with Medical Officer on call with view to immediate administration of

penicillin

ν Notify NUM or Nurse Manager on call

Benzylpenicillin should be withheld ONLY if an individual has a clear history of either an

anaphylactic or an immediate hypersensitivity reaction (such as difficulty in breathing,

angioedema or a generalised urticarial rash) after a previous dose of penicillin, use

Ceftriaxone.

Reconstitute 1.2g Benzylpenicillin with 3.2mls water for injection or

2 X 600mg vials each with 1.6mls water for injection (total 3.2mls)

Administer Benzylpenicillin IMI

or

Ceftriaxone 2g reconstitute 1g in 3.5mls water for injection, administer by deep

intra-gluteal injection, recommend maximum 1 g per side

Assess: temperature, pulse, blood pressure, respirations, O2 saturations

Observe for signs of anaphylaxis

(Refer to: Standing Order Anaphylaxis)

Discuss with Medical Officer on call

Await transfer to hospital

Notify Justice Health,

Population Health Unit

59

59

Refer to the JH&FMHN Policy for the Management of Suspected Cases of Meningococcal disease Policy No 1.275. CLINICAL RECOGNITION OF MENINGOCOCCAL DISEASE:

• Meningococcal disease usually presents as meningitis, septicaemia, or as a combination of the two.

• The hallmark of meningococcal septicaemia is a petechial rash. However, a rash is not always present, especially in the early stages.

• Any patient with a systemic febrile illness should be observed and reassessed frequently.

DRUG NAME: BENZYLPENICILLIN (SODIUM) COMMON BRAND NAMES: BenPen (injection) STRENGTH/PRESENTATION: 1.2 g vials or 600 mg vials DOSE: 1.2g IMI STAT ADMINISTRATION/ROUTE: Reconstitute with 1.6mls Water for each 600mg of Benzylpenicillin powder. Dissolve Benzylpenicillin in Water for Injections and use immediately. PATIENTS HYPERSENSITIVE Ceftriaxone 2 x 1g IM TO PENICILLIN IMI: dissolve 1g in water for injection 3.5mL, administer by deep intragluteal injection, recommend maximum 1g per side. N.B. Ceftriaxone is usually administered in lignocaine to minimise pain associated with intramuscular injection. As lignocaine is not approved for injection without a medical officer’s approval in Justice Health, and medical officers are not immediately available on site in all Justice Health facilities, the Drugs and Therapeutics Committee approved its reconstitution in water.

POPULATION HEALTH CLINICAL STREAM

STANDING ORDERS

SUSPECTED CASES OF MENINGOCOCCAL DISEASE

BENZYLPENICILLIN (SODIUM)

60

All Health Centres should have a supply of Benzylpenicillin 1.2g or 600mg x 2, Ceftriaxone 1g x 2 plus Water for Injections x 10.

Reconstitution Benzylpenicillin

TYPICAL SYMPTOMS AND SIGNS OF MENINGOCOCCAL DISEASE INCLUDE:

• Sudden onset of fever

• Leg pain, cold extremities, and abnormal skin colour (early signs in children aged under 16 years)

• Headache

• Nausea, vomiting

• Irritability, photophobia, with or without neck stiffness

• Drowsiness, decreased level of consciousness

• Swollen or painful joints, difficulty walking

• Rash, however a rash may not appear until later, may be haemorrhagic (i.e. petechial or purpuric) or less commonly maculopapular

• Signs of sepsis or cardiovascular shock (tachypnoea, fever or hypothermia)

INDICATIONS:

• If a patient is suspected of having meningococcal disease urgent transfer by ambulance to hospital and immediate administration of Benzylpenicillin is essential.

• Any patient with an acute systemic febrile illness, and a petechial or purpuric rash should receive immediate antibiotic treatment with Benzylpenicillin.

CONTRAINDICATIONS: Benzylpenicillin should be withheld only if an individual has a clear history of either an anaphylactic or an immediate hypersensitivity reaction (such as difficulty in breathing, angioedema, or a generalised uticarial rash) after a previous dose of penicillin. Most people with a penicillin allergy do not have such a history and can safely be given Benzylpenicillin. If there is a history of either

Reconstitution fluid

Maximum concentration

Recommended route

Intra-muscular

For each 600mg of Benzylpenicillin powder

Dissolve in 1.6mL of water for injection

300mg / ml

As per usual IM injection

61

an anaphylactic or an immediate hypersensitivity reaction, do not administer penicillin, use Ceftriaxone as per the standing order above. Seek urgent advice from the on-call clinician at the referral hospital, but do not delay ambulance transfer.

PRECAUTIONS: Although penicillin’s are generally well tolerated the possibility of allergic reactions must always be considered. Serious, and occasionally fatal hypersensitivity reactions (anaphylaxis) have been reported. Serious anaphylactic reactions require emergency treatment with adrenaline. Refer to the Standing Order and Protocol for the management of Anaphylaxis, and ensure that adrenaline is available. DRUG INTERACTIONS: Probenecid, chloramphenicol, tetracyclines, erythromycin, oral contraceptives.

ADVERSE EFFECTS: Sensitivity, superinfection, GI upset, renal hepatic, haematological, CNS effects, fever localized effects.

DOCUMENTATION:

• Physical Observations including: pulse, blood pressure, respiratory rate, oxygen saturation, and physical assessment must be noted in patient’s medical record.

The registered nurse must record the administration in ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record. REFERENCES: Guidelines for the early clinical and public health management of meningococcal disease in Australia, CDNA, Commonwealth Department of Health and Aging, 2007 MIMS Abbreviated prescribing Information for BenPen. (accessed August 2010). Australian Medicines Handbook 2007

62

MIMS online. Available at http://ciap.health.nsw.gov.au (accessed March 2011) Therapeutic Guidelines, Revised June 2010 (accessed March 2011). Available at http://ciap.health.nsw.gov.au

64

PRIMARY HEALTH

CLINICAL STREAM

STANDING ORDERS

OPIOID OVERDOSE

NALOXONE (NARCAN)

(Likely Opioid Overdose)

Respiratory depression is a principal feature not only of opioid overdose but also of overdose of other substances such as sedatives and hypnotics.

Any patient found unconscious with no apparent cause should be treated as a potential drug overdose.

Any patient who is suspected of being intoxicated or having an altered state of consciousness should be moved to the main clinic for optimal ongoing clinical review. Where access remains difficult, arrangements should be made to transfer the patient to the nearest general hospital, as per normal organizational protocol.

Where there is any altered state of consciousness oxygen should be administered via mask at 15 litres per minute. In many instances opioid overdose can be managed successfully with oxygen administration via mask without requiring naloxone administration. Oxygen saturation levels should be monitored using a pulse oximeter where available. Oxygen saturation levels should be provided to the treating Medical Officer.

Drug Name NALOXONE

Common Brand Names Narcan

Strength 2 mg in 5ml minijet

Dosage Regimen Suspected or known opioid overdose

Administration / Route Adults:

Initially 2 mg IMI or SCI

Repeat every 2-3 minutes if necessary to a maximum dose of 10mg

Do not give to persons with a primary head injury or with known cardiac conditions or if myocardial infarction is suspected

ADMINISTRATION

In the absence of a Medical Officer, a Registered Nurse may commence treatment for suspected drug overdose where there is no other obvious cause for change in consciousness in the patient, such as diabetes or head injury. The effective use of naloxone allows time to further assess the patient and to consult for medical advice and arrange ongoing treatment

65

• If a patient’s life is assessed to be seriously at risk due to suspected opioid overdose, then naloxone is to be used irrespective of the patient’s wishes or consent. In emergency circumstances it is not necessary to seek an order for enforced medication. This can always be obtained retrospectively.

• In cases of buprenorphine suspected overdose, the dose of naloxone required is much greater

• The patient is monitored as per JH&FMHN&FMHN Drug and Alcohol Procedure No. W1-Management of Intoxication and Withdrawal – Broad Principles

INDICATIONS

Suspected Opioid Overdose

Naloxone is an opioid antagonist. If administered to someone suspected of an opioid overdose, it effectively and rapidly reverses respiratory depression and other overdose effects. If administered to a person who is opioid drug free it exerts little or no pharmacological action.

Naloxone also induces withdrawal symptoms when administered to an opioid dependent user. In these cases, the naloxone induced withdrawal is more severe because its opioid blocking effect is immediate -- in unprecipitated withdrawal the body has some time to compensate for the absence of the drug.

Reversal of opioid overdose effects can occur in as little as one to two minutes. Naloxone does not produce dependence and has no potential for abuse. There have been no reported deaths attributed to naloxone overdose. Tolerance to its antagonist actions does not appear to occur.

Where the opioid overdose is due to methadone or other long acting opioids, the patient must be monitored for at least four hours as the half life of naloxone is substantially less than that of methadone and other long-acting opioids. Therefore the patient may experience respiratory depression again, once the initial dose of naloxone is no longer effective. These patients may require a naloxone infusion and should be transported to hospital.

DOCUMENTATION

The nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record.

REFERENCES

MIMS Online. Available at: http:// www.clininfo.health.nsw.gov.au

66

Status Epilepticus Algorithm


(Refer to: Adult Standing Order Status Epilepticus)

Indications – a succession of tonic-clonic “grand mal” convulsions without the patient regaining

consciousness

Seizure activity lasting less than 3

minutes

Administer O2 15L/min via non re-

breathing mask

Place patient in recovery position

Regularly assess airway and breathing

Reassure the patient

Seizure activity lasting greater than 3

minutes

Administer O2 15L/min via non re-

breathing mask

Administer 5mg midazolam (Hypnovel)

IMI- half dose for head injuries,

advanced age, smaller than average size,

CAL and general debility

May be repeated once after 5 minutes if

seizure activity continues

Organise an ambulance to transport to

hospital

Continue monitoring ABC and

maintaining airway with chin lift/jaw thrust

maneuvers, if required

NB. Do not attempt to force an airway into the

mouth of a fitting patient

Assess for signs of injury

Check BGL

Conduct GCS assessment

If able, discuss with Medical Officer

the need for further treatment whilst

awaiting ambulance

Notify NUM or AHNM

Assess differential diagnosis

Consider alcohol / benzodiazepine withdrawal seizure

(Discuss with Drug and Alcohol Medical Officer on call if drug withdrawal seizure suspected)

Discuss with Medical Officer

Monitor GCS for 4 hours post seizure if transfer to hospital is not indicated

67

67

A single epileptic attack is seldom fatal except on the rare occasions when it causes an accident to the patient, such as drowning or falling from a height. Convulsions of CLINICAL SIGNIFICANCE, in emergency situations, are almost always of the tonic-clonic ("Grand Mal”) type; rarely are they of the "complex partial" type. Midazolam is an extremely potent benzodiazepine and this group of drugs has the potential for abuse. "Status epilepticus" is a succession of generalised tonic-clonic ("grand mal") convulsions, without the patient regaining consciousness. It is potentially fatal, unless the fits are arrested, because of hypoventilation and/or apnoea. THE FIRST-AID MANAGEMENT of status epilepticus consists of:

• Maintenance of the airway,

• Oxygen at 10 to 15 L/min and

• Prevention of injury to the patient If the seizures persists for more then 2-3 minutes, nursing staff are authorised to administer Midazolam under the following Standing Order.

PRIMARY HEALTH CLINICAL STREAM

STANDING ORDERS

STATUS EPILEPTICUS

MIDAZOLAM

68

DRUG NAME: MIDAZOLAM COMMON BRAND NAMES: Hypnovel STRENGTH: 5mg/1ml Ampoule DOSE: 5mg IMI

With head injuries,advanced age,smaller than average size,CAL and general debility the dose MUST be Halved

ADMINISTRATION/ROUTE: Intramuscular injection

• May be repeated once after 5 minutes if fitting persists up to a maximum of 10mg

• Depression of the respiratory centre may result in the need for assisted ventilation.

• The advice of a Medical Officer must always be sought, as soon as practicable, regarding further management. The patient should be transferred to hospital.

• Continuous monitoring of the patient during and after administration is required.

INDICATIONS:

Seizures that continue unabated for more than 2 – 3 minutes. CONTRAINDICATIONS:

• Known allergy

• Myasthenia gravis

• Shock

• Coma

• Acute alcohol intoxication

• Narrow angle glaucoma DRUG INTERACTIONS:

• Alcohol

• CNS depressants

• Anaesthetics

• Cimetidine

• Erythromycin

• Sodium Valproate ADVERSE EFFECTS:

• Respiratory depression

• Cardiac/respiratory arrest

69

• Hypotension

• Hiccup, cough

• Elderly – increased risk of over-sedation, ataxia, confusion, falls, respiratory depression and short term memory impairment, reduce dose as above and monitor closely

• Critically ill – Midazolam elimination half life is prolonged, reduce dose as above and monitor closely. DOCUMENTATION:

• Document clinical reason for administration in patient’s notes.

• Monitor and document physical observations including: GCS, pulse, blood pressure, oxygen saturations, and respiratory rate. The registered nurse must record the administration in black ink on the Standing Order chart. A Medical Officer must be consulted as soon as possible regarding ongoing management and this must be documented in the patient’s medical record. REFERENCES:

MIMS Online. Available at: http:// www:ciap.health.nsw.gov.au (accessed 2010) APPENDICIES:

1. A Very Brief Overview of Epilepsy

70

APPENDIX 1: A Very Brief Overview of Epilepsy

Epilepsy is a brief paroxysmal disturbance of cerebral function that occurs periodically and is due to paroxysmal neuronal discharges resulting in fits that are often, but not always, accompanied by loss of consciousness. There are many different forms of epilepsy and attacks may consist of: sudden onset of sustained muscular contractions (tonic):

o Rhythmic jerking of the face, trunk, or limbs (clonic) o Contractions and jerking (tonic-clonic, or "GRAND MAL") o Transient loss of consciousness ("petit mal") o A muscular jerk (myoclonus) o Sudden impairment of postural tone, causing a falling attack (atonic or akinetic) o Unilateral motor or sensory symptoms (focal) o Hallucinations of the special senses and disturbances of memory or emotion ("complex partial") o Tonic-clonic ("GRAND MAL") seizures have the following features: o Patients infrequently have premonitory symptoms, the "aura", e.g. elation, depression, irritability, headache, odd sensations (e.g. feeling a breeze) o There is apnoea during the tonic phase o There is often incontinence of urine o Some form of self-injury often occurs e.g. tongue biting, injury to the head or a limb by striking a hard object etc. o There may be incontinence of faeces o Stupor and confusion for minutes or hours usually follow the convulsion. DRUG WITHDRAWAL FITS and PSEUDO FITS are CLASSICALLY TONIC-CLONIC ("GRAND MAL"). Management rarely requires more than airway maintenance and prevention of self-injury. They usually cease in a couple of minutes with the patient regaining consciousness, partially or completely, (these times may SEEM longer). Recurrence is not unusual but, again, observation and maintenance of the airway and prevention of self-injury is all that is usually necessary. In the rare event that a drug withdrawal fit is so prolonged and severe that it can be classed as status epilepticus, the above Standing Order is indicated.

71

Stab Wound Algorithm


NOTE: Ensure Personal Protective Equipment is donned

prior to treatment

Assess: temperature, pulse, respiration rate, oxygen saturations and extremity observations

Commence O2 at 15L/minute via non re-breathing mask

Assess wound

Knife or foreign object in wound?

Do not remove.

Stabilise object

with normal saline

soaked gauze

Assess blood loss /

signs of shock

Apply pressure dressing to stop bleeding, or

reassess dressing if already applied, do not

remove

Assess blood loss / signs of shock

Are there signs of shock?

(Refer to: Haemorrhage / hypovolaemia algorithm

ϕ Administer O2 at 15 L/minute via

non re-breathing mask

ϕ Control external bleeding if

present

ϕ Insert two large bore IV cannulas

(16-14g)

ϕ Do not administer fluids for

penetrating trauma unless seen

to be only external haemorrhage

i.e. to a limb

ϕ Commence IV normal saline at

20ml/kg over 15 minutes (titrate

to aim for heart rate<100bpm,

systolic blood pressure

>90mmHg

Organise urgent transport to hospital

via Ambulance

Stab wounds to head, neck, chest, back or

abdomen; require urgent transport to hospital for

investigation. Assess extremity injuries for

neurovascular impairment

Does patient require transfer to hospital?

Discuss further

management with

Medical Officer

Insert 16-14g IV

cannula

Organise transport to

hosiptal, notify

Emergency Department

Notify NUM or AHNM

Regularly assess changes in vital

signs, signs of shock, airway,

breathing and circulation

Yes

No

No

No \ Unsure Yes

Yes

71

72

Suicide Risk / Attempt Algorithm


Identified as having increased suicide risk factors

Is this an Acute Suicide attempt?

For completed suicide

Refer to JH Policy 1.120,

Death in Custody

If patient has attempted

hanging, a cervical spine

injury must be suspected.

Apply stiff neck collar and

maintain cervical spine

precautions

Is patient

expressing

suicidal ideation?

Assess patient

and treat any

injuries

Is patient able to

ensure their own

safety?

Activate

Mandatory

Notification Form

Exclude / stabilise physical

health, mental health and / or

substance use problems

Refer via PAS to appropriate

stream

Consider safe environment /

assessment / group cell

placement

Consider need for human

contact

Assess need for mandatory

notification

Refer to Mental Health

clinician if patient has a

mental health issue

Complete health problem

notification form

(JH Policy 1.1380, Suicidal and

self harm behaviour management)

Consider assessment / two

out cell placement with

minimal possessions

(JH Policy 1.340,

Accommodation; Clinical

Recommendations (Adult)

Discuss patient with

psychiatrist

Organise transfer to

hospital for further

assessment

Discuss with Medical

Officer

Notify NUM/AHNM

Is patient

medically stable?

Educate re services and how to

access them

Refer for psychosocial support

Ensure ongoing supervision and reassessment for changes in mental

health status

If concerned discuss patient with psychiatrist or Medical Officer

No

Yes

Yes

No

No

No Yes

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