grad ind protocol and pharmacology study guide

GRAD IND Protocol and Pharmacology Study Guide v1 Jan 2021 of 41

Student Name: Teagan Rogers Employee No:_60258042

GRAD IND Protocol and Pharmacology Study Guide

2021


Dear Graduate P1 Trainee,

This Study Guide is to assist you in your learning of NSW Ambulance Protocols and Pharmacology. Completion is a mandatory part of your training and will be collected at the end of week four (4) of your Induction Course.

To save paper, this document is to be completed electronically and emailed to your Course Coordinator for electronic filing.

The majority of the answers are located within the NSW Ambulance Protocols and Pharmacology book or on the APP. If you have not downloaded the APP yet, it is highly recommend that you do so, as it will give you the latest updates.

Some of the questions will ask you to perform some research to provide an answer. This research does not need referencing and the answer does not need to be exceedingly

detailed, only enough to show your understanding. Completion of this Study Guide will also assist you to study for your Protocol and Pharmacology Quiz.

The quiz will consist of 20 multiple choice questions to be completed in thirty (30) minutes. Students may use their Protocols and Pharmacology Booklets if required to

complete the exam. The pass mark is 100%. Scores greater than or equal to 85% will require written resubmission of incorrect answers. Scores less than 85% will incur a supplementary assessment.


AMBULANCE PARAMEDIC PROTOCOL AND PHARMACOLOGY QUESTIONS WORK BOOK

NB: These scenarios ask questions covering multiple protocols in the Ambulance Foundation, Reference and Pharmacology section of your protocols. Your partner

is a P1 paramedic Scenario 1

You and your partner are dispatched on a lights and sirens case to the local football field for a 38 year old male complaining of shortness of breath.

On arrival, you see a middle-aged male sitting on a lawn mower holding his chest in obvious distress. The patient is in the middle of the field.

1. On reaching the patient, they have irregular breathing, and are able to talk in full

sentences. What must be determined and gained by you and your partner before

commencing any treatment or transport? Define each of these three concepts.

Before any treatment can begin, the paramedics must need to assess the patient

or person responsible for the patient has the capacity and competency to give

consent to treatment. If they do have these three concepts, the paramedics can

begin treatment. Consent is fluid however and can be revoked or reassessed at

any time and should be reassessed before transport.

Consent must be given by someone who has capacity, given freely, sufficiently

specific to the procedure or treatment proposed and must be informed. There is

expressed and implied consent and the person responsible for the patient can

also give consent.

Capacity is based on the patient being able to understand the facts involved,

weigh up the consequences and communicate their decision. Competency refers to the patient’s status under the law to able to make the decision

about their healthcare and well-being. Competency is demonstrated in patients without

chronic


compromise of cognitive function.

2. The patient gives you their consent to assess and treat them. Your partner instructs

you to assess the patient. What are the two assessments that you need to initially

perform. How do these assist you in your initial treatment of the patient?

The first is the primary survey – consisting of danger, response, airway, breathing,

circulation and the patient disability. This should be repeated after the first

intervention as it is the best indication of patients response to treatment.

Secondary survey is the next step of this and includes a full head to toe and

focused assessments dependent on how the patient presents.

On doing your initial survey you find:

Airway Currently patent, though is complaining of airway swelling

Breathing Irregular due to anxiety, able to

talk in full sentences, wheezing audible

Circulation Pulses: Present, rapid, thready Skin: Pale, cool, clammy

Disability Level of Consciousness is Alert

Exposure Hives on chest and throat, there is a welt on the left shoulder.

Initial Observations Blood Pressure – 90/40 Respiratory Rate – 22/per minute Heart Rate – 124 Pupils – Equal and reactive

Oxygen Saturations on room air – 92%,

3. Your partner and you decide that the patient needs oxygen. Explain why oxygen

is required for this patient according to the Oxygen Pharmacology 221.

Oxygen is indicated as the patient has a Sp02 of less than 92% on room air.

Given this patients hypoxic presentation, the targeted outcome is maintain Sp02

of >94-98%.


4. Both paramedics decide due to the patient’s signs and symptoms to administer the

medication Adrenaline. Explain the process that you and your partner must do

when selecting and confirming to administer a medication.

1. Confirm diagnosis and establish the need to administer medication

2. Check for any contraindications to administration

3. Select medication to be administered and confirm with partner

- The correct medication is selected (look alike/sound alike

medications) - The medication is within expiry date - The medication does not appear to be damaged or unusable

4. Draw up or prepare medication to be administered. Medications must not be mixed or administered together unless authorized by protocol or pharmacology

5. Confirm the “5 Rights” of medication administration with your partner

- Right patient

- Right medication - Right dose - Right route - Right time

6. Administer medication and repeat doses. Continue to monitor patient and

above process for each new medication

5. Fill in the following table for the Adrenaline administration.

Route Initial Dose

Repeat Times

Max Total

Dose

IM

500mcg

1:1000

5 mins

No maximum dose


6. What could be any possible adverse effects that your patient could experience post

your administration of Adrenaline?

Adverse effects can include tachycardia, dysrhythmias (ventricular

fibrillation), hypertension, pupillary dilation, anxiety, and nausea with or

without vomiting.

7. The patient’s condition is slow to respond to your treatment regime. You decide

that the patient needs urgent transport. Why do you and your partner make this

decision and under what category would you put this decision? (A8)

The patient is experiencing a distribution and relative hypovolemic shock with due

profound reduction in venous tone and fluid extravasation causing

reduced venous return cause decreased myocardial function.

8. Your transport time to hospital is 20 minutes with lights and sirens. How often are

you required to take the patient’s observations? What system dictates this?

(Reference 28)

According to R28 (Adult observation range guides), the patient meets the Red Zone

Criteria with a systolic blood pressure of 90. This requires repeat observations

every 5 minutes.


Scenario 2

You are called to a 10-year-old riding an ATV was thrown off at about 30kmh, when they

hit a log in tall grass. The patient’s caregivers are present on scene and are very

concerned about their child’s well-being.

Airway Protecting airway, crying, breathing spontaneously

Breathing Clear lungs bilaterally, oxygen saturations 98% on room air

Circulation Capillary refill intact, colour slightly pale skin, heart sounds normal, peripheral pulses palpable

Disability Awake, alert, anxious and crying, moving all extremities, pupils normal

Exposure Deformity and laceration to R mid forearm noted.

Initial Observations Blood Pressure – 100/70 Respiratory Rate – 16/per minute Heart Rate – 128

Pupils – Equal and reactive Oxygen Saturations on room air – 98%,

1. You and your partner have assessed the scene and are with the patient and

caregivers. Whose consent do you need to start assessing and treating this patient?

What determines this decision? (A3)

As per A3 (informed consent, capacity, and competency), there is no set age for

when a minor can independently consent or refuse treatment. Given the

nature of this specific case, the child is anxious and crying. While consent can

be sought by the patient, the caregivers are on scene and will be able to give

consent of behalf of the child/patient.

2. What are two key points that could help you recognize that this 10-year child is sicker

than they could possibly appear? (A5) By having a structured assessment and repeated observations it will assist

in detecting subtle signs or cues or illness. As noted in A5, parental anxiety

should not be discounted even if the child does not seem unwell.


3. The caregivers agree with you and your partner’s decision to try to ease the patient’s

pain. As the patient is 10-years old what is the preferred route of administration of

medications for this child’s complaint? (A6)

As per A6 (Pain Management), consideration should be given to the route for

children <14 years or under (as this patient is) with inhalational/intranasal

administration as the preferred route.

4. What would be the dose of Fentanyl you would administer Include in your answer your preparation, initial dose, repeat doses and maximum dosage.

Preparation

Initial dose

Repeat dose

Max dose

450mcg (1.5mL) in a sealed vial

75mcg

undiluted IN

First Spray is

105mcg

(0.35mL)

30mcg

undiluted

(0.1mL) every five minutes as

needed

No Maximum

Dose

5. What are the contraindications of Fentanyl that you need to check before you

administer the above dose? Contraindications for Fentanyl administration is altered level of consciousness,

epistaxis or occluded nasal passages, patients <1 year of age, previous or

known allergy or adverse reaction to Fentanyl and pregnant women >20 weeks

gestation in labour. This patient has nil known contraindications.


Medical Protocol Questions

These scenarios ask questions covering the Medical/Surgical Protocols and Pharmacology sections of your protocols. Your partner is a P1 Paramedic.

Scenario 1

You and your partner are responded to a R1 case. Upon arrival you find a 65-year-old

male lying on the bed. He complains of sudden onset of severe abdominal pain radiating

through to his back. This began just before calling 000.

Airway Clear and Patent

Breathing Respiratory rate=26

Circulation Heart rate=110, pale and diaphoretic

Disability GCS=15

Exposure When you examine his abdomen you feel a tender pulsatile mass in the mid-

abdomen.

Focused History O2 saturations =95% BGL= 6mmol ECG = sinus tachycardia

Blood Pressure = 180/110 He feels weak but no nausea, vomiting or diarrhoea, past history of hypertension

Pt weight = 63KG

1. List three major headings of the potential “Red Flags” presentations for Abdominal

Pain.

Three major “red flags” for acute abdomen pain are obstruction, cardiovascular

and metabolic causes for the pain.

2. What are the four physical examinations that need to be completed for a patient with

abdominal pain?

The four physical examinations that will help formulate a provisional diagnosis in

a patient with abdominal pain are vital signs, inspect abdomen, auscultate

abdomen as well as percuss and palpate the abdomen.


3. You and your partner provisionally diagnose this patient with a dissecting abdominal

aortic aneurysm. Both of you consider treating the patient under the Medical Hypo-

perfusion/Hypovolaemia Protocol. Explain the “key signs of shock/ Hypo- perfusion”

that would determine your decision.

Two key signs for this patient is that he is tachypnoeic and has poor skin

perfusion which is clinically presenting as pale and diaphoretic.

He would need to be continually monitored for signs of tachycardia, and

changes in his systolic blood pressure as well as level of consciousness.

4. What is the most appropriate dosage of Compound Sodium Lactate for this patient?

Route Initial Dose

Repeat Information

Max Total Dose

IV/IO

20mL/kg bolus

This patient

would be getting a 1.26L bolus as per his weight.

Whilst indicated

No maximum dose


Scenario 2

You and your partner are attending a 30 year old woman who has a past history of

asthma including the use of multiple medications to assist her control and relieve her

asthma. She has been admitted to hospital before for her asthma. For the last 24 hours

she has had a mild productive cough and breathing difficulty that sounds like it could be

a chest infection. Today she has been having continual difficulty with her breathing

gaining no relief from her nebuliser and puffer. Her breathing difficulty has increased

notably over the last hour so, her husband called for Paramedic help.


Breathing Respiratory rate = 30min, c/o severe breathing difficulty, clear dyspnoea evident with

increased effort. On auscultation there is chest wheezing bilaterally.

Circulation Heart rate = 116, pale cool clammy

Disability GCS = 14 eyes open to voice. Patient is very tired and drowsy.

Exposure Use of accessory muscles and retraction

Focused History O2 saturations = 93%

ECG = sinus tachycardia Blood Pressure =130/80

1. Your partner asks you to determine the patient’s Asthma Severity using the above

observations what is the patient’s Asthma Severity and explain your decision.

Using the M4 protocol on Asthma, this patient meets the criteria of severe

asthma. This patient meets this criterion with the tachypnoea, severe breathing

difficulty, dyspnoea, bilateral wheeze, she is tachycardic, showing early signs of

poor perfusion, use of accessory muscles, and her Sp02 is 93% on room air.

2. Based on your above determination what would you and your partner’s treatment

plan be?

After assessing our patient, our priority would be to minimise time on scene.

Secondly, administering Salbutamol (5mg NEB or as per COVID protocol

300mcg through MDI and spacer), Ipratropium Bromide (500mcg NEB or as per

COVID protocol 40mcg through MDI), and Hydrocortisone via IM/IV route at a

single dose of 100mg. Continue to reassess to see patients’ trends and adjust


accordingly. If she begins to trend negatively or there is no improvement call

control for ICP backup for potential IV adrenaline.

3. Your partner asks you to obtain out of the medication kit the correct Salbutamol and

Ipratropium Bromide dose. What are the correct doses of both medications for this

patient?

Secondly, administering Salbutamol 5mg NEB (or as per COVID protocol 300mcg

through MDI and spacer), and Ipratropium Bromide 500mcg NEB (or as per

COVID protocol 40mcg through MDI).

Scenario 3

You are assessing a 2-year-old. The care-giver states that the child has been

experiencing laboured breathing for the past 2 days. The care-giver initially thought the

child had an upper respiratory infection. Yesterday the child began to have a barking

cough, and today they are making a high-pitched sound on inspiration. The child is

playful and took fluids well. The care-giver is extremely concerned.


Breathing Respiratory rate = 22min, Obvious nasal flaring and intercostal and suprasternal retractions can be seen. Laboured breathing but not rapid.

Inspiratory stridor can be heard

Circulation Heart rate = 165, pale skin

Disability GCS = 15

Exposure Use of accessory muscles and retraction. No rashes can be seen.

Focused History O2 saturations = 97%

Blood Pressure =115/75 Temperature = 37.30c

1. Using the above observations and history you decide to administer oxygen. What key findings influenced your decision?

As per protocol A5 (recognition of the sick baby or child) and M7 (Croup) oxygen

is indicated as the 2-year-old is in moderate respiratory distress. Although the

child is showing signs of compensation, the risk of deterioration is high. The

Sp02 is currently sitting at 97% monitoring is needed in the child for signs of

oversaturation.


2. Does this patient fall within or outside the Paediatric White zone criteria of Between

the Flags? If they do, what are you required to do?

They are outside of the Paediatric White Zone Criteria in the criteria of systolic

blood pressure and pulse rate. She is hypertensive and tachycardic. As per

these guidelines paramedics are required to increase frequency in

observations and consider urgent transport with treatment commencing

en-route.

Scenario 4

You and your partner are responded to a person unwell. Upon arrival you find a young

man who is confused. His family states he is a diabetic and took his insulin today but has

not eaten. They noticed he was confused about 20 minutes ago. They have given him

some candy but it has not helped. He is unable to answer questions due to confusion.

You are 30 minutes from the hospital.


Breathing Respiratory rate = 20

Circulation Heart rate= 80

Disability GCS= 13

Exposure Nil

Focused History O2 saturations =98% Blood Pressure=120/80 Temperature=36.30c

1. Discuss the clinical significance of hypoglycaemia in the elderly.

Hypoglycaemia in the elderly has a large and potentially catastrophic outcomes.

Hypoglycaemic elderly patients are more likely to have falls, fractures, injuries

arrhythmias and in severe cases, death. Symptoms may go unrecognised

or can be misdiagnosed as other neurological conditions (i.e TIA or stroke).


2. Referring to the Glucose Gel Pharmacology is Glucose Gel able to be administered to this patient? Explain your answer.

No, due to his GCS of 13 he is unable to self-administer glucose gel. It would

be a choking risk to allow him to swallow the gel.

Scenario 5

You have been responded to a 4-year-old female feeling unwell. The mother states that

the child has a history of increasing lethargy, fever, dizziness when she tries to stand up.

There is no history of vomiting or diarrhoea. Her food and fluid intake has decreased

over the last 12 hours. Typical chicken pox lesions developed 5 days ago. Over the last

18 hours or so several lesions on her abdomen have become red, tender and swollen.

On your arrival the patient is postured supine and listless.


Breathing Respiratory rate = 60, Rapid

Circulation Heart rate= 165 Peripherally pulse is weak and thready.

Disability GCS= 13

Exposure Extremities are warm and bright red. Skin is mottled

Skin is warm to mid forearms and mid calves.

Focused History O2 saturations = 96% Blood Pressure = 90/30

Temperature = 39.40c

1. List the three areas of focus for a patient you suspect has Sepsis.

1. Recognise the risk factors, signs and symptoms of sepsis

2. Resuscitate with IV fluids and antibiotics if indicated for interventions

3. Transport to ED and identify sepsis risk factors during clinical handover


2. What are the Sepsis risk factors for this particular patient?

The risk factors for this child are deterioration despite previous treatment and

high level of parental concern. Given the child has been sick for an extended

period of time they may be considered immunocompromised.

3. According to the Medical Hypoperfusion/Hypovolaemia Protocol what category of

hypovolaemia does Sepsis fall into? Explain this type of hypovolaemia.

According to the M5 protocol sepsis falls into the relative hypovolaemia category.

This is the due to the fact that patients in septic shock have increased size in

the vascular bed due to vasodilation.

4. You and your partner want to ensure that you have made the right diagnosis, so you

look at the Acute Rheumatic Fever Protocol. Explain why it is important to recognise

Acute Rheumatic Fever and report it.

It is important to recognise and report acute rheumatic fever due to the fact it is

caused by the streptococcal bacterium and there may be an increased risk of

the patient developing Rheumatic Heart Disease, resulting in valvular disease or

stroke later in life. In addition, it is a mandatory reportable disease under the

NSW Health policy.

5. Does this patient fit into any of the high risk groups for Acute Rheumatic Fever and

have any signs and symptoms? If so what are these? She fits the high-risk group as she is female.

While this case doesn’t discuss her ethnicity or housing conditions, she may

also fit those groups.


Cardiac/Cardiovascular Protocol Questions

NB: These scenarios ask questions covering the Cardiac/Cardiovascular

Protocols and Pharmacology sections of your protocols.

Your partner is a P1 Paramedic.

Scenario 1

You and your partner are dispatched to a 50-year-old male unwell. Upon arrival, you find

the 50-year-old male sitting on the couch. He complains of mid-sternal chest pain that

began 30 minutes ago. He has also developed nausea, sweating, and dyspnoea. He has

a history of angina but has never had a heart attack. He has taken two nitro-glycerine

tabs (which have expired) with no change in the pain. He also states that he has already

taken his aspirin today about three hours before you arrived. He has a history of angina

and hypertension. He is still a smoker.


Breathing Respiratory rate=20, slight wheeze like sound heard bilaterally.


Disability GCS=15

Exposure Nil findings

Focused History O2 saturations = 95%, BGL= 6mmol, ECG= Sinus Rhythm and

Meets ST elevation MI Criteria Blood Pressure =146/90

1. What is your understanding of the term Acute Coronary Syndrome? (A1)

The term ACS encompasses a spectrum of conditions that affect the

cardiovascular system. It spans from angina to acute myocardial infarctions and

is associated with atherosclerosis in the arteries. It can be something that

patients have well managed and live with or it can be something that can lead to

death, dependent on the severity.

2. List the medications that are required to be administered to a patient with chest pain if

they meet the indications for them.

If patients are indicated, they can receive Aspirin, Glycerol Trinitrate, and oxygen

and pain management – preferably morphine.


3. You decide to administer Aspirin to the patient, what is the dose you are to

administer?

Route Initial Dose

Repeat Times

Max Total Dose

PO

300mg chewed and swallowed

Maybe taken with a few sips

of water

Nil

300mg

4. What are the contraindications you need to check before administering this

medication?

The contraindications for Aspirin include an allergy or hypersensitivity to Aspirin,

active, suspected or known bleeding tendencies, any patient under the age of 16

years. Patients who also meet the T1 trauma protocol criteria are also

contraindicated to receive Aspirin.

5. The patient states that he has already taken his aspirin today. Can you give him

yours? Please explain your answer.

Paramedics need to confirm the dose, route, expiry, and medication he has

taken as Control may have instructed him to take more than his regular daily

amount. As daily aspirin or warfarin is not a contraindication for 300mg of

aspirin when associated with ACS, it would be appropriate to give this patient

more aspirin.


6. Five minutes post your Aspirin administration and you are about to administer

Glyceryl Trinitrate your patient goes quiet and collapses. Your Life Pak 15 shows the

above rhythm. Your partner states this is Ventricular Tachycardia (VT) and is

shockable.

In line with your scope of practice, what pathway according to Cardiac Arrest Protocol

C3 will you take and what are your actions?

The first step in this process is confirm that the patient is in cardiac arrest and

see if he has a ventricular assist device (VAD). If there is no VAD present,

confirm the rhythm is VT and defibrillate. Following the defibrillation, commence

CPR, radio to Control for backup and you would most likely have IV access

already in this patient you can prepare to give IV Adrenaline at a dose of 1mg

(1:10 000) bolus.

7. What are the reversible causes of cardiac arrest?

The eight reversible causes of cardiac arrest are hypoxia, hypovolaemia,

hypo-hypothermia, hyperkalaemia, tamponade, toxins, thrombolysis, and

tension pneumothorax.


8. After eight minutes of CPR, you and your partner notice the above rhythm on your

Life Pak 15 your partner states that it is a perfusing rhythm. You disarm the Life Pak

15, hit the print button twice and check the patient’s carotid pulse, which is present

and strong.

Outline your Spontaneous Circulation Resuscitation care that you will provide to this patient?

Perform full primary survey again. Airway considerations are to insert or

remove advanced airway adjuncts, dependent on indications. Breathing

considerations are to ventilate to a rate that achieves ROSC treatment aims

(avoid hyperventilation). Circulation considerations are to continue CPR if

required. Perform 12 lead ECG and manage dysrhythmias as per protocols.

Consider PAPA or PHT if STEMI indicated. And consider IV infusion if

appropriate to maintain patients BP >100mmHg. Maintaining normoglycaemia

and normothermia should be a large consideration. If ICP on scene consider

post ROSC sedation if indicated.


Scenario 2

You and your partner are dispatched to a 77-year-old female with a suspected Stroke. The husband of a 77-year-old female has called because his wife has slurred speech and left sided weakness. Husband states the symptoms started 30 minutes prior to your

arrival. You are 30 minutes from the hospital.


Breathing Respiratory rate=12, Chest is clear


Disability GCS=15


Focused History O2 saturations =93%, BGL= 5.3 mmol ECG = Sinus Rhythm.

Blood Pressure= 140/90 The patient is a type II diabetic.

1. What are the signs and symptoms of a stroke and define the F.A.S.T mnemonic? Signs of symptoms of stroke can include sudden onset of numbness or

altered sensations in the limbs, sudden onset of memory loss, confusion,

difficulty speaking or swallowing. In addition, a sudden onset of ataxic gait.

F.A.S.T stands for:

F – facial palsy?, A- any weakness present?, S- is any speech impaired/slurring,

T- confirming time around when the signs/symptoms began. 2. List the Hyper Acute Stroke Mandatory criteria.

The Hyperacute stroke criteria is a positive response to any of the F.A.S.T criteria,

AND estimated arrival to ED is <4.5 hours from onset of signs and symptoms or

last time the patient was seen well AND patient is >18 years of age AND BGL is

>4mmol.


3. You decide that the patient is Hyper Acute Stroke Mandatory Criteria positive, outline your treatment and transport requirements. Treatment and transport plans should include gaining IV access using an 18G

cannular in the ACF, pre-notify receiving hospital via the Control centre of

hyperacute stroke mandatory criteria positive patient. If the patient is

unaccompanied during transport obtain a contact name/number of carer or

relative to the patient.

Transport without delay to ED following the transport destination cascade.


Trauma Protocol Questions

NB: These scenarios ask questions covering multiple protocols in the Trauma and

Pharmacology section of your protocols.

Your partner is a P1 Paramedic.

Scenario 1

You and your partner respond to a person fallen > 3meters. Upon arrival, you find a

young man who was putting up a TV antenna and fell off the roof. Family states he has

been unconscious since falling. The family states the patient has no allergies; the patient

fell from the top of the roof approximately 15m. The patient landed onto a concrete

driveway.

Airway Clear and Patent There is no gag reflex

Breathing Respiratory rate=8 Decreased breath sounds on the right side

Circulation Heart rate=65 Pale and diaphoretic

Disability GCS= 6

Eyes – 1 Verbal – 1 Motor – 4

The pupils are medium sized and react sluggishly.

Exposure There is a large hematoma in the occipital area. There is bloody fluid coming from the right ear.

Focused History O2 saturations = 93%,

BGL= 6mmol, ECG=Sinus Rhythm Blood Pressure=170/80

1. Discuss why airway management is extremely important for patient with a head injury

Given the nature of brain injuries, a secondary brain injury can occur due to

hypoxia and hypotension. Airway management that focuses on ventilation and

oxygenation as well as treatment for hypotension is important as neglecting

these factors are associated with poor outcomes.


2. What are the clinical prompts that this patient has that assists your diagnosis that the

patient has a head injury?

Clinical prompts that may suggest the patient has a head injury is GCS>14,

visual deformity of the skull or face, cerebrospinal fluid present from ears or

nose, a systolic BP <90mmHg, a history of LOC or trauma of any kind,

ecchymosis around ears or eyes, with or reduced pupil reactions.

3. According the Head Injury protocol how should this patient be postured during

transport to ED and what should be maintained?

Patients should be transported with considerations to their positioning.

If they are being transported via stretcher, they should be positioned with their

head up at a 30-degree angle where possible, spinal precautions must be

maintained.

4. Examining the Spinal Injuries Protocol and the above observations discuss why you

would apply a cervical collar to this patient.

Due to the high mechanism of injury this patient meets the criteria for a cervical

collar.

5. Pelvic fractures should be considered in patients whose mechanism of injury may

have resulted in a large inertia change on impact. List the high risk mechanisms for a

pelvic fracture. Does your patient fit into any of these?

Pelvic fractures should be considered in all patients with a large inertia change

on impact. High mechanism for these injuries include vehicle vs pedestrian,

motorbike crash, side impact vehicle collisions, crush injuries, falls from or

trampling by livestock. This patient fits the high-risk mechanism criteria of a fall

from height.


6. If you suspect a patient has a pelvic injury what must you not do?

Paramedics should not spring the pelvis or log roll the patient in any

circumstances. Extrication devices should be utilized to facilitate extrication.

7. Using the Trauma Triage Tool-Major Trauma Criteria (MIST) what Mechanisms,

Injuries, Signs and Symptoms, does your patient have to meet the Major Trauma

Criteria?

This patient meets the MIST criteria in multiple sections. M – fall greater than 3m,

rapid deceleration injury. I – head injury with LOC, potential ecchymosis. S-

reduced RR (8), increased BP (170/80), reduced GCS (6). This patient meets the

MIST criteria.

8. From your previous answer, you determine that your patient meets the Major Trauma

Criteria. What does this authorise you to do?

By meeting the criteria, paramedics are authorized to transport up to 60 mins

(metropolitan) or 90 mins (regional) from scene to reach the appropriate

trauma facility.

9. Your partner asks you to provide a full MIST Report to pass a “CODE 3” to the

Control Center who will then pass it to the receiving hospital. Use the above history and observations.

Male patient of unknown age. Mechanism of injury is a fall of 15m onto concrete

driveway, his injuries are periorbital ecchymosis, and fluid coming from right

ear, and ? tension pneumothorax with decreased breath sounds on the right

side. He is GCS 6, E=1, V=1, M=6. HR is 65 (and strong/weak/thready/etc). Pupils

are medium sized and sluggish. ECG shows sinus rhythm, and he is currently

hypertensive at 170/80. We are enroute and “X” minutes away.


10. Enroute to hospital, you reassess the patient’s observation and discover that the

patient has rapidly deteriorated. According to the deteriorating trauma patient protocol,

list the core physiological observations used to identify the deteriorating trauma patient.

The physiological observations used to identify a deteriorating trauma patient

are respiratory rate, LOC, pulse rate, blood pressure (systolic and diastolic),

temperature and oxygen saturation. Being able to identify these negatively

trending observations is important to support positive outcomes for the patients.

11. Under what indication would you administer Compound Sodium Lactate to this patient

and what would your dose be?

Compound sodium lactate would be given to this patient if their systolic

blood pressure dropped <100mmHg as we are treating this patient as if they

they have a head injury.

Route Initial Dose

Repeat Times

Max Total

Dose

IV

250mL bolus

Repeat until BP

>100mmHg

No maximum dose


Scenario 2

You are responded to a fire. Upon arrival, you find a 25-year-old male complaining of

severe pain. The patient was burned when he put gasoline on some rubbish he was trying

to burn. He has Dermal and full thickness burns of his face, neck, anterior chest (he was

not wearing a shirt), and both arms. His nasal hairs are burned but he has no burns in his

mouth. He has no history of any medical problems, takes no medications, and has a known

allergy to opiate medications (Anaphylactic reaction). His last meal was 4 hours ago. You

are 30 minutes from the hospital.



Circulation Heart rate=100

Disability GCS= 15

Exposure Dermal and full thickness burns of his whole face, anterior neck,

anterior chest (he was not wearing a shirt), and both arms to the

elbows.


BGL= 4.6mmol,

ECG= Sinus Rhythm

Blood Pressure =120/70

1. Using the Rules of 9’s, calculate the Total body Surface Area burnt.

His total body surface area is 22.5%. This is made up of head (4.5%), anterior chest

(9%), and both arms (9% - 4.5% each arm).

2. This case is located in the Sydney Metropolitan Area, where should you transport this

patient. Will you transport lights and sirens or normal speed? Why?

This patient should be transported to either Concord Repatriation General Hospital

or Royal North Shore Hospital as they are both trauma facilities and with

specialized burns units and will be able to appropriately care for this patient.

The transport would be a lights and sirens response and would include a Code 3

through Control.


3. Choose one cooling option available for treating this particular patient? Once you have

cooled the burn site your partner asks you to apply clear plastic to the site, how is this

to be done?

The cooling options available for this patient are normal saline or compound

sodium lactate directly to the burned area. Once cooled, apply clear plastic

film longitudinally over the burn as not inhibit swelling of the burned surface

area and surrounding tissues.

4. The patient is complaining of pain, whist you are cooling them your partner states for

you to administer Methoxyflurane. Before you administer the medication, you need to

check for any contraindications. What are the contraindications of Methoxyflurane?

The contraindications for methoxyflurane are malignant hyperthermia, altered or

decreased level of consciousness, pre-eclampsia or eclampsia, untreated renal

failure, patients under the age of 1, acute behaviorally disturbed patients, and

any patient currently on tetracycline use.

5. What is the initial dose and repeat dose of Methoxyflurane?

Route Initial Dose

Repeat Times

Max Total

Dose

INH

3mL delivered by

penthrox inhaler

You may only repeat once as

indicated. As they last

approx. 30 mins,

the second administration would happen

after this.

6mL in 24 hours 15mL in 7 days


6. Examining the history and assessment of your patient, refer to the Inhalation Injuries

Protocol. What category of inhalation injury do you consider your patient may have

experienced? Explain your answer.

This patient has a direct thermal injury. Given that it was a fire, the dry air holds

little heat and therefore dissipates quickly. The clinical observations of singed

nasal hair suggests this as he has no burns to his airway or mouth. This patient

is still at risk for oedema and potential upper airway compromise.

7. List the questions you need to consider to determine the potential severity of exposure.

To determine the potential severity of the burns, the paramedics need to determine

the history and mechanism of injury, the type and duration of exposure, the

physical signs and symptoms, and the patients clinical observations.

8. List the signs of smoke inhalation.

The pneumonic to remember this is HISSCA. It stands for:

H - hoarse voice

I-inspiratory stridor

S- see-saw breathing

S-singed facial and/or nasal hair

C- Carbonaceous material around the mouth, nose or in the sputum

A-anterior burns to the neck


Other Protocol Questions

NB: These scenarios ask questions covering multiple protocols not previously specified and Pharmacology section of your protocols. Your partner is a P1 Paramedic.

Your ambulance has responded to a football field where a player has collapsed at the end

of a 3-hour practice in 36-degree heat. Upon arrival, you find a 17-year-old male who is

unresponsive. He is very flushed. The coach has had him taken to the shower and has

cool water spraying on him. The trainer is getting bags of ice to place under his arms and

in his groin. The patient responds only to pain. You are 30 minutes from the hospital.


Breathing Respiratory rate=24.


Disability GCS=5


Focused History O2 saturations =99%,

BGL=6mmol,

ECG=Sinus Tachycardia Rhythm

Blood Pressure=90/60

Temperature= 42.50

1. Discuss the difference between heat stroke and heat exhaustion including some examples

of the various clinical features.

Heat stroke is hyperthermia in the setting of CNS dysfunction. Heat exhaustion

is a milder form of heat illness and the profound CNS dysfunction is absent.

Heat stroke should be suspected in this patients case as it is often associated

with high heat stress through exertion or environmental factors.

This patients clinical features of ALOC, collapse, and core body temp >40°

suggest he is suffering from heat stroke.


2. According to the Hyperthermia Protocol what is going to be your treatment regime for

your scope of practice.

The treatment process for this patient is to remove any clothing, place ice packs

to the patients neck, armpits and groin. Continually reassessing for hypothermia

Treat any associated conditions such as dehydration, medical hypoperfusion,

seizures, nausea and vomiting, and hypoglycemia.

Scenario 2

It is winter and you are working at the bottom of the Blue Mountains and you have

responded to a call of a homeless man found passed out in the cold. Upon arrival, you

find a disheveled man who appears to be in his 40s. He is shivering, and states he drank

too much wine during the night and passed out without any cover. There is no history of

trauma.




Disability GCS=15

Exposure He is very cold with mottled skin and unable to walk on his own.


BGL=6mmol,

ECG=Sinus Rhythm


Temperature= 330

1. Reviewing the above patient’s history and observations what will be your treatment

regime.

As his temperature is <35° the patient needs to be removed from the cold

environment into the warm ambulance, remove any wet clothing and dry him,

Warm the patient by wrapping him in a dry blanket followed by a space blanket.

Assess the patient for any cold injuries.


2. What must not be done as part of your treatment regime?

According to E4, do not rub any frozen tissue, use any radiant heat to rewarm the

affected part, do not break any blisters that have formed, rewarm any part of the

body if there is a chance of refreezing. It is also important in this patient’s case

to inspect all limbs and not let or make him walk.


Scenario 3

The police have called you. Upon arrival, you find a young man handcuffed, and being

held on the ground by five police officers. He is screaming curses and continues to struggle

in spite of all of the officers holding him down. The police state that they were called

because he was running naked in the traffic. When the police arrived, he became

aggressive and pushed an officer who hit her head and lost consciousness. A paramedic

team is caring for her. The police used their Taser (CEW) in order to subdue him but he

continues to fight in spite of several shocks. He is known to be a methamphetamine (ICE)

addict and has a history of Bipolar Disorder.




Diaphoretic

Disability GCS=15.

Dilated pupils and does not seem to focus when he looks at you.

Exposure Patient is covered with bruises and abrasions.

He continues to scream and struggle.

The two Taser darts are still in the skin of his chest.


BGL=4.4mmol,



Temperature= 370

1. What do the initials CEW stand for? Explain what this devise does to a person.

A CEW is a form of taser known as a conducted electrical weapon. A CEW is a

battery operated hand-held device which can deliver up to 50 000 volts of

electricity, in rapid pulses, via two barbed electrodes or direct contact. CEW’s

produce pain and a loss of voluntary control of muscles.


2. Discuss the treatment regime of a patient sprayed with OC spray. Why is shampoo

and soap no longer required?

A patient who has been sprayed with OC spray should have their face, eyes and

eyelids irrigated with copious amounts of cold water (running where possible).

After irrigation, ice packs may be applied to the area to reduce burning sensation.

Considerations should be applied to prevent hypothermia and removal of the

patients decontaminated clothing.

Shampoo and conditioner is no longer required as NSW police no longer deploy

oil based OC spray, it is water based and can be rinsed with water.

3. Refer to the Delirium Protocol, could the above patient be experiencing delirium.

Explain your answer.

Yes, this patient could be experiencing an excited delirium due to the known

methamphetamine addiction as drugs can be a potential cause of an excited

delirium. Although, given his history of biopolar disorder, he also may be in a

manic phase and may be having an acute psychosis that can sometimes be

misdiagnosed as excited delirium.

4. Your partner states to you that this patient is undergoing a mental health emergency.

How can you establish a rapport with this patient?

To establish a rapport with the patient it is important that the paramedics calmly

identify themselves to the patient, they ask the patients name and main concerns,

it is important to reassure your patients and effectively communicate with

simple words and sentences.


5. As the patient was playing in the traffic, you consider that he may have been trying to

end his life. What Acronym can assist you in assessing this and what does it mean?

It would be appropriate to assess the patients risk of suicide with the THREAT

acronym. It stands for:

T- thinking of suicide

H-history of previous suicide attempts

R-reasons and circumstances

E-emotionally depressed

A-access to lethal means

T-tactics and plans

6. You and your partner assess that the patient is mentally unwell and is having suicidal

thoughts. The patient is unwilling to come to hospital with you voluntarily. Discuss what

actions you and your partner are allowed to do, to take this patient to hospital.

It can be determined by the patients actions and behavior that they do not have

the competency and capacity to adequately keep themselves safe. Under this,

this patient has met the criteria to be sectioned, and as a result the paramedics

will enact an S20. To facilitate safe transport for all involved, the patient should

be considered for sedation, restraint, a search and for police escort to hospital.

7. You and your partner decide to administer Droperidol to this patient, fill in the

following table.

Route Initial Dose

Repeat Times

Max Total

Dose

IV/IM

10mg bolus

Once after 15

minutes if

indicated

20mg


8. Your patient after you have administered Droperidol is still being aggressive and abusive. Can you administer Midazolam to this patient? What is the indication and

dose that you would administer?

Paramedics are authorized to administer a single dose of Midazolam in between

initial and repeat dose of droperidol – ONLY if the patient is physically aggressive.

Given that after the droperidol, the patient is still aggressive he is indicated

for a single bolus of midazolam.

Route Initial Dose

Repeat Times

Max Total Dose

IM/IV

IM: 5-10mg

undiluted bolus

IV: 2.5mg diluted

slow bolus

IM: 5 mins

IV: 3 mins

15mg

9. List the contraindications of Droperidol.

The contraindications of droperidol are a known or suspected allergy,

or hypersensitivity to droperidol, patients who are <14 years of ages, and patients

with Parkinson’s disease.

10. List the adverse effects of Midazolam.

Adverse effects of midazolam include a reduction in LOC which can result in

upper airway obstruction, respiratory and cardiovascular depression which

may be exacerbated in patients with limited physiological reserves and/or who

are under the influence of drugs or alcohol.


Scenario 4

It is winter and you have responded to a home where a man whose electricity has been

cut off has been trying to heat his bedroom with a charcoal grill. He is confused and

complains of severe headache.




His skin is warm, dry, and pink

Disability GCS=15.

Dilated pupils and does not seem to focus when he looks at you.

Exposure His skin is warm, dry, and pink


BGL=4.4mmol,



Temperature= 36.00

1. Briefly describe Carbon Monoxide Poisoning and explain your treatment regime for

your scope of practice.

Carbon Monoxide is a toxic, colourless and odourless gas that has over 200

times the affinity for haemoglobin when compared to oxygen, resulting in a

reduced capacity for blood to oxygen to vital organs, which leads to hypoxia.

The treatment regime is as follows:

1. Identify reason for exposure, 2. Administer 100% oxygen, perform 12

lead ECG, check patients BGL, and treat any associated dyspnoea, 3. Identify if

the poisoning was an attempt at self-harm and then follow the protocol dependent on the answer.


Scenario 5

Your unit has responded to a farm where a 45-year-old male complains of headache and

dizziness when he tries to stand. He has also had several episodes of diarrhea and is now

wheezing though he has no history of asthma. His history is significant in that he has been

spraying insecticide in his field all morning. When you examine the patient, you see that

he is salivating and his nose is running. His pupils are pinpoint and there is a garlic odor

about him.



Bilateral Wheeze evident


Disability GCS=15.

Exposure Nil


BGL=5.4mmol,

ECG=Sinus Rhythm

Blood Pressure = 90/70

Temperature= 36.00

1. How would you decontaminate this patient and what PPE would you wear whilst

doing this?

To decontaminate the patient, you need to remove the patients decontaminated

clothing, where possible wash the skin with soap and water. All paramedics

that are involved with decontamination should be initiating a HAZMAT response.

This includes a charcoal mask, goggles, chemical resistant gloves and

disposable fluid resistant gowns.


Scenario 6

You have been responded to a 2B general sickness call. Upon arrival, you find a 19-year-

old female lying on the bed. She complains of sudden onset of severe abdominal cramping

and profuse vaginal bleeding with many clots. This began just before you were called. She

has already used five pads. She feels weak and gets light headed when she stands. Her

last normal menstrual period was 2 months ago. There is no prior history of severe vaginal

bleeding and she has never been pregnant.




Disability GCS= 15

Exposure When you examine her abdomen she is tender over the lower

abdomen but there is no mass felt. Bowel sounds are present.


BGL=4.6mmol,

ECG=Sinus Rhythm


1. According to the Maternal Emergencies Overview Protocol what are the three

fundamental rules that Paramedics must follow, list these.

The three fundamental rules that paramedics must follow when dealing with

maternal emergencies are:

1. Maternal wellbeing is essential to the survival of the foetus and therefore resuscitation of the woman must always be the priority.

2. Compression of the inferior vena cava by the pregnant uterus

(beyond 20 weeks) can have a significant effect on cardiac output by reducing venous return. Appropriate positioning of the patient (i.e left lateral tilt)

3. Signs of shock may appear very late during pregnancy and hypotension is an extremely late sign. Any signs of hypovolaemia during pregnancy are an indication of significant blood loss and must be treated aggressively.


2. Your 19-year-old patient is suffering from severe abdominal cramping and profuse

vaginal bleeding with many clots. According to “Bleeding in Pregnancy” Protocol, what

are the general questions that you should ask to assist you in assessing the patient’s

problem.

Bleeding da uring pregnancy can be caused by several conditions, some of which

can be life-threatening to both the woman and the foetus. There are clinical

prompts those paramedics can use to help shape the clinical picture. These

include:

- “Are you or could you be pregnant?” If yes, how many weeks/months do you think you are?

- “When did the bleeding start? What were you doing?” - “What is the blood loss like? How much are you bleeding and are you

still bleeding?” - “Has this happened before or in any other pregnancies?” - “Do you have any pain? When does the pain start? What does it feel

like?”

Given that she is most likely less than 20 weeks pregnant, the focused questions

for this patient would be:

- “Do you have any history of tubal infection, surgery or previous ectopic

pregnancy?”

- “Are you using contraception with progesterone only pills or do you have

an IUD?”

3. What are to be your actions in assessing this patient and what must not be conducted?

While assessing this patient, there should be focused and general questions

around the nature of the bleeding as discussed above. Under no circumstances

should the paramedics conduct a pelvic exam or place anything into the vagina

to control blood loss as life threatening haemorrhage may occur but will not be

evident.


You and your partner have responded to R1 medical call. Upon arrival, you find a 30-year-

old female lying on the bed. She says that she is pregnant at term (40 weeks) and the

baby is coming. This is her fourth pregnancy and she has had no problems with any of her

other pregnancies. She receives her prenatal care at the local hospital. When you examine

her perineum, you see that the baby’s head is crowning.




Disability GCS= 15

Exposure When you examine her abdomen she is tender over the lower

abdomen but there is no mass felt. Bowel sounds are present.


BGL=4.8mmol,

ECG=Sinus Rhythm


1. Discuss the stages of labour. What stage of labour is your patient in?

There are four stages of labour. This patient is in the second stage of labour.

First stage: The longest stage of labour and is from the time of onset of regular

contractions until complete cervical dilation (10cm).

Second stage: The time from complete cervical dilation until delivery of the

foetus. In the out of hospital setting this is when the woman has the urge to push

or the presenting part of the foetus becomes visible.

Third stage: Time from delivery of the foetus until delivery of the placenta and

membranes.

Fourth stage: The first hour after delivery of the placenta.


2. What are five questions that you can ask your patient using the Clinical history prompts

to determine the stage of labour?

1. When did the pain commence? Where is the pain? Is the pain constant or

intermittent? How often does the pain occur? How long does the pain last? Is the

pain mild, moderate of severe?

2. Has there been any vaginal discharge or bleeding? What does the

discharge look like?

3. What is the consistency of the discharge?

4. Has the woman had a spontaneous rupture of membranes? If so, what time

did they occur?

5. Does the woman have an urge to push?

6. You deliver a female infant almost immediately. Explain your actions in the care of the

infant.

Post birth, place the newborn on the mothers chest/abdomen with minimal tension

on the umbilical cord and note time of birth. Given this newborn is full term, dry

the newborn whilst maintaining skin to skin with the mother. Perform rapid

assessment of the newborn looking for HR, RR and tone. If the newborn is

positive to the rapid assessment, perform newborn resuscitation. If the newborn is

negative, place newborn lateral or prone on mothers chest, dry the infant and place

a clean, dry wrap around and beanie on the head. Perform APGAR at 1 and 5 minute

mark. Encourage mother to breastfeed.

7. Calculate the APGAR score for your infant patient. The infant is all pink, Pulse= 98, is

coughing and crying, is very active and is breathing fast and regular.

The APGAR of this newborn is a 9. Given this APGAR, once the cord has gone white

(approximately 3-5 minutes after birth) consider cutting the cord in consultation

with the parents wishes.

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