CWIs

• Unconscious pt without gag reflex                
• Ineffective ventilation BVM basic airway mx
• Unable to intubate
• Greater than 10 minutes assisted ventilations

• Intact gag reflex or resistance to insertion
• Strong jaw tone or trismus
• Epiglottitis or upper airway obstruction
• Use of sedation to facilitate or maintain LMA is contraindicated

• Pt 14 years < enlarged tonsils
• Pts req higher airway pressures (obesity, preg), decreased lung compliance (pulm fibrosis), increased airway resistance (asthma)
• Inability to place pt in sniffing position
• Vomit in airway
• Use of SGA does not prevent passive regurgitation or abdominal distension

Unconscious patient presenting with trismus, where an OPA cannot be inserted

• Middle third facial fractures – possibility of intrusion into brain tissue
• Significant nasal trauma – May induce undesirable gag increasing ICP so use must be essential
• Traumatic brain injury or neurological event where airway is patent and tidal volume is adequate despite trismus – may induce undesirable gag reflex increasing intracranial pressure

• Basal skull fractures and any CSF from nares or ears, as there is some possibility of intrusion into brain tissue
• NPA may need to be removed during intubation attempts as it can interrupt the view of the glottis

• Apnoea or significant hypoventilation
• Ventilation of adult patients with cardiac output should generally include the use of a positive end-expiratory pressure (PEEP) valve where accredited

PEEP valves are contraindicated in paediatric patients and any patient in cardiac arrest

None

Suspected tension pneumothorax including in traumatic cardiac arrest

The ARS may not be appropriate for paediatric / small patients (use 14g or 16g decompression needle depending on patient size)

• Tension pneumothorax decompression is a low volume/high risk skill performed in high pressure circumstances and requires regular practice to maintain familiarity with locating the appropriate
• physical landmarks and familiarity with the equipment. • If both sides of the chest are being decompressed, the right side should be decompressed first to minimise the risk of the needle puncturing the heart.
• Once inserted, if air escapes, or air and blood bubble through the cannula, or no air/blood
• detected, leave in situ. If copious blood flows out, remove the cannula and cover the insertion site with an occlusive dressing.
• There is a risk of body fluid being expelled under pressure when the procedure is initially done, or if CPR is subsequently performed.
• This procedure is monitored through the Limited Occurrence Screening process

Patient presenting with cardiogenic pulmonary oedema and shortness of breath that is severe or unresponsive to nitrates

• GCS < 13
• Facial trauma
• Pneumothorax
• Active Vomiting
• Life threatening arrhythmias
• Patients requiring airway management Hypoventilation

• Hypotension
• COPD - CPAP via FlowSafe ll is not indicated for primary COPD management, but patients in cardiogenic pulmonary oedema with a COPD past history can be cautiously managed using this procedure. Consider use of Whisperflow device to manage COPD

None

None

Rhinitis, rhinorrhoea, facial trauma (contraindications for ACO/CERT). Where possible rectify (e.g. if possible ask patient to blow nose before administration)

Medications that, as per the AV CPG’s, are required to be administered via the intra-muscular route

None

• Safety – Ensure correct technique for administration, anatomical location, and disposal of sharps technique is used at all times
• Larger volumes may be painful. Dilution should be avoided

• Middle third femur fractures
• Upper two third tibia fractures

• Pelvic trauma
• Knee or ankle / foot trauma

None

• Suction may be required when a patient is in an altered conscious state and is unable to protect their own airway
• from secretions, vomit, blood etc

None

• Croup
• Epiglottitis
• Upper airway obstructions

Open book fracture of the pelvis

None

• Traction splint creating difficulty in closing legs and hence pelvic injury
• Adult size splints should not be applied to children

• Uncontrolled haemorrhage from a limb despite direct pressure
• Multiple casualty scenes where patient numbers dictate that simple haemorrhage control measures cannot be individually applied

• Bleeding that can be controlled
• using basic first aid measures

• Do not apply the tourniquet over a wound or a joint
• Once applied, the tourniquet must be visible – it cannot be covered by any clothing or other bandages

• Uncontrolled haemorrhage from a non-compressible wound site
• Any traumatic haemorrhage that is not controlled by basic haemorrhage control measures such as direct pressure with a pad and bandage
• Severe limb wounds not controlled by two Combat Application Tourniquets
• Multiple casualty scenes where patient numbers dictate that simple haemorrhage control measures cannot be individually applied

• Bleeding that can be controlled using basic first aid measures
• Ocular trauma
• Haemostatic dressings are not to be used for haemorrhages where they are unlikely to contact the point of bleeding such as PV or PR haemorrhage, or posterior epistaxis

None

• Conscious adult, child or infant with severe foreign body airway obstruction with ineffective cough and unable
• to speak

• Newborns: not recommended at all - suction is preferred
• Unconscious patient: Not preferred option

None

When intravenous medication administration is required, in line with the Ambulance Victoria CPG’s.

None

• Wherever possible do not cannulate arms which show evidence of contamination (e.g. dirt, blood, burns,
• chemicals etc). If it is necessary then all attempts must be made to properly clean the IV site prior to
• decontamination.
• Wherever possible do not cannulate patients with renal failure in the same arm as their arteriovenous fistula if one is present in the limb

The patient is in an altered conscious state, without a gag reflex, requiring inspection of the airway

None

• Epiglottitis
• Croup

Foreign body airway obstruction with altered conscious state

None

None