Advanced Skills

Front 1

NASOPHARYNGEAL AIRWAY
Goal of treament:

Back 1

NPA assist in airway maintenance of a compromised airway - particularly associated with trismus.

Front 2

NASOPHARYNGEAL AIRWAY
Indications:

Back 2

Airway adjunct for use in patients with
potential or actual airway obstruction,
particularly in circumstances where an
oropharyngeal airway is inappropriate
(eg. Patient has trismus or an intact
gag)

Front 3

NASOPHARYNGEAL AIRWAY
Contraindications:

Back 3

Nil in this setting.

Front 4

NASOPHARYNGEAL AIRWAY
Precautions / Complications:

Back 4

Airway trauma, particularly epistaxis.
 Incorrect size or placement will
compromise effectiveness.
 Exacerbate injury in base of skull
fracture, with NPA potentially
displacing into the cranial vault.
 Can still stimulate a gag reflex in
sensitive patients, precipitating
vomiting or aspiration.

Front 5

NASOPHARYNGEAL AIRWAY
Additional Information:

Back 5

An NPA does not protect the patient’s
airway from aspiration.
 The right nostril is often preferred for
NPA insertion given that it is typically
larger and straighter than the left.

Front 6

NASOPHARYNGEAL AIRWAY
Clinical Judgement Issues:

Back 6

Particular caution must be taken for
patients with trauma to the nose or
suspected basilar skull fracture.
 The proper sized airway is slightly
smaller in diameter than the patient’s
nostril and is equal to or slightly longer
than the distance from the tip of the
nose to the earlobe.
 NPAs are smaller than an
Oropharyngeal Airway (OPA). If the
NPA size is too small it will not extend
pass the tongue; one that is too long
may pass into the oesophagus and
result in hypoventilation and gastric
distension when bag mask ventilation
(BVM) is used.
 The nasal mucoa is highly vascular
and is easily damaged. Forceful
insertion can lead to trauma, bleeding,
aspiration of clots and the need for
suctioning. The adenoids can also be
lacerated causing considerable
haemorrhage.
 An NPA is difficult to suction through,
it may kink or block and obstruct the
airway. It can be difficult to insert in
some patients particularly if nasal
damage is present (old or current).
 While semiconscious patients may
tolerate an NPA better than on OPA, it
too can cause vomiting, aspiration and
laryngospasm.
 In some cases a second NPA can be
inserted in the nostril to maximise the
use of the airway adjuncts in
maintaining a patent airway.

Front 7

LARYNGEAL MASK AIRWAY
Goal of treatment:

Back 7

Advanced airway management to provide
patency.

Front 8

LARYNGEAL MASK AIRWAY
Indications:

Back 8

Impending or actual loss of airway
patency or protection, where
advanced airway management is
necessary, but the clinician is unable
to secure airway through endotracheal
intubation
 Rescue airway in the failed intubation
algorithm

Front 9

LARYNGEAL MASK AIRWAY
Contraindications:

Back 9

Nil in this setting

Front 10

LARYNGEAL MASK AIRWAY
Precautions / Complications:

Back 10

 Failure to provide adequate airway or
ventilation
 Can precipitate vomiting and
aspiration in a patient with intact
airway reflexes
 Airway trauma
 Patient intolerance.

Front 11

LARYNGEAL MASK AIRWAY
Additional Information:

Back 11

 An LMA does not protect the airway
from aspiration.[1]
 An LMA typically causes less gastric
insufflation than bag-valve mask
ventilation alone.
 An LMA is often easier to insert if
there is an amount of air (50%
recommended) in the cuff prior to
insertion.
Note: ACPs are only authorised in the
use of size 3, 4 and 5 LMAs in
associated patient groups.

Front 12

LARYNGEAL MASK AIRWAY
Clinical Judgement Issues:

Back 12

 Frequently reassess the LMA
placement as it is not uncommon for
the BVM to create torsion on the tube
and thus twist the mask out of its
anatomical seating.
This is particularly so in the prehospital
setting where patients need to
be moved, often out of awkward
locations and at a rapid pace.

Front 13

Magill Forceps
Goal:

Back 13

The removal of a foreign body from the
airway or the manipulation of an
endotracheal or gastric tube.

Front 14

Magill Forceps
Indications:

Back 14

 Removing an airway obstruction
 Insertion or manipulation of an
endotracheal tube
 Insertion or manipulation of a gastric
tube

Front 15

Magill Forceps
Contraindications:

Back 15

 Nil in this setting if used in conjunction
with a laryngoscope.

Front 16

Magill Forceps
Precautions / Complications:

Back 16

 Laryngospasm
 Hypoxia due to delays in oxygenation
while performing the procedure
 Trauma to mouth or upper airway if
the Magill Forceps are used
incorrectly

Front 17

Magill Forceps
Additional Information:

Back 17

 Nil in this setting.

Front 18

Magill Forceps
Clinical Judgement Issues:

Back 18

 Laryngospasm may be triggered by
touching any part of the anatomy
distal to the epiglottis, including the
posterior surface of the epiglottis or
any part of the laryngopharynx. Be
cautious when moving the Magill
Forceps around near the epiglottis.
 Be aware for the potential to cause
trauma to the airway.

Front 19

Laryngoscopy
Goal:

Back 19

To facilitate the visualisation of the glottis
for the purpose of clearing the airway, or
for the insertion of an endotracheal tube
or gastric tube.

Front 20

Laryngoscopy
Indications:

Back 20

 Clearing the airway
 Insertion of an endotracheal tube
 Insertion of a gastric tube

Front 21

Laryngoscopy
Contraindications:

Back 21

 Epiglottitis

Front 22

Laryngoscopy
Precautions / Complications:

Back 22

 Laryngospasm
 Hypoxia due to delays in oxygenation
while performing the procedure
 Trauma to the mouth or upper airway,
particularly teeth / dentures
 Exacerbation of underlying C-Spine
injuries
 Failure to visualise the glottis

Front 23

Laryngoscopy
Additional Information:

Back 23

 Laryngoscopy is not advised in
patients with intact airway reflexes.
 It is possible to use a blade which is
larger than necessary and still
visualise the glottis effectively.
However, using a blade which is
inappropriately small will make
adequate laryngoscopy impossible.

Front 24

Laryngoscopy
Clinical Judgement Issues:

Back 24

 The QAS uses the Macintosh and
Miller disposable blades. The
Macintosh, or curved blade, is
designed to rest in the epiglottic
vallecular, such that when the
laryngoscope is elevated, the
epiglottis is lifted, allowing
visualisation of the larynx. The Miller
blade is preferred in young children.
Its straight blade is designed to lift the
epiglottis directly, which is often
bulkier compared to adults. An
approximate age guide related to
blade size
 Always consider the need for Manual
Inline Stabilisation (MILS)
 Briefly assess the airway for
predictors of technical difficulty (Refer
to the Endotracheal Intubation CPP
for a detailed outline of the LEMON
pneumonic which is useful in this
assessment)
 Consider adjuncts which may improve
the position of the patient and
therefore the potential success of the
laryngoscopy procedure visualising
the glottis on the first attempt (i.e.
pillows to raise the head in adults or
towels for under the shoulders of the
young paediatric patient under 12
months of age)
The decision to remove dentures
needs to be made on a case by case
basis. Generally speaking dentures
should be removed for the
laryngoscopy process as there is the
potential for them to dislodge at a
critical time during the procedure, or
the dentures themselves can be
damaged.
 Damage to lips, teeth, dentures and
upper respiratory tract tissue can
occur if the laryngoscope is used
incorrectly, such as using teeth as a
pivot.
 Laryngospasm may be triggered by
touching any part of the anatomy
distal to the epiglottis, including the
posterior surface of the epiglottis or
any part of the laryngopharynx.
 Hypoxia and hypercarbia may occur
due to a lack of ventilation while
laryngoscopy is being performed. Be
mindful of how long your patient has
been without ventilation – work swiftly
and closely watch all non-invasive
monitoring and the patient (i.e. pulse
oximetry, cardiac monitor, and patient
colour)
 Physiological effects can also occur
including hypertension, tachycardia
and sometimes profound bradycardia
(particularly in the younger paediatric
patient who responds significantly to
vagal stimulation)
 In the setting of a likely or confirmed
airway obstruction where MILS is
required to be adopted after
assessment, be prepared for the need
to gently move the airway away from
the neutral position to facilitate a view
of the glottis or the offending
obstruction. Airway mu

Front 25

INTRAVENOUS ACCESS
Goal:

Back 25

Intravenous (IV) cannulation provides
access to the circulation to administer
drug therapy or fluids.

(IV access is an invasive procedure and
appropriate consideration must be given to its requirement in the pre-hospital setting).

Front 26

INTRAVENOUS ACCESS
Indications:

Back 26

 The administration of a drug or fluid.

Front 27

INTRAVENOUS ACCESS
Contraindications:

Back 27

 Whenever possible avoid sites of
burn, infection or localised cellulitis.

Front 28

INTRAVENOUS ACCESS
Precautions / Complications:

Back 28

 Air embolus
 Arterial puncture
 Cannula shear or breakage
 Drug/fluid extravasion
 Haematoma or haemorrhage from the
site
 Infection or phlebitis
 Irritation to the vein wall
 Nerve damage
 Vasovagal syncope

Front 29

INTRAVENOUS ACCESS
Additional Information:

Back 29

 IV access should only be implemented
after all basic cares.
 The number of cannulation attempts
should reflect the urgency of the case.
 The following sites are not to be used
for IV access:
Lower limbs when pelvis, abdominal
or thoracic trauma is suspected
Distal to a complex limb injury Limb with a fistula present
An area of phlebitis or cellulitis
When a limb has potential or existing
lymphodema (e.g. the same side as
lymph node clearance)

Front 30

INTRAVENOUS ACCESS
Clinical Judgement Issues:

Back 30

 Use of volume expansion in
uncontrolled haemorrhage (without a
concurrent traumatic brain injury) may
be associated with poor outcomes.
Paramedics are to administer the
minimum amount of IV fluid required
to maintain a radial pulse.
 Hypotension with a concurrent
traumatic brain injury is associated
with poor outcomes. Paramedics are
to administer the minimum amount of
IV fluid required to maintain a systolic
BP of 100 – 120 mmHg (adult).
 Excessive fluid infusion may lead to
neurogenic pulmonary oedema in the
spinal cord injured patient.
 Too rapid infusion of fluids in a patient
without a fluid deficit, or with
underlying cardiac problems, may
cause pulmonary oedema and
congestive heart failure.
 Benefits of fluid infusion must be
carefully analysed against concerns
with the patient’s overall condition.
 A gentle fluid challenge may be
considered for patients with suspected
right ventricular infarct (following 12-
Lead ECG acquisition with V4R) and
no signs of left ventricular failure (e.g.
pulmonary oedema).
 Adult patients must be reassessed
after every 250 – 500 mL of fluid
administration.
 Paediatric patients must be
reassessed after every 10 mL/kg of
fluid administration.
 IV fluids should not be administered to
patients with significant facial, neck or
upper chest burns with high potential
for airway or ventilation compromise
before the airway is formally secured
at hospital. Large amounts of fluids
increase the risk of interstitial oedema
and tissue swelling, potentially
increasing the difficulty of
endotracheal intubation.

Front 31

BREECH BIRTH
Goal:

Back 31

To safely and effectively manage a
breech birth

Front 32

BREECH BIRTH
Indications:

Back 32

 To assist a labouring woman in the
delivery of her child when the child
presents in a breech position

Front 33

BREECH BIRTH
Contraindications:

Back 33

 Nil in this setting

Front 34

BREECH BIRTH
Precautions / Complications:

Back 34

 Failure to deliver
 Pain
 Prolapsed cord
 Shoulder dystocia (refer to CPP)
 Head entrapment
 Meconium aspiration
 Post-partun haemorrhage (refer to
CPG)
 Inversion of the uterus (refer to CPG)
 Complications of breech delivery can
lead to foetal distress and hypoxia
potentiating a compromised neonate.
 Preparation for neonate resuscitation
should be made at the earliest sign of
breech presentation.
 Consideration should be given to early
activation of ICP/obstetric retrieval
team backup.
 Ensure an aseptic technique with
appropriate infection control measures
to be taken at all times

Front 35

BREECH BIRTH
Additional Information:

Back 35

 Nil in this setting

Front 36

BREECH BIRTH
Clinical Judgement Issues:

Back 36

The main categories of breech births
include:
 Frank breech – the foetus’s bottom
comes first, with the legs flexed at the
hips and extended at the knees,
placing the feet near the ears). Most
breech babies (65-70%) are in the
Frank breech position.
 Complete breech – here the hips and
knees are flexed so that the foetus is
sitting cross-legged, with the feet
beside the bottom.
 Footling breech – one or both feet
come first, with the bottom at a higher
position. This is rare at term, but
relatively common with premature
babies.
 Kneeling breech – the foetus is in a
kneeling position, with one or both
legs extended at the hips and flexed
at the knees. This is extremely rare
and often grouped with footling to form
the category “incomplete breech”.
 Foetal trauma is a significant risk if the
required procedures are not
performed gently and without undue
force (e.g. limb fractures and internal
injuries)
 The cord can become nipped under
the pubic arch. The procedure here is
to gently pull the cord around to the
perineum to release any potential
pressure.
 A breech presentation can occur in
the setting of twins. If there is no
antenatal history, be alert for a second
foetus.
 Head entrapment is a critical problem
because the largest part of the infant
(the head) delivers last, and the cervix
may not be fully dilated.
 Remember to collect and consider
carefully all antenatal history that the
patient is able to supply.

Front 37

12-LEAD ECG ACQUISITION
Goal:

Back 37

The 12-lead electrocardiogram (ECG) is
used to detect many conditions affecting
the heart, underlying myocardial
ischaemia, dysrrhythmias, drug toxicity
and electrolyte imbalances.
Use in the pre-hospital setting is
paramount to the diagnosis and treatment
of STEMI, (via the QAS cardiac
reperfusion strategy).

Front 38

12-LEAD ECG ACQUISITION
Indications:

Back 38

 To aid in the identification of:
 myocardial ischaemia or
infarct
 rhythm and conduction
disturbance
 electrolyte imbalance
 hypertrophy of the heart
 drug toxicity

Front 39

12-LEAD ECG ACQUISITION
Contraindications:

Back 39

 Nil in this setting.

Front 40

12-LEAD ECG ACQUISITION
Precautions / Complications:

Back 40

 Nil in this setting.

Front 41

12-LEAD ECG ACQUISITION
Clinical Judgement Issues:

Back 41

To ensure the 12-Lead ECG printout is of
diagnostic quality check that:
 ECG frequency is set at 0.05 – 40 Hz,
and
 Paper speed is set at 25 mm/sec

Front 42

12-LEAD ECG ACQUISITION
Additional Information:

Back 42

 The 12-Lead ECG should be acquired
as part of an early secondary
assessment of the patient, especially
in the setting of suspected cardiac
ischaemia or infarct.
 Electrodes should remain in their
original placement throughout
management to facilitate the
comparison of serial 12-Lead ECGs.