Intermediate skills

Question 1

Laryngoscopy & Magills
Indications

Answer 1

• To identify and remove a suspected foreign body from the hypopharynx that is preventing ventilation.
• In order to create a patent airway and an ability to achieve adequate ventilation

Question 2

Laryngoscopy & Magills
Contraindications

Answer 2

• Conscious patient or Gag reflex intact
• Do not use Magill forceps if obstruction below the vocal cords.
• SpO2 reading of 90% and ventilation is achievable
• Suspected epiglottitis.

Question 3

Laryngoscopy & Magills
Precautions

Answer 3

• Damage to upper respiratory tract, lips and teeth/dentures.
• Further impaction or crumbling of the foreign body
• Vagal stimulation
• Exacerbation of hypoxia / hypercapnia.
• Spinal injury.

Question 4

SGA
Indications

Answer 4

To manage and maintain a compromised airway in the patient with absent pharyngeal and laryngeal reflexes.

Question 5

SGA
Contraindications

Answer 5

Intact gag reflex

Question 6

SGA
Precautions

Answer 6

• Stabilise patient’s head and neck to avoid flexion, rotation or traction during placement
• Confirm placement every time the patient is moved
• Consider gentle use of laryngoscope blade as tongue depressor in infants
• EtCO2 monitoring MUST be applied when available
• Adopt a 30:2 regime during cardiac arrest with mechanical CPR device

Question 7

Peripheral/EJ IV Access
Indications

Answer 7

Intravenous access for fluid or drug administration.

Question 8

Peripheral/EJ IV Access
Contraindications

Answer 8

Directly over or distal to:
Burns
Cellulitis
Infection
Injury
Patients with chlorhexidine sensitivity/allergy, use 10% povidone-iodine swab

Question 9

Peripheral/EJ IV Access
Precautions

Answer 9

MAXIMUM of 2 attempts prior to transport (only 1 vascular (IV/IO) attempt in traumatic cardiac arrests)

EJ - High risk of pneumothorax or lung injury

Question 10

Intraosseous Access
Indications

Answer 10

Cannulation of the intraosseous space using EZ-IO:
* Cardiac arrest:
* First line cardiac arrest management for paediatrics
* Consideration for first line access in traumatic cardiac arrest
* Second line cardiac arrest management for adults following at least one failed intravenous (IV) access attempt.
All other circumstances:
* Where immediate medication administration is required following at least one failed intravenous (IV) access attempt when unable to administer via any other appropriate route.

Question 11

Intraosseous Access
Contraindications

Answer 11

• Fracture to the targeted bone.
• IO within last 48 hours in the targeted bone.
• Inability to locate landmarks or excessive tissue.
• Prosthetic limb or joint (near insertion point).
• Patients with chlorhexidine sensitivity/allergy, use 10% povidone-iodine swab

Question 12

Intraosseous Access
Precautions

Answer 12

• Existing trauma at the insertion site.
• Infection at the insertion site/in targeted bone.
• Use on limbs with possible proximal fractures.
• Previous orthopaedic procedure to targeted limb.

Question 13

Prehospital bloods
Indication

Answer 13

The acquisition of pre-hospital phlebotomy has proven to result in shorter ED times by having the bloods sent to the lab earlier.

Question 14

Prehospital bloods
Contraindication

Answer 14

• Any patient whose clinical condition does not warrant IV cannulation.
• Children <16 years old.

Question 15

Prehospital bloods
Precautions

Answer 15

• If blood fails to draw, assume an unsuccessful cannulation and re-attempt at a new site. Do not attempt to troubleshoot by flushing prior to blood draw.
• If blood flow appears slow or restricted, loosen tourniquet gradually to increase flow.
• Complete the following fields on the pathology request form: ‘clinical notes’ – case number and chief complaint i.e. chest pain, receiving ED and endorse with signature and AP number in ‘collection details’ field. Ensure the Unit No. is left blank and the patient details have been entered correctly.

Question 16

Needle thoracocentesis
Indications

Answer 16

Traumatic cardiac arrest with torso involvement

Question 17

Needle thoracocentesis
Contraindications

Answer 17

Ambulance Paramedics only:
* Patients not in cardiac arrest unless trained and authorised
* Consider ASMA consult in a patient with suspected tension pneumothorax and respiratory and/or haemodynamic compromise.

Question 18

Needle thoracocentesis
Precautions

Answer 18

Perform bilaterally in traumatic cardiac arrest
A patient not in cardiac arrest can receive unilateral treatment on the affected side, with ASMA authorisation where applicable
The site selected should be superior to the third rib to avoid trauma to intercostal blood vessels and nerves.
Procedure can be repeated if tension pneumothorax redevelops.
It is very difficult to detect breath sounds/chest rise and fall in Traumatic Cardiac Arrest, so tension pneumothorax should be assumed whenever there is trauma to the torso
Use the angio cath 14g needle, as shorter cannulas are unlikely to penetrate into the plural space