Paramedicine Care 1

Pain Management

Epidemiology of Pain Presentations

Pain is one of the most common reasons people call for an ambulance. In NSW, a significant portion of daily paramedic caseload involves managing patients with acute or chronic pain. Presentations range from traumatic injuries (fractures, burns) to medical conditions (cardiac pain, renal colic, headaches) and exacerbations of chronic pain (cancer pain, back pain).

Types of Pain & Physiology

• Nociceptive Pain: Caused by stimulation of nociceptors, which are sensory receptors for painful stimuli. It's the "normal" response to injury.
  • Somatic: Arises from bone, joint, muscle, skin, or connective tissue. Usually well-localised, described as aching, throbbing, or sharp. (e.g., fractured bone, burn).
  • Visceral: Arises from internal organs. Often poorly localised and may be referred to other areas. Described as cramping, squeezing, or dull. (e.g., appendicitis, cardiac pain).
• Neuropathic Pain: Caused by a lesion or disease of the somatosensory nervous system. The pain signal is abnormal. Often described as burning, shooting, stabbing, or "pins and needles." (e.g., diabetic neuropathy, sciatica).
• Nociplastic Pain (Central Sensitisation): Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage. The central nervous system becomes sensitised. (e.g., fibromyalgia).

The Pain Pathway

The journey of a pain signal involves four key physiological processes:

1. Transduction: A noxious stimulus (mechanical, thermal, chemical) is converted into an electrical signal (action potential) by a nociceptor.
2. Transmission: The action potential is conducted along nerve fibres (A-delta fibres for sharp, fast pain; C-fibres for dull, slow pain) to the spinal cord. It then ascends via the spinothalamic tract to the brain.
3. Perception: The brain (thalamus, somatosensory cortex, limbic system) processes the signal, resulting in the conscious experience of pain. This is a subjective experience influenced by emotions, beliefs, and past experiences.
4. Modulation: The brain and spinal cord can alter the pain signal. Descending pathways can release endogenous opioids (endorphins, enkephalins) and neurotransmitters (serotonin, norepinephrine) that inhibit pain transmission.

IV & IO Access

Intravenous (IV) Cannulation Technique

1. BSI & Preparation: Standard precautions. Gather equipment: correct size cannula, tourniquet, alcohol wipe, dressing, flush, giving set. Prepare a saline flush.
2. Site Selection: Choose a suitable vein. Start distally and work proximally. The antecubital fossa (ACF) is large but limits mobility. Dorsum of the hand and forearm are common sites. Avoid areas of infection, injury, or near joints where possible.
3. Tourniquet Application: Apply 5-10cm above the chosen site. It should be tight enough to impede venous return but not arterial flow (check for a radial pulse).
4. Vein Preparation: Clean the site with an alcohol wipe for 30 seconds and allow to air dry completely. Do not re-palpate.
5. Cannulation: Anchor the vein by pulling the skin taut distally. Insert the cannula, bevel up, at a 15-30 degree angle. Observe for primary flashback in the cannula chamber.
6. Advancement: Once flashback is seen, lower the angle and advance the cannula and needle a further few millimetres to ensure the cannula tip is in the vein. Then, withdraw the needle slightly while advancing the cannula fully into the vein.
7. Secure & Flush: Release the tourniquet. Occlude the vein proximal to the cannula tip, remove the needle, and attach the bung or giving set. Secure with a dressing. Flush with 5-10mL of Sodium Chloride 0.9% to confirm patency (check for swelling or pain).

Intraosseous (IO) Cannulation Technique

IO access is a rapid, safe, and effective alternative when IV access is difficult or impossible in a critically ill patient.

1. BSI & Site Selection: Standard precautions. Identify landmarks for the chosen site. Common sites include:
   • Proximal Tibia: 2cm medial to the tibial tuberosity (in adults).
   • Proximal Humerus: Palpate the surgical neck of the humerus.
2. Preparation: Clean the site thoroughly with an antiseptic wipe.
3. Insertion (using EZ-IO): Select the correct needle size based on tissue depth. Position the driver at a 90-degree angle to the bone. Push the needle through the skin until the tip touches bone. Ensure at least one black line is visible on the catheter. Squeeze the driver's trigger and apply gentle, steady pressure until you feel a "pop" or loss of resistance as the needle enters the medullary cavity.
4. Confirmation & Secure: Remove the driver and stylet. The needle should stand firm in the bone. Attach the extension set and aspirate for bone marrow (often not possible). Flush with 5-10mL of Sodium Chloride 0.9%. This will be met with resistance and may require a pressure bag. Secure the device.
5. Pain Management: IO infusion is painful. For conscious patients, consider administration of Lignocaine 1% (if within scope/protocol) prior to the main fluid infusion.

Decision Making: IV vs IO

The decision hinges on patient acuity and the difficulty of IV access.

• When to choose IV: The default for most patients requiring fluid or medication. Attempt IV access first unless the patient is in extremis.
• When to choose IO: Indicated in critically ill or injured patients when IV access is not readily obtainable.
  • Cardiac arrest
  • Severe shock / profound hypotension
  • Status epilepticus
  • Major trauma
  • Failed IV attempts in a time-critical patient

Fluid Therapy & Shock

Water Movement and IV Fluids

Water moves between intracellular and extracellular compartments via osmosis, driven by the concentration of solutes. The goal of IV fluid therapy is to manipulate this balance to restore intravascular volume.

• Isotonic Fluids (e.g., Sodium Chloride 0.9%, Hartmann's): Have a similar solute concentration to blood plasma. They primarily expand the intravascular space without causing significant fluid shifts in or out of cells. This is the mainstay of prehospital fluid resuscitation.
• Hypotonic Fluids (e.g., 0.45% NaCl): Have a lower solute concentration. They cause fluid to move from the intravascular space into the intracellular space, causing cells to swell. Rarely used in prehospital care.
• Hypertonic Fluids (e.g., 3% NaCl): Have a higher solute concentration. They draw fluid from the intracellular space into the intravascular space, causing cells to shrink. Used for specific conditions like traumatic brain injury with cerebral oedema.

Types of Shock

Shock is a state of circulatory failure resulting in inadequate cellular oxygen utilisation. Your job is to identify the likely cause to guide treatment.

Low Back Pain

Extremely common presentation. Most cases are benign ("simple" or "non-specific" low back pain), but your primary role is to rule out serious underlying pathology.

Common Aetiology

• Mechanical/Musculoligamentous Strain: Most common cause (>90%). Often related to overuse, heavy lifting, or awkward movement.
• Degenerative Disc Disease: Age-related wear and tear on spinal discs.
• Herniated Disc: The soft centre of a spinal disc pushes through a crack in the tougher exterior, potentially compressing nerve roots (causing sciatica).

Assessment for Cauda Equina Syndrome

A surgical emergency caused by compression of the nerve roots at the end of the spinal cord. Ask about these specific symptoms:

1. Saddle Anaesthesia/Paraesthesia: Ask the patient: "Do you have any numbness or tingling in your groin area, or the area you'd sit on a saddle with?" This is the most reliable symptom.
2. Bladder/Bowel Dysfunction: Ask about new onset urinary retention (inability to pass urine) or incontinence (loss of control). Loss of bowel control is also a late sign.
3. Severe or Progressive Bilateral Neurological Deficit: Weakness or sensory loss in both legs.
4. Unilateral or Bilateral Sciatica.

Management & Disposition

• Analgesia:
  • Step 1: Paracetamol.
  • Step 2: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like Ibuprofen, if no contraindications.
  • Step 3 (for severe pain): Consider Methoxyflurane or Fentanyl as per NSW Ambulance CPGs.
• Non-Pharmacological: Encourage gentle movement. Heat packs can be beneficial. Advise against prolonged bed rest.
• Disposition:
  • Emergency Department (ED): Any patient with RED FLAGS, especially suspected Cauda Equina Syndrome, requires urgent transport to ED.
  • Consider Non-Transport: Patients with simple, non-specific low back pain, no red flags, and adequate pain relief may be suitable for self-care advice and referral to a GP. This must be done in line with jurisdictional guidelines and with thorough documentation.

Musculoskeletal Injuries

Assessment of a Suspected Long Bone Fracture

The primary survey (DRSABCD) always comes first. Once the patient is stable, focus on the injured limb.

1. Look: Expose the limb. Look for deformity, swelling, bruising, open wounds (compound fracture).
2. Feel: Gently palpate along the bone away from the point of maximal pain, moving towards it. Feel for tenderness, crepitus (do not deliberately elicit this), and temperature changes.
3. Move: Assess active and passive range of motion ONLY if the patient can tolerate it and there is no gross deformity. If a fracture is obvious, do not ask the patient to move the limb.
4. Neurovascular Assessment (The 6 P's): This is critical to assess limb viability. Compare the injured limb to the uninjured one.
   • Pain: Out of proportion to the injury (a key sign of compartment syndrome).
   • Pallor: Pale or mottled skin suggests poor arterial supply.
   • Pulselessness: Check distal pulses (e.g., radial, dorsalis pedis). Use a Doppler if necessary.
   • Paraesthesia: Numbness or tingling suggests nerve involvement.
   • Paralysis: Inability to move digits or the limb suggests nerve or muscle damage.
   • Perishingly Cold (Poikilothermia): The limb feels cold to the touch.

Clinical Decision Rules: Ottawa Rules

These rules help determine if an x-ray is required for mid-foot, ankle, or knee injuries, reducing unnecessary imaging. They are highly sensitive (if the rule is negative, a fracture is very unlikely).

• Ottawa Ankle/Foot Rules: An ankle/foot x-ray is required only if there is any pain in the malleolar or midfoot zone AND any of these findings:
  • Bone tenderness at the posterior edge or tip of the lateral malleolus.
  • Bone tenderness at the posterior edge or tip of the medial malleolus.
  • Bone tenderness at the base of the fifth metatarsal.
  • Bone tenderness at the navicular bone.
  • Inability to bear weight both immediately and in the emergency department for four steps.
• Ottawa Knee Rules: A knee x-ray is required for an acute knee injury with any of these findings:
  • Age 55 or over.
  • Isolated tenderness of the patella (no other bony tenderness).
  • Tenderness at the head of the fibula.
  • Inability to flex the knee to 90 degrees.
  • Inability to bear weight both immediately and in the ED for four steps.

Reduction of a Lateral Patella Dislocation

1. Gain Consent & Provide Analgesia: Explain the procedure clearly. Provide Methoxyflurane or Fentanyl as needed. The patient needs to be relaxed.
2. Positioning: Position the patient supine or semi-recumbent. The key is to relax the quadriceps muscle.
3. Technique: While the patient is relaxed, slowly and gently extend the knee. As the knee approaches full extension, the patella will often spontaneously relocate. If it does not, apply gentle, steady medial pressure to the lateral edge of the patella to guide it back into the trochlear groove.
4. Post-Reduction Care: Reassess neurovascular status. Immobilise the knee in extension or slight flexion using a splint. Transport for further assessment and imaging.

Neurological Dysfunction

Causes of Altered Conscious State (AEIOU-TIPS)

A structured approach is vital. The AEIOU-TIPS mnemonic is a great tool to consider the differential diagnoses for a decreased level of consciousness.

• A - Alcohol, Acidosis
• E - Epilepsy (post-ictal), Electrolytes, Endocrine (e.g., hypoglycaemia)
• I - Insulin (hypo/hyperglycaemia)
• O - Overdose, Oxygen (hypoxia)
• U - Uraemia (renal failure)
• T - Trauma (head injury), Temperature (hypo/hyperthermia)
• I - Infection (sepsis, meningitis)
• P - Psychiatric, Poisoning
• S - Stroke, Seizure, Shock

Systematic Neurological Assessment

1. Primary Survey (DRSABCD): Is the airway patent? Are they breathing adequately? What is their circulatory status?
2. Conscious State: Assess GCS. Is the patient Alert, responsive to Voice, responsive to Pain, or Unresponsive (AVPU)?
3. Pupils: Check size, equality, and reaction to light (PERL).
4. Motor/Sensory Function: Can they move all four limbs? Are their hand grips equal? Is sensation intact? Look for facial droop.
5. Vital Signs: Full set of vitals including BGL, Temperature, and SpO2. These can provide crucial clues (e.g., hypoglycaemia, hypoxia).
6. History: Use bystanders or family to get a collateral history if the patient cannot provide one.

GCS, AMTS, and Cranial Nerves

Glasgow Coma Scale (GCS): A standardised tool for assessing level of consciousness.

• Eye Opening (E): 4 - Spontaneous, 3 - To voice, 2 - To pain, 1 - None.
• Verbal Response (V): 5 - Orientated, 4 - Confused, 3 - Inappropriate words, 2 - Incomprehensible sounds, 1 - None.
• Motor Response (M): 6 - Obeys commands, 5 - Localises to pain, 4 - Withdraws from pain, 3 - Abnormal flexion (decorticate), 2 - Abnormal extension (decerebrate), 1 - None.

Limitation of GCS: It measures arousal, not cognition. A patient can have a GCS of 15 but still be significantly confused or have cognitive deficits. It can be affected by alcohol, drugs, hypoxia, and language barriers.

Abbreviated Mental Test Score (AMTS): A quick 10-point test for cognitive impairment, often used in older adults.

1. What is your age?
2. What is the time (to the nearest hour)?
3. Address for recall at end of test (e.g., 42 West Street).
4. What is the year?
5. What is the name of this place?
6. Recognise two people (e.g., doctor, nurse).
7. What is your date of birth?
8. When did World War 1 begin? (or other significant past event).
9. Name the current Monarch/Prime Minister.
10. Count backwards from 20 to 1.

A score of <7 suggests cognitive impairment.

Modified Cranial Nerve Assessment (Prehospital Focus):

• CN II, III, IV, VI (Eyes): Check visual fields, PERL, and ask the patient to follow your finger in an 'H' pattern to check for extraocular movements.
• CN V, VII (Face): Check for facial sensation, ask the patient to clench their teeth, smile, and raise their eyebrows. Look for asymmetry/facial droop.
• CN IX, X, XII (Mouth/Speech): Check for slurred speech (dysarthria) and ask the patient to stick out their tongue (it will deviate towards the side of the lesion).

Headaches, Autonomic Dysreflexia, & Meningitis

Headache Types & Treatment

Autonomic Dysreflexia

A life-threatening condition in patients with a spinal cord injury at or above T6. A noxious stimulus below the level of injury (e.g., full bladder, bowel impaction) causes an imbalanced sympathetic response.

• Pathophysiology: The noxious stimulus sends signals up the spinal cord which are blocked at the level of injury. This triggers a massive, uncontrolled sympathetic discharge below the injury, causing severe vasoconstriction and hypertension. The brain detects the hypertension and tries to slow the heart rate via the vagus nerve (bradycardia) and cause vasodilation above the injury, but the signal can't get past the lesion.
• Signs & Symptoms: Pounding headache, severe acute hypertension (SBP >200mmHg), bradycardia, flushing and sweating above the level of injury, pale/cool skin below the injury.
• Treatment Plan:
  1. Sit the patient upright: This uses gravity to help lower blood pressure.
  2. Identify and remove the stimulus: Loosen tight clothing, check for a blocked urinary catheter, ask about last bowel movement.
  3. Manage Hypertension: If BP remains dangerously high after initial measures, pharmacological intervention is needed. Follow local CPGs, which may include Glyceryl Trinitrate (GTN).
  4. Transport: Urgent transport to hospital is required.

Meningitis & Meningococcal Septicaemia

Meningitis: Inflammation of the meninges. Meningococcal Septicaemia: Meningococcal bacteria in the bloodstream, leading to sepsis.

• Signs & Symptoms: Fever, headache, neck stiffness, photophobia, altered mental state. In septicaemia, look for a non-blanching purpuric or petechial rash (a late and critical sign). Other signs of shock will be present.
• Treatment Plan (for suspected Meningococcal Septicaemia):
  1. High-flow oxygen.
  2. Vascular access (IV or IO) and fluid resuscitation for shock.
  3. Pre-hospital antibiotics (e.g., Ceftriaxone) as per CPG if transport time is prolonged. This is a key intervention.
  4. Rapid transport to a hospital with paediatric/intensive care facilities.
  5. Notify the receiving hospital early.

Stroke & Multiple Sclerosis

Stroke Pathophysiology and Types

A stroke is a "brain attack" caused by a disruption of blood supply to a part of the brain, leading to cell death.

• Ischaemic Stroke (~85%): A clot (thrombus or embolus) blocks a cerebral artery. This is the most common type.
• Haemorrhagic Stroke (~15%): A blood vessel in the brain ruptures, causing bleeding into or around the brain tissue.
  • Intracerebral Haemorrhage: Bleeding within the brain tissue itself.
  • Subarachnoid Haemorrhage: Bleeding into the space between the brain and the meninges, often from a ruptured aneurysm. Presents with a "thunderclap" headache.
• Transient Ischaemic Attack (TIA): "Mini-stroke" where symptoms resolve completely, usually within an hour. It's a major warning sign for a future stroke.

Stroke Assessment and Management

Time is brain! Rapid recognition and transport are critical.

• Recognition (FAST Tool):
  • Face: Has their face drooped on one side?
  • Arms: Can they lift both arms and keep them there?
  • Speech: Is their speech slurred?
  • Time: Time is critical. Call for help immediately.
• Systematic Assessment: Perform a full neurological exam, including GCS, pupils, and limb power. Use a validated tool like the ROSIER (Recognition of Stroke in the Emergency Room) scale if part of your CPGs.
• Priorities of Management:
  1. DRSABCD: Ensure a patent airway and adequate oxygenation (aim SpO2 >94%).
  2. Determine Last Known Well Time: This is the most crucial piece of historical information. It determines eligibility for time-critical treatments like thrombolysis or clot retrieval.
  3. Check BGL: Hypoglycaemia can mimic stroke symptoms.
  4. Vascular Access: Establish IV access, but do not delay transport to do so.
  5. Do not treat hypertension unless extremely high and as per specific CPGs, as it may be a compensatory mechanism.
• Transport Destination: Transport the patient to the nearest designated Stroke Centre. Pre-notify the hospital with a clear handover, including the last known well time.

Multiple Sclerosis (MS)

MS is a chronic autoimmune disease where the body's immune system attacks the myelin sheath that protects nerve fibres in the central nervous system. This demyelination disrupts communication between the brain and the rest of the body.

• Pathophysiology: Inflammation and damage to myelin and nerve cells cause a wide range of unpredictable symptoms. Over time, this can lead to permanent disability.
• Types: Most common is Relapsing-Remitting MS (RRMS), characterized by flare-ups (relapses) followed by periods of recovery (remission).
• Symptoms: Highly variable, but can include fatigue, numbness or tingling, muscle weakness or spasms, walking difficulties, vision problems, and cognitive changes. Your role is often to manage an acute relapse or a complication of their condition.

Seizures, Dementia & Parkinson's

Seizure Pathophysiology and Classifications

A seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is the condition of having recurrent, unprovoked seizures.

Seizure Management & Status Epilepticus

Management Priorities:

1. Protect the patient from injury: Move objects away. Do not restrain the patient or put anything in their mouth. Place something soft under their head if possible.
2. Airway Protection & Ventilatory Support: Once the convulsion ceases, position the patient in the recovery position. Consider simple airway adjuncts (NPA/OPA) if needed. Provide high-flow oxygen.
3. Pharmacological Intervention (for Status Epilepticus): The goal is to terminate the seizure.
   • First-line agent: A benzodiazepine, typically Midazolam.
   • Reassess: If the seizure continues after the first dose, a second dose may be administered according to CPG.
   • Check BGL: Hypoglycaemia can cause seizures and must be corrected.

Dementia & Parkinson's Disease

• Dementia: A syndrome of progressive decline in cognitive function that affects memory, thinking, behaviour, and the ability to perform everyday activities. Alzheimer's disease is the most common cause. Your role is often managing acute complications like falls, infections, or behavioural disturbances in a patient with a known history of dementia. Communication requires patience, simple language, and reassurance.
• Parkinson's Disease: A progressive neurodegenerative disorder primarily affecting dopamine-producing neurons in the substantia nigra. This leads to a characteristic movement disorder.
  • Key Symptoms (TRAP): Tremor (at rest, often "pill-rolling"), Rigidity (stiffness), Akinesia/Bradykinesia (slowness or absence of movement), Postural instability (impaired balance).
  • Progression: Symptoms worsen over time, leading to significant disability. Patients may have "on-off" fluctuations where their mobility changes unpredictably.

Wound Care

Wound Assessment and Description

A structured approach ensures nothing is missed. Use the Triangle of Wound Assessment framework.

1. Wound Bed: What does the tissue look like?
   • Granulating: Red, beefy, bumpy. A healthy healing wound.
   • Epithelialising: Pink/white, new skin growing from edges.
   • Sloughy: Yellow/white, stringy dead tissue.
   • Necrotic: Black/brown, hard, dead tissue (eschar).
2. Wound Edge: Is the edge attached or detached? Rolled? Macerated (white and soggy from excess moisture)?
3. Periwound Skin: Look at the skin around the wound. Is it red (erythema), swollen (oedema), warm, or indurated (hard)? These are signs of infection.

Wound & Injury Classification

• Simple vs. Complicated Wounds:
  • Simple: Superficial, clean, minor bleeding, no underlying structure damage.
  • Complicated: Involves deeper structures (nerves, tendons, arteries), is heavily contaminated, contains foreign bodies, or has significant tissue loss.
• Skin Tears (ISTAP/STAR Classification): Common in the elderly.
  • Type 1: No skin loss. The skin flap can be realigned to cover the wound.
  • Type 2: Partial flap loss. The flap cannot cover the entire wound.
  • Type 3: Total flap loss. The entire skin flap is gone.
• Pressure Ulcers: Classified in stages based on depth of tissue damage. High-risk patients are immobile, have poor nutrition, and have sensory impairment.

Wound Dressing & Aseptic Technique

The goal is to prevent infection and promote healing. An aseptic non-touch technique (ANTT) is used.

Cleaning and Dressing a Skin Tear (e.g., Type 1 or 2):

1. BSI & Consent: Standard precautions. Explain the procedure. Provide analgesia if needed.
2. Prepare Field: Open the dressing pack to create a sterile field.
3. Cleanse: Use gauze soaked in Sodium Chloride 0.9% to gently clean the wound and surrounding skin. Pat dry carefully.
4. Realign Flap: If there is a skin flap, gently realign it back into place using a moistened cotton bud or forceps. Do not stretch it.
5. Select Dressing: For a skin tear, a non-adherent silicone-based dressing is ideal as it won't damage the fragile skin upon removal.
6. Apply Dressing: Apply the primary dressing. Secure with a bandage, not tape, to avoid further skin damage.
7. Document: Document the assessment, procedure, and dressing used. Advise the patient/carer on when the dressing should be checked.

Disposition and Closure

• When is prehospital closure suitable? Only for simple, clean lacerations with well-approximated edges. Steri-strips are a common method. Follow local CPGs.
• When to refer for closure? Wounds that are deep, contaminated, involve specialised areas (face, hands), or show signs of neurovascular compromise require formal closure and assessment in a hospital or GP clinic.
• Disposition: A patient with a simple, well-dressed wound may be suitable for self-care or GP follow-up. A patient with a complicated wound, high risk of infection (e.g., diabetic patient with a foot wound), or uncontrolled bleeding requires transport to the ED.