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CREDITS Editor and Project Manager Cathy Prowd Editor – Medical Content Dr. Michael Lewell Publication Assistants Michelle Priebe Stéphanie Romano ACKNOWLEDGEMENTS The Southwest Ontario Regional Base Hospital Program would like to acknowledge the Program staff and paramedics who took time to provide us with their feedback and suggestions. Your contributions were integral in the development of this protocol book. REPLACEMENT BOOKS Replacement books can be purchased at a cost of $6.00 each. To purchase a replacement book, email: paramedicregistry.on.ca

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Advanced Life Support Patient Care Standards

Introduction

Introduction

TABLE OF CONTENTS

Introduction Acknowledgements .............................................................................................................................. 1

Level of Paramedics .............................................................................................................................. 2 Purpose of Standards ............................................................................................................................ 2

Summary ............................................................................................................................................... 2 Use of the Medical Directives by Paramedics ....................................................................................... 3

Regional Base Hospital Compliance with CPSO Policy .......................................................................... 3 General Structure of a Medical Directive ............................................................................................. 3

ALS Patient Care Standards Paramedic Skill Set ................................................................................... 4 Consent to Treatment and Capacity Assessment ................................................................................. 4

Refusal of Treatment ............................................................................................................................ 6 Comprehensive Care ............................................................................................................................. 6

Intravenous Access and Therapy by Primary Care Paramedics ............................................................ 6 Home Medical Technology and Novel Medications ............................................................................. 7 Patching ................................................................................................................................................ 8

Incident Reporting ................................................................................................................................ 9 Controlled Substances .......................................................................................................................... 9

Responsibility for Care .......................................................................................................................... 9 Research .............................................................................................................................................. 10

Conventions ........................................................................................................................................ 10 Medication Doses and Administration ............................................................................................... 10

Age and Vital Signs .............................................................................................................................. 11 Hypoglycemia ...................................................................................................................................... 12

Level of Awareness ............................................................................................................................. 12 List of Abbreviations ........................................................................................................................... 13

Reference and Educational Notes ...................................................................................................... 16

ACP Core Medical Directives

Medical Cardiac Arrest Medical Directive .......................................................................................... 18 Trauma Cardiac Arrest Medical Directive ........................................................................................... 25

Hypothermia Cardiac Arrest Medical Directive .................................................................................. 30 Foreign Body Airway Obstruction Cardiac Arrest Medical Directive .................................................. 33

Neonatal Resuscitation Medical Directive .......................................................................................... 36 Return of Spontaneous Circulation (ROSC) Medical Directive ........................................................... 39

Cardiac Ischemia Medical Directive .................................................................................................... 43 STEMI Bypass Medical Directive ......................................................................................................... 46

Acute Cardiogenic Pulmonary Edema Medical Directive ................................................................... 48 Cardiogenic Shock Medical Directive .................................................................................................. 51

Symptomatic Bradycardia Medical Directive ...................................................................................... 54 Tachydysrhythmia Medical Directive .................................................................................................. 58

Intravenous and Fluid Therapy Medical Directive .............................................................................. 63 Pediatric Intraosseous Medical Directive ........................................................................................... 67

Hypoglycemia Medical Directive ........................................................................................................ 69 Seizure Medical Directive ................................................................................................................... 73 Opioid Toxicity Medical Directive ....................................................................................................... 76

Orotracheal Intubation Medical Directive .......................................................................................... 79 Bronchoconstriction Medical Directive .............................................................................................. 82

Moderate to Severe Allergic Reaction Medical Directive ................................................................... 86 Croup Medical Directive ..................................................................................................................... 89

Tension Pneumothorax Medical Directive.......................................................................................... 92 Pediatric Analgesia Medical Directive................................................................................................. 95

Adult Analgesia Medical Directive ...................................................................................................... 98 Hyperkalemia Medical Directive ....................................................................................................... 102

ACP Auxiliary Medical Directives Chart of Auxiliary Directives Approved For Use By Ambulance Services ......................................... 106 Adult Intraosseous Medical Directive ............................................................................................... 107

Central Venous Access Device (CVAD) Access Medical Directive ..................................................... 108 Continuous Positive Airway Pressure (CPAP) Medical Directive ...................................................... 109

Supraglottic Airway Medical Directive .............................................................................................. 111 Cricothyrotomy Medical Directive .................................................................................................... 113

Nausea / Vomiting Medical Directive ............................................................................................... 115 Combative Patient Medical Directive ............................................................................................... 117

Procedural Sedation Medical Directive ............................................................................................ 119 Electronic Control Device Probe Removal Medical Directive ........................................................... 121 Nasotracheal Intubation Medical Directive ...................................................................................... 122 Home Dialysis Emergency Disconnect Medical Directive ................................................................. 125 Minor Abrasions Medical Directive‐SPECIAL EVENT ......................................................................... 127 Minor Allergic Reaction Medical Directive‐SPECIAL EVENT .............................................................. 128

Musculoskeletal Pain Medical Directive‐SPECIAL EVENT ................................................................. 130 Headache Medical Directive‐SPECIAL EVENT ................................................................................... 132

Introduction

Chemical Exposure Medical Directives Hydrofluoric Acid Exposure Medical Directive ................................................................................. 136 Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive ......................................................................................... 138 Pediatric Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive ................................................................... 140

Administration of Antidotes for Cyanide Exposure Medical Directive ............................................. 142 Symptomatic Riot Agent Exposure Medical Directive ...................................................................... 143

Reference Material 12‐Lead ECG Review ......................................................................................................................... 146 12‐Lead ECG Placement .................................................................................................................... 147

CPR Guide ......................................................................................................................................... 148 Pediatric CPR Guidelines ................................................................................................................... 148

Relief of Foreign‐Body Airway Obstruction ...................................................................................... 149 Midazolam Dosage Chart .................................................................................................................. 150 Pediatric Vital Signs ........................................................................................................................... 151

Apgar Score ....................................................................................................................................... 151 Pediatric Glasgow Coma Scale .......................................................................................................... 151

Pediatric Trauma Score ..................................................................................................................... 152 Stroke Prompt Card .......................................................................................................................... 153

Stroke Assessment Tool .................................................................................................................... 154 BHP Patch for Trauma TOR ............................................................................................................... 155

BHP Patch for Medical TOR ............................................................................................................... 156 Children’s Aid Reporting Information ............................................................................................... 157

Notes Notes ................................................................................................................................................. 160

BHP Patch Phone Numbers BHP Patch Phone Numbers ............................................................................................................... 164

1

ACKNOWLEDGEMENTS

The development of this edition of the Advanced Life Support Patient Care Standards is the result of a

collaborative effort of a number of stakeholders including:

Association of Paramedic Chiefs (OAPC)

Ontario Base Hospital Group (OBHG)

Ministry of Health and Long Term Care – Emergency Health Services Branch (MOHLTC EHSB)

EHSB Provincial Medical Advisory Committee (MAC)

In particular, the Ministry would like to gratefully acknowledge the following members of the MAC and

regional base hospitals who provided the medical input into these standards:

Dr. Michael Lewell, Chair

Dr. Jason Prpic, Past Chair

Dr. Andrew Affleck

Mr. Andy Benson, Chair, Education Subcommittee

Mr. Chris Day, Primary Care Paramedic Rep.

Dr. Richard Dionne

Mr. Kyle Grant, Advanced Care Paramedic Rep.

Dr. Derek Garniss

Ms. Mary Osinga, College Rep.

Dr. Bruce Sawadsky

Dr. Rudy Vandersluis

Dr. Richard Verbeek

Dr. Michelle Welsford

Introduction

2

LEVELS OF PARAMEDICS

In Ontario, there are three occupational levels of paramedics: Primary Care Paramedic (PCP), Advanced

Care Paramedic (ACP), and Critical Care Paramedic (CCP). A level of paramedic is specified in Ontario

Regulation 257/00 made under the Ambulance Act, RSO 1990, c A‐19. Schedules 1, 2, and 3 to this

regulation specify the mandatory controlled acts for each level of paramedic.

A paramedic may be authorized by a medical director of a Regional Base Hospital (RBH) to perform

controlled acts from the Schedule immediately above their prime occupational level. In this

circumstance, the paramedic will perform the skill to the specific standard set for the skill. This general

concept also applies to the performance of all advanced medical procedures that are not listed as

controlled acts in Schedules 1, 2, and 3, but which are also specified in these standards.

PURPOSE OF STANDARDS

The purpose of the Advanced Life Support Patient Care Standards (ALS PCS) is to guide the specifics of

patient care that are to be undertaken consistent with the scope of practice of the three occupational

levels of paramedics.

The ALS PCS:

Reflects current practices for paramedics in Ontario and provides benchmarks for paramedic

performance.

Communicates the standards of practice and care by paramedics in Ontario to paramedics, patients,

other disciplines, and the public in general.

Delineates paramedic professional responsibilities and accountabilities.

Provides a basis for evaluation of patient care practice by Ontario’s paramedics.

Recognizes that the scope of practice for each occupational level of paramedic may have

incremental add‐ons, with appropriate rationale and accountability.

SUMMARY

ALS PCS for the three occupational levels of paramedics in Ontario establish the practice and patient

care parameters needed to provide high quality patient care in the varied settings throughout the

province. The standards are designed to be dynamic, in order to allow for changes based upon new

medical evidence and/or standards of medical practice.

3

USE OF THE MEDICAL DIRECTIVES BY PARAMEDICS

These medical directives apply to paramedics who provide patient care under the license and/or

authority of the RBH Medical Director. Delegation of controlled acts or medical directives in the ALS PCS

to paramedics falls under the exclusive oversight of the MOHLTC’s RBH Programs.

The medical directives are designed to guide a paramedic in the provision of timely and appropriate care

to ill and injured patients in the prehospital setting, in accordance with the paramedics’ training and

authorized skill set. While great care has been taken in developing these medical directives, they cannot

account for every clinical situation. Thus, they are not a substitute for sound clinical judgment.

REGIONAL BASE HOSPITAL COMPLIANCE WITH CPSO POLICY

As licensed physicians in the Province of Ontario, the RBH Medical Directors must comply with the

policies of the College of Physicians and Surgeons of Ontario (CPSO). CPSO policy #4‐03, as may be

amended from time to time, provides direction to Ontario physicians on the delegation of controlled

acts, regardless of practice setting or type. RBHs will also follow a parallel process for delegation of

other advanced medical procedures included in these Standards.

GENERAL STRUCTURE OF A MEDICAL DIRECTIVE

All medical directives follow the same format and are comprised of the following sections:

Indication: The general medical complaint or problem to which the medical directive

applies.

Conditions: Clinical parameters that must be present for a procedure to be performed or

for a drug to be administered.

Contraindications: Clinical parameters that if present, preclude the performance of a procedure

or the administration of a drug.

Treatment: Description of the type of procedure to be performed or the dosing of a drug.

Clinical Considerations: Key clinical points that provide general guidance to the proper performance

of a procedure or the administration of a drug.

All of these sections must be taken into account before and during the implementation of a medical

directive.

Introduction

4

ALS PATIENT CARE STANDARDS PARAMEDIC SKILL SET

The mandatory skill set for each level of paramedic is derived from the controlled acts outlined in

Schedules 1, 2, and 3 (as referenced above) and is implemented through the PCP and ACP Medical

Directives. A paramedic must meet all applicable requirements set out in Regulation 257/00 to receive

delegation from a RBH medical director.

Additional (“Auxiliary”) skills may be delegated through use of the Auxiliary Medical Directives.

Delegation of Auxiliary Medical Directives by a RBH medical director to paramedics is optional and may

be introduced after consultation and mutual agreement between the RBH and the certified ambulance

service operator that employs the paramedic. Some PCP and ACP Medical Directives contain the phrase,

“(if available)”. This phrase qualifies the skill or procedure as optional (i.e. auxiliary) even if included in

PCP or ACP Medical Directives.

CONSENT TO TREATMENT & CAPACITY ASSESSMENT

Except in emergency circumstances described below, paramedics must obtain the patient’s consent

prior to initiating treatment. Consent may be informed or implied. Informed consent may be either

verbal or written. Implied consent may be assumed where a person provides a physical indication that

they consent to the treatment. For example, a patient who cannot speak but extends his hand to a

paramedic after the paramedic indicates she is going to perform a simple procedure, such as a blood

glucose determination may be giving implied consent to the procedure.

The elements required for consent to treatment are:

consent must be given by a person who is capable of giving consent with respect to treatment,

consent must relate to the treatment,

consent must be informed,

consent must be given voluntarily, and

consent must not be obtained through misrepresentation or fraud.

5

Consent to treatment is informed if, before it is given to the person, he or she has:

received the following information that a reasonable person in the same circumstances would require in order to make a decision about the treatment:

the nature of the treatment,

the expected benefits of the treatment,

the material risks of the treatment,

the material side effects of the treatment,

alternative courses of action,

the likely consequences of not having the treatment; and

received responses to his or her requests for additional information about those matters.

The paramedic who proposes a treatment to a person shall ensure that consent is obtained. Valid

consent requires that a person has the capacity to provide consent. A person is presumed to have the

capacity to provide consent with respect to treatment and a paramedic may rely on that presumption.

However, a capacity assessment may be required if it is not reasonable in the circumstances to presume

the person is capable of consenting to the treatment.

A patient is capable with respect to treatment if the patient is:

Able to understand the information that is relevant to making a decision about the treatment or

alternatives being proposed; and

Able to appreciate the reasonably foreseeable consequences of a decision or lack of decision

with respect to treatment.

If a paramedic is aware or is made aware that the person has a prior capable wish with respect to

treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).

If a person is incapable with respect to a treatment, consent may be given or refused on his or her

behalf by a person who is authorized to do so under section 20 of the Health Care Consent Act, 1996.

In some instances, a person may present in an emergency situation where the person for whom the

treatment is proposed is apparently experiencing severe suffering or is at risk, if the treatment is not

administered promptly, of sustaining serious bodily harm.

Introduction

6

A paramedic may administer treatment to a person without consent in an emergency situation, if there

is no other authorized person available to give or refuse consent and, in the opinion of the paramedic:

the person is not capable of giving a consent or refusal to treatment; and

the delay required to obtain a consent or refusal on the person’s behalf will prolong the

suffering that the person is apparently experiencing or will put the person at risk of sustaining

serious bodily harm.

REFUSAL OF TREATMENT

If a patient refuses treatment, either in whole or in part, a paramedic must comply with the applicable

directions contained in the Basic Life Support (BLS) Patient Care Standards, Section 1, Part I, Patient

Refusal of Treatment and/or Transport.

COMPREHENSIVE CARE

While initiating and continuing treatment prescribed by these medical directives, a paramedic must

ensure that the patient simultaneously receives care in accordance with the BLS Patient Care Standards.

It is acknowledged that there may be circumstances and situations where complying with Advanced Life

Support Patient Care Standards is not clinically justified, possible, or prudent (e.g. multiple crews on

scene, trapped patient, extenuating circumstances, competing patient care priorities). When treatment

deviates from the standards, a paramedic must document the care provided, including reasoning for

deviating from the Standards.

INTRAVENOUS (“IV”) ACCESS AND THERAPY BY PRIMARY CARE PARAMEDICS

Two levels of certification of PCPs for IV cannulation and therapy are possible.

“PCP Assist IV” authorizes a PCP to cannulate a peripheral IV at the request and under the direct

supervision of an ACP. The patient must require a peripheral IV in accordance with the indications listed

in the Intravenous Access and Fluid Therapy Medical Directive ‐ Auxiliary. The ACP will perform all IV

therapy in accordance with the Intravenous Access and Fluid Administration Protocol once intravenous

access is obtained. PCPs certified in PCP Assist IV are not authorized to administer IV therapy.

“PCP Autonomous IV” authorizes a PCP to independently cannulate an IV according to the Intravenous

Access and Fluid Therapy Medical Directive – Auxiliary. PCPs certified in PCP Autonomous IV are

authorized to administer IV therapy according to applicable medical directives.

7

Certification at each level shall meet the requirements established by the provincial Medical Advisory

Committee.

HOME MEDICAL TECHNOLOGY AND NOVEL MEDICATIONS

As community care advances, new home medical technologies and novel medications are being

introduced for home use by highly trained patients and caregivers. They are generally used by patients

with complex medical histories who may require emergent interventions which are not described in, or

aligned with, the BLS PCS or ALS PCS.

A “home medical technology” is an external or internal mechanical device prescribed by a member of a

regulated health profession for the purpose of treating a medical condition.

A “novel medication” is a self/caregiver‐administered medication prescribed by a member of a regulated

health profession that is required to treat patients with generally rare and unusually complex chronic

medical conditions which are often end stage. The medication may be self/caregiver‐administered by

any route into any part of the body.

These can be encountered unexpectedly by paramedics without any prior knowledge that these

technologies or medications are being used in the community. Paramedics may not be familiar with the

use of these technologies or medications, even though they may be required to provide care.

In some cases, when Base Hospital Medical Directors are alerted to these devices, medications or care

requirements, a local medical directive may be issued to guide specific care for these patients. Such

directives should be followed until further consideration by the Medical Advisory Committee.

A paramedic may assume patients or caregivers have knowledge about the technology or medication if

they confirm that they were trained in its use and/or administration. A paramedic should advise the

patient or caregiver to follow any specific steps or provide any advice about restarting/stopping the

device or novel medication. A paramedic may only assist a patient within the authorized paramedic skill

set.

When care requirements are uncertain, but the patient is stable, transport the patient. If the patient is

unstable, consider patching to the Base Hospital Physician. Alternatively, consider contacting the

responsible member of a regulated health profession.

Introduction

8

A paramedic may follow written advice provided by their Base Hospital Medical Directors even if this

advice is outside the conditions and contraindications of the BLS PCS and ALS PCS.

PATCHING

A paramedic should patch to the Base Hospital:

When a medical directive contains a mandatory provincial patch point;

OR

When a RBH introduces a mandatory BH patch point;

OR

For situations that fall outside of these Medical Directives where the paramedic believes the

patient may benefit from online medical direction that falls within the prescribed paramedic

scope of practice;

OR

When there is uncertainty about the appropriateness of a medical directive, either in whole or in

part.

In cases where a treatment option requires the prior authorization by the BHP (i.e. mandatory provincial

patch point or mandatory BH patch point) AND the BHP cannot be reached despite reasonable attempts

by the paramedic to establish contact, a paramedic may initiate the required treatment without the

requisite online authorization if the patient is in severe distress and, in the paramedic’s opinion, the

medical directive would otherwise apply. Clinical judgment must be applied and an acceptable standard

of care must be met. This may be based on peer and expert review. In such cases, a paramedic should

continue attempts to contact the BHP after the treatment has been initiated. All patch failures must be

reported in a timely manner in accordance with local policy and procedures. Paramedics should

document the attempts to patch to the BH on the Ambulance Call Report (ACR).

If a BHP directs a paramedic to perform an assessment or intervention that exceeds the paramedic’s

scope of practice, the paramedic must advise the BHP of such and notify the physician that he or she

cannot comply with the direction as it exceeds his or her scope of practice. In such cases, a paramedic

should ask the BHP to provide alternative direction.

9

INCIDENT REPORTING

Paramedics shall adhere to their ambulance service policies and the Ontario Ambulance Documentation

Standards (incorporated by reference in Regulation 257/00) for incident reporting. Paramedics shall

also adhere to additional RBH policies regarding reporting of clinical care incidents to the RBH.

CONTROLLED SUBSTANCES

Where applicable, paramedics and ambulance service operators shall comply with the Canada

Controlled Drug and Substances Act, SC 1996, c 19 and its Regulations, in accordance with the

ambulance operator and RBH policy. This shall include that controlled substances (opiates and

benzodiazepines) are stored in different carrying cases than other medications.

RESPONSIBILITY FOR CARE

While on scene, the highest level paramedic shall assess the patient and make a decision on the level of

care required, and on the level of paramedic required for the care of the patient. The highest level

paramedic is the ultimate patient care authority on the scene. If there is any disagreement between

paramedics, the Base Hospital physician may be contacted. It is expected that when an intervention has

been performed, the paramedic most appropriate for that intervention will remain responsible for the

patient.

In all patient care, the highest level of paramedic is responsible for the care of the patient, including

decisions on the level of care required during transport. A paramedic may choose to assign aspects of

care and procedures to an alternate level paramedic, as long as the care and procedures are within that

paramedic’s scope of practice. Paramedics must alert the highest level paramedic of any change of

patient status.

When transferring care from one level of paramedic to another, paramedics shall provide:

current CTAS level; a history of the patient’s current problem(s) and relevant past medical history; pertinent physical findings; a summary of management at scene/enroute; the patient’s response to treatment, including most recent vital signs; the reason for transfer in cases of inter‐facility transfers.

Introduction

10

The transfer of responsibility of patient care is a critical juncture along the clinical care continuum.

When transferring patient care to another health care provider (e.g. nurse, physician, etc.), a paramedic

must comply with the BLS Patient Care Standards regarding such transfers.

RESEARCH

Clinical research is fundamental to the practice of medicine and the development of safer, more

effective treatment options for patients. At times, research protocols require temporary changes to

patient care standards. In recognition of the importance of prehospital clinical research, RBH Medical

Directors may delegate changes in patient care standards to paramedics if the research‐related

treatment is endorsed by MAC–OBHG and the certified ambulance operator that employs the

paramedics, approved by MOHLTC, and is supported by an appropriate research ethics review board.

Changes to patient care standards will be introduced as an auxiliary medical directive. Upon completion

of a prehospital clinical trial, research‐related treatment must be halted and care as prescribed by BLS

and ALS Patient Care Standards must resume.

CONVENTIONS

“Conventions” refers to a consistent application of terms throughout the medical directives based on

definitions below.

The word ‘consider’ is used repeatedly throughout the medical directives. Where this word appears, it

indicates that a paramedic should initiate the treatment unless there is strong clinical rationale to

withhold it. A paramedic must document his or her justification for withholding treatment on the ACR.

MEDICATION DOSES AND ADMINISTRATION

Medication doses may be either in per kilogram or fixed doses, depending on common clinical practice.

The number of recommended medication doses may be administered regardless of any previous self‐

administration by a patient. When more than one route of medication administration is listed, the order

of preference for route of administration is from left to right. Clinical circumstances for each case

should determine the final route chosen.

Pediatric medication doses can vary slightly according to the source of expert opinion. The pediatric

medication doses in the ALS PCS are the preferred doses. However, medication doses as determined by

an up‐to‐date version of a widely accepted pediatric emergency tape (e.g. Broselow Tape) are an

11

acceptable alternative. Use of a pediatric emergency tape shall be documented on the ACR when it is

used to determine a pediatric medication dose.

AGE AND VITAL SIGNS

The general age cut off between adults and pediatrics is 18 years. There is a wide range of “normal” for

vital signs in adults and especially pediatrics. As much as possible, ages for pediatrics and cut off points

for vital signs have been kept consistent throughout the medical directives. However, clinical research

and expert opinion have resulted in a number of exceptions which in each case has been deliberately

chosen and is clearly noted in each medical directive. There is a deliberate gap in the definition of

normotension and hypotension in adults.

Adults

Normotension ‐ SBP ≥ 100mmHg

Hypotension ‐ SBP < 90 mmHg

Heart rate: Heart rate is always in beats per minute according to a cardiac monitor when it is

applied. In situations where a cardiac monitor is not indicated then the heart rate is equal to

the pulse rate.

Bradycardia ‐ < 50 BPM

Tachycardia ‐ ≥ 100 BPM

Tachypnea ‐ RR ≥ 28 breath/min Pediatrics

Age Respiratory Rate Heart Rate0 ‐ 3 months 30 ‐ 60 90 ‐ 1803 ‐ 6 months 30 ‐ 60 80 ‐ 1606 ‐ 12 months 25 ‐ 45 80 ‐ 1401 ‐ 3 years 20 ‐ 30 75 ‐ 1306 years 16 ‐ 24 70 ‐ 11010 years 14 ‐ 20 60 ‐ 90

Normotension – SBP ≥ 90 mmHg + (2 x age in years)

Hypotension ‐ SBP < 70 mmHg + (2 x age in years)

Weight (kg) = (age x 2) + 10

Introduction

12

HYPOGLYCEMIA

Age ≥ 2 years: glucometry < 4.0 mmol/L

Age < 2 years: glucometry < 3.0 mmol/L

LOA (Level of Awareness)

The word ‘altered’ refers to a GCS that is less than normal for the patient.

The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS < 15.

13

LIST OF ABBREVIATIONS

The following abbreviations, in alphabetical order, appear in the ALS Patient Care Standards:

A ACP Advanced Care Paramedic ALS Advanced Life Support ALS PCS Advanced Life Support Patient Care Standards ASA acetylsalicylic acid AV atrioventricular B BH Base Hospital BHP Base Hospital Physician BLS Basic Life Support BP blood pressure BPM beats per minute BVM bag‐valve‐mask C CCP Critical Care Paramedic COPD chronic obstructive pulmonary disease cm centimeter CPAP continuous positive airway pressure CPR Cardiopulmonary Resuscitation CPSO College of Physicians and Surgeons of Ontario CTAS Canadian Triage and Acuity Scale CVA cerebral vascular accident CVAD central venous access device D DKA diabetic ketoacidosis E ECD electronic control device ECG electrocardiogram EDD esophageal detection device ETCO2 end tidal carbon dioxide ETT endotracheal tube F FiO2 fraction of inspired oxygen FRI febrile respiratory infection

Introduction

14

G g gram GCS Glasgow Coma Scale H H2O water HR heart rate Hx history I IM intramuscular IN intranasal IO intraosseous IV intravenous K kg kilogram L LOA level of awareness LOC level of consciousness/loss of consciousness M MAC Medical Advisory Committee mcg microgram MDI metered dose inhaler mg milligram min minute ml/kg milliliter per kilogram mmHg millimeters of mercury MOHLTC Ministry of Health and Long‐Term Care N N/A not applicable NaCl sodium chloride nare nostril NEB nebulized NPA nasopharyngeal airway NSAID non‐steroidal anti‐inflammatory drug

15

O OBHG Ontario Base Hospital Group OPA oropharyngeal airway P PCP Primary Care Paramedic PO by mouth/oral PRN as needed Q q every R RBH Regional Base Hospital ROSC return of spontaneous circulation RR respiratory rate S SC subcutaneous SL sublingual SBP systolic blood pressure SpO2 saturation of peripheral oxygen STEMI ST‐segment elevation myocardial infarction T TBI traumatic brain injury TCA tricyclic antidepressant TCP transcutaneous pacing U URTI upper respiratory tract infection V VSA vital signs absent W WNL within normal limits

Introduction

16

REFERENCE AND EDUCATIONAL NOTES

The RBHs have created a companion document of reference and educational notes intended to assist

paramedics in implementing these medical directives. This will facilitate regular updating of these notes

without having to issue frequent changes to the standards. It is expected that paramedics have

mastered the relevant information as part of initial training and certification and have maintained their

knowledge through continuing education and self‐study. The reference and educational notes do not

define a standard of care; however, they should be considered useful in ensuring that an appropriate

standard of care is met.

17

NOTES

ACP Core Medical Directives

ACP CoreMedical

Directives

18

Manual Defibrillation

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: VF or pulseless VT

AED Defibrillation

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Shock indicated Alternative to

manual defibrillation

Epinephrine

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: If anaphylaxis suspected as causative event, IM route may be used

Lidocaine

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: VF or pulseless VT where amiodarone is not available

Amiodarone

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE

An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if certified and authorized.

INDICATIONS

Non‐traumatic cardiac arrest

CONDITIONS

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: performed in 2 minute intervals

19

0.9% NaCl Fluid Bolus

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: PEA Any other rhythm where

hypovolemia is suspected


Rhythms other than VF or pulseless VT

AED Defibrillation

Non‐shockable rhythm

Amiodarone

Allergy or sensitivity to amiodarone

Lidocaine

Allergy or sensitivity to lidocaine

Use / Availability of amiodarone

CONTRAINDICATIONS

CPR

Obviously dead as per BLS standards

Meet conditions of DNR standard

Epinephrine

Allergy or sensitivity to epinephrine


Fluid overload

ACP CoreMedical

Directives

20

Consider AED defibrillation: (alternative to manual defibrillation)

Age Age ≥ 30 days to < 8 years ≥ 8 years

With Ped attenuator

Without Ped attenuator

Dose 1 shock 1 shock 1 shock

Max. single dose As per BH / manufacturer

As per BH / manufacturer


Dosing interval 2 min 2 min 2 min Max. # of doses N/A N/A N/A

Consider Manual defibrillation:

Age Age ≥ 30 days to < 8 years ≥ 8 years Dose 1 shock 1 shock

First dose 2 J/kg As per BH / manufacturer

Subsequent and max. dose(s) 4 J/kg As per BH /

manufacturer

Dosing interval 2 min 2 min

Max. # of doses N/A N/A

Consider CPR

TREATMENT

Consider supraglottic airway insertion: where more than OPA/NPA and BVM required and without interrupting CPR

21

Consider epinephrine:

In the event anaphylaxis is suspected as the causative event of the cardiac arrest, a single dose of 0.01 mg/kg 1:1,000 solution, to a maximum of 0.5 mg IM, may be given prior to obtaining the IV/IO.

Age Age

≥ 30 days to < 12 years ≥ 12 years

Route Route IV / IO / CVAD ETT IV / IO / CVAD ETT

Solution 1:10,000 1:1,000 1:10,000 As per BH

Dose 0.01 mg/kg* 0.1 mg/kg to a max of 2 mg

1 mg 2 mg

Min. single dose 0.1 mg 1 mg 1 mg 2 mg Dosing interval 4 min 4 min 4 min 4 min Max. # of doses N/A N/A N/A N/A

* The epinephrine dose may be rounded to the nearest 0.05 mg.

Consider amiodarone: Age Age ≥ 30 days to < 12 years ≥ 12 years Route Route IV / IO / CVAD IV / IO / CVAD

Initial Dose 5 mg/kg 300 mg Max. initial dose 300 mg 300 mg Repeat dose 5 mg/kg 150 mg Max. repeat dose 150 mg 150 mg Dosing interval 4 min 4 min Max. # of doses 2 2

ACP CoreMedical

Directives

22

Consider lidocaine: (if amiodarone not available)

Age Age ≥ 30 days to 12 years ≥ 12 years Route Route IV / IO / CVAD ETT IV / IO / CVAD ETT

Dose 1 mg/kg 2 mg/kg 1.5 mg/kg 3 mg/kg Min. single dose N/A N/A N/A N/A Dosing interval 4 min 4 min 4 min 4 min Max. # of doses 2 2 2 2

MANDATORY PROVINCIAL PATCH POINT:

Patch to BHP following 3 rounds of epinephrine (or after 3rd analyses if no IV/IO/ETT access). If the BH patch fails, transport to the closest appropriate receiving hospital following the 4th epinephrine administration (or 4th analysis if no IV/IO/ETT access).

Consider intubation: if the airway is not being adequately managed.

Consider 0.9% NaCl fluid bolus:

Age Age ≥ 30 days to < 12 years ≥ 12 years Route Route IV / IO / CVAD IV / IO / CVAD Infusion 20 ml/kg 20 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume 20 ml/kg up to 2,000 ml 2,000 ml

23

CLINICAL CONSIDERATIONS

In unusual circumstances (e.g. pediatric patients or toxicological overdoses), consider initiating transport following the first rhythm analysis that does not result in a defibrillation being delivered.

The IV and IO routes of medication administration are preferred over the ETT route. However, ETT administration may be used if the IV/IO routes are delayed (e.g. > 5 min)

ACP CoreMedical

Directives

24

NOTES

25


AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Shock indicated

Trauma TOR

AGE: ≥ 16 years

LOA: Altered

HR: 0

RR: 0

SBP: N/A

Other: No palpable pulses No defibrillation delivered AND monitored HR = 0 (asystole) OR monitored HR > 0

AND the closest ER ≥ 30 min transport time away.

TRAUMA CARDIAC ARREST MEDICAL DIRECTIVE


INDICATIONS

Cardiac arrest secondary to severe blunt or penetrating trauma

CONDITIONS

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Performed in 2 minute intervals

ACP CoreMedical

Directives

26



AED Defibrillation


CONTRAINDICATIONS

TREATMENT

CPR



Trauma TOR

Age < 16 years

Shock delivered

Monitored HR > 0 and closest ER < 30 min away

Consider CPR



Initial dose 2 J/kg As per BH / manufacturer

Dosing interval 2 min 2 min Max. # of doses 1 1

27


If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat according to the appropriate medical cardiac arrest directive.



With Ped attenuator






Dosing interval 2 min 2 min 2 min Max. # of doses 1 1 1


Patch to BHP for authorization to apply the Trauma (TOR) Termination of Resuscitation if applicable. If the BH patch fails, or the trauma TOR does not apply, transport to the closest appropriate receiving hospital following the first analysis/shock.

ACP CoreMedical

Directives

28

TREATMENT – ALGORITHM FOR TRAUMA ARREST

INDICATIONS: Cardiac arrest secondary to severe blunt or penetrating trauma

CPR (throughout duration of call)

Apply defib pads to all patient ≥ 30 days of age ‐ Rhythm analysis

VF or VT Other monitored rhythm

Defibrillation: 1 shock, Max # doses = 1

Asystole PEA (HR >0)

Pt age ≥ 16 years

Drive time to closest ER ≥ 30 min

Patch

Transport to ED TOR implemented

NO

NO

NO

NO

YES YES YES

YES

YESYES

YES

YES

YES

Transport to Emergency Departm

ent

29

NOTES

ACP CoreMedical

Directives

30


AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A




AED Defibrillation


HYPOTHERMIA CARDIAC ARREST MEDICAL DIRECTIVE


INDICATIONS

Cardiac arrest secondary to severe hypothermia

CONDITIONS

CONTRAINDICATIONS

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


CPR



31

TREATMENT


N/A

Consider CPR







With Ped attenuator







Transport to the closest appropriate facility without delay following the first analysis.

ACP CoreMedical

Directives

32

NOTES

33


AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥ 30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A




AED Defibrillation


FOREIGN BODY AIRWAY OBSTRUCTION CARDIAC ARREST MEDICAL DIRECTIVE An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if certified and authorized.

INDICATIONS

Cardiac arrest secondary to an airway obstruction

CONDITIONS

CONTRAINDICATIONS

TREATMENT

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


CPR



Consider CPR

Consider foreign body removal: (utilizing BLS maneuvers and/or laryngoscope and Magill forceps)

ACP CoreMedical

Directives

34


N/A







With Ped attenuator







If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first analysis.

If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest.

35

NOTES

ACP CoreMedical

Directives

36

Resuscitation

Clear of meconium

Breathing or crying

Good muscle tone

Pink in colour

NEONATAL RESUSCITATION MEDICAL DIRECTIVE


INDICATIONS

Severe cardio‐respiratory distress

CONDITIONS

CONTRAINDICATIONS

Resuscitation

AGE: newborn or < 30 days of age

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Less than full term, OR meconium, OR poor APGAR score

37

Routine care:

Provide warmth Clear airway if necessary Do not routinely suction Dry Ongoing evaluation

Supportive care

Supportive care

TREATMENT

*if meconium is present and baby not vigorous, suction mouth and pharynx, consider ETT and provide BVM ventilations as required and then continue with the remainder of the initial steps following birth.

Birth:

Clear of *meconium? Breathing or crying? Good muscle tone? Colour pink? Term gestation

Provide warmth Position/clear airway (as necessary) Dry, stimulate, reposition

Evaluate respirations, heart rate and colour

Provide positive pressure ventilation (BVM) using air

Provide positive pressure ventilation (BVM/ETT) using 100% oxygen Administer chest compressions

Epinephrine: 0.01 mg/kg (0.1 ml/kg) 1:10,000 IV/IO OR 0.1 mg/kg (1 ml/kg) 1:10,000 ETT q 4 minutes. Initiate transport prior to the 3rd dose if possible.

YES

NO

30 secs

Breathing

HR ≥ 100 + pink

Apnea, gasping or HR < 100

Ventilating

HR ≥ 100 + pink

60 secs

90 secs

HR < 60 HR ≥ 60

120 secs

HR < 60 HR ≥ 60

ACP CoreMedical

Directives

38

NOTES

39

Dopamine

AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

Therapeutic hypothermia

AGE: males ≥ 18 years

females ≥ 50 years

LOA: Altered

HR: N/A

RR: N/A

SBP: ≥ 90 mmHg (spontaneous, following bolus administered or with dopamine)

Other: N/A

Dopamine

Allergy or sensitivity to dopamine

Tachydysrhythmias excluding sinus tachycardia

Mechanical shock states

Hypovolemia

Pheochromocytoma

Therapeutic hypothermia

Traumatic cardiac arrest (blunt, penetrating or burn)

Sepsis or serious infection suspected as cause of arrest

Hypothermic arrest

Known coagulopathy (medical history or medications)

RETURN OF SPONTANEOUS CIRCULATION (ROSC) MEDICAL DIRECTIVE


INDICATIONS

Patient with return of spontaneous circulation (ROSC) after the resuscitation was initiated.

CONDITIONS

CONTRAINDICATIONS

0.9% NaCl fluid bolus

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Chest auscultation is clear

0.9% NaCl fluid bolus

Fluid overload

SBP ≥ 90 mmHg

ACP CoreMedical

Directives

40


Age Age < 12 years ≥ 12 years Route Route IV IV Infusion 10 ml/kg 10 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume 1,000 ml 1,000 ml

Consider dopamine:

Route IV Initial Infusion Rate 5 mcg/kg/min Titration increment 5 mcg/kg/min Titration interval 5 min Max infusion rate 20 mcg/kg/min

NOTE: Titrate dopamine to achieve a systolic BP of 90‐110 mmHg. If discontinuing dopamine electively, do so gradually over 5‐10 minutes.

TREATMENT

Consider rapid transport

Consider optimizing ventilation and oxygenation:

Titrate oxygenation ≥ 94%

Avoid hyperventilation and target an ETCO2 of 35‐40 mmHg with continuous waveform capnography (if available)

41

Consider Therapeutic hypothermia (if available)

Consider 12 lead acquisition


The application of therapeutic hypothermia should not detract from rapid transport, optimizing ventilation and oxygenation or the management of a re‐arrest.

ACP CoreMedical

Directives

42

NOTES

43

Nitroglycerin

AGE: ≥ 18 years

LOA: Unaltered

HR: 60‐159/min

RR: N/A

SBP: Normotension

Other: Prior history of nitroglycerin use or IV access obtained

Morphine

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: N/A

Nitroglycerin

Allergy or sensitivity to nitrates

Phosphodiesterase inhibitor use within the previous 48 hours SBP drops by one third or more of its initial value after nitroglycerin is administered 12‐lead ECG compatible with Right Ventricular infarct

Morphine

Allergy or sensitivity to morphine

Injury to the head or chest or abdomen OR pelvis

SBP drops by one‐third or more of its initial value after morphine is administered

CARDIAC ISCHEMIA MEDICAL DIRECTIVE


INDICATIONS

Suspected cardiac ischemia

CONDITIONS

CONTRAINDICATIONS

ASA

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: Able to chew and swallow

ASA

Allergy or sensitivity to ASA or NSAIDS

If asthmatic, no prior use of ASA

Current active bleeding

CVA or TBI in the previous 24 hours

ACP CoreMedical

Directives

44

Consider 12‐lead ECG acquisition

Consider nitroglycerin: SBP

≥ 100 mmHg

Route SL

Dose 0.3 or 0.4 mg Max. single dose 0.4 mg Dosing interval 5 min Max. # of doses 6

Consider morphine (after the third dose of nitroglycerin or if nitroglycerin is contraindicated):

Route IV Dose 2 mg Max. single dose 2 mg Dosing interval 5 min Max. # of doses 5

TREATMENT


N/A

Consider ASA: Route PO Dose 160‐162 mg Max. single dose 162 mg Dosing interval N/A Max. # of doses 1

45

NOTES

ACP CoreMedical

Directives

46

STEMI BYPASS MEDICAL DIRECTIVE

This page left blank intentionally, awaiting Provincial STEMI Bypass Medical Directive

47

NOTES

ACP CoreMedical

Directives

48

ACUTE CARDIOGENIC PULMONARY EDEMA MEDICAL DIRECTIVE


INDICATIONS

Moderate to severe respiratory distress

AND

Suspected acute cardiogenic pulmonary edema

CONDITIONS

CONTRAINDICATIONS

Nitroglycerin

AGE: ≥ 18 years

LOA: N/A

HR: 60‐159/min

RR: N/A

SBP: Normotension

Other: Ascertain prior history of nitroglycerin use OR establish IV access

Nitroglycerin

Allergy or sensitivity to nitrates

Phosphodiesterase inhibitor use within the previous 48 hours

SBP drops by one third or more of its initial value after nitroglycerin is administered

49

Consider 12‐lead ECG acquisition

TREATMENT


N/A

Consider nitroglycerin:

SBP SBP

100 mmHg to < 140 mmHg ≥ 140 mmHg

IV or Hx IV or Hx IV or Hx Yes No Yes Route Route Route SL SL SL

Dose 0.3 or 0.4 mg 0.3 or 0.4 mg 0.6 or 0.8 mg Max. single dose 0.4 mg 0.4 mg 0.8 mg Dosing interval 5 min 5 min 5 min Max. # of doses 6 6 6

NOTE: Hx refers to a patient with a prior history of nitroglycerin use.

ACP CoreMedical

Directives

50

NOTES

51

Dopamine

AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

Dopamine




Hypovolemia

Pheochromocytoma

CARDIOGENIC SHOCK MEDICAL DIRECTIVE


INDICATIONS

STEMI‐positive ECG

AND

Cardiogenic shock

CONDITIONS

CONTRAINDICATIONS


AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Clear chest on auscultation


N/A

ACP CoreMedical

Directives

52

TREATMENT


Contact BHP if patient is bradycardic.


Age ≥ 18 years Route Route IV IO Infusion 10 ml/kg 10 ml/kg Infusion interval N/A N/A Reassess every 250 ml 250 ml Max. volume 10 ml/kg 10 ml/kg

NOTE: If NaCl bolus contraindicated due to pulmonary crackles, consider dopamine.

Consider dopamine:

Route IV Initial infusion rate 5 mcg/kg/min Titration increment 5 mcg/kg/min Titration interval 5 min Max. infusion rate 20 mcg/kg/min


53

NOTES

ACP CoreMedical

Directives

54

Transcutaneous Pacing

AGE: ≥ 18 years

LOA: N/A

HR: < 50/min

RR: N/A

SBP: Hypotension

Other: N/A

Dopamine

AGE: ≥ 18 years

LOA: N/A

HR: < 50/min

RR: N/A

SBP: Hypotension

Other: N/A

Dopamine




Hypovolemia

Pheochromocytoma

Transcutaneous Pacing

Hemodynamic stability

Hypothermia

SYMPTOMATIC BRADYCARDIA MEDICAL DIRECTIVE


INDICATIONS

Bradycardia

AND

Hemodynamic instability

CONDITIONS

CONTRAINDICATIONS

Atropine

AGE: ≥ 18 years

LOA: N/A

HR: < 50/min

RR: N/A

SBP: Hypotension

Other: N/A

Atropine

Allergy or sensitivity to atropine

Hemodynamic stability

Hypothermia

History of heart transplant

55

TREATMENT

Consider Rhythm determination

Consider 12 lead ECG acquisition (if this won’t delay therapy)

Consider atropine: Route IV Dose 0.5 mg Max. single dose 0.5 mg Dosing interval 5 min Max. # of doses 2


Patch to BHP for authorization to proceed with transcutaneous pacing and/or a dopamine infusion.

Consider transcutaneous pacing

Consider dopamine: Route IV Initial infusion rate 5 mcg/kg/min Titration increment 5 mcg/kg/min Titration interval 5 min Max. infusion rate 20 mcg/kg/min


ACP CoreMedical

Directives

56


Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first degree AV block, or second‐degree Type I AV block. A single dose of atropine should be considered for second degree Type II or third degree AV blocks with fluid bolus while preparing for TCP OR if there is a delay in implementing TCP OR if TCP is unsuccessful. The dopamine infusion should be initiated at 5 mcg/kg/min. and titrated upward to effect in increments of 5 mcg/kg/min every 5 minutes up to a maximum of 20 mcg/kg/min. The desired effect is a SBP of 90‐110 mmHg.

57

NOTES

ACP CoreMedical

Directives

58

Adenosine

AGE: ≥ 18 years

LOA: Unaltered

HR: ≥ 150/min

RR: N/A

SBP: Normotension

Other: Narrow complex and regular rhythm

Amiodarone

AGE: ≥ 18 years

LOA: Unaltered

HR: ≥ 120/min

RR: N/A

SBP: Normotension

Other: Wide complex and regular rhythm

TACHYDYSRHYTHMIA MEDICAL DIRECTIVE


INDICATIONS

Symptomatic Tachydysrhythmia

CONDITIONS

Valsalva Maneuver

AGE: ≥ 18 years

LOA: Unaltered

HR: ≥ 150/min

RR: N/A

SBP: Normotension

Other: Narrow complex and regular rhythm

Lidocaine

AGE: ≥ 18 years

LOA: Unaltered

HR: ≥ 120/min

RR: N/A

SBP: Normotension

Other: Wide complex and regular rhythm

Synchronized Cardioversion

AGE: ≥ 18 years

LOA: N/A

HR: ≥ 120/min (wide) or ≥ 150/min (narrow)

RR: N/A

SBP: Hypotension

Other: Altered mental status, ongoing chest pain, other signs of shock

59

Adenosine

Allergy or sensitivity to adenosine

Sinus tachycardia or atrial fibrillation or atrial flutter

Patient taking dipyridamole or carbamazepine

Bronchoconstriction on exam

Amiodarone

Allergy or sensitivity to amiodarone

CONTRAINDICATIONS

TREATMENT

Valsalva Maneuver

Sinus tachycardia or atrial fibrillation or atrial flutter

Consider Rhythm determination: Confirm regularity

Consider 12 lead ECG acquisition: To confirm QRS width (if this won’t delay therapy)

Consider valsalva maneuver:

Perform a maximum of two attempts lasting 10 to 20 seconds duration each.

Synchronized Cardioversion

N/A

Lidocaine


ACP CoreMedical

Directives

60

Consider adenosine:

Route IV Initial Dose 6 mg Second dose 12 mg Dosing interval 2 min Max. # of doses 2 doses


Patch to BHP for authorization to proceed with amiodarone or lidocaine or if monomorphic wide complex regular rhythm for adenosine.

Consider amiodarone (if available) OR lidocaine:

Drug Drug Amiodarone Lidocaine Route Route

IV* IV First Dose 150 mg 1.5 mg/kg Subsequent Dose(s) 150 mg 0.75 mg/kg Max. single dose 150 mg 150 mg Dosing interval 10 min 10 min Max. # of doses 2 3

*Amiodarone should be administered by IV infusion over 10 min.


Patch to BHP for authorization to proceed with synchronized cardioversion

61


N/A

Consider synchronized cardioversion:

Administer up to three synchronized shocks in accordance with BHP direction and energy settings. (In the setting of a patch failure, the energy settings to be used are 100 J, 200 J and the maximum manufacturer setting.)

ACP CoreMedical

Directives

62

NOTES

63

INTRAVENOUS AND FLUID THERAPY MEDICAL DIRECTIVE


INDICATIONS

Actual or potential need for intravenous medication OR fluid therapy

CONDITIONS

CONTRAINDICATIONS

IV

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

0.9% NaCL Fluid Bolus

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

IV

Suspected fracture proximal to the access site.

0.9% NaCL Fluid Bolus

Signs of fluid overload

ACP CoreMedical

Directives

64

TREATMENT

Consider IV cannulation

Consider 0.9% NaCl maintenance infusion:

Age Age < 12 years ≥ 12 years Route Route IV / IO / CVAD IV / IO / CVAD Infusion 15 ml/hr 30‐60 ml/hr Infusion interval N/A N/A Reassess every N/A N/A Max. volume N/A N/A


Patch to BHP for authorization to administer IV NaCl bolus to patients < 12 years with suspected Diabetic Ketoacidosis (DKA)


Age Age < 12 years ≥ 12 years Route Route IV / IO / CVAD IV / IO / CVAD Infusion 20 ml/kg 20 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml

Max. volume* 20 ml/kg up to 2,000 ml 2,000 ml

*The maximal volume of NaCl is lower for patients in cardiogenic shock.

65


“PCP Assist IV” authorizes a PCP to cannulate a peripheral IV at the request and under the direct supervision of an ACP. The ACP will perform all IV further therapy in accordance with the Intravenous Access and Fluid Therapy Medical Directive once intravenous access is obtained. PCPs certified in PCP Assist IV are not authorized to administer IV fluid or medication therapy.

Adult IO and CVAD procedures are auxiliary Medical Directives described elsewhere. Fluid administration via the IO or CVAD routes only apply to paramedics certified and authorized to perform these procedures.

Microdrips and or volume control administration sets should be considered when IV access is indicated for patients less than 12 years of age.

ACP CoreMedical

Directives

66

NOTES

67

Consider IO access

PEDIATRIC INTRAOSSEOUS MEDICAL DIRECTIVE


INDICATIONS


AND

Intravenous access is unobtainable

AND

Cardiac arrest or near‐arrest state

CONDITIONS

CONTRAINDICATIONS

TREATMENT


N/A

IO

AGE: < 12 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

IO

Fracture or crush injuries or suspected or known replacement / prosthesis proximal to the access site.

ACP CoreMedical

Directives

68

NOTES

69

HYPOGLYCEMIA MEDICAL DIRECTIVE


INDICATIONS

Agitation OR altered LOA OR seizure OR symptoms of stroke

CONDITIONS

CONTRAINDICATIONS

TREATMENT

Dextrose

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Glucagon

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Dextrose

Allergy or sensitivity to dextrose

Glucagon

Allergy or sensitivity to glucagon

Pheochromocytoma

Perform glucometry

ACP CoreMedical

Directives

70

Consider dextrose or glucagon:

Drug Dextrose Age Age Age < 30 days ≥ 30 days to < 2 years ≥ 2 years Weight Weight Weight N/A N/A N/A Concentration Concentration Concentration D10W D25W D50W Route Route Route IV IV IV

Dose 0.2 g/kg (2 ml/kg) 0.5 g/kg

(2 ml/kg) 0.5 g/kg (1 ml/kg)

Max. single dose 5 g (50 ml) 10 g (40 ml) 25 g (50 ml) Dosing interval 10 min 10 min 10 min Max. # of doses 2 2 2

Drug Glucagon Age N/A Weight Weight < 25 kg ≥ 25 kg Concentration Concentration N/A N/A Route Route IM IM Dose 0.5 mg 1.0 mg Max. single dose 0.5 mg 1.0 mg Dosing interval 20 min 20 min Max. # of doses 2 2

71


If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple carbohydrates.

If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of dextrose or glucagon.

If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucometry must be attempted.

ACP CoreMedical

Directives

72

NOTES

73

SEIZURE MEDICAL DIRECTIVE


INDICATIONS

Active generalized motor seizure

CONDITIONS

CONTRAINDICATIONS

Midazolam

AGE: N/A

LOA: Unresponsive

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Midazolam

Allergy or sensitivity to midazolam

Hypoglycemia

ACP CoreMedical

Directives

74

TREATMENT


Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be considered by a paramedic.

Consider midazolam:

Route Route Route Route IV IM IN Buccal

Dose 0.1 mg/kg 0.2 mg/kg 0.2 mg/kg 0.2 mg/kg Max. single dose 5.0 mg 10 mg 10 mg 10 mg Dosing interval 5 min 5 min 5 min 5 min Max. # of doses 2 2 2 2

75

NOTES

ACP CoreMedical

Directives

76

OPIOID TOXICITY MEDICAL DIRECTIVE


INDICATIONS

Altered LOC

AND

Respiratory depression

AND

Suspected opioid overdose

CONDITIONS

CONTRAINDICATIONS

Naloxone

AGE: ≥ 18 years

LOA: Altered

HR: N/A

RR: < 10/min

SBP: N/A

Other: N/A

Naloxone

Allergy or sensitivity to naloxone

Uncorrected hypoglycemia

77

TREATMENT


N/A


Patch to BHP for authorization to proceed with naloxone

Consider naloxone:

Route Route Route Route SC IM IN IV* Dose 0.8 mg 0.8 mg 0.8 mg Up to 0.4 mg Max. single dose 0.8 mg 0.8 mg 0.8 mg 0.4 mg Dosing interval N/A N/A N/A N/A Max. # of doses 1 1 1 1

*For the IV route, titrate naloxone only to restore the patient’s respiratory status.

ACP CoreMedical

Directives

78

NOTES

79

Lidocaine Spray

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Orotracheal Intubation

Orotracheal Intubation

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Lidocaine


Unresponsive patient

Orotracheal Intubation

Age < 50 years AND current episode of asthma exacerbation AND not in or near cardiac arrest.

OROTRACHEAL INTUBATION MEDICAL DIRECTIVE


INDICATIONS

Need for ventilatory assistance or airway control

AND

Other airway management is inadequate or ineffective

CONDITIONS

CONTRAINDICATIONS

ACP CoreMedical

Directives

80

TREATMENT


An intubation attempt is defined as insertion of the laryngoscope blade into the mouth for the purpose of intubation.

The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation attempts is two (2).

At least two primary and one secondary ETT placement confirmation methods must be used.

If the patient has a pulse, an ETCO2 device (quantitative or qualitative) must be used for ETT placement confirmation.

Additional secondary ETT placement confirmation devices may be authorized by the local medical director.

ETT placement must be reconfirmed immediately after every patient movement.

Consider topical lidocaine spray (to the hypopharynx) for “awake” orotracheal intubation:

Route TOPICAL Dose 10 mg/spray Max. dose 5mg/kg Dosing interval N/A Max. # of doses 20 sprays

Consider intubation: with or without intubation facilitation devices. The maximum number of intubation attempts is 2.

Confirm orotracheal tube placement:

Method Method Primary Secondary

Visualization ETCO2 Auscultation EDD Chest rise Other

81

NOTES

ACP CoreMedical

Directives

82

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: BVM ventilation required

SBP: N/A

Other: Hx of asthma

Epinephrine Autoinjector

AGE: N/A

WEIGHT: ≥ 10 kg

LOA: N/A

HR: N/A

RR: BVM ventilation required

SBP: N/A

Other: Hx of asthma

Epinephrine




BRONCHOCONSTRICTION MEDICAL DIRECTIVE An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if certified and authorized.

INDICATIONS

Respiratory distress

AND

Suspected bronchoconstriction

CONDITIONS

CONTRAINDICATIONS

Salbutamol

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Salbutamol

Allergy or sensitivity to salbutamol

83

TREATMENT

Consider salbutamol:

Weight Weight < 25 kg ≥ 25 kg Route Route Route Route MDI* NEB MDI* NEB

Dose Up to 600 mcg (6 puffs) 2.5 mg Up to 800 mcg

(8 puffs) 5 mg

Max. single dose 600 mcg 2.5 mg 800 mcg 5 mg Dosing interval 5‐15 min PRN 5‐15 min PRN 5‐15 min PRN 5‐15 min PRN Max. # of doses 3 3 3 3

* 1 puff=100mcg


Weight Weight Weight Any ≥ 10 kg to < 25 kg ≥ 25 kg Route Route Route

IM PediatricAutoinjector

Adult Autoinjector

Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000

Dose 0.01 mg/kg** 1 injection(0.15 mg)

1 injection(0.3 mg)

Max. single dose 0.5 mg 1 injection 1 injection Dosing interval N/A N/A N/A Max. # of doses 1 1 1

**The epinephrine dose may be rounded to the nearest 0.05 mg.

ACP CoreMedical

Directives

84


Epinephrine should be the first drug administered if the patient is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter.

Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health.

When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths.

A spacer should be used when administering salbutamol MDI.


Patch to BHP for authorization to use pediatric autoinjector for patients < 10 kg.

85

NOTES

ACP CoreMedical

Directives

86


AGE: N/A

WEIGHT: ≥ 10 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: For anaphylaxis only

Diphenhydramine

AGE: N/A

WEIGHT: ≥ 25 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A



Diphenhydramine

Allergy or sensitivity to diphenhydramine

MODERATE TO SEVERE ALLERGIC REACTION MEDICAL DIRECTIVE


INDICATIONS

Exposure to a probable allergen

AND

Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis)

CONDITIONS

CONTRAINDICATIONS

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: For anaphylaxis only

Epinephrine


87


Patch to BHP for authorization to use pediatric autoinjector for patients < 10kg

TREATMENT


Epinephrine should be the first drug administered in anaphylaxis.

Consider epinephrine: Weight Weight Weight N/A ≥ 10 kg to < 25 kg ≥ 25 kg Route Route Route

IM PediatricAutoinjector Adult

Autoinjector Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000

Dose 0.01 mg/kg* 1 injection(0.15 mg)

1 injection(0.3 mg)

Max. single dose 0.5 mg 1 injection 1 injection Dosing interval N/A N/A N/A Max. # of doses 1 1 1

* The epinephrine dose may be rounded to the nearest 0.05 mg.

Consider diphenhydramine (if available):

Weight Weight ≥ 25 kg to < 50 kg ≥ 50 kg Route Route Route Route IV IM IV IM Dose 25 mg 25 mg 50 mg 50 mg Max. single dose 25 mg 25 mg 50 mg 50 mg Dosing interval N/A N/A N/A N/A Max. # of doses 1 1 1 1

ACP CoreMedical

Directives

88

NOTES

89

CROUP MEDICAL DIRECTIVE


INDICATIONS

Severe respiratory distress

AND

Stridor at rest

AND

Current history of URTI

AND

Barking cough OR recent history of a barking cough

CONDITIONS

CONTRAINDICATIONS

Epinephrine

AGE: < 8 years

LOA: N/A

HR: < 200/min

RR: N/A

SBP: N/A

Other: N/A

Epinephrine


ACP CoreMedical

Directives

90

TREATMENT


The minimum initial volume for nebulization is 2.5 ml.


Age Age < 1 year ≥ 1 year to < 8 years Weight Weight Weight < 5 kg ≥ 5 kg N/A Route Route Route NEB NEB NEB Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000 Dose 0.5 mg 2.5 mg 5 mg Max. single dose 0.5 mg 2.5 mg 5 mg Dosing interval N/A N/A N/A Max. # of doses 1 1 1

91

NOTES

ACP CoreMedical

Directives

92

TENSION PNEUMOTHORAX MEDICAL DIRECTIVE


INDICATIONS

Suspected tension pneumothorax

AND

Critically ill OR VSA

AND

Absent or severely diminished breath sounds on the affected side(s)

CONDITIONS

CONTRAINDICATIONS

Needle Thoracostomy

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension or VSA

Other: N/A

Needle Thoracostomy

N/A

93

TREATMENT


Needle thoracostomy may only be performed at the second intercostal space in the midclavicular line.


Patch to BHP for authorization to perform needle thoracostomy

Consider needle thoracostomy

ACP CoreMedical

Directives

94

NOTES

95

PEDIATRIC ANALGESIA MEDICAL DIRECTIVE


INDICATIONS

Severe pain

AND

Isolated hip OR extremity fractures or dislocations OR major burns OR current history of cancer related pain

CONDITIONS

CONTRAINDICATIONS

Morphine

AGE: < 18 years

LOA: Unaltered

HR: ≥ 60/min

RR: N/A

SBP: Normotension

Other: N/A

Morphine

Allergy or sensitivity to morphine

Injury to the head or chest or abdomen or pelvis

SBP drops by one‐third or more of its initial value after morphine is adminstered

ACP CoreMedical

Directives

96

TREATMENT


N/A


Patch to BHP for authorization and dosage verification before administering the medication for children < 8 years.

Consider morphine:

Route IV/SC

Dose 0.05 mg/kg

Max. single dose 3 mg

Dosing interval 5 min

Max. # of doses 2

97

NOTES

ACP CoreMedical

Directives

98

ADULT ANALGESIA MEDICAL DIRECTIVE


INDICATIONS

Mild – Moderate Pain (Acetaminophen/Ibuprofen) OR Mild – Severe Pain (Ketorolac) AND/OR Moderate – Severe Pain (Morphine) AND Trauma OR burns OR renal colic with prior history OR acute musculoskeletal back strain OR current history of cancer related pain.

CONDITIONS

Ibuprofen

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: When used for trauma patients, restricted to those with isolated hip or extremity trauma

Ketorolac

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: When used for trauma patients, restricted to those with isolated hip/extremity trauma AND who are unable to tolerate oral meds.

Acetaminophen

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: When used for trauma patients, restricted to those with isolated hip or extremity trauma

Morphine

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: N/A

99

CONTRAINDICATIONS

Acetaminophen

Acetaminophen use within previous 4 hours

Allergy or sensitivity to acetaminophen

Hx of liver disease

Active vomiting

Unable to tolerate oral medication

Ibuprofen

NSAID or Ibuprofen use within previous 6 hours

Allergy or sensitivity to ASA or NSAIDS

Patient on anticoagulation therapy


Hx of peptic ulcer disease or GI bleed

Pregnant

If asthmatic, no prior use of ASA or other NSAIDs


Known renal impairment

Active vomiting

Unable to tolerate oral medication

Morphine

Allergy or sensitivity to Morphine

SBP drops by one‐third or more of its initial value after morphine is administered

Ketorolac

NSAID or Ibuprofen use within previous 6 hours

Allergy or sensitivity to ASA or NSAIDs

Patient on anticoagulation therapy


Hx of peptic ulcer disease or GI bleed

Pregnant

If asthmatic, no prior use of ASA or other NSAIDs


Known renal impairment

ACP CoreMedical

Directives

100

TREATMENT


Whenever possible, consider co‐administration of acetaminophen and ibuprofen.

In patients with isolated hip or extremity trauma, ibuprofen and acetaminophen is preferred to ketorolac except where the patient is unable to tolerate oral medications.

If ketorolac is administered, neither acetaminophen nor ibuprofen should be administered.

Suspected renal colic patients should routinely be considered for ketorolac AND morphine.

Consider ibuprofen:

Route PO

Dose 400 mg


Dosing interval N/A

Max. # of doses 1

Consider ketorolac:

Route IM/IV

Dose 10‐15 mg


Dosing interval N/A

Max. # of doses 1

Consider acetaminophen:

Route PO

Dose 960‐1000 mg


Dosing interval N/A

Max. # of doses 1

Consider morphine:

Route SC /IV

Dose 2‐5 mg


Dosing interval 5 min

Max # doses 4

101

NOTES

ACP CoreMedical

Directives

102

HYPERKALEMIA MEDICAL DIRECTIVE

An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive If certified and authorized.

INDICATIONS

Suspected hyperkalemia in patients at high risk, including:

currently on dialysis OR

history of end‐stage renal disease (ESRD) OR

other reason to be highly suspicious of hyperkalemia (i.e. prolonged crush injury)

AND

one of the following clinical situations:

Cardiac Arrest

OR

pre‐arrest (i.e. hypotension, altered level of consciousness, symptomatic bradycardia) with

12‐lead ECG suggestive of hyperkalemia (i.e. wide and often bizarre QRS (> 120 ms) with

peaked T waves, loss of p waves and/or may have sine wave appearance)

CONDITIONS

Calcium Gluconate 10%

AGE: ≥ 18 years

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Salbutamol

AGE: ≥ 18 years

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

103

CONTRAINDICATIONS

TREATMENT

Calcium Gluconate 10%

Patients on Digoxin

Salbutamol

Allergy or sensitivity to salbutamol


Patch to BHP for authorization to proceed with calcium gluconate and salbutamol therapies. Record ECG before and after treatment.

Consider calcium gluconate 10%:

Route IV/IO

Dose 1 g (10 ml) over 2‐3 minutes

Max. single dose 1 g (10 ml) Dosing interval 30 minutes Max. # of doses 2

Consider salbutamol (this may not be possible in cardiac arrest):

Route MDI Nebuilized

Dose 1600 mcg*(16 puffs)

10 mg

Max. single dose 1600 mcg 10 mg

Dosing interval immediate immediate Max. # of doses 2 2

*1 puff=100 mcg

ACP CoreMedical

Directives

104


Whenever possible, both calcium gluconate and salbutamol should be given as the two medications have different modes of action.

If appropriate, refer to the Symptomatic Bradycardia, Tachydsrhythmia, or Cardiac Arrest Medical Directives for further management of these patients.

Sodium bicarbonate is not a very effective agent for hyperkalemia and so should not routinely be given.

Caution that calcium gluconate should only be administered in an IV/IO that is running well and that calcium gluconate and sodium bicarbonate should not be mixed or given in the same IV without flushing well.

105

NOTES

ACP Auxiliary

Medical Directives

ACP Auxiliary Medical

Directives

106

AUXILIARY DIRECTIVES APPROVED FOR USE BY EACH AMBULANCE SERVICE

ACP Auxiliary Directives

Adult IO CVAD CPAP SGA CRIC 12

Lead N/V COMB PROC

SED ECD Probe

Essex

Lambton

Middlesex

Oxford

Huron

107

ADULT INTRAOSSEOUS MEDICAL DIRECTIVE ‐ AUXILIARY

An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive if certified and authorized.

INDICATIONS


AND

IV access is unobtainable

AND

Cardiac arrest OR near arrest state

CONDITIONS

CONTRAINDICATION

TREATMENT


N/A

IO AGE: ≥ 12 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

IO

Fracture or crush injuries or suspected or known replacement / prosthesis proximal to the access site.

Consider IO access


Directives

108

CENTRAL VENOUS ACCESS DEVICE ACCESS MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS


AND

IV access is unobtainable

AND

Cardiac arrest OR near arrest state

CONDITIONS

CONTRAINDICATIONS

TREATMENT


N/A

CVAD Access

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Patient has a pre‐existing, accessible central venous catheter in place

CVAD Access

N/A

Consider CVAD access

109

CPAP

Asthma exacerbation

Suspected pneumothorax

Unprotected or unstable airway

Major trauma or burns to the head or torso

Tracheostomy

Inability to sit upright

Unable to cooperate

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Severe respiratory distress

AND

Signs and/or symptoms of acute pulmonary edema OR COPD

CONDITIONS

CONTRAINDICATIONS

CPAP AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: Tachypnea

SBP: Normotension

Other: SpO2 < 90% or accessory muscle use


Directives

110

TREATMENT


N/A

Consider CPAP:

Initial setting 5 cm H2O Or equivalent flow rate of device as per BH direction

Titration increment 2.5 cm H2O Or equivalent flow rate of device as per BH direction

Titration interval 5 min.

Max. setting 15 cm H2O Or equivalent flow rate of device as per BH direction

Consider increasing FiO2 (if available):

Initial FiO2 50‐100%FiO2 increment (if available on device)

SpO2 < 92% despite treatment and/or 10cm H2O pressure or equivalent flow rate of

device as per BH direction Max FiO2 100%

Confirm CPAP pressure by manometer (if available)

111

SUPRAGLOTTIC AIRWAY MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Need for ventilatory assistance OR airway control

AND

Other airway management is inadequate OR ineffective OR unsuccessful

CONDITIONS

CONTRAINDICATIONS

Supraglottic Airway

AGE: N/A

LOA: GCS = 3

HR: N/A

RR: N/A

SBP: N/A

Other: Absent gag reflex

Supraglottic Airway

Active vomiting

Inability to clear the airway

Airway edema

Stridor

Caustic ingestion


Directives

112

TREATMENT


An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into the mouth.


Consider supraglottic airway insertion. The maximum number of attempts is two (2).

Confirm supraglottic airway placement:


Auscultation ETCO2 Chest rise Other

113

CRICOTHYROTOMY MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Need for advanced airway management

AND

Intubation AND supraglottic airway (if available) insertion unsuccessful or contraindicated

AND

Unable to ventilate

CONDITIONS

CONTRAINDICATIONS

Cricothyrotomy

AGE: ≥ 12 years

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Cricothyrotomy

Suspected fractured larynx

Inability to landmark


Directives

114

TREATMENT


At least two primary and one secondary Cricothyrotomy tube placement confirmation methods must be used.

If the patient has a pulse, an ETCO2 device must be used (quantitative or qualitative) for cricothyrotomy tube placement confirmation.

Additional secondary Cricothyrotomy tube placement confirmation devices may be authorized by the local medical director.

Cricothyrotomy tube placement must be reconfirmed immediately after every patient movement.


Patch to BHP for authorization to perform cricothyroidotomy

Consider cricothyrotomy.

Confirm cricothyrotomy: tube placement


Auscultation ETCO2 Chest rise Other

115

NAUSEA / VOMITING MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Nausea OR vomiting

CONDITIONS

CONTRAINDICATIONS

Dimenhydrinate

AGE: N/A

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Dimenhydrinate

Allergy or sensitivity to dimenhydrinate or other antihistamines

Overdose on antihistamines or anticholinergics or TCAs


Directives

116

TREATMENT


Prior to IV administration, dilute dimenhydrinate (concentration of 50 mg/1 ml) 1:9 with Normal Saline or sterile water. If given IM do not dilute.

Consider dimenhydrinate:

Weight Weight Weight < 25 kg ≥ 25 kg to < 50 kg ≥ 50 kg Route Route Route Route Route Route IV IM IV IM IV IM Dose Patch Patch 25 mg 25 mg 50 mg 50 mg Max. single dose N/A N/A 25 mg 25 mg 50 mg 50 mg Dosing interval N/A N/A N/A N/A N/A N/A Max. # of doses N/A N/A 1 1 1 1

117

COMBATIVE PATIENT MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Combative patient

CONDITIONS

CONTRAINDICATIONS

TREATMENT

Midazolam

AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Normotension

Other: No reversible causes (i.e. hypoglycemia, hypoxia, hypotension)

Midazolam



Patch to BHP for authorization to proceed with midazolam if unable to assess the patient for normotension or reversible causes.


Directives

118


N/A

Consider midazolam:

Route Route IV IM Dose 2.5 ‐ 5 mg 2.5 ‐ 5 mg Max. single dose 5 mg 5 mg Dosing interval 5 min 5 min Max. total dose 10 mg 10 mg Max. # doses 2 2

119

PROCEDURAL SEDATION MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Post‐intubation OR transcutaneous pacing

CONDITIONS

*Non‐intubated patients only

CONTRAINDICATIONS

Midazolam

AGE: ≥ 18 years

LOA: N/A

HR: N/A

RR: ≥ 8/min*

SBP: Normotension

Other: N/A

Midazolam



Directives

120

TREATMENT


N/A

Consider midazolam:

Route IV Dose 2.5 ‐ 5 mg Max. single dose 5 mg Dosing interval 5 min Max. total dose 10 mg Max. # doses 2

121

Consider probe removal

ELECTRONIC CONTROL DEVICE PROBE REMOVAL MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Electronic Control Device probe(s) embedded in patient.

CONDITIONS

CONTRAINDICATIONS

TREATMENT


Police may require preservation of the probe(s) for evidentiary purposes.

This directive is for removal of ECD only and in no way constitutes treat and release, normal principles of patient assessment and care apply.

Probe Removal

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Probe removal

Probe embedded above the clavicles, in the nipple(s), or in the genital area


Directives

122

NASOTRACHEAL INTUBATION MEDICAL DIRECTIVE ‐ AUXILIARY

A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive if certified and authorized.

INDICATIONS

Need for ventilatory assistance OR airway control

AND

Other airway management is inadequate or ineffective

CONDITIONS

Xylometazoline

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Nasotracheal Intubation

Lidocaine Spray

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Nasotracheal Intubation

Nasotracheal Intubation

AGE: ≥8 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Spontaneous Breathing

123

CONTRAINDICATIONS

TREATMENT

Consider xylometazoline 0.1% spray: for nasotracheal intubation:

Route TOPICAL Dose 2 sprays/nare Max. single dose 2 sprays/nare Dosing interval N/A Max. # of doses 1

Nasotracheal Intubation

Age < 50 years AND current episode of asthma exacerbation AND not in or near cardiac arrest.

Suspected basal skull fracture or mid‐face fracture

Uncontrolled epistaxis

Anticoagulant therapy (excluding ASA)

Bleeding disorders

Xylometazoline

Allergy or sensitivity to xylometazoline

Lidocaine Spray

Allergy or sensitivity to lidocaine Unresponsive patient


Directives

124


An intubation attempt is defined as insertion of the nasotracheal tube into a nare.


The two primary and at least one secondary nasotracheal placement confirmation methods must be used.

An ETCO2 device (quantitative or qualitative) must be used for ETT placement confirmation.

Additional secondary ETT placement confirmation devices may be authorized by the local medical director.

ETT placement must be reconfirmed immediately after every patient movement.

Consider topical lidocaine spray (to the nares and/or hypopharynx) for “awake” nasotracheal intubation:

Route TOPICAL Dose 10 mg/spray Max. single dose 5mg/kg Dosing interval N/A Max. # of doses 20 sprays

Consider intubation. The maximum number of intubation attempts is two (2).

Confirm nasotracheal tube placement:


Auscultation ETCO2 Chest rise EDD

Other

125

HOME DIALYSIS EMERGENCY DISCONNECT MEDICAL DIRECTIVE ‐ AUXILIARY


INDICATIONS

Patient receiving home dialysis (hemo or peritoneal) and connected to dialysis machine

AND Patient requires transport to the hospital

AND Patient is unable to disconnect OR there is no family member or caregiver available or knowledgeable in dialysis disconnect

CONDITIONS

CONTRAINDICATIONS

TREATMENT

Home Dialysis Emergency Disconnect

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Home Dialysis Emergency Disconnect

N/A

Consider Home Dialysis Emergency Disconnect


Directives

126


Generally, emergency disconnect kit with materials and instructions can be found hanging from dialysis machine or nearby on the wall.

Ensure both the patient side and machine side of the connection are clamped before disconnecting and attaching end caps.

127

Consider release from care

Consider topical antibiotic

MINOR ABRASIONS MEDICAL DIRECTIVE – AUXILIARY – SPECIAL EVENT


INDICATIONS

Minor abrasions

AND

Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director

CONDITIONS

CONTRAINDICATIONS

TREATMENT


Advise patient that if the problem persists or worsens that they should seek further medical attention.

Topical Antibiotic

AGE: N/A

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Topical Antibiotic

Allergy or sensitivity to topical antibiotics


Directives

128

Diphenhydramine

Allergy or sensitivity to diphenhydramine

Antihistamine or sedative use in previous 4 hours

Signs or symptoms of moderate to severe allergic reaction

Signs or symptoms of intoxication

Wheezing

MINOR ALLERGIC REACTION MEDICAL DIRECTIVE – AUXILIARY – SPECIAL EVENT


INDICATIONS

Signs consistent with minor allergic reaction

AND


CONDITIONS

CONTRAINDICATIONS

Diphenhydramine

AGE: ≥ 18 years

LOA: Unaltered

HR: WNL

RR: WNL

SBP: Normotension

Other: N/A

129

TREATMENT



Consider diphenhydramine:

Route PO Dose 50 mg Max. single dose 50 mg Dosing interval N/A Max. # of doses 1



Directives

130

MUSCULOSKELETAL PAIN MEDICAL DIRECTIVE – AUXILIARY – SPECIAL EVENT


INDICATIONS

Minor musculoskeletal pain

AND


CONDITIONS

CONTRAINDICATIONS

Acetaminophen

AGE: ≥ 8 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Acetaminophen

Acetaminophen use within previous 4 hours



131

TREATMENT




Route PO Dose 325 ‐ 650 mg Max. single dose 650 mg Dosing interval N/A Max. # of doses 1



Directives

132

HEADACHE MEDICAL DIRECTIVE – AUXILIARY – SPECIAL EVENT


INDICATIONS

Uncomplicated headache conforming to the patient’s usual pattern

AND


CONDITIONS

CONTRAINDICATIONS

Acetaminophen

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Acetaminophen

Acetaminophen use within the previous 4 hours



133

TREATMENT




Route PO Dose 325 ‐ 650 mg Max. single dose 650 mg Dosing interval N/A Max. # of doses 1



Directives

134

NOTES

135

NOTES

Chemical Exposure Medical Directives

The following Medical Directives have been developed for use when chemical exposure to the listed agent is suspected. NOTE: These Medical Directives may only be used by paramedics who have received special training in treating patients with chemical exposures. This is usually a comprehensive program that includes personal protection and training in CBRNE (Chemical, Biologic, Radiological, Nuclear and Explosive) events.

136

HYDROFLUORIC ACID EXPOSURE MEDICAL DIRECTIVE When the listed indication and condition exist, a paramedic is authorized to administer Calcium Gluconate and/or topical anaesthetic eye drops according to the following protocol. The paramedic will comply with local BHP patching protocols. INDICATIONS:

Patient was exposed to vapour, and/or liquid hydrofluoric acid. CONDITIONS:

Patient is exhibiting signs and symptoms of hydrofluoric acid poisoning. CONTRAINDICATIONS:

Topical anaesthetic eye drops (see Procedure, point #6a) are contraindicated if the patient is allergic to anaesthetics. PROCEDURE:

1. Don appropriate PPE.

2. Remove patient from further hydrofluoric acid exposure, remove contaminated clothing, jewellery,

etc.

3. Decontaminate if not already decontaminated.

4. Assess vital signs; apply cardiac monitor and high flow oxygen.

5. Inhalation:

a) Ensure airway patency and breathing.

b) For dyspnea see Bronchoconstriction Medical Directive.

c) If airway pain (suspected inhalation injury), consider delivering a nebulized Calcium Gluconate

2.5% solution (1 ml 10% Calcium Gluconate and 3 ml sterile normal saline) with high flow

oxygen.

6. Eye Contact:

For eye discomfort, irrigate thoroughly with copious amounts of normal saline.

a) Remove contact lenses.

b) Administer 2 drops of topical anaesthetic eye drops in each eye, repeat every 10 minutes as

needed.

c) Monitor the patient for 20 minutes after the last dose.

137

7. Skin Contact:

a) Irrigate thoroughly with copious amounts of saline for 1 minute if not already done.

b) Massage Calcium Gluconate 2.5% Gel (if available) liberally into the burn area and continue

applying during transport if pain persists.

NOTES:

1. Transport to hospital as soon as possible.

2. Latex gloves are not sufficient. Use Neoprene or Nitrile gloves.

138

ADMINISTRATION OF ATROPINE, EITHER PRALIDOXIME CHLORIDE (2 PAM) OR OBIDOXIME AND DIAZEPAM FOR NERVE AGENT EXPOSURE MEDICAL DIRECTIVE When the listed indication and conditions exist, a paramedic is authorized to administer Atropine, either Pralidoxime or Obidoxime and Diazepam to a victim of nerve agent (or organophosphate) exposure. The paramedic will comply with local BHP patching protocols. INDICATIONS:

Patient was exposed to known or suspected nerve agent. CONDITIONS:

1. Adult (≥ 40 kg)

2. The patient is exhibiting signs and symptoms of a cholinergic crisis. PROCEDURE:

Mild Exposure:

Signs: anxiety about being exposed, may see miosis, rhinorrhea.

1. Remove patient from area of exposure.

2. Remove all contaminated clothing.

Moderate Exposure:

Signs: (ANY ONE OF) vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath, any

known liquid exposure.

Administer:

1. One (1) Atropine 2mg IM or autoinjector. Repeat Atropine 2mg IV/IM every 5 minutes as needed until symptoms improve.

2. One (1) Pralidoxime 600mg IM or autoinjector OR Obidoxime 150mg IM or autoinjector.

3. One (1) Diazepam 10mg IM or autoinjector.

Severe Exposure:

Signs: Signs of moderate exposure and (ANY ONE OF) decreased LOC, paralysis, seizures, apnea.

Administer:

1. Three (3) doses Atropine 2mg IV/IM or autoinjectors. If bronchial secretions persist,

continue Atropine 2mg IV/IM every 5 minutes as needed until secretions clear.

2. Three (3) doses Pralidoxime 600mg IM or autoinjectors OR three (3) Obidoxime 150mg IM

or autoinjectors.

3. One (1) Diazepam 10mg IM or autoinjector.

139

NOTES:

1. Patients receiving treatment should also receive oxygen and be on a cardiac monitor if available.

2. Only Advanced Care Paramedics may administer intravenous medications.

3. ABC’s must also be secured as appropriate in an MCI/contaminated environment. Atropine should

be administered prior to airway interventions if secretions are copious.

4. Decontamination procedures must be integrated with antidote administration.

5. Personal Protective Equipment must be worn at all times.

6. Drugs may be given IV but do not delay IM administration if IV access is not already established.

140

PEDIATRIC ADMINISTRATION OF ATROPINE, EITHER PRALIDOXIME CHLORIDE (2 PAM) OR OBIDOXIME AND DIAZEPAM FOR NERVE AGENT EXPOSURE

MEDICAL DIRECTIVE When the listed indication and conditions exist, a paramedic is authorized to administer Atropine, either Pralidoxime or Obidoxime and Diazepam to a victim of nerve agent (or organophosphate) exposure. The paramedic will comply with local BHP patching protocols. INDICATIONS:

Patient was exposed to known or suspected nerve agent. CONDITIONS:

1. <40 kg

2. The patient is exhibiting signs and symptoms of a cholinergic crisis. PROCEDURE:

Mild Exposure:

Signs: anxiety about being exposed, may see miosis, rhinorrhea.

1. Remove patient from area of exposure.

2. Remove all contaminated clothing.

Moderate/Severe Exposure:

Signs: (ANY ONE OF) vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath,

decreased LOC, paralysis, seizures, apnea, any known liquid exposure.

Administer:

For patients < 10kg:

1. Atropine 0.5 mg IM, repeat IV/IM every 5 minutes as needed until symptoms improve.

2. Diazepam 2mg IV/IM.

3. Pralidoxime 15mg/Kg IV/IM every 1 hour maximum 600mg/single dose, total maximum

dose 1200mg OR Obidoxime 8mg/Kg maximum 320mg total dose.

For patients from 10kg to 39kg:

1. Atropine 1 mg IM, repeat IV/IM every 5 minutes as needed until symptoms improve.

2. Diazepam 0.2 mg/kg IV/IM.

3. Pralidoxime 15mg/Kg IV/IM every 1 hour maximum 600mg/single dose, total maximum

dose 1200mg OR Obidoxime 8mg/Kg maximum 320mg total dose.

141

NOTES:

1. Patients receiving treatment should also receive oxygen and be on a cardiac monitor if available.

2. Only Advanced Care Paramedics may administer intravenous medications.

3. ABC’s must also be secured as appropriate in an MCI/contaminated environment. Atropine should

be administered prior to airway interventions if secretions are copious.

4. Decontamination procedures must be integrated with antidote administration.

5. Personal Protective Equipment must be worn at all times.

6. Drugs may be given IV but do not delay IM administration if IV access is not already established.

142

ADMINISTRATION OF ANTIDOTES FOR CYANIDE EXPOSURE MEDICAL DIRECTIVE When the listed indication and condition exist, a paramedic is authorized to administer antidotes to victims of Cyanide exposure according to the following protocol. The paramedic will comply with local BHP patching protocols. INDICATIONS:

Patient was exposed to vapour, liquid or solid, suspected to contain cyanide.

CONDITIONS:

Patient is exhibiting signs and symptoms of cyanide poisoning. PROCEDURE:

1. Remove patient from further exposure and remove clothes.

2. Assess vital signs, GCS.

3. Ensure airway, administer oxygen and apply cardiac and oxygen saturation monitors as possible.

4. If GCS 15 and patient is asymptomatic, decontaminate and transport to hospital.

5. If GCS < 15 administer:

a) Sodium Thiosulfate 12.5 gm (50 ml of 25% solution) IV

(Pediatric dose = 1.65 ml/kg to max 50 ml).

OR

b) CYANOKIT (hydroxocobalamin) 5.0 g by rapid IV infusion over 30 minutes

(Pediatric dose = 70 mg/kg)

6. Initiate treatment and continue while transport to hospital.

143

SYMPTOMATIC RIOT AGENT EXPOSURE MEDICAL DIRECTIVE When the listed indication and condition exist, a paramedic is authorized to administer therapy to victims of Riot Agent exposure according to the following protocol. The paramedic will comply with local BHP patching protocols. thznkth INDICATIONS:

Exposure to a known or suspected riot agent. CONDITIONS:

Signs and symptoms of riot agent exposure. CONTRAINDICATIONS:

Topical anaesthetic eye drops (see Procedure, point #5a) are contraindicated if the patient is allergic to anaesthetics. PROCEDURE:

1. Remove patient from further exposure, and decontaminate.

2. Assess vital signs, with careful focus on bronchoconstriction.

3. Assess visual acuity by the ability to see light and count fingers at 1 foot. Consider removing contact

lenses.

4. For dyspnea see Bronchoconstriction Medical Directive.

5. For eye discomfort, irrigate thoroughly with copious amounts of normal saline.

a) Administer 2 drops of topical anaesthetic eye drops in each eye, repeat every 10 minutes as

needed.

b) Monitor the patient for 20 minutes after the last dose.

NOTES:

1. If a patient is experiencing significant respiratory distress or eye irritation, immediately advise the

patient of the need for transport to hospital. Transport should be initiated as soon as possible.

2. MDIs are intended for single patient use only. If an MDI is used to treat more than one patient,

cross contamination may occur regardless of whether or not an aerochamber or spacer is used. The

MDI should be safely discarded once the patient has completed treatment.

144

3. The eye drop bottle is designed for multiple patient use. Do not allow the bottle’s administration

nozzle to make contact with the patient. If the administration nozzle does make contact with the

patient, the bottle is considered contaminated and must be discarded appropriately.

4. Under no circumstances should the MDI or eye drop bottle be given to a patient.

5. Advise patient to refrain from rubbing eyes, whether or not anaesthetic drops are used.

6. Have the patient remove their contact lenses. Help if necessary.

7. If a patient with dyspnea or eye irritation caused by a riot control agent refuses EMS transport to

hospital, advise:

CONTINUED EXPOSURE MAY LEAD TO FURTHER PROBLEMS. RELIEF FROM

TREATMENT SO FAR MAY BE TEMPORARY. IF PROBLEMS RECUR OR PERSIST, CONSULT A PHYSICIAN AS SOON AS POSSIBLE

145

NOTES:

Reference

Material

Reference Material

146

12-LEAD ECG REVIEW Lead Placement

V1 - fourth intercostal space to the right of the sternum V2 - fourth intercostal space to the left of the sternum V3 - directly between leads V2 and V4 V4 - fifth intercostal space at left midclavicular line V5 - level with lead V4 at left anterior axillary line V6 - level with lead V5 at left midaxillary line

Modified 12-lead Placement V4 becomes V4R - fifth intercostal space at right midclavicular line

(same as V4 but on right side of chest) V5 becomes V8 - level with V6 at left midscapular line V6 becomes V9 - level with V6 at left paravertebral line

Acute Myocardial Infarction (AMI) Anatomical Location II, III, aVF: Inferior V1, V2: Septal V2, V3, V4: Anterior V5, V6: (low) Lateral I, aVL: (high) Lateral V4R: Right Ventricular (with any two of II, III, and aVF) V8, V9: Posterior

I High Lateral

Reciprocal changes

II, III, aVF

aVR V1

Septal Reciprocal changes I, III, aVF

V4 Anterior Reciprocal changes

II, III, aVF

II Inferior

Reciprocal changes

I, aVL, V-leads

aVL High

Lateral Reciprocal changes

II, III, aVF

V2 Septal

Reciprocal changes

II, III, aVF

V5 Lateral

Reciprocal changes

II, III, aVF

III Inferior

Reciprocal changes

I, aVL, V-leads

aVF Inferior

Reciprocal changes

I, aVL, V-leads

V3 Anterior Reciprocal changes

II, III, aVF

V6 Lateral

Reciprocal changes

II, III, aVF

Limb L

Wheneve

Precord

V1: 4V2: 4V3: bV4: 5V5: aV6: m

Right sid

V4R: oV5R: o

ead Place

er possible,

RA: righ

RL: Groun placed on

dial Leads

th intercostalth intercostaletween V2 ath intercostalnterior axilla

mid-axillary li

ed precordia

pposite V4 opposite V5 o

12

ement

avoid large

ht forearm or

d lead is gethe lower rig

s: V1-V6

V1 V

l space, righl space, left and V4 l space, mid

ary line, in stne, in straig

al leads (sho

on the right son the right s

2-LEAD E

muscle mas

r wrist

nerally ght leg

V2 V3

ht sternal borsternal bord

-clavicular litraight line wht line with V

ould be asse

side of the cside of the c

147

CG PLAC

ss

V4 V5

rder der

ne with V4 V4 and V5

essed in the

chest chest

CEMENT

LA:

LL:

V6

setting of an

left forearm

left lower le

n inferior wa

m or wrist

eg

all infarction))

Reference Material

148

CPR GUIDE

BLS Component Recommendations for Adults, Children and Infants

COMPONENT Adults Children Infants Neonate

AGE RANGE Puberty and older

1 year to puberty

≥ 30 days to 1 year

< 30 days

RECOGNITION

Unresponsive (for all ages)

Refer to N

eonatal Resuscitation M

edical Directive

No breathing or no normal breathing

(i.e. only gasping) No breathing or only gasping

No pulse palpated within 10 seconds for all ages (HCP only) CPR SEQUENCE C-A-B

COMPRESSION RATE At least 100/min

COMPRESSION DEPTH

At least 2 inches (5 cm)

At least ⅓ AP diameter

About 2 inches (5 cm)

At least ⅓ AP diameter

About 1½ inches (4 cm)

CHEST WALL RECOIL Allow complete recoil between compressionsHCPs rotate compressors every 2 minutes

COMPRESSION INTERRUPTIONS

Minimize interruptions in chest compressionsAttempt to limit interruptions to < 10 seconds

AIRWAY Head tilt-chin lift (HCP suspected trauma: Jaw thrust) COMPRESSION-TO-VENTILATION RATIO

(UNTIL ADVANCED

AIRWAY PLACED)

30:2 1 or 2 rescuers

30:2Single Rescuer

15:2 2 HCP Rescuer

VENTILATIONS: WHEN

RESCUER UNTRAINED

OR TRAINED AND NOT

PROFICIENT Compressions Only

VENTILATIONS WITH

ADVANCED AIRWAY

(HCP)

1 breath every 6-8 seconds (8-10 breaths/min)

Asynchronous with Chest compressions About 1 second per breath

Visible chest rise

DEFIBRILLATION Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; resume CPR beginning

with compressions immediately after each shock.

PEDIATRIC CPR GUIDELINES Compressions should be started in an infant or child with a palpable pulse less than 60/min and signs of poor perfusion. Compressions should be started in a neonate with a palpable pulse less than 60/min despite supplemental oxygen and ventilation every 30 seconds.

149

RELIEF OF FOREIGN-BODY AIRWAY OBSTRUCTION Adult Child Infant

1. Ask “Are you choking?” 2. Give abdominal thrusts/Heimlich

maneuver or chest thrusts for pregnant or obese victims.

3. Repeat abdominal thrusts (or chest thrusts if victim is pregnant or obese) until effective or victim becomes unresponsive.

1. Ask “Are you choking?” 2. Give abdominal thrusts/Heimlich

maneuver. 3. Repeat abdominal thrusts until

effective or victim becomes unresponsive.

1. Confirm severe airway obstruction. Check for sudden onset of severe breathing difficulty, ineffective or silent cough, weak or silent cry.

2. Give up to 5 back slaps and up to 5 chest thrusts.

3. Repeat step 2 until effective or victim becomes unresponsive.

Victim Becomes Unresponsive

1. Send someone to activate emergency response system. 2. Lower victim to floor. If victim is unresponsive with no breathing or no normal breathing (i.e. agonal gasps), begin

CPR (no pulse check). 3. Before you deliver breaths, look into mouth. If you see a foreign body that can be easily removed, remove it. 4. Continue CPR for 5 cycles or about 2 minutes. If you are alone, activate EMS system. Return and continue CPR

until more skilled rescuers arrive.

Reference: 2010 American Heart Association Guidelines for CPR and ECC

Reference Material

150

MIDAZOLAM DOSAGE CHART

IN Volume: 0.10 ml Mad dead space is added to dose.

The volume is then rounded to the next highest 0.1 ml if needed.

Age Weight Midazolam IN (5 mg/ml) Dose: 0.04 ml/kg + dead

space or 0.2 mg/kg Volume Dose

Midazolam IM (5 mg/ml) Dose: 0.04 ml/kg or

0.2 mg/kg Volume Dose

Midazolam IV/IO (1 mg/ml) Dose: 0.1 mg/kg

Dilute Volume Dose

Neonate 3 kg 0.3 ml 0.6 mg 0.12 ml 0.6 mg 0.30 ml 0.3 mg

< 1 6 kg 0.4 ml 1.2 mg 0.24 ml 1.2 mg 0.60 ml 0.6 mg

1 10 kg 0.5 ml 2.0 mg 0.40 ml 2.0 mg 1.0 ml 1.0 mg

2 14 kg 0.7 ml 2.8 mg 0.56 ml 2.8 mg 1.4 ml 1.4 mg

3 16 kg 0.8 ml 3.2 mg 0.64 ml 3.2 mg 1.6 ml 1.6 mg

4 18 kg 0.9 ml 3.6 mg 0.72 ml 3.6 mg 1.8 ml 1.8 mg

5 20 kg 0.9 ml 4.0 mg 0.80 ml 4.0 mg 2.0 ml 2.0 mg

6 22 kg 1.0 ml 4.4 mg 0.88 ml 4.4 mg 2.2 ml 2.2 mg

7 24 kg 1.1 ml 4.8 mg 0.96 ml 4.8 mg 2.4 ml 2.4 mg

8 26 kg 1.2 ml 5.2 mg 1.04 ml 5.2 mg 2.6 ml 2.6 mg

9 28 kg 1.3 ml 5.6 mg 1.12 ml 5.6 mg 2.8 ml 2.8 mg

10 30 kg 1.3 ml 6.0 mg 1.20 ml 6.0 mg 3.0 ml 3.0 mg

11 32 kg 1.4 ml 6.4 mg 1.28 ml 6.4 mg 3.2 ml 3.2 mg

12 34 kg 1.5 ml 6.8 mg 1.36 ml 6.8 mg 3.4 ml 3.4 mg

Teen 40 kg 1.7 ml 8.0 mg 1.60 ml 8.0 mg 4.0 ml 4.0 mg

Adult 50 kg 2.0 ml 10.0 mg 2.00 ml 10.0 mg 5.0 ml 5.0 mg

151

NORMAL PEDIATRIC VITAL SIGNS

Age Respiratory Rate Heart Rate

0 - 3 months 30 - 60 90 - 180 3 - 6 months 30 - 60 80 - 160 6 - 12 months 25 - 45 80 - 140

1 - 3 years 20 - 30 75 - 130 6 years 16 - 24 70 - 110 10 years 14 - 20 60 - 90

APGAR SCORE

Parameter 0 1 2

Heart rate (bpm) 0 (absent) Slow (< 100) > 100

Respiratory effort Absent Slow, irregular Good, crying

Muscle tone None, limp Some flexion Active motion

Reflex irritability (suction of nares, tactile stimulation)

None Some grimace Good grimace, cough, cry

Colour Blue or pale Pink body with blue extremities Completely pink

Apgar performed at 1 minute & 5 minutes after delivery; total 10 (5 items x max score of 2) Don’t wait for Apgar to make decision on resuscitation

PEDIATRIC GLASGOW COMA SCALE > 2 years < 2 years

Eye Opening Spontaneously To Voice To Pain None

Spontaneously To Voice To Pain None

4 3 2 1

Verbal Response

Oriented Confused Inappropriate Words Incomprehensible None

Coos, babbles Cries irritably Cries to pain Moans to pain None

5 4 3 2 1

Motor Response

Obeys Commands Localizes Pain Withdrawal to pain Flexion Extension None

Normal Movements Withdraws – touch Withdrawal – pain Abnormal flexion Abnormal extension None

6 5 4 3 2 1

Reference Material

152

PEDIATRIC TRAUMA SCORE

Severity +2 +1 -1

Weight > 20kg (> 44 lbs)

10-20 kg (22 to 44 lbs)

< 10 kg (< 22 lbs)

Airway Normal Maintained

(oral or nasal airway)

Non maintained (intubation or

cricothyrotomy)

Blood Pressure and/or pulses

> 90 mmHg or radial pulse only

50 to 90 mmHg or femoral pulse only

<50 mmHg or absent pulse

Level of consciousness Awake, alert

Obtundance, any loss of

consciousness

Comatose, Unresponsive

Open wounds None Minor Major or penetrating

Fractures None Single, closed Open, multiple

Pediatric Trauma score (PTS): highest possible score is 12, lowest possible score is -6

PTS > 8 < 1 % Mortality predicted

< 8 Suggests need for trauma center

4 Predicts 50% mortality

< 1 Predicts > 98% mortality

153

STROKE PROMPT CARD

Indications for Patient Redirect or Transport Under Stroke Protocol Redirect or transport to a Designated Stroke Centre* will be considered for patients who:

Present with a new onset of at least one of the following symptoms suggestive of the onset of an acute stroke:

Unilateral arm/leg weakness or drift Slurred speech or inappropriate words or mute Unilateral facial droop

AND

Can be transported to arrive at a Designated Stroke Centre within 3.5 hours of a clearly determined time of symptom onset or the time the patient was “last seen in a usual state of health”.

*Note: A Designated Stroke Centre is a Regional Stroke Centre, District Stroke Centre or a Telestroke Centre. Contraindications for Patient Redirect or Transport Under Stroke Protocol

Any of the following conditions exclude a patient from being transported under Stroke Protocol:

CTAS Level 1 and/or uncorrected Airway, Breathing or Circulatory problem

Symptoms of the stoke resolved prior to paramedic arrival or assessment**

Blood Sugar <3 mmol/L Seizure at onset of symptoms or observed by paramedic Glasgow Coma Scale <10 Terminally ill or palliative care patient Duration of out of hospital transport will exceed two (2) hours

CACC /ACS will authorize the transport once notified of the patient’s need for redirect or transport under the Acute Stroke Protocol.

** Note: Patients whose symptoms improve significantly or resolve during transport will continue to be transported to a Designated Stroke Centre.

Version 2.0 February 2011

PARAMEDIC PROMPT CARDFOR

ACUTE STROKE PROTOCOL

Reference Material

154

STROKE ASSESSMENT TOOL

Sign/Symptom Assessment Findings

FACIAL DROOP Have the patient grimace and smileIf one side of the face does not move as

well as the other side, the results are suggestive of an acute stroke.

LEG WEAKNESS/ DRIFT

Have the patient lift one leg up approximately 30 degrees and hold

it in that position for 5 seconds. Repeat with the other leg. Compare

the results.

If one leg drifts downward or falls before the end of the 5 seconds or the patient is

unable to lift one leg, the result is suggestive of an acute stroke.

ARM WEAKNESS/ DRIFT

Have the patient hold both arms outstretched in front of their body, perpendicular to the ground for 5

seconds.

If one arm drifts downward or falls before the end of the 5 seconds, or the patient is

unable to lift one arm, the result is suggestive of an acute stroke.

SLURRED SPEECH, INAPPROPRIATE

WORDS OR MUTE

Ask the patient to name 3 simple objects that you show them. Ask

the patient to repeat a simple sentence.

If the patient slurs words, uses inappropriate words when describing the objects or repeating the sentence, or is

unable to speak at all, the result is suggestive of an acute stroke.

Reference: 2010 AHA Guidelines

155

BHP PATCH FOR TRAUMA TOR

Service / Location:

Medic Name / Number / Level: Call Number:

Patient Info – Age: Sex:

I AM CALLING FOR A TERMINATION OF RESUSCITATION ORDER FOR A TRAUMA PATIENT(specify blunt or penetrating) Incident History / Mechanism of Injury:

Physical Assessment: - confirm patient > 16 years and has no palpable pulses. No defibrillation delivered and monitored HR = 0 (asystole) OR monitored HR >0 AND the closest ER ≥30 min transport time away.

Rhythm:

BH Physician Name:

TOR Order Given – Yes, TOR - No, Transport to closest ER

Time of Death:

Reference Material

156

BHP PATCH FOR MEDICAL TOR

Service / Location:

Medic Name / Number / Level: Call Number:

Patient Info – Age: Sex:

I AM CALLING FOR A TERMINATION OF RESUSCITATION ORDER FOR A MEDICAL PATIENT Incident History / Mechanism of Injury:

Physical Assessment: - confirm patient > 18 years and has no palpable pulses. Arrest not witnessed by EMS, AND No ROSC AND No shocks delivered


Patch to BHP for authorization, following the 3rd analysis, to consider Medical Termination of Resuscitation (TOR) (if applicable). If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate receiving hospital following ROSC or the 4th analysis.

BH Physician Name:

TOR Order Given – Yes, TOR - No, Transport to closest ER

Time of Death:

157

CHILDREN’S AID SOCIETY REPORTING INFORMATION

Bruce Grey Child and Family Services 640 Second Avenue East, Owen Sound, ON N4K 2G8 Phone: 519-371-4453 Toll Free: 855-322-4453 Huron-Perth Children’s Aid Society 639 Lorne Avenue East, Stratford, ON N5A 6S4 Phone: 519-271-5290 Children’s Aid Society of London and Middlesex 1680 Oxford Street East, London, ON N5Y 5R8 Phone: 519-455-9000 Toll Free: 888-661-6167 Family and Children’s Services of St. Thomas and Elgin County 410 Sunset Drive, St. Thomas, ON N5R 3C7 Phone: 519-631-1492 Children’s Aid Society of Oxford County 712 Peel Street, Woodstock, ON N4S 0B4 Phone: 519-539-6176 Toll Free: 800-250-7010 Sarnia-Lambton Children’s Aid Society 161 Kendall Street, Point Edward, ON N7V 4G6 Phone: 519-336-0623 Windsor-Essex Children’s Aid Society 1671 Riverside Drive East, Windsor, ON N8Y 5B5 Phone: 519-252-1171 Toll Free: 800-265-5609 Chatham-Kent Children’s Services 495 Grand Avenue West, Chatham, ON N7L 1C5 Phone: 519-352-0440

GREY | BRUCE | HURON | PERTH

LONDON-MIDDLESEX | ST. THOMAS-ELGIN | ONEIDA | OXFORD | SARNIA

WINDSOR-ESSEX | CHATHAM-KENT

Reference Material

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Base Hospital Physician Patch Phone Numbers

BHP Patch Phone

Numbers

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BASE HOSPITAL PHYSICIAN PATCH PHONE NUMBERS

For paramedics in – Chatham‐Kent, Essex‐Windsor

Hotel Dieu Grace Hospital, Windsor 519‐258‐0109

Windsor Regional Hospital, Met Campus 519‐258‐5472

Public General Hospital – Chatham‐Kent Health Alliance 519‐258‐9343

For paramedics in – Lambton

Bluewater Health, Sarnia 519‐627‐8460

For paramedics in – Bruce, Grey, Huron, Perth

Grey Bruce Health Services, Owen Sound 1‐866‐388‐8512 or 1‐519‐661‐6586

For paramedics in – Elgin, Middlesex, Oneida, Oxford

London Health Sciences Centre – Victoria Hospital 519‐667‐1092

London Health Sciences Centre – University Hospital 519‐667‐4093

www.lh

hsc.on.ca/bhp

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