medical first response program medical control protocols€¦ · providing high quality and safe...

Medical First Response Protocols

January 2017

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Document Authors

Dr. Kevin Hanrahan, Medical Director, MFR Program, Alberta Health Services

John Hein, Strategist, MFR Program, Alberta Health Services

Emily Barclay, Administrator, MFR Program, Alberta Health Services

Contributing Authors

Barody, Blaine – MFR Program Manager, AHS

Campbell, Jamie – Black Diamond Fire Department

Evans, Jennifer – Redwood Meadows Emergency Services

Evans, Rob – Redwood Meadows Emergency Services

Manz-Henezi, Jodi – Alberta Health Services

Martens, Keri – Lake Louise Fire

Meikle, Dave – Black Diamond Fire Department

Mikkelsen, Lisa – Black Diamond Fire Department

Moore, Chad – MFR Strategist, AHS

Munn, Susan – Lake Louise Fire

Paksi, Tyler – Redwood Meadows Emergency Services

Pirie, Mike – Airdrie Fire Department

Rabel, Garth – Airdrie Fire Department

Roe, David – High River Fire Department

Schaaye, Gregg – M.D. of Foothills Fire Department

Provincial MFR MCPs Working Group

Caralho, Pierre – Alberta Health Services

Cohoe, Shauna – Alberta Health Services

Donelon, Becky – Alberta College of Paramedics

Garofalo, Sergio – Alberta Health Services

Kugelstadt, Duane – Alberta Government

Landaker, Kelly – Alberta Health Services

Martens, Keri – Lake Louise Fire

Pedersen, Steen – Alberta Health Services

Pirie, Mike – Airdrie Fire Department

Read, Chris – Alberta Health Services

Roe, Dave – High River Fire Department

Wright, Alissa – Alberta Health Services

Contributing Document

Calgary Fire Department – Medical Protocols – (November 23, 2010*) *Used with Permission

Dr. Kevin Hanrahan – Medical Director, Calgary Fire Department

Stephen Nicholl, Calgary Fire Department

Debbie Bateman, Calgary Fire Department

Contact: Medical First Response Alberta Health Services Grande Prairie EMS Station 10710-97 Street Grande Prairie, AB T8V 7G6 Email: [email protected] Toll Free: 1-866-786-1440

mailto:[email protected]


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Disclaimer and Copyright Alberta Health Services (AHS) Emergency Medical Services (EMS) is committed to providing high quality and safe patient care. AHS EMS has developed this set of Medical First Response (MFR), Medical Control Protocols (MCPs). The MCPs contain best standard practice taken from evidence and expert informed care and treatment information that is specifically intended for the use of medical first responders in Alberta and the physicians who provide medical oversight for these agencies. EMS reserves the right at its own discretion to make changes, including the correction of errors and complete revisions to the MCPs. At the same time, the information is presented “as is” and its use by external organizations or individuals is solely at their own risk. AHS EMS, its employees and physicians accepts no responsibility for any modification or redistribution or use of the MCPs and is not liable for any actions taken by individuals based on the information provided, or for any inaccuracies, errors or omissions in these MCPs. 2015 Alberta Health Services – All rights reserved in relation to these MCPs. Without limiting the reservation of copyright, no person shall reproduce, store in a retrieval system or transmit in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) part or the whole of these MCPs without the prior written permission of Alberta Health Services. Please note that AHS does not retain any liability for the external use of these MCPs or their maintenance outside of the MFR Program. The written protocols have been made available for viewing by the public. It is assumed that your use will be to enhance the care you provide and is not for resale or redistribution purposes. Be advised that these MCP’s will continue to be reviewed and updated at regular intervals to ensure that they meet the above standards.

__________________________

Dr. Ian Phelps Senior Medical Director Alberta Health Services Emergency Medical Services


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Table of Contents

Algorithm 1 Standard Approach and Ongoing Assessment .............................. 5

Algorithm 2 Airway Control – Conscious Patients .............................................. 6

Algorithm 3 Airway Control – Unconscious Patients .......................................... 7

Algorithm 4 Altered Level of Consciousness ...................................................... 8

Algorithm 5 Burns .................................................................................................. 9

Algorithm 6 Cervical-Spine Assessment ........................................................... 10

Algorithm 7 Chest Pain ........................................................................................ 11

Algorithm 9 CPR Adults ....................................................................................... 13

Algorithm 10 CPR Children (1 to 8 years) ............................................................ 13

Algorithm 11 CPR Infants (Less than 1 Year) ...................................................... 15

Algorithm 12 Death On-Scene ................................................................................ 16

Algorithm 13 Drowning / Near Drowning .............................................................. 17

Algorithm 14a Dyspnea (shortness of breath) - Pulmonary Edema / Unknown .. 18

Algorithm 14b Adult Anaphylaxis ............................................................................ 19

Algorithm 14c Pediatric Anaphylaxis ...................................................................... 20

Algorithm 14d Adult Bronchospasm ....................................................................... 21

Algorithm 14e Pediatric Bronchospasm ................................................................. 22

Algorithm 15 Environmental Emergencies – Cold Related ................................. 23

Algorithm 16 Environmental Emergencies – Heat Related .................................. 24

Algorithm 17a Adult Hypoglycemia ......................................................................... 25

Algorithm 17b Pediatric Hypoglycemia ................................................................... 26

Algorithm 18 Obstetrics and Gynecological – Vaginal Bleeding ........................ 27

Algorithm 19 Obstetrics and Gynecology – Childbirth ........................................ 28

Algorithm 20 Obstetrics and Gynecology – Neonatal Resuscitation ................. 29

Algorithm 21 Obstructed Airway – Adults/Children ............................................. 30

Algorithm 22 Obstructed Airway – Infants (Birth – 1 Year) ................................. 31

Algorithm 23 Poisoning .......................................................................................... 32

Algorithm 24 Seizure ............................................................................................... 33

Algorithm 25 Shock ................................................................................................. 34

Algorithm 26 Stroke ................................................................................................ 35

Algorithm 27 Trauma Assessment ........................................................................ 36

Algorithm 28 Overdose – Opioid ............................................................................ 37


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Algorithm 1 Standard Approach and Ongoing Assessment

No

Go to Appropriate

algorithm

SFA

FMR

EMR

EMT

Initial Scene Assessment

· Scene Safety

· Additional Resources

· Crime Scene?

· Note Mechanism of Injury and Number of Patients

SFA

FMR

EMR

EMT

Follow Infection Prevention

Perform Hand Hygiene

Don Appropriate PPE

*SFA

If trained and equipped

SFA*

FMR

EMR

EMT

Perform Primary Patient Assessment

· Assess mental status

· Assess A,B,C,Ds

· Consider Spinal Motion Restriction

· Expose and examine priority areas

· Identify priority patients

· Record Vital Signs

Perform Primary Set of Vital Signs on all Patients

*50th Percentile Values

Blood Pressure

(Systolic)SPO2RespirationsPulse GCS

60 – 100 b/min (90 – 140 mm Hg) 94% – 100%12 – 20 / min 15Adult

100 – 130 b/min 86 mm Hg* 94% – 100%30 – 50 / min 15

70 – 100 b/min 95 mm Hg* 94% – 100%18 - 30 / min 15

65 – 100 b/min 103 mm Hg* 94% – 100%12 – 25 / min 15

1 Yr Old

6 Yr Old

10 Yr Old

110 – 160 b/min 60 – 76 mm Hg 94% – 100%35 – 60 / min n/aNewborn

Temperature

35.5 – 37.5 C

35.5 – 37.5 C

35.5 – 37.5 C

35.5 – 37.5 C

35.5 – 37.5 C


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Algorithm 2 Airway Control – Conscious Patients

SFA*

FMR

EMR

EMT

SFA

FMR

EMR

EMT

Is patient

conscious?

Is the

airway clear?

Rate, rhythm

and quality of

respirations?

No

Yes

Go to

Unconscious

Patients

algorithm

Go to

Obstructed

Airway

algorithm

Consider spinal motion restriction

Ensure open airway

No

Adequate


Administer O2 if SpO2 < 94% on

room air (RA)

SFA*

FMR

EMR

EMT

Treat for Shock

Provide comfort/reassurance

Monitor patient’s LOC and ABC

Inadequate

Suction airway as needed

BVM ventilation

Administer O2 if SpO2 < 94% on RA

SFA

FMR

EMR

EMT

SFA*

FMR

EMR

EMT

Secondary survey

History-SAMPLE

Record Vital Signs

SFA*

FMR

EMR

EMT

Secondary survey

History-SAMPLE

Record Vital Signs

SFA*

FMR

EMR

EMT

Place in recovery position if no

evidence of trauma

Reassess every 5 mins

until EMS arrives

SFA

FMR

EMR

EMT


evidence of trauma


until EMS arrives

SFA

FMR

EMR

EMT

Treat for shock

Provide Comfort/reassurance

Monitor patients LOC and ABC

SFA

FMR

EMR

EMT

*SFA


EMR

EMT

Consider: Nasopharyngeal Airway

(NPA)

Standard Approach and

Ongoing Assessment

Yes


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Algorithm 3 Airway Control – Unconscious Patients

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Initiate and maintain

manual C-Spine control If

needed

Is the airway

clear?

Rate, rhythm

and quality of

respirations?

Adequate

SFA

FMR

EMR

EMT


Ensure open airway

Inadequate or absent**

Go to

Obstructed

Airway

algorithm

Go to CPR

algorithm

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE

Record Vital Signs, Obtain BGL

Is pulse present?

**In the unlikely event there is a pulse but no

breathing, provide ventilations 1 every 5-6 seconds

No

Yes

SFA

FMR

EMR

EMT


evidence of trauma

Reassess patient every 5 min until

EMS arrives

Place in recovery position if no evidence of

trauma

Reassess patient every 5 mins

until EMS arrives

Secondary Survey

History-SAMPLE



BVM ventilation with OPA



Ensure open airway

SFA

FMR

EMR

EMT

SFA

FMR

EMR

EMT

SFA*

FMR

EMR

EMT

SFA*

FMR

EMR

EMT

Is pulse present?

Yes

No

*SFA

If trained and equippedNo

Consider NPA

If ventilation/oxygenation not effective administer

15 LPM high flow O2 via nasal cannula

Continue ventilations with BVM and OPA/NPA

EMR

EMT

Place King LT or LMA (leave 15 LPM high flow

oxygen via nasal cannula in place during airway

capture) Maximum 2 attempts EtCO2 Monitoring

if available

EMT

Yes


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Algorithm 4 Altered Level of Consciousness

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

breathing?

Is pulse present?

Determine LOC

Yes

Yes

SFA

FMR

EMR

EMT


Ensure open airway

SFA*

FMR

EMR

EMT

Maintain Airway


SFA*

FMR

EMR

EMT

Secondary Survey

History / SAMPLE


SFA

FMR

EMR

EMT


evidence of trauma


EMS arrives

Unconscious

Go to

Airway Control-

Unconscious

Patient

algorithm

Go to CPR

algorithmNo*SFA


SFA*

FMR

EMR

EMT

Treat for shock


Altered/Decreased

Go to

Airway Control

Unconscious

Patients

algorithm

BGL less than

4.0mmol/L

Go to

Hypoglycemia

algorithmYes

No


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Algorithm 5 Burns

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

breathing?No

Go to

Airway Control

algorithm

SFA

FMR

EMR

EMT

Cool burn

Cover with clean, moist dressing

SFA*

FMR

EMR

EMT

Secondary Survey

History / SAMPLE

Record Vital Signs

Yes

*SFA


Is burn

less than 10%

body surface

YES

SFA

FMR

EMR

EMT

Cover with clean, dry non-stick

dressing

NO

SFA*

FMR

EMR

EMT

Maintain airway


SFA*

FMR

EMR

EMT

Treat for shock


Keep patient warm

SFA*

FMR

EMR

EMT

Remove risk of further burns

If necessary decontaminate

for 15 min

SFA*

FMR

EMR

EMT


EMS arrives

EMT

Establish IV access

Consider Nitrous Oxide as indicated

Monitor EtCO2 if available


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Algorithm 6 Cervical-Spine Assessment

SFA

FMR

EMR

EMT

SFA

FMR

EMR

EMT

SFA

FMR

EMR

EMT


Ongoing Assessment

Maintain C-spine control (if able)

while assessing need for spinal

motion restriction

Age is greater than 65 or

High risk factor for spinal injury* or

Paresthesia in extremities

Low risk

factor for spinal injury which

allows safe assessment of

range of motion**

Able to voluntarily

Rotate neck 45° left and

right

NO

Yes

No spinal motion restriction needed

Yes

Perform spinal motion restriction if

practical to do so

Yes

No

No

Confounding Factors that may

obscure or invalidate the findings of

a examination include:

· Acute stress reaction

· Intoxication

· Altered level of consciousness

· Distracting injuries

· Communication difficulties

In these situations complete spinal

motion restriction may be indicated.

*High risk factors for spinal injury

include but not limited to:

· Fall greater than or equal to

1m / 5 stairs

· Axial load to head

· Speed greater than 100 kph,

rollover, ejection

· Motorcycle / ATV recreational

vehicle (e.g. snowmobile)

collision

· Bicycle collision

**Low risk for spinal injury include:

· Simple rear-end MVC

(Excludes patient being pushed

into oncoming traffic, hit by bus/

large truck, rollover, hit by high

speed vehicle)

· Ambulatory at any time

· Delayed (not immediate) onset

of neck pain

· Absence of midline C-spine

tenderness


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Algorithm 7 Chest Pain

SFA

FMR

EMR

EMT


Ongoing Assessment

Signs of trauma

No

Yes

*SFA


SFA*

FMR

EMR

EMT

Maintain Airway

Administer O2 if SpO2 <94% on RA

SFA*

FMR

EMR

EMT

Administer ASA 160mg PO* if

suspected cardiac cause

SFA

FMR

EMR

EMT

Treat for shock


Place patient in position of comfort

Minimize patient activity

Notify incoming EMS crew

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE-OPQRST

Record vital signs

Reassess Patient every 5 min until EMS arrives

Go to

Trauma

algorithm

EMTEstablish IV access using left

forearm if possible

EMT

Nitroglycerin 0.4mg SL* q 5

minutes prn only if suspected cardiac

cause and STEMI is not suspected

as long as systolic BP is greater than

100 mmHg

*EMT Nitro Administration

· EMTs will withhold all forms of

nitro if not equipped to obtain a

12-lead ECG or the computer

generated 12-lead

interpretation has any message

in capital letters indicating a

STEMI (e.g. STEMI, ACUTE

MI, SUSPECTED, ST

ELEVATION CRITERIA MET)

STEMI

suspected

Yes

No

EMTMonitor ECG and obtain 12-lead if

equipped

EMT Obtain serial 12-lead ECG q 15 minutes


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Algorithm 8 Control of External Bleeding

SFA

FMR

EMR

EMT


Ongoing Assessment

*SFA


Is bleeding

external?

Is bleeding

controlled?

Yes

SFA

FMR

EMR

EMT

Apply direct pressure with

bandage dressing

Elevate extremity if possible

SFA

FMR

EMR

EMT

Treat concurrently with

shock protocol

Provide comfort / reassurance

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE

Record vital signs

SFA

FMR

EMR

EMT

Reassess patient every 5 min

until EMS arrives

No

Go to Shock

Algorithm

SFA

FMR

EMR

EMT

Apply additional bandage

dressing without removing the

original dressing

No

Yes


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Algorithm 9 CPR Adults

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Visual scan to assess for signs of

“breathing – gasping” (max 10 sec)

Is patient

breathing

normally?

Consider the following:

· Do Not Resuscitate Orders

· Goals of Care

· Personal Directive

Is pulse present

(max 10 sec)

SFA

FMR

EMR

EMT

Give 1 breath every 5 seconds

Check pulse every 2 minutes

SFA

FMR

EMR

EMT

Monitor LOC/ABC

SFA

FMR

EMR

EMT

Place in recovery position

If no evidence of trauma

SFA

FMR

EMR

EMT


until EMS arrives

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE

Record vital signs, Obtain

BGL

NoYes

Yes

SFA

FMR

EMR

EMT

CAB Sequence

Start Chest Compressions

30 Compressions and 2 Breaths

SFA

FMR

EMR

EMT

Prepare AED

Use as soon as available

SFA

FMR

EMR

EMT

Continue CPR and AED use

until EMS arrives

No

SFA*

FMR

EMR

EMT

Manage airway prn


Administer O2

*SFA


EMR

EMTConsider NPA

EMTEstablish IV access

Consider King LT


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Algorithm 10 CPR Children (1 to 8 years)

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT


“breathing-gasping” (max 10 sec)

Is patient

breathing

normally?SFA

FMR

EMR

EMT

Assess Pulse (max 10 sec)

NoYes

SFA

FMR

EMR

EMT

Monitor LOC/ABC

SFA

FMR

EMR

EMT

Give 1 breaths every 3

seconds

Check pulse every 2

minutes

SFA

FMR

EMR

EMT

CAB Sequence


30 compressions / 2 breaths

SFA

FMR

EMR

EMT

Prepare AED

Use after 5 cycles of 30:2 CPR

(approx 2 min)

No

Is pulse present

(max 10 sec)Yes

SFA

FMR

EMR

EMT

If second rescuer present switch

to 15 compressions and 2 breaths

SFA

FMR

EMR

EMT


until EMS crew arrives

SFA*

FMR

EMR

EMT

Place patient in recovery position if

no evidence of trauma

Record vital signs, Obtain BGL

SFA

FMR

EMR

EMT


EMS arrives

SFA

FMR

EMR

EMT

Secondary Survey

History / SAMPLE

SFA*

FMR

EMR

EMT

Manage airway prn


Administer O2

SFA*

FMR

EMR

EMT

Manage airway prn


Administer O2

*SFA




· Goals of Care


EMT

Establish IV access

Insert LMA if unable to adequately

oxygenate and ventilate with

OPA and BVM


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Algorithm 11 CPR Infants (Less than 1 Year)

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT


“breathing-gasping” (max 10 sec)

Is patient

breathing

normally?

No

Yes

SFA

FMR

EMR

EMT

Monitor LOC / ABC

SFA

FMR

EMR

EMT

Give 1 breaths every 3

seconds

Check pulse every 2

minutes

SFA

FMR

EMR

EMT

CAB Sequence


30 compressions / 2 breaths

SFA

FMR

EMR

EMT

Prepare AED

Use after 5 cycles of 30:2 CPR

(approx 2 min)

No or rate is less than 60/min

with signs of poor perfusion

Is pulse present

(max 10 sec)Yes

SFA

FMR

EMR

EMT

If second rescuer present switch

to 15 compressions and 2 breaths

SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT


evidence of trauma

SFA

FMR

EMR

EMT


until EMS arrives

SFA*

FMR

EMR

EMT

Secondary Survey

History / SAMPLE


SFA*

FMR

EMR

EMT

Manage airway


Administer O2

SFA*

FMR

EMR

EMT

Manage airway prn


Administer O2

*SFA




· Goals of Care


SFA

FMR

EMR

EMT

Assess Pulse (max 10 sec)

EMT

Establish IV access

Insert LMA if unable to adequately

oxygenate and ventilate with OPA

and BVM


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Algorithm 12 Death On-Scene

SFA

FMR

EMR

EMT


Ongoing Assessment

Is there evidence

of presumed death?

DRIED*Yes

Is there a document to

withhold resusitation?**

No

SFA

FMR

EMR

EMT

Confirm patient’s

identity

DO NOT RESUSCITATE

Secure the scene and do not

disturb it unnecessarily

No

Yes

SFA

FMR

EMR

EMT

Provide support for

bystanders

*DRIED

Decapitation

Rigor Mortis

Incineration

Evisceration

Decomposition

**DNR / Goals of Care Directive/Personal Directive

Document must be physically present. Verbal orders are not valid

If in doubt, do not delay resuscitative efforts

Go to CPR

algorithm

SFA

FMR

EMR

EMT

Secure the scene


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Algorithm 13 Drowning / Near Drowning

SFA

FMR

EMR

EMT


Ongoing Assessment

Is there a pulse?No

Yes

SFA

FMR

EMR

EMT


Ensure open airway

SFA*

FMR

EMR

EMT




SFA

FMR

EMR

EMT

Treat concurrently with shock protocol


SFA

FMR

EMR

EMT


evidence of trauma


EMS arrives

Go to CPR algorithm

Secondary Survey

History-SAMPLE


SFA*

FMR

EMR

EMT

*SFA


EMR

EMT

Consider NPA

If ventilation/oxygenation not effective administer

15 LPM high flow O2 via nasal cannula

Continue ventilations with BVM and OPA/NPA

EMTConsider King LT or LMA if symptomatic

critical hypoxia (SpO2 < 85%)

EtCO2 Monitoring if available


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Algorithm 14a Dyspnea (shortness of breath) - Pulmonary Edema / Unknown

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

If patient presents with ILI**, refer to IPC

considerations***

Manage airway prn


SFA

FMR

EMR

EMT


Provide comfort / Reassurance

SFA

FMR

EMR

EMT

TREATMENT INTERVENTIONS


Place patient in position that allows for

greatest ease of breathing (usually sitting up)

*SFA


High flow O2

SFA*

FMR

EMR

EMT


TKVO only

***Infection Prevention and Control Considerations

· PPE (gown, N-95 mask, safety glasses, gloves must

be used when performing aerosol generating medical

procedures

a. Airway management (suction/OPA/BVM)

b. Nebulization of medication

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


Immediately

treatable cause?

Refer to Adult

Broncospasm

algorithm

Refer to

Adult

Anaphylaxis

algorithm

NoYes

**Influenza-Like-Illness (ILI) Signs /

Symptoms:

· Acute onset of NEW cough or

change in existing cough PLUS 1 or

more of the following:

a. Fever ( greater than or equal to

38°C on arrival or by history)

b. Sore throat

c. Joint pain

d. Muscle aches

e. Severe exhaustion

· In patients 65 and older, fever may

not be prominent


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Algorithm 14b Adult Anaphylaxis

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Manage airway prn


SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT





*SFA


SFA

FMR

EMR

EMT

Consider Medication Assist

Epi-pen®

Prescribed dosage

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT


EMS arrives

EMT

epiNEPHrine 0.3 mg IM

q 5 minutes prn to maximun

of 0.9 mg

Establish IV access

EMT

If BP <90mmHg systolic:

normal saline 500mL IV bolus prn to

a maximum of 4L titrated to systolic

BP ≥90mmHg systolic

Notes:

· Epinephrine use in bronchospasm should be reserved for patients with severe presentations with signs of deterioration

refractory to nebulized treatments

Anaphylaxis Criteria

Exposure to known or

suspected allergen with a

sudden onset of illness and

at least 1 of the following:

· Sudden respiratory signs

& symptoms

· Sudden systolic BP less

than 90 mmHg or

symptoms of end-organ

dysfunction

Or

Exposure to a known or



BOTH of the following:

· Sudden skin or mucosal

signs and symptoms

· Sudden gastrointestinal

symptoms Patient Safety Considerations

· epiNEPHrine (1:1000) should

never be given IV as it carries

a significant risk of

dysrhythmia; this is a

common prehospital

medication error

· All medications in the Adult

Anaphylaxis Protocol may be

given concurrently based on

the patients presentation

EMT

If bronchospasm is present:

salbutamol 5mg mixed with

ipratropium bromide

500mcg nebulized prn


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Algorithm 14c Pediatric Anaphylaxis

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Manage airway prn


SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT





*SFA


Notes:

· Epinephrine use in bronchospasm should be reserved for patients with severe presentations with signs of deterioration

refractory to nebulized treatments

Anaphylaxis Criteria

Exposure to known or



at least 1 of the following:

· Sudden respiratory signs

& symptoms

· Sudden systolic BP less

than 70 + (2 x age)

mmHg or symptoms of

end-organ dysfunction

Or

Exposure to a known or



BOTH of the following:

· Sudden skin or mucosal

signs and symptoms

· Sudden gastrointestinal

symptoms

Patient Safety Considerations

· epiNEPHrine (1:1000)

should never be given IV as

it carries a significant risk of

dysrhythmia; this is a

common prehospital

medication error

· All medications in the Adult

Anaphylaxis Protocol may

be given concurrently based

on the patients presentation

SFA

FMR

EMR

EMT

Consider Medication Assist

Epi-pen® (Junior) Prescribed dosage

EMT

epiNEPHrine 0.01 mg/kg IM to a single

maximum dose of 0.3 mg

q 5 minutes prn to maximun of 0.9 mg

Establish IV access

EMT

If bronchospasm is present and less than 20

kg:

salbutamol 2.5mg mixed with ipratropium

bromide 250 mcg nebulized prn

EMT

If systolic BP Less than 70 + (2x age) mmHg

normal saline 20mL/kg IV bolus prn titrated

to systolic BP 70 + (2x age) mmHg or greater

SFA

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT


EMS arrives


January 2017

21 | P a g e

AlbertaMFR.ca

Algorithm 14d Adult Bronchospasm

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Manage airway prn


SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT





*SFA


Notes:

· There are many types of inhalers that may be prescribed for patients with frequent bronchospasm

· Check the medication label carefully prior to assisting with patients own medication

· Severe bronchospasm may present as “Silent Chest”

Infection Prevention and

Control Considerations

· Consider Droplet and

Airborne Precautions

SFA

FMR

EMR

EMT

Consider assisting patient with own

salbutamol and/or ipratropium bromide

(inhaler) at the prescribed dosage

EMTsalbutamol 5mg mixed with ipratropium

bromide 500mcg nebulized


TKVO only

EMT

If condition not improved consider

salbutamol 5mg mixed with ipratropium

bromide 500mcg nebulized x 2 prn


January 2017

22 | P a g e

AlbertaMFR.ca

Algorithm 14e Pediatric Bronchospasm

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Manage airway prn


SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT





*SFA


SFA

FMR

EMR

EMT

Consider assisting patient own

salbutamol and/or ipratropium

bromide at the prescribed dosage


TKVO only

EMT

If condition not improved

· Less than 20 kg: salbutamol 2.5 mg nebulized continuously

· Greater than 20 kg: salbutamol 5 mg nebulized continuously

Notes:

· There are many types of inhalers that may be

prescribed for patients with frequent bronchospasm

· Check the medication label carefully prior to

assisting with patients own medication

· Severe bronchospasm may present as “Silent Chest”

EMT

Less than 20 kg: salbutamol 2.5mg mixed with

ipratropium bromide 250Mcg nebulized prn to

a maximum of 7.5/mg/750mcg respectively

Greater than 20 kg: salbutamol 5.0mg mixed

with ipratropium bromide 500mcg nebulized

prn to a maximum of 15mg/1500mcg

respectively

Infection Prevention and

Control Considerations

· Consider Droplet and

Airborne Precautions

EMT

Less than 20 kg: salbutamol 2.5 mg nebulized

prn to a maximum of 7.5/mg

Greater than 20 kg: salbutamol 5 mg

nebulized prn to a maximum of 15mg

Mild* Moderate to Severe*

Classifications of Bronchospasm

· Mild

No substernal indrawing, no

scalene retractions, expiratory

wheezing only or no wheezing,

normal air entry

· Moderate to Severe

Substernal indrawing or scalene

retractions present, wheezes

(inspiratory and expiratory)

widespread or audible without

stethoscope, silent chest

· Impending Respiratory Failure

Lethargy, cyanosis, decreasing

respiratory effort, unimproving

SpO2 with oxygen


January 2017

23 | P a g e

AlbertaMFR.ca

Algorithm 15 Environmental Emergencies – Cold Related

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

conscious?NoYes

SFA*

FMR

EMR

EMT

Manage airway prn

Administer O2

if SpO2 < 94% on RA

SFA

FMR

EMR

EMT


shock protocol


SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT


EMS arrives

Go to CPR

algorithm

Go to Altered

Level of

Consciousness

algorithm

Is Pulse Present

NoYes

*SFA


SFA

FMR

EMR

EMT


Remove from cold environment

Prevent further heat loss

Handle hypothermic patients gently


January 2017

24 | P a g e

AlbertaMFR.ca

Algorithm 16 Environmental Emergencies – Heat Related

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

conscious?NoYes

SFA*

FMR

EMR

EMT

Manage airway as needed

Administer O2

if SpO2 < 94% on RA

SFA

FMR

EMR

EMT


shock protocol


SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT

Consider oral fluid hydration


EMS arrives

Go to CPR

algorithm

Go to Altered

Level of

Consciousness

algorithm

Is Pulse Present

NoYes

*SFA

If trained and equippedSFA

FMR

EMR

EMT


Start passive cooling process

· Remove from hot environment

· Remove excessive clothing

EMTConsider establishing IV access

Consider ECG monitoring


January 2017

25 | P a g e

AlbertaMFR.ca

Algorithm 17a Adult Hypoglycemia

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA*

FMR

EMR

EMT


Reassess every 5 min until EMS

arrives

SFA

FMR

EMR

EMT


shock protocol


SFA

FMR

EMR

EMT

Secondary Survey

History – SAMPLE

Record Vital Signs Obtain BGL

*SFA


Responds to verbal

commands?

SFA

FMR

EMR

EMT

Reassess every 5 min until

EMS arrives

SFA*

FMR

EMR

EMT

Secondary Survey

History – SAMPLE


SFA*

FMR

EMR

EMT

oral glucose 25 g PO q 5

minutes to maximum of 50 g

Yes

Yes

SFA*

FMR

EMR

EMT

Confirm BGL less than

4.0 mmol/L

No

EMT Establish IV access

EMT

glucagon 1 mg IM

q 15 minutes

to maximum 2 mg

Vascular access

successful?No

EMT

D50W 25 g SIVP q 5 minutes prn titrated to

BGL >4.0mmol/L or patient improvement

maximum 50 g

Patient

improvement or BGL

greater than or equal to

4.0mmol/L?

Yes

No

Suspected stroke?

Go to

Stroke

algorithmYes

No

Patient Safety Considerations

· Use D50W with caution in administering to patients with

suspected increased intracranial pressure (i.e. stroke or

head injury); treat as per the appropriate protocol and

then reassess the patient’s neurological status and BGL

· Use D50W with caution in administering to patients

where malnutrition or chronic alcoholism is suspected

because of the risk of developing Wernicke’s

encephalopathy or Korsakoff’s psychosis


January 2017

26 | P a g e

AlbertaMFR.ca

Algorithm 17b Pediatric Hypoglycemia

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA*

FMR

EMR

EMT


Reassess every 5 min until EMS

arrives

SFA

FMR

EMR

EMT


shock protocol


SFA

FMR

EMR

EMT

Secondary Survey

History – SAMPLE


*SFA


Responds to verbal

commands?

SFA

FMR

EMR

EMT

Reassess every 5 min until

EMS arrives

SFA*

FMR

EMR

EMT

oral glucose 25 g PO

Yes

Yes

SFA*

FMR

EMR

EMT

Confirm BGL less than

4.0 mmol/L

No


( 2 attempts only)

EMT

Less than 20 Kg:

glucagon 0.5 mg IM q 15 minutes

to maximum 1 mg

Greater than or equal to 20 Kg:

glucagon 1 mg IM q 15 minutes to

maximum 2 mg

Vascular access

successful?

No

EMT

D10W 0.5 g/kg (5 mL/kg) SIVP q 5

minutes prn titrated to BGL >4.0mmol/L

or patient improvement

Patient

improvement or BGL

greater than or equal to

4.0 mmol/L?

Yes

No

EMT

D25W 0.5 g/kg (2mL/kg) SIVP q 5

minutes prn titrated to BGL >4.0mmol/L

or patient improvement

EMT

D50W 12.5 g (25 mL) SIVP q 5 minutes

prn titrated to BGL >4.0mmol/L or

patient improvement

Patient greater

than 40 kg

Patient

greater than 10 kg and

less than 40 kg

Patient

Less than

than 10 kg


January 2017

27 | P a g e

AlbertaMFR.ca

Algorithm 18 Obstetrics and Gynecological – Vaginal Bleeding

SFA

FMR

EMR

EMT



SFA

FMR

EMR

EMT


Ongoing Assessment

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE

Record vital signs

SFA

FMR

EMR

EMT


shock protocol


Maintain patient dignity

SFA

FMR

EMR

EMT

Place patient in recovery

position if no evidence of

trauma

SFA*

FMR

EMR

EMT

Maintain Airway

Administer O2 if SpO2 < 94%

on RA

*SFA



January 2017

28 | P a g e

AlbertaMFR.ca

Algorithm 19 Obstetrics and Gynecology – Childbirth

HEAD*

· Prep mother and site for delivery

· Administer 100 % O2 to both mom

and baby

· Prevent explosive birth

· Deliver head

· Check for nuchal cord and relieve

· Suction (mouth, then nostrils)

· Deliver torso

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT

Obtain obstetrical history*

EXAMINE FOR CROWNING

Appearance of baby’s head or other part

during labour

Identify

presentation

BREECH*

· Prep mother for delivery

· Administer 100 % O2 to mom

· Allow presenting part to

deliver (no pulling)

· Keep neonatal torso warm

· Support neonate’s body

LIMB OR PROLAPSED CORD*

· Place mother in knee-chest position

or supine with hips elevated on

pillow

· Advise her not to push (coach

breathing to “puff”)

· Administer O2 to mom

· Relieve cord pressure (EMR / EMT

only)

Is head

delivered within 2-3

min?

SFA*

FMR

EMR

EMT

Place baby with mom

Clamp and Cut the cord

Assess APGAR scores at 1, 5, and 10 mins

Reassess every 5 mins until EMS arrives

EMR

EMT

Use gloved “V” fingers, push vaginal wall

away from neonate’s nose (no pulling)

Allow head to deliver

Yes No

SFA

MFR

EMR

EMT


Monitor patient’s LOC and ABC


until EMS arrives

*SFA


If possible notify incoming EMS Crew

*Obstetrical history assessment

· How far into your pregnancy are

you?

· Has your water broken?

· Do you have to push?

· Are the contractions less than 2

minutes apart?

· Is this your first baby? How

many babies?

· Are there any complications with

this pregnancy?


January 2017

29 | P a g e

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Algorithm 20 Obstetrics and Gynecology – Neonatal Resuscitation

Greater than 100 / min

Protect patient from heat

loss

SFA

FMR

EMR

EMT

SFA*

FMR

EMR

EMT


Ongoing Assessment

Immediately dry and cover neonate

if greater than 28 weeks gestation**

SFA

FMR

EMR

EMT

Maintain Airway

Clear airway with suctioning

Provide tactile stimulation?

Are respirations

present

Between 60 – 100 / min

Continue tactile stimulation

Administer O2 and assist ventilations

with BVM

Less than 60 / min

with poor signs of

perfusion

What is the

heart rate?

No

Go to CPR-

Infant

algorithm

SFA

FMR

EMR

EMT

Check rate, rhythm, and

quality of respirations

SFA

FMR

EMR

EMT

Continue tactile stimulation

Go to CPR-

Infant

algorithmSFA

FMR

EMR

EMT


until EMS arrives

Yes


*SFA


**Patient Safety Considerations

· Do not dry babies less than

28 weeks gestation; this leads

to critical heat loss

· These babies should be

placed directly into a

resealable food grade bag

from the neck down. Cover

the head except for the face;

these measures help the baby

maintain heat.


January 2017

30 | P a g e

AlbertaMFR.ca

Algorithm 21 Obstructed Airway – Adults/Children

SFA

FMR

EMR

EMT

SFA

FMR

EMR

EMT


Ongoing Assessment

Is the patient

conscious?

How severe is

the obstruction?

NoYes

ABDOMINAL THRUSTS

until the obstruction

clears or the patient

becomes unconscious

SFA

FMR

EMR

EMT

Encourage patient to

continue to cough

forcefully and monitor the

patient closely

SFA

FMR

EMR

EMT

Start CPR with C-A-B sequence

Every time you open the airway to

give a breath, check the mouth and

remove the object if you can see it

Does the

airway clear?

Complete

Obstruction

SFA

FMR

EMR

EMT

Continue CPR

Every time you open the

airway to give a breath,

check the mouth and

remove the object if you can

see it

Is the Patient

conscious?

NoYes

NoYes

Is there a

pulse?*Yes No

*In the unlikely event there is a pulse but no breathing, provide ventilations 1 every 5-6 seconds

Partial

Obstruction

SFA

FMR

EMR

EMT

If patients condition

changes revert to

appropriate portion of

protocol

Go to CPR

algorithm

Go to

Airway Control-

Conscious

Patient

algorithm

Go to

Airway Control-

Unconscious

Patient

algorithm


January 2017

31 | P a g e

AlbertaMFR.ca

Algorithm 22 Obstructed Airway – Infants (Birth – 1 Year)

SFA

FMR

EMR

EMT

SFA

FMR

EMR

EMT


Ongoing Assessment

Is the patient

conscious?

How severe is

the obstruction?

NoYes

Administer 5 back slaps

and 5 chest thrusts until

the obstruction is

cleared or the patient

becomes unconscious

SFA*

FMR

EMR

EMT

Manage airway as

needed

Administer O2 if SpO2

< 94% on RA

SFA

FMR

EMR

EMT

Start CPR with the C-A-B sequence

Every time you open the airway to

give a breath, check the mouth and

remove the object if you can see it

Does the

airway clear?

Complete

Obstruction

Is the Patient

conscious?

NoYes

NoYes

Is there a

pulse?**Yes No

**In the unlikely event there is a pulse but no breathing, provide ventilations 1 every 3 seconds

Partial

Obstruction

SFA

FMR

EMR

EMT

If patients condition

changes revert to

appropriate portion of

protocol

Go to CPR

algorithm

Go to

Airway Control

Conscious

Patient

algorithm

*SFA


Go to

Airway Control

Conscious

Patient

algorithm

SFA

FMR

EMR

EMT

Continue CPR

Every time you open the

airway to give a breath,

check the mouth and

remove the object if you can

see it


January 2017

32 | P a g e

AlbertaMFR.ca

Algorithm 23 Poisoning

SFA*

FMR

EMR

EMT

SFA

FMR

EMR

EMT


Ongoing Assessment

Identify toxin

Obtain BGL

Treat

concurrently with

other algorithms

as needed

SFA

FMR

EMR

EMT

Poison Control 1-800-332-1414

Consider need for decontamination

Beta Blocker / Calcium Channel Blocker / Benzodiazepines

Assess and treat as per Shock protocol / Assess for chest pain

Caustic or Petroleum

Manage airway / Decontaminate

Narcotic

Manage airway

Organophosphate

Avoid personal exposure / Treat as hazmat

Trycyclic (TCA) Antidepressant

Assess for shock

Toxic Inhalation

Manage airway


EMT Establish vascular access

*SFA



January 2017

33 | P a g e

AlbertaMFR.ca

Algorithm 24 Seizure

SFA

FMR

EMR

EMT

SFA*

FMR

EMR

EMT


Ongoing Assessment


Ensure open airway

Head-Tilt / Chin-Lift

Is patient

actively seizing?NoYes

SFA*

FMR

EMR

EMT

Manage airway

Administer O2 if SpO2 < 94% on

RA

SFA

FMR

EMR

EMT

Protect patient from injury

SFA

FMR

EMR

EMT

Record time and duration of

seizure

SFA

FMR

EMR

EMT


shock protocol


SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT

Go to start of algorithm once

seizure has stopped

*SFA


SFA*

FMR

EMR

EMT


evidence of trauma

SFA

FMR

EMR

EMT

Reassess patient every 5 minutes

until EMS arrives

EMT

Monitor ECG

Establish vascular access

(2 attempts)


January 2017

34 | P a g e

AlbertaMFR.ca

Algorithm 25 Shock

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA

FMR

EMR

EMT


evidence of trauma

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE


SFA

FMR

EMR

EMT

Provide comfort / reassurance

Keep patient warm

SFA*

FMR

EMR

EMT


Maintain Airway


*SFA


SFA

FMR

EMR

EMT

Reassess patient every 5 minutes until

EMS arrives

EMT Establish vascular access

EMT

normal saline 500 mL IV bolus prn to a

maximum of 2 L, titrate to systolic BP

≥90 mmHg

Reassess lungs after each bolus in

suspected cardiogenic shock

Patient Safety Consideration

Reassess patient continually for signs

of fluid overload (i.e. crackles on lung

auscultation) during fluid resuscitation


January 2017

35 | P a g e

AlbertaMFR.ca

Algorithm 26 Stroke

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

breathing?

Determine Signs

and Symptoms

NoYes

SFA*

FMR

EMR

EMT

Maintain Airway


Obtain BGL

SFA*

FMR

EMR

EMT

Determine time last seen normal


Secondary Survey

History / SAMPLE


SFA

FMR

EMR

EMT

Place in recovery position if no evidence of trauma

Reassess patient every 5 min until EMS arrives

Go to

Airway Control-

Unconscious

Patient

algorithm

*SFA


SFA*

FMR

EMR

EMT

Assess for disabling findings:

a) Level of consciousness

i) Responds to painful stimuli

ii) Unconscious

b) Speech

i) Incomprehensible

ii) Mute

c) Arm Strength – maintain arm at 90˚ for 10 seconds

i) Falls rapidly

d) Hand Grips

i) No grip

e) Leg Strength – maintain each leg at 45˚ for 10 seconds

i) Falls rapidly

BGL

3.0 mmol/L or

less?EMT

Establish vascular access

(18 guage or larger bore in proximal vein)

D50W 12.5 g SIVP

Consider additional 12.5 g D50W only if

BGL remains less than 3.0 mmol/L

Yes


January 2017

36 | P a g e

AlbertaMFR.ca

Algorithm 27 Trauma Assessment

SFA

FMR

EMR

EMT


Ongoing Assessment

SFA*

FMR

EMR

EMT

Secondary Survey

History-SAMPLE

Obtain Vitals

Head to toe examination

SFA

FMR

EMR

EMT

Treat any immediate life

threatening injuries

*SFA


SFA

FMR

EMR

EMT


other protocols as

needed

EMTEstablish vascular access

Consider nitrous oxide prn

Medical First Responder Protocol Notes

January 2017

37

Algorithm 28 Overdose – Opioid

SFA

FMR

EMR

EMT


Ongoing Assessment

Is patient

breathing?

Is pulse present?

Yes

Yes

SFA*

FMR

EMR

EMT

Maintain Airway


SFA*

FMR

EMR

EMT

Secondary Survey

History / SAMPLE


SFA

FMR

EMR

EMT

Place in recovery position if no evidence of

trauma

Reassess patient every 5 min until EMS

arrives

Go to

Airway Control-

Unconscious

Patient

algorithm

Go to CPR

algorithmNo

*SFA


Yes

No

Respiratory

depression, or

hemodynamic

instabiltity?

EMT

No

Patient Safety

Considerations· The use of naloxone in the

setting of mixed overdoses,

particularly those involving

narcotics and stimulants

(e.g. cocaine,

amphetamines, etc.) has

been known to cause

complications related to the

pure stimulant overdose

(i.e. CVA, MI, VT, and VF)

when the effect of the

narcotic has been

countered by the naloxone

· Patients can become

agitated or violent following

the administration of

naloxone

NOTES:

· Naloxone is not a substitute

for other emergency care

such as maintaining an open

airway and supporting

ventilation

SFA*

FMR

EMR

EMT

naloxone HCL Nasal Spray 4.0 mg one spray

in one nostril q 2 - 3 minutes repeat as needed

(alternate nostril with each dose)

OR

naloxone 0.4 mg IM q 3 minutes repeat as

needed to total maximum of 1.6 mg

Establish IV access

naloxone 0.4 mg IV q 2 minutes

Repeat as needed to total maximum of 1.6 mg


January 2017

38

Addendum – Medical First Responder

Addendum – Medical First Responder ..................................................................................38

Introduction………….. ................................................................................................. 44

Role of the Medical First Responder (MFR) .............................................................. 44

Scope of Practice ................................................................................................... 44

Care Provider Definitions ........................................................................................... 44

Standard First Aid (SFA) ........................................................................................ 44 First Medical Responder (FMR) ............................................................................. 44

Emergency Medical Responder (EMR) .................................................................. 44 Health Disciplines Act/Health Professions Act ....................................................... 44

MFR Level of Service ............................................................................................. 45 Level of Service – Comparison Chart ..................................................................... 46

Confidentiality ......................................................................................................... 47 Consent .................................................................................................................. 47 Scene Assessment ................................................................................................ 48

Quality Patient Care ............................................................................................... 48 Safety ..................................................................................................................... 48

Routine Practice ..................................................................................................... 48 Mnemonics ............................................................................................................. 49 EMS Pre-arrival Care ............................................................................................. 49

Standard Approach and Ongoing Assessment (Algorithm 1) ................................. 50

Abdominal Pain ........................................................................................................... 50

Patient Care ........................................................................................................... 50

Airway Control (Algorithm 2) ..................................................................................... 51

Conscious Patients ................................................................................................ 51 Confirm a Clear Airway .......................................................................................... 51 Evaluate Respirations ............................................................................................ 51

Patients Benefiting from Oxygen ............................................................................ 52 Vomiting ................................................................................................................. 52 Position .................................................................................................................. 52

Unconscious Patients ............................................................................................. 52

Confirm a Clear Airway .......................................................................................... 52 Altered Level of Consciousness ............................................................................. 53

Anaphylaxis (Algorithm 14) ........................................................................................ 53

Etiology .................................................................................................................. 53 Mild / Moderate Anaphylaxis .................................................................................. 54

Severe Anaphylaxis ............................................................................................... 54 Interventions ........................................................................................................... 54


January 2017

39

Automated External Defibrillation (AED) ................................................................... 55

Legal Position ......................................................................................................... 55 Operation of the AED ............................................................................................. 56 AED Pads ............................................................................................................... 57 Special Situations ................................................................................................... 57 Post-Resuscitation Care ........................................................................................ 58

Reassessment ....................................................................................................... 58 Electric Shock ........................................................................................................ 58 Lightning Strike ...................................................................................................... 58

Bronchospasm (Algorithm 14) ................................................................................... 59

Etiology .................................................................................................................. 59 Asthma ................................................................................................................... 59

Chronic Obstructive Pulmonary Disease (COPD) .................................................. 59 Pneumonia ............................................................................................................. 60 Patient Safety Considerations ................................................................................ 60

Burns (Algorithm 5) ..................................................................................................... 60

Airway .................................................................................................................... 60

Signs of Smoke Inhalation...................................................................................... 60 Oxygen Instructions ............................................................................................... 61 Burn Management .................................................................................................. 61

Burn Measurement ................................................................................................. 61

Chest Pain (Algorithm 7) ............................................................................................ 63

Symptom Recognition ............................................................................................ 63 Angina Pectoris (Chest Pain) ................................................................................. 63

Oxygen Instructions (if trained and equipped) ........................................................ 64 Early Defibrillation .................................................................................................. 64

Questions to Consider ............................................................................................ 64 Myocardial Infarction .............................................................................................. 65 Patient Safety Considerations ................................................................................ 66

Control of External Bleeding (Algorithm 8) ............................................................... 66

Management .......................................................................................................... 66

Elevation ................................................................................................................ 66

Epistaxis (Nosebleed) ............................................................................................ 66 Caution ................................................................................................................... 66 Management of Epistaxis ....................................................................................... 66

Cardio Pulmonary Resuscitation (CPR) (Algorithm 9 - 11) ...................................... 67

CPR for Adults ....................................................................................................... 67

Scene Survey ......................................................................................................... 67 CPR for Children .................................................................................................... 68 CPR for Infants ....................................................................................................... 69


January 2017

40

Crime Scene ................................................................................................................ 70

Some things to consider: ........................................................................................ 70

Death on Scene (Algorithm 12) .................................................................................. 71

Discontinuation Criteria .......................................................................................... 71 Personal Directives ................................................................................................ 71 Medical Direction .................................................................................................... 71

Drowning / Near Drowning (Algorithm 13) ................................................................ 72

Hypothermia ........................................................................................................... 72

Hazards .................................................................................................................. 72 C-Spine .................................................................................................................. 72

Dyspnea (Shortness of Breath) (Algorithm 14) ........................................................ 73

Symptom Recognition ............................................................................................ 73

Treatment ............................................................................................................... 73 Oxygen Instructions ............................................................................................... 73

Environmental Emergencies – Cold Related (Algorithm 15) ................................... 74

Recognizing Frostbite ............................................................................................ 74 Recognizing Hypothermia ...................................................................................... 74

Management .......................................................................................................... 75 Conscious Patients ................................................................................................ 75

Unconscious Patients ............................................................................................. 75

Environmental Emergencies – Heat-Related (Algorithm 16) ................................... 76

Heat Cramps .......................................................................................................... 76 Heat Exhaustion ..................................................................................................... 76 Heat Stroke ............................................................................................................ 76

Treatment ............................................................................................................... 76

Hypoglycemia – Diabetic Emergencies (Algorithm 17) ............................................ 77

Injuries to Bone, Joint and Muscle ............................................................................ 78

Bone Injury ............................................................................................................. 78 Joint Injury .............................................................................................................. 78

Muscle Injury .......................................................................................................... 78 Patient Care ........................................................................................................... 78

Medical…………… ....................................................................................................... 79

Primary survey ....................................................................................................... 79 Interruptions ........................................................................................................... 79 Oxygen ................................................................................................................... 79 O2 Delivery ............................................................................................................. 79 Primary Survey Repetition ...................................................................................... 80 Evidence of Shock ................................................................................................. 80


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Considerations ....................................................................................................... 80

Follow Up Care ...................................................................................................... 80 Medical – Patient Management .............................................................................. 81 Standard Approach and Ongoing Assessment ...................................................... 81 C-Spine Control ...................................................................................................... 81 Level of Consciousness ......................................................................................... 81

Alert and Oriented x 4 ............................................................................................ 81 Airway .................................................................................................................... 81 Assisted Breathing Instructions .............................................................................. 82 Return of Respirations ........................................................................................... 82 Circulation .............................................................................................................. 82

Physical Examination ............................................................................................. 82 History Taking Guidelines ...................................................................................... 83

Medication Assistance ................................................................................................ 84

Medications ............................................................................................................ 84

Mental Health Emergencies ........................................................................................ 85

Common Signs ....................................................................................................... 85

Patient Care ........................................................................................................... 85

Obstructed Airway – Adults / Children (Algorithm 28) ............................................. 86

Etiology .................................................................................................................. 86

Conscious Patients ................................................................................................ 86

Partial Airway Obstruction ...................................................................................... 86 Good air exchange ................................................................................................. 86 Poor air exchange .................................................................................................. 86

Complete Airway Obstruction (Unconscious with poor air exchange) .................... 86 Adults / Children Complete Airway Obstruction ...................................................... 86

Adults / Children Airway Obstruction – Patient Becomes Unconscious ................. 87 Adults / Children Relief of Choking – Patient Still Unconscious ............................. 87

Obstructed Airway – Infants (Birth – 1 Year) (Algorithm 22) ................................... 88

Conscious Patients ................................................................................................ 88

Partial Airway Obstruction ...................................................................................... 88 Complete Airway Obstruction ................................................................................. 88

Conscious Infants with Complete Airway Obstruction ............................................ 88 Infants Airway Obstruction – Infant Becomes Unconscious ................................... 89 Infants Relief of Choking – Infant Still Unconscious ............................................... 89

Obstetrics and Gynecological .................................................................................... 90

Obstetrics and Gynecology – Childbirth (Algorithm 26) .......................................... 90

Identify Imminent Birth ........................................................................................... 90 Perform a Visual Examination (with discretion and permission) ............................. 91 Placenta ................................................................................................................. 92 APGAR Score ........................................................................................................ 92


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Obstetrics and Gynecology – Neonatal Resuscitation (Algorithm 27) ................... 93

Resuscitative Measures ......................................................................................... 93

Opioid Overdose ......................................................................................................... 95

Poisoning (Algorithm 23) ............................................................................................ 98

For poisons that are swallowed .............................................................................. 98 Contamination Reduction (Decontamination) ....................................................... 100

Identify Toxin / Agent / Product ............................................................................ 100 Special Circumstances ......................................................................................... 100 Organophosphate Poisoning Notes ..................................................................... 101

Muscarinic ............................................................................................................ 102 Nicotinic................................................................................................................ 102 Interventions ......................................................................................................... 102

Patient Safety Considerations .............................................................................. 103 Toxic Inhalation Notes .......................................................................................... 103 Carbon monoxide (CO) ........................................................................................ 103

Signs and symptoms include: ............................................................................... 103 Interventions ......................................................................................................... 103

Patient Safety Considerations .............................................................................. 103 CO Monitoring ...................................................................................................... 104 Hydrogen sulphide (H2S) ..................................................................................... 105

Signs and symptoms include: ............................................................................... 105

Interventions ......................................................................................................... 105 Other considerations for Toxic Gas Inhalation: .................................................... 105 Odour Field Guide ................................................................................................ 105

Seizure (Algorithm 24) .............................................................................................. 106

Management ........................................................................................................ 106

Conscious Patients .............................................................................................. 106 Unconscious Patients ........................................................................................... 107

Shock (Algorithm 25) ................................................................................................ 107

Oxygen Instructions (if trained and equipped) ...................................................... 107

Conserving Body Warmth .................................................................................... 107

Elevation of Lower Extremities ............................................................................. 107

Reassess the LOC (AVU) .................................................................................... 107 Anaphylactic Shock .............................................................................................. 107 Neurogenic Shock ................................................................................................ 108 Septic Shock ........................................................................................................ 108 Obstructive Shock ................................................................................................ 108

Hypovolemic Shock .............................................................................................. 108 Cardiogenic Shock ............................................................................................... 108 Shock can be divided into three stages: ............................................................... 108 Interventions ......................................................................................................... 108


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Stroke (Algorithm 26) ................................................................................................ 109

Symptoms ............................................................................................................ 109 Stroke Treatment ................................................................................................. 109 Patient Care ......................................................................................................... 109 Oxygen ................................................................................................................. 109 O2 Delivery ........................................................................................................... 110

Trauma (Algorithm 27) .............................................................................................. 111

Primary Survey ..................................................................................................... 111 Interruptions ......................................................................................................... 111

Helmets ................................................................................................................ 111 Primary Survey Repetition .................................................................................... 111 Sucking or Bubbling Chest Wound ....................................................................... 111

Evidence of Shock ............................................................................................... 112 Considerations ..................................................................................................... 112 Airway Adjuncts .................................................................................................... 112

Ventilation Instructions ......................................................................................... 113 Oxygen ................................................................................................................. 113

O2 Delivery ........................................................................................................... 113 Trauma – Patient Management ............................................................................ 113 Standard Approach and Ongoing Assessment .................................................... 113

Level of Consciousness ....................................................................................... 114

Alert and Oriented x 4 .......................................................................................... 114 Airway .................................................................................................................. 114 Assisted Breathing Instructions ............................................................................ 115

Circulation ............................................................................................................ 115 Physical Examination ........................................................................................... 116

History Taking Guidelines .................................................................................... 117 Follow Up Care .................................................................................................... 117

APPENDIX A – Adult Drug Reference ...................................................................... 118

Acetylsalicylic Acid ................................................................................................... 118

Atrovent ..................................................................................................................... 119

Dextrose (D50

W) ......................................................................................................... 120

Epinephrine ............................................................................................................... 121

Glucose (oral) ............................................................................................................ 122 Glucagon .................................................................................................................... 123

Medical Oxygen ......................................................................................................... 124 naloxone .................................................................................................................... 125 Nitroglycerin .............................................................................................................. 126 Nitrous Oxide ............................................................................................................. 127 Ventolin ...................................................................................................................... 128


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Introduction

Role of the Medical First Responder (MFR)

Scope of Practice Medical First Response is intended to provide basic care and comfort to a patient or patients until the arrival of the Emergency Medical Services (EMS) or higher level of care. The Medical First Responder may provide medical care to an injured or ill person provided that the care follows the responder’s level of training and/or licensure and the local community’s administration supports that level of care.

Care Provider Definitions

Standard First Aid (SFA) Standard First Aid includes completion of training recognized by the Government of Alberta Occupational Health & Safety at the Standard First Aid level. A list of approved courses can be found at: http://work.alberta.ca/

First Medical Responder (FMR) A responder who has completed a recognized Advanced First Aid course or equivalent (80 hours of medical training with certification as defined by MFR Medical Directors) can perform the FMR skills included in the MFR MCPs, provided they are equipped to do so. This scope of practice requires knowledge and skills maintenance with validation conducted by the agency or municipality. This may include but is not limited to; annual CPR certification, Advanced First Aid certification renewal and participation in medical training opportunities.

Emergency Medical Responder (EMR) Practitioners must be registered with the Alberta College of Paramedics in order to use the protected title of EMR.

Health Disciplines Act/Health Professions Act Medical First Responders who provide care as a licensed practitioner must follow the Health Disciplines Act (HDA) or the Health Professions Act (HPA) as legislation is enacted by the Government of Alberta to govern regulated emergency medical professions. The Acts are intended to protect the public by ensuring only competent, ethical professionals practice in the healthcare setting. Those responders not licensed by the Alberta College of Paramedics should provide care at the level of Standard First Aid, Advanced First Aid or equivalent. In the case of the HPA all self-regulating professions are governed under one umbrella legislation with common processes for registration, ongoing competence, and discipline. The Act increases flexibility in the provision of care through elimination of exclusive

http://work.alberta.ca/occupational-health-safety/1348.html


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scopes of practice and implementation of overlapping professional roles. HPA introduces restricted activities or health services that only qualified practitioners are authorized to perform. More than one regulated professional may be authorized to perform the same restricted activity. The Act allows the removal of regulatory barriers that limit interdisciplinary collaboration. The practitioner must be diligent to follow the standard of care outlined by their professional regulation.

MFR Level of Service

Local decision making by municipal councils and administrators determines an agency’s level of service and related scope of practice

In consultation with industry stakeholders, the Alberta MFR Program’s minimum level of service is Standard First Aid with Healthcare Provider CPR and AED training

The MFR program supports five levels of service:

1. Standard First Aid (SFA)

2. First Medical Responder (FMR)

3. Emergency Medical Responder (EMR)

4. Emergency Medical Technician (EMT) ACP registration is required

5. Advanced Life Support (ALS)

Practitioner registration requirements are determined by the Alberta College of Paramedics (ACP); AHS and the MFR program have no involvement in these requirements.

Contact the MFR program for more information about scope of practice and level of service.

Alberta College of Paramedics (ACP) registration is not required


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Level of Service – Comparison Chart

SFA

+/-

En

han

ced

Ski

lls

FMR

EMR

EMT

SFA

+/-

En

han

ced

Ski

lls

FMR

EMR

EMT

Cardio Pulmonary Resuscitation (CPR)

Salbutamol* * *

Automated External Defibrillator (AED)

Ipratropium Bromide* * *

Manual auscultation BP and chest Epinephrine * * *

Blood Glucose Testing Acetylsalicylic acid *

Pulse oximeter Oral glucose gel *

Patient extrication

Naloxone

Splinting techniques 50% Dextrose

Spinal Injury Care 25% Dextrose

Cervical collars Nitroglycerine

Nitrous Oxide

Pocket Mask

Assist with Imminent Delivery

BVM Obstetrical assessment

Administer Oxygen Visual examination

Suction devices Crowning

Oropharyngeal airway Show

Nasopharyngeal airway Membranes (intact / ruptured)

Non-visualized airways; King LT and LMAs Meconium staining

*Patient Assist - refer to the MFR Protocols

= Restricted Skill

SFA

FMR

EMR

EMT

BP

BVM

LMA

LT Version: 2015 Dec 16

Air

way

Man

age

me

nt

Vit

al S

ign

s

= Enhanced Skills Training

Ob

ste

tric

Man

age

me

nt

Laryngeal Tube

Emergency Medical Responder

Emergency Medical Technician

Blood Pressure

Bag-valve-mask

Laryngeal Mask Airway

MFR Level of Service Comparison Chart

Definitions

Standard First Aid

First Medical Responder (Advanced First Aid or equivalent [80+ hour course])

Skill

Me

dic

atio

ns

Skill

Car

dia

c/

Cir

cula

tio

nSp

inal

Re

stri

ctio

n


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Confidentiality Every attempt should be made to ensure that the patient’s personal information is kept strictly confidential. Patient Care documentation should be restricted to only those responsible for the care of the patient and administration of records. By using the Patient Care Report – Medical First Response format provided by the Alberta Health Services you are agreeing to conform to the following disclaimer: “The information that you provide on this form is collected under the authority of Section 19 of the Alberta Health Information Act and Section 33 (c) of the Freedom of Information and Protection of Privacy Act. It may be shared with affiliates of Alberta Health Services and will be used for internal management purposes including, but not limited to quality assurance and auditing. Your personal information is protected by Alberta’s Health Information Act and can be accessed on request. If you have any questions about the collection or use of this information contact your local EMS Service.”

Consent The Medical First Responder should always obtain the consent of each patient they are treating, even if the patient(s) are the ones that activated your response. There are two general types of consent:

Expressed Consent The patient provides you with verbal or other form of acknowledgement that they are alright with your assistance.

Implied Consent The patient is unable to respond to your offer of assistance however is in obvious need of help (unconscious, choking, etc.).

Abandonment Once care is started, the Medical First Responder is expected to continue this care until relieved by someone who has similar or higher training. Only if there is a direct danger to the rescuer should care be stopped without being relieved.

Negligence The Court System of Canada describes negligence as performing a skill that is outside of a person’s level of training or failing to act in what is known as “the reasonable person test”. This test dictates that your actions would be measured against that of what any reasonable person would do in a similar situation.


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Scene Assessment Determine the type of environment you are entering into and assess for dangers, access and egress. Ensure that hazards are assessed and controlled, look for the cause of the illness or injury, and note the number of patients involved. Call for appropriate back up assistance dependant on the type of emergency call:

· Medical Emergency

· Traumatic Injuries

· Motor Vehicle Collisions

· Water Rescue

· Ice Rescue

· Hazardous Materials

· Fires

· Confined Spaces

· Other

Quality Patient Care Safety Responders should always place safety as their first priority and enter an emergency scene only when safe to do so. Consider the following when deciding to help:

· Self – donning personal protective equipment (PPE)

· Crew – ensuring everyone on team is protected

· Patient – your involvement will not place them at further risk

· Public – provide a visual or verbal warning to everyone who may inadvertently enter the scene

Routine Practice Applies to every patient contact and involves:

· Hand hygiene (HH) at the point of care (POC) o Perform HH at POC during non- emergent events o During emergent events performing HH at POC may not be practicable,

during these events sanitize your hands while gaining access to the patient and prior to donning gloves

o Where available soap and water must be used when hands are visibly soiled

o Alcohol based hand rubs are the only approved products for sanitizing hands.

· Using aseptic technique for all invasive procedures

· Dedicating all commonly used medical equipment to a single patient between cleaning and disinfection

· Disposing of all sharps in the proper containers

· Changing stretcher linens after each use


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· Disposing of both general and biomedical waste in the proper receptacle

· Cleaning and disinfecting all medical equipment and transport vehicle after use

· Use the appropriate Infection Prevention Control (IPC) PPE after categorizing a suspected infection as contact, droplet, or airborne.

Mnemonics BLS – Burns, Lacerations, Swelling DCAP – Deformities, Contusions, Abrasions, Penetrations DCAPP – Deformities, Contusions, Abrasions, Penetrations, Paradoxical motion

DRT – Distension, Rigidity, Tenderness JVD – Jugular Vein Distension PEARL – Pupils Equal And Reactive to Light PMS – Pulses, Motor function, Sensation TIC – Tenderness, Instability, Crepitation

EMS Pre-arrival Care Keep the following questions in mind when attending at a medical call while waiting for EMS to arrive:

· Type of call?

· Age and sex of patient?

· Location of the incident?

· Access and egress to the incident?

· How long ago did the incident occur?

· Any Medical First Responders or law enforcement personnel on the scene?

· Has an EMS unit been dispatched?

· Number of patients?

· What treatment or stabilization procedures will be required?

· What are the roles of each team member?

· Gather medical information – history, medications?

· Time dispatched?


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Standard Approach and Ongoing Assessment (Algorithm 1)

The following should be performed as necessary on all patients:

· Assess LOC, Circulation, Airway, Breathing

· Application of AED

· Perform CPR

· Secure Airway

· Administer oxygen

· Establish effective ventilation

· Perform physical exam

· Pulse oximetry

· Vital signs

· Determine blood glucose level

· Obtain detailed history

· Spinal immobilization

· Consider differential diagnosis

· Frequent reassessment

· Assist EMS with patient care

Abdominal Pain

Abdominal pain is often very difficult to identify a cause. The causes of abdominal pain can range from relatively minor conditions to life-threatening emergencies. Patients will often position themselves in an attempt to relieve the discomfort. This should be encouraged if not already done.

Patient Care Ensure adequate breathing Provide comfort measures until EMS arrival Avoid giving anything to eat or drink


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Airway Control (Algorithm 2)

Conscious Patients This includes patients who are awake or who can be awakened with verbal or painful stimuli.

Confirm a Clear Airway On initial contact, rescuers must ensure that all patients have an open and adequate airway.

The head-tilt/chin-lift or modified jaw thrust manoeuvre is used to open the airway of patients who are unable to do so on their own. The modified jaw thrust is used on patients who have suspected c-spine trauma. Noisy respirations indicate airway obstruction. Snoring respirations are usually relieved with proper airway positioning. Gurgling respirations indicate fluid in the oropharynx and these patients require placing in a Recovery Position. The inability to ventilate a patient after the airway has been cleared and repositioned once indicates an airway obstruction and the OBSTRUCTED AIRWAY algorithm is referred to at this point.

Evaluate Respirations Determine the rate, rhythm, and quality of respirations by looking and listening. See if the chest is fully expanding. Count the breaths/min. See if the patient has accessory muscle use or has cyanosis (blue) around the mouth. Does the patient look like he/she is having difficulty breathing? Listen to the breathing. Is it shallow or laboured? How many words can the patient speak in a sentence? Consider rates below 8 slow and rates above 20 fast with signs of inadequate oxygenation, hypoxia, or a decreased LOC.


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Patients Benefiting from Oxygen If crews are equipped and trained to use oxygen, the following patients may benefit from oxygen treatment if SpO2 is less than 94% on room air:

· Any patient whose chief complaint involves the airway, breathing, circulation, or nervous system

· Any patient suspected of being hypoxic or who has a history that indicates the potential for hypoxia

· Any patient with a history of Altered LOC

· Any patient with chest pain

· Signs of smoke or toxic gas inhalation

· History of pulmonary edema

· Signs of shock

· Head injury or evidence of stroke

· Seizures

· Drowning/near drowning

· Trauma

· Poisoning or overdose

Vomiting Patients who vomit require immediate provision for airway protection. If supine, vomiting patients are placed on their side and allow the emesis to drain. Patients with suspected spinal injury are maintained in alignment while they are rolled onto their side

If oxygen administration is discontinued due to vomiting and the vomiting episode lasts more than 30 seconds, consider applying a nasal cannula at 2 - 6 litres/min until the administration of high-flow oxygen can be resumed. Once vomiting is completed, the patient’s status is re-evaluated using the primary survey.

Position Avoid laying anyone in respiratory distress flat. Keep patients sitting upright in a position of comfort. Consider c-spine precautions.

Unconscious Patients This includes patients who do not respond to verbal or painful stimuli.

Confirm a Clear Airway The head-tilt/chin-lift or modified jaw thrust maneuver is used to open the airway. The modified jaw thrust is used on patients with suspected c-spine trauma. An inability to ventilate a patient after the airway has been cleared and repositioned once indicates an


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airway obstruction and the OBSTRUCTED AIRWAY algorithm is referred to at this point.

Altered Level of Consciousness Consciousness is defined as an awareness of self and the environment. Of all the central nervous system functions, mental status is the earliest indication of advancing disease. Changes in a patient’s LOC may be extremely subtle, with the patient appearing awake and alert, but disoriented to person, place, time, or event. Patients who appear asleep represent a more obvious alteration of consciousness and should be immediately evaluated for response levels. This includes noting the response to verbal stimuli and tapping the shoulder. Causes of altered levels of consciousness are many and varied. The mnemonic AEIOU TIPS provides a general overview of some common reasons for decreased or altered consciousness and includes:

· A Alcohol, ingested drugs, Arrhythmias

· E Endocrine disorder, Epilepsy

· I Insulin (too much, too little)

· O Overdose, Opiates, hypoxia “Oxygen”

· U Under dose, Uremia, (renal problems) hypertension

· T Trauma, Temperature, Tumour, Toxins

· I Infections

· P Psychiatric, Poison

· S Shock, Stroke, Seizures Management of patients exhibiting an Altered LOC includes performing a primary survey with early administration of oxygen (if trained and equipped). Airway control and maintenance, although always a priority, requires continuous monitoring in a patient with diminished LOC.

Anaphylaxis (Algorithm 14)

Etiology Anaphylaxis is a severe systemic allergic reaction. It is a life-threatening medical emergency requiring immediate treatment. Clinical Criteria for Diagnosing Anaphylaxis Anaphylaxis is highly likely when either of the following criteria is fulfilled: Acute onset of an illness (minutes to several hours) after exposure to a known or suspected allergen and any of the following: Altered level of consciousness


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Airway edema Systolic BP less than 90 mmHg or associated symptoms of end-organ dysfunction (e.g. hypotonia – collapse, syncope, incontinence) Acute onset of an illness (minutes to several hours) after exposure to a known or suspected allergen and any two of the following: Persistent gastrointestinal symptoms (e.g. cramping, abdominal pain, vomiting) Dyspnea Bronchospasm The majority of anaphylactic reactions (approximately 80%) include skin symptoms, such as generalized hives, pruritis or flushing. Persistent gastrointestinal symptoms have been associated with severe outcomes in anaphylactic reactions. Practitioners must be vigilant in identifying the rare patient whose only sign of anaphylaxis is hypotension.

Mild / Moderate Anaphylaxis · Mild dyspnea or bronchospasm

· Urticaria

· Angioedema May have tachycardia but vital signs remain otherwise stable (no hypotension or clinical evidence of shock)

Severe Anaphylaxis Signs and symptoms as in mild anaphylaxis as well as: Altered level of consciousness Respiratory failure (SpO2 less than 85% refractory to oxygen) Airway compromise Systolic BP less than 90 mmHg When a severe anaphylaxis is suspected, be prepared for a sudden, rapid drop in blood pressure

Interventions Remove the allergen if possible Stingers should be removed by scraping the skin with the dull side of trauma shears to avoid squeezing more venom into the site


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Automated External Defibrillation (AED)

Providing CPR and early defibrillation in the event of cardiac arrest is recognized as the highest priority in emergency cardiac care. Restoration of a perfusing rhythm requires immediate CPR and defibrillation within a few minutes of the initial arrest. Defibrillation is the therapeutic use of electrical current delivered in large amounts over very brief periods of time. The defibrillation shock temporarily depolarizes a fibrillating heart and thus, allows more co-ordinated contractile activity to resume. The Automated External Defibrillators (AED’s) are highly sophisticated machines, embedded with a microprocessor-based device that monitor, assess and automatically treat patients with life-threatening heart rhythms. Built into this processor is a detection system that analyzes the rhythm of a patient’s electrocardiogram (ECG) for characteristics of ventricular fibrillation (VF) and ventricular tachycardia (VT). If VF or VT is present, the AED advises the operator to deliver a shock. All AED’s are configured to store and retrieve patient ECG patterns for further analysis by medical authorities or for quality improvement. Some devices are equipped to record an audio file of the event. Once the AED is turned on do not turn it off until patient care has been transferred to a higher authority. It will continue to analyze and if the victim lapses again, the AED will recommend a shock if needed. When Emergency Medical Services personnel are on the scene, they can remove it. For unwitnessed cardiac arrest in both adults and children, perform the CAB Sequence until the AED is ready for use. For any CPR in progress cardiac arrest, use the AED as soon as it’s ready for use. If EMS arrives prior to delivery of the first shock, early liaison with the attending EMS crew should occur, as all attempts to deliver the appropriate shock rapidly should occur. NOTE: A delay to change over to the EMS monitor should not occur until after the initial shock if the Medical First Responder AED is ready to deliver the shock. Electrical shock delivery via an AED is equivalent to a cardiac heart monitor for the initial shock delivery in cardiac arrest.

Legal Position There is very little legal or liability risk for a person that uses an AED correctly. The concept of having an AED on site has been widely promoted by over 50 heart health organizations in Canada, including the Heart and Stroke Foundation. Having an AED on site is rapidly becoming a basic standard of emergency care, equivalent to the value of having a smoke alarm. In fact, facilities that install AED’s are now reducing their liability by providing this potentially life-saving service.


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Operation of the AED Use the AED only when the patient has no response to verbal command or touch, no breathing, and no pulse. If the patient is not breathing, follow these steps:

Automated External Defibrillator A. Single Responder

1. Confirm arrest and ensure that an emergency response is activated a. If alone retrieve the AED prior to starting patient care b. Use the AED as soon as available c. Continue to Step 3

B. Multiple Responders

2. Initiate CPR with the CAB Sequence while another is preparing the AED 3. Position the patient on their back 4. Turn on the AED and follow instructions 5. Bare patient’s chest and wipe away any moisture and remove any

hair/medical patches and so on 6. Attach one pad to the patient’s upper right chest and one to the lower left

side. The pads will be labelled with a picture of where they go 7. Plug the wire from the pads into the AED if they are not already attached 8. Push the 'Analyze' button or let the AED automatically begin its analysis. Wait

for the analysis to complete its cycle 9. The machine will prompt: “ANALYZING NOW, STAND CLEAR.”

a. Make sure no one is touching the patient so the AED can analyze correctly

b. Shockable rhythm, the machine will begin to charge and advise you when to press the shock button

i. Keep everyone clear of the patient ii. Press the 'shock' button iii. Once the shock is delivered the machine will prompt, “START

CPR.” c. Non-Shockable rhythm, it will give you the prompt, “NO SHOCK

ADVISED.” 10. Continue with the CAB Sequence until the next AED re-analyze cycle 11. Do not turn off the AED until exchange of patient care with EMS 12. If patient shows obvious signs of life, place the patient in a recovery position

and monitor them continuously 13. Return to Step 10 if a pulse is lost or no signs of life


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Notes: Always stand clear of the patient during analysis. Clear the patient before delivering the shock to avoid injury to yourself and your partners. Deliver the SHOCK. After delivering the shock, immediately begin CPR. If there is a no shock advised prompt, immediately begin CPR and ventilations for 5 cycles or 2 min. Continue until EMS arrives. Recheck the pulse every 2 min or when the AED prompts.

AED Pads For infants and children less than 8 years of age or 55 lbs (25 kg), use pediatric pads (reduced energy defibrillation electrodes). For AED’s that are not pediatric capable the use of adult pad is acceptable but not preferred by the guidelines issued by the Heart and Stroke Foundation of Canada. For adults and children who are 8 or older or weigh more than 55 lbs (25 kg), use adult pads.

Use anterior/posterior (A/P) placement on children under 8 years old. Do not place pads on infants less than a day old.

Special Situations Hairy chest – Shave the area with a razor if the pads don’t stick to the skin. Patient in water or with water on the chest – If the patient is in water, pull the patient out of the water. If the patient is lying in snow or a small puddle, you may use the AED. If the chest is wet, quickly wipe the chest before applying the pads. Pacemakers – You may feel the pacemaker as a hard lump beneath the skin of the upper chest or abdomen. Place the AED pads at least 1 inch or 2.5 cm away from the device. Medication patches – Remove all medication patches before applying the AED pads. Hypothermic/cold water drowning – If the patient is hypothermic due to cold exposures, minimize the amount of shocks to 1. (AED will continue to prompt to shock, simply leave device alone and it will automatically drop the charge internally after 15 seconds)


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Post-Resuscitation Care If the patient regains a pulse: Maintain airway control and ventilatory assistance using a BVM at 10 - 12 breaths/min in adults and 12 - 20 breathes/min in pediatrics. Use oxygen at 15 - 25 litres/min. Be prepared for vomiting. Roll the patient and suction the airway if vomiting occurs. Continue to monitor the patient while awaiting EMS arrival. Checking a pulse every 20-30 seconds is paramount to detect early the loss of cardiac output.

Reassessment If patient loses pulse after regaining it: Re-ANALYZE with AED immediately (witnessed). Deliver shock if advised to. If no shock is advised and the patient remains pulseless, start CPR.

Electric Shock Cardiopulmonary arrest in electric shock is the primary cause of immediate death. Ventricular fibrillation or Asystole may occur. Aggressive resuscitation measures are indicated even for those who appear dead on initial evaluation. Electrocution may involve trauma caused by a fall. Therefore, consider taking c-spine precautions when appropriate.

Lightning Strike Lighting acts as a massive DC counter shock. When multiple victims are struck simultaneously by lighting, the highest priority is given to patients in cardiac arrest because their condition is highly reversible if intervention is rapid.


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Bronchospasm (Algorithm 14)

Etiology Bronchospasm is an abnormal contraction of the smooth muscle of the bronchi, resulting in an acute narrowing and obstruction of the lower airway. A cough with generalized wheezing usually indicates this condition. Wheezing is produced by the movement of air through constricted airways. It is critical to recognize there may be little or no air flow in severe bronchospasm attacks with the result being minimal audible wheezing. In cases of severe bronchospasm audible wheezing may be absent prior to treatment. In these cases, the onset of wheezing following treatment may be indicative of improved airflow. Patients (especially children) with inspiratory stridor are more likely to have a partial upper airway obstruction (i.e. croup, epiglottitis, foreign body). Audible wheezing on inspiration is likely referred upper airway noise from stridor.

Asthma Asthma is a reversible obstructive lung disease characterized by:

1. Bronchial smooth muscle contraction 2. Mucosal and submucosal inflammation and edema 3. Increased mucous production and congested airways

Asthma may be triggered by extrinsic factors (e.g. pollution, exercise, cold air, pharmacological products) or intrinsic factors (e.g. allergies

Chronic Obstructive Pulmonary Disease (COPD) COPD is a disease process which causes chronic outflow obstruction; its two dominant forms are:

1. Emphysema (Pink Puffers): characterized by an abnormal enlargement of the air spaces distal to the terminal bronchioles accompanied by the destruction of their walls

2. Chronic Bronchitis (Blue Bloaters): characterized by inflamed and edematous airways filled with secretions. Copious respiratory secretions contribute to expiratory obstruction

3. Despite the risk of suppressing the hypoxic respiratory drive, oxygen should never be withheld from a symptomatic patient or any COPD patient with SpO2 less than 90%

4. Practitioners must be prepared to assist ventilation; assisted ventilations are also indicated for patients who are unable to maintain SpO2 greater than 90% by other adjuncts or whose mentation is compromised by hypoxia.


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Pneumonia Pneumonia is an inflammatory condition of the lung, affecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases. The most common symptoms of pneumonia are:

· Cough (may be productive – greenish/yellow mucus, or even bloody mucus)

· Fever

· Shaking / chills

· Shortness of breath

Patient Safety Considerations Remember, “All that wheezes is not asthma.” Practitioners must consider other causes of bronchospasm such as CHF, toxic inhalation and pneumonia. Asthma or COPD may present as a “Silent Chest.”

Burns (Algorithm 5)

Airway If the patient was in an enclosed space at the time of the burn, whether chemical or thermal, a strong possibility of airway damage exists. Continually monitor the airway for evidence of obstruction and be aware that respiratory problems due to damage of airway tissues may not develop immediately.

· Signs of Upper Airway Burns

· Burns to the face

· Singed eyebrows or nasal hair

· Burns in the mouth

· Sooty sputum

· Brassy cough

· Hoarseness

· History of being in an enclosed space when burned

Signs of Smoke Inhalation · Exposure to smoke in an enclosed space

· Unconscious while exposed to smoke or fire

· Cough developing after exposure to smoke or fire

· Shortness of breath after exposure to smoke or fire

· Chest pain after exposure to smoke or fire

· Hoarseness after exposure to smoke or fire

http://en.wikipedia.org/wiki/Inflammation

http://en.wikipedia.org/wiki/Lung

http://en.wikipedia.org/wiki/Alveoli

http://en.wikipedia.org/wiki/Virus

http://en.wikipedia.org/wiki/Bacteria

http://en.wikipedia.org/wiki/Microorganism

http://en.wikipedia.org/wiki/Medication

http://en.wikipedia.org/wiki/Autoimmune_disease


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Oxygen Instructions All patients who are suspected of suffering from airway exposure to fire, smoke, toxic chemicals, or gases should receive high flow oxygen therapy when it is safe to do so.

Burn Management If you are the first on scene responder ensure that it is safe to approach the patient and you are wearing personal protective equipment. Stop the burning process and remove to a safe place with fresh air. Remove non-adherent clothing and any potentially restricting jewellery. First aid care:

· Cool thermal burns with tepid running water (avoid ice or cold water as this causes vasoconstriction and in turn could worsen the injury)

· Less than 10% burn - cover the burn with clean moist dressing

· Greater than 10% burn – cover with clean, non-stick dressing (cool the burn not the patient)

· Chemical burn – flush with copious irrigation of sterile water if available

· Oxygen should be administered by non-rebreather at 12 - 15 litres/min and patients SpO2 is less than 94% room air.

Burn Measurement Small Burns Rule of Palms - Using the rule of palms, the surface of the patient's palm represents approximately 1% of body surface area and is helpful in estimating the area of small burns. Large Burns Rule of Nines - To approximate the percentage of burned surface area, the body has been divided into eleven sections: Head, Right arm, Left arm, Chest, Abdomen, Upper back, Lower back, Right thigh, Left thigh, Right leg (below the knee), Left leg (below the knee) .


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B. Figure 1 – Rule of Nines


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Chest Pain (Algorithm 7)

Although there are many potential causes of chest pain, all patients with acute onset chest pain should be approached as having a myocardial infarction. Some of the life-threatening causes of chest pain are:

· Unstable angina

· Acute myocardial infarction

· Aortic dissection

· Pulmonary embolus

· Spontaneous pneumothorax

· Esophageal rupture

Symptom Recognition Prompt recognition that a acute myocardial infarction (AMI) or heart attack is occurring is critical, since most deaths associated with acute myocardial infarction (AMI) are due to electrical instability and occur suddenly, often before arrival at the hospital. It is important to aggressively treat patients with symptoms of myocardial infarction since ventricular fibrillation is fifteen times more likely to occur during the first hour after onset of symptoms than at any other time.

Angina Pectoris (Chest Pain) Is induced by exertion, usually lasts 5 to 15 min and is relieved by rest or by nitro-glycerine. The pain of AMI generally lasts longer than 15 - 30 min. The pain of AMI typically builds to its maximum, whereas pain from aortic dissection or pulmonary embolus is usually severe from the onset. Any angina pain that lasts longer than 15 min, is not relieved by the patient’s own nitro-glycerine, or is accompanied by diaphoresis, dyspnea, nausea, or vomiting, suggests an AMI. About 20% of AMI’s are not accompanied by chest pain, especially in elderly persons, females, and/or diabetic patients. When pain is present, it generally has a retro-sternal component; and it may radiate to the neck, shoulders, lower jaw, back, or down the inside of the left or both arms. This pain is typically described as a heavy or squeezing sensation. It may be mild to severe, but it tends to increase in severity over a period of minutes. In some patients, high epigastric discomfort may be a symptom of AMI and is often dismissed by the patient as indigestion.


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The following are at highest risk for sudden death: Patients with a new onset of chest pain either at rest or with ordinary or usual activity. Patients who experience a sudden change in a previously stable pattern of angina pain, such as an increase in frequency or severity, or occurrences at rest for the first time. Patients who are experiencing chest pain and have known coronary heart disease Chest pain or discomfort that is unrelieved by rest and/or nitro-glycerine.

Oxygen Instructions (if trained and equipped) Oxygen should be administered as early as possible. Supplemental oxygen helps reduce both the magnitude and extent of damage in patients with AMI. Patients should be allowed to remain in the position of greatest comfort and ease of breathing. O2 is indicated in acute coronary syndrome if oxygen saturations are less than 94% and the patient is short of breath. O2 delivery should start with nasal cannula at 2 - 4 LPM and progress to higher concentrations as required.

Early Defibrillation Providing early CPR and defibrillation in the event of cardiac arrest is recognized as the highest priority in cardiac care.

Questions to Consider

· Did the pain/discomfort begin suddenly?

· What was the patient doing when the pain/discomfort began?

· Has the patient ever had the pain/discomfort before?

· Has the pain/discomfort become better or worse?

· Has the patient ever had a heart attack? *EMT Nitro Administration Administration of Nitroglycerine WILL NOT be performed if a 12 lead ECG is unavailable. This is due to the increased risk of creating profound hypotension in patients experiencing a Right Ventricular Infarct (RVI). EMTs will withhold all forms of nitro if not equipped to obtain a 12-lead ECG or the computer generated 12-lead interpretation has any message in capital letters indicating a STEMI (e.g. STEMI, ACUTE MI, SUSPECTED, ST ELEVATION CRITERIA MET) Establish IV access prior to administration of Nitro. If possible start IV in patient’s left forearm.


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Refer to the History Taking Guidelines

Myocardial Infarction Signs and Symptoms of Myocardial Infarction Ischemia Signs

· Tachypnea

· Dysrhythmias

· Cyanosis

· Diaphoresis

· Vomiting

· Agitation

· Cardiac arrest

· Cardiogenic shock

· Chest and/or abdominal pain

· Palpitations

· Shortness of breath

· Sweating

· Nausea

· Light-headedness / Pre-syncope

· Confusion

· Weakness

· Anxiety / Feeling of fear or impending

· Feeling of impending doom

Differential Diagnosis Limited differential diagnoses for chest pain include:

· Angina

· Pulmonary embolism

· Dissecting thoracic aortic aneurysm

· Gastrointestinal cause (e.g. esophageal spasm)

· Hyperventilation

· Musculoskeletal cause (e.g. chest wall pain)

· Myocardial infarction

· Pericarditis

· Pneumonia

· Pneumothorax

· Pleurisy

· Dermatologic cause (e.g. shingles)

Life Threatening and Serious Causes of Non-ACS Chest Pain

Life Threatening Potential Life-threatening Less Serious

Aortic dissection Acute pericardial effusion and tamponade Acute pulmonary embolism Tension pneumothorax

Peptic ulcer, perforated Esophageal rupture Acute pneumonia Aortic stenosis (chest pain, syncope, exertional dyspnea) Acute cholecystitis, cholelithiasis, ruptured gall bladder Acute pancreatitis

Gastroesophageal reflux disease (GERD) Esophagitis, gastritis Hiatal hernia Musculoskeletal chest pain Costochondritis


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Patient Safety Considerations 25% of AMI patients present with reproducible chest wall tenderness. The patient may be encouraged to take their own ASA medication and nitro-glycerine as prescribed by a physician. First Aiders are not to provide some else’s medication or any medication carried in their kit.

Control of External Bleeding (Algorithm 8)

Management Direct targeted pressure to the bleeding area with elevation of the limb if possible. *Consider application of tourniquet as indicated.

Elevation If a fracture is suspected in an extremity, do not elevate the limb or subject the patient to unnecessary motion until the fracture has been immobilized in a splint. Note: Maintain as clean a technique as possible. NEVER expose a patient to the blood or body fluids of another patient. Put on a new set of gloves for each patient.

Epistaxis (Nosebleed) Nosebleeds are quite common and are usually controlled with manual, external compression, and tend to be self-limited. Severe nosebleeds can be profuse, persistent, and life threatening. They are complicated by airway compromise and vomiting of swallowed blood. Caution Anyone in close proximity must be aware that this patient they may be spitting up blood which could splatter. Bodily fluid precautions are required.

Management of Epistaxis · Have adequate PPE on.

· Keep the patient sitting up and leaning slightly forward unless there are signs of shock.

· If blood is flowing from the nostrils, pinch the entire soft part of the nose right under the nasal bone and hold for 10 minutes. If the patient is still bleeding, repeat this step once. Then if the patient continues to bleed, maintain pressure until EMS arrives.

· Instruct the patient not to swallow blood and have the patient spit his/her blood into a container.

· If blood has been swallowed, the patient may vomit.

· Maintain a clear airway and carefully suction the mouth if required.


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· If signs of shock are present, keep the patient supine with his/her head or entire body turned to one side (see the SHOCK algorithm).

Cardio Pulmonary Resuscitation (CPR) (Algorithm 9 - 11)

The CPR skills described in this document are targeted towards the Health Care Provider (HCP).

CPR for Adults Adults – Patients that have signs of puberty and older. Signs of puberty include breast development in females; and underarm, chest, and facial hair in males.

Scene Survey Confirm unresponsiveness Assess for breathing – Take at least 5 seconds and no more than 10 seconds. Check pulse – Take at least 5 seconds and no more than 10 seconds to find the pulse. Start CPR Ratio – 30:2, (30 compressions to 2 breaths) for one or two rescuers performing CPR. Use 5 cycles of CPR at a rate of at least 100 compressions/min. Depth – At least 2 inches of chest depth. Push hard, deep, and fast; and release completely. Allow the chest to recoil completely. Minimize interruptions. Provide ventilations – use a BVM, one way valve mask or shield to provide ventilations between cycles of compressions*. Notes: A witnessed arrest is one that is actually witnessed by crews. If high quality CPR is already being performed by someone on-scene, crews do not need to perform the initial 2 minute CPR cycle and can use the AED immediately To avoid fatigue, crews should switch every cycle of 2 minutes. Check for DNR or Goals of Care designation *In the unlikely event there is a pulse but no breathing, provide BVM or mouth to mask/shield ventilations 1 breath every 5 to 6 seconds.


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CPR for Children Children – 1 year of age to puberty. Signs of puberty include breast development in females; and underarm, chest, and facial hair in males. Scene Survey Confirm unresponsiveness Assess for breathing – Take at least 5 seconds and no more than 10 seconds. Check pulse – Take at least 5 seconds and no more than 10 seconds to find the pulse. Start CPR Ratio – 15:2 (15 compressions to 2 breaths) for two rescuers performing CPR and 30:2 for 1 rescuer performing CPR. Use 5 cycles at 100 compressions/min. Depth – 1/3 of chest depth. Push hard, deep, and fast; and release completely. Allow the chest to recoil completely. Minimize interruptions. Provide ventilations – use a BVM, one way valve mask or shield to provide ventilations between cycles of compressions*. Notes: A witnessed arrest is one that is actually witnessed by crews. If high quality CPR is already being performed by someone on-scene, crews do not need to perform the initial 2 minute CPR cycle and can use the AED immediately. Anterior/posterior defibrillator pad placement may have to be considered. Use Pediatric pads and setting if available. For AED’s that are not pediatric capable the use of adult pad is acceptable but not recommended by the guidelines issued by the Heart and Stroke Foundation of Canada.

· For adults and children who are 8 or older or weigh more than 55 lbs (25 kg), use adult pads.

· Use anterior/posterior (A/P) placement on children under 8 years old.

· To avoid fatigue, crews should switch every cycle.

· Check for DNR or Goals of Care designation. *In the unlikely event there is a pulse but no breathing, provide BVM ventilations – 1 breath every 3 seconds.


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CPR for Infants Infant – Neonatal period to 1 year (12 months). Scene Survey Confirm unresponsiveness Assess for breathing – Take at least 5 seconds and no more than 10 seconds. Check pulse – Take at least 5 seconds and no more than 10 seconds to find the pulse. Start CPR Ratio – 15:2 (15 compressions to 2 breaths) for two rescuers performing CPR and 30:2 for 1 rescuer performing CPR. Use 5 cycles at 100 compressions/min. Depth – 1/3 of chest depth. Push hard, deep, and fast; and release completely. Allow the chest to recoil completely. Minimize interruptions. Provide ventilations – use a BVM, one way valve mask or shield to provide ventilations between cycles of compressions*. Notes A witnessed arrest is one that is actually witnessed by crews. If high quality CPR is already being performed by someone on-scene, crews do not need to perform the initial 2 minute CPR cycle and can use the AED immediately.

· AED is indicated for infants less than 1 year. Do not place pads on newborn (one day old)

· A manual defibrillator is preferred but if not available then use an AED equipped with a pediatric dose attenuator

· If a pediatric pads or dose attenuator is not available then use an AED with adult pads

· Anterior-posterior pad placement is preferred To avoid fatigue, crews should switch every cycle of 5. Check for DNR or Goals of Care designation. *In the unlikely event there is a pulse but no breathing, provide BVM or mouth to mask/shield ventilations 1 breath every 3 seconds.


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Crime Scene

If crews are dispatched to a medical call where there is a death or possible crime, it is imperative that all possible precautions are taken to preserve the scene. The mere presence of Medical Responders may contaminate evidence.

Some things to consider: · Ensure appropriate safety precautions and PPE

· Consider extreme risk hazards such as improvised explosive devices (IED)

· Do not touch anything unnecessarily.

· If something must be moved to provide patient care, make note of where it was.

· If crews open a window or turn on a light, this must be noted.

· If the call involves a suicide, don’t disturb any potential evidence such as a note or pill bottle.

· If the crew turns off a motor vehicle found running, make note of it.

· If the crew must cut ropes or similar devices to provide patient care, DO NOT cut or un-tie any knots.

· If the patient is obviously dead, follow the acronym DRIED

· Secure the scene and wait outside for police.


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Death on Scene (Algorithm 12)

Discontinuation Criteria Medical First Response cannot withhold resuscitation unless the patient is obviously dead, a do not resuscitate (DNR)/Goals of Care designation has been made, or a medical doctor with documented credentials is present and directs crews not to resuscitate.

"Under extenuating circumstances (i.e. prolonged code/extrication, obvious futility, and terminal care with no DNR present) the crew’s medical lead may contact the On Line Medical Control (OLMC) to seek further medical control advice to consider discontinuation."

Obvious death removes the need for attempting resuscitation. Follow the acronym DRIED: Decapitated – the head is completely severed from the body Rigor mortis – temporary rigidity of muscles occurring after death Incineration – complete burning of the body Evisceration – removal of the internal organs forced outside the body cavity Decomposition – process by which tissues of a dead body break down

Personal Directives A patient may present with any one of the following directions for end of life care:

Do Not Resuscitate Order (DNR)

A valid do not resuscitate order tells medical professionals not to perform cardiopulmonary resuscitation (CPR) on a patient. DNR orders are beneficial in preventing unnecessary or unwanted treatment at the end of an individual's life. Ask to see the DNR during patient assessment but before resuscitation is attempted.

Goals of Care Designation

Patients and family, as well as home care providers on scene may present responders with a ‘Goals of Care’ designation, which must be presented and verified. Detailed instructions are found on the back of the ‘Goals of Care’ document.

Goal of Care Designations Designation Description

R1 Full Resuscitation

R2 Resuscitation without chest compressions

R3 No Resuscitation

M(all) No Resuscitation

C(all) No Resuscitation

Medical Direction In some situations a medical doctor may be in attendance and has assumed care of the patient. Follow the directions of this on scene physician if they decide to take the medical leadership role. If the physician does not want to be part of the resuscitative efforts, follow existing protocols.


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Drowning / Near Drowning (Algorithm 13)

The most important consequence of prolonged, underwater submersion without ventilation is hypoxia. Therefore, restoration of ventilation and perfusion should be accomplished as rapidly as possible. Every submersion victim, even one who requires only minimal resuscitation and regains consciousness at the scene, should be transferred to a medical facility for follow-up care. Oxygen should be administered continually and the patient status should be frequently evaluated since pulmonary injury may develop several hours after submersion. Successful resuscitation with full neurological recovery has occurred in near-drowning victims with prolonged submersion in extremely cold water. Since it is difficult for rescuers to estimate length of submersion, resuscitation efforts should be initiated unless there is obvious physical evidence of death, such as decomposition or rigor mortis (DRIED). Try to determine the length of submersion, water temperature, water type (salt, fresh), and whether a diving accident is involved. This will determine the course of treatment and the likelihood of survival of the patient.

Hypothermia If the average temperature of outdoor water is 5 - 10° C, hypothermia should be suspected in drowning or near-drowning patients.

Hazards When attempting to rescue a near-drowning victim, the rescuer should get to the victim as quickly as possible while maintaining personal safety. Responders need to have appropriate PPE, training and equipment when working around the water’s edge or attempting to use a throw bag.

C-Spine In all drowning and near-drowning patients, neck injury should be suspected, the neck should be supported in the neutral position, and the victim should be floated supine onto a back support before being removed from the water.

Airway

Initial treatment consists of opening and maintaining the airway. Oxygen should be administered at by NRB.

· If no adequate breathing – Provide ventilations with a mask, BVM and airway adjunct as necessary.


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· Provide high-flow oxygen (if trained and equipped) as soon as possible. Check for a pulse every 2 min.

Complete the Primary survey A rapid initial survey is essential in determining the patient’s status and the presence of immediate life-threatening injuries.

Dyspnea (Shortness of Breath) (Algorithm 14)

Patients with breathing difficulties can present as one of the most challenging emergency calls that responders attend to. Dyspnea can be from several causes including medical or traumatic origin including: Blunt force injury to the chest Shock Asthma Anaphylaxis Cardiac emergencies

Symptom Recognition Rapid or extremely slow breathing Abnormally deep or shallow breaths Noisy breathing (wheezes, snoring, gurgling, rattles) Irregular breathing Blue lips, pale or gray coloured skin Frequent need to pause speech to catch their breath

Treatment Patients should be allowed to remain in the position of greatest comfort and ease of breathing. Provide reassurance Offer coaching on rate of breathing if it is too fast or to slow Do not offer a paper bag if hyperventilating (no longer an acceptable treatment) Encourage patient to inhale through their nose and hold each breath for several seconds, then exhale slowly (This may be unsuccessful at first so continue to offer encouragement). If breathing is too slow, offer a rhythm that will help them (1, 2, 3, breathe / 1, 2, 3, breathe)

Oxygen Instructions Oxygen should be administered as early as possible in patients with SpO2 with less than 94% on room air. Supplemental oxygen helps reduce the patients stress level. Use a non-rebreather mask with oxygen at 12 – 15 litres/min for patients who require high-flow oxygen


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Use a nasal cannula with oxygen at 4 – 6 litres/min for patients who do not require high-flow oxygen or are unable to tolerate a face mask. (I.e. mild shortness of breath, nauseated) Obtain Sp02 on room air prior to administering 02, if possible. Do not delay administering oxygen for patients in respiratory distress. Report the oxygen saturations to responding EMS crews.

Environmental Emergencies – Cold Related (Algorithm 15)

Severe hypothermia (body temperature below 28° C (82° F) is associated with marked depression of cerebral blood flow and oxygen requirement, reduced cardiac output, and decreased arterial pressure. Full resuscitation with intact neurological recovery is possible. The victim’s peripheral pulses and respiratory efforts may be difficult to detect, but life-saving procedures should not be withheld on clinical presentation.

Recognizing Frostbite Cold exposure injuries to the skin and underlying tissues can vary in degree from superficial to deep. Superficial injuries are observed as skin that appears pale and does not return to normal colour with palpation although the underlying structures are soft. Deep injuries involve freezing of the underlying tissues with permanent cell damage. The skin appears white and waxy and the part feels firm when gently palpated. There may be blisters or swelling. When thawed or partially thawed, the skin may appear red with areas of purple or white. When treating frostbite injuries in the pre-hospital setting, constrictive jewellery must be removed and the area covered with dressing. Do not break blisters or apply heat. Do not try to re-warm the area in deep tissue injuries. Do not re-warm superficial frostbite if re-freezing is likely.

Recognizing Hypothermia The signs and symptoms of hypothermia gradually become more severe as the core temperature falls. A general assessment of the patient’s core temperature can be made by feeling the skin temperature of the abdomen with the back of your hand. If the abdomen feels cool to the touch, it is likely that the patient is experiencing a decreased core temperature. At the onset of hypothermia, the patient is usually alert and shivering. As the core temperature drops, shivering stops and muscular activity decreases. Fine muscle co-ordination will be affected first. Eventually, all muscle activity stops. As the core temperature drops to 34° C (93° F), the patient’s LOC begins to decrease. Poor coordination, memory disturbances, impaired judgment, dizziness, and difficulty speaking follow. Below 30° C (86° F), the vital signs begin to diminish. The pulse slows and becomes weaker or may be completely absent. Respirations are extremely shallow or absent. The patient may appear dead.


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Attempting to measure the body temperature in these patients may not be useful due to poor accuracy.

Management Cold Exposure - Remove from cold environment and protect from further heat loss, remove wet cloths, do not attempt to re-warm frozen limbs

Conscious Patients

Stop the Cooling Process It is important to prevent further heat loss from the patient’s body core by removing wet garments; insulating the patient in warm, dry material; and shielding the patient from the wind. Complete the Initial Survey Pulse and respirations may need to be checked for longer periods to detect minimal cardiopulmonary efforts. The pulse should be checked for a span of 30 - 45 seconds to confirm pulselessness or profound bradycardia in severe hypothermia. Manipulation of limbs should be kept to a minimum in order to avoid precipitating ventricular fibrillation. The patient should be moved in the horizontal position to avoid aggravating hypotension.

Administer Oxygen Airway management and patient movement should be undertaken as gently as possible to avoid precipitating ventricular fibrillation. Provide high-flow oxygen (if trained and equipped) as soon as possible.

Unconscious Patients

Stop the Cooling Process Prevent further heat loss from the patient’s body core by insulating the patient in warm, dry material; and shielding the patient from the wind.

Assess the Patient Determine the LOC (AVU). Assess the ABCs.

Assist Ventilations If no adequate breathing – Provide ventilation with a one way valve mask or shield as necessary. Provide high-flow oxygen (if trained and equipped) as soon as possible. Check for a pulse every 2 min. Complete an initial survey.


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Environmental Emergencies – Heat-Related (Algorithm 16)

Hyperthermia results when the body gains or retains more heat than it can lose, resulting in a high core temperature. Mechanisms for body cooling include sweating and dilation of the blood vessels in the skin. When these mechanisms are overwhelmed and the body can no longer tolerate the excessive heat, serious injury results. High humidity reduces the body’s ability to lose heat by evaporation. Vigorous exercise or prolonged strenuous activity leads to fluid and electrolyte loss. Elderly and pediatric patients are at greatest risk for heat injury. Newborns and infants have poor thermo regulation and can overheat easily.

Heat Cramps These painful muscle spasms occur after vigorous activity and usually involve the legs or abdomen. Heat cramps are the result of loss of salt and other electrolytes through sweating without adequate replacement.

Heat Exhaustion Heat exhaustion is the most common form of heat injury. It results from fluid and electrolyte depletion from excess sweating. These patients are mildly hypovolemic and their skin is usually cool, clammy and has poor colour. Their blood pressure is usually normal but their pulse may be elevated. If untreated, heat exhaustion can lead to heat stroke.

Heat Stroke Heat stroke is the least common heat injury, but if it is not promptly treated, it can be fatal. In heat stroke, the normal mechanism for heat release from the body is overwhelmed and body temperature rises to dangerous levels. The skin is usually hot, dry, and flushed; but in early heat stroke, the skin may still be sweaty and pale. As body temperature increases, the LOC decreases. Immediate cooling of the core temperature is vital.

Treatment Cramping (apply direct pressure to muscles with your hand), Conscious (remove from heat source, lie down, elevate legs, give water or diluted sports drink), Unconscious (remove from heat source, cool patient with wet towels, or ice packs to groin, neck, and axilla) Note: These protocols do not apply to hyperthermia caused by a patient fever.


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Hypoglycemia – Diabetic Emergencies (Algorithm 17)

In a diabetic emergency, giving sugar to someone with low blood glucose can be a life saving measure but providing sugar to someone with high blood glucose will have little negative effect. If in doubt, provide the patient with sugar. If trained and equipped to measure a blood glucose level (BGL) utilizing a blood glucometer, a BGL should be acquired early. A BGL is considered one of the core 5 vital signs in patients that have suspected hyperglycemia, hypoglycemia, seizures, or altered level of consciousness. A conscious patient who is able to follow instructions can be encouraged to drink or eat something sweet but must have no serious illness and able to swallow. If this is not the case provide comfort measures until EMS arrival.

Treatment

If trained and equipped provide oral glucose. In the absence of oral glucose prepare a glass of juice (orange/apple) and stir in two tablespoons of sugar. Hand the glass to the patient and encourage them to drink. If unable to comply, do not attempt to force the liquid into their mouth. In the absence of juice, water/milk with added sugar or soda pop/sports drink with sugar as the main ingredient can be substituted. Avoid diet drinks due to their absence of sugar.


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Injuries to Bone, Joint and Muscle

Bone Injury Injuries to bones are often very painful and depending on the location of the injury may prevent them from being able to move. Patients should be encouraged to lie still so that they don’t cause further injury to the surrounding tissue. Fractures to large bones run the risk of causing major blood loss so monitor for signs of shock.

Joint Injury Likewise, an injury to a joint may require that the patient not move until medical assistance is available.

Muscle Injury Muscle injuries can also be very painful but likely won’t prevent the patient from being able to move the affected area. You can still encourage the patient not to move or put strain of the area until assessed by medical staff.

Patient Care Stabilize the affected area using your hands to hold the extremity (pad with a pillow or blanket) Cover any open wounds with dry dressings (apply gentle direct pressure to steady bleeding) Apply ice or cold pack to the injuries area ensuring that a towel or cloth is between the skin and the cold compress Elevate if able to do so (if in too much pain, then leave in the position found) Splint only if EMS will be delayed or patient needs to be moved before their arrival Note: In addition to assessing DCAP BLS TIC, check for a distal pulse, skin temperature and colour. It is very important to document and report to EMS your findings of the injured limb as once it is bandaged or splinted it will be covered.


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Medical

Primary survey The purpose of the primary survey is to provide an organized and consistent means of evaluating patient status in a prioritized manner, so that life threatening conditions are quickly identified. Assessment for Responsiveness:

· Introduction of yourself and level of training – tell the patient not to move

· If unconscious - Tap and shout (painful stimulus is not within the scope of the first aider)

· Painful stimulus

· Assess for level of consciousness (LOC)

· Opens eyes to verbal stimulus

· Opens eyes to tapping on shoulder

· Remains unconscious and unresponsive

· Assess airway, breathing and circulation · If evidence of mechanism of injury, manually maintain the head and spine in a

neutral alignment and apply Spinal Motion Restriction devices

Interruptions The primary survey should not be interrupted except when:

· There is complete airway obstruction or partial airway obstruction without adequate air exchange.

· There is cardiac or respiratory arrest.

· You are stopping major severe external bleeding.

· Anything occurring that may cause harm to the patient if not immediately dealt with.

Oxygen Oxygen should be administered if response personnel are trained and equipped:

· If required, as early as possible.

· To all multiple trauma patients

· To all patients whose mechanism of injury or physical findings suggest the potential for shock

· To all patients with difficulty breathing

· To patients with chest pain if SP02 is less than 94% or patient is short of breath

· To all patients with an altered or diminished LOC

O2 Delivery If oxygen is warranted, provide the following:

· If possible, acquire oxygen saturation prior to oxygen administration


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· Use a non-rebreather mask with oxygen at 12–15 litres/min for patients who require high-flow oxygen

· Use a nasal cannula with oxygen at 4–6 litres/min for patients who do not require high-flow oxygen or are unable to tolerate a face mask. (i.e. mild shortness of breath, nauseated)

Primary Survey Repetition The Primary survey should be repeated every 5 minutes or when there is a change in the patient’s condition, such as a change in LOC, a seizure, a change in respiratory rate and quality, vomiting, or a change in circulatory status.

Evidence of Shock Shock is a term used when there is a failure within the circulatory system to provide an adequate amount of oxygen rich blood to the body. Responders should assess for evidence of shock in all medical and traumatic emergencies. Shock may be evident when:

· There is an altered level of consciousness (ALOC)

· The skin appears pale, cool and/or clammy with cold extremities

· Lips and nail beds are blue

· Rapid breathing and pulse

· The pulse feels rapid and weak.

· The pulse at the wrist is weak or absent.

· Capillary refill is delayed more than 2 seconds (pediatrics).

Considerations Be aware that:

· What constitutes a minor blood loss in an adult may represent a serious blood loss in a pediatric patient.

· Pediatric patients develop skin pallor quite easily.

· Due to their healthy vascular supply and strong vascular responses, pediatric patients can initially sustain a normal blood pressure (BP) in the presence of serious fluid loss.

· Young, healthy patients may not initially exhibit signs or symptoms of shock even with a 25% - 30% fluid loss.

· Pregnant patients can lose 30% - 35% of their blood volume before exhibiting signs or symptoms of shock.

Follow Up Care Patients should be reassessed every 5 minutes or whenever there is a change in the patient’s condition. Reassess LOC, airway, breathing, and circulation (ABC) and all interventions by performing a primary survey.


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Medical – Patient Management Standard Approach and Ongoing Assessment Follow body substance isolation precautions (PPE). Are there any hazards? Do you see, hear, or smell anything dangerous? What is the mechanism of injury or illness? Are there any other patients? (Ask the patient and bystanders, and look around the area.) Do you need more resources?

C-Spine Control On approach, tell the patient, “Please do not move until we have checked you for injuries.” Delegate manual c-spine control while assessing the patient. C-Spine Control can be ruled out in most medical patients when and if appropriate

Level of Consciousness AVU (Alert, Verbal, Unresponsive):

· Does the patient appear to be awake and alert?

· Does the patient respond to verbal stimulus?

· Is the patient unresponsive?

Alert and Oriented x 4 If the patient is responsive to verbal stimuli, ask the patient his/her name, where he/she is, what day or year it is, and what happened:

· Person

· Place

· Time

· Event

Airway

· Is the airway open and clear?

· Open airway with Head-Tilt, Chin-Lift technique

· Once open, airway must be continually maintained

· Use Jaw-Thrust Manoeuvre if Head-Tilt, Chin-Lift technique unsuccessful or evidence of traumatic injuries or unknown cause of unconsciousness

· Breathing Rate

· Present or absent? If breathing is absent and pulse is present assist ventilations using a BVM and airway adjunct (OPA or NPA).


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Continue assisting ventilations until return of breathing, relieved by EMS or physically unable to.

Assisted Breathing Instructions Rescue Ventilations using a BVM and airway adjunct (OPA or NPA).

· Inspect that the valve is in place

· Place mask on patient’s face with the nose covered by the tip end

· Hold mask firmly to patient’s face to ensure a complete seal around lips and nose

· Use Head-Tilt, Chin-Lift technique or modified jaw thrust if C Spine injury suspected or cannot be ruled out.

Return of Respirations If return of respirations, provide the following support:

· Place the patient in a recovery position to prevent aspiration of fluids into the lungs if not contraindicated due to spinal injury

· Use a non-rebreather mask with oxygen at 10 - 15 litres/min for patients who require high-flow oxygen.

Circulation Are pulses present at the neck and wrist? What are the rate, rhythm, and quality of the pulse at the neck and at the wrist? Is there evidence of circulation? What are the colour, condition, and temperature of the skin? Perform a quick blood scan. Look and feel for significant bleeding and control as necessary. If no evidence of circulation, begin Cardiopulmonary Resuscitation (CPR) and continue CPR until return of circulation, relieved by EMS or physically unable to continue.

Physical Examination It is important to perform an examination on medical patients from head to toe to determine if they are experiencing any other problems that are secondary to their main complaint. Skin Warm and dry? Pale? Moist? Cool or hot? Head Pupils equal and reactive to light (PEARL)? Drooling? Headaches, dizziness, or visual disturbances?


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Facial droop (left or right side)? Inability to speak or incomprehensible speech? Neck Pain/discomfort? Accessory muscle use? Medical alert? Chest Symmetrical expansion? Accessory muscle use? Surgical scars? Medication patches? Pacemaker? Internal defibrillator? Evidence of barrel chest? Evidence of chest pain/discomfort? Shortness of breath (SOB), decreased air to the lungs/wet sounds, or wheezes? Abdomen Surgical scars? Needle marks? Pulsating masses? Pain (radiating)? Nausea and vomiting? DRT? (Distension, Rigidity, Tenderness) Pelvis Incontinence (feces or urine)? Painful urination? Blood in urine? Black tarry stool? Vaginal bleeding? Extremities Pulses? Swelling of the ankles (pedal edema)? Motor/sensory function? Surgical scars? Numbness/tingling?

History Taking Guidelines Obtaining a history may be time dependant but responders should attempt to gather any information appropriate to care for the patient.


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On initial contact with a conscious patient, after determining that the scene is safe and taking c-spine control (if required), determine if the patient is Alert and Orientated X 4 (A/O x 4):

· Person – What is your name?

· Place – Do you know where you are?

· Time – Do you know what day it is?

· Event – Do you know what happened? After completing the primary survey and performing critical interventions, a history may be taken. The history follows the mnemonic, SAMPLE:

· Symptoms – Why have you called for help?

· Allergies – Do you have any allergies to medications or anything else?

· Medication – What medications are you currently taking?

· Pertinent medical history – Do you have any other medical problems? Have you ever had this problem before?

· Last oral intake – When and what did you last eat and drink?

· Events leading up to illness or injury – What happened today? As part of history taking and in cases of patients who are experiencing pain or discomfort (such as chest pain, headache, and abdominal pain or discomfort), further information about the patient’s condition can be gathered based on the OPQRST mnemonic:

· Onset – What were you doing?

· Provocation – What makes the pain or discomfort worse or better?

· Quality – In your own words, describe the type of pain or discomfort you are having.

· Radiating – Does the pain or discomfort go anywhere else?

· Severity – On a scale of 1 to 10, rate your pain or discomfort with 10 as the worst.

· Time – When did this start and has it changed?

Medication Assistance

Assisting a patient to take their own medication, place in patients hand and encourage them to take the prescribed dose (i.e. asthma medication). Ensure that this is the patient’s own medication and it is the correct one for this problem. The following medications can be given as a patient assist:

Medications

· Patient assist administration via inhalation nebulizers – Bronchodilators such as; o Salbutamol (ventolin) o Ipratropium Bromide (atrovent)


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· Patient assist administration via intramuscular route – Adrenergic agonists o Epinephrine (adrenalin) o Trade names include EpiPen, Anapen and Twinject

· Prescribed medication administration via oral route – Platelet Inhibitors o Acetylsalicylic acid (ASA)

· Anti-hypoglycemic agents o Oral glucose gel o Common trade names include GlucoBurst Glucose Gel, Insta-Glucose

and Glutose o Contains 15 grams of glucose

Mental Health Emergencies

A mental health emergency may be difficult to identify but often there are some common signs and characteristics that may be recognizable. A crisis may occur at any time and may erupt from any event that interrupts the normality of the person’s life. Environmental conditions, physical events, changes in social status and life cycle passage may all be situations that create an emotional event.

Common Signs

· Inappropriate anger

· Anxiety

· Confusion

· Depression

· Fear

· Loss of contact with reality

· Mania

· Withdrawal

Patient Care · If patient is uncooperative ensure safety to yourself and others by removing

yourself from their presence

· Contact police if any sign of concern

· Provide reassurance

· If possible remove person from any source of disruption

· Take care not to over sympathize or patronize

· Instruct them to focus on their breathing (coach them to slow down their breathing if hyperventilating)

· Determine risk of suicide by asking straight forward questions – “Are you thinking about harming yourself or someone else?”

· Provide comfort until EMS arrival.


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Obstructed Airway – Adults / Children (Algorithm 28)

Etiology The causes of airway obstructions include foreign bodies, the tongue, swelling of the upper airway, trauma to the airway, and infections. Differentiating the cause of the airway obstruction is essential in order to determine the most appropriate treatment. Airway obstructions may be partial or complete.

Conscious Patients Conscious patients with obstructed airways are classified into two groups: those with partial obstruction and those with complete obstruction.

Partial Airway Obstruction Patients with partial airway obstruction are further classified into two subgroups: those with good air exchange and those with poor air exchange.

Good air exchange Do not intervene as long as air exchange is adequate Keep the patient relaxed and comfortable Do not allow these patients to leave your care.

Poor air exchange Perform abdominal thrusts only Continue until successful or patient becomes unconscious:

· This is treated as though it were a complete airway obstruction.

Complete Airway Obstruction (Unconscious with poor air exchange) Assist the patient into the supine position Start CPR C-A-B sequence. After each set of compressions, look in the mouth. If a foreign body can be seen, remove it. Do not perform blind finger sweeps because this may result in the foreign body pushed back into the airway. Open the airway with a head/tilt chin-lift or modified jaw thrust, and attempt to ventilate. If air does not go in, reposition the airway and attempt to ventilate again. If air still does not go in, perform CPR. Every time you open the airway, check the mouth and remove the object if you can see it before giving 2 breaths. The technique for relieving a complete airway obstruction is based upon the patient’s age. Use abdominal thrusts to relieve choking in adults and children over 1 year of age. Do not use abdominal thrusts in infants.

Adults / Children Complete Airway Obstruction Conscious, standing adults and children are given abdominal J-thrusts to relieve complete airway obstruction. (The term ‘abdominal thrust’ is used synonymously with


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‘Heimlich manoeuvre’) When performing this manoeuvre, the area over the xiphoid process (or the lower margin of the rib cage) should never be compressed. The thrusts should be applied below this area but above the navel in the mid-line. Regurgitation may occur and medical responders should be prepared. Abdominal thrusts are performed until the obstruction is relieved or the patient becomes unconscious. Alternatively, if the patient is obese or pregnant, standing chest thrusts may be performed until the obstruction is relieved or the patient becomes unconscious. Chest thrusts can also be used if the patient is seated or supine.

Adults / Children Airway Obstruction – Patient Becomes Unconscious Assist the patient into the supine position. Start CPR C-A-B sequence. After each set of compressions, look in the mouth. If a foreign body can be seen, remove it. Do not perform blind finger sweeps because this may result in the foreign body being pushed back into the airway. Open the airway with a head-tilt/chin-lift or modified jaw thrust, and attempt to ventilate. If air does not go in, reposition the airway and attempt to ventilate again. If air still does not go in, perform CPR. Every time you open the airway, check the mouth and remove the object if you can see it before giving 2 breaths.

Adults / Children Relief of Choking – Patient Still Unconscious If you have successfully removed an airway obstruction in the unresponsive patient, you will feel air movement and see the chest rise when you give breaths. After you have relieved the choking in the unresponsive victim:

· Provide 2 breaths.

· Check for a pulse.

· If there is no pulse – Perform chest compressions and attach the AED.

· If there is a pulse but no breathing – Provide 1 ventilation every 5-6 seconds and check for a pulse every 2 min.

· Pulse / Breathing – Administer oxygen, place the patient in the recovery position, complete the primary survey, take history, and continue monitoring the patient until EMS arrives.


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Obstructed Airway – Infants (Birth – 1 Year) (Algorithm 22)

Conscious Patients Conscious patients with obstructed airways are classified into two groups: those with partial obstruction and those with complete obstruction.

Partial Airway Obstruction Patients with partial airway obstruction are further classified into two subgroups: those with adequate air exchange and those with inadequate air exchange. Adequate air exchange – In partial airway obstruction with adequate air exchange, the infant can cough forcefully, although frequently there is wheezing between coughs. The infant’s LOC remains alert, and the skin colour is pink or red. As long as the patient’s LOC, skin colour, and ability to cough remain unchanged; the patient should be observed closely and oxygen should be administered. Inadequate air exchange – In partial airway obstruction with inadequate air exchange, the patient exhibits a weak, ineffective cry, makes a high-pitched noise while inhaling, and experiences increased respiratory difficulty which may be indicated by bluish skin. There may also be a decreased LOC. This is treated as though it were a complete airway obstruction.

Complete Airway Obstruction · If the patient is unable to cry or make any sounds, a complete airway obstruction

is present.

· Air movement is absent.

· Unconsciousness will develop quickly.

· The technique for relieving a complete airway obstruction is based upon the patient’s age. For the purposes of this protocol, infants are classified as persons less than 1 year of age. Do not use abdominal thrusts in infants. Use chest thrusts and back slaps if the infant is conscious.

Conscious Infants with Complete Airway Obstruction Responsive, conscious infants are given 5 back slaps and then 5 chest thrusts to relieve complete airway obstruction at the basic life support level. Back slaps are given forcefully in the middle of the back between the infant’s shoulder blades, using the heel of your hand while maintaining the infant in a head-lower-than-body position. Back slaps are then followed by chest thrusts. Chest thrusts are given in the same location as chest compressions, which is just below the nipple line using two fingers to perform thrusts. Continue until the airway obstruction is relieved or the infant becomes unconscious.


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Infants Airway Obstruction – Infant Becomes Unconscious Place infant supine on a hard surface. Start CPR C-A-B sequence. After each set of compressions, look in the mouth. If you see a foreign body, remove it. Do not perform blind finger sweeps because this may result in the foreign body being pushed back into the airway. Open the airway with a head-tilt/chin-lift or modified jaw thrust and attempt to ventilate. If air does not go in, reposition the airway and attempt to ventilate again. If air still does not go in, stop giving back slaps and perform CPR. Every time you open the airway, check the mouth and remove the object if you can see it before giving 2 breaths.

Infants Relief of Choking – Infant Still Unconscious If you have successfully removed an airway obstruction in the unresponsive infant, you will feel air movement and see the chest or abdomen rise when you give breaths. After you have relieved choking in the unresponsive victim:

· Provide 2 breaths.

· Check for a pulse.

· If there is no pulse – Start CPR.

· If there is a pulse but no breathing – Provide ventilation with a one way valve mask or shield as necessary check for a pulse every 2 min. Complete an primary survey

· Pulse / Breathing – Complete a primary survey, take history, and continue monitoring the patient until EMS arrives.


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Obstetrics and Gynecological

Vaginal bleeding or pelvic pain is found and managed by performing a primary survey, assessing and initiating early oxygen (if trained and equipped), and treating for shock, even in the absence of obvious signs and symptoms. All women of child-bearing age who are presenting with abnormal vaginal bleeding and/or abdominal pain should be considered to have an ectopic pregnancy until proven otherwise. Prompt on-scene assessment and treatment for shock are essential. The preferred positioning for a pregnant patient is left lateral recumbent. Spontaneous abortion (miscarriage) is the loss of pregnancy before 20 weeks gestation. A potential abortion is indicated by vaginal bleeding and cramping. The products of conception should always be saved and transported to hospital with the patient. (Gestational age and fetal viability are difficult to estimate in the field. When in doubt, assume the fetus is potentially viable.) Vaginal bleeding in the third trimester should always be regarded as a critical emergency. Bleeding may abruptly become very massive. In order to determine external blood loss, the patient should be asked how many pads she has soaked over the last 30 - 60 min. More than three pads in 30 min or more than five pads in 60 min are indicative of a serious hemorrhage. The total number should be recorded on the PCR and the EMS crew should be informed upon their arrival. In any type of vaginal bleeding do not under any circumstances place dressings inside the vagina. Instead, apply bulky dressing externally. To avoid embarrassment to the patient, it is important to make every attempt to preserve the patient’s privacy and dignity. The number of personnel in immediate attendance should be limited to only those needed for the patient’s care. It is extremely important to maintain a professional demeanour, and to be empathetic and discreet. Provide emotional support for the patient.

Obstetrics and Gynecology – Childbirth (Algorithm 26)

The MFR will provide assistance where delivery is imminent but must use caution not to over extend their scope of practice. If you haven’t been trained and licensed to perform the following then avoid these skills:

Identify Imminent Birth · Ask target questions:

· Is this your first baby?

· How far along in your pregnancy are you?

· Are you having twins?

· How many minutes apart are your contractions?


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· Do you have an urge to push or to move your bowels?

· Has your water broken?

· Are there any complications with this pregnancy?

Perform a Visual Examination (with discretion and permission)

1. Vulvar bulging, or the appearance of the top of the neonate’s head during or between contractions indicates that birth is near (crowning). If any body part besides the head is visible, do not handle it. Prevent heat loss and notify incoming EMS crew.

2. Head Presentation (Cephalic) a) Prepare the Mother and the Site for Delivery b) Provide privacy and prepare all equipment including the obstetric kit and a

pediatric BVM. c) Remove the patient’s clothing from the waist down and place her in the

delivery position on her back with her knees flexed. d) Place a disposable yellow blanket underneath her buttocks and another

blanket over her abdomen and legs. e) Encourage the partner to remain with you and the mother during the

delivery.

3. Deliver the Head a) Encourage her to push with her contractions. b) Maintain gentle pressure on the fetal head with your palm to prevent

explosive birth. c) Once the head is delivered, instruct the patient to stop pushing (puff, puff),

check for and relieve nuchal cord (cord wrapped around neck), and suction the neonate (mouth first then nostrils – “M before N”).

4. Nuchal Cord (umbilical cord around the baby’s neck)

a) Attempt to slip the cord over the head. b) If the cord is too tight to remove, clamp the cord in two places as far apart

as possible and immediately cut the cord between the clamps. Use caution!

5. Encourage the mother to push to expel the torso. a) Deliver the Torso b) After checking the neck, instruct the patient to resume pushing with her

contractions. c) Guide the neonate’s anterior shoulder and then its posterior shoulder. The

body will quickly follow.

6. Suction and Dry a) Suction the mouth and then the nostrils (‘M’ before ‘N’). b) Briskly dry and cover the neonate.


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c) Maintenance of body warmth is a priority (silver swaddler). d) Place the baby on the mother’s bare chest. Keep the baby level with the

mom.

7. Cut the Cord The cord is made of tough fibrous material. To cut it: a) Ensure that the cord has stopped pulsing. b) Place a clamp on the cord 6 inches from the baby. c) Place a second clamp 9 inches from the baby. d) With the scalpel, cut the cord in-between the clamps. e) Use extreme caution and be prepared for blood.

Caution: If the stump is actively bleeding, hold direct pressure on it. Without appropriate action, the baby could quickly bleed to death.

Placenta The placenta will naturally deliver shortly after the baby. When it does, place it in the plastic bag provided in the OB kit, and give it to EMS. The placenta must be evaluated in the hospital.

APGAR Score Assess the APGAR score at 1, 5, and 10 minutes; and record the scores on a Patient Care Report.

0 Points 1 Point 2 Point

Appearance Body Blue/Pale Extremities Blue Body Fully Pink

Pulse Absent < 100 > 100

Grimace No Response Some Motion Vigorous Cry

Activity Flaccid Some Flexion Active Movement

Respiratory Effort Absent Weak Cry Strong Cry


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Obstetrics and Gynecology – Neonatal Resuscitation (Algorithm 27)

In the course of a normal delivery, most neonates born in a pre-hospital setting do not require major resuscitation efforts. Drying, warming, stimulation, suction, and blow-by oxygen will be all that most infants require. Major resuscitation efforts should be anticipated in the following types of deliveries:

· Premature labour – labour occurring three or more weeks before the due date around 37 weeks.

· Multiple pregnancy – the mother is carrying more than one fetus. In this case, multiple resuscitations should be anticipated.

· Meconium staining – this is the passage of a green-brown fluid from the vagina which indicates a fetal bowel movement in utero. This indicates fetal distress.

· Abnormal presentation – a presentation other than the head.

Resuscitative Measures Suction Upon delivery, the infant must be thoroughly suctioned using a bulb syringe (mouth first and then nose). Ensure that the bulb syringe is squeezed prior to entering the mouth and nose. Release the bulb and suction only on the way out of the oropharynx and nostrils. Maintain Body Warmth The neonate should be vigorously dried and then placed in a clean, dry, warm material or silver swaddler with attention to keeping the neonate’s scalp covered.

Tactile Stimulation Vigorous drying, flicking the soles of the feet, and suctioning provide tactile stimulation which causes most infants to take their first breath.

Oxygen Perform a gentle chin-lift and provide oxygen (if trained and equipped) via a pediatric mask at 10 litres/min blow-by.


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Further Measures If the neonate exhibits inadequate respirations (less than 20 /min, noisy, cyanotic, etc.) after 15 - 30 seconds of the above measures or an APGAR score less than 8, the First Medical Responder should proceed in the following manner:

· Dry and Wrap the Neonate

· The neonate should be covered as soon as it is born. If the infant has not already been dried, thoroughly dry the infant with minimal exposure to the ambient air. Once this is accomplished, the dried infant is placed naked in the silver swaddler and ensure the scalp is covered. Do not place the silver swaddler inside any other kind of wrapping because this may lead to HYPERTHERMIA.

Clamp and Cut the Cord Cutting the umbilical cord immediately after birth is only done in a resuscitative emergency. A non-breathing neonate who cannot be stimulated by 15 - 30 seconds of tactile stimulation and oxygen administration requires more aggressive resuscitative measures.

Insert Oropharyngeal Airway and Ventilate with the Infant BVM Using the infant BVM and oxygen at 15 litres/min, the neonate should be ventilated at a rate of 40 - 60 /min. This first ventilation will be difficult to instil if the neonate has not yet taken a breath. Ventilate only to the point at which the chest rises. Evaluate the Heart Rate The neonatal pulse is palpated at the brachial artery. If the neonatal heart rate is less than 100, provide BVM ventilations. If the neonatal heart rate is less than 60 beats/min, start CPR. Compressions are performed with two fingers, one finger-breadth below the inter-mammary line at 1/3 to 1/2 of chest depth at a rate of at least 100 compressions/min.


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Overdose - Opioid (Algorithm 28)

Etiology

Opioid is a term used to describe the entire family of opiates including natural, synthetic and semi-synthetic drugs that are used for pain relief. Originally the word opiate was used to describe a narcotic substance (meaning numbness or sleep) called alkaloids derived directly from the poppy flower, such as opium, codeine, morphine and heroin. Now with the introduction of synthetically made chemicals the word opioid is used to cover all forms of narcotics. When taken for pain, synthetic or partly-synthetic opioid drugs are manufactured to work the same way as natural opiates due to the similar nature of their molecular properties.

Types of opioids include: · Methadone · Percocet, Percodan, OxyContin (oxycodone) · Vicodin, Lorcet, Lortab (hydrocodone) · Demerol (pethidine) · Dilaudid (hydromorphone) · Duragesic (fentanyl)

The body naturally produces endorphins that provide relief and pleasure but usually not enough to remove the feeling of pain or to cause overdose. External opioids introduced into the body work by attaching themselves to the opioid receptor sites in the central nervous system. Once attached to the receptor site they either prevent the release of neurotransmitters (a hormone that carries a signal from one neuron to the next) or prevents the reuptake of dopamine (a naturally occurring hormone that provides pleasure) causing a bath of this hormone to wash over the receptors of the next neuron. Neurons are the basic workings of the brain and nervous system designed to transmit signals from nerve cells, muscles or other body parts up to the brain and back to the body. When an opioid has bonded to the opiate receptor site, the result is a feeling of comfort and decreased pain. The pain signals are still been generated from the site of the injury or disease but the signal isn’t able to get to the brain. Side effects include a slowing of heart rate and breathing, at higher doses respirations can slow to the point of respiratory arrest leading to cardiac arrest. With opioids there is a small window between euphoria and death.


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Current Crisis When opioids are taken under medical direction and closely monitored there is normally little chance of developing drug dependency or respiratory distress. When opioids are consumed for purposes other than pain management we see tragic results leading to overdoses or even death. Individuals who abuse opioids exhaust the normal process of acquiring a prescription and purchasing opioids at a pharmacy. This has resulted in an increase for the demand of illegally produced replacement drugs throughout Canada. These drugs have little or no quality control during the manufacturing process and may contain unknown quantities of opioids. It is mostly these drugs that are causing the current fentanyl crisis in Alberta.

Signs of Opioid Overdose Is there a suspicion of narcotic overdose? During your scene assessment look for evidence of opioid use such as drug paraphernalia, witnessed history, blue/green discoloration on face or mouth (pill coating) and patient assessment:

1. Miosis – excessive constriction of the pupil of the eyes (pin point) 2. Hypotension 3. Respiratory depression 4. Hypothermia 5. Decreased level of consciousness 6. Pulmonary edema (non-cardiogenic)

When opioids are taken with other chemicals such as alcohol or sedatives the effects of these drugs can produce a complicated presentation. Responders need to be prepared to deal with specific symptoms as they present.

Interventions 1. Maintain a patent airway and provide ventilatory support (e.g. oxygen, positive

pressure ventilations) to ensure the patient remains well-oxygenated

2. Administer naloxone if unable to maintain adequate oxygen saturation with oxygen and ventilations

Consider the SAVE ME acronym:

Stimulate – check for responsiveness Airway – ensure no restrictions, suction if necessary Ventilation – rescue breathing or initiate CPR with compressions Evaluate the situation Muscular injection or intranasal spray of naloxone Evaluate again – continue rescue breathing. Administer 2nd dose if required


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Naloxone Intervention When administered to a patient in an opioid overdose, Naloxone (Brand name - Narcan) knocks the drug out of the opioid receptors allowing for the return of neurotransmitter flow in the neuron. This allows the body’s respiratory function to return to normal. While naloxone is an effective temporary treatment of opioid overdose it is often metabolized by the body more quickly than the opioid. Naloxone may need to be re-administered frequently until the opioid has been processed by the body and is no longer a risk in interfering with patient respirations. It is important to constantly monitor the patient’s airway patency and respiratory effort throughout intervention. Sudden opioid withdrawal symptoms may include: body aches, diarrhea, increased heart rate, fever, runny nose, sneezing, goose bumps, stomach cramping, weakness, and hypertension

Children Intervention - like adult interventions the child's respirations hold the highest priority of care. It is important to constantly monitor the patient’s airway patency and respiratory effort throughout intervention. Finding positive evidence that the patient's symptoms are from an opioid exposure is important before the administration of naloxone. If not confirmed, naloxone treatment should be withheld in favour of managing their airway and respirations. Infants under 4 weeks require careful monitoring against life threatening symptoms from withdrawal due to the likelihood of prolonged exposure to opioids through the mother's usage.

Patient Safety Considerations · Patient may present with new symptoms after administration of naloxone.

Constantly re-evaluate and treat according to the appropriate MCP.

· The use of naloxone in the setting of mixed overdoses, particularly those involving narcotics and stimulants (e.g. cocaine, amphetamines, etc.) has been known to cause complications related to the pure stimulant overdose (i.e. CVA, MI, VT, and VF) when the effect of the narcotic has been

countered by the naloxone

· Patients can become agitated or violent following the administration of

naloxone


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Poisoning (Algorithm 23)

The following information is taken from the Alberta Poison and Drug Information Service (PADIS) ©2015

If the victim is breathing and conscious call the Poison Centre for additional directions:

1-800-332-1414

For poisons that are swallowed Chemicals or household products Have the container or label of the poison with you Call the Poison Centre at 1-800-332-1414 and follow their instructions DO NOT follow the treatment instructions on the container until you have checked with the Poison Centre. DO NOT give salt water or mustard. DO NOT put your finger down the throat of a poisoned person, or make them vomit. Medications DO NOT give anything by mouth Have the container or label of the medication with you Call the Poison Centre at 1-800-332-1414 Plants that are swallowed Choking is the immediate concern when a child places a plant part in his/her mouth. If the child is gagging or choking, finger-sweep his/her mouth if you can see the object and remove any remaining parts of the plant. Perform appropriate intervention if choking – refer to Obstructed Airway Protocol Gently wipe mouth and surrounding area with a wet cloth. Check for irritation, swelling, discoloration, or difficulty in swallowing. If the child has no difficulty swallowing, give half a glass of water or milk. Call the Poison Centre at 1-800-332-1414 DO NOT make the child vomit. DO NOT wait for symptoms to appear. Symptoms can be delayed.


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For poisons that are spilled on the skin Ensure appropriate safety precautions and PPE Remove all soiled clothing. Avoid getting poison on yourself. Rinse the skin under running water for 15 minutes, then wash gently with soap and water and rinse again. For poisons that are breathed in Ensure appropriate safety precautions and PPE Consider breathing protection for the responder, i.e. self-contained breathing apparatus (SCBA) or a supplied air respirator (SAR) Remember to consider the possibility of a poisonous gas if a person has collapsed in an enclosed space. Move the victim into fresh air if you can do so without putting yourself in danger. Open all doors and windows. DO NOT breathe the fumes. Call the Poison Centre at 1-800-332-1414 If the person is not breathing, start artificial respiration.

For poisons that are splashed in the eye Rinse the eye with lukewarm water for 15 minutes, by pouring lukewarm water from a large glass 2 to 3 inches above the eye, or by standing in the shower. Avoid contaminating unaffected eye. Have the person blink as often as possible while rinsing the eyes. Call the Poison Centre at 1-800-332-1414 DO NOT force the eyelids open. For poisons that are injected (puncture or injection) Apply gentle direct pressure if bleeding Clean the wound with soap and water Soak in warm water for 15 minutes Bandage Apply ice to reduce pain and swelling Call the Poison Centre at 1-800-332-1414 Watch for signs of an allergic reaction or anaphylactic shock Provide airway management if the victim has airway or breathing problems – refer to airway management.


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The priority in managing toxic exposures is to protect responders, the patient, and hospital staff from further harm by reducing the contamination as much as possible

Contamination Reduction (Decontamination) Do not approach the patient until properly trained and equipped personnel are able to perform contamination reduction:

1. Remove all clothing from the contaminated patient 2. Wash the patient with copious amounts of water; be sure to contain

contaminated runoff

Identify Toxin / Agent / Product Use history taking, scene assessment, and patient signs and symptoms to assist in identification of the toxin; look for: Dangerous goods placards WHMIS labels Medication containers Household chemicals Other clues that may aid your assessment

Special Circumstances

1. Anticholinergic OD Common signs and symptoms include: confusion with mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, temperature elevated, urinary retention

· Red as a beet

· Mad as a hatter

· Dry as a bone

· Hot as Hades

· Blind as a bat

Common sources: antihistamines, anti-parkinsonism meds, atropine, antipsychotics, scopolamine, antidepressants, antispasmodics, mydriatics, skeletal muscle relaxants and many plants.


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Organophosphate Poisoning Notes Etiology Organophosphate compounds include insecticides (e.g. malathion, parathion) and nerve agents (e.g. sarin, VX). These compounds have a very high affinity for acetylcholinesterase and irreversibly bind with the enzyme preventing it from metabolizing acetylcholine. Acetylcholine is the neurotransmitter responsible for the transmission of a nerve impulse from one nerve to another or a target organ, gland, or muscle. Normally, acetylcholinesterase almost instantly metabolizes the acetylcholine to stop the stimulation of the target receptor site. Carbamate compounds include insecticides (e.g. carbofuran, Furadan, carbaryl) and polyurethanes (e.g. bisphenol-A). These compounds act similarly to organophosphates in that they bind to acetylcholinesterase; however, an important difference is that the bond formed between carbamates and acetylcholinesterase is reversible. When the acetylcholinesterase is bound to one of the above compounds, the acetylcholine remains active and continues to stimulate the target receptor site causing adverse physiologic effects. This means the organs, glands, and muscles act continuously, eventually leading to respiratory system failure, cardiovascular effects, paralysis of skeletal muscles, and over-stimulation of the brain causing convulsions and death. Signs and symptoms of organophosphate / carbamate poisoning develop rapidly (less than 1 minute to 60 minutes) after exposure and in order of appearance and severity include:

· Constricted pupils (miosis) and dim vision

· Running nose, excessive salivation

· Feeling of tightness in the chest

· Muscular weakness

· Intestinal cramps and diarrhea – indicates a severe organophosphate exposure

· Difficulty breathing

· Convulsions A useful mnemonic to remember these signs and symptoms is SLUDGEM:

· S Salivation

· L Lacrimation

· U Urination

· D Defecation

· G GI upset

· E Emesis


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· M Miosis Other chemicals such as cholinergics and cholinesterase inhibitors (e.g. nicotine, muscarine / poisonous mushrooms, neostigmine, cevimeline) have similar effects on the nerve synapses. Treatment for these chemicals is the same as for organophosphates. Signs and symptoms of poisons that affect the nerve synapses depend on whether they are affecting the muscarinic or nicotinic receptor sites. Muscarinic receptors are predominantly in the parasympathetic nervous system while nicotinic receptors are in the sympathetic system. A mnemonic to remember the signs and symptoms of muscarinic poisoning is DUMBELS and nicotinic poisoning is MTWHF (Monday-Tuesday-Wednesday-Thursday-Friday).

Muscarinic · D Diarrhea

· U Urination

· M Miosis

· B Bradycardia, Bronchorrhea, Bronchospasm

· E Emesis

· L Lacrimation

· S Salivation, Secretion, Sweating A mnemonic to remember the signs and symptoms of nicotinic poisoning is MTWHF (Monday-Tuesday-Wednesday-Thursday-Friday).

Nicotinic

· M Mydriasis

· T Tachycardia

· W Weakness

· H Hypertension, Hyperglycemia

· F Fasciculations

Interventions Contamination Reduction (Decontamination) Request assistance from the local fire department and hazardous materials units if available. Do not approach the patient until properly trained and equipped personnel are able to perform contamination reduction:

a) Remove all clothing from the contaminated victim


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b) Wash the victim with copious amounts of water; be sure to contain contaminated runoff

Patient Safety Considerations The priority in managing organophosphate exposures is to protect responders, the patient, and hospital staff from further harm by reducing the contamination as much as possible.

Toxic Inhalation Notes Etiology

Toxic inhalations occur when a patient has inhaled smoke or fumes which damage the lungs or poison the body. Chemicals that directly damage the lungs cause a chemical pneumonia. Other chemicals such as carbon monoxide and hydrogen sulphide enter the body via the respiratory system, but affect other organs.

Carbon monoxide (CO)

A colorless, odorless gas produced by the incomplete combustion of a material containing carbon. It has a much higher affinity for hemoglobin than oxygen, resulting in hypoxemia. The smaller the patient’s body size, the greater the effect of CO.

Signs and symptoms include:

· Headache

· Nausea

· Flushed skin

· SOB

· Altered level of consciousness

· Dizziness

· Ischemic chest pain

Interventions

· High Flow Oxygen

Administer oxygen to all patients suspected of suffering a toxic inhalation regardless of their SpO2 reading; CO bonds with hemoglobin forming carboxyhemoglobin which gives a false (high) reading on SpO2 monitors

Patient Safety Considerations Fetal hemoglobin has a much greater affinity for CO than adult hemoglobin; pregnant patients may exhibit mild to moderate symptoms, yet the fetus may have devastating outcomes.


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CO Monitoring Monitor SpCO levels (if available) in patients suspected of being exposed to CO; SpCO levels of greater than 5% are considered significant. Treat the patient based on presentation, not on SpCO level. Atmospheric monitoring of CO levels (if available) can prepare you for the patient’s condition; their actual condition is based on the concentration, duration of exposure, and minute ventilation rate:

CO ppm Duration of exposure Signs & Symptoms

200 2 – 3 hours Mild headache, fatigue, nausea, dizziness

400 1 – 2 hours Serious headache, other symptoms intensify Life-threatening if exposure greater than 3 hours

800 45 minutes Dizziness, nausea, convulsions Unconscious within 2 hours, death within 2 – 3 hours

1600 20 minutes Headache, dizziness, nausea Death within 1 hour

3200 5 – 10 minutes Headache, dizziness, nausea Death within 1 hour

6400 1 – 2 minutes Headache, dizziness, nausea Death within 25 – 30 minutes

12800 1 – 3 minutes Death


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Hydrogen sulphide (H2S) A colorless gas that can smell like rotten eggs; however, at higher concentrations, it impairs the olfactory nerves and has no smell. H2S is produced as a result of the bacterial breakdown of organic matter in the absence of oxygen and also occurs in natural gas (sour gas). H2S blocks cellular respiration by preventing oxygen from binding in the mitochondria.

Signs and symptoms include: · Ocular / respiratory irritation

· SOB

· Sudden collapse

· Cardiac arrest

Interventions

· High Flow Oxygen

Other considerations for Toxic Gas Inhalation: Odour Field Guide

Odour Possible Causative Agents

Bitter almonds Cyanide

Garlic Arsenic, organophosphates, phosphorus, thallium

Acetone Methyl alcohol, isopropyl alcohol, aspirin

Wintergreen Methyl salicylate

Pears Choral Hydrate

Fruity Isopropanol, acetone, nail polish remover

Minty Mouthwash , rubbing alcohol

Mothballs Napthalene, p-dichlorobenzene

Peanuts Vacor rat poisons

Shoe polish Nitrobenze


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Seizure (Algorithm 24)

Seizures may be caused by a number of conditions including hypoglycaemia, fever, head injury, stroke, infection, pregnancy, hypoxia, and epilepsy. They can be focal, involving only a certain area of the body; or they can be tonic-clonic, involving the entire body. Most patients experiencing a seizure will lose consciousness and some will vomit. The focus of the Medical First Responder is to ensure patient safety, prevent injury, and ensure airway patency.

Management

· Do not attempt to restrain the patient.

· Move furniture and other objects away from the patient.

· Consider c-spine precautions because the patient may have fallen when the seizure began.

· Provide high-flow oxygen (if trained and equipped) as soon as possible.

· Patients may become combative as they recover from the seizure.

· Document the duration of the seizures and the areas of the body involved.

· Acquire a blood glucose level if time allows

Conscious Patients Stop the Overheating Process As Indicated All patient activity must cease and the patient must be immediately moved to a cooler environment. Excessive outer clothing should be removed to facilitate cooling. Active cooling of the body temperature is instituted in suspected heat stroke by fanning the patient, placing cool compresses in the groin and armpits, or wet-sponging the skin. Do not put ice packs directly onto the patient’s skin as it may cause injury. Do not cool the patient to the point at which shivering takes place because this produces heat. Complete the Primary survey Provide oxygen (if trained and equipped) by NRB at 10 - 15 litres/min.

Treat for Shock If Indicated If the patient has an increased heart rate, is pale, cool, has clammy skin, experiences dizziness/faintness, or is weak or exhausted; treat the patient for shock as per the SHOCK algorithm.


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Unconscious Patients · Determine the LOC (AVU).

· Assess the ABC.

· Treat for shock.

Shock (Algorithm 25)

Perform a Primary survey Assessment of the mechanism of injury is helpful in determining the potential for the development of shock in trauma. It is also essential to quickly search for immediate life-threatening injuries, such as profuse external bleeding and to perform critical interventions. Patients who are suspected of being in shock or who have the potential to develop shock should be placed in a recumbent position as soon as possible.

Oxygen Instructions (if trained and equipped) Oxygen should be administered as early as possible in shock or potential shock patients. Oxygen is a high-priority treatment since it is capable of slowing the progress of shock.

Conserving Body Warmth Maintaining body warmth requires the use of oxygen. By covering the patient with blankets and reducing metabolic demands for thermo regulation, the patient’s need for oxygen is lessened.

Elevation of Lower Extremities This should be done only if there is no risk of spinal injury or fractures of the legs. Patients who are secured on a spine board and are in shock can have the lower end of the board elevated. Use caution if cardiogenic shock is suspected.

Reassess the LOC (AVU) Assess the ABC. A baseline set of vitals is important in determining changes in the patient’s status. Vitals should be repeated frequently, preferably over 5 min intervals in order to monitor cardiovascular and neurological changes. Decrease in peripheral vascular resistance, can be caused by:

Anaphylactic Shock Histamine release causes peripheral vasodilation and a shift of fluid from intravascular spaces into interstitial space


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Neurogenic Shock Spinal cord injury results in unopposed vagal tone. Characterized by bradycardia and hypotension with warm, dry skin.

Septic Shock Pathogen releases toxins that cause peripheral vasodilation.

Obstructive Shock Physical obstruction of the heart or great vessels. May be caused by tension pneumothorax, pulmonary embolism, or cardiac tamponade.

Hypovolemic Shock Loss of vital body fluid to the point where body function is interrupted.

Cardiogenic Shock Cardiac pump failure resulting in loss of perfusing blood to body system. Avoid raising the patient’s feet/legs if cardiogenic shock is suspected due to increased demand on the heart.

Shock can be divided into three stages: a) Compensated

The body is capable of meeting its metabolic needs through a series of compensating actions

b) Decompensated

Compensatory mechanisms begin to fail

c) Irreversible The body’s cells die in quantities with the result that the organs can no longer carry out their normal functions.

Resuscitation may restore blood pressure, but multi-system organ failure leads to death

Interventions · The priority in shock management is to identify and treat the cause of the shock

· Control any external hemorrhage

· Treat shock due to anaphylaxis as per the Dyspnea Protocol

· IV Access (EMT), provide appropriate fluid bolus


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Stroke (Algorithm 26)

A stroke is a sudden loss of brain function. It is caused by the interruption of flow of blood to the brain (ischemic stroke) or the rupture of blood vessels in the brain (hemorrhagic stroke). The interruption of blood flow or the rupture of blood vessels causes brain cells (neurons) in the affected area to die. The effects of a stroke depend on where the brain was injured, as well as how much damage occurred.

Symptoms · Weakness - Sudden loss of strength or sudden numbness in the face, arm or

leg, even if temporary.

· Trouble speaking (aphasia) - Sudden difficulty speaking or understanding or sudden confusion, even if temporary.

· Vision problems - Sudden trouble with vision, even if temporary.

· Headache - Sudden severe and unusual headache.

· Dizziness - Sudden loss of balance, especially with any of the above signs.

Stroke Treatment In the last few years, important new advances have been made in stroke treatment. However, these new treatments must be started within a few hours of the onset of symptoms in order to be effective. That's why it's so important to recognize the warning signs of a stroke as soon as they appear and immediate medical assistance is activated.

Ensure an effort is made to capture the time patient was last seen well and communicate this to the EMS Crew.

Patient Care Establish a timeline for “last seen normal” Ensure adequate breathing Provide appropriate airway management with oxygen Keep a witness at scene or obtain contact information Provide comfort measures until EMS arrival Obtain blood glucose level

Oxygen Oxygen should be administered if response personnel are trained and equipped:

· If required, as early as possible.





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· To patients with chest pain if SP02 is less than 94% or patient is short of breath



· If possible, acquire oxygen saturation prior to oxygen administration

· Use a non-rebreather mask with oxygen at 12–15 litres/min for patients who require high-flow oxygen


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Trauma (Algorithm 27)

Primary Survey The purpose of the primary survey is to provide an organized and consistent means of evaluating patient status in a prioritized manner, so that life threatening conditions are quickly identified.

· Assessment for Responsiveness:

· Introduction of yourself and level of training – tell the patient not to move

· If unconscious - Tap and shout.)

· Assess for level of consciousness (LOC)

· Opens eyes to verbal stimulus

· Opens eyes to tapping on shoulder

· Remains unconscious and unresponsive

· Assess airway, breathing and circulation

· If evidence of mechanism of injury, manually maintain the head and spine in a neutral alignment and apply Spinal Motion Restriction devices.

Interruptions The primary survey should not be interrupted except when: There is complete airway obstruction or partial airway obstruction without adequate air exchange. There is cardiac or respiratory arrest. You are stopping major severe external bleeding. Anything occurring that may cause harm to the patient if not immediately dealt with.

Helmets Full-face motorcycle helmets impede your ability to access and manage the airway; they must be removed in order to assess, evaluate, and maintain the patient’s airway. All open-face helmets, such as football helmets, are best left in place with the face guard removed.

Primary Survey Repetition The Primary survey should be repeated every 5 minutes or when the patient’s condition changes, such as a change in LOC, a seizure, a change in respiratory rate and quality, vomiting, or a change in circulatory status.

Sucking or Bubbling Chest Wound Patients with a sucking or bubbling chest wound should be immediately hand sealed upon initial discovery, then quickly delegated to other team members for hand sealing and application of an occlusive dressing.


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Evidence of Shock Shock is a term used when there is a failure within the circulatory system to provide an adequate amount of oxygen rich blood to the body. Responders should assess for evidence of shock in all medical and traumatic emergencies. Shock may be evident when:

· There is an altered level of consciousness (ALOC)

· The skin appears pale, cool and/or clammy with cold extremities

· Lips and nail beds are blue

· Rapid breathing and pulse

· The pulse feels rapid and weak.

· The pulse at the wrist is weak or absent.

· Capillary refill is delayed more than 2 seconds (pediatrics).

Considerations Be aware that:

· What constitutes a minor blood loss in an adult may represent a serious blood loss in a pediatric patient.

· Pediatric patients develop skin pallor quite easily.

· Due to their healthy vascular supply and strong vascular responses, pediatric patients can initially sustain a normal blood pressure (BP) in the presence of serious fluid loss.

· Young, healthy patients may not initially exhibit signs or symptoms of shock even with a 25% - 30% fluid loss.

· Pregnant patients can lose 30% - 35% of their blood volume before exhibiting signs or symptoms of shock.

Airway Adjuncts Oropharyngeal airways (OPA’s)

· On all unconscious patients who do not have a gag reflex. (Test for a gag reflex by flicking the patient’s eyelashes with your finger. If there is any response, the patient may still have a gag reflex.)

Nasopharyngeal Airway (NPA)

· May be used on a patient with an intact gag reflex.


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Ventilation Instructions · If trained and equipped assist with bag valve mask (BVM) and oxygen at 15

litres/min if the patient’s respirations are inadequate. Ventilate at a rate of 10 - 12/min and only sufficiently to appreciate rise and fall of the chest

· Mouth to mask ventilation is also effective if not trained and equipped to use a BVM

Oxygen Oxygen should be administered to patients with SpO2 less than 94% on room air:

· If required, as early as possible, preferably no later than immediately following assessment of the airway and breathing status




· To all patients with chest pain



· Use a Non-Rebreather mask with oxygen at 12 – 15 litres/min for patients who require high-flow oxygen

· Use a nasal cannula with oxygen at 4 – 6 litres/min for patients who do not require high-flow oxygen or are unable to tolerate a face mask. (i.e. mild shortness of breath, nauseated)

· If time and condition and capabilities warrant, and oxygen saturation acquired prior to oxygen placement may facilitate future care decisions. Do not delay administering oxygen for patients in respiratory distress.

· Report the oxygen saturations to responding EMS crews.

Trauma – Patient Management Standard Approach and Ongoing Assessment

· Follow body substance isolation precautions (PPE).

· Are there any hazards?

· Do you see, hear, or smell anything dangerous?

· What is the mechanism of injury?

· Are there any other patients? (Ask the patient and bystanders, and look around the area.)

· Do you need more resources?

C-Spine Control


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· On approach, tell the patient, “Please do not move until we have checked you for injuries.”

· If no response then assume c-spine control.

· Delegate manual c-spine control to another crew member while assessing the patient.

· Place a cervical device on patient’s neck as indicated once assessment of the neck and cervical spine complete. For medical patients, rule out c-spine if appropriate.

Level of Consciousness AVPU (Appear, verbal, painful, unresponsive)

· Does the patient appear to be awake and alert?

· Does the patient respond to verbal stimulus?

· Does the patient respond to painful stimulus?

· Is the patient unresponsive?

Alert and Oriented x 4 If the patient is responsive to verbal stimuli, ask the patient his/her name, where he/she is, what day or year it is, and what happened:

· Person

· Place

· Time

· Event

Airway

· Is the airway open and clear?

· Open airway with Head-Tilt, Chin-Lift technique

· Once open, airway must be continually maintained

· Use Jaw-Thrust Manoeuvre if Head-Tilt, Chin-Lift technique unsuccessful or evidence of traumatic injuries or unknown cause of unconsciousness

· Breathing Rate

· Present or absent?

· If breathing is absent and pulse is present assist ventilations using a BVM and airway adjunct (OPA or NPA).

· Continue assisting ventilations until return of breathing, relieved by EMS or physically unable to.


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Assisted Breathing Instructions · Rescue Ventilations using a BVM and airway adjunct (OPA or NPA).

· Inspect that the valve is in place

· Place mask on patient’s face with the nose covered by the tip end

· Hold mask firmly to patient’s face to ensure a complete seal around lips and nose

· Use Head-Tilt, Chin-Lift technique or modified jaw thrust if C Spine injury suspected or cannot be ruled out.

· If using an advanced Airway connect the filter and the BVM directly to the advanced airway.

Return of Respirations If return of respirations, provide the following support:

· Place the patient in a recovery position to prevent aspiration of fluids into the lungs if not contraindicated due to spinal injury

· Use a non-rebreather mask with oxygen at 10-15 litres/min for patients who require high-flow oxygen.

Circulation

· Are pulses present at the neck and wrist?

· What are the rate, rhythm, and quality of the pulse at the neck and at the wrist?

· Is there evidence of circulation?

· What are the colour, condition, and temperature of the skin?

· Perform a quick blood scan. Look and feel for significant bleeding and control as necessary.

· If no evidence of circulation, begin Cardiopulmonary Resuscitation (CPR) and continue CPR until return of circulation, relieved by EMS or physically unable to continue.


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Physical Examination It is important to perform an examination from head to toe to determine if the patient has any hidden injuries. Head Look for DCAP-BLS and feel for TIC. Look for battle signs and racoon eyes. Look for CSF in the ears. Look to see if the pupils are PEARL. What is the pupil size, and are the pupils equal and reactive to light? Neck Look for DCAP-BLS and gently palpate for TIC. Look at the neck veins. Note if they are flat or distended. Look at and feel the trachea. Note if it is mid-line or deviated. Look for a Medic Alert tag. Check accessory muscle use. Chest Look for DCAP-BLS and feel for TIC. Auscultate the lungs at the apices and bases. Note if breathing sounds are present and equal. Look for flail chest, sucking chest wounds, and feel for subcutaneous emphysema. Look for equal bilateral expansion. Is there any paradoxical movement? Abdomen Look for DCAP-BLS. Feel for DRT in all four quadrants of the abdomen. Pelvis Look for DCAP-BLS and feel for TIC. Look for priapism and incontinence. Lower Extremities Look for DCAP-BLS. Feel for TIC and PMS. Check for skin colour and temperature. Upper Extremities Look for DCAP-BLS. Feel for TIC and PMS. Check for skin colour and temperature. Back Look for DCAP-BLS. Feel for TIC Observe any blood pooling.


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History Taking Guidelines Obtaining a history may be time dependant but responders should attempt to gather the pertinent information required in caring for the trauma patient. The acronym SAMPLE is helpful to remind yourself:

· Symptoms

· Allergies

· Medications

· Past Medical History

· Last oral intake

· Events leading up to current problem

Follow Up Care Patients should be reassessed every 5 minutes or whenever there is a change in the patient’s condition. Reassess LOC, airway, breathing, and circulation (ABC) and all interventions by performing a primary survey.


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APPENDIX A – Adult Drug Reference

Acetylsalicylic Acid

Generic Name: Acetylsalicylic Acid

Trade Name: Novasen (Canada), Aspirin, ASA, Bufferin

Classification: salicylate, antiplatelet, antipyretic, anti-inflammatory, non-opioid analgesic

Supplied: 80 or 81 mg, 325 mg, 500 mg, 650 mg tabs Actions (Pharmacodynamics): • Anticoagulant: at low doses, appears to impede clotting by blocking prostaglandin synthesis, which prevents formation of platelet-aggregating substance thromboxane A2

(this is irreversible and can prolong bleeding time) • Analgesia/anti-inflammatory: inhibits the synthesis of prostaglandin, preventing or reducing pain • Antipyretic: acts on the hypothalamus to produce peripheral vasodilation causing sweating which leads to heat loss and cooling by evaporation

Indications: Acute coronary syndromes suggestive of an acute myocardial infarction

Dosage: Adult: 160-325 mg chewed as soon as possible *Note: Give even if patient has taken ASA (doses higher than 1000 mg may limit beneficial effect)

Contraindications: • Hypersensitivity: SEVERE allergy (known) • Bleeding disorders (hemophilia, von Willebrand’s disease) • Unconsciousness • Active GI bleed • Asthmatic with past hx of sensitivity

Precautions: • Active ulcer disease, asthma • Impaired renal and hepatic function • May produce bronchoconstriction in asthmatics • Children and adolescents with influenza or chickenpox infections (May increase the risk of Reye’s syndrome) • Reye’s syndrome is a rare but serious illness in childhood that has a mortality rate of 20-30%. Symptoms are encephalopathy and fatty liver degeneration

Note: The effects of a single dose of aspirin persist for the life of the platelet (about 8 days)


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Atrovent

Generic Name: Ipratropium Bromide Trade Name: Atrovent

Classification: anti-cholinergic, bronchodilator

Supplied: 250 mcg, 500 mcg in 2.5 ml nebule, MDI 20 mcg/spray, Combivent (Ventolin 2.5 mg/Atrovent 500 mcg)

Actions (Pharmacodynamics): Inhibits cholinergic receptors in the bronchial smooth muscle, resulting in decreased concentrations of cyclic guanosine monophosphate (cyclic GMP). Decreased levels of cyclic GMP produce local, not systemic, bronchodilation

Indications: bronchospasm in asthma, chronic bronchitis and emphysema

Dosage: Adult: 250 –500 mcg via nebulizer with Salbutamol (mixed) repeat up to two times if necessary *Note: Normally only 1-2 doses in other conditions (e.g. emphysema, chronic bronchitis) Combivent: 2.5 – 5.0 ml nebule – repeat q 10 minutes prn (not to exceed max dose for Atrovent ) MDI: minimum 1- 4 puffs prn; max 10 (give after salbutamol; ipratropium has a much slower onset of action) MDI: minimum 2 puff prn; max 4 (give after salbutamol; ipratropium has a much slower onset of action) *Note: safety and efficacy in children under 12 years of age haven’t been established.

Route: Nebulizer or metered dose inhaler

Contraindications: • Hypersensitivity to drug or atropine or its derivatives

Precautions: • Hypersensitivity to soy lecithin or related food products (soybeans, peanuts) • Patients with narrow angle glaucoma • Be careful to avoid accidental release into the eyes (use mouth piece neb if possible)


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Dextrose (D50

W)

Generic Name: Dextrose (D50

W)

Trade Name:

Classification: carbohydrate, antihypoglycemic

Supplied: preload 25g/50 ml (D50

W)

Actions (Pharmacodynamics): • Rapidly metabolized calories given parenterally, which promotes glycogen stores and prevents ketosis in patients with inadequate oral intake

Indications: • Hypoglycemia • Coma of unknown origin (if unable to obtain blood glucose reading) Contraindications: • Hyperglycemia

Dosage: Adult: 0.5 – 1.0 g/kg of D

50W slow IVP

Second dose may be given if first dose ineffective *Note: Suspected head injury 12.5 g D

50W slow IVP

*Note: Re-check chemstrip in opposite limb and assess patient Pediatric: 0.5-1.0 g/kg of D

25W (2-4 mls/kg) slow IVP

Route: Intravenous

Precautions: • Dextrose greater (>) than 5% is considered a hypertonic solution. It can be very irritating to the vein and could cause cerebral bleeding if not given slowly • Patients with increased intracranial pressure (give a half dose and reassess – Never withhold, if the patient’s metabolic needs are deficient) • Ensure patency of IV – can cause tissue sloughing if interstitial • IV cathalon should be 18g minimum as solution is very viscous *Note: Dextrose: 50% = 0.50 g/ml 25% = 0.25 g/ml


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Epinephrine

Generic Name: Epinephrine Trade Name: Adrenalin

Classification: adrenergic agonist (sympathomimetic)

Supplied: Epi Pen™ 0.3 mg, Epi Pen™

Jr 0.15 mg 1: 1000

Actions (Pharmacodynamics): • Directly stimulates the alpha and beta-adrenergic receptors in the sympathetic nervous system • Bronchodilation: relaxes bronchial smooth muscle (beta

2 receptors) and inhibits

histamine release • CV and vasopressor: produces positive chronotropic and inotropic effects (beta

1

receptors); increasing cardiac output, myocardial oxygen consumption and force of contraction. Vasodilation (beta

2 receptors) and vasoconstriction (alpha receptors)

Indications: Anaphylaxis

Dosage: Adult: 0.3mg (1:1000) IM Repeat q 5-10 minutes prn Pediatric: 0.01 mg/kg IM/SQ (do not exceed 0.3 mg)

*Note: Epinephrine dose is based on body weight. The EpiPen™

auto-injector (0.3mg) is

for patients weighing more than 66 lbs/30 kg while the EpiPen™

Jr (0.15 mg) is for patients weighing between 33 lbs/15 kg and 66 lbs/30 kg.

Route: intramuscular (IM lateral thigh preferred)

Contraindications: • None in the emergent setting

Precautions: • Do not mix with alkaline solutions Ischemic heart disease

Note: Massaging the site after an IM injection may hasten absorption


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Glucose (oral)

Generic Name: Glucose (oral) Trade Name: Insta-glucose, Monogel, Glutose

Classification: glucose

Supplied: 25 g/tube

Actions (Pharmacodynamics): • A monosaccharide that is given orally and is readily absorbed in the intestine

Indications: • Hypoglycemia in patients who are alert, are able to follow commands & can swallow

Dosage: Adult: 25 g orally (may repeat in 10 minutes if necessary) (Administer the entire contents of tube (25 g) slowly and intermittently while patient swallows)

Route: Oral

Contraindications: • Any patient who is not alert • Any patient unable to follow commands • Any patient who lacks a gag reflex • Hyperglycemia

Precautions: • May cause nausea or the patient may gag when administered

Note: • Oral glucose is not absorbed sublingually or buccally


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Glucagon

Generic Name: Glucagon Trade Name:

Classification: hormone, antihypoglycemic

Supplied: 1 mg (unit) vial, 10 mg (units) vial; *Note: must be reconstituted

Actions (Pharmacodynamics): • Stimulates hepatic production of glucose from glycogen stores (glycogenolysis) • Relaxes the musculature of the GI tract • Has positive inotropic and chronotropic effects

Indications: • Hypoglycemia (when IV access cannot be established)

Dosage: Adult: Hypoglycemia: 1 mg IM, q 15-20 minutes (prn) Pediatric: Hypoglycemia: (<5 years) 0.5 mg IM (>5 years) 1.0 mg IM

Route: subcutaneous or intramuscular (IM preferred)

Contraindications: • Hypersensitivity (beef or pork proteins as glucagon derived from beef or pork pancreas) • Pheochromocytoma • Hyperglycemia

Precautions: • After patient regains LOC – supplemental carbohydrates should be provided as soon as possible • Lowers serum potassium levels • Can cause tachycardia, nausea, vomiting or hypertension

Notes: Will not be effective if there are not sufficient stores of glycogen in the liver


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Medical Oxygen

Generic Name: Medical Oxygen Trade Name:

Classification: medicinal gas

Supplied: compressed gas cylinder

Actions (Pharmacodynamics): • Colorless, odorless, tasteless gas essential to respiration • At sea level, oxygen makes up approximately 10% - 16% of venous blood and 17% - 21% of arterial blood • Transported from the lungs to the body’s tissues attached to hemoglobin in the red blood cells • Inhalation/administration will increase arterial oxygen tension (PaO

2) and hemoglobin

saturation

Indications: • Hypoxia from any cause • Chest pain due to cardiac ischemia to an SpO2 saturation of < 94% • Altered level of consciousness

Dosage: Nasal Cannula: @ 2-6 L/min (Provides 24% - 40% O2 concentration)

Simple & Pocket Mask: @ 6 – 10 L/min (Provides 40% - 60% O2 concentration)

Partial/ Non-Rebreather (NRB): @ 10 – 15 L/min (Provides up to 98% O2 concentration)

Bag-Valve Mask (BVM): @ 10 – 15 L/min (Provides up to 100% O2 concentration)

Route: Inhalation

Contraindications: • None for emergency use.

Precautions: • Respiratory: In some cases of COPD, oxygen administration may reduce the patient’s respiratory drive Note: This is not a reason to withhold oxygen, but be prepared to assist ventilations. • Oxygen that is not humidified may dry out or irritate mucous membranes


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naloxone

Generic Name: naloxone Trade Name: narcan

Classification: opioid antagonist

Supplied: Varies

Class

Narcotic antagonist

EMS Indications

Reversal of respiratory depression due to opiate overdose

Adult Dosage

Repeat

4.0 mg Nasal Spray Or 0.4 mg IM

Or 0.4 mg IV/IO

Nasal Spray prn 2 to 3 minutes (alternate nostril between each dose) Or IM q 5 minutes prn to a total maximum of 1.6 mg

Or IV/IO q 2 minutes prn to a total maximum of 1.6 mg

EMS Contraindications · Hypersensitivity

Notes

· The efficacy of IM naloxone is such that it is the preferred route of administration

· Caution in opiate dependent patients; may become very agitated or violent

· Duration of action may be shorter than that of the opiate; watch for return signs of respiratory depression

· Administer only to reverse respiratory depression, not as a “diagnostic tool”


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Nitroglycerin

Generic Name: Nitroglycerin Trade Name: Nitrostat, Nitro-Bid, Tridil

Classification: nitrate, anti-anginal, vasodilator

Supplied: 0.3 mg tabs SL, 0.4 mg/spray SL

Actions (Pharmacodynamics): • Antianginal: relaxes vascular smooth muscle of both venous and arterial beds, resulting in a net decrease in the myocardial oxygen consumption. It also dilates coronary vessels, leading to redistribution of blood flow to ischemic tissue and improves collateral circulation • Vasodilating: dilates peripheral vessels, decreasing venous return to the heart (preload) useful in treating pulmonary edema and heart failure. Arterial vasodilation decreases afterload, thereby decreasing left ventricular work and aiding the failing heart

Indications: • Acute coronary syndromes (pain & ischemia with AMI without hypotension) • Suspected ischemic cardiac pain

Dosage: Adult: SL 0.3 mg tab or 0.4 mg spray q 5 minute intervals (prn) *Note: as long as BP remains > 100 mmHg

Route: sublingual spray or tablet

Contraindications: • Hypersensitivity to nitrates • Unable to initiate IV • Increased intracranial pressure • Hypotension • Uncorrected hypovolemia • Suspected cardiac tamponade or pericarditis • Sildenafil (Viagra, Cialis) or similar generic drug use within 72 hours • Avoid use in extreme bradycardia (<50 bpm) or severe tachycardia (> 180 bpm) • Important! Right ventricular infarction: use with Extreme Caution- if at all!

Note: • *EMT Nitro Administration EMTs will withhold all forms of nitro if not equipped to obtain a 12-lead ECG or the computer generated 12-lead interpretation has any message in capital letters indicating a STEMI (e.g. STEMI, ACUTE MI, SUSPECTED, ST ELEVATION CRITERIA MET) Although not common to prehospital care, nitroglycerine can also be found in the form of a paste and a patch • In the event a patient presents with a Nitro patch already in place, remove the patch and administer Nitroglycerine spray or tabs as per local protocol • Also remove any nitro patches before application or use of an AED


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Nitrous Oxide

Generic Name: Nitrous Oxide Trade Name: Entonox

Classification: gaseous analgesic/anesthetic

Supplied: compressed gas cylinder (50% nitrous oxide with 50% oxygen)

Actions (Pharmacodynamics): • Potent analgesic, weak anesthetic at these percentages • CNS depressant with analgesic properties

Indications: • Pain of musculoskeletal origin, particularly fractures • Burns • Pregnancy (only in active labour)

Dosage: Adult: Self administered until relief or patient drops mask Pediatric: Self administered until relief or patient drops mask

Route: Inhalation by demand valve and mask

Contraindications: • Unable to follow commands – due to interpretive problem, drugs, alcohol • Altered LOC • Significant COPD • Any traumatic chest injury • Any suspicion of pneumothorax, obstructed bowel (abdominal pain with distension) • Decompression sickness (diving in last 48 hours) • Pregnancy – except in active labor

Notes: • Use in well ventilated area • Ensure to invert tank three times prior to use • Do not use outside if ambient temperature is below minus six degrees Celsius (-6°C). • Do not use if frost on the tank • Prolonged use can cause hypoxemia- provide supplemental Oxygen


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Ventolin

Generic Name: Salbutamol (Canada), albuterol sulfate Trade Name: Ventolin

Classification: bronchodilator, beta2-selective adrenergic agonist

(sympathomimetic)

Supplied: 2.5 ml nebule (1 mg/ml), MDI 100 mcg/spray, Combivent (Ventolin 2.5 mg/Atrovent 500 mcg)

Actions (Pharmacodynamics): • Selectively stimulates beta-adrenergic receptors of the lungs, uterus, and vascular smooth muscle • Brochodilation results from relaxation of the vascular smooth muscles, which relieves bronchospasm and reduces airway resistance • Higher doses will drive serum potassium (K+) into the cells.

Indications: • Bronchospasm due to bronchial asthma, chronic bronchitis and other chronic bronchopulmonary disorders • Respiratory distress with bronchospasm

Dosage: Adult: 2.5 – 5.0 mg nebule – repeat q 10 minutes prn

MDI minimum 6 puffs max 20 Pediatric(ages 1 – 4): 0.15 mg/kg diluted to 2.5 ml saline via nebulizer

or < 10 kg give 1.25 mg with NS to 2.5 ml 10-20 kg give 2.5 mg > 20 kg give 2.5 – 5.0 mg MDI (pediatrics) minimum 2 puff max 10

Pediatric(ages 5-11): 25-250 mcg via nebulizer with salbutamol (mixed) repeat up to times two if necessary

Route: Nebulizer or metered dose inhaler

Contraindications: • Hypersensitivity

Precautions: • Should not be used with patients presenting with acute heart failure • Cardiovascular disease – cardiac dysrhythmias, hypertension • Diabetes mellitus – risk of drug induced hyperglycemia • Hypokalemia – risk further reducing serum potassium levels and possible adverse cardiovascular events


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