Advanced Care Paramedic

Transcription

1 Advanced Care Paramedic Pocket Reference Guide 2017 v and 4.1 Page 0 of 65

2 This pocket reference guide has been formatted to align with the ALS PCS version with an in force date of July 17 th, This guide also contains the revised materials applicable to the ALS PCS version 4.1 with an in force date of December 11 th, As always, this guide is intended to support the ALS PCS and is for reference only. Refer to the current medical directives for all treatment decisions. If there are inconsistencies between this reference guide and the current directives always refer to the medical directives. For questions, comments, or suggestions for improvements, please contact us at: Website (follow contact us link): Administration Office 95a Simcoe Street South Oshawa, ON Mailing Address Central East Prehospital Care Program Lakeridge Health 1 Hospital Court Oshawa, ON L1G 2B9 Phone: Fax: Toll Free: Page 1 of 65

3 Patching... 4 Neonatal Resuscitation... 5 Medical Cardiac Arrest Pediatric... 7 Medical Cardiac Arrest Adult... 9 Foreign Body Airway Obstruction Cardiac Arrest Hypothermia Cardiac Arrest Trauma Cardiac Arrest Tension Pneumothorax Return of Spontaneous Circulation (ROSC) Endotracheal Intubation (Oral and Nasal) Endotracheal and Tracheostomy Suctioning Supraglottic Airway Bronchoconstriction Continuous Positive Airway Pressure (CPAP) Croup Opioid Toxicity IV and Fluid Therapy Pediatric / Adult Intraosseous Central Venous Access Device (CVAD) Cardiac Ischemia Acute Cardiogenic Pulmonary Edema Cardiogenic Shock Tachydysrhythmia Symptomatic Bradycardia Procedural Sedation Hypoglycemia Hyperkalemia Moderate to Severe Allergic Reaction Nausea / Vomiting Pediatric Analgesia Page 2 of 65

4 Adult Analgesia Seizure Combative Patient Emergency Childbirth Suspected Adrenal Crisis Home Dialysis Emergency Disconnect Electronic Control Device (ECD) Probe Removal Hydrofluoric (HF) Acid Exposure Cyanide Exposure Headache (Special Events Only) Minor Abrasion (Special Events Only) Minor Allergic Reaction (Special Events Only) Musculoskeletal Pain (Special Events Only) Advanced Care Paramedic Scope of Practice NOTES: Page 3 of 65

5 Patching Advanced Care Paramedics are required to PATCH to the Base Hospital Physician for the following: Core Directives Medical Cardiac Arrest Directive PATCH after 3 rounds of Epinephrine or if unable to get a medication route after 3 interpretations Trauma Cardiac Arrest Directive PATCH for authorization to apply the TOR if applicable Symptomatic Bradycardia Directive PATCH for authorization to proceed with transcutaneous pacing and/or a dopamine infusion Tachydysrhythmia Directive PATCH for authorization to proceed with lidocaine or monomorphic wide complex regular rhythm for adenosine Tachydysrhythmia Directive PATCH for authorization to proceed with synchronized cardioversion Intravenous and Fluid Therapy Directive: PATCH for authorization to administer IV NaCl bolus to a hypotensive patient less than 12 years of age with suspected Diabetic Ketoacidosis (DKA) Tension Pneumothorax Directive PATCH for authorization to perform needle thoracotomy Combative Patient Directive PATCH for authorization to proceed with Midazolam if unable to assess the patient for normotension or reversible causes Auxiliary Directives N/A there are no auxiliary directives requiring a patch to the BHP currently. NOTE: A patch to the Base Hospital Physician may be made at any time to discuss patient care that does not fall within an existing medical directive but is within your scope of practice. Patch failure: is defined as the inability to make contact with a BHP after reasonable attempts. This is to be documented on the ACR in the procedures section using the relevant codes. If the failure resulted in a patient care issue, the Paramedic must contact CEPCP as soon as possible as well as document (with explanation) the failure on their ACR. Patching Page 4 of 65

6 Neonatal Resuscitation Newborn less than 30 Days Neonatal Resuscitation Page 5 of 65

7 Weight kg Less than More than 3 Gestational age wks Less than More than 38 IV/IO Epinephrine 1:10, mg 0.1 ml mg ml mg > 0.03 mg ml > 0.3 ml ETT Epinephrine 1:1, mg 1 ml mg 1 2 ml mg > 0.3 mg 2 3 ml > 3 ml Tube size 2.5 mm 3.0 mm 3.5 mm mm Neonatal Resuscitation Page 6 of 65

8 Medical Cardiac Arrest Pediatric Non-traumatic cardiac arrest NOTE a heart rate of 60 or less in a child is an ominous finding and CPR is indicated if signs of poor perfusion are present. Pediatric 30 days to < 8 years only (if 8 to 12 years old use adult joule settings, but use medication dosages below) Interpret (and print) the rhythm every 2 min (pediatric pads check specific weights) 2 joules / kg (1 st shock) 4 joules / kg (subsequent shocks) Pediatric 30 days to < 12 years only Epinephrine 1:10,000 IV (preferred) / IO / CVAD Epinephrine 1:1,000 ETT (if above delayed > 5 mins) 0.01 mg/kg minimum 0.1 mg 0.1 mg/kg minimum 1 mg to maximum 2 mg 0.01 mg/kg maximum 0.5 mg 4 min 4 min Same as initial Same as initial Epinephrine 1:1,000 IM (for suspected anaphylaxis) N/A N/A 1 dose Lidocaine IV / IO / CVAD 1 mg/kg 4 min 1 mg/kg 2 doses for recurrent VF / pvt Lidocaine ETT for recurrent VF / pvt 2 mg/kg 4 min 2 mg/kg 2 doses Bolus Re-assess For PEA or any other 2, ml/kg every 100 N/A rhythm where hypovolemia ml ml is suspected BHP PATCH following the 3 rd dose of Epinephrine or after the 3 rd rhythm interpretation if no IV / IO / CVAD / ETT access ETT should be inserted when more than OPA/BVM is required, without interrupting CPR. Approximations: Tube size = 4 + (age / 4) Depth = 3 x ETT diameter. Once inserted, begin continuous compressions and ventilate asynchronously at 1 breath every 6 8 seconds and monitor ETCO 2 : mmhg poor prognosis, check quality of CPR and improve where possible mmhg improved prognosis, indicates good CPR quality > 35 mmhg excellent CPR / prognosis, consider pulse check at next interpretation Large spike to above normal values probable ROSC, consider pulse check at next interpretation N/A N/A Medical Cardiac Arrest Pediatric Page 7 of 65

9 Weight Age Epi 1:10,000 IV/IO/CVAD 0.01 mg/kg Epi 1:1,000 ETT 0.1 mg/kg Lidocaine IV/IO/CVAD 1 mg/kg ETT approx. size 4 kg / 9 lbs 30 days 0.10 mg = 1.0 ml 1.0 mg = 1.0 ml 4 mg = 0.2 ml 2.5 mm 6 kg / 13 lbs 30 days 0.10 mg = 1.0 ml 1.0 mg = 1.0 ml 6 mg = 0.3 ml 2.5 mm 8 kg / 18 lbs 30 days 0.10 mg = 1.0 ml 1.0 mg = 1.0 ml 8 mg = 0.4 ml mm 10 kg / 22 lbs < 1 year 0.10 mg = 1.0 ml 1.0 mg = 1.0 ml 10 mg = 0.5 ml 4.0 mm 12 kg / 26 lbs 1 year 0.12 mg = 1.2 ml 1.2 mg = 1.2 ml 12 mg = 0.6 ml 4.5 mm 14 kg / 31 lbs 2 years 0.14 mg = 1.4 ml 1.4 mg = 1.4 ml 14 mg = 0.7 ml 5.0 mm 16 kg / 35 lbs 3 years 0.16 mg = 1.6 ml 1.6 mg = 1.6 ml 16 mg = 0.8 ml 5.0 mm 18 kg / 40 lbs 4 years 0.18 mg = 1.8 ml 1.8 mg = 1.8 ml 18 mg = 0.9 ml mm 20 kg / 44 lbs 5 years 0.20 mg = 2.0 ml 2.0 mg = 2.0 ml 20 mg = 1.0 ml 5.5 mm 22 kg / 48 lbs 6 years 0.22 mg = 2.2 ml 2.0 mg = 2.0 ml 22 mg = 1.1 ml 5.5 mm 24 kg / 53 lbs 7 years 0.24 mg = 2.4 ml 2.0 mg = 2.0 ml 24 mg = 1.2 ml mm 26 kg / 57 lbs 8 years 0.26 mg = 2.6 ml 2.0 mg = 2.0 ml 26 mg = 1.3 ml 6.0 mm 28 kg / 62 lbs 9 years 0.28 mg = 2.8 ml 2.0 mg = 2.0 ml 28 mg = 1.4 ml mm 30 kg / 66 lbs 10 years 0.30 mg = 3.0 ml 2.0 mg = 2.0 ml 30 mg = 1.5 ml 6.5 mm 35 kg / 77 lbs 11 years 0.35 mg = 3.5 ml 2.0 mg = 2.0 ml 35 mg = 1.75 ml mm 40 kg / 88 lbs 12 years 0.40 mg = 4.0 ml 2.0 mg = 2.0 ml 40 mg = 2 ml 7.0 mm Medical Cardiac Arrest Pediatric Page 8 of 65

10 Medical Cardiac Arrest Adult Non-traumatic cardiac arrest Adult 8 years only (if 8 to12 years old use MEDICATION dosages from pediatric arrest page) Interpret (and print) the rhythm every 2 min For Zoll and LP12 / LP15 use adult settings Adult Doses Epinephrine 1:10,000 IV (preferred) / IO / CVAD Epinephrine 1:10,000 - ETT (if above delayed > 5mins) Epinephrine 1:1,000 - IM (for suspected anaphylaxis) Lidocaine IV / IO / CVAD for recurrent VF / pvt Lidocaine ETT for recurrent VF / pvt Bolus For PEA or any other rhythm where hypovolemia is suspected 1.0 mg 4 min 1.0 mg N/A 2.0 mg 4 min 2.0 mg N/A 0.01 mg/kg max 0.5 mg N/A N/A 1 dose 1.5 mg/kg 4 min 1.5 mg/kg 2 doses 3.0 mg/kg 4 min 3.0 mg/kg 2 doses 20 ml/kg Re-assess every 250 ml N/A 2,000 ml BHP PATCH following the 3 rd dose of Epinephrine or after the 3 rd rhythm interpretation if no IV / IO / CVAD / ETT access. ETT or King LT should be inserted where more than OPA/BVM is required, without interrupting CPR. Once inserted, begin continuous compressions and ventilate asynchronously at 1 breath every 6 8 seconds and monitor ETCO 2 : mmhg poor prognosis, check quality of CPR and improve where possible mmhg improved prognosis, indicates good CPR quality > 35 mmhg excellent CPR / prognosis, consider pulse check at next interpretation Large spike to above normal values probable ROSC, consider pulse check at next interpretation Medical Cardiac Arrest Adult Page 9 of 65

11 Lidocaine (IV / IO / CVAD) Volume per weight based on a 20 mg /ml concentration. Double the amounts for ETT administration 40 kg = 3.0 ml (60 mg) 105 kg = 7.9 ml (158 mg) 45 kg = 3.3 ml (66 mg) 110 kg = 8.3 ml (166 mg) 50 kg = 3.8 ml (75 mg) 115 kg = 8.6 ml (172 mg) 55 kg = 4.1 ml (82 mg) 120 kg = 9 ml (180 mg) 60 kg = 4.5 ml (90 mg) 125 kg = 9.4 ml (188 mg) 65 kg = 4.9 ml (98 mg) 130 kg = 9.8 ml (196 mg) 70 kg = 5.3 ml (106 mg) 135 kg = 10.1 ml (202 mg) 75 kg = 5.6 ml (112 mg) 140 kg = 10.5 ml (210 mg) 80 kg = 6 ml (120 mg) 145 kg = 10.9 ml (218 mg) 85 kg = 6.4ml (128 mg) 150 kg = 11.3 ml (226 mg) 90 kg = 6.8 ml (136 mg) 155 kg = 11.6 ml 232 mg) 95 kg = 7.1 ml (142 mg) 160 kg = 12 ml (240 mg) 100 kg = 7.5 ml (150 mg) 165 kg = 12.4 ml (248 mg) King LT Reference Size Colour Patient Amount of Air in Cuff #3 Yellow 4 5 ft tall ml 6 #4 Red 5 6 ft tall ml #5 Purple 6 ft tall ml Confirmation Methods Primary Secondary ETCO 2 (non-waveform capnography) Confirm advanced ETCO 2 (waveform Visualization airway placement capnography) Auscultation Chest rise Esophageal Detection Device Medical Cardiac Arrest Adult Page 10 of 65

12 Foreign Body Airway Obstruction Cardiac Arrest Cardiac arrest secondary to an airway obstruction Not obviously dead as per BLS standard No DNR Interventions Attempt to clear airway with BLS maneuvers and/or laryngoscope / Magill forceps Defibrillate once if the patient is in VF/pVT 30 days to < 8 years old - 2 joules / kg 8 years old adult setting If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first rhythm interpretation If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest Foreign Body Airway Obstruction Cardiac Arrest Page 11 of 65

13 Hypothermia Cardiac Arrest Cardiac arrest secondary to severe hypothermia Not obviously dead as per BLS standard No DNR Interventions Defibrillate once if the patient is in VF/pVT 30 days to < 8 years old - 2 joules / kg 8 years old adult setting Transport to the closest appropriate facility without delay following the first rhythm interpretation Hypothermia Cardiac Arrest Page 12 of 65

14 Trauma Cardiac Arrest Cardiac arrest secondary to severe blunt or penetrating trauma Confirm Trauma Cardiac Arrest Protect C-spine Begin chest compressions Attach pads 30 days of age Begin PPV with BVM Rhythm Determination VF / pvt PEA Asystole Defibrillate once 30 days to < 8 years 2 joules/kg 8 years adult settings Yes Drive-time is < 30 min to nearest hospital? Yes No Patient age < 16 years Continue CPR Transport to hospital PATCH fails, or order not given No PATCH to BHP for Trauma TOR Trauma Cardiac Arrest Page 13 of 65

15 Tension Pneumothorax Suspected tension pneumothorax AND Critically ill or VSA AND Absent or severely diminished breath sounds on the affected side(s) Vital Sign Parameters N/A SBP < 90 OR VSA Interventions PATCH for Needle Thoracostomy Needle thoracostomy may only be performed at the second intercostal space in the midclavicular line Chest wall thickness may reach upwards of 2.5 or 6 cm and women typically have thicker chest walls than males Landmarking: Using three finger widths (average adult fingers) from the centre of the sternum provides an accurate, easy to remember, vertical landmark The rib adjacent to the Angle of Louis is the second rib. The space below the second rib is the second intercostal space. This is the horizontal landmark Tension Pneumothorax Page 14 of 65

16 Return of Spontaneous Circulation (ROSC) ROSC after resuscitation was initiated Adult SBP < 90 mmhg Pediatric SBP < 70 mmhg + (2 x age in years) Bolus: Clear chest / no fluid overload Dopamine: No allergy/sensitivity No pheochromocytoma No tachydysrhythmias (excluding sinus tachycardia) No mechanical shock states (i.e.: tension pneumothorax, pulmonary embolism, pericardial tamponade) No hypovolemia Adult Doses ( 12 years) Bolus IV / IO / CVAD Dopamine IV only 10 ml/kg 5 mcg/kg/min Reassess every 250 ml 5 min N/A 5 mcg/kg/min 1,000 ml 20 mcg/kg/min Pediatric Doses (< 12 years) Bolus IV / IO / CVAD Dopamine IV only and age 8 yrs 10 ml/kg 5 mcg/kg/min Reassess every 100 ml 5 min N/A 5 mcg/kg/min 1,000 ml 20 mcg/kg/min Titrate oxygenation to 94-98% Avoid hyperventilation and target an ETCO 2 of mmhg with continuous waveform capnography Consider 12 lead ECG Return of Spontaneous Circulation (ROSC) Page 15 of 65

17 Endotracheal Intubation (Oral and Nasal) Need for ventilatory assistance OR A/W control AND Other A/W management is ineffective No allergy or sensitivity to the medication considered If < 50 years old AND experiencing asthma exacerbation, do not intubate unless in or near cardiac arrest Oral ETT: N/A Nasal ETT: 8 years old Not apneic No suspected basal skull or mid-face fracture No uncontrolled epistaxis Not on anticoagulant therapy (ASA excluded) No bleeding disorders Lidocaine Topical Spray Xylometazoline For nasal/oral ETT Use for nasal ETT only Not used if patient is unresponsive Adult Doses Lidocaine - Topical 10 mg/spray N/A N/A 5 mg/kg up to 20 sprays Xylometazoline - Topical 2 sprays / nare N/A N/A 1 dose Confirmation Methods Confirm advanced airway placement Primary ETCO 2 (waveform capnography) Secondary ETCO 2 (non-waveform capnography) Visualization (Oral) Auscultation Chest rise Esophageal Detection Device Maximum number of ETT attempts is two An intubation attempt is defined as insertion of the laryngoscope blade into the mouth for the purposes of intubating the patient Must use ETCO 2 (waveform capnography) or at least 3 secondary methods Consider Midazolam (as per the Procedural Sedation Medical Directive) administration for this patient to maintain the tube Endotracheal Intubation (Oral and Nasal) Page 16 of 65

18 Endotracheal and Tracheostomy Suctioning Patient with an ETT or trach tube AND The airway is obstructed or increased secretions are present N/A Suction Patient Initial Suction Pressure Infant mmhg 1 min Child mmhg 1 min Adult mmhg 1 min Q Repeat Max Same as initial Same as initial Same as initial Before each suctioning procedure, pre-oxygenate with 100% oxygen Do not exceed 10 seconds duration of suction application 5 doses 5 doses 5 doses Endotracheal and Tracheostomy Suctioning Page 17 of 65

19 Supraglottic Airway Need for ventilatory assistance OR airway control AND Other airway management is ineffective GCS = 3 No gag reflex Able to clear the airway (with suctioning etc.) No active vomiting No airway edema No stridor No caustic ingestion Confirmation Methods Primary Secondary ETCO 2 (non-waveform Confirm advanced (supraglottic) capnography) ETCO 2 (waveform airway placement Auscultation capnography) Chest rise Maximum number of supraglottic attempts is two An attempt is defined as the insertion of the supraglottic airway into the mouth Must use ETCO 2 (waveform capnography) or at least 2 secondary methods King LT Reference Size Colour Patient Amount of Air in Cuff #3 Yellow 4 5 ft tall ml #4 Red 5 6 ft tall ml #5 Purple 6 ft tall ml Supraglottic Airway Page 18 of 65

20 Bronchoconstriction Respiratory distress AND Suspected bronchoconstriction No allergy or sensitivity to any medication considered Salbutamol: Patient does not have an actual or suspected fever and there is not a declared FRI outbreak for nebulization administration Epinephrine: BVM ventilation is required Must have a history of asthma Adult Doses Salbutamol MDI 25 kg Salbutamol Nebulized 25 kg Epinephrine 1:1,000 IM 800 mcg (8 puffs) 5-15 min 800 mcg 3 doses 5 mg 5-15 min 5 mg 3 doses 0.01 mg/kg to a maximum of 0.5 mg N/A N/A 1 dose Pediatric Doses Salbutamol MDI < 25 kg Salbutamol Nebulized < 25 kg Epinephrine 1:1,000 IM 600 mcg (6 puffs) 5-15 min 600 mcg 3 doses 2.5 mg 5-15 min 2.5 mg 3 doses 0.01 mg/kg to a maximum of 0.5 mg N/A N/A 1 dose Epinephrine should be the first medication administered if the patient is apneic Salbutamol MDI may be administered subsequently using a BVM MDI adapter (if available) Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health When administering Salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths A spacer should be used when administering salbutamol MDI (if available) Bronchoconstriction Page 19 of 65

21 Continuous Positive Airway Pressure (CPAP) Severe respiratory distress AND Signs and/or symptoms of acute pulmonary edema OR COPD exacerbation Respiratory rate 28 breaths / minute SpO 2 < 90% OR accessory muscle use SBP 100 Able to sit upright and cooperate Not asthma exacerbation Stable or protected airway Not suspected pneumothorax No major trauma or burns to the head or torso No tracheostomy Adult Doses ( 18 years of age) Start at Increase by Q Max 5 cm H 2 O 2.5 cm H 2 O 5 min 15 cm H 2 O If the device has adjustable FiO 2, start at the lower setting and only increase if SpO 2 remains < 92% despite treatment and / or CPAP pressure of 10 cmh 2 O N/A Continuous Positive Airway Pressure (CPAP) Page 20 of 65

22 Croup Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough or recent history of a barking cough < 8 years old No allergy or sensitivity to Epinephrine Heart rate less than 200 bpm Pediatric Doses Epinephrine 1:1,000 1 year old Epinephrine 1:1,000 < 1 year old AND 5 kg or more Epinephrine 1:1,000 < 1 year old AND < 5 kg 5.0 mg (5 ml) 2.5 mg (2.5 ml) 0.5 mg (mix with 2 ml of saline to make 2.5 ml) The minimum initial volume for nebulization is 2.5 ml N/A N/A 1 dose N/A N/A 1 dose N/A N/A 1 dose Croup Page 21 of 65

23 Opioid Toxicity Altered LOC AND Respiratory depression AND Inability to adequately ventilate AND Suspected opioid overdose Respiratory rate < 10 breaths/min No allergy or sensitivity to naloxone No uncorrected hypoglycemia Adult Doses ( 18 years of age) Naloxone SC / IM / IN 0.8 mg 10 min 0.8 mg 3 doses Naloxone IV* Up to 0.4 mg immediate Up to 0.4 mg 3 doses *For IV route, consider diluting the medication for more accurate dose control and titrate naloxone only to restore the patient's respiratory status Where possible, account for 0.12 ml dead space in the intranasal (IN) device for more accurate dosing (ensure the correct amount and volume remain in the syringe after zeroing the MAD adapter) Opioid power comparison where Morphine is assigned a strength of 1: Codeine 0.1, Hydromorphone 10; Fentanyl 100, Carfentanil 10,000 Opioid Toxicity typically presents with: Decreased LOA Slow respirations Pinpoint pupils Some Common Opioids: Morphine Percodan MS Contin Oxycocet Statex Oxycontin Hydromorphone Tylenol #1, #2, #3 Fentanyl Heroin Percocet Codeine Opioid Toxicity Page 22 of 65

24 IV and Fluid Therapy Actual or potential need for IV medication OR fluid therapy Cannulation: No fracture proximal to IV insertion site Bolus: No signs of fluid overload Adult SBP < 90 mmhg Pediatric SBP < 70 mmhg + (2 x age in years) Adult Doses ( 12 years of age) TKVO IV / IO / CVAD ml/hr N/A N/A N/A Bolus IV / IO / CVAD 20 ml/kg Reassess every 250 ml N/A 2,000 ml Pediatric Doses TKVO IV/ IO / CVAD 15 ml/hr N/A N/A N/A Bolus IV / IO / CVAD 20 ml/kg Reassess every 100 ml PATCH to the BHP for authorization to administer IV NaCl bolus to a hypotensive patient less than 12 years of age with suspected Diabetic Ketoacidosis (DKA) N/A 2,000 ml IV and Fluid Therapy Page 23 of 65

25 Pediatric / Adult Intraosseous Actual or potential need for intravenous medication OR fluid therapy AND Intravenous access is unobtainable AND Patient is in cardiac arrest or near-arrest state IO Initiation: No fracture or crush injuries or known replacement / prosthesis proximal to the access site Vital Sign Parameters N/A Jamshidi / Cook: < 1 year of age use an 18 gauge needle 1 year of age use a 15/16 gauge needle EZ IO: Pink 15 mm 3-39 kg Blue 25 mm 40 kg Yellow 45 mm 40 kg with excessive tissue over targeted insertion site Pediatric / Adult Intraosseous Page 24 of 65

26 Central Venous Access Device (CVAD) Actual or potential need for intravenous medication OR fluid therapy AND Intravenous access is unobtainable AND Patient is in cardiac arrest or near-arrest state CVAD: Patient has a pre-existing, accessible central venous catheter in place Vital Sign Parameters N/A Prepare equipment: o two 10 ml syringes, one empty and one with 10 ml saline o alcohol swabs o a prepared IV infusion set o sterile gloves Close clamps Wipe med-port and luer lock with alcohol swab Remove med-port from luer lock Attach the empty syringe Open the clamp (if present) Withdraw whatever fluid is within the catheter until approximately 2 ml of blood is in the syringe Close clamp and remove syringe Attach the syringe with saline Open the clamp, and slowly inject the saline using a push/pause technique. If resistance is met discontinue attempt Close clamp and remove syringe Attach the IV line Open clamp Run the IV as per normal, administering IV medications through the medication ports on the IV set Central Venous Access Device (CVAD) Page 25 of 65

27 Cardiac Ischemia Suspected cardiac ischemia No allergies or sensitivity to medication considered Unaltered LOA Nitroglycerin: Prior Nitroglycerin use and/or IV established HR bpm SBP 100 mmhg. Discontinue if SBP drops more than 1/3 of the initial reading No *phosphodiesterase inhibitor use in past 48 hours No right ventricular MI ASA: Able to chew and swallow Prior use of ASA if asthmatic No allergy to ASA or NSAIDs No current, active bleeding No CVA or TBI in past 24 hrs Morphine: (after 3rd Nitroglycerin or if Nitroglycerin is contraindicated) Severe pain ( 7/10 on the pain scale) SBP 100 mmhg. Discontinue if SBP drops more than 1/3 of the initial reading Adult Doses ( 18 years of age) Nitroglycerin (non-stemi) 0.4 mg S/L 5 min 0.4 mg 6 doses Nitroglycerin (STEMI) 0.4 mg S/L 5 min 0.4 mg 3 doses ASA mg PO N/A N/A mg Morphine 2 mg IV 5 min 2 mg 5 doses Perform 12 lead prior to Nitroglycerin administration and a 15 lead (V4R) if ST elevation is present in the inferior leads (two or more of II, III and avf) Page 26 of 65

28 *Phosphodiesterase inhibitors (including but not limited to): Sildenafil: Viagra, Revatio (for pulmonary hypertension) Tadalafil: Cialis, Adcirca (for pulmonary hypertension) Vardenafil: Levitra, Stazyn A 15 lead ECG should be obtained When a 12 lead shows an inferior wall MI (assess V4R) When there is ST depression in V1-V4 (assess V8 and V9) When the 12 lead is normal but the patient is exhibiting signs or symptoms of cardiac ischemia (assess V8 and V9) V4R The V4R lead is obtained by moving V4 to the same location but on the right chest wall. (5th intercostal space, mid clavicular line) V4R is considered anatomically contiguous with II, III and avf ST elevation in V4R indicates an infarct of the right ventricle and NTG is to be withheld V8 and V9 The V8 lead is obtained by moving V5 around to the posterior, left chest wall and placing it on the mid-scapular line just below the scapula The V9 lead is obtained by moving V6 around to the back and placing it between V5 and the vertebral column ST elevation in V8 and V9 indicates an infarct in the posterior wall of the left ventricle Infarcts in the posterior wall often show up as ST depression in leads V1-V4 or as a normal 12 lead Cardiac Ischemia Page 27 of 65

29 Common Imitators of MI s Interpreting ST segment s is not possible in the following rhythms (not a complete list other imitators exist) LBBB Characterised by a supraventricular rhythm (identified by the presence of P waves and a 1:1 occurrence with QRS waves) & a wide (> 120 ms) QRS complex. A LBBB will have a -ve terminal deflection in V1 and typically a secondary R wave in V6 (seen as a notched complex seen as RsR below). A STEMI cannot be determined in the field in the presence of a LBBB. A RBBB will have a +ve terminal deflection in V1 typically with a notched complex & a slurred or prolonged S wave in V6. A RBBB does not preclude the ability to interpret a STEMI in the field. Ventricular Paced Rhythm A pacer spike is typically seen immediately preceding the QRS complex which will be wide. Pacer detect may need to be activated on the cardiac monitor Electrical capture is the presence of a QRS following the pacer spike. Mechanical capture is the presence of a pulse matching the electrical rate of the paced rhythm. Cardiac Ischemia Page 28 of 65

30 LVH (Left Ventricular Hypertrophy) Look at the RS complex in either V1 or V2 and count the small boxes of the -ve deflection Then do the same with either V5 or V6, counting the small boxes of the +ve deflection Add the two numbers together, if they equal 35 mm s then it s likely LVH A STEMI cannot be determined in the field in the presence of LVH Pericarditis A condition in which inflammation of the pericardial sac produces electrical abnormalities in the 12 lead ECG Men aged years of age are most susceptible Often produces global ST elevation, or elevation in leads that are not anatomically contiguous and that is not consistent with the patient s clinical presentation A STEMI cannot be determined in the field in the presence of pericarditis Cardiac Ischemia Page 29 of 65

31 Acute Cardiogenic Pulmonary Edema Moderate to severe respiratory distress AND Suspected acute cardiogenic pulmonary edema No allergy or sensitivity No *phosphodiesterase inhibitors in the past 48 hours If SBP < 140 mmhg patient must have prior Nitroglycerin use or an IV established Vital Sign Parameters HR bpm SBP 100 mmhg SBP drops no more than 1/3 of the initial reading Adult Doses ( 18 years of age) Nitroglycerin SBP mmhg WITH an IV or History of use Nitroglycerin SBP 140 mmhg and NO History or IV Nitroglycerin SBP 140 mmhg WITH History or IV 0.4 mg S/L 5 min 0.4 mg 6 doses 0.4 mg S/L 5 min 0.4 mg 6 doses 0.8 mg S/L 5 min 0.8 mg 6 doses Consider 12 /15 lead *Phosphodiesterase inhibitors (including, but are not limited to): Sildenafil: Viagra, Revatio (for pulmonary hypertension) Tadalafil: Cialis, Adcirca (for pulmonary hypertension) Vardenafil: Levitra, Stazyn Acute Cardiogenic Pulmonary Edema Page 30 of 65

32 Cardiogenic Shock STEMI positive AND Cardiogenic Shock SBP < 90 mmhg Bolus: Clear chest / no fluid overload Dopamine: No allergy or sensitivity No tachydysrhythmias (excluding sinus tachycardia) No mechanical shock state (i.e. Tension Pneumothorax, Pulmonary Embolism, Pericardial Tamponade) No pheochromocytoma No hypovolemia Adult Doses ( 18 years of age) Bolus IV / IO / CVAD 10 ml/kg Reassess every 250 ml Dopamine IV 5 mcg/kg/min 5 min N/A Increase by 5 mcg/kg/min Titrate Dopamine to achieve a SBP of 90 to < 110 mmhg If discontinuing Dopamine electively, do so gradually over 5-10 minutes Contact BHP if patient is bradycardic If the bolus is contraindicated due to crackles, consider Dopamine 1,000 ml 20 mcg/kg/min Cardiogenic Shock Page 31 of 65

33 Tachydysrhythmia Symptomatic tachydysrhythmia No allergy or sensitivity to any medication considered Valsalva / Adenosine SBP 100 mmhg, unaltered LOA Use for regular narrow complex tachycardia 150 bpm Not for sinus tachycardia, A-fib, or A-flutter Adenosine Specific: Not on Dipyridamole (Persantine, Aggrenox) or Carbamazepine (Tegretol) No bronchoconstriction on exam Lidocaine - PATCH: SBP < 100 mmhg, unaltered LOA Use for regular wide complex tachycardia 120 bpm Cardioversion - PATCH: SBP < 90 mmhg, altered LOA, ongoing chest pain, other signs of shock Tachycardia 120 bpm (wide complex) OR 150 bpm (narrow complex) Adult Doses ( 18 years of age) Procedure Initial Dose Duration Max Valsalva 1 attempt Seconds 2 attempts Adenosine IV PATCH only if suspected SVT with aberrancy (wide complex) Lidocaine IV PATCH 6 mg 2 min 12 mg 2 doses 1.5 mg/kg to maximum 150 mg 10 min 0.75 mg/kg to maximum 75 mg 3 doses Procedure Initial Dose Q Repeat Max Cardioversion PATCH 100 joules PRN *200 joules and then maximum energy 3 attempts Tachydysrhythmia Page 32 of 65

34 *Administer cardioversion in accordance with PATCH orders. The energy settings noted above are a guideline and would apply in the event of a PATCH failure. Cardioversion Attach limb leads Attach defibrillation pads Cycle through leads and select the lead that shows the largest 'R' wave Activate 'SYNC' and ensure sync markers appear on the "R" waves (if visible) Select the energy setting ordered Begin running printer (run lots of strips before and after cardioversion) Double check resuscitation equipment is prepared Charge the defibrillator Clear patient and press-and-hold 'SHOCK' until energy is delivered. After cardioversion, the monitor will automatically default out of SYNC mode Reassess Tachydysrhythmia Page 33 of 65

35 Symptomatic Bradycardia Bradycardia AND Hemodynamic Instability SBP < 90 mmhg HR < 50 bpm with hemodynamic instability Allergy or sensitivity to any medication considered Atropine: No hypothermia No heart transplant TCP: No hypothermia Dopamine: No pheochromocytoma Adult Doses ( 18 years of age) Atropine IV 0.5 mg 5 min 0.5 mg 2 doses Dopamine IV - PATCH 5 mcg/kg/min 5 min Increase by 5 mcg/kg/min 20 mcg/kg/min Transcutaneous pacing PATCH Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first degree AV block, or second degree type I AV block A single dose of Atropine should be considered for second degree type II or third degree blocks with fluid bolus while preparing for TCP or if there is a delay in implementing TCP or if TCP is unsuccessful Titrate Dopamine to achieve a SBP of 90 to < 110 mmhg If discontinuing Dopamine electively, do so gradually over 5-10 minutes Symptomatic Bradycardia Page 34 of 65

36 Buretrol Set-up: Close both roller clamps Spike bag Open top roller clamp (between bag and Buretrol) Fill chamber with 100 ml Close top roller clamp OSCAR O - open bottom roller clamp S - squeeze drip chamber C - close bottom roller clamp And R - release drip chamber, and continue to prime the line as usual Rate Control Sets Look closely to the units of measure, typically ml / hr (not drops / min) Typically require rotating the device to the fully open position then setting to the correct rate Ensure the IV bag is elevated approximately 80 cm above the level of the IV to deliver the rate desired Check frequently to confirm the rate of infusion Pacing Attach limb leads Attach defibrillation pads Activate pacing function Increase CURRENT (ma) until electrical capture is evident (pacer spike followed by a QRS complex) Check for mechanical capture (assess for a pulse equivalent to the pacing rate) Assess BP Consider reducing the RATE to 60 bpm if BP is adequate Re-assess BP Consider Midazolam (as per the Procedural Sedation Medical Directive) administration for this patient to relieve discomfort Symptomatic Bradycardia Page 35 of 65

37 Procedural Sedation Post-intubation OR Transcutaneous pacing. No allergies or sensitivity to Midazolam SBP 100 mmhg Respiratory rate 10 breaths/min (unless intubated) Adult Doses ( 18 years of age) N/A Midazolam IV mg 5 min mg 2 doses Procedural Sedation Page 36 of 65

38 Hypoglycemia Agitation OR altered LOA OR seizure OR symptoms of stroke No allergy or sensitivity to any medication considered Dextrose: N/A Glucagon: No Pheochromocytoma Vital Sign Parameters Hypoglycemia: 2 yrs < 4.0 mmol/l < 2 yrs < 3.0 mmol/l Adult Doses D10W D50W 50 kg Dextrose IV 50 kg Dextrose IV 10 g (100 ml) 10 min 10 g 2 doses 25 g (50 ml) 10 min 25 g 2 doses Glucagon IM 25 kg 1 mg 20 min 1 mg 2 doses Pediatric Doses D10W D50W < 30 Days Dextrose IV 30 Days Dextrose IV < 30 Days Dextrose IV Dilute to D10W 30 Days to < 2 yrs Dextrose IV Dilute to D25W 2 yrs to < 50 kg Dextrose IV D50W 2 ml/kg 0.2 g/kg Max 5 g (50 ml) 2 ml/kg 0.2 g/kg Max 10 g (100 ml) 2 ml/kg 0.2 g/kg Max 5 g (50 ml) 2 ml/kg 0.5 g/kg Max 10 g (40 ml) 1 ml/kg 0.5 g/kg Max 25 g (50 ml) 10 min 10 min 10 min 10 min 10 min same as initial same as initial same as initial same as initial same as initial 2 doses 2 doses 2 doses 2 doses 2 doses Glucagon IM < 25 kg 0.5 mg 20 min 0.5 mg 2 doses Hypoglycemia Page 37 of 65

39 If the patient responds to Dextrose or Glucagon, he/she may receive oral glucose or other simple carbohydrates If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of Dextrose or Glucagon If an IV is established after Glucagon is administered, reassess and consider glucometry and administering Dextrose IV immediately Dextrose 50% in Water Reference Age < 30 days 30 days to < 2 years 2 years Weight kg 2 Blood Sugar mmol/l Dextrose prep D10W Dose g/kg Initial dose Vol. ml/kg Amt ml 2 4 Dose g/kg Repeat dose Vol. ml/kg 3 Waste 40ml < 3.0 replace w/ sterile 5 water Amt ml D25W Waste < ml replace w/ 10 sterile water < 4.0 D50W > Hypoglycemia Page 38 of 65

40 Hyperkalemia Suspected hyperkalemia in high risk patient (dialysis; ESRD; other reason e.g. Crush injury) AND Cardiac arrest or pre-arrest with 12 lead ECG changes suggestive of hyperkalemia Contraindications N/A Calcium Gluconate: Patients on Digoxin Allergy or sensitivity Salbutamol: Allergy or sensitivity Consider 12 lead acquisition and interpretation Adult Doses ( 18 years of age) Calcium Gluconate IV / IO / CVAD PATCH Salbutamol MDI PATCH 1 g (10 ml) over 2-3 minutes 1600 mcg 16 puffs 30 min Immediate 1 g (10 ml) over 2-3 minutes 1600 mcg MDI Administer both Calcium Gluconate and Salbutamol whenever possible Calcium Gluconate must be administered through a well running IV / IO / CVAD 2 doses 2 doses Hyperkalemia Page 39 of 65

41 Moderate to Severe Allergic Reaction Exposure to a probable allergen AND Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis) No allergy or sensitivity to any medication considered Epinephrine: Use for anaphylaxis only Diphenhydramine: Weight 25 kg Adult Doses Epinephrine 1:1,000 IM Diphenhydramine IV / IM Pediatric Doses 0.01 mg/kg Max 0.5 mg 50 mg if 50 kg 25 mg if kg Minimum 5 min same as initial 2 doses N/A N/A 1 dose Epinephrine 1:1,000 IM 0.01 mg/kg Max 0.5 mg Minimum 5 min same as initial 2 doses Diphenhydramine IV / IM 25 mg if kg N/A N/A 1 dose Epinephrine should be the first drug administered in anaphylaxis The Epinephrine dose may be rounded to the nearest 0.05 mg Diphenhydramine is commonly referred to as Benadryl Moderate to Severe Allergic Reaction Page 40 of 65

42 Epinephrine 1:1, mg/kg Rounded to the nearest 0.05 ml 4 kg = 0.04 mg administer 0.05 ml 28 kg = 0.28 mg administer 0.3 ml 6 kg = 0.06 mg administer 0.05 ml 30 kg = 0.3 mg administer 0.3 ml 8 kg = 0.08 mg administer 0.1 ml 32 kg = 0.32 mg administer 0.3 ml 10 kg = 0.1 mg administer 0.1 ml 34 kg = 0.34 mg administer 0.35 ml 12 kg = 0.12 mg administer 0.1 ml 36 kg = 0.36 mg administer 0.35 ml 14 kg = 0.14 mg administer 0.15 ml 38 kg = 0.38 mg administer 0.4 ml 16 kg = 0.16 mg administer 0.15 ml 40 kg = 0.4 mg administer 0.4 ml 18 kg = 0.18 mg administer 0.2 ml 42 kg = 0.42 mg administer 0.4 ml 20 kg = 0.2 mg administer 0.2 ml 44 kg = 0.44 mg administer 0.45 ml 22 kg = 0.22 mg administer 0.2 ml 46 kg = 0.46 mg administer 0.45 ml 24 kg = 0.24 mg administer 0.25 ml 48 kg = 0.48 mg administer 0.5 ml 26 kg = 0.26 mg administer 0.25 ml 50 kg = 0.5 mg administer 0.5 ml Moderate to Severe Allergic Reaction Page 41 of 65

43 Nausea / Vomiting Nausea and/or Vomiting Unaltered LOA No allergies or sensitivity to Dimenhydrinate or other antihistamines Not overdosed on Antihistamines, Anticholinergics or Tricyclic Antidepressants Adult Doses ( 50 kg) Dimenhydrinate IV / IM 50 mg N/A N/A 1 dose Pediatric Doses (25 to 50 kg) Dimenhydrinate IV / IM 25 mg N/A N/A 1 dose If administering IV, dilute Dimenhydrinate with 9 ml normal saline to a 50 mg in 10 ml solution Antihistamines Actifed, Astemazole (Hismanal), Azatdine (Zadine), Cetirizine (Zyrtec, Reactine), Chlorpheniramine (Chlor- Trimeton, chlortripalon), Clemastine Cyproheptadine (Periactin), Dexchlorpheniramine, Desloratadine (Clarinex), Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl), Fexofenadine (Allegra), Hydroxyzine (Atarax, Vistaril), Loratadine (Claritin, Alavert), Phenothiazines, Promethazine (Phenergan),Piperzanes, Terfenadine (Seldane) Tricyclic Antidepressants (TCA) Amitriptyline (Elavil, Ednep, Vanatrip), Clomipramine (Anafranil), Desipramine (Norpramin), Doxepin (Sinequan, Adapin, Silenor), Nortriptyline (Aventyl, Pamelor), Protriptyline (Vivactil), Trimipramine (Surmontil) Anticholinergics Atropine, Hyoscine, Glycopyrrolate(Robinul), Ipratropium bromide (Atrovent), Oxybutinin (Ditropan, Lyrinel XL), Oxitropium bromide (Oxivent), Tiotropium (Spiriva) Nausea / Vomiting Page 42 of 65

44 Pediatric Analgesia Severe pain AND: Isolated hip OR extremity fractures or dislocation(s) OR Major burns OR Current history of cancer related pain Unaltered LOA HR 60 bpm SBP 90 mmhg + (2 x age in years) up to 100 mmhg No allergy or sensitivity to any medication considered No injury to the head or chest or abdomen or pelvis No SBP drop of 1/3 or more of the initial reading after Morphine administration Pediatric Doses (< 18 years of age) < 8 yrs Morphine IV / SC PATCH 8 yrs to < 18 yrs Morphine IV / SC 0.05 mg/kg 3 mg max 0.05 mg/kg 3 mg max 5 min 5 min 0.05 mg/kg 3 mg max 0.05 mg/kg 3 mg max 2 doses 2 doses A PATCH is required to administer Morphine to any patient in severe pain who is less than 8 years of age For ease of administration and control, when using 10 mg/ml IV Morphine, dilute the Morphine with 9 ml of saline to create a 10 mg in 10 ml (1 mg/ml) solution Pediatric Morphine Dosing table 10 mg/ml concentration Wt in kg Dose Amt in mg IV volume (diluted to 1 mg/ml) SC volume (undiluted) mg/kg ml 0.05 ml mg/kg ml 0.08 ml mg/kg ml 0.1 ml mg/kg ml 0.13 ml mg/kg ml 0.15 ml mg/kg ml 0.2 ml mg/kg ml 0.25 ml mg/kg ml 0.3 ml Pediatric Analgesia Page 43 of 65

45 Adult Analgesia Mild Moderate Pain (Acetaminophen / Ibuprofen) OR Mild Severe Pain (Ketorolac) OR Moderate Severe Pain (Morphine) AND Trauma OR Burns OR Renal colic with a prior history OR Acute musculoskeletal back strain OR Current history of cancer related pain Unaltered LOA Acetaminophen / Ibuprofen: N/A Ketorolac: Normotension Restricted to those unable to tolerate oral medications Morphine: Normotension Contraindications Acetaminophen: Use within previous 4 hours Allergy / sensitivity Hx of liver disease Active vomiting Unable to tolerate oral medications Ibuprofen / Ketorolac: NSAID / Ibuprofen use within 6 hours Allergy / sensitivity to ASA or NSAIDs Patient on anticoagulation therapy Current active bleeding Hx of peptic ulcer disease or GI bleeds Pregnant If asthmatic, no prior use of ASA or NSAIDs CVA or TBI in previous 24 hours Known renal impairment Ibuprofen only active vomiting / unable to tolerate oral medications Morphine: Allergy / sensitivity to Morphine SBP drops by 1/3 or more of its initial value after Morphine is administered Adult Analgesia Page 44 of 65

46 Adult Doses ( 18 years of age) Acetaminophen PO mg N/A N/A 1 dose Ibuprofen PO 400 mg N/A N/A 1 dose Ketorolac IM / IV mg N/A N/A 1 dose Morphine IV / SC 2-5 mg 5 min 2-5 mg 4 doses Consider co-administration of Acetaminophen / Ibuprofen whenever possible If Ketorolac is administered, neither Ibuprofen nor Acetaminophen should be administered Suspected renal colic patients should be considered for both Ketorolac and Morphine Adult Analgesia Page 45 of 65

47 Seizure Active generalized motor seizure Unresponsive No allergy or sensitivity to Midazolam Not hypoglycemic Adult Doses Midazolam IV 0.1 mg/kg Max 5 mg 5 min 0.1 mg/kg Max 5 mg 2 doses Midazolam IM / IN / Buccal 0.2 mg/kg Max 10 mg 5 min 0.2 mg/kg Max 10 mg 2 doses Pediatric Doses Midazolam IV Midazolam IM / IN / Buccal 0.1 mg/kg Max 5 mg 0.2 mg/kg Max 10 mg 5 min 5 min 0.1 mg/kg Max 5 mg 0.2 mg/kg Max 10 mg Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be considered by a paramedic 2 doses 2 doses Where possible, account for 0.12 ml dead space in the intranasal (IN) device for more accurate dosing (ensure the correct amount and volume remain in the syringe after zeroing the MAD adapter) Seizure Page 46 of 65

48 The IN volume is based on the addition of 0.12 ml prior to attaching the MAD atomizer. The syringe is then to be zeroed thus addressing the dead space in the MAD atomizer. Central East Prehospital Care Program Seizure Midazolam Reference (based on a 5 mg/ml concentration) Page 47 of 65

49 Combative Patient Combative patient No allergies or sensitivity to Midazolam SBP 100 mmhg No reversible causes (i.e. Hypoglycemia, Hypoxia, Hypotension) PATCH to BHP to proceed with Midazolam if unable to assess the patient for normotension or reversible causes. Adult Doses ( 18 years of age) Midazolam IV / IM mg 5 min mg 2 doses The intranasal route is not recommended due to the proximity of the patient s mouth and likelihood of medication expulsion from the nose following administration Combative Patient Page 48 of 65

50 Emergency Childbirth Pregnant patient experiencing labour OR immediately following delivery Child bearing years Delivery Second stage labour and/or imminent birth Umbilical Cord Management Cord complications OR if resuscitation required OR due to transport considerations External Uterine Massage Post Placental delivery Emergency Childbirth Page 49 of 65

51 Suspected Adrenal Crisis Patient with primary adrenal failure who has signs of an adrenal crisis Presented with a vial of Hydrocortisone for that patient AND No allergy or sensitivity to Hydrocortisone AND Patient presents with (any one or more of): o Hypoglycemia o GI symptoms o Syncope o Temperature 38C or suspected fever o Altered LOA o Age related hypotension o Age related tachycardia All Doses Hydrocortisone IM 2 mg/kg Max 100 mg N/A N/A 1 dose Hydrocortisone has a common trade name of Solu-cortef Dose may be rounded to the nearest 10 mg All patients need to be transported Ensure the medication label is examined carefully for its concentration Hydrocortisone may come premixed in a vial or it may be supplied in an ACT-O-VIAL system To use the ACT-O-VIAL : 1. Press down on plastic activator to force diluent into the lower compartment 2. Gently agitate to effect solution 3. Remove plastic tab covering center of stopper 4. Sterilize top of stopper with alcohol 5. Insert needle squarely through center of stopper and withdraw the appropriate dose Suspected Adrenal Crisis Page 50 of 65

52 Home Dialysis Emergency Disconnect Patient connected to home dialysis AND Requires transport to a receiving facility N/A Interventions Disconnect In general, the instructions will be found with the machine Sequence: Ensure the patient side is clamped first, and then the machine side and then the tubing can be disconnected between the clamps Home Dialysis Emergency Disconnect Page 51 of 65

53 Electronic Control Device (ECD) Probe Removal Electronic control device probe(s) embedded in patient Unaltered LOA Probes not embedded; o Above clavicles, o In the nipple(s), or o In the genital area Interventions ( 18 years of age) Remove probes Police may require preservation of the probe(s) for evidentiary purposes This directive is for removal of ECD only and in no way constitutes a treat and release order, normal principles of patient assessment and care apply Electronic Control Device (ECD) Probe Removal Page 52 of 65

54 Hydrofluoric (HF) Acid Exposure Exposure to vapour and/or liquid Hydrofluoric acid (HF) AND Exhibits signs and symptoms of HF poisoning No allergy or sensitivity to any medication considered Doses Calcium Gluconate (10% solution) Inhalation exposure Calcium Gluconate (2.5% gel) Skin exposure 100 mg NEB N/A N/A 1 dose N/A Topical N/A Immediate N/A Anaesthetic Eye Drops 2 gtts/eye 10 min 2 gtts/eye N/A For skin contact, ensure thorough irrigation prior to treatment For eye exposure, remove patient s contact lenses, if applicable, prior to initiating treatment. Use Anaesthetic eye drops for comfort and then irrigate eyes with normal saline for at least 15 minutes Hydrofluoric (HF) Acid Exposure Page 53 of 65

55 Cyanide Exposure Suspected exposure to Cyanide with signs and symptoms of poisoning Altered LOA No allergies or sensitivity to any medication considered Adult Dose ( 18 years of age) Sodium Thiosulfate 25% 12.5 g IV N/A N/A 1 dose OR Hydroxocobalamin 5 g IV over min N/A N/A 1 dose Pediatric Doses Sodium Thiosulfate 25% OR Hydroxocobalamin 1.65 ml/kg IV Max 12.5 g 70 mg/kg over 30 min Max 5 g N/A N/A 1 dose N/A N/A 1 dose Hydroxocobalamin must be reconstituted with 200 ml normal saline prior to administration Cyanide Exposure Page 54 of 65

56 Hydroxocobalamin Dosing Chart Pediatric Weight (kg) Dose Concentration Volume of Administration 5 70 mg/kg 25 mg/ml 14 ml mg/kg 25 mg/ml 28 ml mg/kg 25 mg/ml 42 ml mg/kg 25 mg/ml 56 ml mg/kg 25 mg/ml 70 ml mg/kg 25 mg/ml 84 ml mg/kg 25 mg/ml 98 ml mg/kg 25 mg/ml 112 ml mg/kg 25 mg/ml 126 ml mg/kg 25 mg/ml 140 ml mg/kg 25 mg/ml 154 ml mg/kg 25 mg/ml 168 ml mg/kg 25 mg/ml 182 ml mg/kg 25 mg/ml 196 ml > mg/kg 25 mg/ml 200 ml Cyanide Exposure Page 55 of 65

57 Headache (Special Events Only) Uncomplicated headache conforming to the patient s usual pattern Unaltered LOA No allergy or sensitivity to Acetaminophen No Acetaminophen in the last 4 hours No signs or symptoms of intoxication Adult Doses ( 18 years of age) Acetaminophen PO mg N/A N/A 1 dose The Special Event Medical Directives are in force when they have been preauthorized for use by the Medical Director. Special Event: a preplanned gathering with potentially large numbers of people. Consider release from care Advise patient that if the problem persists or worsens that they should seek further medical attention Page 56 of 65

58 Minor Abrasion (Special Events Only) Minor abrasions 18 years old Unaltered LOA No allergy or sensitivity to topical antibiotics The Special Event Medical Directives are in force when they have been preauthorized for use by the Medical Director. Special Event: a preplanned gathering with potentially large numbers of people. Consider release from care Advise patient that if the problem persists or worsens that they should seek further medical attention Minor Abrasion (Special Events Only) Page 57 of 65

59 Minor Allergic Reaction (Special Events Only) Signs consistent with minor allergic reaction Unaltered LOA SBP 100 mmhg (and other vitals within normal limits) No allergy or sensitivity to Diphenhydramine No antihistamine or sedative use in the previous 4 hours No signs or symptoms of a moderate to severe allergic reaction No signs or symptoms of intoxication No wheezing Adult Doses ( 18 years of age) Diphenhydramine PO 50 mg N/A N/A 1 dose The Special Event Medical Directives are in force when they have been preauthorized for use by the Medical Director. Special Event: a preplanned gathering with potentially large numbers of people. Consider release from care Advise patient that if the problem persists or worsens that they should seek further medical attention Minor Allergic Reaction (Special Events Only) Page 58 of 65

60 Musculoskeletal Pain (Special Events Only) Minor musculoskeletal pain Unaltered LOA No allergy or sensitivity to Acetaminophen No Acetaminophen use in the previous 4 hours No signs or symptoms of intoxication Adult Doses ( 18 years of age) Acetaminophen PO mg N/A None 1 dose The Special Event Medical Directives are in force when they have been preauthorized for use by the Medical Director. Special Event: a preplanned gathering with potentially large numbers of people. Consider release from care Advise patient that if the problem persists or worsens that they should seek further medical attention Musculoskeletal Pain (Special Events Only) Page 59 of 65

61 January 1 st, 2017 Advanced Care Paramedic Scope of Practice The Advanced Care Paramedic (ACP) is not a part of those members included in the Regulated Health Professions Act; as such they are subject to a scope of practice determined by the Ministry of Health, their Base Hospital Medical Director and their service provider. In general, the scope of practice of the ACP is very similar across the province and may vary within that of an individual Base Hospital. The components of the scope of practice are subject to change from time to time, but the following is based on ALS PCS version dated July 17 th, 2017, and includes Emergency Childbirth that is in force as of December 11 th, 2017, and is restricted in application through the Medical Directives or via direct contact (patch) with a Base Hospital Physician. Skill / Advanced Medical Assessment / Delegated Act - CORE Defibrillation Manual Defibrillation Semi-Automated Synchronized cardioversion Trans-cutaneous pacing Intravenous cannulation Fluid maintenance and bolus administration Intraosseous initiation Pediatric Endotracheal intubation Oral Direct laryngoscopy Endotracheal and Tracheostomy suctioning Foreign Body Airway Obstruction (FBAO) removal (e.g.: Magills) Needle thoracostomy Cardiac monitoring and interpretation 3 or 4 lead Cardiac monitoring and interpretation 12 and 15 lead Chest auscultation and interpretation Capillary blood sampling and glucometry Utilization and interpretation of SpO 2 monitoring Utilization and interpretation of ETCO 2 monitoring Valsalva manoeuvre Home Dialysis Disconnect Manage Emergency Childbirth (in force on December 11 th, 2017) Medication administration via IM / IN / SC / IO (pediatric) / Topical / Buccal / ETT oral / PO / IV / NEB / MDI / SL Skill / Advanced Medical Assessment / Delegated Act - AUXILIARY *Cricothyrotomy Central Venous Access Device (CVAD) access Intraosseous initiation Adult Advanced Care Paramedic Scope of Practice Page 60 of 65