Advanced Care Paramedic Guide

Transcription

1 Advanced Care Paramedic Guide Version

2 77 Brown s Line, Suite 100 Toronto, Ontario M8W 3S2 telephone fax web Maud Huiskamp Senior Manager Regional Base Hospital Program maud.huiskamp@sunnybrook.ca , ext. 409 Jim Summers, Manager Professional Standards & Compliance jim.summers@sunnybrook.ca , ext. 205 Sue Thomson, Manager Paramedic Practice sue.thomson@sunnybrook.ca , ext. 210 Reuven Dichter, Manager Paramedic Practice reuven.dichter@sunnybrook.ca , ext. 202 Sioban Kennedy, Manager Paramedic Practice sioban.kennedy@sunnybrook.ca , ext. 212 Scott Gorsline, Manager Paramedic Practice scott.gorsline@sunnybrook.ca , ext. 222 Garry Ross, Manager Integrated Clinical Systems & Patient Safety garry.ross@sunnybrook.ca , ext. 405

3 Research Guidelines ACP RBH Intro To: Sunnybrook Regional Base Hospital Paramedics and Affiliates The Emergency Health Services Branch of the Ministry of Health and Long-Term Care Version 3.3 of the ALS Patient Care Standards will now be the standard of care. These standards contain updated medical directives for paramedics. The charts on the following pages summarize the medications and advanced procedures for all services under Sunnybrook. Please refer to your Sunnybrook letter of certification and medical directives for your specific scope of practice authorized within your service(s). These patient care standards and guidelines include changes and additions to the paramedic scope of practice. Paramedics are dedicated and distinct professional healthcare providers who make complex medical decisions about their patients. Patients are now receiving an unprecedented high level of prehospital medical care that is becoming increasingly integrated with the larger medical community including acute care in hospitals, public health care and community access care. Paul Hoogeveen Sheldon Cheskes Richard Verbeek BSc, MD, CCFP(EM), FCFP MD, CCFP(EM), FCFP MD CM, FRCFC Medical Director, Beausoleil/ Medical Director Medical Director Muskoka/Rama/Simcoe Peel/Halton Toronto This guide is for paramedic reference only and does not always accurately reflect the current scope of practice authorized within each service. Paramedics are to refer to their letter of certification for currently authorized medications and procedures. Note: This paramedic guide contains content from the Ministry of Health and Long-Term Care Advanced Life Support Patient Care Standards, 3.3, dated February Please refer to to access the full document. To view the Ontario Base Hospital Group s companion document of reference and educational notes, use the following link: by the Sunnybrook Centre for Prehospital Medicine This material has been prepared and developed by Sunnybrook Centre for Prehospital Medicine and the Regional Base Hospital. Reproduction of any part of this material, written or electronic, in any form, without the written consent of Sunnybrook Centre for Prehospital Medicine is forbidden. Regional Base Hospital Introduction Notes Chemical Exposure

4 Medication List ACP This checklist is provided for a paramedic to record his/her authorized scope as per most recently issued letter of certification Medication/Substrate List Authorized by Certification Letter Place Checkmark below Acetaminophen Adenosine Amiodarone Acetylsalicylic Acid Atropine Calcium Gluconate Dextrose Dimenhydrinate Diphenhydramine Dopamine Epinephrine 1:1,000 Epinephrine 1:10,000 Furosemide Glucagon Ibuprofen Ketorolac Lidocaine Midazolam Morphine Naloxone Nitroglycerin Normal Saline 0.9% Salbutamol Sodium Bicarbonate Topical Antibiotic Regional Base Hospital Introduction 2

5 Research Guidelines ACP RBH Intro Procedure List ACP This checklist is provided for a paramedic to record his/her authorized scope as per most recently issued letter of certification Procedure List 12 Lead Acquisition Cardioversion Continuous Positive Airway Pressure Cricothyrotomy Central Venous Access Device Access Defibrillation Dialysis Disconnect Electronic Control Device Probe Removal Glucometry Intubation Nasal Intubation Oral Intraosseous Access Adult Intraosseous Access Up to Age 12 Intravenous Access All Ages Needle Decompression Pacing Supraglottic Airway Termination of Resuscitation Therapeutic Hypothermia Authorized by Certification Letter Place Checkmark below Regional Base Hospital Introduction 3 Notes Chemical Exposure

6 Medication List Chemical Exposure This checklist is provided for a paramedic to record his/her authorized scope as per most recently issued letter of certification Medication List Authorized by Certification Letter Place Checkmark below Anaesthetic Eye Drops, Topical Atropine Calcium Gluconate, 2.5% Gel, Topical Calcium Gluconate, 2.5% Solution NEB Diazepam Hydroxocobalamin Obidoxime Pralidoxime Sodium Thiosulfate Regional Base Hospital Introduction 4

7 Research Guidelines ACP RBH Intro On-Call Physicians Base Hospital Physicians (at time of printing) Dr. Sanjay Agarwal Dr. Sheldon Cheskes Dr. Doug Chisholm Dr. Natalie Cousineau Dr. Michael Feldman Dr. Jeff Handler Dr. Paul Hoogeveen Dr. Oscar Karbi Dr. George Karasmanis Dr. David Kazdan Dr. Chris Martin Dr. Frank Martino Emergency Physicians (SHSC) Dr. Zuhair Alsharafi Dr. Valeria Krym Dr. Clare Atzema Dr. Jacques Lee Dr. Mary Ann Badali Dr. Deborah Leung Dr. Melanie Baimel Dr. Carrie McQuarrie Dr. David Barbic Dr. Andrew McDonald Dr. Martin Betz Dr. Russell MacDonald Dr. Michael Brzozowski Dr. Laurie Mazurik Dr. Tina Bhandari Dr. Kevin Mudrik Dr. Alfonso Burga Dr. Petar Novakovic Dr. Ivy Cheng Dr. Luis Robles Dr. Jordan Chenkin Dr. Dominick Shelton Dr. Ross Claybo Dr. Rachel Sheps Dr. Graham Cleghorn Dr. Bruce Sawadsky Dr. Jennifer Chu Dr. Kevin Skarratt Dr. N. Farkhani Dr. Michael Schull Dr. Michael Feldman Dr. Alexandra Stefan Dr. Mark Freedman Dr. Angela Stone Dr. Lynne Fulton Dr. Jeffery Tyberg Dr. Rishi Ghosh Dr. Aikta Verma Dr. Paul Hawkins Dr. Richard Verbeek Dr. Nicole Kester-Greene Dr. Leah Watson Regional Base Hospital Introduction 5 Notes Chemical Exposure

8 Patch Form Regional Base Hospital Introduction 6

9 Guidelines Research ACP RBH Intro Patch Process Patch Number Patch Failure 1. Attempt maximum twice by cell 2. Attempt through CACC 3. Attempt a radio patch through CACC if no cell coverage 4. Refer to your medical directives if unable to contact a physician Contact Self-Report 1. If a procedure was completed without BHP order 2. If a patch failure was experienced Regional Base Hospital Introduction Notes Chemical Exposure 7

10 Self-Reports Rationale Self-reporting is an important part of paramedic practice: it equates to professionalism by taking responsibility for one s own practice and is a form of education through self-remediation. The Base Hospital strives to improve not only individual paramedic performance but also system performance through the clinical audit, self-reports, case review, feedback and educational processes. All processes are linked in order to reach a common goal, to improve patient safety and outcomes. Content Self-reports may include, but are not limited to, medical directive variances, documentation omissions, patch failures or omissions, scene time delays, or any challenges a Paramedic may encounter while on a call. Process Self-reports shall be posted online from the link at or ed to selfreport@socpc.ca to ensure they are received, documented and followed-up in a timely manner. Information in your self-report shall contain: 1. Paramedic Service 2. Paramedic Name 3. Paramedic EHS Number 4. Call Date 5. Run Number and Vehicle Number 6. Call Location 7. A Brief Description of the Occurrence Being Reported 8. Contact Information Note You can expect a confirmation acknowledging your self-report has been received. Additionally, there will be some indication of its status: self-remediation evident and closed or whether it has been redirected to the service-specific Paramedic Practice Manager for further review. Any request for call-back will be done by your Paramedic Practice Manager. Regional Base Hospital Introduction 8

11 Notes Research Guidelines Chemical Exposure A C P P C S I n t r o Patient Care Standards Introduction Chemical Exposure Medical Directives Guidelines Research Notes

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13 Notes Research Guidelines Chemical Exposure ACP PCS Intro PATIENT CARE STANDARDS INTRODUCTION Information contained herein has been carefully compiled and is believed to be accurate at the date of publication. Freedom from error, however, cannot be guaranteed. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n

14 Introduction Table of Contents Acknowledgements... 3 Levels of Paramedics... 4 Purpose of Standards... 4 Format of the Advanced Life Support Patient Care Standards... 5 Use of the Medical Directives by Paramedics... 5 Regional Base Hospital Compliance with CPSO Policy... 5 General Structure of a Medical Directive... 6 ALS Patient Care Standards Paramedic Skill Set... 6 Consent to Treatment and Capacity Assessment... 7 Refusal of Treatment... 8 Comprehensive Care... 9 Intravenous Access and Therapy by Primary Care Paramedics... 9 Home Medical Technology and Novel Medications Patching Incident Reporting Controlled Substances Responsibility of Care Research Conventions List of Abbreviations Reference and Educational Notes P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 2

15 Notes Research Guidelines Chemical Exposure ACP PCS Intro Acknowledgements The development of this edition of the Advanced Life Support Patient Care Standards is the result of a collaborative effort of a number of stakeholders including: Association of Paramedic Chiefs (OAPC) Ontario Base Hospital Group (OBHG) Ministry of Health and Long Term Care Emergency Health Services Branch (MOHLTC EHSB) EHSB Provincial Medical Advisory Committee (MAC) In particular, the Ministry would like to gratefully acknowledge the following members of the MAC and Regional Base Hospitals (RBH) who provided the medical input into these standards: Dr. Michael Lewell Chair Dr. Andrew Affleck Mr. Chris Day Primary Care Paramedic Representative Mr. Kyle Grant Advanced Care Paramedic Representative Ms. Mary Osinga College Representative Dr. Rudy Vandersluis Dr. Michelle Welsford Dr. Jason Prpic Past Chair Mr. Andy Benson Chair, Education Subcommittee Dr. Richard Dionne Dr. Derek Garniss Dr. Bruce Sawadsky Dr. Richard Verbeek P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 3

16 Levels of Paramedics In Ontario, there are three occupational levels of paramedics: Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP). A level of paramedic is specified in Ontario Regulation 257/00 made under the Ambulance Act, RSO 1990, ca-19. Schedules 1, 2 and 3 in this regulation specify the mandatory controlled acts for each level of paramedic. A paramedic may be authorized by a Medical Director of a Regional Base Hospital (RBH) to perform controlled acts from the Schedule immediately above their prime occupational level. In this circumstance, the paramedic will perform the skill to the specific standard set for the skill. This general concept also applies to the performance of controlled and non-controlled acts that are not included in Schedules 1, 2 and 3 but are specified in these standards. Purpose of Standards The purpose of the Advanced Life Support Patient Care Standards (ALS PCS) is to guide the specifics of patient care that are to be undertaken consistent with the scope of practice of the three occupational levels of paramedics. The ALS PCS: Reflects current practices for paramedics in Ontario and provides benchmarks for paramedic performance. Communicates the standards of practice and care by paramedics in Ontario to paramedics, patients, other disciplines and the public in general. Delineates paramedic professional responsibilities and accountabilities. Provides a basis for evaluation of the patient care practice by Ontario s paramedics. Recognizes that the scope of practice for each occupational level of paramedic may have incremental add-ons, with appropriate rationale and accountability. Summary ALS PCS for the three occupational levels of paramedics in Ontario establish the practice and patient care parameters needed to provide high quality patient care in the varied settings throughout the province. The standards are designed to be dynamic to allow for changes based upon new medical evidence and/or standards of medical practice. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 4

17 Notes Research Guidelines Chemical Exposure ACP PCS Intro Format of the Advanced Life Support Patient Care Standards This document is comprised of an Introduction section and six (6) appendices: Appendix 1 PCP Medical Directives Appendix 2 Appendix 3 PCP Auxiliary Medical Directives Appendix 4 ACP Auxiliary Medical Directives Appendix 5 Chemical Exposure Medical Directives Appendix 6 Maintenance of Certification Policy Critical Care Paramedics and Advanced/Primary Care Flight Paramedics will perform controlled acts in accordance with the Base Hospital Medical Directives issued by the Ornge Base Hospital Physician. Use of the Medical Directives by Paramedics These Medical Directives apply to paramedics who provide care under the license and/or authority of the RBH Medical Director. Delegation of controlled acts or Medical Directives in the ALS PCS to paramedics falls under the exclusive oversight of the MOHLTC s RBH Programs. The Medical Directives are designed to guide a paramedic in the provision of timely and appropriate care to ill and injured patients in the prehospital setting, in accordance with the paramedics training and authorized skill set. While great care has been taken in developing these Medical Directives, they cannot account for every clinical situation. Thus, they are not a substitute for sound clinical judgment. Regional Base Hospital Compliance with CPSO Policy As licensed physicians in the Province of Ontario, the RBH Medical Directors must comply with the policies of the College of Physicians and Surgeons of Ontario (CPSO). The Delegation of Controlled Acts CPSO policy, as may be amended from time to time, provides direction to Ontario physicians on the delegation of controlled acts, regardless of practice setting or type. RBHs will also follow a parallel process for delegation of other advanced medical procedures included in these Standards. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 5

18 General Structure of a Medical Directive All Medical Directives follow the same format and are comprised of the following sections: Indication: Conditions: Contraindications: Treatment: Clinical Considerations: The general medical complaint or problem to which the Medical Directive applies. Clinical parameters that must be present for a procedure to be performed or for a drug to be administered. Clinical parameters that if present, preclude the performance of a procedure or the administration of a drug. Description of the type of procedure to be performed or the dosing of a drug. Key clinical points that provide general guidance to the proper performance of a procedure or the administration of a drug. All of these sections must be taken into account before and during the implementation of a Medical Directive. ALS Patient Care Standards Paramedic Skill Set The mandatory skill set for each level of paramedic is derived from the controlled acts outlined in Schedules 1, 2, and 3 (as referenced above) and is implemented through the PCP and. A paramedic must meet all requirements within Regulation 257/00 to receive delegation from a RBH Medical Director. Additional ( Auxiliary ) skills may be delegated through the use of the Auxiliary Medical Directives. Delegation of Auxiliary Medical Directives by a RBH Medical Director to paramedics is optional and may be introduced after consultation and mutual agreement between the RBH and the certified ambulance service operator that employs the paramedic. Some PCP and contain the phrase, (if available). This phrase qualifies the skill or procedure as optional (i.e. auxiliary) even if included in PCP or. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 6

19 Notes Research Guidelines Chemical Exposure ACP PCS Intro Consent to Treatment & Capacity Assessment Except in emergency circumstances described below, paramedics must obtain the patient s consent prior to initiating treatment. Consent may be informed or implied. Informed consent may be either verbal or written. Implied consent may be assumed where a person provides a physical indication that they consent to the treatment. For example, a patient who cannot speak but extends his hand to a paramedic after the paramedic indicates she is going to perform a simple procedure, such as a blood glucose determination, may be giving implied consent to the procedure. The elements required for consent to treatment are: consent must be given by a person who is capable of giving consent with respect to treatment, consent must relate to the treatment, consent must be informed, consent must be given voluntarily, and consent must not be obtained through misrepresentation or fraud. Consent to treatment is informed if, before it is given to the person, he or she has: received the following information that a reasonable person in the same circumstances would require in order to make a decision about the treatment: the nature of the treatment, the expected benefits of the treatment, the material risks of the treatment, the material side effects of the treatment, alternative courses of action, the likely consequences of not having the treatment; and received responses to his or her requests for additional information about those matters. The paramedic who proposes a treatment to a person shall ensure that consent is obtained. Valid consent requires that a person has the capacity to provide consent. A person is presumed to have the capacity to provide consent with respect to treatment and a paramedic may rely on that presumption. However, a capacity assessment may be required if it is not reasonable in the circumstances to presume the person is capable of consenting to the treatment. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 7

20 A patient is capable with respect to treatment if the patient is: Able to understand the information that is relevant to making a decision about the treatment or alternatives being proposed; and Able to appreciate the reasonably foreseeable consequences of a decision or lack of decision with respect to treatment. If a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated). If a person is incapable with respect to a treatment, consent may be given or refused on his or her behalf by a person who is authorized to do so under section 20 of the Health Care Consent Act, In some instances, a person may present in an emergency situation where the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk, if the treatment is not administered promptly, of sustaining serious bodily harm. A paramedic may administer treatment to a person without consent in an emergency situation, if there is no other authorized person available to give or refuse consent and, in the opinion of the paramedic: the person is not capable of giving a consent or refusal to treatment; and the delay required to obtain a consent or refusal on the person s behalf will prolong the suffering that the person is apparently experiencing or will put the person at risk of sustaining serious bodily harm. Refusal of Treatment If a patient refuses treatment, either in whole or in part, a paramedic must comply with the applicable directions contained in the Basic Life Support Patient Care Standards (BLS PCS), Section 1 Part I, Patient Refusal of Treatment and/or Transport. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 8

21 Notes Research Guidelines Chemical Exposure ACP PCS Intro Comprehensive Care While initiating and continuing treatment prescribed by these Medical Directives, a paramedic must ensure that the patient simultaneously receives care in accordance with the BLS PCS. It is acknowledged that there may be circumstances and situations where complying with ALS PCS is not clinically justified, possible, or prudent (e.g. multiple crews on scene, trapped patient, extenuating circumstances, competing patient care priorities). When treatment deviates from the standards, a paramedic must document the care provided, including reasoning for deviating from the Standards. Intravenous ( IV ) Access and Therapy by Primary Care Paramedics Two levels of certification of PCPs for IV cannulation and therapy are possible. PCP Assist IV authorizes a PCP to cannulate a peripheral IV at the request and under the direct supervision of an ACP. The patient must require a peripheral IV in accordance with the indications listed in the Intravenous Access and Fluid Therapy Medical Directive Auxiliary. The ACP will perform all IV therapy in accordance with the Intravenous Access and Fluid Administration Protocol once intravenous access is obtained. PCPs certified in PCP Assist IV are not authorized to administer IV therapy. PCP Autonomous IV authorizes a PCP to independently cannulate an IV according to the Intravenous Access and Fluid Therapy Medical Directive Auxiliary. PCPs certified in PCP Autonomous IV are authorized to administer IV therapy according to applicable Medical Directives. Certification at each level shall meet the requirements established by the provincial Medical Advisory Committee. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 9

22 Home Medical Technology and Novel Medications As community care advances, new home medical technologies and novel medications are being introduced for home use by highly trained patients and caregivers. They are generally used by patients with complex medical histories who may require emergent interventions which are not described in, or aligned with, the BLS PCS or ALS PCS. A home medical technology is an external or internal mechanical device prescribed by a member of a regulated health profession for the purpose of treating a medical condition. A novel medication is a self/caregiver-administered medication prescribed by a member of a regulated health profession that is required to treat patients with generally rare and unusually complex chronic medical conditions which are often end stage. The medication may be self/caregiver-administered by any route into any part of the body. These can be encountered unexpectedly by paramedics without any prior knowledge that these technologies or medications are being used in the community. Paramedics may not be familiar with the use of these technologies or medications, even though they may be required to provide care. In some cases, when Base Hospital Medical Directors are alerted to these devices, medications or care requirements, a local Medical Directive may be issued to guide specific care for these patients. Such directives should be followed until further consideration by the Medical Advisory Committee. A paramedic may assume patients or caregivers have knowledge about the technology or medication if they confirm that they were trained in its use and/or administration. A paramedic should advise the patient or caregiver to follow any specific steps or provide any advice about restarting/stopping the device or novel medication. A paramedic may only assist a patient within the authorized paramedic skill set. When care requirements are uncertain, but the patient is stable, transport the patient. If the patient is unstable, consider patching to the Base Hospital Physician. Alternatively, consider contacting the responsible member of a regulated health profession. A paramedic may follow written advice provided by their Base Hospital Medical Directors even if this advice is outside the conditions and contraindications of the BLS PCS and ALS PCS. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 10

23 Notes Research Guidelines Chemical Exposure ACP PCS Intro Patching A paramedic should patch to the Base Hospital: When a medical directive contains a mandatory provincial patch point; OR When a RBH introduces a mandatory BH patch point; OR For situations that fall outside of these Medical Directives where the paramedic believes the patient may benefit from online medical direction that falls within the prescribed paramedic scope of practice; OR When there is uncertainty about the appropriateness of a medical directive, either in whole or in part. In cases where a treatment option requires the prior authorization by the BHP (i.e. mandatory provincial patch point or mandatory BH patch point) AND the BHP cannot be reached despite reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required treatment without the requisite online authorization if the patient is in severe distress and, in the paramedic s opinion, the medical directive would otherwise apply. Clinical judgment must be applied and an acceptable standard of care must be met. This may be based on peer and expert review. In such cases, a paramedic should continue attempts to contact the BHP after the treatment has been initiated. All patch failures must be reported in a timely manner in accordance with local policy and procedures. Paramedics should document the attempts to patch to the BH on the Ambulance Call Report (ACR). If a BHP directs a paramedic to perform an assessment or intervention that exceeds the paramedic s scope of practice, the paramedic must advise the BHP of such and notify the physician that he or she cannot comply with the direction as it exceeds his or her scope of practice. In such cases, a paramedic should ask the BHP to provide alternative direction. Incident Reporting Paramedics shall adhere to their ambulance service policies and the Ontario Ambulance Documentation Standards (incorporated by reference in Regulation 257/00) for incident reporting. Paramedics shall also adhere to additional RBH policies regarding reporting of clinical care incidents to the RBH. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 11

24 Controlled Substances Where applicable, paramedics and ambulance service operators shall comply with the Canada Controlled Drug and Substances Act, SC 1996, c 19 and its Regulations, in accordance with the ambulance operator and RBH policy. This shall include that controlled substances (opiates and benzodiazepines) are stored in different carrying cases than other medications. Responsibility of Care While on scene, the highest level paramedic shall assess the patient and make a decision on the level of care required, and on the level of paramedic required for the care of the patient. The highest level paramedic is the ultimate patient care authority on the scene. If there is any disagreement between paramedics, the Base Hospital physician may be contacted. It is expected that when an intervention has been performed, the paramedic most appropriate for that intervention will remain responsible for the patient. In all patient care, the highest level of paramedic is responsible for the care of the patient, including decisions on the level of care required during transport. A paramedic may choose to assign aspects of care and procedures to an alternate level paramedic, as long as the care and procedures are within that paramedic s scope of practice. Paramedics must alert the highest level paramedic of any change of patient status. When transferring care from one level of paramedic to another, paramedics shall provide: current CTAS level; a history of the patient s current problem(s) and relevant past medical history; pertinent physical findings; a summary of management at scene/enroute; the patient s response to treatment, including most recent vital signs; the reason for transfer in cases of inter-facility transfers. The transfer of responsibility of patient care is a critical juncture along the clinical care continuum. When transferring patient care to another health care provider (e.g. nurse, physician, etc.), a paramedic must comply with the BLS PCS regarding such transfers. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 12

25 Notes Research Guidelines Chemical Exposure ACP PCS Intro Research Clinical research is fundamental to the practice of medicine and the development of safer, more effective treatment options for patients. At times, research protocols require temporary changes to patient care standards. In recognition of the importance of prehospital clinical research, RBH Medical Directors may delegate changes in patient care standards to paramedics if the research-related treatment is endorsed by MAC OBHG and the certified ambulance operator that employs the paramedics, approved by MOHLTC, and is supported by an appropriate research ethics review board. Changes to patient care standards will be introduced as an auxiliary Medical Directive. Upon completion of a prehospital clinical trial, research-related treatment must be halted and care as prescribed by BLS PCS and ALS PCS must resume. conventions Conventions refers to a consistent application of terms throughout the Medical Directives based on definitions below. The word consider is used repeatedly throughout the Medical Directives. Where this word appears, it indicates that a paramedic should initiate the treatment unless there is strong clinical rationale to withhold it. A paramedic must document his or her justification for withholding treatment on the ACR. Medication Doses and Administration Medication doses may be either in per kilogram or fixed doses, depending on common clinical practice. The number of recommended medication doses may be administered regardless of any previous self-administration by a patient. When more than one route of medication administration is listed, the order of preference for route of administration is from left to right. Clinical circumstances for each case should determine the final route chosen. Pediatric medication doses can vary slightly according to the source of expert opinion. The pediatric medication doses in the ALS PCS are the preferred doses. However, medication doses as determined by an up-to-date version of a widely accepted pediatric emergency tape (e.g. Broselow Tape) is an acceptable alternative. Use of a pediatric emergency tape shall be documented on the ACR when it is used to determine a pediatric medication dose. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 13

26 Age and Vital Signs The general age cut off between adults and pediatrics is 18 years. There is a wide range of normal for vital signs in adults and especially pediatrics. As much as possible, ages for pediatrics and cut off points for vital signs have been kept consistent throughout the medical directives. However, clinical research and expert opinion have resulted in a number of exceptions which in each case has been deliberately chosen and is clearly noted in each medical directive. There is a deliberate gap in the definition of normotension and hypotension in adults. Adults Normotension: Hypotension: Heart Rate: Bradycardia: Tachycardia: Tachypnea: Pediatrics SBP 100mmHg SBP < 90mmHg Heart rate is always in beats per minute according to a cardiac monitor when it is applied. In situations where a cardiac monitor is not indicated then the heart rate is equal to the pulse rate. < 50 BPM 100 BPM RR 28 breath/min Age Respiratory Rate Heart Rate 0 3 months months months yr yr yr Normotension: SBP 90mmHg + (2 x age in years) Hypotension: SBP < 70mmHg + (2 x age in years) Weight (kg) = (age x 2) + 10 Hypoglycemia Age 2 years: Age < 2 years: glucometry < 4.0 mmol/l glucometry < 3.0 mmol/l LOA (Level of Awareness) The word altered refers to a GCS that is less than normal for the patient. The word unaltered refers to a GCS that is normal for the patient. This may be a GCS < 15. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 14

27 Notes Research Guidelines Chemical Exposure ACP PCS Intro List of Abbreviations The following abbreviations, in alphabetical order, appear in the Advanced Life Support Patient Care Standards: A ACP ALS ALS PCS ASA AV Advanced Care Paramedic Advanced Life Support Advanced Life Support Patient Care Standards acetylsalicylic acid atrioventricular B BH BHP BLS BP BPM BVM C CCP COPD cm CPAP CPR CPSO CTAS CVA CVAD D DKA E ECD ECG EDD ETCO2 ETT Base Hospital Base Hospital Physician Basic Life Support blood pressure beats per minute bag-valve-mask Critical Care Paramedic chronic obstructive pulmonary disease centimeter continuous positive airway pressure Cardiopulmonary Resuscitation College of Physicians and Surgeons of Ontario Canadian Triage and Acuity Scale cerebral vascular accident central venous access device diabetic ketoacidosis electronic control device electrocardiogram esophageal detection device end tidal carbon dioxide endotracheal tube P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 15

28 F FiO 2 FRI G g GCS H H 2 O HR Hx I IM IN IO IV K kg L LOA LOC M MAC mcg MDI mg min ml/kg mmhg MOHLTC N NaCl nare NEB NPA NSAID fraction of inspired oxygen febrile respiratory infection gram Glasgow Coma Scale water heart rate history intramuscular intranasal intraosseous intravenous kilogram level of awareness level of consciousness/loss of consciousness Medical Advisory Committee microgram metered dose inhaler milligram minute milliliter per kilogram millimeters of mercury Ministry of Health and Long-Term Care not applicable sodium chloride nostril nebulized nasopharyngeal airway non-steroidal anti-inflammatory drug P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 16

29 Notes Research Guidelines Chemical Exposure ACP PCS Intro O OBHG OPA P PCP PO PRN Q q R RBH ROSC RR S SC SL SBP SpO 2 STEMI T TBI TCA TCP U URTI V VSA W WNL Ontario Base Hospital Group oropharyngeal airway Primary Care Paramedic by mouth/oral as needed every Regional Base Hospital return of spontaneous circulation respiratory rate subcutaneous sublingual systolic blood pressure saturation of peripheral oxygen ST-segment elevation myocardial infarction traumatic brain injury tricyclic antidepressant transcutaneous pacing upper respiratory tract infection vital signs absent within normal limits P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 17

30 Reference and Educational Notes The RBHs have created a companion document of reference and educational notes intended to assist paramedics in implementing these Medical Directives. This will facilitate regular updating of these notes without having to issue frequent changes to the Standards. It is expected that paramedics have mastered the relevant information as part of initial training and certification and have maintained their knowledge through continuing education and self-study. The reference and educational notes do not define a standard of care; however, they should be considered useful in ensuring that an appropriate standard of care is met. P a t i e n t C a r e S t a n d a r d s I n t r o d u c t i o n 18

31 Guidelines ACP ACP MEDICAL DIRECTIVES Notes Research Chemical Exposure PCS Intro

32 Table of Contents ACP Core Medical Directives Medical Cardiac Arrest Medical Directive... 4 Trauma Cardiac Arrest Medical Directive... 9 Hypothermia Cardiac Arrest Medical Directive Foreign Body Airway Obstruction Cardiac Arrest Medical Directive Neonatal Resuscitation Medical Directive Return of Spontaneous Circulation (ROSC) Medical Directive Cardiac Ischemia Medical Directive Acute Cardiogenic Pulmonary Edema Medical Directive Cardiogenic Shock Medical Directive Symptomatic Bradycardia Medical Directive Tachydysrhythmia Medical Directive Intravenous and Fluid Therapy Medical Directive Pediatric Intraosseous Medical Directive Hypoglycemia Medical Directive Seizure Medical Directive Opioid Toxicity Medical Directive Orotracheal Intubation Medical Directive Bronchoconstriction Medical Directive Moderate to Severe Allergic Reaction Medical Directive Croup Medical Directive Tension Pneumothorax Medical Directive Pediatric Analgesia Medical Directive Adult Analgesia Medical Directive Hyperkalemia Medical Directive

33 Guidelines ACP ACP Auxiliary Medical Directives Table of Contents, continued Adult Intraosseous Medical Directive AUXILIARY Central Venous Access Device (CVAD) Access Medical Directive AUXILIARY Continuous Positive Airway Pressure (CPAP) Medical Directive AUXILIARY Supraglottic Airway Medical Directive AUXILIARY Cricothyrotomy Medical Directive AUXILIARY Nausea/Vomiting Medical Directive AUXILIARY Combative Patient Medical Directive AUXILIARY Procedural Sedation Medical Directive AUXILIARY Electronic Control Device Probe Removal Medical Directive AUXILIARY Minor Abrasions Medical Directive AUXILIARY Minor Allergic Reaction Medical Directive AUXILIARY Muskuloskeletal Pain Medical Directive AUXILIARY Headache Medical Directive AUXILIARY Nasotracheal Intubation Medical Directive AUXILIARY Home Dialysis Emergency Disconnect Medical Directive AUXILIARY ACP Reference Material ACP Pediatric Drug Doses ACP Pediatric Cardiac Arrest Dopamine Infusion Post-Resuscitation Care Checklist Blank Pages for Future Medical Directives Notes Research Chemical Exposure PCS Intro

34 Medical Cardiac Arrest Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Non-traumatic cardiac arrest Conditions AGE: LOA: HR: RR: SBP: CPR Altered Other: Performed in 2 minute intervals Manual Defibrillation AGE: LOA: HR: RR: SBP: 30 days Altered Other: VF or pulseless VT AGE: LOA: HR: RR: SBP: AED Defibrillation 30 days Altered Other: Shock indicated Alternative to manual defibrillation AGE: LOA: HR: RR: SBP: Epinephrine 30 days Altered Other: If anaphylaxis suspected as causative event, IM route may be used AGE: LOA: HR: RR: SBP: Amiodarone 30 days Altered Other: VF or pulseless VT AGE: LOA: HR: RR: SBP: Lidocaine 30 days Altered Other: VF or pulseless VT where amiodarone is not available 4

35 Guidelines ACP AGE: LOA: HR: RR: SBP: Other: Altered 0.9% NaCl Fluid Bolus PEA Any other rhythm where hypovolemia is suspected Contraindications CPR Obviously dead as per BLS standards Meet conditions of DNR standard Epinephrine Allergy or sensitivity to epinephrine 0.9% NaCl Fluid Bolus Fluid overload Manual Defibrillation Rhythms other than VF or pulseless VT Amiodarone Allergy or sensitivity to amiodarone AED Defibrillation Non-shockable rhythm Lidocaine Allergy or sensitivity to lidocaine Use / Availability of amiodarone 5 Notes Research Chemical Exposure PCS Intro

36 Treatment Consider CPR Consider supraglottic airway insertion: where more than OPA/NPA and BVM required and without interrupting CPR. Consider Manual defibrillation: Age 30 days to <8 years Age 8 years Dose 1 shock 1 shock As per BH / First dose 2 J/kg manufacturer Subsequent and As per BH / 4 J/kg max. dose(s) manufacturer Dosing interval 2 min. 2 min. Max. # of doses Consider AED defibrillation (alternative to manual defibrillation): Age 30 days to <8 years With Ped attenuator Without Ped attenuator Age 8 years Dose 1 shock 1 shock 1 shock Max. single dose As per BH / manufacturer As per BH / manufacturer As per BH / manufacturer Dosing interval 2 min. 2 min. 2 min. Max. # of doses 6

37 Guidelines ACP Consider epinephrine: In the event anaphylaxis is suspected as the causative event of the cardiac arrest, a single dose of 0.01 mg/kg 1:1,000 solution, to a maximum of 0.5 mg IM, may be given prior to obtaining the IV/IO. Age 30 days to <12 years Age 12 years Route Route IV / IO / CVAD ETT IV / IO / CVAD ETT Solution 1:10,000 1:1,000 1:10,000 As per BH Dose 0.01 mg/kg* 0.1 mg/kg to a max. of 2 mg 1 mg 2 mg Min. single dose 0.1 mg 1 mg 1 mg 2 mg Dosing interval 4 min. 4 min. 4 min. 4 min. Max. # of doses * The epinephrine dose may be rounded to the nearest 0.05 mg Consider amiodarone: Age 30 days to <12 years Route IV / IO / CVAD Age 12 years Route IV / IO / CVAD Initial Dose 5 mg/kg 300 mg Max. initial dose 300 mg 300 mg Repeat dose 5 mg/kg 150 mg Max. repeat dose 150 mg 150 mg Dosing interval 4 min. 4 min. Max. # of doses Notes Research Chemical Exposure PCS Intro

38 Consider lidocaine (if amiodarone not available): Age 30 days to <12 years Age 12 years Route Route IV / IO / CVAD ETT IV / IO / CVAD ETT Dose 1 mg/kg 2 mg/kg 1.5 mg/kg 3 mg/kg Min. single dose Dosing interval 4 min. 4 min. 4 min. 4 min. Max. # of doses Consider 0.9% NaCl fluid bolus: Age Age 30 days to <12 years 12 years Route Route IV / IO / CVAD IV / IO / CVAD Infusion 20 ml/kg 20 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume 20 ml/kg up to 2,000 ml 2,000 ml Consider intubation: if the airway is not being adequately managed MANDATORY PROVINCIAL PATCH POINT: Patch to BHP following 3 rounds of epinephrine (or after 3 rd analyses if no IV/IO/ETT access). If the BH patch fails, transport to the closest appropriate receiving hospital following the 4 th epinephrine administration (or 4 th analysis if no IV/IO/ETT access). Clinical Considerations In unusual circumstances (e.g. pediatric patients or toxicological overdoses), consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being delivered. The IV and IO routes of medication administration are preferred over the ETT route. However, ETT administration may be used if the IV/IO routes are delayed (e.g. >5 min). 8

39 Guidelines ACP Trauma Cardiac Arrest Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Cardiac arrest secondary to severe blunt or penetrating trauma Conditions AGE: LOA: HR: RR: SBP: CPR Altered Other: Performed in 2 minute intervals AGE: LOA: HR: 0 RR: 0 SBP: 16 years Altered Trauma TOR Other: No palpable pulses Manual Defibrillation AGE: LOA: HR: RR: SBP: 30 days Altered Other: VF or pulseless VT No defibrillation delivered AND monitored HR = 0 (asystole) OR monitored HR >0 AND the closest ED 30 min transport time away AGE: LOA: HR: RR: SBP: AED Defibrillation 30 days Altered Other: Shock indicated 9 Notes Research Chemical Exposure PCS Intro

40 Contraindications CPR Obviously dead as per BLS standards Meet conditions of DNR standard Manual Defibrillation Rhythms other than VF or pulseless VT AED Defibrillation Non-shockable rhythm Trauma TOR Age <16 years Shock delivered Monitored HR >0 and closest ED <30 min away Treatment Consider CPR Consider Manual defibrillation: Age 30 days to <8 years Age 8 years Dose 1 shock 1 shock As per BH / Initial dose 2 J/kg manufacturer Dosing interval 2 min. 2 min. Max. # of doses

41 Guidelines ACP Consider AED defibrillation (alternative to manual defibrillation): Age 30 days to <8 years With Ped attenuator Without Ped attenuator If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat according to the appropriate medical cardiac arrest directive. Age 8 years Dose 1 shock 1 shock 1 shock Max. single dose As per BH / manufacturer As per BH / manufacturer As per BH / manufacturer Dosing interval 2 min. 2 min. 2 min. Max. # of doses MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to apply the Trauma (TOR) Termination of Resuscitation if applicable. If the BH patch fails, or the trauma TOR does not apply, transport to the closest appropriate receiving hospital following the first analysis/shock. Clinical Considerations 11 Notes Research Chemical Exposure PCS Intro

42 Treatment Algorithm for Trauma Arrest 12

43 Guidelines ACP Hypothermia Cardiac Arrest Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Cardiac arrest secondary to severe hypothermia Conditions AGE: LOA: HR: RR: SBP: CPR Altered Other: Performed in 2 minute intervals Contraindications CPR Obviously dead as per BLS standards Meet conditions of DNR standard Manual Defibrillation AGE: LOA: HR: RR: SBP: 30 days Altered Other: VF or pulseless VT Manual Defibrillation Rhythms other than VF or pulseless VT AGE: LOA: HR: RR: SBP: AED Defibrillation 30 days Altered Other: Shock indicated AED Defibrillation Non-shockable rhythm Notes Research Chemical Exposure PCS Intro 13

44 Treatment Consider CPR Consider Manual defibrillation: Age Age 30 days to <8 years 8 years Dose 1 shock 1 shock Initial dose 2 J/kg As per BH / manufacturer Dosing interval 2 min. 2 min. Max. # of doses 1 1 Consider AED defibrillation (alternative to manual defibrillation): Age 30 days to <8 years With Ped attenuator Without Ped attenuator Age 8 years Dose 1 shock 1 shock 1 shock Max. single dose As per BH / manufacturer As per BH / manufacturer As per BH / manufacturer Dosing interval 2 min. 2 min. 2 min. Max. # of doses Transport to the closest appropriate facility without delay following the first analysis. Clinical Considerations 14

45 Guidelines ACP Foreign Body Airway Obstruction Cardiac Arrest Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Cardiac arrest secondary to an airway obstruction Conditions AGE: LOA: HR: RR: SBP: CPR Altered Other: Performed in 2 minute intervals Contraindications CPR Obviously dead as per BLS standards Meet conditions of DNR standard Manual Defibrillation AGE: LOA: HR: RR: SBP: 30 days Altered Other: VF or pulseless VT Manual Defibrillation Rhythms other than VF or pulseless VT AED Defibrillation AGE: LOA: HR: RR: SBP: 30 days Altered Other: Shock indicated AED Defibrillation Non-shockable rhythm 15 Notes Research Chemical Exposure PCS Intro

46 Treatment Consider CPR Consider foreign body removal: (utilizing BLS maneuvers and/or laryngoscope and Magill forceps) Consider Manual defibrillation: Age Age 30 days to <8 years 8 years Dose 1 shock 1 shock As per BH / Initial dose 2 J/kg manufacturer Dosing interval 2 min. 2 min. Max. # of doses 1 1 Consider AED defibrillation (alternative to manual defibrillation): Age 30 days to <8 years With Ped attenuator Without Ped attenuator Age 8 years Dose 1 shock 1 shock 1 shock As per BH / As per BH / As per BH / Max. single dose manufacturer manufacturer manufacturer Dosing interval 2 min. 2 min. 2 min. Max. # of doses If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first analysis. If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest. Clinical Considerations 16

47 Guidelines ACP Neonatal Resuscitation Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Severe cardio-respiratory distress Conditions AGE: LOA: HR: RR: SBP: Other: Resuscitation Newborn or <30 days of age Contraindications Clear of meconium Breathing or crying Good muscle tone Pink in colour Less than full term OR meconium OR poor APGAR score Resuscitation Notes Research Chemical Exposure PCS Intro 17

48 Treatment * If meconium is present and baby not vigorous, suction mouth and pharynx, consider ETT and provide BVM ventilations as required and then continue with the remainder of the initial steps following birth. 18

49 Guidelines ACP Return of Spontaneous Circulation (ROSC) Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Patient with return of spontaneous circulation (ROSC) after the resuscitation was initiated. Conditions 0.9% NaCl Fluid Bolus AGE: LOA: HR: RR: SBP: Hypotension Other: Chest auscultation is clear AGE: LOA: HR: RR: SBP: Dopamine 18 years Other: Hypotension Therapeutic Hypothermia AGE: LOA: HR: RR: SBP: Males 18 years Females 50 years Altered Other: 90 mmhg (spontaneous, following bolus administered or with dopamine) Notes Research Chemical Exposure PCS Intro 19

50 Contraindications 0.9% NaCl Fluid Bolus Fluid overload SBP 90 mmhg Dopamine Allergy or sensitivity to dopamine Tachydysrhythmias excluding sinus tachycardia Mechanical shock states Hypovolemia Pheochromocytoma Therapeutic Hypothermia Traumatic cardiac arrest (blunt, penetrating or burn) Sepsis or serious infection suspected as cause of arrest Hypothermic arrest Known coagulopathy (medical history or medications) Treatment Consider rapid transport Consider optimizing ventilation and oxygenation: Titrate oxygenation 94% Avoid hyperventilation and target an ETCO 2 of mmhg with continuous waveform capnography (if available) Consider 0.9% NaCl fluid bolus: Age Age <12 years 12 years Route Route IV IV Infusion 10 ml/kg 10 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume 1,000 ml 1,000 ml 20

51 Guidelines ACP Consider dopamine: Initial Infusion Rate Titration increment Titration interval Max infusion rate Route IV Note: Titrate dopamine to achieve a systolic BP of mmhg. If discontinuing dopamine electively, do so gradually over 5 10 minutes. Consider 12 lead acquisition Consider Therapeutic hypothermia (if available) Clinical Considerations 5 mcg/kg/min 5 mcg/kg/min 5 min. 20 mcg/kg/min The application of therapeutic hypothermia should not detract from rapid transport, optimizing ventilation and oxygenation or the management of a re-arrest. Notes Research Chemical Exposure PCS Intro 21

52 Cardiac Ischemia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Suspected cardiac ischemia Conditions AGE: LOA: HR: RR: SBP: ASA 18 years Unaltered Other: Able to chew and swallow AGE: LOA: HR: RR: SBP: Nitroglycerin 18 years Unaltered bpm Normotension Other: Prior history of nitroglycerin use or IV access obtained Morphine AGE: 18 years LOA: Unaltered HR: RR: SBP: Normotension Other: Contraindications ASA Allergy or sensitivity to ASA or NSAIDs If asthmatic, no prior use of ASA Current active bleeding CVA or TBI in the previous 24 hours Nitroglycerin Allergy or sensitivity to nitrates Phosphodiesterase inhibitor use within the previous 48 hours SBP drops by one-third or more of its initial value after nitroglycerin is administered 12-lead ECG compatible with right ventricular infarct Morphine Allergy or sensitivity to morphine Injury to the head or chest or abdomen OR pelvis SBP drops by one-third or more of its initial value after morphine is administered 22

53 Guidelines ACP Treatment Consider ASA: Consider 12-lead ECG acquisition Consider nitroglycerin: Route PO Dose mg Max. single dose 162 mg Dosing interval Max. # of doses 1 SBP 100 mmhg Route SL Dose 0.3 or 0.4 mg Max. single dose 0.4 mg Dosing interval 5 min. Max. # of doses 6 Consider morphine (after the third dose of nitroglycerin or if nitroglycerin is contraindicated): Clinical Considerations Route IV Dose 2 mg Max. single dose 2 mg Dosing interval 5 min. Max. # of doses 5 23 Notes Research Chemical Exposure PCS Intro

54 Acute Cardiogenic Pulmonary Edema Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Moderate to severe respiratory distress AND Suspected acute cardiogenic pulmonary edema Conditions Nitroglycerin AGE: LOA: HR: RR: SBP: Other: 18 years bpm Normotension Ascertain prior history of nitroglycerin use OR establish IV access Contraindications Nitroglycerin Allergy or sensitivity to nitrates Phosphodiesterase inhibitor use within the previous 48 hours SBP drops by one-third or more of its initial value after nitroglycerin is administered 24

55 Guidelines ACP Treatment Consider nitroglycerin: SBP SBP 100 mmhg to <140 mmhg 140 mmhg IV or Hx IV or Hx IV or Hx Yes No Yes Route Route Route SL SL SL Dose 0.3 or 0.4 mg 0.3 or 0.4 mg 0.6 or 0.8 mg Max. single dose 0.4 mg 0.4 mg 0.8 mg Dosing interval 5 min. 5 min. 5 min. Max. # of doses Note: Hx refers to a patient with a prior history of nitroglycerin use Consider 12-lead ECG acquisition Clinical Considerations 25 Notes Research Chemical Exposure PCS Intro

56 Cardiogenic Shock Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications STEMI-positive ECG AND Cardiogenic shock Conditions 0.9% NaCl Fluid Bolus Dopamine AGE: 18 years AGE: 18 years LOA: LOA: HR: HR: RR: RR: SBP: Hypotension SBP: Hypotension Other: Clear chest on auscultation Other: Contraindications 0.9% NaCl Fluid Bolus Dopamine Allergy or sensitivity to dopamine Tachydysrhythmias excluding sinus tachycardia Mechanical shock states Hypovolemia Pheochromocytoma 26

57 Guidelines ACP Treatment Consider 0.9% NaCl fluid bolus: Note: If NaCl bolus contraindicated due to pulmonary crackles, consider dopamine. Consider dopamine: Contact BHP if patient is bradycardic. Age 18 years Route Route IV IO Infusion 10 ml/kg 10 ml/kg Infusion interval Reassess every 250 ml 250 ml Max. volume 10 ml/kg 10 ml/kg Initial infusion rate Titration increment Titration interval Max. infusion rate Route IV 5 mcg/kg/min. Note: Titrate dopamine to achieve a systolic BP of mmhg. If discontinuing dopamine electively, do so gradually over 5 10 minutes. Clinical Considerations 5 mcg/kg/min. 5 min. 20 mcg/kg/min. 27 Notes Research Chemical Exposure PCS Intro

58 Symptomatic Bradycardia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Bradycardia AND Hemodynamic instability Conditions AGE: LOA: HR: RR: SBP: Atropine 18 years <50/min Other: Hypotension Contraindications Atropine Allergy or sensitivity to atropine Hemodynamic stability Hypothermia History of heart transplant Transcutaneous Pacing AGE: 18 years LOA: HR: <50/min RR: SBP: Hypotension Other: Transcutaneous Pacing Hemodynamic stability Hypothermia AGE: LOA: HR: RR: SBP: Dopamine 18 years <50/min Other: Hypotension Dopamine Allergy or hypersensitivity to dopamine Tachydysrhythmias excluding sinus tachycardia Mechanical shock states Hypovolemia Pheochromocytoma Treatment Consider Rhythm determination 28

59 Guidelines ACP Consider 12 lead ECG acquisition (if this won t delay therapy) Consider atropine: Route IV Dose 0.5 mg Max. single dose 0.5 mg Dosing interval 5 min. Max. # of doses 2 MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with transcutaneous pacing and/or a dopamine infusion. Consider transcutaneous pacing Consider dopamine: Initial infusion rate Titration increment Titration interval Max. infusion rate Route IV 5 mcg/kg/min. 5 mcg/kg/min. 5 min. 20 mcg/kg/min. Note: Titrate dopamine to achieve a systolic BP of mmhg. If discontinuing dopamine electively, do so gradually over 5 10 minutes. Clinical Considerations Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first degree AV block, or second-degree Type I AV block. A single dose of atropine should be considered for second degree Type II or third degree AV blocks with fluid bolus while preparing for TCP OR if there is a delay in implementing TCP OR if TCP is unsuccessful. The dopamine infusion should be initiated at 5 mcg/kg/min and titrated upward to effect in increments of 5 mcg/kg/min every 5 minutes up to a maximum of 20 mcg/kg/min. The desired effect is a SBP of mmhg. 29 Notes Research Chemical Exposure PCS Intro

60 Tachydysrhythmia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Symptomatic Tachydysrhythmia Conditions AGE: LOA: HR: RR: SBP: Valsalva Maneuver 18 years Unaltered 150/min Normotension Other: Narrow complex and regular rhythm AGE: LOA: HR: RR: SBP: Adenosine 18 years Unaltered 150/min Normotension Other: Narrow complex and regular rhythm AGE: LOA: HR: RR: SBP: Amiodarone 18 years Unaltered 120/min Normotension Other: Wide complex and regular rhythm AGE: LOA: HR: RR: SBP: Lidocaine 18 years Unaltered 120/min Normotension Other: Wide complex and regular rhythm AGE: LOA: HR: RR: SBP: Synchronized Cardioversion 18 years 120/min (wide) or 150/min (narrow) Hypotension Other: Altered mental status, ongoing chest pain, other signs of shock 30

61 Guidelines ACP Contraindications Valsalva Maneuver Sinus tachycardia or atrial fibrillation or atrial flutter Lidocaine Allergy or sensitivity to lidocaine Treatment Adenosine Allergy or sensitivity to adenosine Sinus tachycardia or atrial fibrillation or atrial flutter Patient taking dipyridamole or carbamazepine Bronchoconstriction on exam Synchronized Cardioversion Consider Rhythm determination: Confirm regularity Amiodarone Allergy or sensitivity to amiodarone Consider 12 lead ECG acquisition: To confirm QRS width (if this won t delay therapy) Consider valsalva maneuver: Perform a maximum of two attempts lasting 10 to 20 seconds duration each Consider adenosine: Initial Dose Second dose Dosing interval Max. # of doses Route IV 6 mg 12 mg 2 min. 2 doses 31 Notes Research Chemical Exposure PCS Intro

62 MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with amiodarone or lidocaine or if monomorphic wide complex regular rhythm for adenosine. Consider amiodarone (if available) OR lidocaine: Drug Amiodarone Route IV* Drug Lidocaine Route IV First Dose 150 mg 1.5 mg/kg Subsequent Dose(s) 150 mg 0.75 mg/kg Max. single dose 150 mg 150 mg Dosing interval 10 min. 10 min. Max. # of doses 2 3 *Amiodarone should be administered by IV infusion over 10 min. MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with synchronized cardioversion Consider synchronized cardioversion: Administer up to three synchronized shocks in accordance with BHP direction and energy settings. (In the setting of a patch failure, the energy settings to be used are 100 J, 200 J and the maximum manufacturer setting.) Clinical Considerations 32

63 Guidelines ACP Intravenous and Fluid Therapy Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Actual or potential need for intravenous medication OR fluid therapy Conditions AGE: LOA: HR: RR: SBP: Other: IV Contraindications IV Suspected fracture proximal to the access site AGE: LOA: HR: RR: SBP: Other: Fluid Bolus Hypotension 0.9% NaCl Fluid Bolus Signs of fluid overload Notes Research Chemical Exposure PCS Intro 33

64 Treatment Consider IV cannulation Consider 0.9% NaCl maintenance infusion: Age Age <12 years 12 years Route Route IV / IO / CVAD IV / IO / CVAD Infusion 15 ml/hr ml/hr Infusion interval Reassess every Max. volume MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to administer IV NaCl bolus to patients <12 years with suspected Diabetic Ketoacidosis (DKA) Consider 0.9% NaCl fluid bolus: Age <12 years Age 12 years Route IV / IO / CVAD Route IV / IO / CVAD Infusion 20 ml/kg 20 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume* 20 ml/kg up to 2,000 ml 2,000 ml *The maximum volume of NaCl is lower for patients in cardiogenic shock Clinical Considerations PCP Assist IV authorizes a PCP to cannulate a peripheral IV at the request and under the direct supervision of an ACP. The ACP will perform all IV further therapy in accordance with the Intravenous Access and Fluid Administration Medical Directive once intravenous access is obtained. PCPs certified in PCP Assist IV are not authorized to administer IV fluid or medication therapy. Adult IO and CVAD procedures are auxiliary medical directives described elsewhere. Fluid administration via the IO or CVAD routes only apply to paramedics certified and authorized to perform these procedures. Microdrips and/or volume control administration sets should be considered when IV access is indicated for patients less than 12 years of age. 34

65 Guidelines ACP Pediatric Intraosseous Medical Directive An advanced care paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Actual or potential need for intravenous medication OR fluid therapy AND Intravenous access is unobtainable AND Cardiac arrest or near-arrest state Conditions Contraindication Treatment Clinical Considerations NA AGE: LOA: HR: RR: SBP: Other: IO <12 years IO Fracture or crush injuries or suspected or known replacement / prosthesis proximal to the access site Consider IO access Notes Research Chemical Exposure PCS Intro 35

66 Hypoglycemia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Agitation OR altered LOA OR seizure OR symptoms of stroke Conditions Dextrose Glucagon AGE: AGE: LOA: Altered LOA: Altered HR: HR: RR: RR: SBP: SBP: Other: Hypoglycemia Other: Hypoglycemia Contraindications Dextrose Allergy or sensitivity to dextrose Glucagon Allergy or sensitivity to glucagon Pheochromocytoma Treatment Perform glucometry 36

67 Guidelines ACP Consider dextrose or glucagon: Drug Dextrose Age Age Age <30 days 30 days to <2 years 2 years Weight Weight Weight Concentration Concentration Concentration D10W D25W D50W Route Route Route IV IV IV 0.2 g/kg 0.5 g/kg 0.5 g/kg Dose (2 ml/kg) (2 ml/kg) (1 ml/kg) Max. single dose 5 g (50 ml) 10 g (40 ml) 25 g (50 ml) Dosing interval 10 min. 10 min. 10 min. Max. # of doses Drug Glucagon Age Weight Weight <25 kg 25 kg Concentration Concentration Route Route IM IM Dose 0.5 mg 1.0 mg Max. single dose 0.5 mg 1.0 mg Dosing interval 20 min. 20 min. Max. # of doses 2 2 Clinical Considerations If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple carbohydrates. If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of dextrose or glucagon. If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucometry must be attempted. 37 Notes Research Chemical Exposure PCS Intro

68 Seizure Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Active generalized motor seizure Conditions AGE: LOA: HR: RR: SBP: Other: Midazolam Unresponsive Contraindications Midazolam Allergy or sensitivity to midazolam Hypoglycemia Treatment Consider midazolam: Route Route Route Route IV IM IN Buccal Dose 0.1 mg/kg 0.2 mg/kg 0.2 mg/kg 0.2 mg/kg Max. single dose 5.0 mg 10 mg 10 mg 10 mg Dosing interval 5 min. 5 min. 5 min. 5 min. Max. # of doses Clinical Considerations Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be considered by a paramedic. 38

69 Guidelines ACP Opioid Toxicity Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Altered LOC AND Respiratory depression AND Suspected opioid overdose Conditions AGE: LOA: HR: RR: SBP: Other: Naloxone 18 years Altered <10/min Contraindications Naloxone Allergy or sensitivity to naloxone Uncorrected hypoglycemia Treatment MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with naloxone 39 Notes Research Chemical Exposure PCS Intro

70 Consider naloxone: Route Route Route Route SC IM IN IV* Dose 0.8 mg 0.8 mg 0.8 mg Up to 0.4 mg Max. single dose 0.8 mg 0.8 mg 0.8 mg 0.4 mg Dosing interval Max. # of doses *For the IV route, titrate naloxone only to restore the patient s respiratory status Clinical Considerations 40

71 Guidelines ACP Orotracheal Intubation Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Need for ventilatory assistance or airway control AND Other airway management is inadequate or ineffective Conditions AGE: LOA: HR: RR: SBP: Other: Lidocaine Spray Contraindications Orotracheal Intubation Lidocaine Allergy or sensitivity to lidocaine Unresponsive patient AGE: LOA: HR: RR: SBP: Other: Orotracheal Intubation Orotracheal Intubation Age <50 years AND current episode of asthma exacerbation AND not in or near cardiac arrest 41 Notes Research Chemical Exposure PCS Intro

72 Treatment Consider topical lidocaine spray (to the hypopharynx) for awake orotracheal intubation: Route TOPICAL Dose Max. dose Dosing interval Max. # of doses 10 mg/spray 5 mg/kg 20 sprays Consider orotracheal intubation: with or without intubation facilitation devices. The maximum number of intubation attempts is 2. Confirm orotracheal tube placement: Method Method Primary Secondary Visualization ETCO 2 Auscultation EDD Chest rise Other Clinical Considerations An intubation attempt is defined as insertion of the laryngoscope blade into the mouth for the purposes of intubation. The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation attempts is two (2). At least two primary and one secondary ETT placement confirmation methods must be used. If the patient has a pulse, an ETCO 2 device (quantitative or qualitative) must be used for ETT placement confirmation. Additional secondary ETT placement confirmation devices may be authorized by the local medical director. ETT placement must be reconfirmed immediately after every patient movement. 42

73 Guidelines ACP Bronchoconstriction Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Respiratory distress AND Suspected bronchoconstriction Conditions AGE: LOA: HR: RR: SBP: Other: Salbutamol Contraindications Salbutamol Allergy or sensitivity to salbutamol AGE: Epinephrine WEIGHT: LOA: HR: RR: SBP: Other: BVM ventilation required Hx of asthma Epinephrine Allergy or sensitivity to epinephrine Epinephrine Autoinjector AGE: WEIGHT: 10 kg LOA: HR: RR: SBP: Other: BVM ventilation required Hx of asthma Epinephrine Autoinjector Allergy or sensitivity to epinephrine Notes Research Chemical Exposure PCS Intro 43

74 Treatment Consider salbutamol: Dose Max. single dose Dosing interval Max. # of doses * 1 puff = 100 mcg Weight Weight <25 kg 25 kg Route Route Route Route MDI * NEB MDI * NEB Up to 600 mcg (6 puffs) 2.5 mg Up to 800 mcg (8 puffs) 5 mg 600 mcg 2.5 mg 800 mcg 5 mg 5 15 min. PRN 5 15 min. PRN 5 15 min. PRN 5 15 min. PRN Consider epinephrine: Dose Weight Weight Weight Any 10 kg to <25 kg 25 kg Route Route Route IM Pediatric Autoinjector ** The epinephrine dose may be rounded to the nearest 0.05 mg Adult Autoinjector Concentration Concentration Concentration 1:1,000 1:1,000 1:1, mg/kg** 1 injection (0.15 mg) 1 injection (0.3 mg) Max. single dose 0.5 mg 1 injection 1 injection Dosing interval Max. # of doses

75 Guidelines ACP Clinical Considerations Epinephrine should be the first drug administered if the patient is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter. Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health. When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths. A spacer should be used when administering salbutamol MDI. MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to use pediatric autoinjector for patients <10 kg 45 Notes Research Chemical Exposure PCS Intro

76 Moderate to Severe Allergic Reaction Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Exposure to a probable allergen AND Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis) Conditions AGE: Epinephrine WEIGHT: LOA: HR: RR: SBP: Other: For anaphylaxis only Epinephrine Autoinjector AGE: WEIGHT: 10 kg LOA: HR: RR: SBP: Other: For anaphylaxis only Diphenhydramine AGE: WEIGHT: 25 kg LOA: HR: RR: SBP: Other: Contraindications Epinephrine Allergy or sensitivity to epinephrine Epinephrine Autoinjector Allergy or sensitivity to epinephrine Diphenhydramine Allergy or sensitivity to diphenhydramine 46

77 Guidelines ACP Treatment Consider epinephrine: Dose Weight Weight Weight 10 kg to <25 25 kg Route Route Route IM Pediatric Adult Autoinjector Autoinjector Concentration Concentration Concentration 1:1,000 1:1,000 1:1, mg/kg* 1 injection (0.15 mg) * The epinephrine dose may be rounded to the nearest 0.05 mg Epinephrine should be the first drug administered in anaphylaxis. 1 injection (0.3 mg) Max. single dose 0.5 mg 1 injection 1 injection Dosing interval Max. # of doses Consider diphenhydramine (if available): Weight Weight 25 kg to <50 kg 50 kg Route Route Route Route IV IM IV IM Dose 25 mg 25 mg 50 mg 50 mg Max. single dose 25 mg 25 mg 50 mg 50 mg Dosing interval Max. # of doses Clinical Considerations MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to use pediatric autoinjector for patients <10kg 47 Notes Research Chemical Exposure PCS Intro

78 Croup Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough OR recent history of a barking cough Conditions Epinephrine AGE: LOA: HR: RR: SBP: Other: <8 years <200/min Contraindications Epinephrine Allergy or sensitivity to epinephrine 48

79 Guidelines ACP Treatment Consider epinephrine: Age Age <1 year 1 year to <8 years Weight Weight Weight <5 kg 5 kg Route Route Route NEB NEB NEB Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000 Dose 0.5 mg 2.5 mg 5 mg Max. single dose 0.5 mg 2.5 mg 5 mg Dosing interval Max. # of doses Clinical Considerations The minimum initial volume for nebulization is 2.5 ml 49 Notes Research Chemical Exposure PCS Intro

80 Tension Pneumothorax Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Suspected tension pneumothorax AND Critically ill OR VSA AND Absent or severely diminished breath sounds on the affected side(s) Conditions AGE: LOA: HR: RR: SBP: Other: Needle Thoracostomy Hypotension or VSA Contraindications Needle Thoracostomy Treatment MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to perform needle thoracostomy Consider needle thoracostomy Clinical Considerations Needle thoracostomy may only be performed at the second intercostal space in the midclavicular line. 50

81 Guidelines ACP Pediatric Analgesia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Severe pain AND Isolated hip OR extremity fractures or dislocations OR major burns OR current history of cancer related pain Conditions AGE: LOA: HR: RR: SBP: Other: Morphine <18 years Unaltered 60/min Normotension Contraindications Morphine Allergy or sensitivity to morphine Injury to the head or chest or abdomen or pelvis SBP drops by one-third or more of its initial value after morphine is administered 51 Notes Research Chemical Exposure PCS Intro

82 MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization and dosage verification before administering the medication for children <8 years. Treatment Consider morphine: Dose Max. single dose Dosing interval Route IV / SC 0.05 mg/kg 3 mg 5 min. Max. # of doses 2 Clinical Considerations 52

83 Guidelines ACP Adult Analgesia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Mild Moderate Pain (acetaminophen / ibuprofen) OR Mild Severe Pain (ketorolac) AND/OR Moderate Severe Pain (morphine) AND Trauma OR burns OR renal colic with prior history OR acute musculoskeletal back strain OR current history of cancer related pain Conditions AGE: LOA: HR: RR: SBP: Acetaminophen 18 years Unaltered Other: When used for trauma patients, restricted to those with isolated hip or extremity trauma AGE: LOA: HR: RR: SBP: Other: 18 years Ketorolac Unaltered Normotension When used for trauma patients, restricted to those with isolated hip/extremity trauma AND who are unable to tolerate oral medications AGE: LOA: HR: RR: SBP: 18 years Unaltered Ibuprofen Other: When used for trauma patients, restricted to those with isolated hip or extremity trauma AGE: LOA: HR: RR: SBP: 18 years Unaltered Other: Morphine Normotension Notes Research Chemical Exposure PCS Intro 53

84 Contraindications Acetaminophen Acetaminophen use within previous 4 hours Allergy or sensitivity to acetaminophen Hx of liver disease Active vomiting Unable to tolerate oral medication Ibuprofen NSAID or Ibuprofen use within previous 6 hours Allergy or sensitivity to ASA or NSAIDs Patient on anticoagulation therapy Current active bleeding Hx of peptic ulcer disease or GI bleed Pregnant If asthmatic, no prior use of ASA or other NSAIDs CVA or TBI in the previous 24 hours Known renal impairment Active vomiting Unable to tolerate oral medication Ketorolac NSAID or Ibuprofen use within previous 6 hours Allergy or sensitivity to ASA or NSAIDs Patient on anticoagulation therapy Currect active bleeding Hx of peptic ulcer disease or GI bleed Pregnant If asthmatic, no prior use of ASA or other NSAIDs CVA or TBI in the previous 24 hours Known renal impairment Morphine Allergy or sensitivity to Morphine SBP drops by one-third or more of its initial value after morphine is adminstered 54

85 Guidelines ACP Treatment Consider acetaminophen: Dose Max. single dose Dosing interval Route PO mg 1000 mg Max. # of doses 1 Consider ketorolac: Dose Max. single dose Dosing interval Route IM / IV mg 15 mg Max. # of doses 1 Clinical Considerations Consider ibuprofen: Dose Max. single dose Dosing interval Route PO 400 mg 400 mg Whenever possible, consider co-administration of acetaminophen and ibuprofen. In patients with isolated hip or extremity trauma, ibuprofen and acetaminophen is preferred to ketorolac except where the patient is unable to tolerate oral medications. If ketorolac is administered, neither acetaminophen nor ibuprofen should be administered. Suspected renal colic patients should routinely be considered for ketorolac AND morphine. Max. # of doses 1 Consider morphine: Dose Max. single dose Dosing interval Route SC / IV 2 5 mg 5 mg 5 min. Max. # of doses 4 Notes Research Chemical Exposure PCS Intro 55

86 Hyperkalemia Medical Directive An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Suspected hyperkalemia in patients at high risk, including: currently on dialysis OR history of end-stage renal disease (ESRD) OR other reason to be highly suspicious of hyperkalemia (i.e. prolonged crush injury) AND one of the following clinical situations: Cardiac Arrest OR Pre-arrest (i.e. hypotension, altered level of consciousness, symptomatic bradycardia) with 12-lead ECG suggestive of hyperkalemia (i.e. wide and often bizarre QRS (>120 ms) with peaked T waves, loss of p waves and/or may have sine wave appearance) Conditions AGE: LOA: HR: RR: SBP: Other: Salbutamol 18 years Calcium Gluconate 10% AGE: 18 years LOA: HR: RR: SBP: Other: Contraindications Salbutamol Allergy or sensitivity to salbutamol Calcium Gluconate 10% Patients on Digoxin 56

87 Guidelines ACP Treatment MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with calcium gluconate and salbutamol therapies. Record ECG before and after treatment. Consider calcium gluconate 10%: Dose Max. single dose Route IV / IO 1 g (10 ml) over 2 3 mins. 1 g (10 ml) Dosing interval 30 mins. Max. # of doses 2 Consider salbutamol (this may not be possible in cardiac arrest): Route MDI Nebulized 1600 mcg* Dose (16 puffs) 10 mg Max. single dose 1600 mcg 10 mg Dosing interval Immediate Immediate Max. # of doses 2 2 * 1 puff = 100 mcg Clinical Considerations Whenever possible, both calcium gluconate and salbutamol should be given as the two medications have different modes of action. If appropriate, refer to the Symptomatic Bradycardia, Tachydysrhythmia, or Cardiac Arrest Medical Directives for further management of these patients. Sodium bicarbonate is not a very effective agent for hyperkalemia and so should not routinely be given. Caution that calcium gluconate should only be administered in an IV/IO that is running well and that calcium gluconate and sodium bicarbonate should not be mixed or given in the same IV without flushing well. 57 Notes Research Chemical Exposure PCS Intro

88 Adult Intraosseous Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Actual or potential need for intravenous medication OR fluid therapy AND IV access is unobtainable AND Cardiac arrest OR near arrest state Conditions AGE: LOA: HR: RR: SBP: Other: IO 12 years Contraindication IO Fracture or crush injuries or suspected or known replacement / prosthesis proximal to the access site Treatment Consider IO access Clinical Considerations 58

89 Guidelines ACP Central Venous Access Device (CVAD) Access Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Actual or potential need for intravenous medication OR fluid therapy AND IV access is unobtainable AND Cardiac arrest OR near arrest state Conditions AGE: LOA: HR: RR: SBP: Other: CVAD Access Patient has a pre-existing, accessible central venous catheter in place Contraindications Treatment Consider CVAD access CVAD Access Clinical Considerations Notes Research Chemical Exposure PCS Intro 59

90 Continuous Positive Airway Pressure (CPAP) Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Severe respiratory distress AND Signs and/or symptoms of acute pulmonary edema OR COPD Conditions AGE: LOA: HR: RR: SBP: Other: CPAP 18 years Tachypnea Normotension SpO 2 <90% or accessory muscle use Contraindications CPAP Asthma exacerbation Suspected pneumothorax Unprotected or unstable airway Major trauma or burns to the head or torso Tracheostomy Inability to sit upright Unable to cooperate 60

91 Guidelines ACP Treatment Consider CPAP: Initial setting Titration increment Titration interval Max. setting Consider increasing FiO 2 (if available): 5 cm H 2 O 2.5 cm H 2 O 5 min. 15 cm H 2 O Initial FiO % FiO 2 increment (if available on device) Max FiO 2 100% Confirm CPAP pressure by manometer (if available) Clinical Considerations Or equivalent flow rate of device as per BH direction Or equivalent flow rate of device as per BH direction Or equivalent flow rate of device as per BH direction SpO 2 <92% despite treatment and/or 10cm H 2 O pressure or equivalent flow rate of device as per BH direction 61 Notes Research Chemical Exposure PCS Intro

92 Supraglottic Airway Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Need for ventilatory assistance OR airway control AND Other airway management is inadequate OR ineffective OR unsuccessful Conditions AGE: Supraglottic Airway LOA: GCS = 3 HR: RR: SBP: Other: Absent gag reflex Contraindications Supraglottic Airway Active vomiting Inability to clear the airway Airway edema Stridor Caustic ingestion 62

93 Guidelines ACP Treatment Consider supraglottic airway insertion: The maximum number of attempts is 2 Confirm supraglottic airway placement: Clinical Considerations Method Primary Method Secondary Auscultation ETCO 2 Chest rise Other An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into the mouth. The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation attempts is two (2). 63 Notes Research Chemical Exposure PCS Intro

94 Cricothyrotomy Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Need for advanced airway management AND Intubation AND supraglottic airway (if available) insertion unsuccessful or contraindicated AND Unable to ventilate Conditions Cricothyrotomy AGE: LOA: HR: RR: SBP: Other: 12 years Altered Contraindications Cricothyrotomy Suspected fractured larynx Inability to landmark 64

95 Guidelines ACP Treatment MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to perform cricothyrotomy Consider cricothyrotomy Confirm cricothyrotomy: tube placement Clinical Considerations Method Method Primary Secondary Auscultation ETCO 2 Chest rise Other At least two primary and one secondary Cricothyrotomy tube placement confirmation methods must be used. If the patient has a pulse, an ETCO 2 device must be used (quantitative or qualitative) for cricothyrotomy tube placement confirmation. Additional secondary Cricothyrotomy tube placement confirmation devices may be authorized by the local medical director. Cricothyrotomy tube placement must be reconfirmed immediately after every patient movement. 65 Notes Research Chemical Exposure PCS Intro

96 Nausea / Vomiting Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Nausea OR vomiting Conditions Dimenhydrinate AGE: LOA: HR: RR: SBP: Other: Unaltered Contraindications Dimenhydrinate Allergy or sensitivity to dimenhydrinate or other antihistamines Overdose on antihistamines or anticholinergics or tricyclic antidepressants 66

97 Guidelines ACP Treatment Consider dimenhydrinate: Weight Weight Weight <25 kg 25 kg to <50 kg 50 kg Route Route Route Route Route Route IV IM IV IM IV IM Dose Patch Patch 25 mg 25 mg 50 mg 50 mg Max. single dose 25 mg 25 mg 50 mg 50 mg Dosing interval Max. # of doses Clinical Considerations Prior to IV administration, dilute dimenhydrinate (concentration of 50 mg/1 ml) 1:9 with Normal Saline or sterile water. If given IM do not dilute. 67 Notes Research Chemical Exposure PCS Intro

98 Combative Patient Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Combative patient Conditions Midazolam AGE: LOA: HR: RR: SBP: Other: 18 years Normotension No reversible causes (i.e. hypoglycemia, hypoxia, hypotension) Contraindications Midazolam Allergy or sensitivity to midazolam Treatment MANDATORY PROVINCIAL PATCH POINT: Patch to BHP for authorization to proceed with midazolam if unable to assess the patient for normotension or reversible causes. 68

99 Guidelines ACP Consider midazolam: Route Route IV IM Dose mg mg Max. single dose 5 mg 5 mg Dosing interval 5 min. 5 min. Max. total dose 10 mg 10 mg Max. # doses 2 2 Clinical Considerations Notes Research Chemical Exposure PCS Intro 69

100 Procedural Sedation Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Post-intubation OR transcutaneous pacing Conditions AGE: LOA: HR: RR: SBP: Other: Midazolam 18 years 8/min* Normotension *Non-intubated patients only Contraindications Midazolam Allergy or sensitivity to midazolam Treatment Consider midazolam: Route IV Dose mg Max. single dose 5 mg Dosing interval 5 min. Max. total dose 10 mg Max. # doses 2 Clinical Considerations 70

101 Guidelines ACP Electronic Control Device Probe Removal Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Electronic Control Device probe(s) embedded in patient. Conditions AGE: LOA: HR: RR: SBP: 18 years Unaltered Other: Contraindications Probe Removal Probe removal Probe embedded above the clavicles, in the nipple(s), or in the genital area Treatment Consider probe removal Clinical Considerations Police may require preservation of the probe(s) for evidentiary purposes. This directive is for removal of ECD only and in no way constitutes treat and release; normal principles of patient assessment and care apply. 71 Notes Research Chemical Exposure PCS Intro

102 Minor Abrasions Medical Directive AUXILIARY SPECIAL EVENTS An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Minor abrasions AND Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director Conditions AGE: LOA: HR: RR: SBP: Other: Topical Antibiotic Unaltered Contraindications Topical Antibiotic Allergy or sensitivity to topical antibiotics Treatment Consider topical antibiotic Consider release from care Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention. 72

103 Guidelines ACP Minor Allergic Reaction Medical Directive AUXILIARY SPECIAL EVENT An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Signs consistent with minor allergic reaction AND Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director Conditions AGE: LOA: HR: RR: SBP: Other: Diphenhydramine 18 years Unaltered WNL WNL Normotension Contraindications Diphenhydramine Allergy or sensitivity to diphenhydramine Antihistamine or sedative use in previous 4 hours Signs or symptoms of moderate to severe allergic reaction Signs or symptoms of intoxication Wheezing Notes Research Chemical Exposure PCS Intro 73

104 Treatment Consider diphenhydramine: Route PO Dose 50 mg Max. single dose 50 mg Dosing interval Max. # of doses 1 Consider release from care Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention. 74

105 Guidelines ACP Musculoskeletal Pain Medical Directive AUXILIARY SPECIAL EVENT An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Minor musculoskeletal pain AND Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director Conditions AGE: LOA: HR: RR: SBP: Contraindications Acetaminophen 18 years Unaltered Other: Acetaminophen No acetaminophen in the last 4 hours Allergy or sensitivity to acetaminophen Signs or symptoms of intoxication Notes Research Chemical Exposure PCS Intro 75

106 Treatment Consider acetaminophen: Dose Max. single dose Dosing interval Route PO mg 650 mg Max. # of doses 1 Consider release from care Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention. 76

107 Guidelines ACP Headache Medical Directive AUXILIARY SPECIAL EVENT An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications Uncomplicated headache conforming to the patient s usual pattern AND Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director Conditions AGE: LOA: HR: RR: SBP: Other: Acetaminophen 18 years Unaltered Contraindications Acetaminophen Acetaminophen use within previous 4 hours Allergy or sensitivity to acetaminophen Signs or symptoms of intoxication Notes Research Chemical Exposure PCS Intro 77

108 Treatment Consider acetaminophen: Route PO Dose mg Max. single dose 650 mg Dosing interval Max. # of doses 1 Consider release from care Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention. 78

109 Guidelines ACP Nasotracheal Intubation Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Need for ventilatory assistance OR airway control AND Other airway management is inadequate or ineffective Conditions AGE: LOA: HR: RR: SBP: Other: Xylometazoline Nasotracheal intubation AGE: LOA: HR: RR: SBP: Other: Lidocaine Spray Nasotracheal Intubation Nasotracheal Intubation AGE: LOA: HR: RR: SBP: Other: 8 years Spontaneous Breathing 79 Notes Research Chemical Exposure PCS Intro

110 Contraindications Xylometazoline Allergy or sensitivity to xylometazoline Lidocaine Allergy or sensitivity to lidocaine Unresponsive patient Nasotracheal Intubation Age <50 years AND current episode of asthma exacerbation AND not in or near cardiac arrest Suspected basal skull fracture or mid-face fracture Uncontrolled epistaxis Anticoagulant therapy (excluding ASA) Bleeding disorders Treatment Consider xylometazoline 0.1% spray: for nasotracheal intubation Dose Max. single dose Dosing interval Route TOPICAL 2 sprays/nare 2 sprays/nare Max. # of doses 1 80

111 Guidelines ACP Consider topical lidocaine spray (to the nares and/or hypopharynx) for awake nasotracheal intubation: Dose Max. dose Dosing interval Max. # of doses Route TOPICAL 10 mg/spray 5 mg/kg An intubation attempt is defined as insertion of the nasotracheal tube into a nare. The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation attempts is two (2). The two primary and at least one secondary nasotracheal placement confirmation methods must be used. An ETCO 2 device (quantitative or qualitative) must be used for ETT placement confirmation. Additional secondary ETT placement confirmation devices may be authorized by the local medical director. ETT placement must be reconfirmed immediately after every patient movement. 20 sprays Consider intubation: The maximum number of intubation attempts is 2 Confirm nasotracheal tube placement: Clinical Considerations Method Method Primary Secondary Auscultation ETCO 2 Chest rise EDD Other 81 Notes Research Chemical Exposure PCS Intro

112 Home Dialysis Emergency Disconnect Medical Directive AUXILIARY An Advanced Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Patient receiving home dialysis (hemo or peritoneal) and connected to dialysis machine AND Patient requires transport to the hospital AND Patient is unable to disconnect OR there is no family member or caregiver available or knowledgeable in dialysis disconnect Conditions Home Dialysis Emergency Disconnect AGE: LOA: HR: RR: SBP: Other: Contraindications Home Dialysis Emergency Disconnect Treatment Consider Home Dialysis Emergency Disconnect Clinical Considerations Generally, emergency disconnect kit with materials and instructions can be found hanging from dialysis machine or nearby on the wall. Ensure both the patient side and machine side of the connection are clamped before disconnecting and attaching end caps. 82

113 Guidelines Age Kg (lbs) Dextrose in Water Midazolam Midazolam Morphine Epi IV/IO IV IM/IN/Buccal IV/SC IM D10W: 0.2g (2ml)/kg (10mg/2ml) (10mg/2ml) (1:1,000) D25W: 0.5g (2ml)/kg 0.1 mg/kg 0.2 mg/kg 0.05 mg/kg 0.01 mg/kg D50W: 0.5g (1ml)/kg Max Dose: 5.0mg Max Dose: 10mg Max Dose: 3mg Max Dose: 0.5mg Prem 1.5 (3) 0.3g / 3ml D10W 0.15mg / 0.03ml 0.3mg / 0.06ml 0.015mg / 0.015ml Term 3.0 (6.5) 0.6g / 6ml D10W 0.30mg / 0.06ml 0.6mg / 0.12ml 0.03mg / 0.03ml 6 m/o 6 (13) 3.0g / 12ml D25W 0.6mg / 0.12ml 1.2mg / 0.24ml 0.06mg / 0.06ml 9 m/o 9 (20) 4.5g / 18ml D25W 0.9mg / 0.18ml 1.8mg / 0.36ml 0.09mg / 0.09ml 1 y/o 12 (26) 6.0g / 24ml D25W 1.2mg / 0.24ml 2.4mg / 0.48ml 0.6 mg 0.12mg / 0.12ml 2 y/o 14 (30) 7g / 14ml D50W 1.4mg / 0.28ml 2.8mg / 0.56ml 0.7 mg 0.14mg / 0.14ml 3 y/o 16 (35) 8g / 16ml D50W 1.6mg / 0.32ml 3.2mg / 0.64ml 0.8 mg 0.16mg / 0.16ml 4 y/o 18 (40) 9g / 18ml D50W 1.8mg / 0.36ml 3.6mg / 0.72ml 0.9 mg 0.18mg / 0.18ml 5 y/o 20 (44) 10g / 20ml D50W 2.0mg / 0.40ml 4.0mg / 0.80ml 1.0 mg 0.20mg / 0.20ml 6 y/o 22 (48) 11g / 22ml D50W 2.2mg / 0.44ml 4.4mg / 0.88ml 1.1 mg 0.22mg / 0.22ml 7 y/o 24 (53) 12g / 24ml D50W 2.4mg / 0.48ml 4.8mg / 0.96ml 1.2 mg 0.24mg / 0.24ml 8 y/o 26 (57) 13g / 26ml D50W 2.5mg / 0.50ml 5.0mg / 1.00ml 1.3 mg 0.26mg / 2.6ml 9 y/o 28 (62) 14g / 28ml D50W 2.8mg / 0.56ml 5.6mg / 1.12ml 1.4 mg 0.28mg / 0.28ml 10 y/o 30 (66) 15g / 30ml D50W 3.0mg / 0.60ml 6.0mg / 1.20ml 1.5 mg 0.30mg / 0.30ml 11 y/o 32 (70) 16.0g / 32ml D50W 3.2mg / 0.64ml 6.4mg / 1.28ml 1.6 mg 0.32mg / 0.32ml ACP ACP Pediatric Drug Dosages Dosages per pediatric emergency tape (i.e. Broselow) Notes Research Chemical Exposure PCS Intro 83

114 NRP Cardiac Arrest Age Kg (lbs) ETT Size ETT Lips Defib Energy (2 J/kg : 4 J/kg) Prem 1.5 (3) J : 6J < 30 days 3.0 (6.5) J : 14J Epi Epi Initial Amiodarone Lidocaine (1:10,000) (1:1,000) (50mg/ml) (20 mg/ml) IV/IO (ETT) ETT IV/IO ETT 0.01 mg/kg 0.1 mg/kg (ETT) 0.015mg / 0.15ml 0.15mg / 1.5ml 0.03mg / 0.3ml 0.3mg / 3.0ml (ETT) 0.1 mg/kg max 2.0 mg min single dose 1.0 mg 5.0 mg/kg 2.0 mg/kg n/a 7.5mg / 0.15ml n/a n/a 15.0mg / 0.3ml n/a 6 m/o 6 (13) J : 24J 0.06mg / 0.6ml 1.0 mg / 1.0 ml 30mg / 0.6ml 12mg / 0.6ml 9 m/o 9 (20) J : 36J 0.09mg / 0.9ml 1.0 mg / 1.0 ml 45mg / 0.9ml 18mg / 0.9ml 1 y/o 12 (26) J : 48J 0.12mg / 1.2ml 1.2mg / 1.2ml 60mg / 1.2ml 24mg / 1.2ml 2 y/o 14 (30) J : 56J 0.14mg / 1.4ml 1.4mg / 1.4ml 70mg / 1.4ml 28mg / 1.4ml 3 y/o 16 (33) J : 64J 0.16mg / 1.6ml 1.6mg / 1.6ml 80mg / 1.6ml 32mg / 1.6ml 4 y/o 18 (35) J :72J 0.18mg / 1.8ml 1.8mg / 1.8ml 90mg / 1.8ml 36mg / 1.8ml 5 y/o 20 (44) J : 80J 0.20mg / 2.0ml 2.0mg / 2.0ml 100mg / 2.0ml 40mg / 2.0ml 6 y/o 22 (48) J : 88J 0.22mg / 2.2ml 2.0mg / 2.0ml 110mg / 2.2ml 44mg / 2.2ml 7 y/o 24 (53) J : 96J 0.24mg / 2.4ml 2.0mg / 2.0ml 120mg / 2.4ml 48mg / 2.4ml 8 y/o 26 (57) Adult Settings 0.26mg / 2.6ml 2.0mg / 2.0ml 130mg / 2.6ml 52mg / 2.6ml 9 y/o 28 (62) Adult Settings 0.28mg / 2.8ml 2.0mg / 2.0ml 140mg / 2.8ml 56mg / 2.8ml 10 y/o 30 (66) Adult Settings 0.30mg / 3.0ml 2.0mg / 2.0ml 150mg / 3.0ml 60mg / 3.0ml 11 y/o 32 (70) Adult Settings 0.32mg / 3.2ml 2.0mg / 2.0ml 160mg / 3.2ml 64mg / 3.2ml ACP Pediatric Cardiac Arrest Dosages per pediatric emergency tape (i.e. Broselow) 84

115 Guidelines ACP Weight (kg) Dopamine Infusion S I N G L E S T R E N G T H Dopamine Infusion Rate (ml/hr) Using an 800 mcg/ml ( single strength ) solution Dosage (mcg/kg/minute) Weight (kg) D O U B L E S T R E N G T H Dopamine Infusion Rate (ml/hr) Using an 1600 mcg/ml ( double strength ) solution Dosage (mcg/kg/minute) Notes Research Chemical Exposure PCS Intro 85

116 Post-Resuscitation Care Checklist (Consider all actions within delegated scope) Patient Name: Date: Time Completed Step In General Order of Performance Checked 1 Note time of ROSC 2 Repeat Primary Survey 3 Delegate egress planning 4 Ensure monitoring systems are in place a. Defibrillation pads b. Cardiac monitoring c. Blood pressure cuff d. End tidal CO2 e. Pulse Oximetry 5 Address Ventilation a. Consider advanced airway b. Ventilate approximately 10 breaths per minute c. Target end tidal CO2 = mg 6 Address Oxygenation a. Target oxygen saturation = 92-96% 7 Address Hemodynamic status a. Record blood pressure every 5 minutes b. Consider Normal Saline 10 ml/kg bolus for hypotension (in adult <90 mmhg) c. Consider second intravenous d. Consider dopamine if hypotension persists after the initiation of Normal Saline bolus (ACP only) 8 Address Therapeutic Hypothermia (if applicable) a. Consider hypothermia if mental status is altered b. Consider external cooling at carotid, axillia and groin sites 9 Address possibility of STEMI a. Consider 12-Lead ECG approx. 10 minutes post ROSC b. Consider CODE STEMI activation 10 Reassess on route to hospital and update the receiving hospital 86

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123 Notes Research Guidelines Chemical Exposure ACP PCS Intro CHEMICAL EXPOSURE MEDICAL DIRECTIVES Chemical Exposure

124 CBRNE Medical Directives Table of Contents Introduction... 3 Hydrofluoric Acid Exposure Medical Directive... 4 Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive... 5 Pediatric Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive... 7 Administration of Antidotes for Cyanide Exposure Medical Directive... 9 Symptomatic Riot Agent Exposure Medical Directive Blank Pages for Notes Chemical Exposure 2

125 Notes Research Guidelines Chemical Exposure ACP PCS Intro Introduction The following Medical Directives have been developed for use when chemical exposure to the listed agent is suspected. These Medical Directives may only be used by paramedics who have received special training in treating patients with chemical exposures. This is usually a comprehensive program that includes personal protection and training in CBRNE (Chemical, Biologic, Radiological, Nuclear and Explosive) events. Chemical Exposure 3

126 Hydrofluoric Acid Exposure Medical Directive When the listed indication and condition exist, a paramedic is authorized to administer Calcium Gluconate and/or topical anaesthetic eye drops according to the following protocol. The paramedic will comply with local BHP patching protocols. Indications Patient was exposed to vapour, and/or liquid hydrofluoric acid. Conditions Patient is exhibiting signs and symptoms of hydrofluoric acid poisoning. Contraindications Topical anaesthetic eye drops (see Procedure, point #6a) are contraindicated if the patient is allergic to anaesthetics. Procedure 1. Don appropriate PPE. 2. Remove patient from further hydrofluoric acid exposure, remove contaminated clothing, jewellery, etc. 3. Decontaminate if not already decontaminated. 4. Assess vital signs; apply cardiac monitor and high flow oxygen. 5. Inhalation: a) Ensure airway patency and breathing. b) For dyspnea see Bronchoconstriction Medical Directive. c) If airway pain (suspected inhalation injury), consider delivering a nebulized Calcium Gluconate 2.5% solution (1 ml 10% Calcium Gluconate and 3 ml sterile normal saline) with high flow oxygen. 6. Eye Contact: For eye discomfort, irrigate thoroughly with copious amounts of normal saline. a) Remove contact lenses. b) Administer 2 drops of topical anaesthetic eye drops in each eye, repeat every 10 minutes as needed. c) Monitor the patient for 20 minutes after the last dose. 7. Skin Contact: a) Irrigate thoroughly with copious amounts of saline for 1 minute if not already done. b) Massage Calcium Gluconate 2.5% Gel (if available) liberally into the burn area and continue applying during transport if pain persists. Notes 1. Transport to hospital as soon as possible. 2. Latex gloves are not sufficient. Use Neoprene or Nitrile gloves. Chemical Exposure 4

127 Notes Research Guidelines Chemical Exposure ACP PCS Intro Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive When the listed indication and conditions exist, a paramedic is authorized to administer Atropine, either Pralidoxime or Obidoxime and Diazepam to a victim of nerve agent (or organophosphate) exposure. The paramedic will comply with local BHP patching protocols. Indications Patient was exposed to known or suspected nerve agent Conditions 1. Adult ( 40 kg) 2. The patient is exhibiting signs and symptoms of a cholinergic crisis Procedure Mild Exposure Signs: anxiety about being exposed, may see miosis, rhinorrhea 1. Remove patient from area of exposure 2. Remove all contaminated clothing Moderate Exposure Signs: (ANY ONE OF) vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath, any known liquid exposure. Administer: 1. One (1) Atropine 2mg IM or autoinjector. Repeat Atropine 2mg IV/IM every 5 minutes as needed until symptoms improve. 2. One (1) Pralidoxime 600mg IM or autoinjector OR Obidoxime 150mg IM or autoinjector. 3. One (1) Diazepam 10mg IM or autoinjector. Severe Exposure Signs: Signs of moderate exposure and (ANY ONE OF) Decreased LOC, paralysis, seizures, apnea. Administer: 1. Three (3) doses Atropine 2mg IV/IM or autoinjectors. If bronchial secretions persist, continue Atropine 2mg IV/IM every 5 minutes as needed until secretions clear. 2. Three (3) doses Pralidoxime 600mg IM or autoinjectors OR three (3) Obidoxime 150mg IM or autoinjectors. 3. One (1) Diazepam 10mg IM or autoinjector. Chemical Exposure 5

128 Notes 1. Patients receiving treatment should also receive oxygen and be on a cardiac monitor if available. 2. Only Advanced Care Paramedics may administer intravenous medications. 3. ABCs must also be secured as appropriate in an MCI/contaminated environment. Atropine should be administered prior to airway interventions if secretions are copious. 4. Decontamination procedures must be integrated with antidote administration. 5. Personal Protective Equipment must be worn at all times. 6. Drugs may be given IV but do not delay IM administration if IV access is not already established. Chemical Exposure 6

129 Notes Research Guidelines Chemical Exposure ACP PCS Intro Pediatric Administration of Atropine, either Pralidoxime Chloride (2 PAM) or Obidoxime and Diazepam for Nerve Agent Exposure Medical Directive When the listed indication and conditions exist, a paramedic is authorized to administer Atropine, either Pralidoxime or Obidoxime and Diazepam to a victim of nerve agent (or organophosphate) exposure. The paramedic will comply with local BHP patching protocols. Indications Patient was exposed to known or suspected nerve agent Conditions 1. <40 kg 2. The patient is exhibiting signs and symptoms of a cholinergic crisis Procedure Mild Exposure: Signs: anxiety about being exposed, may see miosis, rhinorrhea 1. Remove patient from area of exposure 2. Remove all contaminated clothing Moderate/Severe Exposure: Signs: (ANY ONE OF) vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath, decreased LOC, paralysis, seizures, apnea, any known liquid exposure. Administer: For patients <10kg: 1. Atropine 0.5mg IM, repeat IV/IM every 5 minutes as needed until symptoms improve. 2. Diazepam 2mg IV/IM. 3. Pralidoxime 15mg/kg IV/IM every 1 hour maximum 600mg/single dose, total maximum dose 1200mg OR Obidoxime 8mg/kg maximum 320mg total dose. For patients from 10kg to 39kg: 1. Atropine 1mg IM, repeat IV/IM every 5 minutes as needed until symptoms improve. 2. Diazepam 0.2mg/kg IV/IM. 3. Pralidoxime 15mg/kg IV/IM every 1 hour maximum 600mg/single dose, total maximum dose 1200mg OR Obidoxime 8mg/kg maximum 320mg total dose. Chemical Exposure 7

130 Notes 1. Patients receiving treatment should also receive oxygen and be on a cardiac monitor if available. 2. Only Advanced Care Paramedics may administer intravenous medications. 3. ABCs must also be secured as appropriate in an MCI/contaminated environment. Atropine should be administered prior to airway interventions if secretions are copious. 4. Decontamination procedures must be integrated with antidote administration. 5. Personal Protective Equipment must be worn at all times. 6. Drugs may given IV but do not delay IM administration if IV access is not already established. Chemical Exposure 8

131 Notes Research Guidelines Chemical Exposure ACP PCS Intro Administration of Antidotes for Cyanide Exposure Medical Directive When the listed indication and condition exist, a paramedic is authorized to administer antidotes to victims of Cyanide exposure according to the following protocol. The paramedic will comply with local BHP patching protocols. Indications Patient was exposed to vapour, liquid or solid, suspected to contain cyanide. Conditions Patient is exhibiting signs and symptoms of cyanide poisoning. Procedure 1. Remove patient from further exposure and remove clothes. 2. Assess vital signs, GCS. 3. Ensure airway, administer oxygen and apply cardiac and oxygen saturation monitors as possible. 4. If GCS 15 and patient is asymptomatic, decontaminate and transport to hospital. 5. If GCS <15 administer: a) Sodium Thiosulfate 12.5gm (50 ml of 25% solution) IV (Pediatric dose = 1.65 ml/kg to max 50 ml). OR b) CYANOKIT (hydroxocobalamin) 5.0g by rapid IV infusion over 30 minutes (Pediatric dose = 70mg/kg) 6. Initiate treatment and continue while transporting to hospital. Chemical Exposure 9

132 Symptomatic Riot Agent Exposure Medical Directive When the listed indication and condition exist, a paramedic is authorized to administer therapy to victims of Riot Agent exposure according to the following protocol. The paramedic will comply with local BHP patching protocols. Indications Exposure to a known or suspected riot agent Conditions Signs and symptoms of riot agent exposure Contraindications Topical anaesthetic eye drops (see Procedure, point #5a) are contraindicated if the patient is allergic to anaesthetics. Procedure 1. Remove patient from further exposure, and decontaminate. 2. Assess vital signs, with careful focus on bronchoconstriction. 3. Assess visual acuity by the ability to see light and count fingers at 1 foot. Consider removing contact lenses. 4. For dyspnea see Bronchoconstriction Medical Directive. 5. For eye discomfort, irrigate thoroughly with copious amounts of normal saline. a) Administer 2 drops of topical anaesthetic eye drops in each eye, repeat every 10 minutes as needed. b) Monitor the patient for 20 minutes after the last dose. Notes 1. If a patient is experiencing significant respiratory distress or eye irritation, immediately advise the patient of the need for transport to hospital. Transport should be initiated as soon as possible. 2. MDIs are intended for single patient use only. If an MDI is used to treat more than one patient, cross contamination may occur regardless of whether or not an aerochamber or spacer is used. The MDI should be safely discarded once the patient has completed treatment. 3. The eye drop bottle is designed for multiple patient use. Do not allow the bottle s administration nozzle to make contact with the patient. If the administration nozzle does make contact with the patient, the bottle is considered contaminated and must be discarded appropriately. Chemical Exposure 10

133 Notes Research Guidelines Chemical Exposure ACP PCS Intro 4. Under no circumstances should the MDI or eye drop bottle be given to a patient. 5. Advise patient to refrain from rubbing eyes, whether or not anaesthetic drops are used. 6. Have the patient remove their contact lenses. Help if necessary. 7. If a patient with dyspnea or eye irritation caused by a riot control agent refuses EMS transport to hospital, advise: Continued exposure may lead to further problems. Relief from treatment so far may be temporary. If problems recur or persist, consult a physician as soon as possible. Chemical Exposure 11

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135 Research Guidelines ACP PCS Intro GUIDELINES G u i d e l i n e s Notes Chemical Exposure

136 Table of Contents STEMI Bypass... 3 Interfacility STEMI Transfer... 4 Checklist for STEMI Fibrinolytics... 5 Acute Stroke Protocol... 6 Stroke Assessment Tool... 7 Field Trauma Triage Standard... 8 Unexpected Death Expected Death DNR and Expected Death Protocol Performance of Medical Directives While Waiting at Receiving Emergency Department Requesting a Medical Site Team Burn Triage Patients with an Isolated Appendage Amputation Spinal Motion Restriction (SMR) for Penetrating Trauma Blank Pages for Future Guidelines G u i d e l i n e s 2

137 Guidelines Research ACP PCS Intro STEMI Bypass Notes 1) Do not activate a CODE STEMI solely because the computer interpretation says ****ACUTE MI**** especially if you are not convinced by the ECG and in your judgment the history and current presentation is not high risk. Alternatively, do not exclude activating a CODE STEMI with a worrisome history and suggestive ECG even if ****ACUTE MI**** does not appear on the print out. 2) An on-scene ACP may transfer care of a patient who is STEMI negative to a PCP/ Level 2 unless the patient requires care beyond the scope of a PCP/Level 2. 3) All patients who have been declared STEMI positive will be transported with defib pads applied in the usual position. Use limb leads for monitoring en route. 4) In all cases where any crew performs a 12-Lead ECG, whether STEMI positive or negative, the Zoll monitor shall be uploaded to the epcr tablet so that the 12-Lead ECGs are part of the Toronto Paramedic Services patient chart record. 5) Do not perform additional 12-Leads once rendezvous with the PCP has occurred. G u i d e l i n e s Notes Chemical Exposure 3

138 Interfacility STEMI Transfer G u i d e l i n e s 4

139 Guidelines Research ACP PCS Intro Checklist for STEMI Fibrinolytics Step One Step Two If ANY of the following is checked YES, Fibrinolytics are NOT indicated Systolic BP greater than 180 mmhg (BP must be manual) Yes No Diastolic BP greater than 110 mmhg (BP must be manual) Yes No Right vs. left arm systolic BP difference greater than 15 mmhg Yes No (BP must be manual) History of stroke, TIA, structural CNS disease (e.g. brain tumour, Yes No aneurysm, arterio-venous malformation) Significant closed head/facial trauma within the previous 3 months Yes No Recent (within 6 weeks) major trauma, surgery (including laser eye Yes No surgery), GI/GU bleed Active bleeding or known clotting problem/clotting disorder or Yes No taking Coumadin type blood thinners (e.g. Warfarin) CPR greater than 10 minutes Yes No Pregnant Yes No Serious systemic disease (e.g. advanced/terminal cancer, cirrhosis Yes No or on dialysis) G u i d e l i n e s Notes Chemical Exposure 5

140 Acute Stroke Protocol Indications for Patient Redirect or Transport Redirect or transport to a Designated Stroke Centre* must be considered for patients who: Present with a new onset of at least one of the following symptoms suggestive of the onset of an acute stroke: Unilateral arm/leg weakness or drift Slurred or inappropriate words or mute Unilateral facial droop AND Can be transported to arrive within 3.5 hours of a clearly determined time of symptom onset or the time the patient was last seen in a usual state of health. Note: * A Designated Stroke Centre is a Regional Stroke Centre, District Stroke Centre or a Telestroke Centre. Contraindications for Patient Redirect or Transport Any of the following conditions exclude a patient from being transported under Stroke Protocol: CTAS Level 1 and/or uncorrected airway, breathing or circulatory problem Symptoms of the stroke have resolved prior to paramedic arrival or assessment** Blood sugar < 3 mmol/l Seizure at onset of symptoms or observed by Paramedic Glasgow Coma Scale < 10 Terminally ill or Palliative Care Patient Duration of out of hospital transport will exceed two (2) hours CACC/ACS will authorize the transport once notified of the patient s need for redirect or transport under the Acute Stroke Protocol. Note: ** Patients whose symptoms improve significantly or resolve during transport will continue to be transported to a Designated Stroke Centre. Version 2.0 February 2011 of the Ontario Stoke Protocol Paramedic Prompt Card G u i d e l i n e s 6

141 Research Guidelines ACP PCS Intro Stroke Assessment Tool Sign/ Symptom Assessment Findings Facial Droop Have the patient grimace and smile If one side of the face does not move as well as the other side, the results are suggestive of an acute stroke. Leg Weakness/ Drift Arm Weakness/ Drift Slurred Speech, Inappropriate Words or Mute Reference: 2010 AHA Guidelines Have the patient lift one leg up approximately 30 degrees and hold it in that position for 5 seconds. Repeat with the other leg. Compare the results. Have the patient hold both arms outstretched in front of their body, parallel to the ground for 5 seconds. Ask the patient to name 3 simple objects that you show them. Ask the patient to repeat a simple sentence. If one leg drifts downward or falls before the end of the 5 seconds or the patient is unable to lift one leg, the result is suggestive of an acute stroke. If one arm drifts downward or falls before the end of the 5 seconds, or the patient is unable to lift one arm, the result is suggestive of an acute stroke. If the patient slurs words, uses inappropriate words when describing the objects or repeating the sentence, or is unable to speak at all, the result is suggestive of an acute stroke. G u i d e l i n e s 7 Notes Chemical Exposure

142 Field Trauma Triage Standard (Steps 1 and 2) 1. Transport time is defined as time from depart scene to time arrive at destination. 2. If a paramedic is unable to successfully manage the airway or the patient is unlikely to survive transport to the LTH, the patient must be transported to the closest Emergency Department. 3. Patients with penetrating trauma to the torso or head/neck are to be transported to a LTH with the 30 minute transport rule independent of lack of vital signs. 4. The paramedic will consider using the Trauma Termination of Resuscitation (TOR) contained in the Trauma Cardiac Arrest Medical Directive when appropriate. G u i d e l i n e s 8

143 Guidelines Research ACP PCS Intro Field Trauma Triage Standard (Steps 3 and 4) 5. The criteria used for bypass to a LTH in Steps 3 and 4 are not absolute; rather are indicators of the potentital for significant injury or indicate the patient may require other support services at the LTH. Not all patients in these two categories require transport to a LTH and the paramedic must use their judgement coupled with these criteria to determine the need for transport to a LTH. 6. Local variances in transport time may occur based upon appropriate Patient Priority Bypass Agreements. G u i d e l i n e s Notes Chemical Exposure 9

144 Clinical Considerations Pediatric For known age 16 yrs OR unknown age but adult size, transport to the closest trauma hospital. For known age <16 yrs OR pediatric size, transport to the closest pediatric hospital. Pregnancy Both Sunnybrook and St. Michael s trauma centres will accept any pregnant patient who meets the criteria of the FTT Guidelines. Any other trauma hospital outside Toronto may accept these patients. G u i d e l i n e s 10

145 Guidelines Research ACP PCS Intro Unexpected Death A death that was not imminently anticipated, e.g. traumatic deaths, deaths related to the environment, accidental deaths, and medical deaths not imminently anticipated, such as sudden cardiac arrest. (NB: This definition is for the purposes of paramedics, and not necessarily coroners.) G u i d e l i n e s Notes Chemical Exposure 11

146 Expected Death A death that was imminently anticipated generally as a result of a progressive end stage terminal illness, such as cancer. (NB: This definition is for the purposes of paramedics, and not necessarily coroners.) G u i d e l i n e s 12

147 Guidelines Research ACP PCS Intro DNR and Expected Death Protocol In the absence of a valid provincial DNR Confirmation Form, a paramedic may manage DNR and expected death patients who are VSA according to the following protocol. Indications A substitute-decision maker (SDM) is present and an alternate written or verbal DNR directive is presented to the paramedic indicating that the patient s wishes are not to be resuscitated. OR A health care provider is present and an alternate written DNR directive is presented to the paramedic indicating that the patient s wishes are not to be resuscitated. Conditions The patient is VSA (i.e. not responsive, no pulse, not breathing, fixed and dilated pupils). There is no need to attach a cardiac monitor. Notes 1. A paramedic will initiate CPR on a patient who is VSA when: a. The SDM rescinds the alternate written or verbal DNR directive by stating he/ she wants the patient to have CPR; or b. There is confusion about who the SDM is and/or one or more people present at the time demands that CPR be initiated on the patient; or c. It would, due to immediate circumstances, be clearly unreasonable to honour the alternate written or verbal DNR directive, including but not limited to the case where a combative or aggressive person present at the time is demanding that CPR be initiated on the patient and the paramedic perceives that to not do so would put his/her safety as risk. 2. Full resuscitation will be initiated on any patient who is not VSA. Contact BHP for further direction if the patient subsequently becomes VSA. G u i d e l i n e s Notes Chemical Exposure 13

148 Performance of Medical Directives While Waiting at Receiving Emergency Department Document all findings on your ACR or epcr G u i d e l i n e s 14

149 Guidelines Research ACP PCS Intro Requesting a Medical Site Team Advance Care Paramedics may request, via patch, a medical site team/physician to attend on-scene. Toronto Paramedic Services communications must be notified. If the patch cannot be established, a site request can be made through a Direct Supervisor. The patient status (including age) will assist the Base Hospital to determine necessary staff/equipment requirements. Transport of the site team and all required equipment to the scene will be the responsibility of Toronto Paramedic Services. Medical Site Team Criteria If the time to patient extrication will be > one hour from the time of assessment AND one or more of the following are present: 1) Urgent insertion of a chest tube is required a. Pneumothorax / tension pneumothorax / not responding to needle thoracostomy b. Penetrating chest injuries c. Major blunt chest trauma 2) Urgent blood transfusion is required a. Severe hypovolemia (SBP < 80, pulse > 130) b. Untamponaded bleed (i.e. intra-abdominal) c. No response to crystalloid bolus 3) Surgical extrication is required G u i d e l i n e s Notes Chemical Exposure 15

150 Burn Triage Prehospital burn triage to the Sunnybrook Ross Tilley Burn Centre aims to provide ready access for burn patients according to the following criteria: Prehospital Assessment and Decision for Eligibility Prehospital assessment and triage decision will be made by the most senior Paramedic, either a Primary or Advanced Care Paramedic. There is no need to patch to the base hospital to validate this decision. Indications for Triage and Transport to the Burn Centre 1) Partial-thickness burns 10% of the total body surface area 2) Full-thickness burns 5% of the total body surface area 3) Full-thickness burns that involve the face, hands, feet, genitalia, perineum or major joints 4) Partial and full thickness electrical burns, including burns secondary to lightning injury 5) Partial and full-thickness chemical burns 6) Above burns with coexistent minor trauma not meeting field trauma triage guidelines (e.g. isolated fracture) where the burn injury appears to pose the greatest risk Contraindications for Triage and Transport to the Burn Centre 1) Age < 16 years 2) Isolated smoke inhalation with no other existing criteria listed above 3) Oropharyngeal and suspected airway burns with inability to manage the airway despite existing criteria listed above. Go to the nearest emergency department. This includes patients who deteriorate on route to the Burn Centre. 4) Isolated corneal burns 5) Above burns with coexistent major trauma meeting field trauma triage guidelines where trauma appears to pose the greatest risk. These patients should be triaged to the nearest trauma centre. G u i d e l i n e s 16

151 Guidelines Research ACP PCS Intro Patients with an Isolated Appendage Amputation When the following conditions exist, a paramedic may transport a patient with an isolated appendage amputation to the Emergency Department of the University Health Network (UHN) Western Site. Indications for Triage to UHN Western Site 1) Complete or near complete amputation of any of the following appendages: a. Upper or lower limb b. Finger above (i.e. proximal to) the distal interphalangeal joint c. Thumb above (i.e. proximal to) the interphalangeal joint d. Nose, ear, genetalia 2) The amputated appendage is available (or is expected to be available) for transport to UHN Western Site. Contraindications for Triage to UHN Western Site 1) Toe amputations, (toes are not re-implanted). 2) Suspected multiple trauma involving head, chest, abdomen, or spinal cord that may require full assessment by a trauma team (see notes below). 3) Suspected pelvic fracture or greater than one other major long bone fracture. 4) Presence of penetrating trauma (e.g. stabbing, gunshot, impalement). Conditions 1) Patient must be 16 years of age Procedure 1) Provide care and transport according to basic life support patient care standards 2) Confirm destination with dispatch and notify the receiving emergency department according to usual procedure Notes 1. A multiple trauma patient and the amputated appendage will be transported to a regional facility according to field trauma triage guidelines 2. Pregnancy is not a contraindication to implementing this guideline G u i d e l i n e s Notes Chemical Exposure 17

152 Spinal Motion Restriction (SMR) for Penetrating Trauma Notes 1. Primary Assessment A = Airway B = Breathing C = Circulation D = Disability (assessed in Spinal Neural Assessment step) 2. Neurological Assessment Reliable Patient: Unreliable Patient: GCS = 15 GCS 14 Alert and Cooperative Intoxicated Sober Head/Brain Injury No Distracting Injuries Distracting Injuries Isolated limb numbness or coldness, err on the side of caution. Isolated penetrating trauma to a limb will result in disability in that limb. SMR would not be necessary in this case. G u i d e l i n e s 18

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159 ACP PCS Intro RESEARCH Chemical Exposure IMPORTANT NOTE Any auxiliary research medical directive will require preauthorization by the Medical Director with a specific start date identified. Upon completion of a prehospital clinical trial, research-related treatment must be halted and care as prescribed by BLS and ALS Patient Care Standards must resume. Research Guidelines R e s e a r c h Notes

160 Table of Contents FRONTIER Study Medical Directive... 3 TXA Traumatic Brain Injury Study Medical Directive... 7 Blank Pages for Future Research... 9 R e s e a r c h 2

161 FRONTIER Study Medical Directive An Advanced Care or Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Patient with a new onset of symptoms suggestive of the onset of an acute stroke who qualifies for transport to a designated stroke centre based on the Ontario Paramedic Prompt Card for Acute Stroke Protocol. PCS Intro ACP Conditions AGE: Study Drug Vial years LOA: GCS 10 HR: RR: O2 Sat: SBP: % on room air Weight: kg Other: Patch to on-call trial physician who will review the LAMS and inclusion/exclusion criteria with the paramedic to discuss whether eligible for the trial Neurologic Conditions Last seen in a usual state of health < 3 hours before trial drug initiation Independently Ambulatory with or without devices prior to event LAMS 2-5 for 15 minutes LAMS remains 2-5 at time of randomization to receive study drug Chemical Exposure Research Guidelines R e s e a r c h 3 Notes

162 Conditions, continued LAMS = Los Angeles Motor Scale Facial Droop Absent 0 Present 1 Arm Drift Absent 0 Drifts down 1 Falls rapidly 2 Grip Strength Normal 0 Weak grip 1 No grip 2 Contraindications Study Drug Vial CTAS Level 1 and/or uncorrected airway, breathing or significant circulatory problem Blood sugar < 3 mmol/l Seizure at onset of symptoms or observed by paramedic Major head trauma in past three months Stroke in the past three months Known to be pregnant or breastfeeding Prisoner Study Drug Vial (continued) Not independently ambulatory Long term care facility resident Valid EHS DNRC form Known participation in a drug or device trial in past 30 days Pre-existing condition that would preclude neurological outcome evaluation R e s e a r c h 4

163 Treatment MANDATORY PATCH POINT: Patch to Study Physician Consider FRONTIER Study Drug: PCS Intro Notes Dose Dilution Route IV Infusion Pump On-call trial physician and paramedic will discuss and agree on the dosage based on kg weight estimate by paramedic (reference dosing chart below) 50 ml saline mini-bag Infusion interval 10 min. Max. # doses 1 Estimated Weight (kg) Syringe Volume to Transfer to 50 ml Saline IV Mini-bag (ml) FRONTIER = Field Randomization of NA-1 in Early Responders 2. Study drug vial contains either NA-1 or placebo 3. LAMS = Los Angeles Motor Scale R e s e a r c h Notes Research Guidelines Chemical Exposure ACP 5

164 MEDIC NAME: MEDIC # (OASIS): FRONTIER PATCH ALLERGIES: AMBULANCE #: STUDY DRUG AMOUNT: ML RUN #: WARM MARKER TAG PATIENT INFORMATION NONE BRIEF AGE: SEX: WT: MODERATE PROLONGED INCLUSION CRITERIA PATIENT MEETS STROKE PROMPTCARD Y N B.G: H/R: VITALS SIGNS GCS: PUPILS: IV ESTABLISHED Y N B/P: ECG: AMBULATORY WITH/WITHOUT DEVICES PRIOR TO EVENT COULD GO SHOPPING ON THEIR OWN PRIOR TO EVENT Y N R/R: Y N CTAS 1 EXCLUSION CRITERIA O2SAT: BRAIN TRAUMA < 3 MONTHS AGO Y N Y N PATIENT PRESENTATION/HX STROKE < 3 MONTHS AGO Y N PREGNANT/BREAST FEEDING PRISONER Y N Y N LAMS: LONG TERM CARE FACILITY Y N LAST SEEN NORMAL: HOURS DNR Y N MEDS MEDICAL TRIAL < 30 DAYS AGO Y N PRE-EXISTING NEUROLOGIC CONDITION WHICH HINDERS DAILY INDEPENDENT FUNCTION Y N R e s e a r c h 6

165 TXA Traumatic Brain Injury Study Medical Directive An Advanced Care or Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. PCS Intro Indications Patient with blunt or penetrating mechanism consistent with Traumatic Brain Injury. Conditions ACP AGE: Study Drug Vial 15 years or meets weight condition if age unknown LOA: Initial GCS <13 HR: RR: O2 Sat: SBP: 90 Weight: 50 kg if not known to meet age condition Other: Must go to lead Trauma Centre Glasgow Coma Scale Eye Opening Point Eyes open spontaneously 4 Eyes open to verbal command 3 Eyes open only with painful stimuli 2 No eye opening 1 Verbal Response Oriented and converses 5 Disoriented and converses 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Motor Response Obeys verbal commands 6 Response to painful stimuli (UE) Localizes pain 5 Withdraws from pain 4 Flexor posturing 3 Extensor posturing 2 No motor response 1 Chemical Exposure Research Guidelines R e s e a r c h 7 Notes

166 Contraindications Study Drug Vial GCS = 3 AND bilateral unreactive pupils 2 hr from injury to start of study drug administration Unknown time of injury Clinical suspicion of seizure, STEMI or CVA as part of presentation Known PMHx of seizure, PE, DVT or dialysis CPR prior to randomization Study Drug Vial (continued) Prehospital TXA given for another reason Burns 20% TBSA Known Pregnancy Prisoner Already received open label TXA Opted-out Treatment Consider TXA Study Drug: Dose Route IV One vial of study drug Dilution 250 ml saline Infusion interval Bolus Max. # doses 1 If the GCS increases to 13 or SBP drops to < 90 mmhg after the kit is opened, continue the study drug infusion. Notes 1. TXA = Tranexamic acid 2. PE = pulmonary embolus 3. DVT = deep venous thrombosis 4. TBSA = total body surface area 5. Study drug vial contains either TXA -1 or placebo R e s e a r c h 8

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