PCP Medical Directives Paramedic Handbook 2012 · Self‐reports may include, but are not limited...
Transcript of PCP Medical Directives Paramedic Handbook 2012 · Self‐reports may include, but are not limited...
Credits Editor‐in‐Chief Severo Rodriguez Editor and Project Manager Cathy Prowd Publication Assistant Tracy Gaunt Editor – Medical Content Dr. Michael Lewell
Acknowledgements The Southwest Ontario Regional Base Hospital Program would like to acknowledge the Program staff and paramedics who took time to provide us with their feedback and suggestions. Your contributions were integral in the development of this protocol book.
Replacement Books Replacement books can be purchased at a cost of $20.00 each. To purchase a replacement book, email: [email protected]
ISBN: 978‐0‐9694553‐3‐2 www.lhsc.on.ca/bhp
Introduction
Authorization for Delegation of Medical Directives
The Medical Directives contained in this handbook have been approved for use by paramedics certified with the Southwest Ontario Regional Base Hospital Program. Delegation of these Medical Directives is under the direction of Dr. Michael Lewell, Regional Medical Director, in conjunction with Local Medical Directors Dr. Adam Dukelow, Dr. Don Eby, and Dr. Paul Bradford. Dated: November 14, 2011 Authorized by: Michael Lewell, B.Sc., M.D., FRCP(C) Regional Medical Director Signature: Note: This paramedic handbook contains content from the Ministry of Health and Long‐Term Care Advanced Life Support Patient Care Standards, version 3.0 dated November 2011. To access the full document please refer to www.lhsc.on.ca/bhp.
Introduction
Areas of Regional Medical Oversight
Regional Medical Director: Dr. Michael Lewell Provides medical direction to the region
Local Medical Director: Dr. Adam Dukelow
Provides medical oversight to The County of Lambton EMS, Middlesex London EMS, Oneida Nation of the Thames EMS,
Oxford County EMS, Thames EMS Elgin‐St. Thomas
Local Medical Director: Dr. Don Eby Provides medical oversight to The County of Bruce EMS, Grey County EMS,
Huron County EMS, The County of Perth EMS
Local Medical Director: Dr. Paul Bradford Provides medical oversight to Essex‐Windsor EMS,
Medavie EMS Chatham‐Kent
Assistant Medical Director: Dr. Michael Peddle
Introduction
SWORBHP Staff Contact List
Regional Program Manager Severo Rodriguez Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected] Regional Medical Director Dr. Michael Lewell Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected] Local Medical Director Dr. Adam Dukelow Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected] Local Medical Director Dr. Don Eby Office: 519‐372‐3920 ext. 2023 [email protected] Local Medical Director Dr. Paul Bradford Office: 519‐973‐4411 ext. 2393 [email protected] Assistant Medical Director Dr. Michael Peddle Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected]
Administrative AssistantNoelia Teixeira Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected] Operations & Logistics Specialist Catherine Prowd Office: 519‐372‐3920 ext. 2449 Cell: 226‐668‐5268 [email protected] Coordinator, Professional Standards & Performance Improvement Adeel Ahmed Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 77058 [email protected] Professional Standards Specialist Paul Robinson Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 77620 Cell: 519‐854‐6467 [email protected] Professional Standards Specialist Tracy Gaunt Office: 519‐372‐3920 ext. 2023 Cell: 226‐668‐3559 [email protected] Team Assistant, Professional Standards Brenda Smith‐Huie Office: 1‐866‐544‐9882 Office: 519‐667‐6718 [email protected]
Coordinator, TrainingDavid J. Vusich Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 75847 Cell: 519‐636‐8469 [email protected] Regional Paramedic Educator Dwayne Cottel Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 75580 Cell: 519‐619‐9125 [email protected] Regional Paramedic Educator Stephanie Romano Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 78990 Cell: 519‐200‐2567 [email protected] Regional Paramedic Educator Pete Morassutti Office: 519‐973‐4411 ext. 2387 Cell: 519‐796‐4602 [email protected] Certification Associate Michelle Frazer Office: 1‐866‐544‐9882 Office: 519‐685‐8500 ext. 75621 [email protected] Fax Numbers: London: 519‐652‐2051 Owen Sound: 519‐372‐3948 Windsor: 519‐255‐2191
Introduction
Self‐Report Hotline – 1‐888‐997‐6718
Self‐Reports Rationale Self‐reporting is an important part of paramedic practice: it equates to professionalism and is a form of education through self‐remediation. The Base Hospital strives to improve not only individual paramedic performance but system performance through the clinical audit, self‐reports, and educational processes. All processes are linked in order to reach a common goal, to improve paient safety and outcomes. Content Self‐reports may include, but are not limited to, protocol variances, documentation omissions, patch failure or omissions, or any challenges a paramedic may encounter during a call. Process
Information in your self‐report should contain: 1. Paramedic Service 2. Paramedic Name 3. Call Date 4. Run Number 5. Receiving Hospital 6. A brief description of the occurrence being reported Note You can expect a phone call or email 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 Local Medical Director for further review.
Patient Care Standards Introduction
TABLE OF CONTENTS
Introduction Acknowledgements .............................................................................................................................. 1
Level of Paramedics .............................................................................................................................. 2 Purpose of Standards ............................................................................................................................ 2 Summary ............................................................................................................................................... 2
Use of the medical directives by Paramedics ....................................................................................... 3 Regional Base Hospital Compliance with CPSO Policy .......................................................................... 3
General Structure of a Medical Directive ............................................................................................. 4 ALS Patient Care Standards Paramedic Skill Set ................................................................................... 4
Consent to Treatment and Capacity Assessment ................................................................................. 5 Refusal of Treatment ............................................................................................................................ 6
Comprehensive Care ............................................................................................................................. 7 Intravenous Access and Therapy by Primary Care Paramedics ............................................................ 7
Home Medical Technology and Novel Medications ............................................................................. 8 Patching ................................................................................................................................................ 9
Incident Reporting ................................................................................................................................ 9 Controlled Substances ........................................................................................................................ 10 Responsibility for Care ........................................................................................................................ 10
Research .............................................................................................................................................. 11 Conventions ........................................................................................................................................ 11
Drug Doses and Administration .......................................................................................................... 11 Age and Vital Signs .............................................................................................................................. 12
Hypoglycemia ...................................................................................................................................... 13 Level of Awareness ............................................................................................................................. 13
List of Abbreviations ........................................................................................................................... 14 Reference and Educational Notes ...................................................................................................... 17
PCP Core Medical Directives Medical Cardiac Arrest Medical Directive .................................................................................... 18 Trauma Cardiac Arrest Medical Directive ..................................................................................... 22 Hypothermia Cardiac Arrest Medical Directive ........................................................................... 26 Foreign Body Airway Obstruction Cardiac Arrest Medical Directive ........................................ 28 Neonatal Resuscitation Medical Directive .................................................................................... 30 Return of Spontaneous Circulation (ROSC) Medical Directive................................................... 32 Cardiac Ischemia Medical Directive ............................................................................................... 34 Acute Cardiogenic Pulmonary Edema Medical Directive ........................................................... 36
Patient Care Standards Introduction
Cardiogenic Shock Medical Directive ............................................................................................ 38 Hypoglycemia Medical Directive .................................................................................................... 40 Bronchoconstriction Medical Directive ......................................................................................... 42 Moderate to Severe Allergic Reaction Medical Directive ........................................................... 45 Croup Medical Directive .................................................................................................................. 47
PCP Auxiliary Medical Directives Chart of Auxiliary Directives Approved For Use By Ambulance Services ................................. 49 Intravenous and Fluid Therapy Medical Directive ....................................................................... 50 Continuous Positive Airway Pressure (CPAP) Medical Directive ............................................... 52 Supraglottic Airway Medical Directive .......................................................................................... 54 Nausea / Vomiting Medical Directive ............................................................................................ 56 Electronic Control Device Probe Removal Medical Directive .................................................... 58 Minor Abrasions Medical Directive ............................................................................................... 59 Minor Allergic Reaction Medical Directive ................................................................................... 61 Musculoskeletal Pain Medical Directive ....................................................................................... 63 Headache Medical Directive ........................................................................................................... 65
PCP Reference Material 12‐Lead ECG Review ........................................................................................................................ 67
12‐Lead ECG Placement .................................................................................................................. 68 CPR Guide .......................................................................................................................................... 69 Pediatric CPR Guidelines ................................................................................................................. 70 Relief of Foreign‐Body Airway Obstruction .................................................................................. 70 Pediatric Vital Signs .......................................................................................................................... 71 Apgar Score ....................................................................................................................................... 71 Pediatric Glasgow Coma Scale ........................................................................................................ 71 Pediatric Trauma Score ................................................................................................................... 72 Canadian Triage & Acuity Scale (CTAS) ......................................................................................... 73 Stroke Prompt Card ......................................................................................................................... 74 Stroke Assessment Tool .................................................................................................................. 75 BHP Patch for Trauma TOR ............................................................................................................. 76 BHP Patch for Medical TOR ............................................................................................................. 77
BHP Patch Phone Numbers BHP Patch Phone Numbers ............................................................................................................. 79
Notes
Patient Care Standards Introduction
1
ACKNOWLEDGEMENTS
The development of this edition of the Advanced Life Support Patient Care Standards is the result of a
collaborative effort of a number of stakeholders including:
Association of Municipal Emergency Medical Services of Ontario (AMEMSO)
Ontario Base Hospital Group (OBGH)
Ministry of Health and Long Term Care – Emergency Health Services Branch (MOHLTC EHSB)
EHSB Provincial Medical Advisory Committee (MAC)
In particular, the Ministry would like to gratefully acknowledge the following members of the MAC and
regional base hospitals who provided the medical input into these standards:
Dr. Andrew Affleck Dr. Sheldon Cheskes Northwest Region Base Hospital Program Sunnybrook Centre for Prehospital Medicine Dr. Michael Lewell Dr. Justin Maloney Southwest Ontario Regional Base Hospital Regional Paramedic Program for Eastern Program Ontario Dr. Jason Prpic Dr. Rudy Vandersluis, Senior Medical Editor Northeastern Ontario Prehospital Care Central East Prehospital Care Program Program Dr. Richard Verbeek, Lead Medical Editor Dr. Michelle Welsford Sunnybrook Centre for Prehospital Medicine Centre for Paramedic Education and Research Marc Landriault, ACP Chris Millington, PCP Ottawa Paramedic Service Superior North EMS Doug Socha, Chief Andy Benson Hastings‐Quinte EMS Manager, Education programs Central East Prehospital Care Program Christopher Bourque Tim Dodd Manager, Clinical Performance Management Manager, Education Regional Paramedic Program for Eastern Centre for Paramedic Education and Research Ontario
Patient Care Standards Introduction
2
LEVELS OF PARAMEDICS
In Ontario, there are three occupational levels of paramedics: Primary Care Paramedic (PCP), Advanced
Care Paramedic (ACP), and Critical Care Paramedic (CCP). A level of paramedic is specified in Ontario
Regulation 257/00 made under the Ambulance Act, RSO 1990, c A‐19. Schedules 1, 2, and 3 to this
regulation specify the mandatory controlled acts for each level of paramedic.
A paramedic may be authorized by a medical director of a Regional Base Hospital (RBH) to perform
controlled acts from the Schedule immediately above their prime occupational level. In this
circumstance, the paramedic will perform the skill to the specific standard set for the skill. This general
concept also applies to the performance of all advanced medical procedures that are not listed as
controlled acts in Schedules 1, 2, and 3, but which are also specified in these standards.
PURPOSE OF STANDARDS
The purpose of the Advanced Life Support Patient Care Standards (ALS PCS) is to guide the specifics of
patient care that are to be undertaken consistent with the scope of practice of the three occupational
levels of paramedics.
The ALS PCS:
Reflects current practices for paramedics in Ontario and provides benchmarks for paramedic
performance.
Communicates the standards of practice and care by paramedics in Ontario to paramedics, patients,
other disciplines, and the public in general.
Delineates paramedic professional responsibilities and accountabilities.
Provides a basis for evaluation of patient care practice by Ontario’s paramedics.
Recognizes that the scope of practice for each occupational level of paramedic may have
incremental add‐ons, with appropriate rationale and accountability.
SUMMARY
ALS PCS for the three occupational levels of paramedics in Ontario establish the practice and patient
care parameters needed to provide high quality patient care in the varied settings throughout the
province. The standards are designed to be dynamic, in order to allow for changes based upon new
medical evidence and/or standards of medical practice.
Patient Care Standards Introduction
3
USE OF THE MEDICAL DIRECTIVES BY PARAMEDICS
These medical directives apply to paramedics who provide patient care under the license and/or
authority of the RBH Medical Director. Delegation of controlled acts or medical directives in the ALS PCS
to paramedics falls under the exclusive oversight of the MOHLTC’s RBH Programs.
The medical directives are designed to guide a paramedic in the provision of timely and appropriate care
to ill and injured patients in the prehospital setting, in accordance with the paramedics’ training and
authorized skill set. While great care has been taken in developing these medical directives, they cannot
account for every clinical situation. Thus, they are not a substitute for sound clinical judgment.
REGIONAL BASE HOSPITAL COMPLIANCE WITH CPSO POLICY
As licensed physicians in the Province of Ontario, the RBH Medical Directors must comply with the
policies of the College of Physicians and Surgeons of Ontario (CPSO). CPSO policy #4‐03, as may be
amended from time to time, provides direction to Ontario physicians on the delegation of controlled
acts, regardless of practice setting or type. RBHs will also follow a parallel process for delegation of
other advanced medical procedures included in these Standards.
Patient Care Standards Introduction
4
GENERAL STRUCTURE OF A MEDICAL DIRECTIVE
All medical directives follow the same format and are comprised of the following sections:
Indication: The general medical complaint or problem to which the medical directive
applies.
Conditions: Clinical parameters that must be present for a procedure to be performed
or for a drug to be administered.
Contraindications: Clinical parameters that if present, preclude the performance of a
procedure or the administration of a drug.
Treatment: Description of the type of procedure to be performed or the dosing of a
drug.
Clinical Considerations: Key clinical points that provide general guidance to the proper
performance of a procedure or the administration of a drug.
All of these sections must be taken into account before and during the implementation of a medical
directive.
ALS PATIENT CARE STANDARDS PARAMEDIC SKILL SET
The mandatory skill set for each level of paramedic is derived from the controlled acts outlined in
Schedules 1, 2, and 3 (as referenced above) and is implemented through the PCP and ACP Medical
Directives. A paramedic must meet all applicable requirements set out in Regulation 257/00 to receive
delegation from a RBH medical director.
Additional (“Auxiliary”) skills may be delegated though use of the Auxiliary Medical Directives.
Delegation of Auxiliary Medical Directives by a RBH medical director to paramedics is optional and may
be introduced after consultation and mutual agreement between the RBH and the certified ambulance
service operator that employs the paramedic. Some PCP and ACP Medical Directives contain the phrase,
“(if available)”. This phrase qualifies the skill or procedure as optional (i.e. auxiliary) even if included in
PCP or ACP Medical Directives.
Patient Care Standards Introduction
5
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.
Patient Care Standards Introduction
6
A patient is capable with respect to treatment if the patient is:
Able to understand the information that is relevant to making a decision about the treatment or
alternatives being proposed; and
Able to appreciate the reasonably foreseeable consequences of a decision or lack of decision
with respect to treatment.
If a paramedic is aware or is made aware that the person has a prior capable wish with respect to
treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).
If a person is incapable with respect to a treatment, consent may be given or refused on his or her
behalf by a person who is authorized to do so under section 20 of the Health Care Consent Act, 1996.
In some instances, a person may present in an emergency situation where the person for whom the
treatment is proposed is apparently experiencing severe suffering or is at risk, if the treatment is not
administered promptly, of sustaining serious bodily harm.
A paramedic may administer treatment to a person without consent in an emergency situation, if there
is no other authorized person available to give or refuse consent and, in the opinion of the paramedic:
the person is not capable of giving a consent or refusal to treatment; and
the delay required to obtain a consent or refusal on the person’s behalf will prolong the
suffering that the person is apparently experiencing or will put the person at risk of sustaining
serious bodily harm.
REFUSAL OF TREATMENT
If a patient refuses treatment, either in whole or in part, a paramedic must comply with the applicable
directions contained in the Basic Life Support (BLS) Patient Care Standards, Section 1, Part I, Patient
Refusal of Treatment and/or Transport.
Patient Care Standards Introduction
7
COMPREHENSIVE CARE
While initiating and continuing treatment prescribed by these medical directives, a paramedic must
ensure that the patient simultaneously receives care in accordance with the BLS Patient Care Standards.
It is acknowledged that there may be circumstances and situations where complying with Advanced Life
Support Patient Care Standards is not clinically justified, possible, or prudent (e.g. multiple crews on
scene, trapped patient, extenuating circumstances, competing patient care priorities). When treatment
deviates from the standards, a paramedic must document the care provided, including reasoning for
deviating from the Standards.
INTRAVENOUS (“IV”) ACCESS AND THERAPY BY PRIMARY CARE PARAMEDICS
Two levels of certification of PCPs for IV cannulation and therapy are possible.
“PCP Assist IV” authorizes a PCP to cannulate a peripheral IV at the request and under the direct
supervision of an ACP. The patient must require a peripheral IV in accordance with the indications listed
in the Intravenous Access and Fluid Therapy Medical Directive ‐ Auxiliary. The ACP will perform all IV
therapy in accordance with the Intravenous Access and Fluid Administration Protocol once intravenous
access is obtained. PCPs certified in PCP Assist IV are not authorized to administer IV therapy.
“PCP Autonomous IV” authorizes a PCP to independently cannulate an IV according to the Intravenous
Access and Fluid Therapy Medical Directive – Auxiliary. PCPs certified in PCP Autonomous IV are
authorized to administer IV therapy according to applicable medical directives.
Certification at each level shall meet the requirements established by the provincial Medical Advisory
Committee.
Patient Care Standards Introduction
8
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 or ALS Patient Care Standards. 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 unique devices, medications
or care requirements, a unique 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 and ALS patient care standards.
Patient Care Standards Introduction
9
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.
Patient Care Standards Introduction
10
CONTROLLED SUBSTANCES
Where applicable, paramedics and ambulance service operators shall comply with the Canada
Controlled Drug and Substances Act, SC 1996, c 19 and its Regulations, in accordance with the
ambulance operator and RBH policy. This shall include that controlled substances (opiates and
benzodiazepines) are stored in different carrying cases than other medications.
RESPONSIBILITY FOR CARE
While on scene, the highest level paramedic shall assess the patient and make a decision on the level of
care required, and on the level of paramedic required for the care of the patient. The highest level
paramedic is the ultimate patient care authority on the scene. If there is any disagreement between
paramedics, the Base Hospital physician may be contacted. It is expected that when an intervention has
been performed, the paramedic most appropriate for that intervention will remain responsible for the
patient.
In all patient care, the highest level of paramedic is responsible for the care of the patient, including
decisions on the level of care required during transport. A paramedic may choose to assign aspects of
care and procedures to an alternate level paramedic, as long as the care and procedures are within that
paramedic’s scope of practice. Paramedics must alert the highest level paramedic of any change of
patient status.
When transferring care from one level of paramedic to another, paramedics shall provide:
current CTAS level; a history of the patient’s current problem(s) and relevant past medical history; pertinent physical findings; a summary of management at scene/enroute; the patient’s response to treatment, including most recent vital signs; the reason for transfer in cases of inter‐facility transfers.
The transfer of responsibility of patient care is a critical juncture along the clinical care continuum.
When transferring patient care to another health care provider (e.g. nurse, physician, etc.), a paramedic
must comply with the BLS Patient Care Standards regarding such transfers.
Patient Care Standards Introduction
11
RESEARCH
Clinical research is fundamental to the practice of medicine and the development of safer, more
effective treatment options for patients. At times, research protocols require temporary changes to
patient care standards. In recognition of the importance of prehospital clinical research, RBH Medical
Directors may delegate changes in patient care standards to paramedics if the research‐related
treatment is endorsed by MAC–OBHG and the certified ambulance operator that employs the
paramedics, approved by MOHLTC, and is supported by an appropriate research ethics review board.
Changes to patient care standards will be introduced as an auxiliary medical directive. Upon completion
of a prehospital clinical trial, research‐related treatment must be halted and care as prescribed by BLS
and ALS Patient Care Standards must resume.
CONVENTIONS
“Conventions” refers to a consistent application of terms throughout the medical directives based on
definitions below.
The word ‘consider’ is used repeatedly throughout the medical directives. Where this word appears, it
indicates that a paramedic should initiate the treatment unless there is strong clinical rationale to
withhold it. A paramedic must document his or her justification for withholding treatment on the ACR.
DRUG DOSES AND ADMINISTRATION
Drug doses may be either in per kilogram or fixed doses, depending on common clinical practice. The
number of recommended drugs doses may be administered regardless of any previous self‐
administration by a patient. When more than one route of drug 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 drug doses can vary slightly according to the source of expert opinion. The pediatric drug
doses in the ALS PCS are the preferred doses. However, drug doses as determined by an up‐to‐date
version of a widely accepted pediatric emergency tape (e.g. Broselow Tape) are an acceptable
alternative. Use of a pediatric emergency tape shall be documented on the ACR when it is used to
determine a pediatric drug dose.
Patient Care Standards Introduction
12
AGE AND VITAL SIGNS
The general age cut off between adults and pediatrics is 18 years. There is a wide range of “normal” for
vital signs in adults and especially pediatrics. As much as possible, ages for pediatrics and cut off points
for vital signs have been kept consistent throughout the medical directives. However, clinical research
and expert opinion have resulted in a number of exceptions which in each case has been deliberately
chosen and is clearly noted in each medical directive. There is a deliberate gap in the definition of
normotension and hypotension in adults.
ADULTS
Normotension ‐ SBP ≥100mmHg;
Hypotension ‐ SBP <90 mmHg
Heart rate: Heart rate is always in beats per minute according to a cardiac monitor when it is
applied. In situations where a cardiac monitor is not indicated then the heart rate is equal to
the pulse rate.
Bradycardia ‐ <50 BPM;
Tachycardia ‐ ≥100 BPM
Tachypnea ‐ RR ≥28 breath/min PEDIATRICS
Age Respiratory Rate Heart Rate0‐3 months 30‐60 90‐1803‐6 months 30‐60 80‐1606‐12 months 25‐45 80‐1401‐3 years 20‐30 75‐1306 years 16‐24 70‐11010 years 14‐20 60‐90
Systolic Blood Pressure (for children 1‐10 years) = 70 + (2 x age in years)
Weight (kg) = (age x 2) + 10
Patient Care Standards Introduction
13
HYPOGLYCEMIA:
Age ≥2 years: glucometry <4.0 mmol/L
Age <2 years: glucometry <3.0 mmol/L
LOA (Level of Awareness):
The word ‘altered’ refers to a GCS that is less than normal for the patient.
The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS <15.
Patient Care Standards Introduction
14
LIST OF ABBREVIATIONS
The following abbreviations, in alphabetical order, appear in the ALS Patient Care Standards:
A ACP Advanced Care Paramedic ALS Advanced Life Support ALS PCS Advanced Life Support Patient Care Standards ASA acetylsalicylic acid AV atrioventricular B BH base hospital BHP Base Hospital Physician BLS Basic Life Support BP blood pressure BPM beats per minute BVM bag‐valve‐mask C CCP Critical Care Paramedic COPD chronic obstructive pulmonary disease cm centimeter CPAP continuous positive airway pressure CPR Cardiopulmonary Resuscitation CPSO College of Physicians and Surgeons of Ontario CTAS Canadian Triage and Acuity Scale CVA cerebral vascular accident CVAD central venous access device D DKA diabetic ketoacidosis E ECD electronic control device ECG electrocardiogram EDD esophageal detection device ETCO2 end tidal carbon dioxide ETT endotracheal tube F FiO2 fraction of inspired oxygen FRI febrile respiratory infection
Patient Care Standards Introduction
15
G g gram GCS Glasgow Coma Scale H H2O water HR heart rate Hx history I IM intramuscular IN intranasal IO intraosseous IV intravenous K kg kilogram L LOA level of awareness LOC level of consciousness/loss of consciousness M MAC Medical Advisory Committee mcg microgram MDI metered dose inhaler mg milligram min minute ml/kg milliliter per kilogram mmHg millimeters of mercury MOHLTC Ministry of Health and Long‐Term Care N N/A not applicable NaCl sodium chloride nare nostril NEB nebulized NPA nasopharyngeal airway NSAID non‐steroidal anti‐inflammatory drug
Patient Care Standards Introduction
16
O OBHG Ontario Base Hospital Group OPA oropharyngeal airway P PCP Primary Care Paramedic PO by mouth/oral PRN as needed Q q every R RBH Regional Base Hospital ROSC return of spontaneous circulation RR respiratory rate S SC subcutaneous SL sublingual SBP systolic blood pressure SpO2 saturation of peripheral oxygen STEMI ST‐segment elevation myocardial infarction T TBI traumatic brain injury TCA tricyclic antidepressant TCP transcutaneous pacing U URTI upper respiratory tract infection V VSA vital signs absent W WNL within normal limits
Patient Care Standards Introduction
17
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.
PCP Core Medical Directives
18
Manual Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: VF or pulseless VT
Epinephrine
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Anaphylaxis suspected as causative event
Medical TOR
AGE: ≥18 years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Arrest not witnessed by EMS, AND No ROSC AND No shocks delivered
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Performed for 2 minute intervals
AED Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Shock indicated
MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized
Indications
Non‐traumatic cardiac arrest
Conditions
PCP Core Medical Directives
19
Epinephrine
Allergy or sensitivity to epinephrine
Medical TOR
Arrest thought to be of non‐cardiac origin
Manual Defibrillation
Rhythms other than VF or pulseless VT
CPR
Obviously dead as per BLS standards
Meet conditions of DNR standard
AED Defibrillation
Non‐shockable rhythm
Consider AED defibrillation: (with pediatric attenuator if available)
Age Age ≥30 days to <8 years ≥8 years
With Ped attenuator
Without Ped attenuator
Dose 1 shock 1 shock 1 shock
Max. single dose As per BH / manufacturer
As per BH / manufacturer
As per BH / manufacturer
Dosing interval N/A N/A N/A Max. # of doses 4 4 4
Consider CPR
Contraindications
Treatment
PCP Core Medical Directives
20
Consider Manual defibrillation: (if certified and authorized)
Age Age
≥30 days to <8 years ≥8 years
Dose 1 shock 1 shock
First dose 2 J/kg As per BH / manufacturer
Subsequent and max. dose(s) 4 J/kg As per BH /
manufacturer Dosing interval 2 min 2 min
Max. # of doses 4 4
MANDATORY PROVINCIAL PATCH POINT:
Patch to BHP for authorization, following the 3rd analysis, to consider Medical Termination of Resuscitation (TOR) (if applicable). If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate receiving hospital following ROSC or the 4th analysis.
Consider epinephrine (only if anaphylaxis suspected as causative event):
Weight N/A Route IM Concentration 1:1,000 Dose 0.01 mg/kg* Max. single dose 0.5 mg Dosing interval N/A Max. # of doses 1
* The epinephrine dose may be rounded to the nearest 0.05 mg.
PCP Core Medical Directives
21
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. A Paramedic may choose to move the patient to the ambulance prior to initiating the TOR if family is not coping well or the arrest occurred in a public place. Follow the Deceased Patient Standard once TOR has been implemented.
PCP Core Medical Directives
22
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
AED Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Shock indicated
Manual Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: VF or pulseless VT
Trauma TOR
AGE: ≥16 years
LOA: Altered
HR: 0
RR: 0
SBP: N/A
Other: No palpable pulses No defibrillation delivered and
monitored HR = 0 (asystole) OR monitored HR >0 AND the closest ER ≥30 min transport time away.
TRAUMA CARDIAC ARREST MEDICAL DIRECTIVE
A Primary 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
PCP Core Medical Directives
23
CPR
Obviously dead as per BLS standards
Meet conditions of DNR standard
Consider CPR
Trauma TOR
Age <16 years
Shock delivered
Monitored HR >0 and closest ER <30 min away
Manual Defibrillation
Rhythms other than VF or pulseless VT
AED Defibrillation
Non‐shockable rhythm
Consider AED defibrillation:
Age Age ≥30 days to <8 years ≥8 years
With Ped attenuator
Without Ped attenuator
Dose 1 shock 1 shock 1 shock
Max. single dose As per BH / manufacturer
As per BH / manufacturer
As per BH / manufacturer
Dosing interval N/A N/A N/A Max. # of doses 1 1 1
Contraindications
Treatment
PCP Core Medical Directives
24
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.
Consider Manual defibrillation: (if certified and authorized)
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 N/A N/A Max. # of doses 1 1
Clinical Considerations If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat according to the appropriate medical cardiac arrest directive.
PCP Core Medical Directives
25
Treatment
TOR implementedTransport to ED
Patch
Drive time to closest ER ≥30
min
Pt age ≥16 yrs
PEA (HR >0)AsystoleDefibrillation: 1 shock, Max # doses = 1.
Other monitored rhythm VF or VT
Apply defib pads to all patient ≥30 days of age ‐ Rhythm analysis
CPR (throughout duration of call)
INDICATIONS: Cardiac arrest secondary to severe blunt or penetrating trauma
NO
NO
NO
NO
YES YES YES
YES
YESYES
YES
YES
YES
Transport to Emergency Departm
ent
PCP Core Medical Directives
26
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
AED Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Shock indicated
Manual Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: VF or pulseless VT
AED Defibrillation
Non‐shockable rhythm
CPR
Obviously dead as per BLS standards
Meet conditions of DNR standard
Manual Defibrillation
Rhythms other than VF or pulseless VT
HYPOTHERMIA CARDIAC ARREST MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.
Indications
Cardiac arrest secondary to severe hypothermia
Conditions
Contraindications
PCP Core Medical Directives
27
Consider CPR:
Consider AED defibrillation: (with pediatric attenuator if available)
Age Age ≥30 days to <8 years ≥8 years
With Ped attenuator
Without Ped attenuator
Dose 1 shock 1 shock 1 shock
Max. single dose As per BH / manufacturer
As per BH / manufacturer
As per BH / manufacturer
Dosing interval N/A N/A N/A Max. # of doses 1 1 1
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 N/A N/A Max. # of doses 1 1
Transport to the closest appropriate facility without delay following the first analysis.
Treatment
Clinical Considerations N/A
PCP Core Medical Directives
28
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
AED Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Shock indicated
Manual Defibrillation
AGE: ≥30 days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: VF or pulseless VT
CPR
Obviously dead as per BLS standards
Meet conditions of DNR standard
AED Defibrillation
Non‐shockable rhythm
Manual Defibrillation
Rhythms other than VF or pulseless VT
Consider CPR:
Consider foreign body removal: (utilizing BLS maneuvers)
FOREIGN BODY AIRWAY OBSTRUCTION CARDIAC ARREST MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.
Indications Cardiac arrest secondary to an airway obstruction
Conditions
Contraindications
Treatment
PCP Core Medical Directives
29
Consider AED defibrillation: (with pediatric attenuator if available)
Age Age ≥30 days to <8 years ≥8 years
With Ped attenuator
Without Ped attenuator
Dose 1 shock 1 shock 1 shock
Max. single dose As per BH / manufacturer
As per BH / manufacturer
As per BH / manufacturer
Dosing interval N/A N/A N/A Max. # of doses 1 1 1
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 N/A N/A Max. # of doses 1 1
If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest.
If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first analysis.
Clinical Considerations N/A
PCP Core Medical Directives
30
NEONATAL RESUSCITATION MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.
Indications
Severe cardio‐respiratory distress
Conditions
Contraindications
Resuscitation
Clear of meconium
Breathing or crying
Good muscle tone
Pink in colour
Resuscitation
AGE: newborn or <30 days of age
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Less than full term, or meconium, or poor APGAR score
PCP Core Medical Directives
31
Routine care:
Provide warmth Clear airway if necessary Do not routinely suction Dry Ongoing evaluation
Supportive care
Supportive care
Treatment
*if meconium is present and baby not vigorous, suction mouth and pharynx and provide BVM ventilations as required and then continue with the remainder of the initial steps following birth.
Provide positive pressure ventilation (BVM/ETT) using 100% oxygen Administer chest compressions Initiate transport
Provide positive pressure ventilation (BVM) using air
Evaluate respirations, heart rate and colour
Provide warmth Position/clear airway (as necessary) Dry, stimulate, reposition
Birth:
Clear of *meconium? Breathing or crying? Good muscle tone? Colour pink? Term gestation
YES
NO
30 secs
Breathing
HR ≥100 + pink
Apnea, gasping or HR <100
Ventilating
HR ≥100 + pink
60 secs
90 secs
HR <60 HR ≥60
PCP Core Medical Directives
32
RETURN OF SPONTANEOUS CIRCULATION (ROSC) MEDICAL DIRECTIVE
A Primary 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
Contraindications
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)
0.9% NaCl fluid bolus
Fluid overload
SBP ≥90 mmHg
Therapeutic hypothermia
AGE: males ≥18 years
females ≥50 years
LOA: Altered
HR: N/A
RR: N/A
SBP: ≥90 mmHg (spontaneous or following bolus administered)
Other: N/A
0.9% NaCl fluid bolus
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Chest auscultation is clear
PCP Core Medical Directives
33
Treatment
Clinical Considerations The application of therapeutic hypothermia should not detract from rapid transport, optimizing ventilation and oxygenation or the management of a re‐arrest.
Consider Therapeutic hypothermia (if available)
Consider 12 lead acquisition (if available)
Consider 0.9% NaCl fluid bolus: (if certified and authorized)
Age Age <12 years ≥12 years Route Route IV IV Infusion 10 ml/kg 10 ml/kg Infusion interval Immediate Immediate Reassess every 100 ml 250 ml Max. volume 1,000 ml 1,000 ml
Consider optimizing ventilation and oxygenation:
Titrate oxygenation ≥94%
Avoid hyperventilation and target an ETCO2 of 35‐40 mmHg with continuous waveform capnography (if available)
Consider rapid transport
PCP Core Medical Directives
34
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
CARDIAC ISCHEMIA MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.
Indications Suspected cardiac ischemia
Conditions
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
AGE: ≥18 years
LOA: Unaltered
HR: 60‐159 bpm
RR: N/A
SBP: Normotension
Other: Prior history of nitroglycerin use OR IV access obtained
ASA
AGE: ≥18 years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: Able to chew and swallow
PCP Core Medical Directives
35
Treatment
Clinical Considerations N/A
Consider nitroglycerin:
SBP
≥100 mmHg
Route SL
Dose 0.3 or 0.4 mg Max. single dose 0.4 mg Dosing interval 5 min. Max. # of doses 6
Consider 12‐lead ECG acquisition (if available)
Consider ASA:
Route PO Dose 160‐162 mg Max. single dose 162 mg Dosing interval N/A Max. # of doses 1
PCP Core Medical Directives
36
ACUTE CARDIOGENIC PULMONARY EDEMA MEDICAL DIRECTIVE
A Primary 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
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
Nitroglycerin
AGE: ≥18 years
LOA: N/A
HR: 60‐159 bpm
RR: N/A
SBP: Normotension
Other: Ascertain prior history of nitroglycerin use OR establish IV access
PCP Core Medical Directives
37
Treatment
Clinical Considerations
IV condition applies only to PCPs certified to the level of PCP Autonomous IV.
Consider 12‐lead ECG acquisition (if available)
Consider nitroglycerin:
SBP SBP
100 mmHg to <140 mmHg ≥140 mmHg
IV or Hx IV or Hx IV or Hx Yes No Yes Route Route Route SL SL SL
Dose 0.3 or 0.4 mg 0.3 or 0.4 mg 0.6 or 0.8 mg Max. single dose 0.4 mg 0.4 mg 0.8 mg Dosing interval 5 min. 5 min. 5 min. Max. # of doses 6 6 6
NOTE: Hx refers to a patient with a prior history of nitroglycerin use.
PCP Core Medical Directives
38
CARDIOGENIC SHOCK MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.
Indications STEMI‐positive ECG
AND
Cardiogenic shock
Conditions
Contraindications
0.9% NaCl
N/A
0.9% NaCl
AGE: ≥2 years
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Clear chest on auscultation
PCP Core Medical Directives
39
Treatment
Clinical Considerations
N/A
Consider 0.9% NaCl fluid bolus:
Age Age
≥2 years to <18 years ≥18 years
Route Route IV IV Infusion 10 ml/kg 10 ml/kg Infusion interval N/A N/A Reassess every 100 ml 250 ml Max. volume 10 ml/kg 10 ml/kg
PCP Core Medical Directives
40
HYPOGLYCEMIA MEDICAL DIRECTIVE
A Primary 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
Contraindications
Treatment
Perform glucometry
Glucagon
Allergy or sensitivity to glucagon
Pheochromocytoma
Dextrose
Allergy or sensitivity to dextrose
Glucagon
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia
Dextrose
AGE: ≥2 years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia
PCP Core Medical Directives
41
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 and documented.
IV administration of dextrose applies only to PCPs certified to the level of PCP Autonomous IV.
Consider dextrose (if certified and authorized) or glucagon:
Drug Drug Dextrose Glucagon Age Age ≥2 years N/A Weight Weight Weight N/A <25 kg ≥25 kg Concentration Concentration Concentration D50W N/A N/A Route Route Route IV IM IM
Dose 0.5 g/kg(1 ml/kg) 0.5 mg 1 mg
Max. single dose 25 g (50 ml) 0.5 mg 1 mg Dosing interval 10 min. 20 min. 20 min. Max. # of doses 2 2 2
PCP Core Medical Directives
42
Salbutamol
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
Epinephrine Autoinjector
AGE: N/A
WEIGHT: ≥10 kg
LOA: N/A
HR: N/A
RR: BVM ventilation required
SBP: N/A
Other: Hx of asthma
Epinephrine
AGE: N/A
WEIGHT: N/A
LOA: N/A
HR: N/A
RR: BVM ventilation required
SBP: N/A
Other: Hx of asthma
Epinephrine
Allergy or sensitivity to epinephrine
Epinephrine Autoinjector
Allergy or sensitivity to epinephrine
BRONCHOCONSTRICTION MEDICAL DIRECTIVE
A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Respiratory distress
AND
Suspected bronchoconstriction
Conditions
Contraindications
Salbutamol
Allergy or sensitivity to salbutamol
PCP Core Medical Directives
43
Consider epinephrine:
Weight Weight Weight N/A ≥10 kg to <25 kg ≥25 kg Route Route Route
IM PediatricAutoinjector Adult
Autoinjector Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000
Dose 0.01 mg/kg** 1 injection(0.15 mg)
1 injection(0.3 mg)
Max. single dose 0.5 mg 1 injection 1 injection Dosing interval N/A N/A N/A
Max. # of doses 1 1 1 ** The epinephrine dose may be rounded to the nearest 0.05 mg.
Consider salbutamol:
Weight Weight <25 kg ≥25 kg Route Route Route Route
MDI (if available)* NEB MDI
(if available)* NEB
Dose Up to 600 mcg (6 puffs) 2.5 mg Up to 800 mcg
(8 puffs) 5 mg
Max. Single Dose 600 mcg 2.5 mg 800 mcg 5 mg Dosing interval 5‐15 min. PRN 5‐15 min. PRN 5‐15 min. PRN 5‐15 min. PRN Max. # of doses 3 3 3 3
* 1 puff=100mcg
Treatment
PCP Core Medical Directives
44
MANDATORY PROVINCIAL PATCH POINT:
Patch to BHP for authorization to use pediatric autoinjector for patients <10 kg.
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 (if available).
Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health.
When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths.
A spacer should be used when administering salbutamol MDI (if available).
PCP Core Medical Directives
45
Epinephrine
AGE: N/A
WEIGHT: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: For anaphylaxis only
Diphenhydramine
AGE: N/A
WEIGHT: ≥25 kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
Epinephrine Autoinjector
AGE: N/A
WEIGHT: ≥10 kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: For anaphylaxis only
Epinephrine
Allergy or sensitivity to epinephrine
Diphenhydramine
Allergy or sensitivity to diphenhydramine
Epinephrine Autoinjector
Allergy or sensitivity to epinephrine
MODERATE TO SEVERE ALLERGIC REACTION MEDICAL DIRECTIVE
A Primary 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
Contraindications
PCP Core Medical Directives
46
Consider diphenhydramine (if certified and authorized):
Weight Weight ≥25 kg to <50 kg ≥50 kg Route Route Route Route IV IM IV IM Dose 25 mg 25 mg 50 mg 50 mg Max. single dose 25 mg 25 mg 50 mg 50 mg Dosing interval N/A N/A N/A N/A Max. # of doses 1 1 1 1
Consider epinephrine:
Weight Weight Weight N/A ≥10 kg to <25 kg ≥25 kg Route Route Route
IM PediatricAutoinjector Adult
Autoinjector Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000
Dose 0.01 mg/kg* 1 injection(0.15 mg)
1 injection(0.3 mg)
Max. single dose 0.5 mg 1 injection 1 injection Dosing interval N/A N/A N/A Max. # of doses 1 1 1
*The epinephrine dose may be rounded to the nearest 0.05 mg.
MANDATORY PROVINCIAL PATCH POINT:
Patch to BHP for authorization to use pediatric autoinjector for patients <10 kg
Treatment
Clinical Considerations Epinephrine should be the first drug administered in anaphylaxis.
IV administration of diphenhydramine applies only to PCPs certified to the level of PCP Autonomous IV.
PCP Core Medical Directives
47
CROUP MEDICAL DIRECTIVE
A Primary 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
Contraindications
Epinephrine
Allergy or sensitivity to epinephrine
Epinephrine
AGE: <8 years
LOA: N/A
HR: <200 bpm
RR: N/A
SBP: N/A
Other: N/A
PCP Core Medical Directives
48
Consider epinephrine:
Age Age
<1 year ≥1 year to 8 years
Weight Weight Weight <5 kg ≥5 kg N/A Route Route Route NEB NEB NEB Concentration Concentration Concentration 1:1,000 1:1,000 1:1,000 Dose 0.5 mg 2.5 mg 5 mg Max. single dose 0.5 mg 2.5 mg 5 mg Dosing interval N/A N/A N/A Max. # of doses 1 1 1
Treatment
Clinical Considerations The minimum initial volume for nebulization is 2.5 ml.
PCP Auxiliary Medical Directives
49
Auxiliary Directives approved for use by each Ambulance Service
PCP Auxiliary Directives IV/Fluid CPAP SGA N/V ECD Probe 12‐Lead
Essex
Chatham‐Kent
Lambton
Oneida
Elgin
Middlesex
Oxford
Perth
Huron
Grey
Bruce
PCP Auxiliary Medical Directives
50
INTRAVENOUS AND FLUID THERAPY MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized according to the PCP Autonomous IV level.
Indications Actual or potential need for intravenous medication OR fluid therapy
Conditions
Contraindication
Treatment
Consider IV cannulation
Fluid Bolus
Signs of fluid overload
IV
Suspected fracture proximal to the access site.
Fluid Bolus
AGE: ≥2 years
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: N/A
IV
AGE: ≥2 years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
PCP Auxiliary Medical Directives
51
Consider 0.9% NaCl maintenance infusion: Age Age
≥2 years to<12 years ≥12 years
Route Route IV IV Infusion 15 ml/hr 30‐60 ml/hr Infusion interval N/A N/A Reassess every N/A N/A Max. volume N/A N/A
Consider 0.9% NaCl fluid bolus: Age Age
≥2 years to<12 years ≥12 years
Route Route IV IV 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
MANDATORY PROVINCIAL PATCH POINT:
Patch to BHP for authorization to administer IV NaCl bolus to a patient ≥2 years to <12 years with suspected Diabetic Ketoacidosis (DKA)
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 patient must require a peripheral IV in accordance with the indications listed in this Medical Directive. PCPs certified in PCP Assist IV are not authorized to administer IV fluid or medication therapy.
Microdrips and or volume control administration sets should be considered when IV access is indicated for patients less than 12 years of age.
PCP Auxiliary Medical Directives
52
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
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
Hypotension
CPAP AGE: ≥18 years
LOA: N/A
HR: N/A
RR: Tachypnea
SBP: Normotension
Other: SpO2 <90% or accessory muscle use
PCP Auxiliary Medical Directives
53
Treatment
Clinical Considerations
N/A
Confirm CPAP pressure by manometer (if available)
Consider increasing FiO2 (if available):
Initial FiO2 50‐100%FiO2 increment (if available on device)
SpO2 <92% despite treatment and/or 10cm H2O pressure or equivalent flow rate of
device as per BH directionMax FiO2 100%
Consider CPAP:
Initial setting 5 cm H2O Or equivalent flow rate of device as per BH direction
Titration increment 2.5 cm H2O Or equivalent flow rate of device as per BH direction
Titration interval 5 min.
Max. setting 15 cm H2O Or equivalent flow rate of device as per BH direction
PCP Auxiliary Medical Directives
54
SUPRAGLOTTIC AIRWAY MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized.
Indications Need for ventilatory assistance OR airway control
AND
Other airway management is inadequate or ineffective
Conditions
Contraindications
Supraglottic Airway
Active vomiting
Inability to clear the airway
Airway edema
Stridor
Caustic ingestion
Supraglottic Airway
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: patient must be in cardiac arrest
PCP Auxiliary Medical Directives
55
Treatment
Clinical Considerations An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into the mouth.
Confirm supraglottic airway placement:
Method Method Primary Secondary
Auscultation ETCO2 Chest rise Other
Consider supraglottic airway insertion. The maximum number of attempts is 2.
PCP Auxiliary Medical Directives
56
NAUSEA / VOMITING MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized.
Indications Nausea OR vomiting
Conditions
Contraindications
Dimenhydrinate
Allergy or sensitivity to dimenhydrinate or other antihistamines
Overdose on antihistamines or anticholinergics or tricyclic antidepressants
Dimenhydrinate
AGE: N/A
WEIGHT: ≥25 kg
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
PCP Auxiliary Medical Directives
57
Treatment
Clinical Considerations
IV administration of dimenhydrinate applies only to PCPs certified to the level of PCP Autonomous IV.
Prior to IV administration, dilute dimenhydrinate (concentration of 50 mg/1 ml) 1:9 with Normal Saline or sterile water. If given IM do not dilute.
Consider dimenhydrinate:
Weight Weight ≥25 kg to <50 kg ≥50 kg Route Route Route Route IV IM IV IM Dose 25 mg 25 mg 50 mg 50 mg Max. single dose 25 mg 25 mg 50 mg 50 mg Dosing interval N/A N/A N/A N/A Max. # of doses 1 1 1 1
PCP Auxiliary Medical Directives
58
Consider probe removal
ELECTRONIC CONTROL DEVICE PROBE REMOVAL MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
Contraindications
Treatment
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.
Probe removal
Probe embedded above the clavicles, in the nipple(s), or in the genital area
Probe Removal
AGE: ≥18 years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
PCP Auxiliary Medical Directives
59
MINOR ABRASIONS MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
Contraindications
Topical Antibiotic
Allergy or sensitivity to any of the components of the topical antibiotic
Topical Antibiotic
AGE: N/A
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
PCP Auxiliary Medical Directives
60
Treatment
Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention.
Consider release from care
Consider topical antibiotic
PCP Auxiliary Medical Directives
61
MINOR ALLERGIC REACTION MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
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
Diphenhydramine
AGE: ≥18 years
LOA: Unaltered
HR: WNL
RR: WNL
SBP: Normotension
Other: N/A
PCP Auxiliary Medical Directives
62
Treatment
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
Consider release from care
Consider diphenhydramine:
Route PO Dose 50 mg Max. single dose 50 mg Dosing interval N/A Max. # of doses 1
PCP Auxiliary Medical Directives
63
MUSCULOSKELETAL PAIN MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
Contraindications
Acetaminophen
No acetaminophen in the last 4 hours
Allergy or sensitivity to acetaminophen
Signs or symptoms of intoxication
Acetaminophen
AGE: ≥18 years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
PCP Auxiliary Medical Directives
64
Treatment
Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention.
Consider release from care
Consider acetaminophen:
Route PO Dose 325‐650 mg Max. single dose 650 mg Dosing interval N/A Max. # of doses 1
PCP Auxiliary Medical Directives
65
HEADACHE MEDICAL DIRECTIVE ‐ AUXILIARY
A Primary 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
Contraindications
Acetaminophen
No acetaminophen in past 4 hours
Allergy or sensitivity to acetaminophen
Signs or symptoms of intoxication
Acetaminophen
AGE: ≥18 years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
PCP Auxiliary Medical Directives
66
Treatment
Clinical Considerations Advise patient that if the problem persists or worsens that they should seek further medical attention.
Consider release from care
Consider acetaminophen:
Route PO Dose 325‐650 mg Max. single dose 650 mg Dosing interval N/A Max. # of doses 1
PCP Reference Material
67
12-Lead ECG Review
Lead Placement V1 - fourth intercostal space to the right of the sternum V2 - fourth intercostal space to the left of the sternum V3 - directly between leads V2 and V4 V4 - fifth intercostal space at left midclavicular line V5 - level with lead V4 at left anterior axillary line V6 - level with lead V5 at left midaxillary line
Modified 12-lead Placement
V4 becomes V4R - fifth intercostal space at right midclavicular line
(same as V4 but on right side of chest) V5 becomes V8 - level with V6 at left midscapular line V6 becomes V9 - level with V6 at left paravertebral line
Acute Myocardial Infarction (AMI) Anatomical Location
II, III, aVF: Inferior V1, V2: Septal V2, V3, V4: Anterior V5, V6: (low) Lateral I, aVL: (high) Lateral V4R: Right Ventricular (with any two of II, III, and aVF) V8, V9: Posterior
I High Lateral
Reciprocal changes
II, III, aVF
aVR V1
Septal Reciprocal changes I, III, aVF
V4 Anterior Reciprocal changes
II, III, aVF
II Inferior
Reciprocal changes
I, aVL, V-leads
aVL High
Lateral Reciprocal changes
II, III, aVF
V2 Septal
Reciprocal changes
II, III, aVF
V5 Lateral
Reciprocal changes
II, III, aVF
III Inferior
Reciprocal changes
I, aVL, V-leads
aVF Inferior
Reciprocal changes
I, aVL, V-leads
V3 Anterior Reciprocal changes
II, III, aVF
V6 Lateral
Reciprocal changes
II, III, aVF
PCP Reference Material
68
12-Lead ECG Placement
Limb Lead Placement
Whenever possible, avoid large muscle mass
RA: right forearm or wrist LA: left forearm or wrist
RL: Ground lead is generally placed on the lower right leg LL: left lower leg Precordial Leads: V1-V6
V1 V2 V3 V4 V5 V6
V1: 4th intercostal space, right sternal border V2: 4th intercostal space, left sternal border V3: between V2 and V4 V4: 5th intercostal space, mid-clavicular line V5: anterior axillary line, in straight line with V4 V6: mid-axillary line, in straight line with V4 and V5
Right sided precordial leads (should be assessed in the setting of an inferior wall infarction)
V4R: opposite V4 on the right side of the chest V5R: opposite V5 on the right side of the chest
PCP Reference Material
69
CPR Guide
BLS Component Recommendations for Adults, Children and Infants
COMPONENT Adults Children Infants Neonate
AGE RANGE Puberty and older
1 year to puberty
≥ 30 days to 1 year
< 30 days
RECOGNITION
Unresponsive (for all ages)
Refer to N
eonatal Resuscitation M
edical Directive
No breathing or no normal breathing
(i.e. only gasping) No breathing or only gasping
No pulse palpated within 10 seconds for all ages (HCP only) CPR SEQUENCE C-A-B
COMPRESSION RATE At least 100/min
COMPRESSION DEPTH
At least 2 inches (5 cm)
At least ⅓ AP diameter
About 2 inches (5 cm)
At least ⅓ AP diameter
About 1½ inches (4 cm)
CHEST WALL RECOIL Allow complete recoil between compressionsHCPs rotate compressors every 2 minutes
COMPRESSION INTERRUPTIONS
Minimize interruptions in chest compressionsAttempt to limit interruptions to < 10 seconds
AIRWAY Head tilt-chin lift (HCP suspected trauma: Jaw thrust) COMPRESSION-TO-VENTILATION RATIO
(UNTIL ADVANCED
AIRWAY PLACED)
30:2 1 or 2 rescuers
30:2Single Rescuer
15:2 2 HCP Rescuer
VENTILATIONS: WHEN
RESCUER UNTRAINED
OR TRAINED AND NOT
PROFICIENT Compressions Only
VENTILATIONS WITH
ADVANCED AIRWAY
(HCP)
1 breath every 6-8 seconds (8-10 breaths/min)
Asynchronous with Chest compressions About 1 second per breath
Visible chest rise
DEFIBRILLATION Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock; resume CPR beginning
with compressions immediately after each shock.
PCP Reference Material
70
Pediatric CPR Guidelines Compressions should be started in an infant or child with a palpable pulse less than 60/min and signs of poor perfusion. Compressions should be started in a neonate with a palpable pulse less than 60/min despite supplemental oxygen and ventilation every 30 seconds. Relief of Foreign-Body Airway Obstruction
Adult Child Infant 1. Ask “Are you choking?” 2. Give abdominal thrusts/Heimlich
maneuver or chest thrusts for pregnant or obese victims.
3. Repeat abdominal thrusts (or chest thrusts if victim is pregnant or obese) until effective or victim becomes unresponsive.
1. Ask “Are you choking?” 2. Give abdominal thrusts/Heimlich
maneuver. 3. Repeat abdominal thrusts until
effective or victim becomes unresponsive.
1. Confirm severe airway obstruction. Check for sudden onset of severe breathing difficulty, ineffective or silent cough, weak or silent cry.
2. Give up to 5 back slaps and up to 5 chest thrusts.
3. Repeat step 2 until effective or victim becomes unresponsive.
Victim Becomes Unresponsive
1. Send someone to activate emergency response system. 2. Lower victim to floor. If victim is unresponsive with no breathing or no normal breathing (i.e. agonal gasps), begin
CPR (no pulse check). 3. Before you deliver breaths, look into mouth. If you see a foreign body that can be easily removed, remove it. 4. Continue CPR for 5 cycles or about 2 minutes. If you are alone, activate EMS system. Return and continue CPR
until more skilled rescuers arrive.
Reference: 2010 American Heart Association Guidelines for CPR and ECC
PCP Reference Material
71
Normal Pediatric Vital Signs Age Respiratory Rate Heart Rate
0 - 3 months 30-60 90-180 3 - 6 months 30-60 80-160 6 - 12 months 25-45 80-140
1 - 3 years 20-30 75-130 6 years 16-24 70-110 10 years 14-20 60-90
Apgar Score
Parameter 0 1 2 Heart rate (bpm) 0 (absent) Slow (< 100) > 100
Respiratory effort Absent Slow, irregular Good, crying Muscle tone None, limp Some flexion Active motion
Reflex irritability (suction of nares,
tactile stimulation) None Some grimace Good grimace,
cough, cry
Colour Blue or pale Pink body with blue extremities Completely pink
Apgar performed at 1 minute & 5 minutes after delivery; total 10 (5 items x max score of 2) Don’t wait for Apgar to make decision on resuscitation
Pediatric Glasgow Coma Scale > 2 years < 2 years
Eye Opening Spontaneously To Voice To Pain None
Spontaneously To Voice To Pain None
4 3 2 1
Verbal Response
Oriented Confused Inappropriate Words Incomprehensible None
Coos, babbles Cries irritably Cries to pain Moans to pain None
5 4 3 2 1
Motor Response
Obeys Commands Localizes Pain Withdrawal to pain Flexion Extension None
Normal Movements Withdraws – touch Withdrawal – pain Abnormal flexion Abnormal extension None
6 5 4 3 2 1
PCP Reference Material
72
Pediatric Trauma Score
Severity +2 +1 -1
Weight > 20kg (> 44 lbs)
10-20 kg (22 to 44 lbs)
< 10 kg (< 22 lbs)
Airway Normal Maintained
(oral or nasal airway)
Non maintained (intubation or
cricothyrotomy)
Blood Pressure and/or pulses
> 90 mmHg or radial pulse only
50 to 90 mmHg or femoral pulse only
<50 mmHg or absent pulse
Level of consciousness Awake, alert
Obtundance, any loss of
consciousness
Comatose, Unresponsive
Open wounds None Minor Major or penetrating
Fractures None Single, closed Open, multiple
Pediatric Trauma score (PTS): highest possible score is 12, lowest possible score is -6
PTS >8 < 1 % Mortality predicted
< 8 Suggests need for trauma center
4 Predicts 50% mortality
< 1 Predicts > 98% mortality
PCP Reference Material
73
Canadian Triage & Acuity Scale – CTAS
Page intentionally left blank awaiting new CTAS
PCP Reference Material
74
Stroke Prompt Card
Indications for Patient Redirect or Transport Under Stroke Protocol Redirect or transport to a Designated Stroke Centre* will be considered for patients who:
Present with a new onset of at least one of the following symptoms suggestive of the onset of an acute stroke:
Unilateral arm/leg weakness or drift Slurred speech or inappropriate words or mute Unilateral facial droop
AND
Can be transported to arrive at a Designated Stroke Centre within 3.5 hours of a clearly determined time of symptom onset or the time the patient was “last seen in a usual state of health”.
*Note: A Designated Stroke Centre is a Regional Stroke Centre, District Stroke Centre or a Telestroke Centre. Contraindications for Patient Redirect or Transport Under Stroke Protocol
Any of the following conditions exclude a patient from being transported under Stroke Protocol:
CTAS Level 1 and/or uncorrected Airway, Breathing or Circulatory problem
Symptoms of the stoke resolved prior to paramedic arrival or assessment**
Blood Sugar <3 mmol/L Seizure at onset of symptoms or observed by paramedic Glasgow Coma Scale <10 Terminally ill or palliative care patient Duration of out of hospital transport will exceed two (2) hours
CACC /ACS will authorize the transport once notified of the patient’s need for redirect or transport under the Acute Stroke Protocol.
** Note: Patients whose symptoms improve significantly or resolve during transport will continue to be transported to a Designated Stroke Centre. Version 2.0 February 2011
PARAMEDIC PROMPT CARDFOR
ACUTE STROKE PROTOCOL
PCP Reference Material
75
Stroke Assessment Tool
Sign/Symptom Assessment Findings
FACIAL DROOP Have the patient grimace and smileIf one side of the face does not move as
well as the other side, the results are suggestive of an acute stroke.
LEG WEAKNESS/ DRIFT
Have the patient lift one leg up approximately 30 degrees and hold
it in that position for 5 seconds. Repeat with the other leg. Compare
the results.
If one leg drifts downward or falls before the end of the 5 seconds or the patient is
unable to lift one leg, the result is suggestive of an acute stroke.
ARM WEAKNESS/ DRIFT
Have the patient hold both arms outstretched in front of their body, perpendicular to the ground for 5
seconds.
If one arm drifts downward or falls before the end of the 5 seconds, or the patient is
unable to lift one arm, the result is suggestive of an acute stroke.
SLURRED SPEECH, INAPPROPRIATE
WORDS OR MUTE
Ask the patient to name 3 simple objects that you show them. Ask
the patient to repeat a simple sentence.
If the patient slurs words, uses inappropriate words when describing the objects or repeating the sentence, or is
unable to speak at all, the result is suggestive of an acute stroke.
Reference: 2010 AHA Guidelines
PCP Reference Material
76
BHP Patch for Trauma TOR
Service / Location:
Medic Name / Number / Level: Call Number:
Patient Info – Age: Sex:
I AM CALLING FOR A TERMINATION OF RESUSCITATION ORDER FOR A TRAUMA PATIENT(specify blunt or penetrating) Incident History / Mechanism of Injury:
Physical Assessment: - confirm patient > 16 years and has no palpable pulses. No defibrillation delivered and monitored HR = 0 (asystole) OR monitored HR >0 AND the closest ER ≥30 min transport time away.
Rhythm:
BH Physician Name:
TOR Order Given – Yes, TOR - No, Transport to closest ER
Time of Death:
PCP Reference Material
77
BHP Patch for Medical TOR
Service / Location:
Medic Name / Number / Level: Call Number:
Patient Info – Age: Sex:
I AM CALLING FOR A TERMINATION OF RESUSCITATION ORDER FOR A MEDICAL PATIENT Incident History / Mechanism of Injury:
Physical Assessment: - confirm patient > 18 years and has no palpable pulses. Arrest not witnessed by EMS, AND No ROSC AND No shocks delivered.
MANDATORY PROVINCIAL PATCH POINT:
Patch to BHP for authorization, following the 3rd analysis, to consider Medical Termination of Resuscitation (TOR) (if applicable). If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate receiving hospital following ROSC or the 4th analysis.
BH Physician Name:
TOR Order Given – Yes, TOR - No, Transport to closest ER
Time of Death:
Patch Phone Numbers
79
Base Hospital Physician Patch Phone Numbers
Notes
For paramedics in – Elgin, Middlesex, Oneida, Oxford
London Health Sciences Centre – Victoria Hospital 519‐667‐1092
London Health Sciences Centre – University Hospital 519‐667‐4093
For paramedics in – Bruce, Grey, Huron, Perth
Grey Bruce Health Services, Owen Sound 1‐866‐388‐8512 or 1‐519‐661‐6568
For paramedics in – Lambton
Bluewater Health, Sarnia 519‐627‐8460
For paramedics in – Chatham‐Kent, Essex‐Windsor
Hotel Dieu Grace Hospital, Windsor 519‐258‐0109
Windsor Regional Hospital, Met Campus 519‐258‐5472
Public General Hospital – Chatham‐Kent Health Alliance 519‐258‐9343