paramedic guide - prehospital...

Version 1.3 ▪ March 2014

Paramedic Guide

Jim Summers, Manager Professional Standards & Compliance

E: [email protected] O: 416-667-2200, ext. 205

Sioban Kennedy, Manager Paramedic Practice


Sue Thomson, Manager Paramedic Practice


Scott Gorsline, Manager Paramedic Practice


Reuven Dichter, Lead Faculty


77 Brown’s Line, Suite 100 Toronto, Ontario

M8W 3S2

telephone 416-667-2200 ▪ 1-866-675-3782

fax 416-667-9776 ▪ 1-866-762-7201

web www.prehospitalmedicine.ca

Maud Huiskamp Senior Manager

Regional Base Hospital Program E: [email protected] O: 416-667-2200, ext. 409

mailto:[email protected]




http://www.prehospitalmedicine.ca/


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To: Sunnybrook Regional Base Hospital Paramedics and Affiliates

The Emergency Health Services Branch of the Ministry of Health and Long Term Care Version 3.1 of the ALS Patient Care Standards will now be the standard of care. Dr. Richard Verbeek, Medical Director for the Toronto Paramedic Program, was the lead medical editor of this project. These standards contain updated medical directives for Primary and Advanced Care 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 significant advances to the paramedic scope of practice since they were last published in 2007. 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 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 Phone: 416-667-2200 ext. 0 Phone: 416-667-2200 ext. 0 Phone: 416-667-2203 [email protected] [email protected] [email protected]

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, 3.1, dated November 2013. Please refer to www.prehospitalmedicine.ca to access the full document.

© 2014 by the Sunnybrook Centre for Prehospital Medicine 77 Brown’s Line, Suite 100 Toronto, ON M8W 3S2 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 Preshospital Medicine is forbidden.




http://www.prehospitalmedicine.ca/


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Scope of Practice — ACP The checklists for Scope of Practice are for paramedic reference only and might not accurately reflect the current scope of practice within specific services.

Drug List Halton

ACP Peel ACP

Simcoe ACP

Toronto

Level II Level III

Acetaminophen

Adenosine

Amiodarone

ASA

Atropine

Dextrose

Dimenhydrinate (Gravol)

Diphenhydramine (Benadryl)

Dopamine

Epinephrine 1:10,000

Epinephrine 1:1000

Fentanyl

Glucagon

Ibuprofen

Ketorolac (Toradol)

Lidocaine

Midazolam

Morphine

Naloxone

Nitroglycerin

Salbutamol MDI

Salbutamol Nebulized

Sodium Bicarbonate

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Scope of Practice — ACP The checklists for Scope of Practice are for paramedic reference only and might not accurately reflect the current scope of practice within specific services.

Procedures List Halton

ACP Peel ACP

Simcoe ACP

Toronto

Level II Level III

12 Lead Acquisition

Cardioversion

CPAP

Cricothyrotomy (Needle)

CVAD Access

Electronic Control Device Probe Removal

Intubation (Nasal)

Intubation (Oral)

IO Access Up to Age 12

IV Access All Ages

Needle Decompression

Neonatal Resuscitation

Pacing

Pediatric Defib at 2-4 J/kg

STEMI Bypass to PCI Lab Specific to Geographical Area

Stroke Validation via Patch

Supraglottic Airway

TOR (Termination of Resuscitation) Medical

TOR (Termination of Resuscitation) Trauma


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Scope of Practice — PCP The checklists for Scope of Practice are for paramedic reference only and might not accurately reflect the current scope of practice within specific services.

Drug List Beausoleil

PCP Muskoka

PCP RAMA

PCP Halton

PCP Peel PCP

Simcoe PCP

Toronto

Level I Level II

Acetaminophen

ASA

Dextrose

Dimenhydrinate (Gravol)

Diphenhydramine (Benadryl)

Epinephrine 1:1,000

Glucagon

Ibuprofen

Ketorolac (Toradol)

Nitroglycerin

Salbutamol MDI

Salbutamol Nebulized

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Scope of Practice — PCP The checklists for Scope of Practice are for paramedic reference only and might not accurately reflect the current scope of practice within specific services.

Procedures List Beausoleil

PCP Muskoka

PCP RAMA

PCP Halton

PCP Peel PCP

Simcoe PCP

Toronto

Level I Level II

12 Lead Acquisition

CPAP

Electronic Control Device Probe Removal

IV Access All Ages

IV Autonomous

Neonatal Resuscitation

Pediatric Defib at adult settings

Pediatric Defib at 2-4 J/kg

STEMI Bypass to PCI lab specific to geographical area

Stroke Validation via Patch

Supraglottic Airway

TOR (Termination of Resuscitation) Medical

TOR (Termination of Resuscitation) Trauma


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Base Hospital Physicians

On-Call Physicians

Dr. Sanjay Agarwal Dr. Sheldon Cheskes

Dr. Michael Feldman Dr. Jeff Handler

Dr. Paul Hoogeveen Dr. Oscar Karbi

Dr. George Karasmanis Dr. David Kazdan

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

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Patch Form


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Patch Process

Note

If the on-call physician does not answer within 24 seconds, the call will be automatically transferred to Sunnybrook.

Patch Failure

1. Attempt maximum twice by cell 2. Attempt through CACC 3. If no cell coverage attempt a radio patch through CACC 4. If unable to contact a physician please refer to your medical directives

Contact Self-Report

1. If a procedure was completed out of protocol 2. If a patch failure was experienced

Mandatory Entry

EHS # & Truck #

_______ _______

Physician

Mon − Fri, 8 am − 8 pm On-call Physician

Mon − Fri, 8 pm − 8 am, Sat & Sun Sunnybrook Physician

Patch Number

1-877-822-8594

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Patch Process — Toronto

Patch Failure

1. Attempt maximum twice by cell 2. Attempt through CACC 3. If no cell coverage attempt a radio patch through CACC 4. If unable to contact a physician please refer to your medical directives

Contact Self-Report

1. If a procedure was completed out of protocol 2. If a patch failure was experienced

Patch Number

416-636-9871


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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 www.prehospitalmedicine.ca or emailed to [email protected] to ensure they are received, documented and followed-up in a timely manner.

Mandatory 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 receipt 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.

http://prehospitalmedicine.sunnybrook.ca/


Patient Care Standards Introduction ......... Section 1

PCP Medical Directives ........................................ Section 2

ACP Medical Directives ....................................... Section 3

Special Events Medical Directives .................. Section 4

Notes ............................................................................ Section 8

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PATIENT CARE STANDARDS

INTRODUCTION

Information contained herein has been carefully compiled and is believed to be accurate at date of publication.

Freedom from error, however, cannot be guaranteed.

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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 ............................................................... 10

Patching .............................................................................................................................................. 11

Incident Reporting ........................................................................................................................... 11

Controlled Substances .................................................................................................................... 12

Responsibility of Care ...................................................................................................................... 12

Research ............................................................................................................................................. 13

Conventions ....................................................................................................................................... 13

List of Abbreviations ........................................................................................................................ 15

Reference and Educational Notes ............................................................................................... 18

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Acknowledgements

The development of this edition of the Advanced Life Support Patient Care Standards is the result of a collaborative effort of a number of stakeholders including:

Association of Paramedic Chiefs (OAPC) Ontario Base Hospital Group (OBHG) Ministry of Health and Long Term Care – Emergency Health Services Branch

(MOHLTC EHSB) EHSB Provincial Medical Advisory Committee (MAC)

In particular, the Ministry would like to gratefully acknowledge the following members of the MAC and regional base hospitals who provided the medical input into these standards:

Dr. Jason Prpic, Chair Dr. Michael Lewell, Vice Chair

Dr. Andrew Affleck Mr. Andy Benson Education Subcommittee

Dr. Adam Dukelow Dr. Derek Garniss

Mr. Kyle Grant Dr. Justin Maloney Advanced Care Paramedic Representative

Ms. Amie Maurice Mr. Paul Myre Primary Care Paramedic Representative Chair, Education Subcommittee

Ms. Mary Osinga Dr. Bruce Sawadsky College Representative

Dr. Ruby Vandersluis Dr. Richard Verbeek

Dr. Michelle Welsford

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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 will:

▪ Reflect current practices for Paramedics in Ontario and provide a benchmark for Paramedic performance.

▪ Communicate to Paramedics, patients, other disciplines and the public in general, standards of practice and care by Paramedics in Ontario.

▪ Delineate Paramedic professional responsibilities and accountabilities.

▪ Provide a basis for evaluation of the patient care practice by Ontario’s Paramedics.

▪ Recognize 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.

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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 – ACP Medical Directives 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 act in the provision of controlled acts in accordance with their base hospital medical directives under Ornge.

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). 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 non-controlled acts included in these Standards.

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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 described above) and is implemented through the PCP and ACP Medical Directives. A Paramedic must meet all requirements within 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. 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.

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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.

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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 Basic Life Support (BLS) Patient Care Standards, Section 1 Part I, Patient Refusal of Treatment and/or Transport.

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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 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 Patient Care Standards.

Intravenous 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.

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

A “novel medication” is a self/caregiver administered medication prescribed by a regulated health professional 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 say they were trained. A Paramedic should advise the patient or caregiver to follow any specific steps or to provide any advice about restarting/stopping the device or novel medication. A Paramedic must always 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 regulated health professional.

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.

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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 their call report.

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 she/he cannot comply with the direction as it exceeds her/his scope of practice. In such cases, a Paramedic should ask the BHP to provide alternative direction.

Incident Reporting

Paramedics shall adhere to the Service Operator Policies and MOHLTC Ambulance Service Documentation Standards for incident reporting. Paramedics shall also adhere to additional RBH policies regarding reporting of clinical care incidents to the RBH.

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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 the level of Paramedic responsible for 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 procedure is 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 BLS Patient Care Standards regarding such transfers.

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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, 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/her justification for withholding treatment on the call report.

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) is an acceptable alternative. Use of a pediatric emergency tape shall be documented on the patient care report when it is used to determine a pediatric drug dose.

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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

Systolic Blood Pressure (for children 1-10 yrs) = 70 + (2 x age in years) Weight (kg) = (age x 2) + 10

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.

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 yr 20 − 30 75 − 130

6 yr 16 − 24 70 − 110

10 yr 14 − 20 60 − 90

15


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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

16


F

FiO2 fraction of inspired oxygen FRI febrile respiratory infection

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

17


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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

18


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. To access these documents, type the following address into a web browser: http://www.ontariobasehospitalgroup.ca/educational-resources/Default.aspx

Or, if viewing this document digitally, follow this link: Ontario Base Hospital Group Educational Resources

http://www.ontariobasehospitalgroup.ca/educational-resources/Default.aspx

P C P M e d i c a l D i r e c t i v e s

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PCP MEDICAL

DIRECTIVES

2


PCP Medical Directives Table of Contents

PCP Core Medical Directives Medical Cardiac Arrest Medical Directive .............................................................................. 3

Trauma Cardiac Arrest Medical Directive .............................................................................. 6

Hypothermia Cardiac Arrest Medical Directive ................................................................... 10

Foreign Body Airway Obstruction Cardiac Arrest Medical Directive ............................ 12

Neonatal Resuscitation Medical Directive ........................................................................... 14

Return of Spontaneous Circulation (ROSC) Medical Directive ....................................... 16

Cardiac Ischemia Medical Directive ....................................................................................... 18

Acute Cardiogenic Pulmonary Edema Medical Directive ................................................. 20

Cardiogenic Shock Medical Directive .................................................................................... 22

Hypoglycemia Medical Directive ............................................................................................ 23

Bronchoconstriction Medical Directive ................................................................................ 25

Moderate to Severe Allergic Reaction Medical Directive ................................................ 28

Croup Medical Directive ........................................................................................................... 30

PCP Auxiliary Medical Directives Intravenous and Fluid Therapy Medical Directive – AUXILIARY ....................................... 32

Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY .............. 34

Supraglottic Airway Medical Directive – AUXILIARY ............................................................ 36

Nausea/Vomiting Medical Directive – AUXILIARY ................................................................ 38

Electronic Control Device Probe Removal Medical Directive – AUXILIARY ................... 40

Analgesia Medical Directive – AUXILIARY ............................................................................... 41

Moderate to Severe Pain Medical Directive – AUXILIARY ................................................ 43

Blank pages left for future Medical Directives ......................................................................... 45

3


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Medical Cardiac Arrest Medical Directive

A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized

Non-traumatic cardiac arrest

Indications

Conditions

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

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

4


Contraindications

CPR

Obviously dead as per BLS standards

Meet conditions of DNR standard

AED Defibrillation

Non-shockable rhythm


Rhythms other than VF or pulseless VT

Epinephrine

Allergy or sensitivity to epinephrine

Medical TOR

Arrest thought to be of non-cardiac origin

Treatment

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

Dosing interval N/A N/A N/A

Max. # of doses 4 4 4

Consider Manual defibrillation (if certified and authorized):


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

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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.

Consider epinephrine (only if anaphylaxis suspected as causative event):

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

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

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.

Clinical Considerations

6


Trauma Cardiac Arrest Medical Directive

A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized

Cardiac arrest secondary to severe blunt or penetrating trauma

Indications

Conditions

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



AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


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.

7


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Contraindications

CPR



AED Defibrillation




Trauma TOR

Age <16 years

Shock delivered

Monitored HR >0 and closest ER <30 min away

Treatment

Consider CPR

Consider AED defibrillation:


With Ped attenuator

Without Ped attenuator


Max. single dose

As per BH / manufacturer





8


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

Consider Manual defibrillation (if certified and authorized):

Age Age

≥30 days to

<8 years ≥8 years


Initial dose 2 J/kg As per BH /

manufacturer Dosing interval N/A N/A

Max. # of doses 1 1


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


9


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Treatment – Algorithm for Trauma Arrest

INDICATIONS: Cardiac arrest secondary to severe blunt or penetrating trauma

CPR (throughout duration of call)

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

VF or VT Other monitored rhythm

Defibrillation: 1 shock, Max #

doses = 1

YES

Asystole

YES

PEA(HR >0)

Pt age ≥16 yrs

YES

Drive time to closest ER

>30 min

Patch

YES

TOR implemented

YES

YES

YES

YES

Transp

ort to

Emergen

cy Dep

artmen

t

NO

NO

NO

NOTransport to ED

YES

10


Hypothermia Cardiac Arrest Medical Directive

A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized.

Cardiac arrest secondary to severe hypothermia

Indications

Conditions

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



AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Contraindications

CPR



AED Defibrillation




Treatment

Consider CPR

11


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N/A



With Ped






manufacturer Dosing interval N/A N/A N/A


Consider Manual defibrillation:

Age Age

≥30 days to

<8 years ≥8 years



manufacturer

Dosing interval N/A N/A Max. # of doses 1 1

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


12


Foreign Body Airway Obstruction Cardiac Arrest Medical Directive


Cardiac arrest secondary to an airway obstruction

Indications

Conditions

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



AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Contraindications

CPR



AED Defibrillation




Treatment

Consider CPR

Consider foreign body removal: (utilizing BLS maneuvers)

13


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N/A



With Ped attenuator

Without Ped attenuator





manufacturer




Age Age

≥30 days to <8 years ≥8 years


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.


14


Neonatal Resuscitation Medical Directive


Severe cardio-respiratory distress

Indications

Conditions

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

Contraindications

Resuscitation

Clear of meconium

Breathing or crying

Good muscle tone

Pink in colour

15


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*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.

Treatment

Ventilating

Birth:

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

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

NO

Evaluate respirations, heart rate and colour

Provide positive pressure ventilation (BVM) using air

Apnea, gasping or HR <100

Provide positive pressure ventilation (BVM/ETT) using 100% oxygenAdminister chest compressionsInitiate transport

HR <60

Routine Care:

Provide warmthClear airway if necessaryDo not routinely suctionDryOngoing evaluation

YES

Supportive care

Supportive care

HR ≥60

HR ≥100 + pink

Breathing

HR ≥100 + pink

30 Sec

60 Sec

90 Sec

16


Return of Spontaneous Circulation (ROSC) Medical Directive


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

Indications

Conditions

0.9% NaCl fluid bolus

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Chest auscultation is clear

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

Contraindications

0.9% NaCl fluid bolus

Fluid overload

SBP ≥90 mmHg

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)

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

Treatment

Consider rapid transport

Consider optimizing ventilation and oxygenation:

Titrate oxygenation ≥94%

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

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 12 lead acquisition (if available)

Consider Therapeutic hypothermia (if available)


18


Cardiac Ischemia Medical Directive


Suspected cardiac ischemia

Indications

Conditions

ASA

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: Able to chew and swallow

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

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

19


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N/A

Treatment

Consider ASA:

Route PO Dose 160–162 mg

Max. single dose 162 mg

Dosing interval N/A Max. # of doses 1

Consider 12-lead ECG acquisition (if available)

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


20


Acute Cardiogenic Pulmonary Edema Medical Directive


Moderate to severe respiratory distress AND Suspected acute cardiogenic pulmonary edema

Indications

Conditions

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

Contraindications

Nitroglycerin



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

21


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IV condition applies only to PCPs certified to the level of PCP Autonomous IV.

Treatment


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

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.




22


Cardiogenic Shock Medical Directive


STEMI-positive ECG AND cardiogenic shock

N/A

Indications

Conditions

0.9% NaCl

AGE: ≥2 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Clear chest on auscultation

Contraindications

0.9% NaCl

N/A

Treatment

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


Max. volume 10 ml/kg 10 ml/kg


23


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Hypoglycemia Medical Directive


Agitation OR altered LOA OR seizure OR symptoms of stroke

Indications

Conditions

Dextrose

AGE: ≥2 years

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Glucagon

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Contraindications

Dextrose

Allergy or sensitivity to dextrose

Glucagon

Allergy or sensitivity to glucagon

Pheochromocytoma

Treatment

Perform glucometry

24


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




25


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Bronchoconstriction Medical Directive


Respiratory distress AND Suspected bronchoconstriction

Indications

Conditions

Salbutamol

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: BVM ventilation required

SBP: N/A

Other: Hx of asthma

Epinephrine Autoinjector

AGE: N/A

WEIGHT: ≥10 kg

LOA: N/A

HR: N/A


SBP: N/A

Other: Hx of asthma

Contraindications

Salbutamol

Allergy or sensitivity to salbutamol

Epinephrine




26


Treatment

Consider salbutamol:

* 1 puff=100mcg

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

Consider epinephrine:

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

Weight Weight Weight N/A ≥10 kg to <25 kg ≥25 kg Route Route Route

IM Pediatric

Autoinjector 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



27


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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).



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

28


Moderate to Severe Allergic Reaction Medical Directive


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

Indications

Conditions

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: For anaphylaxis only


AGE: N/A

WEIGHT: ≥10 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A


Diphenhydramine

AGE: N/A

WEIGHT: ≥25 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Epinephrine




Diphenhydramine

Allergy or sensitivity to diphenhydramine

29


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tes

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.

Treatment


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

Weight Weight Weight N/A ≥10 kg to <25 kg ≥25 kg Route Route Route

IM Pediatric

Autoinjector 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

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



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

30


Croup Medical Directive


Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough OR recent history of a barking cough

Indications

Conditions

Epinephrine

AGE: <8 years

LOA: N/A

HR: <200 bpm

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Epinephrine


31


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tes

The minimum initial volume for nebulization is 2.5 ml.

Treatment


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


32


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.

Actual or potential need for intravenous medication OR fluid therapy

Indications

Conditions

IV

AGE: ≥2 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Fluid Bolus

AGE: ≥2 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

Contraindication

IV

Suspected fracture proximal to the access site.

Fluid Bolus

Signs of fluid overload

Treatment

Consider IV cannulation

33


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“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.

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


Patch to BHP for authorization to administer IV NaCl bolus to a patient ≥2 years to <12 years with suspected Diabetic Ketoacidosis (DKA)


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

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


34


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.

Severe respiratory distress AND Signs and/or symptoms of acute pulmonary edema OR COPD

Indications

Conditions

CPAP

AGE: ≥18 years

LOA: N/A

HR: N/A

RR: Tachypnea

SBP: Normotension

Other: SpO2 <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

Hypotension

35


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N/A

Treatment

Consider CPAP:

Initial setting 5 cm H2O Or equivalent flow rate of device

as per BH direction

Titration increment 2.5 cm H2O Or equivalent flow rate of device

as per BH direction

Titration interval 5 min.

Max. setting 15 cm H2O Or equivalent flow rate of device

as per BH direction

Consider increasing FiO2 (if available):

Initial FiO2 50–100%

FiO2 increment (if

available on device)

SpO2 <92% despite treatment and/or 10cm H2O pressure or equivalent flow rate of device as per BH direction

Max FiO2 100%

Confirm CPAP pressure by manometer (if available)


36


Supraglottic Airway Medical Directive – AUXILIARY


Need for ventilatory assistance OR airway control AND Other airway management is inadequate or ineffective

Indications

Conditions

Supraglottic Airway

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: patient must be in cardiac arrest

Contraindications

Supraglottic Airway

Active vomiting

Inability to clear the airway

Airway edema

Stridor

Caustic ingestion

37


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

Treatment

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

Confirm supraglottic airway placement:

Method Method Primary Secondary

Auscultation ETCO2

Chest rise Other


38


Nausea / Vomiting Medical Directive – AUXILIARY


Nausea OR vomiting

Indications

Conditions

Dimenhydrinate

AGE: N/A

WEIGHT: ≥25 kg

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Dimenhydrinate

Allergy or sensitivity to dimenhydrinate or other antihistamines

Overdose on antihistamines or anticholinergics or tricyclic antidepressants

39


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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.

Treatment

Consider dimenhydrinate:



40


Electronic Control Device Probe Removal Medical Directive – AUXILIARY


Electronic Control Device probe(s) embedded in patient.

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.

Indications

Conditions

Probe Removal

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Probe removal

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

Treatment

Consider probe removal


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Analgesia Medical Directive – AUXILIARY A Primary Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized.

Isolated Hip OR Extremity Trauma AND Pain

Indications

Conditions

Acetaminophen

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Ibuprofen

AGE: ≥18 and <50 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Acetaminophen

Acetaminophen use within previous 4 hours

Allergy or sensitivity to acetaminophen

Signs or symptoms of intoxication

Active vomiting

Major burns

Hx of liver disease

Ibuprofen

Ibuprofen or NSAID use within previous 6 hours

Allergy or sensitivity to ASA or NSAIDs

Active vomiting


Major burns

Hx of peptic ulcer disease or GI bleed

Pregnant

Hx cardiovascular disease

If asthmatic, no prior use of ASA or other NSAIDs


42


Whenever possible, both acetaminophen and ibuprofen should be used together.


Treatment

Consider ibuprofen:

Route

PO

Dose 400 mg


Dosing interval N/A

Max. # of doses 1

Consider acetaminophen:

Route

PO

Dose 960–1000 mg


Dosing interval N/A

Max. # of doses 1

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Moderate to Severe Pain Medical Directive – AUXILIARY A Primary Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized.

Moderate to Severe pain AND Isolated hip or extremity trauma OR major burns OR current history of cancer related

pain OR renal colic with prior history OR patients with acute musculoskeletal back strain.

Indications

Conditions

Contraindications

Ketoralac

AGE: ≥ 18 years and < 50 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: Patient must remain NPO or is unable to take oral medications

Ketoralac

NSAID or ibuprofen use within previous 6 hours


Patient on anticoagulation therapy




Pregnant

Known renal impairment

44


IV administration of ketorolac applies only to PCPs certified to the level of PCP Autonomous IV.


Treatment

Route

IM/IV

Dose 30 mg

Max. single dose 30mg

Dosing interval N/A

Max. # of doses 1

Consider Ketorolac:

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A C P M e d i c a l D i r e c t i v e s

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ACP MEDICAL DIRECTIVES

2


ACP Medical Directives Table of Contents

ACP Core Medical Directives Medical Cardiac Arrest Medical Directive ......................................................................... 3 Trauma Cardiac Arrest Medical Directive ......................................................................... 9 Hypothermia Cardiac Arrest Medical Directive ............................................................... 13 Foreign Body Airway Obstruction Cardiac Arrest Medical Directive ................................ 15 Neonatal Resuscitation Medical Directive ....................................................................... 17 Return of Spontaneous Circulation (ROSC) Medical Directive .......................................... 19 Cardiac Ischemia Medical Directive ................................................................................. 22 Acute Cardiogenic Pulmonary Edema Medical Directive .................................................. 24 Cardiogenic Shock Medical Directive ............................................................................... 26 Symptomatic Bradycardia Medical Directive ................................................................... 28 Tachydysrhythmia Medical Directive … ............................................................................ 30 Intravenous and Fluid Therapy Medical Directive ............................................................ 33 Pediatric Intraosseous Medical Directive ......................................................................... 36 Hypoglycemia Medical Directive ...................................................................................... 37 Seizure Medical Directive ................................................................................................. 40 Opioid Toxicity Medical Directive .................................................................................... 42 Orotracheal Intubation Medical Directive ........................................................................ 44 Bronchoconstriction Medical Directive ............................................................................ 46 Moderate to Severe Allergic Reaction Medical Directive ................................................ 49 Croup Medical Directive .................................................................................................. 51 Tension Pneumothorax Medical Directive ........................................................................ 53 Pain Medical Directive ..................................................................................................... 54 Pediatric Pain Medical Directive ..................................................................................... 56

ACP Auxiliary Medical Directives

Adult Intraosseous Medical Directive – AUXILIARY ............................................................. 58 Central Venous Access Device Access Medical Directive – AUXILIARY ............................... 59 Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY .................... 60 Supraglottic Airway Medical Directive – AUXILIARY ........................................................... 62 Cricothyrotomy Medical Directive – AUXILIARY ................................................................. 64 Nausea/Vomiting Medical Directive – AUXILIARY ............................................................... 66 Combative Patient Medical Directive – AUXILIARY ............................................................. 68 Procedural Sedation Medical Directive – AUXILIARY .......................................................... 70 Electronic Control Device Probe Removal Medical Directive – AUXILIARY ......................... 72 Analgesia Medical Directive – AUXILIARY ........................................................................... 73 Moderate to Severe Pain Medical Directive – AUXILIARY .................................................. 75 Nasotracheal Intubation Medical Directive – AUXILIARY ................................................... 77

Blank pages left for future Medical Directives ....................................................................... 80

3


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Medical Cardiac Arrest Medical Directive

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

Non-traumatic cardiac arrest

Indications

Conditions

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: performed in 2 minute increments


AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥8 years

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Alternative to manual defibrillation

Epinephrine

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

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

Amiodarone

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Lidocaine

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: VF or pulseless VT where amiodarone is not available

4


0.9% NaCl Fluid Bolus

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: PEA

Any other rhythm where hypovolemia is suspected

Contraindications

CPR





AED Defibrillation


Epinephrine


Amiodarone

Allergy or sensitivity to amiodarone

Lidocaine

Allergy or sensitivity to lidocaine

Use / Availability of amiodarone


Fluid overload

5


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Treatment

Consider CPR

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


Age Age

≥30 days to

<8 years ≥8 years


First dose 2 J/kg As per BH /

manufacturer Subsequent and max. dose(s)

4 J/kg As per BH /

manufacturer

Dosing interval 2 min 2 min

Max. # of doses N/A N/A

Consider AED defibrillation (alternative to manual defibrillation):

Age Age


With Ped






manufacturer


Max. # of doses N/A N/A N/A

6



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


Age Age


Route Route

IV / IO ETT IV / IO / CVAD ETT

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

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

1 mg 2 mg

Min. single dose 0.1 mg 1 mg 1 mg 2 mg

Dosing interval 4 min. 4 min. 4 min. 4 min.

Max. # of doses N/A N/A N/A N/A

Consider amiodarone:

Age Age

≥30 days to <12 years

≥12 years

Route Route

IV / IO IV / IO / CVAD

Initial Dose 5 mg/kg 300 mg

Max. initial dose 300 mg 300 mg

Repeat dose 5 mg/kg 150 mg

Max. repeat dose 150 mg 150 mg

Dosing interval 4 min. 4 min.

Max. # of doses 2 2

7


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Consider lidocaine (if amiodarone not available):

Age Age

≥30 days to 12 years

and <40 kg ≥12 years

Route Route

IV / IO ETT IV / IO / CVAD ETT

Dose 1 mg/kg 2 mg/kg 1.5 mg/kg 3 mg/kg

Min. single dose N/A N/A N/A N/A




Age Age


Route Route

IV / IO IV / IO / CVAD


Infusion interval Immediate Immediate


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

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


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

8


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.)


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Trauma Cardiac Arrest Medical Directive


Cardiac arrest secondary to severe blunt or penetrating trauma

Indications

Conditions

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A


AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


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.

10


Contraindications

CPR





AED Defibrillation


Trauma TOR

Age <16 years

Shock delivered

Monitored HR >0 and closest ER <30 min away

Treatment

Consider CPR





manufacturer


Max. # of doses 1 1

11


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


Age Age


With Ped



Max. single dose

As per BH /



manufacturer




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.


12


Treatment – Algorithm for Trauma Arrest

INDICATIONS: Cardiac arrest secondary to severe blunt or penetrating trauma

CPR (throughout duration of call)

Apply defib pads to all patient =30 days of age – Rhythm analysis

VF or VT Other monitored rhythm

Defibrillation: 1 shock, Max #

doses = 1

YES

Asystole

YES

PEA(HR >0)

Pt age =16 yrs

YES

Drive timeto closest ER

>30 min

Patch

YES

TOR implemented

YES

YES

YES

YES

Transp

ort to

Emergen

cy Dep

artmen

t

NO

NO

NO

NOTransport to ED

YES

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Hypothermia Cardiac Arrest Medical Directive


Cardiac arrest secondary to severe hypothermia

Indications

Conditions

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A


AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Contraindications

CPR





AED Defibrillation


Treatment

Consider CPR

14


N/A


Age Age

≥30 days to

<8 years ≥8 years



manufacturer


Max. # of doses 1 1


Age Age


With Ped






manufacturer



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


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Foreign Body Airway Obstruction Cardiac Arrest Medical Directive


Cardiac arrest secondary to an airway obstruction

Indications

Conditions

CPR

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A


AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


AED Defibrillation

AGE: ≥30 days

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A


Contraindications

CPR





AED Defibrillation


Treatment

Consider CPR

16


N/A

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


Age Age

≥30 days to

<8 years ≥8 years



manufacturer Dosing interval N/A N/A

Max. # of doses 1 1


Age Age


With Ped






manufacturer



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.


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Neonatal Resuscitation Medical Directive


Severe cardio-respiratory distress

Indications

Conditions

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

Contraindications

Resuscitation

Clear of meconium

Breathing or crying

Good muscle tone

Pink in colour

18


*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.

Treatment

Ventilating

Birth:

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

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

NO

Evaluate respirations, heart rate and colour

Provide positive pressure ventilation (BVM) using air

Apnea, gasping or HR <100

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

HR <60

Routine Care:

Provide warmthClear airway if necessaryDo not routinely suctionDryOngoing evaluation

YES

Supportive care

Supportive care

HR ≥60

HR ≥100 + pink

Breathing

HR ≥100 + pink

30 Sec

60 Sec

90 Sec

Epinephrine: 0.01 mg/kg (0.1 ml/kg) 1:10,000 IV/IO OR 0.1 mg/kg (1ml/kg) 1:10,000 ETT q4 minutes.Indicate transport prior to the 3rd dose if possible

HR <60HR ≥60

120 Sec

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Return of Spontaneous Circulation (ROSC) Medical Directive


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

Indications

Conditions


AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Chest auscul-tation is clear

Dopamine

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

Therapeutic Hypothermia

AGE: Males ≥18 years Females ≥50 years

LOA: Altered

HR: N/A

RR: N/A

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

Other: N/A

20


Contraindications


Fluid overload

SBP ≥90 mmHg

Dopamine

Allergy or sensitivity to dopamine

Tachydysrhythmias excluding sinus tachycardia

Mechanical shock states

Hypovolemia

Pheochromocytoma

SBP ≥ 90 mmHg

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 ETCO2 of 35–40 mmHg with continuous wave-form capnography (if available)

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


Age Age <12 years ≥12 years

Route Route IV IV




Max. volume 1,000 ml 1,000 ml

Consider dopamine:

Route

IV

Initial Infusion Rate 5 mcg/kg/min

Titration increment 5 mcg/kg/min


Max infusion rate 20 mcg/kg/min

Consider 12 lead acquisition (if available)

Consider Therapeutic hypothermia (if available)


22


Cardiac Ischemia Medical Directive


Suspected cardiac ischemia

Indications

Conditions

ASA

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: Able to chew and swallow

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

Morphine

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: N/A

Contraindications

ASA


If asthmatic, no prior use of ASA



Nitroglycerin



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

23


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N/A

Treatment

Consider ASA:

Route PO Dose 160–162 mg Max. single dose 162 mg Dosing interval N/A 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):

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


24


Acute Cardiogenic Pulmonary Edema Medical Directive


Moderate to severe respiratory distress AND Suspected acute cardiogenic pulmonary edema

Indications

Conditions

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

Contraindications

Nitroglycerin



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

25


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N/A

Treatment


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

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.




26


Cardiogenic Shock Medical Directive


STEMI-positive ECG AND Cardiogenic shock

Indications

Conditions

0.9% NaCl

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: Clear chest on auscultation

Dopamine

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

Contraindications

0.9% NaCl

N/A

Dopamine

Allergy or sensitivity to dopamine

Tachydysrhythmias excluding sinus tachycardia

Mechanical shock states

Pheochromocytoma

27


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Contact BHP if patient is bradycardic with respect to age.

Treatment


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

Age Age <18 years ≥18 years Route Route Route Route IV IO IV IO

Infusion 10 ml/kg 10 ml/kg 10 ml/kg 10 ml/kg

Infusion interval N/A N/A N/A N/A

Reassess every 100 ml 100 ml 250 ml 250 ml

Max. volume 10 ml/kg 10 ml/kg 10 ml/kg 10 ml/kg

Consider dopamine:

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

Route IV

Initial infusion rate 5 mcg/kg/min.

Titration increment 5 mcg/kg/min.


Max. infusion rate 20 mcg/kg/min.


28


Symptomatic Bradycardia Medical Directive


Bradycardia AND Hemodynamic instability

Indications

Conditions

Atropine

AGE: ≥18 years

LOA: N/A

HR: < 50 bpm

RR: N/A

SBP: Hypotension

Other: N/A

Transcutaneous Pacing

AGE: ≥18 years

LOA: N/A

HR: < 50 bpm

RR: N/A

SBP: Hypotension

Other: N/A

Dopamine

AGE: ≥18 years

LOA: N/A

HR: < 50 bpm

RR: N/A

SBP: Hypotension

Other: N/A

Contraindications

Atropine

Allergy or sensitivity to atropine

Hemodynamic stability

Hypothermia

History of heart transplant

Transcutaneous Pacing


Hypothermia

Dopamine

Allergy or hypersensitivity to dopamine


Pheochromocytoma

Treatment

Consider Rhythm determination

29


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No

tes

Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first degree AV block, or second-degree Type I AV block.

A single dose of atropine should be considered for second degree Type II or third degree AV blocks with fluid bolus while preparing for TCP OR if there is a delay in implementing TCP OR if TCP is unsuccessful.

The dopamine infusion should be initiated at 5 mcg/kg/min. and titrated upward to effect in increments of 5 mcg/kg/min every 5 minutes up to a maximum of 20 mcg/kg/min. The desired effect is a SBP of 90–110 mmHg.

Consider 12 lead ECG acquisition (if available and 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:

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

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

Max. infusion rate 20 mcg/kg/min.


30


Tachydysrhythmia Medical Directive


Symptomatic Tachydysrhythmia

Indications

Conditions

Valsalva Maneuver

AGE: ≥18 years

LOA: Unaltered

HR: ≥150

RR: N/A

SBP: Normotension

Other: Narrow complex and regular rhythm

Adenosine

AGE: ≥18 years

LOA: Unaltered

HR: ≥150

RR: N/A

SBP: Normotension

Other: Narrow complex and regular rhythm

Amiodarone

AGE: ≥18 years

LOA: Unaltered

HR: ≥120

RR: N/A

SBP: Normotension

Other: Wide complex and regular rhythm

Lidocaine

AGE: ≥18 years

LOA: Unaltered

HR: ≥120

RR: N/A

SBP: Normotension

Other: Wide complex and regular rhythm

Synchronized Cardioversion

AGE: ≥18 years

LOA: N/A

HR: ≥120 (wide) or ≥150 (narrow)

RR: N/A

SBP: Hypotension

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

31


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Contraindications

Valsalva Maneuver

Sinus tachycardia or atrial fibrillation or atrial flutter

Adenosine

Allergy or sensitivity to adenosine

Sinus tachycardia or atrial fibrillation or atrial flutter

Patient taking dipyridamole or carbamazepine

Bronchoconstriction on exam

Amiodarone

Allergy or sensitivity to amiodarone

Lidocaine


Synchronized Cardioversion

N/A

Treatment

Consider Rhythm determination: Confirm regularity.

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

Consider valsalva maneuver:

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

Consider adenosine:

Route IV Initial Dose 6 mg Second dose 12 mg Dosing interval 2 min.

Max. # of doses 2 doses

32


N/A


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:

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

Drug Drug Amiodarone Lidocaine Route Route IV* IV

First Dose 150 mg 1.5 mg/kg

Subsequent Dose(s) 150 mg 0.75 mg/kg

Max. single dose 150 mg 150 mg


Max. # of doses 2 3


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.)


33


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Intravenous and Fluid Therapy Medical Directive


Actual or potential need for intravenous medication OR fluid therapy

Indications

Conditions

IV

AGE: N/A ≥2 years for PCP Assist IV

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Fluid Bolus

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension

Other: N/A

ContraindicationContraindicationContraindication

IV

Suspected fracture proximal to the access site.

Fluid Bolus

Signs of fluid overload

Treatment

Consider IV cannulation

34


“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.

Consider 0.9% NaCl maintenance infusion:

Age Age

<12 years ≥12 years

Route Route IV / IO IV / IO / CVAD

Infusion 15 ml/hr 30–60 ml/hr

Infusion interval N/A N/A

Reassess every N/A N/A

Max. volume N/A N/A


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


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

Age Age

<12 years ≥12 years

Route Route IV / IO IV / IO / CVAD




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


35


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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.

36


Pediatric Intraosseous Medical Directive


Actual or potential need for intravenous medication OR fluid therapy AND Intravenous access is unobtainable AND Cardiac arrest or near-arrest state

N/A

Indications

Conditions

IO

AGE: <12 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindication

IO

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

Treatment

Consider IO access


37


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Hypoglycemia Medical Directive


Agitation OR altered LOA OR seizure OR symptoms of stroke

Indications

Conditions

Dextrose

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Glucagon

AGE: N/A

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: Hypoglycemia

Contraindications

Dextrose

Allergy or sensitivity to dextrose

Glucagon

Allergy or sensitivity to glucagon

Pheochromocytoma

Treatment

Perform glucometry

38


Consider dextrose or glucagon:

Drug

Dextrose

Age Age Age

<30 days ≥30 days to

<2 years ≥2 years

Weight Weight Weight N/A N/A N/A

Concentration Concentration Concentration

D10W D25W D50W

Route Route Route IV IV IV

Dose 0.2 g/kg (2 ml/kg)

0.5 g/kg

(2 ml/kg)

0.5 g/kg (1 ml/kg)

Max. single dose 5 g (50 ml) 10 g (40 ml) 25 g (50 ml)



Drug Glucagon Age N/A Weight Weight <25 kg ≥25 kg Concentration Concentration N/A N/A Route Route IM IM Dose 0.5 mg 1.0 mg

Max. single dose 0.5 mg 1.0 mg


Max. # of doses 2 2

39


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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.


40


Seizure Medical Directive


Active generalized motor seizure

Indications

Conditions

Midazolam

AGE: N/A

LOA: Unresponsive

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Midazolam

Allergy or sensitivity to midazolam

Hypoglycemia

41


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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

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




42


Opioid Toxicity Medical Directive


Altered LOC AND Respiratory depression AND Suspected opioid overdose

Indications

Conditions

Naloxone

AGE: ≥18 years

LOA: Altered

HR: N/A

RR: < 10

SBP: N/A

Other: N/A

Contraindications

Naloxone

Allergy or sensitivity to naloxone

Uncorrected hypoglycemia

Treatment


Patch to BHP for authorization to proceed with naloxone

43


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Consider naloxone:

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

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


44


Orotracheal Intubation Medical Directive


Need for ventilatory assistance or airway control AND Other airway management is inadequate or ineffective

Indications

Conditions

Lidocaine Spray

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Orotracheal / Intubation

Orotracheal Intubation

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Lidocaine


Unresponsive patient

Orotracheal Intubation

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

45


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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

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

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

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

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

ETT placement must be reconfirmed immediately after every patient movement.

Treatment

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

Route TOPICAL Dose 10 mg/spray

Max. dose 5mg/kg

Dosing interval N/A

Max. # of doses 20 sprays

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

Confirm orotracheal tube placement:

Method Method Primary Secondary Visualization ETCO2 Auscultation EDD Chest rise Other


46


Bronchoconstriction Medical Directive


Respiratory distress AND Suspected bronchoconstriction

Indications

Conditions

Salbutamol

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A


SBP: N/A

Other: Hx of asthma


AGE: N/A

WEIGHT: ≥10 kg

LOA: N/A

HR: N/A


SBP: N/A

Other: Hx of asthma

Contraindications

Salbutamol

Allergy or sensitivity to salbutamol

Epinephrine




47


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Treatment

Consider salbutamol:

* 1 puff=100mcg

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


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

Weight Weight Weight

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

IM Pediatric

Autoinjector 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



48



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).


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

49


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Moderate to Severe Allergic Reaction Medical Directive


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

Indications

Conditions

Epinephrine

AGE: N/A

WEIGHT: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A



AGE: N/A

WEIGHT: ≥10 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A


Diphenhydramine

AGE: N/A

WEIGHT: ≥25 kg

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Epinephrine




Diphenhydramine


50


Epinephrine should be the first drug administered in anaphylaxis.

Treatment




N/A ≥10 kg to <25 ≥25 kg

Route Route Route

IM Pediatric

Autoinjector

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



Consider diphenhydramine (if available):




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

51


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Croup Medical Directive


Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough OR recent history of a barking cough

Indications

Conditions

Epinephrine

AGE: <8 years

LOA: N/A

HR: <200 bpm

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Epinephrine


52


The minimum initial volume for nebulization is 2.5 ml.

Treatment


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




53


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Tension Pneumothorax Medical Directive


Suspected tension pneumothorax AND Critically ill OR VSA AND Absent or severely diminished breath sounds on the affected side(s)

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

Indications

Conditions

Needle Thoracostomy

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: Hypotension or VSA

Other: N/A

Contraindications

Needle Thoracostomy

N/A

Treatment


Patch to BHP for authorization to perform needle thoracostomy

Consider needle thoracostomy


54


Pain Medical Directive


Severe pain AND Isolated hip or extremity fractures or dislocations OR major burns OR current history of cancer related pain OR renal colic with prior history OR patients with acute musculoskeletal back strain OR ongoing transcutaneous pacing

Indications

Conditions

Fentanyl

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: N/A

Morphine

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: N/A

Contraindications

Fentanyl

Allergy or sensitivity to fentanyl

Injury to the head or chest or abdomen or pelvis

SBP drops by one-third or more of its initial value

Morphine




55


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Treatment

Consider fentanyl OR morphine:

Drug Drug Fentanyl Morphine

Route Route IV IV

Dose 25–50 mcg 2–5mg

Max. single dose 50 mcg 5 mg


Max. # of doses 4 4


56


Pediatric Pain Medical Directive


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

Indications

Conditions

Morphine

AGE: <18 years

LOA: Unaltered

HR: >60/min

RR: N/A

SBP: Age Related Normotension

Contraindications

Morphine




57


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Treatment

Consider morphine:

Route IV/SC

Dose 0.05mg/kg



Max. # of doses 2



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

58


Adult Intraosseous Medical Directive – AUXILIARY

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

Actual or potential need for intravenous medication OR fluid therapy AND IV access is unobtainable AND Cardiac arrest OR near arrest state

N/A

Indications

Conditions

IO

AGE: ≥12 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindication

IO

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

Treatment

Consider IO access


59


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Central Venous Access Device Access Medical Directive – AUXILIARY


Actual or potential need for intravenous medication OR fluid therapy AND IV access is unobtainable AND Cardiac arrest OR near arrest state

N/A

Indications

Conditions

CVAD Access

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

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

Contraindications

CVAD Access

N/A

Treatment

Consider CVAD access


60


Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY


Severe respiratory distress AND Signs and/or symptoms of acute pulmonary edema OR COPD

Indications

Conditions

CPAP

AGE: ≥18 years

LOA: N/A

HR: N/A

RR: Tachypnea

SBP: Normotension

Other: SpO2 <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

61


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Treatment

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


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

Consider increasing FiO2 (if available):

Initial FiO2 50–100%

FiO2 increment (if available on device)

SpO2 <92% despite treatment and/or 10cm H2O pressure or equivalent flow rate of device as per BH direction

Max FiO2 100%

Confirm CPAP pressure by manometer (if available)


62


Supraglottic Airway Medical Directive – AUXILIARY


Need for ventilatory assistance OR airway control AND Other airway management is inadequate OR ineffective OR unsuccessful

Indications

Conditions

Supraglottic Airway

AGE: N/A

LOA: GCS = 3

HR: N/A

RR: N/A

SBP: N/A

Other: Absent gag reflex

Contraindications

Supraglottic Airway

Active vomiting

Inability to clear the airway

Airway edema

Stridor

Caustic ingestion

63


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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


Treatment

Consider supraglottic airway insertion: The maximum number of attempts is 2.

Confirm supraglottic airway placement:


Auscultation ETCO2 Chest rise Other


64


Cricothyrotomy Medical Directive – AUXILIARY


Need for advanced airway management AND Intubation AND supraglottic airway (if available) insertion unsuccessful or contraindicated AND Unable to ventilate

Indications

Conditions

Cricothyrotomy

AGE: ≥12 years

LOA: Altered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Cricothyrotomy

Suspected fractured larynx

Inability to landmark

65


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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

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

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

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

Treatment


Patch to BHP for authorization to perform cricothyrotomy

Consider cricothyrotomy.

Confirm cricothyrotomy: tube placement


Auscultation ETCO2 Chest rise Other


66


Nausea / Vomiting Medical Directive – AUXILIARY


Nausea OR vomiting

Indications

Conditions

Dimenhydrinate

AGE: N/A

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Dimenhydrinate

Allergy or sensitivity to dimenhydrinate or other antihistamines

Overdose on antihistamines or anticholinergics or TCAs

67


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

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.

Treatment

Consider dimenhydrinate:


<25 kg ≥25 kg to <50 kg ≥50 kg

Route Route Route Route Route Route

IV IM IV IM IV IM

Dose Patch Patch 25mg 25mg 50mg 50mg

Max. single dose N/A N/A 25mg 25mg 50mg 50mg

Dosing interval N/A N/A N/A N/A N/A N/A

Max. # of doses N/A N/A 1 1 1 1


68


Combative Patient Medical Directive – AUXILIARY


Combative patient

Indications

Conditions

Midazolam

AGE: ≥18 years

LOA: N/A

HR: N/A

RR: N/A

SBP: Normotension

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

Contraindications

Midazolam


Treatment


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

69


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Consider midazolam:

Route Route

IV IM

Dose 2.5–5 mg 2.5–5 mg

Max. single dose 5 mg 5 mg


Max. total dose 10 mg 10 mg

Max. # doses 2 2


70


Procedural Sedation Medical Directive – AUXILIARY


Post-intubation OR transcutaneous pacing

*Non-intubated patients only

Indications

Conditions

Midazolam

AGE: ≥18 years

LOA: N/A

HR: N/A

RR: ≥ 8 bpm*

SBP: Normotension

Other: N/A

Contraindications

Midazolam


71


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

N/A

Treatment

Consider midazolam:

Route IV

Dose 2.5–5 mg



Max. total dose 10 mg

Max. # doses 2


72


Electronic Control Device Probe Removal Medical Directive – AUXILIARY


Electronic Control Device probe(s) embedded in patient.

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.

Indications

Conditions

Probe Removal

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Probe removal

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

Treatment

Consider probe removal


73


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Analgesia Medical Directive – AUXILIARY


Isolated Hip OR Extremity Trauma AND Pain

Indications

Conditions

Acetaminophen

AGE: ≥ 18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Ibuprofen

AGE: ≥ 18 and < 50 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Contraindications

Acetaminophen

Acetaminophen use within previous 4 hours



Active vomiting

Major burns

Hx of liver disease

Ibuprofen

Ibuprofen or NSAID use within previous 6 hours


Active vomiting


Major burns

Hx of peptic ulcer disease or GI bleed

Pregnant

Hx cardiovascular disease



74


Whenever possible, both acetaminophen and ibuprofen should be used together.

This medical directive does not replace the ACP Core Pain Medical Directive and may be used in conjunction where appropriate.

Treatment



Route

PO

Dose 960–1000 mg


Dosing interval N/A

Max. # of doses 1

Consider ibuprofen:

Route

PO

Dose 400 mg


Dosing interval N/A

Max. # of doses 1

75


Intr

o

PC

P

AC

P

Sp

ecia

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ven

ts

No

tes

Moderate to Severe Pain

Medical Directive – AUXILIARY

An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary medical directive if certified and authorized. Indications

Moderate to Severe pain

AND Isolated hip or extremity trauma OR major burns OR current history of cancer related pain OR renal colic with prior history OR patients with acute musculoskeletal back strain.

Conditions

Contraindications

Ketorolac

AGE: ≥ 18 years and < 50 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: Normotension

Other: Patient must remain NPO or is unable to take oral medications

Ketorolac

NSAID or ibuprofen use within previous 6 hours


Patient on anticoagulation therapy




Pregnant

Known renal impairment

76


This medical directive does not replace the ACP Core Pain Medical Directive and may be used in conjunction where appropriate.

Treatment


Consider ketorolac:

Route

IM/IV

Dose 30 mg

Max. single dose 30mg

Dosing interval N/A

Max. # of doses 1

77


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Nasotracheal Intubation Medical Directive – AUXILIARY


Need for ventilatory assistance or airway control AND Other airway management is inadequate or ineffective

Indications

Conditions

Xylometazoline

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Nasotracheal intubation

Lidocaine Spray

AGE: N/A

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Nasotracheal Intubation

Nasotracheal Intubation

AGE: ≥ 8 years

LOA: N/A

HR: N/A

RR: N/A

SBP: N/A

Other: Spontaneous Breathing

78


Contraindications

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

Xylometazoline

Allergy or sensitivity to xylometazoline

Lidocaine


Unresponsive patient

Route TOPICAL

Dose 2 sprays/nare

Max. single dose 2 sprays/nare

Dosing interval N/A

Max. # of doses 1

79


Intr

o

PC

P

AC

P

Sp

ecia

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ven

ts

No

tes

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


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

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

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

ETT placement must be reconfirmed immediately after every patient movement.

Consider topical lidocaine spray for “awake” orotracheal or nasotracheal intubation

(to nares and/or hypopharynx):

Consider intubation: The maximum number of intubation attempts is 2.

Confirm nasotracheal tube placement:


Visualization ETCO2

Auscultation EDD Chest rise Other


Route TOPICAL

Dose 10 mg/spray

Max. dose 5mg/kg

Dosing interval N/A

Max. # of doses 20 sprays

80



81


Intr

o

PC

P

AC

P

Sp

ecia

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ven

ts

No

tes


82



83


Intr

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P

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P

Sp

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ts

No

tes


84



S p e c i a l E v e n t s M e d i c a l D i r e c t i v e s

Intr

o

PC

P

AC

P

Sp

ecia

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ven

ts

No

tes

SPECIAL EVENTS MEDICAL

DIRECTIVES

2


Special Events Medical Directives Table of Contents

Minor Abrasions Medical Directive – AUXILIARY ........................................................................ 3

Minor Allergic Reactions Medical Directive – AUXILIARY .......................................................... 4

Musculoskeletal Pain Medical Directive – AUXILIARY ................................................................ 6

Headache Medical Directive – AUXILIARY ..................................................................................... 8

Blank page left for future Medical Directives .......................................................................... 10

3


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Minor Abrasions Medical Directive – auxiliary

A Primary Care Paramedic or 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

Contraindications

Treatment


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

Topical Antibiotic

AGE: N/A

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Topical Antibiotic

Allergy or sensitivity to any of the components of the topical antibiotic

Consider topical antibiotic

Consider release from care

4


Minor Allergic Reaction Medical Directive – auxiliary


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

AGE: ≥18 years

LOA: Unaltered

HR: WNL

RR: WNL

SBP: Normotension

Other: N/A

Diphenhydramine


Antihistamine or sedative use in previous 4 hours

Signs or symptoms of moderate to severe allergic reaction


Wheezing

5


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Treatment



Consider diphenhydramine:

Route PO

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


6


Musculoskeletal Pain Medical Directive – auxiliary


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

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Acetaminophen

No acetaminophen in the last 4 hours



7


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Treatment






8


Headache Medical Directive – auxiliary


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

AGE: ≥18 years

LOA: Unaltered

HR: N/A

RR: N/A

SBP: N/A

Other: N/A

Acetaminophen

No acetaminophen in past 4 hours



9


Intr

o

PC

P

AC

P

Sp

ecia

l E

ven

ts

No

tes

Treatment






10



N o t e s

Intr

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P

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P

Sp

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No

tes

NOTES

2

N o t e s

3

N o t e s

Intr

o

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P

AC

P

Sp

ecia

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ven

ts

No

tes

4

N o t e s

5

N o t e s

Intr

o

PC

P

AC

P

Sp

ecia

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ven

ts

No

tes

6

N o t e s

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