Advanced
Care
Paramedic
Pocket Reference Guide
2011 v. 1.1
CEPCP
2
This pocket reference guide is to be used for reference
only. Refer to the current medical directives for all
treatment decisions. If there are inconsistencies between
this reference guide and the current directives always refer
to the medical directives.
For questions, comments, or suggestions for improvements, please contact
us at:
Website (follow ‘contact us’ link):
www.cepcp.ca
Administration Office:
95A Simcoe St. S.
Oshawa, ON
Mailing Address:
Central East Prehospital Care Program
Lakeridge Health Oshawa
1 Hospital Court
Oshawa, ON
L1G 2B9
Phone: (905) 433-4370
Fax: (905) 721-4737
Toll free: 1-866-423-8820
3
Table of Contents:
Mandatory Patches and BHP names............................!4 - 5
Adult Cardiac Arrest......................................................!6 - 7
Pediatric Cardiac Arrest................................................!8 - 9
Trauma Cardiac Arrest..................................................!10
Tension Pneumothorax.................................................!11
Neonatal Resuscitation.................................................!12 - 13
Hypothermia Cardiac Arrest..........................................!14
Foreign Body Airway Obstruction..................................15
Return of Spontaneous Circulation...............................!16
IV and Fluid Therapy.....................................................!17
Pediatric / Adult IO........................................................!18
Central Venous Access.................................................!19
Endotracheal Intubation................................................!20
Supraglottic Airway........................................................!21
Moderate to Severe Allergic Reaction..........................!22 - 23
Croup............................................................................!24
Bronchoconstriction......................................................!25
CPAP.............................................................................!26
Acute Cardiogenic Pulmonary Edema..........................!27
Cardiac Ischemia..........................................................!28 - 29
STEMI Bypass..............................................................!30 - 31
Cardiogenic Shock........................................................!32 - 33
Bradycardia...................................................................!34 - 35
Procedural Sedation.....................................................!36
Combative Patient........................................................!37
Tachydysrhythmia.........................................................!38 - 39
Seizure..........................................................................!40 - 41
Opioid Toxicity...............................................................!42
Electronic Control Device Probe Removal....................!43
Hypoglycemia................................................................44 - 45
Nausea / Vomiting.........................................................46 - 47
Pain...............................................................................48
Special Events...............................................................49 - 53
Reference Materials
4
Advanced Care Paramedics will now be required to patch for the following
•
Medical Cardiac Arrest Directive patch after 3 rounds of epinephrine or
unable to get a drug route after 3 analyses
•
Trauma Cardiac Arrest Directive patch for authorization to apply the
TOR if applicable
•
Symptomatic Bradycardia Directive patch for authorization to proceed
with transcutaneous pacing and/or a dopamine infusion
•
Tachydysrhythmia Directive patch for authorization to proceed with
lidocaine or monomorphic wide complex regular rhythm for adenosine
•
Tachydysrhythmia Directive patch for authorization to proceed with
synchronized cardioversion
•
Intravenous and Fluid Therapy Directive patch for authorization to
administer IV NaCl bolus to patients <12 years with suspected
Diabetes Ketoacidosis (DKA)
•
Opioid Toxicity Directive patch for authorization to proceed with
naloxone
•
Tension pneumothorax Directive patch for authorization to perform
needle thoracostomy
AUXILIARY DIRECTIVES
•
Combative Patient Directive patch for authorization to proceed with
midazolam if unable to assess the patient for normotension or
reversible causes
•
Nausea and Vomiting Directive patch for authorization to proceed with
dimenhydrinate for patient weighing <25kg IV or IM
Central East Prehospital Care Program
Markham:
For reference only
5
6
Central East Prehospital Care Program
For reference only
Adult Cardiac Arrest
Indications
Adult Cardiac Arrest
Non-traumatic cardiac arrest
CPR ongoing throughout call
Minimize Interruptions
100 - 120 per minute
At least 2 inches depth
30:2
Adult > 8 years only (if 8-12 years old use DRUG dosages from pediatric arrest page)
Defibrillate VF/VT
every 2 mins
Zoll
LP12 / LP15
200 joules (all shocks)
200, 300, 360 joules
Adult > 12 years only
Drug
Dose
Epinephrine
every 4 mins
patch after 3rd dose
IO/CVAD/IV (preferred)
1.0 mg
ETT (if above delayed > 5 mins)
2.0 mg
IM (if suspected anaphylaxis) 0.01 mg/kg 1:1,000 (max 0.5 mg) single dose
Lidocaine
for recurrent V-fib/VT
(typically after 3rd shock)
repeat after 4 mins
2 doses max
Bolus
for PEA or any other rhythm
where hypovolemia is
suspected
IO/IV/CVAD 1.5 mg/kg
typically supplied 20 mg/ml
ETT
3.0 mg/kg
20 ml/kg to 2,000 max
re-assess every 250 ml
ETT or King LT should be inserted where more than OPA/BVM is required,
without interrupting CPR.
Once inserted, begin continuous compressions and ventilate asynchronously at 6-8 breaths / min.
monitor ETCO2:
10 - 15 mmHg - poor prognosis, confirm compressions are adequate
20 - 30 mmHg - improved prognosis, indicates good CPR quality
> 35 mmHg - excellent CPR / prognosis, check for palpable pulse
large spike to above normal values - probable ROSC, check for pulse
For reference only 7
Central East Prehospital Care Program
Lidocaine Volume per weight based on 100 mg/5 ml
40 kg = 3.0 ml
105 kg = 7.88 ml
45 kg = 3.34 ml
110 kg = 8.25 ml
50 kg = 3.75 ml
115 kg = 8.62 ml
55 kg = 4.13 ml
120 kg = 9.0 ml
60 kg = 4.5 ml
125 kg = 9.38 ml
65 kg = 4.88 ml
130 kg = 9.75 ml
70 kg = 5.25 ml
135 kg = 10.13 ml
75 kg = 5.63 ml
140 kg = 10.5 ml
80 kg = 6.0 ml
145 kg = 10.88 ml
85 kg = 6.36 ml
150 kg = 11.25 ml
90 kg = 6.75 ml
155 kg = 11.63 ml
95 kg = 7.13 ml
160 kg = 12.00 ml
100 kg = 7.5 ml
165 kg = 12.37 ml
King LT Reference
Notes:
Size Colour Patient
Amt of air in cuff
#3
Yellow
4-5 ft tall 45 - 60 ml
#4
#5
Red
Purple
5-6 ft tall
≥ 6 ft tall
Confirmation Methods
60 - 80 ml
70 - 90 ml
Primary
• Auscultation
Confirm supraglottic airway placement.
• Chest rise
Secondary
• ETCO2
• Other
8
Central East Prehospital Care Program
For reference only
Pediatric Cardiac Arrest
Pediatric Cardiac Arrest
Indications
Non-traumatic cardiac arrest
CPR ongoing throughout call
Minimize Interruptions
100 - 120 per minute
1/3 to 1/2 of chest diameter for children and infants
30:2 if single rescuer
15:2 for infants and children if two rescuer
Pediatric ≥ 30 days - < 8 years only (if 8-< 12 years old use adult joule settings, but drug dosages below)
Drug
Dose
Defibrillate VF/VT
2 joules / kg ( 1st shock)
4 joules / kg (subsequent shocks)
every 2 mins
(pediatric pads if < 15 kg)
Pediatric ≥ 30 days - < 12 years only
Drug
Dose
Epinephrine
every 4 mins
patch after 3rd dose
IO/IV (preferred) 0.01 mg/kg 1:10,000 (min 0.1 mg)
0.1 ml / kg
ETT (if above delayed > 5 mins) 0.1 mg/kg 1:1,000 (min 1 mg)
0.1 ml / kg
(max 2 mg)
IM (if suspected anaphylaxis) 0.01 mg/kg 1:1,000 (max 0.5 mg) single dose
Lidocaine < 40kg
for recurrent VF/VT
(typically after 3rd shock)
repeat after 4 mins
2 doses max
Bolus
for PEA or any other rhythm
where hypovolemia is
suspected
IO/IV 1.0 mg/kg
typically supplied 20 mg/ml
ETT 2.0 mg/kg
20 ml/kg to 2,000 max
re-assess every 100 ml
ETT should be inserted where more than OPA/BVM is required, without interrupting CPR.
Tube size = 4 + (age / 4) Depth = 3 x ETT diameter
Once inserted, begin continuous compressions and ventilate asynchronously at 6-8 breaths / min.
monitor ETCO2:
10 - 15 mmHg - poor prognosis, confirm compressions are adequate
20 - 30 mmHg - improved prognosis, indicates good CPR quality
> 35 mmHg - excellent CPR / prognosis, check for palpable pulse
large spike to above normal values - probable ROSC, check for pulse
Central East Prehospital Care Program
For reference only 9
10
Central East Prehospital Care Program
For reference only
Trauma Cardiac Arrest
Trauma Cardiac Arrest
Indications
Cardiac arrest secondary to severe blunt or penetrating trauma.
Protect C-spine
Begin chest compressions
Attach SAED pads
Begin PPV with BVM
After 2 minutes interpret rhythm
If in VF/VT Defibrillate once
≥ 30 days - < 8 years - 2 joules / kg
≥ 8 yr - 200 joules
Yes
If in PEA determine
drive-time to nearest
hospital
Less than 30 minutes
drive-time to nearest ER?
No
ASYSTOLE
No
16 years or older?
Yes
Continue CPR
Immobilize Patient
Transport to Hospital
Continue CPR
Patch to BHP for possible trauma TOR
For reference only 11
Central East Prehospital Care Program
Tension Pneumothorax
Suspected tension pneumothorax and critically ill or VSA and absent or severely
diminished breath sounds on the affected side(s).
Clinical Parameters
Vital Sign Parameters
SBP < 90
or
VSA
N/A
PATCH - for needle thoracostomy
Notes:
Needle thoracostomy may only be performed at the second intercostal space in the midclavicular
line.
• Using three finger widths (average
adult fingers) from the centre of
the sternum provides an accurate,
easily remembered landmarking
method.
• The rib adjacent to the angle of louis
is the second rib, the space below
this rib is the second intercostal
space.
• Chest-wall thickness may be as much
as 2 3/4"
Tension Pneumothorax
Indications
Neonatal Resuscitation
12
Central East Prehospital Care Program
For reference only
Central East Prehospital Care Program
For reference only 13
Hypothermic Arrest
14
Central East Prehospital Care Program
For reference only
Hypothermia Cardiac Arrest
Indications
Cardiac arrest secondary to severe hypothermia.
Clinical Parameters
Not obviously dead as per BLS standard
No DNR
Interventions
Defibrillate once if the patient is in VF/VT
≥ 30 days to < 8 years old - 2 joules / kg
≥ 8 years old - 200 joules
Transport to the closest appropriate facility without delay following the first rhythm
interpretation.
Central East Prehospital Care Program
For reference only 15
Foreign body airway obstruction
Cardiac arrest secondary to an airway obstruction.
Clinical Parameters
Not obviously dead as per BLS standard
No DNR
Interventions
Attempt to clear airway with BLS maneuvers and /or laryngoscope Magill forceps
Defibrillate once if the patient is in VF/VT
≥ 30 days to < 8 years old - 2 joules / kg
≥ 8 years old - 200 joules
If the obstruction cannot be removed, transport to the closest appropriate facility
without delay following the first rhythm interpretation.
If the patient is in cardiac arrest following removal of the obstruction, initiate
management as a medical cardiac arrest.
Foreign Body Airway Obstr.
Indications
16
Central East Prehospital Care Program
For reference only
Return of Spontaneous Circulation (ROSC)
Indications
ROSC
ROSC after resuscitation was initiated
Clinical Parameters
SBP < 90 mmHg
Bolus:
• Clear chest / no fluid overload
Dopamine:
• No Allergy/Sensitivity
• No Pheochromocytoma
• No Tachydysrhythmias (excl. sinus tach)
• No Mechanical shock states (i.e: tension pneumothorax, pulmonary
embolism, pericardial tamponade)
• No Hypovolemia
Adult Doses (≥12 years)
Drug
Initial Dose
Reassess Q
10 ml/kg
250 ml
Bolus IV only
Drug
Initial
Dopamine IV only
5 mcg/kg/min
Increase by
5 mcg/kg/min
Max
1,000 ml
every
to max.
5 mins
20 mcg/kg/min
Pediatric Doses
Drug
Initital Dose
Bolus IV only
10 ml/kg
Drug
Initial
Dopamine IV only
5 mcg/kg/min
Reassess Q
100 ml
Increase by
5 mcg/kg/min
Max
1,000 ml
every
5 mins
to max.
20 mcg/kg/min
Notes:
Titrate oxygenation to ≥
94%
Avoid hyperventilation and target an ETCO2 of 35-40 mmHg with continuous capnography.
Consider 12 lead ECG.
For reference only 17
Central East Prehospital Care Program
IV and Fluid Therapy
Indications
Actual or potential need for IV medication or fluid therapy
Actual or potential need for intravenous medication or fluid therapy
Clinical Parameters
IV and Fluid
IV Start:
No fracture proximal to IV site
Bolus:
No signs of fluid overload
SBP < 90
Adult Doses ≥ 12 years
Drug
Initital Dose
TKVO IV/IO/CVAD
Bolus IV/IO/CVAD
Q
Repeat
Max
30 - 60 ml/hr
20 ml/Kg
Reassess q
250 ml
N/A
2,000 ml
Repeat Dose
Max
N/A
2,000 ml
Pediatric Doses < 12 years, Use micro drip or Buretrol
Drug
Initital Dose
TKVO IV/IO
15 ml/hr
Bolus IV/IO
20 ml/Kg
Q
Reassess q
100 ml
Notes:
PATCH to BHP for authorization to administer IV bolus to patients < 12 years
with suspected Diabetic Ketoacidosis (DKA).
18
Central East Prehospital Care Program
For reference only
Pediatric / Adult Intraosseous Medical Directive
Indications:
Pediatric / Adult IO
Actual or potential need for intravenous medication or fluid therapy
AND
Intravenous access is unobtainable
AND
Patient is in cardiac arrest or near-arrest state
Clinical Parameters
Vital Sign Parameters
IO Start:
No fracture or crush injuries or known
replacement / prosthesis proximal to the
access site.
N/A
Notes:
Jamshidi Cook :
≥ 1 year use 15/16 gauge needle
< 1 year use 18 gauge needle
EZ IO:
Pink 15 mm
3-39 kg
Blue 25 mm
≥ 40 kg
Yellow 45 mm
≥ 40 kg with excessive tissue over
targeted insertion site
For reference only 19
Central East Prehospital Care Program
Central Venous Access Device
Indications:
Clinical Parameters
Vital Sign Parameters
CVAD Access:
Patient has pre-existing, accessible central
venous catheter in place
N/A
Notes:
CVAD Procedure :
two 10 cc syringes, one
empty and one with 10 cc
saline drawn up
several alcohol swabs
a primed AIR FREE IV set
clean, preferably sterile,
gloves
Prepare equipment
Close clamps
Wipe med-port and luer lock with alcohol swab.
Remove med-port from luer lock
Attach the empty syringe,
Open the clamp (if present)
Withdraw whatever fluid is within the catheter until approximately 2cc of blood
is in the syringe
Close clamp
Attach the syringe with saline
Open the clamp, and slowly inject the saline using a push/pull technique. If
resistance is met discontinue attempt
Close clamp
Attach the IV line
Open clamp
Run the IV as per normal, administering IV drugs through the medication ports
on the IV set
Central Venous Access
Actual or potential need for intravenous medication or fluid therapy
AND
Intravenous access is unobtainable
AND
Patient is in cardiac arrest or near-arrest state
20
Central East Prehospital Care Program
For reference only
Endotracheal Intubation
Indications
Need for ventilatory assistance or A/W control and other A/W management is
inadequate or ineffective.
Clinical Parameters
Endotracheal Intubation
• No allergy or sensitivity to drugs administered.
• If < 50 years old and having asthma exacerbation, do not intubate unless in or
near cardiac arrest.
Nasal ETT:
• ≥ 8 years old
• No suspected basal skull or mid-face fracture
• No uncontrolled epistaxis
• Not under anticoagulant therapy (ASA excluded)
• No bleeding disorders
• Not apneic
Lidocaine Topical Spray:
• For nasal/oral ETT
• Not used if patient is unresponsive
Drug
Dose
Lidocaine
up to 20 sprays
10 mg/spray
5 mg/kg max
Topical
Xylometazoline
• Use for nasal ETT only
Max
Drug
Dose
1 dose
Xylometazoline
2 sprays / nare
Confirmation Methods
At least two primary and one secondary
ETT placement confirmation methods
must be used.
Primary
• Visualization
• Auscultation
• Chest rise
Max
1 dose
Secondary
• ETCO2
• EDD
• Other
Notes:
An intubation attempt is defined as insertion of the laryngoscope blade into the mouth.
The maximum number of ETT and SGA attempt are two.
If the patient has a pulse, an ETCO2 device (quantitative or qualitative) must be used for ETT
placement confirmation.
ETT placement must be reconfirmed immediately after every patient movement.
Central East Prehospital Care Program
For reference only 21
Supraglottic Airway
Indications
Need for ventilatory assistance OR airway control
AND
Other airway management is inadequate OR ineffective OR unsuccessful
Clinical Parameters
GCS 3
No gag reflex
Able to clear the airway (with suctioning etc.)
No active vomiting
No airway edema
No stridor
No caustic ingestion
Supraglottic Airway
•
•
•
•
•
•
•
Two attempts maximum. An 'attempt' is defined as the insertion of the supraglottic
airway into the mouth.
Confirmation Methods
Primary
• Auscultation
Confirm supraglottic airway placement.
• Chest rise
Notes:
Size Colour Patient
Amt of air in cuff
#3
Yellow
4-5 ft tall 45 - 60 ml
#4
#5
Red
Purple
5-6 ft tall
≥ 6 ft tall
60 - 80 ml
70 - 90 ml
Secondary
• ETCO2
• Other
22
Central East Prehospital Care Program
For reference only
Moderate to SevereAllergic Reaction
Indications
Exposure to a probable allergen and signs and/or symptoms of a moderate to
severe allergic reaction (including anaphylaxis).
Clinical Parameters
No allergy or sensitivity to any drug administered.
Allergic Reaction
Epinephrine:
Use for anaphylaxis only
Adult Doses ( > 50 Kg)
Drug
Initial Dose
Epinephrine IM
0.5 mg
Diphenhydramine IV/IM
50 mg
> 50 kg
Q
> 50 kg
Repeat
Max
N/A
N/A
1 dose
N/A
N/A
1 dose
Pediatric Doses
Drug
Epinephrine IM
Diphenhydramine IV/IM
Initital Dose
0.01 mg/kg
Max 0.5 mg
25 mg
> 25 - < 50 kg
(if < 25 kg Patch)
Q
Repeat Dose
Max
N/A
N/A
1 dose
N/A
N/A
1 dose
Notes:
Epinephrine should be the first drug administered in anaphylaxis.
The epinephrine dose may be rounded to the nearest 0.05 mg.
Central East Prehospital Care Program
For reference only 23
Epinephrine 1:1,000
0.01 mg/kg
Rounded to the nearest 0.05 ml
24
Central East Prehospital Care Program
For reference only
Croup
Indications
Severe respiratory distress and stridor at rest and current history of URTI
and barking cough or recent history of a barking cough.
Croup
Clinical Parameters
•
< 8 years old
•
No allergy or sensitivity to epinephrine
•
Heart rate less than 200 / min
Pediatric Doses
Drug
Epinephrine
≥ 1 year old
Epinephrine
< 1 year old
> 5 kg or more
Epinephrine
< 1 year
< 5 kg
Dose
Max
5.0 mg
1 dose
(5 ml)
2.5 mg
(2.5 ml)
0.5 mg
(mix with 2 ml of saline to make 2.5 ml)
Notes:
The minimum initial volume for nebulization is 2.5 ml.
1 dose
1 dose
For reference only 25
Central East Prehospital Care Program
Bronchoconstriction
Indications
Respiratory distress and suspected bronchoconstriction.
Clinical Parameters
No allergy or sensitivity to any drug administered.
Epinephrine:
• BVM ventilation is required
• Must have a history of asthma
Drug
Salbutamol MDI ≥ 25 kg
Salbutamol Nebulized ≥ 25 kg
Epinephrine IM ≥ 50 kg
Initital Dose
Q
Repeat
Max
800 mcg
5-15 min
800 mcg
3 doses
5 mg
5-15 min
5 mg
3 doses
0.5 mg
N/A
N/A
1 dose
Pediatric Doses
Drug
Salbutamol MDI < 25 kg
Salbutamol Nebulized < 25 kg
Epinephrine IM < 50 kg
Initital Dose
Q
Repeat Dose
Max
600 mcg
5-15 min
600 mcg
3 doses
2.5 mg
5-15 min
2.5 mg
3 doses
N/A
1 dose
0.01 mg/kg
Max 0.5 mg
Notes:
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).
Bronchoconstriction
Adult Doses
26
Central East Prehospital Care Program
For reference only
CPAP
Indications
Severe respiratory distress AND;
Signs and/or symptoms of acute pulmonary edema OR COPD
CPAP
Clinical Parameters
•
•
•
•
•
≥18 years old
Able to sit upright and cooperate
Respiratory rate ≥ 28 / minute
SpO2 < 90% OR accessory muscle use
SBP ≥ 100
•
•
•
•
•
Not asthma exacerbation
No unprotected or unstable airway
Not suspected pneumothorax
No major trauma or burns to the head or torso
No Tracheostomy
Adult Doses ≥18 years
Start at
Increase by
5 cmH20
2.5 cmH20
or
15 lpm if Boussignac
5
or
lpm if Boussignac
Q
5 mins
Max
15 cmH20
or
25 lpm if Boussignac
If device has adjustable FiO2, begin at lower setting and only increase if SpO2 remains
< 92% despite treatment and/or CPAP pressure of 10 cmH2O.
Notes:
Confirm CPAP by manometer if available
For reference only 27
Central East Prehospital Care Program
Acute Cardiogenic Pulmonary Edema
Indications
Moderate to severe respiratory distress from suspected acute cardiogenic
pulmonary edema
Clinical Parameters
Vital Sign Parameters
No allergy or sensitivity
HR: 60 - 159
No phosphodiesterase inhibitors* in past 48 hrs
SBP ≥ 100
If SBP < 140 patient must have prior nitroglycerin
use or IV established
SBP drops no more than
1/3 of initial value
Drug
Initial Dose
Nitroglycerin
BP 100 - 140
Nitroglycerin
BP ≥ 140
Q
Repeat Dose
Max
0.4 mg S/L
5 min
0.4 mg
6 doses
0.4 mg S/L
5 min
0.4 mg
6 doses
0.8 mg S/L
5 min
0.8 mg
6 doses
NO History or IV
Nitroglycerin
BP ≥ 140
WITH History or IV
Notes:
Perform 12 / 15 lead
* Phosphodiesterase inhibitors:
- Sidenafil: Viagra, Revatio (for pulmonary hypertension)
- Tadalafil: Cialis, Adcirca (for pulmonary hypertension)
- Vardenafil: Levitra, Staxyn
Acute Pulmonary Edema
Adult Dose ≥18 years only
28
Central East Prehospital Care Program
For reference only
Cardiac Ischemia Medical Directive
Indications
Suspected Cardiac Ischemia
Clinical Parameters
No allergies or sensitivity to given drug.
≥18 years
Unaltered LOA
Cardiac Ischemia
Nitroglycerin:
Prior nitroglycerin use and/or IV established
HR 60 - 159
SBP ≥100. D/C if BP drops more than 1/3 of initial
No phosphodiesterase inhibitor* in past 48 hrs
No right ventricular MI
ASA:
Able to chew and swallow
Prior use of ASA if asthmatic
No allergy to ASA or NSAIDs
No Current, active bleed
No CVA / TBI in past 24 hrs
Morphine:
(after 3rd nitroglycerin or if nitroglycerin is contraindicated)
No injury to Head / Torso / Pelvis
SBP ≥100. D/C if BP drops more than 1/3 of initial
Adult Dose ≥18 years only
Drug
Initital Dose
Q
Repeat Dose
Max
Nitroglycerin
0.4 mg S/L
5 min
0.4 mg
6 doses
ASA
160 mg PO
N/A
N/A
160 mg
Morphine
2 mg IV
5 min
2 mg
5 doses
Notes:
Perform 12 / 15 lead
* Phosphodiesterase inhibitors:
- Sidenafil: Viagra, Revatio (for pulmonary hypertension)
- Tadalafil: Cialis, Adcirca (for pulmonary hypertension)
- Vardenafil: Levitra, Staxyn
For reference only 29
Central East Prehospital Care Program
Notes:
A 15 lead ECG should be obtained;
•
When a 12 lead shows an inferior wall MI
•
When there is ST depression in V1-V4
•
When the 12 lead is normal but the patient is
exhibiting signs or symptoms of cardiac ischemia
V4R
•
•
•
The V4R lead is obtained by moving V4 to the same location but on the right
chest wall. (5th intercostal space, mid clavicular line).
V4R is considered anatomically contigous with II, III and AVF
ST elevation in V4R indicates an infarct of the right ventricle.
V8 and V9
•
The V8 lead is obtained by moving V5 around to the posterior, left chest wall
and placing it on the mid-scapular line just below the scapula.
•
The V9 lead is obtained by moving V6 around to the back and placing it
between V5 and the vertebral column.
•
ST elevation in V8 and V9 indicates an infarct in the posterior wall of the left
ventricle.
•
Infarcts in the posterior wall often show up as ST depression in leads V1-V4
12 lead versus anatomical region
Lateral Left
Septal
Anterior Left
Inferior Left
Lateral Left
Septal
Lateral Left
Inferior Left
Inferior Left
Anterior Left
Lateral Left
30
Central East Prehospital Care Program
For reference only
STEMI Bypass Policy
Indications
Patient who is experiencing continuous cardiac ischemic "chest pain" or chest
discomfort.
STEMI Bypass
Clinical Parameters
•
•
•
•
•
•
•
•
≥18 yrs
Unaltered LOA
SBP≥ 80 mmHg (with intervention if required)
Secure airway, and able to ventilate
Current episode is < 12 hours in duration
12 lead indicative of ST elevation MI,
NO LBBB or ventricular paced rhythms
No advanced directives indicating a restriction in care
•
•
Call location is in York or Durham Region
Patient contact to arrive the designated cath lab is < 60 min.
If the pick up is in York and transporting to SRHC - call
905-895-4521 ext. 7777
If the pick up is in Durham and transporting to RVHS-C - call
416-287-8364
Central East Prehospital Care Program
For reference only 31
COMMON IMITATORS OF MI’S
INTERPRETING ST SEGMENT ’S IS NOT POSSIBLE IN THE FOLLOWING
RYTHYMS (NOT A COMPLETE LIST – OTHER IMITATORS EXIST)
LBBB
Characterised by a supraventricular rhythm (identified by the
presence of P waves) & a wide QRS complex.
A LBBB will have a -ve terminal deflection in V1 and typically a
secondary R wave in V6 (seen as a notched complex seen as
RsR’ below).
RBBB will have a +ve terminal deflection in V1 typically with a
notched complex & a slurred or prolonged S wave in V6.
VENTRICULAR PACED RHYTHM
A pacer spike is typically seen immediately preceding the QRS
complex which will be wide.
LVH
Look at the RS complex in either V1
or V2 and count the small boxes of
the -ve deflection
Then do the same with either V5 or
V6, counting the small boxes of the
+ve deflection
Add the two numbers together, if
they equal 35 mm’s then it’s likely
LVH
32
Central East Prehospital Care Program
For reference only
Cardiogenic Shock
Indications
STEMI and Cardiogenic Shock.
Clinical Parameters
SBP < 90
Bolus:
Clear Chest
Dopamine:
No allergy or sensitivity
No tachydysrhythmias (excluding sinus tach)
No mechanical shock state (i.e. Tension Pneumothorax, Pulmonary Embolism,
Pericardial Tamponade)
Cardiogenic Shock
No pheochromocytoma
Adult Doses (≥ 18 Years)
Drug
Initial Dose
Q
Repeat Dose
Bolus IV/IO
10 ml/Kg
Reassess q
250 ml
N/A
Dopamine IV
5 mcg/Kg/min
5 min
Increase by
5 mcg/Kg/min
Max
20 mcg/
Kg/min
Pediatric Doses (< 18 years)
Drug
Initial Dose
Q
Repeat Dose
Bolus IV/IO
10 ml/Kg
Reassess q
100 ml
N/A
Dopamine IV
5 mcg/Kg/min
5 min
Increase by
5 mcg/Kg/min
Notes:
Titrate Dopamine to SBP 90 - 110 mmHg.
If discontinuing Dopamine electively, do so gradually over 5-10 minutes.
Contact BHP if patient is bradycardic with respect to age.
If bolus is contraindicated due to crackles, consider Dopamine.
Max
20 mcg/
Kg/min
Central East Prehospital Care Program
For reference only 33
Dopamine Administration
Buretrol Set-up:
•
•
•
•
•
Close both roller clamps
Spike bag
Open top roller clamp (between bag and Buretrol)
Fill chamber with 100 cc
Close top roller clamp
OSCAR
O-open bottom roller clamp
S-squeeze drip chamber
C-close bottom roller clamp
And
R-release drip chamber
Prime the line as usual
34
Central East Prehospital Care Program
For reference only
Symptomatic Bradycardia
Indications
Bradycardia with Hemodynamic Instability
Clinical Parameters
Vital Sign Parameters
Allergy or sensitivity to given drug
HR < 50
with hemodynamic instability
Atropine:
No hypothermia
No heart transplant
Dopamine:
No pheochromocytoma
TCP:
No hypothermia
SBP < 90
Adult Doses ≥18 Years
Bradycardia
Drug
Initital Dose
Q
Repeat Dose
Max
Atropine IV
0.5 mg
5 min
0.5 mg
2 doses
Dopamine IV (patch)
5 mcg/Kg/min
5 min
Increase by
5 mcg/Kg/min
20 mcg/Kg/
min
Transcutaneous Pacing (patch)
Notes:
Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, first
degree AV block, or second degree type I AV block.
A single dose of Atropine should be considered for second degree type II or third
degree blocks with fluid bolus while preparing for TCP or if there is a delay in
implementing TCP or if TCP is unsuccessful.
Titrate dopamine to achieve a SBP of 90-110 mmHg.
For reference only 35
Central East Prehospital Care Program
Dopamine Administration
Buretrol Set-up:
•
•
•
•
•
Close both roller clamps
Spike bag
Open top roller clamp (between bag and Buretrol)
Fill chamber with 100 cc
Close top roller clamp
OSCAR
O-open bottom roller clamp
S-squeeze drip chamber
C-close bottom roller clamp
And
R-release drip chamber
Prime the line as usual
PACING
• Attach limb leads
• Attach large pads
• Activate pacing function
• Increase CURRENT (mA) until
electrical capture is evident
• Check output (BP)
• Reduce RATE to 60 if BP adequate
• Re-assess BP
• Consider Midazolam / Morphine
36
Central East Prehospital Care Program
For reference only
Procedural Sedation
Indications
Post-intubation OR Transcutaneous Pacing
Clinical Parameters
•
•
•
•
≥18 years old
No allergies or sensitivity to midazolam
SBP ≥ 100
Respiratory rate ≥ 8/min (unless intubated)
Procedural Sedation
Adult Doses
Drug
Initial Dose
Midazolam IV
2.5 - 5.0 mg
0.5 - 1.0 ml
Q
5 min
Repeat
2.5 - 5.0 mg
0.5 - 1.0 ml
Max
10 mg
or 2 doses
For reference only 37
Central East Prehospital Care Program
Combative patient
Indications
Combative patient
Clinical Parameters
•
•
•
•
≥ 18 years old
No allergies or sensitivity to midazolam
SBP ≥ 100
No reversible causes (i.e. Hypoglycemia, Hypoxia, Hypotension)
Adult Doses
Drug
Initial Dose
Midazolam IV/IM
2.5 - 5.0 mg
0.5 - 1.0 ml
Q
5 min
Repeat
2.5 - 5.0 mg
0.5 - 1.0 ml
Max
10 mg
2 doses
or
Combative Patient
PATCH to BHP to proceed with Midazolam if unable to assess the patient for
normotension or reversible causes.
38
Central East Prehospital Care Program
For reference only
Tachydysrhythmia
Indications
Symptomatic Tachydysrhythmia
Clinical Parameters
No allergy or sensitivity to given drug
Tachydysrhythmia
Valsalva / Adenosine:
•
SBP ≥ 100, Unaltered LOA
•
Use for narrow complex, regular tachycardias ≥ 150 / minute.
•
Not for sinus tachycardia, a-fib or a-flutter
Adenosine specific:
•
Not on dipyridamole (Persantine, Aggrenox) or carbamazepine (Tegretol)
•
No bronchoconstriction on exam
Lidocaine (PATCH):
•
SBP ≥ 100, Unaltered LOA
•
Use for wide complex regular tachycardias ≥ 120 / minute
Cardioversion (PATCH):
•
SBP < 90, altered LOA, ongoing chest pain, other signs of shock
•
Unstable tachycardia ≥ 120 (wide) ≥ 150 (narrow)
Valsalva 2 x 10-20 seconds
Adult Doses ≥ 18 years
Drug
Initital Dose
Adenosine IV
Q
Repeat Dose
Max
PATCH if suspected SVT with aberrancy
(wide complex)
6 mg
2 min
12 mg
2 doses
Lidocaine IV (PATCH)
1.5 mg/Kg
10 min
0.75 mg/Kg
3 doses
Cardioversion (PATCH) 100j, 200j, Max possible
Notes:
Administer cardioversion in accordance with patch orders. Above joule settings
apply to patch failures.
Central East Prehospital Care Program
For reference only 39
Cardioversion:
• Attach limb leads
• Attach large pads
• Cycle through leads and select the lead that shows the
largest 'R' wave
• Activate 'Synch' and ensure synch markers appear on the
"R" waves (if visible)
• Select ordered joule setting
• Begin running printer (run lots of strip before and after
cardioversion)
• Double check resuscitation equipment is prepared
• Clear patient and press-and-hold 'SHOCK'
after cardioversion monitor will automatically default out of
synch mode.
40
Central East Prehospital Care Program
For reference only
Seizure
Indications
Active generalized motor seizure
Clinical Parameters
•
•
•
Unresponsive
No allergy or sensitivity to Midazolam
Not hypoglycemic
Adult Doses ≥ 50 kg
Seizure
Drug
Initital Dose
Q
Repeat
Max
Midazolam IV
5 mg
5 min
5 mg
2 doses
Midazolam IM/IN/Buccal
10 mg
5 min
10 mg
2 doses
Pediatric Doses
Drug
Initital Dose
Midazolam IV
Midazolam
IM / IN / Buccal
Q
Repeat Dose
Max
0.1 mg/kg
5.0 mg Max
5 min
0.1 mg/kg
5.0 mg Max
2 doses
0.2 mg/kg
10 mg Max
5 min
0.2 mg/kg
10 mg Max
2 doses
Notes:
Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be
considered by a paramedic.
Central East Prehospital Care Program
For reference only 41
Midazolam Reference
IV Dosages
Weights are based on:
(Age x 2) + 10
for 1-10 years
11-14 years based on
CDC data
All volumes based on
5 mg/ml concentration
IM / IN / Buccal Dosages (IN has 0.12 ml added)
42
Central East Prehospital Care Program
For reference only
Opioid Toxicity
Indications
Altered LOC and respiratory depression and suspected opioid overdose.
Clinical Parameters
•
•
•
Respiratory rate < 10
No allergy or sensitivity to naloxone.
No uncorrected hypoglycemia
Adult Doses ≥ 18 years
Drug
Initital Dose
Q
Repeat
Max
Patch - Naloxone IV*
up to 0.4 mg
N/A
N/A
1 dose
Patch - Naloxone
0.8 mg
N/A
N/A
1 dose
Opioid Toxicity
IM/IN/SC
Notes:
*For IV route, titrate naloxone only to restore the patient's respiratory status.
Reference Notes:
Opioid Toxicity typically present with:
- Decreased LOA
- Slow Respirations
- Pinpoint pupils
Some Common Opioids:
Morphine, MS contin, Statex, Hydromorphone
Fentanyl
Percocet, Percodan
Oxycocet, Oxycontin
Tylenol III
Heroin
Codeine
Central East Prehospital Care Program
For reference only 43
Electronic Control Device Probe Removal
Indications
Electronic control device probe(s) embedded in patient
Clinical Parameters
•
•
•
≥18 years old
Unaltered LOA
Probes not embedded;
Above clavicles,
In the nipple(s) or in the
Genital area
Remove probes
Police may require preservation of the probe(s) for evidentiary purposes.
This directive is for removal of ECD only and in no way constitute treat and release, normal
principles of patient assessment and care apply.
ECD Probe Removal
Notes:
44
Central East Prehospital Care Program
For reference only
Hypoglycemia
Indications
Agitation or altered LOA or seizure or symptoms of stroke
Clinical Parameters
Vital Sign Parameters
No allergy or sensitivity to given drug
Hypoglycemia
≥ 2 yrs < 4.0 mmol
< 2 yrs < 3.0 mmol
Glucagon:
No Pheochromocytoma
Adult Doses
Drug
Initital Dose
Q
Repeat
Max
Dextrose IV ≥ 50 kg
25 g
10 min
25 g
2 doses
Glucagon IM ≥ 25 kg
1 mg
20 min
1 mg
2 doses
Q
Repeat
Max
Pediatric Doses
Drug
Initial Dose
Hypoglycemia
< 30 Days
Dextrose IV
D10W
≥ 30 Days to < 2 years
Dextrose IV
D25W
≥ 2 years to < 50 Kg
2 ml/Kg
0.2 g/kg
Max
5 g (50 ml)
2 ml/Kg
1 ml/Kg
Dextrose IV
Glucagon IM
0.5 mg
< 25 Kg
2 ml/Kg
2 doses
0.2 g/kg
Max
5 g (50 ml)
10 min
0.5 g/kg
Max
10 g (40 ml)
0.5 g/kg
Max
25 g (50 ml)
D50W
10 min
2 ml/Kg
2 doses
0.5 g/kg
Max
10 g (40 ml)
10 min
1 ml/Kg
2 doses
0.5 g/kg
Max
25 g (50 ml)
20 min
0.5 mg
2 doses
Notes:
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.
Central East Prehospital Care Program
For reference only 45
Dextrose Reference
46
Central East Prehospital Care Program
For reference only
Nausea / Vomiting
Indications
Nausea OR Vomiting
Clinical Parameters
•
•
•
Unaltered LOA
No allergies or sensitivity to dimenhydrinate or other antihistamines
Not overdosed on antihistamines, anticholinergics or tricyclic antidepressants
Adult Doses
Drug
Dimenhydrinate IV/IM
Initial Dose
Q
50 mg
≥ 50 Kg
Repeat
N/A
N/A
Max
1 dose
Nausea / Vomiting
Pediatric Doses
Drug
Initital Dose
Dimenhydrinate IV/IM
25 mg
≥ 25 - < 50 Kg
(if < 25 Kg Patch)
Q
Repeat Dose
N/A
N/A
Max
1 dose
Notes:
If giving IV dilute dimenhydrinate with 9 ml normal saline to a 50 mg in 10 ml solution.
Central East Prehospital Care Program
Antihistamines
Actifed
Astemazole (Hismanal)
Azatdine (Zadine)
Cetirizine (Zyrtec, Reactine)
Chlorpheniramine (Chlor-Trimeton, chlortripalon)
Clemastine
Cyproheptadine (Periactin)
Dexchlorpheniramine
Desloratadine (Clarinex)
Dimenhydrinate (Dramamine)
Diphenhydramine (Benadryl)
Fexofenadine (Allegra)
Hydroxyzine (Atarax, Vistaril)
Loratadine (Claritin, Alavert)
Phenothiazines
Promethazine (Phenergan)
Piperzanes
Terfenadine (Seldane)
Tricyclic antidepressants (TCA)
Amitriptyline (Elavil, Ednep, Vanatrip)
Clomipramine (Anafranil)
Desipramine (Norpramin),
Doxepin (Sinequan, Adapin, Silenor)
Nortriptyline (Aventyl, Pamelor),
Protriptyline (Vivactil)
Trimipramine (Surmontil)
Anticholinergics
Atropine
Hyoscine
Glycopyrrolate (Robinul)
ipratropium bromide (Atrovent)
oxybutinin (Ditropan, Lyrinel XL)
oxitropium bromide (Oxivent)
tiotropium (Spiriva)
For reference only 47
48
Central East Prehospital Care Program
For reference only
Pain
Indications
Severe pain and;
•
Isolated hip or extremity fractures or dislocation or;
•
Major burns or;
•
Current history of cancer related pain or;
•
Renal colic with prior history or;
•
Acute musculoskeletal back strain or;
•
Ongoing transcutaneous pacing.
Clinical Parameters
No allergy or sensitivity to drug administered.
≥18 years
SBP ≥ 100
No injury to the head or chest or abdomen or pelvis.
No SBP drop by 1/3 or more of the initial reading
Pain
•
•
•
•
•
Drug
Initial Dose
Morphine IV
2 - 5 mg
Q
Repeat
5 min
2 - 5 mg
Max
4 doses
Notes:
For ease of administration and control, when using 10 mg/ml morphine, draw up the morphine
with 9 ml of saline to achieve a 10 mg in 10 ml solution.
Central East Prehospital Care Program
For reference only 49
Special Events Directives
Special event: a preplanned gathering with
potentially large numbers and the Special
Event Medical Directives have been
preauthorized for use by the Medical
Director
50
Central East Prehospital Care Program
For reference only
Headache (Special Events Only)
Indications
Uncomplicated headache conforming to the patient's usual pattern.
Clinical Parameters
•
•
> 18 years old
Unaltered LOA
•
•
•
No allergy or sensitivity to acetaminophen
No acetaminophen in the last 4 hours
No signs or symptoms of intoxication
Adult Doses
Drug
Acetaminophen PO
Initial Dose
325 - 650 mg
Q
Repeat
N/A
None
Max
1 dose
Notes:
Headache
Release from care.
Advise patient that if the problem persists or worsens that they should seek further medical
attention.
Central East Prehospital Care Program
For reference only 51
Minor Abrasion (Special Events ONLY)
Indications
Minor abrasions
Clinical Parameters
•
•
Unaltered LOA
No allergies or sensitivity to topical antiobiotics
Notes:
Advise patient that if the problem persists or worsens that they should seek further medical
attention.
Minor Abrasion
52
Central East Prehospital Care Program
For reference only
Minor Allergic Reaction (Special Events Only)
Indications
Signs consistent with minor allergic reaction.
Clinical Parameters
•
•
•
≥18 years old
Unaltered LOA
SBP ≥100 (and other vitals within normal limits)
•
•
•
•
•
No allergy or sensitivity to diphenhydramine
No antihistamine or sedative use in the previous 4 hours
No signs or symptoms of a moderate to severe allergic reaction
No signs or symptoms of intoxication
No wheezing
Adult Doses
Drug
Minor Allergic Reaction
Diphenhydramine PO
Notes:
Release from care.
Initial Dose
50 mg
Q
Repeat
N/A
N/A
Max
1 dose
For reference only 53
Central East Prehospital Care Program
Musculoskeletal Pain (Special Events Only)
Indications
Minor musculoskeletal pain.
Clinical Parameters
•
•
≥18 years old
Unaltered LOA
•
•
•
No allergy or sensitivity to acetaminophen
No acetaminophen use in the last 4 hours
No signs or symptoms of intoxication
Adult Doses
Drug
Acetaminophen PO
Initial Dose
325 - 650 mg
Q
Repeat
N/A
None
Max
1 dose
Notes:
Advise patient that if the problem persists or worsens that they should seek further medical
attention.
Musculoskeletal Pain
Release from care.
54
Central East Prehospital Care Program
For reference only
Central East Prehospital Care Program
For reference only 55
ReferenceMaterials
Stroke Prompt Card.............................!
Rule of nines charts.............................!
Field Trauma Triage.............................!
ECG Basics.........................................!
IM Injections........................................!
End Tidal CO2.....................................!
Overdose Levels.................................!
Toxidromes..........................................!
Phone Numbers..................................!
Codes of Entry....................................!
Pediatric References..........................!
Medication References.......................!
PCP Scope of Practice........................!
ACP Scope of Practice........................!
VSA Special Circumstances...............!
3
4
5
6
7
8-9
10
11
12 - 13
14
15
16 - 32
33
34 - 35
36
2
3
4
Burn Chart 'Rule of nines'
5
Field Trauma Triage Guidelines
•
spinal cord injury with paraplegia or quadriplegia;
•
penetrating injury to head, neck, trunk or groin;
•
amputation above wrist or ankle;
•
adult patients with a Glasgow Coma Scale less than or equal to 10;
•
If adult GCS is greater than 10, any two of the following:
(1) any alteration in level of consciousness;
(2) pulse rate less than 50 or greater than 120;
(3) blood pressure less than 80 systolic (or absent radial pulse); (4)
respiratory rate less than 10 or greater than 24.
•
Pediatric Trauma Score of less than or equal to 8;
•
paramedic’s judgement that the patient requires assessment and
treatment at a lead trauma centre.
6
ECG BASICS
NORMAL ECG PARAMETERS
P wave
Typically +ve
QRS Complex
<0.12 sec
T wave
May be –ve in V1
PR Interval
0.12 – 0.2 seconds
ST Segment
Compared to TP
QT Interval
< ½ the preceding
RR interval
RATE CALCULATION
Choose a QRS complex that falls on
the thick line and count to your right
until you reach the next complex.
Q WAVES
Pathological: Sign of MI (new or old)
> ¼ of accompanying R wave
and/or > 0.04 sec (1 sm box)
2. Physiological Q waves: Normal
Less then criteria above
QRS Nomenclature
1.
1
2
7
Intra Muscular Injection
Landmarking and Needle Selection
Needle length:
1 - 1.5" for school-age children and
older
Do not use this site in children < 2 years
old.
Base of pictured triangle is 2 - 3 finger
widths below the acromium process.
The insertion site is in the middle of the
triangle.
!
Needle length:
5/8" for small infants
1" for young children
1.5" for school-age children and older
The insertion site is in the middle of the
depicted rectangle, anterolateral aspect
of the middle of the thigh.
!
8
9
10
OVERDOSE LEVELS
THIS CHART IS INTENDNED ONLY AS A GUIDE.
NUMEROUS VARIABLES INFLUENCE TOXIC / LETHAL LEVELS.
ASA
Acetaminophen
Amphetamines
Atropine
Benadryl (diphenhydramine)
Barbiturates
Benzodiazepines
Cocaine
(As most sreet drugs, impurities,
etc make predicting toxic levels
difficult)
Codeine
Demerol
Digitalis Glycosides
Dilantin
GHB
Ibuprofen
Methadone
Methamphetamine
Morhpine
Methanol
Monoamine Oxidase Inhbitors
(MAOI’s)
Tricyclic Anti depressants
(TCA’s)
Valium (Diazepam)
Adults & children:
300 – 500 mg/kg is a severe ingestion
>500 mg/kg may be fatal
Adults:
70 – 140 mg /kg may be toxic
140 mg/kg can be fatal
Children:
< 5 yr’s old 100 200 mg/kg may be toxic
>200 mg/kg may be fatal
100 mg (40 mg in children)
100 mg
20 40 mg/kg may be fatal
1 – 3 gm
Toxicity ranges from 500 – 1500 mg’s
A rock is usually 100 – 200 mg
A typical ‘line’ is usually 20 – 30 mg
A spoon is usually 5 – 10 mg
2 – 25 mg/kg can cause toxic effects
500 – 1000 mg can be fatal
1 gm may be fatal
Digitalis: 2 gm may be fatal
Digitoxin: 3 mg may be fatal
Digoxin: 10 mg may be fatal
20 mg/kg may be toxic
30 – 60 mg may be toxic
Adults:
6 54 mg may be toxic
Children:
200 – 400 mg/kg may be severe ingestion
>400 mg/kg may be fatal
50 mg can be fatal
1 mg/kg may be fatal
200 – 250 mg ingestion can be fatal
30 – 240 ml may be fatal
2 – 3 mg/kg is life threatening
4 – 6 mg/kg is typically fatal
20 – 35 mg/kg may be severe
35 – 40 mg/kg may be fatal
1 gm may be fatal
(TCA’S/BENADRYL
/GRAVOL/ANTIHIST)
Anticholinergic
MARIJUANA
INHALANTS
(Depressant)
GHB
(Anaesthetic)
KETAMINE
(Opiate
Narcotic)
HEROIN
(STIMULANT)
COCAINE / CRACK
(STIMULANT)
METH
(STIMULANT)
ECSTASY
TOXIDROME/ INFO
Pills
Plant material
Alter
+
Alter
+
Alter
Alter
PO, SC,
Alter
Ø
+
+
+
LOA RR HR BP
Smoked, Mixed
Alter
food, Tea
Inhaled
Snorted, IV,
smoked, PO
Drank (often
mixed ETOH)
Snorted, IV,
smoked, SC
Snorted, IV,
smoked
Snorted, IV,
smoked, PO
Diff coloured
powder, Rock,
Crystal
Diff coloured
powders,
Rock, Crystal
Light-Dark
Powders or
Black tarry
substance
Clear liquid,
White powder
Looks like
water
Glue, paint,
petro,
Aerosols
PO
HOW USED
Looks like
pills/candy
APPEARANCE
Arrhythmias
Poss
dilated
Arrhythmias
Arrhythmias
TachyArrhythmias
TachyArrhythmias
Irregular
Dilated
Norm/Dilat
Slugg
MISC
N, Warm, Wet,
Possible seizures
Sweaty, Tº,
Nausea
Nausea,
Seizures,
Slurred speech,
Dizzy,
Hallucinations
Bloodshot eyes,
‘Munchies’
N/V, Restless,
Seizures,
CP, Prone to
MI/CVA, Violent
Tremors , Poss
CVA, Seizures,
Tº, Sweaty
TachyTº, Teeth
Arrhythmias grinding, Irrational
EC G
Norm/Dilat
Slugg
Const
Dilated
Poss
dilated
Dilated
PUPILS
11
12
Phone Numbers
!
13
Phone Numbers
!
14
NOTES:
15
Pediatric Reference
Age
Respiratory Rate
Heart Rate
0-3 months
3-6 months
6-12 months
1-3 years
6 years
10 years
30-60
30-60
25-45
20-30
16-24
14-20
90-180
80-160
80-140
75-130
70-110
60-90
< 2 Year
Spontaneous
To Speech
To Pain
None
EYE OPENING
4
3
2
1
> 2 Year
Spontaneous
To Speech
To Pain
None
BEST RESPONSE TO
AUDITORY / VISUAL
STIMULUS (0-2 years)
BEST VERBAL RESPONSE
(2-5 Years)
Orients to sounds, follows objects,
5
smiles, coos, babbles
Cries appropriately; when upset 4
Inappropriate, persistent cry /
Scream
Agitated / restless; grunts,
Moans
No Response
< 2 Year
3
2
1
Oriented, appropriate words
Confused, inappropriate words
Inappropriate, persistent cry /
scream
Incomprehensible sounds;
grunts
No Response
BEST MOTOR RESPONSE
> 2 Year
Spontaneous movements
6 Spontaneous movements
Localizes pain
5 Localizes pain
Withdraws from pain
4 Withdraws from pain
Abnormal flexion (decorticate)
3 Abnormal flexion (decorticate)
Abnormal extension (decerebrate) 2 Abnormal extension (decerebrate)
No response
1 No response
16
ACETAMINOPHEN
CLASS
Analgesic
ACTION
Although not fully elucidated, believed to inhibit the
synthesis of prostaglandins in the central nervous system
and work peripherally to block pain impulse generation;
produces antipyresis from inhibition of hypothalamic heatregulating center.
ONSET
< 1 hour
HALF-LIFE
ELIMINATION
2 hours (adults)
METABOLISM
PEAK
EFFECT
10-60 minutes
At normal therapeutic dosages, primarily hepatic
metabolism to sulfate and glucuronide conjugates, while a
small amount is metabolized by CYP2E1 to a highly
reactive intermediate, N-acetyl-p-benzoquinone imine
(NAPQI), which is conjugated rapidly with glutathione and
inactivated to nontoxic cysteine and mercapturic acid
conjugates. At toxic doses (as little as 4 g daily)
glutathione conjugation becomes insufficient to meet the
metabolic demand causing an increase in NAPQI
concentrations, which may cause hepatic cell necrosis.
Oral administration is subject to first pass metabolism.
17
ADENOSINE
CLASS
Antiarrhythmic
ACTION
Slows conduction time through the AV node, interrupting
the re-entry pathways through the AV node, restoring
normal sinus rhythm. Adenosine also causes coronary
vasodilation and increases blood flow in normal coronary
arteries with little to no increase in stenotic coronary
arteries; thallium-201 uptake into the stenotic coronary
arteries will be less than that of normal coronary arteries
revealing areas of insufficient blood flow.
ONSET
Rapid
HALF-LIFE
ELIMINATION
< 10 seconds
METABOLISM
DURATION
Very brief
Blood and tissue to inosine then to adenosine
monophosphate (AMP) and hypoxanthine
18
ASPIRIN (ACETYLSALICYLIC ACID)
CLASS
Platelet aggregation inhibitor, analgesic, antipyretic and
anti-inflammatory.
ACTION
Decreases clotting by inactivating cycloxygenase,
interfering with Thromboxane A2 production within the
platelets. Thromboxane A2 also causes arteries to
constrict.
Reduces morbidity/mortality in adult patients with CP from
MI.
ABSORPTION TIME TO PEAK
Rapid
1-2 hours
METABOLISM
DURATION
4-6 hours
Hydrolyzed to salicylate (active) by esterases in GI
mucosa, red blood cells, synovial fluid, and blood;
metabolism of salicylate occurs primarily by hepatic
conjugation; metabolic pathways are saturable.
COMMON NSAIDS (Not a complete list)
OVER-THE-COUNTER
PRESCRIPTION
¬
Aspirin
¬
Ibuprofen (Motrin)
¬
Ibuprofen (Motrin IB, Advil,
Nuprin, Rufen)
¬
Indomethacin (Indocin)
¬
Tolmetin (Tolectin)
¬
Ketoprofen (Actron, Orudis KT)
¬
Ketoprofen (Orudis, Oruvail)
¬
Naproxen (Aleve)
¬
Naproxen (Naprosyn, Anaprox)
¬
Diclofenac (Voltaren, Cataflam,
Solaraze)
19
ATROPINE
CLASS
Parasympatholytic, anticholinergic
ACTION
Blocks the action of acetylcholine at parasympathetic
sites in smooth muscle, secretory glands, and the CNS;
increases cardiac output, dries secretions. Atropine
reverses the muscarinic effects of cholinergic poisoning.
The primary goal in cholinergic poisonings is reversal of
bronchorrhea and bronchoconstriction. Atropine has no
effect on the nicotinic receptors responsible for muscle
weakness, fasciculations, and paralysis.
ONSET
Rapid
HALF-LIFE ELIMINATION
2-3 hours
METABOLISM
Hepatic
DISTRIBUTION
Widely throughout the body; crosses placenta; trace
amounts enter breast milk; crosses blood-brain barrier.
20
DEXTROSE 50% IN WATER
CLASS
Carbohydrate (Caloric Supplement)
ACTION
Replenishes blood glucose levels reversing
hypoglycemia.
METABOLISM
Metabolized to carbon dioxide and water.
21
DIMENHYDRINATE (GRAVOL®)
CLASS
Antiemetic, Antihistamine
ACTION
Competes with histamine for H1-receptor sites on effector
cells in the gastrointestinal tract, blood vessels, and
respiratory tract; blocks chemoreceptor trigger zone,
diminishes vestibular stimulation, and depresses
labyrinthine function through its central anticholinergic
activity.
ONSET
1-5 minutes (IV)
15-30 minutes
(oral)
PEAK
EFFECT
1-2 Hours
DURATION
3-6 hour
22
DIPHENHYDRAMINE (BENADRYL®)
CLASS
Antihistamine
ACTION
Competes with histamine for H1-receptor sites on effector
cells in the gastrointestinal tract, blood vessels, and
respiratory tract; anticholinergic and sedative effects are
also seen.
ONSET
PEAK EFFECT
DURATION
1-5 minutes (IV) 1-2 hours (IV)
4-8 hours
1-3 hours (oral) 2-4 hours (oral)
HALF-LIFE ELIMINATION
2-10 hours
23
DOPAMINE
CLASS
Sympathomimetic agent
ACTION
Stimulates both adrenergic and dopaminergic receptors,
lower doses are mainly dopaminergic stimulating and
produce renal and mesenteric vasodilation, higher doses
also are both dopaminergic and beta1-adrenergic
stimulating and produce cardiac stimulation and renal
vasodilation; large doses stimulate alpha-adrenergic
receptors.
ONSET
5 minutes
HALF-LIFE
ELIMINATION
2 minutes
METABOLISM
DURATION
<10 minutes
Renal, hepatic and plasma, 75% to inactive metabolites
by monoamine oxidase and 25% to norepinephrine.
24
EPINEPHRINE
CLASS
Sympathomimetic agent
ACTION
Stimulates alpha-, beta1-, and beta2-adrenergic receptors
resulting in relaxation of smooth muscle of the bronchial
tree, cardiac stimulation (increasing myocardial oxygen
consumption), and dilation of skeletal muscle vasculature;
small doses can cause vasodilation via beta2-vascular
receptors; large doses may produce constriction of
skeletal and vascular smooth muscle.
ONSET
5-10 minutes (bronchodilation)
METABOLISM
Taken up into the adrenergic neuron and metabolized by
monoamine oxidase and catechol-o-methyltransferase;
circulating drug hepatically metabolized.
25
GLUCAGON
CLASS
Hyperglycemic agent
ACTION
Stimulates adenylate cyclase to produce increased cyclic
AMP, which promotes hepatic glycogenolysis and
gluconeogenesis, causing a raise in blood glucose levels.
ONSET
HALF-LIFE
ELIMINATION
30 minutes (IM) 8-18 minutes
DURATION
60-90 minutes
(SQ)
METABOLISM
Primarily hepatic, some inactivation occurring renally and
I the plasma.
26
LIDOCAINE (XYLOCAINE)
CLASS
Class Ib antiarrhythmic
ACTION
Suppresses automaticity of conduction tissue, by
increasing electrical stimulation threshold of ventricle, HisPurkinje system, and spontaneous depolarization of the
ventricles during diastole by a direct action on the tissues;
blocks both the initiation and conduction of nerve
impulses by decreasing the neuronal membrane's
permeability to sodium ions, which results in inhibition of
depolarization with resultant blockade of conduction.
ONSET
DURATION
45-90 seconds
10-20 minutes
METABOLISM
90% Hepatic
27
Xylometazoline (Baliminil)
CLASS
Sympathomimetic agent
ACTION
Xylometazoline nasal is a decongestant. A
vasoconstrictor. The nasal formulation acts directly on the
blood vessels in the nasal tissues. Constriction of the
blood vessels in the nose and sinuses leads to a
decrease in congestion.
ONSET
DURATION
Rapid
10-20 minutes
METABOLISM
90% Hepatic
28
MIDAZOLAM (VERSED)
CLASS
Benzodiazepine, CNS depressant, Sedative and Amnesic
ACTION
Binds to stereospecific benzodiazepine receptors on the
postsynaptic GABA neuron at several sites within the
central nervous system, including the limbic system,
reticular formation. Enhancement of the inhibitory effect of
GABA on neuronal excitability results by increased
neuronal membrane permeability to chloride ions. This
shift in chloride ions results in hyperpolarization (a less
excitable state) and stabilization.
ONSET
PEAK EFFECT
DURATION
15 minutes (IM) 0.5 – 1 hour
6 hours (IM)
3-5 minutes (IV)
4-8 minutes (IN)
18-41 minutes
(IN)
METABOLISM
Extensively hepatic
HALF-LIFE ELIMINATION
2-6 hours
29
MORPHINE
CLASS
Opioid analgesic
ACTION
Binds to opiate receptors in the CNS, causing inhibition of
ascending pain pathways, altering the perception of and
response to pain; produces generalized CNS depression.
ONSET
PEAK EFFECT
DURATION
2-5 minutes (IV) 20 minutes (IV)
HALF-LIFE ELIMINATION
2-4 hours
METABOLISM
Hepatic
1 hour
30
NALOXONE (NARCAN)
CLASS
Narcotic Antagonist
ACTION
Competitive narcotic antagonist. Displaces any narcotics
bound to opiate receptor sites reversing their effects.
ONSET
HALF-LIFE
ELIMINATION
2-5 minutes (IM)
3-4 hours
(neonates)
8-13 minutes
(IN)
0.5-1.5 hours
(adult)
2 minutes (IV)
METABOLISM
Primarily hepatic
DISTRIBUTION
Crosses placenta
DURATION
30-120 minutes
31
NITROGLYCERIN
CLASS
Coronary vasodilator, smooth muscle relaxant and an
anti-anginal.
ACTION
Produces a vasodilator effect on the peripheral veins and
arteries with more prominent effects on the veins. Primarily
reduces cardiac oxygen demand by decreasing preload (left
ventricular end-diastolic pressure); may modestly reduce
afterload; dilates coronary arteries and improves collateral flow
to ischemic regions. In smooth muscle, nitric oxide activates
guanylate cyclase which increases guanosine 3’5’
monophosphate (cGMP) leading to dephosphorylation of
myosin light chains and smooth muscle relaxation.
ONSET
PEAK EFFECTS
1-3 min.(sl sprays and sl tablet)
15-30 min. (topical)
30 min.(transdermal)
5 min.(tablet)
4-10 min.(sl spray)
60 min.(topical)
120 min. (transdermal)
DURATION
25 min. (sl spray and sl tablet)
7 hours (topical)
10-12 hours (transdermal)
HALF-LIFE
1-4 minutes
METABOLISM
Extensive first-pass effect; metabolized hepatically to glycerol
di- and mononitrate metabolites via liver reductase enzyme;
subsequent metabolism to glycerol and organic nitrate;
nonhepatic metabolism via red blood cells and vascular walls
also occurs.
32
SALBUTAMOL (VENTOLIN)
CLASS
Sympathomimetic, Beta 2 agonist
ACTION
Relaxes bronchial smooth muscle by action on beta2receptors with little effect on heart rate.
ONSET
10 minutes
(nebulized/oral
inhalation)
HALF-LIFE
ELIMINATION
3-8 hours
(inhalation)
METABOLISM
Hepatic to an inactive sulfate
DURATION
3-4 hours
(nebulized/oral
inhalation)
33
PCP Scope of Practice
Perform the following skills:
Ø Semi-Automated External Defibrillation
Ø Manual defibrillation (when working with an ACP who has indicated that a shock
and its energy setting is to be delivered)
Ø Intravenous monitoring
Ø Intravenous Access/Therapy for patients ≥ 2 years of age (if certified / authorized
in autonomous IV)
Ø Volume (crystalloid) Replacement Therapy for patients ≥ 2 years of age (if
certified / authorized in autonomous IV)
Ø Basic Airway management
Ø Advanced Airway management with the King LT
Ø Oro-pharyngeal Suctioning
Ø Current CPR standards for Health-Care Providers
Ø 3 lead monitoring and interpretation
Ø 12 and 15 lead acquisition and interpretation
Ø Administration of CPAP
Ø Preparation of ACP pre-loaded medications
Ø Assessments and Interpretation of findings ie chest sounds & tx
Ø Capillary Blood Sampling & glucometer use
Ø Utilization/interpretation of SpO2
Administer the following medications:
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
ASA (PO)
Dextrose: 50% solution (IV) (if certified / authorized in autonomous IV)
Dimenhydrinate (IV/IM) (IV only if certified / authorized in autonomous IV)
Diphenhydramine (IV/IM) (IV only if certified / authorized in autonomous IV)
Epinephrine 1:1000 (IM/Inhalation)
Glucagon (IM)
Nitroglycerin spray (SL)
Salbutamol MDI and nebulization (Inhalation)
By the following routes:
Ø
Ø
Ø
Ø
Ø
!
Oral (PO)
Sublingual (SL)
Inhalation (nebulized or MDI)
Intramuscular (IM)
Intravenous (IV) (if certified / authorized in autonomous IV)
34
ACP Scope of Practice
Perform the following skills:
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Manual Defibrillation
Synchronized Cardioversion
Transcutaneous Pacing
Intravenous Access/Therapy
Intraosseous Access/Therapy
Volume (crystalloid) Replacement Therapy
Advanced Airway management with the King LT
Oral Endotracheal Intubation
Nasal Tracheal Intubation
Difficult Airway with lighted stylet / Bougie
Laryngoscopy
ETT (Deep) Suctioning
FBAO Removal (Magill Forceps)
Needle Chest Decompression
3 lead monitoring and interpretation
12 and 15 lead acquisition and interpretation
Assessments and Interpretation of findings ie chest sounds & tx
Venous and Capillary Blood Sampling & glucometer use
Utilization/interpretation of SpO2 and Endtidal CO2 monitoring
Application of Continuous Positive Airway Pressure (CPAP)
Administer the following medications:
Ø Atropine (IV/ETT)
Ø ASA (PO)
Ø Dextrose: 50%, 25% or 10% solutions (IV/IO)
Ø Dimenhydrinate (IV/IM)
Ø Diphenhydramine (IV/IM)
Ø Dopamine (IV drip)
Ø Epinephrine 1:1000 (IV/IM/IO/ETT/Inhalation)
Ø Epinephrine 1:10,000 (IV/ETT)
Ø Glucagon (IM)
Ø Lidocaine injectable (IV/ETT)
Ø Lidocaine topical (Inhalation)
Ø Midazolam (IV/IM/IN/Buccal)
Ø Morphine (IV)
Ø Naloxone (IV/IM/IN/SC)
Ø Nitroglycerin spray (SL)
Ø Xylometazoline (Inhalation)
Ø Salbutamol MDI (Inhalation)
!
35
By the following routes:
Ø Intravenous (IV)
Ø Endotracheal (ETT)
Ø Oral (PO)
Ø Sublingual (SL)
Ø Subcutaneous (SC)
Ø Buccal (BU)
Ø Inhalation (nebulized or MDI)
Ø Intraosseous (IO)
Ø Intramuscular (IM)
Ø Intranasal (IN)
Ø Topical
36
Vital Signs Absent Patient
Here are some guidelines to help with the determination of the recognition
of death and/or the termination of resuscitation when presented with a
VSA:
1. Patient presenting as “Obviously Dead”
a. Decapitation, transection, visible decomposition, putrefaction;
or
b. Absence of vital signs and:
A grossly charred body; or
• An open head or torso wounds with gross outpouring of
cranial or visceral contents; or
• Gross rigor mortis; or
• Lividity
•
2. Patient without vital signs and the subject of a Ministry of Health and
Long-Term Care Do Not Resuscitate Confirmation Form. Consider
honoring the DNR Confirmation Form.
3. Patient without vital signs and the subject of a “legal looking’
document or the old DNR Medical Directive and Funeral Home
Transfer Form, consider calling the BHP to receive termination of
resuscitation order.
4. Patient without vital signs and the subject of the possible application
of the TOR Medical Directive (Medical or Trauma). Consider calling
the BHP for termination of resuscitation order. In the event that
a physician on scene is willing to assume care and responsibility
of the patient, provide assistance as possible within your scope
of practice.
*Paramedics must carefully consider matters such as scene integrity,
investigative issues, family concerns and disposition of body.