Advanced Care Paramedic

Pocket Reference Guide 2011 v. 1.1

CEPCP

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 Ofce: 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

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

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

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Markham:

Central East Prehospital Care Program

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Adult Cardiac Arrest

Indications
Non-traumatic cardiac arrest

Adult 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)

Debrillate VF/VT
every 2 mins Adult > 12 years only

Zoll

LP12 / LP15

200 joules (all shocks)

200, 300, 360 joules

Drug Epinephrine
every 4 mins

Dose
IO/CVAD/IV (preferred)

1.0 mg 2.0 mg

patch after 3rd dose

ETT (if above delayed > 5 mins)

IM (if suspected anaphylaxis) 0.01 mg/kg 1:1,000 (max 0.5 mg) single dose

Lidocaine
for recurrent V-b/VT (typically after 3rd shock) repeat after 4 mins 2 doses max

IO/IV/CVAD 1.5 mg/kg typically supplied 20 mg/ml ETT

3.0 mg/kg

Bolus
for PEA or any other rhythm where hypovolemia is suspected

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, conrm 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

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Lidocaine Volume per weight based on 100 mg/5 ml

40 kg = 3.0 ml 45 kg = 3.34 ml 50 kg = 3.75 ml 55 kg = 4.13 ml 60 kg = 4.5 ml 65 kg = 4.88 ml 70 kg = 5.25 ml 75 kg = 5.63 ml 80 kg = 6.0 ml 85 kg = 6.36 ml 90 kg = 6.75 ml 95 kg = 7.13 ml 100 kg = 7.5 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 60 - 80 ml 70 - 90 ml

105 kg = 7.88 ml 110 kg = 8.25 ml 115 kg = 8.62 ml 120 kg = 9.0 ml 125 kg = 9.38 ml 130 kg = 9.75 ml 135 kg = 10.13 ml 140 kg = 10.5 ml 145 kg = 10.88 ml 150 kg = 11.25 ml 155 kg = 11.63 ml 160 kg = 12.00 ml 165 kg = 12.37 ml

Primary Auscultation Conrm supraglottic airway placement. Chest rise

Conrmation Methods

Secondary ETCO2 Other

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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

Debrillate VF/VT
every 2 mins (pediatric pads if < 15 kg) Pediatric 30 days - < 12 years only

2 joules / kg ( 1st shock) 4 joules / kg (subsequent shocks)

Drug

Dose

Epinephrine
every 4 mins

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)

patch after 3rd dose

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

IO/IV 1.0 mg/kg

typically supplied 20 mg/ml

ETT 2.0 mg/kg

Bolus
for PEA or any other rhythm where hypovolemia is suspected

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, conrm 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

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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 Debrillate once 30 days - < 8 years - 2 joules / kg 8 yr - 200 joules

If in PEA determine drive-time to nearest hospital

ASYSTOLE

Yes

Less than 30 minutes drive-time to nearest ER?

No

No

16 years or older?

Yes

Continue CPR

Immobilize Patient Transport to Hospital

Continue CPR Patch to BHP for possible trauma TOR

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Tension Pneumothorax
Indications
Suspected tension pneumothorax and critically ill or VSA and absent or severely diminished breath sounds on the affected side(s).
Tension Pneumothorax

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 nger widths (average adult ngers) 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"

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Neonatal Resuscitation

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Hypothermic Arrest

Hypothermia Cardiac Arrest

Indications
Cardiac arrest secondary to severe hypothermia. Clinical Parameters Not obviously dead as per BLS standard No DNR

Interventions Debrillate 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 rst rhythm interpretation.

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Foreign body airway obstruction

Foreign Body Airway Obstr.

Indications
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 Debrillate 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 rst rhythm interpretation. If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest.

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Return of Spontaneous Circulation (ROSC)

Indications
ROSC after resuscitation was initiated Clinical Parameters SBP < 90 mmHg Bolus: Clear chest / no uid 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

ROSC

Adult Doses (12 years) Drug Bolus IV only Drug Dopamine IV only Pediatric Doses Drug Bolus IV only Drug Dopamine IV only Initital Dose 10 ml/kg Initial 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 Initial Dose 10 ml/kg Initial 5 mcg/kg/min Reassess Q 250 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.

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IV and Fluid Therapy

Indications
Actual or potential need for IV medication or uid therapy Actual or potential need for intravenous medication or uid therapy Clinical Parameters IV Start: No fracture proximal to IV site Bolus: No signs of uid overload SBP < 90

IV and Fluid

Adult Doses 12 years Drug TKVO IV/IO/CVAD Initital Dose 30 - 60 ml/hr Reassess q 250 ml Q Repeat Max

Bolus IV/IO/CVAD

20 ml/Kg

N/A

2,000 ml

Pediatric Doses < 12 years, Use micro drip or Buretrol Drug TKVO IV/IO Initital Dose 15 ml/hr Reassess q 100 ml Q Repeat Dose Max

Bolus IV/IO

20 ml/Kg

N/A

2,000 ml

Notes:

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

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Pediatric / Adult Intraosseous Medical Directive

Indications:
Actual or potential need for intravenous medication or uid therapy AND Intravenous access is unobtainable AND Patient is in cardiac arrest or near-arrest state

Pediatric / Adult IO

Clinical Parameters IO Start: No fracture or crush injuries or known replacement / prosthesis proximal to the access site.

Vital Sign Parameters 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

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Central Venous Access Device

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Indications:
Actual or potential need for intravenous medication or uid therapy AND Intravenous access is unobtainable AND Patient is in cardiac arrest or near-arrest state

Central Venous Access

Clinical Parameters CVAD Access: Patient has pre-existing, accessible central venous catheter in place

Vital Sign Parameters N/A

Notes:
CVAD Procedure :

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 uid 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

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

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Endotracheal Intubation
Indications
Need for ventilatory assistance or A/W control and other A/W management is inadequate or ineffective. Clinical Parameters 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 Xylometazoline Use for nasal ETT only

Endotracheal Intubation

Drug Lidocaine
Topical

Dose
up to 20 sprays 10 mg/spray 5 mg/kg max

Max 1 dose

Drug Xylometazoline

Dose 2 sprays / nare

Max 1 dose

Conrmation Methods
At least two primary and one secondary ETT placement conrmation methods must be used.

Primary Visualization Auscultation Chest rise

Secondary ETCO2 EDD Other

Notes:
An intubation attempt is dened 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 conrmation. ETT placement must be reconrmed immediately after every patient movement.

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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 reex 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 dened as the insertion of the supraglottic airway into the mouth.

Primary Auscultation Conrm supraglottic airway placement. Chest rise

Conrmation Methods

Secondary ETCO2 Other

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

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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. Epinephrine: Use for anaphylaxis only
Allergic Reaction

Adult Doses ( > 50 Kg) Drug Epinephrine IM Diphenhydramine IV/IM Initial Dose 0.5 mg
> 50 kg

Q N/A N/A

Repeat N/A N/A

Max 1 dose 1 dose

50 mg > 50 kg

Pediatric Doses Drug Epinephrine IM Initital Dose 0.01 mg/kg Max 0.5 mg 25 mg
> 25 - < 50 kg (if < 25 kg Patch)

Q N/A

Repeat Dose N/A

Max 1 dose

Diphenhydramine IV/IM

N/A

N/A

1 dose

Notes:
Epinephrine should be the rst drug administered in anaphylaxis. The epinephrine dose may be rounded to the nearest 0.05 mg.

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Epinephrine 1:1,000 0.01 mg/kg Rounded to the nearest 0.05 ml

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Croup
Indications
Severe respiratory distress and stridor at rest and current history of URTI and barking cough or recent history of a barking cough.

Clinical Parameters
Croup

< 8 years old No allergy or sensitivity to epinephrine Heart rate less than 200 / min

Pediatric Doses Drug

Epinephrine

Dose 1 year old

Epinephrine

Max 1 dose

5.0 mg
(5 ml)

< 1 year old > 5 kg or more

Epinephrine

2.5 mg
(2.5 ml)

1 dose

< 1 year < 5 kg

0.5 mg (mix with 2 ml of saline to make 2.5 ml)

1 dose

Notes:
The minimum initial volume for nebulization is 2.5 ml.

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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

Bronchoconstriction

Adult Doses Drug Salbutamol MDI 25 kg Salbutamol Nebulized 25 kg Epinephrine IM 50 kg Pediatric Doses Drug Salbutamol MDI < 25 kg Salbutamol Nebulized < 25 kg Epinephrine IM < 50 kg Initital Dose 600 mcg 2.5 mg Q 5-15 min 5-15 min Repeat Dose 600 mcg 2.5 mg N/A Max 3 doses 3 doses 1 dose Initital Dose 800 mcg 5 mg 0.5 mg Q 5-15 min 5-15 min N/A Repeat 800 mcg 5 mg N/A Max 3 doses 3 doses 1 dose

0.01 mg/kg Max 0.5 mg

Notes:
Epinephrine should be the rst 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 ofcer 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).

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

Clinical Parameters
CPAP

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 Q Max

5 cmH20
or

2.5 cmH20 5
or lpm if Boussignac

15 lpm if Boussignac

5 mins

or 25 lpm if Boussignac

15 cmH20

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:
Conrm CPAP by manometer if available

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Acute Cardiogenic Pulmonary Edema

Indications
Moderate to severe respiratory distress from suspected acute cardiogenic pulmonary edema Clinical Parameters No allergy or sensitivity No phosphodiesterase inhibitors* in past 48 hrs If SBP < 140 patient must have prior nitroglycerin use or IV established Vital Sign Parameters HR: 60 - 159 SBP 100 SBP drops no more than 1/3 of initial value

Adult Dose 18 years only Drug Nitroglycerin BP 100 - 140 Nitroglycerin BP 140 Initial Dose 0.4 mg S/L 0.4 mg S/L Q Repeat Dose 0.4 mg 0.4 mg Max

Acute Pulmonary Edema

5 min

6 doses

5 min

6 doses

NO History or IV
Nitroglycerin BP 140 0.8 mg S/L 5 min 0.8 mg 6 doses

WITH History or IV

Notes: Perform 12 / 15 lead * Phosphodiesterase inhibitors: - Sidenal: Viagra, Revatio (for pulmonary hypertension) - Tadalal: Cialis, Adcirca (for pulmonary hypertension) - Vardenal: Levitra, Staxyn

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Cardiac Ischemia Medical Directive

Indications
Suspected Cardiac Ischemia

Clinical Parameters No allergies or sensitivity to given drug. 18 years Unaltered LOA 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

Cardiac Ischemia

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 Nitroglycerin ASA Morphine Initital Dose 0.4 mg S/L 160 mg PO 2 mg IV Q 5 min N/A 5 min Repeat Dose 0.4 mg N/A 2 mg Max 6 doses 160 mg 5 doses

Notes: Perform 12 / 15 lead * Phosphodiesterase inhibitors: - Sidenal: Viagra, Revatio (for pulmonary hypertension) - Tadalal: Cialis, Adcirca (for pulmonary hypertension) - Vardenal: Levitra, Staxyn

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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

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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 Inferior Left Inferior Left Lateral Left Inferior Left

Septal Septal Anterior Left

Anterior Left Lateral Left Lateral Left

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STEMI Bypass Policy

Indications
Patient who is experiencing continuous cardiac ischemic "chest pain" or chest discomfort.

Clinical Parameters
STEMI Bypass

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

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COMMON IMITATORS OF MIS

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 mms then its likely LVH

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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)

No pheochromocytoma
Cardiogenic Shock

Adult Doses ( 18 Years) Drug Bolus IV/IO Initial Dose 10 ml/Kg Q Reassess q 250 ml 5 min Repeat Dose N/A Increase by 5 mcg/Kg/min 20 mcg/
Kg/min

Max

Dopamine IV

5 mcg/Kg/min

Pediatric Doses (< 18 years) Drug Bolus IV/IO Initial Dose 10 ml/Kg Q Reassess q 100 ml 5 min Repeat Dose N/A Increase by 5 mcg/Kg/min 20 mcg/
Kg/min

Max

Dopamine IV

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.

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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

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Symptomatic Bradycardia
Indications
Bradycardia with Hemodynamic Instability Clinical Parameters Allergy or sensitivity to given drug Atropine: No hypothermia No heart transplant Dopamine: No pheochromocytoma TCP: No hypothermia Adult Doses 18 Years Drug
Bradycardia

Vital Sign Parameters HR < 50 with hemodynamic instability SBP < 90

Initital Dose Atropine IV 0.5 mg

Q 5 min

Repeat Dose 0.5 mg

Max 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 benecial in the setting of sinus bradycardia, atrial brillation, rst 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 uid 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.

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Dopamine Administration

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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 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

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

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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)

Adult Doses

Procedural Sedation

Drug Midazolam IV

Initial Dose 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

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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)

Combative Patient

PATCH to BHP to proceed with Midazolam if unable to assess the patient for normotension or reversible causes.

Adult Doses Drug Midazolam IV/IM Initial Dose 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
or

10 mg 2 doses

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Tachydysrhythmia
Indications
Symptomatic Tachydysrhythmia Clinical Parameters No allergy or sensitivity to given drug Valsalva / Adenosine: SBP 100, Unaltered LOA Use for narrow complex, regular tachycardias 150 / minute. Not for sinus tachycardia, a-b or a-utter Adenosine specic: Not on dipyridamole (Persantine, Aggrenox) or carbamazepine (Tegretol) No bronchoconstriction on exam

Tachydysrhythmia

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 Adenosine IV

PATCH if suspected SVT with aberrancy (wide complex)

Initital Dose 6 mg

Q 2 min

Repeat Dose 12 mg

Max 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

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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

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Seizure
Indications
Active generalized motor seizure Clinical Parameters Unresponsive No allergy or sensitivity to Midazolam Not hypoglycemic

Adult Doses 50 kg Drug Midazolam IV Initital Dose 5 mg Q 5 min Repeat 5 mg Max 2 doses

Midazolam IM/IN/Buccal

10 mg

5 min

10 mg

2 doses

Seizure

Pediatric Doses Drug

Midazolam IV

Initital Dose 0.1 mg/kg 5.0 mg Max

Q 5 min

Repeat Dose 0.1 mg/kg 5.0 mg Max

Max 2 doses

Midazolam
IM / IN / Buccal

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

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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

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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 Patch - Naloxone IV* Patch - Naloxone

IM/IN/SC

Initital Dose
up to 0.4 mg

Q N/A N/A

Repeat N/A N/A

Max 1 dose 1 dose

0.8 mg

Opioid Toxicity

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

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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

ECD Probe Removal

Notes:
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.

44

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Hypoglycemia
Indications
Agitation or altered LOA or seizure or symptoms of stroke Clinical Parameters No allergy or sensitivity to given drug Glucagon: No Pheochromocytoma Adult Doses Drug Dextrose IV 50 kg Glucagon IM 25 kg Pediatric Doses Drug < 30 Days
Dextrose IV

Vital Sign Parameters Hypoglycemia 2 yrs < 4.0 mmol < 2 yrs < 3.0 mmol

Initital Dose 25 g 1 mg

Q 10 min 20 min

Repeat 25 g 1 mg

Max 2 doses 2 doses

Initial Dose 2 ml/Kg

0.2 g/kg Max 5 g (50 ml)

Q 10 min

Repeat 2 ml/Kg
0.2 g/kg Max 5 g (50 ml)

Max 2 doses

Hypoglycemia

D10W

30 Days to < 2 years

Dextrose IV

2 ml/Kg
0.5 g/kg Max 10 g (40 ml)

10 min

2 ml/Kg
0.5 g/kg Max 10 g (40 ml)

2 doses

D25W

2 years to < 50 Kg
Dextrose IV

1 ml/Kg
0.5 g/kg Max 25 g (50 ml)

10 min

1 ml/Kg
0.5 g/kg Max 25 g (50 ml)

2 doses

D50W

Glucagon IM

< 25 Kg

0.5 mg

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 nal set of vital signs including blood glucometry must be attempted.

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Dextrose Reference

46

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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 50 mg 50 Kg Q N/A Repeat N/A Max 1 dose

Pediatric Doses

Nausea / Vomiting

Drug Dimenhydrinate IV/IM

Initital Dose 25 mg 25 - < 50 Kg (if < 25 Kg Patch)

Q N/A

Repeat Dose 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

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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)

48

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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 Morphine IV

Initial Dose 2 - 5 mg

Q 5 min

Repeat 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

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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

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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 N/A Repeat None Max 1 dose

Notes:
Release from care.

Headache

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

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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

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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 Diphenhydramine PO Initial Dose 50 mg Q N/A Repeat N/A Max 1 dose

Minor Allergic Reaction

Notes:
Release from care.

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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 N/A Repeat None Max 1 dose

Notes:

Musculoskeletal Pain

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

54

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Central East Prehospital Care Program

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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

Burn Chart 'Rule of nines'

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; paramedics judgement that the patient requires assessment and treatment at a lead trauma centre.

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
< 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) > of accompanying R wave and/or > 0.04 sec (1 sm box) 2. Physiological Q waves: Normal Less then criteria above QRS Nomenclature
1.

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 nger 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.

10

OVERDOSE LEVELS
THIS CHART IS INTENDNED ONLY AS A GUIDE. NUMEROUS VARIABLES INFLUENCE TOXIC / LETHAL LEVELS.
ASA 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 yrs 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 mgs 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

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 (MAOIs) Tricyclic Anti depressants (TCAs) Valium (Diazepam)

TOXIDROME/ INFO
PO Snorted, IV, smoked, PO Alter Snorted, IV, smoked Dilated Poss dilated TachyArrhythmias TachyArrhythmias Alter Dilated

APPEARANCE

HOW USED

LOA RR HR BP

PUPILS

EC G

MISC

ECSTASY

(STIMULANT)

Looks like pills/candy

TachyT, Teeth Arrhythmias grinding, Irrational Tremors , Poss CVA, Seizures, T, Sweaty CP, Prone to MI/CVA, Violent

METH

(STIMULANT)

Diff coloured powder, Rock, Crystal

COCAINE / CRACK

(STIMULANT)
Snorted, IV, smoked, SC + + Alter + Const

(Opiate Narcotic)

HEROIN

Arrhythmias Arrhythmias

N/V, Restless, Seizures,

(Anaesthetic)
+ Alter +

KETAMINE
Snorted, IV, smoked, PO Drank (often mixed ETOH) Inhaled Smoked, Mixed Alter food, Tea PO, SC, Alter

(Depressant)

GHB

Norm/Dilat Slugg Poss dilated Norm/Dilat Slugg

Irregular Arrhythmias

INHALANTS

Diff coloured powders, Rock, Crystal Light-Dark Powders or Black tarry substance Clear liquid, White powder Looks like water Glue, paint, petro, Aerosols

MARIJUANA
Pills

Plant material

Sweaty, T, Nausea Nausea, Seizures, Slurred speech, Dizzy, Hallucinations Bloodshot eyes, Munchies

Anticholinergic

(TCAS/BENADRYL /GRAVOL/ANTIHIST)

Dilated

N, Warm, Wet, Possible seizures

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
< 2 Year Spontaneous To Speech To Pain None
BEST RESPONSE TO AUDITORY / VISUAL STIMULUS (0-2 years)

30-60 30-60 25-45 20-30 16-24 14-20

EYE OPENING 4 3 2 1

90-180 80-160 80-140 75-130 70-110 60-90

> 2 Year Spontaneous To Speech To Pain None

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 BEST MOTOR RESPONSE

Oriented, appropriate words Confused, inappropriate words Inappropriate, persistent cry / scream Incomprehensible sounds; grunts No Response
> 2 Year

3 2 1

Spontaneous movements Localizes pain Withdraws from pain Abnormal flexion (decorticate)

6 Spontaneous movements 5 Localizes pain 4 Withdraws from pain 3 Abnormal flexion (decorticate) 1 No response

Abnormal extension (decerebrate) 2 Abnormal extension (decerebrate) 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 IB, Advil, Nuprin, Rufen) Ketoprofen (Actron, Orudis KT) Naproxen (Aleve)

Ibuprofen (Motrin) Indomethacin (Indocin) Tolmetin (Tolectin) Ketoprofen (Orudis, Oruvail) 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.

HALF-LIFE ELIMINATION 30 minutes (IM) 8-18 minutes METABOLISM

ONSET

DURATION 60-90 minutes (SQ)

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 1 hour

2-5 minutes (IV) 20 minutes (IV) HALF-LIFE ELIMINATION 2-4 hours METABOLISM Hepatic

30

NALOXONE (NARCAN)
CLASS
Narcotic Antagonist

ACTION
Competitive narcotic antagonist. Displaces any narcotics bound to opiate receptor sites reversing their effects.

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

ONSET

DURATION 30-120 minutes

DISTRIBUTION
Crosses placenta

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 35 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

DURATION 3-4 hours (nebulized/oral inhalation)

Hepatic to an inactive sulfate

33

PCP Scope of Practice

Perform the following skills: Semi-Automated External Debrillation Manual debrillation (when working with an ACP who has indicated that a shock and its energy setting is to be delivered) Intravenous monitoring Intravenous Access/Therapy for patients 2 years of age (if certied / authorized in autonomous IV) Volume (crystalloid) Replacement Therapy for patients 2 years of age (if certied / authorized in autonomous IV) Basic Airway management Advanced Airway management with the King LT Oro-pharyngeal Suctioning Current CPR standards for Health-Care Providers 3 lead monitoring and interpretation 12 and 15 lead acquisition and interpretation Administration of CPAP Preparation of ACP pre-loaded medications Assessments and Interpretation of ndings ie chest sounds & tx Capillary Blood Sampling & glucometer use Utilization/interpretation of SpO2 Administer the following medications: ASA (PO) Dextrose: 50% solution (IV) (if certied / authorized in autonomous IV) Dimenhydrinate (IV/IM) (IV only if certied / authorized in autonomous IV) Diphenhydramine (IV/IM) (IV only if certied / authorized in autonomous IV) Epinephrine 1:1000 (IM/Inhalation) Glucagon (IM) Nitroglycerin spray (SL) Salbutamol MDI and nebulization (Inhalation)

By the following routes: ! Oral (PO) Sublingual (SL) Inhalation (nebulized or MDI) Intramuscular (IM) Intravenous (IV) (if certied / authorized in autonomous IV)

34

ACP Scope of Practice

Perform the following skills: Manual Debrillation 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 Difcult 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 ndings 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: Atropine (IV/ETT) ASA (PO) Dextrose: 50%, 25% or 10% solutions (IV/IO) Dimenhydrinate (IV/IM) Diphenhydramine (IV/IM) Dopamine (IV drip) Epinephrine 1:1000 (IV/IM/IO/ETT/Inhalation) Epinephrine 1:10,000 (IV/ETT) Glucagon (IM) Lidocaine injectable (IV/ETT) Lidocaine topical (Inhalation) Midazolam (IV/IM/IN/Buccal) Morphine (IV) Naloxone (IV/IM/IN/SC) Nitroglycerin spray (SL) Xylometazoline (Inhalation) Salbutamol MDI (Inhalation) !

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By the following routes: Intravenous (IV) Endotracheal (ETT) Oral (PO) Sublingual (SL) Subcutaneous (SC) Buccal (BU) Inhalation (nebulized or MDI) Intraosseous (IO) Intramuscular (IM) Intranasal (IN) Topical

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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 Conrmation Form. Consider honoring the DNR Conrmation 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.