Adult Medical Directives - 2023 Flashcards
Ornge Transport Medicine
1
Q
What is the SBARR patch format?
A
Situation
- The problem and the reason I am calling the physcian
Background
- A brief clinical summary
Assessment
- My assessment of the problem
Recommendations
- What do I want to do?
Readback
- Acknowledge the information given
Adult MDSO 2023 page 8
2
Q
What is an intubation attempt?
A
Insertion of a laryngoscope or flexible scope into the mouth, past the lips, for the purpose of pass an endotracheal tube.
First Pass success is not disqualified by necessary adjustments to the glottic view (ie 30 second drills) or the depth of the endotracheal tube.
Adult MDSO 2023 page 19
3
Q
What are the organizational goals for intubation?
A
- Successful intubation on the first attempt
- No desaturation (SpO2 < 90%)
- No hypotension (SBP < 90 mmHg)(MAP< 65 mmHg)
- No other airway complications
- Vomiting/Aspiration
- Hypoventilation
- Airway trauma caused by intubator
- Misplacement of tracheal tube
- Bradycardia
- Cardiac arrest
Adult MDSO 2023 page 19
4
Q
Rapid Sequence Induction (RSI)
A
An advanced airway procedure involving the near simultaneous administration of a potent sedative followed by a neuromuscular blocking agent, allowing airway manipulation and endotracheeal intubattion.
Adult MDSO 2023 page 19
5
Q
Describe Preintubation Positioning.
A
- Ear to sternal notch (sniffing position)
- Head of bed up 30 degrees
- Head of patient up to head of bed
- Reverse trendeleburg in
- High BMI
- Late Pregnancy
- Spinal immobilization
- 360 degree access to patient
- Head at or just above belt/belly level
Adult MDSO 2023 page 20
6
Q
Post Intubation Checklist
A
Adult MDSO 2023 page 24
7
Q
Stepwise approach to preoxygenation strategies
A
Adult MDSO 2023 page 25
8
Q
Intubation
E-V-L-I approach
A
Epiglottoscopy - follow tongue to the epiglottis.
Valleculoscopy - placing the tip of the blade in the epiglottis and engaging the hypoepiglottic ligament to lift the epiglottis.
Laryngoscopy - manipulating the thyroid cartilage and head lift to bring the volcal cords into better view.
Intubation, with bugie and endotracheal tube delivery.
Adult MDSO 2023 page 25
9
Q
30 Second Drills
A
- NECK - External Laryngeal manipulation of the thyroid cartilage
- HEAD - Extra head lift - right hand under the occiput lifting the patient’s head
- HANDS - Extra head lift - both hands lifting the laryngoscope blade
- SCOOP - Lift epiglottis with laryngoscope blade tip
- PULL BACK - Obtain a purposeful grade II view with VL to decrease delivery angle of the endotracheal tube
Adult MDSO 2023 page 26
10
Q
Bougie
Distal Hold up
A
30 - 40 cm
Adult MDSO 2023 page 26
11
Q
What is the critical saturation threshold
A
Saturations </= 92%
Should ventilate patient with optimized bag valve mask as necessary to re-oxygenate to over 95%
Adult MDSO 2023 page 27
12
Q
What is optimized bag valve mask ventilation?
A
- 2 person BVM, two thumbs down face mask seal, pulling face into mask
- Jaw thrust
- BVM with flush rate oxygen + Nasal oxygen 15 LPM
- Oropharyngeal and two nasopharyngeal airways
- PEEP valve and waveform capnography
Adult MDSO 2023 page 27
13
Q
ORNGE
Universal Airway Algorithm.
A
Adult MDSO 2023 page 28
14
Q
What is the directive for Lidocaine (Xylocaine) Spray for Intubation?
A
10 mg/spray on the pharynx, hyopharynx
Max cumulative dose of 5mg/kg or 400 mg
Adult MDSO 2023 page 32
15
Q
What is the directive for Ketamine (Ketalar) for Intubation?
A
Induction dose
- 0.5 - 2 mg/kg IV over 30 seconds
- Use 0.5 mg/kg in patient exhibiting signs of shock (Shock Index > 0.8)
Reduced titration dose
- 10 - 30 mg IV q 60 seconds
- Goal 2 mg/kg within 5 minutes
- Used for crashing pre-arrest patient, poor cardiovascular reserve or potential difficult airway for awake intubation
Adult MDSO 2023 page 32
16
Q
SHOCK INDEX
A
HR/Systolic Blood Pressure
Normal SI 0.5 - 0.7
SI of 0.8 or greater predicator for decompensation following RSI.
17
Q
What is the directive for Midazolam (Versed) for Intubation?
A
Induction dose
- 0.1 mg/kg IV (to a max of 8 mg)
- Contraindicated if MAP < 80
Reduced titration dose
- 1 -2 mg every 3 - 5 minutes (to a Max of 8 mg)
- Potentially difficult airway in awake intubations
Adult MDSO 2023 page 32
18
Q
What is the directive for Etomidate (Amidate) for Intubation?
A
0.2 - 0.3 mg/kg IV
Adult MDSO 2023 page 32
19
Q
What is the directive for Propofol (Diprivan) for Intubation?
A
1.0 - 1.5 mg/kg IV/IO
Contraindicated if MAP < 100
Caution
- Respiratory apnea and hypotension may occur with rapid induction
- Avoid in elderly or hypovolemia or poor cardiovascular reserve
- Phenylephrine should be used to support BP if hypotension occurs
- Should be avoided in hypotension with head injury
Adult MDSO 2023 page 33
20
Q
What is the directive for Fentanyl (Sublimaze) for Intubation?
A
1 - 2 mcgs/kg IV/IO
MAP > 80
Reduced titration dose
- 25 - 50 mcg IV q 3 - 5 min
- Elderly
- Decreased LOC
- Maximally sympathetically stimulated and poor cardiovascular reserve
Adult MDSO 2023 page 33
21
Q
What is the directive for Succinycholine (Anectine) for Intubation?
A
1.5 mg/kg IV/IO
2.0 mg/kg (Shock Index > 0.8)
Contraindicated With:
- Malignant hyperthermia
- Hyperkalemia (known or concern)
- Myopathies/Muscular dystrophies
- Amyotrophic Lateral Sclerosis, Multiple Sclerosis
- Guillian-Barre Syndrome, botulism
- Burns > 2nd degree over 10% BSA > 24 hours until healed
- Stroke with hemiparesis, spinal cord injury > 72 hours until 6 months post injury
- Severe intra-abdominal sepsis > 72 hours until resolution
Adult MDSO 2023 page 33
22
Q
What is the directive for Rocuronium (Zemuron) for Intubation?
A
1.2 mg/kg IV/IO
1.5 mg/kg IV/IO (Shock Index > 0.8)
Rocuronium is the preferred paralytic in the majority of patients.
Adult MDSO 2023 page 33
23
Q
What is the directive for Phenylephrine (Neosynephrine)?
Treatment of Hypotension associated with Sedation
A
MAP < 65
MAP < 80 (high ICP, Ischemic stroke or spinal cord injury)
100 micrograms IV/IO q 3 minutes prn
Max 3 doses (300 micrograms)
Adult MDSO 2023 page 34
24
Q
Transport of Tracheostomy Patient
Major issues
A
Tracheostomy > 7 days
Sutured in place 2 sutures per side
Trach Secured with tie around neck
Adult MDSO 2023 page 36
25
Emergency Tracheostomy Tube Reinsertion
If cannot re-insert existing tracheosotomy tube or re-insert an alternate tracheostomy tube. Place cuffed ETT 6.0 or smaller over bougie through the patient stoma site.
## Footnote
Adult MDSO 2023 page 37
26
Emergency Tracheostomy Tube Reinsertion
Risk Assessment
## Footnote
Adult MDSO 2023 page 38
27
What are the documented Risk Factors for Severe Asthma?
* Increased use of puffers
* Steroids
* Prior intubations
* Previous ICU adminissions
* Tiring
* Silent chest
* Poor pulmonary functon tests or concerning blood gas
## Footnote
Adult MDSO 2023 page 40
28
What are the markers for deterioration for Severe Asthma?
* Rising carbon dioxide levels (including normalization in a previously hypocapnic patient)
* Exhaustion
* Mental status depression
* Hemodynamic instability and refractory hypoxaemia
These markers aid in the decision to intubate the patient.
## Footnote
Adult MDSO 2023 page 40
29
What are the ventilation strategies for Asthma?
* Prolongation of the I:E ratio (extending E time and shortening I time)
* Using adequate sedation and analgesia
* Tidal volumes of **5 - 6 ml/kg Ideal Body Weight**
* RR 8 - 12 breaths/min
* PEEP 5 cm H2O
* pH above 7.25
* Pplat \< 30 if possible
* Ventilation strategies should focus on minimizing gas trapping
## Footnote
Adult MDSO 2023 page 40
30
Dynamic hyperinflation
Intubated Asthmatic
Compress the chest and allow for exhalation of Auto-PEEP in the case of hypotension, shock and PEA. Pneumothoraces should also be considered.
## Footnote
Adult MDSO 2023 page 40
31
What is the directive for Salbutamol (Ventolin) MIDI
100 microgram/puff
8 puffs
(4 breaths or 45 seconds between each administration)
may reapeat x 3 q 5 - 15 minutes prn
## Footnote
Adult MDSO 2023 page 41
32
What is the directive for Salbutamol (Ventolin) Nebulized?
Nebule ( 2.5 mg/2.5 mL)
5 mg q 5 - 15 minutes x 3 prn
## Footnote
Adult MDSO 2023 page 41
33
What is the directive for Ipratropium Bromide (Atrovent) MDI?
(20 microgram/puff)
5 puffs
(4 breaths or 45 seconds between each administration)
may repeat x 3 every 15 minutes prn
Max 3 doses
## Footnote
Adult MDSO 2023 page 41
34
What is the contraindication to the administration of Ipratropium Bromide (Atrovent)
Allergy to peanuts
35
What is the directive for Ipratropium Bromide (Atrovent) Nebulized?
(250 microgram/ML)
500 micrograms q 15 minutes x 3 prn
Max 3 doses
## Footnote
Adult MDSO 2023 page 41
36
For Severe Bronchoconstriction/Asthma Exacerbation
What is the directive for Epinephrine (Adrenalin) IM?
0.01 mg/kg IM (1:1000)
Max 0.5 mg IM
## Footnote
Adult MDSO 2023 page 42
37
For Severe Bronchoconstriction/Asthma Exacerbation
what is the directive for Epinephrine IV?
**Mandatory Patch**
0.05 - 0.5 micrograms/kg/min IV/IO
## Footnote
Adult MDSO 2023 page 42
38
For Severe Bronchoconstriction/Asthma Exacerbation
What is the directive for Steroids?
Methylprednisolone 125 mg IV/IO
OR
Dexamethasone 8 mg IM/IV/IO
## Footnote
Adult MDSO 2023 page 42
39
For Severe Bronchoconstriction/Asthma Exacerbation
What is the directive for Magnesium Sulfate?
Max 2 g (4mL)/100 mL
IV/IO over 15 minutes
## Footnote
Adult MDSO 2023 page 42
40
Asthma
Bronchoconstriction
Flowchart
## Footnote
Adult MDSO 2023 page 43
41
What are the indications for a Needle Decompression?
* Severe respiratory distress in the setting of chest trauma with hemodynamic compromise
AND/OR
* Traumatic VSAs
AND/OR
* Severe hemodynamic compromise during positive pressure ventilation particularly in trauma or asthma or COPD patients
AND/OR
* Chest trauma, Severe Asthma or COPD and one or more of the following:
* Decreased/absent breath sounds
* Altered LOC
* Cyanosis
* JVD
* Hyper resonance on the affected side
* Tracheal shift (late sign)
## Footnote
Adult MDSO 2023 page 44
42
Tension Pneumothorax
Differential diagnosis to consider
* Mainstem intubation
* Pleural effusion
* Hemothorax
* Consolidated pneumonia
* Autopeep
* Dynamic hyperinflation
## Footnote
Adult MDSO 2023 page 44
43
What is the directive for maintenance of Chest Tubes
* If the patient's chest tube was maintained by suction at the sending facility, the Paramedic may maintain to suction to no greater than -20 cm H2O.
* If the patient's chest tube was maintained by gravity drainage, the Paramedic may maintain by gravity drainage to underwater seal or to suction as per patient presentation.
## Footnote
Adult MDSO 2023 page 45
44
What scenario's are mechanical ventilation indicated in?
* Hypoxemic respiratory failure
* Hypercapnic respiratory failure
* Mixed hypoxemic/hypercapneic respiratory failure
* Transport of a patient intubated for other reasons
* Airway protection for primary neurological issues
* Excessive secretions
* Shock
## Footnote
Adult MDSO 2023 page 46
45
By what mechanisms is mechanical ventilation harmful to patients with acute lung injury (ALI) or acute respiratory distress syndrome ARDS?
* **Volutrauma** (excess tidal volumes- ideal target 6 mL/kg ideal body weight to avoid alveolar distention)
* **Atelectrauma** (recurrent opening and closing of alveoli - ideal target of maintaining an "open" lung using (PEEP)
* **Biotrauma** (release of local and systemic inflammatory cytokine/mediators form lungs due to volutrauma, barotrauma and atelectrauma)
## Footnote
Adult MDSO 2023 page 46
46
How is appropriate endotracheal tube placement confirmed prior to departing the sending facility?
Clinical Practice Guideline
* If available a chest x-ray should be viewed prior to departing the sending facility. Alternatively confirmation of appropriate ETT position can be obtained through discussion with the sending physcian or review of a final report from a radiologist.
* Should the clinical situation warrant in the judgement of the Ornge crew and TMP, clinical confirmation of ETT position without radiological confirmation may be sufficient when delays in transport to definitive care place the patient at greater risk.
* Coninuous ETCO2 monitoring should be performed to idenifty inadvertent ETT dislodgement.
## Footnote
Adult MDSO 2023 page 46
47
In cases of anticipated potential difficulty in reintubation after potential ETT dislodgement what should be considered?
Clinical Practice Guideline
* Ongoing neuromuscular blockade in addition to heavy sedation
## Footnote
Adult MDSO 2023 page 46
48
What is the purpose of clamping the ETT?
* Prior to any intentional disconnection from the ventilator the ETT can be clamped to prevent lung-de-recruitment.
## Footnote
Adult MDSO 2023 page 46
49
When is pressure support ventilation indicated?
* Patient with spontaneous respiratory effort not requiring high levels of mechanical ventilation support should be ventilated using pressure support ventilation.
* PSV has been shown to decrease sedation requirements
* PSV should not be set \< 8 cm H2O
## Footnote
Adult MDSO 2023 page 46
50
When is AC with pressure control, or volume control indicated?
Clinical Practice Guideline
Patients requiring higher levels of mechanical ventilation support due to severe respiratory failure, patients without adequate drive to breath and patients who require control of ETCO2 for non-respiratory reasons.
## Footnote
Adult MDSO 2023 page 46
51
Initial Inspired Oxygen Concentration
Clinical Practice Guideline
* Determined by matching the sending hospital settings or starting at 100% oxygen and titrating down based on oxygen saturation readings.
## Footnote
Adult MDSO 2023 page 47
52
What target range should oxygen saturation routinely be maintained at?
* 92 - 96%
High FIO2 > 0.8 may be associated with increased risk of lung injury due to worsening of lung inflammation.
High FIO2 > 0.8 causes nitrogen washout and alveolar micro-atelectasis.
## Footnote
Adult MDSO 2023 page 47
53
In what settings can Hyperoxia be harmful?
* Acute neurological injury
* Stroke
* Post-cardiac arrest
* Myocardial infarction
## Footnote
Adult MDSO 2023 page 47
54
What are the concerns with High FIO2 \> 0.8
Clinical Practice Guideline
* Increased risk of lung injury due to worsening of lung inflammation
* May cause washout of nitrogen and subsequent alveolar microatelectasis
## Footnote
Adult MDSO 2023 page 47
55
DeltaP
Mechanical Ventilation
Pplat minus PEEP
Keep Less than 15 cm H20
## Footnote
Adult MDSO 2023 page 47
56
"Permissive Hypoxemia"
Clinical Practice Guideline
* In patients with severe hypoxic respiratory failure, lower O2 saturation target may be tolerated
* ( **\> 88% "Permissive hypoxemia"**)
## Footnote
Adult MDSO 2023 page 50
57
What patients should permissive hypoxemia be avoided in?
* Pregnancy
* Carbon monoxide poisoning
*Consider reducing cabin altitude in patients with refactory hypoxemia as tolerated by operational constraints*
## Footnote
Adult MDSO 2023 page 47
58
PEEP
Clinical Practice Guideline
* All intubated patients should have a PEEP of at least 5 cm H2O to compensate for loss of physiologic PEEP
* Patients with ARDS and FiO2 \> 0.6 should receive PEEP higher than 5 cm H20 to support improved lung recruitment
* Patients with ARDS as FiO2 is increased, PEEP should also be increased to improve lung recruitment using the ARDsnet table
## Footnote
Adult MDSO 2023 page 47
59
I:E Ratio
Clinical Practice Guideline
* 1:2 - 1:3 for patients with minimal lung pathology
* Consider adjusting the I:E ratio by increasing inspiratory time as another strategy to increase mean airway pressure and therefore oxygenation (typically 1:1.5 or in extreme situations 1:1)
* Inverse ratio ventilation (I time \> E time) presents significant challenges in terms of ventilation and hemodynamics, and should only be done after careful discussion with the TMP
## Footnote
Adult MDSO 2023 page 47
60
Recruitment Maneuver
Clinical Practice Guideline
* Patients with ARDS and high FiO2 requirements and/or difficulty achieving oxygenation targets
* 40 cm H2O pressure delivered for 40 seconds as tolerated by hemodynamics and oxygenation
* Ideally performed at the sending hospital before placing patient on a transport ventilator
## Footnote
Adult MDSO 2023 page 47
61
Target End Tidal CO2
Clinical Practice Guideline
* Default 35 - 45 mm Hg
* Increased ICP but no signs of herniation 33 - 38 mm Hg
* Life threatening high intracranial pressure or herniation 30 - 35 mm Hg
## Footnote
Adult MDSO 2023 page 48
62
Extreme bicarbonate levels should prompt an adjustment ETCO2 target to avoid causing extreme arterial pH through excessive hyper/hypoventilation.
What bicarbonate levels should be targeted?
* HCO3 \> 35 should warrant a higher ETCO2 target
* HCO3 \< 15 should warrant a lower ETCO2 target
## Footnote
Adult MDSO 2023 page 48
63
Plateau Pressures should not exceed what level?
Why?
* \> 30 cmH2O should be avoided whenever possible
* To reduce the risk of barotrauma (Ventilator induced lung injury, pneumothorax, pneumomediastinum)
## Footnote
Adult MDSO 2023 page 48
64
What should be done with patients with poor respiratory system compliance which prevents achieving a target tidal volume without exceeding a plateau pressure of 30 cm H2O?
TMP should order a strategy of permissive hypercapnea with a target pH \> 7.2 - 7.25 and adjusted higher ETCO2 target depending on baseline serum bicarbonate (i.e., ETCO2 50 - 60) achieved with tidal volumes of 4 - 6 ml/kg IBW
*Tidal volume should never be set below 4 ml/kg*
## Footnote
Adult MDSO 2023 page 48
65
What reversible factors should be considered for intubated patients with higher driving pressure requirements?
* Bronchodilators for higher airway resistance in patients with asthma/COPD
* Main-stem bronchus intubation
* Kinked ET or patient chewing on the ETT
* Suctioning of the ETT in case of excessive secretions
* Decompression of a new pneumothorax
* Diuresis in the setting of pulmonary edema
## Footnote
Adult MDSO 2023 page 48
66
What are the indications for initiating Mechanical Ventilation?
* Need for mechanical ventilation
* Hypoxemic respiratory failure
* Hypercapnic respiratory failure
* Mixed hypoxemic hypercapnic respiratory failure
* ET airway managment for transport
## Footnote
Adult MDSO 2023 page 50
67
CCPs may initiate and maintain mechanical ventilation without patching based on what criteria?
* Patients who are intubated and ventilated for airway protection
* Patients with mild to moderate respiratory failure that do not require high levels of mechanical ventialtion support.
## Footnote
Adult MDSO 2023 page 50
68
CCPs are not required to patch for ventilated patients if they can achieve the following ventilation goals:
* Sp02 94 - 98% (88 - 92% if known CO2 retainer and this is a target Sa02 at the sending facility)
* ETCO2 35 - 45 ( or 33 - 38 if increased ICP)
## Footnote
Adult MDSO 2023 page 50
69
CCPs are not required to patch for mechanical ventilation if they can maintain the following safety parameters:
* Vt 6 - 8 ml/kg IBW (target Vt must be calculated and documented in ePCR)
* Frequency of 10 - 20 breaths per minute
* FI02 0.6 or less
* PEEP range 5 - 10
* Peak and plateau pressure less than or equial to 30 cm H20
* I:E ratio range 1:1.5 - 3.0
## Footnote
Adult MDSO 2023 page 50
70
Contraindications to CCP initiation and maintenance of mechanical ventilation without patch include:
* Sending facility ventilation parameters outside of safety parameters
* Exception: if FI02 is higher than 0.6, CCP medics may attempt a brief weaning trial
* Use of oxygen adjuncts ie heliox, nitric oxide, flolan, prone positioning
* Serum bicarbonate \< 15 or \> 35 (need to clarify pH/ETCO2 target with TMP)
## Footnote
Adult MDSO 2023 page 50
71
What is the acceptable range for Cuff pressures?
20 - 30 cmH20
## Footnote
Adult MDSO 2023 page 51
72
Describe the Ventilation Strategies for COPD/Asthma
* Low frequency 8 - 12 breaths/min
* I:E ratio 1:4 - 1:5
* Vt 4 - 6 mL/kg of IBW
* Sp02 91 - 94%
* Set PEEP 2 - 3 cm H20 \< than autoPEEP
## Footnote
Adult MDSO 2023 page 54
73
Describe the Ventilation Strategies for Acute Lung Injury/ARDS
* Initial frequency 20 - 26/min
* Initial Vt 6 mL/kg (Adjust Vt based on plateau pressure)
* Start with FI02 1.0 and PEEP 5 - 8 cmH20
## Footnote
Adult MDSO 2023 page 55
74
What is the criteria for a recruitment maneuver?
* Severe ARDS P/F ratio \< 100; with
* Diffuse changes on CXR; with
* Decrease in lung compliance; ie elevated plateau pressure
## Footnote
Adult MDSO 2023 page 56
75
Criteria to abort recruitment maneuver
MAP deceases by 20% or SBP decrease to < 80 mm Hg
Spo2 decrease by 10 points from baseline
Cardiac dysrhythmias
## Footnote
Adult MDSO 2023 page 56
76
Calculate the following P/F ratio
PaO2 83
FIO2 45%
* Convert FIO2 into a decimal
* 83/0.45 = 184
A P/F ratio less than 300 is suggestive of Acute Lung Injury (ALI)
A P/F ratio less than 200 is suggestive of ARDS
77
Describe the directive for the 40/40 recruitment maneuver
1. Administer 20 mL/kg bolus of Ringers Lactate for hypotension or evidence of volume depletion
2. Leave patient on hospital critical care ventilator. Request RT to perform 40/40 maneuver. 40 cm H2O for 40 seconds
***Abort RM if***
* MAP decreases by 20% or SBP decreases to \< 80 mmg
* Absolute drop in SpO2 \> 10 points from baseline, or
* Appearance of cardiac dysrhythmias
## Footnote
Adult MDSO 2023 page 56
78
Describe the directive following a recruitment maneuver
1. Clamp ETT
2. Establish AC pressure control target Vt 4 - 6 mL/kg of PIBW
3. Increase PEEP 2 - 4 cm H2O above pre-RM PEEP setting
4. Incrementally adjust PEEP and wean FiO2 using PEEP/FiO2 ARDSnet table
## Footnote
Adult MDSO 2023 page 56
79
Describe Procedure for Recruitment Maneuver on Hamilton T1
Choose APRV
Turn Apnea back up rate off
Set T High for 40
Set P High for 40
Flow trigger can be set at 3
FIO2 1.0
While Ventilator is in inspiratory hold choose PCV and add increase in PEEP to maintain recruited alveoli
## Footnote
Hamilton Medical
80
What are the contraindications for NIPPV
* Active vomiting and unable to manage airway secretions
* Decreased level of consciousness
* inability to protect airway
* Repeated hemoptysis
* Cardiac arrest
* Apnea
* Upper airway obstruction
* Facial trauma
## Footnote
Adult MDSO 2023 page 57
81
What are the initial settings for NIPPV within the directive?
IPAP 10 cm H2O / EPAP 5 cm H2O
Max IPAP 20 cm H2O / EPAP 10 cm H2O
## Footnote
Adult MDSO 2023 page 57
82
Indications for HFNC
Refractory hypoxemia
Sp02 < 90%
COPD/CHF exacerbation requiring minimal amount of PEEP
Palliative respiratory support with no ETT or NIPPV in care plan
## Footnote
Adult MDSO 2023 page 58
83
HFNC initial Adult Settings
30 LPM and titrate flow and FIO2 for SPO2 > 94%
## Footnote
Adult MDSO 2023 page 58
84
Epoprostenol Sodium
Flolan and Caripul
Favourable response
> 20% improvement in PaO2 or P/F ratio, or
> 15% reduction in mean pulmonary artery pressure, and/or
> >15% increase in cardiac output
## Footnote
Adult MDSO 2023 page 59
85
Epoprostenol Sodium
Acute discontinuattion
Precaution
Acute discontinuation can result in rebound pulmonary vasoconstriction. Usually starts within 30 minutes of discontinuation of medication.
Epoprostenol should always be weaned slowly.
## Footnote
Adult MDSO 2023 page 59
86
Epoprostenol
Dosage Range
0-50 ng/kg/min (ideal body weight)
## Footnote
Adult MDSO 2023 page 59
87
Epoprostenol
Acute discontinuation
Causes rebound pulmonary vasoconstriction within 30 minutes of discontinuation. If weaned prior to arrival ensure patient is stable at least 30 minutes prior to transport.
Epoprostenol should always be weaned slowly to avoid rebound pulmonary vasoconstriction.
## Footnote
Adult MDSO 2023 page 59
88
Epoprostenol
Viscosity
Filters can become sticky and blocked. Filters should be changed every 2 hours to ensure consistent drug delivery and avoid auto-PEEPing.
## Footnote
Adult MDSO 2023 page 59
89
Epoprostenol
Bleeding
Bleeding due to inhibition of platelet aggregation. Avoid administration during active hemorrhage (especially pulmonary hemorrhage).
## Footnote
Adult MDSO 2023 page 59
90
Prone Ventilation
Indications
Severe ARDS (P:F <150), FIO2 > 0.6, and PEEP > 5 cm H2O with failed supine ventilation.
## Footnote
Adult MDSO 2023 page 62
91
Prone Ventilation
Paralysis
Rocuronium or Cisatracurium
## Footnote
Adult MDSO 2023 page 62
92
What is the dose of Lorazepam (Ativan) for Pre-Transfer Sedation?
1 mg PO/SL
No patch required
93
What is the pain directive for Toradol (Ketorolac)
* Indicated for Moderate to Severe Pain
* 30 mg IM
* No Patch required
*Contraindicated in impaired renal function, active bleeding or NSAID in past 4 - 6 hours*
94
What is the pain directive for Acetaminophen (Tylenol)
* Moderate to severe pain
* 40 - 60 kg
* 15 mg/kg PO/PR q 4 hours
* \> 60 kg
* 975 - 1000 mg PO/PR q 4 hours prn
* Max 75 mg/kg or 4 grams in 24 hours
No patch required
*Contraindicated if Acetaminophen administered within last 4 hours*
95
What is the pain directive for Fentanyl?
MAP \> 70
MAP \> 80 (ICP, ischemic stroke or spinal injury)
25 - 50 mcg IV/IO q 10 minutes prn
MAX 300 micrograms
No patch required
96
What is the pain directive for Morphine?
MAP \> 70
MAP \> 80 (ICP, ischemic stroke or spinal injury)
2 - 4 mg IV/IO q 20 minutes prn
MAX 10 mg
No patch required
97
What is the pain directive for Ketamine?
Ketamine is not a first line agent for analgesia in normotensive patients but can be considered early for multiple trauma patients or those with concerning hemodyanmic status
0.1 mg/kg IV/IO q 5 minutes prn
MAX 0.5 mg/kg IV/IO
MAP \> 60
98
Intubated patients should have the sedation score titrated to what level?
- 4
99
Intubated patients should have the pain score titrated to what level?
0 - 2
100
What is the directive for Fentanyl for intubated and ventilated patients?
Pain Management
MAP \> 70
MAP \> 80 (ICP, ischemic stroke or spinal cord injury)
1 - 3 mcg/kg/hr
50 - 100 mcg IV/IM q 5 min
MAX 3 mcg/kg/hr
101
What is the directive for midazolam for intubated and ventilated patients?
Sedation
MAP \> 70
MAP \> 80 (ICP, ischemic stroke, spinal cord injury)
0.05 - 0.15 mg/kg/hr
1 - 2 mg IV prn q 5 minutes
MAX 0.15/kg/hr
102
What is the propofol directive for intubated and ventilated patients?
Sedation
MAP \> 70
MAP \> 80 (ICP, ischemic stroke or spinal cord injury)
0 - 80 mcg/kg/min
titrate in increments of 5 mcg/kg/min q 5 min
10 - 20 mg IV q 5 minutes prn if rapid effect is reqquired
103
What is the ketamine directive for intubated and ventilated patients?
Sedation and Pain Management
MAP \> 60
0.3 - 2.0 mg/kg/hr
1-2 mg/kg IV over 1 min x 1 dose
followed by 0.5 mg/kg q 20 min prn
104
What is the phenylephrine directive for treatment of hypotension associated with sedation?
* MAP \< 65
* MAP \< 80 (ICP, ischemic stroke or spinal cord injury)
* 100 mcg IV/IO x 3 q 3 min prn
* MAX 300 micrograms
105
What are the indications for Post Intubation Paralysis?
* Patient with known difficult airways
* Facilitate and optimize mechanical ventilation and oxygenation for transport
* Sedation and Analgesia must be administered in conjunction with muscle relaxation
106
What is the directive for Rocuronium
0.6 mg/kg IV/IO
then
0.3 mg/kg IV/IO q 20 minutes prn
107
What is the reduced titration dose of Ketamine for Intubation?
Push escalating doses of 10 - 30 mg IV q 60 seconds
Goal 2 mg/kg within 5 minutes
Crashing pre-arrest patient
Poor cardiovascular reserve
Potential difficult airway for awake intubation
108
What is the reduced titrating dose of Midazolam for Intubation?
1 - 2 mg every 3 - 5 minutes
In potentially difficult airway for awake intubation
109
What are the escalting energy levels on the Zoll for defibrillation?
120 J
150 J
200 J
110
What is the directive for pulseless VF/VT?
Shock 120 J
CPR 2 min
IV/IO access
Epinephrine 1 mg q 3 - 5 min
Check Rhythm
Shock 150 J
CPR 2 min
Epinephrine 1 mg q 3 - 5 min
**Advanced Airway**
Check Rhythm
Shock 200 J
**Amiodarone 300 mg IV**
**Amiodarone 150 mg IV second dose**
20 mL/kg NS bolus 1 L max
111
What is the dose of Amiodarone for Pulseless Ventricular Fibrillation or Ventricular Tachycardia?
300 mg IV initial dose
150 mg IV second dose
Max 450 mg
112
What are the reversible causes to search for in cardiac arrest?
* Hypovolemia
* Hypoxia
* H+ (Acidosis)
* Hypo/Hyperkalemia
* Hypothermia/Hyperthermia
* Tension pneumothorax
* Tamponade
* Toxins
* Thrombosis, pulmonary/coronary
* Anaphylaxis
113
What is the directive for Asystole/PEA?
CPR 2 min
**Treat reversible causes**
Oxygenate and Ventilate
Advanced Airway
IV/IO access
Epinephrine 1 mg q 3 - 5 min
20 mL/kg NS bolus to 1 L max
Patch
114
Desribe good quality CPR for an Adult?
Push hard \> 1/3 chest AP diameter: 5-6 cm depth
Push Fast (100/min - 120/min)
Rotate q 2 min
30:2 ratio if no advanced airway
With advanced airway, 10 breaths/min with continuous compressions
115
Hypothermic Cardiac Arrest
Temperature Definition
\< 30 C
Main cause of the arrest thought to be due to severe hypothermia
Tympanic thermometry is unreliable in severe hypothermia
116
How is Hypothemia Cardiac Arrest managed?
Initiate appropriate treatment algorithm based on presenting ECG
Treat reversible causes including hypothermia
Rapid transport to the closest appropriate emergency department for agressive rewarming.
Rewarm with external heat sources, shelter and **warmed IV up to 43 C**
**For Termination of Resuscitation core temp must be \> 30 C**
117
ROSC
Clinical Practice Guideline
* Rapid 12 Lead ECG
* Transport to a centre capable of percutaneous coronary intervention (PCI)
* Target MAP \> 65, Administer fluid or pressors to support this
* Targeted temperature at 32 - 36 C
* Oxygend saturations 94 - 98 %
* Hypocarbia and Hypercarbia must be avoided
* Ventilation should be based on ABG
* Target PaCO2 40 - 45 and ETCO2 35 - 45 mmHg
118
Describe the directive for Acute Coronary Syndrome
MAP \> 70
Nitroglycerin 0.4 mg SL q 5 min max 6 doses
Initiate Nitroglycerin IV 10 - 100 mcg/min
(Titrate q 5 min in 5 mcg/min increments)
ASA 160 mg
Morphine 2 mg IV q 10 min max 6 mg or
Fentanyl 25 - 50 mcg IV max 300 mcg
**Plavix (Clopidogrel) 300 - 600 mg PO**
Or
**Ticagrelor 180 mg PO**
119
What are the guidelines for initial "Antiplatelet Therapy" in patients with NSTEMI ?
* Non-enteric coated, chewable aspirin 160 mg to 325 mg with a maintainenance dose of 81 - 160 mg per day
* Clopidogrel 300 - 600 mg loading dose with a maintenance dose of 75 mg per day.
**Or**
* Ticagrelor 180 mg loading dose then 90 mg twice daily
120
What is Ticagrelor?
Brand Name **"Brillinta"**
P2Y(12) platelet inhibitor indicated to reduce the rate of thrombotic cardiovascular events in patients with ACS (unstable angina, non-ST elevation MI, or ST elevation MI) or a history of MI
121
In patients with NSTEMI, anticoagulation, in addition to antiplatelet therapy is recommended. Treatment options include:
* Enoxaparin
* Unfractionated Heparin
* Bivalirudin
* Fondaparinux
122
What is the dose of Enoxaparin?
1 mg/kg subcutaneous every 12 hours
Reduce dose to 1 mg/kg once daily with creatinine clearance \<30mL/min
123
What is the dose of unfractionated heparin for Acute Coronary Syndrome?
80 IU/kg (max 5000 IU) with initial infusion of 18 IU/kg/hr
Adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation
124
Acute coronary syndrome patients who are hypertensive and tachycardic should potentially be managed with?
Metoprolol 5 mg IV q 5 min to max of 15 mg
125
What is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non-PCI-capable hospital?
Immediate transfer to a PCI capable hospital with a goal of first medical contact to device time system goal of **120 minutes**
126
What is the ideal first medical contact to device time for STEMI when EMS is the first contact?
90 minutes
Patients should be transported directly to a PCI capable hospital if possible
127
When should fibrinolytic therapy be administered to patients with STEMI?
* Absence of contraindications
* When First Medical Contact to device time at PCI capable hospital exceeds 120 minutes
128
When fibrinolytic therapy is indicated or chosed as the primary reperfusion therapy it should be administered within what time frame?
30 minutes of hospital arrival
129
What is the guideline for transferring STEMI patients who have received fibrinolytic therapy to a PCI capable hospital?
* Angiography can be performed as soon as logistically possible, ideally within 24 hours.
* Angiogrpahy should not be performed within 2 - 3 hours after fibrinolytic therapy
130
A loading dose of a P2Y12 receptor inhibitor should be given as early as possible to STEMI patients. Options include:
* Clopdiogrel 300 - 600 mg
* Prasugrel 60 mg
* Ticagrelor 180 mg
131
What are the contraindications for Nitrates?
* Hypotension
* Marked bradycardia or tachycardia
* RV infarction
* Phosphodiesterase inhibitor use within the previous 24 - 48 hours.
132
What is the STEMI Criteria related to ECG changes?
* 1 mm ST elevation in 2 or more contiguous limb leads
* 1 mm ST elevation in 2 or more contiguous chest leads
* 1 mm ST depression in V1 and V2 and 1 mm in V8 and V9
* The presence of new LBBB
* 1 mm ST elevation in V4R
133
What are the absolute contraindications to Thrombolytics?
* Suspected Aortic Dissection
* Any prior intracranial hemorrhage, hemorrhagic stroke or stroke of unkown orgin
* Known intracranial neoplasm
* Ischemic stroke \> 3 hours or \< 3 months
* Suspected pericarditis
* Active bleeding or bleeding diathesis
* Gastrointestinal bleeding with last month
* Trauma/Surgery/head injury within 3 months
134
What are the relative contraindications for Thrombolytics?
* Patient with 90 minutes of PCI centre from scene or 120 minutes from PCI centre if in a community hospital.
* Chronic, severe, poorly controlled hypertension
* Severe uncontrolled hypertension on presentation 180 mmHg or DBP \> 110 mmHg
* Ischemic stroke or TIA in last 6 months
* Traumatic or prolonged CPR
* Recent internal bleeding
* Advanced Liver disease
* Active Peptic Ulcer
* Current use of anticoagulants: the higher the INR the higher the risk
135
What is the dosing range for Tenecteplase?
\< 60 kg 30 mg
60 - 70 kg **35 mg**
70 - 80 kg **40 mg**
80 - 90 kg **45 mg**
\> 90 kg **50 mg**
136
What is the dose of unfractionated heparin for STEMI when TNK has been administered?
60 IU/kg IV bolus (Max 4000 IU)
Then
12 IU/kg/hr IV (Max 1000 IU/hr)
*Titrate using heparin Nomogram*
137
Describe the Heparin Nomogram for patients who are not receiving Thrombolytics or Glycoprotein IIb/IIIa inhibitors.
*What is the acceptable aPTT range?*
aPTT should be 60 - 85 seconds
*If it is out of this range you may need to decrease or increase the infusion.*
138
What is the directive for Cardiogenic Pulmonary Edema?
Initial MAP \> 70 mmHg and SBP \> 100
Heart Rate is \> 60 but \< 160
**CPAP/BIPAP**
iPAP 10cmH20/ePAP 5 cmH20
Max iPAP 20 cmH20/ePAP 10 cmH20
**Nitroglycerin**
0.4 mg SL spray q 5 min x 6 doses
**Nitroglycerin Infusion**
10 mcg/min and titrate by 5 mcg q 5 min Max 200 mcg/min
**Furosemide**
40 mg IV or double patients usual daily dose
Max 160 mg
139
What is the directive for Cardiogenic Shock?
200 - 250 mL bolus
*If no signs of pulmonary congestion*
**Norepinephrine**
0.05 - 0.5 mcg/kg/min
**Dobutamine**
5 - 20 mcg/kg/min
*In all cases Target MAP should be \> 65*
140
What is the directive for Adult Symptomatic Bradycardia?
**Atropine**
0.5 mg IV/IO q 3-5 min max 3mg
**Dopamine**
5 - 20 mcg/kg/min
**Transcutaneous Pacing**
Rate 70 Start output at 10 mA and titrate
Once mechanical capture has been confirmed increase mA by 10%
**Procedural Sedation for TCP**
Ketamine 0.5 mg/kg
or
Versed 0.05 mg/kg and Fentanyl 1 mcg/kg
141
What is the directive for Transvenous Pacing?
Maintain transvenous pacing if initiated at sending facility
(Initial pacing settings will reflect sending facility settings)
*Any alteration of settings to be discussed with TMP*
142
What is the directive for Adult Symptomatic Atrial Fibrillation/Flutter?
Cardiorespiratory Compromise with Heart Rate \> 150
**Synchronized Cardioversion**
Atrial Flutter initial 100 joules
Atrial Fibrillation initial 150 joules
Then
Atrial Flutter 150 joules
Atrial Fibrialltion 200 joules
Then
Atrial Flutter 200 Joules
Atrial Fibrillation 200 Joules
**Procedural Sedation**
Ketamine 0.5 mg/kg
or
Versed 0.05 mg/kg and/or (MAP \> 65)
Fentanly 1 mcg/kg
*If MAP \< 65 Ketamine only*
143
What is the directive for Adult PSVT with Cardorespiratory Compromise?
Consider Adenosine 6 mg IV
**Synchronized Cardioversion**
100 Joules
150 Joules
200 Joules
**Procedural Sedation**
Ketamine 0.5 mg/kg or
Versed 0.05 mg/kg and/or
Fentanly 1 mcg/kg
144
What is the directive for Adult PSVT for a patient who is Stable?
Vagal Maneuver
Adenosine 6 mg IV followed by 20 mL flush
Adenosine 12 mg IV repeat x1
145
What is the directive for Adult Ventricular Tachycardia with Perfusion with cardiorespiratory compromise?
**Synchronized Cardioversion**
*With Procedural Sedation if Appropriate*
100 Joules
*Oxygen & Intubate if indicated*
150 Joules
*IV NS bolus 250 mL x 2 prn*
200 Joules
*Amiodarone 150 mg IV over 10 minutes*
146
What is the directive for Adult Ventricular Tachycardia with Perfusion without hemodynamic compromise?
Amiodarone 150 mg IV over 10 minutes
May repeat x 1
147
What is the dosing range for Norepinephrine in the Adult Medical Directives?
0.05 - 0.5 mcg/kg/min
148
Directive for Intraosseous Initiation and Maintenance
I**ndications:**
* Inadequate intravenous access for resuscitation
* Unable to obtain IV access after 2 attempts or 90 seconds
**Contraindications:**
* Known or suspected fracture, injury, deformity, or infection overlying the proposed insertion site
* Absence of adequate anatomic landmarks
* Previous IO insertion in the bone in the past 48 hours
149
Intravenous Line Maintenance Standard
**No Patch Required**
IV infusion containing thiamine, multivitamin prepartions and KCL to MAX of 40 mEq/Litre up to Max of 200 mL/hr as initiated by sending facility.
150
**Ischemic Stroke**
Acute Blood Pressure Management
*Ornge Clinical Practice Guideline*
* Ischemic stroke patients eligible for thrombolytic therapy:reduce blood pressure to a target of below 180/105
* Ischemic stroke patients not eligible for thrombolytic therapy: *Treatment of hypertension should not routinely be undertaken.*
* **Extreme blood pressure elevation** (i.e. systolic greater than 220 or diastolic greater than 120 mmHg) should be treated to reduce the blood pressure by approximately **15%** and not more than **25%** over the first 24 hrs, with further gradual reduction therafter to targets fo long-term secondary stroke prevention.
151
Acute Ischemic Stroke
*Blood Glucose, Oxygen and Temperature Management*
Clinical Practice Guideline
* Check Glucose: Hypoglycemia should be corrected immediately
* Maintain saturations \> 94%
* Monitor Temperature and treat if \> 37.5 C
152
Acute Intracerebral Hemorrhage
Blood Pressure Management
*Ornge Clinical Practice Guideline*
* Insufficient evidence that lower blood pressure targets are associated with better outcomes
* AHA guidelines suggest patients presenting with **SBP 150 - 220 mmHg** that lower pressure to a target of **140 mmHg is safe**
* Labetalol is first line treatment
153
Intracerebral Hemorrhage
Management of Anticoagulation
*Ornge Clinical Practice Guideline*
**Warfarin**
* PCC is first choice because it is fast. FFP and Vitamin K can be used if PCC not available
Antiplatelet agents should be stopped immediately
**Dabigatran**
* Idarucizumab
* 5 grams in 100 mL of NS over 10 minutes
**Rivaroxaban/apixaban**
* PCC 2000 IU and repeat in 1 hour for ongoing bleeding
154
What is the directive for Stroke?
155
What is the dose of Labetalol in the Stroke Directive?
**Labetalol IV push**
10 - 20 mg IV push q 20 minutes
Labetalol Infusion
0.5 - 2 mg/min
156
What is the dose of Hypertonic Saline in the Stroke Directive?
3 mL/kg
Max rate of 20 mL/min
157
What is the dose of Mannitol in the Stroke Directive?
1 g/kg IV/IO bolus
158
What is the Adult Seizure Directive?
Check Blood Glucose if \< 4 mmol/L treat
**Midazolam**
5 mg IV/IO q 5 min max 0.2 mg/kg
or
10 mg IM
**Phenytoin**
20 mg/kg add to 250 mL NS
Infusion no faster than 25 mg/min
**Propofol**
50 mg IV/IO q 5 minutes prn if MAP \> 70
159
What is the directive for Combative Patients?
In the event that a patient becomes agitated or combative, thereby endangering themselves and/or others on board the vehicle, ALL Paramedics are expected to physicially restrain the patient as per MOHLTC BLS standards.
**Ketamine (Ketalar)**
1 -2 mg IV/IO over 1 - 3 minutes
or
3 - 5 mg/kg IM
**or**
**Midazolam (Versed)**
0.05 mg/kg IV/IO
or
0.1 mg/kg IM q 5 min prn
Max dose 0.2 mg/kg
160
Hypotensive patients in hemorrhagic shock should be treated using a damage control resuscitative approach which inludes:
*Ornge Clinical Practice Guideline: Trauma*
* Hypothermia should be prevented and treated aggressively
* Hemorrhage control should be secured using tourniquets for extremity injury
* Blood component therapy should be considered early, in a 1:1:1 ratio, if possible
* Crystalloids shoiuld be minimized, if blood products are available
* Permissive hypotension should be considered for patients suffering penetrating torso injury
* Systolic blood pressure should be 90 mmHg. However, in all cases, perfusion of the brain must be maintained.
161
What are the guidelines for Tranexamic acid in Trauma?
*Ornge Clinical Practice Guideline*
* Administered to patients believed to be bleeding
* 1 g over 10 minutes followed by 1 g over 8 hours
* Should be initiated within **3 hours** of injury
162
What MAP should be maintained for Brain Injury?
*Ornge Clinical Practice Guideline*
MAP \> 80 mmHg
163
What are the general measures for prevention and treatment of ICP?
*Ornge Clinical practice Guideline*
* Head of bed elevated to 30 degrees
* Optimization of venous drainage by keeping neck in neutral position and loosing cervical collar if too tight
* Manage **Analgesia, Sedation and Nausea**
* Target PACO2 33 - 38 mmHg
164
What is the Adult Traumatic Cardiac Arrest Directive?
165
What is the Traumatic Brain Injury Directive?
166
Mannitol should **Not** be used in:
*Ornge Clinical Practice Guideline*
Patients with suspected hypovolemia (tachycardia and/or hypotension)
167
Use of Spinal Boards
*Ornge Clinical Practice Guideline*
* Spinal boards or adjustable break-away strecthers hould be considered primarily as extrication/patient lifting devices. The goal should be to **remove** the patient from these devices as soon as it is safe to do so.
* Patients may be kept on these devices **\< 30 minutes** if the paramedic deems it safer or more comfortable for the patient (short transport times).
168
What is the Adult Directive for Spinal Cord Injury?
169
What is the Neurogenic Shock Adult Directive?
**Normal Saline or Ringers Lactate**
20 - 40 mL/kg IV/IO
**Norepinephrine**
0.05 - 0.5 mcg/kg/min
**Atropine Sulphate**
0.5 mg IV/IO q 3-5 min max 3 mg
170
Traumatic Hemorrhagic Shock Adult Directive
**Normal Saline or Ringers Lactate**
20 mL/kg IV/IO bolus
Target MAP \> 65
**Consider PRBCs & TXA**
171
Blood Product Administration Adult Directive
**Indicaitons**
* Hemorrhagic shock MAP \< 65 mmHg with active, ongoing bleeding
* Hemoglobin \< 70
* TMP judgement
**Initiate then Patch**
1 - 2 PRBC to maintain MAP \> 65 or Hb \> 70
2 U of FFP for every 2 U of PRBC delivered or to reduce INR \< 2
172
Reversal of Anticoagulation Directive
**Indications**
* Emergency reversal of Warfarin therapy (intracranial bleed, emergency surgery, life threatening bleed) and INR \> 1.5
**Prothrombin Complex Concentrate**
Administer PCC and 10 mg Vitamin K
173
What is the usual dose for Octaplex for a patient weighing 50 - 90 kg with an INR of **1.5 - 3.0**
1000 IU (40 mL)
174
What is the usual dose of Octaplex for a patient weighing 50 - 90 kg and an INR of \> 3.0
2000 IU (80 mL)
175
What is the usual dose of Octaplex for a patient weighing \> 90 kg with an INR \>1.5
2000 IU (80 mL)
176
What is Dabigatran?
**Pradaxa**
* Anticoagulant known as a "direct thrombin inhibitor"
* Lowers the chance of blood clots forming in your body by blocking thrombin.
177
What is the directive for reversing Dabigatran?
**Indications**
* Life-threatening hemorrhage (i.e., ICH, major trauma, GI bleed requiring RBC transfusion)
* Emergency surgery (i.e. ruptured spleen, ruptured AAA, ischemic bowel, open fracture
**Idarucizumab**
5 grams (2x2.5 vials) in 100 mL over 10 minutes by bolus infusion
178
What is Idarucizumab?
**Praxbind**
## Footnote
Praxbind bind is a humanized monoclonal antibody fragment that binds to dabigatran thereby inhibiting the activity of dabigatran as an anticoagulant.
Idarucizumab binds to dabigatran with very high affinity, approximately 300-fold more potent than the binding affinity of dabigatran for thrombin.
179
What is the directive for reversing Rivaroxaban (xarelto) and Apixaban (Eliquis)?
**Prothrombin Complex Concentrate (PCC)**
2000 IU and repeat at 1 hour
*PCC is a blood product and requires transfusion consent*
**Tranexamic Acid (TXA)**
1 g repeat in 1 hour (or 1 g over 8 hours)
180
Tranexamic Acid Directive
**Indications**
Treatment of trauma-associated hemorrhage, management of massive bleeding, or prohylaxis of systemic or local hyperfibrinolysis
**Tranexamic Acid (TXA)**
Administer within 3 hours of injury
1 g over 10 minutes
181
For prolonged seizure activity during transport what infusions should be considered?
**Midazolam**
1 - 5 mg/hr
or
**Propofol**
0 - 80 mcg/kg/min
182
Hypovolemic Shock Directive
**Indications**
Hypotensive as defined by a MAP \< 65
**Ringers Lactate or Normal Saline**
20 mL/kg bolus max 1 Litre
Repeat bolus if symptomatically hypotensive
Target MAP \> 65
**Norepinephrine**
0.05 - 0.5 mcg/kg/min
Target MAP \> 65
**Consider PRBCs & FFP**
183
What is the SOFA Score?
*Ornge Clinical Practice Guideline*
**Sequential organ failure assessment score** is used to track a persons status during the stay in an Intensive Care Unit to determine the extent of a person's organ function or rate of failure.
The score is based on six different scores, one each for the respiratory, cardiovascular, hepatic, coagulation, renal and neurological systems.
184
What is Quick SOFA Score for Sepsis?
*Ornge Clinical Practice Guideline*
**Quick Sequential Organ Failure Assessment Score**
* Identifies patients outside the ICU with suspected infection that are at a high risk for in-hospital mortality.
* Can help increase suspicion or awareness of a severe infectious process and prompt further testing and/or closer monitoring.
* A positive qSOFA Score (\>2) suggests high risk of poor outcome in patients with suspected infection.
185
What is the criteria for Septic Shock?
*Clinical Practice Guideline*
* Sepsis with persisting hypotension requiring vasopressors to maintain MAP \> 65 mmHg
* Serum lactate \> 2 mmol/L despite adequate volume resuscitation
186
What is the Adult Septic Shock Directive?
**Normal Saline or Ringers Lactate**
30 mL/kg IV/IO bolus
Target MAP \> 65
**Norepinephrine**
0.05-0.5 mcg/kg.min
Target MAP \> 65
**Vasopressin**
0..00-0.04 units/min
Target MAP \> 65
**Epinephrine**
0.05-0.5 mcg/kg/min
Target MAP \> 65
**Hydocortisone**
100 mg IV
187
What is the dose of Vasopressin for septic shock?
Septic Shock Directive
0.00-0.04 units/min
188
What is the dosing range of Epinephrine in the Adult Septic Shock Directive?
0.05-0.5 mcg/kg/min
189
In the setting of septic shock if the ionized Ca is \< 1 or Ca \< 2 what should be cosidered?
Adult Septic Shock Directive
1 g CaCl in 100 mL NS/1 hour
190
When should Norepinephrine be simultaneously administered with a crystalloid bolus?
Adult Septic Shock Directive
When the MAP is \< 50
191
If Hydrocortisone is not available in the setting of septic shock what should be administered?
Methlprednisolone 125 mg IV/IO
192
What is the directive for extravasation of Vasopressores from a Peripheral IV infusion?
Adult Directive
**Phentolamine within 12 hours**
0.1 mg/kg to a max of 10 mg in 9 mL of NS
Inject Half through the problematic IV catheter over 60 seconds and half as a Sub Q injection around the site using a 25G-30G needle into any area of tissue discoloration or swelling
193
What is the Adult directive for Nausea, Vomiting and Motion Sickness?
**Dimenhydrinate** **(Gravol)**
50 mg IM/PO
or
50 mg/10 mL NS over \> 5 minutes
**Ondansetron (Zofran)**
4 mg IM q 4-8 hours prn
or
4 mg IV in 50 - 100 mL NS over 15 minutes q 4 - 8 hours
194
What are the black box warnings related to the administration of Ondansetron?
Adult Medical Directive
**Risk of Prolonged QT**
* in patients \> 75 of age the initial IV dose must not exceed 8 mg
* In patients \< 75 of age the initial IV dose must not exceed 16 mg
* Subsequent IV doses must not exceed 8 mg and may be given 4 and 8 hours after the initial dose
* All IV doses must be diluted in 50 - 100 mL of saline and infused over 15 minutes
195
What is the directive for Gastric (NG or OG) Tubes?
**Indications**
* Actual or anticipated need to evacuate gastric contents
* Intubated and ventilated patients
**Contraindications**
* Nasogatric-Patients presenting with facial smash or basal skull fracture
196
What is the directive for Gastrointestinal Bleed?
Adult Medical Directive?
**Normal Saline or Ringers Lactate**
20 mL/kg IV/IO bolus
**Consider PRBC**
**Pantoprazole or Octreotide infusion**
Can maintain from sending
197
What is the Directive for Gastroesophageal Ballon Tamponade?
Ideally the patient should be intubated and sedated to increase patient tolerance and comfort
Balloon pressue should be monitored and should remain between 25 - 45 cm H20
If the patient is not intubated, scissors should be readily available to cut the port for balloon deflation should the tube and balloon be pulled back into the pharynx resulting in hypopharyngeal occlusion
198
What are the indications and contraindications of Esophageal Temperature Probes?
Adult Directive
**Indications**
* Continuous core temperature monitoring for any intubated patient with a temperature outside normal range (36.5 to 37.5 C)
* Temperature monitoring during rewarming
* Targeted temperature management in ROSC
**Contraindications**
* Esophageal Strictures or varices or perforation
* Congenital anomalies
* Facial tauma
* Patients receiving Anticoagulants
199
What are the indications and Contraindications for Urinary Catheter Insertion and Maintenance
Adult Medical Directive
**Indications**
* For monitoring urine output
* For urinary tract obstruction
**Contraindications**
* Blood at the urethral meatus
* Perineal or scrotal hematoma
* Suspected urethral tear
* High riding prostate
200
What is the Adult Directive for Fever?
**Indications**
Temperature \> 38 C
**Contraindications**
* Acetaminophen with the last 4 hours
* Ibuprofen
* NSAID or Ibuprofen in last 6 hours
* Patient on anticoagulation therapy
* Current active bleeding
* Hx of petic ulcer disease or GI bleed
* Pregnant
* Asthmatic with no prior use of NSAID
* Known renal impairment
* CVA or TBI in last 24 hours
201
What is the Adult Directive for Anaphylaxis?
**Epinephrine 1:1000 Solution**
0.01 mg/kg IM (min 0.1 mg to max 0.5 mg)
May repeat x 1 after 10-15 minutes
**Salbutamol**
5 mg q 5 - 15 minutes x 3 prn (Neubulized)
8 puffs x 3 q 5-15 minutes prn
**Diphenhydramine**
1 mg/kg/dose IV/IM
Max of 50 mg/dose
**Methylprednisolone**
125 mg IV/IO
202
What is the Adult Hypoglycemic Directive?
**Indications**
Altered LOC (GCS \< 14)
Blood glucose \< 4 mmol
**Glucagon**
1 mg IM (1 mL)
repeat blood glucose in 20 minutes
or
**50% Dextrose**
25 g of D50W IV
repeat blood glucose in 10 minutes
**10% Dextrose Infusion**
Start at 100 mL/hr after Glucagon or Dextrose
**Thiamine (vitamin B1)**
100 mg IV/IM
When alcoholism or malnutrition are susptected
203
What is the Adult Directive for Hyperkalemia?
204
What is the fluid bolus for Hyperkalemia?
Adult Directive
**Normal Saline or Ringers Lactate**
10 mL/kg
Target MAP \> 65
205
What is the dose of Calcium Chloride (Calcijet) for Hyperkalemia?
Adult Directive
20 mg/kg IV/IO q 5 minutes prn
to a single MAX dose of 1 g over 5 minutes if central line (over 20 minutes if peripheral IV)
Max dose of 40 mg/kg or 2 g (whichever is less)
206
What is the dose of Sodium Bicarbonate for Hyperkalemia?
Adult Directive
50 mEq IV/IO prn
207
What is the dose of Insulin for Hyperkalemia?
Adult Directive
**Humulin R (Insulin)**
10 units IV/IO
Obtain blood glucose q 15 min
208
Suspected Acetaminophen Overdose
20% Mucomyst (Acetylcysteine)
Adult Medical Directive
**Indications**
* Mandatory patch to initiate acetylcysteine infusion
* May maintain Mucomyst (acetylcysteine) infusion if established by sending facility
* Ingested or suspected ingestion of 10 g total or 200 mg/kg of ideal body weight
* Rate infusion is to follow dosing table
209
Suspected Acetaminophen Directive
Adult Directive
210
Suspected Opiod Overdose
Adult Medical Directive
**Indications**
GCS \< 12
Respiratory Rate \< 10
Susptected acute opioid overdose
**Naloxone**
0.5 - 1 mg slow IV/IM, repeat q 3 minutes prn
Max 10 mg
*If increased LOC consider continuous IV infusion at 1/2 total waking dose per hour, titrate according to patient response*
211
Sedative Overdose
Adult Medical Directive
212
What is the fluid bolus for Beta Blocker Overdose?
Adult Medical Directive
**Normal Saline or Ringers Lactate**
10-20 mL/kg IV/IO bolus
Target MAP \> 65
213
What is the dose of Atropine for Beta Blocker Overdose?
Adult Medical Directive
**Atropine**
0.5 mg IV/IO q 3-5 minutes prn
Max 3 mg
214
What is the dose of Humulin R (Insulin) for Beta Blocker Overdose?
**Humulin R (Insulin)**
1 unit/kg IV/IO bolus
then
1 unit/kg/hr infusion
215
What is the directive for dextrose administration for Beta Blocker Overdose?
**Indications**
Administer if Humulin R is given
Supplemental glucose to keep sugar \> 11 mmol/L
**Dextrose**
0.5 g/kg IV/IO to a single Max dose of 25 g
216
What is the dose of Intralipid (Fat Emulsion 20%) for beta blocker overdose?
Adult Medical Directive
**Intralipid (Fat Emulsion 20%)**
1.5 mL/Kg IV/IO over 5 minutes; may repeat x 1
followed by 0.25 mL/kg/min infusion post bolus
total Max dose 12 mL/kg
217
Beta Blocker Overdose
Adult Medical Directive
218
What is the directive for Calcium Chloride for Calcium Channel blocker overdose?
Adult Medical Directive
**Indications**
Refractory hypotension and unstable bradydysrhythmias
**Calcium Chloride**
20 mg/kg (Max 1g/10mL) IV/IO over 5 minutes if central line (over 20 minutes if peripheral IV)
Repeat q 5 minutes prn
Max 100 mg/kg up to 5 g
219
Calcium Channel Blocker Overdose
Adult Medical Directive
220
What is the dose of Intralipid (Fat Emulsion 20%) for Calicum Channel Blocker Overdose?
**Intralipid (Fat Emulsion 20%)**
1.5 mL/kg IV/IO over 5 minutes; may repeat x 1
followed by 0.25 mL/kg/min infusion post bolus
Total Max dose of 12 mL/kg
221
Cholinesterase Inhibitor Poisoning
Adult Medical Directive
222
What is the directive for Atropine for Cholinesterase Inhibitor Poisoning?
**Atropine Sulfate**
2 - 5 mg IV/IO q 5 minutes prn
Titrate to the drying of secretions
223
What is the dose of Pralidoxime (2-Pam) for Cholinesterase inhibitor Poisoning?
**Pralidoxime (2-PAM)**
1-2 g IV/IO over 15-20 minutes q 1 hr prn
224
Cyclic Antidepressant Overdose
Adult Medical Directive
225
What is the directive for Sodium Bicarbonate for Cyclic Antidepressant Overdose?
**Sodium Bicarbonate**
1-2 mEq/kg IV/IO
q 5 min; may repeat x 1
for MAP \< 65 or wide complex tachycardias
*Stop Sodium Bicarbonate infusion If QRS \< 0.12 seconds*
Also for refractory seizures while concurrently treating with Seizure Medical Directive
226
What is the directive for Magnesium Sulfate for Cyclic Antidepressant Overdose?
**Magnesium Sulfate**
Max 2 g IV/IO over 15 minutes
for Torsades de Pointes
227
Non-Cyclic Antidepressant Overdose
Adult Medical Directive
228
What is the dose of Cyproheptadine for Non-Cyclic Antidepressant Overdose?
Adult Medical Directive
**Cyproheptadine**
4 mg PO/NG/OG q 1 hour Max 12 mg
229
What are examples of Non-Cyclic Antidepressants?
**Selective Serotonin Reuptake Inhibitors**
* fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Cipralex), sertraline (Zoloft)
**Serotonin and Norepinephrine Reuptake Inhibitors**
* venlafaxine (Effexor), duloxetine (Cymbalta), levomilnacipran (Fetzima) and desvenlafaxine (Pristiq)
230
Salicylate Overdose
Adult Medical Directive
231
Stimulant Overdose
Adult Medical Directive
232
Toxic Alcohol
Adult Medical Directive
233
Minimum documentation on all Obstetric Patients
Ornge Clinical Practice Guideline
Gravida, Para, Aborta
Estimated gestational age
Expected date of confinement
Previous births and complications
Group B Step status
Antibiotics given
Fetal Heart Rate
234
What is the definition of Premature Rupture of Membranes?
Ornge Clinical Practice Guideline
Ruptured membranes before 37 weeks of pregnancy but not in established labour.
235
What antibiotics are administered for Group B Streptococcus (GBS) or considered for PROM?
Ornge Clinical Practice Guideline
Ampicllin 2 g IV q 6 hours and erythromycin 250 mg IV q 6 hours for 48 hours
Then oral amoxicillin 250 mg Q8H and erythromycin 333 mg q 8 hours for 5 days for all PPROM \< 34 weeks
236
Why is ampicillin-clavulanic acid not recommended for PROM?
Ornge Clinical Practice Guideline
Increased rate of necrotizing entercolitis
237
When are antenatal corticosteroids indicated?
For patients between 24 and 33 6/7 weeks gestation with PROM
238
What is the directive for steroids for Preterm Premature Rupture of Membranes?
**Betamethasone**
12 mg IM twice 24 hours apart
**Dexamethasone**
6 mg IM every 12 hours for 4 doses
*Administered for fetal lung maturation for all patients 24 - 34 weeks*
239
What is the directive for Magnesium Sulphate for PPROM?
PPROM before 32 weeks
Imminent delivery
**Magnesium Sulphate**
4 g IV followed by 1 g/hour for 24 hours
***Treatment for Fetal Neuroprotection***
240
What are the indications for Tocolytics during transport?
Ornge Clinical Practice Guideline
For patients in preterm labour the goal is to avoid delivery during transport
241
What are the two Tocolytics that can be considered in the Ornge Directive?
**Indomethacin (\< 30 weeks)**
100 mg PR
**Nifedipine (Adalat)**
Contraindicated with MAP \< 70
20 mg PO then 10 mg PO q 20 minutes to Max dose of 40 mg in the first hour
May continue 20 mg q 4 - 8 hours if contractions persist to MAX dose of 120 mg/day
242
Pre-Term Obstetrical Complications Directive
Adult Medical Directive
243
What are the indications for treatment of Severe pre-eclampsia?
Adult Medical Directive
* Proteinuria
* Platelets \< 100 000
* A doubling of serum creatinine
* LFT 2x normal
* Pulmonary edema or cerebral or visual symptoms
244
What is the dose of Magnesium Sulfate for Pre-eclampsia?
Adult Medical Directive
**Magnesium Sulfate**
IV loading dose of 4g (infused at 150 mg/min) followed by
Maintenance at 1g/hr
*Dilute to a \< 20% solution for IV infusion*
245
What is the dose of Labetalol for Pre-eclampsia?
Adult Medical Directive
**Labetalol**
10 - 20 mg IV/IO q 20 minutes prn
or
1 - 2 mg/min infusion
246
What is the dose of Hydralazine (Apresoline) for Pre-eclampsia?
**Hydralazine (Apresoline)**
5 - 10 mg IV/IO
over 2 minutes
q 20 min prn
247
Pre-eclampsia/Eclampsia Directive
Adult Medical Directive
248
Labour and Delivery - Normal Delivery
Adult Medical Directive
249
250
251
