Advanced Life Support Patient Care Standards Flashcards
In a Medical Cardiac Arrest, what should you consider for early transport after 1st analysis?
Consider very early transport after the 1
st analysis (and defibrillation if indicated) in the following
settings: pregnancy presumed to be ≥20 weeks gestation (fundus above umbilicus, ensure manual
displacement of uterus to left), hypothermia, airway obstruction, suspected pulmonary embolus,
medication overdose/toxicology, or other known reversible cause of arrest not addressed.
What cardiac arrest directive should you follow for opioid overdose?
Is there a role for Naloxone during cardiac arrest?
In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive.
There is no clear role for routine administration of naloxone in confirmed cardiac arrest.
What are the 2 shockable rhythm during cardiac arrest
VF OR pulseless VT
Trauma TOR conditions:
Trauma TOR Age ≥16 years LOA Altered HR 0 RR 0 SBP N/A Other No palpable pulses AND No defibrillation delivered AND Monitored HR = 0 OR Monitored HR >0 with the closest ED ≥30 min transport time away.
Medical TOR conditions:
Medical TOR Age ≥18 years LOA Altered HR N/A RR N/A SBP N/A Other Arrest not witnessed by EMS AND No ROSC AND No defibrillation delivered
Contraindications Medical TOR
Medical TOR
Arrest thought to be of non-cardiac
origin
Contraindications Trauma TOR
Trauma TOR Age <16 years Defibrillation delivered Monitored HR >0 and closest ED <30 min transport time away
If the patient is in cardiac arrest following removal of a obstruction, Do you Still treat as a Foreign Body Airway Obstruction
Cardiac Arrest?
Following removal of the obstruction, initiate management as a
medical cardiac arrest.
What is considered a Neonatal patient?
<30 days of age
If a 7 days old newborn patient HR is under 60 but greater than 0. What should you do
If the patient’s HR is less than 60 bpm but
greater than ‘0’ you must still start with
effective PPV on room air prior to initiating
PPV with 100% O2 and chest compressions.
When a newly born patient is in cardiac
arrest (HR of 0) you must do what?
you must still start with
effective positive pressure ventilations
(PPV) on room air prior to initiating chest
compressions. In other words, follow the algorithm outlined in your medical directive
(without skipping any steps) regardless of
the newly born patient’s initial heart rate. In
MOST cases effective PPV/ventilation of
the lungs will increase the newly born
patient’s heart rate
what is MR SOPA
‘MR SOPA’ - adjusting Mask to assure good seal, Reposition airway to “sniffing” position, Suction mouth and nose of secretions if necessary, Open mouth using manual manoeuvres, increase Pressure to achieve adequate chest rise, consider an Alternate Airway if available (ACP should consider ETT as an alternate airway).
(ROSC) Medical Directive:
Conditions
Contraindications
0.9% NaCl Fluid Bolus Age ≥2 years LOA N/A HR N/A RR N/A SBP Hypotension Other Chest auscultation is clear
(ROSC) Medical Directive:What should you your target SPO2 and ETCO2
Consider optimizing ventilation and oxygenation
Titrate oxygenation 94-98%
Avoid hyperventilation and target ETCO2 to 30-40 mmHg with continuous waveform capnography
(if available)
Cardiac Ischemia Medical Contraindications ASA and NTG
ASA Allergy or sensitivity to ASA or NSAIDs If asthmatic, no prior use of ASA Current active bleeding CVA or TBI in the previous 24 hours
Nitroglycerin Allergy or sensitivity to nitrates Phosphodiesterase inhibitor use within the previous 48 hours SBP drops by one-third or more of its initial value after nitroglycerin is administered 12-lead ECG compatible with Right Ventricular MI
Do you need to do a 12 Lead before administering NTG?
12 Lead Acquisition: Considering 12 lead acquisition and interpretation for STEMI is now a defined step in the treatment of cardiac
ischemia and precedes Nitroglycerin consideration
A 12 lead acquisition should be performed under __ from the PT contact
The recommendation that a 12 lead be performed within the first 10 minutes of patient contact is a goal. Understanding that not all situations allow for a 12 lead to be performed within the first 10 minutes of patient
contact, the Paramedic should document barriers that did not allow for this goal to be achieved
PT presented with an inferior AMI should not receive NTG, WHY?
These patients are often preload dependent and the administration of
nitroglycerin to these patients may cause significant hypotension.
PT presenting with chest pain took 2 ASA at 2pm. Will you still give him more for the Cardiac Ischemia directive?
ASA is a safe medication with a wide therapeutic index (the effective dose without side effects can be from 80
– 1500 mg). The additional dose provided by Paramedics will not exceed the therapeutic dose while ensuring the correct administration of correct dose of the medication. Therefore, apply the cardiac ischemia medical
directive as if no care had been rendered prior to your arrival
PT presenting with CHF and is STEMI positive. What is the maximum number of doses of NTG should you give?
Many patients who are at risk of having a cardiac event (MI) may also have a history of CHF and it can
sometimes be difficult to determine what issue is driving the other. It is likely that the STEMI is causing, or
exacerbating the CHF, and as such, following the Cardiac Ischemia Medical Directive and administering a
maximum of 3 x 0.4mg doses of nitroglycerin is most appropriate. The reduced number of doses in STEMI
reduces adverse outcomes associated with liberal nitroglycerin use.
Phosphodiesterase Inhibitors, are used for what
The use of these medications has diversified to include treatment of pulmonary hypertension and congestive
heart failure (CHF).
The most appropriate categorization is as phosphodiesterase (PDE) 5 inhibitors.
Phosphodiesterase (PDE) 5 inhibitor list (many known as erectile dysfunction drugs [EDD])
your STEMI PT received 2 doeses of NTG he now falls under the 1/3 systolic rule. 5 minutes later his pressure is at an acceptable LVL. Will you give him his last NTG dose?
If a patient’s vital signs fall outside the medical directive’s parameters (i.e.: hypotension), the patient can no
longer receive that medication (i.e.: nitroglycerin or morphine) even if the patient’s vital signs return to acceptable
ranges
In cases where the administration of nitroglycerin results in hypotension in patients with acute cardiogenic
pulmonary edema. Can you still give a fluid bolus?
In cases where the administration of nitroglycerin results in hypotension in patients with acute cardiogenic
pulmonary edema and a PCP AIV paramedic is attending, a fluid bolus is permitted despite the presence of
crackles. Once the patient is normotensive, discontinue the fluid bolus and withhold further doses of nitroglycerin.
Acute Cardiogenic Pulmonary
Edema Medical Directive:
Indications
Contraindications
Indications
Moderate to severe respiratory distress;
AND
Suspected acute cardiogenic pulmonary edema
Contraindications Allergy or sensitivity to nitrates Phosphodiesterase inhibitor use within the previous 48 hours SBP drops by one-third or more of its initial value after nitroglycerin is administered
Hypoglycemia Medical Directive:
Indications
Indications Agitation; OR Altered LOA; OR Seizure; OR Symptoms of stroke.
If you patient is apneic. what should be the first medication considered
Epinephrine should be the 1
st medication administered if the patient is apneic. Salbutamol MDI may
be administered subsequently using a BVM MDI adapter.
Moderate to Severe Allergic Reaction
Medical Directive:
Indications
Indications
Exposure to a probable allergen;
AND
Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis).
where should you capillary blood sample be taken for pediatric patient
heel of the foot (pediatric patients who have not begun to walk).
what are the common symptoms of bronchoconstriction
Symptoms of bronchoconstriction may include wheezing, coughing, dyspnea, decreased air entry and silent
chest.
you Deliver 500mcg of salbutamol to a adult patient. PT no longer has any wheezing, should you continue your treatment or stop?
When a dose of MDI salbutamol is administered, the intent is to deliver all six (6) (pediatric) or eight (8)
(adult) sprays to complete a dose. It would be under unusual circumstances to deliver less than the full
dose.
A PT presenting with 1 severe allergy symptoms to a single body system. will you give Epinephrine or diphenhydramine first?
Usually involves symptoms in more than one body
organ or system, with symptoms presenting as per
above post exposure
Severe symptoms to a single body system should
be considered as a severe allergic reaction
12 years old PT presenting with Severe Croup. what should you do?
Croup is occurring more and more frequently in older patients including adults, and if the indications are met,
a patch to a BHP would be required to consider treatment under this medical directive.
Croup Medical Directive:
Indications
Indications Severe respiratory distress; AND Stridor at rest; AND Current history of URTI; AND Barking cough or recent history of a barking cough.
Contraindications:
Acetaminophen
Acetaminophen use within previous 4 hours Allergy or sensitivity to acetaminophen Hx of liver disease Active vomiting Unable to tolerate oral medication Suspected ischemic chest pain
Contraindications:
Ibuprofen
NSAID or Ibuprofen use within previous 6 hours Allergy or sensitivity to ASA or NSAIDs Patient on anticoagulation therapy Current active bleeding Hx of peptic ulcer disease or GI bleed Pregnant If asthmatic, no prior use of ASA or other NSAIDs CVA or TBI in the previous 24 hours Known renal impairment Active vomiting Unable to tolerate oral medication Suspected ischemic chest pain
Define Unable to tolerate oral medication
Unable to Tolerate Oral Medications Defined:
Definition of ‘unable to tolerate oral medications’: For example: A patient that: must remain in the supine position
(i.e. on a backboard), is vomiting or nauseated, has difficulty swallowing or has a feeding tube in place would not
be able to tolerate oral medications.
Suspected renal colic patients should routinely be considered for NSAIDS: WHY?
Suspected renal colic patients should routinely be considered for NSAIDS (either ibuprofen or ketorolac)
administration because of the anti-inflammatory action and smooth muscle relaxant effects (reduces the
glomerular filtration rate which reduces renal pelvic pressure and stimulation of the stretch receptors) as well as
its inhibition of prostaglandin production makes them ideal agents to treat renal colic (Davenport & Waine, 2010).
The only advantage of parenteral ketorolac over oral ibuprofen is the ability to administer an NSAID despite
vomiting. The overall clinical effect of these drugs is almost identical.
Is Naloxone for respiratory distress AND LOA?
Remember, naloxone is ONLY being administered to improve respiratory status, NOT to improve LOA or for any
other purpose.
what is the preferred method of delivery for naloxone and why?
In keeping with the conventions of the medical directives, the order of preference of route of administration is as
listed: SC is first, then IM, then IN and then IV (where certified and authorized in IV initiation). SC is the preferred
route (Clarke, Dargan & Jones, 2005). Specific details for each subsequent route are included below.
IM
o faster onset and shorter duration than via SC route.
IN
o rapid absorption,
o concern with proximity to the patient’s mouth (for safety),
o no sharps,
o consider splitting dose between nares.
IV
o smaller dose,
o virtually instantaneous effect,
o very short duration,
o ideal in the apneic patient.
Opioid Toxicity Medical Directive:
Indications
Conditions
Contraindications
Indications Altered LOC; AND Respiratory depression; AND Inability to adequately ventilate; AND Suspected opioid overdose.
Conditions Naloxone Age ≥12 years LOA Altered HR N/A RR <10 breaths/min
Contraindications
Allergy or sensitivity to naloxone
Uncorrected hypoglycemia
where should you transport a opioid overdose and why?
Naloxone is shorter acting than most narcotics and these patients are at high risk of having a
recurrence of their narcotic effect. Every effort should be made to transport the patient to the closest
appropriate receiving facility for ongoing monitoring
Suspected Adrenal Crisis Medical
Directive:
Conditions
Hydrocortisone Other Paramedics are presented with a vial of hydrocortisone for the identified patient AND Age-related hypoglycemia OR GI symptoms (vomiting, diarrhea, abdominal pain) OR Syncope OR Temperature ≥38C or suspected/history of fever OR Altered level of awareness OR Age-related tachycardia OR Age-related hypotension
8yrs old PT with suspected DKA is hypotensive. what should you do?
Mandatory Provincial Patch Point
Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive patients ≥2 years
to <12 years with suspected Diabetic Ketoacidosis (DKA)
Cardiogenic Shock Medical Directive – AUXILIARY: Indications conditions Contraindications
Indications
STEMI-positive 12-lead ECG;
AND
Cardiogenic shock.
Conditions 0.9% NaCl Fluid Bolus Age ≥18 years LOA N/A HR N/A RR N/A SBP Hypotension Other Chest auscultation is clear 0.9% NaCl Fluid Bolus
Contraindications
Fluid overload
SBP ≥90 mmHg
Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY: Indications conditions Contraindications
Indications
Severe respiratory distress;
AND
Signs and /or symptoms of acute pulmonary edema or COPD.
Conditions CPAP Age ≥18 years LOA N/A HR N/A RR Tachypnea SBP Normotension Other SpO2 <90% or accessory muscle use
Contraindications CPAP Asthma exacerbation Suspected pneumothorax Unprotected or unstable airway Major trauma or burns to the head or torso Tracheostomy Inability to sit upright Unable to cooperate
Supraglottic Airway Medical Directive – AUXILIARY: Indications Conditions Contraindications
Indications
Need for ventilatory assistance or airway control;
AND
Other airway management is ineffective.
Conditions Supraglottic Airway Age N/A LOA N/A HR N/A RR N/A SBP N/A Other Patient must be in cardiac arrest
Contraindications Supraglottic Airway Active vomiting Inability to clear the airway Airway edema Stridor Caustic ingestion
what is considered an attempt to supraglottic airway insertion and how many can you try?
Clinical Considerations
An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into
the mouth.
The number of attempts is clearly defined as two (2) total per patient, and not per provider
what is the formula to calculate hypotension in Peds PT?
SBP = 70 + (2 x age).
Once a bolus has been initiated what is the minimum volume that may be administered before discontinuing. adults and Peds
Once a bolus has been initiated, a minimum volume of 100 ml in pediatrics and 250 ml in adults may be
administered prior to discontinuing the fluid bolus should the patient become normotensive.
You determine that a 8 years old PT normotension should be 116 SYS (90+(2x8). should you use 116mmHg or 100mmHg for your directives?
Formulas for pediatric normotension and hypotension are to be used until the calculation meets or exceeds the
adult definitions at which point the adult values are to be used. For example, at 6 years of age, the pediatric
calculation for normotension results in 102 mmHg; therefore use the adult value of 100 mmHg.
Define what is a cardiogenic shock?
Cardiogenic shock is normally defined as a state in which the heart has been damaged to such an extent that it
is unable to supply enough blood to the organs, tissues and cells of the body.
VSE PT becomes ROSC, should you remove immediately your SGA?
ROSC:
In the event the patient with a SGA in place sustains a ROSC, the SGA should only be removed if the gag
reflex is stimulated or the patient begins to vomit; expect to remove it as the level of awareness improves.
should you always treat nausea and vomiting with your NAUSEA / VOMITING MEDICAL DIRECTIVE – AUXILIARY?
While the indications list nausea or vomiting, patients presenting with these symptoms do not necessarily
require treatment.
Electronic Control Device Probe Removal Medical Directive – Indications Conditions Contraindications
Indications
Electronic Control Device probe(s) embedded in patient.
Conditions Probe Removal Age ≥18 years LOA Unaltered HR N/A RR N/A SBP N/A Other N/A
Contraindications
Probe embedded above the clavicles,
in the nipple(s), or in the genital area
