ALS PCS Flashcards
ROSC- Indications
Patient with ROSC after the resuscitation was initiated
ROSC- 0.9% NaCl Fluid Bolus Conditions
Age: ≥ 2 years
SBP: Hypotensive
Other: Chest auscultation is clear
ROSC- 0.9% NaCl Fluid Bolus Contraindications
Fluid Overload
ROSC Treamtent- Consider optimizing ventilation and oxygenation
Titrate oxygen 94-98%
Avoid hyperventilation and target ETCO2 to 30-40mmHg with continuous waveform capnography (if available)
ROSC- 0.9% NaCl Fluid Bolus Treatment
Age: ≥ 2 years to < 12 years
Route: IV
Infusion: 10ml/kg
Infusion interval: immediate
Reassess every: 100 ml
Max volume: 1000ml
Age: ≥ 12 years
Route: IV
Infusion: 10ml/kg
Infusion interval: immediate
Reassess every: 250 ml
Max volume: 1000ml
ROSC- Clinical Considerations
Consider initiating transport in parallel with the above treatment.
Cardiac Ischemia- Indications
Suspected cardiac ischemia
Cardiac Ischemia- Conditions ASA
Age: ≥ 18 years
LOA: unaltered
Other: Able to chew and swallow
Cardiac Ischemia- Conditions Nitroglycerin
Age: ≥ 18 years
LOA: unaltered
HR: 60-159 bpm
SBP: normotensive
Other: prior history of nitro use or IV access obtained
Cardiac Ischemia- Contraindications ASA
Allery or sensitivity to NSAIDs
If asthmatic, no prior use of ASA
Current active bleeding
CVA or TBI in the previous 24 hours
Cardiac Ischemia- Contraindications Niroglycerin
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
Cardiac Ischemia- Treatment ASA
Route: PO
Dose: 160-162 mg
Max single dose: 162 mg
Max # of doses: 1
Cardiac Ischemia- Treatment Nitroglycerin
NON STEMI
Route: SL
Dose: 0.3-0.4 mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 6
STEMI POSITIVE
Route: SL
Dose: 0.3-0.4 mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 3
Cardiac Ischemia- Clinical Considerations
Suspect a RV MI in all inferior STEMI’s and perform V4R to confirm (≥1mm of elevation in V4R)
Do not administer nitro to RV MI
Apply defib pads with a STEMI is identified
Get a 12-lead in < 10 mins of patient contact
ACPE- Indications
Moderate to severe resp. distress
AND
Suspected ACPE
ACPE- Conditions Nitroglycerin
Age: ≥ 18 years
HR: 60-159bpm
SBP: normotension
ACPE- Contraindications Nitroglycerin
Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within previous 48 hours
SBP drops by one-third of its initial value after nitroglycerin is administered
ACPE- Treatment Nitroglycerin
SBP: ≥100 mmHg to <140 mmHg
IV or Hx: yes
Route: SL
Dose: 0.3-0.4 mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 6
SBP: ≥140 mmHg
IV or Hx: no
Route: SL
Dose: 0.3-0.4 mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 6
SBP: ≥140 mmHg
IV or Hx: yes
Route: SL
Dose: 0.6-0.8 mg
Max single dose: 0.8mg
Dosing interval: 5 min
Max # of doses: 6
Hypoglycemia- Indications
suspected hypoglycemia
Hypoglycemia- Conditions Dextrose
Age: ≥ 2 years
LOA: altered
Other: hypoglycemia
Hypoglycemia- Conditions Glucagon
LOA: altered
Other: hypoglycemia
Hypoglycemia- Contraindications Dextrose
Alltergy or sensitivity to dextrose
Hypoglycemia- Contraindicaitons Glucagon
Allergy or sensitivity to glucagon
Pheochromocytoma
Hypoglycemia- Treatment Dextrose
Concentration: 10% dextrose
Route: IV
Dose: 0.2g/kg (2ml/kg)
Max single dose: 25g (250ml)
Dosing Interval: 10 mins
Max # of doses: 2
Concentration: 10% dextrose
Route: IV
Dose: 0.5g/kg (1ml/kg)
Max single dose: 25g (50ml)
Dosing Interval: 10 mins
Max # of doses: 2
Hypoglycemia- Glucagon Treatment
Weight: <25kg
Route: IM
Dose: 0.5mg
Max single dose: 0.5mg
Dosing interval: 20 mins
Max # of doses: 2
Weight: ≥ 25kg
Route: IM
Dose: 1mg
Max single dose: 1mg
Dosing interval: 20 mins
Max # of doses: 2
Hypoglycemia- Clinical Considerations
If the patient responds to dectrose or glucagon, they may recieve oral glucose or other simple carbohydrates
If only mild signs or symptoms are exhibited, the pt may recieve oral glucose or other simple carbohydrates instead of medications.
If a patient initiates an informed refusal os transport, a final set of vital signs including blood glucometry must be attempted and documented
Bronchoconstriction- Indications
Resp. distress
AND
Suspected bronchoconstriction
Bronchoconstriction- Conditions Epinepherine
RR: BVM ventilation required
Other: Hx of asthma
Bronchoconstriction- Conditions Salbutamol
NONE
Bronchoconstriction- Conditions Dexamethasone
Hx of asthma
OR
COPD
OR
20-pack-year history of smoking
Bronchoconstriction- Contraindications Salbutamol
Allergy or sensitivity to salbutamol
Bronchoconstriction- Contraindications Epinepherine
Allergy or sensitivity to epinepherine
Bronchoconstriction- Contraindications Dexamethasone
Allergy or sensitivity to steroids
Currently on PO or parental steroids
Bronchoconstriction- Treatment Salbutamol
Weight: < 25 kg
Route: MDI
Dose: up to 600 mcg (6 puffs)
Max single dose: 600 mcg
Dosing interval 5-15 mins PRN
Max # of doses: 3
Weight: < 25 kg
Route: NEB
Dose: 2.5mg
Dosing interval: 5-15 min PRN
Max # of doses: 3
Weight: ≥ 25 kg
Route: MDI
Dose: Up to 800 mcg
Max single dose: 800 mcg
Dosing interval 5-15 mins PRN
Max # of doses: 3
Weight: ≥ 25 kg
Route: NEB
Dose: 5mg
Dosing interval: 5-15 min PRN
Max # of doses: 3
Bronchoconstriction- Treatment Epinepherine
Route: IM
Concentration: 1mg/ml= 1:1000
Dose: 0.01mg/kg
Max single dose: 0.5mg
Max # of doses: 1
Bronchoconstriction- Treatment Dexamethasone
Route: PO/IM/IV
Dose: 0.5mg/kg
Max singl dose: 8mg
Max # of doses: 1
Bronchoconstriction- Clinical Considerations
Epi should be the first med administered if the pt is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter.
Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health.
When administering salbutamol MDI, the rate of administration should be 100 mcg approx. every 4 breaths.
A spacer should be used when administering salbutamol MDI.
Mod to Severe Allergic Rx.- Indications
Exposure to a probable allergen
AND
Signs and symptoms of a moderate to severe allergic reaction (including anaphylaxis)
Mod to Severe Allergic Rx.- Conditions Epinepherine
FOR ANAPHYLAXIS ONLY
Mod to Severe Allergic RX.- Conditions Diphenhydramine
Weight: ≥ 25 kg
Mod to Severe Allergic Rx.- Epinepherine Contraindications
Allergy or sensitivity to epinepherine
Mod to Severe Allergic Rx.- Diphenhydramine Contraindications
Allergy or sensitivity to diphenhyramine
Mod to Severe Allergic Rx.- Treatment Epinepherine
Route: IM
Concentration: 1mg/ml=1:1000
Dose: 0.01mg/kg
Max single dose: 0.5mg
Dosing interval: 5 min
Max # of doses: 2
Mod to Severe Allergic Rx.- Treatment Diphenhydramine
Weight: ≥ 25 to < 50 kg
Route: IV/IM
Dose: 25 mg
Max single dose: 25 mg
Max # of doses: 1
Weight: ≥ 50 kg
Route: IV/IM
Dose: 50 mg
Max single dose: 50 mg
Max # of doses: 1
Mod to Severe Allergic Rx.- Clinical Considerations
Epinepherine administration takes priority over IV access.
Croup- Indications
Current history of URTI
AND
Barking cough or recent history of barking cough
Croup- Conditions Epinepherine
Age: ≥ 6 months to < 8 years
HR: <200 bpm
Other: Stridor at rest
Croup- Conditions Dexamethasone
Age: ≥ 6 months to < 8 years
LOA: unaltered
Other: mild, moderate to severe croup
Croup- Contraindications Epinepherine
Allergy or sensitivity to epinepherine
Croup- Contraindications Dexamethasone
Allergy or sensitivity to steroids
Steroids received within the last 48 hours
Unable to tolerate oral meds
Croup- Treatment Epinepherine
Weight: <10 kg
Route: NEB
Concentration: 1mg/ml=1:1000
Dose: 2.5mg
Max single dose: 2.5mg
Max # of doses: 1
Weight: ≥ 10 kg
Route: NEB
Concentration: 1mg/ml=1:1000
Dose: 5 mg
Max single dose: 5 mg
Max # of doses: 1
Croup- Treatment Dexamethasone
Route: PO
Dose: 0.5 mg/kg
Max single dose: 8 mg
Max # of doses: 1
Supraglottic Airway- Indications
Need for ventilatory assistance or airway control
AND
Other airway management is ineffective
Supraglottic Airway- Conditions
Other: Absent gag reflex
Supraglottic Airway- Contraindications
Airway obstructed by a foreign object
Known esophageal disease (varices)
Trauma to the oropharynx
Caustic ingestion
Supraglottic Airway- What is the maximum number of insertion attempts?
2
Supraglottic Airways- Primary and Secondary methods of confirmation
Primary- ETCO2 (waveform capnography)
Secondary- ETCO2 (non waveform device), auscultation, chest rise
Supraglottic Airways- Clinical Considerations
An attempt at supraglottic airway insertion is defined as the insertion of a supraglottic airway into the mouth. Confirmation of supraglottic airway should use ETCO2 (Waveform capnography). If waveform capnography is not available or is not working, then at least 2 secondary
methods must be used.
N/V- Indications
Nausea or vomiting
N/V- Conditions Ondansetron
Weight: ≥25 kg
LOA: unaltered
N/V- Conditions Dimenhydrinate
Age: < 65 years
Weight: ≥25 kg
LOA: unaltered
N/V- Contraindications Ondansetron
Allergy to ondansetron
Prolonged QT syndrome
Apomorphine use
N/V- Contraindications Dimenhydrinate
Allergy or sensitivity to dimenhydrinate
Overdose on antihistamines or anticholinergics or tryclic antidepressant
Co-administration of diphenhydramine
N/V- Treatment Ondansetron
Route: PO
Dose: 4mg
Max single dose: 4mg
Max # of doses: 1
N/V- Treatment Dimenhydrinate
Weight: ≥25 kg to <50 kg
Route: IV/IM
Dose: 25mg
Max single dose: 25mg
Max # of doses: 1
Weight: ≥50 kg
Route: IV/IM
Dose: 50 mg
Max single dose: 50 mg
Max # of doses: 1
N/V- Clinical Considerations
Prior to IV administration, dilute dimenhydrinate (concentration of 50mg/1ml) 1:9 with normal saline or D5W. If IM, do not dilute.
If a patient has received Ondansetron and has no relief of their nausea & vomiting symptoms after 30 mins, dimenhydrinate may be considered.
Opioid Toxicity- Indications
Altered LOC
AND
Resp. depression
AND
Inability to adequately ventilate OR persistent need for ventilation
AND
Suspected overdose
Opioid Toxicity- Conditions Naloxone
Age: ≥ 24 hours
LOA: altered
RR: < 10 breaths/min
Opioid Toxicity- Contraindications Naloxone
Allergy or sensitivity to naloxone
Opioid Toxicity- Treatment Naloxone
Route: IV
Dose: up to 0.4mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 3
Route: IM
Dose: 0.4mg
Max single dose: 0.4mg
Dosing interval: 5 min
Max # of doses: 3
Route: IN
Dose: 2-4mg
Max single dose: 2-4mg
Dosing interval: 5 min
Max # of doses: 3
Route: SC
Dose: 0.8mg
Max single dose: 0.8mg
Dosing interval: 5 min
Max # of doses: 3
Opioid Toxicity- Clinical Considerations
Upfront aggressive management of the airway is paramount and the initial priority.
If no response to initial treatment; consider patching for further doses.
If the pt does not respond to airway management and the administration of naloxone, glucometry should be considered.
Combative behaviour should be anticipated following naloxone administration and paramedics should protect themselves accordingly, thus the importance of gradual titrating (if given IV) to desired clinical effect; RR: ≥ 10, adequate airway and ventilation, not full alertness.
Adrenal Crisis- Indications
A patient with primary adrenal failure who is experiencing clinical signs of adrenal crisis.
Adrenal Crisis- Conditions Hydrocortisone
Paramedics are presented with a vial of hydrocortisone for the identified patient
AND
Age-related hypoglycemia OR
GI symptoms (vomiting, diarrhea, abdo pain) OR
Syncope
OR
Temp ≥ 38 degrees or suspected/history of fever OR
Altered LOA OR
Age-related tachycardia OR
Age-related hypotension
Adrenal Crisis- Contraindications Hydrocortisone
Allergy or sensitivity to hydrocortisone
Adrenal Crisis- Treatment Hydrocortisone
Route: IM/IV
Dose: 2mg/kg
Max single dose: 100mg
Max # of doses: 1
Emergency Childbirth- Indications
Pregnant patient experiencing labour OR
Post-partum patient immediately following delivery and/or placenta
Emergency Childbirth- Conditions Oxytocin
Age: Childbearing years
SBP: <160 mmHg
Other: Postpartum delivery
AND/OR
Placental delivery
Emergency Childbirth- Contraindications Oxytocin
Allergy or sensitivity to oxytocin
Undelivered fetus
Suspected or known pre-eclampsia with current pregnancy
Eclampsia (seizures) with current pregnancy
≥ 4 hours post placenta delivery
Emergency Childbirth- Treatment Oxytocin
Route: IM
Dose: 10 units
Max single dose: 10 units
Max # of doses: 1
IV and Fluid Therapy- Indications
Actual or potential need for intravenous medication OR fluid therapy
IV and Fluid Therapy- Conditions IV Cannulation
Age: ≥ 2 years
IV and Fluid Therapy- Conditions 0.9% NaCl Fluid Bolus
Age: ≥ 2 years
SBP: hypotensive
IV and Fluid Therapy- Contraindications IV Cannulation
Suspected fracture proximal to the access site
IV and Fluid Therapy Contraindications 0.9% NaCl Fluid Bolus
Fluid Overload
IV and Fluid Therapy- 0.9% NaCl Maintenance Infusion
Age: ≥ 2 years to < 12 years
Route: IV
Infusion 15 ml/hr
Age: ≥ 12 years
Route: IV
Infusion 30-60 ml/hr
IV and Fluid Therapy- Mandatory Patch Point
Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive patients ≥ 2 years to < 12 years with suspected DKA
IV and Fluid Therapy- Treatment 0.9% NaCl Fluid Bolus
Age: ≥ 2 years to < 12 years
Route: IV
Infusion: 20 ml/kg
Reassess every: 100 ml
Max volume: 2000 ml
Age: ≥ 12 years
Route: IV
Infusion: 20 ml/kg
Reassess every: 250 ml
Max volume: 2000 ml
IV and Fluid Therapy- Clinical Considerations
Microdrips and/or volume control administration sets should be considered when IV access is indicated for patients < 12 years of age.
An IV fluid bolus may be considered for a patient who does not meet trauma TOR criteria, where it does not delay transport and should not be prioritized over management of other reversible causes.
Cardiogenic Shock- Indications
STEMI positive 12 lead ECG
AND
Cardiogenic shock
Cardiogenic Shock- Conditions 0.9% NaCl Fluid Bolus
Age: ≥ 18 years
SBP: hypotensive
Other: chest auscultation
Cardiogenic Shock- Contraindications 0.9% NaCl Fluid Bolus
Fluid Overload
SBP ≥ 90 mmHg
Cardiogenic Shock- Treatment 0.9% NaCl Fluid Bolus
Route: IV
Infusion: 10 ml/kg
Reassess every: 250 ml
Max Volume: 1000 ml
CPAP- Indications
Severe resp. distress
AND
signs and/or symptoms of acute pulmonary edema or COPD
CPAP- Conditions
Age: ≥ 18 years old
RR: tachypnea
SBP: normotension
Other: Spo2 < 90% or accessory muscle use
CPAP- Contraindications
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
CPAP- Treatment
Initial Setting: 5 cm H2O or equivalent flow rate of device as per RBHP direction
Titration increment: 2.5 cm H2O or equivalent…
Titration interval: 5 min
Max setting: 15 cm H2O or equvalent…
CPAP- Consider increasing FiO2 (if available)
Initial FiO2: 50-100%
FiO2 increment (if available on device): Spo2 <92% despite treatment and/or 10 cm H2O pressure or equivalent flow rate of device as per RBHP direction
Max FiO2: 100%
