Cardiac/Circulaton

Question 1

MEDICAL ARREST DIRECTIVE - COND

Answer 1

Question 2

MEDICAL ARREST DIRECTIVE - CONT

Answer 2

Question 3

MEDICAL ARREST DIRECTIVE - Tx

Answer 3

Question 4

MEDICAL ARREST DIRECTIVE - Tx (3)

Answer 4

Question 5

MEDICAL ARREST DIRECTIVE - Tx (2)

Answer 5

Question 6

MEDICAL ARREST DIRECTIVE - Tx (4)

Answer 6

Question 7

MEDICAL ARREST DIRECTIVE - CONSIDERATIONS

Answer 7

The initial rhythm interpretation/analysis and defibrillation should be performed as soon as possible. Following the initial rhythm interpretation/analysis, additional rhythm interpretations/analyses should occur at two (2) minute intervals with a focus on the delivery of high quality chest compressions.

The energy settings used for defibrillation typically follow specific manufacturer guidelines and are supported by each respective RBH program.

As a general rule, Paramedics do NOT count pre-arrival interventions into their patient care. Care delivered prior to arrival can be “considered” and documented. However, in the setting of cardiac arrest where a medical TOR might apply, the Paramedics will complete three (3) rhythm interpretations themselves rather than “count” the number completed prior to their arrival.

In all cardiac arrest directives, manual defibrillation has been moved ahead of AED defibrillation in keeping with the preferred treatment being listed first.

Compressions during the charge should be considered to minimize the peri-shock pause.

When en-route and using manual interpretation, the ambulance should be stopped to minimize artifact and the risk of an inaccurate rhythm.

When en-route and using semi-interpretation, the ambulance must be stopped to minimize artifact and the risk of an inaccurate rhythm.

Supraglottic Airways (SGA):

The sequence listed for the advanced airways is deliberate, and based on:

1. The reduced importance on the airway as outlined AHA
2. The ease of supraglottice airway insertion vs. the complexity and risks of intubation.
3. The emphasis placed on minimally interrupted compressions.

and does not preclude the ACP from placing an Endotracheal Tube (ETT) when there is airway compromise of in a prolonged resuscitation. Intubation should normally not require compressions to be stopped or altered as any pause in compressions can lead to a poor outcome.

Once the ETT or supraglottic airway is placed, compressions should be continuous and ventilations provided asynchronously as a rate of 10 breaths/minute (one [1] every six [6] seconds).

Amiodarone:

Is the preferred antiarrhythmic medication if an alternate is available. This is demonstrated in the directive by the preferred medication being listed first.

Lidocaine:

Dosing (reference to weight and age) has been simplified.

Antiarrhythmic Administration:

Is Indicated in VF and pulseless VT that is refractory or recurrent following defibrillation.

Is indicated (if not previously maxed out) following the shock if the patient has been previously defibrillated or following a second defibrillation if none delivered previously.

Question 8

TRAUMA ARREST DIRECTIVE - COND

Answer 8

Question 9

TRAUMA ARREST DIRECTIVE - CONT

Answer 9

Question 10

TRAUMA ARREST DIRECTIVE - TX

Answer 10

Question 11

TRAUMA ARREST DIRECTIVE - COMPANION DOCUMENT

Answer 11

Fluid bolus is not listed in the directive and is not indicated.

The age difference between Medical and Truama TOR reflects the accepted definiftion of a pediatric trauma patient.

The 30 minute time reference is a reflection of transportation time and is relevant only in a PEA rhythms.

The flow chart had been updated to reflect the 2015 AHA guidelines.

Question 12

HYPOTHERMIC VSA

IND - CON - CONT

Answer 12

Question 13

HYPOTHERMIC VSA - TX

Answer 13

Question 14

HYPOTHERMIC VSA - COMPANION DOCUMENT

Answer 14

Pulse check:

The specific reference to a prolonged pulse check was removed because the AHA guidelines advocate for a 10 second pulse check.

When treating the hypothermic arrest, the focus is on passive rewarming and gentle handling. Epinephrine is not indicated in this setting.

The expectation is that these patients will be transported. The old adage says that “the patient is not dead until they are warm and dead”

Question 15

FBAO - IND - CON - CONT

Answer 15

Question 16

FBAO - TX

Answer 16

Question 17

FBAO - COMPANION DOCUMENT

Question 18

NEONATE - IND / C&C

Answer 18

Question 19

NEONATE - TX

Cardiac and pulse ox

Answer 19

Question 20

NEONATE -CD

Answer 20

Question 21

NEONATE CD 2

Answer 21

Question 22

ROSC IND / C&C

Answer 22

Question 23

ROSC - TX

12 lead & transport in parallel.

Answer 23

Question 24

ROSC DOPAMINE DRIP SHEET

Answer 24

Question 25

ROSC - CD

Answer 25

Oxygenation: Optimizing oxygenation and targeting Sp)2 of 94% to 98% (avioding 100%) will provide adequate oxygenation and will minimize vasoconstrction and the development of oxygen free radicals. Despite ideal Sp02 values, oxygen adminstration should be continued if the patient remains unstable.

There is insufficient evidence to support the routine use of an antiarrhythmic post ROSC.

Fluid Bolus and Dopamine Administration:

The fluid bolus precedes the adminstration of dopamine. If started, ensure time is allowed for the intervention to have effect and be evaluated prior to intiating dopamine. IO and CVAD have been added as appropriate routes for fluid administration.

Dopamine in ROSC may be administered to a patient greater than equal to 8 years of age. For symptomatic bradycardia and cardiogenic shock, the age for adminstration of dopamine is greater than or equal to 18 years of age.

Dopamine is optimally administered via a dedicated IV line, however if required, may be piggybacked onto a primary line.

When initiating dopamine, begin at 5 mcg/kg/min and increase incrementally.

Where it is electively discontinued, dopamine administration must be weaned slowly.

Therapeutic Hypothermia:

Is beneficial, however not in the prehospital setting and has therefore been removed.

ETCO2:

Post ROSC, the goal is to maintain ventilation at a rate of approximately ten (10) breaths per minute (or one [1] breath every six [6] seconds) and titrate to acheve an ETCO2 (with waveform capnograghy) 30 - 40 mmHg. Hyperventilation MUST be avoided, but be mindful not to hypoventilate in an attempt to artificially raise a low ETCO2 may reflect metabolic acidosis.

Fluid Therapy:

Regardless of the amount administered prior to ROSC and if chest auscultation is “clear”, a 10ml/kg fluid bolus may be administered to a maximum of 1000 ml targeting a SBP of greater than equal to 90 mmHg.

Question 26

Cardiac Ischemia - IND / CON

Answer 26

Question 27

Cardiac Ischemia - CONT

Answer 27

Question 28

Cardiac Ischemia - TX (1)

Answer 28

Question 29

Cardiac Ischemia TX (2)

Answer 29

Question 30

Cardiac Ischemia - C Doc

Answer 30

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.

While not specified, manual intrepretation of the 12 lead is preferred over a computer generated intrepretation.

In the event the 12 lead ECG indentifies an Inferior STEMI, a 15 Lead ECG (specifically V4R) is to be performed to rule in or out a right ventricular infarct. These patients are often preload dependent and the adminstration of Nitrocylcerin to these may cause significant hypotension.

ASA Adminstration:

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 is no care has been rendered prior to your arrival.

Nitroglycerin Administration:

Conditions for nitroglycerin use are: “a prior history OR an established IV”. An IV must be initiated prior to the administartion of nitroglycerin in first time suspected cardiac ischmia patients. If the patient already had an IV in place (outpatient), the IV would need to be assessed for patency and once confirmed, would allow for first time administration. This will only apply to the PCP(s) with Autonomous IV Certification.

Prior history is defined as previously authorized or prescribed to the paitent for use by certified Medical Doctor.

Nitroglycerin doses taken by the patient for their current ischemic episode should not be used to decide whether to administer morphine.

The Nitroglycerin canister should be considered a single patient use device.

Treatment with nitroglycerin has been revised. In the event of a STEMI positive patient, a maximum of 3 doses of nitroglycerin are to be administered. The research has indicated that nitroglycerin may cause adverse effects in the setting of STEMI.

Many patients who are at risk of having a cardiac event (MI) may also have a history of CHF and it can sometimes de 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 0.4 mg doses of nitrogylcerin is most appropriate. The reduced number of doses in STEMI reduces adverse outcomes associated with liberal nitroglycerin use. Also, a reminder that CPAP is appropriate for these patients should they meet the criteria outlines in the Continuous Positive Airway Pressure Medical Directive.

STEMI Positive:

Treatment with nitroglycerin had been revised. In the event of a STEMI positive patient, a maximum of 3 doses of nitroglycerin are to be administered. Research has indicated that nitroglycerin may cause adverse effects in the setting of STEMI.

In the seeting of right ventricular STEMI ( via V4R), no nitroglycerin is to be administered.

Phosphodiesterase Inhibitors:

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 (some known as erectile dysfuction drugs [EDD]): Viagra, Levitra, Cialis, Revatio, Sildenafil, Tadalafil, Vardenafil, Udenafil, and Avanafil, Lodenafil, Mirodenafil, Acetildenafil, Alidenafil, Benzamindenafil, Zaprinast, and Icariin (a natural product). This may not be an exhaustive list and was current as of the date written.

If myocardial ischemic symptoms/acute coronary syndromes resolve prior to the arrival of Paramedics, a decision to administer ASA will be made based on patient assessment and critical thinking.

Morphine is only to be considered following the third dose of nitrogylcerin (unless nitroglycerin is contraindicated) and where pain is severe in nature (greater than equal to 7).

If a patient’s vital signs fall outside the medical directive’s parameters (i.e. :hypotension) the patient can no longer receive that medication (nitro/morphine) even if the patient’s vitals signs return to acceptable ranges.

Question 31

Acute Cardiogenic Pulmonary Edema - IND - C -C

Answer 31

Question 32

Acute Cardiogenic Pulmonary Edema - TX

Answer 32

Question 33

Acute Cardiogenic Pulmonary Edema - CD

Answer 33

The noted listed above regarding the Cardiac Ischemia Directive are applicable to the Acute Cardiogenic Med as well.

The Condition requiring a prior history or an established IV has been removed. The dosing table is now crrect as written.

The maximum of 6 doses if of either 0.4 or 0.8 mg. The patient may not receive 6 doses for pulmonary edema and 6 more doses for cardiac ischemia symptoms should not co-exist.

Note that 15 lead acquisition and interpretation is not a requirement in this medical directive because Right Ventricular infarcts do not generally present with acute pulmonary edema.

Question 34

Cardiogenic Shock Medical Directive

IND - CON - CONT

Answer 34

Question 35

Cardiogenic Shock Medical Directive

Answer 35

Question 36

Cardiogenic Shock Medical Directive

Companion Document

Answer 36

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.

The directive specifies that fluid (if applicable) is to be used as a means to reverse hypotension prior to the administration of dopamine. IO and CVAD have been added as routes for fluid administration.

The clinical consideration: ‘contact BHP if patient is bradycardic’ is intended to allow Paramedic to use his/her judgement.

Question 37

Symptomatic Bradycardia Medical Directive

Indications and Conditions

Answer 37

Question 38

Symptomatic Bradycardia Medical Directive

Contraindications

Answer 38

Question 39

Symptomatic Bradycardia Medical Directive

Tx - CC

Answer 39

Question 40

Symptomatic Bradycardia Medical Directive

Companion Document

Answer 40

Hemodynamic instability refers specifically to hypotension (SBP < 90 mmHg) that requires pharmacologic or electrical inverventions(s).

All symptomatic patients that present with a heart rate of < 50 bpm are eligible for atropine administration if found to be hypotensive.

A fluid bolus may be administered to bradycardiac patients according to the IV and fluid bolus medical direcitve.

12 lead ECG should be obtained as early as possible.

Atropine is to be administered in the setting of sinus bradycardia, junctional bradycardia, atrial fibrillation, first degree block or second degree block type I. Futher, patients presenting in second degree type II or third degree block may receive a single dose of atropine while preparing pacing or if pacing unavailable or unsuccessful.

Transcutaneous pacing is to be intiated at a rate of 80 bpm with milliamps (mAmps) then increased to obtain electrical capture. Capture is highly variable depending on patient size, weight, pad placement, skin condition, etc. It is difficult to state the target values for capture, however 80 to 100 mAmps is common. If unable to gain capture at maximum mAmps, pacing should be discontinued. Treatment should not be discontinued if the patient responds and develops an improved blood pressure.

Pad placement for pacing should follow the cardiac monitor manufacturer’s recommendations but typically include anterior/posterior or sternum/apex.

Patients may receieve multiple interventions to maintain their heart rate and blood pressure. The treatment provided must be permitted time to take effect and to be evaluated before moving on to the next treatment.

Question 41

Tachydysrhythima Medical Directive

IND - COND

Answer 41

Question 42

Tachydysrhythima Medical Directive

CONTRA

Answer 42

Question 43

Tachydysrhythima Medical Directive

TX 1

Answer 43

Question 44

Tachydysrhythima Medical Directive

TX 2

Answer 44

Question 45

Tachydysrhythima Medical Directive

Companion Document

Answer 45

Specific to this directive, treatments do not necessarily follow the order in which they should be administered. The initial treatment choice will be bases on rhythm interpretation (narrow vs. wide) and hemodynamic stability.

Early lead II and 12 lead acquisitions will prove invaluable for determining the origin of the electrical impulses, the rhythm and the QRS durations.

Contraindications for Adenosine Administration:

Dipyridamole - brand name: Persantine.

Carbamazepine - brand name: Tegretol.

Bronchoconstriction research has shown that inhaled adenosine provokes bronchoconstriction in asthmatic individuals (but not in the control group) and is therefore a contraindication for administration.

Adenosine Therapy:

Has changed to 6 mg and 12 mg based on AHA guidlines findings that a second 12 mg dose is likely ineffective. No BHP patch is required for the administration of adenosine for narrow complex tachycardia.

Lidocaine Dosing:

Initial dose: 1.5 mg/kg to a max of 150 mg. The second and thrid doses are calculated as 0.75 mg/kg with the same maximum dose of 150 mg.

Lidocaine is limited to a maximum of 3 mg/kg total dosing via IV.

Topical doses of Lidocaine as administered in the intubation directive count towards a 5mg / kg total dose.

In the event the patient receives the maximum dose of Lidocaine and then experiences cardiac arrest, he/she will not receive futher doses of Lidocaine.

Question 46

Hyperkalemia Medical Directive

IND - COND - CONTRA

Answer 46

Question 47

Hyperkalemia Medical Directive

Tx

Answer 47

Question 48

Hyperkalemia Medical Directive

CC

Answer 48

Question 49

Hyperkalemia Medical Directive

Companion Document

Answer 49

This directive enables ACPs to treat patients experiencing life threatening hyperkalemia. A patch to the BHP is required.

Pre-Arrest Defined:

A patient presenting with one or more of:

Hypotension

Symptomatic bradycardia

Altered levels of awareness

Recognition of hyperkalemia can be improved by considering:

Patients most at risk:

Patients unable to excrete potassium, for example the chronic kidney disease patient on dialysis that may have missed treatment(s)

Conditions that may precipitate extracellular potassium shift such as crush syndrome, acid-base disturbances, prolonged status seizures, major burns or prolonged immobilization.

Signs and symptoms:

CNS: muscle twitches, cramps or paresthesia

GI: abdominal cramps, diarrhea or nausea/vomiting

CVS: progression to hypotension, decreased LOA, bradycardia or ECG changes.

ECG changes consistent with severe hyperkalemia:

Peaked T-waves, flattened P-waves, lengthened PR interval or widened QRS.

Progressive widening of WRS or bizarre QRS morphology such as sine-wave appearance.

Not all severe hyperkalemia manifests with all possible ECG changes. Consider the overall patient condition and risk factors and include these findings in your patch to the BHP.

Prehospital Goals in Hyperkalemia Treatment are focused on:

Electrophysiological effects of excessive extracellular potassium on myocardium. Calcium Gluconate stabilizes cardiac cell membranes and may prevent life-threatening dysrhythmias. In circumstances of severe hyperkalemia such as cardiac arrest, multiple administrations may be indicated. In the unstable hyperkalemia patient, calcium gluconate should always be the priority treatment. In cases of cardaic arrest due to hyperkalemia, patch to the BHP early. Routine treatments common in medical cardiac arrest management may not respond until calcium is administered.

Redistribution of extracellular potassium into the cells, Salbutamol in large doses may temporarily enhance potassium cellular uptake.

Question 50

Intravenous and Fluid Therapy

IND - CON - CONTRA

Answer 50

Question 51

Intravenous and Fluid Therapy

TX

Answer 51

Question 52

Intravenous and Fluid Therapy

CC

Answer 52

Question 53

Intravenous and Fluid Therapy

Companion Document

Answer 53

The contraindication of a suspected fracture may not seem obvious, but a lack of integrity in a bone may jeopardize the integirty of the associated vascular structures and may result in extravastion.

Pulmonary edema is a sign of fluid overload secondary to a fluid bolus. As such, frequent chest assessments are required.

The treatmetn line specifies “consider IV cannulation”. This may encompass upper and lower extremity veins depending on your Base Hospital’s authorization.

Mandatory Patch Point:

Is required before administering a fluid bolus to a diabetic patient < 12 years old, who is hypotensive and suspected of being in ketoacidosis. A patch is required so that the physician can carefully control the volume of fluid asministered to prevent cerebral edema.

CVAD:

Access is only for patients greater than or equal to 12 years of age and by Paramedics who are authorized by their RBH. To access a CVAD for patients < 12 years of age, a patch to the BHP is required.

Cardiogenic Shock and ROSC:

The maximum volume of NaCl is lower for patients in cardiogenic shock or with ROSC. The maximum volume in volume in those settings in 10 ml/kg or 1000 ml.

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.

Hypotension in pediatric patient (up to 10 years old) is based on the formula: SBP = 70 + (2 x age).

The references to macro, mini, and buretrol drip sets have been removed. Although the choice of drip sets have been left to service operators based on local requirements and RBH insight, some form of rate control must be utilized for patients less than 12 years of age to prevent accidental fluid overload.

External jugular access, while not stated in the directives, remains in the ACP scope of practice and is typically reserved for cardiac arrest.

Prior to initiating a fluid bolus, two blood pressures (of which one must be manually obtained) indicating hypotension are expected.

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.

Question 54

Adult Intraosseous

IND - COND - CONTRA

TX - consider

Answer 54

Question 55

Adult Intraosseous

Companion Document

Answer 55

This auxilliary directive requires serivce operator and Base Hospital advocacy, training and education prior to implementation.

“IV access in unobtainable” does not imply that you must attempt an IV and fail before preoceeding to the IO, but it must be considered. Documentation on the ACR to support the rationale to bypass the IV attemps will be expected.

Typical IO needles range from 15 - 18 gauge.

The typical insertion site is the proximal tibia. Other sites are dependent upon RBH approval and manufacturer recommendation.

Aspriation may be recommended as part of the procedural skill, but an inability to aspirate should be confirmed by testing patency by attempting to push fluid in.

Question 56

Pediatric Intraosseous

IND - COND - CONTRA

Answer 56

Question 57

Pediatric Intraosseous

Companion Document

Answer 57

“IV access is unobtainable” does not imply that you must attempt an IV and fail before preoceesing to the IO, but it must be considered. Documentation on the ACR to support the rationale to bypass the IV attempt will be expected.

The typical insertion site is the proximal tibia. Other sites are dependent on RBH approval.

Aspiration may be recommended as part of the precedural skill, but an inability to aspirate should be confirmed by testing patency by attempting to push fluid.

Typical IO needles range from 15 - 18 gauge.

Question 58

Central Venous Access Device

IND - COND - CONTRA

Answer 58

Question 59

Central Venous Access Device

Companion Document

Answer 59

The patient must be critically ill to access a CVAD device. This requirement is due to the associated risks involved with CVAD access.

The following are some examples of CVAD devices (not an exhaustive list):

Hickman: Central catheter inserted through the anterior chest wall.

Subcutaneous Implanted Port (SIP): Port that resides under the skin and requires the use of a Huber needle to access it.

Peripherally inserted Central Catheter (PICC): Located on the Patient’s upper arm, but is still direct to central circulation.

The steps for accessing a CVAD are very specfic. Please refer to provided skill sheets.