EMRG 1300 Midterm Review Flashcards
What are the indications for IV and fluid therapy medical directive?
- Actual or potential need for intravenous medication OR fluid therapy
What are the conditions for IV cannulation medical directive?
- Age= >2 yrs
What is the condition for 0.9% NaCl fluid bolus medical directive?
- Age= >2 yrs
- SBP= hypotension
What are the contraindications for IV cannulation?
- Suspected fracture proximal to the access site
What are the contraindications for 0.9% NaCl fluid bolus?
- Fluid overload
What is tx for 0.9% NaCl maintenance infusion? (Age- >2 yrs to <12 yrs)
- Route= IV
- Infusion= 15ml/hr
What is tx for 0.9% NaCl maintenance infusion? (Age->12 yrs)
- Route= IV
- Infusion= 30-60ml/hr
What is the mandatory provincial patch point?
- Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive pt’s >2yrs to <12 yrs with suspected DKA
What is tx for 0.9% NaCl fluid bolus? (Age >2 yrs to <12 yrs)
- Route= IV
- Infusion= 20ml/kg
- Reassess every= 100ml
- Max. volume= 2000 ml
What is tx for 0.9% NaCl fluid bolus? (Age >12 yrs)
- Route= IV
- Infusion= 20ml/kg
- Reassess every= 250ml
- Max. volume= 2000ml
Who is the max volume lower for?
- Cardiogenic shock and ROSC
What does “PCP Assist IV” let a PCP do?
- Authorizes a PCP to cannulate a peripheral IV at the request and under the direct supervision of an ACP.
- The pt must require a peripheral IV in accordance with the indications listed in this Medical Directive.
- PCPs authorized for PCP Assist IV are not authorized to administer IV fluid or medication therapy
When can a IV fluid bolus be considered in Cardiac Arrest?
- An IV fluid bolus may be considered for a pt who doesn’t meet trauma TOR criteria, where it does not delay transport & shouldn’t be prioritized over management of other reversible causes
What is considered to be hypotensive?
- 90 mmHg ot under
What does “PCP Autonomous IV” let a PCP do?
- Is authorization for a PCP to independently cannulate an IV according to the IV and fluid therapy medical directive- Auxillary.
- PCPs authorized in PCP Autonomous IV are authorized to administer IV therapy according to applicable Medical Directives`
What are the 3 indications to IV therapy?
- Administer fluids, TKVO
- Administer drugs
- Obtain specimens for laboratory determinations
What are the 2 administration sets?
- Macro & Micro drip sets
What are the macro drip sets?
- 10, 15, 20 gtts/ml
What are the micro drip sets?
- Always 60 gtts/ml
What are macro drip sets good for?
- Are the most commonly utilized admin
- Effective for TKVO & large fluid admin (bolus)
What are the 4 reasons to use a microdrip set?
- To deliver meds over a long period of time
- Assist in precise measurement of meds
- To control the amount of fluid
- To control fluid overload in certain pts
What are crystalloids?
- Dissolving crystals such as salts & sugars in water
- Contains no proteins
- Diffuse across the capillary walls into the tissue
ex. Normal saline & lactated ringers
What are colloids?
- Contain large molecules such as protein
- Don’t pass through the capillary membrane as readily
ex. volume expanders, plasma substitutes, plasma, packed red blood cells and whole blood, plasmanate, dextran, hetastarch
What does hypotonic mean?
- Lower solute in the solution then the cell- causes water to go into the cell
What does hypertonic mean?
- Higher solute in the solution causes water to leave the cell
What does isotonic mean?
- Equal inside and outside the cell
What can PCP’s monitor without an Escort?
- NS, Ringers, D5W, Potassium chloride, Thiamine & multivitamins, Saline locks
What requires an Escort?
- Blood products, Medication being infused, IV pumps, Central lines, Jugular lines
A Paramedic shall monitor an IV line for a Pt who has:
- An IV line to keep the vein open, as follows;
a. The flow rate to maintain IV patency for a pt <12 yrs of age is 15ml/hr of any isotonic crystalloid solution
b. The flow rate to maintain IV patency for a pt >12 yrs of age is 30-60ml/hr of any isotonic crystalloid solution; or - An IV line for fluid replacement with,
a. A max flow rate infused of up to 2 ml/kg/hr to a max of 200ml/hr
b. Thiamine, multivitamin preparations
c. Drugs with his/her level of certification, or
d. potassium chloride (KCl) for pt’s >18 yrs of age, to a max of 10mEq in a 250ml bag
When should a Paramedic request a medically responsible escort for an IV?
a. Being used for blood or blood product administration
b. Administering potassium chloride to a pt who is <18 yrs of age
c. administer meds that aren’t detailed in paragraph 2
d. Requires electronic monitoring or uses a pressurized IV fluid infuser, pump, or central venous line
e. for a neonate or peds pt <2 yrs of age
What is the procedure for IV maintenance pre-transport?
- Confirm physician written IV order with sending facility staff
- Determine IV solution, IV flow rate, catheter gauge, catheter length, and cannulation site
- Note condition of IV site prior to transport
- Confirm amount of fluid remaining in bag
- Determine amount of fluid required for complete transport time and obtain more fluid if applicable; and
- Document all pre-transport IV info on the ACR
What is the procedure for IV maintenance during transport?
- Monitor and maintain IV at the prescribed rate, this may include changing the IV bag as required
- If the IV becomes dislodged or interstitial, discontinue the IV flow and remove the catheter with particular attention to aseptic technique; and
- Confirm condition of catheter if removed
When should the IV bag be changed?
- At approx 150 mls of solution remaining
What are the joule settings for >24hrs to <8 yrs?
- Initial Dose= 2J/kg
- Subsequent Dose= 4J/kg
- Interval= 2 mins
What are the joule settings for a Zoll? (>8 yrs)
- 120J, 150J, 200J
What are the joule settings for a Lifepack? (>8 yrs)
- 200J, 300J, 360J
In what situations should you consider very early transport?
After a min of one analysis (and defib if indicated) once an egress plan is organized
- Pregnancy presumed to be >20 weeks gestation (fundus above umbilicus ensure manual displacement of uterus to left)
- Hypothermia
- Airway obstruction
- Non-opioid drug overdose/ toxicology, or
- Other known reversible cause of arrest not addressed
What are the indications for Medical Cardiac Arrest Medical Directive?
- Non-traumatic cardiac arrest
When do we give epi in a cardiac arrest?
- Only if anaphylaxis is suspected as causative event
What are the indications for a Medical TOR?
- Age= >16 yrs
- Arrest not witnessed by paramedic AND
- No ROSC 20 mins of resuscitation AND
- No defib delivered
What are the contraindications of Medical TOR?
- Known reversible cause of the arrest unable to be addressed
- Pregnancy presumed to be >20 weeks gestation
- Suspected hypothermia
- Airway obstruction
- Non-opoid drug overdose/ toxicology
What are the indications of a Trauma Cardiac Arrest Medical Directive?
- Cardiac arrest secondary to severe blunt or penetrating trauma
What are the indications of a trauma TOR?
- Age= >16 yrs
- No palpable pulses AND
- No defib delivered AND
- Rhythm asystole AND
- No signs of life at any time since fully extricated OR signs of life when fully extricated with the closest ED >30 min transport time away OR
- Rhythm PEA with the closest ED >30 min transport time away
What are the contraindications for a Trauma TOR?
- Age <16 yrs
- Defib delivered
- Signs of life at any time since fully extricated medical contact
- Rhythm PEA and closest ED <30 min transport time away
- Pts with penetrating trauma to torso or head/ neck and Lead Trauma hospital <30 min transport time away
What should we do after 20 mins and no TOR applicable?
- Transport and run the arrest enroute
- Bring appropriate resources with you
- Ensure pt is covered when extricating from the house if possible
- Transport to closest ER, CTAS 1, code 4
- Patch enroute
During transport, if you have a ROSC and the pt. re arrests enroute?
- Resume CPR immediately
- Pull over
- Initiate an immediate rhythm interpretation
- Treat accordingly
- Cont transport to the ER
- 1 analysis and cont arrest en route
What life saving measures are outlined in the Cardiopulmonary Resuscitation?
- Chest compression
- Defibrillation
- Artificial ventilation
- Insertion of OPA, NPA, SGA
- Endotracheal intubation
- Transcutaneous pacing
- Advanced resuscitation drugs
What does Do Not Resuscitate mean in the BLS?
Means that the paramedic will not initiate any of the interventions listed in the definition of CPR
What will a Valid MOH DNR Confirmation Form include on it?
- The name of the pt (surname & first name)
- A checkbox that has been checked to identify that on of the following condition has been met;a. A current plan of tx exists that reflects the pt’s expressed wish when capable, or consent of the SDM when the pt is incapable, that CPR not be included in the pt’s plan of tx
b. The physician’s current opinion is that CPR will almost certainly not benefit the pt and is not part of the plan of tx, and the physician has discussed this with the capable pt or the SDM when the pt is incapable - A checkbox that has been checked to identify the professional designation of the MD, RPN, RN, or RN [EC] who has signed the form
- Printed name of the MD, RPN, RN, or RN [EC] signing the Form
- A signature by the appropriate MD, RPN, RN, or RN [EC[
- The date that the form was signed, which must be the same as or precede the date of request for ambulance service
According to the general directive, when should a paramedic not initiate CPR?
- Upon obtaining a valid MOH DNR Confirmation Form
When should a paramedic initiate CPR on a pt?
- Pt has a valid DNR but is capable and expresses clearly a wish to be resuscitated
- Pt has a valid DNR but is capable and expresses a wish to be resuscitated in the event it’s needed, but the request is vague, incomplete or ambiugous such that it’s no longer clear what the wishes are
What does a deceased pt mean?
- Obviously dead
- Medical certificate of death, presented to the crew, in the form that is prescribed by the Vital Statistics Act (Ontario) and that appears on its face to be completed and signed in accordance with that Act;
- Without vitals signs and DNR present and valid
- VSA and the subject of TOR order was given by BHP
- VSA and the subject of a withhold resuscitation order given by BHP
What does expected death mean?
Death that was imminently anticipated generally as a result of a progressive end stage terminal illness
What indicates a pt to be obviously dead?
- Decapitation
- Transection
- Visible decomposition
- Putrefaction
- Grossly charred body
- Outpouring of cranial or visceral contents
- Rigor mortis
- Dependent lividity
In all cases of death, the paramedic shall:
- confirm the pt is deceased
- Ensure deceased pt is treated with respect & dignity
- Consider the needs of family members and provide compassion-informed decision making
- If suspected foul play, follow directions set out in the police notification standard
- Follow all directions issued by coroner or a person appointed by coroner
- If TOR occurs in the ambulance en route to a health care facility, advise CACC to contact the coroner, and cont to the destination unless otherwise directed
- For obvious death, note and document time at which the paramedic confirms the pt was deceased
In cases of unexpected death:
- In absence of police or coroner on-scene, advise dispatch
- If coroner indicates that they will attend the scene, paramedic shall remain at scene until coroner arrives and assumes custody. If coroner can’t make it, paramedic shall wait till someone appointed by the coroner arrives to claim custody
- If police on scene and have secured the scene, paramedic may depart scene
- Where at any time paramedic has not received any further direction from dispatch, paramedic shall request that dispatch seek direction from coroner, including if they can leave
In cases of expected death:
- Advise dispatch
- Make a request of a responsible person for the pt to the scene
- If responsible person can’t make it to the scene, advise dispatch and they will ask for a primary care practitioner or member of the palliative care team member
- If they can’t make it to the scene, paramedic’s shall wait on scene till they can
- If responsible person is on scene and paramedic’s believe that they will wait for a primary care practitioner or pallitative care member then they can depart
- If no one is able to make it to the scene, paramedic advise dispatch in which case police or coroner will come
- If coroner shows then paramedic will provide them with the circumstances of the death, paramedic will either be able to leave or have to wait
What happens to CPR when an advanced airway is placed?
Compression Ventilation ratio needs to change
- Compressions become continuous 2 min cycles and ventilations 1:6
When do you insert a supraglottic airway?
- Ensure that BLS airways are ineffective or there is a definitive need for more advanced airway (prolonged extrication or ineffective management with other devices)
- Ensure that the insertion doesn’t compromise the quality of other interventions
How can you confirm placement of SGA’s?
- ETCO2 waveform
Additionally, you can utilize:
1. Chest auscultation
2. Chest rise
3. Non waveform ETCO2
4. Tube misting
How does a King Lt work?
- Has a distal and proximal balloon to occlude the esophagus and oropharynx
- By occluding the esophagus, we prevent gastric inflation and aspiration
- Creates a direct route for oxygen/ ventilations to the trachea and lungs
What are the indications for SGA medical directive?
- Need for ventilatory assistance or airway control AND
- Other airway management is ineffective
What are the contraindication’s of a SGA?
- Airway obstructed by a foreign object
- Known espohageal disease (varices)
- Trauma to the oropharynx
- Caustic ingestion
What is the max number of attempts for a SGA?
- 2 insertion attempts per pt
What is the primary way of confirming SGA?
ETCO2 Waveform
What is the secondary way of confirming SGA?
- ETCO2 (Non-waveform device)
- Ascultation
- Chest rise
What is normal ETCO2?
- 35-45 mmHg
What is capnography?
- Represents the amount of CO2 in a exhaled breath
What is low ETCO2?
- Less than 35 mmHg
- Hyperventilation/ hypocapnia
What is high ETCO2?
- Less than 45 mmHg
- Hypoventilation/ hypercapnia
What is phase 1 of the waveform?
- A-B= Inspiratory baseline (low CO2 as its inspired air
What is the start of B waveform?
- Start of alveolar exhalation
What is phase 2 of the waveform?
- B-C= Exhalation upstroke (dead space gas mixes with lung gas)
What is phase 3 of the waveform?
- C-D= Continuation of exhalation (gas is all alveolar now, rich in CO2)
What is the end of D in the waveform?
- Is the end tidal value, peak concentration
What is phase 4 of the waveform?
- D-E+ start of inspiration
How does hyperventilating effect CO2 levels?
- When a person hyperventilates, their CO2 goes down
- Essentially they are blowing off large amounts due to the increased rate of breathing
What are some reasons their ETCO2 may be low?
- Cardiac arrest
- Hypotension
- Decreased cardiac output
- Cold
- Anxiety
- Bronchospasm
- Pulmonary embolus
How does hypoventilation effect CO2 levels?
- When a person hypoventilates, their CO2 goes up
- Essentially they are retaining CO2 due to the slow rate of breathing
What are some reasons their ETCO2 may be high?
- OD
- Sedation
- Intoxication
- Postictal states
- Head trauma
- Stroke
- Tiring CHF
- Fever
- Sepsis
- SOB
When cardiac output (blood flow) is normal:
- ETCO2 measures ventilation
When Cardiac Output (blood flow) is decreased:
- ETCO2 measures cardiac output
ETCO2 in Cardiac Arrest
- Cardiac arrest is the ultimate shock state
- There is no circulation and no metabolism and no CO2 production unless effective CPR is being done
- Capnography provides feedback on the quality of CPR
- ETCO2 of <10 mmHg indicates compressions are not deep enough or fast enough
- ROSC= spike in ETCOW
- Studies show that ETCO2 values <10 mmHg suggest pt’s will not survive
Why is their a sudden spike in ETCO2 when you get a ROSC?
- Large amounts of acidic blood are suddenly returned to the lungs and high amounts of CO2 diffuses into the alveoli
- This flood of CO2 causes a remarkable sharp rise in the ETCO2 levels to much higher than normal
