Level of Consciousness & Procedural Flashcards
Hypoglycemia
IND - COND - CONTRA
Hypoglycemia Medical Directive
TX 1
Hypoglycemia Medical Directive
TX 2 & CC
Hypoglycemia Medical Directive
Companion Document
The directive includes a fairly broad set of patient presentations to enable the Paramedic to use the glucometer to rule in or rule out blood sugar related event.
Blood glucometry is performed using the Paramedic’s supplied device.
Capillary Blood Sample Sites:
Finger tips and the heel of the foot (pediatric patients who have not begun to walk).
Samples cannot be obtained from the flash chamber of an IV catheter. Not only is the practice inherently unsafe, but in involves manipulating a medical device for purposes that it is not intended for and the blood sample obtained is not a capillary sample.
Premixed D 10 W should be run as a piggyback onto an existing IV line to ensure accurate dose administration.
If Glucagon was initially administered with no patient improvement and an IV is subsequently established (if certified and authorized); perform a second glucometry and if the patient remains hypoglycemic administer dextrose regardless of the elapsed time since glucagon administration.
Preparation of 25% Solution:
Waste 25 ml of the preload and replace the 25 ml with sterile water or saline. The will create a 12.5 g / 50 ml solution. Administer 0.5 g/kg for the gram dose of 2 ml / kg for fluid volume and administer no more than 40 ml.
Preparation of 10% Solution:
To prepare a 10 % solution: Waste 40 ml of the preload and replace the 40 ml with sterile water or saline. This will create a 5g / 50 ml solution. Administer 0.2 g / kg for the gram dose or 2 ml / kg for fluid volume and administer no more than 50 ml.
Refusal of Service:
Should the patient initiate a refusal of transportation post treatment, a repeat glucometry must be performed along with a full set of vital signs. The patient (along with family or bystanders) requires a clear explanation of the risks involved, what signs to be vigilant of, and instructions to eat complex carbohydrates. This is to be recorded in the procedures section of the ACR/ePCR as well as an appropriately completed refusal of care section. Paramedics should always attempt to ensure a responsible adult remains with the patient prior to leaving the scene. Patients who are deemed to not have decision-making capacity will need to be signed off by a substitute decision maker and left with that responsible person. Hypoglycemia due to oral hypoglycemic agents or long-acting insulin is associated with the need for ongoing IV therapy, hospital admission and poor outcomes (repeat EMS responses and death). Thus, these patients need to be advised of these risks.
Seizure Medical Directive
IND - COND - CONTRA
** Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be considered.
Seizure Medical Directive
Compantion Document
The indications have been simplified to describe an active generalized motor seizure. This implies the classic tonic clonic presentation (regardless of causation) and therefore excludes partial seizures, petit mals, Jacksonian, etc.
Most seizures are self-limiting. The applcation of this directive in intended for patients experiencing a seizure that is continuous or repetitive.
Contraindications list hypoglycemia - this is a specific reversible cause that is appropriate to correct prior to determining the need for midazolam.
Routes of Administration:
Midazolam has the widest variety of routes of administration to suit the varied presentations.
IV: best route to provide anti-seizure medication, but the administration and time required to secure the route can be difficult. When in place, midazolam should be administered over 1 - 2 minutes.
IM: easy access to large muscle groups with excellent blood, but the patient my be difficult to restrain. Consider sharp safety.
IN: rapid access to the circulation with no sharps to worry about. Spilt doses between nares.
Buccal: good absorptive surface and ease of administration. Consider the risk of aspiration.
Opioid Toxicity
IND - COND - CONTRA
Opioid Toxicity
TX - CC
Opioid Toxicity
Companion Document
The inability to adequately ventilate is a requirement to proceed with the application of this medical directive. The inability to adequately ventilate could apply to situations like moving a patient down a flight of stairs or the inability to ventilate during that time.
Contraindication lists uncorrected hypoglycemia - this is a specific cause that is appropriate to correct prior to determining the need for additional therapy.
Remember, Naloxone is ONLY being administered to improve respiratory status, NOT to improve LOA or for any other purpose.
The mandatory patch point has been removed.
Routes of Administration:
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. Specfic details for each subsequent route are included below:
IM
faster onset and shorter duration than via SC route
IN
rapid absorption
concern with proximity to the patient’s mouth (for safety)
no sharps
IV
smaller dose
virtually instantaneous effect
very short duration
ideal in the apneic patient
Note: IV Naloxone titration refers to administering only small increments of the 0.4 mg dose at a time to restore respiratory effort, but limit the rise in wakefulness.
The directive now allows for three (3) doses of naloxone, administered in ten (10) minute intervals by the SC, IM and IN routes, and immediately for the IV route.
In the setting of bystander asministered naloxone, the Paramedic should use his/her judement to determine the most appropriate patient care, being mindful of the potential risks (unmasking alternative toxidromes and those associated with the route of administration) with the administration of subsequent naloxone.
Suspected Adrenal Crisis
IND - COND
Suspected Adrenal Crisis
TX - CC
Suspected Adrenal Crisis
Companion Document
Patients with primary adrenal failure generally require little assistance from EMS, except in cases of stress when they can become critically ill; in which case they will require the administration of hydrocortisone. Hydrocortisone is not carried by paramedics.
Examples of stress may include, but are not limited to:
Hypoglycemia
Hypotension
Gastrointestinal issues
Fractures
If the patient presents with signs and symptoms consistent with the medical directive. AND his/her medication is available, a Paramedic may administer 2 mg/kg up to 100 mg IM/IV/IO/CVAD of hydrocortisone.
These patients should be transported to a receiving facility for additional care and follow up.
Procedural Sedation
IND - COND - CONTRA
Procedural Sedation
TX
Procedural Sedation
Companion Document
Indications have changed from “combative patient” to “combative ot violent or agitated behaviour that requires sedation for patient safety.
Ketamine has been added as an auxiliary medication (if available and authorized) of the medical directive for patients who present with suspected excited delirium or violent psychosis.
Ketamine is to be used only for patients with suspected excited delirium, violent psychosis. It will be unlikely that reversible causes such as hypoglycemia, hypoxia and hypotension can be ruled out due to combativeness of the patient in these situations. As such, a Mandatory Provinicial patch point mandates a BHP patch when unable to rule out reversible causes. Reversible causes should be considered and evaluated as soon as possible to do so.
Patients who require a volume greater than 5ml will require teo separate injections in different limbs to achive a desired a dose. Separate injections to achive a single dose should be administered within the closest, safest timeframe as possible to each other. The vastus lateralus muscle can accomidate up to 5 ml per injection per leg.
If ketamine emergence reaction develops, a BHP patch is required if futher sedation is required.
Paramedics should consider establishing IV access once the patient is sedated.
Once sedated with ketamine, paramedics should diligently monitor the patient utilizing a cardiac monitor, SPo2 monitor and if available ETCO2 monitor to continuosly monitor the clinical status of the patient who is in a dissociative state.
Like ketamine, prior to sedating patients with midazolam, any possible reversible causes are to be addressed or ruled out. If the patient is combative to the point they cannot be assessed for reversible causes, patch to the BHP prior to treating with midazolam. Reversible causes should be considered and evaluated as soon as possible to do so.
The dosing range of midazolam enables the paramedic to use their clinical judgement to determine dose. The patient’s physical size is not always the best determinant of required dose.
Nausea / Vomiting
IND - COND - CONRTA
Nausea / Vomiting
TX - CC
Analgesia
IND - COND
Analgesia
CONTRA
ACE & IB
Analgesia
CONTRA
KET - MOR - FEN
Analgesia
TX
ACE & IB & KET
Analgesia
TX
MOR & FEN
Electronic Control Device Probe Removal
IND - COND - CONTRA - TX
Electronic Control Device Probe Removal
CC
Home Dialysis Emergency Disconnect
IND - COND - CONTRA
Home Dialysis Emergency Disconnect
TX - CC
Emergency Childbirth
IND - COND
* no CONTRA
Emergency Childbirth
TX - Delivery
Emergency Childbirth
TX - Umbilical cord
Emergency Childbirth
TX - Uterine massage & CC
