Medical Cardiac Arrest Medical Directive

Question 1

Medical Cardiac Arrest Medical Directive

Answer 1

A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if authorized.

Question 2

Indications

Answer 2

Non-traumatic cardiac arrest

Question 3

Conditions - CPR

Answer 3

Age: n/a
LOA: Altered
HR: n/a
RR: n/a
SBP: n/a
Other: Performed in 2 minute intervals

Question 4

Conditions - Manual Defibrillation

Answer 4

Age: ≥30 days
LOA: Altered
HR: n/a
RR: n/a
SBP: n/a
Other: VF OR pulseless VT

Question 5

Conditions - AED Defibrillation

Answer 5

Age: ≥30 days
LOA: Altered
HR: n/a
RR: n/a
SBP: n/a
Other: Defibrillation indicated

Question 6

Conditions - Epinephrine

Answer 6

Age: n/a
LOA: Altered
HR: n/a
RR: n/a
SBP: n/a
Other: Anaphylaxis suspected as causitive event

Question 7

Conditions - Medical TOR

Answer 7

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

Question 8

Contraindications - CPR

Answer 8

Obviously dead as per BLS PCS

Meet conditions of Do Not Resuscitate (DNR) Standard

Question 9

Contraindications - Manual Defibrillation

Answer 9

Rhythms other than VF or pulseless VT

Question 10

Contraindications - AED Defibrillation

Answer 10

Non-shockable rhythm

Question 11

Contraindications - Epinephrine

Answer 11

Allergy or sensitivity to epinephrine

Question 12

Contraindications - Medical TOR

Answer 12

Arrest thought to be of non-cardiac origin

Question 13

Treatment

Answer 13

• Consider CPR
• Consider Manual defibrillation (if available and authorized)
• Consider AED defibrillation (if not using manual defibrillation)
• Consider epinephrine (only if anaphylaxis is suspected as causative event)
• Mandatory Provincial Patch Point

Question 14

Consider Manual defibrillation (if available and authorized)

Answer 14

Age ≥30 days to <8 years:
Dose: 1 defibrillation
Initial dose: 2 J/kg
Subsequent dose(s): 4 J/kg
Dosing interval: 2 min
Max. # of doses: 4

Age ≥8 years
Dose: 1 defibrillation
Initial dose: As per BH/manufacturer
Subsequent dose(s): As per BH/manufacturer
Dosing interval: 2 min
Max. # of doses: 4

Question 15

Consider AED defibrillation (if not using manual defibrillation)

Answer 15

Age ≥30 days to <8 years:

With Pediatric Attenuator Cable:
Dose: 1 defibrillation
Max. single dose: As per BH/manufacturer
Dosing interval: 2 min
Max. # of doses: 4

Without Pediatric Attenuator Cable:
Dose: 1 defibrillation
Max. single dose: As per BH/manufacturer
Dosing interval: 2 min
Max. # of doses: 4

Age ≥8 years:
Dose: 1 defibrillation
Max. single dose: As per BH/manufacturer
Dosing interval: 2 min
Max. # of doses: 4

Question 16

Consider epinephrine (only if anaphylaxis is suspected as causitive event)

Answer 16

Route: IM
Concentration: 1 mg/mL = 1:1000
Dose: 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval: n/a
Max # of doses: 1
*The epinephrine dose may be rounded to the nearest 0.05 mg

Question 17

Mandatory Patch Point

Answer 17

Patch to BHP for authorization, following the 3rd analysis, to consider Medical TOR (if applicable). If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate receiving facility following ROSC or the 4th analysis.

Question 18

Clinical Considerations

Answer 18

Consider very early transport after the 1st 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.

Similarly, plan for extrication and transport for patients with refractory ventricular fibrillation and pediatric cardiac arrest (after 3 analyses), ensure quality CPR can be continued.

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.

Follow the Deceased Patient Standard once TOR has been implemented.

Question 19

Defibrillation Joule Settings

Answer 19

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