Medical Cardiac Arrest Medical Directive

Question 1

What are the indications for the medical cardiac arrest MD?

Answer 1

Non-traumatic cardiac arrest.

Question 2

Primary Clinical Considerations

When should we consider very early transport (after a minimum of 1 analysis) under the medical cardiac arrest directive?

Answer 2

In the following settings, consider very early transport after a minimum of one analysis
(and defibrillation if indicated) once an egress plan is organized:
1. pregnancy presumed to be ≥ 20 weeks gestation (fundus above umbilicus,
ensure manual displacement of uterus to left);
2. hypothermia;
3. airway obstruction;
4. non-opioid drug overdose/toxicology, and;
5. or other known reversible cause of arrest not addressed.

Question 3

What is refractory or pulseless VF?

Answer 3

Refractory VF or pulseless VT is defined for the purpose of this directive, as persistent VF or pulseless VT after 3 consecutive shocks.

Question 4

When should we transport pt’s who have refractory or pulseless VF?

Answer 4

For patients in refractory VF or pulseless VT, transport of the patient should begin after the third consecutive shock.

Question 5

What are the conditions for CPR?

Answer 5

LOA - altered
Other - performed in two minute intervals

Question 6

What are the conditions for manual defibrillation?

Answer 6

Age ≥24 hours
LOA - Altered
Other - VF OR pulseless VT

Question 7

What are the considerations for epi administration under the Medical Cardiac Arrest MD?

Answer 7

Age ≥24 hours
LOA - Altered
Other - Anaphylaxis suspected
as causative event

Question 8

What are the conditions for a Medical TOR?

Answer 8

Age ≥16 years
LOA - Altered
Other - Arrest not witnessed by paramedic AND No ROSC AND 20 minutes of resuscitation AND No defibrillation
delivered

Question 9

What are the contraindications for CPR?

Answer 9

• Obviously dead as per BLS PCS
• Meet conditions of the BLS PCS Do Not Resuscitate (DNR) Standard

Question 10

What are the contraindications for manual defibrillation?

Answer 10

Rhythms other than VF or pulseless VT

Question 11

What are the contraindications for epi administration?

Answer 11

Allergy or sensitivity to EPINEPHrine

Question 12

What are the contraindications for a Medical TOR?

Answer 12

• Known reversible cause of the arrest unable to be addressed
• Pregnancy presumed to be ≥ 20 weeks gestation
• Suspected hypothermia
• Airway obstruction
• Non-opioid drug overdose/toxicology

Question 13

What is the manual defibrillation dosage for patients ≥24 hours to <8 years?

Answer 13

Initial dose - 2 J/kg
Subsequent doses - 4 J/kg
Dosing interval - 2 minutes
Max # of doses - N/A

Question 14

What is the manual defibrillation dosage for patients ≥8 years?

Answer 14

Dose - as per RBHP/manufacturer
Interval - 2 minutes
Max # of doses - N/A

Question 15

What is the dose of epi under the medical cardiac arrest MD?

Answer 15

Route - IM
Concentration - 1 mg/mL = 1:1,000
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 16

What is the mandatory provincial patch point for?

Answer 16

• Patch to consider Medical TOR (if applicable).
• If the patch fails or if Medical TOR does not apply, transport to the closest appropriate hospital following ROSC or 20 minutes of resuscitation without ROSC.
• Patch early (e.g. following the 4th analysis) to consider TOR if there are extenuating circumstances surrounding egress, prolonged transport or significant clinical limitations where the paramedic considers ongoing resuscitation to be futile.

Question 17

What are the clinical considerations for the medical cardiac arrest directive?

Answer 17

• Consider regional base hospital advanced airway strategy (e.g. SGA medical directive) where more than OPA/NPA and BVM is required.
• There is no clear role for routine administration of naloxone in confirmed cardiac arrest.
• The BHP might not authorize TOR even though the patient meets TOR rule. Factors may include: location of the patients, EtCO2, age, bystander witnessed, bystander CPR, transportation time, and unusual cause of cardiac arrest such as electrocution, hanging, and toxicology.
• The BHP may authorize TOR even though the patient does not meet the TOR rule. Factors that may be taken into account include extenuating egress limitations,
  prolonged transport, caregiver wishes, existence of DNR confirmation form, and
  underlying end stage progressive illness.