PCTH - ALS Intro (Auxiliary Directives)

Question 1

What are standing orders and who are they issued by?

Answer 1

Orders that allow paramedics to do medical acts delegated by a physician (comes from the Provincial Base Hospital Advisory Group)

Question 2

When would you use standing orders and what is the importance of them?

Answer 2

When patients fall outside of parameters of the BLS but may benefit from ALS PCS

Importance: allows us to give medications and go beyond BLS scope

Question 3

Base Hospital provides all the following except:

a) medical direction
b) leadership, advice, and training
c) Quality Assurance
d) CMEs (Continuing Medical Education)
e) Funding and equipment standards

Answer 3

e) Funding and equipment standards

Question 4

True or False. As long as you are certified by a Regional Base Hospital (RBH) Medical Director, you are allowed to perform ALS skills on or off duty provided you are within your scope of practice.

Answer 4

False. only while ON DUTY

Question 5

Heart rate vs pulse rate

Answer 5

Heart rate: BPM according to the cardiac monitor when applied

Pulse rate: rate that is felt when assessing patient

Question 6

According to the ALS PCS, bradycardia is considered less than _____ BPM.

Answer 6

50

Question 7

According to the ALS PCS, tachypnea is defined as ______ breaths/min.

Answer 7

≥28 breaths/min

Question 8

According to the ALS PCS, normotension is defined as a SBP of ______ .

Answer 8

≥100mmHg

Question 9

According to the ALS PCS, hypotension is defined as SBP of ______.

Answer 9

<90 mmHg

Question 10

According to the ALS PCS, describe the RR and HR ranges for pediatrics of the following ages.

1) 0-3 months

2) 3-6 months

3) 6-12 months

Answer 10

1) 0-3 months: RR 30-60; HR 90-180

2) 3-6 months: RR 30-60; HR 80-160

3) 6-12 months: RR 25-45; HR 80-140

Question 11

According to the ALS PCS, describe the RR and HR ranges for pediatrics of the following ages.

1) 1-3 yrs

2) 6 yrs

3) 10 yrs

Answer 11

1) 1-3 yrs: RR 20-30; HR 75-130

2) 6 yrs: RR 16-24; HR 70-110

3) 10 yrs: RR 14-20; HR 60-90

Question 12

Formula for calculating the weight (in kg) of a pediatric patient using their age.

Answer 12

weight (kg) = (age x 2) + 10

Question 13

Formula for calculating normotension in a pediatric patient based on age.

Answer 13

SBP ≥ (age x 2) + 90mmHg

ex. a 8 year old would have a SBP of 106 mmHg to be considered normotensive

Question 14

Formula for calculating hypotension in a pediatric patient based on age.

Answer 14

SBP < (age x 2) + 70mmHg

i.e. an 8 year old would be considered hypotensive if their SBP was < 86mmHg

Question 15

Identify the BGL parameters for pediatrics to be considered hypoglycemia.

Answer 15

< 2 yr: BGL < 3.0 mmol/L

≥2 yr: BGL < 4 mmol/L

Question 16

According to the ALS PCS, when discussing Level of Awareness (LOA), what does “altered” and “unaltered” mean?

Answer 16

“Altered”: GCS that is less than normal for the patient.

“Unaltered”: GCS that is normal for the patient. This may be a GCS <15.

Question 17

Define the following terms according to the ALS.

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 17

Indications: The general medical complaint/problem that the Medical Directive applies to.

Conditions: Clinical parameters that must be present for a procedure to be performed/medication to be administered (i.e. LOA, age, HR, SBP, etc.)

Contraindications: Clinical parameters that if they are present, you would not follow through with the Medical Directive.

Treatment: Description of the type of procedure to be performed or the dosing of a medication.

Clinical Considerations: Key clinical points that provide guidance to the proper performance of a procedure or administration of a medication.

*Take into account all of these ^ BEFORE and DURING the implementation of the directive.

Question 18

As per the ALS PCS, what are the five elements required for consent to treatment?

Answer 18

1) consent must be given by a person who is capable of giving consent with respect to treatment
2) consent must relate to the treatment
3) consent must be informed
4) consent must be given voluntarily
5) consent must not be obtained through misrepresentation or fraud

Question 19

As per the ALS PCS, what is considered informed consent to treatment?

Answer 19

Consent to treatment is informed if, before given by the person, they have:

1) received the following info that a reasonable person in the same circumstances would require in order to make a decision about the treatment:

• nature of the tx
• expected benefits of the tx
• material risks of the tx
• material side effects of the tx
• alternative courses of action
• the likely consequences of not having the treatment

2) received responses to their requests for additional information about those (above) matters

Question 20

Can you delegate a medical act to another paramedic/personnel?

Answer 20

Depends. If they are certified in being able to perform that medical act as well, then yes. Otherwise, you cannot do so

Question 21

Capacity to make decisions with respect to treatment is based on what?

Answer 21

The patient’s ability to:

1) understand the information that is relevant to making a decision about the treatment or alternatives being proposed;

AND

2) appreciate the reasonably foreseeable consequencecs of a decision or lack of decision with respect to treatment

Question 22

Do you have 24/7 access to BHP?

Answer 22

Duh of course. Injuries don’t wait til your BHP is on call.

Backup: HGH (will always have BHP available)

Question 23

When shall a paramedic patch to Base Hospital? (4)

Answer 23

1) a medical directive contains a mandatory provincial patch point;
2) a RBH introduces a mandatory provincial patch point;
3) for situations that fall outside of Medical Directives where paramedic believes patient may benefit from online medical direction that falls within the prescribed paramedic scope of practice;
4) there is uncertainty about the appropriateness of a medical directive, with in part or whole.

Question 24

Describe the differences between minor, major, and critical patient care deficiencies.

Answer 24

An action or lack of action (omission or comission) that:

Minor: may have affected patient care in a minor way. No direct effect on patient morbidity

Major: has the potential to affect patient morbidity, but the patient outcome would not be life threatening

Critical: has a clear effect on patient morbidity with potentially life threatening outcome

Question 25

Decribe the primary survey format for medical calls.

Answer 25

Question 26

Describe what a paramedic is assessing for when assessing the neck, chest, abdomen, and extremities in a medical call

Answer 26

Neck: JVD, accessory muscle use

Chest: intercostal indrawing, sternal retractions, pain/discomfort, adventitious sounds

Abdomen: pain/discomfort, pulsating masses

Extremities: peripheral edema, range of motion

Question 27

Describe the general format for medical calls.

Answer 27

• primary
• investigation of c/c
• initiate protocol
• package
• transport
• report

Question 28

12-lead Indications

Answer 28

• patient experiencing Sx consistent with that caused by cardiac ischemia OR experiencing symptoms that may be related to an underlying cardiac problem
• a patient whose 3 or 5 lead shows a rhythm which indicates the need for 12-lead acquisition
• directive dictates
• judgement
• repeating 12 leads

Question 29

To provide treatment prescribed in the Intravenous and Fluid Therapy Medical Directive, a PCP must be certified and authorized to what level?

Answer 29

PCP Autonomous IV level

Question 30

What are the 2 different reasons as to why we start IVs?

Answer 30

1) TKVO: To Keep Vein Open (for giving patient meds)
2) Bolus: for hypotensive (<90 SBP) patients; a predetermined amount of fluid given all at once to increase BP

• 20ml/kg
• can only give up to 250ml at a time before re-ax (i.e. BP and auscultation of lungs)

Question 31

Typical places to start IVs

Answer 31

elbows down (hand, wrist, elbow)

feet

Question 32

IV and Fluid Therapy Medical Directive

Indications

Conditions

Contraindications

Answer 32

Indications: Actual or potential need for IV meds or fluid therapy

Conditions:

• IV Cannulation: Age ≥2 y.o.
• 0/9% NaCl Fluid Bolus: ≥2 y.o.; hypotensive

Contraindications:

• IV Cannulation: suspected fracture proximal to the access site
• 0.9% NaCl Fluid Bolus: Fluid overload; SBP ≥90mmHg

Question 33

IV and Fluid Therapy Medical Directive

Treatment: 0.9% NaCl Maintenance Infusion

Answer 33

Age: ≥ 2 y.o. to < 12 (i.e. 2-11)

• Route: IV
• Infusion: 15mL/hr

Age: ≥ 12 y.o.

• Route: IV
• Infusion: 30-60mL/hr

Question 34

When is there a mandatory provincial patch point when considering fluid administration as per IV and Fluid Therapy Medical Directive?

Answer 34

Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive patient ≥2 years to <12 years with suspected DKA

Question 35

IV and Fluid Therapy Medical Directive

Treatment: 0.9% NaCl Fluid Bolus

Answer 35

Age: ≥ 2 y.o. to < 12 (i.e. 2-11)

• Route: IV
• Infusion: 20ml/kg
• Reassess every 100ml
• Max volume: 2000mL*

Age: ≥ 12 y.o.

• Route: IV
• Infusion: 20ml/kg
• Reassess every 250mL
• Max volume: 2000mL

MAX VOLUME of NaCl is lower for patients in cardiogenic shock and ROSC

Question 36

IV and Fluid Therapy Medical Directive: Clinical Considerations

Answer 36

1) “PCP Assist IV” authorizes a PCP to cannulate a peripheral IV at the request and under direct supervision of an ACP. Pt must require a peripheral IV in accordance with indications listed in the directive/ PCPs authorized for PCP assist IV are not authorized to administer IV fluid or medication therapy
2) Microdrips and/or volume control administration sets should be considered when IV access is indicated for patients <12 y.o.
3) An IV fluid bolus may be considered for a pt who does not meet trauma TOR criteria, if it doesn’t delay transport and should not be prioritized over management of other reversible causes.

ALWAYS HAVE A FULL SET OF VITALS & CARDIAC MONITOR APPLIED.

Question 37

Cardiogenic Shock Medical Directive (AUXILLARY)

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 37

Note: PCP has to be authorized for PCP autonomous IV to use this directive

Indications: STEMI-+ve 12-lead ECG AND Cardiogenic shock (heart not pumping enough blood to body leading to hypoperfusion)

Conditions: 0.9% NaCl Fluid Bolus

• Age: ≥18 y.o.
• SBP: Hypotensive
• Other: Chest auscultation clear

Contraindications: 0.9% NaCl Fluid Bolus

• Fluid overload
• SBP ≥90mmHg

Treatment: for ≥18 y.o., administration via IV

• Infusion: 10ml/kg
• Reassess every 250mL
• Max volume: 1000mL

Clinical Considerations: N/A

Question 38

Nausea/Vomiting Medical Directive

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 38

Indications: N/V

Conditions: Weight ≥25kg (~55lbs); unaltered LOA (because it may make them more drowsy)

Contraindications: for dimenhydrinate

• allergy or sensitivity to dimenhydrinate or other antihistamines
  
  • because they’re the same drug component
• OD on antihistamines or anticholinergics or tricyclic antidepresants
  
  • because they work around the same area of the brain (can lead to anticholinergic toxidrome)

Treatment:

• for ≥25kg to <50kg:
  
  • IV dose: 25mg with a max single dose of 25mg (i.e. max 1 dose)
  • IM dose: 25mg with a max single dose of 25mg (i.e. max 1 dose)
• for ≥50kg:
  
  • IV dose: 50mg, max 1 dose of 50mg
  • IM dose: 50mg, max 1 dose of 50mg

Clinical Considerations:

• IV admin only for PCP autonomous IV paramedics
• prior to IV admin, dilute dimenhydrinate (concentration of 50mg/1ml) 1:9 with NS or sterile water (no dilution needed for IM admin)
  
  • dilution necessary bc it burns when it goes in

Question 39

Electronic Control Device Probe Removal Medical Directive

Indications

Conditions

Contraindications

Treatment/Procedure

Clinical Considerations

Answer 39

Indications: Electronic Control Device probe(s) embedded in patient.

Conditions: ≥18y.o., unaltered LOA (consider pt who are on drugs, altered, etc.)

Contraindications: probe embeeded above clavicles, in the nipple(s), or in genital area

Treatment/Procedure: grab suture removal kit - forceps → apply pressure around site → pull out → treat wound & keep probes for evidence/bring to hospital

Clinical Considerations:

• police may require preservation of probe(s) for evidence
• this directive is for removal of ECD only and in no way constitutes treat and release; normal principles of patient ax and care apply

Question 40

Assessment of Patients with Possible COVID-19 Medical Directive -AUXILIARY

Indications

Conditions

Contraindications

Answer 40

Indications: Confirmed/suspected COVID-19 with mild acute resp illness characterized by a combo of 2+ of the following:

• fever
• new onset of cough
• worsening chronic cough
• SOB or difficulty breathing
• sore throat
• runny nose/nasal congestion (without any known cause)

AND

• the crisis is straining the resources of the host community

Conditions:
Patient Disposition

• ≥18 to <65 y.o.
• unaltered LOA
• HR <110
• RR < 22 breaths/min
• SBP: normotensive
• Other CTAS 3, 4, or 5; SpO2 ≥94%; if temp ≥38.5C, does not look septic/unwell

Nasopharyngeal OR nasal OR pharyngeal swab

• ≥18 y.o.
• Other: patient is being release from care AND meets COVID-19 testing criteria OR as requested by local public health

Contraindications:

Patient disposition:

• Patient and/or SDM cannot demonstrated decision-making capacity based on Aid to Capacity tool
• Pregnancy

Nasopharyngeal OR nasal OR pharyngeal swab

• Recent significant facial trauma (for all types of swabs)
• Current epistaxis OR ++ abnormality of nasal anatomy (for nasopharyngeal or nasal swab)
• ++abnormality of oral anatomy (pharyngeal swab)

Question 41

Assessment of Patients with Possible COVID-19 Medical Directive -AUXILIARY

Treatment

Clinical Considerations

Answer 41

Treatment:

• Mandatory Provincial Patch Point - Patch to BHP for authorization to consider release from care

Patient disposition (if authorized)*

• Transport to closest most appropriate ED - CTAS 1&2; 3 with comorbidity or immunocompromise
• Consider release from care (after BHP patch) - CTAS 3 with mild/no resp distress (without comorbidity/immunocompromise); CTAS 4/5 without immunocompromise

*Assess for safety to remain at home (clinical criteria above, patient is unaltered, can self-isolate, has access to food/phone/other necessities, and has appropriate caregivers available as needed

Prior to release from care, patient and/or SDM must be provided with contact info for their local Public Health unit, education on self-isolation and sx management, info on accessing ax centres. Document these instructions and consent to plan of care received from pt/SDM (in Remarks section of ACR). Advice pt to seek further medical attention if problem persists/worsens.

Consider obtaining nasopharyngeal/nasal/pharyngeal swab (if available and authorized)

• if obtained, complete lab requisition and transport specimen as per local arrangement

Clinical Considerations:

• BHP Patch: provide COVID-19 screening result, hx of illness/Sx, all past medical history, vital signs, and Ax findings + patient/SDM wishes, and follow up plans (if known).
• Immunocompromised definition: pt/caregiver states immunocompromised, cancer tx within past 6 weeks, HIV/AIDS, organ transplant patient, substance-use disorder, and any immunosuppressive meds
• Comorbidity definition: HTN, CV disease, cerebrovascular disease, diabetes, chronic lung disease, CKD, immunocompromised
• Mild resp distress definition: pt may report dyspnes on exertion, but there is mild or no increased work of breathing, pt able to speak in sentences, and RR <22 breaths/min AND SpO₂ ≥94%

Question 42

Minor Abrasions Medical Directive - SPECIAL EVENT

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 42

Indications: Minor abrasions AND special event (preplanned gathering with potentially large numbers of people and the Special Event Medical Directives have been preauthorized for use by Medical Director

Conditions: for Topical Antibiotic (i.e. polysporin)

• unaltered LOA (but consider the need for BLS standards of care in the event of other injuries along with the minor abrasions)

Contraindications: allergy or sensitivity to any of the components of the topical antibiotics

Treatment: apply topical antibiotic; consider release from care

Clinical Considerations: Adivse patient that if problem persists/worsens that they should seek further medical attention

Question 43

Minor Allergic Reaction Medical Directive - SPECIAL EVENT

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 43

Indications: Signs consistent with minor allergic reaction (localized edema, some discolouration in area, etc.) AND special event (preplanned gathering with potentiall large numbers of people and Special Event medical directives have been preauthorized for use by Medical Director

Conditions: for diphenhydramine

• Age: ≥18 y.o.
• Unaltered LOA
• HR: WNL
• RR: WNL
• SBP: Normotensive (≥100 SBP)

Contraindications:

• allergy or sensitivity to diphenhydramine
• antihistamine or sedative use in previous 4 hours (which may compound tx already given)
• S/S of moderate to severe allergic rxn (i.e. 2 or more body systems affected OR 1 major reaction by body system) → in this case, treat under regular BLS
• S/S of intox (due to inaccurate hx from patient)
• Wheezing

Treatment: 50mg tab of diphenhydramine PO, with a max dose of 1 (i.e. max dose 50mg)

• consider release from care

Clinical Considerations: advise pt that is problem persists or worsens, seek further med attention

Question 44

Musculoskeletal Pain Medical Directive - AUXILIARY - SPECIAL EVENT

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 44

Indications: Minor MSK pain AND it’s a special event (as per its definition)

Conditions: for acetaminophen → ≥18 y.o. and unaltered LOA (due to PO med)

Contraindications:

• acetaminophen use within previous 4 hours
• allergy or sensitivity to acetaminophen
• S/S of intox

Treatment: 325-650mg (each tab is 325mg so 1-2 tablets) of acetaminophen PO; max single dose is 650mg and max # of doses is 1 ⇒ consider release from care after

Clinical Considerations: advise pt that if problems persist or worsen, seek further med attention

Question 45

Headache Medical Directive - AUXILIARY - SPECIAL EVENT

Indications

Conditions

Contraindications

Treatment

Clinical Considerations

Answer 45

Indications: uncomplicated headache (meaning no other body systems affected) conforming to the patient’s usual pattern AND special event (as per its definition)

Conditions: for acetaminophen → ≥18 y.o. and unaltered LOA (due to PO med)

Contraindications:

• acetaminophen use within previous 4 hours
• allergy or sensitivity to acetaminophen
• S/S of intox

Treatment: 325-650mg (each tab is 325mg so 1-2 tablets) of acetaminophen PO; max single dose is 650mg and max # of doses is 1 ⇒ consider release from care after

Clinical Considerations: advise pt that if problems persist or worsen, seek further med attention

Question 46

What steps should a paramedic take if authorized to perform a prehospital discharge from care?

Answer 46

1. Determine if the pt can be treated under the Treat and Discharge portion of the medical directive
2. Communicate a clinically reasonable differential diagnosis to pt/SDM
3. Discharge discharge tx plan (see other flashcard)
4. Ensure pt has the necessary support to follow a discharge tx plan (See other flashcard)

Question 47

In order to complete a prehosipital discharge from care, a paramedic must discuss what elements of the discharge plan with the pt? (5)

Answer 47

1. Clinical situation related to the most likely diagnosis and/or differential diagnoses
2. S/S alerting them to seek further medical care (if condition is worsening or dx was not correct)
3. Instructions regarding modifications of ADLs following the health event
4. Where possible, provide additional contacts for follow up care
5. Instructions to call 911 back if condition worsens/recurs

Question 48

In order to complete a prehospital discharge from care, a paramedic must ensure the patient has necessary support to follow a discharge tx plan. What supports would fall under this category?

Answer 48

• access to food
• access to transportation
• access to alternate health care follow up
• a safe place to stay
• responsibe adult at the scene available to monitor the patient
• consideration of other apparent patient vulnerabilities