PCTH - Medical Cardiac Arrest Medical Directive Flashcards
Medical Cardiac Arrest Medical Directive
INDICATIONS
Non-traumatic cardiac arrest
Medical Cardiac Arrest Medical Directive
Primary Clinical Considerations (i.e. TO BE CONSIDERED VERY EARLY)
- Consider very early transport after minimum of one analysis (and defib if indicated) once egress plan is organized:
* pregnancy ≥ 20 weeks gestation (fundus above umbilicus, ensure manual displacement of uterus to left);
* hypothermia
* airway obstruction
* non-opioid drug OD/toxicology
* other known reversible cause of arrest not addressed - Transport of pt should begin after 3rd consecutive shock for:
* refractory VF or pulseless VT
Medical Cardiac Arrest Medical Directive
CONDITIONS (CPR, Manual Defib, AED Defib, Epi, Medical TOR)
CPR: Altered LOA, performed in 2 min intervals
Manual Defib: Age ≥ 24 hours; altered LOA; rhythm VF OR pulseless VT
AED Defib: Age ≥ 24 hours; altered LOA; defibrillation indicated (if not using manual defib)
Epinephrine: Age ≥ 24 hours; Altered LOA; anaphylaxis suspected as causative event
Medical TOR:
- Age ≥ 16 years;
- altered LOA;
- Arrest not witnessed by paramedic AND No ROSC 20 mins of resuscitation AND No defibrillation delivered
Medical Cardiac Arrest Medical Directive
CONTRAINDICATIONS (CPR, Manual Defib, AED Defib, Epi, Medical TOR)
CPR: Obviously dead as per BLS PCS; Meet conditions of DNR Standard
Manual Defib: Rhythms other than VF or pulseless VT
AED Defib: Non-shockable rhythm
Epinephrine: allergy or sensitivity to epinephrine
Medical TOR:
* known reversible cause of the arrest unable to be addressed
* pregnancy ≥ 20 weeks gestation
* suspected hypothermia
* airway obstruction
* non-opioid drug OD/toxicology
Medical Cardiac Arrest Medical Directive
TREATMENT (CPR, Manual Defib, AED Defib, Epi, Medical TOR)
1) Consider CPR as per current Heart & Stroke Foundation (HSF)
2) Consider Manual defib (if available and authorized)
-
≥24 hrs to <8 years
- Dose: 1 defibrillation
- Initial dose: 2 J/kg
- Subsequent dose: 4 J/kg
- Dosing interval: 2 min
- Max # of doses: n/a
-
≥8 years
- Dose: 1 defibrillation
- Initial dose: as per BH/manufacturer
- Subsequent dose: as per BH/manufacturer
- Dosing interval: 2 min
- Max # of doses: n/a
3) Consider AED defib (if not using manual defibrillaion)
-
≥24 hrs to <8 years - WITH OR WITHOUT PED ATTENUATOR CABLE
- Dose: 1 defibrillation
- Max single dose: as per BH/manufacturer
- Dosing interval: 2 min
- Max # of doses: n/a
-
≥8 years
- Dose: 1 defibrillation
- Max single dose: as per BH/manufacturer
- Dosing interval: 2 min
- Max # of doses: n/a
4) Consider epinephrine (only if anaphylaxis is supsected as causative event)
- Route: IM
- Concentration: 1mg/mL = 1:1000
- Dose: 0.01mg/kg* (epi dose may be rounded to the nearest 0.05mg)
- Max single dose: 0.5 mg
- Dosing interval: N/A
- Max # of doses: 1
Mandatory Provincial Patch point for medical cardiac arrest medical directive
Patch to consider Medical TOR (if applicable)
If patch fails or Medical TOR does not apply, transport to closest appropriate hospital following ROSC or 20 mins of resus without ROSC.
Patch early (eg. following 4th analysis) to consider TOR if there are extenuating circumstances; surrounding egress, prolonged transport or significant clinical limitations where paramedic considers ongoing resuscitation to be futile.
Medical Cardiac Arrest Medical Directive
Clinical Considerations
1) Consider RBH advanced airway strategy (eg. SGA medical directive) where more than OPA/NPA and BVM are required.
2) There is no clear role for routine adminsitration of nalosone in confirmed cardiac arrest
3) BHP might not authorize TOR even if pt meets TOR rule. Factors: location of pts, EtCO2, age, bystander witnessed, bystander CPR, transportation time, & unusual cause of cardiac arrest (eg. electrocution, hanging, & toxicology)
4) BHP may authorize TOR even though pt DOES NOT meet TOR rule. Factors taken into account: extenuating egress limitations, prolonged transport, caregiver wishes, existence of DNR, underlying end stage progressive illness
Should you complete the entire medical cardiac arrest directive before moving the patient OR transport as quickly as possible so complete the medical directive en route if need be?
Complete the entire medical cardiac arrest directive with the patient laying where they are
Can a drowning, hanging, electrocution, or overdose cardiac arrest be considered for a medical TOR?
No because not cardiac in nature
If fire witnesses a medical cardiac arrest, is the patient eligible for medical TOR?
NO - the definition of “EMS” when talking about medical TORs includes fire and paramedics
In what situations would indicate protocol completion (i.e. you’ve finished the medical cardiac arrest directive)?
rhythm analysis has been performed by a paramedic 4 times
OR
there has been a ROSC
OR
BHP has issued a TOR or directed you to transport
ROSC Medical Directive
Indications
Conditions
Contraindications
Indications: patient with ROSC after resuscitation was initiated
Conditions: for 0.9% NaCl Fluid Bolus
- Age: ≥2 years
- Hypotension
- Chest auscultation is clear
Contraindications: fluid overload
ROSC Medical Directive
Treatment
Clinical Considerations
Treatment:
-
1) Consider optimizing ventilation and oxygenation
- titrate oxygenation 94-98%
- avoid hyperventilation and target ETCO2 to 30-40 mmHg with continuous waveform capnography (if available)
-
2) Consider 0.9% NaCl fluid bolus (if available and authorized)
- ≥2 years to <12 years
- Route IV @ 10ml/kg
- Infusion interval: immediate
- Re-ax every 100ml
- Max volume: 1000ml
- ≥12 years
- Route IV @ 10ml/kg
- Infusion interval: immediate
- Re-ax every 250ml
- Max volume: 1000ml
- ≥2 years to <12 years
- 3) Consider 12-lead ECG (try 5-10 min after ROSC to avoid false positives due to global hypoperfusion post-arrest state)
Clinical Considerations:
- consider initiating transport in parallel with above tx
- IV fluid bolus applies only to those with PCP autonomous IV
Special considerations for ROSC patients when transporting?
ROSC patients are more prone to cerebral edema so consider elevation of head 30°
Allow head in neutral alignment to allow for optimal jugular vein drainage
You are transporting a ROSC patient that re-arrests en route to the hospital. What are the appropriate next steps?
- establish that patient is VSA
- Pull over! you cannot reliably analyze rhythms while driving
- analyze x1
- continue CPR & transport
you only get one additional analyze with a re-arrest ONLY IF IT IS MEDICAL (not trauma arrest because they are more unstable)
