Paramedic Field Guide 2014 Extended Edition

By Adam Bennett

Your 2014 Protocols are here!

It has always been our intention to bring you accurate, up to date and useful information.

Continuing with our tradition of building upon an already great product we are proud to bring you our best edition to do date.

These protocols follow the guidelines established by the Ontario Base Hospital Group, the Ontario Medical Advisory Committee (MAC) and the American Heart Association (AHA).

You will have rapid access to current ACLS Arrest Guidelines, Medical and Traumatic Emergencies, Emergency Childbirth and Pediatric Emergencies (including Pediatric Drug Calculations), Rapid ECG Interpretation, Cardiology for Paramedics, Paramedic Drug List and much, more.

All content is completely searchable by topic and keywords. You can create your own custom bookmarks for quick access to the information you use the most, you can highlight passages and make your own custom notes and annotations.

• Language: English
• Publisher: Adam Bennett
• Release date: Nov 10, 2013
• ISBN: 9780987870674

Book preview

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REFUSAL OF CONSENT

If a patient refuses treatment, either in whole or in part, a paramedic must comply with the applicable directions contained in the Basic Life Support (BLS) Patient Care Standards, Section 1, Part I Patient Refusal of Treatment and/or Transport:

The Paramedic will:

1.  If, where interventions are deemed necessary, the patient refuses treatment and/or transport despite reasonable efforts to convince the patient otherwise, explain the possible consequences of such refusal.

2.  Obtain/provide appropriate documentation on the Refusal of Service section of the Ambulance Call Report (ACR):

• Patient’s signature or signature of a recognized substitute decision - maker (e.g. legal guardian, attorney for personal care, spouse, parent, other as defined in relevant legislation), indicating refusal of treatment and/or transport, and understanding of explanations provided regarding the consequences of refusal (Capacity Evaluation);

• Patient’s or substitute decision - maker’s refusal to sign the Refusal of Service section of the ACR (in the event this should occur, since there is no legal obligation to sign the ACR);

• Signatures of witnesses to the patient’s refusal of service (if witnessed);

• Signatures of witnesses to the explanation provided to the patient regarding the possible

• consequences of refusal of service (if witnessed);

• Signatures of paramedics.

3.  Carry out emergency treatment and transport if the paramedic determines:

i )  that the patient is at risk, if treatment is not administered promptly, of suffering serious bodily harm, and, is unable to understand the information that is relevant to making a decision concerning the proposed treatment and unable to appreciate the reasonably foreseeable consequences of accepting or refusing the treatment, or

i i )  that the patient is a child / adolescent who is unable to understand the information that is relevant to making a decision regarding the proposed treatment and is therefore not capable to make an informed decision regarding the foreseeable consequences of accepting or refusing treatment, and

iii) it is not reasonably possible to obtain a consent or refusal on the person’s behalf, or the delay required to do so would prolong suffering or put the person at risk of suffering serious bodily harm.

4.  If the paramedic is unable to perform emergency treatment (as per criteria outlined under point 3) without police assistance e.g. the patient is violent, or extremely hostile and/or the patient is deemed to be dangerous to themselves or others (based on current behaviour and present or past history), then carry out the following actions:

• Advise dispatch.

• Request police assistance.

• Use physical restraint only if all reasonable verbal efforts fail to calm the patient and elicit cooperation; use only the minimum restraint required to protect the patient from endangering themselves or others. (See Restraint of Patients Standard ) Remain at the scene until police arrive.

• Maintain communication with dispatch while at scene.

• Initiate transport with a police accompaniment in the patient compartment if police agree to take the patient into custody for medical assessment.

• Document reasons for actions taken.

5.  If a of understanding the implications of refusal, (Capacity Evaluation) or police refuse to take the patient into custody for medical assessment (as per point 4):

• If serious or life - threatening illness/injury is obvious or suspect, attempt to contact an EMS supervisor for advice. If a supervisor is not available, attempt to contact a physician for advice, e.g. base or local hospital physician at a local emergency department or the patient’s family physician.

• If the patient continues to refuse treatment, even with a physician’s advice to the contrary, release the patient into the care of an apparently responsible adult. For the individual assuming responsibility for the patient, provide instructions regarding observation and patient management, physician follow - up, possible complications and other information as deemed appropriate. If no responsible adult is available, release the patient into their own care with similar instructions; attempt to obtain the name and telephone number of a contact person for purposes of patient follow - up.

6. For inter-facility transfers of emotionally disturbed patients, follow procedures as outlined in Emotionally Disturbed Patients - Care and Transportation Standard.

CARDIAC ARREST PROTOCOLS

Non Traumatic Cardiac Arrest

ACLS Non Traumatic Arrest

Traumatic Cardiac Arrest

Foreign Body Airway Obstruction

Neonatal Recusitation

ROSC

Non Traumatic Cardiac Arrest

Indications:  No Pulse with altered LOA and ≥ 30 days of age, AED advises Shock or Manual Defibrillation if patient is in VFib or pulseless VT

AED Defibrillation:  If ≥ 30 days of age deliver 1 shock (energy preset by BHP) every 2 min to max of 4 shocks.

Manual Defibrillation:  If ≥ 30 days of age but < 8 years of age deliver 1 shock every 2 min to a max of 4 shocks (1st shock at 2J/kg and next 3 shocks at 4J/kg or as pre-programmed by Base Hospital or the manufacturer) using pediatric attenuator cables if available.

If ≥ 8 years of age then deliver 1 shock every 2 min to a max of 4 shocks with energy settings preset by BHP without the use of pediatric attenuator cables.

Epinephrine:  May give 1 dose Epinephrine (0.01mg/kg of 1:1,000 to max dose of 0.5mg) if suspected cause of arrest is anaphylaxis.

Medical TOR:  Cardiac arrest is thought to be medical in nature and patient is at least 18 years of age and the arrest was not witnessed by EMS and there is no ROSC and there have been 0 shocks delivered.

Mandatory Provincial Patch Point:  Following the 3rd analyze contact BHP to consider medical TOR.  If the patch fails or medical TOR does not apply, then transport after 4th analysis.

ACLS Non Traumatic Cardiac Arrest

Manual Defibrillation:  If ≥ 30 days of age  but < 8 years of age deliver 1 shock every 2 min to a max of 4 shocks (1st shock at 2J/kg and next 3 shocks at 4J/kg).

Epinephrine:  If patient is ≥ 30 days of age but < 12 years of age administer epinephrine every 4 minutes at the following dosages:

•  if via IV or IO administer 1:10,000 at a dose 0.01mg/kg (minimum single dose is 0.1mg)

•  if via ETT administer 1:1000 at a dose of 0.1mg/kg to a max of 2mg (minimum single dose is 1mg)

If patient is ≥ 12 years then administer epinephrine every 4 minutes at the following dosages:

•  if via IV or IO administer 1mg of 1:10,000

•  if via ETT administer 2mg in the concentration set out by individual base hospital

Amiodarone:  Amiodarone is to be used if patient is found to be in VF or pulseless VT.  If patient is ≥ 30 days of age but < 12 years of age administer Amiodarone via IV or IO at 5mg/kg to a maximum of 300mg for the initial dose.  After 4 minutes, administer a 2nd dose (5mg/kg to a maximum dose of 150mg). 

If the patient is ≥ 12 years of age administer an initial dose of 300mg.  After 5 minutes, administer a 2nd dose (150mg).

Lidocaine:  If Amiodarone is not available and the patient is ≥ 30 days of age and has no known sensitivity or allergy to Lidocaine and they are in VF or pulseless VT administer Lidocaine as follows:

•  If patient is ≥ 30 days of age but < 12 years of age and < 40kg administer via IV/IO 1mg/kg or via ETT 2mg/kg.  After 4 min repeat the dose.

•  If patient is ≥ 12 years of age administer via IV/IO/CVAD 1.5mg/kg or via ETT 3mg/kg.  After 4 minutes repeat the dose.

Intubation:  Consider intubation if the airway cannot be adequately managed with first OPA or supraglottic airway.

Mandatory Patch Point:  Patch to BHP after 3rd round of Epinephrine or after 3 analyses.  If the patch fails, transport after the 4th analyses.

CPR Quality

•  Push hard and fast (at least 5cm) and make sure to allow for complete recoil of the chest

•  Minimize interruptions in chest compressions

•  Change out person doing compressions every 2 minutes

•  Compression: Ventilation ratio of 30:2 (continuous if intubated)  Be aware of ROC study if applicable

•  If PETCO2 is less than 10mmHg attempt to improve CPR

Return of Spontaneous Circulation (ROSC)

•  Obtain pulse rate and blood pressure

•  Abrupt and sustained increase to PETCO2 (greater than 40mmHg)

Energy for Defibrillation

•  Biphasic:  manufacturers recommendations are usually between 120J and 200J (second and subsequent shocks should be at least equivalent).  Make sure to follow local protocols.

•  Monophasic: 360J

Drug Therapy

•  Epinephrine IV/IO: 1mg every 3 to 5 minutes

•  Amiodarone:  1st  dose 300mg bolus, 2nd dose 150mg

Advanced Airway

•  Utilize least invasive and most appropriate means (OPA then  Supraglottic then ETT if necessary)

•  Ventilate at 8 to 10 breaths per minute

Reversible Causes of Arrest:

•  Hypovolemia, Hypoxia, Hydrogen Ion (acidosis), Hypo/Hyperkalemia, Hyperthemia

•  Tension pneuomothorax, Tamponade, Toxins, Thrombosis

Traumatic Cardiac Arrest

Indications:  Cardiac arrest following penetrating or blunt trauma.

AED Defibrillation:  If patient is ≥ 30 days of age deliver 1 shock only (energy preset by BHP).

Manual Defibrillation: If ≥ 30 days of age and < 8 years of age deliver 1 shock (2J/kg) only with pediatric attenuator cables if available.  If ≥ 8 years of age deliver 1 shock only (preset by BHP), for patients found to be in VFib or VTach.

Trauma TOR:  ≥ 16 years of age, NO palpable pulse, NO shock delivered, HR of 0 bpm (asystole) or monitor rate greater than 0 and nearest ER is 30 min or more transport time.

Mandatory Provincial Patch Point:  Contact BHP to consider trauma TOR.  If the patch fails or medical TOR does not apply, then transport after 4th analysis.

Hypothermia Cardiac Arrest

Indications:  Cardiac arrest secondary to severe hypothermia.

AED Defibrillation:  If ≥ 30 days of age deliver 1 shock only (energy preset by BHP).

Manual Defibrillation:  If ≥ 30 days of age and < 8 years of age deliver 1 shock (2J/kg) only with pediatric attenuator cables if available.  If ≥ 8 years of age deliver 1 shock only (preset by BHP), for patients found to be in VFib or VTach.

Foreign Body Airway Obstruction

Indications:  Cardiac arrest secondary to an airway obstruction.

AED Defibrillation:  If ≥ 30 days of age deliver 1 shock only (energy preset by BHP).

Manual Defibrillation:  If ≥ 30 days of age and < 8 years of age deliver 1 shock (2J/kg) only with pediatric attenuator cables if available.  If ≥ 8 years of age deliver 1 shock only (preset by BHP), for patients found to