It is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive.

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1 It is recommended that the reader review each medical directive presented in this presentation along with the actual PCP Core medical directive. This presentation will highlight the changes and any new procedures only and requires the individual medic to review in detail the complete PCP medical directives. 1

2 2

3 Medical Cardiac Arrest Separate Algorithm for ACPs and PCPs; changed from integrated layout Emphasis remains on uninterrupted CPR completed in 2 minute intervals Manual or automated external defibrillation is mentioned in the language. BFN EMS PCP s will continue to utilize SAED mode. The language allows for the ability to expand the PCP scope in the future through education and training. Epinephrine can now be administered for cardiac arrests if anaphylaxis is suspected as causative event. One time administration only (NEW) 3

4 Medical Cardiac Arrest Defibrillation Adult defib / analysis is still every 2 minutes Manual mode (only if certified and authorized) BFN EMS PCP to continue in SAED Mode Now to be used on pediatirics 30 days (NEW) 4

5 Medical Cardiac Arrest No change to maximum # of shocks, still 4 3 on scene 1 in the ambulance prior to transporting the patient (if no TOR) 5

6 Medical Cardiac Arrest Epinephrine: Can now be given once during cardiac arrests if the suspected cause of the arrest is anaphylaxis; one dose only (NEW) Maximum dose of Epinephrine 1:1000 = 0.5 mg IM (0.01 mg/kg) (NEW) 6

7 Medical Cardiac Arrest Medical TOR (NEW) Patching after 3 rounds is a mandatory patch point if the patient meets TOR criteria. Follow the Deceased Patient Standard once TOR has been implemented 7

8 Medical Cardiac Arrest Medical TOR (NEW) Only applies to patient that are: 18 years VSA Arrest not witnessed by EMS, no ROSC and no shocks delivered After 3 rd analysis Patch to BHP following 3 rd analysis if applicable. If patch fails or the TOR does not apply, transport to the closest most appropriate ED following the 4 th analysis or ROSC. Medical TOR serves to protect the public as well as the Paramedics when resuscitation efforts are otherwise futile. In unusual circumstances, consider initiating rapid transport. following 1 st rhythm analysis (no shock advised) If the arrest occurred in a public place or the family is not coping well, Paramedics may choose to move the patient to the ambulance prior to initiating TOR. 8

9 Traumatic Cardiac Arrest Now presented as a flow chart as well 1 shock only if a shockable rhythm is present All traumatic arrests will have the pads applied The previous directives only had pads applied to blunt trauma patients. (NEW) 9

10 Traumatic Cardiac Arrest All traumatic arrests will have the pads applied. The previous directives only had pads applied to blunt trauma patients. (NEW) Maximum 1 shock Shock may be delivered to both blunt and penetrating arrest (NEW) Apply pads to all patients 30 days old (NEW) 10

11 Trauma Cardiac Arrest Still 16 years Trauma TOR is the same for ACPs and PCPs Must meet all requirements and If patch phone failure, TOR does not apply, transport to the closest appropriate facility. 16 years of age is based on the pediatric trauma guidelines whereas any trauma patient under the age of 16 is considered a pediatric patient. Pupillary reflexes, spontaneous respirations and spontaneous movement has been removed from the algorithm (NEW) Time to the closest ER is now 30 minutes (NEW) 11

12 Trauma Cardiac Arrest Algorithm Pupillary reflexes, spontaneous respirations and spontaneous movement has been removed from the algorithm (NEW) 12

13 13

14 Hypothermia Cardiac Arrest Normal length pulse checks acceptable. (NEW) Same defib dosing applies. One defibrillation may be delivered to patients 30 days for VF or VT. (NEW) 14

15 Foreign Body AW Obstruction Cardiac Arrest One defibrillation may be delivered to patients 30 days for VF or VT with unrelieved AW Obstruction. (NEW age) 15

16 Neonatal Resuscitation Indications clarified and specific 16

17 Neonatal Resuscitation Initial treatment no blow by oxygen (NEW) Positive pressure ventilation is to be done with room air only, no oxygen (NEW) until the 90 second point then 100% O2 is to be used via BVM 17

18 18

19 Return of Spontaneous Circulation (NEW) A Primary Care Paramedic certified to the level of PCP Autonomous IV may provide the treatment prescribed in this medical directive if authorized to do so. Conditions 0.9% NaCl fluid bolus must be hypotensive (i.e.. SBP < 90) Therapeutic hypothermia dependent on age, male 18 yrs or older and females 50 yrs or older, LOA must be altered, SBP must be 90 mmhg or higher (spontaneous following bolus administered) (must be available and authorized by BHP) Rational for females 50 is to avoid the pregnant female Contraindications 0.9% NaCl fluid bolus fluid overload or SBP 90 mmhg or greater (only applies to PCP if autonomous IV certified) Therapeutic hypothermia traumatic cardiac arrest (blunt, penetrating or burn), sepsis or serious infection suspected as cause of the arrest, hypothermic arrest, known coagulopathy (medical history or medications)

20 Return of Spontaneous Circulation Treatment Consider rapid transport Consider optimizing ventilation and oxygenation avoid hyperventilation and target an ETCO2 of mmhg with continuous waveform capnography (if available and applies to both ACPs and PCPs) (NEW) Consider 0.9% NaCl fluid bolus age based instead of weight based, infusion interval listed as immediate, max volume 1000 cc (only applies PCPs certified in Autonomous IV program) Consider 12 lead acquisition (if available) (NEW) Consider Therapeutic hypothermia (if available) (NEW) Clinical Considerations The application of therapeutic hypothermia should not detract from rapid transport, optimizing ventilation and oxygenation or the management of a re arrest new 20

21 Cardiac Ischemia ASA Indications now state suspected cardiac ischemia instead of suspected cardiac ischemia chest pain (NEW) TBI = Traumatic Brain Injury Now age specific, 18 years instead of weight (NEW) 21

22 Cardiac Ischemia NTG Now age specific, 18 years instead of weight (NEW) Contraindicated if 12 lead is available and authorized and 15 lead shows RVI (right ventricular infarct) (NEW) EDD Erectile Dysfunction Drug language is out and Phosphodiaterase inhibitor is the new language used (NEW) Note the use of Normotension (NEW). Please refer per the preamble section of the directives under CONVENTIONS AGE AND VITAL SIGNS Normotension SBP 100 mmhg Hypotension SBP < 90 mmhg HR Heart rate is always in beats per minute according to a cardiac monitor when it is applied. In situations where a cardiac monitor is not indicated the heart rate is equal to the pulse rate. Bradycardia < 50 BPM Tachycardia 100 BPM Tachypnea RR 28 breath/min IV conditions apply to PCPs certified to the level of PCP Autonomous IV 22

23 Cardiac Ischemia 23

24 24

25 Acute Cardiogenic Pulmonary Edema NTG Conditions for Nitroglycerin: Age: 18 years (NEW) HR: bpm SBP: normotension SBP 100 mmhg Other: Ascertain prior history of nitroglycerin use or establish IV access. No more weight based. Contraindications to nitroglycerin are as previously stated in Cardiac Ischemia. IV conditions apply to PCPs certified to the level of PCP Autonomous IV 25

26 Acute Cardiogenic Pulmonary Edema NTG Treatment: SBP 100 mmhg to < 140 mm Hg with IV or Hx OR SBP 140 mm Hg without IV or Hx SL dosing of 0.3 to 0.4 mg with intervals of 5 min. to a maximum number of doses of 6. For SBP 140 mmhg with IV or Hx then SL dosing of 0.6 to 0.8 mg with intervals of 5 min. to a maximum number of doses of 6. NOTE: NTG can be given in cases of acute pulmonary edema with a BP 140 mmhg without and IV or Hx of prior use Single dose 0.4 mg only 12 lead ECG if available and authorized IV conditions apply to PCPs certified to the level of PCP Autonomous IV 26

27 A Primary Care Paramedic certified to the level of PCP Autonomous IV may provide the treatment prescribed in this medical directive if authorized to do so. Indications STEMI positive ECG and Cardiogenic Shock Conditions 2 years (NEW) Hypotension (SBP < 90) Chest is clear Contraindications O.9% NaCl none Treatment Consider 0.9% NaCl fluid bolus assessment parameters determined by age not weight. 27

28 28

29 29

30 Hypoglycemia No age requirements for glucagon Directive discusses Dextrose but is intended for PCP s who have been certified and authorized to start IV s and administer dextrose. (this is a directive that allows for expanded scope in the future if needed and approved) 30

31 Hypoglycemia No age criteria for the administration of Glucagon Weight has changed from 20 kg to 25 kg. (NEW) IM route only (NEW) 31

32 32

33 Hypoglycemia Refusal of transport A final set of vital signs must be attempted and documented including glucometry. A follow up care plan must be documented on your ACR/EPCR. This is to Include the information that the paramedic communicated to the patient pertaining to when they should call back or seek medical attention. (one of the most common finding during the QA process is that no follow up care plan is documented) 33

34 34

35 Bronchoconstriction Now combines the moderate to severe asthma exacerbation protocol with SOB (NEW) 35

36 Bronchoconstriction Dosing weight change: (NEW) MDI salbutamol < 25 kg up to 600 mcg (6 puffs) (NEW) MDI salbutamol 25 kg up to 800 mcg (8 puffs) (NEW) NEB salbutamol < 25 kg 2.5 mg NEB salbutamol 25 kg 5 mg Max # of doses = 3 Dosing interval = 5 15 minutes (NEW) 36

37 Bronchoconstriction Previous, the Ventolin weight category was <30 kg and 30 kg Dosing interval = 5 15 minutes (NEW) 37

38 Bronchoconstriction 0.01 mg/kg Max dose of Epinephrine is now 0.5 mg (NEW) Patients > 50 years is no longer a contraindication (NEW) Max # of doses = 1 (NEW) 38

39 Bronchoconstriction Included in the provincial directives as some services utilize Epi pens Not used by BFN EMS 39

40 40

41 Moderate to Severe Allergic Reaction Max. single dose is now 0.5 mg (NEW) SCPS paramedics are not certified or authorized to utilize diphenhydramine Epinephrine for anaphylaxis only 41

42 Moderate to Severe Allergic Reaction Max. single dose is now 0.5 mg (NEW) Max # of doses now = 1 (NEW) Epinephrine for anaphylaxis only 42

43 Moderate to Severe Allergic Reaction Epinephrine Auto injectors Included in the provincial directives as some services utilize Epi pens Not used by SCPS 43

44 Moderate to Severe Allergic Reaction SCPS is not certified or authorized to administer diphenhydramine (Benadryl) via any route 44

45 Croup Indications Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough OR recent history of a barking cough (NEW) 45

46 Croup The minimum initial volume for nebulization is 2.5 ml. Max # of doses = 1 (NEW) (instead of 2) 46

47 Croup Max # of doses = 1 (NEW) 47

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