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Central East Prehospital Care Program, May 1, 2009 – Section One

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EMR

Medical Directives and Guidelines

Central East Prehospital Care Program, May 1, 2009 – Section One

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USE OF MEDICAL DIRECTIVES / GUIDELINES These medical directives and guidelines are not intended to be “all encompassing” of the complex medical and trauma situations that may be encountered in the field. Since patients do not always fit into a “cook book” approach, these medical directives and guidelines are not a substitute for good judgment. As a Firefighter / First Responder, it is your responsibility to assess the situation and use your knowledge and skills to benefit the patient while remaining within your scope of practice. We would strongly recommend that if you are involved in a situation that does not fall within a specific directive and/or guideline as outlined for your level of certification, that you contact the Central East Prehospital Care Program (CEPCP) as soon as possible.

DELEGATION

The Firefighter / First Responder is the extension of the physician in the field and provides care under the direction of the Base Hospital Medical Directors of the CEPCP. The Firefighter / First Responder receives delegation from the Medical Director through written medical directives. The Firefighter / First Responder does not receive delegation from an on-scene physician, nor should the Firefighter / First Responder delegate to another defibrillation provider or citizen. The medical directives that are associated with the use of a Semi-Automated External Defibrillator (SAED) fall under the auspices of delegation. RESPONSIBILITY With the development of SARS (Severe Acute Respiratory Syndrome), the Firefighter / First Responder must recognize their obligation to protect themselves and others while providing patient care. It is strongly recommended that the Firefighter / First Responder utilize all available personal protective equipment (PPE) precautions to limit personal exposure and disease transmission. It is important to note that not all victims of infectious respiratory illnesses are febrile, and some prehospital interventions may increase the risk of contamination. The Firefighter / First Responder must use their judgment and investigative skills to identify situations of risk and take appropriate protective steps.

Central East Prehospital Care Program, July 1, 2009 – Section One

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CARDIAC ARREST GENERAL MEDICAL DIRECTIVE When the following indications and conditions exist, a Firefighter / First Responder may treat victims of cardiac arrest according to the following: Indications Patient is in cardiac arrest (Vital Signs Absent - VSA). Conditions Patient is ≥ 1 year old for application of an SAED. Contraindications 1. Patients who meet the criteria for obvious death. 2. Patients who have a valid and completed Ministry of Health (MOH) DNR Confirmation form

or a York / Durham Base Hospital approved DNR form. Procedure

1. Confirm VSA by the absence of spontaneous respirations and palpable pulses. 2. Initiate airway management, oxygen, ventilation, and CPR. 3. Initiate therapy outlined in a directive according to the causative agent and based upon

SAED prompts received.


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MEDICAL CARDIAC ARREST MEDICAL DIRECTIVE Indication: Patient who is in a medical cardiac arrest Procedure:

1. Ensure Scene Safety

2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 – 6 seconds 4. If no breathing, insert an oral airway and ventilate x 2 with a BVM to ascertain airway patency 5. Check for signs of circulation including carotid pulse 6. If the arrest was unwitnessed, initiate 2 min of dedicated CPR. (If the arrest is witnessed, apply the

cardiac monitor and proceed with an immediate analysis).

7. Attach the SAED and turn it on and follow the prompt to: Stop CPR and analyze – “Stand clear” 8. a) If the rhythm is shockable, defibrillate according to the following chart

Defibrillator standard AHA 2005 compliant

# shocks delivered 1

CPR interval 2 minutes

Reanalyze After 2 min of CPR

b) If the rhythm is non-shockable, proceed to the next step.

9. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse. 10. Continue the cycle of analysis – defibrillation (if shockable) – CPR – circulation assessment. 11. Provide a report of patient care on arrival of EMS. Notes • N/A


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HYPOTHERMIA CARDIAC ARREST DIRECTIVE Indication: Patient who is in a medical cardiac arrest due to hypothermia. Procedure: 1. Ensure Scene Safety 2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 – 6 seconds 4. If no breathing, ventilate x 2 with a BVM to ascertain airway patency 5. Assess the patient’s core temperature by feeling the abdomen

6. Check for signs of circulation including carotid pulse (minimum 30 – 45 seconds) 7. If no pulse, initiate 2 minutes of dedicated CPR.

8. Attach the SAED and turn it on and follow the prompt to: Stop CPR and analyze – “Stand clear”.

9. a) If the rhythm is shockable, defibrillate according to the following chart




Reanalyze NONE b) If the rhythm is non-shockable, proceed to the next step.

10. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse.

11. Resume CPR and ignore subsequent defibrillator prompts to analyze. 12. Provide a report of patient care on arrival of EMS. Notes • An oral airway should only be used if a patent airway cannot be maintained using manual airway

management procedures. • After the first analysis is complete, subsequent defibrillator prompts are to be ignored when following this

directive. The Base Hospital recommends that you unplug your SAED pads if you have an SAED that analyzes automatically.


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TRAUMA ARREST MEDICAL DIRECTIVE

Indication: Patient is in cardiac arrest due to multiple system trauma: Procedure: 1. Ensure Scene Safety 2. Establish Unresponsiveness (AVPU) 3. Open airway and check breathing for 3 – 6 seconds 4. If no breathing, insert an oral airway and ventilate x 2 with a BVM to ascertain airway patency 5. Check for signs of circulation including carotid pulse 6. If no pulse, rapidly extricate the patient using C-spine precautions and initiate 2 minutes of CPR

7. a) If the cause of the cardiac arrest is PENETRATING trauma, continue to perform CPR until EMS

arrives and DO NOT attach the SAED. b) If the cause of cardiac arrest is BLUNT trauma, attach the SAED and continue with the following steps;

8. Turn the SAED on and follow the prompt to: Stop CPR and analyze - “Stand clear” 9. a) If the rhythm is shockable, defibrillate according to the following chart




Reanalyze NONE b) If the rhythm is non-shockable, proceed to the next step.

10. Initiate 2 min of dedicated CPR followed by an assessment of signs of circulation and carotid pulse.

11. Resume CPR and ignore subsequent defibrillator prompts to analyze.

12. Provide a report of patient care on arrival of EMS. Notes • If the cardiac arrest patient (regardless of cause) is trapped, or in a rescue situation where paramedics

cannot safely enter, you should provide immediate extrication while attempting CPR for two minutes. Nothing should delay extrication, but if the patient is still trapped, or in a rescue situation after two minutes, then attempt to attach the SAED. If prompted, deliver one shock and upon completion of the shock all efforts should be put towards extricating the patient.

• After the first analysis is complete, subsequent defibrillator prompts are to be ignored when following this directive. The Base Hospital recommends that you unplug your SAED pads if you have an SAED that analyzes automatically.


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NEONATAL RESUSCITATION MEDICAL DIRECTIVE When the following indications and conditions exist, a Firefighter / First Responder may treat pediatric victims of cardiac arrest/cardio-respiratory distress according to the following: Indications: Patient is in cardiac arrest (Vital Signs Absent - VSA) or in severe cardio-respiratory distress. Conditions: Patient is < 29 days of age Procedure:

If not breathing:

1. Ensure Scene Safety 2. Establish level of responsiveness (AVPU).

In the newly born: dry, warm, position, suction and stimulate as necessary 3. Open airway and check breathing for 3 – 6 seconds

• Insert an oral airway • Ventilate x 2 with BVM to

ascertain airway patency

If breathing • Administer blow-by oxygen (O2)

4. Check for signs of circulation* including carotid/brachial pulse

Assess the newly born using the APGAR scale

If no pulse, start CPR: • 120 compressions/min • 3 compressions : 1 vent

If pulse < 100 bpm: • Secure the airway • Ventilate with BVM at 40

breaths/min x 1 min 5. Reassess

If no pulse and no breathing: • Continue CPR

If pulse < 60 bpm, start CPR: • 120 compressions/min • 3 compressions : 1 vent

6. Continue to reassess frequently 7. Provide a report of patient care on arrival of EMS.

Notes • If meconium is present in the airway of the newborn, the meconium must be suctioned prior to positive

pressure ventilation. The mouth, nose and posterior (back) area of the oral cavity should be suctioned following delivery of head, or as soon as possible.

• *Signs of poor circulation include unresponsiveness, agonal or no breathing, cool skin temperature that is centrally cyanotic or mottled with delayed capillary refill.


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RECOGNITION OF DEATH MEDICAL DIRECTIVE The medical directives for patients that have are Vital Signs Absent (VSA) should be followed, except in the following circumstances:

1. OBVIOUSLY DEAD

The Firefighter / First Responder may presume death, and not initiate resuscitation, when one or more of the following gross signs of obvious death is present: • Decapitation • Transection • Visible decomposition • Putrefaction (smell) • Otherwise (see below)

“Otherwise” is delineated as: • Grossly charred body • Open head or torso wounds with gross outpouring of cranial or visceral contents • Gross rigor mortis in a pulseless, apneic, warm patient

In such cases, no treatment is required, but Central Communications contact is required to notify the Emergency Medical Services and the Police Department.

Documentation Guidelines for the Firefighter / First Responder You need to complete a Medical Assist Report (MAR) for any cardiac arrest including:

• Date and time of the call • Patient’s name, address and date of birth • Incident history, and assessment findings • Names and/or I.D. numbers of EMS paramedics in attendance

2. EXPECTED DEATH – DO NOT RESUSCITATE (DNR) Upon arrival at a scene a Firefighter / First Responder may be presented with a request NOT to initiate

resuscitation. In order to consider the request, one of the following must be present:

A. An appropriately completed “Ministry of Health (MOH) DNR CONFIRMATION FORM” (a sample is provided on page 12).

OR B. A York/Durham Region recognized “DO NOT RESUSCITATE MEDICAL DIRECTIVE AND

FUNERAL HOME TRANSFER FORM” order document clearly identifying the patient, the physician and any substitute decision-maker involved (a sample is provided on page 11).

OR

C. The attending physician is present and he/she indicates that he/she is the patient’s physician and that resuscitation is not indicated.


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If no physician is present, the Firefighter / First Responder will:

• Contact Central Communications: o stating the patient’s condition o verifying the presence of valid documentation o ensure that Emergency Medical Services is responding o ensure that the Police department is responding

• Complete a MAR, leaving the white copy on-scene and retaining the others for distribution. • Remain at the scene until EMS has arrived.

If the family/attending physician is on scene, the Firefighter / First Responder will:

• Contact Central Communications: o stating the patient’s condition o identifying the name of the physician on scene o ensure that Emergency Medical Services is responding

• Complete a MAR, leaving the white copy on scene and retaining the others for distribution.

Documentation Guidelines for the Firefighter / First Responder Do NOT document anything on the “DO NOT RESUSCITATE MEDICAL DIRECTIVE AND FUNERAL HOME TRANSFER FORM”. You need to complete a MAR as for any other cardiac arrest including:

• Date and time of the call • Patient’s name, address and date of birth • That the appropriate DNR was seen by responders • Names of witnesses at the scene (person assuming responsibility for the victim or on-scene

physician • Names and / or numbers of EMS paramedics in attendance

NOTES • In the event of a disagreement on scene between family members regarding the resuscitation, the firefighter

/ first responder on scene will consider the DNR null and void and initiate a resuscitation, until otherwise directed by EMS.


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DO NOT RESUSCITATE MEDICAL DIRECTIVE &

FUNERAL HOME TRANSFER FORM

I ________________________________, have discussed and understand my health status and

(Client’s name-print)

prognosis with my physician, _________________________________. I request that, in the event my

(Physician name-print)

heart stops beating and/or my breathing stops, Emergency Medical Responders (Nurses, Paramedics, Police or Firefighters) shall not attempt to resuscitate me.

In the event that the above named person is incapable of making, or understanding their own health care decisions, _____________________________________ has been appointed as the substitute (Substitute Decision-makername-print) decision-maker and agrees to the preceding information. ___________________________________ _____________________________________________________ (Client’s signature, date) (Client’s name-print) ____________________________________ _____________________________________________________ (Substitute Decision-maker signature, date) (Relationship and/or Power of Attorney for Care) ___________________________________ Tel #____________After Hr #____________Pager/cell____________ (Physician signature, date) (Physician contact no. in event of death) ____________________________________ Tel #____________After Hr #____________Pager/cell____________ (Alternate Physician name/ Physician Group) (alternate Physician/Group contact no. in event of death) Pronounced at home on ____________________________________at __________________________________ (date) (time) by _________________________________________________________________________________________ (Nurse/Paramedic) (Agency) Dr. ___________________________________________notified at _____________________________________ (Doctor’s name) (date & time) Funeral Home _____________________________________________contacted at _________________________ (Funeral Home name) (date & time) Once death has been pronounced, this form will enable a funeral home to remove the deceased prior to signature of the Medical Certificate of Death. The Funeral director will arrange with the Attending Physician for completion of the Medical Certificate of Death. The Paramedics/Nurse or Coroner’s agent will notify the Attending Physician as soon as possible. In the event that the Attending Physician is not immediately available, his/her Alternate will be contacted. It is requested, that a partially completed Medical Certificate of Death be left attached to this form (not yet completed and unsigned by physician). The “Do Not Resuscitate Medical Directive and Funeral Home Transfer Form” must be completed in full, and signed, to be acted upon by Emergency Responders This document has been authored conjointly by the Coroner’s office, Palliative care Physician group, Durham Access To Care, Funeral Director’s group and the Base Hospital Paramedic Program for York / Durham Region. Nov 2006


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CARDIAC ARREST REFERENCE PAGE • “Witnessed” refers to a cardiac arrest that occurs in front of the firefighter / first responder. “Unwitnessed”

refers to the situation in which the firefighter / first responder arrives to find the patient in cardiac arrest.

• If effective CPR is being performed by a bystander upon your arrival, you may credit the bystander’s CPR into your “2 minutes of CPR” to be done before the SAED is applied.

• CPR should be performed according to the Heart and Stroke Foundation of Canada Guidelines for 2006.

PATIENT AGE SINGLE RESCUER

MULTIPLE RESCUERS

COMPRESSION RATE

Adult

(≥ 8 years of age) 30 : 2 30 : 2 100 / min

Child/Infant

(30 days to 8 years of age) 30 : 2 15 : 2 100 / min

Neonate

(< 29 days of age) 3 : 1 3 : 1 120 / min

• If the Firefighter / First Responder encounters a citizen with an SAED on scene, allow the citizen to complete the shock sequence safely. Once the citizen SAED prompts to commence CPR, the Firefighter / First Responder should switch over to their defibrillator and continue the resuscitation. Make sure that treatment provided by the citizen provider is reported to the EMS paramedic, as well as documented on the Medical Assist Report (MAR). It is the responsibility of the citizen responder to download the information from their SAED. The Firefighter / First Responder is only responsible for the information transfer from their own SAED.

• In the event of return of spontaneous circulation and then re-arrest, the rhythm should be reanalyzed immediately and the directive resumed (this may necessitate turning the defibrillator off and back on).

• If the SAED fails to operate, continue CPR. A second rescuer should attempt to trouble shoot the SAED problem (i.e. change battery, examine cables/pads, improve pad adherence to the chest etc.). You should update EMS of the situation and consider calling for a second SAED from your service if it will be faster than EMS. After the call is complete, you should remove the SAED from service and ensure it is flagged for maintenance. You should also document the SAED and details of your management of the patient and SAED situation on the MAR.

• Should exceptional conditions (water rescue, long distance difficult access, etc.) warrant the need for patient movement to facilitate a rendezvous with EMS, the patient may be moved as long as appropriate patient care is continued and safety precautions taken.

• Pad placement – the preferred pad placement in cardiac arrest is the sternum apex position. In the event that the pads cannot be placed in this position without overlapping, as In the smaller patient, including the pediatric patient, the bi-axillary (armpit) position is next in order of preference. If due to curvature of the chest wall, this position cannot be used, the anterior posterior position may be used.


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RAPID TRAUMA EXTRICATION GUIDELINE When the following indications and conditions exist, a Firefighter / First Responder may treat victims of cardiac arrest according to the following: Indications 1. Environmental situations that place the patient’s life in imminent danger. 2. Primary Survey findings that place the victim’s life in imminent danger:

a) no breathing with the inability to ventilate in the position found, and/or b) no pulse with the inability to provide chest compressions in the position found and/or c) serious gross bleeding with the inability to control it in the position found

Conditions N/A Contraindications Firefighter / First Responder safety is at risk Procedure 1. Maintain the patient’s head and neck in neutral alignment. 2. Remove the patient to a safe place and reassess beginning with the primary survey. 3. If available, an appropriately sized cervical collar and a backboard may be applied to the patient. Notes • Immobilization with a collar and backboard is typically undertaken under the direction of an EMS crew.


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ADDITIONAL GUIDELINES FOR THE EMR – IMMOBILIZATION When the following indications and conditions exist, an EMR firefighter may immobilize patients according to the following: Indications 1. Rescue situation that paramedics can’t safely enter (e.g. high angle rescue or confined space, etc.) 2. Under the direction of an “on-scene” paramedic Conditions

N/A Contraindications Firefighter / First Responder safety is at risk Procedure

1. Apply manual stabilization of the head & neck in a neutral position 2. Size and apply cervical collar 3. Log-roll patient supine onto backboard (using 3 rescuers) holding:

a. The head b. The shoulder area c. The pelvic area

4. Apply head blocks on each side of head 5. Secure the head, chest and pelvis (straps and tape) to the backboard

Notes: • Always ensure ABCs are being assessed and treated. Example - oxygen 100%

- ventilation - cardiac compression - AED - control severe bleeding

• Firefighters need to protect the neck and spine of stable patients by holding their head and preventing

movement. Immobilization is typically undertaken under the direction of EMS.


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ADDITIONAL GUIDELINES FOR THE EMR – BURN TREATMENT When the following indications and conditions exist, an EMR firefighter may treat patients with burns according to the following: Indications Primary assessment indicates that the patient has been burned. This includes burns caused by thermal, chemical, radiation and electrical sources. Conditions N/A Contraindications Firefighter / First Responder safety is at risk Procedure

1. Manage the scene safely, especially when removing the patient from the source of the burn.

2. Assess and manage the airway, ventilation and oxygenation.

3. Treat burn patients as trauma patients, and perform a rapid trauma assessment.

4. Properly cool thermal burns if you reach the patient early, but be careful not to induce hypothermia.

5. Initiate therapy according to the appropriate guideline (i.e. thermal, radiation, electrical and chemical). These guidelines are found on the next few pages.

Notes • Patients do not die quickly from burns. It is the injuries and trauma that are associated with the burns (i.e.

potential airway problems, altered levels of consciousness, major injuries) that cause rapid death. Therefore, manage the life threatening injuries before the burns.

• Remember that any victim exposed to smoke and/or fire should be assumed to have carbon monoxide

poisoning, airway swelling and/or airway compromise due to the heat and smoke from the fire. The upper and lower airways could have burns that will not appear serious until the victim’s condition suddenly changes. Physical findings to alert you are:

• Unresponsive or semi-responsive victim • Facial burns • Soot on face and/or in mouth • Difficulty swallowing or talking • Shortness of breath • Use of accessory muscles to breathe (neck, shoulders, in-drawing of chest, JVD, etc.)


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ADDITIONAL GUIDELINES FOR THE EMR –THERMAL & RADIATION BURNS Procedure

1. Ensure the area is safe and you can remove the patient from the hazard safely.

2. Ensure airway, breathing and circulation is adequate. Provide oxygen (high concentration) and ventilation support if required.

3. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal

airway is inserted.

4. Complete a rapid trauma assessment.

5. Remove burned clothing that is not stuck to the burn.

6. Remove rings, watches, or other jewelry if that area is involved (i.e. hands, wrists, or toes).

7. Cover partial thickness burns with a BSA (Body Surface Area) of less than 10% with clean/sterile dressings. You may cool with water/saline or use a manufactured dressing like a Water Jel if the blisters are not broken and the tissue is still hot.

8. Cover partial or full thickness burns with a BSA of 10% or greater with a dry sterile dressing only. Apply

water only to extinguish fire/smoldering clothes or flesh.


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ADDITIONAL GUIDELINES FOR THE EMR – ELECTRICAL BURNS Procedure

1. Ensure the area is safe and you can remove the patient from the hazard safely. Special training is required to safely handle energized electrical equipment. Ensure appropriate personal protective equipment is worn to protect yourself.

2. Ensure airway and breathing are adequate. Provide oxygen (high concentration) and ventilation support if required.

3. Assess circulation. (A common result of electrical contact is ventricular fibrillation. Therefore, check cardiac status and ensure the SAED is readily available. Continue to monitor pulse. With high voltages and lightning strikes, assume spinal injuries as well.)

4. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal airway is inserted.

5. Complete a rapid trauma assessment



8. Cover partial thickness burns with a BSA of less than 10% with sterile dressings. You may cool with water/saline or use a manufactured dressing like a Water Jel if the blisters are not broken.

9. Cover partial or full thickness burns with a BSA of 10% or greater with a dry sterile dressing only. Apply water only to extinguish fire/smoldering clothes or flesh.

10. Additional information will be required by the treating hospital. If possible and without delaying patient transfer inquire about the following:

a. The type and amount of current

b. Path of current flow (through the body)

c. How long the patient was in contact with the current

11. Industrial EMR should also ensure that the appropriate management supervisor follows up with any additional information on the nature of the electrical contact to the treating hospital.

Notes

• N/A


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ADDITIONAL GUIDELINES FOR THE EMR – CHEMICAL BURNS Procedure

1. Identify the chemical. Ensure the area is safe and you can remove the patient from the hazard safely. Special training is required to safely handle hazardous materials like corrosive chemicals. Ensure appropriate personal protective equipment is worn.

2. Ensure the area is safe and you can remove the patient from the hazard safely.

3. Remove any contaminated clothing from the patient. This will protect both the patient and the responder from the chemical. Brush off any dry powder chemicals from the patient before flushing the burn area. Flush the affected area with water for 15 minutes. If it is a liquid chemical, flush immediately before removing the clothing and continue for 15 minutes. Remove the clothing from the liquid contaminated casualty while flushing.

4. Ensure airway, breathing and circulation is adequate. Provide ventilation support if required.

5. If burns involve the face/airway, and the patient is unresponsive to pain, ensure an oropharyngeal airway is inserted.

6. Complete a rapid trauma assessment.



9. Cover burns with a dry sterile dressing.

10. Industrial EMR should also ensure that the appropriate management supervisor follows up communicating any additional information on the chemical to the treating hospital.

Notes

• In some circumstances, steps 3 and 4 may need to be completed at the same time as Step 2, but remember to protect yourself from the chemical.

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