Pocket Reference Guide 2011 - lakeridgehealth.on.ca · Jaun Bothma Deepinder Brar Brenda Burns...

PrimaryCareParamedicPocket Reference Guide

2011 Version 1.2

CEPCP

This pocket reference guide is to be used for reference

only. Refer to the current medical directives for all treatment decisions. If there are inconsistencies between

this reference guide and the current directives always refer to the medical directives.

For questions, comments, or suggestions for improvements, please contact us at:

Website (follow ‘contact us’ link):www.cepcp.ca

Administration Office:95A Simcoe St. S. Oshawa, ON

Mailing Address: Central East Prehospital Care ProgramLakeridge Health Oshawa1 Hospital CourtOshawa, ONL1G 2B9

Phone: (905) 433-4370Fax: (905) 721-4737

Toll free: 1-866-423-8820

2

Table of Contents:

BHP names................................................................ 5Cardiac Arrest............................................................ 6 - 7Trauma Cardiac Arrest............................................... 8Foreign Body Airway Obstruction............................... 9Neonatal Resuscitation.............................................. 10 - 11Hypothermia Cardiac Arrest....................................... 12Supraglottic Airway..................................................... 13Return of Spontaneous Circulation............................ 14IV and Fluid Therapy.................................................. 15Cardiogenic Shock.............................................. 16 Moderate to Severe Allergic Reaction....................... 18-19Croup.......................................................................... 20Bronchoconstriction.................................................... 21CPAP........................................................................... 22Acute Cardiogenic Pulmonary Edema........................ 23Cardiac Ischemia......................................................... 24 - 25STEMI Bypass............................................................ 26 - 27Nausea / Vomiting....................................................... 28 - 29Hypoglycemia............................................................. 30 - 31Electronic Control Device Probe Removal.................. 32 Special Events............................................................ 33 - 37

References (section two)

Central East Prehospital Care Program For reference only 3

4� Central East Prehospital Care Program For reference only

Markham:Shobana AnanthAndrew ArcandDavid AustinLuke BearssKatherine Bingham Tara ByrneJoan Cheng Ross Claybo Nicole Kester GreeneIlana Greenwald Peter Haw Karen HeldRoberta HoodWendy IsemanPaul JacobsonDoug JangMano KanetosScott KapoorMonica KapoorBarb KingTom Leventis Bernice MittlemanPhil MoranMike Nowak Meeta PatelCristina PopaSonia Sabir Seyon SathiaseylonSam SueMichael TaylorPaul YeeJason Zitsow

Durham:Elanchellyan AmbalavanarPeter BlecherTony ChinMike EvansPing FuBenj FullerKevin GreenMichael KahnGeoff KennedyWill LotteringGetachew MazangiaFarley MossTom NovakErik PaidraAbdolreza Paki-JavanJim ShipleyRob StuparykRudy Vandersluis

Peterborough:Vince ArcieriJohn AshbourneKate BinghamJaun BothmaDeepinder BrarBrenda BurnsDavid CarrJennifer DarlingNicole DeFrancescoKirk DillonNick FerozeDale FriesenReinhart FriesenGary HillDan HouptAnthony JefferyBrian LindsayJohn Lingertat Terry MayJames McGormanTemba McWabeniMichael MunozAllen RodgersAndrew Romanowski Grant PetersMark TroughtonNancy White


Base Hospital Physician Names:

6� Central East Prehospital Care Program For reference onlyM

edic

al C

ard

iac

Arr

est Indications

Medical Cardiac Arrest

Non-traumatic cardiac arrest

CPR ongoing throughout callMinimize Interruptions100 - 120 per minute

At least 2 inches depth30:2

Drug Dose

Epinephrine IM

King LT should be inserted where more than OPA/BVM is required, without interrupting CPR. Once inserted, begin continuous compressions and ventilate asynchronously at 6-8 breaths / min. monitor ETCO2: 10 - 15 mmHg - poor prognosis, confirm compressions are adequate 20 - 30 mmHg - improved prognosis, indicates good CPR quality > 35 mmHg - excellent CPR / prognosis, check for palpable pulse large spike to above normal values - probable ROSC, check for pulse

Analyze

every 2 minsTransport to hospital following the 4th analysis unless medical TOR

Shock if indicatedResume CPR immediately

(if suspected anaphylaxis) 0.01 mg/kg 1:1,000 (max 0.5 mg) single dose

Medical TOR • > 18 years old• Presumed cardiac origin• Arrest not witnessed by EMS• 3 analysis with no shocks delivered• No ROSC at any time


Confirmation MethodsPrimary

• Auscultation• Chest rise

Secondary• ETCO2• OtherConfirm supraglottic airway placement.

Notes:

Size Colour Patient Amt of air in cuff#3 Yellow 4-5 ft tall 45 - 60 ml

#4 Red 5-6 ft tall 60 - 80 ml

#5 Purple ≥ 6 ft tall 70 - 90 ml

King LT Reference

Medical TOR Patch

“This is (your name) a Primary Care Paramedic on vehicle (number) patching for Termination of Resuscitation for a cardiac arrest”

Patient is (age) years old (estimate if needed)Gender (male or female)

State the three TOR Guidelines :• we did not witness the arrest• no shocks were given, and • there has been no return of a carotid pulse.

Brief past medical history, history of current presentationThe patient was last seen at______ And was at that time complaining of___________The patient has a history of__________My interpretation of the TOR guideline is that we could consider stopping resuscitation at this time.

Ask the BHP if further information is required? Would you like further clinical information?

______________________________

Questions that may be asked:Estimated number of minutes to the arrival on scene from the time you were notified.Whether or not the cardiac arrest was witnessed by a bystanderWhether or not bystander CPR was done.Extrication problems, if any, that may delay initiating transport.Estimated number of minutes for ambulance transport to the receiving hospital.

8� Central East Prehospital Care Program For reference onlyTr

aum

a C

ard

iac

Arr

est Indications

Trauma Cardiac Arrest

Cardiac arrest secondary to severe blunt or penetrating trauma.

If Shockable Defibrillate once

Protect C-spineBegin chest compressions

Attach SAED padsBegin PPV with BVM

After 2 minutes perform ANALYSIS

If in PEA determine drive-time to nearest

hospital

ASYSTOLE

Less than 30 minutes drive-time to nearest ER?

16 years or older?

Continue CPRImmobilize Patient

Transport to Hospital

Continue CPRPatch to BHP for possible trauma TOR

Yes No

Yes

No

If No Shock Advised Determine Rhythm


Clinical Parameters

Not obviously dead as per BLS standard

No DNR

Interventions

Attempt to clear airway with BLS maneuvers

Indications

Foreign body airway obstruction

Cardiac arrest secondary to an airway obstruction.

Analyze once and defibrillate if the patient is in a shockable rhythm

If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first rhythm analysis.

FB

AO

Card

iac Arrest

10 Central East Prehospital Care Program For reference onlyN

eon

atal

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itat

ion


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ced

from

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eona

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esus

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tion

Text

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Notes:

12 Central East Prehospital Care Program For reference onlyH

ypo

ther

mic

Arr

est

Clinical Parameters

Not obviously dead as per BLS standard

No DNR

Interventions

Indications

Hypothermia Cardiac Arrest

Cardiac arrest secondary to severe hypothermia.

Analyze once Defibrillate if the patient is in a shockable rhythm

Transport to the closest appropriate facility without delay following the first rhythm analysis.


Su

prag

lottic A

/W

Clinical Parameters

• Patient in cardiac arrest• Able to clear the airway (with suctioning etc.)• No active vomiting• No airway edema• No stridor• No caustic ingestion

IndicationsNeed for ventilatory assistance OR airway control

ANDOther airway management is inadequate OR ineffective OR unsuccessful

Supraglottic Airway

Two attempts maximum. An 'attempt' is defined as the insertion of the supraglottic airway into the mouth.

Confirmation MethodsPrimary

• Auscultation• Chest rise

Secondary• ETCO2• OtherConfirm supraglottic airway placement.

Notes:

Size Colour Patient Amt of air in cuff#3 Yellow 4-5 ft tall 45 - 60 ml

#4 Red 5-6 ft tall 60 - 80 ml

#5 Purple ≥ 6 ft tall 70 - 90 ml

14� Central East Prehospital Care Program For reference onlyR

OS

C

Clinical Parameters

Bolus (ONLY IF CERTIFIED AND AUTHORIZED IN AUTONOMOUS IV)• Clear chest / no fluid overload

SBP < 90 mmHg

Drug Initial Dose Reassess Q Max

Notes:

Titrate oxygenation to ≥ 94%

Avoid hyperventilation and target an ETCO2 of 35-40 mmHg with continuous capnography.

Consider 12 lead ECG.

Return of Spontaneous Circulation (ROSC)

Adult Doses (≥12 years)

Pediatric Doses

Bolus IV only 10 ml/kg 250 ml 1,000 ml

IndicationsROSC after resuscitation was initiated

Drug Initital Dose Reassess Q Max

Bolus IV only 10 ml/kg 100 ml 1,000 ml


Clinical Parameters

≥ 2 years old (for IV start and/or bolus)

IV Start:No fracture proximal to IV siteBolus:No signs of fluid overloadSBP < 90

Drug Initital Dose Q Repeat Max

Bolus IV/IO/CVAD 20 ml/Kg Reassess q250 ml

N/A

Notes:

PATCH to BHP for authorization to administer IV bolus to patients ≥ 2 - 12 years with suspected Diabetic Ketoacidosis (DKA).

Actual or potential need for intravenous medication or fluid therapy

2,000 ml

Drug Initital Dose Q Repeat Dose Max

Adult Doses ≥ 12 years

Pediatric Doses ≥ 2 years - 12 years, Use micro drip or Buretrol

TKVO IV/IO/CVAD 30 - 60 ml/hr

Bolus IV/IO 20 ml/Kg Reassess q100 ml

N/A 2,000 ml

TKVO IV/IO 15 ml/hr

IndicationsActual or potential need for IV medication or fluid therapy

IV and Fluid Therapy (ONLY IF CERTIFIED AND AUTHORIZED IN AUTONOMOUS IV)

IV an

d F

luid

s

16 Central East Prehospital Care Program For reference only

Clinical Parameters

Bolus:Clear Chest

SBP < 90

Drug Initial Dose Q Repeat Dose Max

Bolus IV/IO 10 ml/KgReassess q

250 mlN/A


Bolus IV/IO 10 ml/KgReassess q

100 ml N/A

Adult Doses (≥ 18 Years)

Pediatric Doses (< 18 years)

IndicationsSTEMI and Cardiogenic Shock.

Cardiogenic Shock (ONLY IF CERTIFIED AND AUTHORIZED IN AUTONOMOUS IV)

Car

dio

gen

ic S

ho

ck

Notes:


18 Central East Prehospital Care Program For reference onlyA

llerg

ic R

eact

ion

Clinical Parameters

Drug Initial Dose Q Repeat Max

Diphenhydramine IM/IV(IV only if certified in autonomous IV)

Notes:

Epinephrine should be the first drug administered in anaphylaxis.

The epinephrine dose may be rounded to the nearest 0.05 mg.

Diphenhydramine is commonly referred to as Benadryl® and isusually supplied in a vial with a rubber stopper.


Adult Doses ( ≥ 50 kg)

Pediatric Doses

50 mg (1 ml)> 50 Kg N/A N/A 1 dose

Epinephrine IM 0.5 mg> 50 Kg N/A N/A 1 dose

Diphenhydramine IM/IV(IV only if certified in autonomous IV)

25 mg (0.5 ml)> 25-50 Kg N/A N/A 1 dose

Epinephrine IM N/A N/A 1 dose0.01 mg/kgMax 0.5 mg

IndicationsExposure to a probable allergen and signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis).

Moderate to SevereAllergic Reaction

Epinephrine:Use for anaphylaxis only

No allergy or sensitivity to any drug administered.


Epinephrine 1:1,000 0.01 mg/kg

Rounded to the nearest 0.05 ml

20� Central East Prehospital Care Program For reference only

Clinical Parameters

• < 8 years old

• No allergy or sensitivity to epinephrine

• Heart rate less than 200 / min

Notes:

The minimum initial volume for nebulization is 2.5 ml.

Drug Dose Max

Pediatric Doses

Epinephrine ≥ 1 year old 1 dose5.0 mg

(5 ml)

Epinephrine< 1 year old

> 5 kg or more1 dose2.5 mg

(2.5 ml)

Epinephrine< 1 year < 5 kg

1 dose0.5 mg(mix with 2 ml of saline to make 2.5 ml)

IndicationsSevere respiratory distress and stridor at rest and current history of URTI and barking cough or recent history of a barking cough.

Croup

Cro

up


Clinical Parameters

No allergy or sensitivity to any drug administered.


Salbutamol Nebulized ≥ 25 kg

Notes:

Epinephrine should be the first drug administered if the patient is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter (if available).

Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health.

When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths.

A spacer should be used when administering salbutamol MDI (if available).


Adult Doses

Pediatric Doses

Salbutamol MDI ≥ 25 kg 800 mcg 5-15 min 800 mcg

5 mg 5-15 min 5 mg 3 doses

3 doses

Epinephrine IM ≥ 50 kg 0.5 mg N/A N/A 1 dose

Salbutamol Nebulized < 25 kg

Salbutamol MDI < 25 kg 600 mcg 5-15 min 600 mcg

2.5 mg 5-15 min 2.5 mg 3 doses

3 doses

Epinephrine IM < 50 kg N/A 1 dose

IndicationsRespiratory distress and suspected bronchoconstriction.

Bronchoconstriction

0.01 mg/kgMax 0.5 mg

Epinephrine:• BVM ventilation is required• Must have a history of asthma

Bro

nch

oco

nstrictio

n

22� Central East Prehospital Care Program For reference onlyC

PAP

Clinical Parameters

• ≥ 18 years old• Able to sit upright and cooperate• Respiratory rate ≥ 28 / minute• SpO2 < 90% OR accessory muscle use• SBP ≥ 100, discontinue if BP falls to < 90 after initiation

• Not asthma exacerbation• Not suspected pneumothorax• No major trauma or burns to the head or torso• No Tracheostomy

Start at Increase by Q Max

Notes:

Confirm CPAP by manometer if available

Adult Doses ≥ 18 years

5 cmH20or

15 lpm if Boussignac

2.5 cmH20or

5 lpm if Boussignac5 mins

15 cmH20or

25 lpm if Boussignac

IndicationsSevere respiratory distress AND;

Signs and/or symptoms of acute pulmonary edema OR COPD

CPAP

If device has adjustable FiO2, begin at lower setting and increase to max if SpO2 remains < 92% despite treatment and/or 10 cmH2O (20 lpm if Boussignac).


Acu

te Pu

lmo

nary E

dem

a

Clinical Parameters Vital Sign Parameters

No allergy or sensitivity

No phosphodiesterase inhibitors* in past 48 hrs

If BP < 140 mmHg then must have prior nitroglycerine use, or IV initiated

HR: 60 - 159SBP ≥ 100SBP drops no more than 1/3 of initial value


Nitroglycerine BP 100 - 140 0.4 mg S/L 5 min 0.4 mg 6 doses

Adult Dose ≥ 18 years only

Notes:

Perform 12 / 15 lead

Nitroglycerine BP ≥ 140

NO History or IV

0.4 mg S/L 5 min 0.4 mg 6 doses

NitroglycerineBP ≥ 140

WITH History or IV

0.8 mg S/L 5 min 0.8 mg 6 doses

IndicationsModerate to severe respiratory distress from suspected acute cardiogenic pulmonary edema

Acute Cardiogenic Pulmonary Edema

* Phosphodiesterase inhibitors:

- Sidenafil: Viagra, Revatio (for pulmonary hypertension)- Tadalafil: Cialis, Adcirca (for pulmonary hypertension)- Vardenafil: Levitra, Staxyn


Clinical Parameters

ASA:Able to chew and swallowPrior use of ASA if asthmaticNo allergy to ASA or NSAIDsNo Current, active bleedNo CVA / TBI in past 24 hrs

No allergies or sensitivity to given drug ≥18 years oldUnaltered LOA


Nitroglycerine 0.4 mg S/L 5 min 0.4 mg 6 doses

Adult Dose ≥ 18 years only

Notes:

Perform 12 / 15 lead

ASA 160 mg PO N/A N/A 160 mg

IndicationsSuspected Cardiac Ischemia

Cardiac Ischemia Medical Directive

Nitroglycerine:Prior nitroglycerine use or IV initiatedHR 60 - 159SBP ≥100. D/C if BP drops more than 1/3 of initialNo phosphodiesterase inhibitor* in past 48 hrsNo right ventricular MI

* Phosphodiesterase inhibitors:

- Sidenafil: Viagra, Revatio (for pulmonary hypertension)- Tadalafil: Cialis, Adcirca (for pulmonary hypertension)- Vardenafil: Levitra, Staxyn

Car

dia

c Is

chem

ia

Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care

STEMI Hospital Bypass Protocol

In situations in which the paramedic suspects that the patient is suffering from a STEMI, the paramedic shall:

1. assess the patient to determine if they meet all of the following indications: a. ≥18 years of age; b. experience chest pain or equivalent consistent with cardiac ischemia or myocardial

infarction; c. the time from onset of the current episode of pain <12 hours; and d. the 12-lead electrocardiogram (ECG) indicates an acute myocardial

infarction/STEMI, as follows: i. At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads;

OR ii. At least 1 mm ST-elevation in at least two other anatomically contiguous

leads; OR iii. 12-lead ECG computer interpretation of STEMI and paramedic agrees.

2. if the patient meets the criteria listed in paragraph 1 above, assess the patient to determine if they have any of the following contraindications: a. The patient is CTAS 1 and the paramedic is unable to secure the patient’s airway or

ventilate; b. 12-lead ECG is consistent with a Left Bundle Branch Block (LBBB), ventricular

paced rhythm, or any other STEMI imitator; c. Transport to a hospital capable of performing percutaneous coronary intervention

(PCI) ≥60 minutes from patient contact; d. The patient is experiencing a complication requiring primary care paramedic (PCP)

diversion, as follows: i. Moderate to severe respiratory distress or use of continuous positive airway

pressure (CPAP); ii. Hemodynamic instability (e.g. due to symptomatic arrhythmias or any

ventricular arrhythmia) or symptomatic SBP <90 mmHg at any point; or iii. VSA without return of spontaneous circulation (ROSC).

e. The patient is experiencing a complication requiring ACP diversion, as follows: i. Ventilation inadequate despite assistance;

ii. Hemodynamic instability unresponsive to advanced care paramedic (ACP) treatment or not amenable to ACP management; or

iii. VSA without ROSC. 3. notwithstanding paragraphs 2(c), 2(d), and 2(e) above, attempt to determine if the

interventional cardiology program at the PCI centre will still permit the transport to the PCI centre;

4. if the patient does not meet any of the contraindications listed in paragraph 2 above OR the interventional cardiology program permits the transport to the PCI centre as per paragraph 3 above, inform the CACC/ACS of the need to transport to a PCI centre; a. provide the PCI centre the following information as soon as possible: b. that the patient is a “STEMI patient”; c. the patient’s initials; d. the patient’s age; e. the patient’s sex; f. the paramedic’s concerns regarding clinical stability; g. infarct territory and/or findings on the qualifying ECG; h. estimated time of arrival; and i. catchment area of the patient pickup.


5. upon arrival at the PCI centre, in addition to the requirements listed in the Transfer of

Responsibility for Patient Care Standard, provide the following information to the PCI centre staff: a. time of symptom onset; b. time of ROSC, if applicable; c. hemodynamic status; d. medications given and procedure; e. history of acute myocardial infarction/PCI/Coronary artery bypass graft, if applicable; f. a copy of the qualifying ECG; and g. a copy of the Ambulance Call Report in accordance with the Ontario Ambulance

Documentation Standards.

*Note: Once initiated, continue to follow the STEMI Hospital Bypass Protocol even if the ECG normalizes after the intial assessment.

Guideline • Once a STEMI is confirmed, the paramedic should apply defibrillation pads due to the

potential for lethal cardiac arrhythmias. • If intravenous access is indicated and established as per the Advanced Life Support

Patient Care Standards, then the left arm is the preferred site. • If the ECG becomes STEMI-positive en route to a non-PCI destination, the patient

should still be evaluated under this STEMI Hospital Bypass Protocol. • If, in a rare circumstance, the PCI centre indicates that it cannot accept the patient (e.g.

equipment failure, multiple STEMI patients), then the paramedic may consider transport to an alternative PCI centre as long as they still meet the STEMI Hospital Bypass Protocol.


g. estimated time of arrival; and h. catchment area of the patient pickup.

6. upon arrival at the PCI centre, in addition to the requirements listed in the Transfer of Responsibility for Patient Care Standard, provide the following information to the PCI centre staff: a. time of symptom onset; b. time of ROSC, if applicable; c. hemodynamic status; d. medications given and procedure; e. history of AMI/PCI/Coronary artery bypass graft (CABG), if applicable; f. a copy of the qualifying ECG; and g. a copy of the Ambulance Call Report (ACR), where possible.

*Note: Once initiated, continue to follow the STEMI Hospital Bypass Protocol even if the ECG normalizes after the intial assessment.

Guideline 1. If intravenous access is indicated and established as per the Advanced Life Support

Patient Care Standards, then the left arm is the preferred site. 2. If the ECG becomes STEMI-positive enroute to a non-PCI destination, the patient should still be evaluated under this STEMI Hospital Bypass Protocol. 3. If, in a rare circumstance, the PCI centre indicates that it cannot accept the patient (e.g. equipment failure, multiple STEMI patients), then the paramedic may consider transport to an alternative PCI centre as long as they still meet the STEMI Hospital Bypass Protocol.

Basic Life Support Patient Care Standards Section 2 – Medical Patient Categories

4 County Paramedic Services - PRHC STEMI Bypass Protocol

This prompt card provides a quick reference for the EMS modified STEMI Hospital bypass Protocol. It is only applied when bypassing patients to the PRHC PCI Centre. For those patients where the PRHC PCI Centre is not closest, the EHS STEMI Hospital Bypass Protocol contained in the BLS PCS must be used. Please refer to the BLS PCS for the full protocol EHS version.

Indications under the STEMI PRHC Bypass Protocol

Transport to a PCI Centre will be considered for patients who meet ALL of the following:

1. ≥18 years of age. 2. Chest pain or equivalent consistent with cardiac ischemia/myocardial infarction. 3. Time from onset of current episode of pain <12 hours. 4. 12-lead ECG indicates an acute AMI/STEMI*:

a. At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads; OR b. At least 1mm ST-elevation in at least two other anatomically contiguous leads; OR c. 12-lead ECG computer interpretation of STEMI and paramedic agrees.

*Once activated, continue to follow STEMI Hospital Bypass Protocol even if ECG normalizes.

Contraindications under the STEMI Hospital Bypass Protocol

ANY of the following exclude a patient from being transported under the STEMI Hospital Bypass Protocol:

1. CTAS 1 and the paramedic is unable to secure patient’s airway or ventilate. 2. 12-lead ECG is consistent with a LBBB, ventricular paced rhythm, or any other STEMI imitator. 3. Transport to a PCI centre ≥60 minutes from patient contact. 4. Patient is experiencing any of the following complications:

a. Hemodynamic instability unresponsive to treatment b. VSA without ROSC c. Ventilation inadequate despite assistance.

STEMI Protocol Communication Procedure: 1. Call PRHC switchboard directly: 705-876-5067 2. Identify yourself as Peterborough Paramedics, state: “Activate Code STEMI” 3. Patch to the PRHC ED. State “We are transporting a Code STEMI patient to the cardiac

catheter lab” 4. Notify CACC. They will authorize the transport once notified of the patient’s need for bypass

under the STEMI Hospital Bypass Protocol. Note: Apply defibrillation pads to all the patient who have a STEMI


COMMONCOMMON IMITATORS OF MIIMITATORS OF MI ’S’S IINTERPRETINGNTERPRETING STST SEGMENTSEGMENT Δ’Δ’S IS NOT POSSIBLE INS IS NOT POSSIBLE INS IS NOT POSSIBLE IN THE FOLLOWING RYTHYMTHE FOLLOWING RYTHYM SS ((NOT ANOT A

COMPLETE LISTCOMPLETE LIST –– OTHER IMITATORS EXISOTHER IMITATORS EXISOTHER IMITATORS EXIS TT))

LLBBBBBB Characterised by a supraventricular rhythm (identified by the presence of P waves)

& a wide QRS complex. A LBBB will have a -ve terminal deflection in V1 and typically a secondary R wave in

V6 (seen as a notched complex seen as RsR’ below). RBBB will have a +ve terminal deflection in V1 typically with a notched complex & a

slurred or prolonged S wave in V6.

VVENTRICULAR ENTRICULAR PPACEDACED RRHYTHMHYTHM A pacer spike is typically seen immediately preceding the QRS complex which will

be wide.

LVHLVH Look at the RS complex in either V1 or V2 and count the

small boxes of the -ve deflection Then do the same with either V5 or V6, counting the small

boxes of the +ve deflection Add the two numbers together, if they equal ≥35 mm’s

then it’s likely LVH

28 Central East Prehospital Care Program For reference onlyN

ause

a / V

om

itin

g

Clinical Parameters

• Unaltered LOA• No allergies or sensitivity to dimenhydrinate or other antihistamines• Not overdosed on antihistamines, anticholinergics or tricyclic antidepressants


Dimenhydrinate IV/IM(IV only if certified in autonomous IV)

50 mg≥ 50 Kg N/A N/A 1 dose

Indications

Nausea OR Vomiting

Nausea / Vomiting


Pediatric Doses

Dimenhydrinate IV/IM (IV only if certified in autonomous IV)

25 mg≥ 25 - 50 Kg N/A N/A 1 dose

Adult Doses

Notes:

If drawing up dimenhydrinate for IV administration, dilute drug with 9 ml normal saline to a 50 mg in 10 ml solution.

Dimenhydrinate is commonly referred to as Gravol ® and usually comes supplied in a glass ampoule.


AntihistaminesActifedAstemazole (Hismanal)Azatdine (Zadine)Cetirizine (Zyrtec, Reactine) Chlorpheniramine (Chlor-Trimeton, chlortripalon) Clemastine Cyproheptadine (Periactin) DexchlorpheniramineDesloratadine (Clarinex) Dimenhydrinate (Dramamine)Diphenhydramine (Benadryl) Fexofenadine (Allegra) Hydroxyzine (Atarax, Vistaril) Loratadine (Claritin, Alavert)PhenothiazinesPromethazine (Phenergan)PiperzanesTerfenadine (Seldane)

AnticholinergicsAtropineHyoscineGlycopyrrolate (Robinul)ipratropium bromide (Atrovent)oxybutinin (Ditropan, Lyrinel XL)oxitropium bromide (Oxivent)tiotropium (Spiriva)

Tricyclic antidepressants (TCA)Amitriptyline (Elavil, Ednep, Vanatrip) Clomipramine (Anafranil)Desipramine (Norpramin), Doxepin (Sinequan, Adapin, Silenor) Nortriptyline (Aventyl, Pamelor), Protriptyline (Vivactil)Trimipramine (Surmontil)


Clinical Parameters Vital Sign Parameters

No allergy or sensitivity to given drug

Glucagon:No Pheochromocytoma

Dextrose only applies to those certified and authorized in autonomous IV

Hypoglycemia≥ 2 yrs < 4.0 mmol< 2 yrs < 3.0 mmol


Glucagon IM ≥ 25 kg

Notes:

If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple carbohydrates.If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of dextrose or glucagon.If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucometry must be attempted.

Hypoglycemia


Adult Doses

Pediatric Doses

Dextrose IV ≥ 50 kg 25 g 10 min 25 g

1 mg 20 min 1 mg 2 doses

2 doses

≥ 2 years to < 50 Kg Dextrose IV

D50W

1 ml/Kg

0.5 g/kgMax

25 g (50 ml)

10 min 2 doses

Glucagon IM< 25 Kg

0.5 mg 20 min 0.5 mg 2 doses

IndicationsAgitation or altered LOA or seizure or symptoms of stroke

1 ml/Kg

0.5 g/kgMax

25 g (50 ml)

Hyp

og

lyce

mia


Dextrose Reference


Clinical Parameters

• ≥ 18 years old• Unaltered LOA• Probes not embedded;

Above clavicles,In the nipple(s) or in the Genital area

Indications

Electronic control device probe(s) embedded in patient

Electronic Control Device Probe Removal

Remove probes

Notes:

Police may require preservation of the probe(s) for evidentiary purposes.

This directive is for removal of ECD only and in no way constitute treat and release, normal principles of patient assessment and care apply.

EC

D P

rob

e R

emo

val

Special Events Directives

Special event: a preplanned gathering with potentially large numbers and the Special Event Medical Directives have been preauthorized for use by the Medical Director



Clinical Parameters


Acetaminophen PO

Notes:

Release from care.

Advise patient that if the problem persists or worsens that they should seek further medical attention.

Adult Doses

325 - 650 mg N/A None 1 dose

IndicationsUncomplicated headache conforming to the patient's usual pattern.

Headache (Special Events Only)

• > 18 years old• Unaltered LOA

• No allergy or sensitivity to acetaminophen• No acetaminophen in the last 4 hours• No signs or symptoms of intoxication

Hea

dac

he


Clinical Parameters

• Unaltered LOA• No allergies or sensitivity to topical antiobiotics

Indications

Minor abrasions

Minor Abrasion (Special Events ONLY)

Notes:


Min

or A

brasio

n


Clinical Parameters


Diphenhydramine PO

Notes:

Release from care.

Adult Doses

50 mg N/A N/A 1 dose

IndicationsSigns consistent with minor allergic reaction.

Minor Allergic Reaction (Special Events Only)

• ≥18 years old• Unaltered LOA• SBP ≥100 (and other vitals within normal limits)

• No allergy or sensitivity to diphenhydramine• No antihistamine or sedative use in the previous 4 hours• No signs or symptoms of a moderate to severe allergic reaction• No signs or symptoms of intoxication• No wheezing

Min

or

Alle

rgic

Rea

ctio

n


Clinical Parameters


Acetaminophen PO

Notes:

Release from care.


Adult Doses

325 - 650 mg N/A None 1 dose

IndicationsMinor musculoskeletal pain.

Musculoskeletal Pain (Special Events Only)

• ≥18 years old• Unaltered LOA

• No allergy or sensitivity to acetaminophen• No acetaminophen use in the last 4 hours• No signs or symptoms of intoxication

Mu

sculo

skeletal Pain

ReferenceMaterials

Stroke Prompt Card............................. 3Rule of nines charts............................. 4

Field Trauma Triage............................. 5ECG Basics......................................... 6IM Injections........................................ 7

End Tidal CO2..................................... 8 - 9Overdose Levels................................. 10

Toxidromes.......................................... 11Phone Numbers.................................. 12 - 13Codes of Entry.................................... 14

Pediatric References.......................... 15Medication References....................... 16 - 32

PCP Scope of Practice........................ 33ACP Scope of Practice........................ 34 - 35VSA Special Circumstances............... 36

Death Notification Tips........................ 37Blank Pages for Notes or Stickers...... 38 - 41

Pounds to Kilograms Conversion Chart 42

2

3

4

Burn Chart 'Rule of nines'

5

Field Trauma Triage Guidelines

• spinal cord injury with paraplegia or quadriplegia;

• penetrating injury to head, neck, trunk or groin;

• amputation above wrist or ankle;

• adult patients with a Glasgow Coma Scale less than or equal to 10;

• If adult GCS is greater than 10, any two of the following: (1) any alteration in level of consciousness;(2) pulse rate less than 50 or greater than 120;(3) blood pressure less than 80 systolic (or absent radial pulse); (4) respiratory rate less than 10 or greater than 24.

• Pediatric Trauma Score of less than or equal to 8;

• paramedic’s judgement that the patient requires assessment and treatment at a lead trauma centre.

6

EECCGG BBAASSIICCSS NNOORRMMAALL EECCGG PPAARRAAMMEETTEERRSS P wave

Typically +ve QRS Complex

<0.12 sec T wave

May be –ve in V1 PR Interval

0.12 – 0.2 seconds ST Segment

Compared to TP QT Interval

< ½ the preceding RR interval

RRAATTEE CCAALLCCUULLAATTIIOONN Choose a QRS complex that falls on the thick line and count to your right until you reach the next complex.

QQ WWAAVVEESS 11.. Pathological: Sign of MI (new or old)

> ¼ of accompanying R wave and/or > 0.04 sec (1 sm box)

22.. Physiological Q waves: Normal Less then criteria above QQRRSS NNoommeennccllaattuurree

11

22

7

Needle length:

5/8" for small infants1" for young children1.5" for school-age children and older

The insertion site is in the middle of the depicted rectangle, anterolateral aspect of the middle of the thigh.

Needle length:

1 - 1.5" for school-age children and older

Do not use this site in children < 2 years old.

Base of pictured triangle is 2 - 3 finger widths below the acromium process.

The insertion site is in the middle of the triangle.

Intra Muscular Injection Landmarking and Needle Selection

8

9

10 OOVVEERRDDOOSSEE LLEEVVEELLSS

11

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Ø

12

Phone Numbers

13

Phone Numbers

NOTES:

14

Age Respiratory Rate Heart Rate

0-3 months 30-60 90-1803-6 months 30-60 80-160

6-12 months 25-45 80-1401-3 years 20-30 75-1306 years 16-24 70-110

10 years 14-20 60-90

< 2 Year EYE OPENING > 2 YearSpontaneous 4 Spontaneous

To Speech 3 To SpeechTo Pain 2 To PainNone 1 None

BEST RESPONSE TOAUDITORY / VISUAL

STIMULUS (0-2 years)

BEST VERBAL RESPONSE (2-5 Years)

Orients to sounds, follows objects, smiles, coos, babbles 55 Oriented, appropriate words

Cries appropriately; when upset 44 Confused, inappropriate words

Inappropriate, persistent cry / Scream 33 Inappropriate, persistent cry /

screamAgitated / restless; grunts,

Moans 22 Incomprehensible sounds;grunts

No Response 11 No Response

< 2 Year BEST MOTOR RESPONSEE > 2 Year

Spontaneous movements 6 Spontaneous movements

Localizes pain 5 Localizes pain

Withdraws from pain 4 Withdraws from pain

Abnormal flexion (decorticate) 3 Abnormal flexion (decorticate)

Abnormal extension (decerebrate) 2 Abnormal extension (decerebrate)

No response 1 No response

15Pediatric Reference

ACETAMINOPHEN

CLASSAnalgesic

ACTIONAlthough not fusynthesis of proand work periphproduces antipyregulating cente

lly elucidated, believed to inostaglandins in the central nherally to block pain impulsyresis from inhibition of hyper.

nhibit the nervous system e generation;

pothalamic heat-

ONSET HALF-LIFE ELIMINATION

PEAK EFFECT

< 1 hour 2 hours (adults) 10-60 minutesMETABOLISM

At normal therametabolism to ssmall amount isreactive interme(NAPQI), whichinactivated to nconjugates. At tglutathione conjmetabolic demaconcentrations,Oral administra

apeutic dosages, primarily hsulfate and glucuronide cons metabolized by CYP2E1 tediate, N-acetyl-p-benzoquh is conjugated rapidly with ontoxic cysteine and mercatoxic doses (as little as 4 g jugation becomes insufficie

and causing an increase in which may cause hepatic ction is subject to first pass m

hepatic njugates, while a to a highly inone imine glutathione and

apturic acid daily)

ent to meet the NAPQI cell necrosis. metabolism.

16

ADENOSINE

CLASSAntiarrhythmic

ACTIONSlows conduction tithe re-entry pathwanormal sinus rhythmvasodilation and incarteries with little to arteries; thallium-20arteries will be less revealing areas of in

me through the AVys through the AV

m. Adenosine also creases blood flowno increase in ste

01 uptake into the than that of normansufficient blood flo

V node, interrupting node, restoring causes coronary

w in normal coronary enotic coronary stenotic coronary al coronary arteries ow.


DURATION

Rapid < 10 seconds Very briefMETABOLISMM

Blood and tissue to monophosphate (AM

inosine then to adMP) and hypoxant

denosine thine

17

ASPIRIN (ACETYLSALICYLIC ACID)

CLASSPlatelet aggregation anti-inflammatory.

inhibitor, analgesicc, antipyretic and

ACTIONDecreases clotting binterfering with Thromplatelets. Thromboxconstrict. Reduces morbidity/mMI.

y inactivating cyclomboxane A2 produane A2 also cause

mortality in adult pa

oxygenase, uction within the es arteries to

atients with CP from

ABSORPTION TIME TO PEAK DURATIONRapid 1-2 hours 4-6 hours

METABOLISMHydrolyzed to salicylmucosa, red blood cemetabolism of salicylconjugation; metabol

ate (active) by esteells, synovial fluid,late occurs primarilic pathways are sa

erases in GI and blood; ily by hepatic aturable.

COMMON NSAIDS (Not a complete list)OVER-THE-COUNTER

AspirinIbuprofen (Motrin IB, Advil, Nuprin, Rufen)Ketoprofen (Actron, Orudis KT)Naproxen (Aleve)

PRESCRIPTION

Ibuprofen (Motrin)Indomethacin (Indocin)Tolmetin (Tolectin)Ketoprofen (Orudis, Oruvail) Naproxen (Naprosyn, Anaprox)Diclofenac (Voltaren, Cataflam, Solaraze)

18

ATROPINE

CCLASSParasympatholytic, anticholinergic

AACTIONBlocks the action of acetysites in smooth muscle, seincreases cardiac output, reverses the muscarinic eThe primary goal in cholinbronchorrhea and bronchoeffect on the nicotinic receweakness, fasciculations,

lcholine at parasympathetic ecretory glands, and the CNS; dries secretions. Atropine ffects of cholinergic poisoning.

nergic poisonings is reversal of oconstriction. Atropine has no eptors responsible for muscle and paralysis.

ONSET HALF-LIFE ELIMINATIONRapid 2-3 hours

METTABOLISM

HepaticDISTTRIBUTION

Widely throughout the amounts enter breast milk

body; crosses placenta; tracek; crosses blood-brain barrier.

19

DEXTROSE 50% IN WATER

CLASSCarbohydrate (Caloric Supplement)

ACTIONReplenishes blood glucose levels reversing hypoglycemia.

METABOLISM

Metabolized to carbon dioxide and water.

20

DIMENHYDRINATE E (GRAVOL®)

CLASSAntiemetic, Antihistaamine

ACTIONCompetes with histacells in the gastrointerespiratory tract; blocdiminishes vestibulalabyrinthine function activity.

amine for H1-receestinal tract, bloocks chemorecepr stimulation, anthrough its cent

eptor sites on effector od vessels, and

ptor trigger zone, d depresses tral anticholinergic

ONSET PEAK EFFECT

DURATION

1-5 minutes (IV)15-30 minutes

(oral)

1-2 Hours 3-6 hour

21

DIPHENHYDRAMINE E (BENADRYLYL®L®)

CLASSAntihistamine

ACTIONCompetes with histacells in the gastrointrespiratory tract; antalso seen.

amine for H1-receptotestinal tract, blood vticholinergic and sed

or sites on effector vessels, and dative effects are

ONSET PEAK EFFECT DURATION1-5 minutes (IV)1-3 hours (oral)

1-2 hours (IV)2-4 hours (oral)

4-8 hours

HALFF-LIFE ELIMINATIION2-10 hours

22

DOPAMINE

CLASSSympathomimeticc agent

ACTIONStimulates both alower doses are mproduce renal andalso are both dopstimulating and prvasodilation; largereceptors.

drenergic and dopaminmainly dopaminergic stid mesenteric vasodilatioaminergic and beta1-adroduce cardiac stimulate doses stimulate alpha

nergic receptors, mulating and on, higher doses drenergic tion and renal a-adrenergic


DURATION

5 minutes 2 minutes <10 minutesMETABOLISM

Renal, hepatic anby monoamine ox

nd plasma, 75% to inaxidase and 25% to nore

active metabolitesepinephrine.

23

EPINEPHRINE

CLASSSympathomimetic agent

ACTIONStimulates alpha-, beta1-, and beta2-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation (increasing myocardial oxygen consumption), and dilation of skeletal muscle vasculature; small doses can cause vasodilation via beta2-vascular receptors; large doses may produce constriction of skeletal and vascular smooth muscle.

ONSET5-10 minutes (bronchodilation)

METABOLISM

Taken up into the adrenergic neuron and metabolized by monoamine oxidase and catechol-o-methyltransferase; circulating drug hepatically metabolized.

24

GLUCAGON

CLASSHyperglycemic agennt

ACTIONStimulates adenylateAMP, which promotegluconeogenesis, ca

e cyclase to produces hepatic glycogenausing a raise in bl

ce increased cyclic nolysis and ood glucose levels.


DURATION

30 minutes (IM) 8-18 minutes 60-90 minutes (SQ)

METABOLISM

Primarily hepatic, soI the plasma.

ome inactivation occcurring renally and

25

LIDOCAINE E (XYLOCAINE)

CLAASSClass Ib antiarrhythmic

ACTIIONSuppresses automaticity of coincreasing electrical stimulatioPurkinje system, and spontaneventricles during diastole by ablocks both the initiation and cimpulses by decreasing the nepermeability to sodium ions, wdepolarization with resultant b

onduction tissue, by on threshold of ventricle, His-eous depolarization of the direct action on the tissues; conduction of nerve euronal membrane's

which results in inhibition of blockade of conduction.

ONSET DURATION45-90 seconds 10-20 minutes

METABOOLISM

90% Hepatic

26

Xylometazoline (Baliminil)

CLAASSSympathomimetic agent

ACTIIONXylometazoline nasal is a decvasoconstrictor. The nasal formblood vessels in the nasal tissblood vessels in the nose anddecrease in congestion.

ongestant. A mulation acts directly on the

sues. Constriction of the sinuses leads to a

ONSET DURATIONRapid 10-20 minutes

METABOOLISM

90% Hepatic

27

MIDAZOLAM M (VERSED)

CLASSBenzodiazepine, CNNS depressant, Seddative and Amnesic

ACTIONBinds to stereospecpostsynaptic GABA central nervous systreticular formation. EGABA on neuronal eneuronal membraneshift in chloride ions excitable state) and

ific benzodiazepineneuron at several stem, including the lEnhancement of thexcitability results be permeability to ch

results in hyperpostabilization.

e receptors on the sites within the imbic system, e inhibitory effect of by increased hloride ions. This olarization (a less

ONSET PEAK EFFECT DURATION15 minutes (IM)3-5 minutes (IV)4-8 minutes (IN)

0.5 – 1 hour 6 hours (IM)

18-41 minutes (IN)

METABOLISM

Extensively hepatiicHALFF-LIFE ELIMINATTION

2-6 hours

28

MORPHINE

CLASSOpioid analgesic

ACTIONBinds to opiate receascending pain pathresponse to pain; p

eptors in the CNS, chways, altering the produces generalized

causing inhibition of perception of and d CNS depression.

ONSET PEAK EFFECT DURATION2-5 minutes (IV) 20 minutes (IV) 1 hour

HALF-LIFE ELIMINATTION2-4 hours

METABOLISM

Hepatic

29

NALOXONE E (NARCAN)

CLASSNarcotic Antagonisst

ACTIONCompetitive narcotbound to opiate rec

tic antagonist. Displaceceptor sites reversing t

es any narcotics their effects.


DURATION

2-5 minutes (IM)8-13 minutes

(IN)2 minutes (IV)

3-4 hours (neonates)

0.5-1.5 hours (adult)

30-120 minutes

METABOLISM

Primarily hepaticDISTRIBUTION

Crosses placenta

30

NITROGLYCERIN

CLASSSCoronary vasodilator, smoothanti-anginal.

h muscle relaxant and an

ACTIOONProduces a vasodilator effect on arteries with more prominent effereduces cardiac oxygen demandventricular end-diastolic pressureafterload; dilates coronary arterieto ischemic regions. In smooth mguanylate cyclase which increasemonophosphate (cGMP) leading myosin light chains and smooth m

the peripheral veins and ects on the veins. Primarily by decreasing preload (left

e); may modestly reduce es and improves collateral flow

muscle, nitric oxide activates es guanosine 3’5’ to dephosphorylation of

muscle relaxation.ONSET PEAK EFFECTS

1-3 min.(sl sprays and sl tablet)15-30 min. (topical)

30 min.(transdermal)

5 min.(tablet)4-10 min.(sl spray)

60 min.(topical)120 min. (transdermal)

DURATTION25 min. (sl spray

7 hours (t10-12 hours (tr

y and sl tablet)topical)ransdermal)

HALF-LLIFE

1-4 minutesMETABOOLISM

Extensive first-pass effect; metadi- and mononitrate metabolitessubsequent metabolism to glnonhepatic metabolism via red balso occurs.

bolized hepatically to glycerols via liver reductase enzyme;ycerol and organic nitrate;

blood cells and vascular walls

31

SALBUTAMOL L (VENTOLIN)

CLASSSympathomimetic, BBeta 2 agonist

ACTIONRelaxes bronchial sreceptors with little e

mooth muscle by aeffect on heart rate

action on beta2-e.


DURATION

10 minutes (nebulized/oral

inhalation)

3-8 hours (inhalation)

3-4 hours (nebulized/oral

inhalation)METABOLISM

Hepatic to an inactivve sulfate

32

PCP Scope of PracticePerform the following skills:

Semi-Automated External DefibrillationManual defibrillation (when working with an ACP who has indicated that a shock and its energy setting is to be delivered)Intravenous monitoringIntravenous Access/Therapy for patients ≥ 2 years of age (if certified / authorized in autonomous IV)Volume (crystalloid) Replacement Therapy for patients ≥ 2 years of age (if certified / authorized in autonomous IV)Basic Airway managementAdvanced Airway management with the King LTOro-pharyngeal SuctioningCurrent CPR standards for Health-Care Providers 3 lead monitoring and interpretation12 and 15 lead acquisition and interpretationAdministration of CPAPPreparation of ACP pre-loaded medicationsAssessments and Interpretation of findings ie chest sounds & txCapillary Blood Sampling & glucometer useUtilization/interpretation of SpO2

Administer the following medications:

ASA (PO)Dextrose: 50% solution (IV) (if certified / authorized in autonomous IV)Dimenhydrinate (IV/IM) (IV only if certified / authorized in autonomous IV)Diphenhydramine (IV/IM) (IV only if certified / authorized in autonomous IV)Epinephrine 1:1000 (IM/Inhalation) Glucagon (IM)Nitroglycerin spray (SL)Salbutamol MDI and nebulization (Inhalation)

By the following routes:

Oral (PO)Sublingual (SL)Inhalation (nebulized or MDI)Intramuscular (IM)Intravenous (IV) (if certified / authorized in autonomous IV)

33

ACP Scope of PracticePerform the following skills:

Manual DefibrillationSynchronized CardioversionTranscutaneous PacingIntravenous Access/TherapyIntraosseous Access/TherapyVolume (crystalloid) Replacement TherapyAdvanced Airway management with the King LTOral Endotracheal IntubationNasal Tracheal IntubationDifficult Airway with lighted stylet / BougieLaryngoscopy ETT (Deep) SuctioningFBAO Removal (Magill Forceps)Needle Chest Decompression3 lead monitoring and interpretation12 and 15 lead acquisition and interpretationAssessments and Interpretation of findings ie chest sounds & txVenous and Capillary Blood Sampling & glucometer useUtilization/interpretation of SpO2 and Endtidal CO2 monitoringApplication of Continuous Positive Airway Pressure (CPAP)

Administer the following medications:Atropine (IV/ETT)ASA (PO)Dextrose: 50%, 25% or 10% solutions (IV/IO)Dimenhydrinate (IV/IM)Diphenhydramine (IV/IM)Dopamine (IV drip)Epinephrine 1:1000 (IV/IM/IO/ETT/Inhalation) Epinephrine 1:10,000 (IV/ETT)Glucagon (IM)Lidocaine injectable (IV/ETT) Lidocaine topical (Inhalation)Midazolam (IV/IM/IN/Buccal)Morphine (IV)Naloxone (IV/IM/IN/SC)Nitroglycerin spray (SL)Xylometazoline (Inhalation)Salbutamol MDI (Inhalation)

34

By the following routes:Intravenous (IV)Endotracheal (ETT)Oral (PO)Sublingual (SL)Subcutaneous (SC)Buccal (BU)Inhalation (nebulized or MDI)Intraosseous (IO)Intramuscular (IM)Intranasal (IN)Topical

35

Vital Signs Absent Patient

Here are some guidelines to help with the determination of the recognition of death and/or the termination of resuscitation when presented with a VSA:

1. Patient presenting as “Obviously Dead” a. Decapitation, transection, visible decomposition, putrefaction;

orb. Absence of vital signs and:

• A grossly charred body; or• An open head or torso wounds with gross outpouring of

cranial or visceral contents; or• Gross rigor mortis; or• Lividity

2. Patient without vital signs and the subject of a Ministry of Health and Long-Term Care Do Not Resuscitate Confirmation Form. Consider honoring the DNR Confirmation Form.

3. Patient without vital signs and the subject of a “legal looking’ document or the old DNR Medical Directive and Funeral Home Transfer Form, consider calling the BHP to receive termination of resuscitation order.

4. Patient without vital signs and the subject of the possible application of the TOR Medical Directive (Medical or Trauma). Consider calling the BHP for termination of resuscitation order. In the event that a physician on scene is willing to assume care and responsibility of the patient, provide assistance as possible within your scope of practice.

*Paramedics must carefully consider matters such as scene integrity, investigative issues, family concerns and disposition of body.

36

Death Notification Tips:

• Survivors are victims

• Non-verbal communication is important

o Eye contact without staring

o Same level as survivor

• Be aware of your appearance (take off PPE)

• Use a ‘D’ word such as ‘dead’ or has ‘died’

• Pauses and silence are okay!

• Avoid clichés

• Never try to talk the survivors out of their grief

• Be compassionate

• Be careful not to impose our personal religious beliefs

• Empower the survivors to take on their own grief and pain

o Give as much information as possible

o Listen to them and answer questions as best you can

37

Notes or stickers:

38

Notes or stickers:

39

Notes or stickers:

40

Notes or stickers:

41

42

Lbs Kg Lbs Kg

10 5 125 5715 7 130 5920 9 135 6125 11 140 6430 14 145 6635 16 150 6840 18 155 7045 20 160 7350 23 165 7555 25 170 7760 27 175 7965 29 180 8270 32 185 8475 34 190 8680 36 195 8885 39 200 9190 41 205 9395 43 210 95

100 45 215 98105 48 220 100110 50 225 102115 52 230 104120 54 235 107

Pounds to Kilogram Conversion Chart

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