ACP Pocketbook

7/27/2019 ACP Pocketbook

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AdvancedCare

ParamedicPocket Reference Guide2011 v. 1.1

CEPCP


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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 contactus at:

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

Administration Office:

95A Simcoe St. S.

Oshawa, ON

Mailing Address:

Central East Prehospital Care Program

Lakeridge Health Oshawa

1 Hospital Court

Oshawa, ON

L1G 2B9

Phone: (905) 433-4370

Fax: (905) 721-4737

Toll free: 1-866-423-8820

2
http://www.cepcp.ca/http://www.cepcp.ca/http://www.cepcp.ca/


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Table of Contents:

Mandatory Patches and BHP names............................!4 - 5Adult Cardiac Arrest......................................................!6 - 7Pediatric Cardiac Arrest................................................!8 - 9Trauma Cardiac Arrest..................................................!10Tension Pneumothorax.................................................!11Neonatal Resuscitation.................................................!12 - 13Hypothermia Cardiac Arrest..........................................!14Foreign Body Airway Obstruction..................................15

Return of Spontaneous Circulation...............................!16IV and Fluid Therapy.....................................................!17Pediatric / Adult IO........................................................!18Central Venous Access.................................................!19Endotracheal Intubation................................................!20Supraglottic Airway........................................................!21Moderate to Severe Allergic Reaction..........................!22 - 23Croup............................................................................!24Bronchoconstriction......................................................!25CPAP............................................................................. !26Acute Cardiogenic Pulmonary Edema..........................!27Cardiac Ischemia..........................................................!28 - 29STEMI Bypass..............................................................

!30 - 31

Cardiogenic Shock........................................................!32 - 33Bradycardia...................................................................!34 - 35Procedural Sedation.....................................................!36Combative Patient........................................................!37Tachydysrhythmia.........................................................!38 - 39Seizure..........................................................................!40 - 41Opioid Toxicity...............................................................!42Electronic Control Device Probe Removal....................!43Hypoglycemia................................................................44 - 45

Nausea / Vomiting.........................................................46 - 47

Pain...............................................................................48

Special Events...............................................................49 - 53

Reference Materials

3


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Advanced Care Paramedics will now be required to patch for the following

Medical Cardiac Arrest Directive patch after 3 rounds of epinephrine or

unable to get a drug route after 3 analyses

Trauma Cardiac Arrest Directive patch for authorization to apply the

TOR if applicable

Symptomatic Bradycardia Directive patch for authorization to proceed

with transcutaneous pacing and/or a dopamine infusion

Tachydysrhythmia Directive patch for authorization to proceed with

lidocaine or monomorphic wide complex regular rhythm for adenosine

Tachydysrhythmia Directivepatch for authorization to proceed with

synchronized cardioversion

Intravenous and Fluid Therapy Directive patch for authorization to

administer IV NaCl bolus to patients


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Central East Prehospital Care Program For reference only 5


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6 Central East Prehospital Care Program For reference only

Indications

Adult Cardiac Arrest

Non-traumatic cardiac arrest

CPR ongoing throughout call

Minimize Interruptions100 - 120 per minute

At least 2 inches depth

30:2

Drug Dose

Epinephrineevery 4 mins

patch after 3rd dose

IO/CVAD/IV(preferred) 1.0 mg

Adult > 12 years only

Bolusfor PEA or any other rhythm

where hypovolemia is

suspected

20 ml/kg to 2,000 maxre-assess every 250 ml

Lidocainefor recurrent V-fib/VT

(typically after 3rd shock)

repeat after 4 mins

2 doses max

ETT (if above delayed > 5 mins) 2.0 mg

IO/IV/CVAD 1.5 mg/kgtypically supplied 20 mg/ml

ETT 3.0 mg/kg

ETT or 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

Defibrillate VF/VTevery 2 mins

Zoll

200 joules (all shocks)

LP12 / LP15

200, 300, 360joules

Adult > 8 years only (if 8-12 years old use DRUG dosages from pediatric arrest page)

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

AdultCardiac

Arrest


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Lidocaine Volume per weight based on 100 mg/5 ml

40 kg = 3.0 ml 105 kg = 7.88 ml

45 kg = 3.34 ml 110 kg = 8.25 ml

50 kg = 3.75 ml 115 kg = 8.62 ml

55 kg = 4.13 ml 120 kg = 9.0 ml

60 kg = 4.5 ml 125 kg = 9.38 ml

65 kg = 4.88 ml 130 kg = 9.75 ml

70 kg = 5.25 ml 135 kg = 10.13 ml

75 kg = 5.63 ml 140 kg = 10.5 ml

80 kg = 6.0 ml 145 kg = 10.88 ml

85 kg = 6.36 ml 150 kg = 11.25 ml

90 kg = 6.75 ml 155 kg = 11.63 ml

95 kg = 7.13 ml 160 kg = 12.00 ml

100 kg = 7.5 ml 165 kg = 12.37 ml


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


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PediatricCardia

cArrest Indications

Pediatric Cardiac Arrest

Non-traumatic cardiac arrest

CPR ongoing throughout callMinimize Interruptions

100 - 120 per minute

1/3 to 1/2 of chest diameter for children and infants

30:2 if single rescuer

15:2 for infants and children if two rescuer

Drug Dose

Epinephrineevery 4 mins

patch after 3rd dose

IO/IV(preferred) 0.01mg/kg 1:10,000 (min 0.1 mg)

0.1 ml / kg

Pediatric 30 days - < 12 years only

Bolusfor PEA or any other rhythm

where hypovolemia is

suspected

20 ml/kg to 2,000 maxre-assess every 100 ml

Lidocaine < 40kgfor recurrent VF/VT

(typically after 3rd shock)

repeat after 4 mins

2 doses max

ETT (if above delayed > 5 mins) 0.1mg/kg 1:1,000 (min 1 mg)

0.1 ml / kg (max 2 mg)

IO/IV1.0 mg/kgtypically supplied 20 mg/ml

ETT 2.0 mg/kg

ETT should be inserted where more than OPA/BVM is required, without interrupting CPR.

Tube size = 4 + (age / 4) Depth = 3 x ETT diameterOnce 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

Drug Dose

Defibrillate VF/VTevery 2 mins

(pediatric pads if < 15 kg)

2 joules / kg ( 1st shock)

4 joules / kg (subsequent shocks)

Pediatric 30 days - < 8 years only (if 8-< 12 years old use adult joule settings, but drug dosages below)

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


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TraumaCardiacArrest

Indications

Trauma Cardiac Arrest

Cardiac arrest secondary to severe blunt or penetrating trauma.

If inVF/VT Defibrillate once 30 days - < 8 years - 2 joules / kg

8 yr - 200 joules

Protect C-spineBegin chest compressions

Attach SAED padsBegin PPV with BVM

After 2 minutes interpret rhythm

If in PEAdeterminedrive-time to nearest

hospital

ASYSTOLE

Less than 30 minutesdrive-time to nearest ER?

16 years or older?

Continue CPR

Immobilize Patient

Transport to Hospital

Continue CPR

Patch to BHP for possible trauma TOR

Yes No

Yes

No


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Clinical Parameters Vital Sign Parameters

N/ASBP < 90

or

VSA

Notes:

Needle thoracostomy may only be performed at the second intercostal space in the midclavicularline.

PATCH - for needle thoracostomy

Indications

Suspected tension pneumothorax and critically ill or VSA and absent or severely

diminished breath sounds on the affected side(s).

Tension Pneumothorax

Using three finger widths (averageadult fingers) from the centre ofthe sternum provides an accurate,easily remembered landmarkingmethod.

The rib adjacent to the angle of louisis the second rib, the space belowthis rib is the second intercostal

space.

Chest-wall thickness may be as muchas 2 3/4"

TensionPneumothorax


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NeonatalResus

citation


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Clinical Parameters

Not obviously dead as per BLS standard

No DNR

Interventions

Indications

Hypothermia Cardiac Arrest

Cardiac arrest secondary to severe hypothermia.

Transport to the closest appropriate facility without delay following the first rhythminterpretation.

Defibrillate once if the patient is in VF/VT

30 days to < 8 years old - 2 joules / kg

8 years old - 200 joules

Hypothermic

Arrest


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Clinical Parameters

Not obviously dead as per BLS standard

No DNR

Interventions

Attempt to clear airway with BLS maneuvers and /or laryngoscope Magill forceps

Indications

Foreign body airway obstruction

Cardiac arrest secondary to an airway obstruction.

Defibrillate once if the patient is in VF/VT

30 days to < 8 years old - 2 joules / kg

8 years old - 200 joules

If the obstruction cannot be removed, transport to the closest appropriate facilitywithout delay following the first rhythm interpretation.

If the patient is in cardiac arrest following removal of the obstruction, initiatemanagement as a medical cardiac arrest.

ForeignB

odyAirwayObstr.


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ROSC Clinical Parameters

Bolus:

Clear chest / no fluid overload

Dopamine:

No Allergy/Sensitivity No Pheochromocytoma No Tachydysrhythmias (excl. sinus tach)

No Mechanical shock states (i.e: tension pneumothorax, pulmonaryembolism, pericardial tamponade)

No Hypovolemia

SBP < 90 mmHg

Drug Initial Dose Reassess Q Max

Drug Initial Increase by every to max.

DopamineIV only

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

5 mcg/kg/min 5 mins 20 mcg/kg/min

1,000 ml

IndicationsROSC after resuscitation was initiated

5 mcg/kg/min

Drug Initital Dose Reassess Q Max

Drug Initial Increase by every to max.

Dopamine IV only

Bolus IV only 10 ml/kg 100 ml

5 mcg/kg/min 5 mins 20 mcg/kg/min

1,000 ml

5 mcg/kg/min


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IV

andFluid

Clinical Parameters

IV Start:

No fracture proximal to IV site

Bolus:

No signs of fluid overloadSBP < 90

Drug Initital Dose Q Repeat Max

BolusIV/IO/CVAD 20 ml/Kg Reassess q

250mlN/A

Notes:

PATCH to BHP for authorization to administer IV bolus to patients < 12 yearswith 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 < 12 years, Use micro drip or Buretrol

TKVOIV/IO/CVAD 30 - 60 ml/hr

BolusIV/IO 20 ml/Kg Reassess q

100 mlN/A 2,000 ml

TKVOIV/IO 15 ml/hr

Indications

Actual or potential need for IV medication or fluid therapy

IV and Fluid Therapy


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IO Start:

No fracture or crush injuries or known

replacement / prosthesis proximal to the

access site.

N/A

Pediatric / Adult Intraosseous Medical Directive

Indications:

Actual or potential need for intravenous medication or fluid therapy

AND

Intravenous access is unobtainable

AND

Patient is in cardiac arrest or near-arrest state

Notes:

Jamshidi Cook :

1 year use 15/16 gauge needle< 1 year use 18 gauge needle

EZ IO:

Pink 15 mm3-39 kg

Blue 25 mm 40 kg

Yellow 45 mm 40 kg with excessive tissue over

targeted insertion site

Pediatric/AdultIO


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CVAD Access:

Patient has pre-existing, accessible central

venous catheter in place

N/A

Central Venous Access Device

Indications:Actual or potential need for intravenous medication or fluid therapy

AND

Intravenous access is unobtainableAND

Patient is in cardiac arrest or near-arrest state

Notes:

CVAD Procedure :

Prepare equipment

Close clamps

Wipe med-port and luer lock with alcohol swab.

Remove med-port from luer lockAttach the empty syringe,

Open the clamp (if present)

Withdraw whatever fluid is within the catheter until approximately 2cc of bloodis in the syringe

Close clamp

Attach the syringe with saline

Open the clamp, and slowly inject the saline using a push/pull technique. Ifresistance is met discontinue attempt

Close clamp

Attach the IV line

Open clamp

Run the IV as per normal, administering IV drugs through the medication portson the IV set

two 10 cc syringes, oneempty and one with 10 ccsaline drawn up

several alcohol swabs

a primed AIR FREE IV set

clean, preferably sterile,gloves

CentralVenousAccess


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Clinical Parameters

Drug Dose Max Drug Dose MaxLidocaine

Topical

Notes:

An intubation attempt is defined as insertion of the laryngoscope blade into the mouth.

The maximum number of ETT and SGA attempt are two.

If the patient has a pulse, an ETCO2 device (quantitative or qualitative) must be used for ETTplacement confirmation.

ETT placement must be reconfirmed immediately after every patient movement.

Xylometazoline 2 sprays / nareup to 20 sprays

10mg/spray5 mg/kg max

1 dose1 dose


Visualization Auscultation Chest rise

Secondary

ETCO2 EDD Other

Indications

Need for ventilatory assistance or A/W control and other A/W management is

inadequate or ineffective.

Endotracheal Intubation

Xylometazoline Use for nasal ETT only

Lidocaine Topical Spray: For nasal/oral ETT Not used if patient is unresponsive

Nasal ETT:

8 years old No suspected basal skull or mid-face fracture No uncontrolled epistaxis Not under anticoagulant therapy (ASA excluded) No bleeding disorders Not apneic

No allergy or sensitivity to drugs administered.

If < 50 years old and having asthma exacerbation, do not intubate unless in or

near cardiac arrest.

At least two primary and one secondaryETT placement confirmation methodsmust be used.

Endotracheal

Intubation


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Clinical Parameters

GCS 3

No gag reflex

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

AND

Other airway management is inadequate OR ineffective OR unsuccessful

Supraglottic Airway

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


Auscultation Chest rise

Secondary

ETCO2 Other

Confirm 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

Suprag

lotticAirway


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AllergicReaction

Clinical Parameters

Drug Initial Dose Q Repeat Max

Diphenhydramine IV/IM

Notes:

Epinephrine should be the first drug administered in anaphylaxis.

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


Adult Doses ( > 50 Kg)

Pediatric Doses

50 mg> 50 kg

N/A N/A 1 dose

Epinephrine IM0.5 mg> 50 kg

N/A N/A 1 dose

Diphenhydramine IV/IM25 mg

> 25 - < 50 kg

(if < 25 kg Patch)

N/A N/A 1 dose

Epinephrine IM N/A N/A 1 dose0.01 mg/kg

Max 0.5 mg

Indications

Exposure 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.


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Epinephrine 1:1,000

0.01 mg/kg

Rounded to the nearest 0.05 ml


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Crou

p

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 old1 dose

5.0 mg(5 ml)

Epinephrine

< 1 year old

> 5 kg or more

1 dose2.5 mg(2.5 ml)

Epinephrine

< 1 year

< 5 kg1 dose

0.5 mg(mix with 2 ml of saline to make 2.5 ml)

Indications

Severe respiratory distress and stridor at rest and current history of URTI

and barking cough or recent history of a barking cough.

Croup


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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 beadministered subsequently using a BVM MDI adapter (if available).

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

When administering salbutamol MDI, the rate of administration should be 100 mcg approximatelyevery 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

Indications

Respiratory distress and suspected bronchoconstriction.

Bronchoconstriction

0.01 mg/kg

Max 0.5 mg

Epinephrine:

BVM ventilation is required Must have a history of asthma

Bronchoconstriction


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CPAP

Clinical Parameters

18 years old

Able to sit upright and cooperate

Respiratory rate 28 / minute

SpO2 < 90% OR accessory muscle use

SBP 100

Not asthma exacerbation

No unprotected or unstable airway

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


5 cmH20or

15 lpm if Boussignac

2.5cmH20or

5lpm 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 only increase if SpO2 remains< 92% despite treatment and/or CPAP pressure of 10 cmH2O.


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AcutePulmonaryEdema


No allergy or sensitivity

No phosphodiesterase inhibitors* in past 48 hrs

If SBP < 140 patient must have prior nitroglycerinuse or IV established

HR: 60 - 159

SBP 100

SBP drops no more than1/3 of initial value

Drug Initial Dose Q Repeat Dose Max

Nitroglycerin

BP100 - 1400.4 mg S/L 5 min 0.4 mg 6 doses

Adult Dose 18 years only

Notes:

Perform 12 / 15 lead

Nitroglycerin

BP 140

NO History or IV

0.4 mg S/L 5 min 0.4 mg 6 doses

Nitroglycerin

BP 140

WITH History or IV

0.8 mg S/L 5 min 0.8 mg 6 doses

Indications

Moderate 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


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CardiacIschemia


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

Adult Dose 18 years only

Notes:

Perform 12 / 15 lead

Morphine 2 mg IV 5 min 2 mg 5 doses

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

IndicationsSuspected Cardiac Ischemia

Cardiac Ischemia Medical Directive

* 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 yearsUnaltered LOA

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

Morphine:(after 3rd nitroglycerin or if nitroglycerin is contraindicated)

No injury to Head / Torso / PelvisSBP 100. D/C if BP drops more than 1/3 of initial


29/91


Notes:

A 15 lead ECG should be obtained; When a 12 lead shows an inferior wall MI When there is ST depression in V1-V4

When the 12 lead is normal but the patient isexhibiting signs or symptoms of cardiac ischemia

V4R The V4R lead is obtained by moving V4 to the same location but on the right

chest wall. (5th intercostal space, mid clavicular line). V4R is considered anatomically contigous with II, III and AVF ST elevation in V4R indicates an infarct of the right ventricle.

V8 and V9 The V8 lead is obtained by moving V5 around to the posterior, left chest wall

and placing it on the mid-scapular line just below the scapula. The V9 lead is obtained by moving V6 around to the back and placing it

between V5 and the vertebral column. ST elevation in V8 and V9 indicates an infarct in the posterior wall of the left

ventricle. Infarcts in the posterior wall often show up as ST depression in leads V1-V4

Lateral Left

Lateral Left

Lateral LeftInferior Left

Inferior Left Inferior Left

Lateral Left Septal

Anterior Left

Anterior LeftSeptal

12 lead versus anatomical region


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STEMIBypass

If the pick up is in York and transporting to SRHC - call

905-895-4521ext.7777

Indications

Patient who is experiencing continuous cardiac ischemic "chest pain" or chest

discomfort.

STEMI Bypass Policy

Clinical Parameters

18 yrs Unaltered LOA SBP 80 mmHg (with intervention if required) Secure airway, and able to ventilate

Current episode is < 12 hours in duration 12 lead indicative of ST elevation MI, NO LBBB or ventricular paced rhythms No advanced directives indicating a restriction in care

Call location is in York or Durham Region

Patient contact to arrive the designated cath lab is < 60 min.

If the pick up is in Durham and transporting to RVHS-C - call

416-287-8364


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CCOOMMMMOONN IIMMIITTAATTOORRSS OOFF MMIISSIINNTTEERRPPRREETTIINNGGSSTT SSEEGGMMEENNTTSS IISS NNOOTT PPOOSSSSIIBBLLEE IINN TTHHEE FFOOLLLLOOWWIINNGG

RRYYTTHHYYMMSS((NNOOTT AA CCOOMMPPLLEETTEE LLIISSTT OOTTHHEERR IIMMIITTAATTOORRSS EEXXIISSTT))

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 anotched complex & a slurred or prolonged S wave in V6.

VVEENNTTRRIICCUULLAARRPPAACCEEDDRRHHYYTTHHMM

A pacer spike is typically seen immediately preceding the QRS

complex which will be wide.

LLVVHH 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, ifthey equal 35 mms then its likelyLVH


32/91


CardiogenicShock

Clinical Parameters

Bolus:

Clear Chest

Dopamine:

No allergy or sensitivityNo tachydysrhythmias (excluding sinus tach)No mechanical shock state (i.e. Tension Pneumothorax, Pulmonary Embolism,

Pericardial Tamponade)No pheochromocytoma

SBP < 90


Bolus IV/IO 10 ml/KgReassess q

250mlN/A

Notes:

Titrate Dopamine to SBP 90 - 110 mmHg.If discontinuing Dopamine electively, do so gradually over 5-10 minutes.Contact BHP if patient is bradycardic with respect to age.If bolus is contraindicated due to crackles, consider Dopamine.

Dopamine IV 5 mcg/Kg/min 5 minIncrease by

5 mcg/Kg/min

20mcg/

Kg/min


Bolus IV/IO 10 ml/KgReassess q

100 mlN/A

Dopamine IV 5 mcg/Kg/min 5 minIncrease by

5 mcg/Kg/min20mcg/Kg/min

Adult Doses ( 18 Years)

Pediatric Doses (< 18 years)

Indications

STEMI and Cardiogenic Shock.

Cardiogenic Shock


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Buretrol Set-up:

Close both roller clamps Spike bag Open top roller clamp (between bag and Buretrol) Fill chamber with 100 cc Close top roller clamp

OSCAR

O-open bottom roller clampS-squeeze drip chamberC-close bottom roller clampAndR-release drip chamber

Prime the line as usual

Dopamine Administration


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Bradycardia


Allergy or sensitivity to given drug

Atropine:

No hypothermiaNo heart transplant

Dopamine:No pheochromocytoma

TCP:No hypothermia

HR < 50with hemodynamic instability

SBP < 90


Atropine IV 0.5 mg 5min

Notes:

Atropine may be beneficial in the setting of sinus bradycardia, atrial fibrillation, firstdegree AV block, or second degree type I AV block.

A single dose of Atropine should be considered for second degree type II or thirddegree blocks with fluid bolus while preparing for TCP or if there is a delay inimplementing TCP or if TCP is unsuccessful.

Titrate dopamine to achieve a SBP of 90-110 mmHg.

Dopamine IV (patch) 5 mcg/Kg/min 5min Increase by

5 mcg/Kg/min20mcg/Kg/

min

2 doses

Adult Doses 18 Years

0.5 mg

Transcutaneous Pacing (patch)

Indications

Bradycardia with Hemodynamic Instability

Symptomatic Bradycardia


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Buretrol Set-up:

Close both roller clamps Spike bag Open top roller clamp (between bag and Buretrol) Fill chamber with 100 cc Close top roller clamp

OSCAR PACING

O-open bottom roller clampS-squeeze drip chamberC-close bottom roller clampAndR-release drip chamber

Prime the line as usual

Dopamine Administration

Attach limb leads Attach large pads Activate pacing function Increase CURRENT (mA) until

electrical capture is evident Check output (BP) Reduce RATE to 60 if BP adequate Re-assess BP Consider Midazolam / Morphine


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ProceduralSedation

Clinical Parameters

18 years old No allergies or sensitivity to midazolam SBP 100 Respiratory rate 8/min (unless intubated)


Midazolam IV2.5 - 5.0 mg

0.5 - 1.0 ml5 min

10 mg

or2doses

Indications

Post-intubation OR Transcutaneous Pacing

Procedural Sedation

Adult Doses

2.5 - 5.0 mg0.5 - 1.0 ml


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CombativePatient

Clinical Parameters

18 years old No allergies or sensitivity to midazolam SBP 100 No reversible causes (i.e. Hypoglycemia, Hypoxia, Hypotension)


Midazolam IV/IM 2.5 - 5.0 mg0.5 - 1.0 ml 5 min 10 mgor2doses

Indications

Combative patient

Combative patient

Adult Doses

2.5 - 5.0 mg0.5 - 1.0 ml

PATCH to BHP to proceed with Midazolam if unable to assess the patient for

normotension or reversible causes.


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Tachydysrhythmia

Clinical Parameters

No allergy or sensitivity to given drug


Adenosine IVPATCH if suspected SVT with aberrancy

(wide complex)

6 mg 2 min

Notes:

Administer cardioversion in accordance with patch orders. Above joule settingsapply to patch failures.

2 doses


12 mg

Valsalva 2 x 10-20 seconds

Lidocaine IV (PATCH) 1.5 mg/Kg 10 min 3 doses0.75 mg/Kg

Cardioversion (PATCH) 100j, 200j, Max possible

Indications

Symptomatic Tachydysrhythmia

Tachydysrhythmia

Cardioversion (PATCH):

SBP < 90, altered LOA, ongoing chest pain, other signs of shock Unstable tachycardia 120 (wide) 150 (narrow)

Lidocaine (PATCH):

SBP 100, Unaltered LOA Use for wide complex regular tachycardias 120 / minute

Valsalva / Adenosine:

SBP 100, Unaltered LOA Use for narrow complex, regular tachycardias 150 / minute.

Not for sinus tachycardia, a-fib or a-flutter

Adenosine specific: Not on dipyridamole (Persantine, Aggrenox) or carbamazepine (Tegretol)

No bronchoconstriction on exam


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Cardioversion:

Attach limb leads

Attach large pads

Cycle through leads and select the lead that shows thelargest 'R' wave

Activate 'Synch' and ensure synch markers appear on the"R" waves (if visible)

Select ordered joule setting

Begin running printer (run lots of strip before and aftercardioversion)

Double check resuscitation equipment is prepared

Clear patient and press-and-hold 'SHOCK'

after cardioversion monitor will automatically default out ofsynch mode.


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Seizure

Clinical Parameters

Unresponsive No allergy or sensitivity to Midazolam Not hypoglycemic


Midazolam IM/IN/Buccal

Notes:

Conditions such as cardiac arrest and hypoglycemia often present as seizure and should beconsidered by a paramedic.


Adult Doses 50 kg

Pediatric Doses

Midazolam IV 5 mg

Midazolam IV0.1 mg/kg

5.0mg Max

5 min 5 mg

10 mg 5 min 10 mg 2 doses

5 min

2 doses

0.1 mg/kg

5.0mg Max

MidazolamIM / IN / Buccal

0.2 mg/kg

10mg Max5 min

0.2 mg/kg

10mg Max

2 doses

Indications

Active generalized motor seizure

Seizure

2 doses


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IV Dosages

IM / IN / Buccal Dosages (IN has 0.12 ml added)

Weights are based on:(Age x 2) + 10

for 1-10 years

11-14 years based onCDC data

All volumes based on

5 mg/ml concentration

Midazolam Reference


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Opioid

Toxicity

Clinical Parameters

Respiratory rate < 10

No allergy or sensitivity to naloxone.

No uncorrected hypoglycemia


Notes:

*For IV route, titrate naloxone only to restore the patient's respiratory status.

Patch - NaloxoneIM/IN/SC

0.8 mg


Patch - Naloxone IV* up to 0.4 mg N/A N/A

N/A N/A 1 dose

1 dose

Indications

Altered LOC and respiratory depression and suspected opioid overdose.

Opioid Toxicity

Reference Notes:

Opioid Toxicity typically present with:

- Decreased LOA- Slow Respirations- Pinpoint pupils

Some Common Opioids:Morphine, MS contin, Statex, HydromorphoneFentanylPercocet, PercodanOxycocet, OxycontinTylenol III

HeroinCodeine


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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, normalprinciples of patient assessment and care apply.

ECDProb

eRemoval


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Hypoglycemia

Clinical Parameters Vital Sign ParametersNo allergy or sensitivity to given drug

Glucagon:

No Pheochromocytoma

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 simplecarbohydrates.If only mild signs or symptoms are exhibited, the patient may receive oral glucose or othersimple carbohydrates instead of dextrose or glucagon.If a patient initiates an informed refusal of transport, a final set of vital signs including bloodglucometry must be attempted.

Hypoglycemia


Adult Doses

Pediatric Doses

Dextrose IV 50 kg 25 g

< 30 DaysDextrose IV

D10W

2 ml/Kg

0.2g/kgMax

5 g (50 ml)

10 min 25 g

2 doses

1 mg 20 min 1 mg 2 doses

10 min 2 ml/Kg

0.2g/kgMax

5 g (50 ml)

2 doses

30 Days to < 2 yearsDextrose IV

D25W

2 ml/Kg0.5g/kg

Max

10 g (40 ml)

2 doses10 min 2 ml/Kg0.5g/kg

Max

10 g (40 ml)

2 years to < 50 KgDextrose IV

D50W

1 ml/Kg

0.5g/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

0.5g/kgMax

25 g (50 ml)


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DextroseReference


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Nausea/

Vomiting

Clinical Parameters

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


Dimenhydrinate IV/IM50 mg 50 Kg

N/A N/A 1 dose

Indications

Nausea OR Vomiting

Nausea / Vomiting


Pediatric Doses

Dimenhydrinate IV/IM25 mg

25 - < 50 Kg

(if < 25 Kg Patch)

N/A N/A 1 dose

Adult Doses

Notes:

If giving IV dilute dimenhydrinate with 9 ml normal saline to a 50 mg in 10 ml solution.


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Antihistamines

Actifed

Astemazole (Hismanal)

Azatdine (Zadine)

Cetirizine (Zyrtec, Reactine)Chlorpheniramine (Chlor-Trimeton, chlortripalon)

Clemastine

Cyproheptadine (Periactin)

Dexchlorpheniramine

Desloratadine (Clarinex)

Dimenhydrinate (Dramamine)

Diphenhydramine (Benadryl)

Fexofenadine (Allegra)

Hydroxyzine (Atarax, Vistaril)Loratadine (Claritin, Alavert)

Phenothiazines

Promethazine (Phenergan)

Piperzanes

Terfenadine (Seldane)

Anticholinergics

Atropine

Hyoscine

Glycopyrrolate (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)


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Clinical Parameters

No allergy or sensitivity to drug administered. 18 years SBP 100 No injury to the head or chest or abdomen or pelvis. No SBP drop by 1/3 or more of the initial reading


Morphine IV 2 - 5 mg 5 min 2 - 5 mg 4 doses

Indications

Pain

Severe pain and;

Isolated hip or extremity fractures or dislocation or; Major burns or; Current history of cancer related pain or; Renal colic with prior history or; Acute musculoskeletal back strain or; Ongoing transcutaneous pacing.

Notes:

For ease of administration and control, when using 10 mg/ml morphine, draw up the morphinewith 9 ml of saline to achieve a 10 mg in 10 ml solution.

Pain


49/91

Special Events DirectivesSpecial event: a preplanned gathering with

potentially large numbers and the Special

Event Medical Directives have been

preauthorized for use by the MedicalDirector



50/91


Clinical Parameters


Acetaminophen PO

Notes:

Release from care.

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

Adult Doses

325 - 650 mg N/A None 1 dose

Indications

Uncomplicated 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

Headache


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Clinical Parameters

Unaltered LOA No allergies or sensitivity to topical antiobiotics

Indications

Minor abrasions

Minor Abrasion (Special Events ONLY)

Notes:


MinorAbrasion


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Clinical Parameters


Diphenhydramine PO

Notes:

Release from care.

Adult Doses

50 mg N/A N/A 1 dose

Indications

Signs 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

MinorAllergicReaction


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Clinical Parameters


Acetaminophen PO

Notes:

Release from care.


Adult Doses

325 - 650 mg N/A None 1 dose

Indications

Minor 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

MusculoskeletalPain


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ReferenceMaterials

Stroke Prompt Card.............................! 3

Rule of nines charts.............................! 4

Field Trauma Triage.............................! 5

ECG Basics.........................................! 6

IM Injections........................................! 7

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

Toxidromes..........................................! 11

Phone Numbers..................................! 12 - 13

Codes of Entry....................................! 14

Pediatric References..........................! 15

Medication References.......................! 16 - 32PCP Scope of Practice........................! 33

ACP Scope of Practice........................! 34 - 35

VSA Special Circumstances...............! 36


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3


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4

Burn Chart 'Rule of nines'


60/91

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;

paramedics judgement that the patient requires assessment andtreatment at a lead trauma centre.


61/91

6

EECCGG BBAASSIICCSS

NNOORRMMAALLEECCGGPPAARRAAMMEETTEERRSS

P wave Typically +ve

QRS Complex of accompanying R waveand/or > 0.04 sec (1 sm box)

22..Physiological Q waves: Normal

Less then criteria above QQRRSS NNoommeennccllaattuurree

11

22


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7

Needle length:

5/8" for small infants

1" for young children

1.5" 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 fingerwidths below the acromium process.

The insertion site is in the middle of the

triangle.

Intra Muscular Injection

Landmarking and Needle Selection


63/91

8


64/91

9


65/91

10OOVVEERRDDOOSSEE LLEEVVEELLSS

TTHHIISSCCHHAARRTTIISSIINNTTEENNDDNNEEDDOONNLLYYAASSAAGGUUIIDDEE..

NNUUMMEERROOUUSSVVAARRIIAABBLLEESSIINNFFLLUUEENNCCEETTOOXXIICC//LLEETTHHAALLLLEEVVEELLSS..

ASA Adults&children:

300500mg/kgisasevereingestion

>500mg/kgmaybefatal

Acetaminophen

Adults:

70140mg/kgmaybetoxic

140mg/kgcanbefatal

Children:

200mg/kgmaybefatal

Amphetamines 100mg(40mginchildren)

Atropine 100mg

Benadryl(diphenhydramine) 2040mg/kgmaybefatal

Barbiturates

1

3

gm

Benzodiazepines Toxicityrangesfrom5001500mgs

Cocaine

(Asmostsreetdrugs,impurities,

etcmakepredictingtoxiclevels

difficult)

Arockisusually100200mg

Atypicallineisusually2030mg

Aspoonisusually510mg

Codeine 225mg/kgcancausetoxiceffects

5001000mgcanbefatal

Demerol 1gmmaybefatal

DigitalisGlycosides Digitalis:2gmmaybefatal

Digitoxin:3mg

may

be

fatal

Digoxin:10mgmaybefatal

Dilantin 20mg/kgmaybetoxic

GHB 3060mgmaybetoxic

Ibuprofen Adults:

654mgmaybetoxic

Children:

200400mg/kgmaybesevereingestion

>400mg/kgmaybefatal

Methadone 50mgcanbefatal

Methamphetamine 1mg/kgmaybefatal

Morhpine 200250mgingestioncanbefatal

Methanol 30240mlmaybefatal

MonoamineOxidaseInhbitors

(MAOIs)

23mg/kgislifethreatening

46mg/kgistypicallyfatal

TricyclicAntidepressants

(TCAs)

2035mg/kgmaybesevere

3540mg/kgmaybefatal

Valium(Diazepam) 1gmmaybefatal


66/91

11

TTOOXXIIDDRROOMMEE//IINNFFOO

AAPPPPEEAARRAANNCCEE

HHOOWW

UUSSEEDD

LLOOAA

RRRR

HHRR

BBPP

PPUUPPIILLSS

EECCGG

MMIISSCC

EECCSSTTAASSYY

((SSTTIIMMUULLAANNTT))

L

ookslike

pills/candy

PO

Alter

Dilated

Tachy-

Arrhythmias

T,Teeth

grinding,Irrational

MMEETTHH


Diffcoloured

pow

der,Rock,

Crystal

Snorted,IV,

smoked,PO

Alter

Poss

dilated

Tachy-

Arrhythmias

Tremors,Poss

CVA,Seizures,

T,Sweaty

CCOOCCAAIINNEE//CCRRAACCKK


Diffcoloured

p

owders,

Ro

ck,Crystal

Snorted,IV,

smoked

Dilated

Tachy-

Arrhythmias

CP,Proneto

MI/CVA,Violent

HHEERROOIINN

(Opiate

Narcotic)

L

ight-Dark

Powdersor

B

lacktarry

substance

Snorted,IV,

smoked,SC

Alter

+

+

+

Const

Arrhythmias

N/V,Restless,

Seizures,

KKEETTAAMMIINNEE

(Anaesthetic)

Clearliquid,

Wh

itepowder

Snorted,IV,

smoked,PO

Arrhythmias

Sweaty,T,

Nausea

GGHHBB

(Depressant)

L

ookslike

water

Drank(often

mixedE

TOH

)

+

+

Norm/Dilat

Slugg

Irregular

Nausea,

Seizures,

IINNHHAALLAANNTTSS

Glue,paint,

petro,

Aerosols

Inhaled

Alter

Poss

dilated

Arrhythmias

Slurredspeech,

Dizzy,

Hallucinations

MMAARRIIJJUUAANNAA

Pla

ntmaterial

Smoked,Mixe

d

food,Tea

Alter

Norm/Dilat

Slugg

Bloodshoteyes,

Munchies

AAnnttiicchhoolliinneerrggiicc

((TTCCAASS//BBEENNAADDRRYYLL

//GGRRAAVVOOLL//AANNTTIIHHIISSTT))

Pills

PO,SC,

Alter

Dilated

N,Warm,Wet,

Possibleseizures


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13

Phone Numbers

!


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NOTES:

14


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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 Year

Spontaneous 4 Spontaneous

To Speech 3 To Speech

To Pain 2 To Pain

None 1 NoneBEST RESPONSE TOAUDITORY / VISUAL

STIMULUS (0-2 years)

BEST VERBAL RESPONSE(2-5 Years)

Orients to sounds, follows objects,smiles, coos, babbles

Oriented, appropriate words

Cries appropriately; when upset Confused, inappropriate words

Inappropriate, persistent cry /Scream

Inappropriate, persistent cry /scream

Agitated / restless; grunts,Moans

Incomprehensible sounds;grunts

No Response No Response

< 2 Year BEST MOTOR RESPONS > 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

15

Pediatric Reference


71/91

ACETAMINOPHEN

CLASS

AnalgesicACTION

Although not fusynthesis of prand work peripproduces antipregulating cent

lly elucidated, believed to istaglandins in the centralerally to block pain impulsresis from inhibition of hyr.

hibit theervous system

e generation;othalamic heat-

ONSET HALF-LIFEELIMINATION

PEAKEFFECT

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

METABOLISM

At normal thera

metabolism tosmall amount ireactive interm(NAPQI), whicinactivated to nconjugates. Atglutathione con

metabolic demconcentrations,Oral administra

peutic dosages, primarily

ulfate and glucuronide cometabolized by CYP2E1 tdiate, N-acetyl-p-benzoquis conjugated rapidly with

ontoxic cysteine and mercoxic doses (as little as 4 g

jugation becomes insuffici

nd causing an increase inwhich may cause hepatic

tion is subject to first pass

epatic

jugates, while ao a highlyinone imineglutathione andpturic acid

daily)nt to meet the

NAPQIell necrosis.

metabolism.

16


72/91

CLASSAntiarrhythmic

ACTIONSlows conduction tithe re-entry pathwanormal sinus rhyth vasodilation and in

arteries with little toarteries; thallium-2arteries will be lessrevealing areas of i

me through the Ays through the AV.Adenosine alsoreases blood flo

no increase in st1 uptake into thethan that of normsufficient blood fl

node, interruptingnode, restoringcauses coronaryin normal coronary

notic coronarystenotic coronaryl coronary arteries

ow.


DURATION

Rapid < 10 seconds Very brief

METABOLISM

Blood and tissue tomonophosphate (A

inosine then to aP) and hypoxan

enosinehine

17


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CLASS

Platelet aggregationanti-inflammatory.

inhibitor, analgesi , antipyretic and

ACTION

Decreases clotting binterfering with Throplatelets. Thromboxconstrict.

Reduces morbidity/MI.

y inactivating cyclboxane A2 prod

ane A2 also caus

ortality in adult p

xygenase,ction within thes arteries to

tients with CP from

ABSORPTION TIME TO PEAK DURATION

Rapid 1-2 hours 4-6 hours

METABOLISM

Hydrolyzed to salicyl

mucosa, red blood cmetabolism of salicyconjugation; metabo

ate (active) by est

lls, synovial fluid,late occurs primarlic pathways are s

erases in GI

and blood;ily by hepatic

turable. (Not a complete list)

OVER-THE-COUNTER

Aspirin

Ibuprofen (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


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LASS

Parasympatholytic, anticholinergic

CTION

Blocks the action of acetysites in smooth muscle, sincreases cardiac output,reverses the muscarinic eThe primary goal in cholinbronchorrhea and broncheffect on the nicotinic recweakness, fasciculations,

lcholine at parasympatheticcretory glands, and the CNS;

dries secretions. Atropineffects of cholinergic poisoning.ergic poisonings is reversal ofconstriction. Atropine has noptors responsible for muscleand paralysis.

ONSET HALF-LIFE ELIMINATION

Rapid 2-3 hours

ME ABOLISM

Hepatic

DIS RIBUTION

Widely throughout theamounts enter breast mil

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

19


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CLASS

Carbohydrate (Caloric Supplement)

ACTION

Replenishes blood glucose levels reversinghypoglycemia.

METABOLISM

Metabolized to carbon dioxide and water.

20


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CLASS

Antiemetic, Antihistamine

ACTION

Competes with histacells in the gastrointrespiratory tract; blodiminishes vestibula

labyrinthine functionactivity.

mine for H1-recstinal tract, bloks chemorece

r stimulation, an

through its cent

ptor sites on effectord vessels, and

tor trigger zone,d depresses

ral anticholinergic

ONSET PEAKEFFECT

DURATION

1-5 minutes (IV)

15-30 minutes(oral)

1-2 Hours 3-6 hour

21


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CLASS

Antihistamine

ACTION

Competes with histcells in the gastroinrespiratory tract; analso seen.

mine for H1-receptoestinal tract, bloodicholinergic and se

r sites on effectoressels, andative effects are

ONSET PEAK EFFECT DURATION1-5 minutes (IV)

1-3 hours (oral)

1-2 hours (IV)

2-4 hours (oral)

4-8 hours

HAL -LIFE ELIMINAT ON

2-10 hours

22


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CLASS

Sympathomimeti agentACTION

Stimulates both alower doses areproduce renal analso are both dopstimulating and p

vasodilation; largreceptors.

drenergic and dopamiainly dopaminergic stimesenteric vasodilati

aminergic and beta1-aoduce cardiac stimula

doses stimulate alph

ergic receptors,mulating andon, higher dosesrenergicion and renal

-adrenergic


DURATION

5 minutes 2 minutes


79/91

CLASSSympathomimetic agent

ACTION

Stimulates alpha-, beta1-, and beta2-adrenergic receptorsresulting in relaxation of smooth muscle of the bronchialtree, cardiac stimulation (increasing myocardial oxygenconsumption), and dilation of skeletal muscle vasculature;

small doses can cause vasodilation via beta2-vascularreceptors; large doses may produce constriction ofskeletal and vascular smooth muscle.

ONSET

5-10 minutes (bronchodilation)

METABOLISM

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

24


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CLASSOpioid analgesic

ACTION

Binds to opiate recascending pain patresponse to pain; p

ptors in the CNS, cways, altering the

roduces generalize

ausing inhibition oferception of andCNS depression.

ONSET PEAK EFFECT DURATION

2-5 minutes (IV) 20 minutes (IV) 1 hour

HALF-LIFE ELIMINA ION

2-4 hours

METABOLISM

Hepatic

29


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CLASS

Narcotic Antagoni t

ACTION

Competitive narcobound to opiate re

ic antagonist. Displaceptor sites reversing

s any narcoticsheir 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


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CLASS

Sympathomimetic, eta 2 agonist

ACTION

Relaxes bronchial sreceptors with little

mooth muscle byffect on heart rat

ction on beta2-.


DURATION

10 minutes(nebulized/oralinhalation)

3-8 hours(inhalation) 3-4 hours(nebulized/oralinhalation)

METABOLISM

Hepatic to an inacti e sulfate

32


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PCP Scope of Practice

Perform the following skills:

Semi-Automated External Defibrillation Manual defibrillation (when working with an ACP who has indicated that a shock

and its energy setting is to be delivered) Intravenous monitoring Intravenous 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 management Advanced Airway management with the King LT Oro-pharyngeal Suctioning

Current CPR standards for Health-Care Providers 3 lead monitoring and interpretation 12 and 15 lead acquisition and interpretation Administration of CPAP Preparation of ACP pre-loaded medications Assessments and Interpretation of findings ie chest sounds & tx Capillary Blood Sampling & glucometer use Utilization/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


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ACP Scope of Practice

Perform the following skills:

Manual Defibrillation Synchronized Cardioversion Transcutaneous Pacing Intravenous Access/Therapy Intraosseous Access/Therapy Volume (crystalloid) Replacement Therapy Advanced Airway management with the King LT Oral Endotracheal Intubation Nasal Tracheal Intubation Difficult Airway with lighted stylet / Bougie Laryngoscopy

ETT (Deep) Suctioning FBAO Removal (Magill Forceps) Needle Chest Decompression 3 lead monitoring and interpretation 12 and 15 lead acquisition and interpretation Assessments and Interpretation of findings ie chest sounds & tx Venous and Capillary Blood Sampling & glucometer use Utilization/interpretation of SpO2 and Endtidal CO2 monitoring Application 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)

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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

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