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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
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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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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
Central East Prehospital Care Program For reference only 7
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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8 Central East Prehospital Care Program For reference only
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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10 Central East Prehospital Care Program For reference only
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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14 Central East Prehospital Care Program For reference only
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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Clinical Parameters Vital Sign Parameters
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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Clinical Parameters Vital Sign Parameters
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
Confirmation MethodsPrimary
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.
Confirmation MethodsPrimary
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.
Drug Initital Dose Q Repeat Dose Max
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.
Drug Initital Dose Q Repeat Max
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).
Drug Initital Dose Q Repeat Dose Max
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
Adult Doses 18 years
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
Clinical Parameters Vital Sign Parameters
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
Drug Initital Dose Q Repeat Dose Max
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
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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
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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
Drug Initial Dose Q Repeat Dose Max
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
Drug Initial Dose Q Repeat Dose Max
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
Clinical Parameters Vital Sign Parameters
Allergy or sensitivity to given drug
Atropine:
No hypothermiaNo heart transplant
Dopamine:No pheochromocytoma
TCP:No hypothermia
HR < 50with hemodynamic instability
SBP < 90
Drug Initital Dose Q Repeat Dose Max
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)
Drug Initial Dose Q Repeat Max
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)
Drug Initial Dose Q Repeat Max
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
Drug Initital Dose Q Repeat Dose Max
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
Adult Doses 18 years
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
Drug Initital Dose Q Repeat Max
Midazolam IM/IN/Buccal
Notes:
Conditions such as cardiac arrest and hypoglycemia often present as seizure and should beconsidered by a paramedic.
Drug Initital Dose Q Repeat Dose Max
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
Drug Initital Dose Q Repeat Max
Notes:
*For IV route, titrate naloxone only to restore the patient's respiratory status.
Patch - NaloxoneIM/IN/SC
0.8 mg
Adult Doses 18 years
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
Drug Initital Dose Q Repeat Max
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
Drug Initial Dose Q Repeat Max
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
Drug Initial Dose Q Repeat Max
Dimenhydrinate IV/IM50 mg 50 Kg
N/A N/A 1 dose
Indications
Nausea OR Vomiting
Nausea / Vomiting
Drug Initital Dose Q Repeat Dose Max
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
Drug Initial Dose Q Repeat Max
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
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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
Central East Prehospital Care Program For reference only 49
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Clinical Parameters
Drug Initial Dose Q Repeat Max
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:
Advise patient that if the problem persists or worsens that they should seek further medicalattention.
MinorAbrasion
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Clinical Parameters
Drug Initial Dose Q Repeat Max
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
Drug Initial Dose Q Repeat Max
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
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'
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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.
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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
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8
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9
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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
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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
((SSTTIIMMUULLAANNTT))
Diffcoloured
pow
der,Rock,
Crystal
Snorted,IV,
smoked,PO
Alter
Poss
dilated
Tachy-
Arrhythmias
Tremors,Poss
CVA,Seizures,
T,Sweaty
CCOOCCAAIINNEE//CCRRAACCKK
((SSTTIIMMUULLAANNTT))
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
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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
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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.
ONSET HALF-LIFEELIMINATION
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.
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CLASS
Carbohydrate (Caloric Supplement)
ACTION
Replenishes blood glucose levels reversinghypoglycemia.
METABOLISM
Metabolized to carbon dioxide and water.
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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
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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
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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
ONSET HALF-LIFEELIMINATION
DURATION
5 minutes 2 minutes
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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.
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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
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CLASS
Narcotic Antagoni t
ACTION
Competitive narcobound to opiate re
ic antagonist. Displaceptor sites reversing
s any narcoticsheir effects.
ONSET HALF-LIFEELIMINATION
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
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CLASS
Sympathomimetic, eta 2 agonist
ACTION
Relaxes bronchial sreceptors with little
mooth muscle byffect on heart rat
ction on beta2-.
ONSET HALF-LIFEELIMINATION
DURATION
10 minutes(nebulized/oralinhalation)
3-8 hours(inhalation) 3-4 hours(nebulized/oralinhalation)
METABOLISM
Hepatic to an inacti e sulfate
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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)
!
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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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