1. Manage airway as needed (airway maneuver and/or suction and/or adjunct)

• Follow current Heart & Stroke guidelines for management of respiratory arrest

• If severe respiratory distress or respiratory depression assist ventilation with positive pressure ventilation:

o Perform bag mask ventilation (BMV) using 100% O2 as needed

 Consider Predictors of Difficult Bag Mask Ventilation1

 Optimize BMV utilizing Optimal Bag Mask Ventilation2 techniques

 Observe for Signs of Effective Bag Mask Ventilation3

• If airway obstructed follow current Heart & Stroke guidelines for management of foreign body obstructed airway procedures as necessary

2. Continuous cardiac, SpO2 and BP monitoring

3. Request ACP intercept if available

4. IV access during transport

PREDICTORS OF DIFFICULT BAG MASK VENTILATION – “BOOTS”

Beard

Obese

Older

Toothless

Snore / Stridor

OPTIMAL BAG MASK VENTILATION / APPROACH TO DIFFICULT BAG MASK VENTILATION

1) Reposition airway – exaggerated head tilt or exaggerated jaw thrust

2) Position ear level with sternum (Ramp4 patient if obese)

3) Consider foreign body

4) Consider alternative mask size

5) Insert oral and/or nasal airway

6) Perform two-person bag mask ventilation

3SIGNS OF EFFECTIVE BAG MASK VENTILATION

1) Rising SpO2

2) Visible chest rise

3) Audible breath sounds

4) Good seal (no air leak) and good compliance

RESPIRATORY DISTRESS WITH BRONCHOSPASM

(COPD, Emphysema, Chronic Bronchitis, Asthma)

This protocol is intended for management of patients with respiratory distress most likely resulting from COPD, Emphysema, Chronic Bronchitis, or Asthma.

1. Manage airway

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BPmonitoring

4. Measure temperature AND blood glucose

5. IV access during transport

6. Administer a combination of both salbutamol and ipratropium bromide as per dosing guidelines below:

MDI + aerochamber1

OR

Nebulized with O2

Salbutamol

4-8 puffs (100 mcg/puff)

5 mg

Ipratropium bromide

4-8 puffs (20 mcg/puff)

500 mcg

Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations)

1 Each puff must be followed by at least 4 breaths

7. If confirmed COPD (Emphysema or Chronic Bronchitis) only and respiratory status has improved to patient’s baseline after treatment:

• Consider replacing NRB with nasal cannula to maintain SpO2 90-92%

• If there is continued respiratory distress continue O2 via NRB



Contact OLMC if::

• Respiratory distress is unrelieved by salbutamol and/or ipratropium bromide for consideration of:

o Continued administration of salbutamol

o Administration of epinephrine 1:1000 – 0.3 mg IM

• Uncertainty about the cause of the patient’s respiratory distress and for advice regarding appropriate management

NOTES

• Patients should be treated with MDI and aerochamber unless it is deemed inappropriate, ineffective, or patient cannot tolerate

• Salbutamol or ipratropium bromide may be administered singularly if the patient has hypersensitivity to one of the other medications.

ALLERGY AND ANAPHYLAXIS

FINDINGS OF ANAPHYLAXIS

1) Acute onset (minutes to hours) of TWO OR MORE of the following after exposure to a LIKELY ALLERGEN:

• Skin symptoms (hives, itching, flushing)

• Oropharyngeal edema (lips, tongue, uvula)

• Respiratory compromise (dyspnea, wheeze, stridor, hypoxemia)

• Gastrointestinal symptoms (crampy abdominal pain, vomiting, diarrhea)

• Reduced blood pressure or associated symptoms (hypotonia, collapse, syncope)

OR

2) Hypotension (SBP less than 90 mmHg) alone after exposure to a KNOWN ALLERGEN for patient

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. IV access

5. If shock present, administer a fluid bolus as per Adult Fluid Therapy Protocol (Pg 43)

6. If Findings of Anaphylaxis present administer:

• Epinephrine 1:1000 – 0.3 mg IM

o Repeat once in 5 minutes if no improvement

7. If respiratory distress present (including wheezing), administer salbutamol:

MDI + aerochamber1

OR

Nebulized with O2

Salbutamol

4-8 puffs (100 mcg/puff)

5 mg

Repeat every 5 minutes if indicated (Not to exceed a maximum total of 3 administrations)

1Each puff must be followed by at least 4 breaths

1 NOTE

• Patients should be treated with MDI with aerochamber unless it is deemed inappropriate, ineffective, or patient cannot tolerate

• Epinephrine is relatively contraindicated in the setting of ischemic chest pain. In the rare event that you suspect a patient has ischemic chest pain combined with anaphylaxis, contact OLMC prior to administration of epinephrine.

If patient meets criteria outlined in the DNR Protocol (Pg 18) or Obvious Death Protocol (Pg 17) do not proceed with resuscitation

1. Confirm Vital Signs Absent (VSA) and initiate chest compressions

2. 100% O2 via BMV (15 L/min)

3. Continuous cardiac and SpO2monitoring

4. Request ACP intercept if available

5. Consider and treat Reversible Causes1

6. IV access (DO NOT delay or interrupt CPR)

GENERAL GUIDELINES

• Confirm absence of pulse – pulse check NOT exceeding 10 seconds

• Initiate compressions immediately: C-A-B Sequence

• Begin CPR (30 compressions : 2 ventilations) while immediately attaching defibrillator – Analyze, defibrillate without delay if indicated

• Ensure high quality CPR

o Minimize interruptions in CPR

o Allow full recoil of the chest between compressions

o Rotate rescuers every 2 minutes (if resources allow) concurrent with pulse checks

• After third rhythm analysis determine if patient meets Termination of Resuscitation (TOR) Protocol (Pg 16) prior to initiating transport. If patient does not meet TOR, continue CPR and initiate transport.

• Analyze rhythm every 10 minutes thereafter. Continue CPR.

• If return of spontaneous circulation (ROSC) proceed immediately with Post Cardiac Arrest Care Protocol (Pg 15)

• If re-arrest occurs during transport, resume Cardiac Arrest Protocol

HYPOTHERMIC CARDIAC ARREST (CORE TEMPERATURE LESS THAN 32ºC)

• Hypothermic patients are to be resuscitated as per Cardiac Arrest Protocol above

• Resuscitation will be continued until active re-warming has returned core temperature to normal or there has been ROSC

REVERSIBLE CAUSES OF CARDIAC ARREST

Hypovolemia

Hypoxia

Hypothermia

Hypoglycemia

Drug Overdose

1. Manage airway and assist ventilations as necessary

2. O2 via NRB (15 L/min)

• Assist ventilations with BVM if signs of inadequate ventilation are present:

o Abnormal sounds with breathing, such as snoring, gurgling, or stridor

o Fatigue with respiratory effort

o Gasping

o Irregular breathing pattern with periods of apnea

o Little or no chest rise

o Decreased or absent breath sounds (“Silent chest”)

o Rate and/or depth of breathing grossly insufficient for age

o Apnea

• If assisted ventilation is indicated, deliver ventilations by BVM at a rate of 12 breaths per minute (1 breath every 5 seconds)

o Deliver each breath over 1 second

o Deliver sufficient volume to produce visible chest rise

o Avoid excessive ventilation (hyperventilation)

3. If defibrillator was used, leave pads in place

4. Request ACP intercept if available

5. Continuous cardiac (not via defib pads) SpO2 and BP monitoring

6. Perform 12 Lead ECG

7. Two large bore IVs (initiate second IV during transport)

8. Consider and treat Reversible Causes1

9. If re-arrest occurs, resume Cardiac Arrest Protocol (Pg 14)

10.If persistent hypotension proceed with Cardiogenic Shock Protocol (Pg 24)

NOTE:

• A copy of the code summary and PCR must be left with the receiving facility

Termination of resuscitation is to be applied when resuscitation of cardiac arrest has been initiated and prior to transport

The PCP can terminate resuscitative efforts when ALL of the following criteria are met:

1) Cardiac arrest unwitnessed by EMS provider

2) No ROSC has occurred after 3 full rounds of CPR

AND

3) No shock(s) advised or delivered by EMS provider or Medical First Responder

If ALL requirements are met, proceed with the Management of Death Protocol (Pg 19)

TERMINATION OF RESUSCITATION (TOR)

This TOR Protocol CANNOT be utilized in situations related to:

1) Age less than 18 years

2) Pregnancy

3) Hypothermia

4) Electrocution including lightning strike

5) Trauma (Blunt or Penetrating Traumatic Cardiac Arrest Protocol Pg 41-42)

6) Poisoning or drug overdose

7) Sudden reversible event (anaphylaxis, choking, drowning with submersion less than 60 minutes, asphyxia)

In these cases resuscitation and transport must proceed as per usual cardiac arrest protocols.

OBVIOUS DEATH

The PCP will NOT start resuscitation of a patient of any age that has suffered cardiac arrest (not breathing and no palpable pulse) if any of the following signs of obvious death are present:

1) Rigor mortis

2) Dependent lividity

3) Decapitation

4) Transection of the torso

5) Decomposition

6) Confirmed submersion greater than 60 minutes

7) Obvious destruction of brain, heart, or lungs that is incompatible with life

8) Other catastrophic injury that is incompatible with life

NOTES

• Proceed with Management of Death Protocol (Pg 19) upon recognition of cardiac arrest meeting Obvious Death criteria

DO NOT RESUSCITATE (DNR)

This DNR Protocol CANNOT be implemented in situations related to:

1) Trauma (See Blunt or Penetrating Cardiac Arrest Protocol Pg 41-42)

2) Suicide attempt

3) Sudden reversible events: choking, asphyxia, anaphylaxis, drowning, hypothermia, electrocution, toxic ingestion or overdose

4) Pregnancy

The PCP will NOT start or may terminate resuscitation of a patient of any age that has suffered from cardiac arrest (not breathing and no palpable pulse) in either of the following circumstances:

1. A Valid DNR Order or Advance Health Care Directive (Pg 102) is presented AND a reasonable effort has been made to verify the identity of the patient named on the document

OR

2. A legally recognized Substitute Health Care Decision Maker (SHCDM) (Pg 102) is present and states that the patient expressed a desire not to be resuscitated in this type of circumstance OR presents reasons why the patient should not be resuscitated while maintaining the patient’s best interest

AND

The PCP must NOT have any concerns about the appropriateness of withholding resuscitation based on:

1) Doubts about the patients best interest

2) The validity of the DNR order or Advance Health Care Directive

3) The identity of the person making the request as a SHCDM

4) The patient’s family that are present being unable to reach an agreement about withholding resuscitation

NOTES

• If the PCP has any concerns regarding the validity of the DNR request – full resuscitative efforts should be initiated and contact made with OLMC if necessary

• If a request for DNR is made prior to the patient suffering complete cardiac arrest – provide supportive care (oxygen, airway support, and comfort measures) and contact OLMC with transport to hospital as appropriate

• Proceed with Management of Death Protocol (Pg 19) upon recognition of cardiac arrest with valid DNR request

MANAGEMENT OF DEATH (RESUSCITATION TERMINATED OR NOT INDICATED)

CAUTION

This protocol is NOT to be utilized as the initial assessment of the unconscious patient to determine if they are in cardiac arrest. The initial assessment to determine if cardiac arrest is present should be conducted in accordance with the standards outlined in the Cardiac Arrest Protocol, with a pulse check not exceeding 10 seconds duration.

This protocol outlines the criteria that must be evaluated and documented in the PCR AFTER it has been determined that resuscitation from cardiac arrest is not indicated, or should be terminated when directed to do so by the Blunt or Penetrating Cardiac Arrest (Pg 40-41)), DNR (Pg 18), Obvious Death (Pg 17), or Termination of Resuscitation (Pg 16) Protocol(s).

Once it is determined that resuscitation from cardiac arrest is not indicated OR should be terminated proceed with the following steps:

1. Evaluate for, confirm, and document the presence of all the Documentation of Death Criteria1

2. Determine if the death meets criteria for Reportable Death2 or Expected Death3

• If the death was an Expected Death inquire whether the patient is enrolled in the “End of Life Program” and proceed as follows:

o If patient enrolled in the End of Life Program, contact the health care professional that has been identified to the family for purposes of notification of death

o If the patient is not enrolled in the End of Life Program, notify the family physician or designate. If the family physician or designate is unavailable, contact the police

• If the death meets the criteria of a Reportable Death proceed as follows:

1) Do not disturb the scene – limit access only to essential responders

2) Leave ALL disposable medical equipment and supplies used in the resuscitation in place – do not remove from the scene

3) Leave defibrillation pads, and airway adjuncts in position

4) Leave the deceased in position – do NOT move or cover the body

5) Exit the scene of the death immediately using the same pathway as was used to enter

6) Do not permit anyone entrance into the scene

7) Notify police

3. Provide comfort to the bereaved

• Disclose death simply and directly with warmth and compassion

• Listen and empathize

• Assist locating support – relative, friend, clergy, etc.

4. Allow the bereaved to see the body if they wish:

• If not a reportable death, prepare the deceased – clean up medical supplies, cover with blanket, place pillow under head, close eyes, wipe up body fluids, etc.

• Prepare the bereaved for what they will see and answer any questions

• Do not rush the bereaved

5. Remain on-scene until appropriate supports arrive for the bereaved, and/or:

• Family physician, police, medical examiner, or funeral home arrive and assume control of the deceased

• Crew is requested to respond to another life-threatening time-dependent emergency call

DOCUMENTATION OF DEATH CRITERIA

Assess and document ALL of the following criteria:

Assess and document ALL of the following criteria:

1) No palpable carotid pulse (Assess for 60 seconds)

2) No spontaneous respiratory effort (Assess for 60 seconds)

3) No heart sounds (Assess for 60 seconds)

4) Non-reactive pupils

REPORTABLE DEATH CRITERIA

When ANY ONE OR MORE of the following criteria present:

1) Death as a result of violence, accident, or suicide

2) An unexpected death when the person was in good health

3) Where the person was not under the care of a physician

4) The death is obviously suspicious in nature

5) Where the cause of death is undetermined

6) Death is the result of improper or suspected negligent treatment by another person

3EXPECTED DEATH

Any death that does not meet Reportable Death Criteria

NOTE

• Transport of the deceased must be completed by a licensed funeral director

• An ambulance may transport the deceased only if the deceased is in a public place and the funeral director will be extensively delayed (greater than 1 hour), or as directed by police or OLMC

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Control bleeding (if applicable)

4. Assess for Signs and Symptoms of Shock1

5. Continuous cardiac, SpO2, and BP monitoring

6. Measure temperature AND blood glucose

7. Two large bore IVs (initiate second IV during transport)

8. Perform 12 lead ECG

9. Consider causes of shock and treat accordingly:

• If shock due to anaphylaxis, proceed with Allergy and Anaphylaxis Protocol (Pg 13)

• If shock due to sepsis, proceed with Sepsis Protocol (Pg 23)

• If shock due to cardiac etiology, proceed with Cardiogenic Shock Protocol (Pg 24)

10.For all other causes of shock, or when the cause of shock is unknown, administer a fluid bolus as per Adult Fluid Therapy Protocol (Pg 43)

1SIGNS AND SYMPTOMS OF SHOCK

1) Hypotension (SBP less than 90 mmHg)

AND

2) Any ONE OR MORE of the following features:

• Rapid and / or shallow breathing

• Cool and / or clammy skin

• Rapid and / or weak pulse(s)

• Near fainting and / or fainting

• Weakness



Contact OLMC if patient remains hypotensive after initial fluid bolus for consideration of:

• Additional IV fluid administration

NOTES

• Shock is a life-threatening, progressive medical condition that results from the inadequate flow of oxygenated blood to critical organs and tissues of the body.

• When the blood pressure is inadequate to sustain a regular flow of oxygenated blood to the organs and tissues of the body, end-organ damage will ensue and shock will eventually result.

• Shock may result from a number of medical conditions including sepsis, trauma, blood loss, anaphylaxis, severe dehydration, and various medical conditions.

CAUTION

• Trendelenburg positioning is not indicated in the treatment of shock and is not to be utilized

• Position the patient supine unless they are in severe respiratory distress

• If the patient in shock is suffering from severe respiratory distress position them semi-sitting and assist ventilations as indicated

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Measure temperature AND blood glucose

5. Two large bore IVs (initiate second IV during transport)

6. Perform 12 Lead ECG

7. If patient meets Sepsis Inclusion Criteria1 administer a fluid bolus of 20 mL/kg 0.9% NaCl regardless of blood pressure

SEPSIS INCLUSION CRITERIA

1) History suspicious for infection OR confirmed infection

AND

2) Any TWO OR MORE of the following clinical findings:

• Temperature less than 36ºC or greater than 38ºC

• Tachypnea (respiratory rate greater than 20)

• Heart rate greater than 90



Contact OLMC if patient remains hypotensive after fluid bolus for consideration of:

• Additional IV fluid administration

Symptoms of Severe Sepsis

Sepsis Inclusion Criteria + Any evidence of end-organ dysfunction

• Altered mental status, confusion, or coma

• Renal dysfunction, or poor urine output

• Respiratory distress, or hypoxia

• Myocardial ischemia

Septic Shock

Sepsis Inclusion Criteria + SBP less than 90 mmHg despite administration of 20 mL/kg 0.9%

NaCl

CARDIOGENIC SHOCK

CRITERIA FOR TREATMENT OF CARDIOGENIC SHOCK

1) Hypotension (SBP less than 90 mmHg)

AND

2) Chest pain OR severe pulmonary edema OR cardiac dysrhythmia OR known cardiomyopathy

AND

3) No history of trauma OR infection OR dehydration

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Measure temperature AND blood glucose

5. Perform 12 lead ECG

6. IV access

7. Request ACP intercept if available



Contact OLMC for consideration of:

• IV fluid administration

Contact OLMC with full description of history and clinical findings including:

• Vital signs

• Lung sounds

• Cardiac rhythm

• Pedal edema assessment

Carefully observe for signs of fluid overload. Auscultate chest for crackles every 250 mL. If crackles present, stop bolus.

CARDIOGENIC SHOCK

CRITERIA FOR TREATMENT OF CARDIOGENIC SHOCK

1) Hypotension (SBP less than 90 mmHg)

AND

2) Chest pain OR severe pulmonary edema OR cardiac dysrhythmia OR known cardiomyopathy

AND

3) No history of trauma OR infection OR dehydration

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Measure temperature AND blood glucose

5. Perform 12 lead ECG

6. IV access

7. Request ACP intercept if available



Contact OLMC for consideration of:

• IV fluid administration

Contact OLMC with full description of history and clinical findings including:

• Vital signs

• Lung sounds

• Cardiac rhythm

• Pedal edema assessment

Carefully observe for signs of fluid overload. Auscultate chest for crackles every 250 mL. If crackles present, stop bolus.

SIGNS AND SYMPTOMS OF CARDIOGENIC SHOCK

• Altered level of consciousness

• Cool, pale, or mottled skin

• Diaphoresis

• Hypotension

• Severe pulmonary edema (left heart failure)

• Decreased urine output

PULMONARY EDEMA

This protocol is intended for management of patients with SEVERE and ACUTE respiratory distress most likely resulting from pulmonary edema.

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Position patient upright if SBP greater than 100 mmHg

5. Perform 12 lead ECG

6. IV access

7. Request ACP Intercept if available

8. Administer nitroglycerin 0.4mg SL

• Repeat every 5 minutes if indicated to a maximum of 6 sprays, until symptoms are relieved or SBP falls below 100 mmHg

• If hypotension develops or SBP falls below 100 mmHg following the administration of nitroglycerin discontinue further administration.



Contact OLMC:

• For consideration of administration of nitroglycerin beyond six sprays

• If there is uncertainty about the cause of the patient’s respiratory distress and for advice regarding appropriate management

SIGNS AND SYMPTOMS OF PULMONARY EDEMA

• Severe respiratory distress

• Orthopnea

• Crackles

• Diaphoresis

• Nocturnal dyspnea

• Jugular vein distention

• Cough that may contain foamy, blood tinged sputum

• Peripheral edema

ISCHEMIC CHEST PAIN

This protocol is intended for management of patients with chest pain suspected to be of ischemic etiology.

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Perform 12 lead ECG pre and post intervention and in accordance with Serial 12 Lead ECGs2 box

5. IV access

6. Administer ASA 160–162 mg PO chewed

7. Administer nitroglycerin1 0.4 mg SL

• Repeat every 5 minutes if indicated to a maximum of 6 sprays, until chest pain is relieved or SBP falls below 100 mmHg

• If patient has no response to nitroglycerin following the administration of three (3) doses, discontinue use.

8. Request ACP intercept if available

1 INFERIOR WALL MYOCARDIAL INFARCTION (MI)

• Do not administer nitroglycerin if an inferior wall MI is suspected or confirmed by 12 Lead ECG, and/or patients SBP has been less than 100 mmHg at any time during current event

• Fluid therapy is not to be used to increase SBP to greater than 100mmHg to aid in nitroglycerin administration

STEMI ALERT

1) Notify receiving facility of “STEMI Alert” if ECG printout that reads “*****Acute MI***** or Left Bundle Branch Block” in a patient experiencing chest pain

2) ASA 160-162 mg PO if not already administered

3) Establish 2nd IV during transport (same arm, if possible)

4) Complete Thrombolytic Checklist for STEMI during transport

2SERIAL 12 LEAD ECGs

Serial 12 lead ECGs must be performed as outlined below:

1) On scene (prior to treatment)

2) In ambulance just prior to transport

3) Every 15 minutes during transport (if transport time greater than 30 minutes)

4) Just prior to arrival to receiving health care facility

5) Any time patient condition or ECG rhythm changes

If the initial 12 lead demonstrates evidence of ST elevation MI serial 12 leads are not required unless there is a change in patient condition or ECG rhythm changes



Contact OLMC:

• For consideration of administration of nitroglycerin beyond six sprays

SYMPTOMATIC DYSRHYTHMIAS (ADULT)

(Suspected cardiac origin, non-traumatic)

This protocol is intended for patients with symptomatic or clinically significant cardiac dysrhythmias. A variety of cardiac dysrhythmias may lead to symptoms or clinically significant findings including:

• Bradycardia

• Wide Complex Tachycardia

• Narrow Complex Tachycardia

• Atrial Fibrillation with heart rate greater than 120

• Atrial Flutter

Examples of symptoms that should prompt concern for clinically significant dysrhythmia are provided below.

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Perform 12 lead ECG

5. IV access

6. Request ACP Intercept if available

SIGNS AND SYMPTOMS OF CLINICALLY SIGNIFICANT DYSRHYTHMIAS

Signs & Symptoms

• Hypotension

• Shock

• Altered level of consciousness

• Tachypnea

• Hypoxia

• Respiratory distress

• Diaphoresis

• Pallor or mottled skin

• Vomiting

• Chest pain

• Dyspnea

• Syncope or presyncope

• Palpitation

• Nausea

ACUTE STROKE

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Establish and document Last Seen Normal (LSN) Time1

4. Continuous cardiac, SpO2, and BP monitoring

5. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 30)

6. Determine if patient is candidate for direct transport to a Stroke Centre using Paramedic Prompt Card (Pg 29)

7. IV during transport

 CAUTION

• If at any time during your patient contact there is airway compromise or patient condition becomes unstable, transport to the closest Emergency Department, even if it is not a designated Stroke Centre

LAST SEEN NORMAL (LSN) TIME

• The last time the patient was witnessed or confirmed in their usual state of health and completely without signs or symptoms of stroke

PARAMEDIC PROMPT CARD FOR ACUTE STROKE PROTOCOL

Indications for Direct Transport to a Stroke Centre

Direct transport to a designated Stroke Centre will be considered for patient who meet BOTH of the following requirements:

1) New onset of ANY ONE OR MORE of the following symptoms suggestive of the onset of an acute stroke:

• Unilateral arm AND / OR leg weakness or drift

• Slurred speech OR inappropriate words OR unable to speak

• Unilateral facial weakness or droop

AND

2) Can be transported to arrive at a designated Stroke Centre within 3.5 hours of a clearly determined Last Seen Normal Time or time of symptom onset

Contact OLMC without delay if:

• The patient is a candidate for direct transport to a Stroke Centre that requires bypassing a closer healthcare facility

• There is uncertainty whether the patient is a candidate for direct transport to a Stroke Centre

Contraindications for Direct Transport to a Stroke Centre

The presence of ANY ONE OR MORE of the following conditions excludes a patient from being transported directly to a Stroke Centre when there is a closer health care facility available:

• Uncorrected airway, breathing, or circulatory problem

• GCS less than 10

• Blood glucose remains less than 4 mmol/L despite treatment as per Symptomatic Hypoglycemia Protocol

• Seizure at onset of symptoms or observed by paramedics

• Terminally ill or palliative care patient

• Pregnancy

• Symptoms of stroke completely resolved prior to paramedic arrival or assessment1

• No Stroke Centre within 3.5 hours of LSN time in your area

• Any history of:

o Previous brain hemorrhage

o Brain tumor, arteriovenous malformation (AVM), or brain aneurysm

o Stroke or brain surgery within last 3 months

1 If symptoms improve significantly or completely resolve during transport, continue transport to designated Stroke Centre

Contact OLMC without delay if:

• The patient is a candidate for direct transport to a Stroke Centre that requires bypassing a closer healthcare facility

• There is uncertainty whether the patient is a candidate for direct transport to a Stroke Centre

PARAMEDIC PROMPT CARD FOR ACUTE STROKE PROTOCOL

Indications for Direct Transport to a Stroke Centre

Direct transport to a designated Stroke Centre will be considered for patient who meet BOTH of the following requirements:

1) New onset of ANY ONE OR MORE of the following symptoms suggestive of the onset of an acute stroke:

• Unilateral arm AND / OR leg weakness or drift

• Slurred speech OR inappropriate words OR unable to speak

• Unilateral facial weakness or droop

AND

2) Can be transported to arrive at a designated Stroke Centre within 3.5 hours of a clearly determined Last Seen Normal Time or time of symptom onset



Contact OLMC without delay if:

• The patient is a candidate for direct transport to a Stroke Centre that requires bypassing a closer healthcare facility

• There is uncertainty whether the patient is a candidate for direct transport to a Stroke Centre

Contraindications for Direct Transport to a Stroke Centre

The presence of ANY ONE OR MORE of the following conditions excludes a patient from being transported directly to a Stroke Centre when there is a closer health care facility available:

• Uncorrected airway, breathing, or circulatory problem

• GCS less than 10

• Blood glucose remains less than 4 mmol/L despite treatment as per Symptomatic Hypoglycemia Protocol

• Seizure at onset of symptoms or observed by paramedics

• Terminally ill or palliative care patient

• Pregnancy

• Symptoms of stroke completely resolved prior to paramedic arrival or assessment1

• No Stroke Centre within 3.5 hours of LSN time in your area

• Any history of:

o Previous brain hemorrhage

o Brain tumor, arteriovenous malformation (AVM), or brain aneurysm

o Stroke or brain surgery within last 3 months

1 If symptoms improve significantly or completely resolve during transport, continue transport to designated Stroke Centre



Contact OLMC without delay if:

• The patient is a candidate for direct transport to a Stroke Centre that requires bypassing a closer healthcare facility

• There is uncertainty whether the patient is a candidate for direct transport to a Stroke Centre

SYMPTOMATIC HYPOGLYCEMIA

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Measure temperature AND blood glucose level (BGL)

5. IV access

6. If blood glucose is less than 4 mmol/L, administer ONE of the following medications and recheck blood glucose in accordance with table below:

Patient able to maintain own airway

(Awake and able to cough and swallow)

Oral glucose options:1) Dex 4® tablets 20 g (5 tablets)

2) Insta-glucose® 1 tube (30 g)

3) 1 cup (250 mL) of juice or pop (Non-diet)

4) 4 teaspoons (20 mL) or 4 packets of table sugar dissolved in water

-Recheck BGL in 15 minutes-

IV established

Dextrose 50% (D50%) 25 g (50 mL) IVP

-Recheck BGL in 10 minutes-

Unable to establish IV

Glucagon1 1 mg IM

-Recheck BGL in 20 minutes-

7. Repeat Step 6 once if necessary

8. If the patient expresses a wish to remain home rather than continue care to hospital evaluate for Treat and Release inclusion and exclusion criteria (Pg 31)



Contact OLMC if blood glucose remains below 4 mmol/L after 2nd dose of dextrose or glucagon.

1 NOTES

• Anticipate that it could take up to 20 minutes to observe an effect from glucagon.

• While waiting for glucagon to take effect, manage patient’s airway as indicated and initiate transport

CAUTION

• If head injury or stroke suspected administer half of the usual dose of dextrose, recheck blood glucose, and then administer the second half dose if necessary.

• The goal is to correct hypoglycemia while avoiding transient hyperglycemia that may lead to

Dextrose CAUTION Protocol Modification

• If head injury or stroke suspected---

 administer half of the usual dose of dextrose, recheck blood glucose, and then administer the second half dose if necessary.

• The goal is to correct hypoglycemia while avoiding transient hyperglycemia that may lead to ceberal edma

TREAT AND RELEASE PROTOCOL FOR HYPOGLYCEMIA

Protocol is intended to be a patient initiated request for non-transport after resolution of hypoglycemia and return to normal level of consciousness. In all cases, transport to hospital should be presumed to be the usual outcome following treatment of hypoglycemia unless the patient requests non-transport or to remain at home.

If upon resolution of hypoglycemia and return to normal level of consciousness the patient requests non-transport proceed as follows:

1. Does the patient meet ALL inclusion criteria?

2. Does the patient have ANY ONE OR MORE exclusion criteria?

If YES – Patient not eligible for Treat and Release – proceed with transport or contact OLMC if patient refuses transport

If NO – Proceed with Treat and Release (including completion of Patient Refusal Form) and document presence of all inclusion criteria and absence of all Exclusion Criteria on PCR

NOTES

• If the patient meets all Inclusion Criteria and no Exclusion Criteria are identified contact with OLMC is NOT required. PCP’s are required to document the presence of all Inclusion Criteria and absence of all Exclusion criteria on the PCR.

• In all Treat and Release circumstances the patient must be advised to contact his or her family physician to arrange follow-up within 24-48 hours. Document this and all advice given on the PCR.

• Contact with OLMC is mandatory if the patient does not meet all Inclusion Criteria or any Exclusion Criteria are identified and the patient is refusing transport

Hypoglycemic Treat and Release Protocol

INCLUSION CRITERIA

Alert and cooperative

Capacity to refuse transport

In usual state of health before the hypoglycemic episode (No new medical concerns)

Competent adult bystander present to remain with patient

Patient is able to eat and monitor own blood sugar

If YES – Evaluate for Exclusion Criteria

If NO – Patient not eligible for Treat and Release – proceed with transport or contact OLMC if patient refuses transport

2. Does the patient have ANY ONE OR MORE exclusion criteria?

• In all Treat and Release circumstances the patient must be advised to contact his or her family physician to arrange follow-up within 24-48 hours. Document this and all advice given on the PCR.

• Contact with OLMC is mandatory if the patient does not meet all Inclusion Criteria or any Exclusion Criteria are identified and the patient is refusing transport

Hypoglycemic Treat and Release Protocol

EXCLUSION CRITERIA

Non-diabetic patient

Patient on oral diabetic medications

Insulin overdose

Hypoglycemia despite compliance with normal insulin dosing and PO intake

History of hepatic or renal insufficiency

If YES – Patient not eligible for Treat and Release – proceed with transport or contact OLMC if patient refuses transport

If NO – Proceed with Treat and Release (including completion of Patient Refusal Form) and document presence of all inclusion criteria and absence of all Exclusion Criteria on PCR

NOTES

• If the patient meets all Inclusion Criteria and no Exclusion Criteria are identified contact with OLMC is NOT required. PCP’s are required to document the presence of all Inclusion Criteria and absence of all Exclusion criteria on the PCR.

This protocol is intended for patients who demonstrate findings of significant dehydration and presentations suggestive of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Many diabetic patients may have blood glucose levels greater than 15 mmol/L during times of physiologic stress in the absence of dehydration and will NOT require fluid administration.

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Measure temperature AND blood glucose

5. IV access

6. If blood glucose is greater than 15 mmol/L, AND patient shows signs of DKA1 or signs of dehydration2 administer a fluid bolus as per Adult Fluid Therapy Protocol (Pg 43)



Contact OLMC if you are uncertain as to whether the patient meets criteria for fluid administration.

SIGNS AND SYMPTOMS OF DKA

• Polyuria

• Polydipsia

• Polyphagia

• Tachypnea

• Tachycardia

• Nausea and vomiting

• Abdominal pain

• Signs of dehydration

SIGNS OF DEHYDRATION

• Dry mucous membranes

• Decreased urine output (oliguria)

• Tachycardia

• Weakness or lethargy

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Spinal immobilization if unprotected fall to ground and seizure has stopped if indicated by C-Spine Assessment (Pg 38) and Spinal Immobilization Decision Tool (Pg 39)

4. Position patient

• Actively seizing – place supine and protect from injury

• Postictal – place left lateral recumbent and maintain airway

5. Continuous cardiac, SpO2, and BP monitoring

6. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 30)

7. IV access

8. Request ACP intercept for active seizures or recurrent seizures (Status Epilepticus)

1. Contact police and request that they attend the scene immediately

2. Manage airway and assist ventilation as necessary

3. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

4. Continuous cardiac, SpO2, and BP monitoring

5. Measure temperature AND blood glucose

• Treat hypoglycemia as per Symptomatic Hypoglycemia Protocol (Pg 30)

6. Consider and treat Reversible or Treatable Causes of Altered Mental Status1

7. IV access

8. Request ACP intercept if available

9. Attempt verbal management techniques for crisis intervention to de-escalate the situation and calm the patient

10.If Indications for Physical Restraint2 present, apply the least amount of physical restraint necessary to protect the patient from harming themselves or bystanders until police arrive as per Agitated Combative / Physical Restraint Reference (Pg 96)

CAUTION

• There is a high risk of positional asphyxia and/or aspiration in patients undergoing chemical or physical restraint. Close and continuous monitoring of these patients, including airway patency and adequacy of respirations is mandatory

• At NO TIME should the patient be restrained in the prone (face or chest-down) position

• Always maintain an ability to escape the scene. Position yourself between the patient and the exit at all times to maintain a safe exit should the situation escalate

• Be alert for potential weapons and hazards. If the patient has a weapon, do not attempt to disarm them. Instead, leave the scene and stage until the police declare the scene safe to re-enter

• Hypoxia

• Hypotension

• Hypoglycemia

• Medications or Toxins

• Sepsis

1) Imminent danger3 to life OR threat of physical harm to patient and/or bystanders

AND

2) Attempts at verbal de-escalation have failed

AND

3) Attempts to restrain do NOT place the practitioner(s) at significant risk of harm to themselves

NOTES

Imminent Danger – an immediate threat of significant harm to one’s self or others, up to and including death

Examples of Imminent Danger:

• Actively attempting suicide

• Actively attempting to cause serious bodily injury to others

• Attempting to jump from a building or moving vehicle

CAUTION

• There is a high risk of positional asphyxia and/or aspiration in patients undergoing chemical or physical restraint. Close and continuous monitoring of these patients, including airway patency and adequacy of respirations is mandatory

• At NO TIME should the patient be restrained in the prone (face or chest-down) position

• Always maintain an ability to escape the scene. Position yourself between the patient and the exit at all times to maintain a safe exit should the situation escalate

• Be alert for potential weapons and hazards. If the patient has a weapon, do not attempt to disarm them. Instead, leave the scene and stage until the police declare the scene safe to re-enter

o Tense posture

o Loud speech

o Pacing

o Threatening statements

o Clenched hands

o Hostile or aggressive body language

CAUTION

• There is a high risk of positional asphyxia and/or aspiration in patients undergoing chemical or physical restraint. Close and continuous monitoring of these patients, including airway patency and adequacy of respirations is mandatory

• At NO TIME should the patient be restrained in the prone (face or chest-down) position

• Always maintain an ability to escape the scene. Position yourself between the patient and the exit at all times to maintain a safe exit should the situation escalate

• Be alert for potential weapons and hazards. If the patient has a weapon, do not attempt to disarm them. Instead, leave the scene and stage until the police declare the scene safe to re-enter

GENERAL APPROACH TO TOXIN MANAGEMENT

1. Scene safety: protect rescuers and patients from immediate danger and contamination

• Toxic exposures might require special precautions, including CBRNE precautions or decontamination, before patient treatment begins

2. Manage airway and assist ventilations as necessary

3. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

4. Continuous cardiac, SpO2, and BP monitoring

5. Measure temperature AND blood glucose

6. IV access

7. Perform 12 Lead ECG

8. If seizure occurs refer to Convulsive Seizure Protocol (Pg 33)

9. Request ACP intercept if available



Contact OLMC for guidance if required.

TRAUMA ALERT

Trauma Alert allows for 

the highest state of readiness and preparation prior to the trauma patient’s arrival to hospital. It is important that the ambulance crew identify that the situation warrants a “Trauma Alert” and notifies the receiving hospital as soon as possible.

Trauma Alert Criteria

Mechanism of Injury

Death occurs in same compartment of a MVC

Fall greater than 5 meters (15 feet)

Vehicle vs. pedestrian collision

Patient ejected from the vehicle

MVC greater than 30 km/hr

Vehicle roll-over

Any time the practitioner judges the mechanism of injury to constitute a major trauma

Trauma Alert Criteria

Physical Findings

Tachycardia or bradycardia

Hypotension

Tachypnea or bradypnea

Glasgow Coma Scale less than 14

Penetrating injury to head, neck, chest, abdomen, pelvis, or groin

Amputation proximal to wrist or ankle

Two or more proximal long bone fractures

Open long bone fracture

Flail chest

Burns greater than 15% of total BSA or involving face or airway

Multi-system trauma (Involves two or more body systems)

Any time the practitioner judges the physical finding(s) to constitute a major trauma

Trauma Alert Criteria

Co-Morbidities

Age less than 5 or greater than 55 years

Pregnancy

Cardiac or respiratory disease

Morbid obesity

Coagulopathy

C-SPINE ASSESSMENT

This clinical decision tool was developed to detect c-spine injuries among patients who are alert and stable but at risk for neck injury due to trauma. This decision tool applies only to the c-spine. If suspected thoracic or lumbar spinal injury, proceed with immobilization.

Practitioner judgment, in favor of immobilization, should always override the result of the clinical decision tool in situations of uncertainty over interpretation of the tool or perceived risk to the patient. In any situation of uncertainty, practitioner must default towards immobilization of the patient.

Prior to applying the decision tool you must determine if patient is eligible for application of the tool by evaluating Inclusion and Exclusion Criteria.

1. Does the patient meet ALL Inclusion Criteria?

2. Does the patient have ANY ONE OR MORE Exclusion Criteria?

If YES – DO NOT proceed to Spinal Immobilization Decision Tool – the patient MUST be immobilized

If NO – Apply the Spinal Immobilization Decision Tool (Pg 39)

C-SPINE ASSESSMENT

INCLUSION CRITERIA

Age greater than 16 years

Alert (GCS 15, converses spontaneously, FULLY oriented, and follows commands)

Cooperative (Willingly follows commands and is not agitated)

Stable (SBP greater than or equal to 90 mmHg and respiratory rate 10-24 per minute on arrival)

If YES – Evaluate for Exclusion Criteria

If NO – DO NOT proceed to Evaluation for Exclusion Criteria or to Spinal Immobilization Decision Tool – the patient MUST be immobilized

C-SPINE ASSESSMENT

EXCLUSION CRITERIA

Age greater than or equal to 65 years

Numbness or tingling or paralysis

Any HIGH RISK mechanism of injury:

Fall from height (greater than 1 m or 5 stairs)

MVC greater than 100 km/h, AND/OR roll-over, AND/OR ejection from vehicle

Recreational vehicle crash

Pedestrian struck by vehicle

Axial load injury

Bicycle crash

Penetrating neck trauma

Known vertebral disease (Ankylosing Spondylitis, Rheumatoid Arthritis, Spinal Stenosis, or previous

C-Spine Surgery)

Pregnancy

Alcohol or drug ingestion

Greater than 8 hours since injury

Simple Rear End MVC – Any rear-end MVC EXCEPT when any of the following circumstances are ONE OR MORE present:

• Pushed into oncoming traffic

• Struck by a large truck or bus

• Struck by a high speed vehicle

• Collision resulted in a roll-over

Range of Motion Evaluation – Neck rotation must be performed independently by the patient without any assistance from the examiner

BURNS

(Thermal and Chemical)

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. Two large bore IVs if inhalation injury1 OR greater than 20% Total Body Surface Area (TBSA) (Initiate 2nd IV during transport)

5. Stop the burning process:

• Remove involved clothing

• Brush off powdered chemicals and copious irrigation of any other chemical exposure

6. Warm ambient temperature to avoid hypothermia

7. Estimate % Total Body Surface Area (TBSA) affected using Rule of Nines (Pg 103) and provide wound care as outlined below:

Less than 5% TBSA

Cover with moist or saline soaked (10-25ºC) dressing

5 – 20% TBSA

Cover with clean, dry sheet, or commercial dressing

Greater than 20% TBSA

Cover with clean, dry sheet, or commercial dressing

IV fluid administration as per Parkland Formula (Pg 103)

8. Remove all items including jewelry that have the potential to become constrictive to the neck, extremities or digits

9. Request ACP intercept if available

CAUTION

• Cooling with ice or ice water is contraindicated as this may increase severity of injury and lead to hypothermia.

• Inability to swallow

• Sensation of throat swelling

• Hypoxemia

• Closed space fire victim

• Respiratory distress

• Facial burns

• Singed nasal hairs

• Carbonaceous sputum

• Wheezing or crackles

• Voice changes

BLUNT TRAUMATIC CARDIAC ARREST

UNWITNESSED BLUNT CARDIAC ARREST

If the following two criteria are met on arrival to patient side then no resuscitation indicated:

1) Obvious external signs of major blunt trauma consistent with Trauma Alert Activation Criteria in the Trauma Alert Protocol (Pg 37)

AND

2) Confirmed cardiac arrest by absence of spontaneous respiration and palpable pulse

WITNESSED BLUNT CARDIAC ARREST

ON-SCENE

• Begin CPR (30 compressions : 2 ventilations) while attaching defibrillator

• Request ACP intercept if available

• IV access and administer 20 mL/kg 0.9% NaCl IV fluid bolus while transporting

ENROUTE TO HOSPITAL

• Begin CPR (30 compressions : 2 ventilations) while attaching defibrillator

• Request ACP intercept if available

• IV access and administer 20 mL/kg 0.9% NaCl IV fluid bolus while continuing transport

• Notify receiving Emergency Department without delay that cardiac arrest has occurred and continue transport

NOTES

• If no obvious external signs of significant trauma or if unsure of mechanism of injury, consider medical cardiac arrest and treat according to appropriate medical cardiac arrest protocol

• If witnessed blunt cardiac arrest do not delay transport

• Do not delay transport for IV insertion. All interventions must be performed en route to hospital

• Notify receiving Emergency Department without delay of actual or impending cardiac arrest (From the scene if possible)

ADULT FLUID THERAPY

When IV medication or fluid therapy may be required, start a peripheral IV line or lock using 0.9% NaCl solution.

Unless otherwise directed by protocol or OLMC the drip rate will be set at TKVO at 30-60 mL/hr

Fluid bolus should be initiated as follows unless otherwise specified by a specific treatment protocol.

ADULT FLUID THERAPY

FLUID ADMINISTRATION IN TRAUMA CASES

Bolus administration of IV fluid is to be reserved for cases of hypotension with evidence of poor perfusion. When indicated, administer IV 0.9% NaCl as outlined below:

• 20 mL/kg bolus until SBP 90 mmHg achieved

• If brain and/or spinal cord injury is suspected, maintain an optimal SBP of 110-120 mmHg

• There is no limit to the amount of fluid a PCP may administer to achieve the desired target SBP

Routine administration of bolus IV fluids in the absence of hypotension is CONTRAINDICATED in the trauma patient.

IV fluid boluses are only to be administered when above criteria is met to avoid inducing coagulopathy.

ADULT FLUID THERAPY

FLUID ADMINISTRATION IN MEDICAL CASES (NON-TRAUMA)

When indicated as per protocol administer IV 0.9% NaCl as outlined below:

• 20 mL/kg bolus

• May repeat bolus administration while indications persist up to maximum 2000 mL unless otherwise directed by protocol

• If indications for additional IV fluid persist despite administration of 2000 mL IV fluids, contact OLMC

OXYGEN THERAPY

Oxygen therapy should be initiated as follows unless otherwise specified by a specific treatment protocol:

A. Administer high flow oxygen without delay if any of the following critical findings are present, regardless of SpO2. Be prepared to initiate BMV without delay if the patient displays signs of inadequate ventilation1:

• Apnea

• Respiratory distress or failure

• Cyanosis or ashen colored skin

• Loss of consciousness

• Toxin or smoke inhalation

• Suspected or confirmed carbon monoxide exposure

• Hypotension with accompanied signs and symptoms of shock or impending shock

• Complications of pregnancy or high risk childbirth:

o Hemorrhage

o Labour with multiple fetuses

o Premature labor (less than 37 weeks gestation)

o Trauma extending beyond an isolated extremity

o Complications of delivery

o Convulsive seizure in pregnancy (eclampsia)

NOTES

1. If you experience any difficulty obtaining a reliable SpO2, or if at any time you obtain a low SpO2 reading, you must administer high flow oxygen and assume the patient is hypoxic and that any low reading is accurate.

2. There may be additional circumstances beyond those contained in this protocol which will require oxygen therapy. Clinicians are advised to use sound clinical judgement to titrate oxygen therapy to balance the risk of hypoxia with concerns about hyperoxia.

OXYGEN THERAPY

B. Administer high flow oxygen if SpO2 less than 95% AND any of the following chief complaints are present:

C. Once hypoxia has been corrected, titrate oxygen delivery to achieve a target SpO2 of 95%

• Ischemic chest pain

• Cardiac arrhythmia, including STEMI

• Acute stroke

• Decreasing level of consciousness

• Altered mental status

• Uncomplicated pregnancy / childbirth

• Traumatic injury

• Sepsis

• Toxin ingestion

• Hypo / Hyperglycemia

• Convulsive seizures

• Agitation or combative behavior

• Electrocution

• Vision and/or hearing changes

• Near drowning

• Acute severe pain

NOTES

1. If you experience any difficulty obtaining a reliable SpO2, or if at any time you obtain a low SpO2 reading, you must administer high flow oxygen and assume the patient is hypoxic and that any low reading is accurate.

2. There may be additional circumstances beyond those contained in this protocol which will require oxygen therapy. Clinicians are advised to use sound clinical judgement to titrate oxygen therapy to balance the risk of hypoxia with concerns about hyperoxia.

Oxygen Therapy COPD

If confirmed COPD (Emphysema or Chronic Bronchitis) only, administer oxygen according to the following guidelines:

• If the patient is in moderate to severe respiratory distress or has critical findings, administer high flow oxygen. Be prepared to initiate BMV without delay if the patient displays signs of inadequate ventilation1.

o If respiratory status has improved to patient’s baseline after treatment, consider replacing NRB with nasal cannula to maintain SpO2 90-92%

• If the patient is in mild distress, administer low flow oxygen 1 to 2 liters per minute above home oxygen levels, titrated to a target SpO2 of 90-92%

NOTES

1. If you experience any difficulty obtaining a reliable SpO2, or if at any time you obtain a low SpO2 reading, you must administer high flow oxygen and assume the patient is hypoxic and that any low reading is accurate.

2. There may be additional circumstances beyond those contained in this protocol which will require oxygen therapy. Clinicians are advised to use sound clinical judgement to titrate oxygen therapy to balance the risk of hypoxia with concerns about hyperoxia.

1CAUTION

In order for supplementary oxygen to be effective, the patient must have adequate respiratory effort, rate, and volume to ensure oxygen is delivered to the lungs. If the patient’s respiratory effort, rate, or volume is inadequate to maintain oxygenation, the patient is considered to be in respiratory failure, and BMV with high flow oxygen must be delivered without delay.

The following signs of inadequate ventilation may be observed in patients with respiratory failure:

• Abnormal sounds with breathing, such as snoring, gurgling, or stridor

• Fatigue with respiratory effort

• Gasping

• Irregular breathing pattern with periods of apnea

• Little or no chest rise

• Decreased or absent breath sounds (“Silent chest”)

• Rate and/or depth of breathing grossly insufficient for age

• Apnea

If there are findings of airway obstruction, such as stridor, snoring, or gurgling, proceed with basic airway maneuvers to open and/or clear the airway.

LESS THAN LETHAL FORCE Cont’d

CAUTION

• Maintain police presence at all times while on-scene and request police escort during transport.

• Ensure that there is no electricity flowing through the CEW before approaching the patient.

• Assume spinal precautions. All patients exposed to CEW are considered to have fallen until proven otherwise.

• Exercise caution when approaching a patient exposed to CEW energy as they may display violent tendencies post-deployment. Always maintain an ability to escape the scene. Position yourself between the patient and the patient and the exit at all times to maintain a safe exit, should the situation escalate.

• At NO TIME should the patient be restrained in the prone (face or chest-down) position.

• There is a high risk of positional asphyxia and/or aspiration in patients in excessively agitated states. Close and continuous monitoring of these patients, including airway patency and adequacy of respiration, is mandatory.

• Patients with a weakened cardiac system may not tolerate exposure to CEW. Complaints of chest pain or shortness of breath must be taken seriously, evaluated, and treated as appropriate.

• All patients exposed to CEW must be transported to the closest medical facility for evaluation. If police determine transport by ambulance is too dangerous, ensure that the police are clearly informed of the need for medical evaluation at a hospital and document the badge number of the police officer informed.

• Be alert for the possibility of soft tissue burns after the use of a push stun feature on the CEW.

• Be alert for the possibility of blunt force trauma after the use of a bean bag deployment device

PREDICTORS OF DIFFICULT BAG MASK VENTILATION – “BOOTS”

Beard

Obese

Older

Toothless

Snore / Stridor