Set the Language

We weren't able to detect the audio language on your flashcards. Please select the correct language below.

Front

Back

Flashcards
»
ALS Medical Directives

Als Medical Directives

by thiswehave, Mar. 2014

Subjects: Advanced Life Support

Favorite

Add to folder

Flag

Shuffle
Toggle On

Toggle Off
Alphabetize
Toggle On

Toggle Off
Front First
Toggle On

Toggle Off
Both Sides
Toggle On

Toggle Off
Read
Toggle On

Toggle Off

Reading...

Front

Card Range To Study

through

Play button

Progress

1/256

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

256 Cards in this Set

Front
Back

	Medical Cardiac Arrest Indications	Non‐traumatic cardiac arrest.
	Medical Cardiac Arrest CPR Conditions	AGE: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Performed for 2 minute intervals.
	Medical Cardiac Arrest AED Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Shock indicated.
	Medical Cardiac Arrest Manual Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: VF or pulseless VT.
	Medical Cardiac Arrest Epinephrine Conditions	AGE: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Anaphylaxis suspected as causative event.
	Medical Cardiac Arrest Medical TOR Conditions	AGE: ≥18 years LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Arrest not witnessed by EMS AND No ROSC AND No shocks delivered.
	Medical Cardiac Arrest CPR Contraindications	Obviously dead as per BLS standards. Meet conditions of DNR standard.
	Medical Cardiac Arrest AED Defibrillation Contraindications	Non‐shockable rhythm.
	Medical Cardiac Arrest Manual Defibrillation Contraindications	Rhythms other than VF or pulseless VT.
	Medical Cardiac Arrest Epinephrine Contraindications	Allergy or sensitivity to epinephrine.
	Medical Cardiac Arrest Medical TOR Contraindications	Arrest thought to be of non‐cardiac origin.
	Medical Cardiac Arrest 2 Age Categories for treatment with AED Defibrillation (with pediatric attenuator if available)	1. ≥30 days to <8 years. 2. ≥8 years.
	Medical Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years with pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 4
	Medical Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years without pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 4
	Medical Cardiac Arrest Treatment with AED Defibrillation for ≥8 years.	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 4
	Medical Cardiac Arrest 2 Age Categories for treatment with Manual Defibrillation (if certified and authorized)	1. ≥30 days to <8 years. 2. ≥8 years.
	Medical Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥30 days to <8 years	Dose: 1 shock First dose: 2 J/kg Subsequent and max. dose(s): 4 J/kg Dosing interval: 2 min Max. # of doses: 4
	Medical Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥8 years	Dose: 1 shock First dose: As per BH/manufacturer Subsequent and max. dose(s): As per BH/manufacturer Dosing interval: 2 min Max. # of doses: 4
	Medical Cardiac Arrest Treatment with Epinephrine (only if anaphylaxis suspected as causative event	Weight: N/A Route: IM Concentration: 1:1,000 Dose: 0.01 mg/kg* Max. single dose: 0.5 mg Dosing interval: N/A Max. # of doses: 1 *The epinephrine dose may be rounded to the nearest 0.05 mg.
	Medical Cardiac Arrest Mandatory Provincial Patch Point	Patch to BHP for authorization, following the 3rd analysis, to consider Medical Termination of Resuscitation (TOR) (if applicable). If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate receiving hospital following ROSC or the 4th analysis.
	Medical Cardiac Arrest 3 Clinical Considerations	1. In unusual circumstances (e.g.: pediatric patients or toxicological overdoses, consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being delivered. 2. A paramedic may choose to move the patient to the ambulance prior to initiating the TOR if family is not coping well or the arrest occurred in a public place. 3. Follow the Deceased Patient Standard once TOR has been implemented.
	Trauma Cardiac Arrest Indications	Cardiac arrest secondary to severe blunt or penetrating trauma.
	Trauma Cardiac Arrest CPR Conditions	AGE: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: N/A
	Trauma Cardiac Arrest AED Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Shock indicated
	Trauma Cardiac Arrest Manual Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: VF or pulseless VT
	Trauma Cardiac Arrest Trauma TOR Conditions	AGE: ≥16 years LOA: Altered HR: 0 RR: 0 SBP: N/A Other: No palpable pulses No defibrillation delivered and monitored HR = 0 (asystole) OR monitored HR >0 AND the closest ER ≥30 min transport time away.
	Trauma Cardiac Arrest CPR Contraindications	Obviously dead as per BLS standards. Meet conditions of DNR standard.
	Trauma Cardiac Arrest AED Defibrillation Contraindications	Non‐shockable rhythm.
	Trauma Cardiac Arrest Manual Defibrillation Contraindications	Rhythms other than VF or pulseless VT.
	Trauma Cardiac Arrest Trauma TOR Contraindications	Age <16 years. Shock delivered. Monitored HR >0 and closest ER <30 min away.
	Trauma Cardiac Arrest 2 Age Categories for treatment with AED Defibrillation	1. ≥30 days to <8 years. 2. ≥8 years.
	Trauma Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years with pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Trauma Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years without pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Trauma Cardiac Arrest Treatment with AED Defibrillation for ≥8 years	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Trauma Cardiac Arrest 2 Age Categories for treatment with Manual Defibrillation (if certified and authorized)	1. ≥30 days to <8 years. 2. ≥8 years.
	Trauma Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥30 days to <8 years	Dose: 1 shock Initial dose: 2 J/kg Dosing interval: N/A Max. # of doses: 1
	Trauma Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥8 years	Dose: 1 shock Initial dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Trauma Cardiac Arrest Mandatory Provincial Patch Point	Patch to BHP for authorization to apply the Trauma (TOR) Termination of Resuscitation, if applicable. If the BH patch fails, or the trauma TOR does not apply, transport to the closest appropriate receiving hospital following the first analysis/shock.
	Trauma Cardiac Arrest Clinical Considerations	If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat according to the appropriate medical cardiac arrest directive.
	Hypothermia Cardiac Arrest Indications	Cardiac arrest secondary to severe hypothermia.
	Hypothermia Cardiac Arrest CPR Conditions	AGE: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: N/A
	Hypothermia Cardiac Arrest AED Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Shock indicated
	Hypothermia Cardiac Arrest Manual Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: VF or pulseless VT
	Hypothermia Cardiac Arrest CPR Contraindications	Obviously dead as per BLS standards. Meet conditions of DNR standard.
	Hypothermia Cardiac Arrest AED Defibrillation Contraindications	Non‐shockable rhythm.
	Hypothermia Cardiac Arrest Manual Defibrillation Contraindications	Rhythms other than VF or pulseless VT.
	Hypothermia Cardiac Arrest 2 Age Categories for treatment with AED Defibrillation	1. ≥30 days to <8 years. 2. ≥8 years.
	Hypothermia Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years with pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Hypothermia Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years without pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Hypothermia Cardiac Arrest Treatment with AED Defibrillation for ≥8 years	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Hypothermia Cardiac Arrest 2 Age Categories for treatment with Manual Defibrillation (if certified and authorized)	1. ≥30 days to <8 years. 2. ≥8 years.
	Hypothermia Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥30 days to <8 years	Dose: 1 shock Initial dose: 2 J/kg Dosing interval: N/A Max. # of doses: 1
	Hypothermia Cardiac Arrest Treatment with Manual Defibrillation (if certified and authorized) for ≥8 years	Dose: 1 shock Initial dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Hypothermia Cardiac Arrest Treatment Note	Transport to the closest appropriate facility without delay following the first analysis.
	Hypothermia Cardiac Arrest Clinical Considerations	N/A.
	Foreign Body Airway Obstruction Cardiac Arrest Indications	Cardiac arrest secondary to an airway obstruction.
	Foreign Body Airway Obstruction Cardiac Arrest CPR Conditions	AGE: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: N/A
	Foreign Body Airway Obstruction Cardiac Arrest AED Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Shock indicated
	Foreign Body Airway Obstruction Cardiac Arrest Manual Defibrillation Conditions	AGE: ≥30 days LOA: Altered HR: N/A RR: N/A SBP: N/A Other: VF or pulseless VT
	Foreign Body Airway Obstruction Cardiac Arrest CPR Contraindications	Obviously dead as per BLS standards. Meet conditions of DNR standard.
	Foreign Body Airway Obstruction Cardiac Arrest AED Defibrillation Contraindications	Non‐shockable rhythm.
	Foreign Body Airway Obstruction Cardiac Arrest Manual Defibrillation Contraindications	Rhythms other than VF or pulseless VT.
	Foreign Body Airway Obstruction Cardiac Arrest 4 Treatment Considerations	1. CPR. 2. Foreign body removal (utilizing BLS maneuvers). 3. AED Defibrillation. 4. Manual Defibrillation.
	Foreign Body Airway Obstruction Cardiac Arrest 2 Age Categories for treatment with AED Defibrillation	1. ≥30 days to <8 years. 2. ≥8 years.
	Foreign Body Airway Obstruction Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years with pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Foreign Body Airway Obstruction Cardiac Arrest Treatment with AED Defibrillation for ≥30 days to <8 years without pediatric attenuator	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Foreign Body Airway Obstruction Cardiac Arrest Treatment with AED Defibrillation for ≥8 years	Dose: 1 shock Max. single dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Foreign Body Airway Obstruction Cardiac Arrest 2 Age Categories for treatment with Manual Defibrillation	1. ≥30 days to <8 years. 2. ≥8 years.
	Foreign Body Airway Obstruction Cardiac Arrest Treatment with Manual Defibrillation for ≥30 days to <8 years	Dose: 1 shock Initial dose: 2 J/kg Dosing interval: N/A Max. # of doses: 1
	Foreign Body Airway Obstruction Cardiac Arrest Treatment with Manual Defibrillation for ≥8 years	Dose: 1 shock Initial dose: As per BH/manufacturer Dosing interval: N/A Max. # of doses: 1
	Foreign Body Airway Obstruction Cardiac Arrest 2 Treatment Notes	1. If the patient is in cardiac arrest following removal of the obstruction, initiate management as a medical cardiac arrest. 2. If the obstruction cannot be removed, transport to the closest appropriate facility without delay following the first analysis.
	Foreign Body Airway Obstruction Cardiac Arrest Clinical Considerations	N/A.
	Neonatal Resuscitation Indications	Severe cardio-respiratory distress.
	Neonatal Resuscitation Resuscitation Conditions	Age: Newborn or <30 days of age. LOA: N/A HR: N/A RR: N/A SBP: N/A Other: Less than full term, or meconium, or poor APGAR score.
	Neonatal Resuscitation Resuscitation Contraindications	Clear of meconium. Breathing or crying. Good muscle tone. Pink in colour.
	Neonatal Resuscitation Flow Chart	?????
	Return of Spontaneous Circulation (ROSC) Indications	Patient with return of spontaneous circulation (ROSC) after the resuscitation was initiated.
	Return of Spontaneous Circulation (ROSC) 0.9% NaCl Fluid Bolus Conditions	Age: N/A LOA: N/A HR: N/A RR: N/A SBP: Hypotension Other: Chest auscultation is clear
	Return of Spontaneous Circulation (ROSC) Therapeutic Hypothermia Conditions	Age: Males ≥18 years Females ≥50 years LOA: Altered HR: N/A RR: N/A SBP: ≥90 mmHg (spontaneous or following bolus administered) Other: N/A
	Return of Spontaneous Circulation (ROSC) 0.9% NaCl Fluid Bolus Contraindications	Fluid overload. SBP ≥90 mmHg.
	Return of Spontaneous Circulation (ROSC) Therapeutic Hypothermia Contraindications	Traumatic cardiac arrest (blunt, penetrating or burn). Sepsis or serious infection suspected as cause of arrest. Hypothermic arrest. Known coagulopathy (medical history or medications).
	Return of Spontaneous Circulation (ROSC) 5 Treatment Considerations	1. Rapid transport. 2. Optimizing ventilation and oxygenation. 3. 0.9% NaCl fluid bolus (if certified and authorized). 4. 12 lead acquisition. 5. Therapeutic hypothermia (if available).
	Return of Spontaneous Circulation (ROSC) Treatment with Optimizing Ventilation and Oxygenation	Titrate oxygenation ≥94%. Avoid hyperventilation and target an ETCO2 of 35-40 mmHg with continuous waveform capnography (if available).
	Return of Spontaneous Circulation (ROSC) 2 Age Categories for Treatment with 0.9% NaCl Fluid Bolus (if certified and authorized)	1. <12 years. 2. ≥12 years.
	Return of Spontaneous Circulation (ROSC) Treatment with 0.9% NaCl Fluid Bolus (if certified and authorized) for <12 years	Route: IV Infusion: 10 ml/kg Infusion Interval: Immediate Reassess every: 100 ml Max. Volume: 1,000 ml
	Return of Spontaneous Circulation (ROSC) Treatment with 0.9% NaCl Fluid Bolus (if certified and authorized) for ≥12 years	Route: IV Infusion: 10 ml/kg Infusion Interval: Immediate Reassess every: 250 ml Max. Volume: 1,000 ml
	Return of Spontaneous Circulation (ROSC) Clinical Considerations	The application of therapeutic hypothermia should not detract from rapid transport, optimizing ventilation and oxygenation or the management of a re-arrest.
	Cardiac Ischemia Indications	Suspected Cardiac Ischemia
	Cardiac Ischemia ASA Conditions	AGE: ≥18 years LOA: Unaltered HR: N/A RR: N/A SBP: N/A Other: Able to chew and swallow
	Cardiac Ischemia Nitroglycerin Conditions	AGE: ≥18 years LOA: Unaltered HR: 60‐159 bpm RR: N/A SBP: Normotension Other: Prior history of nitroglycerin use or IV access obtained
	Cardiac Ischemia Morphine Conditions	AGE: ≥18 years LOA: Unaltered HR: N/A RR: N/A SBP: Normotension Other: N/A
	Cardiac Ischemia ASA Contraindications	Allergy or sensitivity to ASA or NSAIDS. If asthmatic, no prior use of ASA. Current active bleeding. CVA or TBI in the previous 24 hours.
	Cardiac Ischemia Nitroglycerin Contraindications	Allergy or sensitivity to nitrates. Phosphodiesterase inhibitor use within the previous 48 hours. SBP drops by one third or more of its initial value after nitroglycerin is administered. 12-lead ECG compatible with Right Ventricular infarct.
	Cardiac Ischemia Morphine Contraindications	Allergy or sensitivity to morphine. Injury to the head or chest or abdomen OR pelvis. SBP drops by one-third or more of its initial value after morphine is administered.
	Cardiac Ischemia Treatment Considerations	1. ASA. 2. 12-lead ECG acquisition (if available). 3. Nitroglycerin. 4. Morphine.
	Cardiac Ischemia Treatment with ASA	Route: PO Dose: 160-162 mg Max. single dose: 162 mg Dosing interval: N/A Max. # of doses: 1
	Cardiac Ischemia Treatment with Nitroglycerin	SBP: ≥100 mmHg Route: SL Dose: 0.3 or 0.4 mg Max. single dose: 0.4 mg Dosing interval: 5 min. Max. # of doses: 6
	Cardiac Ischemia Treatment with Morphine (after the third dose of nitroglycerin or if nitroglycerin is contraindicated)	Route: IV Dose: 2 mg Max. single dose: 2 mg Dosing interval: 5 min. Max. # of doses: 5
	Cardiac Ischemia Clinical Considerations	N/A.
	Acute Cardiogenic Pulmonary Edema Indications	Moderate to severe respiratory distress AND Suspected acute cardiogenic pulmonary edema.
	Acute Cardiogenic Pulmonary Edema Nitroglycerin Conditions	Age: ≥18 years LOA: N/A HR: 60-159 bpm RR: N/A SBP: Normotension Other: Ascertain prior history of nitroglycerin use OR establish IV access.
	Acute Cardiogenic Pulmonary Edema Nitroglycerin Contraindications	Allergy or sensitivity to nitrates. Phosphodiesterase inhibitor use within the previous 48 hours. SBP drops by one third or more of its initial value after nitroglycerin is administered.
	Acute Cardiogenic Pulmonary Edema 2 SBP Categories for Treatment with Nitroglycerin	1. 100 mmHg to <140 mmHg 2. ≥140 mmHg (with or without IV or Hx)
	Acute Cardiogenic Pulmonary Edema Treatment with Nitroglycerin for SBP 100 mmHg to <140 mmHg	SBP: 100 mmHg to <140 mmHg IV or Hx: Yes Route: SL Dose: 0.3 or 0.4 mg Max. single dose: 0.4 mg Dosing interval: 5 min. Max. # of doses: 6
	Acute Cardiogenic Pulmonary Edema Treatment with Nitroglycerin for SBP ≥140 mmHg without IV or Hx	SBP: ≥140 mmHg IV or Hx: No Route: SL Dose: 0.3 or 0.4 mg Max. single dose: 0.4 mg Dosing interval: 5 min. Max. # of doses: 6
	Acute Cardiogenic Pulmonary Edema Treatment with Nitroglycerin for SBP ≥140 mmHg with IV or Hx	SBP: ≥140 mmHg IV or Hx: Yes Route: SL Dose: 0.6 or 0.8 mg Max. single dose: 0.8 mg Dosing interval: 5 min. Max. # of doses: 6
	Acute Cardiogenic Pulmonary Edema Treatment Considerations	Nitroglycerin 12-lead ECG acquisition
	Acute Cardiogenic Pulmonary Edema Clinical Considerations	IV condition applies only to PCPs certified to the level of PCP autonomous IV.
	Cardiogenic Shock Indications	STEMI-positive ECG AND Cardiogenic shock.
	Cardiogenic Shock 0.9% NaCl Conditions	Age: ≥2 years LOA: N/A HR: N/A RR: N/A SBP: Hypotension Other: Clear chest on auscultation
	Cardiogenic Shock 0.9% NaCl Contraindications	N/A.
	Cardiogenic Shock 2 Age Categories for Treatment with 0.9% NaCl	1. ≥2 years to <18 years. 2. ≥18 years.
	Cardiogenic Shock Treatment with 0.9% NaCl for ≥2 years to <18 years	Route: IV Infusion: 10 ml/kg Infusion interval: N/A Reassess every: 100 ml Max. Volume: 10 ml/kg
	Cardiogenic Shock Treatment with 0.9% NaCl for ≥18 years	Route: IV Infusion: 10 ml/kg Infusion interval: N/A Reassess every: 250 ml Max. Volume: 10 ml/kg
	Cardiogenic Shock Clinical Considerations	N/A.
	Hypoglycemia Indications	Agitation OR altered LOA OR seizure OR symptoms of stroke.
	Hypoglycemia Dextrose Conditions	Age: ≥2 years LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Hypoglycemia
	Hypoglycemia Glucagon Conditions	Age: N/A LOA: Altered HR: N/A RR: N/A SBP: N/A Other: Hypoglycemia
	Hypoglycemia Dextrose Contraindications	Allergy or sensitivity to dextrose.
	Hypoglycemia Glucagon Contraindications	Allergy or sensitivity to glucagon. Pheochromocytoma.
	Hypoglycemia 3 Treatment Considerations	1. Perform Glucometry. 2. Consider Dextrose. 3. Consider Glucagon.
	Hypoglycemia Treatment with Dextrose	Age: ≥2 years Weight: N/A Concentration: D50W Route: IV Dose: 0.5 g/kg (1 ml/kg) Max. single dose: 25 g (50 ml) Dosing interval: 10 min. Max. # of doses: 2
	Hypoglycemia 2 Weight Categories for Treatment with Glucagon	1. <25 kg 2. ≥25 kg
	Hypoglycemia Treatment with Glucagon for <25 kg	Age: N/A Weight: <25 kg Concentration: N/A Route: IM Dose: 0.5 mg Max. single dose: 0.5 mg Dosing interval: 20 min. Max. # of doses: 2
	Hypoglycemia Treatment with Glucagon for ≥25 kg	Age: N/A Weight: ≥25 kg Concentration: N/A Route: IM Dose: 1 mg Max. single dose: 1 mg Dosing interval: 20 min. Max. # of doses: 2
	Hypoglycemia Clinical Considerations	If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple carbohydrates. If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of dextrose or glucagon. If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucometry must be attempted and documented. IV administration of dextrose applies only to PCPs certified to the level of PCP Autonomous IV.
	Bronchoconstriction Indications	Respiratory distress AND Suspected Bronchoconstriction
	Bronchoconstriction Salbutamol Conditions	Age: N/A LOA: N/A HR: N/A RR: N/A SBP: N/A Other: N/A
	Bronchoconstriction Epinephrine Conditions	Age: N/A Weight: N/A LOA: N/A HR: N/A RR: BVM ventilation required SBP: N/A Other: Hx of asthma
	Bronchoconstriction Epinephrine Autoinjector Conditions	Age: N/A Weight: ≥10 kg LOA: N/A HR: N/A RR: BVM ventilation required SBP: N/A Other: Hx of asthma
	Bronchoconstriction Salbutamol Contraindications	Allergy or sensitivity to salbutamol.
	Bronchoconstriction Epinephrine Contraindications	Allergy or sensitivity to epinephrine.
	Bronchoconstriction Epinephrine Autoinjector Contraindications	Allergy or sensitivity to epinephrine.
	Bronchoconstriction 2 Weight Categories for Treatment with Salbutamol	1. <25 kg 2. ≥25 kg
	Bronchoconstriction 2 Route Categories for Treatment with Salbutamol	1. MDI (if available) 2. NEB
	Bronchoconstriction Treatment with Salbutamol for <25 kg by MDI	Weight: <25 kg Route: MDI (if available)* Dose: Up to 600 mcg (6 puffs) Max. Single Dose: 600 mcg Dosing interval: 5-15 min. PRN Max. # of doses: 3 *1 puff = 100 mcg
	Bronchoconstriction Treatment with Salbutamol for <25 kg by NEB	Weight: <25 kg Route: NEB Dose: 2.5 mg Max. Single Dose: 2.5 mg Dosing interval: 5-15 min. PRN Max. # of doses: 3
	Bronchoconstriction Treatment with Salbutamol for ≥25 kg by MDI	Weight: ≥25 kg Route: MDI (if available)* Dose: Up to 800 mcg (8 puffs) Max. Single Dose: 800 mcg Dosing interval: 5-15 min. PRN Max. # of doses: 3 *1 puff = 100 mcg
	Bronchoconstriction Treatment with Salbutamol for ≥25 kg by NEB	Weight: ≥25 kg Route: NEB Dose: 5 mg Max. Single Dose: 5 mg Dosing interval: 5-15 min. PRN Max. # of doses: 3
	Bronchoconstriction Treatment with Epinephrine	Weight: N/A Route: IM Concentration: 1:1,000 Dose: 0.01 mg/kg Max. single dose: 0.5 mg Dosing interval: N/A Max. # of doses: 1 The epinephrine dose may be rounded to the nearest 0.05 mg.
	Bronchoconstriction 2 Weight Categories for Treatment with Epinephrine Autoinjector	1. ≥10 kg to <25 kg (Pediatric Autoinjector) 2. ≥25 kg (Adult Autoinjector)
	Bronchoconstriction Treatment with Epinephrine Pediatric Autoinjector for ≥10 kg to <25 kg	Weight: ≥10 kg to <25 kg Route: Pediatric Autoinjector Concentration: 1:1,000 Dose: 1 injection (0.15 mg) Max. single dose: 1 injection Dosing interval: N/A Max. # of doses: 1
	Bronchoconstriction Treatment with Epinephrine Adult Autoinjector for ≥25 kg	Weight: ≥25 kg Route: Adult Autoinjector Concentration: 1:1,000 Dose: 1 injection (0.3 mg) Max. single dose: 1 injection Dosing interval: N/A Max. # of doses: 1
	Bronchoconstriction Clinical Considerations	Epinephrine should be the first drug administered if the patient is apneic. Salbutamol MDI may be administered subsequently using a BVM MDI adapter (if available). Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a declared febrile respiratory illness outbreak by the local medical officer of health. When administering salbutamol MDI, the rate of administration should be 100 mcg approximately every 4 breaths. A spacer should be used when administering salbutamol MDI (if available).
	Bronchoconstriction Mandatory Provincial Patch Point	Patch to BHP for authorization to use pediatric autoinjector for <10 kg.
	Moderate to Severe Allergic Reaction Indications	Exposure to a probably allergen AND Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis).
	Moderate to Severe Allergic Reaction Epinephrine Conditions	Age: N/A Weight: N/A LOA: N/A HR: N/A RR: N/A SBP: N/A Other: For anaphylaxis only
	Moderate to Severe Allergic Reaction Epinephrine Autoinjector Conditions	Age: N/A Weight: ≥10 kg LOA: N/A HR: N/A RR: N/A SBP: N/A Other: For anaphylaxis only
	Moderate to Severe Allergic Reaction Diphenhydramine	Age: N/A Weight: ≥25 kg LOA: N/A HR: N/A RR: N/A SBP: N/A Other: N/A
	Moderate to Severe Allergic Reaction Epinephrine Contraindications	Allergy or sensitivity to epinephrine.
	Moderate to Severe Allergic Reaction Epinephrine Autoinjector Contraindications	Allergy or sensitivity to epinephrine.
	Moderate to Severe Allergic Reaction Diphenhydramine Contraindications	Allergy or sensitivity to diphenhydramine.
	Moderate to Severe Allergic Reaction Treatment with Epinephrine	Weight: N/A Route: IM Concentration: 1:1,000 Dose: 0.01 mg/kg* Max. single dose: 0.5 mg Dosing interval: N/A Max. # of doses: 1 *The epinephrine dose may be rounded to the nearest 0.05 mg.
	Moderate to Severe Allergic Reaction 2 Weight Categories for Treatment with Epinephrine Autoinjector	1. ≥10 kg to <25 kg (Pediatric Autoinjector) 2. ≥25 kg (Adult Autoinjector)
	Moderate to Severe Allergic Reaction Treatment with Epinephrine Pediatric Autoinjector for ≥10 kg to <25 kg	Weight: ≥10 kg to <25 kg Route: Pediatric Autoinjector Concentration: 1:1,000 Dose: 1 injection (0.15 mg) Max. single dose: 1 injection Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction Treatment with Epinephrine Pediatric Autoinjector for ≥25 kg	Weight: ≥25 kg Route: Adult Autoinjector Concentration: 1:1,000 Dose: 1 injection (0.3 mg) Max. single dose: 1 injection Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction 2 Weight Categories for Treatment with Diphenhydramine	1. ≥25 kg to <50 kg 2. ≥50 kg
	Moderate to Severe Allergic Reaction 2 Route Categories for Treatment with Diphenhydramine	1. IV 2. IM
	Moderate to Severe Allergic Reaction Treatment with Diphenhydramine for ≥25kg to <50 kg by IV	Weight: ≥25 kg to <50 kg Route: IV Dose: 25 mg Max. single dose: 25 mg Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction Treatment with Diphenhydramine for ≥25 kg to <50 kg by IM	Weight: ≥25 kg to <50 kg Route: IM Dose: 25 mg Max. single dose: 25 mg Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction Treatment with Diphenhydramine for ≥50 kg by IV	Weight: ≥50 kg Route: IV Dose: 50 mg Max. single dose: 50 mg Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction Treatment with Diphenhydramine for ≥50 kg by IM	Weight: ≥50 kg Route: IM Dose: 50 mg Max. single dose: 50 mg Dosing interval: N/A Max. # of doses: 1
	Moderate to Severe Allergic Reaction Clinical Considerations	Epinephrine should be the first drug administered in anaphylaxis. IV administration of diphenhydramine applies only to PCPs certified to the level of PCP Autonomous IV.
	Moderate to Severe Allergic Reaction Mandatory Provincial Patch Point	Patch to BHP for authorization to use pediatric autoinjector for patients <10 kg.
	Croup Indications	Severe respiratory distress AND Stridor at rest AND Current history of URTI AND Barking cough OR recent history of a barking cough
	Croup Epinephrine Conditions	Age: <8 years LOA: N/A HR: <200 bpm RR: N/A SBP: N/A Other: N/A
	Croup Epinephrine Contraindications	Allergy or sensitivity to epinephrine.
	Croup 2 Age Categories for Treatment with Epinephrine	1. <1 year 2. ≥1 year to 8 years
	Croup 2 Weight Categories for Treatment with Epinephrine for <1 year	1. <5 kg 2. ≥5 kg
	Croup Treatment with Epinephrine for <1 year and <5 kg	Age: <1 year Weight: <5 kg Route: NEB Concentration: 1:1,000 Dose: 0.5 mg Max. single dose: 0.5 mg Dosing interval: N/A Max. # of doses: 1
	Croup Treatment with Epinephrine for <1 year and ≥5 kg	Age: <1 year Weight: ≥5 kg Route: NEB Concentration: 1:1,000 Dose: 2.5 mg Max. single dose: 2.5 mg Dosing interval: N/A Max. # of doses: 1
	Croup Treatment with Epinephrine for ≥1 year to 8 years	Age: ≥1 year to 8 years Weight: N/A Route: NEB Concentration: 1:1,000 Dose: 5 mg Max. single dose: 5 mg Dosing interval: N/A Max. # of doses: 1
	Croup Clinical Considerations	The minimum initial volume for nebulization is 2.5 ml.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: The initial rhythm interpretation and defibrillation should be performed at two (2) minutes after CPR is initiated. Following the initial rhythm interpretation/analysis, additional interpretations/analyses should occur at two (2) minute intervals with focus on the delivery of high concentration oxygen.	False. The initial rhythm interpretation and defibrillation should be performed as soon as possible. Following the initial rhythm interpretation/analysis, additional interpretations/analyses should occur at two (2) minute intervals with focus on the delivery of high quality chest compressions.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: The energy settings used for defibrillation should be set at 120 joules initially, with subsequent doses set at 150 joules and 200 joules respectively as requested by the Ontario Base Hospital Group.	False. The energy settings used for defibrillation typically follow the specific manufacturer’s guidelines and are confirmed by the local Base Hospital program.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: To minimize the peri-shock pause, compressions during the charge cycle should be considered.	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: When enroute and using a semi-automated system, the ambulance must be stopped to minimize artifact and the risk of an inaccurate rhythm interpretation.	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: The sequence listed for the advanced airways is deliberate, it is based on: 1. The increased importance placed on the airway as outlined in the 2010 AHA guidelines 2. The difficulty of supraglottic airway insertion vs. the complexity and risks of intubation 3. The emphasis placed on airway management, though interrupted compressions may occur. This precludes the PCP from placing a supraglottic airway when more than an OPA is required for VSA patients or in a prolonged resuscitation.	False. The sequence listed for the advanced airways is deliberate, it is based on: 1. The reduced importance placed on the airway as outlined in the 2010 AHA guidelines 2. The ease of supraglottic airway insertion vs. the complexity and risks of intubation 3. The emphasis placed on minimally interrupted compressions. This does not preclude the PCP from placing a supraglottic airway when more than an OPA is required for VSA patients or in a prolonged resuscitation.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Mandatory Patch point: For PCPs, the patch will follow the 4th rhythm analysis. The intention of this patch point is to receive advice as to whether rapid transport or 1 final analysis/shock is most appropriate.	False. Mandatory Patch point: For PCPs, the patch will follow the 3rd rhythm analysis if considering the medical TOR. The intention of this patch point is to receive advice as to whether rapid transport or termination of resuscitation is most appropriate.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: In the event a ROSC is achieved and the patient re-arrests en route, Paramedics will adhere to the following sequence: 1. Initiate one rhythm interpretation after two (2) minutes of compressions. 2. Defibrillate as appropriate (1 shock max). 3. Continue with transportation to the receiving facility if shock is delivered. If no shock is delivered patch to BHP to receive advice.	False. In the event a ROSC is achieved and the patient re-arrests en route, Paramedics will adhere to the following sequence: 1. Pull over 2. Initiate one immediate rhythm interpretation 3. Defibrillate as appropriate (1 shock max) AND 4. Continue with transportation to the receiving facility.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: If in the opinion of the Paramedic(s) the patient would benefit from further analysis/defibrillation, a patch with a BHP would be indicated for direction.	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: For sudden cardiac arrests that occur “on scene” or enroute, the patient should, in absence of unusual circumstances, be treated utilising the entire medical cardiac arrest directive (complete 4 analyses).	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Glucometry in the vital signs absent (VSA) patient is indicated if hypoglycemia is suspected.	False. Glucometry in the vital signs absent (VSA) patient is of no clinical value.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Anaphylactic cardiac arrest: IM Epinephrine 1:1,000 is indicated if the Paramedic believes the arrest is directly related to the anaphylactic reaction. This patient then continues to be treated under the medical arrest directive and may be transported early as specified in the “unusual circumstances” clinical consideration. An IM dose of Epinephrine for anaphylaxis should not delay defibrillation.	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Asthmatic cardiac arrest : Treatment with Epinephrine 1:1,000 in an anaphylactic arrest is similar to an asthmatic arrest. Delivering Salbutamol effectively is able to be managed in cardiac arrests using the MDI adapter on the BVM. Effective ventilation and oxygenation should not be compromised.	False. Asthmatic cardiac arrest : While there is provision for treatment with Epinephrine 1:1,000 in the anaphylactic arrest, there is no similar recommendation in the asthmatic arrest. It is very difficult to deliver Salbutamol effectively in cardiac arrests, so the focus is placed on effective ventilation and oxygenation.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Electrocution: An event of electrocution should be treated as a medical arrest, as it should respond well to defibrillation.	False. Electrocution: The Paramedic must use judgment in this setting. A simple electrocution is a simple medical arrest that should respond well to defibrillation, but in the event the electrocution was associated with significant trauma, it should be treated as a trauma arrest.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Pulse checks: After the initial pulse check, subsequent checks are indicated when an analysis reveals a non-shockable rhythm (organized electrical activity that could have output or Asystole).	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Clinical consideration: Considering early transportation should not be left to paramedic judgement but limited to the 2 examples provided (pediatrics and toxicological overdoses).	False. Clinical consideration: Considering early transportation is not limited to the 2 examples provided (pediatrics and toxicological overdoses).
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Commotio cordis and hangings: are typically treated as medical cardiac arrests.	True.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: In the setting of cardiac arrest where a medical TOR might apply, the Paramedics will “count” the number of analyses completed prior to their arrival. Paramedics, as a general rule, do NOT count pre-arrival interventions into their patient care. However, the additional analyses/shocks completed prior to arrival may prove harmful to the patient. Care delivered must be documented.	False. As a general rule, Paramedics do NOT count pre-arrival interventions into their patient care. Care delivered prior to arrival can be “considered” and documented. However, in the setting of cardiac arrest where a medical TOR might apply, the Paramedics will complete 3 analyses themselves rather than “count” the number completed prior to their arrival.
	ALS Directives: Reference and Educational Notes Medical Cardiac Arrest True or False: Firefighters are also included in the statement regarding a “witnessed” cardiac arrest	True.
	ALS Directives: Reference and Educational Notes Trauma Cardiac Arrest True or False: Fluid bolus is indicated but the paramedic must patch to BHP for authorization.	False. Fluid bolus is not listed in the directive and is not indicated.
	ALS Directives: Reference and Educational Notes Trauma Cardiac Arrest True or False: The age difference between Medical and Trauma TOR is based on the definition of a pediatric trauma patient.	True.
	ALS Directives: Reference and Educational Notes Trauma Cardiac Arrest True or False: The 30 minute time reference is a reflection of transportation time	True.
	ALS Directives: Reference and Educational Notes Hypothermia Cardiac Arrest True or False: Pulse check: the specific reference to a prolonged pulse check was removed as the AHA guidelines advocate for a 15 second pulse check	False. Pulse check: the specific reference to a prolonged pulse check was removed as the AHA guidelines advocate for a 10 second pulse check
	ALS Directives: Reference and Educational Notes Hypothermia Cardiac Arrest True or False: When treating the hypothermic arrest, the focus is on active re-warming and rapid transport.	False. When treating the hypothermic arrest, the focus is on passive re-warming and gentle handling.
	ALS Directives: Reference and Educational Notes Hypothermia Cardiac Arrest True or False: The expectation is that these patients will be transported as the old adage says that “the patient is not dead until they are warm and dead.”	True.
	ALS Directives: Reference and Educational Notes Foreign Body Airway Obstruction Cardiac Arrest True or False: This directive is intended to apply to a complex airway obstruction that is unrelieved and where the patient presents in cardiac arrest. Initiating a medical cardiac arrest treatment plan is most appropriate for all obstructions where the patient remains pulseless.	This directive is intended to apply to a simple airway obstruction that is unrelieved and where the patient presents in cardiac arrest. Initiating a medical cardiac arrest treatment plan is most appropriate if and when the obstruction is relieved and the patient remains pulseless.
	ALS Directives: Reference and Educational Notes Foreign Body Airway Obstruction Cardiac Arrest True or False: Should the obstruction not be relieved, early/rapid transport is indicated.	True.
	ALS Directives: Reference and Educational Notes Foreign Body Airway Obstruction Cardiac Arrest True or False: This is an infrequently encountered patient presentation and even quick and accurate interventions rarely have a significant impact on the patient’s outcome.	False. This is an infrequently encountered patient presentation but quick and accurate interventions can make a significant impact on the patient’s outcome.
	ALS Directives: Reference and Educational Notes Neonatal Resuscitation True or False: The conditions listed under “other” are not intended to be all encompassing but serve as the “most likely” presentations warranting resuscitation.	True.
	ALS Directives: Reference and Educational Notes Neonatal Resuscitation True or False: The presence of one or all of the listed contraindications (meconium, no breathing or crying, no muscle tone or cyanotic) does not imply that a resuscitation will not be indicated.	False. The presence of one or all of the listed contraindications (clear of meconium, breathing or crying, good muscle tone or pink in colour) does not imply that a resuscitation will not be indicated.
	ALS Directives: Reference and Educational Notes Neonatal Resuscitation True or False: While the steps of warm, dry, position and stimulate are pointed specifically to the newborn, this directive is applicable to all patients under 30 days of age. In the patient that is not newly born, the first treatment bubble in the flow chart may be omitted.	True.
	ALS Directives: Reference and Educational Notes Neonatal Resuscitation True or False: When a newborn or recently born patient is in cardiac arrest, warm, dry and stimulate in an attempt to reverse the patient's presentation, if there is no change after 30 seconds, immediate chest compressions are indicated along with ventilations via BVM at room air. At the 60 second treatment bubble, it is correctly stated that the BVM ventilations are to be performed with an attached oxygen source. The neonate is more susceptible to harm from increased oxygen concentrations (hyperoxemia).	False. When a newborn or recently born patient is in cardiac arrest, chest compressions are indicated immediately and would not be delayed to warm, dry and stimulate and then provide only ventilations. At the 60 second treatment bubble, it is correctly stated that the BVM ventilations are to be performed with room air ONLY and not with an attached oxygen source. The neonate is more susceptible to harm from increased oxygen concentrations (hyperoxemia).
	ALS Directives: Reference and Educational Notes Neonatal Resuscitation True or False: The administration of Epinephrine IM for anaphylaxis does apply to this directive with a necessary patch to the BHP. It would be a very rare circumstance, and the differential diagnosis even more complicated.	False. The administration of Epinephrine IM for anaphylaxis does not apply to this directive. It would be a very rare circumstance, and the differential diagnosis even more complicated.
	ALS Directives: Reference and Educational Notes Return Of Spontaneous Circulation (ROSC) True or False: Optimizing oxygenation and targeting a SpO2 of ≥ 94% (and avoiding 100%) will provide adequate oxygenation and minimize vasoconstriction and the development of oxygen free radicals. These changes have been recommended for inclusion in the BLS-PCS to be consistent. Refer to the oxygen utilization standard in the BLS PCS.	True.
	ALS Directives: Reference and Educational Notes Return Of Spontaneous Circulation (ROSC) True or False: Therapeutic hypothermia is applicable to PCPs certified and authorized in its application. It may include, but is not limited to: cold saline or cold packs. Post arrest the goal is to maintain the ETCO2 (where available) to a range of 55-70 mmHg. Hypoventilation NEEDS to be avoided.	False. Therapeutic hypothermia is applicable to PCPs certified and authorized in its application. It may include, but is not limited to: cold saline or cold packs. Post arrest the goal is to maintain the ETCO2 (where available) to a range of 35-40 mmHg. Hyperventilation NEEDS to be avoided.
	ALS Directives: Reference and Educational Notes Return Of Spontaneous Circulation (ROSC) True or False: Regardless of the amount of fluid administered prior to ROSC and if chest auscultation is “clear”, a 10 ml/kg 0.9% NaCl fluid bolus may be administered to a maximum of 1000 ml targeting a SBP of ≥ 90 mmHg.	True.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: Conditions for Nitroglycerin use are: “a prior history OR an established IV”. An IV must be initiated prior to the administration of Nitroglycerin in first time suspected cardiac ischemia patients. If the patient already had an IV in place (i.e. outpatient), a new IV would need to be inserted to allow for first time administration of Nitroglycerin. This will only apply to the PCP(s) with autonomous IV certification.	False. Conditions for Nitroglycerin use are: “a prior history OR an established IV”. An IV must be initiated prior to the administration of Nitroglycerin in first time suspected cardiac ischemia patients. If the patient already had an IV in place (i.e. outpatient), the IV would need to be tested for patency and once confirmed, would allow for first time administration. This will only apply to the PCP(s) with autonomous IV certification.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: Prior history is defined as previously authorized or prescribed to the patient for use by a certified Medical Doctor.	True.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: Contraindications to Nitroglycerin: Phosphatetriesterase inhibitors. Also known as Viagra, Levitra, Cialis, Revatio etc…and now more broadly as Erectile Dysfunction Drugs (EDD). The use of these medications has diversified to include treatment of pulmonary hypertension and CHF. The most appropriate categorization is as phosphatetriesterase (PDE) 3 inhibitors.	False. Contraindications to Nitroglycerin: Phosphodiesterase inhibitors. Also known as Viagra, Levitra, Cialis, Revatio etc…and now more broadly as Erectile Dysfunction Drugs (EDD). The use of these medications has diversified to include treatment of pulmonary hypertension and CHF. The most appropriate categorization is as phosphodiesterase (PDE) 5 inhibitors.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: PDE5 inhibitor list: Sildenafil, Tadalafil, Vardenafil, Udenafil and Avanafil, Lodenafil Mirodenafil, Acetildenafil, Aildenafil, and Zaprinast. This may not be an exhaustive list and is current as of the date written.	True.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: 12 and/or modified 12 lead ECG(s) consistent with Right Ventricular Infarct (RVI): These patients are often dependent on afterload and the administration of Nitroglycerin to these patients may cause pulmonary hypertension.	False. 12 and/or modified 12 lead ECG(s) consistent with Right Ventricular Infarct (RVI): These patients are often preload dependent and the administration of Nitroglycerin to these patients may cause hypotension.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: If the myocardial ischemia symptoms resolve prior to the arrival of the Paramedics, a decision to administer ASA will be made based on patient assessment(s) and critical thinking.	True.
	ALS Directives: Reference and Educational Notes Cardiac Ischemia True or False: Once a patient’s vital signs fall outside the directive’s parameters (i.e.: hypotension), the paramedic may patch to a BHP for authorization to receive that medication (i.e.: Nitroglycerin or Morphine) if the vital signs return to acceptable ranges.	False. Once a patient’s vital signs fall outside the directive’s parameters (i.e.: hypotension), the patient can no longer receive that medication (i.e.: Nitroglycerin or Morphine) even if the vital signs return to acceptable ranges.
	ALS Directives: Reference and Educational Notes Acute Cardiogenic Pulmonary Edema True or False: The notes for the Cardiac Ischemia Medical Directive also apply here.	True.
	ALS Directives: Reference and Educational Notes Acute Cardiogenic Pulmonary Edema True or False: The dosing chart is accurate: When the Systolic Blood Pressure (SBP) is ≥140 mmHg, and neither an IV nor prior history exists, a 0.4 mg dose of Nitroglycerin is indicated. If the patient has a history of Nitroglycerin use or an IV in place and the SBP is between 100 and 139 mmHg, a 0.4 mg dose of Nitroglycerin is indicated. If the patient has the history or the IV and the SBP is ≥140 mmHg, a 0.8 mg dose of Nitroglycerin is indicated. The maximum of 6 doses is for 0.4 mg and 3 doses is for 0.8 mg. The patient may receive 6 doses for pulmonary edema and 6 more doses for cardiac ischemia symptoms should they co-exist. The dosing interval remains 5 min.	The dosing chart is accurate: When the Systolic Blood Pressure (SBP) is ≥ 140 mmHg, and neither an IV nor prior history exists, a 0.4 mg dose of Nitroglycerin is indicated. If the patient has a history of Nitroglycerin use or an IV in place and the SBP is between 100 and 139 mmHg, a 0.4 mg dose of Nitroglycerin is indicated. If the patient has the history or the IV and the SBP is ≥140 mmHg, a 0.8 mg dose of Nitroglycerin is indicated. The maximum of 6 doses is of either 0.4 mg or 0.8 mg. The patient may not receive 6 doses for pulmonary edema and 6 more doses for cardiac ischemia symptoms should they co-exist.
	ALS Directives: Reference and Educational Notes Acute Cardiogenic Pulmonary Edema True or False: The rule of once out always out for Nitroglycerin applies. If the patient were receiving 0.8 mg doses of nitroglycerin and the SBP drops below 140 mmHg, then 0.4 mg doses are indicated as long as the 1/3rd drop is not observed from the initial SBP and the SBP does not drop below 100 mmHg.	True.
	ALS Directives: Reference and Educational Notes Cardiogenic Shock True or False: This directive is applicable only to those Paramedics that have 12 lead and IV therapy certification.	True.
	ALS Directives: Reference and Educational Notes Cardiogenic Shock True or False: Cardiogenic shock is normally defined as a state in which the heart begins contracting rapidly and blood cannot adequately be brought to organs, tissues and cells of the body.	False. Cardiogenic shock is normally defined as a state in which the heart has been damaged to such an extent that it is unable to supply enough blood to the systems, organs, tissues and cells of the body.
	ALS Directives: Reference and Educational Notes Cardiogenic Shock True or False: Volume of fluid bolus is limited to 50 ml. This is based on the premise that the patient is not actually volume depleted but in need of preload.	False. Volume of fluid bolus is limited to 10 ml/kg. This is based on the premise that the patient is not actually volume depleted but in need of preload.
	ALS Directives: Reference and Educational Notes Cardiogenic Shock True or False: The clinical consideration “patch to the BHP if the patient is bradycardic with respect to age” is intended to allow the Paramedic to use his/her judgment.	True.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: The directive includes a fairly broad set of patient presentations to enable the Paramedic to use the glucometer to rule in or rule out a blood sugar related event.	True.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: Performing glucometry may be performed using the EMS' supplied device or the device belonging to the patient.	False. Performing glucometry is performed using the EMS’ supplied device.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: Glucometry will not be obtained from the flash chamber of an IV catheter. Not only is the practice inherently unsafe, but it involves manipulating a medical device for purposes that it is not intended for and the blood sample obtained is not a capillary sample.	True.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: If Glucagon is utilized, the dosing is based on ≥25 kg or <25 kg. Glucagon may be administered via IM or IV (if certified and authorized).	False. If Glucagon is utilized, the dosing is based on ≥ 25 kg or < 25 kg. Glucagon is only administered via the IM route.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: Both Dextrose and Glucagon may be repeated twice if the patient does not improve and the repeat glucometry remains low. The repeat times are 10 min between Glucagon doses and 20 min between Dextrose doses.	False. Both Dextrose and Glucagon may be repeated once if the patient does not improve and the repeat glucometry remains low. The repeat times are 20 min between Glucagon doses and 10 min between Dextrose doses.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: If Glucagon was initially administered with no patient improvement and an IV is subsequently established (if certified and authorized); perform a second glucometry and if the patient remains hypoglycemic administer Dextrose.	True.
	ALS Directives: Reference and Educational Notes Hypoglycemia True or False: Should the patient declare a refusal of transportation post treatment, ensure that they at least consume complex carbohydrates on scene. The paramedic should always attempt to ensure a responsible adult remains with the patient prior to leaving the scene. Minors refusing transport will need to sign the refusal of transport section of the ACR. Hypoglycemia due to oral hypoglycemic agents or long-acting insulin is associated with the need for ongoing IV therapy, hospital admission and poor outcomes (repeat EMS responses and death). Thus, these patients need to be advised of these risks.	False. Should the patient declare a refusal of transportation post treatment, a repeat glucometry must be performed along with a full set of vital signs. The patient (along with family or bystanders) requires a clear explanation of the risks involved, what signs to be vigilant of, and instructions to eat complex carbohydrates. This is to be recorded in the procedures section of the ACR as well as an appropriately completed refusal of care section. Paramedics should always attempt to ensure a responsible adult remains with the patient prior to leaving the scene. Minors refusing transport will need to be signed off by a substitute decision maker and left with that responsible person. Hypoglycemia due to oral hypoglycemic agents or long-acting insulin is associated with the need for ongoing IVtherapy, hospital admission and poor outcomes (repeat EMS responses and death). Thus, these patients need to be advised of these risks.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: Suspected bronchoconstriction applies to asthma, COPD, and other causes of bronchoconstriction that typically cause wheezing. A “silent chest” is not considered bronchoconstriction, but is a medical emergency and this patient should be transported to the appropriate receiving facility without delay.	Suspected bronchoconstriction applies to asthma, COPD, and other causes of bronchoconstriction that typically cause wheezing. This also addresses the old teaching point of the “silent chest” as that is considered “extreme” bronchoconstriction.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: Epinephrine is indicated when the patient is asthmatic and BVM ventilation is required. This is typically after Salbutamol has had no effect, however could be the initial patient presentation whereas Salbutamol is bypassed immediately due to the severity of the patient presentation. The indications to administer Epinephrine do not change based on the ability to administer Salbutamol.	True.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: Dosing for Salbutamol has been adjusted to match the 8 year old age and 25 kg weight used in many directives.	False. Dosing for Salbutamol has been adjusted to match the 25 kg weight used in many directives.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: The adult dosing has been adjusted from 900 mcg to 800 mcg per dose, based on recommendations from respiratory experts. The larger change is the timing of the repeats. It is no longer immediate, but is 5 – 15 minutes following the completion of the prior dose.	True.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: When a dose of MDI Salbutamol is administered, the intent is to deliver all 6 (pediatric) or 8 (adult) sprays to complete a dose. It would be under unusual circumstances to deliver less than the full dose.	True.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: Nebulization is preferred over MDI administration. If patient is unable to accept or cooperate with nebulized administration, the MDI route may be considered – still to a max of 2 doses.	False. MDI administration is preferred over nebulization. If patient is unable to accept or cooperate with MDI administration, the nebulized route may be considered – still to a max of 3 doses.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: Nebulization increases the mobilization of any contagion and a Paramedic should use PPE to protect themselves when in close proximity to an infected patient.	True.
	ALS Directives: Reference and Educational Notes Bronchoconstriction True or False: The accepted technique for administration is to provide a single MDI spray and to allow for inhalation with the next dose provided 4 breaths later. It will take 2 minutes to deliver a full adult dose to a patient breathing at a rate of 24 breaths per minute. The MDI chamber is not considered a single patient use device.	False. The accepted technique for administration is to provide a single MDI spray and to allow for inhalation with the next dose provided 4 breaths later. It will take 1 minute to deliver a full adult dose to a patient breathing at a rate of 32 breaths per minute. The MDI should be considered a single patient use device.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: The Medical Directive now includes a range of allergic reactions from moderate to severe and the administration of Diphenhydramine.	True.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Anaphylaxis is life-threatening and delays in administration of Epinephrine are associated with greater mortality. If the patient meets the indications and contraindications, epinephrine should be administered because it may prove to be life saving.	True.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Epinephrine 1:1000 is administered via the IM or IV route only.	False. Epinephrine 1:1000 is administered via the IM route only.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Epinephrine Dose = 0.1 mg/kg to a maximum of 3 mg (rounded to the nearest 0.5 mg) and is limited to one dose in the Prehospital setting. If the patient’s clinical condition does not improve and that in the opinion of the Paramedic(s) the patient would benefit from further doses, a patch with a BHP must be initiated.	False. Epinephrine Dose = 0.01 mg/kg to a maximum of 0.3 mg (rounded to the nearest 0.05 mg) and is limited to one dose in the Prehospital setting. If the patient’s clinical condition does not improve and that in the opinion of the Paramedic(s) the patient would benefit from further doses, a patch with a BHP must be initiated.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Epinephrine may be administered via auto-injector.	True.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Skin findings are most common and must be present for a treatment plan with epinephrine.	False. Skin findings are most common but up to 20% of patients do not have hives or other skin symptoms. Therefore ensure that all body systems are assessed to come up with the most appropriate treatment plan.
	ALS Directives: Reference and Educational Notes Moderate to Severe Allergic Reaction True or False: Urticaria alone is not an indication for administration of Epinephrine IM, the patient must present with at least one other sign or symptom.	True.
	ALS Directives: Reference and Educational Notes Croup True or False: The presentation must be severe. Most presentations of croup are mild and are well tolerated by the patient.	True.
	ALS Directives: Reference and Educational Notes Croup True or False: Prior to initiating nebulized epinephrine, moist air and cold air may be attempted if available and patient’s condition permits.	True.
	ALS Directives: Reference and Educational Notes Croup True or False: Croup is occurring more and more frequently in older patients including adults, and if the indications are met, a dose of 0.5 mg Epinephrine 1:1,000 IM is an appropriate treatment plan.	False. Croup is occurring more and more frequently in older patients including adults, and if the indications are met, a patch to the BHP would be required to consider treatment under this directive.
	ALS Directives: Reference and Educational Notes Croup True or False: Dosing for epinephrine has not changed from previous versions of the directive with the exception that there are no repeat administrations.	True.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis List 5 Integumentary (Skin) Signs or Symptoms	1. Hives. 2. Itching. 3. Flushing. 4. Swelling. 5. Angioedema.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis List 5 Cardiovascular Signs or Symptoms	1. Increased HR. 2. Decreased BP. 3. Syncope. 4. Decrease LOC. 5. Hypoxemia.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis List 4 Respiratory Signs or Symptoms	1. Shortness of breath. 2. Wheeze. 3. Cough. 4. Stridor.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis List 4 Gastrointestinal Signs or Symptoms	1. Cramping. 2. Nausea. 3. Vomiting. 4. Diarrhea.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis True or False: Severe symptoms to a single body system (respiratory system) should be considered as a severe allergic reaction.	True.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction vs. Anaphylaxis List 4 Groups of High Risk Patients	1. Very young and very old. 2. Hx of asthma. 3. Hx of cardiovascular disease. 4. Hx of mast cell disease.
	ALS Directives: Reference and Educational Notes Localized Allergic Reaction Primary Treatment	Diphenhydramine (slow onset) relieves symptoms (itching, flushing, urticaria, angioedema, eye and nasal symptoms) does NOT prevent or relieve upper airway obstruction, hypotension, shock.
	ALS Directives: Reference and Educational Notes Anaphylactic Reaction Primary Treatment	Epinephrine 1:1000 IM (fast onset) will increase blood pressure, prevent and relieves hypotension, decreases upper airway obstruction, decreases wheezing, decreases urticaria and angioedema. Secondary treatment to be considered post Epinephrine administration: 1. Diphenhydramine IM/IV. 2. PRN IV Fluids as per Medical Directive. 3. PRN Salbutamol as per Medical Directive.

Share This Flashcard Set

Set the Language

Als Medical Directives

Add to Folders

Upgrade to Cram Premium

Card Range To Study

256 Cards in this Set