Advanced Life Support Patient Care Standards - Version 3.0 - November 2011

Advanced Life Support
Patient Care Standards

November 2011

Version 3.0

Emergency Health Services Branch
Ministry of Health and Long-Term Care
EmergencyHealthServicesBranch,OntarioMinistryofHealthandLongTermCare
AdvancedLifeSupportPatientCareStandardsNovember2011,Version3.0

To all users of this publication:
The information contained herein has been carefully compiled and is believed to be accurate at date
of publication. Freedom from error, however, cannot be guaranteed.

For further information on
the Advanced Life Support Patient Care Standards,
please contact:

Emergency Health Services Branch
Ministry of Health and Long-Term Care
5700 Yonge Street, 6
th
Floor
Toronto ON M2M 4K5
Phone 416-327-7900
Queens Printer for Ontario, 2011 Fax 416-327-7911
Introduction
i
TABLEOFCONTENTS
Introduction
Acknowledgements.1
LevelofParamedics.2
PurposeofStandards....2
Summary....2
FormatoftheAdvancedLifeSupportPatientCareStandards. 3
UseofthemedicaldirectivesbyParamedics 3
RegionalBaseHospitalCompliancewithCPSOPolicy... 3
GeneralStructureofaMedicalDirective.4
ALSPatientCareStandardsParamedicSkillSet..4
ConsenttoTreatmentandCapacityAssessment5
RefusalofTreatment..5
ComprehensiveCare..6
IntravenousAccessandTherapybyPrimaryCareParamedics 6
HomeMedicalTechnologyandNovelMedications. 7
Patching.. 8
IncidentReporting.. 8
ControlledSubstances.. 9
ResponsibilityofCare.9
Research10
Conventions10
ListofAbbreviations.13
ReferenceandEducationalNotes..16
TableofAppendices 17
Appendix1PrimaryCareParamedicCoreMedicalDirectives
Appendix2AdvancedCareParamedicCoreMedicalDirectives
Appendix3PrimaryCareParamedicAuxiliaryMedicalDirectives
Appendix4AdvancedCareParamedicAuxiliaryMedicalDirectives
Appendix5ChemicalExposureMedicalDirectives
Appendix6ProvincialMaintenanceofCertificationPolicy
AdvancedLifeSupportPatientCareStandardsNovember2011,Version3.0 1
Introduction
ADVANCEDLIFESUPPORTPATIENTCARESTANDARDS
ACKNOWLEDGEMENTS
ThedevelopmentofthiseditionoftheAdvancedLifeSupportPatientCareStandardsistheresultofa
collaborativeeffortofanumberofstakeholdersincluding:
AssociationofMunicipalEmergencyMedicalServicesofOntario(AMEMSO)
OntarioBaseHospitalGroup(OBGH)
MinistryofHealthandLongTermCareEmergencyHealthServicesBranch(MOHLTCEHSB)
EHSBProvincialMedicalAdvisoryCommittee(MAC)
Inparticular,theMinistrywouldliketogratefullyacknowledgethefollowingmembersoftheMACandregional
basehospitalswhoprovidedthemedicalinputintothesestandards:
Dr.AndrewAffleck Dr.SheldonCheskes
NorthwestRegionBaseHospitalProgram SunnybrookCentreforPrehospitalMedicine
Dr.MichaelLewell Dr.JustinMaloney
SouthwestOntarioRegionalBaseHospital RegionalParamedicProgramforEastern
Program Ontario
Dr.JasonPrpic Dr.RudyVandersluis,SeniorMedicalEditor
NortheasternOntarioPrehospitalCare CentralEastPrehospitalCareProgram
Program
Dr.RichardVerbeek,LeadMedicalEditor Dr.MichelleWelsford
SunnybrookCentreforPrehospitalMedicine CentreforParamedicEducationandResearch
MarcLandriault,ACP ChrisMillington,PCP
OttawaParamedicService SuperiorNorthEMS

DougSocha,Chief AndyBenson
HastingsQuinteEMS Manager,Educationprograms
CentralEastPrehospitalCareProgram
ChristopherBourque TimDodd
Manager,ClinicalPerformanceManagement Manager,Education
RegionalParamedicProgramforEastern CentreforParamedicEducationandResearch
Ontario
Introduction
LEVELSOFPARAMEDICS
InOntario,therearethreeoccupationallevelsofparamedics:PrimaryCareParamedic(PCP),AdvancedCare
Paramedic(ACP),andCriticalCareParamedic(CCP).AlevelofparamedicisspecifiedinOntarioRegulation
257/00madeundertheAmbulanceAct,RSO1990,cA19.Schedules1,2and3tothisregulationspecifythe
mandatorycontrolledactsforeachlevelofparamedic.
AparamedicmaybeauthorizedbyamedicaldirectorofaRegionalBaseHospital(RBH)toperformcontrolled
actsfromtheScheduleimmediatelyabovetheirprimeoccupationallevel.Inthiscircumstance,theparamedic
willperformtheskilltothespecificstandardsetfortheskill.Thisgeneralconceptalsoappliestothe
performanceofalladvancedmedicalproceduresthatarenotlistedascontrolledactsinSchedules1,2and3,
butwhicharealsospecifiedinthesestandards.
PURPOSEOFSTANDARDS
ThepurposeoftheAdvancedLifeSupportPatientCareStandards(ALSPCS)istoguidethespecificsofpatient
carethataretobeundertakenconsistentwiththescopeofpracticeofthethreeoccupationallevelsof
paramedics.
TheALSPCS:
ReflectscurrentpracticesforparamedicsinOntarioandprovidesbenchmarksforparamedicperformance.
CommunicatesthestandardsofpracticeandcarebyparamedicsinOntariotoparamedics,patients,other
disciplinesandthepublicingeneral.
Delineatesparamedicprofessionalresponsibilitiesandaccountabilities.
ProvidesabasisforevaluationofpatientcarepracticebyOntariosparamedics.
Recognizesthatthescopeofpracticeforeachoccupationallevelofparamedicmayhaveincremental
addons,withappropriaterationaleandaccountability.
Summary
ALSPCSforthethreeoccupationallevelsofparamedicsinOntarioestablishthepracticeandpatientcare
parametersneededtoprovidehighqualitypatientcareinthevariedsettingsthroughouttheprovince.The
standardsaredesignedtobedynamic,inordertoallowforchangesbaseduponnewmedicalevidenceand/or
standardsofmedicalpractice.
Introduction
FORMATOFTHEADVANCEDLIFESUPPORTPATIENTCARESTANDARDS
ThisdocumentiscomprisedofanIntroductionsectionandsix(6)appendices:Appendix1PCPMedical
Directives;Appendix2ACPMedicalDirectives;Appendix3PCPAuxiliaryMedicalDirectives;
Appendix4ACPAuxiliaryMedicalDirectives;Appendix5ChemicalExposureMedicalDirectives;and
Appendix6MaintenanceofCertificationPolicy.CriticalCareParamedicsandAdvanced/PrimaryCareFlight
Paramedicswillperformcontrolledactsinaccordancewiththebasehospitalmedicaldirectivesissuedbythe
OrngeBaseHospitalPhysician.
USEOFTHEMEDICALDIRECTIVESBYPARAMEDICS
Thesemedicaldirectivesapplytoparamedicswhoprovidepatientcareunderthelicenseand/orauthorityofthe
RBHMedicalDirector.DelegationofcontrolledactsormedicaldirectivesintheALSPCStoparamedicsfalls
undertheexclusiveoversightoftheMOHLTCsRBHPrograms.
Themedicaldirectivesaredesignedtoguideaparamedicintheprovisionoftimelyandappropriatecaretoill
andinjuredpatientsintheprehospitalsetting,inaccordancewiththeparamedicstrainingandauthorizedskill
set.Whilegreatcarehasbeentakenindevelopingthesemedicaldirectives,theycannotaccountforevery
clinicalsituation.Thus,theyarenotasubstituteforsoundclinicaljudgment.
REGIONALBASEHOSPITALCOMPLIANCEWITHCPSOPOLICY
AslicensedphysiciansintheProvinceofOntario,theRBHMedicalDirectorsmustcomplywiththepoliciesofthe
CollegeofPhysiciansandSurgeonsofOntario(CPSO).CPSOpolicy#403,asmaybeamendedfromtimeto
time,providesdirectiontoOntariophysiciansonthedelegationofcontrolledacts,regardlessofpracticesetting
ortype.RBHswillalsofollowaparallelprocessfordelegationofotheradvancedmedicalproceduresincludedin
theseStandards.
Introduction
GENERALSTRUCTUREOFAMEDICALDIRECTIVE
Allmedicaldirectivesfollowthesameformatandarecomprisedofthefollowingsections:
Indication: Thegeneralmedicalcomplaintorproblemtowhichthemedicaldirectiveapplies.
Conditions: Clinicalparametersthatmustbepresentforaproceduretobeperformedorfora
drugtobeadministered.
Contraindications: Clinicalparametersthatifpresent,precludetheperformanceofaprocedureor
theadministrationofadrug.
Treatment: Descriptionofthetypeofproceduretobeperformedorthedosingofadrug.
ClinicalConsiderations: Keyclinicalpointsthatprovidegeneralguidancetotheproperperformanceofa
procedureortheadministrationofadrug.
Allofthesesectionsmustbetakenintoaccountbeforeandduringtheimplementationofamedicaldirective.
ALSPATIENTCARESTANDARDSPARAMEDICSKILLSET
ThemandatoryskillsetforeachlevelofparamedicisderivedfromthecontrolledactsoutlinedinSchedules1,2,
and3(asreferencedabove)andisimplementedthroughthePCPandACPMedicalDirectives.Aparamedic
mustmeetallapplicablerequirementssetoutinRegulation257/00toreceivedelegationfromaRBHmedical
director.
Additional(Auxiliary)skillsmaybedelegatedthoughuseoftheAuxiliaryMedicalDirectives.Delegationof
AuxiliaryMedicalDirectivesbyaRBHmedicaldirectortoparamedicsisoptionalandmaybeintroducedafter
consultationandmutualagreementbetweentheRBHandthecertifiedambulanceserviceoperatorthat
employstheparamedic.SomePCPandACPMedicalDirectivescontainthephrase,(ifavailable).Thisphrase
qualifiestheskillorprocedureasoptional(i.e.auxiliary)evenifincludedinPCPorACPMedicalDirectives.
Introduction
CONSENTTOTREATMENT&CAPACITYASSESSMENT
Exceptinemergencycircumstancesdescribedbelow,paramedicsmustobtainthepatientsconsentpriorto
initiatingtreatment.Consentmaybeinformedorimplied.Informedconsentmaybeeitherverbalorwritten.
Impliedconsentmaybeassumedwhereapersonprovidesaphysicalindicationthattheyconsenttothe
treatment.Forexample,apatientwhocannotspeakbutextendshishandtoaparamedicaftertheparamedic
indicatessheisgoingtoperformasimpleprocedure,suchasabloodglucosedeterminationmaybegiving
impliedconsenttotheprocedure.
Theelementsrequiredforconsenttotreatmentare:
consentmustbegivenbyapersonwhoiscapableofgivingconsentwithrespecttotreatment,
consentmustrelatetothetreatment,
consentmustbeinformed,
consentmustbegivenvoluntarily,and
consentmustnotbeobtainedthroughmisrepresentationorfraud.
Consenttotreatmentisinformedif,beforeitisgiventotheperson,heorshehas:
receivedthefollowinginformationthatareasonablepersoninthesamecircumstanceswouldrequirein
ordertomakeadecisionaboutthetreatment:
thenatureofthetreatment,
theexpectedbenefitsofthetreatment,
thematerialrisksofthetreatment,
thematerialsideeffectsofthetreatment,
alternativecoursesofaction,
thelikelyconsequencesofnothavingthetreatment;and
receivedresponsestohisorherrequestsforadditionalinformationaboutthosematters.
Theparamedicwhoproposesatreatmenttoapersonshallensurethatconsentisobtained.Validconsent
requiresthatapersonhasthecapacitytoprovideconsent.Apersonispresumedtohavethecapacitytoprovide
consentwithrespecttotreatmentandaparamedicmayrelyonthatpresumption.However,acapacity
assessmentmayberequiredifitisnotreasonableinthecircumstancestopresumethepersoniscapableof
consentingtothetreatment.
Introduction
Apatientiscapablewithrespecttotreatmentifthepatientis:
Abletounderstandtheinformationthatisrelevanttomakingadecisionaboutthetreatmentor
alternativesbeingproposed;and
Abletoappreciatethereasonablyforeseeableconsequencesofadecisionorlackofdecisionwith
respecttotreatment.
Ifaparamedicisawareorismadeawarethatthepersonhasapriorcapablewishwithrespecttotreatment,
theymustrespectthatwish(forexample,ifthepersondoesnotwishtoberesuscitated).
Ifapersonisincapablewithrespecttoatreatment,consentmaybegivenorrefusedonhisorherbehalfbya
personwhoisauthorizedtodosoundersection20oftheHealthCareConsentAct,1996.
Insomeinstances,apersonmaypresentinanemergencysituationwherethepersonforwhomthetreatmentis
proposedisapparentlyexperiencingseveresufferingorisatrisk,ifthetreatmentisnotadministeredpromptly,
ofsustainingseriousbodilyharm.
Aparamedicmayadministertreatmenttoapersonwithoutconsentinanemergencysituation,ifthereisno
otherauthorizedpersonavailabletogiveorrefuseconsentand,intheopinionoftheparamedic:
thepersonisnotcapableofgivingaconsentorrefusaltotreatment;and
thedelayrequiredtoobtainaconsentorrefusalonthepersonsbehalfwillprolongthesufferingthat
thepersonisapparentlyexperiencingorwillputthepersonatriskofsustainingseriousbodilyharm.

REFUSALOFTREATMENT
Ifapatientrefusestreatment,eitherinwholeorinpart,aparamedicmustcomplywiththeapplicabledirections
containedintheBasicLifeSupport(BLS)PatientCareStandards,Section1,PartI,PatientRefusalofTreatment
and/orTransport.
Introduction
COMPREHENSIVECARE
Whileinitiatingandcontinuingtreatmentprescribedbythesemedicaldirectives,aparamedicmustensurethat
thepatientsimultaneouslyreceivescareinaccordancewiththeBLSPatientCareStandards.
ItisacknowledgedthattheremaybecircumstancesandsituationswherecomplyingwithAdvancedLifeSupport
PatientCareStandardsisnotclinicallyjustified,possible,orprudent(e.g.multiplecrewsonscene,trapped
patient,extenuatingcircumstances,competingpatientcarepriorities).Whentreatmentdeviatesfromthe
standards,aparamedicmustdocumentthecareprovided,includingreasoningfordeviatingfromtheStandards.
INTRAVENOUS(IV)ACCESSANDTHERAPYBYPRIMARYCAREPARAMEDICS
TwolevelsofcertificationofPCPsforIVcannulationandtherapyarepossible.
PCPAssistIVauthorizesaPCPtocannulateaperipheralIVattherequestandunderthedirectsupervisionof
anACP.ThepatientmustrequireaperipheralIVinaccordancewiththeindicationslistedintheIntravenous
AccessandFluidTherapyMedicalDirectiveAuxiliary.TheACPwillperformallIVtherapyinaccordancewith
theIntravenousAccessandFluidAdministrationProtocolonceintravenousaccessisobtained.PCPscertifiedin
PCPAssistIVarenotauthorizedtoadministerIVtherapy.
PCPAutonomousIVauthorizesaPCPtoindependentlycannulateanIVaccordingtotheIntravenousAccess
andFluidTherapyMedicalDirectiveAuxiliary.PCPscertifiedinPCPAutonomousIVareauthorizedto
administerIVtherapyaccordingtoapplicablemedicaldirectives.
CertificationateachlevelshallmeettherequirementsestablishedbytheprovincialMedicalAdvisory
Committee.
Introduction
HOMEMEDICALTECHNOLOGYANDNOVELMEDICATIONS
Ascommunitycareadvances,newhomemedicaltechnologiesandnovelmedicationsarebeingintroducedfor
homeusebyhighlytrainedpatientsandcaregivers.Theyaregenerallyusedbypatientswithcomplexmedical
historieswhomayrequireemergentinterventionswhicharenotdescribedin,oralignedwith,theBLSorALS
PatientCareStandards.
Ahomemedicaltechnologyisanexternalorinternalmechanicaldeviceprescribedbyamemberofa
regulatedhealthprofessionforthepurposeoftreatingamedicalcondition.
Anovelmedicationisaself/caregiveradministeredmedicationprescribedbyamemberofaregulatedhealth
professionthatisrequiredtotreatpatientswithgenerallyrareandunusuallycomplexchronicmedical
conditionswhichareoftenendstage.Themedicationmaybeself/caregiveradministeredbyanyrouteintoany
partofthebody.
Thesecanbeencounteredunexpectedlybyparamedicswithoutanypriorknowledgethatthesetechnologiesor
medicationsarebeingusedinthecommunity.Paramedicsmaynotbefamiliarwiththeuseofthese
technologiesormedications,eventhoughtheymayberequiredtoprovidecare.
Insomecases,whenBaseHospitalMedicalDirectorsarealertedtotheseuniquedevices,medicationsorcare
requirements,auniquelocalmedicaldirectivemaybeissuedtoguidespecificcareforthesepatients.Such
directivesshouldbefolloweduntilfurtherconsiderationbytheMedicalAdvisoryCommittee.
Aparamedicmayassumepatientsorcaregivershaveknowledgeaboutthetechnologyormedicationifthey
confirmthattheyweretrainedinitsuseand/oradministration.Aparamedicshouldadvisethepatientor
caregivertofollowanyspecificstepsorprovideanyadviceaboutrestarting/stoppingthedeviceornovel
medication.Aparamedicmayonlyassistapatientwithintheauthorizedparamedicskillset.
Whencarerequirementsareuncertain,butthepatientisstable,transportthepatient.Ifthepatientisunstable,
considerpatchingtotheBaseHospitalPhysician.Alternatively,considercontactingtheresponsiblememberofa
regulatedhealthprofession.
AparamedicmayfollowwrittenadviceprovidedbytheirBaseHospitalMedicalDirectorsevenifthisadviceis
outsidetheconditionsandcontraindicationsoftheBLSandALSpatientcarestandards.
Introduction
PATCHING
AparamedicshouldpatchtotheBaseHospital:
Whenamedicaldirectivecontainsamandatoryprovincialpatchpoint;
OR
WhenaRBHintroducesamandatoryBHpatchpoint;
OR
Forsituationsthatfalloutsideofthesemedicaldirectiveswheretheparamedicbelievesthepatientmay
benefitfromonlinemedicaldirectionthatfallswithintheprescribedparamedicscopeofpractice;
OR
Whenthereisuncertaintyabouttheappropriatenessofamedicaldirective,eitherinwholeorinpart.
IncaseswhereatreatmentoptionrequiresthepriorauthorizationbytheBHP(i.e.mandatoryprovincialpatch
pointormandatoryBHpatchpoint)ANDtheBHPcannotbereacheddespitereasonableattemptsbythe
paramedictoestablishcontact,aparamedicmayinitiatetherequiredtreatmentwithouttherequisiteonline
authorizationifthepatientisinseveredistressand,intheparamedicsopinion,themedicaldirectivewould
otherwiseapply.Clinicaljudgmentmustbeappliedandanacceptablestandardofcaremustbemet.Thismay
bebasedonpeerandexpertreview.Insuchcases,aparamedicshouldcontinueattemptstocontacttheBHP
afterthetreatmenthasbeeninitiated.Allpatchfailuresmustbereportedinatimelymannerinaccordance
withlocalpolicyandprocedures.ParamedicsshoulddocumenttheattemptstopatchtotheBHonthe
AmbulanceCallReport(ACR).
IfaBHPdirectsaparamedictoperformanassessmentorinterventionthatexceedstheparamedicsscopeof
practice,theparamedicmustadvisetheBHPofsuchandnotifythephysicianthatheorshecannotcomplywith
thedirectionasitexceedshisorherscopeofpractice.Insuchcases,aparamedicshouldasktheBHPtoprovide
alternativedirection.
INCIDENTREPORTING
ParamedicsshalladheretotheirambulanceservicepoliciesandtheOntarioAmbulanceDocumentation
Standards(incorporatedbyreferenceinRegulation257/00)forincidentreporting.Paramedicsshallalsoadhere
toadditionalRBHpoliciesregardingreportingofclinicalcareincidentstotheRBH.
Introduction
CONTROLLEDSUBSTANCES
Whereapplicable,paramedicsandambulanceserviceoperatorsshallcomplywiththeCanadaControlledDrug
andSubstancesAct,SC1996,c19anditsRegulations,inaccordancewiththeambulanceoperatorandRBH
policy.Thisshallincludethatcontrolledsubstances(opiatesandbenzodiazepines)arestoredindifferent
carryingcasesthanothermedications.
RESPONSIBILITYFORCARE
Whileonscene,thehighestlevelparamedicshallassessthepatientandmakeadecisiononthelevelofcare
required,andonthelevelofparamedicrequiredforthecareofthepatient.Thehighestlevelparamedicisthe
ultimatepatientcareauthorityonthescene.Ifthereisanydisagreementbetweenparamedics,theBase
Hospitalphysicianmaybecontacted.Itisexpectedthatwhenaninterventionhasbeenperformed,the
paramedicmostappropriateforthatinterventionwillremainresponsibleforthepatient.
Inallpatientcare,thehighestlevelofparamedicisresponsibleforthecareofthepatient,includingdecisionson
thelevelofcarerequiredduringtransport.Aparamedicmaychoosetoassignaspectsofcareandproceduresto
analternatelevelparamedic,aslongasthecareandproceduresarewithinthatparamedicsscopeofpractice.
Paramedicsmustalertthehighestlevelparamedicofanychangeofpatientstatus.
Whentransferringcarefromonelevelofparamedictoanother,paramedicsshallprovide:
currentCTASlevel;
ahistoryofthepatientscurrentproblem(s)andrelevantpastmedicalhistory;
pertinentphysicalfindings;
asummaryofmanagementatscene/enroute;
thepatientsresponsetotreatment,includingmostrecentvitalsigns;
thereasonfortransferincasesofinterfacilitytransfers.
Thetransferofresponsibilityofpatientcareisacriticaljuncturealongtheclinicalcarecontinuum.When
transferringpatientcaretoanotherhealthcareprovider(e.g.nurse,physician,etc.),aparamedicmustcomply
withtheBLSPatientCareStandardsregardingsuchtransfers.
Introduction
RESEARCH
Clinicalresearchisfundamentaltothepracticeofmedicineandthedevelopmentofsafer,moreeffective
treatmentoptionsforpatients.Attimes,researchprotocolsrequiretemporarychangestopatientcare
standards.Inrecognitionoftheimportanceofprehospitalclinicalresearch,RBHMedicalDirectorsmay
delegatechangesinpatientcarestandardstoparamedicsiftheresearchrelatedtreatmentisendorsedby
MACOBHGandthecertifiedambulanceoperatorthatemploystheparamedics,approvedbyMOHLTC,andis
supportedbyanappropriateresearchethicsreviewboard.Changestopatientcarestandardswillbeintroduced
asanauxiliarymedicaldirective.Uponcompletionofaprehospitalclinicaltrial,researchrelatedtreatmentmust
behaltedandcareasprescribedbyBLSandALSPatientCareStandardsmustresume.
CONVENTIONS
Conventionsreferstoaconsistentapplicationoftermsthroughoutthemedicaldirectivesbasedondefinitions
below.
Thewordconsiderisusedrepeatedlythroughoutthemedicaldirectives.Wherethiswordappears,itindicates
thataparamedicshouldinitiatethetreatmentunlessthereisstrongclinicalrationaletowithholdit.A
paramedicmustdocumenthisorherjustificationforwithholdingtreatmentontheACR.
DRUGDOSESANDADMINISTRATION
Drugdosesmaybeeitherinperkilogramorfixeddoses,dependingoncommonclinicalpractice.Thenumberof
recommendeddrugsdosesmaybeadministeredregardlessofanypreviousselfadministrationbyapatient.
Whenmorethanonerouteofdrugadministrationislisted,theorderofpreferenceforrouteofadministrationis
fromlefttoright.Clinicalcircumstancesforeachcaseshoulddeterminethefinalroutechosen.
Pediatricdrugdosescanvaryslightlyaccordingtothesourceofexpertopinion.Thepediatricdrugdosesinthe
ALSPCSarethepreferreddoses.However,drugdosesasdeterminedbyanuptodateversionofawidely
acceptedpediatricemergencytape(e.g.BroselowTape)areanacceptablealternative.Useofapediatric
emergencytapeshallbedocumentedontheACRwhenitisusedtodetermineapediatricdrugdose.
Introduction
AGEANDVITALSIGNS
Thegeneralagecutoffbetweenadultsandpediatricsis18years.Thereisawiderangeofnormalforvital
signsinadultsandespeciallypediatrics.Asmuchaspossible,agesforpediatricsandcutoffpointsforvitalsigns
havebeenkeptconsistentthroughoutthemedicaldirectives.However,clinicalresearchandexpertopinion
haveresultedinanumberofexceptionswhichineachcasehasbeendeliberatelychosenandisclearlynotedin
eachmedicaldirective.Thereisadeliberategapinthedefinitionofnormotensionandhypotensioninadults.
ADULTS
NormotensionSBP100mmHg;
HypotensionSBP<90mmHg
Heartrate:Heartrateisalwaysinbeatsperminuteaccordingtoacardiacmonitorwhenitisapplied.In
situationswhereacardiacmonitorisnotindicatedthentheheartrateisequaltothepulserate.
Bradycardia<50BPM;
Tachycardia100BPM
TachypneaRR28breath/min
PEDIATRICS
Age RespiratoryRate HeartRate

03months 3060 90180
36months 3060 80160
612months 2545 80140
13yr 2030 75130
6yr 1624 70110
10yr 1420 6090
SystolicBloodPressure(forchildren110yrs)=70+(2xageinyears)
Weight(kg)=(agex2)+10
HYPOGLYCEMIA:
Age2years:glucometry<4.0mmol/L
Age<2years:glucometry<3.0mmol/L
Introduction
LOA(LevelofAwareness):
ThewordalteredreferstoaGCSthatislessthannormalforthepatient.
ThewordunalteredreferstoaGCSthatisnormalforthepatient.ThismaybeaGCS<15.
Introduction
LISTOFABBREVIATIONS
Thefollowingabbreviations,inalphabeticalorder,appearintheALSPatientCareStandards:
A
ACP AdvancedCareParamedic
ALS AdvancedLifeSupport
ALSPCS AdvancedLifeSupportPatientCareStandards
ASA acetylsalicylicacid
AV atrioventricular
BH basehospital
BHP BaseHospitalPhysician
BLS BasicLifeSupport
BP bloodpressure
BPM beatsperminute
BVM bagvalvemask
CCP CriticalCareParamedic
COPD chronicobstructivepulmonarydisease
cm centimeter
CPAP continuouspositiveairwaypressure
CPR CardiopulmonaryResuscitation
CPSO CollegeofPhysiciansandSurgeonsofOntario
CTAS CanadianTriageandAcuityScale
CVA cerebralvascularaccident
CVAD centralvenousaccessdevice
DKA diabeticketoacidosis
ECD electroniccontroldevice
ECG electrocardiogram
EDD esophagealdetectiondevice
ETCO
2
endtidalcarbondioxide
ETT endotrachealtube
FiO
2
fractionofinspiredoxygen
FRI febrilerespiratoryinfection
Introduction
g gram
GCS GlasgowComaScale
H
2
O water
HR heartrate
Hx history
IM intramuscular
IN intranasal
IO intraosseous
IV intravenous
kg kilogram
LOA levelofawareness
LOC levelofconsciousness/lossofconsciousness
MAC MedicalAdvisoryCommittee
mcg microgram
MDI metereddoseinhaler
mg milligram
min minute
ml/kg milliliterperkilogram
mmHg millimetersofmercury
MOHLTC MinistryofHealthandLongTermCare
N/A notapplicable
NaCl sodiumchloride
nare nostril
NEB nebulized
NPA nasopharyngealairway
NSAID nonsteroidalantiinflammatorydrug
Introduction
OBHG OntarioBaseHospitalGroup
OPA oropharyngealairway
PCP PrimaryCareParamedic
PO bymouth/oral
PRN asneeded
q every
RBH RegionalBaseHospital
ROSC returnofspontaneouscirculation
RR respiratoryrate
SC subcutaneous
SL sublingual
SBP systolicbloodpressure
SpO
2
saturationofperipheraloxygen
STEMI STsegmentelevationmyocardialinfarction
TBI traumaticbraininjury
TCA tricyclicantidepressant
TCP transcutaneouspacing
URTI upperrespiratorytractinfection
VSA vitalsignsabsent
WNL withinnormallimits
Introduction
REFERENCEANDEDUCATIONALNOTES
TheRBHshavecreatedacompaniondocumentofreferenceandeducationalnotesintendedtoassist
paramedicsinimplementingthesemedicaldirectives.Thiswillfacilitateregularupdatingofthesenoteswithout
havingtoissuefrequentchangestothestandards.Itisexpectedthatparamedicshavemasteredtherelevant
informationaspartofinitialtrainingandcertificationandhavemaintainedtheirknowledgethroughcontinuing
educationandselfstudy.Thereferenceandeducationalnotesdonotdefineastandardofcare;however,they
shouldbeconsideredusefulinensuringthatanappropriatestandardofcareismet.
Introduction

AdvancedLifeSupportPatientCareStandards
November2011Version3.0

TABLEOFAPPENDICES
Appendix1PrimaryCareParamedicCoreMedicalDirectives
Appendix2AdvancedCareParamedicCoreMedicalDirectives
Appendix3PrimaryCareParamedicAuxiliaryMedicalDirectives
Appendix4AdvancedCareParamedicAuxiliaryMedicalDirectives
Appendix5ChemicalExposureMedicalDirectives
Appendix6ProvincialMaintenanceofCertificationPolicy

Appendix 1

Primary Care Paramedic
Core Medical Directives

November 2011

AdvancedLifeSupportPatientCareStandardsNovember2011,Version3.0 i
PCPCoreMedicalDirectivesAppendix1

TABLEOFCONTENTS
MedicalCardiacArrestMedicalDirective...............................................................................................................11
TraumaCardiacArrestMedicalDirective...............................................................................................................15
HypothermiaCardiacArrestMedicalDirective ......................................................................................................19
ForeignBodyAirwayObstructionCardiacArrestMedicalDirective....................................................................111
NeonatalResuscitationMedicalDirective............................................................................................................113
ReturnofSpontaneousCirculation(ROSC)MedicalDirective .............................................................................115
CardiacIschemiaMedicalDirective...................................................................................................................... 118
AcuteCardiogenicPulmonaryEdemaMedicalDirective .....................................................................................121
CardiogenicShockMedicalDirective....................................................................................................................123
HypoglycemiaMedicalDirective...........................................................................................................................125
BronchoconstrictionMedicalDirective ................................................................................................................127
ModeratetoSevereAllergicReactionMedicalDirective.....................................................................................130
CroupMedicalDirective .......................................................................................................................................133

MEDICALCARDIACARRESTMEDICALDIRECTIVE
APrimaryCareParamedicmayprovidethetreatmentprescribedinthismedicaldirectiveifcertifiedand
authorized
INDICATIONS
Nontraumaticcardiacarrest
CONDITIONS

MedicalTOR
AGE: 18years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: ArrestnotwitnessedbyEMS,ANDNo
ROSCANDNoshocksdelivered
Epinephrine
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Anaphylaxis
suspectedas
causativeevent
ManualDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: VForpulselessVT
AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Shockindicated
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Performedfor2
minuteintervals

CONTRAINDICATIONS

TREATMENT
MedicalTOR
Arrestthoughttobeofnoncardiacorigin
Epinephrine
Allergyorsensitivityto
epinephrine
RhythmsotherthanVFor
pulselessVT
AEDDefibrillation
Nonshockablerhythm
ConsiderAEDdefibrillation:(withpediatricattenuatorifavailable)
Age Age
30daysto<8years 8years

WithPed
attenuator
WithoutPed
attenuator
Dose 1shock 1shock 1shock

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Dosinginterval N/A N/A N/A
Max.#ofdoses 4 4 4
ConsiderCPR
CPR
ObviouslydeadasperBLS
standards
MeetconditionsofDNR
standard

Considerepinephrine(onlyifanaphylaxissuspectedascausativeevent):
Weight
N/A
Route
IM
Concentration
1:1,000
Dose 0.01mg/kg*
Max.singledose 0.5mg
Dosinginterval N/A
Max.#ofdoses 1
*Theepinephrinedosemayberoundedtothenearest0.05mg.
MANDATORYPROVINCIALPATCHPOINT:
PatchtoBHPforauthorization,followingthe3
rd
analysis,toconsiderMedicalTerminationofResuscitation
(TOR)(ifapplicable).IftheBHpatchfails,orthemedicalTORdoesnotapply,transporttotheclosest
appropriatereceivinghospitalfollowingROSCorthe4
th
analysis.
ConsiderManualdefibrillation:(ifcertifiedandauthorized)
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Firstdose 2J/kg
AsperBH/
manufacturer
Subsequentand
max.dose(s)
4J/kg
AsperBH/
manufacturer
Dosinginterval 2min 2min
Max.#ofdoses 4 4

CLINICALCONSIDERATIONS
Inunusualcircumstances(e.g.:pediatricpatientsortoxicologicaloverdoses),considerinitiatingtransportation
followingthefirstrhythmanalysisthatdoesnotresultinadefibrillationbeingdelivered.
AParamedicmaychoosetomovethepatienttotheambulancepriortoinitiatingtheTORiffamilyisnotcoping
wellorthearrestoccurredinapublicplace.
FollowtheDeceasedPatientStandardonceTORhasbeenimplemented.

TRAUMACARDIACARRESTMEDICALDIRECTIVE
authorized
INDICATIONS
Cardiacarrestsecondarytoseverebluntorpenetratingtrauma
CONDITIONS

TraumaTOR
AGE: 16years
LOA: Altered
HR: 0
RR: 0
SBP: N/A
Other: Nopalpablepulses
Nodefibrillationdeliveredand
monitoredHR=0(asystole)OR
monitoredHR>0ANDthe
closestER30mintransport
timeaway.
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

CONTRAINDICATIONS

TREATMENT
TraumaTOR
Age<16years
Shockdelivered
MonitoredHR>0andclosestER<30min
away
pulselessVT
AEDDefibrillation
Nonshockablerhythm
ConsiderAEDdefibrillation:
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1
ConsiderCPR
CPR
standards
MeetconditionsofDNR
standard

Ifnoobviousexternalsignsofsignificantblunttrauma,considermedicalcardiacarrestandtreataccordingto
theappropriatemedicalcardiacarrestdirective.

PatchtoBHPforauthorizationtoapplytheTrauma(TOR)TerminationofResuscitation,ifapplicable.Ifthe
BHpatchfails,orthetraumaTORdoesnotapply,transporttotheclosestappropriatereceivinghospital
followingthefirstanalysis/shock.
ConsiderManualdefibrillation:(ifcertifiedandauthorized)
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Dosinginterval N/A N/A
Max.#ofdoses 1 1


TREATMENTALGORITHMFORTRAUMAARREST

TORimplemented TransporttoED
Patch
Drivetimeto
closestER30
min
Ptage16yrs
PEA(HR>0) Asystole Defibrillation:
1shock,Max#
doses=1.
Othermonitoredrhythm VForVT
Applydefibpadstoallpatient30daysofage Rhythmanalysis
CPR(throughoutdurationofcall)
INDICATIONS:Cardiacarrestsecondarytoseverebluntorpenetratingtrauma
NO
NO
NO
NO
YES YES YES
YES
YES YES
YES
YES
YES
T
r
a
n
s
p
o
r
t
t
o
E
m
e
r
g
e
n
c
y
D
e
p
a
r
t
m
e
n
t

HYPOTHERMIACARDIACARRESTMEDICALDIRECTIVE
authorized.
INDICATIONS
Cardiacarrestsecondarytoseverehypothermia
CONDITIONS

CONTRAINDICATIONS

pulselessVT
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
AEDDefibrillation
Nonshockablerhythm
AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
CPR
standards
MeetconditionsofDNR
standard

TREATMENT
N/A

Transporttotheclosestappropriatefacilitywithoutdelayfollowingthefirstanalysis.
ConsiderManualdefibrillation:
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Max.#ofdoses 1 1
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1
ConsiderCPR:

FOREIGNBODYAIRWAYOBSTRUCTIONCARDIACARRESTMEDICALDIRECTIVE
authorized.
INDICATIONS
Cardiacarrestsecondarytoanairwayobstruction
CONDITIONS

CONTRAINDICATIONS

TREATMENT
pulselessVT
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

AEDDefibrillation
Nonshockablerhythm
AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
ConsiderCPR:
CPR
standards
MeetconditionsofDNR
standard

N/A
Iftheobstructioncannotberemoved,transporttotheclosestappropriatefacilitywithoutdelayfollowing
thefirstanalysis.
Ifthepatientisincardiacarrestfollowingremovaloftheobstruction,initiatemanagementasamedical
cardiacarrest.
Considerforeignbodyremoval:(utilizingBLSmaneuvers)
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Max.#ofdoses 1 1
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1

NEONATALRESUSCITATIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Severecardiorespiratorydistress
CONDITIONS
CONTRAINDICATIONS
Resuscitation
Clearofmeconium
Breathingorcrying
Goodmuscletone
Pinkincolour
Resuscitation
AGE: newbornor<30
daysofage
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Lessthanfull
term,or
meconium,or
poorAPGARscore

TREATMENT

*ifmeconiumispresentandbabynotvigorous,suctionmouthandpharynxandprovideBVMventilationsas
requiredandthencontinuewiththeremainderoftheinitialstepsfollowingbirth.
Supportivecare

Providepositivepressure
ventilation(BVM/ETT)using100%
oxygen
Administerchestcompressions
Initiatetransport
ventilation(BVM)usingair
Supportivecare

Evaluaterespirations,heartrate
andcolour
Routinecare:
Providewarmth
Clearairwayifnecessary
Donotroutinelysuction
Dry
Ongoingevaluation
Providewarmth
Position/clearairway(as
necessary)
Dry,stimulate,reposition
Birth:
Clearof*meconium?
Breathingorcrying?
Goodmuscletone?
Colourpink?
Termgestation
YES
NO
30
secs
Breathing
HR100+pink
Apnea,gaspingorHR<100
Ventilating
HR100+pink
60
secs
90
secs
HR<60 HR60

RETURNOFSPONTANEOUSCIRCULATION(ROSC)MEDICALDIRECTIVE
authorized.
INDICATIONS
Patientwithreturnofspontaneouscirculation(ROSC)aftertheresuscitationwasinitiated.
CONDITIONS

Therapeutichypothermia
AGE: males18years
females50years
LOA: Altered
HR: N/A
RR: N/A
SBP: 90mmHg
(spontaneousor
followingbolus
administered)
Other: N/A
0.9%NaClfluidbolus
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Chest
auscultationis
clear


CONTRAINDICATIONS

TREATMENT

Consideroptimizingventilationandoxygenation:
Titrateoxygenation94%
AvoidhyperventilationandtargetanETCO2of3540mmHgwithcontinuouswaveformcapnography(if
available)
Considerrapidtransport
Traumaticcardiacarrest
(blunt,penetratingor
burn)
Sepsisorseriousinfection
suspectedascauseof
arrest
Hypothermicarrest
Knowncoagulopathy
(medicalhistoryor
medications)
Consider0.9%NaClfluidbolus:(ifcertifiedandauthorized)
Age Age
<12years 12years
Route Route
IV IV
Infusion 10ml/kg 10ml/kg
Infusioninterval Immediate Immediate
Reassessevery 100ml 250ml
Max.volume 1,000ml 1,000ml
0.9%NaClfluidbolus
Fluidoverload
SBP90mmHg

Theapplicationoftherapeutichypothermiashouldnotdetractfromrapidtransport,optimizingventilationand
oxygenationorthemanagementofarearrest.

Consider12leadacquisition(ifavailable)
ConsiderTherapeutichypothermia(ifavailable)

CARDIACISCHEMIAMEDICALDIRECTIVE
authorized.
INDICATIONS
Suspectedcardiacischemia
CONDITIONS

ASA
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: Abletochewand
swallow
Nitroglycerin
AGE: 18years
LOA: Unaltered
HR: 60159bpm
RR: N/A
SBP: Normotension
Other: Priorhistoryof
nitroglycerinuse
ORIVaccess
obtained

CONTRAINDICATIONS

TREATMENT
Consider12leadECGacquisition(ifavailable)
ConsiderASA:
Route
PO
Dose 160162mg
Max.singledose 162mg
Dosinginterval N/A
Max.#ofdoses 1
ASA
ASAorNSAIDS
Ifasthmatic,noprioruse
ofASA
Currentactivebleeding
CVAorTBIintheprevious
24hours
Nitroglycerin
nitrates
Phosphodiesterase
inhibitorusewithinthe
previous48hours
SBPdropsbyonethirdor
moreofitsinitialvalue
afternitroglycerinis
administered
12leadECGcompatible
withRightVentricular
infarct

N/A
Considernitroglycerin:

SBP

100mmHg
Route
SL
Dose 0.3or0.4mg
Dosinginterval 5min.
Max.#ofdoses 6


ACUTECARDIOGENICPULMONARYEDEMAMEDICALDIRECTIVE
authorized.
INDICATIONS
Moderatetosevererespiratorydistress
AND
Suspectedacutecardiogenicpulmonaryedema
CONDITIONS
Nitroglycerin
AGE: 18years
LOA: N/A
HR: 60159bpm
RR: N/A
SBP: Normotension
Other: Ascertainprior
historyof
nitroglycerinuse
ORestablishIV
access

CONTRAINDICATIONS
TREATMENT
IVconditionappliesonlytoPCPscertifiedtothelevelofPCPAutonomousIV.
SBP SBP

100mmHgto
<140mmHg
140mmHg
IVorHx IVorHx IVorHx
Yes No Yes
Route Route Route
SL SL SL
Dose 0.3or0.4mg 0.3or0.4mg 0.6or0.8mg
Max.singledose 0.4mg 0.4mg 0.8mg
Dosinginterval 5min. 5min. 5min.
Max.#ofdoses 6 6 6

NOTE: Hxreferstoapatientwithapriorhistoryofnitroglycerinuse.
Nitroglycerin
nitrates
Phosphodiesterase
previous48hours
administered

CARDIOGENICSHOCKMEDICALDIRECTIVE
authorized.
INDICATIONS
STEMIpositiveECG
AND
Cardiogenicshock
CONDITIONS
CONTRAINDICATIONS
0.9%NaCl
N/A

0.9%NaCl
AGE: 2years
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Clearcheston
auscultation

TREATMENT
N/A

Consider0.9%NaClfluidbolus:
Age Age

2yearsto
<18years
18years
Route Route
IV IV
Infusioninterval N/A N/A
Max.volume 10ml/kg 10ml/kg

HYPOGLYCEMIAMEDICALDIRECTIVE
authorized.
INDICATIONS
AgitationORalteredLOAORseizureORsymptomsofstroke
CONDITIONS

CONTRAINDICATIONS

TREATMENT
Performglucometry
Glucagon
glucagon
Pheochromocytoma
Dextrose
dextrose
Glucagon
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia
Dextrose
AGE: 2years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia

Ifthepatientrespondstodextroseorglucagon,he/shemayreceiveoralglucoseorothersimplecarbohydrates.
Ifonlymildsignsorsymptomsareexhibited,thepatientmayreceiveoralglucoseorothersimplecarbohydrates
insteadofdextroseorglucagon.
Ifapatientinitiatesaninformedrefusaloftransport,afinalsetofvitalsignsincludingbloodglucometrymustbe
attemptedanddocumented.
IVadministrationofdextroseappliesonlytoPCPscertifiedtothelevelofPCPAutonomousIV.
Considerdextrose(ifcertifiedandauthorized)orglucagon:
Drug Drug
Dextrose Glucagon
Age Age
2years N/A
Weight Weight Weight
N/A <25kg 25kg
Concentration Concentration Concentration
D50W N/A N/A
Route Route Route
IV IM IM
Dose
0.5g/kg
(1ml/kg)
0.5mg 1mg
Max.singledose 25g(50ml) 0.5mg 1mg
Max.#ofdoses 2 2 2

BRONCHOCONSTRICTIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Respiratorydistress
AND
Suspectedbronchoconstriction
CONDITIONS

CONTRAINDICATIONS

EpinephrineAutoinjector
epinephrine
AGE: N/A
WEIGHT:10kg
LOA: N/A
HR: N/A
RR: BVMventilation
required
SBP: N/A
Other: Hxofasthma
Epinephrine
epinephrine
Salbutamol
salbutamol
Epinephrine
AGE: N/A
WEIGHT:N/A
LOA: N/A
HR: N/A
RR: BVMventilation
required
SBP: N/A
Other: Hxofasthma
Salbutamol
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
Considerepinephrine:
N/A 10kgto<25kg 25kg
Route Route Route
IM
Pediatric
Autoinjector
Adult
Autoinjector
1:1,000 1:1,000
1:1,000
Dose 0.01mg/kg**
1injection
(0.15mg)
1injection
(0.3mg)
Max.singledose 0.5mg 1injection
1injection
N/A
Max.#ofdoses 1 1
**Theepinephrinedosemayberoundedtothenearest0.05mg.
Considersalbutamol:
Weight Weight
<25kg 25kg
Route Route Route Route

MDI
(ifavailable)*
NEB
MDI
(ifavailable)*
NEB
Dose
Upto600mcg
(6puffs)
2.5mg
Upto800mcg
(8puffs)
5mg
Max.SingleDose 600mcg 2.5mg 800mcg 5mg
Dosinginterval 515min.PRN 515min.PRN 515min.PRN 515min.PRN
Max.#ofdoses 3 3 3 3
*1puff=100mcg

Epinephrineshouldbethefirstdrugadministeredifthepatientisapneic.SalbutamolMDImaybeadministered
subsequentlyusingaBVMMDIadapter(ifavailable).
Nebulizationiscontraindicatedinpatientswithaknownorsuspectedfeverorinthesettingofadeclaredfebrile
respiratoryillnessoutbreakbythelocalmedicalofficerofhealth.
WhenadministeringsalbutamolMDI,therateofadministrationshouldbe100mcgapproximatelyevery
4breaths.
AspacershouldbeusedwhenadministeringsalbutamolMDI(ifavailable).
PatchtoBHPforauthorizationtousepediatricautoinjectorforpatients<10kg.

MODERATETOSEVEREALLERGICREACTIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Exposuretoaprobableallergen
AND
Signsand/orsymptomsofamoderatetosevereallergicreaction(includinganaphylaxis)
CONDITIONS

CONTRAINDICATIONS

epinephrine
AGE: N/A
WEIGHT:10kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Foranaphylaxis
only
Diphenhydramine
diphenhydramine
Epinephrine
epinephrine
Diphenhydramine
AGE: N/A
WEIGHT:25kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

Epinephrine
AGE: N/A
WEIGHT:N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
only

TREATMENT

Epinephrineshouldbethefirstdrugadministeredinanaphylaxis.
IVadministrationofdiphenhydramineappliesonlytoPCPscertifiedtothelevelofPCPAutonomousIV.
Considerdiphenhydramine(ifcertifiedandauthorized):
Weight Weight
25kgto<50kg 50kg
IV IM IV IM
Dose 25mg 25mg 50mg 50mg
Max.singledose 25mg 25mg 50mg 50mg
Dosinginterval N/A N/A N/A N/A
Route Route Route
IM
Pediatric
Autoinjector
Adult
Autoinjector
1:1,000 1:1,000 1:1,000
Dose 0.01mg/kg*
1injection
(0.15mg)
1injection
(0.3mg)
1injection
N/A
Max.#ofdoses 1 1

PatchtoBHPforauthorizationtousepediatricautoinjectorforpatients<10kg

CROUPMEDICALDIRECTIVE
authorized.
INDICATIONS
Severerespiratorydistress
AND
Stridoratrest
AND
CurrenthistoryofURTI
AND
BarkingcoughORrecenthistoryofabarkingcough
CONDITIONS
CONTRAINDICATIONS
Epinephrine
epinephrine
Epinephrine
AGE: <8years
LOA: N/A
HR: <200bpm
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
Theminimuminitialvolumefornebulizationis2.5ml.
Age Age
<1year
1yearto
8years
<5kg 5kg N/A
Route Route Route
NEB NEB NEB
1:1,000 1:1,000 1:1,000
Dose 0.5mg 2.5mg 5mg
Max.singledose 0.5mg 2.5mg 5mg
Max.#ofdoses 1 1 1

Appendix 2

Advanced Care Paramedic
Core Medical Directives

November 2011

AdvancedLifeSupportPatientCareStandardsNovember2011,Version3.0 i
ACPCoreMedicalDirectivesAppendix2

TABLEOFCONTENTS
MedicalCardiacArrestMedicalDirective...............................................................................................................21
TraumaCardiacArrestMedicalDirective...............................................................................................................27
HypothermiaCardiacArrestMedicalDirective ....................................................................................................211
ForeignBodyAirwayObstructionCardiacArrestMedicalDirective....................................................................213
NeonatalResuscitationMedicalDirective............................................................................................................215
ReturnofSpontaneousCirculation(ROSC)MedicalDirective .............................................................................217
CardiacIschemiaMedicalDirective...................................................................................................................... 220
AcuteCardiogenicPulmonaryEdemaMedicalDirective .....................................................................................223
CardiogenicShockMedicalDirective....................................................................................................................225
SymptomaticBradycardiaMedicalDirective........................................................................................................227
TachydysrhythmiaMedicalDirective....................................................................................................................230
IntravenousandFluidTherapyMedicalDirective................................................................................................234
PediatricIntraosseousMedicalDirective .............................................................................................................237
HypoglycemiaMedicalDirective...........................................................................................................................239
SeizureMedicalDirective .....................................................................................................................................242
OpioidToxicityMedicalDirective .........................................................................................................................244
EndotrachealIntubationMedicalDirective..........................................................................................................246
BronchoconstrictionMedicalDirective ................................................................................................................249
ModeratetoSevereAllergicReactionMedicalDirective.....................................................................................252
CroupMedicalDirective .......................................................................................................................................254
TensionPneumothoraxMedicalDirective............................................................................................................256
PainMedicalDirective ..........................................................................................................................................258

MEDICALCARDIACARRESTMEDICALDIRECTIVE
AnAdvancedCareParamedicmayprovidethetreatmentprescribedinthismedicaldirectiveifcerifiedand
authrized.
INDICATIONS
Nontraumaticcardiacarrest
CONDITIONS

AEDDefibrillation
AGE: 8years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Alternativeto
manual
defibrillation
Lidocaine
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
where
amiodaroneis
notavailable
Amiodarone
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Epinephrine
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Ifanaphylaxis
suspectedas
causativeevent,
IMroutemaybe
used
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: performedin2
minute
increments


CONTRAINDICATIONS

Amiodarone
amiodarone
AEDDefibrillation
Nonshockablerhythm
0.9%NaClFluidBolus
Fluidoverload
Lidocaine
lidocaine
Use/Availabilityof
amiodarone
Epinephrine
epinephrine
0.9%NaClFluidBolus
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: PEA
Anyotherrhythm
where
hypovolemiais
suspected
pulselessVT
CPR
standards
MeetconditionsofDNR
standard

TREATMENT
Considersupraglotticairwayinsertion:wheremorethanOPA/NPAandBVMrequiredandwithout
interruptingCPR
ConsiderAEDdefibrillation:(alternativetomanualdefibrillation)
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses N/A N/A N/A

Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Firstdose 2J/kg
AsperBH/
manufacturer
Subsequentand
max.dose(s)
4J/kg
AsperBH/
manufacturer
Dosinginterval 2min 2min
Max.#ofdoses N/A N/A
ConsiderCPR:

Consideramiodarone:
Age Age

30daysto
<12years
12years
Route Route
IV/IO IV/IO/CVAD
InitialDose 5mg/kg 300mg
Max.initialdose 300mg 300mg
Repeatdose 5mg/kg 150mg
Max.repeatdose 150mg 150mg
Dosinginterval 4min. 4min.
Max.#ofdoses 2 2
Intheeventanaphylaxisissuspectedasthecausativeeventofthecardiacarrest,asingledoseof
0.01mg/kg1:1,000solution,toamaximumof0.5mgIM,maybegivenpriortoobtainingtheIV/IO.
Age Age
Route Route
IV/IO ETT
IV/IO/
CVAD
ETT
Solution 1:10,000 1:1,000 1:10,000 AsperBH
Dose 0.01mg/kg
0.1mg/kg
toamax
of2mg
1mg 2mg
Min.singledose 0.1mg 1mg 1mg 2mg
Dosinginterval 4min. 4min. 4min. 4min.
Max.#ofdoses N/A N/A N/A N/A

PatchtoBHPfollowing3roundsofepinephrine(orafter3
rd
analysesifnoIV/IO/ETTaccess).IftheBH
patchfails,transporttotheclosestappropriatereceivinghospitalfollowingthe4
th
epinephrine
administration(or4
th
analysisifnoIV/IO/ETTaccess).
Considerintubation:iftheairwayisnotbeingadequatelymanaged.
Considerlidocaine:(ifamiodaronenotavailable)
Age Age

30daysto12years
and<40kg
12years
Route Route
IV/IO ETT IV/IO/CVAD ETT
Dose 1mg/kg 2mg/kg 1.5mg/kg 3mg/kg
Min.singledose N/A N/A N/A N/A
Age Age

30daysto
<12years
12years
Route Route
IV/IO IV/IO/CVAD
Max.volume
20ml/kgupto
2,000ml
2,000ml

Inunusualcircumstances(e.g.:pediatricpatientsortoxicologicaloverdoses),considerinitiatingtransportation
followingthefirstrhythmanalysisthatdoesnotresultinadefibrillationbeingdelivered.
TheIVandIOroutesofmedicationadministrationarepreferredovertheETTroute.However,ETT
administrationmaybeusediftheIV/IOroutesaredelayed(e.g.:>5min.)

TRAUMACARDIACARRESTMEDICALDIRECTIVE
AnAdvancedCareParamedicmayprovidethetreatmentprescribedinthismedicaldirectiveifcertifiedand
authorized.
INDICATIONS
Cardiacarrestsecondarytoseverebluntorpenetratingtrauma
CONDITIONS

AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
TraumaTOR
AGE: 16years
LOA: Altered
HR: 0
RR: 0
SBP: N/A
Other: Nopalpablepulses
NodefibrillationdeliveredAND
monitoredHR=0(asystole)OR
monitoredHR>0ANDthe
closestER30mintransport
timeaway.
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

CONTRAINDICATIONS

TREATMENT
AEDDefibrillation
Nonshockablerhythm

TraumaTOR
Age<16years
Shockdelivered
MonitoredHR>0andclosestER<30min
away
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Max.#ofdoses 1 1
pulselessVT
ConsiderCPR:
CPR
standards
MeetconditionsofDNR
standard

Ifnoobviousexternalsignsofsignificantblunttrauma,considermedicalcardiacarrestandtreataccordingto
theappropriatemedicalcardiacarrestdirective.
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1
PatchtoBHPforauthorizationtoapplytheTrauma(TOR)TerminationofResuscitationifapplicable.Ifthe
BHpatchfails,orthetraumaTORdoesnotapply,transporttotheclosestappropriatereceivinghospital
followingthefirstanalysis/shock.

TREATMENTALGORITHMFORTRAUMAARREST

TORimplemented TransporttoED
Patch
Drivetimeto
closestER30
min
Ptage16yrs
PEA(HR>0) Asystole Defibrillation:
1shock,Max#
doses=1.
Othermonitoredrhythm VForVT
Applydefibpadstoallpatient30daysofage Rhythmanalysis
CPR(throughoutdurationofcall)
INDICATIONS:Cardiacarrestsecondarytoseverebluntorpenetratingtrauma
NO
NO
NO
NO
YES YES YES
YES
YES YES
YES
YES
YES
T
r
a
n
s
p
o
r
t
t
o
E
m
e
r
g
e
n
c
y
D
e
p
a
r
t
m
e
n
t

HYPOTHERMIACARDIACARRESTMEDICALDIRECTIVE
authorized.
INDICATIONS
Cardiacarrestsecondarytoseverehypothermia
CONDITIONS

CONTRAINDICATIONS

AEDDefibrillation
Nonshockablerhythm
AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

pulselessVT
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
CPR
standards
MeetconditionsofDNR
standard

TREATMENT
N/A
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1
Transporttotheclosestappropriatefacilitywithoutdelayfollowingthefirstanalysis.
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Max.#ofdoses 1 1
ConsiderCPR:

FOREIGNBODYAIRWAYOBSTRUCTIONCARDIACARRESTMEDICALDIRECTIVE
authorized.
INDICATIONS
Cardiacarrestsecondarytoanairwayobstruction
CONDITIONS

CONTRAINDICATIONS

TREATMENT
AEDDefibrillation
Nonshockablerhythm
AEDDefibrillation
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A

pulselessVT
AGE: 30days
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
CPR
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A
ConsiderCPR:
CPR
standards
MeetconditionsofDNR
standard

N/A
Age Age

WithPed
attenuator
WithoutPed
attenuator

Max.singledose
AsperBH/
manufacturer
AsperBH/
manufacturer
AsperBH/
manufacturer
Max.#ofdoses 1 1 1
Ifthepatientisincardiacarrestfollowingremovaloftheobstruction,initiatemanagementasamedical
cardiacarrest.
Iftheobstructioncannotberemoved,transporttotheclosestappropriatefacilitywithoutdelayfollowing
thefirstanalysis.
Considerforeignbodyremoval:(utilizingBLSmaneuversand/orlaryngoscopeandMagillforceps)
Age Age

30daysto
<8years
8years
Dose 1shock 1shock
Initialdose 2J/kg
AsperBH/
manufacturer
Max.#ofdoses 1 1

NEONATALRESUSCITATIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Severecardiorespiratorydistress
CONDITIONS
CONTRAINDICATIONS
Resuscitation
Clearofmeconium
Breathingorcrying
Goodmuscletone
Pinkincolour
Resuscitation
AGE: newbornor<30
daysofage
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Lessthanfull
term,or
meconium,or
poorAPGARscore

TREATMENT

*ifmeconiumispresentandbabynotvigorous,suctionmouthandpharynx,considerETTandprovideBVM
ventilationsasrequiredandthencontinuewiththeremainderoftheinitialstepsfollowingbirth.
Epinephrine:0.01mg/kg(0.1ml/kg)1:10,000IV/IOOR0.1mg/kg(1ml/kg)
1:10,000ETTq4minutes.
Initiatetransportpriortothe3
rd
doseifpossible.
Supportivecare

ventilation(BVM/ETT)using100%
oxygen
Administerchestcompressions
ventilation(BVM)usingair
Supportivecare

Evaluaterespirations,heartrate
andcolour
Routinecare:
Providewarmth
Clearairwayifnecessary
Donotroutinelysuction
Dry
Ongoingevaluation
Providewarmth
Position/clearairway(as
necessary)
Dry,stimulate,reposition
Birth:
Clearof*meconium?
Breathingorcrying?
Goodmuscletone?
Colourpink?
Termgestation
YES
NO
30
secs
Breathing
HR100+pink
Apnea,gaspingorHR<100
Ventilating
HR100+pink
60
secs
90
secs
HR<60 HR60
120
secs
HR<60 HR60

RETURNOFSPONTANEOUSCIRCULATION(ROSC)MEDICALDIRECTIVE
authorized.
INDICATIONS
Patientwithreturnofspontaneouscirculation(ROSC)aftertheresuscitationwasinitiated.
CONDITIONS

AGE: males18years
females50years
LOA: Altered
HR: N/A
RR: N/A
SBP: 90mmHg
(spontaneous,
followingbolus
administeredor
withdopamine)
Other: N/A
Dopamine
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: N/A

0.9%NaClfluidbolus
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Chest
auscultationis
clear


CONTRAINDICATIONS

TREATMENT

Consideroptimizingventilationandoxygenation:
Titrateoxygenation94%
AvoidhyperventilationandtargetanETCO
2
of3540mmHgwithcontinuouswaveformcapnography(if
available)
Considerrapidtransport
Therapeutic
hypothermia
Traumaticcardiacarrest
(blunt,penetratingor
burn)
Sepsisorserious
infectionsuspectedas
causeofarrest
Hypothermicarrest
Knowncoagulopathy
(medicalhistoryor
medications)
Dopamine
dopamine
Tachydysrhythmias
excludingsinus
tachycardia
Mechanicalshockstates
Hypovolemia
Pheochromocytoma
SBP90mmHg
0.9%NaClfluidbolus
Fluidoverload
SBP90mmHg

Theapplicationoftherapeutichypothermiashouldnotdetractfromrapidtransport,optimizingventilationand
oxygenationorthemanagementofarearrest.
Consider12leadacquisition(ifavailable)
ConsiderTherapeutichypothermia(ifavailable)
Considerdopamine:
Route
IV
InitialInfusionRate 5mcg/kg/min
Titrationincrement 5mcg/kg/min
Titrationinterval 5min.
Maxinfusionrate 20mcg/kg/min
Age Age
<12years 12years
Route Route
IV IV
Max.volume 1,000ml 1,000ml

CARDIACISCHEMIAMEDICALDIRECTIVE
authorized.
INDICATIONS
Suspectedcardiacischemia
CONDITIONS

ASA
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: Abletochewand
swallow
Morphine
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: Normotension
Other: N/A
Nitroglycerin
AGE: 18years
LOA: Unaltered
HR: 60159bpm
RR: N/A
SBP: Normotension
Other: Priorhistoryof
nitroglycerinuse
orIVaccess
obtained

CONTRAINDICATIONS

TREATMENT
ConsiderASA:
Route
PO
Dose 160162mg
Dosinginterval N/A
Max.#ofdoses 1
ASA
ASAorNSAIDS
Ifasthmatic,noprioruse
ofASA
Currentactivebleeding
CVAorTBIintheprevious
24hours
Morphine
morphine
Injurytotheheadorchest
orabdomenORpelvis
aftermorphineis
administered
Nitroglycerin
nitrates
Phosphodiesterase
previous48hours
administered
12leadECGcompatible
withRightVentricular
infarct

N/A
Considermorphine(afterthethirddoseofnitroglycerinorifnitroglyceriniscontraindicated):
Route
IV
Dose 2mg
Max.singledose 2mg
Max.#ofdoses 5

SBP

100mmHg
Route
SL
Dose 0.3or0.4mg
Max.#ofdoses 6

ACUTECARDIOGENICPULMONARYEDEMAMEDICALDIRECTIVE
authorized.
INDICATIONS
Moderatetosevererespiratorydistress
AND
Suspectedacutecardiogenicpulmonaryedema
CONDITIONS
Nitroglycerin
AGE: 18years
LOA: N/A
HR: 60159bpm
RR: N/A
SBP: Normotension
Other: Ascertainprior
historyof
nitroglycerinuse
ORestablishIV
access

CONTRAINDICATIONS
TREATMENT
N/A
SBP SBP

100mmHgto
<140mmHg
140mmHg
IVorHx IVorHx IVorHx
Yes No Yes
Route Route Route
SL SL SL
Dose 0.3or0.4mg 0.3or0.4mg 0.6or0.8mg
Max.singledose 0.4mg 0.4mg 0.8mg
Max.#ofdoses 6 6 6

NOTE:Hxreferstoapatientwithapriorhistoryofnitroglycerinuse.
Nitroglycerin
nitrates
Phosphodiesterase
previous48hours
administered

CARDIOGENICSHOCKMEDICALDIRECTIVE
authorized.
INDICATIONS
STEMIpositiveECG
AND
Cardiogenicshock
CONDITIONS

CONTRAINDICATIONS

Dopamine
dopamine
Tachydysrhythmias
excludingsinus
tachycardia
Mechanicalshockstates
Pheochromocytoma
0.9%NaCl
N/A

Dopamine
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: N/A
0.9%NaCl
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: Clearcheston
auscultation

TREATMENT
ContactBHPifpatientisbradycardicwithrespecttoage.
Considerdopamine:
Route
IV
Initialinfusionrate 5mcg/kg/min.
Titrationincrement 5mcg/kg/min.
Max.infusionrate 20mcg/kg/min.
NOTE:TitratedopaminetoachieveasystolicBPof90110mmHg.Ifdiscontinuing
dopamineelectively,dosograduallyover510minutes.
Age Age
<18years 18years
Route Route
Route Route
IV IO
IV IO
Infusion 10ml/kg 10ml/kg 10ml/kg 10ml/kg
Infusioninterval N/A N/A N/A N/A
Reassessevery 100ml 100ml 250ml 250ml
Max.volume 10ml/kg 10ml/kg 10ml/kg 10ml/kg
NOTE:IfNaClboluscontraindicatedduetopulmonarycrackles,considerdopamine.

SYMPTOMATICBRADYCARDIAMEDICALDIRECTIVE
authorized.
INDICATIONS
Bradycardia
AND
Hemodynamicinstability
CONDITIONS

CONTRAINDICATIONS

Dopamine
Allergyorhypersensitivity
todopamine
Hemodynamicstability
Pheochromocytoma
TranscutaneousPacing
Hypothermia
Atropine
atropine
Hypothermia
Historyofheart
transplant
Dopamine
AGE: 18years
LOA: N/A
HR: <50bpm
RR: N/A
SBP: Hypotension
Other: N/A
TranscutaneousPacing
AGE: 18years
LOA: N/A
HR: <50bpm
RR: N/A
SBP: Hypotension
Other: N/A
Atropine
AGE: 18years
LOA: N/A
HR: <50bpm
RR: N/A
SBP: Hypotension
Other: N/A

TREATMENT
Considerdopamine:
Route
IV
Initialinfusionrate 5mcg/kg/min.
Titrationincrement 5mcg/kg/min.
Max.infusionrate 20mcg/kg/min.
NOTE:TitratedopaminetoachieveasystolicBPof90110mmHg.Ifdiscontinuing
dopamineelectively,dosograduallyover510minutes.
Consider12leadECGacquisition(ifavailableandwontdelaytherapy)
ConsiderRhythmdetermination
Considertranscutaneouspacing
PatchtoBHPforauthorizationtoproceedwithtranscutaneouspacingand/oradopamineinfusion.
Consideratropine:
Route
IV
Dose 0.5mg
Max.#ofdoses 2

Atropinemaybebeneficialinthesettingofsinusbradycardia,atrialfibrillation,firstdegreeAVblock,or
seconddegreeTypeIAVblock.
AsingledoseofatropineshouldbeconsideredforseconddegreeTypeIIorthirddegreeAVblockswithfluid
boluswhilepreparingforTCPORifthereisadelayinimplementingTCPORifTCPisunsuccessful.
Thedopamineinfusionshouldbeinitiatedat5mcg/kg/min.andtitratedupwardtoeffectinincrementsof
5mcg/kg/minevery5minutesuptoamaximumof20mcg/kg/min.
ThedesiredeffectisaSBPof90110mmHg.

TACHYDYSRHYTHMIAMEDICALDIRECTIVE
authorized.
INDICATIONS
SymptomaticTachydysrhythmia
CONDITIONS

Amiodarone
AGE: 18years
LOA: Unaltered
HR: 120
RR: N/A
SBP: Normotension
Other: Widecomplexand
regularrhythm
Synchronized
Cardioversion
AGE: 18years
LOA: N/A
HR: 120(wide)or
150(narrow)
RR: N/A
SBP: Hypotension
Other: Alteredmental
status,ongoing
chestpain,other
signsofshock
Lidocaine
AGE: 18years
LOA: Unaltered
HR: 120
RR: N/A
SBP: Normotension
Other: Widecomplex
andregular
rhythm
Adenosine
AGE: 18years
LOA: Unaltered
HR: 150
RR: N/A
SBP: Normotension
Other: Narrowcomplex
andregular
rhythm
ValsalvaManeuver
AGE: 18years
LOA: Unaltered
HR: 150
RR: N/A
SBP: Normotension
Other: Narrowcomplex
andregular
rhythm

CONTRAINDICATIONS

TREATMENT
Consider12leadECGacquisition:ToconfirmQRSwidth(ifavailableandwontdelaytherapy)
Considervalsalvamaneuver:
Performamaximumoftwoattemptslasting10to20secondsdurationeach.
Amiodarone
amiodarone
ConsiderRhythmdetermination:Confirmregularity
Synchronized
Cardioversion
N/A
Lidocaine
lidocaine

Adenosine
adenosine
Sinustachycardiaoratrial
fibrillationoratrialflutter
Patienttaking
dipyridamoleor
carbamazepine
Bronchoconstrictionon
exam
ValsalvaManeuver
Sinustachycardiaoratrial
fibrillationoratrialflutter

PatchtoBHPforauthorizationtoproceedwithsynchronizedcardioversion
Consideramiodarone(ifavailable)ORlidocaine:
Drug Drug
Amiodarone Lidocaine
Route Route
IV* IV
FirstDose 150mg 1.5mg/kg
Subsequent
Dose(s)
150mg 0.75mg/kg
Max.singledose 150mg 150mg
Max.#ofdoses 2 3

*AmiodaroneshouldbeadministeredbyIVinfusionover10min.
PatchtoBHPforauthorizationtoproceedwithamiodaroneorlidocaineorifmonomorphicwidecomplex
regularrhythmforadenosine.
Consideradenosine:
Route
IV
InitialDose 6mg
Seconddose 12mg
Max.#ofdoses 2doses

N/A

Considersynchronizedcardioversion:
AdministeruptothreesynchronizedshocksinaccordancewithBHPdirectionandenergy
settings.(Inthesettingofapatchfailure,theenergysettingstobeusedare100J,200Jandthe
maximummanufacturersetting.)

INTRAVENOUSANDFLUIDTHERAPYMEDICALDIRECTIVE
authorized.
INDICATIONS
ActualorpotentialneedforintravenousmedicationORfluidtherapy
CONDITIONS

CONTRAINDICATION

FluidBolus
Signsoffluidoverload
IV
Suspectedfracture
proximaltotheaccesssite.

FluidBolus
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: N/A
IV
AGE: N/A
2yearsforPCP
AssistIV
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
PatchtoBHPforauthorizationtoadministerIVNaClbolustopatients<12yearswithsuspectedDiabetic
Ketoacidosis(DKA)
ConsiderIVcannulation
Age Age
<12years 12years
Route Route
IV/IO IV/IO/CVAD
Max.volume*
20ml/kgupto
2,000ml
2,000ml
*ThemaximalvolumeofNaClislowerforpatientsincardiogenicshock.
Consider0.9%NaClmaintenanceinfusion:
Age Age
<12years 12years
Route Route
IV/IO IV/IO/CVAD
Infusion 15ml/hr 3060ml/hr
Reassessevery N/A N/A
Max.volume N/A N/A

anACP.TheACPwillperformallIVfurthertherapyinaccordancewiththeIntravenousAccessandFluid
AdministrationMedicalDirectiveonceintravenousaccessisobtained.PCPscertifiedinPCPAssistIVarenot
authorizedtoadministerIVfluidormedicationtherapy.
AdultIOandCVADproceduresareauxiliarymedicaldirectivesdescribedelsewhere.Fluidadministrationviathe
IOorCVADroutesonlyapplytoparamedicscertifiedandauthorizedtoperformtheseprocedures.
MicrodripsandorvolumecontroladministrationsetsshouldbeconsideredwhenIVaccessisindicatedfor
patientslessthan12yearsofage.

PEDIATRICINTRAOSSEOUSMEDICALDIRECTIVE
authorized.
INDICATIONS
AND
Intravenousaccessisunobtainable
AND
Cardiacarrestorneararreststate
CONDITIONS

CONTRAINDICATION
IO
Fractureorcrushinjuries
orsuspectedorknown
replacement/prosthesis
proximaltotheaccess
site.
IO
AGE: <12years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
N/A
ConsiderIOaccess

HYPOGLYCEMIAMEDICALDIRECTIVE
authorized.
INDICATIONS
AgitationORalteredLOAORseizureORsymptomsofstroke
CONDITIONS

CONTRAINDICATIONS

TREATMENT
Performglucometry
Glucagon
glucagon
Pheochromocytoma
Dextrose
dextrose
Glucagon
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia
Dextrose
AGE: N/A
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: Hypoglycemia

Considerdextroseorglucagon:
Drug
Dextrose
Age Age Age
<30days
30daysto
<2years
2years
N/A N/A N/A
D10W D25W D50W
Route Route Route
IV IV IV
Dose
0.2g/kg
(2ml/kg)
0.5g/kg
(2ml/kg)
0.5g/kg
(1ml/kg)
Max.singledose 5g(50ml) 10g(40ml) 25g(50ml)
Max.#ofdoses 2 2 2

Drug
Glucagon
Age
N/A
Weight Weight
<25kg 25kg
Concentration Concentration
N/A N/A
Route Route
IM IM
Dose 0.5mg 1.0mg
Max.singledose 0.5mg 1.0mg
Max.#ofdoses 2 2

Ifthepatientrespondstodextroseorglucagon,he/shemayreceiveoralglucoseorothersimplecarbohydrates.
Ifonlymildsignsorsymptomsareexhibited,thepatientmayreceiveoralglucoseorothersimplecarbohydrates
insteadofdextroseorglucagon.
Ifapatientinitiatesaninformedrefusaloftransport,afinalsetofvitalsignsincludingbloodglucometrymustbe
attempted.


SEIZUREMEDICALDIRECTIVE
authorized.
INDICATIONS
Activegeneralizedmotorseizure
CONDITIONS
CONTRAINDICATIONS
Midazolam
midazolam
Hypoglycemia
Midazolam
AGE: N/A
LOA: Unresponsive
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be considered by a
paramedic.
Considermidazolam:
IV IM IN Buccal
Dose 0.1mg/kg 0.2mg/kg 0.2mg/kg 0.2mg/kg
Max.singledose 5.0mg 10mg 10mg 10mg


OPIOIDTOXICITYMEDICALDIRECTIVE
authorized.
INDICATIONS
AlteredLOC
AND
Respiratorydepression
AND
Suspectedopioidoverdose
CONDITIONS
CONTRAINDICATIONS
Naloxone
naloxone
Uncorrectedhypoglycemia
Naloxone
AGE: 18years
LOA: Altered
HR: N/A
RR: <10
SBP: N/A
Other: N/A

TREATMENT
N/A

PatchtoBHPforauthorizationtoproceedwithnaloxone
Considernaloxone:
SC IM IN IV*
Dose 0.8mg 0.8mg 0.8mg Upto0.4mg
Max.singledose 0.8mg 0.8mg 0.8mg 0.4mg

*FortheIVroute,titratenaloxoneonlytorestorethepatientsrespiratorystatus.

ENDOTRACHEALINTUBATIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Needforventilatoryassistanceorairwaycontrol
AND
Otherairwaymanagementisinadequateorineffective
CONDITIONS

LidocaineSpray
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Orotracheal
/nasotracheal
Intubation
NasotrachealIntubation
AGE: 8years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: spontaneous
breathing
OrotrachealIntubation
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

Xylometazoline
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: nasotracheal
intubation


CONTRAINDICATIONS

TREATMENT
Lidocaine
lidocaine
Unresponsivepatient

Considerxylometazoline0.1%spray:fornasotrachealintubation
Route
TOPICAL
Dose 2sprays/nare
Max.singledose 2sprays/nare
Dosinginterval N/A
Max.#ofdoses 1
NasotrachealIntubation
Age<50yearsAND
currentepisodeofasthma
exacerbationANDnotin
ornearcardiacarrest.
Suspectedbasalskull
fractureormidface
fracture
Uncontrolledepistaxis
Anticoagulanttherapy
(excludingASA)
Bleedingdisorders
OrotrachealIntubation
Age<50yearsANDcurrent
episodeofasthma
exacerbationANDnotinor
nearcardiacarrest.
Xylometazoline
xylometazoline

Anintubationattemptisdefinedasinsertionofthelaryngoscopebladeintothemouth.
The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation
attemptsistwo(2).
AtleasttwoprimaryandonesecondaryETTplacementconfirmationmethodsmustbeused.
If the patient has a pulse, an ETCO
2
device (quantitative or qualitative) must be used for ETT placement
confirmation.
AdditionalsecondaryETTplacementconfirmationdevicesmaybeauthorizedbythelocalmedicaldirector.
ETTplacementmustbereconfirmedimmediatelyaftereverypatientmovement.
ConfirmETTplacement:
Method Method
Primary Secondary
Visualization ETCO
2
Auscultation EDD
Chestrise Other
Considerintubation:withorwithoutintubationfacilitationdevices.Themaximumnumberofintubation
attemptsis2.
Considertopicallidocainesprayforawakeorotrachealornasotrachealintubation(tonaresand/or
hypopharynx):
Route
TOPICAL
Dose 10mg/spray
Max.dose 5mg/kg
Dosinginterval N/A
Max.#ofdoses 20sprays

BRONCHOCONSTRICTIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Respiratorydistress
AND
Suspectedbronchoconstriction
CONDITIONS

CONTRAINDICATIONS

epinephrine
AGE: N/A
WEIGHT:10kg
LOA: N/A
HR: N/A
RR: BVMventilation
required
SBP: N/A
Other: Hxofasthma
Epinephrine
epinephrine
Salbutamol
salbutamol
Epinephrine
AGE: N/A
WEIGHT:N/A
LOA: N/A
HR: N/A
RR: BVMventilation
required
SBP: N/A
Other: Hxofasthma
Salbutamol
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
Epinephrineshouldbethefirstdrugadministeredifthepatientisapneic.SalbutamolMDImaybeadministered
subsequentlyusingaBVMMDIadapter(ifavailable).
Weight Weight
Weight
Any 10kgto<25kg
25kg
Route Route Route
IM
Pediatric
Autoinjector
Adult
Autoinjector
Concentration Concentration
Concentration
1:1,000 1:1,000
1:1,000
Dose 0.01mg/kg**
1injection
(0.15mg)
1injection
(0.3mg)
1injection
N/A
Max.#ofdoses 1 1
1
**Theepinephrinedosemayberoundedtothenearest0.05mg.
Considersalbutamol:
Weight Weight
<25kg 25kg

MDI
(ifavailable)*
NEB
MDI
(ifavailable)*
NEB
Dose
Upto600mcg
(6puffs)
2.5mg
Upto800mcg
(8puffs)
5mg
Max.singledose 600mcg 2.5mg 800mcg 5mg
Dosinginterval 515min.PRN 515min.PRN 515min.PRN 515min.PRN
*1puff=100mcg

Nebulizationiscontraindicatedinpatientswithaknownorsuspectedfeverorinthesettingofadeclaredfebrile
respiratoryillnessoutbreakbythelocalmedicalofficerofhealth.
WhenadministeringsalbutamolMDI,therateofadministrationshouldbe100mcgapproximatelyevery4
breaths.
AspacershouldbeusedwhenadministeringsalbutamolMDI(ifavailable).

PatchtoBHPforauthorizationtousepediatricautoinjectorforpatients<10kg.

MODERATETOSEVEREALLERGICREACTIONMEDICALDIRECTIVE
authorized.
INDICATIONS
Exposuretoaprobableallergen
AND
Signsand/orsymptomsofamoderatetosevereallergicreaction(includinganaphylaxis)
CONDITIONS

CONTRAINDICATIONS

epinephrine
AGE: N/A
WEIGHT:10kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
only
Diphenhydramine
diphenhydramine
Epinephrine
epinephrine
Diphenhydramine
AGE: N/A
WEIGHT:25kg
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

Epinephrine
AGE: N/A
WEIGHT:N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
only

TREATMENT
Epinephrineshouldbethefirstdrugadministeredinanaphylaxis.
PatchtoBHPforauthorizationtousepediatricautoinjectorforpatients<10kg
Considerdiphenhydramine(ifavailable):
Weight Weight
25kgto<50kg 50kg
IV IM IV IM
Route Route Route
IM
Pediatric
Autoinjector
Adult
Autoinjector
1:1,000 1:1,000
1:1,000
Dose 0.01mg/kg*
1injection
(0.15mg)
1injection
(0.3mg)
1injection
N/A
Max.#ofdoses 1 1
1

CROUPMEDICALDIRECTIVE
authorized.
INDICATIONS
AND
Stridoratrest
AND
CurrenthistoryofURTI
AND
BarkingcoughORrecenthistoryofabarkingcough
CONDITIONS
CONTRAINDICATIONS
Epinephrine
epinephrine
Epinephrine
AGE: <8years
LOA: N/A
HR: <200bpm
RR: N/A
SBP: N/A
Other: N/A

TREATMENT
Theminimuminitialvolumefornebulizationis2.5ml.

Age Age
<1year
1yearto
<8years
<5kg 5kg N/A
Route Route Route
NEB NEB NEB
1:1,000 1:1,000 1:1,000
Dose 0.5mg 2.5mg 5mg
Max.singledose 0.5mg 2.5mg 5mg
Max.#ofdoses 1 1 1

TENSIONPNEUMOTHORAXMEDICALDIRECTIVE
authorized.
INDICATIONS
Suspectedtensionpneumothorax
AND
CriticallyillORVSA
AND
Absentorseverelydiminishedbreathsoundsontheaffectedside(s)
CONDITIONS
CONTRAINDICATIONS
NeedleThoracostomy
N/A
NeedleThoracostomy
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotensionor
VSA
Other: N/A

TREATMENT
Needlethoracostomymayonlybeperformedatthesecondintercostalspaceinthemidclavicularline.
Considerneedlethoracostomy
PatchtoBHPforauthorizationtoperformneedlethoracostomy

PAINMEDICALDIRECTIVE
authorized.
INDICATIONS
Severepain
AND
IsolatedhiporextremityfracturesordislocationsORmajorburnsORcurrenthistoryofcancerrelatedpainOR
renal colic with prior history OR patients with acute musculoskeletal back strain OR ongoing transcutaneous
pacing
CONDITIONS

Morphine
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: Normotension
Other: N/A
Fentanyl
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: Normotension
Other: N/A

CONTRAINDICATIONS

TREATMENT
N/A
ConsiderfentanylORmorphine:
Drug Drug
Fentanyl Morphine
Route Route
IV IV
Dose 2550mcg 25mg
Max.singledose 50mcg 5mg
Max.#ofdoses 4 4
Morphine
morphine
Injurytotheheadorchest
orabdomenorpelvis
Fentanyl
fentanyl
Injurytotheheador
chestorabdomenor
pelvis
Appendix 3

Primary Care Paramedic
Auxiliary Medical Directives

November 2011

PCPAuxiliaryMedicalDirectivesAppendix3
i
TABLEOFCONTENTS
IntravenousandFluidTherapyMedicalDirectiveAUXILIARY..............................................................................31
ContinuousPositiveAirwayPressure(CPAP)MedicalDirectiveAUXILIARY ........................................................34
SupraglotticAirwayMedicalDirectiveAUXILIARY................................................................................................37
Nausea/VomitingMedicalDirectiveAUXILIARY .................................................................................................39
ElectronicControlDeviceProbeRemovalMedicalDirectiveAUXILIARY...........................................................311
MinorAbrasionsMedicalDirectiveAUXILIARY ..................................................................................................313
MinorAllergicReactionMedicalDirectiveAUXILIARY .......................................................................................315
MusculoskeletalPainMedicalDirectiveAUXILIARY ...........................................................................................317
HeadacheMedicalDirectiveAUXILIARY.............................................................................................................319

31
INTRAVENOUSANDFLUIDTHERAPYMEDICALDIRECTIVEAUXILIARY
APrimaryCareParamedicmayprovidethetreatmentprescribedinthisauxiliarymedicaldirective
ifcertifiedandauthorizedaccordingtothePCPAutonomousIVlevel.
INDICATIONS
CONDITIONS

CONTRAINDICATION

TREATMENT
ConsiderIVcannulation
FluidBolus
Signsoffluidoverload
IV
Suspectedfracture
proximaltotheaccesssite.
FluidBolus
AGE: 2years
LOA: N/A
HR: N/A
RR: N/A
SBP: Hypotension
Other: N/A
IV
AGE: 2years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

32
PatchtoBHPforauthorizationtoadministerIVNaClbolustoapatient2yearsto<12yearswithsuspected
DiabeticKetoacidosis(DKA)
Age Age

2yearsto
<12years
12years
Route Route
IV IV
Max.volume*
20ml/kgupto
2,000ml
2,000ml

*ThemaximumvolumeofNaClislowerforpatientsincardiogenicshock
Consider0.9%NaClmaintenanceinfusion:
Age Age

2yearsto
<12years
12years
Route Route
IV IV
Infusion 15ml/hr 3060ml/hr
Reassessevery N/A N/A
Max.volume N/A N/A

33
anACP.ThepatientmustrequireaperipheralIVinaccordancewiththeindicationslistedinthisMedical
Directive.PCPscertifiedinPCPAssistIVarenotauthorizedtoadministerIVfluidormedicationtherapy.
MicrodripsandorvolumecontroladministrationsetsshouldbeconsideredwhenIVaccessisindicatedfor
patientslessthan12yearsofage.

34
CONTINUOUSPOSITIVEAIRWAYPRESSURE(CPAP)MEDICALDIRECTIVEAUXILIARY
ifcertifiedandauthorized.
INDICATIONS
AND
Signsand/orsymptomsofacutepulmonaryedemaORCOPD
CONDITIONS
CPAP
AGE: 18years
LOA: N/A
HR: N/A
RR: Tachypnea
SBP: Normotension
Other: SpO
2
<90%or
accessorymuscle
use

35
CONTRAINDICATIONS
TREATMENT
ConsiderCPAP:
Initialsetting 5cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
Titrationincrement 2.5cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
Max.setting 15cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
CPAP
Asthmaexacerbation
Suspectedpneumothorax
Unprotectedorunstable
airway
Majortraumaorburnsto
theheadortorso
Tracheostomy
Inabilitytositupright
Unabletocooperate
Hypotension

36

N/A
ConfirmCPAPpressurebymanometer(ifavailable)
ConsiderincreasingFiO
2
(ifavailable):

InitialFiO
2
50100%
FiO
2
increment
(ifavailableondevice)
SpO
2
<92%despitetreatmentand/or
10cmH
2
Opressureorequivalentflowrateof
deviceasperBHdirection
MaxFiO
2
100%


37
SUPRAGLOTTICAIRWAYMEDICALDIRECTIVEAUXILIARY
INDICATIONS
NeedforventilatoryassistanceORairwaycontrol
AND
Otherairwaymanagementisinadequateorineffective
CONDITIONS
CONTRAINDICATIONS
SupraglotticAirway
Activevomiting
Inabilitytoclearthe
airway
Airwayedema
Stridor
Causticingestion
SupraglotticAirway
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: patientmustbein
cardiacarrest

38
TREATMENT
Anattemptatsupraglotticairwayinsertionisdefinedastheinsertionofthesupraglotticairwayintothemouth.

Confirmsupraglotticairwayplacement:
Method Method
Primary Secondary
Auscultation ETCO
2
Chestrise Other
Considersupraglotticairwayinsertion.Themaximumnumberofattemptsis2.

39
NAUSEA/VOMITINGMEDICALDIRECTIVEAUXILIARY
INDICATIONS
NauseaORvomiting
CONDITIONS

CONTRAINDICATIONS

Dimenhydrinate
dimenhydrinateorother
antihistamines
Overdoseon
antihistaminesor
anticholinergicsor
tricyclicantidepressants
Dimenhydrinate
AGE: N/A
WEIGHT:25kg
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A

310
TREATMENT

IVadministrationofdimenhydrinateappliesonlytoPCPscertifiedtothelevelofPCPAutonomousIV.
PriortoIVadministration,dilutedimenhydrinate(concentrationof50mg/1ml)1:9withNormalSalineorsterile
water.IfgivenIMdonotdilute.
Considerdimenhydrinate:
Weight Weight
25kgto<50kg 50kg
IV IM IV IM


311
ELECTRONICCONTROLDEVICEPROBEREMOVALMEDICALDIRECTIVEAUXILIARY
INDICATIONS
ElectronicControlDeviceprobe(s)embeddedinpatient.
CONDITIONS
CONTRAINDICATIONS
TREATMENT
Proberemoval
Probeembeddedabove
theclavicles,inthe
nipple(s),orinthegenital
area.
Considerproberemoval
ProbeRemoval
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

312
Policemayrequirepreservationoftheprobe(s)forevidentiarypurposes.
ThisdirectiveisforremovalofECDonlyandinnowayconstitutestreatandrelease,normalprinciplesofpatient
assessmentandcareapply.

313
MINORABRASIONSMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Minorabrasions
AND
Specialevent:apreplannedgatheringwithpotentiallylargenumbersandtheSpecialEventMedicalDirectives
havebeenpreauthorizedforusebytheMedicalDirector
CONDITIONS
CONTRAINDICATIONS
TopicalAntibiotic
Allergyorsensitivitytoany
ofthecomponentsofthe
topicalantibiotic
TopicalAntibiotic
AGE: N/A
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

314
TREATMENT
Advisepatientthatiftheproblempersistsorworsensthattheyshouldseekfurthermedicalattention.
Considerreleasefromcare
Considertopicalantibiotic

315
MINORALLERGICREACTIONMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Signsconsistentwithminorallergicreaction
AND
CONDITIONS
Diphenhydramine
AGE: 18years
LOA: Unaltered
HR: WNL
RR: WNL
SBP: Normotension
Other: N/A

316
CONTRAINDICATIONS
TREATMENT
Considerdiphenhydramine:
Route
PO
Dose 50mg
Max.singledose 50mg
Dosinginterval N/A
Max.#ofdoses 1
Diphenhydramine
diphenhydramine
Antihistamineorsedative
useinprevious4hours
Signsorsymptomsof
moderatetosevere
allergicreaction
Signsorsymptomsof
intoxication
Wheezing

317
MUSCULOSKELETALPAINMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Minormusculoskeletalpain
AND
Specialevent: a preplannedgatheringwithpotentiallylargenumbersandtheSpecialEventMedicalDirectives
CONDITIONS
CONTRAINDICATIONS
Acetaminophen
Noacetaminopheninthe
last4hours
acetaminophen
Signsorsymptomsof
intoxication
Acetaminophen
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

318
TREATMENT

Consideracetaminophen:
Route
PO
Dose 325650mg
Dosinginterval N/A
Max.#ofdoses 1

319
HEADACHEMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Uncomplicatedheadacheconformingtothepatientsusualpattern
AND
CONDITIONS
CONTRAINDICATIONS
Acetaminophen
Noacetaminophenin
past4hours
acetaminophen
Signsorsymptomsof
intoxication
Acetaminophen
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A

320
TREATMENT
Route
PO
Dose 325650mg
Dosinginterval N/A
Max.#ofdoses 1

Appendix 4

Advanced Care Paramedic
Auxiliary Medical Directives

November 2011

ACPAuxiliaryMedicalDirectivesAppendix4

i
TABLEOFCONTENTS
AdultIntraosseousMedicalDirectiveAUXILIARY.................................................................................................41
CentralVenousAccessDeviceAccessMedicalDirectiveAUXILIARY ...................................................................43
ContinuousPositiveAirwayPressure(CPAP)MedicalDirectiveAUXILIARY ........................................................45
SupraglotticAirwayMedicalDirectiveAUXILIARY................................................................................................48
CricothyrotomyMedicalDirectiveAUXILIARY....................................................................................................410
Nausea/VomitingMedicalDirectiveAUXILIARY ...............................................................................................412
CombativePatientMedicalDirectiveAUXILIARY ...............................................................................................414
ProceduralSedationMedicalDirectiveAUXILIARY ............................................................................................416
ElectronicControlDeviceProbeRemovalMedicalDirectiveAUXILIARY...........................................................418
MinorAbrasionsMedicalDirectiveAUXILIARY ..................................................................................................420
MinorAllergicReactionMedicalDirectiveAUXILIARY .......................................................................................422
MusculoskeletalPainMedicalDirectiveAUXILIARY ...........................................................................................424
HeadacheMedicalDirectiveAUXILIARY.............................................................................................................426


41
ADULTINTRAOSSEOUSMEDICALDIRECTIVEAUXILIARY
AnAdvancedCareParamedicmayprovidethetreatmentprescribedinthisauxiliarymedicaldirective
INDICATIONS
AND
IVaccessisunobtainable
AND
CardiacarrestORneararreststate
CONDITIONS
CONTRAINDICATION
IO
Fractureorcrushinjuries
orsuspectedorknown
replacement/prosthesis
proximaltotheaccess
site.
IO
AGE: 12years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


42
TREATMENT
N/A
ConsiderIOaccess


43
CENTRALVENOUSACCESSDEVICEACCESSMEDICALDIRECTIVEAUXILIARY
INDICATIONS
AND
IVaccessisunobtainable
AND
CardiacarrestORneararreststate
CONDITIONS
CONTRAINDICATIONS
CVADAccess
N/A
CVADAccess
AGE: N/A
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Patienthasa
preexisting,
accessiblecentral
venouscatheter
inplace


44
TREATMENT
N/A

ConsiderCVADaccess


45
CONTINUOUSPOSITIVEAIRWAYPRESSURE(CPAP)MEDICALDIRECTIVEAUXILIARY
INDICATIONS
AND
Signsand/orsymptomsofacutepulmonaryedemaORCOPD
CONDITIONS
CPAP
AGE: 18years
LOA: N/A
HR: N/A
RR: Tachypnea
SBP: Normotension
Other: SpO
2
<90%or
accessorymuscle
use


46
CONTRAINDICATIONS
TREATMENT
ConsiderCPAP:
Initialsetting 5cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
Titrationincrement 2.5cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
Max.setting 15cmH
2
O
Orequivalentflow
rateofdeviceas
perBHdirection
CPAP
Asthmaexacerbation
Suspectedpneumothorax
Unprotectedorunstable
airway
Majortraumaorburnsto
theheadortorso
Tracheostomy
Inabilitytositupright
Unabletocooperate


47
N/A
ConfirmCPAPpressurebymanometer(ifavailable)
ConsiderincreasingFiO
2
(ifavailable):

InitialFiO
2
50100%
FiO
2
increment(ifavailableon
device)
SpO
2
<92%despitetreatmentand/or
10cmH
2
Opressureorequivalentflowrateof
deviceasperBHdirection
MaxFiO
2
100%


48
SUPRAGLOTTICAIRWAYMEDICALDIRECTIVEAUXILIARY
INDICATIONS
NeedforventilatoryassistanceORairwaycontrol
AND
OtherairwaymanagementisinadequateORineffectiveORunsuccessful
CONDITIONS
CONTRAINDICATIONS
SupraglotticAirway
Activevomiting
Inabilitytoclearthe
airway
Airwayedema
Stridor
Causticingestion
SupraglotticAirway
AGE: N/A
LOA: GCS=3
HR: N/A
RR: N/A
SBP: N/A
Other: Absentgagreflex


49
TREATMENT
Anattemptatsupraglotticairwayinsertionisdefinedastheinsertionofthesupraglotticairwayintothemouth.
The maximum number of supraglottic airway attempts is two (2) and the maximum number of intubation
attemptsistwo(2).

Confirmsupraglotticairwayplacement:
Method Method
Primary Secondary
Auscultation ETCO
2
Chestrise Other
Considersupraglotticairwayinsertion.Themaximumnumberofattemptsis2.


410
CRICOTHYROTOMYMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Needforadvancedairwaymanagement
AND
IntubationANDsupraglotticairway(ifavailable)insertionunsuccessfulorcontraindicated
AND
Unabletoventilate
CONDITIONS
CONTRAINDICATIONS
Cricothyrotomy
Suspectedfracturedlarynx
Inabilitytolandmark
Cricothyrotomy
AGE: 12years
LOA: Altered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


411
TREATMENT
AtleasttwoprimaryandonesecondaryCricothyrotomytubeplacementconfirmationmethodsmustbeused.
If the patient has a pulse, an ETCO
2
device must be used (quantitative or qualitative) for cricothyrotomy tube
placementconfirmation.
Additional secondary Cricothyrotomy tube placement confirmation devices may be authorized by the local
medicaldirector.
Cricothyrotomytubeplacementmustbereconfirmedimmediatelyaftereverypatientmovement.

Confirmcricothyrotomy:tubeplacement
Method Method
Primary Secondary
Auscultation ETCO
2
Chestrise Other
Considercricothyrotomy.
PatchtoBHPforauthorizationtoperformcricothyroidotomy


412
NAUSEA/VOMITINGMEDICALDIRECTIVEAUXILIARY
INDICATIONS
NauseaORvomiting
CONDITIONS

CONTRAINDICATIONS

Dimenhydrinate
dimenhydrinateorother
antihistamines
Overdoseon
antihistaminesor
anticholinergicsorTCAs
Dimenhydrinate
AGE: N/A
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


413
TREATMENT

PriortoIVadministration,dilutedimenhydrinate(concentrationof50mg/1ml)1:9withNormalSalineorsterile
water.IfgivenIMdonotdilute.

Considerdimenhydrinate:
<25kg 25kgto<50kg 50kg
Route Route Route Route Route Route
IV IM IV IM IV IM
Dose Patch Patch 25mg 25mg 50mg 50mg
Max.singledose N/A N/A 25mg 25mg 50mg 50mg
Dosinginterval N/A N/A N/A N/A N/A N/A
Max.#ofdoses N/A N/A 1 1 1 1



414
COMBATIVEPATIENTMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Combativepatient
CONDITIONS
CONTRAINDICATIONS
Midazolam
midazolam
Midazolam
AGE: 18years
LOA: N/A
HR: N/A
RR: N/A
SBP: Normotension
Other: Noreversible
causes(i.e.
hypoglycemia,
hypoxia,
hypotension)


415
TREATMENT
N/A

PatchtoBHPforauthorizationtoproceedwithmidazolamifunabletoassessthepatientfornormotension
orreversiblecauses.
Considermidazolam:
Route Route
IV IM
Dose 2.55mg 2.55mg
Max.singledose 5mg 5mg
Max.totaldose 10mg 10mg
Max.#doses 2 2


416
PROCEDURALSEDATIONMEDICALDIRECTIVEAUXILIARY
INDICATIONS
PostintubationORtranscutaneouspacing
CONDITIONS
*Nonintubatedpatientsonly
CONTRAINDICATIONS
Midazolam
midazolam
Midazolam
AGE: 18years
LOA: N/A
HR: N/A
RR: 8bpm*
SBP: Normotension
Other: N/A


417
TREATMENT
N/A
Considermidazolam:
Route
IV
Dose 2.55mg
Max.singledose 5mg
Max.totaldose 10mg
Max.#doses 2


418
ELECTRONICCONTROLDEVICEPROBEREMOVALMEDICALDIRECTIVEAUXILIARY
INDICATIONS
ElectronicControlDeviceprobe(s)embeddedinpatient.
CONDITIONS
CONTRAINDICATIONS
TREATMENT
Considerproberemoval
Proberemoval
Probeembeddedabove
theclavicles,inthe
nipple(s),orinthegenital
area
ProbeRemoval
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


419
Policemayrequirepreservationoftheprobe(s)forevidentiarypurposes.
ThisdirectiveisforremovalofECDonlyandinnowayconstitutestreatandrelease,normalprinciplesofpatient
assessmentandcareapply.


420
MINORABRASIONSMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Minorabrasions
AND
CONDITIONS
CONTRAINDICATIONS
TREATMENT
Considertopicalantibiotic
TopicalAntibiotic
topicalantibiotics
TopicalAntibiotic
AGE: N/A
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


421


422
MINORALLERGICREACTIONMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Signsconsistentwithminorallergicreaction
AND
CONDITIONS
Diphenhydramine
AGE: 18years
LOA: Unaltered
HR: WNL
RR: WNL
SBP: Normotension
Other: N/A


423
CONTRAINDICATIONS
TREATMENT

Considerdiphenhydramine:
Route
PO
Dose 50mg
Max.singledose 50mg
Dosinginterval N/A
Max.#ofdoses 1
Diphenhydramine
diphenhydramine
Antihistamineorsedative
useinprevious4hours
Signsorsymptomsof
moderatetosevere
allergicreaction
Signsorsymptomsof
intoxication
Wheezing


424
MUSCULOSKELETALPAINMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Minormusculoskeletalpain
AND
Specialevent: a preplannedgatheringwithpotentiallylargenumbersandtheSpecialEventMedicalDirectives
CONDITIONS
CONTRAINDICATIONS
Acetaminophen
Noacetaminopheninthe
last4hours
acetaminophen
Signsorsymptomsof
intoxication
Acetaminophen
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


425
TREATMENT

Route
PO
Dose 325650mg
Dosinginterval N/A
Max.#ofdoses 1


426
HEADACHEMEDICALDIRECTIVEAUXILIARY
INDICATIONS
Uncomplicatedheadacheconformingtothepatientsusualpattern
AND
CONDITIONS
CONTRAINDICATIONS
Acetaminophen
Noacetaminophenin
past4hours
acetaminophen
Signsorsymptomsof
intoxication
Acetaminophen
AGE: 18years
LOA: Unaltered
HR: N/A
RR: N/A
SBP: N/A
Other: N/A


427
TREATMENT
Route
PO
Dose 325650mg
Dosinginterval N/A
Max.#ofdoses 1
Appendix 5

Chemical Exposure
Medical Directives

November 2011

ChemicalExposureMedicalDirectivesAppendix5

i
TABLEOFCONTENTS
Introduction..51
HydrofluoricAcidExposureMedicalDirective....52
AdministrationofAtropine,eitherPralidoximeChloride(2PAM)orObidoximeandDiazepamfor
NerveAgentExposureMedicalDirective....54
PediatricAdministrationofAtropine,eitherPralidoximeChloride(2PAM)orObidoximeandDiazepam
forNerveAgentExposureMedicalDirective.56
AdministrationofAntidotesforCyanideExposureMedicalDirective.58
SymptomaticRiotAgentExposureMedicalDirective.59


51
CHEMICALEXPOSUREMEDICALDIRECTIVES

INTRODUCTION
ThefollowingMedicalDirectiveshavebeendevelopedforusewhenchemicalexposuretothelisted
agentissuspected.TheseMedicalDirectivesmayonlybeusedbyparamedicswhohavereceived
specialtrainingintreatingpatientswithchemicalexposures.Thisisusuallyacomprehensiveprogram
thatincludespersonalprotectionandtraininginCBRNE(Chemical,Biologic,Radiological,Nuclearand
Explosive)events.



52
HydrofluoricAcidExposureMedicalDirective
Whenthelistedindicationandconditionexist,aparamedicisauthorizedtoadministerCalcium
Gluconateand/ortopicalanaestheticeyedropsaccordingtothefollowingprotocol.Theparamedic
willcomplywithlocalBHPpatchingprotocols.
INDICATIONS:
Patientwasexposedtovapour,and/orliquidhydrofluoricacid.
CONDITIONS:
Patientisexhibitingsignsandsymptomsofhydrofluoricacidpoisoning.
CONTRAINDICATIONS:
Topicalanaestheticeyedrops(seeProcedure,point#6a)arecontraindicatedifthepatientisallergicto
anaesthetics.
PROCEDURE:
1. DonappropriatePPE.
2. Removepatientfromfurtherhydrofluoricacidexposure,removecontaminatedclothing,jewellery,
etc.
3. Decontaminateifnotalreadydecontaminated.
4. Assessvitalsigns;applycardiacmonitorandhighflowoxygen.
5. Inhalation:
a) Ensureairwaypatencyandbreathing.
b) FordyspneaseeSOB/RespiratoryDistressProtocol.
c) Ifairwaypain(suspectedinhalationinjury),considerdeliveringanebulizedCalciumGluconate
2.5%solution(1ml10%CalciumGluconateand3mlsterilenormalsaline)withhighflow
oxygen.


53
6. EyeContact:
Foreyediscomfort,irrigatethoroughlywithcopiousamountsofnormalsaline.
a) Removecontactlenses.
b) Administer2dropsoftopicalanaestheticeyedropsineacheye,repeatevery10minutesas
needed.
c) Monitorthepatientfor20minutesafterthelastdose.
7. SkinContact:
a) Irrigatethoroughlywithcopiousamountsofsalinefor1minuteifnotalreadydone.
b) MassageCalciumGluconate2.5%Gel(ifavailable)liberallyintotheburnareaandcontinue
applyingduringtransportifpainpersists.
NOTES:
1. Transporttohospitalassoonaspossible.
2. Latexglovesarenotsufficient.UseNeopreneorNitrilegloves.


54
AdministrationofAtropine,eitherPralidoximeChloride(2PAM)orObidoximeand
DiazepamforNerveAgentExposureMedicalDirective
Whenthelistedindicationandconditionsexist,aparamedicisauthorizedtoadministerAtropine,
eitherPralidoximeorObidoximeandDiazepamtoavictimofnerveagent(ororganophosphate)
exposure.TheparamedicwillcomplywithlocalBHPpatchingprotocols.
INDICATIONS:
Patientwasexposedtoknownorsuspectednerveagent.
CONDITIONS:
1. Adult(40kg)
2. Thepatientisexhibitingsignsandsymptomsofacholinergiccrisis.
PROCEDURE:
MildExposure:
Signs:anxietyaboutbeingexposed,mayseemiosis,rhinorrhea.
1. Removepatientfromareaofexposure.
2. Removeallcontaminatedclothing.
ModerateExposure:
Signs:(ANYONEOF)vomiting,diarrhea,bronchospasmorbronchialsecretions,shortnessofbreath,
anyknownliquidexposure.
Administer:
1. One(1)Atropine2mgIMorautoinjector.RepeatAtropine2mgIV/IMevery5minutesas
neededuntilsymptomsimprove.
2. One(1)Pralidoxime600mgIMorautoinjectorORObidoxime150mgIMorautoinjector.
3. One(1)Diazepam10mgIMorautoinjector.
SevereExposure:
Signs:Signsofmoderateexposureand(ANYONEOF)DecreasedLOC,paralysis,seizures,apnea.
Administer:
1. Three(3)dosesAtropine2mgIV/IMorautoinjectors.Ifbronchialsecretionspersist,
continueAtropine2mgIV/IMevery5minutesasneededuntilsecretionsclear.
2. Three(3)dosesPralidoxime600mgIMorautoinjectorsORthree(3)Obidoxime150mgIM
orautoinjectors.
3. One(1)Diazepam10mgIMorautoinjector.


55
NOTES:
1. Patientsreceivingtreatmentshouldalsoreceiveoxygenandbeonacardiacmonitorifavailable.
2. OnlyAdvancedCareParamedicsmayadministerintravenousmedications.
3. ABCsmustalsobesecuredasappropriateinanMCI/contaminatedenvironment.Atropineshould
beadministeredpriortoairwayinterventionsifsecretionsarecopious.
4. Decontaminationproceduresmustbeintegratedwithantidoteadministration.
5. PersonalProtectiveEquipmentmustbewornatalltimes.
6. DrugsmaybegivenIVbutdonotdelayIMadministrationifIVaccessisnotalreadyestablished.


56
PediatricAdministrationofAtropine,eitherPralidoximeChloride
(2PAM)orObidoximeandDiazepamforNerveAgentExposureMedicalDirective
Whenthelistedindicationandconditionsexist,aparamedicisauthorizedtoadministerAtropine,
eitherPralidoximeorObidoximeandDiazepamtoavictimofnerveagent(ororganophosphate)
exposure.TheparamedicwillcomplywithlocalBHPpatchingprotocols.
INDICATIONS:
Patientwasexposedtoknownorsuspectednerveagent.
CONDITIONS:
1. <40kg
2. Thepatientisexhibitingsignsandsymptomsofacholinergiccrisis.
PROCEDURE:
MildExposure:
Signs:anxietyaboutbeingexposed,mayseemiosis,rhinorrhea.
1. Removepatientfromareaofexposure.
2. Removeallcontaminatedclothing.
Moderate/SevereExposure:
Signs:(ANYONEOF)vomiting,diarrhea,bronchospasmorbronchialsecretions,shortnessofbreath,
decreasedLOC,paralysis,seizures,apnea,anyknownliquidexposure.
Administer:
Forpatients<10kg:
1. Atropine0.5mgIM,repeatIV/IMevery5minutesasneededuntilsymptomsimprove.
2. Diazepam2mgIV/IM.
3. Pralidoxime15mg/KgIV/IMevery1hourmaximum600mg/singledose,totalmaximum
dose1200mgORObidoxime8mg/Kgmaximum320mgtotaldose.
Forpatientsfrom10kgto39kg:
1. Atropine1mgIM,repeatIV/IMevery5minutesasneededuntilsymptomsimprove.
2. Diazepam0.2mg/kgIV/IM.
3. Pralidoxime15mg/KgIV/IMevery1hourmaximum600mg/singledose,totalmaximum
dose1200mgORObidoxime8mg/Kgmaximum320mgtotaldose.


57
NOTES:
1. Patientsreceivingtreatmentshouldalsoreceiveoxygenandbeonacardiacmonitorifavailable.
2. OnlyAdvancedCareParamedicsmayadministerintravenousmedications.
3. ABCsmustalsobesecuredasappropriateinanMCI/contaminatedenvironment.Atropineshould
beadministeredpriortoairwayinterventionsifsecretionsarecopious.
4. Decontaminationproceduresmustbeintegratedwithantidoteadministration.
5. PersonalProtectiveEquipmentmustbewornatalltimes.
6. DrugsmaygivenIVbutdonotdelayIMadministrationifIVaccessisnotalreadyestablished.


58
AdministrationofAntidotesforCyanideExposureMedicalDirective
Whenthelistedindicationandconditionexist,aparamedicisauthorizedtoadministerantidotesto
victimsofCyanideexposureaccordingtothefollowingprotocol.Theparamedicwillcomplywithlocal
BHPpatchingprotocols.
INDICATIONS:
Patientwasexposedtovapour,liquidorsolid,suspectedtocontaincyanide.
CONDITIONS:
Patientisexhibitingsignsandsymptomsofcyanidepoisoning.
PROCEDURE:
1. Removepatientfromfurtherexposureandremoveclothes.
2. Assessvitalsigns,GCS.
3. Ensureairway,administeroxygenandapplycardiacandoxygensaturationmonitorsaspossible.
4. IfGCS15andpatientisasymptomatic,decontaminateandtransporttohospital.
5. IfGCS<15administer:
a) SodiumThiosulfate12.5gm(50mlof25%solution)IV
(Pediatricdose=1.65ml/kgtomax50ml).
OR
b) CYANOKIT(hydroxocobalamin)5.0g(2X2.5gbottleswith100ml0.9%salineperbottle)by
rapidIVinfusionover30minutes(15minutesperbottle)
(Pediatricdose=70mg/Kg,1bottlefor35kgchild)
6. Initiatetreatmentandcontinuewhiletransportingtohospital.


59
SymptomaticRiotAgentExposureMedicalDirective
Whenthelistedindicationandconditionexist,aparamedicisauthorizedtoadministertherapyto
victimsofRiotAgentexposureaccordingtothefollowingprotocol.Theparamedicwillcomplywith
localBHPpatchingprotocols.
INDICATIONS:
Exposuretoaknownorsuspectedriotagent.
CONDITIONS:
Signsandsymptomsofriotagentexposure.
CONTRAINDICATIONS:
Topicalanaestheticeyedrops(seeProcedure,point#5a)arecontraindicatedifthepatientisallergicto
anaesthetics.
PROCEDURE:
1. Removepatientfromfurtherexposure,anddecontaminate.
2. Assessvitalsigns,withcarefulfocusonbronchoconstriction.
3. Assessvisualacuitybytheabilitytoseelightandcountfingersat1foot.Considerremovingcontact
lenses.
4. FordyspneaseeSOB/RespiratoryDistressProtocol.
5. Foreyediscomfort,irrigatethoroughlywithcopiousamountsofnormalsaline.
a) Administer2dropsoftopicalanaestheticeyedropsineacheye,repeatevery10minutesas
needed.
b) Monitorthepatientfor20minutesafterthelastdose.


510
NOTES:
1. Ifapatientisexperiencingsignificantrespiratorydistressoreyeirritation,immediatelyadvisethe
patientoftheneedfortransporttohospital.Transportshouldbeinitiatedassoonaspossible.
2. MDIsareintendedforsinglepatientuseonly.IfanMDIisusedtotreatmorethanonepatient,
crosscontaminationmayoccurregardlessofwhetherornotanaerochamberorspacerisused.
TheMDIshouldbesafelydiscardedoncethepatienthascompletedtreatment.
3. Theeyedropbottleisdesignedformultiplepatientuse.Donotallowthebottlesadministration
nozzletomakecontactwiththepatient.Iftheadministrationnozzledoesmakecontactwiththe
patient,thebottleisconsideredcontaminatedandmustbediscardedappropriately.
4. UndernocircumstancesshouldtheMDIoreyedropbottlebegiventoapatient.
5. Advisepatienttorefrainfromrubbingeyes,whetherornotanaestheticdropsareused.
6. Havethepatientremovetheircontactlenses.Helpifnecessary.
7. IfapatientwithdyspneaoreyeirritationcausedbyariotcontrolagentrefusesEMStransportto
hospital,advise:
CONTINUEDEXPOSUREMAYLEADTOFURTHERPROBLEMS.RELIEFFROM
TREATMENTSOFARMAYBETEMPORARY.IFPROBLEMSRECURORPERSIST,CONSULT
APHYSICIANASSOONASPOSSIBLE

Appendix 6

Provincial Maintenance of
Certification Policy

Summer 2000
(under review)

ProvincialMaintenanceofCertificationPolicyAppendix6

i
TABLEOFCONTENTS
Preamble....61
ClarificationofTerms....62
GuidelinesforPatientCareReviews......64
PatientCareDeficiencyGuidelines..65
RemedialProgramOptions...65
GuidelinesforDecertificationReviews..66


61
ProvincialMaintenanceofCertification
Preamble:
UponcompletionofarecognizedParamedicTrainingProgram,aparamedicmustmaintaincertification
asperRegulation257/00oftheRevisedRegulationsofOntario1990madeundertheAmbulanceAct
R.S.O.1990asamendedbytheServicesImprovementAct1997.ApersonemployedasaParamedic
shallbetheholderofavaliddocumentsignedbytheMedicalDirectorofaBaseHospitalProgram
designatedbytheMinistryofHealthforthatpurpose.
MaintenanceofCertificationrequiresthattheParamedic:
1. BeemployedbyanEmergencyMedicalServiceandworkasaParamedic,and/orParamedic
Preceptor,(andmeettheannualeligibilityrequirementsoutlinedintheproposedProvincial
BaseHospitalStandards)andworkforaminimumof144scheduledhoursintheprevious12
monthsinanemergencymedical/clinicalexperience.Iflessthan144scheduledhourshasbeen
accumulated,anevaluationmaybeinitiatedbytheMedicalDirectortoensurecompetencyin
theskillstheparamedichasbeencertifiedtoperform.Thiswillinclude,butnotbelimitedto:
i) Proofofreasonableattemptstocomplete144scheduledhoursofemergencymedical
experience.
ii) DocumentationofpracticeofskillsoverseenbytheBaseHospital.
2. MeetsallBaseHospitaladministrativerequirementsincludingcompletionandsubmissionof
formsandsuccessfullycompleteallBaseHospitalCMErequirements.Creditforequivalent
learningwillbeatthediscretionoftheMedicalDirector.IfaParamedicisabsentfromCME,
theParamedicisresponsibleforcontactingtheProgramDirectortomakearrangementsto
successfullycompletetheCMEobjectives.
3. Demonstratescompetencyandadherencetostandards,protocolsandlegislationassociated
withtheperformanceofControlledActsandtheprovisionofpatientcareattheirlevelof
certification.ThiswillbedeterminedthroughBaseHospitalCQIinitiatives.Theymayinclude,
butarenotlimitedto:
ChartAudits
PeerReview
Rideouts
Dispatch/BaseHospitalPhysicianCommunicationReview
Patch/CommunicationReview
FieldPerformanceEvaluation
SuccessfulPerformanceatCME
ReviewofSkillsInventory



62
IfatanytimeinthejudgmentoftheBaseHospitalMedicalDirector,conditionshavenotbeen
maintained,theBaseHospitalMedicalDirectormaydeactivate/decertifytheParamedic.The
employeroftheparamedicwillbegivenwrittennoticebytheBaseHospital.TheParamedicwillbe
notifiedverballyimmediatelybytheemployerfollowedbywrittennoticefromtheBaseHospital.
TheParamedicwillnotbeauthorizedtoperformControlledActswhiletheyare
deactivated/decertified.Theconditionsforreactivation/recertificationwillbedeterminedbytheBase
Hospital.TheconditionswillbecommunicatedinwritingtotheParamedic.
ShouldaParamedicfailtosuccessfullycompletetheprescribedreactivationprocess,theMedical
DirectormayprescribefurtherremediationordecertifytheParamedicfromtheProgram.
4. AdheretotheParamedicConductDirectives.TheParamedicConductDirectiveswillapply
wheneverparamedicsparticipateinondutyassignmentsordutiesrelatedtothecertification
processesendorsedbyindividualBaseHospitalPrograms.TheseDirectiveswillberoutinely
evaluatedanduniformlyenforcedbytheemployer.
ClarificationofTerms:
BaseHospitalmeansahospitalthatisdesignatedasaBaseHospitalbytheMinisterinaccordancewith
clause4(2)(d)oftheAmbulanceActasamendedbytheServicesImprovementAct1997.
Inthisdocument,unlessotherwisestated,theuseofthefollowingtermsrefertoambulancepersonnel
asdefinedbytheAmbulanceAct,andbyOntarioRegulation257/00:
EmergencyMedicalAttendant
Paramedic
PrimaryCareParamedic(P1)
AdvancedCareParamedic(P2)
CriticalCareParamedic
EmergencyMedicalServicemeansanambulanceservicedulylicensedtoperformthisserviceas
definedundertheAmbulanceAct.
HoursofServicemeansworknormallydefinedasfieldassignments.WhereaParamedichasno
clinicalduties,butisaclinicaleducator/manager,workinghoursmaybecreditedontheconditionthat
atleastonceevery12monthstheParamedicistestedbytheBaseHospitaltoensurecompetencyin
theskillstheparamedichasbeencertifiedtoperform.


63
Certificationiswrittenapprovaltoperformselectedmedicalcontrolledactsunderthe
license/registrationofaBaseHospitalmedicaldirector.
Deactivationisthetemporarysuspensionofselectedcertifiedparamedicprivilegestoperform
controlledactsbytheBaseHospitalmedicaldirectorforthepurposeofperformingremediation.
Reactivationisthereinstatementofthesuspendedprivilegesafteraperiodofdeactivation.A
paramedicmaybereactivatedbythemedicaldirectoratthetimethatsuchrequirementsfor
remediationhavebeenmet.Theexpenseofremediationdelivery(excludingparamedicattendance)
willbebornebytheBaseHospital.
Decertificationistherevocationofacertifiedparamedicsprivilegestoperformcontrolledacts.



64
GUIDELINESFORPATIENTCAREREVIEWS
1. Complaintsthatdonotinvolvepatientcarewillbedealtwithbytheemployer.IftheBase
Hospitalismadeawareofsuchcomplaintstheywillforwardthemtotheemployerandcopy
themtotheRegionalEHSmanager.
2. PatientCareConcernsorCallReviews*
ifidentifiedbytheBaseHospital*willbecopiedtotheemployer.
ifidentifiedbytheemployerwillbecopiedtotheBaseHospital.
ifidentifiedbyanoutsidesourcewillbecopiedtotheemployer.
TheidentifyingpartyisresponsibleforensuringtheirRegionalEHSmanagerisnotified.
*MinorpatientcareconcernsidentifiedduringtheContinuousQualityImprovementProgram
normallywillbecommunicatedbetweentheBaseHospitalandtheparamedicduringthe
normalCQIprocess.Theemployerwillbemadeawareofminorconcernsfromaggregate
reports.IftheminorpatientcareconcernbecomesrepetitivetheBaseHospitalwillinformthe
employer.
Theemployerwillinvestigatethecomplaint.Theemployerwillproviderelevantevidence
gatheredwithwrittenconclusions,totheotherpartywithin2weeksofreceivingthe
complaint.Iftheinvestigatorrequiresanextensionthiswillbecommunicatedtotheother
partieswithanewdateofcompletion.
3. TheBaseHospitalreservestherighttoactonallpatientcaredeficiencies.
TomaintainandmeasurepatientcareperformancetheBaseHospitalmayperformfieldaudits,ACR
reviewsandconductothercontinuousqualityimprovementinitiativesindependentofcomplaint
investigations.


65
PATIENTCAREDEFICIENCYCLASSIFICATIONS
IfaparamedichasperformedaControlledAct(s)oranypatientcarebelowtherecognized
standards/guidelines,theBaseHospitalresponsemaybeguidedbytheseverityoftheevent(s)in
accordancewiththefollowingtable:
MINOROMISSION/COMMISSION:
Aminoromission/commissionisdefinedasanactionorlackofactionbytheparamedicthatdidnot
haveanydirecteffectonpatientmorbidity,however,mayhaveaffectedpatientcareinaminorway.
Ifaminordeficiencyisidentified,theparamedicmaybegivenverbalcounselling(confirmedinwriting)
orwrittencounsellingviatheAmbulanceCallReviewProcess.
MAJOROMISSION/COMMISSION:
Amajoromission/commissionisdefinedasanactionorlackofactionbytheparamedicthathas
affectedorthepotentialtoaffectpatientmorbidity,however,theoutcomewouldnotbelife
threatening.Ifamajordeficiencyisidentified,orthereisarepetitionofminordeficiencies,the
paramedicwillbegivenwrittencounsellingandmayberequiredtocompleteremedialeducation.At
thediscretionoftheMedicalDirectortheparamedicmaybedeactivated.
CRITICALOMISSION/COMMISSION:
Acriticalomission/commissionisdefinedasanactionorlackofactionbytheparamedicthathasa
clearaffectonpatientmorbiditywithapotentiallylifethreateningoutcome.Ifacriticaldeficiencyis
identifiedorthereisarepetitionofmajororacombinationofmajorandminordeficienciesthe
paramedicwillbegivenwrittencounsellingandwillberequiredtosuccessfullycompleteremedial
education.AtthediscretionoftheMedicalDirector,theparamedicmaybedecertified.
REMEDIALPROGRAMOPTIONS
AremedialprogrambasedonindividualneedswillbemadeavailableattheBaseHospitalMedical
Directorsdiscretion.BaseHospitaltrainingcostswillbeseparatelyfundedbyEHSwithpriorwritten
approval.
REMEDIALPROGRAMSMAYREQUIRE:
1. Timeinclinicalrotationsorsupplementaleducationalprocessesdeemednecessarybythe
MedicalDirector.
2. BaseHospitalrecoverycostspaidbytheParamedicincompliancewithEHSdirection.


66
GUIDELINESFORDECERTIFICATIONREVIEWS
DECERTIFICATION
IfaParamedicwantstohavetheirdecertificationreviewedbytheBaseHospitaltheparamedicmaydo
so. The request for the review must be in writing and received by the Base Hospital staff within 2
weeksofbeingnotifiedofachangeincertificationstatus.TheParamedicmustincludeintherequest
thereasonhe/shethinksareviewshouldbeconsidered.TheParamedicmustalsoincludealternative
solutionsorconclusionsbeforethereviewwillproceed.
ThereviewcommitteewillconsistofaMedicalDirector,aProgramDirectorandapracticingcertified
peerparamedicfromanotherProvincialBaseHospitalProgram.Thisprocessmustbeapprovedbythe
MinistryofHealthEmergencyHealthServicesforanyrequiredfunding.TheParamedicssubmission
tothereviewcommitteewillbeprecirculatedtothemembers.Thepurposeofthereviewwillbeto
determine:
a) IftheinformationusedbytheBaseHospitalinitsevaluationwasvalid.
b) TheappropriatenessoftheBaseHospitalactionfortheevent(s)involved.
c) Iftherequirementsforrecertificationarereasonablefortheevent(s).
Thereviewcommitteewillprovidearecommendationwithin48hours.

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Advanced Life Support

Patient Care Standards

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