Additional Directives

Question 1

What is ondansetron?

Answer 1

• aka Zofran
• 5-HT3 receptor antagonist (blocks action of serotonin which is a natural substance that may cause nausea/vomiting)
• commonly used in cancer pt receiving chemo, radiation therapy, surgery (post-op) & palliative pt at home

Question 2

What is apomorphine and why is apomorphine use a contraindication for ondansetron?

Answer 2

What it is: dopamine agonist which stimulates D2 receptors in the part of the brain that affects locomotor control (so commonly used to tx parkinson’s)

Concomitant use of apomorphine & ondansetron can cause profound hypotension & LOC therefore contraindicated

Question 3

What is dimenhydrinate?

What mechanism of action does this drug have, and what situations would dimenhydrinate work well/not well in?

Answer 3

• aka Gravol
• only functions on certain causes of nausea
• works via H1-antagonism of vestibular center, which reduces input to the vomiting center of the brain (so it is minimally effective when cause of nausea is gastric irritation)
• Works well for vertigo-induced nausea

Question 4

True or False. Not all nausea requires treatment.

Answer 4

True. Sometimes nausea may be a protective mechanism (such as in toxic ingestion) so you want the body to be nauseous/vomit

Question 5

Nausea/Vomiting Medical Directive
Indications, Conditions

Answer 5

Indications: Nausea OR vomiting

Conditions:
* Ondansetron: weight ≥25 kg, unaltered LOA (bc may cause further drowsiness)
* Dimenhydrinate: Age <65y.o. (bc may cause ++drowsiness and delirium in elderly population); weight ≥25 kg, unaltered LOA

Question 6

Nausea/Vomiting Medical Directive
Contraindications

Answer 6

Ondansetron:
* Allergy to ondansetron
* Prolonged QT syndrome (known to pt)
* Apomorphine use

Dimenhydrinate:
* allergy or sensitivity to dimenhydrinate or other antihistamines
* OD on antihistamines or anticholinergics or TCAs (can exacerbate OD states; has anticholinergic and Na+ channel blocking effects
* Co-administration of diphenhydramine

Question 7

Why is prolonged QT syndrome a contraindication for ondansetron?

Answer 7

May cause additional QT prolongation (>440ms or 0.44sec for men; >460ms for women) because it blocks K+ channels

This increases risk of R-on-T & torsades with QT interval >500ms

Question 8

Nausea/Vomiting Medical Directive
Treatment & Clinical Considerations

Answer 8

Treatment: Consider ondansetron; Consider dimenhydrinate (seen screenshot)

Clinical Considerations:
1) IV admin of dimenhydrinate for PCP AIV only.
2) Prior to IV administration, dilute dimenhydrinate [50mg/ml] 1:9 with NS or d5W. If administered IM do not dilute.
3) If a patient has received Ondansetron and has no relief of their nausea & vomiting sx after 30 min, dimenhydrinate may be conisdered.

Question 9

What situations would have preferred uses for ondansetron over dimenhydrinate?

Answer 9

• cause from drug interactions (chemo, alcohol, cannabis, illicit drugs)
• head trauma (less risk of ICP)
• if taking benadryl, anticholinergics, & TCAs
• elderly patients

Question 10

What situations would dimenhydrinate administration be preferred over ondansetron?

Answer 10

• motion sickness/vertigo
• upset stomach due to food ingestion
• avoid with head injuries (potential to cause increased ICP)
• hyperemesis for preggo patient
• best for people on SSRIs

Question 11

What is serotonin syndrome?

Answer 11

• Pts who may be on multiple, high doses or have sensitivities to SSRIs or SNRIs may be at higher risk of serotonin syndrome when given ondansetron

S/S:
* nervousness
* NVD
* dilated puils and tremors
* agitation, restlessnes
* muscle twitching, seizures, abnormal side-to-side eye movements
* confusion, disorientation, delirium
* tachycardiac, HTN, high temp, LOS

Question 12

According to the BLS PCS, what extenuating circumstances would prevent you from complying with the standards? (7)

Answer 12

• Scene conditions
• overwhelmed resources
• equipment failure
• safety concerns
• patient location
• distance from receiving facility
• others not specified (eg. language barrier)

Question 13

As per Patient Assessment Standard in BLS PCS, what types of calls warrant cardiac monitor?

Answer 13

• All VSA (except those meeting obvi death criteria)
• Unconscious or altered LOC
• collapse/syncope
• OD
• Major or Multi-system trauma
• Moderate to severe SOB
• Suspected cardiac ischemia
• CVA
• Hypothermia, heat exhaustion or heat illness
• Submersion injury
• Electrocution
• Abnormal vital signs as per ALS PCS
• If requested by sending facility staff (for inter-facility transfers)

Question 14

As per Patient Transport Standard in BLS PCS, what information (if available) would you need when completing inter-facility transfers?

Answer 14

1. Name of sending physician
2. Name of receiving facility and receiving physician
3. Verbal and/or written tx orders from sending physician
4. Transfer papers/ personal effects, etc.
5. Name(s) of facility staff and list of equipment that is accompanying the pt

Question 15

As per Patient Refusal/Emergency Treatment Standard, when can you provide emergency tx/transport of an incapable person without consent?

Answer 15

1. If Pt does not have capacity
2. If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
3. If delay in obtaining consent/refusal on pt’s behalf will prolong suffering or put them at risk of sustaining serious bodily harm

and then just document your decision

Question 16

As per Patient Refusal/Emergency Transport Standard in BLS PCS, when is a paramedic able to initiate emergency tx/transport of a capable person without consent?

Answer 16

1. If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
2. Communication to get consent/refusal can’t happen (i.e. due to language barrier, disability preventing communication)
3. reasonably steps (within the circumstances) have been taken to allow communication to take place but none have been found
4. If Pt is _experiencing severe sufferin_g or at risk of sustaining serious bodily harm if tx is not provided promptly
5. If there is no reason to believe the pt doesn’t want tx

and document!

Question 17

Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive

Indications

Conditions

Contraindications

Answer 17

Indications: Pt with endotracheal or tracheostomy tube AND airway obstruction or increased secretions

Conditions:

• Suctioning: none
• Emergency tracheostomy reinsertion: Other
  
  • Patient with an existing tracheostomy where the inner and/or outer cannula(s) have been removed from the airway AND
  • Respiratory distress AND
  • Inability to adequately ventilate AND
  • Paramedics are presented with a tracheostomy cannula for the identified patient

Contraindications:

• Suctioning: none
• Emergency tracheostomy reinsertion: Inability to landmark or visualize

Question 18

Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive

Treatment

Clinical Considerations

Answer 18

Treatment: 1) CONSIDER SUCTIONING

​< 1 yr:

• Dose: suction at 60-100mmHg
• Max single dose: 10 seconds
• Dosing interval: 1 min
• Max # of doses: N/A

≥ 1 yr to < 12 yrs:

• Dose: suction at 100-120mmHg
• Max single dose: 10 seconds
• Dosing interval: 1 min
• Max # of doses: N/A

≥ 12 yrs:

• Dose: suction at 100-150mmHg
• Max single dose: 10 seconds
• Dosing interval: 1 min
• Max # of doses: N/A

2) CONSIDER EMERGENCY TRACHEOSTOMY REINSERTION: Max number of attempts is 2

Clinical Considerations:

• Suctioning:
  
  • ​Pre-oxygenate with 100% oxygen (to avoid hypoxia)
  • In an alert patient, whenever possible, have pt cough to clear airway prior to suctioning (to help loosen mucus)
• Emergency tracheostomy reinsertion:
  
  • A resinsertion attempt is defined as the insertion of the cannula into the tracheostomy.
  • A new replacement inner or outer cannula is preferred over cleaning and reusing an existing one.
  • Utilize a family member or caregiver who is available and knowledgeable to replace the tracheostomy cannula

Question 19

As per companion document, what are advantages and disadvantages of ETT & tracheostomy suctioning?

Answer 19

Advantages: allows suction beyond oropharynx

Disadvantages:
* can cause trauma to surrounding mucosa leading to swelling/obstruction
* aggressive suctioning may also increase likelihood of arrhythmia (start at lower end of pressure suctioning range)

Question 20

If all attempts to suction/clear the tracheostomy have failed and PCP is unable to oxygenate/ventilate with PPV, what should a PCP’s next steps be?

Answer 20

tracheostomy is now considered FBAO. Remove tracheostomy to gain access to stoma for oxygenation/PPV

Question 21

If completing tracheostomy/cannula reinsertion, what are a PCPs best practices to follow (i.e. who should be considered to assist and should you use old or new materials)?

Answer 21

1) Utilize family/caregiver first who may be most knowledgeable
2) Use new tracheostomy tube/inner cannula
3) If no new, remove current inner cannula, deflate cuff (if present) and rinse with saline or water rinse for re-use

Question 22

IV Line Maintenance Standard

What patients with an IV line in can be monitored by paramedics?

Answer 22

1. an IV line TKVO

• <12 y.o. - flow rate of 15ml/hr of any isotonic crystalloid soln to maintain IV patency
• ≥12 y.o. - flow rate of 30-60ml/hr of “ ”

1. IV line for fluid replacement with:

• max flow rate infused up to 2mL/kg/hr to max of 200ml/hr
• thiamine (vit B1), multivitamin preparations
• drugs within his/her level of certification
• KCl for ≥18 y.o. to max of 10mEq in a 250ml bag

Question 23

IV Line Maintenance Standard

Which patients require a medically responsible escort when there is a need for IV?

Answer 23

When pt requires an IV:

• for blood (or blood product) administration
• for KCl administration for pt <18 y.o.
• for use of med administration (including pre-packaged medications, except those mentioned earlier) - see prev flashcard
• requires electronic monitoring or uses pressurized IV fluid infuser, pump or central venous line
• neonate or ped pt <2 y.o.

Question 24

IV Line Maintenance Standard

Prior to transport, what steps shall the paramedic take when monitoring a patient with IV?

Answer 24

• confirm MD’s written IV orders to sending facility staff
• determine:
  
  • IV solution
  • IV flow rate
  • catheter gauge
  • catheter length
  • cannulation site
• IV site condition prior to transport
• amount of fluid left in bag
• amount of fluid needed to complete transport time and get more if needed
• document all this in ACR

Question 25

**IV Line Maintenance Standard** During transport, what steps shall the paramedic take when monitoring a patient with IV?

Answer 25

* monitor and maintain IV at prescribe rate (may need to change IV bag if required) * if IV becomes dislodged or interstitial, discontinue IV flow and remove catheter with aseptic technique * confirm condition of catheter if removed

Question 26

As per the **IV Line Maintenance Standard**, the IV bag should be changed where there is ~\_\_\_\_\_ of solution remaining.

Answer 26

150 mL

Question 27

**Home Dialysis Emergency Disconnect Medical Directive** Indications Conditions Contraindications

Answer 27

**Indications:** * Patient receiving home dialysis (hemo or peritoneal) and connected to dialysis machine & requires transport to closest appropriate receiving facility **AND** * Patient is unable to disconnect **AND** * No family member or caregiver available and knowledgeable in dialysis disconnect **Conditions:** N/A **Contraindications:** N/A

Question 28

**Home Dialysis Emergency Disconnect Medical Directive** Treatment Clinical Considerations

Answer 28

**Treatment:** Consider Home Dialysis Emergency Disconnect **Clinical Considerations:** * Generally emergency disconnect kit with materials and instructions can be found hanging from dialysis machine or nearby wall * Ensure both pt side and machine side of connection are clamped _before_ disconnecting and attaching end caps

Question 29

Steps for disconnecting hemodialysis machine (6)

Answer 29

1. Clamp pt side tubing clamps 2. Clamp machine side clamps 3. Disconnect tubing 4. Attach sterile Luer lock caps to the ends of the pt tubing 5. Disregard any alarms that may sound from the machine 6. Secure pt tubing and cover with a large dressing (eg. abdo pad)

Question 30

Steps for disconnecting CAPD (Continuous Ambulatory Peritoneal Dialysis)

Answer 30

1. Close twist clamp 2. Clamp both the fill and drain bag tubing with clamps supplied in the disconnect kits 3. Disconnect the pt from the fill and drain bag tubing 4. Screw a sterile mini cap on the pt tubing 5. Snap a sterile Luer lock on the fill and drain bag tubing 6. Secure pt tubing and cover with a large dressing (i.e. abdo pad)

Question 31

Explain steps to disconnect automatic peritoneal dialysis (APD)

Answer 31

1. Push "stop" button on APD machine 2. Close twist clamp 3. Disconnect pt tubing from machine tubing 4. Screw a sterile mini cap on the pt tubing 5. Snap a mini cap on the machine tubing 6. Secure pt tubing and cover with a large dressing (i.e. abdo pad)

Question 32

IV Flow Rate Calculation Formula

Answer 32

gtt/min = Amount (ml) to be infused x drops per ml (gtt/ml) of admin set / total time of infusion (min)

Question 33

Medication Infusion Rate Formula

Answer 33

ml/hr = Desired dose (mg/min) x 60 min/hr / drug concentration (mg/ml)

Question 34

Formula for calculating MAP (mean arterial pressure)

Answer 34

DBP + 1/3 (PP or SBP-DBP)

Question 35

According to the Incident Reporting Requirements in the Documentation Standards, when is a paramedic required to fill out an incident report? (6)

Answer 35

These are all in relation to something that may have negatively impacted provision of patient care: 1. An unusual response/service delays 2. Delay in accessing patient 3. ++amount of time on scene 4. case of suspicious or unexpected death that may likely require coroner/police investigation 5. Any circumstance that resulted in harm to patient/anyone else transported in ambulance (including equipment failure) 6. Any circumstance which resulted in a risk to, or endangerment of the health and safety of, a patient or any other person transported in ambulance

Question 36

What are the levels of assessment when considering the level of threat (in incident reporting) and when you have to have said incident report submitted to the field office?

Answer 36

**5- Minimal**: Not serious (90 calendar days) **4 - Minor:** Limited risk (15 business days) **3 - Moderate:** Moderate risk (5 business days) **2 - Significant:** Sig risk (2 busines days) **1 - Major:** Known serious -ve impact to pt outcome or paramedic safety (ASAP, within 24 hours)