1
Q
When must you auscultate a patients lungs?
A
if exhibiting signs of resp/cardio or neurological decline
2
Q
When must you put a cardiac monitor on a patient?
A
if showing signs of resp/cardio or neurological decline
3
Q
What situations warrant a cardiac monitor?
A
- VSA patients
- altered LOA
- syncopal
- cardiac ischemia
- major trauma/multi system
- electrocution
- submersion injury
- hypothermia
- heat illness
- abnormal vitals
- if requested by sending facility
4
Q
How often must you assess vitals?
A
every 30 mins at minimum, or more often based on patient condition
5
Q
For inter facility transfer, what 5 things must you get? (if can)
A
- name of sending doctor
- treatment orders from sending doctor
- transfer paper
- name of facility staff and equipment coming with pt
- name of receiving doctor/facility
6
Q
How to extricate patients?
A
CTAS 1/2 - most appropriate lift or carry transported to and from ambulance by stretcher
CTAS 3/4/5 - most appropriate lift/carry or ambulatory assistance in cases of transfers - move pt by stretcher
7
Q
What happens if patient deteriorates on route during transfer?
A
- go to closest facility
- alert dispatch and get them to notify receiving facility
8
Q
Refusals - patient has capacity
A
- inform pt of condition, what happens if they refuse, advise them to go to hospital
- confirm they have mental capacity to refuse
- advise patient to call 911 if needed
- gather documentation/signatures (note: pt can refuse to sign document)
9
Q
Transport of incapable pt with no consent
A
- pt has no capacity and delaying transport to find someone to consent on their behalf will lead to suffering
- pt currently suffering/at risk for prolonged issues if not transported
10
Q
Transporting capable person without consent
A
- pt is suffering or at risk of
- pt unable to give consent due to language barrier or has disability preventing them from doing so
- means to find communication for consent has taken place
- delay to find proper consent will lead to further suffering for pt
- no reason to believe pt does not want to be transported
11
Q
When patching to BH what are things to include?
A
- your level of certification
- provide report with relevant info on pt condition
- provide any other info they request
- confirm direction/orders given after BH gives them
12
Q
Normal oxygen therapy standard for patients:
A
92-96%
13
Q
What patients would you continuously provide oxygen for?
A
- confirmed poisoning (carbon monoxide, cyanide)
- upper airway burns
- scuba diving disorders
- cardiopulmonary arrest
- complete airway obstruction
- sickle cell anemia with vasoocclusive crisis
14
Q
If pulse oximetry not working, who do we give O2 to?
A
- hypotensive pts
- resp distress
- pallor/ashen skin
- cyanotic
- altered LOA
- pregnancy or labour
- as well as everything above
15
Q
Oxygen standard for pts with COPD
A
- keep oxygen between 88-92%
- if pulse oximetry not working administer oxygen at 2lpm above persons home oxygen
- if not on home oxygen, start at 2lpm and titrate by 2lpm every 2-3 mins as needed until condition improved
16
Q
What are the 4 steps in field trauma triage?
A
- physiological
- anatomical
- mechanism
- special consideration
17
Q
FTTS - Physiological criteria
A
1st step in determining if transporting to LTH
- if pt can not follow commands
- BP <90mmHg
- RR < 10 or >30 or <20 for infant under 1
- and less than 30 minutes to LTH
18
Q
FTTS - Anatomical criteria
A
If they do not meet physiological, look @ following types of injuries present:
- penetrating injury to torso/head/neck/extremities proximal to elbow or knee
- chest wall instability
- crush injuries/deglovings/pulseless extremities
- pelvic fractures
- two or more proximal long bone fractures
- open/depressed skull fracture
- paralysis
19
Q
If patient has unstable airway but meets criteria 1/2 for FTTS?
A
transport to closest hospital instead of LTH
20
Q
Penetrating injuries with FTTS
A
if vital signs absent and no TOR granted and less than 30 mins transport to LTH regardless if airway is stable
21
Q
FTTS - Mechanism of Injury criteria
A
- falls over 6m for adults or 3m for children
- intrusion into vehicle of 0/3m on pt side or 0.5m on any side
- ejection from vehicle or death in same compartment
- pedestrian or bicyclist struck at 30km/hr or greater
- motorcycle crash at 30km/hr or greater
22
Q
What are special criteria to consider in FTTS when choosing to go to LTH?
A
- risk of injury increases after 55 - BP under 110 can mean shock if 65+
- if they have bleeding disorders
- burns (if trauma mechanism)
- pregnancy >= 20 weeks
23
Q
Is the max time for LTH transport 30 mins?
A
yes unless service says otherwise
24
Q
What is the general rule for utilizing air?
A
meet one operational and one medical criteria
25
What are the 4 operational criteria for calling air?
1. land will take more than 30 mins to reach the scene and air can get there faster
2. by land it will take longer than 30 mins to get to best hospital for pt and air can reach scene and transport quicker
3. if land and air have equal times for transport, but patient needs higher level of care
4. multiple pts who meet criteria and land ambulances are all utilized
26
What are the medical criteria to utilize air?
- shock (hypotensive, altered)
- acute stroke
- GCS under 10
- acute resp distress/failure
- lethal rhythms/STEMI
- ROSC pt
- unstable airway/airway obstruction
- abnormal pregnancy (cord prolapse, breech, limb presentation)
- twin pregnancies with active labour
- significant vaginal bleed
27
Any other additional reasons to call air?
- if land ambulance can not reach patient (geographic etc.) or if reports of injuries seem severe before confirming criteria
28
When can you wait for air?
if they are seen on the final stretch to scene
29
When can you meet wtih air on route?
- if they can meet along direct route of land
- if it would result in significant decrease in transport time
30
When can air not be used?
- at night unless landing at airports or designated helipads
- for search and rescue calls
31
Under what circumstances should SMR be considered?
- trauma associated with back/neck pain
- diving accidents
- explosions
- electrocution
- pedestrian struck
- penetrating trauma to head/neck/torso
- falls
- sport accidents
32
If patient meets mechanism for SMR, what is the next criteria to consider?
symptoms such as:
- neck/back pain
- neurological symptoms/altered LOA
- intoxication
- any distracting injuries
- high energy mechanism (falls from 3ft, load to the head, high speed MVC - 100km/hr, rollover, ejections - person hit by car)
33
With SMR what is important to remember in terms of elderly?
65+ falls from standing height are eligible for SMR
34
Use of spinal boards:
- goal to remove them once on stretcher via log roll if possible
- device can remain under pt if transport less than 30 mins
- patients with pelvic fracture should remain on spinal board/scoop
35
SMR and agitated patients
if patient is agitated leading to harm for pt or paramedic, apply SMR if needed to best of ability and document
36
When can a DNR be overlooked?
- if patient expresses the wish prior to death
- if pt states wishes that are vague and leads to question about what pt wants
- if power of attorney says otherwise
37
Signs of obvious death
1. decapitation, transection, visible decomposition, putrefaction or
2. absence of vital signs and:
- a grossly charred body
- an open head or torso wound with gross outpouring of contents
- gross rigor mortis
- dependent lividity
38
In all cases of death...
- confirm they are dead, treat patient and family with dignity
- follow police notification standard if foul play present
- if applicable, follow rules by coroner or person appointed by coroner
- if TOR happens en route continue to facility unless otherwise told
- document time of obvious death
39
In cases of unexpected death...
- notify dispatch if no police/coroner on scene
- remain at scene till coroner or police are on scene
- if police are present and have secured scene, can depart once documentation completed
40
In case of expected death
- advise dispatch
- get responsible person present to notify doctor or palliative care team member
- if responsible person unable, notify dispatch who will try to get doctor/member on scene
- wait on scene till they arrive or if responsible person seems okay can depart after documentation
- if police on scene and will wait can depart
- if no doctor or team member coming and no responsible person on scene, notify dispatch who will notify coroner/police
- wait till police/coroner arrive
41
With children, what are some important things to look for:
- change in appetite/behaviours
- excessive drooling
- inconsolable crying
- work of breathing increased
- lethargic
- increase in wet diapers
42
What is duty to report?
if suspicion of child in neglect/danger must tell Children's Aid Society
- request police and do not leave child alone
43
What type of injuries to children should you look for?
- submersion injuries
- burns
- ingestions
- falls
- multiple bruises (unusual areas - genitals, abdomen, chest)
- deformities (especially if child under 2)
- signs of malnutrition/unkempt
- signs of shaking syndrome (blood shot eyes, marks on neck/shoulders, head injury signs)
44
Scene observations to note if suspected child neglact/harm
- dirty living situation
- evidence of violence (broken items...)
- animal abuse
- evidence of substance use/abuse
45
What are some non-physical signs to look out for in terms of child abuse?
- stories changing often
- parents vague, hostile, not caring towards child
- nature of injury inconsistent with story, child too young to get that type of injury
- recurrent injury hx
- child may be fearful of parents or protect one parent
46
What to do if suspecting child abuse?
- do not lead on to parents your suspicions
- transport child in all cases
- contact CAS/police
- let hospital know the situation (PHIPA overrided)
47
Things to remember in terms of elderly
- can present atypically
- more subject to adverse medication affects
- diminished responses to things like pain/heat
- more easily susceptible to injuries (skin tears, bruising)
48
When can a paramedic monitor an IV line?
- thiamine, multivitamins
- max flow rate infused up to 2ml/kg/hr up to max of 200ml/hr
- drugs within cert
- KCL for pts 18+ to max of 10mEq in 250ml bag
49
When can a paramedic not monitor a line without escort?
- if blood product
- if KCL given to pt under 18
- if given meds not in cert
- that needs electronic monitoring, central line or fluid infuser pump
- for neonate or child under 2
50
When should IV bag be changed?
with 150ml left
51
When would you consider possible airway obstruction?
- smoke inhalation
- anaphylaxis
- foreign body aspiration
- pharyngeal malignancy
52
How often do you take vital on a ROSC pt?
every 15 mins for first hour than every 30 mins after that
53
What are some conditions that mimic stroke?
- hypoglycemia
- drug ingestion
- infection
- hypertension emergency
54
For stroke patient, what should end tidal be maintained at?
35-45mmHg
55
For stroke patient, if signs of cerebral herniation are present, what do we maintain end tidal at?
30-35mmHg
56
Signs of cerebral herniation include?
GCS under 9 with any of the following:
- nonreactive pupils or dilated pupils
- nonsymmetrical pupils
- asymmetric motor response
- decorticate or decerebrate posturing, or no response
57
If need to hyperventilate due to herniation, but no end tidal monitoring, what do you ventilate at?
for adult: 20 breaths/min
child: 25
infant (under 1): 30
58
What is stroke bypass standard?
have onset of one of the following symptoms within 6 hours:
- unilateral arm/leg weakness or drift
- slurred speech, mute or inappropriate
- facial droop
59
What are contraindications of stroke bypass?
- CTAS 1 patient
- symptoms resolved prior to EMS arrival
- blood sugar under 3
- seizure at onset
- GCS under 10
- terminally ill
- transport to hospital will be greater than 2 hours
60
What are the STEMI bypass conditions?
- 18+
- have chest pain not lasting more than 12 hours
- 12 lead says STEMI
61
What are STEMI bypass contraindications?
- CTAS 1 patient
- STEMI mimics (not RBBB)
- 60 mins or greater to get to hospital from time of pt contact
- pt needs diversion (moderate to severe resp distress, hemodynamic instability or SBP <90 and symptomatic, or VSA)
62
STEMI - now what?
- place pads
- if possible put IV in left arm
63
What is sepsis determined by?
- fever (38.5+)
- possible infection
- presence of any one of the following: BP< 90, resp rate >=22, altered LOC
64
Target end tidal for COPD/asthma pts
50-60mmHg
65
Signs of carbon monoxide poisoning?
- altered LOA
- arrhythmia
- emesis
- headache
- light-headed
- nausea
- seizures
- weakness
- syncopal episodes
- VSA
66
What is normal blood loss during a womens period?
10-35ml - a pad/tampon can hold around 5ml
67
For hypothermia pts, how long do you check pulse/resps
for 10 seconds
68
If patient is altered, not shivering what can you assume temp to be?
below 32
69
How long do you irrigate acid versus alkali burn?
acid - 10min
alkali - 20min
70
What is proper landing site selection for air?
- will not impact rescue efforts underway
- 45x45m area that is clear
- safety area of 30m
- away from overhead wires/poles
- flat as possible
- no loose debris in landing site
- avoid gravel/sand sites
71
Site safety when utilizing air?
- nobody allowed in landing site/safety area when taking off or landing
- vehicle doors, windows closed
- stretchers should be left in ambulance
- landing site coordinator should stand upwind at the edge of safety area facing the site
- firefighters should not lay out hoses/equipment
- if safety site is compromised - landing site coordinator should wave off air crossing arms overhead
72
How to be safe when working around helicopter?
- stay out of safety area/landing site during takeoff or landing
- approach only when directed by crew member
- do not approach helicopter from rear
- if on uneven ground, approach and depart from downhill side
- carry equipment horizontally, below waist level
- ensure loose articles secured
73
Who qualifies as a deceased patient?
- obvious death
- has a medical death cert
- without vitals, and has DNR
- without vitals and has a TOR order from BH
- without vitals and has a withhold resuscitation order from BH
74
When can someone be transported without consent?
- subject of application for assessment signed by doctor under MHA
- subject of an order for examination signed by justice of peace under MHA
- a person taken into custody by police under MHA
- a patient detained in psych facility for involuntary admission
75
How to restrain patient if need be?
- organize team before attempting, than prepare equipment and explain what are doing to the patient
- immobilize patients hands/limbs in one movement - grasp between main joint and distal end at main joint
- place patient in spread eagle position or in left lateral
- secure one arm above head, and other to stretcher at waist level
- elevate head of stretcher to maintain airway/good visualization
- secure feet
- ensure patient restrained to main frame of stretcher
76
What is the load and go patient standard?
- rapid transport for CTAS 1 patients, patients meeting bypass protocols or obstetrical patients who have: eclampsia/pre, limb presentation, multiple gestation, premature labour and prolapse cord
- however, if birth is imminent, in cardiac arrest where TOR is not indicated, patients who need immediate interventions which paramedics can perform - may need to intervene prior to transport
77
Sexual assault standard
- ensure patient is not left alone
- if child, following need for protection standard/contact police
- if they decline to report, helpful to talk about resources and options
- advise patient to not use washroom, shower, etc. until exam can be done
- upon police request, bag linen, materials in contact with patient & give to officer
78
At minimum, what should you assess on the abdomen?
- look for pulsations
- scars
- masses
- discolouration
- guarding
- rigidity
- tenderness
79
At minimum, what should you assess on the abdomen?
- look for pulsations
- scars
- masses
- discolouration
- guarding
- rigidity
- tenderness
80
What to do if you spot a pulsating mass?
- do not palpate any further
- check femoral pulses for strength/absence and observe for melena
- hematemesis
- rectal bleeding
81
Airway obstruction standard
- perform things as directed by heart and stroke
- attempt to clear airway with oro/naso suction
- consider airway obstruction for patients with smoke inhalation, anaphylaxis, epiglottis, FBAO, oro malignancy
82
Altered LOC Standard
- attempt to determine specific cause
- perform head-to-toe assessment
- perform trauma assessment if can not be ruled out
- if unprotected airway, insert one
- if patient apneic or not ventilating correctly, assist ventilation
83
Symptoms of excited delirium
- impaired thought process
- physical strength
- can not feel pain
- sweating
- extreme agitation
- in frenzy
84
What symptoms can indicate a serious problem with headache?
- sudden rapid onset
- changes in pattern of headaches
- altered LOA
- neuro problems
- nuchal rigidity or other symptoms of infection
- visual problems
- pupil changes
85
Heat Stroke
40 degrees and higher
- overdose on TCAs, antihistamines and beta blockers can also cause heat stroke
86
How to treat heat related illness?
- assess the CNS
- assess the mouth for hydration
- skin colour/temp
- extremities for CSM
- move them to cooler environment, remove layers of clothing (heat exhaustion)
- cover them with wet sheets, apply cold packs to groin, armpits, neck, head (heat stroke)
- provide electrolytes/fluid if patient is able
87
When to stop cooling efforts?
- temp feels normal to touch
- shivering develops
- patients LOC returns to normal
88
What to maintain end tidal at, for COPD or normal patients?
COPD - 50-60mmHg
Normal - 35-40mmHg
89
Respiratory failure standard
- ventilate as per heart and stroke
- observe chest rise, auscultate lungs to make sure adequate
- minimize interruptions to ventilating and continue until patients resps are adequate
90
What to do if patient is in active seizure?
- put them in recovery position
- protect from injury
- observe for: eye deviation, incontinence, type of seizure, what is impacted, oral injury
- prepare for combativeness, reseizure, airway compromise
91
SOB standard
- check for things like edema, nasal flaring, cyanosis, drooling, tracheal deviation, JVD
- if on home oxygen, determine if there is changes in use
- position them in semi-sitting or sitting position
- assist ventilations if apneic or resps are inadequate
92
Syncopal episodes - what to consider?
- hypoglycemia, toxicological, cardiac issue, sepsis, anemia, heat related illness, CVA
- lay them supine or in recovery position
93
Toxicological standard
- attempt to discover agent, route, quantity
- if prescription, attempt to determine date given, compliance with meds
- attempt to refer to MSDS
- can refer to poison control, do not delay transport though
94
Toxicological standard
- attempt to discover agent, route, quantity
- if prescription, attempt to determine date given, compliance with meds
- attempt to refer to MSDS
- can refer to poison control, do not delay transport though
95
What to do if patient is having visual disturbances?
- consider patching eyes for comfort
- check pupil size, redness, swelling, if contact lenses present, abnormal eye movements, visual acuity/loss
96
What are the splinting priorities?
- spine (including neck and head)
- femur
- pelvis
- lower legs
- upper legs
97
What to do if patient is splinted before you get there?
assess, if correct then leave in place
98
What is trauma most often associated with in pregnant patients?
domestic violence
99
In pregnant patients, what often causes trauma based death?
- hemorrhagic shock
- fetal hypoxia
100
In pregnant patients and trauma situations, what to remember?
- observe for uterine enlargement
- things like still birth or placental abruption (can occur hours after blunt trauma)
101
What to do if patient has partial amputation or avulsion? complete amputation?
- assess for CSM at site
- assess distal CSM
- control hemorrhage
- cleanse wound of contaminents
- place remaining tissue close to anatomical position
- if complete amputation, cover stump with most sterile dressing, followed by dry dressing
- immobilize affected part and elevate if possible
102
When are amputations looked at under the field trauma traige?
amputation proximal to wrist or ankle
103
What to do if patient has eviscerated abdomen?
- do not attempt to place organs back
- cover abdomen with moist, bulky dressing
104
What to do if patient has pelvic fracture?
- attempt to stabilize with device or sheet wrap
- secure patient to scoop or spinal board, avoid placing straps over pelvis
- secure and immobilize lower limbs to avoid worse injury
105
Bite injury:
- attempt to determine source of bite
- if patient is stable, irrigate for 5 mins
- if venom suspected, position them supine, immobilize area below heart level, do not apply cold packs
106
If patient has a sucking chest wound?
- seal wound with occlusive dressing or commercial dressing
- dressing should cover entire wound and several cm beyond
- monitor for development of tension pneumo - if becomes suspected replace dressing/release
- have them sitting/semi-sitting if no SMR needed
107
Eye injury standard:
- if eyelids swollen, leave shut
- if bleeding, use minimum pressure only
- cover eye with dressing or both if severe
- if eye is avulsed, do not attempt to put it back, cover with moist sterile dressing and protect/stabilize as if an impaled object
- transport patient supine with head at 30 degree angle
108
Teeth injury standard:
- if patient is alert and stable, replace tooth in socket and have them bite down to stabilize
- if can not be replaced, place tooth in saline or milk
- apply cold pack to area
- if SMR not needed, have patient seated and leaning forward to help draining
- if patient on scoop, elevate head 30 degrees
109
If brain matter protruding:
cover with non-adherent material (moist dressing, plastic wrap)
110
If CSF leak:
apply loose dressing over the source of opening
111
If patient has penetrating wound:
- assess for exit and entry
- apply pressure lateral to site
- apply occlusive dressing if needed
112
If patient has penetrating wound:
- assess for exit and entry
- apply pressure lateral to site
- apply occlusive dressing if needed
113
Signs of smoke inhalation:
- burns to lips
- cough
- droolning
- stridor
- SOB
- wheezing
- singed hair
- decreased air entry
114
How long do you cool a burn?
- if under 15% cool for under 30 mins
115
What do you do if you need to re-wet a dressing?
- remove it, and use the same dressing - wet and then reapply
116
How long do you check resps/pulse for hypothermia patients?
10 seconds
117
If multiple lightning strike patients who do you focus on?
patient that is VSA - has a high chance of ROSC
118
Extremity injury standard:
- assess CSM
- splint joint injuries as found, or apply gentle traction if CSM is not intact
- open/closed femur fractures splint with traction splint unless amputation present
- if injury impacts joint, immobilize above and below
- re-assess CSM, re-manipulate if CSM not intact
- if needed, elevate and apply ice pack
119
How often do you check circulation, sensation, movement of an extremity?
every 10 mins if status was compromised initially
120
What to do if foreign body on surface of eye?
attempt removal - use wet cotton swab tip or gauze
121
How often do you irrigate an unknown chemical substance injury?
20 mins on scene if patient is stable
122
How to eye irrigate?
- ask patient not to rub
- position patient on side with affected eye facing down or supine if both eyes are impacted
- manually open eyelids if needed
- irrigate away from tear ducts
123
What temp do you irrigate areas of chemical exposure at?
cool - not cold
124
Soft tissue standard - treatment
- apply direct pressure
- if needed, apply additional dressings over initial
- apply tourniquet if needed for extremity (5cm above site)
- if tourniquet not working, or can not be used in areas like armpit, or groin - use hemostatic dressing
125
Tourniquet rules:
- do not remove if applied
- document time it was applied
- in cases of MCI make sure it is documented on patient
- do not cover it once in place
126
Hemostatic dressing use:
- do not apply to cranial open wound
- if soaks through first one, apply another on top, do not remove first one - if bleeding persists, use bulky pressure dressings
127
Soft tissue injury - things to remember
- do not remove impaled objects, stabilize
- if patient stable, try to irrigate wounds
- cover protruding organs with non-adherent material
- dress wounds prior to splinting if possible
- dress digits themselves leaving finger/toe tips open for assessment
- reassess CSM, loosen bandages if needed
128
Submersion injury - air embolism suspected
left sided positioning
129
Good things to remember for submersion injury
- rate of ascent
- when symptoms started
- water temp
- duration of submersion
- state of water (debris, etc.)
130
How to ensure airway of neonate?
put towel under shoulders
131
How often do you take APGAR score for neonate?
After 1 min than 5 mins
- if 5 mins score is less than 7, initiate rapid transport
132
How to transport pregnant patients?
left lateral position
133
Pediatric standard:
1. be aware of problems arising due to children anatomy
2. be aware of resp issues - common cause of arrest
3. recognize abnormal vitals
4. assessment: WOB, change in appetitie/behaviour, drooling, increase in wet diapers, lethargy, etc.
5. head-to-toe assessment
6. have caregivers present if not interfering
7. if have fontanelles, assess for swelling
134
Qualifications to be employed:
- speak english
- under 6 demerit points
- no loss of license in 2 years
- no DUI for 3 years prior
- class F license
- no communicable diseases
- no convictions of moral turpitude
- CPR certified - at time of hire, and every 12 months after
135
When is a child in need of protection?
- child has suffered physical harm
- neglect, failure to care for child
- risk of child suffering physical harm
- child has been sexually abused/emotionally harmed
- child is younger than 12 and has killed/harmed someone else
136
Warrant to apprehend child:
- justice of the peace can warrant a child protection worker to bring child to safety if reasonable grounds to believe child needs it and less restrictive action can not be taken
- if child is under 16 and has runaway without parents consent and reason to believe child is at risk
