1
Q
FTT Standard- physiological criteria
A
- Pt does not follow commands
- Systolic blood pressure <90mmHg
- RR <10 or ≥ 30 breaths or need for ventilatory support (<20 in infants aged <1 year)
2
Q
FTT Standard- If they meet any of the physiological criteria, do you go to the trauma hospital? What other criteria needs to be met?
A
Only if the transport time to the LTH is <30 minutes
3
Q
FTT Standard- anatomical criteria
A
- Penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee
- Chest wall instability or deformity
- Two or more proximal long-bone fractures
- Crushed, de-gloved, mangled or pulseless extremities
- Amputation proximal to wrist or ankle
- Pelvic fractures
- Open or depressed skull fracture
- Paralysis
4
Q
FTT Standard- If patient meets anatomical criteria, do you go to the trauma hospital? What other criteria do they need to meet?
A
Only if the transport time is <30 minutes.
5
Q
FTT Standard- If you cannot secure patient’s airway or survival is unlikely, where do you bring them?
A
To the closest hospital
6
Q
FTT Standard- If the patient has penetrating trauma to head, neck, or torso, what criteria do they have to meet in order to be taken to an LTH.
A
- VSA with no TOR
- LTH is <30 mins away
7
Q
FTT Standard- What are some MOI’s that can be considerations for a trauma center?
A
Falls
- Adult ≥6 meters (one story = 3 meters)
- Children (<15 years): falls ≥ 3 meters or 2 to 3 times the height of the child
High Risk Auto Crash
- Intrusion ≥ 0.3 meters occupant site; ≥ 0.5 meters any site, including the roof
- Ejection (partial or complete) from automobile
- Death in the same passanger compartment
- Vehicle telemetry data consistent with high risk injury (if available)
Pedestrian or bicyclist thrown, run over, or struck with significant impact (≥ 30 km/hr) by an automobile
Motorcyle crash ≥ 30 km/hr
8
Q
FTT Standard- If pt meets MOI criteria, do we take them to a trauma center? What do we consider?
A
Has to be < 30 min transport to LTH and make sure you assess the need for the patient to go there!
9
Q
FTT Standard- special criteria
A
Age
- Risk of injury/death increases after age 55
- SBP <110 may represent shock after age 65
- Anticoagulation and bleeding disorders
- Burns
- With trauma mechanism: triage to LTH
- Pregnancy ≥ 20 weeks
10
Q
FTT Standard- If pt meets special criteria, do we take them to a trauma center? What do we consider?
A
Has to be < 30 min transport to LTH and make sure you assess the need for the patient to go there!
11
Q
SMR Standard- MOI’s
A
- Any trauma associated with complaints of neck or back pain
- Sports accidents (impaction, fall)
- Diving incidents and submersion injuries
- Explosions, other types of forceful acceleration/deceleration injuries
- Falls (e.g., stairs)
- Pedestrian struck
- Electrocution
- Lightning strikes
- Penetrating trauma to head, neck or torso
12
Q
SMR Standard- Risk criteria
A
- Neck or back pain
- Spine tenderness
- Neuro signs and symptoms
- Altered LOC
- Suspected drug or alcohol intoxication
- A distracting painful injury
- Anatomic deformity of the spine
- High energy MOI such as:
- Fall from greater than 3 feet/ 5 stairs
- Axial load to the head (e.g., diving accidents)
- High speed motor vehicle collisions (≥ 100 km/hr),
rollover, ejection - Hit by a bus or large truck
- Motorized/ATV recreational vehicles collision
- Bicyclist struck or collision
- Age ≥ 65 years old including falls from standing height
13
Q
SMR Standard- If patient meets MOI but no risk criteria, SMR or no?
A
NO SMR
14
Q
SMR Standard- If patient meets risk criteria, do we apply SMR?
A
YES!
15
Q
SMR Standard- If pt has penetrating trauma to head, neck or torso, determine if they exhibit all of the following criteria:
A
- No spine tenderness
- No neuro signs and symptoms
- No altered LOC
- No evidence of intoxication
- No distracting painful injury
- No anatomic deformity of spine
16
Q
SMR Standard- If they have a penetrating injury to head, neck or torso, but they meet all of the criteria, do we apply SMR?
A
NO SMR
17
Q
SMR Standard- When do we keep the board/scoop?
A
If the paramedic deems it is safer/more comfortable for the patient in consideration of short transport times (<30 mins)
18
Q
SMR Standard- Patients involved in MVC who have isolated neck or back pain and no neurological signs and symptoms or indications of major trauma, how do we extricate?
A
Stand, turn and. pivot onto stretcher, coach patient to maintain neutral spinal alignment.
19
Q
CP Standard- Potential life/limb//function threats?
A
- ACS/Acute MI (STEMI)
- Dissecting thoracic aorta
- Pneumothorax, tension pneumothorax/other respiratory disorders (e.g., pneumonia)
- Pulmonary embolism
- Pericarditis
20
Q
CP Standard- What do we assess for in our secondary survery?
A
- Subcutaneous emphysema
- Accessory muscle use
- Urticaria
- Indrawing
- Shape
- Symmetry
- Tenderness
- Decreased air entry and adventitious sounds (wheezes and crackles) through auscultation
- Abdomen as per standard
- Neck for tracheal deviation and JVD
- Extremities for leg/ankle edema
21
Q
STEMI Protocol- Indications
A
- ≥ 18 years old
- Experience chest pain or equivalent consistent with cardiac ischemia or myocardial infarction
- The time from onset of the current episode of pain < 12 hours
- The 12 lead indicates an acute MI/STEMI as follows:
- At least 2mm of elevation in leads V1-V3
- At least 1mm of elevation in at least two other anatomically contiguous leads
- 12 lead ECG computer says STEMI and paramedic agrees
22
Q
STEMI Protocol- Contraindications
A
- CTAS 1 and no secure airway
- 12 lead ECG is consistent with LBBB, ventricular paced rhythm or other STEMI mimickers
- Transport to a PCI is ≥ 60 minutes from patient contact
- The patient requires PCP diversion:
- Moderate to severe respiratory distress
or use of CPAP - Hemodynamic instability or symptomatic SBP <90 mmHg at any point
- VSA without ROSC
- Moderate to severe respiratory distress
- The patient requires ACP diversion
- Ventilation inadequate despite assistance
- Hemodynamic instability unresponsive to
ACP treatment or not amendable to ACP
management - VSA without ROSC
23
Q
STEMI Protocol- If patient does not meet guidelines, attempt to determine?
A
If the interventional cardiology program at the PCI center will still permit transport.
24
Q
STEMI Protocol- Provide the PCI the following information:
A
- Pt. is STEMI positive
- Pt’s initials
- Pt’s age and sex
- Paramedics concerns regarding clinical stability
- Infarct territory and/or findings on the qualifying ECG
- ETA
- Catchment area of patient pickup
25
STEMI Protocol- Upon arrival what should you tell the staff at the PCI center:
- Time of symptom onset
- Time of ROSC, if applicable
- Hemodynamic status
- Medications given and procedures
- History of acute MI/PCI/Coronary artery bypass graft, if applicable
- A copy of ECG
- A copy of ACR
26
STEMI Protocol- Once STEMI is confirmed what do you do?
Apply defib pads due to potential for lethal cardiac rhythms.
27
STEMI Protocol- If IV access is indicated and established as per the ALS PCS, what arm is preffered?
The left arm is the preferred site for IV.
28
CVA Standard- Stroke mimickers?
- Drug ingestion (e.g., cocaine)
- Hypoglycemia
- Severe HTN
- CNS infection (e.g., meningitis)
29
CVA Standard- What are we assessing for in our secondary survey?
- Facial symmetry
- Pupillary size, equality, and reactivity
- Abnormal speech
- Presence of stiff neck
- Abnormal motor function (e.g., grip strength, arm/leg drift)
- Sensory loss
- Incontinence of urine/stool
30
CVA- What should you do for the limbs?
Ensure extra support for patients body and limbs during patient movement and place extra padding and support beneath affected limbs.
31
CVA Standard- Potential problems?
- possible airway obstruction (if loss of tongue control, gag reflex)
- decreasing LOC
- seizures
- agitation, confusion, or combativeness
32
CVA Standard- What values do we want for our ETCO2?
35-45mmHg
33
CVA Standard- What should we do if signs of cerebral herniation syndrome are present after measures to address hypoxemia and hypotension?
Hyperventilate the patient to maintain ETCO2 values between 30-35mmHg
34
CVA Standard- Signs and symptoms of cerebral herniation syndrome?
A deteriorating GCS <9 with any of the following:
- Dilated and unreactive pupils
- Asymmetric pupillary response
- A motor response that shows either unilateral or bilateral decorticate or decerebrate posturing
35
CVA Standard- How many breaths per minute do you hyperventilate when the patient has signs of cerebral herniation syndrome?
Adult- approx. 20 bpm
Child- approx. 25 bpm
Infant- approx. 30 bpm
36
CVA Standard- What score do they have to get on LAMS to be CTAS 2?
≥ 4
37
Stroke Protocol- Symptoms consistent with onset of an acute stroke?
- inappropriate words or mute
- slurred speech
- unilateral arm weakness or drift
- unilateral facial droop
- unilateral leg weakness or drift
38
Stroke Protocol- Determine if patient can be transported to a stroke center within _________ of a clearly determined time of symptom onset or time patient was last seen in his/her usual state.
6 hours
39
CVA Standard- Contraindications
- CTAS 1 and/or an uncorrected ABCs issue
- Symptoms resolve prior to EMS arrival
- Blood glucose <3 mmol/L
- Seizure at the onset of symptoms or that is observed by the paramedic
- GCS <10
- Terminally ill or palliative care
- Duration of transport to stroke center will exceed 2 hours
40
CVA Standard- What is LAMS score?
Facial Droop?
- Yes- 1
- No- 0
Arm Drift?
- Falls rapidly- 2
- Drifts down- 1
- Absent- 0
Grip Strength?
- No grip- 2
- Weak- 1
- No grip- 0
Total= /5
41
CVA Standard- Can we still take them to the stroke center if their symptoms resolve on route?
YES, do it!
42
CVA Standard- If patients symptoms persist after correct of blood glucose level, is the patient still contraindicated?
NO! they are no longer contraindicated!
43
Abdominal Pain Standard- Potential life/limb/function threats?
- Leaking or ruptured abdominal aortic aneurysm
- Ectopic pregnancy
- Other non-abdominal disorders that may present with abdo pain
- DKA
- Pulmonary embolism
- Perforated or obstructed hollow organs with or without peritonitis
- Acute pancreatitis
- Testicular torsion
- Pelvic infection
- Strangulated hernia
44
Abdominal Pain Standard- What are we looking for in our secondary survey?
- Pulsations
- Scars
- Discolouration
- Distention
- Masses
- Guarding
- Rigidity
- Tenderness
45
Abdominal Pain Standard- If a pulsatile mass is discovered, what do we not want to do anymore?
palpate the abdomen
46
Abdominal Pain Standard- If abdominal aneurysm is suspected, what do we do?
Palpate femoral pulses for weakness/absence and observe for melena, hematemesis, or frank rectal bleeding (hematochezia)
47
O2 Standard- What oxygen sat do we want to achieve?
92-96%
48
O2 Standard- What patients do we consider high concentration oxygen for?
- Confirmed or suspected carbon monoxide or cyanide toxicity or noxious gas exposure
- Upper airway burns
- Scuba-diving related disorders
- Ongoing cardiopulmonary arrest
- Complete airway obstruction
- Sickle cell anemia with suspected vaso-occlusive crisis
49
O2 Standard- If pulse oximetry is not working, what are critical findings that you can give high-concentration oxygen for?
- Age-specific hypotension
- Respiratory distress
- Cyanosis, ashen colour, pallor
- Altered LOC
- Abnormal pregnancy or labour
50
O2 Standard- For patients who have COPD, what is the target oxygen sat?
88-92%
51
O2 Standard- If pulse oximetry is not working, what do we administer to COPD patients?
Nasal cannula at 2L above patient's home oxygen levels, or 2L if they are not on home oxygen. Increase by 2L every 2-3 minutes if pt's status deteriorates or if pt feels worse, prepare to ventilate.
52
Signs and Symptoms of Sepsis
Skin: Cellulitis, wound, burns
Immunocompromise/Neuro: LOA changes, weakness, indwelling medical directive. chemotherapy
Chest: SOB, cough, recent surgery/invasive procedure
Abdomen: Pain, vomiting, diarrhea with a history of fever or rigors
Urine: dysuria, frequency (increased/decreased) odour
53
What symptoms do they have to have 2 of to go on sepsis alert?
Pulse: ≥ 90 bpm
Temp: <36 or >38
RR: ≥ 20 breaths/min
54
What symptoms do they have to have 1 of to go on sepsis alert?
Signs of hypoperfusion (mottled extremities, poor cap refill, etc.)
SBP: <90 mmHg
New altered LOA
55
What is treatment for Sepsis?
IV access
IV Fluid and therapy MD
Consider contacting BHP for giving fluids if they do not meet the directive
56
Air Ambulance Standard- Medical Clinical Criteria?
- Shock, especially hypotension with altered mentation (e.g., suspected aortic aneurysm rupture, massive GI blood, severe sepsis, anaphylaxis, cardiogenic shock, etc.)
- Acute stroke with a clearly determined time of onset or last known to be normal < 6 hours
- Altered LOC (GCS <10)
- Acute resp. failure or distress
- Suspected STEMI or potentially lethal dysrhythmias
- Resuscitation from respiratory or cardiac arrest
- Status epilepticus
- Unstable airway or partial airway obstruction
57
Air Ambulance Standard- Obstetrical Clinical Considerations?
- Active labour with abnormal presentation (i.e., shoulder, breech, or limb)
- Multiple gestation and active labour
- Umbilical cord prolapse
- Significant vaginal bleeding (suspected placental abruption or placenta previa or ectopic pregnancy)
58
Air Ambulance Standard- In conjunction with the ACO, assess if an on-scene air ambulance helicopter is appropriate based on:
- The perceived severity of the reported injuries and without confirmation that the clinical criteria have been met
- The patient cannot reasonably be reached by land ambulance (e.g., sites without road access such as islands, geographically isolated places, etc)
59
Air Ambulance- What do we do if they don't get there in time? or what if we see them on thier final approach?
Paramedic shall not delay transport to wait for the air ambulance unless they can see it on its final approach to the scene. If it is not on its final approach the land ambulance will go to closest hospital with an ED, then air ambulance will proceed to that hospital and assist hospital staff for rapid evacuation.
60
Air Ambulance- Paramedics may rendezvous with the air ambulance helicopter if:
- The air ambulance helicopter is able to land along the direct route of the land air ambulance
- It would result in a significant reduction in transport time to the most appropriate hospital
61
Allergic Reaction- What are you assessing for in your secondary survey?
- the site of allergic reactions
- lungs, for adventitious sounds through auscultation
- skin, for erythema, urticaria, and edema
62
Allergic Reactions- Respiratory symptoms
Dyspnea, wheezing, stridor, hoarse voice
63
Allergic Reactions- Cardiovascular symptoms
Tachycardia or hypotension/shock
64
Allergic Reaction- Neurological symptoms
Dizziness, confusion, or loss of consciousness
65
Allergic Reaction- Gastrointestinal symptoms
Nausea, vomiting, abdominal cramps, diarrhea
66
Allergic Reaction- Dermatological/mucosal symptoms
Facial, orolingual, or generalized swelling/flushing/urticaria
67
Allergic Reactions- What are historical findings that are evidence of suspected anaphylaxis
- Difficulty swallowing/tightness in the throat
- Difficulty breathing/feeling of suffocation
- Fearfulness, anxiety, agitation, confusion, or feeling or doom
- Generalized itching
- History of any of the symptoms listed
68
Allergic Reaction- Potential Problems
- Cardiac arrest
- Airway obstruction
- Anaphylaxis
- Bronchospasm
- Hypotension
69
Heat Illness- Life/limb/function threats
- heat stroke
- hypovolemic shock
70
Heat Illness- consider various heat related illnesses in the setting of hot and/or humid outdoor or indoor conditions with cheif complaint(s), prsenting problems of:
- Heat syncope
- Heat cramps- severe cramping of large muscle groups
- Heat exhaustion- mild alterations in mental status, and non-specific complaints (headache, giddiness, nausea, vomiting, malaise)
- Heat stroke- severely altered mental status, coma, seizure, hyperthermia, ≥40 degrees celcius.
71
Heat Illness- What are you looking for in your secondary survery?
- central nervous system
- mouth, for state of hydration
- skin, for temperature, colour, condition, state of hydration
- extremities for circulation, sensation, and movement, and
- temperature
72
Heat Illness- Treatment
- Move patient to the ambulance
- Remove as much clothing as possible
- Withhold oral fluids
- Cover the patient with wet sheets
- Apply cold packs to the axillae, groin, neck, and head.
73
Seizure Standard- Life/limb/function threats (general)
- Intracranial event
- Hypoglycemia
- Eclampsia (in pregnant pt's)
- In young children, febrile convulsions associated with infection
- Infection (e.g., CNS, meningitis)
- Alcohol withdrawl
- Drug ingestion
- Known seizure disorder
74
Seizure Standard- Life/limb/function threats (in pt's ≥50 years with new onset or recurrent seizures)
- Brain tumour or other intracranial event
- Cardiac dysrhythmias
- Cardiovascular disease
- Cerebrovascular
- Severe HTN
75
Seizure Standard- Life/limb/function threats (in neonates)
- Traumatic delivery
- Congenital disorders
- Prematurity
- Hypoglycemia
76
Seizure Standard- Observe for:
- Eye deviation
- Incontinence
- Parts of body affected
- Type of seizure (e.g., full body, focal)
77
Seizure Standard- What are you assessing for in your secondary survery?
- Bleeding from the mouth
- Incontience
- Secondary injuries resulting from the seizure
- Tongue injury
78
Seizure Standard- What are some potential problems?
- Airway compromise
- Reccurent seizures
- Post-ictal combativeness or agitation
79
SOB Standard- Potential life/limb/function threats (acute respiratory disorders)
- Partial airway obstruction
- Asthma
- Anaphylaxis
- Aspiration
- Inhalation of toxic gases or smoke
- Pneumothorax
- COPD
- Respiratory infections
80
SOB Standard- Potential life/limb/function threats (acute cardiovascular disorders)
- Acute coronary syndrome/Acute MI
- Congestive heart failure
- Pulmonary edema
- Pulmonary embolism
81
SOB Standard- Potential life/limb/function threats (other causes)
- CVA
- Toxicological effects
- Metabolic acidosis
82
SOB Standard- What are we assessing for in our secondary survery?
- Cyanosis
- Nasal flaring
- Excessive drooling
- Tracheal deviation
- JVD
Extremities for;
- cyanosis
- edema
83
Soft tissue injury- What do we do if the wound is located on an extremity?
- Apply well-aimed, direct digital pressure at the site of bleeding
- Apply a tourniquet, if tourniquet fails to stop bleeding completely or cannot be used for any reason then apply a second tourniquet
- Pack the wound with hemostatic dressing if appropriate and available or standard gauze if contraindicated or unavailable. Maintain pressure with a secure pressure dressing.
84
Soft tissue injury- What do we do if the wound is located in a junctional location (e.g., head, shoulders, armpit, neck, pelvis, groin)
- Apply well-aimed, digital pressure at the site of bleeding
- Pack the wound with a hemostatic dressing if appropriate and available or standard gauze if contraindicated or unavailable, maintain pressure and secure with a pressure dressing.
85
Soft tissue injury- What do we do if the wound is located in the hollow spaces of the skull, chest, or abdomen?
- Apply manual manual pressure with a flat palm and a hemostatic dressing where available and appropriate or standard gauze if cannot use hemostatic dressing
- Do not pack dressings of any kind into the hollow spaces of the skull, chest or abdomen
- Do not insert fingers into the hollow spaces of the skull, chest or abdomen
86
Submersion Injury- life/limb/function
- Asphyxia
- Aspiration
- Hypothermia
- Pulmonary Edema
- Underlying disorders which may have precipitated events (e.g., drug or alcohol consumption, hypoglycemia, cardiac dysrhythmias, trauma [spinal/head injury])
- Specific to scuba-diving related disorders:
- Barotrauma
- Decompression
- Arterial gas embolism
87
Submersion Injury- Attempt to determine:
- Duration of submersion
- If water contains known or obvious chemicals, pollutants or other debris
- Water temperature
88
Submersion Injury- What do we want to determine if the injury is scuba-diving related?
- Number, depth and duration of dives
- Rate of ascent
- When symptoms occurred (underwater, upon surfacing or within minutes thereof [possible gas embolus], more than 10 minutes after surfacing [possible decompression sickness]
89
