Advanced Care Paramedic (ACP) Integration

1. Advanced Care Paramedic (ACP)Integration

2. Scope of Practice ProcedureList • 12 Lead Acquisition • Cardioversion • CPAP • CVAD Access • Intraosseous (IO) Access up to 12 yrs old • Intravenous (IV) Access all ages • Needle Decompression • Neonatal Resuscitation • Oral Intubation • Pacing

3. Procedures Continued… • Manual Pediatric Defib at 2-4 J/kg • STEMI Bypass to PCI Lab • Taser Probe Removal • Trauma TOR

4. Drug List • Adenosine 6mg /12mg • Amiodarone • ASA • Atropine • Dextrose • Diazepam (Valium) • Dopamine • Epinephrine 1:1000 • Epinephrine 1:10000 • Fentanyl • Furosemide (Lasix) • Glucagon • Lidocaine • Midazolam • Morphine • Naloxone (Narcan) • Nitroglycerin • Salbutamol Neb/MDI • Sodium Bicarbonate

5. CARDIAC CALLS Adenosine (Adenocard) • Anti-arrhythmic • Used for treatment of SVT / PSVT (narrow complex tachycardia >150bpm) with stable vitals • Patients must be >40kg • Given IV through a large bore catheter close to the core What might you be asked to do during this protocol?

6. Amiodarone Live Patients Anti-arrhythmic • Used for treatment of wide complex tachycardia (V-tach) >120 bpm with stable vitals • Patients must be > 40kg • Given IV What might you be asked to do during this protocol?

7. Amiodarone VSA Patients • V-fib / V-tach VSAs • Supplied in Vials • Given IV every 4 min to a max of 2 doses (alternate CPR cycles) • Not used for pediatrics, must be >40 kg What might you be asked to do during this protocol?

8. Asa & Nitro • Same as PCP protocol • First time nitro can be given with IV access • Double doses of nitro can be given for CHF if IV access is obtained and BP is above 140 mmHg Morphine • Chest pain consistent with cardiac ischemia or pt’s typical angina / MI pain • Opioid analgesic, narcotic (controlled) • Causes venodilation - reduces preload • Given after third dose of Nitro if pain is still present • BP must be greater than 100mmHg systolic • Given IV What might you be asked to do during these protocols?

9. Atropine Live Patients • Used for unstable pts with a pulse and ventricular rate of <50bpm with a BP <100mmHg • Given IV preload, purple box • Patient must be in sinus bradycardia, a-fib, first degree or second degree type 1 heart block What might you be asked to do during this protocol?

10. Atropine VSA Patients • Asystolic VSAs - >12yrs old, >40kg • PEA VSAs - >12yrs old, >40kg, if monitor shows HR< 60bpm • Given in preloaded syringes either IV or ETT (purple boxes) • Given every 4min, max 3 doses (every other CPR interval) What might you be asked to do during these protocols?

11. Epinephrine • IV/ ETT dose - cardiac arrest: v-fib, pulseless v-tach, asystole, PEA • In arrests it improves blood flow to vital organs when used with chest compressions • Carried in 1:1000 ampoules and 1:10000 preloads (brown box) • Given every 3-5min (alternate CPR intervals) • SC or IM dose: anaphylaxis(same as pcp) • Nebulized for severe Croup(same as pcp) What might you be asked to do during these protocols?

12. Lidocaine • Anti-arrhythmic, local anesthetic • V-tach with a pulse, V-fib, pulseless V-tach • Supplied in preloads (pink box) • Given IV if live, given ETT if VSA instead unless pediatric (IV) • Given every 3-5 min (alternate CPR intervals) Anesthetic Use • Suspected severe head injury or stroke prior to intubation • As topical anesthetic in the hypopharynx and on vocal cords prior to intubation

13. Anesthetic Use • Believed that it blunts the rise in ICP caused during intubation (Mixed study results) • Given IV bolus three min prior to intubation from preloaded syringe • Given in sprays onto the cords and into the hypopharynx one min prior to intubation What might you be asked to do during these protocols?

14. 12 / 15 Lead Acquisition • Same as pcp protocol Cardioversion • An electrical shock to the heart (timed to the QRS complex) • Restarts the electrical activity of the heart, allowing the SA node to resume its normal pacemaker activity • Unstable adult patients with tachyarrhythmias >120 bpm if wide complex (V-tach) and >150 bpm if narrow complex (SVT) What might you be asked to do during these protocols?

15. Pacing • Delivering pulses of electric current through the patient's chest, which stimulates the heart to contract at a set rate • Unstable patients with a heart rate of <50bpm and BP <100mmHg Pediatric Manual Defibrillation • VSA pts >30 days <12yrs old • ACP manually interprets rhythm and decides whether to shock (prints a strip of the rhythm) • Shocks are delivered at 2 joules/kg (first shock), 4 joules/kg (all subsequent shocks) What might you be asked to do during these protocols?

16. Neonatal Resuscitation • Same as PCP protocol with the addition of Epinephrine IV/IO/ETT after 30 sec of chest compressions • ACP may intubate, put in an IV or an intraosseous IV STEMI Bypass • Same as PCP protocol • Can administer an IV bolus if BP < 90mmHg and chest is clear • Can administer Dopamine if chest is full Trauma TOR • Same as PCP protocol however, ACP’s can patch for the Trauma TOR if pt is PEA and >16yrs old • ACP may intubate What might you be asked to do during these protocols?

17. Respiratory Calls Salbutamol (Ventolin) • Same indications as per pcp protocols • Can be given down the tube via MDI adaptor or through the BVM port Furosemide (Lasix) • Patients exhibiting severe CHF • Supplied in vials What might you be asked to do during these protocols?

18. CPAP • Same as PCP protocol • ACPs can put an ETCO2 monitor in the circuit • Option to intubate if pt deteriorates Oral Intubation • Patients requiring airway control / protection or ventilatory assistance that cannot be adequately provided by BVM technique (decreasing spo2, increasing HR, decreasing BP) • Golden rule “GCS less then 8 intubate” • Patient may receive sedation after intubation if they are not tolerating the tube What might you be asked to do during these protocols?

19. Needle Decompression • Act of inserting a needle into a patients pleural space to release the buildup of air that cannot escape in a suspect tension pneumothorax • Patients with thoracic trauma or other causes of tension pneumothorax (severe asthma or BVM ventilation) and severe worsening SOB with markedly decreased or absent breath sounds on affected side and a BP <90mmHg • BVM ventilation should not be initiated until the decompression is completed What might you be asked to do during this protocol?

20. Altered LOA Calls Dextrose (D50W) • Carbohydrate substrate • immediate source of glucose • Suspected or known hypoglycemia with LOA and a blood glucose level of <4mmol (adults), <3mmol for peds <2yrs old • Given IV push and supplied in preloaded syringes • Causes tissue necrosis if interstitial Glucagon • Same indications and protocol as pcp What might you be asked to do during these protocols?

21. Nalaxone (Narcan) • For reversal of respiratory depression and depressed mental status secondary to actual or suspected narcotic use Examples: demerol, heroin, codeine, oxymorphone, oxycontin, hydromorphone (Dilaudid), morphine, Percocet Lomotil, Fentanyl, and pentazocine (Talwin) • Given IV, IM, IN and should be titrated to desired affect • Supplied in vials • Caution in chronic users as it causes withdrawal symptoms What might you be asked to do during this protocol?

22. Midazolam (Versed) • Short acting benzodiazepine, CNS depressant with sedative, muscle relaxant and anticonvulsant (Controlled) • For patients unresponsive and in generalized motor seizure, sedation of adult (>12 and >40kg) patients requiring electrical therapy, sedation while intubated and sedation due to combativeness • Given IV/IM/IN, IV is preferable and is required for procedural sedation • Supplied in vials What might you be asked to do during these protocols?

23. Pain Management Calls Fentanyl (Sublimaze) • Synthetic opioid analgesic / synthetic narcotic (Controlled) • Relief of moderate to severe pain in the hemodynamically stable adult patients when experiencing isolated extremity injuries or pain associated with burns • Given IV, supplied in ampoules • May cause respiratory depression and chest wall rigidity What might you be asked to do during this protocol?

24. Morphine • Opioid analgesic, narcotic (controlled) • Causes venodilation • Relief of moderate to severe pain in the hemodynamically stable patient when experiencing isolated extremity injuries or pain associated with burns • Cannot be given for head, chest, abdo or pelvic injuries • Given IV (slow push), supplied in ampoules • BP must be >100mmHg as it can cause hypotension and respiratory depression What might you be asked to do during this protocol?

25. Fluid and Drug Admin Calls IV Access • Same protocol as PCP IV with no age restrictions • Actual or potential need for IV medication or fluid therapy • Patients must be symptomatically hypotensive with a clear chest and a BP <100mmHg to receive a fluid bolus • ACPs can use external jugular veins for access if unconscious or in arrest patients • ACPs can use central venous access devices if available and patent in arrest or pre arrest situations What might you be asked to do during this protocol?

26. Intraosseous IV Access (IO) • Process of inserting a needle directly into the marrow of a bone to provide fluids and medication, when an IV line cannot be obtained • The needle is injected through the bone's hard cortex and into the soft marrow interior • Pediatric patients <12 yrs old in cardiac arrest or pre-arrest, hypovolemic shock, major burns or trauma and no obtainable IV access • Antero-medial aspect of the tibia • IV line is attached to IO in leg • Pressure infuser is used to push in the fluid What might you be asked to do during this protocol?

27. Other Dopamine • Symptomatic hypotension in the absence of hypovolemia E.g. cardiogenic shock, bradyarrhythmia, septic shock • Post-arrest hypotension (ROSC) • Given IV through a micro drip set or a controlled drip set • Supplied in premixed IV bags (silver foil) What might you be asked to do during this protocol?

28. Sodium Bicarbonate • Buffers or neutralizes excess acid raising blood pH • Prolonged cardiac arrest or OD on tricyclic anti-depressant • Given IV • Carried in preloaded syringe (large yellow box) Taser Probe Removal • Same protocol as pcp What might you be asked to do during this protocol?

29. ACP – Cardiac Arrest Scenario • ..\Paramedic Megacode.mp4

30. Class Discussion When should PCPs be calling for ACP backup?

31. Absence of breathing • SOB pts not responding to / excluded from CPAP • Cardiac Arrest (excluding code 5) • Full airway obstructions • Chest pain (if outside PCP parameters) • Unconsciousness (not resolved by PCP protocols) • Entrapment • Gunshot/stabbing or penetrating wounds to the head, thoracic or abdominal area. • Severe bleeding (not including nose, vaginal, rectal or catheter) • MVC (with confirmed or suspected life threatening injuries) • Pedestrian struck or occupant ejected • Drowning/near drowning • Continuous or multiple seizures

32. Other Notes • TOC reports to an ACP One crew needs to be available in 5 min • Crew Types: Precepting ACP Consolidating ACP Crew • Narcotic sheets • Security • Questions???