firefighter prehospital care...

Firefighter Prehospital Care Program

2015 MEDICAL DIRECTIVES REFERENCE GUIDE

Approved by Dr. M. Feldman, Medical Director

CONTACT INFORMATION Sunnybrook Centre for Prehospital Medicine 77 Brown’s Line, Suite 100 Toronto, ON M8W 3S2 Tel: 416.667.2200 Fax: 416.667.9776 Firefighter Prehospital Care Program Medical Director Michael Feldman, PhD MD FRCPC Email: [email protected] Office: 416-849-2454 Cell: 416-558-1529 Pager: 416-235-7141 Firefighter Prehospital Care Program Manager Ken Webb, BA AEMCA Email: [email protected] Office: 416-667-2217 Cell: 647-294-5722 Pager: 416-404-1619 Firefighter Prehospital Care Program Developer Michael Nemeth, AEMCA(f) I.C.P. Email: [email protected] Office: 416-849-2458 Cell: 647-242-2498 Pager: 416-404-1615


TABLE OF CONTENTS

Introduction ......................................................................................... 3 Personal Protective Equipment ......................................................... 7 Cardiac Arrest Medical Directive ....................................................... 9 Cardiac Arrest Flow Chart ................................................................ 11 Defib Pad Placement ........................................................................ 12 Special Considerations .................................................................... 13 Transfer of Care ................................................................................ 19 Obvious Death .................................................................................. 20 DNR and Expected Death ................................................................ 21 Epinephrine for Anaphylaxis ............................................................ 25 Documentation and Data Management .......................................... 29 Defib Reference ................................................................................ 32 Acknowledgement ............................................................................ 34

ABBREVIATIONS AED – automatic external defibrillator

BVM – bag-valve mask

CPR – cardiopulmonary resuscitation

DNR – do not resuscitate

FCC – Fire Chief’s Communique

PPE – personal protective equipment

VSA – vital signs absent


INTRODUCTION USE OF MEDICAL DIRECTIVES/GUIDELINES These medical directives and guidelines are not intended to cover all situations and are not a substitute for good judgment. It is the firefighter’s responsibility to assess the situation and use their knowledge and skills to benefit the patient while remaining within their scope of practice.

DELEGATION AED use and epinephrine administration are delegated medical acts. The firefighter provides care according to medical directives, under the authority of their Medical Director. The firefighter may not accept delegation from another on-scene physician, nor should the firefighter delegate these acts to another defibrillation provider or citizen.

P.P.E. RESPONSIBILITY Firefighters will protect themselves and others from illness or injury while providing patient care. Toronto Paramedic Service Communications will forward any knowledge they have of potential communicable diseases while enroute to the call. The firefighter will also assess the risk of communicable diseases by asking about signs of illness and travel history, observe the presence of, and attempt to avoid unnecessary contact with body fluids, utilize appropriate personal protective equipment (PPE) to limit personal exposure and disease transmission. Additional risk of disease transmission occurs during doffing of PPE, and due care must be exercised when doffing PPE, performing hand hygiene after the call, and disposing of contaminated supplies.


FOCUS ON CPR AND DEFIBRILLATION The most important treatment for the cardiac arrest patient is rapid CPR and early defibrillation; seconds count. The focus in Toronto on excellent emergency cardiac care produced striking improvements in survival rates.

The key steps are: • Rapidly access the patient • Assess level of consciousness and pulse • Turn on the AED if the patient is unresponsive • Begin CPR if there’s no pulse • Follow the AED voice prompts HIGH QUALITY CPR AND DEFIBRILLATION The Zoll AED Pro defibrillators provide real-time CPR feedback to help deliver at least two inch chest compressions, at 100 com-pressions per minute, with full chest recoil between compressions. There are several key elements to providing high quality CPR:

• Minimize delays. Rapidly move the patient to a flat area, start CPR, and apply the AED.

• Minimize interruptions in CPR. Every interruption in CPR decreases blood flow to vital organs.

• If there is a “No shock advised”, resume CPR without a pulse check. This is in keeping with the 2010 Emergency Cardiac Care guidelines and should increase the amount of time spent providing blood flow to the brain and vital organs.

• If there is a “Shock advised”, provide a full fifteen chest compressions during AED charging prior to delivering any shock. Recent research indicates that CPR interruptions decrease survival and must be kept to a minimum. When the device begins to charge, fifteen chest compressions must be completed prior to shocking the patient.


• Provide deep compressions, allowing full chest recoil so that blood is pumped out of the chest with each compression, and flows back with each up-stroke.

• Follow the CPR feedback prompts. Listen for the “Good compressions prompt.” Match the compressions to the rate of the metronome beeps and watch the depth gauge on the AED to provide at least two inch chest compressions.

• Follow the voice prompts. Stop CPR only when prompted by the defibrillator, and resume immediately when prompted to do so.

DEFIBRILLATION FOR INFANTS AND CHILDREN The AED must be applied to VSA infants or children of any age (except neonates – see Special Considerations). The electrode position and CPR technique has to be modified for very young patients.

PARTICIPATION IN MEDICAL RESEARCH Toronto Fire Services continues to be a leader in medical research, sometimes leading to improved treatments for cardiac arrest. Periodically, new resuscitation techniques may be trialed in Toronto to help improve cardiac arrest outcomes. The best way to test new treatments is by using them in a medical trial, and Toronto Fire Services is a participant in the Resuscitation Outcomes Consortium (ROC) trials of cardiac arrest.

PREHOSPITAL DNR Firefighters continue to provide comfort to families when faced with a terminally ill patient and a properly completed OFM DNR form. If a DNR is available, stopping unwanted resuscitation efforts is a compassionate response to patients at the end of their lives.


NOTE FROM THE MEDICAL DIRECTOR I am proud to serve as Medical Director for Toronto Fire Services. Sunnybrook and Toronto Fire Services work together to provide the best possible first responder training and medical care for patients before ambulance arrival. Our program has relied on the contribution and skills of our firefighters, and I encourage firefighters to provide feedback and ask the questions which help continually improve the firefighter prehospital care program.

Michael Feldman PhD, MD, FRCPC Medical Director, Firefighter Prehospital Care Program [email protected]


PERSONAL PROTECTIVE EQUIPMENT

1. ROUTINE PPE FOR ALL MEDICAL CALLS • Disposable medical gloves • Protective eye wear (safety glasses) • Bunker pants and boots

2. PPE FOR ACTIVE AIRWAY MANAGEMENT When active airway management is required (airway insertion, suction, bag-valve-mask ventilation, CPR, assisting with intubation, etc.), firefighters shall wear an N95 mask, in addition to the routine PPE requirements above. 3. PPE FOR COMMUNICABLE ILLNESS, BODY FLUIDS, OUTBREAK CONDITIONS When there is a suspicion of communicable illness or fever, or when there is a risk of contact with patient body fluids, firefighters shall wear a bunker coat or disposable gown and an N95 mask, in addition to routine PPE requirements above. When there is a communicable disease outbreak in the community, the medical director may from time to time issue a directive that requires firefighters to wear additional PPE as specified in applicable FCCs, in addition to routine PPE requirements above. The firefighters may additionally be required to screen for specific illness risk factors, by asking about symptoms or travel history.


The following table summarizes the PPE requirements for medical calls:

Bunker Pants & Boots, Gloves, Safety Glasses

N95 Mask Gowns or Bunker Coat

Coveralls, Double Gloves, Face Shields (additional PPE)

All Calls • Active airway management

• Contact with body fluids

• Suspected communicable illness

• Outbreak conditions

• Contact with body fluids

• Supected communicable illness

• Outbreak conditions

• Outbreak conditions with specific symptoms AND travel history

• Details as per FCC


CARDIAC ARREST MEDICAL DIRECTIVE A firefighter certified in defibrillation will use the following protocol for treatment of victims of cardiac arrest unless excluded as shown below. INDICATIONS This directive applies to any patient who presents in cardiac arrest (Vital Signs Absent – VSA).

EXCLUSIONS The following patients are excluded by this protocol: 1. Valid DNR form (see “Prehospital DNR”, page 21). 2. Obvious death (see “Obvious Death Procedure”, page 20). PROCEDURE 1. Establish level of alertness. If unresponsive, turn on the Zoll AED

Pro automatic external defibrillator (AED). 2. All firefighters will don PPE for airway management as outlined

(page 6). If a gown is necessary, all firefighters must also don a gown.

3. The AED will announce “Unit Okay. Place defib pads on patient’s bare chest.” One firefighter will open the airway and simultaneously check for breathing and pulse. There may be deep, gasping breaths for a few minutes after the heart stops. If there is no pulse, the firefighter will immediately announce the patient is VSA and begin continuous chest compressions. If the patient is found to have a pulse, the AED may be turned off.

4. The second firefighter will apply defibrillation pads as quickly as possible while chest compressions are continuing. Chest compressions may be interrupted transiently during this process.

5. The AED will announce “Stop CPR. Do not touch patient. Analyzing.”


6. If the AED announces “Shock advised”, resume CPR and provide fifteen compressions while the AED is charging. Stop CPR again after the full fifteen compressions have been completed and ensure no personnel are touching the patient when the shock is being delivered. Deliver the shock safely and resume CPR immediately after a shock. No pulse check is needed.

7. If the AED announces “No shock advised”, resume CPR immediately. No pulse check is needed.

8. While one firefighter is providing chest compressions, another will set up oxygen and airway equipment. As soon as feasible, apply the bag-valve mask with a one-handed seal. If in the continuous compressions arm of the trial, ventilate once every tenth compression, without interrupting compressions. If in the 30:2 arm of the trial, ventilate at a ratio of 2 breaths to every 30 compressions (ventilations remain at 2 breaths every 15 compressions for infants or children).

9. Rescuers will switch roles with every “Stop CPR. Do not touch patient. Analyzing.”

10. Continue CPR, stopping only to analyze and shock if prompted, or when paramedics assume responsibility for the patient.

11. CPR may be stopped if there are obvious signs of life (breathing or moving). Presence of a pulse must be confirmed at this point. Please note that VSA patients may continue to breathe (called ‘agonal respirations’). In a patient with agonal respirations, a pulse must be checked. Resume CPR if a patient has agonal respirations but no pulse.

12. If there is a return of pulse, turn off the AED but leave the pads on the patient. Recheck the pulse every 60 seconds because there is a high risk of re-arrest. Obtain a set of vital signs as soon as possible after the restoration of a heartbeat.

See “Cardiac Arrest Flow Chart,” page 11.


CARDIAC ARREST FLOW CHART


DEFIB PAD PLACEMENT FOR ADULTS, CHILDREN, INFANTS

For a child, place the right pad on the upper right front of the chest, and the left pad on the lower left side of the chest. The accelerometer is removed and manually placed in the correct position on the sternum. For infants, the pads are placed on the front and back of the chest, and the accelerometer left off.


SPECIAL CONSIDERATIONS COMPRESSION-ONLY CPR Compression-only CPR means performing uninterrupted chest compressions only at a rate of 100 compressions per minute without administering ventilations. Circulating the blood without ventilations uses the blood’s own store of oxygen which can last several minutes. It is performed only until the defibrillation pads have been attached and all airway equipment is readied. Following this, CPR with ventilations will be used. Certain situations where compression-only CPR should not be used are listed below. CARDIAC ARREST WITNESSED BY FIREFIGHTERS OR PARAMEDICS The priority is to immediately apply the AED and deliver a shock as soon as possible if prompted. Turn on the AED when the patient arrests. Start CPR if it takes more than a few seconds to apply the AED electrodes. If the AED has not automatically prompted “Stop CPR. Do not touch the patient. Analyzing.” then press the ANALYZE softkey. Follow the voice prompts.

TRANSFER OF CARE FROM A PUBLIC LAY RESPONDER USING AN AED TO A FIREFIGHTER Assess the patient’s level of awareness and pulse. • If the patient has no pulse, follow the cardiac arrest medical

directive as in an unwitnessed arrest. • If the patient has a pulse and has received shocks, apply the

TFS AED but do not turn it on. Be prepared in the event of a re-arrest.

• If patient has a pulse and has received no shocks they may not have ever been VSA.

Provide medical care appropriate for the patient condition. For complete directive see “Transfer of Care from an AED-Equipped Public Lay Responder,” page 16.


TRAUMATIC OR UNUSUAL/NON-CARDIAC CAUSES OF CARDIAC ARREST Choking/asphyxia/drowning/hanging are considered to be asphyxiation. Treatment must include spinal protection if spinal trauma is suspected (hanging from a height, trauma to the neck, diving headfirst into water). In lightning strikes and electrocution the patient may be treated using the AED as per directive. Where multiple patients are involved, treat patients in respiratory or cardiac arrest first. Treatment must include spinal protection due to possible fractures from intense muscle contraction. Hypothermia If the patient is suspected of being hypothermic: • Take 30-45 seconds to perform a pulse check. • Use the AED medical directives and allow the defibrillator to

complete one analysis only. If indicated, deliver a single shock as per the shock protocol.

• After the first analysis (and shock if necessary) is complete, turn off the defibrillator after receiving the “Start CPR” voice prompt.

• Further shocks and analyses are unlikely to help until the patient is rewarmed in the hospital. Continue CPR until you transfer care to a paramedic crew.

• If possible, remove or protect the patient from exposure to the elements. Immediately initiate measures to reduce heat loss. Cut off all wet clothing and cover the patient as quickly as possible with blankets.

• Rough handling may cause ventricular fibrillation. • Consider C-spine protection if trauma is suspected.


TRAUMA If the patient is suspected to have had a traumatic cardiac arrest, as defined as obvious severe injuries to the head or torso; or a mechanism of injury likely to cause severe injury such as a fall from a significant height, motor vehicle collisions, etc: • Use the AED medical directives and allow the defibrillator to

complete one analysis only. If indicated, deliver a single shock as per the shock protocol.

• After the first analysis (and shock if necessary) is complete, turn off the defibrillator after receiving the “Start CPR” voice prompt.

• If the patient died from trauma, further shocks and analyses are unlikely to help. Continue CPR until you transfer care to a paramedic crew.

• Avoid movement of the patient when possible. • If possible, protect the patient from exposure to the elements.

Cover the patient as quickly as possible with blankets. • Always maintain C-spine protection. PERMANENT PACEMAKER If possible, avoid putting the defibrillator pads over or near the pacemaker as the AED may damage the implanted pacemaker.

AUTOMATIC IMPLANTABLE DEFIBRILLATORS Implantable defibrillators work in a similar manner to an AED but \use much lower, safer voltages. A patient may feel the painful shocks internally, but it is safe for firefighters to touch a patient with an automatic implantable defibrillator, even if it is firing. If possible, avoid putting the defibrillator pads over or near the implanted defibrillator as the AED may damage it. If required, use CPR and follow Shock or No Shock protocol as required.

CONDUCTIVE SURFACES It is safe to proceed with cardiac arrest protocols on ice, snow, wet grass or concrete/pavement etc. However, if a patient is lying on metal or in a puddle, move the patient to a suitable surface and begin cardiac arrest protocols.


INFANT AND CHILD CARDIAC ARRESTS

The AED Pro may be used on children and infants of any age. Neonates (under 24 hours old) are treated according to protocols outlined in the Obstetrical Emergencies module (no AED needed for under 24 hours old).

If a child or infant suffers a cardiac arrest, start compression-only CPR at 100 compressions per minute and apply the AED. When ready, start ventilations at a compression to ventilation ratio of 15:2. Use only enough oxygen for ventilation to achieve visible chest rise.

When applying the defibrillator pads to a child, every effort must be made to place the right pad on the upper right front part of the chest, and the left pad on the lower left side of the chest. The accelerometer may be removed and manually placed in the correct position on the sternum. For infants, the pads are placed on the front and back of the chest, and the accelerometer left off.

For children over one year, use the heel of one hand for chest compressions. Compress the chest so that it is depressed one third to one half its original depth. For infants (<1 year), use two fingers and compress the chest so that it is depressed one third to one half its original depth. You may ignore the ‘Push harder’ voice prompt, and there is no need to watch the black depth bar on the AED Pro screen.

TRANSFER OF CARE FROM AN AED-EQUIPPED PUBLIC LAY RESPONDER Firefighters who attend to an apparent cardiac arrest patient where an AED has been applied by a lay responder, will assume the care of the patient, using the following Medical Directive whenever possible. Firefighters must be prepared to assume care of the patient immediately. Firefighters will not operate any AED other than the Toronto Fire Services-supplied AED, except to turn off and remove a lay responder AED.


1. Identify yourselves as Toronto Fire Services to the lay responder, and determine how many shocks (if any) have been delivered.

2. Firefighters must be especially diligent in ensuring that no one is touching the patient if the lay responder delivers a shock with their AED.

3. When taking over care, firefighters will initially check responsiveness and check for a carotid pulse. Simultaneously, assist the lay responder to turn off and remove their AED and defibrillation pads. (See Transfer of Care flow chart, page 16).

a) If no carotid pulse is present, follow AED medical directives as for unwitnessed cardiac arrest.

b) If a carotid pulse is found, and the patient has previously been shocked by the lay responder, apply your AED. These patients are very likely to arrest again. Support ventilation, monitor the patient closely for chest rise, and perform frequent carotid pulse checks, as per protocol. Obtain a set of vital signs. If the patient re-arrests, immediately turn on the Fire Services’ AED and push the “ANALYZE” button. Follow the appropriate AED medical directives.

c) If a carotid pulse is found, and the lay responder has delivered no shocks, do not assume the patient was VSA. Do not apply your AED. Support ventilation if necessary and perform frequent carotid pulse checks and assess vital signs. Be prepared to initiate the AED medical directives if the patient loses their carotid pulse.

4. Obtain history from the lay responder. Use the lay responder if necessary in other aspects of scene management (e.g. translation).

5. Immediately report all cases to the Base Hospital (via your EMS Section Command Coordinator) involving the use of a lay responder AED.


6. Instances may occur where an advanced-trained lay responder (such as an off duty paramedic, nurse, or other health care worker) is providing advanced care beyond the firefighters’ scope of practice. The advanced skills of the lay-responder will be evident when they identify themselves, or in their use of specialized equipment (e.g. endotracheal intubation, and/or medications, etc). In these rare cases, the firefighter should offer assistance and assume a supportive role.

INTERACTION WITH A PHYSICIAN ON SCENE Procedure 1. If the caregiver identifies themselves as a physician, identify

yourself as Toronto Firefighter certified by a base hospital physician to use the AED.

2. If firefighters have already initiated care, give the physician a brief verbal report that includes the following information: a) Witnessed or unwitnessed cardiac arrest b) The number of shocks you have delivered, if any c) Whether there has been a return of a pulse

3. Request permission to continue your defibrillation protocol using the AED. (Do not assume the physician knows how to use it.)

4. Follow all instructions given to you by the physician on-scene within the limits of your training and Toronto Fire Services Medical Directives.

5. Allow the physician to use the TFS AED at his/her request.

6. Be prepared to resume your AED Medical Directives at any time upon the request of the physician.

7. Document the physician’s name.


TRANSFER OF CARE TO PARAMEDICS Paramedics will assume responsibility for overall patient care when patient contact is made. 1. Firefighter will provide a verbal report that includes the following:

a) Total number of shocks. b) Total number of “No shock advised” prompts that were

received. c) Presence or absence of a return of spontaneous circulation. d) Witnessed or unwitnessed arrest. e) Presence or absence of bystander CPR; who initiated CPR;

How long had CPR been performed? f) Time patient was last seen before collapse/arrest. g) Vital signs, if obtained on a patient with a pulse.

2. Paramedics will switch to their own defibrillator at TFS AED analysis. If first on scene, firefighters must attempt to COMPLETE AT LEAST ONE ANALYZE CYCLE before handing over care. Once the analysis has begun, firefighters will complete the analysis shock if indicated.

3. A firefighter who is completing compression-only CPR, waiting for the AED to perform a rhythm analysis, or delivering a shock shall continue until completion of that task before handing over care.

4. Utilize all necessary personnel to assure rapid and smooth transfer of care.

5. Paramedic defibrillators utilize technology that reduces or eliminates the need for compressions during charging, by greatly reducing or eliminating the time for charging. They may defibrillate rapidly after recognizing the need for a shock. Follow directions of the paramedics.


DETERMINATION OF OBVIOUS DEATH A patient can be considered “obviously dead” if the patient is: a) Vital Signs Absent

and

b) has one or more of the following findings: – decapitation (severing of the head), or – transection (severing of the body), or – decomposition (putrefaction), or – gross charring or incineration of the body, or – open head or torso wounds with gross outpouring of

contents, or – gross rigor mortis, consisting of all of the following:

– stiffness of all limbs and body, and – coolness to the touch of all parts of the body, especially

the core, and – dependent or fixed lividity (mottled discolouration due to

blood pooling in the lower areas of the body) THE PROVIDER MUST BE CERTAIN THAT OBVIOUS DEATH HAS OCCURRED. FULL RESUSCITATIVE EFFORTS, INCLUDING USE OF THE AED, MUST BE MADE IMMEDIATELY IF ANY DOUBT EXISTS. ALWAYS ERR ON THE SIDE OF RESUSCITATION IF YOU ARE UNCERTAIN WHETHER OBVIOUS DEATH EXISTS. HYPOTHERMIC PATIENTS CAN EXHIBIT MANY OF THE SIGNS OF RIGOR MORTIS. NEVER ASSUME DEATH IN A HYPOTHERMIC PATIENT.


PREHOSPITAL DNR AND EXPECTED DEATH Ontario Do No Resuscitate Confirmation Forms are recognized by Toronto Fire Services firefighters rendering emergency patient care. A sample DNR confirmation form is shown below:


When firefighters arrive at the scene of a cardiac arrest, they will initiate patient care as per the “Cardiac Arrest Medical Directive”. If presented with an Ontario DNR Confirmation Form, one of the firefighters (usually the company officer) will verify that it bears a serial number in the upper right, and that the following four items are completed correctly: • Correct name of patient • A check mark in one of the boxes indicating CPR is not part of the

plan of treatment • Name and profession of the health care provider • Signature and date when the form was completed. A photocopy of the form is acceptable. No other type of DNR form may be accepted by firefighters. Verbal orders to discontinue resuscitative efforts made by a physician, in person, directly to the officer in charge at the scene will be respected. The officer in charge must be satisfied that the person making the request is indeed a physician licensed to practice in Ontario. Before the officer in charge authorizes stopping resuscitation, the physician must indicate that s/he will assume responsibility for the patient and will remain on scene until the arrival of an ambulance crew. If the physician does not comply with the requests of the fire officer, the “Cardiac Arrest Medical Directive” will be initiated. In the absence of a DNR Confirmation Form or a physician on scene, if there is any attempt to prevent firefighters from carrying out their resuscitative efforts, police assistance should be requested as early as possible. Any incident of this nature must be thoroughly documented. Any difficulties implementing this policy are to be directed to the Base Hospital Medical Director or EMS Section Command Coordinator within 24 hours.


GUIDELINES FOR EXPECTED DEATH IN THE HOME WHEN THERE IS NO DNR CONFIRMATION FORM

PURPOSE These guidelines are intended to provide firefighters with clear procedures to follow when faced with caregivers or family members who refuse to allow resuscitation of a patient. CONDITIONS These guidelines are intended for use ONLY IN CASES OF EXPECTED DEATH IN RESIDENCES and ONLY WHEN THERE IS NO ACCOMPANYING ONTARIO DNR CONFIRMATION FORM. Various factors at the scene can substantiate the expected nature of a death. These may include, but are not limited to:

• history of a terminal illness presented to the firefighter (e.g. cancer, AIDS, etc);

• evidence of physical wasting (e.g. gaunt or emaciated appearance);

• jaundice (profound yellowing of the patient’s skin and eyes, indicating liver failure);

• catheters in place in the patient (plastic tubes leading from the patient’s nose, mouth, chest or abdomen);

• presence of home care equipment in the home (hospital-type bed, intravenous equipment, bedpans, urinals, etc);

• presence of highly potent narcotic analgesics, such as morphine, hydromorphone, or oxycodone in tablet or intravenous form.

IN CASES INVOLVING SUSPICIOUS CIRCUMSTANCES, OR WHERE THE DEATH DOES NOT APPEAR TO BE EXPECTED, THE FIRE CREW MUST INSIST ON RESUSCITATING THE PATIENT. POLICE ASSISTANCE SHOULD BE OBTAINED IF WARRANTED.


PROCEDURE 1. IN ALL CASES WHERE A VSA PATIENT IS ENCOUNTERED,

FULL RESUSCITATION, INCLUDING DEFIBRILLATION IF INDICATED, MUST BE INITIATED.

2. If a family member or caregiver refuses to allow resuscitation, or requests the fire crew not resuscitate the patient, the company officer will ask if the family has an Ontario DNR Confirmation Form. If they do not produce one, the officer will explain the obligations of the firefighters to resuscitate. If resuscitation has started, the other crew members should continue with resuscitation during this time.

3. If the family member or caregiver again refuses resuscitation, or again asks that no resuscitation occur, the officer will again explain the obligation to resuscitate and proceed with resuscitation.

4. If the officer determines that continuing or attempting resuscitation could result in physical or verbal confrontation, resuscitation attempts can be discontinued.

5. Update Toronto Fire Communications that resuscitation has been discontinued at the insistence of family or caregiver. Report families’ refusal to paramedics arriving on scene.

6. Complete documentation is essential in these cases. Full reporting of the incident must be forwarded to the Base Hospital, including circumstances of the call, observations at the scene, assessment of the patient, discussions with the family member(s) or caregiver(s), and actions taken.


EPINEPHRINE FOR ANAPHYLAXIS MEDICAL DIRECTIVE DESCRIPTION There are two commercially available epinephrine injection kits for emergency intramuscular use. After injection into the muscle, the medication is rapidly circulated throughout the body to combat the symptoms of anaphylaxis. Epipen/Epipen Jr. The Epipen is an auto-injector that injects 0.3 mg of epinephrine into a muscle. The Epipen Jr. is a pediatric autoinjector for children that injects 0.15 mg of epinephrine into a muscle. Allerject The Allerject is an auto-injector that injects 0.3 mg of epinephrine into a muscle. A pediatric version is similar in all respects except that the dose of epinephrine is 0.15 mg. The device provides verbal instructions when the package is opened. *The Twinject device is no longer produced. INDICATION AND USAGE Epinephrine is indicated in the emergency treatment of severe allergic reaction (anaphylaxis) to insect stings or bites, foods, drugs and other allergens as well as idiopathic (no obvious cause) or exercise-induced anaphylaxis. The epinephrine auto-injector is intended for immediate administration to a person with a history of an anaphylactic reaction. Such reactions may occur within seconds or minutes following exposure to an allergen (a foreign substance that provoked the reaction). The epinephrine auto-injector is designed as emergency supportive therapy only and is not a replacement or substitute for immediate medical or hospital care.


CONTRAINDICATIONS There are no absolute contraindications to the use of epinephrine in life-threatening anaphylaxis. PHARMACOLOGY Epinephrine is a naturally occurring stress hormone released by the body that counteracts the low blood pressure, facial or throat swelling, and shortness of breath in anaphylaxis. Epinephrine has a rapid onset and a short duration of action. WARNINGS Epinephrine is light and temperature sensitive and should be stored in the tube provided. If a vehicle is to be stored outdoors in freezing temperatures for greater that one hour, remove the auto-injectors from the vehicle. The Auto-Injector should only be injected into the thigh. Do not inject into buttock. Chest pain or angina may be induced by epinephrine in patients with heart disease. ADVERSE EFFECTS Minor side effects of epinephrine include the following: palpation, respiratory difficulty, pallor, dizziness, weakness, tremor, head-ache, throbbing, restlessness, anxiety and fear. Serious side effects are rare but cardiac arrhythmias may follow administration of epinephrine. FIREFIGHTER ADMINISTRATION OF EPINEPHRINE DURING ACUTE ANAPHYLAXIS When the listed indications and conditions exist, a firefighter who has completed the didactic and practical training module on anaphylaxis can administer an epinephrine auto-injector (Over age 12, over 40 kg – 0.3 mg; children under 12, or patients under 40 kg – 0.15 mg) in accordance with the following protocol.


INDICATIONS 1. Any patient who: 2. Has a known allergy, and 3. Has previously been prescribed an epinephrine auto-injector, and 4. Has been exposed to or is suspected of having been exposed to

an allergen, and 5. Demonstrates signs and symptoms of a severe allergic reaction

(anaphylaxis) such as: dyspnea, respiratory wheezes, airway stridor, generalized hives, facial or oral or tongue swelling, hypotension (BP< 90 systolic), and

6. Is incapable of self-administrating their prescribed epinephrine auto-injector OR has no trained family member available or willing to administer the prescribed epinephrine auto-injector, and

7. Paramedics have not yet assumed care of the patient.

The firefighter will administer Epinephrine to a patient by means of an epinephrine auto-injector. CONDITIONS 1. Patient has not received 2 doses of epinephrine, either self-

administered or by another person, within 30 minutes since the onset of anaphylaxis.

PROCEDURE 1. Check level of responsiveness, airway, breathing, and pulse.

Ensure airway patency if needed. Ensure the patient has an adequate respiratory rate and volume. Perform ventilatory assistance using a BVM if needed. Administer oxygen (100%) via non-rebreather mask.

2. Inspect the epinephrine auto-injector for the presence of brownish discoloration or precipitate, and verify drug expiry date. Firefighters will not administer any epinephrine auto-injector that is found to have expired, contain precipitate, or is discoloured.


3. Administer the epinephrine auto-injector into the thigh. ADULTS >12 years, >40 kg 0.3 mg ADULTS ≤40 kg 0.15 mg CHILDREN ≤12 years 0.15 mg

4. If NO significant improvement in the patient’s condition occurs, the firefighter will administer a second epinephrine auto-injector if available within 5 minutes following the initial injection. Firefighters will not administer more than 2 epinephrine auto-injector doses to any patient.

5. Any patient who receives an epinephrine auto-injector dose requires paramedic transport to the hospital.

6. Monitor and document vital signs and level of alertness every 5 min.

7. The report to the paramedics should include the standard information outlined in the SOG G-EMSR. In addition, report the number of doses of epinephrine, the vital signs, and the response to treatment.

8. Upon return to the fire station, document in Emergency Incident Report each epinephrine auto-injector dose given (maximum 2 doses). Document any changes in patient condition that were noted.


DOCUMENTATION AND DATA MANAGEMENT DOCUMENTING MEDICAL CARE All procedures performed using delegated medical acts must be documented in the Toronto Fire Services Emergency Incident Report. DOCUMENTATION OF CARDIAC ARREST CARE Application of the AED must be indicated by selecting “Defibrillation by AED” (even if no shocks were delivered) and CPR must be documented by selecting “CPR” as seen below.

CPR DEFIBRILLATION BY AED


UPLOADING DEFIBRILLATOR DATA Upon returning to the fire hall from after the Zoll AED Pro defibrillator was used, the firefighters will position the defibrillator near the designated host computer, launch RescueNet Code Review, and transfer the case from the internal memory of the defibrillator to the host computer via IRDA port. Once the case is transferred, the Toronto Fire Services incident number is entered and the file then saved. Exit RescueNet Code Review. Do not interrupt the file transfer window which launches immediately after Code Review is closed.

Click to start upload

Enter incident number


DOCUMENTATION OF EPINEPHRINE ADMINISTRATION Administration of epinephrine auto-injector must be indicated by selecting “Medications Therapy” on the Emergency Incident Report.

Medications Therapy


DEFIBRILLATOR REFERENCE

ZOLL AED PRO TECHNICAL OVERVIEW Weight With battery: 2.70 kg Temperature Operating: 0 to 50º C Storage: -30 to 70º C Battery Type: Lithium Manganese Dioxide (LiMnO2) disposable Life: 15 hours of continuous use or 300 shocks Shelf life: >5 years Cleaning Wipe with disinfectant wipes or a damp cloth soaked with a dilute solution of soap and water or dilute bleach. Do not immerse the unit in any cleaning solution. Defibrillation The AED Pro uses a rectilinear biphasic waveform. The shocks are delivered at 120, 150, 200 joules. All further shocks are also delivered at 200 J. Memory The defibrillator can store up to four cardiac arrests in internal memory. Memory is automatically cleared after cases are uploaded to a host computer. CPR Stat PADZ The defibrillator pads come as a two-piece assembly with three distinct parts. The red, right sided pad is placed with the accelerometer centred over the sternum and between the nipples. The blue, left sided pad is placed on the left side below the left nipple. Paramedics may use alternate sites for the pads (such as the patient’s back) when they are caring for the patient.


TROUBLESHOOTING Unit beeps and displays a red X while turned off: turn the unit on and follow voice prompts to resolve the problem. If problem persists, take the unit out of service. Unit beeps and displays a red X while turned on: turn the unit off and on and follow voice prompts to resolve the problem. If problem persists, take the unit out of service. Power-on self test fails: turn the unit on and follow the voice prompts. If problem persists, take the unit out of service. Unexpected shutdown: turn the unit on and follow the voice prompts. If problem persists, take the unit out of service. The unit is pro-grammed to automatically shut off if not connected to a patient for 10 minutes. Message: “Check defib pads.” Ensure there is good adherence of defibrillator pads to patient’s chest. Dry and shave the patient’s chest if necessary. Replace with a fresh set of pads. Message: “Analysis halted. Keep patient still.” Check for proper pad adhesion as above. Ensure the patient is not moving and that no one is touching the patient. Message: “Defib maintenance required.” Take the unit out of service.


ACKNOWLEDGMENT We acknowledge the support of Toronto Fire Services in the development and implementation of Firefighter Prehospital Care Program including: Fire Chief J.W. (Jim) Sales Deputy Chief Ron Jenkins District Chief Scott Andrews Captain Ken Webb Captain Michael Nemeth Captain Gordon Thomson Captain Ted Lamch Captain Al Thomas

firefighter prehospital care...

Documents