Synchronized Cardioversion
- Assesses patient, donning appropriate PPE.
- Identifies need for treatment.
- Patient with a symptomatic tachyarrhythmia
- Altered mental status
- ongoing chest pain
- other signs of shock
- Age ≥ 18 years
- Heart Rate ≥ 120 (wide) or ≥ 150 (narrow)
- Hypotension SBP < 90 mmHg
- Identifies equipment required:
- Cardiac Monitor
- IV equipment
- Defib pads
- Airway equipment (oxygen), including BVM
- Suction equipment
- Mandatory patch point to proceed with synchronized cardioversion and requests analgesia/sedation orders if appropriate.
- Attaches ECG electrodes. Confirms and interprets the rhythm. Adjusts lead and amplitude as required.
- Establishes IV access
- Applies the pads in the manufacturer recommended position.
- Administers analgesia/sedation if appropriate.
- Explains procedure to the patient.
- Selects joule setting (device dependent). Administer up to three shocks in accordance with BHP direction and energy settings. (In the setting of a patch failure the energy settings to be used are 100J, 200J and the maximum manufacturer setting.)
- Presses “sync” button. Looks for synch marker (↓) above each R wave.
- Presses the charge button.
- Presses and holds the shock button until shock is delivered.
- Presses sync button for subsequent shocks.
- Evaluates the patient after each shock. If the patient’s condition worsens, if rhythm changes or cardioversions are unsuccessful, contact BHP.
Transcutaneous Pacing
- Assesses patient, donning appropriate PPE.
- Identifies need for treatment.
- Patient with a pulse and ventricular rate < 50 AND patient is clinically unstable secondary to bradycardia AND systolic BP < 90 mm/hg.
- Patient is ≥ 40 kg.
- Confirms that conditions for treatment are satisfied and that there are no contraindications to treatment.
- Hypothermic patients.
- Identifies equipment required:
- Cardiac Monitor
- IV equipment
- Pacing pads
- Airway equipment (oxygen), including BVM
- Suction equipment
- Exposes the patient’s chest.
- Attaches ECG electrodes. Confirms and interprets the rhythm. Adjusts lead and amplitude as required.
- Establishes IV access.
- Applies the pacing pads in the manufacturer’s recommended position.
- Considers Procedural Sedation, if appropriate.
- Explains procedure to the patient.
- Places the cardiac monitor in “Pacing” mode.
- Sets pacing rate at 80 and then increases output (milliamps) slowly until electrical and mechanical capture is achieved. Re-confirms these values often. Increases output by another 10 milliamps to ensure consistent capture.
- If capture is unsuccessful after one minute at maximum milliamps, discontinues pacing attempts and consults with BHP.
- If TCP is not available, considers patching to BHP for Dopamine.
Endotracheal Intubation
- Assesses patient, donning appropriate PPE.
- Identifies need for treatment. Patient meets indications for treatment under one or more Medical Directives.
- Airway control AND
- Other airway management is inadequate or ineffective
- Confirms that conditions for treatment are satisfied
- Lidocaine Spray – orotracheal intubation
- AND that there are no contraindications to treatment
- Lidocaine Spray – allergy or sensitivity to lidocaine, unresponsive patient
- Age <50 years AND current episode of asthma exacerbation AND not in a near cardiac arrest.
- Performs airway assessment using: LEMON
- Look externally (facial trauma, large incisors, beard or moustache and large tongue).
- Evaluate the 3-3-2 rule (incisor distance < 3 fingerbreadths, hyoid/mental distance < 3 fingerbreadths, thyroid-to-mouth distance < 2 fingerbreadths).
- Mallampati (mallampati score > 3).
- Obstruction (presence of any condition that could cause an obstructed airway)
- Neck mobility (limited neck mobility).
- Checks if patient has a gag reflex by oral airway insertion .
- Suctions and clears the airway as required.
- Pre-oxygenates. BVM with 100% O2 for 30-60 seconds.
- Prepares ETT:
- Chooses appropriate size
- Checks for cuff leaks (injects maximum volume)
- Deflates cuff
- Lubricates distal end of ETT, if required
- Precaution: C-Spine.
- Inserts the ETT:
- Pays attention to teeth for trauma
- Identifies vocal cords
- Depth of insertion adequate
- Proper use of B-U-R-P maneuver
- Confirms ETT placement using at least 2 primary methods:
- ETCO2
- Auscultation
- AND one secondary method
- EDD
- other
- Secures Endotracheal tube: SET protocol.
- Placement / No displacement
- Tube fixation
- C-spine collar & Backboard
- Clear/Plan/Command each patient movement
- Verification after each patient movement
- Documentation of ETT confirmation after each patient movement.
- Troubleshooting ETT.
- BVM and transport as initial back-up or after 2 ETT attempts
- 2 attempts are defined as insertion of the laryngoscope into the mouth
Central Venous Access Devices
- Assesses patient, donning appropriate PPE.
- Identifies need for treatment. Patient meets indications for treatment under one or more Medical Directives;
- Actual or potential need for intravenous medication OR fluid therapy AND
- IV access is unobtainable AND
- Cardiac Arrest OR near arrest state
- Confirms that conditions for treatment are satisfied and that no contraindications to treatment exist.
- Patient has a pre-existing, accessible central venous catheter in place.
- Cleans access area with alcohol and allows it to dry.
- Ensures line is clamped.
- Removes cap if applicable and adds 10cc syringe (no air in syringe).
- Unclamps line.
- Aspirates 5cc of blood (if using PICC line, needs to insert 10cc NS prior to aspirating).
- Clamps line.
- Discards blood.
- Attaches line/syringe, unclamps line and infuses fluid/drug. If drug, line needs to be flushed with 10cc of NaCl.
- Updates the receiving hospital and documents procedure accordingly.
- Is able to troubleshoot CVAD – if flow is impeded.
- Line unclamped?
- Line kinked?
- Patient position impeding flow?
- Knows at least five (5) possible complications:
- Embolism
- Occlusion
- Catheter Damage
- Infection
- Infiltration, Extravasations
- Skin erosion, Hematoma
- Dislodgment
- Pneumothorax
