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Basic Life Support
Patient Care Standards
Version 3.0.1
Comes into force December 11, 2017
Emergency Health Services Branch
Ministry of Health and Long-Term Care
To all users of this publication:
The information contained in the Standa
rds has been carefully compiled and is believed to be accurate at
date of publication.
For further information on the Basic
Life Support Patient Care Standards, please contact:
Emergency Health Services Branch
Ministry of Health and Long-Term Care
5700 Yonge Street, 6th Floor
Toronto, ON M2M 4K5
416-327-7900
© Queen’s Printer for Ontario, 2016
Document Control
Version
Number
Date of Issue Comes into Force
Date
Brief Description of Change
3.0
July 2016 N/A (amended prior
to in force date)
Full update. See accompanying training
bulletin for further details
3.0.1
November 2016 December 11, 2017 Update to Paramedic Prompt Card for Acute
Stroke Protocol: Contraindication changed
from “CTAS Level 2” to “CTAS Level 1”.
Table of Contents
Preamble ............................................................................................................................. 7
Preface............................................................................................................................................. 1
Definitions....................................................................................................................................... 1
Introduction ..................................................................................................................................... 1
Research .......................................................................................................................................... 2
Quality Assurance ........................................................................................................................... 2
Commonly Used Abbreviations ...................................................................................................... 3
Section 1 – General Standard of Care ............................................................................... 6
Paramedic Conduct Standard .......................................................................................................... 7
General Measures Standard ............................................................................................................ 9
Patient Assessment Standard ........................................................................................................ 10
Patient Management Standard ...................................................................................................... 12
Patient Transport Standard ............................................................................................................ 13
Patient Refusal/Emergency Treatment Standard .......................................................................... 15
Reporting of Patient Care to Receiving Facility Standard ............................................................ 17
Patch to Base Hospital Physician Standard .................................................................................. 18
Regulated Health Professionals Standard ..................................................................................... 19
Transfer of Care (TOC) Standard ................................................................................................. 20
Documentation of Patient Care Standard ...................................................................................... 21
Patient Care Equipment Use Standard .......................................................................................... 22
Oxygen Therapy Standard ............................................................................................................ 23
Field Trauma Triage Standard ...................................................................................................... 24
Air Ambulance Utilization Standard ............................................................................................ 26
Spinal Motion Restriction (SMR) Standard .................................................................................. 30
Do Not Resuscitate (DNR) Standard ............................................................................................ 33
Deceased Patient Standard ............................................................................................................ 36
General Pediatric Standard ........................................................................................................... 39
Child in Need of Protection Standard ........................................................................................... 40
General Geriatric Standard ........................................................................................................... 43
Mental Health Standard ................................................................................................................ 45
Violent/Aggressive Patient Standard ............................................................................................ 48
Intravenous Line Maintenance Standard ...................................................................................... 49
Load and Go Patient Standard ...................................................................................................... 51
Police Notification Standard ......................................................................................................... 52
Sexual Assault (Reported) Standard ............................................................................................. 54
Section 2 – Medical Standards ........................................................................................ 56
Introduction ................................................................................................................................... 57
Abdominal Pain (Non-Traumatic) Standard ................................................................................. 58
Airway Obstruction Standard ....................................................................................................... 59
Allergic Reaction (Known or Suspected) Standard ...................................................................... 60
Altered Level of Consciousness Standard .................................................................................... 62
Back Pain (Non-Traumatic) Standard ........................................................................................... 63
Cardiac Arrest Standard ................................................................................................................ 64
Cerebrovascular Accident (CVA, “Stroke”) Standard .................................................................. 66
Chest Pain (Non-Traumatic) Standard .......................................................................................... 68
Dysphagia Standard ...................................................................................................................... 71
Epistaxis (Non-Traumatic) Standard ............................................................................................ 72
Excited Delirium Standard ............................................................................................................ 73
Extremity Pain (Non-Traumatic) Standard ................................................................................... 74
Fever Standard .............................................................................................................................. 75
Headache (Non-Traumatic) Standard ........................................................................................... 76
Heat-Related Illness Standard ....................................................................................................... 77
Hematemesis/Hematochezia Standard .......................................................................................... 79
Nausea/Vomiting Standard ........................................................................................................... 80
Respiratory Failure Standard ........................................................................................................ 81
Seizure Standard ........................................................................................................................... 82
Shortness of Breath Standard ........................................................................................................ 83
Syncope/Dizziness/Vertigo Standard............................................................................................ 84
Toxicological Emergency Standard .............................................................................................. 85
Vaginal Bleeding Standard ........................................................................................................... 87
Visual Disturbance Standard......................................................................................................... 89
Section 3 – Trauma Standards ........................................................................................ 90
Introduction ................................................................................................................................... 91
General Trauma Standard ............................................................................................................. 92
Amputation/Avulsion Standard .................................................................................................... 94
Blunt/Penetrating Injury Standard ................................................................................................ 95
Abdominal/Pelvic Injury ......................................................................................................... 95
Bite Injury ................................................................................................................................ 95
Chest Injury ............................................................................................................................. 96
Eye Injury ................................................................................................................................ 96
Face/Nose Injury...................................................................................................................... 97
Head Injury .............................................................................................................................. 97
Neck/Back Injury ..................................................................................................................... 99
Burns (Thermal) Standard........................................................................................................... 100
Cold Injury Standard ................................................................................................................... 102
Electrocution/Electrical Injury Standard..................................................................................... 104
Extremity Injury Standard........................................................................................................... 105
Foreign Bodies (Eye/Ear/Nose) Standard ................................................................................... 106
Hazardous Materials Injury Standard ......................................................................................... 107
Soft Tissue Injuries Standard ...................................................................................................... 109
Submersion Injury Standard ....................................................................................................... 110
Section 4 – Obstetrical Standards ................................................................................. 112
Neonate Standard ........................................................................................................................ 113
Pregnancy Standard .................................................................................................................... 115
Appendix A – Supplemental .......................................................................................... 118
Basic Life Support Patient Care
Standards
Version 3.0.1
This page has been intentionally left blank.
i
Preamble
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Preamble
Basic Life Support Patient Care Standards – Version 3.0.1 1
Preamble
Preface
The Basic Life Support Patient Care Standards (the “Standards”) is the Ministry of Health and
Long-Term Care (MOHLTC) standard by which paramedics shall provide the minimum mandatory
level of patient care in Ontario.
When providing patient care as per the Standards, a paramedic shall ensure that the patient
s
imultaneously receives care in accordance with the Advanced Life Support Patient Care Standards
(
ALS PCS).
Definitions
For the purposes of the Standards the following definitions apply:
Paramedic
Paramedic has the same definition as set out in the Ambulance Act (Ontario) and for the purposes of
the Standards includes an Emergency Medical Attendant as defined under the Ambulance Act
(O
ntario) and Regulation 257/00, as may be amended from time to time.
Patient
Patient refers to an individual for whom a request for ambulance service was made and who a
paramedic has made contact with for the purpose of assessment, patient care and/or transport,
regardless of whether or not an assessment is conducted, patient care is provided, or the patient is
transported by ambulance.
Guideline
General statements intended to provide information and guidance with respect to formulation of
working assessments, or, directing principles of preferred practices applicable to specific clinical
circumstances where a standard is not feasible or practical.
Introduction
In creating the Standards, an assessment-based approach was utilized, e.g. a standard was developed
for assessment and management of shortness of breath, rather than for asthma.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 2
Preamble
The Standards is composed of a number of sections, divided based on category (e.g. Medical
Standards, Trauma Standards, etc.). Respective sections contain various discrete standards.
The majority of standards begin with a foreword that states: “the paramedic shall”. These standards
t
hen itemize differing actions, each of which is intended to be read while considering the standard’s
foreword. It is expected that the paramedic perform all listed actions in a standard unless otherwise
stated.
The Standards is applicable at all times when a paramedic is on duty. Additionally, a paramedic will
follow any required applicable acts (e.g. Personal Health Information Protection Act, 2004
(Ont
ario)), regulations, or standards while off duty (including the Standards, as applicable).
It i
s understood that the Standards will apply to all calls for service. A patient will be present. A
paramedic will have a partner, unless on-scene alone in a first response situation (e.g. Emergency
Response Vehicle). A paramedic will have fully operational patient care equipment as per the
Provincial Equipment Standards for Ontario Ambulance Services.
There may be circumstances and situations in which complying with the Standards is not clinically
j
ustified, possible or prudent as a result of extenuating circumstances. Paramedics shall use all
knowledge, training, skill and clinical judgment to mitigate any extenuating circumstances.
Paramedics shall document in accordance with the Ontario Ambulance Documentation Standards
a
nd the Ambulance Call Report Completion Manual.
Extenuating circumstances may include:
a) Scene conditions
b) Overwhelmed resources (e.g. multi-casualty incident)
c) Equipment failure
d) Safety concerns
e) Patient location
f) Distance from receiving facility
g) Others not specified (e.g. language barrier)
Research
Clinical research is fundamental to the practice of medicine and the development of safer, more
effective treatment options for patients. At times, research protocols require temporary changes to
patient care standards. Changes to patient care standards will be approved and introduced by the
MOHLTC.
Quality Assurance
Ambulance service operators shall have a quality assurance program in place to oversee care
provided by paramedics under the Standards.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 3
Preamble
Commonly Used Abbreviations
Table 1 below outlines abbreviations commonly used in the Standards.
Table 1. Abbreviations commonly used in the Standards
Word/Phrase Abbreviation
Advanced Care Paramedic ACP
Advanced Life Support Patient Care Standards ALS PCS
Ambulance Communications Officer ACO
Ambulance Communication Service ACS
Blood Pressure BP
Canadian Transport Emergency Centre CANUTEC
Canadian Triage and Acuity Scale CTAS
Cardiopulmonary Resuscitation CPR
Central Ambulance Communication Centre CACC
Cerebrovascular Accident CVA
Cervical Spine C-spine
Children’s Aid Society CAS
Chronic Obstructive Pulmonary Disease COPD
Do Not Resuscitate DNR
Electrocardiogram ECG
End-tidal Carbon Dioxide ETCO
2
Glasgow Coma Scale GCS
Hour hr
Intravenous IV
Kilogram kg
Kilometre km
Lead Trauma Hospital LTH
Litre L
Milliequivalent mEq
Millilitre mL
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Word/Phrase Abbreviation
Basic Life Support Patient Care Standards – Version 3.0.1 4
Preamble
Millimole mmol
Ministry of Health and Long-Term Care MOHLTC
Percutaneous coronary intervention PCI
Personal Health Information Protection Act, 2004 PHIPA
Primary Care Paramedic PCP
Pulse oximetry SpO
2
Return of spontaneous circulation ROSC
Spinal Motion Restriction SMR
ST-segment Elevation Myocardial Infarction STEMI
Substitute Decision Maker SDM
Termination of Resuscitation TOR
Vital Signs Absent VSA
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1
Section 1 – General Standard of Care
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Section 1 – General Standard of Care
Basic Life Support Patient Care Standards – Version 3.0.1 7
Section 1 – General Standard of Care
Paramedic Conduct Standard
Paramedic Conduct
The paramedic shall:
1. conserve life, alleviate pain and suffering, and promote health;
2. protect and maintain the patient’s s
afety, dignity and privacy;
3. provide care based on human need with respect for human dignity;
4. demonstrate empathy and compassion for patients and their families;
5. provide patient care until it is no longer required or until another appropriately qualified
he
alth care professional has accepted responsibility for patient care;
6. discharge his/her duties with honesty, diligence, efficiency and integrity;
7. conduct and present oneself in such a manner so as to encourage and merit the respect of
t
he public for members of the paramedic profession;
8. attempt to establish and maintain good working relationships with other professional
c
olleagues and the public;
9. assume responsibility for personal and professional development, including quality
a
ssurance initiatives such as reporting patient safety incidents;
10. maintain familiarity with current applicable legislation and practice, and strive to work to
th
e fullest extent of his/her competencies; and
11. report any incompetent, illegal or unethical conduct by colleagues or other health care
prof
essionals to the ambulance service operator and/or base hospital.
Paramedic Misconduct
The paramedic shall not:
1. practice beyond his/her level of certification;
2. refuse or neglect to serve persons requiring services that are part of the normal
pe
rformance of his/her duties;
3. falsify documentation of any kind;
4. misrepresent qualifications or credentials;
5. threaten or use violent behaviour;
6. take or possess drugs from the ambulance service without authorization;
7. disclose Confidential Information to anyone, unless required or permitted by law.
“
Confidential Information” includes:
a. identifying information about an individual;
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 8
Section 1 – General Standard of Care
b. personal health information (as defined in the PHIPA), such as a medical record or
the name and address of a patient, whether in oral or recorded form (e.g. written,
printed, or in electronic form); and
c. information obtained through one’s position as a paramedic which is not available
to
the public in general;
Guideline
If a paramedic is unsure as to whether Confidential Information may be disclosed, the
paramedic shall refrain from disclosing the Confidential Information, and shall consult with
his or her ambulance service operator for direction.
8. have any form of inappropriate sexual contact, relations or impropriety with a patient; or
9. engage in any other conduct unbecoming of a paramedic.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 9
Section 1 – General Standard of Care
General Measures Standard
The paramedic shall:
1. on receipt of a call, confirm call information with the Central Ambulance
Communication Centre/Ambulance Communication Service (CACC/ACS);
2. use an appropriate route and speed while operating the ambulance, adhere to a
pproved
driving and occupant restraint policies and practices, and operate the ambulance and
utilize ambulance emergency warning systems in a responsible manner;
3. on arrival at the scene, perform an assessment of the environment, park the ambulance in
a
safe place, as close to the point of patient contact as possible, and identify routes of
access and egress;
4. ensure the call environment is safe with no danger to self or others;
5. if danger exists, or there is uncertainty regarding personal and/or patient safety, request
a
ssistance from allied emergency services and maintain communication with
CACC/ACS;
6. bring to the point of initial patient contact all equipment required to establish baseline
v
ital signs and perform defibrillation;
7. use call and scene information to determine any additional equipment likely to be
re
quired to manage the call, and bring to point of initial patient contact;
8. if there is more than one patient and/or additional resources or assistance is required,
m
ake requests to CACC/ACS;
9. utilize personal protective equipment according to the Patient Care and Transportation
St
andards, and take appropriate safety measures;
10. identi
fy and introduce themselves to the patient and others as appropriate;
11. obtain consent for patient care as per the Heath Care Consent Act, 1996 (Ontario);
12. use proper, effective communication techniques to establish patient trust;
13. protect the patient from hazards and exposure to adverse environmental conditions;
14. for scene responses involving hazardous materials, reference the Transport Canada
Em
ergency Response Guidebook;
15. ensure saf
e use and disposal of equipment (e.g. sharps); and
16. perform hand hygiene as per the Patient Care and Transportation Standards.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 10
Section 1 – General Standard of Care
Patient Assessment Standard
The paramedic shall:
1. assume the existence of serious, potentially life-, limb- and/or function-threatening
conditions;
2. make scene observations relevant to the patient’s status;
3. seek medical
information tags;
4. attempt to determine the patient’s name, sex, age (or approximate), and weight (or
a
pproximate);
5. make reasonable attempts to seek other forms of patient identification, if required;
6. determine the patient’s chief complaint;
7. immediately on patient contact perform the primary survey by,
a. noting the patient’s general appearance, degree of distress and CTAS (Arrive Patient)
as per the Prehospital CTAS Paramedic Guide,
b. ensuring manual C-spine protection if C-spine pre
cautions are indicated by the Spinal
Motion Restriction (SMR) Standard,
c. asse
ssing airway patency, breathing, circulation and level of consciousness and
identifying critical findings (i.e. look for and if possible, quickly expose obvious or
suspected external hemorrhage and injury sites), and,
d. upon identifying absent/inadequate airway, breathing or circulation, performing
c
ritical interventions as per the Patient Management Standard;
8. determi
ne history of present illness or incident (including treatment prior to arrival);
9. determine the patient’s symptoms, allergies, past medical history and medications;
10. determine the patient’s compliance with prescribed medications;
11. initiate rapid transport and perform further assessment and management en route, if the
p
aramedic determines that the patients meets the criteria listed in the Load and Go
Patient Standard;
12. es
tablish baseline vital signs, which include:
a. heart rate,
b. respiration rate,
c. blood pressure (BP),
d. Pulse oximetry (SpO
2
),
e. Glasgow Coma Scale (GCS),
f. pupils, and
g. skin colour and condition;
13. auscultate the patient’s lungs for air entry and adventitious sounds (e.g. wheezes,
c
rackles), if the patient is exhibiting signs or symptoms of cardiovascular, respiratory or
neurological compromise;
14. initiate cardiac monitoring, if the patient is exhibiting signs or symptoms of
c
ardiovascular, respiratory or neurological compromise;
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 11
Section 1 – General Standard of Care
Guideline
The following types of calls typically warrant a cardiac monitor:
• All vital signs absent (VSA) patients, except those who are obviously dead as per the
Deceased Patient Standard
• Unconscious or altered level of consciousness
• Collapse or syncope
• Suspected cardiac ischemia
• Moderate to severe shortness of breath
• Cerebrovascular accident (CVA)
• Overdose
• Major or multi-system trauma
• Electrocution
• Submersion injury
• Hypothermia, heat exhaustion or heat illness
• Abnormal vital signs as per the ALS PCS
• If requested by sending facility staff (for inter-facility transfers)
15. perform a secondary survey, as required by patient status or the Standards;
16. obtain a second set of vital signs;
17. if the patient is suspected to be febrile or experiencing hyperthermia, obtain the patient’s
temperature;
18. formulate a working assessment after the primary and secondary survey;
19. if at any time during a call the paramedic provides a critical intervention, or series of
interventions, or a change in patient status occurs, at a minimum reassess the patient’s
airway patency, breathing, circulation, level of consciousness, and consider further
patient assessment or management; and
20. reassess vital signs relevant to patient condition/status,
a. every 30 minutes at a minimum, and
b. more frequently, as required by patient condition, changes to patient status, or the
Standards.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 12
Section 1 – General Standard of Care
Patient Management Standard
The paramedic shall:
1. if the patient is vital signs absent (VSA) and meets “obvious death” criteria as per the
Deceased Patient Standard, follow the procedures outlined within the Deceased Patient
Standard;
2. if the patient has an MOHLTC Do Not Resuscitate (DNR) Confirmation Form, ref
er to
the Do Not Resuscitate (DNR) Standard;
3. perform appropriate critical interventions to establish/improve and maintain airway
pa
tency, ventilation and circulation, which include:
a. protecting C-spine if C-spine precautions are indicated by the Spinal Motion
R
estriction (SMR) Standard,
b. initiating cardiopulmonary resuscitation (CPR) as per current Heart and Stroke
F
oundation of Canada Guidelines and as per the Cardiac Arrest Standards, if the
pa
tient is VSA (perform appropriate cardiac arrest medical directives as outlined in
the ALS PCS),
c. clearing airway obstructions as per the Airway Obstruction Standard, with attention
t
o suctioning of saliva, blood and vomit where necessary,
d. ventilating or assisting ventilations as per the Respiratory Failure Standard or
Shor
tness of Breath Standard, and
e. controlling trauma-related external hemorrhage as per the Soft Tissue Injuries
St
andard, or as specified in other standards for both trauma and non-trauma related
conditions.
4. administer oxygen therapy as per the Oxygen Therapy Standard;
5. initiate management of other life-, limb- and/or function-threatening conditions as
out
lined in other sections of the Standards and the ALS PCS;
6. position or re-position the patient in order to support, protect, improve and/or promote,
a. C-spine alignment,
b. airway patency,
c. breathing,
d. venous return and perfusion,
e. extremity injury, and
f. patient comfort;
7. if the patient is stable, initiate management on-scene for non-critical conditions as
out
lined in other sections of the Standards;
8. continually monitor the patient and provide assessment and management as required by
t
he Standards;
9. give the patient nothing by mouth unless indicated by the Standards or ALS PCS; and
10. ensure the patient maintains a comfortable temperature, or as required by the Standards.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 13
Section 1 – General Standard of Care
Patient Transport Standard
The paramedic shall:
1. determine CTAS level (CTAS Depart Scene) as per Prehospital CTAS Paramedic Guide;
2. make a decision regarding
the appropriate receiving health care facility and initiate
transport of the patient as confirmed or directed by an ambulance communications officer
(ACO);
3. if confirmation or direction cannot be obtained from an ACO, transport to the closest or
m
ost appropriate hospital capable of providing the medical care apparently required by
the patient;
4. collect and transport all relevant patient medications, record of medications, and any
ot
her relevant identification and medical records, as necessary, for review by receiving
facility staff;
5. for inter-facility transfers where the patient’s current care requirements, or reasonably
an
ticipated care requirements, exceed the paramedic’s level of certification request that a
medically-responsible escort be provided by the sending facility;
Guideline
For inter-facility transfers, obtain the following information and/or transfer documents, when
available:
• Name of sending physician
• Verbal and/or written treatment orders from the sending physician
• Transfer paper, e.g. case summary, lab work, x-rays, list of personal effects
acco
mpanying the patient, etc.
• Name(s) of facility staff and list of equipment accompanying the patient
• Name of receiving facility and receiving physician
6. for all CTAS 1 and 2 patients move the patient to the stretcher using the most appropriate
l
ift or carry;
7. for all CTAS 1 and 2 patients transport the patient to and from the ambulance on the
s
tretcher;
8. for all CTAS 3-5 patients transport the patient to and from the ambulance using the
a
ppropriate lift, carry or ambulatory assistance with respect to the situation, the patient’s
clinical condition, or for patient comfort;
9. in cases of inter-facility transfers transport the patient to and from the ambulance on the
s
tretcher;
10. ensure the patient, stretcher, equipment, and all occupants are secured inside the
a
mbulance;
11. attend to the patient at all times;
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 14
Section 1 – General Standard of Care
12. provide support to an escort or team in the patient compartment, in the event the patient is
under the care of a medical escort or a transfer team;
13. if the patient deteriorates during transport, and survival to the directed receiving facility is
questi
onable, transport the patient to the closest or most appropriate hospital capable of
providing the medical care apparently required by the patient. Immediately notify
CACC/ACS of any destination change, and notify or ask CACC/ACS to notify the new
receiving facility; and
14. maintain temperature and lighting conditions which are comfortable for the patient in the
patient compartment, unless otherwise required by the Standards.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 15
Section 1 – General Standard of Care
Patient Refusal/Emergency
Treatment Standard
Patient With Capacity Refusal
1. Where a patient requires care and/or transport to a health care facility and the patient or
substitute decision maker (SDM) refuses such treatment and/or transport, the paramedic
shall:
a. make reasonable efforts to inform the patient or SDM that treatment and/or transport
are
recommended and explain the possible consequences of such refusal;
b. confirm that the patient or SDM has capacity utilizing the Aid to Capacity
Asse
ssment as per the Ambulance Call Report Completion Manual;
c. advise the patient or SDM to call 911 again if further concerns arise; and
d. obtain signatures and complete additional documentation requirements as per the
Ontario Documentation Standards and the Ambulance Call Report Completion
Manual.
Note: The patient or SDM can refuse to sign the Refusal of Service section of the Ambulance Call
Report, as there is no obligation on the patient or SDM to sign the Ambulance Call Report. Should
this occur, the paramedic shall document the patient’s or SDM’s refusal and reason for failing to
provide a signature.
Emergency Treatment and Transport of an Incapable Patient Without
Consent
1. The paramedic shall carry out emergency treatment and transport, if:
a. the patient does not have capacity;
b. the patient is apparently experiencing severe suffering or is at risk, if the treatment is
not a
dministered promptly, of sustaining serious bodily harm; and
c. the delay required to obtain a consent or refusal on the patient’s behalf will prolong
the
suffering that the patient is apparently experiencing or will put the patient at risk
of sustaining serious bodily harm.
2. The paramedic shall document the circumstances that led to the decision in paragraph 1
abov
e.
Emergency Treatment and Transport of a Capable Patient Without Consent
1. The paramedic shall carry out emergency treatment and transport, if:
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 16
Section 1 – General Standard of Care
a. the patient is apparently experiencing severe suffering or is at risk, if the treatment is
not administered promptly, of sustaining serious bodily harm;
b. the communication required in order for the patient to give or refuse consent cannot
take pla
ce because of a language barrier or because the patient has a disability that
prevents the communication from taking place;
c. steps that are reasonable in the circumstances have been taken to find a practical
means of
enabling the communication to take place, but no such means has been
found;
d. the delay required to find a practical means of enabling the communication to take
place will prolong the suffering that the patient is apparently experiencing or will put
the person at risk of sustaining serious bodily harm; and
e. there is no reason to believe that the patient does not want the treatment.
2. The paramedic shall document the circumstances that led to the decision in paragraph 1
above.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 17
Section 1 – General Standard of Care
Reporting of Patient Care to
Receiving Facility Standard
The paramedic shall:
1. transmit a report while en route to the receiving facility for all CTAS 1 and CTAS 2
patients, which includes,
a. unit number identification,
b. patient age,
c. patient sex,
d. CTAS level,
e. chief complaint,
f. pertinent history,
g. pertinent assessment findings,
h. pertinent management and response to management,
i. abnormal vital signs, and
j. estimated time of arrival;
2. confirm that the receiving facility or ACO has acknowledged the report; and
3. provide additional reports if the patient’s CTAS changes to a higher acuity.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 18
Section 1 – General Standard of Care
Patch to Base Hospital Physician
Standard
The paramedic shall:
1. initiate a patch as required by the Standards or the ALS PCS;
2. initiate a patch where there is uncertainty about the appropriateness of a standard or when
f
urther direction is desired;
3. during the patch,
a. state his/her level of certification,
b. provide a report which includes the information necessary to convey the patient’s
c
ondition, situation, or circumstance which requires physician input,
c. provide all other information as requested by the physician, and
d. confirm direction, authorization and orders given; and
4. document as per the Ontario Ambulance Documentation Standards and the Ambulance
Call
Report Completion Manual.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 19
Section 1 – General Standard of Care
Regulated Health Professionals
Standard
In situations involving a patient under the care of a regulated health professional, the paramedic
shall:
Guideline
Recall paragraph 8 of Paramedic Conduct under the Paramedic Conduct Standard;
accordingly, paramedics and regulated health professionals should work cooperatively in
making decisions and providing quality patient care.
1. recognize the training and qualifications of the regulated health professional, e.g.
physician, nurse, midwife, respiratory therapist;
2. determine the nature of the request for ambulance services;
3. obtain confirmation (may be verbal) that the regulated health professional is a registered
m
ember of his/her College within Ontario, and that the patient is under his/her care;
4. upon request, assist the regulated health professional with patient care only to the level in
w
hich the paramedic is authorized; and
5. in conjunction with the Documentation of Patient Care Standard, document on the
Ambulance Call Report,
a. the nam
e of regulated health professional,
b. the type of regulated health professional, and
c. any care provided by the regulated health professional.
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Section 1 – General Standard of Care
Transfer of Care (TOC) Standard
Upon arrival at the receiving facility, the paramedic shall:
1. liaise with receiving facility staff to determine the patient’s destination within the
receiving facility;
2. attend to the patient while awaiting receiving facility staff acceptance
of the patient;
3. provide a verbal report to receiving facility staff, to include,
a. patient name,
b. patient age,
c. patient sex,
d. CTAS (Arrive Destination) as per the Prehospital CTAS Paramedic Guide,
e. chief complaint,
f. a concise history of the patient’s current problem(s) and relevant past medical history,
g. pertinent assessment findings,
h. pertinent management performed and responses to management,
i. vital signs, and
j. the reason for transfer, for inter-facility transfers;
4. provide a copy of any clinically relevant associated biometric data collected;
5. if it appears likely there will be a prolonged delay in accepting the patient,
a. advise CACC/ACS,
b. advise receiving facility if the patient status deteriorates,
c. seek further assistance from the ambulance service operator, and/or
d. for inter-facility transfers, request receiving staff to attempt to contact the sending
ph
ysician or the patient’s family physician;
6. transfer the patient, from the stretcher where applicable, to the receiving facility;
7. transfer any patient medications, record of medications, other relevant identification and
m
edical records, and any other belongings to the receiving facility, if not already done;
8. consider Transfer of Care complete upon completion of paragraphs 1-7 above and when
t
he patient is no longer dependent on ambulance service resources (excluding equipment
that is being left with the patient, e.g. spinal board); and
9. transfer documentation to the receiving facility as per the Ontario Ambulance Service
D
ocumentation Standards.
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Section 1 – General Standard of Care
Documentation of Patient Care
Standard
The paramedic shall:
1. complete documentation as per the Ontario Ambulance Documentation Standards and the
Ambulance Call Report Completion Manual;
2. document clinical response to treatment and procedures performed;
3. docume
nt all instances of threatened violence on the Ambulance Call Report; and
4. for inter-facility transfers, document,
a. pertinent patient history and care information,
b. receipt of transfer papers (e.g. case summary, treatment orders, lab work, x-rays, list
of
personal effects or patient’s personal belongings), and
c. name(s) of escort, transport team members and list of equipment accompanying the
pa
tient, where applicable.
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Section 1 – General Standard of Care
Patient Care Equipment Use
Standard
The paramedic shall:
1. utilize all equipment in the manner in which trained by his/her ambulance service
operator and base hospital, and as per manufacturer specifications; and
2. notify the ambulance service operator of identified equipment problems.
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Section 1 – General Standard of Care
Oxygen Therapy Standard
General Directive
The paramedic shall:
1. administer oxygen therapy using an oxygen delivery system and flow rate to attempt to
maintain a patient’s oxygen saturation between 92-96%, as measured by SpO
2
, unless
specified otherwise in the Standards;
2. continuously administer high concentration oxygen for patients who have,
a. confirm
ed or suspected carbon monoxide or cyanide toxicity or noxious gas
exposure,
b. upper airway burns,
c. scuba-diving related disorders,
d. ongoing cardiopulmonary arrest,
e. complete airway obstruction, and/or
f. sickle cell anemia with suspected vaso-occlusive crisis; and
3. if pulse oximetry equipment is not functioning or not providing an interpretable wave
f
orm, administer high concentration oxygen to all patients specified in paragraph 2 above,
as well as those with critical findings, which include,
a. age-specific hypotension,
b. respiratory distress,
c. cyanosis, ashen colour, pallor,
d. altered level of consciousness, and/or
e. abnormal pregnancy or labour.
Oxygen Therapy and COPD
If a patient with chronic obstructive pulmonary disease (COPD) has increased dyspnea, a decreased
level of consciousness, an altered mental status, and/or has suffered major trauma, the paramedic
shall:
1. administer oxygen therapy as per the General Directive above. If pulse oximetry equipment
i
s not functioning, administer oxygen by nasal cannula with oxygen flow at two litres per
minute above the patient’s home oxygen levels, or two litres per minute if patient is not on
home oxygen;
2. re-assess the vital signs approximately every 10 minute
s;
3. maintain oxygen flow rate at that level, if the patient’s status improves;
4. increase oxygen by increments of two litres per minute above starting level approximately
ev
ery two to three minutes if the patient’s status deteriorates or the patient indicates they feel
worse; and
5. be prepared to ventilate.
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Section 1 – General Standard of Care
Field Trauma Triage Standard
General Directive
The paramedic shall follow the procedure below when conducting field triage of injured patients by a
traumatic mechanism.
The paramedic shall also use this
standard to assess the clinical criteria (i.e. to determine if the
patient meets the clinical criteria) as required by the Air Ambulance Utilization Standard.
The paramedic shall consider using the Trauma Termination of Resuscitation (TOR) contained in the
T
rauma Cardiac Arrest Medical Directive as per the ALS PCS.
CACC/ACS will authorize the transport once notified of the patient’s need for re-direct or transport
unde
r the Field Trauma Triage Standard.
Procedure
The paramedic shall:
1. assess the patient to determine if he/she has one or more of the following physiological
criteria (Step 1):
a. GCS
<14,
b. Systoli
c blood pressure <90mmHg, or
c. Respiratory rate <10 or ≥30 breaths per minute or need for ventilatory support
(<
20 in infant aged <1 year);
2. if the patient meets the physiological criteria listed in paragraph 1 above, AND the land
t
ransport time is estimated to be <30 minutes to a Lead Trauma Hospital (LTH), transport
the patient directly to an LTH (transport time refers to the time from scene departure to
time of arrival at destination);
3. if the patient does not meet the criteria listed in paragraphs 1 and 2, assess the patient to
de
termine if he/she has one or more of the following anatomical criteria (Step 2):
a. Any penetrating injuries to head, neck, torso and extremities proximal to elbow or
kne
e,
b. Chest wall instability or deformity (e.g. flail chest),
c. Two or more proximal long-bone fractures,
d. Crushed, de-gloved, mangled or pulseless extremity,
e. Amputation proximal to wrist or ankle,
f. Pelvic fractures,
g. Open or depressed skull fracture, or
h. Paralysis;
4. if the patient meets the anatomical criteria listed in paragraph 3 above and the land
t
ransport time is estimated to be <30 minutes to the LTH, transport the patient directly to
an LTH;
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Section 1 – General Standard of Care
5. if unable to secure the patient’s airway or survival to the LTH is unlikely, transport the
patient to the closest emergency department despite paragraphs 2 and 4 above;
6. despite paragraph 5 above, transport the patient directly to an LTH if the patient has a
penetra
ting trauma to the torso or head/neck, and meets ALL of the following:
a. Vital signs absent yet not subject to TOR described in the General Directive above,
a
nd
b. Land transport to the LTH is estimated to be <30 minutes;
7. if the patient does not meet the physiological or anatomical criteria listed above, use the
following criteria to determine if the patient may require other support services at the
LTH as a result of his/her traumatic mechanism of injury (Step 3):
a. Falls
i. Adults: falls ≥6 metres (one story is equal to 3 metres)
ii. Children (age <15): falls ≥3 metres or two to three times the height of the
child
b. High Risk Auto Crash
i. Intrusion ≥0.3 metres occupant site; ≥0.5 metres any site, including the roof
ii. Ejection (partial or complete) from automobile
iii. Death in the same passenger compartment
iv. Vehicle telemetry data consistent with high risk injury (if available)
c. Pedestrian or bicyclist thrown, run over or struck with significant impact (≥30 km/hr)
by an automobile
d. Motorcycle crash ≥30 km/hr;
8. if the patient meets the mechanism of injury criteria listed in paragraph 7 above, AND the
land transport time is estimated to be <30 minutes to a Lead Trauma Hospital (LTH),
determine the need for patient transport to the LTH (the paramedic may patch to the base
hospital physician);
9. in conjunction with the physiological, anatomical, and mechanism of injury criteria listed
above, consider the following special criteria (Step 4):
a. Age
i. Older adults
1. Risk of injury/death increases after age 55
2. SBP <110 may represent shock after age 65
ii. Children
1. Should be triaged preferentially to a pediatric-capable trauma centre
b. Anticoagulation and bleeding disorders
c. Burns
i. With trauma mechanism: triage to LTH
d. Pregnancy ≥20 weeks; and
10. if the patient meets any of the special criteria listed above, AND the land transport time is
estimated to be <30 minutes to a Lead Trauma Hospital (LTH), determine the need for
patient transport to the LTH, while considering local Patient Priority Systems bypass
agreements. The paramedic may patch to the base hospital physician for assistance with
transport decision.
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Section 1 – General Standard of Care
Air Ambulance Utilization Standard
General Directive
Requests for an on-scene air ambulance helicopter response should meet at least one of the bulleted
operational criteria PLUS one of the clinical criteria (e.g. known clinical criteria as listed in the Field
Trauma Triage Standard or from the bulleted list of medical or obstetrical criteria listed below).
Procedure
The paramedic shall:
1. assess the scene response to meet one or more of the following operational criteria:
a. The
land ambulance is estimated to require more than 30 minutes to reach the scene
and the air ambulance can reach the scene quicker.
b. The land ambulance is estimated to require more than 30 minutes to travel from the
s
cene to the closest appropriate hospital* and the air ambulance helicopter can reach
the
scene and transport the patient to the closest appropriate hospital* quicker than
t
he land ambulance.
c. The estim
ated response for both land and air is estimated to be greater than 30
minutes, but approximately equal, and the patient needs advanced paramedic level
care which cannot be provided by the responding land ambulance.
d. There are multiple patients who meet the clinical criteria and the local land
a
mbulance resources are already being fully utilized.
2. if the scene response meets the requirements of paragraph 1 above, assess the patient to
d
etermine if he/she meets one or more of the following clinical criteria:
a. Pa
tients meeting the criteria listed in the Field Trauma Triage Standard.
b. Patients meeting one or more of the following:
i. Medical:
1. Shock, especially hypotension with altered mentation (e.g. suspected
a
ortic aneurysm rupture, massive GI bleed, severe sepsis,
anaphylaxis, cardiogenic shock, etc.)
2. Acute stroke with a clearly determined time of onset or last known to
be
normal <3.0 hours
3. Altered level of consciousness (GCS <10)
4. Acute respiratory failure or distress
5. Suspected STEMI or potentially lethal dysrhythmia
6. Resuscitation from respiratory or cardiac arrest
7. Status epilepticus
8. Unstable airway or partial airway obstruction
ii. Obstetrical:
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Section 1 – General Standard of Care
1. Active labour with abnormal presentation (i.e. shoulder, breech or
limb)
2. Multiple gestation and active labour
3. Umbilic
al cord prolapse
4. Signi
ficant vaginal bleeding (suspected placental abruption or
placenta previa or ectopic pregnancy);
3. in conjunction with the ACO, assess if an on-scene air ambulance helicopter is
appropriate, based on:
a. the perceived severity of the reported injuries and without confirmation that the
clinical criteria have been met, or
b. the patient cannot reasonably be reached by land ambulance (e.g. sites without road
access such as islands; geographically isolated places, etc.);
4. if the requirements listed in paragraph 2 or 3 above are met, request an on-scene air
ambulance helicopter response:
a. Provide the ACO with the information set out in operational and clinical criteria
above. In order for the ACO to determine if an air ambulance response and transport
will be quicker than land ambulance, the paramedic will provide the ACO with the
estimated time to prepare the patient for transport, identify separately any time
required for patient extrication, provide the estimated land ambulance driving time to
the closest appropriate hospital* and any additional information as required.
b. The paramedics shall not delay patient transport by waiting for the air ambulance
helicopter, unless the air ambulance helicopter can be seen on its final approach to the
scene. If the air ambulance helicopter is en route but not on final approach to the
scene, and the land paramedics have the patient in his/her ambulance, then the land
ambulance will proceed to the closest local hospital with an emergency department.
The air ambulance helicopter will proceed to that local hospital and, if appropriate,
assist hospital personnel prepare the patient for rapid evacuation.
c. While en route to the local hospital, paramedics may rendezvous with the air
ambulance helicopter if:
i. the air ambulance helicopter is able to land along the direct route of the land
ambulance; and
ii. it would result in a significant reduction in transport time to the most
appropriate hospital*.
5. if the call’s circumstances and patient(s) fail to meet the criteria set out in this standard
and a
n air ambulance helicopter is known to be responding based on the merits of the
initial request for ambulance service, contact the CACC/ACS and advise that an on-scene
air ambulance helicopter response is not required and why it is not required.
*Note: The closest appropriate hospital for on-scene call patients assessed as meeting the criteria
specified within the Field Trauma Triage Standard is the closest LTH.
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Section 1 – General Standard of Care
Guideline
Air Ambulance Helicopter Landing Site Safety and Coordination
Upon confirmation that the air ambulance helicopter is responding, the paramedic shall
designate a Landing Site Coordinator. One rescuer (selected from the police, fire, or
ambulance personnel) shall be chosen to assume the role of Landing Site Coordinator and
take the following actions to coordinate the safe landing of the air ambulance helicopter while
maintaining the safety of the scene.
Wear Safety Apparel
• Don and secure a high visibility vest or coat
• Don and secure a safety
helmet with visor
• Wear safety goggles or safety eyewear
Landing Site Selection
The air ambulance helicopter pilot-in-command is responsible for selecting the landing site
and has the final decision on whether or not to land. Using the air ambulance helicopter
airborne vantage point, the pilot-in-command will select a site that best meets the following
conditions:
• A site that will not affect the re
scue efforts underway.
• A clear area of approximate
ly 45 meters x 45 meters.
• A safety area, extending approximately an additional 30 meters for the purpose of
controlling vehicle and personnel access during landing and take-off.
• The landing site should be away from overhead wires and utility poles.
• The surface should be as flat as possible.
• No loose debris should be within the landing site or the safety area; check ditches.
• Gravel and sand sites should be avoided, if possible, due to the potential of injury from
flying dust particles and reduced visibility.
Site Safety
• No vehicles or personnel are allowed within the landing site and safety area during
landing and take-off.
• Vehicle doors, windows, and access compartments should be closed.
• Stretchers should be left in the ambulance and all loose articles
secured.
• If requested by the flight crew, the Landing Site Coordinator will stand at the upwind
edge of the safety area, back to the wind and facing the site, to maintain security during
landing and take-off.
• Firefighters should not lay out hoses; any lines that have been laid should be charged.
• If site security is compromised, such as personnel or vehicles entering the safety area,
the Landing Site Coordinator is to wave off the air ambulance helicopter by crossing
outstretched arms over his/her head.
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Section 1 – General Standard of Care
Safely Working Around a Helicopter
• Stay out of the safety area and landing site during landing and take-off.
• Approach or depart only when directed by
a member of the air crew.
• Do not approach the helicopter from the rear as the tail rotor is difficult to see.
• If on uneve
n ground, approach and depart from the downhill side.
• Carry all equipment horizontally at or below waist level, never over shoulder.
• Ensure hats, scarves, gloves, glasses and any other loose articles are secure before
entering the safety area.
Other Use of Air Ambulance Helicopter
• Air ambulance helicopters are not permitted to respond to night calls which require a
landing at a site other than night licensed airports, helipads or night approved remote
landing sites.
• Air ambulance helicopters are not permitted to conduct search and rescue calls. For
purposes of
this section, Search and Rescue is defined as “The act of looking diligently
to find a patient whose exact location is not known, and, once located, requires removal
from the location using specialized tools and skills outside the scope of EMS practice.”
• In cases where a land ambulance can reach the patient(s) and an on-scene response by
air ambul
ance helicopter is appropriate, the ACO will assign a land ambulance and
continue the land response until the flight crew requests that the land ambulance be
cancelled.
• In cases where a land ambulance arrives on-scene prior to the air ambulance helicopter,
paramedics shall inform the CACC/ACS as clinical events occur.
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Section 1 – General Standard of Care
Spinal Motion Restriction (SMR)
Standard
The paramedic shall:
1. consider spinal motion restriction (SMR) for any patient with a potential spine or spinal
cord injury, based on mechanism of injury, such as,
a. any
trauma associated with complaints of neck or back pain,
b. sports accidents (impaction, falls),
c. diving incidents and submersion injuries,
d. explosions, other types of forceful acceleration/deceleration injuries,
e. falls (e.g. stairs),
f. pedestrians struck,
g. electrocution,
h. lightning strikes, or
i. penetrating trauma to the head, neck or torso;
2. if the patient meets the criteria listed in paragraph 1 above, determine if the patient
e
xhibits ANY risk criteria, as follows,
a. nec
k or back pain,
b. spine tenderness,
c. neurologic signs or symptoms,
d. altered level of consciousness,
e. suspected drug or alcohol intoxication,
f. a distracting painful injury (any painful injury that may distract the patient from the
pain of a spinal injury),
g. anatomic deformity of the spine,
h. high-energy mechanism of injury, such as,
i. fall from elevation greater than 3 feet/5 stairs,
ii. axial load to the head (e.g. diving accidents),
iii. high speed motor vehicle collisions (≥100 km/hr), rollover, ejection,
iv. hit by bus or large truck,
v. motorized/ATV recreational vehicles collision, or
vi. bicyclist struck or collision, or
i. age ≥65 years old including falls from standing height;
3. if the patient meets the criteria of paragraph 1 above, but does not meet the criteria of
pa
ragraph 2 above, not apply SMR;
4. subject to paragraph 6 below, if the patient meets the requirements of paragraph 2 above,
a
pply SMR using a cervical collar only*, attempt to minimize spinal movement, and
s
ecure the patient to the stretcher with stretcher straps (see Guideline below);
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Section 1 – General Standard of Care
5. if the patient has penetrating trauma to the head, neck or torso, determine if the patient
exhibits ALL of the following,
a. no spine tenderness,
b. no neurologi
c signs or symptoms,
c. no altered level of consciousness,
d. no evidence of drug or alcohol intoxication,
e. no distracting painful injury, and
f. no anatomic deformity of the spine; and
6. notwithstanding paragraph 4 above, if the patient meets the criteria of paragraph 5, not
apply SMR.
*Note: Spinal boards or adjustable break-away stretchers may still be indicated for use to minimize
spinal movement during extrication.
Guideline
General
• This standard does not allow the paramedic to “clear the spine” for blunt trauma
patients. Rather, it identifies patients where the mechanism of injury in combination
with and the absence of risk criteria mean a spine injury does not have to be
considered.
• Using SMR does not mean the paramedic has “cleared” the spine for blunt trauma
patient
s. The paramedic must at all times manage the patient to minimize spinal
movement.
• In conjunction with the Documentation of Patient Care Standard, when possible,
docume
nt t
he neurologic status before and after SMR on the Ambulance Call Report.
Use of spinal boards
• Spinal boards or adjustable break-away stretchers should be considered primarily as
extrication/patient lifting devices. The goal should be to remove the patient from these
devices as soon as it is safe to do so. If sufficient personnel are present, the patient
should be log rolled from the extrication device to the stretcher during loading of the
patient or shortly after loading into the ambulance.
• Spinal boards or adjustable break- away stretchers may remain in place if the
paramedi
c deems it safer/more comfortable for the patient in consideration of short
transport times (<30 min).
• Recall that patients with suspected pelvic fractures should be secured on a spinal board
or adjusta
ble break-away stretcher as per the Blunt/Penetrating Injury Standard.
Patient extrication and transport
• Patient with SMR may be placed in a semi-sitting or supine position, according to
patient comfort/clinical condition.
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Section 1 – General Standard of Care
•
• If patient is unresponsive/uncooperative, apply manual C-spine immobilization until
appropriate SMR has been applied.
• Cervical collars should be placed on the patient prior to movement, if possible.
• Patients involved in an MVC, who remain in a vehicle with isolated neck or back pain
and no neu
rologic signs or symptoms/indications of major trauma may be allowed to
self-extricate using a stand, turn and pivot onto the stretcher. The paramedic should
coach the patient to maintain neutral spinal alignment.
• Patients who have had a spinal board or adjustable break-away stretcher applied by a
first responder prior to the paramedic’s arrival should still be assessed for SMR as per
the Standard. Unless otherwise required, SMR may be modified to meet this standard.
• Patients with SMR undergoing inter-facility transfers may have SMR modified as per
the Standard in consultation with the sending physician. This may involve removal of a
spinal board.
SMR and agitated patients
Patients who are markedly agitated, combative or confused may not be able to follow
commands and cooperate with minimizing spinal movement. There may be rare
circumstances in which attempts to apply SMR using a C-collar, spinal board or
adjustable break-away stretcher leads to an increase in patient agitation that constitutes
a safety hazard to both the patient and the paramedic. In these situations, the paramedic
shall apply SMR to the best of his/her ability and secure the patient to the stretcher with
stretcher straps. In conjunction with the Documentation of Patient Care Standard, the
paramedic shall clearly document the circumstances of the safety hazard and his/her
resulting inability to apply SMR to the patient.
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Section 1 – General Standard of Care
Do Not Resuscitate (DNR) Standard
In a situation where a paramedic obtains a Valid MOHLTC DNR Confirmation Form, the paramedic
shall follow the General Directive set out below.
Definitions
For purposes of the Do Not Resuscitate (DNR) Standard:
Cardiopulmonary Resuscitation (CPR)
An immediate application of life-saving measures to a person who has suffered sudden respiratory or
cardiorespiratory arrest. These measures include but are not limited to basic or advanced cardiac life
support interventions outlined in the ALS PCS such as:
1. Chest compression
2. Defibrillation
3. Artificial ventilation
4. Insertion of an oropharyngeal, nasopharyngeal or supraglottic airway
5. Endotracheal intubation
6. Transcutaneous pacing
7. Advanced resuscitation drugs such as, but not limited to, vasopressors, antiarrhythmic agents
and opioid antagonists
Do Not Resuscitate
means that the paramedic (in accordance with his/her level of certification) will not initiate any of the
interventions listed in the definition of CPR, above.
Treatment
Any action or service that is provided for a therapeutic, preventive, palliative, diagnostic, cosmetic or
other health-related purpose, and includes a course of treatment or plan of treatment.
Valid MOHLTC DNR Confirmation Form
A DNR Confirmation Form with pre-printed serial number that has been completed, in full, with the
following information:
1. The name of the patient (including both surname and first name) to whom the Form applies.
2. A check box that has been checked to identify that one of the following conditions has been
m
et:
a. A current plan of treatment exists that reflects the patient’s expressed wish when
c
apable, or consent of the substitute decision-maker when the patient is incapable,
that CPR not be included in the patient’s plan of treatment.
b. The physician’s current opinion is that CPR will almost certainly not benefit the
pa
tient and is not part of the plan of treatment, and the physician has discussed this
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Section 1 – General Standard of Care
with the capable patient or the substitute decision-maker when the patient is
incapable.
3. A check box that has been checked to identify the professional designation of the Medical
D
octor (M.D.), Registered Practical Nurse (R.P.N.), Registered Nurse (R.N.), or Registered
Nurse in the Extended Class (R.N. [EC]) who has signed the Form.
4. Printed name of the M.D., R.P.N., R.N., or R.N. (EC) signing the Form.
5. A sig
nature by the appropriate M.D., R.P.N., R.N., or R.N. (EC).
6. The date that the Form was signed, which must be the same as or precede the date of request
f
or ambulance service.
A Valid DNR Confirmation Form may be a fully completed original, or a copy of a fully completed
original.
General Directive
1. A paramedic, upon obtaining a Valid MOHLTC DNR Confirmation Form and subject to
paragraph 2 below, SHALL NOT initiate CPR (as per the definition above) on the
patient in the event that the patient experiences respiratory or cardiorespiratory arrest (i.e.
respirations and pulse are absent for at least three minutes from the time that respiratory
or cardiac arrest was noted by the paramedic).
2. A paramedic shall initiate CPR (as per the definition above) on a patient who has
experienced respiratory or cardiorespiratory arrest when:
a. the patient with a Valid MOHLTC DNR Confirmation Form appears to the
pa
ramedic to be capable and expresses clearly a wish to be resuscitated in the event
that he/she experiences a respiratory or cardiac arrest; or
b. the patient with a Valid MOHLTC DNR Confirmation Form appears to the
pa
ramedic to be capable and expresses a wish to be resuscitated in the event that
he/she experiences respiratory or cardiorespiratory arrest, but the request is vague,
incomplete or ambiguous such that it is no longer clear what the wishes of the patient
are.
3. The paramedic shall provide patient management necessary to provide comfort or
alleviate pain, as required by the patient’s clinical condition.
4. Once it has been determined that death has occurred, the paramedic shall:
a. advise the CACC/ACS; and
b. follow the Deceased Patient Standard.
5. In conjunction with the Documentation of Patient Care Standard, the paramedic shall
note and document the time at which the paramedic confirms the patient was deceased as
per paragraph 1 above.
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Section 1 – General Standard of Care
Sample MOHLTC DNR Confirmation Form
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Section 1 – General Standard of Care
Deceased Patient Standard
Definitions
For the purposes of the Deceased Patient Standard, the following definitions apply:
Deceased Patient
means a patient who is:
1. obviously dead;
2. the subject of a medical certificate of death, presented to the paramedic crew, in the form that
i
s prescribed by the Vital Statistics Act (Ontario) and that appears on its face to be completed
a
nd signed in accordance with that Act;
3. without vita
l signs and the subject of an MOHLTC Do Not Resuscitate (DNR) Confirmation
Form;
4. without vital signs and the subject of a Termination of Resuscitation (TOR) Order given by a
Ba
se Hospital Physician; or
5. without vital signs and the subject of a Withhold Resuscitation Order given by a Base
H
ospital Physician.
Expected Death
means a death that was imminently anticipated generally as a result of a progressive end stage
terminal illness.
Obviously Dead
means death has occurred if gross signs of death are obvious, including by reason of:
1. decapitation, transection, visible decomposition, putrefaction; or
2. absence of vital signs and:
a. a grossly
charred body;
b. an open head or torso wound with gross outpouring of cranial or visceral contents;
c. gross rigor mortis (i.e. limbs and/or body stiff, posturing of limbs or body); or
d. dependent lividity (i.e. fixed, non-blanching purple or black discolouration of skin in
de
pendent area of body).
Palliative Care Team
means a team of health care professionals who provide palliative care to a terminally ill patient.
Responsible Person
means an adult who, in the reasonable belief of the paramedic, is capable to remain with the
Deceased Patient and assume responsibility for the Deceased Patient.
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Termination of Resuscitation (TOR) Order
means an order given by a Base Hospital Physician to a paramedic to stop resuscitation measures.
Unexpected Death
means a death that was not imminently anticipated (e.g. traumatic deaths, deaths related to the
environment, accidental deaths, and apparently natural deaths that are sudden and unexpected).
Withhold Resuscitation Order
means an order given by a Base Hospital Physician to a paramedic to not initiate resuscitation
measures.
Procedure
In all cases of death, the paramedic shall:
1. confirm the patient is deceased as per the Definitions above;
2. ensure that the Deceased Patient is trea
ted with respect and dignity;
3. consider the needs of family members of the decedent and provide compassion-informed
de
cision-making;
4. in cases of suspected foul play, follow the directions set out in the Police Notification
St
andard;
5. if applicable, follow all directions issued by a coroner or a person appointed by a coroner
or t
o whom a coroner has delegated any powers or authority pursuant to the Coroners Act
(O
ntario);
6. if termination of resuscitation occurs in the ambulance en route to a health care facility,
a
dvise CACC/ACS to contact the coroner, and continue to the destination unless
otherwise directed by CACC/ACS; and
7. for cases of obvious death, note and document the time at which the paramedic confirms
t
he patient was deceased as per the Standards.
In cases of unexpected death:
1. in the absence of police or a coroner on-scene, the paramedic shall advise CACC/ACS of
the death, in which case CACC/ACS shall notify the police or coroner;
2. if a coroner indicates that he/she wi
ll attend at the scene, the paramedic shall remain at
the scene until the coroner arrives and assumes custody of the Deceased Patient. If the
coroner indicates that he/she will not attend at the scene, the paramedic shall remain on
the scene until the arrival of a person appointed by a coroner or to whom a coroner has
delegated any powers or authority pursuant to the Coroners Act (Ont
ario);
3. notwithstanding paragraph 2 above, if police are present and have secured the scene, the
para
medic may depart as soon as documentation has been completed or he/she is
assigned to another call; and
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4. where at any time the paramedic has not received any further direction from CACC/ACS,
the paramedic shall request that CACC/ACS seek direction from the coroner concerning
his/her responsibilities, including whether he/she may leave the scene.
Guideline
Although a death may be viewed as “unexpected” from the perspective of the person
reporting the death (paramedic, family members), this does not necessarily imply that the
death requires investigation by a coroner under the Coroners Act (On
tario).
In cases of expected death:
1. the paramedic shall advise CACC/ACS of the death;
2. the paramedic shall make a request of a Responsible Person, if one is present, to notify
t
he primary care practitioner or a member of the Palliative Care Team (if any) of the
patient and request his/her attendance at the scene;
3. if the Responsi
ble Person is unable to provide the notice in paragraph 2 above, the
paramedic shall advise CACC/ACS of the death, in which case CACC/ACS shall attempt
to notify the primary care practitioner or member of the Palliative Care Team (if any) of
the Deceased Patient, and request his/her attendance at the scene;
4. if the Deceased Patient’s primary care practitioner or Palliative Care Team member is
c
ontacted and indicates that he/she will attend at the scene, then the paramedic shall
remain at the scene until his/her arrival;
5. notwithstanding paragraph 4 above, if there is a Responsible Person present, and the
pa
ramedics reasonably believe that the Responsible Person will remain until the primary
care practitioner or Palliative Care Team arrives, then the paramedic may depart as soon
as all required documentation has been completed or he/she are assigned to another call.
Alternatively, if the police are at the scene and are willing to remain until the arrival of
the practitioner or Palliative Care Team member, the paramedic may leave the scene;
6. if the primary care practitioner or Palliative Care Team member cannot be contacted or if
he
/she is unable to attend, or there is no Responsible Person on-scene, the paramedic
crew shall advise CACC/ACS, in which case CACC/ACS shall notify the police or
coroner of the death and that there is no one else at the scene who can take responsibility
for the Deceased Patient; and
7. if requested by the coroner, the paramedic will provide the coroner with the
circumstances of the death; the paramedic will either be released from the scene or
instructed to remain with the Deceased Patient until the coroner or a person appointed by
a coroner or to whom a coroner has delegated any powers or authority pursuant to the
Coroners
Act (Ontario) or a Responsible Person can attend the scene and assume
responsibility for the Deceased Patient.
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Section 1 – General Standard of Care
General Pediatric Standard
In situations involving a pediatric patient, the paramedic shall:
1. during the primary survey, be aware of problems arising due to pediatric anatomy and
physiology;
2. be awar
e that respiratory arrest is the primary cause of pediatric cardiac arrest;
3. recognize normal vital signs as per the ALS PCS;
Guideline
Recall that pediatric CTAS levels and GCS differ from those for adults. Determine CTAS as
per the Prehospital CTAS Paramedic Guide.
4. consider assessments for,
a. change in appetite,
b. change in behaviour/personality,
c. excessive drooling,
d. for patients in diapers, decrease in number of wet diapers,
e. inconsolable crying or screaming,
f. lethargy,
g. patient positioning (e.g. tripoding), and
h. work of breathing;
Guideline
Pediatric patients can present with atypical signs and symptoms and may deteriorate rapidly.
Maintain a high index of suspicion when assessing pediatric patients.
5. if performing a full secondary survey, conduct from “toe-to-head”;
6. have caregivers present during patient care unless they are interfering with the care; and
7. for infant patients, assess fontanelles.
Guideline
When handling an infant patient, ensure that proper support is provided to the head and neck.
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Section 1 – General Standard of Care
Child in Need of Protection Standard
Definitions
For the purposes of the Child in Need of Protection Standard, the following definitions apply:
Child in need of protection
means a child who is or who appears to be suffering from abuse and/or neglect. Section 72 of the
Child and Family Services Act (O
ntario) details circumstances for concern (i.e. physical, sexual, or
emotional abuse, neglect, or risk of harm).
Duty to report
means the requirement to promptly report any reasonable suspicion that a child is or may be in need
of protection directly to a Children’s Aid Society (CAS).
Reasonable grounds
refers to the information that an average person, using normal and honest judgement, would need in
order to decide to report.
General Directive
In situations where the paramedic has reasonable grounds to believe that the patient is a child who
is or may be in need of protection, the paramedic shall:
1. ensure the patient is not left alone;
2. request police assistance at the scene when it is believed that the patient is at risk of
imm
inent harm;
Guideline
The following types of pediatric problems are noteworthy for specific attention when a
paramedic is determining if the patient may be a child in need of protection:
• Submersion injury
• All burns
• Accidental ingestions/poisoning
• Other types of in-home injuries, e.g. falls
Scene observations which may prompt consideration that the patient is a child in need of
prot
ection include:
• Household/siblings dirty, unkempt, and/or in disarray
• Evidence of violence, e.g. overturned or broken furniture
• Animal/pet abuse
• Evidence of substance abuse, e.g. empty liquor bottles, drug paraphernalia
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Section 1 – General Standard of Care
Physical signs which may prompt consideration that the patient is a child in need of
protection include:
• Gross or multiple deformities which are incompatible with the incident history,
especially in a child under two years of age who is developmentally incapable of
sustaining this type of injury
• Multiple new and/or ol
d bruises which have not been reported, or which have been
reported as all being new
• Distinctive marks or burns, e.g. belt, hand imprint, cigarette burns;
• Bruises in unusual areas: chest, abdomen, genitals, buttocks
• Burns in unusual areas: buttocks, genitals, soles of feet
• Signs of long-standing physical neglect, e.g. dirty, malodourous skin, hair and clothing,
severe diaper rash, uncut/dirty fingernails
• Signs of malnutrition - slack skin folds, extreme pallor, dull/thin hair, dehydration
• Signs of “shaking” syndrome - hemorrhages over the whites of the eyes; hand or
fingerprints on the neck, upper arms or shoulders; signs of head injury unrelated to the
incident history.
3. obtain as clear a history of the incident as possible, with no display of personal curiosity.
Attempt to determine,
a. the validity of the history provided. Consider if the patient may be a child in need of
protection if,
i. the story changes frequently or parents’ stories differ,
ii. the parents are vague about what happened or blame each other,
iii. the nature of the injury appears to be inconsistent or improbable with the
explanation provided,
iv. the mechanism of injury is obviously beyond the developmental capabilities
of the child,
v. there has been prolonged, unexplained delay in seeking treatment, or
vi. there is a history of recurrent injuries;
b. interaction (or lack thereof) between parents/caretakers and between parents and
child, e.g. the parents are openly hostile, the child is inappropriately fearful, or the
child is avoiding the parents or clinging to one parent and avoiding the other (the
child may also paradoxically protect the abusive party, either out of fear of losing a
parent or because of verbal threats to keep quiet);
c. appropriateness of parental/caretaker response to the child’s injury and/or emotional
distress, e.g. lack of concern, lack of physical comforting, anger inappropriately
directed towards the child; and
d. appropriateness of child’s behaviour relevant to the situation/injury, e.g. inappropriate
fear, indifference, lack of emotion;
4. make no accusations; make no comments about your suspicions in front of the parents or
bystanders;
5. transport the child in all cases; and
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Section 1 – General Standard of Care
6. report suspicions to the receiving hospital and complete the duty to report to the CAS.
Guideline
• The duty to report overrides any other provincial statute, including any provisions that
would otherwise prohibit someone from making a disclosure (i.e. PHIPA). The failure
to report a suspicion in the circumstances set out in the Child and Family Services Act
(Onta
rio) is an offence under that Act.
• Paramedics s
hould be aware that the duty to report under the Child and Family
Servi
ces Act (Ontario) extends to any child he/she encounters in his/her professional
duties and is
not limited to the person(s) requesting 911 services.
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Section 1 – General Standard of Care
General Geriatric Standard
In situations involving a geriatric patient, the paramedic shall:
1. assume that all geriatric patients are capable of normal hearing, sight, speech, mobility
and mental function unless information is provided to the contrary;
Guideline
• Geriatric patients can present with atypical signs and symptoms and may have co-
morbidities.
• Diminished responses to pain, infection, heat/cold may lead the patient and the
paramedic to underestimate the severity of the illness/injury.
• Geriatric patients are susceptible to skin tearing, abrasions, and bruising; use caution
when handling the patient.
• Geriatric patients are more likely to experience adverse effects from medication use.
2. assess living accommodations, living situation, and consider the patient’s ability to
p
erform activities of daily living;
Guideline
• Consider referral to local agency resources, when appropriate, e.g. Community Care
Access Centre (CCAC), 211.
• Activities of daily living include:
o Bathing
o Dressing
o Transferring (e.g. movement and mobility)
o Toileting
o Eating
• If a relative, friend or neighbor is available, they may be able to provide, if necessary,
c
ollateral information, such as patient’s usual level of function and available support.
3. be aware of patient presentations associated with elder abuse; and
Guideline
Forms of elder abuse include:
• Financial abuse
• Psychological abuse
• Physical abuse
• Sexual abuse
• Neglect
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Section 1 – General Standard of Care
4. if elder abuse is suspected,
a. and police not on-scene, offer to contact police; and
b. alert receiving facility staff.
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Section 1 – General Standard of Care
Mental Health Standard
In situations involving a patient with an emotional disturbance (e.g. erratic behaviour), the
paramedic shall:
1. consider underlying organic disorders;
2. give particular attention to personal safety as per the General Measures Standard;
3. in case
s of patients with known or suspected suicide attempts or self-harm,
a. assume that all attempts are of serious intent, and
b. ask the patient directly whether they have ideation or intent of suicide or self-harm;
4. in cases in which a patient is being transported without consent, not proceed with
t
ransport unless in possession of the appropriate documentation and/or escort (see
paragraph 5 below);
Guideline
The Mental Health Act (Ontario) has implications in the manner in which a paramedic may
deliver care. Recall:
• A person who is recommended by a physician for admission to a psychiatric facility as
an informal or voluntary patient pursuant to the Mental Health Act (Ontario) may not
be
transported without consent
• The following persons may be transported without consent, subject to the provisions of
the Mental Health Act (Ont
ario) (Note: this list is not exhaustive, please refer to the
Mental Health Act for further details):
o The subject
of an application for assessment signed by a physician under
subsection 15(1) or 15(1.1) of the Mental Health Act (Ontario) (Form 1)
o The subject of an order for examination signed by a Justice of the Peace under
subsection 16(1) of
the Mental Health Act (Form 2); and
o A person taken i
nto custody by a police officer under subsection 17 of the Ment
al
Health Act (Ontario); and
o A patient d
etained in a psychiatric facility under a certificate of involuntary
admission under subsection 20(4) of the Mental Health Act (Ontario) (Form 3) or
a
certificate of renewal (Form 4).
5. recognize the need for an escort as follows:
a. If a patient is violent or potentially violent, refer to the Violent/Aggressive Patient
St
andard,
b. If a patient is in custody under Court or Ontario Review Board Disposition, a Justice
of
the Peace or hospital’s officer in charge or delegate will designate the escort;
6. with respect to use of restraints,
a. only restrain a patient if,
i. directed by a physician or police officer,
ii. an unescorted patient becomes violent en route, or
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Section 1 – General Standard of Care
iii. use of restraints is required to provide emergency treatment as per the Patient
Refusal/Emergency Treatment Standard,
b. only the reasonable and minimum force shall be used to restrain the patient,
c. where restraints are applied prior to departing a scene call under the direction of a
physic
ian or police officer, a physician escort (or delegate) or police officer ordering
the restraint is required to accompany the patient in the ambulance,
d. concurrent with paragraph 5(c) above, if a police officer has handcuffed a patient, the
paramedic shall not proceed with transport until such a time that the police officer
takes the patient into custody and is present in the patient compartment,
e. for inter-facility transports,
i. in cases in which the sending facility is requesting restraints, advise that all
restraints must be provided and applied by hospital staff or police prior to
transport, and
ii. in cases in which the patient is restrained, the paramedic shall not proceed
with the inter-facility transport unless,
1. the sending physician or sending facility has made a decision that the
patient can be transferred safely without a hospital escort,
2. the patient does not appear to be a safety risk or have the potential to
become violent en route, and
3. the paramedic feels comfortable with the decision that the patient
does not appear to be a safety risk or who has the potential to become
violent en route, and
f. if the patient is restrained, document the following on the Ambulance Call Report, in
conjun
ction with the requirements outlined in the Documentation of Patient Care
Standard:
i. that th
e patient was restrained,
ii. a description of the patient’s behaviour that required that the he/she be
restrained or continue to be restrained,
iii. a description of the means of restraint, including the method of restraint,
iv. the person (e.g. physician, police officer or paramedic) ordering restraint,
v. the position of the patient during restraint, and
vi. the clinical response to restraint; and
Guideline
Restrained patients are more susceptible to rapid deterioration. Maintain a high index of
suspicion for all restrained patients.
7. not transport a patient in the prone position;
Guideline
When initiating full body restraint, or participating in full body restraint, of a patient:
• Attempt to organize the team before attempting restraint.
• Prepare all equipment in advance.
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Section 1 – General Standard of Care
• Inform the patient of the need to restrain them and explain the procedure.
• Immobilize the patient’s limbs and head in one coordinated effort. Grasp each
limb at
the main joint and between the main joint and the distal joint, e.g. one hand on the
elbow, the other on the forearm.
• Place the patient in a supine “spread eagle” position or in the left lateral position.
• Rest
rain extremities as follows:
o Secure one arm above the head and the other to the stretcher at waist level, or
secure both hands to one side of the stretcher.
o Elevate the head of the stretcher to protect the airway and to allow the paramedic
greater visibility.
o Secure the feet.
o Ensure that the limbs are secured to the main frame of the stretcher, not to the
stretcher side rails.
• If the patient is spitting, consider use of a surgical mask on the patient.
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Section 1 – General Standard of Care
Violent/Aggressive Patient Standard
In situations involving a violent or aggressive patient, the paramedic shall:
1. consider underlying organic disorders;
2. give particular attention to personal safety as per the General Measures Standard;
3. requ
est police assistance on-scene;
4. wait for police assistance if,
a. there is an active shooter scenario, or
b. there is direct evidence of ongoing violence;
5. if electing to delay service as per paragraph 4 above, immediately notify CACC/ACS;
6. if the patient is uncooperative, elicit information from others at the scene; attempt to
determine,
a. if illness, injury and/or alcohol/drug ingestion has triggered the present behaviour,
a
nd
b. whether there is a past history of violence;
7. be alert for behavioural signs of impending violence;
8. if confronted, seek a safe egress and attempt to withdraw;
9. if a safe withdrawal is not feasible, attempt to speak with and calm the patient; and
10. consider need for restraints as per paragraph 6 of the Mental Health Standard.
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Section 1 – General Standard of Care
Intravenous Line Maintenance
Standard
General Directive
A paramedic shall monitor an intravenous (IV) line for a patient who has:
1. an IV line to keep the vein open, as follows:
a. The minimum flow rate to maintain I
V patency for a patient <12 years of age is
15mL/hr of any isotonic fluid.
b. The minimum flow rate to maintain IV patency for a patient ≥12 years of age is
30mL
/hr of any isotonic fluid; or
2. an intravenous line for fluid replacement with,
a. a maximum flow rate infused of up to two mL/kg/hr to a maximum of 200 mL/hr,
b. thiamine, multivitamin preparations,
c. drugs within his/her level of certification, or
d. potassium chloride (KCl) for patients ≥18 years of age, to a maximum of 10mEq in a
250 mL
bag.
Use of Escorts
1. Unless within his/her level of certification, a paramedic shall request a medically
responsible escort in the event a patient requires an intravenous:
a. that is being used for blood (or blood product) administration;
b. that is being used to administer potassium chloride to a patient who is <18 years of
age;
c. that
is being used to administer medication (including pre-packaged medications,
except as detailed in paragraph 2 from the General Directive above);
d. that requires electronic monitoring or uses a pressurized intravenous fluid infuser,
pump or c
entral venous line; or
e. for a neonate or pediatric patient <2 years of age.
Procedure
The paramedic shall:
Pre-transport
1. confirm physician’s written IV order with sending facility staff;
2. determine IV solution, IV flow
rate, catheter gauge, catheter length, and cannulation site;
3. note condition of IV site prior to transport;
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Section 1 – General Standard of Care
4. confirm amount of fluid remaining in bag;
5. determine amount of fluid required for complete transport time and obtain more fluid if
ap
plicable; and
6. document all pre-tra
nsport IV information on the Ambulance Call Report.
During transport
1. monitor and maintain IV at the prescribed rate, this may include changing the IV bag as
required;
2. if the
IV becomes dislodged or interstitial, discontinue the IV flow and remove the
catheter with particular attention to aseptic technique; and
3. confirm condition of catheter if removed.
Guideline
The IV bag should be changed when there is approximately 150 mLs of solution remaining.
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Section 1 – General Standard of Care
Load and Go Patient Standard
General Directive
1. Subject to paragraph 2 below, the paramedic shall initiate rapid transport:
a. for CTAS 1 patients as per the Prehospital Paramedic CTAS Guide;
b. for patients who meet bypass protocols as per the Standards (e.g.
Field Trauma
Triage, Stroke); or
c. for obstetrical patients, with:
i. eclampsia/pre-eclampsia,
ii. limb presentation,
iii. multiple births expected,
iv. premature labour, or
v. umbilical cord prolapse.
2. Notwithstanding paragraph 1 above, the following types of patients may require
i
nterventions prior to initiation of rapid transport:
a. vital signs absent patients experiencing cardiac arrest in which a TOR is not indicated
as
per the ALS PCS;
b. patients with conditions which require immediate, life-saving interventions, which
the
paramedic can perform; or
c. obstetrical patients in which delivery appears imminent.
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Section 1 – General Standard of Care
Police Notification Standard
General Directive
Paramedics shall ensure that police are notified in any cases involving unusual or suspicious
situations (e.g. sudden death, violence, foul play, accidents involving emergency vehicles).
Guideline
Requesting Police Assistance
• Paramedics requesting police assistance will:
o Contact his/her CACC/ACS vi
a radio or telephone
o State the nature of the request
o Indicat
e the urgency of response and request the estimated time of arrival
o Advise of possible hazards
o Indicate access routes (where applicable)
o Provide police with an update of the situation when they arrive at the scene
• The following radio codes should be used to contact police in extenuating
ci
rcumstances:
o 10-200 - No immediate danger is evident to patient or paramedic
o 10-2000 - Immediate danger is evident to patient or paramedic
o Emergency button on radio and other communication equipment, when available
• The use of police vehicle escorts during transport for the purpose of traffic control is
di
scouraged due to the prevalent danger it presents
Suspected Foul Play
In cases of suspected foul play, every effort should be made to leave the scene undisturbed
and to preserve as much evidence as possible for the police.
The following should be noted:
• Once a body is moved it can never be put back in its original position
• Careful
attention is required whenever something is moved
• Whenever possible use the shortest, most direct path to the patient and the same path
w
hen leaving the scene
• Attempt to preserve the chain of evidence; do not discard linen/clothes after call
completion without checking with the receiving facility or investigating officer
• The receiving facility staff should also be cautioned regarding the suspected foul play
Hanging
In cases of hanging, the following special precautions should be taken:
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Section 1 – General Standard of Care
• Careful observation should be made of the position of the rope around the patient’s
neck.
• The rope should be cut only if it cannot be readily slipped off and in such a way that
the knot will be preserved.
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Section 1 – General Standard of Care
Sexual Assault (Reported) Standard
In situations involving a patient who is reported to have been sexually assaulted, the paramedic
shall:
1. ensure the patient is not left alone;
2. if the patient is a child, follow the Child in Need of Protection Standard;
3. notwi
thstanding paragraph 2 above, in situation where police are not on-scene, offer to
contact police; and
Guideline
• If the patient declines to report the incident to the police, it is helpful to discuss options
and be knowledgeable regarding local resources (e.g. sexual assault crisis centre; crime
victim assistance programs), and be able to provide phone numbers for same.
• Advise the patient not to wash, urinate or defecate until an examination is conducted at
the receiving facility.
4. upon police request, bag the stretcher linen, dressings, and other materials in contact with
t
he patient, and leave with the attending police officer.
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2
Section 2 – Medical Standards
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Basic Life Support Patient Care Standards – Version 3.0.1 57
Section 2 – Medical Standards
Introduction
Specific standards in Section 2 – Medical Standards have been developed not on the basis of
diagnosis, but on the basis of:
a) chief complaint, as stated by the patient/bystanders;
b) presenting problem as indicated by the patient/bystanders; and/or
c) immediately obvious primary survey critical findings, e.g. respiratory failure.
Paramedics should be aware of a patient’s potential to deteriorate and prepare accordingly. Particular
a
ttention should be paid to the potential for compromises to airway, breathing or circulation, seizures,
and/or emesis.
In conjunction with history gathering, paramedics shall determine provoking factors, quality,
re
gion/radiation/relieving factors, severity, and timing of the chief complaint or presenting problem.
When providing patient care as per Section 2 – Medical Standards, a paramedic shall ensure that the
p
atient simultaneously receives care in accordance with the ALS PCS.
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Section 2 – Medical Standards
Abdominal Pain (Non-Traumatic)
Standard
In situations involving a patient with abdominal pain that is believed to be of a non-traumatic origin,
the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. leaking or ruptured abdominal aortic aneurysm,
b. ectop
ic pregnancy,
c. other non-abdominal disorders that may present with abdominal pain, including:
i. diabetic ketoacidosis, and
ii. pulmonary embolism,
d. perforated or obstructed hollow organs with or without peritonitis,
e. acute pancreatitis,
f. testicular torsion,
g. pelvic infection, and
h. strangulated hernia;
2. perform, at a minimum, a secondary survey to assess the abdomen for,
i. pulsations,
ii. scars,
iii. discolouration,
iv. distention,
v. masses,
vi. guarding,
vii. rigidity, and
viii. tenderness;
3. if a pulsatile mass is discovered, not initiate, or discontinue, further abdominal palpation;
4. if abdominal aneurysm is suspected, palpate femoral pulses for weakness/absence; and
5. observe for melena, hematemesis, or frank rectal bleeding (“hematochezia”).
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Airway Obstruction Standard
In situations involving a patient with an airway obstruction, the paramedic shall:
1. perform assessments and obstructed airway clearance maneuvers as per current Heart
and Stroke Foundation of Canada Guidelines; and
2. attempt to clear the airway using oropharyngeal/nasopharyngeal suction.
Guideline
Consider the possibility of airway obstruction for patients who have smoke inhalation,
anaphylaxis, epiglottitis, foreign body aspiration, or oropharyngeal malignancy.
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i.
i.
i.
i.
i.
Allergic Reaction (Known or
Suspected) Standard
In situations involving a patient with an allergic reaction that is known or suspected, the paramedic
shall:
1. consider potential life/limb/function threats, such as anaphylaxis;
Guideline
Common allergens include:
• Penicillin and other antibiotics in the penicillin family
• Latex
• Venom of bees, wasps, hornets
• Seafood - shrimp, crab, lobster, other shellfish
• Nuts, strawberries, melons; eggs; bananas
• Sulphites (food and wine preservatives)
2. perform, at a minimum, a secondary survey to assess,
a. the site of allergic reaction, if applicable,
b. lungs, for adventitious sounds through auscultation, and
c. skin, for erythema, urticaria, and edema;
3. consider anaphylaxis if the patient presents with two or more body system manifestations
a
s follows:
a. Respiratory:
Dyspnea, wheezing, stridor or hoarse voice
b. Cardiovascular:
Tachycardia or hypotension/shock
c. Neurological:
Dizziness, confusion, or loss of consciousness
d. Gastrointestinal
Nausea, vomiting, abdominal cramps, or diarrhea
e. Dermatological/mucosal:
Facial, orolingual, or generalized swelling/flushing/urticaria;
4. in association with the body systems involvement in paragraph 3 above, consider
hi
storical findings as evidence of suspected anaphylaxis, as follows:
a. Difficulty swallowing/tightness in the throat
b. Difficulty breathing/feeling of suffocation
c. Fearfulness, anxiety, agitation, confusion, or feeling of doom
d. Generalized itching
e. History of any of the body system involvement listed in paragraph 3; and
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5. prepare for potential problems, including,
a. cardiac arrest,
b. airway obstruction,
c. anaphy
laxis,
d. bronchospasm, and
e. hypotension.
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Altered Level of Consciousness
Standard
In situations involving a patient with a suspected acute altered level of consciousness, the
paramedic shall:
1. attempt to determine a specific cause for the altered level of consciousness and provide
further assessment and management as per the Standards;
2. perform a secondary survey to assess the patient from head-to-t
oe;
3. perform trauma assessments if trauma is obvious, suspected or cannot be ruled out;
4. if unprotected airway, insert oropharyngeal airway/nasopharyngeal airway; and
5. if patient is apneic or respirations are inadequate, assist ventilations in accordance with
t
he Respiratory Failure Standard.
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Back Pain (Non-Traumatic) Standard
In situations involving a patient with back pain that is believed to be of a non-traumatic origin, the
paramedic shall:
1. consider potential life/limb/function threats, such as,
a. abdominal/thoracic aortic aneurysm,
b. ac
ute spinal nerve root(s) compression,
c. intra-abdominal disease (e.g. pancreatitis; peptic ulcer), and
d. possible occult injury (e.g. pathologic fracture); and
2. perform, at a minimum, a secondary survey to assess,
a. back, for abnormal appearance/findings,
b. chest, as per Chest Pain (Non-Traumatic) Standard,
c. abdomen, as per Abdominal Pain (Non-Traumatic) Standard,
d. distal pulses, and
e. extremities, for circulation, sensation, and movement.
Guideline
If a thoracic aneurysm is suspected, perform bilateral blood pressures.
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Cardiac Arrest Standard
In situations involving a patient with cardiac arrest, the paramedic shall:
1. position the patient on a firm surface;
2. initiate CP
R (including defibrillation);
Guideline
• When two or more CPR-certified rescuers are available, attempt to switch chest
compressors approximately every two minutes
• Have suction equipment readily available in preparation for emesis
• As per current Heart and Stroke Foundation of Canada Guidelines, use
of mechanical
CPR devices may be considered (if available) when limited rescuers are available, for
prolonged CPR or in a moving ambulance
• End-tidal carbon dioxide (ETCO
2
) monitoring may be considered if available
3. establish a patent airway using authorized techniques;
4. consider reversible causes of cardiac arrest and initiate further assessment and
m
anagement as required by the Standards;
5. minimize disruptions to CPR;
Guideline
In cases where CPR must be interrupted, such as when going down a flight of stairs, plan to
reinitiate CPR as quickly as possible at a predetermined point.
6. continue cardiac arrest resuscitation measures until a TOR order is received as per the
A
LS PCS; and
7. if the patient has a spontaneous return of circulation,
a. continue assisted ventilation if the patient remains apneic or respirations are
i
nadequate,
b. administer oxygen to attempt to maintain the patient’s oxygen saturation 94-98%,
c. in conjunction with the Patient Assessment Standard, obtain vital signs,
i. at least every 15 minutes after the patient’s return of spontaneous circulation
f
or the first hour, and
ii. at a minimum every 30 minutes thereafter or if a change in patient status
oc
curs,
d. continue cardiac monitoring, and
e. resume CPR if cardiac arrest recurs.
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Guideline
Cardiac Arrest in the Pregnant Patient
When performing CPR on a pregnant patient with a uterine height at or above the umbilicus
(approximately greater than 20 weeks gestation), have a second paramedic attempt to
manually perform left uterine displacement.
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Cerebrovascular Accident (CVA,
“Stroke”) Standard
In situations involving a patient with a cerebrovascular accident (CVA, “Stroke”), the paramedic
shall:
General Directive
1. consider other potentially serious conditions that may mimic a stroke, such as,
a. drug ingestion (e.g. cocaine),
b. hypoglycemia,
c. severe hypertension, hypertensive emergency, or
d. central nervous system (CNS) infection (e.g. meningitis);
2. perform, at a minimum, a secondary survey to assess,
a. head/neck, for,
i. facial symmetry,
ii. pupillary size, equality, and reactivity,
iii. abnormal speech, and
iv. presence of stiff neck,
b. central nervous system, for,
i. abnormal motor function, e.g. hand grip strength, arm/leg movement/drift,
a
nd
ii. sensory loss, and
c. for incontinence of urine/stool;
3. ensure adequate support for the patient’s body/limbs during patient movement and place
e
xtra padding and support beneath affected limbs; and
4. prepare for potential problems, including,
a. possible airway obstruction (if loss of tongue control, gag reflex),
b. decreasing level of consciousness,
c. seizures, and
d. agitation, confusion, or combativeness.
Acute Stroke Bypass Protocol
1. assess the patient to determine if he/she has one or more of the symptoms consistent with
the onset of an acute stroke, as follows:
a. Inappropriate words or mute,
b. Slurred speech,
c. Uni
lateral arm weakness or drift,
d. Unilateral facial droop, or
e. Unilateral leg weakness or drift;
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2. if the patient meets the criteria listed in paragraph 1 of the Acute Stroke Bypass Protocol
above, determine if the patient can be transported to a Designated Stroke Centre* within
4.5 hours o
f a clearly determined time of symptom onset or time the patient was last seen
in his/her usual state of health;
3. if the patient meets the criteria listed in paragraph 1 and paragraph 2 above, assess the
patie
nt to determine if he/she has any of the following contraindications:
a. CTAS 1 and/or an uncorrected airway, breathing or circulation issue
b. Stroke
symptoms resolved prior to paramedic arrival or assessment
c. Blood Glucose Level <3 mmol/L**
d. seizure at the onset of symptoms or that is observed by the paramedic
e. Glasgow Coma Scale <10
f. Terminally ill or is in palliative care
g. Duration of transport to the Designated Stroke Centre will exceed two hours;
4. if the patient does not meet any of the contraindications listed in paragraph 3 above,
inform the CACC/ACS of the need for transport to the Designated Stroke Centre; and
5. if transport has been initiated to a Designated Stroke Centre and the patient’s symptoms
improve significantly or resolve during transport, continue transport to the Designated
Stroke Centre.
*Note: A Designated Stroke Centre includes a Regional Stroke Centre, District Stroke Centre or a
Telestroke Centre
**Note: If symptoms persist after correction of blood glucose level, the patient is not
contraindicated as per paragraph 3(c) above.
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Chest Pain (Non-Traumatic) Standard
General Directive
In situations involving a patient with chest pain that is believed to be of a non-traumatic origin, the
paramedic shall:
1. consider potential life/limb/function threats, such as,
a. acute coronary syndrome/acute
myocardial infarction (e.g. ST-segment elevation
myocardial infarction [STEMI]),
b. dissecting thoracic aorta,
c. pneumothorax, tension pneumothorax/other respiratory disorders (e.g. pneumonia),
d. pulmonary embolism, and
e. pericarditis;
2. acquire a 12-lead electrocardiogram, in accordance with the ALS PCS; and
3. perform, at a minimum, a secondary survey to assess,
a. chest, for
i. subcutaneous emphysema,
ii. accessory muscle use,
iii. urticaria,
iv. indrawing,
v. shape,
vi. symmetry, and
vii. tenderness;
b. lungs, for decreased air entry and adventitious sounds (e.g. wheezes, crackles),
t
hrough auscultation,
c. abdomen, as per the Abdominal Pain (Non-traumatic) Standard,
d. neck, for tracheal position and jugular vein distension, and
e. extremities, for leg/ankle edema.
STEMI Hospital Bypass Protocol
In situations in which the paramedic suspects that the patient is suffering from a STEMI, the
paramedic shall:
1. assess the patient to determine if they meet all of the following indications:
a. ≥18 y
ears of age;
b. experience chest pain or equivalent consistent with cardiac ischemia or myocardial
i
nfarction;
c. the time from onset of the current episode of pain <12 hours; and
d. the 12-lead electrocardiogram (ECG) indicates an acute myocardial
i
nfarction/STEMI, as follows:
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i. At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads;
OR
ii. At least 1 mm ST-elev
ation in at least two other anatomically contiguous
leads; OR
iii. 12-lead ECG computer interpretation of STEMI and paramedic agrees.
2. if the
patient meets the criteria listed in paragraph 1 above, assess the patient to determine
if they have any of the following contraindications:
a. The patient is CTAS 1 and the paramedic is unable to secure the patient’s airway or
ventilate;
b. 12-lead ECG is consistent with a Left Bundle Branch Block (LBBB), ventricular
paced rhythm, or any other STEMI imitator;
c. Transport to a hospital capable of performing percutaneous coronary intervention
(PCI) ≥60 minutes from patient contact;
d. The patient is experiencing a complication requiring primary care paramedic (PCP)
diversion, as follows:
i. Moderate to severe respiratory distress or use of continuous positive airway
pressure (CPAP);
ii. Hemodynamic instability (e.g. due to symptomatic arrhythmias or any
ventricular arrhythmia) or symptomatic SBP <90 mmHg at any point; or
iii. VSA without return of spontaneous circulation (ROSC).
e. The patient is experiencing a complication requiring ACP diversion, as follows:
i. Ventilation inadequate despite assistance;
ii. Hemodynamic instability unresponsive to advanced care paramedic (ACP)
treatment or not amenable to ACP management; or
iii. VSA without ROSC.
3. notwithstanding paragraphs 2(c), 2(d), and 2(e) above, attempt to determine if the
interventional cardiology program at the PCI centre will still permit the transport to the
PCI centre;
4. if the patient does not meet any of the contraindications listed in paragraph 2 above OR
the interventional cardiology program permits the transport to the PCI centre as per
paragraph 3 above, inform the CACC/ACS of the need to transport to a PCI centre;
a. provide the PCI centre the following information as soon as possible:
b. that the patient is a “STEMI patient”;
c. the patient’s initials;
d. the patient’s age;
e. the patient’s sex;
f. the paramedic’s concerns regarding clinical stability;
g. infarct territory and/or findings on the qualifying ECG;
h. estimated time of arrival; and
i. catchment area of the patient pickup.
5. upon arrival at the PCI centre, in addition to the requirements listed in the Transfer of
Respons
ibility for Patient Care Standard, provide the following information to the
PCI
centre staff:
a. time of
symptom onset;
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*
b. time of ROSC, if applicable;
c. hemodynamic status;
d. medications given and procedure;
e. hi
story of acute myocardial infarction/
PCI/Coronary artery bypass graft, if applicable;
f. a copy of the qualifying ECG; and
g. a copy of the Ambulance Call Report
in accordance with the Ontario Ambulance
Documentation Standards.
Note: Once initiated, continue to follow the STEMI Hospital Bypass Protocol even if the ECG
normalizes after the intial assessment.
Guideline
• Once a STEMI is confirmed, the paramedic should apply defibrillation pads due to the
potential for lethal cardiac arrhythmias.
• If intravenous access is indicated and established as per the Advanced Life Support
Patient Care Standards, then the left arm is the preferred site.
• If the ECG becomes STEMI-positive en route to a non-PCI destination, the patient
should still be evaluated under this STEMI Hospital Bypass Protocol.
• If, in a rare circumstance, the PCI centre indicates that it cannot accept the patient (e.g.
equi
pment failure, multiple STEMI patients), then the paramedic may consider
transport to an alternative PCI centre as long as they still meet the STEMI Hospital
Bypass Protocol.
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Dysphagia Standard
In situations involving a patient with dysphagia, the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. anaphylaxis, and
b. upper airw
ay infections (e.g. epiglottitis);
2. perform, at a minimum, a secondary survey to assess,
a. head/neck, for
i. drooling,
ii. hoarse voice or cough,
iii. nasal flaring,
iv. swelling or masses, and
v. tracheal deviation, and
b. lungs, for adventitious sounds through auscultation;
3. notwithstanding paragraph 2 above, if epiglottitis is suspected, not open and inspect the
ai
rway;
4. if epiglottis is suspected and oxygen administration is indicated as per the Oxygen
T
herapy Standard, attempt to minimize agitation;
5. position the patient sitting or semi-sitting; and
6. prepare for potential problems, including complete airway obstruction.
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Epistaxis (Non-Traumatic) Standard
In situations involving a patient with epistaxis that is believed to be of a non-traumatic origin, the
paramedic shall:
1. consider potential life/limb/function threats, such as upper airway obstruction;
2. perform, at a minimum, a secondary survey to
assess,
a. for estimated blood loss (e.g. hemorrhage duration, rate of flow, presence of clots,
qua
ntity of blood-soaked materials at scene, quantity of blood vomited), and
b. head/neck, for foreign bodies in nares, and headache;
3. attempt to control bleeding; and
4. prepare for potential problems, including:
a. airway compromise, and
b. hypotension.
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Excited Delirium Standard
In situations involving a patient with excited delirium, the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. asphyxia,
b. cardiopul
monary arrest, and
c. dysrhythmias;
Guideline
Excited delirium is a state of impaired thinking and violent struggling induced by a variety of
causes such as drug abuse, severe alcohol intoxication, and/or acute psychosis. These patients
are at risk of sudden death. Symptoms of excited delirium include:
• Impaired thought processes, e.g. disorientation, acute paranoia, panic, or hallucinations
• Unexpected physical strength
• Significantly decreased sensitivity to pain
• Sweating, fever, heat intolerance, or, dry/hot skin with no sweating despite extreme
a
gitation
• Sudden tranquility after frenzied activity
2. give particular attention to personal safety as per the General Measures Standard;
3. if the patient is violent or potentially violent, refer to the Violent/Aggressive Patient
St
andard;
4. recognize the need for police assistance in conjunction with the Police Notification
St
andard;
5. provide patient care based on presenting signs and symptoms as per the Standards;
6. recognize the potential need for advanced patient care as per the ALS PCS; and
7. prepare for potential problems, including rapid deterioration.
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Extremity Pain (Non-Traumatic)
Standard
In situations involving a patient with extremity pain that is believed to be of a non-traumatic origin,
the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. acute spinal nerve root(s) compression,
b. possible
occult fracture,
c. soft tissue and joint infections, and
d. vascular occlusion (e.g. peripheral vessel, intra-abdominal vessel, intra-thoracic
v
essel);
2. perform, at a minimum, a secondary survey to assess,
a. the affected extremity compared with the unaffected extremity, with respect to,
i. distal pulses,
ii. circulation, sensation, and movement,
iii. skin colour, temperature, and condition, and
iv. swelling, deformity, and tenderness; and
3. attempt to keep movement to the affected extremity to a minimum and protect from
f
urther injury.
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Fever Standard
In situations involving a patient with a fever (known fever >38.5°C or chief complaint of fever), the
paramedic shall:
1. consider potential life/limb/function threats, such as,
a. overdose,
b. sepsis
,
c. meningitis, and
d. heat-related illness;
Guideline
Consideration of sepsis is typically evidenced by all of the following:
• Presence of fever: >38.5°C
• Possible infection suspected, e.g. pneumonia, urinary tract infection, abdominal pain or
d
istension, meningitis, cellulitis, septic arthritis, infected wound
• Presence of any one of:
o SBP <90
o Respiratory rate ≥22 breaths/minute, or intubated for respiratory support
o Acute confusion or reduced level of consciousness
If sepsis is suspected, report findings to receiving facility.
2. perform, at a minimum, a secondary survey to assess,
a. lungs, for adventitious sounds through auscultation,
b. skin, for,
i. jaundice
ii. rash, and
iii. signs of dehydration,
c. head/neck, for,
i. photophobia,
ii. scleral jaundice,
iii. stiff neck, and
iv. headache,
d. abdomen, as per the Abdominal Pain (Non-Traumatic) Standard; and
e. temperature
3. remove excess layers of clothing if required to promote passive cooling;
4. not actively cool the patient, and
5. prepare for potential problems, including seizures, if the patient is a febrile child or an
a
dult in whom serious disorders are suspected (e.g. meningitis).
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Headache (Non-Traumatic) Standard
In situations involving a patient with a headache that is believed to be of a non-traumatic origin, the
paramedic shall:
1. consider potential life/limb/function threats, such as,
a. intracranial/intracerebral events (e.g. hemorrhage, thrombosis, tumour),
b. centr
al nervous system or other systemic infection,
c. severe hypertension, and
d. toxic event/exposure (e.g. carbon monoxide poisoning);
Guideline
The following signs and symptoms can indicate a serious underlying disorder or cause:
• Sudden onset of severe headache with no previous medical history of headache
• Recent onset headache (days, weeks) with sudden worsening
• Change in pattern of usual headaches
• Any of the above accompanied by one or more of the following:
o Altered mental status
o Decrease in level of consciousness
o Neurologic deficits
o Obvious nuchal rigidity and fever or other symptoms of infection.
o Pupillary abnormalities (inequality, sluggish/absent light reactivity)
o Visual disturbances
2. perform, at a minimum, a secondary survey to assess,
a. head/neck, for pupillary size, equality, and reactivity,
b. central nervous system, for,
i. abnormal motor function (e.g. hand grip strength, arm/leg movement/drift),
and
ii. sensory loss; and
3. prepare for potential problems, including seizures.
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o
Heat-Related Illness Standard
In situations involving a patient experiencing a heat-related illness, the paramedic shall:
1. consider life/limb/function threats, such as,
a. heat stroke, and
b. hypov
olemic shock;
Guideline
Consider various heat-related illnesses in the setting of hot and/or humid outdoor or indoor
conditions with chief complaint(s), presenting problems of:
• Heat syncope
• Heat cramps: severe cramping of large muscle groups
• Heat exhaustion: mild alterations in mental status, and non-specific complaints
(he
adache, giddiness, nausea, vomiting, malaise), with excessive sweating in healthy
adults; or hot, dry skin in the elderly
• Heat stroke: severely altered mental status, coma, seizures, hyperthermia ≥40°C
Overdose of tricyclic anti-depressants, antihistamines and β-blockers, as well as
co
caine, Ecstasy or amphetamine abuse may also lead to heat stroke.
2. perform, at a minimum, a secondary survey to assess,
a. central nervous system,
b. mouth, for state of hydration.
c. skin, for temperature, colour, condition, state of hydration,
d. extremities, for circulation, sensation, and movement, and
e. temperature;
3. move the patient to a cooler environment;
4. remove heavy or excess layers of clothing;
5. if available at scene or from bystanders, provide water or electrolyte-containing fluids in
s
mall quantities if the patient is conscious, cooperative, able to understand directions and
is not nauseated or vomiting;
6. if working assessment indicates heat exhaustion,
a. move the patient to the ambulance, and
b. remove as much clothing as possible; and
7. if working assessment indicates heat stroke,
a. provide patient care as per paragraph 6 above,
b. withhold oral fluids,
c. cover the patient with wet sheets, and
d. apply cold packs to the axillae, groin, neck and head.
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Guideline
Monitor the patient to determine if cooling procedures should be discontinued, e.g. skin
temperature feels normal to touch, generalized shivering develops, the patient’s level of
consciousness normalizes.
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Hematemesis/Hematochezia
Standard
In situations involving a patient with hematemesis and/or frank rectal bleeding (“hematochezia”),
the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. esophageal varices, and
b. gastrointestinal disease;
Guideline
If hemoptysis is suspected, attempt to ascertain the origin. Lung tumours and other lung
diseases are common causes of hemoptysis.
2. perform, at a minimum, a secondary survey to assess,
a. chest, if hemorrhage is oral, as per the Chest Pain (Non-Traumatic) Standard, and
b. abdomen, as per the Abdominal Pain (Non-Traumatic) Standard;
3. estimate degree of blood loss (e.g. duration of hemorrhage, rate of flow, presence of
c
lots, quantity of blood-soaked or blood-filled materials); and
4. elicit further information regarding hemorrhage (e.g. type: coffee-grounds emesis,
m
elena, hematochezia, etc.).
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Nausea/Vomiting Standard
In situations involving a patient with a nausea and/or vomiting, the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. acute coronary syndrome/acute m
yocardial infarction (e.g. STEMI),
b. anaphylaxis,
c. increased intracranial pressure,
d. toxicological emergencies,
e. bowel obstructions,
f. infection,
g. acute pancreatitis,
h. intra-abdominal emergencies, and
i. uremia;
2. perform, at a minimum, a secondary survey to assess abdomen, as per Abdominal Pain
(Non-T
raumatic) Standard; and
3. prepare for potential problems, including airway compromise.
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Respiratory Failure Standard
In situations involving a patient in respiratory failure, the paramedic shall:
1. ventilate the patient as per current Heart and Stroke Foundation of Canada Guidelines;
Guideline
If using ETCO
2
monitoring, attempt to maintain ETCO
2
values of 30-40 mmHg unless
indicated otherwise in the Standards. For COPD or asthma patients who have an initial
ETCO
2
of >50 mmHg, attempt to maintain ETCO
2
between 50-60 mmHg.
2. observe chest rise and auscultate lung fields to assess adequacy of ventilation (ventilation
j
ust sufficient to observe chest rise is adequate);
3. minimize interruptions to ventilations; and
4. continue assisted ventilations until patient’s spontaneous respirations are adequate.
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Seizure Standard
In situations involving a patient in seizure (or post-ictal), the paramedic shall:
1. consider potential life/limb/function threats and/or underlying disorders, such as,
a. intracranial event,
b. hypogl
ycemia,
c. in pregnant patients or recent post-partum patients, eclampsia,
d. in patients ≥50 years of age with new onset or recurrent seizures,
i. brain tumour or other intracranial event (e.g. hemorrhage, thrombosis),
ii. cardiac dysrhythmias,
iii. cardiovascular disease,
iv. cerebrovascular disease, and
v. severe hypertension,
e. in neonates,
i. traumatic delivery,
ii. congenital disorders,
iii. prematurity, and
iv. hypoglycemia,
f. in young children febrile convulsions associated with infection,
g. infec
tion (e.g. central nervous system, meningitis),
h. alcohol withdrawal (including delirium tremens)
i. drug ingestion/withdrawal, and
j. known seizure disorder;
2. if patient is in active seizure,
a. attempt to position the patient in the recovery position,
b. attempt to protect the patient from injury, and
c. observe for,
i. eye deviation,
ii. incontinence,
iii. parts of body affected, and
iv. type of seizure (e.g. full body, focal);
3. perform, at a minimum, a secondary survey to assess,
a. for seizure-related occurrences, such as,
i. bleeding from the mouth,
ii. incontinence,
iii. secondary injuries resulting from the seizure, and
iv. tongue injury; and
4. prepare for potential problems, including,
a. airway compromise,
b. recurrent seizures, and
c. post-ictal combativeness or agitation.
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Shortness of Breath Standard
In situations involving a patient with shortness of breath, the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. acute respiratory disorders, including,
i. parti
al airway obstruction,
ii. ast
hma,
iii. anaphylaxis,
iv. aspiration,
v. inhalation of toxic gases or smoke,
vi. pneumothorax,
vii. COPD, and
viii. respiratory infections,
b. acute cardiovascular disorders, including,
i. acute coronary syndrome/acute myocardial infarction (e.g. STEMI),
ii. congestive heart failure,
iii. pulmonary edema, and
iv. pulmonary embolism, and
c. other causes, including,
i. cerebrovascular accident,
ii. toxicological effects, and
iii. metabolic acidosis;
2. assume that all hyperventilation is due to an underlying disorder;
3. perform, at a minimum, a secondary survey to assess,
a. chest, as per Chest Pain (Non-Traumatic) Standard,
b. head/neck, for
i. cyanosis,
ii. nasal flaring,
iii. excessive drooling,
iv. tracheal deviation, and
v. jugular vein distension, and
c. extremities, for
i. cyanosis, and
ii. edema;
4. if the patient is on home oxygen, elicit history regarding changes in use;
5. position the patient in sitting or semi-sitting position; and
6. assist ventilations if patient is apneic or respirations are inadequate in accordance with
the Respiratory Failure Standard.
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Syncope/Dizziness/Vertigo Standard
In situations involving a patient who has had a syncopal episode, is dizzy, and/or is experiencing
vertigo, the paramedic shall:
1. consider potential life/limb/function threats, such as,
a. hypoglycemia,
b. cardiac dysrhythmias,
c. CVA/Transient Ischemic Attack,
d. hypovolemia,
e. toxicological effects,
f. heat-related illness,
g. anemia,
h. renal failure, and
i. sepsis;
2. position the patient supine, or in the recovery position; and
3. prepare for potential problems, including,
a. cardiac dysrhythmias,
b. hypotension,
c. seizures, and
d. decreased level of consciousness.
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Toxicological Emergency Standard
In situations involving a patient with a toxicological emergency (e.g. overdose, poisioning, and/or
drug ingestion), the paramedic shall:
1. attempt to identify/determine agent(s), quantity, time and route of administration
(absorption, inhalation, ingestion or injection);
2. in cases in which the agent(s) is believed to be a prescription medication, attemp
t to
identify date of prescription and compliance or appropriateness of remainder of
prescription amount;
Guideline
• Where available, attempt to refer to a compound or substance’s Material Safety Data
Sheet
• Attempts to refer to poison control resources should be made in consultation with the
BHP and not delay patient care/transport
3. if the patient is unconscious or level of consciousness decreased, refer to the Altered
L
evel of Consciousness Standard; and
4. prepare for potential problems, including,
a. cardiac arrest,
b. airway obstruction,
c. respiratory arrest,
d. respiratory distress,
e. altered or changing level of consciousness,
f. sudden violent behaviour,
g. hyperthermia,
h. seizures, and
i. emesis.
Guideline
Assume carbon monoxide poisoning in setting of exposure to a fuel burning device (e.g.
automobile engine exhaust, heating devices) in an enclosed area where the patient, or
multiple patients, exhibit the following symptoms/signs without other obvious cause:
• Altered mental status
• Cardiac dysrhythmias
• Emesis
• Headache
• Light-headedness
• Nausea
• Seizures
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• Syncope
• Weakness
• VSA
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Vaginal Bleeding Standard
In situation involving a patient with vaginal bleeding, the paramedic shall:
1. consider life/limb/function threats, such as,
a. in post-menopausal women, tumours,
b. first trimester complications, including,
i. spontaneous abortion,
ii. ectopic pregnancy, and
iii. gestational trophoblastic disease, and
c. second and third trimester complications, including,
i. spontaneous abortion,
ii. placental abruption,
iii. placenta previa, and
iv. ruptured uterus;
2. perform, at a minimum, a secondary survey to assess,
a. abdomen, as per Abdominal Pain (Non-Traumatic) Standard, and
b. if the patient is pregnant,
i. note uterine height and palpate for contractions, and
ii. note fetal movements;
3. if the patient is pregnant, attempt to determine,
a. if bleeding is painless or associated with abdominal pain/cramping, and
b. number of prior episodes and causes, if known;
Guideline
Refer to the Sexual Assault (Reported) Standard if vaginal bleeding is suspected to be due to
assault.
4. assess bleeding characteristics; attempt to determine,
a. blood loss,
b. fetal parts,
c. other tissues, and
d. presence of clots;
Guideline
To assist with estimating blood loss, a soaked normal sized pad or tampon can hold
approximately five mL of blood. Normal blood loss during menstruation is 10-35 mL.
5. if bleeding is profuse,
a. place (or have the patient place) an abdominal pad under the perineum and replace
pads as required, and
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b. document number of pads used on the Ambulance Call Report; and
6. prepare for expected problems, including, shock, if bleeding is profuse.
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Visual Disturbance Standard
In situations involving a patient with acute visual disturbances (including generalized eye pain) that
is believed to be of a non-traumatic origin, the paramedic shall:
1. consider threats to life/limb/function, such as,
a. intracranial, intracerebral or retinal hemorrhage/thrombosis, and
b. acute glaucoma;
2. perform, at a minimum, a secondary survey to assess,
a. eyes, for,
i. pupillary size, equality and reactivity,
ii. abnormal movements,
iii. positioning,
iv. redness,
v. swelling,
vi. tearing, and
vii. presence of contact lenses,
b. eye-lids, for ptosis, and
c. vision, for
i. distortion/diplopia,
ii. loss, and
iii. visual acuity; and
Guideline
Consider patching the patient’s eyes for patient comfort and to minimize movement.
3. prepare for potential problems, including,
a. alterations in level of consciousness,
b. neurological deficits, and
c. emesis.
3
Section 3 – Trauma Standards
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Introduction
Specific standards in Section 3 – Trauma Standards have been developed on the basis of the type of
injury.
Paramedics should be aware of a patient’s potential to deteriorate and prepare accordingly. Particular
a
ttention should be paid to the potential for problems related to concurrent conditions, compromises
to airway, breathing or circulation, neurovascular compromise, seizures, shock, alterations in mental
status and/or emesis.
When providing care as per Section 3 – Trauma Standards, a paramedic shall ensure that the patient
simultaneously receives care in accordance with the ALS PCS.
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General Trauma Standard
In situations involving a patient with a traumatic injury, the paramedic shall:
1. if indicated by severity of patient injury or mechanism of injury, advise the patient to
remain still;
2. perform immediate ex
trication if it is safe to do so and,
a. scene survey identifies condition(s) which may immediately endanger the patient, or
b. primary survey identifies condition(s) requiring immediate interventions which
c
annot be performed inside the area in which the patient is located;
3. perform a rapid trauma survey immediately after completion of the primary survey,
unl
ess indicated otherwise in the Standards;
4. perform SMR if indicated by the Spinal Motion Restriction (SMR) Standard, prior to
e
xtrication;
5. attempt to estimate blood loss (i.e. hemorrhage duration, rate of flow, presence of clots,
qua
ntity of blood-soaked materials, quantity of blood vomited);
6. specific to impaled objects, make no attempt to remove; stabilize the object as found
us
ing layers of bulky dressings/bandages, unless otherwise specified by the Standards, or
the object is,
a. compromising the airway, or
b. interfering with CPR in a cardiac arrest patient after attempts to change hand position
h
ave been made;
7. if the stabilized impaled object will not fit into the ambulance, attempt to shorten the
obj
ect or request assistance from other allied emergency services;
8. assess the injury site, when appropriate, and,
a. assess for:
i. contusions/colour/cyanosis/contamination,
ii. lacerations,
iii. abrasions/asymmetrical motion/abdominal breathing (diaphragmatic),
iv. penetrations/punctures/protruding objects or organs,
v. swelling/sucking wounds/subcutaneous emphysema, and
vi. distension/deformity/dried blood/diaphoresis, and
b. palpate for,
i. tenderness,
ii. instability,
iii. crepitus,
iv. swelling/subcutaneous emphysema, and
v. deformity;
9. for obvious or suspected major/multiple trauma, perform a complete secondary survey of
a
ll body systems (including auscultation);
10. if history, mechanism of injury and scene observations indicate an isolated injury, assess
a
t a minimum,
a. the injury site/body system, and
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b. other body parts/systems likely to be injured by considering potentially associated
life/limb/function threats (as indicated by the Standards and otherwise) as well as
possible secondary injuries sustained; and
11. remove any clothing or jewelry that may compromise the injury site.
Guideline
Splinting
• If the injury site is dressed or splinted before paramedic arrival, use judgement when
deciding to remove the dressing or splint. If the site is correctly managed as per the
Standards, leave the dressing or splint as found.
• Splinting priorities are:
o Spine (neck, thoraco-lumbar, head)
o Pelvis
o Femurs
o Lower legs
o Upper limbs
Trauma and the pregnant patient:
• In pregnant patients, trauma is most often associated with domestic violence.
• In pregnant patients, signs of shock may not be obvious until shock is well advanced.
• Hemorrhagic shock and associated fetal hypoxemia are the major causes of trauma
related maternal death and fetal death respectively.
• A pregnant patient’s enlarged uterus is more susceptible to injury and hemorrhage.
• Blunt trauma may result in premature labour, ruptured diaphragm, liver or spleen,
spontaneous abortion, placental abruption, or uterine rupture.
• Placental abruption and subsequent stillbirth can occur within hours of even minor
blunt trauma if acceleration/deceleration forces are involved; these patients may have
no evidence of abdominal trauma on examination; maintain a high index of suspicion
for occult internal injury.
• For blunt trauma to the abdomen, observe for abdominal/uterine enlargement.
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Amputation/Avulsion Standard
In situations involving a patient with a complete or partial amputation or avulsion, the paramedic
shall:
1. consider potential life/limb/function threats, such as,
a. hemorrhagic shock,
b. loss of limb, and
c. loss of function;
2. if patient has a partial amputation or avulsion,
a. assess the injury site for circulation, sensation and movement, and
b. assess distal pulses, circulation, sensation and movement;
3. with respect to the injury site,
a. control hemorrhage as per the Soft Tissue Injury Standard,
b. cleanse wound of gross surface contamination,
c. if partial amputation or avulsion, place remaining tissue or skin bridge in as near-
normal anatomical position as possible,
d. if complete amputation, cover the stump with a moist, sterile pressure dressing,
f
ollowed by a dry dressing, while taking care not to constrict or twist remaining
tissue,
e. immobilize affected extremity, and
f. if possible, elevate; and
Guideline
Recall that any patient with an amputation proximal to wrist or ankle should be evaluated
under the Field Trauma Triage Standard.
4. with respect to the amputated/avulsed part,
a. if located prior to ambulance transport,
i. preserve all amputated tissue,
ii. if the part is grossly contaminated, gen
tly rinse with saline,
iii. wrap or cover the exposed end with moist, sterile dressing, and
iv. place the part in a suitable container/plastic (water-tight if possible) bag and
imm
erse in cold water, if available, or
b. if not able to locate part prior to ambulance transport,
i. attempt to engage others at scene (e.g. allied agencies, bystanders) to look for
t
he amputated/avulsed part and advise them to have it transported to receiving
facility if found, and
ii. not delay transport.
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Blunt/Penetrating Injury Standard
In situations involving a patient with a blunt or penetrating injury, the paramedic shall:
Abdominal/Pelvic Injury
1. consider potential life/limb/function threats, such as,
a. rupture, perforation, laceration, or hemorrhage of organs and/or vessels in the
a
bdomen and potentially in the thorax or pelvis, and
b. spinal cord injury,
2. if the patient has evisceration of intestines,
a. make no attempt to replace intestines back into the abdomen, and
b. cover eviscerated intestines using moist, sterile large, bulky dressings; and
3. if the patient has a pelvic fracture,
a. attempt to stabilize the clinically unstable pelvis with a circumferential sheet wrap or
a
commercial device,
b. secure the patient to a spinal board or adjustable break-away stretcher,
c. avoid placing spinal immobilization or stretcher straps directly over the pelvic area,
a
nd
d. secure and immobilize lower limbs to prevent additional pelvic injury.
Bite Injury
1. consider life/limb/function threats, such as,
a. injuries to underlying organs, vessels, bone, and
b. specific to snake bites,
i. anaphylaxis,
ii. shock,
iii. central nervous system toxicity, and
iv. local tissue necrosis;
Guideline
Recognize the potential for bacterial contaminations or disease transmission (e.g. rabies,
Hepatitis B, HIV) through bites.
2. attempt to determine,
a. source of bite and owner, if applicable, and
b. immunization and communicable disease status of patient and bite source;
3. if patient is stable, irrigate bites for up to five minutes; and
4. if envenomation is known or suspected,
a. position the patient supine,
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b. immobilize the bite area at or slightly below heart level, and
c. not apply cold packs.
Chest Injury
1. consider life/limb/function threats, such as,
a. tension pneumothorax,
b. hemothorax,
c. cardiac tamponade,
d. myocardial contusion,
e. pulmonary contusion,
f. spinal cord injury, and
g. flail chest;
2. auscultate the patient’s lungs for air entry and adventitious sounds;
3. if the patient has a penetrating chest injury,
a. assess for,
i. entry and exit wounds,
ii. tracheal deviation,
iii. jugular vein distension, and
iv. airway and/or vascular penetration (e.g. frothy/foamy hemoptysis sucking
wounds
);
4. if the patient has an open or sucking chest wound,
a. seal wound with a commercial occlusive dressing with one way valve; if not possible,
util
ize an occlusive dressing taped on three sides only,
b. apply dressing large enough to cover entire wound and several centimetres beyond
the
edges of the wound,
c. monitor for development of tension pneumothorax, and
d. if tension pneumothorax becomes obvious or suspected (i.e. rapid deterioration in
ca
rdiorespiratory status), release occlusive dressing and/or replace;
5. for patients who have a suspected pneumothorax and require ventilations, ventilate with a
low
er tidal volume and rate of delivery to prevent exacerbation of increasing intrathoracic
pressure;
6. if the patient is conscious and SMR is not indicated as per the Spinal Motion Restriction
(SMR) St
andard, position the patient sitting or semi-sitting;
7. if the patient has a chest injury, prepare for potential problems, including,
a. tension pneumothorax,
b. cardiac tamponade,
c. cardiac dysrhythmias, and
d. hemoptysis.
Eye Injury
1. assume threats to vision;
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2. assess patient as per the Head Injury subsection below;
3. assess eye as per Visual Disturbance Standard;
4. notwithstanding paragraph 3 above, leave eyelids shut if swollen shut;
5. if active bleeding, control bleeding using the minimum pressure required;
6. if obvious or suspected rupture or puncture of the globe avoid manipulation, palpation,
irri
gation, direct pressure, and application of cold packs;
7. cover the eye with a dressing;
8. if injury/pain is severe in the affected eye, cover both eyes;
9. notwithstanding paragraphs 7 and 8 above, if the eye is extruded (avulsed),
a. make no attempt to replace it inside the socket, and
b. cover the eye with a moist, sterile dressing and protect/stabilize as if an impaled
obje
ct;
10. advise the patient to keep eye movement to a minimum; and
11. transport the patient supine, with head elevated approximately 30 degrees.
Face/Nose Injury
1. consider potential concurrent head, C-spine injuries;
2. assess as per the Head Injury subsection below;
3. if nose injury is obvious or suspected, assess the patient as per the Epistaxis (Non-
tr
aumatic) Standard;
Guideline
• If the patient is alert and stable, replace a completely intact, avulsed tooth in the socket
and have the patient bite down to stabilize
• If the tooth cannot be replaced, place it in saline or milk
4. apply a cold pack to the injury site;
5. if the patient is conscious and SMR is not indicated as per the Spinal Motion Restriction
(SMR) St
andard, position the patient semi-sitting and leaning forward to assist draining
and encourage the patient to expectorate blood, as required;
6. if the patient is on a spinal board or adjustable break-away stretcher, elevate the head 30
deg
rees; and
7. prepare for potential problems, including,
a. airway obstruction if severe injury and/or massive or uncontrolled oral hemorrhage,
and
b. epistaxis.
Head Injury
1. consider potential life/limb/function threats, such as,
a. intracranial and/or intracerebral hemorrhage,
b. neck/spine injuries,
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c. facial/skull fractures, and
d. concussion;
2. observe for,
a. fluid from ears/nose, e.g. cerebrospinal fluid,
b. mastoid bruising,
c. abnormal posturing,
d. periorbital ecchymosis,
e. agitation or fluctuating behaviour,
f. urinary/fecal incontinence, and
g. emesis;
Guideline
Patients with suspected concussions require transport for further assessment.
3. assist ventilations if patient is apneic or respirations are inadequate,
a. if ETCO
2
monitoring is available,
i. attempt to maintain ETCO
2
values of 35-40 mmHg,
ii. notwithstanding paragraph 3(a)(i) above, if signs of cerebral herniation are
present after measures to address hypoxemia and hypotension, hyperventilate
the patient to attempt to maintain ETCO
2
values of 30-35 mmHg. Signs of
cerebral herniation include a deteriorating GCS <9 with any of the following:
1. Dilated and unreactive pupils,
2. Asymmetric pupillary response,
3. Asymmetric motor response, or
4. Motor exam identifies extension posturing or no response, or
b. if ETCO
2
monitoring is unavailable, and measures to address hypoxemia and
hypotension have been taken, and the patient shows signs of cerebral herniation as
per paragraph 3(a)(ii) above, hyperventilate the patient as follows:
i. Adult: approximately 20 breaths per minute
ii. Child: approximately 25 breaths per minute
iii. Infant <1 year old: approximately 30 breaths per minute;
4. if protruding brain tissue is present, cover with non-adherent material (e.g. moist, sterile
dressing; plastic wrap);
5. if cerebrospinal fluid leak is suspected, apply a loose, sterile dressing over the source
opening;
6. if the patient is conscious and SMR is not indicated as per the Spinal Motion Restriction
(SMR) Standard, position the patient sitting or semi-sitting;
7. if the patient is on a spinal board or adjustable break-away stretcher, elevate the head 30
degrees; and
8. prepare for potential problems, including,
a. respiratory distress/arrest,
b. seizures,
c. decreasing level of consciousness, and
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•
d. agitation or combativeness.
Neck/Back Injury
1. if the patient has a penetrating neck injury, assume vascular and airway lacerations/tears;
2. auscultate the patient’s lungs for decreased air entry and adventitious sounds;
3. observe for,
a. diaphragmatic breathing,
b. neurological deficits,
c. priapism, and
d. urinary/fecal incontinence/retention;
4. perform, at a minimum, a secondary survey to assess,
a. for airway and/or vascular penetration (e.g. frothy/foamy hemoptysis),
b. lungs, for decreased air entry and adventitious sounds through auscultation,
c. head/neck, for, jugular vein distension; and tracheal deviation, and
d. chest, for subcutaneous emphysema; and
5. if the patient has a penetrating wound,
a. assess for entry and exit wounds,
b. apply pressure lateral to, but not directly over the airway, and
c. apply occlusive dressings to wounds; use non-circumferential bandaging.
Guideline
The attending paramedic should sit within the patient’s view when possible, so the
patient does not attempt to turn his/her head.
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Burns (Thermal) Standard
In situations involving a patient with a thermal burn, the paramedic shall:
1. if the patient is in a smoke/fume filled environment, request assistance from fire
personnel and ensure that the patient is moved as quickly as possible to a fresh air zone
when safe to do so;
2. consider life/limb/function threats, such as,
a. airway burns,
b. asphyxia (smoke inhalation),
c. carbon monoxide/cyanide poisoning, and
d. shock;
3. attempt to determine,
a. source of burn,
b. if burn due to fire,
i. whether the fire occurred in an enclosed space, and
ii. whether the patient was unconscious or lost consciousness during exposure to
f
ire/fumes/smoke;
4. stop the burning process;
5. when attempting to remove clothing from injury site, cut around clothing that is adherent
t
o skin;
6. perform, at a minimum, a secondary survey burn assessments, as follows:
a. estimate severity to include,
i. area burned (e.g. location, circumferential),
ii. burn depth (degree), and
iii. percentage of body surface area burned,
Guideline
Utilize the Rule of Nines to estimate percentage of body surface burned (or the Modified
Rule of Nines for pediatrics)
b. assess distal neurovascular status in burned extremities,
c. assess for signs of smoke inhalation and upper airway injury,
Guideline
Signs of smoke inhalation and upper airway injury include decreased air entry, burns to lips
or mouth, carbon particles in saliva or sputum, cough, drooling, stridor or hoarseness, facial
burns, burned or singed nasal hair or eyebrows, or shortness of breath, shallow respirations,
audible wheezes, or tachypnea.
d. if burns involve an eye, assess eye as per Visual Disturbances Standard; and
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e. notwithstanding paragraph 5(d) above, if burns involve an eye and eye is swollen
shut, leave eye shut;
Guideline
• If administering oxygen as per the Oxygen Therapy Standard, in case of facial burns,
gauze pads may be placed under the edges of the oxygen mask to decrease pain and
irritation
• Carbon Monoxide (CO) poisoning and cyanide toxicity are potential concerns for any
incident involving combustible materials. Paramedics should administer high
concentration oxygen to known or suspected cases as per the Oxygen Therapy
Standard.
7. for burn sites estimated to involve <15% of body surface area, cool burns and limit
cooling to <30 minutes to prevent hypothermia;
8. cover all 1
st
degree burns with moist sterile dressing and then cover with dry sheet or
blanket;
9. cover all 2
nd
degree burns estimated to involve <15% of body surface area with moist,
sterile dressing, and dry sheet or blanket;
10. cover all 2
nd
degree burns estimated to involve ≥15% of body surface area with dry,
sterile dressing or sheet;
11. if remoistening of the dressing is required to continue to cool the burn, remove the dry
sheet or blanket and remoisten the previously applied sterile dressing;
12. if shivering or hypotension develops, discontinue cooling efforts;
13. cover all 3
rd
degree burns with dry, sterile dressing or sheet;
14. if dressing digits, dress digits individually;
15. leave blisters intact;
16. keep the patient warm; and
17. prepare for expected problems, including,
a. airway obstruction.
b. if airway burns,
i. bronchospasm, and
ii. orolingual/laryngeal edema,
c. respiratory distress/arrest, and
d. agitation or combativeness.
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Cold Injury Standard
In situations involving a patient with a cold injury, the paramedic shall:
1. remove the patient from the cold as soon as it is safe to do so after completing the
primary survey; if the patient is trapped, prevent additional heat loss (e.g. cover with a
blanket or put a blanket between the patient and ground);
2. consider
life/limb/function threats, such as,
a. severe hypothermia,
b. severe frostbite, and
c. underlying disorders/precipitating factors (e.g. alcohol/drug ingestion, hypoglycemia,
t
rauma);
Guideline
For patients with known or suspected hypothermia, pulse and respirations checks should be
performed for up to ten seconds.
3. attempt to determine,
a. duration of exposure, and
b. type of exposure;
4. with respect to secondary survey,
a. only expose areas that are being examined; cover the area as soon as assessment is
c
ompleted,
b. if hypothermia is known or suspected, attempt to determine the severity of
h
ypothermia, and
c. if frostbite is known or suspected, attempt to determine the severity of frostbite (e.g.
m
ild blanching of skin [frostnip]; skin waxy/white, supple [superficial frostbite]; skin
cold, hard and wooden [deep frostbite]);
Guideline
The presence or absence of shivering is an important indicator of severity of hypothermia. If
shivering is minimal or absent and level of consciousness is decreased or mental status is
markedly altered, assume core temperature is below 32
o
C.
5. attempt to remove wet or constrictive clothing and jewelry; if clothing or jewelry is
f
rozen to the skin, leave until thawing occurs;
6. for mild to moderate hypothermia, (i.e. if shivering is present),
a. wrap the patient’s body/affected parts in a blanket or foil rescue blanket, and
b. provide external re-warming, as available (e.g. hot packs, hot water bottles) to axillae,
g
roin, neck and head;
7. for severe hypothermia (i.e. no shivering present, unconscious patient with cold, stiff
l
imbs, slow/absent pulse and respirations and no other signs of “obvious” death),
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a. wrap the patient’s body/affected parts in a blanket or foil rescue blanket, and
b. when suction is required, do not perform vigorous suctioning or airway manipulation
as it may trigger ventricular fibrillation; and
Guideline
SpO
2
reading may be unobtainable or inaccurate due to poor/reduced peripheral circulation in
the cold extremities.
8. for frostbite,
a. wrap the patient’s body/affected parts in a blanket or foil rescue blanket, cover and
protect the part,
b. not rub or massage the skin,
c. leave blisters intact, and
d. if dressing digits, dress digits separately.
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Section 3 – Trauma Standards
Electrocution/Electrical Injury
Standard
In situations involving a patient with an electical injury, the paramedic shall:
1. make no attempt to touch a potential energized source or a patient who is still in contact
with a potential energized source;
Guideline
If there are multiple patients as a result of a lightning strike, focus efforts on those who are
VSA, due to his/her high potential for resuscitation.
2. consider life/limb/function threats, such as,
a. cardiopulmonary arrest,
b. dysrhythmias,
c. extremity neurovascular compromise,
d. multiple and/or severe trauma,
e. seizures, and
f. significant internal tissue damage;
3. attempt to determine,
a. type of current, and
b. voltage;
4. assess for signs of significant electrical injury, including,
a. burns,
b. cold/mottled/pulseless extremities,
c. dysrhythmias,
d. entry/exit wounds,
e. muscle spasms,
f. neurologic impairment, and
g. shallow/irregular respirations;
5. re-assess distal neurovascular status in the affected extremity approximately every 10
min
utes if status was compromised on initial assessment; and
6. prepare for potential problems, including,
a. dys
rhythmias, and
b. extre
mity neurovascular compromise.
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Section 3 – Trauma Standards
Extremity Injury Standard
In situations involving a patient with an extremity injury, the paramedic shall:
1. splint injured extremities, as follows:
a. assess distal circulation, sensation, and movement before and after splinting,
b. splint joint injuries as found,
c. notwithstanding paragraph 1(b) above, if the distal pulse is absent or the fracture is
s
everely angulated, apply gentle traction; if resistance or severe pain is encountered,
splint as found,
d. if open or closed femur fractures, splint with traction splint unless limb is partially
a
mputated,
e. if extremity injury affects a joint, immobilize above and below the injury site,
f. if adequate circulation/sensation is absent after splinting and re-manipulation is
pos
sible, gently re-manipulate the extremity to restore neurovascular status,
g. if it is practical to do so, elevate the affected extremity, and
h. consider application of a cold pack over the affected extremity;
2. in cases of open fractures,
a. irrigate with saline or sterile water if gross contamination, and
b. cover ends with moist, sterile dressings and/or padding; and
Guideline
• With respect to children: if splints do not fit, splint body parts together (e.g. arm-to-
trunk, leg-to-leg) and pad in-between.
• With respect to fractured femur or tibia:
o Stabilize by securing it to the uninjured leg prior to transfer to a spinal board or
a
djustable break-away stretcher when utilized
o If log-rolling, log roll onto the uninjured side, if possible
3. re-assess distal neurovascular status in the affected extremity every approximately 10
min
utes if status was compromised on initial assessment.
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Section 3 – Trauma Standards
Foreign Bodies (Eye/Ear/Nose)
Standard
In situations involving a patient with a foreign body in his/her eye, ear or nose, the paramedic shall:
1. advise the patient not to attempt removal of the foreign body or discontinue attempts;
2. inspect the affected area for visible signs of foreign body, injury, bleeding and discharge;
3. if the foreign body is in the eye,
a. assess eye as per the Eye Injury subsection in the Blunt/Penetrating Injury Standard,
a
nd
b. if penetration of the globe is not suspected, flush the affected eye;
Guideline
For foreign body on the surface of the eye, attempt manual removal if the object is not on the
cornea and is visible, accessible and easily removed, e.g. using a wet cotton-tipped swab or
gauze.
4. if the foreign body is in the ear,
a. consider the potential for a perforated ear drum if a blunt/penetrating object was
inserted, and
b. leave the object in place and support/cover; and
5. if the foreign body is in the nose, leave the object in place.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
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Section 3 – Trauma Standards
Hazardous Materials Injury Standard
In situations involving a patient with exposure to a hazardous material, the paramedic shall:
1. consider life/limb/function threats, such as,
a. if chemical in eye, vision loss,
b. burns, and
c. systemic toxicity secondary to chemical absorption through the skin;
Note: Specific Personal Portective Equipment (PPE) may be required when exposed to hazardous
materials. Consult CANUTEC and other resources, as appropriate.
2. attempt to determine the type and concentration of hazardous material, and duration of
exposure;
Guideline
When attempting to determine the type and concentration of the hazardous material, use
resources:
• Allied emergency services
• Bystanders
• CANUTEC Resources:
o CANUTEC Emergency Line
o Transport Canada Emergency Response Guidebook
• Dangerous goods placard or product code number
• Material Safety Data Sheet
• Poison Control Centre
3. attempt to remove any contaminated clothing or jewelry;
4. attempt decontamination prior to departing scene;
5. if chemical injury to the eye,
a. assess the eye as per the Visual Disturbance Standard, and
b. advise patient to remove contact lens if lens is readily removable;
6. if chemical injury to extremity, assess distal neurovascular status in affected extremity;
7. brush off or manually remove solid, powdered hazardous materials;
8. attempt to follow first aid and decontamination procedures outlined in the Transport
Canada E
mergency Response Guidebook;
9. irrigate exposure site using large volumes of cool, not cold water;
10. notwithstanding paragraph 9 above, not irrigate if chemical known to be water-reactive;
11. if irrigating, contain rinse water, if possible;
12. if an alkali burn is known or suspected, irrigate for a minimum of 20 minutes at scene if
patient is stable, and attempt to continue irrigation en route;
13. for a known acid burn, irrigate for a minimum of 10 minutes at scene if patient is stable;
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Section 3 – Trauma Standards
14. for unknown chemical exposure, irrigate for a minimum of 20 minutes at scene if patient
is stable;
15. with respect to eye irrigation,
a. attempt to utilize eye wash station/equipment if available at scene,
b. advise patient not to rub eye(s),
c. position the patient with his/her affected side down if one eye is affected or supine if
both eyes are affected,
d. manually open eyelids if required, and
e. attempt to irrigate away from tear duct(s);
16. provide burn care as per the Burns (Thermal) Standard;
17. if solid particles remain stuck to the skin after irrigation is complete, attempt manual
removal and then cover affected areas with wet dressing and/or towels;
18. in conjunction with the Reporting of Patient Care to Receiving Facility Standard, notify
the receiving facility of the hazardous material exposure and associated decontamination
efforts; and
19. if gross contamination of ambulance or self, decontaminate immediately after call
completion.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
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Section 3 – Trauma Standards
Soft Tissue Injuries Standard
In situations involving a patient with soft tissue injuries, the paramedic shall:
1. consider underlying injuries to deep structures (e.g. nerves, vessels, bones);
2. control wound hemorrhage on a priority basis, as follows:
a. appl
y direct pressure to bleeding sites (e.g. with digital pressure, the hand, pressure
dressings, and/or bandages),
b. if required, apply additional dressings over the initial dressing and/or tighten the
ba
ndage,
c. for persistent extremity bleeding, apply an arterial tourniquet to the injured limb
a
pproximately five centimetres above the injury until bleeding stops, and
d. for extremity bleeding where a tourniquet is ineffective, or for persistent trunk, axilla,
or g
roin bleeding, apply a hemostatic dressing;
Guideline
Use of a tourniquet
• If a tourniquet is applied to stop uncontrollable extremity hemorrhage, it should not be
removed in the pre-hospital setting
• The time of tourniquet application must be documented and communicated to the
receiving facility at transfer of care
• In situations such as multi-casualty incidents (MCI), the time of tourniquet application
must be listed on the patient and tourniquet
• Do not cover the tourniquet once in place
Use of hemostatic dressings
• Hemostatic dressings should not be applied to an open cranial wound
• If the hemostatic dressing soaks through, apply an additional hemostatic dressing on
t
op of the first one. Do not remove the dressing at any time. If bleeding persists, use
standard bulky pressure dressings.
3. attempt removal of large surface contaminants; leave embedded objects in place;
4. in the stable patient, cleanse injury surfaces using saline or sterile water;
5. during injury care, manually stabilize any impaled objects if object not yet stabilized;
6. cover protruding tissue/organs with non-adherent materials (e.g. moist, sterile dressings
or pl
astic wrap);
7. dress and bandage open wounds, prior to splint application, if applicable;
8. if dressing digits, dress digits individually; leave tips of fingers/toes uncovered to allow
obs
ervations of neurovascular status unless otherwise indicated by the Standards; and
9. re-assess and monitor distal neurovascular status after dressing, bandaging, and/or
s
plinting is completed; loosen bandages to restore neurovascular status.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
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Section 3 – Trauma Standards
Submersion Injury Standard
In situations involving a submersion injury (including scuba-diving related disorders), the
paramedic shall:
1. request appropriate personnel to carry out rescue operations, if required;
2. unless authorized, mak
e no attempt to participate in water or other types of rescue
operations;
3. consider life/limb/function threats, such as,
a. asphyxia,
b. aspiration,
c. hypothermia,
d. pulmonary edema,
e. underlying disorders which may have precipitated events (e.g. drug or alcohol
c
onsumption, hypoglycemia, cardiac dysrhythmias, trauma [spinal/head injury]), and
f. specific to scuba-diving related disorders,
i. barotrauma (ears, sinuses, pneumothorax),
ii. decompression sickness, and
iii. arterial gas embolism;
4. attempt to determine,
a. duration of submersion,
b. if water contains known or obvious chemicals, pollutants or other debris, and
c. water temperature; and
5. if scuba-diving related,
a. attempt to determine,
i. number, depth and duration of dives,
ii. rate of ascent, and
iii. when symptoms occurred (e.g. underwater, upon surfacing or within minutes
t
hereof [possible gas embolus], more than 10 minutes after surfacing
[possible decompression sickness],
b. where air embolism is suspected and the patient is on a spinal board or adjustable
bre
ak-away stretcher, not elevate the head 30 degrees if level of consciousness is
decreased, and
c. prepare for tension pneumothorax.
Guideline
With regards to arterial gas embolisms, left-sided positioning has not been clearly shown to
offer advantages to impede movement of embolism to the head but is recommended for other
reasons, e.g. reduction of aspiration risk.
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4
Section 4 – Obstetrical Standards
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Section 4 – Obstetrical Standards
Basic Life Support Patient Care Standards – Version 3.0.1 113
Section 4 – Obstetrical Standards
Neonate Standard
In situations involving a neonatal patient, the paramedic shall:
1. be aware that the mother, in addition to the neonatal patient, may require care;
2. during the primary survey,
a. be a
ware of problems arising due to neonate anatomy and physiology, and
b. determine if the neonatal patient,
i. is term gestation,
ii. has good tone, and
iii. has unlaboured breathing;
3. if the patient does not meet the criteria listed in paragraph 2(b) above, recognize the
potential need for neonatal resuscitation in conjunction with the ALS PCS;
4. attempt to determine,
a. a brief history of the pregnancy (e.g. length of gestation, number of pregnancies,
num
ber of births),
b. details surrounding labour (e.g. duration),
c. details regarding delivery (e.g. whether delivery was precipitous, complications),
d. who delivered the neonatal patient,
e. the neonatal patient’s colour, breathing and level of activity since delivery, and
f. any clinical care the neonatal patient has received since delivery; and
5. if the neonatal patient has just been delivered (regardless of the paramedic’s participation
i
n the delivery),
a. reassess the mother, if required,
b. wipe the nose and mouth of neonatal patient, if required,
c. clamp and cut umbilical cord, if not yet done, as per the ALS PCS,
d. position the neonatal patient supine on a firm surface and with his/her neck slightly
extended (to establish a patent airway),
Guideline
A small towel roll, such as a face cloth, may be placed beneath the neonatal patient’s
shoulders to facilitate head positioning; be cautious not to hyperextend the neonatal patient’s
neck.
e. record time of delivery (or approximate),
f. tag/tape the neonatal patient’s arm with the time of delivery and the mother’s name, if
tim
e and patient conditions permit,
g. if the neonatal patient does not require neonatal resuscitation,
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Vers
ion 3.0.1 114
Section 4 – Obstetrical Standards
i. prior to transport, attempt to place the neonatal patient skin to skin on the
mother’s chest or abdomen (to facilitate temperature regulation), and advise
the mother she may nurse if she wishes, and
ii. swaddle the neona
tal patient with a blanket,
h. recognize a neonatal patient’s inefficiency at regulating body temperature and
maintain a normal temperature by covering/re-covering the neonatal patient during
care;
i. take an Apgar score at one and five minutes post-delivery, if possible; and
j. in conjunction with the Load and Go Patient Standard, initiate rapid transport if five
minute Apgar score is less than seven.
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term Care
Basic Life Support Patient Care Standards – Version 3.0.1 115
Section 4 – Obstetrical Standards
Pregnancy Standard
In situations involving a pregnant patient, the paramedic shall:
1. consider life/limb/function threats to both the mother and fetus, such as,
a. pre-eclampsia/eclampsia,
b. prol
apsed umbilical cord,
c. first trimester complications, including,
i. spontaneous abortion,
ii. ectopic pregnancy, and
iii. gestational trophoblastic disease, and
d. second and third trimester complications, including,
i. spontaneous abortion,
ii. placental abruption,
iii. placenta previa, and
iv. ruptured uterus;
Guideline
Pre-eclampsia should be assumed for patients beyond 20 weeks of gestation with a blood
pressure ≥140/90 (severe pre-eclampsia = diastolic BP ≥110), with:
• generalized edema (e.g. face, legs), or
• non-specific complaints of headache, nausea, abdominal pain with or without vomiting,
blurred vision, fatigue, generalized swelling or rapid weight gain.
2. give priority to maternal assessment and care;
3. during the primary survey be aware of problems arising due to anatomic and physiologic
c
hanges of pregnancy;
4. attempt to determine,
a. due date (or approximate),
b. problems with the present pregnancy (e.g. infection, bleeding, diabetes, blood
pre
ssure, pre-eclampsia),
c. presence of,
i. abdominal pain/contractions, and
ii. vaginal bleeding/fluid discharge,
d. if contractions are present, the timing and intensity thereof,
e. if vaginal bleeding/fluid discharge is present severity thereof,
f. pregnancy related history, including,
i. number of previous pregnancies,
ii. number of deliveries,
iii. latest ultrasound findings,
iv. history of complications from past pregnancies, and
v. duration of labour from past pregnancies;
Basic Life Support Patient Care Standards – Version 3.0.1 116
Section 4 – Obstetrical Standards
Emergency Health Services Branch, Ontario Ministry of Health and Long-Term
Care
Guideline
Due date = Last normal menstrual period – 3 months + 7 days
5. perform, at a minimum, a secondary survey t
o assess,
a. abdomen, as per Abdominal Pain (Non-Traumatic) Standard, for pregnant patients
who present with,
i. a history indicative of a motor vehicle collision,
ii. abdominal pain, contractions, vaginal bleeding, or cord prolapse,
iii. acceleration/deceleration injuries,
iv. blunt trauma involving the truncal area (regardless of whether there are
specific complaints),
v. fall injuries,
vi. headache, blurred vision, nausea, or swelling,
vii. malaise, weakness, dizziness, light-headedness, seizure, or shortness of
breath, and/or
viii. penetrating trauma to the chest/abdomen,
b. concurrent with the assessments as per paragraph 5(a) above, when palpating the
abdomen of a patient beyond 20 weeks of gestation,
i. note uterine height and palpate for contractions, and
ii. note fetal movements,
Guideline
With respect to uterine height:
• Uterus at the umbilicus = 20 weeks of gestational size
• Uterus at the costal margins = 36 weeks of gestational size
iii.
observe for contractions, as follows:
1. Note timing and intensity of contractions, if present
2. Observe for palpable fetal parts/movement, and
c. don sterile gloves prior to inspection and examination of the perineum;
6. manage labour and delivery as per the ALS PCS;
7. transport the patient in the left-lateral position;
8. notwithstanding paragraph 7 above, if the patient is on a spinal board or adjustable break-
away stretcher, tilt 30 degrees to the left; and
9. in conjunction with the Reporting of Patient Care to Receiving Facility Standard, notify
the receiving facility of status of the patient and neonate, if applicable.
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A
Appendix A – Supplemental
Emergency Health Services Branch
Paramedic Prompt Card for
Acute Stroke Protocol
This prompt card provides a quick reference of the Acute Stroke Protocol contained in the Basic Life Support Patient Care Standards (BLS
PCS). Please refer to the BLS PCS for the full protocol.
Indications under the Acute Stroke Protocol
Redirect or transport to a Designated Stroke Centre* will be considered for patients who meet ALL of
the following:
*A Designated Stroke Center is a Regional Stroke Centre, District Stroke Centre or a Telestroke Centre.
1. Present with a new onset of at least one of the following symptoms suggestive of the onset of an
acute stroke:
a. Unilateral arm/leg weakness or drift.
b. Slurred speech or inappropriate words or mute.
c. Unilateral facial droop.
2. Can be transported to arrive at a Designated Stroke Centre within 4.5 hours of a clearly determined
time of symptom onset or the time the patient was “last seen in a usual state of health”.
Contraindications under the Acute Stroke Protocol
ANY of the following exclude a patient from being transported under the Acute Stroke Protocol:
1. CTAS Level 1 and/or uncorrected airway, breathing or circulatory problem.
2. Symptoms of the stroke resolved prior to paramedic arrival or assessment**.
3. Blood sugar <3 mmol/L***.
4. Seizure at onset of symptoms or observed by paramedics.
5. Glasgow Coma Scale <10.
6. Terminally ill or palliative care patient.
7. Duration of out of hospital transport will exceed two hours.
**Patients whose symptoms improve significantly or resolve during transport will continue to be
transported to a Designated Stroke Centre.
*** If symptoms persist after correction of blood glucose level, the patient is not contraindicated.
CACC/ACS will authorize the transport once notified of the patient’s need for
redirect or transport under the Acute Stroke Protocol.
Emergency Health Services Branch
Paramedic Prompt Card for
Field Trauma Triage Standard
This prompt card provides a quick reference of the Field Trauma Triage Standard contained in the Basic Life Support Patient Care
Standards (BLS PCS). Please refer to the BLS PCS for the full standard.
Emergency Health Services Branch
Paramedic Prompt Card for
Spinal Motion Restriction (SMR) Standard
This prompt card provides a quick reference of the Spinal Motion Restriction (SMR) Standard contained in the Basic Life Support Patient
Care Standards (BLS PCS). Please refer to the BLS PCS for the full standard.
Emergency Health Services Branch
Paramedic Prompt Card for
STEMI Hospital Bypass Protocol
This prompt card provides a quick reference of the STEMI Hospital Bypass Protocol contained in the Basic Life Support Patient Care
Standards (BLS PCS). Please refer to the BLS PCS for the full protocol.
Indications under the STEMI Hospital Bypass Protocol
Transport to a PCI centre will be considered for patients who meet ALL of the following:
1. ≥18 years of age.
2. Chest pain or equivalent consistent with cardiac ischemia/myocardial infarction.
3. Time from onset of current episode of pain <12 hours.
4. 12-lead ECG indicates an acute AMI/STEMI*:
a. At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads; OR
b. At least 1 mm ST-elevation in at least two other anatomically contiguous leads; OR
c. 12-lead ECG computer interpretation of STEMI and paramedic agrees.
*Once activated, continue to follow the STEMI Hospital Bypass Protocol even if the ECG normalizes.
Contraindications under the STEMI Hospital Bypass Protocol
ANY of the following exclude a patient from being transported under the STEMI Hospital Bypass
Protocol:
1. CTAS 1 and the paramedic is unable to secure patient’s airway or ventilate.
2. 12-lead ECG is consistent with a LBBB, ventricular paced rhythm, or any other STEMI imitator.
3. Transport to a PCI centre ≥60 minutes from patient contact.**
4. Patient is experiencing a complication requiring PCP diversion:**
a. Moderate to severe respiratory distress or use of CPAP.
b. Hemodynamic instability or symptomatic SBP <90 mmHg at any point.
c. VSA without ROSC.
5. Patient is experiencing a complication requiring ACP diversion:**
a. Ventilation inadequate despite assistance.
b. Hemodynamic instability unresponsive/not amenable to ACP treatment/management.
c. VSA without ROSC.
**The interventional cardiology program may still permit the transport to the PCI centre.
CACC/ACS will authorize the transport once notified of the patient’s need for
bypass under the STEMI Hospital Bypass Protocol.
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