Ontario EMS protocols,
in your pocket.

• Administer nitroglycerin immediately since SBP is ≥ 100 mmHg
• ✓ Perform lead V4R to rule out Right Ventricular MI before giving nitroglycerin
• Withhold nitroglycerin entirely because any STEMI is a contraindication
• Administer ASA first and then give nitroglycerin without further assessment

The protocol states that paramedics should suspect a Right Ventricular MI in ALL inferior STEMIs and perform at minimum V4R to confirm (ST-elevation ≥ 1mm in V4R). A 12-lead ECG compatible with Right Ventricular MI is a contraindication to nitroglycerin, and the protocol explicitly states 'Do not administer nitroglycerin to a patient with Right Ventricular STEMI.' Therefore, V4R must be checked before giving nitroglycerin in any inferior STEMI.

• No ROSC after 20 minutes of resuscitation
• Arrest not witnessed by a paramedic
• No defibrillation delivered
• ✓ Suspected hypothermia

The protocol lists contraindications to Medical TOR as: pregnancy presumed ≥ 20 weeks gestation, suspected hypothermia, airway obstruction, and non-opioid drug overdose/toxicology. Suspected hypothermia is therefore a contraindication. The other options (no ROSC after 20 min, arrest not witnessed by paramedic, no defibrillation delivered) are actually CONDITIONS required to meet the Medical TOR rule, not contraindications.

• Patient must be 8 years of age or older.
• There must be no signs of tachydysrhythmias.
• ✓ Chest auscultation must be clear AND hypotension must be present.
• IV/IO/CVAD access must already be established prior to ROSC.

According to the ROSC protocol conditions table, 0.9% NaCl fluid bolus requires hypotension AND clear chest auscultation. Both conditions must be met. There is no age restriction for the fluid bolus (age is listed as N/A), and tachydysrhythmias are a contraindication for DOPamine, not the fluid bolus.

• Immediately initiate transport without further defibrillation attempts
• ✓ Perform Vector Change Defibrillation (VCD) and transport after 3 doses of VCD
• Continue standard defibrillation every 2 minutes until ROSC
• Administer EPINEPHrine and continue standard defibrillation

For refractory VF (persistent VF after 3 consecutive shocks), the protocol states to consider DSED if authorized OR VCD if DSED is unavailable or not authorized, AND transport following three (3) doses of DSED or VCD. Since DSED is not authorized, VCD is the correct alternative, followed by transport after 3 doses.

• Administer a 0.9% NaCl fluid bolus at 10 ml/kg IV, reassessing every 250 ml
• Administer a 0.9% NaCl fluid bolus at 20 ml/kg IV to a maximum of 2,000 ml
• ✓ Consider DOPamine, as the NaCl bolus is contraindicated due to pulmonary crackles
• Administer nitroglycerin SL since the patient has a STEMI

The protocol notes that a 0.9% NaCl fluid bolus requires clear chest auscultation as a condition. The treatment section explicitly states: 'If NaCl bolus contraindicated due to pulmonary crackles, consider DOPamine.' Since crackles are present, the fluid bolus is contraindicated and DOPamine should be considered instead.

• Valsalva maneuver followed by adenosine
• Amiodarone 150 mg IV infusion over 10 minutes
• ✓ Patch to BHP for authorization, then proceed with synchronized cardioversion
• Lidocaine 1.5 mg/kg IV

This patient meets the conditions for synchronized cardioversion: HR ≥ 150 bpm (narrow), hypotension, altered mental status, and ongoing chest pain/signs of shock. Per the protocol, a Mandatory Provincial Patch Point requires patching to BHP for authorization before proceeding with synchronized cardioversion. Adenosine and Valsalva require normotension and unaltered LOA, which this patient does not have.