Tip of the Month – June

High-Quality CPR & Defibrillation

Paramedics play a vital role in improving survival outcomes for cardiac arrest patients. High-quality CPR and timely defibrillation are cornerstones of effective resuscitation. By maintaining skill proficiency and adhering to resuscitation guidelines, you help optimize perfusion, support neurologic recovery, and reinforce our essential contribution to emergency care.

What Is High-Quality CPR?

According to the Heart and Stroke Foundation, key elements of quality CPR include:

• Chest Compressions: At least 5 cm (2 inches) deep, 100–120 per minute, allowing full chest recoil.
• Minimal Interruptions: Aim for less than 10 seconds off the chest.
• Effective Ventilations: Use a 30:2 ratio with visible chest rise.
• Early Defibrillation: Apply and use the defibrillator as soon as available.
• Compressor Rotation: Switch every 2 minutes to avoid fatigue and maintain compression quality.

Pediatric Considerations

When to Start CPR:
Initiate chest compressions in infants and children if:

• The patient is vital signs absent
• The heart rate is < 60 bpm with signs of poor perfusion, despite adequate oxygenation and ventilation.

This recommendation aligns with the AHA PALS Guidelines (2020 & 2023 updates) and reflects the fact that pediatric cardiac arrest is often secondary to respiratory failure or hypoxia, not primary cardiac causes.

CPR Compression-to-Ventilation Ratios:

• Single rescuer: Use a 30:2 compression-to-ventilation ratio.
• Two rescuers: Use a 15:2 ratio to improve ventilation support.

✅ Remember: Children need more frequent ventilation than adults due to higher oxygen demand and lower functional reserves.

Compression Depth:

• Infants: About 4 cm (1.5 inches) — or one-third the depth of the chest.
• Children: About 5 cm (2 inches) — also one-third the depth of the chest.

Compression Technique:

• Infants: Two fingers (single rescuer) or two-thumb encircling hands (two rescuers).
• Children: One or two hands on the lower half of the sternum, as appropriate for the child’s size.

Defibrillation & Pad Placement

Why Pad Placement Matters:

• Ensures current flows through the heart for optimal shock efficacy.
• Minimizes risk to surrounding tissues.
• Improves chances of ROSC and survival.

Anterolateral (AL) Pad Placement

"Antero" = front | "Lateral" = side
Pads "sandwich" the heart to direct current through the myocardium.

Anterior (right) pad: Just below the right clavicle, Right of the sternum, avoiding bony structures.

Lateral (left) pad: Over the left lower chest, Around V6 ECG lead level, near the mid-axillary line.

✅ Think: Right upper chest & left side of the chest, near the nipple line or slightly lower.

 Anterior-Posterior (AP) Pad Placement & Vector Change Defibrillation (VCD)

What is VCD?

Vector Change Defibrillation (VCD) involves repositioning defibrillation pads from the anterolateral (AL) to anterior-posterior (AP) position after failed shocks. This changes the direction of current flow, offering another opportunity to achieve ROSC.

✅ Think: New vector, new chance to convert refractory VF/pulseless VT.

Why Use AP Placement?

•  Redirects current through the heart’s vertical axis for deeper myocardial capture.
• Improves ROSC rates, especially in refractory VF/VT (supported by research like the DOSE-VF trial).
• Overcomes limitations like poor AL pad contact or challenging body habitus.

Anterior-Posterior Pad Placement

 Anterior pad: Center of the chest, over the sternum or left precordium.

• Posterior pad: Mid-back, between the scapulae, just left of the spine.

✅ Avoid bony landmarks — ensure good skin contact and full adhesion.

Quick Tip:
Prepare AP pads early during cases of known or suspected refractory VF/pulseless VT. Switching vectors may be the key step toward successful defibrillation and ROSC.

General Pad Placement Tips:

• Avoid bone: Pads work best when placed over muscle/soft tissue.
• Hair removal: Quickly shave the area if the chest is very hairy.
• Dry the skin: Wet skin (sweat, rain) can interfere with pad adhesion and shock delivery.
• Firm pressure: Make sure pads are fully adhered to the skin.
• Correct distance: Pads should not be too close together to ensure the electrical current effectively captures the heart.

Trauma Tip of the Month – May 2025

Trauma is the leading cause of death in adults under 45. In North America, 50 million people receive some sort of trauma related care, with 30% of those people accounting for all hospital admissions.  Prehospital care of trauma patients focuses on addressing immediate life threats, rapid assessments, key interventions, and appropriate and timely transport to minimize and prevent further injury and mortality.

Prehospital Trauma Management

Rapid Assessment (ABCDE approach)

This is a systematic evaluation of a patient’s condition to identify life threatening injuries.

• Airway with Cervical Spine Protection
  • Assess for patency; protect cervical spine during airway management
  • Consider supraglottic or endotracheal airway if the airway is compromised and BLS maneuvers fail
  • Ensure no foreign objects, blood or secretions in the airway
  • Use cervical collars or manual stabilization for suspected spinal injuries
• Breathing and Ventilation
  • Check for symmetrical chest rise, breath sounds and use of accessory muscles
  • Assess for potential injuries like pneumothorax or flail chest
  • Auscultate in at least two locations per lung to detect pneumothorax or hemothorax
  • Apply an occlusive dressing when necessary
  • Avoid over-ventilation, particularly in head injuries – target ETCO2 35-45mmHg
• Circulation with Hemorrhage Control
  • Assess pulse, blood pressure, and signs of external or internal bleeding
  • Immediate interventions: initiate hemorrhage control using direct pressure, tourniquets and hemostatic dressings as indicated
• Disability/Neurological status
  • Conduct a rapid neurological exam
  • Assess verbal response, pupil size/reaction and motor function
• Exposure and Environmental Control
  • Fully expose the patient to identify hidden injuries
  • Take appropriate steps to prevent hypothermia – remove wet clothing, insulate the patient with blankets, and prevent any further heat loss
  • Prevent the “trauma triad of death”: hypothermia, acidosis, coagulopathy

 Transport and Handover Considerations

• Minimize on-scene time < 10mins for unstable patients
• Consider air transport where applicable
• Provide a structured trauma handover
  • Age/Name
  • Time of incident
  • MOI
  • Injuries found
  • Vital Signs
  • Treatments provided

 Common Mistakes in Trauma Care

 Overlooking ongoing bleeding

• Failing to fully expose the patient
• Not reassessing bleeding control measures appropriately
• Distracting injuries

Misjudging airway patency

• Making assumptions about a patient's airway because they are able to speak
• Not reassessing the airway
• Not utilizing BLS airway maneuvers or airway adjuncts

Missing subtle signs of decompensation

• Not noticing subtle changes in respiratory rate or mental status
• Not performing frequent reassessments of vital signs
• Not recognizing downward trends in vital signs

Performing a rapid and systematic trauma assessment using the ABCDE approach, coupled with continuous reassessment, is essential to identify changes in the patient's presentation and determine the effectiveness of interventions, thereby mitigating these common mistakes and improving patient outcomes.

Tip of the Month – April 2025

Paramedic resilience strategies; recognizing and managing burnout

The demanding nature of paramedic work, with its long hours, high-stress situations, and frequent exposure to trauma, makes burnout a serious concern within the profession. Recognizing the signs of burnout and adopting effective resiliency strategies is essential for maintaining well-being and ensuring paramedics can continue delivering the high-quality care that communities depend on

Paramedics experiencing burnout often report feeling less empathy or compassion towards those that they help, which can manifest as irritability, frustration, detachment, cynicism, or a lack of motivation to provide the best care possible. Recognizing these changes in emotions early is crucial in order to address them before they become overwhelming.

When paramedics recognize themselves becoming burnt out, the following are some strategies that can be employed to build resiliency:

• Establish strong support networks: Lean on colleagues who understand the unique challenges of the job. Having a supportive team can provide a sense of camaraderie and emotional relief.
• Prioritize Self-Care: Taking care of your physical and emotional health is essential. Ensure you are getting adequate amounts of sleep, nutrition, and exercise. Even small self-care practices like stretching, meditation, or brief mindfulness breaks at work can have a positive impact on your well-being.
• Establish boundaries/Maintain Work-life balance: Learn to say “no” or set limits when needed. Avoid overcommitting yourself both off and on the job. Make sure that your personal life is given enough time and attention. Spending quality time with loved ones, pursuing creative hobbies, or enjoying outdoor activities are all vital for recovery and long-term resilience
• Seek Help: If burnout symptoms persist, consider seeking help from a counsellor or therapist who specializes in trauma or stress-related conditions

Listed below are several resources available to paramedics in Northwestern Ontario who think they may be experiencing burnout or other stress-related injuries.

By recognizing the signs of burnout early and actively implementing resiliency strategies, paramedics can not only preserve their mental and emotional well-being but also continue to thrive in their demanding roles, ensuring both personal health and the quality of care they provide to their communities.

March 2025 Tip of the Month: Identifying Intimate Partner Violence (IPV) in Prehospital Care

Recognizing the Signs of IPV

Intimate partner violence (IPV) is a significant issue across Canada, and Northwestern Ontario is no exception. Studies indicate that up to 35% of women in the region will experience IPV in their lifetime, with higher rates reported in rural and remote communities. Certain Indigenous populations face even greater vulnerability due to unique socio-economic and systemic factors.

As frontline healthcare providers, paramedics are often the first point of contact for victims of IPV. Your ability to recognize and respond to IPV is critical for patient safety and well-being.

1. Recognizing Common Presentations

IPV victims may present with:

· Unexplained or inconsistent injuries (e.g., bruises, fractures, lacerations).

· Injuries in various stages of healing.

· Vague, non-specific complaints (e.g., headaches, abdominal pain, anxiety).

· Injuries to areas typically covered by clothing, such as the abdomen, chest, or back.

· Behavioral signs, including nervousness, avoidance of eye contact, or reluctance to provide details about injuries.

2. Observing Behavioral Cues

· A controlling or overly attentive partner insists on speaking for the patient.

· The patient appears fearful, anxious, or depressed when discussing their injuries.

· The patient hesitates or resists answering questions when their partner is present.

3. Using Open-Ended and Non-Judgmental Questions

Creating a safe and private environment allows patients to disclose abuse. Consider asking:

· “Can you tell me what happened today?”

· “Do you feel safe at home?”

· “Has anyone hurt you or made you feel afraid?”

4. Utilizing the HITS Screening Tool

The HITS (Hurt, Insulted, Threatened, Screamed) tool is a simple, validated screening method to assess IPV. Patients rate four questions on a scale of 1 to 5 (Never to Frequently):

· Hurt – "How often has your partner physically hurt you?"

· Insulted – "How often has your partner insulted or talked down to you?"

· Threatened – "How often has your partner threatened you with harm?"

· Screamed – "How often has your partner screamed or cursed at you?"

A score of 10 or higher suggests a potential IPV case, warranting further assessment and intervention. The brevity of this tool makes it especially useful in prehospital settings.

5. Identifying High-Risk Factors

Certain factors increase the urgency of IPV intervention:

· Strangulation – A strong predictor of future lethal violence.

· Pregnancy-related injuries.

· Multiple EMS calls for vague complaints in a short timeframe.

6. Documenting Accurately

· Record verbatim statements from the patient.

· Describe visible injuries and behavioural cues objectively.

· Avoid assumptions—stick to observable facts.

7. Referral and Reporting

• Hospital Triage: Communicate any IPV concerns to your receiving facility
• Self-Referral Support Services: IPV survivors can access support services independently. Referring patients to available programs and treatment centres can connect them with vital resources.
• Mandatory Reporting: If there are children in the home aged 16 or under, paramedics have a legal obligation to report suspected IPV to child protective services.
• Resource and Support Links:
  • Ontario Government: IPV Support Services
  • Sexual Assault/Domestic Violence (SADV) Treatment Centres – A list of treatment centres by location.
  • 211 Ontario – Enter your location to find local shelters, crisis lines, and other community services.

Evidence-Based Practice

Research indicates that up to 40% of women treated by EMS have experienced IPV, yet it frequently goes unrecognized. The HITS screening tool has been shown to improve IPV identification and facilitate early intervention in prehospital care.

Your Role in IPV Recognition

By applying these guidelines, paramedics can play a critical role in identifying IPV and ensuring that victims receive the support they need. Early recognition and appropriate action can make a life-saving difference.