SWORBHP would like to provide additional rationale and clarification to the Cardiac Arrest Medical Directive for the management of patients in cardiac arrest who do not qualify for the TOR criteria. The below statements are planned to be released in the next iteration of the Ontario Base Hospital Group (OBHG) Companion Document. SWORBHP currently endorses this clarification to paramedic practice.

A patient in cardiac arrest that is not due to an identifiable reversible cause as outlined in the Primary Clinical Considerations may benefit from longer on scene resuscitation. This directive allows up to 20 minutes of on-scene resuscitation for patients who do not meet TOR criteria. In the majority of these cases whereby patients do not meet TOR criteria, a minimum of four analysis should occur prior to transport. Paramedics can take multiple factors into consideration and use their judgement to initiate transport before the 20-minute mark of resuscitation in patients who do not meet TOR criteria. This can include but is not limited to:

• Younger age
• Distance to hospital
• Arrest witnessed by paramedics
• Availability of ACP level of care for epinephrine administration
• Ability to perform high quality chest compressions and resuscitative care during extrication and transport. This may include on scene and extrication/transport resources such as additional paramedic crews, firefighters, mechanical CPR devices etc.
• Non-agonal PEAs (ex. heart rate greater than 60 and ETCO2 ≥ 30 in keeping with potential circulatory perfusion)

A patient in cardiac arrest that is not due to an identifiable reversible cause may benefit from longer on scene resuscitation. This directive allows up to 20 minutes of on-scene resuscitation for patients who do not meet TOR criteria. In the majority of these cases whereby patients do not meet TOR criteria, a minimum of four analysis should occur prior to transport. Paramedics can take multiple factors into consideration and use their judgement to initiate transport before the 20-minute mark of resuscitation in patients who do not meet TOR criteria. This can include but is not limited to:

• Younger age
• Distance to hospital
• Ability to perform high quality chest compressions and resuscitative care during extrication and transport. This may include on scene and extrication/transport resources such as additional paramedic crews, firefighters, mechanical CPR devices etc.
• Non-agonal PEAs (ex. heart rate greater than 60 and ETCO2 ≥ 30 in keeping with potential perfusion)

We have released a new podcast which covers the contents contained within the above memo. This podcast features SWORBHP’s Regional Medical Director Dr. Matthew Davis and Dr. Sarah Cocco.