Question: Does a patient that suffered from hanging, electrocution, and/or drowning fall under medical tor protocol? Also, if a patient is suffering from anaphylaxis and airway is completely obstructed and you had analyzed once and transported as per FB protocol if on route airway becomes relieved and you have good compliance do you pull over and start your medical cardiac arrest protocol? If first analyze on scene was no shock and you do pull over and have two more no shocks does it fall under a medical tor protocol?

 Thank you for this question - it is certainly one of our most frequent and you are correct - there is a discrepancy in our messaging vs. the directive. This is one of the very rare situations where SWORBHP has varied from the directives. This answer was posted originally to the site on Feb 6, 2012.

The debate has centered upon whether the medical TOR has to be an arrest of suspected cardiac etiology in nature (as it says on the directive) or can it also include arrests felt to be asphyxial in etiology (such as drowning, hanging and electrocution- not an exhaustive list).

The concern of the Medical Council was how does the paramedic decide what arrest was caused by asphyxia vs. one of cardiac etiology when often details even on scene are difficult to obtain? You can imagine how many FAQ we would get as to what constitutes a cardiac arrest from a cardiac cause vs. an asphyxial!

The consensus from the SWORBHP Medical Council was for the paramedic to not attempt to break it down asphyxial vs. cardiac on scene... It gets too confusing.

We feel it is reasonable if all other criteria for TOR are met, patch to the BHP and let them be involved in the decision making. We did not want to have to place the paramedic in the difficult position of having to decide on scene- you have enough to do! If the BHP decides that a TOR is reasonable, then follow that protocol, and if not, transport the patient and continue resuscitation as directed.

As an aside, the support for this decision comes from the ROC trial currently underway all across North America looking at CPR rates. It was felt by ROC investigators that it was too difficult and unfair to make a paramedic decide on scene what caused the arrest, so arrests caused by asphyxia are treated the same as arrests caused by a presumed cardiac etiology. The Medical Council from SWORBHP thought this would be easier for all paramedics to adopt this same strategy for TOR.

As for the second part of your question relating to a cardiac arrest from anaphylaxis. It is interesting that you would choose to follow the Foreign Body Airway Obstruction Cardiac Arrest Medical Directive. While we follow your rationale that the patient's airway has been swollen closed due to the anaphylaxis, we would suggest that patients who arrest from anaphylaxis should be managed as per the Medical Cardiac Arrest Medical Directive (where IM epinephrine for anaphylaxis is indicated and referenced). Basically, in a similar fashion to hanging, electrocutions and drowning, these arrests should be managed as asphyxial in origin following the same rationale as noted above. In terms of pulling over in the ambulance en route to the hospital, this answer was posted previously and is attached below.

How paramedics should treat a "re-arrest" with a patient who has achieved ROSC on scene and now during the transport phase has re-arrested is not explicitly defined by the current set of directives. This has been addressed with the other BH in Ontario and is on the list of suggested edits.

Until such time as a new uniform approach is adopted by the Ontario MAC (not just the SWORBHP), the SWORBHP Medical Council has decided that paramedics should return to the previous practice which has been: Follow appropriate scene protocol for specific cardiac arrest situation. ROSC? Transport. Re-arrest? Pull over and one analysis then transport with no further stops regardless of shock or no shock. This avoids the endless possible permutations of shocking repeatedly a patient en route to the hospital and also the multiple pull overs that were an issue in the past.

Cardiac/Circulation,Medical Cardiac Arrest

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