If a patient has self-administered benadryl prior to our arrival, should a paramedic re-dose under the Allergic Reaction Medical Directive? There appears to be no contraindication for this in the directive. As well, the direction per the Medical Directive in the OBHG Companion Document is, diphenhydrAMINE administration should always follow the administration of EPINEPHrine as outlined in the Medical Directive. However, I have heard from my more senior colleages that we should not re-dose the benadryl, like we can the epineprhine. Can you please clarify?
Question regarding procedural sedation. During a recent call we had a patient that was believed to be flash pulmonary oedema (audible crackles, blood tinged frothy sputum, confusion). The patient was quite agitated, wouldnt answer questions, resistive to any intervention or assessment, resistant to vitals and non-tolerable of O2 via any route and had difficulty remaining still. Is it reasonable to consider sedation for these patients? Would this be considered a special circumstance requiring BHP consultation? Would Ketamine be the drug of choice over Midazolam?
In regards to Dex administration being contraindicated for patients currently on parenteral or PO steroids, can we get some more clarification on what we are referring to specifically – is it basically all steroids? Most patients with COPD tend to be on steroid puffers which presumably would make those patients not able to receive dexamethasone?
In regards to medications with a condition of “unaltered”, should we be administering these if the pt is GCS 15, then has a syncopal episode (or other altered period) in your care and then returns to GCS 15? An example would be a chest pain call where you want to treat with ASA and Ondansetron. Is it a case of “once you’re out you’re out” or would it still be appropriate to treat as they have now returned to an unaltered state? Thanks
In regards to the analgesia directive, should we withhold pain medication in the event that the mechanism of injury is severe even if the patient has no obvious signs of a head injury or a bleed? For example: a car accident at very high speeds where pt is only complaining of severe back pain, no LOC or confusion, would it be appropriate to give either Advil/Tylenol or toradol since there are no obvious contraindications or would it be better to withhold since the mechanism of injury is serious enough that they would still be possibilities?
New Protocol First Arrest On Route If my patient becomes VSA on route (first arrest) am I to complete the full 20 minutes of resuscitation roadside and then continue transport? Our previous protocol was to complete the full arrest protocol and continue transport. Should you be a short distance from the hospital would a BH patch be suggested or should we perform the 20 mins of resuscitation regardless of proximity to the hospital? Thank you. minutes? I understand the research is trending towards scene times longer than 10 minutes for pediatrics (in some studies) and that earlier epinephrine administration has been associated with ROSC but this also leaves PCP only rural services in a very difficult grey zone to be addressed. I am by no means advocating for a “scoop and run” mentality (the new wording in the directive rules that out quite nicely) but any further guidance or clarification is greatly appreciated!
With the new medical cardiac arrest directive I have multiple questions: 1. If a patient re-arrests after getting a ROSC do we a) start the 20mins over? B) analyze once and then carry on to hospital with no further analyzes, or c) complete the remainder of the initial 20mins of CPR? Also does this answer change if the ROSC is at the initial site or in the back of the ambulance? 2. If patient arrests for the 1st time in the back of the ambulance, do you stop for the whole 20mins of CPR, does location of arrest to hospital make a difference? 3. If you have a refractory v-fib and we start early transport to hospital, do we continue to pull over and shock every 2 mins or so we stop shocking while on route to hospital?
Question: Can a paramedic in the field rule out ischemic chest pain and not treat with ASA/Nitro due to the chest pain being reproducible? (eg. worse on deep inspiration but radiating down the left arm/shoulder, and sharp pain in left upper chest and pressure across the lower chest). I recently had this call, and was told that you can rule it out based on it being reproducible, but the history and rhythm strip, clinical presentation was leaning more towards cardiac.
In the latest version of the companion document (v5.1) the following is stated “For a witnessed arrest in the back of the ambulance paramedics should use clinical judgment to decide whether to stay and perform resuscitation or proceed to hospital. Paramedic should perform three full analysis and then proceed/patch or to provide one analysis and go. The paramedic should provide at minimum one analysis. Factors that are part of the decision process include distance to closest hospital, probable cause of arrest, ability to provide adequate CPR/ventilation, shockable vs non-shockable etc..”. I was told during my recert in November that this scenario would warrant a 20 minute resuscitation. Can you please clarify.
If My patient goes VSA in the back of the truck (witnessed, first time VSA). We do not do 20 min CPR? Or we do 3 analysis and go after? And/or 1 analysis and go? Does the same apply witness VSA in the home? Do these require patch to leave early? There has been excessive talk over this and little clarification.
If we pick up a patient and the patient presents with a positive 12-lead STEMI and you are travelling to the PCI Center and the patient codes, do we run the full 20 minute cardiac arrest protocol, or could you consider STEMI as a reversible cause (Hs and Ts) , analyze once and head to the closest receiving which may not be the PCI due to distance.
Hello, with the changes to PCP medical cardiac arrest, since there is no longer a maximum number of analysis are we expected to continue to analysis the rhythm every two minutes on route to hospital if were transporting?. Seems like it would delay our arrival time a fair bit to pull over every two minutes especially in the county. Also, if a confirmed STEMI codes on route, should we be running a full 20 minute resuscitation before continuing transport, or would that be considered a reversible cause to transport after one analysis?. Thanks
The new Medical Cardiac Arrest Directive requires 20 minutes of resuscitation on scene. Point # 5 of the Primary Clinical Consideration(s) states …or other known reversible cause of arrest not addressed. My question has to do with refractory PEA and the amount of potential reversible causes (7 Hs 5 Ts). Would it be reasonable to patch for request of early transport in the presence of 3 consecutive analysis of PEA?
There has been a lot of debate in regard to the new medical cardiac arrest directive, especially when it comes to pediatric patients (1 day to less than 8 years old). Based on my understanding of the new directive, patients 24 hours old now fall under medical cardiac arrest which states that scene time is now 20 minutes unless you have a reversible cause or 3 consecutive shocks, since TOR would not apply here. Some paramedics express significant discomfort staying on scene for that long if the patient has been stabilized with good airway, quality compressions, and possibly defibrillation. Do you support paramedics leaving early in this setting where everything is done early or do you encourage us to stay on scene for 20 minutes? Does this benefit the patient when they could be receiving life saving drugs in a hospital, also knowing that we will eventually have to transport to a hospital no matter what?
In regards to doing a Stroke Bypass for a palliative patient that is not end-stage, the directive clearly states Terminally Ill or palliative care patient. I think the blanket term palliative care patient is misleading, as many people who are palliative are not close to dying. Are we to make our own decision about ‘how palliative’ a patient is and only apply this portion of the directive if they are truly end-stage? I think there should be something about their goals of care in the directive or something more clear so as to not rule out patients just because their palliative status (which could still allow them a good amount of time with quality of life). I think many medics may call for direction in this case, but there are others who would read the directive verbatim, thereby causing some patients to miss out on life-improving interventions. Is there any direction on this or am I on the right track with my thinking?
What is considered the most appropriate means of transporting a pediatric patient? Is securing a child/infant in a car seat provided by parents to the stretcher better than securing them in the neonate or pedimate? We have the pull down jump seat for toddler booster seat, but would like to know what our BHPs think of the car seat on stretcher versus pedi/neonate.
What is the SWORBHP stance on administering salbutamol in patients with suspected ACPE? Most of us have been traditionally taught that salbutamol in patients presenting with crackles due to suspected ACPE is a negative thing because of the bronchodilation and the risk of flooding a patient. However, there are many studies that argue salbutamol administration could be beneficial. Especially in situations where patients are presenting with both wheezes and crackles, it can get confusing. Where does SWORBHP stand on this topic?
In regards to the cardiac ischemia medical directive, the latest indication is now suspected cardiac ischemia. If you have a pt presenting with all signs and symptoms of cardiac ischemia, have given ASA, established an IV, and have given NTG. If the pt’s symptoms improve after administration of NTG should you continue with the directive to the full amount of doses provided the pt still meets the conditions?
Hello, what are the criteria for identifying hypothermia in a VSA patient? This affects our treatment under ALS PCS 5.1 whether we consider early transport after one analysis. The situation that brought up this discussion was a patient who had been on the floor indoors for a number of days, but still presented with a hypothermic body temperature. If the patient had been found VSA, how would we identify to treat them under the full medical cardiac arrest, or be considered for early transport?
In pts with poor peripheral perfusion (ie. sepsis) can we do a blood sugar reading on pts ear? Recently had call where pt was severely septic and we gave glucagon and then dextrose and pts blood sugar kept going down. ER doctor took blood sugar on pts ear where perfusion was better then peripherally and sugar levels were well above normal.
Would SWORBHP be ok with ACP paramedics utilizing the 4-2-1 rule for fluid maintenance rates in paediatrics. Especially, with the high incidence of RSV in the community compounded with sick kids who aren’t taking in as much fluids and may be fluid depleted. Their fast respiratory rates and poor feedings, fever etc increases the insensible fluid loss. I can appreciate the current model, for fluid boluses utilizing the 70 mmHg + (2 x age in years). However, at this point they are decompensating rapidly with the hypotension and progressing to pre-arrest (with signs of delayed peripheral and central cap refill, looks sick as per PAT etc). Is the current protocol 15 ml/hr for
I was just wondering if SWORBHP is still maintaining the same stance for pediatric medical cardiac arrest (as discussed in the May 2022 Tip of the Week and other posts) for the new medical cardiac arrest directive in ALS PCS version 5.0? Is paramedic judgement still recommended for rhythms not amendable by defibrillation or is it expected that we run the cardiac arrest on scene for the full 20 minutes? I understand the research is trending towards scene times longer than 10 minutes for pediatrics (in some studies) and that earlier epinephrine administration has been associated with ROSC but this also leaves PCP only rural services in a very difficult grey zone to be addressed. I am by no means advocating for a “scoop and run” mentality (the new wording in the directive rules that out quite nicely) but any further guidance or clarification is greatly appreciated!
For acetaminophen and ibuprofen, suspected ischemic chest pain is listed as a contraindication. Is this listed mainly to indicate that ischemic chest pain should not be treated with the analgesia directive? Could analgesics be administered to treat a different area of pain that is occurring at the same time as the chest pain that appears to be unrelated? For example, I had a patient with chronic pain that she takes acetaminophen for, but she was experiencing acute chest pain suspected to be ischemic. Would it be correct to withhold acetaminophen in this case and not provide treatment for the chronic pain that she is experiencing at the same time as suspected cardiac ischemia?
I have a scenario that happened and would like to know what the right answer is. We had a patient feeling generally unwell and dizzy. I performed a stroke assessment and he had equal grip strength, no pronator drift, and could raise both of his legs. There was no facial droop, slurred speech, or unilateral weakness. When we were transporting we noticed the patient was severely leaning to the right. He couldnt support himself upright at all, but everything else remained intact. Is this enough evidence to count as unilateral weakness? Would you stroke bypass?
This is a BLS question. For management of a flail chest, most research suggests that we tape the flail segment in place with a large bulky dressing, bag of saline, Asherman chest seal, etc. I’ve been hearing from recent PCP graduates that they have been taught to use a bulky dressing, however they mention that they are being taught to do a circumferential wrap around the chest with a triangular bandage or blanket to hold the dressing in place (which I would assume is incorrect) instead of taping a bulky dressing over the flail segment. What would be the preferred method and why?
Hello! Question for you. If we have a patient who is complaining of unilateral weakness or numbness, but on exam has equal grip strength, no facial droop or slurred speech, and equal strength in both legs, what would be the appropriate destination? Should we still stroke bypass to the nearest stroke center? To clarify, the patient feels as though they have weakness or numbness on one side of their body, but we are unable to find any deficits on our physical stroke exam (LAMS score of zero).
Question from an ACP role, For a pediatric patient who has a HR less than 60 with poor signs of perfusion (cyanosis/pale and apneic€¦..start chest compressions with airway and ventilations via BVM. The question is do we follow it up with epi? In the PALS algorithm it states to do CPR/ventilations, epi, atropine and consider pacing. This is covered under the newborn arrest directive however it is not covered under the adult/pediatric medical cardiac arrest. What does our base hospital want us to? Would it be appropriate to follow the PALS Bradycardia algorithm?
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