When dealing with an anaphylactic patient, the PCP medical directive says to administer up to 2 doses of epi at a maximum single dose of 0.5mg, whereas the bronchoconstriction AND cardiac arrest medical directives are only one dose at a maximum single dose of 0.5mg. Can some explain why?

Does a prescription of NTG patch count as previous history of use for NTG spray? Would it be a concern that the medication would be administered through a different route and therefore have a different onset of effect?

I have had a few calls to nursing homes where the patients IV fell out and the patient is being sent to the hospital for an IV restart. If the patient does not have any complaints otherwise, would an IV certified crew be able to start the IV and patch to not have the patient transported? If so, would this be documented as a refusal? I have always transported these patients but it would be helpful to know if there are other options to avoid an unnecessary trip to the hospital. Thank you!

The AHA and COVID-19 guideline has a caveat that states in “suspected or confirmed COVID-19 cases” we should implement the prescribed practices. In the event that the patient in cardiac arrest is not confirmed or suspected to have COVID-19 symptoms is it reasonable to every to pre-pandemic practice of resuscitation?

Follow-up question that was asked on 29-Jan-2021 about pulse checks after no shock is indicated. Base hospital answered that pulse checks should occur concurrently with each rhythm analysis. Is this true for those of us that are using S-AEDs rather than manual rhythm analysis? The reason I ask is because First Aid & CPR courses suggest that touching a patient during an AED analysis will introduce artifact that could affect the accuracy of the analysis.

As far as the LAMS is concerned, when assessing grip strength, what is the score for a pt who has normal grip on one side only?

Do you recommend a c-collar in patients with SGA or ETT in order to help prevent tube displacement?

Slide in conclusion portion of the course, states capnography waveform is gold standard for ETT/SGA tube placement. Previous slide during course states that this has no been studied on other airway except ETT. Can you please clarify this ambiguity.

I have recently read about recommendations/suggestion for the use of the distal femur as an alternative IO access sites specifically in pediatrics. Is this being considered as an option in Ontario?

Hello and thank you for your time everyone. Module 2 point 2 reinforces the concept that high quality CPR is the primary focus for care of an opioid overdose VSA patient. However, It also highlights that naloxone may be administered as long as AHA guidelines for cardiopulmonary resuscitation are adequately being met. Given this point; is it o.k. for paramedics to administer naloxone for these type of VSA patients? The directive book and phone application Medical Cardiac Arrest directive continues to state, “There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. I found it a little unclear whether this segment was reinforcing the concept to not administering naloxone for a VSA patient, or providing guidance that it is acceptable as long as other aspects of care are effectively delivered.

The current AHA guidelines do not seem to support the use of back blows for conscious choking adults yet this is often taught in Red Cross or St. John courses. Am I mistaken or is there disparity between the current teaching?

Can you please clarify what I should do if a midwife requests we transport to a different receiving facility as opposed to the closest?

Mom is having a post-partum hemorrhage CTAS 1-2 and there is a stable neonate, can we leave neonate on scene with Dad and call for 2nd unit for baby or can we leave? Do we have to wait until arrival of 2nd unit? No policy on this.

In the Toradol protocol it simply uses term “current/active bleed” as a contraindication, the companion document provides little clarification as to how this applies to trauma pts as trauma was removed as a contraindication. Would trauma with high index of suspicion for internal bleeding (MVC, Motorcycle accident, fall from height) be a contraindication? Would multisystem trauma pts? Or would the better course of action be to treat their pain? Thanks!

You have a patient that is VSA from penetrating trauma. The bls states you transport to trauma hospital if less than 30 min. The als pcs states that if your patient VSA from trauma and a TOR does not apply (pt in PEA) you transport to closet ED. So which one is correct the BLS to trauma hospital or ALSPCS to closest ED.

Why do the pandemic guidelines allow for the administration of 2 doses of epinephrine (<50y) in bronchoconstriction (asthma exacerbation) vs the ALS PCS allowing only a single dose (without age guideline)?

What is the correct course of action if a pt goes VSA while crew is on scene, (ex. 1st analyses reveals VF, pt shocked, then 2 more analyses 2 min apart- both PEA), then pt starts spontaneously breathing and has pulse (ROSC)…then rearrests 2 min later and is in VF so crew shocks…CPR continued as pt still pulseless. Keep in mind crew is still on scene waiting for fire to show up as crew needs help with extrication.. this situation has happened and 1 crew member had called BHP for direction as it’s ‘grey” area as normally you are transporting by then and would do 1 analysis following rearrest and shock if necessary and continue with transport/CPR.. BHP was not clear just kept saying “follow your protocol” when in fact the crew was but at that point was very “grey”. Would we treat it as a whole new medical cardiac arrest protocol as its a re-arrest on scene until fire arrives? Or what would be the best course of action?

Is there anywhere to go and practice scenarios with an educator for those of us who learn better hands on and want to freshen up on some skills and directive (including the companion doc, and bypass rules)?

Can we just wear a surgical mask and goggles for all AGMPS and optional gown if we want to? Shouldn’t there be an update for our PPE as well and not just our screening tool, now that we know a little bit more about COVID? Thank you!

My question is regarding STEMI bypass and hyperacute T Waves. We were called out for a 60’s male patient experiencing chest pain after some physical exercise. It was quite apparent patient was likely having a cardiac event upon arrival and first examination. Patient had 8/10 midsternal pain (pressure) with radiation into shoulders. Patient was clammy, cool and diaphoretic. Patient had a weak radial pulse. After giving ASA 12 leads were obtained. Each showing hyperacute T waves in the chest lead V2 – V5. No elevation is noted, upon multiple 12 leads. No nitro was given as heart rate was below 60, but a lock was established. Patient was stable and wouldn’t have any of the contraindication to STEMI bypass. We are a rural service and closest hospital is 7 minutes away and transport time to the cath lab would be roughly 25 minutes. Just curious how base hospital would like us to proceed on these calls in the future? a – go directly to closest hospital as there is no elevation yet and doesn’t quite meet STEMI bypass b- call the closest cath lab and let the cardiologist decide c- first call base hospital to ask for further direction to see if cath lab should be called, then proceed from there. Thanks in advance

Is it considered an Inferior STEMI if only II, aVF are presenting with ST elevation as they are technically not contiguous?

I had a patient who met the criteria for Nitro administration under the ACPE directive. The initial BP was 104/72, with no previous Nitro use, and unable to obtain IV access. The pts blood pressure in the back went up to 143/88 while in the back of the ambulance… can nitro be given now that the blood pressure has increased, even if the pt started <140 SBP?

Given that rapid atrial fibrillation and other tachydysrhythmias can result from myocardial ischemia; is it wise to provide ASA to these patients as a precaution. I am a PCP, and we dont have a defined treatment for pulsed tachycardia.

For the IV bolus directive when one of the contraindications is fluid overload, if a patient has CHF and is presenting hypotensive, and is not experiencing SOB but has chronic edema in his/her feet/legs is that technically a contraindication to not bolus? Considering that would fall under fluid overload ? What are the signs and symptoms of fluid overload you guys are wanting us to look out for and be aware of?

Can you TOR someone who is in PEA

I was just curious to see if there has ever been talk about the idea of reducing fractures in the field, rather then just femur fx’s? Obviously following all of the same protocols as the sager. Not that I have done much research, but could the possibility that some sort of equipment be readily available? We have done so many of those calls that could have gone much smoother and at more of a comfort for the patient in the long run.

This has been a question of mine recently that not many people have the answer for in my service. My question is; if we have given the pt any sort of medication or initiated an IV can the pt be offloaded to the waiting room or to a bed in the hallway? Thank you in advance!

In regards to an IV that you have established are other medical professionals allowed to use it to give drugs on way to hospital? Back story, picked up a female patient who had just given birth with significant post partum hemorrhage. Midwife onscene was unable to establish a line but you subsequently start one. Midwife wants to push oxytocin through the IV that you have established is this OK?

Would it be appropriate to contact a BHP requesting titrated sedation for a compliant and non-combative patient experiencing agitation with inability to remain still preventing proper assessment due to stimulant use? I find these patients are occasionally even difficult to transport due to writhing on the stretcher let alone perform an appropriate assessment.

Why is nasotracheal intubation reserved for patients above the age of 8?

Do we still suction neonates immediately after birth?

If our patient has been accepted for Bypass under STEMI protocol, and pt goes VSA on route, in the event of a ROSC do we continue to proceed to Cath lab or do we now reroute towards closest ED?

In regards to the LAMS score, is it to be used for acute changes only if a patient has deficits from a previous stroke? For example, if the patient already has a weak grip and arm drift from a previous stroke with no reports of acute changes, however they have facial droop that is reported to be new then is only the one point for facial droop counted?

Question: with regards to the Trauma Cardiac Arrest Medical Directive, do you support the placement of a pelvic binder on the patient assuming severe blunt trauma? I understand that under the Blunt/Penetrating Injury Standard in the BLS it is stated: “if the patient has a pelvic fracture, attempt to stabilize the clinically unstable pelvis with a circumferential sheet wrap or a commercial device”. Furthering this thought, the Intravenous and Fluid Therapy Medical Directive found within the ALS PCS now states: “An intravenous fluid bolus may be considered for a patient who does not meet trauma TOR criteria, where it does not delay transport and should not be prioritized over management of other reversible causes.” Thinking about this all together has me wondering that if a patient who is VSA secondary to severe trauma is eligible to receive an IV bolus to presumably treat hypovolemic shock, would the use of a pelvic binder be supported in the same way? If so, when would be the recommendation to apply a pelvic binder when treating under the Trauma Cardiac Arrest Medical Directive? Thank you.

Can you give gravol to a normally altered (Alzheimers) patient?

Question in regards to the IM epi in ‘less than 50 year old patients with Severe Respiratory distress, bronchoconstriction, and a history of asthma without other contributing cardiorespiratory comorbidities’ Does this mean if the patients is less than 50 year old with Severe SOB and signs of bronchoconstriction and a history of asthma but also has a history of COPD or CHF, then we do not consider IM EPI?

Hi Doc(s), Two unrelated questions I’ve been pondering over the last couple of days: 1. In the field I’ve noticed some paramedics withhold dimenhydrinate administration if the patient has already taken any Gravol in the last 4-6 hours. However, the medical directive does not specify a time and simply states overdose on antihistamines or anticholinergics or tricyclic antidepressants. My understanding of their logic is that additional Gravol may cause an overdose in the patient however Gravol brand themselves recommend a dose of 1-2 50mg capsules every 4hrs PRN… Could you please provide some further clarification on this practice, and if we should still be administering it if we do not suspect an overdose but that the medication has been taken appropriately. (and similar practice for if the patient is taking tricyclics or anticholinergics as prescribed to them) 2. I recently had a COPD exacerbation patient who I believe would have benefitted greatly from CPAP. He had equal lung sounds through all fields with no paroxysmal chest movement, however there was a recent history of a collapsed lung approx. 6 weeks prior. (Unknown cause, from his history I suspect possibly a bleb/bullae) The current extenuating circumstance of COVID-19 aside, should CPAP be considered in this patient? Although I am not suspecting a current pneumothorax, due to the recent history I would think that weakening of the lung tissues could put the patient at greater risk for a recurrent event if subjected to significant positive pressures. Thank you and stay safe!

What is our responsibilities once a patient has been arrested under the mental health act? Is it considered implied consent? Are we responsible for vital taking, blood sugar and treatment if the BG is below four? Can the patient refused treatment with a decreased BG and a GCS of 14(confusion)?

Tension pneumothorax Could someone please clarify the BLS section on ventilating a suspected tension pneumothorax. Is it just slower and not as hard of a squeeze as usual

On our ACRS, when we have rhythm interpretation and if we are unsure of what the rhythm is, is it okay to leave it blank?

As far as the contraindications for ketorolac and ibuprofen, what are the medications that are classified as anticoagulation therapy? I know daily ASA is not but are all blood thinners? Or just specific ones? We have been seeing a lot of eliquis and xarelto lately for example.

When working as a first response while covid vaccines are being administered in LTC facilities, are all severe reactions to be considered under the anaphylaxis protocol and be given epi and benadryl as per our current protocol?

Since COVID supraglottic airways are highly recommended to be placed in a VSA patient prior to CPR. Is this for medical VSAs or does this apply to traumatic as well?

I have two questions with regards to the Bronchoconstriction Medical Directive, under the current (February 22nd, 2021) Considerations for Paramedics Managing Patients during the COVID-19 Pandemic. 1) Are we still only administering IM epinephrine to patients who require BVM ventilations? 2) Are we only administering IM epinephrine under this medical directive to patients presenting with a cough? It was previously stated in the January 4th, 2021 update that: “Paramedics should consider administering IM epinephrine for severe respiratory distress with cough in known asthma patients…” I understand that the top of the new memo states: ” This memo replaces both the May 6th, 2020 and the January 4th, 2021 considerations documents and memos.” Just looking for some clarification on the current practice please. Thank you.

With the new bronchoconstriction update, saying you cant give Epi to pts unless theyre <50, does this apply only to the covid guidelines where you can administer it up to 2x if conditions met (asthma, cough, severe respiratory distress) or does the age now apply to the normal bronchoconstriction directive for Epi where you can give up to 0.5mg once too?

With regards to pediatric resuscitation, are we to use the pediatric setting on the zoll for only less than 8 years old, or for >30 days to onset puberty? I was reading old Q&A for this, and it was made to seem like we only use the pediatric setting for less than 8 on the zoll, and anything older than that use the adult setting

Just a question regarding a pediatric VSA. I was reading some other askmac questions and noticed they had said we use the pediatric defib setting for kids under 8, however if the child is over 8 and less than the onset of puberty, does that mean were still using the pediatric defibrillation setting or the adult setting on the semi-auto zoll?

My question is can you TOR an opioid overdose cardiac arrest. The question came up recently and it seemed a simple yes because opioid overdose cardiac arrests are to be run as a standard medical arrest. However, some people have referenced the “very early transport after one analysis… for medication overdose/ toxicology.” This is further confused by the 1-Mar-2012 Ask MAC submission where it was stated you could not obtain a TOR on an OD (but did not specify what type of OD). I am hoping you can provide some clarification on obtaining a TOR during an opioid overdose VSA.

Question: For a pediatric VSA do you stay and run the full cardiac arrest, (4 analysis) or should you depart scene after the first analysis if they are in a non-shockable rhythm? PCP question.

Question: If our patient goes vsa while on route to Cath lab via bypass approval, and we obtain a ROSC, do we continue to Cath lab or divert to closest ED?