Question: When doing resuscitation on babies born prematurely. Do we consider their corrected age to follow the appropriate resuscitation procedure or do we go by their actual birthday? ie) if baby was born 4 weeks premature, do we consider them to be neonatal and follow 3:1 compression and ventilation rate until they are 8 or 9 weeks after birth?

Question: How fast can a pediatric Pt. burn through glucose stores? Scenario: Called for a 13y/o unconscious. Consumption of unknown amount of alcohol & unknown drugs or amount. AOx0, GCS 4=E2V1M1. Eyes open to pain as only response. Pt stable vital signs on Primary & throughout transport & BGL 5.8mmol/L on scene. Transport to appropriate children’s hospital code 4 CTAS 2with a 25 min transport time. On ED assessment Pt. was given an amp of dextrose as ED found BGL to be “low”…. or not able to read on meter, so possibly less than 1.6mmol/L. Crew’s service meter DID pass daily test procedure as per manufacturer’s guidelines. Thank you

Question: Good afternoon. I just have a question regarding a VSA patient scenario. If the patient has a pulse with an SGA inserted (patient tolerates SGA) to give ventilations, how many ventilations would I give? 1 every 10 seconds or 1 every 5-6 seconds? And do I also wear an N95 mask?

Question: Could you please give clarification – On a VSA of a suspected opioid overdose, can we leave after the 1st analysis? Half my co-workers say yes and the other half says no, that you must stay to complete 4 analysis. I understand that early transport can be considered in medication overdose/toxicology. Where we are having difficulty with the interpretation of the protocol is “In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive. There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. Some medics are saying that the “continue standard medical arrest directive ” means to complete 4 analysis. My interpretation is, no narcan and continue protocol, which is to consider early departure. Thanks

During the pandemic, we have been advised to tape over the suction port on King LTs, and now we are switching to iGels, which also have suction capabilities. Are we to tape over the suction port of iGels as well? Furthermore, if the patient is in need of suction, what are the next steps recommended to safely maintain the airway, as only oral suctioning is recommended? Thank you

Hi, I have a question in relation to the FTT standard. If I had a patient who was VSA on arrival due to a multi-system trauma (no penetrating injuries, only blunt), but does not qualify for trauma TOR because the closest ED is 10 minutes away but LTH is 20 minutes away… am I transporting to the ED or the LTH? I understand for penetrating injuries we are going to LTH if it’s < 30 minutes, regardless of vital signs... but for other situations like the one I am stating, what is the appropriate action?

I know our standards as an ACP for over 18 years but if SVT encounter in a pediatric patient and long transport. If we patched got approval would this be appropriate based off the attached studies and success rate in comparison to the REVERT maneuver?

Need some clarification on when we do pulse checks during medical arrest protocol. Do we perform a pulse check after a no shock advised?

Is ASA considered anti coagulation therapy?

Question re potential med administration through a PICC line; would it be prudent to patch to Base Hospital for direction/permission to administer Gravol for example, in a pt who is declining additional IV initiation but already has a PICC line established and knowledge of how they self-administer their own medications? Thank you.

Why was an age restriction of 50 years of age placed on utilizing IM epinephrine for the Bronchoconstrictive Medical Directive in the latest update to the COVID-19 Management considerations?

What exactly are the oxygen flow rates per mask? I was given a different answer (specifically for a NRB) as a working medic than my friend who is in school

Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

Good afternoon, my question is related to current ACS treatment guidelines. I have had several STEMI inter-facility transfers within the last month or so where attending physicians have initiated pain management with Fentanyl. Upon receiving patient handover from these physicians they often request that this treatment modality be continued throughout transfer. Due to the current AMHA research regarding increased mortality in ACS and STEMI patients who are treated with morphine, is there any move to eliminate this contraindication from the fentanyl protocol, or to remove morphine from the ACS treatment guidelines? If a Physician requests this treatment modality (fentanyl) are we able to patch around this contraindication for fentanyl or would this go against the spirit of the protocol patching around contraindications? If the Physician has initiated treatment with Fentanyl and we have exhausted our nitro protocol or it is contraindicated will we suffer repercussions for not initiating morphine treatment even when it was requested that we do not by the sending physician? Would we require a patch to NOT treat this patient with morphine? Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

Has SWORBHP considered push dose epinephrine for ACP’s? This treatment is being used for a variety of indications in many paramedic services throughout the globe and has literature supporting it. I know this was brought up in 2017 and one of the concerns was “anytime drawing up medications, there is a risk for medication error”. There was a code epinephrine shortage in 2019/2020 and ACP’s were reconstituting epinephrine from 1:1,000 to 1:10,000 during active cardiac arrest situations without complications.

I am an PCP IV certified paramedic, working with a non IV medic. If we have a hypoglycemic patient do I need to attend & consider D10/D50 or can my non IV partner treat the patient with Glucagon instead? Same question for Gravol; do they need to get it IV or can non IV certified medic give it IM?

I have a question regarding analgesic administration in regards to abdominal pain (ex diverticulitis, hernia). If the pt is complaining of abdominal pain stating “it feels just like my diverticulitis acting up” Or due to hernia pain with evidence of a protruding hernia, would it be appropriate to consider analgesic medication if no contraindications are met? Although you are not 100% certain of the underlying cause in the pre hospital setting

If you arrive to a patient who is circling the drain very low heart rate respirations are almost none due to opioid overdose and you take a bgl and it comes back no hypoglycemia would you be wrong to administer naloxone before obtaining a full set of vitals and hooking up the cardiac monitor due to the condition of the patient. (covid times so it meets an inability to adequately ventilate).

When do I use a BVM and an oral airway? If my patient is unconscious then can I use these airway tools?

In keeping with the Covid-19 Cardiac Arrest algorithms can Midaz procedural sedation be applied to SGA similar to how it is used for ETT maintenance post ROSC should the pt increase gcs during the ROSC?

As per the neonatal resuscitation directive, for greater than >24 hours and the HR <60 do you start compressions right away? (less than onset puberty <60 HR with signs hypoperfusion start compressions) or start with BVM for 30 sec on room air then see if HR goes up? Then go from there.

Why is ibuprofen contraindicated in cases of active bleeding and cva/tbi in the past 24 hours?

Is external manual compression of the chest and appropriate prehospital consideration for peri-arrested or arrested asthma exacerbated patients who are showing obvious signs of chest hyperinflation and air trapping. I have read about its anecdotal use on website like EMDocs.net and in the Prehospital Care Journal (Harrison, R. Chest compression first aid for respiratory arrest due to acute asphyxic asthma. Emerg Med J 2010;27:59€“61. doi:10.1136/emj.2007.056119) as a few sources. I have also seen it performed in the emergency department by emergency physicians. I assume with good technique, it can assist with expiration and minimize the risk of barotrauma in these patients who require ventilation. Thank you!

Paramedic student here. Question about the medical TOR. Will the BHP grant the TOR after the 3rd analyze, or is the phone call to be made after the 3rd analyze and we are to stay on the phone with them until we have completed our 4th and then they will make their decision?

Under the nausea/vomiting directive contraindications include overdose on antihistamines/anticholinergics/tricyclic antidepressants – my understanding is that if a patient has already taken (gravol) then giving another (Ex. 50mg) dose would potentially cause an overdose thus we would withhold gravol in that case. Being that tricyclics are rarely prescribed these days, I have yet to come across this drug interaction in the field. My question is: does any use of tricyclic antidepressants preclude the administration of dimenhydrinate? Or should we only withhold it if the pt. Presents with a tricyclic overdose toxidrome?

Hello! Question about using CPAP during this time. I’ve had a two instances where my patients could’ve potentially benefitted from the use of CPAP, however they had went into cardiac arrest during transport and ended up pronounced at the hospital. I was wondering what you’re thoughts are now, in terms of applying CPAP to a patient who fits all the criteria as long as we wear the right PPE. In our service Level 1(Tyvek Suit, P100, safety goggles, and gloves) is indicated whenever we are to perform an AGMP. Cardiac arrests are one of these scenarios where we utilize the BVM with a HEPA Filter. I was just wondering, since CPAP is withheld do to it being an AGMP why can’t we use it to our discretion with a HEPA filter and wearing Level 1 PPE. The concern is obviously depending on where the patient is located and having CPAP on a patient and then transporting across public space to get to the ambulance is a risk for transmission to others. How do you feel during that instance if we just get on High Flow o2 @15L/min and then once in the back of the ambulance with the exhaust on and having Level 1 PPE on to be okay to use CPAP? Also giving the hospital a pre-alert to have a negative pressure room ready. Sometimes 5cm of H2O(which is 8L/min or can be helpful to a patients breathing. Also just to confirm anything greater than 15L/min of oxygen is considered an AGMP, according to the new research?

In current pandemic situation, nebulized epinephrine is being withheld for those with croup. What management is recommended, should the patient (without hx of asthma) deteriorate (apnea/silent chest) ? Is epinephrine IM an acceptable route? If not, what is the rationale?

Hello, I was wondering if SWORBHP can offer out some assistance in obtaining CMEs for this year. Since there are no conferences to attend to, the hosting/posting of webinars doesnt seem to happen anymore and online courses are fairly expensive. Could you link in some approved resources that we could utilize? I would love to see SWORB return to posting webinars more frequently.

Due to known patching issues inhibited by the currently required PPE can the OBHG look at omitting mandatory patch points specifically surrounding Midazolam and Ketamine administration for combative and excited delirium patients. I have never been denied an order for either of these medications and the time required to call for an order increases the risk of injury to everyone involved with the extra time required to complete the call delaying treatment. Second question, can we also look at increasing the maximum dose of Midazolam to 10 mg for combative patients as I have found that often times 5mg is insufficient especially when used on patients with known drug abuse. Or, is it possible for the OBHG to considering opening up Ketamine to be used on combative patients, as its my understanding Ketamine is a safer drug with less side effects?

*Updated* I wanted to clarify, which drugs/treatments are contraindicated after the patient is found to be hypotensive, even if the BP normalizes either with or without IV bolus therapy?

I was just reviewing a 2012 webinar regarding DNR confirmation forms. It was said that a DNR confirmation form is a contraindication for transcutaneous pacing but not for synchronized cardioversion. Is this the case? And if so then why? Also, what about the administration of other ALS drugs such as Atropine, Dopamine, and Adenosine?

Hello, Bit of a long winded question so please bear with me. The contraindication for topical lidocaine in ETI of the unresponsive patient: would it be reasonable to administer topical lidocaine to the unresponsive patient IF required to intubate because of the inability to adequately oxygenate and ventilate (after exhausting all BLS measures) when the patient is showing signs of rising ICP. I appreciate the dangers of intubation in a patient that has rising ICP €“ increasing sympathetic activity, periods of not oxygenating even if not adequate, and ultimately worsening ICP. In the setting of acute brain injury, hypoxia, hypercapnia and hypotension (one episode of each in most of the literature €“ less then 90% or <90mmHg) has show to worsen morbidity and mortality via secondary brain injury. I have read on several websites (life in the fast lane) and a few journal articles that topical (not IV) lidocaine can blunt the cardiovascular affects of intubation. Would it then be a good idea to apply topical lidocaine to these unconscious patients in the event that ETI is deemed the only appropriate means of oxygenating and ventilating a patient with TBI and ICP? Again, I will reiterate that I mean ETI in these patients as a desperate means of oxygenating and ventilating, not routinely. References: Williams AM, Ling G, Alam HB. Damage Control Resuscitation for Severe Traumatic Brain Injury. InDamage Control Resuscitation 2020 (pp. 277-302). Springer, Cham. Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Archives of Surgery. 2001 Oct 1;136(10):1118-23. ODRIGUES, F., KOSOUR, C., FIGUEIREDO, L., MOREIRA, M., GASPAROTTO, A., DRAGOSAVAC, D., TUAN, B., MORIEL, P., MARTINS, L., FALCAO, A.. Which is Safer to Avoid an Increase in ICP After Endotracheal Suctioning in Severe Head Injury: Intravenous or Endotracheal Lidocaine?. Journal of Neurology Research, North America, 3, may. 2013. Available at: . Date accessed: 05 Mar. 2020.

When we have a patient who is sob and we have decided to put CPAP on, what code and ctas is mandatory even though they are stabilized because of cpap? Is it code 4 ctas 1 always? And are we suppose to pre alert for an RT?

*Updated* Why do we need to establish an IV in a patient with suspected pulmonary edema? If they fit the directive, they more than likely have crackles which would be contraindicated for a fluid bolus.

If a dentist administers nitroglycerin to a patient who has no previous-prescribed use; does this constitute prescribed use at this point?

What is the difference between medical and traumatic electrocution?

According to the new SWORBHP protocol release May 8th, 2020, IntraNasal Administration is still prohibited (for pain control in the pediatric population & seizure Control) even though it has been deemed as a NON AGMP in said document. 1) Can SWORBHP please re-institute these options since it is no longer an AGMP? 2) Could SWORBHP now consider the addition Midazolam I/N to the combative patient protocol (especially in dealing with the violent post-ictal patient) which would greatly facilitate dealing with these extremely strenuous scenarios while in full Level 1PPE to assists in avoiding PPE breach by venapuncture.

So, just to be perfectly clear, as I have heard this in a round-about way from a few sources… We are not to use high concentration/High Flow oxygen via a BVM with a VSA patient without inserting an SGA – so when treating a VSA pt, we go directly to the SGA without ever using an OPA or NGA, correct? And what are our options if the SGA fails after 2 attempts and we do not have any extra hands to ensure a tight seal on the BVM mask – do we ventilate at all, or just administer compressions and carry on?

Question: With the lockdown in place and time on our hands can we contract out an application programmer to develop a more user friendly protocol app. We have updated to the current version and it still takes almost 10 minutes each time to no matter the device to load. Not very functional on a time sensitive ACP call. I’m sure there are plenty of software engineer students out there bored not in school.

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When dealing with a patient who is VSA due to a complete foreign body airway obstruction, what is recommended in regards to ventilations and OPA use (during this COIVD-19 pandemic) since inability to clear the airway is a contraindication of SGA use.

Clarification: all of the info regarding the protocols say “consider”, but all of your response say “should not”. Why can’t BH come out and say do not, at least where other routes of treatment exist? Or maybe a should not with a patch point if you think you have to? There is so much up in the air right now, a little black and white would be nice.

Question: The latest Base Hospital Memorandum from April 6th says we are to withhold suction via an endotracheal or tracheostomy tube unless using a closed system suction unit. Does this mean we are to withhold suction ONLY via endotracheal or tracheostomy tube? Can we suction an airway full of vomit or blood?

Questions regarding intubation. Should we be opting for aggressive airway management with intubation or SGA on VSA patients as well as severely obtunded non-asthmatic patients where patient presentation would allow? Should this take precedence over ACLS drugs during cardiac arrest? When intubated with inline filter in place are we permitted to BVM an normal rate?

In a previous response to a question, it was mentioned that the SGA is an effective way to create a closed system and reduce risk of aerosolization when ventilating. Would it then be reasonable to go directly to the SGA in the setting of VSAs, to further protect all those involved in the resuscitation from possible aerosolization with an OPA/BVM?

How should I proceed if the patient Im treating tells me that they have already self-administered Gravol, within the past hour, but has since vomited multiple times. Do I proceed with IV Gravol as she has likely thrown up her self-administered dose?

*UPDATED* Question: Regarding the removal of “inability to ventilate” consideration for narcan. In a pt who fails the covid screening, and who has overdosed on opiates, spontaneous resp rate <8, low says. Are we to withhold BVM and apply hi-flo mask at 8L and give narcan? Or use BVM as usual to assist ventilations prior to narcan administration. Its the use of the BVM in this pt that is the question

Question: The latest Memo regarding oxygen delivery states “IN ALL CASES where adult patients require high concentration oxygen, use high-concentration/low flow masks with a hydrophobic submicron filter” and then later reads that high concentration oxygen be avoided unless SGA. The instructions for the FLO2MAX mask our service carries instructs you to set the oxygen flow-meter to 15lpm, or to level prescribed by a physician. What do you recommend we set the flow meter at if we use these masks?

Question: What is the best method to cover the King LT suction port? You mentioned this practice during your 2nd podcast.

*UPDATED* Question: A work email came out on April 8 2020 that lists OBHG recommendations. On the list it states to withhold BVM ventilation in all spontaneously breathing patients that do not improve with BLS airway maneuvers and high conc/low flow mask with filter at 10L/min. A site from OBHG on March 20 2020 states to use BVM in patients with a resp rate < 6 or >40 and sats below 85% with oxygen or ETCO2 >50 and increasing by 5 %. I have also read to limit flow rates no higher than 5 L/M on April 8th it mentions 10 L/M. Can you please confirm a change has been made?