For pediatric VSAs, at what heart rate do we initiate compressions?

Question: If respirations are at or above 28, historically paramedics are taught to assist via BVM. What is the rationale with pulmonary edema to apply NRB with tachypnea instead of assisting with a BVM until CPAP and or nitro is prepared?

Question: Multi-part question on croup. I’ve heard that croup is becoming more prevalent in older children (8 years & up). What is the incidence of croup in older children, and how would their treatment differ in the ER from the < 8 year old group?

Question: I was taught that if there is some clinical improvement, when using CPAP, we are not to titrate the pressure any higher. I understand the rationale for this, however my question is, are there clinical guidelines that quantify a patient having sufficient “clinical improvement”?

Example being a patient breathing at a rate of 34 bpm with accessory muscle use, sp02 of 85%, audible crackles through all 4 lobes. With CPAP applied at 5 cmH20 vitals improve to RR of 28 bpm, sp02 of 91% and crackles remain. This patient has had a degree of improvement but would it not be advisable to titrate the pressure 2.5 cmH20 higher (after 5 mins) to attempt to further normalize the patient’s VS and clinical condition? Or is the goal to increase the sp02 above 90 % with no accessory muscle use and decrease RR below 28 bpm as the directive lists these as conditions needed for application.

Question: We are instructed to get the nitro in, if applicable, apply the CPAP and if there is improvement, do not remove the mask for additional nitro sprays. Is the improvement slight or significant? If slight improvement, do we leave the pressure at the slight improvement pressure or titrate 2.5cmH2O?

Question: Regarding Benadryl, in the auxiliary protocol it states that you cannot give Benadryl if the patient has taken a sedative or antihistamine in past 4 hours. This is not, however, indicated in the normal standing order protocol for Benadryl.

I am wondering if this is applicable as well if you arrive on scene with a patient who has taken Benadryl oral prior to your arrival. Do they still meet the protocol to give Benadryl even if they have already taken it? Should I still give it or withhold since they might have an overdose of Benadryl or have both the doses reacting at the same time? Would this also apply to a patient who has taken Gravol prior to EMS arrival as well?

Hope this can be clarified. I feel it’s a grey area that most of us don’t think about until put in the situation. Thanks.

Question: In a patient with an allergic reaction or anaphylaxis, who is experiencing nausea or vomiting, is it okay to treat them with Gravol after I have administered Benadryl?

Question: CPAP for CHF and COPD is to maintain a constant pressure in the airways (splinting with COPD) and to help push the fluid out of the alveoli and into the circulation with CHF. Would paramedics who do not have CPAP available be wrong, if the patient is conscious and tolerates, assist each inhalation with a BVM to increase tidal volume and create more positive pressure during inhalation, although not maintained with exhalation, in an attempt to force the fluid out with CHF. Debate is that we assist the ventilation at one breath every 5 seconds or 12/minute unless hyperventilating due to head trauma and respiratory problems with coning of the pupil(s). Thanks for the assistance.

Question: VSA trauma patients – chest compressions and defib is the priority for this patient. C-spine maintained manually. In this scenario, is it mandatory to apply a collar prior to a shock being delivered as the manual c-spine must be removed to deliver the shock?

CPAP- indication b/p 100 or above systolic. Contraindication is hypotension. If CPAP is applied while normotensive, can we leave the device on until they become hypotensive or we must remove when b/p drops below 100? Thanks.

Question: In regards to the bronchoconstriction protocol, in order to administer to Epi, the patient must require BVM ventilation and have a history of asthma. What if the patient is alone or they are so short of breath that a history of asthma cannot be obtained? Or possibly this could be their very first asthma attack without an actual diagnosis yet?

We were dispatched to an 8 year old with asthma experiencing SOB; on arrival no wheezing present, lungs clear, no obvious respiratory distress noted, sats at 95 RA; 100 on o2. Mom states he takes puffers but his doctor never actually told her that he has asthma. I found this odd since he is on ventolin and steroid rescue inhaler. If that scenario was different, and we did have to bag him, we absolutely can’t give this patient Epi due to the fact that the doctor never confirmed he has asthma even though he is prescribed inhalers? Is this correct?

Would a BHP patch be appropriate for an order, knowing that his air entry is diminished and the probable cause is severe bronchoconstriction, most likely due to asthma but not confirmed by diagnosis according to parent?

Question: I have heard from our base hospital that MAC is considering removing KING-LT airways from the directives? Is this true, and if so, what supraglottic rescue airway option are they looking at going to, both for ACP’s and PCP’s. Not every patient can be ventilated using BVM alone.

I’ve also heard that they are looking at removing needle cric and intubation from ACP scope? If this is true, then why? Intubation does have major problems in the pre-hospital setting, but outside of cardiac arrest it is a very valuable method of controlling the airway (the gold standard) especially for long transport times or complex patient presentations.

Finally, I understand the theoretical rational behind not using CPAP in asthma PTS, but there are services in North America using it for end-stage asthma exacerbation as a option before intubating the patient. They combine low levels of CPAP (3-5 cmH2O) with a salbutamol nebulizer tied in line to the CPAP mask and are getting good results.

Is there any possibility of a clinical trial of CPAP in asthma exacerbation refractory to salbutamol/epi alone? Is there evidence against using it in asthma (besides theoretical problems).

Question: Could you clarify the Bronchoconstriction directive (epi for asthma exacerbation)? You have to be bagging the patient to give the epi. Our old directives said “any patient with severe SOB from suspected asthma exacerbation AND requires ventilatory support via BVM and OR severe agitation, confusion and cyanosis” but our new directive just says BVM required with history of asthma. I just want to be really clear, now we MUST be bagging them?

Question: This question is regarding advance airway. I really don’t like the basic airway first then if there is a problem, now go to the advance airway, ie: intubation, I have had saves due intubation right away. Once the vomit starts it’s very hard to control the airway or intubate, during CPR, the vomit can come out in excess amounts that the suction cannot keep up with, let alone if by chance you do get a save, the patient dies of aspiration pneumonia later! Yes it’s a paramedic’s discretion to intubate or not, if you have a good seal with a basic airway and an IV you can run a code, and it’s also said intubation stops CPR, well all the CPR in the world won’t help if the airway is uncontrolled. This ROC survey with basic airway for the first 6 minutes can really cause a negative patient outcome if he vomits in excess. Well at least my compression stats are good!!!! Maybe this should be discussed in the next recert. Signed an ALS Paramedic.

Question: If a patient meets the protocol for having CPAP treatment but they have a valid DNR Confirmation Form can a PCP still administer CPAP?

Question: In regards to the bronchoconstriction protocol I was recently in a discussion with a coworker disputing the 5-15 min dosing interval. The question was does this interval begin when treatment begins or once a treatment is completed. For example nebulized ventolin may take approximately 5 mins to fully nebulize could I administer a second treatment immediately or would I have to wait 5-15 mins post completion of a treatment. Clarification would be greatly appreciated.

Question: We had a patient who presented with bi lateral crackles and patient was in obvious distress and fit all of CPAP criteria, however the patient had a temp of 38.5. I remember that during our training it was clearly demonstrated that a patient with pneumonia is contraindicated for use of CPAP. Upon looking over the protocols it is not mentioned as a contra indication. Would CPAP be an appropriate treatment? If so would it still be appropriate if this patient was suspected of having pneumonia a few days prior by nursing staff. Thank you.

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

Question: After 3 treatments of Ventolin be it MDI or NB i was understanding that we could patch for another 3 treatments if needed. I have spoke with other medics and some say yes and some say no could you please verify.

Question: In the area in which I work, there exists a statistical cluster of clients with Myasthenia Gravis. One client that I have now transported at least three times has got the message to call at the first sign of increasing SOB. Most recently he woke up at about 0300 feeling a bit more SOB than normal and not quite right. When we arrived at his house at 0600 he met us outside ambulatory and he had a temp of 39.8C. He was tachypneic. He was in respiratory distress related (In my opinion) to both his MG as well as pneumonia. He adamantly refused the stretcher. He stated that as per his directions he had taken a dose Mestinon when he awoke and that it had not helped. He had a weak or pretty much absent cough. He was placed on placed on high flow O2 by ‘Flow Max’ and was given at least one Ventolin treatment again using the ‘Flow Max’. His condition improved slightly. He was transported with great haste. I have reviewed MG as well as the action of Mestinon. At this point in his disease process he is still requesting that all that can be done be done. Do you have any suggestions as to how we can better care for this client? Putting headers on the ambulance, installing ‘NOS’ or a spoiler is not an acceptable answer. Is CPAP a possibility? I am aware that pneumonia is a relative contraindication for CPAP use. The mechanism of the two disease is quite different but the inability to expand (active muscle use) the chest seems to make them similar. I have attempted to reseach an answer and the best I have gotten after talking with a couple of ED Docs is, ‘Good question. Might buy you some time. How fast can you drive?’ Thank you for your time in considering and answering this question

Question: If the patient requires ventolin and has a fever but cannot tolerate the mdi, would it then be appropriate to use the nebulizer.

Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient’s spo2 31 and 42% with mottling noted. Patient’s initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient’s GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?

Question: Just some clarification in regards to DNR’s. If a patient is having an episode of an exacerbated Asthma and has a valid DNR, do we administer Epi for the asthma? I understand that we cannot “bag” the Patient due to the DNR status.

Question: In the case of a patient who is in obvious respiratory distress with wheezes audible once you make patient contact (i.e. without auscultation), is it necessary to administer o2 via NRB first? Obviously these patients are in need of salbuMtamol and can not tolerate an MDI and spacer. The time it takes to first put on a NRB and then set up a nebulized treatment seems counter productive. Can we start with a nebulized treatment and then apply o2 via NRB after the 1st treatment while we reassess the patient?

Question: I have heard paramedics inquiring amongst fellow paramedics about the use of epi without a cardiac monitor applied or a full set of vitals when dealing with a patient who is suffering from anaphylaxis. My stance is that all meds (except ASA) require a full set of vitals and the cardiac monitor applied. Please clarify.

Question: With regards to the CPAP protocol, one contraindication is a tracheostomy. If this was just temporary and the tube had recently been removed, would CPAP be able to be administered?

Question: For a patient with fluid building up in the lungs (recently having the same issue and having to have fluid drained via chest tube) due to a complication of CA, what is the best course of action? It wouldn’t seem that a bronchodilator wouldn’t be effective and since the fluid is of non-cardiogenic nature would nitro work?

Question: Since we’re now able to administer Epi for VSA Anaphylaxis, why are we not able to do so for Severe Asthma VSA?

Question: On page 11 of the new Medical Directives it states that vital signs have been kept constant throughout the directives and that any exceptions are clearly noted in each directive. Tachypnea is defined as 28 or > however, I noticed confusion amongst peers stating condition for CPAP was still at 24b/m or >. New protocol simply states tachypnea as the condition. Please clarify