If patient is experiencing chest pain and all signs/symptoms lead to suspected cardiac Ischemia, and considering ASA. Patient has a history of sensitivity to ibuprofen however takes ASA daily as well as patient took own ASA prior to EMS arrival Am I still alright to administer my own ASA even though patient has hx if sensitivity to Ibuprofen but takes ASA daily?
is there any consideration(s) to move away from the ” double syringe method” to a single syringe method for adenosine ?? – using 20 ml or larger syringe meaning adenosine mixed with ns and then pushed as 1 dose – medication and flush ?? various studies have shown that is effective, less operational stressors , and easier to manage then attempting use a stop cock valve, ns line wide open with flushes, etc
Revisiting this question from 2020…For a VSA patient who is in refractory vfib after 3 analyses, can we call BHP for double sequential defibrillation (or vector change pad placement) if we have a second PCP unit? This question is asked in the updated context of Dr Cheskis’ DSED study and other Ontario Base Hospitals having already implemented this practice.
Crew responded code 4 to possible allergic reaction. PT was a bad historian, who states he has a chest pain post being stung by a wasp. Pt had swelling on the left side of his lower lip where he got stung. PT complains of dizziness/lightheaded. PT had no adventitious sounds in the lungs. PT complained of mild nausea with no vomiting. No incontinence. PT complained of weakness as well. During the assessment, pt complains of chest tightness post the wasp sting, all the answers to CP questions were leading the crew to believe that patient was experiencing ischemic chest pain. Pt states he has hx of allergic reaction to bee sting. Vitals: 58, sinus bradycardia with LBBB in 12 leads noted. BP: 86/42, RR 22, Sat of 90%. In this case, pt is showing signs of anaphylaxis with multiple symptoms being affected and known allergen exposure, but complaining of ischemic sounding chest pain. Is the crew to be treating with Epi, or should the crew withhold the epi as patient may have ischemic chest pain and it can worsen the cardiac symptoms?
If a PCP crew has a RN onboard from a previous transfer and is assigned a VSA call what is the base hospitals position on said nurse providing ACLS care such as Epinephrine administration if their transfer bag has the medications. What about if a RT is in a similar position when it comes to airway management?
The directive now states that we are to initiate transcutaneous pacing immediately if the pt is severely symptomatic/pre-arrest and not delay for IV access or atropine, etc. If they are in a spot that requires a lifting chair to extricate, should we wait until they are on the stretcher to initiate it or initiate then discontinue for extrication, reinitiate, etc. Then how would you like us to move the pt to the stretcher?
Nitroglycerin – SBP drop by one third. Is this a 1/3 drop directly after a dose of nitroglycerin or a cumulative drop after multiple doses/sprays? My understanding was that this 1/3 drop in SBP was being used to determine the pts sensitivity to nitroglycerin. If the pt had mild/moderate SBP drops after each dose it indicated that the pt tolerated nitro well and it was safe to give higher amounts and more doses. However, a large 1/3 drop immediately after a dose of nitro meant that the pt had a high sensitivity to nitro and further tx should be discontinued for pt safety and impending hypotension. Scenario: Ischemic chest pain (Non-STEMI) with an initial SBP of 180mmHg. 1/3 dictates a drop of 60mmHg. After 4 sprays of nitro (with mild SBP drops between each dose) the pts SBP is now 115mmHg. Is this pt exempt from further nitroglycerin because cumulatively their SBP dropped by more than 1/3 OR can I continue to treat because a large 1/3 drop was not seen following an isolated spray of nitro.
Is there a reason why epinephrine dosing intervals in cardiac arrest patients is set to q4min instead of q3-5 minutes as per AHA guidelines? By having them set at q4min, it puts the provider in stressful situation trying to sequence the doses at a speicific time rather than a range as suggested by AHA.
Hello, I was hoping you can put my overthinking mind at ease. I responded to a traumatic vsa. Single stab wound to the chest with the knife still impaled. Single stab wound to the lower left side of his chest(left of his nipple). He was asystole, very rigored at the jaw but no other obvious signs of “ Obivously Dead Criteria” My question is technically can we deem that enough to not continue resuscitative efforts? Or do they need gross rigor mortis at the extremities or lividity to call it? We decided to run the call as we did not feel comfortable calling it with just rigor at the jaw. Removed the knife as it was impending CPR, applied an asherman seal, rhythm analysis revealing asystole, double NPA with two handed seal and adequate ventilations with equal chest rise and fall with good air entry(did not needle decompress), end tidal of 20-22, IO access and transported. Arrival at the ER, got odd looks from ER team and got questioned why we transported someone who was rigored at the jaw and explained to them that we did not have enough to pronounce them on scene. Hoping you can give some clarification on this challenging scenario and whether I could’ve done that call differently. Thank you!
When giving Epinephrine for anaphylaxis is it expectable to delay administration of diphenhydramine following the first dose of Epinephrine if it is getting close to the 5 minute dose interval for the second dose of Epinephrine and the patient is requiring the second dose of Epinephrine? My understanding is that Epinephrine in anaphylaxis is the priority medication and I could use clarification as to whether or not it is okay to delay administration of diphenhydramine until after the second dose of Epinephrine if the patient requires a second dose and we were not able to administer diphenhydramine in between the required 5 minute dose interval for the second dose of Epinephrine.
Hello, some further clarity/confirmations on the trauma cardiac arrest algorithm is still needed for a rather large group of paramedic students. Note, some of the “greater/less than” symbols in your previous replies show up as papyrus-esque and cannot be deciphered. Please reply with words only in case that issue repeats itself. -A patient with penetrating trauma to head/neck/torso in asystole (and no signs of life): if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, we still patch for trauma TOR, right? Or do we transport to that nearest regular ED? -A patient with penetrating trauma to head/neck/torso in PEA: if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, do we patch for trauma TOR (due to over 30 min transport time to LTH) or do we transport to that nearest regular ED that’s 15 min away? -A patient with a blunt trauma and asystole (and no signs of life) automatically gets a patch for TOR, right? -A patient with blunt trauma in PEA would only get a patch for TOR if there was no hospital (regular ED or LTH) that was less than 30 minutes away? Ie. Only patch for TOR if either ED or LTH were both over 30 minutes away. Thanks!
Hi MAC, hope you folks are well. I was curious if you can provide clarification and potentially rational to the “Mandatory Patch Point” for Medical Cardiac Arrests. Although I understand calling for termination or potentially further direction, I am curious if we have to BHP patch if the attending Paramedic feels the Pt in cardiac arrest [that fits criteria for TOR] would benefit from transportation for any variety of situations (age, geo. location, ect.). It seems it would be counter-intuitive to spend the time calling an MD to tell them we feel transport would be beneficial for a Pt (especially if ready to transport) instead of initiating time critical transport + our active resuscitation efforts. Would a BHP ever say no, do not transport this Pt, regardless of potential ED Tx benefit? I recognize this is an odd question that is a rarity, but I’ve found myself in this position more than once and am wondering how to efficiently tackle these situations in the future without a potential protocol violation. Cheers MAC.
As a PCP I am trying to get a better understanding of what orders a BHP can give and when certain orders may be considered outside our scope of practice. My understanding has always been that deviations can be made to most areas of a protocol like age, RR, SBP, LOA, contraindications, dosing levels, # of doses etc., but what about treating conditions or diseases that are not written into the protocol? ex. Tylenol for fever, Glucagon for beta blocker toxicity, energy for SVT or Ventolin for hyperkalemia? Although we are trained in how to use these drugs are we expected to give them for conditions not listed in our protocol, if ordered by a BHP? Thanks
The question I have is about organ donation/transplant. Just had a young person traumatic VSA in which his core body was still intact I just got thinking afterwards that I should I have called base hospital to see if the family would like to donate his organs. Just thought that pt had been young and healthy. Was wondering the proper way to go about it? How long the organs can be without blood flow. How far from London or where do we take the body? Who do you contact. I know the scene is overwhelming and was one of the last things thinking about.
My question is in regards to our traumatic TOR protocol – more specifically, why is a trauma TOR ALWAYS contraindicated for penetrating trauma to the torso or head/neck when the LTC is <30mins away? I am looking for clarification and rationale on this because this contraindication seems to be all-encompassing without taking other clinical factors into account (ie. extent of injuries, pts age, complications of resuscitation, presenting rhythm, medical hx, etc.) For example: I attended a traumatic VSA, <30mins from the LTH. Pt was 90yo with a suspected self inflicted gsw to the head. In this incident there was no definitive time of arrest and the pts presenting rhythm was asystole. Entry wound identified to the head, no exit wound and no gross distortion of anatomy (did not meet any obviously deceased standards). The initial crew was unable to secure/maintain the pts airway due to bleeding in the pts airway - indicating that there was no oxygenation/ventilation during the initial resuscitative efforts. I may be wrong but I believe that this pt arrested due to anatomical injuries rather than exsanguination. This pt sustained grievous injury not conducive to life for which there is no definitive tx. This pt is an extreme case; pt was elderly, on blood thinners, sustained irreversible injury, asystolic arrest with complications during care. However, none of these clinical factors are applied to our trauma TOR. I am reaching out for clarification/rationale as to why this pt should not be routinely considered for a trauma TOR.
I am looking for clarification on whether or not pre-arrival shocks count towards consideration of a medical TOR with the new 20 minute protocol. I have reviewed the companion document and note it does state, “As a general rule, Paramedics do NOT count pre-arrival interventions in their patient care. Care delivered prior to arrival can be “considered” and documented.” I also found a previous Ask Mac response from Dec 22 2017 asking the same question, however the answer was at the time of the previous Medical Cardiac Arrest Directive (4 analyses only). In Mac’s response at that time they did state, “SWORBHP Medical Council believes that ANY defibrillation delivered to a patient during a cardiac arrest resuscitation should be counted and considered as a contraindication to the application of the TOR.” Looking for clarity between these statements and the new protocol. Thanks for the information!
My question is in regards to ASA being a contraindication for the administration of ibuprofen or ketorolac. I understand that ASA is classified as an NSAID, but in a previous ASKMAC, it was stated that ASA in low doses like baby aspirin is NOT a contraindication of the administration of ibuprofen or ketorolac. More specifically, i would like to know if the dose used by medics for cardiac ischemia (160-162mg ASA) should be considered a contraindication for the admin of ibuprofen or ketorolac. If a patient was initially c/o chest pain that resolved itself after ASA and nitro x1, is it acceptable to treat a 10/10 severe headache that the patient has been experiencing intermittently x2 days if there are no other contraindications?
I was just curious about a possible contradiction in the Trauma TOR VSA Conditions/Contraindications. In the updated Trauma TOR Conditions it lists that a condtion as “Signs of life when fully extricated with the closest ED >30 min transport time away”. However in the following contraindications it lists “Signs of life at any time since fully extricated medical contact” as contraindicated for the TOR. My question is, in a scenario of a Trauma TOR eligble patient that has signs of life after full extrication, then becomes VSA, would the Trauma TOR apply or not? Would distance to the hospital come into play?
In regards to the contraindication for NTG regarding SBP dropping by 1/3 or more, should we basing this off the very first BP obtained on that call, or a BP obtained right before NTG usage? Ie. ischemic chest pain 00:00 BP of 180/100 00:03 SBP of 150/90 00:04 NTG usage 00:09 BP 115/75. In this case a 65 (180-115) point drop would rule us out if 1st BP counted, but a 35 (150-115) point drop would not rule us if BP prior to NTG used. As pts can often be particularly stressed/anxious right when we walk in the door, it would make sense to me that the BP closest to actual administration would be most indicative of their true clinical state.
If I attend scene and the patient has already received care outside of the 911 system (i.e. fluid bolus with homecare or community paramedicine), and they are still hypotensive, can I provide further care via the ALS-PCS (i.e. fluid bolus for a hypotensive patient)? Would I only be able to give 20cc/kg IVF bolus including the fluid administered before my arrival?
I need some clarification on the updates to the trauma arrest algorithm. With a patient with penetrating trauma in asystole with LTH less than 30 minutes are we to transport to the lead trauma hospital as we do with PEA? Also, if the lead trauma hospital is greater than 30 minutes, I am assuming we transport to the closest ED with both asystole and PEA with penetrating trauma.
In the companion document under the medical cardiac arrest directive it lists reasons for early transport. Under here it lists thrombosis (pulmonary and coronary). So to my understanding, if we have a VSA we believe to be caused by a coronary thrombosis (a STEMI) we are to do 1 analyze? In the past it has been said that we are to treat a suspected MI VSA as a medical cardiac arrest and run the entire protocol on scene. Can you please clarify?
In a challenging scenario: You respond to an unplanned home birth on a stormy winter day, with a backup unit facing delays due to adverse weather conditions. Upon arrival, you encounter a situation where a baby requires neonatal resuscitation, while the mother remains in a stable condition. Is it advisable to consider leaving the mother on site and transporting the newborn?
If a patient is suffering a medical event in nature, and goes VSA (for the first time, NOT a re-arrest) en route to the hospital, do we pull over and run the arrest for 20 minutes, or would we use clinical consideration that egress has commenced, and do one analysis and continue transport (under the circumstance that pt at that time is in a non shockable rhythm)?
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
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?
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?
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?
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