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

In the case of a workable drowning VSA, that is not in a shockable rhythm, would it be in the best interest to call for a TOR, preform 20 minutes or resuscitation or transport early? Would this fall under extenuating circumstances?

If a combined crew configuration of PCP and PCP expanded scope (IV) attend a VSA that will be transported and it is the PCP’s turn to attend, can the PCP attend it en route to hospital or should the PCP expanded scope have to take over in case of a ROSC with need of bolus?

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.

What is considered suspected cardiac ischemia? Is it just the presence of chest pain/ discomfort (heaviness or tightness). Are chest palpitations considered a chest discomfort as well?

If we have an asthmatic patient that is refusing transport to the hospital after administering salbutamol, should we still proceed with dexamethasone administration?

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?

With the new protocol books for ACP: under the hyperkalemia directive there is no dosage of salbutamol. Was this a printing error or are we no longer giving salbutamol. 

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)? 

Are ACPs still allowed to do EJs on patients that we are unable to get IVs on? 

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.

Refractory V-fib for the new medical cardiac VSA directive. Are we to only get our three shocks and go. Or can we give an additional shock if time permits due to extrication or extenuating circumstances? Just looking for 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?

Can you please clarify the CPR ratio for different ages with the new neonatal resuscitation changed from 30 days to 24 hours. At what age are we performing 3:1 CPR, 15:2. and 30:2?

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?

Why is diabetic ketoacidosis different than hyperosmolar state?

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?

Why are we waiting to implement the cardiac arrest medical directive changes until Feb?

For ALS-PCS 5.0: If a patient re-arrested prior to extrication, do we carry out another 20 minutes of resuscitation or do we go after first analysis?

Can I attempt the Valsalva on a patient who has chest pain? What if the patient has a clear onset of palpitations, then after onset develops chest pain and or shortness of breath?

My question is in regards to when an IV certified medic is working with a non-certified medic. If the certified medic establishes IV access and has a lock in place, but doesnt give any fluids or medications can the non-certified medic still continue to attend the call? Or does the certified one become the attending. Specific example would be a Code Stroke where we established IV access prior to leaving scene, but it was originally the non-certified medics call.

Should we consider cocaine induced chest pain as ischemic and be treating with ASA and NTG? Example: 20 year old male patient midsternal chest tightness. Admits to using cocaine and the symptoms occurring after that. I guess my question is, is the cocaine causing ischemia which causes the chest pain?

hello when treating a pt with adenosine the contra indications are active bronchial constriction on exam, the companion document also states that adenosine can cause bronchial constriction in asthmatic pts. so may question is … is an asthmatic pt contraindicated for adenosine tx or is more of a relative vs absolute situation

When administering a fluid bolus to a cardiogenic shock patient, what is our targeted systolic blood pressure? Is it similar to that of a ROSC to target 90 mmHg, or reversing hypotension and targeting 100 mmHg?

Is it safe to use blanket warmers in the vehicles for warming IV fluids? I know that the infusion of ambient temperature (21°C) intravenous fluid may be a significant risk factor for severe hypothermia and the manufacturer of our IV fluids recommends a 40 °C for a max of 14 days. Do you know if this is being done anywhere effectively and safely and if so what are they using?

So we had a call to a burn victim that was grossly charred, but was breathing. He started to deteriorate in transport but we made it to the hospital. I was wondering if he were to arrest if that would be a traumatic VSA, I know it’s not a blunt or penetrating trauma but it doesn’t make much sense as a medical cardiac arrest either. Also could a patient meet the standards for an obvious death after patient contact?

If a patient is given first time Nitro by a PCP IV but then isnt ever actually prescribed nitro by a doctor does this count as prior hx of nitro use? Could a then PCP non IV give this pt nitro the next time they call?

Does cpap have to be used with nitro

Hello, How would you like us to proceed with a young pt (say under 30) who complains of chest pain and describes it as ischemic pain, saying all the right things ex; pressure, heaviness etc. But who is vitally stable and doesnt not appear to be in any distress or severe pain. Would you still like us to treat it as ischemia on the side of caution even though its most likely anxiety/stess etc ?

If an IV medic attempts to start an IV on pt and the attempt(s) are unsuccessful do they have to remain the attending medic or can the non IV medic continue to attend the call?

Hello, I have a question regarding the 4th analysis when youre actively calling for a medical TOR. If theyre around Ill speak with family to give them an update on what weve been doing, that Im going to call and doctor and what the outcome of that phone call may be. Often, after Ive had that chat, and made the call by the time Im back the 2mins has passed and a 4th analysis may have been done by my partner. What would you like to see happen there. Do we perform that 4th analysis or is that only performed just prior to departure if were transporting. Thanks for your help.

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?