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: 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

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

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.

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?

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?

*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?

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?

Is a suspected pelvic fracture a contraindication to IO in the tibia?

My question comes from the Medical Cardiac Arrest Directive and specifically in relation to the clinical considerations section. I have two questions relating to this.

First of all, the medical directive lists medication overdose/toxicology as a circumstance where the paramedic can consider very early transport after the 1st analysis. My question is can this also apply to overdoses from recreational drugs? It touches on cardiac arrest with associated opioid overdose but doesn’t go into great detail besides the role of naloxone in these circumstances.

Secondly, it lists pediatric cardiac arrest as a situation where we the paramedics are to plan for extrication and transport after 3 analysis. However due to the rarity of this circumstance and the likelihood of its origin resulting from a reversible cause would the paramedic be correct in transporting these patients immediately following the 1st analysis?

For a VSA patient who is in refractory vfib after 3 analyses, can we call BHP for double sequential defibrillation if we have a second PCP unit?

For pediatric patients, are we supposed to get orders solely from pediatric physicians or can we get orders from physicians an adult ED? Are the pediatric physicians also in the base hospital program?

Wondering what your thoughts are in regards to administering nitro to a patient with atypical angina symptoms and no presentation of chest pain. For example, is it ok for us to administer nitroglycerin if a medic is presented with a female patient who states she becomes nauseated from angina and explains she is prescribed nitro for the symptom? I discussed this question with my colleagues and I have found there is a 50/50 split in regards to those of us who would use nitro or not. I think it is a good question to ask given the differencing of opinion in the field.

If patient receives ASA from a certified provider, such as but not limited to other paramedics, doctors/nurses from clinics, are we required to administer another dose of ASA to the ACS patient. Also, does the patient have to have chest pain to administer ASA?

How do I properly patch for rolling medical TOR or cease resuscitation order, especially in instances involving a public place?

If I am in a first response truck and have no shocks, do I have to wait until the transporting unit gets there to call for a TOR or can I call when I meet all the criteria?

Our directives state that we are allowed to administer 2 doses of epinephrine to a patient suffering from a severe allergic reaction and 1 does to a VSA patient who is expected to have become VSA secondary to anaphylactic shock. Does this mean we are allowed to give a 2nd and possibly 3rd dose of epinephrine to a patient by following the moderate to severe allergic reaction medical directive post ROSC?

Are there any expected changes coming in regards to transporting an organ donor VSA patient? Is there a more appropriate receiving facility to consider and what should we do with an organ donors body after obtaining a TOR?

Question: I was looking through Ask MAC and there are a few questions pertaining to cardiac arrest and shocks or no shocks of other responders. Are Paramedics are to include shocks delivered by the Fire Department prior to arrival in their treatment of a VSA patient?

My understanding from teachings in 2014/2015 is that if Fire delivered shocks we could count what they did. If they did not, we did not count their no shocks and conducted our own working towards the medical TOR which is also covered in the Summary of Changes document.

The question on ASK MAC seems to say if we trust the responders we can count everything I was hoping for a clarification that can be searched when the question comes up again.

Question: How can someone differentiate between crackles found in Acute Cardiogenic Pulmonary Edema between those found in pneumonia?

Question: What are STEMI mimics and their types?

Question: With respect to the updated July 17, 2017 medical directive changes, are hangings, electrocution and anaphylactic cardiac arrests considered reversible causes of arrest, and therefore subject to consideration for early transport after 1 analysis, OR are they to be run as full medical cardiac arrests/4 analyses, regardless of whether defibrillation is indicated? Thank you.

Question: When running an ALS arrest where the patient is showing a PEA on the monitor with an accompanying high ETCO2, could we assume that this patient is in fact perfusing to some degree and pulses are just not palpable for various reasons (obesity, severe hypotension, etc.)?

Secondly, if the above assumption is correct, would it be prudent to stop CPR provided the ETCO2 remains high and administer Dopamine in hopes of increasing BP until pulses are palpable and BP obtainable; or should the vasopressor effects of Epinephrine be sufficient to facilitate this so just continue with Epinephrine q5 min and CPR?

Question: After consistent review of the new ALS, I just came across something that I am hoping you may clarify for me. In regards to the Medical Cardiac Arrest directive, under the “clinical considerations,” it states that under certain circumstances we transport after first rhythm analysis (and lists some examples). In the old ALS, one of these examples was “pediatrics” but now i notice that in the new ALS, also under clinical considerations, it mentions to plan for extrication and transport of pediatric cardiac arrest patients after 3 analyses. So, does this mean we do not transport after first rhythm analysis for pediatrics and must complete the full directive now?

Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 – 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

Question: CPR guidelines: I understand that we start CPR with a patient less than 16 years old, heart rate less than 60 and signs of poor perfusion, agonal respirations as per the CPR guidelines. My question is if we have the same situation with an adult patient, what would be beneficial for this type of patient (CPR)?

Question: Can calcium gluconate be given through a CVAD? The patients requiring it (usually dialysis patients) often have difficult IV access, unstable veins and some sort of CVAD in place. If access of the CVAD for administration of fluids and cardiac arrest meds has already been performed, are we still required to start an IO for the calcium gluconate or can it be requested of the BHP to administer through the CVAD with proper flushing before and after?

Question: How many analyses would you perform on a patient who is VSA following a drowning. Is it considered special circumstances, should the patient be transported after one analysis? Or should we transport after the first rhythm that doesn’t result in a defibrillation? How many shocks total if patient stays in a shockable rhythm (4 max or more)?

Question: I am just wondering if ASA is contraindicated for patients taking Pradaxa?

Question: When attending to a medical VSA, where our monitor energy settings are preprogrammed (120J, 150J, 200J, 200J), if I happen to dump the first charge (non-shockable rhythm), should my second charge be at 120J or 150J? This second charge would be the first shock (assuming shockable rhythm), but the second analysis.

Question: While enroute to the emergency department with a VSA patient, if your patient presents in shockable rhythm (either new, or still in a shockable rhythm), can we continue to shock the patient without pulling over? My understanding of the reason for stopping was because we used to use semi-automated systems, and we did not want false interpretations based on artifact. But, if we are now interpreting the rhythm, and determine that it is a shockable rhythm, not artifact while in transit, shouldn’t we be shocking?

The OBHG companion document states to stop when enroute using semi-automated system, no wording on manual defibrillation.

Question: Hello, When a crew arrives on scene and finds a patient VSA, the ALS and BLS Standards require CPR per the HSFO guidelines at 30:2. When considering that there is strong evidence showing high quality CPR is the most important care to impact patient survival, my question revolves around what care or priorities should be considered when there are just the 2 paramedics on scene awaiting additional crews or resources.

The questions specifically are:

1) While Early defib, high-quality CPR and BVM ventilation’s are a must, should an IV and medications be attempted with such limited resources? In attempting to do so, there is strong likelihood of compromising the quality of CPR because the compressor is doing about 2 compressions a second, and the 2nd medic is ventilating about every 15 seconds, thus making it next to impossible to perform any other tasks without diluting the CPR quality. This should the early defib, High-quality CPR and BVM ventilation’s be the only focus until more resources show up, or should the IV and medication process be attempted to satisfy the requirements of the directive, even if doing so will compromise the CPR quality?

2) In regard to #1 above, when working in a rural setting, in which allied resources can sometimes take upwards of 20 minutes to arrive on scene, how does this play into the care?

3) As a given, I would love to be able to meet all the requirements of the ACP Cardiac arrest directive effectively, but with only 2 paramedics on scene the problem is there is just so much to do, and with quality of CPR and ventilation’s/ETCO2 being able to be monitored and recorded, you can either violate the directive to maintain high-quality CPR, or risk having this data show your CPR quality was not great but got “everything done”. Which is the preferred method of care?

4) While there is evidence supporting that CPR saves lives, is there any strong evidence supporting that the IV/Meds and the Advanced airways lead to better patient survival?

Question: Pushing a dose epinephrine seems to be very popular in the FOAM world for emergency physician. Its use has been promoted for things such as post cardiac arrest, refractory anaphylaxis, and severe bradycardia (some strong pharmacology reasons supporting it over atropine have been presented). Is this something you see being added to the advanced care paramedic treatment options at some point?

Question: The IV Therapy Medical Directive lists hypotension as a required indication for a fluid bolus. In pediatric medicine, blood pressure is rarely used alone as an indication of perfusion and tends more to rely on looking at the overall presentation including: level of awareness/activity, heart rate, capillary refill etc.

If presented with a child who is: irritable, tachycardic (or bradycardic for that matter), with delayed cap refill, and decreased urine output, but is not hypotensive (<5th percentile), is it permissible to administer a fluid bolus?

Question: I was faced the other day with a question by one of my fellow peers in regards to the administration of nitroglycerine. As a contraindication, it states that we cannot administer nitro of the SBP drops by one third or more of its initial value after nitro is administered. This can be interpreted in 2 different ways, as brought to my attention by my fellow peer so now ever since, I second guess myself. So my question is, this “initial value,” is it the very first BP we take even before the first dose of nitro, or is it referring to the initial BP you take AFTER the first dose of nitro. It is such a simple answer I am sure but if I can get clarification so I can also relay the message to my fellow peer that would be great.

Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Question: When administering a fluid bolus, are we to give the full bolus amount (i.e. 1000ml for a 50kg patient) reassessing for fluid overload or return to TKVO when the BP reaches 100mmHg or greater? Given so much fluid shifts, administering the full bolus when no fluid overload is present (either 10 or 20ml/kg), particularly with the septic or preload dependent patient would be beneficial.

Question: How is the DNR standard in the BLS PCS reconciled with this statement in the ALS PCS: “if a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated).”

Obviously the ideal situation is that the patient has the DNR confirmation form and there are no issues. The issue comes up with regards to verbal DNRs issued by a capable patient or SDM (that are reasonable), or in such cases where the patient has a DNR, living will or other advanced directive that specifies the patients wishes, but no prehospital DNR form. Is this form not redundant provided there is a reasonable indication that the patient does not wish to be resuscitated or have aggressive life sustaining therapies delivered?

How can the BLS PCS DNR standard be reconciled with the ALS PCS regarding honouring a prior capable wish when the provider is made aware of such wish (provided its reasonable)? Especially given that in nearly ever other case, a directive in the ALS PCS over-rides the BLS-PCS. Given that this issue is not nearly as cut and dry in reality, or in any other healthcare setting, as it seems to be made out to be in EMS in this province what is the situation with regards to this? Especially given that end-of-life issues are increasingly common, the issue is not going to disappear. There are many other provinces that use a similar wording or philosophy to that mentioned in the ALS-PCS under consent and capacity.

Question: I am a ACP student and was discussing among my colleagues the proper time frame for vitals and drug administration for morphine and NTG in the cardiac ischemia medical directive. I understand that each drug has a 5 minute intervals but someone had mentioned that you could stagger both drugs in 5 minute intervals, for example after administering a third NTG wait 5 minutes then morphine then wait 5 minutes then NTG etc. I was wondering what the preferred interval for vital signs and drug administration would be with two drugs staggered at 5 minute intervals.

Question: My question is regarding fluid bolus for DKA. There seems to be varying belief on whether or not a DKA patient must be hypotensive to administer a bolus. There is no specific language that I can find addressing bolus protocol for DKA other than the mandatory BHP patch point if the suspected DKA pt is 2-12yrs old, but this is listed under the NaCl fluid bolus protocol where hypotension is a condition for treatment. Just looking for a little clarification on the entire DKA bolus protocol.

Question: As per the question posted Feb 5th, 2014, if the FD shocks a patient prior to our arrival, we may count that shock into our protocol assuming we deem their care to adhere to AHA guidelines. In that setting, do we dial up to our second shock dose, or start at our first shock dose and dial up appropriately after that?

Question: After the recent introduction of Narcan for PCPs, I’m still a little confused about the role of Narcan in an arrest. The 2010 AHA Guidelines state there is no role for Naloxone in cardiac arrest but the 2015 Guidelines are less prohibitive, leaving some room for interpretation. I understand that where there is question whether the patient is pulseless or not, there is a role for naloxone in the setting of presumed opioid overdose but what is the direction of base hospital for the use of naloxone where there is definite absence of vital signs in the setting of a PCP-only arrest. Is it the expectation of the base hospital that PCPs attempt to administer naloxone at some point during that call? If so, when during the cardiac arrest protocol? On scene or en route to hospital?

Question: If a pediatric patient is significantly larger than expected (for example, a 6 year old female who weighs 120lbs), do we still use the pediatric dosing chart OR calculation OR adult settings? Personally, if I’d done this call today, I probably would have chosen to use the pediatric calculations of 2J/kg then 4J/kg etc.

i.e.: If using peds dosing chart, this 6 year old would only get a shock of 50J 100J 100J 100J

i.e.: If using peds calculation, she would receive 110J 220J 220J 220J

i.e.: If using adult settings, she would receive 200J 300J 360J 360J

Question: If you have a ROSC and the patient re-arrests and is now in a shockable rhythm do you shock at the next highest setting or do you revert back to 200 joules?For example, if one shock delivered on scene for an adult at 200J, then ROSC, then rearrest – next shock (as I suggest) would be 300J.