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.

Question: In the situation of being an ACP making a rendezvous with a PCP crew to assist on a medical cardiac arrest patient that they already initiated transport with and did not arrest on route, would you suggest once we make patient contact to administer 3 EPI q4/lidocaine or amio/saline bolus (depending on rhythms), BHP patch and then continue transport or continue transport and administer epi q4 until transfer of core or ROSC? There seems to be different opinions about this in my service. I appreciate you taking the time to answer.

Question: A patient is presenting with pulmonary edema. Patient became more symptomatic before calling and dyspnea worsened. Upon gathering history and taking vitals, they meet the criteria for Nitro and CPAP. The patient is currently prescribed Lasix for fluid in the lungs from doctor visit one week ago.

With the history of pulmonary edema and being prescribed Lasix for fluid in the lungs, would this now be considered Non-Acute Pulmonary Edema?

I need a better understanding of Acute Pulmonary Edema vs. Non-Acute Pulmonary Edema. The CPAP protocol indication lists: Suspected Acute Pulmonary Edema.

Since the pulmonary edema is non-acute would CPAP and Nitro be withheld? Or, since the symptoms have worsened, provided I can recognize a patient that is truly in need of CPAP and Nitro, would I administer them? I want to clarify – thanks.

Question: Is it advised that when a patient is not adequately perfusing but still technically with a pulse, that CPR be commenced? In discussing this with my colleagues, we are speaking in regards to a patient who may technically still have an idioventricular or agonal pulse and is circling the drain. Instead of waiting the 30 sec-1 min for the patient to be completely VSA, would it not be better to get on the chest and begin compressions in an attempt at increasing perfusion?

Question: My question is in regards to the Cardiac Ischemia protocol. I am currently a PCP student and we had a chest pain call. The patient was complaining of chest discomfort and described it as a pressure starting sub-sternal and going to patients left shoulder. The patient was also experiencing SOB. This pain was a 6/10 when it first came on and went down to a 5/10 with relaxation. The patient did not have a history of angina but had received NTG in the hospital a couple years before and did not know the why. The patient did not have NTG on their own list of meds. We gave 2 81mg ASA and did a 12-lead which was negative for a right ventricular infarct. My preceptor did establish an IV and got a line started set at TKVO before we gave the NTG.

The question is even though the patient did not have NTG on their own med list at the time of the call; does the time the patient was in hospital and was given NTG count as prior history for the Cardiac Ischemia protocol?

I did see a related question on the site but it was related to a doctor giving the NTG before EMS arrival and it was stated that it should be prescribed. So does that mean it has to be a current prescription or can a patient have it in the hospital and it count? I know it does not matter after you get an IV establish but if we weren’t able to get an IV established then would we have been able to give it?

Question: When managing a cardiac arrest as a PCP and following the Medical Cardiac Arrest Medical Directive, if the patient does not qualify for a TOR (shock delivered, ROSC obtained at some point etc.), why is it required to patch to the BHP (Mandatory Provincial Patch Point) for authorization to transport when it is clear that transport is the only option?

Question: Your partner is preparing O2, obtaining vitals and attaching the monitor for a chest pain patient. You are performing a primary survey, gathering your SAMPLE Hx, ruling the patient in protocol for ASA, giving the ASA and doing the same for Nitro. Vitals are obtained 3-4 minutes earlier than the Nitro administration.

From past experience and following the protocol which states vitals q5 min, nitro q5 min and vitals must be obtained within 5 minutes of medication delivery, is this improper as 3 minutes has lapsed prior to the nitro administration? I have been informed that past deactivation has resulted from this?

Question: There was a question posted in January 2012 that asked if CO poisoning leading from VSA would be considered an unusual circumstance and whether performing one analysis and transporting would be acceptable. Medical Councils answer was that this would be analogous to an asphyxial cardiac arrest such as a drowning and hanging. In these cases, the SWORBHP Medical Directors have preferred that the Medical Cardiac Arrest Medical Directive be followed.

This question was asked a long time ago, however, during one of my Base Hospital training sessions, I was told by an Educator that CO (it specifically said) does fall under an “unusual circumstance” and therefore you would transport after the first analysis leading to a NO SHOCK ADVISED.

Can you clarify what should be done?

Question: I have a question regarding congestive heart failure (CHF) and ASA. If a patient is having acute CHF and is coughing up blood but is also having chest pain are they still a candidate to receive ASA given the active “bleeding”. I would think the blood from back up into your lungs is different than the blood from an ulcer or something. Thanks for your help.

Question: I’m a PCP with autonomous IV. It states that a contraindication for a fluid bolus is “signs of fluid overload”. I realize the obvious one is pulmonary edema as that is the example that is always brought up in this scenario. What about a pt that has a clear chest with no fluid accumulation in the lungs, but has peripheral edema in the legs or abdomen? I’ve also had pt’s with hypotension that are on dialysis and have stated that they cannot receive large amounts of fluid due to kidney failure. Do we just document their condition? I’ve heard different answers from everyone and would appreciate some clarification.

Question: There was a question posted on Sep 23, 2014 in regards to a fluid bolus on a transfer between facilities. As I agree that there should have been an RN escort for this patient, the paramedic was certified in IV fluid therapy including boluses. Your answer has me perplexed however. If a physician gave the paramedic a fluid bolus order how would that differ from getting a similar order from a BHP through phone patch. It is in the scope of practice for the paramedic to administer NaCl 0.9% as a bolus, the volume was prescribed by the physician(s) in charge of this patient’s care. Would any paramedic be wrong in following the order given by the physician?

Question: How often should you reassess the respiratory rate for apneic patients?

Question: Last night I had a 75 year old patient calling because he was SOB x 2 days with it worsening this evening. Patient could not sleep (could not breathe very well laying down) and was more SOB on exertion. I could hear fine crackles in the bases of his lungs.

There was no ischemic chest pain or NTG history. His vitals on contact were HR 90, BP 188/70 (ish), SPO2 95% on Room air, 100% on NRB, RR 24 verified with an with ETCO2 of 40mmHg, No ST changes in 12 lead.

He had some slight increased work of breathing on scene with mild increased diaphragmatic use but was speaking full sentences and in good spirits with us. Patient had a history of COPD and CHF. He also stated he had taken some of his Ventolin puffers prior to our arrival with no relief (probably made things worse). I wanted to treat him with NTG but he did not seem to be in enough distress initially, so I kept him on the NRB which he stated help initially. We got to the truck and started an IV enroute, then administered 0.8mg NTG. Literally… within about 2 minutes of the NTG admin, while I was patching, the patient had a sudden onset of severe SOB. We were right outside the hospital, so I grabbed my BVM, assisted his respirations distress until my partner could get us out of the truck and help me put CPAP on. CPAP helped and he was back to normal shortly after our transfer of care.

My question is, should I have used the CPAP right away with the NTG, even though the patient was not showing signs of severe respiratory distress at the time, and on numerous auscultations of the lung, did not have any increase in crackles… until of course, he developed that sudden severe respiratory distress? My gut was to CPAP him early, but I felt he did not fit the protocol yet given his level of dyspnea, SPO2 sats, RR and minimal accessory muscle use.

Question: This question is in regards to timing during a medical VSA. Would your 2 minutes in between analysis restart when you stop to analyse or after you have analysed or shocked? For example, you stop to analyse at 1500:00 and you start your CPR at 1500:10 after shock or no shock, would your next analyze be at 1502:00 or 1502:10?

Question: In which instance should a transdermal patch be removed in the pre-hospital setting? Example 1: Hypotensive patient with a Nitro patch on. Example 2: VSA with a narcotic patch on. Example 3: Suspected OD with a narcotic patch on (or several).

Question: I am a PCP-IV medic who recently transferred a patient between facilities – from county hospital to trauma centre. On arrival I was told by the attending physician that the patient was to be spinal immobilized as a precaution as instructed by the trauma centre. The physician also informed me that the trauma centre requested that the patient receive 1000ml NaCl prior to arrival at the LTC. I inquired about the patient’s vitals and assessed the patient as normotensive with no indications of poor perfusion. I told the physician that my protocols did not permit me to fluid bolus the patient with up to 1000ml enroute unless the patient was hypotensive and remained hypotensive. Moreover the sending facility was not sending an escort on this long CODE 4 STAT transfer. I called my Duty Manager for advice and was told to abide by my directives and follow the BLS standard for IV monitoring – 200ml/hr max pending patient presentation enroute. This is the direction I proceeded with.

My question is – was I correct in my course of action and was it advisable to press the physician for an escort based on the requirements of the LTC?

Question: If a doctor is someone who can assume care of a VSA patient and decide to have resuscitative efforts ceased, then why is a doctor not someone who counts as a witness in the ‘unwitnessed arrest’ condition of a TOR, along with paramedics and firefighters? Thanks in advance.

Question: My question is regarding our chest pain protocol. There is a 48 year old male complaining of chest pain. It is substernal, 7/10, onset 1 hour, provoked at rest, radiates to left arm sitting steady.

O/E patient’s history is hypertension; vitals H/R 78 regular and full; breathing 20x / minute; B/P 138/99; conscious and alert x 3. Patient is not allergic to ASA, so he receives ASA.

History of nitro is in question. The patient states he was in hospital once with similar chest pain and doctor “gave me a spray of something for my chest pain”. When asked if it was nitro, the patient did not know name of medication.

Could this patient receive NTG or should we patch?

Question: I have a question regarding an MCI scenario. There is a total of 10 patients; 3 patients are dead from trauma and 7 patients are cleared off scene from other ambulances. You now have the 3 black tag patients left. Do we need to re-assess these patients and get trauma TOR for each one?

Question: On a recent ischemic chest pain call with an approximately 60 year old female patient, conscious and alert, 2 nitro sprays prior to arrival. The 12 lead was normal and I gave ASA, but decided to withhold nitro as I had difficulty obtaining a BP on scene. The patient had no palpable radial or brachial pulses bilaterally. My partner and I made 4 NiBP attempts on scene with no reading on either arm and manual BP attempts bilat with no sound on auscultation or deflection of the needle. I was unable to also confirm the HR that showed on the monitor as she was uncooperative while attempting a carotid (although present). After extricating the patient on a stair chair, I decided to continue my care with an IV TKVO in the truck. I did not want to delay scene time any further. While in the truck I continued to attempt NiBPs which was now displaying a reading of hypertension, yet no pulses other than carotid were palpable. Although the monitor was always showing vitals within my parameters to administer nitro, I withheld it, as I was treating the findings with the patient, not the monitor. She had stated her pulses were usually weak. She remained conscious and alert with no signs of hypotension other than weak/absent pulses. My question is€¦ was I ever justified to administer a bolus to this patient?

Question: I have overheard a couple of crews recently discussing the ACP cardiac arrest protocol for when you arrive on-scene and a PCP has already initiated their protocol.

I’ve overheard that some crews use what the PCP crew has done (say two no shocks) and then just do two more and either call for pronouncement or transport. I also know other crews that will show up and do their entire three rounds of epi, etc. and then call/leave regardless of how many or what the first arriving PCP crew has done.

I know what I do but which one is actually correct because now I’m wondering if I’m doing the right method.

Question: You respond to a call for a 57 year old male patient who collapsed while cutting the lawn. On arrival, his neighbour who witnessed the arrest, reports that she saw him fall and when she checked on him, she realized that he was in cardiac arrest and started CPR. You confirm that the patient is VSA and quickly apply the defib pads. You deliver one shock and start CPR again but the patient begins to moan and tries to raise his arms. Your next action would be to…?

Question: I am seeking direction in the management of a patient(s) who have sustained exposure to Hydrogen Sulfide (H2S) in suicide; taking into account the presenting HAZ-Mat situation and the associated dangers to 911 allied agency personnel. Specifically, assessments, resuscitation, TOR, field pronouncement, transport guidelines and recommendations.

My major concern is the potential harm to transporting crews due to external ventilation of the lethal gases notably if the Fire Dep’t “4 Gas Monitor” monitors indicate a presence of H2S.

Question: Once I’ve started my bolus, do I stop once just above 90 say 92 or do I stop once normal tensive at 100? This has been tossed around so many times and I get both answers.

Question: What is the reason why IV certified PCPs cannot bolus PEA patients?

Question: In studying for this year’s recert, I started to wonder why the administration of intramuscular epinephrine was being advocated for a first line drug in the management of an arrest where the patient was suspected to be suffering from anaphylaxis. The impression from the protocol is that this procedure should be given priority over starting an IV or an IO. Given that as a routine course in all arrests, an ACP will usually manage to initiate an IV / IO and administer epinephrine (1.0 mg €“ twice the dose that would be given IM) early in the call, it doesn’t seem to make sense to delay the initiation of the line.

With few hands on scene, and the PCP partner performing CPR, the ACP will only likely be able to perform one procedure during the two minutes between rhythm analyses €“ draw up and deliver epi IM or initiate an IV and deliver epi IV €“ but probably not both. Since the patient was likely suffering profound vasodilation prior to the arrest, there is low likelihood that there would be much effectiveness in circulating the half millilitre of fluid that is administered IM into a deltoid using CPR alone (which, at best, is only 25% as effective as the heart pumping on it’s own). The introduction of epinephrine directly into the bloodstream would likely have a much higher probability of achieving systemic circulation and effect as compared to the IM injection.

The recommendation seems to stem from an interpretation of Part 12 of the 2010 AHA ECC guidelines (Cardiac Arrest in Special Circumstances) where the use of IM epinephrine in arrests of suspected anaphylactic etiology is advised as a modification in the management of a BLS arrest. The recommendation is not present in the modifications in the management of an ALS arrest where, conversely, it is advised that epinephrine is administered by IV where a line is present. In fact, the one recommendation for ALS modification in the management of anaphylactic arrests in the AHA ECC guidelines is absent from our protocols. Currently, a fluid bolus is only indicated where the patient presents in PEA, however, the AHA ECC guidelines make the recommendation that “Vasogenic shock from anaphylaxis may require aggressive fluid resuscitation (Class IIa, LOE C).”

I understand that OBHG MAC might have apprehensions in delaying the administration of epinephrine in circumstances where an IV or IO could not be initiated in short order, however, would it not be more effective to use IM epinephrine as a backup where the line could not be initiated quickly (as in the case with Glucagon vs. IV Dextrose)? The IM administration would also have a higher likelihood of success if given once optimal circulation due to CPR was achieved (which would not occur until a couple minutes into the call).

Thanks for your consideration!

Question: What position should patients be in when we are doing do a 12-lead?

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

Question: If an IV certified paramedic with a non-IV certified partner initiates a saline lock but does not give fluid or medication; can the partner without IV certification attend the call?

Question: The medical directives state that in order to call for a medical TOR one of the conditions is for the arrest to not be witnessed by EMS.

Does this just refer to EMS or does it include other emergency services, such as Nurses, Fire, Police or PSW? For example if PSW or Fire witnessed the arrest before EMS arrival and EMS arrived on scene and completed 4 analyzes and no shocks delivered, can EMS still call for a TOR because it was not witnessed by EMS?

Question: Can ALS take a pronouncement from the on-scene doctor at a retirement home? I ran the code, since the patient was full code, and got a pronouncement on the phone with the BHP. Once we stopped care, the guy who had been watching us, said that he was her doctor and didn’t think we would get her back.

I was wondering if that the on-scene doctor had said something at the beginning of the call, could I just ask him for the pronouncement instead of waiting for the BHP to come to the telephone? We cleared it with management to leave care with that doctor since police didn’t come to the scene to call the coroner and take over. Otherwise we would wait for police until we left scene.

Question: A nitro virgin patient presenting with chest pain attends a doctor’s office. Doctor administers 1 spray of nitro prior to EMS arrival. Upon assessment by EMS, patient still presents with chest pain. Is the patient still considered a virgin nitro patient as this is the first incident he/she has had with nitro? Or since the doctor administered a spray, does that count as a previous use of nitro?

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: 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: If you come to a scenario being a PCP paramedic uncertified in IV, where when finding and assessing the patient you come to terms that he/she is VSA due to anaphylaxis.

Do you have to administer epi, because in the protocol for administering epi on a VSA, it says “in the event anaphylaxis is suspected as the causative event of the cardiac arrest, a single dose of 0.01mg/kg 1:1000 solution, to a maximum of 0.5mg IM, may be give prior to obtaining the IV/IO”. Since it is saying you “may” give it, do you know if you have a choice?

Question: There is some debate in regards to chest compression’s, monitor applied, analyze and then airway. What happens when the compression count is at thirty and the pads are still not applied? Does the paramedic at the chest check the oral cavity, get the airway, insert it, open the BVM bag, prepare the BVM and attempt 2 breaths or continue compression’s until the other medic applies the pads and the analysis is complete?

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: I have read the post Jan. 31 2012 in regards to R/A vs. 02 when resuscitating a neonate. It states that 100% 02 will be used after 90 sec with compressions if HR is below 60. It also states that 100% 02 will be continued until HR is normal. Does this refer to 100 bpm?

The reason I ask is if I read the flow chart to the letter at 90 sec with a HR below 60, 02 and compressions are begun. If I reassess 30 sec later and the HR has improved above 60 but below 100 (ex. 80 bpm), I continue ventilating, but do I discontinue the 02 and use R/A only? Also compressions are to be discontinued. What is stance on using a pedi-mate on a critical or VSA neonate or child (below 40 lbs)? Is it necessary as it can be cumbersome and time consuming when trying to get off scene quickly?

Question: With reference to the cardiac ischemia protocol. Would it be possible to update the protocol for the administration of nitro (without a BHP consult) for normotensive patient on beta blockers by either: a) lowering the heart rate parameters from 60bpm to 50bpm or b) to lower heart rate parameter from 60bpm to 50bpm when patient is currently taking antihypertensive medications within the beta blocker family with an IV established?