Question: If a hypothermic patient re-arrests is it considered a new protocol or just continue transport? Due to the 1 shock protocol.

Question: Is a police officer considered a qualified personnel to be able to witness a cardiac arrest? In regards to “witnessed arrest”.

Question: This question is regarding a cardiac arrest from anaphylaxis. If epi is given and the patient has no ROSC, arrest is unwitnessed, and by the 3rd analysis no shock is given, is it acceptable to patch for TOR, or is the TOR contraindicated due to the arrest being of non-cardiac origin?

Question: This question is regarding cardiac arrest documentation expectations. Is it a requirement to document vital signs every 2 minutes or would it be sufficient to document one set with a comment: Patient remained pulseless throughout? As well, CPR charted once, with a similar comment: CPR performed throughout. In my opinion, this would be more efficient and concise.

As well, if in a position where we are transporting a VSA patient, as an ACP I have always performed a rhythm interpretation even while the vehicle is moving. I have never really noticed artifact as an issue, and cannot find any documentation relating to ACP practice stating I must pull over. I have not had any feedback from base hospital regarding this practice, but my supervisor has mentioned some serious concerns.

Thanks again for this forum that helps our practice.

Question: I have a question regarding nitro use with lung cancer patients. I recently had a patient who was obviously in the end stages of lung CA. Patient was complaining of mild SOB due excessive amounts of fluid buildup in his lungs. He stated that he needed to go to the hospital to have the fluid drained. Patent had 5-6 word dyspnea, O2 sats at 92 %, radial pulse 90, NSR, respiratory rate 22 regular, audible crackles when patient took a deep breath, and B/P 124/86. Patient stated that within the last couple of days he had noticed swelling to his ankles and abdomen which were abnormal for him. Patient had a previous history of nitro use due to angina. Would this patient benefit at all with nitro use? He wasn’t in severe respiratory distress nor did he require assisted ventilations.

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

Question: When dealing with a VSA FB obstruction, directives are to analyze once, load and go, revert to medical cardiac arrest if airway clears. Knowing the concern is no air to the patient due to the obstruction, would it not be advantageous to include airway blockage due to anaphylaxis as a one analysis directive and when or if the epi allows for the delivery of air, revert to a medical cardiac arrest? The airway is blocked either way.

Question: Does a patient that suffered from hanging, electrocution, and/or drowning fall under medical tor protocol? Also, if a patient is suffering from anaphylaxis and airway is completely obstructed and you had analyzed once and transported as per FB protocol if on route airway becomes relieved and you have good compliance do you pull over and start your medical cardiac arrest protocol? If first analyze on scene was no shock and you do pull over and have two more no shocks does it fall under a medical tor protocol?

Question: In the event of a VSA where Anaphylaxis is the suspected cause, when would be the most ideal time to administer Epinephrine IM? I’m assuming we would start with CPR, attach PADS, Analyze, then Epi. Would this be a safe assumption?

Question: I was recently on a call with a patient presenting with a tachy rhythm of 157 and his blood pressure was 74/42. I proceeded to start a line and was going to bolus but subsequent pressures were above 90 systolic. Would it have been reasonable to not bolus due to the fact that this patient most likely had a decreased BP due to the Fast heart rate and not because of a fluid deficit?

Question: I’m an IV certified PCP. A question came up last week in regards to aortic aneurysms and different blood pressures bilaterally. If one BP is hypotensive, and the other is normo- or hyper- do we bolus? Ideas that have come up include: Adding fluid may increase the overall pressure, causing the dissection to enlarge; however, the patient is losing fluid and therefore is compensating and needs more.

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

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

I thank you for your comments and insights.

Question: My questions have to do with resolved suspected ischemic chest pain and if we should administer ASA even if the symptoms have resolved.

Question: I am a PCP student, Under the cardiac ischemia medical directive it states that indications for nitro and ASA are “suspected cardiac ischemia” my question is, a patient without chest pain but has other symptoms such as weakness SOB, N/V etc. and a positive 12 lead showing either ST elevation or depression, do they qualify for Nitro under this protocol?

Question: What are your thoughts on oxygen therapy in myocardial ischemia from a medical evidence standpoint? Even though high flow o2 is regularly administered to PTs with chest pain as per the oxygen therapy and chest pain standards in the BLS standards, there is an increasing body of evidence suggesting that in uncomplicated MI O2 is of no benefit and may cause more harm than good due to ROS and ischemia-reperfusion injury.

The recent ACLS guidelines state to only administer O2 in acute coronary syndromes if the spo2 is < 94% or the PT is in respiratory distress or obviously hypoxic and there are several recent papers and clinical guidelines that suggest a similar course of action in uncomplicated MI. Basically, the evidence is suggesting that titration to spo2 is favorable over high flow o2 due to the risk of oxidative stress injury.

Any thoughts? Obviously you still follow the protocols, but I’m just interested to see if there is any medical opinion on this. Could the standards/guidelines eventually change to reflect the newer evidence?

Question: My question had to do with attending to a call where a patient is VSA and then throughout our medical directive the patient receives a ROSC and then a re-arrest. I know that in the old medical directive we would at this time do one further analysis and then transport the patient but in our current medical directives this is not mentioned. I would like to know if I should be attempting any analysis on a patient who re-arrests after receiving an initial ROSC with our current medical directive.

Question: This question is to clarify a point in the FBAO cardiac arrest protocol. If the airway obstruction is resolved after a first analysis, it is stated that the patient can then be treated per the medical cardiac arrest directive (presumably receiving three more analyses for a total of four). My question is regarding what to do if transport is in progress when the obstruction is removed- is transport continued with CPR only (as it is not a new arrest or a re-arrest after ROSC) or can the vehicle be stopped until the protocol is complete?

Question: Two questions which seem simple but as an educator I get asked all the time. 1.) FBAO VSA patient, you are unable to clear the airway, should we follow the BLS that indicates an oral airway should be inserted? 2.) Unwitnessed VSA, do we need to do a full two minutes of CPR or just CPR until we get the pads on.

Question: I recently had my recerts and have a question concerning Medical TOR. The way it was explained to me was that a TOR was a pronouncement. It was explained to me, if we receive a TOR in the back of the unit before the vehicle is put into drive, we have stay on scene with a patient until the coroner comes. Likewise if we received the TOR while the vehicle was in motion we could continue to the hospital. I really don’t understand the difference as to whether the vehicle is in gear or not. I was under the impression that if we receive a TOR, it is simply that, terminate resuscitation and continue transport (no lights and sirens) with no resuscitation. The decision on route would then be, do we go to the morgue or to the ER. I understand the delicacy of appearances and you may have to leave scene with lights and sirens but once away from the scene, judgment on activation of emergency signals would be up to the driver/crew. Could you elaborate some more on this?

My question concerning TOR is this. Is a patient deemed dead at the time of TOR or are they deemed dead when assessed either at the hospital by an ER physician or at the scene by the coroner?

Question: I am a current PCP taking ACP. I was recently informed, during an ACP class, that on an unconscious CHF patient, nitro can still be administered if vitals are within normal range and the other conditions are met. When I checked the protocols, under conditions, it states that LOA: N/A (whereas for cardiac ischemia, the LOA must be unaltered). However, it seems to me that if the patient is unconscious, the patient is too unstable to receive nitro. I have never experienced a call like this, and it would seem that in most cases an unconscious patient would have vitals outside the perimeters of nitro administration. Can you please verify this? Thanks

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

Question: I just have a quick question regarding IV Monitoring. Are PCP’s allowed to transport a patient without an escort who has an IV running lactated ringers? This question came up the other day at work and everyone seems to have a different answer. I just wanted to clear this up with you so I know the correct answer!

Question: On medical VSA’s, as an IV certified PCP, if you have time and enough hands to start an IV, are you giving a fluid bolus? I realize when you get a ROSC you are doing a fluid bolus of 10ml/kg (if chest is clear), but while the patient is VSA, are you giving a bolus? Or are you starting a line, just running TKVO in preparation of getting a ROSC and then bolusing?

Question: I am a recent graduate and have a question regarding the traumatic VSA protocol. We arrive on scene to find 5 patients. Two are VSA and three are CTAS 2. The next ambulance is 5 min away. We use triage but after the three CTAS 2 patients are gone what do we do with the 2 VSA patients? Are we to do a Trauma TOR? Or is it just left at that point?

Question: Example: A patient presents generally unwell, lightheaded and feels like their heart is beating fast, not an unusual call for any paramedic. On exam the patient has a pulse of 130-150 BPM, sinus tach to match on the monitor and BP is 100-110 systolic. Would it not be safe to assume that the BP is being maintained by the HR?

The question: Could this patient not benefit from a one time fluid bolus/challenge of 250ml to see if it decreases the HR decreasing cardiac demand and maintain the BP thus being beneficial for the patients overall condition? I realize that the IV and fluid therapy directive is for a BP less that 90 Systolic and is to ensure that a patient has an adequate perfusion or actual/potential need for medication, however would this not fall under the fluid therapy part of the IV and fluid therapy directive?

Question: I have recently heard several answers to the following question, so I would really appreciate hearing the answer. How many IV attempts are allowed/permitted/encouraged per paramedic/patient?

Question: I’m curious if it is recommended to take blood sugar readings on VSA patients? If a blood sugar is taken on a VSA patient, and the reading is < 4mmol/L (which may be quite common due to the sample being capillary and CPR not perfusing sugar to the extremities), do we treat with Glucagon or D50? What if we suspect the patient is VSA due to a diabetic event? Does the answer change whether I'm a PCP or an ACP? Thanks!

Question: Do all Phosphodiesterase Inhibitors generic names end in “fil”? Are all drugs that end “fil” Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

Question: I am wondering if it is acceptable to initiate a bolus for hypotension based on “estimated” blood pressures. I.e. you are unable to obtain a BP through auscultation and the patient has no palpable radial pulses. We have been taught that you can estimate a patient’s blood pressure to be 80 systolic or less with the absence of palpable radial pulses. So, can I treat a patient with a bolus, based on estimated BP’s and in conjunction with other symptoms, or do I need an actual and specific number. Thanks in advance.

Question: Our medical cardiac arrest protocol states for pediatric patients consider initiating transportation following the first rhythm analysis that does not result in a defibrillation being delivered. My question is, “Until what age do we consider a patient a pediatric?. Thanks in advance.

Question: At a meeting with Dr. Lewell in the past, he stated that there is no time set for the administration of medication. Some medics are directed by their services to deliver the medication within 5 minutes and yet the Base Hospital directive asks to have the monitor on in 5 minutes. Medication cannot be delivered without the monitor being applied, so is it correct to say that the time limit is not 5 minutes, but ASAP after the monitor is applied?

Question: In a PCP crew with one of those PCP IV certified, should the PCP IV attend on all VSA’s? All chest pains with nitro use? It’s just that the IV directive is very vague and leaves it very open to interpretation. Thanks in advance!

Question: ALS paramedics have directives as to when they must attend/start IV’s to give meds in various situations/bolus etc. The directive for starting an IV is for the “potential need” for an IV, administering meds or bolus. Are there specific times we should always attempt an IV if time permits? (pre arrest, post-ictal, chest pain with past nitro use etc?)

Question: In a hypothermia patient, what is the reason behind the possibility of them going into A Fib?

Question: I have a few questions about some of the omissions from these protocols that were in the old protocols. The first one is in the event chest pain resolves and re-occurs it is treated as a new episode and nitro protocol repeated. This isn’t stated in the new protocol so if this were to occur can we repeat although it isn’t stated? The other question is regarding the medical arrest protocol. No provision is made in regards to on scene ROSC and re-arresting patient in ambulance. The old protocol says we can pull over and analyze once then continue to receiving facility. With nothing in the new protocol do we follow the same format? Thank you.

Question: If a patient from, for example, a structure fire is VSA with severe 3rd degree burns to the majority of their body and asystolic upon arrival would this fall under a medical or trauma cardiac arrest protocol? I would assume there is a high likelihood that the cause of arrest is more asphyxial in nature from smoke and toxic fume inhalation so it would be a medical protocol. That being said would this patient also meet medical TOR protocol since the arrest is asphyxial in origin? In discussion there seems to be so many variables put forward that there is no general consensus on which protocol to follow. Assuming there is no associated blunt trauma (e.g. structural collapse or explosion) or any penetrating trauma (e.g. explosion or injury occurred prior to burns) and the only trauma is the burns themselves what’s the most advisable course of action to follow?

Question: As far as the TOR mandatory patch point goes: if we are able to relay to the BHP that we would like to transport as opposed to terminating (e.g. public place, family insists we do so etc.) then why not allow the discretion of the paramedic to dictate whether to spend the time actually doing the patch? Since the physician is relying on us to paint a picture of the scene and if the BHP will accept our interpretation of the events unfolding and most likely state to transport anyway, patching to get permission to initiate transport seems to be more of a delay than a benefit.

Question: With respect to the Medical TOR, can we leave a deceased patient with family members after the TOR has been granted? It does not state in our medical directive who we can leave the body with (I always presumed it would Police, a family doctor, Coroner, Supervisor, Nurse at Nursing Home / patients home, etc.). In the Deceased Patient Standards it does state under responsible person / unexpected death chart… family members would be acceptable. I would imagine it would depend on the situation at the scene and family members state of mind. If you and your partner are at the scene of a medical TOR and another call comes in down the street for a code 4 – VSA for example, can both crew members leave the scene and have family take over care of the body? I know you could do a first response with one crew member, but again, two would be optimal. If you were a Supervisor on scene taking over care for your crew, could you leave the pt in the care of family and do a first response? You are on scene with a patient who has met the Obvious Death Criteria, can you leave the patient with family members or do we wait for Police, Supervisor etc. to attend the scene?

Just wanting clarification on who would be the ‘responsible person’. If a Paramedic felt that family would meet the criteria for ‘responsible person’, could we have family take over custody of the deceased person for Medical TOR or Obvious Death Criteria providing scene was safe, family coping well, no suspicious events at scene, etc.?

Question: When is a patient no longer considered nitro naive? Issue: you have a patient that is suffering chest pain and qualifies for ischemic protocol. You establish a patient IV and give them nitro. The patient accepts the nitro without any adverse reactions and pressure does not fall out of protocol at any time. After your second dose of nitro you check the IV and discover its no longer patent and you have to discontinue it. You attempt your second IV and are unsuccessful. Nitro has been decreasing patient’s pain but they still have active chest pain. Can we still continue with nitro without an IV as the patient has already been given nitro and not had any reaction?

Question: I was having a debate with another paramedic about the proper order of procedure in the following situation: You are en-route to the hospital, in the back of the ambulance alone with your patient, and they go VSA. You check for pulse and respirations and confirm VSA, update your partner, and ask them to pull over and help. While they are pulling over and moving to the back of the ambulance should you: a) begin chest compressions; or b) immediately apply defib pads and analyze?

Question: I have checked with a SWORBHP Educator and they did confirm that you cannot Medical TOR an OD but you can do Medical TOR on Drowning Hanging and Electrocution. There still seems to be doubt out in the field so I thought I would post so all could see answer

Question: With respect to the Medical Arrest Protocol, are we still to alternate giving Epi and Amio/Lido on the 2 minute mark since each are to be given Q4 minute? Or can we give them at the same time? What is preferred?

Question: This question is in regards to the TOR’s and calling BHP. Some paramedic services lack having a spare cell phone while the primary cell phone for a truck is “out for service”, missing etc. I have heard of some paramedics using their personal cell phones to call for the mandatory BHP patch for a pronouncement. I have spoken to Police and Crown Officials, and they have both stated that our personal phone can be submitted into evidence at an inquest or other matters, as this was the tool used to make that pronouncement (upon further investigation a paramedics credibility can be challenged as the court can see text messages, pictures, and phone calls placed on the personal phone). If our service fails to provide us with a cell phone for that shift for whatever reason, are we obligated to use our personal phone knowing it could be taking from us in an investigation for an unknown length of time? Would we document “no cell phone available” on the ACR?

Question: This question was addressed at the end of January but I’m still unclear on the answer. In our protocol is discusses DKA and the patch point for pts from 2 to 12 for obvious reasons to me. It does not discuss any patient greater than 12. In the past if pt was DKA and showing signs of dehydration we could do a 10ml/kg bolus, then it was changed so that we had to patch for this bolus.

The previous question was weather or not we were doing boluses for adults and it was not addressed. There is no talk of it in our latest protocols. Can we go ahead and bolus an adult in DKA who is showing signs of dehydration without a patch or even with a patch?

Question: In regards to cardiac arrest secondary to drug overdose. A VSA in an instance where Cocaine and or Meth have been used in excess causing death. Would this fall under unusual circumstances and therefore be transported or would it follow a medical TOR and require a patch to base hospital?

Question: This is in regard to the Medical TOR protocol. If we’ve reached the mandatory patch point at three consecutive non-shockable analyses (and made the call to the BHP) and there is any sort of delay (meaning we’ve reached the fourth analysis), do we then transport? People are getting confused because some heard that they were to keep analyzing while they waited for the BHP to come on the line. That’s not how I perceived it. Regardless of any delay at any time, the protocol states that we only analyze a total of four times (unless you are an ERU) followed by CPR for the duration of the call, correct? People hear different things, and I just want clarification so that we can all be on the same page. Thanks

Question: Why do we have a mandatory patch point for pediatric patients (> 2 but less than 12) with a blood sugar over 25 mmol/l and suspected to be in DKA for a fluid bolus but there is no patch point for adult patients.

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

Question: On our ROSC protocol, the ONLY route that we are allowed to give a fluid bolus/dopamine is via an IV. Please confirm that we are NOT allowed to do so via IO or CVAD? This does vary from the IV and Fluid Therapy protocol which allows us to do so.

Question: If a patient is between ages 8-12 and is VSA, are we still using the lowest Joule setting?