Question: Is the IV protocol like others in that once the patient falls out of a protocol, they cannot be put back in. For example, patient initial BP less than 90 systolic, decision made to load patient prior to IV attempt, on loading patient BP now above 90.

Question: I was looking at the PCP Medical Cardiac Arrest Medical Directive. I understand that we can give IM epinephrine in the setting of an anaphylaxis induced VSA. In the event of a ROSC from this type of VSA can Benadryl be administered IM/IV? Is there any benefit to doing this?

Question: Is a non-IV certified paramedic allowed to monitor an IV started TKVO by an IV certified paramedic on route to the hospital?

Question: There have been a few discussions flying around about a call where the patient had an internal defib whose activity was captured shocking the patient X 3 by the EMS defib. Of course, the whole discussion is treat vs. transport and shock once vs. follow the entire protocol. Can you provide some insight into these rare cases?

Question: While taking our manual defibrillation training on the new LP15 we were told “if the rhythm is fast and wide, shock it” obviously the PT is pulseless as well. We were told the “fast” value is greater than 120. We were never told the “wide” value. I have asked both ACP and PCP paramedics and have gotten responses of 0.12, 0.16, and 0.20. So, could you tell me what SWORBHP considers the correct value for “fast”? Thanks!

Question: If we are treating a patient with acute cardiogenic pulmonary edema that is a nitro virgin that’s blood pressure is above 140 systolic and then their blood pressure drops below 140 systolic but not by one third then can we consider them now as not being a nitro virgin and therefore continue treating them with 0.4 nitro? Thank you for taking the time to answer all of these questions.

Question: A CHF patient who has a BP of over 140mmHg systolic who is getting 0.8mg of NTG for SOB, patient’s BP drops below 140mmHg so NTG dosage is changed to 0.4mg, patient’s systolic BP rebounds above 140mmHg. Does patient go back to getting 0.8mg of NTG or is it like the “once you are out, you are out” mentality that they stay at 0.4mg NTG?

General answers to this question from other paramedics I have asked usually say that the patient will continue to get 0.4mg of NTG regardless of systoloic BP, if it has dropped below 140mmHg at any time during the call. Thank you in advance for your time and help.

Question: I have a question regarding the order of cardiac ischemia SR medication in the protocol. I have been informed by a source that 0.4mg nitro should be the first SR medication given in a suspected cardiac ischemic event, followed by x2 80 mg ASA. I respectfully disagree with him due to the fact that although nitro is significantly more fast acting, its effects only last 3-5 minutes, hence the spray every 5 minutes stated in the protocol, and although the ASA is slower in its absorption rate, is effects will benefit the Pt. more (in my opinion) than the nitro. The short and sweet version, am I correct in saying that ASA should be administer first before the initial nitro dose is given, if the protocol for both is met.

Question: In the last year I have been presented with two different special occurrences regarding vital sign absent patients.

The first one involved a patient who was VSA on our arrival. We were presented with a legal living will as well as a note provided by a Doctor stating “DNR”. Unfortunately there was no ministry DNR validity form. We completed a full medical TOR as the patient met the requirements and after I was informed by co-workers that I could have called for a medical TOR after the first no shock indicated. They stated this was covered under special occurrence. I have looked and found no evidence of this existing although this could be very handy. Does such protocol or language exist?

The second incident involved a patient that we witnessed from a reasonable distance to be VSA. Due to safety reasons we could not access the patient for approximately 45 minutes. The patient did not meet obviously dead and didn’t have a DNR. We performed a medical TOR. Again informed that this falls under special occurrence and we could have called for medical tor after the first no shock indicated.

I’d really like to know if this is an option. It would come in handy for similar instances.

Question: I was just wondering if we have a patient with a valid DNR are we still allowed to Bolus if they fit our protocol or is this considered an advanced life saving technique?

Question: I apologize in advance if this question is redundant, but I have searched and cannot find an answer. For a crew where both medics are IV certified (autonomous certification), are both medics allowed 2 starts (4 attempts in total) on a single patient? Or are attempts limited to 2 attempts per patient regardless of who makes the attempts? Thanks.

Question: I am a PCP and was wondering what constitutes a IV attempt. Does simply palpating and visually assessing the patient constitute an attempt if I do not find an accessible vein and do not blindly pic attempt insertion?

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.?