Hi MAC, hope you folks are well. I was curious if you can provide clarification and potentially rational to the “Mandatory Patch Point” for Medical Cardiac Arrests. Although I understand calling for termination or potentially further direction, I am curious if we have to BHP patch if the attending Paramedic feels the Pt in cardiac arrest [that fits criteria for TOR] would benefit from transportation for any variety of situations (age, geo. location, ect.). It seems it would be counter-intuitive to spend the time calling an MD to tell them we feel transport would be beneficial for a Pt (especially if ready to transport) instead of initiating time critical transport + our active resuscitation efforts. Would a BHP ever say no, do not transport this Pt, regardless of potential ED Tx benefit? I recognize this is an odd question that is a rarity, but I’ve found myself in this position more than once and am wondering how to efficiently tackle these situations in the future without a potential protocol violation. Cheers MAC.

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

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

The question I have is about organ donation/transplant. Just had a young person traumatic VSA in which his core body was still intact I just got thinking afterwards that I should I have called base hospital to see if the family would like to donate his organs. Just thought that pt had been young and healthy. Was wondering the proper way to go about it? How long the organs can be without blood flow. How far from London or where do we take the body? Who do you contact. I know the scene is overwhelming and was one of the last things thinking about.

I am looking for clarification on whether or not pre-arrival shocks count towards consideration of a medical TOR with the new 20 minute protocol. I have reviewed the companion document and note it does state, “As a general rule, Paramedics do NOT count pre-arrival interventions in their patient care. Care delivered prior to arrival can be “considered” and documented.” I also found a previous Ask Mac response from Dec 22 2017 asking the same question, however the answer was at the time of the previous Medical Cardiac Arrest Directive (4 analyses only). In Mac’s response at that time they did state, “SWORBHP Medical Council believes that ANY defibrillation delivered to a patient during a cardiac arrest resuscitation should be counted and considered as a contraindication to the application of the TOR.” Looking for clarity between these statements and the new protocol. Thanks for the information!

In the companion document under the medical cardiac arrest directive it lists reasons for early transport. Under here it lists thrombosis (pulmonary and coronary). So to my understanding, if we have a VSA we believe to be caused by a coronary thrombosis (a STEMI) we are to do 1 analyze? In the past it has been said that we are to treat a suspected MI VSA as a medical cardiac arrest and run the entire protocol on scene. Can you please clarify?

If a patient is suffering a medical event in nature, and goes VSA (for the first time, NOT a re-arrest) en route to the hospital, do we pull over and run the arrest for 20 minutes, or would we use clinical consideration that egress has commenced, and do one analysis and continue transport (under the circumstance that pt at that time is in a non shockable rhythm)? 

In the latest version of the companion document (v5.1) the following is stated “For a witnessed arrest in the back of the ambulance paramedics should use clinical judgment to decide whether to stay and perform resuscitation or proceed to hospital. Paramedic should perform three full analysis and then proceed/patch or to provide one analysis and go. The paramedic should provide at minimum one analysis. Factors that are part of the decision process include distance to closest hospital, probable cause of arrest, ability to provide adequate CPR/ventilation, shockable vs non-shockable etc..”. I was told during my recert in November that this scenario would warrant a 20 minute resuscitation. Can you please clarify.

If My patient goes VSA in the back of the truck (witnessed, first time VSA). We do not do 20 min CPR? Or we do 3 analysis and go after? And/or 1 analysis and go? Does the same apply witness VSA in the home? Do these require patch to leave early? There has been excessive talk over this and little clarification.

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

If we pick up a patient and the patient presents with a positive 12-lead STEMI and you are travelling to the PCI Center and the patient codes, do we run the full 20 minute cardiac arrest protocol, or could you consider STEMI as a reversible cause (Hs and Ts) , analyze once and head to the closest receiving which may not be the PCI due to distance.

Hello, with the changes to PCP medical cardiac arrest, since there is no longer a maximum number of analysis are we expected to continue to analysis the rhythm every two minutes on route to hospital if were transporting?. Seems like it would delay our arrival time a fair bit to pull over every two minutes especially in the county. Also, if a confirmed STEMI codes on route, should we be running a full 20 minute resuscitation before continuing transport, or would that be considered a reversible cause to transport after one analysis?. Thanks

The new Medical Cardiac Arrest Directive requires 20 minutes of resuscitation on scene. Point # 5 of the Primary Clinical Consideration(s) states …or other known reversible cause of arrest not addressed. My question has to do with refractory PEA and the amount of potential reversible causes (7 Hs 5 Ts). Would it be reasonable to patch for request of early transport in the presence of 3 consecutive analysis of PEA?

There has been a lot of debate in regard to the new medical cardiac arrest directive, especially when it comes to pediatric patients (1 day to less than 8 years old). Based on my understanding of the new directive, patients 24 hours old now fall under medical cardiac arrest which states that scene time is now 20 minutes unless you have a reversible cause or 3 consecutive shocks, since TOR would not apply here. Some paramedics express significant discomfort staying on scene for that long if the patient has been stabilized with good airway, quality compressions, and possibly defibrillation. Do you support paramedics leaving early in this setting where everything is done early or do you encourage us to stay on scene for 20 minutes? Does this benefit the patient when they could be receiving life saving drugs in a hospital, also knowing that we will eventually have to transport to a hospital no matter what?

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

Hello, what are the criteria for identifying hypothermia in a VSA patient? This affects our treatment under ALS PCS 5.1 whether we consider early transport after one analysis. The situation that brought up this discussion was a patient who had been on the floor indoors for a number of days, but still presented with a hypothermic body temperature. If the patient had been found VSA, how would we identify to treat them under the full medical cardiac arrest, or be considered for early transport?

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

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

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

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

When dealing with an anaphylactic patient, the PCP medical directive says to administer up to 2 doses of epi at a maximum single dose of 0.5mg, whereas the bronchoconstriction AND cardiac arrest medical directives are only one dose at a maximum single dose of 0.5mg. Can some explain why?

The AHA and COVID-19 guideline has a caveat that states in “suspected or confirmed COVID-19 cases” we should implement the prescribed practices. In the event that the patient in cardiac arrest is not confirmed or suspected to have COVID-19 symptoms is it reasonable to every to pre-pandemic practice of resuscitation?

Follow-up question that was asked on 29-Jan-2021 about pulse checks after no shock is indicated. Base hospital answered that pulse checks should occur concurrently with each rhythm analysis. Is this true for those of us that are using S-AEDs rather than manual rhythm analysis? The reason I ask is because First Aid & CPR courses suggest that touching a patient during an AED analysis will introduce artifact that could affect the accuracy of the analysis.

Hello and thank you for your time everyone. Module 2 point 2 reinforces the concept that high quality CPR is the primary focus for care of an opioid overdose VSA patient. However, It also highlights that naloxone may be administered as long as AHA guidelines for cardiopulmonary resuscitation are adequately being met. Given this point; is it o.k. for paramedics to administer naloxone for these type of VSA patients? The directive book and phone application Medical Cardiac Arrest directive continues to state, “There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. I found it a little unclear whether this segment was reinforcing the concept to not administering naloxone for a VSA patient, or providing guidance that it is acceptable as long as other aspects of care are effectively delivered.

What is the correct course of action if a pt goes VSA while crew is on scene, (ex. 1st analyses reveals VF, pt shocked, then 2 more analyses 2 min apart- both PEA), then pt starts spontaneously breathing and has pulse (ROSC)…then rearrests 2 min later and is in VF so crew shocks…CPR continued as pt still pulseless. Keep in mind crew is still on scene waiting for fire to show up as crew needs help with extrication.. this situation has happened and 1 crew member had called BHP for direction as it’s ‘grey” area as normally you are transporting by then and would do 1 analysis following rearrest and shock if necessary and continue with transport/CPR.. BHP was not clear just kept saying “follow your protocol” when in fact the crew was but at that point was very “grey”. Would we treat it as a whole new medical cardiac arrest protocol as its a re-arrest on scene until fire arrives? Or what would be the best course of action?

Can you TOR someone who is in PEA

With regards to pediatric resuscitation, are we to use the pediatric setting on the zoll for only less than 8 years old, or for >30 days to onset puberty? I was reading old Q&A for this, and it was made to seem like we only use the pediatric setting for less than 8 on the zoll, and anything older than that use the adult setting

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?

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?

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?

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?

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: 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: 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: 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)?