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

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: 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: 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: 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!

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

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

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: 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: 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?