This is a very unlikely scenario, but I wondered if Toradol could replace Ibuprophen for the patient experiencing pain. In the unlikely event that a patient is able to take Tylenol and once administered pt refuses Ibuprophen due to nausea (post tylenol administration) could Toradol be used? It would be rare as the contraindications are the same for both nsaids aside from nausea and unable to tolerate oral med administration for Ibuprophen. Could pt preference come into play, a patient in severe pain states “I have had toradol in the past and it works really well for me” assuming all other conditions are met could they receive toradol in addition to tylenol to compliment the nsaid?

If a patient is in pain and states they don’t like taking Advil or can’t take Advil (but no allergy), would it be appropriate to administer Tylenol and Toradol? They are not contraindications of each other.

In regards to medications with a condition of “unaltered”, should we be administering these if the pt is GCS 15, then has a syncopal episode (or other altered period) in your care and then returns to GCS 15? An example would be a chest pain call where you want to treat with ASA and Ondansetron. Is it a case of “once you’re out you’re out” or would it still be appropriate to treat as they have now returned to an unaltered state? Thanks

In regards to the analgesia directive, should we withhold pain medication in the event that the mechanism of injury is severe even if the patient has no obvious signs of a head injury or a bleed? For example: a car accident at very high speeds where pt is only complaining of severe back pain, no LOC or confusion, would it be appropriate to give either Advil/Tylenol or toradol since there are no obvious contraindications or would it be better to withhold since the mechanism of injury is serious enough that they would still be possibilities?

I have a question regarding the PCP analgesia medical directive. If a patient has been using topical gels for pain relief (such as voltaren gel containing diclofenac), is ibuprofen/ketorolac still contraindicated if it has been used within the last 6 hours?

For acetaminophen and ibuprofen, suspected ischemic chest pain is listed as a contraindication. Is this listed mainly to indicate that ischemic chest pain should not be treated with the analgesia directive? Could analgesics be administered to treat a different area of pain that is occurring at the same time as the chest pain that appears to be unrelated? For example, I had a patient with chronic pain that she takes acetaminophen for, but she was experiencing acute chest pain suspected to be ischemic. Would it be correct to withhold acetaminophen in this case and not provide treatment for the chronic pain that she is experiencing at the same time as suspected cardiac ischemia?

Is ASA considered a blood thinner? I understand its an anti-platelet and not an anticoagulant but is it still considered a blood thinner?

Why does Ketorolac in the Analgesia Medical Directive have normotensive as a condition, when other NSAID directives do not include a SBP condition?

Should Ibuprofen be withheld for patients suffering possible Crohns, colitis and IBS flare ups?

Have alternative pain control options such as oral morphine and nitrous oxide been (re)considered recently for pre-hospital administration? If not, what’s the reasoning?

I just have a question regarding analgesics. A contraindication for acetaminophen is use of it within the last 4 hours. Lets say for an adult patient they took 500mg prior to EMS arrival, would it then be okay to administer an additional 500mg to complete the full max single dose of 1000mg or should you withhold the acetaminophen in honour of the contraindication?

Just wondering, I have heard of a few coworkers putting the cardiac monitor on when giving acetaminophen and ibuprofen and others are not putting it on. I was under the impression that the monitor had to be on prior to giving medications. Is this a must or not?

Can we give a lower dose of Tylenol than the dosage of 960-1000mg as written in our directives? I had a patient who would state she could only tolerate one extra strength Tylenol and taking two would upset her stomach. Would it be wrong to give her 650mg instead of 975mg?

Would it be appropriate to contact a BHP requesting titrated sedation for a compliant and non-combative patient experiencing agitation with inability to remain still preventing proper assessment due to stimulant use? I find these patients are occasionally even difficult to transport due to writhing on the stretcher let alone perform an appropriate assessment.

Hi Doc(s), Two unrelated questions I’ve been pondering over the last couple of days: 1. In the field I’ve noticed some paramedics withhold dimenhydrinate administration if the patient has already taken any Gravol in the last 4-6 hours. However, the medical directive does not specify a time and simply states overdose on antihistamines or anticholinergics or tricyclic antidepressants. My understanding of their logic is that additional Gravol may cause an overdose in the patient however Gravol brand themselves recommend a dose of 1-2 50mg capsules every 4hrs PRN… Could you please provide some further clarification on this practice, and if we should still be administering it if we do not suspect an overdose but that the medication has been taken appropriately. (and similar practice for if the patient is taking tricyclics or anticholinergics as prescribed to them) 2. I recently had a COPD exacerbation patient who I believe would have benefitted greatly from CPAP. He had equal lung sounds through all fields with no paroxysmal chest movement, however there was a recent history of a collapsed lung approx. 6 weeks prior. (Unknown cause, from his history I suspect possibly a bleb/bullae) The current extenuating circumstance of COVID-19 aside, should CPAP be considered in this patient? Although I am not suspecting a current pneumothorax, due to the recent history I would think that weakening of the lung tissues could put the patient at greater risk for a recurrent event if subjected to significant positive pressures. Thank you and stay safe!

As far as the contraindications for ketorolac and ibuprofen, what are the medications that are classified as anticoagulation therapy? I know daily ASA is not but are all blood thinners? Or just specific ones? We have been seeing a lot of eliquis and xarelto lately for example.

Is ASA considered anti coagulation therapy?

I have a question regarding analgesic administration in regards to abdominal pain (ex diverticulitis, hernia). If the pt is complaining of abdominal pain stating “it feels just like my diverticulitis acting up” Or due to hernia pain with evidence of a protruding hernia, would it be appropriate to consider analgesic medication if no contraindications are met? Although you are not 100% certain of the underlying cause in the pre hospital setting

Good afternoon, my question is related to current ACS treatment guidelines. I have had several STEMI inter-facility transfers within the last month or so where attending physicians have initiated pain management with Fentanyl. Upon receiving patient handover from these physicians they often request that this treatment modality be continued throughout transfer. Due to the current AMHA research regarding increased mortality in ACS and STEMI patients who are treated with morphine, is there any move to eliminate this contraindication from the fentanyl protocol, or to remove morphine from the ACS treatment guidelines? If a Physician requests this treatment modality (fentanyl) are we able to patch around this contraindication for fentanyl or would this go against the spirit of the protocol patching around contraindications? If the Physician has initiated treatment with Fentanyl and we have exhausted our nitro protocol or it is contraindicated will we suffer repercussions for not initiating morphine treatment even when it was requested that we do not by the sending physician? Would we require a patch to NOT treat this patient with morphine? Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?

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?

Under the nausea/vomiting directive contraindications include overdose on antihistamines/anticholinergics/tricyclic antidepressants – my understanding is that if a patient has already taken (gravol) then giving another (Ex. 50mg) dose would potentially cause an overdose thus we would withhold gravol in that case. Being that tricyclics are rarely prescribed these days, I have yet to come across this drug interaction in the field. My question is: does any use of tricyclic antidepressants preclude the administration of dimenhydrinate? Or should we only withhold it if the pt. Presents with a tricyclic overdose toxidrome?

Can I only give Fentanyl if my patient doesnt qualify for Morphine?

If I want a faster onset of pain relief can I go straight to Ketorolac IV?

When are PCPs going to get some strong pain medications?

Can Morphine be mixed in 50 ml mini bags for easier administration & easier titration?

Are we allowed to give acetaminophen and ibuprofen to someone who has a headache under the pain directive? I had 2 different patients not too long ago and both were complaining of a headache. One patient just ended up having just a headache while the other patient whom had a headache over several days with no facial droop, slurred speech, equal pupils and equal bilateral grip strengths turned out to be a bleed. Would it be ok to just give acetaminophen to our patients complaining of a headache and hold off on the ibuprofen? Headache is not a contraindication for the pain directive so this is why I am asking.

Question: In relation to the Adult Analgesia directive, one of the indications is “acute musculoskeletal back strain”, does this include injuries such herniated discs, radiculopathies etc.?

Question: If we are presented with a hypoglycemic patient that demonstrates signs and symptoms of a TIA/CVA (slurred speech, inability to hold arms/legs up or due to confusion a grip test) and once the hypoglycemia is reversed with treatment and those signs and symptoms are gone, can we now deliver Ibuprofen/Acetaminophen or Ketorolac if the patient complains of CA related pain or muscle strain as per the Adult Analgesic Protocol?

Question: This question is in regards to hypoglycemia mimicking a stroke. You arrive on scene and the patient is presenting with the classic signs of a stroke such as facial droop, arm drift etc. Patient is out of the stroke protocol since GCS was <10, and the patient was terminally ill due to cancer, with a valid DNR. I obtain a BGL and the BS comes back as a 3.0mmol, so I correct the hypoglycemic event. Moments later a second BS was taken and it comes back as 4.1mmol. Another stroke assessment was done, with no signs and or symptoms of a stroke. Patient then complains of severe cancer related pain in her abdomen. My question is now, would I have been save in not giving the patient any NSAIDS since one of the contraindications was "CVA or TBI within previous 24 hours?" I ended up giving Acetaminophen since I thought doing something is better than nothing for the patients abdomen pain. Along with that, I didn't know if the patient experienced both a CVA and a Hypoglycemic event together at the same time, or if the patient experienced a stroke hidden in with the hypoglycemic event. What are your thoughts?

Question: In the 2015 ALS Companion Document Version 3.3 pg 13, it states this: “A clinical consideration states “Suspected renal colic patients should routinely be considered for Ketorolac”. More correctly, this statement should include NSAIDS like Ibuprofen. Ketorolac is preferred when the patient is unable to tolerate oral medication.

There is some confusion over the interpretation of this. I read this statement as suspected renal colic patients should be routinely screened for an NSAID (not just Ketorolac), and therefore should be given ibuprofen first instead, unless the patient cannot tolerate oral medication. My PPC is saying differently that you should be considering Ketorolac first, since the companion document cannot overrule the ALS Directives. What is the true purpose of this statement then?

Question: This question may be a very rare situation but I have not been able to get an answer from any paramedics I have asked. As per the “Patching” section in the introduction of the ALS PCS the literature states “BHP cannot be reached despite reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required treatment without the requisite online authorization if the patient is in severe distress and, in the paramedics opinion, the medical directive would otherwise apply”. In a situation where a cardioversion is required and the unstable patient is still conscious, it is fairly common practice to ask for sedation and pain control (i.e. Morphine/Midazolam) along with orders for cardioversion. If multiple BH patches cannot be completed and in the paramedics opinion cardioversion is required for the unstable but conscious patient, are we able to administer sedation and pain control? I ask this because there is not a directive that directly deals with pain and sedation prior to delivering the cardioversion, but is common to ask for such direction.

Question: We were presented with a patient on scene who stated she had fallen 2 hours prior. The fall was due to a slip on the ice. There was no LOC, no head injuries or any other neuro deficits. The patients vitals weren’t abnormal and was in a mild state of distress on scene. The only injuries noted were some wrist and knee pain, where there was no obvious deformity or injuries evident but stated both as 7/10 pain. She also mentioned her back was in moderate pain from the fall as well. My partner and I were unsure of whether to provide symptom relief for pain management. Yes there is trauma to 2 different extremities but it was the simultaneous back pain that threw a twist in, as the directive states that the patient must have “isolated hip or extremity trauma.” We were minutes from the hospital and I did ask the patient if the pain was tolerable until we got to the hospital where they would provide more effective pain management, but for future reference it would be nice to no! t have to think twice if put in this particular situation again.

Question: Can you give Ketorolac to a HTN patient (180 systolic)? The PCP directive states Normotension.

Question: In regards to the adult analgesia medical directive, it states “in patients with isolated hip or extremity trauma, ibuprofen and acetaminophen are preferred to ketorolac except where the patient is unable to tolerate oral medications.” It is my understanding that together, they provide similar pain relief to ketorolac. If the patient is in severe pain, but is unable to take acetaminophen due to a contraindication (ex. due to having taken some in the past 4 hours), is it appropriate to administer ketorolac instead? Or is it still preferred to administer just the Ibuprofen at this point.

Question: In the setting of an adult who has extremity trauma with severe pain and has vomited along with nausea, could this patient receive dimenhydrinate with ketorolac?

Question: Under the Analgesia & Moderate to Severe Pain Protocol. What is the definition of cancer pain? And if they fall under the guidelines of cancer pain, what kind of relief would a half dose of Ketorolac provide seeing as they are probably on much stronger medications?

Question: Is daily, low dose ASA considered towards ‘NSAID use in the past 6 hours,’ as per the Adult Analgesia Medical Directive?

Question: In Ask MAC it states : “As for Ketorolac, daily ASA is not considered anticoagulation therapy as it affect platelet function and does not result in a true anticoagulated state.” So PLAVIX (clopidogrel) is also affect platelet function, even though ASA affects the cyclooxygenase 1 (COX-1) pathway, and PLAVIX affect the adenosine diphosphate (ADP) pathway, still I think both PLAVIX and ASA affect platelet function . And I think daily dose of PLAVIX also not a true anti-coagulated state and Ketorolac is not contra-indicated. Please let me know if I am right or wrong by those explanations.

Question: The PCP adult analgesia directive is for “isolated extremity injuries”, if there’s more than one injury is it a contraindication? For example, burns to more than one location (shoulder and a portion of the ant chest) or an ankle and a knee injury.

Question: Just to clarify about Ketorolac. The indications states localized hip OR extremity trauma. Are we to interpret this as isolated (single) hip AND isolated (single) extremity trauma? For example, if an old lady has fallen and broken both wrists, can we administer Toradol?

Question: Under the Adult Analgesia Medical Directive, it indicates that for Mild-Moderate Pain, Acetaminophen and Ibuprofen should be considered. If the pain is mild-severe pain than ketorolac should be considered. If a patient is reporting severe pain as a result of isolated hip or extremity trauma, and the MOI is consistent with severe pain, does this mean that only ketorolac should be considered, regardless of the patients ability to tolerate oral medications?
The way that I read this is that Acetaminophen and Ibuprofen would not be indicated if the pain is severe.