I had a call the other day, 40s female with 7/10 central chest pressure radiating to her left arm, under left breast. PT said that how she felt now is identical to how she felt a few years ago; she had SCAD as in sudden coronary arterial dissection then and had stents put in. How does ASA and nitro play a role in this case, because it sounds textbook ischemic but with such a rare and bizarre medical history. Please let me know what you think?
In the analgesia directive, along with the nausea/vomiting directive is has “unaltered” as a condition. Is this written for the acutely altered patient who has a TBI for example? If we have a patient with a baseline GCS of let’s say 13-14 with dementia who presents with pain and/or N/V but no decrease in baseline mental status, is a patch required, or are they considered unaltered from baseline?
When we do a 12-lead and have inferior involvement, the directive states that we assume there is right sided ventricular MI and must confirm with V4R, and then states we should never give nitro for right sided ventricular STEMI. All of that is clear, but what I am wondering is that if the V4R is negative, does that clear the pt for Nitroglycerin use for the inferior STEMI, or does that simply help confirm the STEMI for the emergency department? Thanks.
If a patient has self-administered benadryl prior to our arrival, should a paramedic re-dose under the Allergic Reaction Medical Directive? There appears to be no contraindication for this in the directive. As well, the direction per the Medical Directive in the OBHG Companion Document is, diphenhydrAMINE administration should always follow the administration of EPINEPHrine as outlined in the Medical Directive. However, I have heard from my more senior colleages that we should not re-dose the benadryl, like we can the epineprhine. Can you please clarify?
Question regarding procedural sedation. During a recent call we had a patient that was believed to be flash pulmonary oedema (audible crackles, blood tinged frothy sputum, confusion). The patient was quite agitated, wouldnt answer questions, resistive to any intervention or assessment, resistant to vitals and non-tolerable of O2 via any route and had difficulty remaining still. Is it reasonable to consider sedation for these patients? Would this be considered a special circumstance requiring BHP consultation? Would Ketamine be the drug of choice over Midazolam?
New Protocol First Arrest On Route If my patient becomes VSA on route (first arrest) am I to complete the full 20 minutes of resuscitation roadside and then continue transport? Our previous protocol was to complete the full arrest protocol and continue transport. Should you be a short distance from the hospital would a BH patch be suggested or should we perform the 20 mins of resuscitation regardless of proximity to the hospital? Thank you. minutes? I understand the research is trending towards scene times longer than 10 minutes for pediatrics (in some studies) and that earlier epinephrine administration has been associated with ROSC but this also leaves PCP only rural services in a very difficult grey zone to be addressed. I am by no means advocating for a “scoop and run” mentality (the new wording in the directive rules that out quite nicely) but any further guidance or clarification is greatly appreciated!
With the new medical cardiac arrest directive I have multiple questions: 1. If a patient re-arrests after getting a ROSC do we a) start the 20mins over? B) analyze once and then carry on to hospital with no further analyzes, or c) complete the remainder of the initial 20mins of CPR? Also does this answer change if the ROSC is at the initial site or in the back of the ambulance? 2. If patient arrests for the 1st time in the back of the ambulance, do you stop for the whole 20mins of CPR, does location of arrest to hospital make a difference? 3. If you have a refractory v-fib and we start early transport to hospital, do we continue to pull over and shock every 2 mins or so we stop shocking while on route to hospital?
In regards to doing a Stroke Bypass for a palliative patient that is not end-stage, the directive clearly states Terminally Ill or palliative care patient. I think the blanket term palliative care patient is misleading, as many people who are palliative are not close to dying. Are we to make our own decision about ‘how palliative’ a patient is and only apply this portion of the directive if they are truly end-stage? I think there should be something about their goals of care in the directive or something more clear so as to not rule out patients just because their palliative status (which could still allow them a good amount of time with quality of life). I think many medics may call for direction in this case, but there are others who would read the directive verbatim, thereby causing some patients to miss out on life-improving interventions. Is there any direction on this or am I on the right track with my thinking?
What is considered the most appropriate means of transporting a pediatric patient? Is securing a child/infant in a car seat provided by parents to the stretcher better than securing them in the neonate or pedimate? We have the pull down jump seat for toddler booster seat, but would like to know what our BHPs think of the car seat on stretcher versus pedi/neonate.
Would SWORBHP be ok with ACP paramedics utilizing the 4-2-1 rule for fluid maintenance rates in paediatrics. Especially, with the high incidence of RSV in the community compounded with sick kids who aren’t taking in as much fluids and may be fluid depleted. Their fast respiratory rates and poor feedings, fever etc increases the insensible fluid loss. I can appreciate the current model, for fluid boluses utilizing the 70 mmHg + (2 x age in years). However, at this point they are decompensating rapidly with the hypotension and progressing to pre-arrest (with signs of delayed peripheral and central cap refill, looks sick as per PAT etc). Is the current protocol 15 ml/hr for
I was just wondering if SWORBHP is still maintaining the same stance for pediatric medical cardiac arrest (as discussed in the May 2022 Tip of the Week and other posts) for the new medical cardiac arrest directive in ALS PCS version 5.0? Is paramedic judgement still recommended for rhythms not amendable by defibrillation or is it expected that we run the cardiac arrest on scene for the full 20 minutes? I understand the research is trending towards scene times longer than 10 minutes for pediatrics (in some studies) and that earlier epinephrine administration has been associated with ROSC but this also leaves PCP only rural services in a very difficult grey zone to be addressed. I am by no means advocating for a “scoop and run” mentality (the new wording in the directive rules that out quite nicely) but any further guidance or clarification is greatly appreciated!
I have a scenario that happened and would like to know what the right answer is. We had a patient feeling generally unwell and dizzy. I performed a stroke assessment and he had equal grip strength, no pronator drift, and could raise both of his legs. There was no facial droop, slurred speech, or unilateral weakness. When we were transporting we noticed the patient was severely leaning to the right. He couldnt support himself upright at all, but everything else remained intact. Is this enough evidence to count as unilateral weakness? Would you stroke bypass?
This is a BLS question. For management of a flail chest, most research suggests that we tape the flail segment in place with a large bulky dressing, bag of saline, Asherman chest seal, etc. I’ve been hearing from recent PCP graduates that they have been taught to use a bulky dressing, however they mention that they are being taught to do a circumferential wrap around the chest with a triangular bandage or blanket to hold the dressing in place (which I would assume is incorrect) instead of taping a bulky dressing over the flail segment. What would be the preferred method and why?
Hello! Question for you. If we have a patient who is complaining of unilateral weakness or numbness, but on exam has equal grip strength, no facial droop or slurred speech, and equal strength in both legs, what would be the appropriate destination? Should we still stroke bypass to the nearest stroke center? To clarify, the patient feels as though they have weakness or numbness on one side of their body, but we are unable to find any deficits on our physical stroke exam (LAMS score of zero).
Question from an ACP role, For a pediatric patient who has a HR less than 60 with poor signs of perfusion (cyanosis/pale and apneic€¦..start chest compressions with airway and ventilations via BVM. The question is do we follow it up with epi? In the PALS algorithm it states to do CPR/ventilations, epi, atropine and consider pacing. This is covered under the newborn arrest directive however it is not covered under the adult/pediatric medical cardiac arrest. What does our base hospital want us to? Would it be appropriate to follow the PALS Bradycardia algorithm?
I recently attended a CVA/TIA related call; it had been the first CVA related call I had been to since having a 4-year hiatus out of the trucks. Since being out the trucks the CVA consult/bypass protocol has been implemented. I’m having a difficult time understanding the point of the consult. If the Paramedic on scene is able to identify CVA symptoms accurately/appropriately, why are we delaying transport to discuss with a physician, who is not on scene, if we should transport to the appropriate stroke facility? It was explained to me that Paramedics weren’t correctly identifying CVAs pre-hospital. If that’s the case, those that aren’t recognizing a CVA aren’t performing a consult because they didn’t recognize the CVA in the first place. If I can identify a CVA correctly, announce a code stroke to dispatch, and have the stroke team ready on our arrival, how can there be any benefit to calling someone who knows nothing about the incident other than what I tell them? What is the difference between a doctor incorrectly identifying the CVA over the phone versus the Paramedic incorrectly identifying the CVA on scene other than the 15 minutes saved not trying to call for a consult? There also seems to be some significant discrepancies as to the onset of symptoms time frame between different receiving hospitals and physicians. Our destination guidelines clearly state within 6 hrs of onset of symptoms; however, recently a fellow medic advised me that it was 8 hrs but our guidelines have not yet been changed to reflect this, and a physician told me the window is 12 hrs. Any clarification/suggestions/info would be greatly appreciated. Thank you so much!
What is the rule for stroke bypass when symptoms resolve on scene? It doesnt specify for this scenario in the directive, and only says continue to bypass if symptoms resolve on transport. In this case our patients had stroke symptoms for 1-2 minutes that quickly resolved and he no longer had any symptoms. What is the most appropriate hospital in this scenario?
Hello I attended to a patient who was in adrenal crisis from Addisons disease. Pt presented with nausea/vomiting for 4 days, hypotension, GCS 14, tachycardia, fever of 38.8 tympanic with all other vitals within normal parameters. Pt had no food and minimal water intake for those 4 days. Pt had medic alert bracelet with adrenal crisis on one side and cortisol on the other. Pt states she has been taking her medications as prescribed. We asked pt if she had a vial when she was in an adrenal crisis and she said yes in my car and her family member went and got it. When they returned crew found it to say dexamethasone. My question is should we have called BHP for orders to give dexamethasone as our directive states hydrocortisone only for adrenal crisis pts.
Hello, question regarding cervical collar application. The BLS states that a collar should be applied with appropriate MOI if the Pt is altered LOC – however the Canadian Cspine flow chart states that cervical collars should only be used on stable, ALERT Pts. Is this a grey area where it is expected we use our judgement in terms of when it is appropriate to apply a collar vs manual cspine management? Or is there a certain GCS where manual cspine management is preferred over applying a collar? Thank you.
Should I ask for a DNR in every scenario where I may use what’s contraindicated? If I were to show up for an unconscious but not VSA female and her husband is on scene and doesn’t mention the DNR, should I assume they want treatment and continue with inserting an OPA and bagging if necessary or should I ask for a DNR before starting treatment? Would I get in trouble in this scenario if I treated this patient without the husband saying anything and then once we got to the hospital found out they had a DNR?
Hello, two questions. 1. If I am bagging for a patient in respiratory distress but they do not have a supraglottic airway in, how would I measure their end tidal? Will just attaching my end tidal to the bvm without that same seal provide an accurate reading? 2. If I am assisting ventilations via BVM for a COPD patient who is in respiratory failure should I be concerned about their SpO2 going up to 100? Our current BVM’s don’t have a way to adjust how oxygen they are getting. I don’t want to make my COPD patients hypercapnic by delivering too much O2.
Good day, forgive me if Im mis-reading this, but CPER digest Oct 2021 just published an info-graphic suggestive of staying on scene to run a complete 4 analyses in the case of a pediatric cardiac arrest with a suspected cause/history which is highly suggestive of hypoxia/respiratory in origin. The rationale that theyre presenting is that youve got an arrest where CPR and artificial respirations are our best bet for reversing the cause of the arrest. Any discussion related to this? I believe that our current SWORBHP directives are to depart after 1 analysis for a suspected reversible cause of arrest, (unless the rhythm is shockable). Thanks for any clarification that you can provide.
Curious. Obviously, the previous standard for spinal injury was full immobilization on a spinal board. BLS v3.3 currently states that those with suspected unstable pelvis should be secured onto a spinal board or breakaway stretcher (Scoop). We are then being referred to the blunt/penetrating trauma standard. There it also states to secure onto a spinal board or breakaway stretcher, and secure the lower extremities to reduce further injury/trauma to the pelvis. My question is, what is the current acceptable standard for this immobilization as per SWORBHP. Should this be full immobilization, 4 straps, headlocks etc? I do not see this written anywhere, and just looking for clarification as no one I ask seems to know the answer. Thanks
Antiemetics: unrelated to our current directives but I was just wondering what the rationale was for specifically using dimenhydrinate as our prehospital antiemetic option? As I understand it, and I’ve had a number of conversations with physicians of different disciplines regarding the same, dimenhydrinate is most effective for motion sickness, and other antiemetics exist that are typically more effective for the types of emesis that we typically deal with in the field.
In the Toradol protocol it simply uses term “current/active bleed” as a contraindication, the companion document provides little clarification as to how this applies to trauma pts as trauma was removed as a contraindication. Would trauma with high index of suspicion for internal bleeding (MVC, Motorcycle accident, fall from height) be a contraindication? Would multisystem trauma pts? Or would the better course of action be to treat their pain? Thanks!
You have a patient that is VSA from penetrating trauma. The bls states you transport to trauma hospital if less than 30 min. The als pcs states that if your patient VSA from trauma and a TOR does not apply (pt in PEA) you transport to closet ED. So which one is correct the BLS to trauma hospital or ALSPCS to closest ED.
My question is regarding STEMI bypass and hyperacute T Waves. We were called out for a 60’s male patient experiencing chest pain after some physical exercise. It was quite apparent patient was likely having a cardiac event upon arrival and first examination. Patient had 8/10 midsternal pain (pressure) with radiation into shoulders. Patient was clammy, cool and diaphoretic. Patient had a weak radial pulse. After giving ASA 12 leads were obtained. Each showing hyperacute T waves in the chest lead V2 – V5. No elevation is noted, upon multiple 12 leads. No nitro was given as heart rate was below 60, but a lock was established. Patient was stable and wouldn’t have any of the contraindication to STEMI bypass. We are a rural service and closest hospital is 7 minutes away and transport time to the cath lab would be roughly 25 minutes. Just curious how base hospital would like us to proceed on these calls in the future? a – go directly to closest hospital as there is no elevation yet and doesn’t quite meet STEMI bypass b- call the closest cath lab and let the cardiologist decide c- first call base hospital to ask for further direction to see if cath lab should be called, then proceed from there. Thanks in advance
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