Why is nasotracheal intubation reserved for patients above the age of 8?

Do we still suction neonates immediately after birth?

If our patient has been accepted for Bypass under STEMI protocol, and pt goes VSA on route, in the event of a ROSC do we continue to proceed to Cath lab or do we now reroute towards closest ED?

In regards to the LAMS score, is it to be used for acute changes only if a patient has deficits from a previous stroke? For example, if the patient already has a weak grip and arm drift from a previous stroke with no reports of acute changes, however they have facial droop that is reported to be new then is only the one point for facial droop counted?

Question: with regards to the Trauma Cardiac Arrest Medical Directive, do you support the placement of a pelvic binder on the patient assuming severe blunt trauma? I understand that under the Blunt/Penetrating Injury Standard in the BLS it is stated: “if the patient has a pelvic fracture, attempt to stabilize the clinically unstable pelvis with a circumferential sheet wrap or a commercial device”. Furthering this thought, the Intravenous and Fluid Therapy Medical Directive found within the ALS PCS now states: “An intravenous fluid bolus may be considered for a patient who does not meet trauma TOR criteria, where it does not delay transport and should not be prioritized over management of other reversible causes.” Thinking about this all together has me wondering that if a patient who is VSA secondary to severe trauma is eligible to receive an IV bolus to presumably treat hypovolemic shock, would the use of a pelvic binder be supported in the same way? If so, when would be the recommendation to apply a pelvic binder when treating under the Trauma Cardiac Arrest Medical Directive? Thank you.

Can you give gravol to a normally altered (Alzheimers) patient?

When working as a first response while covid vaccines are being administered in LTC facilities, are all severe reactions to be considered under the anaphylaxis protocol and be given epi and benadryl as per our current protocol?

Since COVID supraglottic airways are highly recommended to be placed in a VSA patient prior to CPR. Is this for medical VSAs or does this apply to traumatic as well?

Question: For a pediatric VSA do you stay and run the full cardiac arrest, (4 analysis) or should you depart scene after the first analysis if they are in a non-shockable rhythm? PCP question.

Question: If our patient goes vsa while on route to Cath lab via bypass approval, and we obtain a ROSC, do we continue to Cath lab or divert to closest ED?

Question: When doing resuscitation on babies born prematurely. Do we consider their corrected age to follow the appropriate resuscitation procedure or do we go by their actual birthday? ie) if baby was born 4 weeks premature, do we consider them to be neonatal and follow 3:1 compression and ventilation rate until they are 8 or 9 weeks after birth?

Question: How fast can a pediatric Pt. burn through glucose stores? Scenario: Called for a 13y/o unconscious. Consumption of unknown amount of alcohol & unknown drugs or amount. AOx0, GCS 4=E2V1M1. Eyes open to pain as only response. Pt stable vital signs on Primary & throughout transport & BGL 5.8mmol/L on scene. Transport to appropriate children’s hospital code 4 CTAS 2with a 25 min transport time. On ED assessment Pt. was given an amp of dextrose as ED found BGL to be “low”…. or not able to read on meter, so possibly less than 1.6mmol/L. Crew’s service meter DID pass daily test procedure as per manufacturer’s guidelines. Thank you

During the pandemic, we have been advised to tape over the suction port on King LTs, and now we are switching to iGels, which also have suction capabilities. Are we to tape over the suction port of iGels as well? Furthermore, if the patient is in need of suction, what are the next steps recommended to safely maintain the airway, as only oral suctioning is recommended? Thank you

Hi, I have a question in relation to the FTT standard. If I had a patient who was VSA on arrival due to a multi-system trauma (no penetrating injuries, only blunt), but does not qualify for trauma TOR because the closest ED is 10 minutes away but LTH is 20 minutes away… am I transporting to the ED or the LTH? I understand for penetrating injuries we are going to LTH if it’s < 30 minutes, regardless of vital signs... but for other situations like the one I am stating, what is the appropriate action?

I know our standards as an ACP for over 18 years but if SVT encounter in a pediatric patient and long transport. If we patched got approval would this be appropriate based off the attached studies and success rate in comparison to the REVERT maneuver?

What exactly are the oxygen flow rates per mask? I was given a different answer (specifically for a NRB) as a working medic than my friend who is in school

If you arrive to a patient who is circling the drain very low heart rate respirations are almost none due to opioid overdose and you take a bgl and it comes back no hypoglycemia would you be wrong to administer naloxone before obtaining a full set of vitals and hooking up the cardiac monitor due to the condition of the patient. (covid times so it meets an inability to adequately ventilate).

When do I use a BVM and an oral airway? If my patient is unconscious then can I use these airway tools?

As per the neonatal resuscitation directive, for greater than >24 hours and the HR <60 do you start compressions right away? (less than onset puberty <60 HR with signs hypoperfusion start compressions) or start with BVM for 30 sec on room air then see if HR goes up? Then go from there.

Why is ibuprofen contraindicated in cases of active bleeding and cva/tbi in the past 24 hours?

Hello! Question about using CPAP during this time. I’ve had a two instances where my patients could’ve potentially benefitted from the use of CPAP, however they had went into cardiac arrest during transport and ended up pronounced at the hospital. I was wondering what you’re thoughts are now, in terms of applying CPAP to a patient who fits all the criteria as long as we wear the right PPE. In our service Level 1(Tyvek Suit, P100, safety goggles, and gloves) is indicated whenever we are to perform an AGMP. Cardiac arrests are one of these scenarios where we utilize the BVM with a HEPA Filter. I was just wondering, since CPAP is withheld do to it being an AGMP why can’t we use it to our discretion with a HEPA filter and wearing Level 1 PPE. The concern is obviously depending on where the patient is located and having CPAP on a patient and then transporting across public space to get to the ambulance is a risk for transmission to others. How do you feel during that instance if we just get on High Flow o2 @15L/min and then once in the back of the ambulance with the exhaust on and having Level 1 PPE on to be okay to use CPAP? Also giving the hospital a pre-alert to have a negative pressure room ready. Sometimes 5cm of H2O(which is 8L/min or can be helpful to a patients breathing. Also just to confirm anything greater than 15L/min of oxygen is considered an AGMP, according to the new research?

In current pandemic situation, nebulized epinephrine is being withheld for those with croup. What management is recommended, should the patient (without hx of asthma) deteriorate (apnea/silent chest) ? Is epinephrine IM an acceptable route? If not, what is the rationale?

Due to known patching issues inhibited by the currently required PPE can the OBHG look at omitting mandatory patch points specifically surrounding Midazolam and Ketamine administration for combative and excited delirium patients. I have never been denied an order for either of these medications and the time required to call for an order increases the risk of injury to everyone involved with the extra time required to complete the call delaying treatment. Second question, can we also look at increasing the maximum dose of Midazolam to 10 mg for combative patients as I have found that often times 5mg is insufficient especially when used on patients with known drug abuse. Or, is it possible for the OBHG to considering opening up Ketamine to be used on combative patients, as its my understanding Ketamine is a safer drug with less side effects?

*Updated* I wanted to clarify, which drugs/treatments are contraindicated after the patient is found to be hypotensive, even if the BP normalizes either with or without IV bolus therapy?

I was just reviewing a 2012 webinar regarding DNR confirmation forms. It was said that a DNR confirmation form is a contraindication for transcutaneous pacing but not for synchronized cardioversion. Is this the case? And if so then why? Also, what about the administration of other ALS drugs such as Atropine, Dopamine, and Adenosine?

Hello, Bit of a long winded question so please bear with me. The contraindication for topical lidocaine in ETI of the unresponsive patient: would it be reasonable to administer topical lidocaine to the unresponsive patient IF required to intubate because of the inability to adequately oxygenate and ventilate (after exhausting all BLS measures) when the patient is showing signs of rising ICP. I appreciate the dangers of intubation in a patient that has rising ICP €“ increasing sympathetic activity, periods of not oxygenating even if not adequate, and ultimately worsening ICP. In the setting of acute brain injury, hypoxia, hypercapnia and hypotension (one episode of each in most of the literature €“ less then 90% or <90mmHg) has show to worsen morbidity and mortality via secondary brain injury. I have read on several websites (life in the fast lane) and a few journal articles that topical (not IV) lidocaine can blunt the cardiovascular affects of intubation. Would it then be a good idea to apply topical lidocaine to these unconscious patients in the event that ETI is deemed the only appropriate means of oxygenating and ventilating a patient with TBI and ICP? Again, I will reiterate that I mean ETI in these patients as a desperate means of oxygenating and ventilating, not routinely. References: Williams AM, Ling G, Alam HB. Damage Control Resuscitation for Severe Traumatic Brain Injury. InDamage Control Resuscitation 2020 (pp. 277-302). Springer, Cham. Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Archives of Surgery. 2001 Oct 1;136(10):1118-23. ODRIGUES, F., KOSOUR, C., FIGUEIREDO, L., MOREIRA, M., GASPAROTTO, A., DRAGOSAVAC, D., TUAN, B., MORIEL, P., MARTINS, L., FALCAO, A.. Which is Safer to Avoid an Increase in ICP After Endotracheal Suctioning in Severe Head Injury: Intravenous or Endotracheal Lidocaine?. Journal of Neurology Research, North America, 3, may. 2013. Available at: . Date accessed: 05 Mar. 2020.

According to the new SWORBHP protocol release May 8th, 2020, IntraNasal Administration is still prohibited (for pain control in the pediatric population & seizure Control) even though it has been deemed as a NON AGMP in said document. 1) Can SWORBHP please re-institute these options since it is no longer an AGMP? 2) Could SWORBHP now consider the addition Midazolam I/N to the combative patient protocol (especially in dealing with the violent post-ictal patient) which would greatly facilitate dealing with these extremely strenuous scenarios while in full Level 1PPE to assists in avoiding PPE breach by venapuncture.

So, just to be perfectly clear, as I have heard this in a round-about way from a few sources… We are not to use high concentration/High Flow oxygen via a BVM with a VSA patient without inserting an SGA – so when treating a VSA pt, we go directly to the SGA without ever using an OPA or NGA, correct? And what are our options if the SGA fails after 2 attempts and we do not have any extra hands to ensure a tight seal on the BVM mask – do we ventilate at all, or just administer compressions and carry on?

When dealing with a patient who is VSA due to a complete foreign body airway obstruction, what is recommended in regards to ventilations and OPA use (during this COIVD-19 pandemic) since inability to clear the airway is a contraindication of SGA use.

Questions regarding intubation. Should we be opting for aggressive airway management with intubation or SGA on VSA patients as well as severely obtunded non-asthmatic patients where patient presentation would allow? Should this take precedence over ACLS drugs during cardiac arrest? When intubated with inline filter in place are we permitted to BVM an normal rate?

How should I proceed if the patient Im treating tells me that they have already self-administered Gravol, within the past hour, but has since vomited multiple times. Do I proceed with IV Gravol as she has likely thrown up her self-administered dose?

*UPDATED* Question: Regarding the removal of “inability to ventilate” consideration for narcan. In a pt who fails the covid screening, and who has overdosed on opiates, spontaneous resp rate <8, low says. Are we to withhold BVM and apply hi-flo mask at 8L and give narcan? Or use BVM as usual to assist ventilations prior to narcan administration. Its the use of the BVM in this pt that is the question

Question: The latest Memo regarding oxygen delivery states “IN ALL CASES where adult patients require high concentration oxygen, use high-concentration/low flow masks with a hydrophobic submicron filter” and then later reads that high concentration oxygen be avoided unless SGA. The instructions for the FLO2MAX mask our service carries instructs you to set the oxygen flow-meter to 15lpm, or to level prescribed by a physician. What do you recommend we set the flow meter at if we use these masks?

Question: What is the best method to cover the King LT suction port? You mentioned this practice during your 2nd podcast.

*UPDATED* Question: A work email came out on April 8 2020 that lists OBHG recommendations. On the list it states to withhold BVM ventilation in all spontaneously breathing patients that do not improve with BLS airway maneuvers and high conc/low flow mask with filter at 10L/min. A site from OBHG on March 20 2020 states to use BVM in patients with a resp rate < 6 or >40 and sats below 85% with oxygen or ETCO2 >50 and increasing by 5 %. I have also read to limit flow rates no higher than 5 L/M on April 8th it mentions 10 L/M. Can you please confirm a change has been made?

Question: Why is SGA preferred over ETT during the pandemic? Will I be penalized if I have to intubate someone?

Question: With the new recommendations for oxygen during the pandemic, Im a bit confused as to what to do if my patient needs >5L NP?

Question: hello, in regards to COVID 19, are paramedics using surgical masks or N-95 when applying Flo2max? will it depend if our patient is screened negative or positive or pending? I understand in AGMP’s we are to use N-95. it is my understanding that Flo2max is a high concentration/ low flow mask system. a second question, would you advise to proceed with applying flo2max rather than NRB masks on all patients who are FREI positive and/or Covid 19 screened positive?

Question: Can you clarify for medications down the ETT (is it only referring to Cardiac Drugs?) : if use of ventolin admin via MDI & BVM in pre-arrest /unconscious state, can follow-up doses with ventolin be administered down ETT post intubation?

Two questions First: Piggbacking on the question regarding nasal cannula vs NRM. Should the service be equipped with a filtered NRM is there a BETTER option between the filtered NRM or low flow nasal cannula. Keeping in mind that the filtered NRM fits large on many pt’s faces and isn’t like CPAP where a good seal is provided. Second: Is high flow oxygen considered aerosol generating where we should be wearing an N95 when providing or no? Thanks!

Questions regarding intubation. Should we be opting for aggressive airway management with intubation or SGA on VSA patients as well as severely obtunded non-asthmatic patients where patient presentation would allow? Should this take precedence over ACLS drugs during cardiac arrest? When intubated with inline filter in place are we permitted to BVM an normal rate?

In light of the COVID 19 crisis occurring and recent posting from the service about the use of the NRB in patients that are experiencing FREI symptoms and potential exposure to COVID 19 with low O2 sats and difficulty breathing, would the paramedics be supported by the Base Hospital if the patient only received a nasal cannula application at max flow rate of 6 lpm or if they were to use high concentration-low flow masks (Hi-OX, FloO2 system).

1)In regards to the bronchoconstriction medical directive with the indication to give epinephrine (severe respiratory distress and cough, with or without BVM, and hx of asthma), does this only apply to patients who screen COVID- POSITIVE? or all patients. 2) Does the new indications for BVM (RR <6 or <40 and SPO2 less than 85% on oxygen) only apply to COVID POSITIVE patients? 3) All other "IN ALL CASES" for medications sent out by SWORBHP (ex. no CPAP, no neb Ventolin, no suctioning) does this only apply to patients screen POSITIVE? OR ALL patients (even if they don't screen positive).

In response to COVID-19 I have two main questions Intubation: With intubation should we be switching to airborne precautions for PPE? NSAIDs: I have read multiple reports from credible sources about withholding NSAIDs from COVID-19 patients. Will this be something coming down the pipe for people who screen positive? Nasal Intubation: Due to removal of CPAP (one of the main reasons nasal intubations became rare) will be seeing nasal intubation reintroduced to services that just removed it as another alternative as we dont know truly when we will be returning to practice as normal?

What is a closed suctioning system?

Does the suctioning restriction apply to all forms of suctioning?

I am seeing information from sources I trust discouraging the use of BVMs (even with filters) and BIPAP for suspected COVID-19 patients with respiratory distress (due to the danger of aerosolizing the virus). NRB use (also not ideal) with early (Safe) intubation (no pre oxygenation with BVM) is encouraged. the last update from SWORBP stated that CPAP should be avoided with suspected Corona virus patients (Im assuming for the same reason), but continuing to advocate for assisted ventilations. Any update on BVM use?

With respect to the Suspected Adrenal Crisis Medical Directive from the ALS PCS, I’m wondering what specific medical conditions would fall under this umbrella because the only one I am familiar with is Addison’s?

As PCPs are we allowed diluting Narcan 0.4mg/ml 1:9 with NS when giving it IV route? (0.04mg/10ml) titrate to effect.

Do we HAVE to take a 12 lead to diagnose SVT?