Welcome to Ask MAC
Ask MAC is a tool aimed at providing paramedics with an opportunity to find question and answers related to the medical directives, challenging or unique calls, or other relevant topics for discussion.
All answers provided on Ask MAC have been reviewed by and reflect the opinions of the Medical Directors within the Southwest Ontario Regional Base Hospital Program (SWORBHP).
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- Trauma Cardiac Arrest
If I’m doing a STEMI bypass and patient goes VSA, do I transport to nearest ED or continue to go to PCI centre? And could you explain as well If I obtain a ROSC during said transfer, closest ED or continue to PCI centre?
Published On: November 21, 2025If I am certified in manual defibrillation, however in a cardiac arrest call am not confident in my rhythm analysis, can I switch to SAED to help interpret/treat the patient?
Published On: November 21, 2025If patient is experiencing chest pain and all signs/symptoms lead to suspected cardiac Ischemia, and considering ASA. Patient has a history of sensitivity to ibuprofen however takes ASA daily as well as patient took own ASA prior to EMS arrival Am I still alright to administer my own ASA even though patient has hx if sensitivity to Ibuprofen but takes ASA daily?
Published On: November 21, 2025is there any consideration(s) to move away from the ” double syringe method” to a single syringe method for adenosine ?? – using 20 ml or larger syringe meaning adenosine mixed with ns and then pushed as 1 dose – medication and flush ?? various studies have shown that is effective, less operational stressors , and easier to manage then attempting use a stop cock valve, ns line wide open with flushes, etc
Published On: November 21, 2025Revisiting this question from 2020…For a VSA patient who is in refractory vfib after 3 analyses, can we call BHP for double sequential defibrillation (or vector change pad placement) if we have a second PCP unit? This question is asked in the updated context of Dr Cheskis’ DSED study and other Ontario Base Hospitals having already implemented this practice.
Published On: November 21, 2025For Oxytocin administration, can you please clarify if the placenta has to be out prior to. Or can the patient have Placenta in and us administer Oxytocin as long as baby is out?
Published On: November 21, 2025Crew responded code 4 to possible allergic reaction. PT was a bad historian, who states he has a chest pain post being stung by a wasp. Pt had swelling on the left side of his lower lip where he got stung. PT complains of dizziness/lightheaded. PT had no adventitious sounds in the lungs. PT complained of mild nausea with no vomiting. No incontinence. PT complained of weakness as well. During the assessment, pt complains of chest tightness post the wasp sting, all the answers to CP questions were leading the crew to believe that patient was experiencing ischemic chest pain. Pt states he has hx of allergic reaction to bee sting. Vitals: 58, sinus bradycardia with LBBB in 12 leads noted. BP: 86/42, RR 22, Sat of 90%. In this case, pt is showing signs of anaphylaxis with multiple symptoms being affected and known allergen exposure, but complaining of ischemic sounding chest pain. Is the crew to be treating with Epi, or should the crew withhold the epi as patient may have ischemic chest pain and it can worsen the cardiac symptoms?
Published On: November 21, 2025If a PCP crew has a RN onboard from a previous transfer and is assigned a VSA call what is the base hospitals position on said nurse providing ACLS care such as Epinephrine administration if their transfer bag has the medications. What about if a RT is in a similar position when it comes to airway management?
Published On: November 21, 2025The directive now states that we are to initiate transcutaneous pacing immediately if the pt is severely symptomatic/pre-arrest and not delay for IV access or atropine, etc. If they are in a spot that requires a lifting chair to extricate, should we wait until they are on the stretcher to initiate it or initiate then discontinue for extrication, reinitiate, etc. Then how would you like us to move the pt to the stretcher?
Published On: November 21, 2025In regards to endotracheal suctionning protocol, how far can we insert the French catheter? I can’t find the answer anywhere in the protocol book, companion document or BLS standards.
Published On: November 21, 2025Nitroglycerin – SBP drop by one third. Is this a 1/3 drop directly after a dose of nitroglycerin or a cumulative drop after multiple doses/sprays? My understanding was that this 1/3 drop in SBP was being used to determine the pts sensitivity to nitroglycerin. If the pt had mild/moderate SBP drops after each dose it indicated that the pt tolerated nitro well and it was safe to give higher amounts and more doses. However, a large 1/3 drop immediately after a dose of nitro meant that the pt had a high sensitivity to nitro and further tx should be discontinued for pt safety and impending hypotension. Scenario: Ischemic chest pain (Non-STEMI) with an initial SBP of 180mmHg. 1/3 dictates a drop of 60mmHg. After 4 sprays of nitro (with mild SBP drops between each dose) the pts SBP is now 115mmHg. Is this pt exempt from further nitroglycerin because cumulatively their SBP dropped by more than 1/3 OR can I continue to treat because a large 1/3 drop was not seen following an isolated spray of nitro.
Published On: November 21, 2025Is there a reason why epinephrine dosing intervals in cardiac arrest patients is set to q4min instead of q3-5 minutes as per AHA guidelines? By having them set at q4min, it puts the provider in stressful situation trying to sequence the doses at a speicific time rather than a range as suggested by AHA.
Published On: November 21, 2025Hello, I was hoping you can put my overthinking mind at ease. I responded to a traumatic vsa. Single stab wound to the chest with the knife still impaled. Single stab wound to the lower left side of his chest(left of his nipple). He was asystole, very rigored at the jaw but no other obvious signs of “ Obivously Dead Criteria” My question is technically can we deem that enough to not continue resuscitative efforts? Or do they need gross rigor mortis at the extremities or lividity to call it? We decided to run the call as we did not feel comfortable calling it with just rigor at the jaw. Removed the knife as it was impending CPR, applied an asherman seal, rhythm analysis revealing asystole, double NPA with two handed seal and adequate ventilations with equal chest rise and fall with good air entry(did not needle decompress), end tidal of 20-22, IO access and transported. Arrival at the ER, got odd looks from ER team and got questioned why we transported someone who was rigored at the jaw and explained to them that we did not have enough to pronounce them on scene. Hoping you can give some clarification on this challenging scenario and whether I could’ve done that call differently. Thank you!
Published On: November 21, 2025How long after someone took an oral steroid (example prednisone) would be contraindicated for giving dexamethasone within the Bronchoconstriction Medical Directive? The Croup Medical Directive is clear that steroids must not have been taken within the past 48 hours. But, the Bronchoconstriction Medical Directive only says, “Currently on PO or parenteral steroids”. What is considered Currently on – taken within the last 24 hours?
Published On: November 18, 2025When giving Epinephrine for anaphylaxis is it expectable to delay administration of diphenhydramine following the first dose of Epinephrine if it is getting close to the 5 minute dose interval for the second dose of Epinephrine and the patient is requiring the second dose of Epinephrine? My understanding is that Epinephrine in anaphylaxis is the priority medication and I could use clarification as to whether or not it is okay to delay administration of diphenhydramine until after the second dose of Epinephrine if the patient requires a second dose and we were not able to administer diphenhydramine in between the required 5 minute dose interval for the second dose of Epinephrine.
Published On: November 18, 2025Hello, some further clarity/confirmations on the trauma cardiac arrest algorithm is still needed for a rather large group of paramedic students. Note, some of the “greater/less than” symbols in your previous replies show up as papyrus-esque and cannot be deciphered. Please reply with words only in case that issue repeats itself. -A patient with penetrating trauma to head/neck/torso in asystole (and no signs of life): if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, we still patch for trauma TOR, right? Or do we transport to that nearest regular ED? -A patient with penetrating trauma to head/neck/torso in PEA: if nearest LTH is greater than 30 min away, but nearest regular ED is 15 min away, do we patch for trauma TOR (due to over 30 min transport time to LTH) or do we transport to that nearest regular ED that’s 15 min away? -A patient with a blunt trauma and asystole (and no signs of life) automatically gets a patch for TOR, right? -A patient with blunt trauma in PEA would only get a patch for TOR if there was no hospital (regular ED or LTH) that was less than 30 minutes away? Ie. Only patch for TOR if either ED or LTH were both over 30 minutes away. Thanks!
Published On: November 18, 2025I have an question regarding the symptomatic tachy/brady directive. A patient with a hx of atrial fibrillation, currently in a rapid afib at 180 BPM. But they have periods of chest pain and pre-syncope every minute or so due to a sinus arrest lasting approximately 8-9 seconds before they flip back into rapid afib. My understanding is that sick sinus syndrome is often the culprit, which can cause alternating rhythms on an ECG and needs to be treated in hospital. In terms of ACLS and pre-hospital care, which would be most appropriate? cardioversion or pacing? providing indications are met and the pt is unstable. Hypothetically, in different scenario, a patient with an underlying regular/brady rhythm and prolonged symptomatic runs of Vtach. What would be most appropriate in that scenario? Any input you could provide is greatly appreciated! Thanks
Published On: November 18, 2025We recently had a call with a 3 year old being exposed to pepper/bear spray. Although our Pt. was not experiencing any respiratory Sx. During and after the call my partner and I were discussing Epinephrine under anaphalaxis as a possible Tx. If the Pt. airway became a serious concern. What are some thoughts from SWORB.
Published On: November 18, 2025Q: pt has been dx by a doctor with pneumonia and the pt is now septic from not taking anti-biotics. Pt is hypotensive from sepsis and has the crackles in lungs from the pneumonia- not fluid overload from CHF. Is it okay to bolus this pt?
Published On: November 18, 2025Should Midazolam be considered in the management of a trauma patient with trismus? In the absence of tonic/clonic seizure.
Published On: November 18, 2025Question is regarding dexamethasone in anaphylaxis. Scenario of a 50s M stung by a bee, known anaphylaxis reactions in past, no epi pen called EMS. Pt had angioedema, hives, and signs of bronchoconstriction. Pt treated with epi, followed by benadryl and some salbutamol for his bronchoconstriction. Pt has a history of asthma. Causative factor of bronchoconstriction likely being from anaphylaxic reaction to the bee sting, which the bronchoconstriction quickly resolved with epi, benadryl and salbutamol. Could this pt benefit from dexamethasone? Is this part of the expectation if you have anaphylaxis and the pt also has bronchostriction, with indications as described in protocol, that we should follow the protocol including dexamethasone? And while I’m on the topic, thoughts on dexamethasone in anaphylaxis in general, often steroids are given in hospital, could dexamethasone be beneficial?
Published On: April 15, 2025This is a 2 part question: 1) Can we effectively administer the newly Provincially Mandated IntraNasal Glucagon 3mg (we carry 2 of them at our service + 1 I/M 1mg Glucagon) to treat either a BetaBlocker or a Calcium Channel Blocker OD? 2) Can it be used in conjunction with IV Glucagon to be within the therapeutic range of efficacy.
Published On: April 15, 2025Hi 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.
Published On: April 15, 2025As a PCP I am trying to get a better understanding of what orders a BHP can give and when certain orders may be considered outside our scope of practice. My understanding has always been that deviations can be made to most areas of a protocol like age, RR, SBP, LOA, contraindications, dosing levels, # of doses etc., but what about treating conditions or diseases that are not written into the protocol? ex. Tylenol for fever, Glucagon for beta blocker toxicity, energy for SVT or Ventolin for hyperkalemia? Although we are trained in how to use these drugs are we expected to give them for conditions not listed in our protocol, if ordered by a BHP? Thanks
Published On: April 15, 2025how does ” take home narcan kits” that are left with pt and family of opioid use pts fall under the ” dispensing of medication” under the ambulance act. is this considered dispensing of medication by paramedics , of any designation, pcp , acp or community paramedic as SWORBHP social media post(S) about dispensing medications was recently released across multiple social media platforms
Published On: April 15, 2025In 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?
Published On: April 14, 2025If 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?
Published On: April 14, 2025From my understanding, the narcan in suboxone is in there in order to abstain individuals from using the drug incorrectly, ie. Crushing and inhaling or injecting, but administered correctly, the narcan gets eliminated via the liver. My question is how does inhaling and sublingual administration differ in terms of first pass? I always thought sublingual administration circumvented the first pass effect. I understand the protocol states oral administration and may not be sublingual but I am just curious about the mechanism of action since suboxone is often administered sublingually. Thank you
Published On: April 14, 2025For a pt who has sustained a head injury and is combative, as an ACP are we able to give low dose midaz or ketamine if required for everyone’s safety? Obviously you don’t want to alter them more but if we are unable to safely transport them is there anything we can do? Or just get police to help restrain them. Thanks.
Published On: April 14, 2025With regard to the croup protocol, I am looking for clarification on the indication of “history of URTI.” Does this need to be diagnosed in hospital, or can recent symptoms of an URTI be enough? If the symptoms are enough, how long should the patient present with them for it to qualify as an URTI?
Published On: April 14, 2025The 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.
Published On: April 14, 2025What is considered suspected cardiac ischemia? Is it just the presence of chest pain/ discomfort (heaviness or tightness). Are chest palpitations considered a chest discomfort as well?
Published On: April 14, 2025If we have an asthmatic patient that is refusing transport to the hospital after administering salbutamol, should we still proceed with dexamethasone administration?
Published On: April 14, 2025My question is in regards to our traumatic TOR protocol – more specifically, why is a trauma TOR ALWAYS contraindicated for penetrating trauma to the torso or head/neck when the LTC is <30mins away? I am looking for clarification and rationale on this because this contraindication seems to be all-encompassing without taking other clinical factors into account (ie. extent of injuries, pts age, complications of resuscitation, presenting rhythm, medical hx, etc.) For example: I attended a traumatic VSA, <30mins from the LTH. Pt was 90yo with a suspected self inflicted gsw to the head. In this incident there was no definitive time of arrest and the pts presenting rhythm was asystole. Entry wound identified to the head, no exit wound and no gross distortion of anatomy (did not meet any obviously deceased standards). The initial crew was unable to secure/maintain the pts airway due to bleeding in the pts airway - indicating that there was no oxygenation/ventilation during the initial resuscitative efforts. I may be wrong but I believe that this pt arrested due to anatomical injuries rather than exsanguination. This pt sustained grievous injury not conducive to life for which there is no definitive tx. This pt is an extreme case; pt was elderly, on blood thinners, sustained irreversible injury, asystolic arrest with complications during care. However, none of these clinical factors are applied to our trauma TOR. I am reaching out for clarification/rationale as to why this pt should not be routinely considered for a trauma TOR.
Published On: April 14, 2025I 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!
Published On: January 7, 2025When having a pt with a spontaneous abortion at 12 weeks. Fetus is visualized on scene and pt is having vaginal bleeding as well as intense cramping (10/10) that comes and goes occurring ~3-5 minutes. Would it be appropriate to give Oxytocin for the hemorrhage?
Published On: January 7, 2025My question is in regards to ASA being a contraindication for the administration of ibuprofen or ketorolac. I understand that ASA is classified as an NSAID, but in a previous ASKMAC, it was stated that ASA in low doses like baby aspirin is NOT a contraindication of the administration of ibuprofen or ketorolac. More specifically, i would like to know if the dose used by medics for cardiac ischemia (160-162mg ASA) should be considered a contraindication for the admin of ibuprofen or ketorolac. If a patient was initially c/o chest pain that resolved itself after ASA and nitro x1, is it acceptable to treat a 10/10 severe headache that the patient has been experiencing intermittently x2 days if there are no other contraindications?
Published On: January 7, 2025I was just curious about a possible contradiction in the Trauma TOR VSA Conditions/Contraindications. In the updated Trauma TOR Conditions it lists that a condtion as “Signs of life when fully extricated with the closest ED >30 min transport time away”. However in the following contraindications it lists “Signs of life at any time since fully extricated medical contact” as contraindicated for the TOR. My question is, in a scenario of a Trauma TOR eligble patient that has signs of life after full extrication, then becomes VSA, would the Trauma TOR apply or not? Would distance to the hospital come into play?
Published On: January 7, 2025In regards to the contraindication for NTG regarding SBP dropping by 1/3 or more, should we basing this off the very first BP obtained on that call, or a BP obtained right before NTG usage? Ie. ischemic chest pain 00:00 BP of 180/100 00:03 SBP of 150/90 00:04 NTG usage 00:09 BP 115/75. In this case a 65 (180-115) point drop would rule us out if 1st BP counted, but a 35 (150-115) point drop would not rule us if BP prior to NTG used. As pts can often be particularly stressed/anxious right when we walk in the door, it would make sense to me that the BP closest to actual administration would be most indicative of their true clinical state.
Published On: January 7, 2025What constitutes as tbi? Does every fall were the person struck their head mean that they can not have any pain management or is there a symptom we can look for to narrow down the risk of increasing bleeding?
Published On: January 7, 2025If I attend scene and the patient has already received care outside of the 911 system (i.e. fluid bolus with homecare or community paramedicine), and they are still hypotensive, can I provide further care via the ALS-PCS (i.e. fluid bolus for a hypotensive patient)? Would I only be able to give 20cc/kg IVF bolus including the fluid administered before my arrival?
Published On: March 21, 2024If I have successfully inserted an SGA and then have to remove it, due to vomitus; do I have 2 further attempts at re-insertion, or is it 2 attempts total despite having successfully completed an insertion previously?
Published On: March 21, 2024This 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?
Published On: March 21, 2024If 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.
Published On: March 21, 2024I need some clarification on the updates to the trauma arrest algorithm. With a patient with penetrating trauma in asystole with LTH less than 30 minutes are we to transport to the lead trauma hospital as we do with PEA? Also, if the lead trauma hospital is greater than 30 minutes, I am assuming we transport to the closest ED with both asystole and PEA with penetrating trauma.
Published On: March 21, 2024In 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?
Published On: March 21, 2024In a challenging scenario: You respond to an unplanned home birth on a stormy winter day, with a backup unit facing delays due to adverse weather conditions. Upon arrival, you encounter a situation where a baby requires neonatal resuscitation, while the mother remains in a stable condition. Is it advisable to consider leaving the mother on site and transporting the newborn?
Published On: March 21, 2024With the new protocol books for ACP: under the hyperkalemia directive there is no dosage of salbutamol. Was this a printing error or are we no longer giving salbutamol.
Published On: December 11, 2023If 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)?
Published On: December 8, 2023Is there a pharmacological benefit to administering dexamethasone PO vs IV/IM or is it the preferred route simply to avoid unnecessary sharp use?
Published On: December 7, 2023
