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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- Acute Cardiogenic Pulmonary Edema
- Adult Intraosseous
- Analgesia
- Bronchoconstriction
- Cardiac Ischemia
- Cardiogenic Shock
- Central Venous Access Device
- Combative Patient
- Continuous Positive Airway Pressure (CPAP)
- Croup
- Cyanide Exposure
- Endotracheal and Tracheostomy Suctioning and Reinsertion
- Hyperkalemia
- Hypoglycemia
- Intravenous and Fluid Therapy
- Medical Cardiac Arrest
- Moderate to Severe Allergic Reaction
- Nausea Vomiting
- Newborn Resuscitation
- Opioid Toxicity
- Orotracheal Intubation
- Pediatric Intraosseous
- Procedural Sedation
- Return of Spontaneous Circulation (ROSC)
- Seizure
- Supraglottic Airway
- Symptomatic Bradycardia
- Tachydysrhythmia
- Trauma Cardiac Arrest
If 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.Â
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)?Â
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?Â
Published On: December 7, 2023Are ACPs still allowed to do EJs on patients that we are unable to get IVs on?Â
Published On: December 6, 2023If my asthmatic patient has an anaphylactic reaction do they also get dexamethasone?Â
Published On: December 5, 2023Now that the PCP scope includes utilizing an SGA in patients outside of cardiac arrest, can salbutamol be administered via SGA utilizing the airway adaptor? This would be the same piece of equipment allowing MDI of Salbutamol for BVM, CPAP, CPAP, ETT and SGA.
Published On: October 12, 2023In regards to Dex administration being contraindicated for patients currently on parenteral or PO steroids, can we get some more clarification on what we are referring to specifically – is it basically all steroids? Most patients with COPD tend to be on steroid puffers which presumably would make those patients not able to receive dexamethasone?
Published On: October 12, 2023In 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
Published On: October 12, 2023In 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?
Published On: October 12, 2023I 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?
Published On: October 12, 2023In the latest version of the companion document (v5.1) the following is stated “For a witnessed arrest in the back of the ambulance paramedics should use clinical judgment to decide whether to stay and perform resuscitation or proceed to hospital. Paramedic should perform three full analysis and then proceed/patch or to provide one analysis and go. The paramedic should provide at minimum one analysis. Factors that are part of the decision process include distance to closest hospital, probable cause of arrest, ability to provide adequate CPR/ventilation, shockable vs non-shockable etc..”. I was told during my recert in November that this scenario would warrant a 20 minute resuscitation. Can you please clarify.
Published On: September 13, 2023If My patient goes VSA in the back of the truck (witnessed, first time VSA). We do not do 20 min CPR? Or we do 3 analysis and go after? And/or 1 analysis and go? Does the same apply witness VSA in the home? Do these require patch to leave early? There has been excessive talk over this and little clarification.
Published On: September 13, 2023Refractory V-fib for the new medical cardiac VSA directive. Are we to only get our three shocks and go. Or can we give an additional shock if time permits due to extrication or extenuating circumstances? Just looking for clarification.
Published On: September 13, 2023If we pick up a patient and the patient presents with a positive 12-lead STEMI and you are travelling to the PCI Center and the patient codes, do we run the full 20 minute cardiac arrest protocol, or could you consider STEMI as a reversible cause (Hs and Ts) , analyze once and head to the closest receiving which may not be the PCI due to distance.
Published On: September 13, 2023Hello, with the changes to PCP medical cardiac arrest, since there is no longer a maximum number of analysis are we expected to continue to analysis the rhythm every two minutes on route to hospital if were transporting?. Seems like it would delay our arrival time a fair bit to pull over every two minutes especially in the county. Also, if a confirmed STEMI codes on route, should we be running a full 20 minute resuscitation before continuing transport, or would that be considered a reversible cause to transport after one analysis?. Thanks
Published On: September 13, 2023The new Medical Cardiac Arrest Directive requires 20 minutes of resuscitation on scene. Point # 5 of the Primary Clinical Consideration(s) states …or other known reversible cause of arrest not addressed. My question has to do with refractory PEA and the amount of potential reversible causes (7 Hs 5 Ts). Would it be reasonable to patch for request of early transport in the presence of 3 consecutive analysis of PEA?
Published On: September 13, 2023There has been a lot of debate in regard to the new medical cardiac arrest directive, especially when it comes to pediatric patients (1 day to less than 8 years old). Based on my understanding of the new directive, patients 24 hours old now fall under medical cardiac arrest which states that scene time is now 20 minutes unless you have a reversible cause or 3 consecutive shocks, since TOR would not apply here. Some paramedics express significant discomfort staying on scene for that long if the patient has been stabilized with good airway, quality compressions, and possibly defibrillation. Do you support paramedics leaving early in this setting where everything is done early or do you encourage us to stay on scene for 20 minutes? Does this benefit the patient when they could be receiving life saving drugs in a hospital, also knowing that we will eventually have to transport to a hospital no matter what?
Published On: September 13, 2023Can you please clarify the CPR ratio for different ages with the new neonatal resuscitation changed from 30 days to 24 hours. At what age are we performing 3:1 CPR, 15:2. and 30:2?
Published On: September 13, 2023Question: Can a paramedic in the field rule out ischemic chest pain and not treat with ASA/Nitro due to the chest pain being reproducible? (eg. worse on deep inspiration but radiating down the left arm/shoulder, and sharp pain in left upper chest and pressure across the lower chest). I recently had this call, and was told that you can rule it out based on it being reproducible, but the history and rhythm strip, clinical presentation was leaning more towards cardiac.
Published On: September 13, 2023Should we be piggy backing dexamethson every time we give ventolin if the pt has a history of copd or asthma or 20 pack history.
Published On: May 19, 2023Hello, what are the criteria for identifying hypothermia in a VSA patient? This affects our treatment under ALS PCS 5.1 whether we consider early transport after one analysis. The situation that brought up this discussion was a patient who had been on the floor indoors for a number of days, but still presented with a hypothermic body temperature. If the patient had been found VSA, how would we identify to treat them under the full medical cardiac arrest, or be considered for early transport?
Published On: May 19, 2023In regards to the cardiac ischemia medical directive, the latest indication is now suspected cardiac ischemia. If you have a pt presenting with all signs and symptoms of cardiac ischemia, have given ASA, established an IV, and have given NTG. If the pt’s symptoms improve after administration of NTG should you continue with the directive to the full amount of doses provided the pt still meets the conditions?
Published On: May 19, 2023What is the SWORBHP stance on administering salbutamol in patients with suspected ACPE? Most of us have been traditionally taught that salbutamol in patients presenting with crackles due to suspected ACPE is a negative thing because of the bronchodilation and the risk of flooding a patient. However, there are many studies that argue salbutamol administration could be beneficial. Especially in situations where patients are presenting with both wheezes and crackles, it can get confusing. Where does SWORBHP stand on this topic?
Published On: May 19, 2023In pts with poor peripheral perfusion (ie. sepsis) can we do a blood sugar reading on pts ear? Recently had call where pt was severely septic and we gave glucagon and then dextrose and pts blood sugar kept going down. ER doctor took blood sugar on pts ear where perfusion was better then peripherally and sugar levels were well above normal.
Published On: May 19, 2023For 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?
Published On: April 17, 2023Why is diabetic ketoacidosis different than hyperosmolar state?
Published On: April 17, 2023Is ASA considered a blood thinner? I understand its an anti-platelet and not an anticoagulant but is it still considered a blood thinner?
Published On: April 17, 2023Does the patient need to be actively smoking to count for the Condition of 20 pack-year history in order to administer Dexamethasone?
Published On: March 13, 2023Does Vaping or marijuana use count towards the 20 pack-year history of smoking.
Published On: March 13, 2023The vial of dexamethasone does not say that it can be given orally. Is it safe to give this route?
Published On: March 13, 2023Why are we waiting to implement the cardiac arrest medical directive changes until Feb?
Published On: March 13, 2023For ALS-PCS 5.0: If a patient re-arrested prior to extrication, do we carry out another 20 minutes of resuscitation or do we go after first analysis?
Published On: March 13, 2023Can I attempt the Valsalva on a patient who has chest pain? What if the patient has a clear onset of palpitations, then after onset develops chest pain and or shortness of breath?
Published On: March 13, 2023Why does Ketorolac in the Analgesia Medical Directive have normotensive as a condition, when other NSAID directives do not include a SBP condition?
Published On: March 13, 2023My question is in regards to when an IV certified medic is working with a non-certified medic. If the certified medic establishes IV access and has a lock in place, but doesnt give any fluids or medications can the non-certified medic still continue to attend the call? Or does the certified one become the attending. Specific example would be a Code Stroke where we established IV access prior to leaving scene, but it was originally the non-certified medics call.
Published On: October 4, 2022Should Ibuprofen be withheld for patients suffering possible Crohns, colitis and IBS flare ups?
Published On: October 4, 2022Should we consider cocaine induced chest pain as ischemic and be treating with ASA and NTG? Example: 20 year old male patient midsternal chest tightness. Admits to using cocaine and the symptoms occurring after that. I guess my question is, is the cocaine causing ischemia which causes the chest pain?
Published On: September 29, 2022Have 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?
Published On: September 29, 2022I have a question in regards to the hypoglycemia directive. We were dispatched to a patient who suffered a fall, with history of diabetes. Upon assessment the patient was GCS 15, answering questions appropriately and oriented to person, place, time and event, however the patient was unable to move their limbs, and had loss of sensation in portions of the arms, torso, and legs, as well as a depressed skull fracture. The patient was hypovolemic and hypoglycemic at 3.2, stating he has not been eating or drinking fluids all day. Due to a complaint of back pain and paralysis, the a c-dollar was applied and scoop was used to extricate. Because the patient was secured to the stretcher supine, treating with oral gel was not an option, and transport was a priority. Some of the symptoms exhibited by the patient are concurrent with typical signs of hypoglycemia. In this situation where the patient is NOT altered, but hypoglycemic, with sufficient suspicion to suspect that low blood sugar may be causing some of the symptoms, would it be reasonable to treat the patient with IV dextrose? How do we proceed in situations where patients may be hypoglycemic, are not altered (GCS less than 15) but are unable to tolerate oral glucose or carbs? I can see this being the case for traumas.
Published On: September 29, 2022hello when treating a pt with adenosine the contra indications are active bronchial constriction on exam, the companion document also states that adenosine can cause bronchial constriction in asthmatic pts. so may question is … is an asthmatic pt contraindicated for adenosine tx or is more of a relative vs absolute situation
Published On: July 21, 2022Can you rationalize the administration of Epi prior to salbutamol in severe asthma exacerbation Pt? I know they both have bronchodilatory properties, just curious as to the additional benefits
Published On: June 20, 2022Pt with Hx of URTI and a Dx of Asthma. With all signs of croup (Barking cough, low grade fever, severe respiratory distress) on auscultation you hear stridor and whizzing in lungs. Which treatment should be prioritized? Salbutamol vs Epi (NEB)? Thank you
Published On: June 20, 2022So we had a call to a burn victim that was grossly charred, but was breathing. He started to deteriorate in transport but we made it to the hospital. I was wondering if he were to arrest if that would be a traumatic VSA, I know it’s not a blunt or penetrating trauma but it doesn’t make much sense as a medical cardiac arrest either. Also could a patient meet the standards for an obvious death after patient contact?
Published On: June 20, 2022
