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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  • Question 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, 2025
  • This 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, 2025
  • Hi 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, 2025
  • As 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, 2025
  • how 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, 2025
  • In 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, 2025
  • If 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, 2025
  • From 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, 2025
  • For 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, 2025
  • With 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, 2025
  • The 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, 2025
  • What 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, 2025
  • If 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, 2025
  • My 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, 2025
  • I 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, 2025
  • When 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, 2025
  • My 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, 2025
  • I 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, 2025
  • In 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, 2025
  • What 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, 2025
  • 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, 2024
  • If 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, 2024
  • 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?

    Published On: March 21, 2024
  • 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.

    Published On: March 21, 2024
  • I 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, 2024
  • In 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, 2024
  • In 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, 2024
  • With 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, 2023
  • If 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, 2023
  • Is 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
  • Are ACPs still allowed to do EJs on patients that we are unable to get IVs on? 

    Published On: December 6, 2023
  • If my asthmatic patient has an anaphylactic reaction do they also get dexamethasone? 

    Published On: December 5, 2023
  • Now 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, 2023
  • In 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, 2023
  • 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

    Published On: October 12, 2023
  • 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?

    Published On: October 12, 2023
  • 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?

    Published On: October 12, 2023
  • In 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, 2023
  • If 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, 2023
  • Refractory 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, 2023
  • If 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, 2023
  • Hello, 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, 2023
  • The 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, 2023
  • There 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, 2023
  • Can 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, 2023
  • Question: 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, 2023
  • Should 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, 2023
  • Hello, 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, 2023
  • In 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, 2023
  • What 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, 2023