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
- Emergency Child Birth
- 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
When administering a fluid bolus to a cardiogenic shock patient, what is our targeted systolic blood pressure? Is it similar to that of a ROSC to target 90 mmHg, or reversing hypotension and targeting 100 mmHg?
Published On: June 20, 2022Is it safe to use blanket warmers in the vehicles for warming IV fluids? I know that the infusion of ambient temperature (21°C) intravenous fluid may be a significant risk factor for severe hypothermia and the manufacturer of our IV fluids recommends a 40 °C for a max of 14 days. Do you know if this is being done anywhere effectively and safely and if so what are they using?
Published On: June 20, 2022I just have a question regarding analgesics. A contraindication for acetaminophen is use of it within the last 4 hours. Lets say for an adult patient they took 500mg prior to EMS arrival, would it then be okay to administer an additional 500mg to complete the full max single dose of 1000mg or should you withhold the acetaminophen in honour of the contraindication?
Published On: June 20, 2022Just wondering, I have heard of a few coworkers putting the cardiac monitor on when giving acetaminophen and ibuprofen and others are not putting it on. I was under the impression that the monitor had to be on prior to giving medications. Is this a must or not?
Published On: June 20, 2022Does cpap have to be used with nitro
Published On: March 30, 2022Hello, I have a question regarding the 4th analysis when youre actively calling for a medical TOR. If theyre around Ill speak with family to give them an update on what weve been doing, that Im going to call and doctor and what the outcome of that phone call may be. Often, after Ive had that chat, and made the call by the time Im back the 2mins has passed and a 4th analysis may have been done by my partner. What would you like to see happen there. Do we perform that 4th analysis or is that only performed just prior to departure if were transporting. Thanks for your help.
Published On: March 30, 2022If a patient is given first time Nitro by a PCP IV but then isnt ever actually prescribed nitro by a doctor does this count as prior hx of nitro use? Could a then PCP non IV give this pt nitro the next time they call?
Published On: March 30, 2022Hello, How would you like us to proceed with a young pt (say under 30) who complains of chest pain and describes it as ischemic pain, saying all the right things ex; pressure, heaviness etc. But who is vitally stable and doesnt not appear to be in any distress or severe pain. Would you still like us to treat it as ischemia on the side of caution even though its most likely anxiety/stess etc ?
Published On: March 30, 2022If an IV medic attempts to start an IV on pt and the attempt(s) are unsuccessful do they have to remain the attending medic or can the non IV medic continue to attend the call?
Published On: March 30, 2022Can we give a lower dose of Tylenol than the dosage of 960-1000mg as written in our directives? I had a patient who would state she could only tolerate one extra strength Tylenol and taking two would upset her stomach. Would it be wrong to give her 650mg instead of 975mg?
Published On: March 30, 2022If you attend to an unresponsive patient with diabetes paraphernalia (glucometer kit, dexcom, empty bag of candy, etc) on them and your glucometer is malfunctioning, do you have sufficient cause to administer dextrose or glucagon?
Published On: March 30, 2022When dealing with an anaphylactic patient, the PCP medical directive says to administer up to 2 doses of epi at a maximum single dose of 0.5mg, whereas the bronchoconstriction AND cardiac arrest medical directives are only one dose at a maximum single dose of 0.5mg. Can some explain why?
Published On: January 19, 2022The AHA and COVID-19 guideline has a caveat that states in “suspected or confirmed COVID-19 cases” we should implement the prescribed practices. In the event that the patient in cardiac arrest is not confirmed or suspected to have COVID-19 symptoms is it reasonable to every to pre-pandemic practice of resuscitation?
Published On: January 19, 2022Follow-up question that was asked on 29-Jan-2021 about pulse checks after no shock is indicated. Base hospital answered that pulse checks should occur concurrently with each rhythm analysis. Is this true for those of us that are using S-AEDs rather than manual rhythm analysis? The reason I ask is because First Aid & CPR courses suggest that touching a patient during an AED analysis will introduce artifact that could affect the accuracy of the analysis.
Published On: January 19, 2022Does a prescription of NTG patch count as previous history of use for NTG spray? Would it be a concern that the medication would be administered through a different route and therefore have a different onset of effect?
Published On: January 19, 2022I have had a few calls to nursing homes where the patients IV fell out and the patient is being sent to the hospital for an IV restart. If the patient does not have any complaints otherwise, would an IV certified crew be able to start the IV and patch to not have the patient transported? If so, would this be documented as a refusal? I have always transported these patients but it would be helpful to know if there are other options to avoid an unnecessary trip to the hospital. Thank you!
Published On: January 19, 2022Do you recommend a c-collar in patients with SGA or ETT in order to help prevent tube displacement?
Published On: November 3, 2021Slide in conclusion portion of the course, states capnography waveform is gold standard for ETT/SGA tube placement. Previous slide during course states that this has no been studied on other airway except ETT. Can you please clarify this ambiguity.
Published On: November 3, 2021Hello and thank you for your time everyone. Module 2 point 2 reinforces the concept that high quality CPR is the primary focus for care of an opioid overdose VSA patient. However, It also highlights that naloxone may be administered as long as AHA guidelines for cardiopulmonary resuscitation are adequately being met. Given this point; is it o.k. for paramedics to administer naloxone for these type of VSA patients? The directive book and phone application Medical Cardiac Arrest directive continues to state, “There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. I found it a little unclear whether this segment was reinforcing the concept to not administering naloxone for a VSA patient, or providing guidance that it is acceptable as long as other aspects of care are effectively delivered.
Published On: November 3, 2021I have recently read about recommendations/suggestion for the use of the distal femur as an alternative IO access sites specifically in pediatrics. Is this being considered as an option in Ontario?
Published On: November 3, 2021What is the correct course of action if a pt goes VSA while crew is on scene, (ex. 1st analyses reveals VF, pt shocked, then 2 more analyses 2 min apart- both PEA), then pt starts spontaneously breathing and has pulse (ROSC)…then rearrests 2 min later and is in VF so crew shocks…CPR continued as pt still pulseless. Keep in mind crew is still on scene waiting for fire to show up as crew needs help with extrication.. this situation has happened and 1 crew member had called BHP for direction as it’s ‘grey” area as normally you are transporting by then and would do 1 analysis following rearrest and shock if necessary and continue with transport/CPR.. BHP was not clear just kept saying “follow your protocol” when in fact the crew was but at that point was very “grey”. Would we treat it as a whole new medical cardiac arrest protocol as its a re-arrest on scene until fire arrives? Or what would be the best course of action?
Published On: September 17, 2021Can you TOR someone who is in PEA
Published On: August 5, 2021Given that rapid atrial fibrillation and other tachydysrhythmias can result from myocardial ischemia; is it wise to provide ASA to these patients as a precaution. I am a PCP, and we dont have a defined treatment for pulsed tachycardia.
Published On: August 5, 2021I had a patient who met the criteria for Nitro administration under the ACPE directive. The initial BP was 104/72, with no previous Nitro use, and unable to obtain IV access. The pts blood pressure in the back went up to 143/88 while in the back of the ambulance… can nitro be given now that the blood pressure has increased, even if the pt started <140 SBP?
Published On: August 5, 2021For the IV bolus directive when one of the contraindications is fluid overload, if a patient has CHF and is presenting hypotensive, and is not experiencing SOB but has chronic edema in his/her feet/legs is that technically a contraindication to not bolus? Considering that would fall under fluid overload ? What are the signs and symptoms of fluid overload you guys are wanting us to look out for and be aware of?
Published On: August 5, 2021In regards to an IV that you have established are other medical professionals allowed to use it to give drugs on way to hospital? Back story, picked up a female patient who had just given birth with significant post partum hemorrhage. Midwife onscene was unable to establish a line but you subsequently start one. Midwife wants to push oxytocin through the IV that you have established is this OK?
Published On: August 5, 2021Would it be appropriate to contact a BHP requesting titrated sedation for a compliant and non-combative patient experiencing agitation with inability to remain still preventing proper assessment due to stimulant use? I find these patients are occasionally even difficult to transport due to writhing on the stretcher let alone perform an appropriate assessment.
Published On: August 5, 2021Question in regards to the IM epi in ‘less than 50 year old patients with Severe Respiratory distress, bronchoconstriction, and a history of asthma without other contributing cardiorespiratory comorbidities’ Does this mean if the patients is less than 50 year old with Severe SOB and signs of bronchoconstriction and a history of asthma but also has a history of COPD or CHF, then we do not consider IM EPI?
Published On: April 27, 2021Hi Doc(s), Two unrelated questions I’ve been pondering over the last couple of days: 1. In the field I’ve noticed some paramedics withhold dimenhydrinate administration if the patient has already taken any Gravol in the last 4-6 hours. However, the medical directive does not specify a time and simply states overdose on antihistamines or anticholinergics or tricyclic antidepressants. My understanding of their logic is that additional Gravol may cause an overdose in the patient however Gravol brand themselves recommend a dose of 1-2 50mg capsules every 4hrs PRN… Could you please provide some further clarification on this practice, and if we should still be administering it if we do not suspect an overdose but that the medication has been taken appropriately. (and similar practice for if the patient is taking tricyclics or anticholinergics as prescribed to them) 2. I recently had a COPD exacerbation patient who I believe would have benefitted greatly from CPAP. He had equal lung sounds through all fields with no paroxysmal chest movement, however there was a recent history of a collapsed lung approx. 6 weeks prior. (Unknown cause, from his history I suspect possibly a bleb/bullae) The current extenuating circumstance of COVID-19 aside, should CPAP be considered in this patient? Although I am not suspecting a current pneumothorax, due to the recent history I would think that weakening of the lung tissues could put the patient at greater risk for a recurrent event if subjected to significant positive pressures. Thank you and stay safe!
Published On: April 27, 2021As far as the contraindications for ketorolac and ibuprofen, what are the medications that are classified as anticoagulation therapy? I know daily ASA is not but are all blood thinners? Or just specific ones? We have been seeing a lot of eliquis and xarelto lately for example.
Published On: April 27, 2021What is our responsibilities once a patient has been arrested under the mental health act? Is it considered implied consent? Are we responsible for vital taking, blood sugar and treatment if the BG is below four? Can the patient refused treatment with a decreased BG and a GCS of 14(confusion)?
Published On: April 27, 2021I have two questions with regards to the Bronchoconstriction Medical Directive, under the current (February 22nd, 2021) Considerations for Paramedics Managing Patients during the COVID-19 Pandemic. 1) Are we still only administering IM epinephrine to patients who require BVM ventilations? 2) Are we only administering IM epinephrine under this medical directive to patients presenting with a cough? It was previously stated in the January 4th, 2021 update that: “Paramedics should consider administering IM epinephrine for severe respiratory distress with cough in known asthma patients…” I understand that the top of the new memo states: ” This memo replaces both the May 6th, 2020 and the January 4th, 2021 considerations documents and memos.” Just looking for some clarification on the current practice please. Thank you.
Published On: April 6, 2021With the new bronchoconstriction update, saying you cant give Epi to pts unless theyre <50, does this apply only to the covid guidelines where you can administer it up to 2x if conditions met (asthma, cough, severe respiratory distress) or does the age now apply to the normal bronchoconstriction directive for Epi where you can give up to 0.5mg once too?
Published On: March 30, 2021With regards to pediatric resuscitation, are we to use the pediatric setting on the zoll for only less than 8 years old, or for >30 days to onset puberty? I was reading old Q&A for this, and it was made to seem like we only use the pediatric setting for less than 8 on the zoll, and anything older than that use the adult setting
Published On: March 30, 2021Just a question regarding a pediatric VSA. I was reading some other askmac questions and noticed they had said we use the pediatric defib setting for kids under 8, however if the child is over 8 and less than the onset of puberty, does that mean were still using the pediatric defibrillation setting or the adult setting on the semi-auto zoll?
Published On: March 30, 2021My question is can you TOR an opioid overdose cardiac arrest. The question came up recently and it seemed a simple yes because opioid overdose cardiac arrests are to be run as a standard medical arrest. However, some people have referenced the “very early transport after one analysis… for medication overdose/ toxicology.” This is further confused by the 1-Mar-2012 Ask MAC submission where it was stated you could not obtain a TOR on an OD (but did not specify what type of OD). I am hoping you can provide some clarification on obtaining a TOR during an opioid overdose VSA.
Published On: March 30, 2021Question: Good afternoon. I just have a question regarding a VSA patient scenario. If the patient has a pulse with an SGA inserted (patient tolerates SGA) to give ventilations, how many ventilations would I give? 1 every 10 seconds or 1 every 5-6 seconds? And do I also wear an N95 mask?
Published On: March 4, 2021Question: Could you please give clarification – On a VSA of a suspected opioid overdose, can we leave after the 1st analysis? Half my co-workers say yes and the other half says no, that you must stay to complete 4 analysis. I understand that early transport can be considered in medication overdose/toxicology. Where we are having difficulty with the interpretation of the protocol is “In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive. There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. Some medics are saying that the “continue standard medical arrest directive ” means to complete 4 analysis. My interpretation is, no narcan and continue protocol, which is to consider early departure. Thanks
Published On: March 4, 2021Need some clarification on when we do pulse checks during medical arrest protocol. Do we perform a pulse check after a no shock advised?
Published On: January 29, 2021Question re potential med administration through a PICC line; would it be prudent to patch to Base Hospital for direction/permission to administer Gravol for example, in a pt who is declining additional IV initiation but already has a PICC line established and knowledge of how they self-administer their own medications? Thank you.
Published On: January 29, 2021Is ASA considered anti coagulation therapy?
Published On: January 29, 2021Why was an age restriction of 50 years of age placed on utilizing IM epinephrine for the Bronchoconstrictive Medical Directive in the latest update to the COVID-19 Management considerations?
Published On: January 12, 2021Has SWORBHP considered push dose epinephrine for ACP’s? This treatment is being used for a variety of indications in many paramedic services throughout the globe and has literature supporting it. I know this was brought up in 2017 and one of the concerns was “anytime drawing up medications, there is a risk for medication error”. There was a code epinephrine shortage in 2019/2020 and ACP’s were reconstituting epinephrine from 1:1,000 to 1:10,000 during active cardiac arrest situations without complications.
Published On: November 10, 2020Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?
Published On: November 10, 2020Good afternoon, my question is related to current ACS treatment guidelines. I have had several STEMI inter-facility transfers within the last month or so where attending physicians have initiated pain management with Fentanyl. Upon receiving patient handover from these physicians they often request that this treatment modality be continued throughout transfer. Due to the current AMHA research regarding increased mortality in ACS and STEMI patients who are treated with morphine, is there any move to eliminate this contraindication from the fentanyl protocol, or to remove morphine from the ACS treatment guidelines? If a Physician requests this treatment modality (fentanyl) are we able to patch around this contraindication for fentanyl or would this go against the spirit of the protocol patching around contraindications? If the Physician has initiated treatment with Fentanyl and we have exhausted our nitro protocol or it is contraindicated will we suffer repercussions for not initiating morphine treatment even when it was requested that we do not by the sending physician? Would we require a patch to NOT treat this patient with morphine? Why there is a heart rate range for nitro? what will happen if HR is below 60bpm and above 159bpm?
Published On: November 10, 2020I have a question regarding analgesic administration in regards to abdominal pain (ex diverticulitis, hernia). If the pt is complaining of abdominal pain stating “it feels just like my diverticulitis acting up” Or due to hernia pain with evidence of a protruding hernia, would it be appropriate to consider analgesic medication if no contraindications are met? Although you are not 100% certain of the underlying cause in the pre hospital setting
Published On: November 10, 2020I am an PCP IV certified paramedic, working with a non IV medic. If we have a hypoglycemic patient do I need to attend & consider D10/D50 or can my non IV partner treat the patient with Glucagon instead? Same question for Gravol; do they need to get it IV or can non IV certified medic give it IM?
Published On: November 10, 2020In keeping with the Covid-19 Cardiac Arrest algorithms can Midaz procedural sedation be applied to SGA similar to how it is used for ETT maintenance post ROSC should the pt increase gcs during the ROSC?
Published On: October 7, 2020Is external manual compression of the chest and appropriate prehospital consideration for peri-arrested or arrested asthma exacerbated patients who are showing obvious signs of chest hyperinflation and air trapping. I have read about its anecdotal use on website like EMDocs.net and in the Prehospital Care Journal (Harrison, R. Chest compression first aid for respiratory arrest due to acute asphyxic asthma. Emerg Med J 2010;27:59€“61. doi:10.1136/emj.2007.056119) as a few sources. I have also seen it performed in the emergency department by emergency physicians. I assume with good technique, it can assist with expiration and minimize the risk of barotrauma in these patients who require ventilation. Thank you!
Published On: September 22, 2020Paramedic student here. Question about the medical TOR. Will the BHP grant the TOR after the 3rd analyze, or is the phone call to be made after the 3rd analyze and we are to stay on the phone with them until we have completed our 4th and then they will make their decision?
Published On: September 22, 2020
