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 Childbirth
- 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
Is 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, 2020Under the nausea/vomiting directive contraindications include overdose on antihistamines/anticholinergics/tricyclic antidepressants – my understanding is that if a patient has already taken (gravol) then giving another (Ex. 50mg) dose would potentially cause an overdose thus we would withhold gravol in that case. Being that tricyclics are rarely prescribed these days, I have yet to come across this drug interaction in the field. My question is: does any use of tricyclic antidepressants preclude the administration of dimenhydrinate? Or should we only withhold it if the pt. Presents with a tricyclic overdose toxidrome?
Published On: September 22, 2020When we have a patient who is sob and we have decided to put CPAP on, what code and ctas is mandatory even though they are stabilized because of cpap? Is it code 4 ctas 1 always? And are we suppose to pre alert for an RT?
Published On: May 21, 2020What is the difference between medical and traumatic electrocution?
Published On: May 21, 2020If a dentist administers nitroglycerin to a patient who has no previous-prescribed use; does this constitute prescribed use at this point?
Published On: May 21, 2020*Updated* Why do we need to establish an IV in a patient with suspected pulmonary edema? If they fit the directive, they more than likely have crackles which would be contraindicated for a fluid bolus.
Published On: May 21, 2020Question: The latest Base Hospital Memorandum from April 6th says we are to withhold suction via an endotracheal or tracheostomy tube unless using a closed system suction unit. Does this mean we are to withhold suction ONLY via endotracheal or tracheostomy tube? Can we suction an airway full of vomit or blood?
Published On: April 27, 2020In a previous response to a question, it was mentioned that the SGA is an effective way to create a closed system and reduce risk of aerosolization when ventilating. Would it then be reasonable to go directly to the SGA in the setting of VSAs, to further protect all those involved in the resuscitation from possible aerosolization with an OPA/BVM?
Published On: April 21, 2020Question: Was just reviewing the SWORBHP document that came out yesterday, just hoping for a little clarification RE bronchoconstriction. In the document it states that we should consider IM administration of Epinephrine for severe respiratory distress w/ cough, hx. asthma. It also states that we should consider using MDI salbutamol only for severe respiratory distress without a cough… My understanding of it would be that we want to keep a surgical mask on the pt. to minimize risk of droplet transmission via cough which you cant do while administering medication via MDI. I understand that if the pt. Has a cough we should use epinephrine as our first line medication same as we normally would if the pt. Is apneic but Are we to be considering these two separate cases for use of these medications and not giving them concurrently during this pandemic? Just wondering as I did not see it specify whether or not we should considering withholding ventolin if there is a cough.
Published On: April 8, 2020Question: Who can receive IM epi under the new COVID-19 considerations?
Published On: April 8, 2020Seeking clarification for salbutamol administration down ETT based on the Ask MAC posted April 3rd regarding ETT administration: Are we still able to use our MDI-adapter wherein the MDI canister is inserted and left in, creating a closed-system circuit?
Published On: April 6, 2020With regards to considerations for Bronchoconstriction it says that with severe resp distress and a cough (with or without need for BVM) that we can consider IM epi as per the bronchoconstriction medical directive. Does that mean they still need to have a hx of asthma?
Published On: March 23, 2020Are we entitled to the scientific reasoning why we are no longer providing CPAP to patients? What is the expectation when I am unable to confirm COVID-19 and my immediate presentation would improve with CPAP administration?
Published On: March 23, 2020My question comes from the Medical Cardiac Arrest Directive and specifically in relation to the clinical considerations section. I have two questions relating to this.
First of all, the medical directive lists medication overdose/toxicology as a circumstance where the paramedic can consider very early transport after the 1st analysis. My question is can this also apply to overdoses from recreational drugs? It touches on cardiac arrest with associated opioid overdose but doesn’t go into great detail besides the role of naloxone in these circumstances.
Secondly, it lists pediatric cardiac arrest as a situation where we the paramedics are to plan for extrication and transport after 3 analysis. However due to the rarity of this circumstance and the likelihood of its origin resulting from a reversible cause would the paramedic be correct in transporting these patients immediately following the 1st analysis?Published On: February 4, 2020For a VSA patient who is in refractory vfib after 3 analyses, can we call BHP for double sequential defibrillation if we have a second PCP unit?
Published On: February 4, 2020For pediatric patients, are we supposed to get orders solely from pediatric physicians or can we get orders from physicians an adult ED? Are the pediatric physicians also in the base hospital program?
Published On: February 4, 2020Is a suspected pelvic fracture a contraindication to IO in the tibia?
Published On: February 4, 2020How does SWORBHP suggest measuring the correct dose of Hydroxycobalamin to a pediatric patient? The Cyanokit is provided as vials that are to be reconstituted with normal salient diluent. The pediatric dose is 70mg/kg, given over 30 minutes. Unlike our other pediatric-dosed medications, this system does not allow for us to easily measure the exact dose given as there are no mL markings on the bottles. Sny help is greatly appreciated.
Published On: February 4, 2020Does wheezing have to be present in the patient assessment to administer Ventolin?
Published On: March 28, 2019Our directives state that we are allowed to administer 2 doses of epinephrine to a patient suffering from a severe allergic reaction and 1 does to a VSA patient who is expected to have become VSA secondary to anaphylactic shock. Does this mean we are allowed to give a 2nd and possibly 3rd dose of epinephrine to a patient by following the moderate to severe allergic reaction medical directive post ROSC?
Published On: March 28, 2019How do I properly patch for rolling medical TOR or cease resuscitation order, especially in instances involving a public place?
Published On: March 28, 2019If I am in a first response truck and have no shocks, do I have to wait until the transporting unit gets there to call for a TOR or can I call when I meet all the criteria?
Published On: March 28, 2019Are there any expected changes coming in regards to transporting an organ donor VSA patient? Is there a more appropriate receiving facility to consider and what should we do with an organ donors body after obtaining a TOR?
Published On: March 28, 2019Wondering what your thoughts are in regards to administering nitro to a patient with atypical angina symptoms and no presentation of chest pain. For example, is it ok for us to administer nitroglycerin if a medic is presented with a female patient who states she becomes nauseated from angina and explains she is prescribed nitro for the symptom? I discussed this question with my colleagues and I have found there is a 50/50 split in regards to those of us who would use nitro or not. I think it is a good question to ask given the differencing of opinion in the field.
Published On: March 28, 2019If patient receives ASA from a certified provider, such as but not limited to other paramedics, doctors/nurses from clinics, are we required to administer another dose of ASA to the ACS patient. Also, does the patient have to have chest pain to administer ASA?
Published On: March 28, 2019Are we allowed to give acetaminophen and ibuprofen to someone who has a headache under the pain directive? I had 2 different patients not too long ago and both were complaining of a headache. One patient just ended up having just a headache while the other patient whom had a headache over several days with no facial droop, slurred speech, equal pupils and equal bilateral grip strengths turned out to be a bleed. Would it be ok to just give acetaminophen to our patients complaining of a headache and hold off on the ibuprofen? Headache is not a contraindication for the pain directive so this is why I am asking.
Published On: March 28, 2019Can Morphine be mixed in 50 ml mini bags for easier administration & easier titration?
Published On: March 28, 2019If I want a faster onset of pain relief can I go straight to Ketorolac IV?
Published On: March 28, 2019Can I only give Fentanyl if my patient doesnt qualify for Morphine?
Published On: March 28, 2019When are PCPs going to get some strong pain medications?
Published On: March 28, 2019I was told during my I.V. course that it is O.K. to give dextrose immediately after Glucagon if an I.V. was achieved after Glucagon administration (failed I.V. attempts – give Glucagon – try another I.V. and succeed – give dextrose). Is this true? If so, would I have to record a new sugar reading prior to dextrose administration even if Im prepared to give dextrose immediately after glucagon? Would there be any changes to the number of max doses of either drug I could administer in this case.
Published On: March 28, 2019Do we really need to get a blood glucose on an actively seizing patient?
Published On: March 28, 2019I have a question regarding our new Emergency Childbirth Medical Directive. My understanding from the protocol is that we can stay on scene to deliver a breech presentation, but for a limb presentation we must transport immediately. I know that we can deliver a complete breech and a frank breech, but what about a footling breech? Is that considered to be a limb presentation that requires immediate transport?
Published On: March 28, 2019Question: Case – Adult patient experiencing an asthma attack. Wheezing in all fields (air entry in all fields) and tachypnea. Historically, we’ve been taught to administer Epi in cases of ‘silent chest’, absent air entry in any fields or patient requiring BVM ventilation. The BVM ventilation has always been associated with diminished air entry/silent chest, but not really with hyperventilation. The old BLS stated to assist with BVM ventilation in any patient with a RR>28. Does this mean that if the patient has RR>28, therefore requiring BVM ventilation, he/she SHOULD receive Epi even if there is air entry (albeit wheezing) in all fields?
Published On: February 14, 2018Question: In relation to the Adult Analgesia directive, one of the indications is “acute musculoskeletal back strain”, does this include injuries such herniated discs, radiculopathies etc.?
Published On: February 14, 2018Question: Im a recent graduate from the paramedic program and was wondering if I can get some feedback regarding the hypoglycemia treatment. The new protocol that came into play that now includes D10, I was curious what the reasoning was for choosing D10 over D50? Is there anything specific separating the 2 options of treatment?
Published On: February 14, 2018Question: I was looking through Ask MAC and there are a few questions pertaining to cardiac arrest and shocks or no shocks of other responders. Are Paramedics are to include shocks delivered by the Fire Department prior to arrival in their treatment of a VSA patient?
My understanding from teachings in 2014/2015 is that if Fire delivered shocks we could count what they did. If they did not, we did not count their no shocks and conducted our own working towards the medical TOR which is also covered in the Summary of Changes document.
The question on ASK MAC seems to say if we trust the responders we can count everything I was hoping for a clarification that can be searched when the question comes up again.Published On: December 22, 2017Question: If we are presented with a hypoglycemic patient that demonstrates signs and symptoms of a TIA/CVA (slurred speech, inability to hold arms/legs up or due to confusion a grip test) and once the hypoglycemia is reversed with treatment and those signs and symptoms are gone, can we now deliver Ibuprofen/Acetaminophen or Ketorolac if the patient complains of CA related pain or muscle strain as per the Adult Analgesic Protocol?
Published On: December 22, 2017Question: A couple questions with regards to D10. We have used D10 a few times now to treat hypoglycemia and have noticed some issues. It seems that for anyone with a BLG that is very low (say less than 2.0 for argument sake) the max dose of 10g will not get them over 4.0 mmol/L. Is there plans in the future to increase the dose? Perhaps something like if the patient is < 2.0 mmol/L then a 20g max or 4ml/kg loading dose followed by a 10g or 2ml/kg maintenance dose if necessary?
Second, with regards to Buretrol administration of D10, the process is very slow. Both the setup of the Buretrol and the infusion take quite a bit of time obviously more so if a second dose is required. Is there any reason a 60ml syringe can’t be used (draw up and push 60cc and follow up with 40cc) as a push administration instead of the Buretrol? For most situations the slow drip is okay but in the case of an agitated or aggressive patient the quicker option would be nice. I realize the benefits of D10 over D50 in not sky rocketing BGL but the way it is laid out now seems that we have gone too far the other way in not raising BGL enough.Published On: December 22, 2017Question: Can we draw up D10 in a 50cc syringe and administer it that way instead of going through the Buretrol?
Published On: December 22, 2017Question: Although very rare, how should Paramedics manage a uterine inversion?
Published On: December 22, 2017
