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
Would 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, 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, 2019
