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
Question: In a patient with an allergic reaction or anaphylaxis, who is experiencing nausea or vomiting, is it okay to treat them with Gravol after I have administered Benadryl?
Published On: November 22, 2013Question: CPAP for CHF and COPD is to maintain a constant pressure in the airways (splinting with COPD) and to help push the fluid out of the alveoli and into the circulation with CHF. Would paramedics who do not have CPAP available be wrong, if the patient is conscious and tolerates, assist each inhalation with a BVM to increase tidal volume and create more positive pressure during inhalation, although not maintained with exhalation, in an attempt to force the fluid out with CHF. Debate is that we assist the ventilation at one breath every 5 seconds or 12/minute unless hyperventilating due to head trauma and respiratory problems with coning of the pupil(s). Thanks for the assistance.
Published On: November 22, 2013Question: VSA trauma patients – chest compressions and defib is the priority for this patient. C-spine maintained manually. In this scenario, is it mandatory to apply a collar prior to a shock being delivered as the manual c-spine must be removed to deliver the shock? CPAP- indication b/p 100 or above systolic. Contraindication is hypotension. If CPAP is applied while normotensive, can we leave the device on until they become hypotensive or we must remove when b/p drops below 100? Thanks.
Published On: November 22, 2013Question: I have read the post Jan. 31 2012 in regards to R/A vs. 02 when resuscitating a neonate. It states that 100% 02 will be used after 90 sec with compressions if HR is below 60. It also states that 100% 02 will be continued until HR is normal. Does this refer to 100 bpm? The reason I ask is if I read the flow chart to the letter at 90 sec with a HR below 60, 02 and compressions are begun. If I reassess 30 sec later and the HR has improved above 60 but below 100 (ex. 80 bpm), I continue ventilating, but do I discontinue the 02 and use R/A only? Also compressions are to be discontinued. What is stance on using a pedi-mate on a critical or VSA neonate or child (below 40 lbs)? Is it necessary as it can be cumbersome and time consuming when trying to get off scene quickly?
Published On: November 22, 2013Question: I was looking at the PCP Medical Cardiac Arrest Medical Directive. I understand that we can give IM epinephrine in the setting of an anaphylaxis induced VSA. In the event of a ROSC from this type of VSA can Benadryl be administered IM/IV? Is there any benefit to doing this?
Published On: November 4, 2013Question: With reference to the cardiac ischemia protocol. Would it be possible to update the protocol for the administration of nitro (without a BHP consult) for normotensive patient on beta blockers by either: a) lowering the heart rate parameters from 60bpm to 50bpm or b) to lower heart rate parameter from 60bpm to 50bpm when patient is currently taking antihypertensive medications within the beta blocker family with an IV established?
Published On: November 4, 2013Question: Is the IV protocol like others in that once the patient falls out of a protocol, they cannot be put back in. For example, patient initial BP less than 90 systolic, decision made to load patient prior to IV attempt, on loading patient BP now above 90.
Published On: November 4, 2013Question: Is a non-IV certified paramedic allowed to monitor an IV started TKVO by an IV certified paramedic on route to the hospital?
Published On: September 25, 2013Question: There have been a few discussions flying around about a call where the patient had an internal defib whose activity was captured shocking the patient X 3 by the EMS defib. Of course, the whole discussion is treat vs. transport and shock once vs. follow the entire protocol. Can you provide some insight into these rare cases?
Published On: September 5, 2013Question: In regards to the bronchoconstriction protocol, in order to administer to Epi, the patient must require BVM ventilation and have a history of asthma. What if the patient is alone or they are so short of breath that a history of asthma cannot be obtained? Or possibly this could be their very first asthma attack without an actual diagnosis yet? We were dispatched to an 8 year old with asthma experiencing SOB; on arrival no wheezing present, lungs clear, no obvious respiratory distress noted, sats at 95 RA; 100 on o2. Mom states he takes puffers but his doctor never actually told her that he has asthma. I found this odd since he is on ventolin and steroid rescue inhaler. If that scenario was different, and we did have to bag him, we absolutely can’t give this patient Epi due to the fact that the doctor never confirmed he has asthma even though he is prescribed inhalers? Is this correct? Would a BHP patch be appropriate for an order, knowing that his air entry is diminished and the probable cause is severe bronchoconstriction, most likely due to asthma but not confirmed by diagnosis according to parent?
Published On: July 30, 2013Question: While taking our manual defibrillation training on the new LP15 we were told “if the rhythm is fast and wide, shock it” obviously the PT is pulseless as well. We were told the “fast” value is greater than 120. We were never told the “wide” value. I have asked both ACP and PCP paramedics and have gotten responses of 0.12, 0.16, and 0.20. So, could you tell me what SWORBHP considers the correct value for “fast”? Thanks!
Published On: July 30, 2013Question: I have heard from our base hospital that MAC is considering removing KING-LT airways from the directives? Is this true, and if so, what supraglottic rescue airway option are they looking at going to, both for ACP’s and PCP’s. Not every patient can be ventilated using BVM alone. I’ve also heard that they are looking at removing needle cric and intubation from ACP scope? If this is true, then why? Intubation does have major problems in the pre-hospital setting, but outside of cardiac arrest it is a very valuable method of controlling the airway (the gold standard) especially for long transport times or complex patient presentations. Finally, I understand the theoretical rational behind not using CPAP in asthma PTS, but there are services in North America using it for end-stage asthma exacerbation as a option before intubating the patient. They combine low levels of CPAP (3-5 cmH2O) with a salbutamol nebulizer tied in line to the CPAP mask and are getting good results. Is there any possibility of a clinical trial of CPAP in asthma exacerbation refractory to salbutamol/epi alone? Is there evidence against using it in asthma (besides theoretical problems).
Published On: July 11, 2013Question: If we are treating a patient with acute cardiogenic pulmonary edema that is a nitro virgin that’s blood pressure is above 140 systolic and then their blood pressure drops below 140 systolic but not by one third then can we consider them now as not being a nitro virgin and therefore continue treating them with 0.4 nitro? Thank you for taking the time to answer all of these questions.
Published On: July 11, 2013Question: Could you clarify the Bronchoconstriction directive (epi for asthma exacerbation)? You have to be bagging the patient to give the epi. Our old directives said “any patient with severe SOB from suspected asthma exacerbation AND requires ventilatory support via BVM and OR severe agitation, confusion and cyanosis” but our new directive just says BVM required with history of asthma. I just want to be really clear, now we MUST be bagging them?
Published On: April 17, 2013Question: In the last year I have been presented with two different special occurrences regarding vital sign absent patients. The first one involved a patient who was VSA on our arrival. We were presented with a legal living will as well as a note provided by a Doctor stating “DNR”. Unfortunately there was no ministry DNR validity form. We completed a full medical TOR as the patient met the requirements and after I was informed by co-workers that I could have called for a medical TOR after the first no shock indicated. They stated this was covered under special occurrence. I have looked and found no evidence of this existing although this could be very handy. Does such protocol or language exist? The second incident involved a patient that we witnessed from a reasonable distance to be VSA. Due to safety reasons we could not access the patient for approximately 45 minutes. The patient did not meet obviously dead and didn’t have a DNR. We performed a medical TOR. Again informed that this falls under special occurrence and we could have called for medical tor after the first no shock indicated. I’d really like to know if this is an option. It would come in handy for similar instances.
Published On: April 17, 2013Question: I have a question regarding the order of cardiac ischemia SR medication in the protocol. I have been informed by a source that 0.4mg nitro should be the first SR medication given in a suspected cardiac ischemic event, followed by x2 80 mg ASA. I respectfully disagree with him due to the fact that although nitro is significantly more fast acting, its effects only last 3-5 minutes, hence the spray every 5 minutes stated in the protocol, and although the ASA is slower in its absorption rate, is effects will benefit the Pt. more (in my opinion) than the nitro. The short and sweet version, am I correct in saying that ASA should be administer first before the initial nitro dose is given, if the protocol for both is met.
Published On: April 17, 2013Question: A CHF patient who has a BP of over 140mmHg systolic who is getting 0.8mg of NTG for SOB, patient’s BP drops below 140mmHg so NTG dosage is changed to 0.4mg, patient’s systolic BP rebounds above 140mmHg. Does patient go back to getting 0.8mg of NTG or is it like the “once you are out, you are out” mentality that they stay at 0.4mg NTG? General answers to this question from other paramedics I have asked usually say that the patient will continue to get 0.4mg of NTG regardless of systoloic BP, if it has dropped below 140mmHg at any time during the call. Thank you in advance for your time and help.
Published On: April 17, 2013Question: I was just wondering if we have a patient with a valid DNR are we still allowed to Bolus if they fit our protocol or is this considered an advanced life saving technique?
Published On: April 17, 2013Question: If a hypothermic patient re-arrests is it considered a new protocol or just continue transport? Due to the 1 shock protocol.
Published On: April 9, 2013Question: Is a police officer considered a qualified personnel to be able to witness a cardiac arrest? In regards to “witnessed arrest”.
Published On: April 9, 2013Question: This question is regarding a cardiac arrest from anaphylaxis. If epi is given and the patient has no ROSC, arrest is unwitnessed, and by the 3rd analysis no shock is given, is it acceptable to patch for TOR, or is the TOR contraindicated due to the arrest being of non-cardiac origin?
Published On: April 9, 2013Question: This question is regarding cardiac arrest documentation expectations. Is it a requirement to document vital signs every 2 minutes or would it be sufficient to document one set with a comment: Patient remained pulseless throughout? As well, CPR charted once, with a similar comment: CPR performed throughout. In my opinion, this would be more efficient and concise. As well, if in a position where we are transporting a VSA patient, as an ACP I have always performed a rhythm interpretation even while the vehicle is moving. I have never really noticed artifact as an issue, and cannot find any documentation relating to ACP practice stating I must pull over. I have not had any feedback from base hospital regarding this practice, but my supervisor has mentioned some serious concerns. Thanks again for this forum that helps our practice.
Published On: April 9, 2013Question: I apologize in advance if this question is redundant, but I have searched and cannot find an answer. For a crew where both medics are IV certified (autonomous certification), are both medics allowed 2 starts (4 attempts in total) on a single patient? Or are attempts limited to 2 attempts per patient regardless of who makes the attempts? Thanks.
Published On: April 9, 2013Question: I am a PCP and was wondering what constitutes a IV attempt. Does simply palpating and visually assessing the patient constitute an attempt if I do not find an accessible vein and do not blindly pic attempt insertion?
Published On: April 9, 2013Question: What is the Medical Director’s direction on doing repeated blood sugars after treatment for hypoglycemia? I recently had a patient who complained of chest pain after a fall. He was a diabetic with a GCS of 14 on initial assessment. His blood sugar was 3.8 and I treated him with oral glucose. He felt better and his GCS became 15. I got a comment back from an auditor who felt I should have done a follow up blood sugar after treating him. I was always taught that it was unnecessary to do a blood glucose if the patient had a GCS of 15. Has there been a change in thinking?
Published On: April 9, 2013Question: This question is regarding advance airway. I really don’t like the basic airway first then if there is a problem, now go to the advance airway, ie: intubation, I have had saves due intubation right away. Once the vomit starts it’s very hard to control the airway or intubate, during CPR, the vomit can come out in excess amounts that the suction cannot keep up with, let alone if by chance you do get a save, the patient dies of aspiration pneumonia later! Yes it’s a paramedic’s discretion to intubate or not, if you have a good seal with a basic airway and an IV you can run a code, and it’s also said intubation stops CPR, well all the CPR in the world won’t help if the airway is uncontrolled. This ROC survey with basic airway for the first 6 minutes can really cause a negative patient outcome if he vomits in excess. Well at least my compression stats are good!!!! Maybe this should be discussed in the next recert. Signed an ALS Paramedic.
Published On: March 6, 2013Question: I have a question regarding nitro use with lung cancer patients. I recently had a patient who was obviously in the end stages of lung CA. Patient was complaining of mild SOB due excessive amounts of fluid buildup in his lungs. He stated that he needed to go to the hospital to have the fluid drained. Patent had 5-6 word dyspnea, O2 sats at 92 %, radial pulse 90, NSR, respiratory rate 22 regular, audible crackles when patient took a deep breath, and B/P 124/86. Patient stated that within the last couple of days he had noticed swelling to his ankles and abdomen which were abnormal for him. Patient had a previous history of nitro use due to angina. Would this patient benefit at all with nitro use? He wasn’t in severe respiratory distress nor did he require assisted ventilations.
Published On: March 6, 2013Question: This question is regarding not giving Narcan to a DNR patient. Obviously, if there is not an underlining medical issue (e.g. terminal CA) and a patient ODs, even with a DNR, we attempt to reverse any issues. However, if the patient does have a medical issue with a DNR, has decided to OD to commit suicide and is in a pre-arrest / arrested state, is it reasonable to assume that since they are breaking the law, that the DNR can no longer be valid?
Published On: March 3, 2013Question: If a patient meets the protocol for having CPAP treatment but they have a valid DNR Confirmation Form can a PCP still administer CPAP?
Published On: February 25, 2013Question: In regards to the bronchoconstriction protocol I was recently in a discussion with a coworker disputing the 5-15 min dosing interval. The question was does this interval begin when treatment begins or once a treatment is completed. For example nebulized ventolin may take approximately 5 mins to fully nebulize could I administer a second treatment immediately or would I have to wait 5-15 mins post completion of a treatment. Clarification would be greatly appreciated.
Published On: February 1, 2013Question: When dealing with a VSA FB obstruction, directives are to analyze once, load and go, revert to medical cardiac arrest if airway clears. Knowing the concern is no air to the patient due to the obstruction, would it not be advantageous to include airway blockage due to anaphylaxis as a one analysis directive and when or if the epi allows for the delivery of air, revert to a medical cardiac arrest? The airway is blocked either way.
Published On: February 1, 2013Question: We had a patient who presented with bi lateral crackles and patient was in obvious distress and fit all of CPAP criteria, however the patient had a temp of 38.5. I remember that during our training it was clearly demonstrated that a patient with pneumonia is contraindicated for use of CPAP. Upon looking over the protocols it is not mentioned as a contra indication. Would CPAP be an appropriate treatment? If so would it still be appropriate if this patient was suspected of having pneumonia a few days prior by nursing staff. Thank you.
Published On: January 18, 2013Question: Does a patient that suffered from hanging, electrocution, and/or drowning fall under medical tor protocol? Also, if a patient is suffering from anaphylaxis and airway is completely obstructed and you had analyzed once and transported as per FB protocol if on route airway becomes relieved and you have good compliance do you pull over and start your medical cardiac arrest protocol? If first analyze on scene was no shock and you do pull over and have two more no shocks does it fall under a medical tor protocol?
Published On: January 18, 2013Question: In the event of a VSA where Anaphylaxis is the suspected cause, when would be the most ideal time to administer Epinephrine IM? I’m assuming we would start with CPR, attach PADS, Analyze, then Epi. Would this be a safe assumption?
Published On: January 18, 2013Question: I was recently on a call with a patient presenting with a tachy rhythm of 157 and his blood pressure was 74/42. I proceeded to start a line and was going to bolus but subsequent pressures were above 90 systolic. Would it have been reasonable to not bolus due to the fact that this patient most likely had a decreased BP due to the Fast heart rate and not because of a fluid deficit?
Published On: December 18, 2012Question: I’m an IV certified PCP. A question came up last week in regards to aortic aneurysms and different blood pressures bilaterally. If one BP is hypotensive, and the other is normo- or hyper- do we bolus? Ideas that have come up include: Adding fluid may increase the overall pressure, causing the dissection to enlarge; however, the patient is losing fluid and therefore is compensating and needs more.
Published On: December 18, 2012Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed. Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation. I thank you for your comments and insights.
Published On: December 3, 2012Question: After 3 treatments of Ventolin be it MDI or NB i was understanding that we could patch for another 3 treatments if needed. I have spoke with other medics and some say yes and some say no could you please verify.
Published On: November 22, 2012Question: In the area in which I work, there exists a statistical cluster of clients with Myasthenia Gravis. One client that I have now transported at least three times has got the message to call at the first sign of increasing SOB. Most recently he woke up at about 0300 feeling a bit more SOB than normal and not quite right. When we arrived at his house at 0600 he met us outside ambulatory and he had a temp of 39.8C. He was tachypneic. He was in respiratory distress related (In my opinion) to both his MG as well as pneumonia. He adamantly refused the stretcher. He stated that as per his directions he had taken a dose Mestinon when he awoke and that it had not helped. He had a weak or pretty much absent cough. He was placed on placed on high flow O2 by ‘Flow Max’ and was given at least one Ventolin treatment again using the ‘Flow Max’. His condition improved slightly. He was transported with great haste. I have reviewed MG as well as the action of Mestinon. At this point in his disease process he is still requesting that all that can be done be done. Do you have any suggestions as to how we can better care for this client? Putting headers on the ambulance, installing ‘NOS’ or a spoiler is not an acceptable answer. Is CPAP a possibility? I am aware that pneumonia is a relative contraindication for CPAP use. The mechanism of the two disease is quite different but the inability to expand (active muscle use) the chest seems to make them similar. I have attempted to reseach an answer and the best I have gotten after talking with a couple of ED Docs is, ‘Good question. Might buy you some time. How fast can you drive?’ Thank you for your time in considering and answering this question
Published On: November 22, 2012Question: My question had to do with attending to a call where a patient is VSA and then throughout our medical directive the patient receives a ROSC and then a re-arrest. I know that in the old medical directive we would at this time do one further analysis and then transport the patient but in our current medical directives this is not mentioned. I would like to know if I should be attempting any analysis on a patient who re-arrests after receiving an initial ROSC with our current medical directive.
Published On: November 22, 2012Question: This question is to clarify a point in the FBAO cardiac arrest protocol. If the airway obstruction is resolved after a first analysis, it is stated that the patient can then be treated per the medical cardiac arrest directive (presumably receiving three more analyses for a total of four). My question is regarding what to do if transport is in progress when the obstruction is removed- is transport continued with CPR only (as it is not a new arrest or a re-arrest after ROSC) or can the vehicle be stopped until the protocol is complete?
Published On: November 22, 2012Question: My questions have to do with resolved suspected ischemic chest pain and if we should administer ASA even if the symptoms have resolved.
Published On: November 22, 2012Question: I am a PCP student, Under the cardiac ischemia medical directive it states that indications for nitro and ASA are “suspected cardiac ischemia” my question is, a patient without chest pain but has other symptoms such as weakness SOB, N/V etc. and a positive 12 lead showing either ST elevation or depression, do they qualify for Nitro under this protocol?
Published On: November 22, 2012Question: What are your thoughts on oxygen therapy in myocardial ischemia from a medical evidence standpoint? Even though high flow o2 is regularly administered to PTs with chest pain as per the oxygen therapy and chest pain standards in the BLS standards, there is an increasing body of evidence suggesting that in uncomplicated MI O2 is of no benefit and may cause more harm than good due to ROS and ischemia-reperfusion injury. The recent ACLS guidelines state to only administer O2 in acute coronary syndromes if the spo2 is < 94% or the PT is in respiratory distress or obviously hypoxic and there are several recent papers and clinical guidelines that suggest a similar course of action in uncomplicated MI. Basically, the evidence is suggesting that titration to spo2 is favorable over high flow o2 due to the risk of oxidative stress injury. Any thoughts? Obviously you still follow the protocols, but I’m just interested to see if there is any medical opinion on this. Could the standards/guidelines eventually change to reflect the newer evidence?
Published On: November 22, 2012Question: With regards to the administration of D50W. I was just curious if it has ever been to considered for us to titrate this drug for effect. By this I mean, if you are pushing the 10ml of D50 then flushing and repeating this until the entire 50ml is given it is assumed that you will likely notice positive effects of the drug before it is all given. So would we be better off to stop the infusion and re-check a blood sugar at this point to see if we have achieved a blood glucose above 4 or within normal range as opposed to giving the whole dose and pushing their blood sugars usually above 10.
Published On: November 22, 2012Question: If the patient requires ventolin and has a fever but cannot tolerate the mdi, would it then be appropriate to use the nebulizer.
Published On: October 30, 2012Question: Two questions which seem simple but as an educator I get asked all the time. 1.) FBAO VSA patient, you are unable to clear the airway, should we follow the BLS that indicates an oral airway should be inserted? 2.) Unwitnessed VSA, do we need to do a full two minutes of CPR or just CPR until we get the pads on.
Published On: October 30, 2012Question: I recently had my recerts and have a question concerning Medical TOR. The way it was explained to me was that a TOR was a pronouncement. It was explained to me, if we receive a TOR in the back of the unit before the vehicle is put into drive, we have stay on scene with a patient until the coroner comes. Likewise if we received the TOR while the vehicle was in motion we could continue to the hospital. I really don’t understand the difference as to whether the vehicle is in gear or not. I was under the impression that if we receive a TOR, it is simply that, terminate resuscitation and continue transport (no lights and sirens) with no resuscitation. The decision on route would then be, do we go to the morgue or to the ER. I understand the delicacy of appearances and you may have to leave scene with lights and sirens but once away from the scene, judgment on activation of emergency signals would be up to the driver/crew. Could you elaborate some more on this? My question concerning TOR is this. Is a patient deemed dead at the time of TOR or are they deemed dead when assessed either at the hospital by an ER physician or at the scene by the coroner?
Published On: October 30, 2012Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient’s spo2 31 and 42% with mottling noted. Patient’s initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient’s GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?
Published On: October 11, 2012Question: I am a current PCP taking ACP. I was recently informed, during an ACP class, that on an unconscious CHF patient, nitro can still be administered if vitals are within normal range and the other conditions are met. When I checked the protocols, under conditions, it states that LOA: N/A (whereas for cardiac ischemia, the LOA must be unaltered). However, it seems to me that if the patient is unconscious, the patient is too unstable to receive nitro. I have never experienced a call like this, and it would seem that in most cases an unconscious patient would have vitals outside the perimeters of nitro administration. Can you please verify this? Thanks
Published On: October 11, 2012
