Date Archives: 11-Jul-2013

Question: 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.

Question: I have a number of questions in regards to the management of obstetrical emergencies and the established standards outlined in the BLS. I know that out of hospital delivery in comparison to other call types is a rare occurrence for Paramedics. So it may be reasonable to deter pre-hospital management of certain situations for definitive care, just based on training, risk and benefit. However, I think it is important for Paramedics to know how to manage these situations when they arise.

For an example, In the BLS standards shoulder dystocia although rare is not specifically outlined. If one does some research or digs back to many college programs where the HELPER mnemonic is touched on we find that suprapubic pressure and the McRoberts maneuver can resolve many of these situations, preventing trauma and harm to the mother and newborn. Although not identified clearly in the BLS both of these interventions are touched on in other areas such as breech delivery and emergency delivery. I wondered the reason why these interventions are not applied specifically to the situation where the shoulders do not deliver and rather the Paramedic is to initiate transport immediately? Secondly, what would MAC's direction be to the Paramedic managing a possible shoulder dystocia? With the potential for fetal hypoxia and stress it seems reasonable to apply these same interventions in this setting.

If we go along the same question of course we aren't performing field episiotomy or controlled clavicle fractures but why can we not assist a shoulder or roll the pt on all fours in this setting? Sure we can and use our judgment but with the legalities of following the standards it may be deemed as a deviation. Can Paramedics really apply the appropriate measures from various parts of the standards to situations like dystocia and still remain legally within their scope?

The only other question this may bring up is how do we hold midwives, who have a higher level of training and knowledge to the BLS Standards?

Question: 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).