23-Jul-2015 | SWORBHP Ask MAC

Date Archives: 23-Jul-2015

July 23, 2015 SWORBHP Category: Adult Analgesia | Date: 23-Jul-2015

Question: My question is in regards to abdominal pain and analgesia. I was always under the understanding that as ACP's we should not be patching to a BHP for analgesia when a patient is experiencing severe abdominal pain. I have come into discussion with other ACP's where some have and some have not patched for analgesia in severe abdominal pain. I am a bit confused about this particular situation. Should I be patching a BHP for analgesia orders for a patient experiencing severe abdominal pain?

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Adult Analgesia

July 23, 2015 SWORBHP Category: Oxygen Therapy | Date: 23-Jul-2015

Question: I would like to know the actual medical directive and/or guidelines regarding PCP's transporting trach patients with no nurse, doctor or RT escort.

Additionally, what the medical directive is if staff is sending the patient to the ER without their vent, therefore, the paramedic is required to bag the patient via BVM for the duration of transport and until there is transfer of care at the ER?

Is this in the BLS scope of practice?

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Answer: Great question! The short answer is that a medical directive does not exist. In fact, it has been years since the gap has been noted in both the BLS Patient Care Standards (BLS-PCS) for the management of patients with tracheostomies and the ALS-PCS (your medical directives) for the suctioning of patients with tracheostomies.

The BLS-PCS provides paramedics with the direction as to when it is appropriate to suction a patient but does not address patients with tracheostomies specifically:

“Position the patient as required to support, protect, improve and/or promote C-Spine alignment, airway patency and breathing, with attention to suctioning of saliva, blood and vomitus where necessary.” (Basic Life Support Patient Care Standards- January 2007, Version 2.0, Section 1- General Standards of Care, page 1-8).

The BLS Standards do not speak specifically on “how to” suction a patient with a stoma or a tracheostomy (as is also the case with “how to” perform other procedures – e.g. inserting an airway, placing a patient on a backboard, etc.). It is expected that paramedic students receive this training as part of the curriculum of their PCP program.

In this regard, The Prehospital Emergency Care Syllabus, which outlines the professional competencies required for current practice as a PCP, speaks to suctioning in Section 3-Systems and Associated Pathological Problems.

Section 3, 15(a) – Summarize the indications and explain the rationale for oral, nasal, pharyngeal and tracheal bronchial suctioning of a patient.

Section 3, 15(b) – Describe the techniques, precautions and vacuum levels to be utilized with each type of suctioning listed in 15(a).

Section 3, 17(c) – Describe the method to be utilized when suctioning a patient with a tracheostomy/stoma.

Paramedics performing deep suctioning of patients with tracheostomies would most likely require a medical directive as putting an instrument beyond the level of the larynx is listed as a controlled medical act. For this reason, work is underway at the Ontario Base Hospital Group to develop a medical directive to address this very gap.

At this time, we suggest discussing with the health care team your concerns regarding the possible need for suctioning during transport and the need for an escort who can perform the procedure.

It is anticipated that in the future, that both the BLS-PCS and the ALS-PCS will address patient with tracheosptomies and their unique needs.

As for the second portion of your question, this speaks to inter-facility transports and the scope of practice of paramedics vs the responsibility of the sending physician to ensure that the patient is managed safely during transport. This is an enormously complex topic and not easily answered through the ASKMAC forum. We have attempted in the past to answer this and other similar questions. Ultimately, the sending physician is responsible for the welfare of the patient on transport and the role of appropriate medical escorts. However, when situations have arisen in the past, crucial conversations as to the various escorts that may be available to assist you (RT, RN, MD, Ornge) have led to enhanced patient safety on transport. Your supervisor and or the Base Hospital Physician may also be a useful resource if you are confronted with a transport where you feel the patient may benefit from an enhanced scope of practice. The Base Hospital will stand behind you in addressing safety concerns you may have when asked to transfer an unstable patient you feel requires additional medical escorts.

If this is not an inter-facility transport but rather a 911 response for a chronic vented patient then there may not be any additional resources to send with the patient from the sending (non-hospital) facility. Chronic mechanically vented patients are being managed in the community with increasing frequency highlighting the need for further medical direction for these patients. Should the responding paramedic team be required to suction the tracheotomy and bag the patient to the receiving ED, then at this time paramedics are expected to provide this care to the best of their abilities and to the limit of their respective scopes of practice and training.

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Oxygen Therapy

July 23, 2015 SWORBHP Category: Symptomatic Bradycardia | Date: 23-Jul-2015

Question: In the Symptomatic Bradycardia Medical Directive, both atropine administration and TCP have hypothermia listed in the contraindications. However, this contraindication is not present for dopamine administration.

This seems to contradict the practice of not giving drugs to the severely hypothermic patient and focusing prehospital care on rapid transport and passive rewarming. Was this omission voluntary and if so, what is the rationale or the studies that support the use of dopamine in such a case? Thank you!

PS: Hypothermia is not listed as a contraindication for dopamine in the ROSC protocol either.

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Answer: Thanks for the very interesting question! To be frank, we are not sure why the contraindications list hypothermia for Atropine and Transcutaneous Pacing (TCP) but do not list hypothermia as a contraindication for Dopamine administration. We will be bringing this back up this Fall when the entire ALS-PCS is opened for revision pending the 2015 AHA Guidelines release. Great pick up!

We are wondering if the reason for listing hypothermia as a contraindication in general for symptomatic bradycardia is that severely hypothermic patients tend to be bradycardic and relatively hypotensive. In these clinical scenarios, it may be a superior strategy to treat the underlying cause (hypothermia) rather than perhaps making the hypothermic myocardium more irritable with Atropine or TCP. That being said, this does not explain the exemption (if you will) of Dopamine using the same argument.

As for your point about the practice of not giving drugs to the severely hypothermic patients, the 2010 AHA Guidelines (Vanden Hoek et al, Part 12: Cardiac Arrest in Special Situations) states the following for the management of the severely hypothermic patient on page S846:

ACLS management of cardiac arrest due to hypothermia focuses on aggressive active core rewarming techniques as the primary therapeutic modality. Conventional wisdom indicates that the hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical. In addition, drug metabolism may be reduced, and there is a theoretical concern that medications could accumulate to toxic levels in the peripheral circulation if given repeatedly to the severely hypothermic victim. For these reasons, previous guidelines suggest withholding IV drugs if the victim’s core body temperature is <30°C (86°F).

In the last decade a number of animal investigations have been performed evaluating both vasopressors and antiarrhythmic medications that could challenge some of this conventional wisdom. In a meta-analysis of these studies, Wira et al found that vasopressor medications (ie, epinephrine or vasopressin) increased rates of return of spontaneous circulation (ROSC) when compared with placebo (62% versus 17%; P<0.0001, n=77). Coronary perfusion pressures were increased in groups that received vasopressors compared with placebo. But groups given antiarrhythmics showed no improvement in ROSC when compared with control groups, although sample sizes were relatively small (n=34 and n=40, respectively).

One small-animal investigation suggested that the application of standard normothermic ACLS algorithms using both drugs (ie, epinephrine and amiodarone) and defibrillation improved ROSC compared with a placebo arm of defibrillation only (91% versus 30%; P<0.01; n=21). Human trials of medication use in accidental hypothermia do not exist, although case reports of survival with use of intra-arrest medication have been reported.

Given the lack of human evidence and relatively small number of animal investigations, the recommendation for administration or withholding of medications is not clear. It may be reasonable to consider administration of a vasopressor during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies (Class IIb, LOE C).

In other words, it may be reasonable to continue giving medications to profoundly hypothermic patients in the setting of cardiac arrest or cardiovascular collapse as long as we do so along with aggressive rewarming strategies. Since invasive active core rewarming is available in-hospital, this is why there continues to be a focus of early rapid transport as well with these patients.

Thanks again for the terrific question!

The relevant references from the AHA for this section are listed below:

Winegard C. Successful treatment of severe hypothermia and prolonged cardiac arrest with closed thoracic cavity lavage. J Emerg Med. 1997;15:629–632.

Dobson JA, Burgess JJ. Resuscitation of severe hypothermia by extracorporeal rewarming in a child. J Trauma. 1996;40:483–485.

Reuler JB. Hypothermia: pathophysiology, clinical settings, and management. Ann Intern Med. 1978;89:519–527.

Elenbaas RM, Mattson K, Cole H, Steele M, Ryan J, Robinson W. Bretylium in hypothermia-induced ventricular fibrillation in dogs. Ann Emerg Med. 1984;13:994–999.

Kornberger E, Lindner KH, Mayr VD, Schwarz B, Rackwitz KS, Wenzel V, Krismer AC, Mair P. Effects of epinephrine in a pig model of hypothermic cardiac arrest and closed-chest cardiopulmonary resuscitation combined with active rewarming. Resuscitation. 2001;50:301–308.

Schwarz B, Mair P, Raedler C, Deckert D, Wenzel V, Lindner KH. Vasopressin improves survival in a pig model of hypothermic cardiopulmonary resuscitation. Crit Care Med. 2002;30:1311–1314.

Schwarz B, Mair P, Wagner-Berger H, Stadlbauer KH, Girg S, Wenzel V, Lindner KH. Neither vasopressin nor amiodarone improve CPR outcome in an animal model of hypothermic cardiac arrest. Acta Anaesthesiol Scand. 2003;47:1114–1118.

Stoner J, Martin G, O’Mara K, Ehlers J, Tomlanovich M. Amiodarone and bretylium in the treatment of hypothermic ventricular fibrillation in a canine model. Acad Emerg Med. 2003;10:187–191.

Wira C, Martin G, Stoner J, Margolis K, Donnino M. Application of normothermic cardiac arrest algorithms to hypothermic cardiac arrest in a canine model. Resuscitation. 2006;69:509–516.

Wira CR, Becker JU, Martin G, Donnino MW. Anti-arrhythmic and vasopressor medications for the treatment of ventricular fibrillation in severe hypothermia: a systematic review of the literature. Resuscitation. 2008;78:21–29.

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Symptomatic Bradycardia

July 23, 2015 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 23-Jul-2015

Question: A patient is presenting with pulmonary edema. Patient became more symptomatic before calling and dyspnea worsened. Upon gathering history and taking vitals, they meet the criteria for Nitro and CPAP. The patient is currently prescribed Lasix for fluid in the lungs from doctor visit one week ago.

With the history of pulmonary edema and being prescribed Lasix for fluid in the lungs, would this now be considered Non-Acute Pulmonary Edema?

I need a better understanding of Acute Pulmonary Edema vs. Non-Acute Pulmonary Edema. The CPAP protocol indication lists: Suspected Acute Pulmonary Edema.

Since the pulmonary edema is non-acute would CPAP and Nitro be withheld? Or, since the symptoms have worsened, provided I can recognize a patient that is truly in need of CPAP and Nitro, would I administer them? I want to clarify - thanks.

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Acute Cardiogenic Pulmonary Edema