28-Mar-2012 | SWORBHP Ask MAC

Date Archives: 28-Mar-2012

March 28, 2012 SWORBHP Category: Cardiac Ischemia | Date: 28-Mar-2012

Question: In the previous cardiac ischemia medical directive it said that if the patients symptoms resolved after the administration of nitro and then returned that you could administer another 6 sprays of nitro. I was wondering if this was still the case.

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Cardiac Ischemia

March 28, 2012 SWORBHP Category: Hypoglycemia, Intravenous and Fluid Therapy | Date: 28-Mar-2012

Question: This question is a follow-up to clarify between two questions previously asked- specifically, regarding advanced resuscitation in the setting of DNR, and treatment of FBAO in the setting of DNR. In the most recent question the DNR validity form is quoted as stating that chest compressions should not be initiated on patients with a valid DNR, while in the earlier question it was stated that DNR does not preclude treatment for choking. Should we come across this situation, would we then only administer 'Heimlich'-like abdominal thrusts and not proceed to chest compressions when the patient goes unresponsive, or should chest compressions be initiated until the heart has arrested and then discontinued (i.e. not proceeding to true CPR)?

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March 28, 2012 SWORBHP Category: Medical Cardiac Arrest | Date: 28-Mar-2012

Question: If a patient from, for example, a structure fire is VSA with severe 3rd degree burns to the majority of their body and asystolic upon arrival would this fall under a medical or trauma cardiac arrest protocol? I would assume there is a high likelihood that the cause of arrest is more asphyxial in nature from smoke and toxic fume inhalation so it would be a medical protocol. That being said would this patient also meet medical TOR protocol since the arrest is asphyxial in origin? In discussion there seems to be so many variables put forward that there is no general consensus on which protocol to follow. Assuming there is no associated blunt trauma (e.g. structural collapse or explosion) or any penetrating trauma (e.g. explosion or injury occurred prior to burns) and the only trauma is the burns themselves what's the most advisable course of action to follow?

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Answer: This would not be a traumatic arrest. We agree, most likely they have arrested from an asphyxial etiology or the burns themselves. As such, this care for this patient would fall under the medical cardiac arrest directive and possibly the Medical TOR.

I would direct you to the Feb 6th question here:
http://www.sworbhp.com/askmac/searchengine/med_cardiac_arrest.html

The debate of the Medical TOR applying to arrests of an asphyxial nature is one of our most common questions. This is one of the very rare situations where the teaching philosophy of SWORBHP has varied from the directives.

The debate has centered upon whether the medical TOR has to be an arrest of suspected cardiac etiology in nature (as it says in the directive) or can it also include arrests felt to be asphyxial in etiology (such as drowning, hanging, inhalational exposure, electrocution- not an exhaustive list).

The concern of the Medical Council was how does the paramedic decide what arrest was caused by asphyxia vs. one of cardiac etiology when often details even on scene are difficult to obtain? You can imagine how many FAQ we would get as to what constitutes a cardiac arrest from a cardiac cause vs. an asphyxial!

The consensus from the SWORBHP Medical Council was for the paramedic to not attempt to break it down asphyxial vs. cardiac on scene… It gets too confusing.

We feel it is reasonable if all other criteria for TOR are met, patch to the BHP and let them be involved in the decision making. We did not want to have to place the paramedic in the difficult position of having to decide on scene- you have enough to do! If the BHP decides that a TOR is reasonable, then follow that protocol, and if not, transport the patient and continue resuscitation as directed.

As an aside, the support for this decision comes from the ROC trial currently underway all across North America looking at CPR rates. It was felt by ROC investigators that it was too difficult and unfair to make a paramedic decide on scene what caused the arrest, so arrests caused by asphyxia are treated the same as arrests caused by a presumed cardiac etiology. The Medical Council from SWORBHP thought this would be easier for all paramedics to adopt this same strategy for TOR.

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Medical Cardiac Arrest

March 28, 2012 SWORBHP Category: Cardiac Ischemia, Return of Spontaneous Circulation | Date: 28-Mar-2012

Question: I have a few questions about some of the omissions from these protocols that were in the old protocols. The first one is in the event chest pain resolves and re-occurs it is treated as a new episode and nitro protocol repeated. This isn't stated in the new protocol so if this were to occur can we repeat although it isn't stated? The other question is regarding the medical arrest protocol. No provision is made in regards to on scene ROSC and re-arresting patient in ambulance. The old protocol says we can pull over and analyze once then continue to receiving facility. With nothing in the new protocol do we follow the same format? Thank you.

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March 28, 2012 SWORBHP Category: Medical Cardiac Arrest | Date: 28-Mar-2012

Question: As far as the TOR mandatory patch point goes: if we are able to relay to the BHP that we would like to transport as opposed to terminating (e.g. public place, family insists we do so etc.) then why not allow the discretion of the paramedic to dictate whether to spend the time actually doing the patch? Since the physician is relying on us to paint a picture of the scene and if the BHP will accept our interpretation of the events unfolding and most likely state to transport anyway, patching to get permission to initiate transport seems to be more of a delay than a benefit.

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Medical Cardiac Arrest