Date Archives: 29-Sep-2016

Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Question: I know that the standard practice for Epinephrine administration in the case of anaphylaxis is in the patient's deltoid. I have heard and read that the time to maximal serum concentration of epinephrine is 7 times faster with IM administration to the anterolateral thigh.

My question therefore is: Would it be acceptable to administer epinephrine in the anterolateral thigh as opposed to the deltoid? Or, is SWORBHPs preferred administration site the deltoid and if so why?

References:
http://emergencymedicinecases.com/anaphylaxis-anaphylactic-shock/

Simmons, F.E., Kelso J.M., Feldweg A.M. (2015). Anaphylaxis: Rapid recognition and treatment. In T. W. Post (Ed.), UpToDate. Retrieved from http://www.uptodate.com/contents/anaphylaxis-rapid-recognition-and-treatment/

Question: Can a PCP, certified AEMCA in good standing with their Base Hospital, administer symptom relief medication while off duty? We know that some medics carry their own first aid kit in their car and that some services support this.

Question: How is the DNR standard in the BLS PCS reconciled with this statement in the ALS PCS: "if a paramedic is aware or is made aware that the person has a prior capable wish with respect to treatment, they must respect that wish (for example, if the person does not wish to be resuscitated)."

Obviously the ideal situation is that the patient has the DNR confirmation form and there are no issues. The issue comes up with regards to verbal DNRs issued by a capable patient or SDM (that are reasonable), or in such cases where the patient has a DNR, living will or other advanced directive that specifies the patients wishes, but no prehospital DNR form. Is this form not redundant provided there is a reasonable indication that the patient does not wish to be resuscitated or have aggressive life sustaining therapies delivered?

How can the BLS PCS DNR standard be reconciled with the ALS PCS regarding honouring a prior capable wish when the provider is made aware of such wish (provided its reasonable)? Especially given that in nearly ever other case, a directive in the ALS PCS over-rides the BLS-PCS. Given that this issue is not nearly as cut and dry in reality, or in any other healthcare setting, as it seems to be made out to be in EMS in this province what is the situation with regards to this? Especially given that end-of-life issues are increasingly common, the issue is not going to disappear. There are many other provinces that use a similar wording or philosophy to that mentioned in the ALS-PCS under consent and capacity.

Question: You have a patient who you obtain ROSC and return of spontaneous respiration on scene who was in a VF (post rosc 12lead shows STEMI). They arrest on route into a VF, we pull over, defibrillate. You resume transport and reassess after each cycle of CPR. If you obtain ROSC again during transport, and the patient rearrests for a second time, is it prudent to pause transport quickly again for defibrillation. The treatment for VF is defibrillation. If there is still prolonged transport the pt will likely deteriorate to asystole if not defibrillated, correct? I appreciate we do not want to delay definitive care, would it be helpful or harmful to continue defibrillation in this setting.

Question: In regards to the adult analgesia medical directive, it states "in patients with isolated hip or extremity trauma, ibuprofen and acetaminophen are preferred to ketorolac except where the patient is unable to tolerate oral medications." It is my understanding that together, they provide similar pain relief to ketorolac. If the patient is in severe pain, but is unable to take acetaminophen due to a contraindication (ex. due to having taken some in the past 4 hours), is it appropriate to administer ketorolac instead? Or is it still preferred to administer just the Ibuprofen at this point.

Question: When administering a fluid bolus, are we to give the full bolus amount (i.e. 1000ml for a 50kg patient) reassessing for fluid overload or return to TKVO when the BP reaches 100mmHg or greater? Given so much fluid shifts, administering the full bolus when no fluid overload is present (either 10 or 20ml/kg), particularly with the septic or preload dependent patient would be beneficial.

Question: In reviewing literature addressing treatment and management of tachyarrhythmias, I've encountered several articles stating that lidocaine and amiodarone are contraindicated for treatment of Torsades de Pointes as they could prolong the QT interval and worsen the situation. However, our medical directives for ventricular tachycardia make no mention of this contraindication and make no distinction in the management of VT vs TdP. Recognizing that lidocaine as a Class I antiarrythmic would be worse for the patient than amiodarone (Class III) and that amiodarone is the preferred drug in our protocols for VTach, should we nonetheless be concerned with the use of either of these in managing TdP? Thanks for providing the forum in which to ask and share with colleagues.

Question: A recent study, published in the Lancet showed an alternative way of performing a Valsalva maneuver, that is much more effective.

It is described and shown in a video here:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61485-4/abstract

Is it acceptable for us to perform this when a Valsalva is called for in our directives?

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