Date Archives: 3-Dec-2014

Question: This question is based around a call that has had some interesting discussion and I am curious to get your input on. The call was initially for an allergic reaction, updated while en route to say that the patient was seizing.

Upon arrival, you find a 28 year old male lying on the ground. A family member states that the patient was stung by a wasp on the back of the neck approximately 15 minutes ago. They immediately gave him Benadryl orally and he self-administered his EpiPen (the family seems reliable and as far as you can ascertain both of these medications were administered appropriately and were not expired).

They continue on to tell you that about five minutes ago, the patient had a seizure that just ended as you arrived. The patient has never had a seizure before. There was no trauma suffered from the seizure. The patient has a history of anaphylaxis to wasp stings but no other past medical history.

On examination, there are no signs of trauma and the patient denies any pain. The patient is conscious, but agitated and confused to place and time (GCS 14). He has slight swelling of the lip but no urticaria anywhere on his body and no other facial swelling. His breath sounds are clear on auscultation. He appears to have been incontinent of urine. There has been no vomiting or diarrhea.

Initial vitals are a heart rate of 102 regular and full, respirations 24 regular and full, pupils PEARL 4mm. Blood sugar is 6.7 mmol/L. BP is unobtainable as the patient continues to become more agitated and will not remain still. Oxygen saturation is also unobtainable as the probe keeps coming off his finger while he moves around.

Specific points that came up in our discussion that we would love to hear your thoughts on are:

1. Based on the information available here, should this patient receive epinephrine (epi)? It is easy for us to second guess the inability to obtain a blood pressure (BP) on this patient, but for the purposes of discussion, I think we should accept that none of us were on the call and it was not possible for this medic to obtain a BP even by palp.

2. Are we held strictly to the traditional "two systems involvement" view of the diagnosis of anaphylaxis or are we permitted to consider a broader definition such as that published by Sampson et al. in the summary report of the Symposium on the Definition and Management of Anaphylaxis?

Question: Can an obstruction of the esophagus cause an obstruction of the airway?

Question: My question is in regards to pneumonia and continuous positive airway pressure (CPAP). Bacterial infections are a common trigger for chronic obstructive pulmonary disease (COPD) exacerbations.

If we have a patient who has possibly developed a pneumonia (isolated crackles mid lobe in one lung, low grade fever, purulent sputum) but is in respiratory distress with a history of COPD and is showing signs of a COPD exacerbation (decreased breath sounds in bases, showing signs of hypoxia, accessory muscle use, tachypnea, mild diffuse exp wheezes), are we not to treat with CPAP and just use bronchodilators and high flow O2? Thank you!

Question: I have been to a few calls where the patient does not have a DNR, but the death is expected and family does not want CPR or other interventions. The family will make statements like "we don't want CPR" or “they wouldn't want CPR", etc. Do we initiate the CPR and Defibrillation protocols until we can get hold of the BHP or do we run the call and transport regardless of family request?

Question: There was a question posted on Sep 23, 2014 in regards to a fluid bolus on a transfer between facilities. As I agree that there should have been an RN escort for this patient, the paramedic was certified in IV fluid therapy including boluses. Your answer has me perplexed however. If a physician gave the paramedic a fluid bolus order how would that differ from getting a similar order from a BHP through phone patch. It is in the scope of practice for the paramedic to administer NaCl 0.9% as a bolus, the volume was prescribed by the physician(s) in charge of this patient's care. Would any paramedic be wrong in following the order given by the physician?

Question: What is the criteria necessary for the starting process of implementing a new directive/protocol for pre-hospital settings?

Question: How often should you reassess the respiratory rate for apneic patients?

Question: I'm a PCP with autonomous IV. It states that a contraindication for a fluid bolus is "signs of fluid overload". I realize the obvious one is pulmonary edema as that is the example that is always brought up in this scenario. What about a pt that has a clear chest with no fluid accumulation in the lungs, but has peripheral edema in the legs or abdomen? I've also had pt's with hypotension that are on dialysis and have stated that they cannot receive large amounts of fluid due to kidney failure. Do we just document their condition? I've heard different answers from everyone and would appreciate some clarification.

Question: I have a question regarding congestive heart failure (CHF) and ASA. If a patient is having acute CHF and is coughing up blood but is also having chest pain are they still a candidate to receive ASA given the active "bleeding". I would think the blood from back up into your lungs is different than the blood from an ulcer or something. Thanks for your help.