7-Jul-2017 | SWORBHP Ask MAC

Date Archives: 7-Jul-2017

July 7, 2017 SWORBHP Category: Intravenous and Fluid Therapy, Do Not Resuscitate (DNR) | Date: 7-Jul-2017

Question: In a setting where you arrive on scene and you are presented with a patient who is unconscious and is hypotensive, the patient has a valid DNR. Can you still administer fluids to this patient or does that fall under the same category as inserting an OPA/NPA and BVM to a patient with a DNR?

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July 7, 2017 SWORBHP Category: Tachydysrhythmia, Adult Analgesia | Date: 7-Jul-2017

Question: This question may be a very rare situation but I have not been able to get an answer from any paramedics I have asked. As per the "Patching" section in the introduction of the ALS PCS the literature states "BHP cannot be reached despite reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required treatment without the requisite online authorization if the patient is in severe distress and, in the paramedic’s opinion, the medical directive would otherwise apply". In a situation where a cardioversion is required and the unstable patient is still conscious, it is fairly common practice to ask for sedation and pain control (i.e. Morphine/Midazolam) along with orders for cardioversion. If multiple BH patches cannot be completed and in the paramedics opinion cardioversion is required for the unstable but conscious patient, are we able to administer sedation and pain control? I ask this because there is not a directive that directly deals with pain and sedation prior to delivering the cardioversion, but is common to ask for such direction.

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Answer: Thanks for this question. There is no definite criteria that would constitute a patch failure. This is an instance in which paramedic judgment must come into play. If two or three unsuccessful patch attempts have been made, and in your judgment the patient is at risk for serious harm with further delay in care, then you would be right in carrying out a treatment (cardioversion for unstable tachycardia in this case).

This scenario in particular, however, can be problematic. Additional agents that may be used for analgesia and sedation can result in hypotension and respiratory depression as common side effects. The purpose behind using your judgment in order to carry out a treatment prior to completion of a BHP patch is to prevent serious deterioration or harm to a patient as a result of a time-sensitive medical issue. Administering analgesia and sedation doesn’t necessarily fall into the same category as time-sensitive. The administration of those medications may help with comfort but in an already unstable patient might actually cause further harm.

In the unlikely event that you have a patch failure with a patient who needs cardioversion who is unstable, paramedic judgement is required. If the patient requires medication for sedation due to maintained level of consciousness, this most likely reflects adequate perfusion to allow time for either successful patch connection with the BHP or transport if transport times are relatively short. If the paramedic judges that the patient does not require analgesia or sedation due to altered LOC, this most likely represents poor perfusion and cardioversion would be appropriate and a patch to a BHP as soon as possible.

The Regional Base Hospital would not routinely support sedation and or analgesia without a patch prior to cardioversion. However every call is different and these scenarios can be dynamic. If the patch attempt fails and the paramedic judges the patient is too unstable to wait for transport or a successful patch AND requires some analgesia /sedation prior to cardioversion AND will tolerate the adverse effects of sedation / analgesia the paramedic may proceed with sedation / analgesia and subsequent cardioversion. The situation should be well documented on the ACR and BHP contact should be made as soon as possible. Again the call you describe would be a very unlikely situation.

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July 7, 2017 SWORBHP Category: Miscellaneous, Oxygen Therapy | Date: 7-Jul-2017

Question: For teaching purposes. While assessing a patient, how important is it to determine any and all treatments or interventions provided to the patient by allied agencies, bystanders, self-administration or other medical professionals prior to the arrival of the Paramedics? How important is it to determine an accurate time line of those treatments or interventions? Is oxygen a treatment and/or intervention?

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July 7, 2017 SWORBHP Category: CPAP, Oxygen Therapy | Date: 7-Jul-2017

Question: Is PEEP being considered for inclusion into the paramedic scope of practice? I recently had a patient who was in CHF to the point of unconsciousness whom we would have absolutely given CPAP had he been conscious. Although PEEP isn't exactly the same as CPAP, would it not have potentially provided some benefit?

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Answer: You are correct, Positive End Expiratory Pressure (PEEP) is not exactly the same as CPAP. PEEP can be administered by application of a PEEP valve to a BVM. PEEP works by limiting exhalation by way of maintaining a small amount of positive pressure. This helps to splint alveoli open, and increases functional residual capacity, which is the volume of gas that remains in lungs after a normal breath. CPAP, on the other hand, provides continuous positive pressure throughout the respiratory cycle, thereby improving oxygenation and tidal volumes.

The issue of CPAP vs BVM has been brought up with Ask MAC previously, so some of the following is taken from that (from Nov. 2013)

Both interventions may lead to improved lung compliance and reduced work of breathing. This effect will be much more prominent in the case of CPAP compared to PEEP. Nonetheless, the decision to use a BVM is a decision that must be made on paramedic judgment as to the patient’s level of consciousness and respiratory effectiveness/distress as well as where indicated by the BLS Patient Care Standards.
If a patient is in respiratory distress and has an oxygen saturation of less than 90% or accessory muscle use such that CPAP would be considered (and CPAP is not available or contraindicated) then it would be reasonable to consider using a BVM to assist with ventilations. In this case, using a PEEP valve on the BVM would be of benefit. As PEEP valves are not controlled medical acts, these equipment components fall under the oversight of paramedic services.

Strictly speaking however, providing ventilations through the BVM does not provide a continuous level of airway pressure (although with the use of a PEEP valve on a BVM we may be able to approach some level of continuous airway pressure) therefore the physiology (and potentially the benefit) may not be the same. Bottom line: the use of the BVM is a skill that paramedics must be familiar with and used as per their own judgment and the BLS Patient Care Standards but not as a substitute for CPAP.

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July 7, 2017 SWORBHP Category: Miscellaneous | Date: 7-Jul-2017

Question: I've heard of crews being asked to transfer patients between facilities with indwelling tubes and lines that are not within their scope, and they don't have suitable escorts. I had a colleague asked to transport a patient with a chest tube, without an RN escort, to which they refused, but recently saw a crew transporting a patient with a nasal epistax in-situ. I know these have the potential to migrate and cause airway obstruction so didn't think we should move these without a hospital escort. Could the Base Hospital provide some direction so that it is clearer to paramedics as to what they should do in these cases?

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Miscellaneous

July 7, 2017 SWORBHP Category: Cardiac Ischemia, Cardiogenic Shock, CPAP | Date: 7-Jul-2017

Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 - 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

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July 7, 2017 SWORBHP Category: Medical Cardiac Arrest | Date: 7-Jul-2017

Question: CPR guidelines: I understand that we start CPR with a patient less than 16 years old, heart rate less than 60 and signs of poor perfusion, agonal respirations as per the CPR guidelines. My question is if we have the same situation with an adult patient, what would be beneficial for this type of patient (CPR)?

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Medical Cardiac Arrest