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Can I give dextrose immediately after glucagon IV? Is it acceptable to administer dextrose immediately after glucagon if an IV was achieved after glucagon administration (failed IV attempts, give glucagon, try another IV with success, give dextrose). If so, would I have to record a new sugar reading prior to dextrose administration even if Im prepared to give dextrose immediately after glucagon? Would there be any changes to the number of max doses of either drug I could administer in this case?

In summary, based on the pharmacokinetics of these medications, you should give time for them to work before re-checking and potential re-administering the medication. Give 10 minutes for dextrose and 20 minutes for glucagon. There would be no change to the number of maximum doses. However, note, if further glycemic treatment is required (patient still symptomatic and hypoglycemic despite appropriate dosages and after waiting the appropriate time) it is reasonable to patch to the BHP for direction.

Can we give Tylenol for fevers? Why isn't there a "febrile medical directive" to give Tylenol? having something like this, especially around flu season would enhance patient care.

In summary, one has to consider the benefit of this medication for fever given the relative short transport times for the majority of patient contacts (we are aware of longer transports in rural areas) vs the time required for acetaminophen (Tylenol) to impact fever. As with any new Medical Directive, there are training costs in terms of medical math for dosing calculations as well as medication costs for the operator. None of these are insurmountable in any way of course, however these may be some of the reasons that acetaminophen for fever has not been considered to this point.

Diluting Diphenhydramine The Benadryl Medication Reference states "Benadryl given IV should be diluted with 9 ml of Normal Saline prior to administration" yet the ALS protocol makes no mention of diluting the medication like it does for Gravol. Which is the correct way to administer Benadryl IV?

Is ETCO2 a good indicator of perfusion in VSA patients? When running an ALS arrest where the patient is showing a PEA on the monitor with an accompanying high ETCO2, could we assume that this patient is in fact perfusing to some degree and pulses are just not palpable for various reasons (obesity, severe hypotension, etc.)? Secondly, if the above assumption is correct, would it be prudent to stop CPR provided the ETCO2 remains high and administer dopamine in hopes of increasing BP until pulses are palpable and BP obtainable; or should the vasopressor effects of Epinephrine be sufficient to facilitate this so just continue with Epinephrine q5 min and CPR?

You have correctly identified that ETCO2 can be a valuable tool in cardiac arrest situations and may be a physiological markers of ROSC when the patient is hypoperfusing. The AHA has reviewed all of the relevant literature regarding ETCO2 in cardiac arrest and unfortunately, there is not enough evidence to support its sole use as an indicator for ROSC at this time. You have also correctly identified that it can be very difficult to assess for a pulse in a patient who may be hypoperfusing. Studies have shown that healthcare providers often have difficulties ascertaining a pulse when one is present or believing one is present when it is in fact absent. Furthermore, with a focus on high quality CPR, we are seeing higher baseline ETCO2 levels in patients in cardiac arrest. As per Part 7, 3.3.1 of the 2015 AHA guidelines, ROSC is likely when an abrupt increase in any of these parameters (ETCO2) is a sensitive indicator of ROSC rather than the absolute value. The use of ETCO2 can be used in conjunction with other signs of life (pulse, breathing, movement etc.) to help determine ROSC. Furthermore, Part 5, 3.2 of the AHA guidelines state The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions . When faced with a situation where a rise in ETCO2 is noted and you are having difficulty determining a pulse, you can always ask your partner to confirm your findings at another site. If a pulse cannot be obtained, then resume CPR and follow your directive accordingly.

Do we need to check BGL prior to Narcan? Do you feel it is necessary in all cases to check BGL prior to administering Narcan? The Medical Directive reads uncorrected hypoglycemia as contraindication but in the presence of no diabetic history and an incident history which is clearly indicating opioid overdose combined with critically low oxygen saturation and no ability to ventilate are we to invariably to take a BGL prior to treating obvious signs and symptoms of opioid overdose or can we use clinical judgement based on findings? It goes without saying that a BGL should eventually be taken on such a patient at some point but my question is with a critical patient, no history or finding consistent with low BGL and multiple indicators for OD are we not safe to presume OD, treat accordingly and follow up with BGL afterwards to rule out hypoglycemia?

This is a good question to ask. It illustrates the complexity of practice in the real world. The reality of practice is that in emergent situations practitioners do multiple things simultaneously. If there is no urgency to treat the overdose (you are able to ventilate easily etc.) it is reasonable to have your partner obtain the blood glucose while you are assisting ventilations of the patient. If everything points to a narcotic overdose AND there is no indication the patient is a diabetic taking hypoglycemics AND the patient is unstable, it is reasonable to administer naloxone prior to obtaining a blood glucose determination. As you stated in the question, a blood glucose should be obtained as soon as possible but the priority is to stabilize the patient

Is a footling breech considered a limb presentation requiring immediate transport? I have a question regarding the Emergency Childbirth Medical Directive. My understanding from the protocol is that we can stay on scene to deliver a breech presentation, but for a limb presentation we must transport immediately. I know that we can deliver a complete breech and a frank breech, but what about a footling breech? Is that considered to be a limb presentation that requires immediate transport?

Great question. A limb presentation includes when either an arm OR a leg (such as in a footling breech) is presenting first. Although a footling breech falls technically under the umbrella term of Breech, which involves a stay-on-scene initial approach, a footling would be considered a limb presentation, which is as you mention an indication for immediate transport under the Load and Go Standard within the BLS-PCS.
The reason for this being a 3x increased risk of cord prolapse (5 vs 15%, Breech vs Footling respectively). Cord prolapse causes ischemia to the fetus and therefore is associated with high rates of fetal morbidity and mortality. Management of cord prolapse is emergent C-section. Therefore, this condition is correlated with increased rates of cord prolapse and is therefore an indication for Load and Go.

How many doses of epinephrine can we administer to VSA and/or ROSC patients? Our directives state that we are allowed to administer 2 doses of epinephrine to a patient suffering from a severe allergic reaction and 1 dose to a VSA patient who has become VSA secondary to anaphylactic shock. Does this mean we are allowed to give a 2nd and possibly 3rd dose of epinephrine to a patient by following the moderate to severe allergic reaction medical directive post ROSC?

Yes, this is correct. If your patient has achieved ROSC after suspected anaphylaxis and is still exhibiting signs of anaphylaxis, it is reasonable to follow the Moderate to Severe Allergic Reaction Medical Directive. Note, that in these reversible causes of arrest, and in the face of requiring further epinephrine, expedient transport to definitive care is paramount.

Does wheezing have to be present in the patient assessment to administer Ventolin?

Great question. You are correct that bronchoconstriction can be manifested in symptoms apart from wheezing, for which Ventolin (salbutamol) may be indicated. The OBHG Companion Document states that Symptoms of bronchoconstriction may include wheezing, coughing, dyspnea, decreased air entry and silent chest. and stipulates that, suspected bronchoconstriction applies to asthma, COPD, and other causes of bronchoconstriction.
The Indication for Bronchoconstriction Medical Directive is, Respiratory distress; AND Suspected bronchoconstriction. Therefore, if you have a patient experiencing respiratory distress and is manifesting other symptoms of bronchoconstriction (with a condition such as asthma, COPD or other cause of bronchoconstriction), it would be reasonable to administer salbutamol.

Should we give ASA or Nitro first? I have a question regarding the order of cardiac ischemia medication in the protocol. I have been informed by a source that 0.4 mg Nitro should be the first medication given in a suspected cardiac ischemic event, followed by 2 80 mg ASA. I respectfully disagree with him due to the fact that although nitro is significantly more fast acting, its effects only last 3-5 minutes, hence the spray every 5 minutes stated in the protocol, and although the ASA is slower in its absorption rate, is effects will benefit the Pt. more (in my opinion) than the nitro. The short and sweet version, am I correct in saying that ASA should be administer first before the initial nitro dose is given, if the protocol for both is met?

Great question. The previous iteration of the Medical Directives were quite specific as to the sequence of actions a paramedic is instructed to follow within a given clinical situation. With the current Medical Directives, the intent was to be less prescriptive with regard to paramedic practice. The convention on the Medical Directives however is that preferred routes of administration are listed from left to right. In terms of treatment, the convention is that medication administration should also follow the sequence as listed on the Medical Directive.
In the Cardiac Ischemia Medical Directive, the treatment section outlines that ASA should first be considered, followed by 12 lead (if available) then Nitro. ASA has been proven to decrease mortality in MI so it should be administered as soon as possible. In fact, the 2010 AHA Guidelines even suggest that dispatchers should instruct patients to chew an aspirin while awaiting EMS (OConnor et al Part 10: Acute Coronary Syndromes, Circulation 2010). Nitro will relieve symptoms and is certainly essential, but does not appear to have the same life saving benefits.
Imagine the scenario where a patient receives nitro first and may be suffering from an inferior MI, or is overly sensitive to nitro. They then drop their blood pressure, become nauseated and vagal, and now cant chew the ASA due to impending vomiting. In a practical sense, the order you give the meds can matter. Great question!

Which route is more effective when administering Ventolin? I have a question about the benefits between using MDI vs. nebulized Ventolin. I understand the direction is to use MDI as the preferred route. It certainly makes sense with anybody who is infectious but seems counter intuitive when you could be administering drug with oxygen at the same time as in the case of nebulization. There is also a perceived psychological benefit when patients can feel and see the mist. I have heard about studies that were done at Sick Kids to support MDI use. I was unable to locate them. Is there any other evidence you can suggest as to why MDI is the preferred route?

There has been a fair amount of research done comparing MDI vs nebulized Ventolin. The Canadian Pediatric Society provides a good review of asthma and bronchoconstriction in children. In short, the actual amount of drug delivered to the lungs is thought to be greater with MDI delivery, as much of the drug can end up deposited on the face or dispersing away from the patient with nebulized drug delivery. Somewhat paradoxically, in randomized clinical trials there have been no differences between the two methods of drug delivery with respect to oxygenation, respiratory rate, or clinical scores, however, those who receive Ventolin via nebulizer have significantly higher rates of tachycardia, again supporting the MDI route as the preferred method.
Bottom line, you have a device that can deliver the medicine more effectively without increasing the infection exposure risk to yourself or your partner.
Lastly, dont forget that you can administer Ventolin via MDI while still providing supplemental oxygen. If needed, nasal prongs could be used simultaneously with MDI administration.