HSNCPC

Regarding TXA administration, the guidelines listed in the Companion document outline administration methods (in a 50cc bag or in a 10cc syringe IV over 5 minutes to avoid exacerbating hypotension). However, some services practice administering TXA in a 500 cc bag and infusing a bolus, as advised by their service. Is this an additional administrative option that is being considered for services by Base Hospital for hemorrhagic events, or is this service-dependent?

Also, a rare but plausible question— in the Companion document, it outlines "recommended" IM injection sites. Considering risk versus reward, and assuming a patient has bilateral femur fractures, can TXA be administered in the buttocks (5 mL and 5 mL bilaterally)? It may seem like a silly question, since my interpretation of "recommended" may differ from others. Some services are stern and state the only "approved" IM injection sites are the vastus lateralis: 5 mL, and the deltoid: 2.5 mL, indicating that paramedics are not allowed to utilize other IM injection sites. Personally, I consider the term "recommended" as the preferred method, but not the only method.  Again, the risk of injections in the buttock is a high risk of adverse effects; however, if it was documented, the reasoning behind it, whether it's access or injury, would this be appropriate without the need to contact the base hospital over an injection site?

Very good questions.

The topic of how fast to administer TXA is not a new one because the risk of possible hypotension with a bolus is often cited.

This was based upon studies and cases in which non-trauma patients were administered TXA for hemorrhagic shock. The hypotension was not due to the TXA but rather the rapidity of the IV bolus. Hence we give it over a 5-10 minute interval to avoid potential hypotension. Within our region, a small number of services are currently using a 500 mL NS bag strictly as a vehicle for TXA administration. This option was included in our teaching last year, with the strong recommendation that 50 mL or 100 mL bags remain the preferred choice. The 500 mL bag was discussed as an acceptable alternative when smaller bags were not available.

In all cases, the expectation is that paramedics continue to administer TXA over a minimum of 5 minutes, consistent with the ALS PCS Clinical Considerations 

• “TXA solution for injection should be administered intravenously by slow injection over a period of at least 5 minutes, as rapid administration can cause hypotension.”

Again the issue is not the TXA but rather the rapidity of the bolus and these services are not using the 500cc option as a rapid bolus.

With respect to IM injections, you want to ensure you have enough muscle to inject for proper and full absorption. Fat interferes with IM injection and the bioavailability of a drug. Since the fat content of buttocks can vary from person to person, it is not a reliable IM injection site, especially in the situation of hemorrhagic shock when the full absorption of TXA is vital.

What are the acceptable suction ranges for oropharynx suctioning with a Yankauer? The max setting on our portable suction units, as per the equipment manual, must be 0-550mHg. Does that mean we can suction up to 550mmHg for an adult, or is there a preferred range? For ETT or Trach Suctioning. In the ALS PCS, it's 100-150mmHg. However, there are no guidelines for simple oropharynx suctioning.

Thank you for your question. The Recommendation is to follow current deep suctioning guidelines and increase suction pressure as required to clear oropharynx contents. 

In pediatric defibrillation, should I round-up, or down (nearest) with available joule settings? For example, for a 10-month-old who weighs approximately 9kg, the initial suggested energy setting would be 18 Joules, followed by 36 Joules. DFIB allows 15,20,30,50 Joules.

Thank you for your question. 

In pediatric defibrillation, energy dosing is weight-based (initially 2 J/kg, followed by 4 J/kg for subsequent shocks, with escalation as required).

When the exact calculated joule dose cannot be selected on the defibrillator, the recommended approach is to select the nearest available setting without underdosing. Practically, this means rounding up to the next available joule setting rather than down, particularly in cardiac arrest, where ineffective defibrillation may reduce the likelihood of ROSC.

Using your example:

1. A 10-month-old weighing approximately 9 kg
2. Initial dose: 18 J (2 J/kg) → select 20 J
3. Second dose: 36 J (4 J/kg) → select 50 J

As always, early high-quality CPR, minimizing interruptions, and timely defibrillation remain the most critical determinants of outcome.

If someone has changed sexes, when performing a 12-lead do we input the sex at birth or the new sex?  Furthermore, does the computer generated answer change the monitor interpretation  between male and female?

Thank you for your question. 

Sex is your physiology, gender is how one identifies. In medicine we must treat the physiology of the patient. The differences in physiology do not disappear when one’s identity changes.

We treat the physiology. There are sex related differences with respect to cardiac function and activity and so it is important.

If you respond to a VSA and pt has a valid DNR however, it is strongly suspected that they may have died by suicide, do we resuscitate or honour the DNR?

Thank you for your question. 

Suicide is not considered a natural cause of death, it is a psychiatric condition. In the instance of death by suicide, I would not honour the DNR. If attempts at resuscitation are unsuccessful, a termination of resuscitation may be entertained.

When attending a call, and a patient exclaims immediately they do not want to receive transport to the hospital, what are the directions in terms of treating and providing symptom relief medications. Example, pain - Tylenol/Advil.  Shortness of breath - Ventolin.

Thank you for your question. 

Administering a medication to a patient that you know will not be transported to hospital is dispensing medication and not within the scope of a paramedic. The Medical Directives outline treatment options for patients who are expected to be transported to hospital (exception being the approved Treat and Discharge subset). Therefore, the direction for paramedics is not to provide any medications if a patient is not going to be transported to hospital.  

You may consider educating your capable patient who is refusing transport that you are unable to give medications due to the incomplete work-up for the cause of their symptoms.  This will assist in making an informed decision in refusing transport. 

How come the patient can be altered to administer nitro under the Cardiogenic Pulmonary Edema directive but has to be unaltered under the Cardiac Ischemia directive? Also, if a STEMI is identified and the patient is now being treated under the Cardiac Ischemia directive (3 doses of nitro) do they now have to fit the conditions as well (unaltered) or contraindications (RV MI)?

Thank you for your question. 

With respect to the administration of nitroglycerin for pulmonary edema, the patient’s mental status may be due to hypoxia and with the improvement in oxygenation and ventilation, the mentation improves. However, for the cardiac ischemia directive requires an unaltered sensorium because the history matters. They must tell us that they are having pain or discomfort consistent with cardiac ischemia. We treat the patient and their pain and so they must be able to relate to us what they are experiencing. 

When you are treating a STEMI , you are also treating cardiac ischemia, so yes, the same protocol applies, as well as all the contraindications such as RV MI.

How come the patient can be altered to administer nitro under the Cardiogenic Pulmonary Edema directive but has to be unaltered under the Cardiac Ischemia directive? Also, if a STEMI is identified and the patient is now being treated under the Cardiac Ischemia directive (3 doses of nitro) do they now have to fit the conditions as well (unaltered) or contraindications (RV MI)?

Thank you for your question. 

With respect to the administration of nitroglycerin for pulmonary edema, the patient’s mental status may be due to hypoxia and with the improvement in oxygenation and ventilation, the mentation improves. However, for the cardiac ischemia directive requires an unaltered sensorium because the history matters. They must tell us that they are having pain or discomfort consistent with cardiac ischemia. We treat the patient and their pain and so they must be able to relate to us what they are experiencing. 

When you are treating a STEMI , you are also treating cardiac ischemia, so yes, the same protocol applies, as well as all the contraindications such as RV MI.

If a patient with primary adrenal insufficiency is presenting on scene with lethargy, hypotension, hypoglycemia, and abdominal pain; which treatment is the most appropriate initial intervention? Say the family presents you with a bottle of Hydrocortisone, are we to administer first before correcting the hypoglycemia? Or should the process be to correct the hypoglycemia, and then administer the Hydrocortisone?

Thank you for your question. 

If you have a patient with known adrenal insufficiency and hypoglycemia, treat the most important symptom first which is the blood glucose. I would then patch for appropriate orders for the administration of hydrocortisone.

If a patient with primary adrenal insufficiency is presenting on scene with lethargy, hypotension, hypoglycemia, and abdominal pain; which treatment is the most appropriate initial intervention? Say the family presents you with a bottle of Hydrocortisone, are we to administer first before correcting the hypoglycemia? Or should the process be to correct the hypoglycemia, and then administer the Hydrocortisone?

Thank you for your question. From a prehospital prioritization standpoint, the initial intervention should address immediate life threats first:

• If the patient is hypoglycemic with altered LOC, treat hypoglycemia immediately per ALS PCS/BLS Standards.
• Hydrocortisone is important for adrenal crisis, but it is not typically the first priority over correcting hypoglycemia and supporting airway/breathing/circulation.