HSNCPC

At what gestation would it be deemed appropriate for neonatal resuscitation?

Although the neonatal resuscitation directive does not outline a minimal age to initiate resuscitation in a premature neonate, as per the BLS PCS: 5-22,"infants born between 20-25 weeks may be stillborn or die quickly. Initiate immediate resuscitation and rapid transport. We would encourage you to contact the base hospital physician as soon as possible to assist with any further direction in these rare but high stress and difficult cases.

Can we administer fluids to a hypotensive patient who has a DNR? In a setting where you arrive on scene and you are presented with a patient who is unconscious, hypotensive and 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?

Situations involving end of life can be very complicated, and its very hard, if not impossible, to capture a patients wishes for their care on a single form. The ideal scenario would be that the patient would have some more specific advanced directive outlining their wishes in terms of iv fluid. IV fluid is not listed as a therapy that paramedics are not to provide a patient with a valid DNR and could be considered in the hypotensive patient as long as the other conditions of the medical directive are met. As an example, a patient in septic shock could have an altered LOC from poor perfusion and despite the DNR could benefit from IV fluid.

Narcan use in children Could narcan be administered to children when their respirations rate falls below the parameters of normal breaths/min? For example, the RR for infants 0-3 months range between 30-60 breaths/min; so, if they are breathing <30 and meet all the indications would narcan administration be justified?

Good question.
I assume you mean in the context of an opioid overdose then as with all narcotic ODs, narcan is justified if the neonate/child is showing signs of an impending respiratory arrest. Since the majority of pediatric VSAs are respiratory in nature, preventing a respiratory arrest is key.
The current medical directives allow for the use of naloxone for any person greater than 24 hours of age. The dose for the pediatric population is the same as that for the adult and IM is the preferred route of administration.
As mentioned above since respiratory arrest is the most common cause of cardiac arrest in this population, early and effective BVM may be all that is necessary to resuscitate the child and naloxone can be used if this is not successful.

How long should a patient be off anti-coagulant therapy before it is safe to administer NSAIDS? This question came to me via a self report so I thought it was a good one to put here. The situation was:
Patient was released from hospital less than 1 week ago and while in hospital they were on heparin. They were no longer on heparin at this time. When would it be safe to administer NSAID's again to this patient? The medic wasn't sure so they withheld NSAID's.

To answer the question on when NSAIDS would be contraindicated for patients taking anticoagulants it is important to understand the timeframe that these medication remain active. The effects of IV heparin will only last a few hours once discontinued, while low molecular weight heparin or novel anticoagulants (rivaroxaban, dabigatran, apixaban) will normally take about 24 hours to become ineffective. The longest acting anticoagulant would be warfarin (Coumadin) and effects would last for 4-5 days. To keep things simple, I would consider withholding NSAIDs only if a patient is actively taking an anticoagulant as part of their regular medications.

Would it be appropriate to administer analgesia to a patient with cardiac ischemia who experienced concurrent trauma? This question was emailed to me on the weekend so I thought why not put it here. The example was:
Patient is experiencing chest pain and also fractures their ankle. While the directive states suspected ischemic chest pain is a contraindication to analgesia, these are 2 separate events and would it be appropriate to treat them each accordingly? Would the analgesia affect the patients chest pain perception?

Thankfully the scenario where a traumatic event includes cardiac ischemia is low, the question regarding use of analgesia is important. Although the current evidence for narcotics in cardiac ischemia is questionable at best, the AHA still includes morphine as a treatment for this disease process. Morphine also remains a treatment in the ALS PCS for cardiac ischemia. I would therefore recommend that if you are to treat a trauma patient who is experiencing cardiac ischemia symptoms, you should use morphine as indicated in the ALS PCS. For PCP paramedics who do not carry narcotics, acetaminophen would be reasonable to treat pain (other than cardiac ischemia pain) and NSAIDs should be avoided. The really tricky part with a traumatic patient who is experiencing cardiac ischemia symptoms is whether or not to administer ASA. This really depends on the nature of the trauma. The risk of bleeding from the trauma vs the benefit of antiplatelet therapy for the cardiac ischemia would need to be considered. This decision may be best done at the hospital.

Patellar Dislocation Question Teenage patient who dislocated his knee on trampoline while play fighting(fit conditions, no contraindications). Assessment showed obvious deformity to his knee, but the patellar may have "rolled", looks pointy, and appears to be perpendicular to the anterior side. We did not attempt to put it back due to the presentation of the injury, just administered analgesia, and transported. Partner and I wanted to stay in the ER a bit and see what the physician would do, but it was quite busy shift and we didn't have a chance to. I am wondering what are some other things we could have done.

Very good question. Sometimes when we have a new directive, there is an eagerness to use it whenever possible. In this case, the patients presentation was not as expected and so in keeping with the number one mantra in medicine - first, do no harm - you chose wisely not to attempt reduction. More than likely this case will have involved imaging to assess the position of the patella and procedural sedation if it was reducible. All you can do is to stabilize the leg, provide analgesia and then timely transport. It may not sound like enough, but sometimes, less is more. Good work.

Early Transport for Exsanguination VSA
I'm wondering if I picked up a patient who exsanguinated from a non-traumatic event, if it would be appropriate to consider early transportation following the 1st analysis. For example if the patient had ruptured esophageal varices and bled to the point of cardiac arrest. I understand the importance of establishing an airway and treating within our scope, however; this individual needs a surgeon/physician in the same manner that someone who bleeds out from blunt or penetrating trauma needs a surgeon.
Thanks.

Thank you for your question regarding VSA patients secondary to non-traumatic exsanguination. I would agree with your rational. Staying on scene to provide further analysis in these scenarios would most likely be futile, unless the patient is in a shockable rhythm. If the patient is in a non-shockable rhythm, I would consider a single analysis and then a load-and-go priority only if the proximity to the hospital is reasonable (10 minutes or less) and the patient went VSA while you were attending to them. If the patient was VSA on arrival or you are not in close proximity to the hospital, I would suggest you run your medical arrest directive in full and patch for a consult/TOR if no ROSC achieved.

Is it safe to give PO Dexamethasone from a vial that says IM/IV only? On the vials of Dexamethasone my service has it says for IV/IM use only. Is it safe to administer this PO or should we have another type of Dexamethasone on board for PO administration?

Thank you for the question on whether IV/IM Dexamethasone can be given orally.
The quick answer is yes. IV/IM dexamethasone formulation has been given via the oral route for years in the ED.

What should I do if my patient re-arrests into a shockable rhythm and my transport time is excessive? If my patient re-arrests into a shockable rhythm and I did my one analysis but they remain in a shockable rhythm, or I departed the scene because they are in a refractory VF or Pulseless VT, should I stop every 2 minutes to analyze and shock? Continue transport with CPR only? Patching to the BHP could be challenging to do if we are alone in the back or out of cell range.

Thank you for the question regarding re-arrest with shockable rhythms.
In this situation, no one process would cover all situations. Things to consider would be patient age and comorbidities, availability of antiarrhythmic medications, potential for vector change of double sequential defibrillation, quality of CPR, distance to ED and I am sure a few other factors could play a role.
I would encourage you not to stop every two minutes as this would lead to very prolonged transport time. In the event of ongoing refractory VF or pulseless VT where you have decided to leave the scene and proceed to the ED, I would pre-plan 1 or 2 stops to perform a rhythm interpretation. These stops should be based on your distance to hospital and can occur at 10 or 15 minute intervals.
If the patient re-arrests after a ROSC, I would consider stopping and attempt defibrillation at least 3 times if the patient is in a shockable rhythm. If the patient is in a non-shockable rhythm, I would base my resuscitation efforts on proximity to the hospital (one analysis and go if close proximity, 3 analysis with medication delivery if not in close proximity).
Also dont forget about vector change to the AP position if you have a patient with refractory shockable rhythm.