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Brady STEMI Hello, I had an interesting call over the weekend where we were dispatched for a fall code three.
On arrival in the hallway of this apartment was a rather small lady, vomiting c/o dizziness and nausea. Apparently she went to the bathroom, felt dizzy, collapsed and called for help. Got a quick sugar and palpated a Brady pulse and I just opted to get the pt extricated giving the small quarters and little room. Pt was collared and cleaned up and we got out as quicky as we could. When we loaded her, pt started vomiting which we managed and pt discovered to have an inferior STEMI w HR at 33bpm. The B/P was low 90s, confirmed manually. I gave fluids, activated STEMI alert, and began transport.
What's bothering me, is the opportunity to pace or not with an inferior STEMI but the B/P was slightly above 90. I spoke to the doc in the ER and he stated it was probably better to just give the fluids and get her here like we did. Pt was a/o x 3 and she remained with eyes closed and throughout call when asked any question she would open her eyes and answer well.

Thank you for the question.
One of the more common side effects of an inferior MI is bradycardia. Remember bradycardia is just a number, the key thing is if the patient is perfusing which is usually quantified by blood pressure. We accept a mean arterial pressure of 65 or a systolic BP of 90 if the patient is showing signs of good end organ perfusion-mentation, strong pulses etc. If not then administration of atropine or TCP is required. The nice thing about inferior MIs is that they are usually vagal mediated and so they respond to atropine.
In this case, although the patient had a HR of 33, her SBP was in the 90s so was not in immediate need of pacing but you can argue that she did fall and hence is not well perfused. So I think a dose of atropine could be considered or a BHP patch to discuss atropine if unsure.

Ondansetron There is no mention of administration of Ondansetron when the patient has already taken it prior to arrival in new directives. If they have, when should we administer vs withhold?

Thank you for the question.
The maximum dose of ondansetron is 8 mg every 8 hours, therefore if the patient had taken 4 mg prior to our arrival we could safely give another 4 mg. However, sometimes patients are not sure of their dosing or the timing of their medications, furthermore in those with hepatic failure a reduced dosage is preferred. To address this situation we added to the bottom of the directives that should thepatient still feel nauseous, or is still vomiting after ondansetron administration (either by us or themselves) we can safely give dimenhydrinate should the patient meet the conditions and have no contraindications.

Gravol vs Ondansetron If a patient has flu like symptoms, nausea and vomiting, no vertigo and less than 65 years of age....which is preferred?

Thank you for your question. Both antiemetics have a role, but ondansetron is more effective for "rock star vomiting" without the side-effects of drowsiness or anti-cholinergic symptoms, which is important in our elderly population. If there are no contraindications such as prolonged QTc than this is the antiemetic I use for profound vomiting secondary to flu like illness. However, if it is for more nausea and mild vomiting, then Gravol is effective, and if they have vertigo, it is an added bonus.

What to do for first time arrest on route? During ALS PCS v4.9 for a first time arrest while on route we would pull over and run the full 4 analysis cardiac medical arrest directive.
Now with the new ALS PCS v5.1 when do we resume transport? How many analysis? Would it very from shockable to non shockable?
If they meet any of the 5 primary clinical considerations we would resume transport after one analysis but what if they are asystole?
Or V-fib and then asystole after shock?
I'm thinking for a patient in asystole we wouldn't stay on the side of the road for 20 minutes of CPR to call for a TOR.

Thank you for your question. For a witnessed arrest in the back of the ambulance, paramedics should use clinical judgment to decide whether to stay and perform resuscitation or proceed to hospital. The paramedic should perform three full analysis and then proceed/patch or to provide one analysis and go. The paramedic should provide at minimum one analysis. Factors that are part of the decision process include distance to closest hospital, probable cause of arrest, ability to provide adequate CPR/ventilation, shockable vs non-shockable etc.

Can we give Naloxone in Cardiac Arrest with the longer scene time now? Understanding that naloxone plays no clear role in cardiac arrest, but knowing that sometimes an order for naloxone is given when the BHP is patched to discuss a possible TOR and now that we are treating cardiac arrest patients on scene for upwards of 20 minutes and trying to rule out the H\'s and T\'s. Would it be appropriate if the arrest is suspected to be due to an opioid overdose to administer Naloxone during the resuscitation as long as all other treatment (airway/CPR/Epi if ACP) is being performed as required? Should we just go ahead and administer it or should we patch?

Thank you for your question. As you are aware, the medical directive at this time notes that there is no clear role for routine administration of naloxone in confirmed cardiac arrest. However, as in the setting you describe with a longer scene time and addressing the reversible causes that could have resulted in Cardiac Arrest, it would be very appropriate for the administration of naloxone when opioid overdose is suspected. It is important of course to document your reasoning very clearly as to why it was administered. Documentation cannot be stressed enough when it comes to any intervention, particularly in the scenario you describe that may not exactly fit into the directive, thus allowing for all care providers to understand the context and reasoning of your decision.

Contraindications for Dexamethasone Currently on PO or parenteral steroids is the contraindication for dexamethasone.
Are routine cortisone injections or anabolic steroid use considered current use or only the day it was taken?
For patients who have been prescribed prednisone can dex be administered the day after the prescription has ended or should there be a wait time?

Thank you for your question! The are two different classes of steroids. These include Corticosteroids (ie. dexamethasone and prednisone) and Anabolic steroids (ie. testosterone). Corticosteroids work on the pathways to reduce inflammation and results in the positive effects we see when treating croup and allergic reactions. Corticosteroids can be administered orally, intravenously, topically, and they can be inhaled. How they are administered does affect the overall systemic absorption of the medication. For example, inhaled steroids (ie. Flovent) have much less systemic absorption compared to oral steroids such as dexamethasone. Whereas oral and IV steroids have very similar systemic absorption.
If a patient has been using inhaled steroids, no matter when it was last administered, this would not be considered to be a contraindication for dexamethasone.
If a patient has taken oral steroids in the last 48hrs it is less likely an additional dose will have much effect on their clinical outcome in the prehospital setting.
There is no contraindication to give corticosteroids no matter when any anabolic steroids may have been used.

Clarification regarding CPAP Could you please explain the mechanism of action of CPAP on bronchoconstriction? I recently had a patient who stated they had both COPD and asthma. They were taking fluticasone and salbutamol and she met the conditions for CPAP, however, she had audible wheezing. Upon auscultation, it seemed that wheezing was coming from the upper airways. While this seemed it was a COPD exacerbation, we had concerns on how the CPAP would effect the obvious bronchoconstriction. Ultimately, we gave this patient salbutamol and dex, and they significantly improved by the time we arrived at the ED. However, I would like to know where the line is when it comes to these patients with respiratory comorbidities? And what cautions should we have with CPAP?

Good question. Non-invasive positive pressure ventilation such as CPAP in the prehospital setting or BIPAP in the emergency room work to reduce the work of breathing by stenting open airways to improve exhalation. CPAP delivers continuous positive airway pressure to the upper airways and is designed to prevent airway collapse. It is very effective for those who are experiencing COPD exacerbations or acute congestive heart failure.
Patients with reactive airway disease such as COPD have upper airway narrowing secondary to inflammation resulting inobstruction to exhalation. So it takes them a long time to exhale. A fast respiratory rate shortens the time available for exhalation, leading to breath stacking and ultimately hyperinflation, which increases the obstruction to exhalation and compounds the patient's respiratory distressresulting in a vicious cycle.
Our treatment for COPD patients are designed to lessen the resistance to air entry and expulsion and we can do this with bronchodilators and CPAP. CPAP, for lack of better words, splints the airways and prevents their collapse during exhalation thereby allowing the lungs to empty. In situations where bronchodilators are not effective, CPAP is the next step. In fact CPAP should be started in conjunction with bronchodilators for any moderate to severe reactive airway COPD patient. Although exact pathophysiology of asthma is different than that of COPD, the respiratory compromise of this obstructive disease is similar. There is significant air trapping and excessive use of respiratory muscles to exhale against smaller airways. The air trapping and intrinsic PEEP makes inhalation difficult and taxes the respiratory muscles. NIPPV offers several mechanisms that may benefit an asthma exacerbation, such as offloading the work of inspiratory muscles, a direct bronchodilatory effect, allowing improved flow of bronchodilatory agents in the bronchial tree, and improving ventilation/perfusion matching. However medicine is like a snowflake in that no two diseases, no matter how similar, are alike with respect to treatment. The data supporting NIPPV in asthma are lacking. The existing limited data do not show the mortality benefit seen with NIPPV in the treatment of COPD. Improvements in respiratory rate and airflow have been noted. Some studies point toward an overall decrease in intubation rates and shorter ICU stays. For this reason we reserve pre-hospital CPAP for COPD and CHF patients. Asthmatic patients should be treated with aggressive bronchodilation and transported to the ED where the decision to start BiPap may be entertained. Thank you!

When is transport required after newborn resus? Just wondering what the definitive time is for transporting after a newborn resus; I know that we should leave ASAP, however how many rounds through the flowchart between the PPV and compressions would be appropriate before transporting?

Thank you for your question. Neonatal resuscitation is a terrifying event, even for the most seasoned ER physicians.
As per the patient care standards If newborn resuscitation is required, initiate cardiac monitoring and right-hand pulse oximetry monitoring. Infants born between 20-25 weeks gestation may be stillborn or die quickly. Initiate resuscitation and transport as soon as feasible. If gestational age cannot be confirmed, initiate resuscitation and rapid transport. If newborn is less than 20 weeks gestation, resuscitation is futile. Provide the newborn with warmth and consider patching to BHP for further direction.
In short, the decision to transport a neonatal resuscitation should be as early as possible. If you have performed your three 30-second assessments/interventions-rewarming/stimulation-PPV via BVM-CPR with no change then transport immediately and continue resuscitation enroute. The child will need more aggressive measures in the hospital which cannot be done in the home.

Pain Management with Abortions I recently had a patient who had taken misoprostol and mifepristone for an abortion. We were called due to abdominal pain and vaginal bleeding. The patient hadnt been advised on any pain medication to take so Im wondering what the viewpoint of base hospital is on pain management for the patients due to the vaginal bleeding and potential for the patient to become hypotensive due to potentially excessive bleeding.

Thank you for your question. The use of acetaminophen, ibuprofen and Toradol would be appropriate options in treating pain in this clinical scenario. Acetaminophen is not associated with risk of bleeding. Although there is a low risk of GI bleeding with ibuprofen and Toradol, the use of these NSAIDS in this clinical scenario would be beneficial for pain control and would not increase the risk of vaginal bleeding. NSAIDS reduce the production of prostaglandins which helps to control pain, but they can also help control menstrual flow due via mechanisms on the uterine lining. The use of narcotics would also be appropriate for ACP providers.

Pediatric Chest Needle Thoracostomy For pediatrics presenting with a tension pneumothorax, the supplied 14G angiocath would be much too large. What would the appropriate needle gauge be? Can we use an IV catheter to manage this patient condition?

In reference to a 2019 study, it is suggested for children 0-10 years of age, use of a 22G, 20G, 18G, with favour of 22G, including 24G in neonates are most deemed appropriate.

Thank you for your question. Yes, with everything in the pediatric world, adult equipment and sizes does not extrapolate to the pediatric patient. You are correct in your determination that the length of the 14 gauge angiocath would be too large for the pediatric chest, therefore we go by the age of the patient to determine the appropriate size as per the ALS PCS companion document.When determining the catheter sizing for pediatrics, the age of the patient should be taken into consideration. Pediatrics that are adolescents of adult size, should be treated as adults and a needle thoracostomy should be performed using the 4th intercostal space anterior axillary line with a minimum of a 14G 2 inch angiocath needle.
For pediatrics that are less than 13 years of age, or small adolescents, a 14G or 16G 1.5 inch angiocath needle is appropriate for performing a needle thoracostomy. Any needle that is longer can increase the risk of iatrogenic injury to the patient. A 2-inch needle is more than double the chest wall thickness of most children. The 2nd intercostal space is the preferred location for this patient population.