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ACP Epi for rearrest As an ACP if I have a patient who arrests, ROSCs and then rearrests, how should I proceed with my epi's after re-arrests?

If on scene should I continue until 20 minutes then transport?
If on route already should I continue epi's q4 all the way in to the hospital?
How about amio/lido in the setting of re-arrests?

1. Re-Arrest On Scene:
Thank you for your question. In the event of a re-arrest occurring on scene after ROSC (Return of Spontaneous Circulation), the following steps should be followed based on the normal ACLS (Advanced Cardiac Life Support) algorithms:
-Initiate CPR (Cardiopulmonary Resuscitation).
-Administer Epinephrine (Epi) every 4 minutes.
-Administer Lidocaine or Amiodarone as required if not already done while preparing for extrication/transport.
-Perform rhythm checks and defibrillation every two minutes.
-Utilize your clinical judgement and plan for extrication/transport.
-Consider initiating a BHP patch for further consult if needed.

2. Re-Arrest Enroute:
In the event of a re-arrest occurring during transport, different considerations come into play. A decision needs to be made whether to pull over and re-initiate resuscitation or provide a single analysis and transport. Here's the approach in such a situation:
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If a re-arrest happens during transport, the first step is to pull over and analyze for a shockable rhythm.
-If you are in close proximity to the hospital, it is advisable to perform a single rhythm analysis and proceed with transport while continuing CPR. Single ACP with no additional resources should prioritize effective CPR over Epinephrine administration.
-If there are multiple rescuers in the vehicle, one provider can perform CPR while the second provider briefly checks for a pulse every 4 minutes to determine if Epi is required. Consider utilizing ETC02 as a diagnostic aid to confirm or rule out ROSC.
-It's important to note that rhythm analysis during transport would not be feasible if transport is chosen after a single analysis due to the hospital's proximity as you will need to pull over for each analysis.
By considering these factors, you can make informed decisions regarding resuscitation efforts during transport and ensure the best possible care for the patient.

What is base hospitals stance on transferring care of patients who have been treated with narcotics to PCPs in AOD?

Thank you for your question. In any transfer of care from ACP to PCP the question that needs to be considered is will the patient need a scope of practice that only the ACP can perform. In the case of pain management, only ACP medics can provide narcotic analgesia (at present). If the ACP feels that the patients pain is controlled to the point of not requiring further narcotics, the transfer of care to PCPs can occur. PCPs have the ability to provide naloxone should narcotic overdose occur, a rare phenomenon in prehospital treatment.

Zofran vs Gravol in Pregnancy I noticed there were no preferences listed in the ALS PCS or the companion document for antiemetics during pregnancy. Is there a preference of one vs the other when administering an antiemetic to a pregnant patient?

Thank you for your question. The companion document contains some additional information that permits paramedics to use their clinical judgement as it pertains to the selection of either Dimenhydrinate or Ondansetron. Both medications are considered safe in this patient population; however, dimenhydrinate has years of data showing safety in all trimesters of pregnancy. Ondansetron has shown to be safe in all trimesters with a possible mild increase in oral cleft malformation (risk difference of 2.7 per 10000 births), for this reason, dimenhydrinate should be considered in pregnant patients.

Dexamethasone and CPAP for Pneumonia Patients I recently completed a call for a patient with suspected pneumonia. We put the patient on CPAP and there was some improvement. We didnt give the patient any nitro due to her having a fever and recent history of a cough so decided the best course was treating it as pneumonia. We did give the patient 8mg of dexamethasone and when we were talking about the call afterwards, we realized there could be some questioning about our decision to give dex. Our thoughts behind it were that since it was a steroid for breathing issues, pneumonia would be applicable since there can be some constriction with the infection. Her crackles were too coarse to hear any constriction and there was some confusion from staff on scene as to whether the patient had COPD or not so we decided that it would only benefit the patient. In our call review, we realized it probably would have been more prudent to call BHP since it wasnt a clear cut situation. Just wondering what your thoughts are on this call and how we treated it.

Thank you for your question. Pneumonia is a radiologic diagnosis. Many patients who have fever and respiratory symptoms may have pneumonia or COPD exacerbation, or viral illness, or empyema, etc There is no evidence for steroids in pneumonia except for patients who are severe, requiring mechanical ventilation or impending respiratory failure. Also, steroids will have no effect in the prehospital timeframe. Therefore I would avoid giving steroids in suspected pneumonia and leave this potential treatment decision for later.

Oxytocin before placental delivery? The directive says Postpartum delivery AND/OR Placental delivery. Do I have to wait until the placenta is delivered to give oxytocin?

Thank you for the question.
Oxytocin is used to decrease the frequency of postpartum hemorrhage by inducing/increasing uterine contraction. This can be very dangerous if given prior to delivery of the fetus. Oxytocin is not dangerous to the undelivered placenta.
For this reason, oxytocin should only be given after the fetus or fetuses are delivered. Delivery of the placenta can take place before or after oxytocin administration.

Treat and Discharge Seizure and MTO guidelines? Are Paramedics responsible to report or have an obligation to report a seizure to the patient's physician to be filed with the MTO? Although these patients are to follow up with their primary HCP post Treat and Discharge, is there a chance some patients may be missed? Our ALS v5.2 states >24hours however the following references >6 months. Any insight would be greatly appreciated. Thank you for your time.
In accordance with the OntarioHighway Traffic Act, the Ministry of Transportation makes all decisions about drivers licenses in Ontario. In the province, physicians are required under law to report anyone over 16 who they believe is not able to safely drive. These reports go to the MTO whether you have a drivers licence or not.
When the report is received, the MTO will review the information and make a decision about the status of your drivers licence. The MTO might ask for more information or suspend your licence without the need for further evidence. If this happens, your licence will be reinstated when conditions are met and when the appropriate medical information is received, reviewed, and approved.
You may drive with a seizure disorder in Ontario, if:
-medication appears to have prevented your seizures AND:
-you have been free from seizures for 6 months and your medication does not impair your consciousness (e.g., doesnt cause drowsiness), or cause poor coordination or muscle control.
-your physician believes you are a conscientious patient who will take your medication responsibly and follow all the physicians instructions carefully.
-you are under regular medical supervision and your physician believes you will report to him/her immediately should any further seizure(s) occur.
-you have had a single spontaneous seizure unrelated to any toxic illness and for which a full neurological examination reveals no form of epileptic activity.
-you have seizures only during sleep or immediately upon awakening (nocturnal seizures) and it has either been 6 months since your last seizure OR if you still have seizures, the pattern has been consistent for at least 1 year.
-you have simple partial seizures and it has either been 6 months since your last seizure OR if you still have seizures, the pattern has been consistent for at least 1 year; you also must have favourable assessment from a treating physician or neurologist, no impairment in your level of consciousness/cognition, and no head or eye deviation.
-you have been seizure-free for at least 6 months, but had a seizure after decreasing medication under your physicians advice and supervision. You may drive once you have resumed taking your previous medication at the prescribed dosage.

Thank you for your question. Discharge of patients is new to paramedicine and these types of reporting processes are currently being addressed by the OBHG and Ministry of Health. We hope to have some direction soon.

DNR & Airway Obstruction Cardiac Arrest During a cardiac arrest caused by an airway obstruction, would you treat this as an unusual circumstance, do one analysis, and transport due to the DNR being for their medical conditions or would you honor the DNR and provide no chest compressions?

Thank you for your question. I think we can extrapolate this question to DNR with any potential reversible cause. This situation brings an ethical dilemma because the patient has now experienced a death secondary to something that was not a part of their disease process. Regardless of this, the patient obviously has made a decision to be a DNR due to medical or social reasons and because of this, I would honour the DNR.

What is the reasoning for withholding oxytocin with a systolic blood pressure of >160? Just looking for clarification as to why oxytocin is not given when there is a blood pressure of greater than 160mmhg systolic.

Thank you for your question. Although the numbers are small, studies have shown that the hemodynamic effects of oxytocin on patients with severe preeclampsia are not predictable. Oxytocin may cause decreased cardiac output and subsequent hypotension. For this reason, oxytocin is contraindicated in patients with a systolic BP >160 mm Hg.
I have attached a link to a 2011 study on this.

Under the revised medical arrest directive can hypothermic patients get Epi 1:10,000?

Thank you for your question. In hypothermic cardiac arrest, ACLS protocols still apply but with a twist based upon core temperature, as the colder the temperature the less or delayed the response to drugs and electricity.
The revised guidelines recommend:
-Less than 30 degrees Celsius - one dose of IV epinephrine,
-Greater than 30 degrees Celsius - may use normal ACLS protocols but double the duration for shocks and doses, i.e. every 4 minutes for shocks and every 6-10 minutes for IV epinephrine,
-Over 35 degrees Celsius - it is business as usual.
So how does this apply to the ACP paramedic who does not have a rectal thermometer? If hypothermia is suspected - you can give one dose of epinephrine during transport. You may receive further direction from the Base Hospital Physician.

Should Dexamethasone be given to asthma or COPD patients who present with a respiratory infection as the main problem? Is it ok to administer dexamethasone in these cases even though asthma or COPD is not the primary cause of the dyspnea?

Thank you for your question. Dexamethasone is used in reactive airway diseases such as asthma and COPD to help reduce inflammation and improve bronchodilation. Asthma and COPD exacerbations are triggered by the environment, infections, allergens etc. Whatever the cause, the answer is to reverse the exacerbation by our various symptom relief interventions. Therefore if the patient qualified for dexamethasone as per the patient care standards then it can be administered.