2024-09-19

Emergency Childbirth

Should we administer oxytocin in event of a miscarriage?

Thank you for your question. Oxytocin should not be administered in miscarriages. It should be administered in postpartum delivery whereby the newborn is deemed to be an age of viability (20 weeks). Oxytocin is rarely needed in miscarriages. Miscarriages can be hard to diagnose in the prehospital setting and the administration of oxytocin could increase pain and could lead to a miscarriage in the event the pregnancy is still viable.


2024-09-27

Bronchoconstriction

RSV/Bronchiolitis and Ventolin. Is it recommended that Ventolin be withheld or used in pediatric cases where wheezing due to RSV/Bronchiolitis is present with no previous medical history? Usually, these patients are vitally stable versus how they look. The question stems from a Sick Kids Hospital presentation that I completed which reflected that utilizing bronchodilators, epi, or corticosteroids could increase demand, therefor supportive airway management is the recommended tx. and to avoid these medication administration.
As I am aware, this information is not specific to prehospital. I am curious about the recommendations now that we are approaching RSV/Bronchiolitis season.

Great question and one that comes up frequently, particularly as the RSV season approaches!
Bronchiolitis is inflammation of the bronchioles usually caused by an acute viral illness. It is the most common lower respiratory tract infection in children younger than two years of age. The most common infectious agent causing acute bronchiolitis in children is the respiratory syncytial virus (RSV). Bronchiolitis is a clinical diagnosis based on history and physical examination. It can present various symptoms and severity, from a mild upper respiratory tract infection (URTI) to impending respiratory failure (grunting, nasal flaring, indrawing, retractions or abdominal breathing).
Management of bronchiolitis generally requires only supportive care (oxygenation (Sats< 93%), hydration, nasal suctioning). It is recommended to avoid activities that may agitate the child as they can worsen the clinical presentation, allowing the child to remain comforted by a parent and avoiding any unnecessary application of monitors and devices. Evidence does not support the routine use of salbutamol, nebulized epinephrine, or corticosteroids, given the possible side effects weighed against any clinical improvement. Suppose a child has persistent issues with oxygenation despite supplemental oxygen, increased work of breathing that is interfering with hydration or oxygenation, or a family history of asthma. In that case, it is not uncommon for a trial of salbutamol and/or nebulized epinephrine to be used to see if there is any clinical improvement.
In summary, bronchiolitis is a common lower respiratory tract infection in children <2 years of age that is usually best managed by supportive care.


2024-10-15

Analgesia

Is low dose ASA still a contraindication for administering analgesics? What is considered low dose? If someone is taking 81 or 162 mg of daily preventative ASA, is that considered low dose? Or if they were just told by dispatch to take 2 ASA - and do not usually take it, is that considered low dose?
what would be considered low dose in order for us to give the full medication dose of analgesics if it is needed.

Thank you for the question. Concurrent use of ASA would not be a contraindication to analgesia. NSAIDS would be contraindicated if the patient had an ASA allergy (which is unlikely if they are using ASA). Therefore, if a patient is using ASA at any dose, the analgesia medical directive can be used in its entirety.


2024-11-05

Cardiac Ischemia

Elevation criteria for low lateral STEMI. According to our guidelines in the ALS for STEMI diagnosis, we are required to identify 1mm of elevation in 2 or more contiguous leads to diagnose a STEMI unless those leads are in V1-V3, therefore including V4 as well. However, the wording does not include lateral leads V5 and V6. For diagnostic criteria in these leads specifically, how many mm of elevation are required when isolated for the high lateral leads?
Also, what is the recommendation for elevation criteria in posterior leads? >.5mm or >1mm?

Thank you for your question. The leading cardiology associations define ECG STEMI criteria by the Universal Definition of Myocardial Infarction , which includes:
1. New ST elevation in V2-V3 of at least: 2mm in men or 1.5 mm in women, OR
2. New ST elevation of at least 1 mm in two contiguous leads (except for V2 or V3)

The reason V2 and V3 have different criteria is because the amplitude of the QRS tends to be higher in these leads, often leading to some ST elevation and the prevalence of concave ST segments in these leads. So to answer your question, leads V5, V6 or Posterior leads would only require 1mm or greater of ST elevation.


2024-11-13

Medical Cardiac Arrest

Witnessed VSA in truck. We were transporting a pre-arrest pt who on route went VSA. Pt had no known reversible causes, and we were 6 mins from hospital. We pulled over and began resuscitation efforts. Does this pt still get 20 mins of CPR then transport (due to not calling for a TOR as it was a witnessed arrest) and no shocks advised? Or early transport and work pt on route?


Thank you for your question. VSA arrest route to hospital is a regular question. Our companion document states the following: 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. Paramedics should perform three full analysis and then proceed/patch or provide one analysis and go. The paramedic should provide at minimum one analysis. The decision to do one analysis vs three is based upon proximity to the hospital. If you are close- in this case 6 minutes- it would be acceptable to do one analysis and then continue transport. If a patient goes VSA due to ventricular fibrillation than immediate defibrillation is the answer so one analysis is a must. If the patient remains in ventricular fibrillation with significant transport time, VCD or DSED (if authorized/available) could be considered is where the grey area emerges- immediate transport vs stay and provide the second and third analyses - in my opinion the latter option would be an appropriate choice, because the answer to ventricular fibrillation is electricity and CPR. If they are in a non shockable rhythm however there is nothing to be gained from providing further analysis because definitive care is what is required and that is provided in the ED.



2024-11-27

Cardiac Ischemia

ASA administration post ischemic chest pain? Would it be within the scope to administer ASA - 162mg PO for a pt post ischemic chest pain? the pt was transported to hospital for a new onset of symptomatic rapid AFIB.

Thank you for your question. Without knowing the details of the specific patient and case, if the chest pain was thought to be ischemic in nature, it would be reasonable to treat with ASA. ASA works by inhibiting the COX-1 enzyme on platelets therefore decreasing the production of thromboxane A2, a potent platelet aggregator. This will diminish the potential platelet aggregation/thrombus formation at the site of the plaque rupture.
In the case of rapid atrial fibrillation, the chest pain may be due to demand because of the tachycardia and not due to plaque rupture. This however cannot be confirmed immediately and ASA would be reasonable even if the ischemia is thought to be based on demand phenomena.


2024-12-23

Moderate to Severe Allergic Reaction

Question regarding Epi for medical vsa suspected cause is anaphylaxis. Arrived and pt is conscious with anaphylaxis and meets Epi directive; We administer 2 doses of Epi with the proper interval and then the Pt goes VSA . Could they have another dose (3rd dose) as the Medical Cardiac Arrest Directive has a consideration for Epinephrine if anaphylaxis is the suspected cause of the arrest?

Great question. In this scenario, after transitioning from the Anaphylaxis to the Medical Cardiac Arrest Directive, it would be appropriate to give another dose of Epinephrine as long as the proper dosing interval has been respected between the last dose that was given during the administration when it was given in the Anaphylaxis directive.


2024-12-23

General

Defib w/ LUCAS. In the interest of reducing Peri - Shock pauses, can we be defibrillating with CPR on going from the LUCAS device?

Thank you for your question. Defibrillation can be performed during LUCAS device operation, the device does not need to be stopped when delivering the shock. However your rhythm analysis needs to occur with the device on pause to properly interpret the rhythm.


2024-12-23

Cardiac Arrest

ROSC CTAS The Prehospital CTAS Paramedic Guide 2.0 lists ROSC under CTAS 1 Resuscitation, if our ROSC pt is vitally stable with no active resuscitation, are we transporting CTAS 1?

Yes, a ROSC patient who is vitally stable should still be transported as CTAS 1, even without active resuscitation. The CTAS level reflects not just current status but also the high risk of deterioration and need for immediate interventions if required. ROSC patients remain at significant risk for re-arrest and other complications during transport, warranting the highest acuity designation.


2025-01-16

Trauma Cardiac Arrest

Can a deceased pt have a gag reflex? Pt was involved in an MVC, trapped, possible head injury, GCS 4, pt went VSA post extrication. When OPA attempted there was a loud gag, we have never seen this. Was this a gag reflex or something else?

As you rightly pointed out, a GCS of 4 signifies severe neurological compromise, and a genuine gag reflex is typically absent at this level of consciousness. What you observed in this clinical scenario is more likely a brainstem reflex rather than a true protective gag reflex. Brainstem reflexes can persist even with severe brain injury when higher functions are compromised. Furthermore, you may have experienced agonal respirations or gasping, which can mimic the gagging sounds in the VSA scenario. As a side note, this can often be distressing to the family and requires explanation when they observe what appears to be breathing or signs of life.