HSNCPC

Extricating a paced pt If I have a pt who requires pacing for bradycardia but they are not stretcher accessible how should I extricate them? Should I delay pacing until they are on the stretcher or should I disconnect them for extrication? (ex. Have to be stair chaired and there's no room for the monitor or if they are being paced and we need to move them) should I stop the pacing so I don't get shocked?

Excellent question pertaining to the clinical scenario of transcutaneous pacing and safe patient movement. Temporary discontinuation of transcutaneous pacing during essential patient movement should be minimized, but may be necessary in certain situations. If the bradycardia is stable and the patient is compensating (blood pressure, mentation), a brief delay for safe extraction is reasonable, as in the case of your example involving the extraction with a stair chair with limited space for the monitor and equipment. Modern transcutaneous pacing devices are designed with safety features to prevent shock to providers. However, it is crucial to ensure proper pad placement and cable management to prevent any accidental application outside of the intended area. For instance, during challenging extractions, it is essential to assign someone to monitor, pad, and cable management to avoid disruptions and ensure clear communication with all members involved in the patients care. If any temporary discontinuation is required, it is imperative to document the time and circumstances of its occurrence, including the reason for its necessity. Never compromise provider safety during patient care.

CTAS Is there ever a scenario where a patient with stroke symptoms would not be classified as a CTAS 2 ?

Patients experiencing stroke symptoms within a 6-hour window or with persistent symptoms within a 24-hour window should be classified as CTAS level 2 from a practical standpoint. While the current Ontario CTAS guidelines incorporate a CTAS level 3 modifier, this classification would only be considered if the patient exhibits no further symptoms and falls outside the specified time frame. It is frequently challenging to identify the initial signs of a stroke, and considering the potential consequences of time on patient outcomes, it is best to adopt a cautious approach when any uncertainty exists.

Oxygen standard As per the BLS oxygenation standard #3. If pulse oximetry equipment is not functioning or not providing an interpretable waveform, administer high-concentration oxygen to all patients specified in paragraph 2 above, as well as those with critical findings, which include:
A. age-specific hypotension,
B. respiratory distress,
C. cyanosis, ashen colour, pallor,
D. altered level of consciousness, and/or
E. abnormal pregnancy or labour.

Are we only giving oxygen to those sets of people if the waveform or equipment is malfunctioning or are we to give it when ever these presentations are present?

Thank you for the question regarding oxygen therapy when pulse oximetry is not functioning. The standard is written in such a way to ensure that the sickest patients receive oxygen when required. If pulse oximetry is functioning properly, you would only administer oxygen if the patients saturations were below 92%. If pulse oximetry is not working or not reliable, then administer oxygen to patients outlined in section 3. There is a cohort of patients who should receive oxygen therapy regardless of saturation values, and these are the patients noted in section 2 of the general directive.

Gravol in the presence of head injury According to the companion document, avoiding Gravol in cases of head injury is recommended, as it may contribute to increased intracranial pressure (ICP). However, I am unable to find supporting documentation explaining how Gravol leads to increased ICP. Could you please clarify this mechanism?

Thank you for your question. I agree that dimenhydrinates effect on ICP is not well documented in literature review. Dimenhydrinate can have effects on blood pressure which I would assume could increase ICP. Realistically, the reason I would avoid this medication in head injured patients is because of the sedative effects. When assessing a head injured patient, it is important to have them as alert as possible, giving them dimenhydrinate may make neurological assessment more difficult. For this reason, I would encourage ondansetron in this population.

Shocking an SVT I heard of a crew that was ordered by the BHP to shock a rapid SVT rhythm in a pulseless patient. It is my understanding that this is a very rare event. If we encounter this, do we treat it as a PEA or should we try to patch and get approval to shock since SVT is not one of the two rhythms that we are authorized to shock? There is an ACP Tachydysrhythmia protocol that gives direction on shocking SVTs, would this even be within our PCP scope of practice? Thanks.

Thank you for the question. Not knowing the exact details of the case, I will respond as best possible. SVT is usually a very stable rhythm. Most patients can be in SVT for prolonged periods without becoming unstable. If a patient were to become unstable, synchronized cardioversion is the mainstay of treatment. If this patient was truly VSA (and not just severely hypotensive) I would still consider electrical treatment to help restore the rhythm. Whether I would use synchronized cardioversion vs defibrillation would depend on the timing and the story. If I felt the patient was in true SVT and just hypotensive, I would use cardioversion. If there was doubt about the underlying rhythm I would consider defibrillation. The electrical treatment of SVT is a mandatory patch point and only part of the ACP scope of practice. For PCPs , I would still patch for guidance and possible defibrillation orders.

Ventolin and respiratory infection. Is Ventolin indicated for respiratory infection/pneumonia? The companion document states other causes of bronchoconstriction and lists a multitude of s/s that are frequently present during lung infections. Technically pneumonia itself is not a reactive airway disease but can cause the same symptoms. If the s/s listed in the companion document under other causes of bronchoconstriction are present should we be treating the patient under the bronchoconstriction medical directive despite the likely differential being respiratory infection/pneumonia? Thank you in advance.

Thank you for your question. Pneumonia/suspected respiratory infection itself isn't a direct indication for salbutamol but if a patient with a suspected respiratory infection is also experiencing wheezing or signs of bronchospasm, administering salbutamol would be treating the bronchoconstriction component of their presentation, not the pneumonia directly.
The key consideration is whether the patient is experiencing bronchoconstriction (wheezing, bronchospasm) alongside their respiratory infection or pneumonia. If bronchoconstriction is present as a component of their presentation, then salbutamol would be appropriate under the bronchoconstriction medical directive, regardless of the underlying cause.

PPV for a DNR pt? Arrive on-scene to find a pt with an altered LOA, bradypnea, and vomit/saliva in the airway; do you suction and then provide PPV as a comfort measure?

Thank you for the question regarding treatments in patients who have a DNR in place. The DNR-C form for Ontario has a list of resuscitation treatments that should not be performed by paramedics or firefighters, these include insertion of an oropharyngeal or nasopharyngeal airway. The DNR-C form also states the comfort measure such as oropharyngeal suctioning may be provided. In reality, these calls are not always black and white and understanding the circumstances for the DNR form is truly important. Many patients' understanding is that the DNR means that they will not receive CPR or mechanical ventilation if they are VSA. I would consider the circumstances of the call and if the reason for the call is not related to their normal health issues, I would provide care in accordance with BLS and ALS PCS up to the point of VSA status. In the scenario you describe, I would provide suction of the airway and ventilatory assistance via non invasive measures. For further direction please dont hesitate to reach out to your service provider.

Three consecutive shocks vs. one and go. Regarding the cardiac arrest protocol, there has been discussion if we come to a scene with one of the indicated reversible causes indicated in our medical cardiac arrest protocol. For example and theoretical; when we arrive at a scene and identify a shockable rhythm, such as pulseless V-tach, the appropriate response is to administer a shock promptly. If, while preparing for transport, the patient reverts to pulseless V-tach, is it advisable that we remain on scene to continue analyzing and shock on the scene to obtained the "three consecutive shocks" and continue to the new directive coming into effect? Or, could we continue to transport with the indications that cardiac arrest is an obvious reversible cause based on clinical judgement?

Thank you for your question. In patients with shockable rhythms, it would be prudent to stay on scene and continue resuscitation (including defibrillation) until you either achieve ROSC or you have reached 3 defibrillations (or 3 epinephrine doses for ACP). Now that we will be starting Vector Change or Double Sequential External Defibrillation, you may give up to 3 more defibrillations on scene when the scenario calls for it (Refractory shockable rhythm). The load and go criteria for cardiac arrest is based on reversible causes that cannot be addressed prehospital. This would include: patients in cardiac arrest who have a pregnancy greater than 20 weeks gestational age, patients for whom hypothermia might have caused the arrest, patients with an airway obstruction the paramedic cannot clear, and those with a drug overdose for which ED treatments could be beneficial (Beta blockers, Calcium Channel blockers, Digoxin, etc). Importantly, if the paramedic has decided that the patient is salvageable and will benefit from transportation, this can be initiated at the soonest opportunity, once treatments beneficial at the scene are exhausted. There is no requirement to resuscitate on scene for a specific period of time if your interventions are exhausted and you believe transport is indicated.
There is also no requirement for a patch in this circumstance. You are welcome to patch to a BHP if you have questions about treatment or the timing of transportation, but if you have no questions and have elected to transport to hospital, please do not spend time patching unless you feel it will benefit you or the patient.

Ondansetron and prolonged QT on 12 lead. This is a 2 part question:
1. One of the contraindications of ondansetron is "prolonged QT syndrome (known to patient)". If a 12 lead is performed before administering an antiemetic (i.e. in an elderly pt with acute onset of nausea/vomiting/chest pain) and a prolonged QTc is found, should ondansetron be withheld?
2. If ondansetron has to be withheld, if it's contraindicated, or if the primary cause of the nausea/vomiting is vertigo, can dimenhydrinate be administered to>65-year-old patients? The directive only says it can be administered to that patient population when "ondansetron is unavailable."

Thank you for your questions.
1. Yes, I would withhold ondansetron if prolonged QT is noticed on ECG. This does not mean you need to perform an ECG prior to ondansetron administration but if you do for other reasons, I would not ignore it.
2. As you have indicated, dimenhydrinate is a better choice when vertigo is the cause of nausea. In these cases, a patch to the BHP would be in order. Provincially, we are reviewing all of the medical directives and the use of dimenhydrinate for vertigo has been discussed as a possible change.

Should the cord be clamped and cut before administration of oxytocin? Assuming the mother does not require resuscitation.

Thank you for your question. The timing of oxytocin prior to or after cord clamping is not crucial. In order to minimize cognitive load, I would suggest delivery of the baby with cord clamping and cutting prior to oxytocin administration.