HSNCPC

I have a question about nitro administration for a pt with a nitro patch. Is this something you would approach with more hesitation due to the fact they are already receiving a slow release of the nitro?

Thank you for your question. The nitro patch is prescribed for cardiac patients to provide a steady dosing of nitroglycerin to allow them to perform their daily activities without angina. However if they do develop symptoms consistent with angina or even congestive heart failure, there is no danger in giving more nitro as long as their vitals are in the correct range. With respect to angina, pain means the heart requires more nitro for symptom relief; with CHF, there is need for fluid redistribution and preload reduction which nitro provides. As long as the patient is not hypotensive, they are safe to receive nitro as required.

Toradol vial says for IM use only. Can we still use it for IV use as well? Someone had noticed that our Toradol vials say "for IM use only" however the ALS states we can give it IM/IV. Are we able to still give this via IV?

Thank you for your question. Yes, toradol can be used IV or IM. This has been a standard practice in medicine for many years.

The current cardiac ischemia medical directive lists phosphodiesterase inhibitor use as a contraindication to nitroglycerin and the companion document speaks to the more appropriate category as being phosphodiesterase 5 inhibitors.   Are non selective PDI’s contraindicated with nitro?

Good question. Yes it would be safe to use nitroglycerin in patients taking pentoxifylline as there is no known additive effect that would create hypotension. It would also be reasonable to use nitro in the non-selective PDI such as theiophylline, aminophylline, etc…

Good day, A few of us have been having discussions surrounding options for ACPs providing pain management to patients in the form of opioids and then handing the patient over to a PCP crew for transport. Some of the scenarios that have been discussed are:

1. A single ACP arrives on scene to MVC where multiple individuals are complaining of severe pain. Additional units are PCP level of care. Can the ACP treat multiple patients with an opiate and/or ketamine to facilitate extrication and immobilization or do they select only one patient to treat?
2. An ACP arrives on a scene to provide pain management for extrication/immobilization are they required to remain with the patient for transport once the pain has been managed?

Thank you for your question. In the scenarios described above, I think it would be reasonable to handover a patient who has received opioid to a PCP crew. PCPs possess the ability to treat any respiratory depression that may be associated with this intervention. Since there is no reversal agent for ketamine, I would avoid this treatment if the ACP was wishing to handover care.

This is a two-part question regarding SGA: 

1. Would airway burn be considered "trauma" and a contraindication to SGA as outlined in the directive? 

2. Would anaphylaxis with pending airway closure be an indication or contraindication for SGA?

Thank you for your questions.

1. Airway burns can occur in a trauma context, but the contraindication to using a SGA is based on the specific airway pathology—such as tissue damage, edema, obstruction, or inability to create an adequate seal—rather than the broader category of “trauma” itself. A SGA depends on the ability to visualize and establish a seal around the supraglottic structures. Significant edema, friable burned tissue, or anatomical distortion from a burn can compromise this, making SGA placement unreliable and potentially harmful. In these situations, SGA use should be avoided. If airway compromise is anticipated or develops, early intubation is the priority. Attempting SGA in this context may not be effective, can worsen tissue injury, and may complicate subsequent intubation attempts in hospital. Effective BVM ventilation remains the cornerstone if definitive airway management cannot be secured prehospital.

 2. In contrast, in severe anaphylaxis—when epinephrine has not resolved the airway obstruction and basic airway maneuvers with BVM ventilation are insufficient—advanced airway management, including SGA or ETT, may be indicated. Unlike airway burns, anaphylaxis does not involve direct tissue destruction, and edema may improve with treatment, making SGA a more viable option in this scenario

We recently had a call for a patient who was severely short of breath and in acute CHF. The patient was treated with CPAP and nitroglycerin. He was also presenting with slurred speech; however, before the family informed us that this was his baseline due to tongue cancer, we opted to check a blood glucose level. The BG result was 3.6 mmol/L. 

The patient remained fully alert with a GCS of 15 throughout the entire call. Since CPAP was in place, we were unable to administer oral glucose gel.

My question is: the directive specifies that for a patient who is hypoglycemic and requires glucagon or dextrose, the level of awareness must be altered. Should we have still treated this “hypoglycemia,” given that the patient was asymptomatic and alert?

Thank you for your question. Clinical context is always important when deciding on when to treat laboratory findings. In this context, the patient was completely asymptomatic and the more important treatment of CPAP should take precedence. In general, hypoglycemia only requires treatment when symptoms of hypoglycemia are present.

If a patient qualifies for ACP treatment does the ACP assume the call even if it's a one time treatment? (i.e. ACP administers one dose of Fentanyl and is no longer giving any more pain management due to patient's pain being a zero, is the ACP still required to be "attendant" and stay in the back with the patient during transport?)

Thank you for your question. We often get this question. The key question to ask yourself is “do you foresee the patient requiring treatment at the ACP scope during transfer?"  If the answer is easily a no, then a PCP can assume care and transport the patient. If you are uncertain, or foresee ACP scope requirements, then the ACP should transport. 

In your specific scenario, if you are certain that no more narcotics are required, the PCP could transport the patient. The fact that PCPs carry naloxone adds to the safety net in cases where complications secondary to drug administration may arise. 

Also, if the ACP has treated with a medication that is outside of the PCP scope (excluding narcotics as PCPs carry the reversal agent) then I would assume the ACP would transport.  Example of this would be sedation with midazolam or ketamine. 

I'd like a better understanding on integrating Calcium Gluconate into a suspected hyperkalemic VSA. Now that our service carries 50cc saline bags, it seems so much more plausible to fit this 2-3 minute infusion somewhere in a code by simply hanging that mixed bag wide open. At the same time, I would also like to think that CG and salbutamol are strong prehospital treatments for hyperkalemia and I'd want to stay on scene to work a shockable rhythm vs consider very early transport.  Now, I understand there are so many variables (time to ED, how much help is on scene etc.)  For purposes of simplicity, lets say I've got plenty of educated hands (defib, other drugs, CPR will not be compromised) and plenty of transport time. Ideally, what does best-practice look like?

Thank you for your question. HSN is currently leading the working group to revise the hyperkalemia protocol. 

In the interim let’s focus on the current protocol. There are two pathways of treatment - membrane stabilization and potassium shifting. Calcium (be it chloride or gluconate) is the only drug used for membrane stabilization. With respect to potassium shifting there are two options insulin and glucose and salbutamol. Insulin is not practical because it needs to be refrigerated. Salbutamol is effective but in doses far exceeding the typical doses for bronchoconstriction 10 - 20 mg.

For the ACP in a code situation, since the patient is VSA, the usual practice applies and is unchanged. This is not a shockable rhythm. It is a PEA arrest. It mimics a wide complex tachycardia but it is usually too wide and too slow to be considered ventricular tachycardia. So electricity plays no role. The only treatment is CPR and epinephrine. The only change is calcium gluconate. This should be given immediately in a suspected hyperkalemic arrest and by a rapid push. The patient is dead and an infusion is never warranted. It should be given as soon as a  hyperkalemic arrest is suspected and it can be given concurrently with epinephrine. It can be repeated if there is no change in the patient. Ideally in an arrest situation it should be given 3 times. Through intubation you can administer the equivalent MDI dosage of 10 mg and it can be given as often as necessary. 

There really is no benefit to staying on scene. The treatment is CPR, epi and calcium. In the ER we can try other agents such as calcium chloride (which has more elemental calcium) or even bicarbonate as a last ditch effort. 

So my approach is...

• Determined hyperkalemic arrest
• Immediate CPR with Airway management
• Calcium IV IO- repeat Q 5x 2 
• Call for a third if no change 
• Epinephrine IV IO repeat Q3-5 minutes 
• Ventolin 16 puffs throughout each cycle of CPR

As mentioned above this protocol will be tweaked as we review the evidence.