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How do we position the patient for 12 lead? What position should patients be in when we are doing do a 12-lead?

Thanks for the question. The optimal position is one where the patient is semi recumbent, relaxed (to avoid muscle tension), and stationary to limit as much artifact as possible on the 12 lead tracing. That being said, there are a myriad of scene factors that paramedics encounter every day which may limit the ideal positioning therefore as long as a clear 12 lead tracing can be acquired, any reasonable position is acceptable.

When do we transport a pediatric VSA? After consistent review of the new ALS, I just came across something that I am hoping you may clarify for me. In regards to the Medical Cardiac Arrest directive, under the clinical considerations, it states that under certain circumstances we transport after first rhythm analysis (and lists some examples). In the old ALS, one of these examples was pediatrics but now I notice that in the new ALS, also under clinical considerations, it mentions to plan for extrication and transport of pediatric cardiac arrest patients after 3 analyses. So, does this mean we do not transport after first rhythm analysis for pediatrics and must complete the full directive now?

The majority of peds cardiac arrest cases fall under reversible causes, so yes, go ahead and transport after one analysis (generally, these will present as Asystole or PEA). However, the directive allows for use of clinical judgment, case by case where you can stay on scene for peds VF/VT.
Very basically, the medical directive allows for transport after the 1st analysis (because most peds arrests are from reversible causes), OR stay on scene for 3 analyses (plus one immediately prior to transport) in cases of shockable rhythms.

Do we give epinephrine in anaphylaxis before running the code? In the event of a VSA where anaphylaxis is the suspected cause, when would be the most ideal time to administer epinephrine IM? I'm assuming we would start with CPR, attach Pads, Analyze, then epi. Would this be a safe assumption?

Thanks for the question. We agree entirely. Begin CPR, attach pads, analyze while you have your partner attend to the airway with BVM, then consider epinephrine as per the medical directive.

Do we treat STEMI patient and CHF with 0.8 mg or 0.4 mg nitro? In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

This is a great question and one that was brought to the provincial level to achieve consensus. It highlights the reality which is that its just not possible to write a directive for each patient encounter, since there can be a tremendous amount of variability. In situations like this, its important to ask yourself what the primary issue is, or what the greatest threat to life is. Many patients who are at risk of having a cardiac event (MI) may also have a history of CHF, and it can sometimes be difficult to determine what issue is driving the other. In this case, it is likely that the STEMI is causing, or exacerbating the CHF, and as such, following the cardiac ischemia directive and administering only up to 3 X 0.4 mg doses would be appropriate. For what its worth, the reduced number of doses in STEMIs are to reduce adverse outcomes associated with liberal NTG use, and as such, administering higher doses of NTG may affect the patient adversely. Remember that CPAP is a potential option for this patient population if indications are met. This may have more of a morbidity and mortality benefit than nitro and may result in substantial CHF symptom improvement.

Can we titrate naloxone 0.8 mg SC/IM/IN? The Opioid Medical Directive allows for Naloxone to be administered 0.8mg SC/IM/IN and 0.4mg IV. The IV route allows the paramedic to titrate to restore the patient's respiratory status. Can this titration also be applied to the SC/IM/IN?

The dosing and intervals in the ALS PCS Opioid Toxicity Medical Directive for SC/IM and IN Naloxone are based on the pharmacologic properties of the drug and the route it is being given. Given the quick onset of action via the IV route, this property allows for titration of the dose to effect. SC/IM/IN routes have longer times to peak effect and therefore cannot be titrated, in addition to the actual mechanical difficulties of providing a titrated dose through these routes. Providing smaller doses via the SC/IM/IN routes that may be ineffective will lead to prolonged periods of hypoventilation given they cannot be ventilated with a BVM. The balance of prolonged periods of hypoventilation must be weighed against the risk of a large dose that causes acute withdrawal. Paramedics can give a maximum of 3 doses of SC/IM/ IN Naloxone which allows for titration to the clinical response.

Should Dimenhydrinate be administered if the patient has already taken some? In regards to the administration of Dimenhydrinate the ALS PCS stats that a contraindication is an over dose on antihistamines or
anticholinergics or tricyclic antidepressants. If a patient has taken an antihistamine/anticholinergic/TCA should Dimenhydrinate be withheld?

If the patient has taken an adequate dose of dimenhydrinate (50 mg for adults and 25 mg for those 25kg to 50kg) within the past 4 hours, you should not provide any more dimenhydrinate. The sedative effects of dimenhydrinate will make it more difficult to assess the patient on arrival to the ED. This is especially true in the elderly population. The new ALS PCS will also make Ondansetron available for the treatment of Nausea and Vomiting. This drug would be the first choice in any patient >65 years old. It could also be used should a patient have taken dimenhydrinate at home and continue to experience nausea and vomiting.

Can we give a narcotic (morphine/fentanyl) in combination with ketorolac? In the ACP Analgesia medical directive, it states patients with renal colic should routinely be considered for both ketorolac AND morphine or fentanyl. Are there any other scenarios where it would be indicated to consider both? Ex: acute back strain where you would want to reduce inflammation but also might need narcotics for extrication/transport purposes...

You can definitely give a narcotic in conjunction with a NSAID if there are no contraindications i.e allergy, GI bleed, etc.
The two work on different pathways and provide a synergistic relief of pain.In the case of renal colic, it usually takes the toradol at least 20-30 minutes to provide relief, so IV morphine helps alleviate the pain immediately.The NSAID has a more prolonged duration of pain relief.
It is common to prescribe both an NSAID for its anti-inflammatory properties as well as a narcotic for pain relief of acute medical conditions such as renal colic or sciatica.

Single PCP response to a VSA Hey I'm just wondering what you guys would like from us as a single PCP (PRU) responding to a VSA if there will be a prolonged (>15 minutes) response from a transporting unit. Should I just do compressions and defib or should I be attempting to manage the airway as well? I know my focus is on high quality CPR and defib but should I maybe one hand CPR for a moment to get an OPA? Please let me know exactly what the expectations is as the AHA Guideline is unclear except for the rates of compressions to ventilations for a single rescuer.
Thanks.

Great question, and a challenging scenario for a single PCP (PRU).
You are correct in that the focus with resuscitation has definitely shifted towards the importance of high quality CPR and early defibrillation. These interventions have been shown to have the greatest impact on survival rates.
With that said, taking into consideration the short amount of time it takes to insert an OPA, this could be done upon initial assessment and remaining care as per the AHA guidelines.

Why can't we administer epi to a patient with asthma exacerbation who become VSA? I was wondering recently while reviewing my re-cert material why it is that if asthma exacerbation is the reason for a pt. becoming VSA why 0.5 mg of epi IM would not be administered while preparing for iv in a similar fashion that epi is used for anaphylaxis if it is the causative reason a pt. becomes VSA. Thanks for the help.

Possible reasons for this would include that the etiology for patients arresting from asthma is generally hypoxia and IM epi is not necessarily particularly helpful in that regard. In anaphylaxis however, epinephrine has so many therapeutic properties that it should not be withheld; one of the rare silver bullets in medicine. It is entirely possible that a patient who is arrested from anaphylaxis may be in PEA and but actually have some forward flow and pulses are just not palpable. Given the role of epinephrine in mitigating the anaphylaxis cascade, epinephrine should not be withheld.

Do all Phosphodiesterase Inhibitors generic names end in "fil"? Do all Phosphodiesterase Inhibitors generic names end in "fil"?

Are all drugs that end "fil" Phosphodiesterase Inhibitors?

Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

The short answer is that unfortunately no, not all phosphodiesterase inhibitors end in fil. For instance, aminophylline, theophylline, milrinone are but only a few phosphodiesterase inhibitors with different names. That being said, most of these medications are not used routinely in the community (if at all) nor are they used for erectile dysfunction (ED).
While sildenafil, tadalafil, vardenafil, and the newer udenafil and avanafil all are medications ending in fil and do have indications for erectile dysfunction (ED), it may be somewhat risky to rely upon the suffix only to identify this class of medications. For instance, the ace inhibitor class (ramipril, lisinopril. enalapril, captopril) all end with a similar suffix and this could be confusing.
The best approach is to recognize the full name of the medication, then confirm with the patient why they are taking it and the timing of the last dose.