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Medical Directives

Articles 2

Should SGAs be avoided in patients with esophageal disease

11 April 2023
I have a question concerning the contraindication in the Supraglottic Airway Medical Directive. The "Known esophageal disease (varices)" do also include all the esophageal disease like example eosinophilic esophagitis, dysphagia, esophagitis, Barrett's esophagus, gastroesophageal reflux disease (...

Pediatric airway options

31 March 2023
Given that the success rate for intubations in the pediatric populations is low, the infrequency at which these skills are performed, coupled with the stress induced by such calls I am curious what RPPEO's position is on SGA's like the i-gel specifically for the pediatric population.
Allergic Reaction
Articles 1

Is there a place in pre-hospital care for push dose epi?

22 February 2024
In severe anaphylaxis, or after 2 dose of epinephrine and a patient that is still deteriorating. Should paramedic consider initiating base hospital patch to consider IV push dose epi (1mcg/kg q 0.5-2min PRN). Obviously there is different factors to consider (signs of respiratory failure, angioede...
Articles 12

Opioid analgesia in the hypotensive patient

23 January 2024
If you have a patient who is complaining of severe pain and is initially hypotensive requiring a fluid bolus. After the fluid bolus they are now normotensive-are we then able to treat them with morphine or fentanyl as now they meet the directive? or is it expected that we patch for orders?

May acetaminophen and/or ibuprofen be administered to patients with headaches

30 January 2024
Can acetaminophen and ibuprofen be given to patients to treat headaches, assuming they meet the other aspects of the directives? I’ve been told by colleagues that even PCP scope analgesia used specifically for headaches isn’t allowed, but I never interpreted the directive this way, so just looki...

What must be considered in coadministration of morphine and fentanyl?

07 November 2023
Under analgesia directive, It sates, "Fentanyl should not be used in combination with morphine unless authorized by BHP." Is this specific to co-administration? For example, we treated a fracture with fentanyl on scene to splint and extricate the patient. Then we sat on offload delay at the hospi...

Thrombocytopenia and Ketorolac

01 June 2023
Why is thrombocytopenia not a contraindication for Ketorolac administration but being on a blood thinner is?

Should opioid analgesia be administered to a patient with opioid use disorder?

15 December 2022
Opioid pain control for recovering addicts. What is the RPPEO stance on this? It could be severely detrimental to introduce opioids to someone currently in recovery of opioid addiction. It is not contraindicated. I often don’t bring up the possibility of opioid pain relief when presented with a ...

Why is a normotensive SBP a condition for ketorolac?

30 November 2022
Why is a normotensive SBP a condition for ketorolac? As a side note there is no SBP condition for Ibuprofen, which is also an NSAID

PCP's - How long would a patient have to be discontinued any anticoagulation therapy before considering them for NSAID treatment for pain?

03 October 2022
Hello, I just had a patient whose blood thinners were temporarily discontinued due to an episode of hematuria. Although this patient was contraindicated for NSAIDs under our analgesia directive, it got me wondering that if we have similar patients, assuming no contraindications (as in the potenti...

Analgesia on Offload

29 September 2022
I was wondering about the ability to utilize a mix of narcotics for our patients in light of the long offload delays that we are all now facing. In discussion with my fellow ACP's there have been many of us that have called to be allowed to switch to the longer acting Morphine after beginning wit...

Contraindications for Adult Analgesia - Ischemic Patient with Chest pain

23 February 2022
Under the new contraindications for Acetaminophen, Ibuprofen/Ketorolac for Adult analgesia, if a patient is being treated for ischemic chest pain with ASA/nitro, is the suspected ischemic pain means we cannot under any circumstances give A/I/K to someone being treated for ischemic chest pain or w...

PCP AIV - Pain management alternatives

23 February 2022
Good afternoon, Does the RPPEO have any long term plans for the PCP scope of practice now that we will soon all be AIV? Is there any plans to add additional pain management alternatives to our scope of practice other then Ibuprofen, Tylenol, Toradol, with less contraindications. Often times as a...
Articles 7

TCP for bradycardic ROSC patients

10 August 2023
If you have a ROSC with bradycardia and hypotension that's not responding to Dopamine, at what point may TCP be considered...after Dopamine is maxed out at 20mcg/kg/min? Dopamine is increased q5 minutes.

Do the medical directives for bradycardia require always trying TCP first before proceeding to dopamine, or is trying dopamine first reasonable?

13 July 2022
The ECC guidelines for bradycardia show that both IV adrenergics with beta accelerating effects and TCP have equal levels of recommendation and thus, based on that, one probably isn't better than the other. Based on my limited experience with pacing, I have noted a high degree of failed or false ...

Recommended Management Approach for patient who is Symptomatically Bradycardic from Suspected Hyperkalemia?

19 August 2022
What would be the recommended management approach for a patient who is symptomatically bradycardic from suspected hyperkalemia? I see a large number of potential interventions: Calcium Salbutamol Fluid Bolus Atropine Pacing Dopamine My inclination would be to treat the hyperkalemia fir...

Patch Point to BHP - Cardiogenic Shock + Severely Bradycardic

22 March 2022
According to our cardiogenic shock medical directive, if a patient is to be bradycardic, a BHP patch is required. In the setting of a patient in cardiogenic shock and severely bradycardic and does not respond to regular fluid therapy (STEMI found on ECG), should we be initiating treatment such as...

Atropine dose change ALS PCS 4.9

31 January 2022

Priorities in Symptomatic Bradycardia

10 February 2022

Transcutaneous Pacing - Symptomatic Bradycardia

10 February 2022
Articles 7

Administering Dex With a Prescribed Steroid

01 December 2023
With patients who are already taking PO Dexamethasone who have yet to take their PO Dex, and are having an acute COPD exacerbation or another ailment that causes them to meet the directive for Dex, would Dex be contraindicated due to the current use of steroids (even though it’s the same we are ...

Dex Admin with Pneumonia

07 November 2023
For patients with bronchoconstriction not believed to be due to asthma/COPD/20 pack year smoking history (ie suspected pneumonia), but who still meet the protocol for dexamethasone, is administration of dexamethasone beneficial or recommended?

Is Epi appropriate for 55+ pt with suspected severe acute COPD with silent chest requiring BVM Ventilation & a Hx of Asthma?

04 January 2023

Dexamethasone Route

14 February 2023

Dexamethasone Administration for Mild Bronchoconstriction

22 March 2023

Is ETT administration of salbutamol liquid appropriate?

11 April 2023

Dexamethasone Contraindications

18 May 2023
Articles 2


13 October 2023
Hello! I had 2 questions where the answer was never quite clear: 1) Can CPAP be used on a pt who has a DNR? I heard that the answer is yes- if they were able to cooperate - but I wanted to make 100 percent sure. 2) If a patient is unconscious would we be allowed to BVM assist them (if they are ...

Why can we administer CPAP for COPD exacerbation but not for Asthma?

30 August 2022


Articles 7

If our patient has DKA, should we encourage patient insulin administration?

I recently attended a call for a 30 y.o. in DKA. The patients BGL registered as "high", he was exhibiting kussmaul respirations, hypotensive, intermittently bradycardic and GCS 3. We later found out from hospital staff that pts PH was 6.75. I am aware that the treatment plan in hospital was an i...

PCP or ACP - For a CTAS 1 patient who is in the back of ambulance?

Hello, In regards to a PCP and ACP working together. If we have a return CTAS 1 patient what is the direction we are being given as to who is in the back. If the PCP is comfortable being in the back and the care the patient is receiving is something within the PCP scope could they be in the back...

ALS vs BLS Medic - Narcotic Administration

Transport after Administering Narcan

Acetaminophen for Febrile patients

NIBP vs manual. Are medics to take a manual?

Could you please define the TBI contraindication for NSAID administration?

Patient Care

Articles 4

Retained Products of Conception and Miscarriage

We had a patient that had a miscarriage this am, she was 3 months gestation. She had started to have vaginal bleeding 4 days ago. She was examined at civic on Saturday, after an ultrasound was informed that there was no heart sounds. My partner informed me that we needed to retrieve the tissues ...

Joint Reduction/Manipulation

Would RPPEO consider education on joint reductions/manipulations? Under the BLS, in Extremity Injury Standard (page 125 1. f.) it states, "If adequate circulation/sensation is absent, after splinting and re-manipulation is possible, gentle re-manipulate the extremity to restore neurovascular sta...

May the Canadian C-Spine Rule be applied in patient assessment

Just a question in regards to spinal immobilization. Is it still acceptable to apply the Canadian C-spine rule? Or was that just a temporary study and we should now revert to the BLS SMR standard?

Pharmacological Overdose Resources

Broselow tape
Articles 1

Pedi Stat App

Just wanting to confirm if the Pedistat app is a recognized resource by the RPPEO i.e. for pt weight, ETT size/depth etc.
Articles 1

PCP Manual Defibrillation

As a PCP in my service for Medical cardiac arrest i am required to utalize the Analyze button on our monitor instead of manual interpretation. When asking my service why they state the BH doesnt want it, when asking at BH CME's im informed my service does not want it. I am slightly confused as to...
Interfacility transfers
Articles 3

Inter-facility Transfers - Patient under our care or care of sending physician?

Bladder Irrigation During Transfers

Inter-facility transfer of chest tubes

Patient Transport & Disposition
Articles 2

CTAS 1 and STEMI Bypass

I wanted to follow up on clarification of STEMI bypass and our CTAS level, in our companion documentation it shows a STEMI should be a CTAS 1 but our guide for bypass says a CTAS 1 is contraindicated and the paramedic cannot secure airway or ventilate. Is this pertaining to you can still go back ...

Trauma Timelines

Working for Cornwall SDG, our trauma bypass have amendments extending our transport time from 30 minutes to 60 minutes. In the contraindication for Trauma TOR, it states “patients with penetrating trauma to the torso or head/neck and Lead Trauma Hospital < 30 min transport away”. Does this 30...


Articles 3

PHIPPA and Death

I am curious on the PHIPPA guidelines surrounding a deceased patient that may be known to the paramedic's social circle. I appreciate that protecting patients health information is critical during 911 calls, does that change if the patient has died? For example, paramedic responds to a VSA in t...

Sharing of Personal Health Information

If a minor has harmed themselves (I.e. ingestion of drugs) what role does the parent or legal guardian have if the pt does not give consent to disclose information? RN at CHEO and PD stated parents MUST be notified. How does PHIPA apply to these situations?

Age of Consent

What is the minimum age that a patient needs to be to refuse treatment and transport to hospital?
Paramedic Practice
Articles 16

Rigor Mortis

My question pertains to obvious signs of death, and specifically with respect to rigor mortis of the smaller muscles of the face. I recognize the standard for obvious signs of death as documented by the RPPEO is "gross rigor mortis" ie stiffening of the limbs/body. However, given that the onset...

Flail Chest Management

Regarding a flail chest, what is the RPPEO’s preferred treatment? There is conflicting data on whether to splint and do PPV. What is the RPPEO’s stance?

Posterior STEMI Bypass

In regards to STEMI protocol and bypass, does it apply to posterior STEMI? The colored coded card in the protocol booklet only shows lateral, inferior, septal, anterior. I understand we would still treat the patient under the cardiac ischemia protocol but as far as rerouting to a STEMI hospital o...

SET Protocol

Is SET protocol still the expectation from the RPPEO, why or why not? Should we still have the receiving hospital sign off on tube placement once TOC in the event of a Coroner's inquest? This was part of the protocol along with a c-collar and ETCO2/auscultation with every pt. movement in order to...

Defib Pad Placement

Does the RPPEO have a stance with respect to defibrillator pad placement?

Trauma VSA Transport Times

Following up on question #738 Trauma Timelines answered on October 16th, Currently in our OPCG Base Hospital app in the Destination Guidelines under Pediatric Bypass, there is a category for "greater than or equal to 16 years old, penetrating trauma VSA, 60 minute bypass to the Civic." This is ...

MAP vs. BP

Knowing that monitoring devices, (LP15/Zoll), use oscillometry to accurately detect MAP and not SIBP, have the MOH and BHs made any strides in reviewing and changing all medical directives to reflect MAP as the accurate measure of hypo-perfusion and not “SBP >90mmhg”?

Rounding Medication Doses

When preparing medication, for example IM Midazolam for a 36kg pt, the 0.2mg/kg dose would be 7.2mg. Using a 5mg/ml concentration that would be 1.44ml volume of medication. Using a 3ml syringe, I would only be able to accurately measure 1.4ml dose. Is it acceptable to round down the dose in this...

Palliative Care Medications

With palliative care directives now becoming a core directive, what is the RPPEOs stance on using these medications for general practice. Examples include: using hydromorphone for pain management for someone who has previous hx of hydromorphone use, ondansetron IV as opposed to SL (we still are o...

PCP AIV Ondansetron Administration

Within the palliative care directive, PCP’s can only give odanestron PO/SC. Can AIV PCP’s give odanestron IV?