Frequently Asked Questions

Q - What are aliquots and when should you use them?

A - Small, equal parts of the maximum single dose that are administered q 3 minutes until the desired analgesia is achieved or the maximum single dose is reached. Paramedics should document the total amount of a single dose administered and not each individual aliquot as a separate dose.

Q - What are the differences between opiate naïve and opiate tolerant? And why is this important in dose preparations?

A - o An opiate naive individual is someone who has not taken opioids regularly or recently enough to develop tolerance. This can include people who have never used opioids or those who have not used them for a significant period, often defined as 7 to 120 days, depending on clinical guidelines. Because their bodies have not adapted to opioids, even a small dose can produce a strong effect.

Q - Which analgesia option is best?

A - Paramedics are encouraged to use their clinical judgment when choosing which analgesia is best suited for their patient.

Q - How do I choose between using an opioid and ketamine?

A - Clinical judgement should include weighing the risks and benefits of using the various medications. This includes: previous use, other medications the patient is taking, medical history, event history, current and expected hemodynamic stability.

Q - What are the main methods to monitor patients that have received opioids, benzos, or ketamine?

A - EtCO2, RR, HR, BP, LOA, O2 sats, signs of adverse reactions.

Q - Can you start dosing at lower amounts than what is written in the medical directives?

A - Yes, it is appropriate to consider utilizing a lower dosing regimen set out in the ALS PCS. Aliquots are also useful in these situations. Paramedics are encouraged to use clinical judgement to promote patient safety. Document all reasoning on ePCR. If unsure, patch to a BHP.

Q - When Palliative first came out there was discussion around increased “breakthrough” dosing of +10% of the patient’s regular dose. Is this something we are still doing and can patch for?

A - Currently it is recommended to stick with the current dosing regimen of 0.5mg-2mg. The recommendation is to stick with these standard doses, reassess, and titrate if required.

Q - With some services getting Methoxyflurane, what is the recommendation on using it concurrently with opiates and ketamine?

A - As with other medications, it is not explicitly recommended to go back and forth between two pain medications. Switching to a different medication is a clinical decision (previous medication isn’t working, pt not tolerating previous medication, etc.), therefore there should be no reason to revert back to using it after the switch. 

Q - Can I use a prefilled saline flush to dilute pain medications?

A - Using prefilled saline flushes is not recommended for mixing medications. It is not a standardized syringe (sticker with markings) and could easily be confused for a flush, potentially causing a significant patient safety event.  Labelling of all medications drawn up and/or mixed in syringes is recommended and contributes highly to patient safety.

Q - How important is the Medication Cross-Check when in an emergency?

A - Pain management for our patients is a priority, but not a life saving situation. Take the additional time to complete medication cross checks prior to all medication administrations.

Q - Can you recommend a standard dilution strategy for ketamine?

A - Consider drawing 1ml (50mg) of Ketamine into 10cc syringe and diluting with 9cc of saline. That give 50mg/10ml or 5mg/1ml in the syringe. For a 100kg patient, IV dose of 0.25mg/kg, that would 5cc from the syringe, or 25mg.

Q - Is there a chance a "Better Pressor" is coming in the future?

A - That is currently being worked on provincially (a shock medical directive with potential push dose epi). That said, dopamine is what we have for now and it is still important to be comfortable with the medication and USE it when indicated, as the alternative (no pressor for certain shock states) is worse for the PT.