Category: Medical Cardiac Arrest

CPAP & Nebulized Medical Administration (COVID)

Question#: 545


Hi Dr. Dionne, Thank you for all the work that you do and your never ending support for us. I have a question with regards to CPAP and nebulized medication administration. With the on set of COVID, CPAP and nebulized medication administration was suspended. We are responding to calls where CPAP or nebulized medications would have been a benefit to our patients. I realize that COVID is still going and who knows when it will be over. Given that most Paramedics have both doses of vaccines, PPE such as PAPRs, N95s etc., will we be seeing the return of CPAP? Even if we have caviats of no fever, PPE must be worn etc.. can we please get these beneficial treatments back? With regards to PCP seeking medical TORs. Can the TOR guideline be changed so that if ACPs are responding, PCPs hold off on calling for TORs, especially if ACP ETA is < 10 min. Given some of the new literature from the AHA on administration of EPI IV for non shockable arrests.


A Google search conducted on 03-Nov-2021 for aha epinephrine non shockable cardiac arrest, revealed four relevant results on the first page (10 results) that were AHA or trusted websites published in 2020 or 2021. One of these was AHA guidelines and the other three original research; comprising of a multicenter retrospective analysis, a cohort study and systematic review.

Essentially the three studies conclude that early epinephrine is associated both with better intermediate outcomes, such as ROSC, and survival with favorable neurological outcomes. One study showed that each minute delay of epinephrine was associated with a 33% decrease in odds of sustained ROSC. Thus after 6 minutes the percentage of patients who are likely to have ROSC due to epinephrine administration is 0.3%. The AHA study compared <10 minutes to >=10 minutes epinephrine administration and found significantly better outcomes in the earlier group.

It therefore makes sense to withhold TOR in the first 6 to10 minutes following cardiac arrest if epinephrine can be given in that time.

As TOR should be requested after the third analysis (minimum 4 minutes post arrival) and is only indicated for unwitnessed arrest. It, therefore, appears unlikely that a TOR will be requested under the current medical directive if an ACP has an ETA of <10 minutes of cardiac arrest. Therefore we do not recommend changing the medical directive at this time.

We do recommend that responding paramedics and on scene paramedics communicate with each other to provide the best patient-centered care. We also encourage further research into this topic and will gladly revisit the subject should there be compelling evidence to support change.

Ran, L. et al. 2020. Early Administration of Adrenaline for Out‐of‐Hospital Cardiac Arrest: A Systematic Review and Meta‐Analysis. Accessed 03-Nov-2021.
Okubo, M. 2021. Association of Timing of Epinephrine Administration With Outcomes in Adults With Out-of-Hospital Cardiac Arrest. Accessed 03-Nov-2021.
Bakhsh, A. et al. 2021. Immediate intravenous epinephrine versus early intravenous epinephrine for in-hospital cardiopulmonary arrest. Accessed 03-Nov-2021.
AHA. 2021. Top Things to Know: 2020 AHA Guidelines for CPR and ECC, Part 3: Adult Basic and Advanced Life Support. Accessed 03-Nov-2021.

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