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Medical Directives

Acute Cardiogenic Pulmonary Edema
Articles 1

Pulmonary Edema, Cardiac Ischemia and Nitro

Articles 2

Should SGAs be avoided in patients with esophageal disease

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

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.
Articles 16

What must be considered in coadministration of morphine and fentanyl?

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

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?

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?

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?

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

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

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

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...

NSAIDS in high mechanism of injury

The Analgesia Medical Directive does not include any relationship to the administration of Ibuprofen and high risk MOI. It would be nice to see a correlation between the C-spine study guidelines for high risk MOI and the administration of an anticoagulant to a patient in the field

RPPEO Standards - Renal Impairment (Ketorolac)

In respects to the Ketorolac protocol, one of the contraindications is renal impairment. What is the definition, as per the RPPEO standards, of renal impairment? Is it a known pre existing disease process of the renal system or would it also include a UTI that has manifested into a potential kidn...
Articles 8

TCP for bradycardic ROSC patients

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?

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?

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

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...

Priorities in Symptomatic Bradycardia

Transcutaneous Pacing - Symptomatic Bradycardia

Sedation and Analgesia Post TCP - BHP consult or not?

Atropine dose change ALS PCS 4.9

Articles 8

Administering Dex With a Prescribed Steroid

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

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?

Dexamethasone Route

Dexamethasone Administration for Mild Bronchoconstriction

Is ETT administration of salbutamol liquid appropriate?

Dexamethasone Contraindications

COVID 19 considerations - EPI interval - bronchoconstriction

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

Articles 5


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 ...

CPAP - "Alternative Treatments"

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

CPAP - Medical Directive vs Sleep Apnea

CPAP with Pneumonia and COPD


Articles 15

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...

Nuchal cord – manual means not working

ALS vs BLS Medic - Narcotic Administration

Pediatric Bradycardia with a Pulse

Transport after Administering Narcan

ALS PCS booklet availability

Acetaminophen for Febrile patients

COVID considerations - Aerosol Generating Medical Procedures (AGMPs)

NIBP vs manual. Are medics to take a manual?

Treatment Prior to Arrival - Care and Documentation

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 transfer of chest tubes

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

Bladder Irrigation During Transfers

Patient Transport & Disposition
Articles 1

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 2

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 14

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?

Pediatric Airway Equipment Dead Space

Question received from a paramedic in regards to the length of the "tree" (filter, ETCO2, tube extender) at the end of a SGA - iGel in our case - for pediatrics. Has previously been taught that this should be minimized due to tidal volume of pediatric patients and potential to be rebreathing expe...

Postural Vital Signs