2025-06-03

Opioid Toxicity

When can Suboxone be giving again after theyve received it?

If you respond to a patient who receives naloxone and suboxone from you, still has a COWS of > 8, but is refusing transport, should we be patching for additional doses? If not, if that same patient calls an ambulance a few hours later for continued withdrawal symptoms, when is it safe for them to receive more suboxone?


Thank you for your question. It would be very appropriate to patch for an additional 8 mg of Suboxone, despite the patient refusing transport, because harm reduction is our goal. Once the patient feels better, they may be more open to transport or addiction services. If, however, the patient refuses further doses or your request is denied and you are called back to the same patient a few hours later, it would be reasonable to continue with our protocol and administer another 8 mg of Suboxone.


2025-06-05

Trauma Cardiac Arrest

Is there any role in the administration of TXA for the pt in traumatic cardiac arrest, given we have performed all other interventions already (CPR, hemorrhage control, etc).


Thank you for your question. TXA works best in a diffuse bleed as opposed to penetrating which is typically what we see in a traumatic cardiac arrest. There would be no harm in giving it, but much like we discovered with GI bleeds, it is of no benefit.



2025-06-05

General

TXA for head injuries Why does TXA have a contraindication of "isolated head injury" when some research (CRASH-3) has shown potential benefits in the hemorrhagic TBI populations when administered early (where pre-hospital administration would benefit pts most)?

Thank you for your question. Although TXA appears to improve outcomes in injured patients with major bleeding, the effects in patients with isolated TBI are less clear. Initially it was contraindicated in CRASH-2 because TBI was not the focus of the study, but it was specifically studied in the CRASH-3 trial to see if it made a difference. The study design included brain injury (GCS<12), no major external bleeding and <3 hours from the onset of injury. Overall there was unequivocal evidence for benefit across all patients with TBI, and further research is needed to determine which patients actually do profit from TXA administration. Current literature suggests that TXA may decrease mortality in patients with mild to moderate TBI (GCS >9) but may increase mortality in patients with isolated severe TBI (GCS <9). Therefore until the evidence is more robust, TXA is contraindicated in patients with isolated TBI.


2025-06-05

General

TXA for PPH (postpartum hemorrhage) Given that TXA is shown to be beneficial for PPH, is there any place for it in the prehospital setting given oxytocin, bimanual compression/massage have all been given/attempted and bleeding is still present?

Thank you for your question. With PPH much like any massive hemorrhage protocol, TXA is of a benefit in the hemorrhaging post partum patient, especially when you have reached the limit of your interventions. There is definitely a role in the prehospital world and is something which is happening with Ornge Air Ambulance. Paramedics should patch to the BHP for TXA consideration in PPH if other methods of PPH Management are ineffective.


2025-06-17

Medications

Procedural Sedation Fentanyl and Midazolam Concurrently I am hoping to clarify that the administration of Fentanyl and Midazolam, for the intention of procedural sedation, are to be administered concurrently as stated in the medical directive and companion document. My understanding of this is to administer one of them in a single IV catheter, flush the catheter, administer the second medication immediately and flush the catheter. Or are we cannulating two IV catheters and administering them simultaneously. Finally, I am assuming we are absolutely not mixing the two medications in the same syringe.

Thank you for your question. The goal is to administer the two medications back-to-back (not in the same syringe) in a single IV.


2025-06-17

Medications

Procedural Sedation - Fentanyl and hypotension With the removal of "normotension" as a condition for Fentanyl administration under the Analgesia Medical Directive, are we anticipating the removal of "normotension" as a condition of Fentanyl administration under the Procedural Sedation Medical Directive?

Thank you for your question. Yes, this will occur in the next ALS PCS update.


2025-06-17

Withold Resuscitation

Withold resuscitation. If you arrived on scene to find a patient VSA, and they were a frail older individual, do you commence CPR even if a family says they do not have a physical copy of the DNR but want you to refrain from commencing CPR? I am looking for some clarity on the wording under the BLS PCS where it talks about withholding resuscitation or initiating CPR as an order from a base hospital physician, you would have to patch for this. Im wondering as to what is happening while you are waiting for those patch orders if they are approved.

Thank you for your question. At present you would need to patch for a withhold resuscitation order. I would assess the scenario and patch immediately if everything seems appropriate. In the near future, the BLS PCS will be changed to allow for verbal DNR from family members.


2025-07-31

Cardiac Arrest

What is considered refractory VF or VT to be eligible for dual sequential defibrillation? To be eligible for DSED, does the patient have to be VF x3 or VT x3 in a row? Or can the patient present in VF, then VT, then back to VF and still qualify?

I was under the assumption that it was 3 shockable rhythms in a row, regardless of what the shockable rhythm was, qualifies the patient for DSED or VC, but there has been some confusion lately and now I am not too sure. 


Great question.  Under the Cardiac Arrest Medical Directive, a patient is considered to be in refractory shockable rhythm if:

  • They have had three consecutive rhythm analyses where a shock was advised
  • There has been no sustained ROSC between any of the shocks

The rhythms do not need to be VF only. Any combination of VF and pulseless VT qualifies, such as:

  • VF → VF → VF
  • Pulseless VT → Pulseless VT → Pulseless VT
  • VF → Pulseless VT → VF
  • Pulseless VT → VF → Pulsess VT

As long as all three were shockable and there was no ROSC in between, the patient qualifies for dual sequential defibrillation.



2025-07-31

General Questions

When to transport for pts not meeting TOR?
When we have a patient who does not qualify for a TOR ex. ‘energy delivered’, or qualify for early transport ex. ‘reversible cause’ or ‘3 doses of VCD’, are we staying on scene to administer 20 mins of resuscitation, for these patients we plan to transport?  


Thank you for the question regarding when to stay on scene during cardiac arrest and when to transport early.  This question is often asked and please reference the resources section on the OMC page. 

In short, patients with shockable rhythms or reversible causes are much more likely to survive than those with PEA/Asystole, and aggressive and lengthy resuscitation should be considered.

For shock-refractory VF/VT, administer antiarrhythmics early, change pad positioning, perform DSED if trained and authorized, and consider early transportation to the closest ED for consideration of IV betablockers. For patients with reversible causes, provided early defibrillation and ALS care and consider early transport especially if the reversible cause cannot be treated prehospital (ie hypothermia)

 If the paramedic determines that transportation is indicated, there is no requirement to resuscitate on-scene for a specific period of time once your interventions are exhausted.  There is no requirement to patch to a BHP if you are going to transport a cardiac arrest patient and you have no questions about the care you are providing.  For patients whom the prognosis seems very poor and TOR is being considered, we recommend 20minutes of on-scene resuscitation to avoid terminating too early and missing a potential survivor.



2025-07-31

Nausea/Vomiting

In ALS PCS v5.4, Gravol 25 mg for patient over 65, is it only for Ondansetron medication shortage or when unavailable?

The meaning of unavailable, would being allergic to ondansetron count as not being available for the patient/. So a 70 yr old patient allergic to ondansetron could receive 25mg of Gravol? Also, if symptoms have not improved in 30 minutes, we could administer another 25mg to a max of 50mg?

 


Thank you for your question. 

Older adults are more sensitive to the anticholinergic effects of medications such as dimenHYDRINATE. Consequently, ondansetron is generally the preferred antiemetic in this population. However, dimenHYDRINATE may be used at lower doses when ondansetron is unavailable or contraindicated. Additionally, if nausea is associated with vertigo, dimenHYDRINATE might be the medication of choice, as it tends to be more effective in that context.