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Advanced Life
Support Patient Care
Standards
Version 4.9
Comes into force February 1, 2022
Emergency Health Regulatory and Accountability Branch
Ministry of Health
To all users of this publication:
The information contained in th
is standard has been carefully compiled and is believed to be accurate at
date of publication.
For further information on the Advanc
ed Life Support Patient Care Standards, please contact:
Emergency Health Regulatory and Accountability Branch
Ministry of Health
5700 Yonge Street, 6th Floor
Toronto, ON M2M 4K5
416-327-7900
ParamedicStandards@ontario.ca
© Queen’s Printer for Ontario, 2021
Document Control
Version
Number
Date of Issue Comes into
Force Date
Brief Description of Change
3.1 N/A November 2013 Existing document
3.2 Retired Retired Retired
3.3 April 20, 2015 February 1, 2016 Finalized version 3.3
3.4 October 2016 February 1, 2017 Full update to Appendix 6. Appendix 6 retitled:
Ce
rtification Standard.
4.0 October 2016 N/A (amended
pri
or to in force
date)
Full update. See accompanying Summary of
Changes.
4.1 November
2016
N/A (amended
prior to in force
date)
Version 4.0.1 with the addition of the Emergency
Childbirth Medical Directive (PCP/ACP).
4.2 May 2017 N/A (amended
pri
or to in force
date)
Updates to Emergency Childbirth Medical Directive
(PCP/ACP), Suspected Adrenal Crisis Medical
Directive (PCP/ACP) and various housekeeping
edits (e.g. IV provisions)
4.3 July 2017 July 17, 2017 Amends 4.0.1. Change in the “Age” Condition for
naloxone from ≥ 18 years to ≥ 12 years and change
to epinephrine concentration labeling.
Version Date of Issue Comes into Brief Description of Change
Number Force Date
4.4 July 2017 December 11,
2017
Amends 4.2. Change in the “Age” Condition for
naloxone from ≥ 18 years to ≥ 12 years and change
to epinephrine concentration labeling.
4.5 April 2018 May 1, 2018 Updates to the Combative Patient Medical
Directive. Addition of Analgesia Medical Directive
and Emergency Tracheostomy Tube Reinsertion
Medical Directive to the auxiliary appendices. See
accompanying Summary of Changes.
4.6 September
2019
September 3,
2019
Minor housekeeping
Migration of Analgesia Medical Directive and
Emergency Tracheostomy Tube Reinsertion
Medical Directive (PCP / ACP) from “Auxiliary” to
“Core” appendices.
Addition of the Research Trial Standard.
4.6.1 October 2019 October 23, 2019 Amends version 4.6 to correct table formatting and
branch name.
4.7 April 8, 2020 April 8, 2020 Addition of the auxiliary “Assessment of Patients
with Possible COVID-19” Medical Directive.
4.8 November 9,
2020
November 23,
2020
Updates to the following Medical Directives:
Moderate to Severe Allergic Reaction (PCP/ACP),
Suspected Adrenal Crisis (PCP/ACP), added
Endotracheal and Tracheostomy Suctioning &
Reinsertion (PCP/ACP), Intravenous and Fluid
Therapy (ACP), Pediatric Intraosseous (ACP),
Intravenous and Fluid Therapy – AUXILIARY
(PCP), Adult Intraosseous – AUXILIARY (ACP),
Assessment of Patients with Possible COVID-19 –
AUXILIARY (PCP/ACP)
4.9 December
2021
February 1, 2022 Updates to the following Medical Directives:
Analgesia (PCP/ACP), Cardiac ischemia
(PCP/ACP), Cricothyrotomy (ACP), Hyperkalemia
(ACP), Hypoglycemia (PCP/ACP), Opioid Toxicity
(PCP/ACP), Orotracheal Intubation (ACP), ROSC
(PCP/ACP), Seizure (ACP) and Bradycardia (ACP).
See accompanying Summary of Changes.
Table of Contents
Preamble ..........................................................................................................................................
Levels of Paramedics ...................................................................................................................... 1
Purpose of Standards....................................................................................................................... 1
Format of the ALS PCS .................................................................................................................. 1
Use of the Medical Directives by Paramedics ................................................................................ 2
General Structure of a Medical Directive ....................................................................................... 2
Auxiliary Medical Directives .......................................................................................................... 3
Consent to Treatment in Non-Emergency Situations ..................................................................... 3
Consent to Treatment in Emergency Situations .............................................................................. 4
Refusal of Treatment....................................................................................................................... 4
Comprehensive Care ....................................................................................................................... 5
Intravenous (IV) Access and Therapy by Primary Care Paramedics ............................................. 5
Home Medical Technology and Novel Medications ...................................................................... 6
Patching........................................................................................................................................... 7
Incident Reporting .......................................................................................................................... 8
Responsibility for Care ................................................................................................................... 8
Research .......................................................................................................................................... 9
Conventions .................................................................................................................................... 9
Medication Doses and Administration ...................................................................................... 9
Age and Vital Signs ................................................................................................................. 10
Commonly Used Abbreviations .................................................................................................... 12
Reference and Educational Notes ................................................................................................. 16
Appendix 1 – PCP Core Medical Directives ............................................................................. 17
Medical Cardiac Arrest Medical Directive ................................................................................... 18
Trauma Cardiac Arrest Medical Directive .................................................................................... 23
Hypothermia Cardiac Arrest Medical Directive ........................................................................... 27
Foreign Body Airway Obstruction Cardiac Arrest Medical Directive ......................................... 30
Neonatal Resuscitation Medical Directive.................................................................................... 33
Return of Spontaneous Circulation (ROSC) Medical Directive ................................................... 36
Cardiac Ischemia Medical Directive ............................................................................................. 38
Acute Cardiogenic Pulmonary Edema Medical Directive ............................................................ 41
Hypoglycemia Medical Directive ................................................................................................. 43
Bronchoconstriction Medical Directive ........................................................................................ 46
Moderate to Severe Allergic Reaction Medical Directive ............................................................ 49
Croup Medical Directive............................................................................................................... 51
Analgesia Medical Directive......................................................................................................... 53
Opioid Toxicity Medical Directive ............................................................................................... 57
Home Dialysis Emergency Disconnect Medical Directive .......................................................... 59
Suspected Adrenal Crisis Medical Directive ................................................................................ 61
Emergency Childbirth Medical Directive ..................................................................................... 63
Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive ........................... 67
Appendix 2 – ACP Core Medical Directives ........................................................................... 70
Medical Cardiac Arrest Medical Directive ................................................................................... 71
Trauma Cardiac Arrest Medical Directive .................................................................................... 79
Hypothermia Cardiac Arrest Medical Directive ........................................................................... 83
Foreign Body Airway Obstruction Cardiac Arrest Medical Directive ......................................... 86
Neonatal Resuscitation Medical Directive.................................................................................... 89
Return of Spontaneous Circulation (ROSC) Medical Directive ................................................... 92
Cardiac Ischemia Medical Directive ............................................................................................. 96
Acute Cardiogenic Pulmonary Edema Medical Directive ............................................................ 99
Cardiogenic Shock Medical Directive ........................................................................................ 101
Symptomatic Bradycardia Medical Directive ............................................................................. 103
Tachydysrhythmia Medical Directive......................................................................................... 106
Intravenous and Fluid Therapy Medical Directive ..................................................................... 110
Pediatric Intraosseous Medical Directive ................................................................................... 113
Hypoglycemia Medical Directive ............................................................................................... 115
Seizure Medical Directive ........................................................................................................... 117
Opioid Toxicity Medical Directive ............................................................................................. 119
Orotracheal Intubation Medical Directive .................................................................................. 121
Bronchoconstriction Medical Directive ...................................................................................... 123
Moderate to Severe Allergic Reaction Medical Directive .......................................................... 126
Croup Medical Directive............................................................................................................. 128
Tension Pneumothorax Medical Directive ................................................................................. 130
Analgesia Medical Directive....................................................................................................... 132
Hyperkalemia Medical Directive ................................................................................................ 137
Combative Patient Medical Directive ......................................................................................... 140
Home Dialysis Emergency Disconnect Medical Directive ........................................................ 143
Suspected Adrenal Crisis Medical Directive .............................................................................. 145
Emergency Childbirth Medical Directive ................................................................................... 147
Endotracheal and Tracheostomy Suctioning & Reinsertion Medical Directive ......................... 151
Appendix 3 – PCP Auxiliary Medical Directives ................................................................... 154
Intravenous and Fluid Therapy Medical Directive - AUXILIARY............................................ 155
Cardiogenic Shock Medical Directive – AUXILIARY .............................................................. 158
Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY ................... 160
Supraglottic Airway Medical Directive – AUXILIARY ............................................................ 162
Nausea/Vomiting Medical Directive – AUXILIARY ................................................................ 164
Electronic Control Device Probe Removal Medical Directive – AUXILIARY ......................... 166
Assessment of Patients with Possible COVID-19 Medical Directive – AUXILIARY .............. 168
Minor Abrasions Medical Directive – AUXILIARY- SPECIAL EVENT ................................ 171
Minor Allergic Reaction Medical Directive – AUXILIARY - SPECIAL EVENT ................... 173
Musculoskeletal Pain Medical Directive – AUXILIARY - SPECIAL EVENT ........................ 175
Headache Medical Directive – AUXILIARY - SPECIAL EVENT ........................................... 177
Appendix 4 – ACP Auxiliary Medical Directives................................................................... 180
Adult Intraosseous Medical Directive - AUXILIARY ............................................................... 181
Central Venous Access Device Access Medical Directive – AUXILIARY .............................. 183
Nasotracheal Intubation Medical Directive – AUXILIARY ...................................................... 185
Continuous Positive Airway Pressure (CPAP) Medical Directive – AUXILIARY ................... 188
Supraglottic Airway Medical Directive – AUXILIARY ............................................................ 191
Cricothyrotomy Medical Directive – AUXILIARY ................................................................... 193
Nausea/Vomiting Medical Directive – AUXILIARY ................................................................ 195
Procedural Sedation Medical Directive – AUXILIARY ............................................................ 197
Electronic Control Device Probe Removal Medical Directive – AUXILIARY ......................... 199
Assessment of Patients with Possible COVID-19 Medical Directive – AUXILIARY .............. 201
Minor Abrasions Medical Directive – AUXILIARY- SPECIAL EVENT ................................ 204
Minor Allergic Reaction Medical Directive – AUXILIARY - SPECIAL EVENT ................... 206
Musculoskeletal Pain Medical Directive – AUXILIARY - SPECIAL EVENT ........................ 208
Headache Medical Directive – AUXILIARY - SPECIAL EVENT ........................................... 210
Appendix 5 – Chemical Exposure Medical Directives........................................................... 212
Chemical Exposure Medical Directives...................................................................................... 213
Hydrofluoric (HF) Acid Exposure Medical Directive ................................................................ 214
Adult Nerve Agent Exposure Medical Directive ........................................................................ 216
Pediatric Nerve Agent Exposure Medical Directive ................................................................... 220
Cyanide Exposure Medical Directive ......................................................................................... 224
Symptomatic Riot Agent Exposure Medical Directive .............................................................. 227
Appendix 6 – Certification Standard ...................................................................................... 229
Preamble ..................................................................................................................................... 230
Definitions................................................................................................................................... 230
Processes ..................................................................................................................................... 233
New Certification ........................................................................................................................ 235
Cross Certification ...................................................................................................................... 236
Maintenance of Certification ...................................................................................................... 236
Paramedic Practice Review Committee (PPRC) ........................................................................ 237
Appendix A - Paramedic Practice Review Committee Letter .................................................... 240
Appendix 7 – Research Trial Standard .................................................................................. 243
Research Trial Standard .............................................................................................................. 244
Advanced Life Support Patient Care
Standards
Version 4.9
This page has been intentionally left blank
This page is intentionally left blank
i
Preamble
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 1
Preamble
Preamble
Levels of Paramedics
In Ontario, there are 3 levels of qualification for paramedics which lead to Certification as a: Primary
Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP). The
qualification for each are set out in Ontario Regulation 257/00 made under the Ambulance Act, RSO
1990, c A-19. The qualifications for each include a requirement that the paramedic be authorized by
a Medical Director of a Regional Base Hospital (RBH) to perform the controlled acts set out in
Schedules 1, 2 and 3 to O. Reg. 257/00.
A paramedic may be authorized by the Medical Director to perform controlled acts from the
Sc
hedule immediately above their Certification. In this circumstance, the paramedic is required to
perform the controlled act to a specific standard as set out in the Advanced Life Support Patient Care
Standards (ALS PCS). All advanced medical procedures that are not listed as controlled acts in
Schedules 1, 2 and 3, shall also be performed as set out in the ALS PCS.
Purpose of Standards
The ALS PCS reflects current practices for paramedics in Ontario and provides benchmarks for
paramedic performance. It also communicates the standards of practice and care by paramedics in
Ontario to paramedics, patients, other disciplines and the public in general.
Format of the ALS PCS
This document is comprised of a Preamble section and six (6) appendices: Appendix 1 – PCP Core
Medical Directives; Appendix 2 – ACP Core Medical Directives; Appendix 3 – PCP Auxiliary
Medical Directives; Appendix 4 – ACP Auxiliary Medical Directives; Appendix 5 – Chemical
Exposure Medical Directives; and Appendix 6 – Certification Standard. Critical Care Paramedics
and Advanced/Primary Care Flight Paramedics will perform controlled acts in accordance with the
Base Hospital (BH) Medical Directives issued by the Ornge Base Hospital Physician (BHP).
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 2
Preamble
Use of the Medical Directives by
Paramedics
These Medical Directives apply to paramedics who are authorized by a RBH Medical Director to
provide patient care. Delegation of controlled acts in the ALS PCS to paramedics falls under the
exclusive oversight of the RBH Programs.
General Structure of a Medical
Directive
All Medical Directives follow the same format and are comprised of the following sections:
Indications:
The general medical complaint or problem to which the Medical Directive applies.
Conditions:
Clinical parameters that must be present for a procedure to be performed or for a medication to be
administered.
Contraindications:
Clinical parameters that if present, preclude the performance of a procedure or the administration of a
medication.
Treatment:
Description of the type of procedure to be performed or the dosing of a medication.
Clinical Considerations:
Key clinical points that provide general guidance to the proper performance of a procedure or the
administration of a medication.
All of these sections must be taken into account before and during the implementation of a Medical
Directive.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 3
Preamble
Auxiliary Medical Directives
Additional (“Auxiliary”) skills may be delegated through use of the Auxiliary Medical Directives.
Delegation of Auxiliary Medical Directives by a RBH Medical Director to paramedics is optional
and may be introduced after consultation and mutual agreement between the RBH and the certified
ambulance service that employs the paramedic. Some PCP and ACP Medical Directives contain the
phrase, “(if available and authorized)”. This phrase qualifies the skill or procedure as optional (i.e.
auxiliary) even if included in PCP or ACP Medical Directives.
Consent to Treatment in Non-
Emergency Situations
Except in emergency circumstances described below, paramedics shall obtain consent prior to
administering treatment. If a patient is incapable of consenting to the treatment being proposed by a
paramedic, consent may be given or refused on his or her behalf by the patient’s substitute decision-
maker (SDM). Consent may be expressed or implied. Implied consent may be assumed where a
person provides a physical indication that they consent to the treatment being proposed. For
example, a patient who cannot speak but extends his hand to a paramedic after the paramedic
indicates she is going to perform a simple procedure, such as a blood glucose determination, may be
giving implied consent to the treatment.
The elements required for consent to treatment are:
a) consent must be given by a person who is capable of giving consent with respect to
treatment;
b) consent must relate to the treatment;
c) consent must be informed;
d) consent must be given voluntarily; and
e) consent must not be obtained through misrepresentation or fraud.
Consent to treatment is informed if, before it is given by the person, he or she has:
a) received the following information that a reasonable person in the same circumstances would
require in order to make a decision about the treatment:
i. the nature of the treatment;
ii. the expected benefits of the treatment;
iii. the material risks of the treatment;
iv. the material side effects of the treatment;
v. alternative courses of action;
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 4
Preamble
vi. the likely consequences of not having the treatment; and
b) received responses to his or her requests for additional information about those matters.
Vali
d consent requires that a person has the capacity to provide consent. A person is presumed to
have the capacity to provide consent with respect to treatment and a paramedic may rely on that
presumption unless the paramedic has reasonable grounds to believe that the person is incapable with
respect to the treatment. A paramedic must perform a capacity assessment if it is not reasonable in
the circumstances to presume the person is capable of consenting to the treatment.
A patient is capable with respect to treatment if the patient is:
a) Able to understand the information that is relevant to making a decision about the treatment
or alternatives being proposed; and
b) Able to appreciate the reasonably foreseeable consequences of a decision or lack of decision
with respect to treatment.
If a patient is incapable of consenting to a proposed treatment, and the paramedic is aware or is made
aware that the person has a prior capable wish with respect to the proposed treatment, they must
respect that wish (for example, if the person does not wish to be resuscitated).
Consent to Treatment in Emergency
Situations
Where the person for whom the treatment is being proposed is apparently experiencing severe
suffering or is at risk of sustaining serious bodily harm if the treatment is not administered promptly,
it is considered to be an emergency.
For situations involving consent to treatment in emergency situations, a paramedic shall comply with
the applicable directions contained in the Basic Life Support Patient Care Standards (BLS PCS).
Refusal of Treatment
If a patient refuses treatment, either in whole or in part, a paramedic shall comply with the applicable
directions contained in the BLS PCS.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 5
Preamble
Comprehensive Care
While initiating and continuing treatment prescribed by these Medical Directives, a paramedic must
ensure that the patient simultaneously receives care in accordance with the BLS PCS.
It is acknowledged that there may be circumstances and situations where complying with ALS PCS
is not clinically justified, possible, or prudent (e.g. multiple crews on scene, trapped patient,
extenuating circumstances, competing patient care priorities). When treatment deviates from the
standards, a paramedic must document the care provided, including reasoning for deviating from the
ALS PCS.
Intravenous (IV) Access and Therapy
by Primary Care Paramedics
There are 2 types of authorization for PCPs IV cannulation and therapy.
“PCP Assist IV” is authorization for a PCP to cannulate a peripheral IV at the request and under the
direct supervision of an ACP. The patient must require a peripheral IV in accordance with the
indications listed in the Intravenous and Fluid Therapy Medical Directive - Auxiliary. The ACP will
perform all IV therapy in accordance with the Intravenous and Fluid Administration Medical
Directive once intravenous access is obtained. PCPs authorized in PCP Assist IV are not authorized
to administer IV therapy.
“PCP Autonomous IV” is authorization for a PCP to independently cannulate an IV according to the
Intravenous and Fluid Therapy Medical Directive – Auxiliary. PCPs authorized in PCP Autonomous
IV are authorized to administer IV therapy according to applicable Medical Directives.
Authorization for each type shall meet the requirements established by the provincial Medical
Advisory Committee.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 6
Preamble
Home Medical Technology and Novel
Medications
As community care advances, new home medical technologies and novel medications are being
introduced for home use by highly trained patients and caregivers. They are generally used by
patients with complex medical histories who may require emergent interventions which are not
described in, or aligned with, the BLS PCS or ALS PCS.
A “home medical technology” is an external or internal mechanical device prescribed by a member
of a re
gulated health profession for the purpose of treating a medical condition.
A “novel medication” is a self/caregiver-administered medication prescribed by a member of a
regulated health profession that is required to treat patients with generally rare and unusually
complex chronic medical conditions which are often end stage. The medication may be
self/caregiver-administered by any route into any part of the body.
These can be encountered unexpectedly by paramedics without any prior knowledge that these
technologies or medications are being used in the community. Paramedics may not be familiar with
the use of these technologies or medications, even though they may be required to provide care.
In some cases, when Base Hospital Medical Directors are alerted to these devices, medications or
care requirements, a local medical directive may be issued to guide specific care for these patients.
Such directives should be followed until further consideration by the Medical Advisory Committee.
A paramedic may assume patients or caregivers have knowledge about the technology or medication
if they confirm that they were trained in its use and/or administration. A paramedic should advise the
patient or caregiver to follow any specific steps or provide any advice about restarting/stopping the
device or novel medication. A paramedic may only assist a patient within the authorized paramedic
skill set.
When care requirements are uncertain, but the patient is stable, transport the patient. If the patient is
unstable, consider patching to the BHP. Alternatively, consider contacting the responsible member of
a regulated health profession.
A paramedic may follow written advice provided by their Base Hospital Medical Directors even if
this advice is outside the conditions and contraindications of the BLS PCS and ALS PCS.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 7
Preamble
Patching
A paramedic shall patch to the Base Hospital when:
a) a medical directive contains a mandatory provincial patch point; OR
b) an RBH
introduces a mandatory BH patch point; OR
c) for situations that fall outside of these Medical Directives where the paramedic believes the
patient may benefit from online medical direction that falls within the prescribed paramedic
scope of practice; OR
d) there is uncertainty about the appropriateness of a medical directive, either in whole or in
part.
In cases where a treatment option requires the prior authorization by the BHP (i.e. mandatory
provincial patch point or mandatory BH patch point) AND the BHP cannot be reached despite
reasonable attempts by the paramedic to establish contact, a paramedic may initiate the required
treatment without the requisite online authorization if the patient is in severe distress and, in the
paramedic’s opinion, the medical directive would otherwise apply. Clinical judgement must be
applied and an acceptable standard of care must be met. This may be based on peer and expert
review. In such cases, a paramedic should continue attempts to contact the BHP after the treatment
has been initiated. All patch failures must be reported in a timely manner in accordance with local
policy and procedures. Paramedics should document the attempts to patch to the BH on the
Ambulance Call Report (ACR).
If a BHP directs a paramedic to perform an assessment or intervention that exceeds the paramedic’s
scope of practice, the paramedic must advise the BHP of such and notify the physician that he or she
cannot comply with the direction as it exceeds his or her scope of practice. In such cases, a
paramedic should ask the BHP to provide alternative direction.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 8
Preamble
Incident Reporting
Paramedics shall adhere to their ambulance service policies and the Ontario Ambulance
Documentation Standards (incorporated by reference in Ontario Regulation 257/00) for incident
reporting. Paramedics shall also adhere to additional RBH policies regarding reporting of clinical
care incidents to the RBH.
Responsibility for Care
While on scene, the highest level paramedic shall assess the patient and make a decision on the level
of care required, and on the level of paramedic required for the care of the patient. The highest level
paramedic is the ultimate patient care authority on the scene. If there is any disagreement between
paramedics, the Base Hospital physician may be contacted. It is expected that when an intervention
has been performed, the paramedic most appropriate for that intervention will remain responsible for
the patient.
In all patient care, the highest level of paramedic is responsible for the care of the patient, including
decisions on the level of care required during transport. A paramedic may choose to assign aspects
of care and procedures to an alternate level paramedic, as long as the care and procedures are within
that paramedic’s scope of practice. Paramedics must alert the highest level paramedic of any change
of patient status.
When transferring care from one level of paramedic to another, paramedics shall provide:
a) current CTAS level;
b) a history of the patient’s current problem(s) and relevant past medical history;
c) pertinent physical findings;
d) a summary of management at scene/en route;
e) the patient’s response to treatment, including most recent vital signs; and
f) the reason for transfer in cases of inter-facility transfers.
The transfer of responsibility of patient care is a critical juncture along the clinical care continuum.
When transferring patient care to another health care provider (e.g. nurse, physician, etc.), a
paramedic must comply with the BLS PCS regarding such transfers.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 9
Preamble
Research
Clinical research is fundamental to the practice of medicine and the development of safer, more
effective treatment options for patients. At times, research protocols require temporary changes to
patient care standards. Changes to patient care standards will be approved and introduced by the
MOH.
Conventions
“Conventions” refers to a consistent application of terms throughout the Medical Directives based on
definitions below.
The word ‘consider’ is used repeatedly throughout the Medical Directives. Where this word appears,
it indicates that a paramedic should initiate the treatment when the indications are first identified
unless there is strong clinical rationale to withhold or delay treatment, or other extenuating
circumstances. A paramedic must document his or her justification for withholding or delaying
treatment on the ACR.
Medication Doses and Administration
Medication doses may be either in per kilogram or fixed doses, depending on common clinical
practice. The number of recommended medication doses may be administered regardless of any
previous self-administration by a patient. When more than one route of medication administration is
listed, the order of preference for route of administration is from left to right. Clinical circumstances
for each case should determine the final route chosen.
Pediatric medication doses can vary slightly according to the source of expert opinion. The pediatric
me
dication doses in the ALS PCS are the preferred doses. However, medication doses as determined
by an up-to-date version of a widely accepted pediatric emergency tape (e.g. Broselow Tape) are an
acceptable alternative. Use of a pediatric emergency tape shall be documented on the ACR when it
is used to determine a pediatric medication dose.
Medication doses may be calculated based upon weight or other factors and result in a fraction that
ca
nnot be measured accurately. Depending on the delivery method used, medication doses may
require rounding from the exact dose calculated. In these cases, the medication dose delivered will be
rounded to the closest dose that can accurately be measured.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 10
Preamble
Age and Vital Signs
The general age cut off between adults and pediatrics is 18 years. There is a wide range of “normal”
for vital signs in adults and especially pediatrics. As much as possible, ages for pediatrics and cut off
points for vital signs have been kept consistent throughout the Medical Directives. However, clinical
research and expert opinion have resulted in a number of exceptions which in each case has been
deliberately chosen and is clearly noted in each Medical Directive. There is a deliberate gap in the
definition of normotension and hypotension in adults.
Adults
Normotension
SBP ≥100 mmHg
Hypotension
SBP <90 mmHg
Heart rate
Heart rate is always in beats per minute according to a cardiac monitor when it is applied. In
situations where a cardiac monitor is not indicated then the heart rate is equal to the pulse rate.
Bradycardia
HR <50 BPM
Tachycardia
HR ≥100 BPM
Tachypnea
RR ≥28 breaths/min
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 11
Preamble
Pediatrics
Age Respiratory Rate Heart Rate
0-3 months 30-60 90-180
3-6 months 30-60 80-160
6-12 months 25-45 80-140
1-3 yr 20-30 75-130
6 yr 16-24 70-110
10 yr 14-20 60-90
Normotension
SBP ≥90 mmHg + (2 x age in years)
Hypotension
SBP <70 mmHg + (2 x age in years)
Weight (kg)
= (age x 2) + 10
Hypoglycemia
Age Blood glucose
level
<2 yr <3.0 mmol/L
≥2 yr <4.0 mmol/L
Level of Awareness (LOA)
The word ‘altered’ refers to a GCS that is less than normal for the patient.
The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS <15.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 12
Preamble
Commonly Used Abbreviations
Table 1 below outlines abbreviations commonly used in the ALS PCS.
Table 1. Abbreviations commonly used in the ALS PCS
Word/Phrase Abbreviation
A
Advanced Care Paramedic ACP
Advanced Life Support ALS
Advanced Life Support Patient Care Standards ALS PCS
Acetylsalicylic acid ASA
As needed PRN
Atrioventricular AV
Automated external defibrillation AED
B
Base Hospital BH
Base Hospital Physician BHP
Basic Life Support BLS
Basic Life Support Patient Care Standards BLS PCS
Beats per minute BPM
Bag-valve-mask BVM
By mouth/oral PO
C
Critical Care Paramedic CCP
Chronic obstructive pulmonary disease COPD
Centimetre cm
Continuous positive airway pressure CPAP
Cardiopulmonary Resuscitation CPR
College of Physicians and Surgeons of Ontario CPSO
Canadian Triage and Acuity Scale CTAS
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 13
Preamble
Word/Phrase
Abbreviation
Cerebral vascular accident CVA
Central venous access device CVAD
D
Diabetic ketoacidosis DKA
Do Not Resuscitate DNR
Drops gtts
E
Electronic control device ECD
Electrocardiogram ECG
Esophageal detection device EDD
Emergency department ED
End tidal carbon dioxide ETCO
2
Endotracheal tube ETT
Every q
F
Fraction of inspired oxygen FiO
2
Febrile respiratory infection FRI
G
Gram g
Glasgow Coma Scale GCS
H
Heart Rate HR
History Hx
I
Intramuscular IM
Intranasal IN
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Advanced Life Support Patient Care Standards – Version 4.9 14
Preamble
Word/Phrase
Abbreviation
Intraosseous IO
Intravenous IV
J
Joule J
K
Kilogram kg
L
Level of awareness LOA
Level of consciousness LOC
M
Maximum Max.
Metered dose inhaler MDI
Microgram mcg
Milligram mg
Milliseconds ms
Minimum Min.
Minute min
Millilitre per kilogram ml/kg
Millimetres of mercury mmHg
Ministry of Health MOH
N
Not applicable N/A
Nostril nare
Nebulized NEB
Nasopharyngeal airway NPA
Non-steroidal anti-inflammatory drug NSAID
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 15
Preamble
Word/Phrase
Abbreviation
O
Ontario Base Hospital Group-Medical Advisory Committee OBHG-MAC
Oropharyngeal airway OPA
P
Pediatric Ped
Primary Care Paramedic PCP
Pulseless electrical activity PEA
R
Regional Base Hospital RBH
Return of spontaneous circulation ROSC
Respiratory rate RR
S
Sodium chloride NaCl
Subcutaneous SC
Sublingual SL
Systolic blood pressure SBP
Saturation of peripheral oxygen SpO
2
ST-segment elevation myocardial infarction STEMI
T
Topical TOP
Termination of Resuscitation TOR
Traumatic brain injury TBI
Tricyclic antidepressant TCA
Transcutaneous pacing TCP
U
Upper respiratory tract infection URTI
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.9 16
Preamble
Word/Phrase
Abbreviation
V
Ventricular Fibrillation VF
Ventricular Tachycardia VT
Vital signs absent VSA
W
Water H
2
O
Within normal limits WNL
Reference and Educational Notes
The RBHs have created a companion document of reference and educational notes intended to assist
paramedics in implementing these Medical Directives. This will facilitate regular updating of these
notes without having to issue frequent changes to the standards. It is expected that paramedics have
mastered the relevant information as part of initial training and certification and have maintained
their knowledge through continuing education and self-study. The reference and educational notes do
not define a standard of care; however, they should be considered useful in ensuring that an
appropriate standard of care is met.
1
Appendix 1 – PCP Core Medical Directives
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Advanced Life Support Patient Care Standards – Version 4.9 18
Appendix 1 – PCP Core Medical Directives
Medical Cardiac Arrest Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Non-traumatic cardiac arrest.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
Epinephrine
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Anaphylaxis suspected as
causative event
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Appendix 1 – PCP Core Medical Directives
Medical TOR
Age ≥18 years
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Arrest not witnessed by
EMS AND No ROSC
AND No defibrillation
delivered
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR
) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Epinephrine
Allergy or sensitivity to epinephrine
Medical TOR
Arrest thought to be of non-cardiac
origin
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider CPR
Consider Manual defibrillation (if available and authorized)
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Subsequent dose(s) 4 J/kg As per BH / manufacturer
Dosing interval 2 min 2 min
Max. # of doses 4 4
Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval 2 min 2 min 2 min
Max. # of doses 4 4 4
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Appendix 1 – PCP Core Medical Directives
Consider epinephrine (only if anaphylaxis is suspected as
causative event)
Route
IM
Concentr
ation
1 mg/mL =
1:1,000
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval N/A
Max. # of doses 1
*The epinephrine dose may be rounded to the nearest 0.05 mg
Mandatory Provincial Patch Point
Patch to BHP for authorization, following the 3
rd
analysis, to consider Medical TOR (if applicable).
If the BH patch fails, or the medical TOR does not apply, transport to the closest appropriate
receiving facility following ROSC or the 4
th
analysis.
Clinical Considerations
Consider very early transport after the 1
st
analysis (and defibrillation if indicated) in the following
settings: pregnancy presumed to be ≥20 weeks gestation (fundus above umbilicus, ensure manual
displacement of uterus to left), hypothermia, airway obstruction, suspected pulmonary embolus,
medication overdose/toxicology, or other known reversible cause of arrest not addressed.
Similarly, plan for extrication and transport for patients with refractory ventricular fibrillation and
pediatric cardiac arrest (after 3 analyses), ensure quality CPR can be continued.
In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive.
There is no clear role for routine administration of naloxone in confirmed cardiac arrest.
Follow the Deceased Patient Standard once TOR has been implemented.
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Appendix 1 – PCP Core Medical Directives
Defibrillation Joule Settings
This section is intentionally left blank.
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Appendix 1 – PCP Core Medical Directives
Trauma Cardiac Arrest Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to severe blunt or penetrating trauma.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
Trauma TOR
Age ≥16 years
LOA Altered
HR 0
RR 0
SBP N/A
Other No palpable pulses AND
No defibrillation delivered
AND Monitored HR = 0
OR Monitored HR >0
with the closest ED ≥30
min transport time away.
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Appendix 1 – PCP Core Medical Directives
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Trauma TOR
Age <16 years
Defibrillation delivered
Monitored HR >0 and closest ED <30
min transport time away
Treatment
Consider CPR
Consider Manual defibrillation (if available and authorized)
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Appendix 1 – PCP Core Medical Directives
Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Mandatory Provincial Patch Point
Patch to BHP for authorization to apply the Trauma TOR if applicable. If the BH patch fails, or the
Trauma TOR does not apply, transport to the closest appropriate receiving facility following the 1
st
analysis/defibrillation.
Clinical Considerations
If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat
according to the appropriate medical cardiac arrest directive.
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Appendix 1 – PCP Core Medical Directives
VF or VT
Asystole or PEA (HR >0)
No
Yes (Rhythm=Asystole)
Yes (Rhythm=PEA)
No
Yes
No
Treatment – Algorithm For Trauma Arrest
Cardiac arrest secondary to severe
blunt or penetrating trauma
CPR (throughout duration of
call)
Apply defib pads to all
patients ≥30 days of age
Determine Rhythm
Defibrillation x 1
Pt ≥16 years of age?
Patch
Drive time to closest
ED ≥30 min
TOR granted?
TOR implemented Transport to Emergency Department
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Advanced Life Support Patient Care Standards – Version 4.9 27
Appendix 1 – PCP Core Medical Directives
Hypothermia Cardiac Arrest Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to severe hypothermia.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
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Appendix 1 – PCP Core Medical Directives
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Treatment
Consider CPR
Consider Manual defibrillation (if available and authorized)
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Advanced Life Support Patient Care Standards – Version 4.9 29
Appendix 1 – PCP Core Medical Directives
Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
W
ith Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
Transport to the closest appropriate facility without delay following the 1
st
analysis.
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Advanced Life Support Patient Care Standards – Version 4.9 30
Appendix 1 – PCP Core Medical Directives
Foreign Body Airway Obstruction
Cardiac Arrest Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to an airway obstruction.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
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Appendix 1 – PCP Core Medical Directives
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Treatment
Consider CPR
Consider foreign body removal (utilizing BLS PCS maneuvers)
Consider Manual defibrillation (if available and authorized)
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Advanced Life Support Patient Care Standards – Version 4.9 32
Appendix 1 – PCP Core Medical Directives
Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
W
ith Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
If the patient is in cardiac arrest following removal of the obstruction, initiate management as a
medical cardiac arrest.
If the obstruction cannot be removed, transport to the closest appropriate facility without delay
following the 1
st
analysis.
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Appendix 1 – PCP Core Medical Directives
Neonatal Resuscitation Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Neonatal patient.
Conditions
Resuscitation
Age <30 days of age
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Resuscitation
N/A
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Appendix 1 – PCP Core Medical Directives
Treatment
Targeted
Preductal SpO
2
(Right Hand)
1 min 60% - 65%
2 min 65% - 70%
3 min 70% - 75%
4 min 75% - 80%
5 min 80% - 85%
10 min 85% - 95%
Neonatal patient
Term gestation and
good muscle tone and
breathing or crying?
Provide warmth;
clear airway as necessary
(do not routinely suction)
dry; and
ongoing evaluation
Supportive care
Evaluate respirations and heart
rate (consider use of SpO
2
and
cardiac monitoring)
Breathing and
HR ≥100 bpm?
HR ≥60 bpm?
HR ≥60 bpm?
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Appendix 1 – PCP Core Medical Directives
Clinical Considerations
If neonatal resuscitation is required, initiate cardiac monitoring and pulse oximetry monitoring.
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Appendix 1 – PCP Core Medical Directives
Return of Spontaneous Circulation
(ROSC) Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient with return of spontaneous circulation (ROSC) after the resuscitation was initiated.
Conditions
0.9% NaCl Fluid Bolus
Age ≥2 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other Chest auscultation is clear
Contraindications
0.9% NaCl Fluid Bolus
Fluid overload
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider optimizing ventilation and oxygenation
Titrate oxygenation 94-98%
Avoid hyperventilation and target ETCO
2
to 30-40 mmHg with continuous waveform capnography
(if available)
Consider 0.9% NaCl fluid bolus (if available and authorized)
Age Age
≥2 years to <12 years ≥12 years
Route Route
IV IV
Infusion 10 ml/kg 10 ml/kg
Infusion interval Immediate Immediate
Reassess every 100 ml 250 ml
Max. volume 1,000 ml 1,000 ml
Consider 12-lead ECG acquisition and interpretation
Clinical Considerations
Consider initiating transport in parallel with the above treatment.
IV fluid bolus applies only to PCPs authorized for PCP Autonomous IV.
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Appendix 1 – PCP Core Medical Directives
Cardiac Ischemia Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected cardiac ischemia.
Conditions
ASA
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other Able to chew and swallow
Nitroglycerin
Age ≥18 years
LOA Unaltered
HR 60-159 bpm
RR N/A
SBP Normotension
Other Prior history of nitroglycerin
use OR IV access obtained
Contraindications
ASA
Allergy or sensitivity to NSAIDs
If asthmatic, no prior use of ASA
Current active bleeding
CVA or TBI in the previous 24 hours
Nitroglycerin
Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within
the previous 48 hours
SBP drops by one-third or more of its
initial value after nitroglycerin is
administered
12-lead ECG compatible with Right
Ventricular MI
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider ASA
Route
PO
Dose 160-162 mg
Max. single dose 162 mg
Dosing interval N/A
Max. # of doses 1
Consider 12-lead ECG acquisition and interpretation for STEMI
Consider nitroglycerin
STEMI
No Yes
SBP SBP
≥100 mmHg ≥100 mmHg
Route Route
SL SL
Dose 0.3 mg OR 0.4 mg 0.3 mg OR 0.4 mg
Max. single dose 0.4 mg 0.4 mg
Dosing interval 5 min 5 min
Max. # of doses 6 3
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Appendix 1 – PCP Core Medical Directives
Clinical Considerations
Suspect a Right Ventricular MI in all inferior STEMIs and perform at minimum V4R to confirm (ST-
elevation ≥ 1mm in V4R).
Do not administer nitroglycerin to a
patient with Right Ventricular STEMI.
IV condition applies only to PCPs authorized for PCP Autonomous IV.
Apply defibrillation pads when a STEMI is identified.
The goal for time to 12-lead ECG from first medical contact is < 10 minutes where possible.
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Appendix 1 – PCP Core Medical Directives
Acute Cardiogenic Pulmonary
Edema Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Moderate to severe respiratory distress;
AND
Suspected acute cardiogenic pulmonary edema.
Conditions
Nitroglycerin
Age ≥18 years
LOA N/A
HR 60-159 bpm
RR N/A
SBP Normotension
Other N/A
Contraindications
Nitroglyercin
Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within
the previous 48 hours
SBP drops by one-third or more of its
initial value after nitroglycerin is
administered
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider nitroglycerin
SBP SBP
≥100 mmHg to
<140 mmHg
≥140 mmHg
IV or Hx* IV or Hx* IV or Hx*
Yes No Yes
Route Route Route
SL SL SL
Dose 0.3 mg or 0.4 mg 0.3 mg or 0.4 mg 0.6 mg or 0.8 mg
Max. single dose 0.4 mg 0.4 mg 0.8 mg
Dosing interval 5 min 5 min 5 min
Max. # of doses 6 6 6
*Hx refers to a patient with a prior history of nitroglycerin use
Consider 12-lead ECG acquisition and interpretation
Clinical
Considerations
IV condition applies only to PCPs authorized for PCP Autonomous IV.
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Appendix 1 – PCP Core Medical Directives
Hypoglycemia Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected hypoglycemia
Conditions
Dextrose
Age ≥2 years
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Hypoglycemia
Glucagon
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Hypoglycemia
Contraindications
Dextrose
Allergy or sensitivity to dextrose
Glucagon
Allergy or sensitivity to glucagon
Pheochromocytoma
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider glucometry
Consider dextrose (if available and authorized)
Age
≥2 years
Concentration Concentration
10% dextrose 50% dextrose
Route Route
IV IV
Dose 0.2 g/kg (2 ml/kg) 0.5 g/kg (1 ml/kg)
Max. single dose 25 g (250 ml) 25 g (50 ml)
Dosing interval 10 min 10 min
Max. # of doses 2 2
Titrate dextrose to a level of awareness where the patient can safely consume complex carbohydrate.
Consider glucagon (if not using dextrose)
Age
N/A
Weight Weight
<25 kg ≥25 kg
Route Route
IM IM
Dose 0.5 mg 1 mg
Max. single dose 0.5 mg 1 mg
Dosing interval 20 min 20 min
Max. # of doses 2 2
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Appendix 1 – PCP Core Medical Directives
Clinical Considerations
If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple
carbohydrates.
If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple
ca
rbohydrates instead of dextrose or glucagon.
If a patient initiates an informed refusal of transport, a final set of vital signs including blood
glucometry must be attempted and documented.
IV administration of dextrose applies only to PCPs authorized for PCP Autonomous IV.
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Bronchoconstriction Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Respiratory distress;
AND
Suspected bronchoconstriction.
Conditions
Salbutamol
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Epinephrine
Age N/A
Weight N/A
LOA N/A
HR N/A
RR BVM ventilation required
SBP N/A
Other Hx of asthma
Contraindications
Salbutamol
Allergy or sensitivity to salbutamol
Epinephrine
Allergy or sensitivity to epinephrine
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Appendix 1 – PCP Core Medical Directives
Treatment
Consider salbutamol
Weight Weight
<25 kg ≥25 kg
Route Route Route Route
MDI* NEB MDI* NEB
Dose Up to 600 mcg
(6 puffs)
2.5 mg Up to 800 mcg
(8 puffs)
5 mg
Max. single dose 600 mcg 2.5 mg 800 mcg 5 mg
Dosing interval 5-15 min PRN 5-15 min PRN 5-15 min PRN 5-15 min PRN
Max. # of doses 3 3 3 3
*1 puff=100 mcg
Consider epinephrine
Route
IM
Concentration
1 mg/mL =
1:1,000
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval N/A
Max. # of doses 1
*The epinephrine dose may be rounded to the nearest 0.05 mg
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Appendix 1 – PCP Core Medical Directives
Clinical Considerations
Epinephrine should be the 1
st
medication administered if the patient is apneic. Salbutamol MDI may
be administered subsequently using a BVM MDI adapter.
Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a
dec
lared febrile respiratory illness outbreak by the local medical officer of health.
When administering salbutamol MDI, the rate of administration should be 100 mcg approximately
every 4 breaths.
A spacer should be used when administering salbutamol MDI.
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Moderate to Severe Allergic Reaction
Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Exposure to a probable allergen;
AND
Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis).
Conditions
Epinephrine
Age N/A
Weight N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other For anaphylaxis only
Diphenhydramine
Age N/A
Weight ≥25 kg
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Epinephrine
Allergy or sensitivity to epinephrine
Diphenhydramine
Allergy or sensitivity to
diphenhydramine
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
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Treatment
Consider epinephrine
Route
IM
Concentration
1 mg/mL =
1:1,000
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval Minimum 5 min
Max. # of doses 2
*The epinephrine dose may be rounded to the nearest 0.05 mg
Consider diphenhydramine
Weight Weight
≥25 kg to <50 kg ≥50 kg
Route Route
IV/IM IV/IM
Dose 25 mg 50 mg
Max. single dose 25 mg 50 mg
Dosing interval N/A N/A
Max. # of doses 1 1
Clinical Considerations
Epinephrine administration takes priority over IV access.
IV administration of diphenhydramine applies only to PCPs authorized for PCP Autonomous IV.
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Croup Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Severe respiratory distress;
AND
Stridor at rest;
AND
Current history of URTI;
AND
Barking cough or recent history of a barking cough.
Conditions
Epinephrine
Age <8 years
LOA N/A
HR <200 bpm
RR N/A
SBP N/A
Other N/A
Contraindications
Epinephrine
Allergy or sensitivity to epinephrine
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Treatment
Consider epinephrine
Age Age
<1 year ≥1 year to <8 years
Weight Weight Weight
<5 kg ≥5 kg N/A
Route Route Route
NEB NEB NEB
Concentration Concentration Concentration
1 mg/mL =
1:1,000 1 mg/mL = 1:1,000 1 mg/mL = 1:1,000
Dose 0.5 mg 2.5 mg 5 mg
Max. single dose 0.5 mg 2.5 mg 5 mg
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
The minimum initial volume for nebulization is 2.5 ml.
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Analgesia Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Pain
Conditions
Acetaminophen
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Ibuprofen
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Ketorolac
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP Normotension
Other N/A
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Contraindications
Acetaminophen
Acetaminophen use within previous 4
hours
Allergy or sensitivity to
acetaminophen
Hx of liver disease
Active vomiting
Unable to tolerate oral medication
Suspected ischemic chest pain
Ibuprofen
NSAID use within previous 6 hours
Allergy or sensitivity to NSAIDs
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or
other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Active vomiting
Unable to tolerate oral medication
Suspected ischemic chest pain
Ketorolac
NSAID use within previous 6 hours
Allergy or sensitivity to NSAIDs
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or
other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Suspected ischemic chest pain
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Treatment
Consider acetaminophen
Age Age
≥12 years to <18 years ≥18 years
Route PO PO
Dose 500-650 mg 960-1,000 mg
Max. single dose 650 mg 1,000 mg
Dosing interval N/A N/A
Max. # of doses 1 1
Consider ibuprofen
Age
≥12 years
Route PO
Dose 400 mg
Max. single dose 400 mg
Dosing interval N/A
Max. # of doses 1
Consider ketorolac
Age
≥12 years
Route IM/IV
D
ose 10-15 mg
Max. single dose 15 mg
Dosing interval N/A
Max. # of doses 1
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Clinical Considerations
Whenever possible, consider co-administration of acetaminophen and ibuprofen.
Suspected renal colic patients should routinely be considered for ibuprofen or ketorolac.
IV a
dministration of ketorolac applies only to PCPs authorized for PCP Autonomous IV.
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Opioid Toxicity Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Altered LOC;
AND
Respiratory depression;
AND
Inability to adequately ventilate; OR persistent need to assist ventilations;
AND
Suspected opioid overdose.
Conditions
Naloxone
Age ≥24 hours
LOA Altered
HR N/A
RR <10 breaths/min
SBP N/A
Other N/A
Contraindications
Naloxone
Allergy or sensitivity to naloxone
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Treatment
Consider naloxone
Route Route Route Route
IV IM IN SC
Dose Up to 0.4 mg* 0.4 mg 2-4 mg 0.8 mg
Max. single dose 0.4 mg 0.4 mg 2-4 mg 0.8 mg
Dosing interval 5 min 5 min 5 min 5 min
Max. # of doses 3 3 3 3
*For the IV route, titrate naloxone only to restore the patient’s respiratory status.
Clinical Considerations
IV administration of naloxone applies only to PCPs authorized for PCP Autonomous IV.
Upfront aggressive management of the airway is paramount and the initial priority.
If no response to initial treatment; consider patching for further doses.
If the patient does not respond to airway management and the administration of naloxone,
glucometry should be considered.
Combative behaviour should be anticipated following naloxone administration and paramedics
should protect themselves accordingly, thus the importance of gradual titrating (if given IV) to
desired clinical effect: respiratory rate ≥10, adequate airway and ventilation, not full alertness.
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Home Dialysis Emergency
Disconnect Medical Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient receiving home dialysis (hemo or peritoneal) and connected to dialysis machine and requires
transport to the closest appropriate receiving facility;
AND
Patient is unable to disconnect;
AND
There is no family member or caregiver who is available and knowledgeable in dialysis disconnect.
Conditions
Home Dialysis Emergency Disconnect
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Home Dialysis Emergency Disconnect
N/A
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Treatment
Consider Home Dialysis Emergency Disconnect
Clinical Considerations
Generally, emergency disconnect kit with materials and instructions can be found hanging from
dialysis machine or nearby on the wall.
Ensure both the patient side and machine side of the connection are clamped before disconnecting
and attaching end caps.
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Suspected Adrenal Crisis Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
A patient with primary adrenal failure who is experiencing clinical signs of an adrenal crisis.
Conditions
Hydrocortisone
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Paramedics are presented with a vial of hydrocortisone for the identified patient
AND
Age-related hypoglycemia OR
GI symptoms (vomiting, diarrhea, abdominal pain) OR
Syncope OR
Temperature ≥38C or suspected/history of fever OR
Altered level of awareness OR
Age-related tachycardia OR
Age-related hypotension
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Contraindications
Hydrocortisone
Allergy or sensitivity to
hydrocortisone
Treatment
Consider hydrocortisone
Route
IM/IV
Dose 2 mg/kg*
Max. single dose 100 mg
Dosing interval N/A
Max. # of doses 1
*Dose should be rounded to the nearest 10 mg
Clinical Considerations
IV administration of hydrocortisone applies only to PCP’s authorized for PCP Autonomous IV.
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Emergency Childbirth Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Pregnant patient experiencing labour; OR
Post-partum patient immediately following delivery.
Conditions
Delivery
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Second stage labour
and/or imminent birth
Umbilical Cord Management
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Cord complications OR if
neonatal or maternal
resuscitation is required
OR due to transport
considerations
External Uterine Massage
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Post-placental delivery
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Contraindications
Delivery
N/A
Umbilical Cord Management
N/A
External Uterine Massage
N/A
Treatment
Consider delivery
Patient of childbearing years
experiencing second stage labour
and/or imminent birth
Position the patient supine on a
firm surface, with her head and
shoulders slightly elevated, legs
flexed and abducted at hips and
knees, feet flat and perineum
clearly visible.
Complicated
delivery?
For head-first delivery,
deliver the head in a
controlled fashion, allow
spontaneous head rotation,
and deliver the neonate’s
shoulders/body.
Assess maternal and neonatal patients,
consider further umbilical cord management,
delivery of placenta, and external uterine massage
Shoulder dystocia?
Attempt the McRoberts
Manoeuvre and apply
suprapubic pressure
Breech delivery?
‘Hands off’ until the body has been
born to the umbilicus. Allow the
head to deliver spontaneously, or
gently lift and hold the neonate
upwards and backwards while
avoiding hyperextension
If the head does not deliver
within approximately three
minutes of the body,
attempt the Mauriceau-
Smellie-Veit Manoeuver
Nuchal or
prolapsed cord?
Consider umbilical
cord management
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Yes
No
Yes
No
Yes
No
Yes
No
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Consider umbilical cord management
If a cord prolapse is present, the fetal part should be elevated to relieve pressure on the cord. Assist
the patient into a knee-chest position or exaggerated Sims position, and insert gloved fingers/hand
into the vagina to apply manual digital pressure to the presenting part which is maintained until
transfer of care in hospital.
If a nuchal cord is present and loose, slip cord over the neonate’s head. Only if a nuchal cord is tight
and cannot be slipped over the neonate’s head, clamp and cut the cord, encourage rapid delivery.
Following delivery of the neonate, the cord should be clamped and cut immediately if neonatal or
mate
rnal resuscitation is required. Otherwise, after pulsations have ceased (approximately 2-3
minutes), clamp the cord in two places and cut the cord.
Consider external uterine massage
Clinical Considerations
If the patient presents with limb-presentation, do not attempt to push the limb back into the vagina;
discourage the patient from pushing, cover the limb using a dry sheet to maintain warmth, and
initiate transport as per the Load and Go Patient Standard of the BLS PCS.
If labour is failing to progress, discourage the patient from pushing or bearing down during
contractions.
If delivery has not occurred at scene within approximately ten minutes of initial assessment, consider
transport in conjunction with the following:
a. Patient assessment findings:
i. Lack of progression of labour;
ii. Multiple births expected;
iii. Neonate presents face-up;
iv. Pre-eclampsia;
v. Presence of vaginal hemorrhage;
vi. Premature labour;
vii. Primip;
b. Distance to the closest appropriate receiving facility.
When the placenta is delivered, inspect it for wholeness, place in a plastic bag from the OBS kit,
label it with the maternal patient’s name and time of delivery, and transport it with the maternal or
neonatal patient. Delivery of the placenta should not delay transport considerations/initiation.
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Endotracheal and Tracheostomy
Suctioning & Reinsertion Medical
Directive
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient with endotracheal or tracheostomy tube
AND
Airway obstruction or increased secretions.
Conditions
Suctioning
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Emergency tracheostomy reinsertion
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient with an existing tracheostomy
where the inner and/or outer
cannula(s) have been removed from
the airway AND
Respiratory distress AND
Inability to adequately ventilate
AND Paramedics are presented with
a tracheostomy cannula for the
identified patient.
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Contraindications
Suctioning
N/A
Emergency tracheostomy reinsertion
Inability to landmark or visualize
Treatment
Consider suctioning
Age < 1 year ≥ 1 year to < 12 years ≥ 12 years
Dose suction at
60-100 m
mHg
suction at
100-120 mmHg
suction at
100-150 mmHg
Max. single dose 10 seconds 10 seconds 10 seconds
Dosing interval 1 minute 1 minute 1 minute
Max. # of doses N/A N/A N/A
Consider emergency tracheostomy reinsertion
The maximum number of attempts is 2
Clinical Considerations
Suctioning:
Pre-oxygenate with 100% oxygen.
In an al
ert patient, whenever possible, have patient cough to clear airway prior to suctioning.
Emergen
cy tracheostomy reinsertion:
A reinsertion attempt is defined as the insertion of the cannula into the tracheostomy.
A new replacement inner or outer cannula is preferred over cleaning and reusing an existing one.
U
tilize a family member or caregiver who is available and knowledgeable to replace the
tracheostomy cannula.
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2
Appendix 2 – ACP Core Medical Directives
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Medical Cardiac Arrest Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Non-traumatic cardiac arrest.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
If not using manual
defibrillation
Epinephrine
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Anaphylaxis suspected as
causative event, IM route
may be used
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Amiodarone
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
Lidocaine
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
where amiodarone is not
available
0.9% NaCl Fluid Bolus
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other PEA
Any other rhythm where
hypovolemia is suspected
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
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AED Defibrillation
Non-shockable rhythm
Epinephrine
Allergy or sensitivity to epinephrine
Amiodarone
Allergy or sensitivity to amiodarone
Lidocaine
Allergy or sensitivity to lidocaine
Use/Availability of amiodarone
0.9% NaCl Fluid Bolus
Fluid overload
Treatment
Consider CPR
Consider supraglottic airway insertion: where more than OPA/NPA and BVM required and without
interrupting CPR
Consider Manual defibrillation
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Subsequent dose(s) 4 J/kg As per BH / manufacturer
Dosing interval 2 min 2 min
Max. # of doses N/A N/A
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Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Pediatric N/A N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval 2 min 2 min 2 min
Max. # of doses N/A N/A N/A
Consider epinephrine (if anaphylaxis is suspected as the
causative event of the cardiac arrest)
Route
IM
Concentration
1 mg/mL =
1:1,000
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval NA
Max. # of doses 1
*The epinephrine dose may be rounded to the nearest 0.05 mg
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Appendix 2 – ACP Core Medical Directives
Consider epinephrine
Age Age
≥30 days to <12years ≥12 years
Route Route
IV/IO/CVAD ETT IV/IO/CVAD ETT
Solution 0.1 mg/mL =
1:10,000
1 mg/mL =
1:1,000
0.1 mg/mL =
1:10,000
as per BH
Dose 0.01 mg/kg* 0.1 mg/kg to a
max of 2 mg
1 mg 2 mg
Min. single dose 0.1 mg 1 mg 1 mg 2 mg
Dosing interval 4 min 4 min 4 min 4 min
Max. # of doses N/A N/A N/A N/A
*The epinephrine dose may be rounded to the nearest 0.05 mg
Consider amiodarone
Age Age
≥30 days to <12 years ≥12 years
Route Route
IV/IO/CVAD IV/IO/CVAD
Initial dose 5 mg/kg 300 mg
Max. initial dose 300 mg 300 mg
Subsequent dose(s) 5 mg/kg 150 mg
Max. repeat dose 150 mg 150 mg
Dosing interval 4 min 4 min
Max. # of doses 2 2
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Consider lidocaine (if not using amiodarone)
Age Age
≥30 days to <12 years ≥12 years
Route Route
IV/IO/CVAD ETT IV/IO/CVAD ETT
Dose 1 mg/kg 2 mg/kg 1.5 mg/kg 3 mg/kg
Min. single dose N/A N/A N/A N/A
Dosing interval 4 min 4 min 4 min 4 min
Max. # of doses 2 2 2 2
Consider 0.9% NaCl fluid bolus
Age Age
≥30 days to <12 years ≥12 years
Route Route
IV/IO/CVAD IV/IO/CVAD
Infusion 20 ml/kg 20 ml/kg
Infusion interval Immediate Immediate
Reassess every 100 ml 250 ml
Max. volume 2,000 ml 2,000 ml
Consider intubation (if the airway is not being adequately managed)
Mandatory Provincial Patch Point
Patch to BHP following 3 rounds of epinephrine (or after 3
rd
analyses if no IV/IO/CVAD/ETT
access). If the BH patch fails, transport to the closest appropriate receiving facility following the 4
th
epinephrine administration (or 4
th
analysis if no IV/IO/CVAD/ETT access).
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Clinical Considerations
Consider very early transport after the 1
st
analysis (and defibrillation if indicated): in the following
settings pregnancy presumed to be ≥20 weeks gestation (fundus above umbilicus, ensure manual
displacement of uterus to left), hypothermia, airway obstruction, suspected pulmonary embolus,
medication overdose/toxicology, or other known reversible cause of arrest not addressed.
Similarly, plan for extrication and transport for patients with refractory ventricular fibrillation and
pedi
atric cardiac arrest (after 3 analyses), ensure quality CPR can be continued.
In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive.
There is no clear role for routine administration of naloxone in confirmed cardiac arrest.
Follow the Deceased Patient Standard once TOR has been implemented.
The IV and IO routes of medication administration are preferred over the ETT route. However, ETT
administration may be used if the IV/IO routes are delayed (e.g. ≥5 min).
If hyperkalemia is suspected as the causative event of the cardiac arrest, consider patching early for
calcium gluconate.
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Defibrillation Joule Settings
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Trauma Cardiac Arrest Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to severe blunt or penetrating trauma.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
If not using manual
defibrillation
Trauma TOR
Age ≥16 years
LOA Altered
HR 0
RR 0
SBP N/A
Other No palpable pulses AND
No defibrillation delivered
AND Monitored HR = 0
OR Monitored HR >0
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Trauma TOR
with the closest ED ≥30
min transport time away.
Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Trauma TOR
Age <16 years
Defibrillation delivered
Monitored HR >0 and closest ED <30
min transport time away
Treatment
Consider CPR
Consider Manual defibrillation
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Max. # of doses 1 1 1
Mandatory Provincial Patch Point
Patch to BHP for authorization to apply the Trauma TOR if applicable. If the BH patch fails, or the
Trauma TOR does not apply, transport to the closest appropriate receiving facility following the 1
st
analysis/defibrillation.
Clinical Considerations
If no obvious external signs of significant blunt trauma, consider medical cardiac arrest and treat
according to the appropriate medical cardiac arrest directive.
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VF or VT
Asystole or PEA (HR >0)
No
Yes (Rhythm=Asystole)
Yes (Rhythm=PEA)
No
Yes
No
Treatment – Algorithm For Trauma Arrest
Cardiac arrest secondary to severe
blunt or penetrating trauma
CPR (throughout duration of
call)
Apply defib pads to all
patients ≥30 days of age
Determine Rhythm Defibrillation x 1
Pt ≥16 years of age?
Patch
Drive time to closest
ED ≥30 min
TOR granted?
TOR implemented Transport to Emergency Department
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Hypothermia Cardiac Arrest Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to severe hypothermia.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
If not using manual
defibrillation
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Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Treatment
Consider CPR
Consider Manual defibrillation
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Atten
uator Cable
Without Pediatric
Attenuator Cable
N/A
D
ose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing Interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
Transport to the closest appropriate facility without delay following the 1
st
analysis.
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Foreign Body Airway Obstruction
Cardiac Arrest Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Cardiac arrest secondary to an airway obstruction.
Conditions
CPR
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Performed in 2 minute
intervals
Manual Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other VF OR pulseless VT
AED Defibrillation
Age ≥30 days
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Defibrillation indicated
If not using manual
defibrillation
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Contraindications
CPR
Obviously dead as per BLS PCS
Meet conditions of Do Not
Resuscitate
(DNR) Standard
Manual Defibrillation
Rhythms other than VF or pulseless
VT
AED Defibrillation
Non-shockable rhythm
Treatment
Consider CPR
Consider foreign body removal (utilizing BLS PCS maneuvers and/or laryngoscope and Magill
forceps)
Consider Manual defibrillation
Age Age
≥30 days to <8 years ≥8 years
Dose 1 defibrillation 1 defibrillation
Initial dose 2 J/kg As per BH / manufacturer
Dosing interval N/A N/A
Max. # of doses 1 1
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Consider AED defibrillation (if not using manual defibrillation)
Age Age
≥30 days to <8 years ≥8 years
With Pediatric
Attenuator Cable
Without Pediatric
Attenuator Cable
N/A
Dose 1 defibrillation 1 defibrillation 1 defibrillation
Max. single dose As per BH /
manufacturer
As per BH /
manufacturer
As per BH /
manufacturer
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
If the patient is in cardiac arrest following removal of the obstruction, initiate management as a
medical cardiac arrest.
If the obstruction cannot be removed, transport to the closest appropriate facility without delay
following the 1
st
analysis.
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Neonatal Resuscitation Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Neonatal patient.
Conditions
Resuscitation
Age <30 days of age
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Resuscitation
N/A
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Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
For 30 seconds:
1. Provide warmth;
2. Position/clear airway; and
3. Dry, stimulate, reposition
For 30 seconds:
1. Provide positive pressure ventilation (BVM/ETT) using room air
For 30 seconds:
1. Administer chest compressions; and
2. Provide positive pressure ventilation (BVM/ETT) using 100% oxygen
As long as HR < 60 bpm;
1. Continue chest compressions; and
2. Provide positive pressure ventilation (BVM/ETT) using 100% oxygen;
3. Administer epinephrine: 0.01 mg/kg (0.1 ml/kg) 1:10,000 IV/IO OR
0.1 mg/kg (1 ml/kg) 1:10,000 ETT q 4 minutes; and
4. Initiate transport prior to the 3
rd
dose if possible
Treatment
Targeted
Preductal SpO
2
(Right Hand)
1 mi n 60% - 65%
2 mi n 65% - 70%
3 mi n 70% - 75%
4 mi n 75% - 80%
5 mi n 80% - 85%
10 min 85% - 95%
Neonatal patient
Term gestation and
good muscle to ne and
breathing or crying?
Provide warmth;
clear airway as necessary
(do not routinely suction)
dry; and
ongoing evaluation
Supportive care
Evaluate respirations and heart
rate (consider use of SpO
2
and
cardiac monitoring)
Breath ing and
HR ≥100 bp m?
HR ≥60 bp m?
HR ≥60 bp m?
HR ≥60 bp m?
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Clinical Considerations
If neonatal resuscitation is required, initiate cardiac monitoring and pulse oximetry monitoring.
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Return of Spontaneous Circulation
(ROSC) Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient with return of spontaneous circulation (ROSC) after the resuscitation was initiated.
Conditions
0.9% NaCl Fluid Bolus
Age N/A
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other Chest auscultation is clear
DOPamine
Age ≥8 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other N/A
Contraindications
0.9% NaCl Fluid Bolus
Fluid overload
DOPamine
Allergy or sensitivity to dopamine
Tachydysrhythmias excluding sinus
tachycardia
Mechanical shock
Hypovolemia
Pheochromocytoma
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Treatment
Consider optimizing ventilation and oxygenation
Titrate oxygenation 94-98%
Avoid hyperventilation and target ETCO
2
to 30-40 mmHg with continuous waveform capnography
(if available)
Consider 0.9% NaCl fluid bolus
Age Age
<12 years ≥12 years
Route Route
IV/IO/CVAD IV/IO/CVAD
Infusion 10 ml/kg 10 ml/kg
Infusion interval Immediate Immediate
Reassess every 100 ml 250 ml
Max. volume 1,000 ml 1,000 ml
Consider DOPamine
Age
≥8 years
Route
IV
Initial infusion rate 5 mcg/kg/min
Titration increment 5 mcg/kg/min
Titration interval 5 min
Max. infusion rate 20 mcg/kg/min
NOTE: Titrate dopamine to achieve a SBP of ≥90 to <110 mmHg. If discontinuing dopamine
electively, do so gradually over 5-10 minutes.
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Consider 12-lead ECG acquisition and interpretation
Clinical Considerations
Consider initiating transport in parallel with the above treatment.
Adult IO administration of a NaCl bolus requires the ACP to be authorized.
Notify receiving hospital staff if DOPamine drip goes interstitial.
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Single Strength DOPamine Dosing Chart
DOPAMINE INFUSION RATE (ml/hr or drops/min with a microdrip set)
[Using an 800 mcg/ml ('single strength') solution]
Weight (kg)
Drip Rate (drops/min)
2
(mcg/kg/minute)
5
(mcg/kg/minute)
10
(mcg/kg/minute)
15
(mcg/kg/minute)
20
(mcg/kg/minute)
5 1 2 4 6 8
10 2 4 8 11 15
15 2 6 11 17 23
20 3 8 15 23 30
25 4 9 19 28 38
30 5 11 23 34 45
35 5 13 26 39 53
40 6 15 30 45 60
45 7 17 34 51 68
50 8 19 38 56 75
55 8 21 41 62 83
60 9 23 45 68 90
65 10 24 49 73 98
70 11 26 53 79 105
75 11 28 56 84 113
80 12 30 60 90 120
85 13 32 64 96 128
90 14 34 68 101 135
95 14 36 71 107 143
100 15 38 75 113 150
105 16 39 79 118 158
110 17 41 83 124 165
115 17 43 86 129 173
120 18 45 90 135 180
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Cardiac Ischemia Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected cardiac ischemia.
Conditions
ASA
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other Able to chew and swallow
Nitroglycerin
Age ≥18 years
LOA Unaltered
HR 60-159 bpm
RR N/A
SBP Normotension
Other Prior history of nitroglycerin
use OR IV access obtained
Morphine
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP Normotension
Other Severe pain
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Contraindications
ASA
Allergy or sensitivity to NSAIDs
If asthmatic, no prior use of ASA
Current active bleeding
CVA or T
BI in the previous 24 hours
Nitroglycerin
Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within the
previous
48 hours
SBP drops by one-third or more of its initial
value
after nitroglycerin is administered
12-lead ECG compatible with Right
Ventricular MI
Morphine
Allergy or sensitivity to morphine
SBP drops by one-third or more of its
initial value after morphine is
administered
Treatment
Consider ASA
Route
PO
Dose 160-162 mg
Max. single dose 162 mg
Dosing interval N/A
Max. # of doses 1
Consider 12-lead ECG acquisition and interpretation for STEMI
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Consider nitroglycerin
STEMI
No Yes
SBP SBP
≥100 mmHg ≥100 mmHg
Route Route
SL SL
Dose 0.3 mg OR 0.4 mg 0.3 mg OR 0.4 mg
Max. single dose 0.4 mg 0.4 mg
Dosing interval 5 min 5 min
Max. # of doses 6 3
Consider morphine (after the 3
rd
dose of nitroglycerin or if
nitroglycerin is contraindicated)
Route
IV
Dose 2 mg
Max. single dose 2 mg
Dosing interval 5 min
Max. # of doses 5
Clinical Considerations
Suspect a Right Ventricular MI in all inferior STEMIs and perform at minimum V4R to confirm (ST-
elevation ≥ 1mm in V4R).
Do not administer nitroglycerin to a patient with Right Ventricular STEMI.
Apply defibrillation pads when a STEMI is identified.
The goal for time to 12-lead ECG from first medical contact is < 10 minutes where possible.
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Acute Cardiogenic Pulmonary
Edema Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Moderate to severe respiratory distress;
AND
Suspected acute cardiogenic pulmonary edema.
Conditions
Nitroglycerin
Age ≥18 years
LOA N/A
HR 60-159 bpm
RR N/A
SBP Normotension
Other N/A
Contraindications
Nitroglyercin
Allergy or sensitivity to nitrates
Phosphodiesterase inhibitor use within
the previous 48 hours
SBP drops by one-third or more of its
initial value after nitroglycerin is
administered
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Treatment
Consider nitroglycerin
SBP SBP
≥100 mmHg to
<140 mmHg
≥140 mmHg
IV or Hx* IV or Hx* IV or Hx*
Yes No Yes
Route Route Route
SL SL SL
Dose 0.3 mg or 0.4 mg 0.3 mg or 0.4 mg 0.6 mg or 0.8 mg
Max. single dose 0.4 mg 0.4 mg 0.8 mg
Dosing interval 5 min 5min 5 min
Max. # of doses 6 6 6
*Hx refers to a patient with a prior history of nitroglycerin use
Consider 12-lead ECG acquisition and interpretation
Clinical Considerations
N/A
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Cardiogenic Shock Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
STEMI-positive 12-lead ECG;
AND
Cardiogenic shock.
Conditions
0.9% NaCl Fluid Bolus
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other Chest auscultation is clear
DOPamine
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other N/A
Contraindications
0.9% NaCl Fluid Bolus
Fluid overload
SBP ≥90 mmHg
DOPamine
Allergy or sensitivity to dopamine
Tachydysrhythmias excluding sinus
tachycardia
Mechanical shock
Hypovolemia
Pheochromocytoma
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Treatment
Consider 0.9% NaCl fluid bolus
Age
≥18 years
Route
IV/IO/CVAD
Infusion 10 ml/kg
Infusion interval N/A
Reassess every 250 ml
Max. volume 1,000 ml
NOTE: If NaCl bolus contraindicated due to pulmonary crackles, consider dopamine.
Consider DOPamine
Route
IV
Initial infusion rate 5 mcg/kg/min
Titration increment 5 mcg/kg/min
Titration interval 5 min
Max. infusion rate 20 mcg/kg/min
NOTE: Titrate dopamine to achieve a SBP of ≥90 to <110 mmHg. If discontinuing dopamine
electively, do so gradually over 5-10 minutes.
Clinical Considerations
Contact BHP if patient is bradycardic.
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Symptomatic Bradycardia Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Bradycardia;
AND
Hemodynamic instability.
Conditions
Atropine
Age ≥18 years
LOA N/A
HR <50 bpm
RR N/A
SBP Hypotension
Other N/A
Transcutaneous Pacing
Age ≥18 years
LOA N/A
HR <50 bpm
RR N/A
SBP Hypotension
Other N/A
DOPamine
Age ≥18 years
LOA N/A
HR <50 bpm
RR N/A
SBP Hypotension
Other N/A
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Contraindications
Atropine
Allergy or sensitivity to atropine
Hypothermia
History of heart transplant
Transcutaneous Pacing
Hypothermia
DOPamine
Allergy or sensitivity to dopamine
Mechanical shock
Pheochromocytoma
Treatment
Consider Rhythm determination
Consider 12-lead ECG acquisition and interpretation (if this won’t delay therapy)
Consider Atropine
Route
IV
Dose 1 mg
Max. single dose 1 mg
Dosing interval 5 min
Max. # of doses 2
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Consider transcutaneous pacing
Consider DOPamine
Route
IV
Initial infusion rate 5 mcg/kg/min
Titration increment 5 mcg/kg/min
Titration interval 5 min
Max. infusion rate 20 mcg/kg/min
NOTE: Titrate dopamine to achieve a SBP of ≥90 to <110 mmHg. If discontinuing dopamine
electively, do so gradually over 5-10 minutes.
Clinical Considerations
TCP should not be delayed for placement of an IV.
A fluid bolus should be considered with all symptomatic bradycardia patients if indicated.
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Tachydysrhythmia Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Symptomatic Tachydysrhythmia.
Conditions
Valsalva Maneuver
Age ≥18 years
LOA Unaltered
HR ≥150 bpm
RR N/A
SBP Normotension
Other Narrow complex and
regular rhythm
Adenosine
Age ≥18 years
LOA Unaltered
HR ≥150 bpm
RR N/A
SBP Normotension
Other Narrow complex and
regular rhythm
Amiodarone
Age ≥18 years
LOA Unaltered
HR ≥120 bpm
RR N/A
SBP Normotension
Other Wide complex and regular
rhythm
Lidocaine
Age ≥18 years
LOA Unaltered
HR ≥120 bpm
RR N/A
SBP Normotension
Other Wide complex and regular
rhythm
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Synchronized Cardioversion
Age ≥18 years
LOA N/A
HR ≥120 bpm (wide) OR
≥150 bpm (narrow)
RR N/A
SBP Hypotension
Other Altered mental status,
ongoing chest pain, other
signs of shock
Contraindications
Valsalva Maneuver
Sinus tachycardia or atrial fibrillation
or atrial flutter
Adenosine
Allergy or sensitivity to adenosine
Sinus tachycardia or atrial fibrillation
or atrial flutter
Patient taking dipyridamole or
carbamazepine
Bronchoconstriction on exam
Amiodarone
Allergy or sensitivity to amiodarone
Lidocaine
Allergy or sensitivity to lidocaine
Synchronized Cardioversion
N/A
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Treatment
Consider Rhythm determination (confirm regularity)
Consider 12-lead ECG acquisition and interpretation to confirm QRS width (if this won’t delay
therapy)
Consider valsalva maneuver
Perform a maximum of 2 attempts lasting 10 to 20 seconds duration each.
Consider adenosine
Route
IV
Initial dose 6 mg
Subsequent dose 12 mg
Dosing interval 2 min
Max. # of doses 2
Mandatory Provincial Patch Point
Patch to BHP for authorization to proceed with amiodarone or lidocaine or if monomorphic wide
complex regular rhythm for adenosine.
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Consider amiodarone (if available and authorized) OR lidocaine (if not using amiodarone)
Medication Medication
Amiodarone Lidocaine
Route Route
IV* IV
Initial dose 150 mg 1.5 mg/kg
Subsequent dose 150 mg 0.75 mg/kg
Max. single dose 150 mg 150 mg
Dosing interval 10 min 10 min
Max. # of doses 2 3
*Amiodarone should be administered by IV infusion over 10 min.
Mandatory Provincial Patch Point
Patch to BHP for authorization to proceed with synchronized cardioversion.
Consider synchronized cardioversion
Administer up to 3 synchronized shocks in accordance with BHP direction and energy settings. (In
the setting of a patch failure, the energy settings to be used are 100 J, 200 J and the maximum
manufacturer setting.)
Clinical Considerations
N/A
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Intravenous and Fluid Therapy
Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Actual or potential need for intravenous medication OR fluid therapy.
Conditions
IV Cannulation
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
0.9% NaCl Fluid Bolus
Age N/A
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other N/A
Contraindications
IV Cannulation
Suspected fracture proximal to the
access site
0.9% NaCl Fluid Bolus
Fluid overload
Treatment
Consider IV cannulation
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Consider 0.9% NaCl maintenance infusion
Age Age
<12 years ≥12 years
Route Route
IV/IO/CVAD IV/IO/CVAD
Infusion 15 ml/hr 30-60 ml/hr
Infusion interval N/A N/A
Reassess every N/A N/A
Max. volume N/A N/A
Mandatory Provincial Patch Point
Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive patients <12
years with suspected Diabetic Ketoacidosis (DKA).
Consider 0.9% NaCl fluid bolus
Age Age
<12 years ≥12 years
Route Route
IV/IO/CVAD IV/IO/CVAD
Infusion 20 ml/kg 20 ml/kg
Infusion interval Immediate Immediate
Reassess every 100 ml 250 ml
Max. volume* 2,000 ml 2,000 ml
*The maximum volume of 0.9% NaCl is lower for patients in cardiogenic shock and return of
spontaneous circulation.
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Clinical Considerations
Adult IO and CVAD procedures are auxiliary Medical Directives described elsewhere. Fluid
administration via the IO or CVAD routes only apply to paramedics authorized to perform these
procedures.
Microdrips and/or volume control administration sets should be considered when IV/CVAD access is
indicated for patients <12 years of age.
An intravenous fluid bolus may be considered for a patient who does not meet trauma TOR criteria,
where it does not delay transport and should not be prioritized over management of other reversible
causes.
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Pediatric Intraosseous Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Actual or potential need for intravenous medication OR fluid therapy;
AND
Intravenous access is unobtainable;
AND
Cardiac arrest or pre-arrest state.
Conditions
IO
Age <12 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
IO
Fracture or crush injuries proximal to
the access site
Suspected or known replacement /
prosthesis proximal to the access site
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Treatment
Consider IO access
Clinical Considerations
N/A
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Hypoglycemia Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected hypoglycemia
Conditions
Dextrose
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Hypoglycemia
Glucagon
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other Hypoglycemia
Contraindications
Dextrose
Allergy or sensitivity to dextrose
Glucagon
Allergy or sensitivity to glucagon
Pheochromocytoma
Treatment
Consider glucometry
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Consider dextrose (D50W diluted as required if not using D10W)
Age Age
<2 years ≥2 years
Concentration Concentration Concentration
10% dextrose 10% dextrose 50% dextrose
Route Route Route
IV IV IV
Dose 0.2 g/kg (2 ml/kg) 0.2 g/kg (2 ml/kg) 0.5 g/kg (1 ml/kg)
Max. single dose 5 g (50 ml) 25 g (250 ml) 25 g (50 ml)
Dosing interval 10 min 10 min 10 min
Max. # of doses 2 2 2
Titrate dextrose to a level of awareness where the patient can safely consume complex carbohydrate.
Consider glucagon (if not using dextrose)
Weight Weight
<25 kg ≥25 kg
Route Route
IM IM
Dose 0.5 mg 1 mg
Max. single dose 0.5 mg 1 mg
Dosing interval 20 min 20 min
Max. # of doses 2 2
Clinical Considerations
If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple
carbohydrates.
If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple
carbohydrates instead of dextrose or glucagon.
If a patient initiates an informed refusal of transport, a final set of vital signs including blood
glucometry must be attempted and documented.
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Seizure Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Active generalized motor seizure.
Conditions
Midazolam
Age N/A
LOA Unresponsive
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Midazolam
Allergy or sensitivity to midazolam
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Treatment
Consider midazolam
Route
IV / IO IM / IN / Buccal
Dose 0.1 mg/kg 0.2 mg/kg
Max. single dose 5 mg 10 mg
Dosing interval 5 min 5 min
Max. # of doses 2 2
Clinical Considerations
Conditions such as cardiac arrest and hypoglycemia often present as seizure and should be
considered by a paramedic.
Do not delay midazolam administration for blood glucometry in cases where hypoglycemia is not
thought to be the causative agent.
Blood glucose should be routinely checked in patients who do not respond to midazolam or have not
returned to their baseline LOA after a seizure.
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Opioid Toxicity Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Altered LOC;
AND
Respiratory depression;
AND
Inability to adequately ventilate; OR persistent need to assist ventilations;
AND
Suspected opioid overdose.
Conditions
Naloxone
Age ≥24 hours
LOA Altered
HR N/A
RR <10 breaths/min
SBP N/A
Other N/A
Contraindications
Naloxone
Allergy or sensitivity to naloxone
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Treatment
Consider naloxone
Route Route Route Route
IV/IO IM IN SC
Dose Up to 0.4 mg* 0.4mg 2-4 mg 0.8 mg
Max. single dose 0.4 mg 0.4mg 2-4 mg 0.8 mg
Dosing interval 5min 5 min 5 min 5 min
Max. # of doses 3 3 3 3
*For the IV route, titrate naloxone only to restore the patient’s respiratory status.
Clinical Considerations
Upfront aggressive management of the airway is paramount and the initial priority.
If no response to initial treatment; consider patching for further doses.
If the patient does not respond to airway management and the administration of naloxone,
glucometry should be considered.
Combative behaviour should be anticipated following naloxone administration and paramedics
should protect themselves accordingly, thus the importance of gradual titrating (if given IV) to
desired clinical effect: respiratory rate ≥10, adequate airway and ventilation, not full alertness
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Orotracheal Intubation Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Need for ventilatory assistance or airway control;
AND
Other airway management is ineffective.
Conditions
Liodcaine spray
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Orotracheal Intubation
Orotracheal Intubation
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Liodcaine spray
Allergy or sensitivity to lidocaine
Unresponsive patient
Orotracheal Intubation
Age <50 years
AND current episode of asthma
exacerbation
AND not in or near cardiac arrest.
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Treatment
Consider topical lidocaine spray (to the hypopharynx)
for orotracheal intubation when GCS is
Route
TOP
Dose 10 mg/spray
Max. dose 5 mg/kg
Dosing interval N/A
Max. # of doses 20
Consider orotracheal intubation
With or without intubation facilitation devices. The maximum number of intubation attempts is 2.
Confirm orotracheal tube placement
Method Method
Primary Secondary
ETCO
2
(Waveform capnography) ETCO
2
(Non-waveform device)
Visualization
Auscultation
Chest rise
Esophageal detection device
Clinical Considerations
An intubation attempt is defined as insertion of the laryngoscope blade into the mouth for the
purposes of intubation.
Confirmation of orotracheal intubation must use ETCO
2
(Waveform capnography). If waveform
capnography is not available or not working then at least 3 secondary methods must be used.
Additional secondary ETT placement confirmation devices may be authorized by the local medical
director.
ETT placement must be reconfirmed immediately after every patient movement.
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Bronchoconstriction Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Respiratory distress;
AND
Suspected bronchoconstriction.
Conditions
Salbutamol
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Epinephrine
Age N/A
Weight N/A
LOA N/A
HR N/A
RR BVM ventilation required
SBP N/A
Other Hx of asthma
Contraindications
Salbutamol
Allergy or sensitivity to salbutamol
Epinephrine
Allergy or sensitivity to epinephrine
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Treatment
Consider salbutamol
Weight Weight
<25 kg ≥25 kg
Route Route Route Route
MDI* NEB MDI* NEB
Dose Up to 600 mcg
(6 puffs)
2.5 m
g U
p to 800 mcg
(8 puffs)
5 mg
M
ax. single dose 600 mcg 2.5 mg 800 mcg 5 mg
Dosing interval 5-15 min PRN 5-15 min PRN 5-15 min PRN 5-15 min PRN
Max. # of doses 3 3 3 3
*1 puff=100 mcg
Consider epinephrine
Concentration
1 mg/mL = 1:1,000
Route
IM
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval N/A
Max. # of doses 1
*The epinephrine dose may be rounded to the nearest 0.05 mg
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Clinical Considerations
Epinephrine should be the 1
st
medication administered if the patient is apneic. Salbutamol MDI may
be administered subsequently using a BVM MDI adapter.
Nebulization is contraindicated in patients with a known or suspected fever or in the setting of a
dec
lared febrile respiratory illness outbreak by the local medical officer of health.
When administering salbutamol MDI, the rate of administration should be 100 mcg approximately
every 4 breaths.
A spacer should be used when administering salbutamol MDI.
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Moderate to Severe Allergic Reaction
Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Exposure to a probable allergen;
AND
Signs and/or symptoms of a moderate to severe allergic reaction (including anaphylaxis).
Conditions
Epinephrine
Age N/A
Weight N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other For anaphylaxis only
Diphenhydramine
Age N/A
Weight ≥25 kg
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Epinephrine
Allergy or sensitivity to epinephrine
Diphenhydramine
Allergy or sensitivity to
diphenhydramine
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Treatment
Consider epinephrine
Route
IM
Concentration
Dose 0.01 mg/kg*
Max. single dose 0.5 mg
Dosing interval Minimum 5 min
Max. # of doses 2
1 mg/mL = 1:1,000
*The epinephrine dose may be rounded to the nearest 0.05 mg
Consider diphenhydramine
Weight Weight
≥25 kg to <50 kg ≥50 kg
Route Route
IV/IM IV/IM
Dose 25 mg 50 mg
Max. single dose 25 mg 50 mg
Dosing interval N/A N/A
Max. # of doses 1 1
Clinical Considerations
Epinephrine administration takes priority over IV access.
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Croup Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Severe respiratory distress;
AND
Stridor at rest;
AND
Current history of URTI;
AND
Barking cough or recent history of a barking cough.
Conditions
Epinephrine
Age <8 years
LOA N/A
HR <200 bpm
RR N/A
SBP N/A
Other N/A
Contraindications
Epinephrine
Allergy or sensitivity to epinephrine
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Treatment
Consider epinephrine
Age Age
<1 year ≥1 year to <8 years
Weight Weight Weight
<5 kg ≥5 kg N/A
Concentration Concentration Concentration
1 mg/mL = 1:1,000 1 mg/mL = 1:1,000 1 mg/mL = 1:1,000
Route Route Route
NEB NEB NEB
Dose 0.5 mg 2.5 mg 5 mg
Max. single dose 0.5 mg 2.5 mg 5 mg
Dosing interval N/A N/A N/A
Max. # of doses 1 1 1
Clinical Considerations
The minimum initial volume for nebulization is 2.5 ml.
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Tension Pneumothorax Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected tension pneumothorax;
AND
Critically ill or VSA;
AND
Absent or severely diminished breath sounds on the affected side(s).
Conditions
Needle Thoracostomy
Age N/A
LOA N/A
HR N/A
RR N/A
SBP Hypotension or VSA
Other N/A
Contraindications
Needle Thoracostomy
N/A
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Treatment
Mandatory Provincial Patch Point
Patch to BHP for authorization to perform needle thoracostomy.
Consider needle thoracostomy
Clinical Considerations
Needle thoracostomy may only be performed at the 2
nd
intercostal space in the midclavicular line.
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Analgesia Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Pain
Conditions
Acetaminophen
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Ibuprofen
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Ketorolac
Age ≥12 years
LOA Unaltered
HR N/A
RR N/A
SBP Normotension
Other N/A
Morphine
Age ≥1 year
LOA Unaltered
HR N/A
RR N/A
SBP Normotension
Other N/A
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FentaNYL
Age ≥1 years
LOA Unaltered
HR N/A
RR N/A
SBP Normotension
Other N/A
Contraindications
Acetaminophen
Acetaminophen use within previous 4
hours
Allergy or sensitivity to
acetaminophen
Hx of liver disease
Active vomiting
Unable to tolerate oral medication
Suspected ischemic chest pain
Ibuprofen
NSAID use within previous 6 hours
Allergy or sensitivity to NSAIDs
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or
other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Active vomiting
Unable to tolerate oral medication
Suspected Ischemic chest pain
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Ketorolac
NSAID use within previous 6 hours
Allergy or sensitivity to NSAIDs
Patient on anticoagulation therapy
Current active bleeding
Hx of peptic ulcer disease or GI bleed
Pregnant
If asthmatic, no prior use of ASA or
other NSAIDs
CVA or TBI in the previous 24 hours
Known renal impairment
Suspected ischemic chest pain
Morphine
Allergy or sensitivity to morphine
Treatment of headache
Trea
tment of chronic pain
SBP drops by one-third or more of its
initial value after morphine is
administered
Suspected ischemic chest pain (refer
to Cardiac Ischemia Medical Directive
for suspected cardiac ischemia)
Active labour
FentaNYL
Allergy or sensitivity to fentaNYL
Treatment of headache
Treatment of chronic pain
SBP drops by one-third or more of its
initial value after fentaNYL is
administered
Suspected ischemic chest pain
Active labour
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Treatment
Consider acetaminophen
Age Age
≥12 years to <18 years ≥18 years
Route PO PO
Dose 500-650 mg 960-1,000 mg
Max. single dose 650 mg 1,000 mg
Dosing interval N/A N/A
Max. # of doses 1 1
Consider ibuprofen
Age
≥12 years
Route PO
Dose 400 mg
Max. single dose 400 mg
Dosing interval N/A
Max. # of doses 1
Consider ketorolac
Age
≥12 years
Route IM/IV
Dose 10-15 mg
Max. single dose 15 mg
Dosing interval N/A
Max. # of doses 1
Mandatory Provincial Patch Point
Patch to BHP for authorization and dosage verification before administering morphine or fentaNYL
for children < 12 years old.
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Consider morphine
Age Age
≥1 year to <18 years ≥18 years
Route IV/SC IV/SC
Dose 0.05-0.1 mg/kg 2 -10 mg
Max. single dose 5 mg 10 mg
Dosing interval 15 min 15 min
Max. # of doses N/A N/A
Max. cumulative dose 10 mg 20 mg
Consider fentaNYL (if available and authorized)
Age Age
≥1 year to <18 years ≥18 years
Route IV/IN IV/IN
Dose up to 1 mcg/kg 25 -75 mcg
Max. single dose 75 mcg 75 mcg
Dosing interval 5 min 5 min
Max. # of doses N/A N/A
Max cumulative dose 200 mcg 200 mcg
Clinical Considerations
Whenever possible, consider co-administration of acetaminophen and ibuprofen.
Suspected renal colic patients should routinely be considered for ibuprofen or ketorolac, and
morphine or fentaNYL.
Exercise caution when using narcotics in opioid naïve patients and patients ≥ 65 years old as they
may be more sensitive to dosages.
When higher doses of morphine (5-10 mg) or fentaNYL (50-75 mcg) are given intravenously,
consider administering medication in small aliquots q 3 minutes until desired effect or max. single
dose is reached to avoid nausea and vomiting.
FentaNYL should not be used in combination with morphine unless authorized by BHP.
The maximum volume of fentaNYL that may be administered IN is 1 mL per nare.
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Hyperkalemia Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Suspected hyperkalemia in patients at high risk, including:
Currently on dialysis; OR
History of end-stage renal disease; OR
Relevant incident history (i.e. prolonged crush injury)
AND
One of the following clinical situations:
Cardiac Arrest; OR
Pre-arrest with 12-lead ECG changes associated with Hyperkalemia.
Conditions
Calcium Gluconate 10%
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Salbutamol
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
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Contraindications
Calcium gluconate
N/A
Salbutamol
Allergy or sensitivity to salbutamol
Treatment
Consider 12-lead ECG acquisition and interpretation
Consider calcium gluconate 10%
Route
IV/IO/CVAD
Dose 1 g (10 ml) over 2-3 minutes
Max. single dose 1 g (10 ml)
Dosing interval 5 minutes
Max. # of doses 2*
*Note: an additional 3rd dose may be administered after 30 minutes if the patient improved initially
and symptoms meeting the indications recur.
Consider salbutamol
Route
MDI* NEB
Dose 1,600 mcg (16 puffs) 10 mg
Max. single dose 1,600 mcg 10 mg
Dosing interval Immediate Immediate
Max. # of doses 2 2
*1 puff=100 mcg
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Clinical Considerations
In the Indications, the pre-arrest patient would present with one or more of the following:
o hypotension;
o alter
ed levels of awareness; or
o symptomatic bradycardia.
12-lead changes suggestive of hyperkalemia are:
o wide and bizarre QRS complexes [≥120 ms];
o peaked T waves;
o loss of P waves; and/or
o a QRS complex with a “sine wave” appearance.
(12-lead acquisition is intended for the patient not in cardiac arrest to establish the QRS duration
before and after treatment.)
Whenever possible, both calcium gluconate and salbutamol should be administered as the 2
medications have different modes of action.
The action of calcium gluconate is often visible through the normalization of observed ECG changes
of hyperkalemia. If ECG changes do not improve, or if they worsen, additional doses may be
required. The duration of action is 20-60 minutes: consider repeat dosing if ECG changes recur
during extended transport times.
Caution that calcium gluconate should only be administered in an IV/IO/CVAD that is running well.
Calcium gluconate and sodium bicarbonate should not be mixed or administered in the same IV
without flushing well.
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Combative Patient Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Combative or violent or agitated behviour that requires sedation for patient safety.
Conditions
Midazolam
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP Normotension
Other No reversible causes (e.g.
hypoglycemia, hypoxia,
hypotension)
Ketamine
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP Normotension
Other Suspected excited delirium,
severe violent psychosis
No reversible causes (e.g.
hypoglycemia, hypoxia,
hypotension)
Contraindications
Midazolam
Allergy or sensitivity to midazolam
Ketamine
Allergy or sensitivity to ketamine
Known history of asthma
Known pregnancy
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Treatment
Mandatory Provincial Patch Point
Patch to BHP for authorization to proceed with midazolam or ketamine if unable to assess the patient
for normotension or reversible causes.
Consider midazolam
Age
≥18 years
Route IV/IM
Dose 2.5-5 mg
Max. single dose 5 mg
Dosing interval 5 min
Max. total dose 10 mg
Max. # of doses 2
Consider ketamine (if available and authorized)
Age Age
≥18 years to <65 years ≥65 years
Route IM IM
Dose 5 mg/kg 3 mg/kg
Max. single dose 500 mg 300 mg
Dosing interval N/A N/A
Max. # of doses 1 1
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Clinical Considerations
Do not co-administer midazolam and ketamine unless direction received from BHP.
If ketamine emergence reaction develops, a BH
P patch is required if further sedation orders are
required.
Consider obtaining IV access once patient has been sedated.
End tidal CO
2
monitoring is recommended once patient has been sedated
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Home Dialysis Emergency
Disconnect Medical Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient receiving home dialysis (hemo or peritoneal) and connected to dialysis machine and requires
transport to the closest appropriate receiving facility;
AND
Patient is unable to disconnect;
AND
There is no family member of caregiver who is available and knowledgeable in dialysis disconnect.
Conditions
Home Dialysis Emergency Disconnect
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Home Dialysis Emergency Disconnect
N/A
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Treatment
Consider Home Dialysis Emergency Disconnect
Clinical Considerations
Generally, an emergency disconnect kit with materials and instructions can be found hanging from
the dialysis machine or nearby on the wall.
Ensure both the patient side and machine side of the connection are clamped before disconnecting
and attaching end caps.
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Suspected Adrenal Crisis Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
A patient with primary adrenal failure who is experiencing clinical signs of an adrenal crisis.
Conditions
Hydrocortisone
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Paramedics are presented with a vial of hydrocortisone for
the identified patient AND
Age-related hypoglycemia OR
GI symptoms (vomiting, diarrhea, abdominal pain) OR
Syncope OR
Temperature ≥38C or suspected/history of fever OR
Altered level of awareness OR
Age-related tachycardia OR
Age-related hypotension
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Contraindications
Hydrocortisone
Allergy or sensitivity to
hydrocortisone
Treatment
Consider hydrocortisone
Route
IM/IV/IO/CVAD
Dose 2 mg/kg
Max. single dose 100 mg
Dosing interval N/A
Max. # of doses 1
*Dose should be rounded to the nearest 10 mg
Clinical Considerations
N/A
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Emergency Childbirth Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Pregnant patient experiencing labour; OR
Post-partum patient immediately following delivery.
Conditions
Delivery
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Second stage labour
and/or imminent birth
Umbilical Cord Management
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Cord complications OR if
neonatal or maternal
resuscitation is required
OR due to transport
considerations
External Uterine Massage
Age Childbearing years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Post-placental delivery
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Contraindications
Delivery
N/A
Umbilical Cord Management
N/A
External Uterine Massage
N/A
Yes
No
Yes
No
Yes
No
Yes
No
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Treatment
Consider delivery
Patient of childbearing years
experiencing second stage labour
and/or imminent birth
Position the patient supine on a
firm surface, with her head and
shoulders slightly elevated, legs
flexed and abducted at hips and
knees, feet flat and perineum
clearly visible.
Complicated
delivery?
For head-first delivery,
deliver the head in a
controlled fashion, allow
spontaneous head rotation,
and deliver the neonate’s
shoulders/body.
Assess maternal and neonatal patients,
consider further umbilical cord management,
delivery of placenta, and external uterine massage
Shoulder dystocia?
Attempt the McRoberts
Manoeuvre and apply
suprapubic pressure
Breech delivery?
‘Hands off’ until the body has been
born to the umbilicus. Allow the
head to deliver spontaneously, or
gently lift and hold the neonate
upwards and backwards while
avoiding hyperextension
If the head does not deliver
within approximately three
minutes of the body,
attempt the Mauriceau-
Smellie-Veit Manoeuver
Nuchal or
prolapsed cord?
Consider umbilical
cord management
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Consider umbilical cord management
If a cord prolapse is present, the fetal part should be elevated to relieve pressure on the cord. Assist
the patient into a knee-chest position or exaggerated Sims position, and insert gloved fingers/hand
into the vagina to apply manual digital pressure to the presenting part which is maintained until
transfer of care in hospital.
If a nuchal cord is present and loose, slip cord over the neonate’s head. Only if a nuchal cord is tight
and cannot be
slipped over the neonate’s head, clamp and cut the cord, encourage rapid delivery.
Following delivery of the neonate, the cord should be clamped and cut immediately if neonatal or
maternal resuscitation is required. Otherwise, after pulsations have ceased (approximately 2-3
minutes), clamp the cord in two places and cut the cord.
Consider external uterine massage
Clinical Considerations
If the patient presents with limb-presentation, do not attempt to push the limb back into the vagina;
discourage the patient from pushing, cover the limb using a dry sheet to maintain warmth, and
initiate transport as per the Load and Go Patient Standard of the BLS PCS.
If labour is failing to progress, discourage the patient from pushing or bearing down during
contractions.
If delivery has not occurred at scene within approximately ten minutes of initial assessment, consider
transport in conjunction with the following:
a. Patient assessment findings:
i. Lack of progression of labour;
ii. Multiple births expected;
iii. Neonate presents face-up;
iv. Pre-eclampsia;
v. Presence of vaginal hemorrhage;
vi. Premature labour;
vii. Primip;
b. Distance to the closest appropriate receiving facility.
When the placenta is delivered, inspect it for wholeness, place in a plastic bag from the OBS kit,
label it with the maternal patient’s name and time of delivery, and transport it with the maternal or
neonatal patient. Delivery of the placenta should not delay transport considerations/initiation.
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Endotracheal and Tracheostomy
Suctioning & Reinsertion Medical
Directive
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Patient with endotracheal or tracheostomy tube
AND
Airway obstruction or increased secretions.
Conditions
Suctioning
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Emergency tracheostomy reinsertion
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient with an existing tracheostomy
where the inner and/or outer
cannula(s) have been removed from
the airway AND
Respiratory distress AND
Inability to adequately ventilate
AND Paramedics are presented with
a tracheostomy cannula for the
identified patient.
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Contraindications
Suctioning
N/A
Emergency tracheostomy reinsertion
Inability to landmark or visualize
Treatment
Consider suctioning
Age < 1 year ≥ 1 year to < 12 years ≥ 12 years
Dose suction at
60-100 mmHg
suction at
100-120 mmHg
suction at
100-150 mmHg
Max. single dose 10 seconds 10 seconds 10 seconds
Dosing interval 1 minute 1 minute 1 minute
Max. # of doses N/A N/A N/A
Consider emergency tracheostomy reinsertion
The maximum number of attempts is 2
Clinical Considerations
Suctioning:
Pre-oxygenate with 100% oxygen.
In an ale
rt patient, whenever possible, have patient cough to clear airway prior to suctioning.
Emergency
Tracheostomy Reinsertion:
A reinsertion attempt is defined as the insertion of the cannula into the tracheostomy.
A new replacement inner or outer cannula is preferred over cleaning and reusing an existing one.
Utilize a family member or caregiver who is available and knowledgeable to replace the
tracheostomy cannula.
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Intravenous and Fluid Therapy
Medical Directive - AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized for PCP Autonomous IV.
Indications
Actual or potential need for intravenous medication OR fluid therapy.
Conditions
IV Cannulation
Age ≥2 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
0.9% NaCl Fluid Bolus
Age ≥2 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other N/A
Contraindications
IV Cannulation
Suspected fracture proximal to the
access site
0.9% NaCl Fluid Bolus
Fluid overload
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Treatment
Consider IV cannulation
Consider 0.9% NaCl maintenance infusion
Age Age
≥2 years to <12 years ≥12 years
Route Route
IV IV
Infusion 15 ml/hr 30-60 ml/hr
Infusion interval N/A N/A
Reassess every N/A N/A
Max. volume N/A N/A
Mandatory Provincial Patch Point
Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotensive patients ≥2 years
to <12 years with suspected Diabetic Ketoacidosis (DKA)
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Consider 0.9% NaCl fluid bolus
Age Age
≥2 years to <12 years ≥12 years
Route Route
IV IV
Infusion 20 ml/kg 20 ml/kg
Infusion interval N/A N/A
Reassess every 100 ml 250 ml
Max. volume* 2,000 ml 2,000 ml
*The maximum volume of NaCl is lower for patients in cardiogenic shock and return of spontaneous
circulation.
Clinical Considerations
“PCP Assist IV” authorizes a PCP to cannulate a peripheral IV at the request and under the direct
supervision of an ACP. The patient must require a peripheral IV in accordance with the indications
listed in this Medical Directive. PCPs authorized for PCP Assist IV are not authorized to administer
IV fluid or medication therapy.
Microdrips and/or volume control administration sets should be considered when IV access is
indicated for patients <12 years of age.
An intravenous fluid bolus may be considered for a patient who does not meet trauma TOR criteria,
where it does not delay transport and should not be prioritized over management of other reversible
causes.
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Cardiogenic Shock Medical Directive
– AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized for PCP Autonomous IV.
Indications
STEMI-positive 12-lead ECG;
AND
Cardiogenic shock.
Conditions
0.9% NaCl Fluid Bolus
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP Hypotension
Other Chest auscultation is clear
Contraindications
0.9% NaCl Fluid Bolus
Fluid overload
SBP ≥90 mmHg
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Treatment
Consider 0.9% NaCl fluid bolus
Age
≥18 years
Route
IV
Infusion 10 ml/kg
Infusion interval N/A
Reassess every 250 ml
Max. volume 1,000 ml
Clinical Considerations
N/A
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Continuous Positive Airway Pressure
(CPAP) Medical Directive –
AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Severe respiratory distress;
AND
Signs and /or symptoms of acute pulmonary edema or COPD.
Conditions
CPAP
Age ≥18 years
LOA N/A
HR N/A
RR Tachypnea
SBP Normotension
Other SpO
2
<90% or accessory muscle use
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Contraindications
CPAP
Asthma exacerbation
Suspected pneumothorax
Unprot
ected or unstable airway
Major trauma or burns to the head or torso
Tracheostomy
Inability to sit upright
Unable to cooperate
Treatment
Consider CPAP
Initial Setting 5 cm H
2
O Or equivalent flow rate of device as per BH direction
Titration increment 2.5 cm H
2
O Or equivalent flow rate of device as per BH direction
Titration interval 5 min
Max. setting 15 cm H
2
O Or equivalent flow rate of device as per BH direction
Consider increasing FiO
2
(if available)
Initial FiO
2
50-100%
FiO
2
increment (if available on
device)
SpO
2
<92% despite treatment and/or 10 cm H
2
O pressure or
equivalent flow rate of device as per BH direction
Max. FiO
2
100%
Confirm CPAP pressure by manometer (if available)
Clinical Considerations
N/A
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Supraglottic Airway Medical
Directive – AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Need for ventilatory assistance or airway control;
AND
Other airway management is ineffective.
Conditions
Supraglottic Airway
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient must be in cardiac
arrest
Contraindications
Supraglottic Airway
Active vomiting
Inability to clear the airway
Airway edema
Stridor
Caustic ingestion
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Treatment
Consider supraglotttic airway insertion
The maximum number of supraglottic airway insertion attempts is 2.
Confirm supraglotttic airway placement
Method Method
Primary Secondary
ETCO
2
(Waveform capnography) ETCO
2
(Non-waveform device)
Auscultation
Chest rise
Clinical Considerations
An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into
the mouth.
Confirmation of supraglottic airway must use ETCO
2
(Waveform capnography). If waveform
capnography is not available or is not working, then at least 2 secondary methods must be used.
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Nausea/Vomiting Medical Directive –
AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Nausea or vomiting.
Conditions
Dimenhydrinate
Age N/A
Weight ≥25 kg
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Dimenhydrinate
Allergy or sensitivity to
dimenhydrinate or other
antihistamines
Overdose on antihistamines or
anticholinergics or tricyclic
antidepressants
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Treatment
Consider dimenhydrinate
Weight Weight
≥25 kg to <50 kg ≥50 kg
Route Route Route Route
IV IM IV IM
Dose 25 mg 25 mg 50 mg 50 mg
Max. single dose 25 mg 25 mg 50 mg 50 mg
Dosing interval N/A N/A N/A N/A
Max. # of doses 1 1 1 1
Clinical Considerations
IV administration of dimenhydrinate applies only to PCPs authorized for PCP Autonomous IV.
Prior to IV administration, dilute dimenhydrinate (concentration of 50 mg/1 ml) 1:9 with Normal
Saline or sterile water. If administered IM do not dilute.
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Electronic Control Device Probe
Removal Medical Directive –
AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Electronic Control Device probe(s) embedded in patient.
Conditions
Probe Removal
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Probe Removal
Probe embedded above the clavicles,
in the nipple(s), or in the genital area
Treatment
Consider probe removal
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Clinical Considerations
Police may require preservation of the probe(s) for evidentiary purposes.
This directive is for removal of ECD only and in no way constitutes treat and release, normal
principles of patient assessment and care apply.
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Assessment of Patients with
Possible COVID-19 Medical Directive
– AUXILIARY
A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Confirmed COVID-19 or suspected COVID-19 with mild acute respiratory illness characterized by a
combination of 2 or more of the following: fever, new onset of cough, worsening chronic cough,
shortness of breath or difficulty breathing, sore throat, runny nose/nasal congestion (without any
known cause).
AND
The crisis is straining the resources of the host community
Conditions
Patient disposition
Age ≥ 18 years to < 65 years
LOA unaltered
HR < 110 bpm
RR < 22 breaths/min
SBP normotension
Other CTAS 3, 4 or 5
SpO
2
≥ 94%.
If temperature ≥ 38° C,
does not appear
septic/unwell
Nasopharyngeal OR nasal OR pharyngeal swab
Age ≥ 18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient is being released from care
AND
Meets COVID-19 testing criteria OR
as requested by local Public Health
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Contraindications
Patient disposition
Patient and/or substitute decision maker
(SDM) cannot demonstrate decision-
making capacity based on the Aid to
Capacity Evaluation Tool
Pregnancy
Nasopharyngeal OR nasal OR pharyngeal swab
Recent significant facial trauma (all)
Current epistaxis OR
significant abnormality of the nasal anatomy
(nasopharyngeal or nasal swab)
Significant abnormality of the oral anatomy
(pharyngeal swab)
Treatment
Mandatory Provincial Patch Point
Patch to BHP for authorization to consider release from care
Consider patient disposition* (if authorized)
*Assess for safety to remain at home including clinical criteria above, and the following: patient is unaltered, the
patient can self-isolate, the patient has access to food, phone, and other necessities, and appropriate caregivers
are available (if needed).
Tr
ansport to closest most
appropriate emergency department
Consider release from care
(following BHP patch)
CTAS 1 & 2
3 with comorbidity or
immunocompromise
3 with mild or no respiratory distress
(without comorbidity/immunocompromise)
4 & 5 without immunocompromise
Prior to a release from care, the patient and/or SDM must be provided with contact information for their Local
Public Health Unit, education on self-isolation and symptom management, and information for accessing
assessment centres. Paramedics must document these instructions and patient and/or SDM consent to the plan
of care in the remarks section of the Ambulance Call Report. Advise the patient that if the problem persists or
worsens they should seek further medical attention.
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Consider obtaining nasopharyngeal OR nasal OR pharyngeal swab (if available and authorized)
If swab obtained, complete the lab requisition and transport the specimen as per local arrangement.
Clinical Considerations
Base Hospital Physician Patch:
When a patch is made to the BHP, the Paramedic will provide the following: patient’s COVID-19
screening result, history of illness and symptoms, all past medical history, vital signs, and assessment
findings, in addition to patient and/or SDM’s wishes, and follow-up plans (if known).
Immunocompromised definition:
Patient or caregiver states immunocompromised, cancer treatment within past 6 weeks, HIV/AIDS,
organ transplant patient, substance-use disorder, and any immunosuppressive medications.
Comorbidity definition:
Hypertension, cardiovascular disease, cerebrovascular disease, diabetes, chronic lung disease,
chronic kidney disease, immunocompromised.
Mild Respiratory Distress definition:
Patient may report dyspnea on exertion, but there is mild or no increased work of breathing, patient
able to speak in sentences, and RR < 22 breaths/min AND SpO
2
≥ 94%.
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Minor Abrasions Medical Directive –
AUXILIARY- SPECIAL EVENT
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Minor abrasions;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Topical Antibiotic
Age N/A
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Topical Antibiotic
Allergy or sensitivity to any of the
components of the topical antibiotic
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Treatment
Consider topical antibiotic
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
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Minor Allergic Reaction Medical
Directive – AUXILIARY - SPECIAL
EVENT
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Signs consistent with a minor allergic reaction;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Diphenhydramine
Age ≥18 years
LOA Unaltered
HR WNL
RR WNL
SBP Normotension
Other N/A
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Contraindications
Diphenhydramine
Allergy or sensitivity to
diphenhydramine
Antihistamine or sedative use in
previous 4 hours
Signs or symptoms of moderate to
severe allergic reaction
Signs or symptoms of intoxication
Wheezing
Treatment
Consider diphenhydramine
Route
PO
Dose 50 mg
Max. single dose 50 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
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Musculoskeletal Pain Medical
Directive – AUXILIARY - SPECIAL
EVENT
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Minor musculoskeletal pain;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Acetaminophen
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
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Contraindications
Acetaminophen
Acetaminophen use within previous 4
hours
Allergy or sensitivity to
acetaminophen
Signs or symptoms of intoxication
Treatment
Consider acetaminophen
Route
PO
Dose 325-650 mg
Max. single dose 650 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
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Headache Medical Directive –
AUXILIARY - SPECIAL EVENT
A Primary Care Paramedic may provide the treatment prescribed in this auxiliary Medical Directive
if authorized.
Indications
Uncomplicated headache conforming to the patient’s usual pattern;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Acetaminophen
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Acetaminophen
Acetaminophen use within previous 4
hours
Allergy or sensitivity to
acetaminophen
Signs or symptoms of intoxication
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Treatment
Consider acetaminophen
Route
PO
Dose 325-650 mg
Max. single dose 650 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
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Adult Intraosseous Medical Directive
- AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Actual or potential need for intravenous medication OR fluid therapy;
AND
IV access is unobtainable;
AND
Cardia
c arrest or pre-arrest state.
Conditions
IO
Age ≥12 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
IO
Fracture or crush injuries proximal to
the access site.
Suspected or known replacement /
prostheses immediately proximal to
the access site
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Treatment
Consider IO access
Clinical Considerations
N/A
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Central Venous Access Device
Access Medical Directive –
AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Actual or potential need for intravenous medication OR fluid therapy;
AND
IV access is unobtainable;
AND
Cardiac arrest or near arrest state.
Conditions
CVAD Access
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient has a pre-existing
accessible central venous
catheter in place
Contraindications
CVAD Access
N/A
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Treatment
Consider CVAD access
Clinical Considerations
N/A
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Nasotracheal Intubation Medical
Directive – AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Need for ventilatory assistance or airway control;
AND
Other airway management is ineffective.
Conditions
Xylometazoline
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Lidocaine Spray
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Gag reflex
Nasotracheal Intubation
Age ≥8 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Spontaneous Breathing
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Contraindications
Xylometazoline
Allergy or sensitivity to
xylometazoline
Lidocaine Spray
Allergy or sensitivity to lidocaine
spray
Unresponsive patient
Nasotracheal Intubation
Age <50 years AND current episode
of asthma exacerbation AND not in or
near cardiac arrest.
Suspected basal skull fracture or mid-
face fracture
Uncontrolled epistaxis
Anticoagulant therapy (excluding
ASA)
Bleeding disorders
Treatment
Consider xylometazoline 0.1% spray
Route
TOP
Dose 2 sprays/nare
Max. single dose 2 sprays/nare
Dosing interval N/A
Max. # of doses 1
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Consider topical lidocaine spray (to the nares and/or
hypopharynx)
Route
TOP
Dose 10 mg/spray
Max. single dose 5 mg/kg
Dosing interval N/A
Max. # of doses 20 sprays
Consider nasotracheal intubation
The maximum number of intubation attempts is 2.
Confirm nasotracheal tube placement
Method Method
Primary Secondary
ETCO
2
(Waveform capnography) ETCO
2
(Non-waveform device)
Auscultation
Esophageal detection device
Chest rise
Clinical Considerations
A nasotracheal intubation attempt is defined as insertion of the nasotracheal tube into a nare.
Confirmation of nasotracheal placement must use ETCO
2
(Waveform capnography). If wave-form
capnography not available or not working, then at least 2 secondary methods must be used.
ETT placement must be reconfirmed immediately after every patient movement.
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Continuous Positive Airway Pressure
(CPAP) Medical Directive –
AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Severe respiratory distress;
AND
Signs and /or symptoms of acute pulmonary edema or COPD.
Conditions
CPAP
Age ≥18 years
LOA N/A
HR N/A
RR Tachypnea
SBP Normotension
Other SpO
2
<90% or accessory
muscle use
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Contraindications
CPAP
Asthma exacerbation
Suspected pneumothorax
Unprotected or unstable airway
Major trauma or burns to the head or
torso
Tracheostomy
Inability to sit upright
Unable to cooperate
Treatment
Consider CPAP
Initial Setting
5 cm H
2
O
Or equivalent flow rate of device as
per BH direction
Titration increment
2.5 cm H
2
O
Or equivalent flow rate of device as
per BH direction
Titration interval 5 min
Max. setting
15 cm H
2
O
Or equivalent flow rate of device as
per BH direction
Consider increasing FiO
2
(if available)
Initial FiO
2
50-100%
FiO
2
increment (if
available on device)
SpO
2
<92% despite treatment and/or
10 cm H
2
O pressure or equivalent
flow rate of device as per BH
direction
Max. FiO
2
100%
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Confirm CPAP pressure by manometer (if available)
Clinical Considerations
N/A
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Supraglottic Airway Medical
Directive – AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Need for ventilatory assistance or airway control;
AND
Other airway management is ineffective.
Conditions
Supraglottic Airway
Age N/A
LOA GCS = 3
HR N/A
RR N/A
SBP N/A
Other Absent gag reflex
Contraindications
Supraglottic Airway
Active vomiting
Inability to clear the airway
Airway edema
Stridor
Caustic ingestion
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Treatment
Consider supraglotttic airway insertion
The maximum number of supraglottic airway insertion attempts is 2.
Confirm supraglottic airway placement
Method Method
Primary Secondary
ETCO
2
(Waveform capnography)
ETCO
2
(Non-waveform device)
Auscultation
Chest rise
Clinical Considerations
An attempt at supraglottic airway insertion is defined as the insertion of the supraglottic airway into
the mouth.
Confirmation of supraglottic airway must use ETCO
2
(Waveform capnography). If waveform
capnography is not available or is not working, then at least 2 secondary methods must be used.
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Cricothyrotomy Medical Directive –
AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Need for advanced airway management;
AND
Intubation AND supraglottic airway insertion unsuccessful or contraindicated;
AND
Unable to ventilate.
Conditions
Cricothyrotomy
Age ≥12 years
LOA Altered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Cricothyrotomy
Suspected fractured larynx
Inability to landmark
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Treatment
Consider cricothyrotomy
Consider cricothyrotomy tube placement
Method Method
Primary Secondary
ETCO
2
(Waveform capnography) ETCO
2
(Non-waveform device)
Auscultation
Chest rise
Clinical Considerations
Confirmation of cricothyrotomy must use ETCO
2
(Waveform capnography). If waveform
capnography is not available or not working, then at least 2 secondary methods must be used.
Additional secondary Cricothyrotomy tube placement confirmation devices may be authorized by the
local medical director.
Cricothyrotomy tube placement must be reconfirmed immediately after every patient movement.
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Nausea/Vomiting Medical Directive –
AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Nausea or vomiting.
Conditions
Dimenhydrinate
Age N/A
Weight ≥25 kg
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Dimenhydrinate
Allergy or sensitivity to
dimenhydrinate or other
antihistamines
Overdose on antihistamines or
anticholinergics or tricyclic
antidepressants
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Advanced Life Support Patient Care Standards – Version 4.8 196
Appendix 4 – ACP Auxiliary Medical Directives
Treatment
Consider dimenhydrinate
Weight Weight
≥25 kg to <50 kg ≥50 kg
Route Route Route Route
IV IM IV IM
Dose 25 mg 25 mg 50 mg 50 mg
Max. single dose 25 mg 25 mg 50 mg 50 mg
Dosing interval N/A N/A N/A N/A
Max. # of doses 1 1 1 1
Clinical Considerations
Prior to IV administration, dilute dimenhydrinate (concentration of 50 mg/1 ml) 1:9 with Normal
Saline or sterile water. If administered IM do not dilute.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 197
Appendix 4 – ACP Auxiliary Medical Directives
Procedural Sedation Medical
Directive – AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Post-intubation; OR
Transcutaneous pacing.
Conditions
Midazolam
Age ≥18 years
LOA N/A
HR N/A
RR ≥10/min*
SBP Normotension
Other N/A
*Non-intubated patients only
Contraindications
Midazolam
Allergy or sensitivity to midazolam
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 198
Appendix 4 – ACP Auxiliary Medical Directives
Treatment
Consider midazolam
Route
IV
Dose 2.5-5 mg
Max. single dose 5 mg
Dosing interval 5 min
Max. total dose 10 mg
Max. # of doses 2
Clinical Considerations
N/A
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 199
Appendix 4 – ACP Auxiliary Medical Directives
Electronic Control Device Probe
Removal Medical Directive –
AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Electronic Control Device probe(s) embedded in patient.
Conditions
Probe Removal
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Probe Removal
Probe embedded above the clavicles,
in the nipple(s), or in the genital area
Treatment
Consider probe removal
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 200
Appendix 4 – ACP Auxiliary Medical Directives
Clinical Considerations
Police may require preservation of the probe(s) for evidentiary purposes.
This directive is for removal of ECD only and in no way constitutes treat and release, normal
pri
nciples of patient assessment and care apply.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 201
Appendix 4 – ACP Auxiliary Medical Directives
Assessment of Patients with
Possible COVID-19 Medical Directive
– AUXILIARY
An Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if
authorized.
Indications
Confirmed COVID-19 or suspected COVID-19 with mild acute respiratory illness characterized by a
combination of 2 or more of the following: fever, new onset of cough, worsening chronic cough,
shortness of breath or difficulty breathing, sore throat, runny nose/nasal congestion (without any
known cause).
AND
The crisis is straining the resources of the host community
Conditions
Patient disposition
Age ≥ 18 years to < 65 years
LOA unaltered
HR < 110 bpm
RR < 22 breaths/min
SBP normotension
Other CTAS 3, 4 or 5
SpO
2
≥ 94%.
If temperature ≥ 38° C,
does not appear
septic/unwell
Nasopharyngeal OR nasal OR pharyngeal swab
Age ≥ 18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Patient is being released from care
AND
Meets COVID-19 testing criteria OR
as requested by local Public Health
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 202
Appendix 4 – ACP Auxiliary Medical Directives
Contraindications
Patient disposition
Patient and/or substitute decision maker
(SDM) cannot demonstrate decision-
making capacity based on the Aid to
Capacity Evaluation Tool
Pregnancy
Nasopharyngeal OR nasal OR pharyngeal swab
Recent significant facial trauma (all)
Current epistaxis OR
significant abnormality of the nasal anatomy
(nasopharyngeal or nasal swab)
Significant abnormality of the oral anatomy
(pharyngeal swab)
Treatment
Mandatory Provincial Patch Point
Patch to BHP for authorization to consider release from care
Consider patient disposition* (if authorized)
*Assess for safety to remain at home including clinical criteria above, and the following: patient is
unaltered, the patient can self-isolate, the patient has access to food, phone, and other necessities,
and appropriate caregivers are available (if needed).
Transport to closest most
appropriate emergency department
Consider release from care
(following BHP patch)
CTAS 1 & 2
3 with comorbidity or
immunocompromise
3 with mild or no respiratory distress
(without comorbidity/immunocompromise)
4 & 5 without immunocompromise
Prior to a release from care, the patient and/or SDM must be provided with contact information for
their Local Public Health Unit, education on self-isolation and symptom management, and
information for accessing assessment centres. Paramedics must document these instructions and
patient and/or SDM consent to the plan of care in the remarks section of the Ambulance Call
Report. Advise the patient that if the problem persists or worsens they should seek further medical
attention.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 203
Appendix 4 – ACP Auxiliary Medical Directives
Consider obtaining nasopharyngeal OR nasal OR pharyngeal swab (if available and authorized)
If swab obtained, complete the lab requisition and transport the specimen as per local arrangement.
Clinical Considerations
Base Hospital Physician Patch:
When a patch is made to the BHP, the Paramedic will provide the following: patient’s COVID-19
screening result, history of illness and symptoms, all past medical history, vital signs, and assessment
findings, in addition to patient and/or SDM’s wishes, and follow-up plans (if known).
Immunocompromised definition:
Patient or caregiver states immunocompromised, cancer treatment within past 6 weeks, HIV/AIDS,
organ transplant patient, substance-use disorder, and any immunosuppressive medications.
Comorbidity definition:
Hypertension, cardiovascular disease, cerebrovascular disease, diabetes, chronic lung disease,
chronic kidney disease, immunocompromised.
Mild Respiratory Distress definition:
Patient may report dyspnea on exertion, but there is mild or no increased work of breathing, patient
able to speak in sentences, and RR < 22 breaths/min AND SpO
2
≥ 94%.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 204
Appendix 4 – ACP Auxiliary Medical Directives
Minor Abrasions Medical Directive –
AUXILIARY- SPECIAL EVENT
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Minor abrasions;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Topical Antibiotic
Age N/A
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Topical Antibiotic
Allergy or sensitivity to any of the
components of the topical antibiotic
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 205
Appendix 4 – ACP Auxiliary Medical Directives
Treatment
Consider topical antibiotic
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 206
Appendix 4 – ACP Auxiliary Medical Directives
Minor Allergic Reaction Medical
Directive – AUXILIARY - SPECIAL
EVENT
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Signs consistent with minor allergic reaction;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Diphenhydramine
Age ≥18 years
LOA Unaltered
HR WNL
RR WNL
SBP Normotension
Other N/A
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 207
Appendix 4 – ACP Auxiliary Medical Directives
Contraindications
Diphenhydramine
Allergy or sensitivity to
diphenhydramine
Antihistamine or sedative use in
previous 4 hours
Signs or symptoms of moderate to
severe allergic reaction
Signs or symptoms of intoxication
Wheezing
Treatment
Consider diphenhydramine
Route
PO
Dose 50 mg
Max. single dose 50 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 208
Appendix 4 – ACP Auxiliary Medical Directives
Musculoskeletal Pain Medical
Directive – AUXILIARY - SPECIAL
EVENT
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Minor musculoskeletal pain;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Acetaminophen
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Acetaminophen
Acetaminophen use within previous 4 hours
Allergy or sensitivity to acetaminophen
Signs or symptoms of intoxication
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 209
Appendix 4 – ACP Auxiliary Medical Directives
Treatment
Consider acetaminophen
Route
PO
Dose 325-650 mg
Max. single dose 650 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 210
Appendix 4 – ACP Auxiliary Medical Directives
Headache Medical Directive –
AUXILIARY - SPECIAL EVENT
An Advanced Care Paramedic may provide the treatment prescribed in this auxiliary Medical
Directive if authorized.
Indications
Uncomplicated headache conforming to the patient’s usual pattern;
AND
Special event: a preplanned gathering with potentially large numbers of people and the Special Event
Medical Directives have been preauthorized for use by the Medical Director.
Conditions
Acetaminophen
Age ≥18 years
LOA Unaltered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Acetaminophen
Acetaminophen use within previous 4
hours
Allergy or sensitivity to
acetaminophen
Signs or symptoms of intoxication
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 211
Appendix 4 – ACP Auxiliary Medical Directives
Treatment
Consider acetaminophen
Route
PO
Dose 325-650 mg
Max. single dose 650 mg
Dosing interval N/A
Max. # of doses 1
Consider release from care
Clinical Considerations
Advise patient that if the problem persists or worsens that they should seek further medical attention.
Appendix 5 – Chemical Exposure Medical
Directives
5
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 213
Appendix 5 – Chemical Exposure Medical Directives
Chemical Exposure Medical
Directives
Introduction
The following Medical Directives have been developed for use when chemical exposure to the listed
agent is suspected. These Medical Directives may only be used by paramedics who have received
special training in treating patients with chemical exposures. This is usually a comprehensive
program that includes personal protection and training in CBRNE (Chemical, Biologic, Radiological,
Nuclear and Explosive) events.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 214
Appendix 5 – Chemical Exposure Medical Directives
Hydrofluoric (HF) Acid Exposure
Medical Directive
A Paramedic may provide the treatment prescribed in this Medical Directive if authorized.
Indications
Exposure to vapour and/or liquid hydrofluoric acid (HF);
AND
Exhibits signs and symptoms of HF poisoning.
Conditions
Calcium Gluconate
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Topical Anaesthetic Eye Drops
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Calcium Gluconate
Allergy or sensitivity to Calcium
Gluconate
Topical Anaesthetic Eye Drops
Allergy or sensitivity to local
anaesthetics
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 215
Appendix 5 – Chemical Exposure Medical Directives
Treatment
Consider calcium gluconate
Inhalation exposure Skin exposure
Concentration Concentration
10% solution 2.5% gel
Route Route
NEB TOP
Dose 100 mg N/A
Max Single Dose 100 mg N/A
Dosing Interval N/A Immediate
Max # of doses 1 N/A
Consider topical anaesthetic eye drops
Eye exposure
Route
TOP
Dose 2 gtts/eye
Max Single Dose 2 gtts/eye
Dosing Interval 10 min
Max # of doses N/A
Clinical Considerations
For skin contact, ensure thorough irrigation prior to treatment.
For eye exposure remove patient`s contact lenses, if applicable, prior to initiating treatment. Use
anaesthetic eye drops for comfort and then irrigate eyes with normal saline for at least 15 minutes.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 216
Appendix 5 – Chemical Exposure Medical Directives
Adult Nerve Agent Exposure Medical
Directive
A Paramedic may provide the treatment prescribed in this Medical Directive if authorized.
Indications
Exposure to a known or suspected nerve agent;
AND
Signs and symptoms of a cholinergic crisis.
Conditions
Atropine
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Moderate Exposure
A
ny one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath or any
known liquid exposure
Severe Exposure
S
igns and symptoms of a
moderate exposure and
any one of the following:
decreased LOA, paralysis,
seizure or apnea
Pralidoxime
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath or any
known liquid exposure
Severe Exposure
S
igns and symptoms of a
moderate exposure and
any one of the following:
decreased LOA, paralysis,
seizure or apnea
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 217
Appendix 5 – Chemical Exposure Medical Directives
Obidoxime
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath or any
known liquid exposure
Severe Exposure
Signs and symptoms of a
moderate exposure and
any one of the following:
decreased LOA, paralysis,
seizure or apnea
Diazepam
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath or any
known liquid exposure
Severe Exposure
Signs and symptoms of a
moderate exposure and
any one of the following:
decreased LOA, paralysis,
seizure or apnea
Contraindications
Atropine
Allergy or sensitivity to atropine
Pralidoxime
Allergy or sensitivity to pralidoxime
Obidoxime
Allergy or sensitivity to obidoxime
Diazepam
Allergy or sensitivity to diazepam
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 218
Appendix 5 – Chemical Exposure Medical Directives
Treatment
Consider Atropine
Moderate
Ex
posure
Severe
Exposure
Moderate
Exposure
Severe
Exposure
Moderate
Exposure
Severe
Exposure
Route Route Route Route Route Route
IM IM
Auto-
injector
Auto-
injector
IV
(ACP only)
IV
(ACP only)
Initial Dose 2 mg 6 mg 2.1 mg 6.3 mg 2 mg 6 mg
Subsequent
doses
2 mg 2 mg 2.1 mg 2.2 mg 2 mg 2 mg
Dosing
interval
5 min. 5 min. 5 min. 5 min. 5 min. 5 min.
Max # of
doses
N/A N/A N/A N/A N/A N/A
Consider Pralidoxime
Moderate
Exposure
Severe
Exposure
Moderate
Exposure
Severe
Exposure
Route Route Route Route
IM IM Autoinjector Autoinjector
Dose
600 mg 1,800 mg 600 mg 1,800 mg
Max. single dose
600 mg 1,800 mg 600 mg 1,800 mg
Dosing interval
N/A N/A N/A N/A
Max # of doses
1 1 1 1
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 219
Appendix 5 – Chemical Exposure Medical Directives
Consider Obidoxime (if not using pralidoxime)
Moderate
Exposure
Severe
Exposure
Moderate
Exposure
Severe
Exposure
Route Route Route Route
IM IM Autoinjector Autoinjector
Dose
150 mg 450 mg 150 mg 450 mg
Max. single dose
150 mg 450 mg 150 mg 450 mg
Dosing interval
N/A N/A N/A N/A
Max # of doses
1 1 1 1
Consider Diazepam
Moderate Exposure Severe Exposure
Route Route
IM Autoinjector
Dose
10 mg 10 mg
Max. single dose
10 mg 10 mg
Dosing interval
N/A N/A
Max # of doses
1 1
Clinical Considerations
Only one of pralidoxime or obidoxime should be administered.
Administration of IV medications applies to ACPs only.
Do not delay IM administration if IV access is not already established.
Atropine should be administered prior to airway interventions if secretions are copious.
Subsequent doses of atropine are intended for patients showing signs of bronchial secretions and may
be repeated as indicated until airway secretions are controlled.
Decontamination procedures must be integrated with antidote administration.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 220
Appendix 5 – Chemical Exposure Medical Directives
Pediatric Nerve Agent Exposure
Medical Directive
A Paramedic may provide the treatment prescribed in this Medical Directive if authorized.
Indications
Exposure to a known or suspected nerve agent.
Conditions
Atropine
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Any one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath,
decreased LOC, paralysis,
seizure, apnea or any
known liquid exposure
Diazepam
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Any one of the following:
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath,
decreased LOC, paralysis,
seizure, apnea or any
known liquid exposure
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 221
Appendix 5 – Chemical Exposure Medical Directives
Pralidoxime
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Any one of the following;
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath,
decreased LOC, paralysis,
seizure, apnea or any
known liquid exposure
Obidoxime
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic
crisis
Any one of the following;
vomiting, diarrhea,
bronchospasm or
bronchial secretions,
shortness of breath,
decreased LOC, paralysis,
seizure, apnea or any
known liquid exposure
Contraindications
Atropine
Allergy or sensitivity to atropine
Diazepam
Allergy or sensitivity to diazepam
Pralidoxime
Allergy or sensitivity to pralidoxime
Obidoxime
Allergy or sensitivity to obidoxime
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 222
Appendix 5 – Chemical Exposure Medical Directives
Treatment
Consider Atropine
Weight Weight Weight Weight
<10 kg <10 kg
≥10 kg to
<40 kg
≥10 kg to
<40 kg
Route Route Route Route
IV (ACP only) IM IV (ACP only) IM
Dose
0.5 mg 0.5 mg 1 mg 1 mg
Max. single dose
0.5 mg 0.5 mg 1 mg 1 mg
Dosing interval
5 min. 5 min. 5 min. 5 min.
Max. # of doses
N/A N/A N/A N/A
Consider Diazepam
Weight Weight Weight Weight
<10 kg <10 kg
≥10 kg to
<40 kg
≥10 kg to
<40 kg
Route Route Route Route
IV (ACP only) IM IV (ACP only) IM
Dose
2 mg 2 mg 0.2 mg/kg 0.2 mg/kg
Max. single dose
2 mg 2 mg 8 mg 8 mg
Dosing interval
N/A N/A N/A N/A
Max. # of doses
1 1 1 1
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 223
Appendix 5 – Chemical Exposure Medical Directives
Consider Pralidoxime
Weight Weight Weight Weight
<10 kg <10 kg
≥10 kg to
<40 kg
≥10 kg to
<40 kg
Route Route Route Route
IV (ACP only) IM IV (ACP only) IM
Dose 15 mg/kg 15 mg/kg 15 mg/kg 15 mg/kg
Max. single dose 150 mg 150 mg 600 mg 600 mg
Dosing interval 60 min. 60 min. 60 min. 60 min.
Max. # of doses 2 2 2 2
Consider Obidoxime (if not using pralidoxime)
Weight Weight Weight Weight
<10 kg <10 kg
≥10 kg to
<40 kg
≥10 kg to
<40 kg
Route Route Route Route
IV (ACP only) IM IV (ACP only) IM
Dose 8 mg/kg 8 mg/kg 8 mg/kg 8 mg/kg
Max. single dose 80 mg 80 mg 320 mg 320 mg
Dosing interval N/A N/A N/A N/A
Max. # of doses 1 1 1 1
Clinical Considerations
Only one of pralidoxime or obidoxime should be administered.
Administration of IV medications applies to ACPs only
Do not delay IM administration if IV access is not already established.
Atropine should be administered prior to airway interventions if secretions are copious.
Subsequent doses of atropine are intended for patients showing signs of bronchial secretions and may
be repeated as indicated until airway secretions are controlled.
Decontamination procedures must be integrated with antidote administration.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 224
Appendix 5 – Chemical Exposure Medical Directives
Cyanide Exposure Medical Directive
A Paramedic may provide the treatment prescribed in this Medical Directive if authorized.
Indications
Suspected exposure to cyanide with signs and symptoms of poisoning.
Conditions
Sodium Thiosulfate 25%
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other N/A
Hydroxocobalamin
Age N/A
LOA Altered
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Sodium Thiosulfate 25%
Allergy or sensitivity to Sodium
Thiosulfate 25%
Hydroxocobalamin
Allergy or sensitivity to
Hydroxocobalamin
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
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Appendix 5 – Chemical Exposure Medical Directives
Treatment
Consider sodium thiosulfate 25%
Age Age
<18 years ≥18 years
Route Route
IV infusion IV infusion
Dose 1.65 ml/kg 12.5g (50 ml of 25% solution)
Max. single dose 12.5g (50 ml of 25% solution) 12.5g (50 ml of 25% solution)
Dosing interval N/A N/A
Max. # of doses 1 1
Consider hydroxocobalamin (if not using sodium thiosulfate 25%)
Age Age
<18 years ≥18 years
Route Route
IV infusion IV infusion
Dose
70 mg/kg over 30 min. 5 g over 15 - 30 min.
Max. single dose
5 g 5 g
Dosing interval N/A N/A
Max. # of doses 1 1
Clinical Considerations
Hydroxocobalamin must be reconstituted with 200 ml normal saline prior to use.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 226
Appendix 5 – Chemical Exposure Medical Directives
Hydroxocobalamin Dosing Chart
Dose Concentration Volume of Administration
5 70 mg/kg 25 mg/ml 14 ml
10
70 mg/kg
25 mg/ml
28 ml
15
70 mg/kg
25 mg/ml
42 ml
20
70 mg/kg
25 mg/ml
56 ml
25
70 mg/kg
25 mg/ml
70 ml
30
70 mg/kg
25 mg/ml
84 ml
35
70 mg/kg
25 mg/ml
98 ml
40
70 mg/kg
25 mg/ml
112 ml
>40 kg 5 g 25 mg/ml 200 ml
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 227
Appendix 5 – Chemical Exposure Medical Directives
Symptomatic Riot Agent Exposure
Medical Directive
A Paramedic may provide the treatment prescribed in this Medical Directive if authorized.
Indications
Known or suspected exposure to a riot agent with signs and symptoms of a riot agent exposure.
Conditions
Topical Anaesthetic Eye Drops
Age N/A
LOA N/A
HR N/A
RR N/A
SBP N/A
Other N/A
Contraindications
Topical Anaesthetic Eye Drops
Allergy or sensitivity to local
anaesthetics
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 228
Appendix 5 – Chemical Exposure Medical Directives
Treatment
Consider topical anaesthetic eye drops
Route
TOP
D
ose 2 gtts/eye
Max. single dose 2 gtts/eye
Dosing interval 10 min
Max. # of doses N/A
Clinical Considerations
For skin or mucous membrane contact, ensure thorough irrigation.
For eye exposure, remove patient`s contact lenses if applicable prior to initiating treatment. Use
anaesthetic eye drops for comfort and then irrigate eyes with normal saline for at least 15 minutes.
6
Appendix 6 – Certification Standard
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 230
Appendix 6 – Certification Standard
Preamble
All Paramedics shall obtain and maintain the qualifications required by the Ambulance Act. This
document sets out the requirements and processes related to Certification.
Definitions
Terms defined in the Ambulance Act and Ontario Regulation 257/00 shall have the same meaning in
this Certification Standard and the following terms have the following meanings:
“Authorization”
means written approval to perform Controlled Acts and other advanced medical procedures requiring
medical oversight of a Medical Director;
“Business Day”
means any working day, Monday to Friday inclusive, excluding statutory and other holidays, namely:
New Year’s Day; Family Day; Good Friday; Easter Monday; Victoria Day; Canada Day; Civic
Holiday; Labour Day; Thanksgiving Day; Remembrance Day; Christmas Day; Boxing Day and any
other day on which the Province has elected to be closed for business;
“Certification”
means the process by which Paramedics receive Authorization from a Medical Director to perform
Controlled Acts and other advanced medical procedures in accordance with the ALS PCS;
“Continuing Medical Education (CME)”
means a medical education program and confirmation of its successful completion as approved by
the Regional Base Hospital Program (RBHP);
“Consolidation”
means the process by which a condition is placed on a Paramedic’s Certification restricting his or her
practice to working with another Paramedic with the same or higher level of qualification (i.e.
Certification);
“Controlled Act”
means a Controlled Act as set out in subsection 27(2) of the Regulated Health Professions Act, 1991;
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 231
Appendix 6 – Certification Standard
“Critical Omission or Commission”
means the performance of a Controlled Act or other advanced medical procedure listed in the ALS
PCS that a Paramedic is not authorized to perform; or an action or lack of action, including the
performance of a Controlled Act or other advanced medical procedure listed in the ALS PCS, by the
Paramedic that has negatively affected or has the potential to negatively affect patient morbidity or
mortality, with a potentially life, limb or function threatening outcome;
“Deactivation”
means the temporary revocation, by the Medical Director, of a Paramedic’s Certification;
“Decertification”
means the revocation, by the Medical Director, of a Paramedic’s Certification;
“Director”
means a person who holds that position within the Emergency Health Regulatory and Accountability
Branch (EHRAB) of the Ministry of Health (MOH);
“Employer”
means an ambulance service operator certified to provide ambulance services as defined in the
Ambulance Act;
“Major Omission or Commission”
means an action or lack of action, including the performance of a Controlled Act or other advanced
medical procedure listed in the ALS PCS, by the Paramedic that has negatively affected or has the
potential to negatively affect patient morbidity without a potentially life, limb or function threatening
outcome;
“Medical Director”
means a physician designated by a RBH as the Medical Director of the RBHP;
“Minor Omission or Commission”
means an action or lack of action, including the performance of a Controlled Act or other advanced
medical procedure listed in the ALS PCS, by the Paramedic that may have negatively affected patient
care in a way that would delay care to the patient or lengthen the patient’s recovery period, but has
not negatively affected patient morbidity;
“Ontario Base Hospital Group (OBHG) Executive”
means a provincial body comprised of representatives from RBHPs as defined in the Terms of
Reference for OBHG Executive and approved by the MOH;
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 232
Appendix 6 – Certification Standard
“Paramedic”
means a paramedic as defined in subsection 1(1) of the Ambulance Act, and for purposes of this
Standard a reference to the term includes a person who is seeking Certification as a Paramedic, where
applicable;
“Paramedic Practice Review Committee (PPRC)”
is a committee that performs an independent, external advisory role, providing information and
expert opinion to the Medical Director on issues related to Paramedic practice when the Medical
Director is considering Decertification of a Paramedic;
“Patient Care Concern”
means a Critical Omission or Commission, Major Omission or Commission, or Minor Omission or
Commission;
“Reactivation”
means the reinstatement of a Paramedic’s Certification after a period of Deactivation;
“Regional Base Hospital (RBH)”
means a base hospital as defined in subsection 1(1) of the Ambulance Act, and provides an RBHP
pursuant to an agreement entered into with the MOH;
“Regional Base Hospital Program (RBHP)”
means a base hospital program as defined in subsection 1(1) of the Ambulance Act;
“Remediation”
means a customized plan by the RBHP to address a Patient Care Concern or to address any concerns
identified during Certification, including a failure to meet a requirement for the maintenance of
Certification;
“Senior Field Manager”
means a person who holds that position within the EHS Division of the MOH, and for the purposes
of this Standard a reference to the term means the relevant Senior Field Manager responsible for the
applicable RBHP.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 233
Appendix 6 – Certification Standard
Processes
Certification
A Medical Director may certify a Paramedic to perform Controlled Acts and other advanced medical
procedures listed in the ALS PCS. A Medical Director may stipulate other requirements relating to
Paramedic Certification. The Medical Director shall communicate such requirements to the
Paramedic and the Employer in writing. The Medical Director shall notify the Paramedic and
Employer within three (3) Business Days of the decision with respect to Certification as to whether
the Paramedic was successful or not in attaining his or her Certification.
Consolidation
The Medical Director shall require Consolidation on all new Certifications
1
. A Medical Director may
require Consolidation with respect to a Paramedic’s Certification where the Paramedic is returning to
practice, a Patient Care Concern has been identified in respect of the Paramedic, or as identified in
the Paramedic’s customized plan for Remediation. Consolidation provides for the opportunity to
acquire more skills and confidence while ensuring that a support mechanism is in place for the
Paramedic. The Medical Director shall determine the requirements for the Consolidation, which
include the presence of another Paramedic, the level of qualification of that other Paramedic, and the
restrictions of the Paramedic’s practice in relation to the presence of that other Paramedic. The
Medical Director, in consultation with the Employer, shall determine the duration for the
Consolidation. However, the duration for Consolidation on all new Certifications shall be a minimum
of 36 hours for a PCP and a minimum of 168 hours for an ACP or CCP. The Medical Director shall
provide notice of Consolidation and the requirements thereof in writing to the Paramedic and
Employer within two (2) Business Days. Any changes to the Consolidation by the Medical Director
shall be communicated to the Paramedic and Employer immediately and any changes to the
requirements thereof shall be provided in writing as soon as possible.
1
See New Certification process
Responding to a Patient Care Concern
The RBHP shall assess all matters regarding patient care to determine whether or not there is a
Patient Care Concern and the Employer shall assist where required. Where a matter regarding patient
care is identified by the Employer that may be a Patient Care Concern, the Employer shall notify the
RBHP as soon as possible.
Where the Patient Care Concern is a Minor Omission or Commission the RBHP shall notify the
Paramedic and Employer by aggregate reports provided semi-annually. Where the Patient Care
Concern is a Major Omission or Commission, a Critical Omission or Commission, or a repetition of
Minor Omissions or Commissions the RBHP shall immediately notify the Paramedic and Employer
of the Patient Care Concern and provide notice in writing as soon as possible. The notice in writing
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 234
Appendix 6 – Certification Standard
shall indicate that the Patient Care Concern is being considered to determine whether the Paramedic
will be subject to Remediation, Deactivation or Decertification.
Remediation
A Medical Director may require the Paramedic to receive Remediation. The customized plan in the
Remediation shall identify the concern, the remedial action to be followed, and the objectives to be
achieved. The plan shall include a specific timeframe in which the Paramedic must successfully
complete the Remediation. The RBHP shall develop the plan, in consultation with the Employer as
necessary, as soon as possible. Once developed, the RBHP shall provide the written plan to the
Paramedic and Employer. Any changes to the plan by the RBHP shall be communicated to the
Paramedic and Employer immediately and the updated written plan shall be provided as soon as
possible. The Medical Director shall notify the Paramedic and Employer in writing within three (3)
Business Days of the successful completion of the Remediation.
Deactivation
A Medical Director may deactivate a Paramedic’s Certification for which the Paramedic has received
Authorization.
Deactivation may occur as a result of:
1. a Patient Care Concern;
2. failure to respond to the RBHP’s requests for feedback or interviews regarding a Critical
Omission or Commission, Major Omission or Commission or Minor Omission or
Commission within a reasonable period of time as specified by the RBHP;
3. failure to successfully complete Remediation;
4. misconduct related to Certification (e.g.
falsification of documentation, failure to
disclose previous Deactivations and Decertifications, including practice in other
jurisdictions);
5. repeated Deactivations in similar clinical areas; or
6. failure to meet the requirements for maintenance of Certification.
The Medical Director shall immediately notify the Paramedic, Employer, the Senior Field
Manager and all other RBHPs of a Deactivation. The Medical Director shall provide a brief
written reason for the Deactivation to the Paramedic, Employer, the Senior Field Manager and all
other RHBPs as soon as possible.
Following a Deactivation, the Medical Director shall determine whether the requirements for
Remediation or the requirements for maintenance of Certification have been met, as the case
may be, at which time the Medical Director shall either proceed with Reactivation or
Decertification. The Remediation and Reactivation process shall be completed as soon as
possible; however it shall not exceed ninety (90) consecutive days in length. Where the Medical
Director has proceeded with Reactivation, the Medical Director shall immediately notify the
Paramedic, Employer, the Senior Field Manager, and all other RBHPs of the Reactivation.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 235
Appendix 6 – Certification Standard
Decertification
A Medical Director shall revoke a Paramedic’s Certification where that person is no longer employed
or retained as a volunteer by an Employer and that person shall be deemed to have undergone
Decertification and the PPRC process does not apply. In all other circumstances, a Medical Director
shall not proceed with a Decertification unless: (i) a PPRC has been convened and has provided its
written recommendations to the Medical Director and the Paramedic; or (ii) the Paramedic has
waived the PPRC process in writing.
The Medical Director shall immediately notify the Paramedic, Employer, the Senior Field Manager
and all ot
her RBHPs of his or her decision to either proceed with Reactivation or Decertification of
the Paramedic. Where the Medical Director proceeds with Decertification, he or she shall provide
a
written explanation to the Paramedic, outlining the reasons for Decertification. The Medical
Director shall provide a brief written explanation confirming the reason for the Decertification to the
Employer, the Senior Field Manager and all other RHBPs as soon as possible.
New Certification
The following requirements apply with respect to Paramedics who are seeking Certification from an
RBHP and who are not currently certified at that level by another RBHP, including Paramedics who
have been previously certified in Ontario.
1. The Paramedic shall be employed or retained by an Employer.
2. The Paramedic shall complete a form provided by the RBHP that includes the following:
a. a list of all RBHPs or other certifying bodies under which the Paramedic has
previously received Certification within the ten (10) year period immediately
preceding the application;
b. a declaration of the dates of all previous Deactivations and/or Decertifications that
have previously occurred at all other RBHPs or other certifying bodies
2
within the
ten (10) year period immediately preceding the application; and
c. written permission for the prospective RBHP to obtain information in writing from
other employers, other physicians, other programs, etc. regarding the Paramedic’s
previous practice.
3. The Paramedic shall successfully complete an evaluation by the RBHP and any
orientation and training required by the RBHP. The evaluation may include:
a. an assessment of knowledge and skills;
b. scenario evaluation; and
c. oral interview or clinical evaluation with the Medical Director or designate.
2
Or a declaration of dates when certification was denied, revoked, suspended or under review as other certifying
bodies may not use the terms Deactivation and Decertification
Upon meeting the above requirements, for new Certification, the Medical Director shall certify the
Paramedic and require a condition of Consolidation on the Paramedic’s Certification.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 236
Appendix 6 – Certification Standard
Cross Certification
The following requirements apply with respect to Paramedics who are already certified and who are
seeking Certification by a Medical Director in another RBHP.
1. The Paramedic shall be employed or retained by an Employer within the specified
catchm
ent area.
2. The Paramedic shall complete a form provided by the RBHP that includes the following:
a. a list of all RBHPs under which the Paramedic has received Certification within the
ten (10) year period immediately preceding the application;
b. a declaration of the dates of all previous Deactivations and/or Decertifications that
have occurred within the ten (10) year period immediately preceding the application;
c. status of all current Certifications from all RBHPs; and
d. written permission for the prospective RBHP to obtain information in writing from
other physicians, other programs, etc. regarding the Paramedic’s previous practice.
3. The Paramedic shall successfully complete an evaluation by the RBHP and any
orientation and training required by the RBHP. The evaluation may include:
a. an assessment of knowledge and skills;
b. scenario evaluation; and
c. oral interview or clinical evaluation with the Medical Director or designate.
Upon meeting the above requirements for Cross Certification, the Medical Director shall certify the
Paramedic.
Maintenance of Certification
The following requirements apply with respect to Paramedics regarding the maintenance of
Certification.
1. The Paramedic shall demonstrate competency in the performance of Controlled Acts and
other advanced medical procedures, compliance with the ALS PCS, and the provision of
patient care at the Paramedic’s level of Certification. Competency and compliance shall be
determined by the Medical Director and may include chart audits, field evaluations, and
RBHP patch communication review.
2. The Paramedic shall not have an absence from providing patient care that exceeds ninety
(90) consecutive days.
3. The Paramedic shall either,
a. provide patient care to a minimum of ten (10) patients per year whose care requires
assessment and management at the Paramedic’s level of Certification, or
b. where a Paramedic is unable to assess and manage the minimum of ten (10) patients
per year, demonstrate alternate experience, as approved by the Medical Director, that
may involve 1 or more of the following:
i. other patient care activities;
ii. additional CME;
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 237
Appendix 6 – Certification Standard
iii. simulated patient encounters; and
iv. clinical placements.
4. The P
aramedic shall complete at least 1 evaluation per year at the appropriate level of
Certification, which may include: an assessment of knowledge and evaluation of skills;
scenarios; and on-line learning and evaluation.
5. The Paramedic shall complete a minimum of CME hours per year as follows: eight (8)
hours for PCPs, twelve (12) hours for PCP Flight, twenty-four (24) hours for ACPs
3
, and
seventy-two (72) hours for ACP Flight and CCP. CME hours include hours completed as
part of an evaluation required by paragraph 4.
3
With respect to an ACP whose Certification has been for a period of less than a year and who has completed a minimum of
eight (8) hours of CME, the Medical Director shall proportionally adjust the remaining required CME hours
.
Upon meeting the above requirements for maintenance of Certification, the Medical Director shall
certify the Paramedic.
Paramedic Practice Review
Committee (PPRC)
The PPRC is convened by another RBHP through the OBHG Executive Chair to perform an
independent, external advisory role, providing information and expert opinion to the affected
Medical Director on issues related to Paramedic practice when a Medical Director is considering
Decertification of a Paramedic following Deactivation. When the RBHP is engaged for the purposes
of a PPRC process the RBHP is termed the "host RBHP". The parties to the PPRC process are the
affected Medical Director and the Paramedic who is subject of the consideration of Decertification.
Membership
The members of the PPRC shall be:
• the host RBHP Manager/Director, who will act as Chair;
• host Medical Director; and
• two (2) Peer Paramedics.
Selection of Peer Paramedics: One (1) peer Paramedic shall be selected by the host RBHP and one
(1) peer Paramedic by the affected Paramedic from a pre-identified group of eligible Paramedics. All
members of this group shall:
• hold Certification from the host RBHP for the preceding twelve (12) months at the same level
or higher as the Paramedic who is subject of the consideration of Decertification; and
• not have any operational relationship or personal relationship with the affected RBHP, Medical
Director, or the Paramedic;
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 238
Appendix 6 – Certification Standard
Confidentiality: All members of the PPRC shall keep confidential all information obtained during
the PPRC process.
Recommendations
The PPRC shall provide written recommendations to the Medical Director who is considering
Decertification of a Paramedic. The recommendation of the PPRC shall be made by consensus. The
recommendation rendered by the PPRC is not subject to appeal or other challenge, and is not binding
on the affected Medical Director. The affected Medical Director is responsible for making the final
decision with respect to the Decertification of the affected Paramedic.
PPRC Process
1. The affected Medical Director shall notify the OBHG Executive Chair that a PPRC is
required regarding a consideration to proceed with the Decertification of a Paramedic.
2. If the OBHG Executive Chair is employed by the affected RBHP, he/she shall send the
request to the OBHG Executive Vice Chair. (All subsequent references to the “OBHG
Executive Chair” shall be references to the OBHG Executive Vice Chair, as applicable.)
3. The OBHG Executive Chair shall ensure that the PPRC adheres to all established
timelines in the process by communicating directly with the PPRC Chair.
4. The OBHG Executive Chair shall select an appropriate host RBHP.
5. The OBHG Executive Chair shall provide notice to the affected Medical Director and
Paramedic, in a format set out in Appendix A, that a PPRC has been convened to review
the case.
6. The affected Medical Director and Paramedic shall provide any written submissions to the
OBHG Executive Chair within fifteen (15) Business Days of receiving notice that a PPRC
has been convened.
7. Submissions shall be sent via courier requiring signature of receipt, registered mail, fax
(with confirmation) or email (with confirmation).
8. The OBHG Executive Chair shall provide a copy of each party’s submission to the other
party within five (5) Business Days.
9. Both parties shall have the opportunity to respond to the original submissions within
fifteen (15) Business Days of their receipt.
10. The OBHG Executive Chair shall provide a copy of all submissions to the affected
Paramedic, Medical Director and four (4) copies to the PPRC Chair.
11. The PPRC Chair shall provide copies of the submissions to the other members of the
PPRC.
12. The PPRC shall not begin its review until receipt of all submissions.
13. If clarification of an issue or information regarding applicable standards or legislation is
required, the PPRC Chair shall request the clarification or information in writing from the
relevant party. The response to the request shall be provided to the PPRC Chair and the
other party in writing, within ten (10) Business Days of the request.
14. The PPRC Chair shall provide a copy of the response to OBHG Executive Chair.
15. The PPRC shall review the submissions and any responses within fifteen (15) Business
Days from receipt of the full submission. If an extension is required the request will be
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 239
Appendix 6 – Certification Standard
made to the OBHG Executive Chair. The PPRC will render a written recommendation
containing the supporting rationale, within ten (10) Business Days of the final review
meeting and submit it to the OBHG Executive Chair.
16. The OBHG Executive Chair shall send a copy of the final recommendation to both parties.
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 240
Appendix 6 – Certification Standard
Appendix A - Paramedic Practice
Review Committee Letter
<<Date>>
A Paramedic Practice Review Committee (PPRC) has been convened to review <<brief details of
case/incident>>.
The PPRC is convened by another RBHP through the OBHG Executive Chair to perform an
independent, external advisory role, providing information and expert opinion to the affected
Medical Director on issues related to Paramedic practice when a Medical Director is considering
Decertification of a Paramedic following Deactivation. When the RBHP is engaged for the purposes
of a PPRC process the RBHP is termed the "host RBHP". The affected Medical Director shall not
proceed with Decertification unless a PPRC has been convened and has provided its written
recommendations to the affected Medical Director and the Paramedic.
Recommendations
The PPRC shall provide written recommendations, including supporting rationale, to the Medical
Di
rector regarding the consideration to decertify a Paramedic. The recommendation of the PPRC
shall be made by consensus. The recommendation rendered by the PPRC is not subject to appeal or
other challenge, and is not binding on the affected Medical Director. The affected Medical Director is
responsible for making the final decision with respect to the Decertification of the affected
Paramedic.
Membership
<<Medical Director>> <<Regional Base Hospital Program Manager/Director>>
<<Peer Paramedic>> <<Peer Paramedic>>
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 241
Appendix 6 – Certification Standard
Process:
• The affected Medical Director shall notify the OBHG Executive Chair that a PPRC is required
regarding a consideration to proceed with the Decertification of a Paramedic.
• The OBHG Executive Chair shall select an appropriate host RBHP and provide notice to both
parties that a PPRC has been convened to review the case.
• Both parties shall provide any written submissions to the OBHG Executive Chair within fifteen
(15) Business Days of receiving notice that a PPRC has been convened.
• The OBHG Executive Chair shall provide a copy of each party’s submission to the other party
within five (5) Business Days and both parties shall have the opportunity to respond to the
original submissions within fifteen (15) Business Days of their receipt.
• The OBHG Executive Chair shall provide a copy of all submissions to both parties and four (4)
copies to the PPRC Chair to distribute to the other members of the PPRC. The PPRC shall begin
its review once all submissions are received.
• If clarification of an issue or information regarding applicable standards or legislation is required,
the PPRC Chair shall request the clarification or information in writing from the relevant party.
The response to the request shall be provided to the PPRC Chair and the other party in writing,
within ten (10) Business Days of the request.
• The PPRC shall review the submissions and any responses within fifteen (15) Business Days
from receipt of the full submission. If an extension is required the request will be made to the
OBHG Executive Chair.
• The PPRC will render a written recommendation containing the supporting rationale, within ten
(10) Business Days of the final review meeting and submit it to the OBHG Executive Chair.
• The OBHG Executive Chair shall send a copy of the final recommendation to both parties.
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7
Appendix 7 – Research Trial Standard
Emergency Health Regulatory and Accountability Branch, Ontario Ministry of Health
Advanced Life Support Patient Care Standards – Version 4.8 244
Appendix 7 – Research Trial Standard
Research Trial Standard
MOH may, at its discretion, approve research trials that include patient care practices that are
different from those otherwise set out in the Standards.
A paramedic properly enrolled in an approved research trial shall:
1. determine whether a patient may be treated in accordance with a research trial, only if the
following conditions have been met:
a. MOH has approved the patient care practices set out in the research trial as an
alternate standard than to those set out in the Standards;
b. The research trial has been approved by a Research Ethics Board (REB) that:
i. abides by and is consistent with the version of the Tri-Council Policy
Statement on Ethical Conduct for Research Involving Humans current at the
time of submission, and
ii. meets the requirements for an REB set out in section 15 of O. Reg. 329/04
made under PHIPA, and
Guideline
Recall section 44 of PHIPA, which includes provisions related to personal health information
and researchers.
c. The research trial has been reviewed and supported in writing by the Ontario Base
Hospital Group Medical Advisory Committee;
2. obtain the appropriate patient consent for participation in the research trial; and
Guideline
Recall paragraph 11 of the General Measures Standard of the Basic Life Support Patient
Care Standards, which specifies that the paramedic shall also obtain consent for patient care
as per the Health Care Consent Act, 1996 (Ontario)
3. where authorized, provide care in accordance with the approved research trial.
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