Ontario Base Hospital Group
Education Subcommittee
MEMOR ANDUM
TO: Ontario Paramedics
FROM: Ontario Base Hospital Group Education Subcommittee (OBHG ESC)
DATE: January 12, 2022
RE: Advanced Life Support Patient Care Standards (ALS PCS) Version 4.9 Update
— Impact on Clinical Practice and Educational Summary
On February 1, 2022, an updated version of the ALS PCS comes into force by the Ministry of
Health (MOH). This communication memo has been developed in addition to the summary
of changes document released by the MOH and will focus on the impact to clinical practice
to patient care within the ALS PCS version 4.9 utilized by Ontario paramedics. It is the
responsibility of the paramedic to ensure they have reviewed all directives in their entirety.
Contents
1. Opioid Toxicity Medical Directive...............................................................................................2
2. Analgesia Medical Directive........................................................................................................3
3. Hypoglycemia Medical Directive................................................................................................4
4. Cardiogenic Shock Medical Directive........................................................................................4
5. Cardiac Ischemia Medical Directive...........................................................................................5
6. Return of Spontaneous Circulation (ROSC) Medical Directive.............................................5
7. Hyperkalemia Medical Directive.................................................................................................6
8. Orotracheal Medical Directive....................................................................................................7
9. Seizure Medical Directive.............................................................................................................7
10. Cricothyrotomy Medical Directive.............................................................................................8
11. Symptomatic Bradycardia Medical Directive..........................................................................8
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 1
Ontario Base Hospital Group
Education Subcommittee
1. Opioid Toxicity Medical Directive
Changes were made to the Opioid Toxicity Medical Directive to align care with current best practices
as well as expanding the age indication to include pediatrics.
INDICATIONS REVISED TREATMENT REVISED
Inability to adequately ventilate OR persistent • Change in order of route preference (IV/IO; IM;
need to assist ventilations IN; SC)
• IM dosing is now decreased to 0.4 mg
Impact to Clinical Practice
• IN dosing is now increased to 2–4 mg
Allows for the administration of naloxone to
• Dosing interval for ALL routes is 5 minutes
patients who are not responding to assisted ven
tilations or in situations whereby the provision of Impact to Clinical Practice
persistent ventilations is difficult (i.e. challenging Route specific dosing to align with current
extrications, prolonged transport times). evidence. Recent evidence shows that naloxone
begins to have clinical effect within 2–3 minutes
regardless of route.
CONDITIONS NEW
Age ≥ 24 hours
CLINICAL CONSIDERATIONS REVISED
Impact to Clinical Practice
Initial aggressive management of the airway is
Allows for treatment of the pediatric population
paramount and the priority in patient care.
who are experiencing suspected opioid toxicity
with respiratory depression and unsuccessful If no response to 3 doses, consider patching for
ventilatory support (inability to adequately venti further orders.
late or persistent need to assist ventilations).
If the patient does not respond to airway man
agement and the administration of naloxone,
glucometry should be considered.
CONTRAINDICATIONS REMOVED
Removed ‘uncorrected hypoglycemia’ Impact to Clinical Practice
Airway management should always be the prior
Impact to Clinical Practice ity when managing the suspected opioid toxicity
Airway management is paramount and should not patient. If the patient does not respond to airway
be delayed to check for hypoglycemia when there management and naloxone administration, con
is a suspected opioid overdose. Considerations sider other potential causes for their presentation
for treatment should be airway management including glucometry.
(ventilatory support) followed by naloxone admin
istration where appropriate. If the patient does
not respond to airway management and nalox ACP – TREATMENT REVISED
one, consider glucometry to rule out other
Addition of intraosseous route in the setting of
potential reversible causes.
the pre-arrest patient.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 2
Ontario Base Hospital Group
Education Subcommittee
2. Analgesia Medical Directive
Changes to the Analgesia Medical Directive were made to allow for paramedic clinical judgement when
managing pain in the pre-hospital setting.
CONDITIONS REMOVED ACP – CONTRAINDICATIONS NEW
Ketorolac is restricted to those who are unable to Morphine and fentaNYL – Active labour
tolerate oral medications.
Impact to Clinical Practice
Impact to Clinical Practice To restrict administration during active labour.
To allow for paramedics to use more clinical
judgement in selecting the appropriate medica
tion based on clinical presentation. ACP – TREATMENT REMOVED
Morphine and fentaNYL – removed max number
of doses.
CLINICAL CONSIDERATIONS NEW
Impact to Clinical Practice
Patients presenting with suspected renal colic
To allow for intravenous dosing utilizing aliquots
may receive either ketorolac or ibuprofen.
to effectively titrate analgesia.
Impact to Clinical Practice
To allow for consideration of ketorolac or ibupro
fen for suspected renal colic. ACP – TREATMENT NEW
FentaNYL – change to a max cumulative dose of
200 mcg.
ACP – CONDITIONS REMOVED
Impact to Clinical Practice
Morphine and fentaNYL – severe pain
For consistency of maximum dosing and tracking
Impact to Clinical Practice purposes.
To allow for paramedics to use more clinical
judgement in selecting the appropriate medica
tion based on clinical presentation.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 3
Ontario Base Hospital Group
Education Subcommittee
3. Hypoglycemia Medical Directive
Changes to the Hypoglycemia Medical Directive allow for titration of Dextrose administration for
improved patient outcomes.
TREATMENT NEW ACP – TREATMENT NEW
Suspected hypoglycemia Dosing table has been simplified with only 2 age
parameters. Review the dosing table within the
Impact to Clinical Practice
medical directive for the details.
Allows the paramedic to use clinical judgement.
Impact to Clinical Practice
Simplified dosing table.
TREATMENT NEW
Max single dose of D10W is now 25 g in 250 ml
ACP – TREATMENT REMOVED
Impact on Clinical Practice
Removal of D25W
Max dose of D10W now aligns with max dose of
D50W. Impact on Clinical Practice
Simplifies the treatment options for hypoglyce
mic pediatric patients.
TREATMENT NEW
Titrate dextrose to a level of awareness where
the patient can safely consume complex carbo-
hydrates.
Impact on Clinical Practice
Allows for appropriate administration of dextrose
without over treatment of the hypoglycemic
patient.
4. Cardiogenic Shock Medical Directive
There were no changes to the PCP Cardiogenic Shock (Auxiliary) Medical Directive. Changes were
made to the contraindications in the ACP Cardiogenic Shock (Core) Medical Directive to be consistent
with other medical directives.
ACP – CONTRAINDICATIONS REVISED
DOPamine – Mechanical shock
Impact on Clinical Practice
There is no impact to clinical practice as this was
simply a wording change for consistency.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 4
Ontario Base Hospital Group
Education Subcommittee
5. Cardiac Ischemia Medical Directive
Changes to the Cardiac Ischemia Medical Directive are to allow for the best practice in defibrillation
pad placement upon identification of STEMI.
CLINICAL CONSIDERATIONS NEW ACP – CONDITIONS REVISED
Apply defibrillation pads when a STEMI is Removed the numerical pain scale from severe
identified pain for morphine.
Impact to Clinical Practice Impact to Clinical Practice
Now included as part of the standard. To allow for paramedics to use more clinical
judgement in selecting the appropriate medica
tion based on clinical presentation.
CLINICAL CONSIDERATIONS NEW
The goal for time to 12-lead ECG from first medi
cal contact is < 10 minutes where possible.
Impact to Clinical Practice
Whenever feasible, obtaining a 12-lead ECG with
in 10 minutes of patient contact is best practice.
6. Return of Spontaneous Circulation (ROSC) Medical Directive
Changes to the Return of Spontaneous Circulation Medical Directive were for the purpose of clarification.
CONTRAINDICATIONS REMOVED ACP – CLINICAL CONSIDERATIONS NEW
0.9% NaCl Fluid Bolus – removed SBP greater Notify receiving hospital staff if the DOPamine
than or equal to 90 mmHg. drip goes interstitial.
Impact to Clinical Practice
DOPamine can cause tissue necrosis if it goes
ACP – CLINICAL CONSIDERATIONS NEW
interstitial. This can be mitigated by a phen
Adult IO administration of a NaCl bolus requires tolamine injection at the hospital into affected
the ACP to be authorized. tissue.
Impact to Clinical Practice
For clarification that an ACP cannot take an order
from a BHP for an adult IO if not authorized by
their Regional Base Hospital program.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 5
Ontario Base Hospital Group
Education Subcommittee
7. Hyperkalemia Medical Directive
Changes to the Hyperkalemia Medical Directive allow for the timely critical intervention for patients
presenting with hyperkalemia.
CONTRAINDICATION CLINICAL CONSIDERATIONS REMOVED
– CALCIUM GLUCONATE REMOVED
If appropriate, refer to the Symptomatic Brady
Current Digoxin use cardia, Tachydysrhythmia or Cardiac Arrest
Impact on Clinical Practice Medical Directives for further management of
There are no longer any documented contra these patients.
indications to the administration of calcium Sodium bicarbonate may not be an effective agent
gluconate when the patient meets the indications for hyperkalemia and, so should not routinely be
and conditions for the Hyperkalemia Medical administered.
Directive.
Impact on Clinical Practice
The clinical considerations that have been removed
TREATMENT REMOVED can be found within the Companion Document.
Mandatory provincial patch point
Impact on Clinical Practice CLINICAL CONSIDERATIONS REVISED
To allow for critical treatment to be performed
The action of calcium gluconate is often visi
without delay.
ble through the normalization of observed ECG
changes of hyperkalemia. If ECG changes do not
improve, or if they worsen, additional doses may
TREATMENT
be required. The duration of action is 20–60
– CALCIUM GLUCONATE NEW
minutes: consider repeat dosing if ECG changes
Dosing interval is reduced to 5 minutes between recur during extended transport times.
the first and second dose.
Impact to Clinical Practice
Max number of doses – *An additional 3rd dose Information related to the action and duration
may be administered after 30 minutes if the of action of calcium gluconate, in the context of
patient improved initially and symptoms meeting hyperkalemia and ECG changes, has been added
the indications recur. for the paramedic’s reference.
Impact on Clinical Practice
Allows for time-appropriate medication adminis
tration if there is no effect from the first dose of
calcium guconate.
The 3rd dose allows for further treatment if
required.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 6
Ontario Base Hospital Group
Education Subcommittee
8. Orotracheal Medical Directive
The change to the Orotracheal Intubation Medical Directive was to provide clearer direction for the
use of topical Lidocaine.
TREATMENT REVISED
Consider topical lidocaine spray (to the hypo
pharynx) when GCS is greater than or equal to 4.
Impact to Clinical Practice
Provides clearer direction for the use of topical
lidocaine instead of simply “awake”.
9. Seizure Medical Directive
Changes to the Seizure Medical Directive were to align care with the current recommendations for the
priority treatment of seizure patients.
CONTRAINDICATIONS REMOVED CLINICAL CONSIDERATION NEW
Hypoglycemia Do not delay midazolam administration for blood
glucometry in cases where hypoglycemia is not
Impact on Clinical Practice
suspected to be the causative agent.
Allows paramedic to use more clinical judgement
to determine the most likely etiology of the Blood glucose should be routinely checked in
seizure and provide appropriate therapy. patients who do not respond to midazolam or
have not returned to their baseline LOA after a
seizure.
TREATMENT NEW Impact on Clinical Practice
Addition of intraosseous (IO) route for midazolam Directs the priority to benzodiazepine therapy for
administration. non-hypoglycemic causes of seizure.
Impact on Clinical Practice
Aligns with other medical directives for medica
tions that can be administered via the IO route in
the setting of pre-arrest.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 7
Ontario Base Hospital Group
Education Subcommittee
10. Cricothyrotomy Medical Directive
The change to the Cricothyrotomy Medical Directive allows for the treatment to be performed without
delay.
TREATMENT REMOVED
Mandatory provincial patch point
Impact on Clinical Practice
To allow for potential lifesaving treatment to be
performed without delay.
11. Symptomatic Bradycardia Medical Directive
The changes made to the Symptomatic Bradycardia Medical Directive should allow for the timely
critical intervention and align with the current American Heart Association (AHA) guidelines.
CONTRAINDICATIONS REMOVED TREATMENT REVISED
DOPamine Atropine dose has changed to 1 mg IV.
• Tachydysrhythmias, excluding sinus tachycardia
Impact on Clinical Practice
• Hypovolemia
Aligns with the current AHA guidelines.
Atropine and Transcutaneous pacing
• Hemodynamic stability
Impact on Clinical Practice CLINICAL CONSIDERATIONS REMOVED
Removal of non-applicable contraindications. All previous clinical considerations have been
removed.
Impact to Clinical Practice
CONTRAINDICATIONS REVISED The clinical considerations that have been
Dopamine – Mechanical shock removed can be found within the Companion
Impact on Clinical Practice Document.
There is no impact to clinical practice as this was
simply a wording change for consistency. CLINICAL CONSIDERATIONS NEW
Transcutaneous pacing (TCP) should not be
delayed for placement of an IV.
TREATMENT REMOVED
A fluid bolus should be considered with all
Mandatory provincial patch point
symptomatic bradycardia patients if indicated.
Impact on Clinical Practice
To allow for transcutaneous pacing to be initiated
Impact to Clinical Practice
without delay. If TCP is the appropriate treatment it should be
prioritized over the initiation of IV access.
Patients who meet this directive are hypotensive,
but not necessarily hypovolemic and a fluid bolus
should be considered.
Memorandum – ALS PCS v4.9 Updates – Educational Summary of Changes; January 12, 2022 8
