National Model EMS Clinical Guidelines

1 National Model EMS Clinical Guidelines August 2021 VERSION These Guidelines will be maintained by the National Association of State EMS (NASEMSO) to facilitate the creation of state and local EMS system Clinical Guidelines , protocols, or operating procedures. System medical directors and other leaders are invited to harvest content as will be useful. These Guidelines are either evidence-based or consensus-based and have been formatted for use by field EMS professionals. NASEMSO Medical Directors Council Rev. August 2021 2 Contents HRSA PAGE ..ERROR! BOOKMARK NOT DEFINED. INTRODUCTION .. 6 PURPOSE AND NOTES .. 8 TARGET AUDIENCE .. 9 WHAT IS NEW IN THE 2022 EDITION .. 9 ACKNOWLEDGEMENTS .. 9 UNIVERSAL CARE .. 10 UNIVERSAL CARE GUIDELINE .. 10 FUNCTIONAL NEEDS .. 20 PATIENT REFUSALS .. 24 CARDIOVASCULAR .. 27 ADULT AND PEDIATRIC SYNCOPE AND PRESYNCOPE .. 27 CHEST PAIN/ACUTE CORONARY SYNDROME (ACS)/ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI).

2 31 BRADYCARDIA .. 35 IMPLANTABLE VENTRICULAR ASSIST DEVICES .. 39 TACHYCARDIA WITH A PULSE .. 42 SUSPECTED STROKE/TRANSIENT ISCHEMIC ATTACK .. 48 GENERAL MEDICAL .. 51 ABDOMINAL PAIN .. 51 ABUSE AND MALTREATMENT .. 55 AGITATED OR VIOLENT PATIENT/BEHAVIORAL 59 ANAPHYLAXIS AND ALLERGIC REACTION .. 66 ALTERED MENTAL STATUS .. 71 BACK PAIN .. 75 END-OF-LIFE CARE/PALLIATIVE CARE .. 78 HYPERGLYCEMIA .. 81 HYPOGLYCEMIA .. 85 NAUSEA-VOMITING .. 90 PAIN MANAGEMENT .. 94 SEIZURES .. 102 SHOCK .. 108 SICKLE CELL PAIN CRISIS .. 115 RESUSCITATION .. 118 CARDIAC ARREST (VF/VT/ASYSTOLE/PEA) .. 118 ADULT POST-ROSC (RETURN OF SPONTANEOUS CIRCULATION) CARE .. 127 DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS .. 131 DO NOT RESUSCITATE STATUS/ADVANCE DIRECTIVES/HEALTHCARE POWER OF ATTORNEY (POA) STATUS .. 134 TERMINATION OF RESUSCITATIVE EFFORTS .. 137 RESUSCITATION IN TRAUMATIC CARDIAC ARREST .. 142 PEDIATRIC-SPECIFIC Guidelines .

3 145 BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) & ACUTE EVENTS IN INFANTS .. 145 Rev. August 2021 3 PEDIATRIC RESPIRATORY DISTRESS (BRONCHIOLITIS) .. 151 PEDIATRIC RESPIRATORY DISTRESS (CROUP) .. 156 NEONATAL RESUSCITATION .. 161 OB/GYN .. 167 CHILDBIRTH .. 167 ECLAMPSIA/PRE-ECLAMPSIA .. 173 OBSTETRICAL AND GYNECOLOGICAL CONDITIONS .. 177 RESPIRATORY .. 180 AIRWAY MANAGEMENT .. 180 RESPIRATORY DISTRESS (INCLUDES BRONCHOSPASM, PULMONARY EDEMA) .. 192 MECHANICAL VENTILATION (INVASIVE) .. 205 TRACHEOSTOMY MANAGEMENT .. 210 215 GENERAL TRAUMA MANAGEMENT .. 215 BLAST INJURIES .. 222 BURNS .. 226 CRUSH INJURY/CRUSH SYNDROME .. 230 EXTREMITY TRAUMA/EXTERNAL HEMORRHAGE MANAGEMENT .. 233 FACIAL/DENTAL TRAUMA .. 238 HEAD INJURY .. 241 HIGH THREAT CONSIDERATIONS/ACTIVE SHOOTER 246 SPINAL CARE .. 249 TRAUMA MASS CASUALTY INCIDENT .. 257 TOXINS AND ENVIRONMENTAL .. 260 POISONING/OVERDOSE UNIVERSAL CARE.

4 260 ACETYLCHOLINESTERASE INHIBITORS (CARBAMATES, NERVE AGENTS, ORGANOPHOSPHATES) EXPOSURE .. 268 RADIATION EXPOSURE .. 279 TOPICAL CHEMICAL BURN .. 283 STIMULANT POISONING/OVERDOSE .. 287 CYANIDE EXPOSURE .. 291 BETA BLOCKER POISONING/OVERDOSE .. 295 BITES AND ENVENOMATION .. 299 CALCIUM CHANNEL BLOCKER POISONING/OVERDOSE .. 303 CARBON MONOXIDE/SMOKE INHALATION .. 307 OPIOID POISONING/OVERDOSE .. 311 AIRWAY RESPIRATORY IRRITANTS .. 316 RIOT CONTROL AGENTS .. 325 HYPERTHERMIA/HEAT EXPOSURE .. 328 HYPOTHERMIA/COLD EXPOSURE .. 333 DROWNING .. 341 DIVE (SCUBA) INJURY/ACCIDENTS .. 345 ALTITUDE ILLNESS .. 349 CONDUCTED ELECTRICAL WEAPON INJURY ( , TASER ) .. 353 ELECTRICAL INJURIES .. 357 LIGHTNING/LIGHTNING STRIKE INJURY .. 361 Rev. August 2021 4 APPENDICES .. 366 I. AUTHOR, REVIEWER AND STAFF INFORMATION .. 366 II. PUBLIC REVIEW COMMENT CONTRIBUTORS .. 374 III. UNIVERSAL DOCUMENTATION GUIDELINE.

5 375 IV. MEDICATIONS .. 389 V. APPROVED ABBREVIATIONS .. 406 VI. BURN AND BURN FLUID CHARTS .. 410 VII. NEUROLOGIC STATUS ASSESSMENT .. 416 VIII. ABNORMAL VITAL SIGNS .. 417 IX. EVIDENCE-BASED Guidelines : GRADE METHODOLOGY .. 418 X. 2011 Guidelines FOR FIELD TRIAGE OF INJURED patients .. 419 Rev. August 2021 5 Acknowledgement Rev. August 2021 6 Introduction We are honored to present the third edition of the National Association of State EMS Officials (NASEMSO) National Model EMS Clinical Guidelines and thank the entire EMS community for contributing to its evolution. The inaugural edition was released in September 2014 and has been warmly welcomed by EMS clinicians, agencies, medical directors, and healthcare organizations in our nation as well as abroad. The creation of this document was a pinnacle event in the practice of EMS medicine as it fulfilled a recommendation in The Future of Emergency Care: Emergency Medical Services at the Crossroads published by the Institute of Medicine (now the National Academies of Sciences) in 2007.

6 Specifically, this report states NHTSA, in partnership with professional organizations, should convene a panel of individuals with multidisciplinary expertise to develop evidence-based Model prehospital care protocols for the treatment, triage, and transport of patients . The NASEMSO National Model EMS Clinical Guidelines were developed with funding from NHTSA (Cooperative Agreement 693JJ92050001-0002) and the Health Resources and Services Administration. The opinions, findings, and conclusions expressed in this publication are those of the authors and not necessarily those of the United States Government. The United States Government assumes no liability for its content or use thereof. If trade or manufacturers names or products are mentioned, it is because they are considered essential to the object of the publication and should not be construed as an endorsement. The United States Government does not endorse products or manufacturers.

7 The National Association of State EMS Officials (NASEMSO) recognizes the need for National EMS Clinical Guidelines to help state EMS systems ensure a more standardized approach to the practice of patient care now and, as experience dictates, adoption of future practices. The value of EMS clinicians to the patient has no boundaries as magnified by the historic 2019 novel Coronavirus pandemic and other interjurisdictional and global responses. Model EMS Clinical Guidelines promote uniformity in EMS medicine which, in turn, promotes more consistently skilled practice as EMS clinicians move across healthcare systems. They also provide a standard to EMS medical directors upon which to base practice. Supported by initial and subsequent grant funding from NHTSA OEMS and the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau s EMS for Children program, NASEMSO authorized its Medical Directors Council to partner with National stakeholder organizations with expertise in EMS medical direction and subject matter experts to create a unified set of patient care Guidelines .

8 For the aspects of Clinical care where evidence-based Guidelines derived in accordance with the National evidence-based guideline Model process were not available, consensus-based Clinical Guidelines were developed utilizing currently available research. The NASEMSO Model EMS Clinical Guidelines are not mandatory nor are they meant to be all-inclusive or to determine local scope of practice. The focus of these Guidelines is solely patient-centric. As such, they are designed to provide a resource to Clinical practice, maximize patient care, safety, and outcomes regardless of the existing resources and capabilities within an EMS system. They are a set of Clinical Guidelines that can be used as is or adapted for use on a state, organizational, regional, or local level to enhance patient care and benchmark performance of EMS practice. NASEMSO s ongoing support of this project underlines the critical evolution of the Model EMS Clinical Guidelines as new EMS research and evidence-based patient care measures emerge in the future.

9 Finally, we are grateful to be able to continue the work on this initiative considering the group of talented, committed individuals we have been fortunate to call our partners in the endeavor. Rev. August 2021 7 Carol Cunningham, Richard Kamin, Co-Principal Investigator Co-Principal Investigator Rev. August 2021 8 Purpose and Notes These Guidelines are intended to help state EMS systems ensure a more standardized approach to the practice of patient care, and to encompass evidence-based Guidelines (EBG) as they are developed. The long-term goal is to develop a full range of evidence-based Clinical Guidelines for the practice of EMS medicine. However, until there is a sufficient body of evidence to fully support this goal, there is a need for this interim expert, consensus-based step. The National Model EMS Clinical Guidelines can fill a significant gap in uniform Clinical guidance for EMS patient care, while also providing input to the evidence-based guideline (EBG) development process.

10 These Guidelines will be maintained by the Medical Directors Council of the National Association of State EMS Officials (NASEMSO) and will be reviewed and updated periodically. As EBG material is developed, it will be substituted for the consensus-based Guidelines now comprising the majority of the content of this document. In the interim, additional consensus-based Guidelines will also be added as the need is identified. For Guidelines to be considered for inclusion, they must be presented in the format followed by all Guidelines in the document. Universal Care and Poisoning/Overdose Universal Care Guidelines are included to reduce the need for extensive reiteration of basic assessment and other considerations in every guideline. The appendices contain material such as neurologic status assessment and burn assessment tools to which many Guidelines refer to increase consistency in internal standardization and to reduce duplication.