National Model EMS Clinical Guidelines September 2017 VERSION 2.0 These guidelines will be maintained by 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 www.nasemso.org Contents INTRODUCTION .................................................................................................................................5 PURPOSE AND NOTES ........................................................................................................................6 TARGET AUDIENCE ......................................................................................................................................... 7 NEW IN THE 2017 EDITION ............................................................................................................................. 7 ACKNOWLEDGEMENTS ................................................................................................................................... 7 UNIVERSAL CARE ...............................................................................................................................8 UNIVERSAL CARE GUIDELINE ........................................................................................................................... 8 FUNCTIONAL NEEDS ..................................................................................................................................... 16 PATIENT REFUSALS ...................................................................................................................................... 20 CARDIOVASCULAR ........................................................................................................................... 23 ADULT AND PEDIATRIC SYNCOPE AND PRESYNCOPE ........................................................................................... 23 CHEST PAIN/ACUTE CORONARY SYNDROME (ACS)/ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) ..... 27 BRADYCARDIA ............................................................................................................................................. 30 IMPLANTABLE VENTRICULAR ASSIST DEVICES ................................................................................................... 34 TACHYCARDIA WITH A PULSE ......................................................................................................................... 37 SUSPECTED STROKE/TRANSIENT ISCHEMIC ATTACK ........................................................................................... 43 GENERAL MEDICAL........................................................................................................................... 46 ABDOMINAL PAIN ........................................................................................................................................ 46 ABUSE AND MALTREATMENT......................................................................................................................... 49 AGITATED OR VIOLENT PATIENT/BEHAVIORAL EMERGENCY ................................................................................ 53 ANAPHYLAXIS AND ALLERGIC REACTION .......................................................................................................... 59 ALTERED MENTAL STATUS ............................................................................................................................ 64 BACK PAIN ................................................................................................................................................. 67 END-OF-LIFE CARE/PALLIATIVE CARE .............................................................................................................. 70 HYPERGLYCEMIA ......................................................................................................................................... 73 HYPOGLYCEMIA ........................................................................................................................................... 76 NAUSEA-VOMITING ..................................................................................................................................... 80 PAIN MANAGEMENT .................................................................................................................................... 83 SEIZURES .................................................................................................................................................... 90 SHOCK ....................................................................................................................................................... 95 SICKLE CELL PAIN CRISIS ............................................................................................................................. 101 RESUSCITATION ............................................................................................................................. 104 CARDIAC ARREST (VF/VT/ASYSTOLE/PEA) ................................................................................................... 104 ADULT POST-ROSC (RETURN OF SPONTANEOUS CIRCULATION) CARE ............................................................... 113 DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ................................................................ 116 DO NOT RESUSCITATE STATUS/ADVANCE DIRECTIVES/HEALTHCARE POWER OF ATTORNEY (POA) STATUS ............. 119 TERMINATION OF RESUSCITATIVE EFFORTS .................................................................................................... 122 PEDIATRIC-SPECIFIC GUIDELINES .................................................................................................... 127 BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) .............................................................................................. 127 PEDIATRIC RESPIRATORY DISTRESS (BRONCHIOLITIS) ....................................................................................... 132 PEDIATRIC RESPIRATORY DISTRESS (CROUP) .................................................................................................. 137 NEONATAL RESUSCITATION ......................................................................................................................... 141 Updated October 4, 2017 2 OB/GYN ......................................................................................................................................... 145 CHILDBIRTH .............................................................................................................................................. 145 ECLAMPSIA/PRE-ECLAMPSIA ....................................................................................................................... 149 OBSTETRICAL AND GYNECOLOGICAL CONDITIONS ........................................................................................... 153 RESPIRATORY ................................................................................................................................ 156 AIRWAY MANAGEMENT ............................................................................................................................. 156 BRONCHOSPASM (DUE TO ASTHMA AND OBSTRUCTIVE LUNG DISEASE) .............................................................. 166 PULMONARY EDEMA .................................................................................................................................. 173 TRAUMA ........................................................................................................................................ 177 GENERAL TRAUMA MANAGEMENT ............................................................................................................... 177 BLAST INJURIES ......................................................................................................................................... 183 BURNS ..................................................................................................................................................... 187 CRUSH INJURY ........................................................................................................................................... 191 EXTREMITY TRAUMA/EXTERNAL HEMORRHAGE MANAGEMENT ........................................................................ 194 FACIAL/DENTAL TRAUMA ........................................................................................................................... 199 HEAD INJURY ............................................................................................................................................ 202 HIGH THREAT CONSIDERATIONS/ACTIVE SHOOTER SCENARIO ........................................................................... 207 SPINAL CARE ............................................................................................................................................. 210 TOXINS AND ENVIRONMENTAL ...................................................................................................... 217 POISONING/OVERDOSE UNIVERSAL CARE ...................................................................................................... 217 ACETYLCHOLINESTERASE INHIBITORS (CARBAMATES, NERVE AGENTS, ORGANOPHOSPHATES) EXPOSURE