National Model EMS Clinical Guidelines January 2019 VERSION 2.2 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 .................................................................................................................................................. 91 SHOCK ..................................................................................................................................................... 96 SICKLE CELL PAIN CRISIS ............................................................................................................................ 102 RESUSCITATION ............................................................................................................................... 105 CARDIAC ARREST (VF/VT/ASYSTOLE/PEA) .................................................................................................. 105 ADULT POST-ROSC (RETURN OF SPONTANEOUS CIRCULATION) CARE .............................................................. 114 DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ............................................................... 117 DO NOT RESUSCITATE STATUS/ADVANCE DIRECTIVES/HEALTHCARE POWER OF ATTORNEY (POA) STATUS ............. 120 TERMINATION OF RESUSCITATIVE EFFORTS ................................................................................................... 123 PEDIATRIC-SPECIFIC GUIDELINES ...................................................................................................... 128 BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) ............................................................................................. 128 PEDIATRIC RESPIRATORY DISTRESS (BRONCHIOLITIS) ...................................................................................... 133 PEDIATRIC RESPIRATORY DISTRESS (CROUP) ................................................................................................. 138 NEONATAL RESUSCITATION ........................................................................................................................ 142 Updated November 23, 2020 2 OB/GYN ........................................................................................................................................... 146 CHILDBIRTH ............................................................................................................................................. 146 ECLAMPSIA/PRE-ECLAMPSIA ...................................................................................................................... 150 OBSTETRICAL AND GYNECOLOGICAL CONDITIONS .......................................................................................... 154 RESPIRATORY ................................................................................................................................... 157 AIRWAY MANAGEMENT ............................................................................................................................ 157 BRONCHOSPASM (DUE TO ASTHMA AND OBSTRUCTIVE LUNG DISEASE) ............................................................. 167 PULMONARY EDEMA ................................................................................................................................ 174 TRAUMA .......................................................................................................................................... 178 GENERAL TRAUMA MANAGEMENT .............................................................................................................. 178 BLAST INJURIES ........................................................................................................................................ 184 BURNS ................................................................................................................................................... 188 CRUSH INJURY ......................................................................................................................................... 192 EXTREMITY TRAUMA/EXTERNAL HEMORRHAGE MANAGEMENT ....................................................................... 195 FACIAL/DENTAL TRAUMA .......................................................................................................................... 200 HEAD INJURY ........................................................................................................................................... 203 HIGH THREAT CONSIDERATIONS/ACTIVE SHOOTER SCENARIO .......................................................................... 208 SPINAL CARE ........................................................................................................................................... 211 TOXINS AND ENVIRONMENTAL ........................................................................................................ 218 POISONING/OVERDOSE UNIVERSAL CARE ..................................................................................................... 218 ACETYLCHOLINESTERASE INHIBITORS (CARBAMATES, NERVE AGENTS, ORGANOPHOSPHATES) EXPOSURE ................ 226 RADIATION EXPOSURE