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 .......................................................................................................... 60 ALTERED MENTAL STATUS ............................................................................................................................ 66 BACK PAIN ................................................................................................................................................. 69 END-OF-LIFE CARE/PALLIATIVE CARE .............................................................................................................. 72 HYPERGLYCEMIA ......................................................................................................................................... 75 HYPOGLYCEMIA ........................................................................................................................................... 78 NAUSEA-VOMITING ..................................................................................................................................... 83 PAIN MANAGEMENT .................................................................................................................................... 86 SEIZURES .................................................................................................................................................... 94 SHOCK ..................................................................................................................................................... 100 SICKLE CELL PAIN CRISIS ............................................................................................................................. 106 RESUSCITATION ............................................................................................................................. 109 CARDIAC ARREST (VF/VT/ASYSTOLE/PEA) ................................................................................................... 109 ADULT POST-ROSC (RETURN OF SPONTANEOUS CIRCULATION) CARE ............................................................... 118 DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ................................................................ 121 DO NOT RESUSCITATE STATUS/ADVANCE DIRECTIVES/HEALTHCARE POWER OF ATTORNEY (POA) STATUS ............. 124 TERMINATION OF RESUSCITATIVE EFFORTS .................................................................................................... 127 PEDIATRIC-SPECIFIC GUIDELINES .................................................................................................... 132 BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) .............................................................................................. 132 PEDIATRIC RESPIRATORY DISTRESS (CROUP) .................................................................................................. 142 NEONATAL RESUSCITATION ......................................................................................................................... 147 OB/GYN ......................................................................................................................................... 151 2 CHILDBIRTH .............................................................................................................................................. 151 ECLAMPSIA/PRE-ECLAMPSIA ....................................................................................................................... 156 OBSTETRICAL AND GYNECOLOGICAL CONDITIONS ........................................................................................... 160 RESPIRATORY ................................................................................................................................ 163 AIRWAY MANAGEMENT ............................................................................................................................. 163 BRONCHOSPASM (DUE TO ASTHMA AND OBSTRUCTIVE LUNG DISEASE) .............................................................. 173 PULMONARY EDEMA .................................................................................................................................. 180 TRAUMA ........................................................................................................................................ 184 GENERAL TRAUMA MANAGEMENT ............................................................................................................... 184 BLAST INJURIES ......................................................................................................................................... 190 BURNS ..................................................................................................................................................... 194 CRUSH INJURY ........................................................................................................................................... 198 EXTREMITY TRAUMA/EXTERNAL HEMORRHAGE MANAGEMENT ........................................................................ 201 FACIAL/DENTAL TRAUMA ........................................................................................................................... 206 HEAD INJURY ............................................................................................................................................ 209 HIGH THREAT CONSIDERATIONS/ACTIVE SHOOTER SCENARIO ........................................................................... 214 SPINAL CARE ............................................................................................................................................. 217 TOXINS AND ENVIRONMENTAL ...................................................................................................... 225 POISONING/OVERDOSE UNIVERSAL CARE ...................................................................................................... 225 ACETYLCHOLINESTERASE INHIBITORS (CARBAMATES, NERVE AGENTS, ORGANOPHOSPHATES) EXPOSURE ................. 233 RADIATION EXPOSURE ...............................................................................................................................