CAREMS EMS Guidelines

Central Arizona Regional EMS Guidelines

• The guidelines come from the Arizona Department of Health Services, Bureau of Emergency Medical, Bureau of Emergency Medical Services and Trauma System's "Triage, Treatment, and Transport Guidelines (T3Gs) and the National Association of State EMS Officials (NASEMSO).
• The guidelines are collaboratively developed, maintained by Arizona EMS entities, which include: Central Arizona Region EMS Medical Directors Consortium (CAREMDC), EMS Regional Operations Consistency Committee (ROCC), and Westside EMS Consortium (WEMSCOM).
• The AEMS Board approved the guidelines on December 18, 2019.
• The guidelines were updated and approved in November 2023.

Disclaimer

• The guidelines are a resource document for Medical Direction Authorities as defined by A.R.S. § 36-2205.
• Medical Direction Authorities oversee the administrative, organizational, and on-line medical direction of pre-hospital Emergency Medical Care Technicians (EMCTs).
• Documented regional or local variations are specifically recognized not only as acceptable, but also as appropriate, depending on circumstances of involved areas and organizations.
• All advanced life support pre-hospital EMCTs require administrative and on-line medical direction according to Statute and Rule.
• These guidelines are not a substitute for such medical direction.
• Any conflict between the guidelines and medical direction default to the Medical Direction.
• The guidelines are deemed within the acceptable standard of medical care.
• Acceptable documented regional or local variations from these procedures and protocols may also satisfy the standard of care.
• The included manual does not establish the legal standard of care.

How to Use These Guidelines

• The guidelines adapt the National Association of State EMS Officials (NASEMSO) Model EMS Clinical Guidelines published online in January 2019.
• Algorithms include specific recommendations for evaluation and treatment.
• The inclusion and exclusion patient criteria are listed under the title of each guideline.
• Recommendations are listed in order by provider level scope of practice.
• More advanced levels of EMCT will perform all recommended evaluations and treatments included in the preceding level of care.
• STR stands for Special Training Required which means "Specialty Training Requirement skill," defined as a medical treatment, procedure, or technique, or administration of a medication for which an EMCT needs specific training per R9-25-502, and includes oversight by administrative and online medical direction.
• Specific pediatric recommendations are highlighted by the EMS for Children bear logo, where specific pediatric recommendations differ from those for adults.
• Unless specific pediatric recommendations are included in the algorithm, it is assumed that children will receive the evaluation and care recommended for all patients.
• A pediatric patient is defined as age less than 15 years.
• Age 15 and above is considered an adult patient concerning treatment guidelines.
• Energy/shock recommendations for cardioversion and defibrillation are highlighted by the lightning bolt symbol.
• The Universal Care treatment guideline should be applied to all patient encounters and encompasses both adult and pediatric patients.
• All initial patient care is included in this guideline to reduce the need for extensive reiteration of basic assessment and other considerations.
• When IV/IO access and drug routing is specified, it is intended to include IO access, and any IV/IO medication may be administered IO.
• IO is preferred for life-threatening conditions.
• On-line medical direction may be utilized at any time during the patient encounter.
• The appendix includes additional reference material, such as burn assessment and neurologic assessment tools.
• The NASEMSO model guidelines include additional information medical direction authorities may use for education, training, and quality improvement activities, like patient safety considerations, educational pearls, performance measures, and literature references: https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines_2022.pdf
• Version 3.0 was published in March 2022.
• "TOC" stands for Table of Contents.

General Policies and Guidance Documents - Titles and Pages

• Universal Care: Adult & Pediatric (2 pages) - Page 5
• Pediatric Assessment Triangle - Page 6
• Functional Needs: Adult & Pediatric - Page 7
• Patient Refusals: Adult & Pediatric - Page 8
• Abuse and Maltreatment: Adult & Pediatric - Page 9
• Pain Management: Adult & Pediatric - Page 10
• Communication Options - Page 11
• Initial Medical Care – Special Circumstances - Page 12
• On Scene Physician - Page 13
• Healthcare Facilities - Page 14
• Destination Guideline - Page 15
• Destination Decisions for Pediatric Cardiac Arrest - Page 16
• Additional Personnel Ride-in/Follow-up Guideline - Page 17
• ALS Release of Patients for BLS Transportation: Adult & Pediatric - Page 18

Universal Care: Adult & Pediatric (2 pages)

• These general recommendations apply to all patient encounters.
• Patient care goals are to facilitate appropriate initial assessment and manage treatment of any EMS patient.

EMT

• Assess scene safety.
• Use appropriate personal protective equipment (PPE).
• Determine the number of patients.
• Determine the need for formal triage and additional resources.
• Determine the mechanism of injury.
• Determine SMR needs.
• For minors, a parent or legal guardian who can provide consent for treatment is preferable; however, EMS providers may provide emergency treatment when a parent is unavailable to provide consent.
• Use commercially available tools for weight estimation.

Primary Survey (Airway, Breathing, Circulation, Disability, Exposure)

• Open airway as indicated.
• Consider position, suction, and airway adjuncts as indicated.
• Administer oxygen as appropriate.
• Assess circulatory status.
• Control any major external bleeding & Initiate chest compressions as indicated.
• Evaluate patient responsiveness using AVPU/GCS.
• Evaluate gross motor and sensory function in all extremities.
• Expose the patient as appropriate to the chief complaint.

Secondary Survey

• Obtain baseline vital signs.
• Assess blood glucose as indicated.
• Obtain OPQRST and SAMPLE history.
• Check temperature as indicated, and treat environmental hyperthermia/hypothermia.

Ongoing Reassessment

• Proceed to the appropriate guideline as indicated.
• Determine the need for transport, resources available, and the location of the most appropriate destination - transport as indicated.
• Reassess chief complaint, assessment findings, and the patient's response to treatment.
• Assess vital signs at least every 5 minutes for unstable patients; every 15 minutes for stable patients.

Paramedic

• Consider appropriate airway management adjuncts.
• Confirm supraglottic or endotracheal airway placement with waveform capnography (EtCO2); remove airway and place alternate device if unable to confirm.
• Use commercially available tool for medication dosing and equipment size selection.
• Initiate IV/IO access as indicated.
• Initiate IV/IO fluids as indicated.
• Consider appropriate airway management adjuncts, and escalate as indicated.
• Perform 12-lead ECG early in patients with potential cardiac complaints, aiming for within 5 minutes of patient contact.
• Continuous cardiac monitoring in patients with cardiac or respiratory complaints.
• Consider waveform capnography (EtCO2) combined with pulse oximetry (SpO2).

Pediatric Assessment Triangle

• The Pediatric Assessment Triangle assesses appearance, work of breathing, and circulation to the skin.
• Appearance is assessed by abnormal tone, decreased interactiveness, decreased consolability, abnormal look/gaze, and abnormal speech/cry.
• Work of breathing is assessed by abnormal sounds, abnormal position, retractions, flaring, and apnea/gasping.
• Circulation to skin is assessed by pallor, mottling, and cyanosis.

Functional Needs: Adult & Pediatric

• Includes patients with physical, sensory, mental health, and cognitive and/or intellectual disabilities affecting their ability to function independently without assistance.

EMT

• Identify functional needs by means of: patient, family, bystanders, medic alert bracelets, documents, or the patient's adjunct assistance devices.
• Do not intentionally shorten exam, but modify to accommodate the specific needs of the patient.
• Do not intentionally reduce or abbreviate medical care during triage, treatment, and transport, but care may need to be modified.
• For patients with communication barriers (language or sensory), secondary confirmation of pertinent data (e.g. allergies) from the patient's family, interpreters, or written or electronic medical records is desirable.
• Family embers can be an excellent source of information and a calming influence.
• Transport patients with all assistance adjuncts and service animals where feasible.

Informed Consent/Non-Treatment/Non-Transport: Adult & Pediatric

• If a patient (or their legal guardian) declines care/transport after EMS arrival, determine decision-making capacity and document encounter/refusal using a signed statement.

Decision-Making Capacity

• An individual who is alert, oriented, and can understand their illness/impairment along with risks of refusing care/transport typically has decision-making capacity.
• Decision-making capacity is demonstrated/documented by all 4 criteria below.
• The decision to refuse treatment/transport must be made without undue influence from others, and the patient must:
• Receive and comprehend information to make the decision
• Process and deliberate potential consequences
• Make and articulate a consistent decision
• Justify decision with values
• Decision-making judgements cannot be impaired by illness, injury or apparent intoxication with GCS score normal (15).
• Individuals with suicidal attempts, verbalized intent, or reasonably suspected of such may not decline transport.
• Patients with court order for psychiatric care cannot refuse care.
• If a patient in a healthcare facility wants to refuse transport, refer to Healthcare Facilities guideline.
• All patients, who request transport, will be transported.

EMT

• Make all reasonable efforts to avoid danger.
• Obtain complete vital signs.
• Complete initial assessment paying attention to neurologic/mental status.
• Perform care given consent.

Minors

• A parent or legal guardian provide consent unless treatment is an emergency.
• Must refuse care or legal guardian behalf to avoid abuse neglecting cases, and law are necessary for facilities to state-emancipated is required identification.
• Must consult a medical professional to access the patient's medical history, possible medical problems that are needed.

Abuse and Maltreatment: Adult & Pediatric

• Be aware of potential abuse/maltreatment clues from caregivers, the environment, and the patient’s condition.
• Recognize acts of commission/omission by a caregiver/powerful person that harms, potentially harms, or threatens harm to the patient.

EMS Role

• Document all concerns
• Assess any stabilize injured persons and state or authorities notify reports, neglecting suspected people with concerns reports minor.
• Legal and not fulfilling their report, investigation is required.
• Survey identified with trauma patients and avoid extreme medical needs.