NASEMSO Model EMS Clinical Guidelines:

Phase 2

2017 Update

Model EMS Clinical Guidelines

� Project funded by National Highway Traffic Safety Administration, Office of EMS (NHTSA-OEMS) and the Health Resources Services Administration, EMS for Children Program (HRSA/EMS-C)

� Co-Primary Investigators:� Carol Cunningham, MD� Richard Kamin, MD

� Multi-organizational effort, led by NASEMSO Medical Directors Council

Model EMS Clinical Guidelines

� Goals: � Develop model clinical field treatment guidelines

(protocols) for EMS providers based on the most current standards of practice and evidence.

� Promote uniformity and quality of prehospital care� Improve EMS data collection efforts� Provide resource to assist state, regional, and local medical

directors in the development and maintenance of field treatment protocols

� Promote nationwide consistency and mobility amongst EMS providers

Evidence Based?

� Evidence-based where possible

� Consensus-based where no current evidence based guideline exists

� References

Development and Maintenance

� Initial “core” set of 56 guidelines released in 2014. Currently being updated and expanded with 16 more to be added in 2017.

� Development team members:� State EMS Medical Directors (NASEMSO)� American College of Surgeons-Committee on Trauma� American Association of Pediatrics� American College of Emergency Physicians� Air Medical Physician Association� American Academy of Emergency Medicine� American College of Osteopathic Emergency Physicians� National Association of EMS Physicians

Chapters

� Universal Care

� Cardiovascular

� General Medical

� Resuscitation

� Pediatric-Specific

� Ob/Gyn

� Respiratory

� Trauma

� Toxins and Environmental

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Burns (9914085 – Burns – Thermal) Patient Care Goals Minimize tissue damage and patient morbidity from burns Patient Presentation Observe and document:

1. Airway – stridor, hoarse voice 2. Mouth and nares – redness, blisters, soot, singed hairs 3. Breathing – rapid, shallow, wheezes, rales 4. Skin – Estimate Body Surface Area (BSA) and depth (partial v. full thickness) 5. Associated trauma – blast, fall, assault

Inclusion Criteria Patients sustaining thermal burns

Exclusion Criteria Electrical, chemical, and radiation burns (see Toxins and Environmental section)

Special transport considerations:

1. Transport to most appropriate trauma center when there is airway or respiratory involvement, or when multi-trauma or blast injury is suspected

2. Consider transport directly to burn center if BSA > 20% partial thickness, BSA > 10% full thickness involvement of hands/feet, genitalia, face; circumferential burns

3. Consider air ambulance transportation for long transport times, pain control requiring deep sedation, and airway concerns that might necessitate advanced airway management

Scene Management: Assure crew safety: power off, electrical lines secure, gas off, no secondary devices, hazmat determinations made, proper protective attire including breathing apparatus may be required Patient Management Assessment

1. Circumstances of event-- consider: a. related trauma in addition to the burns b. inhalation exposures such as CO and cyanide c. pediatric or elder abuse

2. Follow ABCs of resuscitation 3. If evidence of possible airway burn, consider aggressive airway management. 4. Consider spinal immobilization (See Spinal Care guideline) 5. Estimate BSA burned and depth of burn (See burn related tables in Appendix V) 6. Document pain scale

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Burns (9914085 – Burns – Thermal) Patient Care Goals Minimize tissue damage and patient morbidity from burns Patient Presentation Observe and document:

1. Airway – stridor, hoarse voice 2. Mouth and nares – redness, blisters, soot, singed hairs 3. Breathing – rapid, shallow, wheezes, rales 4. Skin – Estimate Body Surface Area (BSA) and depth (partial v. full thickness) 5. Associated trauma – blast, fall, assault

Inclusion Criteria Patients sustaining thermal burns

Exclusion Criteria Electrical, chemical, and radiation burns (see Toxins and Environmental section)

Special transport considerations:

1. Transport to most appropriate trauma center when there is airway or respiratory involvement, or when multi-trauma or blast injury is suspected

2. Consider transport directly to burn center if BSA > 20% partial thickness, BSA > 10% full thickness involvement of hands/feet, genitalia, face; circumferential burns

3. Consider air ambulance transportation for long transport times, pain control requiring deep sedation, and airway concerns that might necessitate advanced airway management

Scene Management: Assure crew safety: power off, electrical lines secure, gas off, no secondary devices, hazmat determinations made, proper protective attire including breathing apparatus may be required Patient Management Assessment

1. Circumstances of event-- consider: a. related trauma in addition to the burns b. inhalation exposures such as CO and cyanide c. pediatric or elder abuse

2. Follow ABCs of resuscitation 3. If evidence of possible airway burn, consider aggressive airway management. 4. Consider spinal immobilization (See Spinal Care guideline) 5. Estimate BSA burned and depth of burn (See burn related tables in Appendix V) 6. Document pain scale

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Treatments and interventions 1. Stop the burning:

a. Soak clothing and skin with water if burning or smoldering, then remove clothing if not stuck to the patient

b. Remove jewelry. It may be hot c. Leave blisters intact

2. Minimize burn wound contamination. Cover burns with dry dressing or clean sheet. 3. Vital signs including SPO2, consider SPCO and ETCO2 if available

a. ETCO2 monitoring may be particularly useful to monitor respiratory status in patients receiving significant doses of narcotic pain medication

b. Cardiac monitor is important in chemical inhalations and electrical burns. 4. Supplement oxygen titrated to SPO2, if available. Give to all burn patients rescued from a

confined space 5. Establish IV access, avoid placement through burned skin 6. Evaluate distal circulation in circumferentially burned extremities 7. Consider early management of pain and nausea/vomiting. 8. Initiate fluid resuscitation: Use lactated ringers or normal saline

a. If patient in shock, give fluid per shock protocol b. If patient not in shock: Begin fluids based on estimated TBSA (see Initial Fluid Rate Chart

for Burns in Appendix V). For children, use length-based tape for weight estimate c. Initial fluid rate can also be calculated as: body weight (kg) X TBSA = cc of fluid to be given

in first 2 hours 9. Prevent systemic heat loss – keep patient warm

Special treatment considerations 1. If blast mechanism, see Blast Injury guideline 2. Airway burns can rapidly lead to upper airway obstruction and respiratory failure 3. Have a high index of suspicion for cyanide poisoning in a patient with depressed GCS,

respiratory difficulty and cardiovascular collapse in the setting of an enclosed-space fire. Give antidote (hydroxocobalamin), if available, in this circumstance

4. Particularly in closed space fires, carbon monoxide toxicity is a consideration; pulse oximetry may not be accurate; see Carbon Monoxide Poisoning guideline

5. For specific chemical exposures (cyanide, hydrofluoric acid, other acids and alkali) see Chemical Burn guideline

6. Consider contamination and notification of receiving facility of potentially contaminated patient (e.g. meth lab incident)

Notes/Educational Pearls

1. Onset of stridor and change in voice are sentinel signs of potentially significant airway burns, which may rapidly lead to airway obstruction or respiratory failure

2. If the patient is not in shock, the fluid rates recommended above will adequately maintain patient’s fluid volume per the Parkland Formula

3. Pain management is critical in acute burns Quality Improvement Burn trauma is relatively uncommon. Providers should receive regular training on burn assessment and management

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Treatments and interventions 1. Stop the burning:

a. Soak clothing and skin with water if burning or smoldering, then remove clothing if not stuck to the patient

b. Remove jewelry. It may be hot c. Leave blisters intact

2. Minimize burn wound contamination. Cover burns with dry dressing or clean sheet. 3. Vital signs including SPO2, consider SPCO and ETCO2 if available

a. ETCO2 monitoring may be particularly useful to monitor respiratory status in patients receiving significant doses of narcotic pain medication

b. Cardiac monitor is important in chemical inhalations and electrical burns. 4. Supplement oxygen titrated to SPO2, if available. Give to all burn patients rescued from a

confined space 5. Establish IV access, avoid placement through burned skin 6. Evaluate distal circulation in circumferentially burned extremities 7. Consider early management of pain and nausea/vomiting. 8. Initiate fluid resuscitation: Use lactated ringers or normal saline

a. If patient in shock, give fluid per shock protocol b. If patient not in shock: Begin fluids based on estimated TBSA (see Initial Fluid Rate Chart

for Burns in Appendix V). For children, use length-based tape for weight estimate c. Initial fluid rate can also be calculated as: body weight (kg) X TBSA = cc of fluid to be given

in first 2 hours 9. Prevent systemic heat loss – keep patient warm

Special treatment considerations 1. If blast mechanism, see Blast Injury guideline 2. Airway burns can rapidly lead to upper airway obstruction and respiratory failure 3. Have a high index of suspicion for cyanide poisoning in a patient with depressed GCS,

respiratory difficulty and cardiovascular collapse in the setting of an enclosed-space fire. Give antidote (hydroxocobalamin), if available, in this circumstance

4. Particularly in closed space fires, carbon monoxide toxicity is a consideration; pulse oximetry may not be accurate; see Carbon Monoxide Poisoning guideline

5. For specific chemical exposures (cyanide, hydrofluoric acid, other acids and alkali) see Chemical Burn guideline

6. Consider contamination and notification of receiving facility of potentially contaminated patient (e.g. meth lab incident)

Notes/Educational Pearls

1. Onset of stridor and change in voice are sentinel signs of potentially significant airway burns, which may rapidly lead to airway obstruction or respiratory failure

2. If the patient is not in shock, the fluid rates recommended above will adequately maintain patient’s fluid volume per the Parkland Formula

3. Pain management is critical in acute burns Quality Improvement Burn trauma is relatively uncommon. Providers should receive regular training on burn assessment and management

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Key Documentation Elements 1. Initial airway status

2. Body surface area of second and third degree burns

3. Mechanism of burn injury

4. Pulse and capillary refill exam distally on any circumferentially burned extremity

5. Pain scale documentation and pain management

Performance Measures 1. Patient transported to most appropriate hospital, preferably a burn center

2. Pain scale documented and pain appropriately managed

3. Airway assessment and management appropriately documented

References 1. Mitra B, Fitzgerald M, Wasiak J et al. The Alfred pre-hospital fluid formula for major burns.

Burns, 2011; 37:1134-1139

2. Fluid Rate charts (based on Parkland formula) and TBSA diagrams courtesy of the University

of Utah Burn Center; 2014

3. American Burn Association. Advanced Burn Life Support (ABLS) Handbook; 2011

Revision Date

September 15, 2014

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Key Documentation Elements 1. Initial airway status

2. Body surface area of second and third degree burns

3. Mechanism of burn injury

4. Pulse and capillary refill exam distally on any circumferentially burned extremity

5. Pain scale documentation and pain management

Performance Measures 1. Patient transported to most appropriate hospital, preferably a burn center

2. Pain scale documented and pain appropriately managed

3. Airway assessment and management appropriately documented

References 1. Mitra B, Fitzgerald M, Wasiak J et al. The Alfred pre-hospital fluid formula for major burns.

Burns, 2011; 37:1134-1139

2. Fluid Rate charts (based on Parkland formula) and TBSA diagrams courtesy of the University

of Utah Burn Center; 2014

3. American Burn Association. Advanced Burn Life Support (ABLS) Handbook; 2011

Revision Date

September 15, 2014

How have they been used?

� One of the most frequently downloaded items from NASEMSO website. Can be requested in Word format, to make it easier to adapt.

� Of 30 States with mandatory or model EMS protocols:� 73% used National Model Guidelines in revising their state

protocols/guidelines, mostly as a reference.

� Offered to anyone who requests it – Local EMS agency, state EMS office, international

2017 Update

� Development Committee reconvened

� Latest published evidence gathered/reviewed

� Original guidelines fully updated

� 16 new guidelines being added

� Completion date – September 2017

2017 New Guidelines Added: By Popular Demand

� Abdominal Pain

� Amputation

� Back Pain

� Crush Syndrome

� Airway Irritants

� Biologic/Infectious Agents

� Blistering Agents

� Hypertension

� Impaled Objects

� Cardiac Devices

� Sickle Cell Crisis

� Management of Trachs

� Active Shooter

� Palliative Care

� Recognition of Human Trafficking

“What Do They Mean to My Agency?” � Check them out against your own protocols

� Update required?� Something new/different/useful?

� Great educational resource� Explanations� Key considerations� References

� Ammo to bring to your medical director

� Great nighttime reading� Don’t need sleep aids

Questions/Contacts

� Mary Hedges: hedges@nasemso.org

� Dr. Carol Cunningham: CACunningham@dps.state.oh.us

� Dr. Rich Kamin: rkamin@uchc.edu