Equipment for Ambulances A Joint Statement from the National Association of EMS Physicians, the American College of Emergency Physicians, andthe American College of Surgeons Committee on Trauma

Almost four decades ago, the Committee on Trauma (COT) of the American College of Surgeons (ACS) developed a list of standardized equipment for ambulances. Since 1988, the American College of Emergency Physicians (ACEP) has published a similar list. Both of those organizations collaborated on the existing joint document, published in 2000. With this revision, the National Association of EMS Physicians (NAEMSP) has agreed to participate in this collaboration.

All three organizations adhere to the principle that emergency medical technicians (EMTs) at all levels must have the appropriate equipment andsupplies to optimize prehospital delivery of care. Since EMTs care for patients of all ages, with a wide variety of medical andtraumatic conditions, the ACS COT, ACEP, andNAEMSP have joined to produce this document to serve as a widely accepted standard in the field of emergency ambulance service both in the United States andCanada. Based on the need for increased domestic preparedness, this current revision addresses for the first time those resources needed on ambulances for appropriate terrorism preparedness.

Principles of Prehospital Care

High-quality, consistent emergency care demands continuous quality improvement andis directly dependent on effectively monitoring, integrating, andevaluating all components of the patient's care.

The goal of prehospital care is to minimize further systemic insult or injury through a series of well-defined andappropriate interventions.

Integral to this process is medical oversight of prehospital care by preexisting protocol (indirect medical oversight) or by physician via voice and/or video communication (direct medical oversight). The protocols that guide patient care should be established in concert by medical directors for ambulance services, emergency physicians, trauma surgeons, andappropriately trained basic andadvanced emergency medical personnel.

Equipment andSupplies

The guidelines list the supplies andequipment that should be stocked on ambulances to provide patient care. Previous documents regarding ambulance equipment have referred to essential or minimal equipment necessary to adequately equip an ambulance. However, very little scientific evidence supports requirements for specific equipment andsupplies. Equipment requirements will vary, depending on the certification levels of the providers, population densities, geographic andeconomic conditions of the region, andother factors.

The following list represents a consensus of recommendations for equipment andsupplies that will facilitate patient care activities in the out-of -hospital setting.

Basic Level Providers

1. VENTILATION andAIRWAY EQUIPMENT

   1. Portable andfixed suction apparatus *Wide-bore tubing, rigid pharyngeal curved suction tip; tonsillar andflexible suction catheters, 5F-14F

   2. Portable andfixed oxygen equipment. *Variable flow regulator

   3. Oxygen administration equipment *Adequate length tubing; mask (adult, child, andinfant sizes), transparent, non-rebreathing, andvalveless; nasal cannulas (adult, child, andinfant sizes)

   4. Pocket mask with one-way valve

   5. Bag-valve mask *Hand-operated, self-reexpanding bag (adult andinfant sizes), with oxygen reservoir/accumulator; clear mask (adult, child, infant sizes, andneonate sizes); valve (clear, disposable, operable in cold weather)

   6. Airways *Nasopharyngeal, oropharyngeal (adult, child, andinfant sizes)

   7. Alternative airway devices (e.g., ETDLA [esophageal-tracheal double lumen airway]) as approved by local medical direction

1. MONITORING andDEFIBRILLATION

   Automatic external defibrillator is strongly recommended for systems that do not have immediate availability of an advanced life support service. All ambulances should be equipped with an automated external defibrillator unless staffed at all times by advanced life support personnel with a monitor/defibrillator

1. IMMOBILIZATION DEVICES

   1. Cervical collars *Rigid for children ages 2 years or older, infant, child, andadult sizes (small, medium, large, andother available sizes)

   2. Head immobilization device (not sandbags) *Firm padding or commercial device

   3. Lower extremity (femur) traction devices *Lower extremity, limb-support slings, padded ankle hitch, padded pelvic support, traction strap (adult andchild sizes)

   4. Upper andlower extremity immobilization devices *Joint-above andjoint-below fracture (adult andchild sizes), rigid-support appropriate material (cardboard, metal, pneumatic, vacuum, wood, or plastic)

   5. Radiolucent backboards (long, short) andextrication device *Joint-above andjoint-below fracture site (chin strap alone should not be used for head immobilization), adult andchild sizes, with padding for children, handholds for moving patients, short (extrication, head-to-pelvis length), long (transport, head to feet), with at least three appropriate restraint straps

1. BANDAGES

   1. Burn pack *Standard package, clean burn sheets (or towels for children)

   2. Triangular bandages *Minimum 2 safety pins each

   3. Dressings *Sterile multitrauma dressings (various large andsmall sizes) *ABDs, 10″ × 12″ or larger *4″ × 4″ gauze sponges

   4. Gauze rolls

   5. Elastic bandages *Nonsterile (various sizes)

   6. Occlusive Dressing *Sterile, 3″ by 8″ or larger

   7. Adhesive tape *Various sizes (including 2″ or 3″) hypoallergenic *Various sizes (including 2″ or 3″) adhesive

1. COMMUNICATION

   *Two-way radio communication (UHF, VHF) between EMT, dispatcher, andmedical oversight (physician) *Two-way disaster communication *Cellular phone

1. OBSTETRICAL

   1. Kit (separate sterile kit) *Towels, 4″ × 4″ dressing, umbilical tape, sterile scissors or other cutting utensil, bulb suction, clamps for cord, sterile gloves, blanket

   2. Thermal absorbent blanket andhead cover, aluminum foil roll, or appropriate heat-reflective material (enough to cover newborn)

   3. Appropriate heat source for ambulance compartment

1. MISCELLANEOUS

   1. Sphygmomanometer (infant, pediatric, andadult regular andlarge, for example, thigh sizes)

   2. Stethoscope (pediatric andadult)

   3. Length/weight-based chart for pediatric equipment sizing

   4. Thermometer with low temperature capability

   5. Heavy bandage or paramedic scissors for cutting clothing, belts, andboots

   6. Cold packs

   7. Sterile saline solution for irrigation (1-liter bottles or bags)

   8. Flashlights (2) with extra batteries andbulbs

   9. Blankets

   10. Sheets, linen or paper (minimum 4), andpillows

   11. Towels

   12. Triage tags

   13. Disposable emesis bags or basins

   14. Disposable bedpan

   15. Disposable urinal

   16. Wheeled cot (properly secured patient transport system)

   17. Folding stretcher

   18. Stair chair or carry chair

   19. Patient care charts/forms

   20. Lubricating jelly (water soluble)

   21. Appropriate CBRNE PPE (chemical, biological, radiological, nuclear, explosive personal protective equipment), including respiratory andbody protection

   22. Applicable chemical antidote autoinjectors (at a minimum for crew members' protection; additional for victim treatment as appropriate)

1. INFECTION CONTROL*

   *Latex-free equipment should be available.

   1. Eye protection (full peripheral glasses or goggles, face shield)

   2. Masks

   3. Gloves, nonsterile

   4. Jumpsuits or gowns

   5. Shoe covers

   6. Disinfectant hand wash, commercial antimicrobial (towelette, spray, liquid)

   7. Disinfectant solution for cleaning equipment

   8. Standard sharps containers

   9. Disposable trash bags (identifiable color, such as red)

   10. HEPA mask

1. INJURY PREVENTION EQUIPMENT

   1. Appropriate restraints (seat belts, air bags) for patient, crew, andfamily members.

   2. Child safety restraints

   3. Protective helmet andcoat with reflective material (1 each per crew member)

   4. Fire extinguisher

   5. Hazardous material reference guide

   6. Traffic signaling devices (reflective material triangles or other reflective, nonigniting devices)

1. OPTIONAL BASIC EQUIPMENT

   1. Pheumatic antishock garment (PASG) *Compartmentalized (legs andabdomen separate), control valves (closed/open), inflation pump, lower leg to lower ribcage (does not include chest)

   2. Respirator *Volume-cycled valve, on/off operation, 100% oxygen, 40–50 psi pressure (child/infant capabilities)

   3. Appropriate medication as approved by local medical director

Advanced Level Providers

For EMT-paramedic, including all the equipment listed for the basic level provider plus the following additional equipment andsupplies. For EMT-Intermediate (and other nonparamedic advanced levels), include all the equipment for the basic level provider andselected equipment andsupplies from the following list, as appropriate.

1. VASCULAR ACCESS

   1. Cyrstalloid solution Ringer's lactate or normal saline solution (1,000-mL bags × 4), 5% dextrose in water (optional) (fluid must be in bags, not bottles)

   2. Antiseptic solution (alcohol wipes andpovidone-iodine wipes preferred)

   3. IV pole or roof hook

   4. Intravenous catheters 14G–24G, 1″ long

   5. Intraosseous needles

   6. Tourniquet, rubber bands

   7. Syringes of various sized, including tuberculin

   8. Needles, sizes 19G–25G

   9. Intravenous administration sets (microdrip andmacrodrip)

   10. Intravenous arm boards, adult andpediatric

1. AIRWAY andVENTILATION EQUIPMENT

   1. Laryngoscope handle with extra batteries andbulbs, adult andpediatric

   2. Laryngoscope blades, sized 0, 1, and2, straight; sizes 3 and4, straight andcurved

   3. Endotracheal tubes, sizes 2.5–6.0 mm uncuffed and6.5–8.0 mm cuffed (2 each), other sizes optional

   4. Meconium aspirator

   5. 10-mL non-Luerlock syringes

   6. Stylettes for endotracheal tubes, adult andpediatric

   7. Magill forceps, adult andpediatric

   8. Lubricating jelly (water soluble)

   9. Nasogastric tubes, pediatric sized 5F and8F, Salem sump sizes 14F, 16F, and18F

   10. End-tidal CO₂ detectors *Colorimetric or quantitative

1. CARDIAC

   1. Portable, battery-operated monitor/defibrillator *With tape write-out/recorder, defibrillator pads, quick-lock paddles or hands-free patches, ECG leads, adult andpediatric chest attachment electrodes, adult andpediatric paddles, with capability to provide electrical discharge below 25 watt-seconds.

   2. Transcutaneous cardiac pacemaker *Either stand-alone unit or integrated into monitor /defibrillator

1. OTHER ADVANCED EQUIPMENT

   1. Nebulizer

   2. Glucometer or blood glucose measuring device *With reagent strips

   3. Pulse oximetry with pediatric andadult probes

1. MEDICATIONS (PRELOAD WHEN AVAILABLE)

   Medications used on advanced level ambulances should be compatible with current standards as indicated by the American Heart Association's Emergency Cardiac Care Committee, as reflected in the Advanced Cardiac Life Support Course, or other such organizations andpublications (ACEP, ACS, NAEMSP, andso on). In general, medications should include:

   • Cardiovascular medications, such as 1:10,000 epinephrine, atropine, antidysrhythmics, calcium channel blockers, beta-blockers, nitroglycerin tablets, aspirin, pressors

   • Cardiopulmonary/respiratory medications, such as albuterol (or other inhaled beta agonist), 1:1,000 epinephrine, furosemide

   • 50% dextrose solution (and sterile dilutent or 25% dextrose solution for pediatrics)

   • Analgesics, narcotic andnonnarcotic

   • Antiepileptic medications, such as diazepam or midazolam

   • Sodium bicarbonate, magnesium sulfate, glucagons, naloxone hydrochloride

   • Bacteriostatic water andsodium chloride for injection

   • Sedation or other intubation adjuncts such as paralytics should only be used with approval andclose medical oversight

1. OTIONAL ADVANCED EQUIPMENT

   1. Portable automatic ventilators

   2. Blood sample tubes, adult andpediatric

   3. Automatic blood pressure device

Appendix

Extrication Equipment

Adequate extrication equipment must be readily available to the emergency medical services responders, but is more often found on heavy rescue vehicles than on the primary responding ambulance.

In general, the devices or tools used for extrication fall into several broad categories: disassembly, spreading, cutting, pulling, protective, andpatient-related.

The following is necessary equipment that should be available either on the primary response vehicle or on a heavy rescue vehicle.

Disassembly Tools

• Wrenches (adjustable)

• Screwdrivers (flat andPhillips head)

• Bolt cutter

• Tin snips

• Hammer

• Spring-loaded center punch

• Axes (pry, fire)

• Bars (wrecking, crow)

• Ram (4 ton)

Spreading Tools

• Hydraulic jack/spreader/cutter combination

Cutting Tools

• Saws (hacksaw, fire, windshield, pruning, reciprocating)

• Air-cutting gun kit

Pulling Tools/Devices

• Ropes/chains

• Come-along

• Hydraulic truck jack

• Air bags

Protective Devices

• Reflectors/flares

• Hard hats

• Safety goggles

• Fireproof blanket

• Leather gloves

• Jackets/coats/boots

Patient-Related Devices

• Stokes basket

Miscellaneous

• Shovel

• Lubricating oil

• Wood/wedges

• Generator

• Floodlights

Local extrication needs may necessitate additional equipment, (i.e., water, aerial, or mountain rescue).