Four decades ago, the Committee on Trauma of the American College of Surgeons (ACS) developed a list of standardized equipment for ambulances. In 1988, the American College of Emergency Physicians (ACEP) published a similar list. The two organizations collaborated on a joint document published in 2000, and the National Association of EMS Physicians (NAEMSP) participated in the 2005 revision. The 2005 revision included resources needed on emergency ground ambulances for appropriate homeland security. All three organizations adhere to the principle that emergency medical services (EMS) providers at all levels must have the appropriate equipment and supplies to optimize out-of-hospital delivery of care. The document was written to serve as a standard for the equipment needs of emergency ground ambulance services both in the United States and Canada.
EMS providers care for patients of all ages who have a wide variety of medical and traumatic conditions. The 2009 revision included updated pediatric recommendations developed by members of the Federal Emergency Medical Services for Children (EMSC) Stakeholder Group and endorsed by the American Academy of Pediatrics (AAP). The EMSC program has developed several performance measures for the program's state partnership grantees. One of the performance measures evaluates the availability of essential pediatric equipment and supplies for basic life support (BLS) and advanced life support (ALS) patient care units. This document is used as the standard for this performance measure. The National Association of State EMS Officials and the Emergency Nurses Association have participated in the latest revision process. The recommendations in this document specifically pertain to ALS and BLS emergency ground ambulance services in the United States.
For purposes of this document, the following definitions have been used: a neonate is 0–28 days old, an infant is 29 days to 1 year old, and a child is >1 year through 11 years old with delineation into the following developmental stages:
Toddlers (1–3 years old)
Preschoolers (3–5 years old)
Middle childhood (6–11 years old)
Adolescents (12–18 years old)
These standard definitions are age based. Length-based systems have been developed to more accurately estimate the weight of children and predict appropriate equipment sizes, medication doses, and guidelines for fluid volume administration.
Principles of Out-of-hospital Care
The goal of out-of-hospital care is to minimize further systemic injury and manage life-threatening conditions through a series of well-defined and appropriate interventions and to embrace principles that ensure patient safety. High-quality, consistent emergency care demands continuous quality improvement and is directly dependent on the effective monitoring, integration, and evaluation of all components of the patient's care.
Integral to this process is medical oversight of out-of-hospital care by using preexisting patient care protocols (indirect medical oversight), which are evidence based when possible, or by medical control via voice and/or video communication (direct medical oversight). The protocols that guide patient care should be established collaboratively by medical directors for ground ambulance services, adult and pediatric emergency medicine physicians, adult and pediatric trauma surgeons, and appropriately trained basic and advanced emergency medical personnel. Current recommendations of the Institute of Medicine (IOM) encourage each EMS agency to have a pediatric coordinator to specifically coordinate the capability of the service to care for non-adult patients.
Equipment and Supplies
The current guidelines provide a recommended core list of supplies and equipment that should be stocked on ground ambulances to provide the accepted standards of patient care. Equipment requirements will vary, depending on the certification or licensure levels of the providers (as defined by the National EMS Scope of Practice Model 2007 www.ems.gov/education/EMSScope.pdf), local medical direction and jurisdiction, population densities, geographic and economic conditions of the region, and other factors.
The National EMS Scope of Practice Model defines and describes four certification or licensure levels of EMS provider: emergency medical responder (EMR), emergency medical technician (EMT), advanced EMT (AEMT), and paramedic. Each level represents a unique role, set of skills, and knowledge base. The National EMS Scope of Practice Model establishes a framework that ultimately determines the range of skills and roles that an individual possessing a state EMS license is authorized to do in a given EMS system. Individual state EMS rules or regulations that limit provider scope of practice may impact the need for availability of certain pieces of equipment.
The current equipment list is derived from a number of sources, which may be found in the reference list at the end of the document. The use of a proprietary name that is inextricably linked with its product should not be construed as an endorsement.
The following list is divided into equipment for basic life support (BLS) and advanced life support (ALS) emergency ground ambulances. ALS ambulances must have all of the equipment on the required BLS list as well as equipment on the required ALS list. This list represents a consensus of recommendations for equipment and supplies that will facilitate patient care in the out-of-hospital setting.
Required Equipment for BLS Emergency Ground Ambulances
Ventilation and Airway Equipment
Portable and fixed suction apparatus with a regulator, per federal specifications
Wide-bore tubing, rigid pharyngeal curved suction tip; tonsil and flexible suction catheters, 6F–16F, are commercially available (have one between 6F and 10F and one between 12F and 16F)
Portable oxygen apparatus, capable of metered flow with adequate tubing
Portable and fixed oxygen supply equipment
Variable flowmeter
Oxygen administration equipment
Adequate-length tubing; transparent mask (adult and child sizes), both non-rebreathing and valveless; nasal cannulas (adult, child)
Bag-valve mask (manual resuscitator)
Hand-operated, self-expanding bag; adult (>1000 mL) and child (450–750 mL) sizes, with oxygen reservoir/accumulator, valve (clear, operable in cold weather), and mask (adult, child, infant, and neonate sizes)
Airways
Nasopharyngeal (16F–34F; adult and child sizes)
Oropharyngeal (sizes 0–5; adult, child, and infant sizes)
Pulse oximeter with pediatric and adult probes
Saline drops and bulb suction for infants
Monitoring and Defibrillation
BLS ground ambulances should be equipped with an automated external defibrillator (AED) unless staffed by advanced life support personnel who are carrying a monitor/defibrillator. The AED should have pediatric capabilities, including child-sized pads and cables OR dose attenuator with adult pads.
Immobilization Devices
Cervical collars
Rigid for children ages 2 years or older; child and adult sizes (small, medium, large, and other available sizes) OR pediatric and adult adjustable cervical collars
Head immobilization device (not sandbags)
Firm padding or commercial device
Upper and lower extremity immobilization devices
Joint-above and joint-below fracture (sizes appropriate for adults and children) rigid support, constructed with appropriate material (cardboard, metal, pneumatic, vacuum, wood, or plastic)
Impervious backboards (long, short; radiolucent preferred) and extrication device
Short extrication/immobilization device (e.g., KED)
Long transport (head-to-feet length) with at least 3 appropriate restraint straps (chin strap alone should not be used for head immobilization) and with padding for children and handholds for moving patients
Bandages/Hemorrhage Control
Commercially packaged or sterile burn sheets
Bandages
Triangular bandages
Dressings
Sterile dressings, including gauze sponges of suitable size
Abdominal dressing
Gauze rolls
Various sizes
Occlusive dressing or equivalent
Adhesive tape
Various sizes (including 1′′ and 2′′) hypoallergenic
Various sizes (including 1′′ and 2′′) adhesive
Arterial tourniquet (commercial preferred)
Communication
Two-way communication device between ground ambulance, dispatch, medical control, and receiving facility
Obstetrical Kit (commercially packaged are available)
Kit (separate sterile kit)
Towels, 4′′ × 4′′ dressing, umbilical tape, sterile scissors or other cutting utensil, bulb suction, clamps for cord, sterile gloves, blanket
Thermal absorbent blanket and head cover, aluminum foil roll, or appropriate heat-reflective material (enough to cover newborn infant)
Miscellaneous
Access to pediatric and adult patient care protocols
A length-based resuscitation tape OR a reference material that provides appropriate guidance for pediatric drug dosing and equipment sizing based on length OR age
Sphygmomanometer (pediatric and adult regular size and large cuffs)
Adult stethoscope
Thermometer with low-temperature capability
Heavy bandage or paramedic scissors for cutting clothing, belts, and boots
Cold packs
Sterile saline solution for irrigation
Two functional flashlights
Blankets
Sheets (at least one change per cot)
Pillows
Towels
Triage tags
Emesis bags or basins
Urinal
Wheeled cot
Stair chair or carry chair
Patient care charts/forms or electronic capability
Lubricating jelly (water soluble)
Infection Control*
Eye protection (full peripheral glasses or goggles, face shield)
Face protection (e.g., surgical masks per applicable local or state guidance)
Gloves, nonsterile
Fluid-resistant overalls or gowns
Waterless hand cleanser, commercial antimicrobial (towelette, spray, or liquid)
Disinfectant solution for cleaning equipment
Standard sharps containers, fixed and portable
Biohazard trash bags (color coded or with biohazard emblem to distinguish from other trash)
Respiratory protection (e.g., N95 or N100 mask—per applicable local or state guidance)
*Latex-free equipment should be available
Injury-prevention Equipment
Availability of necessary age/size-appropriate restraint systems for all passengers and patients transported in ground ambulances. For children, this should be according to the National Highway Traffic Administration's document: Safe Transport of Children in Emergency Ground Ambulances (www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf)
Fire extinguisher
Department of Transportation Emergency Response Guide
Reflective safety wear for each crewmember (must meet American National Standard for High Visibility Public Safety Vests if working within the right of way of any federal-aid highway. Visit www.reflectivevest.com/federalhighwayruling.html for more information)
Required Equipment: Advanced Life Support (ALS) Emergency Ground Ambulances
For paramedic services, include all of the required equipment listed above, plus the following additional equipment and supplies. For advanced EMT services (and other non-paramedic advanced levels), include all of the equipment from the above list and selected equipment and supplies from the following list, based on scope of practice, local need, and consideration of out-of-hospital characteristics and budget.
Airway and Ventilation Equipment
Laryngoscope handle with extra batteries and bulbs
Laryngoscope blades, sizes:
0–4, straight (Miller), and
2–4, curved
Endotracheal tubes (if ALS service scope of practice includes tracheal intubation), sizes:
2.5, 3.0, 3.5, 4.0, 4.5, 5.0, and 5.5 mm cuffed and/or uncuffed, and
6.0, 6.5, 7.0, 7.5, and 8.0 mm cuffed (1 each), other sizes optional
10-mL non-Luer Lock syringes
Stylettes for endotracheal tubes, adult and pediatric
Magill forceps, adult and pediatric
End-tidal CO2 detection capability (adult and pediatric)
Rescue airway device, such as the ETDLA (esophageal–tracheal double-lumen airway), laryngeal tube, disposable supraglottic airway, or laryngeal mask airway (as approved by local medical direction)
Vascular Access
Isotonic crystalloid solutions
Antiseptic solution (alcohol wipes and povidone–iodine wipes preferred)
Intravenous fluid bag pole or roof hook
Intravenous catheters, 14G–24G
Intraosseous needles or devices appropriate for children and adults
Latex-free tourniquet
Syringes of various sizes
Needles, various sizes (including suitable sizes for intramuscular injections)
Intravenous administration sets (microdrip and macrodrip)
Intravenous arm boards, adult and pediatric
Cardiac
Portable, battery-operated monitor/defibri- llator
With tape write-out/recorder, defibrillator pads, quick-look paddles or electrode, or hands-free patches, electrocardiogram leads, adult and pediatric chest attachment electrodes, adult and pediatric paddles
Transcutaneous cardiac pacemaker, including pediatric pads and cables
Either stand-alone unit or integrated into monitor/defibrillator
Other Advanced Equipment
Nebulizer
Glucometer or blood glucose measuring device with reagent strips
Long large-bore needles or angiocatheters (should be at least 3.25” in length for needle chest decompression in large adults)
Medications
Drug dosing in children should use processes minimizing the need for calculations, preferably a length-based system. In general, medications may include:
Cardiovascular medication, such as 1:10,000 epinephrine, atropine, antidysrhythmics (e.g., adenosine and amiodarone), calcium channel blockers, beta-blockers, nitroglycerin tablets, aspirin, vasopressor for infusion
Cardiopulmonary/respiratory medications, such as albuterol (or other inhaled beta agonist) and ipratropium bromide, 1:1000 epinephrine, furosemide
50% dextrose solution (and sterile diluent or 25% dextrose solution for pediatrics)
Analgesics, narcotic and nonnarcotic
Anti-epileptic medications, such as diazepam or midazolam
Sodium bicarbonate, magnesium sulfate, glucagon, naloxone hydrochloride, calcium chloride
Bacteriostatic water and sodium chloride for injection
Additional medications, as per local medical director
Optional Equipment
The equipment in this section is not mandated or required. Use should be based on local needs and resources.
Optional Equipment for BLS Ground Ambulances
Glucometer or blood glucose test strips (per state protocol and/or local medical control approval)
Infant oxygen mask
Infant self-inflating resuscitation bag
Airways
Nasopharyngeal (12F, 14F)
Oropharyngeal (size 00)
CPAP/BiPAP capability
Neonatal blood pressure cuff
Infant blood pressure cuff
Pediatric stethoscope
Infant cervical immobilization device
Pediatric backboard and extremity splints
Femur traction device (adult and child sizes)
Pelvic immobilization device
Elastic wraps
Ocular irrigation device
Hot packs
Warming blanket
Cooling device
Soft patient restraints
Folding stretcher
Bedpan
Topical hemostatic agent/bandage
Appropriate CBRNE PPE (chemical, biological, radiological, nuclear, explosive personal protective equipment), including respiratory and body protection; protective helmet/ jackets or coats/pants/boots
Applicable chemical antidote auto-injectors (at a minimum for crew members’ protection; additional for victim treatment based on local or regional protocol; appropriate for adults and children)
Optional Equipment for ALS Emergency Ground Ambulances
Respirator, volume-cycled, on/off operation, 100% oxygen, 40–50 psi pressure (child/infant capabilities)
Blood sample tubes, adult and pediatric
Automatic blood pressure device
Nasogastric tubes, pediatric feeding tube sizes 5F and 8F, sump tube sizes 8F–16F
Size 1 curved laryngoscope blade
Gum elastic bougies
Needle cricothyrotomy capability and/or cricothyrotomy capability (surgical cricothyrotomy can be performed in older children in whom the cricothyroid membrane is easily palpable, usually by puberty)
Rescue airway devices for children
Atomizers for administration of intranasal medications
Optional Medications
Optional Medications for BLS Emergency Ambulances
Albuterol
Epi-pen
Oral glucose
Nitroglycerin (sublingual tablet or paste)
Aspirin
Optional Medications for ALS Emergency Ground Ambulances
Intubation adjuncts, including neuromuscular blockers
Interfacility Transport
Additional equipment may be needed by ALS and BLS out-of-hospital care providers who transport patients between facilities. Transfers may be made to a lower or higher level of care, depending on the specific need. Specialty transport teams, including pediatric and neonatal teams, may include other personnel, such as respiratory therapists, nurses, and physicians. Training and equipment needs may be different depending on the skills needed during transport of these patients. There are excellent resources available that provide detailed lists of equipment needed for interfacility transfer, such as Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients from the AAP and The Interfacility Transfer Toolkit for the Pediatric Patient from the EMSC, ENA, and the Society of Trauma Nurses.
Any ground ambulance that, either by formal agreement or by circumstance, may be called into service during a disaster or mass casualty incident to treat and/or transport any patient from the scene to the hospital or to transfer between facilities any patient other than those within their designated specialty population should carry, at a minimum, all equipment, adult and pediatric, listed under “Required Equipment for All Emergency Ground Ambulances.”
Extrication Equipment
In many cases, optimal patient care mandates appropriate and safe extrication or rescue from the patient's situation or environment. It is critical that EMS personnel possess or have immediate access to the expertise, tools, and equipment necessary to safely remove patients from entrapment or hazardous environments. It is beyond the scope of this document to describe the extent of these. Local circumstances and regulations may affect both the expertise and tools that are maintained on an individual ground ambulance, and on any other rescue vehicle that may be needed to accompany an ambulance to an EMS scene. The tools and equipment carried on an individual ground ambulance need to be thoughtfully determined by local features of the EMS system with explicit plans to deploy the needed resources when extrication or rescue is required.
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