402.1 - Clinical Standards and General Therapies Guide

Purpose and Scope

This document outlines authorized procedures, therapies, and medications that may be utilized at EMS provider discretion above and beyond those noted in specific protocols. These standards serve as foundational guidance for patient care while maintaining clinical judgment and safety. Providers should understand that these guidelines represent the minimum standard of care and may be exceeded based on patient presentation and provider judgment.

Airway Management and Ventilation

Oxygen therapy stands as a cornerstone of emergency medical care, yet its administration requires careful consideration and monitoring. Providers should target oxygen saturation between 90-99% for most patients, with a higher target range of 94-99% for obstetric patients. The work of breathing and overall clinical presentation should guide oxygen administration more than numeric values alone. Special consideration must be given to COPD patients who may have chronic hypoxemia, where aggressive oxygen administration may be detrimental. Providers should remain mindful that pulse oximetry readings may be unreliable in shock states, and clinical assessment should take precedence.

Advanced airway management represents a critical skill set that must be employed judiciously. Paramedics may secure airways when patients demonstrate actual or potential compromise, inadequate ventilation or oxygenation, or require airway protection, particularly in cases of GCS ≤8. Any advanced airway intervention necessitates comprehensive monitoring including continuous EtCO2 waveform capnography, pulse oximetry, cardiac monitoring, and frequent blood pressure measurements. The success of airway management relies heavily on proper preparation, including positioning, equipment selection, and post-placement verification.

Vascular Access

Establishing vascular access requires careful consideration of both immediate and anticipated needs. Providers should evaluate patient condition, stability, and the likelihood of requiring fluid or medication administration when determining the necessity and urgency of access. After two unsuccessful IV attempts by a single provider, strong consideration should be given to transitioning to IO access, particularly in cardiac arrest or critical patients requiring immediate intervention. The choice of access site should balance factors such as patient position, anticipated transport time, and the nature of required interventions.

Medication Administration

Pain management in the prehospital setting demands a comprehensive approach that begins with thorough assessment and incorporates both pharmacological and non-pharmacological interventions. Initial measures should include appropriate positioning, splinting, and temperature management when indicated. Acetaminophen serves as an appropriate first-line medication for mild pain or fever, while moderate to severe pain may necessitate opioid analgesics. Following any pain intervention, providers must perform thorough reassessment to evaluate effectiveness and monitor for adverse effects.

Nausea and vomiting require prompt attention and appropriate intervention to prevent deterioration and ensure patient comfort. Ondansetron stands as the preferred first-line antiemetic due to its favorable side effect profile and rapid onset. Promethazine may be considered as a second-line agent, particularly in cases refractory to initial intervention. Providers should maintain awareness of the potential for underlying serious conditions presenting with nausea and vomiting, particularly in special populations.

Blood glucose management begins with appropriate assessment and continues through intervention and reassessment. Any patient presenting with altered mental status requires blood glucose evaluation. For levels below 70 mg/dL, intervention should be tailored to patient presentation and capabilities. Conscious patients with intact gag reflex may receive oral glucose, while altered patients require IV/IO dextrose administration. In cases where malnutrition is suspected, thiamine administration should precede dextrose to prevent precipitation of Wernicke's encephalopathy.

Monitoring Standards

The foundation of patient care rests upon thorough and consistent monitoring. Initial vital signs must be obtained within 5 minutes of patient contact, with subsequent measurements dictated by patient acuity. Critical patients require assessment every 5 minutes, urgent patients every 10 minutes, and stable patients every 15 minutes. When barriers to obtaining complete vital signs exist, providers must clearly document these challenges and their mitigation efforts.

Cardiac monitoring serves as an essential diagnostic tool, particularly in cases of chest pain, shortness of breath, syncope, altered mental status, or any complaint potentially cardiac in nature. The acquisition of 12-lead ECGs should occur early in patient contact when indicated, with interpretation skills focusing on both obvious and subtle abnormalities that may indicate serious pathology.

Special Population Considerations

Pediatric care requires a modified approach that accounts for both physiological and developmental differences from adult patients. Equipment selection must be based on accurate weight estimation using appropriate tools such as length-based tapes or age-based calculations. Assessment strategies should adapt to the child's developmental level, incorporating parent or guardian input whenever possible. The threshold for invasive procedures should remain higher in pediatric patients, with emphasis placed on rapid transport when indicated. Providers must maintain familiarity with age-specific vital sign ranges and recognition patterns for serious illness or injury.

Geriatric patients present unique challenges that demand careful consideration. These patients often demonstrate poor physiological reserve and may manifest shock with subtle presentations. The assessment of geriatric patients must include thorough evaluation of baseline mental status, medication review for potential interactions, and comprehensive trauma assessment even in seemingly minor mechanisms. Fall risk evaluation should occur during all patient movements, with appropriate assistance and safety measures implemented.

Documentation and Quality Assurance

Complete and accurate documentation serves as both a medical and legal record of patient care. Each patient encounter requires thorough documentation of initial presentation, physical examination findings, all interventions performed, and patient response to treatment. Timing of reassessments must be clearly noted, along with any contact with medical control for orders or guidance. Patient disposition and handoff information should provide receiving facilities with a clear picture of the patient's course of care.

Quality metrics provide essential feedback for system improvement and maintaining high standards of care. Scene times should be monitored and analyzed based on call type and patient acuity. Procedure success rates require tracking to identify training needs and potential equipment modifications. Protocol compliance review ensures consistent delivery of care while identifying areas requiring clarification or modification. Patient outcomes, when available, should be incorporated into quality improvement processes to guide system evolution.

Medical Direction

The relationship between providers and medical direction forms the backbone of effective emergency medical services. Contact with medical control should occur for protocol clarification, orders outside standard protocols, high-risk refusals, and unusual patient presentations. Complex clinical scenarios may require physician input to determine optimal treatment paths or destination decisions. Providers should maintain clear communication with medical control, presenting pertinent information in an organized manner to facilitate effective decision-making.