The National Association of EMS Physicians (NAEMSP) has released several position statements and literature reviews that provide evidence-based guidance for prehospital care. These publications represent comprehensive systematic reviews with recommendations from the NAEMSP Board of Directors, supported by detailed resource documents summarizing current literature.
Blood Products in Trauma Care
Guidelines – Transfusion of Blood Products in Trauma
Key Recommendations
The NAEMSP blood compendium emphasizes a pragmatic approach to prehospital blood administration. The position acknowledges that while blood products are preferred, their absence should not discourage providers from delivering optimal care with available resources.
Clinical Guidelines
- Product Hierarchy: Use whole blood preferentially over blood components when available; use blood components over crystalloids when whole blood is unavailable; if no blood products are available use crystalloids
- Indication Criteria: Decisions should be based on physiological indicators rather than mechanism of injury alone. A young trauma patient with stable vital signs may not require blood despite significant mechanism, while a patient with shock index greater than 1.0 (heart rate 120, systolic BP 60) clearly benefits from blood products.
- Safety Monitoring: Actively monitor for adverse events, though research from San Antonio demonstrates these are rare with prehospital blood administration
- Operational Requirements: Establish blood exchange programs with trauma centers to prevent wastage of products approaching expiration
Implementation Considerations
Successful blood programs require regional coordination and cannot be implemented in isolation. The “takes a village” approach involves multiple stakeholders and differs from medications that individual medical directors can implement independently.
Unexpected Applications
Early implementation data from Dr. Jeff Jarvis’ experience implementing such a program in Fort Worth, Texas revealed that approximately 43% of blood product administrations occur in medical patients rather than trauma cases, including severe gastrointestinal bleeding, postpartum hemorrhage, and other non-traumatic bleeding emergencies.
Traumatic Circulatory Arrest
Partnership Guidelines – Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest
This represents a collaborative effort between NAEMSP and the American College of Surgeons and the American College of Emergency Physicians
Terminology and Approach
The literature emphasizes “traumatic circulatory arrest” rather than “traumatic cardiac arrest” to highlight the fundamental difference in pathophysiology and treatment approach compared to medical cardiac arrest. This distinction reinforces that the primary problem is circulatory rather than cardiac rhythm-based.
Treatment Priorities
The approach focuses on rapidly reversible causes:
Hemorrhage Control
- Apply direct pressure, pack wounds, and use tourniquets as indicated
- Address bleeding as the primary reversible cause
Airway Management
- Secure airway patency using the least invasive method that achieves adequate oxygenation and ventilation
- Avoid prolonged intubation attempts if simpler methods achieve ventilation
Chest Decompression
- Perform needle decompression only with suspicion of tension pneumothorax, not empirically for all traumatic arrests
- Consider simple thoracostomy in systems with appropriate training and protocols
- Avoid empirical bilateral decompression unless there is evidence of chest trauma
Evidence-Based Limitations
- Medications: Discontinue epinephrine use in traumatic circulatory arrest
- Chest Compressions: Provide minimal benefit and should not interrupt life-saving interventions
- Duration: No evidence supports specific resuscitation time limits
- Transport Decisions: Organ donation potential should not influence transport decisions, as less than 1% of successfully harvested organs come from patients who arrest outside the hospital
Pneumothorax Management
Guidelines – Traumatic Pneumothorax Care: Position Statement and Resource Document of NAEMSP
Diagnostic Criteria
The position statement distinguishes between simple pneumothorax and tension pneumothorax, emphasizing that interventions should target only tension pneumothorax with hemodynamic compromise.
Treatment Algorithm
I really like Dr. Jeff Jarvis’ simplified approach: “No hypotension equals no tension equals no needle.” Patients without hypotension should not receive needle decompression in the field setting.
Technique Recommendations
- Primary intervention: Needle decompression for suspected tension pneumothorax
- Advanced technique: Simple thoracostomy in appropriately trained systems
- Avoid routine decompression without clear physiological indicators
Postpartum Hemorrhage
Partnership Guidelines – Postpartum Hemorrhage
This represents a collaborative effort between NAEMSP and the American College of Obstetricians and Gynecologists (ACOG), addressing the leading cause of maternal mortality in the United States.
Treatment Protocol
Initial Interventions
- Oxytocin should be administered as soon as possible after delivery
- Perform fundal massage with gentle traction on umbilical cord
- Administer oxytocin: 10 units intramuscularly unless IV access is readily available, once IV access has been established add additional 20 units in one liter normal saline infused wide open until arriving at the hospital or a significant decrease in bleeding is noted
Advanced Pharmacotherapy
- Tranexamic Acid (TXA): If immediate postpartum hemorrhage continues despite available measures, administer TXA within 3 hours of birth. One gram bolus followed by one gram over eight hours
- Misoprostol: If there is ongoing bleeding despite oxytocin administration, and the time to arrival at a hospital with obstetric capabilities is prolonged, then misoprostol is recommended as an additional therapy. 600-1000 micrograms orally, sublingually, or rectally.
- Blood: When available, blood product administration should be considered for patients with one or more of the following:
- Estimated blood loss of 1.5L or more
- Abnormal vital signs (tachycardia and hypotension) in accordance with local transport protocols
- Ongoing blood loss not controlled with the measures described throughout the guideline
Hypertensive Emergencies in Pregnancy
Partnership Guidelines – Hypertension in Pregnancy, Eclampsia
Clinical Thresholds
The guidelines establish clear treatment criteria for pregnant patients from 20 weeks gestation through six weeks postpartum:
Symptomatic Hypertension
- Criteria: Systolic BP >140 mmHg or diastolic BP >90 mmHg with symptoms (headache, visual changes, right upper quadrant or epigastric pain)
- Treatment: Magnesium sulfate only
Severe Hypertension
- Criteria: Systolic BP >160 mmHg or diastolic BP >110 mmHg regardless of symptoms
- Treatment: Magnesium sulfate plus aggressive blood pressure reduction with labetalol, nifedipine, or hydralazine
Pathophysiological Rationale
This approach differs from chronic hypertension management, where aggressive blood pressure reduction can cause ischemic complications. The pregnancy-related endothelial changes create different risk-benefit profiles that support more aggressive intervention.
Cardiac Arrest Ventilation Strategies
Evidence Base
Recent studies examining ventilation effectiveness during cardiac arrest provide insights into optimal airway management:
Ventilation Quality Assessment
- Research using impedance monitoring demonstrates that many prehospital ventilations are ineffective, failing to deliver adequate tidal volume
- Patients receiving >50% effective ventilations showed improved survival compared to those with less effective ventilation
Compression-Ventilation Timing
- Studies using end-tidal CO2 monitoring reveal that simultaneous chest compressions and ventilation may negate effective air delivery
- The mechanical pump action of compressions can oppose ventilation efforts, reducing tidal volume delivery
Clinical Implications
Based on emerging evidence, some systems have returned to interrupted chest compressions (30:2 ratio) with supraglottic airways, continuing this pattern even after advanced airway placement rather than switching to continuous compressions.
Time-Sensitive Interventions
Intubation Duration Study
Research from Seattle’s cardiac arrest registry examined the relationship between time to successful intubation and patient outcomes:
Key Findings
- Median time from last ventilation to first post-intubation ventilation: 83 seconds
- Patients intubated within 60 seconds showed significantly higher survival to discharge and neurologically intact survival
- Extended airway attempts without chest compression interruption may still compromise outcomes through ventilation delays
Clinical Application
The evidence supports rapid decision-making: attempt intubation quickly, but if unsuccessful within 60 seconds, consider alternative airway management rather than prolonged attempts.
