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AMERICAN COLLEGE OF SURGEONS 
COMMITTEE ON TRAUMA 



AMERICAN COLLEGE OF 
EMERGENCY PHYSICIANS 



NATIONAL ASSOCIATION 
OF EMS PHYSICIANS 



PEDIATRIC EQUIPMENT GUIDELINES 

COMMITTEE— EMERGENCY 

MEDICAL SERVICES FOR CHILDREN 

(EMSC) PARTNERSHIP FOR CHILDREN 

STAKEHOLDER GROUP 



AMERICAN ACADEMY 
OF PEDIATRICS 



Almost four decades ago, the 
Committee on Trauma (COT) 
of the American College of 
Surgeons (ACS) developed a list 
of standardized equipment for 
ambulances. Beginning 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 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 
prehospital delivery of care. The 
document was written to serve as a 
standard for the equipment needs of 
emergency 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. 
With permission from the ACS COT, 
ACEP, and NAEMSP, the current 
revision includes updated pediatric 
recommendations developed by 
members of the federal Emergency 
Medical Services for Children 
(EMSC) Stakeholder Group. 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 
and Advanced Life Support patient 
care units. This document will 
be used as the standard for this 
performance measure. The American 
Academy of Pediatrics (AAP) has 
also officially endorsed this list. 



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 
Prehospital Care 

The goal of prehospital care is 
to minimize further systemic 
insult or 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 prehospital care by 
using preexisting 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 




EQU tPMEN T 



for ambulance services, adult and 
pediatric emergency medicine 
physicians, adult and pediatric trauma 
surgeons, and appropriately trained 
basic and advanced emergency 
medical personnel. Current Institute 
of Medicine (IOM) recommendations 
encourage each EMS agency to have 
a pediatric coordinator to specifically 
coordinate the capability of the 
service to care for nonadult patients. 

Equipment and Supplies 

The guidelines list the supplies and 
equipment that should be stocked on 
ambulances to provide the accepted 
standards of patient care. Previous 
documents regarding ambulance 
equipment referred to essential or 
minimal equipment necessary to 
adequately equip an ambulance. 
Equipment requirements will vary, 
depending on the certification levels 
of the providers, population densities, 
geographic and economic conditions 
of the region, and other factors. 

The following list is divided into 
equipment for basic life support 
(BLS) and advanced life support 
(ALS) 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: 
Basic Life Support 
(BLS) Ambulances 

A. Ventilation and Airway Equipment 

1. Portable and fixed suction 
apparatus with a regulator 
(per Federal specifications; 
see Federal Specification 
KKK-A-1822F reference) 

• Wide-bore tubing, rigid 
pharyngeal curved suction 
tip; tonsillar and flexible 
suction catheters, 6F-16F are 
commercially available (have 
one between 6F and 10F and 
one between 12F and 16F) 

2. Portable oxygen apparatus, 
capable of metered flow 
with adequate tubing 

3. Portable and fixed oxygen 
supply equipment 

• Variable flow regulator 

4. Oxygen administration 
equipment 

• Adequate length tubing; 
transparent mask (adult 
and child sizes), both 
non-rebreathing and 
valveless; nasal cannulas 
(adult, child) 

5. Bag-valve mask (manual 
resuscitator) 

• Hand-operated, self- 
reexpanding bag; adult 
(>1000 ml) and child (450- 
750 ml) sizes, with oxygen 
reservoir/accumulator; 
valve (clear, disposable, 
operable in cold weather); 
and mask (adult, child, 
infant, and neonate sizes) 



6. Airways 

• Nasopharyngeal (16F-34F; 
adult and child sizes) 

• Oropharyngeal (sizes 0-5; 
adult, child, and infant sizes) 

7. Pulse oximeter with 
pediatric and adult probes 

8. Saline drops and bulb 
suction for infants 

B. Monitoring and Defibrillation 

All 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. 

C. Immobilization Devices 

1. Cervical collars 

• Rigid for children ages 
2 years or older; child 
and adult sizes (small, 
medium, large, and 
other 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 and child sizes) 




EQU tPMEN T 



4. 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) 

5. Impervious backboards (long, 
short; radiolucent preferred) 
and extrication device 

• Short (extrication, head- 
to-pelvis length) and long 
(transport, head-to-feet 
length) with at least three 
appropriate restraint 
straps (chin strap alone 
should not be used for 
head immobilization) 
and with padding for 
children and handholds 
for moving patients 

D. Bandages 

1. Commercially-packaged or 
sterile burn sheets 

2. Triangular bandages 

• Minimum two 
safety pins each 

3. Dressings 

• Sterile multitrauma 
dressings (various large 
and small sizes) 

• ABDs, 10"xl2" or larger 

• 4"x4" gauze sponges 
or suitable size 

4. Gauze rolls 

• Various sizes 

5. Occlusive dressing 
or equivalent 

• Sterile, 3"x8" or larger 



6. Adhesive tape 

• Various sizes (including 1" 
and 2") hypoallergenic 

• Various sizes (including 
1" and 2") adhesive 

7. Arterial tourniquet 
(commercial preferred) 

E. Communication 

Two-way communication 
device between EMS provider, 
dispatcher, and medical control 

F. Obstetrical Kit (commercially 
packaged is available) 

1. Kit (separate sterile kit) 

• Towels, 4"x4" dressing, 
umbilical tape, sterile 
scissors or other cutting 
utensil, bulb suction, 
clamps for cord, sterile 
gloves, blanket 

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

G. Miscellaneous 

1. Sphygmomanometer 
(pediatric and adult 
regular and large 
size cuffs) 

2. Adult stethoscope 

3. Length/weight-based tape or 
appropriate reference material 
for pediatric equipment sizing 
and drug dosing based on 
estimated or known weight 

4. Thermometer with low 
temperature capability 

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

6. Cold packs 



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

8. Flashlights (2) with extra 
batteries and bulbs 

9. Blankets 

10. Sheets (minimum 4), linen 
or paper, and pillows 

11. Towels 

12. Triage tags 

13. Disposable emesis 
bags or basins 

14. Disposable bedpan 

15. Disposable urinal 

16. Wheeled cot (conforming 
to national standard at the 
time of manufacture) 

17. Folding stretcher 

18. Stair chair or carry chair 

19. Patient care charts/forms 

20. Lubricatingjelly 
(water soluble) 

H. Infection Control* 



* 



'Latex-free equipment should be available 

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

2. Face protection (for example, 
surgical masks per applicable 
local or state guidance) 

3. Gloves, nonsterile (must meet 
NFPA 1999 requirements 
found at http://www.nfpa.org/) 

4. Coveralls or gowns 

5. Shoe covers 

6. Waterless hand cleanser, 
commercial antimicrobial 
(towelette, spray, liquid) 

7. Disinfectant solution for 
cleaning equipment 

8. Standard sharps containers, 
fixed and portable 




EQU tPMEN T 



9. Disposable trash 
bags for disposing of 
biohazardous waste 

10. Respiratory protection 
(for example, N95 or N100 
mask — per applicable 
local or state guidance) 

I. Injury Prevention Equipment 

1. All individuals in an 
ambulance need to 
be restrained (there is 
currently no national 
standard for transport of 
uninjured children) 

2. Protective helmet 

3. Fire extinguisher 

4. Hazardous material 
reference guide 

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

6. Reflective safety wear for 
each crewmember (must 
meet or exceed ANSI/ISEA 
performance class II or III if 
working within the right of 
way of any federal-aid highway. 
Visit http://www.reflectivevest. 
com/federalhighwayruling. html 
for more information.) 



Required Equipment: 
Advanced Life Support 
(ALS) Ambulances 

For EMT-Paramedic services, include 
all of the required equipment listed 
for the basic level provider, plus the 
following additional equipment and 
supplies. For EMT-Intermediate 
services (and other nonparamedic 
advanced levels), include all of the 
equipment for the basic level provider 
and selected equipment and supplies 
from the following list, based on local 
need and consideration of prehospital 
characteristics and budget. 

A. Airway and Ventilation Equipment 

1. Laryngoscope handle with 
extra batteries and bulbs 

2. Laryngoscope blades, sizes 
0-4, straight (Miller); sizes 
2-4, curved, (Macintosh) 

3. Endotracheal tubes, sizes 
2.5-5.5 mm uncuffed and 
6-8 mm cuffed (2 each), 
other sizes optional 

4. Meconium aspirator adaptor 

5. 10-mL non-Luerlock syringes 

6. Stylettes for endotracheal 
tubes, adult and pediatric 

7. Magill (Rovenstein) forceps, 
adult and pediatric 

8. Lubricatingjelly 
(water soluble) 

9. End-tidal C0 2 detection 
capability 

• Colorimetric (adult and 
pediatric) or quantitative 
capnometry 



B. Vascular Access 

1. Crystalloid solutions, such 
as Ringer's lactate or normal 
saline solution (1,000-mL 
bags x 4); fluid must be in 
bags, not bottles; type of fluid 
may vary depending on state 
and local requirements 

2. Antiseptic solution (alcohol 
wipes and povidone- 
iodine wipes preferred) 

3. IV pole or roof hook 

4. Intravenous catheters 14G-24G 

5. Intraosseous needles or 
devices appropriate for 
children and adults 

6. Venous tourniquet, 
rubber bands 

7. Syringes of various sizes, 
including tuberculin 

8. Needles, various sizes (one at 
least 1 W for IM injections) 

9. Intravenous administration 
sets (microdrip and 
macrodrip) 

10. Intravenous arm boards, 
adult and pediatric 

C. Cardiac 

1. Portable, battery-operated 
monitor/defibrillator 

• With tape write-out/ 
recorder, defibrillator 
pads, quick-look paddles 
or electrode, or hands- 
free patches, ECG leads, 
adult and pediatric chest 
attachment electrodes, adult 
and pediatric paddles 

2. Transcutaneous cardiac 
pacemaker, including 
pediatric pads and cables 

• Either stand-alone 
unit or integrated into 
monitor/defibrillator 




EQU tPMEN T 



D. Other Advanced Equipment 

1. Nebulizer 

2. Glucometer or blood 
glucose measuring device 

• With reagent strips 

3. Large bore needle (should 
be at least 3.25" in length for 
needle chest decompression 
in large adults) 

E. Medications (pre-loaded 
syringes when available) 

Medications used on advanced 
level ambulances should be 
compatible with current guidelines 
as published by the American 
Heart Association's Committee 
on Emergency Cardiovascular 
Care, as reflected in the 
Advanced Cardiac Life Support 
and Pediatric Advanced Life 
Support Courses, or other such 
organizations and publications 
(ACEP, ACS, NAEMSP, and so on). 
Medications may vary depending 
on state requirements. 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 
(for example, 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, 
1:1,000 epinephrine, furosemide 

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



• Analgesics, narcotic 
and nonnarcotic 

• Antiepileptic 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 Basic Equipment 

This section is intended to assist EMS 
providers in choosing equipment 
that can be used to ensure delivery 
of quality prehospital care. Use 
should be based on local resources. 
The equipment in this section 
is not mandated or required. 

A. Optional Equipment 



1. 



3. 
4. 
5. 

6. 



7. 



8. 



Glucometer (per 
state protocol) 

Elastic bandages 

• Nonsterile (various sizes) 
Cellular phone 

Infant oxygen mask 

Infant self-inflating 
resuscitation bag 

Airways 

• Nasopharyngeal (12, 14 Fr) 

• Oropharyngeal (size 00) 

Alternative airway devices 
(for example, a rescue airway 
device such as the ETDLA 
[esophageal-tracheal double 
lumen airway] , laryngeal 
tube, or laryngeal mask 
airway) as approved by 
local medical direction. 

Alternative airway devices 
for children (few alternative 
airway devices that are FDA 



approved have been studied in 
children. Those that have been 
studied, such as the LMA, have 
not been adequately evaluated 
in the prehospital setting). 

9. Neonatal blood pressure cuff 

10. Infant blood pressure cuff 

11. Pediatric stethoscope 

12. Infant cervical 
immobilization device 

13. Pediatric backboard 
and extremity splints 

14. Topical hemostatic agent 

15. Appropriate CBRNE PPE 
(chemical, biological, 
radiological, nuclear, 
explosive personal 
protective equipment), 
including respiratory 
and body protection 

16. Applicable chemical antidote 
autoinjectors (at a minimum 
for crew members' protection; 
additional for victim treatment 
based on local or regional 
protocol; appropriate for 
adults and children) 

B. Optional Advanced Equipment 

1. Respirator 

• Volume-cycled, on/off 
operation, 100% oxygen, 
40-50 psi pressure (child/ 
infant capabilities) 

2. Blood sample tubes, 
adult and pediatric 

3. Automatic blood 
pressure device 

4. Nasogastric tubes, pediatric 
feeding tube sizes 5F and 
8F, sump tube sizes 8F-16F 

5. Pediatric laryngoscope handle 

6. Size 1 curved (Macintosh) 
laryngoscope blade 




EQU tPMEN T 



7. 3.5-5.5 mm cuffed 
endotracheal tubes 

8. 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 the age of 12 years) 

Optional Medications 

A. Optional Basic Life 
Support Medications 

1. Albuterol 

2. Epi pens 

3. Oral glucose 

4. Nitroglycerin (sublingual 
tablet or paste) 

B. Optional Advanced Life 
Support Medications 

1. Anxiolytics 

2. Intubation adjuncts including 
neuromuscular blockers 

Interfacility Transport 

Additional equipment may be needed 
by ALS and BLS prehospital care 
providers who transport patients 
between facilities. Transfers may be 
done 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 the American Academy of 
Pediatrics Guidelines for Air and 
Ground Transport of Neonatal and 
Pediatric Patients. 

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, and patient-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 and Phillips head) 
Pliers 
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 for 
water, aerial, or mountain rescue. 




EQU tPMEN T 



Selected References 

American Academy of Pediatrics Section 
on Transport Medicine. Guidelines for 
Air and Ground Transport of Neonatal and 
Pediatric Patients, 3rd edition. George A. 
Woodward, MD, MBA, FAAP (ed). 2007. 

American College of Surgeons Committee 
on Trauma, Advanced Trauma Life Support 
Student Course Manual (8th Edition). 2008. 

American Heart Association, 
Pediatric Advanced Life Support 
Provider Manual. 2006. 

Brennan JA, Krohmer J (eds), Principles 
of EMS Systems. Sudbury, MA: Jones 
and Bartlett Publishers, 2005. 

Brown MA, Daya MR, Worley JA. 
Experience with chitosan dressings 
in a civilian EMS system. JEmerg 
Med. 2007:Nov 14 (doi:10.1016/j. 
jemermed.2007.05.043). 

Cervical spine immobilization 
before admission to the hospital. 
Neurosurgery. 2002;50(3 Suppl):S7-17. 

Doyle GS, Taillac PP. Tourniquets: a 
review of current use with proposals 
for expanded prehospital use. Prehosp 
EmergCare. 2008;12(2):241-256. 

Equipment for Ambulances 
ACEP Policy Statement, American College 
of Emergency Physicians and Medical 
Direction of Emergency Medical Services. 
Available at: http://www.acep.org. 

Federal Specifications for the Star-of-Life 
Ambulance KKK-A-1822F. August 1, 2007. 

Future of EMS in the US 
Health Care System 
Institute of Medicine, May 17, 2007 
Available at: www.iom.edu. 

James I. Cuffed tubes in children 
(editorial). Paediatr Anaesth. 
2001;ll(3):259-263. 

Kwan I, Bunn F. Effects of prehospital 
spinal immobilization: a systematic review 
of randomized trials on healthy subjects. 
Prehosp Disaster Med. 2005;20(l):47-53. 



Orliaguet G, Renaud E, Lejay M, 
et al. Postal survey of cuffed or 
uncuffed tracheal tubes used for 
paediatric tracheal intubation. Paediatr 
Anaesth. 2001;11(3):277-281. 

Federal Highway Administration, DOT 
CFR-634.2 and 634.3 -Worker Visibility 
Use of High-Visibility Apparel When 
Working on Federal-Aid Highways 
Available at: http://www.reflectivevest. 
com/federalhighwayruling.html. 

Resources for Optimal Care 
of the Injured Patient 
American College of Surgeons 
Committee on Trauma 
Chicago 1999, 2006. 

Rumball CJ, MacDonald D. The PTL, 
combitube, laryngeal mask, and oral 
airway: a randomized prehospital 
comparative study of ventilatory device 
effectiveness and cost-effectiveness in 
470 cases of cardiorespiratory arrest. 
Prehosp Emerg Care. 1997;1(1):1-10. 

Salomone JP, Pons PT, McSwain NE. 
Prehospital Trauma Life Support, 6th 
edition. Saint Louis, MO: Elsevier, 2007. 

Treloar OJ. Nypaver M. Angulation 
of the pediatric cervical spine with 
and without cervical collar. Prehosp 
EmergCare. 1997;13(l):5-8. 

Wedmore I, McManus JG, Pusateri AE, 
Holcomb JB. A special report on the 
chitosan-based hemostatic dressing: 
experience in current combat operations. 
J Trauma. 2006;60(3):655-658. 

Youngquist S, Gausche-Hill M, Burbulys 
D. Alternative airway devices for use in 
children requiring prehospital airway 
management: Update and case discussion. 
Pediatr Emerg Care. 2007;23:1-10. 



FOOTNOTE: The evidence in children 
for selected prehospital care interventions 
or topics was reviewed in preparation for 
finalizing this ambulance equipment list. 
These topics included: (a) child safety 
and booster seats approved for EMS 
use; (b) alternative airway devices; (c) 
spinal immobilization devices including 
collars; and (d) prehospital use of cuffed 
endotracheal tubes. The results of 
this evidence evaluation including full 
citations will be provided in a companion 
article authored by the primary reviewers 
of the topics and the EMSC Stakeholders 
Group. The evidence in all ages for use of 
arterial tourniquets and hemostatic agents 
was also reviewed and will be provided 
in separate consensus review articles. 



REVISED April 2009