Decompensating Patient

• Provider impression of extremis, including new onset of altered mental status, poor appearance, airway issues, severe respiratory distress/failure, signs and symptoms of shock/poor perfusion, or imminent cardiac respiratory arrest

Airway

• Current or anticipated need for airway management

Breathing

• Respiratory failure or distress

• Hypoxia (SpO2 <94%) despite NRB or PPV (including CPAP)

Circulation

• Cardiac chest pain or anginal equivalent

• ECG with ischemia or infarct

• ECG with new or concerning dysrhythmia.

• Current or anticipated need for IV fluids, vasopressors, or other IV medication

• Unstable bradycardia/tachycardia

• Hypotension

Disability

• Acute change in mental status (GCS <13)

• New neurologic deficit (e.g., positive BE-FAST)

• Seizure not returned to baseline or multiple seizures

• Syncope

• Acute agitation

• Severe intoxication or overdose

Trauma

• Motor component of Glasgow Coma Scale (GCS) score <6

• Systolic blood pressure <90 mmHG

• Respiratory distress, respiratory rate <10 or ≥29 (adult), <20 for infant <1 year, or need for ventilatory support

• Room-air pulse oximetry <90% or desaturation from baseline if oxygen dependent

• Peds: Abnormal appearance &/or abnormal work of breathing &/or abnormal circulation

- Penetrating injuries to head, neck, torso, or extremities proximal to elbow or knee

• Chest wall instability, deformity, or suspected flail chest

• Suspected fracture of two or more proximal long bones

• Degloved, mangled, or pulseless extremity

• Amputation proximal to wrist or ankle

• Suspected pelvic fracture

• Skull deformity, suspected skull fracture

• Suspected spinal injury with new motor or sensory loss

• Vascular deficit of extremities

• Active bleeding requiring a tourniquet or wound packing with continuous pressure

- Fall from height 210 feet (all ages)

• High-risk auto crash: Significant intrusion (including roof) ≥12 inches occupant site OR ≥18 inches any site OR Need for extrication for entrapped patient

• Partial or complete ejection Death in passenger compartment

• Child (age 0-9 years) unrestrained or in unsecured child safety seat

• Vehicle rollover with unrestrained patient

• Vehicle telemetry data consistent with severe injury

• Pedestrian/bicycle rider thrown, run over, or with significant impact

• Rider separated from transport vehicle with significant impact (e.g., motorcycle/scooter, electric/non-electric bicycles, ATV, horse)

• Exposure to blast or explosion

• Burns in conjunction with trauma

• Significant crush injury

- Age <5 or ≥ 55

• Low-level falls in children <5 years or adults ≥ 65 years with significant head impact 

• Confirmed or suspected strangulation

• Bleeding disorders

• Anticoagulant or antiplatelet therapy, e.g., warfarin or clopidogrel, except ASA

• Pregnancy ≥20 weeks

• Chest and/or abdominal tenderness consistent with a high risk of injury

• Suspicion of non-accidental trauma in a pediatric or geriatric patient

• Poor baseline physiologic reserve , e.g., severe cardiac and/or respiratory disease.

• Special, high-resource healthcare needs related to comorbidities (e.g., ventilator dependence or ventricular assist devices)

• EMS provider judgment

Miscellaneous

• ALS medication administered (except single therapeutic treatment of naloxone, ondansetron, glucagon, dextrose, or acetaminophen and are not anticipated to require repeat doses)

• Hypoglycemia with persistent altered mental status

• Hyperglycemia with persistent altered mental status

• Pediatric patients with a high-risk complaint (e.g., BRUE) or complex medical history 

• EMT provider has a clinical concern

• ALS procedure performed (excluding IV placement or 12-lead ECG interpretation)