The National Association of EMS Physicians, along with these coauthoring associations: American Academy of Pediatrics, American College of Surgeons Committee on Trauma, EMS for Children Innovation and Improvement Center, Emergency Nurses Association, and National Association of State EMS Officials and as also endorsed by the National Association of Emergency Medical Technicians, believes that the delivery of high-quality and effective EMS care is dependent on several factors, including but not limited to the presence of the following:

  • providers who have been credentialed to ensure they demonstrate appropriate cognitive knowledge, affective ability, psychomotor skills, and critical thinking1 ;

  • clinical protocols or guidelines that are supported by the best available scientific evidence; and

  • equipment and supplies necessary to deliver appropriate care as directed by clinical protocols and/or guidelines for patients of all ages.

Several documents, including previous versions of this joint position statement, the National Model EMS Clinical Guidelines Version 2.2, the 2018 National EMS Scope of Practice Model, the Clinical Credentialing of EMS Providers, Physician Oversight of Pediatric Care in Emergency Medical Services, Pediatric Readiness in Emergency Medical Services Systems, and core performance measures from the US Department of Health and Human Services Health Resources and Services Administration EMS for Children (EMSC) Program have been developed to lay the foundation of several of the concepts noted above.19 

Ensuring that EMS providers are properly equipped to perform their clinical duties is an important function of oversight in EMS systems. In the past, this regulatory oversight has been based on the publication of minimum recommended equipment standards, including previous versions of this document.24  These efforts have attempted to provide a listing of the minimum items recommended for basic life support (BLS) and advanced life support (ALS) ground ambulances.

The field of EMS medicine continues to evolve, and the EMS Scope of Practice Model continues to undergo important longitudinal revisions, reflecting ongoing improvements in clinical technology and practice.5  In effect, these advancements have caused many interventions, once limited to the scope of advanced providers, to begin transitioning into the scope of basic providers. Additionally, interventions that were once considered outside the scope of EMS medicine continue to find appropriate places in the EMS setting of care. These contemporary updates make the delivery of EMS-based interventions safer and easier for EMS providers to perform.

TABLE 1

List of Recommended Essential Equipment for BLS and ALS Ground Ambulances, 2020

CategoryBLSALS (All BLS Equipment Plus the Following)
AdultPediatricAdultPediatric
Airway, ventilation, and oxygenation • Oxygen supply, portable and on-board • Direct and/or video laryngoscopy equipment appropriate for neonates to adultsa 
 • Devices capable of delivering oxygen in a titratable manner through nasal, partial face, or full-face mask routes in sizes to fit neonates through adults • Magill forceps 
 • Oropharyngeal airways in sizes to fit neonates to adults • Extraglottic airways in sizes to fit neonates to adultsb 
 • Nasopharyngeal airways in sizes to fit neonates to adults  
 • Manual and/or powered suction device(s) with rigid oral and flexible pharyngeal/tracheal suction catheters in sizes to fit neonates to adults  
 • A device capable of providing noninvasive positive pressure ventilation  
 • Self-inflating manual ventilation devices and masks to fit neonates to adults11,12   
  • Bulb suction   
Bleeding, hemorrhage control, shock management, and wound care • Commercial arterial tourniquets
• Wound-packing materialc
• Gauze sponges
• Adhesive bandages
• Adhesive tape
• Fluid for irrigation of wounds
• Occlusive dressing (also known as “chest seal”) 
• Chest decompression needles ≥14 g diameter, minimum length 3.25 in (8.25 cm) or commercial chest decompression device1319  • Chest decompression needles:
o 14 g diameter, maximum length 1.5 in (3.8 cm) for patients <56 in (144 cm) long20 
o 23 g diameter, maximum length 0.75 inches (2 cm) for newborns 
Cardiovascular and circulation care • Automatic external defibrillator with adult and pediatric or combination pads • A device capable of performing automatic and/or manual defibrillation, cardiac rhythm monitoring (in at least 3 leads), 12-lead ECG acquisition, and transcutaneous pacing 
Diagnostic Tools • Glucometer • Continuous waveform capnography 
 • Pulse oximeter with sensors to fit neonates to adults   
 • Stethoscope   
 • Blood pressure cuffs in sizes to fit neonates to adults   
 • Thermometer   
Infection Control • Items necessary for universal and standard precautions21 No additional ALS recommendations 
 o Waterless hand cleanser  
 o Sharps container  
 o Supplies for collection or absorption of patient vomit, urine, and/or feces  
 o Biohazardous materials collection bags  
 o Products appropriate for cleaning and disinfecting surfaces and equipment  
 • Items necessary for the following transmission-based precautions2224   
 o Contact precautions: examination gloves, eye protection, gowns   
 o Droplet precautions: surgical masks and eye protection   
 o Airborne precautions: N95 facemasks in provider-appropriate sizes and eye protection or powered air-purifying respirator (PAPR)   
 • General trash collection bags   
Medications • Medications that are germane to approved agency BLS protocols • Medications that are germane to approved agency ALS (and/or higher level) protocols 
Medication delivery and vascular access • Devices and supplies needed to administer medications via routes (oral, inhaled, intramuscular, intranasal) included in locally approved scope of practice and locally applicable protocol(s) and in sizes to fit neonates to adults • Devices and supplies needed to administer medications via routes (oral, inhaled, intramuscular, intranasal, intravenous, intraosseous) included in locally approved scope of practice and locally applicable protocol(s) in sizes to fit neonates to adults 
 • Supplies for application of antiseptic to skin • Isotonic crystalloid fluids and administration tubing capable of adjustable fluid delivery rate 
   • A device to provide pressure infusion of IV fluids 
  • Tools that provide precalculated wt-based dosing and preclude the need for calculation by EMS providers can reduce dosing errors.25   • A device suitable for administering a fluid bolus to pediatric patients that limits risk for inadvertent overadministration of fluid 
Neonatal care  Newborn delivery supplies: No additional ALS recommendations 
  • 2 umbilical cord clamps,  
  • Tool for cutting umbilical cord,  
  • Bulb suction,  
  • Infant head cover,  
  • Towels,  
  • Blanket,  
  • Gauze dressings,  
  • Material or device intended to maintain body temperature  
Orthopedic injury care • Splinting material or commercial devices for immobilization of orthopedic extremity injuries including but not limited to: No additional ALS recommendations 
   o Femoral splinting materials, which may include either simple nontraction devices or devices that provide femoral traction.d,26,27   
   o Pelvic splinting materials, which may include either a commercial pelvic circumferential compression device (PCCD) designed specifically to splint the pelvis or a dedicated bedsheet and towel clips to perform circumferential pelvic antishock sheeting.2832   
 • Cold packs   
 • Elastic bandages   
Patient packaging, evacuation, and transport • Extrication board or devicee,33  No additional ALS recommendations 
 • Materials or devices that can be used to provide spinal motion restriction of the cervical, thoracic, and lumbar spine for neonates to adults   
 • Portable stretcher or litter   
 • Collapsible “stair chair”   
 • Wheeled multilevel gurney   
  • Pediatric-specific restraint system or age/size-appropriate car safety seatf,34,35    
Safety • Fire extinguisher (5lb ABC)36  No additional ALS recommendations 
 • ANSI Class 2 or 3 reflective vest or outerwear37    
 • Impact-resistant eye protection (ANSI Z87.1)38    
 • Nonflammable reflective and/or illuminated roadside warning devices   
 • Portable reusable light source   
Temperature management and heat-loss prevention • Blankets• Towels• Heat packs No additional ALS recommendations 
Miscellaneous items • Bandage and trauma shears No additional ALS recommendations 
 • A device that allows for two-way communication between the field and EMS communications and dispatch centers, direct medical control, and receiving hospitals  
 • Triage marking system (colored tape, tags, or other system) that is interoperable with other local health care system entities and that follows recommendations from the US Department of Health and Human Services Assistant Secretary for Preparedness and Response39    
Items that should no longer be carried on BLS or ALS ground ambulances because of evidence of harm or proven lack of clinical efficacy: 
• Military antishock trousers (MAST), aka pneumatic antishock garment (PASG)40  
• Syrup of ipecac41  
CategoryBLSALS (All BLS Equipment Plus the Following)
AdultPediatricAdultPediatric
Airway, ventilation, and oxygenation • Oxygen supply, portable and on-board • Direct and/or video laryngoscopy equipment appropriate for neonates to adultsa 
 • Devices capable of delivering oxygen in a titratable manner through nasal, partial face, or full-face mask routes in sizes to fit neonates through adults • Magill forceps 
 • Oropharyngeal airways in sizes to fit neonates to adults • Extraglottic airways in sizes to fit neonates to adultsb 
 • Nasopharyngeal airways in sizes to fit neonates to adults  
 • Manual and/or powered suction device(s) with rigid oral and flexible pharyngeal/tracheal suction catheters in sizes to fit neonates to adults  
 • A device capable of providing noninvasive positive pressure ventilation  
 • Self-inflating manual ventilation devices and masks to fit neonates to adults11,12   
  • Bulb suction   
Bleeding, hemorrhage control, shock management, and wound care • Commercial arterial tourniquets
• Wound-packing materialc
• Gauze sponges
• Adhesive bandages
• Adhesive tape
• Fluid for irrigation of wounds
• Occlusive dressing (also known as “chest seal”) 
• Chest decompression needles ≥14 g diameter, minimum length 3.25 in (8.25 cm) or commercial chest decompression device1319  • Chest decompression needles:
o 14 g diameter, maximum length 1.5 in (3.8 cm) for patients <56 in (144 cm) long20 
o 23 g diameter, maximum length 0.75 inches (2 cm) for newborns 
Cardiovascular and circulation care • Automatic external defibrillator with adult and pediatric or combination pads • A device capable of performing automatic and/or manual defibrillation, cardiac rhythm monitoring (in at least 3 leads), 12-lead ECG acquisition, and transcutaneous pacing 
Diagnostic Tools • Glucometer • Continuous waveform capnography 
 • Pulse oximeter with sensors to fit neonates to adults   
 • Stethoscope   
 • Blood pressure cuffs in sizes to fit neonates to adults   
 • Thermometer   
Infection Control • Items necessary for universal and standard precautions21 No additional ALS recommendations 
 o Waterless hand cleanser  
 o Sharps container  
 o Supplies for collection or absorption of patient vomit, urine, and/or feces  
 o Biohazardous materials collection bags  
 o Products appropriate for cleaning and disinfecting surfaces and equipment  
 • Items necessary for the following transmission-based precautions2224   
 o Contact precautions: examination gloves, eye protection, gowns   
 o Droplet precautions: surgical masks and eye protection   
 o Airborne precautions: N95 facemasks in provider-appropriate sizes and eye protection or powered air-purifying respirator (PAPR)   
 • General trash collection bags   
Medications • Medications that are germane to approved agency BLS protocols • Medications that are germane to approved agency ALS (and/or higher level) protocols 
Medication delivery and vascular access • Devices and supplies needed to administer medications via routes (oral, inhaled, intramuscular, intranasal) included in locally approved scope of practice and locally applicable protocol(s) and in sizes to fit neonates to adults • Devices and supplies needed to administer medications via routes (oral, inhaled, intramuscular, intranasal, intravenous, intraosseous) included in locally approved scope of practice and locally applicable protocol(s) in sizes to fit neonates to adults 
 • Supplies for application of antiseptic to skin • Isotonic crystalloid fluids and administration tubing capable of adjustable fluid delivery rate 
   • A device to provide pressure infusion of IV fluids 
  • Tools that provide precalculated wt-based dosing and preclude the need for calculation by EMS providers can reduce dosing errors.25   • A device suitable for administering a fluid bolus to pediatric patients that limits risk for inadvertent overadministration of fluid 
Neonatal care  Newborn delivery supplies: No additional ALS recommendations 
  • 2 umbilical cord clamps,  
  • Tool for cutting umbilical cord,  
  • Bulb suction,  
  • Infant head cover,  
  • Towels,  
  • Blanket,  
  • Gauze dressings,  
  • Material or device intended to maintain body temperature  
Orthopedic injury care • Splinting material or commercial devices for immobilization of orthopedic extremity injuries including but not limited to: No additional ALS recommendations 
   o Femoral splinting materials, which may include either simple nontraction devices or devices that provide femoral traction.d,26,27   
   o Pelvic splinting materials, which may include either a commercial pelvic circumferential compression device (PCCD) designed specifically to splint the pelvis or a dedicated bedsheet and towel clips to perform circumferential pelvic antishock sheeting.2832   
 • Cold packs   
 • Elastic bandages   
Patient packaging, evacuation, and transport • Extrication board or devicee,33  No additional ALS recommendations 
 • Materials or devices that can be used to provide spinal motion restriction of the cervical, thoracic, and lumbar spine for neonates to adults   
 • Portable stretcher or litter   
 • Collapsible “stair chair”   
 • Wheeled multilevel gurney   
  • Pediatric-specific restraint system or age/size-appropriate car safety seatf,34,35    
Safety • Fire extinguisher (5lb ABC)36  No additional ALS recommendations 
 • ANSI Class 2 or 3 reflective vest or outerwear37    
 • Impact-resistant eye protection (ANSI Z87.1)38    
 • Nonflammable reflective and/or illuminated roadside warning devices   
 • Portable reusable light source   
Temperature management and heat-loss prevention • Blankets• Towels• Heat packs No additional ALS recommendations 
Miscellaneous items • Bandage and trauma shears No additional ALS recommendations 
 • A device that allows for two-way communication between the field and EMS communications and dispatch centers, direct medical control, and receiving hospitals  
 • Triage marking system (colored tape, tags, or other system) that is interoperable with other local health care system entities and that follows recommendations from the US Department of Health and Human Services Assistant Secretary for Preparedness and Response39    
Items that should no longer be carried on BLS or ALS ground ambulances because of evidence of harm or proven lack of clinical efficacy: 
• Military antishock trousers (MAST), aka pneumatic antishock garment (PASG)40  
• Syrup of ipecac41  

ANSI, American National Standards Institute; ECG, electrocardiogram; IV, intravenous.

a

Laryngoscopy equipment is included to facilitate ALS provider identification and mechanical removal of upper airway foreign bodies by using Magill forceps, regardless of whether the ALS agency includes pediatric or adult endotracheal intubation within their ALS provider scope of practice.

b

Depending on locally approved scope of practice and locally applicable protocol(s), other invasive airways (endotracheal tubes or needle or surgical cricothyrotomy supplies) may also be carried but are not recommended to be universally required on all ALS ground ambulances.

c

Wound-packing material may include plain gauze and/or hemostatic dressings.

d

Traction is not a necessary or required element of prehospital stabilization of suspected femur fracture(s) and is often contraindicated.26,27 

e

Devices used for extrication, such as backboards, should not be used for transport. Whenever feasible, patients should be removed from extrication devices before transport. Spinal motion restriction can be maintained by securing the patient to the transport stretcher.33 

f

Restraint devices should meet applicable crash-testing standards as they are developed and published and should appropriately meet individual patient wt, length, and developmental status needs.34,35 

In 2019, our organizations undertook a review and revision of the 2014 version of this joint position statement. Part of this revision process also included review of equipment lists established by individual state and territory rules and statutes for all 56 US states and territories. Our review identified that portions of either the 2014 document and/or state- and territory-level equipment lists required items that:

  • are no longer clinically recommended because they have been demonstrated to be either harmful or lacking efficacy or have been replaced by clinically superior options. (eg, military antishock trousers [MAST], syrup of ipecac);

  • are no longer correctly dichotomized to BLS versus ALS levels of care (eg, continuous positive airway pressure [CPAP], nebulized medications);

  • fail to include equipment that evidence-based guidelines suggest should be available on ground ambulances (eg, commercial arterial tourniquets are currently lacking on 29 state and territory lists); and

  • require arbitrary quantities of items.

Establishing recommended equipment standards has value in helping build consistency across the EMS system of care. Documents such as this can be used to help guide both agency leadership and frontline staff in evaluating whether their agency is properly equipped to provide care that meets recommended community requirements. However, the process of creating and revising rules, statutes, and other legislative mechanisms at the state level of government is often onerous and time consuming and can sometimes have unpredictable results and generate unintended consequences.

Our review of existing state and territory EMS equipment regulations revealed that 39 states and territories had statutory EMS equipment lists that were more than 5 years old. Equipment lists should serve to facilitate advances in the delivery of quality and cost-effective EMS care, not to create a barrier to EMS system improvement and development. In light of this, we offer the following recommendation to governmental entities with jurisdiction involving the practice of EMS medicine–

 Ensure that legislative and/or administrative mechanisms that establish equipment standards for ground ambulances:

  • avoid requiring arbitrary minimum amounts of equipment list items;

  • reflect expert and evidence-based recommendations such as those provided in this position statement;

  • undergo review and updates at intervals not to exceed five years;

  • do not create unnecessary barriers to implementation of new technology at the local level;

  • allow for flexibility and adaptability to make rapid unplanned changes in response to unpredicted equipment or medication shortages affecting local EMS agencies; and

  • reinforce that all EMS agencies should carry the age-appropriate equipment, supplies, and medications necessary for their clinical providers to effectively conduct patient care as defined by the clinical protocols and guidelines that are applicable to each agency.

It cannot be overemphasized that the mere presence of certain pieces of equipment on an ambulance does not equate to individual EMS provider competence in the use of that equipment or to an EMS program’s practice of high-quality and effective EMS medicine. In addition to establishing minimum equipment standards, we also recommend that states consider establishing standards requiring local EMS agencies to demonstrate that their EMS providers are competent in their use of the equipment and supplies necessary to administer care within their scope of practice as defined or allowed by locally applicable clinical protocols or guidelines. Such assessment of provider competency in use of equipment has been established as a key component of EMS readiness in the joint position statement, “Pediatric Readiness in Emergency Medical Services Systems,” and also as a core performance measure by the US Department of Health and Human Services Health Resources and Services Administration through its EMS for Children (EMSC) Program.8,9 

Furthermore, although the implementation of equipment lists at the state level is an important level of system oversight, it remains critically important that EMS agency medical directors evaluate that the equipment available on their agency’s ambulances is appropriate for the delivery of care and transport of both pediatric and adult patients in their service area. Each agency’s physician medical director should have direct involvement in the selection, approval, and deployment of the devices each agency chooses to fulfill both the clinical and regulatory equipment requirements that are germane to their agency.

In continued support of establishing and maintaining a foundation for standards of care, our organizations remain committed to periodic review and revision of this position statement. This latest revision was created on the basis of a structured review of the National Model EMS Clinical Guidelines Version 2.2 to identify the equipment items necessary to deliver the care defined by those guidelines.6  In addition, to ensure congruity with national definitions of provider scope of practice, the list is differentiated into BLS and ALS levels of service by using the National Scope of Practice-defined levels of emergency medical responder (EMR) and emergency medical technician (EMT) as BLS and advanced emergency medical technician (AEMT) and paramedic as ALS.5  Equipment items listed within each category were cross-checked against recommended scopes of practice for each level to ensure they were appropriately dichotomized to BLS or ALS levels of care. Some items may be considered optional at the local level, as determined by agency-defined scope of practice and applicable clinical guidelines.

In addition to the items included in this position statement, our organizations agree that, as modeled in the Iowa Administrative Code, “all EMS service programs shall carry equipment and supplies in quantities as determined by the medical director and appropriate to the agency's level of care and available certified EMS personnel and as established in the agency's approved protocols.”10 

Finally, in addition to taking steps to determine that appropriate equipment is routinely available and that EMS providers are competent in using this equipment, our organizations also recommend that all EMS agencies include in their routine quality assurance practices efforts to evaluate that:

  • their EMS providers are outfitted with all of the equipment necessary for them to perform clinical care;

  • all equipment and supplies undergo appropriate preventive maintenance and routine function checks; and

  • malfunctioning or missing equipment issues are rapidly mitigated to preserve readiness to respond and provide patient care continuously.

This document is intended to represent minimum essential equipment recommendations (Table 1) and should not be used to limit the addition of items to a service’s repertoire. Carriage of items that supplement those listed herein should be based on local clinical and operational needs, including the needs of specialty transport teams, and should be left to the discretion of the physician medical director and other agency administrative and operational officers.

  1. Equipment should always be appropriate for the size and age of patients. Availability and use of appropriate pediatric-sized equipment is necessary, not discretionary.

    • a. Adult-sized items should not be substituted or adapted for use on pediatric patients except in cases in which available pediatric-focused equipment has malfunctioned and in which failure to provide further intervention by adapting an adult device for pediatric use would result in serious harm to the pediatric patient.

  2. Several items that were included in previous versions of this list, including items previously listed as “optional,” are not included in this revision. Their absence from this list demonstrates lack of sufficient evidence to support inclusion of these items universally for all BLS and/or ALS ground ambulances but should not be interpreted to mean that such items should not be carried on any BLS and/or ALS ground ambulance. Local clinical protocols and scope of practice may dictate that such items are prudent and proper to carry.

  3. Evidence supporting inclusion of specific items in this recommended equipment list is cited where available.

  4. Certain items are included in this list on the basis of sound judgment and logic (eg, “portable reusable light source”) rather than on the basis of the presence of supporting evidence.

  5. Several items were identified on review of existing state and territory equipment lists or in previous versions of this document that should no longer be carried on ground ambulances because of evidence of harm or proven lack of efficacy. These items have been identified in a section that is new in this revision of this joint position statement.

  6. Equipment specifications exist for several items contained in this document. The sources for those specifications are cited.

  7. Latex-free items should be used whenever possible and practical.

  8. Specific medication recommendations have been removed from this minimum recommended equipment list because of the following:

    • a. the diversity of clinical protocols across the United States, even across the same echelons of care, precludes development of an appropriately brief but comprehensive recommended medication list;

    • b. the frequency and unpredictable nature of medication shortages requiring frequent and rapid revision to local medication supplies preclude the development of a recommended medication list that would remain germane on a daily basis; and

    • c. the variability in the availability and use of therapeutic alternatives across EMS agencies precludes development of an appropriately brief but comprehensive recommended medication list.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: No external funding.

     
  • ALS

    advanced life support

  •  
  • BLS

    basic life support

  •  
  • EMS

    emergency medical services

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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