First Responder Protocols (Notes)

BOOK: Blue Book II SECTION: First Responder Protocols (CAPTAIN NOTES) Page 1 of 21

First Responder Protocols
(SERGEANT) Notes
(Updated through 8/7/04)

Due to the nature of the way the Protocols are written, these notes may seem
excessive and awkward to read, however, all key points should be covered.

SECTION I - ADMINISTRATIVE PROTOCOLS

PROTOCOL I.1Communication Reports

Objective findings make take precedence over detailed Hx.

Patient care decisions are made by the highest medically-trained first responder on scene until arrival of ALS.

PROTOCOL I.2Code 1 Trauma Reports

Early notification required for ALL patients.

Notify hospital of Code 1 Trauma Patients as soon as possible.

Multiple patients should be IMMEDIATELY triaged.

Use closest COMPREHENSIVE treatment facility for Code 1 trauma patients.

PROTOCOL I.3Multi-Patient Scene/Mass Casualty Incident/Triage

A Multi-Pt. Scene (MPS) is < 5 critical or < 10 non-critical.

A Mass Casualty Incident (MCI) is 5 or more critical or 10 or more non-critical.

Triage tags identify severity of injury, location victim was found, and where victim was sent (approved by MCB).

RED (Level I) is Critical, requires care within 0-30 min.

YELLOW (Level II) is Urgent, requires care within 30-120 min.

GREEN (Level III) is Delayed, requires care within 12 hours.

BLACK (Level IV) is Dead or near dead.

Overall Incident Command at MCI or MPS scenes is the responsibility of the police/fire.

On MPS, advise dispatch of Pt. #, units needed, hazardous conditions, best access, and staging area.

The Medical Sector Coordinator at MPS shall manage patient care (NO hands on), establish communications, assign ambulances to specific pts, and maintain pt. worksheets.

The Triage Officer at MPS shall perform rapid triage, tag pts, fill out pt. log w/ tag color and age/sex, relay triage info to MSC, update reports as needed, and assist treatment and transport teams after triage is completed.

The 1stALS unit at an MCI shall relay to dispatch: location, incident type, environmental conditions, # or ALS rigs needed, immediate danger zone, staging area, best access, and # of pts.

Vests and task cards should be used at MCI incidents.

The Med. Director assumes Medical Command at an MCI on arrival and will coordinate activities of sectors (Triage, Treatment, Transportation, Communications).

Colored tape should be used for triage in the Rescue Area and tags used in the Triage Area.

Triage tags usually come 25 in a bundle.

On first pass triage, only open airway if needed and tag.

Attach triage tags string to body, NOT clothing (head or upper arm).

Ambulatory patients (Green Tag) should be directed to the GREEN treatment area.

Reports # of triages pts to Triage Officer upon completion.

Confer w/ Med. Command for Treatment location.

Personnel in Treatment sector will perform BASIC packaging and FWD pts to GREEN, RED, or YELLOW treatment areas.

Tags should be filled out by treatment personnel (injuries on body diagram, BP, Pulse, Resp.)

IV or IM drugs given to triages pts should be noted on the ADMIN side of the triage tag with time, date, pt. name, address, city, state, and past Hx/prescriptions.

On the LAST line of the triage tag, the primary treating paramedic shall enter their name.

The Red Cross symbol (contains tracking #) should be torn from triage tags prior to letting patient leave treatment area w/ # entered on run report.

The tracking number on triage tags is found on the perforated corners, the main portion of the tag, and on each colored tear-off strip.

No more than 1 category RED per ambulance.

The Unit # and #/injury types of pts on board each ambulance that leaves the transportation sector should be relayed to Medical Command.

Ambulatory pts may be loaded on buses.

Prior to leaving the transportation sector, the AMBULANCE portion of the triage tag should be removed and notation of pt. name, age, condition (mandatory), and destination (mandatory).

Ambulances arriving on scene for transport at an MCI should stay w/ their ambulance.

The Communications Sector will maintain an MCI log using info from the Transportation Sector.

Communications sector will request additional ambulances through Medical Command.

When ambulances are ready for transport, relay #/injury types of pts on board to dispatch. Dispatch will determine destination.

The Communications Sector will notify each receiving hospital of the unit #s and types of pts on their way.

The first paramedic on scene is in charge of overall patient care (no hands on).

Transporting units should not contact the receiving hospital except for deteriorating patient condition and Medical Control contact is needed.

PROTOCOL I.4No Code Orders and Discontinuance of CPR

First Responders may accept a written statement from 2 physicians that patient is qualified for DNR.

First Responders may discontinue or NOT start CPR if no pulse AND no respirations AND pupils fixed/dilated AND rigor OR decapitation decomposition OR lividity OR Directive/DNR.

Blunt traumatic arrest w/out signs of life or shockable rhythm (AED) does not require CPR.

If injuries are incompatible w/ life, rhythm does NOT have to be determined.

Termination of treatment from a physician can be verbal or in writing.

DNR orders are based on pts decision, terminal conditions, imminent death, or cardiovascular unresponsiveness.

First Responders will carry out orders of the pt’s personal physician if on scene.

On infants, children, young adults, and in cases of unexpected death, CPR should not be discontinued unless prolonged death is evident.

Hypothermia pts must be given aggressive resucitative efforts if a significant factor in arrest.

PROTOCOL I.5Patient Refusal or Non Transport

Refusals should be evaluated f/ urgency of condition.

EMSA FOS must be contacted f/ refusals where service is requested, pt contact is made AND pt has acute medical condition AND age <2 or >55 OR chest pain OR S.O.B. OR ?LOC OR Trauma OR Diabetes OR Seizures OR all NON-emancipated minors OR any pt which paramedic thinks refusal would hurt be detrimental to pt.

The FOS will explain the condition, risks, alternatives to Tx, and assumption of risks to the pt on a recorded line.

NON-transport form must include: C/C, vitals, & paramedic assessment.

Leave pt instruction sheet f/ refusals.

Documentation f/ refusal form include: pt statements, options given, paramedic’s observations, & pt signature.

PROTOCOL I.6Physician on Scene

The MCP should be contacted if a NON-MCP requests procedures against protocols.

If a NON-MCP goes against the MCP, they must sign the medical record & if NOT riding w/ pt to hospital, they must contact the MCP for transfer of care.

Physicians on scene can be verified by their license f/ the OK State Board of Medical Licensure & Supervision.

Orders f/ a pts personal physician on scene should be followed unless they go against protocol, if so, contact MCP.

PROTOCOL I.7Staging

Stage 2 city blocks or at a 120o angle f/ violent scenes (outside “Danger Zone”).

PROTOCOL I.8Crime Scene Management Policy

Only units assigned will respond to crime scene.

On arrival at crime scene, protected by law enforcement, first responders will request entry to determine life status of pt.

If law enforcement at a crime scene does NOT allow entry by first responders, complete incident report & forward it to supervisor.

Only one first responder should enter a crime scene to minimize disturbance of scene.

Victims of penetrating trauma at crime scene should be checked f/ pupil reactivity, carotid pulse, & respirations.

Head, neck, or truncal penetrating wounds w/ pupils fixed/dilated & carotid pulse/respirations absent: DO NOT WORK.

Isolated EXT wounds w/ pupils fixed/dilated & carotid pulse/respirations absent: continue BLS until rhythm verified, if asystolic, DO NOT WORK.

Victims of blunt traumatic arrest w/OUT signs of life OR shockable rhythm (AED): DO NOT WORK THEM.

If injuries incompatible w/ life, determination of rhythm NOT necessary.

If verifying rhythm on a prone pt, apply electrodes to appropriate back locations (L. Arm, R. Arm, & Lower Back). Fast Patches may also be used (Upper R Back, Lower L Back).

If NO signs of trauma w/ no signs of life AND either rigor, decapitation, decomposition, lividity, Directive, OR DNR, do not attempt resuscitation.

If pt at crime scene has signs of life, initiate resuscitative efforts by: keeping equipment close, staying close to pt, keep hands out of pooled blood, do NOT wander around scene, minimize destruction of pt clothing (don’t cut through holes).

At a crime scene DO NOT go through pts effects (if expired), cover body w/ sheet (if expired), move/take/handle objects, clean body of blood, wander around scene, or litter crime scene w/ equipment, dressings, bandages, etc.

Victims at crime scenes should be taken to the ambulance f/ stabilization if possible.

Information pertaining to a crime relayed by pt during transport should be given to police at once.

PROTOCOL I.9Care of Minors Protocol

If on scene w/ a minor & no parents/guardian, paramedics can treat if given consent by minor AND reasonable attempt has been made to contact parents/guardian.

If a minor refuses treatment and parent/guardian is not present AND cannot be reached, and pt IS in need of further evaluation, contact OCPD to put them in protective custody.

If a minor has significant illness/injury OR ?LOC OR post-altered LOC OR impaired decision-making capability, do not leave pt without a parent/guardian.

Have minor patients sign refusal form and leave instruction sheet if not in need of medical evaluation.

A minor can NOT revoke consent after giving it.

Minor – any person < 18yo, except persons on active duty or who has served in military (considered Adult).

Emancipated Minor – any minor who is married, has a dependent child, pregnant, or emancipated (separated & not supported by parents/guardian)-TREATED AS ADULTS.

PROTOCOL I.10Use of Helicopter Within the Regulated Service Area

Helicopter is NOT used on the following pts: Cardiac arrest w/o spontaneous return of circulation, Trauma pts w/ trauma score 4 or less, Trauma pts no meeting Code 1 Trauma criteria, and pts w/ stable vitals and no serious illness/injury.

Use helicopter within 10 mile radius of helicopter hospital ONLY for impassable road conditions, multiple patients, and lengthy extrication (delayed by ground).

EMSA can request helicopter through dispatch, first responder must get ETA from EMSA before dispatching helicopter.

Fire or law enforcement is responsible for safe landing zone.

All helicopter dispatches are reviewed by Office of the Medical Director (MCB).

SECTION II - TREATMENT PROTOCOLS

Initial Arrival at the Scene

If pt condition is unknown, take PPE, trauma bag, BVM or demand valve mask, suction unit, BP cuff/stethoscope, and AED to scene.

Guidelines for requesting additional EMSA units include:2 or more critical pts or 3or more non-critical pts.

Take a complete set of vitals and repeat every 5-10 minutes.

Trauma Patient Assessment - Primary Survey

Trauma pt assessment consists of environmental assessment (hazards, # of pts, MOI, surroundings), and primary survey.

Trauma Patient Assessment - Ongoing Survey

Ongoing assessment is the systematic assessment of the entire pt (head-to-toe, look for non-life threatening problems).

Ongoing survey is performed after initial survey and stabilization of life-threatening ABC problems.

Record 2 or more sets of vitals/neuro assessments prior to transport.

Pts can NOT be called stable without at least 2 sets of vitals with similar normal readings.

Medical Patient Assessment

• Initial survey (ABCDEs) are done on medical and trauma patients.
• Head-to-toe survey for medical pts follows initial assessment.

• Alertness, eye contact, attention to surroundings
• Muscle tone
• Responsiveness to parents

• Trauma
• Fontanelle (depression/bulging)

• Pupils (brightness of eyes-hydration)

• Stiffness

• Stridor, retractions, depressions between ribs on inspiration
• Auscultate heart/lung sounds

• Distention, rigidity, bruising, tenderness

• Brachial pulse
• Skin temp/color
• Muscle tone, guarding

• Observe eyes for direction of gaze during neuro assessment.
• The lowest GLASGOW score is 3, NOT 0.
• Mild (noxious) painful stimuli used in neuro assessment includes: light pinch, dull pin prick.
• Use several observers to elicit the best verbal response from children to avoid under-estimation of GLASGOW score.

Patient History

• Medical pt Hx should include chief complaint (CC), associated complaints, past medical Hx, allergies, medications/drugs, last oral intake.
• Trauma pt Hx should include CC, associated complaints, mechanism of injury (MOI), and mental status.
• For medical pts, Hx is commonly obtained during or before physical assessment.

• Assessment/Hx
• 2 sets of vitals
• Airway (patient positioning/manual maneuvers for patent airway)
• OPA/NPA if positioning/manual maneuvers do NOT work
• S/S of hypoxia (tachypnea, cyanosis, tachycardia, altered LOC, chest pain)
• Hypoxic pts get 10-15 lpm O2 by NRB, unless COPD (then 2 lpm by NC)

• Same as Adult except chest pain/COPD

• Patients with chest pain or high-risk medical conditions should NOT be ambulated.
• Infants less than 4 mo. old are obligate nose-breathers (nasal congestion can cause resp. depression).
• Position of comfort is best for pt's breathing.

• MOI (forces, speed, trajectory)
• Pt complaints
• Car condition
• Past medical Hx.

• Vitals: pulse >120, BP <90 systolic
• LOC
• Skin (color, temp, moisture)
• Signs of injury/bleeding
• JVD

• Scene size up
• Initial assessment (primary survey)
• Airway (patient positioning/manual maneuvers for patent airway) w/ C-spine
• Hypoxic pts get 10-15 lpm O2
• If resp. rate <12, shallow/inadequate resp., or < LOC, assist with BVM at 24 breaths/min
• Hemorrhage control, Long spine board
• Consider Immediate Transport if SOB, circulation bad, < LOC
• Stabilize resp. problems (sucking chest wound, flail)
• On-going assessment
• Bandaging, splinting, packaging (not to delay transport)

• Same as adult

• Hypotension is a late sign of hypovolemia
• Elderly pts can by hypovolemic at BPs higher than 90 systolic
• Neurogenic shock is cause by relative hypovolemia (loss of blood vessel tone)

• Hx of arrest (onset, symptoms, CPR performed, duration)
• Past Hx and meds

• Absence of consciousness, pulse, respirations
• Signs of trauma
• Air/skin temp

• Initiate CPR and/or defibrillation (AED)
• Check carotid for effectiveness of CPR
• Check pupil response
• Observe pt color & chest rise/fall for effectiveness of ventilations
• Determine time of arrest and medical Hx

• Same as adult