Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials.

I. INITIAL ASSESSMENT

This assessment is to discover and treat immediately life-threatening conditions.

Airway

• Open airway if needed:
• Medical - head tilt chin lift
• Trauma - jaw thrust
• Look for airway obstructions - vomit, bleeding, facial trauma, etc.
• Identify and correct any existing or potential airway obstruction or problems.
• Consider oxygen therapy at this time.
• Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA).

• Check adequacy of ventilation - should be done by quickly observing chest rise/fall, approximate rate and listening to patient talk.
• Expose chest and observe chest wall movement.
• Consider oxygen therapy at this time.

• Palpate for pulse
• Radial pulse not present indicates systolic blood pressure < 80 mm Hg.
• Carotid pulse no present indicates systolic blood pressure < 60 mm Hg.
• Note skin temperature, color, and condition.
• Note capillary refill in children.
• Identify and treat life threatening conditions or injuries and control bleeding, as needed.

Determine level of consciousness by:

• A - Alert
• V - Responds to voice
• P - Responds to pain
• U - Unresponsive
• Check pupils for size and reaction time.

• Age
• Sex
• Injury or illness
• Immediate environment

This section will identify any additional injuries or conditions that may also be life threatening.

Re-evaluate the mechanism of injury (trauma) or nature of illness (medical).

Trauma patients with significant mechanism of injury should be assessed as follows:

Rapid head to toe assessment (inspect, palpate, and ausculate)

Assess baseline vital signs to include:

• Respirations
• Pulse
• Skin color, temperature, and condition
• Pupils
• Blood pressure

Signs and Symptoms
Allergies
Medications (prescribed and over the counter)
Pertinent past medical history
Last oral intake
Events prior to injury

Focused assessment

Focuses primarily on the injury site, rather than head to toe.

Assess baseline vital signs (as listed above)

Obtain SAMPLE history

Medical patients who are unresponsive should be assessed as follows:

Rapid head to toe assessment

Assess baseline vital signs (listed above)

Obtain SAMPLE history

Assess patient's complaints (OPQRST)

• Onset When and how did the symptom begin?
• Provocation What makes the symptom worse?
• Quality How would you describe the pain?
• Radiation Where do you feel the pain?
• Severity How bad is the pain?
• Time How long have you had the symptoms?

Focused assessment

Assessment of specific complaint area unless general "I don't feel well," which would require head to toe exam.

Assess baseline vital signs

III. ONGOING ASSESSMENT

Reassess interventions.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.

Determine the following:
Nature, duration, location, and radiation of pain.
Associated symptoms or complaints.
Related history (trauma, ingestion, pregnancy, surgery, etc.)
Be alert for vomiting and the potential for aspiration.
Place the patient in a position of comfort.
If signs/symptoms of shock occur, place patient in supine position with feet elevated.
Flexion of the knees and hips may help decrease pain.
Never give anything by mouth.

Continue monitoring of patient's condition in reference to treatment.

Basic

I. Initial Assessment

Assess ABC's while protecting airway.
Administer oxygen or use bag valve mask, if needed.
Consider Nasopharyngeal Airway (NPA).

Identity mechanism of injury or reason for altered LOC (diabetic, shock, seizure, overdose)
Obtain history.
Perform neurological examination of all extremities.

Monitor airway during transport for changes.

Basic

I. Initial Assessment

Assess ABC's.
Administer oxygen as needed.
Control external bleeding if needed.

Identify mechanism of injury.
Care of amputated part:
Rinse the part gently with saline to remove debris.
Place amputated part in plastic bag and label with name and date.
Place in mixture of ice and water.

Reassess interventions.

Basic

I. Initial Assessment

Maintain open airway.
Administer highest concentration of oxygen, as tolerated.

Determine possible cause and known allergies.
Assess bilateral breath sounds.
Assess for swelling of tongue, mouth, throat, and/or extremities.
Assist with administration of prescribed epinephrine auto-injector after contact of Medical Control in severe allergic reaction.

Be alert for indications that reaction is worsening and that further intervention may be needed. The patient with severe allergic should be reassessed to determine if the epinephrine injection was effective in reversing the life-threatening condition.

Basic

I. Initial Assessment

Control bleeding by direct pressure.
Apply pressure dressings or elevate as needed.

Identify mechanism of injury.

Monitor dressing and vital signs.
Be alert to change in mental status.

Basic

I. Initial Assessment

Maintain and protect airway.
Administer highest concentration of oxygen as tolerated.

Identify contaminant or cause:

Chemical on skin:
Remove contaminated clothing.
Flush skin with water for ten (10) minutes, then with soap and water.
If contaminant is dry powder, brush off before washing.

Chemical in eyes:
Flood eye(s) with water continuously for at least 20 minutes.
Have patient blink as much as possible.

Electrical:

Identify all electrical contact points.

Thermal:

Stop burning process by removing patient or cause.

Remove jewelry and non-adherent clothing from burned areas.
Cover burn area with sterile dressings.

Basic

I. Initial Assessment

Initiate cardiopulmonary resuscitation (CPR) as necessary.
Apply oxygen via bag valve mask 100% concentration.
Apply automated external defibrillation device.

Identify pertinent events prior to arrest.

Basic

I. Initial Assessment

Maintain airway.
Administer highest concentration of oxygen as tolerated.

Assess neurological functions (AVPU).
Check pupils and motor/sensory.

Protect and maintain airway.
Keep patient informed and reassured.

I. Initial Assessment

Maintain airway.
Administer the highest concentration of oxygen as tolerated.
Assist ventilation with BVM, as needed.
Stabilize any impalements.
Occlude any open wounds.
Stabilize any flail segments.
Treat any other life-threatening trauma.

Assess mechanism of injury.

Reassess breathing status.
Reassess interventions.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.

Find out what patient's prescribed dosage is and how many doses has been taken prior to your arrival, by what route it was taken, and what effect it has had.
Assess vital signs to ensure that systolic blood pressure is greater than 100 mm Hg.
Make sure the nitroglycerin is prescribed for this patient, the correct dosage, the right route of administration and expiration date.
Contact Medical Control for orders for assistance with administration of prescribed nitroglycerin up to three (3) doses (one dose 3-5 minutes) if patient has no relief and systolic blood pressure remains above 100 mm Hg. Patient should be in a seated position when administering nitroglycerin.

Continue monitoring of vital signs and patient's condition.

Basic

I. Initial Assessment

Determine presence of labor.
Administer highest concentration of oxygen, as needed.

Obtain information about pregnancy:
Problems or complications.
Any other pregnancies?
Due date.
Assess for vaginal bleeding.
Determine onset and duration of contractions.
Did water break? Describe color of fluid.
Visualize perineum and check for bulging and crowning or if the urge to push or bear down or move bowels is evident. If so, prepare for birth.
Position mother for delivery if normal delivery imminent.
Apply gentle pressure against baby's head to guide and control the delivery.
Support the head and thorax as they appear.
Cut cord only if cord is tightly wound around baby's neck. Apply two clamps and between the clamps.
Assess baby's respiratory status and give APGAR score.
Dry infant, cover its head, and wrap the baby to minimize heat loss.
Assess mother for excess bleeding.

Spontaneous abortion
Bring fetus and tissue to hospital.

Breech birth

Maintain infants airway by inserting gloved fingers into vagina and pushing wall of vagina away from baby's mouth and nose, deliver if necessary.

Prolapsed cord

Place mother in Trendelenburg position.

Insert gloved hand into vagina and push baby's presenting part off the cord.

III. Ongoing Assessment

Monitor mother and baby.

Basic

I. Initial Assessment

Administer highest concentration of warmed oxygen, as tolerated.
Assess neuro status, AVPU.

Assess mechanism of injury.
Remove only wet clothing and maintain the patient in a warm, draft free environment.
Cover with warm blankets if available.

Reassess ABC's.
Monitor vital signs.
Monitor neuro status of patient.

Basic

I. Initial Assessment

Be alert and treat for shock.

Identify mechanism of injury.
Splint in position found unless realignment is necessary for transport.
Check pulse and sensation distal to the injury before and after splinting.

Protect injury from excessive movement.
Apply cold packs to injury site when practical.
Elevate injured limb if possible.
Apply manual traction when signs and symptoms suggest possible femur fracture.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.

Determine past history.
Place patient upright or in a position of comfort.
Identify patient medications.

Continue monitoring of vital signs and patient's condition.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.

Identify
Assess neurological functions.
Assess breath for fruity odor.
If unconscious, administer nothing by mouth and transport lateral recumbent.
If conscious, with gag reflex present, administer oral glucose or sugar and transport in a position of comfort.

Assess level of consciousness after administration of oral glucose and/or sugar.

Basic

I. Initial Assessment

Assess airway and initiate spinal precautions.
Administer highest concentration of oxygen as tolerated.
Assist with breathing as needed with BVM and supplemental oxygen.
Control any hemorrhage.
Assess AVPU.

Identify mechanism of injury.
Assess for cerebrospinal fluid from ears, nose, and mouth.
Assess neuro function of all extremities.
Maintain spinal precautions.

Continue to monitor neuro status and vital signs every 5 minutes.

Basic

I. Initial Assessment

Remove patient from the source of heat.
Administer highest concentration of oxygen, as tolerated.

Assess for skin temperature.

Moist, Pale, Normal to Cool Skin:
Cool the patient by applying cold, wet compresses and/or fan lightly.
Place patient in supine position with feet elevated 8 to 12 inches.
If responsive, have patient drink cool water.

Hot Skin, Moist or Dry:
Pour cool water over the patient's body.
Place cold packs in the patient's groin, each side of the neck, in the armpits, and behind each knee to cool large vessels.

Continue to monitor patient's skin temperature.
Reevaluate mental status of patient.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.

Obtain history of high blood pressure.

Basic

I. Initial Assessment
Mechanism of injury.
Administer highest concentration of oxygen, as tolerated.
II. Focused History and Physical Exam
Maintain a patent airway.
Bring suspected poison, drugs, (dead) insect or reptile to hospital.
Determine cause:

Swallowed Poisons

Do not give anything by mouth unless directed by Poison Control.

Inhaled Poisons

Get patient to fresh air.
Continue oxygen.

Poison on Skin

Remove contaminated clothing.
If powder, brush from skin.
Flush skin with water for 20 minutes.

Poison in Eyes

Flush eyes continuously with water.

Poison by Injection

If injection site on extremity, keep it dependent and apply a splint.

Monitor changes in patient's condition.
Continue monitoring of oxygen therapy.

Basic

I. Initial Assessment

Determine possible causes of abnormal behavior (hypoxia, hypoglycemia, etc.).

Speak in a calm, quiet voice when approaching and caring for this patient.

Restrain, if necessary, with orders from Medical Control.

Basic

I. Initial Assessment

Determine whether breathing difficulty is due to trauma or medical condition.
Administer highest concentration of oxygen as tolerated.

If patient has personal prescribed inhaler, allow the patient to use it (as prescribed).
Contact Medical Control for orders of assistance with prescribed inhaler.
Assure that medication has been prescribed to patient in question, that the medication is to be inhaled, and that the patient is alert enough to use the inhaler.
Check the expiration date.
Shake the inhaler vigorously several times and remove any protective caps.
Remove the oxygen mask from the patient, have the patient exhale deeply, pushing air from the lungs as possible.
Have the patient place the lips around the mouthpiece and inhale slowly and deeply as you depress the hand-held inhaler.
Have patient hold their breath as long as is comfortable so the medication can be absorbed.
Replace oxygen mask.
Record time, date, vital signs, and changes in patient's condition.

Be alert for changes in patient's condition with oxygen therapy and/or inhaler.

Basic

I. Initial Assessment

Administer highest concentration of oxygen as tolerated.
Consider underlying cause.

Assess level of consciousness.
Evaluate neurological functions: speech, eye movement, motor/sensory.
Protect patient from hurting themselves by removing hazards from area.

Evaluate patient's airway and level of consciousness during transport.

Basic

I. Initial Assessment

Maintain airway.
Consider Oropharyngeal Airway (OPA) or Nasopharyngeal Airway (NPA).
Administer highest concentration of oxygen as tolerated.
Control external bleeding.

Identify mechanism of injury or cause.
Assess vital signs every 5 minutes.

Elevate legs if patient's condition allows.

Basic

I. Initial Assessment

Maintain cervical spine.
Maintain airway.
Consider Oropharyngeal Airway (OPA) or Nasapharyngeal Airway (NPA).
Administer highest concentration of oxygen as tolerated.
Control external bleeding.

Identify mechanism of injury.
Chest:

Examine chest for injuries.
Check for tracheal deviation, subcutaneous emphysema, and/or jugular venous distention.
Place patient in position of comfort.
Watch for signs of tension pneumothorax.
Stabilize rib fracture or flail segment.
Impaled object should be stabilized in place.

Head/Spine/Neck:

Manually stabilize head, neck, and spine until secured on appropriate device.
DO NOT HYPEREXTEND THE NECK.
Note cerebrospinal fluid or blood from ears, nose, and mouth.
Perform neurological assessment on all four extremities.

Maintain and transport with full spinal immobilization.

Purpose: This establishes the minimum guidelines for Prehospital Automated External Defibrillator (AED) for persons functioning under the medical control authority of the North Mississippi Emergency Medical Services Authority (NMEMSA) and the Tupelo Fire Department. All persons who are identified as Prehospital AED operators shall meet the requirements of this standard.

Use of AEDs in the prehospital setting by First Responders is limited to EMRs, EMT-Bs,

EMT-Is, EMT-Ps, Nurses, Physicians who have successfully completed an approved AED

Training Program. First Responders must be certified by the NMEMSA to perform this skill.

NMEMSA "AED Authorization" forms must be signed by the First Responder, operations manager of the fire rescue service, off-line medical director(s) and NMEMSA Executive Director, to allow the First Responder to use the AED.

AED training program must adhere to guideline established by the American Heart Association (AHA), Mississippi Affiliate, and NMEMSA.

AED training is valid for 24 months at which time the full AED training program (4 hour minimum) must be repeated. Periodic AED practice (30-60 minutes) is required at least every 90 days. Successful performance of defibrillation skills on actual patients can be counted in lieu of this practice. Documentation of full training and practice training should be kept on file at the fire/rescue department.

AED devices must be a defibrillator which: (a) is capable of cardiac rhythm analysis; (b) will charge and deliver a shock after electrically detecting the presence of a cardiac dysrhythmia or is a shock-advisory device in which the defibrillator will analyze the rhythm and display a message advising the operator to press a "shock" control to deliver the shock; (c)must be capable of printing a post event summary (at a minimum the post event summary should include times, joules delivered, ECG; and (d) an on screen display of the ECG (optional).

All agencies utilizing AEDs should also be equipped with extra batteries on hand with the device and an ECG simulator to use for practice training (optional).

First Responders are prohibited from operating manual defibrillator or operating AEDs in the manual mode. If the AED is equipped with manual override, only authorized ALS providers (EMT-Ps, Rns, or Physicians) may use this feature.

The AED shall be carried to the patients' side on any call involving a cardiac and/or pulmonary related emergency. AED authorized First Responders may apply the device only if the patient is in complete cardiac arrest, is 8 years of age or older.

Once resuscitation and use of AED is initiated by an authorized First Responder, patient care efforts must continue until the First Responder is relieved by a Mississippi licensed ambulance service.

When AED trained First Responders are present along with ALS providers, the ALS trained (and authorized) providers always have the authority over the scene in accordance with the Mississippi EMS Laws, Rules, and Regulations.

EKG rhythms should not be analyzed by AEDS if the patient is in a moving vehicle. Exception: If an ALS provider, by visual interpretation, confirms the presence of a shock rhythm.

If the AED algorithm is implemented initially with subsequent intervention by a ALS provider, the ALS provider will recognize any therapy delivered under the AED algorithm and include this prior therapy as part of this ACLS protocol/algorithm.

The ALS provider is responsible for completing the patient care report including information provided by the First Responder. Information provided to the ALS provider from the First Responder shall include:

Approximate time of collapse/arrest
Time First Responder en route to scene
Time First Responder arrived at scene
Time BLS/CPR initiated
Time of all defibrillation by AED
All patient interventions performed prior to arrival of ALS

Periodic care and maintenance of AEDs shall, at a minimum, be performed in accordance with guidelines suggested by the manufacturer and printed in JAMA Vol. 264, No. 8, August 22/29, 1990, page 1024. AEDs shall be checked by an AED trained First Responder. The minimum requirements for this check shall be in accordance with guidelines established by the Defibrillator Working Group of the Center for Devices and Radiological Health, Food, and Drug Administration, rev 1.1d, 2/90.

The single rescuer with an AED should verify unresponsiveness, open the airway (a),give two respirations(b,) and check the pulse(c). If full cardiac arrest is confirmed, the rescuer should attach the AED and proceed with algorithm.

If "NO SHOCK INDICATED" appears, check pulse, repeat 1 minute CPR, then reanalyze. After three "NO SHOCK INDICATED" messages are received, repeat analyze period every 1-2 minutes.

Pulse check not required after shocks 1,2,4 and 5 unless "NO SHOCK INDICATED" message appears.

If Ventricular Fibrillation recurs after transiently converting (rather than persist without ever converting), restart the treatment algorithm from the top.

In the unlikely event that ventricular fibrillation persists after nine shocks, then repeat sets of three stacked shocks, with 1minute of CPR between each set.