EMS Flashcards
The first step in initial patient assessment of a cardiac arrest includes checking for..
Responsiveness
Breathing
Pulse
- if unresponsive, determine presence, or absence of a pulse
if unresponsive patient is encountered you should next ?
Determine presence or absence of a pulse
During cardiac arrest, primary attention is paid to immediate…
Continuous chest compressions
and
Assessment of the patient’s cardiac rhythm
In cardiac arrest, the emphasis is on…
Continuous chest compressions
with adequate rate and death
Chest compressions involve compressing at a rate of..
100-120 compressions per minute
(Cardiac arrest)
One adult cycle is..
2 minutes of CPR
Between each rhythm check you should perform _____ minute of CPR
2 minutes
(Cardiac arrest)
Do not check for a pulse unless…
There is an organized rhythm on the monitor
and
an increase in the ETCO2 level of 20 mm or more
(Cardiac arrest)
Change the compressor (with manual compressions) after every..
2 minutes of CPR
(Cardiac arrest)
Minimize interruptions of chest compressions ..
Less than 10 seconds
Do not interrupt compressions, when..
Applying defibrillator pads
Establishing IV access
Delivering medications
Ventilate
Once the advanced airway is in place, you should next..
Attached CO2 sensor
&
Ventilate once every 6 seconds 10-12 bpm
If an automatic compression device (auto pulse) is available, do not apply until..
2 minutes of manual CPR have been performed
Or per department protocol
Automatic compression device auto pulse
3 steps
a. Do not interrupt a 2-minute cycle of compressions to place the device.
b. Set up and position the device during compressions and place it to begin the next
2-minute cycle of compressions.
c. For optimal performance, and easy transport, consider using a carry-all or backboard.
In order to minimize the time from stopping compressions and delivering the shock, as well as to minimize any interruptions in chest compressions, the monitor or AED should…
Be charged while continuing chest compressions
An advanced airway should be properly placed, when..
The patient is in respiratory arrest or prolonged PPV is required with a BVM or an automatic ventilator
__________ airway is placed in the initial set of compressions in cardiac arrest. It can be used in respiratory arrest and respiratory distress when there is no gag reflex.
Supraglottic airway
Supraglottic airways are contraindicated when..
Damaged tissue in the supraglottic area
&
if there is a high risk of aspiration
Example of Supraglottic airway is ..
I gel
__________ is no longer the primary airway in cardiac arrest
Endotracheal tube (ETT)
When is use of an ETT is acceptable ?
-On the initial advanced airway attempt
(If unsuccessful go to Supraglottic airway)
-When there is a high risk of aspiration
-When supraglottic airways are contraindicated
Ventilation should be done once every
6 seconds (10-12 BPM)
In a patient with a witnessed/unwitnessed cardiac arrest the emphasis is on..
Continuous compressions
and
Early defibrillation, if a shockable rhythm is present
Airway management can be deferred to the _____
Cycle of compressions, and can be safely managed with a quick placement of a supraglottic airway
Next cycle
Endotracheal intubation is preferred as the initial airway management intervention, when..
Upper airway inhalation burns (suspected)
Severe facial trauma
Vomittus in the mouth (presence of)
If you were going to use endotracheal intubation…
1) Attempt once after defibrillating and/or checking the rhythm.
2) If the vocal cords are not immediately visible, or the single attempt fails - immediately resume compressions and quickly insert a Supraglottic Airway without interrupting compressions.
3) Attach an ETCO sensor and monitor waveform capnography during resuscitation efforts to ensure proper placement of the Advanced Airway, and also for an increase of 20 mm or greater in the CO2 level, which is frequently an indicator of ROSC.
In what situations is early ventilation appropriate..
Respiratory arrest
Pediatric arrest
Unwitnessed arrest
Asystole/PEA
Near drowning
In cardiac arrest, what is the preferred vascular access ?
IO
However, if paramedic judgment suggests IV access is obtainable and can be performed within 30 to 60 seconds. Then IV access is acceptable and should be attempted once.
As a last resort, and if both Io and IV access are not successful, what route may be used?
Advanced airway route
Which medications can be given down the advanced airway route??
Epinephrine
Atropine
Narcan
2X the IV dose
Diluted with normal saline to a total of 10 ML
5 rapid ventilations to enhance the drug delivery
Avoid placing defibrillator pads over…
Pacemaker
Internal defibrillator
Transdermal medication patch
(AED)
If a pulse is present (ROSC), the next step is to…
Check for breathing then initiate post resuscitation care
Do not check for a pulse unless..
There is a organized rhythm on the monitor
&
There has been an increase in the ETCO2 level of 20MM or more
Zoll
SHOCK 1
SHOCK 2
SHOCK 3
200J
200j
200j
Lifespak
SHOCK 1
SHOCK 2
SHOCK 3
360j
360j
360j
MRX
Shock 1
Shock 2
Shock 3
150j
200j
200j
(Cardiac arrest)
A pulse check should be for no longer than ..
10 seconds
Double sequential defibrillation may be performed at the ______ defibrillation
5th defibrillation
Double sequential defibrillation
2 Zoll
2 MRX
1 Zoll or MRX & 1 lifepak
2 lifepak
2 Zoll - 400j
2 MRX - 400j
1 Zoll or MRX & 1 lifepak - 560j
2 lifepak- 720j
Attempt a double sequential defibrillation after _______ initial defibrillation have failed
After 4 initial defibrillation have failed
Double sequential defibrillation pads will be set in either the..
Anterior/Apex position or anterior/posterior position
The second set of pads should be placed in the alternative position
Same person will hit both shock buttons at the same time
Discharges should be done with an oral signal
All subsequent defibrillation should be at the same maximum joules
Ensure that ED personnel know that Max shocks have been delivered
Sodium bicarb may be administered earlier in the protocol if a pre-existing, metabolic acidosis is suspected such as…
Near drowning
Insulin dependent patients (diabetic keto acidosis)
Renal dialysis
Psychiatric medication OD
COCAINE INTOXICATION
PATIENT WITH EXCITED DELIRIUM
Magnesium sulfate 2G IO/IV should be considered in patience with…
-Torsades de pointes
-Recurrent ventricular fibrillation (V fib that occurs more than 5 seconds, after a successful defibrillation)
-Persistent ventricular fibrillation, not responsive to above medications
A clinical situation, where there is an organized rhythm other than ventricular tachycardia on the cardiac monitor in a patient without a palpable carotid pulse is known as…
PEA
The treatment for a patient with PEA will depend on…
The rhythm that presents on the monitor
The approach to Asystole as in PEA is…
CPR
Epinephrine
(H’s & T’s)
What is the best indicator of a viable Asystole ?
CO2 reading of 20 with good CPR on waveform capnography
If the patient is suspected to be in traumatic arrest, perform…
Bilateral chest decompression
All patients in PEA / Asystole Need oxygen..
Listen to lungs bilaterally as patient with ________ can present with a PEA situation
Tension pneumothorax
Kidney dialysis patients may present with a __________ cardiac rhythm without a carotid pulse these patients may have ____________
Slow and wide cardiac rhythm
High serum levels of potassium
Kidney dialysis patients with a slow and wide PEA rhythm should be treated with…
Sodium bicarbonate 1meq/kg
May repeat in 10 minutes at 0.5 meq/kg
IF NO RESPONSE ..
Flush the IO/IV line with at least 20 ML normal saline
Calcium chloride 1g slowly over 1 minute
Asystole must be confirmed in at least ..
2 leads
you must attach limb leads to perform this procedure
If no ROSC after _______ refer to death in the field protocol
30 minutes
PEA
H’s & T’s
• Hypovolemia: normal saline fluid challenge(s) / dopamine / rapid transport.
• Hypoxemia: confirm adequacy of oxygenation.
• Hydrogen lon Acidosis: administer sodium bicarbonate.
• Hypothermia: warm the patient.
• Hyperkalemia: sodium bicarbonate, calcium chloride.
• Hypoglycemia: administer dextrose 50% (D50W).
• Tension Pneumothorax: perform needle decompression (bilateral chest decompression if trauma is suspected).
• Toxins / OD: contact Poison Control 1-800-222-1222 for antidote.
• Thrombus: (Coronary or Pulmonary) Clot Buster in the ER.
• Tamponade: (Cardiac) normal saline fluid challenge(s).
• Trauma: (Hypovolemia) normal saline fluid challenge(s)
Rad 57 is the ..
CO Monitor
The patients CO level is used to determine…
Transport and treatment options
Firefighters who develop an altered level of consciousness, and or hemodynamic instability, should be considered for possible..
Cyanide exposure (CN)
Carbon monoxide poisoning - signs and symptoms
• Dyspnea
• Headache
• Chest pain
• Muscle weakness
• Nausea
• Vomiting
• Dizziness
• Altered mental status
• Death
Cyanide poisoning may result from..
3 types of exposure
Inhalation
Ingestion
Dermal exposure
Prior to administration of Cyanokit, smoke inhalation victims should be assessed for…
a. Exposure to fire or smoke in an enclosed area
b. Presence of soot around the mouth, nose, or oropharynx
c. Altered mental status
Cyanide poisoning treatment is based on..
A high clinical index of suspicion for CN poisoning
In addition to Cyanokit, treatment of cyanide poisoning must include…
a. Immediate attention to airway patency
b. Adequacy of oxygenation
c. Adequacy of hydration
d. Cardiovascular support
e. Management of any seizure activity
CO/CN
High risk situations
• Building fires, including salvage & overhaul
• Areas where generators are used or misused
• The report of symptomatic or unconscious patients in a car where the garage door is closed
• Areas where paint or varnish is stripped from furniture
• Areas where gasoline engines, gas powered heaters or water heaters are run with poor ventilation
• In some cases with symptomatic divers from contaminated air in their SCUBA tanks
• Indoor grills
• Hookah Bars
CO/CN
High-risk patients
• Elderly
• Children
• Pregnant women
• Patients with cardiac disease
• Patients with chronic lung disease
• Patients with chronically elevated CO levels (e.g., cigarette smokers)
Obtaining a CO level should routinely be done when evaluating vital signs of firefighters during..
Rehab
Inaccurate or unattainable CO readings can be caused by?
Poor perfusion states where circulation to the fingers is severely compromised
(CO exposure)
Apply finger probe to finger with capillary refill less than ..
5 seconds
(CO exposure)
Spco less than 3%
No further evaluation for SPCO needed
(CO exposure)
SPCO less than 12% with no symptoms ..
No further evaluation for SPCO needed
(CO exposure)
SPCO less than 12% with symptoms ..
transport on 100% O2 to nearest ER
(CO exposure)
SPCO 12% or greater, but less than 25% with symptoms or pregnant..
Transport on 100% O2 to a hyperbaric oxygen facility
(CO exposure)
SPCO 25% or greater..
Transport on 100% O2 to a hyperbaric oxygen facility
(CO exposure)
Treatment 4 steps ..
- Universal Initial Adult Patient Assessment / Care
- All patients should receive oxygen via NRB.
- Document the CO reading in your Patient Care Record.
- If condition does not improve or gets worse after treatment with 100% O2, consid: treating for Cyanide Poisoning with Cyanokit
Cardio pulmonary resuscitation will be initiated on all patients who have sustained a cardio pulmonary arrest, unless…
Do not resuscitate order
Obvious death
Irreversible death
CPR may be terminated if a valid DNRO ______ copy is presented after CPR was begun
Yellow copy
No ECG or attempts at resuscitation are necessary. In these patients. This is applicable to patients with signs of _________
Obvious death
Obvious death (no ecg)
Conditions..
a. Decapitation
b. Massive crush injury to head or torso
c. Incineration with black charring of the whole body
d. Evisceration/Expulsion from the body of vital organ(s): brain, heart, liver, both lungs
e. Hemicorpectomy (body cut in half through the torso)
f. General body decomposition
Patients with apparently irreversible death require asystole recorded on a cardiac monitor and confirmed in at least _______
2 leads
Signs of irreversible death include…
Rigor mortis - Hardening of the body muscles. This sign is not reliable for true death if the patient is a victim of hypothermia.
Livor Mortis - can start as soon as 30 minutes after death, and usually becomes fixed 6 to 8 hours after death
This sign is not reliable for true death if the patient is a victim of hypothermia..
Rigor mortis
Resuscitation efforts may be terminated in the field, if all of the following and conditions are met..
a. The event was not witnessed by emergency medical services personnel.
b. There is no Return of Spontaneous Circulation (ROSC) after 30 minutes of resuscitation efforts.
c. Patients with asystole or an agonal terminal rhythm at the time of termination of CPR.
Resuscitation efforts may be withheld in any patient with ________ / ________ trauma who, based on the paramedics’ thorough primary patient assessment, is found upon the arrival of EMS at the scene.
Blunt trauma / penetrating trauma
apneic, pulseless, and without organized ECG activity (asystole)
Excluded from termination in the field..
Pediatric cardiac arrest
Obviously obviously pregnant woman cardiac arrest
unless the patient meets criteria for obvious death or apparently irreversible death or has a valid DNRO
When resuscitation is withheld or terminated at the scene, who is responsible for the body once the death has been determined..
The local law enforcement agency with jurisdiction
When resuscitation is withheld or terminated at the scene, and you are releasing the scene/body, you should document..
Officer/persons on scene. Assuming responsibility.
(Death in the field)
EPCR should include the following..
Reason for terminating or not initiating resuscitation
All resuscitative measures if applicable, including the location of unsuccessful vascular access attempts
Location most appropriate for Rehab group set up..
Shaded locations
Away from the immediate operational area are preferred
Firefighters shall be assigned to rehab when…
Based on departmental SOG’s
If 2 SCBA tanks are used or after 30 minutes of strenuous operations
if any member FEELS that another member needs evaluation by the rehab group
If any member exhibits abnormal, physical or mental functioning
If any member has any medical complaint
__________ Should be always advised of any personnel sent to rehab for any reason
The incident commander
(FF REHAB)
For all emergency operations oral fluid replacement up to ..
20 ounces for each 20 minutes of activity
(FF REHAB)
An electrolyte solution should contain ..
100 mg of sodium
8 to 14 mg of carbohydrate
Per 12 fluid oz
(Gatorade / Powerade ect)
(FF REHAB)
During rehab, a seated rest interval of at least _______
10 minutes
(FF REHAB)
If nausea or intolerance to oral fluids is present, you should …
Establish vascular access
&
normal saline 500ML
* This may be repeated once, if additional fluids are indicated after reassessment of vital signs
(FF REHAB)
If any heat related emergency symptoms are present and/or the firefighter has abnormal vital signs, the firefighter should be ______ & given ______
Cooled rapidly
Ample oral hydration fluids
*1 ounce for each 1 minute of operational activity
Firefighters with temperatures of 104°F or higher, or feels hot to the touch with changes in mental status and or develop seizures should have..
Rapid cooling treatment
-Ice packs in the neck, axillae and growing areas
-move firefighter to cooler environment and or fan blowing on them
-Take and document baseline temperature before administering cold normal sailing. Also document a temperature at time of patient transfer in the ED.
-Bolus is cold 34°F normal saline 30 ML/KG - IV/IO maximum 2 Liters
(FF REHAB)
During rapid cooling treatment, if shivering develops you should ..
Administer midazolam (versed)
5 mg slow IV/IO or 10mg IM/intranasal
If patient is agitated, and or in pain after versed and systolic, BP remains at 90 or greater
Administer morphine sulfate 5 mg IV/IO/IM
Total morphine should not exceed 20 mg
(FF REHAB)
For operations lasting longer than two hours, nutritional supplementation should be provided at a rate of at least ..
500 calories per hour for each member
What are three life-threatening problems that should take priority before obtaining a 12 lead ECG ?
Dysrhythmia
pulmonary edema
shock
The key to early recognition and management of the AMI patient is?
Identification of signs / symptoms of patient at risk for coronary artery / heart disease
Obtaining and interpreting a 12 lead ECG will allow the paramedic to provide definitive diagnostic information to the ________, which can greatly reduce delays in care
Medical control physician
Patients who demonstrate and inferior wall MI on their 12 lead, ECG should have a _______ performed to evaluate for a ________
V4R
Right ventricular infarct
- in these patients, the use of
nitroglycerin
morphine sulfate
furosemide (Lasix)
*may cause hypotension
If hypotension develops lay patient flat, if tolerated and administer normal saline, 500ml IV bolus
Indications for obtaining a 12 lead ECG include..
All chest pain or chest discomfort, consistent with myocardial ischemia
Upper abdominal/epigastric pain, unless evidence of G.I bleeding and patience, older than 35 years of age
Sudden onset of shortness of breath (CHF / PE)
After treatment of cardiac dysrhythmia
Fast or slow heart rates/cardiac dysrhythmias/ PVC’s > 6 min unchanged by oxygen treatment
Weakness or fatigue
Diaphoresis not explained by environment
All overdoses
Syncope or dizziness, altered mental status
Post cardiac arrest
Acute stroke patient
Electric lightning injuries
Non-traumatic jaw or arm pain
Unexplained, non-traumatic back pain, known or suspected carbon monoxide poisoning
New onset of pain/discomfort from nose to navel
Any significantly ill patient
What Patients may present with atypical signs and symptoms of general malaise, sweating, nausea, and or shortness of breath with no acute chest pain
Women
Elderly
Diabetics
W/ ACS /STEMI
What type of capnography system is used in the patient with an advanced airway?
Inline or mainstream capnography
The non-intubated patient uses what kind of capnography system?
Sidestream capnography
Such as with a nasal cannula
Indications for End tidal CO2 assessment ..
To confirm, initial placement of an advanced airway
To confirm the placement of an advanced airway up upon release of a patient at the emergency department or other transport unit
For continuous monitor of tube placement throughout, patient care and transport
To assess ventilation status
____________________________________________
To identify proper ETCO2 values when providing treatment to patients exhibiting signs of brain stem herniation
To assess the effectiveness of CPR
The capnometer will require approximately _______ breaths to display a change and ETCO2
6 breaths
ETCO2 35-45..
Normal ETCO2 values
ETCO2 46-50
Mild hypercarbia
increase the frequency of ventilations
ETCO2 greater than 50
Severe hypercarbia
Increase the frequency of ventilations
ETCO2 30-34..
Maintain for increased intracranial pressure management
(ICP)
A ROSC will be indicated during resuscitation following..
A rhythm change
&
A corresponding increase of greater than 20mmhg ETCO2 value
As a minimum when should you conduct / document an ETCO to reading
Upon placement of an advanced airway patient
or
Upon receipt of a patient
&
Upon release of a patient in the emergency department must be documented in patient care record
In a patient with spontaneous circulation, if the ETCO2 value is below _________, proper ET tube placement must be verified preferably by _________
10mmhg
Direct visualization
Decreasing ETCO2 values during CPR may indicate…
An excessive ventilation rate (hyperventilation)
Poor CPR
Circulation of high-dose epinephrine (causing profound vasoconstriction)
Colorimetric CO2 detectors available can be used to confirm proper and endotracheal tube placement by assessing ?
Exhaled CO2
Colorimetric CO2 detectors attaches directly to the endotracheal tube and responds quickly to exhaled CO2 by changing from..
Purple to yellow
The Lucas may be used in patients ______ years of age and older, who have suffered cardiac arrest, where manual CPR would otherwise be used
12 years of age & older
Lucas contraindications..
Under 12 years of age
Patients who are too large, and with whom you cannot attach upper part to backplate without compressing chest
Patients who are too small and with whom you cannot pull the pressure pad down to touch the sternum (3 quick beeps will be heard if the patient is too small)
(Lucas)
How many quick beeps will be heard if the patient is too small ?
3 quick beeps will be heard if the patient is too small
(Lucas)
Manual chest compressions, utilizing the ResQpump shall be initiated for the first _______ minutes prior to Lucas device being placed on the patient
10 minutes
(Lucas)
At what point shall the Lucas device be removed from its carrying device?
While resuscitative measures are initiated
(Lucas)
The back plate should be centered on the _______
&
The top of the backplate should be located just below the patients _________
Nipple line
Armpits
(Lucas)
In cases for which the patient is already on the stretcher, where is the back plate to be placed?
Place the back plate underneath the thorax
-Log rolling
Or
-Raising the torso
(Lucas)
Placement of the Lucas should occur during..
Scheduled discontinuation of compressions
(Lucas)
To activate push on/off button for ______ to start self test and power up
1 second
(Lucas)
Center the suction cup over the chest, with the ______ of the suction cup placed immediately above the end of the ______
Edge of the suction cup
Sternum
(Lucas)
After successful resuscitation or termination of activities, press and hold the on/off button for ______
1 second
(Lucas)
How do you prevent the Lucas from migrating toward the patient’s feet? ?
Place the neck roll behind the patient’s head and attach the straps to the Lucas device
What are the modes the Lucas can operate under?
Adjust mode
Pause
&
Active mode (continuous)
Active mode (30:2)
(Lucas)
If the rhythm strip cannot be assessed during compressions, one may stop the compressions for analysis by pushing the _______ button
PAUSE button
Interruptions in compressions should not be > 10 seconds
(Lucas)
Pulse checks should occur_______ while compressions are occurring
Intermittently
(Lucas)
If there is a change in rhythm, but no obvious indication of responsiveness, or ROSC ________ should be undertaken
A pulse check while compressions are occurring
-if pulse remains reassess the patient
-If pulse disappears, one should immediately restart the Lucas device
(Lucas)
If disruption or malfunction of the Lucas device ..
Immediately revert to manual CPR
(Lucas)
When fully charged the lithium polymer, battery should allow _______ of uninterrupted operation
45 minutes
(Lucas)
Where is there an extra battery?
In the Lucas device bag
(Lucas)
When the last bar/LED on battery turns orange you have ________ left and should replace battery or connect to wall outlet
10 minutes left
(Lucas)
The suction cup is reusable as long as it can …
Be cleaned
Inspected
Without holes
Hold suction on a flat surface
Emergency support functions at a larger MCI requiring mutual aid can be provided through …
The Miami Dade county office of emergency management
(OEM)
(MCI)
In order of priority, what is the first arriving units functions?
-Establish incident command
-Perform scene size up
-Identify a staging area
-Triage / extricate (decide priority)
-Designate group officers
(MCI)
Estimation of the approximate number of victims and identifying the level of the incident occurs during ..
Size up
Example.. level 1, level 2 level 3 ect
(MCI)
Level 1 MCI
5-10 victims
Notify 2 closest hospitals geographically to incident & the trauma center
4 ALS transport rescue
2 Suppression units
Command staff
IC SHOULD CONSIDER REQUESTING
BLS transport units
Hazmat or ladder trucks for lighting and equipment
Air rescue units as needed
(MCI)
Level 2 MCI
11-20 victims
Notify 3 closest hospitals geographically to incident & the trauma center
6 ALS transport rescue
3 Suppression units
Command staff
IC SHOULD CONSIDER REQUESTING
BLS transport units
Hazmat or ladder trucks for lighting and equipment
Air rescue units as needed
(MCI)
Level 3 MCI
Over 20 victims
Notify 4 closest hospitals geographically to incident & the trauma center
8 ALS transport rescue
3 Suppression units
Command staff
IC SHOULD CONSIDER REQUESTING
BLS transport units
Hazmat or ladder trucks for lighting and equipment
Air rescue units as needed
(MCI)
Level 4 MCI
Over 100 victims
Notify 10 closest hospitals geographically to incident & 5 closest trauma centers
10 ALS transport rescue
5 Suppression units
10 BLS transport units
2 mass transit buses
Communications/command trailer
Command staff
(MCI)
Level 5 MCI
Over 1000 victims
Notify 20 closest hospitals geographically to incident & 10 closest trauma centers
20 ALS transport rescue
10 Suppression units
20 BLS transport units
4 mass transit buses
Communications/command trailer
Supply trailer
Command staff
Activate DMAT
Activate MMRS
(MCI)
MCI level 4 response will give you _____ units to be assigned into _____ MCI task forces
25 units assigned
5 task forces
(MCI)
MCI level 5 response will give you _____ units to be assigned into _____ MCI task forces
50 units assigned
10 task forces
(MCI)
Command will designate group officers, and assign personnel to the following areas…
Triage group
Treatment group
Transport group
(MCI)
Additional groups may be required, depending on the complexity of the incident they may include..
Staging
Landing zone
Extrication
Hazmat
Rehabilitation
Manpower
PIO
(MCI)
The incident commander shall maintain a visible presence with a _______ while staying in a fixed location
Green flashing light
(MCI)
The incident commander controls his resources through ______ and ______
Staging and grouping
(MCI)
The incident commander should encourage group officers to provide frequent updates, reflecting ..
Manpower needs
Equipment requirements
Total number of patients
(MCI)
The triage officer shall advise command, and medical control as soon as possible as to..
Total number of victims
&
Number of victims in each category
(MCI)
The triage officer shall coordinate with treatment to ensure that _____ victims are moved to the treatment area first, then move the _____ victims
Red victims
Then
Yellow victims
(MCI)
Who shall ensure that all areas around the scene have been checked for potential victims, walking wounded, ejected, victims, etc. and that all victims have been triaged ?
Triage officer
(MCI)
Who shall ensure that all victims are reassessed and re-triaged, and this assessment is documented on the disaster tag reflecting the appropriate disaster, tag color ?
Treatment officer
(MCI)
The goal of MCI is rapidly…
Triage and transport victims
- if transport is available, consideration, must be given to bypassing a formal treatment area for a critical patient.
(MCI)
What are considerations for a treatment area?
Capable of accommodating, the number of victims and equipment
Consider weather safety and the possibility of hazardous materials (Decon, runoff, wind direction)
Designate entrance and exit areas that are readily accessible
On large scale incident divide the treatment area into three distinct areas based on triage priority
Red yellow green
(MCI)
Ground transported patients should be assigned to hospitals on an ..
Alternating and rotating basis
(MCI)
Who shall communicate with the LZ group the number of patients to be transported by air ?
Transport officer
(MCI)
When a unit is prepared to transport, the transport officer will contact medical control, and report the following information ..
Transport unit number
Number of patients going to specific facility
Their priority (red yellow green)
(MCI)
Who will be updating the hospital capability sheet?
Medical control once receiving the information from transport
(MCI)
Transporting fire rescue units will not contact the receiving facility on their own unless there is ?
Changing condition
Or
Further treatment is required
(MCI)
When will the medical control officer begin a tally to determine hospital capabilities and capacities ?
Once notified of an MCI
(MCI)
During the tally, the hospital will be advised of the total potential victims involved based on ?
The level and genetic nature of the incident
(MCI)
In the event, a hospital is unable to provide a tally. Medical control will advise them of our standard tally that they may expect…
A standard tally is ..
10 green
5 yellow
2 red
(MCI)
Medical control will indicate the tallies on a __________. This information will be maintained and updated for the duration of the incident.
Hospital Capability sheet
(MCI)
Who shall be advising receiving facilities to keep the disaster tag with the patient for future documentation?
Medical control
(MCI)
Who shall be advising the medical examiner of fatalities and complies with the request of the medical examiner?
Medical control
(MCI)
Staging officer will be responsible for maintaining what kind of work sheet ?
Unit staging log worksheet
(MCI)
The unit staging log worksheet shall be maintained by whom.
Staging officer
(MCI)
If personnel are directed to assist in another function, the staging officer shall ensure that..
Keys to the vehicle stay with each vehicle
(MCI)
The staging officer shall determine from _______, a location for loading BLS and ALS patients
Transport
(MCI)
The staging officer shall maintain a reserve of at least _______, transport vehicles
When the reserve is depleted, advise ______
1 BLS and 1 ALS transport vehicles
Advise command
(MCI)
All units will respond to the staging area unless otherwise, directed by _______
Command
The incident commander will add the completion of the incident, coordinate the gathering of all permanent documentation. This can be facilitated with the assistance of a _______ and _______.
District supervisor
&
Medical control officer
(MCI)
___________ is designed to assess a large number of victims rapidly, and can be used by all EMT’s and paramedics
START method
(MCI)
___________ is the method to triage a large number of pediatric victims while considering the differences in children
Jump START method
(MCI)
The red triage tag shall signify ..
Immediate - first priority - critical
(MCI)
The yellow triage tag shall sign ..
Delayed - second priority - non-ambulatory and non-critical
(MCI)
The green triage tag shall signify..
Minor - ambulatory - walking wounded
(MCI)
The black triage tag shall sign..
Deceased / expected
(MCI)
When is secondary triage performed?
During the treatment phase
(MCI)
The priority used for transport should be determined by ..
The triage priority during the treatment phase
(Secondary triage)
(MCI)
The triage priority, determined in the ______ should be the priority used for transport
Treatment phase
(MCI)
Using jumpstart, evaluate first all …
Children/infants who did not walk under their own power - carried by (ambulatory victims)
(MCI)
What is the first step in the START / jumpSTART method?
Corral all the walking wounded into one supervised location
Do not forget to triage these patients
- tag as minor “Green”
(MCI)
What is the second step in the START / jumpSTART method?
Begin assessing all non-ambulatory victims, where they lay if possible
Each victim should be triaged in 60 seconds or less
(MCI)
What is the START algorithm?
RPM
Respirations
Perfusion / pulse
Mental status
(MCI)
If all 3 RPM assessments are normal, but the patient is non-ambulatory tag as ..
Yellow - delayed
(MCI)
If respiratory rate is
____ /min for adult
&
___ / min for pediatric
Tag as RED
30 / min or greater - adult
<15 or >45 / min - pediatric
(MCI)
During triage if adult victim is not breathing..
Open the airway
Remove obstructions if seen
Assess for respiratory rate & tag accordingly
If adult victim is still not breathing
Tag BLACK
(MCI)
During triage if pediatric victim is not breathing..
Open airway
remove obstructions if seen
Assess respiratory rate & tag according
Still not breathing..
check for pulse
IF THERE IS A PULSE - give 5 rescue breaths
If child starts breathing tag RED
If the child is not breathing tag BLACK
(MCI)
When assessing perfusion, this can be performed by..
Palpating a peripheral pulse in the least injured limb
or
Assessing capillary refill time in adults
(MCI)
Assessing perfusion ..
If peripheral pulse is present in the child or cap, refill is 2 seconds or less in the adult
Go onto mental assessment
If there is no peripheral pulse in the child or cap refill is > 2 seconds
Tag RED - immediate
(MCI)
How is mental status assessed during START jumpSTART method ..
Adult victims ability to follow, simple commands and their orientation to time place and person oriented x 3
For the child use the AVPU method
(MCI)
Only correction of life-threatening problems, such as ________ or ________ should be managed during the triage phase
Airway obstruction
Or
Severe Hemorrhage
(MCI)
Triage personnel should carry only minimal equipment limit …
Ribbons
Bandages
Airway adjuncts (oropharyngeal airways)
(MCI)
Unless clearly suffering from injuries, incompatible with life victims tagged ________ should be reassessed once critical interventions have been completed for the ________ & ________ patient
Black
Red & yellow
Restraints should only be used when …
Less restrictive means of controlling a patient’s behavior have been exhausted
When facing a violent patient, what is the first priority?
Scene safety
Physical restraint may be necessary under the following 3 conditions
Patient exhibiting violent behavior toward themselves or others
Incapacitated patients who require emergency medical intervention
A person who is in immediate danger, such as walking into the path of oncoming traffic, or trying to move down electrical wire
What are the four types of “acceptable restraints”
Verbal restraint
Soft type restraint
Manual restraint
Chemical restraint
Unacceptable restraints..
Handcuffs
Flexicuffs
any restraint < 1” wide
Any discrepancies in restraints should be noted in..
The EPCR
(Patient restraint)
Sitting position ..
Secure restraints by tying or taping around the side bars of the main stretcher frame
do not secure to the fold down side rails
(Patient restraint)
Supine patient
First place them on a backboard and secure the restraints to the board. If the patient vomits, the patient can be turned as a unit.
(Patient restraint)
Soft restraints (applying)
- Place the restraint around the wrist or ankle and form a bight holding the running pieces together and close to the patient.
- Secure the running pieces together with tape. DO NOT tie a knot unless the device is specifically made as an extremity restraint.
- If needed, additional restraints such as a rolled sheet or blanket may be used around the chest and under the armpits, over the hips, or over the legs.
- After restraints are applied, assess distal circulation via capillary refill and document its presence a minimum of once after the restraints are applie upon release at the hospital.
- Continually monitor the patient’s circulatory and respiratory status. Always keep cissors on hand to release restraints in the event the patient experiences any spiratory or circulatory compromise.
(Patient restraint)
Manual restraint - placing
Use of as many fire rescue or law enforcement personnel as possible, as preferred in order to reduce the chance of injury to personnel, or the person being restrained
Continually reassess the patient’s circulatory and respiratory status
Release manual restraint in the event, the patient experiences any respiratory or circulatory compromise
(Patient restraint)
Chemical restraint
Careful assessment and documentation should support the need..
Obtain and document a pre-sedation GCS as well as pupillary reaction
Note any significant neurological findings, such as movement of extremities, posturing, or changes while under care
Establish IV access..
If unable to safely establish an IV..
administration of intranasal versed and / or Ativan, and ketamine is indicated per protocol
Monitor and record ECG. Monitoring should continue throughout the procedure
if the patient’s heart rate decreases by more than 20 BPM stop chemical restraint therapy and oxygenate with 100% 02 via BVM for minimum of 2 minutes
(ResQcpr)
The ResQcpr is a cpr adjunct that consists of two synergistic devices
2 devices
ResQPod ITD
&
ResQPUMP ACD-CPR device
(ResQCPR)
Position 1 -
Compressor
Expose the chest, begin ACD-CPR AT A RATE OF
80 COMPRESSIONS PER MINUTE ROTATING EVERY TWO MINUTES FROM THE ROLE OR AS NEEDED
POSITION 1 WILL PERFORM ACD-CPR FOR 10 MINUTES
(ResQCPR)
How many compressions per minute while using the ResQpump ACD CPR
80/ min for 10 min
Rotate every 2 minutes or as needed
(ResQCPR)
Position 2 -
Monitor
Applies and operates monitor and assist position 3 with airway. If Shock is not indicated.
(ResQCPR)
Position 3 -
Airway
Primary objective - open airway. Insert an OPA give 2 ventilations to ensure there’s no foreign body obstruction.
Secondary objective -
If no obstruction, insert an advanced airway, followed by impedance threshold device (unless pt has trauma related injury) followed by ETCO2 filter line & then ventilate 1 breath every 6 seconds
(ResQCPR)
Position 4
Vascular access / medications
Primary objective - Establish an IV or humeral I/O, unless contraindicated
Secondary objective - prepare and administered medication’s during compressions
(ResQCPR)
Position 5
Auto pulse
Primary objective - apply mechanical CPR device auto pulse after 10 minutes of ACD-CPR + ITD & start mechanical CPR device at a continuous rate
Secondary objective - prepare rescue truck for transport
(ResQCPR)
Position 6
Code commander
Primary objective - gather information for the ECPR
Secondary objective -
-console the family if needed
-ensure no equipment is left behind on scene
-ensure rotation of CPR compressor
(ACD - CPR Device ResQPUMP)
When properly used, it increases, blood return by re-expanding the chest with a lift force of up to ______ KG
10 KG
(ACD - CPR Device ResQPUMP)
The _________ pressure created helps increase perfusion to the brain and vital organs
Negative pressure
(ACD - CPR Device ResQPUMP)
Contraindications
Moving vehicle
Cardiac arrest due to trauma
Children
Sternotomy (within 6 months)
LVAD patients
(ACD - CPR Device ResQPUMP)
Position the suction cup in the middle of the _________ make sure the edge of the suction cup does not extend below the ________ as this could result in an adequate suction and rib injury
Sternum between the nipples (mid nipple line)
Xiphoid process
(ACD - CPR Device ResQPUMP)
If no ROSC after _______ minutes Stop ResQPUMP and apply mechanical CPR device (auto pulse) at a continuous rate
10 minutes
(Care of minors)
Treatment & transportation of minors shall include ____________ when possible
Informed parental consent
(Care of minors)
If after reasonable attempt the treatment provider cannot contact the parent who has the power to consent any of the following persons, in order of priority may consent to the medical care and treatment of the minor ..
- A person who possesses a power of attorney to provide medical consent for the minor.
- The step parent.
- The grandparent.
- An adult sister, or brother of the minor.
- An adult aunt or uncle.
- DCF caseworker, or administrator, assigned to delinquent or dependent child.
(Care of minors)
Minors who become ill or injured, while attending either public private school may be treated and released to school officials as long as ______
These officials accept responsibility to await arrival of parents, when the minors condition is stable
(Care of minors)
Release of care ..
- If minor is not in need of further medical assistance, the unit OIC shall evaluate the minor surroundings and capacity (mentally/ physically) to function in the environment.
The OIC should consider..
Does the minor know what to do in an emergency?
Does the minor know how to get in contact with a parent or other responsible party?
Is the minor mature enough to take care of himself /herself?
In the judgment of the OIC, the minor is able to provide for themselves then they will be released to themselves
If in the judgment of the OIC, the minor is not able to provide for themselves, then the police department should be called
(Care of minors)
Refusal of treatment/transportation
If in the judgment of the OIC, the situation is life-threatening __________ should be summoned to assist.
The police department
(Care of minors)
The primary goal of rescue is to ________
Stabilize the patient
(Care of minors)
Refusal of treatment / transport
In non-life-threatening situations, the same guidelines should be followed. As for an adult and the patient care record refusal or treatment area should be signed by __________. If possible, the refuses should be witnessed by.___________
The parent or guardian
Sworn law enforcement officer
a third-party witness
last resort - a crewmember
(Consent / refusal)
Patients or legal guardians able to refuse care, include ..
Mentally competent
Adult 18 years of age or older, except
-Emancipated minors
-Self-sufficient minors
-Minors in the military
-Married minors
(Consent / refusal)
Based on the following circumstances, a patient may not refuse medical care and or transportation ..
Altered mental status (GCS less than 15)
Suicide attempt (actual or verbal)
Unstable vital signs
Mental retardation or deficiency
Not acting as a reasonable person would given the same circumstances
Under 18 years of age (except those defined above)
** under these circumstances patients are is to be treated under implied consent or the Incapacitated persons act **
(Consent / refusal)
Unconscious adult patients may be treated and transported under the doctrine of ..
Implied consent
(Consent / refusal) - incapacitated persons law
Fire rescue personnel may examine, treat, and or transport a patient without their informed verbal consent under the following conditions …
Patient is intoxicated, on drugs, incapable of providing informed consent
AND
Patient is experiencing a emergency medical condition
AND
Patient would reasonably under all surrounding circumstances, undergo exam, treatment or transport, if they were capable
Reasonable force (restraint) may be applied
(Consent / refusal) - involuntary examination
(baker act)
A person may be taking to a receiving facility for involuntary examination, if there’s a reason to believe that the person has a mental illness
AND
because of his or her mental illness …
Person refuses exam after conscientious explanation and disclosure of the purposes of the exam
OR
Person is unable to determine for themselves whether exam is necessary
AND
PERSON IS LIKELY TO SUFFER FROM NEGLECT TO CARE FOR THEMSELVES, WHICH PRESENTS A THREAT OF SUBSTANTIAL HARM TO THEMSELVES, AND NOT A PARENT THAT THIS HARM CAN BE AVOIDED THROUGH HELP OF WILLING, FAMILY MEMBERS AND FRIENDS
OR
SUBSTANTIAL LIKELIHOOD THAT WITHOUT CARE TREATMENT, THE PERSON WILL CAUSE SERIOUS BARLEY HARM TO THEMSELVES OR OTHERS IN NEAR FUTURE, AS EVIDENCE BY RECENT BEHAVIOR
(Consent / refusal) - involuntary examination
(Marchman act)
Ma ybe implemented when the patient has threatened or inflicted physical harm toward themselves or others while ________
Under the influence of drugs or alcohol
Or
If it appears in individuals, judgment is so impaired by alcohol drugs, that while in the state, they cannot make appropriate judgments as relates to their health and well-being
If it appears in individuals, judgment is so impaired by alcohol drugs, that while in the state, they cannot make appropriate judgments as relates to their health and well-being .. the _________ may be implemented
Marchman act
Patient refusal (steps)
- Informed the refusing party of the potential consequences of their actions.
- Make attempts to enlist, family members, friends, etc. to try and convince the patient to accept medical care/transport
- A release on the patient care record must be signed by refusing party.
-If the person refuses to sign, this must be documented on the patient care record, and if possible, be witnessed by..
Sworn law-enforcement officer
Third-party witness
Last resort a crewmember
__________________________________________________
Encourage the patient and our family to call back if patient’s condition changes.
If multiple patients are refusing care, a separate patient care record with signed release must be documented for each patient
(Patient refusal)
If the patient refuses to be transported to the closest appropriate facility and wishes to be transported to a more distant facility, this will be treated like __________ depending on the patient condition. Fire rescue personnel have two options.
Any other refusal of care
Option 1- stable patient - transport the patient to the facility of their choice within reason or per specified department transport boundaries
Option 2- unstable patient - explain to them the seriousness of the illness injury. If still refusing transport them to the closest appropriate facility, utilizing the incapacitated persons law if necessary.
(Patient refusal)
In situations where the decision to examine treat or transport, a patient is difficult based on patient / gurdian refusal assistance can be obtained from following resources ..
EMS supervisor
Medical control
(Patient transport)
Problems are encountered at Any part of Patient transport _________ Or ________ can be contacted to provide guidance / clarification
EMS supervisor
Or
Medical control
(ALS transport)
All patients deemed ________ will be transported to the closest appropriate facility
Critical
(ALS transport)
All stable patients requiring transportation will be transported to ________________ facility
Consider ..
The most appropriate, but not necessarily the nearest
Consider..
Specialized treatment
Patient / physician request
(ALS transport)
If there is any doubt or concern about a patient’s condition or stability, the patient will be transported in a ________ to the ________
Fire rescue ALS unit
To the most appropriate facility
(ALS transport)
If a dispute arises regarding the transport of patients or transport destination of patients, ________ or _______ will make the final decision
EMS supervisor
Or
Medical control
(ALS transport)
The decision to transport a patient utilizing emergency lights and sirens will be at the discretion of ..
The OIC
(Non ALS transport)
After complete patient assessment, if it’s determined that the patient is stable, the OIC may elect to ..
Transport in a fire rescue unit to a hospital located within the city limits
(South Miami Hospital to the south and Northshore Hospital to the north)
Transport to a facility outside city limits with approval from EMS supervisor
Release to an ambulance service if fire rescue units are not available or if patient request transport to a hospital that is not approved
Use alternative transport
(Non ALS transport)
Transport to facility outside city limits requires approval from ?
EMS supervisor
(Non ALS transport)
If a patient wants to be transported by ambulance, fire personnel will remain on scene until arrival of ambulance a unit may clear an incident to respond to another incident, only if the OIC determines ..
There are no other units available in Zone
Documents that the patient’s condition is stable at time of release
(Non ALS transport)
If a patient consents to alternative means of transportation, every effort will be made to ensure that the transportation can be initiated while ..
Fire rescue unit is on the scene
(Non ALS transport)
It is imperative that a ______ with ______ is probably documented to support the decision to release a patient to either an ambulance or alternative means of transportation
Complete patient assessment
Vital signs
(OB/GYN transport)
Stable pregnant patients with less than 20 weeks gestation can be transported to ..
The closest appropriate OB/GYN facility
By fire rescue, ambulance, or alternate means
(OB/GYN transport)
Any patient with at least 20 weeks gestation experiencing complications of pregnancy or exhibiting signs and symptoms of imminent delivery will be transported by
Fire rescue unit only
to the closest appropriate OB/GYN facility
(OB/GYN transport)
Patients in suspected, active labor should be transported by ________ to _________
Fire rescue to the closest appropriate OB/GY facility
(Trauma alert transport)
Patients meeting trauma, transport criteria will be transported to _______ via __________
The closest appropriate trauma center
Via a fire rescue ALS unit or air rescue
- this includes patients who status changes to trauma transport criteria DURING transport to another facility
(Trauma alert transport)
Trauma patients who meet trauma, transport criteria may be transported to a non-trauma center only when …
An airway cannot be established
Trauma center is on bypass
An MCI is declared & trauma center is overwhelmed
(STEMI / stroke alert transport)
Patient meeting stemi/stroke alert criteria will be transported to ________ via fire Rescue ALS unit. This includes patient who status changes to meet stemi alert/stroke alert criteria during transport to another facility.
The closest appropriate facility
(HAZMAT transport)
When dealing with hazmat incident, hazmat teams typically handle …
Extrication
And
Decontamination
(Trauma alert transport)
Hazmat exposures are …
Biological
Chemical
Radiological
& may be part of an MCI
(HAZMAT transport)
It may be necessary to prep the transport unit with ..
Visqueen
(Hazmat transport)
Ensure the patient is transported to the ______ capable of dealing with the type of your patient contamination
Closest appropriate facility capable of dealing with the type of your patients contamination
(Hazmat transport)
Before loading the patient onto the rescue vehicle, you should ..
Remove the patient’s clothing
&
Wash the patient down
(Hazmat transport)
Who’s directions regarding preparation and management of the hazmat patient should you follow ..
The receiving facilities directions
(Contagious patient transport)
How are biological pathogens, transmitted by?
Airborne
Blood-borne
Fecal oral exposures
(Contagious patient transport)
The responder must consider both the _______ as well as the ________
The contaminated patient
Environment in which the patient became ill
(Contagious patient transport)
Consideration in controlling contamination should be done by ________
Applying appropriate PPE to the patient
(Contagious patient transport)
When advising receiving facility of the possible contagious patient, this is known as ..
Universal precautions
(Contagious patient transport)
Who is directions regarding preparation and management of the contagious? Patient should you follow ..
The receiving facilities directions
(Inter-facility transport)
EMS may be requested to provide an interfacility transport for a ________ patient
Critical patient
(Inter-facility transport)
EMS may transport with a ________ agreement between the doctor at the facility and the doctor at the receiving facility.
Verbal agreement
- the names of the sending, and receiving doctors should be obtained and recorded in the EPCR
(Inter-facility transport)
If any equipment needed to treat, the patient is unfamiliar to EMS personnel or not in the EMS protocol then ..
The sending facility must send a person qualified to use that equipment during the patient transfer
(Inter-facility transport)
The patient will be assessed and treated per EMS protocol unless ..
A doctor accompanies the patient and directs EMS to follow an alternative protocol
Contact EMS supervisor for any conflicts
(Air rescue transport)
The OIC should consider the use of air rescue for victims of critical illness/trauma when ..
The arrival time to the scene
or
The treatment/transport time from the scene
to the nearest appropriate hospital or trauma center is > 20 minutes - due to prolonged extrication or traffic conditions
(Air rescue transport)
Air rescue should also be considered for ..
Patients requiring immediate medical specialties, not available at the nearest appropriate hospital
(Air rescue transport)
When transporting children via air rescue a non-injured family, member may accompany the patient at the discretion of ..
The air crew
(Patient release at hospital)
Fire rescue personnel will not release a patient until they have provided the emergency to department with a minimum of ..
A face-to-face verbal transfer of pertinent information
&
preliminary patient care record
(Patient release at hospital)
If an advanced airways in place placement shall be confirmed at _______ by by running _______ & documenting the co2 reading in the patient care record
The time of transfer
By running Capnography
(Physician on scene)
Procedure..
- Act in a professional manner.
- Advise the physician that you have a protocol to follow.
- If the physician insist in participating in patient care, ask to see a copy of ..
Florida DOH MD or DO license - Determine if the physician is willing to ride with the patient during transport unless the EMS supervisor or medical control agrees that this is not necessary.
- Contact EMS supervisor or medical control and advise that physician on scene is assuming responsibility for the treatment
- Inform physician unseen that your documenting this assumption of care in your PCR
- Advised that their signature is required in the electronic PCR for any orders given during this incident
- if paramedic and charge questions in order or considers it harm for informed the physician, I’m seeing that this issue must be resolved with the EMS supervisor or medical control
- All interactions between physician on scene and the EMS supervisor or medical control must be documented in the PCR
- And the event there is not agreement the paramedical follow established protocols and/ or the orders of the EMS supervisor or medical control.
(Physician on scene)
The physician insist on actively participating inpatient care ask to see a copy of their ..
Current Florida DOH MD or DO license
(Physician on scene)
Determine if the physician is willing to ride with the patient during transport, unless ..
The EMS supervisor or medical control agrees that this is not necessary
(Physician on scene)
When a physician is on the scene and is assuming responsibility for treatment of the patient you shall contact and advise ..
EMS supervisor or medical control
(Physician on scene)
Any orders given during an incident with a physician on scene will require..
The physicians signature in the electronic PCR for any orders given
(Physician on scene)
If the paramedic in charge questions in order or considered in harmful, inform the physician on scene that this issue must be resolved with …
EMS supervisor or medical control
(Physician on scene)
In the event there is not agreement the paramedic will follow ..
Establish protocols
and/or
the orders of EMS supervisor or medical control
