BLS ROUTINE MEDICAL CARE

BLS ROUTINE MEDICAL CARE Scene safety # Assure scene safety prior to patient contact C-spine # Perform manual cervical spine stabilization if indicated (Follow the cervical spine protocol.) ABCs # Assess airway, breathing, and circulation (ABCs) # ABCs NOT OK # Begin CPR, Early Defibrillation (if authorized) or Airway obstruction maneuvers as indicated # Control significant external bleeding # ABCs OK # Administer oxygen (follow the Airway Oxygen protocol) # Check vital signs (repeat every 5 minutes) # Obtain # chief complaint # history of current event # past medical history # medications # allergies # Perform secondary-full patient exam BLS-1

BLS CERVICAL SPINE STABILIZATION Indications # Obvious head trauma # Obvious spinal trauma # Complaints of neck pain, spinal pain, or numbness in the extremities # Blunt or multisystem trauma # Falls with possible head, neck or spine trauma # Any decelerating mechanism of injury # Penetrating injuries to the neck # Unconscious patients with unknown injuries # Impaired patient at risk for spinal injury Manual stabilization and Cervical Collar # If indication, apply manual stabilization and cervical collar # Where a cervical collar is difficult or impossible to apply, manual stabilization alone may be used # A cervical collar alone does not provide acceptable cervical-spine stabilization # Maintain manual stabilization during and after patient movement until the patient has been fully immobilized on a backboard. BLS-2

BLS AIRWAY/OXYGEN Treatment # Routine Medical Care # Assess respiratory rate Respirations <10/minute # Clear airway as necessary. This may include placing the patient on his/her side (coma position) and suctioning # Consider inserting an airway adjunct. # Nasopharyngeal airway for patients with gag reflex # Oropharyngeal airway for patients without gag reflex Respirations >10/minute # Place on high-flow oxygen (10-15 liters/minute by non-rebreather mask) if ANY of the following: # trauma # unconscious/altered mental status # chest pain # shortness of breath # burns # pregnancy with complications # shock # smoke/toxic inhalations # Place on low-flow oxygen (2-6 liters/minute by nasal cannula) only if NONE of the above and ALL of the following criteria are met: # skin pink/warm/dry # blood pressure >100 systolic in adults # pulse 60-100/minute # respirations 12-20/minute and unlabored # alert & fully oriented Consider # Maintaining low flow oxygen (2 liters by cannula) in COPD patients who are oxygen dependent and/or known CO 2 retainers BLS-3

BLS SHORTNESS OF BREATH/CHEST PAIN Treatment # Routine Medical Care # Position of Comfort. (Never force a patient with shortness of breath to lie down.) # If pregnant, Do not place patient on back # Administer high-flow oxygen (10-15 liters/minute by non-rebreather mask.) Be prepared to assist ventilations with bag/valve/mask and 100% oxygen. # Provide supportive care # EMTs and First Responders must not administer medications to patients # EMTs and First Responders may assist patients in locating or retrieving medications at the patient's request. # Patients who want to take their own medications must do so on their own. Consider # Maintaining low flow oxygen (2 liters by cannula) in COPD patients who are oxygen dependent and/or known CO 2 retainers BLS-4

CPR Treatment # Routine Medical Care # Place patient supine on a hard surface, with legs elevated approximately twelve inches if possible. # Open airway with head-tilt/chin lift method. If trauma or cervical-spine injuries are present or suspected, use jaw-thrust method only. Apneic patient # Ventilate X2 # If unable to ventilate, reposition head and attempt to ventilate again. # If still unable to ventilate, go to the appropriate Airway Obstruction protocol. # Consider inserting oral or nasal airway. Pulseless patient # Begin CPR. If patient weighs more than 90 pounds, initiate Early Defibrillation immediately if authorized. # Chest compression -to-ventilation ratios: # one rescuer: 15 to 2 # two rescuer: 5 to 1 # Compression rates: # child and adult: 80-100/minute # infant 100/minute # Compression depths: # adult: 1 ½ to 2 inches # child: 1 to 1 ½ inches # infant: ½ to 1 inch # Assess the efficiency of chest compressions by feeling for a carotid pulse while compressions are being performed. If no pulse is felt, reassess the depth and location of compressions. Reassess # Reassess for the return of pulses/breathing after 1 minute and every 3 minutes thereafter. If pulses return, discontinue chest compressions and continue to ventilate the patient at a rate of 20/minute (every 3 seconds) BLS-5

ALTERED MENTAL STATUS Treatment # Routine Medical Care Suspicion of Poisoning or Overdose # Maintain airway and coma position # Attempt to determine cause Observed seizure # If still seizing, protect from injury # During and after seizure, maintain airway and coma position Trauma Mechanism # Maintain Cervical Spine precautions and airway Known or suspected Diabetic Unknown cause and/or history # If awake, able to hold head upright, and gag reflex present, assist patient to selfadminister glucose paste or solution. Patient MUST be able to swallow without difficulty. # If not awake, not able to swallow or hold head upright, or if non gag reflex, maintain airway and coma position # Maintain airway and coma position. BLS-6

TRAUMA MANAGEMENT Treatment # Routine Medical Care. In multiple-casualty incidents where resources are overwhelmed, use "START" triage # Institute Cervical Spine precautions as necessary # EXPEDITE TRANSPORT # Remove or cut away the patient's clothing to expose injuries # Control significant external bleeding as follows (tourniquets should not be used) # Direct pressure # Elevation- Use caution if suspect possible fracture # Pressure points # Treat suspected shock. Shock should be suspected when there is a mechanism of injury or the skin is pale, cool and diaphoretic. Vital signs alone are an unreliable indicator of shock. # Elevate legs only if shock is suspected. # Administer high-flow oxygen. # Keep the patient warm. # Stabilize fractures in the position found or the patient's position of comfort. # Pulses distal to the fracture should be checked within 2 minutes of completing the primary survey and every 5 minutes thereafter. # Distal pulses and capillary refill should also be checked before and after any movement of a suspected fracture. BLS-7

BURNS Treatment # Extinguish burning or smoldering clothing. # Flush chemical burns with copious amounts of water # Routine Medical Care Airway # Assess airway for burns. Airway burns should be suspected when the patient: # is burned or exposed to smoke in an enclosed space # has been exposed to toxic fumes # has burns to the face and/or the upper airway # has redness/blisters/soot in the mouth or nose, or singed nasal hair # has carbaceous sputum Treatment con t # Assess for other injuries and treat as indicated # Maintain airway and administer high-flow oxygen (see Airway/Oxygen protocol) # Treat burns appropriately # Use saline-moistened sterile dressings to stop the burning process. # Burns <10% total body surface area may be kept wet with salinemoistened (sterile preferred) dressings. # For burns >10% total body surface area, wet dressings must be removed once the burning process has stopped. # The wet dressings should be replaced with clean (sterile preferred) dressings. # The patient should then be covered with a sterile burn sheet and blanket to prevent loss of body heat. BLS-8

AIRWAY OBSTRUCTION DEFINITION CONSCIOUS PATIENT-ABLE TO SPEAK CONSCIOUS PATIENT- UNABLE TO SPEAK OR COUGH ADULT PATIENT AND CHILD > 1 YEAR OLD WHO IS OR BECOMES UNCONSCIOUS INFANTS WITH COMPLETE OBSTRUCTION Mechanical upper airway obstruction with history of food aspiration (especially if elderly), alcohol abuse, child playing with small toys # Offer reassurance, do not intervene, encourage coughing # Offer oxygen via cannula # Frequent gentle suctioning in needed to control secretions # Confirm airway obstruction # Administer abdominal thrust if adult, back blows for infant, until the foreign body is expelled or the patient becomes unconscious # After obstruction is relieved, reassess airway, lung sounds, skin color and vital signs # Oxygen therapy as indicated by clinical condition # Roll patient supine; open airway (tongue-jaw lift); perform finger sweep. In children, avoid finger sweeps unless foreign body can be seen and removed from mouth with fingers. # Attempt bag-valve-mask ventilations; if unable to ventilate, perform five (5) additional abdominal thrust # Perform finger sweep and attempt to ventilate # In infants < 1 year old, begin with five (5) back blows with the infant straddled over the arm in the prone position, head lower than trunk # Administer back blows by resting the free elbow on rescuer's thigh and delivering blows with heel of the hand # Turn infant over and deliver five (5) chest compressions in a manner similar to CPR (but slower). Finger sweeps are to be avoided unless the foreign body can be seen and removed (with fingers) from mouth # If still obstructed, repeat above sequence BLS-9

ENVIRONMENTAL EMERGENCIES Treatment # Routine Medical Care HEAT # Protect Patient from further exposure to heat. # Move patient to cool environment # Remove heavy or constricting clothing # Apply moist dressing and fan patient. COLD # Protect patient from further exposure to cold # Move patient to warm environment # Remove wet clothing # Do not actively rewarm patient or insert oral airway. # Prevent unnecessary movement. # Cover patient with a blanket. BITES or STINGS # Remove stinger if still present. # Administer 100% oxygen and ventilate as needed # Assess for signs and symptoms of shock and airway obstruction. Treat appropriately. SMOKE INHALATION # Administer 100% oxygen and ventilate as needed. # Examine nose and mouth for soot and other signs of airway burns. HAZARDOUS MATERIALS # ASSURE PERSONNEL AND SCENE SAFETY FIRST # Do not approach patient # Isolate and deny access to hazard area. # Initiate HAZ-MAT response # Establish safe treatment area uphill and upwind of the hazard area. Receive patient from rescue personnel. # Routine Medical Care BLS-10

ROUTINE OBSTETRIC DELIVERY Treatment # Routine Medical Care for the mother Baby's Head Visible # Assist delivery # Suction airway as soon as possible # Check for cord around baby s neck and gently remove if present # Clamp cord X2 and cut between clamps # Assess, dry, and wrap the baby # Massage fundus if infant is delivered and there is heavy vaginal bleeding # Deliver the placenta if presenting but do not force # See Newborn Care protocol Baby's Head Not Visible # Transport BLS-11

NEWBORN CARE Treatment # Routine Medical Care for mother Assess # Assess the baby. A normal newborn: # has a completely pink appearance # has a pulse >100/minute # cries when stimulated # actively moves all extremities # has a good strong cry # A depressed newborn lacks one or more of the above characteristics Normal Newborn # Routine Medical Care, including suctioning # Dry the baby # Cover the head and baby to maintain body heat # Allow mother to hold and breast feed the baby if she wishes. Depressed Newborn # Suction # Apply vigorous stimulation by touch, do not spank newborn # Provide 100% oxygen by pediatric mask, and assist ventilation as necessary. # Check pulse rate # Pulse >60/minute: Expedite Transport # Pulse <60/minute: Start CPR (if pulse <60/minute, perfusion is inadequate. CPR is indicated even though the newborn may have a pulse.) BLS-12

OBSTETRIC EMERGENCIES Treatment # Routine Medical Care for mother Cord Around Baby's Neck # Attempt to slip the cord over the baby's head # If unable, insert gloved finger between newborn s neck and cord and rotate around neck in circular fashion in attempt to slide cord over neck # As last resort, consider double clamping cord and cutting between clamps, expediting delivery ASAP # See Newborn Care protocol Prolapsed Cord or Breech Presentation Other Obstetric Emergency (including abnormal vaginal bleeding, abdominal pain that is not labor-related, hypertension or seizures.) # Administer 100% oxygen to the mother # Place mother supine with hips and legs elevated higher that the thorax. # Lift any present part off umbilical cord. # Advise mother not to push. # Administer 100% oxygen to mother # Place mother in left lateral position # Elevate legs if signs or symptoms of shock. Do not lay flat on back. # Advise no pushing # IF SEIZURE: # Maintain airway. Protect mother from injury. Position mother to enable blood return, i.e. left lateral position if possible BLS-13

EARLY DEFIBRILLATION Consider Determination of Death in the Prehospital Setting Policy CONFIRM # Unconscious, Non-Breathing and Pulseless # Non-Trauma # Not Hypothermic # Body weight over 90 pounds (41 kg) CPR ANALYZE RHYTHM DEFIBRILLATE Initiate CPR/Set up defibrillator (If alone, do not start chest compressions) # Have machine analyze rhythm (Stop CPR) If machine determines that a shock is necessary; stand clear. Press button to shock patient at 200 joules.** # Immediately have machine analyze rhythm (No CPR). If machine determines that a shock is necessary; stand clear. Press button to shock patient at 200 joules.** # Immediately have machine analyze rhythm (No CPR). If machine determines that a shock is necessary; stand clear. Press button to shock patient at 360 joules.** REASSESS # Reassess for pulselessness and apnea. If indicated, do CPR for one minute. # Have machine analyze rhythm; if indicated, repeat series of three shocks. Again, reassess for pulselessness and apnea. If indicated, do CPR for one minute. Have machine analyze rhythm; if indicated, repeat series of three shocks. TOTAL NUMBER OF SHOCK # A total of 9 shocks may be delivered or until ALS unit arrives and assumes care # of patient. After 9 shocks continue CPR until transport unit arrives. If the patient remains unconscious and pulseless after 1 minute of CPR: Repeat the series of three shocks twice or until a transport unit arrives. NO MORE THAN 9 SHOCKS MAY BE GIVEN PER CALL. RETURN TO PULSELESS STATE IF THE INITIAL RHYTHM IS NOT SHOCKABLE If patient returns to a pulseless state, have machine analyze rhythm. If shockable rhythm has occurred, repeat a series of three shocks. Do CPR for one minute and reevaluate. Check pulse and have machine analyze rhythm. If unshockable rhythm remains, continue CPR until paramedics arrive. If shockable, follow shock series as above. If pulse returns, maintain airway and breathing, check B/P. ** Early Defibrillation Devices using Alternative Technologies may be set to deliver energy levels recommended by the manufacturer BLS-14