Closed - Captain 2020 Promo Exam - EMS - pages 1-63.docx

CAPTAIN 2020 Promotional Exam EMS Pages 1-63 Fire Rescue may be called to the scene to manage patients that are agitated and presenting with verbally and/or physically threatening behavior. These patients are agitated, restless, sometimes crying, sometimes confused, and they appear to be out of...

CAPTAIN 2020 Promotional Exam EMS Pages 1-63 Fire Rescue may be called to the scene to manage patients that are agitated and presenting with verbally and/or physically threatening behavior. These patients are agitated, restless, sometimes crying, sometimes confused, and they appear to be out of control. Their agitated condition may be related to mental illness and/or drug use (particularly stimulants such as cocaine). Alcohol withdrawal and head trauma may contribute to the condition. Excited Delirium Syndrome Agitated patients may be experiencing an excited delirium syndrome, and when managing the care of these patients it is important to evaluate the agitated patient for possible excited delirium syndrome. Patients with the Excited Delirium Syndrome may demonstrate some or all of these finds: Extremely aggressive or violent behavior Constant physical activity, restless Not responsive to police/fire presence Attracted to bright lights, loud sounds, their own reflections in glass or mirrors May be naked or near naked Rapid breathing Profuse sweating Little response to pain Superhuman strength Hot to the touch Law enforcement agencies may utilize a TASER, as a non-lethal method to temporarily incapacitate individuals who exhibit threatening behavior. Thus, it is important when approaching a patient who has been TASERed, to evaluate the patient for possible excited delirium syndrome. Patients with excited delirium syndrome typically continue to be agitated again after being TASERed. TREATMENT Have enough personnel on the scene to handle the situation, and if necessary, to physically manage the patient. Secure the scene and use universal precautions. Attempt to calm the patient down. Speak softly and non-threateningly. Avoid loud noises and sudden movements. 3 1 1 Use the least restrictive method of restraint. Providers should ensure their own safety. If possible, allow the patient to correct inappropriate behavior. Use restraints if unable to calm the patient down, and the patient remains a threat to himself/herself or others. If restraint is necessary, DO NOT put the patient prone (face down). Use a supine or recovery position. Use as many providers/police present to safely restrain the patient. If chemical restraint is indicated and available, administer ketamine, 4 mg/kg 1M (maximum dose 400 mg). Ketamine may be given in the mid shaft anteriolateral aspect of the thigh OR the lateral deltoid muscle of the shoulder. It may be given through clothing. If the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off, OR IF KETAMINE IS NOT AVAILABLE. If vascular access is available: Administer lorazepam (Ativan), 2 mg IV slowly over 1 minute OR Administer midazolam (Versed), 5 mg IV. If vascular access is NOT available: Administer lorazepam (Ativan), 2 mg 1M OR Administer midazolam (Versed), 10 mg 1M / IntraNasal. Both medications may each be repeated in 3-5 minutes if indicated. Universal Initial Adult Patient Assessment / Care. Ensure a maintainable airway. Obtain a blood glucose level and treat with dextrose 50% (D50W), if indicated. 10. Monitor cardiac rhythm, ETC02 and Sp02. Give supplemental 02, if indicated. Treat any medical complaint per the appropriate protocol(s). If the patient is exhibiting disrhytmias indicative of metabolic acidosis, such as a wide QRS and/or loss of P waves, consider giving sodium bicarbonate, 1 mEq/kg IV/IO. 12 of3 13. IF THE AGITATED PATIENT IS EXHIBITING SIGNS OF EXCITED DELIRIUM AND THE PATIENT IS FEBRILE OR HOT TO THE TOUCH (temperature reading of 104 0 F (40 0 C) or higher OR if unable to obtain a temperature and the patient feels hot to the touch) attempt to cool the patient down. Remove as much clothing as possible. If possible, move patient to a cooler environment and/or fan blowing on patient. If available, apply ice packs to the neck, axillae, and groin areas. If available, take and document a baseline temperature before administering cold normal saline. Also take and document a temperature at the time of patient transfer in the ED. Establish vascular access and bolus cold (340 F) normal saline, 30 mL/kg IV/IO (maximum 2 Liters). If Ativan or Versed have not already been given, AND the patient is shivering, administer midazolam (Versed), 5 mg IV/IO or 10 mg 1M / IntraNasaI. If the patient is agitated and/or in pain after midazolam (Versed) and the systolic BP remains at 90 mmHg or greater, administer morphine sulfate, 5 mg IV/IO/IM. If the patient continues with agitation and/or pain, the morphine may be repeated every 5 minutes as needed. The total amount of morphine given should not exceed 20mg. INITIAL PATIENT ASSESSMENT Check for responsiveness, breathing, and pulse. If the patient is unresponsive, determine presence or absence of a pulse. Start chest compressions and continue uninterrupted until the monitor or AED is ready to assess the rhythm. Primary attention is paid to immediate continuous chest compressions and assessment of the patient's cardiac rhythm. Defibrillator pads should be applied without interrupting compressions. Quickly determine whether the patient has a shockable rhythm, and if so, immediately DEFIBRILLATE. If defibrillated, resume compressions immediately after, and manage according to the appropriate protocol(s). If patient does not have a shockable rhythm, resume compressions and manage according to the appropriate protocol(s). If a pulse returns (Return Of Spontaneous Circulation — ROSC), Initiate Post Resuscitation Care. If no ROSC, refer to Death in the Field Protocol. Refer to Initial Cardiac Arrest Approach with ResQCPR System, if available CHEST COMPRESSIONS (use a manual Active Compression-Decompression Device and ITD, if available) 1 . In cardiac arrest, the emphasis is on continuous chest compressions with adequate rate and depth, rather than on ventilations. PUSH HARD. PUSH FAST. ALLOW FULL CHEST RECOIL. MINIMIZE INTERRUPTION OF COMPRESSIONS. Compress at a rate of 100-120 compressions per minute (or per active compression/decompression procedure, if available). One adult cycle is 2 minutes of compressions. 51 6) Perform 2 minutes of CPR between each rhythm check. DO NOT CHECK FOR A PULSE UNLESS THERE IS AN ORGANIZED RHYTHM ON THE MONITOR AND THERE HAS BEEN AN INCREASE IN THE ETC02 LEVEL OF 20 MM OR MORE. Change the compressor (with manual compressions) after every 2 minutes of CPR. Compressions must be delivered on a HARD SURFACE. Minimize interruptions of chest compressions to less than 10 seconds. DO NOT INTERRUPT COMPRESSIONS to establish vascular access or to administer medication. Once the Advanced Airway is in place, attach the C02 sensor and ventilate once every 6 seconds (10-12 breaths per minute). DO NOT INTERRUPT COMPRESSIONS to ventilate. Monitor waveform capnoqraphy (C02 levels). If an automatic compression device (AutoPulse) is available, do not apply until 2 minutes of manual compressions have been performed (or per department procedure). Do not interrupt a 2-minute cycle of compressions to place the device. Set up and position the device during compressions and place it to begin the next 2-minute cycle of compressions. For optimal performance, and easy transport, consider using a carry-all or backboard. The monitor or AED should be charged while continuing chest compressions in order to minimize the time from stopping compressions and delivering the shock as well as to minimize any interruption in chest compressions. Immediately resume chest compressions after a shock is delivered without pausing to check for rhythm/pulse. AIRWAY MANAGEMENT 1 . If there is no pulse, and the patient is not breathing, continue compressions and start ventilations with a BVM until ready to place an Advanced Airway (if any difficulty ventilating, consider an airway obstruction). Advanced Airway: When the patient is in respiratory arrest, or prolonged PPV is required with a BVM or an Automatic Ventilator, an advanced airway should be properly placed. There is a choice of a Supraglottic Airway or an oral Endotracheal Tube. In preparation for an advanced airway the patient should be given 100% oxygen while preparing for the procedure. Supraglottic Airway: is placed in the initial set of compressions in cardiac arrest. It can also be used in respiratory arrest and respiratory distress when there is no gag reflex. Supraglottic Airways are contraindicated when there is damaged tissue in the supraglottic area or if there is a high risk of aspiration. I-gel is an example of a supraglottic airway. Endotracheal Tube (ETT): is no longer the primary airway in cardiac arrest, however use of an ETT is acceptable on the initial Advanced Airway attempt and if not successful then immediately go to a Supraglottic Airway. It is the airway of choice when there is a high risk of aspiration. It is also usually indicated when Supraglottic Airways are contraindicated. If you have not already done so, attach an ETC02 sensor and monitor wave capnoqraphy during resuscitation efforts. Ventilate once every 6 seconds (10-12 breaths per minute) without interrupting compressions to ventilate. Avoid excessive ventilation. 2. What is the best approach for airway management in the patient with a cardiac arrest? In a patient with a witnessed/unwitnessed cardiac arrest, the emphasis is on continuous compressions and early defibrillation if a shockable rhythm is present. Charge the defibrillator as soon as it is ready. Determine the rhythm and deliver a shock if appropriate. Airway management can be deferred to the next cycle of compressions and can be safely managed with the quick placement of a Supraglottic Airway. There are situations where endotracheal intubation might be the preferred initial airway management intervention. These include, but are not limited to: Suspected upper airway inhalation burns 2) Severe facial trauma 3) Presence of vomitus in the mouth. 53 If you are going to use endotracheal intubation: Attempt endotracheal intubation once after defibrillating and/or checking the rhythm. If the vocal cords are not immediately visible, or the single endotracheal tube intubation attempt fails, then immediately resume compressions and quickly insert a Supraglottic Airway without interrupting compressions. Attach an ETC02 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 C02 level, which is frequently an indicator of ROSC. Early ventilation is appropriate in the following situations: Respiratory Arrests Pediatric Arrests Near drowning Asystole / PEA Unwitnessed arrest VASCULAR ACCESS In cardiac arrest, the preferred vascular access should be 10. However, if paramedic judgment suggests IV access is obtainable and can be performed within 30-60 seconds, then IV access is acceptable and should only be attempted once. As a last resort, and only if both 10 and IV access are not successful, the Advanced Airway route may be used. a. Only epinephrine, atropine sulfate and naloxone (Narcan) can be given down the Advanced Airway, at 2 times the IO/IV dose diluted with normal saline to a total of 10 mL. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Repeat epinephrine every 3 to 5 minutes during the arrest. Medications should be given early in the 2-minute compression cycle to allow time for them to circulate before pulse checks and/or other interventions. 54 AED Attach an AED as soon as possible. Avoid placing defibrillator pads over a pacemaker, internal defibrillator or transdermal medication patch. Do not interrupt compressions to place defibrillator pads. Start CPR, turn on the AED and attach defibrillator pads during CPR. Stop CPR as soon as you are ready to identify the rhythm and follow AED prompts. If a shockable rhythm is determined by the AED, the unit will charge to the appropriate joules. Verbally and visually "clear the patient" and have the compressor discharge the AED once. Immediately resume CPR for 2 minutes. Do NOT perform a pulse or rhythm check. After 2 minutes of CPR the AED will prompt you to repeat the above steps. Repeat this sequence for shockable rhythm as long as a pulseless and shockable rhythm persists or until a monitor/defibrillator and ALS are available. If the patient is pulseless and a NON-shockable rhythm is present, i.e., "shock is NOT advised," perform CPR until a monitor/defibrillator and ALS are available. If a pulse is present (ROSC), check breathing, then initiate Post Resuscitation Care. MONITOR/DEFIBRILLATOR Immediately start CPR. Turn on the monitor/defibrillator. Attach defibrillator pads during compressions and charge the monitor/defibrillator to appropriate joules. a. Avoid placing defibrillator pads over a pacemaker, internal defibrillator, or transdermal medication patch. 55 Determine whether the patient has a shockable rhythm. If so, immediately DEFIBRILLATE Perform 2 minutes of CPR between each rhythm check. DO NOT CHECK FOR A PULSE UNLESS THERE IS AN ORGANIZED RHYTHM ON THE MONITOR AND THERE HAS BEEN AN INCREASE IN THE ETC02 LEVEL OF 20 MM OR MORE. If no shockable rhythm, follow the appropriate protocol. INITIAL RECORDED RHYTHM Ventricular Fibrillation (VF) I Pulseless V-Tach 1 . If the ECG indicates VF/ Pulseless V-Tach DEFIBRILLATE (#1) and immediately resume CPR for 2 minutes without checking for a pulse or rhythm change. DEFIBRILLATION JOULES ZOLL LIFEPAK MRX SHOCK #1 200J 360J 150J SHOCK #2 200J 360J 200J SHOCK 200J 360J 200J After 2 minutes of CPR check rhythm/pulse. If the rhythm is NOT shockable, check for pulse (no longer than 10 seconds) and if absent, resume CPR and treat as PEA/Asystole. If the monitor indicates VF or Pulseless V-Tach, DEFIBRILLATE (#2) and immediately resume CPR for 2 minutes without checking for a pulse or rhythm change. Within the first minute after resuming CPR, administer epinephrine 1 mg IOP/IVP (10 mL) [or epinephrine 1:1 ,000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if 10/1V access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Complete the 2 minutes of CPR without checking for a pulse or rhythm change. Repeat epinephrine every 3 to 5 minutes during the arrest. After completing 2 minutes of CPR, check rhythm. If the rhythm is NOT shockable, check for pulse (no longer than 10 seconds) and if absent, resume CPR and treat as PEA/Asystole. If the monitor indicates VF/Pulseless V-Tach, DEFIBRILLATE (#3) and immediately resume 2 minutes of CPR without checking for a pulse or rhythm change. 56 Within the first minute after resuming CPR, administer amiodarone, 300 mg IOP/IVP and complete the 2 minutes of CPR without checking for a pulse or rhythm change. After completing 2 minutes of CPR, check rhythm. If the rhythm is NOT shockable, check for pulse (no longer than 10 seconds) and if absent resume CPR and treat as PEA/Asystole. If the monitor indicates VF/Pulseless V-Tach, DEFIBRILLATE (#4) and immediately resume 2 minutes of CPR without checking for a pulse or rhythm change. Within the first minute after resuming CPR, administer epinephrine 1: 10,000, 1 mg IOP/IVP (10 mL) [or epinephrine 1 :1 ,000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if IO/IV access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Complete the 2 minutes of CPR without checking for a pulse or rhythm change. Epinephrine may be repeated every 3-5 minutes during the arrest. After completing every 2 minute cycle of CPR, check rhythm, and if the patient remains in a shockable rhythm, DEFIBRILLATE. If the rhythm is not shockable, check for pulse (no longer than 10 seconds) and if absent resume CPR and treat as PEA/Asystole. If the monitor indicates VF/PulseIess V-Tach, if available consider DOUBLE SEQUENTIAL DEFIBRILLATION* (#5) and immediately resume 2 minutes of CPR without checking for a pulse or rhythm change. *Double Sequential Defibrillation — If 2 defibrillators are available on scene, DEFIBRILLATE at 400 joules if two Zolls or two MRXs, or at 560 joules if one MRX plus one LifePak AED, or 720 joules if two LifePak monitors. New research and clinical experience suggest that maximum energy levels using two defibrillators simultaneously (sequentially) may be effective when standard defibrillation levels have failed to convert. Attempt a double sequential defibrillation after the 4 initial defibrillations have failed: One set of pads will already be placed in either the Anterior/Apex position or Anterior/Posterior position. The second set of pads should be placed in the alternative position. Ideally, the same person will hit both "SHOCK" buttons at the same time Alternatively, the discharges should be done with an oral signal. All subsequent defibrillations should be at the same maximum joules. Ensure that ED personnel know that maximum shocks have been delivered. 57 Within the first minute after resuming CPR, administer second dose of amiodarone, at 150 mg IOP/IVP. Complete the 2 minutes of CPR without checking for a pulse or rhythm change. After 10 minutes of cardiac arrest, consider sodium bicarbonate, 1 mEq/kg 10/1V. May repeat after an additional 10 minutes at 0.5 mEq/kg 10/1V. Sodium bicarbonate may be administered earlier in the protocol if a preexisting metabolic acidosis is suspected such as: Near Drowning Insulin dependent patients, e.g., Diabetic Ketoacidosis Renal Dialysis Psychiatric medication OD Cocaine intoxications Patients with Excited Delirium 1 1 . Consider administration of magnesium sulfate, 2 grams 10/1V in patients with: Torsades de Pointes Recurrent ventricular fibrillation (V-Fib that recurs more than 5 seconds after a successful defibrillation). Persistent ventricular fibrillation not responsive to above medications. If a pulse returns (Return Of Spontaneous Circulation — ROSC), Initiate Post Resuscitation Care. If no ROSC, refer to Death in the Field Protocol. Pulseless Electrical Activity (PEA) and Asystole (Including Agonal and Idioventricular rhythms) PEA is a clinical situation and not a specific rhythm on the monitor/defibrillator. It is defined as 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. The treatment for a patient with PEA will depend on the rhythm that presents on the monitor. Patients with a pacemaker may present with asystole and the rhythm strip will demonstrate pacer spikes without capture. Asystole was once thought to be the "Death" rhythm. Now we understand that it frequently follows PEA. Therefore the approach to Asystole, as in PEA, is CPR, epinephrine, and to evaluate for and treat the underlying cause(s) (Hs and Ts). The best indicator of a viable asystole is a C02 reading of 20, with good CPR, on waveform capnoqraphy. All of these patients need oxygen. Listen to the lungs bilaterally, as patients with a Tension Pneumothorax can present with a PEA situation. Note: if the patient is suspected to be in traumatic arrest, perform bilateral chest decompression. NORMAL / FAST and NARROW Rhythm with PEA Immediately resume CPR for 2 minutes. During compressions, administer epinephrine 1: 10,000, 1 mg IOP/IVP (10 mL) [or epinephrine 1:1 ,000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if IO/IV access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Repeat epinephrine every 3 to 5 minutes during the arrest. Is this patient hypovolemic? Is there a recent history of fluid loss? Administer a normal saline, 500 mL 10/1V bolus. May repeat once as needed. SLOW and WIDE Rhythm with PEA Immediately resume CPR for 2 minutes. During compressions, administer epinephrine 1: 10,000, 1 mg IOP/IVP (10 mL) [or epinephrine ,000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if 10/1V access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Repeat epinephrine every 3 to 5 minutes during the arrest. Kidney dialysis patients may present with a slow and wide cardiac rhythm without a carotid pulse. These patients may have high serum levels of potassium. Administer sodium bicarbonate, 1 mEq/kg 10/1V. May repeat in 10 minutes at 0.5 mEq/kg 10/1V. If no response, flush the IO/IV access line with at least with 20 mL normal saline and then administer calcium chloride, 1 gram 10/1V slowly over one minute. 59 SLOW and NARROW Rhythm with PEA Immediately resume CPR for 2 minutes. During compressions, administer epinephrine 1: 10,000, 1 mg IOP/IVP (10 mL) [or epinephrine 1:1 ,000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if IO/IV access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Repeat epinephrine every 3 to 5 minutes during the arrest. Is this patient hypovolemic? Is there a recent history of fluid loss? Administer a normal saline, 500 mL 10/1V bolus. May repeat once as needed. ASYSTOLE 1 . Confirm Asystole in at least two leads. You must attach limb leads to perform this procedure. Immediately resume CPR for 2 minutes. During compressions, administer epinephrine 1: 10,000, 1 mg IOP/IVP (10 mL) [or epinephrine 1:11000, 2 mg (2 mL) diluted with normal saline to a total of 10 mL via Advanced Airway if IO/IV access cannot be established. After the drug has been administered, provide 5 rapid ventilations to enhance the drug delivery into the lungs. Repeat epinephrine every 3 to 5 minutes during the arrest. Pacing is NOT recommended for Asystole. If no ROSC after 30 minutes, refer to Death in the Field Protocol. PEA, if not treated, will progress to Asystole. Therefore determining and correcting the underlying causes of PEA, also applies to Asystole. With all PEA rhythms remember the 6Hs and 5Ts. Hypovolemia: normal saline fluid challenge(s) / dopamine I rapid transport. Hypoxemia: confirm adequacy of oxygenation. Hydrogen Ion 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) 61 Introduction Patients or Firefighters who become ill or are being evaluated for a possible Carbon Monoxide (CO) exposure will be monitored on a CO Monitor (i.e., Rad 57) as close to the time of exposure as possible. The CO level is used to determine transport and treatment options. There is no pre-hospital test for CN and treatment is based on a high clinical index of suspicion for CN poisoning. In the setting of a building fire, consider possible Cyanide (CN) exposure, particularly in firefighters who develop an altered level of consciousness and/or hemodynamic instability. Siqns and Symptoms for CO/CN Poisoninq 1 . The signs and symptoms for Carbon Monoxide poisoning are non-specific: Dyspnea Headache Chest pain Muscle weakness Nausea Vomiting Dizziness Altered mental status Death Cyanide poisoning may result from inhalation, ingestion, or dermal exposure. Prior to administration of Cyanokit, smoke inhalation victims should be assessed for: Exposure to fire or smoke in an enclosed area Presence of soot around the mouth, nose, or oropharynx Altered mental status In addition to Cyanokit, treatment of cyanide poisoning must include: Immediate attention to airway patency Adequacy of oxygenation Adequacy of hydration Cardiovascular support Management of any seizure activity Hiqh Risk Situations 1 . Your best asset will be a high index of suspicion in high risk situations (especially in fire scene rehab and treatment sectors). 2. The following are to be considered as high risk: Buildinq fires, including salvage & overhaul Areas where generators are used or misused The report of symptomatic or unconscious patient(s) 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 Hiqh Risk Patients 1. Patients at higher risk include: Elderly Children Pregnant women Patients with cardiac disease Patients with chronic lung disease Patients with chronically elevated CO levels (e.g., cigarette smokers) Special Circumstances for Consideration 1 . An individual who is exposed to a high-risk situation and experiences hemodynamic instability and/or a cardiac arrest may also have cyanide (CN) toxicity. 2. During the management of these high-risk situations, including cardiac arrest, shock, seizures and coma, consider administration of Cyanokit. 72 Indications for obtaininq a CO level. Apply to patients when CO poisoning is suspected. Apply to patients being treated for Smoke Inhalation. Apply to individuals when CO poisoning must be ruled out as with firefighters in a major fire scene or other high-risk incidents. This should routinely be done when evaluatinq vital signs of firefiqhters durinq rehab. Caution Poor perfusion states where circulation to the fingers is severely compromised may make readings inaccurate or unattainable. Procedure 1 . Apply finger probe to finger with capillary refill less than 5 seconds. SpCO less than 3% — No further evaluation for SpCO needed. SpCO less than 12% with NO symptoms — No further evaluation for SpCO needed. SpCO less than 12% with symptoms — transport on 100% 02 to nearest ER. SpCO 12% or greater, but less than 25%, with symptoms or preqnant —transport on 100% 02 to a hyperbaric oxyqen facility. SpCO 25% or greater - transport on 100% 02 to a hyperbaric oxyqen facility. TREATMENT 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 withl 02, consider treating for Cyanide Poisoning with Cyanokit. 73 Cardiopulmonary resuscitation will be initiated on all patients who have sustained a cardiopulmonary arrest, UNLESS: Natural Death In Field: 1 . Do Not Resuscitate Order (DNRO) — those terminally ill patients who have properly documented their desire not to be resuscitated through a valid Do Not Resuscitate Order (DNRO). CPR may be terminated if a valid DNRO (yellow copy) is presented after CPR was begun. Patients with obvious death. Patients with these conditions will be pronounced dead in the field. No ECG or attempts at resuscitation are necessary in these patients. These criteria are applicable to all ages. These conditions include: Decapitation Massive crush injury to head or torso Incineration with black charring of the whole body Evisceration/ExpuIsion from the body of vital organ(s): brain, heart, liver, or both lungs Hemicorpectomy (body cut in half through the torso) General body decomposition Patients with apparently irreversible death. The following conditions require asystole recorded on a cardiac monitor and confirmed in at least 2 leads Rigor mortis - hardening of the body muscles, which makes the joints rigid. This sign is not reliable for true death if the patient is a victim of hypothermia. Livor mortis - large areas of dark red or purple discoloration that do not blanch with pressure and that are seen in the dependent body parts - where the venous blood pools after death due to gravity. This sign must not be confused with birthmarks, traumatic contusion, skin rashes, or the milder discoloration seen in patients with shock who have been lying in one position for an extended period of time. Livor mortis can start as soon as 30 minutes after death and usually becomes fixed 6-8 hours after death. 75 Livor Mortis Further Recommendations Consider the following in adults: 1 . Resuscitation efforts may be terminated in the field if ALL of the following conditions are met: The event was not witnessed by emergency medical services personnel. There is no Return of Spontaneous Circulation (ROSC) after 30 minutes of resuscitation efforts. Patients with asystole or an agonal terminal rhythm at the time of termination of CPR. Patients with persistent PEA rhythms OR Ventricular Fibrillation OR Ventricular Tachycardia without a pulse should be transported to the closest appropriate facility. Resuscitation efforts may be withheld in any patient with blunt trauma who, based on the paramedics' thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity (asystole) upon the arrival of EMS at the scene. Resuscitation efforts may be withheld in any patient with penetrating trauma to the head, neck, or torso who, based on the paramedics' thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity (asystole) upon the arrival of EMS at the scene. In suspected Traumatic Cardiac Arrest patients where the mechanism of injury does not correlate with the clinical condition, suggesting a non-traumatic cause of the arrest, Resuscitate and Transport. For example, a patient in cardiac arrest found at the scene of a minor motor vehicle accident. 6. WHEN IN DOUBT - RESUSCITATE AND TRANSPORT Pediatric cardiac arrests are excluded from termination in the field, UNLESS the child meets the criteria for obvious death OR apparently irreversible death OR has a valid DNRO. (see above or appropriate Pediatric Death In Field Protocol), Cardiac arrests in obviously pregnant women are excluded from termination in the field, UNLESS the mother meets the criteria for obvious death OR apparently irreversible death OR has a valid DNRO. Consider the possibility of the patient being an Organ Donor. However, this should not be the sole reason for resuscitation and transport. When Resuscitation is Withheld or Terminated at the Scene. The local law enforcement agency with jurisdiction will be responsible for the body once death has been determined. The body is to be left at the scene until a disposition has been made by the Medical Examiner's Office. When releasing the scene/body, document officer/persons on scene assuming responsibility. Additional Information l. Refer to VALID DNRO for further information and DH Form 1896 2. ePCR documentation must include the following: Reason(s) for terminating or not initiating resuscitation. All resuscitative measures, if applicable, including the location(s) of unsuccessful vascular access attempts. 77 Introduction Fire Department operations frequently involve working and/or training under strenuous conditions and hot environments. Structure fires, vehicle extrications, hazardous materials incidents, and water rescue operations are some of the situations that could predispose fire personnel to heat-related emergencies, over-exertion emergencies, and/or toxic conditions. Officers responsible for Rehab Operations should attempt to find the most appropriate location for rehab group set-up. Shaded locations, away from the immediate operational area are preferred. Firefighters shall be assigned to rehab: Based on departmental S.O.G.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. The Incident Commander should always be advised of any fire personnel sent to rehab for any reason. TREATMENT Standard rehabilitation for all firefighters involved in strenuous operations shall include the following: Universal Initial Adult Patient Assessment / Care (this includes a completed patient record as per SOG) CO levels monitored and recorded for all fire incidents. If CO level is elevated, or firefighter exhibits signs and symptoms suggestive of significant CO exposure, refer to CO/CN Exposure Protocol. For all emergency operations, oral fluid replacement* of up to 20 ounces for each 20 minutes of activity. * An electrolyte solution should contain at least 100 mg of sodium and 8-14 mg of carbohydrate per 12 fluid oz. (Gatorade, Powerade, etc...) 87 A seated rest interval of at least 10 minutes. Air conditioning or shade from heat and sunlight should be used. Bunker gear should be removed to aid with heat dissipation and recovery. An assessment for any heat-related emergency signs and symptoms must be performed on every firefighter in rehab: Vital Signs including Blood Pressure, Heart Rate, Respiratory Rate, Sp02, CO levels, and ECG. Altered Mental Status Fatigue and weakness Nausea and/or vomiting Headache Dizziness Muscle cramps Irritability or ANY CNS dysfunction If nausea or intolerance to oral fluids is present, establish vascular access and administer normal saline, 500 mL IV should be administered. This may be repeated once if additional fluids are indicated after reassessment of vital signs. If ANY heat related emergency symptoms are present and/or the firefighter has abnormal vital signs, the firefighter should be cooled rapidly and given ample oral hydration fluids. (Ample shall mean at least 1 ounce for each 1 minute of operational activity.) Remove as much clothing as possible. Move firefighter to cooler environment and/or fan blowing on them. Firefighters with temperatures of 104 0 F (40 0 C) or higher (OR if unable to obtain a temperature and the firefighter feels hot to the touch), with changes in their mental status and/or develop seizures should also have the following rapid coolinq treatments: If available, place ice packs in the neck, axillae and groin areas. If available, take and document a baseline temperature before administering cold normal saline. Also take and document a temperature at the time of patient transfer in the ED Establish vascular access, and bolus cold (34 0 F) normal saline, 30 mL/kg IV/IO (maximum 2 Liters). 88 Administer midazolam (Versed), 5 mg slow IV/IO or 10 mg 1M / IntraNasaI to reduce shivering, if indicated. If the patient is agitated and/or in pain after midazolam (Versed) and the systolic BP remains at 90 mmHg or greater, administer morphine sulfate, 5 mg IV/IO/IM. If the patient continues with agitation and/or pain, the morphine may be repeated every 5 minutes as needed. The total amount of morphine given should not exceed 20 mg. Any firefighter seen in rehab should be reevaluated after their recovery. The reevaluation exam should be documented appropriately as per department SOG. For operations lasting longer than 2 hours, nutritional supplementation should be provided at a rate of at least 500 calories per hour for each member. Treat any other medical complaint as per the appropriate protocol (chest pain, difficulty breathinq, traumatic injury, etc.) 89 COMMON EMS PROTOCOLS PROCEDURES INDICATIONS FOR 12-LEAD ECG INTRODUCTION Pre-hospital 12-lead ECG determination is a significant step forward in the ability of the paramedic to help identify patients with an Acute Myocardial Infarction (AMI). This procedure outlines the minimum criteria for obtaining a 12-lead ECG. PRECAUTIONS Treatment of life-threatening problems such as: dysrhythmias, acute pulmonary edema, and shock should take priority before obtaining a 12-lead ECG. Obtaining a 12-lead ECG should not delay transport of critically ill patients. ALS The key to the early recognition and management of the AMI patient is identification of the signs and symptoms of patients 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 Medical Control Physician which can greatly reduce delays in care. Patients meeting any of the below criteria should also have continuous cardiac monitoring of the ECG for any changes in the rhythm until transfer of care is completed. Patients who demonstrate an inferior wall MI on their 12-lead ECG should have a V4R lead performed to evaluate for a right ventricular infarction. A 0.5 mm ST-segment elevation of V4R signifies a right ventricular infarction. In these patients, the use of nitroqlvcerin, morphine sulfate and/or furosemide (Lasix) may cause hypotension. If hypotension develops lay patient flat if tolerated, and administer normal saline, 500mL IV bolus. If available, transmit the 12-Lead ECG to the appropriate receiving facility. INDICATIONS FOR OBTAINING A 12 LEAD ECG All chest pain or chest discomfort consistent with myocardial ischemia, unless due to penetrating injury. Upper abdominal / epigastric pain unless evidence of G.l. bleeding in patients older than 35 years of age. Epigastric pain is defined as pain in the area above the umbilicus and below the sternum. INDICATIONS FOR 12-LEAD ECG Sudden onset of shortness of breath (including sudden onset of CHF / Pulmonary Edema). After treatment of a cardiac dysrhythmia in an adult. Fast or slow heart rates / cardiac dysrhythmia / PVC's > 6/min unchanged by oxygen treatment Weakness or fatigue Diaphoresis, not explained by environment. May be associated with nausea and/or vomiting. Syncope or dizziness, altered mental status (including children.) All overdoses. Post cardiac arrest 1 1 . Acute Stroke patients Electrical/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. 17.Any significantly ill patient. NOTE: Women, the elderly, and diabetics with ACS I STEMI may present with atypical signs and symptoms of general malaise, sweating, nausea, and/or shortness of breath with no acute chest pain. 422 INDICATIONS FOR 12-LEAD ECG 423 END TIDAL C02 ASSESSMENT Introduction The capnometer measures expired carbon dioxide expressed as end-tidal C02 (ETC02). Inline or mainstream capnography is used in the patient with an Advanced Airway, and sidestream capnography is used in the non-intubated patient, such as with a nasal cannula. Indications for Use 1 . To confirm initial placement of an Advanced Airway. For continuous monitoring of tube placement throughout patient care and transport. To identify the proper ETC02 values when providing treatment to patients exhibiting signs of brainstem herniation. To confirm the placement of an Advanced Airway upon release of a patient at the Emergency Department or other transport unit. To assess the effectiveness of CPR. To assess ventilation status. Normal Values NOTE: The capnometer will require approximately six breaths to display a change of ETC02. 1 . The following guidelines will be used for patients with a pulse and/or blood pressure: 35-45mmHg .Normal ETC02 values 46-50mmHgMild hypercarbia (increase the frequency of ventilations) Greater than 50mmHg .Severe hypercarbia (increase the frequency of ventilations) 30-34mmHgMaintain for increased intracranial pressure management (ICP). 2. A return of spontaneous circulation (ROSC) will be indicated during resuscitation, following a rhythm change and a corresponding increase of greater than 20mmHg ETC02 value. 473 END TIDAL C02 ASSESSMENT Procedure (For Zoll Capnography) Select the correct C02 sampling line for the patient. Attach the sampling line to the unit's C02 inlet port. Apply the Filterline airway adaptor or Smart CapnoLine Nasal or Nasal/Oral cannula to the patient. Check that the X Series unit is set up for the correct patient type -- Adult, Pediatric, or Neonate. Configure alarms (if the current alarm settings are not appropriate) and other C02 features. Press the C02 quick access key to initiate C02 monitoring. As a minimum, an initial ETC02 reading upon placement of an Advanced Airway, or and ETC02 reading upon receipt of a patient, and an ETC02 reading upon release of a patient in the Emergency Department must be documented in the Patient Care Record. (For LifePack 15 Capnography) Select the appropriate ET C02 accessory for the patient. Open C02 port door and insert the FilterLine connector; turn connector clockwise until tight. Verify C02 area is displayed. The ETC02 monitor performs the autozero routine as part of the initialization self-test. NOTE: If using ventilation system, do not connect the FilterLine set to the patient/ventilation system until the ETC02 monitor has completed its self-test and warm-up. Display C02 waveform in Channel 2 or 3. Connect the C02 FilterLine set to patient. Confirm that the ETC02 value and waveform are displayed. The monitor automatically sets the best visualization of the waveform. of3 474 COMMON EMS PROTOCOLS PROCEDURES END TIDAL C02 ASSESSMENT (For MRX Capnography) Select the appropriate Microstream accessories based on the type and airway status of the patient. Set up the Microstream accessories. Attach the FilterLine tubing to the C02 Inlet port. The measurement is automatically turned on when the FilterLine is connected to the C02 Inlet port. Connect the C02 FilterLine set to patient. The C02 waveform displays in the configured Wave Sector, if available; otherwise, the wave fills the first available empty Wave Sector. Precautions 1 . In a patient with spontaneous circulation, if the ETC02 value is below 10 mmHg, proper ET tube placement must be verified, preferably by direct visualization. 2. Decreasing ETC02 values during CPR may indicate: An excessive ventilation rate (hyperventilation) Poor CPR Circulation of high-dose epinephrine (causing profound vasoconstriction) Colorimetric ETC02 Sensor Colorimetric C02 detectors, if available, can be used to confirm proper endotracheal tube (ETT) placement by assessing exhaled C02. The detector attaches directly to the endotracheal tube and responds quickly to exhaled C02 by changing from purple to yellow. "Cood as Cold" "Yellow Is sunshbne99 "Yellow Is Yes" "Purple is Poor" 3 475 This procedure describes the appropriate methods to apply, operate, and discontinue the LUCAS device in patients > 12 years of age requiring mechanical chest compression related to cardiac arrest. Indications The Lucas, if available, may be used in patients 12 years of age and older who have suffered cardiac arrest, where manual CPR would otherwise be used. Contraindications Patients who are too large and with whom you cannot attach upper part to back plate 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 patient is too small). Placement Manual chest compressions utilizing the ResQPump shall be initiated for the first 10 minutes prior to LUCAS device being placed on the patient. While resuscitative measures are initiated, the LUCAS device should be removed from its carrying device and placed on the patient in the following manner. Backplate Placement The backplate should be centered on the nipple line and the top of the backplate should be located just below the patient's armpits. In cases for which the patient is already on the stretcher, place the backplate underneath the thorax. This can be accomplished by log-rolling the patient or raising the torso (placement should occur during scheduled discontinuation of compressions — for example, after five cycles of 30:2 or two minutes of uninterrupted compressions). Position the Compressor Initiate CPR, Maintain high-quality compressions. Hold handle on bag with left hand and Pull red handle on bag to open. To activate, push ON/OFF button for one second to start self-test and power up. The green LED adjacent to ADJUST illuminates. Take the back plate out of the bag. Pause manual CPR. With one rescuer on each side of patient, grab the patient's arm to lift the upper body. One person should lift the patient and support the head, and the other person should lift the patient and slide the back plate below the armpits. Continue manual compressions. Take the upper part of the LUCAS 2 unit out of the bag. Hold the LUCAS 2 device by the handles on the support legs and make sure the support legs have reached their outer position. Pull once on green release rings to check that the claw locks are open and then remove fingers from rings. Interrupt manual chest compressions and connect the upper part to back plate, starting on side closest to user. Listen for the CLICK when attached. Check by pulling upward that both support legs are locked onto the back plate. 1 1 . Center the suction cup over the chest with the lower edge of the suction cup placed immediately above the end of the sternum. Push the suction cup down using two fingers (V pattern), making sure you are in the ADJUST MODE and the green led is lit. The pressure pad should touch the patient's chest. If pad does not touch or LUCAS 2 does not fit properly, remove and continue manual compressions. Press PAUSE to lock the start position then remove your fingers from the suction cup. Check for proper position and press ACTIVE (continuous) or ACTIVE (30:2). Attach stabilization strap by fully extending the buckles and placing cushion under patient's neck. Connect buckles on support cushion straps to straps on device support legs and tighten firmly. Check for proper position of suction cup and adjust if needed. Delay the application of the stabilization strap when it might prevent or delay treatment. Attach the wrist straps to each of the patient's wrists to assist with securing the arms during movement/transportation. Use caution to determine that the intravenous site is not compromised due to a slight bend that will occur in the patient's arm. If this does occur release the arm. Press PAUSE to stop compressions during ECG analysis. Keep interruptions to a minimum. 23.After successful resuscitation or termination of activities, Press and hold the ON/OFF button for one second. Patient Adjuncts Place the neck roll behind the patient's head and attach the straps to the LUCAS device. This will prevent the LUCAS from migrating toward the patient's feet. Place the patient's arms in the straps provided. Defibrillation Defibrillation can and should be performed with the LUCAS device in place and in operation. One may apply the defibrillation electrodes either before or after the LUCAS device has been put in position. The defibrillation pads and wires should not be underneath the suction cup If the electrodes are already in an incorrect position when the LUCAS is placed, you must apply new electrodes. Defibrillation should be performed according to ems protocols and following the instructions of the defibrillator manufacturer. If the rhythm strip cannot be assessed during compressions, one may stop the compressions for analysis by pushing the PAUSE BUTTON (The duration of interruption of compressions should be kept as short as possible and should not be > 10 seconds. There is no need to interrupt chest compressions other than to analyze the rhythm). Once the rhythm is determined to require defibrillation, the appropriate ACTIVE BUTTON should be pushed to resume compressions while the defibrillator is charging and then the defibrillator should be discharged. Pulse Checks/Return of Spontaneous Circulation (ROSC) Pulse checks should occur intermittently while compressions are occurring. If the patient moves or is obviously responsive, the LUCAS Device should be paused, and the patient evaluated. 3 of4 497 LUCAS CHEST COMPRESSION DEVICE If there is a change in rhythm, but no obvious indication of responsiveness or ROSC, a pulse check while compressions are occurring should be undertaken. If the palpated pulse is asynchronous, one may consider pausing the LUCAS Device. If the pulse remains, reassess the patient. If the pulse disappears, one should immediately restart the LUCAS Device. Device Management If disruption or malfunction of the LUCAS device occurs, immediately revert to Manual CPR. When fully charged, the Lithium Polymer battery should allow 45 minutes of uninterrupted operation. There is an extra battery in the Lucas Device bag. When last green bar/LED on battery turns orange, you have 10 minutes left and should replace battery or connect to wall outlet. Care of the LUCAS Device after use 1 . Remove the Suction cup and the Stabilization Strap inspect for wear and contamination (if used, remove the Patient Straps). Clean all surfaces and straps with a cloth and warm water with an appropriate cleaning agent. Let the device and parts dry. Replace the used Battery with a fully-charged Battery. Remount (or replace) the Suction Cup and straps if they are not damaged. Note: If the suction cup can be cleaned, inspected, & it's without holes, AND can hold suction on a flat surface. ...then it's "reusable". Repack the device into the carrying bag. Purpose To efficiently triage, treat, and transport victims of Mass Casualty Incidents (MCIs). The following procedure is applicable to all mass victim situations. This MCI procedure is intended for situations when the number of injured exceeds the capabilities of the first arriving units. This procedure applies when the MCI can be handled by Fire-Rescue resources, as well as larger MCIs requiring mutual aid and/or the use of Emergency Support Functions (ESFs) provided through the Miami-Dade County Office of Emergency Management (OEM). Procedure 1. First arrivinq unit: Establishes INCIDENT COMMAND. Performs a scene size up: Estimate an approximate number of victims and identify the level of the incident: Level 1 MCI for 5 to 10 victims. Level 2 MCI for 1 1 to 20 victims. Level 3 MCI for over 20 victims. Level 4 MCI for over 100 victims. Level 5 MCI for over 1 ,000 victims. Request standard MCI response from dispatch. Identify a staging area that will permit an orderly flow in and out without creating congestion. Assume control of Triage and decide if the priority is to triage or to extricate. If you decide to Triage first: Direct remaining crew members to initiate triage (see G.). Direct the walking wounded to a place away from the incident. These persons shall be triaged as soon as manpower permits. As additional units arrive, Command will designate GROUP officers and assign personnel to the following areas: Triage GROUP Treatment GROUP Transport GROUP 499 Additional GROUPS may be required depending on the complexity of the incident. These GROUPS may include but are not limited to; Staging Landing Zone Extrication (may be a priority e.g., Hazmat or Submerged bus) Hazmat Rehabilitation Manpower PIO Incident Management Responsibilities 1 . INCIDENT COMMANDER Use the radio designation COMMAND. Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Perform the initial size-up as well as an ongoing evaluation of changing conditions. Request the appropriate level of response and augment as necessary. Maintain a visible presence with a green flashing light, staying in a fixed location. Control resources through staging and grouping. Encourage GROUP officers to provide frequent updates reflecting manpower needs, equipment requirements, and total numbers of patients. 2. TRIAGE OFFICER Use the radio designation, TRIAGE. Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Organize the Triage Team to begin the initial triaging of victims using the MCI TRIAGE TAGS. Use the START / jumpSTART method of Triage (R.P.M.) Advise COMMAND and MEDICAL CONTROL as soon as possible as to the total number of victims and the number of victims in each category. Coordinate with TREATMENT to ensure that the RED victims are moved to the treatment area first, then move the YELLOW victims. 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. Report to COMMAND upon completion of duties for further assignments. 500 3. TREATMENT OFFICER Use the radio designation, TREATMENT. Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Complete a "Treatment GROUP Log". Consider requesting or designating a "Documentation Aide" to assist with the log. Direct personnel to either begin treatment on the victims, were they lie, when there are only a few victims involved, OR establish a Treatment Area in a safe location that is readily accessible to victims from the scene, as well as to units transporting victims to the hospitals. Ensure that all victims are re-assessed and re-triaged, and the assessment is documented on the Disaster tag, reflecting the appropriate Disaster tag color. Personnel assigned to the Treatment Area that physically assess and/or treat a patient will document pertinent information on the Disaster tag, affix the Disaster tag on the patient in a visible location, and scan the bar code or retain the portion of the disaster tag for future documentation. Ensure that adequate equipment and personnel are available to effectively treat the victims. NOTE: The goal of MCI management is to rapidly triage and transport victims. If transport is available consideration must be made to coordinate transport of the critical patient (s), bypassing a formal treatment area. 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, etc.). Designate entrance and exit areas that are readily accessible. On large-scale incidents, divide the treatment area into three distinct areas based on triage priority (red, yellow, green). Communicate with TRANSPORT to coordinate proper transport of the appropriate patients. 4. TRANSPORT OFFICER Use the radio designation, TRANSPORT. Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Maintain a "Transport GROUP Log". Consider requesting or designating a "Documentation Aide" with a second radio to assist with the log and communications. 501 Establish continuous contact with MEDICAL CONTROL and advise to begin a "Tally" of hospitals close to the affected area. Coordinate the transport of all victims from the treatment area(s). NOTE:Ground transported patients should be assigned to hospitals on an alternating and a rotating basis. Communicate with the LZ Group the number of patients to be transported by air. NOTE: Air transported patients should be assigned to distant hospitals, unless patient needs dictate otherwise (Trauma Center, Burn unit, etc.). When units are prepared to transport, TRANSPORT will contact MEDICAL CONTROL and report the following information: The transporting unit number. The number of patients going to a specific facility and, 3) Their priority, RED, YELLOW, or GREEN. Once receiving the information from TRANSPORT, MEDICAL CONTROL will notify the appropriate hospital and then update the "Hospital Capability Sheet". Transporting fire rescue units will not contact the receiving facility on their own unless there is a change in condition OR further treatment is required. 5. MEDICAL CONTROL OFFICER Use the radio designation MEDICAL CONTROL Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Once notified of an MCI begin a "Tally" to determine hospital capabilities and capacities. The following guidelines will be followed unless otherwise directed by COMMAND or TRANSPORT: If a Level 1 MCI is declared, notify the 2 closest hospitals geographically to the incident AND the Trauma Center. If a Level 2 MCI is declared, notify the a closest hospitals geographically to the incident AND the Trauma Center. 502 If a Level 3 MCI is declared, notify the 4 closest hospitals geographically to the incident AND the Trauma Center. If a Level 4 MCI is declared, notify the 10 closest hospitals geographically to the incident AND the closest 5 Trauma Centers. If a Level 5 MCI is declared, notify the 20 closest hospitals geographically to the incident AND the closest 10 Trauma Centers During the Tally the hospital will be advised of the total potential victims involved based on the level and of the generic nature of the incident, e.g., traffic accident, chemical exposure, etc. In the event a hospital is unable to provide a tally, Medical Control will advise them of our "Standard Tally" that they may expect: 1) 2REDS 2) 5 YELLOWS 3) 10 GREEN MEDICAL CONTROL will indicate the tallies on a "Hospital Capability Sheet". This information will be maintained and updated for the duration of the incident. Once a TRANSPORT Group has been established, the tally will be passed on to TRANSPORT. Once a patient is ready for transport, TRANSPORT will notify MEDICAL CONTROL The transporting unit number. The number of patients going to a specific facility and, 3) Their priority, RED YELLOW, or GREEN. MEDICAL CONTROL will relay this information to the receiving facility. There will be no specific patient information available and no direct communication between the transporting unit and the receiving facility. MEDICAL CONTROL will also advise the receiving facility to keep the Disaster tag with the patient(s) for our future documentation. MEDICAL CONTROL advises the Medical Examiner (ME) of fatalities and complies with the requests of the ME. 503 6. STAGING OFFICER Use the radio designation, STAGING. Follow the appropriate field guide from the MCI bag. Don the appropriate vest. Maintain a "Unit Staging Log Worksheet". Ensure that all personnel stay with their vehicles unless otherwise directed. If personnel are directed to assist in another function ensure that the keys to the vehicles stay with each vehicle. Determine from TRANSPORT a location for loading BLS and ALS patients. Maintain a reserve of at least 1 BLS and 1 ALS transport vehicles. When the reserve is depleted advise COMMAND. Levels of Response The following levels of response are considered the minimum amount required to manage a specific number of patients. 1 . MCI Level 1 Response (5-10 victims): 4 ALS Transport Rescue 2 Suppression units Command Staff The Incident Commander should consider requesting: BLS transport units Haz-Mat or Ladder Trucks for lighting and equipment. Air-Rescue units as needed MCI Level 2 Response (11-20 victims): 6 ALS Transport Rescues 3 Suppression units Command Staff The Incident Commander should consider requesting: BLS transport units Haz-Mat or Ladder Trucks for lighting and equipment. Air-Rescue units as needed 504 3 MCI Level 3 Response (Over 20 victims): 8 ALS Transport Rescues 3 Suppression units Command Staff The Incident Commander should consider requesting: BLS transport units Haz-Mat or Ladder Trucks for lighting and equipment. Air-Rescue units as needed MCI Level 4 Response (Over 100 victims): 25 Units to be assig