Lisbon Fire Department Standard Operating Guidelines and Policies

The following content will be considered the Guideline/Standard of care for the patient with a provider impression of:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
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  Assess for unresponsiveness and signs of life.
  
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  Basic life support (CPR) will be started on all patients in cardiopulmonary arrest with the exception of victims with:
  

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  Decapitation or other trauma incompatible with life
  
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  Rigor mortis
  
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  Evidence of tissue decomposition
  
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  Extreme dependent lividity
  
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  Present of valid Do-Not-Resuscitate Order (see guideline 305)
  
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  The on-line medical control physician is to be consulted on all questionable resuscitation cases. CPR and Advanced Life Support procedures will neither be withheld nor delayed while the decision regarding resuscitation is made.
  

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  If ALS is available, assure that they have been dispatched to the scene.
  
• Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (see guideline # 101,201)
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  Assure adequate respiratory exchange, ventilate with supplemental oxygen, consider advanced airway (see guideline # 2002-2009). Defibrillation should not be delayed to insert an advanced airway.
  
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  Monitor the ECG.
  

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  Complete the history and focused physical assessment (see guideline #103, 1001). Attempt to determine the cause of the cardiac arrest.
  
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  AED with pediatric capabilities may be used on children ages 12 months and older. Adult biphasic AED may be used on children ages 12 months and older but should not be considered preferred equipment for EMS agencies servicing pediatric populations. Adult monophasic AEDs may be used
  

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  When indicated, manual defibrillation of patients less than 8 years of age and/or less than 55 pounds by advanced life support personnel is done is accordance with AHA guidelines (see guideline #3006)
  
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  Consider intravenous access (see guideline # 3002-3004).
  

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  Contact medical control for orders as necessary.
  
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  Reassess and document the patient’s condition frequently.
  
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  Complete a patient care report (see guideline # 102) documenting all pertinent information received, procedures ordered/completed, results of interventions and changes in the patient’s condition.
  
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  Transport to the closest, most appropriate hospital.
  
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  Document reasons for any deviation from the preceding Guideline/Standard of care.
  
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  For situations in which resuscitation attempts are not started, see DNR guideline #305.
  

Modification of the attached protocol when the victim is apparently pulseless and non-breathing AND probably significantly hypothermic based on circumstances:

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  Secure the airway and ventilate with 100% oxygen. (see guideline #2002, 2004, 105)
  
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  Evaluate the patient, using a minimum of one minute to check carotid and apical pulse.
  
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  Simultaneous with pulse evaluation, monitor (and record if possible) the ECG rhythm.
  

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  For the suspected hypothermic patient in ventricular fibrillation (or the AED recommends shock), defibrillate (see guideline 3006) one (1) time only. If no conversion
  

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  Begin Chest compressions
  
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  If ALS, give 1 dose epinephrine/vasopressin)
  
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  Continue with ventilation
  
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  Transport to the closest, most appropriate medical facility
  
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  For the suspected hypothermic patient in asystole or pulseless electrical activity (PEA) (or no shock advised by AED),
  
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    Continue ventilation
    
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    Begin chest compressions
    
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    If ALS, give 1 dose of epinephrine/vasopressin
    
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    Transport to the closest, most appropriate medical facility.
    

When the victim is apparently pulseless and non-breathing AND involved in major/multiple trauma, see guideline #507.

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  Complete documentation of the events of the resuscitation on the patient care report.
  
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  Document final evaluation of patient including absence of heart tones, pulses, respiratory effort, final ECG rhythm (in 3 leads) and the time of cessation of efforts.
  
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  Notify the County Medical Examiner.
  
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  Notify the appropriate law enforcement agency.
  
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  Notify (or document inability to notify) relatives of the patient.
  

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  Insure support and assistance to family/significant others until role is assumed by others.
  

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  Arrange appropriate transport of the body or document agency assuming responsibility for the body. If transport has been initiated, continue transport to the appropriate emergency department and follow medical control direction to stop resuscitation.
  

{To use this protocol, a training plan and quality improvement process must be submitted to the state}

• 
  The new CCR guideline is being updated prior to its release. The new guideline will be distributed after the changes have been made
  

The following content will be considered the Guideline/Standard of care for the patient with a provider impression of:

The guideline/standard should be applied to patients with chest pain and/or other symptoms suggestive of ischemic cardiac disease, e.g. chest pressure, radiation pattern to shoulders, arm, diaphoresis, nausea, dyspnea and in whom the pain is not reproduced by deep breathing or coughing

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway (see guideline # 101,201).
• Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
• 
  Determine the degree of respiratory distress (mild/moderate/severe).
  
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  Allow the patient to assume the position of comfort unless contraindicated by medical condition.
  
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  Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate for the condition of the patient.
  
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  Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
  

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  Complete the history and focused physical assessment (see guideline #103, 1001).
  

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  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
  
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  Assess for typical signs/symptoms of ischemic cardiac disease including:
  

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  Crushing chest pain, pressure
  
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  Radiation pattern to arm(s), neck, back, jaw
  
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  Pain unchanged/not reproduced by deep breathing, palpation
  
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  Nausea
  
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  Diaphoresis
  
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  Epigastric pain
  

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  Consider other causes of chest pain:
  

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  Pulmonary
  

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  Spontaneous pneumothorax
  
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  Pulmonary emboli
  
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  Infectious process (pneumonia, pleurisy)
  

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  Musculoskeletal
  
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  Gastrointestinal
  

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  Hiatal hernia
  
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  Esophageal reflux
  

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  Vascular
  

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  Aneurysm
  

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  Assess for other descriptions of chest pain including pleuritic, sharp, stabbing, etc.
  
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  Consider intravenous access (see guideline # 3002-3004).
  

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  Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia guidelines.
  
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  Consider drug therapy.
  

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  In the patient with normal or elevated blood pressure and who has his/her own nitroglycerine, the EMT may assist the patient in taking his/her medications (see drug profile #015). In patients with no prior experience with nitroglycerin, an IV line should be started prior to administration of nitroglycerin.
  

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  If not contraindicated, administer aspirin (see drug profile #004).
  
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  For patients with moderate to severe pain unrelieved by nitroglycerine, administer morphine IV (see drug profile #013).
  
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  For patient with moderate to severe pain unrelieved by at least three nitroglycerin doses, consider Nitroglycerin drip (see drug profile 047)
  
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  In patients with ST elevation Myocardial Infarction consider contacting medical control for Metropolol (see drug profile #051)
  

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  Consider 12-lead electrocardiogram (see guideline #3008). Do not delay nitroglycerin administration. (EMT requires Operational Plan approval)
  
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  Contact medical control for orders as necessary.
  
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  Reassess and document the patient’s respiratory and cardiovascular systems frequently.
  
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  Complete a patient care report (see guideline #102) documenting all pertinent information received, procedures ordered/completed, results of interventions and changes in the patient’s condition.
  
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  Transport to the closest, most appropriate hospital.
  
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  Document reasons for any deviation from the preceding Guideline/Standard of care.
  

The following content will be considered the Guideline/Standard of care for the patient with a provider impression of:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
• 
  Determine the degree of respiratory distress (mild/moderate/severe).
  
• 
  Allow the patient to assume the position of comfort unless contraindicated by medical condition.
  
• 
  Administer supplemental oxygen (see guideline # 105, 2001) with a device and at a rate appropriate for the condition of the patient.
  
• 
  Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
  

• 
  Complete the history and focused physical assessment (see guideline #103, 1001).
  

• 
  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  

• 
  Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia guidelines.
  
• 
  Consider the following therapies.
  

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  In the patient with normal or elevated blood pressure and who has his/her own nitroglycerine supply, the EMT may assist the patient in taking his/her medication (see drug profile #015).
  
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  For patient with moderate to severe signs/symptoms of respiratory distress:
  

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  Nitroglycerin sublingually (see drug profile #015)
  
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  Consider CPAP (see guideline #2018) (Basic level systems require Operational Plan Approval)
  
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  Consider Nitroglycerin drip (see drug profile #047)
  
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  Consider Vasotec (see drug profile # 053)
  

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  Consider 12-lead electrocardiogram (see guideline #3008). (Basic level systems require Operational Plan Approval)
  
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  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory and cardiovascular systems frequently.
  
• 
  Complete a patient care report (see guideline #102) documenting all pertinent information received, procedures ordered/completed, results of interventions and changes in the patient’s condition.
  
• 
  Transport to the closest, most appropriate hospital.
  
• 
  Document reasons for any deviation from the preceding Guideline/Standard of care.
  

GUIDELINE/STANDARD OF CARE

The following content will be considered the Guideline/Standard of care for the patient with a provider impression of:

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  Assure scene safety and observe universal precautions (see guideline #107).
  
• 
  Complete the history and focused physical assessment (see guideline # 103, 1001) to establish that the patient is not a candidate for attempted resuscitation:
  

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  Trauma incompatible with life
  
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  Dependent lividity
  
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  Rigor mortis
  
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  Tissue decomposition
  
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  Valid Do-Not-Resuscitate order
  

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  A valid Do-Not-Resuscitate order must include:
  

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  In a health care institution (hospital or nursing home):
  

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  A written order on the patient’s chart for “No-Code” or “Do-Not-Resuscitate” signed and dated by the patient’s attending physician. Contact medical control for advice if questions arise.
  

• Outside a health care institution, the patient must be wearing a valid Wisconsin Do-Not-Resuscitate bracelet:

• A plastic wrist band with a white insert containing the state seal and the words “Do-Not-Resuscitate” in blue, the patient’s name, the physician’s name, business telephone number and signature.
• A metal bracelet displaying the international recognized symbol Staff of Aesculapius (staff and snake) on the front and the words “Wisconsin Do-Not-Resuscitate-EMS”. The patient’s first and last name must be engraved on the back.
• Note: A DNR order is only valid on persons 18 years of age or older and who are not pregnant.

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  A DNR order may be revoked by the patient, patient’s guardian or health care agent by expressing to EMS personnel that the patient should be resuscitated or by defacing, cutting, removing or asking someone to remove the bracelet.
  
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  Contact medical control if there are any questions.
  

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  A Do-Not-Resuscitate order is only implemented if the patient does NOT have a pulse. If the patient still has an obtainable pulse, respirations, pupil reaction or other obvious signs of life, standard medical care, excluding manual CPR and the use of an advanced airway. Contact medical control for advice on the use of other advanced pharmacologic support such as vasopressors and antiarrhythmics.
  
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  Special Situations:
  

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  If circumstances are unclear, start resuscitation and contact medical control.
  
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  Placement of an advanced airway or surgical airway is considered heroic and should not be done in the case of a valid DNR order. Airway positioning, suctioning and laryngoscopy for foreign body removal are considered comfort measures and may be performed.
  
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  CPAP is a noninvasive airway adjunct and decreases the work of breathing. It is considered a comfort care measure.
  
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  Medical control reserves the right to honor any form of DNR identification including local facility bracelets, medic alert tags, written physician orders, out-of-state bracelets, tags and orders. Contact medical control when encountering such documents.
  

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  PEDIATRIC DO-NOT-RESUSCITATE
  

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  Wisconsin law does not permit a DNR order on a patient under the age of 18.
  
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  Terminally ill children may have a hospital-directed DNR order
  
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  EMS personnel can only honor a hospital-directed DNR order on a child with prior approval by the off-line system medical director or on-line medical control at the time of the call. (Example: The EMS system has prior knowledge of a terminally ill child in their response area and the system medical director has written a directive for them to honor the hospital-directed DNR if they should respond to the scene.)
  
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  Comfort measures for the child prior to death should be instituted as soon as possible.
  

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  Complete a patient care report (see guideline #102) documenting all pertinent information received.
  

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  Follow department policy regarding transport of the body to the appropriate facility.
  
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  Document reasons for any deviation from the preceding Guideline/Standard of care.