Lisbon Fire Department Standard Operating Guidelines and Policies

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. (see guideline # 101,201).
• Consider trauma as a possible cause. (see guideline # 506)
• Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009)
• Consider toxin inhalation (e.g. carbon monoxide) as a possible cause. (see guideline # 204)
• 
  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.
  
• 
  Evaluate for possible cause
  

• 
  Tension
  

• 
  Muscle contractions of face, neck, scalp
  
• 
  Dull, persistent, non-throbbing
  

• 
  Migraine
  

• 
  Constriction and dilation of cerebral blood vessels
  
• 
  May have aura (visual/GI)
  
• 
  Unilateral, throbbing pain, nausea, vomiting
  

• 
  Cluster
  

• 
  Related to release of histamine and dilated carotid arteries
  
• 
  Usually awakens from sleep
  
• 
  Severe pain in and around eye, nasal congestion, tearing
  

• 
  Sinus
  

• 
  Pain forehead, nasal area, eyes
  

• 
  Document potentially serious symptoms
  

• 
  Hypertension, bradycardia
  
• 
  Unequal pupils
  
• 
  Altered level of consciousness
  
• 
  Projectile vomiting
  
• 
  Posturing
  

• 
  Consider intravenous access (see guideline # 3002-3004).
  

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

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  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:

• 
  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).
• 
  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).
  
• 
  Document associated symptoms.
  
• 
  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 12-lead electrocardiogram (see guideline #3008).
  
• 
  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.
  

Note: Pre-hospital intervention is usually not indicated for hypertensive patients with a working assessment of CVA. Contact medical control if in doubt.

GUIDELINE/STANDARD OF CARE

• 
  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).
  
• 
  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.
  
• 
  Move the patient to a cool environment.
  
• 
  Remove clothing.
  
• 
  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.
  

• 
  Cool patient with misting spray/sprinkle and fan patient to promote evaporation.
  
• 
  For patients with high core temperatures (as evidenced by altered mental status), attempt to cool the core with ice applied to neck, axillae and femoral areas. Ice should be wrapped to prevent injury due to direct contact with skin.
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  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:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. Consider the potential for cervical spine injury when performing airway maneuvers. (see guideline # 101,201).
• Assure adequate respiratory exchange, ventilate with warmed supplemental oxygen (if available) in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
• 
  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. Additional time (35-45 seconds) should be used to check for peripheral pulses in the hypothermic patient. Begin CPR as appropriate.
  
• 
  Hypothermic patients in cardiac arrest should be transported as soon as possible to a medical facility for rewarming.
  
• 
  Hypothermic patients in ventricular fibrillation should be defibrillated once to determine response to electrical cardioversion, then transport. Further defibrillation attempts should be deferred until the patient’s core temperature is greater than 30º C or 86º F. Focus on CPR.
  
• 
  Depending on patient temperature, ACLS drugs may be ineffective. Contact medical control prior to administration of second round of ACLS drugs.
  
• 
  Remove wet clothing, move to a warm environment, minimize physical jostling of the patient.
  
• 
  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). ). Encourage warmed IV fluids if available.
  

• 
  Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia guidelines.
  
• 
  Sinus bradycardia with a pulse may be physiologic and usually does not require specific cardiac rate treatment.
  
• 
  Avoid rubbing frost bitten extremities.
  

• 
  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:

• 
  Assure scene safety and observe universal precautions (see guideline #107). Consider the need for law enforcement assistance.
  
• Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (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).
• 
  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). Attempt to identify and document the type and quantity of substance(s) abused. Patients should be asked directly if they used any substance(s) as opposed to assuming that they did. If the patient is unable or unwilling to supply the information, seek and document the source of information from family or bystanders.
  
• 
  Attempt to identify specific health problems known to be related to the patient’s type of substance abuse.
  
• 
  Consider concurrent trauma, medication overdose or toxic exposure (see guidelines #412, 506).
  
• 
  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).
  

• 
  Measure blood sugar (see guideline 4001). If the patient is hypoglycemic, consider Thiamine (see drug profile 022) prior to administration of Dextrose (see guideline 406).
  
• 
  Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia guideline
  

• 
  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

• 
  Assure scene/environmental 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).
• 
  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.
  
• 
  Attempt to identify and document:
  

• 
  Time of ingestion
  
• 
  Amount of substance ingested, injected, inhaled or absorbed
  
• 
  Substance(s) ingested, injected, inhaled or absorbed
  

• 
  Name and strength of medication
  
• 
  Name, active ingredients of toxic substances
  

• 
  For patients older than age 6, ask specifically why they ingested the substance(s). Document the answer.
  
• 
  Closely supervise all patients who admit to or who appear to have ingested, injected or inhaled a substance in an attempt at self-harm. Evaluate suicide potential. Consider need for assistance from law enforcement.
  
• 
  If patient has mental status changes, rule out and treat hypoxia and hypoglycemia (see guideline 406, 4001) if present
  
• 
  Consider intravenous assess (see guideline # 3002-3004).
  

• 
  Consider electrocardiograph monitoring (see guideline #3009).
  

• 
  For situations involving envenomation (bites/stings), see appropriate guideline. (see guideline #405)
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  Consider contact of Poison Center.
  
• 
  If vital signs are unstable and narcotic overdose is likely, consider Narcan (see drug profile 014).
  
• 
  If pure benzodiazepine overdose is suspected and the patient’s airway is compromised, consider Romazicon with the approval of on-line medical control. (see drug profile 025).
  
• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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.
  
• 
  Transport all medications or other substances believed to have been taken by the patient to the hospital with the patient.
  
• 
  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 patent airway. Consider the potential for cervical spine injury during airway maneuvers. (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).
• 
  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.
  
• 
  Protect patient from injury.
  
• 
  Complete the history and focused physical assessment (see guideline # 103, 1001).
  
• 
  Document:
  

• 
  Description of the seizure activity
  
• 
  Time of onset and length of seizure activity
  

• 
  Attempt to ascertain and document the probable cause of the seizure, e.g. hypoglycemia, hypoxia, medication noncompliance, use of illicit drugs or alcohol. Consider concurrent trauma, medication overdose or toxic exposure (see guidelines #412, 506).
  
• 
  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
  
• 
  Measure blood sugar level. (see guideline #4001). If hypoglycemic (See Dextrose/Glucagon guidelines #006.)
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  

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

• 
  Consider drug therapy.
  

• 
  Diazepam (Valium) (see drug profile #007)
  
• 
  Lorazepam (Ativan) (see drug profile #038)
  
• 
  Midazolam (Versed) (see drug profile #022)
  
• 
  Dextrose (See drug profile # 006).
  
• 
  Glucagon (see drug profile #011)
  
• 
  Magnesium Sulfate for seizures associated with hypertension of pregnancy (see drug profile #026)
  

• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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:

• 
  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).
• 
  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).
  
• 
  Complete Cincinnati Prehospital Stroke Scale
  

• 
  Have patient smile or show teeth (Look for facial droop on one side.)
  
• 
  Have patient close eyes and hold out both arms in front of him/her (Look for arm drift—one arm doesn’t move or one arm drifts down compared with the other.)
  
• 
  Have patient say a familiar phrase e.g. You can’t teach an old dog new tricks.” (Listen for slurring of words, using inappropriate words or inability to speak.)
  

• 
  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
  
• 
  Attempt to ascertain the patient’s normal mental status and physical capabilities.
  
• 
  Assess for signs of trauma, including head and neck evaluation. Immobilize if indicated.
  
• 
  Obtain information as to exact time of onset of symptoms.
  
• 
  Notify receiving hospital as soon as possible allowing mobilization of hospital resources.
  
• 
  Take precautions to avoid accidental injury to paralyzed extremities during patient movement.
  
• 
  Check blood sugar. (see guideline #4001). If hypoglycemic (Blood glucose less than60 mg%) follow appropriate guideline. (see guideline # 403, 406).
  
• 
  Begin transport as soon as possible for evaluation and possible administration of thrombolytic agents.
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  

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

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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.
  

Note: Pre-hospital intervention is usually not indicated for hypertensive patients with a working assessment of CVA. Contact medical control if in doubt.

END

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 patent airway. Consider potential for cervical spine injury during airway maneuvers. (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).
• 
  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.
  
• 
  Attempt to establish and document a reason for the syncopal episode e.g. cardiac, trauma, metabolic, neurologic problems. See appropriate guideline.
  
• 
  Obtain a blood sugar measurement (see guideline #4001). If hypoglycemic, follow appropriate guideline (see guideline # 403.406).
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  

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

• 
  Obtain and document orthostatic vital signs, provided the patient is not hypotensive when supine. Orthostatic hypotension will be defined as a drop in systolic blood pressure of 20 mmHg or more and/or pulse increase of 20 or more/min. For individuals with orthostatic hypotension, follow appropriate guideline (see guideline # 505).
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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.
  

The following content will be considered the Guideline/Standard of care for

Smoke inhalation in the setting of burning plastics, nylon, other synthetic polymers, or wool.

Occupational exposure to cyanide salts or inhalation of hydrocyanide gas.

Accidental, suicidal, or homicidal ingestions of cyanide containing substances or plants.

 Cyanide is a cellular toxin that inhibits cellular utilization of oxygen.

Cyanide does not affect the transfer of oxygen by the lungs to blood cells. The oxygen saturation (SPO2) will not be affected by cyanide poisoning. It may read normal; high in the setting of simultaneous carbon monoxide poisoning; or low if there was a thermal or other injury to the lungs.

6. 
   . Assure scene safety and observe universal precautions (see guideline #107).
   
7. . Assure patent airway. (see guideline # 101,201).
8. . Assure adequate respiratory exchange, ventilate with supplemental oxygen in those patients with inadequate or absent respirations, consider advanced airway (see guideline # 2002-2009).
9. 
   . Determine the degree of respiratory distress (mild/moderate/severe). Evaluate for potential for inhalation injury. (see guideline #204)
   
10. 
    . Administer supplemental oxygen (see guideline # 105, 2001) with a device appropriate for the condition of the patient, and with the highest percent oxygen inspired (FIO2) possible.
    
11. 
    . Assess for adequate circulation to perfuse the vital organs. Begin CPR as appropriate.
    
12. 
    . Complete the history and focused physical assessment (see guideline # 103, 1001).
    
13. 
    . Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
    
14. 
    . In patients in whom there is a high clinical suspicion of cyanide poisoning and with more than mild signs or symptoms, contact medical control for consideration of administration of Cyanokit cyanide antidote (see DRUG PROFILE Number: ).
    
15. 
    . Example: 40 yo male found unconscious in an industrial fire with dense smoke present with no evidence of trauma, a respiratory rate of 8, pulse of 50 and BP 86/50.
    
16. 
    . Cyanide toxicity as outlined in the table in this protocol can present with mild to severe symptoms. There is no test in the field to determine if it is present. Many of the signs and symptoms could also be caused by other conditions such as carbon monoxide poisoning, trauma, cardiac events, overdoses, etc. Cyanide toxicity can of course also occur at the same time as these other conditions and require simultaneous treatment. The key is to keep this diagnosis in mind in the settings where someone may have been exposed; most commonly this would be from smoke inhalation or industrial chemicals.
    
17. 
    I. In patients with more than mild signs and symptoms, consider possibility of carbon monoxide poisoning in addition to cyanide toxicity, communicate with medical control and consider direct transport (or flight) to appropriate hyperbaric center.
    

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 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).
• 
  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.
  

• 
  For patients with suspected domestic violence:
  
• 
  Ask directly if someone hurt them.
  
• 
  Convey awareness that injuries may be due to their spouse/partner.
  
• 
  Consider safety issues.
  
• 
  Supply information on community resources and how to access them.
  
• 
  For patients with suspected elder abuse
  
• 
  Assess for medical, social and economic stresses.
  
• 
  Use direct questions as in domestic abuse.
  
• 
  Involve law enforcement and social agencies as appropriate.
  
• 
  For patients with suspected child abuse
  
• 
  Involve law enforcement and social agencies as appropriate
  
• 
  For patients with suspected sexual assault/abuse:
  
• 
  Assess and treat physical injuries (see guideline # 504).
  
• 
  Preserve evidence.
  
• 
  Consider transport to Sexual Assault Treatment Center.
  
• 
  Involve law enforcement as appropriate.
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  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:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• 
  Stop the burning process.
  
• 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). Evaluate for potential for inhalation injury. (see guideline #204)
  

• 
  Consider toxic inhalation and follow appropriate guideline if indicated.
  

• 
  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.
  
• 
  Document causative agent of the burn injury.
  
• 
  Calculate the extent of the burn injury using the Rule of 9’s or Rule of Palms.
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  
• 
  Consider pain management (see guideline #112).
  

• 
  Consider electrocardiograph monitoring (see guideline #3009). See appropriate dysrhythmia guidelines.
  
• 
  Remove nonadherent contaminated clothing
  

• 
  Provide wound care for the burn injury.
  

• 
  For burns less than25% of total body surface area, use wet dressings.
  
• 
  For burns greater than 25% of total body surface area, use dry dressings.
  
• 
  May use alternative clear plastic wrap (eg. Glad wrap) on thermal burns (non-circumferential application)
  

• 
  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:

• 
  Rescue safely.
  
• 
  Assure scene safety and observe universal precautions (see guideline #107).
  

• Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (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), including prior vomiting or aspiration.
  
• 
  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). Consider the potential for hypothermia.
  
• 
  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.
  

• 
  Document the estimated time of submersion.
  
• 
  Attempt to ascertain why the incident occurred (child left unattended, seizure or other medical emergency, head/neck injury, etc.)
  
• 
  Document the type and temperature of the water.
  
• 
  Minimize heat loss from the patient.
  
• 
  Apply appropriate guideline/standard for associated trauma or medical condition.
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  Contact medical control for orders as necessary.
  
• 
  Consider Positive End Expiratory Pressure (PEEP). (see guideline # 2011)
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. Consider cervical spine during airway maneuvers. (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).
  
• 
  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).
  

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

• 
  Provide appropriate wound care. (see guideline # 5001).
  
• 
  Evaluate for fractures and dislocations due to muscle contractions during electrical injury.
  

• 
  Consider 12-lead electrocardiogram (see guideline #3008).
  
• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, nervous 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.
  
• 
  Document type of current and duration of contact if known.
  
• 
  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:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. Consider the potential for cervical injury during airway maneuvers. (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).
• 
  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.
  
• 
  Stop all obvious hemorrhage (see guideline # 5001). Splint major fractures. (see guideline # 5003-5010)
  
• 
  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. Document, if known, specific information about the mechanism of injury.
  

• 
  If hypovolemia is not believed to be the cause of hypotension, consider Dopamine (see drug profile 024).
  

• 
  Attempt to ascertain and document cause of hypotension and inadequate perfusion. If nontraumatic etiology, follow appropriate guideline.
  
• 
  Expedite transport of hypotensive trauma victims.
  
• 
  The patient should have nothing to eat or drink.
  
• 
  Consider intravenous access (see guideline # 3002-3004). For hypovolemia, one IV line with a pressure bag should be started and a second attempted in route if possible.
  
• 
  In trauma cases, administer IV fluids to maintain systolic blood pressure at 90 mmHg. Additional IV fluid to elevate the blood pressure may cause unnecessary bleeding and hemodilution when administered prior to surgical repair of bleeding site.
  
• 
  Consider the use of the PASG. (see guideline # 5004)
  

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

• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular and nervous 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:

• 
  Assure scene safety and observe universal precautions (see guideline #107).
  
• Assure patent airway. Consider the potential for cervical spine injury during airway maneuvers. (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).
• 
  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.
  
• 
  Stop all obvious hemorrhage (see guideline # 5001), splint major fractures (see guideline #5003-5010). Dressings applied to the proximal wound (stump) in the case of traumatic amputations should be dry.
  
• 
  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. If the patient is hypotensive, see hypotension—shock. (see guideline # 505).
  
• 
  Document, if known, specific information about the mechanism of injury.
  
• 
  In the instance of traumatically amputated or avulsed tissue, that tissue should be enclosed in a water-proof plastic bag and cooled. The tissue can be wrapped in dry dressings to prevent cold injury before placing in water-proof bag. The patient and separated tissues should be conveyed to a medical facility capable of attempting to reattach it.
  
• 
  Consider intravenous access (see guideline # 3002-3004). The number of intravenous lines and the rate of administration are adjusted according to the clinical condition of the patient.
  

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

• 
  Contact medical control for orders as necessary.
  
• 
  Reassess and document the patient’s respiratory, cardiovascular, nervous and musculoskeletal 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. Include computation of the Glasgow Coma Scale.
  
• 
  Transport to the closest, most appropriate hospital. Expedite transport of unstable trauma victims.
  
• 
  Document reasons for any deviation from the preceding Guideline/Standard of care.