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).
  
• 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. Pregnant women should be transported lying on their left side.
  
• 
  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) including:
  

• 
  Length of pregnancy, due date
  
• 
  Problems with pregnancy, prenatal care
  
• 
  Previous obstetrical history
  

• 
  Obtain initial vital signs (see guideline #1002) and repeat at a minimum of 15-minute intervals. Critical patients may need more frequent monitoring.
  
• 
  Evaluate the progress of labor, frequency and intensity of contractions.
  
• 
  Document the amount and duration of any vaginal bleeding.
  
• 
  If the patient appears to be straining, pushing, or states she feels as if she has to move her bowels, inspect the perineum for crowning.
  
• 
  Consider intravenous access (see guideline # 3002-3004).
  

• 
  Consider electrocardiograph monitoring (see guideline #3009).
  

• 
  For women in active labor, assist as necessary (see guideline #6001, 6002)
  

• 
  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. For the patient who delivers in the field, the mother and newborn should be kept together and transported to the same hospital, preferably where prenatal care was obtained.
  
• 
  The stable newborn should be transported in a rear-facing car seat with a cap in place (for warmth, to minimize heat loss) while taking appropriate warming considerations.
  

• 
  The temperature in the ambulance should be raised (“light perspiration temperature range for an adult”).
  
• 
  The newborn should have been dried and wrapped in dry, warm blankets as soon as the initial assessments are complete.
  
• 
  Warm packs should be placed outside the blankets but inside the car seat.
  

OB-GYN cont.

• 
  Consider transporting Newborn infants in distress to a Level III Neonatal Intensive Care Unit (Children’s Hospital, St. Joseph’s-Milwaukee, St. Mary’s—Milwaukee, Aurora Sinai, Waukesha Memorial) (see guideline # 6003)
  
• 
  Document reasons for any deviation from the preceding Guideline/Standard of care.
  

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

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To complete a initial and focused assessment of a patient

To identify life threatening or potentially life-threatening conditions

To establish a working assessment

To prioritize treatment
EQUIPMENT

Stethoscope

Blood pressure cuff of appropriate size for patient

Light source (e.g. pen light)

Medical equipment necessary to treat conditions identified by the assessment

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Survey the scene as you approach for information and potential hazards to rescuers:
   

• 
  Hazards
  
• 
  Potential number of patients
  
• 
  Need for additional or specialized equipment, manpower
  
• 
  Environment (mechanism of injury, nature of illness, living conditions, etc.).
  
• 
  Evaluate Mechanism of Injury (MOI), Nature of Illness (NOI), potential for C-spine injury
  
• 
  Delay entry until the scene is safe if necessary
  

3. 
   Make patient contact; establish patient’s normal and current level of consciousness.
   

• 
  Use AVPU scale to describe
  
• 
  Identify self; explain role if time and patient condition permits.
  
• 
  Attempt to determine nature of illness or mechanism of injury
  

4. 
   Assess the airway: (see guideline # 101,201).
   

• 
  Consider the need for cervical spine stabilization.
  
• 
  Monitor for patency of airway, need for adjuncts to control airway.
  
• 
  Open airway of unresponsive patients (chin lift or jaw thrust).
  

5. 
   Assess breathing: (see guideline # 2002-2009).
   

• 
  Look for chest movement.
  
• 
  Listen and feel for air exchange.
  
• 
  Ventilate with pocket mask or bag-valve device if patient is not breathing or exchange is not adequate.
  
• 
  Suction as necessary.
  
• 
  Start supplemental oxygen as soon as possible at rate and with device appropriate for patient’s condition. (see guideline # 105, 2001).
  

6. 
   Assess circulatory status.
   

• 
  Check central and peripheral pulses.
  
• 
  Look for signs of hemorrhage, apply direct pressure, hemostatic agents, or tourniquet to bleeding wounds.
  
• 
  Evaluate capillary refill.
  
• 
  Evaluate skin color, temperature and condition. Look for cyanosis, diaphoresis.
  
• 
  Begin CPR as needed.
  
• 
  Establish peripheral IV line as soon as possible if condition warrants it.
  

7. 
   Consider need for ALS if not already dispatched or on-scene.
   
8. 
   Perform cursory body survey to identify “Load and Go” situations.
   

• 
  Immediate transport is indicated in a limited number of situations (unstable trauma, complicated obstetrical, etc.).
  

9. 
   Obtain baseline vital signs. (see guideline # 1002).
   

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  Blood pressure including both systolic and diastolic readings
  
• 
  Pulse, counted peripheral or centrally
  
• 
  Respiratory rate and effort
  
• 
  Reassess level of consciousness (AVPU)
  

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  Alert
  
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  Verbal stimuli response
  
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  Painful stimuli response
  
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  Unresponsive
  

10. 
    Obtain history of the present problem: (OPQRST)
    

• 
  Chief complaint
  
• 
  Onset, origin
  
• 
  Provokes
  
• 
  Quality
  
• 
  Region/priority
  
• 
  Severity
  
• 
  Time
  
• 
  Associated symptoms
  

11. 
    Obtain pertinent past medical history: (SAMPLE)
    

• 
  Signs, symptoms
  
• 
  Allergies
  
• 
  Medications
  
• 
  Past medical history
  
• 
  Last meal or oral intake
  
• 
  Events before the emergency
  

Focused physical assessment as appropriate:

12. 
    Assess head and face:
    

• 
  Re-evaluate the airway
  
• 
  Signs of trauma – DCAP-BTLS
  
• 
  Blood or discharge from ears or nose
  
• 
  Pupil size and reaction
  
• 
  Presence of identifiable odors
  

13. 
    Assess neck:
    

• 
  Signs of trauma – DCAP-BTLS
  
• 
  Carotid pulses
  
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  Position of trachea in the midline
  
• 
  Jugular vein distention
  
• 
  Subcutaneous emphysema
  

14. 
    Assess chest:
    

• 
  Signs of trauma – DCAP-BTLS
  
• 
  Pain
  
• 
  Subcutaneous emphysema
  
• 
  Listen to breath sounds
  

15. 
    Assess abdomen:
    

• 
  Signs of trauma – DCAP-BTLS
  
• 
  Pain
  
• 
  Distention
  
• 
  Pregnancy
  
• 
  Rigidity
  

16. 
    Assess spine and back:
    

• 
  Signs of trauma/deformity – DCAP-BTLS
  
• 
  Pain
  

17. 
    Assess pelvis and buttocks:
    

• 
  Signs of trauma/deformity – DCAP-BTLS
  
• 
  Signs of bleeding (melena, blood)
  
• 
  Presence of secretions (e.g. amniotic fluid)
  
• 
  Pain
  

18. 
    Assess upper and lower extremities:
    

• 
  Signs of trauma/deformity – DCAP-BTLS
  
• 
  Pain
  
• 
  Pitting edema
  
• 
  Circulation, sensation, movement
  

19. 
    Establish working assessment.
    
20. 
    Prioritize interventions.
    
21. 
    Obtain necessary medical control orders.
    

GUIDELINE/STANDARD OF CARE

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

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To accurately measure and monitor the systolic and diastolic blood pressure

Stethoscope

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE
Blood pressure measurement, auscultation method

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Position the patient with the arm to be used at the level of the heart.
   
3. 
   Select a blood pressure cuff that covers 2/3 of the distance between the axilla and antecubital fossa of the patient, long enough to securely wrap around the arm.
   
4. 
   Wrap the cuff around the arm, positioning the bladder over the anterior aspect of the arm with the lower edge at least 1 inch above the antecubital space.
   
5. 
   Place stethoscope earpieces in rescuer’s ears with tips pointing forward; check that the appropriate head of the stethoscope is in the open position.
   
6. 
   Palpate the brachial artery while inflating the cuff approximately 30 mmHg above loss of pulse.
   
7. 
   Place head of stethoscope firmly over the brachial artery and listen while slowly deflating the cuff pressure, watching the pressure gauge as the cuff deflates.
   
8. 
   Record the pressure when sound is first heard as the systolic pressure.
   
9. 
   Record the pressure when the sound disappears as the diastolic pressure.
   
10. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

1. 
   Observe universal precautions.
   
2. 
   Position the patient with the arm to be used at the level of the heart.
   

3. 
   Select a blood pressure cuff that covers 2/3 of the distance between the axilla and antecubital fossa of the patient, long enough to securely wrap around the arm.
   
4. 
   Wrap the cuff around the arm, positioning the bladder over the anterior aspect of the arm with the lower edge at least 1 inch above the antecubital space.
   
5. 
   Palpate the radial or brachial artery while inflating the cuff approximately 30 mmHg above loss of pulse.
   
6. 
   Deflate the cuff slowly, watching the pressure gauge.
   
7. 
   Record the pressure when the pulse returns as the systolic pressure/palpated.
   
8. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

ORTHOSTATIC VITAL SIGNS

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Take and record the blood pressure (both systolic and diastolic) and pulse rate with the patient supine.
   
3. 
   Have the patient stand, assisting as necessary. Observe carefully for associated signs and symptoms. Protect the patient from falling.
   
4. 
   After 30 seconds, repeat the blood pressure and pulse reading. A drop of systolic pressure of 20 mmHg or increase in pulse of 20/min or presence of clinical signs/symptoms is significant.
   
5. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

Note: If the cuff is too wide, the measured blood pressure will be lower than the true pressure. If the cuff is too narrow, the measured blood pressure will be higher than the true pressure.

END

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