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Firefighter Prehospital Care Program

Maintenance Module 1

SFT

MM1

Upon successful completion of the Firefighter Prehospital Care Maintenance Module 1 Program, on line knowledge evaluation and in-class practical session, the firefighter will:

• refresh their knowledge of what to check for when completing their morning Controlled Medical Device check

• review the requirements of documentation

• understand the importance of decreasing “off chest time”

• provide CPR during charging to decrease “off chest time”

• review Primary Assessment and acquiring a patients Vital Signs.

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ControlledMedical Device Review

DM

C

Zoll AEDPro Defibrillator(Green check mark showing in self-test window)

Daily

Zol

l AED

Pro

Defib

Chec

k

Two Batteries( one in the unit and one spare )

Two Non-Expired Adult Defibrillation Pads( one plugged in the unit and one spare )

Patient Prep Kit( contains a disposable razor, 4x4’s, alcohol wipes )

Present in 0.3 mg and 0.15 mg dosages

Daily

Epi

Pen®

& E

piPe

n Jr.

® Ch

eck

Medication has not passed its expiry date

Medication has not changed to a brown colour

No condensation present in themedication window

EpiP

en®

Prog

ram

Upd

ate

• between June 1st, 2012 and August 1st, 2012 we have administered an EpiPen® at four incidents

• FCC 12-158 addresses all Frequently Asked Questions ( FAQ’s) about Epinephrine Auto Injectors

• When the medication becomes non-useable, it will turn to a brown coloured liquid as seen below.

Normally,medication

appears slightly cloudy due to

plastic windowMedication

appears watery brown in colour

when non-useable

Remember that you may administer an EpiPen® to any patient who:

has a known allergy, and

has been prescribed an epinephrine auto-injector, andhas been exposed to or is suspected of having been exposed to an allergen, and

demonstrates signs and symptoms of a severe allergic reaction (anaphylaxis) such as: dyspnea, respiratory wheezes, airway stridor, generalized hives, facial or oral tongue swelling, hypotension (BP<90 systolic), and

is incapable of self-administering their prescribed epinephrine auto-injector OR has no trained family member available or willing to administer the prescribed epinephrine auto-injector, and

Paramedics have not yet assumed care of the patient

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Medical DocumentationReview

RDM

• Medical documentation fields in RMS are required to be completed appropriately after every patient care call

• Regulations that affect your medical documentation can be found in:

Toronto Fire Service FCCs

Toronto Fire Service SOGs

Sunnybrook Centre for Prehospital Medicine Medical Directives

National Occupational Competency Profile ( NOCP )

Ontario College of Physicians & Surgeons

Ontario BLS Patient Care Standards

OFM Company Officer Standards

Med

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Doc

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RMS

Med

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• Medical documentation fields, found in the EMS tab in your incident form are required to be completed after every patient care call

• Complete all required fields to the best of your ability

• Care provided fields are descriptors of the care your crew only provided to the patient during the call

→ In the incident form, click the “EMS Provided” box

RMS

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→ Click on the EMS tab.

→ Within the “Identification” tab, complete all fields to the best of your ability

→ If you are unable to obtain a patient’s name, place CNO in the name fields

→ Within the “Scene” tab, complete all drop down fields to the best of your ability

→ Remember to adjust the “Arrived at Patient” time if you did not have immediate access to the patient

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→ Within the “Injuries” tab, complete all fields to the best of your ability

→ Under Procedures Used, only check the skills that you and your crew performed while using TFS equipment

→ Within the “Narrative” tab, document the actions you and your crew took on scene

→ Point form is acceptable

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Resuscitation OutcomesConsortiumUpdate

COR

• When chest compressions are not being performed, the brain continues to die

• Upfront CPR helps to perfuse the brain and heart prior to the first shock

• Upfront CPR of 15-30 seconds is all that’s required to begin the perfusion process

• As an AED battery ages and as the shock delivery increases, it takes thebattery longer to reach the “Press the Flashing Button” point

Wha

t hav

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arne

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• If a sudden cardiac arrest patient’s first rhythm is Ventricular Fibrillation, their likelihood of survival has increased to 25%

• Between August 2009 and December 2011 you have participated in returning 196 cardiac arrest patients back to their families

• Firefighters follow feedback given by the AEDPro such as the 2” compression depth and the metronome @ 100 bpm.

• Firefighters do great CPR when following the feedback on the AEDPro

Beca

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of th

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Impo

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f “O

ff Ch

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ime”

Perfusion of oxygen to brain with CPR

CPR stops. No perfusion of oxygen to brain while analysis, charging and shock

delivery occurring

Perfusion resumes with CPR

15 to 40 seconds dependent on battery and charge

• Perfusion of the brain with oxygen while performing chest compressions is essential.

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CPR

CPR stopped for analysis/charging

Decr

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Off

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Perfusion of oxygen to brain with CPR

CPR stops for analysis. Perfusion resumes while AED charges.

CPR stops for SHOCK delivery

Perfusion resumes with CPR

10 sec. 3 sec.

• Perfusion of the brain with oxygen while performing chest compressions is essential.

CPR

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Decr

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Off

Ches

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10 sec. 3 sec.

• Notice how a few more seconds of CPR can fit in between the “shock advised” and the “press flashing shock button” prompts, while the AED Pro charges

Bloo

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CPR Performed CPR stoppedfor analysis

CPR resumes duringcharging

CPR stopped Shock button

pressed

Stop CPR. Analyzing.

Press flashing shock button.

Shock advised.

Start CPR.

CPR cont..

Good compressions

As we continue to participate in the ROC-CCC Trail, Toronto Fire will be returning to Traditional CPR (30:2 with two rescuer ventilations) on:

November 1st, 2012

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PrimaryAssessmentReview

YRA

MI

RP

Putt

ing

the

Puzz

le To

geth

er The Primary Assessment completed by the firefighter first responder begins an important process to the continued medical care that the patient will receive.

Each part of your assessment will add another piece to the puzzle so that all levels of ongoing medical care will have a clearer picture of the concerns affecting the patient.

Scen

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PAC

ME

EnvironmentAssess where the patient is located. Look for additional signs to call such as Oxygen In Use Signs, Medications, how is the patient positioned, etc.

Mechanism of InjuryWhat caused the injury or illness that is causing concern to the patient

CasualtiesHow many patients are there? Ensure all are accounted for.

Assistance RequiredDo you require more ambulances, police or specialized equipment

Personal Protective EquipmentMinimum PPE is gloves, glasses, bunker boots and bunker pants. N95 required for airway management and outbreak calls.

Neu

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AlertDoes the patient respond to you when you enter the scene?

Patient is able to protect their airway

VoiceDo you have to call out to the patient in order for them to respond to you?

Painful StimuliDo you have to provide painful stimuli such as sternal rub or tapping shoulders to the patient in order to generate a response?

UnresponsiveThe patient does not respond to any of the above.U

PV

A

Patient is able to protect their airway

Patient may not be able to protect their airway

Patient is not able to protect their airway

Prim

ary

Asse

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CBA

Airway• Is the patient able to speak which implies an open

airway and breathing, can they maintain an open airway on their own ( patency ).

• If their airway is closed, consider opening with a head tilt/ chin lift or modified jaw thrust.

Breathing• Consider….Is the patient breathing and if yes, how well.

• If they are unresponsive, look / listen / feel for breathing after opening their airway

Circulation• Assess the patients pulse ( carotid, radial or brachial )• Assess capillary refill ( <2 seconds is normal )• Assess their overall skin condition

( normal colour for them, pale, cyanotic ) • Assess for any large bleeds or fluid loss

Visu

al A

sses

smen

tBy using the CLAPS-D memory aid you are LOOKING for:

C ontusions ( bruising )

L acerations ( cuts )

A brasions ( scraps )

P enetrations ( both from external and internal injuries )

S ymmetry ( does the area equal in diameter )

D eformity / distension

Palp

atio

n As

sess

men

tBy using the TICS-D memory aid you are FEELING for:

T enderness ( easily hurt, sensitive )

I nstability ( not able to support, maintain )

C repitus ( a sound or feeling that resembles a crackling noise )

S ubcutaneous Emphysema

( air pockets beneath the skin of the neck and upper torso)

D eformity / distension

Ausc

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Asse

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When listening for air entry by using a stethoscope:

1. begin with the apices ( top of the lungs ), landmark just below the clavicles and compare the right side to left side

2. conclude with the bases ( bottom of the lungs ), landmark at the side of the patient just below the axilla ( underarm ) and compare the right side to left side

1 1

2 2

Trau

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A trauma assessment is a rapid assessment completed on any patient that has a physical injury caused by violent or disruptive action.

PelvisCLAPS-D & TICS-DStability in 3 planes

FemursCLAPS-D & TICS-D

ChestCLAPS-D & TICS-DAuscultate air entryAbdomen

CLAPS-D & TICS-DVisualize for pulsating massesPalpate 4 quadrants

NeckCLAPS-D & TICS-DTracheal DeviationJugular Vein Distension 1

2

3

4

5 5

Med

ical

Ass

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A medical assessment is a rapid assessment completed on any patient that in distress due to an existing medical condition ( i.e. diabetes, heart attack, asthma )

ChestCLAPS-D & TICS-DAuscultate air entryAbdomen

CLAPS-D & TICS-DVisualize for pulsating massesPalpate 4 quadrants

NeckCLAPS-D & TICS-DTracheal DeviationJugular Vein Distension 1

2

3

Com

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tUpon completion of your Primary Assessment, you will be required to make a decision about patient care and patient priority if multiple patients are found.

Items to consider with respect to patient care include:

• Environmental protection

• Warmth protection

• Administration of oxygen if the patient is in respiratory distress

• Treatment of non-life threatening injuries

Remember: Life threatening injuries should be treated as soon as they are found

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Vital SignAssessmentReview

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Puls

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tThe pulse is the pressure wave that occurs as each heartbeat causes a surge in the circulating blood.

Pulses can be obtained from the:a) Radial Artery ( on the thumb side of the wrist )b) Carotid Artery ( on the lateral side of the neck )c) Brachial Artery ( inside of the upper arm )

When assessing a patient’s pulse:

1. Count beats for 30 seconds and multiple by two

2. Assess whether the pulse is regular or irregular

3. Determine if the pulse is full and easy to assess or weak and difficult to assess

Resp

irato

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sses

smen

tBreathing is normally a spontaneous, automatic process that occurs without conscious thought, visible effort, marked sounds or pain.

Each complete breath includes two distinct phases: inspiration and expiration

When assessing a patient’s respiratory rate:

1. Count breaths for 30 seconds and multiple by two

2. Assess whether the chest movement is regular or irregular

3. Determine if the breath is full or shallow

Blood Pressure is the pressure of circulating blood against the walls of the arteries. Adequate blood pressure is necessary to maintain perfusion to the vital organs.

When assessing a patient’s blood pressure:1. Assess their arm for ports, central lines, mastectomy or injury. If they are present,

use the other arm. Apply cuff snuggly.

2. The lower border of the BP cuff should be 2½ cm ( 1” ) above the elbow

3. Place the stethoscope over the brachial artery

4. Close the valve and inflate the cuff to 20 mmHg above point at which you stopped hearing pulse sounds

5. Slowly release the pressure and note the reading whenyou heard the sound return (systolic) and when you heard the sound stop (diastolic)

6. Release remaining air pressure in BP cuffBloo

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Palp

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nNoisy environments, excessive patient movement and external vibrations from the ambulance may make auscultation of a blood pressure difficult. In these cases you may choose to obtain the blood pressure by palpation.

When assessing a patient’s blood pressure by palpation:1. Assess their arm for ports, central lines, mastectomy or injury. If they are present,

use the other arm. Apply cuff snuggly.

2. The lower border of the BP cuff should be 2½ cm ( 1” ) above the elbow

3. Feel for the radial pulse

4. Close the valve and inflate the cuff to 20 mmHg above point at which you stopped feeling the radial pulse

5. Slowly release the pressure and note the reading when you felt the pulse return (systolic)

6. Release remaining air pressure in BP cuff

Skin

Ass

essm

ent

Assessing the skin helps you determine the adequacy of perfusion. When assessing a patient’s skin condition:

1. Assess if the patients skin is of a normal colour for them or does it appear to be pale / ashen / cyanotic

2. Assess the skin’s temperature by placing the back of your p.p.e. gloved hand on the patient's forehead or torso. Is the skin warm or cold?

3. Assess the skin’s condition. Is it dry or wet to the touch?

Pupi

l Ass

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The diameter and reactivity to light of the patient’s pupils reflect the status of the brain’s perfusion. If the patient is responsive, have them close their eyes for a few seconds and when they open them, visualize if they:

1. Respond equally to light ( PEARL - Pupils Equal and Reactive to Light )

2. Remain constricted

3. Remain dilated

4. Are unequal

Skills videos demonstrating the material discussed within this presentation and other Firefighter Prehospital Care Programs can be found at:

www.prehospitalmedicine.ca

or

insideto.city.toronto.ca/wes/fire/ems/videos

Skill

Rev

iew

Vid

eos

For all questions pertaining to this module, contact your E.M.S. Command Coordinator.

North – (416) 338-9428

South – (416) 338-9901

East – (416) 849-2458

West – (416) 667-2217

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