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INDEX
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
GENERAL STANDING ORDER
DATE APPROVED
2/01/07
DATE REVISED
2
ADULT STANDING ORDERS
Airway Control
Allergic Reaction
Asthma (See Bronchospasm)
Bronchospasm (Asthma / COPD)
Burns / Burn Diagram (Rule of 9’s)
Cardiac Management
Cardiac Arrest – BLS
Chest Pain
Cervical Spine Stabilization
Chest Pain (see Cardiac Chest Pain)
Chronic Obstructive Pulmonary Disease (see Bronchospasm)
Closed Head Injury
Diabetic Emergencies
Do Not Resuscitate
Drowning
Heat Emergencies
Hypothermia
Hypoglycemia (see Diabetic)
Obstetrics
Physician On Scene
Stroke
Trauma Management
‘Multi-System Trauma Criteria’
Triage – Start
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
PEDIATRIC STANDING ORDERS
Allergic Reaction / Anaphylaxis
Bronchospasm (Asthma)
Burns / Pediatric Burn Diagram
Cardiac
Cardiac Arrest
Diabetic (Hypoglycemia)
22
23
24
25
26
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DATE APPROVED
GENERAL STANDING ORDER
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
1. Assure scene safety before entering scene.
2. Cervical Spine, Airway, Breathing, and Circulation are the initial treatment unless
otherwise stated. Begin and maintain CPR when appropriate following AHA guidelines.
3. Provide supplemental oxygen via appropriate means using current standard of care
based on curriculum, State and National guidelines.
4. Obtain history of present illness, medical history, medications, and allergies when
possible.
5. All stable patients will have their vital signs checked every 30 minutes, critical patients
every 10 minutes as treatment permits. Vitals include level of consciousness, skin
color, temperature, texture, respiratory rate, lung sounds, heart rate, and blood
pressure and pulse oximetry. If able, continually monitor the patient’s vitals with
automated equipment if available.
6. On-line Medical Control is the on-duty ER physician at your Hospital. If you are not a
Hospital provider, then it is the closest participating Hospital within the County you are
providing care in.
7. When there is no standing order for a particular situation, any orders must be obtained
from Medical Control.
8. Report any possible criminal activity; such as, but not limited to, child protective and
adult protective issues, scene deaths, and suicide attempts to the proper authorities.
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DATE APPROVED
AIRWAY CONTROL
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
Evaluate the airway. Take into account the possibility of cervical injury. Secure the airway
by positioning, oropharyngeal airway or nasopharyngeal if possible. (EMTS ONLY) Place
non-visualized airway (i.e. Combitube) if necessary.
3 of 26
DATE APPROVED
ALLERGIC REACTION
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Remove offending agent if possible.
2. May assist patient with administration of Epi-pen.
4 of 26
BRONCHOSPASM (ASTHMA / COPD)
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE APPROVED
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Vitals including pulse oximetry if possible.
2. Oxygen
3. (EMTS ONLY) may help patient administer own inhaler.
5 of 26
DATE APPROVED
BURNS
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
FIRST RESPONDER / BASIC EMT
1. Remove patient from source and stop the burning process.
 Remove clothes and jewelry.
 Brush any dry powders from patient.
 Irrigate chemical burns with copious amounts of normal saline or water.
 Continuously irrigate the eyes if involved with saline.
2. Oxygen 15 lpm via non-rebreather.
3. Apply dry, clean dressings. May consider moist dressings for comfort if less
than 10% Body Surface Area (BSA) involved.
4. Identify source, duration of exposure, and presence of enclosed space.
Look for other trauma.
5. Determine percent of BSA involved.
HEAD
9
BACK
18
The patient should be transported to the
closest appropriate hospital. Please see
local procedures and protocols.
BURN DIAGRAM
Rule of Nines
FRONT
18
ARM
ARM
9
9
LEG
18
1
LEG
18
6 of 26
DATE APPROVED
CARDIAC ARREST
BLS
CPR WITH AED
CHEST
PAIN
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
No movement or response
Open Airway, check Breathing
If not breathing, give
2 BREATHS
that make chest rise.
Give 1 breath every
If no response, check pulse.
Do you DEFINITELY feel pulse
within 10 seconds?
5 to 6 seconds.
PULSE
Recheck pulse every
2 minutes.
NO PULSE
Give cycles of 30 COMPRESSIONS and 2 BREATHS.
Complete 5 cycles of CPR while applying AED unless: a) the arrest is
witnessed by EMS personnel and AED is immediately available or
b) bystander CPR has been in progress for two minutes.
Push hard and fast (100/min) and release completely.
Minimize interruptions in compressions.
Check Rhythm
SHOCKABLE
Give 1 shock.
Resume CPR immediately
for 5 cycles.
Place advanced airway during
compressions if possible.
NOT SHOCKABLE
Resume CPR immediately
for 5 cycles.
Check Rhythm every 5 cycles;
continue until victim starts to move.
Place advanced airway during
compressions if possible.
During CPR






One cycle of CPR : 30 compressions then 2 breaths; 5 cycles = 2 minutes
o After an advanced airway is placed, rescuers no longer deliver “cycles” of
CPR. Give continuous chest compressions without pauses for breaths.
Give 8 – 10 breaths / minutes. Check rhythm every 2 minutes.
Avoid hyperventilation
Secure airway and confirm placement
Rotate compressors every 2 minutes with rhythm checks when possible
Defibrillate per manufacturer’s recommendations (monophasic 360J)
ResQpod must be used during resuscitation (Remove when pulses return)
7 of 26
DATE APPROVED
CHEST PAIN
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
BASIC EMT
1. Aspirin 81 mg x 4 orally (baby aspirin)
2. Nitroglycerin
 May assist patient in taking his/her own prescribed nitroglycerin.
 Hold if systolic blood pressure < 100.
 Give one tablet sublingual every 5 minutes up to 3 tablets.
 DO NOT USE IF RECENT USE of erectile dysfunction medications. MAY RESULT
IN INTRACTABLE HYPOTENSION if given within 24 – 48 hours.
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CERVICAL SPINE STABILIZATION
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE APPROVED
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
All patients that have a positive mechanism of injury must have immediate spinal
stabilization taken until spinal injuries can be ruled out through the spinal exam.
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DATE APPROVED
CLOSED HEAD INJURY
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
FIRST RESPONDER / BASIC EMT
1. Stabilize cervical spine following spinal stabilization protocol.
2. Oxygen via nonrebreather
 or BVM following airway protocol if indicated.
3. Document GCS.
GLASCOW COMA SCORE
Eye Opening Response
Spontaneous
4
To Voice
3
To Pain
2
None
1
Best Verbal Response
Oriented
5
Confused
4
Inappropriate Word
3
Incomprehensible Sounds
2
None
1
Best Motor Response
Obeys Command
6
Localizes Pain
5
Withdraws to Pain
4
Flexion to Pain
3
Extension to Pain
2
None
1
TOTAL POSSIBLE
15
10 of 26
DIABETIC EMERGENCIES
DATE APPROVED
2/01/07
ALTERED LEVEL OF CONSCIOUSNESS
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
Hypoglycemia
BASIC EMT
1. If patient has an intact gag reflex and is responsive.
 Oral Glucose 30 Gm PO. Repeat to desired effect.
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DATE APPROVED
DO NOT RESUCITATE
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
PATIENT VIABILITY
1. If there is any possibility that life exists or when in doubt
RESUSCITATE.
DO NOT RESUSCITATE:
1. Decapitation
2. Decomposition
3. Rigor mortis
4. Dependent lividity
5. Injuries that are conclusively incompatible with life
 massive head and/or chest.
SPECIAL CONSIDERATIONS
Multiple Casualties
Start Triage
Living Will
DO NOT ACCEPT – RESUSCITATE
DNR orders issued
by patient’s doctor
Visualize signed DNR
DO NOT RESUSCITATE
Contact Medical Control
Patient’s doctor wishes DNR
If patient’s doctor is immediately available
DO NOT RESUSCITATE
Contact Medical Control
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DATE APPROVED
DROWNING
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
A patient who is submerged for one hour or less and is pulseless and apneic shall be resuscitated.
Consider resuscitation of pediatric patients who have been in icy water for prolonged periods.
FIRST RESPONDER / BASIC EMT
1. Check pulse, if absent and patient is apneic begin CPR and apply AED.
2. Advise Medical Control of situation as soon as possible.
Routine cervical spine stabilization is NOT necessary; however, cervical spine stabilization should
be initiated if any of the following exist:
 history of diving
 use of a water slide
 signs of injury
 signs of alcohol intoxication.
13 of 26
DATE APPROVED
HEAT EMERGENCIES
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Move patient to a cool environment and begin cooling process.
 Air conditioner on high in ambulance
 Cool packs to the patient’s neck, groin, and axilla
 Wash down with wet sponge or towels.
14 of 26
DATE APPROVED
HYPOTHERMIA
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Initiate re-warming techniques.
2. If pulseless and unresponsive, CPR
 Defibrillate only once using AED.
Consider aeromedical transport. Patients who are severely hypothermic may require
cardiopulmonary bypass.
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OBSTETRICS
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE APPROVED
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
Obtain Obstetric History
Prepare for delivery if:
 Crowning
 Contractions < 2 minutes apart
 Bulging perineum or involuntary pushing with contractions.
Transport ALL pregnant patients in left lateral recumbent position.
IF delivery is imminent prepare for birth
 Suction the mouth and nose (observe for meconium staining).
 Check for the umbilical cord around the neck and if present attempt to slide the cord
over the head.
 If the cord is too tight to slide over the head then clamp and cut the cord.
 Clamp the cord approximately 6-8 inches from the baby and then another 2 inches
closer to the mother.
APGAR Scoring System
0
1
Sign
2
Appearance (Skin Color)
Blue, pale
Body pink, blue extremities
Completely pink
Pulse Rate (Heart Rate)
Absent
Less then 100/minute
Greater than 100/minute
Grimace (Irritability)
No response
Grimace
Cough, sneeze, cry
Activity (Muscle Tone)
Limp
Some flexion
Active motion
Respirations (Breathing Effort)
Absent
Slow, irregular
Good, crying
NEWBORN RESUSCITATION
1.
2.
3.
4.
5.
Suction airway repetitively in the presence of meconium until clear.
Dry and stimulate infant.
Document APGAR at 1 and 5 minutes.
Assess respirations and support as needed (40 – 60 per minute).
If HR 60 – 100
 support ventilations using 100% oxygen.
6. If HR < 60
 Begin CPR.
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DATE APPROVED
PHYSICIAN ON SCENE
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
Upon request by any physician on the scene to give orders or directions the personnel will:
1. Verify the physicans’ credentials and document his/her name.
2. Inform the physician
 that personnel are operating under the control of the base station physician
and routine standing orders,
 that personnel can take orders only from the base station physician,
 of the procedure for taking over Medical Control.
If the physician at the scene INSISTS on assuming Medical Control, the medics will:
1. Inform the base station physician of the request,
2. Allow the physician at the scene to speak with the base station physician as necessary,
3. Follow directions of the base station physician.
Should, at any time, the physician at the scene give inappropriate directions or orders which
could adversely affect patient care the personnel will:
1. Immediately inform the base station physician of the situation.
2. Follow direction and orders of the base station physician.
.
CONTACT MEDICAL CONTROL as soon as possible to update them of the situation.
17 of 26
DATE APPROVED
STROKE
2/01/07
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Identify time of onset (time last seen normal).
2. Document findings of exam: Cincinnati Stroke Scale.
EARLY NOTIFICATION OF THE ED IS CRITICAL.
CINCINNATI PRE-HOSPITAL STROKE SCALE
NORMAL
ABNORMAL
1. Facial Droop
Both sides of face move equally
One side of face does not move at all
2. Arm Drift
Both arms move equally or not at all
One arm drifts compared to the other
3. Speech
Patient uses correct words with no
Slurred or inappropriate words or mute
slurring
(Kothari R, et al. Acad Emerg Med. 1997; 4:986-990)
CONSIDER FIBRINOLYTIC SCREEN ENROUTE.
18 of 26
DATE APPROVED
TRAUMA MANAGEMENT
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
2/01/07
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Airway
 Cervical spine stabilization
 Airway management
2. Breathing
 Assist if necessary with high flow oxygen.
3. Circulation
 Control severe bleeding per BLS standards.
AEROMEDICAL TRANSPORT
Possible indications for an air ambulance include but are not limited to
 ‘Multi-System Trauma’ Criteria (see below)
 Extended scene time (entrapment and/or extrication)
 Critical burns
 Multiple critical victims
 Road conditions inhibiting rapid ground transportation.
In general, when response time to the scene by an air ambulance exceeds the transport time to a
hospital by ground transport, the patient should be transported by ground.
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TRAUMA
DATE APPROVED
2/01/07
MULTI-SYSTEM TRAUMA CRITERIA
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
MULTI-SYSTEM TRAUMA CRITERIA
 Respiratory compromise / airway obstruction / intubation / field surgical airways
 Systolic BP < 90 at any time
 Penetrating injury to head, neck, chest, abdomen or extremity proximal to elbow or
knee
 Severe maxillofacial injury
 GCS 13 and below
 Spinal injuries and / or limb paralysis
 Flail chest or significant blunt chest trauma
 Amputations or near amputations proximal to ankle or wrist
 Degloving of entire extremity
 Two or more proximal long bone factures
 Pelvic fractures
 Injuries involving two or more body systems
 Patients receiving blood products to maintain vital signs
 Evidence of high impact
o Initial speed of greater than 40 mph
o Velocity change greater than 20 mph
o Auto deformity greater than 20 inches
o Passenger compartment intrusion greater than 12 inches
o Extrication time more than 20 minutes
 Rollover
 Ejection from vehicle
 Death in same vehicle
 Motorized vehicle / pedestrian or bicycle injury
o Motorcyclist thrown or run over
o Recreational vehicle
o Pedestrian
o Bicyclist
 Fall from greater than 15 feet
20 of 26
DATE APPROVED
TRIAGE - START
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
Yes
No
Able To Walk?
Walking Wounded
Assess Respiratory Status.
No
Yes
Respirations present?
>30/min.
Position airway.
<30/min.
Immediate
Respirations adequate?
No
Yes
Non-salvageable
Immediate
Assess hemodynamic status.
Hemodynamic status adequate?
NO
Radial pulse absent
OR
Skin cool, moist, pale/cyanotic
OR
Capillary refill > 2 sec.
Immediate
YES
Radial pulse present
AND
Skin warm, dry, pink
OR
Capillary refill <2 sec.
Assess mental status.
Hemodynamic status adequate?
NO
Unresponsive to
awake but disoriented
(Fails to follow simple commands)
Immediate
YES
Awake and
oriented
(Follows simple commands)
Delayed
21 of 26
PEDIATRIC ALLERGIC REACTION
DATE APPROVED
2/01/07
ANAPHYLAXIS
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Administer oxygen.
2. Remove offending agent if possible.
3. BLS may administer patient’s own Epi-pen.
NORMAL PEDIATRIC VITALS
AGE
Infant (1 to 12 mo)
RESPIRATORY RATE
HEART RATE
30 to 60
100 to 160
BLOOD PRESSURE
> 60 mm Hg or
strong central pulse
Toddler (1 to 3 yr)
24 to 40
90 to 150
> 70 mm Hg or
Preschooler (4 to 5 yr)
22 to 34
80 to 140
> 75 mm Hg
School-age (6 to 12 yr)
18 to 30
70 to 120
> 80 mm Hg
Adolescent (13 to 18 yr)
12 to 16
60 to 100
> 90 mm Hg
strong central pulse
22 of 26
PEDIATRIC BRONCHOSPASM
DATE APPROVED
2/01/07
ASTHMA
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
FIRST RESPONDER / BASIC EMT
1. Vitals including pulse oximetry if possible.
2. Oxygen therapy.
3. (EMTS ONLY) may assist patient with his/her own prescribed inhaler.
23 of 26
DATE APPROVED
PEDIATRIC BURNS
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
FIRST RESPONDER / BASIC EMT
1. Remove patient from source and stop the burning process.
 Remove clothes and jewelry.
 Brush any dry powders from patient.
 Irrigate chemical burns with copious amounts of normal saline or water.
 Continuously irrigate the eyes if involved with saline.
2. Oxygen 15 lpm via non-rebreather.
3. Apply dry, clean dressings. May consider moist dressings for comfort if less than 10%
Body Surface Area (BSA) involved.
4. Identify source, duration of exposure, and presence of enclosed space. Look for other
trauma (explosions).
5. Determine % of BSA involved.
HEAD
The patient should be transported to the
closest appropriate hospital. Please see
local procedures and protocols.
18
BACK
18
FRONT
18
ARM
ARM
9
PEDIATRIC BURN
DIAGRAM
Rule of Nines
9
1
LEG
LEG
13.5
13.5
24 of 26
DATE APPROVED
PEDIATRIC CARDIAC ARREST
2/01/07
DATE REVISED
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
FIRST RESPONDER / BASIC EMT
1. Step through adult algorithm with the following changes:
 Chest compressions at a rate 100/minute.
 One cycle of CPR = 15/2 (Two Rescuer) 30/2 (One Rescuer)
 AED: > 1 year of age; may use pediatric system if available (2 – 4 Joules / kg).
a. May use adult AED if pediatric system is not available.
Open Airway, check Breathing.
If not breathing, give 2 BREATHS that
make chest rise.
If no response, check pulse.
Do you DEFINITELY feel pulse
within 10 seconds?
PULSE
Give 1 breath every
3 seconds.
Recheck pulse every
2 minutes.
NO PULSE
Give cycles of 15 COMPRESSIONS and 2 BREATHS.
Complete 5 cycles of CPR while applying AED unless: a) the arrest is
witnessed by EMS personnel and AED is immediately available or
b) bystander CPR has been in progress for two minutes.
Check Rhythm with AED if > 1 year
Check Pulse
SHOCKABLE
Give 1 shock.
Resume CPR immediately
for 5 cycles.
Place advanced airway during
compressions if possible.
NOT SHOCKABLE
Resume CPR immediately
for 5 cycles.
Check Rhythm every 5 cycles;
continue until victim starts to move.
Place advanced airway during
compressions if possible.
25 of 26
PEDIATRIC DIABETIC
DATE APPROVED
2/01/07
(HYPOGLYCEMIA)
NOBLE COUNTY FIRE DEPARTMENT PROTOCOLS
DATE REVISED
BASIC EMT
1. If patient has an intact gag reflex and is responsive.
 Oral Glucose 30 Gm PO. Repeat to desired effect.
26 of 26