> For the complete documentation index, see [llms.txt](https://handbook.teddwa.xyz/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://handbook.teddwa.xyz/arriving-on-scene.md).

# Arriving on scene

Secure the scene, triage patients, and complete an initial assessment.

{% stepper %}
{% step %}

### Protect yourself and secure the scene

1. Perform body substance isolation (BSI) before approaching the patient.
2. Use gloves, a face mask, and other required protection.
3. Bring the stretcher to the patient once the scene is safe.
   {% endstep %}

{% step %}

### Triage multiple patients

Assess each patient’s injuries and condition. Assign the appropriate tag:

* **Red — immediate care:** Life threatening injuries require urgent treatment and transport.
* **Yellow — delayed care:** Serious injuries can wait until red tag patients receive care.
* **Green — minor injuries:** The patient needs little or no immediate treatment.
* **White — uninjured:** The patient does not require treatment. Some agencies use this tag.
* **Blue — expectant:** Critical injuries have a very low chance of survival.
* **Black — deceased**

{% hint style="info" %}
Treat the most critical viable patient first. Do not prioritize black or blue tag patients.
{% endhint %}
{% endstep %}

{% step %}

### Complete the primary assessment

#### Check responsiveness

Check for consciousness. Ask, “Can you hear me?” Observe movement and response.

#### Assess the airway

Assess whether the airway is open, obstructed, or swollen.

For a severe airway problem, request ALS support. If ALS is unavailable, administer oxygen by non rebreather mask at 10 L/min. Treat other injuries and transport urgently.

#### Assess breathing

Apply a pulse oximeter and check oxygen saturation (SpO₂). A normal reading is 94–100%.

If SpO₂ is below 94%, administer oxygen by non-rebreather mask. Adjust flow to the situation, up to 15 L/min.

#### Assess circulation

Check pulse and vital signs. A normal heart rate is 60–100 BPM.

A gunshot patient may have a heart rate up to 120 BPM. If it approaches 140 BPM, attach a 12 lead ECG and monitor closely. If it falls below 60 BPM, request ALS support and transport urgently.
{% endstep %}
{% endstepper %}

{% hint style="info" %}
Reassess airway, breathing, circulation, and injuries throughout care and transport.
{% endhint %}

### Advanced airway management

Follow your service’s airway protocol and medical direction. Request ALS when needed.

{% stepper %}
{% step %}

#### Identify indications and assess difficulty

Consider advanced airway management when the patient:

* Cannot protect their airway, including GCS ≤8 or an absent gag reflex.
* Has respiratory failure or apnea unresponsive to BVM ventilation.
* May deteriorate from burns, trauma, or toxic ingestion.
* Has GSW to the neck area.
  {% endstep %}

{% step %}

#### Prepare

* **Oxygen:** Preoxygenate with 100% oxygen. Use an NRB or BVM for at least three minutes when possible. Consider apneic oxygenation with a nasal cannula at 15 L/min.
* **Monitor:** Apply SpO₂, waveform EtCO₂, cardiac, and blood-pressure monitoring.
* **Equipment for failure:** Prepare a BVM, supraglottic airway, and surgical cricothyrotomy kit.
  {% endstep %}

{% step %}

#### Administer RSI medications

**Pretreatment** may include fentanyl 1–3 mcg/kg IV. Use it selectively to blunt sympathetic response.

Choose one **induction agent**:

* Etomidate 0.3 mg/kg IV.
* Ketamine 1–2 mg/kg IV.
* Midazolam 0.1–0.3 mg/kg IV.

Choose one **paralytic**:

* Succinylcholine 1–1.5 mg/kg IV. Avoid it with hyperkalemia, burns over 24 hours old, crush injury, neuromuscular disease, or malignant hyperthermia history.
* Rocuronium 1–1.2 mg/kg IV when succinylcholine is contraindicated. Its duration is about 45 minutes.
  {% endstep %}

{% step %}

#### Manage a failed airway

Follow your failed-airway algorithm:

1. Ventilate with a BVM.
2. Place a supraglottic airway, such as an i-gel or King LT.
3. Perform a surgical airway if the patient cannot be oxygenated.
   {% endstep %}

{% step %}

#### Provide post-intubation care

Provide analgesia and sedation immediately. Do not allow paralysis to outlast sedation.

Reconfirm tube placement after every move. If the patient decompensates, use **DOPE**:

* **Displacement**
* **Obstruction**
* **Pneumothorax**
* **Equipment failure**

Set the ventilator or BVM rate to about 10 breaths/minute. Avoid hyperventilation.
{% endstep %}
{% endstepper %}


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