6.3 Emergency Response: RACE, PASS, Choking, CPR & Disasters

Emergency Response: RACE, PASS, Choking, CPR & Disasters

Healthcare facilities are vulnerable to diverse, unpredictable emergencies ranging from internal structural fires and acute cardiovascular crises to catastrophic natural disasters. Nursing assistants provide direct care around the clock and are often the very first staff members to discover a smoldering fire, witness an airway obstruction during mealtime, or manage residents during severe weather outbreaks.

In Mississippi, Certified Nursing Assistants must be prepared to respond instantly, decisively, and correctly under high-stress conditions. Adhering to standardized safety algorithms—including RACE, PASS, AHA Basic Life Support (BLS), and state disaster protocols—saves lives, mitigates panic, and maintains an unbroken chain of resident safety.

1. Fire Safety Protocols: RACE & PASS

Fires in healthcare settings present extreme hazards due to congregate living, immobile or cognitively impaired residents, specialized medical equipment, and high-concentration piped medical oxygen systems.

+-----------------------------------------------------------------------------+
|                        THE HEALTHCARE FIRE TRIANGLE                         |
|                                                                             |
|   [FUEL]                 +   [HEAT / IGNITION]     +   [OXYGEN]             |
|   - Bedding, linens,         - Electrical faults,      - Ambient air plus   |
|     trash, paper,              overheated motors,        piped supplemental |
|     clothing, grease.          smoking violations.       medical oxygen.    |
+-----------------------------------------------------------------------------+

The RACE Protocol (Sequential Execution)

When a fire, smoke, or burning odor is detected, facility personnel must immediately execute the RACE algorithm in strict sequential order:

+-----------------------------------------------------------------------------+
|                           THE R.A.C.E. FIRE PROTOCOL                        |
|                                                                             |
|   [R - RESCUE]        ---> Remove anyone in immediate danger from the room  |
|                            or fire zone into a safe compartment.            |
|                                                                             |
|   [A - ALARM]         ---> Pull the manual fire alarm pull station and dial |
|                            facility emergency code (e.g., Code Red).        |
|                                                                             |
|   [C - CONTAIN]       ---> Close all doors, windows, and fire dampers to    |
|                            starve the fire and contain smoke migration.     |
|                                                                             |
|   [E - EXTINGUISH /   ---> Extinguish small, localized fires with PASS or   |
|        EVACUATE]           evacuate horizontally past fire barrier doors.   |
+-----------------------------------------------------------------------------+

1. R - RESCUE (Remove): The first and highest priority is always human life. Immediately remove any resident, visitor, or staff member in immediate danger from the room or area where the fire or smoke is located. Move bedbound residents by pushing their beds, using wheelchairs, or performing emergency blanket drags into an adjacent hallway compartment.
2. A - ALARM (Activate): Immediately pull the nearest manual fire alarm pull station on the wall. Dial the facility's internal emergency operator or overhead paging system to announce the facility fire code (e.g., "Code Red, Room 214, East Wing"), alerting all facility staff and triggering automatic fire department dispatch.
3. C - CONTAIN (Confine): Confine the fire, deadly toxic smoke, and superheated gases by closing all resident room doors, hallway smoke barrier doors, and windows. Stuff rolled damp towels or blankets along door bottoms if smoke is intense. If medical oxygen is flowing in the fire room, shut off the flowmeter at the wall (zone valve shut-offs are handled by designated maintenance or nursing leadership).
4. E - EXTINGUISH / EVACUATE:
   • Extinguish: If the fire is small, contained (e.g., a wastebasket fire), and you have a clear unblocked exit behind you, use the correct portable fire extinguisher to put out the fire.
   • Evacuate: If the fire is large, spreading rapidly, or smoke is heavy, evacuate the area immediately. In healthcare facilities, evacuation follows a strict hierarchy:
     • Horizontal Evacuation (First): Move residents laterally on the same floor through heavy smoke-barrier fire doors into an adjacent, protected fire compartment.
     • Vertical Evacuation (Second): Move residents downward to ground-level exits via enclosed stairwells (never elevators) only upon direct orders from the Fire Department Incident Commander.

The PASS Fire Extinguisher Technique

Portable fire extinguishers in healthcare facilities are typically Class ABC Multipurpose Dry Chemical extinguishers, capable of extinguishing Class A (ordinary combustibles like wood, paper, cloth), Class B (flammable liquids like grease, oils), and Class C (electrical equipment) fires.

+-----------------------------------------------------------------------------+
|                        THE P.A.S.S. EXTINGUISHER TECHNIQUE                  |
|                                                                             |
|   [P - PULL]    ---> Pull the safety pin locking the handle.                |
|   [A - AIM]     ---> Aim the extinguisher nozzle at the BASE of the fire.   |
|   [S - SQUEEZE] ---> Squeeze the operating handle to release the agent.     |
|   [S - SWEEP]   ---> Sweep the nozzle from side to side across the base.    |
+-----------------------------------------------------------------------------+

   FIRE EXTINGUISHER OPERATING STEPS:

   1. PULL PIN               2. AIM AT BASE            3. SQUEEZE & SWEEP
       [  ]                      ( )                      ___
      --||--                      |                      /   \
     [HANDLE]                    [==]===                |     |===>> [SPRAY]
        ||                        ||                     \___/
      [BODY]                    [BODY]                   [BODY]   ~~~~~~~~~
                                                                 (BASE OF FIRE)

• P - PULL: Pull the safety pin located at the top of the extinguisher handle to break the plastic tamper-evident inspection seal.
• A - AIM: Aim the discharge nozzle or hose at the BASE of the fire (the burning fuel source on the ground), not up at the flames or rising smoke.
• S - SQUEEZE: Squeeze the top operating lever/handle down firmly to discharge the pressurized extinguishing chemical.
• S - SWEEP: Sweep the nozzle smoothly from side to side across the base of the fire in a sweeping motion until the flames are completely smothered. Maintain a safe distance of 6 to 8 feet from the fire and keep an unblocked escape exit behind your back at all times.

2. Foreign Body Airway Obstruction (Choking) & The Heimlich Maneuver

Geriatric residents in long-term care are at extreme risk for Foreign Body Airway Obstruction (FBAO) due to age-related swallowing disorders (dysphagia), poor dentition, ill-fitting dentures, neurological deficits from strokes or Parkinson's disease, and sedative medications.

+-----------------------------------------------------------------------------+
|                   AIRWAY OBSTRUCTION CLINICAL RECOGNITION                   |
|                                                                             |
|   [MILD / PARTIAL OBSTRUCTION]          [SEVERE / COMPLETE OBSTRUCTION]     |
|   - Resident is coughing forcefully.    - Silent, unable to speak or cough. |
|   - Can speak or make audible sounds.   - Universal choking sign (clutching)|
|   - Skin color remains normal.          - High-pitched wheeze (stridor).    |
|   - ACTION: Encourage continuous        - Cyanosis of lips and nailbeds.    |
|     forceful coughing; DO NOT           - ACTION: Deliver immediate         |
|     interfere or give back blows.         abdominal thrusts (Heimlich).     |
+-----------------------------------------------------------------------------+

The Heimlich Maneuver (Abdominal Thrusts on Conscious Adult)

When a conscious resident displays signs of severe airway obstruction:

1. Verify Choking & Obtain Consent: Ask: "Are you choking? Can you speak? I know what to do, let me help you!"
2. Position Yourself: Stand directly behind the resident and wrap your arms around their waist.
3. Form a Fist: Make a fist with one hand. Place the thumb side of your fist against the resident's abdomen, slightly above the navel (belly button) and well below the xiphoid process (tip of the breastbone).
4. Grasp and Thrust: Grasp your fist firmly with your other hand. Deliver quick, forceful inward and upward subdiaphragmatic thrusts into the abdomen.
5. Repeat: Continue delivering rapid upward and inward thrusts until the foreign object is forcefully expelled from the airway or the resident becomes unresponsive.

Special Choking Populations & Modifications

• Obese or Late-Term Pregnant Residents: If the caregiver's arms cannot encircle the resident's abdomen, or if the resident is pregnant, perform Chest Thrusts. Stand behind the resident, place the thumb side of your fist against the center of the sternum (breastbone), grasp your fist with the other hand, and deliver quick, forceful backward chest thrusts.
• Wheelchair-Bound Residents: Lock the wheelchair brakes. Lean the resident slightly forward in the chair. Stand or kneel behind the wheelchair, wrap your arms around the resident's torso above the navel, and deliver upward and inward abdominal thrusts.

Management of the Unresponsive Choking Victim

If a choking resident loses consciousness and collapses during abdominal thrusts:

+-----------------------------------------------------------------------------+
|                 UNRESPONSIVE CHOKING ADULT EMERGENCY ALGORITHM              |
|                                                                             |
|   [1. EASE TO FLOOR]     ---> Carefully ease victim supine onto floor.      |
|                                                                             |
|   [2. ACTIVATE CODE]     ---> Call for emergency help / Code Blue / 911.    |
|                                                                             |
|   [3. START CPR]         ---> Immediately begin 30 CHEST COMPRESSIONS       |
|                               (do not perform a pulse check first).         |
|                                                                             |
|   [4. AIRWAY INSPECTION] ---> Open airway (head-tilt/chin-lift) & look in   |
|                               mouth before delivering rescue breaths.       |
|                               - If object VISIBLE: Perform finger sweep.    |
|                               - If object NOT visible: NEVER blind sweep.   |
|                                                                             |
|   [5. ATTEMPT BREATHS]   ---> Deliver 2 rescue breaths; resume CPR cycle.   |
+-----------------------------------------------------------------------------+

[!WARNING] The Strict Prohibition on Blind Finger Sweeps: Never perform a blind finger sweep. Inserting your fingers blindly into a resident's pharynx can push a partially lodged food bolus deeper into the laryngeal inlet, converting a treatable partial obstruction into a fatal, total tracheobronchial occlusion. Only sweep if the foreign object is clearly visible in the anterior mouth.

3. Basic Life Support (BLS) / CPR Overview

When a resident experiences sudden cardiac arrest, clinical death begins within 4 to 6 minutes without effective cardiopulmonary resuscitation (CPR). The American Heart Association (AHA) Basic Life Support protocol follows the C-A-B (Compressions - Airway - Breathing) sequence.

+-----------------------------------------------------------------------------+
|                        ADULT BLS RESUSCITATION METRICS                      |
|                                                                             |
|   [COMPRESSION DEPTH]    ---> At least 2.0 inches (5 cm), max 2.4 inches.   |
|   [COMPRESSION RATE]     ---> 100 to 120 compressions per minute.           |
|   [RECOIL]               ---> Allow FULL chest recoil between compressions. |
|   [RATIO (ADULT)]        ---> 30 compressions to 2 breaths (1 or 2 staff).  |
|   [AED APPLICATION]      ---> Apply pads immediately upon arrival.          |
+-----------------------------------------------------------------------------+

Step-by-Step BLS Sequence for CNAs:

1. Verify Scene Safety: Ensure the surrounding area is safe for rescuers and the victim.
2. Check Responsiveness: Tap both shoulders firmly and shout: "Are you okay? Can you hear me?"
3. Call for Help & Activate Emergency Response: Shout for nearby help. Activate the emergency call light, call out "Code Blue", and direct someone to retrieve the Crash Cart and Automated External Defibrillator (AED).
4. Simultaneous Pulse & Breathing Check: Look at the chest for breathing (normal chest rise vs. absent/agonal gasping) while simultaneously palpating the carotid artery pulse on the side of the neck closest to you for at least 5 but no more than 10 seconds.
5. High-Quality Chest Compressions: If there is no pulse or you are uncertain:
   • Position resident supine on a firm, flat surface (insert cardiac backboard if in bed).
   • Place the heel of one hand on the lower half of the sternum (center of the chest), and place the other hand on top with fingers interlaced.
   • Lock your elbows straight and position your shoulders directly over your hands.
   • Compress the chest at a rate of 100–120 beats per minute to a depth of at least 2.0 inches (5 cm), allowing complete chest recoil between each compression.
   • Deliver 30 compressions followed by 2 rescue breaths using a barrier mask or bag-valve-mask (BVM).
6. AED Operation: As soon as the AED arrives, turn it on immediately. Apply the adhesive electrode pads to the resident's bare, dry chest (one pad on upper right chest below the clavicle, one pad on lower left ribcage). Follow AED audio prompts: Ensure nobody touches the resident during rhythm analysis ("Clear!"), deliver shock if advised, and immediately resume chest compressions starting with compressions.

4. Acute Seizure Management Protocols

A seizure is an episode of abnormal, excessive electrical discharge within the cerebral cortex. In long-term care settings, seizures commonly result from cerebrovascular accidents (strokes), head trauma, brain tumors, Alzheimer's disease, electrolyte imbalances, high fever, or antiepileptic medication non-compliance.

+-----------------------------------------------------------------------------+
|                        ACUTE SEIZURE SAFETY CHECKLIST                       |
|                                                                             |
|   MANDATORY ACTIONS (DO THIS):          STRICTLY PROHIBITED (NEVER DO):     |
|   - Clear hard/sharp objects away.      - NEVER restrain resident limbs.    |
|   - Cradle head with pillow/towel.      - NEVER put ANYTHING in the mouth.  |
|   - Loosen tight clothing around neck.  - Never force open clenched teeth.  |
|   - Time the exact duration.            - Never offer food, pills or water. |
|   - Turn to side post-seizure.          - Never leave resident unattended.  |
+-----------------------------------------------------------------------------+

Clinical Management During the Active Seizure

• Protect from Physical Trauma: If the resident is standing or seated in a wheelchair, ease them gently to the floor. Move furniture, chairs, footrests, and sharp objects out of reach.
• Protect the Head: Place a soft folded blanket, pillow, or jacket beneath the resident's skull to prevent repetitive head impact on the floor.
• Loosen Restrictive Clothing: Loosen tight shirt collars, neckties, or belts to facilitate respiratory expansion.
• Zero Restraint Policy: NEVER attempt to hold down or restrain the resident's seizing arms, legs, or body. Restraining violent involuntary muscle spasms can cause bone fractures, joint dislocations, and severe muscle tears.
• Zero Mouth Insertion Policy: NEVER place any object (tongue blades, spoons, fingers, airways, or washcloths) inside the resident's mouth. Seizing residents cannot swallow their tongues; forcing objects into clenched jaws breaks teeth, lacerates gums, amputates rescuer fingers, and causes lethal airway obstruction.
• Time the Seizure: Note the exact time the seizure began. Time the duration of active motor convulsions. A continuous seizure lasting longer than 5 minutes, or multiple consecutive seizures without recovery of consciousness between episodes, is a life-threatening medical emergency known as Status Epilepticus requiring rapid intravenous anticonvulsant therapy.

Post-Seizure (Post-Ictal) Care

Once active convulsions stop, the resident enters the post-ictal phase (characterized by extreme lethargy, deep sleep, confusion, and headache):

1. Turn the resident onto their side (Recovery Position) to allow saliva, vomitus, and oral secretions to drain out of the mouth, keeping the airway open and preventing aspiration pneumonia.
2. Ensure the airway remains clear; monitor pulse and respirations.
3. Provide gentle reassurance as the resident regains consciousness; orient the resident to surroundings.
4. Report full objective details to the charge nurse (onset time, duration, seizure presentation, incontinence, post-ictal state).

5. Severe Hemorrhage Management

Severe external bleeding from trauma, skin tears, or surgical wound dehiscence requires rapid intervention to prevent hypovolemic shock.

+-----------------------------------------------------------------------------+
|                        HEMORRHAGE CONTROL PROTOCOL                          |
|                                                                             |
|   1. APPLY PPE: Don medical gloves (and face shield if spurting).           |
|   2. DIRECT PRESSURE: Place sterile gauze pad directly over wound; press.   |
|   3. DO NOT REMOVE SOAKED DRESSINGS: Layer new gauze directly over old.     |
|   4. ELEVATE EXTREMITY: Elevate above heart level if no fracture suspected. |
|   5. NOTIFY NURSE: Summon RN immediately; keep resident warm and calm.      |
+-----------------------------------------------------------------------------+

• Arterial Bleeding: Bright red blood spurting synchronously with heartbeats (highest emergency).
• Venous Bleeding: Dark red blood flowing in a steady, continuous stream.
• Direct Pressure Technique: Apply continuous, firm manual pressure directly over the bleeding site using sterile gauze pads or a clean cloth. If blood saturates the initial dressing, never peel it off (peeling disrupts the delicate fibrin blood clot forming underneath); simply apply additional thick absorbent pads on top of the original dressing and maintain continuous manual pressure.

6. Mississippi Severe Weather & Tornado Disaster Protocols

Mississippi ranks among the most tornado-prone states in the nation, located in the heart of "Dixie Alley"—a geographic corridor characterized by high-intensity nocturnal tornadoes, severe straight-line windstorms, and catastrophic hurricane inland tracks. Long-term care facilities must execute rapid, organized disaster sheltering procedures when severe weather threatens.

+-----------------------------------------------------------------------------+
|                        TORNADO WATCH VS. TORNADO WARNING                    |
|                                                                             |
|   [TORNADO WATCH]                       [TORNADO WARNING]                   |
|   - Conditions favor tornado formation. - Tornado sighted or on radar.      |
|   - ACTION: Monitor NOAA weather radio, - ACTION: IMMEDIATE EMERGENCY       |
|     review disaster assignments, check    RELOCATION OF ALL RESIDENTS TO    |
|     flashlights and emergency supplies.   INTERIOR HALLWAYS / LOWEST FLOOR. |
+-----------------------------------------------------------------------------+

Step-by-Step Mississippi Tornado Emergency Protocol:

1. Immediate Resident Relocation: When a Tornado Warning is announced, immediately evacuate all residents out of perimeter rooms with exterior windows. Move residents into designated interior hallways or windowless core rooms on the lowest floor of the facility.
2. Isolate Windows & Doors: Close all exterior room doors and window blinds/curtains to contain flying glass shards and reduce internal air pressure turbulence.
3. Protect Bedbound Residents: Move bedbound residents in their beds into interior hallways. If beds cannot be moved, lower the beds to their lowest position, position beds against interior walls away from glass, and cover residents completely with heavy blankets, quilts, and pillows over their heads and faces.
4. Protect Wheelchair & Ambulatory Residents: Lock all wheelchair brakes in the hallway facing interior walls. Have ambulatory residents sit on the floor against the interior wall in a protective crouch position (head between knees, hands clasped over neck and head).
5. Account for Every Resident: Conduct an immediate, rigorous census headcount using the unit roster to ensure 100% of residents and visitors are accounted for in the safe shelter area.
6. Emergency Supplies: Maintain access to battery-powered NOAA weather radios, emergency flashlights, first-aid kits, and portable suction units until local emergency authorities give the official "All Clear."