5.5 Fire Safety (RACE/PASS), Disasters & Medical Emergencies
Key Takeaways
- In a healthcare fire emergency, staff must execute the RACE protocol: Rescue residents in immediate danger, Activate alarm pull stations, Contain fire and smoke by closing all doors/windows, and Extinguish small fires or Evacuate.
- Operating a fire extinguisher follows the PASS acronym: Pull the safety pin, Aim low at the base of the fire, Squeeze the operating handle, and Sweep side-to-side across the fire base.
- Oxygen safety mandates strict no-smoking rules, cotton fabrics, avoiding petroleum-based lubricants on lips/nares, and securing pressurized cylinders in approved racks.
- For conscious adult choking (complete airway obstruction), deliver rapid inward and upward abdominal thrusts (Heimlich maneuver) between the navel and xiphoid process; if the resident becomes unresponsive, lower to the floor and begin CPR starting with 30 chest compressions.
- Crucial medical emergency responses include Basic Life Support CPR (C-A-B sequence, 100–120 compressions/min, 2–2.4 in depth), seizure safety (cradling head, no restraints, nothing in mouth, side-lying recovery position), and stroke recognition via the FAST protocol.
5.5 Fire Safety (RACE/PASS), Disasters & Medical Emergencies
Quick Answer: In a fire emergency, immediately execute RACE: Rescue residents in danger, Activate the fire alarm, Contain fire/smoke by closing doors, and Extinguish or Evacuate. To operate a fire extinguisher, use PASS: Pull pin, Aim at base, Squeeze handle, Sweep side-to-side. Oxygen safety prohibits smoking/open flames and petroleum-based nares lubricants. For conscious choking adults, deliver abdominal thrusts between the navel and xiphoid process (chest thrusts for pregnancy/obesity); if unresponsive, lower to floor, call 911, and begin CPR with 30 compressions. For seizures, protect the head, clear surroundings, NEVER restrain, NEVER place anything in mouth, and position on side post-seizure. Recognize stroke with FAST (Face, Arm, Speech, Time). Hypoglycemia (cold, clammy, confused) requires fast-acting sugar; hyperglycemia (warm, dry, fruity breath) requires nurse notification and insulin.
Healthcare facilities are dynamic environments where clinical emergencies, environmental hazards, and acute medical crises can arise without warning. Certified Nursing Assistants are the primary direct-care staff present at the resident's bedside when emergencies unfold. Whether managing a sudden room fire, a choking resident in the dining hall, a cardiac arrest, a grand mal seizure, an acute ischemic stroke, or a diabetic crisis, the CNA must react with rapid, calm, disciplined execution of standardized emergency protocols.
1. Fire Safety: The RACE Protocol
Healthcare fires present extreme dangers due to the presence of non-ambulatory residents, compressed medical gases (oxygen), and toxic smoke accumulation. When smoke or fire is discovered, every healthcare worker must immediately execute the RACE protocol in sequential order:
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| THE RACE FIRE PROTOCOL |
| |
| [R] - RESCUE / REMOVE --> Remove anyone in IMMEDIATE DANGER from the fire|
| [A] - ALARM / ACTIVATE --> Pull nearest fire alarm & notify operator / 911|
| [C] - CONTAIN / CONFINE--> Close all room doors, corridor doors & windows |
| [E] - EXTINGUISH / --> Extinguish small fires using PASS or |
| EVACUATE Evacuate unit horizontally past fire barriers |
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Detailed Breakdown of RACE Actions
1. R - Rescue / Remove
- The absolute first priority is removing residents in immediate, direct danger from the room or area containing the fire or heavy smoke.
- Evacuation Priority Sequence:
- Ambulatory residents: Direct ambulatory residents to walk together to a safe zone.
- Wheelchair-bound residents: Transport residents seated in wheelchairs or rolling commodes.
- Bedridden / Dependent residents: Transport using wheelchairs, bed rolls (rolling entire bed if corridors permit), or emergency evacuation drag methods (blanket drag or two-person carry).
2. A - Alarm / Activate
- Pull the nearest manual fire alarm pull station located in the hallway.
- Alert facility staff by calling the emergency switchboard (e.g., announcing "Code Red, Room 214") or dialing 911.
3. C - Contain / Confine
- Close the door to the room where the fire originated to trap fire and smoke.
- Close all resident room doors, corridor fire doors, and windows along the hallway.
- Turn off air conditioning/ventilation systems (if centrally controlled) and shut off local oxygen zone valves (only if specifically trained and authorized by the nurse supervisor).
- Clear the corridor of all meal carts, linen hampers, and medical equipment.
4. E - Extinguish / Evacuate
- Extinguish: If the fire is small, contained (e.g., a wastebasket fire), and staff are trained, use a portable fire extinguisher using the PASS protocol. Never turn your back on a fire or attempt to fight a spreading fire.
- Evacuate: If the fire is spreading or smoke is heavy, evacuate following facility disaster plans:
- Horizontal Evacuation: Move residents horizontally past smoke-barrier fire doors into an adjacent safe wing on the same floor.
- Vertical Evacuation: If directed by the Fire Department, move residents downward to lower floors and out of the building via stairwells. NEVER use elevators during a fire.
2. Operating Fire Extinguishers: The PASS Acronym
Portable fire extinguishers in healthcare facilities are typically multipurpose Class ABC dry chemical extinguishers capable of extinguishing wood/paper (Class A), flammable liquids/grease (Class B), and energized electrical equipment (Class C).
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| THE PASS EXTINGUISHER PROTOCOL |
| |
| [P] - PULL --> Pull the safety pin located at the top of the handle. |
| [A] - AIM --> Aim the nozzle or hose LOW at the BASE of the fire. |
| [S] - SQUEEZE--> Squeeze the operating handle/lever to discharge agent. |
| [S] - SWEEP --> Sweep nozzle from SIDE TO SIDE across the fire base. |
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| FIRE EXTINGUISHER CLASSIFICATIONS |
| |
| CLASS A: Ordinary Combustibles (Wood, paper, cloth, trash, rubber) |
| CLASS B: Flammable Liquids & Gases (Grease, oil, gasoline, paints) |
| CLASS C: Energized Electrical Equipment (Appliances, outlets, wiring) |
| CLASS ABC: Multipurpose Dry Chemical (Standard in healthcare facilities) |
| CLASS K: Commercial Kitchen Grease (Cooking oils, deep fryers) |
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3. Oxygen Safety Protocols
Supplemental oxygen is a medical drug prescribed to residents with respiratory failure or hypoxemia. While oxygen is non-flammable itself, it is a powerful oxidizer that dramatically accelerates combustion, causing fires to ignite faster, burn hotter, and spread explosively.
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| OXYGEN SAFETY RULES FOR CNAs |
| |
| 1. POST WARNING SIGNS: "OXYGEN IN USE - NO SMOKING" on room door & bed. |
| 2. STRICT NO SMOKING / NO OPEN FLAMES: Matches, lighters, candles, vaping|
| 3. ELECTRICAL SAFETY: Use grounded 3-prong plugs; inspect for frayed cords|
| 4. AVOID STATIC ELECTRICITY: Use 100% cotton blankets; no wool/synthetics |
| 5. NO PETROLEUM PRODUCTS: Do NOT use Vaseline or petroleum jelly on lips |
| or nares (use water-soluble lubricants like K-Y Jelly only). |
| 6. SECURE OXYGEN CYLINDERS: Always store upright in approved metal stands |
| or wall brackets. NEVER leave tanks standing free or lying on floors. |
| 7. DO NOT ALTER FLOW RATES: CNAs are legally prohibited from adjusting |
| oxygen flowmeter flow rates (liters/min) without licensed nurse orders. |
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4. Foreign Body Airway Obstruction (FBAO) & Choking
Choking is a common and life-threatening emergency in long-term care due to age-related swallowing disorders (dysphagia), poor dentition, ill-fitting dentures, cognitive distraction, and neurological deficits from stroke or Parkinson's disease.
Assessing Airway Obstruction
- Partial Obstruction (Good Air Exchange): Resident is coughing forcefully, wheezing, and able to speak or breathe.
- CNA Action: DO NOT INTERFERE. Do not deliver back slaps or abdominal thrusts. Encourage the resident to continue coughing forcefully. Stay with the resident and observe closely.
- Complete Obstruction (Severe / Poor Air Exchange): Resident exhibits the Universal Choking Sign (clutching hands to throat), is unable to speak, cannot cough, makes silent high-pitched stridor noises, and develops rapid facial cyanosis (bluish lips/nail beds).
- CNA Action: ACT IMMEDIATELY. Deliver abdominal thrusts (Heimlich maneuver).
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| CONSCIOUS ADULT CHOKING: ABDOMINAL THRUSTS |
| |
| 1. Ask: "Are you choking? Can you speak? Can I help you?" |
| 2. Stand behind the resident and wrap your arms around their waist. |
| 3. Make a tight fist with one hand. |
| 4. Place the THUMB SIDE of your fist against the resident's abdomen, |
| SLIGHTLY ABOVE THE NAVEL (umbilicus) and WELL BELOW THE XIPHOID. |
| 5. Grasp your fist firmly with your other hand. |
| 6. Deliver quick, distinct, upward and inward ABDOMINAL THRUSTS. |
| 7. Repeat thrusts continuously until the foreign body is expelled or |
| the resident becomes unconscious. |
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Special Choking Populations & Modifications
- Obese or Late-Stage Pregnant Residents: If you cannot wrap your arms around the abdomen, perform Chest Thrusts: Place the thumb side of your fist over the center of the resident's sternum (breastbone), grasp with other hand, and deliver straight backward chest thrusts.
- Unresponsive (Unconscious) Choking Resident:
- Gently lower the resident to the floor onto their back.
- Shout for help, activate the emergency call system, and call 911.
- Begin CPR immediately starting with 30 chest compressions (compressions create artificial intrathoracic pressure to dislodge the foreign body).
- Open the airway (head-tilt, chin-lift) and look inside the mouth before attempting breaths.
- If an object is visible, perform a finger sweep to remove it. NEVER perform a blind finger sweep (sweeping blindly can force the object deeper into the laryngeal airway).
- Attempt 2 rescue breaths. If chest does not rise, reposition head and reattempt breaths. Continue 30:2 CPR cycles.
5. Basic Life Support (BLS) CPR & AED Guidelines (AHA Standards)
When a resident experiences sudden cardiac arrest, immediate high-quality Cardiopulmonary Resuscitation (CPR) and rapid defibrillation are critical to survival.
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| ADULT BLS CPR QUICK REFERENCE |
| |
| [SEQUENCE] --> C - A - B (Compressions, Airway, Breathing) |
| [CHECK RESPONSE] --> Tap shoulder and shout: "Are you okay?" |
| [CHECK PULSE/BREATH] --> Carotid pulse & breathing checked SIMULTANEOUSLY |
| for at least 5 but NO MORE THAN 10 SECONDS. |
| [COMPRESSION RATE] --> 100 to 120 compressions per minute |
| [COMPRESSION DEPTH] --> At least 2.0 inches (5 cm), max 2.4 inches (6 cm)|
| [CHEST RECOIL] --> Allow COMPLETE chest recoil between compressions |
| [RATIO (1 Rescuer)] --> 30 compressions to 2 rescue breaths |
| [AED APPLICATION] --> Turn ON immediately; attach pads to bare chest; |
| follow voice prompts; clear resident for shock. |
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Step-by-Step Adult BLS Sequence
- Verify Scene Safety: Ensure environment is safe for rescuers.
- Check Responsiveness: Tap resident's shoulders firmly and shout, "Are you okay?"
- Call for Help & AED: Shout for nearby staff, activate facility emergency code (e.g., "Code Blue"), and retrieve the crash cart and Automated External Defibrillator (AED).
- Simultaneous Pulse and Breathing Assessment: Check the carotid pulse (in neck groove beside trachea) while scanning the chest for normal breathing for 5 to 10 seconds.
- If no pulse or only agonal gasping: Initiate CPR immediately.
- High-Quality Chest Compressions:
- Place heel of one hand on lower half of sternum; place other hand on top, interlacing fingers.
- Position shoulders directly over hands with elbows locked straight.
- Compress at 100–120 beats/min to a depth of 2.0 to 2.4 inches.
- Allow complete chest wall recoil; avoid leaning on chest.
- Minimize compression interruptions to less than 10 seconds.
- Airway and Ventilations (30:2): Open airway via head-tilt, chin-lift maneuver. Deliver 2 rescue breaths using a bag-valve-mask (BVM) or pocket mask over 1 second each, observing for visible chest rise.
- Automated External Defibrillator (AED) Use:
- Turn AED unit ON.
- Expose and wipe dry the resident's chest.
- Attach adhesive pads: one pad on upper right chest below clavicle, one pad on lower left chest below armpit.
- Plug in pad connector; shout "Clear!" while AED analyzes cardiac rhythm.
- If shock is advised, ensure nobody is touching the resident ("Clear!"), push the Shock button, and immediately resume chest compressions starting with compressions.
6. Acute Medical Emergencies: Seizures, Stroke & Diabetic Crises
1. Seizure Management (Epilepsy / Convulsions)
A seizure is a sudden, uncontrolled surge of electrical activity in the brain causing involuntary muscle contractions, tremors, loss of consciousness, and altered breathing.
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| SEIZURE EMERGENCY ACTION PLAN |
| |
| DO THESE ACTIONS: |
| 1. Lower resident gently to floor if in bed/chair. |
| 2. Cradle and protect the head (place folded towel or pillow underneath). |
| 3. Move nearby hard furniture, sharp objects, and bed rails out of reach. |
| 4. Loosen tight clothing around the neck (ties, collars, buttons). |
| 5. TIME THE SEIZURE (Note exact start time and duration). |
| 6. After convulsing stops, turn resident onto their SIDE (Recovery Pos.) |
| to drain oral saliva and prevent aspiration. |
| |
| NEVER DO THESE ACTIONS (STRICT PROHIBITIONS): |
| - NEVER restrain the resident or hold down convulsing limbs. |
| - NEVER put anything into the resident's mouth (No tongue blades, spoons).|
| - NEVER give oral fluids or medications during or immediately after. |
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2. Acute Stroke Recognition (The FAST Protocol)
A stroke (cerebrovascular accident [CVA]) occurs when cerebral arterial blood flow is interrupted by an occlusive blood clot (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke). Immediate recognition is vital; thrombolytic "clot-busting" drugs (tPA) must be administered within 3 to 4.5 hours of symptom onset.
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| THE FAST STROKE PROTOCOL |
| |
| [F] - FACE DROOPING --> Ask resident to smile. Is one side uneven/droop? |
| [A] - ARM WEAKNESS --> Ask resident to raise both arms. Does one drift? |
| [S] - SPEECH SLURRED --> Ask to repeat a phrase. Is speech slurred/garbled|
| [T] - TIME TO CALL --> ACT IMMEDIATELY. Call nurse / 911 / Code Stroke. |
| Note EXACT TIME symptoms were first observed. |
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3. Diabetic Emergencies: Hypoglycemia vs. Hyperglycemia
Diabetes mellitus involves impaired glucose regulation. Certified Nursing Assistants must quickly distinguish between low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia):
| Assessment Parameter | Hypoglycemia (Insulin Shock / Low Glucose) | Hyperglycemia (Diabetic Coma / High Glucose) |
|---|---|---|
| Blood Glucose Level | Low (<70 mg/dL). | High (>200 mg/dL; often >300 mg/dL). |
| Onset Speed | Rapid / Sudden (minutes to hours). | Gradual / Slow (hours to days). |
| Skin Characteristics | Cold, clammy, pale, diaphoretic (sweaty). | Warm, dry, flushed, hot to touch. |
| Breathing Pattern | Normal or shallow respirations. | Deep, rapid, labored respirations (Kussmaul breathing). |
| Breath Odor | Normal (no distinct odor). | Sweet, fruity, or acetone breath odor. |
| Mental State | Shakiness, irritability, anxiety, dizziness, slurred speech, confusion, seizures. | Drowsiness, lethargy, extreme fatigue, gradual confusion, eventual coma. |
| Other Symptoms | Extreme hunger, headache, rapid bounding pulse. | Extreme thirst (polydipsia), frequent urination (polyuria), nausea/vomiting. |
| Immediate CNA Action | Notify charge nurse immediately. If resident is conscious and oriented (and approved by nurse), provide 15–20g of fast-acting sugar (4 oz fruit juice, 4 oz regular soda, 3–4 glucose tablets). If unconscious, never give oral liquids. | Notify charge nurse immediately. Check blood glucose (by nurse/CNA per policy); nurse administers prescribed insulin and IV fluids. |
[!TIP] Clinical Memory Rhyme: "Cold and clammy, give some candy" (Hypoglycemia) "Warm and dry, sugar is high" (Hyperglycemia)
A nurse aide discovers a small wastebasket fire in a resident's bathroom. The resident is sitting on the bed four feet away from the smoke. Following the standardized RACE protocol, what is the nurse aide's very FIRST priority?
Where should a nurse aide place their fist when delivering abdominal thrusts (Heimlich maneuver) to a conscious choking adult?
A resident in the dayroom suddenly experiences a generalized tonic-clonic (grand mal) seizure, falling to the floor. Which nursing assistant intervention is correct?
A diabetic resident complains of sudden shakiness, dizziness, and intense hunger. The nurse aide notes that the resident's skin feels cold and clammy, and speech is slightly slurred. How should the nurse aide interpret these findings and respond?