Emergency

I. Cardiac Arrest A. Adult/child/infant CPR

1.

2. 3.

4. 5. 6.

7.

Definition of ages a. adult and older child (15 and older) b. child 1 to 14 years c. infant less than 1 year Assess responsiveness a. shake gently b. shout "are you okay?" If unresponsive, activate the emergency response system a. if hypoxic arrest call emergency response system after 2 minutes of CPR b. if child or infant call after 2 minutes of CPR unless sudden witnessed arrest call emergency response system first Call for a defibrillator Position the client to a resuscitation position, if no evidence of trauma (if trauma, see section III of this lesson) Open the airway a. head tilt-chin lift b. jaw thrust (if trauma is evident or spinal injury suspected) Assess for breathing: look, listen and feel a. if breathing, position in a recovery position b. if not breathing, give 2 rescue breaths at 1 second/breath c. assess if breaths go into lungs by chest movement d. if air does not go in, reposition airway (see #4 above) e. if air still does not go in, check for foreign body i. abdominal thrust for adults, older child and child (Heimlich maneuver)

f.

g.

back blows and chest thrusts for infants do not proceed until airway and rescue breathing is established iv. no blind finger sweeps when airway is clear, check for presence of a pulse i. check pulse for 10 seconds or less ii. adult or older child check carotid iii. child check carotid or femoral iv. infant brachial or femoral begin chest compressions if pulse is absent or in child/infant if heart rate is < 60 with signs of poor perfusion i. be sure client is on a firm surface ii. hand position is critical adult/older child center of chest between nipples; two hands with heel of one hand and the other hand on top child center of chest between nipples; one hand or two hands with use of the heel(s) of the hands infant just below the nipple line; one rescuer - two fingers or two rescuers two thumbs encircling hands around chest iii. compression depth adults/older child - 1.5 to 2 inches child/infants 1/3 to 1/2 the depth of the chest iv. compression rate 100 compressions per minute for all ages v. PUSH HARD, PUSH FAST for chest compressions vi. allow chest recoil vii. minimize interruptions in chest compression keep at 10 seconds or less viii. compressions-ventilation ratios

ii. iii.

adult/child 30:2 [30 compressions to 2 breaths] for one or two rescuers child or infant one rescuers 30:2 (30 compressions to 2 breaths) two rescuers 15:2 (30 compressions to 2 breaths)

II.

h. apply monitor or defibrillator when available i. reassess cardiopulmonary status after every five cycles of compressions to ventilations j. continue until ACLS providers take over or the client starts to move k. differences for lay persons i. lay rescuers do not need to assess for pulse or signs of circulation for an unresponsive victim ii. lay rescuers do not need to provide rescue breathing without chest compressions Early defibrillation In adults, the arrhythmia most correctable is ventricular fibrillation if treated promptly Before starting CPR for ventricular fibrillation, call for help

II. III.

Shock - see the discussion of shock in Cardiovascular Trauma Care

A. Airway with simultaneous cervical spine immobilization 1. Must use jaw thrust 2. Do not use head-tilt chin-lift: it could injure neck B. Breathing 1. Look, listen and feel for respirations 2. Follow CPR procedure C. Circulation 1. Assess pulses a. carotid pulse: BP at least 60 b. femoral pulse: BP at least 70 c. radial pulse: BP at least 80 2. Stop any active, visible bleeding by applying direct pressure 3. After initial assessment, start two large-bore IVs

D. Disability: brief neurological exam 1. Level of consciousness 2. Pupil response to light 3. Ability to move extremities 4. Ability to move against resistance E. Expose 1. Undress client 2. Inspect for injuries or deformities F. Fahrenheit 1. Take temperature 2. Maintain warmth a. warm blankets b. warming lights G. Get vitals 1. Pulse 2. Respiratory rate 3. Blood pressure H. History and head-to-toe full assessment 1. How did injury occur - mechanism of injury 2. Client's medical history 3. Full body system assessment I. Inspect the back 1. Roll the client over - log roll with help 2. Inspect for injuries or deformities CPR

Early defibrillation is the key to successful resuscitation for many adults. Continually reassess during CPR to see if the client regains a pulse or begins breathing. Reassess to see that the chest moves and pulses are palpable during CPR.

SHOCK

In shock, the first hour of treatment is most critical. Early detection is key. There are different ways to categorize shock. Basically, shock presents three potential problems: 1. Not enough fluid in the blood vessels (hypovolemia) OR 2. Fluid has moved outside the vessels, so cannot be pumped to the organs (distributive) OR 3. Heart cannot pump fluid that is present (cardiogenic)

Shock and Temperature

In septic shock, the skin and body temperature may increase. In other shock states, body and skin temperature will decrease.

Shock and Heart Signs

Early stages of shock activate the sympathetic nervous system. So in early stages, the client will not always be hypotensive. Bradycardia is a very late sign in shock. Another late sign is cardiac arrhythmia (other than sinus tachycardia). Arrhythmias reflect less perfusion of the coronary arteries and myocarditis. As the myocardium receives less perfusion, heart pumps less. Because less blood perfuses the brain, level of consciousness drops.

Shock and Urinary Output

Average adult urinary output is 0.5 to 1.0 ml/kg/hr. Less than 30 ml/hour reflects decreased renal blood flow. Acute renal failure can result.

Shock and Respiration

As blood flow to lungs decreases, less gas exchange will occur. When tissues receive less oxygen, they produce more lactate and metabolic acidosis sets in. Metabolic acidosis increases risk of cardiac arrhythmias. For a client in shock, body cells receive less oxygen and nutrients. Thus treatment aims at increasing both available oxygen and volume of blood in vessels (unless the heart has failed). Medications can improve tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics). When treating a trauma client, you must quickly assess ABCs. After you know the client is breathing and has a pulse, vital signs can wait while you stop any bleeding and start other interventions (such as starting IVs). Don't rely only on the vital sign numbers.

Head and Spine Injury

If client has head injury, the most important assessment is level of consciousness; next is pupil response to light. Changes in vitals are very late sign. With trauma clients, assume spine is injured until proven otherwise. While you open the airway, you must keep cervical spine immobile.