Chapter 48 EMERGENCY CARE
Emergencies can happen at any time and, when confronted with an urgent situation, it is vital that the nurse is aware of the correct procedure to follow. In a health care facility the nurse is most likely to be the first person to be on the scene and needs to be able to recognise an emergency and respond appropriately. This emergency care chapter will prepare the nurse to make appropriate decisions regarding first aid care, and to act on those decisions.
It was 9:30 pm and I was just doing the final paper work after a fairly busy evening in the Emergency Department when I heard a woman’s voice screaming out ‘someone help my baby’. I rushed into the waiting room to find a woman holding her baby in her arms. The baby was pale and floppy. I took the baby from her arms and went into the examination room. The baby was about 10 months old — the same age as my little girl, home safe and well in bed. It is always harder to work on someone if they remind you of a loved one — harder to dissociate from what you are doing. I had to suppress my ‘mothering’ response and work in a systematic manner. I pressed the emergency button, as I knew I needed help, and calmly began the mental checklist. Danger, response, airway, breathing and compression …
First aid is the emergency care of a sick or injured person until medical aid is available or until the person recovers. The nurse may encounter an emergency situation in a health care facility, in the home environment or in a public place. Knowing what to do in an emergency situation may mean the difference between a person living and dying. An emergency situation within a health care facility may involve a patient, a visitor or a staff member. Under these circumstances lifesaving equipment and expert help are usually at hand, but prompt emergency care given by the person who is first on the scene may still save lives. Documentation of the incident will be required, and health care facilities provide incident and accident forms for this purpose. Information to be documented includes: details of the onset of the incident; the date, time and location; the emergency care provided; and the name of any person who witnessed the incident. The nurse attending the emergency must remain with the individual and summon assistance. If the incident occurs within a ward area, the nurse in charge must be notified immediately.
An emergency is a situation requiring immediate action. Recognising an emergency is the first step in responding. You may become aware of an emergency because of certain things you observe (Australian Red Cross 1998), such as unusual noises, sights, smells, signs or behaviours.
Many smells are part of our everyday life, such as petrol fumes at a petrol station. You may become aware of an unusual smell in the workplace when smells are stronger than usual or are not easily identified or are unrecognisable. Remember to put your safety first if you find yourself in a situation in which there is an unusual or very strong smell, as many fumes can be poisonous.
Certain signs and symptoms can indicate an emergency; for example, you may find a client collapsed on the bathroom floor or sliding out of their chair. Other signs and symptoms that may draw your attention to an emergency event are if the person:
It may be difficult to detect whether someone’s appearance or behaviour is unusual, especially if the person is unfamiliar to you. If an incident occurs within the ward environment, where the clients are familiar to you, this will be more easily recognisable. Some unusual behaviours include:
Recognising that an emergency situation has occurred is the first phase in providing emergency care. It is worth mentioning at this point that these indicators may occur individually or together. For example, a person having a cerebrovascular accident may present with a headache alone or with a headache accompanied by weakness down one side and slurred speech.
In an emergency situation your involvement as a nurse may be critical, as staffing levels are frequently at a minimum and all personnel are called on to give assistance. In a health care environment, strict emergency protocol is laid out and should be firmly adhered to. When working as a nurse it is part of your responsibility to ensure that you are familiar with each facility’s protocol. All the relevant information will be located in the facility’s policy and procedure manuals, commonly located at the nurse’s station, or electronically on the facility’s intranet site.
In a first aid situation you may be the only person available to assist the casualty. There are many ways to help, but to do this you must first make the decision to respond. Sometimes people do not respond to an emergency because they are unaware that a situation is occurring, and at other times they are reluctant to offer help for various reasons. These include:
CLINICAL INTEREST BOX 48.1 Barriers to responding to an emergency
When it becomes apparent that an emergency has occurred and you decide to respond, you must ensure that the scene is safe for you and for others. Take the time to look at the scene and observe for anything that may pose a threat to your safety and that of the casualty or other bystanders. If any dangers are evident, do not approach the scene — call emergency personnel immediately for help. If you decide that the area is safe, then proceed to perform the primary survey. Figure 48.2 shows the basic life support flow chart that should be followed when attending all emergencies.
In every emergency situation you must first look for conditions that are an immediate threat to the casualty’s life. These are briefly mentioned here and will be discussed in more detail under ‘Resuscitation’. Clinical Interest Box 48.2 lists some definitions the first aider must be familiar with. In the primary survey, check for:
The emergency number to call for ambulance, fire or police is 000 in Australia and 111 in New Zealand. For emergencies involving bites, stings or poisoning, call 13 11 26 in Australia and 0800 764 766 (0800 POISON) in New Zealand.
Resuscitation is the preservation of life by establishment and/or maintenance of airway, breathing and circulation. The objective of resuscitation techniques is to ensure adequate supply of oxygen to the brain, not only to preserve life but also to prevent the damage to brain cells that results from lack of oxygen (Australian Red Cross 1998). Clinical Interest Box 48.3 presents more detail on resuscitation.
CLINICAL INTEREST BOX 48.3 Resuscitation
The central focus of resuscitation is the protection of the brain and heart from ischaemia, and the steps involved in resuscitation are systematic and implemented in order of priority. The principles of basic life support (BLS) include: (i) establishing and maintaining an airway; (ii) breathing; and (iii) circulation — the objective being to provide the brain and heart with an oxygenated blood supply. If a defibrillator is available, defibrillation is performed by attaching an AED (Automated External Defibrillator), and following the prompts (Australian Resuscitation Council [ARC] 2006).
Effective BLS techniques rely on rapid assessment of the situation and initiating procedures that facilitate and maintain an adequate supply of oxygenated blood to the brain before irreversible damage occurs.
The level of consciousness is determined by the use of verbal and tactile stimuli. These stimuli should never reach a level that causes or aggravates injury, and infants and small children should never be shaken. The shoulders should be firmly grasped and squeezed to elicit a response. Verbal stimuli should also be used. If conscious, the person will respond. Allow the person to adopt a comfortable position and observe them closely for any changes in condition.
If there is no response to the stimuli, the person is unconscious and should be turned on their side. Help should be summoned. Anyone who fails to respond to touch or the spoken word is considered to be unconscious, and more vigorous efforts to obtain a response (such as painful stimuli) are not warranted.
The key to successful resuscitation is a clear airway. When an unconscious person is lying on their back, the lower jaw tends to drop, which causes the tongue to fall to the back of the pharynx and occlude the airway. The problem is compounded by relaxation of soft palate tissues and the epiglottis. In addition, an unconscious person is unable to swallow or cough, and any foreign material in the mouth or pharynx can contribute to obstruction of the airway. Simply turning the person on his or her side, and supporting the jaw, can often prevent death. This often relieves the obstruction, and gravity assists any foreign material to drain from the mouth. Visible material or debris that could be blocking the airway can be actively removed by sweeping a gloved index finger around the mouth.
Airway assessment and management can take place with the person lying on his or her side or back. In many instances, lying on the side is preferable for the reasons stated above. However, because many cardiac arrests result from ventricular fibrillation, it might be appropriate to manage a person on their back to facilitate early defibrillation when a defibrillator is immediately available.
If breathing is abnormal or absent, turn the person on their back and perform rescue breathing by giving two initial breaths, observing for the rise and fall of the chest. If the chest does not rise and/or rescue breathing is not effective:
Note: Distension of the stomach with air occurs if the breaths delivered are too hard or are delivered when the airway is partially obstructed. This can precipitate regurgitation and vomiting and can further compromise the airway.
As the pulse check is no longer used to identify the need for chest compressions, CPR — rescue breathing and chest compressions — is given to all victims requiring resuscitation, that is, victims not displaying signs of life (ARC 2006):
The end result is that the heel of one hand is lying on the long axis of the lower half of the sternum. The other hand is used to provide additional force, so that all pressure is exerted through the heel of the bottom hand.
Correctly performed, CPR can re-establish cardiac function, or at least maintain an artificial circulation sufficient to preserve neurological function until personnel trained in ALS arrive at the scene.
When the heart stops beating, circulation of the blood stops. Performing external cardiac compressions (ECC) provides an artificial pumping mechanism, which when carried out effectively, distributes blood around the body. Figures 48.7 and 48.8 show the correct location of ECC on an adult and child. ECC provides an artificial blood circulation by exerting rhythmic pressure at regular intervals (Figure 48.9) compressing the heart between the sternum and the spinal column.
Cardiopulmonary resuscitation (CPR) is the technique of rescue breathing with external cardiac compressions. As the pulse check is not used to identify the need for chest compressions, CPR — rescue breathing and ECC — are given to all casualties displaying no signs of life: unconscious, unresponsive, not breathing normally, not moving.
Every emergency situation must be assessed, and appropriate measures taken in the sequence most logical for that particular situation. A variety of factors influences the actions taken and the order in which they are taken; for example, the presence of life-threatening circumstances, the availability of assistance, the location where the emergency occurs and the availability of transport. Clinical Interest Box 48.4 outlines the emergency response steps. The general principles of emergency care are: