Chapter 48 EMERGENCY CARE

KEY TERMS/CONCEPTS

bystander

cardiopulmonary resuscitation (CPR)

danger, response, airway, breathing, compression, defibrillation (DRABCD)

external cardiac compressions (ECC)

primary and secondary survey

rescue breathing

CHAPTER FOCUS

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.

LIVED EXPERIENCE

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 …

Karen Lawrence, RN

INTRODUCTION

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.

This chapter addresses some emergencies and the basic care that needs to be provided. For more detailed information, the nurse is advised to consult a current first aid text.

RECOGNISING AN EMERGENCY

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.

UNUSUAL SMELLS

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.

RESPONDING TO AN EMERGENCY

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.

BARRIERS TO ACTION

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:

• Presence of bystanders

• Uncertainty about the casualty

• Nature of the illness or injury

• Fear of disease transmission

• Fear of doing something wrong.

See Clinical Interest Box 48.1. However, the worst thing to do is nothing!

CLINICAL INTEREST BOX 48.1 Barriers to responding to an emergency

Presence of bystanders^

• Can cause confusion

• May cause you to feel reluctant to offer assistance

• Can endanger themselves and the casualty

^* There are also positive aspects to the presence of bystanders: for example, you can ask them to call an ambulance, send them for blankets or other supplies, and they can meet and direct the ambulance to the scene, keep the area free of unnecessary traffic and help you to give care.

PRIORITIES OF ACTION IN AN EMERGENCY

The following four emergency action principles (Australian Red Cross 1998) should guide the nurse’s actions in an emergency:

1. Survey the scene

2. Do a primary survey and check for life-threatening problems

3. Call emergency help

4. Do a secondary survey when appropriate, and care for additional problems.

Implementing these principles (Figure 48.1) provides safety for you and for others and ensures that critical care is given to those who need it.

Figure 48.1 Emergency action plan

(adapted from Australian Red Cross, First Aid, 1998)

Survey the scene

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.

Figure 48.2 Basic life support flow chart

(adapted from Australian Red Cross, First Aid, 1998)

Call emergency personnel

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

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.

Advanced life support (ALS) techniques include a range of therapeutic and technological interventions carried out by trained health personnel. These are not discussed here.

Basic life support

If a person collapses, the rescuer must assess the situation quickly, ensure the safety of the rescuer, casualty and bystanders, call for help, and start basic life support (BLS).

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 priorities of BLS are:

• Airway

• Breathing

• Compression.

Airway

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 management

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.

The steps involved in airway management include:

• Clear the airway: remove loose-fitting dentures and any visible foreign material from the mouth. Allow fluids or vomitus to drain by turning the face slightly downwards

• Open the airway: tilt the head backwards and support the jaw. The head is tilted backwards by placing one hand on the forehead and supporting the jaw at the point of the chin in such a way that there is no pressure on the soft tissues of the neck. This brings the jaw and tongue forwards, thus opening the airway. If it is suspected that the person has injured their neck or back, the head should not be moved; the jaw-thrust method to open the airway should be used (see next point)

• Jaw thrust: pressure is applied behind the angle of the jaw to thrust it forwards.

Breathing

Once the airway is open, the unconscious person’s breathing should be checked. With an ear placed over the person’s nose and mouth:

• look for movement of the chest and abdomen

• listen for the passage of air into and out of the mouth and nose

• feel for the escape of exhaled air on your face.

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:

• Check the head-tilt and jaw-support technique to prevent an air leak

• Ensure that the breaths delivered are full inflations, approximately 1 second per inspiration.

If no signs of life, commence CPR.

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.

Methods of rescue breathing include mouth-to-mouth respiration, mouth-to-nose respiration, mouth-to-stoma respiration and mouth-to-mask respiration.

Compression

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):

• Ensure the person is on a firm flat surface

• Begin external cardiac compression (ECC) by locating the middle of the lower half of the sternum; the rescuer should visualise the ‘centre of the chest’ and compress at that point (ARC 2006)

— place heel of hand on the lower half of the sternum, and place heel of other hand on top of the first.

— interlock fingers of both hands and raise fingers

— do not apply pressure over the ribs, upper abdomen or bottom half of the sternum.

Position yourself vertically above the casualty’s chest, and with straight arms, press down on the sternum (St John Ambulance 2007).

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.

Depth and rate of compression

The sternum should be compressed 4–5 cm (1–2 inches) with each compression. The rate of compression is approximately 100 times per minute. During ECC, the heel of the hand remains on the sternum.

Ratio of compressions to inflations

The compression/ventilation ratio is 2 breaths to 30 compressions (30:2), and this ratio applies regardless of the number of rescuers.

CPR is continued until the casualty shows signs of life (breathing, moving or responding), or until appropriate assistance arrives (ARC 2006).

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.

BLS for infants and children

BLS for infants (age < 1 year) and children (1–8 years) is essentially the same as for adults, with the following exceptions:

Airway

• Avoid over-extension of the head and neck when opening the airway, especially with infants

Breathing

• Infants: Obtain a firm seal over the mouth and nose and deliver a volume that is less than for a child but enough to ensure that the chest rises. Give 2 initial breaths, listen and feel for signs of air being expelled. Repeat sequence of 2 breaths. If no signs of life, commence CPR.

• Children: As for adults, maintain head tilt and chin lift, give 2 breaths, listen and feel for signs of air being expelled. Repeat sequence of 2 breaths. If no signs of life, commence CPR. (St John Ambulance 2007)

Compression

• Infants: Using two fingers, compress the sternum below the mid-point. Depth of compression is about one-third of the depth of the chest, at a rate of 100/minute

• Children: For children aged 1–8 years, use the heel of one hand to compress the sternum below the mid-point. For children older than 8 years, perform compressions as for adults. For children 1 year and older the depth of compression is about one-third the depth of the chest, at a rate of 100/minute.

Cardiopulmonary resuscitation management steps

Andrea Marshall (This is an edited version of the ARC Guidelines March 2008. For full details please visit the ARC website at www.resus.org.au/)’

EXTERNAL CARDIAC COMPRESSIONS

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.

Figure 48.7 Location of ECC point in an adult. Proper hand position for CPR

A: Finding the rib cage

B: Moving fingers along the rib cage to the notch

C: Placing the heel of the hand next to the index finger

Figure 48.8 Location of ECC point in a child. Locating hand position for infant chest compressions

A: Drawing an imaginary line between the nipples

B: Placing 2 fingers on the sternum about 1 finger-width below the imaginary line

Figure 48.9 Compressing the heart

CARDIOPULMONARY RESUSCITATION

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.

CPR consists of 30 compressions, followed by 2 ventilations (ratio of 30:2).

Interruptions to compressions should be avoided, however compressions must be paused to allow for ventilation (ARC 2006).

PRINCIPLES OF EMERGENCY CARE

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:

• Check whether there is danger to self, the casualty or any bystanders. Proceed only if it is safe to do so

• Remain calm, as calmness and efficiency will help the casualty to feel more secure

• Assess the situation quickly and decide the order of priorities. Perform lifesaving actions first

• Remove the cause of the emergency or, if this is not practicable, remove the casualty from the cause

• Assess the casualty. Assessment is made of the individual’s conscious state, airway, breathing and circulation

• Begin to manage the situation according to priorities decided on as a result of assessment

• Provide emotional support for a conscious casualty

• Keep the casualty lying down or in the position in which you found them, as any injury could be exacerbated if moved. Exceptions to this principle are when the casualty is unconscious and must be positioned to maintain a clear airway, or when resuscitation measures must be implemented

• Seek assistance from any helpers who are available

• Arrange for medical aid. Ask a bystander to telephone for an ambulance. Information provided to the ambulance service should include your location, the number of casualties and the nature of the emergency

• Maintain the casualty’s normal body temperature. Use coats or knitwear if a rug is not available

• Prevent bystanders from giving the casualty any food or fluids, as the ingestion of substances may cause harm or delay any surgical intervention that may be required

• Remain with the casualty and continue to provide physical and emotional care until medical assistance arrives

• Provide emergency personnel with information regarding your assessment of the casualty, and any care provided.

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