Personal Safety

The safety of the care environment should always be a primary consideration. Having adequate police, security, or additional personnel to ensure that the environment is safe for the health care providers is paramount. Although this is especially true in the prehospital care environment, it must also be thought about in the hospital.

As you approach the apparent patient, always perform a brief evaluation to determine whether you are in a safe environment; if not, protect yourself and your patient to limit exposure to possible injury. Assess environmental hazards; the potential of agitation from a delirious patient, causing aggressive action; and other personnel hazards such as family members and bystanders.

While uncommon, if the situation exists in which it is likely that the rescuer(s) could be injured or killed while rendering care, the rescuer should wait until the situation can be made safe. For example, in an automobile accident, a patient trapped in a car in a busy traffic lane should not be given first aid until safety flares or cones can be placed to prevent secondary accidents. Other hazards, such as downed power lines, should be investigated as well.

When providing care in the field, is also important to assess the situation to determine what further resources may be needed to ideally care for the patient(s). Identifying the situation of the patient at the scene may help determine the mechanisms of injury to assist in the diagnostic workup and in treatment for the patient.

The initial task for the health care provider in approaching most, if not all, patients in acute situations involving an unconscious patient is to first ascertain that they are not in cardiopulmonary arrest. If so, summoning help and performing cardiopulmonary resuscitation (CPR) are the initial priorities. If the patient is not in need of CPR, immediate identification of the causes of their non-responsiveness should be initiated through an organized two-step approach to the rapid patient assessment, which includes a primary survey and secondary survey. This organized approach helps to lend a prioritization to the approach to ensure the major threats to life are identified first. The acceptable approach to these acute, undefined encounters is to consider the patient unstable until you can confirm, through a series of diagnostic steps, that the patient is well enough for you to take the time to perform a more rigorous and complete physical examination and document a complete history.

Current Cardiopulmonary Resuscitation Guidelines

For the unconscious patients who are determined to be in cardiac arrest, the health care provider should initiate cardiopulmonary resuscitation according to the guidelines set by the American Heart Association (AHA).

Chest compressions provide blood flow to the heart and brain during a cardiac arrest, and research has shown that delays or interruptions to compressions reduced survival rates. Ventilations are less critical, as victims will have oxygen remaining in their lungs and bloodstream for the first few minutes after a cardiac arrest. Starting CPR with chest compressions can effectively circulate blood to the victim’s brain and heart sooner, with the principal goal of maintaining some amount of oxygenated blood circulating through the brain.

In the original A-B-C sequence, chest compressions were often delayed while the responder opened the airway to give mouth-to-mouth breaths or retrieved a barrier device or other ventilation equipment. By changing the sequence to C-A-B, chest compressions can be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions (30 compressions should be accomplished in approximately 18 seconds).

The assessment of the acutely ill patient involves moving through a series of simple evaluations, which are grouped into two categories termed the primary and secondary surveys. The primary survey is a check for conditions that are an immediate threat to the patient’s life. This initial assessment should take no longer than 10 to 15 seconds. The primary survey is subdivided into a cardiopulmonary resuscitation (CPR) survey and a key vital functions assessment. The secondary survey is a check for conditions that could become life-threatening problems if not recognized and attended to.

The primary and secondary surveys are used for both adult and pediatric patients, as well as for medical and injury-related problems. The treatment process is integrated into the diagnostic process. For example, if the patient is not breathing, ventilations are begun immediately, before you move on to the next diagnostic step.

Remember that an acutely ill patient is anxious and frightened; a calm and reassuring voice can go a long way toward comforting the patient. It is always easier to care for a relaxed patient than for an anxious one.