The Acutely Ill or Injured Patient

Personal Safety

No discussion of caring for the acutely ill and injured would be complete without a reminder to health care providers to look out for their own personal safety and wellness as an initial priority. Protection of oneself from pathogen exposure as well as trauma or additional injury is of paramount importance.

In caring for an acutely ill patient there are high risks for exposure to body fluids and exposure to communicable diseases. When caring for the patient with an altered mental status, the initial responder needs to take precautions in case the patient becomes aggressive or violent. In the case of the injured patient, the initial care provider needs to ensure that the scene is safe to begin to care for the patient to avoid harm to the care provider.

Standard precautions should always be taken to minimize the possibility for contamination and exposure. The potential for concern should be evaluated to determine the appropriate level of precautions needed. Wearing protective gloves is certainly considered a minimum step, but as the potential for contamination escalates, consideration should be given to masks with eye shields, protective gowns, respiratory masks, and so on, which are appropriate for the situation.

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 before providing care. 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. In an active shooter situation, care of the injured cannot begin until the scene has been appropriately secured by police personnel.

Approach to the Unconscious 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 nonresponsiveness should be initiated through an organized two-step approach to the rapid patient assessment, which includes a primary survey and secondary survey . When caring for the acutely ill out of the traditional care environment, particular attention should be paid to the primary survey. This organized approach helps ensure that 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 patient who is determined to be in cardiac arrest, the health care provider should initiate CPR according to the guidelines set by the American Heart Association (AHA). Cardiac arrest survival is directly related to how fast high-quality chest compressions (CPR) are started, along with defibrillation by an automatic external defibrillator (AED) as early as possible.

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. Additional research demonstrates increased survival from cardiac arrest correlating with the onset of defibrillation, if appropriate. 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.

Initiating ventilations are less critical, as victims will have oxygen remaining in their lungs and bloodstream for the first few minutes after a cardiac arrest.

Fig. 26.1 shows the AHA CPR overview for adults. Fig. 26.2 shows the AHA CPR overview for children.

Current guidelines of the AHA make recommendations based on if the lay rescuer is trained in CPR or not. According to the 2015 AHA Guidelines, ¹

1 https://www.sca-aware.org/sites/default/files/comparison_chart_2015_aha_guidelines_for_cpr_and_ecc.pdf . Accessed February 25, 2019.

the sole lay rescuer trained in CPR should do four basic things:

• Ensure Scene Safety

• Call for Help

• Start and Continue Compression-Only CPR

• Send second person to find an AED

On the other hand, when a patient is in cardiac arrest and there are two or more rescuers who are trained in CPR (and/or working in the health care environment), add rescue breathing and aggressive use of an AED via a second rescuer/team of rescuers in this sequence:

• Ensure Scene Safety

• Call for Help/Activate Resuscitation Team

• Apply AED as soon as available

• Start 2 Rescuer CPR using a ratio of 30 Chest Compressions to Two Rescue Breaths

In the early days of CPR, an original A-B-C (airway, breathing, circulation) sequence was taught. However, it was later realized that survival rates improved with early chest compressions. 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. Since 2010, the AHA Guidelines have recommended an overall change in the mnemonic to C-A-B . By changing the sequence to C-A-B, chest compressions can be initiated sooner, and ventilation delayed only minimally until completion of the first cycle of chest compressions (30 compressions should be accomplished in approximately 18 seconds).

C-A-B

• C ompressions: Push hard and fast on the center of the victim's chest.

• A irway: Tilt the victim's head back and lift the chin to open the airway.

• B reathing: Give rescue breaths.

Cardiopulmonary Resuscitation Survey

Because of the time sensitivity associated with interrupted blood flow to the brain and vital organs, it is safest to suspect cardiac arrest in any patient who is not obviously interacting with his or her environment. Performing a quick rapid assessment can oftentimes easily rule out cardiac arrest.

As you approach the patient, observe the scene and surrounding for potentials hazards. Then observe the patient closely, looking for spontaneous breathing or movements. If these are not discernible, stimulate the patient by talking loudly to him or her and gently shaking them while asking, “Are you okay?”

If there is no response or evidence of spontaneous breathing, call for help in any way you can without leaving the patient; it is unlikely that you can manage the entire resuscitation by yourself. If another person is available, have them locate the nearest AED.

Determine whether there is spontaneous cardiac function by feeling for a carotid pulse for 10 seconds or, in an infant, by palpating the arm for a brachial artery impulse. If there is no pulse, begin external chest compressions, at least 100 per minute.

To open an unconscious victim's airway, hyperextend the head and lift the patient's chin; place one hand on the patient's forehead and the other behind the patient's occiput, and tilt his or her head backward. This maneuver moves the tongue away from the back of the throat, allowing air to pass around the tongue and into the trachea. Caution should be exercised with any patient who has a suspected neck injury such as someone in a serious car crash. With such a patient, try to open the airway by lifting the chin and jaw without tilting the head backward; grasp the lower teeth and pull the mandible forward. If necessary, tilt the head back very slightly. If a patient is wearing dentures, remove them only if they occlude the airway.

Summary of Cardiopulmonary Resuscitation Guidelines for Adults, Children, and Infants

Continue Sets of 30 Pushes and 2 Breaths

• Continue compressions and breaths—30 compressions, 2 breaths—until help arrives.

• CPR ratio for CPR is 30 compressions to 2 breaths.

• In two-person CPR, the rescuers should change positions after every 2 minutes to avoid fatigue and a deterioration in the chest compression quality.

• Attach and use AED as soon as available.

Fig. 26.3 is a summary of these key basic life support components for adults, children, and infants (excluding newborn infants).

There is continued emphasis on providing high-quality chest compressions. Remember to:

• Get an AED

• Push hard

• Push fast

Table 26.1 summarizes the components of high-quality chest compressions.

TABLE 26.1

Components of High-Quality Chest Compressions

Ensuring chest compressions of adequate rate

Ensuring chest compressions of adequate depth

Allowing full chest recoil between compressions

Minimizing interruptions in chest compressions

Avoiding excessive ventilation