(part-ii)first aid and emergency care professor dr anil ohri

(PART-II)First Aid and Emergency

CareProfessor Dr Anil Ohri

Learning Objectives

Chocking Fainting Heart attack. Haemorrhage. Shock. Fractures

CHOCKING-I

Foreign object lodged in the throat or windpipe, blocking the flow of air. In adults piece o fFood. Young children -swallow small objects.

Effects: cuts off oxygen to the brain First Aid: Quick. Sign:Hands clutched to the throat

Inability to talk

Difficulty breathing or noisy breathing

Inability to cough forcefully

Skin, lips and nails turning blue or dusky

Loss of consciousness

CHOCKING Contd: Red Cross recommends a "five-and-

five“ : Give 5 back blows. First, deliver five back blows

between the person's shoulder blades with the heel of

your hand. Give 5 abdominal thrusts. Perform five abdominal

thrusts (also known as the Heimlich maneuver). Alternate between 5 blows and 5 thrusts until the

blockage is dislodged.

CHOCKING –For Unconscoius Person Lower the person on his or her back onto the floor.

Clear the airway. Be careful not to push the food or object deeper into the airway, which can happen easily in young children.

Begin cardiopulmonary resuscitation (CPR) object remains lodged and the person doesn't respond after. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically.

CHOCKING-Child Less Than One Year Assume a seated position and hold the infant

facedown on your forearm, which is resting on your thigh.

Thump the infant gently but firmly five times on the middle of the back using the heel of your hand. The combination of gravity and the back blows should release the blocking object.

Hold the infant faceup on your forearm with the head lower than the trunk if the above doesn't work. Using two fingers placed at the center of the infant's breastbone, give five quick chest compressions.

Repeat the back blows and chest thrusts if breathing doesn't resume. Call for emergency medical help.

Begin infant CPR if one of these techniques opens the airway but the infant doesn't resume breathing.

FAINTING-

Fainting -Blood supply to the brain is momentarily inadequate, causing you to lose consciousness(Brief),

No medical significance. But Investigate to rule out Any An emergency.

FAINTING-Contd Lie down or sit down. Place your head between your knees If someone else faints Position the person on his or her back. person is

breathing, raising the person's legs above heart level — about 12 inches (30 centimeters) Loosen belts, collars or other constrictive clothing

Check the person's airway to be sure it's clear. Watch for vomiting.

Check for signs of circulation (breathing, coughing

or movement). If absent, begin CPR.

Cardiac Emergency - Heart Attack

Clinical Manifestations

Chest pain my have radiation of pain to back, jaw, or left arm. Palpitation. Dyspnea. Diaphoresis. Dizziness.

Clinical Manifestations

Weakness. Elevated BP and HR.

later, BP may drop. Nausea and vomiting cool and clammy skin (cold sweats). Fever.


Rapid Assessment1. Is the patient’s airway patent? a. The airway is patent when speech is clear and no noise is associated with breathing. b. If the airway is not patent, consider cleaning the mouth and placing an airway.

2. Is the patient's breathing effective? a. Breathing effective.....the skin color normal, capillary refill is < 2 second. b. If breathing is not effective, consider O2 administration.


Rapid Assessment Cont.

1. Is the patient’s circulation effective? a. Circulation is effective when the radial pulse is present and the skin is warm and dry.

b. If circulation is not effective, consider:- Placing the patient in the recumbent position. Establish IV access. Giving a 2oo ml fluid bolus.


Initial assessment and intervention1. Ask the patient to undress, remove all jewellery, put on

gown.

1. Get vital signs include pulse oximetry, or test capillary refill.

a. Institute continuous heart monitoring, and non invasive blood pressure monitoring.

b. Document the initial heart monitor strip and document changes of rhythm.


Initial assessment and intervention Cont.3. Place on oxygen at 4 litres by nasal cannula.

4. Assure the patient that he is safe.

5. Perform a focused physical examination a. Auscultate the lung. b. Listen to heart sound. c. Inspect for peripheral oedema.

6. Evaluate the level of consciousness to use as a baseline.


Initial assessment and intervention Cont.6. Establish intravenous access, hang normal saline and

draw laboratory blood specimens.

7. Initiate any medications covered under nurse or paramedic initiated hospital protocol.

8. Initiate any diagnostic test e.g., ECG, laboratory studies, chest x- ray.

9. Instruct the patient not to eat or drink .


Initial assessment and intervention Cont.10. Elevate the side rails and place the stretcher in the lowest position.11. Inform the patient, family, and caregivers of the usual plan of care .12. Ask the patient to call for help before getting of the stretcher.


Ongoing evaluation and intervention10. Monitor vital signs an effective breathing.

11. Monitor therapy closely for the patient's therapeutic response ( effect within 20 – 30 minutes).

12. Monitor closely for the development of adverse reaction to therapy.

13. Monitor the patient's laboratory and x-ray results and notify the physician.

Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) is a

lifesaving technique useful in many emergencies,

Situations:Heart attack or Near drowning, Done When: someone's breathing or heartbeat has stopped. AHA-

recommends that everyone — untrained bystanders and medical personnel alike — begin CPR with chest compressions.

Better to do something than nothing Remember, the difference between your doing something and doing nothing could be someone's life.

Cardiopulmonary resuscitation

If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR.

Remember to spell C-A-B The AHA uses the acronym of CAB —

compressions, airway, breathing — to help people remember the order to perform the steps of CPR.

Cardiopulmonary resuscitation CPR Before starting CPR, check: Is the person conscious or unconscious?

If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?"

NO response and two people are available, one call the local emergency number and one should begin CPR.

Alone and have access to phone, call before beginning

CPR — unless you think the person has become unresponsive because of suffocation (such as from drowning). In this special case, begin CPR for one minute and then call local emergency number.

Cardiopulmonary resuscitation (CPR) Advice By AHA: Untrained. Provide hands-only CPR. i.e uninterrupted chest

compressions of about 100 a minute until paramedics arrive (described

in more detail below). You don't need to try rescue breathing. Trained and ready to go. 30 chest compressions before

checking the airway and giving rescue breaths.

Trained but rusty. If you've previously received CPR training but you're not confident in your abilities, then just do chest compressions at a rate of about 100 a minute. (Details described below.)

IMPORTANCE OF LEARNING CPR

Advice applies to adults, children and infants needing CPR, but not newborns.

CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart

rhythm. When the heart stops, the lack of oxygenated

blood can cause brain damage in only a few minutes. A person may die within eight to 10 minutes.

CPR-HOW TO LEARN Take an accredited first-aid training

course, CPR and to use an automated external defibrillator (AED).

Before you begin Remember to spell C-A-B The American Heart Association uses the

acronym of CAB — compressions, airway, breathing — to help people remember the order to perform the steps of CPR.

Cardiopulmonary resuscitation (CPR) Contd-I Compressions: Restore blood circulation

Put the person on a firm surface. Kneel next to the person's neck and shoulders. Place the heel of one hand over the center of the person's chest,

between the nipples. Use your upper body weight the chest at least 2 inches (approximately 5

centimeters). Push hard at a rate of about 100 compressions a minute. If you haven't been trained in CPR, continue chest compressions until

signs of movement or until emergency medical personnel take over& Go on to checking the airway and rescue breathing.

Cardiopulmonary resuscitation (CPR) Contd-I Airway: Clear the airway

A-trained in CPR perform 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.

Check breathing in five or 10 seconds. Look for chest motion, listen for normal breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not

considered to be normal breathing.

Cardiopulmonary resuscitation (CPR) Contd-II Trained: No Normal breathing normally and you are

trained in CPR, begin mouth-to-mouth breathing. Untrained: person is unconscious from a heart attack,

skip mouth-to-mouth breathing and continue chest compressions.

Breathing: Breathe for the person Rescue breathing can be mouth-to-mouth breathing or

mouth-to-nose breathing if the mouth is seriously injured or can't be opened.

Cardiopulmonary resuscitation (CPR) Contd-III With the airway open (using the head-tilt, chin-lift

maneuver), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.

30:2 considered one cycle. Resume chest compressions to restore circulation.

Cardiopulmonary resuscitation (CPR) Contd-Iv If the person has not begun moving after five cycles (about

two minutes) and an automated external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR — starting with chest compressions

— for two more minutes before administering a second shock. Untrained In AED:Other emergency medical operator may be

able to guide you in its use. If an AED isn't available, go to step 5 below.

Continue CPR until there are signs of movement or emergency

medical personnel take over.

Cardiopulmonary resuscitation (CPR) Contd-V To perform CPR on a child The procedure for giving CPR to a child age 1 through 8 is

essentially the same as that for an adult. Differences are as follows:

If you're alone, perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling your local emergency number or using an AED.

Use only one hand to perform chest compressions. Breathe more gently.

Cardiopulmonary resuscitation (CPR) Contd-VI Use the same compression-breath rate as is used for

adults:One Cycle-30:2 Five cycles (about two minutes) of CPR, if there is no

response and an AED is available, apply it and follow the prompts. Use pediatric pads if available, for children ages 1 through 8. If pediatric pads aren't available, use adult pads. Do not use an AED for children younger than age 1. Administer one shock, then resume CPR — starting with chest compressions — for two more minutes before administering a second shock.

Continue until the child moves or help arrives

Cardiopulmonary resuscitation (CPR) Contd-VII To perform CPR on a baby Cardiac arrests in babies occur from lack of oxygen,

such as from drowning or choking. If you know the baby has an airway obstruction, perform first aid for choking. If you don't know why the baby isn't breathing, perform CPR.

To begin, examine the situation. Stroke the baby and watch for a response, such as movement, but don't shake the baby.

Cardiopulmonary resuscitation (CPR) Contd-VIII If there's no response, follow the CAB procedures below

and time the call for help as follows: If you're the only rescuer and CPR is needed, do CPR

for two minutes — about five cycles — before calling your local emergency number.

If another person is available, have that person call for help immediately while you attend to the baby.

Cardiopulmonary resuscitation (CPR) Contd-IX Compressions: Restore blood circulation Place the baby on his or her back on a firm, flat surface,

such as a table. The floor or ground also will do. Imagine a horizontal line drawn between the baby's

nipples. Place two fingers of one hand just below this line, in the center of the chest.

Gently compress the chest about 1.5 inches (about 4 centimeters).

Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of 100 compressions a minute.

Cardiopulmonary resuscitation (CPR) Contd-X Airway: Clear the airway After 30 compressions, gently tip the head back by lifting

the chin with one hand and pushing down on the forehead with the other hand.

In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.

Cardiopulmonary resuscitation (CPR) Contd-X Breathing: Breathe for the baby Cover the baby's mouth and nose with your mouth. Prepare to give two rescue breaths. Use the strength of

your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.

Cardiopulmonary resuscitation (CPR) Contd-XI If the baby's chest still doesn't rise, examine the mouth to make

sure no foreign material is inside. If an object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking baby.

Give30:2. Perform CPR for about two minutes before calling for help unless

someone else can make the call while you attend to the baby. Continue CPR until you see signs of life or until medical

personnel arrive.

Respiratory Emergency – Pulmonary Embolus

DefinitionIs an embolus that causes obstruction of arterial

pulmonary blood flow to the distal lung.

Causes Trauma to the lower extremities or pelvis, long

term fractures Immobility but is seen occasionally with obesity. Decreased peripheral circulation. Congestive heart failure & MI.


How to assess pulmonary embolusIt can be assessed through the signs and symptoms:

signs and symptoms signs and symptomsShortness of breathTachypneaTachycardiaSudden- onset pleuritic chest pain increase with respirations.Cough, haemoptysis

Diaphoresis, syncope, fever.If the embolus occludes a large vessel symptoms :Anxiety, hypotension, and signs of right ventricular failure.


Diagnostic Test Arterial blood gas value and lung scan. Computed tomography angiography. Decreased O2 pressure and decreased pCO2. Chest radiography. ECG


Management O2 administration, from low- flow oxygen by nasal cannula to intubation. Analgesic IV if the pt. Extremely uncomfortable. IV fluids and vasopressors to maintain pressure. IV anticoagulants to prevent farther clot formation. Fibrinolytic therapy should be started immediately in the unstable pt.

Respiratory Emergency – Pulmonary Oedema

Description Acute pulmonary oedema is a result of an acute

event.

Cardiogenic PE is caused by inadequate pumping of the left ventricle.

Noncardiogenic PE or adult respiratory distress syndrome is a result of damage to the alveolar – capillary membrane.


Assessment Assess signs and symptomsCardiovascular symptoms Respiratory symptoms

Lower extremity pitting oedema.Weight gain.Rapid, bounding pulse.Skin is cool, moist and may appear cyanotic.Blood pressure initially increases.

Dyspnea, respiratory rate increases in an effort.Productive cough with frothy, white sputum. or a pink ting.Cyanosis Oxygen saturation decreases as hypoxia increased.Wheezing.


Diagnosis Chest x- ray.

Management Administration of high- flow oxygen. Bronchodilators inhalation . Digoxin IV to increase contractility ( heart rate increased lead to decreased filling and

contractility). Diuretic therapy


Management Cont.

Nitroglycerin to increase venous distension and venous pooling, which decrease blood return to the heart.

Urinary catheter to monitor urine output. IV morphine.

Haemorrhage

DefinitionIt refers to a large amount of bleeding in a short

time. Type of external bleeding A –Arterial A –Arterial Bleeding B-Venous Bleeding C- Capillary Bleeding D- Melaena

HaemorrhageType of external bleeding Cont.

E-Hematemesis

F-Epistaxis

G-Hemoptysis

H-Rectal Bleeding

I- Vaginal bleeding

HaemorrhageRapid ABC AssessmentAs Cardiac emergency .

Initial Assessment and interventions Get vital signs and place on continuous heart and

automatic blood pressure monitoring.

Establish IV access with two large bore cannula. Draw a variety of tubes ( haematology,

chemistry, coagulation study, PTT

Haemorrhage

Initial Assessment and interventions Assure the patient that he is safe. Perform a focused physical examination: Auscultate the lungs. Assess for signs of anaemia by noting the color of

the conjunctiva, nail beds and capillary refill in the palm of the hand.

HaemorrhageInitial Assessment and interventions Cont. Evaluate the level of consciousness by AVPU:- A. alert V. Responds to voice but not fully orient. P. Responds to pain. U. Unresponsive.

For pt. With GIT bleeding: Inspect the abdomen for injury and scars post surgery. Look for Cullen’s sign ( periumbilical bruising) and

distention

HaemorrhageInitial Assessment and interventions Cont. For pt. With GIT bleeding: Auscultate abdominal bowel sounds, Percuss, palpate.

For pt. With vaginal bleeding: Inspect perineum for lacerations. Estimate vaginal blood flow.

Consider placing drains e.g., nasogastric tube to reduce risk of vomiting., urinary catheter to monitor urinary output.

Instruct the patient to be NPO.

HaemorrhageControl of External bleedingFor haemorrhage of the extremities.

Elevate the extremities as high as possible above the heart level and compress the area.

With elevation of the extremity maintained , a compression bandage will control the bleeding.

HaemorrhageControl of Internal bleeding Venous access with two large bore ( 18 to 14)

cannula or a central venous catheter.

Continuous monitoring of the heart, blood pressure, pulse oximetry, and hourly urine output.

Fluid resuscitation with isotonic IV solution ( normal saline), albumin, fresh plasma, in

patients with coagulopathy, PRBC to maintain a hematocrit of 25 to 30.

HaemorrhageControl of Internal bleeding Cont. Administer vitamin K 10 mg SC or IM for patient with

coagulopathy.

Administration of drug therapy specific to problem.

Exploratory emergency surgery for uncontrolled or prolonged bleeding.

For upper GIT bleeding gastric lavage with normal saline to remove blood clots beside endoscopy for diagnosis.

HaemorrhagePenetrating wound of the abdomen Start with initial assessment and intervention.

Testing of urine, stool, and gastric content for blood.

CT for suspicion of solid organ lacerations.

IVP for suspected disruption of the kidney, ureter, bladder, or urethra.

Ultrasound visualizes the configuration of organs and hematoma.

HaemorrhagePenetrating wound of the abdomen Start venous access with two large bore cannula & IV

fluids of normal saline and blood products.

Give oxygen via mask.

Insert an indwelling urinary catheter ( do not insert if injury is suspected to the urethra.

Insert a nasogastric tube to reduce the risk of aspiration..

HaemorrhagePenetrating wound of the abdomen Perform dressing of wounds, and stabilization of

impaled objects.

Keep the patient NPO.

Give prophylactic antibiotics.

Prepare the patient for possible surgery and hospital admission or transfer.

ShockShock is a fatal condition that occurs when cells become

hypoxic as a result of decreased perfusion.

Causes of shock1. Hypovolaemic shock Massive external bleeding. Hemothorax, fractures, GIT bleeding, burn. Massive vomiting & diarrhea. Excessive diuretic use.

ShockCauses of shock Cont. 2. Cardiogenic shock MI, cardiomyopathy, dysrhythmias, heart valve d.

3. Distributive shock Sepsis, anaphylaxis, spinal cord injury, overdose.

4. Obstructive shock Pneumothorax, pericardial tamponade, aortic

aneurysm, pulmonary embolus, valvular diseases

ShockClinical manifestations1. Respiratory Elevation of respiratory rate, rhythm, and depth. Tachypnea, wheezes. breath sounds may be absent, unequal, or diminished.

2. Circulatory Weak thready pulses, drop in systolic pressure. Flattened jugular vein when the patient is supine. Cardiac dysrhythmias & presence of S3 or S4 Restlessness, anxiety, or confusion, unresponsive patient.

ShockClinical manifestations3. Nonessential Organs Skin: Cool skin, pallor, cyanosis and diaphoresis. Capillary refill take more than two second.

Kidney: Urine output is decreased. BUN and creatinine increased.

GIT : Hypoactive or absent bowel sounds.

ShockInitial Stabilization and ManagementGoal:Manage inadequate tissue perfusion. Supplemental oxygen at 100% should be provided.

Endotracheal intubation and mechanical ventilation anticipated.

Peripheral and central venous assess should maintained.

Shock

Administration of IV fluids and blood as appropriate .

Warmed IV fluids are preferable to avoid hypothermia.

Acid – Base Balance Administration of sodium bicarbonate to correct

metabolic acidosis documented by measurement of ABG.

Shock

Hemodynamic Monitoring Pulse oximetry and non-invasive blood pressure

monitor. Central venous pressure (CVP) to measure

circulating volume ( 4 to 10 cm H2O). Arterial pressure may be measured invasively

using an arterial line . Normal between 70 and 90.

(A pressure less than 70 indicates inadequate circulating volume)

FracturesDefinition

A fracture consists of a break or crack in the bone.

Signs and Symptoms Deformity. Pain. Tenderness. Swelling. Crepitus. Bony fragment protrusion Impaired neurovascular status and may be shock.

FracturesManagement1. Expose the areaRemove all clothing and jewellery near the suspected

fracture.

2. Perform a physical assessment Inspect for color, position and obvious differences as

compared to the uninjured side. Look for break in the skin. Assess for bleeding and deformity. Assess the extremity for pain, pallor, pulses, paresthesia, and paralysis

FracturesManagement Cont.3. ImmobilizeSplint with the appropriate splint to immobilize the joints

below and above the injury.

4. PRICE P....... Protect R....... Rest I......... Ice C........ Compress E......... Elevate

FracturesManagement Cont.Use heated blankets on the rest of the body to maintain

normal body temperature. 5. Medications Administer analgesics. Open fractures are often treated with prophylactic

intravenous antibiotics.

6. Diagnostic Testing X- ray

FracturesManagement Cont. 6. On- going monitorsFrequently reassess the five Ps: Pain. Pallor. Pulses. Paresthesia. Paralysis

FracturesManagement Cont.

7. AnticipateAnticipate definitive stabilization, cast,

traction, internal or external, fixation, and hospitalization for closed or open reduction.

Thank You

(part-ii)first aid and emergency care professor dr anil ohri

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