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Emergency and Urgent Conditions Encountered in the Chiropractic Office Recognition, Care, Management and Referral Considerations, David Quist, EMT-B, D.C., DIBCN Outline Emergency preparedness Shock Cardiac
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Emergency and Urgent Conditions Encountered in the Chiropractic Office Recognition, Care, Management and Referral Considerations, David Quist, EMT-B, D.C., DIBCN Outline Emergency preparedness Shock Cardiac emergencies Respiratory emergencies Seizures Acute Abdomen Diabetic emergencies Environmental emergencies (Heat and cold) Stroke and hypertensive emergencies Head injuries Are you prepared for an emergency? You are required by OSHA standard to have first aid kit and a biohazard spill kit in your office. Does everyone know where it is and is it up to date? Have an emergency procedures section in your office policy manual You and your staff should be current in CPR and first aid. What are you going to do if There is sudden illness i.e. cardiac arrest, stroke etc. There is a fire in your office or building There is a tornado There is an earthquake There is a chemical spill Plan for emergencies before they happen Stay current Make plans Keep supplies up to date Have practice drills If you plan and prepare for an emergency things will go smoother, time will be saved and you will have better outcomes BODY SUBSTANCE ISOLATION Take BSI precautions prior to evaluating the victim. Non-Latex gloves Eye protection if there is a splatter hazard of bodily fluids - goggles Rescuer Wears Protective Eyewear Always use Protective Gear Diagnostic signs Pulse: Adult bpm Respirations: Adult breaths per minute Blood Pressure: Male, systolic 100 plus age up to 150 mm Hg. Diastolic 65 to 90 mm Hg Females are about 10 mm Hg lower in both systolic and diastolic Temperature Skin color and condition Capillary refill. normal is 2 seconds or less. Pupil size and reactivity to light. Level of Consciousness Ability to move Reaction to pain. SHOCK The insufficient supply of oxygen and other nutrients to some of the body s cells that results from inadequate circulation of blood AKA hypoperfusion Physiologic causes of shock Pump Failure Hypovolemia Lack of adequate air exchange Vessel failure Pump Failure Cardiogenic Shock a. Myocardial contusion b. Myocardial infarction C. Percardial tamponade Hypovolemia Hypovolemic shock A loss of fluids which causes shock is called hypovolemic shock. Examples would include fluid loss from burns, vomiting, diarrhea, etc. Hemorrhagic shock Shock associated with blood loss. Lack of adequate air exchange Respiratory insufficiency causes of shock 1. Airway obstruction 2. Open pneumothorax 3. Tension pneumothorax 4. Flail chest 5. Toxic gas inhalation Vessel Failure Leaking vascular system: results in lack of fluid volume Dilated vascular system: results in too much space and a relative hypovolemia a. Spinal shock b. Anaphylactic shock c. Septic shock d. Syncope Vasovagal response Pathophysiology of Hypovolemic Shock As blood volume decrease, the amount of blood returning to the heart decreases which decreases cardiac output.this results in lower BP. Baroreceptors in the aorta and great vessels detect this and signal the release of catecholamines (epinephrine and norepinephrine). Catecholamines cause: 1.Vasoconstriction in skin and muscles in order to raise perfusion pressure in the vital organs 2.Increased rate and strength of contraction of the heart to raise the blood pressure 3. Sweating (not helpful but an effect of catecholamines) Pathophysiology of hypovolemic shock continued The previous effects combine to maintain BP and perfusion until the fluid loss is replaced. If the loss continues, the perfusion pressure of the body will eventually become to low to maintain aerobic metabolism. At this point anaerobic metabolism begins.. by-products are lactic and pyruvic acids. As the tissues become more acidotic, there is eventual loss of response to catecholamines. This results in vasodilation and sudden pooling of blood, causing precipitous loss of blood pressure and often V fib.(acidotic, anoxic heart muscle) and death. Signs and Symptoms of Hypovolemic Shock Mental Status: Restlessness, anxiety (may be first sign), combative, or altered Peripheral perfusion : Pale, cool, clammy skin. Weak thready or absent peripheral pulses. Delayed Capillary refill. Vital signs: Increased pulse rate 100 (early sign) with a thready pulse. Increased breathing rate 24 that may be deep or shallow, labored and irregular. Decreased BP 100 systolic (late sign). Other signs and symptoms: Dilated pupils (sluggish), marked thirst, Nausea and vomiting, Pallor with cyanosis to lips Treatment for hypovolemic shock Call 911 Secure an airway, give oxygen if available (12-15 L/min by nonrebreather mask) Control bleeding Elevate legs ~ 12 inches (unless contraindicated) Keep patient warm (don t over heat) Keep patient supine (unless contraindicated) Handle gently Monitor vitals NPO (Nil Per Os) Nothing to eat or drink. Important Points When evaluating the Shock Victim 1. Young people often lose 30 percent of their blood volume before they get a drop in BP. Do not base your diagnosis of shock on hypotension. 2. It is easy to underestimate the severity of blood loss until it is too late. 3. Hypotension, tachycardia, and pallor indicates bleeding into the chest or abdomen in the trauma patient, if no obvious external injuries are present. 4. Hypotension is almost never due to head injury; look elsewhere for blood loss. 5. The degree of head injury can t be assessed accurately in the presence of deep shock. 6. Any degree of shock means that the patient is near death. All shock requires aggressive treatment if the patient is to survive. Anaphylactic Shock Shock caused by exposure to an allergen which then causes bronchospasm and blood vessel dilation Signs and Symptoms of Anaphylaxis Flushing, itching or burning of the skin, especially over the face and chest Urticaria (hives) Edema, especially of the tongue face, and lips Cyanosis about the lips Sneezing, wheezing and chest tightness Dyspnea Falling BP Weak and thready pulse Pallor Dizziness Occasional abdominal cramps Fainting and coma may follow Respiratory failure Treatment for Anaphylaxis Call 911 Give Basic Life Support Treat for shock (sit up with respiratory distress) Give Oxygen Assist with bee sting kit if needed and available (epinephrine and antihistamine) EpiPen Epinephrine Auto-injector EpiPen The patient should self administer using the following rules: Check to see that the medication has not expired and does not contain paticulates or sediments. 1. Remove gray safety cap. 2. Place tip on lateral thigh 1/2 way between the waist and knee. 3. Push firmly on injector 4. Hold down for a full 10 seconds. 5. Dispose of injector in a biohazard container. Syncope/vasovagal response/fainting One of various stimuli (sudden fright, sight of blood, etc.) causes excitement of nucleus tractus solitarius within the brainstem. This initiates a twofold response 1. enhancement of vagal tone (parasympathetic) 2. inhibition of sympathetic tone This leads to decreased cardiac output and vasodilation. Treatment for fainting Have patient supine, elevate legs 12 inches and loosen restrictive clothing Shake/shout/painful stimuli A. If no response - call 911 and check ABC s, begin emergency care B. If patient starts to come around 1. If patient is fully alert give fruit juice 2. Check vitals and for injury 3. Stay with patient until they are fully alert Cardiac Emergencies Heart Disease Heart attacks Sudden Cardiac arrest Congestive Heart failure Angina pectoris Angina Coronary Artery Disease Heart Attack - Acute Myocardial Infarction Sudden Cardiac Death Smoking High Blood Pressure High Cholesterol Physical Inactivity Diabetes Risk Factors for Heart Attack Obesity Stress Heredity Race Sex Age Pain of AMI Chest pain that is : substernal squeezing or heavy in nature It lasts longer than 30 minutes It is not necessarily related to exertion or stress It is not relieved by nitroglycerin It may radiate to the mandible, neck, either shoulder or arm, epigastrium, and back NOTE: AMI may not have associated pain-- silent AMI Many women have more vague symptoms and are often misdiagnosed. How to recognize a Heart Attack Chest Pain- substernal pressure, fullness, squeezing or pain. It usually lasts longer than a few minutes. It may come and go. The pain may radiate to either shoulder or arm, neck, jaw, back and epigastric region. Lightheadedness Pale, ashen skin Occasional cyanotic skin Fainting Sweating Nausea Shortness of Breath Anxiety Denial Palpitations Feeling of Impending Doom If you SUSPECT a HEART ATTACK TIME IS MUSCLE Protocols for a suspected heart attack Call 911 Don t Delay Reassure the patient Take a history Take Vitals Position the patient - Position of Comfort usually sitting or semi-reclining Assist with nitroglycerin Oxygen L\min by nonreabreather mask Review CPR in you mind in case the patient goes into sudden death Acute Myocardial Infarction (AMI) Heart attack; specifically, death (necrosis) of the heart muscle from obstruction of its blood flow.) This can lead to sudden cardiac arrest (death) Sudden Death Sudden death associated with AMI occur because of sudden abnormalities in the heart rhythm called arrhythmias. Ventricular fibrillation. Disorganized, ineffective quivering of the ventricles. Ventricular tachycardia Asystole This is where there is no cardiac action going on at all All of these constitute sudden death and require CPR Other arrhythmias associated with AMI that may not cause sudden death Tachycardia: Rapid but regular beating of the heart 100 beats per minute. Bradycardia: Unusually slow but regular beating of the heart 50 beats per minute. Atrial flutter: Beating of the atria up to rates of 300/minute Atrial fibrillation: Disorganized, ineffective quivering of the atria. Ventricular extrasystoles: Additional beats of the ventricles interspersed with the regular rhythm. Congestive Heart Failure (CHF) Failure of the heart occurs when the heart muscle is so damaged by infarction or other disease that it can no longer pump enough blood for the needs of the body. CHF can occur any time after an AMI but it usually happens between the first few hours and the first few days. Cardiogenic Shock Cardiogenic shock is an early complication of AMI that occurs within 24 hours of the event. It means that there has been so much damage to the heart that it is unable to sustain normal systemic blood pressure, and shock results. Shock with AMI is an extremely serious complication and may result in death. Clinic presentation of AMI Sudden onset of weakness, nausea, and sweating without an obvious cause. Chest pain (crushing or squeezing). Sudden arrhythmia with fainting. Pulmonary edema. Sudden death. Why Should I Know CPR Approximately 500,000 people die every year in the USA from heart attacks. About two thirds of these deaths occur before the victim reaches the hospital. Some of these people could have been saved had early CPR been started by a bystander people die every day from SCA (sudden cardiac arrest) in the USA This is the leading cause of death in people over 40. SCA kills about the same number of victims as Alzheimers disease, assault with firearms, breast cancer, cervical cancer, colorectal cancer, diabetes, HIV, house fires, motor vehicle accidents, prostate cancer and suicides combined. National survival rate of SCA is only 10% Where you live makes a difference Seattle close to 50% survival rate Davenport about 27% survival rate Detroit only about 7% survival rate Why the difference? EDUCATION Chain of Survival Early Access ( Call 911 ) Early CPR Early Defibrillation Early Advanced Cardiac Life Support When cardiac arrest occurs Critical Timing Clinical Death begins with the cessation of breathing and pulse.this is reversible Biological death begins within 4 to 6 minutes following clinical death.this is when permanent brain damage begins If a victim is resuscitated prior to 4 to 6 minutes if they do survive the likelihood for permanent brain damage is minimal If a victim is resuscitated after 4 to 6 minutes the likelihood is that they will have permanent brain damage Exception Cold water drowning and cold exposure. Due to the mammalian diving reflex many victims have been revived following prolonged periods of PNB (pulseless and non-breathing) Establish unresponsiveness Activate EMS 911 CPR Saves lives Adult CPR steps 30:2 30 Compressions at least 2 inches deep at a rate of 100 per minute - middle of lower half of sternum on bare chest 2 breaths each breath lasting about 1 second (allow chest to relax between breaths) Continue cycle. Try keep non-compressing times to 10 seconds or less. Continue CPR until EMS arrives The scene becomes unsafe You see obvious signs of life An AED arrives You are too exhausted to continue Variations of CPR Mouth to nose Mouth to stoma Modified jaw thrust Barrier Devices Gloves and CPR mask Pace makers ( Perform CPR as usual) Recent open heart surgery (Perform CPR as usual) Complications of CPR Vomiting immediately roll victim on side and clear airway continue CPR Gastric distention Don t blow hard and fast, let chest relax Strain/Sprain Rib fractures - Don t stop, make sure you are in correct place Lacerated liver Punctured lung Cardiac contusion Splenic rupture Dentures keep in place, unless dislodged or broken What about aspirin? %20Lay%20Resps.pdf The ARC recommends giving 2 chewable (162 mg) baby aspirin or 1 (325mg) tablet with a small amount of water for Heart attack victims: If the patient is conscious and able to take oral medication and the patient denies Allergy to aspirin 2. Stomach ulcer disease, or, 3. Taking blood thinners (Coumadin, Warfarin, or other anti-platelet drugs) CPR HANDS ONLY Hands Only CPR Can be done if you don t have a barrier device There is enough oxygen in a persons system to do hands-only CPR for about 7 to 8 minutes. That is usually provides enough time for EMS to arrive. Automated External Defibrillator AED Allows a person with minimal training to deliver a life threatening shock AED will only allow a person to shock a shockable rhythm V fib. And V tach The AED shock (about 300 Joules of electricity) stops the heart in order to stop the abnormal rhythm. The heart hopefully will then start beating in a normal sinus rhythm Asystole is not shockable rhythm AED USE Use as soon as available Keep CPR going while getting the AED ready Turn on the AED Bare and dry the chest Apply pads Plug connector into AED Stop CPR and allow AED to analyze (Clear everyone to analyze) Push shock button if indicated (Clear everyone prior to shock) Start compressions right after shock Continue cycle of 2 minutes of CPR, analyze, and shock if indicated until - help arrives, you see obvious signs of life or your too exhausted to continue What are obvious signs of life? Adequate breathing Movement AED considerations Make sure no one is touching the victim when shocking or analyzing Can t be done lying in water Remove medication patches if they are in the way of pad Shave hairy chest (pad area only) or place pads and see if they work. If not tear them off, removing hair and put on new pads Don t place pad on top of internal defibrillator/pacemaker move the pad over Should I purchase an AED? Age of your patient population Do you participate in community events? Are you a team physician? Do you do on-field response\care? The cost of an AED can range from about $800 to $3500. Commotio Cordis A sudden impact or blow to the chest from a non-penetrating projectile (i.e. a baseball) or a strike to the chest which causes the heart to go into V. fib and often results in death Bag-valve-mask The bag-valve-mask system 1. Position yourself at the patient s head and maintain the patient s neck in extension (unless contraindicated). 2. Select correct mask size. 3. Place the mask with the apex over the bridge of the nose of the patient. 4. With the mask firmly applied to the patient s face and the neck maintained in extension with one hand, use the other hand to compress the bag once every 5 seconds (adult rate). Proper ventilation will be evidenced by rise and fall of the chest. 5. Whenever possible, two rescuers should provide bag-valve-mask ventilation. It is very difficult to maintain an adequate seal by yourself. 6. This device can be used with or without supplemental oxygen. Oxygen Therapy Iowa Code on Oxygen use by Chiropractors Conditions Requiring Oxygen Respiratory or cardiac arrest Heart attacks and stroke Shock Blood loss Lung diseases Fractures Head injuries and more Using Supplemental Oxygen Inspect cylinder and markings. Crack the cylinder. Attach the regulator/flow meter. Using Supplemental Oxygen (cont.) Open the cylinder. Attach proper delivery device to flowmeter. Oxygen Regulators Using Supplemental Oxygen (cont.) Adjust flowmeter to desired flow rate. Apply the oxygen device to the patient. When done, discard the delivery device. Turn off the flow meter. Oxygen Delivery Equipment Nonrebreathing mask Provides up to 90% oxygen Used at 10 to 15 L/min Fill reservoir bag 1 st by holding valve when you start O2 Nasal cannula Provides 24% to 44% oxygen Used at 2 to 6 L/min Artificial Ventilation One- or two-person bag-value-mask (BVM) Mouth-to-mask ventilation Oxygen-powered ventilation device Hazards of Oxygen Oxygen supports combustion. Keep possible ignition sources away from the area. Oxygen tanks are under high pressure. Angina Pectoris Stable and unstable Angina Pectoris Chest pain from preexisting heart disease that is brought on by excitement and/or exertion and relieved by rest and nitroglycerine. The pain is caused by hypoxia to cardiac tissue when the oxygen demands increase in a heart with coronary artery disease (CAD). Arteriosclerosis narrows the lumen of the coronary vessels so that inadequate oxygen reaches the heart under increased demand. There is no cell death (necrosis) or permanent damage with Angina. Unstable Angina Starts to feel different, is more severe, comes more often, or occurs with less activity or while you are at rest Lasts longer than minutes Occurs without cause (for example, while you are asleep or sitting quietly) Does not respond well to nitroglycerin Occurs with a drop in blood pressure or shortness of breath Unstable Angina can lead to a heart attack seek medical attention Stable Angina Pectoris Signs and Symptoms The s/s associated with angina can be very similar to those of an AMI. These are some differences The pain is usually related to stress or exertion. The pain usually lasts only 3 to 10 minutes The pain is relieved by rest and/or nitroglycerin. Nitroglycerin Nitroglycerin is a potent vasodilator. It causes the coronary vessels to dilate, thus relieving hypoxia. It comes in four forms: sublingual tablets sublingual spray dermal patches (more often seen with the treatment of unstable angina) ointments Emergency Treatment of Angina If a patient has a diagnosed history of angina: Calm and reassure the patient Have patient rest and assist with nitroglycerin Take vitals If pain persists greater than a few minutes call 911 and treat as AMI Nitroglycerin Side Effects Because nitroglycerin is a potent vasodilator of blood vessels throughout the body it can have the following side effects: headaches drop in blood pressure changes in pulse rate as the body tries to compensate for the vasodilation Nitroglycerin Contraindications Baseline blood pressure is below 100 mmhg systolic Suspected head injury The patient has already taken three doses of nitroglycerin Patient has recently taken Viagra or Cialis Congestive Heart Failure A condition where the heart no longer is able to pump sufficient blood to meet the demands of the body. It can have a gradual onset with chronic conditions such as a stenotic heart valve, uncontrolled hypertension, etc. Or a sudden onset such as following a heart attack There can be right sided, left sided failure or both CHF S/s Marked dyspnea Great anxiety Desire to sit upright Chest pain may or may not be present Distended neck veins Pedal edema Rapid, shallow respirations rapid pul
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