Author: Claire

Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta. Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.

Basic Principles of Intensive Care Nursing

Basic Intensive Care Nursing

Intensive Care Nursing Principles include care of the following immediate care aspects: airway safety, breathing, circulation, disability a.k.a. level of consciousness, and exposure. Basic ABCDE assessments of the patient in intensive care increases the patient’s survival rate.

Airway Safety in Intensive Care Nursing

In intensive care nursing, one may observe two types of airways used on patients, both of which are considered to be invasive: an endotracheal tube or a tracheostomy.

An endotracheal tube is usually indicated for patients in respiratory failure who are unable to breathe adequately by themselves, or who are experiencing physiological disturbances, leaving their airway unprotected.

A tracheostomy is a planned procedure indicated for patients in need of a prolonged period of mechanical ventilation.

Both devices deliver ventilation to the patient through a closed system
Both devices deliver oxygen from the trachea directly into the lungs
Both devices have an inflatable cuff near the tube end which provides a seal to avoid air from escaping as well as protection from aspiration of gastric content into the lungs.

intensive care nursing — Endotracheal Tube

Endotracheal Tube

To ensure proper care of an intubated patient, the following measures need to be taken:

Tube Sizing

tube size is identifiable on the cuff balloon
tube is usually tied at the lips
a standard ETT is around 26mm long

Cuff Pressure

cuff pressure must be checked every 4 hours using a manual device
cuff pressure must stay between 20-30cm of water
an over-inflated cuff causes tracheal pressure damage; an under-inflated cuff causes air to escape and the ventilator to sound its alarm for inadequate ventilation
cuff leaks may happen due to inadequate air in the cuff, damage to the cuff, higher pressure from ventilator exceeding pressure in the cuff, wrong tube fit for the person’s anatomy, or positional leaks on patient movement

ETT Securing

ensure that the endotracheal tube is secure (unplanned extubation or tube misplacement can jeopardise the patient’s safety)
note length mark at teeth/lips and document clearly on the nursing report
ensure tube is tied appropriately with tapes or devices used within your clinical area
recheck tapes regularly to ensure they do not become loose – only two fingers may be inserted between the patient’s face and ties; if ties become loose, re-tie using a two-person technique to ensure prevention of extubation: one person holds the tube in place whilst the other ties the tapes
do not tie tapes around the connector at the tube’s end since this can easily become disconnected
call for assistance if the tube becomes dislodged or if you are concerned

Breathing

Ventilation is the in-out air movement within the lungs’ alveoli during which gas exchange occurs.

During normal breathing, ventilation occurs through negative pressure – energy causes the respiratory muscles to contract, which then lead the respiratory muscles to enlarge the thoracic cavity, creating a negative intra-thoracic pressure, which then results in airflow from atmospheric pressure to enter the lungs…

In simple terms, during normal breathing, air is sucked into the lungs.

Mechanical ventilation uses a positive pressure approach in which a pneumatic system delivers gas into the lungs during the inspiration phase. Following inspiration, the patient exhales to the level of PEEP which is set on the ventilator, thus, expiration happens passively.

In simple terms, during positive pressure ventilation (PPV), air is blown into the lungs.

NOTE: PEEP stands for Positive End Expiratory Pressure, which is the pressure set on the ventilator – pressure set above the atmospheric pressure – aimed to improve oxygenation through the recruit of collapsed alveoli.

Mechanical Ventilation Indications

Respiratory failure can be classed in 2 categories:

Type 1: Acute Respiratory Failure
Type 2: Hypercapnic Respiratory Failure

NOTE: Occasionally patients may have both.

Type 1: Acute Respiratory Failure

Acute respiratory failure occurs when arterial oxygen level is <8kPa, which is then reflected in a significant drop in the oxygen saturation level – hypoxaemia.

In hypoxaemia, the patient becomes visibly short of breath, with rapid shallow breathing usually accompanied by anxiety and confusion due to insufficient oxygen saturation within the tissues.

Acute respiratory failure typically happens due to conditions affecting gas exchange within the alveoli, such as in COVID-19 which can result in severe pneumonia, commonly bilateral pneumonia affecting both lungs, Acute Respiratory Distress Syndrome (ARDS) which causes the lungs to become waterclogged like sponges, and Pulmonary Embolism.

Type 2: Hypercapnic Respiratory Failure

In hypercapnic respiratory failure, respiratory demand is not met due to inability to breathe in enough air or breathe quickly enough, and so, the patient experiences hypoventilation.

Hypercapnic respiratory failure causes a rise in carbon dioxide along with a decrease in oxygen level; PaCO2 >6.6kPa (50mmHg) with pH of <7.25; pH fall happens due to the rise in carbon dioxide causing acidity in the blood.

Causes of hypercapnic respiratory failure include: upper airway obstruction, epiglottis obstructive sleep apnoea, asthma, bronchospasm, narcotic overdose, chest trauma, flail chest, pleural effusion, pneumothorax, haemothorax, CVA, cranial trauma, Guilllain-Barre Syndrome, and spinal cord injury.

Respiratory Assessment & Physical Examination – Look, Feel & Listen!

Look…

Look at the patient’s chest:

can you see any obvious deformities?
is chest expansion equal on both sides?
are accessory muscles being used?
is there paradoxical chest wall movement in comparison to the ventilator?

Along with the above observations, take note of the patient’s rate, rhythm, and quality of respirations.

Feel…

Palpate the patient’s chest:

can you feel both sides of the chest expand?
can you feel any vibrations within the chest? If yes, this may be an indication of respiratory secretions or fluid – check further by auscultating with a stethoscope

Listen…

auscultate for breath sounds by pressing the diaphragm side of the stethoscope firmly against the patient’s skin directly
normal breathing sound a.k.a. vesicular, is soft and low pitched, with inspiration lasting longer than the expiration sound
crackles are intermittent non-musical sounds which are caused by collapsed or fluid-filled alveoli, most commonly heard on inhalation; crackles may not clear up following coughing or suctioning
wheezing is a high-pitched musical sound caused by airway narrowing, commonly heard in COPD, Asthma, chest infection or heart failure
if no chest sounds can be auscultated and chest expansion is absent or limited, call for urgent assistance

Measuring the Effects of Mechanical Ventilation on Gas Exchange

Oxygen saturations and carbon dioxide levels are shown on the monitor and ventilator, as well as on an ABG result strip. Capnography is another way of monitoring carbon dioxide. A CO2 waveform can confirm that the tube is in the right position and that the patient is being ventilated. Flat or dampened waveforms require adjustments.

NOTE: sick patients may be aimed for a higher CO2 than normal – permissive hypercapnia.

Ventilation Risks

increased pressure in the thoracic cavity can cause lung trauma
increased risk of ventilator acquired pneumonia – a secondary lung infection; a good precautionary measure is to keep the patient’s head elevated to 30 degrees

Sputum Management

Intubated and ventilated patients cannot cough to clear their own secretions. For this reason, humidification, which is attached to the ventilator and should be checked regularly, is vital. In addition, closed suctioning of the ETT enables secretions to be suctioned out without breaking the circuit to atmospheric pressure.

Related Terminology

FiO2 – the fraction of inspired oxygen eg. 0.3 = 30% oxygen
Peak Pressure – airway pressure + alveolar pressure
PEEP -Positive End Expiratory Pressure
Tidal Volume – volume of air expired in one breath
Minute Volume – total volume of air expired in one whole minute

Circulation

As a nurse working in the ICU setting you need to make sure you go through a lot of ‘checks’ prior to starting your shift:

get a good handover by the nurse who was taking care of your newly assigned patient so that you know the patient’s normal parameter values
set the alarm limits based on the values given by the handover nurse; set alarms just above the highest and just below the lowest parameters taken during the previous shift
check all equipment to make sure all is in good working order

Setting alarms related to the cardiovascular system

heart rate – usually set between 60-100bpm; observe the patient’s ECG trace for a whole minute to know its normal trend
mean arterial pressure (MAP) – usually set between 60-65mmHg, however, these values are normally based on the patient’s normal limits to allow space for patient movement, coughing, etc
arterial line trace – observe the A-line trend for a minute so you familiarise yourself with it and be able to notice any differences straight away

Checking Equipment related to the Cardiovascular system

arterial line – needs to be monitored at all times; related alarms need to be always switched on; check for air bubbles and if any are visible, make sure you remove them; arterial line site needs to be kept clean, dressed with an intact see-through dressing, and kept visible at all times for easy monitoring

NOTE: the Arterial Line is marked with a red line all the way down the side so as to alert healthcare professionals that it is not a regular line.

IMPORTANT: Never inject anything into an arterial line! Special caps are used for arterial lines with the aim of preventing this!

central venous pressure line (CVP) – certain infusions need to be administered via a CVP line since if injected into smaller veins, these can be destroyed
check that all lines attached to the patient are clearly labelled with the medication being administered, and dated; this helps identify which line is which, in case a medication needs to be abruptly stopped or disconnected

NOTE: the Central Venous Pressure line may be clear or it may have a blue line running all the way down the side for easier recognition.

pressure bag + saline bag – the arterial line AND the CVP line should both be connected to a bag of 500ml normal saline 0.9% which sits in a pressure bag; pressure bag needs to be set at a pressure of 300mmHg which is clearly indicated by a green section on the pressure bag gauge
before zeroing the set, ensure that the bags of saline have enough fluid within them, and that they are up to pressure

transducer – this needs to be zeroed, sitting approximately in line with the right atrium, so as to ensure that both the arterial line and the cvp line are monitored continuously and accurately; zeroing needs to be done at every change of shift as well as whenever the patient is disconnected
both the arterial line and the cvp line need to be switched off to the patient, and be open to air, at the correct height, and with the pressure bag blown up, following which ‘zero all’ should be set on the monitor; then, both should be switched back on to the patient, caps should be put back on , and both should be reading correctly

Checking the patient

check that the patient’s heart rate corresponds to the ECG and arterial line trace and to the radial pulse of the patient
check that the ECG tabs are correctly placed and have good contact with the patient
check every line insertion site for any signs of infection or migration
re-check any significant heart rate change with a manual pulse, blood pressure output and a 12 lead ECG
check the patient’s limbs and note capillary refill time of all four
check for skin pallor, warmth, sweating, dry skin, wounds, and bleeding
check the MAP is reading adequately and whether it needs any fluids or drugs to maintain it
check the patient’s temperature: >39 degrees celsius needs to be taken care of; on the other hand, a patient can easily become cold in an ICU setting…avoid hypothermia – keep your patient warm!
ASK FOR HELP IF IN DOUBT AT ANY TIME!

NOTE: In the ICU setting, 5-lead ECG monitoring is used!

Check Urine Output

a urinary catheter is inserted in every sedated and ventilated patients
an average person’s urine output should be about 0.5ml/kg/hr; an inadequate blood pressure may later lead to a decrease in urine output, thus, check urine output every hour
a patient with a low blood pressure and poor urine output may be commenced on inotropes
common inotropes include Noradrenaline, Adrenaline, and Metaraminol

Inotropes:

are calculated in mcg/kg/min and titrated according to patient parameters to maintain an adequate MAP
should be administered through a central line
use should be accompanied with patient monitoring through an arterial line
are short-acting, thus, should be set to infuse continuously without running out; if left empty, patient’s blood pressure may drop dangerously low, possibly leading to a cardiac arrest
IV fluid boluses may also be prescribed, though usually, this is done more in other ward settings

Electrolytes

electrolytes which have a direct effect on the heart’s conduction, contraction and rhythm need to be closely monitored in intensive care nursing
potassium level should be >4 – 5.5mmols/L
magnesium level should be >1.0mmols/L
phosphate level should be >0.7mmols/L

Disability

Sedating the patient – why?

Sedation level is always decided by the ICU consultant. Reasons for patient sedation include:

ventilation facilitation
anxiety relief
acute confusion management
treatment implementation
diagnostic procedures
reduction of tachycardia, hypertension, or raised intracranial pressure

Commonly used Sedative drugs

Propofol – anaesthetic agent (negative inotrope)
Morphine – opiate
Midazolam – benzodiazepine
Fentanyl – synthetic opiate
Remifentanyl – short half life
Atracurium – muscle relaxant

The Non-Sedated Patient

assess and document the non-sedated and awake patient using the GCS or the AVPU scale to find out the patient’s level of consciousness and current mental state
assess and document the patient’s pupillary size and reaction
identify changes within the patient’s neurological state; if a patient becomes newly confused or difficult to wake up, check for any respiratory issues or medical condition deterioration

The Sedated Patient

assess the sedated patient using the GCS; include pupillary size and reaction in your assessment and documentation
document at which level is your patient sedated using the Richmond Agitation Sedation Scale (RASS)
assess patient at the beginning of your shift; continue performing assessments throughout your shift especially since the necessity for patient sedation level may change

NOTE: always check thoroughly syringe drivers with sedation, including rate and time; ensure replacement syringes are ready to be replaced prior to stopping. Sedation which is abruptly stopped may lead to patients waking up frightened and disoriented, leading to unplanned extubating or high levels of distress and anxiety!

Retrieved from https://handbook.bcehs.ca/clinical-resources/clinical-scores/richmond-agitation-and-sedation-rass/ on 22nd October 2022

Glucose Level Check

Whilst a patient may not be diabetic, one may still be on insulin in Intensive Care Nursing. This is because in ICU, patients often require an insulin infusion so as to keep their blood glucose level between 4-10mmols.

Thus, it is important to check the patient’s blood glucose levels frequently as per local guidelines, especially since in sedated patients, noticing hypoglycaemia is quite difficult.

Pain Assessment

Pain assessment is vital in intensive care nursing, especially since it may be a good indication of a newly evolving critical condition such as a Myocardial Infarction or an infection.

If a sedated patient exhibits physical stress responses such as an increased heart rate, blood pressure or agitation, consider pain as a possible culprit. A good Critical Care Pain Observations Tool (CPOT) may be used to assess pain in sedated patients. This considers the following aspects:

facial expression
body movements
ventilator compliance
muscle tension

If pain is suspected, analgesia should be administered. Whilst all ventilated patients are already on sedation and analgesia, an increased rate or a bolus may be considered, followed by a reassessment to check for improvement.

Retrieved from https://www.researchgate.net/publication/337928045_PAIN_MANAGEMENT_IN_INTENSIVE_CARE_UNIT_A_BRIEF_REVIEW/figures?lo=1 on 22nd October 2022

Exposure

Nutrition

In intensive care nursing, the patient should ideally be fed early. If awake and extubated and can eat and drink, assist in doing so. Remember that invasive lines and air mattresses can restrict patient mobility, and some assistance can go a long way!

Following intubation or tracheostomy, a patient needs to undergo a swallow assessment to ensure oral intake is advisable. At times, a nasogastric tube or jejuno tube may be indicated.

Retrieved from https://medlineplus.gov/ency/imagepages/19965.htm on 23rd October 2022

Positioning needs to be checked well whenever a new shift is taking over, as well as before oral intake is administered:

note tube position and compare current length with the previously documented length
ensure tube is well secured so as to prevent migration; change adhesive holder if necessary
checking pH of patients in intensive care nursing may be misleading; aspirate gastric contents every 4 hours and replace or discard as per local policy
to help with absorption, motility agents may be prescribed
tube feeding prescriptions are based on body weight and caloric and electrolyte needs; electrolytes, magnesium and phosphate replacement is usually prescribed together
cartridge may need to be changed every 24 hours
new lines should always be labelled with date and time of change

If enteral feeding fails, total parenteral nutrition is usually considered. TPN is administered via a PICC line or Central Line through a specific lumen – a white port. Medications are not administered via the same line.

NOTE: TPN is lipid based and so it requires strict asepsis when lines and bags are changed. New lines need to be labelled clearly with the date and time of change.

Nausea & Vomiting

An abdominal assessment needs to be performed on the patient in intensive care nursing …

LOOK at the shape and for distension, masses, ascites, prominent veins, bruising, scars, drains, or stomas.

LISTEN for bowel sounds using your stethoscope over the right lower quadrant.

FEEL and assess for localised or radiating pain and masses.

Bowel Assessment

check the last documented bowel action – patients in the Intensive Care Setting are prone to becoming constipated due to reduced bowel motility
administer any prescribed aperients (drugs to help with constipation) which are usually started early on in this setting to promote regular bowel movements
promote dignity especially in the case of incontinence
take positioning into consideration – assisting the patient with a hoist to a more natural defecation position can help conscious patients
if patient experiences uncontrolled diarrhoea, rectal tubes may be indicated to protect the skin and to measure fluid loss
record frequency and consistency

Assessing for Venous thromboembolism (VTE)

Patients in the intensive care setting are often provided with intermittent compression boots eg. flowtron, to help stimulate blood flow to deep veins, so as to help prevent thrombosis. Such devices need to be removed at least once per shift so the underlying skin is thoroughly assessed.

Mouth Care in the ICU Setting

Mouth care in the intensive care setting provides the patient with comfort. Additionally, it helps prevent Ventilator Associated Pneumonia. Toothpaste and baby toothbrushes are used twice daily. Ideally, water is given every 4 hours, and vaseline is applied to the patient’s lips every time.

Eye Care in the ICU Setting

Sedated patients are not able to blink, which leads to an increased risk of corneal sores. Use recommended eye drops as per local policy for this reason. Check the patient for redness, pus, dryness, and Scleroderma. Use eye drops and lacrilube.

Patient Skin Care

check for skin breakdown, redness, blistering surgical sites, existing pressure sores, wounds, dressings, or rashes; if needed, change the type of mattress they are currently on
encourage position changes or move sedated patients regularly to avoid formation of pressure sores
check the skin beneath flotrons or devices to avoid thrombosis at least when starting your shift
check the NGT for any markings onto the nostrils
check ETT and holders, repositioning / pressure alleviating devices; check tapes’ last change and note any ulcerations, bleeding gum or loose teeth
change saturation probe position at least every 2 hours
check for any lines or drain catheters underneath the patient
minimise shear and friction damage whilst handling the patient
ensure no creases are on the bed sheets since these may cause pain and sores
change any IV lines and feeding tubes as per local policy

Reference

Critical Care Outreach Team (2020). Basic Principles of Intensive Care Nursing. Royal Berkshire NHS Foundation Trust. Retrieved from https://www.baccn.org/media/resources/Basic_principles_of_Intensive_Care_Nursing.pdf on 18th October 2022

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Critical Care Setting Haemodynamic and Respiratory Monitoring

In the critical care setting the nurse’s observatory role is crucial in maintaining optimum care of the critical patient, which is why, ideally, the nurse-patient ratio should be 1:1. Additionally, technology plays a very important role within the same setting. However, one must not forget the GI-GO paradigm, a.k.a. Garbage In, Garbage Out – whilst analytical technology can be very useful in critical care, produced data always depends on how well the data is collected.

Invasive Monitoring Equipment in Critical Care

Invasive monitoring equipment used within the critical care setting includes:

invasive (arterial) catheter – a small cannula, usually containing an anti-reflux switch, which is inserted (sometimes with the help of a guidewire) into an artery to constantly monitor a patient’s blood pressure
high pressure tubing – helps preserve pressure and prevent loss of pressure between the patient’s vein or artery and the transducer
transducer – delivers numerical blood pressure readings and arterial pressure waveforms with every heartbeat to a bedside monitor by sensing blood-generated pressure passing past a catheter tip; readings and waveforms delivered are dynamic and change with every beat of the cardiac cycle; the transducer and line are attached to the arterial line via a connector, allowing the changing of the transducer set (ideally every 96 hours) without requiring re-insertion of the arterial line
flush system – helps keep the line clear and avoid blood backflow through the catheter; saline bag is used under the pressure bag, usually with 2 units of heparin per cc, to help keep the artery open UNLESS the patient has a known allergy to heparin; NOTE: even a little bit of heparin can cause heparin-induced thrombocytopaenia (immune system causes platelets to clot in the presence of heparin, resulting in platelet levels dropping), so if the patient’s platelet count drops for no apparent reason, remove the heparinised saline bag and change to saline bag instead
monitor – commonly displays ECG, heart rate, intermittent cuff blood pressure, arterial blood pressure, internal temperature, peripheral venous oxygen saturation, partial pressure of CO²

Critical Care Setting Haemodynamic and Respiratory Monitoring — Retrieved from https://tinyurl.com/3zm7dt7t on 10th October 2022

Arterial Catheter Indications

An arterial catheter is indicated in instances:

when continuous blood pressure monitoring is required eg. during surgery, during use of vasoactive medications, or in the case of compromised cardiac output, fluid volume, and tissue perfusion
when patients require frequent arterial blood gas sampling eg. if they are experiencing respiratory failure or are on mechanical ventilation

Arterial Line Placement Sites

Radial Artery – easily accessible site which is also considered to be safe since collateral hand circulation is supplied by the ulnar artery – circulation within both these arteries can be checked via an allens test; this site is also preferred due to a decreased risk of complications when compared to other larger vessels
Brachial Artery – located close to joint thus blood flow may be easily interrupted
Femoral Artery – large vessel which, due to its location, is difficult to observe on a continuous basis
Dorsalis Pedis Artery – needs to be avoided if the patient has severe peripheral vascular disease

Allens Test

Arterial Blood Pressure Reading

When using an arterial catheter, a constant second by second reading of the systolic (SBP), diastolic (DBP), and the mean arterial blood pressure (MAP) can be provided. The MAP is a more accurate indicator of the patient’s condition since it also reflects the perfusion rate of essential organs such as the kidneys.

The MAP is usually calculated automatically by most monitors. However, it can be calculated using the following formula:

Retrieved from https://clinicalview.gehealthcare.com/white-paper/measuring-mean-arterial-pressure-choosing-most-accurate-method on 10th October 2022

Arterial Waveform

Respiratory Swing

The respiratory swing is more pronounced in the case of mechanical ventilation. It can help indicate dehydration.

Retrieved from https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Arterial%20Line%20Waveform%20Interpretation%20UHL%20Paediatric%20Intensive%20Care%20Guideline.pdf on 10th October 2022

Care of the Patient with an Arterial Line

perform regular checks for loose connections, blood backflow, a deflated pressure bag, or lack of fluid in the flush bag
ensure that the arterial catheter site is easily accessible and always visible
DO NOT inject any medication in the arterial catheter!

A patient with an arterial line may eventually develop complications. Monitor the patient for:

Infection – perform frequent patient checks, noting any redness, discharge, warmth to touch, or fever; preventative measures include using an aseptic non-touch technique during insertion of catheter, blood sampling, and line maintenance
Haemorrhage – perform frequent checks at the arterial catheter insertion site especially if it was inserted into the femoral artery since this is a large vessel
Thrombosis – perform frequent checks on patient’s legs, taking note of the colour, pulse, temperature and sensation; preventative measures include adequate flushing following blood sampling, and using the smallest catheter possible during the insertion procedure

Levelling and re-zeroing

The transducer system must be leveled and zeroed to provide accurate haemodynamic values, since this eliminates atmospheric pressure effects. The exact point where the 4th intercostal space crosses the mid-axillary line is referred to as the Phlebostatic Axis. The nurse should ensure that zeroing is done at the beginning of every shift, as well as after any major positional changes.

How To Remove Arterial Line

perform hand hygiene
don gloves
gather necessary equipment
remove any dressings and sutures if present
whilst applying firm pressure to insertion site pull out the arterial line gently
apply manual pressure and elevate limb
apply small occlusive dressing which allows periodic observation for blood leakage

NOTE: an adequate blood pressure reading doesn’t automatically signify adequate perfusion…always take into consideration the whole clinical picture, biochemical values, along with haemodynamic parameters.

NOTE: additional monitoring equipment can also be used along with the arterial line to measure cardiac output.

Central Venous Catheters CVC

Central Venous Catheters are indwelling catheters within the superior vena cava, inferior vena cava, right atrium, or any large vein leading to these vessels. They are sought in the case of:

administration of large amounts of fluid
administration of vesicant drugs (drugs that can cause tissue necrosis or blister formation if accidentally infused into tissue surrounding vein)
total parenteral nutrition
repeated venous blood sampling
measurement of pressure within the right atrium (Central Venous Pressure a.k.a. CVP) – this provides the measurement of the right atrium filling pressure, and indicates right ventricular function.

CVCs are inserted via the:

internal jugular veins
subclavian veins
femoral veins

Retrieved from https://www.schn.health.nsw.gov.au/_policies/pdf/2019-182.pdf on 14th October 2022

CVCs usually have 3 or 5 lumens. The distal port is used for monitoring of the CVP, however, it can also be used to administer blood products since it is the biggest port in a CVC. The other ports are used for fluid or drug administration. CVC line requires priming by approximately 1ml of fluid.

In a triple port lumen, the brown port opens up distally (at the tip), the blue port is the medial one, and the white port opens up proximally. If TPN is planned for the patient, it cannot be used intermittently with other infusions. Once TPN is stopped from being run through a particular port for any reason, and another infusion or medication is run instead, TPN cannot be re-administered again through that port.

NOTE: Always label CVC catheters and include insertion date! Note that central lines should be removed within a week from insertion.

Central Venous Catheter Insertion

provide patient with information about the procedure and address any questions or concerns
patient is positioned head down
patient’s skin is prepared for insertion
local anaesthetic is administered
preferred vein is located by needle and syringe
a guide wire is introduced through the needle, after which the needle is removed
CVC is introduced over the guide wire, and is then attached to primed system
CVC is sutured in place
a chest x-ray is performed to confirm correct placement

Central Line Dressing Change

Possible CVC Insertion Complications

pneumothorax – lung collapse following air leakage into the pleural space between the lung and chest wall
right atrium perforation
cardiac tamponade – when the pericardial space fills up with blood or other fluid, putting pressure on the heart, reducing blood pumping activity whilst causing a drop in blood pressure
arterial puncture
haemorrhage
air embolus

NOTE: preventative measures pre-procedure include positioning the patient in the Trendelberg position for both insertion and removal, and performing a chest x-ray following CVC insertion.

Other Complications related to CVC

CVC occlusion – may happen due to mechanical obstruction, precipitation of medications or parenteral nutrition, or due to thrombosis
CVC displacement
air entering the system (always check connections and taps)
local infection
systemic infection

NOTE: preventative measures for infection include adequate and correct hand hygiene, using an aseptic technique whilst handling the CVC, and replacing catheter when needed or required.

CVC Removal

CVCs pose a great risk of infection and are considered as major causes of morbidity and mortality. Additionally, they are also the main source of bacteraemia and septicaemia in hospitalised patients. Thus, CVCs should be removed as soon as possible.

ensure that no medication or fluids are being administered to the patient and/or listed in the patient’s treatment chart
use an aseptic non-touch technique
remove dressing and cut sutures
place patient head-down and lying flat
using the valsava maneuver, ask patient to hold his breath while you slowly remove the catheter; if resistance is felt on removal seek further help
apply pressure to the punctured site until bleeding stops
use an air occlusive dressing for the first 24 hours
if required send tip of CVC for culture and sensitivity

CVP Central Venous Pressure Measurement

Central Venous Pressure measurement, which is transduced electronically through the use of the CVC, should read between 0-8mmHg in normally breathing patients, and higher in mechanically ventilated patients. Attention should be given more to the measurement trend rather than individual readings.

The main limitation of the CVP measurement is that it does not initially reflect left ventricular dysfunction.

Whilst traditionally CVP monitoring was used to assess a patient’s fluid status on which hydration management was decided, studies have shown no correlation between CVP and preload (left ventricular end diastolic volume). Thus, CVP measurements should no longer be relied upon when making clinical decisions on patient fluid management (Marik et al., 2008).

Patient Monitoring – Non-Invasive & Minimally Invasive Techniques in Critical care

minimally invasive using data from arterial or CPV lines, a special type of transducer or catheter
calculations based on arterial waveform and patient demographic data such as weight, sex, age, and height
calculates CO (cardiac output), CI (cardiac index), SV (stroke volume), SVI (stroke volume index) and SV Variation; if interfaced with CVP data, calculations of SVR (systemic vascular resistance) and SVRI (systemic vascular resistance index) are also produced (more info on listed terms here)
may be calibrated (eg. PiCCO) or non-calibrated (eg. Vigileo)

Vigileo / flotrac (non-calibrated)

Vigileo uses a normal arterial catheter without the need for intermittent calibration. However, it is not recommended in the case of arterial wave artefacts, compromised arterial cannula, intense peripheral vasoconstriction, or arrhythmias. It also does not measure advanced volumetrics which can provide accurate CO measuring in a non-invasive way.

Key parameters provided by a Vigileo include:

SV and SVI
CO (CO = SV x HR)
SVV – reflects preload and fluid responsiveness

Limitations can be imposed by spontaneous breaths, open chest, or arrhythmias.

Picco Monitoring (calibrated)

PiCCO, which stands for Pulse Contour Cardiac Output, combines pulse contour analysis with transpulmonary thermodilution using a Thermodilution Arterial Catheter, which is inserted preferably in the femoral artery, or else through the brachial, axillary, or radial artery (which requires a longer catheter).

Retrieved from https://www.getinge.com/int/products/picco/ on 14th October 2022

Transpulmonary thermodilution is picked up by a temperature sensor located at the catheter tip, whilst the arterial blood pressure ABP is measured through the pressure extension line.

The artery pressure curve provides the following parameters:

CCO (CCI) – Continuous Cardiac Output
SV (SVI) – Stroke Volume
SVR (SVRI) – Systemic Vascular Resistance
CPO (CPI) – Cardiac Power Output
SVV – Stroke Volume Variation
PPV – Pulse Pressure Variation
dPmx – Left Ventricular Contractility
HR – Heart Rate
pArt-M – Mean Arterial Blood Pressure
pArt-S – Systolic Arterial Blood Pressure
pArt-D – Diastolic Arterial Blood Pressure
CVP – Central Venous Pressure

The Intermittent Transpulmonary Thermodilution provides the following parameters:

Q – Cardiac Output / CI – Cardiac Index
GEDV (GEDI) – Global End-Diastolic Volume
EVLW (ELWI) 0 Extravascular Lung Water
GEF – Global Ejection Fraction
PVPI – Pulmonary Vascular Permeability Index
CFI (Cardiac Function Index
ITBV (ITBI) – Intrathoracic Blood Volume

GEDV and ITBV reflect PRELOAD – GEDV indicates end volume at rest in all 4 heart chambers and ITBV indicates the volume in heart and pulmonary vessels.

ELWI indicates the water content in the lungs, thus can clearly indicate pulmonary oedema, if present.

GEF indicates the ration of 4 stroke volumes divided by GEDV. It helps detect ventricular dysfunction, if present.

PICCO Setup & Monitor

Retrieved from http://mindray.sy/patient-monitors/ on 14th October 2022

PiCCO Advantages

Picco Disadvantages

cannot be used with an intra-aortic balloon pump
needs to be recalibrated whenever patient changes position, therapy or condition
EVLW is underestimated when it comes to use on obese patients and post-pneumonectomy patients
AAA (abdominal aortic aneurysm) raises GEDV and ITBB measurements

Haemodynamic and Volumetric Monitoring

Pulse Oximetry in Critical Care

Pulse Oximetry is a non-invasive method which monitors oxygen saturation (SaO₂). It indiates the percentage of haemoglobin bound to oxygen.

In normal healthy adults, oxygen saturation should be >96%.

Accurate pulse oximeter readings depend on whether it is positioned well on a patient’s finger, ear, toe or nose, and how good the patient’s peripheral circulation is. Similarly, if a patient is shivering, the pulse oximeter may not be able to pick up a signal. Nail varnish may also affect reading outcome. Additionally, pulse oximetry cannot differentiate between normal and abnormal haemoglobin, thus may result in false high readings.

NOTE: always interpret pulse oximeter readings in conjunction with shown waveform.

Capnography in Critical Care

Capnography measures exhaled carbon dioxide gas, depicting a squarish waveform. Its measurement approximates PaCO₂, usually being about 1-5mmHg lower than the actual PaCO₂.

Capnography is non-invasive.

Capnography is very useful in cases where the patient is suffering from a head injury or from intracranial hypertension.

Very low ETCO₂ values given through capnography can help indicate gastric intubation rather than an intended tracheal intubation.

With regards to CPR assessment, one should aim for a minimum of 10mmHg.

An increased disparity between PaCO₂ and ETCO₂ suggests poor pulmonary blood flow, poor cardiac output, or lung disease.

Reference

Marik, P. E., Baram, M., & Vahid, B. (2008). Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest, 134(1), 172–178. https://doi.org/10.1378/chest.07-2331

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Environmental Emergencies – Bites, Stings, Poisoning & More…

Environmental Emergencies are emergencies arising from the surrounding environment. These typically include bites and stings, poisoning, envenomation, intoxication, as well as hyperthermia and hypothermia triggered by environmental exposure.

Bites & Stings Environmental Emergencies

Bites and stings are considered to be environmental emergencies resulting from insect stings, animal bites, human bites, fish stings, and jelly fish stings. Possible complications to bites and stings include pain, bleeding, infection, envenomation, and anaphylaxis.

Bites & Stings Signs & Symptoms

bite marks
bite wounds
localised pain
localised tenderness
redness, swelling and warmth to touch – indication of inflammation & possible infection: check casualty’s temperature to confirm

First Aid for Bites & Stings

take necessary precautions – assess possible dangers and wear gloves
provide reassurance
assess for any ABC compromise
identify signs of anaphylaxis or envenomation
provide first aid based on casualty’s condition or injury
call 112
monitor casualty for possible respiratory compromise or development of shock

For Animal & Human Bites…

control bleeding by applying direct pressure on site
once bleeding is under control, wash wound with soap and water to get the wound clean from any saliva etc.
rinse wound thoroughly
cover with a clean dressing or if unavailable, a clean cloth or clothes
take or send casualty to the hospital or to a health centre to be reassessed

For Snake or Spider Bites…

limit casualty’s movements
lower bitten area
wash bitten area gently with soap and water to remove any saliva
irrigate area but DO NOT RUB and DO NOT USE ANY TOURNIQUETS
provide stabilisation of the bitten limb so that chemical absorption is slowed down

For Insect Stings…

limit casualty’s movements
remove any embedded sting or insect part by scraping the area gently with a credit card or a knife (using its blunt side)
wash area gently with soap and water
apply ice over stung area to promote vasoconstriction
DO NOT USE ANY OINTMENTS
monitor for signs of inflammation and/or infection eg. for Lyme Disease following a tick bite

For Jelly Fish Stings…

irrigate stung area with white vinegar so as to stop the chemical reaction on the skin; if unavailable use sea water or saline to irrigate…DO NOT USE FRESH WATER!
using forceps or tweezers remove any visible remaining tentacles from the skin’s surface
monitor ABCs
watch out for possible signs of anaphylaxis, envenomation, and shock

For Fish Stings…

remove any visible remaining pieces of the fish’s stinger
irrigate area with water
immerse wound area in hot water for a minimum of 30 minutes so as to kill the enzymes found in the venom; this stops absorption and spreading of the venom throughout the body
help casualty into a supine position, keeping immobilised the affected limb

For Sea Urchins…

In the case of sea urchins DO NOT ATTEMPT TO TAKE STINGERS OUT! Help the casualty to the hospital or health centre since a cream may be prescribed to help the skin expel any sea urchin remaining pieces.

For Contact Irritants…

scrub and irrigate wound bed with sea water or saline water
remove any visible debris
cover wound if required
monitor casualty for signs of infection such as swelling, redness, pus and fever, in which case encourage casualty to seek medical advice

Poisoning, Envenomation and Intoxication

Poisoning happens when one eats something poisonous, and in return gets poisoned.

Envenomation happens when venom penetrates the skin by means of a snake bite, scorpion sting, spider bite, or any other environmental factors. While venom is not always lethal, it can still lead to complications.

Intoxication happens when one self-ingests or self-injects a chemical, such as alcohol and drugs, which are toxic to the body and thus may cause severe consequences.

Poisoning, envenomation and intoxication can happen through 4 different modes of entry, namely through inhalation, ingestion, absorption, or injection.

Poisoning Signs & Symptoms

history
visible signs surrounding casualty eg. drug/poison containers, used syringes, drug-abuse related material
needle marks
animal bite marks

Respiratory Signs & Symptoms…

burns
odours
stains around mouth
coughing
dyspnoea
respiratory distress

Circulatory Signs & Symptoms…

sweating
fainting
shock
discomfort in chest area

Digestive Signs & Symptoms…

nausea and vomiting
abdominal discomfort and/or cramping
diarrhoea

Consciousness Signs & Symptoms…

headache
dizziness
drowsiness
confusion
altered level of consciousness
pupillary changes eg. dilation or constriction of the pupil/s

Poisoning First Aid

use the S.A.F.E. approach
if casualty is responsive, establish cause of poisoning, monitor, and be prepared to resuscitate if needed
if casualty is unresponsive but breathing, put in recovery position
if casualty is unresponsive and not breathing start CPR
call 112 for medical assistance
DO NOT ADMINISTER ORAL FLUIDS as that would dilute poison
DO NOT INDUCE VOMITING
DO NOT WASTE TIME trying to identify type of poison if uncertain
DO NOT SUCK ANIMAL VENOM OUT OF WOUND
DO NOT APPLY A TOURNIQUET or compression bandage

Alcohol & Drugs First Aid

use the S.A.F.E. approach
provide first aid for any injuries incurred
if casualty is unresponsive but breathing, assist in recovery position
if casualty is unresponsive and not breathing, resuscitate by performing CPR
if casualty is responsive with altered level of response, call 112 for medical assistance since this indicates intoxication

Hyperthermia & Hypothermia Environmental Emergencies

Temperature extremes a.k.a. hyperthermia and hypothermia can be incurred either through environmental exposure or else as a disease process. They are both considered to be environmental emergencies.

NOTE: For accuracy purposes, core temperature should always be measured either rectally or through the ear by infrared.

Thermoregulation factors include:

illness
awareness
age
nutrition
infection
substance misuse
environmental conditions

Hypothermia Indications

core temperature of 20 = increased risk for cardiac arrest
core temperature of 25 = increased risk of cardiac arrhythmias
core temperature of <30 = severe hypothermia
core temperature of 30-32 = moderate hypothermia
core temperature of 32-35 = mild hypothermia

temperature <35^oc
cold pale skin
uncontrollable shivering which may eventually stop
rapid pulse which eventually decreases
slow breathing
cyanosis
slow and uncoordinated reflexes
altered level of consciousness
loss of consciousness
respiratory arrest
cardiac arrest

Hypothermia First Aid

cover casualty and take any necessary environmental considerations
assist into a comfortable position to reduce respiratory effort
if available administer high-concentration oxygen
call 112 and ask for an ambulance since hypothermia can only be properly treated in a hospital environment
monitor casualty and be prepared to resuscitate if necessary

Hyperthermia Indications

temperature of >37 = pyrexia = risk of heat exhaustion
temperature of > 40.6 = hyperpyrexia = risk of heat stroke
temperature of > 42 = increased risk of irreversible brain injury

A casualty with heat exhaustion…

temperature of >37
sweating
thirst
headache
dizziness
nausea
vomiting
weakness
fainting
rapid pulse

A casualty with heat stroke…

temperature of >40
heat exhaustion signs as per above PLUS
disorientation
confusion
altered level of response
seizures

Hyperthermia First Aid

assist casualty in a cool area to rest
elevate casualty’s legs
apply cold tepid sponging
promote rehydration
call 112 in case of severe heat exhaustion signs OR if symptoms do not lessen within 30 mins OR in case of heat stroke symptoms

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Sudden Acute Illness

Illness can be categorised under either acute or chronic. Whilst chronic illness is long-lasting, potentially worsening over time, sudden acute illness happens suddenly with immediate or rapidly developing symptoms, which is why it usually requires immediate care.

Altered Level of Consciousness

Retrieved from https://www.nursingtimes.net/roles/hospital-nurses/patient-narratives-4-the-meaning-behind-communication-04-04-2016/ on 2nd October 2022

When normal brain activity is interrupted, a casualty may experience loss of awareness of their surroundings. At times the casualty may only show responsiveness when stimulated eg. through shaking, shouting, or pain stimulus.

Causes

hypoglycaemia – most common cause of unconsciousness
any issue with the airway, breathing or circulation leading to brain hypoxia
neurological issues (eg. CVA)
serious infection (eg. meningitis or infection in relation to the brain)
brain injury following trauma to the head
poisoning which affects the brain directly, or which leads to ABC compromise that induces brain hypoxia
other sudden acute illness eg. myocardial infarction

Signs & Symptoms of Neurological Issues

dizziness
disorientation
confusion
lethargy
drowsiness
low level of response
unequal pupil size
abnormal pupil reaction
limb weakness
unresponsiveness
seizures

NOTE: in CVA, limb weakness is commonly experienced on one side of the body.

A casualty’s level of consciousness is typically tested using the Glasgow Coma Scale, while the level of response is tested using the AVPU score.

Cerebrovascular Accident CVA

A cerebrovascular accident is considered to be a sudden acute illness. It can happen in 2 ways:

Haemorrhagic Stroke – a stroke which happens when weakened or deceased blood vessels rupture, causing blood leaks into the brain tissue
Ischaemic Stroke – a stroke caused by a blood clot that stops the normal flow of blood to a part within the brain

Signs & Symptoms of Cerebrovascular Accident

sudden headache
blurred vision
facial asymmetry
drooling
slurred speech
numbness and/or weakness focused on one side of the body

First Aid for CVA

Retrieved from https://www.cedars-sinai.org/blog/stroke-strikes-act-fast.html on 2nd October 2022

In an unresponsive casualty:

maintain ABCs
assist into recovery position
call 112
monitor & provide reassurance

In a responsive casualty:

assist in a comfortable position, preferably on a bed if available
elevate head and shoulders to promote comfort and to minimise pressure
incline head towards affected (drooling) side to avoid aspiration pneumonia
loosen any tight clothing
call 112
monitor & provide reassurance

Hypoglycaemia

Hypoglycaemia, which can be considered as a sudden acute illness, can be defined as a glucose concentration of 3.9mmol/l or below.

Signs & Symptoms of Hypoglycaemia

history of Type 1 Diabetes
weakness
fatigue
hunger
pale, cold, clammy skin (this side effect helps differentiate between hypoglycaemia and a CVA)
aggressiveness or unusual behaviour
possible speech slurring

First Aid for Hypoglycaemia

In an unresponsive casualty:

maintain ABCs
assist into recovery position
call 112
monitor & provide reassurance

In a responsive casualty:

give sugary drink (you may mix 2 tsp sugar in a little bit of water) or assist with own medication if available (eg. glucose gel)
provide privacy (casualty may become incontinent)
provide reassurance
monitor
if condition improves encourage casualty to seek medical advice; if condition deteriorates call 112

Seizure

A seizure is considered to be a sudden acute illness, however, it is not exactly an illness by itself, but a sign of another illness affecting the activity of the brain eg. fever, head trauma, cerebral hypoxia, epilepsy, etc.

Signs & Symptoms of a seizure

face twitching
lip smacking
individual limb spasm
uncontrollable muscle spasms
convulsions
staring spell
drooling or frothing at the mouth
abnormal sounds
tongue biting
incontinence

First Aid for Seizures

During a seizure:

notice starting time of seizure and time its duration
reduce injury risk – provide protection for the casualty’s head and remove any nearby items which may be of danger
DO NOT RESTRAIN
DO NOT PUT ANYTHING INTO THE CASUALTY’S MOUTH
ensure casualty’s privacy especially due to possible incontinent episode
apply tepid sponging in case of casualty being febrile

After a seizure:

perform primary assessment and assist if necessary
perform secondary assessment and assist if necessary
manage ABCs
assist in recovery position
call 112
monitor casualty’s condition

Fainting Episode

Retrieved from https://onewelbeck.com/cardiology/symptoms/blackouts-fainting/ on 2nd October 2022

Fainting is a circulatory condition affecting consciousness. Fainting can present as follows:

possible brief loss of consciousness
slow pulse
pale, cold, clammy skin

First Aid for Fainting

remove tight clothing
increase air circulation (eg. by opening windows)
assist to the floor to prevent casualty from getting hurt in case of a fall
elevate legs (approximately 30cm)
maintain casualty’s body temperature so as to help keep a stable blood pressure
provide privacy and reassurance
monitor
call 112 if required

Cerebral Infection

Signs & Symptoms

fever
stiffness in the neck area
sensitivity to light
signs of shock
non-blanching rash – press area covered by rash and let go…a rash that still shows points to a neurological infection eg. meningitis

First Aid for Cerebral Infection

Seek medical advice immediately by calling 112!

Dyspnoea

Dyspnoea is otherwise known as experiencing difficulty in breathing. Dyspnoea can happen due to various reasons:

Airway Obstruction
Cardiac & Circulatory Disorders
Respiratory Disorders affecting either the inhalation/exhalation process (eg. asthma), the lower airways, the diffusion process across the alveolar membrane, or the uptake of oxygen in pulmonary circulation (eg. anaemic patients)

Causes of Dyspnoea

asthma
pulmonary oedema – caused either by a cardiac problem or by accumulation of fluid in the alveoli within the lungs
hyperventilation syndrome – stress => hyperventilation => not feeling well => anxiety => increased hyperventilation => increasing symptoms (respiration rate of more than 30 breaths per minute; numbness)
chest infection
inhalation of fumes/chemicals
drowning syndrome
choking
strangulation or suffocation

Dyspnoea signs and symptoms

inability to speak
use of accessory muscles to breathe
abnormal respiratory rate and rhythm pattern
noisy breathing
cyanosis
disorientation, confusion, or unusual aggressiveness – these are classic signs of cerebral hypoxia irrespective of its cause

First Aid for Dyspnoea

provide reassurance to reduce anxiety and increased symptoms
encourage good breathing pattern
increase ventilation in casualty’s area
help sit up properly
release tight clothing
if casualty is on medication eg. inhalers, assist with self medication
call 112
monitor casualty and be prepared to resuscitate if need be

Foreign Body Airway Obstruction (FBAO)

Foreign Body Airway Obstruction can manifest in two ways: foreign bodies may cause partial, or complete airway obstruction.

Signs & symptoms of foreign body airway obstruction

In mild (partial) airway obstruction, the casualty is able to speak and cough.

In severe (complete) airway obstruction, the casualty:

is unable to speak or cough
has noisy breathing (wheezing)
shows signs of severe dyspnoea
shows signs of distress
may be or become unresponsive

First Aid for Foreign Body Airway Obstruction

In a conscious patient:

5 back blows followed by 5 abdominal thrusts
continue, alternating between the two methods until either foreign body gets dislodged, or else casualty becomes unresponsive

In an unconscious patient:

start CPR

NOTE: in casualties who are either obese, pregnant, or children, do not perform abdominal thrusts…instead do chest thrusts; after the intervention, the casualty should be taken to hospital to be assessed for possible internal damage.

Chest Pain

Chest pain can result due to Ischaemic Heart Disease – a disease in which there is an obstruction of blood flow to an area within the heart which causes hypoxia and death of that particular area in the heart.

Signs & Symptoms of Acute Ischaemia

feeling generally unwell
pale and cold skin
profuse sweating
feeling persistent pain or heaviness in the chest
chest pain may radiate to the left arm, jaw and back
may experience palpitations
may experience nausea
dyspnoea

First Aid for Acute Ischaemia

provide reassurance
ensure surrounding area is well ventilated
assist in a sitting position
release any tight clothing
assist with own medication if available on casualty eg. 300mg of aspirin
call 112
ask someone to get an AED
monitor
be prepared to resuscitate if need arises

Anaphylaxis & Anaphylactic Shock

Anaphylaxis happens when a person comes into contact or exposure to an allergen.

Signs & Symptoms of Anaphylaxis

changes within the skin and mucous membranes eg. rash, burning sensation, swelling of the mouth and tongue
sudden illness development
rapid ABC deterioration eg. swelling of airway structures, altered level of consciousness, dyspnoea, wheezing, cyanosis, dizziness & weakness (neurological response)

NOTE: If a casualty experiences all the above PLUS signs of shock (including pale, clammy skin), the indication would be an ANAPHYLACTIC SHOCK, which is even worse than anaphylaxis!

First Aid for Anaphylaxis & Anaphylactic Shock

identify cause (eg. if cause was an insect sting, remove it)
if unconscious, resuscitate
if unresponsive but breathing, assist into the recovery position
if patient is responsive, assist in a supine position UNLESS patient is exhibiting signs of shock, in which case, elevate legs, OR if experiencing severe dyspnoea, in which case assist in fowlers position or elevate back as much as possible
administer high concentration of oxygen
if an epipen is available on the casualty and the casualty is responsive, administer, assist in self injecting Epinephrine

NOTE: Epinephrine helps DECREASE severity of anaphylaxis, EASE bronchospasms due to causing bronchial airways to dilate, and REDUCE circulatory collapse through a triggered increase in cardiac contraction as well as reversal of peripheral vasodilation.

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First Aid for Trauma to Specific Body Sites

The way first aid for trauma is delivered differs based on which specific body site was affected in the injury.

Trauma related to the musculoskeletal system (bones, joints, muscles, ligaments, and tendons) include the following:

FRACTURES: when the continuity of the bone is disrupted, influencing its function
DISLOCATIONS: when the normal structure of a joint is disrupted, causing a difference in the shape, posture, and movement related to it
SPRAINS : overstretching a ligament, influencing the movement of the area
STRAINS: overstretching a muscle or tendon

Patient Assessment

Conduct primary assessment using the S.A.F.E. and D.R. A.B.C. approach
Attend to unconsciousness, serious bleeding, and cardiac arrest
Position patient in a comfortable position with caution
Perform secondary assessment and provide first aid for main complaint
Look for D.O.T.S. – deformities, open wounds, tenderness, and swelling
Take vital signs – pulse and respiratory rate especially if casualty is in a lot of pain
Take S.A.M.P.L.E. history

Retrieved from https://www.alsg.org/fileadmin/*temp*/Specific/Ch04_BLS.pdf on 3rd September 2022

Retrieved from https://www.alucansa.com/showroom/?ss=5_6_4_26_36&pp=basic+first+aid+training&ii=2293819 on 5th September 2022

Retrieved from https://explorefirstaid.com/what-does-dots-stand-for-in-first-aid/ on 28th September 2022

Retrieved from https://www.slideserve.com/carter/baseline-vital-signs-and-sample-history on 4th September 2022

First Aid for Fractures

trauma — Fractured Femur, Broken thigh x-rays image – Retrieved from https://www.oaidocs.com/2019/02/22/why-you-may-need-surgery-for-a-fracture/ on 28th September 2022

Signs & Symptoms of a fracture

history in relation to the injury
loss of function
locked joint
abnormal movement
exposed musculoskeletal fragments
signs of pain, tenderness, and area guarding
swelling, bruising, deformity, or crepitus (popping, clicking or cracking sounds in a joint)

Fracture Complications

bleeding
loss of function
instability
injury to the covering soft tissue
limb loss – amputation

First Aid for Fractures

provide support to the fractured area
expose injury site (eg. remove shoes)
touch the area to assess sensation
test circulation within the injured limb by pressing on area and determining whether normal colour is restored in 2 seconds
address bleeding and cover wound
immobilise area
following any intervention on the area, reassess sensation and circulation
reassure casualty
seek medical help

First Aid for Sprains

Signs & Symptoms of a Sprain

pain, swelling and bruising
inability to use limb appropriately

NOTE: signs and symptoms of a sprain are very similar to a fracture…if in doubt, treat as a fracture!

First Aid for Sprains & Strains

follow the R.I.C.E. acronym…
R – rest (and remove footwear)
I – use ice packs on area for not more than 10 minutes to reduce pain and swelling
C – compress using bandage
E – elevate affected limb

Trauma Amputation First Aid

First Aid on Stump

control bleeding
address shock
irrigate area using saline water or water
remove gross debris
apply dressing
elevate limb
ensure casualty comfort and reassurance

Care for Amputated Part

remove gross debris
wrap in a saline-moisted gauze
place in a plastic bag
store in a container with ice and water, ensuring that ice does not come into direct contact with severed part
DO NOT CLEAN OR WASH AMPUTATED PART WITH WATER!

Trauma to the Head, Neck & Back

Retrieved from https://medicine.wustl.edu/news/new-guidance-developed-for-children-hospitalized-with-mild-head-trauma/ on 30th September 2022

If a casualty falls from a height at least double his or her own weight, head injury should be suspected, even if there are no visible signs and symptoms. In such case, head injury should only be excluded following medical investigations.

Possible Head Trauma Consequences

surface injury – bruising or actual wounds
skull fracture – leading to lack of protection to the brain
facial fracture – causes bleeding and possible bone fragments which may lead to airway obstruction
brain injury – may lead to epidural & subdural haematoma as well as intracerebral haematoma
intracranial bleeding – eg. subarachnoid haemorrhage in the brain
concussion – soft tissue damage to the brain without evident bleeding

Indications

history of head trauma
headache
dizziness
nausea
vomiting
limb weakness and/or loss of sensation (may be a sign of neurological damage)
disorientation and/or confusing
altered level of response
seizures

Further signs may include:

unequal and/or unresponsive pupils
ecchymosis (racoon eyes)
battle’s sign (bruising around the eyes or behind the ear
rhinorrhoea (bleeding or clear liquid emerging from the nose)
otorrhoea (bleeding or clear liquid emerging from the ear/s)
halo sign (can be seen on the bedsheet under a casualty’s head)
abnormal posture (eg. stretching, flexing etc)

Assess further for…

intoxication (ask relatives if available, and look for obvious intoxication signs)
evidence suggesting a possible suicide attempt
casualty’s age (risks increase when over 65 years of age)
current treatments eg. anticoagulants
history of coagulation disorders

First Aid for Head Trauma

NOTE: prior to first aid, consider possible trauma to the cervical spine and neck…signs include an altered level of response, pain and/or tenderness, weakness, or loss of sensation in the neck/back area.

if casualty is unresponsive and not breathing, perform CPR
use sterile or, if unavailable, clean dressings for head wounds
in case of severe facial trauma clear casualty’s mouth from foreign material, blood and fragments
in case of eye injuries, DO NOT REMOVE any embedded fragments; just cover both eyes
apply ice packs on haematomas for a maximum of 15 minutes
apply pressure ALWAYS with caution
elevate the casualty’s head and shoulders

IMPORTANT: manually stabilise the head and neck, maintaining alignment to avoid complications or further damage.

Trauma to the Neck & Back

prevent movement of the casualty’s head and neck
use the jaw-thrust technique to open the airway of an unresponsive casualty
turn the casualty using the log-roll method to perform a secondary assessment or for putting into the recovery position OR
use the Haines recovery position if log-roll method cannot be used

Trauma to the Chest

Retrieved from https://www.distancecme.com/chest-wall-trauma-field-ready-facts-and-treatments/ on 30th September 2022

Complications

Trauma to the chest may lead to complications such as:

rib fracture
flail chest – consists of 2 or more broken ribs
pneumothorax – air trapped in chest that compresses the lung causing a collapsed lung, whilst also pressing onto the heart; evident in an x-ray as a dark space in the lungs; visually evident as chest asymmetry during breathing
haemothorax – same as a pneumothorax, except that blood is trapped in the chest instead of air
cardiac tamponade – build-up of blood between the pericardium and the myocardium which increases pressure on the heart, causing obstructive shock

Signs of Chest Trauma

history of trauma to the chest
severe pain
severe dyspnoea
bruising
open chest wound
shock

First Aid for Chest Trauma

leave any foreign bodies embedded in the chest – DO NOT REMOVE!
leave chest wound uncovered if not bleeding
if chest wound is oozing blood, cover with a non-occlusive dressing such as a gauze swab and apply pressure with caution
stabilise affected chest side with an arm sling
if possible, help casualty into a semi-sitting position, supporting the back
if available, administer high-concentrated oxygen
if oxygen is unavailable open windows to increase air circulation

Trauma to the Abdomen

Retrieved from https://www.lecturio.com/concepts/penetrating-abdominal-injury/ on 30th September 2022

Complications

bleeding
shock

First Aid for Abdominal Wounds

leave any foreign bodies embedded in the abdomen – DO NOT REMOVE!
cover wound with moist sterile dressing
if there are any visible protruding organs DO NOT PUSH BACK INSIDE as this may cause further complications and damage

First Aid for Abdominal Trauma Without Visible WOunds

assist casualty in a comfortable position, preferably with legs pulled towards the abdomen
monitor for deterioration
address shock if evident

Fractured Pelvis & Hips

Retrieved from https://www.healthpages.org/health-a-z/hip-fracture-older-adults/ on 30th September 2022

Signs & Symptoms

history of trauma to the pelvis or the hips
pain and tenderness
swelling
bruising
wounds
deformity
shortening/external rotation
unable to bear weight

First Aid for the Pelvis and Hips

limit casualty’s movement of the back, the pelvis, and the lower limbs
control external bleeding
splint open fractures or use body splinting for lower limbs
monitor for shock and provide first aid for shock if necessary

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First Aid for Compromised Airway

Compromised airway can result from three issues, namely obstruction, constriction, or trauma.

Obstruction can happen through tongue positioning, foreign body, vomiting, or aspiration
Constriction a.k.a. swelling can happen in the mouth, by the tongue, or due to airway structures
Trauma can be either maxillo-facial (trauma to the jaw and face) or mandibular (trauma to the lower jaw)

Assessment for Compromised Airway

1. look

Watch out for accessory muscle use, tracheal tug, or paradoxical (see-saw) chest-abdo movements…

2. Listen

Can you hear any gurgling, stridor, snoring or hoarseness coming out of the casualty’s mouth?

3. feel

Can you feel air moving in and out of the casualty’s mouth or nose?

First Aid for Compromised Airway by Foreign Bodies

If a person coughs excessively whilst eating, keep a hands-off approach and encourage the person to cough. Coughing signifies that air is still going in and out of the lungs, thus, encourage to deep breathe and cough as hard as possible to cough out the obstructed foreign body.

If the person is not coughing, or coughing is ineffective, follow the 3 first aid maneuvers for compromised airway by foreign body listed below:

Back Blows

give up to 5 back slaps – hit back from low direction upwards (least effective, least damaging)

Abdominal Thrusts

perform up to 5 abdominal thrusts (moderately effective, moderately damaging – may cause organ rupture)

Chest Thrusts

perform up to 5 chest thrusts (most affective, most damaging – casualty needs to be taken to hospital following chest thrusts to have internal organs checked due to possible damage)

NOTE: If obstruction doesn’t get cleared out, the casualty eventually collapses. At this point perform CPR and before giving mouth-to-mouth check inside the mouth to see if object has dislodged with compressions.

Paediatric Compromised Airway

Babies usually deal with choking on their own, without needing first aid
DO NOT perform abdominal thrusts on infants, since doing so may cause liver rupture. Instead, perform chest thrusts and back blows

Narcan (Naloxone)

Narcan (Naloxone) is a medication used to block the effects of opioids. It is commonly used in the case of decreased breathing triggered by opioid overdose such as in heroin overdose.

Naxolone may be combined with an opioid to decrease the risk of opioid misuse.

Retrieved from https://www.princeedwardisland.ca/en/information/health-and-wellness/preventing-opioid-related-overdoses on 27th September 2022

Retrieved from https://rightpathaddictioncenters.com/opiate-withdrawal/ on 27th September 2022

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First Aid for Wounds and Burns

Wounds are skin breakages caused by injury. Complications in relation to wounds include bleeding and infection.

Types of Wounds

incision – a cut, such as one made with a knife
laceration – pulled off skin
abrasion – wound caused by friction
contusion – a.k.a. bruising
puncture wound – wound caused by a pointy object eg. nail

Retrieved from https://emedicodiary.com/que/437/wound on 20th September 2022

First Aid for Traumatic Wounds

There are 3 concepts required in providing immediate care for traumatic wounds:

control the bleeding
clean the wound
protect the wound

1. Control the Bleeding

Step 1: wear gloves to protect self from casualty’s blood
Step 2: control the bleeding
Step 3: assess for shock & if suspected, provide first aid for shock
Step 4: call 112 for assistance

2. Clean The Wound

Step 5: once the bleeding is under control, irrigate the wound with running water
Step 6: remove gross debris

3. Protect The Wound

Step 7: cover wound with a clean cloth or sterile dressing if available
Step 8: seek medical advice as required

NOTE: DO NOT remove any foreign objects embedded in wounds! Such objects need to be removed in a hospital setting, with adequate pain relief. If foreign object is embedded, apply bandaging to hold it in place until casualty arrives at the hospital.

First Aid for Particular Types of Wounds

Fracture site wounds

If there is a visible fracture at the injury site, or a fracture is suspected, do not apply a lot of pressure to stop the bleeding since this would cause a lot of pain, as well as create further problems with the fracture. In such case you can still irrigate the wound by running water.

Thoracic Wounds

When dealing with thoracic wounds, do not apply too much pressure to stop the bleeding. Additionally, leave the chest wound uncovered. You may clean the area surrounding the wound, but there is no need to irrigate the wound with running water.

Abdominal Wounds

If an injury to the abdomen causes the intestines to be pushed out of the abdomen, do not attempt to push them back inside the casualty, as this may cause serious damage. Instead, use a moist sterile cloth and cover the intestines, or else leave the intestines uncovered and wait for the ambulance to arrive.

Burns

Burns occur when the body is exposed to thermal, chemical, or electrical energy which leads to skin loss and damage to the underlying tissue. Complications arising from burns include tissue damage, fluid loss, heat loss, and infection.

Types of Burns

thermal burns – flames, hot objects, flash burns, radiation, hot liquids, and steam burns
chemical/corrosive burns
electrical burns – caused by electric conduction which usually causes 2 wounds: a small entry wound and a larger wound at the earthing area; electrical burns can easily cause a cardiac arrest!

The severity of an injury caused by a burn depends on factors such as the site of injury, the depth and extent of injury, the cause, as well as the casualty’s age, prior health status and additional injuries.

Burn Depth

1. Superficial Burn

In a superficial burn, the burn affects only the epidermis of the skin. Signs of a superficial burn include:

pain
redness
blanches with pressure
absent oedema

2. Partial Burn

In a partial burn, the burn affects both the epidermis and the dermis. In such burns, blisters may appear, which are fluid-filled located between the epidermis and the dermis. NEVER burst a blister unless in a hospital setting! Signs of a partial burn include:

pain
blisters
moisture

3. Full Burn

In a full burn, the burn uncovers the structure of the affected area – structures such as muscles and bones. Nerves are usually burned in these types of burns, which causes the casualty to experience no pain sensation. Signs of a full burn include:

uncovered structures
discolouration
dryness
absent pain

Retrieved from https://suprathelu.com/row/ on 20th September 2022

Measuring the Extent of a Burn

Method #1: The Palmar Method
Method #2: The Rule of 9’s

Retrieved from https://twitter.com/hp_ems/status/1421585002073149445 on 20th September 2022

Managing Burn Injuries

In burn injuries the main aims are to:

reduce pain
reduce the burning process
protect the injury

cool burn down with running water
remove ALL burnt clothing
cover burned area with a moist dressing and keep it wet so it doesn’t stick to the burnt area
if a moist dressing is not available, cover the area with plastic film
seek medical attention

DO NOT use any creams to treat burns.
DO NOT use ice to calm down the burning sensation as ice can cause a burn too.
DO NOT remove any clothing that is seemingly stuck to the burnt area.

First Aid for Other Types of Burns

Electrocution burn

Whilst an electrocuted casualty may not experience a cardiac arrest immediately, it is still possible after some time. Thus, if the casualty complains of chest pain and dyspnoea, get ready to resuscitate as a cardiac arrest may become quite possible.

Liquid chemical burn

If a casualty experiences a liquid chemical burn, flood burned area with water.

Dry Powder Chemical Burn

In the case of dry powder chemical burns, brush dry powder off, making sure it is still safe for you, and then flood with water.

NOTE: Inhaling hot or chemical fumes causes burns within the airway and the lungs. Thus, a casualty experiencing inhalation in such cases should go to the hospital for treatment as soon as possible.

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Bleeding and Shock First Aid

In the acronym DR ABC, C stands for circulation. Signs of circulation compromise to watch out for include bleeding or shock symptoms.

The Human Circulatory System

The human circulatory system comprises of the heart, the blood vessels, and the blood. All these components need to be working efficiently so that every tissue within the body is supplied with oxygenated blood.

Shock Causes

A decrease in blood pressure and SPO² indicate circulatory failure – the brain is slowly dying due to lack of oxygen, and so, it triggers a defense mechanism: SHOCK.

Any issue affecting the heart, the blood vessels, or the blood volume, may lead to a decrease in the body’s blood circulation, leading to a reduction in blood pressure and volume, which in return cause a decrease in tissue perfusion.

Decreased Cardiac Output = Decreased Circulating Volume & Pressure = Reduced Venous Return

Types of shock include:

cardiogenic shock
obstructive shock
neurogenic shock
septic shock
anaphylactic shock
hypovolaemic shock

Causes of shock can be divided into 3 categories:

1. Decrease in the Pumping Action of the Heart

A drop in cardiac output can result in a:

Cardiogenic Shock – this may happen due to a heart defect or disorder (cardiogenic = issue originating from the heart itself) eg. Congestive Heart Failure (CHF) or Ischaemic Heart Disease (IHD);
Obstructive Shock – this may happen due to cardiac compression in cases such as in cardiac tamponade (bleeding within the pericardial space) and tension pneumothorax (air accumulation in the pleural space which compresses the lungs and decreases venous return to the heart).

2. Blood Vessel Dilation

Following vasodilation, which refers to the dilation of the blood vessels, a casualty can suffer a distributive shock:

Neurogenic Shock – happens following a spinal injury, head injury, or opiate overdose;
Septic Shock – happens following a severe infection which causes the casualty’s blood pressure to drop to a dangerously low level;
Anaphylactic Shock – happens following a severe allergic reaction

NOTE: due to a biochemical process in the body, chemicals released cause vasodilation, which then causes either a septic shock or an anaphylactic shock.

3. Blood or Fluid Loss

Severe bleeding or severe dehydration can lead to a hypovolaemic shock. This happens due to the drop in blood volume.

Progressive Shock Clinical Indicators

initial weak rapid pulse that eventually becomes thready or absent (body increases heart rate to compensate due to lack of blood; eventually, drop in cardiac output = drop in stroke volume = weak heartbeat)
initial rapid irregular breathing that eventually becomes laboured and dyspnoeic
initial pale skin that eventually becomes cold, clammy and mottled (happens since the body compensates lack of oxygen circulation by sending it in the most important areas rather than in the extremities)
cyanosis – signifies established hypoxia
weakness and fatigue – signifies cerebral hypoxia (lack of oxygen in the brain)
confusion and disorientation
altered level of response leading to unresponsiveness…casualty is now at risk of cardiac arrest!

Shock First Aid

identify cause of shock
control cause of shock
assist casualty in shock position – elevate legs by about 30cm to increase venous return; if casualty is conscious but dyspnoeic, a semi-sitting position helps provide better breathing
maintain casualty’s body temperature – this helps in avoiding hypothermia, which would disrupt an open wound’s clotting process, leading to longer bleeding time
administer high-concentrated oxygen if available
increase ventilation by opening windows if inside
call 112 for assistance
monitor casualty for deterioration – if casualty is in recovery position, attempt to maintain shock position i.e. elevated legs, if possible
provide reassurance at all times

NOTE: The term vasoconstriction refers to constriction of the blood vessels. It can be clinically indicated in blood pressure results that show a difference of about 20 only between the systolic and diastolic readings. In such case, the pulse is weak or not palpable.

Bleeding

Bleeding amount depends on what it is originating from:

ARTERIES – spurting blood, pulsating flow, bright red colour
VEINS – steady, slow blood flow, dark red colour
CAPILLARIES – slow and even flow

Bleeding severity depends on the injury body site, blood loss volume, time frame of blood loss volume, casualty’s age (worse in children and the elderly), and casualty’s health status prior to the injury.

Catastrophic bleeding refers to bleeding in which 30% of blood volume is lost. Such bleeding takes priority over Airway and Circulation in the DR ABC acronym.

The major consequence of blood loss is a hypovolaemic shock (explained further up). During this type of shock, the heart becomes unable to pump enough blood throughout the body due to severe blood or fluid loss. This leads to organs shutting down.

External Bleeding First Aid

wear gloves to protect self
control bleeding through direct pressure or using a pressure dressing
monitor and provide first aid for shock

Notes:

In bleeding circumstances without signs of shock, elevation is not recommended anymore.
Indirect pressure (pressing on arteries eg. on femoral or brachial artery) is not a recommended bleeding control technique anymore.
If direct pressure method fails, you may use an emergency bandage, tourniquet, or haemostatic agents, all of which require prior specific training.
In catastrophic bleeding first aid, one may pack the wound with a towel. Worrying about an infection is not a primary concern at this point, since catastrophic bleeding may lead to loss of life.
Haemostatic Agents can be poured on wounds to stop catastrophic bleeding. Only materials specifically prepared for bleeding purposes may be used
A tourniquet is a device that helps apply pressure to a limb or extremity to limit the flow of blood. It may be used in emergency situations, during surgery, or in the post-operative rehabilitation period.
Normal use tourniquets are orange in colour, while the Combat Application Tourniquet (CAT) is usually black.

Internal Bleeding

Internal bleeding may be caused as a disease process eg. due to a stomach ulcer, or trauma.

Common sites of serious internal bleeding include the head, the chest, the abdomen and pelvis.

Internal bleeding is more difficult to diagnose, since it usually doesn’t show. The worst type of internal bleeding happens in the pelvic area, right in the retroperitoneum.

Recognition of internal bleeding may be done through:

History
Signs & Symptoms
Pain & Tenderness
Revealed Internal Bleeding (eg. internal bleeding in the head may produce trickling blood out of orifices such as from the ear)

Types of Internal Bleeding:

Otorrhoea – blood coming out of the ear
Rhinorrhoea – blood coming out of the nose
Haemoptysis – coughed out blood
Haematemesis – vomited blood
Haematuria – bleeding in the urine
Rectal Bleeding – bleeding coming out of the intestines
Bruising

Retrieved from https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device on 18th September 2022

NOTE: If there is suspicion of internal bleeding, it NEEDS TO BE ASSUMED! Monitor for ABC compromise and signs of shock, and provide first aid as needed!

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Believe In Yourself – Never Give Up!

When I embarked on my journey for a Degree in Nursing as a mature student 4 years ago, I must admit I was pretty sure I wouldn’t make it past the interview phase.

I had zero self confidence. I did not believe in myself. Not at all. But there were a few individuals around me who did believe in me. And so, although I couldn’t see a possibility, I tried. I applied. I attended…and I passed the interview phase.

When I was asked to sit for an English Proficiency Test, I walked in, terrified, trembling. My mouth dried up…I could probably use an IV infusion at that time! And when we were asked to start writing, I could hear other students starting to write frantically on their exam papers while I had to close my eyes and calm my heart’s drastically increasing rate through deep breathing. It took me probably about 5 minutes to start writing…but I did it. I finished on time. And I passed.

When I stepped in a lecture room at the University of Malta for the first time at 37 years old after being accepted to take the 5 year long course, I wanted to do my best to sink into the seat I was sitting on, hoping that I would blend in or even better, go unnoticed amongst all the other students, most of who were the same age as my oldest daughter.

But day by day, the course started changing me.

Now, 4 years later, I can affirm I’ve probably been one of the biggest butt-pains my amazing lecturers have experienced so far (some of them know this…I’ve literally told them so because I feel it’s true!!).

Asking questions following deep reflections has become the norm for me. I no longer sink into my seat…I don’t mind speaking up anymore. I don’t mind advocating for others, be it students, patients, or anyone in need of support for a good cause.

A new challenge is now coming up…speaking up on a broader spectrum – speaking up with the aim of breaking health-related taboos that we still are dealing with here in Malta.

I know beyond doubt that this is going to be quite a tough challenge for me, yet I am ready to face it. For even as a registered nurse, in 2 years’ time I want to have enough experience to be a better advocate for my patients, both on an individual level, and if necessary, even on a larger scale. I want to be the voice of those who haven’t yet found theirs…who are still in the same spot I was 4 years ago, just sinking in my seat to avoid being seen.

Never did I imagine I could be where I am today, and for this I can only humbly thank those who believed in me when I didn’t, as well as all the lovely lecturers and academics at UM who were willing to listen and to encourage me from the very beginning to always speak up whenever I deem necessary.

One final piece of advice… It is NEVER TOO LATE to start something new! Believe in yourself and when hurdles pop up, jump. If you fall, get back up, dust yourself off and retry…keep trying until you make it through!

You too can be all you have ever wanted to be. You have all the potential you need to be or have whatever you wish.

Are you ready to turn your dreams into reality?

Acknowledge your power! Believe in yourself! YOU are the sole creator of your life! Start living the Life of your Dreams today!

5 Simple Steps To Creating The Life Of Your Dreams

Sudden Cardiac Arrest CPR & AED Basic Life Support

A sudden cardiac arrest is a sudden cessation of the pumping action of the heart.

A sudden cardiac arrest is NOT the same as a Myocardial Infarction (heart attack), which occurs when the blood flow to the heart (or part of) decreases or stops, causing damage to the cardiac muscle. A Myocardial Infarction usually produces symptoms such as chest pain, or discomfort traveling into the shoulder, arm, back, neck, or jaw.

In Cardiovascular Disease a.k.a. Heart Disease, narrowed or blocked blood vessels may lead to a Myocardial Infarction, angina, or a stroke.

Sudden Cardiac Arrest ~ Facts

A Myocardial Infarction may lead to a sudden cardiac arrest
Heart disease is the most common cause of a sudden cardiac arrest
Individuals who suddenly fall and die eg. during shopping, swimming, running etc are presumed to have experienced a sudden cardiac arrest
40% of the total amount of deaths of individuals less than 75 years of age are attributed to individuals suffering a sudden cardiac arrest without knowing that they have a cardiovascular disease

What Happens During a Sudden Cardiac Arrest?

the heart stops beating in an effective way
breathing stops
blood flow within the body stops
oxygen supply to the body’s organs stops
the heart and the brain suffer irreparable damage
the individual dies

CPR & AED Use For Sudden Cardiac Arrest

A Sudden Cardiac Arrest is identified right away during the primary assessment:

casualty is unresponsive
casualty is not breathing

DO NOT SPEND MORE THAN 10 SECONDS DOING THE ABOVE…TIME IS CRUCIAL!

4 minutes post start of a Sudden Cardiac Arrest, brain damage starts to take place;
10 minutes post start of a Sudden Cardiac Arrest, brain is dead.

NOTE: Do not confuse agonal breathing with normal breathing. During agonal breathing, the casualty’s chest doesn’t rise and fall. Agonal breathing is not breathing…it is in fact just a reflex.

How To Perform Artificial Ventilations

To perform artificial ventilations on adult casualties:

pinch nose
open airway
take a normal breath
seal your lips around the casualty’s mouth
blow air in until the casualty’s chest rises
allow the casualty’s chest to fall back
repeat

To perform artificial ventilations on children and infants follow the above BUT seal your lips around both the casualty’s mouth AND nose.

The AED: Automated External Defibrillator

Contrary to what is believed by many, an AED’s shock doesn’t restart the heart. About 65% of casualties suffering a sudden cardiac arrest present with an abnormal cardiac rhythm known as ventricular fibrillation, where the heart quivers rather than beats as normal. This rhythm is fatal unless proper treatment is provided in a timely manner. A normal sinus rhythm can be restored following ventricular fibrillation by proper pressure through:

Early CPR
Early AED

Adult Basic Life Support Sequence

If casualty is unresponsive:

open casualty’s airway using the head-tilt chin lift technique
look, listen, & feel for breathing signs
if unresponsive and not breathing call 112 or ask someone to do so & send for an AED
start CPR (30 chest compressions : 2 breaths)
aim for a chest compression rhythm of approximately 2 compressions per second using 2 hands (fingers interlocked) aiming for the middle of the breastbone and a depth of 5-6cm, allowing full chest recoil after each compression
breaths should amount to approximately 1 second each
remember to protect yourself from any vomit/bleeding by using available devices – face sheet & gloves
use an AED if or when available whilst following its verbal instructions (continue CPR unless instructed by AED to not touch the patient)

Stop CPR if help arrives, if the casualty starts breathing again, if the scene becomes dangerous, or if you become too tired and there is no one else who can substitute you.

Infants & Children Basic Life Support Sequence

Paediatric guidelines are as follows…

In the case of individuals responsible for children such as paediatric nurses, educators following special cases, etc. and trained in paediatric basic life support:

open child’s airway using the head-tilt chin lift technique
look, listen, & feel for breathing signs
give 5 rescue breaths
if phone is promptly reachable call 112 immediately while starting CPR
if phone is NOT promptly reachable do 1 min CPR before leaving to fetch a phone
perform paediatric CPR doing 15 compressions : 2 ventilations
use 1 hand for chest compressions in children up to 8 years of age and 2 hands in largely built children
rate of compressions should be approximately 2 per second (100 – 120 per minute)
depth of compression should be 1/3 of chest but never deeper than 6cm
each breath should be approx 1 sec long providing an effective chest rise
remember to protect yourself from any vomit/bleeding by using available devices – face sheet & gloves
use an AED if or when available whilst following its verbal instructions (continue CPR unless instructed by AED to not touch the patient); IMPORTANT – on a child, one electrode is placed on the front of the chest, and the other is placed on the back, both parallel to each other

NOTE: INFANTS <1 YEAR = 15 chest compressions : 2 breaths (use 2 fingers only on lower half of breastbone); each breath should be approx 1 sec long providing an effective chest rise. IMPORTANT – cover mouth and nose with mouth for an effective breath but do not over-do it!

For those not trained in paediatric BLS or not confident enough, adult basic life support technique should be used, ideally giving 5 rescue breaths before calling for assistance.

Stop CPR if help arrives, if the casualty starts breathing again, if the scene becomes dangerous, or if you become too tired and there is no one else who can substitute you.

Cardiac Pump Theory VS Thoracic Pump Theory

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