MEDICAL EMERGENCIES The dictionary defines an emergency as a serious, unexpected event that demands immediate attention. Sudden deterioration in the status of any patient under your care is an acute situation requiring an appropriate response. Whether such a situation leads to a more serious problem may depend on your ability to act quickly and efficiently. Seen from this perspective, no patient problem can be considered trivial. You will experience many acute situations over the years, and you must be prepared to minimize the possibility of further injury or complication. EMERGENCY DEPARTMENT The emergency departments (EDs) of most hospitals serve a variety of clients. Individuals with health insurance may use urgent care or surgical centers for minor emergencies. For the poor and uninsured, however, the ED often serves the additional function of family physician. Many such admissions to the ED present valid problems, even if they are not emergencies. This can rapidly overload both staff and facilities, especially in an urban setting. Establishing priorities and functioning effectively under such circumstances can demand intense application of your patient care and assessment skills. Many hospitals have specialized facilities designated as trauma units, which are usually part of the ED. There are three designated levels of trauma facilities: •Level I trauma centers are able to care for all levels of injuries and are usually found in large institutions. They are staffed around the clock with physicians, surgeons, and support personnel who are highly trained in the care and treatment of traumatic injuries. Level I hospitals have access to transfer facilities, such as helicopter rescue units, that permit the most seriously injured patients to reach the center in a relatively short time. A Level I hospital must be able to provide emergency radiography, fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI) procedures around the clock. There must also be access to nuclear medicine studies, angiography, and sonography. Facilities for neurologic care must also be available. •Level II trauma centers are the next level of trauma care. An ED physician is on 24- hour duty, as are emergency trained nurses and radiology staff. Surgical radiographic and fluoroscopic procedures must be available, as well as the ability to perform angiography, CT, and MRI procedures. Patients will be transferred to Level I facilities only if necessary. •Level III trauma centers are smaller community hospitals that usually have an ED physician and radiographer on call at night. Trauma patients with life-threatening conditions will be transported to a Level I or Level II hospital as needed. Research has proven that victims of massive trauma who survive the initial injury have a greater chance of recovery if their condition can be stabilized within the first “golden” hour after the accident. For this reason, every minute is precious, and trauma teams work under great pressure. The care of highly trained personnel and the immediate availability of equipment for diagnosis and treatment have greatly improved the potential for saving lives. The transport team, usually made up of qualified emergency medical technicians (EMTs), delivers the patient to the trauma unit as soon as an airway has been established, bleeding has been controlled, and the patient has been immobilized. The first assessments made by the physician at the trauma center involve evaluation of cardiac status, respiratory status, and the possibility of vertebral fracture. Trauma patients are transported on a rigid backboard and are not removed from it until spinal fracture has been ruled out. The danger of paralysis is so great that this ranks directly after respiratory arrest (cessation of breathing) and cardiac arrest (cessation of heartbeat) in terms of priority. When accident victims must be taken to the imaging department, their conditions have usually been stabilized. They have been thoroughly examined by a physician, blood loss has been controlled, an airway has been established, intravenous (IV) fluids have been started, and medication for pain or blood pressure control has been given. When radiographs are taken on the way to the operating room, cast room, or intensive care unit (ICU), a nurse usually accompanies the patient. Emergency patients are subject to sudden changes in condition and may go into shock. Once the acute phase of an accident is over, many patients who were full of fortitude experience a delayed emotional reaction. This may consist of uncontrollable crying or a compulsive urge to tell everyone about the accident. They may even have a physical reaction, such as fainting, trembling, or violent nausea. Your most positive action is to be available, offer nonverbal support, and watch carefully for any signs of a deteriorating physical condition. Your ability to speak calmly and work competently under pressure is reassuring. When accident victims are brought to x-ray dressed in street clothes, it is sometimes necessary to remove garments before the radiographic examination. Avoid cutting or tearing clothing whenever possible. Keep all the patient's personal possessions in one place. One easy system is to place everything in a plastic bag clearly identified with the patient's name. The bag is then placed on the stretcher or wheelchair with the patient. Check the procedure in your clinical area and be consistent in using it. MULTIPLE EMERGENCIES Radiographers ordinarily encounter only one emergency at a time. Occasionally, however, a single accident will have multiple victims, or several acute situations may develop simultaneously. In these cases, you must assess priorities. If you see that it may be difficult for you to cope alone, do not hesitate to call for assistance before the situation places lives in jeopardy. Although patients are usually admitted to the radiology department on a scheduled or first-come, first-served basis, exceptions must be made for emergencies. An order designated STAT (from the Latin statim) is to be done at once and indicates that the patient's well-being may be seriously jeopardized by any delay. When more than one patient from the ED requires examination at the same time, the radiographer may need to determine which patient's status is the most urgent. Generally speaking, the highest priority is assigned to patients whose vital signs are unstable and whose immediate care depends on the results of the examination, such as those in severe respiratory distress. With two cases of apparently equal urgency, start with the patient who can be examined in the shortest amount of time, because this decision will result in the shortest total waiting period. DISASTER RESPONSE A disaster is an emergency of huge magnitude that creates an unforeseen, serious, or immediate threat to public health. It could be a natural event, such as a tornado, earthquake, flood, hurricane, or pandemic; or it could be accidental, as in the case of a plane crash or train wreck. Events of terrorism are manmade disasters. Every general hospital is required to have a carefully designed and written disaster plan, and each member of the health care team must be familiar with the plan and his or her role in it. Disaster drills are regularly scheduled exercises that prepare the hospital staff to function effectively if the disaster plan must be implemented. A major disaster may involve all emergency services in the community, so your hospital may coordinate its drills with those of other agencies. You must be familiar with the plan for the institution and participate actively in the practice drills. The process of identifying the victims, performing initial examinations, and assigning priorities for further care is called triage. A triage station is set up in a large area, such as a lobby. The triage officer, usually an emergency care physician, directs triage activity. Simplified methods of patient identification and record keeping are used to minimize the time required for paperwork. Usually patients are assigned numbers, which are written on tags and attached to their wrists or ankles. These numbers are used to identify the radiographs and any required records. Emergency Call Systems When working alone, or when qualified assistance is not immediately available, you can obtain help by using the emergency call system. Each hospital has a procedure to call for emergency help, and several different codes may be used to identify specific situations. The fire code is one example. Other codes may be used to announce the arrival of trauma patients in the ED or to cope with a situation that demands security personnel. If you need to summon help for the patient undergoing cardiopulmonary arrest, there is also a special code for this emergency. Emergency Response Team Hospitals have a designated group of health care workers who respond to this type of code. The emergency response team, or code team, usually consists of one or more physicians, several nurses, a respiratory therapist, and an electrocardiographer. Assisting the Emergency Response Team When a code is called in the diagnostic imaging department, you must know your role and be completely familiar with whatever system is used. When the code team arrives, allow the emergency response personnel to take over immediately upon their arrival. Tell them the history of the situation and then stand by to follow their directions. There will be important tasks that you can perform. Record keeping is essential. Write down the time the emergency started and when the code team responded. You may be asked to record times and amounts of medications. It may be necessary to obtain equipment, call for other personnel, or monitor a telephone. It is important to keep unnecessary bystanders out of the way and to keep family members calm in an appropriate location, such as a waiting room. You should practice going through each code procedure until you feel comfortable and are able to function professionally, even under very stressful circumstances. Recent research shows that rapid response teams save lives. You should call for help whenever you question that the patient may be deteriorating. Emergency Carts Emergency carts, or “crash carts,” are rolling, multidrawered cabinets that are kept in strategic locations throughout the hospital. The code team usually brings the cart from the location nearest the patient. These carts vary somewhat, but each has certain essential items, such as airways, artificial ventilation equipment, emergency medications and the equipment for administering them, a board to slip under the patient when giving external cardiac massage, a blood pressure cuff, a stethoscope, and a defibrillator that can also serve as a cardiac monitor. The cart should have a list of contents and should be inspected daily to ensure that emergency supplies are available for instant use and that their dates are within the expiration limits. Some hospitals seal the cart after supplies are replenished. Never borrow equipment or supplies from the emergency set for routine use! This practice results in the absence of lifesaving items when they are most needed. Backboard Stethoscope Blood pressure cuff Bag valve mask Laryngoscope Endotracheal tubes Carbon dioxide detector for ET tube placement Tongue blades Suction catheters Tracheostomy tubes Flashlight Sterile and nonsterile gloves Cardiac monitor Defibrillator Cutdown tray Suction bottle Hemostat Scissors Needles, syringes IV solutions and tubing IV cannulas Blood collection tubes Drugs according to institutional protocol Protective gowns, eyewear, masks Pen, paper, checklist for cart contents PATIENT ASSESSMENT Patients come to the imaging department in widely varying states of health. Individuals suffering from prolonged illness or trauma, or those who are weakened by extensive preparation for examination, may suffer a sudden, life- threatening change in status. Patients with a history of chronic cardiac or pulmonary disease are at greater risk when an invasive procedure is performed. Before any patient is injected with a contrast medium or subjected to an invasive procedure, a thorough history of previous cardiac events, allergies, chronic diseases, and medications should be taken. Baseline vital signs must also be taken and recorded. Patients in the ED are classified as nonurgent, urgent, or acute (life- threatening). Obviously, the most acute cases are seen first. Even with the specialized care available in the United States today, trauma is the most common cause of death for individuals under the age of 40. Deciding the order in which patients receive treatment is ultimately the ED physician's responsibility. Families of trauma victims can be distraught and demanding when they perceive that others are being cared for first. On these occasions, your role is to reassure and explain to concerned individuals how priorities are set in such emergency situations. Assessment of Levels of Neurologic and Cognitive Functioning • Ask the patient to state his or her name, date, address, and the reason for coming to the radiographic imaging department. • Note the patient's ability to follow directions during instruction regarding positioning for the examination. Also note any movement that causes pain or other difficulty in movement, as well as any alterations in behavior or lack of response. • Assess the patient's vital signs at this time if current readings are not on the chart. Baseline readings are a must to have in order to note any changes that may occur. An increasing systolic blood pressure or widening of the pulse pressure may indicate increasing intracranial pressure. Slowing of the pulse may also indicate increasing intracranial pressure. As compression of the brain increases, the vital signs change. Respirations increase, blood pressure decreases, and the pulse rate decreases further. A rapid rise in body temperature or a decrease in body temperature is also an ominous sign. TRAUMA: Head Injuries Patients who have received a blow to the head may have sustained serious injury, even when there are no external signs of trauma. Damage may occur with or without a skull fracture. The brain is soft, has a rich blood supply, and is suspended in cerebrospinal fluid within the skull. A severe blow to the head causes the brain to bounce from side to side, resulting in injury on the side opposite the blow. This is called a contrecoup injury. A minimal amount of damage, characterized by “seeing stars” or a very brief loss of consciousness, is called a concussion. If bleeding or swelling occurs inside the skull, a rise in intracranial pressure (ICP) may cause seizures, loss of consciousness, or respiratory arrest. Incidentally, similar symptoms may also occur in patients with increased ICP related to brain tumors. Four levels of consciousness (LOCs) are generally recognized and are described as follows: • Alert and conscious • Drowsy, but responsive • Unconscious, but reactive to painful stimuli • Comatose The Glasgow Coma Scale is a numerical scale that can be used to objectively assess changes in a patient's level of consciousness over time. The patient who is alert and oriented when admitted, but then becomes increasingly incoherent, drowsy, and stuporous, may be showing signs of increased ICP. The earliest signs of increasing pressure may be irritability and lethargy, frequently associated with a slowing pulse and slow respirations. Notify the attending physician immediately if you suspect a change in LOC. Remember that the unconscious patient must have side rails in place, should not be left alone, and must be constantly monitored to maintain an airway. Some trauma patients are under the influence of alcohol. Their condition may vary from inappropriate jocularity to an alcoholic stupor, or they may be argumentative or verbally abusive. It is easy to assume that the unconscious intoxicated patient has only “passed out” because of a high level of blood alcohol, but these patients are just as subject to sudden changes in condition as nonintoxicated persons. Be especially alert to LOC changes in these patients, because the effects of alcohol may obscure important symptoms. Patients taking pain medications, or those who are insulin-dependent and have gone too long without insulin, may exhibit similar signs and symptoms. GLASGOW COMA SCALE Action Response Score Eyes open Spontaneously 4 To speech 3 To pain 2 None 1 Verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Motor response Obeys commands 6 Localized pain 5 Flexion withdrawal 4 Abnormal flexion 3 Abnormal extension 2 Flaccid 1 Highest Possible Score 15 SHOCK Shock is a general term used to describe a failure of circulation in which blood pressure is inadequate to support oxygen perfusion of vital tissues and is unable to remove the by-products of metabolism. Shock is a dangerous, potentially fatal condition. Early signs of shock are pallor, increased heart rate and respirations, and restlessness or confusion. There are five main types of shock, categorized according to the cause, which may be medical or traumatic: hypovolemic, septic, neurogenic, cardiogenic, and allergic (anaphylactic). Type of Shock Cause Loss of blood from injury or internal Hypovolemic hemorrhage; loss of plasma from burns, or other cause of severe dehydration Injury to the nervous system caused by head Neurogenic or spinal trauma Cardiac failure caused by interference with heart function. May be caused by embolism, Cardiogenic cardiac tamponade, or complications of anesthesia. Massive infection, usually by Gram-negative Septic bacteria. Contact with foreign substances, usually proteins, to which the individual has become sensitized (including bee stings and some Anaphylactic medications). Iodine contrast agents for radiographic imaging may precipitate a similar response Syncope Fainting, or syncope, is a very mild form of shock that sometimes occurs when fright, pain, or unpleasant events are beyond the coping ability of the patient's nervous system. Blood pressure falls as the diameter of the blood vessels increases and the heart rate slows. When the blood pressure is too low to supply the brain with oxygen, the patient faints. Placing the patient in a dorsal recumbent position with the feet elevated usually relieves this type of shock. Patients who have been allowed nothing by mouth (NPO) for 12 hours and are feeling anxious and stressed may undergo syncope. Patients who feel faint should be assisted into a sitting or recumbent position. If a chair is not within reach, ease the patient to the floor. If the patient does not respond immediately, spirits of ammonia held under the nose usually bring a rapid return to consciousness. Small, crushable vials of ammonia are usually kept in imaging departments for this purpose. A physician's order is not usually required for their use. A physician should assess anyone who has more than a momentary loss of consciousness before the examination is resumed. Recognizing and Treating Shock The following symptoms indicate some degree of shock in any or all combinations: •Restlessness and a sense of apprehension •Increased pulse rate •Pallor accompanied by weakness or a change in thinking ability •Cool, clammy skin (except in patients with septic or neurogenic shock) •A fall in blood pressure of 30 mm below the baseline systolic pressure •Decreased urination •Increased and shallow respirations Anaphylactic Shock Because some imaging procedures use contrast agents that contain iodine, to which some people are allergic, this is the most frequently seen type of shock in radiographic imaging. The radiographer must be able to recognize it at its onset to prevent life-threatening consequences. Anaphylactic shock (anaphylaxis) is the result of an exaggerated hypersensitivity reaction (allergic reaction) to re-exposure to an antigen that was previously encountered by the body's immune system. When this occurs, histamine and bradykinin are released, causing widespread vasodilatation, which results in peripheral pooling of blood. This response is accompanied by contraction of nonvascular smooth muscles, particularly the smooth muscles of the respiratory tract. This combined reaction produces shock, respiratory failure, and death within minutes after exposure to the allergen. Usually, the more abrupt the onset of anaphylaxis, the more severe the reaction will be. The signs of anaphylactic shock may be classified as mild, moderate, or severe as follows: Mild Systemic Reaction: •Nasal congestion, periorbital swelling, itching, sneezing, and tearing of eyes •Peripheral tingling or itching at the site of injection •Feeling of fullness or tightness of the chest, mouth, or throat •Feeling of anxiety or nervousness Moderate Systemic Reaction: •All of the above symptoms, plus: •Flushing, feeling of warmth, itching, and urticaria •Bronchospasm and edema of the airways or larynx Dyspnea, cough, and wheezing Severe Systemic Reaction: •All symptoms listed above with an abrupt onset •Decreasing blood pressure; weak, thready pulse either rapid or shallow •Rapid progression to bronchospasm, laryngeal edema, severe dyspnea, cyanosis •Dysphasia, abdominal cramping, vomiting, and diarrhea •Seizures, respiratory and cardiac arrest Radiographer's Response: •Do not leave the patient. Stop any infusion or injection of contrast immediately and notify the radiologist if any of the symptoms occur. •If the patient complains of respiratory distress or has any of the symptoms listed in the severe reaction section, call the emergency team. •Place the patient in semi-Fowler position or in a sitting position to facilitate respiration. •Monitor pulse, respiration, and blood pressure every 5 minutes or until the emergency team arrives to assume responsibility. •Prepare to assist with oxygen, intravenous fluid, and medication administration. Have large-gauge venous catheters available. •Prepare to administer CPR as required. •Chart the occurrence, the treatment administered, and the patient's response on an incident report form and/or in the chart. The medications usually given for anaphylactic shock are epinephrine, diphenhydramine, hydrocortisone, and aminophylline. Information Requested before Administration of Contrast Agents Name Age Date Have you had the study you are having today at any other time? If the answer is yes, did you have any allergic or unusual reaction? Are you allergic to any food, medications or any other substance? If you are, please specify. Recent laboratory tests performed and results Blood urea nitrogen (BUN) and createnine Have you had any protein in your urine? If so, to what degree? Do you have heart disease? Hypertension? Diabetes mellitus? Sickle cell anemia? Asthma? Have you had any procedures such as a cryptogram that involved use of contrast agents? If so, please explain. Pulmonary Embolus A pulmonary embolus is an occlusion of one or more pulmonary arteries by a thrombus or thrombi. The thrombus originates in the venous circulation or in the right side of the heart and is carried through the vessels to the lungs, where it blocks one or more pulmonary arteries Clinical Manifestations •Rapid, weak pulse •Hyperventilation •Dyspnea and tachypnea •Tachycardia •Apprehension •Cough and hemoptysis •Diaphoresis •Syncope •Hypotension •Cyanosis •Rapidly changing levels of consciousness •Coma; sudden death may result Radiographer's Response •Stop the procedure immediately, and call for emergency assistance. •Notify the physician, and bring the emergency cart to the patient's side. •Monitor vital signs. •Do not leave the patient alone; reassure the patient. •Prepare to assist with oxygen administration and administration of intravenous medication and fluid Diabetic Emergencies Diabetes mellitus is now recognized as a group of metabolic diseases resulting from a chronic disorder of carbohydrate metabolism. It is caused by either insufficient production of insulin or inadequate utilization of insulin by the cells of the body. There are four major types of diabetes mellitus • Type 1 diabetes mellitus. • Type 2 diabetes mellitus • Diabetes mellitus associated with or produced by other medical conditions or syndromes. • Gestational diabetes There are three complications of diabetes mellitus that may occur when caring for a patient: •Hypoglycemia occurs when persons who have diabetes mellitus have an excess amount of insulin or oral hypoglycemic drug in their bloodstream, an increased metabolism of glucose, or an inadequate food intake with which to utilize the insulin. This may occur when the patient has not had anything to eat or drink prior to coming to the department for his or her procedure. The onset of symptoms is rapid, and immediate action is necessary to prevent coma. •Diabetic ketoacidosis occurs when insufficient insulin causes the liver to produce more glucose, resulting in hyperglycemia. The kidneys attempt to compensate by excreting glucose with water and electrolytes. There is excessive urination (polyuria) with an outcome of dehydration and electrolyte imbalance in the body. •Hyperglycemic hyperosmolar nonketotic syndrome (coma) may be a complication of mild type 2 diabetes mellitus, or it may occur in the elderly person with no known history of diabetes mellitus. Clinical Manifestations The following occur in all cases: •Tachycardia •Headache •Blurred or double vision •Extreme thirst •Sweet odor to the breath may occur in diabetic ketoacidosis Radiographer's Response •Stop the procedure and notify the radiologist in charge of the procedure. •Do not leave the patient unattended. •Monitor the vital signs and prepare to administer intravenous fluids, medication, and oxygen as they may be needed and requested by an emergency team. Hypoglycemia The diabetic patient who has taken insulin but no food may develop hypoglycemia, or low blood sugar. Unlike the slow onset of diabetic coma, hypoglycemia is characterized by a sudden onset of weakness, sweating, tremor (quivering), hunger, and finally, loss of consciousness. While the patient is still alert and cooperative, hypoglycemia can be quickly treated by giving the patient a small amount of candy or sweet fruit juice. Squeeze tubes containing a measured amount of glucose may be stored with the emergency medications. These prepackaged doses of glucose are useful because the gel-like material can be placed inside the patient's cheek. This decreases the chance that a semiconscious or confused patient will aspirate it, as might be the case with candy or juice. Cerebral Vascular Accident (Stroke) Cerebral vascular accidents (CVAs) are caused by occlusion of the blood supply to the brain, rupture of the blood supply to the brain, or rupture of a cerebral artery, resulting in hemorrhage directly into the brain tissue or into the spaces surrounding the brain Clinical Manifestations •Possible severe headache •Numbness •Muscle weakness or flaccidity of face or extremities, usually one-sided •Eye deviation, usually one-sided; possible loss of vision •Confusion •Dizziness or stupor •Difficult speech (dysphasia) or no speech (aphasia) •Ataxia •May complain of stiff neck •Nausea or vomiting may occur •Loss of consciousness Myocardial Infarction Myocardial infarction (MI) is the medical term for what is also called a heart attack. When a coronary artery becomes occluded, a portion of the heart wall becomes ischemic, and the heart muscle supplied by the artery will die if blood flow is not quickly restored. When a patient complains of sudden, intense chest pain, often described as a crushing pain, you should assume that the patient is having a heart attack until proven otherwise. Patients may underestimate the importance of this type of pain and assume instead that the sudden onset is terrible heartburn or indigestion. Pain may be referred to the left arm, jaw, or neck. These patients often become diaphoretic, have an irregular heartbeat, become pale, and may feel nauseated and short of breath. You must prevent further damage by minimizing patient exertion. Stay with the patient, call a physician, and assist the patient to a comfortable position. If the patient has shortness of breath, raise the head of the bed or stretcher and administer oxygen at 2 to 4 L/min. The treatment for MI varies and can include the administration of pain medication, aspirin, oxygen, and often vasodilating and/or clot-dissolving drugs. Angina Pectoris Angina pectoris, often shortened to “angina,” occurs when the coronary arteries are unable to supply the heart with sufficient oxygen. These episodes of chest pain are precipitated by exertion or stress and are usually relieved by rest or the sublingual administration of nitroglycerin The discomfort caused by angina varies from a vague ache to an intense crushing sensation. It is frequently mistaken for indigestion, because it often presents as pain under the sternum. If substernal pain is not immediately relieved with rest, inform the radiologist and be prepared to give a dose of a vasodilating medication such as nitroglycerin. A second dose may be ordered 5 minutes later. An emergency supply of nitroglycerin is usually stocked in the imaging department. Remember that patients with chronic angina can also suffer an MI. Cardiac Arrest For health care workers, one of the most anxiety-producing situations is to discover an unconscious patient or to observe a patient suddenly lose consciousness. When this occurs, it is important to initiate the “shake and shout” maneuver. Patients who have simply fainted will respond if you call out their name and give them a gentle shake. If there is no response, feel for the carotid pulse and observe for respiration. If the patient has stopped breathing, or if no pulse is detected, an emergency code must be initiated to summon an emergency response team immediately. Clinical Manifestations of Cardiac Arrest •Loss of consciousness, pulse, and blood pressure •Dilation of the pupils within seconds •Possibility of seizures you must allow the emergency response personnel to take over immediately when they arrive. They will initiate or continue CPR. Stand by to keep records of medication administration and defibrillation. Your help may be needed to connect the patient to the cardiac monitor. Clinical Manifestations of a Partially Obstructed Airway •Labored, noisy breathing •Wheezing •Use of accessory muscles of the neck, abdomen, or chest on inspiration •Neck vein distention •Diaphoresis •Anxiety •Cyanosis of the lips and nail beds •Possibly a productive cough with pink-tinged frothy sputum Radiographer's Response to a Patient with a Partially Obstructed Airway •Call for assistance; do not leave the patient alone. •Assist the patient to a sitting or semi-Fowler position. •Attempt to relieve the patient's anxiety. •Prepare to administer oxygen. •Prepare to use the emergency cart. Respiratory Arrest Clinical Manifestations •The patient stops responding •The pulse continues to beat briefly and then quickly becomes weak and stops •Chest movement stops, and no air is detectable moving through the patient's mouth Radiographer's Response to Both Cardiac and Respiratory Arrest •If the patient is an adult and is found to be unresponsive, shake the patient and ask, “Are you all right?” If there is no response, call immediately for emergency medical services (call a CODE). If no one is near, shout for help, stating the location as well. “I need help STAT in Room 102.” Do not leave the patient. •Assess the carotid pulse of an adult patient. Do not waste time taking the blood pressure or listening for a heartbeat. •If the patient is an adult with no pulse and the CODE has been called, place the patient in a supine position on a hard surface. If the patient is already on the radiographic table, leave the patient there, as this is a perfect place to perform CPR. Cardiopulmpnary resucitation (CPR) • A – airway In order to breath, or in the case of CPR, to breath for another individual, one must secure a patent, or viable, airway. Usually by checking for any airway obstruction (Choking hazard) and placing the adult patient's head into a "neutral" position so that the chin is essentially centered, not too far towards the chest or in a "sniffing" position where the head is basically "looking upwards" one can generally maintain an adequate Airway • B - Look, listen and feel for ventilation, or breathing. Look for rise and fall in the chest, which would indicate the patient is breathing. Listen for sounds of breathing, or in the case of a partial choking victim, listen for wheezing or high pitch noises, called "stridors" If breathing is indadequate, one should initiate rescue breathing or CPR. • C - Body tissue receives nourishment and oxygenation through circulation. Circulation is provided by a major pump in the body called the heart. To check for circulation, one should feel for a pulse by palpating one of several "pulse points" on the body. The most common is the Carotid, which is palpated by placing two fingers forward, resting on the center of the neck and sliding gently towards the back of the neck until roughly at center. There are points on either side of the neck. Another spot to check is the radial artery, which is felt by placing two fingers between the radial bone and ligament on the arm. This would be the side of the forearm situated on the same side as the patient's thumb. If indadequate circulation is present, then one should initiate rescuscitative efforts, such as CPR compressions. • Variations in CPR Techniques for Infants and Children • Neonate • Infant under 1 year of age • Child ages 1 to 8 years Cardiac compression •Keep the elbows straight and use the body weight to help compress the sternum 1.5 to 2 inches directly downward; then release the compression completely. •Find the lower margin of the patient's rib cage at the area where the ribs and sternum meet. Place the index finger above this junction and the heel of the other hand next to the finger. Place the second hand on top and interlace the fingers. •This should place the hands about 1.5 inches from the xiphoid tip toward the patient's head. The fingers should not touch the chest wall of the patient Airway Obstruction A foreign body such as a piece of chewing gum or food may lodge in a patient's throat and produce respiratory arrest. This type of accident occurs most often in the elderly, the very young, or the intoxicated while eating. However, the radiographer must consider this possibility in any case of respiratory arrest. When airway obstruction caused by a foreign object occurs, the patient usually appears to be quite normal, and then suddenly begins to choke. The patient grabs the throat and is unable to speak. If no one is present to observe this, the patient eventually loses consciousness. Unless the early signs are observed, it is impossible to know the cause of the unconscious state. Airway obstruction may occur with the patient sitting, standing, or lying down and must be dealt with initially in that position. Radiographer's Response •If the patient does not respond and breathlessness is established as described in the preceding paragraphs, seal the patient's nose and mouth, and ventilate him or her as in the initial steps of CPR. •If the patient's chest rises and falls, proceed as for basic CPR. •If the patent's chest does not rise and fall, reposition the head using the head tilt, chin lift, or jaw thrust as indicated. Then attempt to ventilate again.. •If this is unsuccessful, assume that the airway is obstructed and use the abdominal thrust to attempt to remove the obstruction. Seizures A seizure is an unsystematic discharge of neurons of the cerebrum that results in an abrupt alteration in brain function. It usually begins with little or no warning and may last only seconds or for several minutes. A seizure is accompanied by a change in the level of consciousness. Seizures themselves are not a disease, but are a syndrome or symptom of a disease. They may be caused by infections or disease, especially those that are accompanied by high fever. They may also be caused by extreme stress, head trauma, brain tumors, structural abnormalities of the cerebral cortex, genetic defects (epilepsy), birth trauma, vascular disease, congenital malformations, or postnatal trauma. Odors and flashing lights can cause a seizure in a person who is seizure prone. There are basically two types of seizure: generalized and partial. Generalized Clinical Manifestations •May utter a sharp cry as air is rapidly exhaled •Muscles become rigid and eyes open wide •May exhibit jerky body movements and rapid, irregular respirations •May vomit •May froth and have blood-streaked saliva caused by biting the lips or tongue •May exhibit urinary or fecal incontinence •Usually falls into a deep sleep after the seizure Partial Clinical Manifestations of a Complex Partial Seizure •Patient may remain motionless or may experience an excessive emotional outburst of fear, crying, or anger •Patient may manifest facial grimacing, lip smacking, swallowing movements, or panting •Patient will be confused for several minutes after the episode with no memory of the incident Clinical Manifestations of a Simple Partial Seizure •Only a finger or a hand may shake •Patient may speak unintelligibly •Patient may be dizzy •Patient may sense strange odors, tastes, or sounds •Patient will not lose consciousness Radiographer's Response to a Patient Having a Seizure •Stay with the patient and gently secure him or her to prevent injury. •Call for assistance. •Do not attempt to insert anything into the patient's mouth. •Remove dentures and foreign objects from the patient's mouth if possible, but do not put fingers into the mouth. •Place a blanket or pillow under the patient's head to protect it from injury. •Do not restrain the arms or legs but protect them from injury. •Do not attempt to move the patient to the floor if he or she has not fallen there; if on a radiographic table, do not allow the patient to fall to the floor. •Observe the patient carefully and keep track of the time of the seizure to record later. •Provide the patient privacy. •After the seizure has ceased, position the patient to prevent aspiration of secretions and vomitus. Turn the patient to a Sim's position and put the face downward so that secretions may drain from his or her mouth. Epistaxis A nosebleed, or epistaxis, can be rather frightening to the patient but is usually not serious. Remove eyeglasses when necessary, and provide an ample supply of tissues. Instruct the patient to breathe through the mouth and to squeeze firmly against the nasal septum for 10 minutes. The patient should not lie down, blow the nose, or talk. Provide an emesis basin, instructing the patient to spit out blood that runs down the nasopharynx rather than swallow it. If bleeding lasts more than a few minutes, inform the physician, who may want to apply more direct treatment. Nausea and Vomiting Nausea and vomiting are frequently encountered, and a well-prepared radiographer learns to cope easily with this situation. Occasionally patients may feel nauseated for a specific reason, such as after swallowing a barium preparation. Vomiting can often be prevented by the radiographer's reassuring presence and by offering breathing suggestions. “Breathe through your mouth, taking short, rapid, panting breaths,” or “Take some long, slow, deep breaths through your nose,” are both effective instructions. These suggestions are helpful because they encourage a focus on breathing that distracts the patient from the nausea until it passes. On the other hand, if a patient expresses a need for an emesis basin, offer it immediately. Bring the patient a clean emesis basin before removing the soiled one. Provide tissues and water to rinse the mouth. It is especially important to support the patient in a sitting or lateral recumbent position to avoid aspiration of vomitus. The lateral recumbent position is safest for the patient with nausea who is unable to sit up. If the patient loses consciousness, be sure to turn the head to the side and clear the airway. Wear gloves when handling soiled emesis basins or cleaning up after a patient has vomited. Extremity Fractures Trauma involving the long bones of the body may be classified in two categories: (1) compound fractures, in which the splintered ends of bone are forced through the skin, and (2) closed fractures. Compound fractures are usually partially reduced and a dressing applied before radiographic examination. Fractures may also be classified according to the nature of the injury. There are many ways of temporarily immobilizing extremity fractures. The two legs may be fastened together for stability during transportation (self-splinting), or a stiff object, such as a board or rolled-up magazine, may serve as a splint. Ambulances often carry pneumatic splints, which are air-filled sleeves that protect and immobilize the extremity (Splinting devices should not be removed except under the physician's direct supervision.) When you must position a fractured extremity that is not supported by a splint, maintain gentle traction while supporting and moving the arm or leg. Two people may be required to support and position patients with a potential long bone fracture, because the extremity must be supported at sites both proximal and distal to the injury. It is important to minimize motion of the fracture fragments. This helps minimize pain, prevent damage to the soft tissues around the fracture site, and avoid the initiation of a muscle spasm that could interfere with the physician's attempt to reduce and immobilize the fracture more permanently. Movement of fracture fragments may tear surrounding soft tissues, nerves, and blood vessels, seriously complicating the patient's condition.