[Objectives 13]
Patient assessment is a systematic method of evaluating a patient ’s condition and is the foundation of med-ical care. The information obtained by the clinician when performing a patient assessment helps guide treatment decisions. Recognizing when a patient ’s condition becomes unstable requires good patient assessment skills and is essential for improved patient outcomes.
Before approaching the patient, make sure that the scene is safe. Note any hazards or potential hazards and any visible mechanism of injury or illness. Always use appropriate personal protective equipment.
Once you come into view of the patient, immediately begin to form a general impression, which is an“across-the-room” or “from-the-doorway ” assessment of the severity of the patient ’s condition. Your general impression should focus on three main areas that can be remembered by the mnemonic ABC:
A ppearance, (work of) Breathing, and Circulation. As you finish forming your general impression, you will have a good idea if the patient is sick (unstable) or not sick (stable).
Fig. 1.9 The LUCAS®2 Chest Compression System is electrically powered. (Courtesy Physio-Control, Inc., Redmond, WA;
Jolife AB, Lund, Sweden)
Fig. 1.10 The Life-Stat is a gas-powered piston device that is equipped with an automatic transport ventilator. (Courtesy Michigan Instruments, Grand Rapids, MI)
14 CHAPTER 1 Emergency Cardiovascular Care
• Appearance. The patient ’s appearance reflects the adequacy of oxygenation, ventilation, and central nervous system function. When forming a general impression, normal findings include a patient who is aware of your approach and has normal muscle tone and equal movement of all extremities.
• Breathing. Breathing reflects the adequacy of the patient ’s oxygenation and ventilation. Normal find-ings include breathing without excessive respiratory muscle effort that is quiet and regular with equal rise and fall of the chest. Abnormal findings include use of accessory muscles to breathe, the presence of retractions, and audible respiratory sounds that can be heard without a stethoscope such as stridor, gasping, wheezing, snoring, or gurgling.
• Circulation. Circulation reflects the adequacy of cardiac output and perfusion of vital organs. When forming a general impression, circulation refers to skin color. Skin color normally is some shade of pink. Even patients who have heavy pigmentation have an underlying pink color to the skin. Abnor-mal findings include pallor, mottling, and cyanosis.
An abnormal finding that is observed when assessing any of these areas suggests that the patient is sick (unstable); move quickly and proceed immediately to the primary survey. If the patient ’s condition does not appear to be urgent, proceed systematically starting with the primary survey and then the secondary survey.
Primary Survey [Objectives 14]
The primary survey is a rapid hands-on patient assessment that focuses on basic life support interventions and management. The purposes of the primary survey are to detect the presence of life-threatening prob-lems and to immediately correct them. During this phase of patient assessment, assessment and man-agement occur at the same time.
The ABCDE sequence of the primary survey is taught to physicians, nurses, and prehospital person-nel in many types of educational courses. In programs other than cardiac-related courses, the primary survey sequence stands for A irway, Breathing, Circulation, Disability (referring to a brief neurologic exam), and E xposure. In cardiac-related courses, the “D” also stands for Defibrillation.
Repeat the primary survey:
• With any sudden change in the patient ’s condition
• When interventions do not appear to be working
• When vital signs are unstable
• Before any procedures are performed
• When a change in rhythm is observed on the cardiac monitor
Begin the primary survey by assessing responsiveness. Start by asking,“ Are you all right?”or “Can you hear me?” If there is no response, then gently tap or squeeze the victim’s shoulder while repeating verbal cues. Look at the chest for movement for 5 to 10 seconds. Call for help and ask someone to get an AED or defibrillator.
ACLS Pearl
Use the AVPU acronym when evaluating level of responsiveness:
• A ¼ A lert
• V ¼Responds to v erbal stimuli
• P¼Responds to painful stimuli
• U¼Unresponsive
Responsive Patient
Ask the patient questions to determine his or her level of responsiveness and the adequacy of his or her airway and breathing.
Airway
If the airway is not clear, clear it with suctioning or positioning as indicated. If the airway is open, move on and assess the patient ’s breathing.
Breathing
An open airway does not ensure adequate breathing. Evaluate the depth (tidal volume) and symmetry of movement with each breath. Chest expansion should be adequate, with sufficient tidal volume to make the chest rise, and equal, with no excessive use of accessory muscles during inspiration or expiration.
Assess the patient ’s breathing with regard to rate, quality, and regularity. A patient who has breathing difficulty often has a ventilatory rate outside the normal limits for his or her age. Normal, noisy, labored, or shallow are terms used to describe the quality of ventilations. Note if breathing is quiet, absent, or noisy (eg, stridor, gasping, wheezing, snoring, gurgling). Labored breathing is evident when a patient is working hard to breathe. It is often evidenced by the use of accessory muscles to breathe, pursed-lip
breathing, retractions, leaning forward to inhale, or the patient ’s inability to speak in full sentences with-out pausing to take a breath. Shallow breathing may result in ineffective delivery of oxygen to the body ’s tissues and ineffective elimination of carbon dioxide, even when the ventilatory rate is normal. A bag-mask device (BMD) is often used to provide assisted ventilation for the patient who has an inadequate rate or depth of breathing (see Chapter 2). If the patient ’s breathing is adequate, move on to assessment of circulation.
Circulation
Quickly estimate the patient ’s heart rate and determine the quality of the pulse (ie, fast or slow, regular or irregular, weak or strong). Evaluate the patient ’s skin temperature, color, and moisture to assess perfusion.
Disability/Defibrillation
Perform a brief neurologic evaluation (ie, obtain a Glasgow Coma Scale score) and assess the need for a defibrillator.
Exposure
Expose the patient for further evaluation.
Unresponsive Patient [Objective 15]
If your assessment of responsiveness indicated that the patient is unresponsive, call for help and ask someone to get an AED or defibrillator. Look at the chest for movement while simultaneously feeling for a carotid pulse for no more than 10 seconds.
ACLS Pearl
If the patient is unresponsive buthas normal breathing, CPR is not needed. Perform a primary survey as you would for a responsive patient.
If a pulse is present, open the airway and begin rescue breathing, providing one breath every 5 to 6 sec-onds, or about 10 to 12 breaths/min (Kleinman, et al., 2015). Recheck a pulse every 2 minutes for up to 10 seconds. If there is no pulse or if you are unsure if there is a pulse and the patient is an adult, begin chest compressions, remembering to allow the chest wall to rebound after each compression. Minimize interruptions of chest compressions. Rotate chest compressors at 2-minute intervals (ideally in less than 5 seconds) to avoid tiring. If an opioid overdose is suspected, administer naloxone if it is available (check your agency ’s protocol).
If there is no pulse, check for a shockable rhythm using a monitor-defibrillator or AED. Provide shocks as indicated. Refer to the specific operating instructions of the AED model being used as models may vary. After each shock, immediately resume CPR beginning with chest compressions for 2 minutes.
After 30 compressions, open the airway using a head tilt – chin lift (see Chapter 2). If head or neck trauma is suspected, open the airway using the jaw thrust without neck extension maneuver. Next, use a pocket mask or BMD and deliver 2 breaths, ensuring that the delivery of each breath takes about 1 second. Make sure the breaths are effective (the chest rises). If the chest does not rise, reposition the head, make a better seal, and try again. Avoid excessive ventilation (ie, too many breaths, too large a volume).
16 CHAPTER 1 Emergency Cardiovascular Care
Secondary Survey [Objectives 14]
The purpose of the physical examination during the secondary survey is to detect potentially life-threatening conditions and to provide care for those conditions (Box 1.2). The secondary survey focuses on advanced life support interventions and management. If the patient is responsive, obtain the patient ’s vital signs; attach a pulse oximeter, ECG, and BP monitor; and obtain a focused history. The history is often obtained while the physical examination is being performed and emergency care is being given.
Reassess the effectiveness of initial airway maneuvers and interventions. If needed, insert an advanced airway. If an advanced airway has been inserted, confirm proper placement using clinical assessment and waveform capnography. Make sure the tube is adequately secured. Obtain a chest radiograph to confirm
proper placement. If bag-mask ventilation is adequate, advanced airway insertion may be deferred until spontaneous circulation returns or the patient fails to respond to initial resuscitation efforts.
Reassess the adequacy of oxygenation (using pulse oximetry) and ventilation (using capnography).
Reassess chest rise. If oxygenation is inadequate, administer supplemental oxygen to achieve an oxygen saturation of 94% or greater. If breathing is inadequate, assist ventilations with a BMD at an age-appropriate rate.
If the patient has a pulse, check its rate and quality often. If not already done, attach ECG electrodes and connect the patient to an ECG monitor. ECG monitoring allows continuous recording and reas-sessment of the cardiac rhythm. Obtain a 12-lead ECG if appropriate. Perform defibrillation or cardio- version as indicated. Establish vascular access and give medications appropriate for the cardiac rhythm/
clinical situation. Vascular access is usually established via a peripheral IV; however, intraosseous (IO) access in cardiac arrest is safe, effective, and appropriate for patients of all ages. Consider limiting periph-eral IV attempts to no more than two unsuccessful attempts before initiating IO access. During cardiac arrest, establishing vascular access is important, but it should not interfere with CPR and the delivery of shocks. Each medication given during a cardiac arrest should be followed with a 20 mL IV fluid bolus and elevation of the extremity. These techniques help speed delivery of the medication to the central circulation. During a cardiac arrest, medications should be given without interrupting CPR.
Search for, find, and treat reversible causes of the cardiac arrest, rhythm, or clinical situation. Reassess the effectiveness of the care given thus far and troubleshoot as needed. If the patient is responsive and complaining of discomfort, begin appropriate pain management if his or her BP and other vital signs will tolerate it. Facilitate family presence for invasive and resuscitative procedures. Explain what is being done for the patient to family members who are present.
BOX 1.2 Secondary Survey Components
• Airway
• Breathing
• Circulation
• Differential diagnosis and diagnostic procedures
• Evaluate interventions and pain management
• Facilitate family presence for invasive and resuscitative procedures