4-17 COMMON MEDICAL EMERGENCIES

LEARNING OBJECTIVE: Choose the appropriate treatment and management techniques for the common medical emergencies.

This section of the chapter deals with relatively common medical emergencies a Hospital medical technician may face. Generally speaking, these particular problems are the result of previously diagnosed medical conditions; so, at least for the victim, they do not come as a complete surprise. Many of these victims wear a medical identification device (necklace or bracelet), or carry a medical identification card that specifies the nature of the medical condition or the type of medications being taken. In all cases of sudden illness, search the victim for a medical identification device.

SYNCOPE

Uncomplicated syncope (fainting) is the result of blood pooling in dilated veins, which reduces the amount of blood being pumped to the brain. Causes of syncope include getting up too quickly, standing for long periods with little movement, and stressful situations. Signs and symptoms that may be present are dizziness; nausea; visual disturbance from pupillary dilation; sweating; pallor; and a weak, rapid pulse. As the body collapses, blood returns to the head, and consciousness is quickly regained. Revival can be promoted by carefully placing the victim in the shock position or in a sitting position with the head between the knees. Placing a cool, wet cloth on the patient’s face and loosening their clothing can also help.

Syncope may also result from an underlying medical problem such as diabetes, cerebrovascular accident (stroke), heart condition, or epilepsy.

DIABETIC CONDITIONS

Diabetes mellitus is an inherited condition in which the pancreas secretes an insufficient amount of the protein hormone insulin. Insulin regulates carbohydrate metabolism by enabling glucose to enter cells for use as an energy source. Diabetics almost always wear a medical identification device.

Diabetic Ketoacidosis

Diabetic ketoacidosis most often results either from forgetting to take insulin or from taking too little insulin to maintain a balanced condition. Diabetics may suffer from rising levels of glucose in the blood stream (hyperglycemia). The rising levels of glucose result in osmotic diuresis, an increased renal excretion of urine. Serious dehydration (hypovolemia) may result. Concurrently, the lack of glucose in the cells leads to an increase in metabolic acids in the blood (acidosis) as other substances, such as fats, are metabolized as energy sources. The result is gradual central nervous system depression, starting with symptoms of confusion and disorientation, and leading

to stupor and coma. Blood pressure falls, and the pulse rate becomes rapid and weak. Respirations are deep, and a sickly sweet acetone odor is present on the breath. The skin is warm and dry.

NOTE

Diabetic victims are often mistakenly treated as if intoxicated since the signs and symptoms presented are similar to those of alcohol intoxication.

The diabetic under treatment tries to balance the use of insulin against glucose intake to avoid the above problems. The victim or the victim’s family may be able to answer two key questions:

  1. Has the victim eaten today?
  2. Has he taken the prescribed insulin?

If the answer is yes to the first and no to the second question, the victim is probably in a diabetic coma.

Emergency first aid centers around ABC support, administration of oral or intravenous fluids to counter shock, and rapid evacuation to a physician’s supervision.

Insulin Shock

Insulin shock results from too little sugar in the blood (hypoglycemia). This type of shock develops when a diabetic exercises too much or eats too little after taking insulin. Insulin shock is a very serious condition because glucose is driven into the cells to be metabolized, leaving too little glucose in circulation to support the brain. Brain damage develops quickly. Signs and symptoms of insulin shock include

Treatment is centered on getting glucose into the system quickly to prevent brain damage. Placing sugar cubes under the tongue or administering oral liquid glucose are the most beneficial treatments. Transport the victim to a medical treatment facility as soon as possible.

NOTE

If you are in doubt as to whether the victim is in insulin shock or a ketoacidotic state, give them sugar. Brain damage develops very quickly in insulin shock and must be reversed immediately. If the victim turns out to be ketoacidotic, a condition that progresses slowly, the extra sugar will do no appreciable harm.

CEREBROVASCULAR ACCIDENT

A cerebrovascular accident, also known as stroke or apoplexy, is caused by an interruption of the arterial blood supply to a portion of the brain. This interruption may be caused by arteriosclerosis or by a clot forming in the brain. Tissue damage and loss of function result.

Onset of a cerebrovascular accident is sudden, with little or no warning. The first signs include weakness or paralysis on the side of the body opposite the side of the brain that has been injured. Muscles of the face on the affected side may be involved. The patient’s level of consciousness varies from alert to unresponsive. Additionally, motor functions including vision and speechon the affected side are disturbed, and the throat may be paralyzed.

Emergency treatment for a cerebrovascular accident is mainly supportive. Special attention must be paid to the victim’s airway, since he may not be able to keep it clear. Place the victim in a semi-reclining position or on the paralyzed side.

ANAPHYLACTIC REACTION

This condition, also called anaphylaxis or anaphylactic shock, is a severe allergic reaction to foreign material. The most frequent causes are probably penicillin and the toxin from bee stings, although foods, inhalants, and contact substances can also cause a reaction. Anaphylaxis can happen at any time, even to people who have taken penicillin many times before without experiencing any problems. This condition produces severe shock and cardiopulmonary failure of a very rapid onset. Because of the rapidity and severity of the onset of symptoms, immediate intervention is necessary. The general treatment for severe anaphylaxis is the subcutaneous injection of 0.3 cc of epinephrine and supportive care.

The most characteristic and serious symptoms of an anaphylactic reaction are loss of voice and difficulty breathing. Other typical signs are giant hives, coughing, and wheezing. As the condition progresses, signs and symptoms of shock develop, followed by respiratory failure. Emergency management consists of maintaining vital life functions. Summon the physician immediately.

POISONS/DRUG ABUSE/HAZARDOUS MATERIALS

As a Hospital medical technician, you could encounter special situations that include poisoning, suspected drug abuse, or exposure to hazardous materials. Knowledge of these conditionsalong with the ability to assess and treat themis essential. These situations are discussed in detail in chapter 5, “Poisoning, Drug Abuse, and Hazardous Material Exposure.”

HEART CONDITIONS

A number of heart conditions are commonly referred to as heart attacks. These conditions include angina pectoris, acute myocardial infarction, and congestive heart failure. Together these heart conditions are the cause of at least half a million deaths per year in our country. Heart conditions occur more commonly in men in the 50-to-60-year age group. Predisposing factors are the lack of physical conditioning, high blood pressure and blood cholesterol levels, smoking, diabetes, and a family history of heart disease.

Angina Pectoris

Angina pectoris, also known simply as angina, is caused by insufficient oxygen being circulated to the heart muscle. This condition results from a spasm of the coronary artery, which allows the heart to function adequately at rest but does not allow enough oxygen-enriched blood to pass through the heart to support sustained exercise. When the body exerts itself, the heart muscle becomes starved for oxygen. The result of this condition is a squeezing, substernal pain that may radiate to the left arm and to the jaw.

Angina is differentiated from other forms of heart problems because the pain results from exertion and subsides with rest. Many people who suffer from angina pectoris carry nitroglycerin tablets. If the victim of a suspected angina attack is carrying a bottle of these pills, place one pill under the tongue. Relief will be almost instantaneous. Other first aid procedures include providing supplemental oxygen, reassurance, comfort, monitoring vital signs, and transporting the victim to a medical treatment facility.

Acute Myocardial Infarction

Acute myocardial infarction results when a coronary artery is severely occluded by arteriosclerosis or completely blocked by a clot. The pain associated with myocardial infarction is similar to that of angina pectoris but is longer in duration, not related to exertion or relieved by nitroglycerin, and leads to death of heart-muscle tissue. Other symptoms are sweating, weakness, and nausea. Additionally, although the patient’s respirations are usually normal, his pulse rate increases and may be irregular, and his blood pressure falls. The victim may have an overwhelming feeling of doom. Death may result.

First aid for an acute myocardial infarction includes

Congestive Heart Failure

A heart suffering from prolonged hypertension, valve disease, or heart disease will try to compensate for decreased function by increasing the size of the left ventricular pumping chamber and increasing the heart rate. This condition is known as congestive heart failure. As blood pressure increases, fluid is forced out of the blood vessels and into the lungs, causing pulmonary edema. Pulmonary edema leads to rapid shallow respirations, the appearance of pink frothy

bubbles at the nose and mouth and distinctive rattling sounds (known as ra!es) in the chest. Increased blood pressure may also cause body fluids to pool in the extremities.

Emergency treatment for congestive heart failure is essentially the same as that for acute myocardial infarction. Do not start CPR unless the patient’s heart function ceases. If an intravenous line is started, it should be maintained at the slowest rate possible to keep the vein open since an increase in the circulatory volume will make the condition worse. Immediately transport the patient to a medical treatment facility.

CONVULSIONS

Convulsions, or seizures, are a startling and often frightening phenomenon. Convulsions are characterized by severe and uncontrolled muscle spasms or muscle rigidity. Convulsive episodes occur in one to two percent of the general population.

Although epilepsy is the most widely known form of seizure activity, there are numerous forms of convulsions that are classified as either central nervous system (CNS) or non-CNS in origin. It is especially important to determine the cause in patients who have no previous seizure history. This determination may require an extensive medical workup in the hospital. Since epilepsy is the most widely known form of seizure activity, this section will highlight epileptic seizure disorders.

Epi!epsy, also known as seizures or fits, is a condition characterized by an abnormal focus of activity in the brain that produces severe motor responses or changes in consciousness. Epilepsy may result from head trauma, scarred brain tissue, brain tumors, cerebral arterial occlusion, fever, or a number of other factors. Fortunately, epilepsy can often be controlled by medications.

Grand ma! seizure is the more serious type of epilepsy. Grand mal seizure may bebut is not alwayspreceded by an aura. The victim soon comes to recognize these auras, which allows him time to lie down and prepare for the seizure’s onset. A burst of nerve impulses from the brain causes unconsciousness and generalized muscular contractions, often with loss ofbladder and bowel control. The primary dangers in a grand mal seizure are tongue biting and injuries resulting from falls. A period of sleep or mental confusion follows this type of seizure. When full consciousness returns, the victim will have little or no recollection of the attack.

Petit ma! seizure is of short duration and is characterized by an altered state ofawareness or partial loss of consciousness, and localized muscular contractions. The patient has no warning of the seizure’s onset and little or no memory of the attack after it is over.

First aid treatment for both types of epileptic seizure consists of protecting the victim from self-injury. Additional methods of seizure control may be employed under a physician’s supervision. In all cases, be prepared to provide suction to the victim since the risk of aspiration is significant. Transport the patient to a medical treatment facility once the seizure has ended.

DROWNING

Drowning is a suffocating condition in a water environment. Water seldom enters the lungs in appreciable quantities because, upon contact with fluid, laryngeal spasms occur, and these spasms seal the airway from the mouth and nose passages. To avoid serious damage from the resulting hypoxia, quickly bring the victim to the surface and immediatelyeven before the victim is pulled to shorestart artificial ventilation. Do not interrupt artificial ventilation until the rescuer and the victim are ashore. Once on dry ground, quickly administer an abdominal thrust (Heimlich maneuver) to empty the lungs, and then immediately restart the ventilation until spontaneous breathing returns. Oxygen enrichment is desirable if a mask is available.

Remember that an apparently lifeless person who has been immersed in cold water for a long period of time may be revived if artificial ventilation is started immediately.

PSYCHIATRIC EMERGENCIES

A psychiatric emergency is defined as a sudden onset of behavioral or emotional responses that, if not responded to, will result in a life-threatening situation. Probably the most common psychiatric emergency is the suicide attempt. A suicide attempt may range from verbal threats and suicidal gestures to a successful suicide. Always assume that a suicide threat is real; do not leave the patient alone. In all cases, the prime consideration for a Hospital medical technician is to keep patients from inflicting harm to themselves and to get them under the care of a trained psychiatric professional. When dealing with suicidal gestures or attempts, treat any self-inflicted wounds appropriately.

In the case of ingested substances, do not induce vomiting in a patient who is not awake and alert. For specific treatment of ingested substances, refer to the section on poisons in chapter 5.

There are numerous other psychiatric conditions that would require volumes to expound upon. In almost all cases, appropriate first aid treatment consists of a calm, professional, understanding demeanor that does not aggravate or agitate the patient. With an assaultive or hostile patient, a “show of force” may be all that is required. Almost all cases of psychiatric emergencies will present with a third party]often the family or friend of the patientwho has recognized a distinct change in the behavior pattern ofthe patient and who is seeking help for them.

DERMATOLOGIC EMERGENCIES

Most dermatologic cases that present as emergencies are not real emergencies. The patient perceives them as such because of the sudden presentation and/or repulsive appearance or excessive discomfort. Treat most dermatologic conditions symptomatically. The major exception to symptomatic treatment is toxic epidermal necrolysis (TEN).

Toxic epidermal necrolysis is a condition characterized by sudden onset, excessive skin irritation, painful erythema (redness of skin produced by congestion of the capillaries), bullae (large blisters), and exfoliation of the skin in sheets. TEN is also known as the scalded skin syndrome because of its appearance. TEN is thought to be caused by a staphylococcal infection in children and by a toxic reaction to medications in adults.

Since skin is the largest single organ of the body and serves as a barrier to infection, prevention of secondary skin infection is very important. Treatment of skin infections consists of isolation techniques, silver nitrate compresses, aggressive skin care, intravenous antibiotic therapy and, in drug-induced cases, systemic steroids.

EMERGENCY CHILDBIRTH

Every hospital medical technician must be prepared to handle the unexpected arrival of a new life into the world. If the medical technician is fortunate, a prepackaged sterile delivery pack will be available. This pack will contain all the equipment needed for the normal delivery of a healthy baby. If the pack is not available, a hospital medical technician will require imaginative improvisation of clean alternatives.

When faced with an imminent childbirth, the Hospital medical technician must first determine whether there will be time to transport the expectant mother to a hospital. To help make this determination, the medical technician should try to find out

The medical technician must weigh the answers to these questions and decide if it will be safe to transport the patient to the hospital.

Prior to childbirth, a medical technician must quickly “set the stage.” The mother must not be allowed to go to the bathroom since straining may precipitate delivery. Do not try to inhibit the natural process of childbirth. The mother should lie back on a sturdy table, bed, or stretcher with a folded sheet or blanket placed under her buttocks for absorption and comfort. Remove all the patient’s clothing below the waist, bend the knees, move the thighs apart, and drape her lower extremities with clean towels or sheets. Don sterile gloves, or, if these are not available, rewash your hands.

In a normal delivery, your calm professional manner and sincere reassurance to the mother will reduce her anxiety and make the delivery easier for everyone. Help the woman rest and relax as much as possible between contractions. During a contraction, deep, open-mouth breathing will relieve some pain and straining. As the child’s head reaches the area of the rectum, the mother will feel an urgent need to defecate. Reassurance that this is a natural feeling and a sign that the baby will be born soon will help alleviate her apprehension.

Watch for the presentation of the top of the baby’s head. Once the head appears, take up your station at the foot of the bed and gently push against the head to keep it from emerging too quickly. Allow it to come out slowly. As more of the head appears, check to be sure that the umbilical cord is not wrapped around the neck. If it is, either gently try to untangle the cord, or move one section over the baby’s shoulder. If neither of these actions is possible, clamp the cord in two places, 2 inches apart, and cut it. Once the baby’s chin emerges, support the head with one hand and use the bulb syringe from the pack to suction the nostrils and mouth. Before placing the bulb in the baby’s mouth or nose, compress it; otherwise, a forceful aspiration into the lungs will result. The baby will now start a natural rotation to the left or right, away from the face-down position. As this rotation occurs, keep the baby’s head in a natural relationship with the back. The shoulders appear next, usually one at a time.

NOTE

From this point on, it is essential to remember that the baby is VERY slippery, and great care must be taken so that you do not drop it. The surface beneath the mother should extend at least 2 feet out from her buttocks so that the baby will not be hurt if it does slip out of your hands. Keep one hand beneath the baby’s head, and use the other hand to support its emerging body.

Once the baby has been born, suction the nose and mouth again if breathing has not started. Wipe the baby’s face, nose, and mouth clean with sterile gauze. Your reward will be the baby’s hearty cry.

Clamp the umbilical cord as the pulsations cease. Use two clamps from the prepackaged sterile delivery pack, 2 inches apart, with the first clamp 6 to 8 inches from the navel. Cut the cord between the clamps. For safety, use gauze tape to tie the cord 1 inch from the clamp toward the navel. Secure the tie with a square knot. Wrap the baby in a warm, sterile blanket, and log its time of arrival.

The placenta (afterbirth) will deliver itself in 10 to 20 minutes. Massaging the mother’s lower abdomen can aid this delivery. Do not pull on the placenta. Log the time of the placenta’s delivery, and wrap it up for hospital analysis.

Place a small strip of tape ( 1/2 -inch wide), folded and inscribed with the date, time of delivery, and mother’s name, around the baby’s wrist.

COMPLICATIONS IN CHILDBIRTH

Unfortunately, not all deliveries go smoothly. The following sections cover various complications in childbirth.

Breech Delivery

A breech delivery occurs when the baby’s legs and buttocks emerge first. Follow the steps for a normal delivery, and support the lower extremities with one hand. Ifthe head does not emerge within 3 minutes, try to maintain an airway by gently pushing fingers into the vagina. Push the vagina away from the baby’s face and open its mouth with one finger. Get medical assistance immediately.

Prolapsed Cord

If the cord precedes the baby, protect it with moist, sterile wraps. If a physician cannot be reached quickly, place the mother in an extreme shock position. Give the mother oxygen, if available, and gently move your gloved hand into the vagina to keep its walls and the baby from compressing the cord. Get medical assistance immediately.

Excessive Bleeding

If the mother experiences severe bleeding, treat her for shock and give her oxygen, if available. Place sanitary napkins over the vaginal entrance and rush her to a hospital.

Limb Presentation

If a single limb presents itself first, immediately get the mother to a hospital.