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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.
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.
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.
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, 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.
Blood pressure cuff
Bag valve mask
Carbon dioxide detector for ET tube placement
Sterile and nonsterile gloves
IV solutions and tubing
Blood collection tubes
Drugs according to institutional protocol
Protective gowns, eyewear, masks
Pen, paper, checklist for cart contents
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
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
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
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).
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
•Increased and shallow respirations
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.
Information Requested before Administration of Contrast Agents
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?
Sickle cell anemia?
Have you had any procedures such as a cryptogram that involved use of contrast agents? If so, please explain.
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
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 three complications of diabetes mellitus that may occur when caring for a patient:
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
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, 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.
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.
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.
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.
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.
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.
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.