Chapter 26; Medical Office Emergencies

The Physical Examination

A head-to-toe survey that includes examination of the head and neck, chest and back, abdomen, and extremities in this sequence should be done only after completing the primary and secondary surveys. Although the physician usually performs this examination, you must be prepared to assist as needed while continuing to reassure the patient.

Neurologic Emergencies

A seizure is caused by an abnormal discharge of electrical activity in the brain. During a seizure, erratic muscle movements, strange sensations, and a complete loss of consciousness can occur. A seizure is not a disease but a manifestation or symptom of an underlying disorder. Epilepsy, head injury, and drug toxicity can cause seizures. A thorough patient history is important when assessing these patients. It should include the following: • Information about previous seizure disorders • Frequency of seizures if recurrent • Prescribed medications • Any history of head trauma • Alcohol or drug abuse • Recent fever • Stiff neck (as seen in meningitis) • A history of heart disease, diabetes, or stroke In managing a patient having a seizure, you must give priority to assessing the patients responsiveness, airway, breathing, and circulation. In certain types of seizures, the patient loses consciousness and, therefore, cannot protect the airway. During the seizure, and muscles of the body, including those of the face, will contract tightly. If you attempt to force an object between the teeth to prevent the patient from biting the tongue, the result will most likely be injury to you or the patient. Frequently, patients vomit during the seizure and lose bowel or bladder control. Particular attention and care are necessary to clear and maintain the airway without causing injury to yourself or to the patient. Assisting the patient into the recovery position (on one side) will help secretions such as blood or vomit drain from the mouth. Secreations may be removed from the mouth using a suction machine if available. The most important thing that you can do for a patient during a seizure is protect the patient from injury. If the patient lost consciousness and fell at the beginning of the seizure, care will be necessary to protect the neck and cervical spine until immobilization can occur.

Allergic and Anaphylactic Reactions

A severe allergic reaction called anaphylaxis causes most emergency department visits related to allergies. An allergic reaction is a generalized reaction that can occur within minutes to hours after the body has been exposed to a substance recognized by the immune system as foreign and to which it is oversensitive. The systemic signs and symptoms of anaphylaxis are more severe than for a simple allergic reaction, but repeated exposure to a substance that produces allergic reactions may ultimately lead to anaphylactic reaction and should be avoided.

The Secondary Assessment

After conducting a primary assessment and assessing that the patient's airway, breathing, and circulation are adequate, a secondary assessment can be performed. The secondary assessment includes asking the patient questions to obtain additional information and performing a more thorough physical evaluation to find less obvious problems than those noted in the primary assessment.

Vital Signs

After noting the general appearance and determining the level of consciousness, assess the vital signs, including the pulse and respiratory rate and blood pressure. Assessment of temperature is important for patients who have altered skin temperature or have been exposed to environmental temperature extremes. Patients with a history of infection, chills, or fever and children with seizures should always have their temperature taken.

Common Allergens

An allergen is a substance that gives rise to hypersensitivity or allergy. The allergen may be a drug, insect venom, food, or pollen and may be injected, ingested, inhaled, or absorbed through the skin or mucous membranes. A person may have symptoms within seconds after exposure to an allergen, or the reaction may be delayed for several hours. You must ask every patient about allergies at every visit and indicate them on the front of the patient's chart and the medication record.

Arms and Legs

An examination of the arms and legs is the last step of the head-to-toe survey. Inspect the arms and legs for swelling, deformity, and tenderness. Also note any tremors in the hands. To determine the neurological status of the arms and legs, excess strength, movement, range of motion, and sensation, including comparing one side of the body with the other. Muscle strength in the upper extremities is checked by having the patient squeeze both of your hands at the same time. Leg strength may be determined by having the patient push each foot against your hand, again at the same time, while noting any weakness in one side or the other. Assess sensation by using a safety pin or other tool to determine the patient's response to pain. Throughout the examination, you must note the comparison of both sides, including any weakness or decreased sensation in one side or the other. Again, the physician will most likely be performing this examination, but you must be prepared to assist as needed.

Skin

An initial evaluation of the temperature and moisture of skin should have been noted during the primary survey. A more thorough look should now be taken. Skin is normally dry and somewhat warm. Moist, cool skin may indicate poor blood flow to the tissues and possibly shock. The color of the skin should be noted as an indication of the circulation near the surface of the body and oxygenation of the tissues.

Anaphylactic Shock

Anaphylactic shock is an acute general allergic reaction within minutes to hours after the body has been exposed to an offending foreign substance. You must carefully observe patients for this type of shock after giving medications and during allergy testing.

Types of Splints

Any device used to immobilize a sprain, strain, fracture, or dislocated limb is a splint. Splinting material may be soft or rigid and can be improvised from almost any object that can provide stability. Commercial types include traction, air, wire ladder, and padded board splints. Regardless of the type of splint, once applied, you must examine the extremity for signs of impaired circulation. To check the circulation of an extremity: • Observe the skin color and nail beds of the affected extremity. A pale or cyanotic color indicates that the circulation is impeded. • Locate a pulse in the artery distal to the affected extremity. A weak or absent pulse also indicates that circulation is decreased to the area. • Watch for increased swelling of the extremity. Although this may not indicate that the circulation is impaired, the swelling itself can reduce circulation. If the circulation is impaired with the splint in place, it must be removed or loosened immediately to provide for adequate blood flow, or tissue ischemia (decrease in oxygen) and infarction (death) may occur.

Management of the Patient in Shock

Because shock can result from many types of medical situations or trauma, you should always be prepared to treat a patient for shock in any emergency situation that occurs in the medical office. After performing the primary and secondary assessments, the following list of general guidelines for managing a patient in shock should be observed: • Observe the patient for and maintain an open airway and adequate breathing • Control bleeding • Administer oxygen as directed by the physician • Immobilize the patient if spinal injuries may be present • Splint fractures • Prevent loss of body heat by covering the patient with a blanket, especially if the patient is cold • Assist the physician with starting an intravenous line as ordered • Evaluate the feet and legs of the patient with low systemic blood pressure • Transport the patient to the closest hospital as soon as possible by notifying the EMS as directed by the physician

What would you document before the ambulance arrives in an emergency?

Before the ambulance arrives, you should document basic identification, the chief complaint, times that specific events occurred, vital signs, techniques used to treat the patient, and any observations.

Level of Consciousness

By the time you have completed the primary survey and noted the patient's general appearance, the level of consciousness may be apparent. A decrease in oxygen to the cells of the brain, neurologic damage from a cerebrovascular accident (stroke), and intracranial swelling are just some of the conditions that may alter a patient's level of consciousness. The AVPU system uses a common language to describe the patient's level of consciousness: • A, Awake and alert • V, responds to voice • P, response only to pain • U, unresponsive or unconscious

Cardiogenic Shock

Cardiogenic shock is an extreme form of heart failure that occurs when the function of the left ventricle is so compromised that the heart can no longer adequately pump blood to body tissues. This type of shock may follow death of cardiac tissue during a myocardial infarction (heart attack).

Cardiovascular Emergencies

Cardiovascular disease accounts for nearly 1 million deaths each year in the United States. The most common problem is coronary artery disease. Approximately two-thirds of sudden death from coronary artery disease occur out of the hospital, and most occur within 2 hours of the onset of symptoms. As coronary artery disease progresses, less and less oxygen can get to the cardiac muscle, which leads to tissue ischemia and eventually infarction of the cardiac tissue. The early symptoms of myocardial infarction (heart attack) include the following: • Chest pain not relieved by rest • A complaint of pressure in the chest or upper back • Nausea or indigestion • Chest pain that radiates up into the neck and jaw or down one arm • Anxiety Early treatment, including basic life support, early defibrillation, and advanced life support, can prevent many of these deaths. If cardiopulmonary resuscitation is initiated promptly and the patient is rapidly and successfully defibrillated, the patient's survival chances improve. As noted earlier, an automatic external defibrillator, or AED, may be available in your medical office and should be used as soon as possible after it is determined that the victim does not have a pulse.

Classification of Burn Injuries

Classification of burn injuries depends on the depth, or tissue layers involved. Factors that determine the depth of the burn include the agent causing the burn, the temperature, and the length of time exposed. Burns are classified according to the depth of injury: • Superficial (first degree) • Partial thickness (second degree) • Full thickness (third degree)

Management of Poisoning Emergencies

Exactly how and when a poison control center is consulted should be part of the medical office's protocol. Few toxic substances have specific antidotes, so the management of the poisoning is aimed at treating the signs and symptoms and assessing the involved organ systems. The patient may go to the medical office after the poisoning, or more commonly, the patient or caregiver telephones the office requesting information. In either situation, you must obtain the following information before making the call to poison control: • The nature of the poisoning (ingested, inhaled, skin exposure) • The age and weight of the victim • The name of the substance • An estimate of the amount of poison • When the exposure occurred • The patients present signs and symptoms Once the Poison Control Center has been notified and instructions given, you must be prepared to treat the patient as directed and notify the EMS to transport the patient to the hospital. Never give a patient syrup of ipecac or otherwise induce vomiting unless directed to do so by the professionals at the poison control center.

Medical Office Emergency Procedures

Emergency medical care is the immediate care given to sick or injured persons. When properly performed, it can mean the difference between life and death, rapid recovery and long hospitalization, and temporary disability and permanent disability. Emergency medical care in the medical office entails identifying the emergency, delivering basic first aid, and furnishing temporary assistance or basic life support until a rescue squad and advanced life support can be obtained. An emergency can occur anywhere and to anyone. In a life-threatening situation, the well-prepared medical assistant can obtain important information and perform lifesaving procedures before the ambulance or rescue squad arrives, increasing the patient's chance for survival. Medical assistant should be certified in CPR and removing foreign body airway obstruction. Currently, the American Association of Medical Assistants (AAMA) requires certified medical assistants (CMAs) to demonstrate proof of current CPR certification to recertify their credentials. This training may be provided by the American Red Cross, American Heart Association, American Safety and Health Institute, or National Safety Council.

Heat- and Cold-Related Emergencies

Environmental temperature is one of the many variables to which the body normally adjusts, maintaining equilibrium. Human beings depend on the ability to control core body temperature within a range of several degrees. Measured rectally, this core temperature is 37.6°C (99.6°F). The peripheral temperature is usually lower 98.6°F orally. Several conditions can disrupt normal heat regulating mechanisms of the body. These are divided into two main categories hyperthermia and hypothermia.

What are some causes of seizure activity in a patient?

Epilepsy, head injury, and drug toxicity can cause seizure activity in a patient.

Emergency Action Plan

Every medical office should have an emergency action plan, including the following: • The local emergency rescue service telephone number (usually 9-1-1). • Location of the nearest hospital emergency department. • Telephone number of the local or regional poison control center. • Procedures for various emergencies. • List of office personnel who are trained in CPR. • Location and list of contents of the emergency medical kit or crash cart. Whether confronted with a cardiac emergency or psychiatric crisis, medical assistants must be able to coordinate multiple ongoing events while rendering patient care. Contributing to the complexity of a medical emergency are such factors as panicky family members, the arrival of emergency personnel, and possibly language barriers. You must be able to remain calm in these situations while reacting competently and professionally.

Management of the Burn Victim

Follow these guidelines for managing burn patients in the medical office: • Eliminate the source of the burn, if necessary, by washing the area with cool water. • Have someone notify the physician, and take the patient immediately to an examination or treatment room. • Continually assess the patient's airway, breathing, and circulation. Begin CPR if necessary. • Remove all jewelry and clothing as necessary to evaluate the extent of the burn. • Administer oxygen as instructed by the physician. • Treat the patient for shock and accompanying low blood pressure. • Notify the EMS as directed by the physician. • Document the time and type of treatment given. • Assist with necessary procedures for transporting the patient to the hospital.

What is the difference between heat exhaustion and heat stroke?

Heat exhaustion is caused by physical exertion in a hot environment while the body temperature remains normal or slightly above normal. Heat stroke is characterized by a rapid rise in body temperature, often above 105°F. Heat stroke is a true medical emergency.

Hyperthermia

Hyperthermia is a general condition of excessive body heat. Correct management depends on assessment of the underlying cause. The first type of hyperthermia includes heat cramps, which is muscle cramping that follows a period of heavy exertion and profuse sweating in a hot environment. While sweating is primarily water, it also contains the electrolyte sodium, which is needed for muscle function. Heavy sweating, which is a normal compensatory mechanism to cool the body, will result in a sodium deficit, which compromises muscle function and produces muscle cramps. Heat cramps signal the need for cooling and rest. In uncomplicated cases, the patient is encouraged to take fluids by mouth, but nausea may make intravenous infusion necessary. If the patient is able to take fluids by mouth, give a commercial electrolyte solution such as Gatorade, or salt can be added to water or fruit juice at one tsp. per pint. Heat exhaustion results most often from physical exertion in a hot environment without adequate fluid replacement. Body temperature usually remains normal or slightly above normal. Patients have central nervous system symptoms such as headache, fatigue, dizziness, or syncope (fainting). Heat stroke is a true emergency. The body is no longer able to compensate for the rapid rise in body temperature (past 105°F) and may undergo brain damage or death. Heat stroke victims can deteriorate quickly to coma, and many patients have seizures. The skin is classically hot, flush, and dry. Vital signs are elevated initially but may drop, with ensuing cardiopulmonary arrest. Heat stroke demands rapid cooling of the body. After alerting the physician, follow office policy for the management of hypothermia and heat stroke, which will include these steps: • Moved patient to a cool area. • Remove clothing that may be holding in the heat. • Place cool, wet clothes or a wet sheet on the core surface area of the body where the ability to cool the central blood is the greatest: the scalp, neck, axilla, and groin. • Administer oxygen as directed by the physician and apply a cardiac monitor. • Notify the EMS for transportation to the hospital as directed by the physician.

Hypovolemic Shock

Hypovolemic shock is caused by loss of blood or other body fluids. If the cause is blood loss, it is hemorrhagic shock. Dehydration caused by diarrhea, vomiting, or profuse sweating can also lead to hypovolemic shock.

Head and Neck

If a cervical spine injury is suspected, immediately immobilize the spine and avoid manipulating the neck during examination of the head. Inspect the face for edema, bruising, bleeding, and drainage from the nose or ears. Examine the mouth for loose teeth and dentures. The condition and severity of the neurologic injury or patients with altered consciousness can be assessed by checking the pupils with a flashlight or penlight. The pupils should be checked for several characteristics: • Equality and size • Dilation bilaterally in darkness or dim light • Rapid constriction to light in both eyes • Equal reaction to light To evaluate the pupils for these qualities, shade both eyes from the light and use a flashlight or small penlight at an angle 6- to 8-inches from each eye. The conscious patient should not look directly into the light. Report the findings to the physician.

Musculoskeletal Injuries

Injuries to muscles, bones, and joints are some of the most common problems encountered in providing emergency care. The seriousness varies widely, from simple injuries, such as a fractured finger, to major or life-threatening conditions, such as an open fracture to the femur, which can cause severe bleeding. Injuries to muscles, tendons, and ligaments occur when a joint or muscle is torn or stretched beyond its normal limits. Fractures and dislocations are usually associated with external forces, although some arise from disease, such as bone degeneration.

Management of Musculoskeletal Injuries

It is often difficult to distinguish between strains, sprains, fractures, and dislocations in an emergency. Therefore, in most cases, assume the area is fractured and immobilize it accordingly. Proper splinting includes immobilizing the joint above and below the fracture site. Splinting helps prevent further injury of soft tissues, blood vessels, and nerves from sharp bone fragments and relieves pain by stopping motion at the fracture site. As soon as possible, apply ice to the injured area to reduce the swelling that commonly occurs with this type of injury, but never attempt to reduce, or put back into place, a dislocated area. For injuries to the upper extremities, an arm sling may be order.

Management of Bleeding and Soft Tissue Injuries

Management of open soft tissue injuries includes controlling bleeding by applying direct pressure. Sterile gauze should be used to cover the wound if possible to avoid introduction of microorganisms into the wound. Management of an amputated body part includes controlling the bleeding but also preserving the severed parts for possible reattachment later. To preserve a severed body part: • Place the severed part in a plastic bag. • Place this bag in a second plastic bag. The second bag will provide added protection against moisture loss. • Place both sealed bags in a container of ice or ice water, but do not use dry ice. An impaled object should not be removed but requires careful immobilization of the patient and the injured area of the body. Because any motion of the impaled object can cause additional damage to the surface wound and underlying tissue, you must stabilize the object without moving it by placing gauze pads around the object and securing with tape. The immobilized impaled object can be carefully removed after transportation to the hospital.

Poisoning

Most toxic exposures occur in the home, and almost 50% occur in children aged 1- to 3-years. Although about 90% of reported poisonings are accidental, intentional exposures usually effect adolescents and adults, and they tend to have a higher death rate. Fortunately, deaths from drug overdoses and poisoning are rare, but you must know how to respond if a patient comes to the office or telephones with a possible poisoning.

Emergency Medical Kit

Proper equipment and supplies should be readily available in a medical emergency. Although the offices equipment and supplies vary with the medical specialty, emergency equipment and supplies are fairly standard. This equipment should be kept in a designated location that is accessible to all staff. Although items used during an emergency should be replaced as soon as possible, a medical assistant or other staff member should check the contents of the emergency kit or crash cart regularly, perhaps weekly, to verify that contents are available and that no item has gone beyond the expiration date. If so, expired items should be replaced immediately.

Neurogenic Shock

Neurogenic shock is caused by a dysfunction of the nervous system following a spinal cord injury. Normally, the diameter of all blood vessels is controlled by the involuntary nervous system and smooth muscles surrounding the vessels. After a spinal cord injury, the nervous system loses control of the diameter of the blood vessels, and vasodilation ensues. Once the blood vessels are dilated, there is not enough blood in the general circulation, so that blood pressure falls and shock ensues.

The Primary Assessment

Once you are at the victim's side, an initial survey of the patient is the first step in emergency care. This is a rapid evaluation, usually done in less than 45 seconds. The purpose of the primary assessment is to identify and correct any life-threatening problems. Quickly assess the following aspects of the patient: • Responsiveness • Airway • Breathing • Circulation Checking for responsiveness means noting whether the patient is conscious or unconscious. If the patient is unconscious, attempt to awaken the patient by speaking and touching the shoulder. If no response occurs, assess the patient's airway by using the head tilt-chin lift method. Patients who may have neck injuries should have their airway open using the jaw thrust method to avoid injury to the spinal cord. Once the airway is open, evaluate the patient's breathing by watching for movement of the chest up or down while listening and feeling over the mouth and nose for signs of adequate ventilation. If the patient is not breathing, artificial respiration must be started immediately. A mask with a one-way valve or a bag valve mask device is recommended when performing rescue breathing and should be used if available. Respirations that are too fast, too slow, or irregular also require medical intervention. Immediate intervention for these conditions may include breathing into a mask or paper bag for respirations that are too fast (hyperventilation) or administering oxygen as directed by the physician. Any obvious noises such as stridor or wheezes, are noted and reported to the physician. Evaluate circulation in adults and children by checking the carotid pulse. The brachial pulse is used to evaluate circulation in infants. If no pulse is found, begin cardiopulmonary resuscitation (CPR) chest compressions immediately. Some medical offices may have an automated external defibrillator (AED) as part of the emergency medical kit. Training to use the AED is included in most CPR classes. Many public places such as airports and shopping malls have AED units available for use by those individuals trained appropriately. During the primary assessment, also check for any hemorrhage, and if found, control the bleeding quickly. Evaluate perfusion, or blood flow through the tissues, by checking the temperature and moisture of the skin.

Behavioral and Psychiatric Emergencies

Psychological distress may be mild, moderate, or severe. The degree of intensity determines the type and amount of intervention necessary. A psychiatric emergency is different from an emotional crisis, and you must know how to differentiate between the two. A psychiatric emergency is any situation in which the patient's mood, thoughts, or actions are so disordered or disturbed that harm or death may result from the patient or others if no intervention occurs. An emotional crisis, on the other hand, is a situation with much less intensity. While it may be distressing to the patient, in most cases, it is not likely to end in danger, harm, or death without immediate intervention. However, if neglected entirely, an emotional crisis may escalate to a full psychiatric emergency. A true behavioral emergency, like a medical emergency, carries a serious threat. Urgent behavioral situations usually require some form of professional psychological evaluation and intervention and require transportation to the hospital. The following guidelines are useful for handling a psychiatric emergency: • Notify the physician and the EMS as directed. • Offer reassurance and general support to the patient and any caregivers or family members who may be present. • Accurately document information, including vital signs and the patient's behavior.

Shock

Shock is lack of oxygen to the individual cells of the body, including the brain, as a result of a decrease in blood pressure. As shock progresses, the body has more difficulty trying to adjust, and eventually tissues and body organs have such severe damage that the shock becomes irreversible and death ensues. The signs and symptoms of shocked include: • Low blood pressure • Restlessness or signs of fear • Thirst • Nausea • Cool, clammy skin • Pale skin with cyanosis (bluish color) at the lips and ear lobes • Rapid and weak pulse

Septic Shock

Septic shock is caused by general infection of the bloodstream in which the patient appears seriously ill. It may be associated with an infection such as pneumonia or meningitis, or it may occur without any apparent source of infection, especially in infants and children. Initially, a fever is present, but the body temperature falls, a clinical sign suggestive of sepsis.

What does it mean when a patient is in shock?

Shock is defined as lack of oxygen to individual cells resulting from low blood pressure. The patient in shock will have a variety of signs including low blood pressure, a rapid and weak pulse, cool and clammy skin, and pale skin with cyanosis.

Bleeding

Soft tissue injuries involve damage to the skin and/or underlying masculature. When a blunt object strikes the body, it may crush the tissue beneath the skin. Although the skin does not always break, severe damage to tissue and blood vessels may cause bleeding within a confined area. This is called a closed wound. Types of closed wounds include contusions, hematomas, and crush injuries. In contusion is a bruise or collection of blood under the skin or in damaged tissue. The site may swell immediately or 24 to 48 hours later. As blood accumulates in the area, a characteristic black and blue mark, called ecchymosis, is seen. A blood clot that forms at the injury site, generally when large areas of tissue are damaged, is a hematoma. As much as a liter of blood can be lost in the soft tissue when a large bone is fractured. Crush injuries are usually caused by extreme external forces that crush both tissue and bone. Even though the skin remains intact, underlying organs may be severely damaged. Regardless of the type of swelling in a closed wound, the treatment includes the application of ice to reduce and prevent additional swelling to the area. In an open wound, the skin is broken, and the patient is susceptible to external hemorrhage and wound contamination. An open wound may be the only surface evidence of a more serious injury, such as a fracture. Open wounds include abrasions, lacerations, major arterial lacerations, puncture wounds, avulsions, amputations, and implements. When managing any patient with an open wound, follow standard precaution to protect yourself against disease transmission and to protect the patient from further contamination.

What is the purpose of applying a splint?

Splinting helps prevent further injury of soft tissues, blood vessels, and nerves from sharp bone fragments and relieves pain by stopping motion at the fracture site.

Poison Control Center

The American Association of Poison Control Centers has established standards and regional poison control centers throughout the country. The centers are staffed by physicians, nurses, and pharmacist. When information about a poisoning or drug overdose is not readily available, the Poison Control Center is a valuable resource, and the phone number should be posted near all phones in the medical office. The professionals at the poison control center can usually evaluate a potential or known toxic exposure, instruct the caller in the use of syrup of ipecac to induce vomiting if indicated, and check on the patient's progress by follow-up telephone calls.

Abdomen

The abdomen of all patients is evaluated, but it is particularly important for those with GI symptoms or suspicion of blood or fluid loss as seen in vaginal bleeding, vomiting, or melena (blood in the stool). The abdomen is inspected for scars, bruises, and masses. A distended abdomen may indicate hemorrhage in the abdominal cavity.

Chest and Back

The anterior chest is evaluated to some degree when the patient's respiratory status is evaluated. A further inspection of the chest should be done after removing clothing from a patient with trauma or abnormal vital signs. Patients with cardiac or respiratory complaints should also have their chest more thoroughly evaluated. Palpation of the chest and back may reveal the possibility of rib fractures.

Hypothermia

The body's core temperature can drop several degrees without loss of normal body function. The body usually tolerates a 3° to 4° drop in temperature without symptoms; hypothermia is an abnormally low body temperature, below 35°C (95°F). Internal metabolic factors and significant heat loss to the external environment can lead to hypothermia. Very cold air and immersion in cold water can cause a rapid drop in core temperature. The following are the signs and symptoms of hypothermia: • Cool, pale skin • Lethargy and mental confusion • Shallow, slow respirations • Slow, faint pulse pulse rate Basic management of hypothermia includes handling the patient gently, removing wet clothing, and covering the patient to prevent further cooling. If there is evidence of rewarming (skin warm, respirations approaching normal, no shivering) and the patient is alert and able to swallow, give warm fluids by mouth.

What diagnostic signs are evaluated in the secondary assessment?

The diagnostic signs of the Secondary Assessment are general appearance, level of consciousness, vital signs, and skin appearance.

Calculation of Body Surface Area Burned

The extent of body surface area (BSA) injured by the burn is most commonly estimated by a method called the rule of nines. This method calculates the percentage of total body surface of individual sections of the body. With the rule of nines for an adult, 9% of the skin is estimated to cover the head and another 9% for each arm, including front and back. Twice is much, or 18%, of the total skin area covers the front of the trunk, another 18% covers the back of the trunk, and 18% covers each lower extremity. The area around the genitals is an additional 1% of the BSA. In infants and children, the percentages are the same except that the head is 18% and each lower extremity is 13.5% of the total BSA. Usually, the emergency room physician determines the percentage of body burned using this rule, not the medical assistant.

Emergency Medical Kit and Equipment

The following are standard supplies that can be used to make an emergency medical kit: • Activated charcoal • Adhesive strip bandages, assorted sizes • Adhesive tape • Alcohol 70% • Alcohol wipes • Antimicrobial skin ointment • Chemical ice pack • Cotton balls • Cotton swabs • Disposable gloves • Elastic bandages, 2- and 3-inch • Gauze pads, 2 x 2 and 4 x 4 inch • Roller, self-adhesive gauze, 2- and 4-inch • Safety pins, various sizes • Scissors • Syrup of Ipecac • Thermometer • Triangular bandage • Tweezers In addition to these contents, the following equipment should be available: • Blood pressure cuff (pediatric and adult) • Stethoscope • Bag-valve mask device with assorted size masks • Flashlight or penlight • Portable oxygen tank with regulator • Oxygen masks • Suction unit and catheters Additional equipment that may be available includes: • Various sizes of endotracheal tubes • Laryngoscope handle in various sizes of blades • Automatic external defibrillator • Intravenous supplies (catheters, administration set tubing, assorted solutions) • Emergency drugs including atropine, epinephrine, and sodium bicarbonate

Burns

The four major sources of burn injury are thermal, electrical, chemical, and radiation. Thermal burns, also called heat burns, results from contact with hot liquids, solids, superheated gases, or flame. Chemical burns result when wet or dry corrosive substances come into contact with the skin or mucus membranes. The amount of injury with a chemical burn depends on the concentration and quantity of the chemical agent and the length of time it is in contact with the skin. Radiation burns are similar to thermal burns and can occur from over exposure to ultraviolet light or from any extreme exposure to radiation.

What are the four major sources of burn injuries?

The four major types of burn injuries are thermal, electrical, chemical, and radiation.

The Emergency Medical Services System

The initial element of any emergency medical services (EMS) system is citizen access. The availability of rapid, systematic intervention by personnel specifically trained in providing emergency care is an integral part of the EMS system. Most communities have a 911 system to report emergencies and summon help by telephone. communications operator at the local EMS station will answer the call, take the information, and alert the EMS, fire, or police department as needed. In communities without a 911 system, emergency calls are usually made directly to the local ambulance, fire, or police department. You should know the emergency system used in your community. Emergency phone numbers should be prominently displayed by all telephones in the medical office. Some communities have an enhanced 911 system that automatically identifies the caller's telephone number and location. If the telephone is disconnected or the caller loses consciousness, the communications operator can still send emergency personnel to the scene. In the medical office, an emergency requiring notification of the EMS includes situations that are life threatening or have the potential to become life threatening, such as the symptoms of a heart attack, shock, or severe breathing difficulties. In each of these cases, the medical assistant provides immediate care to the patient, including CPR if necessary, while directing other staff members to notify the physician. During assessment of the emergency by the physician, the medical assistant should continue to provide first aid or be prepared to assist the physician in administering first aid while another staff member notify the EMS. The staff members who calls EMS should be able to describe the emergency to the communications operator. The operator will then know what level of emergency personnel and rescue equipment to send. Excellent communication skills and corporation between health care team members is essential during a medical office emergency. Documentation in the medical record is an important responsibility in all patient care, including emergency care. EMS personnel depend on accurate and complete information regarding the patient's symptoms, the nature of the emergency, and any treatment performed prior to their arrival. This information should be placed in the patient's record in chronological order as events occurred or treatments were performed. Any vital signs taking during the emergency should also be recorded. Emergencies that involve visitors or staff must also be documented, and in this case, a blank paper or progress note page will be sufficient to record the details and outline the care provided. Information should include but not be limited to the following: • Basic identification, including name, age, address, and location of the patient's emergency contact if known • The chief complaint if known • Times of events, beginning with recognition of the emergency, management techniques, and changes in patient's condition • The patient's vital signs • Specific emergency management rendered in the office, such as CPR, bandaging, splinting, and medications administered before and after the emergency • Observations of the patient's condition, including any slurred speech, lethargy, confusion, and so on • Any medical history, allergies, or current medications if known When the EMS personnel arrive assist them as necessary. Let them examine the patient and take over the emergency care. You can also help by removing any obstacles to removal of the patient by stretcher and keeping family members in the reception area or private room.

Signs and Symptoms

The initial signs and symptoms of an allergic reaction may include severe itching, a feeling of warmth, tightness in the throat or chest, or a rash. The primary rule for any exposure is that the sooner the symptoms occur after the exposure, the more severe the reaction is likely to be. Be observant and ready to treat any patient who has these symptoms, since airway obstruction, cardiovascular collapse, and shock can occur if the situation worsens. Since the primary cause of death in an anaphylactic reaction is swelling of the tissues in the airway, leading to airway obstruction, observe the patient closely for signs of airway involvement, including wheezing, shortness of breath, and coughing. Choking or tightness of the neck and throat may signal this danger.

General Appearance

The patient's skin color and moisture, facial expression, posture, motor activity, speech, and state of alertness provide important clues about the mental and physical condition. Check for a medical bracelet or necklace. Medicine bottles in a pocket or purse can also be helpful.

Why is it important to have the phone number of the poison control center near the telephone in the medical office?

The poison control center staff can assist with evaluating a potential or known toxic exposure and instruct you on procedures to follow including possibly administering syrup of ipecac to induce vomiting if indicated.

What is the primary cause of death in anaphylaxis?

The primary cause of death from anaphylaxis is airway obstruction.

Management of Allergic and Anaphylactic Reactions

The primary goal when treating a patient having an anaphylactic reaction is restoring respiratory and circulatory function. The following steps are required for managing allergic reactions, including anaphylaxis: • Do not leave the patient, but have another staff member request that the physician immediately evaluate the patient and bring the emergency kit or crash cart, including oxygen. • Assist the patient to a supine position. • Assess the patient's respiratory and circulatory status by obtaining the blood pressure, pulse, and respiratory rate. • Observe the skin color and warmth. • If the patient complains of being cold or is shivering cover him or her with a blanket. • Upon the direction of the physician, start an intravenous line and administer oxygen. • As ordered by the physician, administer medications as ordered. • Document vital signs and any medications and treatment given, noting the time each set of vital signs is taken or medications are administered. • Communicate relevant information to the EMS personnel, including copies of the progress notes or medication record as needed.

What is the purpose of the primary assessment?

The purpose of the primary assessment is to identify and correct any life-threatening problems.

Patient Assessment

The two primary objectives in assessment of the patient are to identify and correct any life-threatening problems and provide necessary care. Each step of the assessment must be managed effectively before proceeding to the next. In addition, survey the scene quickly to identify hazards or clues to the patient's condition.

How should an open wound that is bleeding be treated?

Treat an open wound that is bleeding by applying direct pressure until the bleeding has been controlled. If an item is impaled, immobilize the impaled object, but do not remove it.

Recognizing the Emergency

When providing emergency care, do not assume that the obvious injuries are the only ones. Less noticeable or internal injuries may also have occurred during an accident. You should look for the causes of the injury, which may provide a clue to the extent of physical damage. In the case of an injury to the head or back, when spinal fracture is possible, be especially careful not to move the victim any more than necessary and avoid rough handling.

Frostbite

Windy subfreezing weather creates the greatest risk for frostbite. Small body parts with a high ratio of surface area to tissue mass (fingers, toes, ears, and nose) are most vulnerable to frostbite, although larger areas of the extremities are also vulnerable during profound cooling. Exposure to cold can cause tissues to freeze, and the frozen cells will die. The type and duration of contact are the two most important factors in determining the extent of frostbite injury. The combination of wind and cold is dangerous. Superficial frostbite appears as firm and waxy grey or yellow skin in an area that loses sensation after hurting or tingling. Prolonged exposure can lead to blistering and eventually deep frostbite, which most often affects the hands and feet. No warning symptoms appear after the initial loss of feeling. Freezing progresses painlessly once the nerve endings are numb. Skin becomes inelastic and the entire area feels hard to the touch. Deep frostbite results and tissue death, and the affected tissue must be removed surgically or amputated.

Splint

a device used to immobilize a sprain, strain, fracture, or dislocated limb

Heat Exhaustion

a type of hypothermia that causes an altered mental status due to an adequate fluid replacement

Cardiogenic Shock

a type of shock in which the left ventricle fails to pump enough blood for the body to function

Seizure

abnormal discharge of electrical activity in the brain, resulting in involuntary contractions of voluntary muscles

Allergen

any substance that causes manifestations of an allergy, usually a protein to which the body has built antibodies

Hypothermia

below normal body temperature

Melena

black, tarry stools caused by digestive blood from the gastrointestinal tract

Hematoma

blood clot that forms at an injury site

Superficial Burn

burn limited to the epidermis

Full-Thickness Burn

burn that has destroyed all skin layers

Partial-Thickness Burn

burn that involves epidermis and varying levels of the dermis

Ecchymosis

characteristic black and blue marks that result from blood as it accumulates under the skin

Infarction

death of tissue due to lack of oxygen

Ischemia

decrease in oxygen to tissues

Hyperthermia

general condition of excessive body heat

Shock

lack of oxygen to individual cells of the body

Heat Stroke

most serious type of hyperthermia; body is no longer able to compensate for elevated temperature

Anaphylactic Shock

severe allergic reaction within minutes to hours after exposure to a foreign substance

Hypovolemic Shock

shock caused by loss of blood or other body fluids

Neurogenic Shock

shock that results from dysfunction of nervous system following spinal cord injury

Septic Shock

shock that results from general infection in the bloodstream

Confusion

state of mind in which one is unsure of the present time, place, or self identity, causing bewilderment and inability to act decisively; it usually indicates organic mental disorder but may also occur in times of severe stress

Frostbite

tissue damage, especially of the fingers, toes, ears, or nose, caused by freezing and generally due to prolonged exposure to very cold weather

Heat Cramps

type of hypothermia that causes muscle cramping resulting from high-sodium heat exhaustion; hyperthermia resulting from physical exertion in heat without adequate fluid replacement