Primary Survey

Cardiopulmonary Resuscitation Survey

It should not be assumed that any patient who is not obviously interacting with his or her environment is simply sleeping. For the purpose of this approach, the patient is in cardiopul-monary arrest until it is proved otherwise. As you approach the patient, observe the patient closely, looking for spontaneous breathing or movements. If these are not discernible, stimulate the patient by talking loudly to him or her. If necessary, shout ''ARE YOU OKAY?''

Begin Secondary Survey

Figure 26-2 Key vital functions assessment algorithm.

If there is no response, obtain an open airway by the chin-lift/head-tilt maneuver and look, listen, and feel (feel air movement against your cheek) for breathing. To open an unconscious victim's airway, hyperextend the head and lift the patient's chin;place one hand on the patient's forehead and the other behind the patient's occiput, and tilt his or her head backward. This maneuver moves the tongue away from the back of the throat, allowing air to pass around the tongue and into the trachea. Caution should be exercised with any patient who has a suspected neck injury. With such a patient, try to open the airway by lifting the chin without tilting the head backward; grasp the lower teeth and pull the mandible forward. If necessary, tilt the head back very slightly. If a patient is wearing dentures, remove them only if they occlude the airway.

If there is no evidence of spontaneous breathing, deliver two full breaths by using mouth-to-mouth ventilation. Next, call for help in any way you can without leaving the patient;it is unlikely that you can manage the entire resuscitation by yourself.

Determine whether there is spontaneous cardiac function by feeling for a carotid pulse or, in an infant, by palpating the precordium for a cardiac impulse. If there is no pulse, begin external chest compressions and intersperse them with ventilations;in other words, begin CPR. Current guidelines (Hazinski et al, 2005) are 30 chest compressions for every two rescue breaths for five cycles (2 minutes). Recheck breathing after every five cycles. The 30:2 ratio is the same for CPR that a single rescuer provides for adults, children, and infants (except newborns). The only exception to this guideline is when two rescuers perform CPR on a child or infant (except newborns), in which they should provide 15 compressions for every two rescue breaths.

Key Vital Functions Assessment Survey

Once it has been determined that the patient does not need CPR or the patient has recovered spontaneous cardiopulmonary activity, ascertain whether key life-sustaining functions are adequate and stable or whether augmentation or other supportive measures are necessary.

In the initial overview of the patient, two observations can save a great deal of time and help avoid unnecessary or untimely interventions. First, if the patient's central nervous system is functioning, as manifested by the patient's ability to respond appropriately to questions, it is unlikely that key vital functions are so deranged as to necessitate immediate intervention. Second, if the patient's skin is warm, dry, and of normal color, it is likely that oxygenation and flow of blood to the periphery are adequate. In shock, peripheral blood flow is shunted centrally; thus, skin changes are early indicators of hypovolemic or cardiogenic (low cardiac output) shock. The key diagnostic skin signs associated with these major acute cardiopulmo-nary derangements are gray, mottled, or cyanotic color; cold skin temperature; and markedly sweaty skin. The last sign, termed diaphoresis, is caused by activation of the sympathetic nervous system by any major threat to homeostasis.

At this point in the algorithm, if the patient has sustained a possible head injury, immobilize the patient's head and neck by using boards, tape, bulky dressings, or towels or by assigning someone to hold the head immobile. Once the evaluation is complete and imaging studies are performed, if necessary, these restrictions to movement can be removed. However, once a patient is immobilized, removal of these measures requires careful decision-making.

The next two orders of priority are the search for and the management of arterial bleeding and open chest injuries. The latter are termed sucking chest wounds because they allow air to enter the pleural space, leading to collapse of the underlying lung (pneumothorax). Arterial bleeding and a sucking chest wound can cause death in a short time, and both are treated by application of a pressure dressing to occlude the area.

At this point in the algorithm, the patient has been stabilized to the point at which formal vital signs can be obtained. In the field, these include the patient's mental status, respiratory rate and pattern, pulse, blood pressure, and, in some circumstances, body temperature. Mental status can be assessed according to the AVPU system (more traditionally categorized as alert, lethargic, stuporous, or comatose). The AVPU mnemonic for level of consciousness is as follows:

A: patient is alert

V: patient responds to a verbal stimulus P: patient responds to a painful stimulus U: patient is unresponsive

The blood pressure can be estimated by the pulse wave fullness and by assessing which pulses are palpable. If the radial pulse at the wrist is palpable, the systolic blood pressure is at least 80 mm Hg. If the radial pulse is impalpable and only the femoral pulse is perceptible, the systolic blood pressure is 60 to 70 mm Hg. If a vital sign is abnormal, treat the abnormality to bring it back to normal. For example, if the patient is breathing spontaneously at a rate of only five breaths per minute, augment and assist the patient's breathing so that the depth and rate of breathing are normalized. This can be accomplished by applying interspersed mouth-to-mouth ventilations, using a self-inflating bag-valve-mask device, or performing endotra-cheal intubation and placing the patient on a ventilator. In a similar manner, the blood pressure can be supported by raising the legs, thus emptying the blood stored in the venous system back into the central circulation.

A trauma victim should have a cardiopulmonary examination as well. You are seeking to rule in or rule out a tension pneumothorax (shift of the heart away from the tension, increased breath sounds over the side with the tension pneumothorax, distended neck veins, subcutaneous emphysema), cardiac tamponade (distended neck veins, distant heart sounds, hypotension, pulsus paradoxus, normal breath sounds), and chest wall disruption (paradoxical movement of a flail segment).

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