EMERGENCIES

Natalia Fernandez, MPT and Alyssa Trotsky, DPT

University of Michigan Health System

May 23rd, 2013

LEARNING OBJECTIVES:

By the end of this lecture, students will be able to:

VITAL SIGNS

In emergency situations, always assess vital signs!

Blood Pressure Heart Rate Oxygen Saturation Respiratory Rate Temperature Pain

Monitor vitals at rest, during activity, and after recovery.

BLOOD PRESSURE

Definition: pressure exerted by the blood upon the walls of the blood vessels, especially arteries.

Measured by a sphygmomanometer, indwelling lines, or automatic

Systolic pressure (top number) is defined as the amount of pressure that blood exerts on arteries and vessels while the heart is contracting.

Diastolic pressure (bottom number) is defined as the pressure that is exerted on the walls of the arteries when the heart is relaxing and the ventricle is filling.

BLOOD PRESSURE CONTINUED

Classification of Blood Pressure (BP) for Adults:

Classification Systolic (mmHg) Diastolic (mmHg)

Hypotension <90 <60

Desired 90-119 60-79

Prehypertension 120-139 80-89

Stage I Hypertension

140-159 90-99

Stage II Hypertension

160-179 100-119

Hypertensive Crisis

>180 >110

BLOOD PRESSURE CONTINUED

Precautions/Contraindications to Initiating Activity:

Mild (150/90) to Moderate (170/100) Hypertension: light activity only. monitor vitals at rest, with activity, and after recovery.

Moderate to Severe (180/110) Hypertension: light supine exercises only. monitor for changes. no out of bed activity.

Activity contraindicated for resting systolic blood pressure >200 and diastolic blood pressure >110.

Low BP (90/60): proceed with caution. Light supine or seated exercises only.

Low BP (<90/60): passive range of motion only. No out of bed activity.

ORTHOSTATIC HYPOTENSION

Decrease >20mmHG systolic pressure after standing from supine within 3 min (or a diastolic drop >10mmHg.

Normal response is to accommodate to the posture change within 1-2 min for BP and 45-60s for HR.

BLOOD PRESSURE CONTINUED

Precautions/Contraindications During Activity:

Stop activity during exercise if systolic blood pressure >240 or diastolic blood pressure >110.

Severe changes in diastolic pressure (>10 mmHg) from rest to exercise: proceed with caution.

BLOOD PRESSURE CONTINUED

If a patient is found to have an abnormal blood pressure:

1. Look at patient’s medication list. Have they taken their medications?

2. In acute care or inpatient rehab, contact the patient’s nurse and/or doctor. Patient may be able to quickly receive medication that could allow you to continue with treatment.

3. In the outpatient setting, cease activity, and call patient’s primary care physician to determine if the patient should come in to the office or get sent straight to ER (patient should not drive).

HEART RATE (HR) Definition: number of heart beats per minute (bpm). Normal HR is between 60-100 bpm

Precautions/Contraindications to Activity: Resting HR <50: light exercises and light activity only. monitor for

decreases. cease activity if there is a decrease more than 10 bpm. Resting HR <40: PROM only and monitor. Resting HR 110-130: light exercise and light activity only. monitor

for increases. cease activity if increases more than 10 bpm Resting HR 130-150: light exercise only. monitor. cease activity if

there is a increase more than 10 bpm and allow rest.

Failure of HR to increase from supine to sit and sit to stand is associated with an impaired cardiovascular system. Symptoms may include dizziness, lightheadedness, and even syncope.

If abnormal HR found, check to see if patient is on medications which would increase/decrease heart rate.

PULSE PRESSURE

Definition: difference between the systolic and diastolic blood pressures.

At rest, 30-40 mmHg is normal value. With activity, pulse pressure should not to increase >100 mmHg.

The larger the difference, the more perfused the organs are.Ex: 10 mmHg is not as good 50 mmHg

90/60 VS. 90/80180/90 VS. 210/90

RESPIRATORY RATE Definition: number of breaths per minute Normal RR is between 12-20 breaths/minute

Precautions/Contraindications to Activity: >20: proceed with activity, but cautiously >30: light supine exercise only >35-40: passive range of motion only and

monitor response >40: no gentle exercise, possible relaxation

exercises/guided imagery. provide hypnotic-like commands to relax breathing

<10: no gentle exercise or activity.

If patient is on a ventilator, there may be alarms that will beep if RR is too high/low.

OXYGEN SATURATION (SAO2)

Definition: amount of oxygen the blood is carrying as a percentage of the maximum it could carry.

If patient without a cardiopulmonary disorder: SaO2 should be in the mid to high 90s. If SaO2 between 90%-94% monitor and proceed

cautiously with activity. If SaO2 drops below 90% cease activity.

If patient has a cardiopulmonary disorder: <85%: cease activity If patients baseline resting SaO2 is between 88%-90%:

do not allow for more than a 2% drop with activity below patients norm.

TEMPERATURE

Low Body Temperature: Patient may not want to participate due to

feeling “cold” Depending on how low, patient may be

“crashing” Some interventions for medical treatment

call for cooling patients body temperature to slow metabolism (patients most likely semi-comatose or comatose). PT interventions could include passive range of motion, joint compression, stretching, and assist with repositioning

Hypothermia = <94oF

TEMPERATURE CONTINUED

High Body Temperature:

Low grade fever 99-102oF may be normal in a post surgical population. Patients can perform light activity like supine or seated exercise, and short distance ambulation with a slower gait.

Higher fever >102oF: should not perform aerobic activity, light supine exercises only.

PAIN

Ask pain level and pain tolerance. Pain tolerance can be lower or higher

than actual pain level. Attempt to modify and coordinate pain

medications to help patient achieve maximal participation.

Report findings to MD if pain is limiting maximal participation.

ASSESS OTHER SIGNS

In emergency situations, make sure to also check the following:

Change in mental status Change in mood Fatigue/Exhaustion/Lethargy Slow to respond or react Decreased response to verbal or tactile

stimuli Complaints of nausea, syncope, vertigo Diaphoresis Changes in appearance (cyanotic, pallor) Pupil constriction or dilatation Loss of consciousness

PREPARATION FOR AN EMERGENCY Acute Care, Inpatient Rehab, SNF, and ECF: Know codes in facility Familiarize location of emergency equipment

Code buttons CPR release on bed Crash cart Oxygen tank Vital machines/pulse oximeter Oxygen regulator

Know how to use equipment Take control of the situation

If the emergency is initiated in your presence Know your role

During the emergency After the emergency

Plan ahead – in case of an emergency Practice and Review Recognize signs, precautions, contraindications Proper procedures during evaluation or treatment

PREPARATION FOR AN EMERGENCY

Outpatient and Home: Know codes in facility or how to respond in the home

Dial 911 In Case of Emergency (ICE) information

Familiarize location of emergency equipment Automatic Electronic Defib (AED) location Oxygen tank Blood Pressure cuff/stethoscope/pulse oximeter

Know how to use equipment Take control of the situation Know your role

During the emergency After the emergency

Plan ahead – in case of an emergency Practice and Review Recognize signs, precautions, contraindications Proper procedures during evaluation or treatment

EMERGENCY SITUATION

Emergency Telephone Numbers Calling 911

State your nameType of injuryTime of incidentWhat is being done for the patientLocation

Place next to phone with specific directions from the N, S, E, or W

DO NOT HANG UP More specific directions – best entrance, your

phone number

Ask estimated time of arrival

To save the patient’s life To prevent further harm

Time is of the essences Primary Assessment takes about 30 seconds to 2

minutes

Emergency Evaluation Check responsiveness 5-10sec Active emergency response system-get an AED Check for pulses/HR 5-10secs Begin with chest compression if no HR IF there is a pulse begin rescue breathing.

Airway 5 – 7 sec Ventilation 5 – 8 secCirculation/heart rate 20 – 30 sec Blood loss 20 – 30 sec Neurological injury 10 – 20 sec Total time 60 – 95 sec

EMERGENCY SITUATION Prioritize

Airway Obstruction Respiratory Failure Cardiac Arrest Severe Bleeding

Head (craniocerebral) Injury Cervical Spine Injury Severe Heat Injury

Prioritize Airway Obstruction: Heimlach Respiratory Failure: CPR Cardiac Arrest: CPR Severe Bleeding

Pressure

Severe Heat Injury: Cool the patient Head (craniocerebral) Injury

Neuro Assessment – cognition, sensory, motor Cervical Spine Injury

Neuro Assessment – cognition, sensory, motor Stabilize

EMERGENCY

Levels of Decision Is the injury life threatening Can the patient be moved and how How transported? – ambulance or car Follow up after emergency

Physician clearance through script

Helping to Make the Decision Abnormal pupil or extraocular movement Increasing facial or extremity weakness Amnesia, confusion, or lethargy Sensory or cranial nerve abnormality Post traumatic seizures

Incident Reports System form Detail of what occurred Facility to investigate, make improvements, not

to penalize

Documentation Briefly write what happened Do not write you completed an incident report

If you do it now becomes part of the medical record and may be included in the subpena