EMERGENCY ROOM - First Aid and Basic Life Support

In an emergency condition, measures taken during the first few minutes are of utmost importance for a patient or a casualty to survive. Cardiac arrest means no pulse from the artery, that is to say, the heart stops beating. Approximately 70% of cases with cardiac arrest occur outside the hospital. It is found that if the BLS is employed within the first 4 minutes and defibrillation is employed within the first 8 minutes, the rate of survival will be around 43 percent.

BLS includes following procedures:

- Diagnose the heart attack immediately and take actions to save the patient.

- Open the airway in unconscious patients.

- Apply artificial respiration to patients who cannot breathe.

- Heart massage to patients with cardiac arrest.

- Identifying the patient with respiratory tract obstructed by a foreign object and apply necessary procedures to remove the foreign object.

BLS should be practiced by people certified by an authorized institution.

TRAUMA

Trauma is the leading cause of death in healthy young adults aged between I and 44 years. The major causes of traumas are traffic accidents, fall-down accidents and blunt and/or sharp injuries caused by fire-arms or sharp objects. Around 400-500 thousand traffic accidents take place annually and about 4-5 thousands of deaths occur in Turkey.

Who can we rescue?

About 50% of the deaths occur within seconds or minutes right after the accidents. In this short period of time, deaths take place due to the injuries to brain, brain stem, spinal cord or heart and aortic or arterial rupture. Generally, an early intervention is not possible for such casualties and they lose their lives at the site of event. Such deaths can only be eliminated by taking protective measures. About 30% of the deaths take place within minutes to a few hours (6 hours). During that time, the death occurs due to bleeding over or under the cerebral cortex, lung injuries, spleen injuries, liver injuries, femoral fracture, or other injuries leading to the significant loss of blood. Early and effective response in the gold-time may save the patients.

The patients who may have the most benefit from the healthcare personnel working in emergency rooms or ambulances are the ones who could be intervened within the gold-time. Therefore, it is of utmost importance for the patients being transferred to a well-equipped healthcare institution as soon as possible.

In addition, 20% of the deaths often occur due to infection at the hospital (nosocomial infection) or multiple organ failure.

In the event site, it is necessary to ensure first the safety of the environment and the lifesaver, then to call for help and keep the airway patent, intervene to external bleeding and shock and finally to stabilize the patient.

During the baseline evaluation, the patency of the airway should be always checked. The lifesaver should try to talk to the patient. Reasonably speaking patient implies the patent airway, presence of respiration and sufficient blood supply to the brain. If the respiration is rough and the wheezing is present it may imply the partial obstruction.Absence of an attempt to respond may lead one to think the patient is unconscious. The presence of respiration is assessed using the technique of “look, listen and feel”. For the patient who may not respond, has no gag (pharyngeal) reflex and has with secretions accumulating in the mouth, there is risk of aspirating the secretions and the stomach content. Dental plates and other foreign objects in the mouth should be removed. The most common cause of airway obstruction is the tongue falling back. While assessing the airway, possible neck injuries should also be taken into consideration since the most common cervical spine damages occur when one attempts to open the airway. The neck should never be moved. Unless otherwise is proven, the patient should be deemed to have a neck injury. A chin lift technique (lifting the chin by grasping mandibular bones) may be applied to open the airway. If the respiratory arrest persists following the assessment performed using the technique of “look listen, and feel”, artificial respiration can be performed.

Circulation is evaluated after two life-saving breaths are given to the patient. If there is no pulse, then the heart massage is started. Until the respiration and circulation returns to normal or help is received, basic life support is continued.

BLEEDING

The first thing to stop the bleeding visible in any part of the body is to apply pressure to the bleeding site with a clean cloth. The blood clot over the bleeding site should not be removed. Foreign objects such as glass or stones and bone pieces should not be removed. Since tourniquet may be more harmful rather than beneficial, it can be applied, but it should be loosening in every I5 - 20 minutes when the compression is not sufficient to stop bleeding in the presence of multiple casualties. In case of an organ amputation, the dismembered limb is wrapped in a clean and wet cloth and put into a bag. The bag is then put into another bag full of ice and taken with the patient in the shortest time to a hospital that has a Microsurgery Expert.

ELECTRIC SHOCK

About 2/3 of deaths due to electric shock occurs between the ages of 15 and 40 years. Electric shock may result from the contact with high or low voltage electric current. A normal household current is powerful enough to cause severe damage. Damages by high voltage can happen to factory workers or with direct contact with a high-voltage transmission line.

Damages of electric current on human body include heart rhythm disorder, cardiac arrest, nerve damage, and soft tissue burns. The highest resistance to electric current is demonstrated by the skin and bones. However, wetting the skin with water or sweat decreases such resistance and increases the damage given by the electric current. Respiration may stop as a result of electric current flowing through the brain and damaging the respiratory center in the brain, or of chest wall muscles and respiratory muscles remaining contracted. A high-voltage electric power can damage muscles and skin so as to render them unusable. There are 6 factors determining the severity of the damage: the type of current voltage, ampere, resistance, channel, and contact duration. Alternating current is 3 times more dangerous than direct current of the same magnitude. The danger is greater especially if the direct contact site is the hands. Direct current hurts the person away from the electric source after the first contact. With alternating current entire body begins to tremble along with the contact. Since the outer muscles of the hand is stronger than the inner muscles, the hands remain contracted on the current source leading to the person caught with the current and freeze, and thus, exposed to electric current for longer periods. Tissue damage increases as the electric current rises. Current flowing from the hand to the other hand can be more severe compared with the current flowing from hand to feet or from feet to feet.

Pre-hospitalization evaluation:

Unless cut by the utility company, any exposed voltage line should be deemed to carry electricity. Voltage lines can have I I5 - 50,000 volts. Telephone lines have much lower voltage but sufficient for a shock. Unless an exposed cable is ensured to have low voltage, it should be assumed to have high voltage and contact should be avoided.

In the case of an electric cable falling on a vehicle and there are people in the vehicle, they are safe as long as they stay indoors. Tires of the car shall act as an insulator. A circuit needs to be complete from the power source to the earth for an electric current to flow. Electrical burns occur when the body or part of it completes the circuit between the power source and the earth.

Most of the electrical burns at home occur due to misconnected electrical devices or their careless use. Children may insert metal objects into power sockets. Outside the house, most of the electrical burns take place as a result of accidental contact with power lines or during an excavation when a construction worker accidentally gets into contact with the line. Electricity should be cut off before approaching to a person still in contact with an electric wire or an electric device. If there are people in a vehicle in which an electric cable fell on, they should be told to stay put until the electricity is cut off by the utility company. In rare cases, fire hazard occurs as an addition. If their life is threatening, the passengers should be told to jump off the vehicle showing care to not getting into contact with the vehicle and the ground at the same time. First children should be rescued (by hurling so as two people not to contact with the child at the same time).

The energy coming from a high-voltage electric current and flowing through the body may affect the electrical rhythm of the heart and cause it to stop. In addition, electric shock may induce muscle contractions so powerful that can result in breaks or dislocation of bones. Electric shock can cause the patient falling down or other injuries as well. Therefore, an electric accident should be approached just like it is a traffic accident.

Lightning Injuries

Lightning injuries are a specific type of electric shocks. Lightning strikes with thousands of volts of electricity but lasts a fraction of a second. Not everyone who are struck by lightning dies. Oftentimes, people survive from a lightning strike.

Lightning is a high voltage of 20 – 100 million volts that the entire body is exposed to. It affects numerous systems, predominantly nervous and cardiovascular systems.

Many people suffer from a short-term memory loss following a lightning strike and they do not remember the event. The patient might complain from numbness, pins and needles, partial or complete paralysis, blindness, loss of hearing, speech impediment or inability to speak. These symptoms are generally temporary. The most important issue is the cardiac arrest or arrhythmia If the first aid is practiced immediately, such patients can mostly be resuscitated with success. It is not dangerous to touch a lightning struck patient There is no risk of shock when the patient is contacted. There may be skeleton system and other system injuries in a lightning struck patient. Spinal fractures are especially frequent. All the patients should be carried with spinal board.

Although there are no laboratory findings demonstrating heart damage following an electric shock, severe rhyme disorders have been observed in 8- l 2 hours. This is why even the clinically normal patients suffering from an electric shock should be monitored for at least 24 hours.

Resuscitation success after an electric shock or lightning strike is higher compared with patients who had cardiac arrest due to other reasons. Therefore, it should be kept in mind that resuscitation can be effective even though a longer period time is passed before a resuscitation procedure is practiced.

FAINTING

Fainting means inability to stand up, temporary unconsciousness, and then spontaneous recovery following a decrease in the blood flow to brain. It makes up of 1 – 3% of patients

visiting Emergency Rooms. It occurs less in children.

In order to provide the brain with sufficient oxygen and glucose, 55 ml of blood is necessary per 100-gram brain tissue. If this flow drops down to below 20 ml, fainting occurs and lasts from a few seconds to a few minutes.

Of the 40% of its reasons are non-critical extremely hot weather, hyperirritability. bad odors, severe pain, and response of the body to the sight of blood. In 10 – 15% of the cases, such cardiac causes as heart valve disorders and rhythm disorders bear importance. Fainting as a result of bleeding, loss of fluid, sudden standing up is observed in 20% of the cases.

Patient generally feels they are about to faint. Hot flashes, sweating and feeling of nausea-vomiting occur. Patient wishes to sit down or lie down, however they are often late to do these. They recuperate in one or two minutes as the blood circulation and blood flow to brain goes back to normal.

Fainting should not be confused with epileptic seizure. Contractions are predominant in epileptic seizures. However, there is a complete loss of tonus in fainting.

When a person faints, they should be laid down on their back and their legs should be raised up at 30 degrees. Then, help should be called. Bearing in mind the underlying cause may constitute a life risk the patient needs to be taken to a hospital.

Patient going through an epileptic seizure should be turned on their side and any objects around the patient should be put away due to the hazard of hit during contractions. Their teeth should never be attempted to separate and help should be called immediately.

BURNS

The burned subjects are to be hold under the clean and cold water immediately. Ice should not be applied since it would increase edema. Substances like creams, toothpaste, oil, and alcohol should never be used. As swelling related to edema may occur when hands or fingers are burned, jewelry such as rings, watches, and bracelets should be taken off. Patient must immediately be taken to hospital as infection may develop in the burned area and loss of fluid may occur in bigger burns.