Unit 4

Unit 4 - Vital Signs, Medical Emergencies and Shock

Key Terms

Vital Signs

Pulse

Respiratory Rate

Blood Pressure

Temperature

Loss of consciousness

Glasgow Coma Scale

Cerebrovascular Accident

Cardiac Arrest

Heart Attack

Diabetic Crisis

Seizures

Nausea and Vomiting

Epistaxis

Vertigo and Syncope

Shock

Hypovolemic Shock

Cardiogenic Shock

Neurogenic Shock

Septic Shock

Anaphylactic Shock

 

Reading Assignment

Introduction to Radiologic Sciences and Patient Care 5th Edition ( Adler and Carlton)
Chapter 15 - Vital Signs - Pages 172-184

Chapter 19 - Pages 248 - 260

 

Course Assignments For Unit 4

Here is what you must complete within Unit 4!!!

1. Reading Assignment

2. Read through the Lesson

3. Unit 4 Discussion

4. Complete the Unit 4 Dropbox Assignment

5. Unit 4 Exam

 

Vital Signs

An important part of dealing with medical emergencies is to know and understand the vital signs of the patient.

 

Vital Signs— There are four vital signs which are standard in most medical settings:   Body temperature, pulse rate (or heart rate), blood pressure and respiratory rate.    

 

Pulse—Arterial palpations of a heartbeat.   The easiest places to check for a pulse are the carotid artery (neck) and the radial artery (wrist).

Normal pulse for a resting adult is 60-100 beats/minute (BPM).   Pulse below 60 BPM is bradycardia and pulse above 100 is tachycardia.

Pulse can go as low as 40 BPM during sleep and 150-200 BPM during exercise.

Normal pulse for an infant is around 110 BPM.

Normal pulse for a child is approximately 70-110 BPM.

 

 Respiratory Rate—This is the number of breaths a person takes in a minute.

The average breaths per minute are:

Newborns: 44 breaths per minute

Infants: 20-40 breaths per minute

Preschool children: 20-30 breaths per minute

Older children: 16-25 breaths per minute

Adults: 12-20 breaths per minute

Adults during strenuous exercise 35-45 breaths per minute

Athletes' peak 60-70 breaths per minute

 

Blood Pressure—Blood Pressure is the pressure (force per unit area ) exerted by circulating blood on the walls of blood vessels .   For each heartbeat, blood pressure varies between systolic and diastolic pressures. Systolic pressure is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting (the heart at work). Diastolic pressure is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood (the heart at rest).

 

Normal pressure can be stated as 120 over 80, where 120 is the systolic reading and 80 is the diastolic.

 

 

Systolic

Diastolic

Hypotension

< 90

< 60     

Normal

  90 - 119

60 - 79      

Prehypertension

120 - 139

80 - 89  

Stage 1 Hypertension

140 - 159

90 - 99  

Stage 2 Hypertension

≥ 160

≥ 100

 

A person should not drink coffee, smoke cigarettes, or engage in strenuous exercise for 30 minutes before taking his/her blood pressure.   For 5 minutes before the reading, one should sit upright in a chair with one's feet flat on the floor and with limbs uncrossed. The blood pressure cuff should always be against bare skin, as readings taken over a shirt sleeve are less accurate. During the reading, the arm that is used should be relaxed and kept at heart level. You can keep it at the level of the heart by resting it on a table.

You should be able to take blood pressure manually using a stethoscope and a sphygmomanometer which consists of an inflatable cuff, a measuring unit, and an inflation bulb and valve.

You should also be able to use an automatic blood pressure machine.

 

Temperature--Body temperature is the degree of heat of the deep tissues of the human body.

Normal Ranges:

Newborn to three years - 99°F to 100°F

Five years to adult - 97.7°F to 98.6°F

Rectal temperatures are from .5°F to 1°F higher than oral temperatures.

Axillary temperatures are from .5°F to 1°F lower than oral temperatures.

 

 

O2 Therapy

Oxygen is an odorless and tasteless gas.

Nasal Cannula—The tubing that is delivers oxygen through the nose.

When using a nasal cannula, the amount of oxygen delivered is usually 1-4 LPM (can go up to 6 LPM).  LPM = liters/minute

The nasal cannula is a low-flow oxygen delivery device. 

 

Oxygen Face Mask—A mask that covers the mouth and nose to deliver oxygen and humidity.   There are 2 main types of masks.

 

Simple Mask—Used short term.   The mask delivers 30-50% oxygen to the patient (the rest is outside air).  

At least 5 liters/minute of oxygen needs to be used to remove CO2 out of the mask.   5-10 LPM of oxygen is delivered when using a simple mask.

 

Non-rebreathing Mask—These masks include a reservoir bag.   The reservoir bag contains 100% oxygen.   This mask delivers 60-80% oxygen to the patient.

The valve on the mask prevents exhaled gas from being breathed in again.

Up to 15 LPM of oxygen is administered when using a non-rebreathing mask. This is a high-flow oxygen delivery device.

 

Patients with COPD should not be given more than 2-3 liters/minute of oxygen.

When a patient with COPD comes into the department, he/she must be watched carefully! If the patient is on oxygen, he/she can stop breathing because of excess oxygen inhalation. Their bodies don't respond to access CO2 in the bloodstream, like normal breathers, they only respond hypoxia. So, if they are receiving too much oxygen, they never get hypoxic, they just "shut down".

 

 

Medical Emergencies

An emergency is a situation in which the condition of the patient or sudden change in medical status requires immediate action. The injury or illness is acute and poses an immediate risk to the person's life or long-term health.

It is important for all radiologic technologist and students to know where the adult and pediatric crash carts are located within the imaging department. As a student, in an emergency situation, you may be asked to retrieve the crash cart.

Head Injuries

A patient with a head injury may present with an altered gait, drowsiness or confusion, headache, dizziness, dampness at the back of the head (leaking CSF), hearing loss or "raccoon eyes". A patient with a head injury may also have a neck injury. Assume this until proven otherwise.

You must keep the patient immobile when transferring. It is important to keep the patient warm and to never leave the patient alone. In any medical emergency, you should wear personal protective apparel to include gloves, a face shield, etc.

Dressings applied to the skull, such as gauze, should not be removed because it may disturb the clotting of the wound. If the dressing is soaked with blood or other fluid, you may add additional dressing on top.

Patients can be assessed using levels of consciousness (LOC). Levels of consciousness can range from fully alert to comatose.

 

Levels of Consciousness (LOC)

There are four levels of consciousness:

1. Alert and conscious

2. Drowsy but responsive

3. Unconscious but reactive to painful stimuli

4. Comatose - Completely unresponsive

 

As a technologist, you should assess your patient at the start of the exam. If the patient changes level of consciousness at any time during the exam, you should stop the exam and get medical help. While waiting for additional help, make sure the airway remains open.

 

Glasgow Coma Scale - A numerical scale that can be used to objectively assess changes in the patient's level of consciousness over time. The higher the number, the higher the level of consciousness.

Glasgow Coma Scale Good.jpg

 

Children may be assessed differently for verbal response.

Verbal Response

Points

Speaks appropriately

Babies will smile and chatter appropriately

5

Mumbles illogical words

Babies will cry appropriately and respond to consolation

4

Incessant crying

Babies crying will occur independent of unpleasant stimuli

3

Grunts

2

Silent or unresponsive

1

 

 

More Medical Emergencies

Spinal Injuries

When there is question of the spinal cord injury, DO NOT move the patient until the injury is proven or disproven. If the patient must be turned, 3 to 4 people must use the "log roll".

The patient's spine should stay straight and all involved should move as a single unit. Do not let the patient move and keep the patient warm.

The patient may already be partially paralyzed, have trouble breathing or have bowel or bladder incontinence.

Fractured Extremity

A patient who has a fracture may have swelling, deformity of the limb, a grating sound when moved and possible shock. Make sure to keep the limb immobilize at all times.

Support the limb by placing one hand above the fracture site and the other hand below the fracture site. Make sure you support the extremity while the patient is moving.

Cerebrovascular Accident (CVA)

CVA - The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke.

Symptoms:

1. The most common symptom is weakness or paralysis of one side of the body. The paralysis can be with partial or complete loss of voluntary movement or sensation in a leg or arm.

2. There can be speech problems and weak face muscles, causing drooling.

3. Numbness or tingling is very common.

4. A stroke involving the base of the brain can affect balance, vision, swallowing, breathing and even consciousness.

Cardiac Arrest

Cardiac arrest is the abrupt loss of heart function in a person who may or may not have diagnosed heart disease. In cardiac arrest, death results when the heart suddenly stops working properly.

Heart attacks are caused by a blockage that stops blood flow to the heart. A heart attack (or myocardial infarction) refers to death of heart muscle tissue due to the loss of blood supply.

A myocardial infarction does not necessarily result in the death of the person. But, a heart attack could cause cardiac arrest and sudden death.

Diabetic Crisis

 

Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia.

There are 2 types of Diabetes:

1. Diabetes Insipidus

2. Diabetes Mellitus:

 

There are two types of diabetes mellitus:

•Type I

•Type II

 

Diabetes Insipidus - An uncommon condition that occurs when the kidneys are unable to conserve water as they perform their function of filtering blood. The amount of water conserved is controlled by antidiuretic hormone ADH, also called vasopressin. It is caused by a kidney or pituitary disorder. It is characterized by polyuria and thirst.

Symptoms:

1. Fever

2. Vomiting

3. Convulsions

If untreated, dehydration results, so fluid replacement is essential.

 

Diabetes Mellitus - A chronic metabolic disease caused by a disturbance in the production, action or utilization of insulin in the pancreas.

 

Type I (Previously known as juvenile diabetes) - Insulin-dependent form of diabetes.

Treatment for type 1 diabetes may include:

1. Taking insulin - Anyone who has type 1 diabetes needs lifelong insulin therapy.

2. Carbohydrate counting

3. Frequent blood sugar monitoring

4. Eating healthy foods

5. Exercising regularly and maintaining a healthy weight

The goal is to keep your blood sugar level as close to normal as possible to delay or prevent complications.

People with type 1 diabetes are more likely to lapse into diabetic coma.

Signs and symptoms:

1. Extreme thirst

2. Polyuria

3. Fruity-smelling breath

 

Hypoglycemic Reactions (Insulin Shock) - Caused by excess insulin and not enough sugar in the body (low blood sugar). Can occur when a patient takes the daily dose of insulin, but has not eaten. Occurs in Type I when insulin is taken and a meal is skipped

Sudden Onset (5-20 minutes)

Symptoms and Signs:

1. Shaking, nervousness, irritability, dizziness and hunger

2. Profuse perspiration, cold and clammy skin

 

Type II - Insulin-resistant form of diabetes., your body produces insulin, but does not use it properly. It is related to obesity.

Type 2 diabetes is the most common form of diabetes.

Treated with hyperglycemic drugs, these are oral diabetes medications that help control blood sugar levels.

 

Hyperosmolar hyperglycemic nonketotic (HHNK) syndrome is a emergent condition and occurs in neglected type II DM as a result of dehydration and hyperglycemia.

 

Hypoglycemia is a condition characterized by an abnormally low level of blood sugar (glucose). It must be treated very promptly because it interferes with the oxygen supply to nerve tissues, which can lead to severe brain damage and death.

Radiographer's Response - Administer some type of sugar immediately. You can give the patient sugar, a piece of candy, orange juice or other sugar containing foods.

 

Hyperglycemia ( Ketoacidosis) - Caused by insufficient insulin in the body. Occurs with the patient misses an insulin injection.

Slow Onset (6-12 hours)

Symptoms:

1. Weakness, drowsiness and a dull headache

2. Dry hot skin

Radiographer's Response - Notify a radiologist immediately. Sugar may be given as a preventative measure, sugar will not hurt a patient in ketoacidosis, but will save a hypoglycemic patient. Sometimes symptoms overlap and it is difficult to distinguish one reaction from another.

Treatment:

1. Candy

2. Sweet fruit juice

Emergency medications may include squeeze tubes of glucose gel administered inside patient's cheek.

 

 

Minor Medical Emergencies

Seizures

Seizures are episodes of disturbed brain activity that cause changes in attention or behavior. Epilepsy is a brain disorder in which a person has repeated seizures (convulsions) over time.

Grand Mal Seizure - Muscles become rigid, jerky body movements, loss of consciousness, may vomit and may have urine and fecal control failure.

Radiographer's Response:

1. Most important is to prevent the patient from injuring himself during a seizure. You should make sure that any furniture and other objects are out of the way.

2. Do not try to insert hard objects into the mouth.

3. Call for help, but do not leave the patient alone.

4. After the seizure, position the patient on his side to prevent swallowing of vomitus.

5. Verify there's an open airway and remind patient to breathe.

Nausea and Vomiting

Nausea is the feeling of having an urge to vomit.

 Vomiting or throwing up is forcing the contents of the stomach up through the esophagus and out of the mouth.

 Nausea and vomiting are both a common occurrence. Nausea tends to be both a psychologic and a physiologic reaction.

Epistaxis (Nosebleed)

A nosebleed is loss of blood from the tissue lining the nose. Bleeding most commonly occurs in one nostril only.

Vertigo and Syncope

Vertigo - Vertigo is a feeling that you or your surroundings are moving when there is no actual movement. You may feel as though you are spinning, whirling, falling or tilting.

1. Dizziness

2. Lightheadedness

 

Syncope (fainting) - Caused by an insuffieciency in the supply of blood to the brain.

Symptoms:

1. Pallor, dizziness and possible nausea

2. Cold, clammy skin

Falls

If a patient is falling, you should try and lessen the impact of the fall if possible. Be careful, if you try to catch the patient, you may suffer a back injury. Medical attention may be needed according to the injuries of the patient.

Burns

Do not remove bandages. Keep the area as sterile as possible. Handle the patient with care and gentleness.

Wound Dehiscence

Occurs when a wound or suture bursts or splits open. If this occurs cover area with sterile covering and get medical attention for the patient. This is not a common postoperative occurrence.

 

 

Shock

Shock -The body's pathological response to illness, trauma or severe psychological or emotional stress.

Shock is a general term that indicates a failure of the circulatory system to support vital body functions.

 

A clinical picture of shock:

  1. Skin is cold and clammy
  2. Decreased urine output
  3. Increased respirations
  4. Normal BP
  5. Anxiety levels increase, may become uncooperative
  1. BP drops precipitously (rapidly)
  2. Respiration becomes rapid and shallow
  3. Severe pulmonary edema (fluid in the lungs) results from leakage of fluid from pulmonary capillaries
  4. Tachycardia (radid heartbeat) of up to 150 bpm
  5. Pt may complain of chest pain

Mental status changes are subtle at first, progressing from confusion to lethargy (state of sluggishness or inactivity) and later to unconsciousness

 

 

Hypovolemic Shock

Hypovolemic shock - Caused by abnormally low volume of circulating blood due to internal or external hemorrhage, loss of plasma from burns or fluid loss from prolonged vomiting, diarrhea or medications.

Signs and symptoms:

Radiographer's Response -

 

Cardiogenic Shock

Cardiogenic Shock - Caused by failure of the heart to pump an adequate amount of blood to the vital organs. May occur over a period of time or may be of sudden onset. Patients are most at risk if they are suffering from:

1. MI - Myocardial Infarction

2. Cardiac tamponade (compression of the heart caused by increased intrapericardial pressure due to collection of fluid in the pericardium)

3. Dysrhythmias (disturbance of rhythm - abnormal cardiac rhythm)

4. Other cardiac pathologies

Signs and Symptoms:

Radiographer's Response:

 

Obstructive shock

Obstructive Shock - A form of shock associated with physical obstruction of the great vessels or the heart itself.

It can be caused by a pulmonary embolism, aortic aneurysm, cardia tamponade, etc.

Signs can be hypotension, weakness, shallow breathing, confusion, anxiety and tachycardia.

 

 

 

Distributive Shock

Distributive Shock - A medical crisis where a patient has a normal blood volume, but the blood does not circulate effectively.

Occurs when there is pooling of blood in peripheral vessels that results in decreased venous return of blood to the heart, decreased BP and decreased tissue perfusion. May result from loss of sympathetic tone. Characterized by the blood vessels inability to constrict and return blood to the heart. May also occur when chemicals released by the cells cause vasodilation and capillary permeability causing a large portion of the blood volume to pool peripherally.

There are three types of Distributive Shock: Neurogenic, Septic and Anaphylactic

 

 

Neurogenic Shock

Neurogenic Shock - It is caused by damage to the nervous system.

Results from loss of sympathetic tone resulting in vasodilation of peripheral vessels. Can be caused by spinal cord injury, severe pain, neurologic damage, extreme psychological stress or adverse effects of spinal anesthesia.

Signs and Symptoms:

  1. Hypotension (low blood pressure)
  2. Bradycardia (low heart rate)
  3. Warm, dry skin
  4. Initial alertness if not unconscious due to head injury
  5. Coolness of extremities and diminishing peripheral pulses

Radiographer's Response:

  1. Summon emergency assistance
  2. Notify physician in charge
  3. Keep patient supine; may elevate patient's legs with physician's OK
  4. Have crash cart brought to patient's side
  5. If spinal cord injury is possible, do not move patient
  6. Stay with patient and offer support
  7. Monitor vitals signs q 5 min
  8. Prepare to assist with O2, IV fluids

 

 

Septic Shock

Septic Shock - A complication of an infection where toxins can initiate a full-body inflammatory response.

Septic shock is least likely to be observed by the radiographer in his department; however he must recognize it as a possible consequence of poor practice of medical or surgical asepsis (free from disease causing contaminants). He may also be called upon to take portable radiographs of a patient in septic shock. In spite of the wide availability and use of antibiotics in recent years, the incidence of septic shock has risen and has a 40% to 50% mortality rate (number of deaths) for its victims.

Gram-negative bacteria (can cause disease in a host organism) are the most frequent causative organisms in septic shock; however, gram-positive bacteria and viruses can also be the cause. When invaded by bacteria, the body begins an immune response by releasing chemicals that increase capillary permeability and vasodilation, leading to the shock syndrome.

Signs and Symptoms - Symptoms of septic shock are divided into two phases:

First Phase:

  1. Skin is hot, dry and flushed
  2. Heart and respiratory rate are increased
  3. Fever, though the elderly patient may not be febrile
  4. Nausea, vomiting and   diarrhea
  5. Normal to excessive urine output

Second Phase:

  1. Cool, pale skin
  2. Normal to subnormal temperature

  3. Drop in BP
  4. Rapid heart and respiratory rate
  5. Oliguria or anuria
  6. Seizures and organ failure if symptoms are not reversed

Radiographer's Response - The radiographer will rarely be the person who initiates action if this condition is present; however, if he cares for a patient in septic shock, he must remember to keep the patient from becoming chilled. This is important because shivering increases the body's oxygen consumption. If the radiographer is first on the scene, he should do the following:

  1. Stop the procedure and notify the physician in charge
  2. Notify the emergency team and have the emergency cart available
  3. Place the patient in a supine position
  4. Keep patient as quiet and calm as possible
  5. Do not leave the patient unattended
  6. If the skin is very warm, cover the patient with a lightweight blanket
  7. Monitor vital signs q 5 min
  8. Prepare for O2, IV and medication administration

 

 

Anaphylactic Shock

Anaphylactic Shock - A sudden, severe allergic reaction.

Because some imaging procedures use contrast agents containing iodine, to which some people are allergic, this is the type of shock seen most frequently in radiographic imagng. 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.

Symptoms develop quickly, often within seconds or minutes and may include the following:

 Signs include:

Radiographer's Response -

1. Call for help

2. Check for open airway and breathing

3. Have allergy medication (usually benadryl) available for the physician

4. The patient should be supine

5. Elevate the head of the patient

6. Cover the patient with a blanket

 

Agitated or Confused Patient

1. Maybe caused by alcohol intoxication, hallucinogenic drugs or psychotic illness.

2. Do not approach face-to-face, the patient may lash out at you. Always approach from the side.

3. Do not argue or lecture, this might make the patient more agitated.

4. If necessary, restrain or call for help. The patient may need to be sedated.