Chapter 3: Emergency Resuscitation
Learning objectives for this chapter
By the end of this chapter, we would like you:
-To describe the fundamental goals of resuscitation in the emergency care setting.
-To explain the rationale of routine vascular access for patients in emergency care settings.
-To administer aggressive fluid therapy to resuscitate patients in emergency care settings.
-To administer blood and blood products to resuscitate patients in emergency care settings.
-To provide emergency resuscitative care in a manner consistent with relevant guidelines.
-To be able to manage a compromised airway in an emergency care setting.
-To administer cardiopulmonary resuscitation (CPR) to sustain the life of a patient.
What is resuscitation?
The term resuscitation is used to describe the processes involved in sustaining the life of an acutely unwell patient. Resuscitation relates in particular to the management of the function of the cardiovascular and respiratory systems, as these are two of the body's fundamental, life sustaining systems. Resuscitation involves the use of emergency actions to correct, in the short term, the physiological disorder/s affecting the patient. The fundamental goals of resuscitation are to sustain life, and to provide time for other interventions to correct the physiological disorder/s affecting the patient to be implemented and to take effect.
Rationale for vascular access and fluid replacement
In emergency care settings in the UK, it is routine for patients who require immediate or urgent care - regardless of their presenting complaint - to have vascular access established. This is achieved via the insertion of a cannula - a hollow, fine-bore, flexible and sterile plastic tube - usually into the peripheral veins, most commonly in the hands and / or the arms. Vascular access allows for fluid replacement - that is, the intravenous administration of fluid solutions and blood / blood products. Fluid replacement aims to increase the volume of fluid in the cardiovascular system, thereby promoting organ perfusion and minimising hypoxia.
Vascular access is established via the insertion of a cannula into the peripheral veins of, most commonly, the hands and / or the arms. However, a variety of other vascular access sites may also be used; indeed, in emergency care settings it is not uncommon to see cannulas inserted into the veins of the legs, the feet and even the head / scalp. Occasionally, specialised cannulas will also be inserted into the large central veins, the low-pressure arteries, and / or into the bone marrow. Also, some patients with chronic disease may present with semi-permanent catheters or implanted ports which allow for long-term therapy without the need for repeated vascular access. The exact site at which a cannula is inserted will depend on a number of factors - including the acuity of the patient's condition and the urgency of the care required, the condition of the patient's veins, and the characteristics of the solution/s to be administered to the patient.
The type of fluid solution used, the rate at which it is administered, and the amount administered are determined by a number of factors. Most importantly, the emergency care team must take into account the patient's condition, any current underlying pathophysiological conditions, and the extent of their fluid imbalance.
There are two main approaches to fluid replacement used in an emergency care setting:
- Maintenance fluid replacement involves solution/s administered in low volumes over a long period of time. This approach is used for patients who are physiologically stable but have little to no oral intake of fluid.
- Aggressive fluid replacement involves solution/s administered in high volumes over a comparatively short period of time. This approach is used for patients who have significant volume depletion and may be very physiologically unstable.
It is aggressive fluid replacement that is used most often in emergency care settings. Algorithms for the administration of aggressive fluid therapy can be found in the National Institute of Health and Clinical Excellence's (NICE, 2013) Intravenous Fluid Therapy in Adults in Hospital (CG174) guideline, or the current equivalent. Nurses working in emergency care settings must also ensure they are familiar with their organisation's policies and procedures for the administration aggressive of fluid therapy, including local protocols, and that they work in a manner consistent with these at all times.
Generally, a patient requires aggressive fluid replacement when: they have a systolic blood pressure of <100mmHg, their heart rate is >90 beats per minute, their capillary refill time is >2 seconds or they have peripheral hypothermia, their respiratory rate is >20 breaths per minute, and / or their National Early Warning System (NEWS) score is ≥5. All these are objective signs of volume depletion and physiological instability. If any of these signs are evident, the Intravenous Fluid Therapy in Adults in Hospital (CG174) guideline recommends that nurses begin by identifying, and responding to, the cause of the fluid deficit (NICE, 2013). Concurrently, aggressive fluid replacement should be administered.
There are a variety of different types of intravenous fluids available for use in emergency care settings in the UK. These are organised into three categories:
- Isotonic fluids are similar in composition to the body's own fluids. They act to directly increase the intravascular volume. 0.9% normal saline (NS) is an example of an isotonic solution used commonly in the emergency care setting.
- Hypotonic fluids act to shift fluid into the intracellular space (i.e. from the vessels into the cells). They act to prevent cellular dehydration; however, in doing so they deplete circulatory volume. These are not often used in emergency care settings.
- Hypertonic fluids act to shift fluid into the extravascular space (i.e. from the cells into the vessels). They are particularly useful for replacing serum electrolytes (discussed later in this chapter). 0. 5% dextrose in NS and 10% dextrose in NS are examples of hypertonic solution used commonly in the emergency care setting.
In addition, fluids may be categorised as:
- Crystalloid solutions, which act to increase the intravascular volume directly, through the actual volume of fluid administered. As highlighted above, it is crystalloid solutions which are most often used in aggressive fluid therapy in emergency care settings in the UK.
- Colloid solutions, which act to increase the intravascular volume indirectly, by moving fluid into the vascular space. Colloid solutions may be synthetic or natural. Fresh frozen plasma, albumin and packed red blood cells are examples of colloid solutions used commonly in the emergency care setting.
As noted in an earlier section of this chapter, the fundamental aim of fluid therapy is to increase intravascular volume, promote organ perfusion and minimise hypoxia. However, aggressive fluid therapy may also be administered for other reasons - including to promote balance in the concentration of electrolytes in the body. Electrolytes are charged particles which are vital for the functioning of the organ systems at the cellular level; in particular, potassium electrolytes (K+) are fundamentally important for cardiac contractility. The administration of electrolyte-containing substances during aggressive fluid therapy is often used in emergency care settings to support the functioning of the organ systems.
As stated in the National Institute of Health and Clinical Excellence's (NICE, 2013: p. 5) Intravenous Fluid Therapy in Adults in Hospital (CG174) guideline, "errors in prescribing intravenous fluids and electrolytes are particularly likely in emergency departments". The mismanagement of fluid therapy can have significant negative effects on a patient, resulting in one or more of hypo- or hypervolaemia, hypo- or hypernatraemia, hypo- or hyperkalaemia, and / or pulmonary or severe peripheral oedema. Disability or even death may result from such errors. Prior to administering any intravenous therapy, it is therefore essential that nurses understand the fluid needs of the individual patient, the composition of the intravenous fluids being administered, and the rationale for this.
Administration of blood and blood products
As with fluid therapy, described earlier in this chapter, the fundamental aim of the administration of blood in emergency care settings is to promote organ perfusion and minimise hypoxia. However, whilst fluids do this by increasing the intravascular volume, transfused blood does so by providing a greater number of binding sites for oxygen molecules entering the body via the respiratory system. Like blood, blood products may be administered to minimise hypoxia, however the administration of blood products is also done for a variety of other reasons:
- Red blood cells: these are often administered to patients with a frank haemorrhage. Prior to a transfusion of red blood cells, a cross-match will be performed to ensure that the patient's blood type is compatible with the donor type. Type O blood - a 'universal' type which is compatible with all other types - may be administered to patients where there is no time for a cross-match to be obtained.
- Platelets: these are cells which have a crucial role in blood clotting. A platelet transfusion may be given to patients with thrombocytopaenia and clinically-significant or severe bleeding, including bleeding within the central nervous system (NICE, 2015).
- Plasma: this is a nutrient-rich fluid which contains the blood cells in the cardiovascular system. A transfusion of fresh frozen plasma may be considered for patients with clinically-significant bleeding if they have abnormal coagulation test results (NICE, 2015)
- Cryoprecipitate: this is a substance within the blood that plays a key role in blood clotting. A transfusion of cryoprecipitate may be considered for patients with clinically-significant bleeding who have low levels of fibrinogen (NICE, 2015).
- Prothrombin complex concentrate: this is an artificial combination of blood clotting factors - including factors II, VII, IC, and X, as well as proteins C and S - prepared from fresh frozen plasma. A transfusion of prothrombin complex concentrate may be considered for patients with severe bleeding, and / or a head injury with a suspected intracerebral haemorrhage (NICE, 2015).
In situations of frank blood loss, such as haemorrhage, the body is depleted of all the blood components - blood cells, clotting factors, and other key substances. In these situations, whole blood replacement would be ideal - however, this is an expensive option, and due to chronic shortages of donated blood stocks in the UK whole blood is not often readily available. For this reason, blood components most suitable for a patient's particular needs are selected and administered.
Protocols for the administration of blood and blood products can be found in the National Institute of Health and Clinical Excellence's (NICE, 2013) Blood Transfusion (NG24) guideline, or the current equivalent. Nurses working in emergency care settings must also ensure they are familiar with their organisation's policies and procedures for the administration aggressive of fluid therapy, and that they work in a manner consistent with these at all times.
Where the airway of a patient in an emergency care setting is not patent, there are a number of ways the medical team may respond. Consider the following examples:
- The airway may be opened using a jaw-thrust manoeuver. This involves placing fingers and thumb on the patient's jaw, and tilting their head backwards. This has the effect of pulling the patient's soft tissues away from the back of their throat. However, this manoeuvre must be used cautiously if a patient has suspected spinal injuries, as it may result in spinal cord damage.
- The airway may be mechanically suctioned. This is a particularly important technique to remove secretions or a foreign body present in the airway. If the patient is conscious, they may be encouraged to cough deeply to achieve a similar effect.
- The airway may be opened via the insertion of an artificial airway and use of artificial ventilation. This is only appropriate if the patient is unconscious and medically sedated.
Cardiopulmonary resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a fundamental skill for nurses in the emergency care setting. It involves the use of a simple combination of cardiovascular and respiratory management techniques to sustain life. You will receive CPR training as part of your undergraduate nursing degree, and you will be required to regularly update it throughout the time you practice as a registered nurse.
This chapter has introduced the principles and processes of emergency resuscitation. It began with a brief discussion of the purpose of resuscitation in the emergency care setting, and went on to consider fluid resuscitation - including vascular access, aggressive fluid therapy and the administration of blood and blood products in the emergency care setting. The chapter then provided an overview of the management of a patient with a compromised airway. Finally, it discussed cardiopulmonary resuscitation (CPR), a fundamental skill for nurses in the emergency care setting.
NICE. (2013). Intravenous Fluid Therapy in Adults in Hospital. Retrieved from: https://www.nice.org.uk/Guidance/cg174
NICE. (2015). Blood Transfusion. Retrieved from: https://www.nice.org.uk/guidance/ng24
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