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Chapter 6: Respiratory and Cardiovascular Emergencies

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To explain how to rapidly and accurately assess a variety of medical conditions related to the respiratory, cardiovascular and neurologic systems in the emergency care setting.

-To describe the common presentation of medical conditions related to the respiratory, cardiovascular and neurologic systems in the emergency care setting.

-To explain how to effectively manage a variety of medical conditions related to the respiratory, cardiovascular and neurologic systems in the emergency care setting.

Respiratory emergencies

People may present to emergency care settings in the UK with a variety of respiratory conditions, with symptoms ranging from relatively mild and transient to severe and life-threatening. Respiratory compromise can result in brisk deterioration, and without rapid intervention, respiratory failure and death may result. It is essential that nurses working in emergency care settings are able to assess and manage patients with respiratory illness. 

The assessment of the patient with respiratory illness must begin with an assessment of airway, breathing and circulation (ABC). A more focused assessment of the respiratory system can then be undertaken; this will involve:

  • A detailed assessment of the patient's respiratory system. The nurse should measure the patient's respiratory rate with the aim of identifying dyspnoea (i.e. shortness of breath). Other signs of dyspnoea include increased work of breathing, nasal flaring, retractions, accessory muscle use, tracheal tugging, grunting, difficulty speaking in compete sentences, pallor or cyanosis, and tripod positioning. The nurse should also auscultate the patient's lungs, listening for adventitious lung sounds.
  • A rapid neurological assessment. Tools such as the GCS assess the functioning of a patient's central nervous system, including their level of consciousness, via their response to verbal and / or painful stimuli. Changes to mental status in a patient with respiratory illness are early warning signs of deterioration.
  • A rapid head-to-toe assessment. As one of the body's fundamental life-sustaining systems, complications with the respiratory system can have a variety of (sometimes subtle) systemic effects. In particular, the nurse should observe for characteristics such as 'barrel chest' and clubbing of the fingernails - both key signs of chronic hypoxia and respiratory illness.
  • Additional assessments to assist with diagnosis - including chest X-rays or CT scans, a full blood count (FBC), and arterial blood gas (ABG) analysis - will also be used. 

A health history is particularly important during respiratory assessment. Nurses must ask a patient about their smoking history, as smoking is a leading cause of respiratory disease in the UK. Nurses must also ask patients about their exposure to respiratory pathogens and hazards.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the respiratory system. The most common conditions, and their management in the emergency care setting, are described following:

  • Acute bronchiolitis - this is a severe inflammation of the bronchioles, caused most often by a virus (e.g. influenza, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, etc.). Patients with bronchiolitis present with symptoms of a cold or virus, and a severe cough with dyspnoea, chest pain and fatigue.
  • Pneumonia - pneumonia is an acute inflammatory reaction in the lungs in response to the presence of pathogens, often bacteria. Patients with pneumonia present with fever, fatigue, a cough with haemoptysis, dyspnoea and pleuritic chest pain. On auscultation of the patient's chest, 'crackles' will be heard, and it may also be possible to identify areas of consolidation.
  • Asthma -a chronic obstructive disease of the lungs, characterised by hyper-reactive inflammation and narrowing of the airways. Although this is a chronic disease, patients can present with acute exacerbations which present as severe dyspnoea, coughing, wheezing, chest tightness and distress.
  • Chronic obstructive pulmonary disease (COPD) - COPD is a progressive and irreversible disease, often associated with smoking. Although this is a chronic disease, patients can develop acute complications, presenting as severe dyspnoea, the production of purulent sputum, pleuritic chest pain and distress.
  • Spontaneous pneumothorax - pneumothorax involves an accumulation of air in the pleural space around the lung/s, and the resultant 'collapse' of the lung/s. Pneumothoraxes may develop following a traumatic insult; however, they can also be spontaneous, or develop during severe respiratory illness.
  • Pulmonary embolus (PE) - a PE is a condition where a substance occludes a large vessel in the lungs. Patients with PE present with a variety of non-specific symptoms, including worsening dyspnoea, tachycardia, cough, diaphoresis and anxiety. Diagnosis is difficult, and may require CT scans, ABG analysis, electrocardiography (ECG) and also perhaps ultrasonography.
  • Inhalational injury - these are injuries caused when a person inhales substances - including hot gasses produced by fire, water, and / or a foreign body. Patients with an inhalational injury will present with a variety of non-specific symptoms, including dyspnoea, coughing, gagging and choking, tachypnoea and pleuritic chest pain.

There are a variety of less-serious medical conditions related to the respiratory system. These conditions include influenza, acute viral rhinitis, epistaxis, sinusitis, acute pharyngitis / laryngitis, peritonsillar abscess, among others. In most cases these are mild and self-limiting conditions.

Any of the conditions described above can lead to acute respiratory distress syndrome (ARDS), or the failure of the respiratory system. There are two types of ARDS:

  • Hypoxaemic respiratory failure - also referred to as oxygenation failure, which is caused by an imbalance between ventilation and perfusion in the lungs. In severe cases, this may result in shunt, where blood leaves the heart without having participated in gas exchange (e.g. no oxygen in, no carbon dioxide out).
  • Hypercapnoeic respiratory failure - also referred to as ventilation failure, which is caused by an imbalance between the supply of, and demand for, oxygen in the lungs. Although this often presents as an acute condition, it may also be chronic.

The administration of high-flow oxygen via a non-rebreather mask is fundamental to the management of all the respiratory conditions described in this section. A patient with a respiratory condition must also have their blood oxygen saturation (SaO2) continuously monitored, using a pulse oximeter. The psychosocial care of a patient with a respiratory condition is also important for nurses in the emergency care setting.

Cardiovascular emergencies

As with the respiratory conditions described in the previous section of this chapter, cardiac conditions are commonly seen in emergency care settings in the UK. Patients with cardiac conditions often present with symptoms that are mild, transient and non-specific. If these conditions are not rapidly assessed, identified and properly managed, significant disability or death can result.

As always, the assessment of a patient with cardiac illness must begin with an assessment of airway, breathing and circulation (ABC). A more focused assessment of the cardiovascular system can then be undertaken; this will involve:

  • A detailed assessment of the patient's cardiovascular system. The nurse should measure the patient's heart rate as well as the quality of the patient's peripheral pulses and their blood pressure. The nurse should also observe the patient for other signs of cardiac dysfunction - including pallor and / or cyanosis, diaphoresis and dyspnoea. The nurse should also auscultate the patient's heart, listening for adventitious heart sounds.
  • A rapid head-to-toe assessment. In particular, nurses should assess the patient for sensory and motor deficits, and altered mental status with neurological symptoms. Although they are an 'acute' condition, most acute coronary syndromes occur progressively over several hours, and may present with general and non-specific symptoms.
  • An assessment of the patient's chest pain, using the 'OPQRST' mnemonic. Pain due to cardiac dysfunction is often described as 'crushing' or 'squeezing' and it may not necessarily be felt in the chest.
  • Additional assessments to assist with diagnosis - including chest X-rays or CT scans, blood tests to assess for cardiac biomarkers, and perhaps an ultrasound. An electrocardiogram (ECG) is a standard part of the assessment for all patients with suspected cardiovascular conditions.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the cardiovascular system. The most common conditions, and their management in the emergency care setting, are described following:

  • Myocardial infarct (MI) - a MI occurs when one of the arteries in the heart becomes occluded. An MI may be diagnosed by ECG and may be classified as one of two types: (1) an ST-Segment MI (STEMI), or (2) a Non ST-Segment MI (Non-STEMI). Patients experiencing an MI present with chest or radiating pain, nausea, dyspnoea, diaphoresis, fatigue and dizziness, and they may be very anxious.
  • Angina pectoris - angina occurs when the arteries in a patient's heart become partially occluded, often due to narrowing. Angina may be classified into one of two types: (1) stable, where chest pain occurs in a pattern following a predictable amount of exertion, or (2) unstable, where chest pain may occur unpredictably at any time, including without exertion.

Patients experiencing an acute exacerbation will present with many of the same symptoms as for an MI. But whereas an MI will be evident on an ECG, angina pectoris will not.

  • Dysrhythmias - 'dysrhythmia' is a term used to describe an abnormality in the normal rhythm of the heart. These are classified into two categories: (1) tachycardias (heart rate >100 beats per minute), and (2) bradycardias (heart rate <60 beats per minute). Dysrhythmias may be due to a variety of causes; however, acute coronary syndromes, such as MI and angina, are common causes.
  • Pericarditis - this occurs when the pericardium is inflamed, often due to infection. Pericarditis can lead to a range of significant complications, including MI and cardiac arrest. Patients with pericarditis experience a range of non-specific symptoms of infection, dyspnoea and severe chest pain, and dysrhythmias may also be evident.
  • Aortic aneurysm - an aneurysm is a dilated area of a blood vessel. Often, aneurysms occur in the aorta which carries oxygenated blood from the lungs / heart to the rest of the body. Aneurysms may occur anywhere along the aorta, and if they rupture (or dissect) massive haemorrhage and rapid deterioration may result.
  • Hypertensive crisis - a hypertensive crisis occurs when a patient's blood pressure is so high that there is a risk of acute end-organ damage. It is often due to dysfunction in the endocrine and / or renal systems. The close monitoring of patients is important so that complications can be rapidly identified and managed.

Neurological emergencies

In addition to traumatic injury, neurologic emergencies may also originate from physiological and medical causes. These can result in rapid disability and death; therefore, it is essential for nurses working in emergency care settings to be able to assess and manage these conditions.

During assessment, a nurse may identify one or more of a variety of medical conditions related to the neurologic system. The most common conditions, and their management in the emergency care setting, are described following:

  • Headache, including migraine - headaches are one of the most common neurological conditions seen in emergency care settings in the UK. People typically present to emergency care settings with migraines, severe headaches. Migraines may be classified as: (1) vascular, caused by acute cerebral vasodilation, or (2) muscular, due to skeletal muscle contractions in the head or neck. There are a variety of 'triggers' for migraines - however they may also occur spontaneously. Headaches are a common symptom of other acute neurological illnesses, and a patient should be investigated for other underlying causes. 
  • Seizures - a seizure is caused by abnormal, excessive electrical activity in the brain. Seizures may have a variety of causes, including physiological disorders and conditions of the central nervous system. Most seizures are self-limiting, and do not usually require emergency intervention. If the cause of the seizure is undetermined, further investigations must take place when the patient is stable.
  • Stroke - the term 'stroke' is used to describe the loss of neurological functioning resulting from an acute disruption of blood flow to, and hypoxia in, a section of the brain. Strokes may be classified as: (1) ischaemic, when a vessel in the brain becomes occluded (often by a blood clot or atherosclerotic plaque), or (2) haemorrhagic, when a vessel in the brain ruptures and bleeds. In both types of strokes, patients will present with unilateral weakness or paralysis, difficulty with speech / gait / coordination, a severe headache, altered vision, sensory impairments and / or a changed mental status.

Despite the importance of waiting for a differential diagnosis, it is important to highlight that strokes must be treated rapidly. If a stroke patient presents late, supportive therapy only may be used.

  • Meningitis - this is the inflammation of the meninges caused by a pathogen. Patients with meningitis usually present with the signs of acute infection - including fever, headache, photophobia, lethargy and nausea / vomiting - and they may also have seizures. Patients will sometimes, but not always, have a characteristic petechial rash. Meningitis is diagnosed conclusively using a lumbar puncture. Regular neurological assessment is essential in identifying patient deterioration.

Conclusion

This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of respiratory, cardiovascular and neurologic conditions in the emergency care setting. It has also described the most common emergency presentations of conditions related to the respiratory, cardiovascular and neurologic systems.  


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