What is the appropriate action to take?

Nurses General Nursing

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This is just a totally random question I thought of on a trip home from New Orleans recently. There was a very bad accident off one of the exits and it got me thinking.. If I were to witness a bad car accident, pulled over to assist--and for whatever reason it was clear that the person probably had neck injuries--but was not breathing/no pulse and needed CPR.. What is the appropriate action to take? I'm a student nurse, and I realize that I could get sued for potentially paralyzing someone in an effort to help, but the person would die without CPR.. So what would be the appropriate action to take? Hope this makes sense.

Specializes in ITU/Emergency.

the quote below is from the aha website. i went looking as i was under the impression that when the lack of pulse or respirations was the only time it is acceptable to move a suspected spinal injury patient or remove a helmet from a motorcyclist. i remember being told by a paramedic that the patients definately dead if you leave them but only maybe dead if you move them and provide cpr. however, even if you move them you need to maintain spine alignment and use jaw thrust not chin lift, difficult to do without proper equipment and at least a handful of rescuers if the patient is in a vehicle. the same paramedic told me they hate these cases as well but at least they have the equipment! i think thats a reason why medical professionals don't stop....they know that so much can go wrong and its not like it is in the movies, where a person looks dead, get pulled out of a burning car using no spine alignment and is given one cycle of cpr, opens their eyes and is fine!

"if spinal cord injury is suspected, do not allow the victim to move in any direction. immobilize the victim’s head, neck, and trunk. if cpr is required, open the airway with jaw thrust (see "part 3: adult bls") rather than head extension. if the victim is stable and does not require cpr or lifesaving first aid, such as hemorrhage control, do not move him or her until ems personnel arrive. if movement is necessary (to provide cpr or lifesaving first aid or because of potential danger), support the victim’s head, neck, and trunk securely so that the head and neck do not move in any direction. (see previous section and references 100a and 100b regarding diagnostic studies.) "

Specializes in ER, Occupational Health, Cardiology.
If the person has obvious neck injuries (badly out of alignment, etc.) and no pulse and is not breathing, chances are the spinal cord has injuries not compatible with life. In other words, he's already dead.

Exactly what Tazzi said.

Specializes in Cardiac, ER.

Check with your state laws,..I'm in Missouri and am not required to stop,.if I do I am covered under the Good Samaritan Laws , (which were designed to encourage off duty medical person to help)as long as I stay within my scope of practice,..I was under the impression that some state do mandate that off duty medical persons stop IF there is no other responder at the scene,...now how they would ever know and how they enforce that law is another story,.. Scattycarrot is correct,.you will learn later in your studies about the "A, B, C's" and perhaps the "D,E,F,G,H,I 's", if a person doesn't have a patent airway, isn't breathing and circulating the O2,.then nothing else matters! Now,.do I want you to secure my airway, breath for me and circulate that O2 when I have a C2 fx and massive head injury? Would it really matter? That too is another post!!

Specializes in ITU/Emergency.
HoorahFLY - In the case that you describe - NO I would NOT start CPR. Blunt force trauma that has NO VITAL SIGNS on scene has a ZERO 0% factor to survive, no matter what is done. But as a student you probably did not know that.

I don't think this statement is necessarily true. In trauma the patient may well be in PEA, which is potentialy reversable. I agree that the outcome is usually dire but you just don't know until you have tried CPR and tried to treat the causes of PEA,eg...hypovalemaia, tension pnemo,tamponade,etc...

Obviously,if the patient has obviously died, with a gaping head wound or deformed neck, than you are right...survival would be zero% and CPR would be pointless but if not, than you have to try!

If movement is necessary (to provide CPR or lifesaving first aid or because of potential danger), support the victim’s head, neck, and trunk securely so that the head and neck do not move in any direction. (See previous section and References 100A and 100B regarding diagnostic studies.) "

Right. Hoorah is going to move a nonresponsive, dead-weight pt by herself and maintain alignment.

Yeah, sure.

Specializes in ITU/Emergency.

Didn't Hoorah mention that shes superwoman? Yeah, theres no way on earth she could do it!

BUT aren't all nurses supposed to be superwoman which is why we have to do about 5 peoples jobs all at once. Ok, slight exaggeration but you know what I mean!

Superwoman/man couldn't do it either, not unless s/he's an octopus!

Specializes in ITU/Emergency.

True. I have always thought that they should surgically implant extra arms on us in Nursing School. One pair of hands is just not enough!!!!!!!! Heehee, that made me think of my nans favorite expression (she was a matron during WW2): "Stick a broom up my a*s and I will sweep the floor as well". Ok, slightly off the subject......

Specializes in Flight, ER, Transport, ICU/Critical Care.

Well, this topic has taken an interesting spin. Good discussion.

The OP asked what to do if ALONE with a set of circumstances. I think we can all agree that the gravity of being alone and extricating a patient, while maintaining c-spine precautions AND starting CPR on a victim that has NO RR or HR has its own set of challenges.

Even an octopus will have a challenge. :eek:

I want to add some clarity (I hope) to my post.

Blunt force trauma that has NO Vital Signs on the scene has a ZERO chance of survival. I can find no documented case where the patient of this category has survived (ever). I can, however, find multiple references in the ACEP.org and the ACS.org position on termination of efforts in patients of blunt force trauma WITHOUT vital signs.

Almost all HEMS programs DO NOT FLY field cardiac arrests (blunt trauma or not) - generally not worth the risk (crash, crew resource commitment) vs. benefit of good outcome (survival is 0%). The rare exception that I am aware of is penetrating trauma with initial vital signs and aggressive resuscitation in progress.

scattycarrott - I will AGREE that cardiac tamponade can exist in blunt trauma. In theory, this is could be corrected with field pericardiocentesis. In reality, most of the population of this country is more than 6 minutes from the first due ALS units. No vital signs for 6 minutes is not compatible with survival. Even with CPR in a tamponade state the best CPR will be even further reduced by the physical limitations in the mechanical operation of the heart. The mechanical limitations in cardiac output/stroke volume are about 40% (CO) with textbook CPR and no tamponade. Tamponade can restrict the blood flow thru the heart by upwards of 60%+. So, this with textbook CPR (compression) means that you will have only about 16% or less of "ordinary" circulation (CO). This state will have to be field corrected or there is NO CHANCE of survival. My experience with several cases of cardiac tamponade (blunt, penetrating and even 1 spontaneous case) will confirm that WITHOUT vital signs on my arrival these patients will die. NO MATTER WHAT. I can even do field pericardiocentesis and even with that it is still gonna be nil survival - with blunt force trauma. Usually the forces with this type of trauma will have other co-morbid injuries.

I have field coded the multiple trauma patients with suspected tamponate, c-spine instability, tenuous airways - all of which were not successful. A few of these cases DID put me as the first arriving provider. You just KNOW you will not be successful, but in the case of a 14 years old vs. auto - well, you know...you just do it. AND it stays with you forever. Luckily, I was in the dawn of my career when the majority of these responses took place. READ: Young and hopeful.

AND you do not know what you do not know. I now know what I did not.

I'm not sure that I would do the same today. Difficult yes. But, futility is a very real thing. Accepting this took time. No less difficult, though.

Now to the C-Spine vs. Airway debate.

As a paramedic/nurse I can guarantee that I can defend sacrificing your c-spine for an airway. Would I want to? NO. But, in the event that I cannot establish an airway - it will not matter that I guarded your c-spine. You will be dead. I have rapidly extricated patients that were without an airway. The risk vs. benefit favored their airway. Luckily, it is a very infrequent event. But, had I taken the time to completely immobilize the patient they would have been anoxic too long. In this case, c-collar placement, inline stabilization and rapid (but, deliberate) removal onto a long spine board was the best course of action. But, I am proficient in this skill. I can defend my actions. Luckily, I have never had a bad outcome from this act.

There are so many more airway tricks I have now (surgical rescue airway) that it would not be necessary to remove a c-collar to extend your neck for intubation - but, in the case of no airway/no oxygen the fact that a c-collar remains in place is of NO BENEFIT to the patient. Hard to think about - but, it is a practice reality in emergent environments. Albeit rare, these days.

Anyway, these are good questions. I encourage folks to discuss these "situations" with groups of your peers/co-workers. It is ALWAYS a good idea to think about WHAT you may do in ANY situation before you find yourself in a situation. WHAT IF? is difficult at times, and everyone may not agree - but, it can be so valuable to have an idea of different options/perspectives. Often, there is no clear right - wrong answer in cases of getting involved as a bystander. I encourage all to do what they are comfortable doing. That is what I do.

Practice SAFE.

;)

Specializes in ITU/Emergency.

Thanks for your post NREMT! Very interesting and informative. Thats what I love about this site is the ability to learn from one another. After I read your post I sat here and thought about all the trauma patients I have seen in my career and of all the patients I have seen that have coded in the field or just as they enter the ER, and only a handful have survived. None who I have seen had pericardiocentesis have made it. And your right, even though everyone working on the patient, knows it going to be a bad outcome you give it your best shot....particulary with children.

Anyway, I think I inadvertantly hijacked this thread but its an interesting area.

Thanks for giving us food for thought, Hoorah!

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