20.2 Emergency Procedures

Why Emergency Procedures Matter on Part II

Chiropractors are first-contact providers. NBCE Part II tests whether you can recognize life-threatening conditions, initiate basic life support, immobilize unstable injuries, and refer immediately — not whether you can perform hospital-level procedures. Emergency items often embed a musculoskeletal complaint (neck pain after a fall, ankle injury on the field) and ask for the next correct action before any adjustive care.

The universal priority sequence is C-A-B in cardiac arrest (Compressions, Airway, Breathing) and scene safety → activate EMS → primary survey in trauma. When in doubt, stabilize and call 911.

Cardiopulmonary Arrest (CPA) and AED Use

Adult BLS (single rescuer):

1. Verify unresponsiveness and absent normal breathing (gasping counts as arrest)
2. Call 911 / activate emergency response and retrieve an AED
3. Begin chest compressions: center of chest on lower half of sternum; rate 100–120/min; depth at least 2 inches (5 cm); allow full recoil; minimize interruptions
4. 30 compressions : 2 ventilations if providing rescue breaths (compression-only CPR is acceptable for untrained lay rescuers)
5. Apply AED as soon as available — follow voice prompts; one shock for shockable rhythms (VF/pulseless VT), then immediate compressions for two minutes before rhythm re-check

Pediatric note (high-yield contrast): infants use two-thumb encircling technique or two fingers; depth roughly one-third anterior-posterior diameter; ratio 15:2 with two rescuers (30:2 single rescuer). Part II may contrast adult and child ratios.

Choking (conscious adult): abdominal thrusts (Heimlich) until object expelled or patient becomes unresponsive. Unresponsive choking victim: begin CPR; look in mouth before each breath and remove visible object — do not blind finger sweeps.

Poisoning and Anaphylaxis in the Office

For ingested poisons, call Poison Control (1-800-222-1222 in the US). Do not induce emesis for caustics, hydrocarbons, or altered mental status. Activated charcoal may help selected early ingestions but is not universal.

Anaphylaxis is a systemic allergic reaction with airway compromise, hypotension, or involvement of two or more organ systems (skin, respiratory, cardiovascular, GI) after allergen exposure (food, drug, insect sting, latex). Treatment sequence:

1. Epinephrine 0.3–0.5 mg IM (1:1000) in the anterolateral thigh — repeat every 5–15 minutes if needed
2. Place patient supine with legs elevated; do not let them stand (empty-venous syndrome can cause sudden death)
3. Supplemental oxygen, IV fluids for hypotension, albuterol for bronchospasm, H1/H2 blockers and corticosteroids as adjuncts — they do not replace epinephrine

A patient stung in the parking lot who develops urticaria, wheeze, and lightheadedness needs epinephrine before you evaluate their thoracic spine.

Thermal Injuries

Rule of Nines (adult TBSA): head/neck 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%. Burns involving face, hands, genitals, circumferential limbs, or >10–20% TBSA need burn-center referral.

Shock: Recognize the Pattern

Shock is inadequate tissue perfusion. Four types dominate board questions:

Neurogenic shock after high spinal cord injury is a Part II favorite: bradycardia with hypotension because sympathetic outflow is lost — do not treat with fluids alone; may need vasopressors and atropine in hospital. Distinguish from spinal shock (temporary loss of reflexes below lesion).

Head and Spinal Injury

Traumatic brain injury red flags: declining consciousness (GCS drop), repeated vomiting, seizure, unequal pupils, post-traumatic amnesia, Battle sign (mastoid ecchymosis), Raccoon eyes (periorbital ecchymosis) suggesting basilar skull fracture, clear fluid from nose/ears (CSF leak — halo sign on tissue).

Cervical spine precautions are mandatory when mechanism includes axial load, diving injury, high-speed MVC, fall from height, or midline neck pain with neurologic deficit. Inline stabilization and rigid collar when trained; log-roll for movement. Do not remove football helmet on field without trained team protocol. A patient who wants their "neck adjusted" after a locker-room fall must be cleared for fracture and instability first.

Concussion: remove from play, rest, gradual return-to-play protocol; second impact syndrome is catastrophic — never return same day.

Fractures, Dislocations, Strains, and Sprains

Neurovascular compromise (5 P's: pain out of proportion, pallor, pulselessness, paresthesias, paralysis) after fracture or dislocation — especially knee dislocation with popliteal artery injury — is limb-threatening. Immobilize and activate EMS.

Compartment syndrome: increasing pain despite immobilization, pain with passive stretch, tense compartment, late pulselessness — fasciotomy emergency; do not massage or adjust through it.

Chiropractic Relevance

Your duty is recognize, stabilize, refer. Perform CPR/AED when indicated; administer epinephrine if your state protocol and training allow; immobilize suspected spine fractures; splint gross deformities; and defer all adjustive care until medical clearance after trauma, shock, burns, or altered mental status.

Takeaways: 30:2 at 100–120/min with AED early; epinephrine IM first in anaphylaxis; heat stroke needs cooling now; neurogenic shock is bradycardic hypotension; open fractures and absent distal pulses are EMS cases; and cervical spine precautions trump convenience.