4.3 Medical Emergencies: Choking, CPR & Seizure Management
Key Takeaways
- Foreign Body Airway Obstruction (FBAO) management depends on airflow: if a conscious choking victim can cough forcefully, do NOT interfere; if coughing is silent, absent, or ineffective, deliver rapid abdominal thrusts (Heimlich maneuver).
- Chest thrusts must be used instead of abdominal thrusts for conscious choking victims who are visibly pregnant or severely obese.
- High-quality Basic Life Support (BLS) CPR requires a chest compression rate of 100–120 per minute, a depth of 2 to 2.4 inches (5–6 cm) in adults, complete chest recoil, minimal interruptions, and a 30:2 compression-to-ventilation ratio.
- During a seizure, the CNA must ease the resident to the floor, protect their head, turn them to the side-lying position, loosen tight neckwear, and time the event; NEVER insert any object into the mouth or restrain convulsing limbs.
- Rapid clinical recognition of acute medical emergencies—including the FAST assessment for stroke, atypical cardiac symptoms in elderly/diabetic residents, and differentiating hypoglycemia ('cold and clammy') from hyperglycemia ('warm and dry')—is life-saving.
Medical Emergencies: Choking, CPR & Seizure Management
In long-term care and healthcare facilities, life-threatening medical emergencies can strike abruptly without warning. When a resident experiences acute airway obstruction, cardiac arrest, a grand mal seizure, or a cerebrovascular event, the Certified Nursing Assistant (CNA) is almost invariably the first healthcare responder at the bedside.
The speed, composure, and clinical accuracy of the CNA's immediate interventions directly dictate whether the resident survives without permanent neurological damage. Adherence to American Heart Association (AHA) Basic Life Support (BLS) guidelines and North Dakota Department of Health and Human Services (ND HHS) standards is imperative.
1. Foreign Body Airway Obstruction (FBAO / Choking)
Choking is a catastrophic risk in geriatric care due to age-related swallowing disorders (dysphagia), neurological deficits from previous strokes, missing or poorly fitted dentures, cognitive distraction during dining, and altered cough reflexes.
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| AIRWAY OBSTRUCTION TRIAGE ALGORITHM |
| |
| [ASSESS RESIDENT] ---> Hands clutching neck? (Universal Choking Sign) |
| | |
| +----------------------------------+ |
| | | |
| v v |
| [PARTIAL OBSTRUCTION: [COMPLETE / SEVERE OBSTRUCTION: |
| GOOD AIR EXCHANGE] POOR / NO AIR EXCHANGE] |
| • Forceful, loud coughing • Silent cough or no sound at all |
| • Can speak or make sounds • Inability to speak, cry, or breathe |
| • CNA ACTION: • High-pitched wheeze (stridor) |
| - STAY with resident. • Cyanosis (blue lips / nailbeds) |
| - ENCOURAGE forceful coughing. • CNA ACTION: |
| - DO NOT perform thrusts! - DELIVER ABDOMINAL THRUSTS! |
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Clinical Signs & Immediate Interventions:
- The Universal Choking Sign: The resident grasps their throat with one or both hands, displaying wide, panicked eyes.
- Partial Obstruction with Good Air Exchange:
- The resident is responsive, agitated, breathing, and able to cough forcefully and speak.
- CNA Protocol: DO NOT INTERFERE. Stay with the resident, offer calm reassurance, and encourage them to keep coughing forcefully to clear the obstruction. Do not deliver back slaps or abdominal thrusts, which can dislodge the foreign body deeper into the trachea.
- Severe / Complete Airway Obstruction:
- The resident cannot speak, breathe, or cough; coughing efforts are completely silent; high-pitched squeaking (stridor) may be heard; facial cyanosis (bluish discoloration of lips, tongue, and nailbeds) develops rapidly.
- CNA Protocol: Immediately ask, "Are you choking? Can you speak?" If the resident nods yes and cannot speak, state, "I am going to help you," and initiate Abdominal Thrusts (the Heimlich Maneuver) immediately.
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| CONSCIOUS ADULT ABDOMINAL THRUST TECHNIQUE |
| |
| 1. POSITIONING ---> Stand behind resident; wrap arms around waist. |
| | |
| v |
| 2. HAND PLACEMENT ---> Make a fist; place THUMB-SIDE against abdomen |
| | MIDWAY BETWEEN NAVEL AND XIPHOID PROCESS. |
| v |
| 3. THRUST ACTION ---> Grasp fist with other hand; deliver QUICK, |
| | FORCEFUL UPWARD AND INWARD THRUSTS. |
| v |
| 4. TERMINATION ---> Repeat thrusts until foreign object is expelled |
| OR the resident becomes UNRESPONSIVE. |
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Special Choking Populations:
- Chest Thrusts for Pregnant or Obese Residents: If the resident is in the late stages of pregnancy or is severely obese such that your arms cannot encircle their abdomen, perform Chest Thrusts. Stand behind the resident, place your arms under their axillae (armpits), position the thumb-side of your fist on the middle of the sternum (breastbone), grasp your fist with your other hand, and deliver rapid, straight-back chest thrusts.
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| UNRESPONSIVE CHOKING VICTIM PROTOCOL |
| |
| [RESIDENT COLLAPSES] ---> Gently lower resident to the floor on back. |
| | |
| v |
| [ACTIVATE 911 / CODE]--> Call loudly for help; summon crash cart & nurse. |
| | |
| v |
| [START CPR: 30 COMP] ---> Begin CPR immediately starting with 30 CHEST |
| | COMPRESSIONS (do not perform a pulse check). |
| v |
| [OPEN AIRWAY & LOOK] ---> Open airway (head-tilt chin-lift); look inside |
| | mouth for foreign object. |
| | - If object SEEN: Finger sweep to remove it. |
| | - NEVER DO A BLIND FINGER SWEEP! |
| v |
| [2 RESCUE BREATHS] ---> Attempt 2 rescue breaths; if chest doesn't rise,|
| | re-tilt head and re-attempt breaths. |
| v |
| [CONTINUE 30:2 CPR] ---> Repeat cycle: 30 compressions -> check mouth |
| -> 2 breaths until help arrives. |
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[!CAUTION] The Blind Finger Sweep Prohibition: Never perform a "blind" finger sweep by blindly swirling your finger inside a resident's mouth or throat. Doing so pushes a partially lodged foreign body deeper into the larynx, causing total tracheobronchial occlusion. Only perform a finger sweep if the foreign object is clearly visible in the oral cavity.
2. Healthcare Provider Basic Life Support (BLS) & CPR Fundamentals
When cardiac arrest occurs, clinical death transitions to biological (irreversible brain) death within 4 to 6 minutes without active circulation. High-quality cardiopulmonary resuscitation (CPR) manually circulates oxygenated blood to the brain and myocardial tissue until defibrillation can be achieved.
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| ADULT BLS CPR SEQUENCE FOR CNAs |
| |
| [1. SCENE SAFETY] ---> Ensure environment is safe for rescuers. |
| | |
| v |
| [2. RESPONSIVENESS] ---> Tap shoulders firmly: "Are you okay?!" |
| | |
| v |
| [3. CALL FOR HELP] ---> Shout for help; activate code / call 911 & AED. |
| | |
| v |
| [4. PULSE & BREATH] ---> Check CAROTID pulse and breathing simultaneously|
| | for AT LEAST 5 but NO MORE THAN 10 SECONDS. |
| v |
| [5. CHEST COMPRESS] ---> If NO pulse / breathing: Start 30 COMPRESSIONS. |
| | • Rate: 100–120 / min |
| | • Depth: 2 to 2.4 inches (5–6 cm) |
| | • Full recoil & minimal pauses (<10 sec) |
| v |
| [6. VENTILATIONS] ---> Deliver 2 RESCUE BREATHS (1 sec each). |
| | Ratio: 30 compressions to 2 breaths (30:2). |
| v |
| [7. ATTACH AED] ---> Turn on AED; attach pads; follow voice prompts. |
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Critical BLS Performance Metrics:
| BLS Component | Adult Healthcare Provider Standard |
|---|---|
| Pulse Assessment Site | Carotid Artery (in the anatomical groove between the trachea and the sternocleidomastoid neck muscle). Check for 5 to 10 seconds maximum. |
| Compression Rate | 100 to 120 compressions per minute (matching the tempo of "Stayin' Alive"). |
| Compression Depth | At least 2 inches (5 cm), avoiding depths exceeding 2.4 inches (6 cm). |
| Chest Recoil | Allow the chest to completely re-expand (recoil) between compressions to permit full ventricular filling. Never lean on the chest. |
| Hand Placement | Heel of one hand on the lower half of the sternum (breastbone); interlock fingers of the second hand on top. |
| Compression-to-Ventilation Ratio | 30 compressions to 2 breaths (30:2) for both 1-rescuer and 2-rescuer adult CPR. |
| Rescue Breaths | Deliver 2 breaths using a bag-valve-mask (BVM) or pocket mask with one-way filter. Each breath over 1 second, observing for visible chest rise. |
| Minimizing Interruptions | Limit all pauses in chest compressions to less than 10 seconds (for pulse checks, defibrillator pad placement, or airway management). |
Automated External Defibrillator (AED) Operation:
- Power On: Immediately turn on the AED (press power button or open lid). Listen to the voice prompts.
- Pad Attachment: Expose the resident's bare chest. Wipe away sweat/water. Peel backing from pads and apply firmly:
- Pad 1 (Upper Right): Below the right collarbone (clavicle), upper right sternal border.
- Pad 2 (Lower Left): Below the left armpit (mid-axillary line), slightly below the left breast/nipple.
- Special Conditions: If a pacemaker/ICD bump is present, place the pad at least 1 inch away from the device. Remove transdermal medication patches (e.g., nitroglycerin) with gloved hands and wipe skin dry before pad placement.
- Analyze Rhythm: Command everyone to "STAND CLEAR!" Ensure no one is touching the resident while the AED analyzes the cardiac rhythm.
- Shock Delivery: If a shock is advised (ventricular fibrillation or pulseless ventricular tachycardia), re-verify all personnel are clear, command loudly "EVERYONE CLEAR!", and press the flashing Shock button.
- Immediate CPR Resumption: Immediately resume chest compressions starting with 30 compressions—do not pause to re-check pulse or rhythm after the shock.
3. Seizure Management Protocols (During & Post-Ictal)
A seizure is a sudden, uncontrolled surge of electrical activity in the brain. In geriatric facilities, seizures frequently arise from cerebrovascular disease (stroke), traumatic brain injury, brain tumors, metabolic disturbances (severe hypoglycemia, electrolyte imbalance), high fevers, or epilepsy.
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| ACUTE SEIZURE RESPONSE FLOW |
| |
| [SEIZURE BEGINS] ---> STAY WITH RESIDENT. Call loudly for charge nurse|
| | |
| v |
| [SAFE POSITIONING] ---> If in bed/chair, ease gently to the FLOOR. |
| | |
| v |
| [HEAD PROTECTION] ---> Place soft pillow / folded blanket under head. |
| | |
| v |
| [ENVIRONMENTAL CLEAR]---> Move sharp furniture, chairs, tables away. |
| | |
| v |
| [AIRWAY & SIDE LIE] ---> Turn resident onto LATERAL (side-lying) position|
| | to drain saliva/vomit; loosen tight collars. |
| v |
| [TIME & OBSERVE] ---> Note exact start time, duration, and movements. |
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Mandatory Rules During Active Convulsions:
- STAY CALM & STAY WITH THE RESIDENT: Never leave a seizing resident unattended. Call out loudly for the charge nurse or push the emergency call bell.
- Protect from Trauma: If the resident is standing or seated in a wheelchair, gently guide and ease them down to the floor to prevent fall fractures. Place a soft folded towel, pillow, or jacket under the resident's head to prevent repetitive head trauma.
- Clear the Area: Push away bedside tables, chairs, trash cans, and hard objects.
- Turn to Lateral Recovery Position: Gently roll the resident onto their side (lateral position). This prevents the tongue from falling back to occlude the airway and allows oral secretions, saliva, or vomitus to drain freely out of the mouth, preventing pulmonary aspiration.
- Loosen Restrictive Clothing: Loosen tight collars, ties, belts, or buttons around the neck to facilitate breathing.
- Time the Seizure: Note the exact time the seizure began and how many minutes the active tonic-clonic motor activity lasts. A seizure lasting longer than 5 minutes, or multiple seizures occurring without regaining consciousness, represents Status Epilepticus—a life-threatening medical emergency requiring immediate intravenous anti-epileptic intervention.
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| CRITICAL SEIZURE PROHIBITIONS |
| |
| ❌ NEVER force any object into the resident's mouth! |
| (No bite blocks, spoons, tongue depressors, or fingers). |
| -> Teeth clenching causes shattered teeth, airway blockage & bites! |
| |
| ❌ NEVER attempt to restrain, hold down, or pin convulsing limbs! |
| -> Forcibly fighting muscle spasms causes joint dislocations & breaks! |
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Post-Ictal Care (After the Seizure Ends):
- Following a seizure, the resident enters the post-ictal state—a phase of profound neurological exhaustion characterized by deep sleep, lethargy, confusion, headache, and disorientation lasting minutes to hours.
- Maintain the resident in a lateral recovery position to ensure a patent airway.
- Check vital signs (pulse, blood pressure, respirations, pulse oximetry) as directed by the nurse.
- Assess the resident for bodily injuries, head trauma, and urinary or fecal incontinence. Provide gentle perineal care and clean linens with dignity.
- Offer calm, quiet orientation ("Mr. Davis, you had a seizure. You are safe in your room, and the nurse is here").
- Document observations: seizure onset time, duration, body parts involved, eye movements, incontinence, and post-ictal response.
4. Recognizing Acute Medical Emergencies: CVA, MI & Diabetic Crises
Certified Nursing Assistants spend more direct one-on-one time with residents than any other healthcare team member. Recognizing the subtle, early clinical warning signs of life-threatening acute medical emergencies can prevent catastrophic disability or death.
A. Cerebrovascular Accident (CVA / Stroke) & The FAST Screen
A stroke occurs when cerebral blood flow is interrupted by an arterial thrombus/embolus (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke), depriving brain cells of oxygen.
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| THE FAST STROKE SCREEN |
| |
| [F] - FACE DROOPING ---> Ask resident to smile. Is one side drooping? |
| [A] - ARM WEAKNESS ---> Ask resident to raise both arms. Does one arm |
| drift downward or feel numb? |
| [S] - SPEECH DIFFICULTY -> Ask resident to repeat a simple phrase. |
| Is speech slurred, garbled, or absent? |
| [T] - TIME TO ACT ---> TIME IS BRAIN! Note EXACT time symptoms started|
| and notify the nurse / activate 911 instantly! |
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Note on Stroke Window: Intravenous thrombolytic ("clot-busting") medication (tPA) can only be administered within 3 to 4.5 hours of the exact time the resident was last known to be well. The CNA must report symptom onset timing immediately!
B. Myocardial Infarction (MI / Heart Attack)
A myocardial infarction occurs when coronary blood flow is acutely occluded, causing ischemic death of heart muscle.
| Clinical Feature | Classic Presentation | Atypical Presentation (Geriatric / Women / Diabetics) |
|---|---|---|
| Chest Symptoms | Severe crushing, squeezing substernal chest pressure ("elephant sitting on chest"). | Mild or absent chest pain; vague epigastric discomfort, indigestion, or heartburn. |
| Radiation | Pain radiating down the left arm, neck, jaw, or between the shoulder blades. | Pain in right arm, throat, upper back, or teeth. |
| Autonomic Signs | Profuse cold diaphoresis (sweating), pale/ashen skin, nausea, vomiting. | Sudden severe fatigue, general weakness, unsteadiness, dizziness. |
| Respiratory / Mental | Acute shortness of breath (dyspnea), sense of impending doom. | Sudden acute confusion (delirium), unexplained dyspnea without chest pain. |
[!IMPORTANT] Silent MIs in the Elderly: Elderly residents—especially those with diabetic autonomic neuropathy—frequently experience "silent heart attacks" with zero chest pain. A sudden drop in blood pressure, acute shortness of breath, unexplained lethargy, or sudden confusion may be the only clinical indicators of a massive myocardial infarction.
C. Diabetic Emergencies: Hypoglycemia vs. Hyperglycemia
Nursing assistants frequently care for diabetic residents and must instantly differentiate between low blood glucose (hypoglycemia) and high blood glucose (hyperglycemia).
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| DIABETIC EMERGENCY DIFFERENTIATION |
| |
| [HYPOGLYCEMIA] (Low Blood Sugar < 70 mg/dL) |
| "COLD AND CLAMMY, NEED SOME CANDY!" |
| • Onset: RAPID (minutes to hours). |
| • Signs: Shakiness, trembling, cool/clammy sweat, hunger, rapid pulse, |
| dizziness, pallor, acute irritability, slurred speech, coma. |
| • CNA Response: Report immediately to nurse; give 15g fast-acting sugar |
| (4 oz juice, 3-4 glucose tablets) if directed and alert. |
| |
| [HYPERGLYCEMIA] (High Blood Sugar > 200 mg/dL) |
| "WARM AND DRY, SUGAR IS HIGH!" |
| • Onset: GRADUAL (days to weeks). |
| • Signs: The 3 Ps (Polydipsia/Thirst, Polyuria/Urination, Polyphagia), |
| warm/flushed/dry skin, fruity/acetone breath odor, deep rapid |
| Kussmaul respirations, nausea, extreme drowsiness, coma. |
| • CNA Response: Report immediately to charge nurse; check vitals/fluids. |
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A conscious resident eating in the dining room suddenly stands up, grasps their throat with both hands, and cannot speak or cough. What should the CNA do FIRST?
A resident in the activity room suddenly collapses to the floor and begins experiencing a generalized tonic-clonic seizure. Which action by the CNA is CORRECT?
According to American Heart Association (AHA) Basic Life Support guidelines, what are the CORRECT chest compression rate and depth metrics for adult CPR?
A CNA notices that an 80-year-old resident has sudden left-sided facial drooping, weakness when attempting to lift the left arm, and slurred, garbled speech. Which action is the CNA's IMMEDIATE priority?