a u d i oc r a s hc o u r s e tm
F o l l o wA l o n gM a n u a l
AudioLearn Crash Course
EMR
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TABLE OF CONTENTS Preface........................................................................................................ 8 Chapter One: Basic First Aid ..................................................................... 12 Contusions ..................................................................................................................... 12 Bleeding.......................................................................................................................... 14 A Word about Tetanus ................................................................................................... 16 Control of Bleeding ........................................................................................................ 16 Dressings .........................................................................................................................17 Foreign Bodies ............................................................................................................... 19 Basic Splinting and Fracture Care ................................................................................. 20 Eye Injuries .................................................................................................................... 21 Burn Care ....................................................................................................................... 24 First Aid Kits .................................................................................................................. 27 Key Takeaways ............................................................................................................... 30 Quiz ................................................................................................................................ 31 Chapter Two: Patient Assessment ............................................................. 35 Getting a History ............................................................................................................ 35 Vital Signs ...................................................................................................................... 39 Respiratory Rate ............................................................................................................ 40 Pulse Rate ....................................................................................................................... 41 Blood Pressure ............................................................................................................... 42 Other Things to Assess................................................................................................... 43 Primary Survey............................................................................................................... 44
Secondary Survey ........................................................................................................... 46 Follow-up Assessment ................................................................................................... 46 Patient Positioning......................................................................................................... 47 Recovery Position .......................................................................................................... 48 Key Takeaways ............................................................................................................... 49 Quiz ................................................................................................................................ 50 Chapter Three: Breathing Emergencies .................................................... 54 Anatomy and Physiology ............................................................................................... 54 Respiratory Pathophysiology ......................................................................................... 62 Patient Assessment ........................................................................................................ 63 Airway Techniques ......................................................................................................... 64 Oxygenation ................................................................................................................... 67 Respiratory Emergencies ............................................................................................... 68 Drowning.........................................................................................................................71 Using Metered-Dose Inhalers and Nebulizers .............................................................. 72 Key Takeaways ............................................................................................................... 75 Quiz ................................................................................................................................ 76 Chapter Four: Cardiology Emergencies ..................................................... 79 Anatomy and Physiology of the Cardiovascular System ............................................... 79 Coronary Circulation ..................................................................................................... 84 Cardiac Output ............................................................................................................... 86 The Cardiac Cycle ........................................................................................................... 89 Circulation...................................................................................................................... 91 Atherosclerosis ............................................................................................................... 93
Chest Pain Evaluation .................................................................................................... 96 Prehospital Management of Acute Myocardial Infarction ............................................ 98 Hypertension Emergencies............................................................................................ 98 Shock ............................................................................................................................ 100 Key Takeaways ............................................................................................................. 102 Quiz .............................................................................................................................. 103 Chapter Five: Cardiopulmonary Resuscitation and AEDs ........................ 106 Principles of CPR ......................................................................................................... 106 Performing CPR ........................................................................................................... 108 Using an AED ............................................................................................................... 109 Implanted Defibrillators ............................................................................................... 111 CPR and AEDs on Children .......................................................................................... 112 Foreign Object Aspiration............................................................................................. 113 Key Takeaways .............................................................................................................. 116 Quiz ............................................................................................................................... 117 Chapter Six: Neurologic Emergencies ..................................................... 120 Anatomy and Physiology ............................................................................................. 120 Stroke ........................................................................................................................... 124 Evaluating Level of Consciousness ...............................................................................127 Loss of Consciousness .................................................................................................. 129 Concussion .................................................................................................................... 131 Seizures ........................................................................................................................ 132 Approach to Headache................................................................................................. 133 Syncope ........................................................................................................................ 135
Key Takeaways ............................................................................................................. 138 Quiz .............................................................................................................................. 139 Chapter Seven: Pharmacology and Toxicology in EMS ............................ 142 Medication Routes and Administration ...................................................................... 142 Medication Allergy Emergencies ................................................................................. 145 Medication Record and Medication Errors ................................................................. 146 Toxicology Emergencies .............................................................................................. 148 Food Poisoning ............................................................................................................ 152 Plant Poisoning ............................................................................................................ 152 Key Takeaways ............................................................................................................. 154 Quiz ...............................................................................................................................155 Chapter Eight: Behavioral Emergencies .................................................. 158 Approach to the Behavioral Emergency ...................................................................... 158 Recognizing and Treating PTSD .................................................................................. 159 Approach to Psychosis .................................................................................................. 161 Suicidality..................................................................................................................... 164 Transport of a Behavioral Emergency ......................................................................... 165 Restraining a Patient ................................................................................................... 166 Key Takeaways ............................................................................................................. 167 Quiz .............................................................................................................................. 168 Chapter Nine: Gastrointestinal and Genitourinary Tract Emergencies ..... 172 Gastrointestinal Anatomy and Physiology ...................................................................172 Stomach........................................................................................................................ 176 Small Intestine ............................................................................................................. 178
Large Intestine ............................................................................................................. 179 Accessory Organs .......................................................................................................... 181 Approach to Abdominal Pain ...................................................................................... 182 Gastrointestinal Bleeding ............................................................................................ 185 Genitourinary Tract Anatomy and Physiology ............................................................ 186 Genitourinary Emergencies ......................................................................................... 190 Key Takeaways ............................................................................................................. 195 Quiz .............................................................................................................................. 196 Chapter Ten: Obstetrical and Gynecological Emergencies ....................... 199 Anatomy and Physiology ............................................................................................. 199 Approach to Pelvic Pain ...............................................................................................204 Vaginal Bleeding .......................................................................................................... 207 Normal Pregnancy ...................................................................................................... 208 Pregnancy-related Emergencies .................................................................................. 210 Approach to the Emergent Delivery ............................................................................ 212 Key Takeaways ............................................................................................................. 215 Quiz .............................................................................................................................. 216 Chapter Eleven: Endocrine, Immunological, and Hematologic Emergencies ...........220 Anatomy and Physiology of the Endocrine System.....................................................220 Diabetic Emergencies .................................................................................................. 223 Hematologic and Oncologic Emergencies ................................................................... 227 Anaphylaxis .................................................................................................................. 228 Key Takeaways ............................................................................................................. 230 Quiz .............................................................................................................................. 231
Chapter Twelve: Trauma ......................................................................... 235 Triage ........................................................................................................................... 235 Back and Neck Trauma ................................................................................................ 237 Abdominal Trauma ...................................................................................................... 237 Chest Trauma ............................................................................................................... 239 Blast Injuries ................................................................................................................ 241 Recognizing Death ....................................................................................................... 241 Key Takeaways ............................................................................................................. 243 Quiz .............................................................................................................................. 244 Summary ................................................................................................ 248 Course Questions and Answers ............................................................... 252
PREFACE This course is intended to help you pass the NREMT exam in order to become a certified emergency medical responder or EMR. The EMR is the first line of defense in many communities that need emergency services in the event of an accident, illness, or injury. You will need to know the basics of first aid as well as how to do cardiopulmonary resuscitation as part of becoming an EMR. You will also need to know how to examine a patient and what questions to ask them. Common medical complaints like headache, shortness of breath, chest pain, and abdominal pain are all things you will have to understand and manage as a first responder. By the end of this course, you will understand how to be a bridge between the field and emergency services in a hospital or emergency department. Chapter one in the course introduces first aid as it is practiced by the emergency medical responder. Not every patient or victim will need to be urgently transported to the emergency department and can be managed with some common sense approaches to everyday injuries. In addition, first aid, when properly administered, should do three things, often referred to as the 3 P’s of first aid: 1) Preserve life, 2) Prevent further injury, and 3) Promote recovery. This chapter will help you to accomplish these. The topic of chapter two is patient assessment. As an emergency medical responder, you will take a basic history and will perform a focused physical examination. The physical examination is divided into the primary survey and the secondary survey, which will have to be repeated at different intervals, depending on the situation. Once these have been done, decisions will have to be made about the best position to place the patient in, which is also a part of this chapter. The purpose of chapter three in the course is to cover the emergency medical responder’s management of breathing emergencies. It starts with a discussion of the major anatomical structures and physiology of the respiratory system, and the diagnosis and management of airway-related issues. The diseases you might encounter in respiratory emergencies is covered, such as asthma, shortness of breath, and drowning.
The EMR might also apply oxygen to patients and may need to assist a respiratory patient in the use of their prescribed metered dose inhaler or nebulizer. The different cardiology-related emergencies are discussed in chapter four in the course. The chapter starts with the anatomy and physiology of the heart and circulation, including the coronary artery circulation and the electrical activity of the heart. The EMR will often have to evaluate and manage the patient with chest pain, which may or may not be of cardiac etiology. Disorders of blood pressure, such as hypertensive emergencies and shock will need aggressive management at times so these will be important to learn about. The focus of chapter five is cardiopulmonary resuscitation and the use of automated external defibrillators. Anyone who attends to the cardiac patient should be able to flawlessly perform CPR on adults, infants, and children. AEDs are also used for all ages of patients. You should also understand the basics of implantable defibrillators because some patients will have these and youshould know how to manage the patient who has sustained a foreign body aspiration. Chapter six in the course discusses the anatomy and physiology of the human nervous system and the different nervous system disorders a first responder may attend to. Ways to evaluate loss of consciousness and to approach the unconscious patient are covered as well as the emergency medical response to nervous system conditions, such as concussion, headache, seizures, and syncope. These are the more common things an emergency responder will encounter related to the nervous system in adults and children. The main things discussed in chapter seven are pharmacology in emergency medicine and toxicological emergencies. There are a few medications that a basic life support provider can give; the EMR should know these drugs and how they are used in emergency situations. There are also many different toxicological emergencies in emergency medicine, such as medication allergies, toxic ingestions, food poisoning, and ingestion of toxic plants. Behavioral emergencies are a common occurrence in emergency medical services and are the topic of chapter eight in the course. The general approach to the behavior
emergencies is discussed, including those related to post-traumatic stress disorder, acute psychosis, and suicidality. During these types of interactions, it is important to maintain safety for the patient and providers, and to make decisions on how and when to transport the patient. Some patients may have to be restrained for their own or others ’safety, which is also covered in this chapter. Chapter nine discusses the anatomy and physiology of the gastrointestinal and genitourinary tract as well as the common conditions in these areas that an EMS provider must deal with on a regular basis. Abdominal pain is an extremely common complaint that usually merits some type of transport to an emergency facility. The same is true of gastrointestinal bleeding, which can be life-threatening. Genitourinary disorders most commonly seen include acute scrotal pain, hematuria, urinary tract infections, urinary retention, and renal colic. The structure and abnormalities of the female reproductive system are the subject of chapter ten in the course. It starts with a discussion of the female anatomy and how it functions. The EMR may be asked to deal with pelvic pain or vaginal bleeding. Pregnancy can also be problematic or normal with a need for emergency intervention at different times in the pregnancy. You will also need to be able to handle the occasional emergent delivery. Chapter eleven covers the different endocrine, immunological, and hematological emergencies an EMR might deal with. The endocrine system involves many glands, most of which do not lead to an emergency situation. Diabetes or dysfunction of the pancreas, however, can cause emergency situations that will often come to the attention of the 911 system. Low blood sugar and high blood sugar situations need to be recognized and managed urgently. Cancer and blood diseases can cause an emergency situation, depending on the patient and their underlying problem. The major immunologic emergency the EMR will have to attend to is anaphylactic shock, which is discussed in this chapter. Chapter twelve in the course introduces the emergency medical responder to the recognition and management of trauma. In a multiple casualty incident, the EMS provider will need to understand the triage system and how to identify the different
levels of care necessary in this setting. In addition, patients can present with spinal injuries that need to be managed with spinal precautions, blunt or penetrating trauma to the abdomen, or trauma to the chest. Blast injuries are also important to recognize and treat. Finally, the chapter discusses the evidence you might encounter in deciding whether a patient can or cannot be resuscitated.
CHAPTER ONE: BASIC FIRST AID This first chapter introduces first aid as it is practiced by the emergency medical responder. Not every patient or victim will need to be urgently transported to the emergency department and can be managed with some common sense approaches to everyday injuries. In addition, first aid, when properly administered, should do three things, often referred to as the 3 P’s of first aid: 1) Preserve life, 2) Prevent further injury, and 3) Promote recovery. This chapter will help you to accomplish these.
CONTUSIONS A contusion is also referred to as a bruise. It happens when blood vessels are damaged internally, leading to blood pooling. Contusions can happen to any body area but are most commonly seen in the subcutaneous tissue, leading to a blue or black discoloration. This color generally does not last but, because of hemoglobin breakdown, turns red, yellow, or green as it heals itself. Most bruises come from the breakage of tiny blood vessels or capillaries so the bleeding isn’t very extensive. Some large bruises are raised, although most are flat and flush with the skin. Expect bruising mainly on areas a person used to break a fall, such as the hands and arms or the knees. Contusions are rarely dangerous unless the patient is on a blood thinner, has a coagulation or clotting problem like hemophilia, or if the bruise is located in the brain. In these cases, bruises can be very dangerous and require medical attention. Aspirin and warfarin or Coumadin are the main blood thinners a person can take. Figure 1 shows a typical contusion:
Figure 1.
Most contusions will not need emergency management and can be treated at home. The RICE method determines treatment for a contusion. The RICE method includes the following: •
Rest—the patient should rest the affected area because exercise or even stretching the tissues can worsen the bleeding. In some cases, a wrap or splint might be necessary in order to make sure the area remains still.
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Ice—an ice pack for twenty minutes at a time with a twenty-minute break between ice packs can effectively slow bleeding and ease pain.
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Compression—wrap the area with a compression bandage in order to decrease pain and bleeding. Do not apply the wrap too tight or the patient will have increased pain in the affected area.
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Elevation—try to keep the area above the level of the heart to decrease the blood pressure to the affected area.
Most bruises can be conservatively treated with these measures; however, hemophiliacs, those with immune disorders like HIV disease, and those on blood thinners will likely need transport or referral to an emergency department for further evaluation.
BLEEDING Bleeding can be internal or external. Internal bleeding cannot be seen by you but will sometimes show up as bruising, swelling, or increased pain to the affected area, while severe internal bleeding can lead to shock. External bleeding involves some type of wound through which the blood leaves the body. You should know how to deal with these types of injuries as they also can lead to severe loss of blood and shock. You have about 8 to 12 pints of blood in your body under normal circumstance. Of course, it depends on size and age so if your patient is a child, a smaller amount of blood loss will potentially lead to shock. Babies have just a pint of blood so blood loss is more dangerous. There are three kinds of bleeding you should know about: •
Arterial—Arterial bleeding will be seen as brisk bleeding that is bright red in color because the blood is highly oxygenated. The blood can literally spurt out of the wound and may come in a pulsatory fashion because the blood is pumping from the heart. This is the most dangerous form of bleeding because it can rapidly exsanguinate the patient; they will more quickly go into shock.
•
Venous—Venous bleeding comes from an injury to a vein. The blood will be dark blue, purple, or black because it is not oxygenated blood. This type of bleeding is slower and generally will not spurt or pulsate. Blood loss can still be severe from a major vein so you should still actively treat this type of bleeding.
•
Capillary—Capillary bleeding comes from practically all types of wounds. It is not very active bleeding and will often trickle from the wound. The color will generally be dark. While blood loss is less severe, it should still be treated.
The most common causes of open wounds are falls, cutting oneself with a sharp object, and accidents involving some type of vehicle, such as a bicycle, motorcycle, or automobile. If these are severe, they can be life-threating. It is up to you to decide if a wound is life-threatening. Sometimes, the bleeding will look severe but the patient’s vital signs will be normal. In the same way, a seemingly minor wound with vital sign changes can be considered severe. You should know that the first sign of a severe wound with bleeding and shock is an increase in heart rate or “tachycardia”. The blood pressure will fall later. Other things that might change are the temperature and respiratory rate but these will not be as sensitive in evaluating severe bleeding as the heart rate. There are four major classifications of wounds. These include the following: •
Abrasion—an abrasion or scrape happens when the skin rubs against something hard or rough enough to cause a break in the skin. People who get road rash usually have abrasions. The bleeding is generally slight and the wound is not very deep. These can still be dirty and can get infected so they need to be carefully scrubbed to remove debris before dressing them.
•
Laceration—this is a cut or tear in the skin that can be deep. Not all of them are linear; some can be quite jagged. They come from incidents involving knives or other sharp objects that cause a break in the skin that bleeds more heavily than an abrasion. They need to be cleaned, have debris removed, and possibly stitched together in the emergency department.
•
Puncture—a puncture wound is generally smaller than a laceration but much deeper. It stems from the intrusion into the skin by a sharp and pointy object, such as a needle, sharp stick, or a nail. Bullets can cause particularly deep punctures. These tend not to bleed very much but can be deep enough to cause
internal organ damage and internal bleeding. These may not need stitching but they may need to be explored for foreign bodies. With all wounds (and not just puncture wounds), a tetanus shot is necessary if it is not current. •
Avulsion—this involves a tearing away of skin that may be partial or complete. With a complete avulsion the tissue is lost. Avulsions can happen of the fingertips or in other body areas that are affected by a severe injury. These tend to bleed the most of all the wounds because they involve loss of protective skin tissue from the body.
A WORD ABOUT TETANUS Tetanus or “lockjaw” is a disease that arises from an infection with the bacterium called Clostridium tetani. It is a soil organism that will generally not affect a person unless they have an open wound that is contaminated with the bacterium. To protect against tetanus, children are given a tetanus series that boosts their immunity against the organism. If a person has had childhood immunizations against tetanus, they need a tetanus shot every ten years. If the patient has a particularly dirty wound, the tetanus shot should have been given within five years of the injury. If not protected, the patient will need a tetanus shot within 48 to 72 hours of getting an injury. The rare patient without tetanus coverage who has a dirty wound might also need tetanus immune globulin given in the emergency department when they are seen.
CONTROL OF BLEEDING One thing you can do in the field with a bleeding patient is to control the bleeding. Wash your hands first in order to minimize infection. Use a dressing big enough to cover the wound and apply gentle pressure. Elevate the area so it is above the level of the heart if possible until the bleeding slows and stops.
Then clean the wound. Rinse it with water and wash around the area with soap. Try not to get soap in the wound itself. Do not use iodine, alcohol, or hydrogen peroxide on the wound. Clean a tweezers with alcohol and remove dirt or debris with that. If the patient is not going to be seen urgently or at all in the emergency department, you can apply petrolatum jelly or an antibiotic ointment to the wound before dressing it. These will prevent sticking of the dressing to the wound. Be aware that some people can be allergic to ingredients in antibiotic ointment so if a rash develops, use petrolatum jelly instead. As always, you should watch for evidence of infection, such as redness, increased pain, warmth, swelling, or drainage. This means you should change the dressing at least once daily and should look for these things. Infected wounds most likely need to be seen to see if antibiotics are necessary. Ice can be used for bruising or swelling of a wound and Tylenol (acetaminophen) can be used for pain. Aspirin should not be used for pain because it has anti-platelet activity that will contribute to bleeding from the wound.
DRESSINGS Dressings come in several forms. The goal of a dressing is to protect the wound from infection, promote healing, absorb exudate, decrease pain, decrease psychological stress, debride the wound, and stop bleeding. A dressing is the actual covering of a wound, while a bandage is what is used to hold the dressing in place. Exudate is the yellowish fluid that leaks from a wound. Clear exudate is normal for a wound and represents plasma fluid that comes from the bloodstream. You should use a dressing to absorb this. If for some reason the exudate becomes greenish or cloudy, this could indicate an infection that needs to be seen and treated by a doctor. Older dressings were usually made from cloth, while newer dressings are made from many different things. Gauze dressings can be dry or impregnated with petrolatum jelly or an antibiotic. Some dressings are gel-based, foam-based, or made from alginates, hydrocolloids, polysaccharide pastes, or hydrogels.
The ideal dressing will absorb exudate if there is any. Hydrocolloidal dressings remain moist for dry wounds and do not absorb exudate like dry gauze will. The dressing should be gas-permeable so water vapor and oxygen can pass through. Mechanical debridement is nice in some cases and pressure dressings will help prevent swelling in burns, etcetera. Some dressings can be impregnated with analgesics or antibiotics. Dry gauze will best debride a wound. Dressings are held to the tissue with either adhesive tape or a compressive bandage (or both). Some dressings are considered “island dressings” because they are already surrounded by an adhesive backing that is directly applied to the wound. It does not require adhesive tape or a bandage. The biggest advantage of a bandage is that it can provide additional compression to the wound. There are many passive dressings like gauze and pieces of cotton cloth for wounds. There are also interactive dressings that are not often used in the field but are used to promote healing in certain situations. These include things like transparent film dressings made from polyurethane, which allows oxygen, carbon dioxide, and water vapor to pass through the dressing. It allows for autolytic rather than mechanical debridement, which is less painful. It is transparent so that the wound can be visualized directly. Semi-permeable foam dressings attract water on the inside and repel water on the outside. The inner layer absorbs exudate, while the outer layer prevents extraneous water from getting on the wound. This is used when there is healing tissue or what’s called granulation tissue. It is used in moist wounds and is made from silicone. Hydrogel dressings have a high water content themselves and cool a wound. These are used for dry wounds with a lot of dead tissue, pressure ulcers or burns. It cannot be used for very moist wounds because it doesn’t absorb very well. Hydrocolloidal dressings have an inner colloidal layer and a waterproof layer on the outside. It contains agents within it that will form a gel, such as gelatin, pectin, or carboxymethylcellulose. Wound discharge forms a gel within the dressing, which promotes healing and protects the wound from contamination by bacteria. It is best for drier wounds rather than wounds with a lot of discharge.
Alginate dressings contain some type of salt or alginic acid. It can absorb a great deal of discharge and can help to form a film that protects the wound from being contaminated by bacteria. It cannot be used for third-degree burns, dry wounds, or deep wounds that have exposed bone. They can dry out easily so they need another dressing on top of them to keep moisture within the wound.
FOREIGN BODIES You may need to deal with a foreign body, which can be just about anywhere. Small foreign bodies in the skin can be plucked out with a tweezers from a first aid kit. In order to do this, the splinter must be easy to grasp without digging into the skin. Large foreign bodies impaling a person should not be removed because there will be pain and the possibility of bleeding after the object is removed but small splinters can be removed. Tetanus shots should probably be up to date unless the splinter is very superficial. You need to do these things when removing a splinter: •
Wear gloves or wash your hands well to reduce the risk of infection.
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Clean a tweezers with rubbing alcohol. You may need a magnifying glass to see the area properly.
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Clean the skin with rubbing alcohol and use the tweezers to pluck the splinter from the skin.
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If the splinter is just under the skin, use a clean, alcohol-washed needle to lift the skin above the object so that it can be grasped with the tweezers.
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You can gently squeeze the wound in order to wash the bacteria out of the punctured area.
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Wash the area again with soap and water and apply some antibiotic ointment and a dressing.
Deeply imbedded or large foreign bodies cannot be removed in the field. Instead, control the bleeding by pressing around the wound so as to bring the wound edges together. Raise the wound so that it is above the level of the heart. Put a piece of gauze around the splinter or on top of it if it is completely imbedded. Then pad the area with more gauze and apply a bandage that slightly compresses the area but doesn’t push directly on the foreign object. Foreign objects in the nose can also be managed in the field in some cases. Do not use any kind of tool or cotton swab to probe the object because that would potentially push the object further into the nose. Instruct the patient to breathe through the nose because deep inhalation can suck the object into the nose. Instead, have the patient gently blow out through their nose to see if the object can be removed. Hold the unaffected nostril shut in the process. If the object extrudes from the nose and is easily grasped, you may use tweezers to remove the object. Do not force it because it may irritate the nose and cause bleeding. If bleeding does occur, put direct pressure on the nose by pinching it until the bleeding stops. Use an antibiotic ointment in the nose to prevent infection.
BASIC SPLINTING AND FRACTURE CARE You may be asked to deal with a probable broken bone. Broken bones may or may not break the skin. If the fracture breaks the skin, it is called a compound fracture and is dangerous because of the risk for infection. Any time there is pain, swelling, or deformity of an extremity, you should treat it as if there was a fracture. Other symptoms include localized or distal numbness, bluish coloration over the painful area from bruising, or the presence of a bone protruding through the skin with heavy bleeding at the site. You will do the patient a great favor by splinting or otherwise immobilizing the fractured area as this will partially relieve the pain. You do not need to re-align the fracture; that would be painful and is unnecessary. Just have them lie still and use a makeshift splint or sling to protect the affected area.
If you suspect that the patient has a fractured back or neck, have them lie as still as possible. Use a C-collar to protect the neck and a backboard to load the patient safely into the ambulance. Continually assess the patient’s extremity function—both sensation and movement because these travel through different channels in the spinal cord. If there is an open or compound fracture, stop any excessive bleeding by direct pressure and elevation. Apply a clean gauze to the wound and a pressure dressing if possible, to staunch the flow of blood. Do not try to put the piece of bone back into the body because this will not help and can damage the tissues further. Wrap an ice pack around the injured area to relieve pain and swelling. Blood loss in any fracture situation can be severe so keep the person lying down and comfortable so as to avoid shock. Keeping them warm will also help to reduce symptoms of shock. When dealing with any fracture, you should always check the distal pulses. If the distal pulses are absent, usually the extremity will be pale and cold. If there will be a delay in treatment, such as when you are in a remote area, you can realign the fracture ends in that situation so as to restore the pulses to the area. Bleeding and swelling might get worse if you do but the extremity may have restored circulation if the artery wasn’t completely severed and was just compressed by the fracture ends.
EYE INJURIES Eye injuries can always threaten sight, even if they seem trivial in nature. There are things you may need to do at the scene in order to minimize damage and preserve sight as much as possible. In any complaint of eye pain, you should inspect the eye carefully. In the case of chemical burns, just about anything can be splashed into the eye. Acid burns, petroleum burns, and burns with things like acetone or rubbing alcohol can be irritating but tend not to cause significant damage to tissues. Alkali burns, however, are likely to damage tissues deeply so these are the most dangerous. The first thing you need to do is to keep the patient calm and explain to them that you are going to flush out the eye. Use plain tap water in all situations to flush out the eye. Keep the eye open and flush continually for about twenty minutes to clear out the eye. Most patients will tolerate this procedure and will experience relief of their pain.
Bring the chemical or carefully record what it was on your records so the emergency department physicians can assess the problem and determine how much eye damage to expect. After flushing, you can cover the eye with gauze and transport the patient. Blows to the eye can be very serious. When examining an eye that has sustained blunt trauma, look at the iris and pupil. The pupil should react to light and the iris should be easy to see. If bleeding has occurred into the anterior chamber in front of the iris, you will see blood layering out on the inferior aspect of the eye. This is called a hyphema. Figure 2 shows what a hyphema looks like:
Figure 2.
Hyphemas are serious and the patient should be seen in the emergency department. Keep the patient sitting up to keep the pressure down in the eye. Do not apply pressure to the eye with a dressing and keep the patient calm prior to transport. Another thing that can happen with blunt trauma to the eye is an orbital fracture, involving the bones that surround the eye. You may gently palpate the superior and inferior orbital ridges to see that they are smooth and undamaged. Anytime they are damaged, you may find a step off where the fracture ends to not line up. With an inferior orbital fracture in particular, you may find that one of the muscles that controls eye movement is trapped within the fracture. When examining the eye, have
the patient move the eye to all quadrants. If the patient cannot look upward, this can be from just such a fracture. With a blow to the eye that is relatively minor, cool compresses should be applied to the affected eye. Do not apply ice directly to the eye as this would possibly damage the eye. Do not put heat or even warm compresses on the eye because the swelling could worsen. The patient may complain of a foreign body sensation in the eye with increased pain and tearing of the eye. In such a situation, you can encourage the patient to blink but not to rub their eyes. The foreign body may dislodge itself and will be washed away with tears. You can aid the process by flushing the eye out with tap water. Foreign bodies that do not appear to move about the eye so that the patient says it’s sitting in one place may or may not actually have a foreign body but may instead have a corneal abrasion or possibly an imbedded foreign body in the cornea. These will feel just like a foreign body but will only be seen on examination by the emergency physician. Imbedded foreign bodies should be left in the eye and not removed because this will tend to further damage the eye. Instead, once the eye is flushed, you should cover the eye with an eye shield that doesn’t put pressure on the eye. Transport the patient for further evaluation. If the patient has sustained a puncture wound to the eye or eyelid, you can examine the eye. If there is active bleeding from an eyelid laceration, you can apply direct pressure to the affected area to stop the bleeding. Do not do this with an eyeball puncture wound because it could damage the eye. Instead, put an eye shield on the affected eye and transport the patient. If there is bleeding, you can simply elevate the patient’s head for transport.
BURN CARE There are things you should do with all burns and things that apply specifically to the type of burn the patient has. For all burns, you should stop the burning process. Remove the patient from the heat source, which may be a fire, steam, heat source or hot liquid. Use stop, drop, and roll in order to smother the fire and remove all burned or hot clothing. You may need to cut off clothing that is sticking to a burn. Even if a piece of clothing wasn’t directly burned, you may need to remove it if it is constricting the patient’s breathing or if it is distal to the burn. All belts and jewelry should be removed in order to help maintain the circulation to the areas of the body. Burns quickly swell and tight things can constrict the circulation to the extremities. Assess the nature of the burn. There are four degrees seen in a burn situation. These are the following: 1. First-degree burns—these will be red and very painful; they will resemble a sunburn. They will not blister and represent a burn just to the epidermis. 2. Second-degree burns—these will be painful and blistered. The skin overlying it will be red and there will be a lot of exudate if the blisters rupture. The whole epidermis and part of the dermis will be affected. 3. Third-degree burns—these will involve a full-thickness burn to the epidermis and dermis. Because the nerves are affected, the person will not feel much pain. The skin will be leathery and either brown or black in color. 4. Fourth-degree burns—these involve subcutaneous tissues, muscle, and/or bone. They are very deep and have varying amounts of pain. These are the most severe type of burn. The skin will often appear black and charred.
Figure 3 shows the four degrees of burns:
Figure 3.
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