LIFELINE (366 511) by Junep Ocampo

START OF PART 3 (PAGES 366-‐511)

LIFELINE PREHOSPITAL EMERGENCY CARE

ALL over the world, diabetes is fast becoming a threat to public health. In the Philippines, the Department of Health estimates that at least 1 million Filipinos have this condition. In the past, diabetes was considered â&#x20AC;&#x153;disease of affluenceâ&#x20AC;? as its victims were mostly the rich. However, diabetes has become a scourge even of the working class, no thanks to the sedentary lifestyle that modern life promotes. Experts consider diabetes as the biggest epidemic that is going to happen in human history. That is if nothing drastic is done to address it. As a future EMT, you will be called to provide care to diabetes patients -- both those who have low sugar levels in their blood and those who have high levels. To be able to respond properly to diabetic emergencies, you would need to do a lot of reading and studying. In this chapter, you would be familiarized to the different types of diabetes, and you will also learn how diabetes leads to an altered mental state on the part of the patient. You would also be taught how to assess a diabetic patient, how to respond to seizures, and what to do if the patient had a stroke. On top of these, you would also encounter in this chapter a section about hematologic problems or those related to the blood, as well as renal challenges of those that have to do with the kidneys. Though hematologic disorders are rare, they are often life threatening and require emergency care. Renal problems are also deadly, and sadly, more and more Filipinos are experiencing them. This is a compelling reason why you should study this chapter all the more.

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Diabetic Emergencies and Altered Mental Status Management of Diabetic Emergencies Causes of Seizure and Strokes Hematologic and Renal Emergencies

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PRINCIPLES OF EMT CLINICAL PRACTICE

DIABETIC EMERGENCIES AND ALTERED MENTAL STATUS LEARNING OBJECTIVES • Identify the patient taking diabetic medications with altered mental status. and the implications of a diabetes history. • State the steps in the emergency medical care of the patient taking diabetic medicine with an altered mental status and a history of diabetes. • Explain the rationale for administering oral glucose.

INTRODUCTION Altered mental status is a term used to describe a broad spectrum of abnormal behavior that ranges from unconsciousness to slight anxiety. These changes often result from a lack of oxygen; a brain-related problem, like a seizure; a stroke; or other serious medical issues such as a diabetic emergency. As an EMT. you should always consider altered mental status to be a serious finding and a potential concern. Although sometimes it may be a normal state for the patient, altered mental status can be the most important sign of a life-threatening condition. Use a thorough patient assessment to rapidly identify and treat life threats and use a good secondary assessment to help determine the cause of the unusual behavior Remember, treating life threats is always more important than finding the overall cause of altered mental status.

PATHOPHYSIOLOGY

Normal consciousness is regulated by a series of neurologic circuits in the brain that comprise the reticular activating system (RAS). The RAS is essentially responsible for the functions of staying awake, paying attention, and sleeping. The brain tissue of the RAS has simple requirements to function properly and. thereby, keep a person alert and oriented. Oxygen is needed to perfuse brain tissue, glucose is needed to nourish brain tissue, and water is needed to keep brain tissue hydrated. A lack of any of these can lead to rapid and serious alterations of function and result in altered mental status. In addition to deficiencies in any of these basic needs, other causes such as trauma. infection, and A patient with chemical toxins (as in overdoses altered mental status and substance abuse) can also often can be dangerous harm brain tissue. to responders. Always Altered mental status can consider the safety of result from a primary brain yourself and your team problem, like a stroke: but it may prior to approaching also be a symptom of a problem a patient who is not within another system, like acting appropriately. Use hypoxia due to an asthma attack. law enforcement when Often, altered menial status is necessary. rapidly correctable by treating the underlying cause.

Safety

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Bilang isang EMT, importante namalaman mo kung papaano tatratuhin ang pasyente na may ibang takbo ng pag-iisip. Kadalasan kasi, ang pag-iiba ng takbo ng isip ay senyales na may seryosong kondisyon ang pasyente na kailangang gamutin.

ASSESSING THE PATIENT WITH ALTERED MENTAL STATUS

Later in the chapter we will discuss the assessment of specific disorders that may lead to altered menial status. However, there are some general approaches to assessing the altered mental status patient that are important regardless of the cause.

Primary Assessment One of the most common causes of altered mental status is hypoxia. Even simple anxiety and combativeness may be the result of a failing respiratory system. Always consider the possibility of an airway and/or breathing problem in a patient with altered mental status. Although you should complete a thorough primary assessment on every patient, be especially attentive in the event of altered mental status. Remember that the purpose of the primary assessment is to identify and treat life-threatening problems as found. You will begin oxygen to the patient with an altered mental status during the primary assessment (or ensure that another is doing so). Be alert to the need for positioning and suction if the patient requires it or if the patient’s mental status worsens.

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

Secondary Assessment Often, altered mental status is a subtle sign. Although you may rule out immediate life threats, even a slightly altered menial status indicates serious underlying issues. Any patient exhibiting new, unusual behavior must be examined thoroughly. A body systems exam and complete history may reveal important information about the suspected cause of the altered mental status. Based on this exam you may find that field treatments are available, including administering glucose in the case of a hypoglycemia or prompt transport to an appropriate facility for stroke. Consider interviewing family members and bystanders who may be able to tell you if the patient’s behavior and mental condition are or are not normal for him and provide information the patient may not be able to give you himself. Review the patient’s medicines to point to relevant medical history, and look for clues such as medic alert bracelets and other health-related items at the scene.

PEDIATRIC NOTE Young children may not be able to answer questions in the same manner as adults, and therefore their mental status is often difficult to establish. In these cases, use parents or caregivers to identify their baseline level of consciousness by asking, “Are they acting differently than normal?” Most often parents are the best judge of their child’s current mental status.

DIABETES

Glucose and insulin are key elements in human physiology. The condition known as diabetes mellitus occurs as a result of an alteration in either of these substances or in the interaction between them

Glucose and the Digestive System Glucose, a form of sugar, is the body’s basic source of energy. The cells of the body require glucose to remain alive and create energy. We take sugars into our body from the foods we eat, either sugar itself or other carbohydrates that the body’s digestive system will convert to glucose. After the digestive system converts sugar and other carbohydrates into glucose, the glucose is absorbed into the bloodstream. The glucose molecule is large and will not pass into the cell without the assistance of insulin (described next). The pancreas secretes insulin when the blood glucose rises above about 90 mg/dL. Insulin binds to receptor sites on cells—especially those in the liver and muscles—and allows the large glucose molecule to pass into the cells.

Insulin and the Pancreas

The pancreas is an organ found along the midline of the upper abdomen. The pancreas has a variety of functions, but one of its most important roles is the production of the hormone insulin. Within the pancreas, specialized clusters of cells called the islets of Langerhans secrete insulin. Insulin secreted hy the pancreas is then used by the body to help transfer glucose from the blood across cell membranes into the cell. The insulin-glucose relationship has been described as a “lock and key” mechanism. Consider insulin the key. Without the insulin “key,” glucose cannot enter the locked cells. When sugar intake and insulin production are balanced, the body can effectively use sugar as an energy source.

Diabetes Mellitus About 20 million, or roughly 1 in every 5 Filipinos, have a condition called diabetes mellitus. Generally speaking, this condition results either from an underproduction of insulin by the pancreas or from an inability of the body’s cells to use insulin properly. There are two types of diabetes, type 1 and type 2. Type 1 diabetes (formerly known as insulin-dependent diabetes) occurs when pancreatic cells fail to function properly and insulin is not secreted normally. A type 1 diabetic simply does not have enough insulin in his system to transfer circulating glucose into the cells. If left untreated, glucose levels will build up in the blood while the cells of the body starve for sugar—too much glucose in the blood, not enough in the cells. A type 1 diabetic typically would be prescribed synthetic insulin to supplement his inadequate naturally occurring insulin. Patients who Type 2 diabetes are diabetic (formerly known as noninsulin-dependent diabetes) 1. Don’t produce insulin. occurs when the body’s 2. Don’t produce cells fail to utilize insulin enough insulin, or properly. The pancreas may 3. Have a body that be secreting enough insulin, has become resistant but the body is unable to to the insulin use it to move glucose out that is produced. of the blood and into the Medications taken by cells. Patients with type 2 diabetics are designed diabetes can often control to overcome these their condition with diet conditions. and/or oral antidiabetic medications.

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DIABETIC EMERGENCIES

Diabetic Emergencies The most common medical emergency for the diabetic is hypoglycemia, or low blood sugar (Hypo means “less than normal” or “deficient.” Glyc means “sugar”). Hypoglycemia is caused when the diabetic does any one of the following: • Takes too much insulin (or, less commonly, takes too much of an oral medication used to treat diabetes), thereby transferring glucose into the cells too quickly and causing a rapid depletion of available sugar. • Reduces sugar intake by not eating. • Overexercises or overexerts himself, thus using sugars faster than normal. • Vomits a meal, emptying the stomach of sugar as well as other food. When blood sugar is thus reduced brain cells, as well as other cells of the body, starve. Even when the cause is too much insulin, the rapid uptake of sugar into the cells soon depletes the available supply in the bloodstream. Altered mental status, possibly unconsciousness, and even permanent brain damage can occur quickly if the sugar is not replenished. The brain and body do not tolerate low levels of sugar. Because of this fact, hypoglycemia typically has a very rapid onset. Abnormal behavior that often mimics a drunken stupor is very common. Other signs of hypoglycemia include pale, sweaty skin, tachycardia, and even seizures. Quick replenishment of blood sugar, often in the form of oral glucose, is critical to this patient’s outcome. When it can be given without threatening the patient’s airway, oral glucose should be administered promptly, before the patient becomes unconscious Hyperglycemia is high blood sugar. (Hyper means “more than normal” or “excessive.” Glyc means “sugar.”) Hyperglycemia is usually caused by a decrease in insulin, which leaves sugar in the bloodstream rather than helping it to enter the cells.The insulin deficiency may be due to the body’s inability to produce insulin or may exist because insulin injections were forgotten or not given insufficient quantity. Infection, stress, or increasing dietary intake can also be a factor in hyperglycemia. Hyperglycemia typically develops over days and even weeks—in contrast to the typically rapid onset of hypoglycemia. Glucose levels in the blood creep up while the cells of the body begin to starve for sugar. As blood sugar levels increase, the patient may complain of chronic thirst and hunger. In an attempt to rid the blood of excess sugar, the body will increase urination. Nausea is also a frequent complaint. Extremely high levels of sugar in the blood begin to draw water away from the body’s cells, potentially resulting in profound dehydration. Starving body cells begin to burn fats and proteins in a manner that results in excessive waste products being released into the system. These waste products build up and combine with dehydration to cause a condition called diabetic ketoacidosis (DKA). A person who has diabetic ketoacidosis will commonly have a profoundly altered mental status. He will also have the signs and symptoms of shock, caused by dehydration. A waste product of diabetic ketoacidosis is ketones. A person having this complication will breathe rapidly and often emit a fruity, acetone odor on his breath as the body works to breathe off these byproducts. Remember that it is not part of the scope of practice for an EMT to determine exactly which condition has caused a diabetic emergency. However, a later section of this lesson, “Hypoglycemia and Hyperglycemia Compared.” provides more information on these conditions.

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Inside/Outside HYPOGLYCEMIA Inside the body of a hypoglycemic patient, the cells are starving for sugar (even if the cause was too much insulin). Brain cells, and particularly the cells of the reticular activating system, are at a loss for glucose and, therefore, energy. As the body attempts to compensate, the fight-orflight mechanism of the autonomic nervous system engages. Blood vessels constrict, the heart pumps faster and harder, and breathing accelerates. Outside of the body we see these changes in the form of signs and symptoms. Starving brain cells result in altered mental status. Confusion, stupor, unconsciousness, and seizures are common. Constricted blood vessels give the patient pale and sweaty skin. The fight-or-flight response increases the pulse rate and the respiratory rate. HYPERGLYCEMIA In a hyperglycemic patient’s body, particularly if he has progressed to diabetic ketoacidosis, major changes are occurring. As sugar levels in the blood skyrocket, water is pulled away from cells, causing a systemic dehydration and potentially hypovolemic shock. Brain cells are damaged as a result. In a last resort measure, cells begin to breakdown fats and proteins, giving off ketones and other waste products. Outside the body, we see a profound mental status change resulting from dehydration of brain cells. The overall dehydration results in the signs and symptoms of shock, including tachycardia, rapid respirations, and dropping blood pressure. The production of ketones can result in a fruity smell, similar to nail polish remover, on the breath.

² Limmer, O’Keefe, “Emergency Care”, 12th Edition. Brady, NJ (2012) ³ Pollack, “Emergency Care and Transport of Sick and Injured”, 10th Edition. AAOS, MS (2011) 4 National Highway and Traffic Safety Administration (NHTSA), “EMT Basic Standard Curriculum“, Department of Transportation, USA, (2005)

PATIENT ASSESSMENT Diabetic Emergencies Prehospital treatment of the diabetic depends on rapid identification of the patient with an altered mental status and a history of diabetes to assess the patient. 1. Ensure a safe scene. People with diabetic emergencies can be agitated and sometimes violent Always ensure the safety of yourself and your crew before approaching a patient with altered menial status 2. Perform a primary assessment. Identify altered mental status. 3. Perform a secondary assessment. Gather the history from the patient or bystanders. • Gather a history of the present episode. Ask about how the episode occurred, time of onset, duration, associated symptoms, any mechanism of injury or other evidence of trauma. whether there have bean any interruptions to the episode seizures, or a fever. • During the SAMPLE history determine if the patient has a history of diabetes. Question the patient or bystanders about such a history. Look for a medical Identification bracelet, wallet card, or other identification of a diabetic condition such as a homeuse blood glucose meter. Look in the refrigerator or elsewhere at the scene for medications such as insulin, a medication with a trade name for insulin (such as Humulin). or an oral medication used to treat diabetes (such as metformin, Glucotrol, Glucophage, Mieronase). Some diabetic patients use an implanted insulin pump. These small pumps are about the size of an MP3 player and are usually found worn on the belt. The pump will have small catheters that enter into the abdomen. Also ask about the patient’s last meal, last medication dose, and any related illnesses. • Perform blood glucose monitoring if local protocols permit you to do so. 4. Determine if the patient is alert enough to be able to swallow 5. Take baseline vital signs. In some jurisdictions, oral glucose will be administered before the vital signs are taken.

PEDIATRIC NOTE

Diabetic children are more at risk for medical emergencies than diabetic adults. Children are more active and may exhaust blood sugar levels by playing hard—especially if they have taken their prescribed insulin. Children are also less likely to be disciplined about eating correctly and on time As a consequence, children are more at risk of hypoglycemia

The following signs and symptoms are associated with a diabetic emergency: • Rapid onset of altered mental status • After missing a meal on a day the patient took prescribed insulin • After vomiting a meal on a day the patient took prescribed insulin • After an unusual amount of physical exercise or work • May occur with no identifiable predisposing factor • Intoxicated appearance, staggering, slurred speech, to unconsciousness • Cold, clammy skin • Elevated heart rate • Hunger • Uncharacteristic behavior • Anxiety • Combativeness • Seizures

Blood Glucose Meters One of the many advances in managing diabetes has been the development of portable, reliable blood glucose meter. People with diabetes now routinely test the level of glucose in their blood at least once a day. and sometimes as often as five or six times a day. By determining the amount of glucose in their blood, they can determine very precisely how much insulin they should take and how much and how often they should eat. Keeping blood glucose levels as close to normal as possible leads to significantly fewer diabetesrelated complications (heart disease, blindness, and kidney failure, to name a few), so a person with diabetes has a strong motivation to keep his blood glucose level within the normal range. If the patient has a glucose Humingi muna ng meter, the patient or a family pahintulot sa Medical member can use it to determine Director bago gumamit the patient’s blood glucose level. ng blood glucose meter Generally. EMTs should not use at sukatin ang glucose sa a patient’s glucose meter. There dugo ng pasyente. are many different types of these devices on the market, each with its own instructions for use. which may be very different from device to device. Additionally, there is no way for the EMT to know whether the test strips have been stored properly or when the device was last calibrated. These facts are very important if the reading is to be accurate. ² Limmer (Brady) ³ Pollack, (AAOS) 4 NHTSA

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Day 15 A value less than 60 to 80 mg/dL (milligrams per deciliter) in a symptomatic diabetic (i.e.. a patient with a mild alteration in mental status or who is diaphoretic (sweaty) is typical of hypoglycemia and indicates the need for prompt administration of glucose. Patients with values less than 50 mg/dL will typically have significant alterations in mental status that may include complete unresponsiveness. Patients with a blood glucose level that is this low will often be unable to safely receive oral glucose. A reading over 140 (depending on the manufacturer’s instructions) indicates hyperglycemia. Patients with glucose levels in the mid and high 100s are often without acute symptoms, although over time this level of hyperglycemia can cause damage to various body organs. Patients with blood glucose levels over 200-300. especially for a prolonged time, may experience dehydration and other more serious symptoms and should receive medical care. A reading inconsistent with the patient’s symptoms (such as 25 mg/dL in a patient who is alert and oriented) should make the EMT question the result. There are many potential causes of inaccurate results, including insufficient blood on the test strip, a strip past its expiration date or not stored properly, or a meter that needs calibration. Although many people use blood glucose meters appropriately and accurately, it is quite common to get an inaccurate reading, especially when the device is not used properly. It is critical that any health care provider using a blood glucose meter to test a patient’s blood have the proper training in use of the device and be thoroughly familiar with its care and maintenance. Calibration and testing on a regularly scheduled basis are essential if the device is to give accurate results. On occasion, the glucometer will display the word HIGH rather than a number. Depending on the manufacturer, a “High’ or “HI “reading indicates an extremely high glucose level, usually in excess of 500 mg/dL. The word LOW usually indicates blood glucose levels which are extremely low (often less than 15 mg/dL). Remember that the blood glucose monitor is just one tool used in your assessment of a patient with an altered mental status. Blood glucose monitoring, or any other examinations, should never be done before a thorough primary assessment has been performed. Some areas recommend that the blood glucose measurements be done while en route to the hospital. 372

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DIABETIC EMERGENCIES

Management of a Diabetic Emergency 1. Perform a primary assessment. Determine if the patient’s mental status is altered. 2. Perform a secondary assessment and take the patient’s vital signs. Be sure to find out if she has a history of diabetes. Observe for a medical identification device. If your protocols allow, check the patient’s blood glucose level. 3. If the patient has a history of diabetes, has an altered mental status, and is alert enough to swallow, prepare to administer oral glucose. 4. Assist the patient in accepting oral glucose. 5. Reassess the patient.

PATIENT CARE Diabetic Emergencies If the patient is not awake enough to swallow, treat him like any other patient with an altered mental status That is. secure the airway, provide artificial ventilations if necessary, and be prepared to perform CPR if needed Position the patient appropriately If the patient does not need to be ventilated, place him in the recovery position (on his side) so that he is less likely to choke on or to aspirate fluids or vomitus into his lungs Request an ALS intercept if available. The most important decision point in choosing to give oral glucose is the patient’s ability to swallow Although a severely hypoglycemic patient may desperately need sugar, if he is unable to protect his airway, the administration of oral gel may be the worst thing you can do We only administer oral glucose to those patients we feel can swallow it and protect their airway From aspiration Emergency care of a patient with a diabetic emergency includes the following: 1. Occasionally a person with only mild hypoglycemia and minor altered mental status can be treated by simply giving him something to eat. In a person who is only slightly confused, it may be more appropriate to ask him to ingest a glass of milk or a piece of toast than a tube of oral glucose. You must understand that this course of treatment will take longer to resolve the hypoglycemia and is certainly not appropriate for a patient who has severe hyperglycemia. Always use good clinical judgment to determine if your patient needs more aggressive care. 2. Determine if all of the following criteria for administration of oral glucose are present. The patient has a history of diabetes, has an altered mental status, and is awake enough to swallow. 3. If the patient meets the criteria for administration of oral glucose and if he is able, let the patient squeeze the glucose from the tube directly into his mouth. 4. Reassess the patient. If the patient’s condition does not improve after administration of oral glucose, consult medical direction about whether to administer more. If at any time the patient loses consciousness, remove the tongue depressor from his mouth and take steps to ensure an open airway.

Hypoglycemia and Hyperglycemia Compared Many students find that they confuse hypoglycemia and hyperglycemia. Fortunately, the use of reliable blood glucose monitoring in the field has made this decision much easier. It is also important to note that it is not necessary to distinguish between the two conditions in order to give the proper treatment. There are three typical differences between hypoglycemia and hyperglycemia: • Onset. Hyperglycemia usually has a slower onset, whereas hypoglycemia tends to come on suddenly. This is because some sugar still reaches the brain in hyperglycemic (high blood sugar) states. With hypoglycemia (low blood sugar), it is possible that no sugar is reaching the brain. Seizures may occur.

• Skin. Hyperglycemic patients often have warm. red. dry

skin. Hypoglycemic patients have cold. pale, moist, or “clammy” skin. • Breath. The hyperglycemic patient often has acetone breath (like nail polish remover), whereas the hypoglycemic patient does not. Also, patients who are hyperglycemic frequently breathe very deeply and rapidly, as though they have just run a race. Dry mouth, intense thirst, abdominal pain, and vomiting are all common signs and symptoms of this condition. The proper treatment is given under close medical supervision in a hospital.

Oral Glucose MEDICATION NAME INDICATIONS CONTRAINDICATIONS

1. Generic: Glucose, oral 2. Trade: Glutose, Insta-glucose Patients with altered mental status and a known history of diabetes mellitus 1. Unconsciousness 2. Known diabetic who has not taken insulin for days 3. Unable to swallow

MEDICATION FORM

Gel, in tooth paste-type lubes

DOSAGE

One lube

ADMINISTRATION

1. Ensure signs and symptoms of altered mental status with a known history of diabetes, 2. Ensure patient is conscious. 3. Administer glucose. a. Place on tongue depressor between cheek and gum, or b. Have patient self-administer between cheek and gum. 4. Perform reassessment.

ACTIONS

Increases blood sugar

SIDE EFFECTS

None when given properly. May be aspirated by the patient without a gag reflex,

REASSESSMENT STRATEGIES

If patient loses consciousness or seizes, remove tongue depressor from mouth.

There appear to be clear-cut differences between the signs and symptoms of hyperglycemia and hypoglycemia, but distinguishing between them in the field can he difficult and is not necessary. If your system allows the use of blood glucose monitoring, it may provide the patient’s actual blood glucose level. This can be used to identify someone with hypo- or hyperglycemia. Remember that this is just one tool in your assessment which, when combined with the patient’s history (e.g. food intake and medications taken) and your protocols will aid in your decisionmaking process. Always consult medical direction if questions or concerns arise. Giving glucose will help the hypoglycemic patient by getting needed sugar into his blood-stream and to the brain. Although the hyperglycemic patient already has too much sugar in his blood, the extra dose of glucose will not have time to cause damage in the short time, before he reaches the hospital and can be diagnosed and treated. This is why “sugar (glucose) for everyone” is the rule or thumb for diabetic emergencies, whether the patient is hypo- or hyperglycemic, and why you do not need to distinguish between the two conditions. May mga pasyente na hyperglyxemic at hypoglycemic na ang hitsura ay parang lasing lang sa alak. Laging isipin na posibleng diabetes ang dahilan ng hindi normal na pag-uugali nito. Tandaan na ang pasyente na lasing sa alak ay posibleng diabetic din. Hindi mo mahahalata ito dahil ang amoy alak na hininga ng pasyente ay itinatago ang amoy acetone na hininga na dulot ng diabetes ketoacidosis. Ang isang diabetic na mahilig maglasing ay kandidato na maospital. ² Limmer (Brady) ³ Pollack, (AAOS) 4 NHTSA

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SEIZURES AND STROKE

OTHER CAUSES OF ALTERED MENTAL STATUS In addition to diabetic emergencies, there are many other causes of altered mental status. Examples include hypoxia; drug and alcohol use; brain injuries, both traumatic and medical; metabolic abnormalities; brain tumors; and infectious diseases such as meningitis. In all cases, use a thorough primary assessment to identity immediate life threats. Gather a careful history then calm the patient and transport him to the hospital. The following sections provide additional information on three other causes of altered mental status: seizure disorders, stroke, and dizziness or syncope.

Causes of Seizures The most common cause of seizures in adults is failure to take prescribed antiseizure medication. The most common cause of seizures in infants and children 6 months to 3 years of age is high fever (febrile seizures). Other, causes include: • Hypoxia. A lack of oxygen frequently causes seizures These seizures often immediately precede respiratory and/or cardiac arrest. • Stroke. Clots and bleeding in the brain are frequent causes of seizure. We will discuss this topic in greater detail later in this chapter. • Traumatic brain injury. Brain injuries can cause seizures. So can scars formed at the site of previous brain trauma. • Toxins. Drug or alcohol use, abuse, or withdrawal can cause seizures. Other poisons can also alter brain function to cause a seizure. • Hypoglycemia. As we discussed earlier in this chapter, hypoglycemia (low blood sugar) is a frequent cause of seizures. • Brain tumor. A brain tumor may occasionally cause seizures. • Congenital brain defects. Seizures due to congenital defects of the brain (defects one is born with) are most often seen in infants and young children. • Infection. Swelling or inflammation of the brain caused by an infection can cause seizures. • Metabolic. Seizures can be caused by irregularities in the patient’s body chemistry (metabolism). • Idiopathic. This means occurring spontaneously, with an unknown cause. This is often the case with seizures that start in childhood. In addition, seizures may also be seen with: • Epilepsy • Measles, mumps, and other childhood diseases • Eclampsia (a severe complication of pregnancy) • Heat stroke (resulting from exposure lo high temperatures)

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Epilepsy is perhaps the best-known of the conditions that result in seizures. Epilepsy is not a disease itself, but rather an umbrella term used when a person has multiple seizures from an unknown cause. Some people are born with epilepsy, whereas others develop epilepsy after a head injury or surgery , Conscientious use of medications allows most epileptics to live normal lives without seizures of any type. However, it is common for an epileptic patient to seize if he fails to take his medications properly or if an illness interferes with the normal medication routine. Remember that, although a patient with seizures may be an epileptic, epilepsy is only one condition that causes seizures.

Inside/Outside A tonic-clonic seizure originates in the brain. For any number of possible reasons, neurons in both sides of the brain begin to fire simultaneously in a very disorganized fashion. Think of it as ventricular fibrillation of the brain. This irregular activity significantly disturbs brain activity and, in turn, disrupts any number of bodily functions. Outside the body, this activity will be seen first as a loss of consciousness. Uncoordinated neurologic function then causes a body-wide contraction of muscles (the tonic phase). During this brief phase, breathing is typically stopped, and you may note that the patient has lost control of his bladder and/ or bowels. You may also find blood in the patient’s mouth and airway if he has bitten his tongue. Cyanosis is also a common finding in this phase. In the next phase, the clonic phase, the patient typically begins to breathe again, and paired muscle groups begin jerking movements. Often this is seen as flexion and extension of the arms and legs. This typically lasts for only a few minutes. As the seizure concludes, the patient begins the postictal phase. At this point, the patient is unconscious and will slowly regain mental status over a variable period of time. The patient may not know he has had a seizure (amnesia of the event) and confusion and repetitive questions are common. Not all seizures you will see are generalized tonic-cIonic seizures. Although infrequent, partial seizures may require your assistance. In these types of, seizures you may see uncontrolled muscle spasm or convulsion in a patient with a fully alert mental status. You may also see a patient who has only a brief loss of consciousness without muscle convulsions These seizures may be very difficult to distinguish from other disorders. Always use a thorough patient assessment to guide your care.

PATIENT ASSESSMENT Seizure Disorders

It is very important to be able to describe the seizure to emergency department personnel. If you have not observed the seizure (usually EMS is called after the seizure has taken place), always try to find out what the patient was like by asking the following questions of bystanders. Be sure to record and report your findings. • What was the person doing before the seizure started? Was there an aura? • Exactly what did the person do during the seizure—movement by movement—especially at the beginning’’ Was there loss of bladder or bowel control? findings. • How long did the seizure last? • What did the person do after the seizure? Was he asleep (and for how long)’ Was he awake? Was he able to answer questions’ (If you are present during the seizure, use the AVPU scale to assess mental status).

PATIENT CARE Seizure Disorders

Emergency care of a patient with a seizure disorder includes the following: If you are present when a convulsive seizure occurs... • Place the patient on the floor or ground. If there is no possibility of spine injury, position the patient on his side for drainage from the mouth. • Loosen restrictive clothing. • Remove object that may harm the patient. • Protect the patient from injury, but do not try to hold the patient still during convulsions. After Convulsions Have Ended: • Protect the airway. A patient who has just had a generalized seizure will sometimes drool and will usually be very drowsy for a little while, so you may need to suction the airway. If there is no possibility of spine injury. position the patient on his side for drainage from the mouth. • lf the patient is cyanotic (blue), ensure an open airway and provide artificial ventilations with supplemental oxygen. Patients who are breathing adequately may be given oxygen by nasal cannula or nonrebreather based on pulse oximetry readings. Hypoxia is common after long periods of seizure activity. • Treat any injuries the patient may have sustained during the convulsions, or rule out trauma. Head injury can cause seizures, or the patient may have injured himself during the seizure. Immobilize the neck and spine if trauma is suspected. • Transport to a medical facility, monitoring vital signs and respirations closely.

Normal lang na makakita ng isang pasyente na nag-seizure. Subalit kung sabay-sabay na mag-seizure ang maraming tao sa iisang lugar, hindi na ito normal. Isa itong malinaw na red flag na magsasabi sa iyo na may malaking problema. Puwede itong magmula sa isang kemikal na nasa hangin o tubig na posibleng aksidenteng nalanghap o nainom ng mga pasyente, o di kaya ay sadyang ginawa ng mga terorista.

NOTE: Never place anything in the mouth of a seizing patient. Many objects can be broken and obstruct the patient’s airway.

PEDIATRIC NOTE Remember that seizures caused by high fevers and idiopathic seizures (with no known cause) are common in children. Seizures in children who frequently have them are rarely life threatening. However, as an EMT. you should treat any seizure in an infant or child as if it is life threatening. The epileptic is often knowledgeable about his condition, medications, and history. Since seizures may be common for the patient, he may refuse transportation. The patient should be encouraged to accept transportation to a hospital for examination. Should the patient continue to refuse, he should not be left alone after the seizure and he must not drive. A competent person must remain with the patient. Seizures usually last no more than 1 to 10 minutes. When the patient has two or more convulsive seizures lasting 5 to 10 minutes or more without regaining full consciousness, it a known as status epilepticus. Some systems consider all patients who are still seizing when EMS arrives on the scene to be in status epilepticus. This is a high-priority emergency requiring immediate transport to the hospital and possible ALS intercept (having an advanced life support team meet your ambulance en route). The paramedic/nurse must open and suction the airway and administer a high concentration of oxygen at the scene and while en route. LIFELINE

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Types of Seizures

Stroke

It is beyond the EMTs scope of practice to identify the type of seizure the patient is having. The EMT’s job is to treat immediate life threats, gather a history, and provide other normal assessment and care as previously described. However, some additional background information about types of seizures can preside perspective.

Partial Seizures. In a simple partial seizure (also called focal motor. focal sensory, or Jacksonian) there is tingling, stiffening, or jerking in just one part of the body. There may also be an aura, which is a sensation such as a smell, bright lights, a burst of colon, or a rising sensation in the stomach. There is no loss of consciousness. However, in some cases the jerking may spread and develop into a tonic-clonic seizure. A complex partial seizure (also called psychomotor or temporal lobe) is often preceded by an aura. This type of seizure is characterized by abnormal behavior that varies widely from person to person, it may involve confusion, a glassy stare, aimless moving about, lip smacking or chewing, or fidgeting with clothing. The person may appear to be drunk or on drugs. He is not violent but may struggle or fight if restrained. Very rarely, such extreme behavior as screaming, running, disrobing, or showing great fear may occur. There is no loss of consciousness, but there may be confusion and no memory of the episode afterward. In some cases, the seizure may develop into a tonic-clonic seizure. Generalized Seizures. When we think of generalized seizures, we think of the tonic-clonic seizure. However, there are other types of generalized seizures we should know about. An absence seizure (also called petitmal) is brief, usually only 1 to 10 seconds. There is no dramatic motor activity and the person usually does not slump or fall. Instead, there is a temporary loss of concentration or awareness. An absence seizure may go unnoticed by everyone except the person and knowledgeable members of his family. A child may suffer several hundred absence seizures a day, severely interfering with his ability to pay attention and do well in school. Absence seizures often stop before adulthood hut sometimes worsen and become tonic-clonic seizures. Patient care for the generalized tonic-clonic seizure was described earlier. For a simple or complex partial seizure, do not restrain the person; simply remove objects from his path and gently guide him away from danger. For an absence seizure, if you are aware that it has occurred, simply provide the patient with any information he may have missed. 376

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SEIZURES AND STROKE

One of the many causes of altered mental status may be a stroke. Formerly called a cerebral vascular accident (CVA). The term stroke refers to the death or injury of brain tissue that is deprived of oxygen. This can be caused by blockage of an artery that supplies blood to part of the brain or bleeding from a ruptured blood vessel in the brain. A stroke caused by a blockage, called an ischemic stroke, can occur when a clot or embolism occludes an artery. This mechanism is responsible for most strokes. A stroke caused by bleeding into the brain, called a hemorrhagic Stroke. frequently is the result of longstanding high blood pressure (hypertension). It also can occur when a weak area of an artery (an aneurysm) bulges out and eventually ruptures, forcing the brain into a smaller than usual space within the skull. Different patients experiencing a stroke may have very different signs and symptoms, depending on the size and location of the arteries involved. One of the most common signs is one-sided weakness (hemiparesis). Because the left side of the brain controls movement on the right side of the body (and vice versa), someone with right-sided weakness from a stroke actually has a problem on the left side of his brain. However. The nerves that control the face muscles do not necessarily cross over in the same way. so sagging or drooping on one side of the face is not a reliable sign of injury to the opposite side. A less common, but very important, sign of stroke is a headache; caused by bleeding from a ruptured vessel If you find in gathering a history that the patient cried out in pain, clutched his head, and collapsed, this is very important information to relay to the hospital staff. This patient may have had a particular kind of bleeding from an artery under the arachnoid layer of the meninges (the meninges are several layers of tissue that surround the brain and spinal cord). This is called a subarachnoid hemorrhage. Fortunately, most stroke patients are not hemorrhaging and do not experience headaches. In many cases, you will find it difficult to communicate with the stroke patient. The damage to the brain sometimes causes a partial or complete loss of the ability to use words, The patient may be able to understand you but will not be able to talk or will have great difficulty with speech. Sometimes, the patient will understand you and know what he wants to say. but he will say the wrong words. This difficulty in using words is known as expressive aphasia. Aphasia is a general term that refers to difficulty in communication. Another form of it is receptive aphasia. In this case, the patient can speak clearly, but cannot understand what you are saying, so he will clearly say things that do not make much sense or are inappropriate for the situation.

Transient Ischemic Attack

UNIT 3 A common occurrence is for an EMT to respond to a patient described as being confused, weak on one DAY 15 side, and having difficulty speaking. The EMT arrives, only to find an elderly patient who is alert, oriented, and perfectly normal without any evident weakness or speech difficulties. This patient may have had a transient ischemic attack (TIA), sometimes called a mini-stroke by laypeople When this condition occurs, a patient looks as though he is having a stroke because he has the typical signs and symptoms of the condition. However, unlike stroke, a patient with a TIA has complete resolution of his symptoms without treatment within 24 hours (usually much sooner).

With TIA. small clots may be temporarily Making PRINCIPLES OF EMT CLINICAL PRACTICE circulation to part of the brain. When the clot breaks up. the patient’s symptoms resolve because the affected brain tissue had only a short period of hypoxia and did not sustain permanent damage. However, this patient Cincinnati Prehospital Stroke Scale is at significant risk of having a full-blown stroke. If the patient refuse Transport, you have a responsibility to 1. attempt to persuade the patient to be evaluated as soon as Assess for facial droop. The face of a stroke patient often is an abnormal drooped appearance on one side. possible so that a subsequent stroke can be prevented. 2. Assess for speech difficulties. A stroke patient will often have slurred speech, use Always remember that if symptoms are present, it is the wrong words, or be unable to speak at all. 3. impossible to distinguish between a stroke and a TIA in Assess for arm drift by asking the patient to close her eyes and extend her arms for 10 seconds. (A) A patient who has not suffered a stroke can usually the field. Always assume the worst and treat as if it is a hold her arms in an extended position with eyes closed. (B) A stroke patient stroke. will often display arm drift. That is, one arm will remain extended but the arm on the affected side will drift downward.

PATIENT ASSESSMENT Stroke A very good way to assess conscious patients (or stroke is to evaluate three items:

Facial Droop

1. Normal: Both sides of face move equally. 2. Abnormal: One side of face does not move at all.

Arm Drift

1. Normal: Both arms move equally or not at all. 2. Abnormal: One arm drills compared to the other.

Speech

1. Normal: Patient uses correct words with no slurring. 2. Abnormal: Slurred or inappropriate words or mute. “

• Ask the patient to grimace or smile. Demonstrate to the patient what you want him to do. making sure that you show your teeth. This allows you to test control of the facial muscles. A normal response is for the patient to move both sides of his face equally and to show you his teeth an abnormal response is unequal movement or no movement at all. • Ask the patient to close his eyes and extend his arms straight out in front of him for 10 seconds. A normal response is for the patient to move both arms at the same time. An abnormal response is for one arm to drift down or not move at all • Ask the patient to say something like, “The sky is blue in Manila.” An uninjured person’s speech is usually clear. A stroke patient is more likely to show an abnormal response to the test, like slurred speech, the wrong words, or no speech at all.

Cincinnati Prehospital Stroke Scale

Other signs and symptoms of stroke, which will often fluctuate in severity while you observe the patient, include:  Confusion  Dizziness  Assess for facial droop. The face of a stroke patient often Numbness, weakness, or paralysis (usually on one side of the body) 1.  is an abnormal drooped appearance on one side. Loss of bowel or bladder control  Assess for speech difficulties. A stroke patient will often Initialled vision 2.  have slurred speech, use the wrong words, or be unable to High blood pressure  speak at all. Difficult respiration 01 snoring 3.  Assess for arm drift by asking the patient to close her Nausea or vomiting  eyes and extend her arms for 10 seconds. Seizures A patient who has not suffered a stroke can usually  a. Unequal pupils hold her arms in an extended position with eyes  Headache closed.  Loss of vision in one eye  b. A stroke patient will often display arm drift. That Unconsciousness (uncommon) NOTE:

is, one arm will remain extended but the arm on the affected side will drift downward.

A patient who demonstrates any one of the three findings of the Cincinnati Prehospital Stroke Scale has(Brady) a 70 percent chance of having an acute stroke. ² Limmer ³ Pollack, (AAOS) LIFELINE PREHOSPITAL EMERGENCY CARE 377 4 NHTSA ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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DIABETIC EMERGENCIES

Other signs and symptoms of stroke, which will often fluctuate in severity while you observe the patient, include: • Confusion • Dizziness • Numbness, weakness, or paralysis (usually on one side of the body) • Loss of bowel or bladder control • Initialled vision • High blood pressure • Difficult respiration 01 snoring • Nausea or vomiting • Seizures • Unequal pupils • Headache • Loss of vision in one eye • Unconsciousness (uncommon)

PATIENT CARE Stroke

It is not necessary to determine that a stroke has taken place, although you may suspect it. There are many problems that can mimic strokes, including tumor or infection in the brain, head injury, seizures, hypoglycemia, and bacterial or viral infections that cause weakness or paralysis of facial nerves. Treat the patient as you would any patient with similar symptoms. • For a conscious patient who can maintain his airway, calm and reassure him: monitor the airway, and administer high-concentration oxygen. Transport the patient in a semi-sitting position. • For an unconscious patient, or a patient who cannot maintain his airway, maintain an open airway, provide high-concentration oxygen; and transport with the patient lying on the affected side. • Transport to a hospital with the capabilities to manage a stroke patient (CT scan at a minimum) Your destination choice may be guided by a local stroke care protocol, so follow local guidelines. Because of recent research and advances in the treatment of stroke, you may have special protocols for management and transport of patients with signs and symptoms of stroke. New treatments are being used and tried in many hospitals, but time is of the essence if any of these treatments is to be effective There appears to be a very narrow window within which assessment must be completed and treatment must be started.

NOTE:

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Masusuri mo ang isang pasyente kung ito ay nagkaroon ng stroke sa pamamagitan ng pagtingin sa mukha nito, pakikinig sa pagsasalita nito, at pag-angat ng braso nito. Ang isang taong nastroke ay hindi pantay ang mukha, at hirap magsalita. Hirap din itong itaas ang isang braso.

The most widespread advance in stroke care is the use of clot-busting (thrombolytic) drugs in cases of ischemic stroke. This therapy can potentially reverse the symptoms of stroke, but patients must meet very specific criteria: • Definite onset of stroke symptoms less than 3 hours prior to the administration of the thrombolytic drug. • An emergency CT scan of the brain confirming that there is no evidence of a hemorrhagic stroke. • Blood pressure that is not excessively hypertensive at the time the drug is administered. One of the most important things the EMT can do to optimize the care of stroke patients who are potential candidates for thrombolytics is to determine and document the exact time of onset of symptoms. If the person who provides you with the patient’s time of onset is someone other than the patient, it is a good idea to document who that person is and how he can be contacted (eg, cell phone number) if the physician in the emergency department should have to verify any information. In cases where the exact time of onset is not known, the patient will not be able to receive thrombolytics. For example, the patient who awakens at 7am and is immediately noted by the family to have new stroke symptoms but who was last seen in a normal condition at 11:30p.m. the night before cannot get thrombolytic therapy, because it is not known when the stroke occurred during the night

If you suspect the patient has had a stroke, it is important to transport him promptly and notify the hospital of symptoms you see and the results of the Cincinnati Prehospital Stroke Scale. If you have a choice of hospitals, your protocols may direct you to a hospital capable of providing the most recent stroke treatments.

PREHOSPITAL EMERGENCY CARE

Dizziness and Syncope Dizziness and syncope (another term for fainting) are common reasons EMS is called. Although this is especially true for the elderly population, these problems can occur to patients of any age. Although these complaints might stem to be harmless, in fact they can be indicators of serious or even life-threatening problems. In many cases you will not be able to diagnose the true cause of the syncope. However, you should use your assessment to rapidly identify and treat life threats and to gather important information that will assist in the overall treatment of the patient. Dizziness and syncope are separate problems that are sometimes related. It is not uncommon for someone to complain of dizziness before fainting. Because these two conditions are often caused by the same problems, we will consider them together in this chapter.

Dizziness is a common term that means different things to different people. It is important in your assessment to find out what the patient means by “dizziness.” Does he mean weakness, as in a sensation of loss of strength? Does he feel vertigo? Vertigo is the sensation of your

surroundings spinning around you. Is it light-headedness, the sensation that he is about to pass out (sometimes called presyncope or near syncope)? Is it something else?

Syncope is a brief loss of consciousness with spontaneous recovery. Typically, it is very short, from a few seconds to at most a few minutes. The patient usually regains consciousness very soon after being allowed to lie flat. Patient will often have some warning that a syncopal episode or fainting spell a about to occur. This may include such symptoms as lightheadedness, dizziness, nausea, weakness, vision changes, sudden pallor (loss of normal skin color), or sweating. Occasionally incontinence of bladder or bowel occurs as part of the episode, but this is more common with seizures. Patients may be able to describe specific signs or symptoms that indicate certain causes of the episode are more likely than others. This may include fluttering in the chest (palpitations) a sensation of a racing heart (tachycardia), a slow heart rate (bradycardia), or headache.

Causes of Dizziness and Syncope The factors that cause dizziness and syncope are generally related to the brain. Problems like hypoxia, hypoglycemia, and hypovolemia all interfere with normal brain function. These events may happen rapidly, like blood flow to the brain being reduced by a cardiac dysrhythmia; or they may happen slowly, like slow gastrointestinal bleeding that finally reaches the point where the patient is unable to stand without losing consciousness.

There are many causes of dizziness and syncope. The more common ones can be grouped into four categories: • Hypovolemic, • Metabolic, • Environmental/toxicological, and • Cardiovascular

Hypovolemic Causes.

Hypovolemia, or low fluid/blood volume, can cause dizziness or syncope when the patient attempts to sit up or stand. In this case, there is enough blood to perfuse the brain when the patient is lying down. However, when the patient tries to get up. the body is unable to quickly divert enough blood from the legs to the brain. There are several common causes of hypovolemia, including dehydration, internal bleeding, and trauma. The most serious cause of hypovolemia is bleeding. In a patient with dizziness or syncope, the source of the bleeding may not be obvious. A woman of childbearing age can have a ruptured ectopic pregnancy that results in significant blood loss. This is usually accompanied by lower abdominal pain. A slowly bleeding (“leaking”) abdominal aortic aneurysm can also lead to life-threatening blood loss. Such an aneurysm often causes the patient to experience abdominal pain radiating to the back. Gastrointestinal bleeding, with or without associated abdominal pain, is fairly common, especially among the older population. There are other ways to become hypovolemic besides bleeding. Dehydration results from losing more fluid than the patient takes in. This is very common in hot weather, when the patient sweats a great deal but does not drink enough liquid to keep up with this fluid loss (heat exhaustion). It can also happen when someone becomes ill with diarrhea. Because eating or drinking anything is followed by a painful, watery bowel movement, the patient is reluctant to drink any fluids at all and becomes dehydrated. Sometimes, with severe diarrhea, this happens despite the patient’s efforts to drink liquids.

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Metabolic and Structural Causes.

When the cause of dizziness or syncope is metabolic, something is wrong with the brain or the structures near it. Because a properly functioning brain is necessary to maintain consciousness, alterations in the brain chemistry or structure can lead to a diminished level of consciousness. Similarly, because the inner and middle car must be properly functioning for a person to maintain a sense of balance, a problem in this region can lead to dizziness. Inflammation of this area is a very common cause of dizziness. A patient who has been diagnosed with such a problem may be taking the drug medicine. Hypoglycemia deprives the brain of glucose, which it needs all the time to function properly. An interruption in this supply can lead to both dizziness and syncope. If the patient remains unconscious more than a few minutes, however, it is not considered syncope, or fainting. There is likely to be a more serious cause of the episode. Occasionally, a stroke will present with either dizziness or syncope. In this case, there may be other neurological signs and symptoms present, like one-sided weakness, drooping of one side of the face, or slurred speech. A seizure can cause a temporary loss of consciousness. Also you learned about managing a patient having a seizure earlier in this chapter.

Environmental/Toxicological Causes Environmental and toxicological imbalances can lead to alterations in consciousness. Alcohol is the most commonly used drug and, when a patient drinks too much, it can lead to an altered level of consciousness. Many people who are intoxicated display a fluctuating level of consciousness that can appear to be syncope. Other drugs that are central nervous system depressants can cause similar effects. Syncope and near-syncope also commonly occur with carbon monoxide poisoning. Panic attacks and anxiety attacks can lead a patient to become so anxious that the patient hyperventilates by breathing faster and deeper. When a patient breathes this hard, it can change the blood chemistry in a way that constricts the blood vessels supplying the brain with oxygen. Fortunately, when the patient loses consciousness, the hyperventilation ceases and things return at least partly to normal. Cardiovascular Cause.

Cardiovascular causes of dizziness and syncope also deserve mention. A dysrhythmia that results in the heart healing extremely fast (tachycardia) can lead to either dizziness or syncope. This is often the result of a problem with the electrical system in the heart. Ordinarily, increases in the heart rate result in increased blood being pumped out of the heart (greater cardiac output). However, w hen the heart beats extremely fast.

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DIABETIC EMERGENCIES The ventricles do not have time to fill before they pump blood out again. So, even though the heart is healing much faster than normal, it is actually pumping out less blood than usual. A very slow heart rate (bradycardia) may also lead to dizziness or syncope through reduced cardiac output, in this case because the heart is not beating fast enough to pump out sufficient blood. This may not be noticeable to the patient when he is lying flat. When the patient tries to sit or stand, though, dizziness and syncope can occur when blood goes to the legs and the brain does not get sufficient blood. A cardiovascular cause of syncope that is not the result of a problem with the heartâ&#x20AC;&#x2122;s electrical system is stimulation of the carotid sinus. This area is located in the carotid artery under the mandible. When stimulated, it sends signals to the heart to slow down. Some people have a very sensitive carotid sinus. All that may be needed to stimulate it in some sensitive individuals is turning the head while wearing a shirt with a tight collar. One of the most common types of syncope is vasovagal syncope or simple fainting. This is thought to be the result of stimulation of the vagus nerve, which in turn signals the heart to slow down. When someone is suddenly frightened or put under significant emotional stress, this nerve can be stimulated, leading to reduced cardiac output, which in the upright individual can quickly result in syncope. When the patient reaches a horizontal position, the brain regains perfusion and the patient regains consciousness.

OTHER CAUSES The causes previously discussed are just a few of the causes of dizziness and syncope. There are many others. In some cases, you will gather information that suggests one of them is the culprit. In many cases, you will not. Determining the cause is extremely difficult. In half of the cases of dizziness or syncope, no cause is ever found despite thorough evaluation by emergency physicians and other specialists

PATIENT ASSESSMENT Dizziness and Syncope Dizziness or syncope is usually easily recognized by the patients complaint of a brief loss of consciousness. The secondary assessment for a patient with dizziness or syncope includes an appropriate history and vital signs. Questions to ask include: • Describe what you mean by “dizziness ‘ Let the patient use his own words • Did you have any warning? If so. what was it like? • When did it start? • How long did it last? • What position were you in when the episode occurred? • Have you had any similar episodes in the past? If so, what cause was found’ • Are you on medication for this kind of problem? • Did you have any other signs or symptoms? Nausea? Vomiting (is there blood or material resembling coffee grounds}? Black tarry stools (digested blood)? • Did you witness any unpleasant sight or experience a strong emotion? • Did you hurt yourself? • Did anyone witness involuntary movements of the extremities (like seizures)?

PATIENT CARE Dizziness and Syncope When a patient has experienced dizziness or syncope, provide the following care after attending to any threats to life: 1. Administer high-concentration oxygen. 2. Call for ALS if the patient has signs of instability and it is available in your area. 3. Loosen any tight clothing around the neck. 4. Lay the patient flat. 5. Treat any associated injuries the patient may have incurred from the fall.

MENTAL STATUS REGULATION 1. Regulated by neurologic circuits in brain that comprise Reticular Activating System (RAS) 2. Reticular Activating System (RAS) is responsible for the functions of: a. Staying Awake b. Paying Attention c. Sleeping 3. RAS keeps person alert and oriented 4. Requirements to Maintain Mental Status a. Oxygen to perfuse brain tissue b. Glucose to nourish brain tissue c. Water to keep brain tissue hydrated 5. Causes of Altered Mental Status a. Deficiencies in Oxygen, Glucose, Water to brain tissue b. Trauma/Head Trauma, Chemical toxins harming brain tissue c. Primary Brain Problem (stroke) d. Problem with another system (hypoxia due to asthma) e. Poisoning f. Infection

Assessing the Patient with Altered mental Status 1. Safety – always the most important concern. a. Patient with altered mental status can be dangerous to responders. b. Always consider safety of yourself and your team before approaching a patient. c. Use law enforcement when necessary. 2. Primary Assessment a. Hypoxia is one of the most common causes of altered mental status. b. Always consider the possibility of an airway and/or breathing problem. c. Identify and treat life-threatening problems. d. Consider oxygen administration. e. Be alert to the need for positioning and suctioning if patient requires it or if mental status worsens. 3. Secondary Assessment a. Thoroughly examine patient exhibiting new, unusual behavior. b. Even slightly altered mental status indicates serious underlying issues. c. Body systems exam and complete history may reveal information about the suspected cause of altered mental status. d. Interview family members and bystanders to obtain patient’s baseline mental status. e. Family may provide information patient is unable to give. f. Patient’s medicine may point to relevant medical history. g. Look for medic alert bracelets of other health-related items at scene. LIFELINE

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PRINCIPLES OF EMT CLINICAL PRACTICE

HEMATOLOGIC AND RENAL EMERGENCIES LEARNING OBJECTIVES • Recognize the clinical manifestations of hematologic disorders and describe current options for diagnosis, management and therapy, including the efficacy, doses, and interactions of individual drugs. • Evaluate and treat hematologic manifestations of systemic disorders • Identify risk factors for and strategies to prevent hematologic disorders. • Recognize the clinical manifestations of renal disorders and hypertension and describe current options for diagnosis, management and therapy, including the efficacy, doses, and interactions of individual drugs.

INTRODUCTION Our good health depends on the human body’s multiple organ systems working seamlessly together. As an EMT, you will focus much of your medical attention on acute emergencies that can be attributed to the cardiovascular and respiratory systems. In this chapter, we will discuss patients who have diseases or problems with their hematologic system (pertaining to blood) or renal system (pertaining to the kidneys). Hematology is the medical specialty concerned with blood disorders. Nephrology is the medical specialty concerned with renal/ kidney diseases. Dozens of medical conditions can arise from diseases involving these two body systems. However, certain patients with certain diseases in this group are most likely to require EMS services as a result of their illnesses.

THE HEMATOLOGIC SYSTEM Our blood—although central to the function of our cardiovascular system— actually represents its own organ system. Each component of the blood has specific functions that, when all are working properly, arc critical to a patient’s health and survival, such as: • Control of bleeding by clotting. • Delivery of oxygen to the cells. • Removal of carbon dioxide from the cells. • Removal and delivery of other waste products to organs that provide filtration and removal such as the kidneys and liver.

Blood is made up of solid components (including red blood cells, white blood cells and platelets) suspended in a liquid called plasma. The solid components of blood are created in the bone marrow that forms the specialized core of many of the body’s bones. Red blood cells, white blood cells, and platelets survive in the circulation for only a finite period of time— and are then removed from the circulation by means such as the filtration by the spleen.

Each component of the blood has specialized functions. • Red blood cells (RBCs). RBCs make up the majority of the cells in the

circulation and give blood its characteristic red color. These cells contain specialized molecules called hemoglobin that bind to oxygen and are responsible for oxygen delivery to the cells. • White blood, cells (WBCs). WBCs are critical blood cells that respond to infection and are mediators of the body’s immune response. • Platelets. Platelets are actually fragments of larger cells that are crucial to the formation of clots. Clumping (called aggregation) of platelets is 382

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the body’s most rapid response to stop bleeding from an injured site. However, in some situations the clumping of platelets is not desirable, such as when plaque in a coronary artery ruptures. In this situation, the rapid clumping of platelets can cause a clot that then completely blocks the coronary artery and results in a heart attack (myocardial infarction). One of the most effective and widely available drugs to prevent the aggregation of platelets is aspirin. That is why patients who are having an acute heart attack, or a potential heart attack, are routinely given an aspirin. • Plasma. Plasma is the liquid in which the blood cells and platelets are suspended. Plasma contains dissolved nutrients and also carries certain crucial proteins such as the clotting factors. These clotting factors form the most stable clots, replacing the initial efforts of the platelets to stop bleeding.

Anemia Lack of a normal number of red blood cells in the circulation is called anemia. There are many reasons why a patient becomes anemic. Acute anemia may be the result of trauma or of sudden massive bleeding from the gastrointestinal tract. Chronic anemia occurs over time and can be caused by conditions such as recurrent heavy menstrual periods, slow gastrointestinal blood loss, or diseases that affect the bone marrow or the structure of the hemoglobin molecule itself. Patients with chronic anemia will often appear more pale than normal (from a lack of circulating red blood cells) and often complain of fatigue and shortness of breath with exertion (because of a lack of adequate oxygen being delivered to the body’s ceils).

Sickle Cell Anemia

Sickle cell anemia (SCA) is an inherited disease in which patients have a genetic defect in their hemoglobin that results in an abnormal structure of the red blood cells. Sickle cell anemia can occur in patients of African. Middle Eastern, or Indian descent but is most common in patients of African descent. A normal red blood cell is donut-shaped with a depression rather than a hole in the center. Normal red blood cells are able to be compressed as they move and squeeze through small capillaries lo deliver oxygen to the cells of the body’s organs. Patients with sickle cell disease have red blood cells composed of defective hemoglobin that causes them to lose their ability to have a normal shape and compressibility. These abnormal RBCs resemble the shape of a sickle when observed under a microscope. Because of their abnormal shapes, these RBCs do not survive in the circulation as long as normal RBCs, This results in chronic anemia.

NOTE:

There are certain medical conditions in which the normal ability to form clots can worsen the patient ‘s disease: for example, in those at risk for heart attacks or strokes, or those with abnormal cardiac rhythms such as atrial fibrillation. For this reason, thousand of patients are on prescription drugs commonly referred to as “blood thinners “Drugs such as Coumadin (warfarin) and Lavenox* (enoxaparin) inhibit certain clotting factors. Other drugs such as aspirin and plavix, inhibit platelet aggregation. Patients on these medications are more prone to have life-threatening bleeding when they are injured than patients who are not on these medications. In some EMS systems, injured patients taking these medications are frequently upgraded to trauma center transport, even with apparently minor injuries, because of their increased risk of uncontrolled bleeding, Follow your local protocols.

The complications of SCA are generally attributed to the sludging of the abnormally shaped red blood cells, which causes blockages within the body’s small blood vessels. The complications of sickle cell anemia include. • Destruction of the spleen. The spleen, as it filters the blood, becomes blocked by the abnormal RBCs. Because the spleen is important in fighting infections, its loss places patients with SCA at higher risk for severe, lifethreatening infections. • Sickle cell pain crisis. Sickle cell crisis is caused by the sludging of sickled RBCs in capillaries, which results in severe pain in the arms, legs, chest, and/or abdomen. • Acute chest syndrome. Chest syndrome is characterized by shortness of breath and chest pain associated with hypoxia (low oxygen saturation) when blood vessels in the lungs become Some patients blocked, may tell you that they • Priapism. Painful prolonged erections have “sickle cell trait” in males occur because sludging RBCs as part of their past prevent normal blood drainage from medical history. These the erect penis patients carry the gene • Stroke. Stroke can occur when sludging or sickle cell disease RBC block blood vessels that supply the but do not have the disease. Therefore, brain these patients do not • Jaundice. The liver becomes suffer the complications overwhelmed by the breakdown in of sickle cell anemia red blood cells, resulting in yellowish and have normal life pigmentation of body tissues. spans. This condition is rare among Filipinos Despite advances in modern medical but common in African care, patients with SCA still have an Americans. abnormally short life span.

NOTE:

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HEMATOLOGIC AND RENAL EMERGENCIES

PATIENT CARE

Sickle Cell Anemia

Emergency treatment of a patient with sickle cell anemia is as follows: 1. Administer high-concentration supplemental oxygen. 2. Monitor patients with acute chest syndrome for signs ol inadequate respiration and provide bag-valve-mask ventilation as necessary. 3. Monitor patients with high fever let signs of hypoperfusion and treat for shock as necessary. 4. Transport patients with acute stroke symptoms to a designated stroke center, it available Follow local protocols.

OUTSIDE

We have just listed some common complications of sickle cell anemia. As you assess your patient, what outside signs and symptoms are associated with which inside complications? The following chart makes the connections.

INSIDE

Infection

The spleen may be so damaged from the sickled red blood cells that it no longer functions. This means that the spleen’s normal role in immune function is lost, predisposing the sickle cell patient to more frequent and severe infections.

Pain in bones, joints, abdomen, soft tissues

A vaso-occlusive crisis is a condition where sickled red blood cells block microcirculation. This causes hypoxia and severe pain in the affected organs. This often occurs in bones and joints but can also involve the abdomen and soft tissues.

Difficulty breathing, chest pain, cough, fever

When vaso-occlusive crisis occurs in the lungs it can result in acute chest syndrome. Patients will complain of difficulty breathing (often severe), chest pain, cough, and sometimes fever.

Prolonged penile erection

Sickled red blood cells are believed to block blood that is trying to exit the corpus spongiosum, causing the prolonged, painful erection of the penis called priapism.

Stroke symptoms

Sickle cell patients (adults and children) are more likely to experience ischemic stroke. The exact mechanism for this isn’t known. While sickled cells may affect the microcirculation of the brain and cause stroke, many strokes involve larger vessels in the arterial circulation.

Yellowed skin, yellowed eye whites

The liver is overwhelmed with the massive breakdown of red blood cells. This lack of normal liver function causes jaundice (a yellowish pigmentation ol the skin, whites of the eyes, and other body tissues and fluids).

THE RENAL SYSTEM

The renal system is made up of two kidneys, two ureters (to carry urine from each kidney to the bladder), and a single urethra (to carry urine from the bladder to the outside of the body). The kidneys are responsible for the filtration of the blood and the removal of certain waste products, excessive salts, and excessive fluid from the body. In addition, in times of dehydration the kidneys also help the body retain needed fluid. Because they perform these critical functions, the kidneys are essential to life. Many diseases involve the renal system. Urinary tract 384

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infections are perhaps the most common disease process that afflicts the renal and urinary system. Similarly, stones that form in the kidneys can cause severe flank pain when the stone becomes lodged in the ureter and is unable to pass into the bladder. This chapter, however, will focus not on the most common or most painful disease of the renal system. Instead, it will discuss the challenges of patients whose kidneys no longer function properly—or at all—and the emergencies that arise as a result of this organ system failure.

Renal Failure The most serious disease of the kidneys is called renal failure. Renal failure occurs when the kidneys loses their ability to adequately filter the blood and remove toxins and excess fluid from the body. There are many reasons why patients develop renal failure. Some causes for renal failure are sudden (acute) and some develop gradually over time (chronic). Acute renal failure can occur as a result of shock, toxic ingestions, and other causes. Some patients who experience acute renal failure can recover normal kidney function if the underlying cause of the insult to the kidneys is rapidly identified and corrected. An example of this would be severe dehydration in a patient trapped in a building collapse for several days who. with aggressive treatment with intravenous fluids, can recover normal renal function over time However, others who suffer acute renal failure never recover normal kidney function. Cause of chronic renal failure can include inherited diseases such as polycystic kidney disease. More commonly, however, the long-term damage is caused by poorly controlled diabetes and/or high blood pressure that results in the loss of normal renal function. Patients who go on to develop irreversible renal failureâ&#x20AC;&#x201D;to the extent that their kidneys can no longer provide adequate filtration and fluid balance to sustain lifeâ&#x20AC;&#x201D;are defined as patients with end-stage renal disease (ESRD). Patients with ESRD usually require dialysis to survive. In 2013, some 120,000 Filipinos suffered from kidney failure and required dialysis or transplant, according to the Department of Health. Dialysis is the process by which an external medical system independent of the kidneys is used to remove toxins and excess fluid from the body. There are two general types of dialysis: hemodialysis and peritoneal dialysis. All of the ESRD patients who require dialysis get hemodialysis in specialized outpatient dialysis centers rather than peritoneal dialysis. Filipinos who are treated in dialysis centers undergo three treatments a week, each lasting 3 or 4 hours, Although some patients get to their dialysis appointments by their own means, many others utilize medical transport to get to and from dialysis. This need for medical transport has created a frequent interface between EMTs and patients with ESRD.

Hemodialysis In hemodialysis (HD), the most common form of dialysis, a patient is connected to a dialysis machine that pumps his blood through specialised filters to remove toxins and excess fluid. A patient is connected to a dialysis machine by two large catheters. One catheter allows blood to flow out of the body into the dialysis machine and the other catheter returns blood to the body after filtration. This creates a circuit by which the blood is removed from the body, filtered, and returned to the body continuously over several hours while the patient is connected to the machine. Because HD requires a large blood flow from the body. ESRD patients on this type of chronic dialysis have specialized means of access to the bodyâ&#x20AC;&#x2122;s blood circulation. Hemodialysis patients will have either a specialized two-port catheter that is inserted in one of the major veins of the torso or have a special surgically created fistula in one of their extremities that connects arterial and venous blood flow. Because a fistula contains turbulent flow between a surgically connected artery and vein (A-V), a properly functioning A-V fistula will have a characteristic vibration, called a thrill, when gently palpated. ESRD patients are very protective of their fistulas and will insist that you use another extremity to obtain a blood pressure. This is appropriate, given the importance and vulnerability of the fistula

Peritoneal Dialysis Patients who manage their ESRD with peritoneal dialysis (PD) usually do so in their own home. PD is a slower process than HD and requires multiple treatments every day for most patients. Despite requiring more frequent treatments, many patients prefer PD over HD because it allows them to be treated at home. Peritoneal dialysis works by utilizing the large surface area inside the peritoneal cavity that surrounds the abdominal organs as a means of removing toxins and excess fluid from the body. ESRD patients on PD have a permanent catheter that is implanted through their abdominal wall and into the peritoneal cavity. Several liters of a specially formulated dialysis solution are run into the abdominal cavity and left in place for several hours, where it absorbs waste material and excess fluid; then the fluid is drained back out into the bag and is discarded. The PD fluid setup looks much like a large IV bag and tubing. Each cycle of filling and draining the peritoneal cavity is called an exchange. There are two types of peritoneal dialysis: continuous ambulatory peritoneal dialysis (CAPD) and continuous cycler-assisted peritoneal dialysis (CCPD). In CAPD. the most common type of PD. the fluid is left in the peritoneal cavity by clamping the catheter for 4 to 6 hours. The patient then repeals the exchange several times a day. This is a simple gravity exchange process where the bag is elevated above the abdominal catheter in order to run dialysis fluid in, and then lowered below the level of the abdomen to drain the fluid out. Continuous cycler-assisted peritoneal dialysis (CCPD) uses the same type of peritoneal catheter as CAPD. However, rather than using a gravity exchange, a machine is used to fill and empty the abdominal cavity with dialysis fluid three to five times during the night while the person sleeps. In the morning, the last fill remains in the abdomen with a dwell time that lasts the entire day

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HEMATOLOGIC AND RENAL EMERGENCIES

Medical Emergencies with End-Stage Renal Disease Medical emergencies encountered in patients with ESRD can be broadly divided into two groups: those that arise from the loss of normal kidney function and those that are complication of their dialysis treatments. In addition, never forget that the vast majority of dialysis patients have other underlying diseases such as diabetes and high blood pressure, so these patients are at risk for medical emergencies related to those diseases as well, independent of their renal failure.

Complications of ESRD The most serious complications of ESRD seen by the EMT occur when patients fail to be dialyzed. Bad weather, illness and poor compliance are all common reasons why patients with ESRD miss their dialysis appointments. Because these patients lack the ability to rid the body of excess fluid, patients who have missed dialysis will often present with signs and symptoms similar to those seen in congestive heart failure. These include shortness of breath, because of fluid build up in the lungs, and the accumulation of fluids elsewhere, such as the ankles, hands, and face. In addition, because patients with ESRD can no longer balance and clear excess electrolytes as well as other toxins, patients who have missed dialysis may suffer from electrical disturbances of the heart (dysrhythmias). This is because the proper functioning of the heart’s electrical system requires that the balance of electrolytes in the bloodstream be kept within a certain tight range. Elevated levels of the electrolyte potassium are particularly dangerous, and can result in patient death from dysrhythmias. May mga pasyente na nagdadialysis na minsan ay hindi makakapunta sa dialysis center. Magiging masama ang pakiramdam nila at ang mga simtomas na makikita ay kahalintulad ng sa taong inaatake sa puso. Hirap sila huminga, may pamamanas sa mga kamay at paa, at hindi maayos ang tibok ng puso.

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PATIENT CARE

ESRD Patient Who Has Missed Dialysis

When encountering an ESRD patient who has missed dialysis and is experiencing problems, follow these steps: 1. Assess the ABCs. 2. W hen you obtain vital signs, obtain a blood pressure on an arm that does not have a fistula. 3. Place the patient in a position of comfort, this is usually sitting upright on the stretcher. 4. Administer oxygen at 15 Ipm by nonrebreather mask. 5. Monitor the patient’s vital signs carefully and be prepared to attach and use the automatic external defibrillator (AED) if the patient becomes unresponsive and pulseless. Be aware that ESRD patients who suffer cardiac arrest may not respond to defibrillation Paramedics/nurses carry certain drugs that can be administered in the held to help stabilize ESRD-induced dysrhythmias Consider ALS backup, but do not delay transport to the hospital. 6. Transport the patient to a hospital with renal dialysis capabilities.

Complications of Dialysis The major complications for patients on hemodialysis have to do with the fact that they must frequently have large blood vessels accessed multiple times each week for their dialysis. Other complications include: • Bleeding from the site of the A-V fistula when the dialysis needles are removed while being disconnected from the machine. • Dolling and loss of function of the A-V fistula. This results in the fistula feeling hard to the touch and in loss of the normal thrill felt on palpation. • Bacterial infection of the blood due to contamination at the A-V fistula or dialysis catheter site during machine connection and disconnection. The most common serious complication of ESRD patients on peritoneal dialysis is acute peritonitis, a bacteria infection within the peritoneal cavity. Patients on PD who develop peritonitis may develop abdominal pain, fever, and the tell-tale sign that their dialysis fluid appears cloudy when it is drained from the peritoneal cavity rather than its normal clear appearance. Infected peritoneal dialysis fluid is much like chicken broth in color and turbidity.

PATIENT CARE

ESRD Patient with Complications of Dialysis When encountering an ESRD patient who is experiencing complications of dialysis, follow these steps: 1. Assess the ABCs. 2. Immediately control any serious bleeding from the site of the A-V fistula Use direct pressure, elevation, and hemostatic dressings as needed. Generally, a tourniquet should be avoided in this situation as it may damage the A-V fistula. Contact medical direction if bleeding remains uncontrolled and you are considering tourniquet use. 3. Administer oxygen at 15 lpm by nonrebreather mask.

4. Be aware that ESRD patients with peritonitis or a bacterial infection in then blood may present in shock with signs of hypoperfusion Treat for shock by keeping the patient supine and warm. 5. If peritonitis is suspected in a patient on peritoneal dialysis, transport the bag of exchanged dialysis fluid with the patient so it may be tested for bacteria at the hospital to confirm the diagnosis.

Finally, never forget that the vast majority of dialysis patients have other underlying diseases such as diabetes and high blood pressure, so they are at increased risk for medical emergencies related to those diseases as well, independent of their renal failure.

Kidney Transplant Patients Kidneys are the most commonly transplanted organs. Patients with endstage renal disease may be candidates for renal transplant which, if successful, can provide the patient with a normally functioning kidney and end his need for dialysis. There are approximately 16,000 kidney transplants performed by specialized surgeons in the United Stales each year. Thanks to the kindness of organ donors, a renal transplant places a single healthy kidney in the lower abdomen of the

patient with ESRD. The surgeon then connects a blood supply and a ureter to the transplanted kidney, allowing the patient the opportunity to regain normal renal function. Patients with kidney transplants spend the rest of their lives on a special class of drugs that prevent organ rejection by suppressing the bodyâ&#x20AC;&#x2122;s immune system. However, these same drugs that help protect the transplanted kidney also make these patients more susceptible to serious infections.

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ABDOMINAL emergencies are one of the most common cases that you would encounter, and these usually come with abdominal pain in association with other signs and symptoms. Though common, however, abdominal emergencies are hard to diagnose. In fact, even hospitals with a wide range of diagnostic facilities would find it difficult to rapidly assess the cause of an abdominal emergency. As a future EMT, you should concentrate on assessing the severity of the patientâ&#x20AC;&#x2122;s condition and managing it appropriately, particularly, identifying time-critical patients and commencing treatment immediately. While the exact causes of abdominal pain can almost be endless, your role as EMT is to recognize and manage the more serious conditions appropriately. You must be able to know if there is internal bleeding, or if there is an abdominal aortic aneurysm which can be life threatening. You would also encounter cases of patients suffering from one or more kidney stones or gallstones, and female patients with ectopic pregnancy. Better be ready because these patients will usually be in extreme distress. This chapter will help you prepare to deal with such emergencies. It will also provide you the basic knowledge in dealing with cases of poisoning and drug overdose which you would definitely encounter from time to time.

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DAY

Abdominal Emergencies Organs located in the abdomen Abdominal pain or discomfort Gastrointestinal bleeding Abdominal aortic aneurysm Poisoning and overdose emergencies

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Day 16

PRINCIPLES OF EMT CLINICAL PRACTICE

ABDOMINAL EMERGENCIES LEARNING OBJECTIVES • Discuss the pathophysiology of nontraumatic abdominal emergencies. • Discuss the signs and symptoms of non-traumatic acute abdominal pain. • Describe the technique for performing a comprehensive physical examination on a patient with nontraumatic abdominal pain. • Describe the management of the patient with non-traumatic abdominal pain.

INTRODUCTION Abdominal emergencies are challenging for EMTs because the cause of the patient’s pain is not visible. Further complicating these challenges, many organs within the abdomen will cause pain if affected. This can cause confusion in determining the priority and stability of the patient with abdominal pain. Fortunately, these challenges can be overcome. The patient assessment process will help you determine the patient’s priority. Although there are various potential causes for abdominal pain, the treatment for most conditions is the same and will not require a specific diagnosis. This chapter will detail information about assessing and treating abdominal emergencies. “

ABDOMINAL ANATOMY AND PHYSIOLOGY The abdomen—the area below the diaphragm and above the pelvis—contains a variety of organs that perform digestive, reproductive, endocrine, and regulatory functions. Although we may think the abdomen only handles the digestion of food, in reality organs and structures within the abdomen do much more, including secreting insulin to regulate blood sugar (the islets of Langerhans of the pancreas), filtering blood and assisting with immune response (the spleen). and removing toxins from the body (the liver). The abdomen can be divided into quadrants. Imaginary lines drawn both vertically and horizontally through the umbilicus (the navel) create the four quadrants; right upper quadrant (RUQ). left upper quadrant (LUQ). right lower quadrant (RLQ) and left lower quadrant (LLQ). These quadrants are used to identify and describe areas of pain, tenderness, discomfort, injury, or other abnormalities.

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Most of the organs of the abdomen are enclosed within the peritoneum. These organs include the stomach, liver, spleen, appendix, small and large colon, and in women the uterus, fallopian tubes, and ovaries. There are two layers of the peritoneum: the visceral peritoneum, which covers the organs, and the parietal peritoneum, which is attached to the abdominal wall. A slight space between the two layers contains a lubricant fluid. The area outside the peritoneum is called extraperitoneal space, which includes the retroperitoneal space, the area between the abdomen and the back. The organs in the retroperitoneal area, which is technically not part of the abdomen, include the kidneys, the pancreas, and the aorta. This information will be important when types of pain are discussed later in the chapter. The bladder and most of the rectum is inferior to the peritoneum.

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

DAY 16

PRINCIPLES OF EMT CLINICAL PRACTICE The female reproductive organs and structures also lie within the abdomen and pelvis. These include the ovaries, fallopian lubes, and uterus, which may be sources of abdominal pain.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Ang pananakit ng tiyan ay isang komplikadong sitwasyon para sa mga EMT. Komplikado ito dahil maraming puwedeng pagmulan ang pananakit. Maraming internal organs sa katawan ng tao ang nasa tiyan. Nandyan ang sikmura, bituka. pantog (gall bladder), bato (kidney), at iba pa. At sa mga kababaihan, nakapuwesto rin diyan ang mga reproductive organs gaya ng matris (uterus) at obaryo (ovaries). Anuman sa mga internal organs na ito ang magkadiprensya ay magdudulot ng pananakit sa tiyan o puson ng pasyente.

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Structures and Functions of the Organs Located in the Abdomen ORGAN

392

STRUCTURE

FUNCTIONS

Esophagus

Hollow digestive

This structure carries food from the mouth and pharynx to the stomach.

Stomach

Hollow digestive

This expandable organ, located below the diaphragm and connected to the esophagus and small intestine, begins the break-down of foods.

Small intestine

Hollow digestive

The small intestine, consisting of the duodenum, jejunum, and ileum, takes stomach contents and removes nutrients as it passes its contents to the large intestine.

Large Intestine (colon)

Hollow digestive

The large intestine absorbs fluid from its contents, creating fecal waste for excretion through the rectum and anus.

Appendix

Hollow lymphatic

This dead-ended sac of bowel rich in lymphatic tissue has no function in digestion. It may become infected (appendicitis), causing pain and requiring surgery.

Liver

Solid digestive

This organ is involved in regulating levels of carbohydrate and other substances. It is invoked in bile secretion for digestion of fats, and has many other functions including detoxification of the blood.

Gallbladder

Hollow digestive

This organ stores bile before its release into the intestine.

Spleen

Solid lymphatic

This organ removes abnormal blood cells and is involved in the immune response.

Pancreas

Solid digestive

This organ releases enzymes that assist in breaking down food in the small intestine into absorbable molecules. It also secretes hormones into the blood that regulate blood sugar levels

Kidneys

Solid urinary

These organs filter and excrete waste. They also regulate water, blood, and electrolyte levels and assist the liver with detoxification.

Bladder

Hollow urinary

This organ collects urine from the kidneys prior to excretion (urination).

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â&#x20AC;&#x153;

ABDOMINAL PAIN OR DISCOMFORT The potential exists for huh medical and traumatic emergencies to the abdomen. This chapter covers the Understanding the nature of most common acute (sudden or emergent) medical abdominal emergencies abdominal pain or discomfort

ABDOMINAL PAIN OR DISCOMFORT

The potential exists for both medical and traumatic emergencies to the abdomen. As noted earlier in this chapter, there are This chapter covers the understanding the nature of most common acute (sudden or emergent) medical abdominal emergencies, abdominal pain or discomfort As many organs within the peritoneal and noted earlier in this chapter, there are many organs within the peritoneal and retroperitoneal cavities. These organs can retroperitoneal cavities. These organs can be sources of a wide range of problems or be sources of a wide range of problems complaints in patients of all ages. Some classic patterns and types of pain involving or complaints in patients of all ages. Some the abdomen include the following:

classic patterns and types of pain involv-

• Visceral pain originates from the organs (the viscera) as worsening when he moves and getting better when he ing the abdomen include the following: within the abdomen. The organs themselves do not remains still or lies with the knees drawn up. have a large number of nerve endings to detect pain. • Tearing pain is not the most common type of abdominal  VisceralUNIT pain originates from the organs (the viscera) within the abdo3 Therefore, visceral pain is often described as dull. achy, pain. Most abdominal structures or organs do not have OF EMT CLINICAL PRACTICE men. The themselves do not have a large number of nerve DAYorgans 16 PRINCIPLES or intermittent and may be diffuse, or difficult to locate. the ability to detect tearing sensations. The exception (The patient may say he has abdominal pain hut cannot is the aorta. In cases of an expanding abdominal aortic endings to detect pain. Therefore, visceral pain is often described as point to a specific location.) Pain that may be described aneurysm (AAA), the inner layer of the aorta is damdull. achy, or intermittent and may be diffuse, or difficult to locate. as intermittent, crampy, or colicky often comes from aged and blood leaks from the inner portions of the ABDOMINAL CONDITIONS (The patient may say he has abdominal pain hut cannot point to a hollow organs of the abdomen. Pain that is dull and vessel to the outer layers. This causes a tearing of the specific location.) Many Pain types that of may be described intermittent, abdominal conditionsas lead to abdominal crampy, complaints. Remember persistent often originates from solid organs. vessel lining and pockets of blood resting in a weak area that, asfrom an EMT, it is more important to abdomen. provide proper assessment or colicky often comes hollow organs of the Pain that and man• Parietal pain, as the name implies, arises from the of the vessel. Much like a balloon, the area of collected agement (including transport i than it is to field diagnose specific conditions. is dull and persistent often originates from solid organs. Although many conditions have "classic" signs and symptoms, there arc many parietal peritoneum, the lining of the abdominal cavity— blood creates an expanding pouch in the blood vessel patients who do not display them. Sonic patients may be pain-free with a ragthus, it is often referred to as peritoneal tenderness. wall, This is often sensed as a “tearing” pain in the  Parietal pain, a* the implies, arises from the parietal peritoneum, ingname infection inside the abdomen, whereas others may be in agony from a Because of its more widespread and efficient nerve minorback. (Remember that parts of the aorta are in the irritant.cavity—thus, it is often referred to as perithe lining of the abdominal endings, pain originating from the parietal peritoneum retroperitoneal space, This is why the pain is felt in (he toneal tenderness. Because of its more widespread and efficient nerve can be more easily located and described than pain from Appendicitis back.) endings, pain originating from the parietal peritoneum can be more the visceral organs. Parietal pain is the direct result of • Referred pain is pain felt in a place other than where Appendicitis, an infection of the appendix, is the most common cause of a pereasily located andson described than pain from thepeople visceral Parielocal irritation of the peritoneum. Such irritation may be the pain originates. For example, when a gallbladder needing surgery. About I in 15 will organs. develop appendicitis at some timeresult in theirof lives. Signs and symptoms include nausea andSuch sometimes vomittal pain is the direct local irritation of the peritoneum. caused by internal bleeding (as from blood leaking into is diseased, pain is often felt not in the area of the ing, pain in the area of the umbilicus (initially), followed by persistent pain in the peritoneum from an injured spleen) or infection/ gallbladder but instead, in the area of the right shoulder irritation may be caused by internal (as from blood leaking the right lower quadrantbleeding (RLQ). If (he appendix ruptures, the patient will typiinflammation (such as pain in the RLQ from an infected blade. This is because nerve pathways from the callyfrom experience a sudden severe or increase in pain. This is a result of the bowel into the peritoneum an injured spleen) infection/inflammation contents being let loose into the peritonea! cavity, leading to gallbladder return to the spinal cord by way of shared appendix). Parietal pain may be sharp or constant and (such as pain in the RLQ from an infected appendix). Parietal pain may peritonitis. pathways with nerves that sense pain in the shoulder localized to a particular area When obtaining the history, be sharp or constant and localized to a particular area When obtainyou may find the patient will describe this type of pain area.

ing the history, you may find [he patient will describe this type of pain as worsening when he moves and getting better when he remains still or lies with the knees drawn up.  Tearing pain is not the most common type of abdominal pain. Most abdominal structures or organs do not have the ability to detect tearMany types of abdominal conditions lead to abdominal ing sensations. The exception is the aorta. In cases of an expanding complaints. Remember that, as an EMT, it is more important to provide proper assessment and management (including transport) abdominal aortic aneurysm (AAA), the inner layer of the aorta is damthan it is to field diagnose specific conditions. Although many aged and blood leaks from the inner portions of the vessel to the conditions have “classic” signs and symptoms, there are many outer layers. This causes a tearing of the vessel lining and pockets of patients who do not display them. Some patients may be painfree blood resting in a weak area of the vessel. Much like a balloon, the “ with developing infection inside the abdomen, whereas others may area of collected blood creates an expanding pouch in the blood vesbe in agony from a minor irritant. sel wall, This is often sensed as a "tearing" pain in the back. (Remember that parts of the aorta are in the retroperitoneal space, This is why the pain is felt in (he back.)  Referred pain is pain felt in a place other than where the pain origiAppendicitis, an infection of the appendix, is the most common nates. For example, when a gallbladder is diseased, pain is often felt cause of a person needing surgery. About 1 in 15 people will develop appendicitis at some time in their lives. Signs and not in the area of Peritonitis the gallbladder but instead, in the area of the right symptoms include nausea and sometimes vomiting, pain in the area of the umbilicus (initially), followed by persistent pain shoulder blade. This is because nerve pathways from the gallbladder in the right lower quadrant (RLQ). If the appendix ruptures, the patient will typically experience a sudden severe increase in The peritoneum, the lining of the abdomen, is veiy sensitive lo foreign subpain. This is a result of the bowel contents being let loose into the peritonea! cavity, leading to peritonitis. return to the spinal cordThis by isway of shared pathways nerves that stances especially true with irritating with substances such as gastric juices Kin el contents and blood. The result of such an insult is peritonitis. Peritonitis sense pain in the shoulder area. may be the result of a medical condition (such as the inflammation of a rup-

ABDOMINAL CONDITIONS

Appendicitis

tured appendix) or the result of trauma (such as bleeding from a ruptured 393This is not LIFELINE extremely PREHOSPITAL EMERGENCY CARErigid. spleen). The abdomen typically becomes painful and a voluntary response like guarding (discussed later in the chapter). Rather, the rigidity of peritonitis is an involuntary response of the muscles over the peritoneum. Peritonitis represents a potentially life-threatening emergency. The patient needs prompt evaluation by a physician to determine the appropriate treatment, which is often surgery.

Day 16

UNIT 3 DAY 16

ABDOMINAL EMERGENCIES

PRINCIPLES OF EMT CLINICAL PRACTICE Peritonitis Gastrointestinal (Gl) Bleeding Cholecystitis/Gallstones

The peritoneum, the lining of the and rigid. This is not a voluntary abdomen, is very sensitive lo foreign response like guarding. Rather, the substances This is especially true with rigidity of peritonitis is an involuntary UNIT 3 irritating substances such as gastric response of the muscles over the is an inflammation of the gallbladder, often caused by gallstones. DAYCholecystitis 16 juices with contents and blood. peritoneum. Peritonitis represents a The patient with this condition will experience severe and sometimes sudden Bleeding can occur from within the Gl system anywhere from the esophagus Peritonitis may be the result right upper quadrant (RUQ)potentially life-threatening emergency. and/or epigastric (upper central abdomen just to the rectum. Depending on the size of below Cholecystitis/Gallstones the xiphoid process) pain, which may radiate lo the shoulder. The pain of a medical condition (such as the The patient needs prompt evaluation may be caused or worsened by ingestion of foods high in fat. the source blood vessel. Bleeding may be inflammation of a ruptured appendix) by a physician to determine the gradual or sudden and massive. Because this or the result of trauma (such as bleeding appropriate treatment, which is often Cholecystitis is an inflammation of the gallbladder, often caused by gallstones. type of bleeding occurs inside the lumen The patient with this condition from a ruptured spleen). The abdomen surgery. will experience severe and sometimes sudden right upper quadrant (RUQ) and/or epigastric (upper central abdomen of the esophagus stomach or intestines, just typically becomes extremely painful below the xiphoid process) pain, which may radiate lo the shoulder. The pain blood eventually has to pass out through the may be caused or worsened by ingestion of foods high in fat. rectum and/or through the mouth. Patients may report the passage of abnormal stools that are black or maroon in color and tarry in appearance, or they may simply pass Cholecystitis is an blood without stool from the rectum. If the inflammation of the patient is bleeding from an upper Gl source gallbladder, often caused (the esophagus stomach, or first portion by gallstones. The patient of the small bowel), he also may exhibit with this condition will vomiting of blood or “coffee-ground’” vomit. experience severe and The coffee-ground appearance is due to the sometimes sudden right partial breakdown of blood by digestive upper quadrant (RUQ) and/ enzymes. or epigastric (upper central Patients most commonly have no abdomen just below the significant or constant pain associated with Gl xiphoid process) pain, which bleeding. An exception to this rule is patients may radiate to the shoulder. with perforated ulcers in the stomach (gastric The pain may be caused or ulcers). These lesions are the result of acidic Pancreatitis worsened by ingestion of gastric juices wearing a hole in the upper foods high in fat. gastrointestinal system. If the erosion eats Pancreatitis, an inflammation of the pancreas is common in patients with into a blood vessel. Gl bleeding will result. If chronicPancreatitis alcohol problems The pain from pancreatitis is found in the epigastric the acid causes erosion all the way through area. Because of the retroperitoneal location of the pancreas behind the stomthe stomach or proximal small bowel wall, ach, the pain may radiate lo the back and/or shoulders. This is a serious condiPancreatitis, an inflammation of the pancreas is common in patients with then this very acidic liquid leaks into the tion which, in advanced cases can present with signs of shock. chronic alcohol problems The pain from pancreatitis is found in the epigastric peritoneum, resulting in significant abdominal Pancreatitis, an inflammation of the pancreas is common in patients with area. Because of the retroperitoneal location of the pancreas behind the stompain from chemical irritation and peritonitis. chronic alcohol problems The pain from pancreatitis is found in the epigastric ach, the pain may radiate lo the back and/or shoulders. This is a serious condiPatients with Gl bleeding may present area. Because of tion which, in advanced cases can present with signs of shock. in different ways. If the source vessel of the retroperitoneal the bleed is a small one, the patient may location of the experience a slow loss of blood, referred to pancreas behind as chronic gastrointestinal hemorrhage. This the stomach, the results in the patient becoming pale and pain may radiate weak over a period of days to weeks, unaware to the back and/or that he is bleeding inside. The body can shoulders. This is a compensate for most of this blood loss over serious condition a period of time, but eventually the patient which, in advanced develops signs and symptoms of shock. cases can present If the source of bleeding is from a larger with signs of shock. blood vessel, the patient may present with brisk bleeding from the rectum or vomiting of either bright red blood or material that resembles coffee grounds This type of bleeding is associated with the sudden onset of signs and symptoms of hypoperfusion.

PRINCIPLES OF EMT CLINICAL PRACTICE

Cholecystitis/Gallstones

UNIT UNIT UNIT 33 3 PRIN PRIN PR DAY DAY DAY 16 1616

Pancreatitis

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PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

UNIT 3 DAY 16

PRINCIPLES OF EMT CLINICAL PRACTICE

Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm

Abdominal aortic aneurysm Abdominal aortic aneurysm (AAA) is a ballooning or (AAA) is a ballooning or weakening weakening in the wall of the in the wall of the aorta as it aorta as it passes through passes through the abdomen. The the abdomen. The weakenweakening results in tearing of the ing results in tearing of the internal layer of the blood vessel, internal layer of the blood which allows blood to escape into vessel, which allows blood to When the aorta is the weaker, outer layers The affected escape into the weaker, weakened, it can rupture area can gradually grow and rupture. outer layers The affected quite suddenly or leak Ruptured aneurysms are associated area can gradually grow and relatively slowly. It can also with an extremely high rate of death rupture. Ruptured aneurysms dissect, which means that if they are discovered after they are associated with an exan inner layer of the aorta rupture. tremely high rate of death if tears, allowing the high You may encounter a patient who they are discovered after UNIT 3 pressures in the aorta to is aware he has an aneurysm. These they rupture. dissect (spread apart) the conditions are sometimes found DAY 16 layers of the vessel. As the when a test for another condition, Youpressure continues to exert may encounter a patient such as an abdominal ultrasound who is aware he has an anforce on the aorta, the area or CT scan, reveals the presence eurysm. These conditions are of dissection can spread. In of a small aneurysm. Not all are sometimes found when a some cases, the dissection surgically repaired immediately. If testspreads so far that it for another condition, you have a patient who tells you that such as an abdominal ultrainterferes with or even he has an aneurysm and he has abdominal pain, it is a serious emergency requiring sound or CT scan, reveals the eliminates the blood flow prompt transportation to an appropriate hospital. presence of a small aneurysm. Not all are surgically repaired immediately. If you to an artery that branches UNIT 3 who tells you that he has an aneurysm Patients with a slowly leaking AAA usually present with gradually developing have a patient and he has abdominal off the aorta. In this case, abdominal pain, which can he described as sharp pain or tearing pain and may DAY 16 pain, it is a serious emergency requiring prompt transportation to an appropriyou may see decreased radiate to the back. The association of back pain with ruptured AAA is why back ate hospital. perfusion of an extremity pain in older adults is considered a highest-priority dispatch in medical priority with a decreased or absent dispatch systems. A sudden rupture of the aorta typically causes sudden onset Patients with a slowly leaking AAA usually present with pulse.gradually developing of excruciating abdominal and back pain. Signs of shock are usually present. abdominal pain, which can he described as sharp pain or tearing pain and Depending on the location of the AAA. there may be inequality between the femoral may radiate to the back. The association of hack pain with ruptured AAA is or pedal pulses. why back pain in older adults is considered a highest-priority dispatch in medical priority dispatch systems. A sudden rupture of the aorta typically causes sudden onset of excruciating abdominal and back pain. Signs of shock are usually present. Depending on the location of the AAA. there may be inequality “ between the femoral or pedal pulses.

Inside/Outside AORTIC DAMAGE

PRINCIPLES OF EMT CLINICAL PRACT

PRINCIPLES OF EMT CLINICAL PRACTICE

NCIPLES RINCIPLES NCIPLESOF OF OF EMT EMT EMT CLINICAL CLINICAL CLINICAL PRACTICE PRACTICE PRACTICE

Inside/Outside AORTIC DAMAGE When the aorta is weakened, it can rupture quite suddenly or leak relatively slowly. It can also dissect, which means that an inner layer of the aorta tears, allowing the high pressures in the aorta to dissect (spread apart) the layers of the vessel. As the pressureHernia continues to exert force on the aorta, the area of dissection can spread. In some cases, the dissection spreads so far that il interferes with or even eliminates the blood flow to an artery that branches off the aorta. In this case, you may see decreased perfusion of an extremity with a decreased or absent pulse. “

Hernia

² Limmer (Brady) ³ Pollack, (AAOS)

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ernia

Hernia

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A hernia is a hole in the muscle layers of the abdominal wall, allowing tissue—

hernia is a hole in the muscle layers of the abdominal wall, usually intestine—to protrude up against the skin. This can be aggravated b ually intestine—to against theto skin. This can be heavy lifting or protrude straining that up causes the intestine push through the weak avy lifting or straining that wall. causes intestine push thr ened area in the abdominal SuchUnder certain conditions the kidneys may form athe hernia will cause ato sudden onset o A hernia is a hole in the muscle layers of the ed areaabdominal wall, allowing tissue—usually intestine—to in the abdominal wall.may Such a hernia willorcause small, hard stones. If one of these stones begins to pain, usually after lifting. A hernia be palpated as a mass lump onath descend down the ureter on the way to the bladder, it protrude up against the skin. This can be aggravated n, usually afterwall lifting. Acreases hernia may abdominal or in the of the groin.be palpated as a mass can cause severe pain that often radiates anteriorly to by heavy lifting or straining that causes the intestine dominal wall or in the creases ofthe groin area. The visceral pain from such a “kidney the groin. to push through the weakened area in the abdominal

Hernia

wall. Such a hernia will cause a sudden onset of pain, usually after lifting. A hernia may be palpated as a mass or lump on the abdominal wall or in the creases of the groin. ² Limmer (Brady) Although it may be very painful, it is a life³ Pollack, (AAOS) ⁴ NHTSA mmer (Brady) threatening condition only if the hernia causes an lack, (AAOS) obstruction or twisting of the intestine. HTSA Because pain at the site of a hernia may indicate obstruction or strangulation of the intestine, all patients with a painful hernia should be transported for further evaluation at the hospital.

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Renal Colic

stone” is often severe and may be associated with nausea and vomiting. These patients are typically described as “writhing,” because they move around, trying unsuccessfully to find a position of comfort.

Cardiac Involvement Pain from a heart attack (myocardial infarction) may be felt as abdominal discomfort. This pain, often described as indigestion or digestive discomfort, is commonly felt in the epigastric region (the area below the xiphoid, in the upper center of the abdomen). If the patient complains of this type of pain, consider the possibility of cardiac involvement.

ASSESSMENT AND CARE OF ABDOMINAL PAIN OR DISCOMFORT There are so many potential causes of abdominal pain that the EMT should not be concerned with field diagnosing a particular cause. Diagnosing can be difficult even in a hospital. where advanced diagnostic tests are available. The focus of your assessment process

Scene Size-Up As you approach and take the important scene size-up steps, be prepared to protect your face and clothes in case vomiting occurs. Odors can be clinically important. For example, blood in vomit or feces creates a distinctly strong odor. Identifying this odor early will help you identify potential shock. Your search for a mechanism of injury may help you determine if this is a traumatic or a medical condition.

— allowing tissue— by e k- aggravated by rough the weakof sudden onset of he

History

will be to accurately perform a secondary assessment to describe the condition and identify potentially serious conditions such as shock. For each of the steps in the assessment process, you may observe specific concerns and points of interest in the abdominal pain patient.

Primary Assessment The general impression you obtain as you approach the patient will be valuable in determining the seriousness of the patient’s condition and the urgency of your care. First, the patient’s level of consciousness will help you determine the required airway care. If the patient is conscious, you will be able to begin talking to him to gain information, and if the patient is talking, you will know he has an open airway. Unconscious patients require airway care, and any history will be obtained from family or bystanders. At this stage of assessment, you will be able to notice the early signs of shock. An altered mental status; anxiety; pale, cool, or moist skin; and rapid pulse and respirations will alert you to shock—long before you would take a blood pressure or see trends in the blood pressure. The position of the patient also provides important clues. Does the patient appear to be in pain? Is he guarding the abdomen? Is he in the fetal position? Apply oxygen to all patients with abdominal pain or distress at 15 lpm via non-rebreather mask.

Ang pananakit ng tiyan o puson ay kailangan ikonsidera bilang emergency, kahit pa walang senyales ng shock ang pasyente. Hindi trabaho ng isang EMT na alamin kung saan nagmumula ang pananakit ng tiyan o puson. Ang trabaho mo ay maiwasan na lumala ang sitwasyon.

The history is vital in the assessment of the patient with an abdominal emergency. Be systematic s or lump on the in your interviewing of the patient.

History of the Present Illness Have the patient describe the pain in his own words by answering your open-ended questions. While gathering information about the patient’s signs and symptoms, use the OPQRST mnemonic (onset, provocation/palliation, quality, region/radiation, severity, time) as a mental checklist to help you elicit information from the patient about his pain or discomfort. • Onset. When did the pain or discomfort begin? Did it begin while at rest or during activity? How did the pain begin? Did it begin as steady and severe, or did it gradually build to this point? • Provocation/palliation. What makes the pain better or worse? Does any position make the pain better or worse? Does movement affect the pain? • Quality Describe the sensation in your abdomen to me. • Region/Radiation. Point to or show me where the pain or discomfort is (Remember that the patient’s pain or discomfort may span more than one region or quadrant or

may be difficult for the patient to localize.) Do you have pain anywhere else? Does the pain radiate or shoot to other parts of your abdomen, back, or body? • Severity. How severe is the pain or discomfort? Ask the patient to report the pain on a 1-to-10 scale. • Time. How long have you had the pain or discomfort? Has it changed over time? Is it better or worse? Keep in mind that using only the word “pain” in talking to the patient about his symptoms may cause your history to be inaccurate. If you ask the patient if he has “pain” in his abdomen, he may reply, “No.” The patient may have discomfort, pressure, bloating, cramping, or another sensation that he would not call “pain.” This response will reduce the effectiveness of your exam, care for the patient, and subsequent reporting. The initial use of open-ended questions will help you to get accurate information in the patient’s own words. LIFELINE

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History Specific to Female Patients When female patients, especially those within child-bearing years, have abdominal pain, you must ask additional questions as part or the history. Emergencies such as ectopic pregnancy (a pregnancy developing outside of the uterus) can be life-threatening conditions and must be considered in the history. Other conditions, such as ruptured ovarian cysts, pelvic inflammatory disease, and menstrual irregularities can also cause significant pain. The questions you will need to ask of a female in child-bearing years who is suffering abdominal pain are highly personal but important to include in the history. Ask the questions directly, with the terminology taught in class. If the patient senses you are not at ease in asking the questions, she will be uneasy answering them. Assuring privacy for the patient while you ask these questions may help communication. Remember, this is important assessment information. The following list includes important questions to ask when gathering a female patient’s history:

Past Medical History

• Where are you in your menstrual cycle? • Is your period late? • Do you have bleeding from the vagina now that is not menstrual bleeding? • If you are menstruating, is the flow normal? • Have you had this pain before? • If so. when did it happen and what was it like? If the patient is within childbearing years, ask if she believes she is pregnant or could be pregnant. If you ask a questions such as, “Is it possible you are pregnant?” it leaves the answer to the patient’s judgment. Some patients may not even be fully aware of how one becomes pregnant. Some may not realize that, even if they have used birth control devices or techniques, they could be pregnant. If the answer is “Yes” to any of these questions, suspect ectopic pregnancy. (Even if the answers arc “No.” pregnancy—with ectopic pregnancy being the potential cause of the patient’s pain—is still a possibility.) An ectopic pregnancy is a serious emergency, requiring immediate transport to the hospital.

After you have elicited information about the patient’s signs and symptoms (the OPQRST questions), continue with questions pertaining to the patient’s allergies, medications, pertinent past history, last oral intake, and events leading to the present emergency. • Allergies. Inquire if the patient has any allergies and. if so, what he is allergic to. • Medications. Ask if the patient takes any medications. This includes over-the-counter, herbal, and illegal medications or drugs. For example, aspirin used to prevent heart attack and stroke can cause bleeding in the stomach. Some illegal substances can cause abdominal distress in use and withdrawal. Diabetics can experience abdominal pain as a symptom of blood sugar abnormalities for which they may be taking prescribed medications. • Pertinent Past History. The patient’s medical history may provide information about past problems that may be related to the current problem. If the patient has a history of past abdominal problems, ask what these conditions are. if the pain resembles past experiences with the condition, and what happened last time. (Was it serious? Was the patient in shock? Was surgery necessary?) A

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NOTE: Ectopic pregnancy occurs at the beginning of pregnancy. A patient with an ectopic pregnancy will not “look pregnant”—that is, she will not have an abdomen that appears outwardly pregnant.

patient’s cardiac history with epigastric discomfort may lead you to be concerned for heart attack. • Last Oral Intake. This is very important in patients with abdominal complaints. Determine the patient’s last oral intake (liquids, meals, snacks). Additionally, determine if this intake and the intake over the past hours-to-days has been normal for this patient. • Events Leading to the Emergency. The events leading up to the call for EMS (similar to the onset question in the OPQRST questions) can help you determine a timeline and progression of signs and symptoms. Ask again specifically about activity (even over the past few days) which seems related lo the problem. Vomiting, nausea, diarrhea, and/or constipation are also important history items. Ask specifically if any dark red, bright red, or coffee-ground-like substances were noted in the vomit or feces, indicating internal bleeding. Many geriatric patients also take medications e.g. beta blockers such as atenolol or metoprolol) for high blood pressure or heart conditions, which will reduce the heart rate. These medications may prevent the patients pulse from rising during shock. An EMT could find a pulse of 72 and think that shock isn’t present when in fact it is.

Geriatric patients may present some dilemmas when you are assessing abdominal pain. Older people may have a decreased ability to perceive pain This will, of course, make obtaining a history and description of the pain or discomfort more difficult. It is also important to remember that older patients are likely to have a more serious cause of abdominal pain than younger patients. Research has demonstrated that elderly patients with abdominal pain are up to 9 times more likely to die than younger patients with the same cause of the abdominal pain. PREHOSPITAL EMERGENCY CARE

Physical Examination of the Abdomen Assessment of the abdomen involves two procedures for patient. If the initial gentle palpation does not cause pain EMS personnel: inspection and palpation. You may see some or discomfort, you may palpate a bit deeper. Once you have healthcare providers in the hospital auscultating (listening to) found pain, discomfort, or abnormality, there is no need to bowel sounds. This can be a long process (listening 3 minutes palpate further in that area. per quadrant) which will not change prehospital care and is You may observe that the patient is guarding the not recommended as part of prehospital assessment. abdomen. The term guarding is used to describe two possible Before you physically assess the abdomen, you will presentations: the patient drawing his arms down across the have asked the patient where it hurts. The patient may have, abdomen or the patient tensing the muscles before you touch pointed to a spot or may have moved his hand around an area the abdomen. Guarding is a voluntary or involuntary attempt indicating diffuse pain or discomfort. This will he important to protect the abdomen and prevent further pain. for your physical exam. In cases of abdominal aortic aneurysm, you may palpate First, inspect the patient’s abdomen. Look for distention, a pulsating mass (abnormal bulge or lump). This mass may be bloating, discoloration, abnormal protrusions, found in conjunction with a tearing or sharp or other signs that appear abnormal or pain in the back. This indicates advanced unusual. You may have to ask the patient or aneurysm. If you gently palpate this mass, do family members if the current appearance of not palpate it again. Instead, report this mass to the abdomen is normal or has changed, since the receiving hospital. Some patients may have A common assessment body types and shapes vary widely. knowledge of an aneurysm which, when first error is not assessing the Then palpate the abdominal quadrants. found, was not serious and has worsened, or lower quadrants properly. Always palpate the area that has pain or was inoperable. This history is important. The lower quadrants discomfort last. If this area is palpated first Remember that the aorta normally extend from the umbilicus and causes additional pain, it will mask or creates a slight sensation of pulsing on deeper downward to the pelvis. In alter the patient’s response to palpation of the palpation of the abdomen, especially in very most people, this extends thin patients. The presence of the pulsating other quadrants. way below the belt or mass indicates an aneurysm. In larger patients, To palpate the abdomen, use the tips waistline and requires you will not be able to palpate a mass, even of several fingers and gently press into the loosening of clothing to though an aneurysm is present. In this case, the abdomen in each quadrant. While palpating, actually assess the lower feel for rigidity or hardening and ask or patient’s report of tearing pain may be the only quadrants. observe whether this causes pain for the indication of a possible aortic aneurysm.

NOTE:

Vital Signs Vital signs should be taken initially and then every 5 minutes for a patient complaining of abdominal pain. These vital signs are pulse, respiration, blood pressure, and skin color, temperature, and condition. Mental status is also important to observe. Remember that shock will appear initially with increased pulse and respirations; pale, moist skin: and anxiety. Falling blood pressure will be a late sign. Since patients with abdominal pain may have an increased pulse simply as a result of the pain, serial vitals taken over time will help identify potentially dangerous trends. Calming, placing the patient in a position of comfort, and administering oxygen may actually reduce the pulse, which is a good sign. Respirations may also he affected by abdominal pain. If breathing worsens the abdominal pain, the patient may be breathing shallowly and sometimes more rapidly.

General Abdominal Distress You may be called to evaluate patients who have complaints that appear non-specific but involve the digestive system. Nausea, vomiting, and diarrhea are examples, Some of these complaints will result from digestive system disorders, whereas other causes could be cardiac issues, diabetic issues, food poisoning, or the flu. Your assessment and care for these patients, like any others discussed in this chapter, will involve providing a proper scene size and primary assessment with appropriate airway care. Your history, physical exam, and vital signs assessments will be critical for determining the patient’s priority and condition (stable vs. unstable). The assessment techniques discussed previously in the chapter will apply in the same manner to these patients. Determining if there is pain, tenderness, discomfort, or any associated complaints; the time of onset (sudden vs. over a period of lime); fever and malaise; and abdominal inspection and palpation are all appropriate. Patient care will involve monitoring for airway problems if the patient is vomiting. Place the responsive patient in a position of comfort. Place the unresponsive patient of the patient who is having difficulty maintaining an airway in a left lateral recumbent position for drainage from the mouth.

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PATIENT ASSESSMENT Abdominal Distress To assess a patient suffering from abdominal pain or distress 1. Perform a scene size-up, looking for clues to a possible mechanism of injury while taking standard precautions as well as safety precautions 2. Perform a primary assessment including the general impression of the patientâ&#x20AC;&#x2DC;s level of distress, mental status, airway, breathing, and circulation. Apply oxygen. Make a transport/ priority decision. Vomiting may cause airway compromise, so be prepared to suction 3. Assist the patient to a position of comfort Calm and reassure the patient. This will help the patient and, by relaxing him, also help complete your next assessment steps 4. Perform a history, physical examination, and vital signs 5. Perform a reassessment every 5 minutes en route

Kung nagsusuka o nagtatae ang pasyente, mas kailangan mong sumunod sa mga standard precautions at maglinis nang mabuti ng ambulansya matapos maihatid ang pasyente sa ospital.

ABDOMINAL EMERGENCIES

PATIENT CARE Abdominal Distress Although there are many types of abdominal emergencies, the care you will provide for all abdominal conditions is the same You may find patients who appear unstable and obviously have a serious condition as well as those who are in pain, yet appear stable. In every case, despite the differences in patient presentation, you should follow these steps when treating a patient with an abdominal emergency: 1. While performing the primary assessment, maintain the patientâ&#x20AC;&#x2122;s airway. If the patient has an altered level of responsiveness, this will compromise the airway. Keep in mind that patients with abdominal emergencies may vomit. Suction whenever necessary. 2. Administer 15 lpm of oxygen to the patient by nonrebreather mask. 3. Place the patient in a position of comfort. However, if shock and/or airway problems are present, position the patient to treat these conditions. The left laterally recumbent position will help maintain the airway. 4. Transport the patient promptly to an appropriate facility. You should always work to calm the patient and reduce his anxiety. Patients who are in pain will require calming and reassurance. Never give a patient with a complaint of abdominal pain or discomfort anything by mouth.

Assessment of the Patient with Abdominal Distress 1. Perform a scene size up. 2. Perform a primary assessment and apply oxygen. 3. Take a patient history. 4. Expose the site. 5. Palpate the abdominal quadrants. 6. Transport the patient.

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This chapter has talked in great detail about assessment of the abdomen, searching for abnormal findings. Keep in mind, however, that the absence of abnormal findings does not mean the patients condition is not serious. PATIENTS WITH ABDOMINAL PAIN SHOULD ALWAYS BE CONSIDERED AT LEAST POTENTIALLY UNSTABLE AND TRANSPORTED PROMPTLY.

PREHOSPITAL EMERGENCY CARE

POISONING AND OVERDOSE EMERGENCIES LEARNING OBJECTIVES • List various ways that poisons enter the body. • List signs/symptoms associated with poisoning. • Discuss and demonstrate the steps the emergency medical care for the patient with possible overdose or poisoning. • Describe the steps in the emergency medical care for the patient with suspected poisoning. • Establish the relationship between the patient suffering from poisoning or overdose and airway management.

INTRODUCTION How can you, as an EMT. know that the patient you encounter at the scene of an emergency call has been poisoned? Family members or bystanders may report this fact when they call for help There may be clues at the scene, such as empty pill bottles or containers of toxic substances, and the patient’s signs and symptoms may indicate poisoning or overdose. After you identify and treat immediately life-threatening problems, such as airway or breathing difficulties, your main assessment task will be to gather information for medical direction They will guide your care and management of the poisoning or overdose patient.

POISONING A poison is any substance that can harm your body, sometimes seriously enough to create a medical emergency. In the Philippines, there are numerous reported cases of poisoning annually. Although some of these result from murder or suicide attempts, most are accidental and involve young children. These incidents usually involve common substances such as medications, petroleum products, cosmetics, and pesticides. In fact, a surprisingly large percentage of chemicals in everyday use contain substances that are poisonous if misused. We usually think of poison as some kind of liquid or solid chemical that has been ingested by the poisoning victim. Although this is often the case, many living organisms are capable of producing a toxin, a substance that is poisonous to humans. For example, some mushrooms and other common plants can be poisonous if eaten. These include some varieties of house plants, including the rubber plant and certain parts of holiday plants such as mistletoe and holly berries. In addition, bacterial contaminants in food may produce toxins, some of which can cause deadly diseases (such as botulism). A great number of substances can be considered poisonous, with different people reacting differently to various poisons. As odd as it may seem, what may be a dangerous poison for one person may have little effect on another. For most poisonous substances the reaction is far more serious in the ill, the very young, and the elderly. Once on or in the body, poisons can do damage in a variety of ways. A poison may act as a corrosive or irritant, destroying skin and other body tissues. A poisonous gas can act as a suffocating agent, displacing oxygen in the air. Some poisons are systemic poisons, causing harm to the entire body or to an entire body system. These poisons can critically depress or over stimulate the central nervous system, cause vomiting and diarrhea, prevent red blood cells from carrying oxygen, or interfere with the normal biochemical processes in the body at the level of the cell. The actual effect and extent of damage is dependent on the nature of the poison, on its concentration, and sometimes on how it enters the body. These factors vary in importance depending on the patient’s age. weight, and general health. Kung may suspetsa ka na sadyang nilason o nagtangkang magpakamatay ang pasyente, maging maingat sa iyong pagsusuri at pagtrato sa pasyente. Humingi agad ng tulong sa pulis kung sa tingin mo ay ganito ang sitwasyon.

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Day 16 Poisons can be classified into four types, according to how they enter the body: ingested, inhaled, absorbed, and injected. • Ingested poisons (poisons that are swallowed) can include many common household and industrial chemicals, medications, improperly prepared or stored foods, plant materials, petroleum products, and agricultural products made specifically to control rodents, weeds, insects, and crop diseases. • Inhaled poisons (poisons that are breathed in) take the form of gases, vapors, and sprays. Again, many of these substances are in common use in the home, industry, and agriculture. Such poisons include carbon monoxide (from car exhaust, wood-burning stoves, and furnaces), ammonia, chlorine, insect sprays, and the gases produced from volatile liquid chemicals (volatile means “able to change very easily from a liquid into a gas”: many industrial solvents are volatile). • Absorbed poisons (poisons taken into the body through unbroken skin) may or may not damage the skin. Many are corrosives or irritants that will injure the skin and then be slowly absorbed into body tissues and the bloodstream, possibly causing widespread damage. Others are absorbed into the bloodstream without injuring the skin. Examples of these poisons include insecticides and agricultural chemicals. Contact with a variety of plant materials and certain forms of marine life can lead to skin damage and possible absorption into tissues under the skin. • Injected poisons (poisons inserted through the skin) enter the body through a means that penetrates the skin. The most common injected poisons include illicit drugs injected with a needle and venoms injected by snake fangs or insect stingers.

PEDIATRIC NOTE Preventing poisoning is of course, preferable to creating it. The EMTs own home and the squad building should be “childproofed” against poisoning by keeping medications and other dangerous substances out of children’s reach. The EMT can also share poisoning prevention information with members of the public during school visits and community outreach activities.

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COMMON INGESTED POISONS SUBSTANCE

SIGNS AND SYMPTOMS

Acetaminophen

Nausea and vomiting. Jaundice is a delayed sign. There may be no signs or symptoms.

Acids and alkalis

Bums on or around the lips. Burning in mouth, throat, and abdomen. Vomiting.

Antiarrhythmics (drugs to regulate electrical impulses and the speed of the heart)

Bradycardia, hypotension, decreased consciousness, respiratory depression.

Antidepressants (selective serotonin reuptake inhibitors)

Tachycardia, hypertension, nausea, tremors.

Antihistamines and cough or cold preparations

Hyperactivity or drowsiness. Rapid pulse, flushed skin, dilated pupils.

Antipsychotics

Drowsiness, coma, tachycardia

Aspirin

Delayed signs and symptoms, including ringing in the ears, deep and rapid breathing, bruising.

Food poisoning

Different types of food poisoning have different signs and symptoms of varying onset. Most include abdominal pain, nausea, vomiting, and diarrhea, some-times with fever.

Ibuprofen and other nonsteroidal antiinflammatory drugs (NSAlDs)

Upset stomach, nausea, vomiting, drowsiness, abdominal pain, gastrointestinal bleeding.

Insecticides

Slow pulse, excessive salivation and sweating, nausea, vomiting, diarrhea, difficulty breathing, constricted pupils.

Petroleum products

Characteristic odor of breath, clothing, vomitus. If aspiration has occurred, coughing and difficulty breathing.

Plants

Wide range of signs and symptoms, ranging from none to nausea and vomiting to cardiac arrest.

Abdominal Distress Ingested poisons are those poisons that have been swallowed. An ingested poison is often a toxic substance that a curious child eats or drinks. In adults, an ingested poison is often a medication on which the patient has accidentally or deliberately overdosed.

PATIENT ASSESSMENT

You must gather information quickly in cases of possible ingested poisoning. In order to determine if activated charcoal is appropriate, online medical direction will need certain information • What substance was involved? Many products have similar names. It is important to get the exact spelling of the substance. If it is possible and safe, bring the container to the hospital with the patient. • When did the exposure occur? Some poisons act very quickly and will require immediate treatment. Others may take longer to affect the body, which may allow for other treatments to be used. It is important for emergency department personnel to know as closely as possible the time of ingestion so that appropriate testing and treatment can be done. It is sometimes difficult to determine the time of the exposure from the reports of family members or witnesses. If you cannot get an exact time, determine the earliest and latest possible times of exposure. • How much was Ingested? Tins may be determined by simply counting the number of tablets left in a brand new prescription. However, it can also be difficult to determine, such as when estimating the amount of gasoline spilled on a garage floor. When the amount cannot be reliably estimated, determine the maximum amount that might have been Ingested. • Over how long a period did the ingestion occur? Someone who takes a certain medication chronically and then overdoses on it may require very different hospital treatment from the patient who has the same overdose but has never taken that medication before.

• What interventions has the patient, family, or wellmeaning bystanders taken? Many traditional home remedies

•

for medical problems are harmful, particularly when someone has been exposed to enough of a substance to suffer ill effects. Product labels have been improved over the last few years, but some still contain inaccurate or even dangerous instructions for management of potentially toxic exposures. What is the patient’s estimated weight? This estimate, in combination with the amount of substance ingested, may be critical in determining the appropriate treatment.

• What effects is the patient experiencing from the ingestion? Nausea and vomiting are two of the most common

results of poison ingestion, but you may also find altered mental status, abdominal pain, diarrhea, chemical burns around the mouth, and unusual breath odors.

Food Poisoning Another way someone can be poisoned is through food that has been improperly handled or cooked. Food poisoning can he caused by several different bacteria that grow when exposed to the right conditions. This frequently happens when raw meal, poultry, or fish is left at room temperature before being cooked or the food does not reach a high enough temperature to kill the bacteria. Some food poisonings are the result of bacteria causing an infection in the patient (symptoms may occur a day or so after ingestion); other times it may be the result of toxins formed by the bacteria that contaminate the food and it is these toxins that result in symptoms (usually within hours of ingestion). Signs and symptoms vary somewhat, depending on the bacteria involved, but frequently include nausea, vomiting, abdominal cramps, diarrhea, and fever. You can prevent food poisoning at home and at the station by washing your hands, utensils, cutting boards, and any surface the food touches before—and especially after—any contact with raw meat, fish, or poultry (the bacteria can easily be spread to other foods from hands or surfaces); by storing and cooking foods at appropriate temperatures; and by not leaving raw or cooked foods at room temperature for long periods of time.

Activated Charcoal To provide the proper emergency care for ingested poisons, follow the instructions given to you by medical direction. In some cases of ingested poisoning, medical direction will order administration of activated charcoal. Activated charcoal works through adsorption, the process of one substance becoming attached to the surface of another. In contrast to ordinary charcoal, which adsorbs some substances, activated charcoal has been manufactured to have many cracks and crevices. As a result, activated charcoal has an increased amount of surface available for poisons to bind to (similar to corrugated cardboard which, if you cut it open, has many more surfaces than you would expect by looking at the smooth outer surface). Activated charcoal is not an antidote; however, through the adsorption or binding process, in many cases it will prevent or reduce the amount of poison available for the body to absorb. Many poisons are adsorbed by activated charcoal, but not all. Since there are millions of potential poisons available and the number is always increasing, it makes little sense to memorize lists of poisons where activated charcoal should not be used. Instead, medical direction will determine whether the use of activated charcoal is appropriate.

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There are, however, a few instances you should know about where the use of activated charcoal is contradicted: • Patients who cannot swallow obviously cannot swallow activated charcoal and aspirate it into the lungs. • Patients who have ingested acids or alkalis should not take activated charcoal because the caustic material may have severely damaged the mouth, throat, and esophagus. Activated charcoal cannot help the damage that has already been done, and swallowing it may cause further damage. Examples of such caustic substances are oven cleaners, drain cleaners, toilet bowl cleaners, and lye. • Patients who have accidentally swallowed while siphoning gasoline should not be given activated charcoal. The patient will be coughing violently and possibly aspirating the gasoline. This patient will be unable to swallow activated charcoal.

• • •

•

FIRST TAKE STANDARD PRECAUTIONS Quickly gather information. Call medical direction on the scene or en route to the hospital. If directed, administer activated charcoal. You may wish to administer the medication in an opaque cup that has a lid with a hole for a straw. Position the patient for vomiting and save all vomitus. Have suction equipment ready.

In addition, activated charcoal is not indicated in cases of food poisoning. Many brands of activated charcoal are on the market, but some have greater surface area than others. Medical direction can guide you in the selection of an appropriate brand. Some patients, especially those who have taken an intentional overdose, may refuse to take activated charcoal. Never attempt to force a patient to swallow activated charcoal. If the patient refuses, notify medical direction and continue reassessment and care. Activated Charcoal vs. Syrup of Ipecac. A traditional treatment for poisoning used to be syrup of ipecac. This orally administered drug causes vomiting in most people with just one dose. When vomiting occurs, it results on the aver-age, in removal of less than onethird of the stomach contents. Because ipecac is slow, is relatively ineffective, and has the potential to make a patient aspirate vomitus, it is rarely used today. Although poison control centers on rare occasions instruct parents of young children in the proper use of syrup of ipecac, activated charcoal is the medication of first choice for health care providers in most poisoning and overdose cases,

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Dilution Occasionally, medical direction will give an order for dilution of a poisonous substance. This means an adult patient should drink one to two glasses of water or milk, whichever is ordered. A child should typically be given one-half to one full glass Dilution with water may slow absorption slightly, whereas milk may soothe stomach upset. This treatment is frequently advised for patients who, as determined by medical direction or poison control, do not need transport to a hospital.

PATIENT CARE Ingested Poison

Emergency care of a patient who has ingested poison includes the following steps: 1. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need for prompt transport for critical patients. 2. Perform a secondary assessment. Use gloved hands to carefully remove any pills, tablets, or fragments from the patient’s mouth, package the material and transport it with the patient. 3. Assess baseline vital signs 4. Consult medical direction As directed, administer activated charcoal to absorb the poison, or water or milk to dilute it. This can usually be done en route. 5. Transport the patient with all containers, bottles, and labels from the substance. 6. Perform reassessment en route. May mga kaso na ang pasyente na nalason ay hindi humihinga. Hindi puwede gawin dito ang pagbuga sa bibig ng pasyente dahil posibleng makahigop ng lason ang magbibigay ng mouth-tomouth resuscitation. Kung ganito ang sitwasyon, gumamit ng face mask na may one-way valve o kaya ay bag-valve-mask na may oxygen. Tiyakin din na naka-gloves ka kung magbibigay ng tulong sa isang biktima ng pagkalason. Laging tandaan na ang kaligtasan mo at kaligtasan ng iyong mga kasama ay kasinghalaga ng kaligtasan ng pasyente.

Activated Charcoal MEDICATION NAME

1. Generic: Activated charcoal 2. Trade: SuperChar, Inst a Char, Acti dose, Liqui-Char, and others

INDICATIONS

Poisoning by mouth

CONTRAINDICATIONS

1. Altered mental status 2. Ingestion of acids or alkalis 3. Inability to swallow

ACTIONS

MEDICATION FORM

1. Premixed in water, frequently available in a plastic bottle containing 12.5 grams of activated charcoal 2. Powderâ&#x20AC;&#x201D;should be avoided in the field

DOSAGE

1. Adults and children: 1 gram activated charcoal/kg of body weight 2. Usual adult dose: 25 to 50 grams 3. Usual pediatric dose: 12.5 to 25 grams

ADMINISTRATION

1. Consult medical direction. 2. Shake container thoroughly.

Antidotes

Many lay people think that every poison has an antidote, a substance that will neutralize the poison or its effects. This is not true. There are only a few genuine antidotes, and they can be used only with a very small number of poisons. Modem treatment of poisonings and overdoses consists primarily of prevention of absorption w hen possible (such as by administration of activated charcoal) and good supportive treatment (such as airway maintenance, administration of oxygen, treatment (or shock). In a small number of poisonings, advanced treatments are administered in a hospital (administration of antidotes and kidney dialysis).

3. Since medication looks like mud, the patient may need to be persuaded to drink it. Providing a covered container and a straw will prevent the patient from seeing the medication and so may improve patient compliance. 4. If the patient does not drink the medication right away, the charcoal will settle. Shake or stir it again before administering. 5. Record the name, dose, route, and time of administration of the medication. 1. Activated charcoal adsorbs (binds) certain poisons and prevents them from bring absorbed into the body. 2. Not all brands of activated charcoal are the same. Some adsorb much more than others, so consult medical direction about the brand to use.

SIDE EFFECTS

1. Some patients have black stools. 2. Some patients may vomit, particularly those who have ingested poisons that cause nausea. If the patient vomits, repeat the dose once.

REASSESSMENT STRATEGIES

1. Be prepared for the patient to vomit or further deteriorate.

Likas sa mga sanggol at mga bata na maging mapanuklas. Tinitikman nila ang lahat ng puwedeng tikman. Nilulunok nila ang lahat ng puwedeng lunukin, pati na ang mga masama ang lasa na gaya ng kemikal na panlaba o panlinis ng banyo. Ang ugaling ito ng mga bata ay nagiging dahilan kung bakit marami sa kanila ang aksidenteng nakakainom ng lason. Importante na malaman ang timbang ng bata at ang tinatantiyang dami ng lason na nainom nito para makapagdesisyon ang isang EMT ng tamang paraan ng paggamot. Bilang isang EMT, lagi mong isipin ang posibilidad na nakainom ng madaming lason ang bata na puwede nitong ikamatay. Dahil imposible na malaman kung gaano talaga kadami ang nainom nito, pinakamaganda na laging maghanda sa pinakagrabeng sitwasyon. Humingi agad ng payo sa medical director kung ano ang pinakamabisang lunas na puwedeng ibigay, gawin agad ang payong matatanggap, at ibiyahe agad ang pasyente sa ospital.

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Inhaled Poisons Inhaled poisons are those that are present in the atmosphere and that you. as well as the patient, are at risk of breathing in. Carbon monoxide poisoning is a common problem. Other possible inhaled poisons include chlorine gas (often from swimming pool chemicals), ammonia (often released from household cleaners), sprayed agricultural chemicals and pesticides, and carbon dioxide (from industrial sources).

Inside/Outside Acetaminophen Poisoning

Acetaminophen overdose is the most common cause of hospitalization of overdose patients. This is not surprising, given its effectiveness as an analgesic and its presence as an ingredient in many medications. It is very safe in recommended doses for healthy people who do not abuse alcohol or have liver problems, but acetaminophen is very dangerous in overdose. Fortunately, the toxic effects of acetaminophen do not appear right away. After someone takes too much of the drug, the liver becomes overwhelmed and unable to detoxify the substance. Over the next several hours, the liver sustains irreparable damage if nothing is done. If the antidote is given within the first 4 to 12 hours after an overdose, however, the patient should recover with a functioning liver. Unfortunately, the signs and symptoms of acetaminophen overdose are delayed and not very specific. During the first 4 to 12 hours, the most the patient may experience is loss of appetite, nausea, and vomiting. It isn’t until a day or two later that the patient typically experiences right upper quadrant pain and jaundice, when it is too late for the antidote to work. This points to the importance of several aspects of prehospital assessment and management: • Suspect acetaminophen poisoning in conjunction with any other overdose. • It may be appropriate to search medicine cabinets and garbage cans for empty pill bottles, depending on the circumstances. • Deal with apparent threats to life first. Because the effects of acetaminophen poisoning are delayed, there is time to institute treatment in the hospital.

NOTE:

PATIENT ASSESSMENT Inhaled Poison Gather the following information as quickly as possible: • What substance was involved? Get its exact name. • When did the exposure occur? Estimate as well as you can when the patient was exposed to the poisonous gas by finding out the earliest and latest possible times of exposure. • Over how long a period did the exposure occur? The longer someone is exposed to a poisonous gas. the more poison that will probably be absorbed. • What interventions has anyone taken? Did someone remove the patient or ventilate the area right away? When did this happen? • What effects is the patient experiencing from the exposure? Nausea and vomiting are very common in poisoning of all types. With inhaled poisons, find out if the patient is having difficulty breathing. chest pain, coughing, hoarseness, dizziness, headache, confusion, seizures, or altered mental status.

PATIENT CARE Inhaled Poison

The principal prehospital treatment of inhaled poisoning consists of maintaining the airway and supporting respiration. In the case of inhaled poisoning, oxygen is a very important drug. Some inhaled poisons prevent the blood from transporting oxygen in the normal manner. Some prevent oxygen from getting into the bloodstream in the first place. In either case, your ability to keep the airway open, ventilate as needed, and give high-concentration oxygen may make the difference in the patient’s survival and quality of life.

If you suspect that a patient has inhaled a poison, approach the scene with care. Some EMS systems provide training in the use of protective clothing and self-contained breathing apparatus (SCBA) to be used in a hostile environment (such as chlorine gas. ammonia, or smoke). Remember that many inhaled poisons can also be absorbed through the skin. Go only where your protective equipment and clothing wilt allow you to go safely to perform your mission, and only after you have been trained in the use of this equipment. If you do not have the necessary equipment or training, get someone there who is properly equipped and trained.

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Emergency care steps include the following: 1. If the patient is in an unsafe environment, have trained rescuers remove the patient to a safe area. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need to promptly transport critical patients. 2. Perform a secondary assessment, obtain vital signs. 3. Administer high-concentration oxygen. This is the single most important treatment for inhaled poisoning after the patient’s airway is opened. 4. Transport the patient with all containers, bottles, and labels from the substance. 5. Perform reassessment en route.

Inhaled Poisons 1. Remove the patient from the source of the poison. 2. Establish an open airway. 3. Insert an oropharyngeal airway and administer high concentration oxygen. 4. Gather the patient’s history, take baseline vital signs, and expose the chest for auscultation. 5. Contact medical direction 6. Transport the patient.

Kung ikaw ay napasok sa lugar na may mga nakalalasong usok, magsuot ng damit na may proteksyon at gumamit ng SelfContained Breathing Apparatus para ikaw ay makahinga nang ligtas. Kung wala ka nito, tumawag ng iba na may kagamitan at sanay sa mga ganitong sitwasyon.

Carbon Monoxide Carbon monoxide (CO) is one of the most commonly inhaled poisons, but usually associated with motor-vehicle exhaust and fire suppression. The number of carbon monoxide cases has increased recently because of the carbon monoxide that can accumulate from the use of improperly vented wood-burning moves and the use of charcoal for heating and indoor cooking in areas without adequate ventilation. Malfunctioning oil-, gas-, and coal-burning furnaces and stoves can also be sources of carbon monoxide. The indoor use of gasoline-powered small engines such as electrical generators or pumps is another common cause of CO poisoning. Since carbon monoxide is an odorless, colorless, and tasteless gas, you will not be able to directly detect its presence without special equipment. Look for indications of possible carbon monoxide poisoning like wood-burning stoves, doors that lead to a garage, bedrooms above a garage where motor repair work is in progress, and evidence that suggests the patient has spent a long period of time sitting in an idling motor vehicle. When inhaled, carbon monoxide prevents the normal carrying of oxygen by the red blood cells. Long exposure, even to low levels of the gas. can cause dramatic effects. Death may occur as hypoxia becomes more severe.

NOTE: There is a commonly accepted idea that a patient exposed to carbon monoxide will have cherry red lips. In fact, cherry red skin is NOT typically seen in patients with carbon monoxide poisoning.

You should suspect carbon monoxide poisoning whenever you are treating a patient with vague, flu-like symptoms who has been in an enclosed area. This is especially true when a group of people in the same area have similar symptoms. A patient with carbon monoxide poisoning may begin to feel better shortly after being removed from the dangerous environment. However, it is still very important to continue to administer oxygen and to transport these patients lo a hospital. Oxygen is an antidote for carbon monoxide poisoning, but it takes time to “wash out” the carbon monoxide from the patient’s blood-stream, These patients need medical evaluation because they can have serious consequences, including neurological deficits, from their exposure. The signs and symptoms of carbon monoxide poisoning arc deceptive, because they can resemble those of the flu. Specifically, you may see: • Headache, especially “a band around the head” • Dizziness • Breathing difficulty • Nausea • Cyanosis • Altered mental status: in severe cases, unconsciousness may result

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Smoke Inhalation

Smoke inhalation is a serious problem associated with fire scenes. Smoke inhalation is often associated with thermal burns as well as with the effects of chemical poisons within the smoke. The smoke from any fire source contains many poisonous substances. Modern building materials and furnishings often contain plastics and other synthetics that release toxic fumes when they bum or are overheated. It is possible for the substances found in smoke to burn the skin, irritate the eyes, injure the airway, cause respiratory arrest, and, in some cases, cause cardiac arrest. As an EMT. you will most likely find irritated (reddened, watering) eyes and, of far greater concern, injury to the airway associated with smoke. The following signs indicate an airway injured by smoke inhalation: • Difficulty breathing • Coughing • Breath that has a “smoky” smell or the odor of chemicals involved at the scene • Black (carbon) residue in the patient’s mouth and nose • Black residue in any sputum coughed up by the patient • Nose hairs singed from superheated air Move the patient suffering from smoke inhalation to a safe area and provide the same care you would provide for any inhaled poison: assess the patient, administer high concentration oxygen, and transport.

NOTE:The body’s reaction to toxic

gases and foreign matter in the airway can often be delayed. Convince all smoke inhalation patients that they must be seen by a physician, even if they are not yet feeling serious effects.

Detergent Suicides A method of suicide that is popular in Japan is called “detergent suicide.” By mixing two easily obtained chemicals, a person can cause the release of toxic hydrogen sulfide gas. The chemicals involved are frequently toilet cleaner and bath salts. The same kind of bath salts are not available in the Philippines, but other chemicals that are available locally can lead to the same result. Typically, a source of acid, such as a strong household cleaner, and a

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source of sulfur, often a pesticide, will quickly release significant amounts of toxic hydrogen sulfide gas when mixed together. Hydrogen sulfide is best known for its rotten egg odor, but less well known is that, even at moderate concentrations, it can be quite dangerous. Hydrogen sulfide not only takes the place of oxygen but also bonds with iron in cells, preventing oxygen from binding to those cells and getting to where it is needed Mild exposure can result in coughing, eye irritation, and sore throat. More severe exposures can lead to dizziness, nausea, shortness of breath, headache, and vomiting. In severe cases, fluid will collect in the lung (pulmonary edema), resulting in death. The typical method of committing suicide in Japan with this toxic gas includes combining the chemicals in a small enclosed space and posting warning signs advising people not to try to gain access to the patient but to call a hazardous materials team. Although this warning is common in Japan, it is not clear how often others attempting suicide in this manner will be so courteous toward rescuers. Although this method of suicide has not yet become common in the Philippines, EMTs must be extremely careful when approaching a scene where a “detergent suicide” may have taken place. Warning signs to look for include a small enclosed space, such as a car, with tape scaling the windows and doors. Any kind of sign or note warning people not to approach should be taken very seriously. Call the appropriate agency to open the space and remove the body. Do not become another casualty.

Absorbed Poisons

Absorbed poisons frequently irritate or damage the skin. However, some poisons can be absorbed with little or no damage to the skin.

NOTE:

Just as poisonous substances can be absorbed by patients, they can also be absorbed by EMTs. It is critical that the EMT take protective measures to prevent exposure to these substances. It may be necessary for fire fighters to decontaminate a patient before the EMT touches him.

PATIENT ASSESSMENT Absorbed Poison

When treating a patient with absorbed poisoning, gather the following information as quickly as possible • What substance was involved? Get its exact name. If the exposure occurs at a commercial silo, then by law material safety data sheets (MSDS) should be available on-site that will help identify the substance. • When did the exposure occur? • How much of the substance was the patient exposed to? How large an area or skin was the substance on? • Over how long a period did the exposure occur? The longer someone’s skin is exposed to a poison, the more likely it is to be well absorbed. • What interventions has anyone taken? Did someone attempt to wash the substance off the patient? If so. with what? Did anyone attempt to use a chemical to “neutralize” the substance? • What effects is the patient experiencing from the exposure? Common signs and symptoms include a liquid or powder on the patient’s skin, burns, itching, irritation, and redness.

PATIENT CARE Absorbed Poison Emergency care of a patient with absorbed poisons includes the following steps: 1. Detect and treat immediately life-threatening problems in the primary assessment. Evaluate the need for prompt transport of critical patients. 2. Perform a secondary assessment, obtain vital signs. This includes removing contaminated clothing while protecting oneself from contamination. 3. Remove the poison by doing one of the following: • Powders. Brush powder off the patient, then continue as for other absorbed poisons. • Liquids. Irrigate with clean water for at least 20 minutes and continue en route if possible. • Eyes. Irrigate with clean water for at least 20 minutes and continue en route if possible. 4. Transport the patient with all containers, bottles, MSDS sheets, and labels from the substance. 5. Perform reassessment en route. The most important part of the treatment of a patient with an absorbed poison is to get the poison off the skin or out of the eye. The best way to do this is by irrigating the skin or the eye with large amounts of clean water. A garden hose or tire hose can be used to irrigate the patient’s skin,

but care must be taken not to injure the skin further with high pressure. “Neutralizing” acids or alkalis with solutions such as dilute vinegar or baking soda in water should not be done. When incidents like these occur, such substances are almost never readily available. Even if they were, they would not be appropriate. They have never been shown to help, and there is good reason to believe they would make matters worse. When an acid is mixed with an alkali, it is true that the two may he neutralized. It is also true, though, that this reaction produces heat. Skin that has been injured already by an acid or alkali may be further damaged by attempts to neutralize the chemical.

Injected Poisons As mentioned earlier, the most common injected poisons are illicit drugs injected with a needle and the venom of snakes and insects.

Poison Control Centers

Emergency care in poisoning cases presents special problems for the EMT. Signs and symptoms can vary greatly. Some poisons produce a characteristic set of signs and symptoms very quickly, whereas others are subtle and slow to appear. Poisons that act almost immediately usually produce obvious signs, and the particular poison or its container is often still nearby. Slow-acting poisons can produce effects that mimic an infectious disease or some other medical emergency. There will be times when you will not know the substance that caused the poisoning. In some of these cases, an expert may be able to tell, based on the combination of signs and symptoms. Even when you know the source of the poison, correct emergency care procedures may still be in question. Ideas about proper care keep changing as more research is done on poisoning. This constant change makes it impossible to print guides and charts for poison control and care that will be up-to-date when you use them. Although manufacturers have improved the instructions on many container labels, some still have inaccurate or even dangerous advice. Fortunately, the Department of Health operates the National Poison Management and Control Center under the University of the Philippines-Philippine General Hospital in Manila. There are also designated toxicologists (experts on poisoning cases) in major hospitals nationwide. You may contact the National Poison Management and Control Center or these toxicologists for help. An EMT should consult a poison control center only when directed by local protocol. In most cases. EMTs gel medical direction from physicians or nurses who are in hospital emergency departments. Unless special arrangements have been made, the poison control center staff does not have the authority LIFELINE

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Day 16 to provide online medical direction. If the poison control center staff does have the authority to do so, they can tell you what should be done for most cases of poisoning. If you are permitted to communicate directly with the toxicologist in your area, do so by telephone. Even if you have radio contact with your local toxicologist, the telephone is the preferred way to communicate. The toxicologist may need to talk to you for several minutes, far too long a period to monopolize the air waves. The telephone will also allow you to maintain patient confidentiality. Make certain you have memorized the number and/or carry the toxicologist’s number with you into the residence— perhaps pasted inside your kit—so that you do not have to return to the rig to get it. To help the toxicologist, gather all of the information you need before you call. Many people have the impression that the toxicologist should be called only for cases of ingested poisonings. However, the toxicologist can provide valuable care information for all types of poisoning. Your community may have special poisoning problems. For example, not every community is exposed to rattlesnakes, jellyfish, or powerful agricultural chemicals. Many EMS systems have compiled lists of poisoning problems specific for their areas. Check to see if this has been done for the area in which you will be an EMT.

Absorbed Poisons First take standard precautions 1. Remove the patient from the source or the source from the patient. Avoid contaminating yourself with the poison. 2. Brush powder from the patient. Be careful not to abrade the patient’s skin. 3. Remove contaminated clothing and other articles 4. Irrigate with clear water for at least 20 minutes. Catch contaminated run off and dispose of it safely. 5. Contact medical direction. 6. Transport the patient.

NOTE: Take care to protect your skin from contact with poisonous substances. Wear protective clothing. If necessary, have fire fighters or others who are properly protected hose off the patient before you touch him.

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ALCOHOL AND SUBSTANCE ABUSE Many patients’ conditions are caused directly or indirectly by alcohol or drug abuse- problems that cross all geographic and economic boundaries.

Alcohol Abuse

Many persons consume alcohol without having any problems. However, others occasionally or chronically abuse alcohol. Even though adults can legally drink alcohol, it is still a drug that can have a potent effect on a person’s central nervous system. Emergencies arising from abuse the use of alcohol may be due to the effect of alcohol that has just been consumed, or it may be the result of the cumulative effects of years of alcohol abuse. EMTs often do not take alcohol abuse patients seriously. This may be due to some such patients’ belligerent or unusual behavior, frequent calls to EMS when intoxicated, or less than desirable hygiene. Nevertheless, you should provide care for the patient suffering from alcohol abuse the same as you would for any other patient. Patients who appear intoxicated must be treated with the same respect and dignity as those who are “sober.” Above all. you must not neglect your duty to provide medical care. Not only do alcohol- abuse patients often have injuries from accidents and falls but they are also candidates for many medical emergencies. Chronic drinkers (alcoholics) often have derangements in blood sugar levels, poor nutrition, the potential for considerable gastrointestinal bleeding, and other problems. A person can be both intoxicated and having a heart attack or hypoglycemia. If the patient has ingested alcohol and other drugs, this can produce a serious medical emergency. When alcohol is combined with other depressants such as antihistamines and tranquilizers, the effects of alcohol can be more pronounced and, in some cases, lethal. Since EMT safety is a critical part of all calls, do not hesitate to ask for police assistance with any patient who appears intoxicated or irrational or exhibits potentially dangerous behavior. The nature of intoxication is such that a passive person may suddenly become aggressive. Always be prepared for this event.

PATIENT ASSESSMENT Keep in mind that, although alcohol abuse may be the patient’s only problem, there may be another problem present. Conduct a complete assessment to identify any medical emergencies Remember that diabetes, epilepsy, head injuries, high fevers, hypoxia, and other medical problems may make the patient appear to be intoxicated when he is not. Also look for injuries. Do not allow the presence of alcohol or the signs and symptoms of alcohol abuse to override your suspicions of other medical problems or injuries. Since getting a history from any patient who appears intoxicated will be difficult and perhaps unreliable, your powers of observation and resourcefulness will be tested. Family members and bystanders may provide important information. The following list, contains signs and symptoms of alcohol abuse: • Odor of alcohol on the patient’s breath or clothing By itself, however, this is not enough to conclude alcohol abuse. Be certain that the odor is not ‘acetone breath.” as with some diabetic emergencies. • Swaying and unsteadiness of movement. • Slurred speech, rambling thought patterns, incoherent words or phrases. • A flushed appearance to the face, often with the patient sweating and complaining of being warm. • Nausea or vomiting. • Poor coordination. • Slowed reaction time. • Blurred vision. • Confusion. • Hallucinations, visual or auditory (“seeing things” or “hearing things”). • Lack of memory (blackout). • Altered mental status.

The alcoholic patient may not be under the influence of alcohol but, instead, may be suffering from alcohol withdrawal This can be a severe condition occurring when the alcoholic patient cannot obtain alcohol, is too sick to drink alcohol, or has decided to quit drinking suddenly The alcohol-withdrawal patient may experience seizures or delirium tremens (DTs). a condition characterized by sweating, trembling, anxiety and hallucinations In some cases, alcohol withdrawal can be fatal Signs of alcohol withdrawal include: • Confusion and restlessness. • Unusual behavior, to the point of demonstrating “insane” behavior. • Hallucinations. • Gross tremor (obvious shaking) of the hands. • Profuse sweating. • Seizures (common and often very serious). • Hypertension. • Tachycardia.

Be on the alert for signals—such as depressed vital signs—that the patient has mixed alcohol and drugs also. When interviewing the intoxicated patient or the patient suffering from alcohol withdrawal, do not begin by asking the patient if he is taking drugs. He may react to this question as if you are gathering evidence of a crime. Ask if any medications have been taken while drinking. If necessary, when you are certain that the patient knows you are concerned about his well-being, you can repeat the question using the word drugs.

NOTE:

All patients with seizures or DTs must be transported to a medical facility as soon as possible.

PATIENT CARE

Alcohol Abuse

Since alcohol abuse patients often vomit, take standard precautions including gloves, mask, and protective eyewear as necessary. To provide basic care for the intoxicated patient and the patient suffering alcohol withdrawal, follow these steps:

1. Stay alert for airway and respiratory problems. Be prepared to perform airway maintenance, suctioning, and positioning of the patient should the patient lose consciousness, seize, or vomit. Help the patient so that vomitus will not be aspirated. Have a rigid-tip suction device ready. Provide oxygen and assist respirations as needed. 2. Assess for trauma the patient may be unaware of because of his intoxication. 3. Be alert for changes in mental status as

alcohol is absorbed into the bloodstream. Talk to the patient in an effort to keep him as alert as possible. 4. Monitor vital signs. 5. Treat for shock. 6. Protect the patient from self-injury. Use restraint as authorized by your EMS system. Request assistance from law enforcement if needed. Protect yourself and your crew. 7. Stay alert for seizures. 8. Transport the patient to a medical facility. LIFELINE

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Day 16 Note that, in some systems, patients under the influence of alcohol who are not suffering from a medical emergency or apparent injury are not transported. They are given over to the police. This may not be wise since these patients having an alcohol-related emergency may die if they don’t receive additional care. In addition, EMS personnel may have missed a medical problem or injury. Remember that the patient’s condition may worsen as the alcohol continues to be absorbed by his system. Be especially careful of patients with even minor head injuries, since subdural hematoma is common in alcoholics.

POISONING AND OVERDOSE Ang pasyente na lasing ay hindi puwedeng asahan na magbigay ng matinong sagot kung tatanungin mo siya kung gusto ba niya o hindi na bigyan ng lunas. Kung ang pasyente ay tumatanggi at ayaw tumanggap ng tulong, tulungan mo pa rin ito at dalhin ito sa ospital kapag nakakuha ka na ng permiso mula sa medical director. Maging maingat sa pagbiyahe sa pasyente na umaayaw sa tulong. Tiyakin na dokumentado ang paghahatid mo at pagbibigay lunas dito para makaiwas sa anumang kaso.

Substance Abuse Substance abuse is a term that indicates a chemical substance is being taken for other than therapeutic (medical) reasons. Many substances have legitimate purposes when used properly. When these same substances are abused, however, the results can be devastating. Not only are substance abuse patients at risk for dangerous effects of the substances they abuse, they are also at increased risk of trauma as a result of their impaired judgment when under the influence and the inherent risks of violence related to “drug deals.” Individuals who abuse drugs and other chemical substances should be considered to have an illness. Therefore, they have the right to the same professional emergency care as any other patient. The most common drugs and chemical substances that are abused and can lead to problems requiring an EMS response can be classified as uppers, downers, narcotics, hallucinogens, and volatile chemicals. • Uppers are stimulants that affect the nervous system and excite the user. Many abusers use these drugs in an attempt to relieve fatigue or to create feelings of wellbeing. The best example of this is metamphetamine hydrochloride or more popularly known as shabu. Considered as “poor man’s cocaine,” shabu is available in crystal form, melted in aluminum foil, and the fumes inhaled by the user. It is the most abused illegal drug in the Philippines. • Downers have a depressant effect on the central nervous system. This type of drug may be used as a relaxing agent, sleeping pill, or tranquilizer. Barbiturates are an example, usually in pill or capsule form. One example of a downer that you may encounter on an EMS call is Rohypnol (flunitrazepam), also known as Roofies. Because it is colorless, odorless, tasteless, and has been put into unsuspecting people’s drinks, it has become known as a “date rape” drug. Another downer you may see is

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marijuana which is often smoked by users. It produces euphoria and sometimes hallucinations. • Narcotics are drugs capable of producing stupor or sleep. They are often used to relieve pain. Many drugs legitimately used for these purposes (such as codeine) are also abused, affecting the nervous system and changing many of the normal activities of the body, often producing an intense state of relaxation or feeling of well-being. A relatively new narcotic. OxyContin (oxycodone), has become a common drug of abuse. This is unfortunate, because it has done an excellent job of controlling chronic pain in patients with certain conditions. Illegal narcotics such as heroin are also commonly abused. Heroin is often injected into a vein. Other narcotics are typically in pill form. Narcotic overdoses are generally characterised by three signs: coma (or depressed level of consciousness), pinpoint pupils, and respiratory depression (slow, shallow respirations). Together, these are sometimes referred to as the opiate triad. • Hallucinogens such as LSD. PCP. and certain types of mushrooms are mind-affecting drugs that act on the nervous system to produce an intense excitement or a distortion of the users perceptions. This class of drugs has few legal uses. They are often eaten or dissolved in the mouth and absorbed through the mucous membranes. A newer hallucinogen is ecstasy, also known as XTC, X. or MDMA (because it is methylenedioxymethamphetamine). Often taken at “rave” parties with other drugs, this hallucinogen also has the stimulant properties of uppers. • Volatile chemicals produce vapors that can be inhaled. They can give an initial “rush” and then act as a depressant on the central nervous system. Cleaning fluid, glue, model cement, and solutions used to correct typing mistakes are commonly abused volatile chemicals.

PATIENT ASSESSMENT Substance Abuse As an EMT, you will not need to know the names of the many abused drugs or their specific reactions. It is far more important for you to be able to detect possible drug abuse at the overdose level and to relate certain signs to certain types of drugs and drug withdrawal provides some of the names of commonly abused drugs. Do not worry about memorizing this list. Read it through so that you can place some of the mote familiar drugs into categories in terms of drug type. The signs and symptoms of substance abuse, dependency, and overdose can vary from patient to patient, even for the same drug or chemical. The problem is made more complex by the fact that many substance abusers take more than one drug or chemical at a time. Often, you will have to carefully combine the information gained from the signs and symptoms, the scene, the bystanders, and the patient in order to determine if you may be dealing with substance abuse In many cases, you will not be able to identify the substance involved. When questioning the patient and bystanders. you will get better results. if you begin by asking if the patient has been taking any medications Then, if necessary, ask if the patient has been taking drugs. Some significant signs and symptoms related to specific types of drugs include those listed in the following text These are offered to help you recognize possible drug abuse in general Your patient care may not change as a result of this knowledge, but information you can gather about what kind of drug the patient may have been taking will be useful to hospital personnel.

When reading the just-listed signs and symptoms of drug abuse, you will have noticed that many of the indications are similar to those for quite a few other medical emergencies. As an EMT. you must never assume drug abuse is occurring by itself You must be on the alert for medical emergencies, injuries, and combinations of drug abuse problems with other emergencies. In addition to the effects of long-term drug use and overdose, you may encounter cases of severe drug withdrawal. Withdrawal occurs when the long-term user of certain drugs such as narcotics suddenly stops taking the drug As m reactions to the use of various drugs, withdrawal varies from patient to patient and from drug to drug In cases of drug withdrawal, you may see: • Shaking • Anxiety • Nausea • Confusion and irritability • Hallucinations (both visual and auditory—”seeing things’ or “hearing things’) • Profuse sweating • Increased pulse and breathing rates

The following list features signs and symptoms of drug abuse for various types of drugs: • Uppers. People who abuse these drugs display

•

excitement, increased pulse and breathing rates, rapid speech, dry mouth, dilated pupils, sweating, and the complaint of having gone without sleep (or long periods Repeated high doses can produce a “speed run.” The patient will be restless, hyperactive, and usually very apprehensive and uncooperative. Downers. People who abuse these drugs are sluggish, sleepy patients lacking typical coordination of body and speech Pulse and breathing rates are low. often to the point of a true emergency. Narcotics. People who abuse these drugs have a reduced rate of pulse and rate and depth of breathing, which is often seen with a lowering of skin temperature. The pupils are constricted, often pin-point in size The muscles are relaxed and

•

sweating is profuse The patient is very sleepy and does not wish to do anything In overdoses, coma is common. Respiratory arrest or cardiac arrest may rapidly develop. Hallucinogens. People who abuse these drugs have a fast pulse rate dilated pupils, and a flushed face. The patient often “sees’ or “hears” things, has little concept of real time, and may not be aware of the true environment. Often what he says makes no sense to the listener The user may become aggressive or be very timid. Volatile chemicals. People who abuse these drugs appear dazed or show temporary loss of contact with reality. The patient may develop a coma The linings of the nose and mouth may show swollen membranes. The patient may complain of a “funny numb feeling” or “angling” inside the head. Changes in heart rhythm can occur. This can lead to death.

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Day 16 Many drug abusers may appear calm at first and then become violent as time passes. Always be on the alert and ready to protect yourself. If the patient creates an unsafe scene and you are not a trained law enforcement officer, GET OUT and find a safe place until the police arrive. When dealing with drug abuse, you must also protect yourself from the substance itself. Many hallucinogens can be absorbed through the skin and mucous membranes. Intravenous drug users may possess hypodermic syringes, which pose a hazard of infectious disease transmission through accidental punctures. Take standard precautions and follow all infection exposure control procedures. Never touch or taste any suspected illicit substance. Kadalasan ang mga pasyente na nagaabuso sa droga ay wala sa tamang pag-iisip at nagiging bayolente. Maging maingat sa pagresponde sa mga ganitong kaso. Kung hindi sigurado na ligtas ang paligid, huwag muna pumasok at humingi agad ng back-up. Maging maingat din sa paghawak sa mga ineksyon na ginamit ng pasyente. Puwede kang mahawa sa anumang sakit kung ikaw ay aksidenteng matutusok nito.

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SUBSTANCE ABUSE

PATIENT CARE

Substance Abuse

Your care for the drug-abuse patient will be basically the same for all drugs and will not change unless you are so ordered by medical direction. When providing care for substance-abuse patients, make certain that you are safe and identify yourself as an EMT to the patient and bystanders. Since these patients often vomit, take standard precautions, including gloves, mask, and protective eye-wear as necessary Be aware of loose hypodermic needles or weapons on the scene that can pose significant risks to you as an EMT.

Emergency care includes the following 1. Perform a primary assessment. Provide basic life support measures if required. 2. Be alert for airway problems and inadequate respirations or respiratory arrest. Provide oxygen and assist ventilations if needed. 3. Treat for shock. 4. Talk to the patient to gain his confidence and to help maintain his level of responsiveness. Use his name often, maintain eye contact, and speak directly to the patient. 5. Perform a physical exam to assess (or signs of injury to all parts of the body. Assess carefully for signs of head injury. 6. Look (or gross soft-tissue damage on the extremities resulting from the injection of drugs (tracts). Tracks usually appear as darkened or red areas of scar tissue or scabs over veins. 7. Protect the patient from self-injury and his attempts to hurt others. Use restraint as authorized by your EMS system Request assistance from law enforcement if needed. 8. Transport the patient as soon as possible. 9. Contact medical direction according to local protocols. 10. Perform reassessment with monitoring of vital signs. Stay alert for seizures, and be on guard for vomiting that could obstruct the airway. 11. Continue to reassure the patient throughout all phases of care.

COMMONLY ABUSED DRUGS UPPERS

NARCOTICS

DOWNERS

AMPHETAMINE (Benzedrine, bennies, pep pills, ups, uppers, cartwheels)

CODEINE (often in cough syrup)

BIPHETAMINE (bam)

D1LAUDID FENTANYL (Sublimaze)

BARBITURATES (downers, dolls, barbs, rainbows) Note: Barbiturates include amobarbital, pentobarbital, phenobarbital, and secobarbital

COCAINE {coke, snow, crack)

HEROIN (“H,” horse, junk, smack, stuff)

AMOBARBITAL (blue devils, downers, barbs, Amytal)

METHADONE (dolly)

PENTOBARBITAL (yellow jackets, barbs, Nembutal)

DESOXYN (black beauties) DEXTROAMPHETAMINE (denies, Dexedrine)

DEMEROL (meperidine)

MORPHINE OPIUM (op, poppy) METHAMPHETAMINE (speed, crank, meth, crystal, diet pills, methedrine) METHYLPHENI DAT E (Ritalin)

PAREGORIC (contains opium)

PHENOBARBITAL (goofballs, phennies, barbs)

ACETOMINOPHEN WITH CODEINE (1,2. 3, & 4)

SECOBARBITAL (red devils, barbs, Seconal)

PRELUDIN

MIND ALTERING DRUGS

VOLATILE CHEMICALS

HALLUCINOGENIC:

AMYL NITRATE (snappers, poppers)

DMT LSD (acid, sunshine)

BUTYL NITRATE (Locker Room, Rush)

MESCALINE (peyote, mesc)

CLEANING FLUID (carbon tetrachloride)

OTHER DOWNERS: CHLORAL HYDRATE (knockout drops, Noctet) METHAQUALONE (Quaalude, ludes, Sopor, sopors)

MORNING GLORY SEEDS PCP (angel dust, bog, peace pills)

FURNITURE POLISH

NON BARBITURATE SEDATIVES (various tranquilizers and sleeping pills: Valium or diazepam, Miltown, Equanil, meprobamate, Thorazine, Compazine, Librium or chiordiazepoxide, reserpine, Tranxene or clorazepate, and other benzodiazepines)

PSILOCYBIN (magic mushrooms)

GASOLINE

PARALDEHYDE

STP (serenity, tranquil-ity, peace)

GLUE

NONHALLUCINOCE-NIC:

HAIR SPRAY

HASH, MARI|UANA (grass, pot, tea, wood, dope)

NAIL POLISH REMOVER

THC PAINT THINNER TYPEWRITING CORRECTION FLUIDS

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DEPRESSION is a growing concern among Filipinos, particularly the youth. And with depression comes various forms of substance abuse, and in extreme cases it leads to suicide. Wile suicide rate in the Philippines is considerably lower compared to other countries, figures have steadily risen over a period of 20 years from 1992 to 2012. Experts found that in 2012 alone, as many as seven Filipinos took their own lives in a day. Thatâ&#x20AC;&#x2122;s an alarming rate of one person committing suicide every three and a half hours. Experts say that these people who commit suicide were faced with stressful events. Many of them experienced negative thoughts about oneâ&#x20AC;&#x2122;s self, the world, and the future. In short, they have lost hope. Oftentimes, you as a future EMT would be called in to deal with people suffering from depression, or exhibiting abnormal behavior due to alcoholism or drug abuse. How do you handle such cases? This chapter will provide you with the basic tools in dealing with mentally disturbed and/or depressed people. These tools are designed to first and foremost keep you safe, and also to prevent the patient from hurting himself and other people. These tools will serve as your guide. Keep them in mind and they will prove handy when the need for them arises.

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DAY

Emergencies In Mentally Disturbed Patient Behavioral emergency Potential or attempted suicide Aggressive or hostile patients Medical and legal considerations Schizophrenia, bipolar disorder, etc.

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Day 17

PRINCIPLES OF EMT CLINICAL PRACTICE

EMERGENCIES IN MENTALLY DISTURBED PATIENTS LEARNING OBJECTIVES

INTRODUCTION

• Define behavioral emergencies. • Discuss the general factors that may cause an alteration in a patient’s behavior. • Discuss the characteristics of an individual’s behavior which suggests that the patient is at risk for suicide or violence. • Discuss special medical/legal considerations for managing behavioral emergencies. • Discuss the special considerations for assessing a patient with behavioral problems. • Discuss methods to calm behavioral emergency patients.

As an EMT, you will respond to many emergencies in which the patient is behaving in unexpected and sometimes dangerous ways. The unusual behavior may be the result of stress, physical trauma or illness, drug or alcohol abuse, or a psychiatric condition (mental disorder).

BEHAVIORAL AND PSYCHIATRIC EMERGENCIES

What Is a Behavioral Emergency?

We all exhibit behavior. Behavior is defined as the manner in which a person acts or performs. It involves any or all activities of a person, including physical and mental activity. Of course, behavior differs from person to person and from situation to situation. A behavioral emergency exists when a person exhibits abnormal behavior—that is, behavior within a given situation that is unacceptable or intolerable to the patient, the family, or the community, A key part of that definition is “within a given situation.” You may have observed that, in your own life or in that of friends or family, behavior varies. depending on the situation at hand. For example, if a person is notified unexpectedly of the death of a loved one, a common

reaction is screaming, crying, throwing things, or other emotional outbursts. In the context of the situation, this behavior would not be unusual. If the same behaviors were exhibited for no apparent reason in the middle of a shopping center, they might indicate a behavioral emergency. Remember that you will be exposed to persons from other cultures and with different lifestyles. Some behaviors may seem unusual to you but might be quite normal to the person performing them. Behavioral conditions require full patient assessment, including primary and secondary assessments, just like any other emergency. Remain objective. Do not judge patients hastily or solely on the way they look or act.

Psychiatric Conditions Some, but not all. behavioral emergencies arc caused by psychiatric conditions, which may also be called mental disorders. The Department of Health has listed mental disorder, particularly depression, as one of its priority concerns. Not visible to the eye, depression is something that affects millions of Filipinos. According to the DOH, depression, if not addressed, can lead to suicides.

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As an EMT, you will be trained to be a “crisis responder” who will answer calls from people with suicidal tendencies and other psychiatric crises. These people have mood disorders, anxiety or panic issues. Some of them may even suffer from schizoprenia and bipolar disorder. This chapter will help you understand these people and care for them.

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

CRITICAL CONCEPTS

Physical Causes of Altered Mental Status It is helpful to consider patients who are exhibiting crisis or unusual behavior to he having an altered mental status from a non psychiatric cause until proven otherwise. Many medical and traumatic conditions are likely to alter a patient ‘s behavior. These problems may include: • Low blood sugar, which may be the cause of rapid onset of erratic or hostile behavior (similar to alcohol intoxication), dizziness and headache, fainting, seizures, sometimes coma, profuse perspiration, hunger, drooling, and rapid pulse but normal blood pressure. • Lack of oxygen, which may cause restlessness and confusion, cyanosis (blue or gray skin), and altered mental status. • Stroke or inadequate blood to the brain, which may cause confusion or dizziness impaired speech, headache, loss of function of paralysis of extremities on one side of the body, nausea and vomiting, and rapid full pulse. • Head trauma, which can cause personality changes ranging from irritability to irrational behavior, altered mental status, amnesia or confusion, irregular respiration, elevated blood pressure, and decreasing pulse. • Mind altering substances, which can cause highly variable signs and symptoms depending on the substance ingested. • Excessive cold, which may cause shivering, feelings of numbness, altered mental status, drowsiness, staggering walk, slow breathing, and slow pulse. • Excessive heal, which may cause decreased or complete loss of consciousness. When dealing with someone who appears to be having a behavioral emergency, always consider the possibility that his unusual behavior is caused by something other than a psychological problem.

Situational Stress Reactions When faced with severe, unexpected stress, most patients will display emotions such as fear, grief, and anger These are typical stress reactions at the accident scene and common reactions to serious illness and death. In the vast majority of cases, as you begin to take control of the situation and treat the patient as an individual, your personal interaction will inspire confidence in your ability to help. The patient will begin to calm down and may even begin to feel able to cope with the emergency. Be as unhurried as you can. If you rush your patient assessment and interview, the patient may feel as if the situation is out of control. The patient also may believe that you are concerned about the problem but not about him. Let the patient know that you are there to help.

Whenever you care for a patient who is displaying typical stress reactions, act in a calm manner, giving the patient time to gain control of his emotions. Quietly and carefully evaluate the situation, keeping your own emotions under control. Let the patient know that you are listening to what he is saying, and honestly explain things to the patient. Stay alert for sudden changes in behavior. By acting in this manner, you are applying crisis management techniques to help the patient deal with stress. If the patient does not begin to interact with you or calm down, and if there are no apparent physical causes for the behavior, you must assume that there is a problem of a more serious nature, such as a psychiatric problem. Proceed according to the recommendations in the following segments of this chapter.

As an EMT, be sure to ensure your own safely before entering a scene or caring for a violent or potentially violent patient. A considerable portion of the population has a diagnosable psychiatric condition. However, not all patients are violent, It is important to remember that patients in crisis are patients— and people— who need your compassion as well as your care. Always consider patients acting in an unusual or bizarre fashion to be experiencing an altered mental status: this will help you to avoid overlooking a medical or traumatic cause for the patient’s problem. Because the treatment for these patients usually requires long-term management, little medical intervention can be done in the acute psychiatric situation. However, the way you interact with the patient during the emergency and assess your patient throughout the call is crucial for their continued well-being.

Maging maingat sa pagtrato sa pasyente lalo pa’t ito ay takot, galit o sobra ang lungkot. Huwag magmadali. Iparamdam sa pasyente na mahalaga siya sa iyo at nais mo siyang matulungan.

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MENTALLY DISTURBED PATIENTS

EMERGENCY CARE FOR BEHAVIORAL OR PSYCHIATRIC EMERGENCIES Behavioral and Psychiatric Emergencies Behavioral and psychiatric problems have a wide variety of manifestations and presentations. One patient may be withdrawn and not wish to communicate, whereas another may be agitated, talkative, or exhibiting bizarre or threatening behavior. Some patients may act as if they wish to harm themselves or others. Follow these general rules when dealing with a patient who is experiencing a behavioral or psychiatric emergency: • Identify yourself and your role. • Speak slowly and clearly. Use a calm and reassuring tone. • Make eye contact with the patient. • Listen to the patient. You can show you are listening by repeating part of what the patient says back to him. • Do not be judgmental. Show compassion, not pity. • Use positive body language. Avoid crossing your arms or looking uninterested. • Acknowledge the patient’s feelings. • Do not enter the patient’s personal space. Stay at least 3 feet from the patient. Making the patient feel closed in can cause an emotional outburst. • Be alert for changes in the patient’s emotional status. Watch for increasingly aggressive behavior and take appropriate safety precautions.

PATIENT ASSESSMENT

Behavioral or Psychiatric Emergency To assess a patient who appears to be suffering a behavioral or psychiatric emergency. • Perform a careful scene size-up. If there are indications at the time of dispatch that the call may involve a potentially violent or agitated patient, then police should be requested to respond to the scene, arriving ahead of EMS units to assure the scene is safe for EMS to enter. • Identify yourself and your role. It may not be obvious to the patient who you ate and what you intend to do • Complete a primary assessment, including assessment of the patient’s mental status (level of responsiveness, orientation to person. place, and time). • Perform as much of the detailed examination as possible. Be alert for medical and traumatic conditions that could be causing the patient’s behavior. • Gather a thorough patient history. This will alert 420

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you to past psychiatric problems, or psychiatric medications the patient may be taking (or not taking— causing the outburst). This may also alert you to conditions such as diabetes that can closely mimic a psychiatric condition. The following are common presentations or signs and symptoms, of patients experiencing psychiatric emergencies • Panic or anxiety. • Unusual appearance, disordered clothing, or poor hygiene. • Agitated or unusual activity, such as repetitive motions, threatening movements, or withdrawn stance. • Unusual speech patterns, such as too rapid or pressuredsounding speech (as if being forced out), or an inability to carry on a coherent conversation. • Bizarre behavior of thought patterns. • Suicidal or self-destructive behavior. • Violent or aggressive behavior with threats or intent to harm others.

Inside/Outside The nervous system works through the use of neurotransmitters. Electrical impulses travel along neurons until they reach a synapse—a space between nerve cells. Neurotransmitters are chemicals within the body that transmit the message from the distal end of one neuron (the pre-synaptic neuron) to the proximal end of the next neuron (postsynaptic neuron). Although it sounds like a complicated process, it actually takes only milliseconds. Neurotransmitters are released from a neuron, then travel across the synapse to the next neuron. The receptors on the postsynaptic neuron receive the neurotransmitter. This is the mechanism by which the impulse is moved along the nervous system. After the impulse is transmitted, the neurotransmitter goes through a process called reuptake, In which the neurotransmitter is returned to the pre-synaptic neuron. Neurotransmitters—-or the lack of neurotransmitters—have been implicated in depression and other mental disorders. Medications prescribed for these conditions are designed to affect the relevant neurotransmitters. One commonly prescribed class of drugs is the selective serotonin reuptake inhibitor (SSRI). This medication is believed to elevate mood by preventing the reuptake of the neurotransmitter serotonin in the synapse- Prozac, Paxil, and Zoloft are trade names of commonly prescribed SSRI medications. Newer medications offer reuptake inhibition of more than one neurotransmitter. In addition to serotonin, neurotransmitters include norepinephrine, epinephrine, and dopamine.

PATIENT CARE

UNIT 3 DAY 17

PRINCIPLES OF EMT

Behavioral or Psychiatric Emergency Emergency care of a patient having a behavioral or psychiatric emergency involves these stops: • Be alert (or personal or scene safety problems throughout the call. • Treat any life-threatening problems during the primary assessment. • Be alert for medical or traumatic conditions that could mimic a behavioral emergency. Treat conditions you identify (e.g. low blood sugar level). • Be prepared to spend time talking to the patient Use the skills listed earlier in dealing with the patient Remember

SUICIDE WOUNDS

to talk In a calm, reassuring voice. Use positive body language and good eye contact. Avoid unnecessary physical contact and quick movements. • Encourage the patient to discuss what is troubling him. • Never play along with any visual or auditory hallucinations that a patient may be experiencing. Do not lie to the patient. • If it appears it will help, involve family members or friends in the conversation. Evaluate the patient’s response to the presence of others If it agitates the patient, ask the others to leave.

Neurotransmitters—-or the lack of neur depression and other mental disorders. tions are designed to affect the relev prescribed class of drugs is the selective medication is believed 10 elevate mood rotransmitter serotonin in the synaps names of commonly prescribed SSRI me Sa tuwing ikaw ay ipapadala para tulungan ang isang pasyente na nagtangka o magtatangka nang magpakamatay, ang unang dapat mong isipin ay ang iyong sariling kaligtasan. Hindi lahat ng pasyente na makakaharap mo ay gusto kang saktan, pero ang paraan nito sa pagtatangkang magpakamatay ay maaaring makasakit sa iyo. Maging alisto. Protektahan palagi ang sarili mula sa panganib.

Newer medications offer reuptake inhi ter. In addition to serotonin, neurotra nephrine, and dopamine.

PATIENT CARE

Behavioral or Psychiatric Eme

Emergency care of a patient having involves these stops: SUICIDE WOUNDS  Be alert (or personal or scene s  Treat any life-threatening prob SUICIDE Suicide is the second leading cause of death globally among people 15 to 29 years of age, according to the 2014  Be alert for medical or traumat global report on preventing suicide by the World Health Organization. ioral emergency. Treat condit In the Philippines, the estimated number of suicides in 2012 was 2,558 (550 female, 2009 male), according to the same report. level) Anyone may become suicidal if emotional distress is severe, regardless of gender, age. or ethnic, social, or economic background.  Be prepared to spend time ta People attempt suicide for many reasons, including depression caused by chemical imbalance, the death of a loved one. financial problems, the end to a love affair, poor health, loss of esteem, divorce, fear of failure, and alcohol earlier in dealing with the pati and drug abuse. People attempt to end their lives by any one of a variety of methods. You may observe suicides or ing voice. Use positive body l attempted suicides by drug overdose, hanging, jumping from high places, ingesting poisons, inhaling gas. wrist-cut ling, self-mutilation, stabbing, or shooting. unnecessary physical contact a  Encourage the patient to discu LIFELINE PREHOSPITAL EMERGENCY CARE 421  Never play along with any vis tient may be experiencing. Do

Day 17

PATIENT ASSESSMENT Potential or Attempted Suicide Factors often associated with a risk for suicide appeal in the following list Although some or even all of them may be present in a patient, it is not possible to use these characteristics to predict who will or who will not commit suicide:

• Depression. Take seriously a patient s feelings and expressions of despair or suicidal thoughts

• High current or recent stress levels. If

these are present, take the threat of suicide seriously • Recent emotional trauma. This could be job loss, loss of a significant relationship, serious illness, arrest, or imprisonment • Age. High suicide rates occur at ages 15 to 25 and over age 40. The elderly are a population where suicide rates are increasing • Alcohol and drug abuse. • Threats of suicide. The patient may have told others that he is considering suicide Take all threats of suicide seriously • Suicide plan. A patient who has a detailed suicide plan is more likely to commit suicide. Look for a plan that includes a method to carry out the suicide, notes, giving away personal possessions, or getting affairs in order • Previous attempts or suicide threats. These could include a history of selfdestructive behavior Often patients who have attempted suicide on a previous occasion are considered to be ‘looking for attention’ and are not taken seriously on subsequent attempts However, statistics reveal that a person who has attempted suicide in the past is more likely to commit suicide than one who has not. • Sudden improvement from depression. A patient who has made the decision to commit suicide may actually appeal to be coming out of a depression The fact that the decision has been made and an end is in sight can cause this apparent ‘improvement.” You may find family members and friends of suicidal patients who will report that the patient had seemed “better” in the past few days

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PATIENT CARE Potential or Attempted Suicide Patients who are in an emotional, psychiatric, or attemptedsuicide emergency are cared for in similar ways In all cases, your personal interaction with the patient is key. Try to establish visual and verbal contact as soon as possible. Avoid arguing Make no threats, and show no indication of using force. Remember that you are the first professional to begin both the physical and mental health care of the patient The more reassurance you can provide for the patient, the easier it will be for the hospital emergency department staff to continue care. Emergency care includes the following steps: 1. Treatment must begin with scene size-up. Make sure it is safe to approach the patient. If the scene is not safe, request assistance from the police and wait until they have secured the scene. Do not leave the patient alone unless you are at risk of physical harm. Try to talk with the patient from a safe distance until the police arrive Take Standard Precautions. 2. When the scene is secure, look for and treat lifethreatening problems to the extent that the patient will permit it. Seek police assistance in restraining the patient if necessary for care of life-threatening problems 3. As possible, perform a secondary assessment and provide emergency care 4. Perform a detailed physical exam only if it is safe and you suspect the patient may have an injury. 5. Perform a reassessment. Watch for sudden changes in the patient s behavior and physical condition 6. Contact the receiving hospital and report on the patient’s current mental status and other essential information Note that a physical exam may be difficult with the emotional or psychiatric patient. Because of this, you may not be able to proceed beyond the primary assessment. Throughout your interaction with the patient, speak slowly and patiently await answers to your questions. As you gain the patient’s confidence, explain what questions must be answered and what must be done as part of the physical exam and taking vital signs. Let the patient know that you think it would be best if he goes to the hospital and that you need his cooperation and help. Back off if necessary. If the patient’s fear or aggression increases, do not push the issues of the examination or transport. Instead, try to reestablish the conversation and give the patient more time before you again suggest that going to the hospital is a good idea. Transport all suicidal patients. Seek police assistance, if necessary. Report any attempted suicide or expression of suicidal thoughts to the medical facility, police, or government agency designated by your state law and local protocols.

Aggressive or Hostile Patients Aggressive or disruptive behavior may be caused by trauma to the brain and nervous system, metabolic disorders, stress, alcohol, other drugs, or psychological disorders. Sometimes you will know that your patient is aggressive from the information you receive from dispatch. Other times the scene may provide quick clues (such as drugs, yelling, unclean conditions, broken furniture). Neighbors, family members, or bystanders may tell you that the patient is dangerous or angry or has a history of aggression or combativeness. The patient’s stance (tense muscles, fists clenched, or quick irregular movements, for example) or his position in the room may give you an early warning of possible violence. On rare occasions, you may start with an apparently calm patient who suddenly turns aggressive. As already noted, when a patient acts as if he may hurt himself or others, your first concern must be your own safety. Take the following precautions: • Do not isolate yourself from your partner or other sources of help. Make certain that you have an escape route. Do not let the patient come between you and the door. If a patient should become violent, retreat and wait for police assistance. • Do not take any action that may be considered threatening by the patient To do so may bring about hostile behavior directed against you or others. • Always be on the watch for weapons. Stay out of kitchens, as they are filled with dangerous weapons. Stay in a safe area until the police can control the scene.

PATIENT ASSESSMENT Aggressive or Hostile Patient Your assessment of the aggressive or hostile patient may not go beyond the primary assessment phase until the patient is appropriately calmed or restrained. Most of your time may be spent trying to calm the patient and ensuring everyone s safety. However, aggression or hostility in a patient should never be used as an excuse for not assessing the patient as thoroughly as possible An aggressive or hostile patient: • Responds to people in appropriately • Tries to hurt himself or others • May have a rapid pulse and breathing • Usually displays rapid speech and rapid physical movements • May appear anxious, nervous, or “panicky”

PATIENT CARE Aggressive or Hostile Patient Follow these steps for the emergency care of an aggressive or hostile patient’ 1. Treatment begins with scene size-up. Make sure it is safe to approach the patient If needed, request assistance from law enforcement before making your approach. Practice Standard Precautions. 2. Seek advice from medical direction if the patient’s behavior prevents normal assessment and care procedures 3. As part of reassessment, watch for sudden changes in the patient’s behavior An agitated patient who suddenly becomes silent may be experiencing a serious medical emergency Complete reassessments involve rechecking the primary assessment frequently and upon any change in mental status 4. Seek assistance from law enforcement, as well as from medical direction, if restraint seems necessary.

Reasonable Force and Restraint Reasonable force is the force necessary to keep a patient from injuring himself or others. Reasonableness is determined by looking at all circumstances involved, including the patient’s strength and size, type of abnormal behavior, mental status, and available methods of restraint. Understand that you may protect yourself from attack, but otherwise you must avoid actions that can cause injury to the patient. In addition, in most localities an EMT cannot legally restrain a behavioral emergency patient, move such a patient against his will, or force such a patient to accept emergency care—even at the family’s request. The restraint and forcible moving of patients is usually within the jurisdiction of law enforcement. The police (and. in some areas, a physician) can order you to restrain and transport a patient to the appropriate medical facility. However, the physician is not empowered to order you to take action that could place you in danger. If the police order restraint and transport for the patient, they must perform or assist with these procedures as necessary. Remember to follow local protocol. At times, a patient with a medical or traumatic emergency may display violent behavior to the extent that restraint is necessary before the patient can receive the medical treatment he needs. For example, a diabetic patient with hypoglycemia may be acting abnormally and even aggressively. If the patient’s behavior interferes

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Day 17 with or prevents treatment and the EMT can safely restrain the patient, he should do so in order to initiate treatment. Similarly, a patient with a head injury may be hypoxic and acting abnormally. Again, if it can be done safely, the EMT should institute the needed treatment which, in this case, includes restraint so the patient can be safely transported to a facility where his head injury can be treated. Determining whether a particular patient has a medical or traumatic emergency that is causing his abnormal behavior can be difficult. Consider whether the patient is capable of giving or refusing informed consent, consult medical direction, and administer the care that is in the patient’s best interest without endangering yourself. Never try to assist in restraining a patient unless there are sufficient personnel to do the job. You must be able to ensure your safely as well as the patient’s safety. If you help the police or a physician to restrain a patient, make certain that the restraints are humane. For example, handcuffs and plastic “thrown way” criminal restraints should not be used because of the soft-tissue damage they can inflict. Initially, the police may have to use such restraints. However, in some states they can be replaced with soft restraints such as leather cuffs and belts. If authorized in your state and by local protocol, an ambulance should carry leather cuffs, a waist-size bell, and at least three short bells. Restraints for the wrists and ankles can be made from gauze roller bandages.

NOTE: The medical literature refers to a condition called excited delirium (also called agitated delirium). In this situation, a patient begins to act extremely agitated or psychotic. It is believed that a patient with this condition has an elevated temperature and sometimes alcohol or drug intoxication. The patient will cease struggling, and often within minutes the patient is found to have inadequate or absent respirations and subsequently dies. It is important for the EMT to be alert for this sequence of events if patients exhibit this behavior and monitor the patient constantly throughout the call. Do not remove police restraints until you and the police are certain that soft restraints will hold the patient, To ensure everyone’s safely once they are on. Do not remove soft restraints, even if the patient appears to be acting rationally.

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MENTALLY DISTURBED PATIENTS Follow these guidelines when a patient must be restrained: • Be sure to have adequate help, • Plan your activities: have a well-delineated plan of action before initiating the restraint. • Estimate the range of motion of the patient’s arms and legs and slay beyond that range until ready. • Once the decision to restrain the patient has been reached, act quickly. • Have one EMT talk to and reassure the patient throughout the restraining procedure. • Approach with a minimum of four persons, one assigned to each limb, all to act at the same time. (Five rescuers would allow an extra person to control the head. However, the rescuer at the head should use caution to prevent being bitten.) • Secure all four limbs with restraints approved by medical direction. • Position the patient face up. The position will be dictated by what the restraining process itself permits, the patient’s condition (e.g.. injuries, breathing problems), and local protocols. Monitor the patient’s airway, Never “hog tic” the patient or restrain the patient in any manner that will impair breathing. Patients who have been improperly restrained have died as a result of a condition often referred to as positional asphyxia. Carefully monitor all restrained patients. Many times a patient will become quiet and stop fighting, leading EMTs and police officers to relax because the patient appears to have calmed down. In some cases, the patient has stopped breathing and dies. It can’t be repeated enough: Monitor your restrained patient constantly throughout the call. • Use multiple straps or other restraints to ensure that the patient is adequately secured. Anticipate that the patients behavior may turn more violent and be sure that restraint is adequate for this possibility. • If the patient is spitting on rescuers, place a surgical mask on the patient if he has no breathing difficulty or likelihood of vomiting and if local protocols permit, or have rescuers wear protective masks, eye-wear, and clothing. • Reassess the patient’s distal circulation frequently and adjust restraints as safe and necessary if distal circulation is diminished. • Use sufficient force, but avoid unnecessary force. • Document the technique and reasons why the patient was restrained.

Transport to an Appropriate Facility Your medical protocols or procedures should direct you to the most appropriate medical facility within your service area. Not all hospitals are prepared to treat behavioral cases

Medical/Legal Considerations A patient who refuses emergency care or transport is a significant medical/legal risk for EMS agencies and EMTs. What should you do when a behavioral emergency patient refuses or resists your efforts to provide care? Most states have a provision in law that will allow a patient lo be transported against his will if he is a danger to himself or others. This is an exception to the rule that patients must provide consent for their care and transportation. Know your state laws on treating patients without consent. Many states give this authority to law enforcement personnel. It will always be beneficial to have the police present if the patient must be restrained as a matter of safety. You may also be required to contact medical direction about the psychiatric patient who refuses care. Many communities have mental health teams that will respond to the scene to help with the care of a patient with behavioral problems. This team will also help evaluate the need for transporting the pattern against his will. Emotionally disturbed patients sometimes accuse EMS personnel of sexual misconduct. If possible. EMTs of the same sex as the patient should attend to the emergency care of disturbed patients. For the aggressive or violent patient, make sure law enforcement officers accompany you to the hospital to protect you and the patient. In the event of a legal problem, they can serve as third-party witnesses. Restraining a Patient 1. Plan your approach to the patient in advance and remain outside the range of the patient’s arms and legs until you are ready to act. 2. Assign one EMT to each limb, and have all the EMTs approach the patient at the same time. 3. Place the patient on the stretcher as his/her condition and local protocols indicate. Do not let go until the patient is properly secured. 4. Use multiple straps or other soft restraints to secure the patient to the stretcher. 5. When the patient is secure, assess distal circulation and continually monitor airway and breathing.

NOTE:

A fifth rescuer, if available, can control the patient’s head—taking special care, however, not to be bitten.

General Rule for Interactions 1. Identify yourself and role. 2. Speak slowly and clearly. 3. Eye contact. 4. Listen. 5. Don’t Judge. 6. Open, positive body language. 7. Don’t enter patient space (within 3 ft.). 8. Alert for behavior changes. 9. Perform as much of the focused and detailed examinations as possible. Be alert for medical and traumatic conditions that could be causing the patient’s behavior. a. This will alert to past psychiatric problems or medications the patient may or may not be taking. b. This may also alert to conditions such as diabetes that can closely mimic a psychiatric condition.

Patient Care

1. Treat life-threatening problems. 2. Consider medical or traumatic causes. 3. Follow general rules for positive interactions. 4. Encourage patient to discuss feelings. 5. Never play along with hallucinations. 6. Consider involving family or friends.

Cognitive Disorders

1. May be organic a. Organic Brain Syndrome – temporary or permanent dysfunction of brain caused by disturbance in physical or physiologic functioning of brain tissue. 2. May be from physical or chemical injury a. disturbance of cognitive functioning. b. may manifest as delirium or dementia. i. Delirium 1) Abrupt disorientation (time and place). 2) Often illusions and hallucinations. a) Symptoms vary according to: i) Personality. ii) Environment. iii) Severity. b) Treatment: i) Correct underlying condition. ii. Dementia 1) Slow loss of function in multiple cognitive domain. a) Loss of awareness of time and place. b) Inability to learn new things. c) Short-term memory loss. 2) Causes a) Stroke. b) Alzheimer’s disease. LIFELINE

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DAY 17 Day 17

1. Group of disorders 2. Recurrent psychotic behavior episodes 3. Abnormalities of: a. Thought process b. Thought content UNIT 3 c. Perception d. Judgment DAY 17 4. Management of Paranoid Reactions a. Ignore if problem is not troubling patient b. Approach slowly if patient is hallucinating c. Don’t argue or rationalize d. Offer reassurance e. Check reality of situation 1. Anxiety useful and needed to adapt to stress a. anxiety disorders produce persistent fearful feelings 2. Severe anxiety may result in panic disorder 3. May mimic medical emergencies 4. Management a. Don’t leave patient alone b. Treatment is mainly supportive c. Consider sedation d. Transport for evaluation 5. Types 1. a. “Panic attack” 2. i. Hyperventilation ii. Feeling breathless iii. Blurred vision 3. iv. Paresthesia 4. v. Fear of losing control vi. Fear of dying vii. Somatic complaints viii. Chest discomfort ix. Palpitations x. Tachycardia xi. Dyspnea xii. Choking “ b. Phobia i. Transfer anxiety to a situation or an object 1) Irrational, intense fear 2) Often recognizes fear is unreasonable 3) Cannot prevent phobia ii. Explain steps in care iii. Reassure 1) Nightmares 2) Survivor guilt iii. Often complicated by substance abuse c. Obsessive-Compulsive Disorder i. Stress or anxiety related to thoughts or rituals that patient can’t control ii. Many forms (e.g. excessive hand washing) iii. Begin at any age – Heritable component iv. Treat with medication and therapy

Anxiety Disorders

“

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Schizophrenia

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PRI

d. Post-Traumatic Syndrome i. Anxiety reaction to severe psychosocial event (events often life threatening) ii. Manifestations: 1) Depression 2) Sleep disturbances 3) Nightmares 4) Survivor guilt PRINCIPLES OF EMT CLINICAL PRACTICE iii. Often complicated by substance abuse c. Obsessive-Compulsive Disorder i. Stress or anxiety related to thoughts or rituals that patient can’t control c. Obsessive-Compulsive Disorder ii. Many forms (e.g. excessive hand washing) i. stress or anxiety related to thoughts or rituals that patient iii. Begin at any age – heritable component can’t control iv. Treat with medication and therapy ii. many forms (e.g. excessive hand washing) d. Post-Traumatic Syndrome iii. begin at any age – heritable component iv. treat with medication and therapy i. Anxiety reaction to severe psychosocial event (events d. Post-Traumatic Syndrome often life threatening) i. anxiety reaction to severe psychosocial event (events often ii. Manifestations: life threatening) 1) Depression ii. manifestations: 2) Sleep disturbances 1) depression 3) Nightmares 2) sleep disturbances 4) Survivor guilt 3) nightmares iii. Often complicated by substance abuse 4) survivor guilt iii. often complicated by substance abuse

Mood Disorders

Alterations in emotions 1. Alterations in emotions Mood include: 2. Disorders Mood Disorders include: a. Depression a. Depression b. bipolar disorder b. Bipolar disorder 3. suicide risk with both Suicide risk with both 4. Depression Depression a. weight loss or gain a. Weight loss or gain b. decreased libido b. Decreased libido c. feelings of guilt and worthlessness c. Feelings of guilt and worthlessness d. hopelessness d. Hopelessness e. isolation e. Isolation f. tenseness f. Tenseness g. irritability h. anhedonia - inability to experience pleasure from activities usually g. Irritability found enjoyable h. Anhedonia - inability to experience pleasure from i. Major Features of Depression activities usually found enjoyable “ ““In SAD CAGES” i. Major Features of Depression Interest Sleep Appetite “In SAD CAGES” Depressed mood Interest Sleep Concentration Appetite Depressed mood Activity Concentration Activity Guilt Energy Guilt Suicide

Energy Suicide

PREHOSPITAL EMERGENCY CARE ² Limmer (Brady)

³ Pollack, (AAOS) ⁴ NHTSA

Soma Som

1 2.

Som Factit Fac

Diss Disso Fact 1

INCIPLES OF EMT CLINICAL PRACTICE d. Management

i. if unconscious: 1) ABC 5. Bipolar Disorder 5. a. Bipolar Disorder 2) Transport biphasic emotional disorder a. biphasic emotional disorder b. depressive and manic episodes alternate ii. try to establish a rapport and provide support 5. Bipolar Disorder b. depressive and manic episodes alternate c. Mania Rare Factitious Disorders a. Biphasic emotional disorder. iii. conduct interview to assess situation c. Mania Rare d. Management 1. Disorders in which symptoms mimic a true b. Depressive and manic episodes alternate. illness but actually have been invented. c. Mania Rare d. Management i. if unconscious: iv. provide physical safety a. Under control of patient to receive attention. d. Management i. if unconscious: ABC 1) i. If unconscious: v.Transport determine support systems available ABC 2) 1) 1) ABC 2) 2) Transport Dissociative Disorders Transport vi. establish reassure patient during crisis ii. try to a rapport and provide support ii. Try to establish a rapport and provide support. 1. Mental function is separated from the mind to establish a rapport and provide support try iii. Conduct interview to assess situation. iii. ii. conduct interview to to assess situation a. Dissociative amnesia. vii. transport appropriate facility iii. conduct iv.Provide physical safety. interview to assess situation iv. provide physical safety v. Determine support systems available. iv. provide physical systems safety available vi. Reassure patient during crisis. v. determine support determine vii. Transport to appropriate facility. support systems vi. v. reassure patient during crisis available reassureto patient during facility crisis vii.vi. transport appropriate vii. transport to appropriate facility

b. Dissociative identity disorder. c. Depersonalization.

Eating Disorders 1. Common psychiatric eating disorders. a. Anorexia nervosa. b. Bulimia nervosa. 2. Can result in starvation and death. a. Managed with regulation of eating habits, psychotherapy, antide-pressants. b. Most require hospitalization.

Personality Disorder 1. Fail to learn from experience or adapt appropriately to changes. 2. Distress and impaired social functioning. a. Generally recognized social functioning. b. Continue through life. 3. Treatment with behavior modification, counseling, psychotherapy.

atoform Disorders matoform Disorders

1. physical symptoms but nono physical cause 1. physical symptoms but physical causecan canbebefound found . definite or or strong evidence that underlying 2. definite strong evidence that underlyingcause causeisispsychological psychological

Somatoform Disorders matoform Disorders tious Disorders

1. Physical symptoms but no physical cause can ctitious Disorders be found. 2. 1. 1. Disorders in which symptoms DisordersDefinite or strong evidence that underlying in which symptomsmimic mimica atrue trueillness illnessbut butactually actuallyhave have cause is psychological.

1. physical symptoms but no physical cause can be found been invented been invented 2. a.definite or strong evidence that underlying cause is psychological under control of of patient toto receive attention a. under control patient receive attention

sociative Disorders ociative Disorders

titious Disorders

1. Mental function is separated from the mind 1. Mental function is separated from the mind a. dissociative amnesia dissociative amnesia 1. a.Disorders in which symptoms b. dissociative identity disorder

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mimic a true illness but actually have

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VERY few people are aware that July 8 has been declared in the Philippines as National Allergy Day. Though the day is not popular, it only proves that allergy is one of the major concerns of Filipinos. Experts say that one in five people either have allergies or allergic symptoms, and their reactions can range anywhere from an itchy nose to a swollen tongue, or something more dire. If youâ&#x20AC;&#x2122;re not an allergy sufferer yourself, you probably know someone who is. Allergies are so mundane in our everyday lives that it almost seems trivial to fuss about it. However, only those with allergies know what itâ&#x20AC;&#x2122;s like to suffer from allergies. Only those allergic to fur can sense a cat a mile away. Only those who are allergic to dust mites are awoken by their own sneeze. And only those who are allergic to seafood feel the itch whenever they ingest anything with the tiniest bit of shrimp in it. It is definitely inconvenient and stressful, and in some cases scary and even life-threatening. As an EMT, allergies are one of the things that you would have to deal with. This is the reason why we have devoted one chapter of this textbook to dealing with allergies.

DAY

Allergic Reaction

Causes of allergic reactions Allergic reaction or anaphylaxis Administering epinephrine

Day 18

CRITICAL CONCEPTS � Allergic reactions are common. But anaphylaxis, a true life-threatening allergic reaction, is rare. � The most common symptom in all of these cases is itching. Patients with anaphylaxis, though, will also display life-threatening difficulty breathing and/ or signs and symptoms of shock (hypoperfusion). These patients will also he extremely anxious. Their bodies are in trouble and are letting the patients know it. � The signs and symptoms of anaphylaxis are are results of physiological changes: vasodilation, bronchoconstriction, leaky capillaries, and thick mucus. � By quickly recognizing the condition, consulting medical direction, and administering the appropriate treatment, you can literally make the difference between life and death for these patients.

Ang pagkakaroon ng allergic reaction ay isang karaniwang problema sa mga pasyente. Kadalasan ng makakaharap mong may allergic reaction ay hindi grabe. Pero may mga pagkakataon na sobrang tindi ng allergic reaction na puwedeng malagay sa bingit ng kamatayan ang pasyente. Mahalaga na malaman kung ano ang mga dapat gawin sa mga ganitong pagkakataon.

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PRINCIPLES OF EMT CLINICAL PRACTICE

ALLERGIC REACTION LEARNING OBJECTIVES • Recognize the patient experiencing an allergic reaction. • Describe the emergency medical care of the patient with an allergic reaction. • State the generic and trade names, medication forms, dose, administration, action, and contraindications for the epinephrine auto-injector. • Differentiate between the general category of those patients having an allergic reaction and those patients having an allergic reaction and requiring immediate medical care, including immediate use of epinephrine auto-injector. • Explain the rationale for administering epinephrine using an autoinjector. • Establish the relationship between the patient with an allergic reaction and airway management.

INTRODUCTION

Allergic reactions can be mild or extremely severe. A mild allergic reaction can rapidly develop into a severe reaction. A severe allergic reaction can quickly become life threatening. For these reasons, prompt recognition and appropriate assessment and treatment of allergic reactions can be critical.

SO WHAT IS AN ALLERGIC REACTION? A natural response of the human body’s immune system is to react to any foreign substance—in other words, to defend the body by neutralizing or getting rid of the foreign material. Sometimes the immune response is exaggerated: this exaggerated reaction is called an allergic reaction. Almost any of a wide variety of substances can be an allergen, something that causes an allergic reaction. For example, cat dander can be an allergen. A person who is allergic to cat dander will itch and sneeze whenever a cat is nearby. The reaction is unpleasant but harmless. In some people, however, contact with certain foreign substances triggers an immune response that gets out of hand. Consider bee stings. Most people have no reaction to a bee sting other than pain and some swelling at the sting site. However, a few people have very severe, life-threatening reactions to bee stings. This kind of severe allergic reaction is called anaphylaxis, or anaphylactic shock. In anaphylaxis, exposure to the allergen will cause blood vessels to rapidly dilate, which causes a drop in blood pressure (hypotension). Many tissues may swell, including those that line the respiratory system. This swelling can obstruct the airway, leading to respiratory failure. NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

There are many causes of allergic reactions (in some individuals), such as: • Insects. The stings of bees, yellow jackets, wasps, and hornets can cause rapid and severe reactions. • Foods. Foods such as nuts. eggs. milk, and shellfish can cause reactions. In most cases, the effect is slower than that seen with insect stings. An exception is peanuts. Peanut allergies are frequently very severe and very rapid in onset. Many people with allergies to one food will have allergies to related foods (for example, someone who is allergic to almonds is more likely to be allergic to walnuts). Again, peanuts are an exception. People who are allergic to peanuts do not necessarily have any other allergies, including nuts (in part because peanuts are legumes, not nuts). • Plants. Contact with certain plants such as poison ivy. poison sumac, and poison oak can cause a rash that is sometimes severe. The rash associated with poison ivy is actually an allergic reaction. Approximately two-thirds of the population is allergic to the oil on poison ivy leaves. Plant pollen also causes allergic reactions in many people, but rarely anaphylaxis. • Medications. Antitoxins and drugs, especially antibiotics such as penicillin, may cause severe reactions. Just as with foods, people who are allergic to one kind of antibiotic can be allergic to related antibiotics. In the course of evaluating patients, you will hear many of them say they are allergic to penicillin or other antibiotics. Many of them are wrong, because they confuse side effects such as nausea or diarrhea, with an allergic reaction. • Others. Dust, chemicals, soaps, makeup, and a variety of other substances can cause allergic reactions—which are occasionally severe—in some people. One particular product EMTs should be aware of as a possible allergen is latex. Two groups of people are especially likely to be allergic to latex. One of these groups is patients with conditions that require multiple surgeries. The repeated exposure to the latex in doctors’ and nurses’ gloves is probably the reason many such patients develop a severe allergy to latex. This is very important to understand, because if you wear latex gloves when treating a patient with a latex allergy, you may actually cause an allergic or anaphylactic reaction in the patient.

Inside/Outside ALLERGIC REACTIONS Inside Something that all allergic reactions share is that people do not have them the first time they are exposed to an allergen. This is because the body’s immune system has not “learned” to recognize the allergen yet. The first time someone is exposed to an allergen, the immune system forms antibodies in response. These antibodies are the body’s attempt to attack the foreign substances. A particular antibody will combine with only the allergen it was formed in response to (or another allergen very similar to the original one). The second time the person is exposed to the allergen, the antibodies already exist in the person’s body. This time, the antibody combines with the allergen, leading to the release of histamine and other chemicals into the bloodstream. Together, these substances have several effects that may lead to a spectrum of allergic reactions including, at times, the life-threatening condition known as anaphylaxis: They dilate blood vessels, decrease the ability of capillaries to contain fluid, cause bronchoconstriction, and promote the production of thick mucus in the lungs.

Outside

The dilation of blood vessels reduces the amount of blood returning to the heart, leading to decreased cardiac output and an increased risk of shock. Skin also becomes flushed as blood vessels near the surface open up. When capillaries become leaky, fluid moves into the tissue and appears as swelling, especially around the site of an injection (or sting) and the face, including the eyes, lips, ears, tongue, and airway. If the area around the vocal cords becomes swollen, the patient may have a muffled voice or display stridor on inspiration. Urticaria, also called hives—red, itchy, possibly raised blotches on the skin —is another result of the release of histamines and related substances in response to allergens. Bronchoconstriction causes decreased movement of air in the lungs, leading to wheezing and difficulty breathing. Thick mucus worsens this effect. Irritation of nerve endings results in itching.

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ALLERGIC REACTION

The other group that is becoming more sensitive to latex is health care professionals, including EMTs. Again, this increased sensitivity is probably because of more frequent exposure to latex as a result of practicing Standard Precautions. Fortunately, it is now possible to find virtually all medical equipment and supplies in forms that do not contain latex. Many hospitals and EMS agencies maintain latex-free environments to avoid causing reactions in latex-sensitive individuals. There is no way to predict the exact course of an allergic reaction. Severe reactions most often take place immediately, but they are occasionally delayed 30 minutes or more. A mild allergic reaction may turn into more serious anaphylactic shock in a matter of minutes. When a patient with an exposure to a known allergen is displaying only minor signs and symptoms, you must closely monitor the patient for signs of the condition becoming more serious. This patient’s airway may swell and close off in just a few minutes. Be prepared to manage the airway and to administer epinephrine if so advised by medical direction.

May mga taong allergic sa latex. Kung isa ka sa mga ito, malalaman mo ito kapag nagsuot ka na ng gloves na gawa sa latex. May mga EMT na hindi alam na allergic sila sa latex at natuklasan lamang iyon nang magsimulang mangati ang kanilang mga kamay habang suot ang guwantes na dapat ay magpuprotekta sa kanila sa impeksyon. Kung allergic ka sa latex, sabihin agad ito sa medical director mo para mapag-isipan ng iyong grupo kung papaano ka puprotektahan.

The signs and symptoms of an allergic reaction or anaphylactic shock can include: Skin:

• Itching • Hives (may be localized—especially around an insect sting—or generalized over wide areas of the body) • Flushing (red skin) • Swelling of the face (especially the eyes and lips), neck, hands, feet, or tongue • Warm, tingling feeling in the face, mouth, chest, feet, and hands

Respiratory:

• Patient may report a feeling of lightness in the throat or chest • Cough • Rapid breathing • Labored, noisy breathing • Hoarseness, muffled voice, or loss of voice entirely • Stridor (harsh, high-pitched sound during inspiration) • Wheezing (audible without a stethoscope)

Cardiac:

• Increased heart rate • Decreased blood pressure

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Generalized Findings:

• Itchy, watery eyes • Headache • Runny nose • Patient expresses a sense of impending doom

Signs and Symptoms of Shock:

• Altered mental status • Flushed, dry skin or pale. cool, clammy skin • Nausea or vomiting • Changes in vital signs: increased pulse, increased respirations, decreased blood pressure

Distinguishing Anaphylaxis from Mild Allergic Reaction

Any of the signs and symptoms discussed previously can he associated with an allergic reaction. To he considered a severe allergic reaction, or anaphylaxis, the patient must have either respiratory distress or signs and symptoms of shock.

PATIENT ASSESSMENT

Allergic Reaction or Anaphylaxis Conduct the usual assessment sequence, as follows: 1. Perform the primary assessment and care for any immediately life-threatening problems with the patient’s airway, breathing, or circulation 2. Perform a secondary assessment. Inquire about • History of allergies • What patient was exposed to • How patient was exposed (contact, ingestion, and so on) • What signs and symptoms the patient is having • Progression (What happened first? What happened next? How rapidly?) • Interventions (Has any care been provided? Has the patient taken any medication?) 3. Assess baseline vital signs and get the remainder of the past medical history Suspect an allergic reaction whenever the patient has come in contact with a substance that has caused an allergic reaction in the past; whenever the patient complains of itching, hives, or difficulty breathing (respiratory distress), or when the patient shows signs or symptoms of shock (hypoperfusion).

Distinguishing Allergic from Anaphylactic Reactions Signs and symptoms in the “Allergic” column are more likely to be associated with allergic reactions that are not life threatening. Signs and symptoms in the “Anaphylactic” column are more likely to be associated with anaphylactic reactions that are life threatening.

PATIENT CARE

Allergic Reaction or Anaphylaxis

1. Manage the patient’s airway and breathing Apply highconcentration oxygen through a nonrebreather mask, if you have not already done so during the primary assessment If the patient has or develops an altered mental status, open and maintain the patient’s airway If the patient is not breathing adequately, provide artificial ventilations. 2. You may be able to assist the patient in administering an epinephrine auto-injector or you may be allowed to carry auto-injectors on your ambulance To find out if use of an auto-injector is appropriate, consider each of the following: • If the patient has come in contact with a substance that caused an allergic reaction in the past, and if the

patient has respiratory distress or exhibits signs and symptoms of shock, and if the patient has a prescribed epinephrine auto-injector (or if your protocols allow you to carry and use epinephrine auto-injectors), then contact medical direction and. if so ordered, assist the patient with his prescribed auto-injector or administer epinephrine from an auto-injector you carry on the ambulance. Record the administration of the epinephrine auto-injector. Transport. Reassess 2 minutes after epinephrine administration and record reassessment findings • If the patient has come in contact with a substance that caused an allergic reaction in the past, and if the patient has respiratory distress or exhibits signs and symptoms of shock, and if the patient has a prescribed epinephrine auto-injector (or if your protocols allow you to carry and use epinephrine auto-injectors), then contact medical direction and. if so ordered, assist the patient with his prescribed auto-injector or administer epinephrine from an auto-injector you carry on the ambulance. Record the administration of the epinephrine auto-injector. Transport. Reassess 2 minutes after epinephrine administration and record reassessment findings • If the patient has come in contact with a substance that caused an allergic reaction in the past, and it the patient complains of respiratory distress or exhibits signs and symptoms of shock, but the patient does not have a prescribed epinephrine auto injector available or has never had one prescribed, and your protocols do not allow you to carry and use epinephrine autoinjectors, then perform care for shock and transport the patient immediately. If the patient meets the criteria just listed but does not have an epinephrine auto-injector and your protocols do not allow you to carry and use one. consider requesting an ALS intercept. Paramedics/nurse carry and can administer epinephrine. You probably will not see many patterns with allergic reactions. However, most of those you do see will be able to give you a history of their allergies. Once in a while, you will see a patient who has no history and is having his first allergic reaction. In this case, the patient will not be earning an epinephrine auto-inject or because his physician has not prescribed one. Treat the patient for shock and transport immediately. Consider requesting ALS intercept.

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ALLERGIC REACTION

SYSTEM

ALLERGIC

ANAPHYLACTIC

Respiratory complaints

Sneezing, cough, mild dyspnea

Moderate to severe dyspnea, tightness in chest

Respiratory sounds

Wheezing

Wheezing, muffled voice, stridor

Skin texture

Local hives

Generalized hives

Skin color

Possible pallor, little or no flushing of skin

Generalized pallor or flushed skin

Swelling

Local swelling

Swelling of face, lips, eyes, tongue, mouth, injection site

Vital signs

Normal or nearly normal vital signs

Tachycardia, hypotension, tachypnea, decreased oxygen saturation

Mental status

Mild, moderate, or severe anxiety

Feeling of impending doom

Summary of Assessment and Care of Patients with Allergic or Anaphylactic Reactions In some areas. EMTS carry and administer epinephrine. If this is the cue, a pro-scription for epinephrine Is not necessary. • Epinephrine prescription • History of exposure • Signs and symptoms of anaphylaxis

• Epinephrine prescription • History of exposure • No signs and symptoms of anaphylaxis

1. Standard treatment 2. Consult physician for order to give epinephrine

• NO epinephrine prescription

• Epinephrine prescription • NO epinephrine available

1. Standard treatment 2. Transport

Assessing and managing an allergic reaction

If a patient suffers a severe allergic reaction: First take standard precautions 1. Perform a primary assessment. Provide high concentration oxygen by nonrebreather mask. 2. Perform a secondary assessment. 3. Take the patients vital signs. 4. Find out if the patient has a prescribed epinephrine auto-injector and if it is prescribed for this patient or ensure that your protocols allow administering an epinephrine auto-injector you carry on the ambulance. Then check the expiration date and check for cloudiness or discoloration if liquid is visible. Contact medical directions. 5. If medical direction orders use of epinephrine autoinjector, prepare it for use by removing the safety cap. 6. Press the injector against the patient’s thigh to trigger 434

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release of the spring-loaded needle and inject the dose of epinephrine into the patient. 7. Dispose of the used single-dose injector in a portable biohazard container. 8. If using the Twinject™, follow the manufacturer’s direction to remove color-coded caps and administer the first dose. Save the device and transport it with the patient in case the second dose it contains is needed later. (If needed, again follow the manufacturer’s directions to remove the color-coded cap and tab to administer the second dose). 9. Document the patient’s response to the medication. 10. Perform a reassessment, paying special attention to the patient’s ABCs and vital signs en route to the hospital.

SELF-ADMINISTERED EPINEPHRINE Physicians have long prescribed epinephrine in bee sting kits. AnaKits. or Epipen for patients who are susceptible to severe allergic reactions. Epinephrine is a hormone produced by the body. When administered as a medication, it will constrict blood vessels (helping to raise the blood pressure and improve perfusion) and dilate the bronchioles (helping to open the airway and improve respiration). Many people who are subject to severe allergic reactions are prescribed an epinephrine auto-injector by their physician to carry with them and use when such a reaction occurs. An auto-injector is a spring-loaded needle and syringe with a single dose of epinephrine that will automatically release and inject the medication. The reason it is important for a patient with severe allergic reactions to carry an epinephrine auto-injector is that an allergic reaction can become life threatening so quickly that there is not enough time to transport the patient to a hospital to receive the medication. When authorized by medical direction, you may administer or help the patient administer a dose of epinephrine from an auto-injector that has been prescribed for the patient by a physician. Some states allow EMTs to carry epinephrine auto-injectors on the ambulance to administer with approval from medical direction. After you make sure that the liquid is clear (if you can see it), remove the cap and press the injector

firmly against the patient ‘s thigh. Hold inhere until the entire dose is injected. (Injection on the outside of the thigh midway between the waist and knee is recommended.) On reassessment 2 minutes after the epinephrine is administered, in addition to some relief of symptoms, expect the patient’s pulse to have increased. Epinephrine is a very powerful medication. It not only saves lives, it can also occasionally take lives. One of the good things epinephrine docs for patients is make the heart beat more strongly. This is beneficial when the patient is hypoperfusing (that is. when the patient is in shock), because one reason for the hypoperfusion is that the patient’s blood vessels are dilated and blood is not returning to the heart as quickly. Unfortunately, once you give a drug, you cannot lake it back. If the dose of epinephrine in the auto-injector is more than the patient needs, the patient’s heart will be working harder than it needs to. This can be dangerous in a patient with a heart condition or who is hypertensive (has high blood pressure). The power of epinephrine and its possible adverse effects are among the reasons why EMTs have been taught to give epinephrine only to patients with prescribed autoinjectors by their physicians. They have been evaluated by physicians who have considered the patient’s history and physical condition, were satisfied that the patient is a good candidate for epinephrine, and wrote a prescription.

Epinephrine Auto-Injector MEDICATION NAME

1. Generic: epinephrine 2. Trade: Adrenalin™ 3. Delivery system: EpiPen* or EpiPen Jr.• or Twinject* (adult or child size)

INDICATIONS

Must meet the following three criteria: 1. Patient exhibits signs of a severe allergic reaction, including either res-piratory distress or shock (hypoperfusion). 2. Medication is prescribed for this patient by a physician or is carried on the ambulance. 3. Medical direction authorizes use for this patient.

CONTRAINDICATIONS—No contraindications when used in a life-threatening situation.

MEDICATION FORM

Liquid is administered by an auto-injector—an automatically injectable needle and syringe system.

DOSAGE

1. Adult: one adult auto-injector (0.3 mg) 2. Infant and child: one infant/child auto-injector (0.15 mg)

ADMINISTRATION

1. Obtain patient’s prescribed auto-injector. Ensure: a. Prescription is written (or the patient who is experiencing the severe allergic reaction or your protocols permit carrying the auto-injector on the ambulance. b. Medication is not discolored (if visible). c. Medication has not expired. 2. Obtain an order from medical direction, either on-line or off-line. 3. Remove the safety cap(s) from the auto-injector 4. Grasp the center of the auto-injector (to avoid accidentally injecting yourself). 5. Place the tip of the auto-injector against the patient’s thigh. a. Lateral portion of the thigh b. Midway between waist and knee LIFELINE

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ALLERGIC REACTION

6. Push the injector firmly against the thigh until the injector activates. 7. Hold the injector in place until the medication is injected (at least 10 seconds). 8. Record the administration and time. 9. Dispose of a single-dose injector, such as the EpiPen, in a biohazard container; save a two-dose injector, such as the Twinject, and transport it with the patient in case the second dose is later required.

ACTIONS

1. Dilates the bronchioles 2. Constricts blood vessels 3. Makes the capillaries less permeable (leaky)

SIDE EFFECTS

1. Increased heart rate 2. Pallor 3. Dizziness 4. Chest pain 5. Headache 6. Nausea 7. Vomiting 8. Excitability, anxiety

gives an injection, the clothing over the injection site is rolled up or down and the area is cleansed with an alcohol pad. These steps are not necessary with an epinephrine autoinjector. The risk of giving a patient an infection because you did not take those steps is so small, in fact, that the manufacturer’s instructions for auto-injectors do not advise patients to take those steps. However, your protocols may direct you to act differently. Follow your local protocols. One of the most difficult things you may have to do is distinguish between the patient with a (localized) allergic reaction, who should not receive epinephrine, and the patient with a (generalized) anaphylactic reaction, who should be given epinephrine Patients can and do present in many different ways. One patient in anaphylaxis may have severe difficulty breathing with no hives or decreased blood pressure, whereas another patient may have a rapid heart-beat and decreased blood pressure with no difficulty breathing. The important thing to recognize in any patient is the presence of either respiratory distress or signs and symptoms of shock (hypoperfusion). Very often, both of these—indications of respiratory distress and indications of shock—are present. How-ever, only one of these needs to be present for the patient to be in anaphylaxis.

Additional Doses of Epinephrine

REASSESSMENT STRATEGIES

1. Transport 2. Continue secondary assessment of airway, breathing, and circulatory status. • If the patient’s condition continues to worsen (decreasing mental status, increasing breathing difficulty, decreasing blood pressure): A. Obtain medical direction for an additional dose of epinephrine. B. Treat for shock (hypoperfusion). C. Prepare to initiate basic life support procedures (CPR, AED). • If the patient’s condition improves, provide supportive care: A. Continue oxygen. B. Treat for shock (hypoperfusion). Although some patients receive instruction from their physicians in how to use the auto injector, others will be uncomfortable or afraid to use one because of their unfamiliarity with the device and will prefer to have you help them with it. Ordinarily, when a health care provider

A patient with an allergic reaction may have a compromised airway or respiratory function, or these conditions may develop as the allergic reaction progresses. Carefully monitor the patient’s airway and breathing throughout your care and transport. In your reassessment, you will frequently find that the patient’s condition improves, although sometimes it will deteriorate. You may need to give additional doses of epinephrine in this case. You will be able to do this only if the patient has one or more extra auto-injectors and you have remembered to ask the patient to bring them in the ambulance and you obtain permission for the second dose from medical direction. Don’t forget: If a patient has an extra epinephrine autoinjector, bring it along. Most auto-injectors on the market today, such as the EpiPen’ and EpiPen Jr, can give only one dose of epinephrine. Recently, an auto-injector became available that can provide two doses of epinephrine, the Twinject. which also comes in adult and child sizes. Because administering the second dose from the Twin-ject* requires you to disassemble part of the apparatus, you should become familiar with the auto-injector before you need to use it.

Ang mga Epinephrine auto-injectors ay may dalawang sukat. Ang para sa adults ay may dosage na 0.3 mg. Ang para naman sa bata (na may timbang na hindi lalampas sa 66 pounds) ay 0.15 mg. May mga makikita kang pasyente na sanggol na meron nang anaphylactic reaction. Ang kanilang immune system kasi ay hindi pa nakakabuo ng mga antibodies na panlaban sa mga reaksyon na ito. 436

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Lifeline in Action

By Andre Borsari, Batch 12 (Excalibur)

RESPONDING TO A FOREIGNER

(Note: Andre is a 19-year-old Australian who had an on-the-job training at Lifeline)

We got a call saying that a woman had fallen over in elevator to keep her in the stretcher. the bathroom of a hotel. It was a Canadian woman aged 43. We would have taken the stairs but the floors where made Approximate time was 1530 hours. of tiles and someone has recently been cleaning them so we When we got to the room she was lying on the floor of the didn’t want to take the chance of slipping and falling. shower in her bathroom. Once finally on ground level we carried her to the She had told me that she had been screaming for help since ambulance and rushed her to the nearest hospital. 0700 but no one has heard her. The patient seemed to have grown attached to me since As soon as she saw me her eyes lit up and told me that the I could understand her clearly. Once finally at the hospital hotel staff couldn’t understand her accent. Being Australian I she didn’t want me to leave her side, so we went in to help the know the feeling. She was trying to say that her hip and her ribs doctors move her from the stretcher to the X-ray table so they hurt a lot. As we examined her we found she had a could take scans. dislocated hip and rib fractures. But we came to the same dilemma Trying to move her from the shower floor to the as before -- she couldn’t stand the pain of stretcher was a hard task. Not only did she scream being moved. We tried with her consent WE GOT A CALL out in pain if we moved her slightly but she weighed multiple times to move her but to no avail. SAYING THAT A approximately 300 pounds. The doctors had to put her under Even after giving her as much pain reliever heavy anesthesia to knock her out. Funnily WOMAN HAD as we could it had no effect. We had to put several enough the doctors had to come back three FALLEN OVER IN towels underneath her with the help of the staff and times to administer higher doses because slowly inch her body onto the stretcher, all while her being such a big woman, it just couldn’t THE BATHROOM trying to support her hip as to not do more damage. knock her out. OF A HOTEL. IT After finally getting her onto the stretcher We spent about 2 hours at the hospital (which took about an hour and a half) we strapped all because we couldn’t leave without our WAS A CANADIAN stretcher that she was still on. At last the her in and moved to the elevator of the hotel. Problem was the elevator wasn’t big enough to WOMAN AGED 43. patient fell asleep and the doctors moved her fit the stretcher. So we literally had to have the entire and we finally were able to get our stretcher team hold this 300-pound woman diagonally in the back. LIFELINE

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EVERY New Yearâ&#x20AC;&#x2122;s Eve, our team in Lifeline always gets ready to respond to injuries caused by firecrackers or stray bullets. It becomes almost a routine for our EMTs to respond to calls of a boy or a drunk man who had lost a finger or two to firecrackers. The number of such cases have declined over the years, yet they can still overwhelm a new EMT like you if you are not up to it. For example, in 2017, the Department of Health tallied 350 firecracker related injuries. Six out of 10 of these involved children. Just like any of the cases that you would have to face, soft-tissue injuries need a lot of getting used to. You would be staring at damaged body parts, a lot of blood, and, of course, distressed patients. In this chapter, you would learn how to handle such cases, including closed wounds, open wounds, lacerations, burns, and impaled objects. You would be taught how to bandage a wound, the different types of bandage you can use, and how to deal with injuries not only of the flesh but even the bones. Here you will learn how to apply a splint. All these will involve a lot of hands-on lessons, so be prepared to participate. It will be an exciting day for you and your classmates because here youâ&#x20AC;&#x2122;ll get to really practice your future work as EMTs.

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Soft Tissue Injuries Soft tissues, closed wounds and open wounds Treating specific types of wounds Classifying burns by agent and source Electrical injuries Dressing and bandaging Mechanisms of musculoskeletal injuries Realignment of deformed extremity LIFELINE

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PRINCIPLES OF EMT CLINICAL PRACTICE

SOFT TISSUE INJURIES LEARNING OBJECTIVES • • • • • • • • • • • •

State the major functions of the skin. List the layers of the skin. List the types of closed and open soft tissue injuries. Describe and demonstrate the emergency medical care of the patient with a closed and open soft tissue injury. Differentiate the care of an open wound to the chest from an open wound to the abdomen. List the classifications of burns. Describe and demonstrate the emergency medical care of the patient with a superficial, partial thickness and full thickness burn. List the functions and purpose of dressing and bandaging. Establish the relationship between body substance isolation (BSI) and soft tissue injuries. Establish the relationship between airway management and the patient with chest injury, burns, blunt and penetrating injuries. Describe the effects of improperly applied dressings, splints and tourniquets. Describe the emergency medical care of a patient with an impaled object, amputation, chemical burn and electrical burn.

SOFT TISSUES The soft times of the body include the skin, fatty tissues, muscles, blood vessels, fibrous tissues, membranes (tissues that line or cover organs), glands, and nerves. Teeth, bones, and cartilage are considered hard tissues. The most obvious soft-tissue injuries involve the skin (Figure 28-2). Most people do not think of the skin as a body organ, but it is. In fact it is the largest organ of the human body. The skin’s total surface area is over 20 square feet. Its major functions are:

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INTRODUCTION You will frequently be called to deal with injuries to the soft tissues of the body. These injuries may range from minor scrapes and bruises to life-threatening bleeding or amputations. Although serious external bleeding is uncommon, this is an opportunity for the EMT to make a significant difference in a patient’s life. Many soft-tissue injuries are open wounds, which can be very upsetting to the patient. Your emotional care and demeanor will mean a great deal. Overall, the assessment and care of the patient with a softtissue injury will be a challenging part of your responsibilities as an EMT. Ang malambot na bahagi ng katawan ng tao ay ang balat, taba, muscles, ugat, mga laman na tumatakip sa mga maseselang bahagi ng katawan, Ang pinakamadaling makita na malambot na bahagi ng katawan ay ang balat at ito ang kadalasang nasusugat o napapaso. Sa chapter na ito ay pagaaralan mo kung papaano bibigyang lunas ang mga pasyente na may injury sa balat at iba pang malambot na bahagi ng katawan.

• Protection. The skin is a barrier that keeps out microorganisms (germs), debris, and unwanted chemicals. Underlying tissues and organs are protected from environmental contact. • Water balance. The skin helps prevent water loss and stops environmental water from entering the body. This helps preserve the chemical balance of body fluids and tissues. • Temperature regulation. Blood vessels in the skin can dilate (increase in diameter) to carry more blood to the skin, allowing heat to radiate away from the body. When the body needs to conserve heat, these vessels constrict (decrease in diameter) to prevent heat loss. The sweat glands found in the skin produce perspiration, which will evaporate and help cool the body. The fat that is part of the skin serves as a thermal insulator. • Excretion. Salts, carbon dioxide, and excess water can be released through the skin. • Shock (impact) absorption. The skin and its layers of fat help protect the underlying organs from minor impacts and pressures.

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

“

 

Excretion. Salts, carbon dioxide, and excess water can be released through the skin. Shock (impact) absorption. The skirt and its layers of fat help protect the underlying organs from minor impacts and pressures.

The skin has three major layers: the epidermis, the dermis, and the subcutaneous layer. The outer layer of the skin is the epidermis. The outermost epidermis is composed of dead cells, which are rubbed off or sloughed off and are replaced. The pigment granules of the skin and living cells are found deeper in the epidermis The cells of the innermost portion are actively dividing, replacing the dead cells of the outer layers. The epidermis contains no blood vessels or nerves. Except for certain types of burns and injuries due to cold, injuries of the epidermis present few problems in EMT-level care. The layer of skin below the epidermis is the dermis. This layer is rich with blood vessels, nerves, FIGURE 28-2 and specialized structures such as sweat glands, sebaceous (oil) glands, and hair follicles. Specialized The skin The layers of fat and soft tissue below the dermis are called has three major layers: the epidermis, the dermis, and the subcutanenerve endings in the dermis are involved with the “ the subcutaneous layers. Shock absorption and insulation ous layer. The outer layer of the skin is the epidermis. The outermost epidermis senses of touch, heat, and pain Once the dermis is are major functions of this layer. Again, when these layers is composed of dead CLOSED WOUNDS opened to the outside world, contamination and cells,are injured there are problems of tissue and bloodstream which are rubbed off or sloughed off and are replaced. The pigment graninfection become major problems. Such wounds can ules contamination, bleeding, and pain. Soft issue injuries are of the skin and living cells are found deeper in the epidermis The cells of A closed wound is anthe internal injury; thatareis.actively there dividing, is no open pathway from innermost portion replacing the dead cells of the outer be serious, especially when accompanied by profuse generally classified as closed wounds or open wounds. site. wounds usually resultvessels from the impactExcept of layers. TheThese epidermis contains no blood or nerves. for certain bleeding and intense pain. the outside to the injured types burns andmay injuries to cold, injuries of the a blunt object. Although theofskin itself not due be broken, (here may beepidermis exten- present few problems it. in Closed EMT-level care. can be simple bruises, internal sively crushed tissues beneath wounds lacerations (cuts), and internal punctures caused by fractured bones, crushing The layer of skin below the epidermis is the dermis. This layer is rich with blood forces, or the rupturevessels, (bursting open) of internal organs. Internal bleeding nerves, and specialized structures such as sweat glands, sebaceous (oil) from a closed wound can range from minor 10 life threatening. glands, and hair follicles. Specialized nerve endings in the dermis are involved A closed wound is an internal injury; that is. there is with the senses o( touch, heat, and pain Once the dermis is opened to the outTypes of Closed Wounds no open pathway from the outside to the injured site. These side world, contamination and infection become major problems. Such wounds Types of Closed Wounds wounds usually result from the impact of a blunt object. can be serious, especially when accompanied by profuse bleeding and intense There are three types of Although the skin itself may not be broken, there may be pain. closed wounds: extensively crushed tissues beneath it. Closed wounds can There are three types of closed wounds: contusions, hematomas, and crush contusions, below the dermis are called the subcutaneous be simple bruises, internal lacerations (cuts), and internal The layers of fat and soft I issue injuriespunctures caused by fractured bones, crushing forces, or layers. Shock absorption and insulation are major functions of this layer. Again, hematomas, when these layers arecrush injuries injured there are problems of tissue and bloodstream the rupture (bursting open) of internal organs. Internal and Contusions contamination, bleeding, and pain. Soft issue injuries are generally classified as bleeding from a closed wound can range from minor to life closed wounds or open wounds. threatening. A contusion is a bruise. the most frequently encountered type of closed wound. In a contusion, the ² Limmer (Brady) epidermis ³ Pollack, (AAOS) remains intact, but cells and blood ves⁴ NHTSA sels in the dermis are damaged. A variA contusion is a bruise. the most frequently encountered type of closed able amount of internal bleeding occurs wound. In a contusion, the epidermis remains intact, but cells and blood at the lime of injury and may continue vessels in the dermis are damaged. A variable amount of internal bleeding for a few hours. There is pain, swelling, occurs at the time of injury and may continue for a few hours. There is pain, swelling, and discoloration at the wound site. Swelling and discoloration and discoloration at the wound site. may occur immediately or may be delayed as much as 24 to 48 hours. The Swelling and discoloration may occur swelling is caused by a collection of blood under the skin or within the immediately or may be delayed as much damaged tissues. Other organs such as the kidneys or brain may also be as 24 to 48 hours. The swelling is caused contused. by a collection of blood under the skin or within the damaged tissues. Other organs such as the kidneys or brain may also be contused.

UNIT 3 DAY 19

PRINCIPLES OF EMT CLINICAL PRACTICE

CLOSED WOUNDS

Contusions

Hematomas

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Blood almost always collects at the injury site, this results in a hematoma. A hematoma differs from a contusion in that hematomas involve a larger

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Hematomas

Blood almost always collects at the injury site, this results in a hematoma. A hematoma differs from a contusion in that hematomas involve a larger amount of tissue damage, including damages to larger blood vessels with greater internal blood loss. As much as a liter of blood may accumulate in a hematoma.

Maging maingat sa pagsusuri sa mga sugat na sarado. Kailangan itong gamitan ng standard precautions kahit pa hindi dumudugo ang balat ng pasyente.

Closed Crush Injuries Force can be transmitted from the body ‘s exterior to its internal structures, even when the skin remains intact and the only indication of injury is a simple bruise. This force can cause the internal organs to be crushed or ruptured, causing internal bleeding. This is called a crash injury. Solid organs such as the liver and spleen normally contain considerable amounts of blood. When crushed, they bleed severely and cause shock. Contents of hollow organs, such as digested food or urine, can leak into the body cavities, causing severe inflammation and tissue damage.

PATIENT ASSESSMENT Closed Wounds

Bruising may be an indication of internal injuries and related internal bleeding. In addition, consider the possibility of closed soft tissue injuries whenever there is swelling, pain, or deformity, as well as a mechanism of blunt trauma. Always consider the mechanism of injury (MOI) when you examine a patient with a closed wound. Crush injuries may be difficult or impossible to identity during assessment, so you must rely on the MOI. Patients with a significant MOI should be considered to have internal bleeding and shock until they are ruled out in the emergency department

Contusions (Bruises) as Signs of Soft-Tissue Injury SIGN INDICATES Large bruise or bruised areas directly over the body

Possible injury to underlying organs such as the spleen, liver, or kidneys.

Swelling or deformity at the site of the bruise

Possible underlying fracture.

Bruise on the head or neck

Possible injury to the cervical spine or brain. Search for blood in the mouth, nose, and ears.

Bruise on the trunk or signs of damage to the ribs or sternum

Possible chest injury. Determine if the patient is coughing up frothy red blood, which may indicate a punctured lung, and assess for difficult breathing. Use your stethoscope to listen for equal air entry and any unusual breath sounds.

Bruise on the abdomen

Possible injury to the abdominal organs. Look to see if the patient has vomited. If so, is there any substance in the vomitus that looks like coffee grounds (partially digested blood)? Palpate to detect if the patient’s abdomen is rigid or tender. “

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knees, road rash, mat burns, run burns, and brush burns are examples of abrasions. With abrasions, there may be no detectable bleeding or only the minor ooze of blood from the capillary beds. The patient may be experiencing great pain, even if the injury is minor. Because of dirt or other substances ground into the skin, the opportunity for infection is great.

PATIENT CARE Closed Wounds

Lacerations

“

Take the appropriate Standard Precautions and follow these steps for emergency care of a patient with closed wounds: 1. Manage the patient’s airway, breathing, and circulation Apply high-concentration oxygen by nonrebreather mask 2. Manage as if there is internal bleeding and provide care for shock if you believe that there is any possibility of internal injuries 3. Splint extremities that are painful, swollen, or deformed 4. Stay alert in case the patient vomits 5. Continue to monitor the patient for the development of shock and transport as soon as possible

UNIT 3 DAY 19

A laceration is a cut. It may he smooth or jagged. This type of wound is often caused by an object with a sharp edge, such as a A laceration is a cut. It may razor blade, broken glass, or a jagged be smooth or jagged. This type piece of metal. However, a laceration can also result from a severe blow or impact of wound is often caused by an with a blunt object. If the laceration has object with a sharp edge, such as rough edges, it may lend to fall together and obstruct the view as you try to detera razor blade, broken glass, or a mine the wound depth. It is usually imposjagged piece of metal. However, a sible to look at the outside of a laceration and determine the extent of the damage laceration can also result from a to underlying tissues. If significant blood severe blow or impact with a blunt vessels have been torn, bleeding will be object. If the laceration has rough considerable. Sometimes the bleeding is partially controlled when blood vessels are edges, it may tend to fall together and stretched and torn. This is due to the natuobstruct the view as you try to deterral retraction and constriction of the cut ends that aid in rapid clot formation. mine the wound depth. It is usually impossible

to look at the outside of a laceration and determine the extent of the damage to underlying tissues. If significant blood vessels have been torn, bleeding will be considerable. Sometimes the bleeding is partially controlled when blood vessels are stretched and torn. This is due to the natural retraction and constriction of the cut ends that aid in rapid clot formation

PRINCIPLES OF EMT CLINICAL PRACTICE

OPEN WOUNDS

An open wound is an injury in which the skin is interrupted, or broken, exposing the tissues underneath. Punctures The interruption can come from the outside, as a laceration, or from the inside when a fractured bone end When a sharp, pointed object passes through breaks the skin. the skin or other tissue, a puncture wound

UNIT 3 DAY 19

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

has occurred. Typically, puncture wounds are

caused by objects such as PRACTICE nails, ice picks, PRINCIPLES OF EMT CLINICAL

Types of Open Wounds

splinters, or knives. Often, there is no severe external bleeding, although internal bleeding may he profuse. The threat of contamination OPEN WOUNDS must always be seriously considered. There are numerous types of open

wounds, including abrasions, lacerations, An open wound is an injury in which the skin is interrupted, or broken, exposA puncture wound can be shallow or deep. In

ing the tissues underneath. The interruption can come from the outside, as a punctures, avulsions, amputations, crush either case, tissueshone andend blood vessels laceration, or from the inside when a fractured breaks the skin.are injured. If the object causing the injury passes and high pressure injuries, blast injuries, Types of Open Wounds through the body and out again, the exit injection injuries. wound may he more serious than the enThere are numerous types of open wounds, abrasions, lacerations, trance wound, as inincluding a gunshot wound. punctures, avulsions, amputations, crush injuries, blast injuries, and high pressure injection injuries.

Abrasions

Avulsions

The classification of abrasion includes simThe classification of abrasion ple scrapes and scratches in avulsion, which the flaps of skin and tissues are In an includes simple scrapes and scratches outer layer of the skin istorn damaged loosebutornotpulled off completely. When all the layers are penetrated. Abrasions in which the outer layer of the skin the tip of the nose is cut or torn off. this is an can range in severity. Skinned elbows and an avulsion. The same applies to is damaged but not all the layers are knees, road rash, mat example burns, runofburns, external ear. A degloving avulsion occurs and brush burns are (he examples of abrapenetrated. Abrasions can range in sions. With abrasions, when there may no is caught in a roller. In this the be hand severity. Skinned elbows and knees, detectable bleeding ortype onlyofthe minor the skin is stripped off like a incident, ooze of blood from the capillary beds. The road rash, mat burns, run burns, glove. great An pain, eye pulled from its socket patient may be experiencing and brush burns are examples of (extruded) also a form of avulsion. The even if the injury is minor. Because ofisdirt abrasions. With abrasions, there may or other substances ground the skin, term into avulsed is used in reporting the wound, the opportunity for infection as inis great. "an avulsed eye" or "an avulsed ear." be no detectable bleeding or only the

“

Punctures

When a sharp, pointed object passes through the skin or other tissue, a puncture wound has occurred. Typically, puncture wounds are caused by objects such as nails, ice picks, splinters, or knives. Often, there is no severe external bleeding, although internal bleeding may be profuse. The threat of contamination must always be seriously considered. A puncture wound can be shallow or deep. In When tissue is avulsed. it is cut off from its minor ooze of blood from the capillary either case, tissues and blood vessels are injured. If the Lacerations oxygen supply and will soon die. beds. The patient may be experiencing great object causing the injury passes through the body and A laceration is a cut. It may he smooth or pain, even if the injury is minor. Because of dirt or out again, the exit wound may be more serious than jagged. This type of wound is often caused other substances ground into the skin, the opportunity for by an object with a sharp edge, such as a the entrance wound, as in a gunshot wound. infection is great. razor blade, broken glass, or a jagged piece of metal. However, a laceration can also result from a severe blow or impact with a blunt object. If the laceration has rough edges, it may lend to fall together and obstruct the view as you try to determine the wound depth. It is usually impossible to look at the outside of a laceration and determine the extent of the damage to underlying tissues. If significant blood vessels have been torn, bleeding will be considerable. Sometimes the bleeding is partially controlled when blood vessels are

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wound.

nd tissues are pletely. When n off. this is an me applies to vulsion occurs roller. In this pped off like a m its socket avulsion. The g the wound, avulsed ear." ut off from its e.

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SOFT TISSUE INJURIES

Avulsions In an avulsion, flaps of skin and tissues are torn loose or pulled off completely. When the tip of the nose is cut or torn off. this is an example of an avulsion. The same applies to the external ear. A degloving avulsion occurs when the hand is caught in a roller. In this type of incident, the skin is stripped off like a glove. An eye pulled from its socket (extruded) is also a form of avulsion. The term avulsed is used in reporting the wound, as in “an avulsed eye” or “an avulsed ear.” When tissue is avulsed. it is cut off from its oxygen supply and will soon die.

Amputations The extremities are sometimes subject to amputation. Amputated fingers, toes, handy feel, or limbs are completely cut through or torn off. Jagged skin and bone edges can sometimes be observed. There may be massive bleeding; or the force that amputates a limb may close off torn blood vessels, limiting the amount of bleeding. Often, blood vessels collapse, or they retract and constrict, which limits bleeding from the wound site.

Open Crush Injuries

Although crush injuries were discussed earlier in this chapter as closed wounds, crush injuries also can be open wounds. An open crush injury can result when an extremity is caught between heavy items, such as pieces of machinery. Blood vessels, nerves, and muscles are involved, and swelling may be a major problem with resulting loss of blood supply distally. Bones are fractured and may protrude through the wound site. Soft tissues and internal organs can be crushed to produce profuse bleeding, both externally and internally.

Blast Injuries When a patient is injured from a blast or explosion, he may sustain a combination of all of the injuries just described. The unusual characteristics of a blast mean that a mixture of open and closed injuries can be the result. Primary injuries occur because of the intense high pressure (pressure wave) that hits the patient. Injuries can include damage to any air-or fluid-filled body organ or cavity, especially pressure injury to the lungs. Secondary injury is the result of projectiles such as debris hitting the patient (blast wave), leading to open wounds such as sharpnel wounds. Tertiary (third level) injuries occur if the patient is picked up and moved to a different location. Tertiary injuries can include not just soft-tissue injuries but also fractures, avulsions, and amputations. Finally, the patient may sustain additional injuries such as exposure to chemicals or toxins, burns, and crush injuries. These are sometimes referred to as quaternary (fourth level) injuries.

Sumunod sa standard precautions kapag bukas na sugat ang sinusuri. Bukod sa paggamit ng gloves, magsuot din ng proteksyon sa mata. Maging maingat din sa pagtatapon ng mga ginamit sa pagsusuri o paglilinis ng sugat. Maghugas mabuti ng kamay pagkatapos.

High Pressure Injection Injuries An uncommon but important injury can occur when a patient is working with a machine that injects grease, paint, air. or some other substances under high pressure. If the nozzle injects the substance into the patient, typically the finger, rather than the object it was intended for, this can lead to significant injury. These machines may use pressures of thousands of pounds per square inch, which results in a wound that is much worse than it looks- There is typically very little (or even no) injury apparent on inspection. The real damage is not visible because it is under the skin. When the high pressure device injects its solution, it can travel a significant distance: for example, moving through most or all of a limb. The injected solution causes extensive tissue damage, both from the force of the pressure and from the toxic nature of some solutions. Over the course of the next few hours, tissue begins to die. If the patient does not get the appropriate treatment early enough, there is a high probability that at least part, and perhaps all. of the patient’s limb will have to be amputated. EMT treatment for high pressure injection includes elevating and splinting the limb. Although the patient may complain of severe pain, do not apply cold. This causes vasoconstriction and can lead to further tissue damage and death from lack of perfusion. If the incident occurred just before your arrival, the patient may not have any pain and may not wish to go to an emergency department. It is nonetheless vital that you persuade the patient to be evaluated in an Emergency Department as soon as possible. If the patient delays treatment, he may end up losing his hand or forearm. 444

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PATIENT ASSESSMENT Open Wounds Airway, breathing, circulation, and severe bleeding are identified and treated in the primary assessment Once the primary assessment and the appropriate physical examination have been completed, care for the individual wounds begins

PATIENT CARE Open Wounds

The following steps are general guidelines for emergency care of open wounds. Steps for specific kinds of open wounds appear on the following pages Be sure to take appropriate Standard Precautions when performing these steps 1. Expose the wound Clothing that covers a soft-tissue injury must be lifted, cut. or split away. For some articles of clothing, this is best done with scissors or a seam cutter. Do not attempt to remove clothing in the usual manner, which can aggravate existing injuries and cause additional damage and pain. 2. Clean the wound surface. Do not try to pick embedded particles and debris from the wound. Simply remove large pieces of foreign matter from the surface. When possible, use a piece of sterile dressing to brush away large debris while protecting the wound from contact with your soiled gloves. Do not spend much time cleaning the wound. Control of bleeding is the priority 3. Control bleeding. Start with direct pressure, or direct pressure and elevation. When necessary, apply a tourniquet. 4. For all serious wounds, provide care for shock, including administration of high-concentration oxygen. 5. Prevent further contamination. Use a sterile dressing. When none is available, use the cleanest cloth material at the scene 6. Bandage the dressing in place after you have controlled the bleeding. If an extremity is involved, check for a distal pulse to make certain that circulation has not been interrupted by the application of a tight bandage. With the exception of a pressure dressing, bleeding must be controlled before bandaging is started. Periodically recheck the bandage to make certain that bleeding has not restarted. 7. Keep the patient lying still. Any movement will increase circulation and could restart bleeding 8. Reassure the patient This will help ease the patientâ&#x20AC;&#x2122;s emotional response and perhaps lower his pulse rate and blood pressure. In some cases, this may help to reduce the bleeding rate. Also, a patient who feels reassured will usually be more willing to be still, reducing the chances of restarting bleeding.

TREATING SPECIFIC TYPES OF OPEN WOUNDS Treating Abrasions and Lacerations In treating abrasions, take care to reduce wound contamination. Although bleeding from a long, deep laceration may be difficult to control, direct pressure over a dressing usually works well. The air-inflated splint can be useful in the management of this type of wound when it is applied over a dressing. Do not pull apart the edges of a laceration in an effort to see into the wound. Most lacerations can be cared for by bandaging a dressing in place. Some EMS systems recommend using special wound-closure strips for minor lacerations. A butterfly bandage is made up of thin strips of adhesive bandaging and is designed to bring the sides of a laceration together.) Bandage a gauze dressing over the butterfly strip. Kung may malaking hiwa ang pasyente, suriin mabuti ang pulso pati na ang kondisyon ng mga bahagi ng katawan na malapit sa sugat nito. Posibleng kailanganin ng pasyente ng operasyon para tahiin ang kanyang sugat. Posible rin na mangailangan ito ng ineksyon kontra tetano. Huwag basta iiwan ang pasyente kahit pa naka-bandage na ito. Malaki pa rin ang posibilidad na magkaroon ito ng impeksyon kaya matinding pag-iingat ang kailangan.

Treating Puncture Wounds Use caution when caring for puncture wounds. An object that appears to be embedded only in the skin may actually go all the way to the bone. In such cases, it is possible that the patient may not have any serious pain. Even an apparently moderate puncture wound may cause extensive internal injury with serious internal bleeding. What appears at first to be a simple, shallow puncture wound may be only part of the problem. There also could be a severe exit wound that requires immediate care, so be sure to search for one. Gunshot wounds are puncture wounds that can fracture bones and cause extensive soft-tissue and organ injury. The seriousness of the wound cannot be determined by the caliber of the bullet or the point of entry and exit. The bullet may have tumbled through tissues, deflected off a boot, fragmented, or exploded inside the body. All bullet wounds are considered serious. If the bullet has penetrated the body, you must assume that there is considerable internal injury. Close-range shootings often have burns around the entry wound. Remember that any gunshot wound to the face, no matter how minor, can create airway problems. Air guns fired at close range can cause serious damage by injecting air into the tissues. LIFELINE

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All stab wounds should be considered serious, especially when they involve the head, neck, chest, abdomen, groin, or are inflicted proximal to the knee or elbow. Care for a patient with a moderate or serious puncture wound includes these steps:

1. Reassure the alert patient. Such wounds can be frightening.

2. Search for an exit wound, especially when there is a

gunshot wound. Control bleeding and provide adequate wound treatment to both the entry and exit wounds.

3. Assess the need for basic life support whenever there is a gunshot wound. Care for shock, administering highconcentration oxygen.

4. Follow your local protocols with regard to immobilizing the spine when the patient’s head. neck, or torso is involved. Many EMS systems have included this step in their protocols, but the wisdom of doing so is in question. There is some evidence to suggest that immobilizing a patient with a penetrating injury may extend prehospital time and lead to worse outcomes for patients, yet there is disagreement in the trauma community about how to treat these patients. 5. Transport the patient. If the object that caused the puncture wound is available, and if the scene of the emergency is not a crime scene, take the object to the emergency department for examination as well.

Treating Impaled Objects A puncture wound may contain an impaled object. The object may be a knife, a fence post or guard rail, a sharp of glass, or even a wooden stick—or part of any of these that has broken off in the wound, piercing any part of the body. Even though it is rare, you may be confronted with an impaled object that is long enough to make transport impossible unless the object is shortened. In such cases, contact the emergency department physician for specific directions. Usually, someone must hold the object, keeping it very stable, while you gently cut through it at the desired length. A fine-toothed saw with rigid blade support (e.g., a hack saw or reciprocating saw) should be used. In some cases, you may need to leave the object in place as found. The challenge in these cases is stabilization of the object. In general, when caring for a patient with a puncture wound involving an impaled object, do not remove the impaled object. The object may be plugging bleeding from a major artery while it is in place. If you remove it, you may cause severe bleeding when the pressure is released. Removal of the object also may cause further injury to nerves, muscles, and other soft tissues. Any movement of the impaled object at the skin’s surface w ill be magnified several times in the inner tissues. Proceed as follows: 1. Expose the wound area. Cut away clothing, taking great care not to disturb the object. Do not attempt to lift clothing over the object, as you may accidentally move it. Long impaled objects may have to be stabilized by hand 446

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during exposure, bleeding control, and dressing.

2. Control profuse bleeding by direct pressure, if possible. Be careful to position your gloved hands on

either side of the object and exert pressure downward. Do not put pressure on the object. Apply pressure with great care if the object has a cutting edge, such as a knife or a shard of glass: otherwise, you may cause additional injury to the patient. Be careful not to injure your hands or damage your gloves.

3. While you continue to stabilize the object and control bleeding, have another trained rescuer place several layers of bulky dressing around the injury site so that the dressings surround the object on all sides. Manual stabilization must continue until the stabilizing dressings are secured in place. Have the other rescuer begin by placing folded universal pads or some other bulky dressing material on opposite sides of the object. For long or large objects, folded towels blankets or pillows may have to be used in place of dressing pads. Remove your hands from under the pads Place them on top and apply pressure as each layer is placed in position. The next layer of pads should be placed on opposite sides of the object, perpendicular to the first layer. Continue this process until as much of the object as possible has been stabilized. Once bandaged in place, the dressings will stabilize the object and exert downward pressure on bleeding vessels. Keep in mind that there is a limited amount of time that can be given to stabilizing an impaled object. Stay in contact with the Medical Director for directions and recommendations. 4. Secure the dressings in place. Although adhesive strips may hold the dressings in place, blood around the wound site, sweat, and body movements may not allow you to use tape. Triangular bandages folded into strips (cravats) can be applied by tying one above and one below the impaled object. The cravats should be wide (no less than 4 inches in width once folded). A thin rigid splint can be used to push the cravats under the patient’s back when they are needed to care for objects impaled in the trunk of the body. 5. Care for shock. Provide oxygen at the highest possible flow and concentration When appropriate, oxygen administration and heat conservation measures should be accomplished as soon as possible. When working by yourself, these may have to be delayed while you attempt to control bleeding, 6. Keep the patient at rest. Position the patient for minimum stress. If possible, immobilize the affected area—for example, with a splint or a spine board. Provide emotional support.

7. Transport the patient carefully and as soon as possible. Avoid any movement that may jar. loosen, or

dislodge the object. If the object was removed by bystanders before you arrived, bring it to the hospital for examination. 8. Reassure the patient throughout all aspects of care. An alert patient who is afflicted with an impaled object is usually very frightened.

Object Impaled in the Cheek A dangerous situation exists when the check has been penetrated by a foreign object. First, (he object may go into the oral cavity and create an airway obstruction, or it may stay impaled in the cheek wall but work its way free and enter the oral cavity later. Second, when the check wall is perforated, bleeding into the mouth and throat can he profuse and interfere with breathing, or it may make the patient nauseated and induce vomiting. External wound care will not stop the flow of blood into the mouth. If you find a patient with an object impaled in the cheek, you should:

1. Examine the wound site. Gently inspect both the

external cheek and the inside of the mouth. Use your penlight and look into the patient’s mouth. If need be. carefully use your gloved fingers to probe the in-side cheek to determine if the object has passed through the cheek wall. This is best done with a dressing pad used to protect your fingers and any wound you touch.

2. Remove the object, if you find perforation and you can see both ends of the object. Pull it out in

the direction that it entered the check. If this cannot be easily done, leave the object in place. Do not twist the object. If you find perforation but die tip of the object is also impaled into a deeper structure (e.g..the palate), stabilize the object. Do not try to remove it. 3. Position the patient. Make certain that you allow for drainage (the possibility of spine injuries may require you to immobilize the head, neck, and spine first, then lilt the patient and the spine board as a unit).

4. Monitor the patient’s airway, once the object is removed or stabilized. Be prepared to suction as

necessary: Keep in mind that an object penetrating the check wall also may have caused teeth or dentures to break, creating potential airway obstruction. Pay close attention, especially if the patient is not alert. Blood in the patient’s mouth can compromise the airway.

5. Dress the outside of the wound using a pressure dressing and bandage or apply a sterile dressing and use direct hand pressure to control the bleeding. You may be able to place gauze on the inside

of the cheek to help control bleeding into the mouth, but only if the patient is alert and cooperative. Monitor the patient’s menial status closely, and make sure the dressing does not work its way into the airway. 6. Provide oxygen and care for shock. You may have to use a nasal cannula if constant suctioning is required. If any dressing materials are placed in the patient’s mouth, use of standard face masks can be dangerous unless you leave 3 to 4 inches of the dressing outside of the patient’s mouth.

Puncture Wound or Object Impaled in the Eye Use loose dressings for a puncture wound to the eye with no impaled object. If you find an object impaled in the eye. you should: 1. Stabilize the object. Place a roll of 3-inch gauze bandage or folded 4 X 4s on either side of the object, along the vertical axis of the head, in a manner that will stabilize the object. 2. Apply rigid protection. Fit a disposable paper drinking cup or paper cone over the impaled object and allow it to come to rest on the dressing rolls. Do not allow it to touch the object. Do not use a Styrofoam cup, which can flake.

3. Have another rescuer stabilize the dressings and cup while you secure them in place with a selfadherent roller bandage or with a Hindi ginagawa sa lahat wrapping of gauze. Do not secure the bandage on top of the cup.

4. Dress and bandage the uninjured eye. This will help to reduce sympathetic eye movements

5. Provide oxygen and care for shock. 6. Reassure the patient and provide emotional support.

ng lugar ang Step 4 kung saan binebendahan din pati ang mata na walang injury. May mga pasyente na ayaw matakpan ang parehong mata nila. Nadagdagan lang ang kanilang alalahanin. Sundan na lamang ang local protocol para sigurado. Ang kabutihan ng pasyente ang lagi mong iisipin.

This method can also be used as a pressure dressing to control bleeding in the area of the An alternative to the eye. previous method calls for the rescuer to make a thick dressing with several layers of sterile gauze pads or universal dressings. A hole approximately the size of the impaled object is cut in the center of this pad. The rescuer then carefully passes this dressing over the impaled object and positions the pad so that the impaled object is centered in the opening. The rest of the procedure remains the same as previously described. If your EMS system instructs you to use this technique, remember that you must take great care not to touch the object as the dressing is set in place. LIFELINE

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Treating Avulsions Emergency care for avulsions requires the application of large, bulky pressure dressings. In addition, you should make every effort to preserve any avulscd parts and transport them to the medical facility along with the patient. It may be possible to surgically restore the part or to use it for skin grafts. In eases in which flaps of skin have been torn loose but not off, follow these steps: 1. Clean the wound surface. 2. Fold the skin back to its normal position as gently as possible. 3. Control bleeding and dress the wound using bulky pressure dressings. If skin or another body part is torn from the body, control bleeding and dress the wound using a bulky pressure dressing. Save the avulsed part and wrap it in a sterile dressing kept moist with sterile saline. Make certain that you label the avulsed part with what it is, the patient’s name and date, and the time the part was wrapped and bagged. Your records should show the approximate time of the avulsion. Be sure to keep the part as cool as possible, without freezing it. by placing it in a cooler or any other available container so that it is on top of a cold pack or a sealed bag of ice. Do not use dry ice. Do not immerse the avulsed part in ice. cooled water, or saline. Label the container the same as the label used for the saved part. Ang avulsion ay tumutukoy sa uri ng sugat kung saan natanggal ang isang bahagi ng katawan. Halimbawa, natanggal ang tenga o naputol ang daliri. Madalas na ganito ang sugat na tinatamo ng mga biktima ng aksidente sa sasakyan. May mga protocol na nagsasabi na dapat balutin ng bandage na binasa ng saline solution o tubig na may asin. Ang salite solution na ito ay dapat sterilized upang hindi maimpeksyon ang sugat. Maging maingat sa pagbabalot ng natanggal na bahagi ng katawan ng pasyente. Maging handa rin sa hitsura ng sugat at ng bahaging natanggal dahil kadalasan ay nakakadiri ang mga ito. Huwag mo na itong ipakita sa pasyente upang hindi ito matakot. Kausapin nang mahinahon ang pasyente at sabihan ito palagi na magiging maayos din ang lahat.

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SOFT TISSUE INJURIES

Treating Amputations Never complete an amputation. As in other external bleeding situations, the most effective method to control bleeding is a snug pressure dressing. 1. Apply the pressure dressing. Place it over the stump. 2. Use pressure points to control bleeding. A tourniquet should not be applied unless other methods used to control bleeding have failed. 3. Care for the amputated part. When possible, wrap it in a sterile dressing and secure the dressing with a self-adhesive gauze bandage. Wrap or bag the amputated part in a plastic bag and keep cool by cold packs. Do not immerse the amputated part directly in water or saline. In addition, do not let the part come in direct contact with ice or it may freeze.

Treating Genital Injuries

Injuries to the genitals are not very common, but they often bleed heavily and cause significant anxiety in patients. The genitals are very vascular (contain lots of blood vessels), so when they are injured they bleed heavily. Because they are also part of the reproductive system, injuries in this area can affect a patient’s ability to have children. Males tend to sustain trauma to the genitals more frequently than females because of the less-protected position of male genitalia, but anyone can sustain a genital injury. Specific injuries that occur to the genitals are: • Lacerations, contusions, and abrasions, which can result from either blunt or penetrating trauma. • Avulsions, including a degloving injury of the penis, in which the skin and tissue are pulled off and torn in the same way as a degloving injury to the hand, as described earlier. • Blunt trauma, including straddle injuries in which the patient injures the perineum be landing heavily on a narrow structure. • Zipper injuries, which are especially common in uncircumcised boys. The foreskin may get caught in the zipper of the patient’s pants. • Foreign bodies and impaled objects in the vagina or penis. • Blood at the meatus, which is often an indication of a disruption of the urethra. In patients who have sustained blunt trauma, the cause of the urethral injury may be a fracture of the pelvis.

Care for a patient with a genital injury includes these steps: 1. Control bleeding as you would for other soft-tissue injuries. 2. Preserve any avulsed parts as described in your local protocols. 3. Consider whether the injury you see suggests another, possibly more serious injury (e.g.. blood at the meatus suggesting pelvic trauma). 4. Display a calm, professional manner to maintain the patient’s dignity. Although treatment is usually the same as for other soft-tissue injuries, the modest patient may need more reassurance. 5. If the patient is a child or other possibly vulnerable person, inquire in a nonthreatening way whether sexual abuse was involved. 6. Dress and bandage the wound in accordance with the principles of bandaging (covered later in this chapter).

BURNS Most people think of burns as injuries to the skin, but burns can affect much more. Burn injuries often involve structures below the skin, including muscles, bones nerves, and blood vessels. Burns can injure the eyes beyond repair. Respiratory system structures can be damaged, producing airway obstruction due to tissue swelling, and even cause respiratory failure and respiratory arrest. In addition to the physical damage caused by burns, patients often suffer emotional and psychological problems that begin at the emergency scene and may last a lifetime. When caring for a burn patient, always think beyond the burn. For example, a medical emergency or accident may have led to the burn. The patient may have had a heart attack while smoking a cigarette and the unattended cigarette caused a fire. During the patient assessment, you should detect the heart problem even though the burn may be the most obvious injury. Conversely, a fire or burn may cause or aggravate another injury or medical condition. For example, someone trying to escape a fire may fall and suffer spinal damage and fractures. As an EMT. you should not only detect the burn but detect the spinal damage and fractures as well.

PATIENT ASSESSMENT Burns

AGENTS AND SOURCES OF BURNS AGENTS

When your patient has been burned, patient assessment Involves classifying, then evaluating the burns. Burns can be classified and evaluated in three ways: • By agent and source Huwag madaliin ang • By depth pagsusuri sa pasyente • By severity kahit pa binibigyan mo All three are important in na ng paunang lunas deciding the urgency and the kind of emergency care the burn ang napasong pasyente. requires. These classifications are discussed in detail in the following text

Classifying Burns by Agent and Source Burns can be classified according 10 the agent causing the burn (eg., chemicals or electricity). Noting the source of the burn (e.g.. dry lime or alternating current) can make the classification more specific. You should report the agent and also, when practical, the source of the agent. For example, a burn can be reported as “chemical burns from contact with dry lime.” Never assume the agent or source of the burn. What may appear to be a thermal burn could in fact be caused by radiation. You may find minor thermal bums on the patient’s face and forget to consider light burns to the eyes. Always gather information from your observations of the scene, bystanders’ reports, and the patient interview.

SOURCES

Thermal

Flame; radiation; excessive beat from fire, Steam, hot liquids, and hot Objects

Chemicals

various acids, bases, and caustics

Electricity

Alternating current, direct current, and lightning

UNIT 3

Light (typically involving the eyes) Radiation

PRINCIPLES OF Intense ultraviolet light DAYlight 19 sources; can also be considered a source of radiation bums

EMT CLIN

Classifying Burns by Depth Usually from nuclear sources; ultraviolet light caninvolving also be the considered Bums skin arc classified as supe thicknessburns bums. These classifications are also so a source of radiation

ond-degree, and third-degree bums, with firstsuperficial bums, and so on. as described next.

UNIT 3 DAY 19

PRINCIPLES OF EMT CLINICAL PRACTICE Classifying Burns by Depth

Burns involving the skin are classified as superficial, partial thickness, and full Classifying Burns by Depth thickness bums. These classifications are also Bums involving the skin arc classified as superficial, partial thickness, and full sometimes called first-degree, second-degree, thickness bums. These classifications are also sometimes called first-degree, secand third-degree burns, with first-degree ond-degree, and third-degree bums, with first-degree burns corresponding to burns corresponding to superficial burns, and superficial bums, and so on. as described next. so on. as described next. • A superficial burn involves only the epidermis (the outer layer of the skin). It is characterized by reddening of the skin and perhaps some swelling. An example is a sunburn. The patient will usually complain about pain (sometimes severe) at the site. The burn will heal of its own accord, without scarring. Superficial burns are also called first-degree burns.



A superficial burn involves only the e skin). It is characterized by reddening swelling. An example is a sunburn. Th about pain (sometimes severe) at the s accord, without scarring. Superficial b burns.

“



A superficial burn involves only the epidermis (the outer layer of the skin). It is characterized by reddening of the skin and perhaps some LIFELINE The PREHOSPITAL CARE 449 swelling. An example is a sunburn. patient willEMERGENCY usually complain about pain (sometimes severe) at the site. The burn will heal of its own accord, without scarring. Superficial bums are also called first-degree burns.

 A superficial A superficial burnburn involves involves onlyonly the the epidermis epidermis (the(the outer outer layerlayer of the of the

skin).skin). It is Itcharacterized is characterized by reddening by reddening of the of the skin skin and and perhaps perhaps some some swelling. swelling. An example An example is a issunburn. a sunburn. The The patient patient will will usually usually complain complain about about painpain (sometimes (sometimes severe) severe) at the at site. the site. The The burnburn will will healheal of itsofown its own accord, accord, without without scarring. scarring. Superficial Superficial bums bums are are also called first-degree first-degree Dayalso 19 called burns. burns.

SOFT TISSUE INJURIES

Determining the Severity of Burns

When determining the severity of a burn. consider the following factors: • Agent or source of the burn • Body regions burned • Depth of the burn • Extent of the burn • Age of the patient • Other illnesses and injuries

The agent or source of the burn can be significant in terms of patient assessment. A burn caused by electrical current may cause only small areas of skin injury but pose a great risk of severe internal injuries. Chemical burns ar of special concern since the chemical may remain TNIT 3 3 on the skin and continue to burn for hours or AY 1919 even days, eventually entering the bloodstream. This is sometimes the case with certain alkaline chemicals. When you are considering the body regions burned, keep in mind that any burn to the face is of special concern since it may involve injury to the airway or the eyes. The hands and feet also are areas of concern because scarring ² Limmer ² Limmer (Brady)(Brady) ³ Pollack, ³ Pollack, (AAOS)(AAOS) may cause loss of movement of fingers or toes. ⁴ NHTSA ⁴ NHTSA Special care is required to avoid aggravation to these injury sites when moving the patient and to prevent the damaged tissues from sticking to one another. When the groin, genitalia, buttocks or medial thighs are burned, potential bacterial contamination can be far more serious than the initial damage to the tissues. Note that circumferential burns (burns that encircle the body or a body part) can be very serious because they constrict the skin. When they occur to an extremity, they can interrupt circulation to the distal tissues. When they occur around the chest,  • InIn a full thickness burn, all the layers of the skin are aInfull a full thickness thickness burn, burn, all the all the layers layers of the of the skinskin arc arc damaged. damaged. Some Some full full thickness thickness burns burns are are difficult difficult to tell to tell apart apart fromfrom partial partial thickness thicknessthey can restrict breathing by limiting chest wall damaged. Some full thickness burns are difficult to tell bums: bums: however, however, there there are are usually usually areas areas thatthat are are charred charred black black or ormovement. In addition, the burn healing process apart from partial thickness burns: however, there are brown brown or areas or areas thatthat are are dry dry andand white. white. the the patient patient maymay complain complain of ofcan be very complicated. This is particularly true usually areas that are charred black or brown or areas severe severe painpain or. ifor. enough if enough nerves nerves have have been been damaged, damaged, he may he may not not feel feelwhen circumferential burns occur to joints, the that are dry and white. the patient may complain of any any painpain at all at (except all (except at the at the periphery periphery of the of the burn burn where where adjoining adjoiningchest, and the abdomen where the encircling severe pain or. if enough nerves have been damaged, he partial partial thickness thickness burns burns maymay be causing be causing pain) pain) ThisThis typetype of burn of burn maymayscarring tends to limit normal functions. may not feel any pain at all (except at the periphery of require require skinskin grading. grading. As these As these burns burns heal,heal, dense dense scars scars form. form. Full Full thickthickThe depth of the burn is important to the burn where adjoining partial thickness burns may be ness ness bums bums damage damage all layers all layers of the of the skinskin andand additionally additionally maymay damage damagedetermine its severity. In partial thickness and causing pain) This type of burn may require skin grading. subcutaneous subcutaneous tissue, tissue, muscle, muscle, bone, bone, andand underlying underlying organs. organs. These Thesefull thickness burns the outer layer of the skin As these burns heal, dense scars form. Full thickness bums bums are are sometimes sometimes called called third-degree third-degree burns. burns. is penetrated. This can lead to contamination burns damage all layers of the skin and additionally of exposed tissues and the invasion of harmful may damage subcutaneous tissue, muscle, bone, and Determining Determining thethe Severity Severity of Burns of Burns chemicals and microorganisms into the underlying organs. These burns are sometimes called circulatory system. third-degree burns. You also will need to roughly estimate the When When determining determining the the severity severity of aof bum. a bum. consider consider the the following following factors: factors: extent of the burn area. The amount of skin  Agent Agent or source or source of the of the burnburn  Body Body regions regions burned burned  Depth Depth of the of the burnburn 450 LIFELINE PREHOSPITAL EMERGENCY CARE  Extent Extent of the of the burn burn  AgeAge of the of the patient patient  Other Other illnesses illnesses andand injuries injuries • In a partial thickness burn, the epidermis is burned through  In aand the dermis (the second layer of the skin) is damaged, but Inpartial a partial thickness thickness burn, burn, the the epidermis epidermis is burned is burned through through and and the the dermis dermis (the(the second second layerlayer of the of the skin)skin) is damaged, is damaged, but but the the bumbum docsdocs the burn does not pass through to underlying tissues. There notwill be deep intense pain, noticeable reddening, blisters, not passpass through through to underlying to underlying tissues. tissues. There There will will be deep be deep intense intense pain, pain, noticeable noticeable reddening, reddening, blisters, blisters, and and a mottled a mottled (spotted) (spotted) appearappearand a mottled (spotted) appearance to the skin. Burns of ance ance to the to skin. the skin. Bums Bums of this of this typetype cause cause swelling swelling and and blistering blistering for 48 for 48 this type cause swelling and blistering for 48 hours after the hours hours afterafter the the injury, injury, as plasma as plasma and and tissue tissue fluids fluids arc released arc released and and rise rise injury, as plasma and tissue fluids are released and rise to the to the to the top top layerlayer of skin. of skin. When When treated treated withwith reasonable reasonable care,care, partial partial top layer of skin. When treated with reasonable care, partial thickness thickness hums hums will will healheal themselves, themselves, producing producing veryvery littlelittle or no or scarno scarring.thickness burns will heal themselves, producing very little or ring. Partial Partial thickness thickness burns burns are also are also called called second-degree second-degree burns. burns. no scarring. Partial thickness burns are also called seconddegree burns.

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE

TheThe agent agent or source or source of the of the burnburn can can he significant he significant in terms in terms of patient of patient assessassess-

surface involved can be calculated quickly by using the rule of nines. For an adult, each of the following areas represents 9 percent of the body surface: head and neck, each upper extremity, chest, abdomen, upper back, lower back and bullocks. The front of each lower extremity, and the back of each lower extremity. These make up 99 percent of the body’s surface. The remaining 1 percent is assigned to the genital region. In the rule of nines, the percentages are modified for infants and young children, whose heads are much larger in relationship to the rest of the body. An infant’s or young child’s head and neck are counted as 18 percent; each upper extremity as 9 percent; chest and abdomen as 18 percent; the entire back as 18 percent; each lower extremity as 14 percent: and the genital region as 1 percent. (This adds up to 101 percent, but it is only used to give a rough determination. Some systems count each lower limb as 13.5 percent to achieve an even 100 percent.) An alternative way to estimate the extent of a burn is the rule of palm, which uses the patient’s own hand to approximate the surface area. The rule of palm can be applied to any patient—infant, child, or adult. Since the palm of the hand equals about 1 percent of the body’s surface area, mentally compare the patient’s palm with the size of the burn to estimate its extent. (For example, a burn the size of five palms = 5 percent of the body.) The rule of palm may be easier to apply to smaller or localized burns, whereas the rule of nines may be easier for larger or more widespread burns. The patient ‘s age is a major factor in considering the severity of burns Infants, children under age 5, and adults over age 55, because of their anatomy and physiology, have the most severe responses to burns and the greatest risk of death. They also have different healing patterns than other age groups. Iba ang epekto ng paso sa katawan ng matandang pasyente. Ang paso na mukhang hindi grabe sa isang medyo batang pasyente ay posibleng ikamatay ng matandang pasyente. Ito ay dahil mas marupok na ang laman ng matanda at mas matagal na itong gumaling.

When determining the severity of a burn, you also must consider the other illnesses and injuries a patient may have. Obviously, a patient with an existing respirators; illness will be especially vulnerable to exposure to heated air or chemical vapors. Likewise, the stress of a fire or other environmental emergency will be of particular concern for patients with heart disease. Patients with respiratory ailments, heart disease, or diabetes will react more severely to burn damage. What may be a minor burn for a healthy adult could be of major significance to a patient with a pre-existing medical condition. Similarly, the stress of a burn added to other injuries sustained during the emergency may lead to shock or other life-threatening problems that would not have resulted from the nonburn injuries or the burn alone.

NOTE: All burns are to be treated more serious if accompanied by other injuries or medical problems. If you discover that the patient has a decreased blood pressure, always assume that he has other serious injuries. Attempt to determine the patient’s problem through standard assessment techniques.

Classifying Burns by Severity The severity of burns must be classified to determine the order and type of care, to determine the order of transport, and to provide maximum information to the emergency department. In some cases, the severity of the burn may determine if the patient is to be taken directly to a hospital with special burn-care facilities.

Adults—CLASSIFICATIONS BY THICKNESS, PERCENT OF BODY SURFACE AREA, AND COMPLICATING FACTORS Minor Bums

• Full thickness burns of less than 2 percent of the body surface, excluding the face, hands, feel, genitalia, or respiratory tract • Partial thickness burns of less than 15 percent of the body surface • Superficial burns of 50 percent of the body surface or less

Moderate Burns

• Full thickness burns of 2 to 10 percent of the body surface, excluding the face, hands, feet, genitalia, or respiratory tract • Partial thickness burns of 15 to 30 percent of the body surface • Superficial burns that involve more than 50 percent of the body surface

LIFELINE

NOTE: Burns which, by the prior classification, are moderate should be considered critical in a person less than 5 or greater than 55 years of age

PREHOSPITAL EMERGENCY CARE

451

Day 19

Critical Burns

SOFT TISSUE INJURIES

Mas delikado ang paso sa mga sanggol at bata kesa sa mga malalaki na. Ito ay dahil ang kanilang balat ay lubhang mas maliit kumpara sa kabuuan ng kanilang sukat. Kapag napaso ang sanggol o bata, mas malaki ang tsansa na ito ay mamatay dahil sa shock, hirap na paghinga, at hypothermia dahil sa malaking pagkabawas ng tubig sa kanilang katawan. Iba rin dapat ang pagsusuri sa pinagmulan ng paso sa mga bata na limang taong gulang pababa. Kapag ganitong edad ang pasyente, may posibilidad na inabuso ang bata.

• All burns complicated by injuries of the respiratory tract, other softtissue injuries, and injuries of the bones • Partial thickness or full thickness bums involving the face, hands, feet, genitalia, or respiratory tract • Full thickness burns of more than 10 percent • Partial thickness burns of more than 30 percent • Burns complicated by musculoskeletal injuries • Circumferential burns

Classifications of Burn Severity: Children Less than 5 Years of Age CLASSIFICATIONS BY THICKNESS AND PERCENT OF BODY SURFACE AREA Minor Burns

• Partial thickness burns of less than 10 percent of the body surface

Treating Specific Types of Burns There are special approaches to the care of thermal burns, general chemical burns and chemical burns to the eyes.

DEPTH Of BURN

452

Moderate Burns

• Partial thickness burns of 10 to 20 percent of the body surface

Critical Burns

• Full thickness burns of any extent or partial thickness burns of more than 20 percent of the body surface

PATIENT CARE Thermal Burns

As an EMT you will have to care for thermal burns caused by scalding liquids, steam, contact with hot objects, flames, flaming liquids, and gases. Sunburn can also be severe in infants and young children, who may have other heat-related injuries. Currently, dry sterile dressings are recommended by the national EMT curriculum for all burns. The standing orders for burn care are determined by

OUTER SKIN LAYER SECOND SKIN LAYER IS BURNED IS BURNED

TISSUE BELOW SKIN IS BURNED

your EMS Medical Director and the regional EMS system. Some EMS systems state that all partial thickness and full thickness burns are to be wrapped with dry sterile dressing or a burn sheet, whereas other burn centers recommend moist dressings for partial thickness burns to less than 10 percent of the body and dry dressings for more severe cases. The latter protocol is now being adopted by most EMS systems.

COLOR CHANGE

PAIN

BLISTERS

Superficial

Yes

Red

Yes

Partial thickness

Yes

Deep red

Yes

Full thickness

Yes

Charred black or white

Yes/no

LIFELINE

PREHOSPITAL EMERGENCY CARE

Care for Thermal Burns 1. Stop the burning process • Flame—Wet down, smother, then remove any affected clothing. • Semi-solid (grease, tar, wax)—Cool with water. Do not remove the substance. 2. Ensure that open airway. Assess breathing. 3. Look for signs of airway injury: soot deposits, burnt nasal hair, facial burns. 4. Complete the primary assessment. 5. Treat for shock Provide high-concentration oxygen. Treat serious injuries. 6. Evaluate burns by depth (see below), extent (rule of nines or rule o( palm), and severity. 7. Do not clear debris. Remove clothing and jewelry. 8. Wrap with dry sterile dressing. 9. Burns to hands or feet—Remove the patient’s rings or jewelry that may constrict blood flow with swelling. Separate fingers or toes with sterile gauze pads. Burns for the eyes—Do not open the patient’s eyelids if burned. Be certain the burn is thermal, not chemical. Apply sterile gauze pads to both eyes to prevent sympathetic movement, (Some local protocols recommend covering only the injured eye. Follow your local protocols.) If the burn is chemical, flush the eyes for 20 minutes en route to the hospital. FOLLOW LOCAL BURN CENTER PROTOCOLS, AND TRANSPORT ALL BURN PATIENTS AS SOON AS POSSIBLE. Note that EMTs must manage burns correctly until the patient can be transferred to the care of a medical facility’s staff. Never apply ointments, sprays, or butter (which would nap the heat against the burn site and have to be scraped off by the hospital staff) Do not break blisters Do not apply Ice to any burn (as it can cause tissue damage). Keep the burn site clean to prevent infection Keep the patient warm, as the temperature regulation function of the skin may be affected by the burn.

NOTE: Do not attempt to rescue persons trapped by fire unless you are trained to do so and have the equipment and personnel required. The simple act of opening a door might cost you your life. In some fires, opening a door or window may greatly intensify the fire or even cause an explosion.

PATIENT CARE Chemical Burns

Chemical burns require immediate care, and in an ideal situation people in the scene will begin this care before you arrive At many industrial sites, workers and Emergency Medical Responders are trained to provide initial care for Incidents involving the chemicals in use at that facility Most major industries have emergency deluge-type safety showers to wash dangerous chemicals from the body. However, this will not always be the case Be prepared for situations in which nothing has been done and there is no running water near the scene. Emergency care for a patient with chemical burns includes the following: 1. The primary care procedure is to wash away the chemical with flowing water If a dry chemical is involved. brush away as much of the chemical as possible and then flush the skin. Simply wetting the burn site is not enough Continuous flooding of the affected area is required, using a copious but gentle flow of water. Avoid hard sprays that may damage badly burned tissues Continue to wash the area for at least 20 minutes, and continue the process en route to the hospital. Take steps as needed to avoid contaminating yourself with the chemical agent Remove the patient’s contaminated clothing, shoes, socks, and jewelry as you apply the wash Do not contaminate skin that has not been in contact with the chemical 2. Apply a sterile dressing or burn sheet 3. Heat for shock. 4. Transport Continue to be on the alert for delayed reactions that may cause renewed pain or interfere with the patient’s ability to breathe. If the patient complains of increased burning or irritation, wash the burned areas again with flowing water for several minutes.

Treating Specific Chemical Burns When possible, find out the exact chemical or mixture of chemicals that were involved in the incident Most industrial sites will have a material safety data sheet (MSDS) that provides specific emergency information about the chemical agents being used Some special chemical burns require specific care procedures.

• Mixed or strong acids or unidentified substances. Many

of the chemicals used in industrial processes are mixed acids, whose combined action can be immediate and severe. The pain produced from the initial chemical burn may mask any pain being caused by renewed burning due to small concentrations left on the skin. When the chemical is a strong acid (e g . hydrochloric acid or sulfuric acid), a combination of acids, or an unknown, play it safe and continue washing over after the patient claims he is no longer experiencing pain. • Dry Lime. If dry lime is the burn agent, do not wash the burn site with water. To do so will create a corrosive liquid. LIFELINE

PREHOSPITAL EMERGENCY CARE

453

Day 19

SOFT TISSUE INJURIES

Brush the dry lime from the patient’s skin, hair, and clothing. Make certain that you do not contaminate the patient’s eyes or airway. Use water only after the lime has been brushed from the body, contaminated clothing and jewelry have been removed, and the process of washing can be done quickly and continuously with running water • Carbolic acid (phenol). Carbolic acid does not mix with water When available, use alcohol for the initial wash of unbroken skin, followed by a long steady wash with water. • Sulfuric acid. Heat is produced when water is added to concentrated sulfuric acid, but it is still preferable to wash rather than leave the contaminant on the skin

Inside/Outside Chemical Burns ACIDS AND ALKALIS Although part of the treatment for both acid and alkali burnt is irrigation, alkali burns should be irrigated longer because of the different ways in which these chemicals react with the human body.

• Hydrofluoric add. This acid is used for etching glass as well as many other manufacturing processes. Burns from it may be delayed, so treat all patients who may have come into contact with the chemical, even if burns are not in evidence Flood the affected area with water. Do not delay care and transport to find neutralizing agents. • Inhaled vapors. Whenever a patient is exposed to a caustic chemical and may have inhaled the vapors, provide high-concentration oxygen (humidified, if available) and transport as soon as possible. This is very important when the chemical is an acid that is known to vaporize at standard environmental temperatures (Examples include hydrochloric acid and sulfuric acid)

When acids encounter tissue, they break down proteins. This results in coagulated tissue that limits further progression of the acid. Alkalis, on the other hand, break down protein, but they also liquefy the damaged tissue. In fact, this process, called saponification, is how soap has been made for centuries. A strong alkali like lye is mixed with fat or oil. The chemical reaction that occurs changes the two substances into soap. Because a strong alkali liquefies dead tissue, the alkali is able to eat into the tissue much farther than an acid can. Continued irrigation is the best method of diluting and removing the alkali and limiting the damage it causes. There is a well-known exception to the principle of acids causing limited damage. Hydrofluoric acid not only causes burns like any other acid, but it also penetrates much more deeply. The fluoride released from the acid combines with calcium and magnesium in the tissue until the fluoride is used up. This typically results in significant tissue damage, since there isn’t that much calcium or magnesium outside of bone. Much of the damage is internal and not visible, especially with low concentrations. Higher concentrations will cause both internal damage and external damage. Hydrofluoric acid is used in industrial applications such as glass etching and electronics manufacturing, but it is also available in some rust removers intended for use around the home. • Protect yourself during If you encounter a patient with a hydrofluoric acid exposure, you the washing process of must irrigate copiously and for as long as you can or until medical a chemical burn. Wear direction tells you to stop. Hydrofluoric acid burns can cause great protective gloves and tissue damage with few external signs, so do your best to persuade eyewear and control the a reluctant patient to go to the emergency department for further wash to avoid splashing. treatment. • Do not use neutralizers

NOTE:

PATIENT CARE

Chemical Burns to the Eyes A corrosive chemical can burn the globe of a person’s eye before he can react and close the eyelid. Even with the lid shut, chemicals can seep through onto the globe. To care for chemical burns to the eye, you should take the following steps:

1. Immediately flood the eyes with water. Often the burn will involve areas of the face as well as the eye When this is the case, flood the. entire area Avoid washing chemicals back into the eye or Into an unaffected eye. 2. Keep running water from a faucet, low454

LIFELINE

PREHOSPITAL EMERGENCY CARE

pressure hone, bucket, cup. bottle, rubber bulb syringe, IV setup, or other such source flowing into the burned eye The flow should be from the medial (nasal) corner of the eye to the lateral corner Since the patient’s natural reaction will be to keep the eyes tightly shut, you may have to hold the eyelids open. 3. Start transport and continue washing the eye for at least 20 minutes or until the patient’s arrival at the medical facility. 4. After washing the eye. cover both eyes with moistened pads. 5. Wash the patient’s eyes for 5 more minutes if he begins to complain about renewed burning sensations or irritation.

such as vinegar or baking soda in a patient’s eyes. • Some scenes where chemical burns have taken place can be very hazardous. Always evaluate the scene. There may be large pools of dangerous chemicals around the patient. Acids could be spurting from containers. Toxic fumes may be present. If the scene will place you in danger, do not attempt a rescue unless you have been trained for such a situation and have the needed equipment and personnel at the scene.

ELECTRICAL INJURIES Electric current, including lightning, can cause severe damage to the body. In these cases, the skin is burned where the energy enters the body and where it flows into a ground. Along the path of this flow, tissues are damaged due to heat. In addition, significant chemical changes take place in the nerves, heart, and muscles, and body processes are disrupted or may completely shut down.

PATIENT ASSESSMENT

Electrical Injuries

The victim of an electrical accident may have any or all of the following signs and symptoms: • Burns where the energy enters and exits the body. • Disrupted nerve pathways displayed as paralysis. • Muscle tenderness, with or without muscular twitching. • Respiratory difficulties or respiratory arrest. • Irregular heartbeat or cardiac arrest. • Elevated blood pressure or low blood pressure with the signs and symptoms of shock. • Restlessness is irritability if conscious, or loss of consciousness. • Visual difficulties. • Fractured bones and dislocations from severe muscle contractions or from falling (This can include the spinal column). • Seizures (in severe cases). Tiyakin na ikaw at ang pasyente ay nasa lugar na ligtas at hindi malapit sa pinagmumulan ng kuryente bago mo bigyan ng lunas ang pasyente. Laging tandaan na ang pagliligtas sa pasyente ay hindi dapat maglagay sa iyo sa panganib.

Ang lugar kung saan nangyari ang aksidente dahil sa kuryente ay kadalasang delikado. Isipin palagi na posibleng nandun pa ang pinagmulan ng kuryente. Huwag sumubok magligtas ng pasyente sa ganitong mga lugar kung hindi ka sanay at wala ka pang karanasan sa mga ganitong sitwasyon.

PATIENT CARE

Electrical Injuries

Follow these steps to provide emergency care to a patient with electrical injuries 1. Provide airway care Electrical shock may cause severe swelling along the airway. 2. Provide basic cardiac life support as required Since cardiac rhythm disturbances are common, be prepared to perform defibrillation if necessary. 3. Care for shock and administer high-concentration oxygen. 4. Care for spine injuries, head injuries, and severe fractures All serious electrical shock patients should be fully immobilized because electrical current can cause severe muscular contraction. Also, the patient may have been thrown by a high-voltage current In either case, there is the possibility of spinal injury that requires immobilization. 5. Evaluate electrical burns, looking for at least two external burn sites: contact with the energy source and contact with a ground. 6. Cool the burn areas and smoldering clothing the same as you would for a flame burn. 7. Apply dry sterile dressings to the burn sites. 8. Transport as soon as possible. Some problems have a slow onset If there are burns, there also may be more serious hidden problems In any case of electrical shock, heart problems may develop. Remember that the major problem caused by electrical shock is usually not the burn. Respiratory and cardiac arrest are real possibilities. Be prepared to provide basic cardiac life support measures with automated defibrillation.

LIFELINE

PREHOSPITAL EMERGENCY CARE

455

Day 19

REMINDER: 1. Treat the wound first and apply appropriate dressing before you apply a bandage. 2. If your case is possible dislocation and/or fracture, splint the injured part first then support it with a bandage. 3. One important Principle of splinting “YOU SPLINT TO MOVE, NOT MOVE TO SPLINT.” 4. Always check PMS (Pulse, Motor, Sensory) of your patient. 5. Tie the bandage snugly. Do not apply too much force unless needed. 6. Each type of injury corresponds with appropriate size of bandage and technique. 7. Do not forget your local protocols. 8. Always have your BSI on.

Sa pagbebenda ng sugat ng pasyente, lagyan muna ng gamot ang sugat bago ito ibalot. Kung meron namang nabali na buto, lagyan muna ng splint ang injured na bahagi ng katawan bago ito suportahan ng benda. At sa pagbebenda, tiyakin na nakasuot ka ng guwantes para hindi ka mahawa kung sakaling may iba pang sakit ang pasyente.

456

LIFELINE

PREHOSPITAL EMERGENCY CARE

SOFT TISSUE INJURIES

DRESSING AND BANDAGING Most cases of open wound care require the application of a dressing and a bandage. A dressing is any material applied to a wound in an effort to control bleeding and prevent further contamination. Dressings should be sterile. A bandage is any material used to hold a dressing in place. Bandages need not be sterile.

dislocation and/or ture, splint the injure first then support it w bandage. 3. One important Princ splinting “YOU SPLIN MOVE, NOT MOV SPLINT” 4. Always check PMS ( Motor, Sensory) of patient. 5. Tie the bandage sn Do not apply too force unless needed. 6. Each type of injury sponds with appro size of bandage and nique. Be certain to wear 7. Do not forget your disposable gloves and protocols. 8. devices Always have your BS other barrier

NOTE:

Various dressings are carried in emergency care kits. These dressings should be sterile, meaning that all microorganisms and spores that can grow into active to avoid contact with organisms have been killed. Dressings also should be aseptic, the patient’s blood and meaning that all dirt and foreign debris have been removed. body fluids. Follow Many EMS systems now also carry hemostatic dressings used infection control to stop bleeding. In emergency situations, when commercially procedures. prepared dressings are not available, clean cloth, towels, sheets, handkerchiefs, and other similar materials may be suitable alternatives. The most popular dressings are individually wrapped sterile gauze pads, typically 4 inches square. A variety of sizes are available, referred to according to size in inches such as 2X2S, 4x4s, 5x9s and 8X10s. Large bulky dressings, such as the multitrauma or universal dressing, are available when bulk is required for profuse bleeding or when a large wound must be covered. These dressings are especially useful for stabilizing impaled objects. Sanitary napkins can sometimes be used in place of the standard bulky dressings. Although not sterile, they are separately wrapped and have very clean surfaces. (Do not apply any adhesive surface of the napkin directly to the wound) Of course, bulky dressings can be made by building up layers of gauze pads. A pressure dressing is used to control bleeding. Gauze pads are placed on the wound and a bulky dressing is placed over the pads. A self-adherent roller bandage is wrapped lightly over the dressing and above and below the wound. You must check and frequently recheck the distal pulse, and you may need to readjust the pressure to ensure distal circulation. An occlusive dressing is used when it is necessary to form an airtight seal. This is done when caring for open wounds to the abdomen, for external bleeding from large neck veins and for open wounds to the chest Sterile, commercially prepared occlusive dressings are available in two different forms: plastic wrap and petroleumgel-impregnated gauze occlusive dressing. Local protocols vary as to which form to use. Nonsterile wrap also can be used in emergency situations. In emergencies EMTs TRIA TRIA NGULA NGULA RR FOLDING FOLDING have been known to fashion occlusive dressings from plastic credit cards, plastic bags, sterile medical equipment wrappers, and defibrillator pads. Open Cravat Cravat Large dressings are sometimes needed in emergency care. Sterile, disposable Open Bandaging burn sheets are commercially available, lied sheets can also be sterilized and kept in 1. 1. Bandaging under under Broad Broa plastic wrappers to be used later as dressings These sheets can make effective hum Top Top Side; Side; Fro F dressings or may be used in some cases to cover exposed abdominal organs ofofChest; Chest;Fro F Bandages are provided in a wide variety of types the preferred bandage is the ofofHead; Head;ArA self-adhering, form-fitting roller bandage. It eliminates the need in know many Underarm Underarm s specialized bandaging techniques developed for use with ordinary gauze roller Bandage; Bandage; bandages Dressings can be secured using adhering or non-adhering gauze roller bandages Broad Broad Cravat Cravat triangular bandages strips of adhesive tape, or an air splint. In a situation where one 1. 1. Hawakan Hawakanana of these is not available, you can use strips of cloth, handkerchiefs, and other such sasabase baseatata materials. Elastic bandages that are used in the general care of strains and sprains wan—kanang wan—kanan apex, apex,kaliwan kaliw should not be used to hold dressings in place. They can become constricting bands base) base)ngngiyon iy interfering with circulation. This is very likely to occur as the tissues around the ang ang dalawan dalawa wound site begin to swell after the elastic bandage is in place.

nakalabas nakalabas 2. 2. Pagdikitin Pagdikitin an apex, apex,ipitin ipitinn wang wanghinlala hinla Ipasok Ipasok ang ang ka sasa loob loob ngng bab gang gangmaabot maab bahagi. bahagi.

fraced part with a

become constricting bands interfering with circulation. This is very likely to occur as the (issues around the wound site begin to swell after the elastic bandage is in place.

ciple of NT TO VE TO

DRESSING AND BANDAGING TRIANGULAR BANDAGE

TRIANGULAR BANDAGE

(pulse, your

nugly. much . correopriate d tech-

BANDAGING TECHNIQUE WITH OPEN AND BROAD CRAVAT

Open Cravat

1. Bandaging Technique under Broad Cravat: Head Top Side; Front and Back of Chest; Front and Back of Head; Arm sling and Underarm sling; Hand Bandage;

r local

SI on.

Broad Cravat

UNIT UNIT33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY19 19 PRINCIPLES TRIANGULAR TRIANGULARBANDAGE BANDAGEFOLDING FOLDING

1. Hawakan ang T-bandage sa base at apex (sa larawan— kanang kamay sa apex, kaliwang kamay sa base) ng iyong 8 daliri at ang 2 hinlalaki ay nakalabas 2. Pagdikitin ang base at apex. Ipitin ng iyong kaliwang hinlalaki ang apex. Ipasok ang kanang kamay sa loob ng bandage hanggang maabot ang dulong bahagi. 3. Kapag naabot na ang dulo, hawakan ito at hilahin papalabas upang mabaligtad ang T-bandage. 4. Ayusin ito. Hawakan ang T-bandage ng iyong mga daliri tulad ng naunang hakbang. 5. Ang bandaging technique na ito ay para sa pagbebenda sa tiyan o kaya ay sa tuhod.

BANDA BANDA GE GE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

g Technique Technique ad Cravat: Cravat: Head Head Front ont and andBack Back Front ont and andBack Back rm Armsling slingand and sling; sling; Hand Hand

ng angT-bandage T-bandage apex apex(sa(salaralaragng kamay kamay sasa wang ng kamay kamaysasa yong ng 8 8daliri daliriatat ng ang hinlalaki hinlalaki ayay

ng ang base base atat ngngiyong iyongkalikaliaki alakiang angapex. apex. anang kanang kamay kamay andage bandage hanghangbot t ang angdulong dulong

LIFELINE

PREHOSPITAL EMERGENCY CARE

457

e age araa sa a sa t at y ay

baligtad ang T-bandage. Ayusin ito. Hawakan ang T-bandage ng iyong mga daliri tulad ng naunang hakbang. Bandaging Day 19 Technique under Broad Cravat: AbUNIT dominal Bandage; UNIT3 3 Knee DAY Bandage DAY1919

BANDAGE FOLDING

Semi-Broad Cravat 1. Mula sa Broad Cravat BANDAGE BANDAGE FOLDING FOLDING Hawakan ang T-bandage BANDAGE BANDAGE FOLDING FOLDING 5. SOFT TISSUE INJURIES sa Semi-Broad base at apex (sa lara Semi-Broad Cravat Cravat Semi-Broad Semi-Broad Cravat Cravat wan—kanang kamay sa 1. 1.Mula Mulasa sa Broad BroadCr PRINCIPLES OF EMT CLINICAL PRACTICE 1. 1.Hawakan Mula Mula sa sa Broad Broad Cr Hawakan ang ang T-ban T-b bahagi ng apex, kaliwang PRINCIPLES OF EMT CLINICAL PRACTICE t at ang ang T-ban T-b(8 sa sa base base atng at apex apex (sa kamay Hawakan saHawakan base) iyong kalisa sa base base at at apex apex (sa ( wan—kanang wan—kanang kamay kam daliri wan—kanang at wan—kanang ang dalawang . pex. kamay kam bahagi bahagi ng ng apex, apex, kaliw k y hinlalaki ay nakalabas TRIANGULAR FOLDING may bahagi bahagi ngbase) ng apex, apex, k TRIANGULARBANDAGE BANDAGE FOLDING kamay kamay sa sa base) ngkaliw ng iyo ng2. Pagdikitin ang base a BANDAGE FOLDING kamay kamay sa base) sa base) ng ng iyo daliri daliriat atang angdalaw da BANDAGE FOLDING g ong apex, ipitin ng iyong kal daliri daliri at at ang ang dalaw da hinlalaki hinlalaki ay ay nakalabas nakalab Broad Cravat hinlalaki hinlalaki ayang ay nakalabas nakalab Broad Cravat wang hinlalaki apex 2. 2.Pagdikitin Pagdikitin ang ang basb g 1. Hawakan ang T-bandage ang 1. Hawakan ang T-bandage 2. 2.Pagdikitin Pagdikitin ang ang bas b Ipasok ang kanang kamay apex, apex, ipitin ipitin ng ng iyong iyo sa base at apex (sa larahilasa base at apex (sa laraapex, apex, ipitin ipitin ngng iyong iyoa wan—kanang kamay sa wang wang hinlalaki hinlalaki ang an masa loob ng bandage hang wan—kanang kamay sa apex, kaliwang kamay sa wang wang hinlalaki hinlalaki ang an Ipasok Ipasok ang ang kanang kanang kaa e. apex, kaliwang kamay sa gang maabot ang dulong base) ng iyong 8 daliri at UNIT 3 UNIT 3 Ipasok Ipasok ang ang kanang kanang ka g base) ng iyong 8 daliri at ang loob sa loob ngng bandage bandag h ang dalawang hinlalaki ay ay bahagi.sa ang dalawang hinlalaki a sa loob sa loob ng ng bandage bandag h mga gang gang maabot maabot ang ang du DAY 19 DAY 19 nakalabas 3. kapag gang naabot naangang ang nakalabas g gang maabot maabot du ang 2. 2.Pagdikitin ang base at bahagi. bahagi. Pagdikitin ang base at dulo, ito at hila bahagi. bahagi. apex, ipitin ngngiyong kali3. 3.hawakan kapag kapag naabot naabot na n apex, ipitin iyong kalie que wang hinlalaki ang apex. 3. 3. kapag kapag naabot naabot na hin papalabas upang ma wang hinlalaki ang apex. dulo, dulo, hawakan hawakan ito ito atn NIT 3 T- 3 Ipasok ang kanang kamay Abdulo, dulo, hawakan hawakan ito ito at Ipasok ang kanang kamay baligtad T-bandage. PRINCIPLESOF OFEMT EMTCLINICAL CLINICAL PRACTICE hinang hin papalabas papalabas upang upa TRIANGULAR BANDAGE FOLDING TRIANGULAR PRACTICE sa sa loob ngng bandage hang19 PRINCIPLES eY19 nee loob bandage hanghin hin papalabas papalabas upang upa baligtad ang ang T-banda T-ban 4. Ayusinbaligtad ito. Hawakan ang gang maabot ang dulong BANDAGEFOLDING FOLDING BANDAGE gang maabot ang dulong baligtad baligtad ang ang T-banda T-ban bahagi. 4. 4.Ayusin Ayusin ito. Hawakan Hawak T-bandage ngito. iyong mga bahagi. 4. 4.Ayusin Ayusin ito.ito. Hawakan Hawak 3. 3.kapag T-bandage T-bandage ng iyong iyon kapagnaabot naabotnanaang ang BroadCravat Cravat Broad daliri tulad ng ng naunang dulo, hawakan itoito at at hilaT-bandage T-bandage ng ng iyong iyon TRIANGULAR BANDAGE FOLDING dulo, hawakan hilaTRIANGULAR BANDAGE FOLDING daliri daliri tulad tulad ng ng naun n Hawakan ang ang T-bandage T-bandage 1.1. Hawakan hakbang. hinhin papalabas upang ma² Limmer (Brady) daliri daliri tulad tulad ng ng naun n papalabas upang mahakbang. hakbang. sa base at apex (sa lara³ Pollack, (AAOS) sa base at apex (sa larabaligtad ang T-bandage. baligtad ang T-bandage. 5. Bandaging Technique ⁴ NHTSA hakbang. hakbang. 5. 5.Bandaging Bandaging Techn Tec wan—kanang kamay kamay sa sa 4. 4.Ayusin wan—kanang ito.ito. Hawakan ang Ayusin Hawakan ang 5. 5.Bandaging Bandaging Techn Tec under Semi-Broad Cravat apex, kaliwang kaliwang kamay kamay sa sa T-bandage ngng iyong mga under under Semi-Broad Semi-Broad Cr apex, T-bandage iyong mga age ge under under Semi-Broad Semi-Broad Cr daliri tulad ng naunang base) ng iyong 8 daliri at Shoulder Bandage; Hip base) ng iyong 8 daliri at Shoulder Shoulder Bandage; Bandag daliri tulad ng naunang araahakbang. Shoulder Shoulder Bandage; Bandag ang dalawang hinlalaki ay hakbang. ang dalawang hinlalaki ay Bandage Bandage Bandage sasa 5. Bandaging Technique

ysasa riatat i ay ay

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que ue Abbnee ee

PRINCIPLES OF EMT CLINICAL PRACTICE

nakalabas nakalabas Pagdikitin ang ang base base at at 2.2. Pagdikitin apex, ipitin ipitin ng ng iyong iyong kalikaliapex, wang hinlalaki hinlalaki ang ang apex. apex. wang Ipasok ang ang kanang kanang kamay kamay Ipasok saloob loobng ngbandage bandage hanghangsa gang maabot maabot ang ang dulong dulong gang bahagi. bahagi. kapag naabot naabot na na ang ang 3.3. kapag dulo, hawakan ito at hiladulo, hawakan ito at hilahin papalabas papalabas upang upang mamahin baligtadang angT-bandage. T-bandage. baligtad Ayusin ito. ito. Hawakan Hawakan ang ang 4.4. Ayusin T-bandage ng iyong iyong mga mga ² Limmer (Brady) T-bandage ng ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) daliri tulad ng ng naunang naunang daliri tulad ⁴ NHTSA ⁴ NHTSA hakbang. hakbang. Bandaging Technique Technique 5.5. Bandaging under Broad Cravat: Abunder Broad Cravat: Abdominal Bandage; Bandage; Knee Knee dominal Bandage Bandage

458

LIFELINE

PREHOSPITAL EMERGENCY CARE

Bandage Bandage

Bandaging Technique under Broad Cravat: under Broad Cravat:Ab-Abdominal dominalBandage; Bandage;Knee Knee Bandage Bandage

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

TRIANGULAR TRIANGULAR BANDAGE BANDAGE FOLDING FOLDING TRIANGULAR TRIANGULAR BANDAGE BANDAGE FOLDING FOLDING

t, e aaCravat, ravat, ravat, Cravat, ndage bandage g ndage bandage (sa lara8lara(sa laramay ylarasa sa g may y sa sa

BANDAGING TECHNIQUE USING SEMI-BROAD CRAVAT

kaliwang wang kaliwang wang ong iyong 8 8 at ong iyong 8 8 alawang wang lialawang wang sbas sbas at at x. se base se base atkaliat y kalig ong g ong kalikaling apex. apex. gng apex. apex. gg amay kamay g amay kamay ge hanghangge hanghangulong dulong gdulong ulong anaang ang ang ang aona t at hilahilaog tang at hilahilama-mag ang age. ndage. g ma-maage. ndage. n kan a angang nkan ang ang ng mga mga g ng mga mga naunang nang naunang nang e nique chnique nique chnique t:Cravat: ravat: ravat: pCravat: ge; HipHip ge;HipHip

Semi-Broad Cravat

1. Mula sa Broad Cravat, Hawakan ang T-bandage sa base at apex (sa larawan— kanang kamay sa bahagi ng apex, kaliwang kamay sa base) ng iyong 8 daliri at ang 2 hinlalaki ay nakalabas. 2. Pagdikitin ang base at apex. Ipitin ng iyong kali-wang hinlalaki ang apex. Ipasok ang kanang kamay sa loob ng bandage hanggang maabot ang dulong bahagi. 3. Kapag naabot na ang dulo, hawakan ito at hilahin papalabas upang mabaligtad ang T-bandage. 4. Ayusin ito. Hawakan ang T-bandage ng iyong mga daliri tulad ng naunang hakbang. 5. Ang bandaging technique na ito ay para sa pagbebenda sa balikat at sa balakang.

² Limmer ² Limmer (Brady) (Brady) ³² Limmer Pollack, ³² Limmer Pollack, (AAOS) (AAOS) (Brady) (Brady) ⁴³ Pollack, NHTSA ⁴³ Pollack, NHTSA (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

459

UNIT 3 DAY 19

PRINCIPLES OF EMT CLINICAL PRACTICE Day 19

TRIANGULAR FOLDING BANDAGE FOLDING BANDAGE Narrow Cravat 1. Mula sa Semi-Broad CraNarrow Cravat vat, Hawakan ang T1. Mula sa Semi-Broad bandage sa baseCravat, at apex hawakan ang T-bandage sa ka(sa larawan—kanang mayatsa bahagi ng apex, base apex (sa larawan— kaliwang kamay sa ng base) kanang kamay sa bahagi ng iyong 8 kamay daliri saat ang apex, kaliwang dalawang base) ng iyong 8hinlalaki daliri at ang ay 2nakalabas hinlalaki ay nakalabas. 2.2. Pagdikitin Pagdikitin ang ang base atbase apex, at apex,ngipitin iyong kaliipitin iyongng kaliwang wang hinlalaki ang apex. hinlalaki ang apex. Ipasok Ipasok ang kanang kamay ang kanang kamay sa loob ng sa loobhanggang ng bandage hangbandage maabot gang maabot ang dulong bahagi.ang dulong bahagi. 3. Kapag naabot na ang dulo, 3. hawakan kapag ito naabot at hilahinna ang dulo, hawakan ito at hilapapalabas upang ma-baligtad hinT-bandage. papalabas upang maang baligtad T-bandage. 4. Ayusin ito.ang Hawakan ang 4. T-bandage Ayusin ito. Hawakan ng iyong mga ang T-bandage iyong mga daliri tulad ng ng naunang daliri tulad ng naunang hakbang. hakbang. 5. Ang bandaging technique 5. na Bandaging Technique ito ay magagamit para Narrow Cravat: saunder pagbebenda sa mata, sa Eye Bandage; Forehead noo, sa tenga at mukha, saBandage;saEar-Cheek-Jaw Banbraso, binti at hita, kapag dage; Arm Forenakasuot ang Bandage; sapatos, kapag arm Bandage; Lego Bannakadiretso ang kamay, dage; Thigh nakadiretso ang siko.Bandage; Shoe-on and off Bandage; Palm Straight Bandage; Pam Bend Bandage; Elbow Straight Bandage; Elbow Bend Bandage

460

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

SOFT TISSUEBANDAGE INJURIES FOLDING TRIANGULAR

PATIENT CARE

Dressing Open Wounds The following rules apply to the general dressing of wounds. 1. Take standard precautions. 2. Expose the wound. Cut away any clothing necessary so the entire wound is exposed 3. Use sterile or very clean materials. Avoid touching the dressing in the area that will come into contact with the wound. Grasp the dressing by the corner, taking it directly from its protective pack, and place it on the wound. 4. Cover the entire wound. The entire surface of the wound and the immediate surrounding areas should be covered. 5. Control the bleeding. Use direct pressure and/or hemostatic agents or dressings to stop or slow the bleeding. With the exception of the pressure dressing, a dressing should not be bandaged in place if it has not controlled the bleeding. You should continue to apply dressings and pressure as needed for the proper control of bleeding. 6. Do not remove dressings. Once a dressing has been applied to a wound, it must remain in place. Bleeding may restart and tissues at the wound site may be injured if the dressing is removed If the bleeding continues, reapply pressure, apply additional hemostatic agent, and put new dressings over the blood-soaked ones. There is an exception to the rule prohibiting the removal of dressings. If a bulky dressing has become soaked with blood, it may be necessary to remove the dressing so that direct pressure can be re-established or a new bulky dressing can be added and a pressure dressing created. Protection for the wound site is better maintained if one or more gauze pads are placed over the injured tissues before placing the bulky dressing. This will allow for the removal of a bulky dressing without disturbing the wound.

Bandaging Open Wounds The following rules apply to general bandaging: 1. Do not bandage too lightly all dressings should be held snugly in place, but they must not restrict the blood supply to the affected part. 2. Do not bandage too loosely Hold the dressing by bandaging snugly, so the dressing does not move around or slip from the wound Loose bandaging is a common error in emergency care. 3. Do not leave loose ends Any loose ends of gauze, tape, or cloth may get caught on objects when the patient is moved. 4. Do not cover the tips of fingers and toes When bandaging the extremities, leave the fingers and toes exposed whenever possible to observe skin color changes that indicate a change in circulation and to allow for easier neurologic reassessment. Pain, pale or cyanotic skin, cold skin, numbness, and tingling are all indications that a bandage may be too tight The exception is burned fingers or toes, which have to be covered. 5. Cover all edges of the dressing This will help to reduce additional contamination The flutter-valve dressing for an open chest wound is an exception. Two special problems occur when bandaging an extremity. First, point pressure can occur if you bandage around a very small area It is best to wrap a large area, ensuring a steady, uniform pressure. Apply the bandage from the smaller diameter of the limb to the larger diameter (distal to proximal) to help ensure proper pressure and contact. Second, the joints have to be considered. You can bandage across a joint, but do not bend the limb once the bandage is in place. Doing so may restrict circulation, loosen the dressing and bandage, or do both. In some cases it may be necessary to apply an inflatable or rigid splint, or to use a sling and swathe to present the jointâ&#x20AC;&#x2122;s movement.

CRITICAL CONCEPT Soft-tissue injuries may be closed (internal, with no pathway to the outside) or open (an injury in which the skin is interrupted, exposing the tissues below). Closed injuries include contusions (bruises), hematomas, and crush injuries. Open wounds include abrasions, lacerations, punctures, avulsions, amputations, and crush injuries. For open wounds, expose the wound, control bleeding, and prevent further contamination. For both open and closed injuries, take appropriate Standard Precautions; note the mechanism of injury: protect the patientâ&#x20AC;&#x2122;s airway and breathing: administer high concentration oxygen by nonrebreather mask: treat for shock; transport. Burn severity is determined by considering the source of the burn, body regions burned, depth of the burn (superficial, partial thickness and full thickness), extent of the burn (by rule of nines or rule of palm), age of the patient (children under 5 and adults over 55 react most severely), and other patient illnesses or injuries. Care for burns includes stopping the burning process (using water for a thermal hum, brushing away chemicals), covering a thermal hum with a dry sterile dressing, flushing a chemical burn with sterile water, protecting the airway, administering oxygen, treating for shock, and transporting the patient to a medical facility. For treatment of electrical injuries be sure that you and the patient are in a safe BOM away from possible contact with electrical sources Protect the airway, breathing, and circulation. Be prepared to care for respiratory or cardiac arrest. Treat for shock, care for burns and transport the patient. LIFELINE

PREHOSPITAL EMERGENCY CARE

461

, with no pathICAL TICAL CONCEPT CONCEPT ICAL TICAL CONCEPT ICAL TICALCONCEPT CONCEPT CONCEPT

ide) or open (an the skin is interue e injuries injuries may may he he ue e injuries injuries may may he he ue e injuries injuries may may he he ng the nternal, nternal, with withtissues no nopathpath-

nternal, nternal, with with no no pathnternal, nternal, with with no nopathpathpathhe e outside) outside) or or open open (an (an he e outside) outside) or or open open (an (an he e outside) outside) or or open open (an (an which which the the skin skin is is interinterwhich which the the skin skin is is interinterinclude contuwhich which the the skin skin is is interinterexposing exposing the the tissues tissues exposing exposing the tissues tissues exposing exposing the the the and tissues tissues hematomas,

Openinclude wounds njuries injuries include contucontunjuries injuries include include contucontunjuries injuries include include contucontuons, lacerations, uises), ises), hematomas, hematomas, and and uises), ises), hematomas, hematomas, and and uises), ises), hematomas, hematomas, and and njuries. uries. Open Open wounds wounds ulsions, amputanjuries. uries. Open Open wounds wounds njuries. uries. Open Open wounds wounds abrasions, abrasions, lacerations, abrasions, abrasions, lacerations, lacerations, injuries. lacerations, abrasions, abrasions, lacerations, lacerations, es, , avulsions, avulsions, amputaes, , avulsions, avulsions, avulsions, amputaamputaamputaes, ,nds, avulsions, amputaamputaexpose the d crush crush injuries. injuries. dcrush crush crushinjuries. injuries. injuries. d crush injuries. l wounds, bleeding, andthe n wounds, expose expose the n wounds, wounds, expose expose the the ncontrol wounds, wounds, expose exposeand the the control bleeding, bleeding, and contamination. control control bleeding, bleeding, and and control control bleeding, bleeding, and and urther further contamination. contamination. urther further contamination. contamination. urther further contamination. contamination. and closed injuh open open and and closed closed injuinjuh open open and and closed closed injuinjuh open open and and closed closed injuinjuopriate Standard e appropriate appropriate Standard Standard e appropriate appropriate Standard Standard e appropriate appropriate Standard Standard ote the the mechaons; ns; note note the mechamechaons; ns; note note the the mechamechaons; ns; note note the the the mechamechanjury: injury: protect protect the paprotect the pa-panjury: injury:protect protect protectthe the the papanjury: injury: protect the papaairway rway and and breathing: breathing: airway rway and and breathing: breathing: and and breathing: airway rway and breathing: breathing: rrer high-concentration high-concentration high-concentration high-concentration rer ernonrebreather high-concentration high-concentration gh-concentration by y nonrebreather mask: mask: by y nonrebreather nonrebreather mask: mask: by y nonrebreather nonrebreather mask: mask: rebreather mask: hock; shock; transport. transport. hock; shock; transport. transport. hock; shock;transport. transport. transport. erity verity determined by erity verityis isis isdetermined determined determinedby by by erity verity is is determined determined by by ng ing the the source source of of the the ng ing the the source source source of ofof of the the sing determined bythe ng the the source the body ody regions regions burned, burned, body ody regions regions burned, burned, body ody regions regions burned, burned, efthe source of the the burn burn (superficial, (superficial, ffthe the burn burn (superficial, (superficial, the the burn burn (superficial, (superficial, egions burned, hickness ckness and and full full thickthickhickness ckness and and full full thickthickhickness ckness and and full full thickthickent tent of of the the burn burn (by (by rule rule burn (superficial, ent tent of of the the burn burn (by (by rule rule ent tent of of the the burn burn (by (by rule rule or or rule rule of of palm), palm), age age of of or or rule rule of of palm), palm), age age of of s and full thickor or rule rule of of palm), palm), age age of of nt ent (children (children under under 5 5 nt ent (children (children under under 5 5 nt ent (children (children under under 5 5 the burn (by rule ults ts over over 55 55 react react most most ults ts over over over55 55 55react react reactmost most most ults ts over 55 react most of palm), age of ,,and and other other patient patient illilland andother other otherpatient patient patientillill-ill,and and other patient rrinjuries. injuries. hildren under 5 illinjuries. rinjuries. injuries. injuries. rrrburns burns includes includes stopstop55 react most burns includes stopstopr burns burns burns includes includes includes stopstopburning burning process process (using (using burning burningpatient process process(using (using (using other illburning burning process process (using rra thermal hum, brushaa athermal thermal thermalhum, hum, hum,brushbrushbrusha thermal thermal hum, hum, brushbrushyyras. chemicals), chemicals), covering covering a a chemicals), chemicals), covering covering a y chemicals), chemicals), covering covering aa a hum hum with with a a dry dry sterile sterile shum includes stophum with with a a dry dry sterile sterile hum hum with with a a dry dry sterile sterile ,,gflushing flushing chemical chemical flushing chemical chemical processaaa aaa(using ,hflushing flushing flushing chemical chemical h sterile sterile water, water, protectprotecth h sterile sterile water, water, protectprotectmal hum, brushhairway, hsterile sterile water, water, protectprotectairway, administering administering airway, airway, administering administering airway, airway, administering administering icals), covering aand reating treating for for shock, shock, and reating treating for for shock, shock, and and reating treating for for shock, shock, and and ng ting patient patient to with athe sterile ng ting the the thedry patient patient toto to a aa a ng ting the the patient patient to to a a acility. facility. ing a chemical acility. facility. acility. facility. ment tment of ofelectrical electrical injuinjument tment of electrical injuinjue water, protectment tment ofof ofelectrical electrical electrical injuinjuure sure that that you you and and the the ure sure that that you you and and the the y, administering ure sure that that you you and and the the are e in in a a safe safe BOM BOM away away are e in in a a safe safe BOM BOM away away are e in in a a safe safe BOM BOM away away g for shock, and ssible ible contact with elecssible ible contact contact contactwith with withelecelecelecssible ible contact contact with with elecelecurces ces Protect Protect the the airway, airway, he patient to a urces ces Protect Protect Protectthe the theairway, airway, airway, urces ces Protect the airway, g, ,, and and circulation. circulation. Be Be g, and and circulation. circulation. Be Be g, ,toto and and circulation. circulation. Be Be d care care for for respiratory respiratory d to to care care for for respiratory respiratory d to to care care for for respiratory respiratory of electrical injuccarrest. arrest. Treat Treat for for shock, shock, arrest. Treat Treat for for shock, carrest. arrest. arrest. Treat Treat for forshock, shock, shock, burns urns and and transport transport the the at you and the burns urns and and transport transport the burns urns and andtransport transportthe the the

safe BOM away ontact with elecotect the airway, circulation. Be 462 LIFELINE re for respiratory t. Treat for shock, nd transport the

ensure proper pressure and contact. Second, the joints have to be considered. Two Two special special problems problems occur occur when when bandaging bandaging an an extremity. extremity. First, First, point point prespresTwo Two special special problems problems occur occur when bandaging bandaging an an extremity. First, First, point point prespresTwo Two special special problems problems occur occurwhen when when bandaging bandaging an anextremity. extremity. extremity. First, First, point point prespressure sure can can occur occur if if you you bandage bandage around around a a very very small small area area It It is is best best to to wrap wrap a a bandage is You can bandage across a joint, but do not bend the limb once the sure sure can can occur occur if you bandage bandage around around a a very small area area It It is best wrap wrap a sure sure can can occur occur if if ifyou you you bandage bandage around around apressure. avery very verysmall small small area area Itbandage Itis is isbest best bestto toto to wrap wrap aa a large large area, area, ensuring ensuring a a steady, steady, uniform uniform pressure. Apply Apply the the bandage from from the the in place. Doing soaamay restrict circulation, loosen the dressing and bandage, or large large area, area, ensuring ensuring a steady, steady, uniform uniform pressure. pressure. Apply Apply the the bandage bandage from from the the large large area, area, ensuring ensuring a steady, steady, uniform uniform pressure. pressure. Apply Apply the the bandage bandage from from the the smaller smaller diameter diameter of the limb to the the larger diameter diameter (distal to proximal) to help smaller smaller diameter diameter ofof ofthe the thelimb limb limb toto to the thelarger larger larger diameter diameter(distal (distal (distal toto toproximal) proximal) proximal) toto tohelp help helpor rigid splint, do both. In some eases it may be necessary to apply an inflatable smaller smaller diameter diameter of of the the limb limb to to the the larger larger diameter diameter (distal (distal to to proximal) proximal) to to help help ensure ensure proper proper pressure pressure and and contact. Second, Second, the joints joints have have to be considered. ensure ensure proper proper pressure pressure and andcontact. contact. contact. Second, Second,the the the joints joints have have toto tobe be beconsidered. considered. considered. ensure ensure proper proper pressure pressure and contact. contact. Second, Second, the the joints joints have have to to be be considered. considered. or tocan use a sling and swathe todo present the joint's movement. You You can bandage bandage across across aand ajoint, joint, but but do not notbend bend the the limb limb once once the the bandage bandageisis You You can can bandage across across a joint, do not not bend bend the the limb limb once once the the bandage bandage is is SOFT TISSUE INJURIES Day but 19but You You can canbandage bandage bandage across across aa ajoint, joint, joint, but butdo do do not not bend bend the thedressing limb limb once once the the bandage bandage isor is in in place. place. Doing Doing so so may may restrict restrict circulation, circulation, loosen loosen the the dressing and and bandage, bandage, or in in place. place. Doing Doing so so may may restrict restrict circulation, circulation, loosen loosen the the dressing dressing and and bandage, bandage, or or in in place. place. Doing Doing so so may may restrict restrict circulation, circulation, loosen loosen the the dressing dressing and and bandage, bandage, or or do do both. both. In In some some eases eases it itmay may be be necessary necessary to to apply apply an an inflatable inflatable oror rigid rigid splint, splint, do do both. both. In In some some eases eases it may be be necessary necessary to to apply an an inflatable rigid splint, do do both. both. In In some some eases eases itit itmay may may be be necessary necessary tojoint's toapply apply apply an aninflatable inflatable inflatableor oror orrigid rigid rigidsplint, splint, splint, or or to to use use a a sling sling and and swathe swathe to to present present the the joint's movement. movement. or or to to use use a a sling sling and and swathe swathe to to present present the the joint's joint's movement. movement. orortotouse usea asling slingand andswathe swathetotopresent presentthe thejoint's joint'smovement. movement.

HE 1.

SIMPLE KNOT

SIMPLE SIMPLE KNOT SIMPLE SIMPLEKNOT KNOT KNOT

A knot used in bandaging technique, 3. done by creating a simple loop and A A knot knot used used in in bandaging bandaging technique, technique, A A knot knot used used in bandaging technique, A A knot knot used used inin inbandaging bandaging bandaging technique, technique, inserting an endtechnique, to secure done done by by creating creating a a simple simple loop loop and and 4. UNIT 3 it and form done done by by creating creating a a simple simple loop loop and and done done by by creating creating a a simple simple loop loop and and inserting inserting an an end end to to secure secure it it and and form form PRINCIPLES OF EMT a knot. inserting insertingan an anend end endto toto tosecure secure secureit itit itand and and form form DAY 19 inserting inserting an end secure and form form a knot. aa aknot. knot. knot. a a knot. knot.

SIMPLE KNOT

A knot used in bandaging technique, done by creating a simple loop and inserting an end to secure it and form a knot. HEAD TOP SIDE 1.

2. 3. 4.

² Limmer ² Limmer (Brady) (Brady) (Brady) (Brady) ³²² Limmer Pollack, ³²² Limmer Pollack, (AAOS) (AAOS) Limmer Limmer (Brady) (Brady) ³⁴³ Pollack, ³ Pollack, (AAOS) (AAOS) NHTSA ⁴³ Pollack, NHTSA Pollack, (AAOS) (AAOS) NHTSA NHTSA ⁴⁴ NHTSA ⁴⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

Open Phase Bandage is to be used. Hold the base part of the bandage and fold it inward about 1 inch of size twice. Place the base on top of the patient’s head up to the eyebrows. Hold the sides and roll it inwards until you get the head’s contour. Get the 2 rolled sides and interchange it with the other and put the ends on top of the patient’s forehead. Tie it using square knot. Hold the apex at the back while supporting the patient’s head, gently pull the apex to follow the head’s contour. Roll the apex upward and tuck it inside the roll you’ve created at the beginning. Make sure that all ends are tucked in to make your bandage neat.

HEAD TOP SID 5. 6.

UNIT33 UNIT DAY 19 P DAY 19

HEADTOP TOPSIDE SIDE HEAD OpenPhase PhaseBandage Bandageisistoto 1.1. Open used.Hold Holdthe thebase base bebeused. partofofthe thebandage bandageand and part foldit itinward inwardabout about1 1inch inch fold sizetwice. twice. ofofsize Placethe thebase baseon ontop topofof 2.2. Place thepatient’s patient’shead headup uptoto the theeyebrows. eyebrows. the Holdthe thesides sidesand androll rollit it 3.3. Hold inwardsuntil untilyou youget getthe the inwards head’scontour. contour. head’s Getthe the2 2rolled rolledsides sidesand and 4.4. Get interchange it it with with the the interchange otherand andput putthe theends endson on other topofofthe thepatient’s patient’sforeforetop head.Tie Tieit itusing usingsquare square head. knot. knot. Holdthe theapex apexatatthe theback back 5.5. Hold whilesupporting supportingthe thepapawhile tient’s head, head, gently gently pull pull tient’s the apex apex toto follow follow the the the head’scontour. contour. head’s Rollthe theapex apexupward upwardand and 6.6. Roll tuck it it inside inside the the roll roll tuck you’vecreated createdatatthe thebebeyou’ve ginning. ginning. Makesure surethat thatallallends ends 7.7. Make are tucked tucked inin toto make make are yourbandage bandageneat. neat. your

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

UNIT 3 DAY 19

PRINCIPLES

Holdthe thesides sidesand androll rollitit 3.3. Hold inwardsuntil untilyou youget getthe the inwards head’scontour. contour. head’s Getthe the22rolled rolledsides sidesand and 4.4. Get interchange itit with with the the interchange otherand andput putthe theends endson on other top ofof the the patient’s patient’s foreforetop head.Tie Tieititusing usingsquare square head. knot. knot. Holdthe theapex apexatatthe theback back 5.5. Hold while supporting supporting the the papawhile tient’s head, head, gently gently pull pull tient’s the apex apex toto follow follow the the the head’scontour. contour. head’s Rollthe theapex apexupward upwardand and 6.6. Roll tuck itit inside inside the the roll roll tuck you’vecreated createdatatthe thebebeyou’ve ginning. ginning. Make sure sure that that allall ends ends 7.7. Make are tucked tucked inin toto make make are yourbandage bandageneat. neat. your

inwards until you get the

head’s contour. UNIT UNIT 33 4. Get the 2 rolled sidesUNIT and 3 PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE DAY DAYEMT 19 19 CLINICAL PRACTICE interchange it PRACTICE OF with the PRINCIPLES DAY other and put the ends on 19

HEAD TOP SIDE

HEAD HEADTOP TOPSIDE SIDE EAD TOP SIDE 1. 1. Open OpenPhase PhaseBandage Bandageisisto to Open Phase Bandage is to be be used. used. Hold Hold the the base base be used. Hold the base part part of of the the bandage bandage and and part of the bandage and fold foldititinward inwardabout about11inch inch fold it inward about 1 inch of ofsize sizetwice. twice. of size twice. 2. 2. Place Place the the base base on on top top of of Place the base on top of the the patient’s patient’s head head up up to to the patient’s head up to the theeyebrows. eyebrows. the eyebrows. 3. 3. Hold Hold the the sides sides and and roll roll itit Hold the sides and roll it inwards inwards until until you you get get the the inwards until you1. getOpen Phase Bandage is to be used. the head’s head’scontour. contour. head’s contour. UNIT 4. 4. Get Get the the 22 rolled rolled sides sides and and 33 UNIT Get the 2 rolled sides Hold the base part of the bandage and interchange interchange itit with withDAY the the 19 interchange it with and fold it inward about 1 inch of the DAY 19 other otherand andput putthe theends endson on other and put the ends on size twice. top top of of the the patient’s patient’s foreforetop of the patient’s forehead. head. Tie Tie itit using using square square Place the base on top of the head. Tie it using2. square knot. knot. knot. patient’s head up to the eyebrows. 5. 5. Hold Hold the the apex apex at at the the back back Hold the apex at the 3. back Hold the sides and roll it inwards HEAD TOP SIDE while whileTOP supporting supporting the the papaHEAD SIDE while supporting the paOpen Phase Bandage tient’s tient’s head, head, gently gently pull pull 1.1. Open Phase Bandage isistoto tient’s head, gently until you get the head’s contour. pull be used. Hold thethe base the thebe apex apex to toHold follow follow the used. the base the apex to follow the 4. Get the 2 rolled sides and partcontour. ofthe thebandage bandageand and head’s head’s contour. part of head’s contour. interchange it with the other and fold inward aboutand 1inch inch 6. 6. Roll Roll the theitit apex apex upward upward and fold inward about 1 Roll the apex upward and size twice. the tuck tuck it it twice. inside inside the roll roll ofofsize tuck it inside the put the ends on top of the patient’s roll Place thebase base ontop top you’ve you’ve created created at at on the the bebe-ofof 2.2. Place the you’ve created at theforehead. Tie it using square knot. bethepatient’s patient’shead headup uptoto ginning. ginning. the ginning. 5. Hold the apex at the back while theeyebrows. eyebrows. 7. 7. Make Make sure sure that that all all ends ends the Make sure that all ends Hold thesides sides and rollitit 3.3. the and roll are areHold tucked tucked in in to to make make supporting the patient’s head, are tucked in to make inwards until youget getthe the inwards until you your your bandage bandage neat. neat. your bandage neat. gently pull the apex to follow the head’scontour. contour. head’s Getthe the22rolled rolledsides sidesand and head’s contour. 4.4. Get interchange itit with with the the interchange 6. Roll the apex upward and tuck it otherand andput putthe theends endson on other inside the roll you’ve created at the topofofthe thepatient’s patient’sforeforetop head.Tie Tieititusing usingsquare square beginning. head. knot. knot. 7. Make sure that all ends are tucked Holdthe theapex apexatatthe theback back 5.5. Hold in to make your bandage neat. whilesupporting supportingthe thepapawhile tient’s head, head, gently gently pull pull tient’s the apex apex toto follow follow the the the head’scontour. contour. head’s Rollthe theapex apexupward upwardand and 6.6. Roll tuck itit inside inside the the roll roll tuck you’vecreated createdatatthe thebebeyou’ve ginning. ginning. Make sure sure that that allall ends ends 7.7. Make are tucked tucked inin toto make make are yourbandage bandageneat. neat. your

HEAD TOP SIDE

T CLINICAL PRACTICE

top of the patient’s forehead. Tie it using square knot. 5. Hold the apex at the back whileTOP supporting the paHEAD SIDE pull 1.tient’s Openhead, Phase gently Bandage is to thebeapex follow used.toHold the the base head’s part contour. of the bandage and 6. Rollfold theit apex upward inward about and 1 inch tuck it twice. inside the roll of size at on the top be- of 2.you’ve Placecreated the base ginning. the patient’s head up to 7. Make sure that all ends the eyebrows. tucked in toand make 3.areHold the sides roll it your bandage neat. inwards until you get the head’s contour. 4. Get the 2 rolled sides and interchange it with the other and put the ends on top of the patient’s forehead. Tie it using square knot. 5. Hold the apex at the back while supporting the patient’s head, gently pull the apex to follow the head’s contour. 6. Roll the apex upward and tuck it inside the roll you’ve created at the beginning. 7. Make sure that all ends are tucked in to make your bandage neat.

HEAD HEAD TOP TOP SIDE SIDE

HEAD TOP SID

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES HEADTOP TOPSIDE SIDECONTINUED CONTINUED HEAD

DE CONTINUED

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

UNIT UNIT33 DAY DAY19 19

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE

HEADTOP TOPSIDE SIDECONTINUED CONTINUED HEAD

UNIT 3 DAY 19

OF EMT

HEAD HEAD TOP TOP SIDE SIDE CONTINUED CONTINUED HEAD HEADTOP TOPSIDE SIDE 1.1. Open OpenPhase PhaseBandage Bandageisisto to be be used. used. Hold Hold the the base base part part ofof the the bandage bandage and and fold foldititinward inwardabout about11inch inch ofofsize sizetwice. twice. 2.2. Place Place the the base base on on top top ofof the the patient’s patient’s head head up up to to the theeyebrows. eyebrows. 3.3. Hold Hold the the sides sides and and roll roll itit inwards inwardsuntil untilyou youget getthe the head’s head’scontour. contour. 4.4. Get Getthe the22rolled rolledsides sidesand and interchange interchange itit with with the the other otherand andput putthe theends endson on top top ofof the the patient’s patient’s foreforehead. head. Tie Tie itit using using square square knot. knot. 5.5. Hold Holdthe theapex apexatatthe theback back while while supporting supporting the the papatient’s head, gently tient’s head, gently pull pull the apex to follow the the apex to follow the head’s head’scontour. contour. ² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) 6. Roll 6. Rollthe theapex apexupward upwardand and ⁴ ⁴ NHTSA NHTSA tuck it tuck it inside inside the the roll roll you’ve created at the beyou’ve created at the beginning. ginning. 7.7. Make Make sure sure that that all all ends ends are are tucked tucked inin to to make make your yourbandage bandageneat. neat.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

PRINCIPLES OF EMT CLINICAL PRACTICE HEAD TOP SIDE CONTINUED

HEAD TOP SIDE 1. Open Phase Bandage is to be used. Hold the base part of the bandage and fold it inward about 1 inch of size twice. 2. Place the base on top of the patient’s head up to the eyebrows. 3. Hold the sides and roll it inwards until you get the head’s contour. 4. Get the 2 rolled sides and interchange it with the other and put the ends on top of the patient’s forehead. Tie it using square knot. 5. Hold the apex at the back while supporting the patient’s head, gently pull the apex to follow the head’s contour. 6. Roll the apex upward and tuck it inside the roll you’ve created at the beginning. 7. Make sure that all ends are tucked in to make your bandage neat.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

463

FRONT AND BACK OF THE HEAD UNIT UNIT 4.4. Instruct Instruct the the patient patient toto33

FRONT FRONT AND AND BACK BACK OF OF THE THE HEAD HEAD 1. 1. Open Open Phase Phase Bandage Bandage isis to to be be used. used. Tie Tie the the apex apex ususing ing aa simple simple knot. knot. 2. 2. Place Place the the apex apex on on top top of of Day 19 the the head head and and spread spread the the bandage bandage 3. 3. Roll Roll each each side side of of the the banbandage dage inward inward up up to to the the back back of of the the ear. ear. 4. 4. Instruct Instruct the the patient patient to to raise two fingers raise his/her his/her twoAND fingers FRONT FRONT AND BACK BACK OF OF THE THE UNIT 33 UNIT (index (index and and middle) middle) and and 1. Open Phase Bandage is to be used. Tie the apex using a simple HEAD HEAD place itit in front of his/her place in front of his/her DAY 19 DAY 19 knot. 1.1.Take Open Open PhaseBandage Bandageisistoto chin both rolled chin then then Take bothPhase rolled 2. Place the apex on top of the head and spread the bandage ends front of ends to to the thebe front of his/ his/ be used. used. Tie Tiethe theapex apexususher and inter3. Roll each side of the bandage inward up to the back of the ear. her fingers fingersing and inter- knot. ing aasimple simple knot. change the change itit with the other other 4. Instruct the patient to raise his/her two fingers (index and 2.2. with Place Place the the apex apexon on top top ofof ends. ends. middle) and place it in front of his/her chin then Take both the the head head and and spread spread the the FRONT AND BACK OFOF THE FRONT AND BACK THE 5. Pull the two ends going to 5. Pull the two ends going to HEAD rolled ends to the front of his/her fingers and interchange it bandage HEAD the tie the back back and andbandage tie itit using using aa 1. Open Phase Bandage is to Open Phase Bandage is to square knot. Hide and square3.3. knot. Hide and Roll Roll each each side sideof of1. the the banbanwith the other ends. be be used. TieTie thethe apex us-usused. apex tuck the excess ends intuck the excess ends indage dage inward inward up up ing totoathe the 5. Pull the two ends going to the back and tie it using a square knot. ingsimple a simple knot. side side the the roll roll you’ve you’ve crecreback back ofofthe the ear. ear.2. 2.Place knot. Hide and tuck the excess ends inside the roll you’ve thethe apex on on toptop of of Place apex ated. ated. 4.4. knotted Instruct Instructapex the the patient patient to to andand thethe head spread thethe head spread 6. created. 6. Hold Hold the the knotted apex bandage raise his/her twobandage fingers fingers and while your and twist twist ititraise whilehis/her your two 6. Hold the knotted apex and twist it while your fingers are in 3. 3.RollRoll each side of of thethe baneach side banfingers in fingers are are (index in between, between, (index and and middle) middle) and and between, once it is snugly fit, tuck it in. dage inward up up to to thethe dage inward once fit, tuck ititfront once itit isis snugly snugly fit, it tuck place place it in in front of of his/her his/her back of the ear.ear. back of the 7. Take the base part from the back and pull it upward to cover in. in. chin chin then then Take Takeboth rolled rolledthethepatient 4.both 4.Instruct Instruct patientto to Take the the base base part part from from UNIT33 7.7. Take UNIT the knot you’ve created to make the bandage neat. his/her twotwo fingers his/her fingers ends ends to the the front frontraise ofofraise his/ his/ the back and pull itto upthe back and pull it up8. Same procedures apply if the affected part is the face, cut DAY19 19 andandmiddle) andand DAY (index middle) ward knot her herthe fingers fingers and and(index interinterward to to cover cover the knot place it in of of his/her place it front in front his/her holes that corresponds to the eyes nose and mouth before you’ve to make you’ve created created to make change change itit with with the the other other chin then Take both rolled chin then Take both rolled the neat. putting the bandage covering his/her face. the bandage bandageends. neat. ends. ends to to thethe front of of his/his/ ends front 8. 8. Same Same procedures procedures apply apply ifif herherfingers 5.5. Pull Pull the the two endsgoing going toto fingersandandinterinterthe part isis two the the affected affected part the ends change it with thethe other change it with other the the back back and and tie tie it it using using a a face, cut holes that correface, cut holes that correRONT AND BACK OF THE ONT AND BACK OF THE ends. ends. sponds eyes sponds to to the the eyes nose nose square square knot. knot. 5. Hide Hide and and HEAD EAD thethe two ends going to to 5.PullPull two ends going and mouth before putting and mouth before putting . Open OpenPhase PhaseBandage Bandageis istoto tuck tuck the the excess excess ends ends inin-andand thethe back tie tie it using a a back it using the bandage covering his/ the bandage covering his/ used.Tie Tiethe theapex apexususbebeused. side side the the roll roll you’ve you’ve crecre-knot. square Hide andand square knot. Hide her face. her face. inga asimple simpleknot. knot. ing tuck thethe excess ends inintuck excess ends ated. ated. . Place Placethe theapex apexon ontop topofof side thethe rollroll you’ve cre-creside you’ve 6.6. Hold Hold the the knotted knotted apex apex thehead headand andspread spreadthe the the ated. ated. bandage and and twist twist itit while while your your bandage 6. 6.Hold Holdthetheknotted knottedapex apex . Roll Rolleach eachside sideofofthe thebanbanfingers fingers are are inin between, between, andandtwist it it while your twist while your dage inward inwardup up toto the the dage fingers once onceititisissnugly snuglyfit, fit, tuck tuck itare it arein inbetween, fingers between, back of the ear. back of the ear. once it isit snugly fit, fit, tuck it it once is snugly tuck in. in. . Instruct Instruct the the patient patient toto in. in. 7. 7. Take Take the the base base part part from from raisehis/her his/hertwo twofingers fingers raise 7. 7.Take thethe base part from Take base part from (index and and middle) middle) and and (index the the back back and and pull pull itthe it back upupthe andand pullpull it upback it upplaceit itininfront frontofofhis/her his/her place ward to to cover thethe knot ward ward toto cover cover the the knot knot ward cover knot chinthen thenTake Takeboth bothrolled rolled chin created you’ve createdto tomake make you’ve you’ve created created totoyou’ve make make endstotothe thefront frontofofhis/ his/ ends bandage neat. bandage neat. the thebandage bandageneat. neat.thethe her fingers fingers and and interinterher 8. 8.Same procedures apply if if Same procedures apply changeit itwith withthe theother other 8.8. Same Same procedures procedures apply apply if if change thethe affected part is is thethe affected part ends. ends. the the affected affected part partface, isisface, the the cut holes that correcut holes that corre. Pull Pullthe thetwo twoends endsgoing goingtoto sponds to to thethe eyes nose sponds eyes nose face, face, cut cut holes holes that that correcorretheback backand andtietieit itusing usinga a the andand mouth before putting mouth before putting sponds sponds to to the the eyes eyes nose nose square knot. knot. Hide Hide and and square ²²Limmer Limmer (Brady) the(Brady) bandage covering his/his/ the bandage covering ³³Pollack, (AAOS) Pollack, (AAOS) and andmouth mouthbefore before putting putting tuckthe theexcess excessends endsin-intuck her face. ⁴⁴ NHTSA NHTSA her face. sidethe theroll rollyou’ve you’vecrecreside the thebandage bandagecovering coveringhis/ his/ ated. ated. her herface. face. . Hold Hold the the knotted knotted apex apex and twist twist it it while while your your and fingers are are inin between, between, fingers onceit itis issnugly snuglyfit,fit,tuck tuckit it once in.in. . Take Takethe thebase basepart partfrom from theback backand andpull pullit itupupthe wardtotocover coverthe theknot knot ward you’ve created created toto make make you’ve thebandage bandageneat. neat. the . Same Sameprocedures proceduresapply applyif if the affected affected part part is is the the the face,cut cutholes holesthat thatcorrecorreface, spondstotothe theeyes eyesnose nose sponds andmouth mouthbefore beforeputting putting and thebandage bandagecovering coveringhis/ his/ the mmer ² Limmer (Brady) (Brady) ollack, ³ Pollack, (AAOS) (AAOS) herface. face. her

raise raisehis/her his/hertwo two fingers fingers DAY DAY 19 19 (index (indexand andmiddle) middle)and and place placeit itininfront frontofofhis/her his/her chin chin then then Take Take both both rolled rolled ends endstotothe thefront frontofofhis/ his/ her her fingers fingers and and interinterFRONT FRONT AND AND BACK OF OFother THE THE change change it BACK itwith withthe the other HEAD HEAD ends. ends. 1. Open Phase Phase Bandage Bandage isisto 5.1.5. Open Pull Pull the the two two ends ends going going toto to be be used. used. Tie Tie the the apex ususthe the back backand and tie tieitapex it using using aa ing ing a asimple simple knot. knot. square square knot. knot. Hide Hide and and 2.2. Place Place the theexcess apex apex on on top topinofof tuck tuckthe excess ends ends inthe the head head and spread spread the the side side the theand roll rollyou’ve you’vecrecrebandage bandage ated. ated. 3. Roll each each side side ofofthe theapex banban6.3.6. Roll Hold Hold the the knotted knotted apex dage dage inward inward up up totoyour the the and andtwist twist it itwhile while your back back ofofthe the ear. ear. fingers fingers are are ininbetween, between, 4.4. Instruct Instruct the patient patient toittoit once onceit itis the issnugly snugly fit,fit,tuck tuck raise raise his/hertwo two fingers fingers in. in. his/her UNIT UNIT 3 (index and and middle) middle) and and 3 7.7. (index Take Takethe the base base part part from from place place it it in in front front of of his/her his/her the theback backand andpull pull it it upupDAY 19 DAY 19 chin chin then then Take both both rolled rolled ward ward totoTake cover cover the the knot knot ends ends totocreated the thefront front ofof his/ his/ you’ve you’ve created toto make make her her fingers fingersneat. and and interinterthe the bandage bandage neat. change it itwith withthe the other other 8.8. change Same Sameprocedures procedures apply apply if if UNIT 3 ends. ends. the theaffected affectedpart partis isthe the 5. Pull Pull the the two two ends ends going going toto AND BACK OF THE face, face, cut cut holes holes that that correcorreDAY 195.FRONT FRONT AND BACK OF THE the the back back and and tietie iteyes itusing using aa HEAD sponds sponds to to the the eyes nose nose HEAD square knot. knot. Hide Hide and 1. Open Phase Bandage isand and and mouth mouth before before putting putting 1. square Open Phase Bandage isto to tuck tuck the theexcess excess ends ends ininthe the bandage bandage covering covering his/ his/ be used. Tie the apex usbe used. Tie the apex usside side the the roll roll you’ve you’ve crecreher her face. face. ing aa simple knot. ing simple knot. FRONT AND BACK OF THE 2. ated. ated. Place the apex on top of 2. Place the apex on top of HEAD 6.6. Hold Hold the the and knotted knotted apex apex the spread the the head head and spread the 1. Open Phase Bandage is to and and twist twist it it while while your your bandage bandage be used. Tie the apex usfingers are are ininof between, between, ing a simple knot. 3. Roll side the 3. fingers Roll each each side of the banban2. Place the apex on top of once once issnugly snugly fit,fit,tuck tuck it it dage inward up to the dageit itis inward up to the the head and spread the in. in. back of the ear. back of the ear. bandage 7. Take the thebase basepatient part partfrom from Instruct the to 4. Take Instruct the patient to 3. Roll each side of the ban- 7.4. the the back back and andtwo pull pullit itupupraise his/her fingers raise his/her two fingers dage inward up to the back of the ear. ward ward toto cover cover the the knot knot (index and middle) and (index and middle) and 4. Instruct the patient to you’ve you’ve created tohis/her make make place in of place ititcreated in front frontto of his/her raise his/her two fingers the the bandage bandage neat. neat. chin then both chin thenTake Take bothrolled rolled (index and middle) and 8. 8. Same Same procedures procedures apply apply if if ends to the front of ends to the front of his/ his/ place it in front of his/her the the affected part the the her fingers and chin then Take both rolled heraffected fingers part andisisinterinterends to the front of his/ face, face, cut cutholes that that correchange ititholes with the other change with thecorreother her fingers and intersponds sponds totothe theeyes eyesnose nose ends. ends. change it with the other and mouth before before putting putting 5. Pull the two ends to 5. and Pullmouth the two endsgoing going to ends. the the bandage covering covering his/ his/ the back tie aa thebandage back and and tie itit using using 5. Pull the two ends going to her her face. face.knot. the back and tie it using a square square knot. Hide Hide and and square knot. Hide and tuck tuck the the excess excess ends ends inintuck the excess ends inside the roll you’ve creside the roll you’ve creside the roll you’ve created. ated. ated. 6. Hold the knotted apex 6. 6. Hold Hold the the knotted knotted apex apex and twist it while your and and twist twist itit while while your your fingers are in between, fingers fingers are are in in between, between, once it is snugly fit, tuck it once once itit isis snugly snugly fit, fit, tuck tuck itit in. in. in. 7. Take the base part from the back and pull it up- 7. 7. Take Take the the base base part part from from ward to cover the knot the the back back and and pull pull itit upupyou’ve created to make ward to cover the knot ward to cover the knot the bandage neat. you’ve you’ve created created to to make make 8. Same procedures apply if the the affected part is the thebandage bandageneat. neat. face, cut holes that corre- 8. 8. Same Same procedures procedures apply apply ifif sponds to the eyes nose the the affected affected part part isis the the and mouth before putting face, cut holes that correface, cut holes that correthe bandage covering his/ sponds sponds to to the the eyes eyes nose nose her face. and mouth before putting ² Limmer (Brady) and mouth before putting ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA the ⁴ NHTSA thebandage bandagecovering coveringhis/ his/ her herface. face.

UNIT UNIT33 PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTIC TISSUE INJURIES DAY DAY19 19 SOFT

FRONT AND BACK OF THE HEAD

FRONT FRONT AND AND BACK BACK OF OF THE THE HEAD HEAD

RINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTIC

FRONT FRONTAND ANDBACK BACKOF OFTHE THEHEAD HEAD

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

PRINCIPLES OF EMT C

FRONTAND ANDBACK BACKOF OFTHE THEHEAD HEAD FRONT

T CLINICAL PRACTICE

ACK OF THE HEAD

HTSA ⁴ NHTSA

464

LIFELINE

PREHOSPITAL EMERGENCY CARE

FRONT AND BACK

Instruct the the patient patient toto 4.4. Instruct raisehis/her his/hertwo twofingers fingers raise (index and and middle) middle) and33 UNIT UNIT (index and placeit itininfront frontofofhis/her his/her place DAY 19 DAY 19 chinthen thenTake Takeboth both rolled chin rolled ends to the front of his/ ends to the front of his/ her fingers fingers and and interinterher changeit itwith withthe theother other change ends. ends. 5. Pull Pullthe thetwo two endsgoing going 5. ends toto FRONT AND BACK OF THE FRONT AND BACK OF THE theback backand andtietieit itusing usinga a the HEAD HEAD square knot. Hide and knot. Hide Open Phase Bandage 1.1. square Open Phase Bandage isisand toto tuck theTie excess endsinintuck the excess be used. Tie theends apex usbe used. the apex usside the roll you’ve creside the roll you’ve creingaasimple simpleknot. knot. ing ated. the Place the apex apex on on top top ofof 2.2. ated. Place Hold theand knotted apex 6.6. Hold the knotted apex the head and spread the the head spread the and twist twist it it while while your your and bandage bandage fingers are between, are inin between, Roll each side thebanban3.3. fingers Roll each side ofof the once it is snugly once it is snugly fit, tuck it it dage inward up totuck the dage inward up fit, to the in. ofofthe in. back theear. ear. back UNIT UNIT 7. Take Takethe thethe basepatient part from 7. base part from Instruct the patient 4.4. Instruct toto 33 theback back and pullfingers itupupthe and pull it raise his/her two fingers raise his/her two DAY 19 DAY 19 wardtoto cover theknot knot ward cover the (index and middle) and (index and middle) and you’ve created make you’ve to make place frontof ofto his/her place ititcreated inin front his/her thebandage bandage neat. the neat. chin thenTake Take bothrolled rolled chin then both Sameto procedures apply 8.8. Same procedures if if ends to the front frontapply of his/ his/ ends the of the affected affected part the the the her fingers part andis is interher fingers and interface,AND cut that correface, cut that correFRONT AND BACK OF THE FRONT BACK OF THE change itholes with the other change itholes with the other spondstotothe theeyes eyesnose nose sponds HEAD HEAD ends. ends. and mouth before putting mouth before putting 1. and Open Phase Bandage to 1. Open Phase Bandage isisto to 5. Pull the two ends going to 5. Pull the two ends going the bandage covering his/ the his/ bebandage used. Tiecovering the apex usbe used. Tie the usthe back and tie using the back and tie ititapex using aa her her ingface. asimple simple knot. ing aface. knot. square knot. Hide and and square knot. Hide Placethe theexcess apex on on topinof 2.2. tuck Place apex top of tuck the excess ends inends the head head andyou’ve spreadcrethe the and spread the side the roll roll you’ve creside the bandage bandage ated. ated. 3. Hold Rolleach each side theapex ban3. Roll ofofthe ban6. Hold theside knotted apex 6. the knotted dagetwist inward up totoyour the dage inward up the and twist while your and itit while backofofthe the ear. back fingers areear. between, fingers are inin between, Instruct the patient patient 4.4. once Instruct the once snugly fit,tuck tuckto it ititisissnugly fit, itto raise his/her his/her two two fingers fingers raise in. in. (index and middle) and (index and middle) and Take the base part from from 7.7. Take the base part place front his/her place ititininand front ofofhis/her the back and pull it upupthe back pull it chinthen then Takeboth both rolled chin Take ward cover therolled knot ward toto cover the knot ends toto the front front ofmake his/ ends the his/ you’ve created you’ve created totoofmake herbandage fingersneat. and interinterher fingers and the bandage neat. the change with the the other change itit with other Same procedures apply 8.8. Same procedures apply ifif ends. ends. the affected part part isis the the the affected Pullthe the two ends going 5.5. face, Pull ends going toto face, cuttwo holes that correcut holes that corretheback back and tie using the and tie ititusing aa sponds the eyes nose sponds toto the eyes nose square knot. Hide and square knot. Hide and and mouth before putting and mouth before putting tuck the excess excess ends intuck the ends inthe bandage covering his/ the bandage covering his/ side the roll roll you’ve you’ve crecreside the her face. her face. ated. ated. Hold the the knotted knotted apex apex 6.6. Hold and twist twist itit while while your your and fingers are are inin between, between, fingers onceititisissnugly snuglyfit, fit,tuck tuckitit once in. in. Take the the base base part part from from 7.7. Take the back back and and pull pull itit upupthe ward toto cover cover the the knot knot ward you’ve created created toto make make you’ve thebandage bandageneat. neat. the Same procedures procedures apply apply ifif 8.8. Same the affected affected part part isis the the the face,cut cutholes holesthat thatcorrecorreface, sponds toto the the eyes eyes nose nose sponds andmouth mouthbefore beforeputting putting and thebandage bandagecovering coveringhis/ his/ the herface. face. her

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES

FRONTAND ANDBACK BACKOF OFTHE THEHEAD HEAD CE E FRONT

E CE

FRONT AND AND BACK BACK OF OF THE THE HEAD HEAD FRONT

PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE FRONT AND AND BACK BACK OF OF THE THE HEAD HEAD FRONT FRONT AND AND BACK BACK OF OF THE THE HEAD HEAD FRONT

CLINICAL PRACTICE

K OF THE HEAD

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer(Brady) (Brady) ² Limmer ³ Pollack,(AAOS) (AAOS) ³ Pollack, NHTSA ⁴ ⁴NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) 4 NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

465

UNIT 3 DAY 19

Hold the base and roll it

unaffected area whilt unaffected area while

Hold the base and roll it

2. Hold the base and roll it upward until you reach ARM ARM SLING SLING apex is placed unde UNIT UNIT33 apex is placed under t upward until until you you reach reach upward below his/her breast or at 1. 1.Arm Arm sling sling is used isaffected used to su toe PRINCIPLES OF EMT CLINICAL PRACTICE elbow of the affecte PRINCIPLES OF EMT CLINICAL PRACTICE belowhis/her his/herbreast breast oratat below or elbow of the DAY 19 UNIT 3 DAYEMT 19 CLINICAL PRINCIPLES OF PRACTICEthe xiphoid area. port port theOF the patient patient who who su thexiphoid xiphoidarea. area. tremity. the tremity. EMT C 3. Pull both ends DAY towards19 PRINCIPLES Pull both both ends ends towards towards 3.3. Pull fered from from a fracture a inward fractu Fold the base 5. 5.fered Fold the base inward un the back and tie it using a theback backand andtie tieititusing usingaa the squareknot. knot. square Longest end will be be tied tied 4.4. Day Longest will 19 theendapex up atat the and the the up apex and shorterend endwill willbe betucked tucked shorter make the the bandage bandage inin toto make neat. neat. Same procedure procedure apply apply ifif 5.5. Same the back back isis injured. injured. Only Only the you will will start start placing placing the the you bandageatatthe theback backand and bandage theknots knotswill willbe beininfront. front. the

square knot. AND BACK OF FRONT AND BACK OFTHE THE CHEST 4. Longest end willCHEST be tied FRONT AND BACKFRONT OF THE CHEST SOFT TISSUE INJURIES up at the apex and the FRONT FRONTAND ANDBACK BACKOF OFTHE THE

FRONT AND BACK OF THE CHEST CHEST CHEST 1.1. Open Phase Bandage is is toto Open Phase Bandage 1. Open Phase Bandage is to bebe used. The affected area used. The affected area be used. The affected area is isthe theleft leftchest. chest.Place Placethe the is the left chest. Place the apex onon top ofofthe injured apex top the injured apex on top of the injured part. Let the patient hold it it part. Let the patient hold part. Let the patient hold it forforawhile awhile(if(ifpatient patientis is for awhile (if patient is cooperative cooperative and and conconcooperative and conscious) scious) scious) 2.2. Hold Holdthe thebase baseand androll rollit it 2. Hold the base and roll it upward upwarduntil untilyou youreach reach upward until you reach below belowhis/her his/herbreast breastororatat below his/her breast or at the xiphoid area. the xiphoid area.UNIT UNIT33 the xiphoid area. 3.3. Pull Pullboth bothends endstowards towards 3. Pull both ends towards DAY 19 DAY the a 19 1. Open Phase Bandage is to be used. theback backand andtietieit itusing using a the back and tie it using a square knot. square knot. The affected area is the left chest. square knot. 4.4. Longest Longestend endwill willbebetied tied 4. Longest end will be tiedPlace the apex on top of the injured upupatatthe theapex apexand andthe the up at the apex and thepart. Let the patient hold it for shorter shorterend endwill willbebetucked tucked shorter end will be tucked in to make the bandage inAND to make theOFbandage FRONT BACK FRONT AND BACK OFTHE THE in to make the bandageawhile (if patient is cooperative neat. neat. CHEST neat. and conscious) 5.CHEST Same procedure apply if 5. Same procedure apply 1. 1. Open Phase Bandage is is totoif Open Phase Bandage 5. Same procedure apply ifHold the base and roll it upward the 2. theback backis isinjured. injured.Only Only be used. The affected area be used. The affected area the back is injured. Only you youwill willstart startplacing placingthe the isbandage the isthe theleftleftchest. chest.Place Place the you will start placing theuntil you reach below his/her bandageatatthe theback backand and apex on top of the injured apex on top of the injured bandage at the back andbreast or at the xiphoid area. the knots will bebe inin front. the knots will front. part. LetLet the patient hold it it part. the patient hold the knots will be in front. 3. Pull both ends towards the back forforawhile awhile(if (ifpatient patientis is and tie it using a square knot. cooperative cooperative and and conconscious) scious) 4. Longest end will be tied up at the 2. 2. Hold Holdthe thebase baseand androllrollit it apex and the shorter end will be upward upwarduntil untilyou youreach reach UNIT UNIT 33 tucked in to make the bandage below his/her breast oror at at below his/her breast DAY area. xiphoid area. neat. thethexiphoid DAY 19 19 3. 3. Pull Pullboth bothends endstowards towards 5. Same procedure apply if the back is the back and tietie it using aa the back and it using injured. Only you will start placing square knot. square knot. the bandage at the back and the 4. 4. Longest Longestend endwill willbebetied tied upupat atthe theapex apexand andthe the knots will be in front. FRONT FRONT AND AND BACK BACK OF OF THE THE shorter end will bebe tucked shorter end will tucked CHEST CHEST in intotomake makethe thebandage bandage 1. Open Phase Bandage is 1. Open Phase Bandage is to to neat. neat. be be used. used. The The affected affected area area 5. 5. Same Sameprocedure procedureapply applyif if isis the left chest. Place the the left chest. Place the the theback backis isinjured. injured.Only Only apex apex on on top top of of the the injured injured you youwill willstart startplacing placingthe the part. Let the patient hold part. Let the patient hold itit bandage bandageat atthe theback backand and for for awhile awhile (if (if patient patient isis the knots will bebe in in front. the knots will front. cooperative cooperative and and conconscious) scious) 2. 2. Hold Hold the the base base and and roll roll itit upward upward until until you you reach reach UNIT UNIT 33 below below his/her his/her breast breast or or at at the DAY DAY 19 19 the xiphoid xiphoid area. area. 3. 3. Pull Pull both both ends ends towards towards the the back back and and tie tie itit using using aa square knot. square knot. 4. 4. Longest Longest end end will will be be tied tied up up at at the the apex apex and and the the RONT AND FRONT AND BACK BACK OF OF THE THE shorter end will be tucked shorter end will be tucked CHEST CHEST in to make the bandage in to make the bandage 1. 1. Open OpenPhase PhaseBandage Bandageisisto to ² Limmer (Brady) neat. ² Limmer (Brady) neat. ³ Pollack, (AAOS) ² Limmer (Brady) ³ Pollack, (AAOS) be beused. used.The Theaffected affectedarea area ⁴ NHTSA 5. procedure ³ Pollack, (AAOS) ⁴ Same NHTSA 5. Same procedure apply apply ifif ⁴ NHTSA isis the the left left chest. chest. Place Place the the the the back back isis injured. injured. Only Only apex apex on on top top of of the the injured injured you you will will start start placing placing the the part. part.Let Letthe thepatient patienthold holditit bandage bandage at at the the back back and and for for awhile awhile (if (if patient patient isis the the knots knots will will be be in in front. front. cooperative cooperative and and conconscious) scious) 2. 2. Hold Hold the the base base and and roll roll itit upward upward until until you you reach reach below below his/her his/her breast breast or or at at the thexiphoid xiphoidarea. area. 3. 3. Pull Pull both both ends ends towards towards the the back back and and tie tie itit using using aa square squareknot. knot. 4. 4. Longest Longest end end will will be be tied tied up up at at the the apex apex and and the the shorter shorter end end will will be be tucked tucked in in to to make make the the bandage bandage neat. neat. 5. 5. Same Same procedure procedure apply apply ifif 466 LIFELINE Only the isis injured. the back back injured. Only PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) you you will will start start placing placing the the ⁴ NHTSA ⁴ NHTSA bandage bandage at at the the back back and and the theknots knotswill willbe bein infront. front.

shorter end will be tucked in to make the bandage FRONT AND BACK OF THE neat. CHEST 5. Open Same Phase procedure apply if 1. Bandage is to theused. backThe is injured. be affected Only area you placing is thewill leftstart chest. Place the the bandage at of thethe back and apex on top injured the knots willpatient be in front. part. Let the hold it for awhile (if patient is cooperative and conscious) 2. Hold the base and roll it upward until you reach below his/her breast or at the xiphoid area. 3. Pull both ends towards the back and tie it using a square knot. 4. Longest end will be tied up at the apex and the shorter end will be tucked in to make the bandage neat. 5. Same procedure apply if the back is injured. Only you will start placing the bandage at the back and the knots will be in front.

FRONT AND BACK OF THE CHEST

MT CLINICAL PRACTICE

dislocation, usually usually th the patient’s finger thedislocation, patient’s fingers a injury injury is splinted is splinted first.first. If s exposed. exposed. isitTake aismust a the must the the you you che end at the 6. 6.itTake the end at the bc PMS PMS before before and and yot tom and raise itafter ove tom and raise itafter over intervention intervention as as partpar affecterextremity extremity affecter a splinting splinting principles. gently pull it going t gently pull itprinciples. going to u 2. 2.Injured Injured part part is the is Tie the rig affected side. affected side. Tie bo forearm. forearm. Open Open phase phase is ends using square ends using square kn be used. be used. hide the excess t hide the excess andand tuck 3. 3.Tie the the apex apex using using aU sim a in. UN in. Tie ple knot. knot. Hold Hold one one en Make sure that th 7. 7.ple Make sure that the DAY with with your your hand hand and and th fected extremity is fected extremity isDA su apex apex withwith the other. other. ported by the ban ported bythe the bandag 4. 4.Place Place the base base side side on o th twist the apex side twist thethe apex side un unaffected areaarea th the bandage is whil snug theunaffected bandage is while snugly apex apex is placed isitplaced under unde th then tuck it inside. then tuck inside. elbow ofswathe the of the affected affecte e 8.elbow Tie a over th 8. Tie a swathe over the a ARM SLING ARM SLING tremity. sling for better suppo sling for better support. 1. 1.tremity. Arm sling is used to to su Arm sling is used 5. Fold the the base base inward inward un 9.Fold Check PMS after the 9. 5. Check PMS after the ps port the patient who port the patient who the the patient’s patient’s fingers fingers a cedure. cedure. fered from a fracture fered from a fractur exposed. exposed. usually t dislocation, dislocation, usually 6. 6.Take Take the endend at first. the at the bo injury is the splinted If injury is splinted first. tom tom and and raise raise it over it ove it is a must the you che it is a must the youth c affecter affecter extremity extremity an PMS before and after yo PMS before and after gently gently pullpull it going itasgoing topar ut intervention intervention aspart affected affected side. side. Tie Tie bo splinting principles. splinting principles. ends using using square kno 2. 2.ends Injured part is square rig Injured part isthethe hide hide the the excess excess and and tuck forearm. Open phase ist forearm. Open phase in. bein. used. be used. 7.3. 7. sure that that theathsaa TieMake thesure apex using 3.Make Tie the apex using fected extremity extremity su ise plefected knot. Hold one ple knot. Hold isone ported ported by by the the bandag band with hand and withyour your hand andt twist twist the the apex apex side side un apex with thethe other. apex with other. the bandage bandage is side snugly isside snug 4. 4.the Place the base onot Place the base then then tucktuck it inside. it area inside. unaffected area while unaffected whilt 8. 8.Tie Tie a swathe a swathe overover the the art apex is placed under apex is placed unde sling sling for of better forof better support. suppo elbow the affected elbow the affecte 9. 9.Check Check PMSPMS after after the the pr tremity. tremity. cedure. cedure. 5. Fold the base inward un 5. Fold the base inward ² Limmer (Brady) ³ Pollack, (AAOS) thethepatient’s patient’sfingers fingersa ⁴ NHTSA exposed. exposed. 6. 6. Take thethe end at at thethe b Take end tom and raise it over tom and raise it ovet affecter affecter extremity extremity a gently pull it going to to u gently pull it going affected affectedside. side.TieTiebo ends endsusing usingsquare squarekn hide thethe excess and tuct hide excess and in.in. 7. 7. Make Makesure surethat thattheth fected fectedextremity extremityis issu ported portedbybythethebandag band twist twistthetheapex apexside sideun thethe bandage is is snugly bandage snug then tuck it inside. then tuck it inside. 8. 8. TieTie a swathe over thethe a a swathe over sling forfor better support. sling better suppo ² Limmer (Brady) PMS after thethe p ³ Pollack, (AAOS)9. 9. Check Check PMS after ⁴ NHTSA cedure. cedure.

FRONT AND BACK

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE FRONT FRONTAND ANDBACK BACKOF OFTHE THECHEST CHEST

ACK OF THE CHEST

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PRINCIPLES OF EMT CLINICAL PRACTICE

FRONT FRONTAND ANDBACK BACKOF OFTHE THECHEST CHEST

FRONT AND BACK OF THE CHEST ² Limmer(Brady) (Brady) ² Limmer ³ Pollack,(AAOS) (AAOS) ³ Pollack, NHTSA ⁴ ⁴NHTSA

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE FRONT FRONT AND AND BACK BACK OF OF THE THE CHEST CHEST

le the the er thethe upoed supexexufo sufure oruntil or dntil he the rs are are so, . If so, eck echeck botbotour reryour the the rt ofand of and to ununght right both oth eto is to knot, not, tuck k it it am-simNIT 33 UNIT e nd end he afafYup19 AY 19 he d supthe ndage, ge, on he the e until ntil he le gly fit fitthe er he the ed ex-arm exhe arm upoort. supntil de until prosufo prosufare s orare re or thethe eotbot. so, If so, er he the eck check and our rnd your unto rtofunof oth both ot, knot, ght right kestuck it to is toit

CLINICAL PRACTICE

K OF THE CHEST

he afsimaaf-simupsupend e end ge, dage, dthe the ntiluntil gly fitthe fit the on thethe le rm e arm the er the ort. ex-exed ero-prodntil until sareare

bote botthethe er and and uno unoth both not, knot, ck it it tuck

heaf-afupsupge, dage, ntil until ygly fit fit

arm e arm ort. proe pro-

unaffected area while thethe unaffected area while apex is is placed under thethe apex placed under elbow of of thethe affected ex-exelbow affected ARM SLING ARM SLING tremity. tremity. 1. 1. Arm sling is isused supArm sling usedto to sup5. the base inward until 5. Fold Fold the base inward until port thethe patient who sufport patient who sufthe thepatient’s patient’sfingers fingersareare fered from a fracture or fered from a fracture or exposed. exposed. dislocation, usually the dislocation, usually the 6. 6. Take thethe end at at thethe botTake end botinjury is splinted If the so, injury is raise splinted first. If so, tom and it first. over tom and raise it over the it is a must the you check it is a must the you check affecter extremity and affecter extremity and PMS before and after your PMS before and after your gently pull it going to to ungently pull itasgoing intervention part ofunintervention as part of affected side. TieTie both affected side. both splinting principles. splinting principles. ends using square knot, ends part usingis square knot, 2. 2. Injured right Injured part and isthethe right hide thethe excess tuck it it hide excess and tuck forearm. Open phase is to forearm. Open phase is to33 UNIT UNIT in.in. bebe used. used. 7. 7. Make sure that the af-19 Make sure that afDAY DAY 3. 3. TieTie thethe apex using athe simapex using sim-19 fected extremity is isa supfected extremity supplepleknot. Hold one end knot. Hold one end ported bybythethebandage, ported bandage, with your hand with your handand andthethe twist thetheapex side twist apex sideuntil until apex with thethe other. apex with other. thethe bandage is is snugly fit fit bandage snugly 4. 4. Place thethe base side onon thethe Place base side then tuck it inside. then tuck it inside. unaffected area while thethe unaffected area while ARM SLING SLING 8.ARM Tie a swathe over thethe arm 8. Tie a swathe over arm apex is under the apex isplaced placed under the 1.1. sling Arm Arm sling sling is is used used to to supsupfor better support. sling for better support. elbow of the affected exelbow of the affected export port the the patient patient who who sufsuf9. 9. tremity. Check PMS after thethe proCheck PMS after protremity. fered feredfrom froma afracture fractureoror cedure. cedure. 5. 5. Fold thethe base inward until Fold base inward until dislocation, dislocation, usually usually the the thethepatient’s fingers areare fingers injury injurypatient’s is issplinted splinted first. first.If Ifso, so, exposed. it exposed. itis isa amust mustthe theyou youcheck check 6. 6. Take thetheend at atthethebotTake end botPMS PMSbefore before and and after afteryour your tom and raise it it over thethe tom and raise over intervention intervention asas part part ofof affecter extremity affecter extremity and and splinting splintingprinciples. principles. gently pull it going to to un-ungently pull it going 2.2. Injured Injuredpart partis isthe theright right affected side. TieTieboth affected side.phase forearm. forearm.Open Open phaseisboth istoto ends using ends usingsquare squareknot, knot, be beused. used. hide thethe excess and tuck it it hide excess and tuck 3.3. Tie Tiethe theapex apexusing usinga asimsimin.in. ple pleknot. knot.Hold Holdone oneend end 7. 7. Make sure that thetheaf-afMake sure thatand with withyour your hand hand andthe the fected extremity is supfected extremity is supapex apexwith with the theother. other. ported bybythethebandage, ported bandage, 4.4. Place Placethe thebase baseside side ononthe the twist thetheapex side until twist apex side until unaffected unaffected area areawhile whilethe the thethebandage is snugly fit snugly fit apex apexbandage is isplaced placedisunder under the the then tuck it inside. then tuck itthe inside. elbow elbow ofofthe affected affectedexex8. 8. TieTie a swathe over thethe arm a swathe over arm tremity. tremity. sling forfor better support. sling better support. 5.5. Fold Foldthe thebase baseinward inwarduntil until 9. 9. Check PMS thetheproCheck PMSafter after prothe thepatient’s patient’s fingers fingers are are cedure. cedure. exposed. exposed.

ARM ARMSLING SLING

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE ARM ARMSLING SLING

ARM ARMSLING SLING

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

6.6. Take Takethe theend endatatthe thebotbottom tomand andraise raiseit itover overthe the affecter affecter extremity extremity and and gently gentlypull pullit itgoing goingtotoununaffected affected side. side. Tie Tie both both ends endsusing usingsquare squareknot, knot, hide hidethe theexcess excessand andtuck tuckit it in.in. 7.7. Make Make sure sure that that the the af-affected fected extremity extremity is is supsupported portedbybythe thebandage, bandage, twist twistthe theapex apexside sideuntil until the thebandage bandageis issnugly snuglyfitfit then thentuck tuckit itinside. inside. 8.8. Tie Tiea aswathe swatheover overthe thearm arm sling slingfor forbetter bettersupport. support. ² Limmer ² Limmer (Brady)(Brady) 9.9. Check CheckPMS PMSafter afterthe thepropro³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA 1. Arm sling is used to support the patient who suffered cedure. cedure.

ARM SLING

5. Fold the base inward until the patient’s fingers are ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) from a fracture or dislocation, usually the injury is ⁴ NHTSA ⁴ NHTSAexposed. splinted first. If so, it is a must that you check PMS 6. Take the end at the bottom and raise it over the affecter before and after your intervention as part of splinting extremity and gently pull it going to unaffected side. Tie principles. both ends using square knot, hide the excess and tuck it 2. Injured part is the right forearm. Open phase is to be in. used. 7. Make sure that the affected extremity is supported by the 3. Tie the apex using a simple knot. Hold one end with your bandage, twist the apex side until the bandage is snugly hand and the apex with the other. fit then tuck it inside. 4. Place the base side on the unaffected area while the 8. Tie a swathe over the arm sling for better support. apex is placed under the elbow of the affected extremity. 9. Check PMS after the procedure. LIFELINE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

467

ated ated the the fore fore tion ntion are are

ured ured icle. vicle. sed. used. simsimend end NIT the the 3

Ythe19

the the the the the d exex-

until until ated are ated are the the fore botfore bottion the tion the are and are and sing sing ured arm ured rarm vicle. gicle. g to to sed. Tie sed. Tie simuare simuare end and end and the the NIT 33 NIT afafthe supYsupYthe19 19 the age, the age, the until the until exyyexfit fit

until arm until arm are are t..ted ated proprothe the botbotore fore the the ion tion and and are are sing sing arm arm red ured to gg to cle. icle. Tie Tie sed. sed. uare uare simsimand end and end the the afafsupthe the supage, the the age, until the the until fit exyyexfit

until until arm arm are t..are proprobotbotthe the and and ing sing arm arm gg to to Tie Tie uare uare and and

afafupsupage, age, until until yy fit fit

arm arm . propro-

UNDERARM UNDERARM SLING SLING

DAY 19

UNIT 3

UNIT 3 PRINCIPLESDAY OF EMT DAY19 19 PP

UNDERARM UNDERARMSLING SLING

UNDERARM UNDERARMSLING SLING 1.1. This Thistechnique techniqueisisindicated indicated for for injury injury involving involving the the KNEE BANDAGE KNEE BANDAGE KNEE BANDAGE clavicle. before clavicle.Check CheckPMS PMS before 5. Day 19 1. Broad Cravat is to be 1.1. Broad Broad Cravat Cravat is is toto bebe and andafter afterthe theintervention intervention used. Hold the Cravat on used. Hold the Cravat on used. Hold the Cravat on especially especially ifif splints splints are are the side where the apex the theside sidewhere wherethe theapex apex applied. applied. are is folded. Be sure that are is isfolded. BeBesure are folded. surethat that 2.2. Right Right extremity extremity isis injured injured the folded part is touching the folded part is is touching the folded part touching involving involving right right clavicle. clavicle. the injured knee. (in the the theinjured injuredknee. knee.(in(inthe the 1. This technique is indicated for injury involving the 5. Take the end at the bottom and raise it over the affected Open Openphase phaseisistotobe beused. used. picture—left knee) picture—left knee) picture—left knee) clavicle. Check PMS before and after the intervention extremity and gently pull it passing through the Tie the apex using a sim2. Place the bandage on top Tie the apex using a sim2.2. Place Placethe thebandage bandageonontop top especially if splints are applied. underarm and pull it gently going to the unaffected side. ple of the knee, then hold ple knot. knot. Hold Hold one one end end ofofthe theknee, knee,then thenhold hold both sides like the one with both with your your hand hand and and the the3 UNIT bothsides sideslike likethe theone one 2. Right extremity is injured involving right clavicle. Open Tie both ends using square knot, hide the excess and tuck shown in the picture. apex shown inin the picture. apexwith withthe theother. other. shown the picture. phase is to be used. Tie the apex using a simple knot. Hold it in. DAY 19 3. Pull the ends going to the 3.3. Pull 3.3. Place Pullthe theends endsgoing goingtotothe the Placethe thebase baseside sideon onthe the one end with your hand and the apex with the other. 6. Make sure that the affected extremity is supported by the popliteal area and interpopliteal poplitealarea areaand andinterinterunaffected unaffectedarea areawhile whilethe the UNIT 3 change it with each other. change it it with each other. 3. Place the base side on the unaffected area while the apex bandage, twist the apex side until the bandage is snugly fit change with each other. apex apex isis placed placed under under the the 4. Pull the ends forward, one 19 4.4. Pull Pullthe theends endsforward, forward,one one DAY elbow is placed under the elbow of the affected extremity. then tuck it inside. elbowofofthe theaffected affectedexexend will be pulled over end endwill willbebepulled pulledover over tremity. tremity. 4. Fold the base inward until the patient’s fingers are 7. Tie a swathe over the arm sling for better support. the thigh side (Above the the thethigh thighside side(Above (Abovethe the 4.4. Fold base UNDERARM SLING UNDERARM Foldthe theSLING baseinward inwarduntil until knee) and the other to the exposed. 8. Check PMS after the procedure. knee) and the other toto the knee) and the other the are 1. the Thispatient’s technique indicated 1. This technique isis indicated the patient’s fingers fingers are leg side (Below the knee). leg side (Below the knee). leg side (Below the knee). for injury involving the for injury involving the exposed. exposed. 5. Let the two ends meet on 5.5. Let onon Letthe thetwo twoends endsmeet meet clavicle. Check PMS before clavicle. Check PMS before 5.5. Take the end botKNEE Take the end at at the the boteitherBANDAGE side of the knee. Tie either eitherside sideofofthe theknee. knee.Tie Tie andand after the intervention intervention and after the 1. Broad Cravatknot. is to be tom ititover tom andraise raise overthe the it using a square it it using aa square knot. using square knot. used. Hold the Cravat on especially extremity splints and are especially ifif splints are affected affected extremity and the side where the apex applied.pull applied. gently gently pull itit passing passing are is folded. Be sure that 2. through Right extremity extremity injured 2. Right isis injured the through the underarm underarm the folded part is touching involving right going clavicle. involving right clavicle. and pull toto and pullititgently gently going the injured knee. (in the Open phase isis to toside. be used. used. Open phase be the unaffected Tie the unaffected side. Tie picture—left knee) Tie the the apexusing usingsquare simTie apex using aa simboth ends both ends using square 2. Place the bandage on top ple knot. Hold one end ple knot. Hold one end knot, of the knee, then hold knot,hide hidethe theexcess excessand and withit your your hand hand and and the the with both sides like the one tuck in. tuck itwith in. the other. UNIT UNIT 3 3 apex with apex the other. shown in the picture. 6.6. Make sure that the afMake sure the af3. Place Place the the basethat side on on the the 3. base side 3. Pull the ends going to the UNIT UNIT33 DAY DAY 19 19 fected extremity isis supfected extremity supunaffected area while the unaffected area while the popliteal area and interported by the bandage, ported by the bandage, DAY DAY 19 19 apex isis placed placed under under the the apex change it with each other. twist the side twist the apex side until until elbow of apex the affected exelbow of the affected ex4. Pull the ends forward, one the bandage the bandage isis snugly snugly fitfit end will be pulled over tremity. tremity. ititinside. then tuckbase inside. the thigh side (Above the 4. then Foldtuck the base inward until until 4. Fold the inward 7.UNDERARM Tie over the knee) and the other to the 7.UNDERARM Tie swathe over thearm arm theaaswathe patient’s fingers are the patient’s fingers are SLING SLING for leg side (Below the knee). sling forbetter bettersupport. exposed. exposed. 1.1. sling This Thistechnique technique issupport. isindicated indicated KNEE KNEEBANDAGE BANDAGE 5. Let the two ends meet on 8.8. PMS after Check PMS after the propro5. Check Take the end at the the bot5. Take the end at the bot1.1. Broad Broad Cravat Cravat isis to to be be for for injury injury involving involving the the either side of the knee. Tie cedure. cedure. tom andCheck raise PMS it over over the used. used. Hold Hold the the Cravat Cravat on on tom and raise itPMS the clavicle. clavicle. Check before before it using a square knot. the the side side where where the the apex apex affected extremity and affected extremity and and and after after the the intervention intervention are are isisfolded. folded.Be Be sure sure that that gently pull passing gently pull ititsplints passing especially especially ifif splints are are the thefolded foldedpart partisistouching touching through the underarm underarm through applied. applied. the the the injured injured knee. knee. (in (in the the and pull gentlyisisgoing going to and pull itit gently to 2.2. Right Right extremity extremity injured injured picture—left picture—leftknee) knee) the unaffected side. Tie the unaffected Tie involving involving right right side. clavicle. clavicle. 2.2. Place Placethe thebandage bandageon ontop top both ends using square both ends square Open Openphase phaseusing is isto tobe be used. used. of of the the knee, knee, then then hold hold knot, hide theusing excess and knot, hide the excess and Tie Tie the the apex apex using aa simsimboth both sides sides like like the the one one tuck in. Hold tuck itit in. ple ple knot. knot. Hold one one end end shown shownininthe thepicture. picture. 6. with Make sure that the af6. Make sure that the afwith your your hand hand and and the the 3.3. Pull Pullthe theends endsgoing goingto tothe the fected extremity supfected extremity isis supapex apexwith with the theother. other. popliteal popliteal area area and and interinterported by theside bandage, ported by the bandage, 3.3. Place Placethe the base base side on onthe the change changeititwith witheach eachother. other. twist the apex apex side until twist the side 4.4. Pull Pullthe theends endsforward, forward,one one unaffected unaffected area area while whileuntil the the the bandage snuglythe fit the isisunder snugly fit end end will will be be pulled pulled over over apex apexbandage isis placed placed under the the the thigh thigh side side(Above (Above the the then tuck itthe inside. then tuck inside. elbow elbow of of it the affected affected exexknee) knee)and andthe theother otherto tothe the 7. tremity. Tie swathe over over the the arm arm 7. Tie aa swathe tremity. leg legside side(Below (Belowthe theknee). knee). sling for better support. sling for support. 4.4. Fold Foldthe thebetter base baseinward inward until until 5.5. Let Letthe thetwo twoends ends meet meeton on 8. the Check PMS after after the propro8. Check PMS the the patient’s patient’s fingers fingers are are either eitherside sideof ofthe theknee. knee.Tie Tie cedure. cedure. exposed. exposed. ² Limmer (Brady) ² ititusing usingaasquare squareknot. knot. ³ Pollack, (AAOS) ³ 5.5. Take Take the the end end at at the the botbot⁴ NHTSA ² ²Limmer Limmer(Brady) (Brady) ⁴ ² Limmer (Brady) ³ ³Pollack, ² Limmer (Brady) Pollack,(AAOS) (AAOS) tom tom and and raise raise itit over over the the ³ Pollack, (AAOS) ⁴⁴ NHTSA ³ Pollack, (AAOS) NHTSA ⁴ ⁴NHTSA NHTSA affected affected extremity extremity and and gently gently pull pull itit passing passing through through the the underarm underarm and andpull pullititgently gentlygoing goingto to the the unaffected unaffected side. side. Tie Tie both both ends ends using using square square knot, knot, hide hide the the excess excess and and tuck tuckititin. in. 6.6. Make Make sure sure that that the the afaffected fected extremity extremity isis supsupported ported by by the the bandage, bandage, twist twist the the apex apex side side until until the the bandage bandage isis snugly snugly fitfit then thentuck tuckititinside. inside. 7.7. Tie Tieaaswathe swatheover overthe thearm arm ² Limmer (Brady) sling slingfor forbetter bettersupport. support. ³ Pollack, (AAOS) ⁴ NHTSA 8.8. Check Check PMS PMS after after the the proproLimmer(Brady) (Brady) ²²Limmer Pollack,(AAOS) (AAOS) ³³Pollack, 468 LIFELINE PREHOSPITAL EMERGENCY CARE cedure. cedure. NHTSA ⁴⁴ NHTSA

KNEE BA

SOFT TISSUE INJURIES

UNDERARM SLING

PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE UNDERARM SLING

UNDERARM SLING

PRINCIPLES OF EMT

KNEE B

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE UNDERARM UNDERARM SLING SLING

Limmer(Brady) (Brady) ²²Limmer Pollack,(AAOS) (AAOS) ³³Pollack, NHTSA ⁴⁴ NHTSA

UNDERARM UNDERARM SLING SLING

poplitealarea areaand and interpopliteal interpopliteal area and interTPRINCIPLES CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE OF CLINICAL PRACTICE change it with each other.EMT change change it with each other. it with each other. 4. PullPull ends forward, one thethe ends forward, one endwillwillbebepulled pulledover over end thigh side (Above thethe thigh side (Above thethe knee) and other knee) and thethe other to to thethe side (Below knee). legleg side (Below thethe knee). 5. LetLet two ends meet thethe two ends meet onon either side knee. either side of of thethe knee. TieTie it using a square knot. it using a square knot.

UNIT 3 DAY 19

Pull the ends forward, one end will be pulled over the thigh side (Above the knee) and the other to the leg side (Below the knee). Let the two ends meet on either side of the knee. Tie it using a square knot.

ANDAGE KNEE KNEEBANDAGE BANDAGE 5.

T CLINICAL PRACTICE

UNIT 3 DAY 19

PRINCIPLES OF EMT C

KNEE BAN KNEE BANDAGE 1. Broad Cravat is to be used. Hold the Cravat on the side where the apex are is folded. Be sure that the folded part is touching the injured knee. (in the picture—left knee) 2. Place the bandage on top of the knee, then hold both sides like the one shown in the picture. 3. Pull the ends going to the popliteal area and interchange it with each other. 4. Pull the ends forward, one 1. Broad Cravat is to be used. Hold the end will be pulled over the Cravat on the side where the apex are thigh side (Above the knee) and the other to the is folded. Be sure that the folded part leg side (Below the knee). is touching the injured knee. (in the 5. Let the two ends meet on picture—left knee) either side of the knee. Tie it using a square knot. 2. Place the bandage on top of the knee,

KNEE BANDAGE

PRINCIPLES OF EMT CLINICAL PRACTICE KNEE BANDAGE

BANDAGE KNEE BANDAGE 1. Broad Cravat is to be used. Hold the Cravat on the side where the apex are is folded. Be sure that the folded part is touching the injured knee. (in the picture—left knee) 2. Place the bandage on top of the knee, then hold both sides like the one shown in the picture. 3. Pull the ends going to the popliteal area and interchange it with each other. 4. Pull the ends forward, one end will be pulled over the thigh side (Above the knee) and the other to the leg side (Below the knee). 5. Let the two ends meet on ² Limmer (Brady) side of the knee. Tie ² Limmer (Brady) either ³ Pollack, (AAOS) ³ Pollack, (AAOS) it using a square knot. ⁴ NHTSA ⁴ NHTSA

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE

UNIT UNIT33 DAY DAY19 19

KNEE KNEE BANDAGE BANDAGE

UNIT UNIT 33 DAY DAY 19 19

KNEE KNEEBANDAGE BANDAGE 1. 1. Broad Broad Cravat Cravat isis to to be be used. used. Hold Hold the the Cravat Cravat on on ² Limmer (Brady) ² Limmer (Brady) the the side side where where the the apex apex ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA are are isis folded. folded. Be Be sure sure that that the thefolded foldedpart partisistouching touching the the injured injured knee. knee. (in (in the the picture—left picture—leftknee) knee) 2. 2. Place Place the the bandage bandage on on top top of of the the knee, knee, then then hold hold both both sides sides like like the the one one shown shownin inthe thepicture. picture. 3. 3. Pull Pull the the ends ends going going to to the the popliteal popliteal area area and and interinterchange changeititwith witheach eachother. other. 4. 4. Pull Pull the the ends ends forward, forward, one one end end will will be be pulled pulled over over the the thigh thigh side side (Above (Above the the knee) knee)and andthe theother otherto tothe the leg legside side(Below (Belowthe theknee). knee). 5. 5. Let Let the the two two ends ends meet meeton on either either side side of of the the knee. knee. Tie Tie ititusing usingaasquare squareknot. knot.

then hold both sides like the one shown in the picture. 3. Pull the ends going to the popliteal area and interchange it with each other. 4. Pull the ends forward, one end will be pulled over the thigh side (Above PRINCIPLES OF PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE the knee) and the other to the leg side (Below the knee). 5. Let the two ends meet on either side KNEE KNEEBANDAGE BANDAGE of the knee. Tie it using a square knot.

KNEE KNEEBANDAGE BANDAGE 1.1. Broad Broad Cravat Cravat isis toto be be ² Limmerused. (Brady) used.Hold Holdthe theCravat Cravaton on ³ Pollack, (AAOS) theside sidewhere wherethe theapex apex ⁴ NHTSAthe are areisisfolded. folded.Be Besure surethat that the thefolded foldedpart partisistouching touching the theinjured injuredknee. knee.(in (inthe the picture—left picture—leftknee) knee) 2.2. Place Placethe thebandage bandageon ontop top ofof the the knee, knee, then then hold hold both both sides sides like like the the one one shown shownininthe thepicture. picture. 3.3. Pull Pullthe theends endsgoing goingtotothe the popliteal popliteal area area and and interinterchange changeititwith witheach eachother. other. 4.4. Pull Pullthe theends endsforward, forward,one one end end will will be be pulled pulled over over the thigh side (Above the the thigh side (Above the knee) knee)and andthe theother othertotothe the leg legside side(Below (Belowthe theknee). knee). 5.5. Let the two ends meet on Let the two ends meet on either eitherside sideofofthe theknee. knee.Tie Tie ititusing usingaasquare squareknot. knot.

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE KNEE KNEE BANDAGE BANDAGE

²² Limmer Limmer (Brady) (Brady) ³³ Pollack, Pollack, (AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

469

DAY DAY19 19

touch touch the the affected affected area. area. 2. Hold Holdboth bothsides sidesofofthe the bandage bandageand andpull pullit itatatthe the back. back. 3. Tie Tie both both ends ends using using a a square square knot. knot. 4. Tuck Tuckthe theexcess excesstotomake make the the bandage bandage neat. neat.

PRINCIPLES PRINCIPLES OF EMT CLINICAL PRACTIC PRACTIC bandage OF and pullEMT it at the CLINICAL 3.

back. Tie both ends using a square knot. Tuck the excess to make the bandage neat.

4. UNIT UNIT33 ABDOMINAL BANDAGE ABDOMINAL BANDAGE PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE DAY DAY19 19

ABDOMINAL ABDOMINALBANDAGE BANDAGEDay 19 1.1. Broad Broad Cravat Cravat isis to to be be used. used. Hold Hold the the bandage bandage on on the the side side where where the the ABDOMINAL ABDOMINAL BANDAGE BANDAGE apex apex isis folded. folded. Be Be sure sure 1. 1. Broad BroadCravat Cravatis isto tobebe that the that the folded folded part part will will used. used.Hold Holdthe thebandage bandage touch touchthe theaffected affectedarea. area. ononthe theside sidewhere wherethe the 2.2.BeBe Hold Hold both sides sides of of the the apex apexis isfolded. folded. sure sureboth bandage bandage andpull pullititatatthe the that thatthe thefolded foldedpart part will will and back. back. touch touch the the affected affected area. area. 2. 2. Hold Holdboth bothsides sides ofthe the 3. both 3. ofTie Tie both ends ends using using aa 1. Broad Cravat is to be used. Hold bandage bandage and and pull pull it square at itsquare at the the knot. knot. the bandage on the side where back. back. 4.4. Tuck Tuck the the excess excess to to make make the apex is folded. Be sure that 3. 3. TieTieboth bothends endsusing usinga a the bandage neat. the bandage neat. the folded part will touch the square square knot. knot.

T CLINICAL PRACTICE

SOFT TISSUE INJURIES

ABDOMINAL ABDOMINALBANDAGE BANDAGE

HA 1. 2.

AL BANDAGE

ABDOMINAL BANDAGE

UNIT 3 DAY 19

PRINCIPLES OF EMT 4.

PRINCIPLES4. 4.OF EMT CLINICAL PRACTICE Tuck Tuckthe theexcess excesstotomake make affected area. the the bandage bandage neat. neat. 2. Hold both sides of the bandage and pull it at the back. 3. Tie both ends using a square knot. 4. Tuck the excess to make the bandage neat.

ABDOMINAL BANDAGE

UNIT33 UNIT DAY19 19 DAY

HAND 5.B

HAND BANDAGE 1. Right hand is injured, put finger separator (it can be a dry sterile dressing ) 2. Open Phase is to be used. Hold the base and fold it twice at least 1 inch in size. Place the hand on top of the bandage. Make sure that the folded base 6. is at the area of the wrist. The apex is on the direcUNIT UNIT33 tion of the fingers. 3. Hold the apex and pull it DAY DAY19 19 over the hand to cover it entirely. 4. Roll each sides inwards until you follow the contour of the hand 5. Get both ends and interHAND HANDBANDAGE BANDAGE change it at the top of the 1.1. Right Righthand handisisinjured, injured,put put hand along the folded finger fingerseparator separator(it(itcan canbe be base (wrist area). Bring aadry drysterile steriledressing dressing) ) the ends back en forth 2.2. Open OpenPhase Phaseisistotobe beused. used. encircling the wrist area Hold Holdthe thebase baseand andfold folditit (be careful not to encircle twice twice atat least least 11 inch inch inin it tightly). Once almost the size. size. Place Place the the hand hand on on ends are consumed, tie it top topofofthe thebandage. bandage.Make Make using a square knot and sure surethat thatthe thefolded foldedbase base tuck it. isisatatthe thearea areaofofthe thewrist. wrist. 6. Pull the apex gently until ² Limmer (Brady)The Theapex apexisison onthe thedirecdirec(AAOS) the bandage is snugly fit. ⁴³ Pollack, tion tionofofthe thefingers. fingers. NHTSA Cover the bandage and 3.3. Hold Holdthe theapex apexand andpull pullitit knot with the apex and over overthe thehand handtotocover coveritit tuck it. entirely. entirely. 4.4. Roll Roll each each sides sides inwards inwards until untilyou youfollow followthe theconcontour of the hand tour of the hand 5.5. Get Getboth bothends endsand andinterinterHA H change changeititatatthe thetop topofofthe the 1.1 hand hand along along the the folded folded base base (wrist (wrist area). area). Bring Bring the the ends ends back back en en forth forth encircling encircling the the wrist wrist area area 2.2 (be (becareful carefulnot nottotoencircle encircle itittightly). tightly).Once Oncealmost almostthe the ends endsare areconsumed, consumed,tie tieitit using usingaasquare squareknot knotand and tuck tuckit.it. 6.6. Pull Pullthe theapex apexgently gentlyuntil until the thebandage bandageisissnugly snuglyfit. fit. Cover Cover the the bandage bandage and and knot with the apex and knot with the apex and 3.3 tuck tuckit.it.

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTIC PRINCIPLES ABDOMINALBANDAGE BANDAGE ABDOMINAL

ABDOMINALBANDAGE BANDAGE ABDOMINAL Broad Cravat Cravat isis toto be be 1.1. Broad used. Hold Hold the the bandage bandage used. on the the side side where where the the on apex isis folded. folded. Be Be sure sure apex that the the folded folded part part will will that touchthe theaffected affectedarea. area. touch Hold both both sides sides ofof the the 2.2. Hold bandageand andpull pullititatatthe the bandage back. back. Tie both both ends ends using using aa 3.3. Tie squareknot. knot. square Tuckthe theexcess excesstotomake make 4.4. Tuck thebandage bandageneat. neat. the

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

4.4 ² Limmer ² Limmer(Brady) (Brady) ³ Pollack, ³ Pollack,(AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA

470

LIFELINE

PREHOSPITAL EMERGENCY CARE

5.5 ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

CE CE

DAY DAY1919

DAY 19

over hand cover over thethe hand to to cover it it entirely. entirely. Rolleach eachsides sidesinwards inwards 4. 4. Roll until you follow conuntil you follow thethe contour hand tour of of thethe hand Get both ends and inter5. 5. Get both ends and interHAND HAND BANDAGE BANDAGE AND BANDAGE change it at change it at thethe toptop of of thethe 1. 1. Right Right hand hand is injured, is injured, putput Right hand is injured, put handalong alongthethefolded folded hand finger finger separator separator (it (it can can bebe finger separator (it can be base(wrist (wristarea). area).Bring Bring base a dry a dry sterile sterile dressing dressing ) ) a dry sterile dressing ) endsback backenenforth forth thetheends 2. 2. Open Open Phase Phase is to is to be be used. used. Open Phase is to be used. encirclingthethewrist wristarea area encircling Hold Hold thethe base base and and fold fold it it Hold the base and fold it careful encircle (be(be careful notnot to to encircle twice twiceat atleast least1 1inch inchin in twice at least 1 inch in it tightly). Once almost it tightly). Once almost thethe size. size.Place Placethethehand handonon size. Place the hand on ends consumed, ends areare consumed, tietie it it toptop of of thethe bandage. bandage. Make Make top of the bandage. Make using square knot and using a a square knot and sure sure that that thethe folded folded base base sure that the 1. folded base Right hand is injured, put finger tuck tuck it. it. is at is at thethe area area of of thethe wrist. wrist. is at the area of the wrist. separator (it can be a dry sterile Pull apex gently until thethe apex gently until The The apex apex is is onon thethe direcdirec- 6. 6. Pull The apex is on the direcbandage snugly thethe bandage is is snugly fit.fit. tion tion of of the the fingers. fingers. dressing). tion of the fingers. Coverthethebandage bandageand and Cover 3. 3. Hold Hold thethe apex apex and and pull pull it it Hold the apex2. and pull it Open Phase is to be used. Hold the base UNIT UNIT 33 knot knotwith withthetheapex apexand and over over thethe hand hand to to cover cover it it over the hand to and fold it twice at least 1 inch in size. cover it tuck it. it. entirely. entirely. DAY19 19 tuck DAY entirely. 4. 4. Roll Rolleach eachsides sidesinwards inwards Roll each sides Place the hand on top of the bandage. inwards until until you you follow follow thethe conconMake sure that the folded base is at the until you follow the contour tour of of thethe hand hand tour of the hand area of the wrist. The apex is on the 5. 5. Get Get both both ends ends and and interinterGet both ends and interdirection of the fingers. change change it at it at thethe toptop of of thethe change it at the top of the HAND BANDAGE HAND BANDAGE hand hand along alongthethefolded folded hand along 3. the Hold the apex and pull it over the hand folded Right handarea). injured, put 1.1.base Right hand isisarea). injured, put base (wrist (wrist Bring Bring base (wrist area).to cover it entirely. Bring finger separator (it can be finger separator (it can be the the ends ends back back en en forth forth the ends back en forth adry drysterile sterile dressing a dressing ) ) area 4. Roll each sides inwards until you follow encircling encircling the the wrist wrist area encircling the wrist area OpenPhase Phaseisisto beused. used. 2.2.(beOpen be (be careful careful notnot to to to encircle encircle (be careful not to the contour of the hand. encircle Hold the the base base and and fold fold itit Hold it tightly). it tightly). Once Once almost almost the the it tightly). Once5. almost the Get both ends and interchange it at twice atat least least 11 inch inch inin twice ends ends areare consumed, consumed, tietie it it ends are consumed, tie it size. Place the hand on size. Place the hand on the top of the hand along the folded using using a square a square knot knot and and using a square knot and topof ofthe thebandage. bandage.Make Make top tuck tuck it. it. base (wrist area). Bring the ends back tuck it. sure that that the the folded folded base base sure 6. 6. Pull Pull thethe apex apex gently gently until until Pull the apex gently until and forth encircling the wrist area (be thearea areaof ofthe thewrist. wrist. isisatatthe thethe bandage bandage is on snugly is snugly fit.fit. the bandage is snugly fit. The apex apex isis on the direcdirecThe the careful not to encircle it tightly). Once Cover Cover the the bandage bandageand and UNIT UNIT33 Cover the bandage and tionof ofthe the fingers. tion fingers. knot with with theapex apexand and almost the ends are consumed, tie it knot with the apex and Hold thethe apex and pull 3.3.knot Hold the apex and pull itit DAY DAY19 19 tuck tuck it. it. using a square knot and tuck it. over the hand hand to to cover cover itit tuck it. over the

UNIT over the hand to cover it 3 entirely. DAY 19 4. Roll each sides inwards until you follow the contour of the hand 5. Get both ends and interchange it at the top of the HAND BANDAGE hand along the folded 1. base Right(wrist hand isarea). injured, put Bring finger separator (it can be the ends back en forth a dry sterile dressing encircling the wrist )area 2. (be Open Phase to encircle be used. careful notis to theOnce base almost and fold it Hold tightly). theit twiceareatconsumed, least 1 inch ends tie itin size. aPlace the knot handand on using square topit.of the bandage. Make tuck surethe that the gently folded until base 6. Pull apex is at the areaisofsnugly the wrist. the bandage fit. The apex on the direcCover the isbandage and tion of the fingers. knot with the apex and 3. tuck Hold it. the apex and pull it over the hand to cover it entirely. 4. Roll each sides inwards until you follow the contour of the hand 5. Get both ends and interchange it at the top of the hand along the folded base (wrist area). Bring the ends back en forth encircling the wrist area (be careful not to encircle it tightly). Once almost the ends are consumed, tie it using a square knot and tuck it. 6. Pull the apex gently until the bandage is snugly fit. Cover the bandage and knot with the apex and tuck it.

PRINCIPLES OF EMT C

HANDBANDAGE BANDAGE HAND BANDAGEHAND

HAND BANDAGE

HAND BAN

PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES

T CLINICAL PRACTICE

HAND BANDAGE BANDAGE HAND

BANDAGE

CE E

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE entirely. entirely. 6. Pull the apex gently until the bandage is Roll each each sides sides inwards inwards 4.4. Roll snugly fit. Cover the bandage and knot until you you follow follow the the conconuntil HAND with the apex and tuck it. tourof ofthe thehand hand HANDBANDAGE BANDAGE tour Get both both ends ends and and interinter5.5. Get changeititatatthe thetop topof ofthe the change hand along along the the folded folded hand base (wrist (wrist area). area). Bring Bring base the ends ends back back en en forth forth the encircling the the wrist wrist area area encircling (becareful carefulnot notto toencircle encircle (be tightly).Once Oncealmost almostthe the itittightly). ends are are consumed, consumed, tie tie itit ends using aa square square knot knot and and using tuckit.it. tuck Pull the the apex apex gently gently until until 6.6. Pull the bandage bandage isis snugly snugly fit. fit. the Cover the the bandage bandage and and Cover knot with with the the apex apex and and knot tuckit.it. tuck

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE HAND HANDBANDAGE BANDAGE

HAND HANDBANDAGE BANDAGE 1.1. Right Righthand handisisinjured, injured,put put finger fingerseparator separator(it(itcan canbe be aadry drysterile steriledressing dressing) ) 2.2. Open OpenPhase Phaseisistotobe beused. used. Hold Holdthe thebase baseand andfold folditit twice twice atat least least 11 inch inch inin size. size. Place Place the the hand hand on on top topofofthe thebandage. bandage.Make Make sure that the folded base sure that the folded base isisatatthe thearea areaofofthe thewrist. wrist. The Theapex apexisison onthe thedirecdirection tionofofthe thefingers. fingers. 3.3. Hold Holdthe theapex apexand andpull pullitit over overthe thehand handtotocover coveritit entirely. entirely. 4.4. Roll Roll each each sides sides inwards inwards until untilyou youfollow followthe theconcontour tourofofthe thehand hand 5.5. Get both ends and interGet both ends and interchange changeititatatthe thetop topofofthe the ² Limmer ² Limmer (Brady) (Brady)along the folded hand hand ³ Pollack, ³ Pollack, (AAOS) (AAOS) along the folded ⁴ NHTSA ⁴ NHTSA base base (wrist (wrist area). area). Bring Bring the the ends ends back back en en forth forth encircling encircling the the wrist wrist area area (be (becareful carefulnot nottotoencircle encircle itittightly). tightly).Once Oncealmost almostthe the ends endsare areconsumed, consumed,tie tieitit using usingaasquare squareknot knotand and tuck tuckit.it. 6.6. Pull the apex gently until Pull the apex gently until the thebandage bandageisissnugly snuglyfit. fit. Cover Cover the the bandage bandage and and knot knot with with the the apex apex and and tuck tuckit.it.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

UNIT UNIT33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY19 19 PRINCIPLES

HAND AND BANDAGE BANDAGE 1. Right Righthand handis isinjured, injured,put put finger fingerseparator separator(it(itcan canbebe a adry drysterile steriledressing dressing) ) 2. Open OpenPhase Phaseis istotobebeused. used. Hold Holdthe thebase baseand andfold foldit it twice twiceatatleast least1 1inch inchinin size. size.Place Placethe thehand handon on top topofofthe thebandage. bandage.Make Make sure surethat thatthe thefolded foldedbase base is isatatthe thearea areaofofthe thewrist. wrist. The Theapex apexis ison onthe thedirecdirection tionofofthe thefingers. fingers. 3. Hold Holdthe theapex apexand andpull pullit it over overthe thehand handtotocover coverit it entirely. entirely. 4. Roll Roll each each sides sides inwards inwards until untilyou youfollow followthe theconcontour tourofofthe thehand hand 5. Get Getboth bothends endsand andinterinterchange changeit itatatthe thetop topofofthe the hand hand along along the the folded folded base base (wrist (wrist area). area). Bring Bring the theends endsback backenenforth forth encircling encirclingthe thewrist wristarea area (be (becareful carefulnot nottotoencircle encircle it ittightly). tightly).Once Oncealmost almostthe the ends endsare areconsumed, consumed,tietieit it using usinga asquare squareknot knotand and tuck tuckit.it.

HAND HANDBANDAGE BANDAGE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer(Brady) (Brady) ² Limmer ³ Pollack,(AAOS) (AAOS) ³ Pollack, NHTSA ⁴ ⁴NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

471

cooperative) cooperative) 3.3. Pull Pullthe thebandage bandagetowards towards UNIT UNIT 3 3 thetheaffected affectedhip hipgoing goingtoto theback backand andunder underbebeDAY DAY 1919 the tween the thighs. tween the thighs. 4.4. Pull the end going toto front Pull the end going front and andback backononthe theinjured injured hip hipforming forminganan“X” “X”over over Day 12 the injury the injury HIP BANDAGE 5.5. Let Letthe theend endpass passthrough through HIPHIP BANDAGE BANDAGE . Semi-broad Cravat is to be the theback backand andmeet meetthe the 1. 1. Semi-broad Semi-broad Cravat Cravat is to is to be be used. This is intended for one oneend endatatthe theunaffected unaffected used. used. This This is intended is intended forfor open wounds and not for hip, hip,tietieboth bothends endsusing using open open wounds wounds and and notnot forfor dislocations and/or fracsquare squareknot. knot.Tuck Tuckthe theex-exdislocations dislocationsand/or and/orfracfractures. cess make cesstoto makethe thebandage bandage tures. tures. . Right Hip is injured. Hold neat. neat. 2. 2.Right Right HipHip is injured. is injured. Hold Hold one end and leave it on one one end end and and leave leave it on it on the unaffected hip (left thetheunaffected unaffectedhiphip(left (left hip) and let the patient hip) hip) and and let let thethe patient patient hold it (if conscious and hold hold it (if it (if conscious conscious and and cooperative) cooperative) cooperative) UNIT UNIT3 3 . Pull the bandage towards 3. 3.PullPull thethe bandage bandage towards towards the affected hip going to DAY DAY thethe affected affected hiphip going going to19 to19 Semi-broad Cravat is to be used. the back and under1. bethe the back back and and under under bebetween the thighs. This is intended for open wounds tween tween thethe thighs. thighs. . Pull the end going to front and not for dislocations and/or 4. 4.PullPull thethe end end going going to front to front and back on the injured and and back back onon thethe injured injured fractures. hip forming an “X” over hip hip forming forming an an “X”“X” over over the injury HIP HIP BANDAGE BANDAGE 2. Right Hip is injured. Hold one end the injury injury Cravat . Let the end pass through 1. 1. the Semi-broad Semi-broad Cravat is to is to bebe and leave it on the unaffected hip 5. 5. Let Let theThis the end end pass through through the back and meet the used. used. This ispass is intended intended forfor thetheback backand andmeet meetthethe (left hip) and let the patient hold it one end at the unaffected open open wounds wounds and and not not forfor one one end end at the at the unaffected unaffected hip, tie both ends using (if conscious and cooperative) dislocations dislocationsand/or and/orfracfrachip,hip, tie tie both both ends ends using using square knot. Tuck the tures. tures. 3. ex-Pull the bandage towards the square square knot. knot. Tuck Tuck the the exexcess to make the bandage 2. 2. Right Right Hip Hip is is injured. injured. Hold Hold cess cess to to make make thethe bandage bandage affected hip going to the back and neat. one oneend endand andleave leaveit itonon neat. neat. under between the thighs. thetheunaffected unaffectedhiphip(left (left hip) hip)and andletletthethepatient patient 4. Pull the end going to front and back hold holdit it(if (ifconscious consciousand and on the injured hip forming an “X” cooperative) cooperative) over the injury 3. 3. Pull Pull the the bandage bandage towards towards thethe affected affected hiphip going going to to 5. Let the end pass through the thetheback backand andunder underbe-beback and meet the one end at the tween tween thethe thighs. thighs. unaffected hip, tie both ends using 4. 4. Pull Pull thethe end end going going to to front front HIP BANDAGE BANDAGE square knot. Tuck the excess to and andback backononthetheinjured injured HIP hiphipforming forminganan“X”“X”over over 1.1. Semi-broad Semi-broad Cravat Cravat is is toto bebe make the bandage neat. thethe injury injury used. used.This Thisis isintended intendedforfor 5. 5. LetLet thethe end end pass pass through through open openwounds woundsand andnot notforfor the theback backand andmeet meetthethe dislocations dislocationsand/or and/orfracfracone one end end at at thethe unaffected unaffected tures. tures. hip, hip,tietieboth bothends endsusing using 2.2. Right RightHip Hipis isinjured. injured.Hold Hold square square knot. knot. Tuck Tuck thethe ex-exone oneend endand andleave leaveit itonon cess cess to to make make the the bandage bandage the theunaffected unaffectedhip hip(left (left neat. neat. hip) hip)and andletletthe thepatient patient hold holdit it(if(ifconscious consciousand and cooperative) cooperative) 3.3. Pull Pullthe thebandage bandagetowards towards the theaffected affectedhip hipgoing goingtoto the theback backand andunder underbebetween tween the the thighs. thighs. 4.4. Pull Pull the the end end going going toto front front and andback backononthe theinjured injured hip hipforming forminganan“X” “X”over over the the injury injury HIP P BANDAGE BANDAGE 5.5. Let Letthe theend endpass passthrough through . Semi-broad Semi-broadCravat Cravatisistotobe be the theback backand andmeet meetthe the used. used.This Thisisisintended intendedfor for one one end end atat the the unaffected unaffected open openwounds woundsand andnot notfor for hip, hip,tietieboth bothends endsusing using ² Limmer (Brady) dislocations dislocations and/or and/or fracfrac³ Pollack, (AAOS) ² Limmer ² Limmer (Brady) (Brady) square square knot. knot.Tuck Tuckthe theex-ex⁴ NHTSA tures. tures. ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA cess cess toto make make the the bandage bandage . Right RightHip Hipisisinjured. injured.Hold Hold neat. neat. one oneend endand andleave leaveititon on

UNIT 3 DAY 19

UNIT UNIT 3 cooperative) 3 Pull the bandage towards DAY 19 the affected hip going toDAY 19 the back and under between the thighs. 4. Pull the end going to front and back on the injured hip forming an “X” over HIP BANDAGE SHOULDER BANDAGE the injury 1. Semi-broad Cravat is to bewith Hip Same procedure 5. used. Let 1. the end through This is pass intended for Bandage. Semi-Broad Crathe back andand meet the open wounds notused. for This is vat is to be one end at the unaffected dislocations and/or fracnten d e d using for open hip, tie iboth ends tures. wounds and not square knot. Tuck the ex-for dislo2. Right Hipcations is injured. Hold and/or fractures. cess to make the bandage one 2.endRight and leave it on is injured. neat.unaffectedShoulder the Hold onehip end (left and leave it hip) andonletthe theunaffected patient shoulhold it (if derconscious (left hip) and and let the cooperative) patient hold it (if con3. Pull the bandage scious andtowards cooperative) the 3. affected hip bandage going to towards Pull the the backthe and undershoulder beaffected gotween the ingthighs. to the back and to the 4. Pull the end going to front armpit. and 4.back onthethe Pull endinjured going to front hip forming an “X”onover and back the injured the injuryshoulder forming an “X” 5. Let the end through overpass the injury the 5.backLetand the through the meet end pass one end the at the unaffected back and meet the hip, tie one bothend ends using at the unaffected square knot. Tuck the shoulder, tie exboth ends cess to make bandage usingthe square knot. Tuck neat. the excess to make the bandage neat.

PRINCIPLES OF EMT PRINCIPLES OF EC PRINCIPLES OF EMT CLINICALOF PRACTICE PRINCIPLES PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE HIP BANDAGE

HIP BANDAGE

MT CLINICAL PRACTICE

HIP BAN SHOULD

HIP HIP BANDAGE BANDAGE SOFT TISSUE INJURIES

UNIT3 UNIT DAY19 1 DAY

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

ANDAGE

HIP HIPBANDAGE BANDAGE

SHOULDER SHOULDERBANDAGE BANDAGE 1.1. Same Sameprocedure procedurewith withHip Hip Bandage. Bandage.Semi-Broad Semi-BroadCraCravat vat isistotobe beused. used.This Thisisis i ni nt et ennddeedd f of or r ooppe enn wounds woundsand andnot notfor fordislodislocations cationsand/or and/orfractures. fractures. 2.2. Right RightShoulder Shoulderisisinjured. injured. Hold Holdone oneend endand andleave leaveitit on on the the unaffected unaffectedshoulshoulder der (left (lefthip) hip)and andlet letthe the patient patient hold hold itit (if(if conconscious sciousand andcooperative) cooperative) 3.3. Pull Pullthe thebandage bandagetowards towards the affected the affectedshoulder shouldergogoing to the back and ing to the back andtotothe the armpit. armpit. 4.4. Pull Pullthe theend endgoing goingtotofront front and and back back on onthe theinjured injured shoulder shoulder forming forming an an “X” “X” over overthe theinjury injury 5.5. Let Letthe theend endpass passthrough through the ² Limmer (Brady) the back back and and meet meet the the ³ Pollack, (AAOS) one ⁴ NHTSA oneend endatatthe theunaffected unaffected shoulder, shoulder, tie tie both both ends ends using using square square knot. knot. Tuck Tuck the excess to make the excess to make the the bandage neat. bandage neat.

UNIT UNIT33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTIC PRACTIC DAY DAY19 19 PRINCIPLES

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

HIP HIPBANDAGE BANDAGE

HIPBANDAGE BANDAGE HIP

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

UNIT UNIT33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY19 19 PRINCIPLES

the the unaffected unaffected hip hip (left (left hip) hip) and and let let the the patient patient hold holditit(if(ifconscious consciousand and cooperative) cooperative) . Pull Pullthe thebandage bandagetowards towards the theaffected affectedhip hipgoing goingtoto the the back back and and under under bebetween tweenthe thethighs. thighs. . Pull Pullthe theend endgoing goingtotofront front and andback backon onthe theinjured injured hip hip forming forming an an “X” “X” over over the theinjury injury . Let Letthe theend endpass passthrough through the the back back and and meet meet the the one oneend end472 atatthe theunaffected unaffected LIFELINE PREHOSPITAL EMERGENCY CARE hip, hip, tie tie both bothends ends using using square squareknot. knot.Tuck Tuckthe theexexcess cesstotomake makethe thebandage bandage neat. neat.

HIP HIPBANDAGE BANDAGE

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

UNIT 3 DAY 19

PRINCIPLES OF E

SHOULD SHOULDER BANDAGE 1. Same procedure with Hip ² Limmer (Brady) ² Limmer (Brady) Bandage. Semi-Broad Cra³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA vat is to be used. This⁴ NHTSA is intended for open wounds and not for dislocations and/or fractures. 2. Right Shoulder is injured. Hold one end and leave it on the unaffected shoulder (left hip) and let the patient hold it (if conscious and cooperative) 3. Pull the bandage towards the affected shoulder going to the back and to the armpit. 4. Pull the end going to front and back on the injured shoulder forming an “X” over the injury 5. Let the end pass through the back and meet the one end at the unaffected shoulder, tie both ends using square knot. Tuck the excess to make the bandage neat.

scious sciousand andcooperative) cooperative)

3.3. Pull Pullthe thebandage bandage towards towards CLINICAL PRACTICE EMT CLINICAL PRACTICE the theaffected affectedshoulder shouldergogo-

scious and cooperative) UNIT UNIT 33 3. Pull the bandage towards UNIT33PRINCIPLES UNIT PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE affected shoulder goDAY DAY 19 19 PRINCIPLESOF OFEMT EMTthe CLINICAL PRACTICE CLINICAL PRACTICE DAY 19 PRINCIPLES DAY 19

ing ingtotothe theback backand andtotothe the armpit. armpit. 4.4. Pull Pullthe theend endgoing goingtotofront front and andback backon onthe theinjured injured shoulder shoulder forming an an “X” “X” 1. forming Same procedure with Hip Bandage. Semiover overthe theinjury injury SHOULDER SHOULDER BANDAGE BANDAGE Broad Cravat is to be used. This is intended for SHOULDER BANDAGE BANDAGE 5.5. Let Letthe theend endpass passthrough through 1.1.SHOULDER Same Same procedure procedure with with Hip Hip 1. Same procedurewith withHip Hip 1. Same procedure open wounds and not for dislocations and/or the the back back and and meet meet the the Bandage. Bandage. Semi-Broad Semi-Broad CraCraBandage. Semi-Broad CraBandage. Semi-Broad Craone oneend endatfractures. atthe theunaffected unaffected vat vat is is to to be be used. used. This This is used.This Thisis vatvatis istotobebeused. is is shoulder, shoulder, tietie both both ends ends i ni tn etin ntneeddndeeddde df offroofrro ro p ooepponeepn 2. Right Shoulder is injured. Hold one end and in tened ne n using using square square knot. knot. Tuck Tuck wounds wounds and and not not for for dislodislowounds and not dislowounds and not forfor disloleave it on the unaffected shoulder (left hip) the the excess excess toto make make the the cations cations and/or and/or fractures. fractures. cations and/or fractures. cations and/or fractures. bandage bandageneat. neat. and let the patient hold it (if conscious and 2.2.2. Right Shoulder Shoulder is isisinjured. injured. 2.Right Right Shoulder is injured. Right Shoulder injured. Hold Hold one one end end and and leave leave it itit it cooperative) Hold one end and leave Hold one end and leave onon the the unaffected unaffected shoulshoulon the unaffected shoulon the unaffected shoul3. Pull the bandage towards the affected shoulder der der (left (left hip) hip) and and letlet der (left hip) and letthe the der (left hip) and letthe the going to the back and to the armpit. 4. Pull patient patient hold hold it itit(ifit(if patient hold (ifconconpatient hold (ifconconUNIT UNIT scious scious and and cooperative) cooperative) the end going to front and back on the injured UNIT UNIT333 3 scious and cooperative) scious and cooperative) 33 3.3.3. Pull the the bandage bandage towards towards 3.Pull Pull the bandage towards Pull the bandage towards DAY 19 DAY 19 shoulder forming an “X” over the injury. 19 DAY DAY19 19 9 the the affected affected shoulder shoulder gogothe affected shoulder gothe affected shoulder 5. Let the end pass through the back and meet ing ing to to the the back back and and toto the the ing to the back and to the ing to the back and to the one end at the unaffected shoulder, tie both armpit. armpit. armpit. armpit. 4.Pull Pull the end going to front Pull the end going to front 4.4.4. Pull the the end end going going toto front front ends using square knot. Tuck the excess to and back on the injured and back onthe the injured and and back back onon the injured injured make the bandage neat. SHOULDER BANDAGE SHOULDER BANDAGE shoulder forming shoulder forming anan shoulder shoulder forming forming anan “X” “X”“X” SHOULDER SHOULDER BANDAGE BANDAGE 1. Same Same procedure with Hip over the injury over the injury Same procedure with Hip over over the the injury injury 1.1. 1. Same procedure procedure with with Hip Hip 5.Let Let the end pass through Let the end pass through Bandage. Semi-Broad CraBandage. Semi-Broad Cra5.5.5. Let the the end end pass pass through through Bandage. Bandage. Semi-Broad Semi-Broad CraCrathe back and meet the the back and meet vat is to be used. This vat is to be used. This the the back back and and meet meet the the vatvatis isto tobebeused. used.This Thisis isis is one end at the unaffected one end at the unaffected netttn ed ne dd edd d f offfroo orrr o p ee nn dd ee oo ee one one end end atat the the unaffected unaffected i niiitnn op ep pn enn n shoulder, both ends shoulder, tietie both ends wounds and not for dislowounds and not for disloshoulder, shoulder, tietie both both ends ends wounds wounds and and not not forfor dislodislousing square knot. Tuck using square knot. Tuck cations and/or fractures. cations and/or fractures. using usingsquare squareknot. knot.Tuck Tuck cations cations and/or and/or fractures. fractures. the excess tomake make the 2. the excess tomake make the 2. Right Right Shoulderis isis injured. Right Shoulder injured. the the excess excess toto the the 2. 2. Right Shoulder Shoulder isinjured. injured. bandage neat. bandage neat. Hold one end and leave Hold one end and leave bandage bandage neat. neat. Hold Hold one one end end and and leave leave it itit it on the the unaffected unaffected shoulshoulon ononthetheunaffected unaffectedshoulshoulder (left (left hip) hip) and and let let the the der derder(left (lefthip) hip)and andletletthethe patient hold hold it (if conconpatient patient patienthold holdit itit(if(if (ifconconsciousand andcooperative) cooperative) scious scious scious and and cooperative) cooperative) UNIT UNIT33 3. Pull Pull the the bandage bandage towards towards 3. 3. 3. Pull Pull thethe bandage bandage towards towards the affected affected shoulder shoulder gogothe DAY DAY19 19 thethe affected affected shoulder shoulder go-goingto tothe theback backand andto tothe the ing inging to to thethe back back and and to to thethe armpit. armpit. armpit. armpit. 4. Pull Pullthe theend endgoing goingto tofront front 4. 4. 4. Pull Pull thethe end end going going to to front front and back back on on the the injured injured and and andback backononthetheinjured injured shoulder forming forming an an “X” “X” shoulder shoulder shoulderforming forminganan“X”“X” SHOULDER SHOULDERBANDAGE BANDAGE overthe theinjury injury over over over the the injury injury 1.1. Same Same procedure procedure with with Hip Hip 5. Let Let the the end end pass pass through through 5. ² Limmer ² Limmer (Brady) (Brady) 5. 5. LetLet thethe end end pass pass through through Bandage. Bandage.Semi-Broad Semi-BroadCraCra³ Pollack, ³ Pollack, (AAOS) (AAOS) the back back and and meet meet the the the ⁴ NHTSA ⁴ NHTSA the the back back and and meet meet thethe vat vat isis to to be be used. used. This This isis one end end at at the the unaffected unaffected one one one end end at at the the unaffected unaffected in i nt teennddeedd f foorr ooppeenn shoulder, tie tie both both ends ends shoulder, shoulder, shoulder,tietieboth bothends ends wounds woundsand andnot notfor fordislodislousing square square knot. knot. Tuck Tuck using using usingsquare squareknot. knot.Tuck Tuck cations cationsand/or and/orfractures. fractures. the excess excess to to make make the the the thetheexcess excessto tomake makethethe 2.2. Right Right Shoulder Shoulder isis injured. injured. bandageneat. neat. bandage bandage bandage neat. neat. Hold Holdone oneend endand andleave leaveitit

SHOULDER BANDAGE

NDAGE DER BANDAGE

ing to the back and to the armpit. Pull the end going to front and back on the injured shoulder forming an “X” over the injury Let the end pass through the back and meet the one end at the unaffected shoulder, tie both ends using square knot. Tuck the excess to make the bandage neat.

SHOULDER SHOULDER BANDAGE SHOULDERBANDAGE BANDAGE SHOULDER BANDAGE 5.

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTIC

SHOULDER SHOULDERBANDAGE BANDAGE

SHOULDER BANDAGE SHOULDER BANDAGE SHOULDER SHOULDERBANDAGE BANDAGE

CE CE

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE

UNIT 3 DAY 19

PRINCIPLES OF EMT C

SHOULDER B

SHOULDER SHOULDER BANDAGE BANDAGE

on on the the unaffected unaffected shoulshoulder der (left (left hip) hip) and and let let the the patient patient hold hold itit (if(if conconscious sciousand andcooperative) cooperative) 3.3. Pull Pullthe thebandage bandagetowards towards the the affected affected shoulder shoulder gogoing ingto tothe theback backand andto tothe the armpit. armpit. 4.4. Pull Pullthe theend endgoing goingto tofront front and and back back on on the the injured injured shoulder shoulder forming forming an an “X” “X” over overthe theinjury injury 5.5. Let Let the the end end pass pass through through the the back back and and meet meet the the one oneend endatatthe theunaffected unaffected shoulder, shoulder, tie tie both both ends ends using using square square knot. knot. Tuck Tuck the the excess excess to to make make the the bandage bandageneat. neat.

EMT CLINICAL PRACTICE

DER BANDAGE

² Limmer (Brady) ³ Pollack, (AAOS) ² Limmer (Brady) ⁴ NHTSA ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴² Limmer NHTSA ⁴ NHTSA ² Limmer (Brady) (Brady)

³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

SHOULDER BANDAGE 1. Same procedure with Hip Bandage. Semi-Broad Cravat is to be used. This is intended for open wounds and not for dislocations and/or fractures. 2. Right Shoulder is injured. Hold one end and leave it on the unaffected shoulder (left hip) and let the patient hold it (if conscious and cooperative) 3. Pull the bandage towards the affected shoulder going to the back and to the armpit. 4. Pull the end going to front and back on the injured shoulder forming an “X” over the injury 5. Let the end pass through the back and meet the one end at the unaffected shoulder, tie both ends using square knot. Tuck the excess to make the bandage neat.

Limmer(Brady) (Brady) ² ²Limmer Pollack, (AAOS) ³ ³²Pollack, (AAOS) ² Limmer Limmer (Brady) (Brady) NHTSA ⁴ ⁴³NHTSA ³ Pollack, Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

473

the back and interchange the back and interchange it while pulling it again it while pulling it again to to thefront. front.TieTieit itusing using the square knot. square knot. Tuck ends make 3. 3. Tuck thethe ends to to make thethe bandage neat. UNIT bandage neat. UNIT 3

it while pulling it again to the front. Tie it using square knot. Tuck the ends to make the bandage neat.

UNIT UNIT3 UNIT 33 DAY DAY19 19 P DAY 19

PRINCIPLES OF EMT EMTCLINICAL CLINICAL PRACTICE PRINCIPLES OF EMT PRACTICE CLINICAL PRACTICE Day 19 OF ES OF EMT CLINICALDAY PRACTICE DAY 1919PRINCIPLES EYE EYE BANDAGE BANDAGE EYE BANDAGE EYE BANDAGE 1. Narrow Cravat 1. Narrow NarrowCravat Cravatis isto tobe be 1. 1. Narrow Cravat is is toto bebe used. used. Place Place the the middle middle of used. Place the middle of used. Place the middle ofof the the bandage top thebandage bandageon ontop topof of the bandage onon top ofof both both eyes (regardless botheyes eyes(regardless (regardlessof of both eyes (regardless ofof what what eye eye has has an an injury). injury). what eye has injury). what eye has anan injury). 2. Pull both ends towards 2. Pull Pullboth bothends endstowards towards 2. 2. Pull both ends towards the the back back and and interchange interchange the back and interchange the back and interchange itit while it pulling pulling itit again it to it while while pulling it again again to while pulling again toto the the front. using thefront. front.Tie Tieitit ititusing using the front. TieTie using square square knot. Careful not squareknot. knot.Careful Carefulnot not square knot. Careful not to put pressure the toput putpressure pressureon onthe the toto put pressure onon the eyes, eyes, better better to tie itit above it eyes, better to tie it above above eyes, better toto tietie above the the eye eye or at the the center center of the eye or at the center of the eye oror atat the center ofof the the forehead forehead the forehead the forehead UNIT 3 3. 3. Tuck Tuck the the ends ends to make make the the Tuck the ends to make the 3. 3. Tuck the ends toto make the DAY 19 bandage bandage neat. neat. bandage neat. bandage neat.

FOREHEAD FOREHEAD BANDAGE UNIT3 3BANDAGE UNIT

OREHEAD BANDAGE FOREHEAD FOREHEAD BANDAGE BANDAGE 1. 1.Narrow Narrow Cravat Cravat is to is to be be used. used. Place Place thethe middle middle of of thethe bandage bandage on on toptop of the of the forehead forehead or or where where thethe injury injury is. is. 2. 2.PullPull both both ends ends towards towards thethe back back andand interchange 1. Narrow Cravat isinterchange to be used. it while it while pulling it again it again to to Place thepulling middle of theusing thethefront. front.Tie Tieit itusing bandage on top of the forehead square square knot. knot. or where theends injury is.thethe 3. 3. Tuck Tuck thethe ends to make to make bandage bandage neat. 2. Pull bothneat. ends towards the

FOREHEAD BANDAGE

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTIC DAY1919PRINCIPLES DAY FOREHEADBANDAGE BANDAGE FOREHEAD

FOREHEAD BANDAGE FOREHEAD BANDAGE NarrowCravat Cravatis isto tobebe 1. 1. Narrow used. Place middle used. Place thethe middle of of bandage thethe bandage onon toptop of of thethe foreheador orwhere wherethethe forehead injury injury is. is. bothends endstowards towards 2. 2. PullPullboth back and interchange thethe back and interchange it while pulling it again it while pulling it again to to front.TieTieit itusing using thethefront. square knot. square knot. Tuck ends make 3. 3. Tuck thethe ends to to make thethe bandage neat. bandage neat.

back and interchange it while pulling it again to the front. Tie it using square knot. 3 3ends to make the UNIT 3. UNIT Tuck the PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY 19 DAY 19neat. bandage

FOREHEAD FOREHEADBANDAGE BANDAGE

OREHEAD BANDAGE FOREHEAD BANDAGE . 1.Narrow Cravat is is to to be be Narrow Cravat used. Place thethe middle of of used. Place middle thethe bandage on on toptop of the bandage of the forehead foreheador orwhere wherethethe injury is. is. injury . 2.PullPullboth bothends endstowards towards thethe back andand interchange back interchange it while pulling it again to to it while pulling it again thethefront. front.TieTieit itusing using square knot. square knot. . 3.Tuck thethe ends to make thethe Tuck ends to make bandage neat. bandage neat.

FOREHEAD BANDAGE 1. Narrow Cravat is to be used. Place the middle of the bandage on top of the forehead or where the injury is. 2. Pull both ends towards the back and interchange it while pulling it again to the front. Tie it using square knot. 3. Tuck the ends to make the bandage neat.

CLINICAL PRACTICE

PRINCIPLES OF EMT

FOREHEAD

UNIT 3 3 UNIT PR DAY 1919 DAY

D BANDAGE ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer (Brady) (Brady)

³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

474

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

Limmer (Brady) EYE³² EYE BANDAGE BANDAGE Pollack, (AAOS) NHTSA 1. ⁴ 1. Narrow Cravat is tois be Narrow Cravat to be used. Place the the middle of of used. Place middle the the bandage on on top top of of bandage bothboth eyeseyes (regardless of of (regardless what eye eye has has an injury). what an injury). 2. 2. Pull Pull bothboth endsends towards towards the the backback and and interchange interchange it while pulling it again to to it while pulling it again the the front. Tie Tie it using front. it using square knot.knot. Careful not not square Careful to put pressure on on the the to put pressure eyes,eyes, better to tie above better toittie it above the eye or atorthe of of the eye at center the center the forehead the forehead 3. 3. TuckTuck the ends to make the the the ends to make bandage neat.neat. bandage

put pressure pressure on on the the toto put eyes,better bettertototietieit itabove above eyes, theeye eyeororatatthe thecenter centerofof the theforehead forehead the Tuckthe theends endstotomake makethe the 3.3. Tuck bandageneat. neat. bandage

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE EYE EYEBANDAGE BANDAGE

CE E

EYE BANDAGE 1. Narrow Cravat is to be used. Place the middle of the bandage on top of both eyes (regardless of what eye has an injury). 2. Pull both ends towards the back and interchange it while pulling it again to the front. Tie it using square knot. Careful not to put pressure on the eyes, better to tie it above the eye or at the center of the forehead 3. Tuck the ends to make the bandage neat.

UNIT UNIT 3 3 PRINCIPLES OF EMT CLINICAL PRACTIC OF EMT CLINICAL PRACTICE DAY DAY 1919PRINCIPLES

T CLINICAL PRACTICE

D BANDAGE

BANDAGE EYEEYE BANDAGE Narrow Cravat is to 1. 1.Narrow Cravat is to be be used. Place middle used. Place the the middle of of bandage the the bandage on on toptop of of both (regardless both eyeseyes (regardless of of what an injury). what eyeeye hashas an injury). both ends towards 2. 2.PullPull both ends towards back interchange the the back andand interchange it while pulling it again it while pulling it again to to front. it using the the front. Tie Tie it using square knot. Careful square knot. Careful notnot pressure to to putput pressure on on the the eyes, better to ittieabove it above eyes, better to tie orthe at the center the the eyeeye or at center of of forehead the the forehead Tuck ends to make 3. 3.Tuck the the ends to make the the bandage neat. bandage neat.

EYE BANDAGE EYE BANDAGE

RINCIPLES OFOF EMT CLINICAL PRACTICE PRINCIPLES EMT CLINICAL PRACTICE EYE BANDAGE EYE BANDAGE ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ²² Limmer (Brady) (Brady) Limmer (Brady) ² Limmer (Brady) ³ Pollack, ³³ Pollack, (AAOS) (AAOS) Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴⁴ NHTSA NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

475

2.2. Place Placethe themiddle middlepart partofof 2. 2.Place Place thethe middle middle partpart of of the the bandage bandage over over the the thethebandage bandageover overthethe affected side. affected side. affected affected side. side. 3.3. Pull Pullone oneend endgently gentlyover over 3. 3.PullPull oneone endend gently gently over over the thetop topofofthe thehead headwhile while thethe toptop of the of the head head while while theother otherend endwill willpass pass the thethe other other endend willwill pass pass belowthe thechin chin below below below thethe chin chin ARM ARM && THIGH THIGH BANDAGE BANDAGE 4. Let the two ends meet 4. Let the two ends meet atat 4. 4.LetLet thethe twotwo ends ends meet meet at at UNIT UNIT 33 theunaffected unaffectedarea areaand and the thethe unaffected unaffected area area andand Day 19 1. 1. Narrow Narrow Cravat Cravat is istot interchangeit itabove abovethe the interchange interchange interchange it above it DAY above the19 the DAY 19 & JAW EAR, CHEEK, & JAW EAR, CHEEK, unaffectedear. ear. unaffected used. used. This This technique techniqu unaffected unaffected ear.ear. BANDAGE BANDAGE Pullone oneend endpassing passingover over 5.5. Pull 5. 5.PullPull oneone endend passing passing over over similarly similarly applied applied toto Narrow Cravatis isto tobebe 1. 1.and Narrow the forehead forehead and and the the the thetheforehead forehead and thetheCravat used. Left Ear/Cheek/Jaw other end will pass other end will pass used. Left Ear/Cheek/Jaw ARM & THIGH BANDAGE other otherendendwillwillpass pass arm armand andthigh thighif ifit itis i throughthe theback. back. through is injured. through through thethe back. back. is injured. 1. Narrow Cravat is to be injured injured part. part. EAR, EAR, CHEEK, CHEEK, & & JAW JAW 6. Let the two ends meet at 6. Let the two ends meet at 6. 6.Let Let thethe two two ends ends meet meet at at 2. Place the middle part of 2. Place the middle part of used. This technique is BANDAGE BANDAGE theaffected affectedside sideand andtietieit it the thethe affected affected sideside and and tiebandage tie it bandage it 2. Right Right Arm Arm is is Injur Inj the overthethe the over similarly applied to 2. the 1. 1. using Narrow Narrow Cravat is isto tobe be usinga asquare squareknot. knot.Tuck Tuck using using a square aCravat square knot. knot. Tuck Tuck affected side. affected side. arm and thigh if it is the Leave Leave one one end end at at used. used. Left Left Ear/Cheek/Jaw Ear/Cheek/Jaw the excess to make the the excess to make the thethe excess excess to to make make thethe Pull one end gently over 3. 3. Pull one end gently over is is injured. injured. bandageneat. neat. bandage injured part. bandage bandage neat. neat. shoulder shoulder area, area, meas me the top head while 2. 2. Place Placethe themiddle middle part part of of the top of of thethe head while 2. Right Arm is Injured. the the bandage bandage over over the the theother otherend endwillwillpass pass the length length ofof the the arm arm u the Leave one end at the the affected affected side. side. chin 1. Narrow Cravat is to below bebelow thethe chin the arm arm folds folds (antecub (antec shoulder area, measure the 3. 3. Pull Pullone oneend endgently gently over over ends meet 4. 4. LetLet thethe meet at at used. Left Ear/Cheek/Jaw istwotwoends the length of the arm until area) the the top topofofthe thehead headwhile while area)ororuntil untilyou yourer theunaffected unaffectedarea areaand and the theother otherend endwill willpass pass the arm folds (antecubital injured. the interchange it above the interchange it above the the thelocation locationofofinjury. injury( below below the the chin chin area) or until you reach unaffected ear. 2. Place4.the middle part of the unaffected 4. Let Let the thetwo twoends ends meet meet atat ear. timethe themeasuremen measureme the location of injury. (this time UNIT UNIT3 3 5.area Pull one end passing over theunaffected unaffected area and and 5.affected Pull one end passing over bandagethe over the time the measurement is up interchange interchangeit itabove above the up toto the the antecubital antecubital ar thethe foreheadand andthethe DAY DAY1919 the forehead side. unaffected up to the antecubital area. unaffected ear. ear. other other end end will will pass pass 3. 3. Fold Fold the the bandage bandage upw up 5. 5. Pull Pullone oneend endpassing passing over over the back. 3. Fold the bandage upward through 3. Pull one end gently over the through the back. EAR,EAR, CHEEK, CHEEK, & JAW & JAW the the forehead forehead and and the the andslightly slightlyturn turnit itgog and slightly turn it going and Let the two ends meet 6. 6. Let the two ends meet at at BANDAGE BANDAGE top of the headend while the other other end will will pass pass to your right to form a totoyour affected side and yourright righttotoform fo thethe affected side and tietie it it 1. 1.Narrow through through the the back. back. Narrow Cravat Cravat is to is to be be other6.end will pass below small triangle. using a square knot. Tuck EAR, EAR, CHEEK, CHEEK, & JAW & JAW using athe square knot. Tuck 6. Let Letthe thetwo twoends ends meet meetat at used. used. LeftLeft Ear/Cheek/Jaw Ear/Cheek/Jaw small small triangle. triangle. BANDAGE BANDAGE 4. The end that is in the dithe makethethe affected side side and and tie tie itexcess it chin. thetheaffected the excess to tomake is injured. is injured. 1. 1. Narrow NarrowCravat Cravatis isto tobebe 4.4. The Theend endthat thatis isininthe th using usinga asquare squareknot. knot. Tuckneat. bandage neat. rection of the small trianbandage 4. Let the two ends meet atTuck 2. 2.Place Place the the middle middle part part ofEar/Cheek/Jaw of used. used. Left Left Ear/Cheek/Jaw the theexcess excesstotomake makethe the gle will be used to encircle rection rection of of the the small small tr the the bandage bandage over the the is injured. isover injured. bandage bandage neat. neat. and the unaffected area the affected area until the gle 2. side. 2. Place Placethethemiddle middlepart partof of affected affected side. gle will will bebe used used toto enci en interchange it above the end is consumed enough the the bandage bandage over overthethe 3. 3.PullPull oneone endend gently gently overover the the affected affected area area until unt affected affected side. side. to tie it afterwards. unaffected ear. the the top top of the of the head head while while 3. 3. Pull Pull one one end end gently gently over over 5. Take the other end that end endis isconsumed consumedenou en the the other other end end will will pass pass 5. Pull one end passing over the thethe toptop of of thethe head head while while was left at the shoulder toto below below the the chinthe chin tietie it afterwards. it afterwards. theother otherend endwillwillpass pass forehead and the other end area, fold it slightly to4. 4.Let Let the the twotwo ends ends meet meet atchinat below below thethe chin 5.5. Take Takethe theother otherend endt wards your left (opposite will pass through the back. the the unaffected unaffected area area and and 4. 4. LetLet thethe two two ends ends meet meet at at the direction you made the the unaffected unaffected area area and and was was left left at at the the shou sho interchange interchange it above it above the the 6. Let the two ends meet at the interchangeit itabove abovethethe with the first end) to form area, unaffected unaffected ear.interchange ear. area, fold fold it it slightly slightl affected side and tie it using a unaffected unaffected ear. ear. a small triangle. 5. 5.PullPull oneone endend passing passing over over 5. 5. Pull Pull one one end end passing passing over over wardsyour yourleft left(oppo (opp square knot. Tuck the excess 6. Encircle the area until the wards the the forehead forehead and and the the thethe forehead forehead and andthethe thedirection directionyou youmm other otherendend will willend pass pass end is also consumed the to make the bandage neat. other other end will will pass pass through through the the back. back. thethe through through back. back. EAR, CHEEK, & JAW withthe thefirst firstend) end)totofo EAR, CHEEK, & JAW EAR, CHEEK, enough & JAW to tie together with 6.two 6.ends LetLet the the two two ends meet at at 6. 6.Let Let the the two ends meet meet atends at meet ² Limmer (Brady) with the other end using BANDAGE BANDAGE ² Limmer (Brady) BANDAGE ² Limmer ² Limmer (Brady) (Brady) a small a small triangle. triangle. ³ Pollack, (AAOS) thethe affected affected side and tietie it it ³ Pollack, (AAOS) ³ Pollack, ³ Pollack, (AAOS) (AAOS) the the affected affected side side and and tie it tieside itand a square ⁴ NHTSA Cravat 1.Narrow Narrow Cravat is to ⁴ NHTSA Cravat is to be be 1. Narrow is to knot. be ⁴ NHTSA ⁴ NHTSA using using a square aTuck square knot. knot. Tuck Tuck using using a square a square knot. knot. Tuck 6. Encircle Encirclethe thearea areauntil unt 7. Tuck the excess ends6.to used. Ear/Cheek/Jaw used. LeftLeft Ear/Cheek/Jaw thetheexcess excessto tomake makethethe used. Left Ear/Cheek/Jaw the the excess excess to make to make the the make the bandage neat. end is injured. is injured. end is is also also consum consu bandage bandage neat. neat. is injured.

UNIT3 3 UNIT PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY1919PRINCIPLES DAY UNIT 3 DAY 19

PRINCIPLES O EAR, CHEEK & JAW BANDAGE EAR, PRINCIPLES CHEEK & JAW BANDAGE OF EMT CLINICAL PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE ARM &

EAR, CHEEK, & JAW BANDAGE

EAR, EAR,CHEEK CHEEK&&JAW JAWBANDAGE BANDAGE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

UNIT UNIT 3 3 PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE DAY DAY 1919PRINCIPLES

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

EAR, EAR, CHEEK CHEEK && JAW JAW BANDAGE BANDAGE

EAR, EAR,CHEEK CHEEK&&JAW JAWBANDAGE BANDAGE

UNIT UNIT 33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 1919PRINCIPLES

EAR,CHEEK CHEEK&&JAW JAWBANDAGE BANDAGE EAR,

2.Place Place middle thethe middle partpart of of bandageover overthethe thethebandage affected side. affected side. 3.PullPull gently over oneone endend gently over of the head while thethe toptop of the head while other pass thethe other endend willwill pass below chin below thethe chin 4.Let Let ends meet thethe twotwo ends meet at at unaffected area thethe unaffected area andand interchange it above interchange it above thethe unaffected unaffected ear.ear. 5.PullPull passing over oneone endend passing over foreheadandandthethe thetheforehead otherendendwillwillpass pass other through back. through thethe back. 6.Let Let ends meet thethe twotwo ends meet at at affected thethe affected sideside andand tie tie it it using a square knot. Tuck using a square knot. Tuck excess make thethe excess to to make thethe bandage neat. bandage neat.

bandage bandage neat. neat.

T CLINICAL PRACTICE JAW BANDAGE

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

476

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

UNIT 3 DAY 19

PRINCIPLES OF EMT C

UNITEAR, 3 CHEEK & JA DAY 19 PRINCIPLES O

Checkpart for of PMS to ensure Place the middle ARMthat & over THIGH BANDAGE the applied force and the bandage the 1. tightness Narrow Cravat is to is enough. If itbe is affected side. used. This technique is tight repeat the proce3. Pull one end too gently over similarly applied to force the lessen the the top of thedure headand while 7. 7. armwill andpass thigh if it is the applied. the other end injured part. below the chin 2. ends Rightmeet Arm 4. Let the two at is Injured. Leave the unaffected area one and end at the area, measure interchange itshoulder above the the length of the arm until unaffected ear. the armover folds (antecubital 5. Pull one end passing the foreheadarea) andor the until you reach other end the will pass of injury. (this location through the back. time the measurement is 6. Let the two ends at up tomeet the antecubital area. the affected it 3. side Foldand thetie bandage upward using a square knot. Tuck turn it going and slightly the excess toto make your the right to form a bandage neat.small triangle. 4. The end that is in the direction of the small triangle will be used to encircle the affected area until the end is consumed enough to tie it afterwards. 5. Take the other end that was left at the shoulder area, fold it slightly towards your left (opposite ² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) the direction you made ⁴ NHTSA ⁴ NHTSA with the first end) to form a small triangle. 6. Encircle the area until the end is also consumed ² Limmer ² Limmer (Brady)(Brady) enough to tie together ³ Pollack, ³ Pollack, (AAOS)(AAOS) ⁴ NHTSA ⁴ NHTSA with the other end using a square knot. 7. Tuck the excess ends to make the bandage neat. Check for PMS to ensure that the applied force and 2.

ARM &

enough enoughtototietietoget tog with withthe theother otherend endus a square a square knot. knot. Tuck Tuckthe theexcess excessends end make makethe thebandage bandagen Check CheckforforPMS PMStotoens e that thatthe theapplied appliedforce forcea tightness tightnessis isenough. enough.If too too tight tight repeat repeat the the pro p dure dureand andlessen lessenthe thefo applied. applied.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

thethe length of the arm until length of the arm until thethe arm folds (antecubital arm folds (antecubital area) or or until youyou reach area) until reach thethe location of of injury. (this location injury. (this time thethe measurement is is time measurement upup to the antecubital area. to the antecubital area. 3. 3.Fold thethe bandage upward Fold bandage upward and slightly turn it going and slightly turn it going to to your right to to form a a your right form small triangle. small triangle. 4. 4.TheThe end that is in thethe di- diend that is in rection of of thethe small trianrection small trianglegle willwill be be used to encircle used to encircle thethe affected area until thethe affected area until end is consumed enough end is consumed enough to tie it afterwards. to tie it afterwards. 5. 5.Take thethe other end that Take other end that was leftleft at at thethe shoulder was shoulder area, area,fold foldit itslightly slightlyto- towards your leftleft (opposite wards your (opposite thethedirection directionyouyoumade made with thethe firstfirst end) to to form with end) form a small triangle. a small triangle. 6. 6.Encircle thethe area until thethe Encircle area until UNIT 33 UNIT end endis isalso alsoconsumed consumed DAY 19 DAY 19 enough enoughto totie tietogether together with thethe other end using with other end using a square knot. a square knot. 7. 7.Tuck thethe excess ends to to Tuck excess ends make thethe bandage neat. make bandage neat. Check forfor PMS to to ensure PMS ensure ARM &Check THIGH BANDAGE ARM & THIGH BANDAGE that thethe applied force and that applied and 1. 1. Narrow Cravat Narrow Cravatis force istotobe be tightness is enough. If itIfisit is tightness istechnique enough. used. This is is used. This technique tootoo tight repeat the procetightapplied repeat the similarly totoprocethe similarly applied the dure and lessen the force dure and lessen force arm and thigh if ifitthe is isthe arm and thigh it the applied. applied. injured part. injured part.

and slightly turn it going to your right to form a small triangle. UNIT 3 4. The end that is in the diOF EMT CLINICAL PRACTICE DAY 19 PRINCIPLES OF EMT CLINIC rection of the small trianE gle will be used to encircle tobebe the affected area until the eue is is ARM & THIGH BAN THIGH BANDAGE end is consumed enough o& the the ARM & THIGH BANDAGE to tie it afterwards. isthe the 1. Narrow Cravat is to be 5. Take the other end used. that This technique is was left at the similarly shoulder applied to the jured. red. arm andtothigh if it is the area, fold it slightly t the the injured part. wards your left easure sure 2. (opposite Right Arm is Injured. the direction you made Leave one end at the m until until with the first end)shoulder to formarea, measure bital ubital length of the arm until a small triangle. the each reach E the arm folds (antecubital 6. Encircle the area area) untilorthe y.(this (this until you reach the location of injury. (this end is also consumed nt entis is time the measurement UNITis 3 Erea. enough to CLINICAL tie together PRACTICE area. PRINCIPLES PRINCIPLESOF OFEMT EMT CLINICAL PRACTICE up to the antecubital area. with the other 19 PRINCIPLES OF EMT CLINIC ward pward 3. end Fold using the bandageDAY upward and slightly turn it going a square knot. oing going your to right to form a 7. Tuck the excess toends orm m aa small triangle. ARM & THIGH BANDAGE ARM & THIGH BANDAGE make the bandage neat. ARM & THIGH BAN 4. The end that is in the direction of the small trianCheck for PMS to ensure ehedi-diARM & THIGH BANDAGE gle will be used to encircle that the applied riantrian1. force Narrowand Cravat is to be the affected area until the used. is tightness is enough. If This it is technique ncircle ircle end is consumed enough similarly applied to the too tight repeat the proceto tie it afterwards. tilthe the it is that the 5. arm Takeand the thigh otherif end dure and lessen the force nough ugh injured part. 2. 2. Right was left at the shoulder Right Arm Arm is is Injured. Injured. 2. Right Arm is Injured. applied. Leave area, fold it slightly toLeaveone oneend endatatthe the Leave one end at the shoulder dthat that wards your left (opposite shoulder area, area, measure measure shoulder area,you measure CLINICAL PRACTICE the length ofof the arm until the direction made the length the arm until ulder oulder the length of the arm the with the first end) to until form thearm armfolds folds(antecubital (antecubital the armtriangle. folds (antecubital lyto-toarea) a small area)ororuntil untilyou youreach reach area) or until you reach osite posite the location ofof injury. (this 6. Encircle the area until the the location injury. (this the location of injury. (this time AW end is also consumed timethe themeasurement measurementis is made madeBANDAGE time the measurement is OF EMT CLINICAL PRACTICE upup toto the antecubital area. enough to tie together the antecubital area. oorm form up to the 3. 3. Fold the bandage upward with the antecubital other end area. using Fold the bandage upward

ARM ARM &&THIGH THIGHBANDAGE BANDAGE

sdstoto neat. neat. ensure sure eand and Ifit itis is proceoceorce force

and andslightly slightlyturn turnit itgoing going

totoyour yourright righttotoform forma a tilthe the small triangle. small triangle. & THIGH BANDAGE med umed 4. 4. The Theend endthat thatis isin inthe thedi-digether ther rection rectionofofthe thesmall smalltriantrianglegle will bebe used toto encircle will used encircle sing using

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

the affected area until the the affected area until the end endis isconsumed consumedenough enough toto tietie it afterwards. it afterwards. 5. 5. Take Takethe theother otherend endthat that was wasleft leftatatthe theshoulder shoulder area, area,fold foldit itslightly slightlyto-towards wardsyour yourleftleft(opposite (opposite the thedirection directionyou youmade made with the first end) toto form with the first end) form a small triangle. a small triangle. 6. 6. Encircle Encirclethe thearea areauntil untilthe the end end is is also also consumed consumed enough enoughtototietietogether together with withthe theother otherend endusing using a square knot. a square knot. 7. 7. Tuck Tuckthe theexcess excessends endstoto make makethe thebandage bandageneat. neat. Check CheckforforPMS PMStotoensure ensure that the applied force and that the applied force and tightness is is enough. If If it it is is tightness enough. too tight repeat the procetoo tight repeat the procedureand andlessen lessenthe theforce force 1.dure Narrow Cravat is to be used. This technique is similarly applied. applied.

ARM & THIGH BANDAGE

applied to the arm and thigh if it is the injured part. 2. Right Arm is Injured. Leave one end at the shoulder area, measure the length of the arm until the arm folds (antecubital area) or until you reach the location of injury. (this time the measurement is up to the

Fold the bandage upward a square knot. turn itends going 7. and Tuckslightly the excess to to your right to form a make the bandage neat. small triangle. Check for PMS to ensure 4. The end that is in the dithat the applied force and rection of isthe small triantightness enough. If it is gle will be used encircle too tight repeatto the procethe area the untilforce the dureaffected and lessen end is consumed enough applied. to tie it afterwards. 5. Take the other end that was left at the shoulder area, fold it slightly² Limmer to- (Brady) ³ Pollack, (AAOS) wards your left (opposite ⁴ NHTSA the direction you made with the first end) to form a small triangle. 6. Encircle the area until the end is also consumed enough to tie together with the other end using a square knot. 7. Tuck the excess ends to make the bandage neat. Check for PMS to ensure ² Limmer (Brady) that the applied force and ³ Pollack, (AAOS) ⁴ NHTSA tightness is enough. If it is too tight repeat the proceantecubital dure and lessenarea. the force 3. applied. Fold the bandage upward and slightly turn it going to

your right to form a small triangle. 4. The end that is in the direction of the small triangle will be used to encircle the affected area until the end is consumed enough to tie it afterwards.

LIFELINE

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady)

PREHOSPITAL EMERGENCY CARE

477

ARM ARM && THIGH THIGH BANDAGE BANDAGE 1. 1. Narrow NarrowCravat Cravatis istotobebe used. used.This Thistechnique techniqueis is similarly similarlyapplied appliedtotothe the arm armand andthigh thighif ifit itis isthe the injured injured part. part. 2. 2. Right Right Arm Arm is is Injured. Injured. Leave Leaveone oneend endat atthe the Day 19 shoulder shoulder area, area, measure measure the the length length ofof the the arm arm until until the thearm armfolds folds(antecubital (antecubital area) area)ororuntil untilyou youreach reach 5. Take the other end that was the the location location ofof injury. injury. (this (this3 UNIT UNIT 3 left at the shoulder area, fold timethe themeasurement measurement is isleft (opposite the direction you ittime slightly towards your DAY DAY 19 19 upup toto the the antecubital antecubital area. area. made with the first end) to form a small triangle. 3. 3. Fold Fold the the bandage bandage upward upward 6. Encircle the area until the and andslightly slightlyturn turnit itgoing going end is also consumed enough to tie with the other tototogether your yourright right totoform form a a end using a square knot. small small triangle. triangle. 4. 4. The Theend endthat thatis isin inthe thedi-diARM ARM&&THIGH THIGHBANDAGE BANDAGE rection rectionofofthe thesmall smalltriantrian1.1. Narrow Narrow Cravat Cravat isis toto be be glegle will will bebe used used toto encircle encircle used. used. This This technique technique isis the the affected affected area area until until the the similarly similarly applied applied toto the the end endis isconsumed consumedenough enough arm armand andthigh thighififititisisthe the toto tietie it afterwards. it afterwards. injured injuredpart. part. 5. 5. Take Takethe theother otherend endthat that 2.2. Right Right Arm Arm isis Injured. Injured. was wasleftleftat atthe theshoulder shoulder Leave Leave one one end end atat the the area, area,fold foldit itslightly slightlyto-toshoulder shoulder area, area, measure measure wards wardsyour yourleftleft(opposite (opposite the thelength lengthofofthe thearm armuntil until the thedirection directionyou youmade made the thearm armfolds folds(antecubital (antecubital with with the the first first end) end) toto form form area) area) oror until until you you reach reach a small a small triangle. triangle. the thelocation locationofofinjury. injury.(this (this 6. 6. Encircle Encircle the the area area until until the the time timethe themeasurement measurementisis end end is is also also consumed consumed up uptotothe theantecubital antecubitalarea. area. enough enoughtototietietogether together 3.3. Fold Foldthe thebandage bandageupward upward with withthe theother otherend endusing using and andslightly slightlyturn turnititgoing going a square a square knot. knot. toto your your right right toto form form aa 7. 7. Tuck Tuckthe theexcess excessends endstoto small smalltriangle. triangle. make makethe thebandage bandageneat. neat. 4.4. The Theend endBANDAGE that thatisisininthe thedidiARM ARM && THIGH THIGH Check CheckBANDAGE forforPMS PMStotoensure ensure rection rection ofofthe the small small triantrian1. 1. Narrow Narrow Cravat Cravat is is to to be be that that the the applied applied force force and and gle gleThis will will be be used usedtotoencircle encircle used. used. This technique technique tightness tightness is is enough. enough. If isit If isis it is the theaffected affected area area until the the similarly similarly applied applied tothe tountil the the too too tight tight repeat repeat the proceproceend end is is consumed consumed enough enough arm arm and and thigh thigh if ifit the itisthe isthe the dure dure and and lessen lessen force force tototie tie itpart. itafterwards. afterwards. injured injured part. applied. applied. 5.5. Take Take the the other other end end that that 2. 2. Right Right Arm Arm is is Injured. Injured. was was left left atat the the shoulder shoulder Leave Leaveone oneend endatatthe the area, area, fold fold itit slightly slightly totoshoulder shoulder area, area, measure measure wards wardsyour your left left (opposite (opposite the the length length ofof the the arm arm until until the the direction direction you you made made the the arm arm folds folds (antecubital (antecubital with with the the first first end) end)totoform form area) area) or oruntil until you youreach reach aasmall small triangle. triangle. the the location location of of injury. injury. (this (this 6.6. Encircle Encirclethe thearea areauntil untilthe the time time the theismeasurement is is end end ismeasurement also also consumed consumed upup to to the the antecubital antecubital area. area. enough enough toto tie tie together together 3. 3. Fold Fold the the bandage bandage upward with with the the other otherupward end end using using and and slightly turn turnit itgoing going aslightly asquare square knot. knot. to yourright right totoform form a to ato 7. 7.toyour Tuck Tuck the the excess excess ends ends make make the the bandage bandage neat. neat. small small triangle. triangle. Check Check for forPMS to tothe ensure ensure 4. 4. The The end endthat that isPMS isin in the di-dithat thatof the the applied applied force force and and rection rection ofthe the small small triantrian² Limmer ² Limmer (Brady) (Brady) tightness tightness isisenough. enough. IfIfititisis ³ Pollack, ³ Pollack, (AAOS) (AAOS) glegle will will bebe used used to to encircle encircle ⁴ NHTSA ⁴ NHTSA too too tight tightrepeat repeat the theproceprocethe the affected affected area area until until the the dure dure and andlessen lessen the theforce force end end is isconsumed consumed enough enough applied. applied. toto tie tie it afterwards. it afterwards. 5. 5. Take Takethe theother otherend endthat that was wasleft leftatatthe theshoulder shoulder area, area,fold foldit itslightly slightlyto-towards wardsyour yourleftleft(opposite (opposite the thedirection directionyou youmade made with with the the first first end) end) toto form form a small a small triangle. triangle. 6. 6. Encircle Encirclethe thearea areauntil untilthe the end end is is also also consumed consumed enough enoughtototietietogether together with withthe theother otherend endusing using a square a square knot. knot. 7. 7. Tuck Tuckthe theexcess excessends endstoto make makethe thebandage bandageneat. neat. Check CheckforforPMS PMStotoensure ensure ² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) that that the the applied applied force force and and ⁴ NHTSA ⁴ NHTSA tightness tightness is is enough. enough. If If it it is is too too tight tight repeat repeat the the proceprocedure dureand andlessen lessenthe theforce force 478 LIFELINE PREHOSPITAL EMERGENCY CARE applied. applied.

Narrow Cravat is to be used. This technique is similarly applied to the arm and thigh if it is the injured part. UNIT 33 UNIT 2. Right Arm is Injured. Leave one end at the DAY 1919 DAY shoulder area, measure the length of the arm until the arm folds (antecubital area) or until you reach location of injury. (this FOREARM & LEG BANDAGE 7. the Tuck the excess ends to make the bandage neat. Check FOREARM & LEG BANDAGE time the measurement is Cravat is is to to be be 1.Narrow Narrow Cravat for to ensurearea. that the applied force and1.tightness is up toPMS the antecubital used. used.ThisThistechnique techniqueis is enough. If it is too tight repeat the procedure and lessen 3. Fold the bandage upward similarly applied to to foresimilarly applied foreand slightlyapplied. turn it going armarm andand legleg if itif isit the ininthe force is the to your right to form a jured part. jured part. 2. 2.Right Forearm is Injured. small triangle. Right Forearm is Injured. Leave oneone endend at hand of of ARM BANDAGE 4. & THIGH The end that is in the diLeave at hand thethe patient, measure thethe 1. Narrow to trianbe patient, measure rectionCravat of the issmall length of the forearm until length of the forearm until used. Thisbe technique is gle will used to encircle thethefolds folds(antecubital (antecubital the affected areatountil similarly applied thethe area) or or until youyou reach area) until reach consumed enough armend andis thigh if it is the thethe location of injury. (this location of injury. (this to tiepart. it afterwards. injured time thethe measurement is is time measurement Take Arm the other end that 2. 5.Right is Injured. up up to the antecubital area. to the antecubital area. was one left atend the atshoulder Leave the 3. 3.Fold thethe bandage downFold bandage downarea, fold it slightly toward andand slightly turn it it shoulder area, measure ward slightly turn leftarm (opposite going to to your leftleft to form going your to form thewards lengthyour of the until you made a small triangle. a small triangle. thethe armdirection folds (antecubital 4. 4.TheThe endend that is in di- diwith first you end) reach to form that is the in the area) orthe until rection of of thethe small triansmall triangle. rection small trianthealocation of injury. (this glegle willwill be be used to encircle used to encircle 6. Encircle the area until the time the measurement is thethe affected area until thethe affected area until end is also consumed up to the antecubital area. endend is consumed enough is consumed enough enough to tie together to tie it afterwards. 3. Foldwith the the bandage to tie it afterwards. other upward end using 5. 5.Take thethe other endend that anda square slightlyknot. turn it going Take other that waswas leftleft at the hand of the at the hand of the your the rightexcess to form 7.to Tuck endsa to patient, foldfold it slightly to- topatient, it slightly small triangle. make the bandage neat. wards your right (opposite wards your right (opposite 4. TheCheck end that is in the difor PMS to ensure thethe direction youyou made direction made ARMrection & THIGH of BANDAGE the smallforce trianthat the applied and with thethe firstfirst end) to form with end) to form 1. gle Narrow Cravat is to be will be used to encircle tightness is enough. If it is a small triangle. a small triangle. used. This repeat technique UNIT 3 6. 6.Encircle the affected area until theis thethe area until thethe too tight the proceEncircle area until similarly applied to endendis isalsoalsoconsumed end is consumed dure and lessenenough the the force consumed DAY 19 arm and thigh if it is the enough enoughto totie tietogether together applied. to tie it afterwards. with thethe other endend using injured part. with other using 5. Take the other end that a square knot. a square knot. 2. was RightleftArm is shoulder Injured. at the 7. Tuck the excess ends to to 7. Tuck the excess ends Leave fold one it end at the area, slightly tomake thethe bandage neat. make bandage neat. shoulder area, measure wards your left (opposite Check for for PMS to to ensure Check PMS ensure FOREARM the length of the arm until & LEG BANDAGE the direction you that thethe applied force andand that applied force 1.made Narrow Cravat is to be the arm foldsend) (antecubital tightness is enough. If with the first to form tightness is enough.itIfisit is used. This technique is until you reach tootoo tight repeat thethe proceaarea) smallor triangle. tight repeat procesimilarly applied to foredure andand lessen thethe force the location of injury. dure lessen force arm and leg if it is the in6. Encircle the area until (this the applied. time the measurement is part. applied. jured end is also consumed 2. area. Right Forearm is Injured. up to the to antecubital enough tie together Leave one end at hand of 3. with Fold the the bandage other endupward using the patient, measure the slightly aand square knot.turn it going of the forearm until to your formlength 7. Tuck the right excessto ends toa folds (antecubital the small triangle. make the bandage neat. area) or until you reach UNIT 33 4. Check The end in ensure thethe di-location of injury. (this UNIT forthat PMSis to ² Limmer (Brady) rection the small time the measurement ³ Pollack, (AAOS) is that the of applied forcetrianand DAY 19 DAY 19 ⁴ NHTSA gle will beisused to encircle tightness enough. If itupisto the antecubital area. 3.proceFold the tight affected area until the the bandage downtoo repeat the ward and slightly turn it end isand consumed enough dure lessen the force going to your left to form to tie it afterwards. applied. a small triangle. 5. Take the other end that 4. The end that is in the diFOREARM & LEG BANDAGE FOREARM & LEG BANDAGE was left at the shoulder rection of the small trian1. 1.Narrow Cravat is to be be Narrow Cravat is to area, fold it slightly gle to-will be used to encircle used. ThisThis technique is is used. technique wards your left (opposite the affected area until the similarly applied to to foresimilarly applied foreend is consumed enough armarm andand leg leg if it ifisitthe ininthe direction you made is the to tie it afterwards. jured part. jured part. with the first end) to form 5. Take the other end that 2. 2.Right Forearm is Injured. Right Forearm is Injured. a small triangle. Leave oneone endend at hand of of Leave at hand 6. Encircle the area until was the left at the hand of the patient, fold it slightly tothethe patient, measure thethe patient, measure end is also consumed wards your right (opposite length of the forearm untiluntil length of the forearm enough to tie together the direction you made thethefolds folds(antecubital (antecubital with the other end using with the first end) to form area) or or untiluntil youyou reach area) reach a square knot. a small triangle. thethe location of injury. (this(this location of injury. 6. Encircle the area until the 7. Tuck the excess ends to timetime thethe measurement is is measurement end is also consumed up to antecubital area. make the bandage neat. upthe to the antecubital area. enough to tie together 3. 3.FoldFold the the bandage downbandage downCheck for PMS to ensure with the other end using ward andand slightly turnturn it it ward slightly that the applied force and ² Limmer (Brady) a square knot. going to your left left to form going to your to form ³ Pollack, (AAOS) tightness is enough. it is the excess 7. If Tuck ends to ⁴ NHTSA a small triangle. a small triangle. too tight repeat the procemake the bandage neat. 4. 4.TheThe endend thatthat is inis the di- diin the dure and lessen the force Check for PMS to ensure rection of the small trianrection of the small trianthat the applied force and applied. gle gle willwill be used to encircle be used to encircle

PRINCIPLES OF EMT CLINICAL PRACTICE UNIT 3 DAY 19

PRINCIPLES OF EMT CLINIC PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE EMT CLINICAL PRACTICE

THIGH BANDAGE

ARM & THIGH BAN

ARM ARM &&THIGH THIGHBANDAGE BANDAGE

UNIT UNIT33 UNIT 3 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY19 19 PRINCIPLES DAY 19 PRINCIPLES

EMT CLINICAL PRACTICE

HIGH BANDAGE

ARM ARM &&THIGH THIGHBANDAGE BANDAGE

OF EMT CLINIC

ARM & THIGH BAN

PRINCIPLES OF EMT

FOREARM

tightness is enough. If it is too tight repeat the procedure and lessen the force applied.

thethe affected areaarea untiluntil thethe affected endend is consumed enough is consumed enough to tie to ittieafterwards. it afterwards. 5. 5.Take the the other endend thatthat Take other waswas left left at the hand of the at the hand of the

Leave one end at at hand ofof Leave one end hand the thepatient, patient,measure measurethe the length ofof the forearm until length the forearm until the the folds folds (antecubital (antecubital area) area)ororuntil untilyou youreach reach the location ofof injury. (this UNIT UNIT33 the location injury. (this time UNIT UNIT 3193 timethe themeasurement measurementis is DAY DAY 19 upup toto the antecubital area. the antecubital area. DAY DAY 19 19 the 3. Fold thebandage bandagedowndown1. Narrow Cravat is3.to beFold used. the end is consumed enough to ward wardand andslightly slightlyturn turnit it This technique is similarly tie it afterwards. going toto your leftleft toto form going your form a small applied to forearm and legtriangle. iftriangle. it is 5. Take the other end that was left a small Theend endthat thatis isin inthe thedi-diFOREARM & LEG LEG BANDAGE BANDAGE the injured part. 4. 4. The at theFOREARM hand of&the patient, fold rection rectionofofthe thesmall smalltriantrian1.1.FOREARM Narrow Narrow Cravat is is totobebe FOREARM & LEG &Cravat LEG BANDAGE BANDAGE 2. Right Forearm is Injured. it slightly towards your right glegle will bebe used toto encircle will used encircle used. used. This This technique technique is 1. 1.Narrow Narrow Cravat Cravat is is to to beisbe the affected until the Leave one end at hand of the area (oppositeused. the direction you made the affected area until the similarly similarly applied to toforeforeused. Thisapplied This technique technique is is end is isconsumed enough end consumed enough arm arm and and leg leg if ifitform itis the insimilarly applied applied toisthe to foreforepatient, measure thetolength with thesimilarly first end) to aintietie it afterwards. to it afterwards. jured jured part. part. arm arm and and legleg if itifisit the is the ininof the forearm until the folds small2.triangle. 5. 5. Take the Take theother otherend endthat that 2. jured Right Right Forearm Forearmis isInjured. Injured. jured part. part. leftleft at at the hand ofof the was the hand the (antecubital area) orwas until you 6. Encircle the area until the end Leave Leave one one end end atat hand ofof 2. 2.Right Right Forearm Forearm is Injured. is hand Injured. patient, patient,fold foldit itslightly slightlyto-tothe the patient, patient, measure measure the Leave Leave one one end end at hand at hand ofthe of reach the location ofwards injury. (this is also consumed enough to your right (opposite wards your right (opposite length length ofofthe the forearm forearm until until the the patient, patient, measure measure the the time the measurement is up to tie together with the other end the direction you made the direction you made the the folds (antecubital (antecubital length length offolds the of the forearm forearm until until the first end) toto form with the first end) form the antecubital area.with using a square area) area) orknot. or until until you youreach reach the thefolds folds (antecubital (antecubital UNIT 3 a small triangle. a small triangle. the the location location ofof injury. injury. (this (thisthe area) area) or or until until you you reach reach 3. Fold the bandage and 7. Tuck the excess ends to make UNIT UNIT 33 6.downward DAY Encircle the area until the 6. Encircle the area until the time time the themeasurement measurement is is UNIT193 the the location location of injury. of injury. (this (this is is also slightly turn it goingend to your left bandagetime neat. Check for PMS to end also consumed consumed up up toto the the antecubital antecubital area. area. time the the measurement measurement is is DAY 19 DAY 19 DAY 19 enough enoughtototietietogether together 3.3.that Fold Fold bandage bandage downdownup up tothe the tothe the antecubital antecubital area. area. to form a small triangle. ensure applied force and with withthe theother otherend endusing using ward ward and and slightly slightly turn turn it it 3. 3. Fold Fold the the bandage bandage downdown4. The end that is in thea square tightnessward isgoing enough. Ifleft itto is too knot. adirection square knot. going toto your your left toform form ward and and slightly slightly turn turn it it 7. 7. Tuck excess Tuckthe excessends endstoto of the small triangle will betheused tight repeat the procedure a asmall small triangle. going going totriangle. your to your leftleft to form toand form FOREARM & LEG BANDAGE make the bandage neat. make bandage neat. The end end that thatis isininthe thedi-diaThe small a small triangle. triangle. to encircle the affected areathe until lessen4.4. the force applied. 1. Narrow Cravat is to be Check CheckforforPMS PMStotoensure ensure FOREARM&&LEG LEGBANDAGE BANDAGE FOREARM 4. 4.The The endend that issmall in is the in trianthe di- direction rection ofthat ofthe the small trianFOREARM LEG technique BANDAGE is used. & This that the applied force and that the applied force and Narrow Cravat Cravat isis toto be be 1.1. Narrow gle gle will will bebe used used tosmall toencircle encircle rection rection of of the the small triantrian1. similarly Narrow applied Cravat isto toforebe tightness is is enough. If it tightness enough. If is it is used. This This technique technique isis used. gle gle will will be be used used to until encircle tountil encircle the the affected affected area area the the used.andThis technique arm leg if it is the in-is too tight repeat the procetoo tight repeat the procesimilarly applied applied toto foreforesimilarly the the affected area area until until thethe end end is affected isconsumed consumed enough enough similarly jured part.applied to foredure dureand andlessen lessenthe theforce force armand andleg legififititisisthe theininarm end end is consumed enough enough toto tieis tieitconsumed it afterwards. afterwards. arm and leg if itis isInjured. the in2. Right Forearm applied. applied. juredpart. part. jured tie to tie itthe afterwards. it afterwards. 5.5. to Take Take the other otherend endthat that jured part. Leave one end at hand of Right Forearm Forearm isis Injured. Injured. 2.2. Right 5. 5.Take Take the the other other endend that was was left leftat at the the hand hand ofthat ofthe the 2. the Right Forearm is Injured. patient, measure the Leaveone oneend endatathand handofof Leave was was leftleft atfold the at the hand of the ofto-the patient, patient, fold ithand itslightly slightly toLeave one end at hand of length of the forearm until the patient, patient, measure measure the the the patient, patient, fold fold itright slightly it(opposite slightly to- towards wards your your right (opposite the patient, the the folds measure (antecubital lengthofofthe theforearm forearmuntil until length wards wards your your right right (opposite (opposite the the direction direction you you made made lengthorof until the forearm until area) you reach the folds folds (antecubital (antecubital the the the direction direction you you made with with the the first firstend) end) tomade toform form the location folds of(antecubital the injury. (this area) oror until until you you reach reach area) with with the the first first end) end) to form to form a a small small triangle. triangle. UNIT 33 UNIT area)the or measurement until you reach time is thelocation locationofofinjury. injury.(this (this the small a small triangle. triangle. 6.6. aEncircle Encircle the thearea areauntil untilthe the thetolocation of injury.area. (this up the antecubital DAY 1919 6. 6.Encircle time the the measurement measurement isis DAY time Encircle the the area area until until thethe end end is is also also consumed consumed time the the bandage measurement 3. Fold down-is uptotothe theantecubital antecubitalarea. area. up end endis isalso also consumed consumed enough enough toto tietie together together up to the area. ward andantecubital slightly turn it Foldthe thebandage bandagedowndown3.3. Fold enough enough to to tie tie together together with with the the other other end end using using 3. going Fold the bandage to your left todownform ward and and slightly slightly turn turn itit ward with with thethe other other endend using using a asquare square knot. knot. ward and slightly turn it a small triangle. goingtotoyour yourleft lefttotoform form going square a square knot. knot. 7.7. aTuck Tuck the the excess excessends endstoto going to that yourisleft 4. The end in to theform dismalltriangle. triangle. aasmall 7. 7.Tuck Tuck the excess excess ends ends to to make make the the bandage bandage neat. neat. a small triangle. FOREARM & LEG BANDAGE FOREARM & LEG BANDAGE rection of the small trianTheend endthat thatisisininthe thedidi4.4. The make make the the bandage bandage neat. neat. Check Check forfor PMS PMS totoensure ensure 4. gle Thewill end the di1. 1.Narrow Cravat is is to to be be Narrow Cravat bethat usedistoinencircle rectionofofthe thesmall smalltriantrianrection Check Check forapplied for PMS PMS to to ensure ensure that that the the applied force force and and rection of the small used. used.This Thistechnique techniqueis is the affected area untiltrianthe ² Limmer (Brady) glewill willbe beused usedtotoencircle encircle gle ² Limmer (Brady) that that the the applied applied force force and and tightness tightness is is enough. enough. If If it it is is ³ Pollack, (AAOS) gle will be used toenough encircle ³ Pollack, (AAOS) similarly applied to to foresimilarly applied foreend is consumed theaffected affectedarea areauntil untilthe the ⁴ NHTSA the ⁴ NHTSA tightness tightness is enough. is enough. If proceitIfisit is too too tight tight repeat repeat the theprocethe affected area until the arm and legleg if itif isit the in- inarm and is the to tie it afterwards. endisisconsumed consumedenough enough end too too tight tight repeat repeat the the proceprocedure dure and and lessen lessen the the force force end isthe consumed enough jured part. jured part. 5. Take other end that tieititafterwards. afterwards. tototie dure dure and and lessen lessen the the force force applied. applied. to tieleft it afterwards. 2. 2.Right Forearm is Injured. Right Forearm is Injured. was at the hand of the Take the the other other end end that that 5.5. Take applied. applied. 5. patient, Take thefold other end that Leave oneone endend at hand of of Leave at hand it slightly towasleft leftatatthe thehand handofofthe the was was left at the hand of the thethe patient, measure thethe patient, measure wards your right (opposite patient,fold foldititslightly slightlytotopatient, patient, fold it slightly tolength of the forearm until length of the forearm until the direction you made wardsyour yourright right(opposite (opposite wards wards your thethe folds folds (antecubital (antecubital with the firstright end)(opposite to form the direction direction you you made made the direction area) or or until youyou reach area) until reach athe small triangle. you made withthe thefirst firstend) end)totoform form with with the first end) to form thethe location of injury. (this location of injury. (this 6. Encircle the area until the smalltriangle. triangle. aasmall a small triangle. time thethe measurement is is time measurement Encirclethe thearea areauntil untilthe the end is also consumed 6.6. Encircle 6. Encircle the area until the up up to the antecubital area. to the antecubital area. end isis also also consumed consumed enough to tie together end end is also consumed 3. 3.Fold thethe bandage downFold bandage downenough toto tie tie together together with the other end using enough enough to tie together ward andand slightly turn it it ward slightly turn withthe theother otherend endusing using a square knot. with with the other end using going to to your leftleft to to form going your form squareknot. knot. 7. Tuck the excess ends to aasquare a square knot. a small triangle. Tuck the the excess excess ends ends toto a small triangle. 7.7. Tuck make the bandage neat. 7. Tuck the excess ends to 4. 4.TheThe endend that is in thethe di- dimake the the bandage bandage neat. neat. that is in make Check for PMS to ensure make the bandage neat. rection of of thethe small trianCheckfor forPMS PMStotoensure ensure rection small trianCheck that the applied force and Check for PMS to ensure glegle willwill be be used to encircle thatthe theapplied appliedforce forceand and used to encircle that tightness is enough. If it is ² Limmer ² Limmer (Brady) (Brady) that the applied force and ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) tightness is enough. If it is the affected area until the the affected area until the tightness is enough. If it is too ³ Pollack, (AAOS) ² ⁴Limmer Limmer (Brady) (Brady)tight repeat the proce³ Pollack, (AAOS) NHTSA ⁴ ² NHTSA tightness is enough. If it is ⁴ NHTSA ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA tootight tightrepeat repeatthe theproceproceendend is consumed enough too is consumed enough dure and lessen the force ⁴ NHTSA ⁴ NHTSAtoo tight repeat the procedureand andlessen lessenthe theforce force to tie it afterwards. dure to tie it afterwards. applied. dure and lessen the force applied. 5. 5.Take thethe other endend that applied. Take other that applied. was leftleft at the hand of the was at the hand of the patient, foldfold it slightly to- topatient, it slightly wards your right (opposite wards your right (opposite thethedirection directionyouyoumade made with thethe firstfirst end) to to form with end) form a small triangle. a small triangle. 6. 6.Encircle thethe area until thethe Encircle area until endendis isalso alsoconsumed consumed enough enoughto totie tietogether together with thethe other end using with other end using a square knot. a square knot. 7. 7.Tuck thethe excess ends to to Tuck excess ends make thethe bandage neat. make bandage neat. Check forfor PMS to to ensure Check PMS ensure LIFELINE PREHOSPITAL EMERGENCY CARE that thethe applied force andand that applied force ² Limmer (Brady) ³ Pollack, (AAOS) ² Limmer (Brady) ² Limmer (Brady) tightness is enough. If itIfisit is tightness is enough. ⁴² Limmer NHTSA (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ³ Pollack, (AAOS) NHTSA tootoo tight repeat thethe procetight repeat proce⁴ ⁴NHTSA ⁴ NHTSA dure andand lessen thethe force dure lessen force applied. applied.

FOREARM & LEG BANDAGE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

FOREARM FOREARM&&LEG LEGBANDAGE BANDAGE

FOREARM FOREARMBANDAGE BANDAGE FOREARM BANDAGE FOREARM FOREARM &&LEG LEG BANDAGE BANDAGE

CAL PRACTICE

NDAGE

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES FOREARMBANDAGE BANDAGE FOREARM

PRINCIPLES OF EMT PRINCIPLES OF EMT FOREARM B FOREARM B

CAL PRACTICE

NDAGE

T CLINICAL PRACTICE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

M BANDAGE

FOREARM FOREARMBANDAGE BANDAGE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE FOREARM FOREARMBANDAGE BANDAGE

479

one oneend endatatthe theankle anklearea area one end the ankle area one end at at the ankle area not nottouching touchingthe thefloor, floor, nottouching touchingthe thefloor, floor, not measure the length ofof the measure the length the measure the length the measure the length ofof the leg leguntil untilbelow belowthe theknee knee untilbelow belowthe theknee knee legleguntil area oror until you reach the area until you reach the area until you reach the area oror until you reach the UNIT UNIT3 3 location location ofof injury. injury. (this (this locationof ofinjury. injury.(this (this location time is is33 timethe themeasurement measurement UNIT UNIT timethe themeasurement measurementis is DAY DAY1919 time upup toto below the knee) below the knee) below the knee) upup toto below the knee) DAY DAY 19 19 Day 19 3. 3. Fold downFoldthe thebandage bandage downFoldthe thebandage bandagedowndown3. 3. Fold ward wardand andslightly slightlyturn turnit it wardand andslightly slightlyturn turnit it ward going goingtotoyour yourright righttoto goingtotoyour yourright righttoto going form a small triangle. form a small triangle. form a small triangle. form a small triangle. 4. 4. The Theend endthat thatis isininthe thedi-di- FOREARM FOREARM & LEG & LEG BANDAGE BANDAGE Theend endthat thatis isin inthe thedi-di4. 4. The rection the small rection of the smalltriantrian- 1. 1. Narrow NarrowCravat Cravatis isto tobebe FOREARM FOREARM &of &LEG LEG BANDAGE BANDAGE rectionofofthe thesmall smalltriantrianrection gle will be used to encircle gle will be used to encircle used. used.This Thistechnique techniqueis is 1.1. Narrow NarrowCravat Cravatis istotobebe will used encircle glegle will bebe used toto encircle the affected area until the the affected area until the similarly similarlyapplied appliedto toforeforeused. used. This This technique technique is is the affected area until the the affected area until the end is isconsumed end consumed enough similarly similarly applied appliedenough toto foreforeend consumed enough arm arm and and legleg if itif is it the is the in-inend is is consumed enough to tie it afterwards. to tie it afterwards. arm armand andleg legif ifit itis isthe thein-init afterwards. jured jured part. part. toto tietie it afterwards. 5. 5. Take Takethe theother otherend endthat that 2. 2. Right jured jured part. part. Takethe theother otherend endthat that Right legleg is Injured. is Injured. Leave Leave 5. 5. Take atisatthe ankle area, wasleft left the ankle area, 2.2. was Right Right leg leg isInjured. Injured. Leave Leave was the ankle area, one one end end at at thethe ankle ankle area area was leftleft at at the ankle area, fold itend towards foldend it slightly towards one one atslightly atthe theankle ankle area area fold it slightly towards notnottouching touchingthethefloor, floor, fold it slightly towards your left the yourtouching left (opposite (opposite the not not touching the the floor, floor, yourleftleft(opposite (oppositethe the measure measure thethe length length of of thethe your direction you made direction you made with measure measure the the length length ofwith ofthe the directionyou youmade madewith with legleg until until below below thethe knee knee direction the first tothe form aa theuntil firstend) end) tothe form leg leg until below below knee knee thefirst firstend) end)toUNIT toform forma3a area area or or until until you you reach reach thethe the UNIT 3 small triangle. small triangle. area area or or until untilyou youreach reachthe the small triangle. small triangle. location locationof ofinjury. injury.(this (this 3 6.6. Encircle area until the Encirclethe the area until the UNIT UNIT 3 3 DAY 19 location location of of injury. injury. (this (this 6. Encircle the area until the DAY 6. Encircle the area until the 19 time timethethemeasurement measurementis is end isthe consumed endthe is also also consumed time time measurement measurement is is end is is also also consumed consumed 9 end up up to to below below the the knee) knee) DAY DAY 19 19 enough totothe tie together enough tie together upup totobelow below the knee) knee) enoughtototietietogether together enough 3. 3. Fold Fold thethe bandage bandage downdownend using withthe the other end using 3.3. with Fold Fold the theother bandage bandage downdownwiththe theother otherend endusing using with ward wardand andslightly slightlyturn turnit it award square knot. a square knot. ward and and slightly slightlyturn turnit it a square knot. a square knot. going going to to your your right right to to 7. 7. Tuck the excess ends to Tuck excess endstoto to going going the toto your your right right Tuckthe theexcess excessends endstoto 7. 7. Tuck form form a small a small triangle. triangle. make bandage neat. make the bandage neat. & the LEG BANDAGE FOREARM &the LEG BANDAGE form form athe asmall small triangle. triangle. make bandage neat. make bandage neat. 4. 4. The The end end that that is is in in thethe di-di- FOREARM Check for PMS to ensure Check for PMS to ensure Narrow Cravat istois to bebe 4.4. The Theend endthat thatis isininthe thedi-diCheck for PMS to ensure 1. Narrow Cravat to Check PMS ensure FOREARM & for LEG & LEG BANDAGE BANDAGE rection rection of of thethe small small triantrian- 1.FOREARM that the applied force and that the applied force and This technique isand rection rectionofofthe thesmall smalltriantrianthat the applied force used. This technique is that the applied and 1. 1.used. Narrow Narrow Cravat Cravat isforce is to to be be glegle willwill bebe used used to to encircle encircle tightness isused If Ifit itis is tightness isenough. enough. similarly applied to toforegle glewill willbebe used totoencircle encircle tightness is enough. If it isis similarly foretightness isapplied enough. If it used. used. This This technique technique isis thethe affected affected area area until until thethe too tight repeat the procetoo tight repeat the procearm and leg if itif is the inthe theaffected affectedarea areauntil untilthe the too tight repeat the procearm and leg itto isto the intoo tight repeat the procesimilarly similarly applied applied foreforeend end is is consumed consumed enough enough dure lessen force dure and lessenthe the force end endisand isconsumed consumed enough enough jured part. dure and lessen the force jured part. dure and lessen force arm arm and and leg leg if itif is itthe is the the ininto to tietie it afterwards. it afterwards. applied. applied. tototietieit itafterwards. afterwards. applied. leg is Injured. Leave Right leg is Injured. Leave applied. jured jured part. part. 5. 5. Take Takethetheother otherend endthat that 2. 2. Right 5.5. Take Takethe theother otherend endthat that one end at the ankle area one end at the ankle area 2. 2. Right Right legleg is is Injured. Injured. Leave Leave was was leftleft at at thethe ankle ankle area, area, was wasleft leftatatthe theankle anklearea, area, not touching the floor, not touching the floor, one one end end at at the the ankle ankle area area fold foldit itslightly slightlytowards towards fold fold it it slightly slightly towards towards measure the length of the measure the length of the not nottouching touchingthethefloor, floor, your yourleftleft(opposite (oppositethethe your your left left (opposite (opposite the the leg until below the knee leg until below the knee measure measure thethe length length of of thethe direction directionyou youmade madewith with direction directionyou youmade madewith with area oruntil until you reach the area or until you reach the leg leguntil below below the theknee knee thethefirst firstend) end)to toform forma a the thefirst firstend) end)totoUNIT form forma a3 location of injury. (this location of injury. (this UNIT 3 area area oror until until you you reach reach the the small small triangle. triangle. small smalltriangle. triangle. time thethe measurement is is time location location ofmeasurement ofinjury. injury.(this (this Encircle Encircle thethe area area until until thethe DAY 19 6. 6. end 6.6. Encircle Encirclethe thearea area until untilthe the DAY 19 up to below the knee) up to below the knee) time timethe themeasurement measurementis is endis isalso alsoconsumed consumed end end is is also also consumed consumed bandage downthe bandage downupFold up tothe to below below thethe knee) knee) enough enoughto totietietogether together 3. 3. Fold enough enough toto tietie together together ward and slightly turn it it ward and slightly turn 3. 3. Fold Foldthethebandage bandage downdownwith with thethe other other end end using using with withthe theother otherend endusing using going toand right toittoit going toyour your right ward wardand slightly slightly turn turn a square a square knot. knot. a asquare squareknot. knot. form a small triangle. form atosmall triangle. going going toyour your right rightto to Tuckthetheexcess excessends endsto to 7.7. Tuck Tuckthe theexcess excessends endstoto 7. 7. Tuck 4. 4. The end that istriangle. in thethe di- diThe end that is in form form a small a small triangle. make make the the bandage bandage neat. neat. FOREARM & LEG BANDAGE FOREARM & LEG make make the theBANDAGE bandage bandageneat. neat. rection of the small trianrection ofthat the small trian4. 4. The The end end that is is in in the the di-diCheck Check for for PMS PMS to to ensure ensure 1. Narrow Cravat is to be 1. Narrow istoto toensure be Check CheckCravat forforPMS PMS ensure gle willwill be used tosmall encircle gle used to encircle rection rection ofbe of the the small triantrianthat that thethe applied applied force force and and ² Limmer (Brady) ² Limmer (Brady) used. This technique is used. This technique isand that thatthe the applied applied force forceand ³ Pollack, (AAOS) ³ Pollack, (AAOS) the affected area until the the affected area until the gle gle will will bebe used used to to encircle encircle tightness tightness is enough. is enough. If itIf isit is ⁴ NHTSA ⁴ NHTSA similarly applied tightness tightness is isenough. enough. If foreIfit itis is similarly applied to toforeend is affected consumed enough end is consumed enough the the affected area area until until the the tootoo tight tight repeat repeat thethe proceprocearm and leg itthe is the too too tight tight repeat repeat the proceprocearm and leg if itif is the in-into tie it afterwards. to tie it afterwards. end end is is consumed consumed enough enough dure dure and and lessen lessen thethe force force dure dure and andlessen lessenthe theforce force jured part. jured part. 5. Take the other end that 5. toTake the other end that to tietie it afterwards. it afterwards. applied. applied. applied. applied. Right Injured. Leave 2. 2. Right legleg is is Injured. Leave left at the ankle area, was left the ankle area, 5. 5.was Take Take the theat other other end end that that one end the ankle area one end at at the ankle area fold it left slightly towards fold it slightly towards was was left at at the the ankle ankle area, area, nottouching touchingthe thefloor, floor, not your leftitleft (opposite thethe your (opposite fold foldit slightly slightly towards towards measure the length the measure the length of of the direction you made with direction you made with your yourleftleft (opposite (opposite the the untilbelow belowthetheknee knee legleguntil the firstfirstend) a a the end) toform form direction direction you youto made made with with area until you reach area oror until you reach thethe small triangle. small triangle. the thefirst first end) end)to toform forma a locationof ofinjury. injury.(this (this location 6. 6. Encircle thethe area until thethe Encircle area until small small triangle. triangle. timethe themeasurement measurementis is time is isthe also consumed end also consumed 6. 6.end Encircle Encircle the area area until until thethe below the knee) upup to to below the knee) enough tietie together enough to together end end is isto also also consumed consumed Foldthe thebandage bandagedowndown3. 3. Fold with thethe other using with end using enough enough toother totieend tietogether together wardand andslightly slightlyturn turnit it ward awith square knot. awith square knot. thethe other other end end using using goingto toyour yourright rightto to going 7. 7. Tuck thethe excess ends to to a Tuck square a square knot. knot. excess ends form a small triangle. form a small triangle. bandage neat. 7. 7.make Tuck Tuckthe the excess excess ends ends to to make the bandage neat. The end that the 4. 4. The end that is is in in the di-diCheck PMS to to ensure make makefor the the bandage bandage neat. neat. Check for PMS ensure rection thesmall small trianrection of of the trianthat thethe applied force and Check Check for for PMS PMS to to ensure ensure that applied force and will used encircle glegle will bebe used to to encircle tightness is applied enough. If it that that thethe applied force force and and tightness is enough. If is it is ² Limmer ² Limmer (Brady) (Brady) ² Limmer ² Limmer (Brady) (Brady) the affected area until the the affected area until the ³ Pollack, ³ Pollack, (AAOS) (AAOS) ³ Pollack, ³ Pollack, (AAOS) (AAOS) too tight repeat thethe procetightness tightness isrepeat enough. is enough. IfproceitIf is it is too tight ⁴ NHTSA ⁴ NHTSA ⁴ NHTSA ⁴ NHTSA end consumed enough end is is consumed enough dure and lessen the force too too tight tight repeat repeat the the proceprocedure and lessen the force it afterwards. to to tietie it afterwards. applied. dure dure and and lessen lessen thethe force force applied. Takethe theother otherend endthat that 5. 5. Take applied. applied. was the ankle area, was leftleft at at the ankle area, foldit itslightly slightlytowards towards fold yourleftleft(opposite (oppositethe the your directionyou youmade madewith with direction thefirst firstend) end)to toform forma a the small triangle. small triangle. Encircle the area until 6. 6. Encircle the area until thethe end is is also also consumed consumed end enoughto totietietogether together enough with the other end using with the other end using a square knot. a square knot. Tuckthe theexcess excessends endsto to 7. 7. Tuck makethe thebandage bandageneat. neat. make CheckforforPMS PMSto toensure ensure Check that the applied force and that the applied force and 480 enough. LIFELINE EMERGENCY CARE tightness enough. itPREHOSPITAL is tightness If itIf is ² Limmer (Brady) ² Limmer (Brady) is is ³ Pollack, (AAOS) ³ Pollack, (AAOS) too tight repeat the procetoo tight repeat the proce⁴ NHTSA ⁴ NHTSA dure and lessen force dure and lessen thethe force applied. applied.

ELBOWSTRAIGHT STRAIGHTBANDA BAND ELBOW thistechnique techniqueis isindic ind 1.1. this forvertical verticalcut cutinjuri inju for wound at the ante wound at the antecu area. area. Narrow Cravat Cravat is is to 2.2. Narrow used.Place Placethe theban ba used. ontop topofofthe theinjured injured on Pullboth bothends endstowar towa 3.3. Pull elbowand andinterchan intercha elbow goingtotothe thetop. top. going the top top (antecu (ante 4.4. AtAt the UN U area—injured part)joijo area—injured part) twoends endsand andtwist twis DA D two addpressure pressureon onthe thei add especiallyif ifit itis isstill stillb especially ing. ing. After twisting, twisting, pull pu 5.5. After twoends endsagain againtow to two ELBOW ELBOW STRAIGHT STRAIGHT BANDA BAN the elbow and the elbow and 1. 1. this this technique technique is indic is in change again change it it again w forpulling for vertical vertical cutcut injurie inju towards th pulling it ittowards the wound wound at thethe antecu ante theat bandage 6.6. If If the bandage is area. area. enough, twistit itaga ag enough, twist 2. 2. Narrow Narrow Cravat Cravat is isto not, the ends not, tietie the ends u used. used.Place Place thethe ban ba square knot. Tuck square knot. Tuck tht oncess on toptop ofmake of thethe injured injure a to the ba cess to make the ban 3. 3. Pull Pull both both ends ends toward tow neat. neat. elbow elbow and and interch Check forinterchan PMS fo 7.7. Check for PMS for going going to to thethe top. top. tightness and/or tightness and/or l 4. 4. Atness Atthethe top top (antecu (ante application. ness ofofapplication. area—injured area—injured part) part) join j two twoends endsand andtwist twi add add pressure pressure onon thethe i especially especially if itif is it still is stilb ing. ing. 5. 5. After Aftertwisting, twisting,pull pu ELBOW ELBOW STRAIGHT STRAIGHT BANDAGE BANDAG two twoends ends again againtow t 1. 1. thisthis technique technique is indicated is indica thethe elbow elbow and and change change itinjuries itinjuries again againow forfor vertical vertical cutcut pulling it antecubita towards it towards theth wound wound atpulling at thethe antecub 6. 6. If Ifthethebandage bandageis area. area. enough, enough,twist twistit itaga a 2. 2. Narrow Narrow Cravat Cravat istheis toends tobe not, not, tietiethe ends u used. used. Place Place the the bandage banda square square knot. knot. Tuck Tuck th cess cess to to make make thethe ban ba onon toptop of of the the injured injured area ar neat. neat. 3. 3. Pull Pull both both ends ends toward toward the 7. 7. Check CheckforforPMS PMSforf elbow elbow and and interchange interchange i tightness tightness and/or and/or lo going going toness to the the top. ness oftop. of application. application.

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICAL PRACTICE PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE LEG LEGBANDAGE BANDAGE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

LEG BANDAGE

UNIT UN

DAY DAY1 PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

LEG LEGBANDAGE BANDAGE LEG LEGBANDAGE BANDAGE

LEG LEGBANDAGE BANDAGE

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES

MT CLINICAL PRACTICE

BANDAGE

LEG LEGBANDAGE BANDAGE

UNIT 3 DAY 19

4. 4. At Atthethetoptop(antecubita (antecub area—injured area—injured part) part) join join the two two ends ends and and twist twist it to it add add pressure pressure onon thethe injury inj especially especially if itif isit still is still bleed ble ing. ing. 5. 5. After Aftertwisting, twisting,pull pullthe two twoends endsagain againtoward towa thethe elbow elbow and and inter in change changeit itagain againwhile wh pulling pulling it towards it towards thethe top. to 6. 6. If Ifthethebandage bandageis isstil enough, enough, twist twist it again. it againI not, not,tietiethetheends endsusing us square square knot. knot. Tuck Tuck thethe ex cess cess to to make make thethe bandage banda neat. neat. 7. 7. Check CheckforforPMS PMSforforthe tightness tightnessand/or and/orloose loo ness ness of of application. application.

PRINCIPLES OF EMT CL

LEGBANDAGE BANDAGE LEG

LEG BAND

FOREARM & LEG BANDAGE 1. Narrow Cravat is to be ² Limmer (Brady) This ² Limmer (Brady) used. technique is ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA similarly applied to fore⁴ NHTSA arm and leg if it is the injured part. 2. Right leg is Injured. Leave one end at the ankle area not touching the floor, measure the length of the leg until below the knee UNIT 3 area or until you reach the DAY 19 location of injury. (this time the measurement is up to below the knee) 3. Fold the bandage downward and slightly turn it going to your rightSTRAIGHT to ELBOW BANDAGE form a small triangle. 1. this technique is indicated 4. The end that is infor thevertical di- cut injuries or wound rection of the small trian-at the antecubital area. gle will be used to encircle 2. until Narrow the affected area the Cravat is to be Place the bandage end is consumed used. enough to tie it afterwards.on top of the injured area. 3. end Pull both 5. Take the other that ends toward the elbow and interchange it was left at the ankle area, going to the top. fold it slightly towards 4. At the top (antecubital your left (opposite the area—injured part) join the direction you made twowith ends and twist it to the first end) to add form a pressure on the injury small triangle. especially if it is still bleed6. Encircle the area until ing. the end is also 5. consumed After twisting, pull the two ends again towards enough to tie together theusing elbow and interwith the other end change it again while a square knot. pulling 7. Tuck the excess ends toit towards the top. 6. If neat. the bandage is still make the bandage Check for PMS toenough, ensure twist it again. If not, tie the ends using that the applied force and ² Limmer (Brady) ² Limmer (Brady) square knot. Tuck the ex³ Pollack, (AAOS) ³ Pollack, (AAOS) tightness is enough. If to it ismake the bandage ² Limmer ² Limmer (Brady) (Brady) ⁴ NHTSA cess ⁴ NHTSA ³ Pollack, ³ Pollack, (AAOS) (AAOS) too tight repeat the proce⁴ NHTSA ⁴ NHTSA neat. dure and lessen forcefor PMS for the 7. the Check applied. tightness and/or looseness of application.

PRINCIPLES OF

ELBOW (VER

ELBOW(VERTICAL (VERTICAL CUT) BANDAGE ELBOW CUT) BANDAGE ELBOW ELBOW STRAIGHT STRAIGHT BANDAGE BANDAGE

1. 1. this thistechnique technique is isindicated indicated forforvertical verticalcut cutinjuries injuriesoror wound woundatatthe theantecubital antecubital area. area. 2. 2. Narrow NarrowCravat Cravatis istotobebe used. used.Place Placethe thebandage bandage onon top top ofof the the injured injured area. area. 3. 3. Pull Pull both both ends ends toward toward the the elbow elbowand andinterchange interchangeit it going going toto the the top. top. 4. 4. AtAtthe thetop top(antecubital (antecubital area—injured area—injured part) part) join join the the two two ends ends and and twist twistit itto to ELBOW STRAIGHT BANDAGE ELBOW STRAIGHT BANDAGE add add pressure pressure onon the the injury injury 1. this this is indicated 1.especially technique is indicated especially if ifittechnique itis isstill stillbleedbleedvertical injuries vertical cutcut injuries or or ing. ing.forfor 5. 5. After After twisting, twisting, pull the the wound at the antecubital wound at pull the antecubital two two ends ends again again towards towards area. area. the the elbow elbow and and interinter2. Narrow Narrow Cravat 2.change Cravat is isto tobebe change it it again again while while used. Place the bandage used. Place the bandage pulling pulling it towards it towards the the top. top. top injured area. 6. 6. If If the theon bandage bandage isinjured is still still area. on top of of thethe enough, twist twist itends itagain. again. Iftoward If 3. Pull Pull both ends 3.enough, both toward thethe not, not,tieelbow tiethe theends ends using using and interchange elbow and interchange it it square squareknot. knot.Tuck Tuckthe theex-exgoing to the top. going to the top. cess cess toto make make the the bandage bandage 4. AtAtthethetoptop(antecubital (antecubital 4.neat. neat. 7. 7. Check Check forforPMS PMSforfor the thejoin area—injured part) join area—injured part) thethe tightness tightness and/or and/or looseloosetwo ends and twist two ends and twist it it to to ness ness ofof application. application.

DAGE AGE dicated cated uries ies oror ecubital ubital

UNIT3 3 UNIT PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY1919PRINCIPLES DAY

oto bebe andage ndage darea. area. ardthe the rd angeit it nge

ecubital ubital UNIT NITthe3 3 ointhe in stit itto to19 DAY AY 19 einjury injury bleedbleed-

ELBOW(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE ELBOW

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

ull the l the owards wards NDAGE AGE interinterndicated cated while while uries es top. or or ehetop. ubital ecubital still s is still gain.If If ain. o to bebe using using ndage andage the exhe exed area. area. andage ndage ward d thethe hange nge it it the ror the looselooseubital ecubital join n thethe istit itto to injury e injury bleedll bleed-

ELBOW (VERTICAL ELBOW ELBOW(VERTICAL (VERTICALCUT) CUT) BANDAGE BANDAGE

ELBOW STRAIGHT BANDAGE

CUT) BANDAGE

1. This technique is indicated for vertical cut injuries or wound at the antecubital area. 2. Narrow Cravat is to be used. Place NIT T 33 the bandage on top of the injured PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE Y1919 add pressure injury add pressure onon thethe injury UNIT UNIT3 3 area. especially is still bleedespecially if itif isit still bleedPRINCIPLES OF PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE UNIT 33 ing. UNIT ing. DAY 19 DAY 19 3. PRINCIPLES PRINCIPLES OF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE Pull both ends toward the elbow and Aftertwisting, twisting, pull 5. 5. After pull thethe DAY DAY 1919 interchange it going to the top. ELBOW ELBOW(VERTICAL (VERTICAL CUT) CUT) BANDAGE BANDAGE two endsagain again towards two ends towards elbow and and interinterthethe elbow ullthethe 4. At the top (antecubital area— GE wards towards changeit itagain againwhile while ELBOW CUT) ELBOW(VERTICAL (VERTICAL CUT) BANDAGE change ELBOW ELBOW(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE injured part) join the BANDAGE two ends and ated dinterinterpulling it towards top. pulling it towards thethe top. while or swhile or ELBOW STRAIGHT BANDAGE ELBOW STRAIGHT BANDAGE ELBOW ELBOW STRAIGHT STRAIGHT BANDAGE BANDAGE 6. If the bandage is still twist it to add pressure on the injury 6. If the bandage is still he top. top. bital al 1. 1. thisthis technique is indicated technique is indicated 1. 1.thisthis technique technique is indicated is twist indicated enough, twist again. enough, it it again. If If isstillstill especially if it is still bleeding. forfor vertical vertical cutcut injuries injuries or or for vertical cut injuries or for vertical cut injuries or not, tie endsusing using again. ain. If If not, tie thetheends wound wound at at thethe antecubital antecubital ebe wound at at thethe antecubital wound antecubital susing using 5. After twisting, pull the two ends square knot. Tuck knot. Tuck thethe ex-exarea. area. square age etheex-exarea. he area. cess to the bandage cess to make bandage 2. 2.Narrow Narrow Cravat Cravat is make isto tothe be be again towards the elbow and interndage andage a. rea. 2. Narrow Cravat is to be 2. Narrow Cravat is to be used. used. Place Place the the bandage bandage neat. neat. used. Place thethe bandage used. Place bandage ethe change it again while pulling it on on top top of the of the injured injured area. area. 7. Check for PMS for the 7. Check for PMS for the rforthethe onon toptop of of thethe injured area. 3. 3.PullPull both both ends ends toward toward thethe injured area. it e looseit oosetightness and/orlooseloosetightness and/or towards the top. elbow elbow and and interchange interchange it it 3. 3. PullPull both ends toward thethe both ends toward of application. oftop. application. going going toness the toness the top. elbow and interchange it it elbow and interchange 6. If the bandage is still enough, twist bital al 4. 4.At Atthethetoptop(antecubital (antecubital going to to thethe top. going top. ethe area—injured area—injured part) part) joinjoin thethe it UNIT again. 3If not, tie the ends using 4. 4. At Atthethetoptop(antecubital (antecubital to to two two ends ends and and twist twist it to it to square knot.PRINCIPLES Tuck the excess OF to EMT CLIN area—injured part) join thethe area—injured part) join jury y pressure onon thethe injury injury UNIT UNIT3add 3addpressure DAY 19 especially especially if itif isit still is still bleedbleed- OF two ends and twist it to two ends and twist it to deedPRINCIPLES PRINCIPLES OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE make the bandage neat. DAY DAY 19 19 ing. LINICAL PRACTICE5. 5.ing. add pressure onon thethe injury add pressure injury After Aftertwisting, twisting,pullpullthethe 7. Check for PMS for the tightness especially if itif isit still bleedespecially is still bleedethe two two ends ends again again towards towards ing. ing. ds ards ELBOW (VERTICAL CU and/or looseness of application. thetheelbow elbowand andinterinter5. 5. After Aftertwisting, twisting,pull pullthethe

nterr-

llstill n. If If sing g x-exage e

ethe eose-

ELBOW ELBOW(VERTICAL (VERTICALCUT) CUT) BANDAGE BANDAGE two ends again towards two ends again towards ELBOW STRAIGHT BANDAGE

change changeit itagain againwhile while pulling pulling it towards it towards thethe top. top. 6. 6.If Ifthethebandage bandageis isstillstill enough, enough, twist twist it again. it again. If If 1. 1. thisthis technique technique is indicated is indicatednot,not,tie tiethetheends endsusing using forfor vertical vertical cutcut injuries injuries or orsquare square knot. knot. Tuck Tuck thethe ex-excess to to make make thethe bandage bandage wound wound at at thethe antecubital antecubitalcess neat. neat. area. area. 7.be 7.Check CheckforforPMS PMSforforthethe 2. 2. Narrow NarrowCravat Cravatis isto tobe tightness tightnessand/or and/orlooselooseused. used. Place Place thethe bandage bandageness ness of application. of application.

e hile DAGE op. . ELBOW ELBOW STRAIGHT STRAIGHT BANDAGE BANDAGE ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

onon toptop of of thethe injured injured area. area. 3. 3. PullPull both both ends ends toward toward thethe elbow elbow and and interchange interchange it it going going to to thethe top. top. 4. 4. At Atthethetoptop(antecubital (antecubital area—injured area—injured part) part) join join thethe two two ends ends and and twist twist it to it to ² Limmer ² Limmer (Brady) (Brady) add add pressure pressure on on the the injury injury ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA especially especially if itif isit still is still bleedbleeding. ing. 5. 5. After Aftertwisting, twisting,pull pullthethe two twoends endsagain again towards towards thethe elbow elbow and and interinterchange changeit itagain againwhile while pulling pulling it towards it towards thethe top. top. 6. 6. If Ifthethebandage bandageis isstillstill enough, enough, twist twist it again. it again. If If not, not,tietiethetheends endsusing using square square knot. knot. Tuck Tuck thethe ex-excess cess to to make make thethe bandage bandage neat. neat. 7. 7. Check CheckforforPMS PMSforforthethe tightness tightnessand/or and/orlooselooseness ness of of application. application.

thethe elbow elbow and and interinterchange changeit itagain againwhile while pulling it towards thethe top. pulling it towards top. 6. 6. If Ifthethebandage bandageis isstillstill enough, twist it again. If If enough, twist it again. not, not,tie tiethetheends endsusing using square knot. Tuck the exsquare knot. Tuck the excess to to make thethe bandage cess make bandage neat. neat. 7. 7. Check CheckforforPMS PMSforforthethe tightness tightnessand/or and/orlooselooseness of of application. ness application.

2. 3. 4.

EMT CLINICAL PRACTICE 5.

RTICAL CUT) BANDAGE ² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

this technique is indicated for vertical cut injuries or wound at the antecubital area. Narrow Cravat is to be used. Place the bandage on top of the injured area. Pull both ends toward the elbow and interchange it going to the top. At the top (antecubital area—injured part) join the two ends and twist it to add pressure on the injury especially if it is still bleeding. After twisting, pull the two ends again towards the elbow and interchange it again while pulling it towards the top. If the bandage is still enough, twist it again. If not, tie the ends using square knot. Tuck the excess to make the bandage neat. Check for PMS for the tightness and/or looseness of application.

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

481

DAY DAY19 19

UNIT UNIT 33 CLINICAL the injury is still bleeding. PRINCIPLES EMT PRACTICE PRINCIPLES OF OF EMT CLINICAL PRACTICE ness of application. PRINCIPLES PRINCIPLES OF OF EMT EMTCLINICAL CLINICALPRACTICE PRACTICE 4. Instruct the patient to DAY DAY19 19

bend his arm. Pull one end and encircle the forearm area, do the BEND BANDAGE same with the ELBOW other end 1. through this technique is indicated but it will pass for horizontal cut injuries the arm. While doing so, wound at the antecubiit’ll create a figure oforeight. talconarea. 6. If the bandage is not Narrow sumed or is still 2. enough to Cravat is to be used.ofPlace the bandage create another figure the elbow of the ineight, repeat the on procejured area. dure. Pull apboth ends toward the 7. The ends will 3.meet antecubital area, join it proximately at the center, tie it using a squaretogether knot. then twist it, to UNIT pressure especially of 3 Tuck the excess toadd make the bandage neat. the injury is still bleeding. DAY 19 UNIT 3 4. for Instruct 8. Check for PMS the the patient to bend tightness and/or DAY loose-his 19arm. 5. Pull one end and encircle ness of application. the forearm area, do the same with the other end but itBEND will BANDAGE pass through ELBOW While isdoing so, 1. the thisarm. technique indicated ELBOW BEND BANDAGE it’ll a figure of injuries eight. forcreate horizontal cut 1. this technique6.is indicated If or thewound bandage is not conat the antecubifor horizontal cut sumed injuries or is still enough to tal area. or wound at the2.antecubicreate another Narrow Cravat figure is to of be tal area. eight, the bandage proceused. repeat Place the 2. Narrow Cravat is dure. to on be the elbow of the inused. Place the 7. bandage The ends jured area.will meet apon the elbow 3. of proximately the at the center, Pullinboth ends toward the jured area. tieantecubital it using a square knot.it area, join 3. Pull both ends toward the together then twist it, to Tuck the excess to make antecubital area, the join it add pressureneat. especially of 3 bandage UNIT together then8.twist it, injury to for isPMS the still bleeding. Check for the add pressure especially of DAY 19 4. tightness Instruct the patient and/or loose-to the injury is still bleeding. bend arm. ness of his application. 4. Instruct the patient 5. Pull to one end and encircle bend his arm. the forearm area, do the 5. Pull one end and encircle same with the other end the forearm area, do buttheit will pass through BEND BANDAGE same with the ELBOW otherthe end arm. While doing so, 1. through this technique is indicated but it will pass it’ll create a figure of eight. for so, horizontal cut injuries the arm. While doing 6. If the bandage is not conwound at the antecubiit’ll create a figure ofor eight. sumed or is still enough to talconarea. 6. If the bandage is not create another of ² Limmerfigure (Brady) Narrow to be sumed or is still 2. enough to Cravat ³ Pollack,is (AAOS) eight, repeat the proceNHTSA used.of Place ⁴the bandage create another figure dure. eight, repeat the on procethe elbow of the in7. The ends will meet apdure. jured area. proximately at the center, 7. The ends will 3.meet Pullapboth ends toward the tie it using a square knot. proximately at the center, antecubital area, join it Tuck excess to make tie it using a squaretogether knot.the then twist it, to the bandage neat. Tuck the excess to add make pressure especially of 8. Check for PMS for the the bandage neat. the injury is still bleeding. tightness and/or loose8. Check for PMS the the 4. for Instruct patient to ness application. tightness and/or bend loose-of his arm. ness of application. 5. Pull one end and encircle the forearm area, do the same with the other end but it will pass through the arm. While doing so, it’ll create a figure of eight. 6. If the bandage is not consumed or is still enough to create another figure of eight, repeat the proce² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) dure. ⁴ ⁴NHTSA NHTSA 7. The ends will meet approximately at the center, tie it using a square knot. Tuck the excess to make the bandage neat. 8. Check for PMS for the tightness and/or looseness of application.

ELBOW (HOR ELBOW (HORIZONTAL CUT) BANDAGE ELBOW CUT) BANDAGE ELBOW (HORIZONTAL (HORIZONTAL CUT) BANDAGE ELBOW ELBOW(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGE ELBOW ELBOWBEND BENDBANDAGE BANDAGE ELBOW ELBOWBEND BENDBANDAGE BANDAGE PRINCIPLES OF EMT CLINICAL PRACTICE Day 19 1.1. this thistechnique techniqueisisindicated indicated 5.

NDAGE e is indicated l cut injuries the antecubi-

vat is to be the bandage w of the in-

ds toward the area, join it n twist it, to especially of till bleeding. patient to

and encircle area, do the he other end pass through ile doing so, gure of eight. ge is not contill enough to her figure of t the proce-

will meet apat the center, square knot. cess to make neat. PMS for the nd/or looseation.

for for horizontal horizontal cut cut injuries injuries or orwound woundatatthe theantecubiantecubital talarea. area. 2.2. Narrow Narrow Cravat Cravat isis to to be be used. used. Place Place the the bandage bandage on on the the elbow elbow ofof the the ininjured juredarea. area. 3.3. Pull Pullboth bothends endstoward towardthe the antecubital antecubital area, area, join join itit together together then then twist twist it,it, to to add addpressure pressureespecially especiallyofof the theinjury injuryisisstill stillbleeding. bleeding. 4.4. Instruct Instruct the the patient patient to to bend bendhis hisarm. arm. 5.5. Pull Pullone oneend endand andencircle encircle the the forearm forearm area, area, do do the the same same with with the the other other end end but but itit will will pass pass through through the the arm. arm. While While doing doing so, so, it’ll it’llcreate createaafigure figureofofeight. eight. 6.6. IfIfthe thebandage bandageisisnot notconconsumed sumedor orisisstill stillenough enoughto to create create another another figure figure ofof eight, eight, repeat repeat the the proceprocedure. dure. This technique is indicated 7.7. The The ends ends will will meet meet apapfor horizontal cut injuries proximately center, proximatelyat atthe the center,or tie using aasquare tieititat using squareknot. knot. wound the antecubital area. Tuck the excess make Tuck the excess make Narrow Cravat is tototobe used.3 UNIT the thebandage bandageneat. neat. Place the bandage onfor the 8. the DAY 8. Check Check for for PMS PMS for the19 elbow of the injured area. tightness and/or loosetightness and/or looseofofends application. ness application. Pullness both toward the

ELBOW BEND BANDAGE

1. 2. 3.

4. 5.

antecubital area, join it together then twist it, to add ELBOW BEND ELBOW especially BEND BANDAGE BANDAGE pressure of the 1. 1. this this technique technique is is indicated indicated injuryfor is still bleeding. for horizontal horizontal cut cut injuries injuries Instruct the patient bend or at antecubior wound wound at the the to antecubital tal area. area. his arm. 2. Narrow Cravat is 2. one Narrow Cravat is to to be be Pull end and encircle the used. used. Place Place the the bandage bandage forearm area, do the same on the elbow of the inon the elbow of the injured area. with the other jured area. end but it will 3. Pull ends toward the 3. through Pull both both the endsarm. toward the pass While antecubital antecubital area, area, join join it it doing together so, it’ll create a figure of together then then twist twist it, it, to to eight. add add pressure pressure especially especially of of bleeding. the injury injury is isisstill still bleeding. If the the bandage not 4. the patient to 4. Instruct Instruct thestill patient to to consumed or is enough bend bend his his arm. arm. create another figure of eight, 5. Pull one end and encircle 5. Pull one end and encircle area, repeatthe theforearm procedure. the forearm area, do do the the same with the samewill withmeet the other other end end The ends but through but it it will will pass through approximately atpass thedoing center, the so, the arm. arm. While While doing so, tie it using a square knot. it’ll create a figure of it’ll create a figure of eight. eight. 6. IfIf the bandage is 6. the the bandage is not not conconTuck excess to make the ² Limmer (Brady) sumed or is still enough to ³ Pollack, (AAOS) sumed or is still enough to bandage neat. ⁴ NHTSA create create another another figure figure of of Checkeight, for PMS for the eight, repeat repeat the the proceprocedure. tightness dure.and/or looseness of 7. 7. The The ends ends will will meet meet apapapplication.

8. 8.

482

LIFELINE

proximately proximately at at the the center, center, tie tie it it using using aa square square knot. knot. Tuck the excess to Tuck the excess to make make the the bandage bandage neat. neat. Check Check for for PMS PMS for for the the tightness tightness and/or and/or looselooseness ness of of application. application.

PREHOSPITAL EMERGENCY CARE

1.1. this thistechnique techniqueisisindicated indicated for forhorizontal horizontalcut cutinjuries injuries ororwound woundatatthe theantecubiantecubital talarea. area. 2.2. Narrow Narrow Cravat Cravat isis toto be be used. used. Place Place the the bandage bandage on on the the elbow elbow ofof the the ininjured juredarea. area. 3.3. Pull Pullboth bothends endstoward towardthe the antecubital antecubital area, area, join join itit together togetherthen thentwist twistit,it,toto add addpressure pressureespecially especiallyofof the theinjury injuryisisstill stillbleeding. bleeding. 4.4. Instruct Instruct the the patient patient toto bend bendhis hisarm. arm. 5.5. Pull Pullone oneend endand andencircle encircle the theforearm forearmarea, area,do dothe the same samewith withthe theother otherend end but but itit will will pass pass through through the thearm. arm.While Whiledoing doingso, so, it’ll it’llcreate createaafigure figureofofeight. eight. 6.6. IfIfthe thebandage bandageisisnot notconconsumed sumedororisisstill stillenough enoughtoto create create another another figure figure ofof eight, eight, repeat repeat the the proceprocedure. dure. 7.7. The The ends ends will will meet meet apapproximately proximatelyatatthe thecenter, center, tie tieititusing usingaasquare squareknot. knot. Tuck Tuck the the excess excess totoUNIT make make 3 the thebandage bandageneat. neat. DAY 8.8. Check Check for for PMS PMS for for the the19 tightness tightness and/or and/or looselooseness nessofofapplication. application.

ELBOW (HORIZONTAL CUT) BANDAGE

PRINCIPLES O PRINCIPLES OF EMT CLIN ELBOW (HOR ELBOW (HORIZONTAL C ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PRINCIPLES O PRINCIPLES OF EMTPRINCIPLES CLINICAL PRACTICE OF EMT CLINICAL PRACTICE

ELBOW (HOR ELBOW (HORIZONTAL CUT)(HORIZONTAL BANDAGE CUT) BANDAGE ELBOW

ELBOW BEND BANDAGE 1. this technique is indicated for horizontal cut injuries or wound at the antecubital area. 2. Narrow Cravat is to be used. Place the bandage on the elbow of the injured area. 3. Pull both ends toward the antecubital area, join it together then twist it, to add pressure especially of the injury is still bleeding. 4. Instruct the patient to bend his arm. 5. Pull one end and encircle the forearm area, do the same with the other end but it will pass through the arm. While doing so, it’ll create a figure of eight. 6. If the bandage is not consumed or is still enough to ² Limmer ² Limmer(Brady) (Brady) ³ Pollack, ³ Pollack,(AAOS) (AAOS) create another figure of ⁴ ⁴NHTSA NHTSA eight, repeat the procedure. 7. The ends will meet approximately at the center, tie it using a square knot. Tuck the excess to make the bandage neat. 8. Check for PMS for the tightness and/or looseness of application.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

bend bendhis hisarm. arm. 5. 5. Pull Pull one one end end and and encircle encircle the the forearm forearm area, area, do do the the same same with with the the other other end end but butBEND itBEND it will will pass pass through through ELBOW BANDAGE ELBOW BANDAGE the arm. arm. While While doing so, so, 1.1. the this isisdoing indicated thistechnique technique indicated it’ll it’ll create aafigure figure of of eight. eight. for horizontal cut injuries forcreate horizontal cut injuries 6. 6. If Ifor the the bandage bandage isisantecubinot not conconor wound atatthe wound the antecubisumed sumed or orisisstill stillenough enoughto to tal talarea. area. create another another of of 2.2. create Narrow Cravat isfigure Narrow Cravatfigure is toto be be eight, eight, repeat repeat the the proceproceused. bandage used.Place Placethe the bandage dure. dure. on onthe theelbow elbowofofthe thein-in7. 7. The The ends ends will meet meet apapjured area. jured area.will proximately at at toward the the center, center, 3.3. proximately Pull the Pullboth bothends ends toward the tie tie itit using using aaarea, square square knot. knot. antecubital join it it antecubital area, join Tuck Tuck the the then excess excess to to make make together it, together thentwist twist it,toto the the bandage bandage neat. neat. UNIT UNIT add pressure especially ofof 33 add pressure especially 8. 8. Check Check for for PMS PMS for for the the the isisstill theinjury injury stillbleeding. bleeding. DAY 19 DAY 19 tightness and/or and/or looseloose4.4. tightness Instruct patient toto Instruct the the patient ness ness of of application. application. bend his arm. bend his arm. 5.5. Pull Pullone oneend endand andencircle encircle the theforearm forearmarea, area,do dothe the same samewith withthe theother otherend end but pass but it it will willBANDAGE pass through through ELBOW BEND ELBOW BEND BANDAGE While so, the arm. Whileisdoing so, 1.1. the this technique indicated thisarm. technique isdoing indicated it’ll create a afigure ofof eight. it’ll create figure eight. for horizontal cut injuries for horizontal cut injuries 6.6. Ifor bandage isisnot Ifthe bandage notconconwound atatthe antecubiorthe wound the antecubisumed ororisisstill sumed stillenough enoughtoto tal talarea. area. another create another figure of 2.2. create Narrow Cravat is be Narrow Cravatfigure is to to of be eight, the proceused. Place bandage eight, repeatthe the proceused.repeat Place the bandage dure. on dure. on the the elbow elbow ofof the the inin7.7. The ends jured area. The ends will meet meet apapjured area.will 3.3. proximately Pull toward the atatthe center, proximately the center, Pullboth bothends ends toward the antecubital area, join itit tie it itusing knot. antecubital area, join tie usinga asquare square knot. together then it, Tuck the totomake together then twist twist it, to to Tuck theexcess excess make add pressure especially the bandage neat. add pressure especiallyofof the bandage neat. the still bleeding. theinjury injury still bleeding. 8.8. Check for for Check forisisPMS PMS for the the 4.4. tightness Instruct patient to Instruct the the patient to and/or loosetightness and/or loosebend his arm. bend his arm. ness ofof application. ness application. 5.5. Pull Pullone oneend endand andencircle encircle the the forearm forearm area, area, do do the the same same with with the the other other end end but but itit will will pass pass through through the the arm. arm. While While doing doing so, so, it’ll it’llcreate createaafigure figureofofeight. eight. 6.6. IfIfthe ² ²Limmer Limmer(Brady) (Brady) thebandage bandageisisnot notconcon³ ³Pollack, Pollack,(AAOS) (AAOS) sumed sumedor orisisstill stillenough enoughto to ⁴ ⁴ NHTSA NHTSA create create another another figure figure ofof eight, eight, repeat repeat the the proceprocedure. dure. 7.7. The The ends ends will will meet meet apapproximately proximatelyatatthe thecenter, center, tie tieititusing usingaasquare squareknot. knot. Tuck Tuck the the excess excess to to make make the thebandage bandageneat. neat. 8.8. Check the Check for for PMS PMS for for the 3 UNIT UNIT 3 tightness tightness and/or and/or looselooseness DAY19 19 nessofofapplication. application.DAY

bend his arm. Pull one end and encircle the forearm area, do the same with the other end but BEND it willBANDAGE pass through ELBOW Whileisdoing so, 1. the this arm. technique indicated it’ll a figure eight. forcreate horizontal cutofinjuries 6. Iforthe bandage is antecubinot conwound at the sumed or is still enough to tal area. of 2. create Narrowanother Cravat figure is to be eight, repeatthe thebandage proceused. Place dure. on the elbow of the in7. The juredends area. will meet apat the center, 3. proximately Pull both ends toward the tie it using a area, squarejoin knot.it antecubital Tuck the excess to make together then twist it, to the addbandage pressureneat. especially of 3 UNIT 8. Check foris PMS for the the injury still bleeding. DAY and/or loose4. tightness Instruct the patient to19 ness application. bendofhis arm. 5. Pull one end and encircle the forearm area, do the same with the other end but it will pass through ELBOW BEND BANDAGE the arm. While doing so, 1. this technique is indicated it’ll create a figure of eight. for horizontal cut injuries 6. If the bandage is not conor wound at the antecubisumed or is still enough to tal area. create another figure of 2. Narrow Cravat is to be eight, repeat the proceused. Place the bandage dure. on the elbow of the in7. The ends will meet apjured area. proximately at the center, 3. Pull both ends toward the tie it using a square knot. antecubital area, join it Tuck the excess to make together then twist it, to the bandage neat. add pressure especially of 8. Check for PMS forUNIT the 3 the injury is still bleeding. tightness and/or loose4. Instruct the patient to ness of application. DAY 19 bend his arm. 5. Pull one end and encircle the forearm area, do the same with the other end but it will pass through ELBOW BEND BANDAGE the arm. While doing so, 1. it’llthis technique indicated create a figureis of eight. for horizontal 6. If the bandage iscut notinjuries conor wound at the antecubisumed or is still enough to tal area. create another figure of 2. Narrow Cravat is to be eight, repeat the proceused. Place the bandage dure. on the elbow of the in7. The ends will meet apjured area. proximately at the center, 3. Pull both ends toward the tieantecubital it using a square knot.it area, join Tuck the excess to make together then twist it, to the bandage neat. add pressure especially of 8. Check for PMS for the the injury is still bleeding. and/or loose-to 4. tightness Instruct the patient ness of application. bend his arm. 5. Pull one end and encircle the forearm area, do the same with the other end but it will pass through the arm. While doing so, it’ll create a figure of eight. 6. If the bandage is not consumed or is still enough to create another figure of eight, repeat the procedure. 7. The ends will meet approximately at the center, tie it using a square knot. Tuck the excess to make the bandage neat. 8. Check for PMS for the tightness and/or looseness of application. 5.

ELBOW(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGEELBOW (HORIZONTAL C RIZONTAL CUT) BANDAGEELBOW

PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICEPRINCIPLES OF EMT CLIN OF EMT CLINICAL PRACTICEPRINCIPLES NICAL PRACTICE ELBOW (HORIZONTAL (HORIZONTAL CUT) CUT) BANDAGE BANDAGE ELBOW (HORIZONTAL C RIZONTAL CUT) BANDAGEELBOW CUT) BANDAGE

OF EMT CLINICAL PRACTICE

RIZONTAL CUT) BANDAGE

PRINCIPLES OF EMT CLIN

ELBOW (HORIZONTAL C ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE ELBOW ELBOW(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGE

ELBOW ELBOWBEND BENDBANDAGE BANDAGE 1.1. this thistechnique techniqueisisindicated indicated for for horizontal horizontal cut cut injuries injuries ororwound woundatatthe theantecubiantecubital talarea. area. 2.2. Narrow Narrow Cravat Cravat isis toto be be used. used. Place Place the the bandage bandage on on the the elbow elbow ofof the the ininjured juredarea. area. 3.3. Pull both ends toward the Pull both ends toward the antecubital antecubital area, area, join join itit together together then then twist twist it,it, toto add addpressure pressureespecially especiallyofof the theinjury injuryisisstill stillbleeding. bleeding. 4.4. Instruct Instruct the the patient patient toto bend bendhis hisarm. arm. 5.5. Pull Pullone oneend endand andencircle encircle the the forearm forearm area, area, do do the the same samewith withthe theother otherend end but it will pass through but it will pass through the the arm. arm. While While doing doing so, so, it’ll it’llcreate createaafigure figureofofeight. eight. 6.6. IfIfthe thebandage bandageisisnot notconconsumed sumedororisisstill stillenough enoughtoto create create another another figure figure ofof eight, eight, repeat repeat the the proceprocedure. dure. 7.7. The The ends ends will will meet meet apapproximately proximatelyatatthe thecenter, center,

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer ² Limmer(Brady) (Brady) ³ Pollack, ³ Pollack,(AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

(Brady) LIFELINE³² Limmer PREHOSPITAL EMERGENCY CARE Pollack, (AAOS) ⁴ NHTSA

483

This technique is indicated forvertical verticalcut cutor orwounds wounds for onthe thepalm. palm. on Narrow Cravat Cravat isis toto be be 2.2. Narrow used. used. Place the the middle middle ofof the the 3.3. Place bandage on on top top ofof the the bandage wound. wound. Day 19 First Rotation—Pull Rotation—Pull the the 4.4. First bandage nearest nearestyou you gogobandage ingtowards towardsthe thepalm palmcovcoving ering the the pinky pinky finger, finger, ering PALM PALMSTRAIGHT STRAIGHT BANDAGE BANDAGE UNIT33 passing the palm palm and toto UNIT passing the and thetechnique back ofof the the thumb the back thumb 1.1. This This technique isis indicated indicated DAY19 19 DAY area. area. for for vertical vertical cut cutororwounds wounds Second Rotation—Pull Rotation—Pull the the 5.5. Second on on the thepalm. palm. bandage side farther farther toto bandage side you going going towards the you towards 1. This is indicated for vertical 2.2.technique Narrow Narrow Cravat Cravat is isthe to to be becut or palm passing behind behind the the palm woundsused. on the passing palm. used. hand and between the the PALM STRAIGHT BANDAGE hand between PALM STRAIGHT BANDAGE 2. Narrow Cravat isand to be used. finger 3.3. Place Place the the middle middle ofof the the thumb and index finger Thistechnique techniqueis isindicated indicated thumb and index 1.1. This 3. Place the middle of on the onthe top the then back back to bandage its normal forvertical verticalcut cutororwounds wounds then toon its normal bandage bandage top top ofof theoffor wound.wound. position. the palm. position. onon the palm. wound. RepeatFirst Firstthe Rotation pro-nearest NarrowCravat Cravatis istotobebe 6.6. Repeat Rotation pro2.2. you Narrow 4. First Rotation—Pull bandage 4.4. First First Rotation—Pull Rotation—Pull the the used. cedure then Second Rotaused. cedure then Second Rotagoing towards the palm covering the pinky finger, tion procedure procedure untilyou the goPlacethe themiddle middleofofthe the tion until the bandage nearest nearest you go3.3. Place passingbandage the palm and to the back area. bandage consumed andof the thumb bandage topofofthe the bandage isisconsumed and bandage onontop ing ing towards towards the the palm palm covcov5. Second Rotation—Pull the bandage side farther readyfor forsecuring. securing. wound. ready wound. ering ering the using pinky pinky finger, finger, Tietowards thethe ends using square First the Rotation—Pull the the Tie the ends square to you7.7. going the palm passing behind 4.4. First Rotation—Pull knot.Check Check PMS fortighttightbandagenearest nearestyou yougogoknot. PMS for bandage passing passing the the palm palm and andindex toto finger hand and between the thumb and ness and/or and/or looseness looseness ofof ingtowards towardsthe thepalm palmcovcovness ing UNIT 3 the the back back of of the the thumb thumb then back to its normal position. UNIT ering the the pinky pinky finger, finger, theapplication. application. ering UNIT33 the 6. Repeat First Rotation procedure then Second area. area. DAY 19 passingthe thepalm palmand andtoto passing DAY 19 procedure until the bandage is consumed DAY Rotation theback backofofthe thethumb thumb 5.5. 19 Second SecondRotation—Pull Rotation—Pullthe the the area. and ready for securing. bandage bandage side side farther farther toto5. area. Second Rotation—Pullthe the 5.PMS Second 7. Tie the you ends using square knot. Check for Rotation—Pull you going going towards towards the the bandage bandageside sidefarther farthertoto tightness and/or looseness of the application. you going going towards towards the the palm palmpassing passingbehind behindthe the you palmpassing passingbehind behindthe the PALM STRAIGHT BANDAGE M STRAIGHT BANDAGE LM STRAIGHT BANDAGE hand hand and and between between the the palm handand andbetween betweenthe the 1. This technique is indicated hand This technique is is indicated This technique indicated for vertical cut or wounds thumb thumb and andindex indexfinger finger thumb thumb and andindex indexfinger finger orforvertical verticalcut cutororwounds wounds on the palm. then back to its normal then back to its normal onon the palm. then then back back to to its its normal normal the palm. 2. Narrow Cravat is to be position. position. Narrow Cravat is to be Narrow Cravat is to be position. position. used. RepeatFirst FirstRotation Rotationpropro6.6. Repeat used. used. 6. 6. Repeat RepeatFirst FirstRotation Rotationpropro- cedure cedurethen thenSecond SecondRotaRota- 3. Place the middle of the Place Placethe themiddle middleofofthe the bandage on top of the tionprocedure procedureuntil untilthe the bandage cedurethen thenSecond SecondRotaRota- tion bandageonontop topofofthe the cedure wound. bandage is consumed and bandage is consumed and wound. wound. tion tion procedure procedure until until the the 4. First Rotation—Pull the ready for securing. ready for securing. First First Rotation—Pull Rotation—Pull the the bandage nearest you goTiethe theends endsusing usingsquare square bandageisisconsumed consumedand and 7.7. Tie bandage bandagenearest nearestyou yougogobandage ing towards the palm covknot. Check PMS for tightknot. Check PMS for tightng towards the palm covreadyfor forsecuring. securing. ing towards the palm cov- ready ering the pinky finger, ness and/or looseness of ness and/or looseness of ering the pinky finger, ering the pinky finger, passing the palm and to 7. 7. Tie Tie the the ends ends using using square square the application. the application. passing passingthe thepalm palmand andtoto the back of the thumb knot.Check CheckPMS PMSfor fortighttighthe theback backofofthe thethumb thumb knot. area. area. ness nessand/or and/orlooseness loosenessofof area. 5. Second Rotation—Pull the Second Rotation—Pull the Second Rotation—Pull the the bandage side farther to theapplication. application. bandage bandageside sidefarther farthertoto you going towards the you yougoing goingtowards towardsthe the palm passing behind the palm passing behind the palm passing behind the hand and between the hand and between the hand and between the thumb and index finger humb ² Limmer (Brady) ² Limmer (Brady) thumb and andindex indexfinger finger then back to its normal ³ Pollack,(AAOS) (AAOS) ³ Pollack, hen thenback backtotoitsitsnormal normal NHTSA ⁴ ⁴NHTSA position. position. position. 6. Repeat First Rotation proRepeat First Rotation proRepeat First Rotation procedure then Second Rotacedure cedurethen thenSecond SecondRotaRotation procedure until the ion tionprocedure procedureuntil untilthe the bandage is consumed and bandage is consumed and bandage is consumed and ready for securing. eady for securing. ready for securing. 7. Tie the ends using square TieTiethe theends endsusing usingsquare square knot. Check PMS for tightknot. knot.Check CheckPMS PMSforfortighttightness and/or looseness of ness and/or looseness of ness and/or looseness of the application. he application. the application.

bandage nearest you going towards towards the the palm palm covcoving UNIT UNIT 33 ering the the pinky pinky finger, finger, ering passing the the palm palmDAY and to to19 DAY 19 passing and the back back of of the the thumb thumb the area. area. 5. Second Second Rotation—Pull Rotation—Pull the the 5. bandage side side farther farther to to bandage you going going towards towards the the you PALM PALM STRAIGHT STRAIGHT BANDAGE palm passingBANDAGE behind the the palm passing behind 1. 1. hand This This technique technique isis indicated indicated hand and between between the and the for for vertical vertical cut cut or or wounds wounds thumb and index finger thumb and index finger on onthe the palm. palm. then back to its its normal normal then back to 2. 2. position. Narrow Narrow Cravat isis to to be be position. Cravat used. used. First 6. Repeat Repeat First Rotation Rotation propro6. 3. 3. cedure Place Place the the middle of the the cedure thenmiddle Secondof Rotathen Second Rotabandage bandage on on top top of of the the tion procedure until the tion procedure until the wound. wound. is bandage is consumed consumed and and bandage 4. 4. ready First First for Rotation—Pull Rotation—Pull the the ready for securing. securing. bandage bandage nearest nearest you gogo7. Tie Tie the ends ends usingyou square 7. the using square ing ing towards towards the the palm palm covcovknot. Check Check PMS PMS for for tighttightknot. ering eringand/or the the pinky pinky finger, finger, ness and/or looseness of ness looseness of passing passing the the palm palm and and to to the application. the application. the the back back of of the theUNIT thumb thumb33 UNIT area. area. DAY DAYthe 19 19 5. 5. Second Second Rotation—Pull Rotation—Pull the bandage bandage side side farther farther to to you you going going towards towards the the palm palm passing passing behind behind the the hand hand and and between between the the thumb thumb and andBANDAGE index index finger finger PALM PALM STRAIGHT STRAIGHT BANDAGE then then back back to toisits its normal normal 1.1. This Thistechnique technique isindicated indicated position. position. for forvertical verticalcut cutororwounds wounds 6. 6. on Repeat Repeat First First Rotation Rotation proproonthe thepalm. palm. cedure cedure then then Second Second RotaRota2.2. Narrow Narrow Cravat Cravat is is toto bebe used. used. tion tion procedure procedure until until the the 3.3. Place Placethe the middleofofand the the bandage bandage isismiddle consumed consumed and bandage bandage on on top top ofof the the ready ready for forsecuring. securing. wound. 7. 7. wound. Tie Tie the the ends ends using using square square 4.4. First First Check Rotation—Pull Rotation—Pull the the knot. knot. Check PMS PMS for for tighttightbandage bandage nearest nearest you yougogoness ness and/or and/or looseness looseness of of ing ingtowards towardsthe thepalm palmcovcovthe the application. application. ering ering the the pinky pinky finger, finger, passing passingthe thepalm palmand andtoto the the back back ofof the the thumb thumb area. area. 5.5. Second SecondRotation—Pull Rotation—Pullthe the bandage bandage side side farther farther toto you you going going towards towards the the palm palmpassing passingbehind behindthe the hand hand and and between between the the thumb thumb and andindex indexfinger finger then thenback backtotoitsitsnormal normal position. position. 6.6. Repeat RepeatFirst FirstRotation Rotationproprocedure cedurethen thenSecond SecondRotaRotation tionprocedure procedureuntil untilthe the bandage bandageis isconsumed consumedand and ready readyfor forsecuring. securing. 7.7. Tie Tiethe theends endsusing usingsquare square knot. knot.Check CheckPMS PMSfor fortighttightness nessand/or and/orlooseness loosenessofof the theapplication. application.

UNIT UNIT33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTIC PRACTIC DAY DAY19 19 PRINCIPLES PRINCIPLES OF EMT CLINICAL PRACTICE

PALM PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE

RINCIPLES INCIPLES OF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PALM STRAIGHT BANDAGE

PALM PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE

PALM (VERTICAL CUT)EMT BANDAGE PRINCIPLES OF CLINICALPRACTIC PRACTI PRINCIPLES OF EMT CLINICAL

PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE PALM

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PRINCIPLES OF EMT C

PALM PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE

PALM (VERTICAL

T CLINICAL PRACTICE

AL CUT) BANDAGE

mer r (Brady) (Brady) k, ack, (AAOS) (AAOS) A TSA

484

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

ing ing towards towards the the palm palm covcovering ering the the pinky pinky finger, finger, passing passing the the palm palm and and to to the thumb UNIT the back back of of the theUNIT thumb 33 area. area. DAY 19 DAY 19 5. 5. Second Second Rotation—Pull Rotation—Pull the the bandage bandage side side farther farther to to you you going going towards towards the the palm palm passing passing behind behind the the hand hand and and between between the the PALM STRAIGHT thumb and index thumb andBANDAGE index finger finger PALM STRAIGHT BANDAGE 1.1. then This back normal then back to to isits its normal Thistechnique technique isindicated indicated for position. forvertical verticalcut cutororwounds wounds position. on 6. First onthe thepalm. palm. 6. Repeat Repeat First Rotation Rotation propro2.2. cedure Narrow Cravat isis toto be Narrow Cravat be then Second Rotacedure then Second Rotaused. used. tion procedure tion procedure until until the the 3.3. bandage Place middle the Place the the middle ofofand the isisconsumed bandage consumed and bandage on bandage on top top ofof the the ready for ready forsecuring. securing. wound. wound. 7. the 7. Tie Tie the ends ends using using square square 4.4. knot. First Rotation—Pull the First Check Rotation—Pull the PMS knot. Check PMS for for tighttightbandage nearest you bandage nearest you goness of ness and/or and/or looseness loosenessgoof ing towards ingapplication. towardsthe thepalm palmcovcovthe the application. UNIT ering finger, ering the the pinky pinkyUNIT finger,33 passing and passing the the palm palm and to19 DAYto19 DAY the the back back ofof the the thumb thumb area. area. 5.5. Second Second Rotation—Pull Rotation—Pull the the bandage bandage side side farther farther toto you you going going towards towards the the palm passing behind PALM STRAIGHT BANDAGE palm passing behind the the PALM STRAIGHT BANDAGE hand and the Thistechnique technique indicated hand and between between the 1.1. This is isindicated thumb and index finger forvertical vertical cut wounds thumb and index finger for cut ororwounds then back toto its onthe the palm. then back its normal normal on palm. position. NarrowCravat Cravatis istotobebe position. 2.2. Narrow 6.6. used. Repeat used. First Repeat FirstRotation Rotationproprocedure then Second RotaPlacethe the middle the cedure then Second Rota3.3. Place middle ofof the tion procedure until the bandage top the tion procedure until the bandage onontop ofofthe bandage wound. isisconsumed bandage consumedand and wound. ready for securing. 4. First Rotation—Pull the ready for securing. 4. First Rotation—Pull the 7.7. bandage Tie the using square bandage nearest you goTie theends ends using square nearest you goknot. Check for ingtowards towards thepalm palm covknot. CheckPMS PMS fortighttighting the covness looseness ofof eringand/or the pinky pinky finger, ness and/or looseness ering the finger, the application. passing the palm and the application. passing the palm and toto the back back ofofthe the thumb thumb the area. area. SecondRotation—Pull Rotation—Pullthe the 5.5. Second bandageside sidefarther farthertoto bandage you going going towards towards the the you palmpassing passingbehind behindthe the palm hand and and between between the the hand thumb and andindex indexfinger finger thumb thenback backtotoitsitsnormal normal then position. position. RepeatFirst FirstRotation Rotationpropro6.6. Repeat cedurethen thenSecond SecondRotaRotacedure tionprocedure procedureuntil untilthe the tion bandageis isconsumed consumedand and bandage readyfor forsecuring. securing. ready Tiethe theends endsusing usingsquare square 7.7. Tie knot.Check CheckPMS PMSfor fortighttightknot. nessand/or and/orlooseness loosenessofof ness theapplication. application. the

PRINCIPLES PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTICE CE CE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PALM PALM (VERTICAL (VERTICAL CUT) CUT) BANDAGE BANDAGE PALM PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE

ICE CE

PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PALM(VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE CLINICAL PALM PALMPRACTICE (VERTICAL (VERTICALCUT) CUT)BANDAGE BANDAGE PALM CUT) BANDAGE

Limmer (Brady) (Brady) ²² Limmer Pollack, (AAOS) (AAOS) ³³ Pollack, NHTSA ⁴⁴ NHTSA

² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) ⁴ ⁴ NHTSA NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ ⁴NHTSA NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

485

bandage bandagenearest nearestyou yougogobandage nearest you gobandage nearest you going ing towards towards the the knuckles knuckles ing towards the knuckles ing towards the knuckles covering coveringthe thefingers fingersfrom from covering the fingers from covering the fingers from the thepinky pinkyside, side,passing passingthe the the pinky side, passing the the pinky side, passing the closed closedfingers fingersand andto tothe the closed fingers and to the closed fingers and to the back backof ofthe thethumb thumbarea. area. back of the thumb area. back of the thumb area. 5. 5. Second Second Rotation—Pull Rotation—Pull the the 5. Second Rotation—Pull the 5. Second Rotation—Pull the bandage bandage side side farther farther to to bandage side farther to bandage side farther to you you going going towards towards the the you going towards the you going towards the back backof ofthe thehand handcovering covering back of the hand covering back of the hand covering the the remaining remaining uncovered uncovered the remaining uncovered the remaining uncovered area area on on the the pinky pinky side side area on the pinky side area on the pinky side and andpassing passingbetween betweenthe the and passing between the and passing between the thumb thumb and and index index finger finger thumb and index finger thumb and index finger area areathen thenback backto toits itsnornorarea then back to its norarea then back to its normal malposition. position. mal position. mal position. 6. 6. Repeat RepeatFirst FirstRotation Rotationpropro6. Repeat First Rotation pro6. Repeat First Rotation procedure cedurethen thenSecond SecondRotaRotacedure then Second Rotacedure then Second Rotation tion procedure procedure until until the the tion procedure until the tion procedure until the bandage bandageisis consumedand and bandage consumed and bandage isisconsumed consumed and ready ready for for securing. securing. Leave Leave ready for securing. Leave ready for securing. Leave the thethumb thumbuncovered. uncovered. the thumb uncovered. the thumb uncovered. 7. 7. Tie Tiethe theends endsusing usingsquare square 7. Tie the ends using square 7. Tie the ends using square knot. knot.Check CheckPMS PMSfor fortighttightknot. Check PMS for tightknot. Check PMS for tightness ness and/or and/or looseness looseness of of ness and/or looseness of ness and/or looseness of the theapplication. application. the application. the application.

UNIT UNIT UNIT3333 UNIT PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE DAY 19 DAY DAY19 19PRINCIPLES DAY 19 Day 19

PALM CLOSED BANDAGE

1. 2. 3. 4. 5.

PRINCIPLES OF EMT CLINICAL PRACTICE

PALM (HORIZONTAL CUT) BANDAGE PALM PALM(HORIZONTAL (HORIZONTAL CUT) CUT)BANDAGE BANDAGE PALM (HORIZONTAL BANDAGE PALM (HORIZONTAL CUT) CUT) BANDAGE

PALM PALM CLOSED CLOSED BANDAGE BANDAGE PALM PALM CLOSED CLOSED BANDAGE BANDAGE PALM CLOSED BANDAGE 1.1. This This This technique technique isindicated indicated indicated 1.1. This technique technique isis is indicated 1. forThis technique indicated This technique is indicated horizontal cutisor wounds for for horizontal horizontal cut cut or oror on for for horizontal horizontal cut cut or for horizontal cut or the palm. wounds wounds on on the the palm. palm. wounds wounds on on the the palm. palm. wounds on the palm. Narrow Cravat is to be used. 2.2. Narrow Narrow Narrow Cravat Cravat is isto to to be bebe 2.2. NarrowCravat Cravatisis 2. Narrow is totobebe Place the middle of the bandage on theCravat wrist area. used. used. used. used. used. 3. Place Place the the middle middle of ofofthe the the First Rotation—Pull the3.3. bandage nearest you going towards Place the themiddle middle of the 3.3. Place Place the middle of the bandage bandage on on the the wrist wrist the knuckles covering the fingers from the pinky side, passing bandage bandage on on the the wrist wrist bandage on the wrist area. area. the closed fingers and to thearea. back of the thumb area. area. area. 4.4.bandage First First Rotation—Pull Rotation—Pull the the 4.4. First Rotation—Pull Rotation—Pull the the Second Rotation—Pull the side farther to you 4. First First Rotation—Pull the bandage bandage nearest nearest you you gogobandage bandage nearest nearest you you gogogoing towards the back of the hand covering the remaining bandage nearest you going ing towards towards the the knuckles knuckles ing towards towards the the knuckles knuckles uncovered area on the pinkying side and passing between ing towards the knucklesthe covering covering the the fingers fingers from from covering covering the the fingers from from thumb and index finger area then back tofingers its normal position. covering the fingers from the the pinky pinky side, side, passing passing the the the the pinky pinky side, side, passing passing the the thethen pinkySecond side, passing the Repeat First Rotation procedure Rotation closed closed fingers fingers and and to toto the the closed fingers fingers and and to the fingers and tothe the procedure until the bandageclosed isclosed consumed and ready for back back of ofof the the thumb thumb area. area. back back of the the thumb thumb area. area. back of the thumb area. securing. Leave the thumb 5.5.uncovered. Second Second Rotation—Pull Rotation—Pull the the 5.5. Second Second Rotation—Pull Rotation—Pull the the Second the Tie the ends using square5.knot. CheckRotation—Pull PMS for tightness bandage bandage side side farther farther to toto and/ bandage bandage side side farther farther to bandage side farther to or looseness of the application. you you going going towards towards the the you yougoing goingtowards towardsthe the you going towards the back back of ofof the the hand hand covering covering back back of the hand hand covering covering back ofthe the hand covering the the remaining remaining uncovered uncovered the the remaining remaining uncovered uncovered the remaining uncovered area area on on the the pinky pinky side side area areaon onthe thepinky pinkyside side area on the pinky side and and passing passing between between the the and and passing passing between between the the and passing between the thumb thumb and and index index finger finger thumb thumband and index index finger finger thumb and index finger area area then then back back to toto its itsits nornorarea area then then back back to nornorarea then back toitsits normal mal position. position. mal mal position. position. mal position. 6.6. Repeat Repeat Repeat First First Rotation Rotation propro6.6. Repeat First First Rotation Rotation propro6. Repeat First Rotation procedure cedure then then Second Second RotaRotacedure cedure then then Second Second RotaRotacedure then Second Rotation tion procedure procedure until until the the tion tionprocedure procedureuntil untilthe the tion procedure until the bandage bandage is isconsumed consumed consumed and and bandage bandage is is consumed and and bandage is consumed and ready ready for for securing. securing. Leave Leave ready ready for for securing. securing. Leave Leave ready for securing. Leave the the thumb thumb uncovered. uncovered. the the thumb thumb uncovered. uncovered. the thumb uncovered. 7.7. Tie Tie Tie the the ends ends using using square square 7.7. Tie the the ends ends using using square square 7. Tie the ends using square knot. knot. Check Check PMS PMS for for tighttightknot. knot. Check Check PMS PMS for for tightknot. Check PMS fortighttightness ness and/or and/or looseness looseness of of ness ness and/or and/or looseness looseness ness and/or loosenessofofof the the application. application. the the application. application. the application.

PRINCIPLES OF EMT CLINICAL PRACTICE 6. PRINCIPLES PRINCIPLES OF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE 7.

PALM (HORIZONTAL CUT) BANDAGE PALM PALM(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGE

486

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer Limmer (Brady) (Brady) ² ²Limmer ² Limmer (Brady) (Brady) ²²Pollack, Limmer Limmer (Brady) (Brady) ³ Pollack, (AAOS) (AAOS) ³ ³Pollack, ³ Pollack, (AAOS) (AAOS) ³³NHTSA Pollack, Pollack, (AAOS) (AAOS) NHTSA ⁴ ⁴⁴NHTSA ⁴ NHTSA ⁴⁴ NHTSA NHTSA

UNIT UNIT3 3 P DAY DAY19 19PR

P PALM PALM CLOSED CLOSED BANDAGE BANDAGE 1. 1. This This technique technique is indicated is indicated forfor horizontal horizontal cutcut oror wounds wounds onon the the palm. palm. 2. 2. Narrow NarrowCravat Cravatis isto tobebe used. used. 3. 3. Place Placethe themiddle middleof ofthe the bandage bandage onon the the wrist wrist area. area. 4. 4. First First Rotation—Pull Rotation—Pull the the bandage bandagenearest nearestyou yougo-goingingtowards towardsthe theknuckles knuckles covering covering the thefingers fingersfrom from the the pinky pinky side, side, passing passing the the closed closedfingers fingersand andto tothe the back back of of the the thumb thumb area. area. 5. 5. Second SecondRotation—Pull Rotation—Pullthe the bandage bandageside sidefarther fartherto to you yougoing goingtowards towardsthe the back back of of the the hand hand covering covering the theremaining remaininguncovered uncovered area areaononthe thepinky pinkyside side and and passing passing between between the the thumb thumb and andindex indexfinger finger area area then then back back to to itsits nornormal mal position. position. 6. 6. Repeat Repeat First First Rotation Rotation proprocedure cedure then then Second Second RotaRota-

²²²L²L ³³³P³P ⁴⁴⁴⁴N

EEE

bandage is consumed and ready for securing. Leave the thumb uncovered. Tie the ends using square knot. Check PMS for tightness and/or looseness of the application.

UNIT UNIT UNIT UNIT3 33 3 PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTIC DAY DAY 19 19 DAY DAY19 19

PALM PALM(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGE PALM PALM CLOSED CLOSED BANDAGE BANDAGE PALM PALM CLOSED CLOSED BANDAGE BANDAGE 1. This technique technique is indicated indicated 1.1. 1. This This This technique technique is is is indicated indicated for for horizontal horizontal cut cut forfor horizontal horizontal cut cut or oror or wounds wounds on the the palm. palm. wounds wounds onon on the the palm. palm. 2. Narrow Cravat 2.2. 2. Narrow Narrow NarrowCravat Cravat Cravatis is is isto toto tobe bebe be used. used. used. used. 3. Place the middle the 3.3. 3. Place Place Placethe the themiddle middle middleof ofof ofthe the the bandage bandage on on the the wrist wrist bandage bandage onon the the wrist wrist area. area. area. area. 4. 4. First First Rotation—Pull the 4. 4. First First Rotation—Pull Rotation—Pull Rotation—Pull the the the bandage bandage nearest you gobandage bandagenearest nearest nearestyou you yougogogoing ing towards the knuckles ing ingtowards towards towardsthe the theknuckles knuckles knuckles covering covering the fingers from covering coveringthe the thefingers fingers fingersfrom from from the the pinky pinky side, side, passing passing the the the the pinky pinky side, side, passing passing the the closed closed fingers and the closed closedfingers fingers fingersand and andto toto tothe the the back back of the the thumb thumb area. area. back back ofof of the the thumb thumb area. area. 5. Second Rotation—Pull the 5.5. 5. Second Second SecondRotation—Pull Rotation—Pull Rotation—Pullthe the the bandage bandage side farther bandage bandageside side sidefarther farther fartherto toto to you you going towards the you yougoing going goingtowards towards towardsthe the the back back of the the hand hand covering covering back back ofof of the the hand hand covering covering the the remaining remaining uncovered uncovered the theremaining remaininguncovered uncovered area area the pinky side area areaon onon onthe the thepinky pinky pinkyside side side and and passing between the and andpassing passing passingbetween between betweenthe the the thumb thumb and and index index finger finger thumb thumb and andindex indexfinger finger area area then back norarea areathen then thenback back backto toto toits itsits itsnornornormal mal position. position. mal mal position. position. 6. Repeat First Rotation pro6.6. 6. Repeat Repeat RepeatFirst First FirstRotation Rotation Rotationproproprocedure cedure then then Second Second RotaRotacedure cedurethen thenSecond SecondRotaRotation tion procedure until the tion tionprocedure procedure procedureuntil until untilthe the the bandage bandage is consumed consumed and and bandage bandage is is is consumed consumed and and ready ready securing. Leave ready readyfor forfor forsecuring. securing. securing.Leave Leave Leave the the thumb thumb uncovered. uncovered. the the thumb thumb uncovered. uncovered. 7. the the ends ends using using square square 7.7. 7. Tie TieTie Tie the the ends ends using using square square knot. knot. Check Check PMS PMS for tighttightknot. knot. Check Check PMS PMS forfor for tighttightness ness and/or and/or looseness looseness ness nessand/or and/orlooseness loosenessof ofof of the the application. application. the the application. application.

²² Limmer Limmer (Brady) (Brady) ³³ Pollack, Pollack, (AAOS) (AAOS) ⁴⁴ NHTSA NHTSA

PRINCIPLES RINCIPLES OF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE

PALM PALM(HORIZONTAL (HORIZONTALCUT) CUT)BANDAGE BANDAGE

Limmer ²Limmer Limmer (Brady) (Brady) (Brady) Limmer (Brady) Pollack, ³Pollack, Pollack, (AAOS) (AAOS) (AAOS) Pollack, (AAOS) ⁴NHTSA NHTSA NHTSA NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

487

4. 4.4. 4.

or or up up to to where where the thepatient patient patient or orup upto towhere wherethe the patient can can tolerate tolerate it.it. can cantolerate tolerateit. it. Interchange Interchange the the ends ends bebebeInterchange Interchange the the ends ends behind hind the the leg leg and and pull pull pull itititit hind hind the the leg leg and and pull towards towards the the front front and and and towards towards the the front front and interchange interchange again again the the the interchange interchange again again the ends ends while while inserting inserting one one ends ends while while inserting inserting one one end end to the bandage ininend to to the the bandage bandage ininward ward going outward then then wardgoing goingoutward outwardthen then do do to the other end. doitit itto tothe theother otherend. end. Pull Pull the ends upward to to to Pull the the ends ends upward upward to fix fix the position ofthe thefoot, foot, foot, fixthe theposition positionofof the foot, then then tie the ends using using using then tie tie the the ends ends using square square knot, hide the exexexsquare knot, knot, hide hide the the excess cess to make the bandage bandage cessto tomake makethe thebandage bandage neat. neat.

UNIT UNIT33 3 UNIT 33 UNIT UNIT PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES OF PRINCIPLES EMT CLINICAL PRACTICE DAY 19 DAY 19 DAY 19 DAY19 19 PRINCIPLES DAY Day 19

PRINCIPLES OF EMT CLINICAL PRACTICE

SHOE ON BANDAGE SHOE ON BANDAGE ON BANDAGE SHOE SHOE BANDAGE SHOE ON ON BANDAGE 5.5. 5.

SHOE ON BANDAGE

1. 2. 3. 4.

SHOE ON BANDAGE SHOE ON BANDAGE SHOE SHOEON ONBANDAGE BANDAGE SHOE ON BANDAGE 1. Indicated for sprain condiIndicated forsprain spraincondicondi1.1. 1. Indicated Indicatedfor for sprain condi1. Indicated for sprain condition that needs support. tion that needs support. tionthat thatneeds needssupport. support. tion tion that needs support. 2. Narrow Cravat to be Indicated for condition that needs Narrow Cravat is to tobe be 2.sprain Narrow Cravat to be 2.2. Narrow Cravat isis to be 2. Narrow Cravat isis used. Put the middle part used. Put the middle part support. used. Put Putthe themiddle middlepart part used. used. Put the middle part of the bandage underthe bandage underNarrow Cravat of is be Put the middle oftothe theused. bandage underbandage underofof the bandage underneath the shoe for anneath the shoe for anpart of the bandage underneath shoe for neath the shoe shoethe for anneath the for anneath the shoe for anchoring purposes. choring purposes. choring purposes. choring purposes. anchoring purposes. choring purposes. 3. Pull the bandage gently Pull the bandage gently 3. Pull Pull theor bandage gently 3. the bandage gently 3.3. Pull Pull the bandage gently up to where the the bandage gently oror up toto where the patient up wherethe thepatient patient or up to where the patient or up to where or upit.to where the patient patient can tolerate can tolerate it.it. can tolerate cantolerate tolerate it. can tolerate it.it. Interchange4.4. thecan ends behind the leg and pull Interchange the ends beInterchange theends endsbebe4. Interchange the ends be4. Interchange the 4. front Interchange the ends beit towards the and interchange again the hind the leg and pull it hind the leg and pull hindthe theleg legand andpull pullitititit hind hind the leg and pull ends while inserting one end to the bandage towards the front and towards the front front and and towards the the front and towards towards the front inward going outward then doagain it to theand other interchange again the interchange again the interchange again the interchange the interchange again one the end. ends while inserting ends while inserting one ends while inserting one ends while inserting one ends while inserting one end to the bandage inPull the ends upward tothe fix position of the end to to thethe bandage inend bandage inend to the bandage inward going outward then ward going foot, then tie the ends using square knot, hide outward then ward going outward then ward going outward then do to the other end. doititthe itto tothe the excess to make bandage neat. the other end. do other end. do it to the other end. to 5.5. Pull Pull upward Pull the the ends endsupward upwardto to 5. 5. Pull the the ends ends upward to fix the position ofofthe the foot, fixthe theposition positionof thefoot, foot, fix fix thetie position of theusing foot, then the ends then tiethe theends ends using then tie using then tie the ends using square knot, hide the exsquareknot, knot,hide hidethe theexexsquare square knot, hide the excess totomake make the bandage cessto makethe thebandage bandage cess cess to make the bandage neat. neat. neat. neat.

PRINCIPLES OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLESOF OF EMT CLINICAL PRACTICE PRINCIPLES 5.

SHOEON BANDAGE ONBANDAGE ON BANDAGE SHOE

UNIT 3 DAY 19

488

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ² ²Limmer (Brady) Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ ³Pollack, (AAOS) Pollack, (AAOS) ³ Pollack, (AAOS) ⁴Limmer NHTSA(Brady) ⁴ ⁴²²NHTSA Limmer (Brady) NHTSA ⁴ NHTSA Pollack, (AAOS) (AAOS) ³³ Pollack, NHTSA ⁴⁴ NHTSA

SHOE ON BANDAGE 1. Indicated for sprain condition that needs support. 2. Narrow Cravat is to be used. Put the middle part of the bandage underneath the shoe for anchoring purposes. 3. Pull the bandage gently or up to where the patient can tolerate it. 4. Interchange the ends behind the leg and pull it towards the front and interchange again the ends while inserting one end to the bandage inward going outward then do it to the other end. 5. Pull the ends upward to fix the position of the foot, then tie the ends using square knot, hide the excess to make the bandage neat.

³ ⁴

E EE

UNIT 3 UNIT 33 UNIT DAY 19 19 DAY 19 DAY

PRINCIPLES OF OF EMT EMT CLINICAL CLINICAL PRACTICE PRACTIC PRACTICE PRINCIPLES SHOE ON ON BANDAGE BANDAGE SHOE

SHOE ON ON BANDAGE BANDAGE SHOE SHOE SHOE ON ON BANDAGE BANDAGE 1. Indicated Indicated for for sprain sprain condicondi1. 1. 1. Indicated Indicated for for sprain sprain condicondition that that needs needs support. support. tion tion tion that that needs needs support. support. 2. Narrow Narrow Cravat Cravat isis to to be be 2. 2. 2. Narrow Narrow Cravat Cravat is is to to be be used. Put Put the the middle middle part part used. used. used. Put Put the the middle middle part part of the the bandage bandage underunderof of of the the bandage bandage underunderneath the shoe for anneath the shoe for anneath neath the the shoe shoe for for ananchoring purposes. purposes. choring choring choring purposes. purposes. 3. Pull Pull the the bandage bandage gently gently 3. 3. 3. Pull Pull the the bandage bandage gently gently or up up to to where where the the patient patient or or or up up to to where where the the patient patient can tolerate tolerate it. it. can can can tolerate tolerate it. it. 4. Interchange Interchange the the ends ends bebe4. 4. 4. Interchange Interchange the the ends ends bebehind the the leg leg and and pull pull itit hind hind hind the the leg leg and and pull pull itit towards the the front front and and towards towards towards the the front front and and interchange again again the the interchange interchange interchange again again the the ends while while inserting inserting one one ends ends ends while while inserting inserting one one end to to the the bandage bandage ininend end end to to the the bandage bandage ininward going going outward outward then then ward ward ward going going outward outward then then do it to to the the other other end. end. do do do ititit to to the the other other end. end. 5. Pull Pull the the ends ends upward upward to to 5. 5. 5. Pull Pull the the ends ends upward upward to to fix the the position position of of the the foot, foot, fix fix fix the the position position of of the the foot, foot, then tie tie the the ends ends using using then then then tie tie the the ends ends using using square knot, knot, hide hide the the exexsquare square square knot, knot, hide hide the the exexcess to to make make the the bandage bandage cess cess cess to to make make the the bandage bandage neat. neat. neat. neat.

² ²Limmer Limmer(Brady) (Brady) ³ ³Pollack, Pollack,(AAOS) (AAOS) ⁴ ⁴ NHTSA NHTSA

PRINCIPLES OF EMT CLINICAL PRACTICE

² Limmer (Brady) Limmer (Brady) ² ²²Limmer Limmer(Brady) (Brady) ³ Pollack, (AAOS) Pollack, (AAOS) ³ ³³Pollack, Pollack,(AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA ⁴ ⁴NHTSA NHTSA

SHOE ON BANDAGE

LIFELINE

PREHOSPITAL EMERGENCY CARE

489

1.1. Indicated Indicatedfor forsprain spraincondicondi1.1. Indicated Indicatedfor forsprain spraincondicondition tionthat thatneeds needssupport. support. tion tionthat thatneeds needssupport. support. 2. 2. Narrow Narrow Cravat Cravat is is to to be be 2.2. Narrow Narrow Cravat Cravat isis toto be be used. used. Put Putthe themiddle middlepart part used. used. Put Putthe themiddle middlepart part ofofthe thebandage bandageon ontop topofof ofofthe thebandage bandageon ontop topofof the thefoot. foot. the thefoot. foot. 3. 3. Pull Pull both both sides sides going going 3.3. Pull Pull both both sides sides going going down downand andinterchange interchangeit,it, down downand andinterchange interchangeit,it, while while pulling pulling it it again again upupwhile whilepulling pullingititagain againupupward wardUntil Untilititreaches reachesbebeward ward Until Until itit reaches reaches bebehind hindwhile whileconsidering consideringifif hind hind while while considering considering ifif the the patient patient can can tolerate tolerate UNIT the tolerate the patient patient can canUNIT tolerate33 the thepulling pulling(if(ifnot, not,adjust adjust the adjust the pulling pulling (if(if not, not, adjust DAY DAY 19 19 SHOE OFF BANDAGE accordingly) accordingly) SHOE OFF BANDAGE accordingly) accordingly) 4. 4. Interchange Interchange the the ends ends Indicated sprain condi1. 1. Indicated forfor sprain condi4.4. Interchange the Interchange the ends ends again againbehind behindthe theleg legand and tion that needs support. again the leg and tion that needs support. againbehind behind the leg and pull pull the the ends ends going going toto pull ends going totoCravatis isto tobebe Narrow pull the the ends goingCravat 2. 2. Narrow front, front, interchange interchange itit front, itthe front, interchange interchange it the used.PutPut middle part used. middle part again. again. again. SHOE SHOE OFF OFFBANDAGE BANDAGE again. of the bandage on top of of the bandage on top of 5.5. After After interchanging interchanging the the 5. After the 1. 1. Indicated for forsprain spraincondicondi5. Indicated After interchanging interchanging ends, ends, insert insert one one end end toto the foot.the the foot. ends, insert one end tion tion that that needs needs support. support. ends, insert one end toto the the bandage bandage inward inward gogo3. Pull both sides going 3. Pull both sides going the bandage inward go2.2. Narrow Narrow Cravat Cravatinward isis toto be be the bandage going ingoutward outwardthen thendo doitittoto ing then do itpart totointerchange down interchange down and it, it, used. used. Put Putthe the middle middle part ingoutward outward then do itand the the other other end. end. the other end. of of the the bandage bandage on ontop toppulling ofof it again while it again the other end. while pulling up-up6.6. Pull Pullthe theends endsupward upwardtoto 6.6. the Pull the upward toto it reaches bethe foot. foot. Pull the ends ends upward ward Until ward Until it reaches befixfixthe theposition positionofofthe thefoot, foot, fix position ofofthe foot, 3.3. Pull Pull both both sides sides going going fixthe the position the foot, hind while considering if hind while considering if then then tie tie the the ends ends using using then the ends down down and and interchange interchange it,it, then tie tie the ends using using square squareknot, knot,hide hidethe theexexthe patient can tolerate the patient can tolerate square knot, hide the exwhile while pulling pulling itagain again upsquare knot,ithide theupexcess cesstotomake makethe thebandage bandage the pulling not, adjust pulling not, adjust cess make the bandage ward ward Until Until ititthe reaches reaches bebe- (if (if cesstoto make the bandage neat. neat. neat. accordingly) accordingly) hind hind while considering considering ifif neat.while 7.7. Check Checkfor forPMS PMS 7.7. the Check for the patient patient can can tolerate tolerate Check forPMS PMS 4. Interchange ends 4. Interchange thethe ends UNIT UNIT3 3 the thepulling pulling(ifagain (ifnot, not, adjust adjust again behind and behind thethe legleg and accordingly) accordingly) pull the ends going to DAY DAY 1919 pull the ends going to SHOE OFF BANDAGE 4.4. Interchange Interchange the the ends ends front, interchange it it SHOE OFF BANDAGE front, interchange again againbehind behind the theleg legand and 1. 1. Indicated forfor sprain condiIndicated sprain condiagain. again. pull pull the the ends ends going going toto tion that needs support. tion that needs support. 5. After Afterinterchanging interchanging thethe front, front, 5. interchange interchange itit NarrowCravat Cravatis isto tobebe again. again. ends,insert insertone oneend endto to 2. 2. Narrow ends, SHOE SHOE OFF OFF BANDAGE BANDAGE used. thethe middle part 5.5. After After interchanging interchanging the the inward used.PutPut middle part bandage inwardgo-gothethebandage 1. 1. Indicated Indicated for sprain sprain condicondiends, ends, insert insert one one end end toto of of thethe bandage on toptop offor bandage on of ing outward then it to ing outward then dodo it to tion tion that that needs needs support. support. the the bandage bandage inward inward gogothethe foot. foot. the other end. the other end. 2. 2. Narrow NarrowCravat Cravatis isto tobebe ing ingoutward outwardthen thendo doitittoto going 6. Pullthetheends endsupward upwardto to 3. 3. Pull Pullboth bothsides sides going used. used. PutPut thethe middle middle part part 6.end. Pull the theother other end. down and interchange it,bandage of of thethe bandage toptop of of fix position foot, 6.6. Pull Pull the the ends ends upward toto fixupward thethe position of of thethe foot, down and interchange it, onon the foot. foot. while pulling it again upfix fixthe theposition position of ofthe the foot, foot, then tiethetheends endsusing using then tie while pulling it the again up3. 3. Pull Pull both both sides sides going going then then tie tie the thesquare ends ends using using ward Until it reaches besquare knot, hide knot, hide thethe ex-exward Until it reaches be-interchange down down and and interchange it, it, square squareknot, knot,hide hide the the exexcess to make the bandage hind while considering if cess to make the bandage hind while considering if while while pulling pulling it again it again up-upcess cesstotomake makethe thebandage bandage neat. neat. the patient can tolerate ward ward Until Until it it reaches reaches bebethe patient can tolerate neat. neat. 7. Check PMS 7.PMS Check forfor PMS hind hind while whileconsidering consideringif if thethe pulling (if (if not, adjust 7.7. Check Checkfor for PMS pulling not, adjust thethepatient patientcan cantolerate tolerate accordingly) accordingly) thethepulling pulling (if (if not, not, adjust adjust 4. 4. Interchange ends Interchange thethe ends accordingly) accordingly) again behind the leg and again behind the leg and thethe ends 4. 4. Interchange Interchange ends pull tobehind again again behind and and pullthetheends endsgoing going to thethelegleg pull pull the the ends ends going going to to front, interchange it front, interchange it front, front, interchange interchange it it again. again. again. again. SHOE SHOE OFF OFF BANDAGE BANDAGE 5. 5. After the Afterinterchanging interchanging the 5. 5. After After interchanging interchanging thethe SHOE OFF BANDAGE 1.1. Indicated Indicatedforforsprain spraincondicondi² Limmer ² Limmer (Brady) (Brady) ends, end toinsert ends, ends, insert oneend to ² Limmer (Brady) ends,insert insertone one end to one ² Limmer (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) 1.endtoIndicated for sprain condi³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA tion tion that that needs needs support. support. the the bandage bandage inward inward gogothe bandage inward go⁴ ⁴NHTSA the bandage inward goNHTSA tion that needs support. ing ing outward outward then then do do it to it to 2.2. Narrow NarrowCravat Cravatis istotobebe inging outward then dodo it to outward then it end. toend. 2. Narrow Cravat is to be thethe other other used. used.Put Putthe themiddle middlepart part thethe other end. other end. 6. 6. Pull Pullthetheends endsupward upwardto to used. Put the middle part ofofthe thebandage bandageonontop topofof 6. 6. Pull thethe ends upward toposition Pull ends upward to of of fixfix thethe position thethe foot, foot, of the bandage on top of the the foot. foot. fix fix thethe position of of the foot, then then tie tiethetheends endsusing using position the foot, the foot. 3.3. Pull Pull both both sides sides going going square square knot, knot, hide hide thethe ex-exthen using thentietiethetheends ends using 3. Pull both sides going cess cess to to make make the the bandage bandage down downand andinterchange interchangeit, it, square knot, hide thethe ex-exsquare knot, hide down and interchange it, neat. neat. while whilepulling pullingit itagain againupupcess to to make the cess make bandage 7.the 7.bandage Check Check forfor PMS PMS while pulling it again up-

UNIT3 3 UNIT PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY1919PRINCIPLES DAY Day 19

SHOE OFF BANDAGE

PRINCIPLES OF EMT CLINICAL PRACTICE

SHOEOFF OFFBANDAGE BANDAGE SHOE

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE SHOE SHOEOFF OFFBANDAGE BANDAGE

1. Indicated for sprain condition that needs support. 2. Narrow Cravat is to be used. Put UNIT UNIT3 3 the middle part of the bandage on PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY 1919PRINCIPLES DAY top of the foot. T3 3 3. Pull bothOF sides going down and PRACTICE PRINCIPLES OFEMT EMTCLINICAL CLINICAL PRACTICE 919PRINCIPLES interchange it, while pulling it SHOE BANDAGE SHOEOFF OFF BANDAGE again upward Until it reaches PRINCIPLES PRINCIPLES OF OFEMT EMT CLINICAL CLINICALPRACTICE PRACTICE behind while considering if the SHOE SHOEOFF OFFBANDAGE BANDAGE patient can tolerate the pulling (if SHOE SHOEOFF OFFBANDAGE BANDAGE not, adjust accordingly) i4. Interchange the ends again behind e the leg and pull the ends going to t f front, interchange it again. 5. After interchanging the ends, g insert one end to the bandage t, pinward going outward then do it eto the other end. f UNIT UNIT 33 UNIT 3 e 6. Pull the ends upward to fix the PRINCIPLES PRINCIPLES OF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 19 19 t position of the foot, then tie the DAY 19 PRINCIPLES OF EMT CL ends using square knot, hide the s d excess to make the bandage neat. o SHOE SHOEOFF OFFBANDAGE BANDAGE SHOE OFF BA 7. Check for PMS t

e o oo

o t, g xe

ward wardUntil Untilit itreaches reachesbebehind hindwhile whileconsidering consideringif if the thepatient patientcan cantolerate tolerate the thepulling pulling(if(ifnot, not,adjust adjust accordingly) accordingly) Interchange Interchange the the ends ends again againbehind behindthe theleg legand and pull pullthe theends endsgoing goingtoto front, front, interchange interchange it it again. again. After After interchanging interchanging the the ends, ends,insert insertone oneend endtoto the thebandage bandageinward inwardgogoing ingoutward outwardthen thendodoit ittoto the the other other end. end. Pull Pullthe theends endsupward upwardtoto fixfix the the position position ofof the the foot, foot, then thentietiethe theends endsusing using square squareknot, knot,hide hidethe theex-excess cess toto make make the the bandage bandage neat. neat. Check Check forfor PMS PMS

neat. neat. 7. 7. Check forfor PMS Check PMS

EMT CLINICAL PRACTICE 4.4.

OFF BANDAGE 5.5.

6.6.

7.7.

4. ² Limmer ² Limmer (Brady) (Brady)

³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ ⁴NHTSA NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

ward Until it reaches behind while considering if the patient can tolerate the pulling (if not, adjust accordingly) Interchange the ends again behind the leg and pull the ends going to front, interchange it again. After interchanging the ends, insert one end to the bandage inward going outward then do it to the other end. Pull the ends upward to fix the position of the foot, then tie the ends using square knot, hide the excess to make the bandage neat. Check for PMS ² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

490

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ² Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

MUSCULOSKELETAL TRAUMA LEARNING OBJECTIVES

INTRODUCTION

• Describe the function of the muscular and skeletal system. • List the major bones or bone groupings of the spinal column, the thorax, the upper extremities, and the lower extremities. • State the reasons, general rules and complications of splinting. • List the emergency medical care for a patient with a painful, swollen, deformed extremity. • Explain the rationale for splinting at the scene versus load and go. • Differentiate between an open and a closed painful, swollen, deformed extremity.

MUSCULOSKELETAL SYSTEM

The musculoskeletal system is composed of all the

LINICAL PRACTICE body’s bones, joints, and muscles, as well as cartilage,

tendons, and ligaments. As an EMT, you do not need to know every structure found in the body. However, you do ANDAGEneed to remember how complex the structures are and what kinds of damage may be done in case of injury. Review the skeleton and its major divisions, the axial skeleton and the appendicular skeleton. The bones of the axial skeleton include the skull (including the cranium and face), the sternum, the ribs, and the spine including the cervical, thoracic, and lumbar vertebrae, the sacrum, and the coccyx. In this topic, we will pay special attention to the appendicular skeleton, particularly the extremities — the upper extremities (clavicles, scapulae, arms, wrists, and hands) and the lower extremities (pelvis, thigh*, legs, ankles, and feet).

Anatomy of Bone Bones are formed of dense connective tissue. As components of the skeleton, they provide the body’s framework. They need to be strong to provide support and protection for the internal organs, but they also need to be somewhat flexible to withstand stress. The bones store salts and metabolic materials and provide a site for the production of red blood cells. Because of this, hones are very vascular—that is. they contain a rich supply of blood. It is important to know this because, simply stated, bones bleed. Although broken bone ends may cause damage to surrounding tissue and blood vessels, the bones themselves also bleed. This is why a patient with a fractured pelvis, hip, or femur—or multiple fractures—may actually develop shock from blood loss from the bone itself.

Musculoskeletal injuries are common. As an EMT, you will be called upon to treat injuries to muscles and bones, which range from minor to life threatening. Many musculoskeletal injuries can have a grotesque appearance When called upon to fully evaluate the patient, do not be distracted from life-threatening conditions by a deformed limb.

Joints are the places where bones articulate, or meet, and are a critical clement in the body’s ability to move. Generally, bones are classified according to their appearance—long, short, flat, and irregular. The bones found in the arm and thigh are examples of long bones. The major short bone of the body are in the hands and feet. The flat bones include the sternum, shoulder blades, and ribs. The vertebrae of the spinal column are examples of irregular bones. The outward appearance of a typical long bone creates the impression that it is a simple, rigid structure made of the same material throughout. Actually, it is quite complex. Most people are aware that bone contains calcium, which helps to make it very hard. Bone also contains protein fibers that make it somewhat flexible. The strength of our bones is due to a combination of this hardness and flexibility. As we age. less protein is formed in the bones, and less calcium is stored. As a result, bones become brittle and more easily break. Bones are covered by a strong, white, fibrous material called the periosteum. Blood vessels and nerves pass through this membrane as they enter and leave the bone. When bone is exposed as a result of injury, the periosteum becomes visible. Although you may see fragments of bones and foreign objects on this covering, do not remove them. If they have pierced the periosteum, the objects may be held firmly in place and offer a great resistance to any pulling or sweeping efforts. In addition, you will not be able to tell if the object has entered the bone or is impaled in an underlying blood vessel or nerve. Bones are covered by a strong, white, fibrous material called the periosteum. Blood vessels and nerves pass through this membrane as they enter and leave the bone. When bone is exposed as a result of injury, the periosteum becomes visible. Although you may see fragments of bones and foreign objects on this covering, do not remove them. If they have pierced the periosteum, the objects may be held firmly in place and offer a great resistance to any pulling or sweeping efforts. In addition, you will not be able to tell if the object has entered the bone or is impaled in an underlying blood vessel or nerve.

LIFELINE

PREHOSPITAL EMERGENCY CARE

491

Day 19

Self-Healing Nature of Bone The most common bone injury is a break, or fracture. The first effects of a bone injury are swelling of soft tissue and the formation of a blood clot in the area of the fracture. Both the swelling and the clotting are due to the destruction of blood vessels in the periosteum and the bone as well as to loss of blood from adjacent damaged vessels. Interruption of the blood supply causes death to the cells at the injury site. Cells a little farther from the fracture remain intact and. within a few hours, begin to more rapidly divide. They soon grow together to form a mass of tissue that completely surrounds the fracture site. New bone is generated from this mass to eventually heal the damaged bone. The whole process can take weeks or months depending on the bone that has been fractured, the type of fracture, and the patient’s health and age. It is very important for a broken bone to be immobilized quickly and remain immobilized in order to properly heal. If the fractured bone is mishandled early in care, more soft tissue may be damaged, which would require a longer period for the formation of a tissue mass and replacement of bone. If the bone ends are disturbed during regeneration, proper healing will not take place and a permanent disability may result. In children, the majority of growth of a long bone occurs in the area known as the growth plate, which is near the end of the shaft. If a fracture in this area is not properly handled, the child may grow up with one limb shorter than the other.

PRINCIPLES OF EMT CLINICAL PRACTICE

GENERAL GUIDELINES FOR EMERGENCY CARE Mechanisms of Musculoskeletal Injury There are basically three types of mechanisms that cause musculoskeletal injuries: direct force, indirect force, and twisting force. An example of direct force is a person being struck by an automobile, causing crushed tissue and fractures. Twisting or rotational forces can cause stretching or tearing of muscles and ligaments, as well as broken bones, such as occur when a ski digs into the snow while the skier’s body rotates. Sporting activities such as football, basketball, soccer, inline skating, skiing, snow-boarding, and wrestling—in addition to motor-vehicle collisions—account for many musculoskeletal injuries. It is easy to see how direct forces cause injuries, but an indirect force can be just as powerful. For example, a well-known injury pattern occurs when people fall from heights and land on their feet. The direct forces cause injuries to the feet and ankles, whereas indirect forces usually cause injuries to the knees, femurs, pelvis, and spinal column. In fact, most injuries to the upper extremities are caused by forces applied to an outstretched arm. In the course of a fall, the person reaches out with an arm in an effort to break the fall and, in doing so. often breaks the radius, ulna, or clavicle, or dislocates the shoulder.

Injury to Bones and Connective Tissue A fracture is the breaking of a bone. Some fractures you may encounter are grossly deformed and painful. However, you may also encounter extremities that have minimal pain and deformity but are, in fact, fractured. Unless there is a very obvious deformity, it is not possible or even important for you to decide if a patient’s

Muscles, Cartilage, Ligaments, and Tendons In addition to bones, the elements of the musculoskeletal system are the muscles, cartilage, ligaments, and tendons. Muscles are the tissues or fibers that cause movement of body parts or organs. There are three kinds of muscles: skeletal (voluntary), smooth (involuntary), and cardiac (myocardial). Smooth, or involuntary, muscles are found in the walls of organs and digestive structures. These muscles move food through the digestive system, Cardiac muscle is found in the walls of the heart. The muscles that are of chief concern in trauma and musculoskeletal injury are the skeletal, or voluntary, muscles. These muscles control all conscious or deliberate motions. The skeletal or voluntary muscles include all the muscles that arc connected to bones as well as the muscles in the tongue, pharynx, and upper esophagus. Cartilage is connective tissue that covers the outside of the bone end (epiphysis) and acts as a surface for articulation, allowing for smooth movement at joints. Cartilage, which is less rigid than bone, forms or helps to form some of the more flexible structures of the body, such as the septum of the nose (the wall between the nostrils), the external ear. the trachea, and the connections between the ribs and sternum (breastbone). Tendons are bands of connective tissue that bind the muscles to bones. The tendons allow for the power of movement across the joints Ligaments are connective tissues that support joints by attaching the bone ends and allowing for a stable range of motion. Two mnemonics can help you distinguish between the connective functions of tendons and ligaments: MTB - muscle-tendon-bone; BLB = bone-ligament-bone. 492

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injury is a fracture, a dislocation, a sprain, or a severe bruise. Most patients simply present with pain, swelling, and— sometimes—deformity. It will take an X-ray or other imaging process to precisely diagnose the injury. In the field, therefore, the worst must be assumed, and a patient with signs and symptoms of a fracture—a painful, swollen, or deformed extremity—should be treated as though he has a fracture. Although most fractures are not life threatening, remember that bones are living tissue. Even in simple uncomplicated fractures, bones bleed. For example, a simple closed tibia-fibula fracture typically causes a 1-pint (500 cc) blood loss. Fractures of the femur typically cause a 2-pint (1,000 cc) blood loss, and pelvic fractures cause a 3- to 4-pint (1300-2.000 cc) blood loss. In World War I. the battlefield death rate from closed fractures of the femur was about 80 percent, because of complications such as blood loss. Two surgeons noticed that large muscle groups in the thigh go into spasms (contract, or shrink), forcing the broken femoral ends to override each other, injuring the blood vessels. To correct the problem, they invented the traction splint, a splint that applies constant pull along the length of the leg to help stabilize the fractured bone and reduce muscle spasms. With early application of a traction splint, the mortality rate from femur fractures dropped to under 20 percent (and is much lower today). Remember that splinting an extremity with a suspected fracture can prevent additional blood loss. pain, and complications from nerve and blood vessel injury. Therefore, treat for the worst (a fracture) and immobilize. Physicians in the hospital will diagnose the actual injury with an X-ray.

Assessment of Musculoskeletal Injuries Examination involves your senses and the skills of inspection (looking), palpation (feeling), and auscultation (listening). One of the basic principles of assessment is that it is difficult to do a proper examination on patients when they are fully clothed. However, it is often difficult, impractical, or inadvisable to completely disrobe or cut away a patient’s clothing due to weather, the patient’s modesty, or patient refusal. A good rule of thumb is to cut or remove clothing according to the environment and severity of the situation. In cases of severe extremity trauma, injuries can be very obvious. However, when treating trauma patients, your priority must be to rapidly identify and treat lifethreatening conditions first. Do not let a grotesque but relatively minor extremity injury sidetrack you—or the patient. The pain or terrible appearance of an extremity injury may distract the patient from awareness of other injuries or symptoms, such as abdominal pain from internal bleeding. Be sure to assess the patient fully and ask appropriate questions to avoid missing other injuries. Only after your primary assessment and rapid trauma assessment have ruled out obvious lifethreatening airway, breathing, or circulation problems and injuries to the head, spine, chest, and abdomen should you focus your attention on musculoskeletal injuries to the extremities.

Four Types of Musculoskeletal Injury • Fracture. A fracture is any break in a bone.

Fractures can be classified as open or closed, and are also classified by the way a bone is broken— comminuted fractures if broken in several places, greenstick fractures if the break is incomplete, or angulated fractures if the broken bone is bent at an angle. • Dislocation. The disruption or “ coming apart” of a joint is called a dislocation. In order for a joint to dislocate, the soft tissue of the joint capsule and ligaments must be stretched beyond the normal range of motion and torn. • Sprain. A sprain is caused by the stretching and tearing of ligaments. It is most commonly associated with joint injuries. • Strain. A strain is a muscle injury caused by overstretching or overexertion of the muscle.

A closed extremity injury is one in which the skin is not broken. An open extremity injury is one in which the skin has been broken or torn through from the inside by the injured bone or from the outside by something that has caused a penetrating wound with associated injury to the hone. An open injury is a serious situation because of the increased likelihood of contamination and subsequent infection. Although many closed injuries can be handled simply in the hospital emergency department, patients with open fractures require surgery Proper splinting and prehospital care of musculoskeletal injuries help prevent closed injuries from becoming open ones.

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PRINCIPLES OF EMT CLINICAL PRACTICE

Compartment Syndrome A critical complication of extremity fracture is compartment syndrome. This is a serious condition caused by severe swelling in the extremity—in this case, as the result of a fracture. Compartment syndrome progresses as follows: 1. A fracture or crush injury causes bleeding and swelling within the extremity. 2. Pressure and swelling caused by the bleeding within the muscle compartment becomes so great that the body can no longer perfuse the tissues against the pressure. 3. Cellular damage occurs and causes additional swelling. 4. Blood flow to the area is lost. The limb itself may be lost if the pressure is not relieved.

Signs and symptoms of compartment syndrome arc similar to those of the injury that caused the condition. Expect to see pain and swelling. The patient may complain of a sensation of pressure. The extremity may feel ‘hard” on palpation when compared to the uninjured side, and distal circulation, sensation, and motor function (CSM) may be reduced or absent. EMTs can best treat compartment syndrome by some of the same treatments as for fracture, including cold application and elevation of the extremity (if this can be done safely after splinting). Prompt transport to an appropriate facility is important.

PATIENT ASSESSMENT Musculoskeletal Injuries

Signs and symptoms of musculoskeletal injuries in a patient include the following • Pain and tenderness. The patient with a painful, swollen, or deformed extremity experiences pain when the injured part is touched or moved Generally, a patient will hold the injured part till, or guard it. in an effort to minimize pain When examining a conscious patient, ask him to point to the location of the pain, if possible Then, initially avoiding that location, carefully examine the injured part to assess if there are any other painful or injured areas. With unresponsive patients, suspicion of injury must be based on other physical findings. • Deformity or angulation. The force of trauma causes bones to fracture and become deformed, or angulated. out of the anatomical position. Note that when a patient has joint injuries. the deformity is sometimes subtle. When in doubt, look at the uninjured side and compare it to the injured one • Grating, or crepitus. This is a sound or feeling caused by broken bone ends rubbing together. It can be painful for the patient, so never intentionally cause crepitus. The patient may report grating noises or sensations that occurred prior to your arrival and examination • Swelling. When bones break and soft tissue is torn, bleeding causes swelling that may increase the proportions of a deformity Rings, watches, and other jewelry can easily constrict and injure underlying tissue Therefore, slide or cut them off as soon as possible if swelling is likely to occur • Bruising. Ecchymosis or large black-and-blue discoloration of the skin, indicates an underlying injury that may be hours or days old Obvious bruises indicate the need for splinting. • Exposed bone ends. Bone ends protruding through 494

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the skin indicate a fracture that requires splinting Again, the more gruesome the appearance of the extremity the greater the temptation is for you to treat that injury first. Remember that you should care for life-threatening injuries first. Extremity injuries rarely kill patients. • Joints locked Into position. When joints are dislocated, they may lock into normal or abnormal anatomical positions. Joint injuries usually need to be splinted as found • Nerve and blood-vessel compromise. Examine for pulses, sensation, and movement distal to the injury site This must be accomplished before and after splinting. Check for nerve injury by asking the patient if he can sense your touch and can move all his fingers or toes. Any problem of sensation or movement must be noted. Next, feel for pulses in the wrist (radial), ankle (posterior tibial), or foot (dorsalis pedis). Obviously, to accurately examine lot sensation, movement, and pulses, the patient’s gloves and footwear must be removed. Another method of assessing compromise to an extremity when a musculoskeletal injury is suspected is to team and follow the “six Ps”: • Pain or tenderness • Pall or (pale skin or poor capillary refill) • Paresthesia, or the sensation of “pins and needles’ • Pulses diminished or absent in the injured extremity • Paralysis or the inability to move • Pressure

PATIENT CARE

Musculoskeletal Injuries Emergency care of a patient with musculoskeletal injuries includes the following steps 1. Take and maintain appropriate Standard Precautions 2. Perform the primary assessment Remember, do not get distracted from your primary assessment and from determining patient priority by focusing on a dramatic looking or painful extremity injury Keep in mind, however, that multiple fractures, especially to the femurs, can cause life-threatening external or internal bleeding 3. During the secondary assessment, apply a cervical collar if you suspect a spine injury 4. After life-threatening conditions have been addressed, any suspected extremity fracture must be splinted. For a low-priority (stable) patient, splint individual injuries before transport For a high-priority (unstable) patient, immobilize the whole body on a long spine board, then “load and go” If time and the patient’s condition permit, you may be able to splint a specific injury en route 5. If appropriate, cover open wounds with sterile dressings, elevate the extremity. And apply a cold pack to the area to help reduce swelling

Splinting Emergency care for all suspected extremity fractures starts by splinting. For any splint to be effective, it must immobilize adjacent joints and bone ends. Effective splinting minimizes the movement of disrupted joints and broken bone ends, and it decrease the patient’s pain. It helps prevent additional injury’ to soft tissues such us nerves, arteries, veins, and muscles. It can prevent a closed fracture from becoming an open fracture, a much more serious’ condition, and it can help to minimize blood loss. In the case of the spine, splinting on a back-board prevents injury to the spinal cord and helps to prevent permanent paralysis.

Realignment of the Deformed Extremity The object of realignment (straightening) is to assist in restoring effective circulation to the extremity and to fit it to a splint. Some injuries, such as certain wrist fractures, may be easily splintable because they are only slightly deformed In this case, the only reason to attempt realignment is to restore circulation to the hand if it appears to be cyanotic or lacks a pulse. The thought of realigning on angulated injury can be a frightening one. However, remember these points: • If the extremity is not realigned, the splint may be ineffective, causing increased pain and possible further injury (including an open fracture) during transportation.

Kung sa pagsusuri mo ay nalaman mo na ang pasyente ay hindi stable, ipagpaliban mo na muna ang paglalapat ng gamot sa mga injuries nito. Unahin ang pagbibigay ng ABC -- Airway, Breathing at Compression -- at ilagay ang pasyente sa spine board kung may posibilidad na may injury ito sa likod. Huwag mag-aksaya ng oras sa pagbebenda sa pasyente. Tiyakin na maliligtas muna ang buhay ng pasyente bago gamutin ang mga injuries nito.

• If the extremity is not realigned, the chance of nerves, arteries, and veins being compromised increases. When distal circulation is compromised or shut down, tissues beyond the injury become starved for oxygen and die. • Pain is increased for only a moment during realignment under traction Pain is reduced by effective splinting. Due to the size and weight of extremities, attempting to splint one in the deformed position is usually futile and only increases the chance of its becoming an open fracture. When angulated injuries to the tibia or fibula, femur, radius or ulna, or humerus cannot be fit into a rigid splint, realign the bone. Also re-align a long bone when the distal extremity is cyanotic or lacks pulses, indicating compromised circulation. The general guidelines for realigning an extremity are as follows: 1. One BUT grasps the distal extremity, while a partner places one hand above and one hand below the injury site. 2. The partner supports the site while the first EMT pulls gentle manual traction in the direction of the long axis of the extremity. If you feel resistance or if it appears that bone ends will come through the skin, stop realignment and splint the extremity in the position found. 3. If no resistance is fell, maintain gentle traction until the extremity is properly aligned and splinted. Generally, injured joints should be splinted in the position found unless the distal extremity is cyanotic or lacks pulses. If these conditions are present, try to align the joint to a neutral anatomical position using gentle traction, provided that no resistance is felt.

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Strategies for Splinting Effective splinting may require some ingenuity. Even though you carry different types of splinting devices, many situations will require you to improvise. In a pinch, you can use pillows or rolled blankets as soft splints. For rigid splints, you can use a piece of lumber, cardboard, a rolled newspaper, an umbrella. a cane, a broom handle, a catcher’s shin guard, or a tongue depressor for a finger. A bystander can often rummage through his car trunk and find something suitable. Splints carried on EMS units come in three basic types: rigid splints, formable splints, and traction splints. Rigid splints require the limb to be moved or the anatomical position. They tend to provide the greatest support and are ideally used to splint long-bone injuries. Examples are cardboard, wood. Velcro, pneumatic splints such as air splints and vacuum splints, and the pneumatic anti-shock garment. Formable splints are capable of being molded to different angles and generally allow for considerable movement. They are most commonly used to immobilize joint injuries in the position found. Examples are pillow and blanket splints. Traction splints are used specifically for femur fractures. Regardless of the method of splinting, general rules that apply to all types of immobilization are as follows: • Care for life-threatening problems first, If the patient is unstable, do not waste time with splinting. You can align the injuries in the anatomical position and immobilize the whole body to a long spine board. • Expose the Injury site. Before moving the injured extremity, expose the area and control any bleeding. • Assess distal CSM. Because complications of musculoskeletal injury include nerve and blood vessel injury, assess and record distal circulation, sensation, and motor function (CSM) both before and after splinting. • Align long-bone injuries to the anatomical position. Do this under gentle traction. if severe deformity exists or distal circulation is compromised. • Do not push protruding bones back into place. However, when you realign deformed open injuries, they may slip back into position under traction. • Immobilize both the injury site and adjacent joints. In order for splints to be infective, they must keep the injury site and the joints above and below still. (If the joint is injured, splint to immobilize the joint and the adjacent bones.) • Choose a method of splinting. This is always dictated by the severity of the patient’s condition and priority decision. If the patient is a high priority for “load and go” transport, choose a fast method of splinting. If the patient is a low priority for transport, choose a slower-but-better splinting method The methods of splinting from slowest to fastest are: Each site is 496

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individually splinted (slowest but best). The limb is secured to the torso or an uninjured leg (a bit faster, but second choice to individual splints). The entire body is secured to a spine board (fastest, but only better than no splint at all). • Splint before moving the patient to a stretcher or other location, if possible. A good rule of thumb is “least handling causes least damage.” Sometimes patients must be extricated from where they are before ideal splinting technique* can occur. Attempt to immobilize the extremity as well as you can. (For example, prior to extrication, the injured extremity might he immobilized to the uninjured one.) • Pad the voids. Many rigid splints do not conform to body curves and allow too much movement of the limb. Pad the voids, or spaces between the body pan and the splint, to ensure proper immobilization and increase patient comfort.

Hazards of Splinting By far the most serious hazard of splinting is “splinting someone to death”—splinting before life-threatening conditions are addressed, or spending time splinting a highpriority patient instead of immediately getting the patient into the ambulance and to the hospital. Remember that deformed fractures look painful and grotesque. Do not let that distract you from your priorities. Always ensure the parent’s airway, breathing, and circulation before going on to care for other injuries. Remember, the method of splinting is always dictated by the severity of the patient’s condition and by the priority for transportation. Other hazards include improper or inadequate splinting. If a splint is applied too tightly, it can compress soft tissue and injure nerves, blood vessels, and muscles. If it is applied too loosely or inappropriately, it will allow so much movement that further soft-tissue injury or an open fracture may occur. In addition, because rescue workers may be insecure about realigning a deformed injury, they may attempt to splint it in a deformed position and actually do more harm than goodRemember, it can be very difficult to splint deformed long-bone injuries well enough to prevent excessive movement.

Splinting Long-Bone and Joint Injuries Before you start the splinting process, select a splint appropriate to the severity of the patient’s condition and method of transportation. Be sure to have cravats, padding, and roller bandages immediately at hand. The splinting of joints usually requires considerable ingenuity. In most cases, formable splints are used to splint the joint in the position it is found. If the distal extremity is pulseless or cyanotic, try to align it to the anatomical position using gentle traction. As with long-bone splinting, get all of your equipment ready before starting the splinting process.

To splint long-bone or joint injuries, follow these guidelines: 1. Take appropriate Standard Precautions and. if possible, expose the area to be splinted. 2. Manually stabilize the injury site. This can be done either by you or by a helper 3. Assess circulation, sensation, and motor function (CSM). Check for pulses and see if the patient can feel your touch distal to the injury. Ask the patient to wiggle his fingers or toes to assess movement. Do not ask the patient to grasp, press, or pull an extremity you believe may be fractured. This will cause unnecessary pain and may aggravate the injury. 4. Realign the injury if deformed or if the distal extremity is cyanotic or pulseless. Be sure to attempt to realign an injured joint only if the distal extremity is pulseless or cyanotic. 5. Measure or adjust the splint and move it into position under or along-side the limb. Maintain manual stabilization or traction during positioning and until the splinting procedure is complete. 6. Apply and secure the splint to immobilize adjacent joints and the injury site. 7. Reassess CSM distal to the injury. If using a vacuum splint, use the previous steps to assess and prepare the extremity for splinting. Move the vacuum splint into position. Place the splint around the extremity, leaving the distal end (fingers or toes) exposed. Using the pump, withdraw the air from the splint until it is firm and then secure the Velcro straps. Monitor the patient.

Traction Splint

Splinting a femur injury is different from splinting other long-bone or joint injuries. The major problem with femur fractures is the tendency for the large muscle groups of the thigh (quadriceps and hamstrings) to go into spasm, forcing the bone ends to override each other, causing pain and further soft-tissue injury. A traction splint counteracts the muscle spasms and greatly reduces the pain. Traction splints come in two basic varieties: bipolar and unipolar. A bipolar splint cradles the leg between two metal rods; a unipolar splint has a single metal rod that is placed alongside the leg. Examples of the bipolar splint are the half-ring splint. Hare, and Fernotrac. Examples of the unipolar splint are the Sager and the Kendrick traction devices. One of the most common EMT questions is, “How much traction should I pull?” An answer commonly given is, “Pull enough traction to give the patient some relief from the pain.” This answer can be misleading. When the thigh muscles begin to spasm and the bones begin to override, the patient is in real pain. When manual or

mechanical traction is applied, you are pulling against a muscle spasm, and that hurts, too. Most patients do not begin to feel relief with the traction splint until it has been applied for several minutes and the muscle spasm begins to subside. With the Sager unipolar splint, traction can be measured. The amount of traction applied should be roughly 10 percent of the patient’s body weight and not exceed 15 pounds. With a bipolar splint, firm traction should be applied to align the limb. Exert and maintain a firm pull to prevent bones from continuing to override. No traction splint applied in the field pulls true traction. Instead, all exert “counter traction” The splint pulls on an ankle hitch and the splint frame is anchored against the pelvis. Once anchored, a pull is felt on the leg. With bipolar splints, any movement of the pelvis off the ground causes a shifting of the splint and loss of traction. Unipolar splints, such as the Sager, are anchored against the pubis between the legs and are less apt to shift and cause a loss of traction during patient movement. The indications for a traction splint are a painful, swollen, deformed mid-thigh with no joint or lower leg injury. A traction splint is contra indicated if there is a pelvis, hip, or knee injury: if there is an avulsion or partial amputation where traction could separate the extremity; or if there is an injury to the lower third of the leg that would interfere with the ankle hitch. When possible, use three rescuers to apply a traction splint. One can support the injury site when the limb is lifted to position the traction splint. General guidelines for the application of a traction splint are as follows: 1. Take Standard Precautions and. if possible, expose the area to be splinted. 2. Manually stabilize the leg and apply manual traction. 3. Assess CSM distal to the injury. 4. Adjust the splint to the proper length, and position it at or under the injured leg. 5. Apply the proximal securing device (ischial strap). 6. Apply the distal securing device (ankle hitch). 7. Apply mechanical traction. 8. Position and MM support straps. 9. Reevaluate the proximal and distal securing devices, and reassess CSM distal to the injury. 10. Secure the patient’s torso and the traction splint to a long spine board to immobilize the hip and to prevent movement of the splint.

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FIRST TAKE STANDARD PRECAUTIONS Immobilizing a Joint

Immobilizing a Long Bone 1. Manually stabilize the injured limb. 2. Assess distal circulation, sensation, and motor function (CSM). 3. Measure the splint. It should extend several inches beyond the joints above and below the injury. 4. Apply the splint and immobilize the joints above and below the injury. 5. Secure the entire injured extremity. 6. Secure the foot in the position of function. Or, if splinting an arm, secure the hand in the position of function. This is the position the hand would be in if the patient were holding a palm-sized ball. A roll of bandage can be placed in the patient’s hand to help maintain the position of function. 7. Reassess distal CSM.

INSIDE Bones are vascular. Bone marrow is involved in the production of red blood cells. There are many types of fractures. Greenstick fractures, comminuted fractures, and fractures without displaced bone ends do not appear deformed. Swelling and inflammation are the body’s natural responses to injury. The body sends blood and cells to the affected area to light infection. This causes a swollen, often warm extremity around the injury.

1. Manually stabilize the injured limb, in this case an injured elbow 2. Assess distal pulse, motor function, and sensation (CSM). 3. Select the proper splint material. Immobilize the site of injury and bones above and below. 4. Secure the splint. 5. Reassess distal CSM.

OUTSIDE Patients with skeletal injuries—especially those involving long bones and multiple bones—will experience shock. You may see patients who have fractures without obvious deformity. This is why you splint all actual and suspected musculoskeletal fractures. Some patients may appear to have a fracture but actually don’t. The swelling—especially in areas where the bone is close to the skin—can cause the appearance of fracture.

EMERGENCY CARE OF SPECIFIC INJURIES The specific injuries described in this section are usually identified as fractures or dislocations. Remember that you do not need to determine the exact nature of an extremity injury. You will simply immobilize any painful, swollen, or deformed extremity. Specific techniques are discussed on the following pages. 498

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Applying a Vacuum Splint 1. Stabilize the extremity and check distal circulation, sensation, and motor function (CSM). 2. Apply the splint to the extremity and secure it with the straps. 3. Remove the air from the splint with the pump provided by the manufacturer. 4. Reassess distal CSM.

Upper Extremity Injuries

PATIENT ASSESSMENT

Shoulder Girdle Injuries

The following are common signs and symptoms of an injury to the shoulder girdle • Pain in the shoulder may indicate several types of injury. Look for specific signs • A dropped shoulder, with the patient holding the arm of his injured side against the chest, often indicates a fracture of the clavicle. • A severe blow to the back over the scapula may cause a fracture of that bone (All the bones of the shoulder girdle can be felt except the scapula Only the superior ridge of the scapula, called its spine, can be easily palpated Injury to the scapula is rare but must be considered if there are indications of a severe blow at the site of this bone) Check the entire shoulder girdle Feel for deformity and tenderness where the clavicle joins the anterior scapula (the acromion). Feel and look along the entire clavicle for deformity from the sternum medially to the shoulder laterally. Note if the head of the humerus can be felt or moves in front of the shoulder This is a sign of possible anterior dislocation or fracture.

PATIENT CARE

Shoulder Girdle Injuries Emergency care of a patient with a shoulder girdle injury includes the following steps: 1. Assess distal CSM If distal CSM is impaired, immobilize and transport as soon as possible, notifying the receiving facility 2. It is not practical to use a rigid splint for injuries to the clavicle, scapula, or the head of the humerus. Use a sling and swathe. If there is a possible cervical-spine injury, do not tie a sling around the patient’s neck. 3. If there is evidence of a possible anterior dislocation of the head of the humerus (the bone head is pushed toward the front of the body), place a thin pillow between the patient’s aim and chest before applying the sling and swathe 4. Do not attempt to straighten or reduce any dislocations 5. Reassess distal CSM Posibleng mabalian ng balakang ang isang pasyente sa aksidente sa kotse. Kung may bali o durog ang balakang nito, malamang na may mga nadali rin itong internal organs at mga ugat. Maging maingat sa pagbabiyahe sa pasyente.

Lower Extremity Injuries

PATIENT ASSESSMENT

Pelvic Injuries

Fractures of the pelvis may occur with falls, in motorvehicle collisions, or when a person is crushed by being squeezed between two objects Pelvic fractures may be the result of direct or indirect force The following are common signs and symptoms of a pelvic injury • Complaint of pain in the pelvis, hips, groin. or back This may be the only indication but it is significant if the mechanism of injury indicates possible fracture Usually, obvious deformity is associated with the pain • Painful reaction when pressure is applied to the iliac crests (wings of the pelvis) or to the pubic bones • Complaint that the patient cannot lift his legs when lying on his back (Do not test for this, but do check for sensation) • Foot on the injured side may turn outward (lateral rotation) This also may indicate a hip fracture. • Patient has an unexplained pressure on the urinary bladder and the feeling of having to empty the bladder • Bleeding from the urethra, rectum, or vaginal opening in the setting of a high-impact mechanism of injury. Blood at the meatus of the penis (opening of the urethra) is a finding unique to pelvic trauma/fracture.

PATIENT CARE Pelvic Injuries

Emergency care for pelvic injuries includes the following steps: 1. Move the patient as little as possible If you must move the patient, move him as a unit. Never lift, the patient with the pelvis unsupported Warning: Use caution when using a log roll to move a patient with a suspected pelvic fracture Roll the patient gently to the uninjured side, when possible. 2. Determine CSM distal to the injury site. 3. Straighten the patient s lower limbs into the anatomical position if there are no injuries to the hip joints and lower Limbs and If It can be done without meeting resistance or causing excessive pain 4. Prevent additional injury to the pelvis by stabilizing the lower limbs Place a folded blanket between the patient’s legs, from the groin to the feet, and bind them together with wide cravats Thin rigid splints can be used to push the cravats under the patient The cravats can then be adjusted for proper placement at the upper thigh, above the knee, below the knee, and above the ankle. 5. If permitted by local protocol, apply a pneumatic anti shock garment (PASG) to stabilize the pelvis m a patient with hypotension (blood pressure below 90) 6. Assume that there are spinal injuries Immobilize the patient on a long spine board. When securing the patient, avoid placing the straps or ties over the pelvic area 7. Reassess distal CSM 8. Care for shock, providing high-concentration oxygen 9. Transport the patient as soon as possible 10. Monitor vital signs Once the patient is in the ambulance, some EMTs are allowed to make adjustments to improve patient comfort and reduce muscle spasms of the abdomen and lower limb by gently flexing the legs and placing a pillow under the knees. If you are allowed to follow this protocol, be extremely careful not to move the spine, since the patient may have associated spinal injuries

NOTE:

It may be very difficult to tell a fractured pelvis from a fracture of the upper femur. When there is doubt, to protect blood vessels and nerves associated with the femur-pelvis (hip) joint, care for the patient as if there is a pelvic fracture. Remember, there may also be spinal injuries.

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Day 19

PRINCIPLES OF EMT CLINICAL PRACTICE

Pelvic Wrap One method of treating pelvic injuries is the pelvic wrap. Performed with commercially available devices or formed from a sheet (these steps are described in the following text), the wrap reduces internal bleeding and pain while providing stabilization to the pelvis. It may also present further injury Since many system* no longer carry the pneumatic anti-shock garment (PASG), the pelvic wrap provides an alternative treatment for suspected pelvic fracture. The pelvic wrap should he performed on patients who have pelvic deformity or instability (movement upon palpation) whether or not signs of shock are present. Some systems may also recommend use of the pelvic wrap with a mechanism of injury that would indicate pelvic injury (eg., motorcycle crashes, autopedestrian collisions) even if obvious deformity is not present. A sheet may be placed on the backboard even if the wrap is not immediately secured in the event evidence of instability or shock develops. Always follow your local protocols. To apply a sheet as a pelvic wrap:

1. Complete a scene size-up and primary assessment. 2. Once you determine the patient is a candidate for a pelvic wrap (unstable pelvis with or without signs of shock or positive MOI). prepare a backboard with a sheet, folded flat, approximately 10 inches wide and lying across the backboard. 3. Carefully roll the patient to the backboard. Center the sheet at the patients greater trochanter (the bony prominence at the proximal end of the femur). This will position the sheet lower than the iliac “wings”. This is the correct position. 4. Bring the sides of the sheet around to the front of the patient. As you bring the sides of the sheet together and tuc them, you will cause compression and stabilization of the pelvis. The sheet should feel dim enough on the pelvis to keep it in normal position without over compression. 5. Secure the sheet using ties or clamps so that the compression is maintained.

Gamitin ang pelvic wrap sa pasyente bago ito ilagay sa backboard para mabawasan ang sakit na nararamdaman nito.

Pneumatic Anti-Shock Garment

The pneumatic anti-shock garment (PASG, also known as a MAST garment) may be used (where available) for splinting a suspected pelvic fracture in a patient with hypotension (blood pressure below 90). Some EMS systems also use the anti-shock garment for splinting hip femoral, and multiple leg fractures. An anti-shock garment is to be applied in accordance with local protocols. In many localities, its application requires an order from a physician. When pelvic fracture is a possibility, always be alert for shock and possible injuries to internal organs. Always take vital signs before applying an anti-shock garment and monitor vital signs every 5 minutes thereafter.

PATIENT ASSESSMENT Hip Dislocation

A hip dislocation occurs when the head of the femur is pulled or pushed from its pelvic socket It is difficult to tell a hip dislocation from a fracture of the proximal (uppermost portion of the) femur Conscious patients will complain of intense pain with both types of injury. Patients who have had a surgical replacement of the hip joint are at increased risk of hip dislocation. The hip can be either anteriorly or posteriorly dislocated.

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The following ate common signs and symptoms of a hip dislocation. • Anterior hip dislocation. The patient s entire lower limb is rotated outward and the hip is usually flexed • Posterior hip dislocation (most common) The patient’s leg is rotated inward, the hip is flexed, and the knee is bent. The fool may hang loose (foot drop), end the patient is unable to flex the foot or lift the toes Often, there is a lack of sensation in the limb. These signs indicate possible damage, caused by the dislocated femoral head, to the sciatic naive, the major nerve that extends (torn the lower spine to the posterior thigh. This injury often occurs when a poison ‘s knees strike the dashboard during a motor-vehicle collision.

PATIENT CARE Hip Dislocation

Emergency care of a patient with a hip dislocation includes the following steps: 1. Assess distal CSM. 2. Move the patient onto a long spine board Some systems use a scoop-style stretcher. When this device is used, the limb should be immobilized 3. Immobilize the limb with pillows or rolled blankets 4. Secure the patient to the long spine board with straps or cravats 5. Reassess distal CSM If there Is a pulse, motor, or sensory problem, notify medical direction and immediately transport 6. Care for shock by providing high-concentration oxygen 7. Transport carefully, monitor vital signs, and continue to check for nerve and circulation impairment

NOTE:

If you find a painful, swollen, or deformed thigh and the leg is flexed and will not straighten, the patient may also have a fractured femur.

PATIENT ASSESSMENT

Hip Fracture

As noted earlier, a hip fracture is a fracture of the proximal femur, not the pelvis The fracture can occur to the femoral head, the femoral neck, or at the portion of the femur just below the neck of the bone. The following are common signs and symptoms of a hip fracture: • Pain is localized, although some patients also complain of pain in the knee • Sometimes the patient is sensitive to pressure exerted on the lateral prominence of the hip (greater trochanter) • Surrounding tissues are discolor ad. however, discoloration may be delayed • Swelling may be evident • Patient is unable to move his limb while on his back • Patient complains about being unable to stand • Foot on injured side usually turns outward, however, it may rotate inward (rarely). • Injured limb may appear shorter

GERIATRIC NOTE Direct force (as occurs in a motor-vehicle collision) and twisting forces (as may occur in falls) can cause a hip fracture Elderly people are more susceptible to this type of injury than others because of their brittle bones or bones weakened by disease

PATIENT CARE

Hip Fracture

Be certain to assess distal CSM before and after splinting and during transport The patient should be managed for shock and receive oxygen at a high concentration. You should place the patient on a long spine board or orthopedic stretcher after splinting. One of the following emergency care methods can be used to stabilize a hip fracture: • Bind the legs together. Place a folded blanket between the patient’s legs and bind the legs together with wide straps. Velcro-equipped straps, or wide cravats Carefully place the patient on a long spine board and use pillows to support the lower limbs Secure the patient to the board An orthopedic stretcher can be used in place of the long spine board • Padded boards. Use thin splints to push cravats or straps under the patient at the natural voids (such as the small of the back and back of the knees) and readjust them so that they will pass across the chest, the abdomen just below the belt, below the crotch, above and below the knee, and at the ankle Splint with two long padded boards Ideally, one should be long enough to extend from the patient’s armpit to beyond the foot The other should be long enough to extend from the crotch to beyond the foot. Cushion with padding in the armpit and notch and pad all voids created at the ankle and knee. Secure the boards with the cravats or straps. • Apply an anti-shock garment. Do this if local protocols indicate.

PATIENT ASSESSMENT

Femoral Shaft Fracture

Because the femur is a large, strong bone, considerable force is necessary to cause a fracture of the femoral shaft Remember also that muscle contractions can cause bone ends to ride over each other The bone ends may or may not protrude from an open wound. Never assume that a wound on the thigh is superficial because you do not see bone ends Always check for signs and symptoms that this wound may be an open fracture. The following are common signs and symptoms of a femoral shaft fracture • The patient may complain of pain, which is often intense • Often there will be an open fracture with deformity and sometimes with the end of the bone protruding through the wound. When the injury is a closed fracture, often there will be deformity with possible severe angulation • The injured limb may appear to be shortened because the contraction of the thigh muscles caused the bone ends to override each other LIFELINE

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Day 19

PATIENT CARE

Femoral Shaft Fracture Emergency care of a patient with a femoral shaft fracture includes the following steps: 1. Control any bleeding by applying direct pressure (avoiding the possible fracture site) forcefully enough to overcome the barrier of muscle mass. The femoral artery pressure point may be used. 2. As soon as possible, manage the patient for shock (hypoperfusion) and provide highconcentration oxygen. 3. Assess distal CSM. 4. Apply a traction splint. If a traction splint is not available, bind the legs together after placing them in the anatomical position. 5. Reassess distal CSM.

PRINCIPLES OF EMT CLINICAL PRACTICE

NOTE:The traction splint should

not he applied if you suspect that there may he additional injuries or fractures to the area of the knee or tibia/ fibula of the same limb. If local protocols permit. you may use an anti-shock garment if there are multiple leg fractures. It is not, however, a good splint for the lower leg since it does not immobilize the ankle.

Kung gagamit ng traction splint sa hita ng pasyenteng bata, tiyakin na tama ang sukat ng splint. May mga pag-aaral na nagsasabing kapag may bali ang hita ng bata, malaki ang posibilidad na may tama din sa mga internal organs nito.

PATIENT ASSESSMENT Knee Injury

The knee is a joint and not a single bone Fractures can occur to the distal femur, to the proximal tibia and fibula, and to the patella (kneecap) The following are common signs and symptoms of a knee injury: • Pain and tenderness • Swelling • Deformity with obvious swelling

PATIENT CARE Knee Injury

There are two general emergency care methods used (or immobilizing the knee—one the knee is bent, the other if it is straight. • Knee is bent. Assess distal CSM Immobilize the knee in the position in which the leg is found Tie two padded board splints to the thigh and above the angle so that the knee is held in position. You can use a pillow to support the leg. Reassess distal CSM. • Knee is straight or returned to the anatomical position. Assess distal CSM. Immobilize the knee with two padded board splints or a single padded splint. When using two padded boards, placing one medial and one lateral offers the best support. Remember to pad the voids created at the knee and ankle. Reassess distal CSM.

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Do not confuse a knee dislocation with a patella dislocation. The patella can become displaced when the lower leg and knee are twisted, as in a skiing or racquetball accident. In patellar dislocation, the knee will be stuck in flexion and the kneecap will be displaced and laterally palpable. A knee dislocation occurs when the tibia itself is forced either anteriorly or posteriorly in relation to the distal femur. Always check for a distal pulse, since the dislocated knee joint can compress the popliteal artery and stop the major blood supply to the lower leg. If there is no pulse, this is a true emergency. Contact medical direction for permission to gently move the lower leg anteriorly to allow for a pulse, and immediately transport the patient. What may appear to be a dislocation may prove to be a fracture or a combined fracture and dislocation. Even if you believe that the patient has suffered a dislocated patella and the kneecap has repositioned itself, realize that other damage may be hidden. Whether you suspect a fracture, a dislocation, a sprain, or a strain, always splint the injury and transport the patient. Once splinting is done, monitor the patient. If there is a loss of distal CSM, or if the foot becomes discolored (while, mottled, or blue) and turns cold, transport the patient without delay. Notify medical direction while en route.

UNIT UNIT 3 UNIT 3 UNIT3 3PRINCIPLES UNIT 33 UNIT PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 19 19 DAY 19 DAY 19 DAY DAY1919PRINCIPLES OF EMT CLINICAL PRACTICE

(STRAIGHT) SPLINT KNEE KNEE (STRAIGHT)SPLINT SPLINT KNEE(STRAIGHT) (STRAIGHT) SPLINT KNEE

KNEE KNEE STRAIGHT STRAIGHT SPLINT SPLINT KNEE STRAIGHT SPLINT KNEE STRAIGHT SPLINT KNEE STRAIGHT SPLINT KNEE STRAIGHT SPLINT 1. 1. The The patient patient is found is found in this in this 1. The patient is found in this 1. The patient is found in this this 1. 1. The patient is found indislocathis The patient is found in position, position, possible possible dislocaposition, possible dislocaposition, possible dislocaposition, possible dislocaposition, possible dislocation tion and/or and/or fracture fracture cases. cases. tion and/or fracture cases. tion and/or fracture cases. tion and/or fracture cases. tion and/or fracture cases. 2. 2. Check Check PMS PMS before before and and 2. Check PMS before and 2. Check PMS before and 2. 2.nerve Check PMS before and Check PMS before and If there is a distal pulse and function, or the after after the the procedure. procedure. after the procedure. after the procedure. after the procedure. after the procedure. limb cannot be straightened without meeting resistance or 3. 3. Measure Measure Measure thethe unaffected unaffected 3. 3. Measure Measurethe theunaffected unaffected 3. 3. the unaffected Measure the unaffected leg leg for for appropriate appropriate sizing sizing causing severe pain, knee injuries should be splinted with leg forfor appropriate sizing leg for appropriate sizing leg for appropriate sizing leg appropriate sizing of the the splint splint to to be be used. used. of the splint to be used. the knee in the position in whichof itof is the found. of the splint to be used. of the splint toboard, beboard, used. splint to be used. 4. 4. Using Using an an thin thin insert insert 4. Using an thin board, insert 4. Using an thin board, insert 1. Assess distal CSM. 4. 4. Using an thin board, insert Using an thin board, insert thethebandage bandage bandagebelow below below the the the the thebandage bandagebelow belowthethe the the the bandage below 2. Stabilize the knee above and below the injury site. splint splint to to reach reach the the other other splint to reach the other splint to reach the other splint to reach the other splint to reach the other side side 3. Place the padded side of the splints next to the injured side side side side 5. 5. Tie Tie the the bandage bandage to to secure secure 5. the bandage to secure extremity. Note that they should bethe equal in length and 5. Tie Tie the bandage to secure 5. 5. Tie the bandage topatient. secure Tie bandage to secure the the splint splint to to the the patient. the splint to the patient. the splint to the patient. extend 6 to 12 inches beyond the mid-thigh and midthe splint to the patient. the splint to the patient. PutPut pads pads onon bony bony promipromiPut pads on bony promiPut pads on bony promiPut pads onon bony promiPut pads bony promicalf. nence. nence. nence. nence. nence. 4. Place a cravat through the knee nence. void and tie the boards

Two-Splint Method—Bent Knee

together. 5. Using a figure-eight configuration, secure one cravat to the ankle and the boards, and the second cravat to the thigh and the boards. Re-assess distal CSM.

One-Splint Method-Straight Knee 1. Assess distal CSM. 2. Stabilize. The padded board splint should extend from the buttocks to 4 inches beyond the heel. 3. Maintain stabilization and lift the limb. 4. Place the splint along the posterior of the limb. 5. Pad the voids. 6. Use a 6-inch roller bandage or cravats to secure the injured leg to the splint. 7. Place the folded blanket between the patient’s legs, groin to feet. 8. Tie the patient’s thighs, calves, and ankles together. Do not tie the knot over the injured area. 9. Reassess the distal CSM. 10. Provide emergency care for shock, and continue to administer high-concentration oxygen. 11. Monitor distal pulse and vital signs. Ang ibig sabihin ng distal CSM ay ang circulation, sensation at motor function ng mga dulong bahagi ng katawan ng pasyente.

Two-Splint Method—Straight Knee 1. Stabilize the injured limb, and assess distal CSM. 2. Measure the padded board splints, medial from groin, lateral from iliac crest, both to 4 inches beyond the foot. 3. Position the splints. 4. Pad the groin. 5. Secure the splints at the thigh, above and below the knee, and at mid-calf. Pad all voids, 6. Cross and tie two cravats at the ankle or hitch the ankle, Reassess distal CSM, care for shock, and provide highconcentration oxygen.

² Limmer ² Limmer (Brady) (Brady) (Brady) ² Limmer (Brady) ³²² Limmer Pollack, Pollack, (AAOS) (AAOS) Limmer (Brady) ²³ Limmer (Brady) (AAOS) ³ Pollack, (AAOS) ⁴³³ Pollack, NHTSA NHTSA (AAOS) ³⁴⁴Pollack, (AAOS) ⁴ Pollack, NHTSA NHTSA ⁴ NHTSA ⁴ NHTSA

KNEE STRAIGHT SPLINT

1. The patient is found in this position, possible dislocation and/or fracture cases. 2. Check PMS before and after the procedure. 3. Measure the unaffected leg for appropriate sizing of the splint to be used. 4. Using an thin board, insert the bandage below the splint to reach the other side 5. Tie the bandage to secure the splint to the patient. Put pads on bony prominence. LIFELINE

PREHOSPITAL EMERGENCY CARE

503

and

ected izing NIT 3 d. nsert AY 19 the other

tion and/or fracture cases. Check PMS before and after the procedure. Measure the unaffected leg for appropriate sizing of the splint to be used. Using an thin board, insert the bandage below the splint to reach the otherDay 19 side Tie the bandage to secure the splint to the patient. Put pads on bony prominence.

KNEE BEND SPLI (SANDWICH TECHNIQUE) 1.

The patient is found in position, possible disl tion and/or fracture ca 2. Check PMS before after the procedure. UNa 3. Measure the affected in a way that it’ll sec DAY both the thigh and and to not move the kn 4. Manually hold the sp while the other rescue the bandage to secure K N Esplint E BtoE Nthe D patient. SPLI (SANDWICH TECHNIQUE) pads on bony pro nence. 1. The patient is found in position, possible dislo tion and/or fracture cas 2. Check PMS before a after the procedure. 3. Measure the affected a in a way that it’ll sec both the thigh and and to not move the kn 4. Manually hold the sp while the other rescuer the bandage to secure splint to the patient. pads on bony pro nence.

PRINCIPLES OF EMT CLINICAL PRACTICE 4.

PRINCIPLES OF EMT CLINICAL PRACTICE

SPLINT KNEE (STRAIGHT) 5.

ecure tient. romin this locaases. and

KNEE STRAIGHT SPLINT

ected izing d. nsert the other

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NIT UNIT 33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE NIT 3PRINCIPLES YAY 1919

AY 19 NIT 3 AY 19

this in this ocaislocacases. es. neand this and

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PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL (STRAIGHT) SPLINT SPLINT PRACTICE KNEE KNEE(STRAIGHT) KNEE (STRAIGHT) SPLINT KNEE (STRAIGHT) SPLINT

PRINCIPLES OF EMT CLINIC

KNEE STRAIGHT SPLINT SANDWICH TECHNIQUE

1. 2.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

sizlimb

secure ure t to nt is ent. atient. rom promimilimb

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

504

LIFELINE

² Limmer ² Limmer (Brady) (Brady) ³ Pollack, ³ Pollack, (AAOS) (AAOS) ⁴ NHTSA ⁴ NHTSA

KNEEKNEE STRAIGHT SPLINT STRAIGHT SPLINT 1. The is found in this 1. patient The patient is found in this position, possible dislocaposition, possible dislocation and/or fracture cases.cases. tion and/or fracture 2. Check PMS PMS before and and 2. Check before after after the procedure. the procedure. 3. Measure the unaffected 3. Measure the unaffected leg for sizingsizing leg appropriate for appropriate of the to betoused. ofsplint the splint be used. 4. Using a thin board, insertinsert 4. Using a thin board, the the bandage below the the bandage below splintsplint to reach the other to reach the other side side 5. Tie to secure 5. the Tiebandage the bandage to secure the splint to the the splint to patient. the patient. Put pads on bony promiPut pads on bony prominence. nence. SANDWICH TECHNIQUE SANDWICH TECHNIQUE 1. Check PMS PMS before and and 1. Check before after after the procedure. the procedure. 2. Measure the the unaffected 2. Measure unaffected area area for appropriate siz- sizfor appropriate ing. ing. Exceed the splint to to Exceed the splint prevent the fromfrom prevent the patient PREHOSPITAL EMERGENCY CARE patient walking the affected limb limb walking the affected especially if theif patient is is especially the patient uncooperative. uncooperative. 3. Using a thin board insert 3. Using a thin board insert the bandage to reach the the the bandage to reach otherother end end to prevent fur- furto prevent ther movement

KNEE (STRAIGHT) S

KNEE STRAIGHT SPLINT 1. The patient is found in this position, possible dislocation and/or fracture cases. 2. Check PMS before and after the procedure. Check PMS before and after the procedure. 3. Measure the unaffected Measure the unaffected area for leg for appropriate sizing appropriate Exceed of thesizing. splint to be used. the splint to 4. Using a thin board, prevent the patient frominsert walking the the bandage below the affectedsplint limbtoespecially if the patient is reach the other side uncooperative. 5. Tie the bandage to secure Using a the thinsplint board insert the bandage to the patient. to reachPut thepads other prevent further on end bony to prominence. movement SANDWICH TECHNIQUE Tie the secureand the splint to the 1. bandage Check PMSto before procedure. patient. after Put the pads on bony prominence. 2. Measure the unaffected area for appropriate sizing. Exceed the splint to prevent the patient from walking the affected limb especially if the patient is uncooperative. 3. Using a thin board insert the bandage to reach the other end to prevent further movement 4. Tie the bandage to secure the splint to the patient. Put pads on bony prominence.

UNIT 3 3 UNIT PRINCIPLES OFOF EMT CLINICAL PRACTICE PRINCIPLES EMT CLINICAL PRACTICE DAY 19 19 DAY 3.

sizsert insert ch theto the nt cted nt furfurfrom

nsert nt is h the furnsert the cure furient. omicure ient. omi-

UNIT 3 DAY 19

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

(STRAIGHT) SPLINT KNEE KNEE 4. (STRAIGHT) SPLINT

the bandage to secure the K N Esplint E B N D patient. S P L I Put NT toE the (SANDWICH pads onTECHNIQUE) bony promi-

INT

nence. The patient is found in this position, possible dislocation and/or fracture cases. 2. Check PMS before and after the procedure. 3. Measure the affected area in a way that it’ll secure both the thigh and leg 1. The patient is found in this position, and to possible not move the knee. dislocation and/or fracture4.cases. Manually hold the splint the other rescuer tie 2. Check PMS before and after thewhile procedure. the bandage secure the 3. Measure the affected area in a way that it’ll to secure both splint to the patient. Put pads on bony prominence.

n this locaases. and

NIT area 3 cure Y 19

PRINCIPLES OF EMT CLINICAL PRACTICE

KNEE BEND SPLINT (SANDWICH TECHNIQUE)

leg nee. plint er tie e the N T Put omi-

KNEE (BEND) SPLINT

this ocases. and

the thigh and leg and to not move the knee. 4. Manually hold the splint while the other rescuer tie the bandage to secure the splint to the patient. Put pads on bony prominence.

area cure leg nee. plint r tie the Put omi-

CAL PRACTICE

SPLINT

PATIENT ASSESSMENT

Tibia or Fibula Injury The following are common signs and symptoms of a tibia or fibula injury • Pain and tenderness • Swelling • Possible deformity (You might expect to see a deformity of the lower leg when the tibia or fibula is fractured. However, such ² Limmer (Brady) deformity is often absent)

³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PATIENT CARE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Tibia or Fibula Injury

Emergency care of a patient with a tibia or fibula injury includes providing care for shock and administering high-concentration oxygen Because immobilizing the leg can help to relieve pain and control blooding, apply a splint using one of the following methods Remember to assess distal CSM before and after application. • Air-inflated splint. Apply an air-inflated splint. Slide the uninflated splint over your hand and gather it in place until the lower edge clears your wrist. Using your free hand, grasp the patient’s foot and leg just above the injury site.² Limmer While maintaining manual traction, have your partner slide (Brady) ³ Pollack, (AAOS) the splint over ⁴ NHTSAyour hand and onto the injured leg Your partner must make sure that the splint is relatively wrinkle free and that it covets the injury Site Continue to maintain traction while your partner inflates the splint Test to see if you can cause a slight dent in the plastic with finger-up pressure Remember to check periodically to see that the pressure in the splint has remained adequate and has not decreased or increased. • Two-splint method. You can immobilize the fracture using two rigid board splints. • Single splint with an ankle hitch. A single splint with an ankle hitch can be applied. LIFELINE

PREHOSPITAL EMERGENCY CARE

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Day 19

PATIENT ASSESSMENT Ankle or Foot Injury

Sprains (joint ligaments) and fractures are the most common musculoskeletal injuries to the ankle and foot It is often difficult to distinguish between them, so always treat for a fracture. The following are common signs and symptoms of an ankle or foot injury: • Pain • Swelling • Possible deformity

PATIENT CARE

Ankle or Foot Injury Long splints, extending from above the knee to beyond the foot, can be used. However, soft splinting is an effective, rapid method and is recommended for most patients. To soft splint. you should follow the emergency care steps described in the following list: 1. Assess distal CSM 2. Stabilize the limb. Remove the patient’s shoe if possible, but only if it removes easily and can be done with no movement to the ankle 3. Lift the limb, but do not apply manual traction (tension). 4. Place three cravats on the floor under the ankle Then place a pillow lengthwise under the ankle on top of the cravats The pillow should extend 6 inches beyond the foot 5. Gently lower the limb onto the pillow, taking care not to change the ankle’s position. Stabilize by tying the cravats and adjust them so they are at the top of the pillow, midway, and at the heel 6. Tie the pillow to the ankle and foot 7. Tie a fourth cravat loosely at the arch of the foot. 8. Elevate with a second pillow or blanket Reassess distal CSM 9. Care for shock (hypoperfusion) if needed 10. Apply an ice pack to the injury site to reduce bleeding and swelling, if appropriate. Do not apply the ice pack directly to the skin. Ang splint para sa paa at binti na lagpas tuhod ang haba ay mas maganda kay sa unan dahil pipigilan din nito ang tuhod at sakong na gumalaw.

506

LIFELINE

PREHOSPITAL EMERGENCY CARE

PRINCIPLES OF EMT CLINICAL PRACTICE

Applying a Sling and Swathe A sling is a triangular bandage used to support the shoulder and arm. Once the patient’s arm is placed in a sling, a swathe can be used to hold the arm against the side of the chest. Commercial slings are available. Velcro straps can be used to form a swathe. Use whatever materials you have on hand, provided they will not cut into the patient. Alto, remember to assess distal pulse, motor function, and sensation both before and after immobilizing or splinting an extremity. 1. Prepare the sling by folding cloth into a triangle. 2. Position the sling over the top of the patient’s chest as shown. Fold the injured arm across his chest… If the patient cannot hold his arm, have someone assist him until you tie the sling. 3. Extend one point of the triangle beyond the elbow on the injured side. Take the bottom point and bring it up over the patient’s arm. Then take it over the top of the injured shoulder. 4. If appropriate, draw up the ends of the sling so that the patient’s hand is about A inches above the elbow. 5. Tie the two ends of the sling together, making sure that the knot does not press against the back of the patient’s neck. Pad with bulky dressings. (If spine injury is possible, pin the ends to the patient’s clothing. Do not tie them around the neck.) 6. Check to be sure you have left the patient’s fingertips exposed. Then assess distal circulation, sensation, and motor function (CSM). If the pulse has been lost, take off the sling and repeat the procedure. Then check again. 7. To form a pocket for the patient’s elbow, take hold of the point of material at the elbow and fold it forward, pinning it to the front of the sling. Or.... If you do not have a pin, twist the excess material and tie a knot in the point. 8. Form a swathe from a second piece of material. Tie it around the chest and the injured arm, over the sling. Do not place it over the patient’s arm on the uninjured side. 9. Reassess distal circulation, sensation, and motor function (CSM). Treat for shock, and provide high-concentration oxygen. Take vital signs. Perform detailed assessments and reassessments as appropriate.

Splinting an Injured Humerus

ELBOW IN OR RETURNED TO THE BENT POSITION

SIGNS: Injury to the humerus can take place at the proximal end (shoulder), along the shaft of the bone, or 1. Move the limb only if necessary for splinting or if UNIT3333 UNIT UNIT at the distal end (elbow). Deformity is the key sign used UNIT the pulse is absent. Stop if you meet resistance of PRINCIPLES OFthe EMT CLINICAL PRACTICE PRINCIPLES OF EMT to detect fractures to this bone in any of these locations; PRINCIPLES OF EMT CLINICALPRACTICE PRACTICE DAY19 19 PRINCIPLES DAY 19 significantly increase pain.CLINICAL DAY DAY 19 however, assess for all signs of skeletal injury, including 2. Use a padded board splint that will extend 2 to 6 inches pain or swelling. Follow the rules and procedures for care beyond the arm and wrist when placed diagonally. ELBOW INOR OR RETURNED TO THE BENT POSITION ELBOW IN OR RETURNED ELBOW RETURNED of an injured extremity. 3. PlaceIN the splint so it is justTO proximal to the POSITION elbow and ELBOW IN OR RETURNED TOTHE THEBENT BENT POSITION wrist. Use cravats to secure it to the forearm, then the E LO BO W BEN D S P LN INT 1. Move Movethe thelimb limbonly only if necessaryfor for splintingororififthe thepulse pulseisisisabsent. absent. W 1. EE 1. ELLLBB BO OW W BBBEEENN NDD D SSSPPPLLLI IN I NTTT 1. Move Movethe thelimb limbonly onlyififnecessary necessary forsplinting splinting or if thepulse pulse isabsent. absent. arm. (SANDWICH TECHNIQUE) Slopifififyou youmeet meetresistance resistanceofofsignificantly significantlyincrease increasethe thepain. pain. (SANDWICH TECHNIQUE) Slop you meet resistance TECHNIQUE) Slop pain. VARIATION ONE: Apply (SANDWICH VARIATION TWO: If (SANDWICH TECHNIQUE) Slop if you meet resistance of significantly increase the pain. 4. 2.2.A sling can be applied to support the limb. Keep the 2. wrist Use a padded board splint that will extend 2 to 6 inches beyond the Use padded board aaapadded board will inches beyond the 2. Use Use padded boardsplint splintthat that willextend extend22toto66inches inchesbeyond beyondthe the a sling and swathe. If you youThe have onlyisisafound narrow or 1. The patient found this arm and wristApply when placed diagonally. elbow exposed a swathe, if possible. patient ininthis this arm and wrist when 1.1. The patient is found in arm and wrist when placed diagonally. The patientpossible is found in this arm and wrist when placed diagonally. have only enough material for 1.short length of material to position, disloca3. Place the splint so it is just proximal to the elbow and wrist. Use cravats position, possible disloca3. Place the splint so it is just proximal to the elbow and wrist. Use cravats position, possible disloca3.3. Place the sosoititisisjust totothe position, possible Place thesplint splint justproximal proximal theelbow elbowand andwrist. wrist.Use Usecravats cravats tion and/or fracture cases. secure the forearm, thenthe thearm. arm. tion and/or fracture cases. a swathe, bind the patient’s use asand/or aand/or sling, applydislocaitcases. so totosecure secure totothe the forearm, then the arm. tion fracture cases. to ititititto then tion fracture to secure tocan theforearm, forearm, then the arm. the limb. Keep the elbow ex2. Check PMS before and 4. A wrist sling be applied to support ELBOW BEND SPLINT (SANDWICH TECHNIQUE) 2. Check PMS before and 4. AA wrist wrist sling sling can can be be applied applied to to support support the limb. Keep the elbow exCheck PMS before and upper arm to her body, taking 2.2.that it supports the wrist 4. Check PMS before and 4. A wristApply sling can be applied to supportthe thelimb. limb.Keep Keepthe theelbow elbowexexafter the procedure. posed swathe, ifpossible. possible. after the procedure. posed Apply aaaswathe, swathe, possible. after the procedure. posed Apply ififif great care not to cut off only. after the procedure. posed Apply a swathe, possible. 1. The patient is found in this position, possible dislocation 3. Measure Measurethe theaffected affectedarea area Measure the affected area 3.3. 3. Measure affected area circulation to the forearm. inaaaway waythe that it’ll secure secure way that it’ll and/or fracture cases. inin that it’ll inboth a way thatand it’llsecure secure the arm forearm both the arm and forearm NOTE: Assess the distalpulse, pulse, motor function, andsensation sensationboth bothbefore beforeand and both the arm and forearm 2. Check PMSthe before and after the procedure. NOTE: Assess distal pulse, motor function, and both the not arm move and forearm NOTE: Assess distal motor function, NOTE: Assessthe the distal pulse, motor function,and andsensation sensationboth bothbefore beforeand and andto theeleland totonot not move move the the elafter immobilizing splinting anextremity. extremity. and after immobilizing oror splinting an extremity. 3. Measure the affected area in a way that it’ll secure both and to not move the elafter immobilizing or splinting an bow after immobilizing or splinting an extremity. bow bow bow Laging suriin ang circulation,4.4. Manually the arm and forearm and to not move the elbow Manuallyhold holdthe thesplint splint hold the splint 4.4. Manually Manually hold the splint sensation at motor function sa mga whilethe theother otherrescuer rescuer tie 4. Manually hold the splint while the other rescuer tie the while tie while the other rescuer tie while the other rescuer tie thebandage bandage securethe the the toto secure dulong bahagi ng katawan ng ng bandage to secure the splint to the patient. Put pads on the bandage to secure the bandage securethe the splint to the theto patient. Put splint to patient. Put (BEND)SPLINT SPLINT ELBOW(BEND) ELBOW pasyente bago at matapos maglagay splint toto the patient. Put bony prominence. splint the patient. Put (BEND) SPLINT ELBOW pads on on bony bony promipromipads on bony proming splint. Kung wala kang masalat napads pads on bony promi5. You can use arm sling to support the injured area nence. nence. nence. nence. pulso, Galawin mo nang 5. You Youcan canuse usearm armsling slingtoto 5.5. can use arm to 5. You You canthe useinjured armsling sling support the injured areato bahagya ang bahagi ng support area support supportthe theinjured injuredarea area katawan ng pasyente na lalagyan ng split. Kung wala senyales na may pakiramdam ang pasyente at hindi nito magalaw ang apektadong bahagi, ulitin ang paglalagay ng splint. Huwag subuking idiretso ang bahagi ng katawan ng pasyente kung ito ay nawala sa puwesto o nabali.

Splinting Arm and Elbow Injuries SIGNS: The elbow is a joint and not a bone. It is composed of the distal humerus and the proximal ulna and radius, which form a hinge joint. You will have to decide if the injury is truly to the elbow. The location of deformity and tenderness will direct you to the injury site. CARE: If there is a distal pulse, the dislocated elbow should be immobilized in the position in which it is found. The joint has too many nerves and blood vessels to risk movement. When a distal pulse is absent, make one attempt to slightly reposition the limb after contacting medical direction. Do not force the limb into the anatomical position. LIFELINE ² Limmer (Brady) ² Limmer (Brady)

³ Pollack, (AAOS) ³ Pollack, (AAOS) ² ⁴Limmer (Brady) NHTSA ²⁴NHTSA Limmer (Brady) ³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

507

UNIT 3 DAY 19

LINT und in this e dislocaure cases. fore and ure. unaffected for approthe splint

to secure e patient. ny promiet the pad cloth or pport the hand and d/or limit of the

ELBOW STRAIGHT SPLINT 1. 1. The patient is found in this 2. position, possible dislocation and/or fracture cases. 3. 2. Check PMS before and after the procedure. 3. Measure the unaffected 4. upper extremity for appro5. priate sizing of the splint 6. to be used. 4. Tie the bandage to secure the splint to the patient. Put pads on bony promiELBOW IN A STRAIGHT POSITION nence and/or let the patient hold a rolled cloth or bandage to support 1. Assess distal circulation, sensation, and motor functionthe (CSM). contour of from the hand 2. Use a padded board splint that extends underand the armpit to a to stabilized and/or limit point past the fingertips. Pad the armpit. thepatient's movement of help the maintain the 3. Place a roll of bandages in the hand to position of function. Place thehand. padded side of the board against the medial side of the limb. Pad all voids. 4. Secure the splint. Leave the patient's fingertips exposed, 5. Place pads between the patient's side and the splint. UNIT 3 placing 6. Secure the splinted limb to the body with two cravats. Avoid the cravats over the suspected injury site. Reassess the distal DAY 19 circulation, sensation, and motor function (CSM).

tient hold a rolled cloth or bandage to support Assess distal circulation, sensation, and motor function the (CSM). contour the hand Use a padded board splint that extendsoffrom under and the armpit to a toarmpit. stabilized and/or limit point past the fingertips. Pad the the movement themaintain the Place a roll of bandages in the patient's hand toofhelp position of function. Place the hand. padded side of the board against the medial side of the limb. Pad all voids. Secure the splint. Leave the patient's fingertips exposed, Place pads between the patient's side and the splint. UNIT 3 Secure the splinted limb to the body with two cravats. Avoid placing DAY 19circulathe cravats over the suspected injury site. Reassess the distal tion, sensation, and motor function (CSM).

PRINCIPLES OF EMT CLINICAL PRACTICE Day 19

ELBOW (STRAIGHT) SPLINT

WRIST SPLINT WRIST SPLINT

1. The patient is found in in this 1. EMT The patient is found this PRINCIPLES OF EMTPRINCIPLES CLINICALOF PRACTICE CLINICAL PRACTICE

position, position,possible possibledislocadislocation and/or fracture cases. tion and/or fracture cases. 2. 2.(STRAIGHT) Check CheckPMS PMSbefore beforeand and SPLINT ELBOW after thethe procedure. after procedure. SPLINT ELBOW (STRAIGHT) ELBOW STRAIGHT SPLINT 3. 3. Measure Measurethethewrist wristarea area 1. The patient is found in this Assess distal circulation, sensation, and motor theposition, limb. possible Pad alldislocavoids. and andslightly slightlyabove aboveand and tion and/or fracture cases. function (CSM). 4. Secure the splint. Leave the patient’s fingertips below it to secure it propbelow it to secure it prop2. Check PMS before and after the procedure. Use a padded board splint that extends from under exposed, erly. erly. 3. Measure the unaffected 4. 4. thethe bandage to to secure the armpit to a point past the fingertips. Pad the 5. Place pads between theTiesplint. Tie bandage secure upper extremity for appro-the patient’s side and UNIT 3 priate sizingsplinted of the splint thethesplint splintto tothethepatient. patient. PRINCIPLES OF6.EMT CLINICAL PRACTICE armpit. Secure the limb to the body with PRINCIPLES OF EMT CLINICAL PRACTICE to be used. DAY 19 UNIT 33 UNIT promipadsononbony bony promi4. Tiecravats. the bandage to secure Place a roll of bandages in the patient’s hand to two Avoid placing the cravats over PutPutpads the splint to the patient. nence nenceand/or and/orletDAY letthethepapahelp maintain the position of function. Place the thePut suspected injury site. Reassess the distal 19 DAY 19 pads on bony promitient hold a rolled cloth oror (STRAIGHT) ELBOW tient hold a rolled cloth nence and/orSPLINT let the paSPLINT ELBOW padded side(STRAIGHT) of the board against the medial side of circulation, sensation, and motor function(STRAIGHT) (CSM). SPLINT ELBOW tient hold a rolled cloth or bandage to support the bandage to support the ELBOW STRAIGHT SPLINT ELBOW STRAIGHT SPLINT the bandage to support 1. The patient is found in this contour of of thethehand and contour hand and 1. The patient found this contour of is the handin and position, possible dislocaposition, possible dislocato stabilized and/or limit to tostabilized stabilizedand/or and/orlimit limit tion and/or fracture cases. tion and/or fractureofcases. the movement the 2. Check PMS before and thethe movement movement of of thethe 2. Check hand. PMS before and after the procedure. after the procedure. hand. hand. WRIST SPLINT 3. Measure the unaffected WRIST SPLINT 3. Measure the unaffected upper extremity for appro5. 5. You can use arm sling You can to 1. patient isuse found insling this 1.The The patient isarm found intothis upper extremity for appropriate sizing of theUNIT splint 3 priate sizing of the splint PRINCIPLES OF EMT CLINICAL PRACTICE support the injured area support the injured area position, possible dislocato be used. position, possible dislocaDAY 19 to be used. 4. Tie the bandage to secure tiontion and/or fracture cases. and/or fracture cases. 4. Tie the bandage to secure the splint to the patient. the splint to the patient. 2. 2.Check PMSPMS before andand Put pads on bony promiCheck before Put pads on bony prominence and/or let the paELBOW (STRAIGHT) after thethe procedure. after procedure. nence and/or SPLINT let the patient hold a rolled cloth or tient hold a rolled cloth or ELBOW STRAIGHT SPLINT the 3. 3.Measure thethe wrist areaarea Measure wrist bandage to support bandage to support the 1. contour The patient is found this of the handinand andand slightly above andand slightly above contour of the hand and position, possible dislocato stabilized and/or limit to stabilized and/or limit below it toit secure it proption and/or fracture below to secure it propthe movement ofcases. the the movement of the 2. hand. Check PMS before and erly.erly. hand. after the procedure. The patient is found in this position, 4. 4.Tie Tie thethe bandage to secure 3. Measure the unaffected bandage to secure upper extremityfracture for appropossible dislocation and/or thethe splint to the patient. splint to the patient. priate sizing of the splint cases. PutPut pads on on bony promito be used. pads bony promi4. Tie the bandage to secure Check PMS before and after the nence and/or let let thethe pa- panence and/or the splint to the patient. tient hold a rolled cloth or or Put pads on bony promiprocedure. tient hold a rolled cloth nence and/or let the pabandage to support the bandage to support the Measure the unaffected upper tient hold a rolled cloth or contour of the hand andand bandage tosizing support of the the contour of the hand extremity for appropriate contour of the hand and to to stabilized and/or limitlimit stabilized and/or splint to be used. to stabilized and/or limit thethemovement of ofthethe the movement of the movement Tie the bandage tohand. secure the splint hand. hand. to the patient. Put pads on bony 5. 5.YouYou cancan useuse armarm sling to to sling prominence and/or let the patient hold support thethe injured areaarea support injured

ELBOW IN A STRAIGHT POSITION

2. 3.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

ELBOW STRAIGHT SPLINT

1. 2. 3.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

a rolled cloth or bandage to support the contour of the hand and to stabilized and/or limit the movement of the hand. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Splinting Forearm, Wrist, and Hand SIGNS:

• Forearm Deformity and tenderness, if only one bone is broken, deformity may be minor or absent. • Wrist. Deformity and tenderness. • Hand. Deformity and pain. Dislocated fingers are obvious. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

CARE: Injuries occurring to the forearm, wrist, or hand can be splinted using a padded rigid splint that extends from the elbow past the fingertips. The patient’s elbow, forearm, wrist, and hand all need the support of the splint. Tension must be provided throughout the splinting. A roll of bandages should be placed in the patient’s hand to ensure the position of function. After rigid Splinting, apply a sling and swathe. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

508

LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

ALTERNATIVE CARE: Injuries to the hand and wrist can be cared for with soft splinting by placing a roll of bandages in the hand to maintain the position of function, then tying the forearm, wrist, and hand into the fold of one pillow or between two pillows. An injured finger can be taped to an adjacent uninjured finger or splinted with a tongue depressor. Some emergency department physicians prefer that care be limited to a wrap of soft bandages. Do not try to “pop* dislocated fingers back into place. ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

NOTE:

Assess the distal circulation, sensation, and motor function both before and after immobilizing or splinting tin extremity.

WRIST SPLINT WRISTSPLINT

WRIST SPLINT WRIST SPLINT 1. 1. TheThe patient is found in this patient is found in this position, possible dislocaposition, possible dislocation and/or fracture cases. tion and/or fracture cases. 2. 2. Check CheckPMS PMSbefore beforeand and after thethe procedure. after procedure. 3. 3. Measure Measurethethewrist wristarea area and andslightly slightlyabove aboveand and Check distal circulation, sensation, and motor function (CSM). Grasp below it to secure it propbelow it to secure it propthe hand of the patient’s injured limb as though you were going to shake erly. erly. hands and apply tension. 4. steady the bandage to to secure 4. TieTie the bandage secure While you support the herthe arm, your partner gently slides the splint over splint to to the patient. splint the patient. your hand and ontoPut the patient’s injured limb. pads onon bony promiPut pads bony promi-The lower edge of the and/or let let thethe pa-pa-sure the splint is free of splint should be justnence above her knuckles. Make nence and/or tient hold a rolled cloth or or tient hold a rolled cloth wrinkles. support thethe and inflates the splint bandage to support Continue to supportbandage the arm to while your partner of of the hand and contour the hand and dent in the plastic when by mouth to a pointcontour where you can make a slight to to stabilized and/or limit stabilized and/or limit you press it with your thumb. thethemovement movementof ofthethe Continue to assess distal circulation, sensation, motor function (CSM). hand. hand. 5. 5. You cancan useuse arm sling to to You arm sling support thethe injured area support injured area

Applying an Air Splint

1. 2.

PRINCIPLES PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE 3. 4.

Ang splint na de-hangin ay posibleng mabutas at sumingaw kung inilagay mo ito sa lugar na malamig at ang pasyente ay ililipat sa lugar na mainit. Naapektuhan din ito ng pagbabago sa pressure, depende sa taas ng lugar. Laging suriin ang splint kung maayos pa ito.

WRIST SPLINT WRISTSPLINT

UNIT UNIT 33 PRINCIPLESOF OFEMT EMTCLINICAL CLINICALPRACTICE PRACTICE DAY DAY 1919PRINCIPLES

WRISTSPLINT SPLINT WRIST WRIST SPLINT WRIST SPLINT patient is found in this 1. 1.TheThe patient is found in this position, possible dislocaposition, possible dislocaand/or fracture cases. tiontion and/or fracture cases. CheckPMS PMSbefore beforeandand 2. 2.Check after procedure. after thethe procedure. Measure wrist area 3. 3.Measure thethe wrist area slightly above andand slightly above andand below to secure it propbelow it toit secure it properly.erly. bandage to secure 4. 4.Tie Tie thethe bandage to secure splint patient. thethe splint to to thethe patient. pads bony promiPutPut pads on on bony prominence and/or nence and/or let let thethe pa-patient hold a rolled cloth tient hold a rolled cloth or or bandage support bandage to to support thethe contour hand contour of of thethe hand andand stabilized and/or limit to to stabilized and/or limit movementof ofthethe thethemovement hand. hand. sling 5. 5.YouYou cancan useuse armarm sling to to support injured area support thethe injured area

WRIST SPLINT

² Limmer (Brady) ² Limmer (Brady)

³ Pollack, (AAOS) ³ Pollack, (AAOS) ⁴ NHTSA ⁴ NHTSA

1. The patient is found in this position, possible dislocation and/or fracture cases. 2. Check PMS before and after the procedure. 3. Measure the wrist area and slightly above and below it to secure it properly. 4. Tie the bandage to secure the splint to the

² Limmer (Brady) ² Limmer (Brady) Applying aPut Bipolar Traction Splint and/or patient. padsTraction on bony prominence Applying a Bipolar Splint ³ Pollack, (AAOS) ³ Pollack, (AAOS)

let the patient hold a rolled cloth or bandage to

⁴ NHTSA ⁴ NHTSA

support the contour of the hand and to stabilized Take Standard Precautions. 1. 1.Take Standard Precautions. and/or limit the movement ofleg, the Manually stabilize injured leg,hand. 2. 2.Manually stabilize thethe injured circulation, sensation, motor function (CSM). YouAssess can use arm sling to support the injured 3.5.3.Assess circulation, sensation, andand motor function (CSM). Adjust splint to the proper length position it next to the injured 4. 4.Adjust thethe splint to the proper length andand position it next to the injured area. leg.leg. Apply ischial securing device. 5. 5.Apply thethe ischial securing device. LIFELINE PREHOSPITAL EMERGENCY CARE 509 Apply ankle hitch. 6. 6.Apply an an ankle hitch. Apply manual traction. 7. 7.Apply manual traction. Secure support straps, as appropriate. 8. 8.Secure support straps, as appropriate. Re-evaluate ischial securing device. 9. 9.Re-evaluate thethe ischial securing device. Reassess CSM function. 10.10. Reassess CSM function. Secure patient's torso to the long board to immobilize hips. 11.11. Secure thethe patient's torso to the long board to immobilize thethe hips.

Day 19

PRINCIPLES OF EMT CLINICAL PRACTICE

Applying a Bipolar Traction Splint 1. Take Standard Precautions. 2. Manually stabilize the injured leg, 3. Assess circulation, sensation, and motor function (CSM). 4. Adjust the splint to the proper length and position it next to the injured leg. 5. Apply the ischial securing device. 6. Apply an ankle hitch. 7. Apply manual traction. 8. Secure support straps, as appropriate. 9. Re-evaluate the ischial securing device. 10. Reassess CSM function. 11. Secure the patient’s torso to the long board to immobilize the hips. 12. Secure the splint to the long board to prevent movement of the splint.

Assess the distal circulation, sensation, and motor function both before and after immobilizing or splinting an extremity.

Applying the Sager Traction Splint 1. Place the splint medially. 2. The length of the splint should be from groin to 4 inches below the heel. Unlock the clasp to extend the splint. 3. Secure the thigh strap. 4. Wrap the ankle harness above the ankle (malleoli) and secure it under the heel. 5. Release the lock and extend the splint to achieve the desired traction (in pounds on the pulley wheel). 6. Secure the straps at the thigh, lower thigh and knee, and lower leg. Strap the ankles and feet together. Secure the patient to the spine board.

LIFELINE

1. Assess the distal CSM. Measure the splints. They should extend above the knee and below the ankle. 2. Apply manual traction (tension) on the leg, then place one splint medially and one laterally. Padding is toward the leg. 3. Secure the splints, padding the voids. 4. Reassess distal CSM. 5. Provide emergency care for shock, and administer higconcentration oxygen. Transport on a long spine board.

NOTE:

Assess distal circulation, sensation and motor function both before and after immobilizing or splinting an extremity.

One-Splint Method—Leg Injuries

NOTE:

510

Two-Splint Method—Leg Injuries

PREHOSPITAL EMERGENCY CARE

1. 2. 3. 4. 5. 6.

Assess distal C5M. Measure the splint. Lift the limb off the ground. Apply manual traction (tension). Secure the splint to the injured leg. Reassess distal CSM. Care for shock, and continue to administer highconcentration oxygen. Package the patient and prepare to transport.

NOTE:

Assess distal circulation, sensation, and motor function berth before and after immobilizing or splinting an extremity.

Lifeline in Action

SUICIDE AT THE MRT

– Dealing with a Mental Case A WOMAN – ALLEGEDLY JUMPED ONTO THE TRACK WHEN THE TRAIN WAS ABOUT TO ENTER THE STATION, PINNING HER DOWN.

When we were stationed beside a mall in Ortigas waiting, the Red Room dispatched us to a case at the MRT Shaw Boulevard station for a reported suicide. According to the man who called Lifeline, the patient -- a woman -- allegedly jumped onto the track when the train was about to enter the station, pinning her down. Although the train was already about to stop at the station, it still skidded about 10 meters with the patient underneath. When we got there, I checked the patient underneath and saw pieces of skin on the wheels of the train. Her left leg had serious trauma yet with minimal bleeding. It was pinned between the tracks and I could hear some crepitus when she tried to move. The barangay rescue personnel from the area assisted us in extricating the patient, but due to the leg that was stuck we could not get her out. We waited a few minutes for a veteran train driver to move the train slowly so it would not cause another injury to the patient. The patient was conscious and was able to ask for water.

When the train finally cleared out, our team immediately managed to control the bleeding on the patient’s leg by using a tourniquet and splinting the injured extremity. A c-collar was placed by the barangay rescue personnel and the patient was put into the spine board to be transported to nearest hospital. As my crew took some initial interviews and assessment with the patient, I remembered her saying that the reason why she jumped off the track was “Ayoko nang maging sagabal sa mga plano ng Diyos.” We met with the family of the patient at the hospital and was told that the patient was just released from the National Institute for Mental Health four months before that incident and she was not taking medications because they were too expensive for them. The patient was admitted in the hospital and was advised that surgery to cut her leg was urgent.

LIFELINE

PREHOSPITAL EMERGENCY CARE

511