NZ Outdoor First Aid Manual 33 | 3rd Edition | 2012 by New Zealand Mountain Safety Council

Information may not be accurate. Available for historical purposes only.

NEW ZEALAND

OUTDOOR FIRST AID FIRST AID SKILLS FOR THE NEW ZEALAND OUTDOORS

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NEW ZEALAND

OUTDOOR FIRST AID va

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Mountain Safety Manual 33

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The New Zealand Mountain Safety Council

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We facilitate the setting of standards, offer training and education opportunities, create and distribute resources, lead public awareness campaigns and foster positive support in the community so that more people can discover and enjoy New Zealand’s outdoors safely.

The New Zealand Mountain Safety Council (MSC) is a national organisation with a mandate from our member organisations to encourage safe participation in land-based outdoor activities.

Our mission is to:

• Foster positive community support for outdoor safety.

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• Enable people to enjoy their recreation safely in the outdoors.

• Promote the development and maintenance of national outdoor safety standards for land-based activities.

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Our outcome:

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Our goals are that:

• More people participating safely in land-based outdoor activity.

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• An increased number of leaders, teachers, instructors and guides are inspired, inspiring, competent and retained as leaders.

• Groups and clubs effectively promote and deliver increased safety in the outdoors.

• Commercial operators operate safely.

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• The community is more aware of outdoor safety.

• The MSC is financially strong.

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More information regarding the Mountain Safety Council’s objectives, responsibilities and current projects can be found at www.mountainsafety.org.nz

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NEW ZEALAND

Mountain Safety Manual 33

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OUTDOOR FIRST AID In fo

Third edition Author: Christine McLeod (née Griffin) Medical advisor: Dr Dick Price Managing editor: Jen Riley

Published by: New Zealand Mountain Safety Council

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Email: info@mountainsafety.org.nz www.mountainsafety.org.nz

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ISBN: 978-0-908931-29-3 ISSN: 2744-4023

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Author: Christine McLeod (née Griffin) Managing editor: Jen Riley Cover and design: Danielle Millar Marketing and communications manager: Andrea Corrigan Illustrations: Trevor Plaisted Cover photograph: Danielle Millar Publishing services: Lift Education Medical advisor: Dr Dick Price

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The New Zealand Mountain Safety Council gratefully acknowledges the financial contributions received from the New Zealand Community Trust (NZCT) and the Lottery Grants Board, which have enabled this manual to be fully revised.

Disclaimer: The information contained in this manual is based on the latest first aid information available. The New Zealand Mountain Safety Council has sought advice from experts to ensure the situations described in the manual reflect current best practice, however the information given is general in nature. For this reason, whenever possible, first aiders should seek proper medical advice when managing a medical or outdoor emergency situation. The New Zealand Mountain Safety Council accepts no legal liability or responsibility for any adverse reactions from techniques and treatments described in this manual.

CONTENTS ILLUSTRATIONS LIST vi PREFACE ix ACKNOWLEDGEMENTS

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INTRODUCTION 1 CHAPTER 1: ACCIDENT MANAGEMENT

CHAPTER 3: CARDIOPULMONARY RESUSCITATION (CPR)

CHAPTER 2: PATIENT ASSESSMENT AND MANAGEMENT

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CHAPTER 4: AIRWAY EMERGENCIES (CHOKING) 43 CHAPTER 5: BREATHING EMERGENCIES

CHAPTER 6: CIRCULATION EMERGENCIES 61

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CHAPTER 7: CARE OF AN UNCONSCIOUS PATIENT 83

CHAPTER 8: HEAD INJURIES

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CHAPTER 9: FRACTURES AND DISLOCATIONS

CHAPTER 10: SOFT TISSUE INJURIES 127

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CHAPTER 11: BURNS 135 CHAPTER 12: WOUND CARE AND INFECTION 143

CHAPTER 13: ENVIRONMENTAL MEDICAL CONDITIONS

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CHAPTER 14: EXISTING MEDICAL CONDITIONS

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197

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CHAPTER 15: OTHER MEDICAL CONDITIONS

159

CHAPTER 16: POISONS, STINGS AND BITES 215 CHAPTER 17: UROGENITAL CONDITIONS 229 CHAPTER 18: EVACUATION

239

CHAPTER 19: NURSING THE PATIENT

259

CHAPTER 20: FATALITIES

263

CHAPTER 21: CRITICAL INCIDENT STRESS

267

APPENDICES 271 REFERENCES

282

INDEX 286 v

ILLUSTRATIONS LIST

Figure 0.1

Pre-trip planning

Figure 1.1

Assess scene for danger, then eliminate, isolate or minimise risks

Figure 1.2

Patient assessment and management

Figure 1.3

Effective leadership 10

Figure 2.1 Figure 2.2

Examining head to toe

Usual positions of medical ID jewellery

Figure 2.3

Taking the pulse

Figure Figure Figure Figure Figure

3.1

Respiratory system 28

3.2

Opening the airway – head-tilt, chin-lift

3.3

Opening the airway – jaw-thrust 33

3.4

Chest compressions: adult

3.5

Give breaths and watch chest deflate

Figure 3.6

Chest compressions: child

Figure 3.7 Figure 3.8

Compression depth: child

Figure 3.9

Compression depth: infant

Figure 3.10

Giving breaths (puffs) to an infant

Figure 4.1

Signs of a fully obstructed airway

Figure 4.2

Back blows for adult and child

Figure 4.3 Obstucted airway, chest thrusts Chest thrusts for pregnant woman Figure 4.4

Figure 4.5

Removing object from unconscious person’s mouth

Figure 4.6

Back blows for choking infant

Figure 4.7

Chest compressions for choking infant

Figure 5.1

Avoiding CO poisoning

Figure 5.2

Treating hyperventilation 54

Figure 5.3

Managing an unconscious patient with a flail chest

4 6

39 39 39 45

46 48

56 59 62

Figure 6.2 Figure 6.3

The circulatory system

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Chest compressions: infant

The heart, lungs and oxygen transfer

Treating shock 66

Figure 6.4

Angina 70

Figure 6.5

Heart attack 71

Figure 6.6

Direct pressure to stop bleeding

Figure 6.7

Pressure points 77

Figure 6.8

Tourniquet 79

Figure 7.1

Placing a person in the recovery position

Figure 7.2 Figure 7.3

Recovery positon for infant

Figure 7.4

Emergency rollover, suspected neck injury

Figure 8.1

The head, spine, spinal cord and nerves

Figure 8.2

Brain compression 94

Figure 6.1

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Improvising a one-way air valve

Figure 5.4

Emergency rollover 88

Reaction of pupils 95

Figure 9.1

The skeleton 98

Figure 9.2

Types of fractures 99

Figure 9.3

Straightening a fractured limb

102

Figure 9.4

Moving head to neutral spine position

106

Figure 9.5

Neck collar improvisation

108

Figure 9.6

Log roll 109

Figure 9.7

Log roll with three people

110

Figure 9.8

Lifting a person with a spinal injury

111

Figure 9.9

Sling to support a fractured collarbone

112

Figure 9.10 Figure 9.11

Sling for a fractured arm or wrist

Figure 9.12 Figure 9.13 Figure 9.14

Elevation sling 116

Figure 9.15

Placement of ties for traction splint

120

Figure 9.16

Improvised traction splint

121

Figure 9.17

Splinting a fractured leg

123

Figure 9.18

Reducing a dislocated shoulder

126

Figure 10.1

Assessing severity of a sprain

128

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115

116

Improvised arm slings

Figure 8.3

Removing a ring 117

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Splinting a fractured thigh (femur)

119

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Figure 10.2 Treating a sprain 129 Figure 10.3 Taping a wrist 130 Strapping an ankle 131

Figure 11.1

Burn injury 136

Figure 11.2

Rule of nines

Figure 11.3

Cooling a burn

139

Figure 12.1

Types of wounds

144

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137

Managing a wound 147 Cleaning a wound 148

Figure 12.3

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Figure 12.2

Figure 10.4

Infected wound 149

Figure 12.5

Wound closures 151

Figure 12.6 Figure 12.7

Stabilising an embedded object

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Figure 12.4

153

Removing fish-hook s 154

Figure 12.8

Managing an abdominal wound

Figure 12.9

Gunshot wound 156

Figure 12.10

Managing blisters 158

Figure 13.1

Thermograph 160

Figure 13.2

Managing heat exhaustion

161

Figure 13.3

Managing heat stroke

162

Figure 13.4

How heat is lost from the body

164

Figure 13.5

Managing cold exhaustion

165

Figure 13.6

Warning signs of hypothermia

166

Figure 13.7

Managing hypothermia

168

Figure 13.8

Superficial frostbite (frost nip)

171

Figure 13.9

Preventing immersion foot

173

155

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Figure 13.10

Acute mountain sickness

Figure 13.11

Improvising to reduce snow blindness

Figure 14.1

Asthma – narrowing of the bronchial tubes

187

Figure 14.2

A breathing position for asthma

188

Figure 14.3

Asthma inhalers 189

Figure 14.4

Food to treat hypoglycaemia (diabetic low)

Figure 15.1

A blocked artery or bleeding artery in the brain 198

Figure 15.2

Signs and symptoms of stroke: FAST

Figure 15.3

The abdomen 201

Figure 15.4

Preventing dehydration 204

175

179

194

Figure 15.7

Managing foreign bodies in the eye

Figure 16.1

Relieve itching with a cold water pack

Figure 16.2

Bluebottle (Portuguese man-of-war)

Figure 16.3 Figure 16.4

Stingray wounds 222

Figure 16.5

Whitetail spider 224

Figure 16.6 Figure 17.1

Ongaonga 225

Figure 17.2

Female urogenital system 234

Figure 18.1

Getting help 241

Figure 18.2

Handover requirements 243

Figure 18.3

Two-handed seat 245

Figure 18.4

Four-handed seat 246

Figure 18.5

One-person back carry with rope

247

Figure 18.6

Two-person fore-and-aft carry

247

Figure 18.7

Lifting a stretcher 248

Figure 18.8

Carrying a stretcher 248

Figure 18.9

Improvised pole stretcher (survival bag)

249

Figure 18.10

Improvised pole stretcher (flysheet or tarpaulin)

249

Figure 18.11

Improvised pole stretcher (clothing)

250

Figure 18.12

Improvised pack stretcher

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Figure 15.5 Treating dehydration 206 Figure 15.6 Cooling a person with fever 208

199

Figure 18.13

Making a rope stretcher

251

Figure 18.14

Improvised bivvy bag sledge

252

Figure 18.15

Ski and shovel sledge

253

Figure 18.16 Figure 18.17

Indicating wind direction to helicopter pilot

255

How to approach a helicopter

257

Figure 18.18

Helicopters and hills 257

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220

Katipo spider 223

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Male urogenital system

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212

PREFACE The New Zealand Mountain Safety Council (MSC) ensures that safety standards for all levels of outdoor activity are developed and promoted, and that quality media and other communications exist so the community is more aware of outdoor safety. This fully revised Outdoor First Aid manual is one of the tangible ways in which we do this.

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This manual is suitable for all outdoor enthusiasts, but it is especially useful for those leading groups in the outdoors. It contains essential information about how to handle first aid or medical emergencies in New Zealand’s outdoors. These could occur during a family walk in the local park, a half-day tramp, an overnight trip or a multi-day expedition.

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We have built upon previous editions of the manual and introduced current outdoor safety and medical standards. While you might never encounter a real emergency, we hope this resource will give you increased confidence to effectively deal with any incidents that might occur.

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Further, we suggest that, while this manual will be of immense value, first aid skills are best learned by attending practical courses. I personally encourage you to attend a first aid training course to build on the skills and knowledge you gain from reading this manual. Many opportunities exist for you to do this in your local community. Contact your local MSC branch for details.

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I present this Outdoor First Aid manual to you with a sense of achievement and pride. Our team have worked diligently in its review and production, and I acknowledge and appreciate the energy and enthusiasm that has gone into completing this work.

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I wish you many years of safe and enjoyable outdoor recreation.

Darryl Carpenter Chief Executive Officer New Zealand Mountain Safety Council

ACKNOWLEDGEMENTS The MSC would like to thank the following people and organisations (in no particular order) for their contributions to this edition of the text.

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• Dr Mark Gilbert and Dr Scott Pearson, emergency consultant and emergency physician, Christchurch Emergency Department, Christchurch Hospital, for advice on backboarding patients.

• Don Bogie and Andrew Hobman for advice on avalanche first aid.

• Penny Jorgensen, Allergy New Zealand, for advice on adrenaline usage and anaphylaxis protocols in New Zealand.

• Dan Moore, Outward Bound New Zealand, for advice on cramp and common medical conditions in the New Zealand outdoors.

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• Fraser Petegrew, The Stroke Foundation of New Zealand, for advice on recognising and treating strokes.

• Kiri Pullen, Urtica Inc. for advice on New Zealand plants and animals.

• Keith Riley, Tai Poutini Polytechnic, for advice on emergency procedures, rope work and cramp.

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• Roo Riley, National Outdoor Leadership School (NOLS) New Zealand, for advice on sun bumps and other common medical conditions in the New Zealand outdoors.

• Dr Jenny Visser for advice on hypothermia.

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• Henry Worsp, Peak Safety, for advice on fractures and dislocations.

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• The following MSC Outdoor First Aid instructors for reviewing chapters: Heather Grady, Gail Geange, Ian McGregor, Peter Oldham, Robert Taylor, Warwick Thompson and Alex Warriner.

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• The following MSC Outdoor First Aid instructors for reviewing changes, answering countless questions, and providing limitless time, energy and advice to the Outdoor First Aid programme and this text: Bridget Janse and Nigel Seebeck.

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The MSC is also grateful to all those involved in earlier editions of this manual: John Coleman, Arnold Heine, Ian Taylor, Sue Webb and Christine McLeod (née Griffin). The MSC thanks the following people and organisations for the use of photographs in this manual: Cover: © MSC, by Danielle Millar; Pages 1, 5, 51, 61, 83, 185, 197, 215, 263: © Peter Waworis; Pages 13, 43, 135, 159, 229, 239, 267: © Kerry Adams; Pages 27, 91, 259: © Jen Riley; Page 97: © MSC, by Laura Wilson; Page 127: © Samantha West; Page 143: © MSC, by Léonce Jones; Figure 16.4: © Landcare Research – Manaaki Whenua; Figure 16.5: © Dougal Clunie, Landcare Research – Manaaki Whenua; Figure 16.6: © Bev Davidson, Oratia Native Plant Nursery; Page 271: © Bex Dryland. Jen Riley would like to thank Léonce Jones, the education manager at the MSC, for giving her the freedom and support to manage this project.

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INTRODUCTION .A

IN THIS CHAPTER:

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THE PARTY MEMBERS

FIRST AID KIT

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PRE-TRIP PLANNING 3 4

COPING WITH EMERGENCIES

PHOTO Peter Waworis

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FIRST AID TRAINING

Each year, thousands of people spend time in the outdoors for recreation, work and educational programmes. Usually their experiences are immensely enjoyable and rewarding. Occasionally, however, a situation arises where they need to help someone who has been injured or affected by a medical condition. This manual outlines the steps to prevent and prepare for such situations. It describes how to provide good basic first aid when help is not immediately available, equipment and supplies are scarce, or the first-aider needs to provide care for an extended time.

The aims of first aid are to:

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• Preserve life

• Prevent the patient’s condition worsening

• Promote recovery

Knowing and applying these principles are especially important when:

• There is more than one patient.

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• A patient has more than one injury.

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‘Performing miracles’ is not one of the principles of first aid. Outdoor first aid is not about whipping out a Swiss Army Knife and performing intricate surgery; it is about making the most of whatever skills, knowledge and resources you have.

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Any party members with medical conditions should make these known to others travelling with them in the outdoors. At least one other party member should be able to provide any care they may need during the trip.

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If a party member is dependent on medication, consider splitting the supply into smaller units and carrying it in more than one pack. This lessens the chances of the whole supply being lost if a pack goes missing.

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It is important to be aware of the fitness and ability of party members. If you expect people to work at or near their maximum levels of fitness, you increase the risk of accidents.

FIRST AID KIT A basic first aid kit is an essential piece of equipment for spending time in the outdoors. The types and quantities of first aid equipment will vary, depending on the type and duration of the trip. Suggestions for the contents of first aid kits are included in Appendix II.

INTRODUCTION

PRE-TRIP PLANNING A safe, successful and enjoyable trip is the result of careful planning and preparation. The MSC recommends that before you go into the outdoors, you follow the five simple rules of New Zealand’s Outdoor Safety Code.

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1. PLAN YOUR TRIP

Seek local knowledge and plan the route you will take and the amount of time you can reasonably expect it to take. Department of Conservation (DOC) Visitor Centres and i-SITEs are a good source of local information.

2. TELL SOMEONE

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Tell someone your plans and complete written Outdoors Intentions using the tools available at www.adventuresmart.org.nz

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At the very least, tell a friend or family member where you are going. Tell them a date and time they should raise the alarm if you haven’t returned.

3. BE AWARE OF THE WEATHER

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New Zealand’s weather can be highly unpredictable. Check the forecast and expect weather changes. Check track and hut conditions. Beware of rivers – if in doubt, STAY OUT.

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4. KNOW YOUR LIMITS

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Challenge yourself within your physical limits and experience. Learn essential skills and expand your limits through an MSC course.

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5. TAKE SUFFICIENT SUPPLIES Make sure you have enough food, clothing, equipment and emergency rations for the worst-case scenario. Take appropriate means of communication, such as a mountain radio or Personal Locator Beacon (PLB), and know how to use them.

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Anyone going into the outdoors should do a first aid course and refresh their skills regularly. The MSC offers practical 2-day Workplace First Aid in the Outdoors courses, 1-day Outdoor Emergency Management courses and 1-day refresher courses. These courses are designed to equip people for situations where they need to provide first aid or manage an emergency in the outdoors for extended periods of time.

FIRST AID TRAINING

COPING WITH EMERGENCIES

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Before your trip, prepare a safety plan, listing things that could go wrong (for example, loss of track, rising river levels) and steps that could be taken to minimise or deal with each situation. Make sure the safety plan addresses accidents and medical emergencies, and includes details such as escape routes, communication methods and how to get help.

Figure 0.1 Pre-trip planning

CHAPTER 1 | ACCIDENT MANAGEMENT

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CHAPTER 1:

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ACCIDENT MANAGEMENT .A

IN THIS CHAPTER:

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DANGER 7

LEADERSHIP 8 8

GROUP MANAGEMENT

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PATIENT ASSESSMENT AND MANAGEMENT

PHOTO Peter Waworis

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DECISION TIME 10

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An accident management plan can help reduce panic and the risk of further injuries. You can adapt the following general plan to suit the size and experience of your group.

Accidents in the outdoors happen with little or no warning. Bad weather, rough terrain and remoteness make things worse, and the last thing you need is panic, confusion and chaos. When an accident happens, it is an automatic reaction to rush in and help. However, this can do more harm than good. For example, jumping into the water to help someone in difficulty can result in two fatalities, and rushing down a steep slope to rescue someone who has fallen can dislodge stones above them, injuring them further.

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The five components of the accident management plan are Danger, Leadership, Patient Assessment and Management, Group Management, and Decision Time.

Figure 1.1 Assess scene for danger, then eliminate, isolate or minimise risks

What danger is there to: YOU? THE GROUP? THE PATIENT?

Assess the whole scene before acting.

LEADERSHIP

How can you stabilise the scene? Are all group members accounted for?

Remove the patient from any life-threatening situations. Keep the team together. Eliminate, isolate or minimise hazards.

PATIENT ASSESSMENT AND MANAGEMENT

How can other group members help? What does the patient need?

Delegate roles to other group members. As leader, stand back to keep an eye on the whole situation, if possible. Roles: First-aider Patient supporter Recorder Gofer Radio/communications

GROUP MANAGEMENT

Are party members feeling: Anxious? Upset? Useless? Angry? Cold? Hungry? Guilty? Bored?

DECISION TIME

What is the best course of action? • Stay and play • Scoop and run • Rest and walk out

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Keep group members busy. Communicate with group members and the patient.

Make a plan. Brief the group: ‘This is what is going on and this is the plan’. Brief the patient. Communicate with external people or organisations, such as emergency services, if necessary.

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DANGER Always STOP and THINK about the danger to yourself, the group and the patient. Take a few seconds to calm down and assess the whole scene before acting. Ensuring your own safety is vital. Look at the situation and ask yourself: • What can kill me? • What can harm me? • What can kill group members? • What can harm group members? • What can kill the patient? • What can harm the patient?

CHAPTER 1 | ACCIDENT MANAGEMENT

DANGER

In outdoor situations, awareness of danger has to be immediate and on-going. All necessary steps must be taken to keep you, the patient and the group safe. Special care needs to be taken in steep country, rivers and avalanche-prone terrain. Even areas that seem safe should be carefully assessed. In dangerous areas, it may be necessary to have someone constantly monitor possible dangers until the patient is taken to safety or the risk is eliminated.

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LEADERSHIP

The leader needs to act quickly to stabilise the scene and eliminate, isolate or minimise danger. First of all, remove the patient from any life-threatening hazards, giving clear, calm instructions to other group members to assist. Where possible, eliminate the hazard:

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• Remove the danger from the patient, for example, by turning off an overturned stove or removing a heavy branch.

• Remove the patient from the danger, for example, if they are lying face down in water or on an avalanche-prone slope.

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Sometimes completely removing the danger is not possible, in which case do your best to minimise or isolate the danger, for example, move to a more sheltered area, or ask bystanders to help or move aside.

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The leader also needs to protect the other group members from immediate danger and keep them together. Ask yourself:

• Are all members accounted for?

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• Is there more than one patient?

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The leader has overall responsibility for the patient and the group. Therefore, they need to stand back and delegate as many tasks as possible.

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PATIENT ASSESSMENT AND MANAGEMENT

The person with the best first aid skills should attend to the patient. If this person is the leader, then they should delegate the leadership role to someone else. A physical ailment is usually accompanied by anxiety, apprehension and pain, so have someone be the patient’s constant companion – a TLC (tender loving care) giver. The TLC giver looks after the patient’s emotional needs, gives them support and keeps them informed about what is happening. The TLC giver can also support and help the first-aider. Give this job to the person whom the

Have gofers/runners available to fetch and carry any resources that are needed and to relay messages to the leader and group.

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Ask someone to be the recorder, writing down the time the incident occurred and the findings of the first-aider (for example, the patient’s name, what happened, the patient’s condition, what treatment is being given and Figure 1.2 Patient assessment and management when). See more details in chapter 2.

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GROUP MANAGEMENT

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Delegate to someone the task of accounting for all members of the group and keeping them together. Group members may be feeling anxious, upset, useless, angry and even guilty. They may be cold, tired and hungry. They will usually want to help too.

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Good communication and delegation of constructive tasks will help boost group morale. As soon as possible, let the group know how they can best help you and the patient. In the first instance, this may be by staying calm and looking after each other. A buddy system, where two people care for each other’s well-being, may help. Communicate with the group, telling them that you will let them know the patient’s condition and what your plans are as soon as you can. Delegate as many tasks as you can. This will help keep the group members occupied and allow you to focus on the whole situation. To start with, this may involve preparing hot drinks and food. Later, when you know the patient’s condition, there may be a need for shelter, a fire, a stretcher and external communication, using a mobile phone, EPIRB (emergency position indicating radio beacon) or mountain radio. If you do not know already, find out what resources the group has that could be useful, for example, first aid supplies, extra food and tent flies.

CHAPTER 1 | ACCIDENT MANAGEMENT

patient would most want to have with them.

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Any unusual behaviour from a group member may be the result of stress. Recognition and management of critical incident stress is discussed in chapter 21.

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Figure 1.3 Effective leadership. In big groups, the leader delegates roles and maintains an overview of the whole situation.

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DECISION TIME m

If the injury or illness is severe, you may know immediately that you need to evacuate the patient. Other times, you will need to wait until you have further information.

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Information about the patient’s condition, along with other factors, such as the time of day, the duration of the trip, the terrain and suggestions from group members will determine what you decide to do: • Rest for a while and then carry on. • Rest overnight and walk out the next day. • Have your patient evacuated. Where appropriate, hold a debriefing session, enabling group members to discuss how they feel about the incident. It gives people a chance to process what has happened and can assist them in dealing with stress. Be prepared to change your plan if circumstances change.

Triage is the classification system commonly used by civil defence and ambulance teams to make decisions about multiple patients. It is a systematic way for you to decide: • Who you should attend to first when you come across multiple patients in the outdoors, such as in an avalanche or car crash.

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• How to prioritise when there is more than one casualty and limited resources are available. Resources need to be used for the patients who have the highest chance of surviving.

• Who will be evacuated from the scene to receive medical treatment.

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The classification criteria are based on the likelihood of the patient surviving if they receive professional medical treatment. The triage system uses four colours to classify the patients: DESCRIPTION

CRITERIA

RED

Immediate medical care required

YELLOW

Injuries moderate. A delay in treatment would not be life-threatening

Receiving medical intervention will save this person’s life Not receiving treatment is likely to result in change of classification to black. Delaying medical intervention would not cause a change in classification or worsening of the injury. Can wait 2 hours or more in an outdoor environment.

Minor injuries, can move around with assistance

Patient has minor injuries that can be treated and they are able to assist where required. Often called ‘walking wounded’.

Non-urgent, not likely to survive regardless of medical intervention

Receiving medical intervention now would not change the patient’s chance of surviving.

GREEN

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COLOUR

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BLACK

A patient’s classification can change over time as their condition deteriorates or improves. It is important to constantly monitor patients. A patient’s outcome is not a reflection on the first-aider’s skill. Triage allows unemotional evaluation of a patient to assess what treatment, if any, is given. It does not, however, remove any moral or social responsibilities for that patient.

CHAPTER 1 | ACCIDENT MANAGEMENT

TRIAGE

PATIENT STATUS

A patient status describes the individual patient’s condition. Assigning a status to a patient helps you and emergency services gauge the seriousness of the situation and decide on the appropriate response. In an urban environment, a patient’s status dictates whether an ambulance uses their lights and siren. In an outdoor environment, many factors influence the emergency services’ responses, such as weather, location and time of day. DESCRIPTION

CRITERIA

Critical, needs medical attention now

Injuries need advanced medical treatment that the patient can only receive in a hospital.

Serious, high likelihood of becoming unstable

Injuries are treated, worsening condition, vital signs indicate deterioration.

Moderate, may become unstable

Injuries are treated, but there may be other factors that could cause condition to worsen.

Minor injuries and stable

Injuries are not life-threatening, and patient is usually not immobilised.

Already dead

No signs of life.

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STATUS

NOTE

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In New Zealand, CIMS (Coordinated Incident Management System) outlines protocols for when multiple emergency service agencies are involved in dealing with an emergency.

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

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CHAPTER 2:

IN THIS CHAPTER:

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PATIENT ASSESSMENT AND MANAGEMENT cu ra

STEP ONE: URGENTLY

STEP THREE: EXTENDED CARE

PHOTO Kerry Adams

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STEP TWO: CAREFULLY

In the first few seconds after witnessing an accident or collapse, you may experience a surge of panic in which your mind goes completely blank. Simple memory aids can help you to remember what to do, what to treat and in what order of priority. The three steps of patient management can be remembered as:

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Step two: Carefully (SAMPLE/vital signs)

Step one: Urgently (DRSABC) Identify anything immediately life-threatening (such as obstructed airway, no breathing, no circulation or severe bleeding) that needs to be treated within a few minutes if the patient is to survive.

Gather information, including:

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• A baseline of vital signs, repeated to monitor trends

• Signs and symptoms that may indicate life-threatening conditions that require evacuation or non-life-threatening conditions that can be treated in the field

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Non-life-threatening conditions can become life-threatening in the outdoors. For example, someone with a mildly sprained ankle can delay the group. Delays can put an ill-prepared party at risk if they are caught out by darkness or weather changes. Or, a minor wound left untreated can develop a serious infection after a couple of days.

Step three: Extended care (WRAPT/monitor)

DRSABC

Circulation/ CPR severe Defibrillate bleeding

Urgent

STEP TWO: CAREFULLY

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STEP ONE: URGENTLY

Danger Response Send for help Airway Breathing

Ask

Examine Monitor

Signs/ Symptoms Allergies Medications Past medical history Last ins and outs Events prior

Whole body Done by one person Look, listen, feel, smell Compare sides

Information gathering Write it down!

WRAPT

Vital signs

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SAMPLE Head to toe

Pulse Respiration rate Level of consciousness Skin signs Temperature Pupils Pain

STEP THREE: EXTENDED CARE

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Ensure the patient is as comfortable as possible while recovering or waiting for an evacuation.

Warmth Reassurance Assess and monitor Position Treatment

Comfort/ monitoring

The assessment begins as soon as you encounter an ill or injured person. Observations including the position of the patient and bystanders, terrain and weather are the first clues as to what happened and what needs to be done.

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If there is more than one patient, assess and treat patients with immediate life-threatening problems first. Go to the quiet patient first; a noisy patient may be seriously injured, but they are alive.

The first priority is always DRSABC. For details on how to assess and manage airway, breathing and circulation, see chapters 3, 4, 5 and 6. Danger: Think about what can kill or harm you, the group, bystanders or the patient and deal with that first, then constantly keep danger in mind. Eliminate, isolate or minimise the hazards.

Response: Call out and talk to the patient as you approach. A verbal response tells you that the patient has a clear airway, is breathing and has circulation. It can also give you some idea of their level of consciousness. If there is no response:

Send for help

Airway: Can air get in and out of the lungs? If not, open the airway.

Breathing: Is the patient breathing well enough to support life?

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IF NO:

CPR: Give 30 compressions/2 breaths

Circulation (and severe bleeding): Look for bleeding and control it. Large wounds and bleeding can be hidden by bulky clothing, so do a blood sweep. Run your hands over and under clothing. If you feel dampness, investigate further, as it may be serious bleeding that needs to be stopped.

Defibrillate: In an urban setting, send for an AED (automated external defibrillator). Open the machine, and then follow the instructions given by the electronic voice prompts.

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IF YES:

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STEP TWO: CAREFULLY Once all immediate threats to life have been addressed, there is no need to rush. Take a deep breath, reassess the scene and collect your thoughts, before starting the information-gathering phase. Reassure the patient, use their name and arrange privacy if needed.

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

STEP ONE: URGENTLY

Write down all the information you gather. This record will go with the patient if they are handed on to professional care. Gather information through questioning, examining and monitoring. If the patient is unresponsive or confused, you many need to ask bystanders. Clues may be gathered from the scene, for example, a half-eaten meal or a fallen rock.

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One person should ask the SAMPLE questions to ensure that the process is thorough, accurate and complete. It is easier for the patient to listen and respond to one person.

SAMPLE QUESTIONS

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Where possible, leave the patient in the position you find them in until you have determined what their injuries are. If the accident site is unsafe, do a quick check of the patient to find any serious injury and administer essential treatment before moving them. Do a complete assessment when the patient is safe and sheltered. Taking photographs of the accident site can be useful for the patient record.

Signs and symptoms

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What do you as the first-aider see and what do they as the patient feel?

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Talk with the patient to find out their symptoms, then examine them to get the signs. • Ask the patient:

• Can you describe what you are feeling?

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• Where does it hurt?

• Does it hurt anywhere else?

• Are there any other problems?

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• How painful is it on a scale of 1 to 10? 10 being the worst pain you have ever felt and 1 being pain you hardly notice.

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• Look, listen and feel for signs, such as deformity, noisy breathing and wet skin.

If the patient is unconscious after an injury, always suspect a neck or spinal injury. You must immediately immobilise the patient’s neck (see page 107). Have someone constantly monitor the airway, breathing and circulation of the unconscious patient. Intense pain from one injury can mask pain of another that may be life-threatening, for example, the pain from a broken ankle may mask the pain from an injured internal organ. Asking ‘Does it hurt anywhere else?’ makes the patient focus on other areas of pain.

Allergies Are you allergic to anything?

• Have you had an allergic reaction before? Describe it.

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• Are you allergic to anything? Pollen? Wasps? Insects? Food? Animals? Medications, such as penicillin or anaesthetics? Sticking plaster?

• Ask the patient:

Medications

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Are you on any presciption medicines or taking drugs of any form? Have you been drinking alcohol?

• Ask the patient:

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• Are you on any medication? Over-the-counter medication? Prescription medicine? Drugs? Alcohol?

• Have you skipped your medication? Have you taken more than usual?

• Record names of medications and when the last dosage was taken.

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• Check: Are they wearing a medical ID bracelet or necklace?

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A patient’s regular medication may be due. A patient with diabetes may need food.

A patient’s level of consciousness may be altered due to the drugs they took earlier rather than to the gash on their head.

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Past medical history

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Is there anything relevant about your health that could relate to this event? • Ask the patient: • Has this happened before? If so, what did you do? • Do you have any medical conditions (for example, heart disease, high blood pressure, diabetes, asthma, epilepsy, urogenital or abdominal conditions, mental illness)? • Do you have any health issues that may be relevant (for example, poor hearing or vision, migraines, a shoulder you have dislocated multiple times in the past)? • Do you wear glasses or contact lenses?

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

Asking these questions before touching the patient may prevent you causing more harm. It is tempting to put a reassuring hand on the arm of a patient with an obviously broken leg, only to find out that their arm is also broken.

Last input/output When and what did you last eat/drink? When/what/how much did you last pee and poo or vomit? • Ask the patient: • What did you last eat, how much and when? • Have you vomited recently?

• When did you last drink and how much?

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• Do you smoke? When did you last have a cigarette?

• When did you last go to the toilet – pee and poo?

The patient may be feeling faint due to hunger, be vomiting due to dehydration or have abdominal pain due to constipation rather than appendicitis. Recent smoking may increase heart rate and withdrawal may cause a tremor.

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Events

What caused this illness/injury? What happened?

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Never make assumptions about a patient’s condition. Instead, ask the patient, and any bystanders:

• What happened?

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• When did it happen?

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• How did it happen?

• Why did it happen?

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Their answers may provide vital clues about the patient’s injuries or illness and reveal underlying conditions and problems, for example:

• What happened? ‘I slipped and twisted my ankle’ or ‘I can’t remember ... ’.

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• How/why did it happen? ‘The boulders were slippery’, ‘I felt a bit dizzy’ or ‘I was running away from wasps’.

While a twisted ankle is the obvious injury, possible other problems include head injury, a medical condition and an allergic reaction.

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Check that the injuries the patient says they have are consistent with what happened. For example, you would expect someone who fell from the top of an abseil site to be complaining of more than just a sore wrist.

HEAD-TO-TOE EXAMINATION Remember to leave the patient in the position you find them until you have completed a head-to-toe examination. This is a slow, hands-on, physical examination of the whole body – from the head down to the toes. The physical examination needs to be done by one person, for accuracy, for comparison purposes and for the patient’s comfort. In some situations, such as with a young patient and with some ethnicities, it

Before you start, ask the patient for permission to examine them, and explain what you are going to do and why. This involves the patient in their own care.

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The examination involves looking, listening, feeling and smelling. Ensure you have clean, warm hands. As you move down the body, always watch the patient’s face, particularly if the patient is unconscious, to see any reaction to pain. You need to be thorough enough to find even subtle indications of injuries, such as bruising and swelling. If you find discomfort or deformity, examine the skin to see if the cause is visible. If you cannot see it, you cannot treat it. When it is difficult to tell if something is different or abnormal, either compare it with the other side of the body or with an uninjured party member.

Enlist a note taker to write down all your findings and actions. Dictate to them what you find and do.

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If you need to remove a patient’s clothing to complete the examination, investigate injuries or carry out treatment, explain this to the patient. Remove only what is necessary and replace it as soon as the area is checked as clothing is essential for warmth. It is easier to remove shirts and jackets from the uninjured side first. Minimise damage by cutting along seams.

NOTE

Slow, thorough, firm

Compare one side with the other

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Eighty percent of your diagnosis comes from taking a thorough history; twenty percent from the examination. Remember to talk with your patient and ask questions.

Watch patient’s face to see their response to touch, which may indicate pain at that point

Figure 2.1 Examining head to toe

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

is important for the examiner to be the same gender as the patient, or for the patient to choose their own same-gender support person to be present.

Head • Look for blood or straw-coloured (cerebral spinal) fluid coming from the ears or nose. • Check the face for symmetry – one side should look the same as the other. • Gently feel for damage to bones on the face, including the nose. • Check the mouth for damaged teeth, dentures and foreign matter – can the patient open their mouth? Do not put your fingers in their mouth unless you are intentionally picking out an object that you can see.

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• Feel the entire skull for bleeding, depressions and tenderness.

• Check the eyes for damage. Are both pupils equal? Hold up one or two of your fingers. Can the patient see them? Can they see with both eyes? Can the patient move their eyes up and down and from side to side?

Neck

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A broken bone (vertebra) in the neck will hardly ever be obvious to the touch. If the patient is unconscious after an accident, always assume a neck injury.

• Look for a medical ID necklace.

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• Feel from the base of the skull to the top of the shoulders for tenderness, muscle rigidity and deformity.

• Check that the windpipe is central, not forced to one side.

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Shoulders

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• Feel the shoulders and collarbones for tenderness and deformity. Compare both sides.

Chest

• Feel the entire chest for tenderness and deformity.

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• Press down on the breast bone with the side of your hand.

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• Check the ribs by pressing down from the top and in from the sides, gently but firmly. If the patient is conscious, ask them to take a deep breath – if this hurts them, stop and examine the area. • Check that both sides of the chest rise and fall evenly.

Abdomen • Divide the abdomen into four, and feel each quadrant – is it soft (normal), tender or rigid? • Warm your hands first, or feel through the patient’s clothing. • Be gentle, using light pressure. • If a quadrant is tender, look for discolouration, bruising and distension (swelling).

• Look for deformity. • Press down on the front of the pelvic bones and in from the sides, gently but firmly. Stop if this causes pain. • Ask if the patient has passed urine and if there was blood in it.

Arms and legs

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• Examine each part of each limb (arm – above the elbow, forearm – below the elbow, thigh – above the knee, leg – below the knee) applying gentle but firm pressure, as if trying to bend the bone. Stop if the patient complains of pain or if the bone appears to be broken.

• Compare one side with the other to help detect swelling and deformity.

• Look at and feel hands and feet for deformity, swelling and discolouration.

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• Ask the patient if they have normal feeling in their limbs and test this by squeezing the limbs gently.

• Check for circulation in a limb that appears to be broken, either by feeling for a pulse or by observing the colour.

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• Squeeze the base of the nail to check capillary refill – the nail will be white when squeezed and will quickly return to pink if blood is flowing normally.

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• Most checking of the limbs of a conscious patient can be done by asking them to use their limbs. Can they move each arm through its full range of movement? Grasp their toes. Can the patient pull, push away, rotate the ankle and flex the knee?

• Check wrists and ankles for medical ID bracelets.

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• If feeling in or movement of the hands and feet are affected, consider a spinal/neck injury.

Back • Feel the spine and ribs for tenderness and deformity. • Feel each vertebra (back bone) from the shoulder to the pelvis, without causing any movement of the spine. This is not easy to do with a patient lying on their back. Crossing the patient’s arms (once they are checked for injury) across their chest makes it easier to slide your hands under the back.

Figure 2.2 Usual positions of medical ID jewellery

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

Pelvis

It is important to remember that, as with the neck, an injury to the vertebrae can be difficult, if not impossible, to detect. An injury may be present even though the patient has movement and sensation in the limbs. The way the injury happened should indicate whether to suspect a spinal injury. For example, a fall from the patient’s head height is enough to cause spinal damage. If it was awkward, a fall from a lower height can cause spinal damage.

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Note: If there is definitely no spinal injury it is acceptable for the head-to-toe exam to be completed with the patient sitting up. Lying flat on their back can leave a patient feeling rather vulnerable and uncomfortable.

VITAL SIGNS

Level of consciousness, pulse, breathing, skin signs, temperature, pain, pupils

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Have one person measure the vital signs for consistency. Write the vital signs down rather than trying to remember them. Record vital signs every 5–10 minutes initially or while the patient’s condition is changing. If the patient and their vital signs are stable, record information at longer intervals. The initial recordings provide useful baseline information, and the on-going recording of vital signs show trends in the progress of the patient’s condition.

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Level of consciousness

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A pulse oximeter is a useful electronic device for measuring how much oxygen is in the blood. These are becoming more common. To check the normality of the patient’s reading, compare it with other party members’ readings.

Record how conscious the patient is using the AVPU scale.

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A: Alert. There are different levels of alertness. A person who can answer the following four questions is alert and oriented x 4.

What is your name? Where are we? What time is it? What happened?

• A and O x 4 (can answer who, where, when and what accurately)

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• A and O x 3 (can answer who, where and when)

• A and O x 2 (knows their name and the time of day, but is otherwise confused)

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• A and O x 1 (knows their name, but is confused about the time, where they are and what happened)

V: Responds to voice only. They may squeeze your hand if asked or moan in response to questions. P: Responds to pain only. They do not react to your voice, but will flinch or pull away if you pinch them or tap their collar bone. U: Unresponsive. They do not react to voice or pain.

Pulse A patient’s pulse is usually taken at their wrist or neck. The normal rate for an adult is 60–90 beats per minute; slower for an athlete, faster for a child. To find

• The pulse is 120 bpm, irregular and weak. • The pulse is 70 bpm, regular and strong.

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Note: Thumbs have pulses, too. Therefore when taking a pulse, be sure to use your fingers rather than your thumb, to avoid measuring your own pulse instead of the patient’s. (a) Wrist (radial) pulse

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Figure 2.3 Taking the pulse

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(b) Neck (carotid) pulsenec

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Breathing (respiration rate)

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The normal respiration rate for an adult is 12–20 breaths per minute; faster for a child; even faster for an infant. Count the number of breaths for 30 seconds and multiply this number by two. It is important to note whether the breathing is noisy or wheezy, or if the patient is having difficulty breathing. Noisy breathing can be a sign of an obstructed airway. Note any unusual breath odours. Record the rate, rhythm, character and odour of the breath, for example: • The respiration rate is 15 breaths per minute, regular, easy, no odours. • The respiration rate is 30 breaths per minute, irregular, laboured, smells of vomit.

Skin signs Skin signs can indicate the condition of the respiratory and circulatory systems. Look for changes in colour, temperature and moisture levels. In a fair-skinned person, changes in skin colour are easy to see. In a darkerskinned person, look for colour changes in the fingernail beds and palms. Note if the patient’s skin is pale or flushed. The skin of a healthy person is warm and relatively dry. Assess the skin at

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

the wrist (radial) pulse, place two or three fingers over the bone on the thumb side of the wrist. To find the neck (carotid) pulse, place two or three fingers on the Adam’s apple and slide across into the groove under the jawbone on the side closest to you. Count the number of beats for 15 seconds and multiply the number by four. Record the rate, rhythm and strength of the pulse, for example:

several sites, such as forehead, hands and trunk. Is the patient’s skin hot and dry, hot and sweaty, cool and clammy? Record the colour, temperature and moisture of the skin, for example: • The skin is pale, cool and clammy. • The skin is red, hot and sweaty.

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It is difficult to accurately record temperature without a thermometer, so consider the environmental conditions. Compare the patient’s skin temperature with a healthy party member’s. Carry a low-reading thermometer in the first aid kit.

Temperature

Pain

Let the patient describe their pain rather than agreeing with words you suggest. To help them describe it, ask:

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• Where is the pain centred and does it spread out to another site?

• What is it like – dull, sharp, radiating?

• What causes it?

• What level is it on a scale of 1 to 10?

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• Is it increasing or decreasing?

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Pupils

PEARL: Are pupils equal and reactive to light?

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Cover the patient’s eyes for a few moments. Then, remove your hands and notice if the pupils quickly shrink when exposed to light. If the pupils are not equal and reactive to light, the patient may have a brain injury. Remember that eye injuries and some medications can influence pupil reaction.

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STEP THREE: EXTENDED CARE This step is about getting your patient ‘WRAPT up’ for comfort while recovering or waiting for professional care to arrive. The things to remember are Warmth, Reassurance, Assess again, Positioning, Treatment.

WARMTH Insulate the patient from the ground as soon as possible with a sleeping mat. If you suspect the patient has a spinal injury, move them using the log roll method (see page 109) to ensure their spine stays neutral throughout the movement. Protect the patient from wet, wind and cold; for example, dress them warmly,

REASSURANCE

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Reassurance is an essential, often underrated, component of patient care. A patient will experience a variety of emotions, including distress and embarrassment. Some patients will understate the extent of their pain or illness, so as not to be a nuisance. They may be fearful of the quality of care, the outcome of their injury or illness, or their loss of independence and control.

Reassurance, concern and empathy can help the patient cope, and they are particularly helpful in the treatment of shock, as explained in chapter 6.

• Where possible kneel next to the patient, making eye contact. You may appear threatening to an injured person lying on the ground if you stand over them.

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• Do not step over the patient. Walk around their feet end so they can see you.

• Deal with or remove anything that may cause the patient distress.

ASSESS AGAIN – MONITOR THEIR VITAL SIGNS

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Patient assessment is not an exact science. In hospital, patients are examined and re-examined following an accident or sudden illness. Sometimes, quite significant findings are made hours and even days later. If the patient’s condition is changing, or if the patient was involved in a high impact accident, it is important to reassess them regularly. Monitoring and recording their vital signs will highlight if their condition is deteriorating.

POSITIONING

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Place the patient in the position appropriate for their illness or injury, which is often the most comfortable position for the patient. The three main positions are:

• Sitting or semi-sitting, if the patient is having breathing difficulties

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• Lying flat with the legs raised, if the patient is in shock

• The recovery position (also called stable side position), if the patient is unconscious These positions are described in detail in chapters 5, 6 and 7.

TREATMENT Now that you know what the injuries are, or have some idea of the possible illness, you can begin treatment. Chapters 8 to 16 deal with treatments for specific injuries and medical conditions. Arrange an evacuation if treatment and recovery cannot happen in the field.

CHAPTER 2 | PATIENT ASSESSMENT AND MANAGEMENT

insulate them with wet weather gear, move them to shelter or set up a tent over them. (See chapter 13 on hypothermia for more information on keeping warm.)

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CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

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CHAPTER 3:

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IN THIS CHAPTER:

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CARDIOPULMONARY RESUSCITATION (CPR) ac

WHEN TO DO CPR

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GETTING HELP

NEAR DROWNING

FREQUENTLY ASKED QUESTIONS

ADULT CPR

QUICK REFERENCE

INFANT CPR

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CHILD CPR

PHOTO Jen Riley

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When we breathe, air is carried through the airway – the nose, mouth, throat and windpipe – into the air sacs in the lungs. Blood circulating from the body to the chest is pumped from the heart to the lungs, where it absorbs oxygen. The blood then returns to the heart which pumps it out to the body. Every cell in the body needs an adequate and constant supply of oxygen to survive.

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Figure 3.1 Respiratory system

If a person’s airway is blocked, they are unable to breathe. If they stop breathing, their heart will continue to beat for several minutes, circulating existing stores of oxygen to the brain and the rest of the body. Without oxygen, the heart will stop within minutes.

• The Airway to be blocked (airway obstruction) • The Breathing to stop (respiratory arrest) • The Circulation of the blood by the heart to stop (cardiac arrest)

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Cardio refers to the heart, and pulmonary refers to the lungs. The purpose of cardiopulmonary resuscitation (CPR) is to keep oxygen circulating to the brain and other vital organs until medical help arrives, or until the heart and/or breathing restart. By doing CPR, you do for the patient what they cannot do for themselves:

• A: If their airway is not open, you open it.

• B: If they are not breathing, you breathe into them.

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• C: If their heart has stopped beating, you compress the chest, forcing blood to flow via the heart and lungs to the brain.

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Timing is critical when recognising the need for, and starting, CPR. In general, if the brain is deprived of oxygen for longer than 4–6 minutes, some permanent damage, but not necessarily death, will occur. When considering the need for CPR, remember:

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• The time a person collapsed, was washed away in a river or was buried in an avalanche is not necessarily the time that their breathing or circulation stopped.

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• People have been known to survive after long periods of submersion in cold water, so always attempt CPR even if you know the person has been underwater for some time.

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Remember that CPR is done on a patient whose heart is not circulating blood and who is therefore essentially dead. You cannot make the patient’s situation worse, but by doing CPR, you may succeed in reviving them or maintaining them until emergency services arrive with an AED (automated external defibrillator).

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

Some accidents or medical conditions (such as drowning, suffocation, choking, drug overdose and poisoning) may cause:

GETTING HELP All patients who are receiving CPR, and those who have been resuscitated, need expert medical attention. Advise emergency services that CPR is being performed, and get an evacuation underway as soon as possible. If there is more than one first-aider:

• One should start CPR.

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• Another should arrange an urgent evacuation.

If you are alone, and the patient is an adult or child:

• Open the airway.

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• Once you determine that they are not breathing, go for help immediately, before starting CPR. This is because the patient’s collapse is likely to be heart-related, and the sooner they receive expert medical treatment, the better their chance of survival.

If you are alone, and the patient is an infant, or an adult whose likely cause of collapse is injury or drowning:

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• Do CPR for 1 minute.

• Quickly get help (or carry the infant with you, continuing to do CPR, as you go for help)

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• Resume CPR.

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In an outdoor setting, calling for help can take a long time depending on your situation and location, so use your judgement. It may be more appropriate to start CPR rather than spend time setting up a mountain radio or running back to get mobile phone coverage. Remember, once you start CPR it should not be interrupted.

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When a patient is not revived through CPR, the emotional cost to those involved can be high. The feelings of failure, inadequacy and guilt can last for years. The rescuers will need support after the event to help them to come to terms with their experience. Guidelines for dealing with critical incident stress are detailed in chapter 21.

NOTE For the most up-to-date guidelines, visit the New Zealand Resuscitation Council website: www.nzrc.org.nz

CPR is part of the first urgent step of patient assessment and management. Remember: DRSABC. CHILD CPR

INFANT CPR

(approximately 1–8 years)

(approximately 0–1 years)

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ADULT CPR (from approximately 9 years)

Two hands Centre of chest, imaginary line between armpits

DEPTH OF COMPRESSIONS

Compress 1/3 of chest, at least 5cm

COMPRESS WITH

Immediately – call for help before starting chest compressions

Do CPR for 1 minute before calling for help

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GETTING HELP IF ALONE

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Danger – Check and deal with hazards. Response – Call out, ‘Can you hear me?’ Tap collar bone or sternum. If no response: Send for help – If not alone, ask another person to call emergency services and tell you when they have done so. In the outdoor environment, this will mean setting up communication, such as a mobile phone, a mountain radio or an EPIRB. Airway – Open airway with head-tilt, chin-lift/jaw-thrust methods. Breathing – Check for up to 10 seconds. If breathing is not normal (less than six breaths per minute):

Two fingers Centre of chest, just below nipple line

Compress 1/3 of chest, 4cm

Compress 1/3 of chest, 3cm

100/minute

30 compressions : 2 breaths

RESCUE BREATHING

Breaths – block their nose, seal your mouth over theirs

Breaths – seal your mouth over their nose and mouth

DEFIBRILLATE

Attach AED and follow Attach paediatric voice prompts. (child) specific AED pads and follow voice prompts.

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One hand Centre of chest, imaginary line between armpits

COMPRESSIONS PER MINUTE

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RATIO OF BREATHS TO COMPRESSIONS

Do not defibrillate unless medically trained.

If there is no AED available, continue CPR until: •

There is spontaneous return of circulation and they are very obviously conscious. (Note: Vomiting is NOT a sign of consciousness.)

•

Professional medical help arrives.

•

You and your group are unable to continue CPR due to exhaustion or danger.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

QUICK REFERENCE

ADULT CPR DANGER Check for danger to you, the group and the patient. Leave the patient in the position you found them unless it is unsafe.

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RESPONSE

Check for a response.

• Shout out as you approach, ‘Can you hear me? Are you okay?’.

• Tap the patient’s shoulder or rub their sternum with your knuckles.

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SEND FOR HELP

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If the patient does not respond and you are on your own, call loudly for help. If you are not alone, ask someone to call emergency services and come back to tell you when they have done so. In the outdoor environment, this may mean setting up a mountain radio or trying to get mobile phone reception.

AIRWAY

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Check that the airway is open.

REMEMBER

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Immediate opening of the airway is the first priority with an unconscious person, as their tongue can fall back across their throat, blocking their airway.

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Opening a patient’s airway may be all that is needed to save their life.

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• Remove any visible objects from the mouth, including vomit. Do not put your fingers in their mouth unless you are intentionally picking out an object that you can see.

• Open the airway, without moving the patient from their original position if possible. Turn them onto their back if necessary. Use the head-tilt, chinlift method: 1. Place one hand on the patient’s forehead. 2. Place the fingers of your other hand on the bony part of their chin.

3. Tilt the head back and lift the jaw up. This will lift the tongue off the back of the throat.

4. Place 5cm of clothing as a pillow under an adult patient’s head to help open their airway.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

Tongue blocks airway

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Tilt head so tongue lifts up and opens airway

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Figure 3.2 Opening the airway – head-tilt, chin-lift method (not used for patients with suspected spinal injuries)

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• If you suspect the patient has a neck or spinal injury, do not use the head-tilt, chin-lift method. Use the jaw-thrust technique to minimise any movement of the neck:

2. Grasp the angles of the lower jaw (just below the earlobes). 3. Lift the lower jaw forwards – the bottom teeth come forward of the upper teeth.

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Figure 3.3 Opening the airway – jawthrust method (used for patients with suspected spinal injuries)

1. Position yourself at the top of the patient’s head, place one hand on each side of the patient’s head.

BREATHING Check for breathing, without moving the patient. Spend no more than 10 seconds doing this. • Look: Can you see the chest rise and fall? • Listen: Can you hear normal breath sounds (more than the occasional gasp)? • Feel: Can you feel breath on your cheek or hand if you hold it close to the patient’s mouth and nose? Can you see moisture on a cold surface, such as a watch or glasses, if you hold it to their mouth and nose?

If the patient is breathing, you can assume they have circulation. Do not do CPR. See chapter 7 for care of an unconscious breathing patient. Agonal breathing, short irregular gasps for breath, is common in the first few moments after a cardiac arrest. It should not be mistaken for normal breathing. If agonal breathing is present, start CPR. Fingers interlocked

CPR

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Elbows locked, arms vertical

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Heel of hand in centre of chest at armpit level

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Figure 3.4 Chest compressions: adult

If the patient is not breathing or there is only the occasional gasp, begin chest compressions: The patient must be on their back on a firm, preferably flat surface for compressions to be effective. You may have to move the patient to achieve this. If you are on a slope, position the patient across, not down, the line of the slope.

Kneel next to the patient.

Position the heel of one hand in the centre of the chest, on an imaginary line between the armpits.

Place the heel of the other hand on top of the first.

Interlock the fingers to lift them off the chest. If it is easier for you, use the hand on top to grasp the wrist of the hand on the chest.

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Push down vertically, by leaning forward so your shoulders, arms and hands are in a straight line.

Press the chest down firmly, approximately one-third of the depth of the chest, at least 5cm for most adults. Using a smooth, regular rhythm, do 30 compressions at a rate of 100 per minute (15 per 9 seconds, slightly fewer than 2 per second). Do not lift your hands off the chest between compressions.

Allow equal time for compression and recoil – chest recoil sucks the blood back into the chest and compression forces blood out to oxygenate the brain.

After every 30 compressions, do two rescue breaths.

11. After every 3 minutes check for signs of life. If there are no signs of life: 12. Give two breaths and continue the cycle.

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If the patient starts breathing, and can breathe without assistance, place them in the recovery position, insulated from the ground, and check their vital signs frequently. If they need help breathing, do rescue breaths (follow the steps below).

RESCUE BREATHING Remove any visible objects from the patient’s mouth.

Maintain the head-tilt, chin-lift position.

Pinch the patient’s nostrils shut to prevent air from escaping.

Take a deep breath.

Make a tight seal with your mouth around the patient’s mouth and blow until you see their chest rise.

Give two steady, effective breaths, pausing momentarily between each breath.

Each breath should take one second to deliver.

Turn your head and look towards the patient’s chest. You should be able to see the chest fall and feel air coming out of the mouth.

If the patient’s chest does not rise, reposition their head and try again. If the chest still does not rise after five attempts, the airway may be obstructed. Follow the steps for clearing airway obstructions on page 44.

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Turn your head.

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Create a seal around their mouth.

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Pinch the patient’s nostrils.

Watch the chest fall.

Blow in until you see the chest rise.

Maintain head-tilt position.

Feel the air coming out against your cheek.

Figure 3.5 Give breaths and watch chest deflate.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

10. Continue the cycle of two breaths to 30 compressions.

REMEMBER

The head-tilt, chin-lift position keeps the tongue off the airway. This position prevents air entering the stomach, which may cause the patient to vomit. Breathing faster than one steady breath per second may also cause them to vomit. Try not to overinflate their lungs. The only way you can tell that the rescue breaths are effective is to see if the patient’s chest or upper abdomen rises and falls with each breath.

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• •

Mouth-to-nose breathing

You can use mouth-to-nose breathing if:

• The patient is in water.

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• There are injuries to the mouth that make mouth-to-mouth breathing impossible, or the mouth cannot be opened.

• The patient has taken poison. However, do not do any mouth-to-mouth or mouth-to-nose breathing if you suspect cyanide poisoning (see page 218).

To give mouth-to-nose breathing:

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• Lift the patient’s chin to close the mouth, using your fingers on the bony part of their jaw.

• Seal your lips around the patient’s nose, and blow into it.

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DEFIBRILLATION

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• Open the patient’s mouth to enable them to breathe out.

Automated External Defibrillation (AED)

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An AED is a portable computerised device programmed to recognise heartbeats and shock the heart into beating in the correct rhythm. An AED sends an electric current through the heart, effectively shocking it back into normal rhythm. AEDs recognise problems such as: • Ventricular tachycardia – when the heart is beating too fast to effectively pump blood around the body. • Ventricular fibrillation – when the heart is beating even faster than tachycardia. It is a rapid quivering with no effective pumping of blood.

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AEDs have written instructions and usually have voice prompts, giving step-bystep instructions on how to use the machine. An AED will only shock a heart that needs shocking.

CHILD CPR ic

CPR is adapted to suit the size of the patient. A child is considered to be approximately between one and eight years old. An infant is younger than one year old. As a rough guide, if you can lift the patient using one arm, they are an infant. If you need both arms to lift them, they are a child. If you struggle to lift or move them using both arms, they are an adult.

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Heel of ONE hand in centre of chest at armpit level

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Figure 3.6 Chest compressions: child

One-third of chest depth, approximately 4cm

Figure 3.7 Compression depth: child

The only difference between adult CPR and child CPR is that the rescuer uses one hand, not two, for compressions. However, a small rescuer may need to use both hands to achieve effective compressions. Remember, you need to compress the chest by one-third of its depth to be effective. For a child this is approximately 4cm. A child’s lungs are not as big as an adult’s so a rescue breath will be smaller, just enough to fill the lungs, not overinflate them.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

Although access to an AED is often not possible when in the remote outdoors, AEDs are becoming more common in urban environments, for example, in shopping malls, airports, medical outposts and ski fields, and on ships. The sooner an AED is used, the better the result. The AED Locations website, www.aedlocations.co.nz, displays where available AEDs are located and has a downloadable smart phone app for locating AEDs in your area.

INFANT CPR DANGER Check for danger to you, the group and the patient.

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RESPONSE

• Pick the infant up. An unresponsive infant will be floppy and limp.

Check for a response.

• Pinch the skin enough to make them cry. If there is no response, place the infant on their back on a firm, preferably flat surface.

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SEND FOR HELP

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If you are not alone, send someone to ring an ambulance and tell you when they have done so. If you are alone, and the infant is not breathing, do CPR for 1 minute before going to get help. Carry the infant with you, continuing to do CPR, as you go for help.

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AIRWAY Check that the airway is open:

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• Tilt the infant’s head back only very slightly. Infants have very short necks, so do a head-tilt, chin-lift, but do not push the head back too far as this may kink and block the windpipe.

• Avoid any pressure on the soft part under the chin.

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BREATHING

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Check for breathing. Take no more than 10 seconds to look, listen and feel for breathing. If the infant is not breathing or only making the occasional gasp, start chest compressions. Glasses or a watch held close to an infant’s mouth or nose will steam up if they are breathing.

CPR 1.

Place two fingers on the infant just below an imaginary nipple line.

Press down approximately one-third of the depth of the chest, approximately 3cm.

Using a smooth, regular rhythm, give 30 compressions at the rate of 100 per minute (15 per 9 seconds, slightly fewer than 2 per second).

Give two puffs (see below) and repeat the cycle of 30 compressions to two puffs.

Every 3 minutes, check for signs of life.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

If there are no signs of life: Give two puffs and continue the cycle of 30 compressions to two puffs.

Centre of chest, just below the nipple line

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Figure 3.8 Chest compressions: infant

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Figure 3.9 Compression depth: infant

Press down one-third of chest depth, approximately 3cm

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RESCUE BREATHING (PUFFS) Remove any visible objects from the infant’s mouth.

Quickly wipe out any vomit from the mouth, using gloved fingers.

Cover the infant’s mouth and nose with your mouth and make a tight seal. Or pinch the infant’s nose and seal your mouth over theirs.

Give small gentle breaths. You should just see the chest and/or abdomen rise and fall slightly. Remember, an infant’s lungs are small so do not give large forceful breaths.

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If air does not enter freely or the infant’s chest does not rise, reposition the head and try again, up to five times. Do this gently so as not to kink the windpipe.

A foreign body is a likely cause of breathing difficulties in an otherwise healthy infant or child.

Seal your mouth over their mouth and nose. Use small puffs of air.

Do not over-extend the neck.

Figure 3.10 Giving breaths (puffs) to an infant

NEAR DROWNING

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Danger to yourself is the prime consideration if you are involved in a drowning rescue. Remember the lifesaving expression, ‘reach, throw, row, go’:

Near drowning is the term used when someone has been unconscious in water and has been resuscitated with rescue breathing or full CPR. It does not apply to a person who has an involuntary dunking and comes up coughing and spluttering.

• Reach to the patient, if possible, using an arm, leg, stick, paddle or anything that enables you to stay on land.

• Throw a rope and pull the patient to safety.

• Row – use a boat, kayak or surfboard while wearing a flotation device.

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• Go – swim, only as a last resort, because of the increased risk to the rescuer.

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REMEMBER

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Rescue breathing, if needed, should be started immediately, at a rate of 12–20 breaths per minute. This can be done in deep water, if you are a strong swimmer, or when you can stand in shallow water. Many drowning patients breathe in only a moderate amount of water, and some, none at all. Be prepared to turn the patient if their airway fills with water or they vomit. Continue the rescue breathing while the patient is being removed from the water, and protect their neck and spine from movement if you suspect a neck or spinal injury.

Chest compressions, if needed, will only be effective when the patient is on a firm, preferably flat surface.

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If the patient starts breathing:

• Check for other injuries.

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• Protect from or treat hypothermia.

• Place in the recovery position if unconscious. • Monitor their vital signs.

All near-drowning patients need to be evacuated to hospital immediately, because anyone who has been unconscious in water may have water in their lungs. This irritates the lining of the lung, causing congestion and breathing difficulties that may not be apparent until several hours later. If there are no symptoms, do not assume it has not happened – the patient is at risk for 48 hours. Long-term problems can also arise from bacteria, dirt and minerals in the inhaled water.

CHAPTER 3 | CARDIOPULMONARY RESUSCITATION (CPR)

FREQUENTLY ASKED QUESTIONS When should I stop doing CPR?

When the person revives, when medical personnel take over, when you are exhausted and/or when you and your party are being put at risk. Usually the decision to stop CPR is made by a medical professional. For groups in remote areas, without medical help, this is a very difficult decision to make. Those at the scene will need to make the final decision based on the circumstances in which the accident or illness occurred and the extent of the patient’s injuries.

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The following points may be of some help:

• Not many people who require CPR survive, even in communities served by high-quality ambulance and medical services.

• People who have suffered major damage to their body, such as a heart attack, injury or poisoning, have a poor chance of being revived.

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• People who require resuscitation only because they have been deprived of oxygen for a brief period have a reasonable chance of recovery. Examples include people who have nearly drowned, or have been choked or struck by lightning.

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• As a general rule, the patient’s chances of recovery diminish as time passes, and if CPR has been necessary for more than 30 minutes, it is unlikely resuscitation will be successful.

• There have been accounts of patients being revived after receiving CPR for extended periods. These patients were usually suffering from hypothermia associated with cold water or snow immersion.

Have I failed at CPR if the person does not survive?

No, you are doing a ‘holding’ procedure, keeping the vital organs supplied with oxygenated blood until the rescue service arrives with the specialised equipment to try to restart the heart. Despite the best possible care, the patient may not be able to be revived. You cannot fail if the person is beyond help.

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Can I do any harm by doing CPR incorrectly?

No, remember that this person is dead, so you cannot make them any worse. If you do nothing, they stay dead; if you do something, there is a chance that they can be revived.

Turn the patient onto their side, facing towards you, and support them on your knees. Wipe out their mouth, return them to their back, recheck ABCs and continue CPR, if necessary.

What if I forget how many breaths/compressions to do?

Do not worry – unless you are refreshing your CPR skills often, the stress of the moment may cause you to forget how many breaths and compressions to do. Just think, ABC: A – airway, open it; B – if they are not breathing, breathe into them; C – if no circulation, compress the chest. Your aim is to keep oxygen supplied to the vital organs, and it is more important that you try to do this than that you remember the exact ratio of compressions to breaths. (The recommended rate and sequence of compressions to breaths have varied over the years.)

Is it possible to break ribs when doing compressions?

Yes, even professionally performed chest compressions can break the patient’s ribs . Do not let concern for this stop or interrupt CPR. Although the sound of a rib breaking may be stressful for you, the patient is better off alive with broken ribs than dead.

How do you do two-person CPR?

The two rescuers alternate. CPR can be physically exhausting, so one rescuer does CPR, with the other rescuer ready to take over when the first rescuer starts feeling tired. The person resting can count out loud for the resuscitator.

Why do we no longer check for a pulse before starting chest compressions? It really worries me that I will harm the patient if there is a pulse and I cannot find it.

Unless professionally trained to do so, it can take some time to locate a pulse, especially when under stress. (Recent research shows that the time taken for a first-aider to confidently and accurately assess the presence or absence of a pulse is far greater than what is normally recommended.) Remember that by this stage you have already spent time coming across the patient, establishing unresponsiveness, checking and opening the airway, attending to breathing and checking for signs of life, such as colour in the skin. If the patient shows no signs of life, it is in their best interest that you start compressions.

What should I do if the patient vomits?

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Do I remove the patient’s false teeth?

No, they help to make an airtight seal around the mouth. Only remove them if they are loose fitting and get in your way.

Should I try to remove water from the lungs of a person who has drowned?

No, it is more important to start rescue breathing than to attempt to remove water.

PHOTO Kerry Adams

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IN THIS CHAPTER:

PARTIAL OBSTRUCTION

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AIRWAY EMERGENCIES (CHOKING) es

CHAPTER 4:

FULL OBSTRUCTION 44

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CHAPTER 4 | AIRWAY EMERGENCIES

An airway can become obstructed or blocked by food, broken teeth, snow or dirt driven into the mouth. A child’s airway might be blocked by a sweet, nut, small toy or an object they have been playing with. This chapter is mostly about airway obstructions caused by an object and how to assist patients in removing that object. For burn injuries of the airway, see chapter 11.

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Upper airway infections can narrow and, in some cases, block the airway. Signs of infection are a sore throat, drooling and difficulty swallowing. To assist a patient with these signs, reposition their head to open the airway, reassure them and seek medical help.

An unconscious patient’s airway may be blocked by the tongue falling across the back of the throat, or by fluids such as blood, mucus or vomit. Repositioning the head and removing obvious obstructions may open the airway.

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PARTIAL OBSTRUCTION bl

SIGNS AND SYMPTOMS

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MANAGEMENT

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The patient will be coughing and spluttering and will usually clutch their throat. They may be wheezing and have difficulty speaking in full sentences.

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Forceful coughing may dislodge the object. Encourage the patient to cough and spit out the object. Reassure them, as this is a frightening experience. The patient is not getting enough oxygen if:

• They have increased breathing difficulties.

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• They have an ineffective cough.

• They make high pitched noises when inhaling.

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• Their skin is looking pale or is going blue around their lips. If they show any of these signs and symptoms, treat as for a full obstruction.

EXTENDED CARE AND EVACUATION GUIDELINES If coughing fails to remove the obstruction, the patient needs to be evacuated. Even if the patient is breathing adequately despite the object, evacuate them quickly. The foreign object may irritate the airway, causing swelling and further difficulty breathing.

CHAPTER 4 | AIRWAY EMERGENCIES

FULL OBSTRUCTION SIGNS AND SYMPTOMS

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The patient cannot breathe, cough or speak. They look frightened, their eyes may appear to bulge and they are likely to clutch their throat.

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Figure 4.1 Signs of a fully obstructed airway

The patient is unable to clear their own airway by coughing, so the treatment is to force air out of their lungs with a combination of back blows and chest thrusts.

TREATMENT OF CONSCIOUS ADULT OR CHILD

Ask if they are choking. Usually they will nod. Encourage them to cough to attempt to dislodge the object.

Stand behind and slightly to the side of an adult patient. Kneel beside a child.

Supporting their chest with one hand, lean the patient well forward so that when the obstruction is dislodged, it will come out of the mouth rather than go further down the airway.

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Give five sharp blows between the shoulder blades with the heel of your other hand. Make sure each back blow is given with the intention of dislodging the obstruction.

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Figure 4.2 Back blows for adult and child

If, after five back blows, the obstruction is not dislodged, perform chest thrusts. 1.

Stand behind an adult patient and wrap your arms around their chest.

Kneel behind a child patient or sit them on your lap.

Make a fist and place the thumb side in the middle of the patient’s chest, on their sternum, at armpit level.

Place your other hand on top.

Give five quick inward thrusts. Make sure each thrust is a separate and distinct jolt and is given with the intention of getting rid of the obstruction.

Repeat the sequence of five back blows followed by five chest thrusts until the object is dislodged or the patient becomes unresponsive.

Note: There are no special considerations for pregnant women. Perform chest thrusts as per usual. Kneel behind child

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Stand behind adult

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Figure 4.3 Obstructed airway, chest thrusts: adult and child. Clasp your fist in the centre of their chest, at armpit level. Pull in sharply, 5 times.

Figure 4.4 Chest thrusts for pregnant woman, same as for non-pregnant adult

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TREATMENT OF UNCONSCIOUS ADULT OR CHILD

In the past, the ‘Heimlich manoeuvre’, which involved abdominal thrusts rather than chest thrusts, has been taught. There have been reported cases of this technique causing damage to internal organs in the abdomen. Therefore, it is no longer recommended.

If the choking adult or child becomes unconscious, place them on their back. Perform CPR, with these additions:

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• Breathing: Attempt to breathe into the patient. If the air does not enter freely, reposition their head and try again.

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• Airway: When opening the airway, look for any visible objects at the back of the throat. Remove any obstructions you can see, but do not blindly sweep your finger in their mouth.

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• CPR: Begin chest compressions.

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• Check: Look for and remove any visible objects in the mouth.

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Continue the sequence of attempting to breathe, chest compressions and looking for and removing any visible objects from the mouth or throat until the object is removed, qualified help arrives or the decision is made to stop CPR. If CPR is stopped, the rescuers will need support to help them to come to terms with their experience. Guidelines for dealing with critical incident stress are detailed in chapter 21.

Figure 4.5 Removing object from unconscious person’s mouth

CHAPTER 4 | AIRWAY EMERGENCIES

When the object is expelled, the patient will feel tired, relieved and possibly embarrassed. They may burst into tears. They have just undergone a life-threatening experience and may need to talk about this with a sympathetic listener.

TREATMENT OF CONSCIOUS INFANTS (APPROXIMATELY 0–1 YEAR) Support their head firmly by holding the jaw.

Lay the infant face down over your arm. Rest their body on your thigh with their head lower than their trunk.

Give five blows high up on the infant’s back between the shoulder blades with the heel of your hand. Avoid excessive force.

Place your other arm over the infant’s back, with your hand supporting their head and neck. Then turn them face up, keeping their head lower than their trunk.

Give five chest thrusts, just below the nipple line, the same as for CPR chest compressions, but slower.

Look in their mouth, and hook out any visible foreign body with your finger. If you cannot see anything, do not put your finger in the infant’s mouth as you could push any foreign body further back.

Repeat the sequence of five back blows, five chest thrusts and checking the airway until the object is dislodged or the infant becomes unresponsive.

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Figure 4.6 Back blows for choking infant. Support their head by clasping both sides of their jaw, 5 blows.

Treat a conscious infant with a modified version of back blows and chest thrusts:

CHAPTER 4 | AIRWAY EMERGENCIES

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Figure 4.7 Chest compressions for choking infant (centre of chest, between the nipples) 5 times.

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TREATMENT OF UNCONSCIOUS INFANTS (APPROXIMATELY 0–1 YEAR)

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If the choking infant becomes unconscious, perform infant CPR with these additions:

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• Airway: When opening the airway, look for and remove any visible objects at the back of the throat. Remember with infants to tilt the head back only slightly to avoid kinking and blocking the windpipe.

• Breathing: Attempt to breathe into the infant. If air does not enter freely, gently reposition the head and try again up to five times.

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• Compressions: Give 30 chest compressions.

• Check: Look down the back of the throat and remove any visible objects.

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EXTENDED CARE AND EVACUATION GUIDELINES

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If a patient has been unconscious, they should be evacuated, even if they have regained consciousness and appear to have fully recovered.

Usually, after having time to rest and recover, a patient who did not lose consciousness is able to continue the activity they were doing before. Be aware that swelling of the airway may occur later, if the airway was sufficiently irritated. Watch for signs of breathing difficulty and for signs of shock (see chapter 6), which may indicate internal bleeding. If these signs occur, arrange an urgent evacuation.

TREATMENT OF YOURSELF IF YOU ARE ALONE

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If you are alone, with a fully obstructed airway, you should try to dislodge the obstruction yourself. Try coughing. If that fails, you could try falling forwards onto a solid object, such as the back of a chair, a pack or a log. Your chest (sternum) should hit the object with enough force to compress your chest. You may need to try several times.

CHAPTER 5 | BREATHING EMERGENCIES

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CHAPTER 5:

IN THIS CHAPTER:

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BREATHING EMERGENCIES cu ra

CARBON MONOXIDE POISONING

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CLOSED CHEST INJURY

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FLAIL CHEST

HYPERVENTILATION SYNDROME

PHOTO Peter Waworis

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OPEN CHEST INJURY

Remember patient assessment and management. In DRSABC, ‘B’ is for breathing.

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This chapter covers breathing emergencies arising from chest injuries, carbon monoxide (CO) poisoning and hyperventilation. Severe allergic reaction (anaphylaxis) is covered in chapter 6 and existing medical conditions (asthma) are covered in chapter 14.

Breathing emergencies can be caused by injuries, medical conditions or severe allergic reactions. They can range from the immediately life-threatening, needing CPR, to the possibly life-threatening, needing urgent attention to prevent the situation from becoming worse. Inadequate breathing (less than six breaths per minute) requires CPR.

A person experiencing breathing difficulty (respiratory distress) will exhibit some or all of the following symptoms:

• Difficulty speaking

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• Faster breathing rate

• Very slow breathing (fewer than six breaths per minute)

• Noisy breathing

• Blueness around the lips, ears, nose, toes and/or fingers

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• Anxiety and distress

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CARBON MONOXIDE (CO) POISONING

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CO poisoning is the largest cause of deaths related to camping appliances in New Zealand. CO is formed by incomplete burning of gaseous or liquid fuels or by appliance malfunction. CO poisoning occurs when stoves and lamps are used in poorly ventilated areas, for example, huts, tents, snow caves or vehicles. CO is particularly dangerous because it is colourless, odourless and tasteless. People are unaware they are inhaling the gas and being poisoned. CO combines more readily with haemoglobin than oxygen, effectively lowering the oxygen available in a person’s blood.

NOTE CO poisoning can be avoided by ensuring you keep cooking appliances in good condition and use them in well-ventilated areas. When cooking, open hut windows or tent flies.

CHAPTER 5 | BREATHING EMERGENCIES

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Figure 5.1 To avoid CO poisoning, use well-maintained appliances in well-ventilated areas.

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SIGNS AND SYMPTOMS

A person with CO poisoning will exhibit some or all of the following symptoms:

• Headache

• Convulsions

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• Confused and erratic behaviour

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• Cardiac and respiratory failure

• Bright pink skin

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MANAGEMENT

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Either ventilate the area (to remove the CO) or remove the patient from the area. Once the patient has been removed from the source of the poison, make them comfortable. • If the patient is still conscious, encourage them to rest. Sitting, rather than lying down, will let more air into the lungs. • Monitor an unconscious patient, place them in the recovery position and be prepared to administer CPR. There is nothing that can be done in the field to quickly remove CO from the body. In mild cases of CO inhalation, the patient will recover over time without any specific treatment.

EXTENDED CARE AND EVACUATION GUIDELINES As a general rule, anybody exposed to CO should be evacuated and seen by a doctor. Oxygen, if available, should be administered at 100 percent. See chapter 16 for information on other poisons.

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HYPERVENTILATION SYNDROME al

Hyperventilation, or over-breathing, lowers the level of carbon dioxide (CO2) in the blood. It can be caused by:

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• Nervousness

• Stress

• Fear (for example, of heights or some risky activity)

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• Blowing up an air mattress

SIGNS AND SYMPTOMS

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A person who is hyperventilating will exhibit some or all of the following symptoms:

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• Rapid breathing not associated with activity or exercise

• Rapid pulse • Sweating

• Dizziness and faintness

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• Feeling of suffocation

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• Numbness and/or tingling around the mouth, cheeks, hands and/or feet • Painful cramps or spasms in the hands or feet – hands may turn inwards, clawlike (carpo-pedal spasm) • Chest tightness

Figure 5.2 Treating hyperventilation to correct CO2 balance

MANAGEMENT • Sit the person down, explain the problem and reassure them. • Put a paper bag, a stuff sack or the patient’s cupped hands over their mouth and nose. Breathing into a bag or their hands will help them to regain the correct CO2 balance.

• It may take 10–20 minutes for the hyperventilating patient to recover.

EXTENDED CARE AND EVACUATION GUIDELINES

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Some people hyperventilate at the top of an abseil site, crossing a three-wire bridge, rock climbing for the first time or doing any activity that makes them feel nervous. Once they have been reassured and treated, they are usually fine. However, as some serious medical conditions (such as a severe allergic reaction, a heart attack or internal bleeding) look like hyperventilation, make sure you get a detailed history. If you are unsure if hyperventilation is the problem, have the patient evacuated.

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FLAIL CHEST

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Flail chest occurs only with a high impact injury to the chest, such as a heavy fall against rock, which causes two or more ribs to break in two or more places. This creates a floating segment of ribcage, which moves in a different direction from the rest of the chest. As the patient inhales, the segment is pulled in, and as they exhale, the segment is pushed out. As well as being very painful, the lung under the broken segment is unable to fill with air, causing serious breathing problems (respiratory distress).

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SIGNS AND SYMPTOMS

A person with flail chest will exhibit the signs of respiratory distress (see page 52) and:

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• You will see and feel the chest segment moving separately from the rest of the chest.

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• The patient’s breathing will be shallow and painful.

MANAGEMENT The aim is to stabilise the flail segment so the patient can breathe normally. Apply pressure with your hand to the flail segment, as a temporary measure, until you are able to stabilise it in either of the following ways: • Position the patient in a sitting position, with their arm on the injured side secured to their chest. This stabilises the flail segment. • Tape a large pad firmly over the area. Extend tape to both sides of the chest, but not right around, as this may cause breathing difficulty.

CHAPTER 5 | BREATHING EMERGENCIES

• Encourage them to try to breathe at the same slow rate as you.

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Floating section of rib cage

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Figure 5.3 Managing an unconscious patient with a flail chest – injured side down

Once you have stabilised the flail chest:

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• Position the patient so they are leaning towards the injured side. Sitting up expands the chest, which allows more air into the lungs.

• Give the patient pain relief.

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• If you have an unconscious patient with a flail chest, put them in the recovery position with the injured side down.

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EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation.

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If the patient is required to move, the injury may worsen and the pain may increase. Keep the patient quiet and rested, and if it is necessary to move them any distance, consider using a stretcher.

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CLOSED CHEST INJURY

A closed chest injury is a condition where air (pneumo) and/or blood (haemo) enters the chest (thorax) cavity between the chest wall and the lungs, taking up space usually filled by the lungs and heart. It can be caused by a fractured rib puncturing a lung and allowing air to escape into the chest cavity or by blood from injured lungs and/or fractured bone ends entering the chest.

Spontaneous pneumothorax occurs when a weak spot on the surface of the lung ruptures, causing air to leak out. This is not always related to exercise or injury and can occur at rest. This most commonly happens to tall, slim males who are younger than 40 years old, sometimes with a family history of the condition.

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Air and/or blood in the chest cavity can create pressure on a lung, causing it to collapse. If the pressure continues to build, the lung may fully collapse. The pressure can, in the late stage, cause the windpipe to be pushed towards the unaffected side of the chest, affecting the heart and the good lung.

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SIGNS AND SYMPTOMS

A person with a closed chest injury will exhibit the signs of respiratory distress (see page 52) and may have:

• Sudden sharp chest pain made worse by deep breathing

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MANAGEMENT

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• Signs and symptoms of shock (see page 64)

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• Attend to any rib fractures (see page 113).

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• If the patient is conscious, position them in a semi-sitting position, with their legs straight and their upper body leaning back slightly and well supported. Lean them towards the injured side, to help them breathe and keep blood and other matter in the chest away from the uninjured side.

• If the patient is unconscious, position them in the recovery position with the injured side down.

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• Give the patient pain relief if needed.

EXTENDED CARE AND EVACUATION GUIDELINES

Arrange an urgent evacuation. Moving a patient may make their injury and pain worse. Keep the patient quiet and rested, and if it is necessary to move them any distance, consider using a stretcher.

CHAPTER 5 | BREATHING EMERGENCIES

Sometimes air escapes into the tissues around the chest and neck (surgical/ trauma emphysema). Signs of this are swollen spongy skin and a crackling sound when the area is pushed due to the trapped air. This condition can progress to compress the airway, so an urgent evacuation is needed.

OPEN CHEST INJURY A chest wound that penetrates the chest wall and/or a lung can also cause a pneumothorax. Air is sucked into the chest cavity through the wound when the patient inhales. Air may also escape from a damaged lung.

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SIGNS AND SYMPTOMS

A person with an open chest injury will exhibit some or all of the following signs and symptoms:

• Increasing breathing difficulties

• Bubbles in the blood around a chest wound • A sucking sound at the wound site when the patient breathes

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Note: If the wound is difficult to assess, treat it as a penetrating wound (see page 146). Finding out how the accident happened will help you assess the wound (for example, a wound caused by a heavy fall on an ice axe would suggest penetration).

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MANAGEMENT

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In managing an open chest injury, the aim is to stop air being sucked into the chest cavity while allowing air to escape from the chest cavity (to reduce pressure). Cover the wound with the patient’s hand (or your gloved hand) until a non-porous dressing is available. Suitable dressings include gauze dressing still in its plastic wrapper, survival blanket foil, petroleum jellyimpregnated gauze held in place with a pressure dressing, or strong plastic. DO NOT use cling film – it is not strong enough and can be sucked into the wound.

Ensure the dressing is large enough that it will not be sucked into the wound. It should be larger than the wound by about 5cm on all sides. Tape the dressing into place on three sides, leaving the fourth side open. This creates a flap valve, which prevents air being sucked into the chest cavity when the patient inhales, but allows air to escape on exhalation.

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Attend to any rib fractures (see page 113).

If the patient is conscious, position them in a semi-sitting position, with their legs straight and their upper body leaning back slightly and well supported. Lean them towards the injured side to assist breathing and help keep blood and other matter in the chest away from the uninjured side. If the patient is unconscious, position them in the recovery position with the injured side down.

Give the patient pain relief.

CHAPTER 5 | BREATHING EMERGENCIES

NOTE DO NOT REMOVE any penetrating object that remains in the wound. It creates its own seal and removing it can cause more damage.

EXTENDED CARE AND EVACUATION GUIDELINES

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Arrange an urgent evacuation. Chest injuries with damage to a lung need urgent medical treatment.

Moving a patient may make their injury and pain worse. Keep the patient quiet and rested, and if it is necessary to move them any distance, consider using a stretcher.

(a)

Collapsed lung

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Good lung

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AIR

(b)

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Wound into chest cavity

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Patch

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One side free

(c)

INHALE Suction seals the wound

(d)

EXHALE Air escapes out of flap

Figure 5.4 Improvising a one-way air valve for an open chest injury

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CHAPTER 6 | CIRCULATION EMERGENCIES

CIRCULATION

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EMERGENCIES

CHAPTER 6:

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CIRCULATION EMERGENCIES ila

IN THIS CHAPTER:

DEEP-VEIN THROMBOSIS

PULMONARY EMBOLISM

SEVERE EXTERNAL BLEEDING

INTERNAL BLEEDING

CRUSH INJURIES

SHOCK 64

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ANAPHYLACTIC SHOCK/ANAPHYLAXIS

FAINTING (VASOVAGAL EVENT)

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ANGINA 70 71

HEART FAILURE

PHOTO Peter Waworis

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HEART ATTACK

Remember patient assessment and management. In DRSABC, ‘C’ is for circulation. If a patient’s breathing is adequate, you can move on to circulation. The circulatory system consists of the heart, the blood vessels and the blood. The average adult heart pumps 6L of blood per minute through the blood vessels, ensuring that all organs and cells of the body receive a constant supply of oxygen.

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Note: Capillary refill refers to how quickly blood returns to fingernails or toenails. It is a good way to test a patient’s circulation. Press firmly on a patient’s nail until it turns white, and then release the pressure. If the nail returns to pink quickly, the patient’s circulation to that part of their body is effective. If the nail remains white, circulation is not effective.

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This chapter covers circulation emergencies caused by shock, anaphylaxis, heart disorders, severe bleeding and major crush injuries.

No part of the body can exist for long without oxygen. Organs such as the brain and heart require a constant supply of oxygenated blood, and loss of oxygen may affect their ability to function normally.

Figure 6.1 The heart, lungs and oxygen transfer

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EMERGENCIES

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CIRCULATION

Figure 6.2 The circulatory system

CHAPTER 6 | CIRCULATION EMERGENCIES

SHOCK

TYPE OF SHOCK

Blood or fluid loss

Hypovolaemic (low volume) shock: Blood or fluid loss, caused by damage to the blood vessels, allows blood to escape from the circulatory system. This results in less oxygen being circulated to the vital organs. Fluid is also lost from the circulatory system in the case of burns, dehydration and diarrhoea.

Vessels damaged and/ or dilated

Septic shock (septicaemia): In some bacterial infections, toxins are released by the bacteria into the bloodstream, causing the blood vessels to widen (dilate). Blood vessel walls are damaged and become leaky, so blood is lost into the tissues. Circulation becomes inadequate due to decreased pressure and volume. Any patient with an infection showing signs of shock needs to be treated for shock and evacuated urgently.

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CAUSE

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Neurogenic shock: This occurs as a result of a brain injury interfering with the nerves that maintain the muscle tone of the blood vessels. The vessels relax and dilate, so the blood pools, causing the blood pressure to drop. The treatment for brain injuries is covered in chapter 8. Patients with neurogenic shock should be evacuated urgently.

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Spinal shock: An injury to the spinal cord can paralyse the muscles of the blood vessels, causing the blood vessels to dilate. The treatment for spinal cord injuries is outlined on page 106. Any patient with a spinal cord injury needs to be urgently evacuated.

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Anaphylactic shock: This is a severe allergic reaction. Blood vessels dilate and leak, causing the blood pressure to drop. See separate treatment for anaphylactic shock on page 67. Cardiogenic shock: Damage to the heart, caused by a heart attack or high impact accident, means it can no longer pump effectively enough to ensure adequate circulation to the vital organs.

Heart rate slowed and vessels dilated

Fainting (Vasovagal event): A sudden momentary widening of the blood vessels and slowing of the heart rate (caused by the vagus nerve) cause a temporary reduction of blood supply to the brain. This type of shock is not serious, as it can be treated quickly and easily. The treatment for fainting is outlined on page 69.

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Heart not pumping effectively

In all of the above examples, the result of shock is the same. Shock is a serious condition that needs to be recognised and managed quickly. A patient with severe shock needs medical treatment urgently.

Shock is the name given to the condition when the circulatory system fails to provide our body’s cells with sufficient oxygen. A malfunction of any part of the circulatory system can cause shock.

When the brain detects that the blood flow is inadequate, it immediately starts to compensate to reduce the body’s need for oxygen. Blood is drawn from the surface of the skin and the digestive system to the core of the body, to divert oxygen to the vital organs. A person in the early stages of shock will exhibit some or all of the following CIRCULATION signs and symptoms:

• Cool, pale skin

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EMERGENCIES • Nausea and vomiting

• Rapid breathing, to get more oxygen into the body

• Fast and weak pulse, as the heart is trying to keep the vital organs supplied with blood, and there is a lower volume of blood (Note: Pulse may be slow in cases of fainting, heart attack or internal organ dysfunction)

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• Dizziness, caused by a reduction of oxygen to the brain (let the patient lie down to allow blood to flow to the heart, then on to the brain)

• Anxiety

If the level of shock increases, the brain loses the ability to compensate and the patient will exhibit some or all of the following signs and symptoms:

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• Cold, moist, blue skin

• Listlessness

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• Confused speech

• Very fast breathing and pulse

• Decreased body temperature

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• Dilated pupils • Restlessness

• Severe thirst

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• Unconsciousness and eventually death

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How quickly these signs and symptoms appear will depend on the cause. A person suffering a heart attack or major injury will usually show signs of shock very quickly, while symptoms of shock may take hours to appear in a patient with a slow internal bleed. A fit, healthy person may not show signs of shock for some time after an accident. Initially, a fit body can compensate for even a significant loss of blood. In all significant injuries, the patient should be treated for shock, particularly in the outdoor environment.

CHAPTER 6 | CIRCULATION EMERGENCIES

SIGNS AND SYMPTOMS

MANAGEMENT The early signs and symptoms of shock – often seen immediately after an accident or collapse – can usually be managed in the outdoors. The later signs and symptoms of shock are more serious, and evacuation will usually be necessary. In managing shock, the aim is to keep blood circulating through the vital organs:

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• Reassure the patient. Anxiety, worry and pain use precious oxygen and energy reserves.

• Check and monitor the ABCs.

• Lay the patient down on insulated ground, with their head and body flat and their feet and legs raised just above the level of the heart. Make sure both legs are completely supported.

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• Keep the patient warm to try to maintain normal body temperature. Do not place hot water bottles at the feet, as this will draw blood away from the core of the body.

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• If the patient is likely to need surgery, do not give them anything to drink. If the digestive system is not functioning, the fluid cannot be absorbed and the patient may vomit. If the patient is very thirsty, you can moisten their lips. If the patient is fully conscious and alert, and their condition is not deteriorating, give them small sips of water. DO NOT give them alcohol as it causes the blood vessels to dilate, which will increase the level of shock. DO NOT allow the patient to smoke.

Raise legs above heart level

Figure 6.3 Treating shock

CHAPTER 6 | CIRCULATION EMERGENCIES

EXTENDED CARE AND EVACUATION GUIDELINES The need for evacuation is determined by the cause of shock. As detailed on page 64, any patients with septic shock, neurogenic shock or spinal shock should be evacuated.

ANAPHYLACTIC SHOCK/ ANAPHYLAXIS

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EMERGENCIES

CIRCULATION

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Anaphylactic shock (also called anaphylaxis) is a severe allergic reaction to any substance that the body recognises as foreign (an allergen), for example, insect venom, food, medication or pollen. Chemicals released into the bloodstream in response to the allergen cause the blood vessels to dilate, leading to a drop in blood pressure. Blood vessels can leak fluid, leading to a further drop in blood pressure and flushed skin. Fluid released into the skin causes hives. Fluid released into the upper airway can cause swelling of the throat, mouth and tongue. It can also cause asthma.

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The onset of anaphylactic shock can begin seconds or minutes after encountering the allergen, or can progress over 24 hours. If the reaction is going to be severe, the onset of symptoms will be rapid. The reaction will probably peak after 10–40 minutes.

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Adrenaline should be given to anyone with signs of anaphylaxis. Adrenaline is usually carried as an auto-injector. There are two main brands available in New Zealand: EpiPen and Anapen. Junior versions of both can be prescribed to children younger than five years old. Some organisations will carry autoinjectors in their first aid kits. If you are carrying an auto-injector, you should store with it a generic ‘Action Plan for Anaphylaxis’ with instructions for use. This action plan can be downloaded from www.allergy.org.au/healthprofessionals/anaphylaxis-resources. The alternative to auto-injectors is adrenaline in ampoules. These are inexpensive, but the adrenaline must be drawn up into a syringe before injecting. Before administering adrenaline, a first-aider should be trained in how to recognise the symptoms of anaphylaxis and how to give adrenaline. Online e-training in auto-injector use is available at www.allergy.org.au. If in doubt, follow the action plan instructions for using the adrenaline auto-injector. People who know they are at risk of anaphylaxis usually carry adrenaline and an individualised action plan with instructions. If someone in your group is at risk, make sure you are familiar with their action plan.

However, not everyone who has an anaphylactic reaction has a history of them. Someone who has had only mild reactions to stings in the past may experience a full-body reaction and go into anaphylactic shock. ASCIA, the Australasian Society for Clinical Immunology and Allergy, has useful up-to-date information and resources about anaphylaxis, available at www.allergy.org.au, including online resources about the use of auto-injectors.

ASSESSMENT AND MANAGEMENT

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TREATMENT

SIGNS/SYMPTOMS

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Mild to moderate allergic reaction • Swelling of face, lips and eyes

• If the patient has been stung by an insect, flick the sting out if it is visible.

• Hives or welts on the skin

• Give the patient an antihistamine tablet if they are able to swallow.

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• Tingling mouth • Itchy eyes, nose, mouth, genitals

• Monitor the patient for symptoms of a more severe reaction.

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• Stomach pain and/or vomiting (these are signs of a mild/moderate reaction to most allergens, but can indicate an anaphylactic reaction)

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Anaphylactic shock – severe allergic reaction TREATMENT

SIGNS/SYMPTOMS

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• Difficulty breathing, wheezing • Swollen tongue

• Swelling/tightness in throat

• Difficulty talking/croaky voice

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• Dizziness or collapse

• Pale and floppy (young children)

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The general signs and symptoms of shock (see page 64) may also be present.

• Administer adrenaline. • Give the patient an antihistamine tablet if they are able to swallow. • Lay the patient flat with their legs raised. • If breathing is difficult, allow the patient to sit, but keep their legs raised. • If there is no response after 5 minutes, give the patient another dose of adrenaline. • If the patient stops breathing, start CPR.

If in doubt, administer adrenaline. It must be used quickly, so do not wait until the patient stops breathing. Recognise the signs and act.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation. Even though the patient may appear to recover after the adrenaline, they may need further medical treatment, including oxygen, intravenous fluids and more adrenaline.

CHAPTER 6 | CIRCULATION EMERGENCIES

FAINTING (VASOVAGAL EVENT)

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Fainting (also known as a vasovagal event) is a sudden short period of CIRCULATION unconsciousness. When the vagus nerve is stimulated, the blood vessels widen suddenly and the heart rate slows, resulting in decreased oxygen to the brain. Sudden pain, the sight of blood, fear, bad news, standing for long periods and EMERGENCIES lack of food can all result in fainting.

The signs and symptoms of fainting are:

• Dizziness or light-headedness

• Nausea

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• Collapsing with relatively little warning

• Slow pulse for a short time

MANAGEMENT

If the patient faints:

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If the patient is looking pale, or feeling dizzy or light-headed, lay them down flat and raise their legs. DO NOT tell them to put their head between their legs as this makes it difficult to breathe, and if they collapse from this position, they may land on their head. Get all the details to help determine the cause. If it was a momentary loss of oxygen to the brain, the patient should feel better quickly.

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• Check and monitor their ABCs. • Examine them for injuries that could have been caused by collapsing.

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• Place them in the shock position, with their head and torso flat, and their feet and legs raised and supported.

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• As soon as the patient is flat on the ground, they should recover quickly, as blood flows easily to the heart and on to the brain in this position. • If the patient is not conscious and alert within one minute, they have not fainted. Place them in the recovery position and treat as for an unconscious patient.

EXTENDED CARE AND EVACUATION GUIDELINES Once the patient is fully recovered and before they resume any activity, find out what caused them to faint. Knowing the cause will help to prevent a recurrence.

ANGINA

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Angina occurs in people with coronary arteries narrowed by plaque. These arteries supply blood to the heart muscle. Angina pain is triggered by exercise, stress or cold because the narrowed arteries are unable to supply sufficient oxygen to meet the increased demands of the heart. Usually the patient will tell you if they suffer from angina and will carry medication.

SIGNS AND SYMPTOMS

Normal coronary artery

A person experiencing an angina attack will exhibit some or all of the following signs and symptoms:

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• Chest pain and pain radiating to the throat, arms and/or upper back • Pale skin

• Breathlessness

• Nausea

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Heart

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The patient will usually have a history of angina attacks.

• Irregular heart beat

Figure 6.4 Angina is caused by narrowing of a coronary artery.

MANAGEMENT

Narrowed coronary artery with plaque

• Reassure the patient.

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• Encourage them to rest.

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• Give the patient their medication (usually nitroglycerin spray or tablets, which are administered under the tongue). Repeat as necessary. • If the patient has no previous history of chest pain, or if the pain lasts more than 15 minutes, treat as for a heart attack.

EXTENDED CARE AND EVACUATION GUIDELINES If the pain is relieved within 15 minutes, or by medication, the patient should be able to resume normal activities. Change trip plans if necessary to avoid triggering another attack with strenuous exercise, stress or cold. If a patient’s pain is not relieved, or if it returns, the patient should be treated as for a heart attack.

A heart attack (myocardial infarction or coronary thrombosis) occurs when a coronary artery becomes completely blocked or is severely narrowed, resulting in the death of a portion of the heart muscle. The severity of the attack can CIRCULATION vary from chest pain with few or no other symptoms, through to sudden death, depending on what part of the heart is involved and how much of it is damaged.

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EMERGENCIES

SIGNS AND SYMPTOMS

A person experiencing a heart attack will exhibit some or all of the following signs and symptoms:

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• Chest pain, lasting for more than 15 minutes, that is not relieved by rest or nitroglycerin spray or tablets

• An unusual feeling of heavy pressure, crushing pain or tightness in the centre of the chest

• Pain radiating to the neck, arms, jaw and or back

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• A pulse that is rapid, slow or irregular

• Profuse sweating

• Nausea

Coronary artery Damaged area

Clot

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The signs and symptoms of shock (see page 64) may also be present.

Figure 6.5 Heart attack caused by a clot (thrombosis) blocking a coronary artery. The damaged area is called an infarct.

CHAPTER 6 | CIRCULATION EMERGENCIES

HEART ATTACK

MANAGEMENT • Check and monitor the ABCs. • Reassure the patient.

• If the patient is feeling faint, lay them down on insulated ground, with the head and body flat, and raise the feet and legs just above the level of the heart. Remember to place support under the thighs.

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• If the patient is conscious, place them in the position in which it is easiest for them to breathe. If they are short of breath, sit them up.

• Keep the patient still, rested and warm.

• Give the patient pain relief (and angina medication if available).

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• Do not allow the patient to walk or exercise. If necessary, carry them to a safer, more suitable location.

• Closely monitor vital signs.

• Start CPR if the patient stops breathing.

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Note: Patients will sometimes dismiss the pain as indigestion. If in doubt, treat as a heart attack.

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EXTENDED CARE AND EVACUATION GUIDELINES

Arrange an urgent evacuation.

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The main danger with a heart attack is that the heart may stop (cardiac arrest). This is possible at any stage but is more likely in the first 72 hours following the onset of pain. It is important to take all practical measures to rest the heart as much as possible while waiting for evacuation.

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• Give the patient pain relief, for example, paracetamol or codeine. Do not give anti-inflammatory medication, such as ibuprofen (Nurofen) or diclofenac (Voltaren).

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• Do not let the patient walk or exercise. • Keep the patient warm.

HEART FAILURE Heart failure occurs when the pumping action of the heart is not sufficient to circulate blood. This may happen if the heart has been weakened by previous heart attacks. The result is that blood ‘backs up’ in the veins, lungs and liver. If untreated, shock and death may follow.

• Ask the patient if they are allergic to Aspirin. If not, place half a 300mg Aspirin tablet under their tongue to be dissolved in the mouth, or give them half a 300mg tablet dissolved in water.

A person with heart failure will exhibit some or all of the following signs and symptoms: • Shortness of breath • Pursing of lips when breathing • Noisy breathing CIRCULATION

EMERGENCIES

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• Swollen legs

• Blueness of the lips and extremities

• Pink, frothy sputum

MANAGEMENT

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• Keep the patient sitting up, if possible. In this position, the chest is expanded and it is easier to breathe because more air can enter the lungs.

• Keep the legs low, if possible. This will help to retain some fluid in the legs and away from the lungs.

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• Keep the patient warm.

• Keep the patient still and rested.

• If the patient has medication for heart failure, ensure they take it.

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EXTENDED CARE AND EVACUATION GUIDELINES

Arrange an urgent evacuation.

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Without treatment, heart failure is likely to become progressively worse. The patient will become increasingly breathless and agitated, and may lose consciousness as the lungs fill with fluid. The speed with which a patient’s condition changes depends on the extent of the damage to the heart.

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DEEP-VEIN THROMBOSIS

A thrombosis is clotting of the blood within a blood vessel. Surface clots are quite common, but a deep thrombosis is of concern because it has the potential to move around the body and lodge somewhere else (for example, in the lungs or heart). Prolonged immobilisation can result in deep-vein thrombosis in the legs, such as in the calf. Signs include pain, tenderness, warmth and swelling in the affected limb.

CHAPTER 6 | CIRCULATION EMERGENCIES

SIGNS AND SYMPTOMS

PULMONARY EMBOLISM

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When a blood clot (thrombus) breaks off and travels through the bloodstream, it can lodge in the vessels of a vital organ. A pulmonary embolism is when the blood clot lodges in the lung. This damages the lung tissue, so breathing can become painful and oxygen transfer is affected with serious consequences. It can lead to cardiac arrest.

SIGNS AND SYMPTOMS

• Sharp chest pain

• Pain worse when breathing in

• Shortness of breath

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• Pale skin

• Blue lips and fingers

• Dizziness, weakness

• Rapid heart rate and breathing

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• Collapse

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MANAGEMENT

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Treat as for a heart attack (page 71).

SEVERE EXTERNAL BLEEDING In fo

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Cuts from sharp objects, blows from blunt objects, falls or broken bone ends can damage blood vessels. A torn major blood vessel with severe blood loss is immediately life-threatening.

SIGNS AND SYMPTOMS

A person who has experienced severe blood loss will exhibit the signs and symptoms of shock. In assessing the injury, expose the wound and look for impaled, embedded objects. Try to describe and record the amount of blood lost, for example, a cupful, a litre or a square metre. This can be difficult as blood spreads over non-absorbent surfaces and soaks into clothing. Save any evidence of blood loss, such as soaked clothing.

• Large wounds and significant blood loss can be concealed under clothing – so do a thorough blood sweep. • Never risk infection through contact with another person’s blood or body fluids. Protect yourself by using surgical gloves, cling film or plastic bags. Wash your hands thoroughly after treating a wounded patient.

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Your first priority is to stop the blood loss. There are three methods for EMERGENCIES controlling bleeding:

CIRCULATION MANAGEMENT

• Direct pressure, with elevation if it is an injured limb

• Indirect pressure

• Tourniquets, as a last resort only

Place a pad (such as a T-shirt or bandana) over the wound and press down firmly. Imagine the blood vessel is a straw – the pressure you apply should be enough to seal the straw. If no dressings are available, use their hand (or yours, if they are unable to assist).

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Direct pressure

• Apply pressure around an embedded object, never directly on it.

• Pack large wounds with dressing material.

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• Squeeze or pull the sides of gaping wounds together. Maintain firm pressure until a clot forms. This can take 5–15 minutes.

Reassure the patient and lay them down with any bleeding limbs elevated above the heart. Remove rings and jewellery from affected limbs, as swelling may occur.

5–15 minutes firm pressure

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If the first dressing becomes soaked with blood, do not remove it. This will disturb the clotting process. Place another dressing pad on top.

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If bleeding continues after a second dressing is applied, do not use another on top. Pressure on the wound gets less effective as the number of dressings increases. Carefully remove the dressings, check the wound and start again with a new dressing.

Gloves or plastic bag for safety

Figure 6.6 Direct pressure to stop bleeding

CHAPTER 6 | CIRCULATION EMERGENCIES

Remember:

After 5 minutes, slowly release pressure (this is the time to put on a dressing if you did not have one initially). If the bleeding resumes, reapply direct, firm pressure for 15 minutes.

Once bleeding has stopped and a clot has formed, apply a compression (firm) bandage over the dressing to hold it in place and maintain some pressure.

Treat the patient for shock.

Check the fingers or toes of an affected limb for circulation every 10 minutes. If the circulation is affected:

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• The extremities will be cold and/or pale. • The patient will have sensations of tingling and numbness in the limb.

• Capillary refill will be delayed.

The bandage should be removed.

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10. Splint a limb with a major wound, to prevent the patient moving it and opening the wound.

NOTE

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In most cases, bleeding from a limb wound can be controlled by a combination of applying direct pressure and elevating the affected limb.

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Indirect pressure

Press firmly on the appropriate pressure point.

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Indirect pressure can be used for controlling bleeding of a limb but not bleeding of the torso. If direct pressure alone is not effective, apply pressure to pressure points. These points are parts of the body where arteries lie close to the skin and against the bone. You are able to feel a pulse at these points. Pressure applied to an artery compresses it against the bone and can slow or stop the flow of blood in that artery, reducing the bleeding at the injury site. Use this method in conjunction with direct pressure. 2.

Do not maintain pressure for more than 10 minutes, as loss of circulation to a limb may cause permanent damage.

After 10 minutes, release the pressure point for 10 seconds, while maintaining direct pressure over the wound, allowing normal circulation to resume. If the wound is still bleeding, reapply indirect pressure, and release again after another 10 minutes.

CHAPTER 6 | CIRCULATION EMERGENCIES

Temporal

CIRCULATION

Brachial

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EMERGENCIES

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Femoral

Popliteal

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Figure 6.7 Pressure points (where arteries can be pressed against the bone to stop or reduce bleeding)

REDUCES BLOOD FLOW TO

INSTRUCTIONS

Temporal

Side and top of the head on that side (not face and forehead)

Place 2 or 3 fingers on the temple (side of the face) between the top of the ear and the eyebrow.

arm above the elbow

Arm and forearm below the point of pressure

Place 2 or 3 fingers in the body of the arm muscle (bicep), pressing inwards and upwards.

Popliteal

Leg from knee down

Place 2 or 3 fingers behind the knee, midline and slightly to the outer side, just below the bend.

Lower limb from lower half of thigh down

Lay the patient down with the limb bent at the knee. You can feel this artery pulsing in the groin. Press it against the bone using your thumbs, fist or heel of hand.

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PRESSURE POINT

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head, above ear

Brachial

behind the knee

Femoral thigh

Tourniquets Use tourniquets as a last resort only when the combination of direct and indirect pressure does not stop the bleeding of an injured limb.

Use a tie that is about 10cm wide. Never use cord or wire that will cut into the skin.

Wrap the tie around the limb several times, as close to the injury as possible, between the wound and the heart.

Tie a knot and place a stick (or something similar, such as a tent peg) into the knot. Twist the stick, tightening the tie until the bleeding stops.

WRITE DOWN the time the tourniquet is applied.

After 30 minutes, release the tourniquet.

Leave the tourniquet released for 30 seconds, using direct pressure to control the bleeding. If direct pressure controls the bleeding, remove the tourniquet completely. Continue with direct pressure.

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If bleeding does not stop:

Tighten the tourniquet again to completely cut off the circulation. After another 30 seconds, loosen the tourniquet to allow some circulation and removal of toxic substances.

Tighten again after 30 seconds. Repeat this pattern of loosening then tightening every 30 seconds for 5 minutes.

Leave the tourniquet tightened for another 30 minutes, and repeat the above steps.

Write down the times that the tourniquet was applied and released and give them to the rescue personnel.

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1. 2.

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REMEMBER

This is a last resort treatment. Tourniquets are only applied when bleeding is excessive and uncontrollable by direct and indirect pressure.

If you use a tourniquet, assume that the patient will lose the limb. The major problems with a tourniquet are that it completely cuts off circulation to the affected limb and causes a build-up of toxins in the limb.

CHAPTER 6 | CIRCULATION EMERGENCIES

CIRCULATION

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EMERGENCIES

Figure 6.8 Tourniquet, used to stop bleeding ONLY if direct and indirect pressure fails

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EXTENDED CARE AND EVACUATION GUIDELINES

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Any patient who has lost a considerable amount of blood will need to be evacuated. The urgency of evacuation will depend on the degree of shock and the size of the wound. Infection is a risk.

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Evacuate anyone who has had a tourniquet applied.

While waiting for evacuation, treat the patient for shock and keep them warm. Handle them gently so as not to disturb the wound. Do not remove the dressings, as this disturbance could restart the bleeding.

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Give the patient pain relief and sips of fluid if they are fully conscious. If the patient is unconscious, place them in the recovery position and monitor their vital signs.

INTERNAL BLEEDING

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Internal bleeding should be considered if the patient has had a significant fall or has been struck by a blunt object (such as a rock). Obtaining all the details about the accident or injury will help you determine if internal bleeding is likely.

Internal bleeding may result from a medical condition (such as a perforated stomach ulcer) or from a serious injury. Internal bleeding may present no visible signs, but a lethal amount of blood can be lost from the circulation system into surrounding tissues. Often, by the time the signs of shock are apparent, the situation is serious.

SIGNS AND SYMPTOMS

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A person with internal bleeding will exhibit the general signs and symptoms of shock. Other signs that may indicate internal bleeding include:

• Frothy red blood coughed up, indicating injury to the lungs

• Dark blood vomited up, sometimes similar in appearance to coffee grounds, indicating bleeding in the stomach

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• Dark tarry stools, indicating bleeding in the upper intestine

• Bright red blood in the stools, indicating bleeding in the lower bowel

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• Smoky coloured or blood-stained urine, indicating damage to kidneys or the bladder

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• A rigid abdomen, indicating blood or bowel contents are present in the abdominal cavity

Sudden swelling (distension) of the abdomen is a late sign that the patient’s condition is life-threatening and requires urgent surgery.

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A previous history of abdominal problems, such as a stomach ulcer, may indicate that internal bleeding is the result of a medical condition.

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MANAGEMENT • Treat the patient for shock. • Place support under the thighs of the patient in the shock position, to relieve tension in the abdominal cavity. • If the patient loses consciousness, place them in the recovery position. • A conscious patient will probably assume the most comfortable position for themselves. • If the accident or symptoms suggest a lung injury, sit the patient up. Leaning them towards the injured lung will help them breathe, as it keeps blood from collecting in the uninjured lung and creates space for it to function properly. If the patient becomes unconscious, place them in the recovery position with the damaged lung downwards.

Arrange an urgent evacuation. Internal bleeding can usually only be managed in the operating theatre.

While waiting for evacuation, treat the patient for shock and keep them warm. Giving the patient pain relief and sips of fluid may help keep them comfortable. However, as a general rule, food and fluid should be withheld so that the patient arrives at hospitalCIRCULATION with an empty stomach. Food should definitely be withheld if an intestinal injury is suspected.

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EMERGENCIES

CRUSH INJURIES

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In the outdoors, crush injuries can be caused by rockslides, avalanches or falling trees. They can involve serious damage to internal organs and body tissue, and can cause fractures. There is often considerable blood loss, internally and/or externally.

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MANAGEMENT

Remove the crushing object as soon as possible, taking care to protect the patient’s spine and to prevent further injury.

Stop any external bleeding, following the instructions on page 74.

Treat other injuries, including fractures. For fractures, follow the instructions in chapter 9.

Treat for shock, following the instructions on page 64.

Relieve tension in the abdomen by elevating the legs.

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If a significant area of the body, such as both lower limbs, has been crushed for longer than 1 hour, all circulation to the legs will have been cut off for that length of time. Toxins will have built up in the affected limbs. These toxins can cause serious problems or death when released suddenly into the circulatory system. One option is to apply a tourniquet above the crushed area (only if the area is a limb) just before removing the crushing object. Apply the tourniquet for 5 minutes, then release for 5 minutes, then repeat, following the steps on page 78. This allows a gradual release of the toxins.

CHAPTER 6 | CIRCULATION EMERGENCIES

EXTENDED CARE AND EVACUATION GUIDELINES

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation. If the crushing object has been in place for more than 1 hour, request specialist medical personnel to come to the scene and administer the appropriate intravenous fluids and medications to counteract the toxins, and to give oxygen.

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Keep the patient in the shock position, with their head and body lying flat. If their injuries permit, elevate their legs. Monitor their vital signs.

CHAPTER 8 | HEAD INJURIES

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CHAPTER 7:

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IN THIS CHAPTER:

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CARE OF AN UNCONSCIOUS PATIENT ac

ASSESSMENT 84

THE RECOVERY POSITION

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MANAGEMENT

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EMERGENCY ROLLOVER 88 90

PHOTO Peter Waworis

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EXTENDED CARE AND EVACUATION GUIDELINES

Remember patient assessment and management. In DRSABC, ‘R’ is for response. Is the patient alert, do they respond to voice or pain, or are they unresponsive?

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The treatment is the same for all three levels of unconsciousness: whether the patient responds to voice (V), responds to pain (P) or is unresponsive (U). (See page 22 for details about the AVPU scale.)

Causes of unconsciousness include head injury, choking, stroke, epilepsy, diabetes, meningitis or other infections, alcohol or drug abuse, heat stroke or hypothermia.

ASSESSMENT is

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• Assess the patient’s level of consciousness. Are they completely unresponsive or do they respond to voice or pain?

• Do a thorough head-to-toe examination to ensure you find all their injuries. Look for medical ID bracelets and necklaces on the wrists, ankles and neck.

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Note: It is easier to do a full head-to-toe examination while the patient is lying on their back.

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Never leave an unconscious patient unattended on their back. The normal reflexes that protect the airway of a conscious person will fail. An unconscious person cannot cough, swallow or gag and:

• Their tongue may fall across the back of their throat.

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• Their stomach contents may flow back up into the throat (this can happen quickly and more than once).

• Any fluid in the mouth, such as vomit or blood, will be breathed into the lungs, causing tissue damage and swelling, and affecting breathing.

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Frequently check that the patient is breathing by listening for gurgling noises in the throat and watching for vomit in the mouth. Because the patient cannot gag, you will not hear the usual gagging vomiting noises – the stomach contents will just flow up. The person who is checking the breathing should be kneeling at the side of the patient that best allows for ease and speed of turning, and use of gravity. They need to be ready to do an emergency rollover (see page 88).

• Remember this patient may still be able to hear, so speak to and about them as if they were conscious. Offer constant reassurance. Do not allow anything negative to be said within earshot. • Treat any other injuries.

• Place the patient in the recovery position.

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• Record the patient’s vital signs, including their level of consciousness, every 5 minutes to establish their base lines and to notice trends.

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Contact lenses move with blinking and are lubricated by tears to prevent harm to the cornea of the eye. This action is lost with unconsciousness, so an unconscious patient may need to have the lenses removed. Different types of contact lenses require different methods of removal and storage. Discuss these methods with the lens wearers in the party.

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Dentures maintain the shape of a person’s mouth. When a person is unconscious their dentures can fall back and block the airway. Only remove the dentures if you cannot constantly monitor the patient.

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THE RECOVERY POSITION

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It is impractical to remain kneeling beside the patient for extended periods. The recovery position (sometimes called the ‘stable-side position’) can be used if you need to leave the patient for any reason or once the patient no longer requires supervision. For the position to be effective, the patient needs to:

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• Be on their side

• Have no pressure on their chest

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• Be unable to roll over onto their face or back • Have their head positioned so their tongue cannot fall across the back of the throat, and so vomit or fluid will drain out of their mouth, not into their lungs

CHAPTER 7 | CARE OF AN UNCONSCIOUS PATIENT

MANAGEMENT

GETTING INTO THE RECOVERY POSITION Before moving the patient, make sure you are ready so that only one move is required. Have insulation and a sleeping bag ready. Clear away any stones or twigs that will dig into your patient.

Place insulation on top of a groundsheet for the patient to roll onto. This will protect the patient from the cold ground and make it easier to move them later if needed. Use clothing as a small pillow to support their head before and after you move them.

Kneel beside the patient, and tell them what you are doing. They may be able to hear you.

Remove the patient’s glasses and any sharp, bulky objects from their pockets.

With the patient lying on their back, place their hand on the side closest to you, palm up, under their buttock.

Place their far arm across their chest.

Bend their far leg up so that the knee is elevated.

Support their neck and head with one hand and push down on their knee with the other, rolling the patient towards you. Act quickly as rolling over their arm will be uncomfortable for the patient.

Pull their lower arm out behind their body (see figure 7.1).

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10. Position their uppermost arm at a right angle to their body, bending the elbow so the hand points towards the face.

11. Bend their uppermost leg until the thigh is at a right angle to their body.

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12. Tilt their head towards the back of their body until the airway is fully open.

13. Finally, recheck the patient’s airway and ensure their head is tilted slightly back.

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Once in position, check that circulation to the patient’s limbs is not being cut off by the head or body resting on an arm, or one leg lying across the other. Trees, rocks and sloping, uneven ground may cause difficulties. In difficult terrain, you may want to practice positioning an uninjured party member first.

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If the patient is in the recovery position for an extended period, parts of the body pressing on the ground may develop pressure sores. A slight change in position every couple of hours will help to relieve pressure on these areas. If possible, the patient should be turned to the recovery position on the other side.

CHAPTER 7 | CARE OF AN UNCONSCIOUS PATIENT

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a. Place patient’s hand closest to you under their body, grasp their shoulder and knee.

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b. Pull patient towards you.

c. Place patient’s upper arm at right angles to their body, pull their lower arm out behind them.

Figure 7.1 Placing a person in the recovery position

RECOVERY POSITION FOR AN INFANT Cradle the infant face down on one of your arms. Hold the head by supporting the bony part of the chin in your hand, ensuring that the spine is neutral. Another recovery position for infants is the common ‘burping’ position, held against and supported by the adult’s shoulder. This way the infant’s tongue falls forwards (not backwards) and breathing sounds can be heard.

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a. Burping position b. Face down, supported

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Figure 7.2 Recovery position for infant

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EMERGENCY ROLLOVER

Figure 7.3 Emergency rollover

If the patient is on their back, and you hear or see any vomit, you must turn them quickly regardless of their injuries, to allow the vomit to flow away and not choke them. Two methods are:

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• Pull the patient towards you by grabbing clothing at their shoulder and hip, then pulling so they are on their side resting on your knees.

• Push the patient away from you by bending their knee closest to you, and pushing it away and down to lever the body over. This method requires slightly less strength and decreases the chance of you getting splashed with vomit.

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If the patient has a neck or spinal injury, the head must be supported during the emergency rollover, even if a neck brace is in place. Place a pillow of folded clothing next to the patient’s head, to support the head when the patient is rolled onto it. The pillow’s thickness should be the height of the patient’s shoulders, to keep the head level and the spine neutral, and to minimise movement in the neck.

Figure 7.4 Emergency rollover for suspected neck injury: support the head

CHAPTER 7 | CARE OF AN UNCONSCIOUS PATIENT

Sometimes you will need to keep the patient on their back, for example, when doing a patient assessment, or if you suspect they have spinal injuries. While they are on their back, use the head-lift, chin-tilt method or the jawthrust technique (if you suspect a neck or spinal injury) to keep the tongue off their airway.

Place their arm closest to you above their head, or at a right angle to their body.

Bend their far leg up at the knee.

Support their head with one hand.

With the other hand, push the bent knee down levering their body towards you.

As the patient comes over onto your knees, keep supporting their head, always keeping their spine as neutral as possible.

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When you suspect a neck injury, use this emergency rollover method:

This method will cause some twisting in the patient’s lower back, but it is more important to protect the neck. Recognise the risk to the neck and spine, but remember your priority is to clear the airway quickly, otherwise the patient will not survive.

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Practise these manoeuvres at home so you will be able to do them quickly and confidently in the field.

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EXTENDED CARE AND EVACUATION GUIDELINES no tb e

Anyone who is or was unconscious, even very briefly, needs to be assessed and treated by a doctor. Arrange for prompt evacuation. • Keep the patient warm and as comfortable as possible.

• Use towels or clothing to deal with any loss of bladder/bowel control. Check often, and wash and dry the area if necessary.

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• Monitor and record the patient’s vital signs and levels of consciousness.

CHAPTER 8 | HEAD INJURIES

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CHAPTER 8:

IN THIS CHAPTER:

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HEAD INJURIES

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ANATOMY OF THE HEAD

COMPRESSION (CLOSED) HEAD INJURY

OPEN HEAD INJURY

PHOTO Jen Riley

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CONCUSSION

All head injuries should be considered serious. They are often difficult to assess. A person with a significant head injury can initially appear to be symptom-free but can deteriorate quickly over time. Decreasing levels of consciousness indicate a worsening injury. Head injuries can be caused by: • Direct trauma to the head or spine • Rapid acceleration or deceleration, causing the brain to shake violently

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• Closed: The brain may be bruised (contusion) or blood vessels may be damaged causing blood to pool and clot. Symptoms relate to the pressure building up inside the skull as bruised brain tissue swells, blood clots enlarge or bleeding occurs. Patients with a closed head injury can deteriorate over time.

Head injuries can be:

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• Open: The skull is broken. The brain can be damaged by fragments of broken bone or an object penetrating the skull. Symptoms relate to the damage caused by the initial injury, and the situation may be relatively stable.

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• Skull (cranium): A roughly circular set of bones, attached at the base to the spine.

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ANATOMY OF THE HEAD

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• Spine: Made up of 33 vertebrae.

• Spinal cord: An extension of the brain that extends down through the vertebrae.

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• Cerebrospinal fluid: Surrounds the brain and spinal cord acting as a shock absorber and providing nutrition to the brain cells. • Brain: A complex set of nerves that allows communication with most parts of the body.

Brain/spinal cord/nerves Cerebrospinal fluid Bones

SKULL CEREBROSPINAL FLUID BRAIN BASE OF SKULL SPINAL CORD VERTEBRAE NERVES

Figure 8.1 The head, spine, spinal cord and nerves

CHAPTER 8 | HEAD INJURIES

• Nerves: Branch out from the spinal cord between vertebrae in pairs. There are: • Motor nerves that stimulate movement. • Sensory nerves that detect sensations (heat, cold, pain, touch). The skull, vertebrae and cerebrospinal fluid all act to protect the brain and spinal cord.

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CONCUSSION

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Concussion occurs when the brain is shaken, for example, by a blow to the head or when a patient lands heavily from a height. Concussion causes a temporary decrease in brain function, ranging from momentary confusion to brief loss of consciousness.

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Note: A concussed person’s mental state progressively improves. If the patient becomes more confused, improves temporarily and then worsens, and/or loses consciousness several minutes or hours after the initial impact, they may have a more serious brain injury.

CONCUSSION

MORE SERIOUS BRAIN INJURY • Symptoms develop and worsen minutes or hours after impact.

• Effects gradually disappear within 24 hours.

• Symptoms do not subside.

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• Symptoms appear immediately/soon after impact.

SIGNS AND SYMPTOMS

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A person with concussion will exhibit some or all of the following signs and symptoms:

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• A brief period of unconsciousness, semi-consciousness or confusion • Short-term memory loss, the extent of which will depend on the severity of the injury • Nausea and vomiting • Headache • Irritability, combativeness • Drowsiness • Blurred vision

MANAGEMENT • Do a very thorough head-to-toe examination to ensure all injuries are found and treated. • Let the patient rest until they are recovered.

• If the patient is drowsy, let them sleep in the recovery position (with their head slightly elevated). Wake them to check and record their level of consciousness every 15 minutes for the first 2 hours. Extend the interval if their level of consciousness remains stable.

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• Treat any other injuries.

• Give the patient pain relief if needed.

• If the patient does not recover, or their level of consciousness decreases, they are likely to have a more serious head injury and an urgent evacuation is required.

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EXTENDED CARE AND EVACUATION GUIDELINES

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A patient who has been unconscious, even for a short time, should be evacuated. If the patient appears to have recovered, and the journey is straightforward, it may be appropriate to allow the patient to walk with assistance.

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COMPRESSION (CLOSED) HEAD INJURY

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Compression occurs when a head injury bruises the brain or damages blood vessels in the skull. A build-up of pressure within the skull compresses the brain. This is caused by bleeding and/or the bruised tissue swelling. Bleeding and/or swelling compresses brain

Figure 8.2 Brain compression caused by bleeding and/or swelling

CHAPTER 8 | HEAD INJURIES

SIGNS AND SYMPTOMS A person with compression will exhibit some or all of the following signs and symptoms: • Loss of consciousness at the time of injury – if they regain consciousness, they may lapse into unconsciousness again

• Headache

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• Incoherent speech

• Unusual behaviour

• Poor coordination, balance and gait

• Bleeding from the ears and/or nose

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• An initially rapid pulse, which slows and can become quite slow and forceful

• Clear or straw-coloured liquid (cerebrospinal fluid) leaking from ears and/or nose – liquid may smell of almonds

• Laboured breathing

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• Changes to one or both pupils in regard to size and reaction to light

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• Convulsions involving the whole body, or just one side or limb, depending on the location and/or severity of the injury

Figure 8.3 Reaction of pupils indicating brain damage

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Note: It may be hours or even days before the patient’s level of consciousness deteriorates, so monitoring and recording the level of consciousness is important.

MANAGEMENT • Do a thorough head-to-toe examination to ensure all injuries are found and treated. • If the patient is conscious, lay them down with their head slightly raised. • Monitor the level of consciousness constantly – deterioration indicates a worsening condition. • If the patient is unconscious, treat them for a possible neck injury (see page 105). Place them in the recovery position (see page 85) with the head slightly higher than the rest of the body.

• If the patient is drowsy, let them sleep in the recovery position (head slightly raised), but wake them to check and record their level of consciousness every 15 minutes. Extend the interval if the level of consciousness remains stable. • Treat any other injuries. • Give the patient pain relief, such as paracetamol. • Patients with head injuries often vomit, so give them only small amounts of fluid to drink.

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• DO NOT give anything by mouth to an unconscious patient.

EXTENDED CARE AND EVACUATION GUIDELINES

Arrange an urgent evacuation.

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You should monitor and record the patient’s level of consciousness and other vital signs on a regular basis. A written record of the patient’s progress is valuable for medical professionals taking over treatment.

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Take care to ensure the patient is kept as warm and comfortable as possible. Keep the patient’s head slightly higher than the rest of their body. The patient may be incontinent, or they may be retaining urine and need assistance in getting to an upright position to urinate. Prolonged urine retention can lead to permanent damage to the bladder.

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OPEN HEAD INJURY

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A person with an open head injury will have a damaged skull and will exhibit the signs and symptoms of a compression injury (see page 94). It takes considerable force to penetrate the skull, so you should suspect brain injury, a broken neck and other spinal damage.

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MANAGEMENT Treat an open head injury as for compression injury (see page 94). It is okay to remove debris from the overlying skin, but DO NOT attempt to remove objects embedded in the patient’s brain or skull. DO NOT apply direct pressure. Cover the wound with sterile bandages.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation. Care as for compression injury (see page 94).

CHAPTER 9 | FRACTURES AND DISLOCATIONS

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CHAPTER 9:

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FRACTURES AND DISLOCATIONS e

IN THIS CHAPTER:

99 FRACTURED THIGH (FEMUR) 119

103 FRACTURED KNEE

104 FRACTURED LEG (KNEE TO ANKLE) 122

105 FRACTURED ANKLE OR FOOT 124

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FRACTURED SKULL

FRACTURES

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FRACTURED JAW

SPINAL INJURES

112 DISLOCATIONS

FRACTURED RIBS

113

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FRACTURED COLLARBONE (CLAVICLE)

FRACTURED ARM (BETWEEN SHOULDER AND ELBOW) 114

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PHOTO Laura Wilson

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FRACTURED FOREARM (BETWEEN ELBOW AND WRIST) 115 FRACTURED HAND AND FINGERS

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FRACTURED PELVIS

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122

125

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A FORE

ARM

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LEG

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THIGH

Figure 9.1 The skeleton

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To explain the exact site of injury to a limb, describe it as either upper limb (above or below the elbow) or lower limb (above or below the knee).

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UPPER LIMB

LOWER LIMB

The arm (shoulder to elbow) The forearm (elbow to wrist) The thigh (hip to knee) The leg (knee to ankle)

The 206 bones in the adult skeleton protect the vital organs and give the body shape and rigidity. Bone is very strong living tissue supplied with blood vessels and nerves, with a central core called the marrow. Joints, where bones meet, can be moveable (such as the knee) or fixed (such as the skull). Ligaments attach bone to bone. Tendons attach muscle to bone. Bones are moved by contraction and relaxation of muscles.

A fracture is a break, crack or chip in a bone, caused by direct force (when the bone is fractured at the point of impact) or indirect force (where the fracture occurs away from the point of impact due to force being transferred through the body).

Common types of fracture:

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• Closed fracture: A bone is fractured, but the skin is intact.

• Open fracture: The skin is broken, so the fracture site may become infected. The skin wound is caused by either the fractured bone penetrating the skin from the inside or the object causing the fracture (for example, a rock or axe) penetrating from the outside.

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• Complicated fracture: Fractured bone ends cause damage to underlying organs, nerves or major blood vessels. (Note: In considering treatment, it is the complication that is important rather than the fracture).

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In fractures of long bones, muscle spasms around the fracture site can pull the fractured bone ends together, causing them to override. The overriding increases pain and can cause soft tissue, artery and nerve damage.

(b) Open fracture (a) Closed fracture

Figure 9.2 Types of fractures

CHAPTER 9 | FRACTURES AND DISLOCATIONS

FRACTURES

ASSESSMENT You should check any patient who has suffered a significant accident or injury for fractures. A person with a fracture will exhibit some or all of the following signs and symptoms: • Cracking sound as the bone is injured

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• Deformity – a fractured limb may be bent or twisted or may be shorter than the opposite limb (comparing the injured side with the uninjured side may reveal a subtle change in shape)

• ‘Grating’ noise or feeling when the fracture is moved

• Signs and symptoms of shock

• Inability to move the injured area

• Instability of affected bones

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It can be difficult to tell whether or not a bone has been fractured. Always err on the side of caution. It is better to immobilise a sprain than to fail to immobilise a fracture.

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MANAGEMENT

In an outdoor environment:

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• Support and immobilise the fractured bone. • Minimise the patient’s pain.

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• Ensure an adequate blood supply to any fractured limb by checking circulation (capillary refill), sensation and movement. • Protect an open fracture from infection.

In an urban environment, you should not move the broken limb or apply a splint. Simply keep the patient still and contact emergency services.

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Immobilising fractures

Fractures are immobilised to:

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• Prevent movement of bones • Reduce pain and swelling • Reduce the likelihood of further injury to internal organs, blood vessels and nerves • Prevent a closed fracture from becoming an open fracture

Assess circulation, sensation and movement in fingers or toes before you immobilise a fracture. Compromised circulation is a sign of a more serious injury. Damage to circulation and nerves can result in permanent damage or eventual loss of the limb. Arrange an urgent evacuation.

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• Pain and swelling – point tenderness over fracture site

Gain the patient’s cooperation and confidence by explaining what you are doing and why.

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A good splint should:

• Be approximately as wide as the fractured limb.

• Be long enough to provide effective support, but not so long that it may be knocked.

• Immobilise the joint above and below the fracture.

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• Allow access to the patient’s fingers and toes, so circulation can be monitored.

When immobilising a limb:

• Follow the instructions on pages 103–124 for immobilising specific types of fractures.

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• For comfort, pad splints well, especially where they lie against bony joints at the knee, ankle, elbow and wrist. Pack all natural hollows, such as behind the knee, with padding.

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• Hold splints in place with wide ties (not cord, which may cut into the skin).

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Once the fracture is immobilised, reassess circulation, sensation and movement in the patient’s fingers or toes. Check circulation regularly.

Minimising pain

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• Give the patient pain relief before or immediately after immobilising a fracture.

• Avoid touching and moving a fracture any more than is necessary.

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• Keep fractures slightly elevated to lessen swelling and to help relieve pain. For lower limb fractures, support the knee – elevating the lower leg without knee support is uncomfortable. • Apply gentle traction to long-bone fractures, especially the femur (thigh bone). Traction can greatly reduce pain, by preventing muscle spasm from driving broken bone ends any further into the surrounding soft tissue. You may want to do a trial run on an uninjured party member first, to ensure that the traction can be maintained.

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CHAPTER 9 | FRACTURES AND DISLOCATIONS

Once you have discovered a fracture, do not move the patient until it has been splinted. Where practical, take your time to carefully improvise a splint that will be comfortable and effective. You can make improvised splints from internal pack frames, walking poles, closed cell foam in a ‘U’ shape, tree branches or thick bark. Work out what materials you need and have them in place before you start. You may want to practise on an uninjured party member or the patient’s uninjured side.

Ensuring an adequate blood supply When a fractured limb is out of its usual alignment, the blood supply to the limb can be affected because blood vessels have been damaged, twisted or kinked. This is a serious emergency. The limb may be permanently damaged if deprived of blood supply for more than 2 hours. The following are indications of compromised circulation in the fractured limb. • There is no pulse past the site of the fracture.

• The extremity (hand or foot) is cold or looks white or blue.

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• The patient feels pins-and-needles or numbness in the extremity.

If the limb is twisted and the circulation impaired, you should straighten the limb in an attempt to restore the blood supply. This can be painful but will result in far less pain afterwards.

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Grasp firmly and pull gently to straighten bones

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Figure 9.3 Straightening a fractured limb (applying gentle traction)

To straighten the limb:

• Have someone support the joint above the fracture.

• Grasp and support the limb below the fracture site.

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• Apply gentle traction along the line of the limb.

• Straighten the limb until it is in its proper position.

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• Maintain traction by hand while someone else applies a splint.

Note: Stop repositioning the limb if this process causes the patient a significant increase in pain or there is resistance that prevents the limb from moving. If you need to stop, immobilise the fracture as it is.

CARING FOR AN OPEN FRACTURE Infection is a serious problem with open fractures, and can result in long term complications. If your patient has an open fracture: • Control any bleeding with direct pressure around the site, not on it. • Cover bone ends with temporary protection, such as a plastic bag, until you have your materials ready.

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• Minimise accidental pressure on the broken bone ends by securing padding on either side of the wound.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an evacuation.

• Keep the patient as warm and as pain free as possible.

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• Continue giving the patient pain relief according to the recommended dose.

• Patients are often more comfortable if a fractured limb is elevated.

• Check circulation regularly. If it is impaired, loosen and reapply splints. If this is unsuccessful, traction and realign the limb.

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Urgent evacuation is needed when circulation is compromised.

FRACTURED SKULL

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A fractured skull can be caused by a direct blow or by indirect force. When a patient lands heavily on their feet, force can be transmitted up the body and fracture the base of the skull. Injuries to underlying tissue can result in life-threatening bleeding.

If the skull is fractured, the patient will also have a head injury (see chapter 8).

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ASSESSMENT

A person with a fractured skull will exhibit some or all of the following signs and symptoms:

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• Obvious bone damage

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• Blood or clear fluid (cerebrospinal fluid) leaking from the nose and/or ears, indicating that the base of the skull has been fractured • Bruising around the eyes and behind the ears, usually appearing several hours after the injury

MANAGEMENT • If there was sufficient force to break the skull, the neck may also have been broken and must be immobilised. • Follow the guidelines for treating the underlying head injury (see chapter 8). Be careful not to probe any wound or fracture as you may cause further damage to the brain. To control bleeding, apply gentle pressure around any wound, rather than directly on it.

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• Gently clean any debris from the bones and cover the wound with a light, dry, sterile dressing.

• Do not try to stop blood or cerebrospinal fluid draining from the ears or nose, as you could cause increased pressure in the skull. Cover the ear with a clean pad, to help prevent infection. If the patient is unconscious, place them in the recovery position with the discharging ear or nostril downwards. • Keep the patient in a horizontal position with their head elevated slightly.

EXTENDED CARE AND EVACUATION GUIDELINES

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Arrange an urgent evacuation.

FRACTURED JAW

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It takes significant direct force to fracture the jaw, because the lower jaw is very strong. A patient with a fractured jaw may also have head and neck injuries (see chapter 8).

ASSESSMENT

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A patient with a fractured jaw will exhibit some or all of the following signs and symptoms:

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• Pain and tenderness, especially when they move their jaw • Visible deformity

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• Broken teeth

• Soft tissue injury inside the mouth

• Drooling, caused by pain and difficulty swallowing

MANAGEMENT

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• Attend to any bleeding in the mouth, using a clean pad to apply direct pressure.

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• Have the patient sit leaning forward so saliva can drain from their mouth. • DO NOT try to bandage the jaw, as this could cause airway problems. Saliva and vomit need to be able to drain away. • Hold a cold cloth against the jaw to help relieve the pain and swelling.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation.

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The bones (vertebrae) in the spine protect the spinal cord. The spinal cord is the nervous connection between the brain and the rest of the body. It is roughly the same diameter as a person’s little finger and has the consistency of toothpaste. A broken vertebra can easily damage or cut the cord.

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The extent and location of a spinal injury will determine whether the patient might be paralysed from the neck, chest or waist down.

The neck is the most vulnerable part of the spine because it contains the smallest vertebrae with the greatest range of movement.

ASSESSMENT

• Have a head injury

• Are unconscious after an accident

Assume a patient has a spinal injury if they:

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It is difficult to assess a spinal injury in the outdoors. Only an X-ray can give a definite answer. If you are uncertain, it is better to err on the side of caution.

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• Have fallen from height (falling from their own head height can be enough to cause spinal damage)

• Have had a diving accident

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• Have had a direct blow to the head or spine

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Any numbness, tingling, or loss of movement or sensation can indicate spinal cord damage. Swelling may also cause these sensations, and they may not necessarily be permanent. Only examine the spine if you can do so without aggravating a possible spinal injury or it is necessary to deal with major bleeding.

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Note: The bones in the spine may appear normal even when the spine is fractured.

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Never assume that because the patient has sensation and movement, and can wiggle their fingers and toes, their spine is not fractured. A vertebra can break without damaging the spinal cord.

MANAGEMENT Try to manage the patient at the accident site if possible rather than moving them. Most spinal damage occurs at the time of the accident, but poor handling can make it worse. Immediately have someone hold the patient’s head to prevent any movement. Use the jaw-thrust method to open the airway of an unconscious patient with a spinal injury.

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SPINAL INJURIES

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The aim of managing a spinal injury is to prevent any damage, or further damage, to the spinal cord. To prevent any movement, support the patient’s head in the neutral position and with a neck collar (improvised with rolled up clothing). If the patient’s head is over to one side, flopped forwards or extended backwards, the space in their spinal canal is narrowed significantly, increasing the risk of damage from swelling.

Make sure the patient is kept warm. The body’s heat-regulating system is often affected by a spinal injury. Insulate the patient from cold ground to prevent hypothermia, a significantly increased risk in patients with spinal injuries. Use a log roll (see page 109) to get insulation beneath the patient while keeping the spine neutral.

Imagine the patient standing up, with a straight back and their eyes and nose facing straight ahead – that is the neutral position. If the patient is lying flat on their back with the head on the ground, the neck is not in the neutral position, it is tilted slightly backwards.

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Placing the head into the neutral position

Place your hands on either side of the head and face, with your fingers under the jaw to support and control the airway.

Move the head very gently and slowly into the neutral position.

Support the patient’s head until a neck collar is applied to keep the head in the neutral position.

Gently move head to neutral position

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Stand behind the patient.

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If the patient is sitting:

If the patient is lying down: Kneel behind the patient. Place your hands under the head and the nape of the neck, supporting either side of the head.

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1. 2.

Move their head very gently and slowly into the neutral position

Support the patient’s head until a neck collar is applied and padding is placed under the head to maintain the neutral position.

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Figure 9.4 Moving head to neutral spine position

• Movement causes pain or muscle spasms. • Their head is held rigidly to one side. • It would cause airway or breathing problems.

Applying a neck collar

You need to immobilise and support the patient’s head and neck while another party member makes and applies the neck collar.

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The improvised collar needs to be pliable enough to go around the neck but rigid enough to support the jaw. It needs to be shaped to fit snugly under the jawbone and held firmly in place without restricting breathing.

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Measure from the patient’s jawbone to their collarbone and fashion the neck collar to that width, with a dip for the chin. Use the resources you have, for example, closed cell foam, pack waist belt, clothing, sleeping bag or tent fly. Tie the collar in place. Remove the patient’s necklaces and earrings. If they are wearing a medical ID necklace, wrap it around their wrist.

• Holding it between your knees.

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If you are alone, you need to improvise to immobilise the patient’s head while you prepare the neck collar and padding, and come up with a plan of action. Hold the head steady by:

• Using a scarf or triangular bandage held in place by rocks.

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• Placing bags filled with dry sand or dirt (not snow) on either side.

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Remember that the only truly effective collars are custom made and adjustable, as carried by rescue teams. You can never rely on improvised collars to be effective. They provide support only for still patients. Even if your improvised collar looks effective, it is essential to support the head by holding it at all times when the patient is being moved.

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Apply the neck collar without placing the patient’s head in the neutral position, if:

Towel or jacket

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Secure with triangular bandage

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Head support. Towel or clothing folded and rolled up

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Gently tighten around head and support towel.

Figure 9.5 Neck collar improvisation

Immobilising the spine Ideally a patient is only moved by using a rigid backboard, carried by most rescue teams. However, you may need to move the patient to safer ground, onto insulation or onto a backboard. You need to do this with minimal movement of the patient’s spine, using either the log roll method or the lift method.

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The aim is to roll the patient as a log, keeping the head and spine as neutral as possible. • First person stabilises the patient’s head, gives the commands and controls the roll. • Second person holds the shoulder and hip (on one side of the patient’s body). • Fourth person holds the thigh and lower leg.

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• Second, third and fourth persons interlock arms for greater stability.

• Third person holds the waist and knee.

• Fifth person is ready to check the back for injuries and to push the insulation or improvised stretcher into place.

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Ready to roll? Roll!

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Figure 9.6 Log roll of a person with a suspected spinal injury

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Fold or roll back the insulation or stretcher and push it right up against the patient’s body, so that when they are lowered, they are in the middle of the material. 1.

The person at the head gives the command, ‘Ready to roll? Roll!’

Everyone very slowly rolls the patient towards them, keeping the patient’s body as straight as possible.

When the patient is on their side, the fifth person can examine the back for injuries and push the insulation or improvised stretcher into place.

The person at the head gives the command to lower, and everyone slowly rolls the patient on to their back and into the middle of the insulation or improvised stretcher.

The log roll can be achieved by fewer people, as shown in figure 9.7.

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The log roll method

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Ready to roll? Roll!

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Figure 9.7 Log roll with three people

The lift method

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The lift method needs six people. This method can be used if the backboard, insulation or stretcher is too thick or rigid to do the log roll. The aim is to lift the patient approximately 20cm off the ground, again keeping the head and spine straight, while the backboard, insulation or stretcher is placed underneath them. The first person stabilises and lifts the patient’s head and gives the command to lift.

Two people kneel on each side of the patient and place their hands over them, to determine exactly where their hands will be (see figure 9.8) when placed underneath the patient’s back. They gently and slowly slide their hands as far under the patient as possible, careful not to jostle them. Crossing the patient’s arms across the chest helps to get your hands well under the back.

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On the command of the first person, the others lift the patient slowly and evenly, then lower them onto the backboard, stretcher or insulation that is positioned underneath.

Note: Bend at the knees to protect your back.

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Have backboard, stretcher or insulation ready.

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Figure 9.8 Lifting a person with a spinal injury

Extended care and evacuation guidelines

Arrange an urgent evacuation.

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Urine retention leading to permanent damage of the bladder is a problem in spinal injuries, as is incontinence, especially when there is no feeling below the waist. Help the patient to urinate and inform rescue crew if the patient has not urinated.

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If you are waiting for an extended time before moving a patient, ensure paralysed body parts do not become damaged by being left in the same position too long. Turn patients every two hours to avoid pressure sores.

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Remember that a backboard is designed to transport a patient. Ideally, paralysed patients should not be on them for more than two hours. If a paralysed patient is no longer being transported, or is likely to be waiting for more than an hour before further transport with emergency services, you may move them from the backboard to a more comfortable surface (for example, a mattress in a hut). This should be done by log rolling them off the backboard (see page 109). This is less important for patients who are not paralysed, as pressure sores are much less of an issue because they can shift themselves regularly. Continue to monitor and record vital signs.

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FRACTURED COLLARBONE (CLAVICLE) y.

The collarbone is commonly fractured by indirect force when a person falls onto an outstretched hand or their shoulder.

• The patient is often supporting the arm on the injured side with the other hand.

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ASSESSMENT

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• The patient will often report hearing the bone break.

• Often the break is easily seen and felt as a ‘step’ in the bone – compare one side with the other.

MANAGEMENT

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First sling elevates arm.

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• Support the arm on the injured side in a sling, elevating the lower arm. A sling will make the patient feel more supported and comfortable. Improvise by folding up the bottom of a jacket or shirt and securing it as a sling.

Second sling supports arm against torso.

Figure 9.9 Sling to support a fractured collarbone (elevate arm and support it against torso)

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• Place padding between the arm and the body. Bandaging the arm to the body may make the patient a little more comfortable. • Securing the sling to the torso can prevent the arm from bouncing painfully if the patient walks. • Give the patient pain relief if needed.

EXTENDED CARE AND EVACUATION GUIDELINES The patient should be able to walk out but not carry a pack.

CHAPTER 9 | FRACTURES AND DISLOCATIONS

FRACTURED RIBS Fractured ribs are caused by direct impact.

ASSESSMENT

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A patient with fractured ribs will exhibit some or all of the following signs and symptoms:

• Bruising and sharp pain around the fracture site

• Increased pain caused by deep breathing or coughing

• Movement of ribs – the broken area should move in the same direction as the rest

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COMPLICATIONS

Possible complications caused by fractured ribs are:

• Puncturing of internal organs

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• Damage to lungs and possible sucking chest wound

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• Flail segment – a chest deformity where the broken area moves in the opposite direction to the rest of the ribs. This suggests multiple broken ribs (see page 55 for more information)

MANAGEMENT

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If a flail segment is suspected, see page 55. Otherwise: • Support the patient’s arm on their injured side in a sling.

• Give the patient pain relief if needed.

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• Apply a supporting bandage around their chest, if it makes the patient feel more comfortable.

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• If complications such as punctured lungs are suspected, monitor the patient closely. See page 58 for information on managing a sucking chest wound.

EXTENDED CARE AND EVACUATION GUIDELINES Unless there are complications, the patient should be able to walk out on easy terrain with a lightened pack. Ensure the waist strap is taking all the weight of the pack. If the fracture is complicated, the patient’s condition will deteriorate, so arrange an urgent evacuation.

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FRACTURED ARM (BETWEEN SHOULDER AND ELBOW) ASSESSMENT

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• The general signs and symptoms of a fracture will be present.

• Circulation may be affected below the site of the fracture.

MANAGEMENT

• If circulation is affected, straighten the patient’s injured arm (see page 102).

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• Support the injured arm in a sling.

• Bandage the injured arm to the body.

• If the fracture is unstable, apply a splint. In particular, if the elbow joint is fractured, splint it in the position found. There is danger that if the elbow is moved, blood vessels and nerves could be damaged.

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• Give the patient pain relief.

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EXTENDED CARE AND EVACUATION GUIDELINES

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The patient may be able to walk out. If their circulation is affected, prompt evacuation is required.

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A fractured arm can be tied to the torso as a means of splinting, if the patient is not required to walk. This method is generally uncomfortable if used for long periods, and even small movements in the torso can cause further pain.

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ASSESSMENT

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• If the fracture involves the wrist, there may be general swelling, making it difficult to decide whether the injury is a fracture or a sprain. If in doubt, treat as a fracture.

• The bone may split rather than completely break (greenstick fracture), especially with children.

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MANAGEMENT

• Give the patient pain relief if needed.

• Remove watches and jewellery.

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• Straighten the injured forearm if necessary, to restore circulation (see page 102).

• Apply a splint to immobilise the fracture and the wrist.

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• Apply a sling to give support and to immobilise the elbow and wrist.

EXTENDED CARE AND EVACUATION GUIDELINES

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Evacuation will depend on the severity of the fracture and the degree of pain and shock. Some patients will be able to walk. Others will need evacuation.

Figure 9.10 Sling for a fractured arm or wrist

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FRACTURED FOREARM (BETWEEN ELBOW AND WRIST)

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Figure 9.11 Improvised arm slings

Figure 9.12 Elevation sling

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FRACTURED HAND AND FINGERS ASSESSMENT

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• The hand is usually swollen.

• Movement of the fingers may be restricted and painful.

MANAGEMENT

• Remove any jewellery.

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• Cover the injured hand with padding, secured with a gently applied bandage.

• Elevate the hand towards the opposite shoulder, and support it in that position with an elevation sling.

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• Give the patient pain relief.

Figure 9.13 Removing a ring

EXTENDED CARE AND EVACUATION GUIDELINES The patient should be able to walk out.

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FRACTURED PELVIS A fractured pelvis is usually associated with a fall, a severe blow or a crush injury. Complications include damage to underlying organs such as the bladder, and internal bleeding.

A patient with a fractured pelvis will exhibit some or all of the following signs and symptoms:

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ASSESSMENT

• General pain and tenderness

• Inability to walk or extreme difficulty walking

• Shock

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• They may not be able to pass urine, but if they do, note the time and if there was any blood in it

COMPLICATIONS

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Possible complications caused by a fractured pelvis are:

• Severe bleeding

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MANAGEMENT

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• Damage to organs in the pelvic area

• Because of the danger to adjacent blood vessels and the bladder, treat as for a spinal injury.

• Immobilise the trunk and tie the legs together to minimise movement.

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• Use a belt or broad bandage around the pelvis, just above the hips, to help stabilise the fracture.

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• The patient is usually most comfortable lying on his or her back with some support under the knees. • Give the patient pain relief if needed. • Treat for shock.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation.

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This is a serious injury. A lot of force is required to fracture a thigh bone. The patient may be in significant pain due to muscle spasms causing the bone ends to override. Broken femurs are potentially life-threatening, due to internal bleeding (the possible exception is a fracture of the neck of the femur, which is common in elderly patients).

ASSESSMENT

• The injured limb may be shorter than the other.

• The foot on the injured leg may be turned outwards.

• The general signs and symptoms of a fracture will be present.

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• The patient will usually be in shock and in significant pain.

Figure 9.14 Splinting a fractured thigh (femur)

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MANAGEMENT

• Give the patient pain relief.

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• Carefully remove footwear to check for circulation. • Have someone apply traction with a steady pull. The amount of the pull can be gradually increased until the muscle spasm releases, and then reduced to maintain traction without stretching. (Often it is not possible to overcome the muscle spasm.) DO NOT begin to apply traction unless you can maintain it – letting go will cause more pain as bone ends override. • Splint the leg to maintain traction. While traction is still being applied by hand, you can splint the leg by: • Placing one splint from the armpit to the foot and another from the crotch to the foot. Pad the ends and the natural hollows where the splints do not contact the body.

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FRACTURED THIGH (FEMUR)

• Tying the splints firmly in place, being careful not to restrict breathing with the tie across the chest. To get ties in place, gently push one end under the natural body hollows (use a slim object, such as a twig or pencil, to help) or attach a length of thin string onto the tie and then gently pull it into position. The ideal treatment for a fractured femur is a specialised traction splint that maintains traction. It requires training and experience to use, and even then it can cause circulation problems to the foot.

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It is possible to improvise a traction splint. If you ever need to apply one of these, try it out on another party member first.

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Improvised traction splint

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Figure 9.15 Placement of ties for traction splint

Find two strong poles (such as tent poles, paddles or walking poles), one measuring from the patient’s crotch to 50cm beyond their foot, the other measuring from the patient’s armpit to 50cm beyond their foot.

Splint the limb with closed cell foam or other suitable materials to provide support, padding and insulation (see figure 9.17).

Pad the top of the inside pole to protect the groin.

Anchor the outside pole to the chest, waist and hips using wide ties. Then secure a tie to the top of the pole, pass the tie between the legs and back to the pole. See figure 9.16a.

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Attach 2–3m of rope to the foot of the affected leg (see figure 9.15). Leave the boot on for warmth.

Secure a strong stick (such as a tent peg or ice screw) between the bottom ends of the two poles as a base.

Pass the two lengths of rope from the foot down around the base and back to the foot.

Insert a stick or carabiner between the rope. Then twist the rope until the patient feels their leg being stretched (see figures 9.16b and c). A lot of force is required to release the spasm of the thigh muscle, so ensure the poles are secured in place well.

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PADDING PADDING

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BIND SPLINTS TOGETHER

SKI POLES

PADDING

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(a)

CARABINERS

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10. Check for circulation to the foot by asking the patient to relate any sensations of numbness and tingling. If the patient is unconscious, loosen their boot and feel the temperature of their foot. If the skin is cold or pale, circulation is being compromised. (Consider cutting the toe of the boot off, to make checking circulation easier.) If necessary, modify or relax the traction splint periodically, allowing circulation to the foot.

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(b)

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Carabiners can be used to apply tension and clip onto ski pole to maintain traction.

(c)

Figure 9.16 Improvised traction splint

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation

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ANCHOR SPLINT FIRMLY AT WAIST

Tighten the traction as the thigh muscles relax and lengthen. Remember, loosening the traction can cause the muscle to spasm, drawing the broken bone ends together. This can be very painful, so once traction is applied, maintain it until emergency services can take over.

FRACTURED KNEE The kneecap can be fractured by a direct blow to the knee.

ASSESSMENT • The knee is usually very painful and swollen.

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• The patient may report hearing the kneecap ‘crack’.

• The kneecap may be difficult to locate.

MANAGEMENT

• Remove clothing from the injured leg.

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• Apply a cold compress to the knee if there is obvious swelling. Improvise with a bladder of cold water, or a bag of snow or cold dirt.

• Apply a splint to immobilise the knee, leg and ankle.

• Give the patient pain relief.

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Note: The knee is an important and delicate joint. Do not move it unless absolutely necessary.

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EXTENDED CARE AND EVACUATION GUIDELINES

The patient will not be able to walk, so arrange an evacuation.

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The patient’s legs can be tied together as a means of splinting. In remote settings, however, this should be a last resort. It is generally uncomfortable if done for long periods, and even small movements of the good limb can cause further pain. It will also make it difficult for the patient to go to the toilet.

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FRACTURED LEG (KNEE TO ANKLE)

The bones of the lower leg are the tibia and fibula. Fractures of either one, or both, are relatively common in the outdoors.

ASSESSMENT • The general signs and symptoms of a fracture will usually be present.

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• Circulation may be affected below the fracture site.

MANAGEMENT • Remove clothing from the injured leg.

• Give the patient pain relief.

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• If circulation is compromised, straighten the leg (see page 102).

• Remove the boot to check circulation to the foot.

• Apply a splint from mid-thigh to the foot. Ensure the knee and ankle are both immobilised.

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EXTENDED CARE AND EVACUATION GUIDELINES

Arrange an evacuation.

Boot off.

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Pad natural hollows and bones at knee and ankle.

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Pad leg. Pressure from splint can be painful.

Check circulation often. Put sock back on for warmth. Do not tie over knee as this is uncomfortable.

Figure 9.17 Splinting a fractured leg

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• If the ankle is fractured, there may be general swelling, and it can be difficult to tell whether the injury is a fracture or a sprain. If in doubt, treat as a fracture.

FRACTURED ANKLE OR FOOT ASSESSMENT • There is usually significant pain and swelling.

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MANAGEMENT

• Remove footwear and socks.

• Apply a cold compress if there is any obvious swelling. Improvise with a bladder of cold water, or a bag of snow or cold dirt.

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• Wrap the injured foot with thick padding (such as a towel or clothing), secured with a bandage.

• Elevate the limb above the heart to reduce swelling and pain.

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• Give the patient pain relief.

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EXTENDED CARE AND EVACUATION GUIDELINES Arrange an evacuation.

NOTE

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See page 128 for how to assess whether an ankle or foot is fractured or sprained.

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• It may be difficult to tell whether the injury is a fracture or a sprain. If in doubt, treat as a fracture.

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A joint is a mobile or fixed assembly of bones, ligaments, cartilage, tendon and muscle. Dislocation of a joint happens when enough force tears the restraining ligaments and the bones move out of their normal position. Dislocations of shoulders, fingers and kneecaps are common in the outdoors. Some people have loose ligaments due to previous injuries, leaving them prone to dislocations. Dislocations often result in injury to the supporting structures around the joints (such as ligaments). Dislocations can also be associated with fractures of the bones that they affect.

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• There is usually pain and deformity at the joint.

ASSESSMENT

• The signs and symptoms of a fracture may also be present. It is often difficult to distinguish between a fracture and a dislocation.

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MANAGEMENT

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As a general rule, you should not attempt to reduce the dislocation or manipulate the bone back to its normal position. The bone may be fractured and you can cause further damage by moving it. Blood vessels and nerves run close to joints and can be pinched or cut during manipulation.

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• Give the patient pain relief.

• Support the affected limb as appropriate. In some situations it may be possible to apply a supporting bandage or sling.

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• In the case of a dislocated shoulder, lay the patient face down on a table or rock with the affected limb hanging down. This position may ‘passively’ relocate the bone (figure 9.18). Place padding between the armpit and table and around the wrist. Attach a weight (such as a stuff bag full of stones or snow, or a billy of water) of about 4.5–7kg to the wrist. As the muscles fatigue and relax, the shoulder should slip back into place. The patient should not hold the weight – it should be attached to the wrist – as the arm needs to be as relaxed as possible. • If gentle traction on dislocated fingers and thumbs does not correct the deformity, treat the injury as a fracture. • If the knee cap is dislocated, it will be off to one side. Straightening the lower limb and applying a little sideways pressure at the same time will often pop it back.

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CHAPTER 9 | FRACTURES AND DISLOCATIONS

DISLOCATIONS

If circulation has been affected (a pulse cannot be felt below the injury, the limb appears cold or the patient feels tingling), the injury is serious and you need to arrange an urgent evacuation. Manipulation of the injury and/or applying traction is best left to those trained in the procedure. If you have means of communication, ask for specialist medical advice from the rescue service.

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Patients with dislocations affecting the shoulder, elbow, hips or any joints in the lower limbs will need to be evacuated and assessed by a medical professional as soon as is practical. Even if the bone has gone back into its usual position, a medical professional needs to assess the patient for potential nerve damage.

EXTENDED CARE AND EVACUATION GUIDELINES

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Padding or gloves under belt

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Patients with dislocated fingers, thumbs or toes should be able to walk. If the dislocation is reduced and pain subsides within a few hours, they can continue with the activity. If the pain continues, they should seek medical advice as soon as practical.

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Stuff sack full of water bottles, wet sand etc. About 4½–7kg

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Padding

Figure 9.18 Reducing a dislocated shoulder

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Webbing or belt, pack straps, etc

CHAPTER 11 | BURNS

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SOFT TISSUE INJURIES

CHAPTER 10:

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IN THIS CHAPTER:

SPRAINS 129

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STRAINS 132

TENDONITIS 132

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EXTENDED CARE AND EVACUATION GUIDELINES

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PHOTO Samantha West

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CRAMP 134

127

Soft tissue refers to muscles, tendons (fibrous cords attaching muscle to bone) and ligaments (tough fibrous bands connecting the bones at joints). Soft tissue injuries caused by slipping, tripping, lifting, twisting or falling are common in the outdoors.

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The most difficult part of dealing with a soft tissue injury in a remote setting is determining the severity of the injury. It can be impossible to identify bone fractures or damage to important structures (such as ligaments) because of the complexity of joints and the swelling associated with some sprains. If in doubt, treat the injury as a fracture.

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1. Push down against my hand.

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2. Pull up against my hand.

3. Push out, pull in against my hand.

4. Weight-bearing test: Apply firm pressure under the heel to assess injury without the patient having to stand up. 5. Wiggle toes. 6. Palpate around the ankle joint. 7. Pain scale 1–10. If 7 or more and unable to bear weight, treat as a fracture.

Figure 10.1 Assessing severity of a sprain

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SPRAINS rp

Rest

Icy cold

Compression

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Elevation

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Figure 10.2 Treating a sprain

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A sprain occurs when sudden twisting or wrenching of a joint tears ligaments and/or tendons. Ankle and knee sprains are common in the outdoors. They range in severity from very mild to requiring surgery and a long rehabilitation. Even a moderate sprain can take up to 6 weeks to heal.

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ASSESSMENT

A person with a sprain will exhibit some or all of the following signs and symptoms:

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• The joint is swollen and discoloured (dark red or bruised).

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• The joint is painful and tender.

• There may be loss of function of the joint.

MANAGEMENT Use the RICE treatment: • Rest: Stop any movement to prevent further injury. • Icy cold: Apply something cold to the area as soon as possible to help reduce swelling and to relieve pain. Apply a cold compress, such as a cloth soaked in icy water or cold mud in a plastic bag, or immerse a sprained ankle in a stream. Do not use ice or anything frozen as it can damage the tissues. Keep the area cold for 20 minutes. Cold cloths warm up quickly, so keep changing them or adding more cold water.

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If the injury is minor and the patient can keep walking, let them do so. If the pain increases, you should assume the injury is serious and/or getting worse. In this case, remove the boot and follow the RICE treatment (see below), or treat the injury as a fracture if you are in doubt. If the boot is left on, and swelling increases, circulation can be impaired and difficult to assess, and removing the boot becomes difficult and painful.

• Elevation: Elevate the limb to help reduce swelling.

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The aim is to reduce swelling, not prevent it. Swelling is the body’s natural reaction to trauma. It brings extra blood and tissue-healing materials to the area to help healing, and it immobilises the area. However, too much swelling can cause circulation and nerve problems.

Figure 10.3 Taping a wrist to reduce movement – never tape in a full circle around limb

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• Compression: Move the foot and ankle, or hand and wrist, into the neutral position and apply a compression bandage that covers the injury site completely. The aim is to help reduce swelling and to provide support. The neutral position is the most comfortable position, because it requires no muscle strength to hold. If the foot is turned inwards, start the bandage from the inside, bringing it over the top of the foot towards the outside. This helps support the foot in its neutral position. The bandage needs to be firm but not too tight, allowing circulation past the injury. A sprained joint may continue to swell, so remove any jewellery and check circulation. Use a combination of icy cold and compression if you can, removing the cold after 20 minutes and reapplying a dry bandage.

Anchor – used to provide firm base to attach other straps to.

Stirrup – a vertical U-shaped piece of tape supporting either side of the joint. Pull firmly in the opposite direction to the way the ankle rolled. Tape half way up the calf.

Spur – horizontal piece of tape that holds stirrup in place.

Overlap stirrups and spurs until ankle is well supported, approximately 3–6 stirrups, depending on width of tape.

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Note: Always leave gaps rather than taping in a full circle around the limb. This allows for swelling and reduces the risk of cutting off circulation.

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Figure 10.4 Strapping an ankle

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CHAPTER 10 | SOFT TISSUE INJURIES

Strapping an ankle

STRAINS Strains occur when muscle tissue is suddenly over-stretched and torn.

ASSESSMENT • The injured muscle is painful and tender to touch.

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• Normal movement is painful.

• There may be redness, bruising and swelling at the injury site.

MANAGEMENT

Use the RICE treatment described in the sprains section (see page 129).

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After a few hours rest, the patient may be able to use the injured muscle, although it may take weeks before it is strong again.

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TENDONITIS

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Tendonitis is an inflammation of a tendon and the surrounding sheath, caused by overuse. The sheath becomes rough, and the patient can feel a grating of the tendon. This inflammation restricts the patient’s movement of the tendon. The injury is painful and heals slowly.

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Common injury sites for trampers are the Achilles tendon that connects calf muscles to the heel, and the tendons on the front of the foot. People who use kayak paddles, ski poles or ice axes may experience problems with tendons in their forearms.

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ASSESSMENT • The area may be warm. • A ‘crackling’ sensation is felt under the skin when the tendon is being used. • There may be some swelling. • The tendon is painful when used.

MANAGEMENT • Use the RICE treatment described in the sprains section (see page 129). • The ideal treatment is to stop using the affected tendon, but this is not always an option in the outdoors.

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• Loosen the boot laces if the injury site is the foot. • Tape the wrist and hand to limit movement if the injury site is the forearm. A spoon taped to the palm and wrist makes an effective splint.

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• Give the patient anti-inflammatory medication, such as ibuprofen (Nurofen) or diclofenac (Voltaren) if needed.

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EXTENDED CARE AND EVACUATION GUIDELINES fo

For all soft tissue injuries:

• Give the patient pain relief.

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• Keep the compression bandage on and keep injured limbs elevated whenever possible.

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• Follow the RICE treatment every four hours for 48 hours. If the patient can walk with minimal pain, use the RICE treatment during rest breaks. If the patient cannot walk, use the RICE treatment every four hours while resting in camp. • Reassess the injury after 48 hours. If the patient is still having difficulty using a joint, treat the injury as a fracture.

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• If the ankle or knee is injured, and the patient can walk, strap the joint to provide extra support.

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• If the ankle, knee or hip is injured, and the patient cannot stand and walk on the injured limb, arrange an evacuation.

REMEMBER The progress of your entire party will be slowed by an injured person. The time of day, the weather and the distance to shelter or the road end will help you decide whether or not to evacuate.

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• If the injury site is the Achilles tendon, try to relieve the stretch on the tendon by placing something inside the patient’s boot to lift the heel. If the boot is putting pressure on the tendon, place a strip of closed cell foam, about 3cm by 15cm, on either side of the tendon. This will help take the pressure off the tendon without touching it.

CRAMP

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Cramp is a sudden and painful contraction of muscles. It may be caused by muscle fatigue during or after exercise, loss of salts from the body (for example, through sweating, especially in hot weather) or injury. Cold conditions may cause muscles to fatigue faster, therefore increasing the chances of cramp.

Currently cramp is not well understood and there are many conflicting theories on cause and treatment.

ASSESSMENT

A person suffering from cramp will exhibit some or all of the following signs and symptoms:

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• Sudden pain and contraction of one or more muscle groups.

• The cramped muscles may appear knotted and feel hard and tight.

MANAGEMENT

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• Gently stretch the muscle to overcome the contraction.

• Massage the muscle to help prevent further cramping.

• If necessary, keep the area warm by putting on more clothing.

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• Rehydrate the patient by giving them isotonic drinks (see page 206).

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CHAPTER 11 | BURNS

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CHAPTER 11:

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BURNS bl

IN THIS CHAPTER:

137

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ASSESSMENT

MANAGEMENT 138 142

PHOTO Kerry Adams

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EXTENDED CARE AND EVACUATION GUIDELINES

135

In the outdoors, burns can be caused by accident with stoves, fires, boiling liquids, rope, chemicals (for example, from leaking batteries) and the sun. Burns can be categorised into five main types: • Thermal – caused by fire, hot liquids or objects, friction and flashes of heat. Severe cold can cause burns similar to thermal burns • Inhalation – caused by breathing in hot air, gases or particles

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• Radiation – usually caused by sunburn

The skin has various functions including:

• Temperature regulation

• Sensation and touch

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• Barrier to infection

• Control of fluid loss

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When skin is burnt, all these functions are compromised. Fluid loss can lead to shock. The amount of lost fluid will be in proportion to the size of the burn. The lost fluid can be seen weeping from the burn or collecting in blisters. The chance of infection increases with the size of the burn, as a burn is an open wound.

Figure 11.1 Burn injury

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• Chemical – caused by contact with alkalis or acids • Electrical – caused by an electrical current, such as lightning entering and exiting the body

CHAPTER 11 | BURNS

ASSESSMENT The severity of a burn is measured by the: • Area of the burn relative to the total body surface area (TBSA) • Depth of the burn • Location of the burn

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A burn is considered to be severe if:

• It involves the hands, feet, genitals or face.

• It covers more than 10 percent of the TBSA for adults or 5 percent for children.

• The patient has other significant injuries or illness.

• The airway is burnt due to inhalation burns.

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Adult

BACK 18%

• The patient is very young or elderly (under 6 or over 65).

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SURFACE AREA OF BURN

BACK 18%

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Infant

There are two methods of assessing the surface area of a burn. • Rule of nines: The body is divided into 11 areas of 9 percent. (See figure 11.2). • Hand method: The surface area of a person’s palm is approximately 1 percent of their TBSA. For example, a burn the size of 5 palms is approximately 5 percent of their TBSA.

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It is useful to calculate the percentage of the TBSA burnt as this is the largest factor in determining the degree of shock that is likely to be associated with the burn. If more than 20 percent of the TBSA is burnt, every organ in the body is affected and the patient can take months to recover. Figure 11.2 Rule of nines (estimating the surface area of a burn)

137

DEPTH OF BURN The depth of a burn is usually described as: • Superficial (partial thickness): Only the outer layer of the skin is burnt. The skin will be painful, red and possibly blistered and swollen.

• Deep (full thickness): The full thickness of the skin is burnt. Nerves, blood vessels and underlying structures may be damaged. A deep burn will be painless and will appear waxy or charred.

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LOCATION OF BURN

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Except for minor ones, burns to the face, hands, feet and genitals are always serious and require medical attention. Burns to the face may also indicate damage to the airway. A burnt airway can develop into a critical situation in a matter of hours because swelling causes narrowing of the upper airway, making breathing difficult.

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Circumferential burns (burns that go all the way around a body part) are also serious because swelling will affect circulation and nerves. Burns encircling a limb can limit movement, and burns encircling the chest may restrict breathing.

NOTE

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Use the mnemonic SCALD to assess the severity of a burn: Size, Cause, Age of patient, Location of burn, Depth.

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MANAGEMENT at

• Stop the burning.

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• Remove the patient from the burning or the burning from the patient. • Treat any airway, breathing and circulation problems.

• Quickly remove anything that retains heat, such as watches, rings, clothing and boots.

• Cool the burn area with water (cool, not ice cold) for 20 minutes. This prevents the heat penetrating further into the skin layers, causing more damage. You may need to cool the area for longer. Check with the patient that the area no longer feels hot. • Try to avoid immersing the patient or getting un-burnt areas wet – you do not want to cause hypothermia.

138

• If water is in short supply, recycle it by collecting in a raincoat or plastic bag.

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• If the only way you can cool the burn is by using cold, wet cloths, remember that they will heat up quickly and need to be replaced frequently.

Ideal: Cold running water for 20 minutes.

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Recycle for 20 minutes

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Figure 11.3 Cooling a burn

• After cooling, cover the burn area lightly with a sterile dressing or clean absorbent coverings. Cling film is an effective covering, but do not wrap film right around a limb, as it may become tight as the area swells.

• Burns can be very painful due to the nerves being exposed to the air. The patient may think that the area is still burning, even if it has been sufficiently cooled. Immediate covering of the area will help. • Swelling is not limited to the burn area so remove rings from fingers when legs are burnt. • Place padding between burnt fingers and toes. • Elevate burnt limbs above heart level to help relieve swelling. • Treat the patient for shock.

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CHAPTER 11 | BURNS

• If the only water supply is unclean, cover the burn with cling film or a plastic bag before pouring the water over it. Infection is a major problem with burns.

• Give the patient sips of fluid to help replace lost fluid and to prevent dehydration and kidney failure. • Give the patient pain relief. • If you are 24 hours or more away from medical assistance, place paraffin gauze between the patient’s fingers and toes to prevent the skin sticking together. Also use paraffin gauze on surfaces where skin layers have been removed and you do not want a dry dressing to stick to or become embedded in the burn.

What not to do:

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• Do not remove clothing stuck to a burn – cut around it.

• Do not break burn blisters – they create a barrier to infection.

• Do not apply creams or ointment – they trap bacteria on the burnt skin and will have to be scrubbed off if the area becomes infected.

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• Do not use up all your water if it is limited – dehydration will be a safety consideration for all the party members. Recycle the water you are using to cool the burn.

• Do not put ice directly on the burn as this can cause more swelling and/or frostbite.

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INHALATION BURNS

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Inhalation burns cause the same problems as burns to the skin – swelling, blisters and leaking fluid. Swelling of the airway can occur and fluid may build up in the lungs. Signs and symptoms of breathing difficulty may appear for up to 48 hours.

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• Look for singed face, lips, facial hairs or nasal hairs. • Check the mouth and throat for redness, swelling and soot.

• Check for signs of breathing difficulty; hoarse croaky voice; coughing; and noisy, rapid breathing.

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• Maintain the airway (see page 32).

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• Give the patient something cold to suck on. This may delay swelling of the mouth and tongue. • Arrange an urgent evacuation. Even if the patient is breathing well straight after the accident, the airway is likely to swell.

140

• Read and follow emergency care instructions on the chemical container. • Brush off any dry chemical, while maintaining your own safety. • Remove anything that may retain the chemical, such as contact lenses, jewellery and clothing.

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• If there are no specific emergency care instructions or you do not have the chemical container, flush the burn copiously with water for at least 20 minutes. For a larger burn, flush for longer.

ELECTRICAL BURNS

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With a low voltage (less than 1000V) burn, the skin may be burnt where the current entered and exited the body. The electrical current can also cause extensive injury to internal organs. Both low and high voltages can cause heart problems.

• Beware of your own safety first. Electrical currents can jump short distances without direct contact: 1000V can jump a few millimetres; 40,000V can jump more than 10cm.

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• Use non-conducting materials (such as wood or plastic) to move the patient from danger. Do not touch them until you are sure it is safe to do so.

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• Treat any surface burns.

• Closely monitor the patient’s ABCs – there may be internal damage. • Arrange an evacuation.

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Note: Lightning (high voltage burns) is covered in chapter 13.

SUNBURN

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Avoid sunburn by wearing a wide-brimmed hat, covering up and using sunblock. Remember that reflected glare from water and snow causes sunburn, too.

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Severe cases of sunburn can cause shock, due to the loss of fluid associated with blisters. The burn can become infected. If the patient has sunburn with blisters over a large surface area (see page 137 for burn assessment), treat as a severe burn. • Apply cooling lotion or cream only if the skin is not blistered. • Discourage the patient from licking their lips if they are cracked and dry, as the moisture evaporating off them dries them more.

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CHAPTER 11 | BURNS

CHEMICAL BURNS

EXTENDED CARE AND EVACUATION GUIDELINES Minor burns should be treated the same as a wound (see chapter 12) to prevent infection.

• Try to keep the patient as comfortable and pain-free as possible.

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• Put the patient in the shock or recovery position.

• If the patient is conscious, give them regular small sips of fluid to offset dehydration due to fluid loss. Isotonic drinks, if you have them, are preferable, as they replace the body’s natural salts.

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• Give the patient pain relief, but not anti-inflammatory medications such as ibuprofen (Nurofen) and diclofenac (Voltaren) as they can damage the kidneys of a dehydrated patient.

If the patient is suffering from shock, they may not absorb fluid or pain relief, and they may vomit.

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People with severe burns need medical help as quickly as possible. Do not be misled by a patient in an apparently stable condition shortly after they were burnt. Do not underestimate burns in an outdoor environment, as complications occur quickly.

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Arrange an urgent evacuation when:

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• More than 10 percent (adults) or 5 percent (young and elderly) of the TBSA is burnt. • There are burns to hands, face, feet or genitals.

• The patient has inhalation, chemical or electrical burns.

• There are other significant illnesses or injuries.

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If in doubt, get them out.

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CHAPTER 11 | BURNS

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CHAPTER 12:

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WOUND CARE AND INFECTION va

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IN THIS CHAPTER:

145

HYGIENE AND PERSONAL SAFETY

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ASSESSMENT 145

MANAGEMENT 146

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INFECTED WOUNDS 149

WOUND DRESSINGS 150

EXTENDED CARE AND EVACUATION GUIDELINES

152

MANAGEMENT OF SPECIFIC WOUNDS

152

PHOTO Léonce Jones

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WOUND CLOSURES 151

143

This chapter covers the general care of wounds, management of specific wounds, and identifying and treating infection. The control of severe, life-threatening bleeding and internal bleeding is described in chapter 6. A wound is an injury that damages the skin and/or underlying tissue. A wound may be: • OPEN with broken skin and blood easily seen • CLOSED where the bleeding is under the unbroken skin

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• Cuts (incisions) – usually caused by a sharp object cutting the skin cleanly

Types of wounds include:

• Tears (lacerations) – usually caused by something sharp, such as barbed wire, causing a torn or ragged wound

• Grazes (abrasions) – occur when skin is scraped away

• Bruises – or bleeding under the skin caused by falls or knocks

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• Punctures – caused by a sharp object penetrating the skin. Punctures can carry infection deep into the tissues

• Avulsions – or the tearing away of skin and tissue, leaving a flap held on by skin, muscle or tendon

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• Crush – caused by blunt force that can damage underlying organs and cause internal bleeding (see chapter 6 for more information)

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• Blisters – caused by friction

Flap of skin

Figure 12.1 Types of wounds

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CHAPTER 12 | WOUND CARE AND INFECTION

Complications of wounds include: • Blood loss and shock • Infection • Swelling, which may affect circulation

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HYGIENE AND PERSONAL SAFETY

• Loss of sensation and function

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Diseases such as HIV, Hepatitis B and Hepatitis C can be spread when infected blood or body fluids enter another person’s body via cuts and scratches. Unbroken skin forms a natural barrier to this method of infection.

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Never risk infection of yourself or your patient through contact with another person’s blood or body fluids. You may not know if your patient has a blood- or fluid-borne disease and they do not know if you do either. You may have tiny cuts to your skin that you are not aware of. Protect yourself and your patient by using surgical gloves, cling film or plastic bags. If possible, get the patient to apply direct pressure to their wound, while you cover your own skin with gloves. Wash your hands thoroughly after treating a wounded patient.

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In snow, gloves can be impractical as they are slippery and cold. However, do your best to protect yourself.

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ASSESSMENT In fo

In the outdoors, you should assess a wound to determine what treatment is needed and whether to continue the activity, rest or evacuate. Assess the wound by asking yourself the following questions: • How big is the wound? Large open wounds are difficult to keep clean in the outdoors. They bleed and weep a lot, increasing the risk of infection and shock. • How dirty is the wound? Foreign matter embedded in wounds carries bacteria, which can cause infection. • How deep is the wound? Deep wounds can affect underlying structures and are difficult to keep clean.

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• Could there be damage to underlying blood vessels, organs, bones, joints and muscles? Is the patient’s use of their hands and feet affected due to damaged tendons or nerves? • Where is the wound? Can the patient walk? Will movement prevent the wound from healing? Can it be easily knocked? Does it involve the hands, and therefore restrict the patient’s ability to care for themselves?

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• When was the patient’s last tetanus injection? Tetanus can occur 1–60 days after infection. Tetanus vaccinations are usually given as part of childhood immunisations and again at ages 11, 45 and 65, and after major trauma or deep penetrating wounds in a dirty environment. Check with your doctor if you are unsure when you were last vaccinated.

• Is there circulation, sensation and movement below the wound site?

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MANAGEMENT bl

CLOSED WOUNDS

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• Assess the patient’s airway, breathing and circulation. Sit them down and reassure them. Watch for and treat signs and symptoms of shock (see page 64).

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• Cool the affected area for 20 minutes. Pads soaked in cold water work well but warm up quickly, so keep changing them or adding more cold water.

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If the wound is on a limb, elevate the limb above the heart and support it to reduce bleeding and swelling.

OPEN WOUNDS

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• Assess the patient’s airway, breathing and circulation.

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• Stop severe bleeding immediately, by asking the patient to apply direct pressure. Sit them down and reassure them. Watch for and treat signs and symptoms of shock (see page 64). • Stop bleeding by applying direct pressure or, if there is an embedded object, by applying pressure around it. • Bandage the wound with a clean dressing or pad, pulling the edges of the wound together. If bandages are not easily accessible, use what you can – a clean handkerchief, clean clothes or the patient’s hands. Clean toilet paper, tissues or sanitary pads will also do. Due to possible infection, use your own hands as a last resort and only if wearing gloves.

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• Follow the instructions for severe external bleeding on page 74. • Tape the dressing firmly in place when the bleeding has stopped. If the wound is on a limb: • Elevate and support the bleeding limb to help reduce bleeding and swelling.

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• Apply a compression bandage – a bandage wrapped firmly around the wound, extending above and below the wound.

• Swelling may occur, making a firm bandage tight, so check the circulation below the wound every 10 minutes. Remove any jewellery or watches from the affected limb immediately after applying pressure.

Elevate limb. Apply compression bandage. Swelling may occur, so remove jewellery. Treat for shock. Check capillary refill every 10 minutes.

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• Prevent the patient moving the limb by splinting it. This will help to prevent the clots breaking up.

Figure 12.2 Managing a wound

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CHAPTER 12 | WOUND CARE AND INFECTION

• The bleeding will stop when a clot has formed. This can take 5–15 minutes. Damaged blood vessels automatically constrict, slowing down the blood flow to help the clot form. So be careful not to disturb this process by moving the injured part.

CLEANING THE WOUND

Flush wound with lots of water.

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You need to clean the wound, and keep it clean, to prevent infection. An infection that starts in a wound may spread to the skin (cellulitis), under the skin (fasciitis) or into the blood stream (septicaemia).

Most superficial cuts and grazes need only to be kept clean, dry and covered. Once you have dressed the wound, check it regularly for signs of infection, changing the dressing daily or when it becomes wet or dirty.

Use body temperature water, not icy.

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Blood flowing from the wound starts the cleaning process by removing some dirt and bacteria. It is not generally necessary for you to clean the wound if the patient will be receiving medical attention within 2 hours.

To clean a wound:

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Figure 12.3 Cleaning a wound

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Note: Do not attempt to clean the wound if it is life-threatening, or if there is severe arterial bleeding that is hard to control, as the bleeding may start again.

Thoroughly wash and dry your hands.

Make sure the bleeding has completely stopped.

Wash around the wound site with soap and water.

Wash the wound by gently pouring body temperature water over it. This should flush out any bacteria and dirt.

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Brush out any leftover dirt and particles with gauze or another material that will not leave fibres behind.

Rinse the wound again with saline. If you are carrying salt, make a saline solution by adding 1/3tsp of salt to 1 cup of water, or 1tsp of salt to 1L of water. If saline is not available, use clean, fresh water. The most effective way to clean a deeper wound is to irrigate it with a syringe.

Dry around the wound, and cover it with a sterile dressing held in place by a bandage or tape.

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INFECTED WOUNDS on l

Infected wounds can be recognised by:

• Increased tenderness around the wounded area

• Redness and heat spreading around the wound

Swollen lymph nodes in armpit or groin

• Pus and an unpleasant smell

• Red lines tracking away from the wound

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If a wound becomes infected:

• A high temperature, with the patient sweating and shivering

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• Swollen lymph nodes in the armpit or groin

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• Soak the infected area in warm water (40– 45°C) three or four times a day to encourage blood to flow to the area.

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• Change the dressings every time you soak the area.

Red lines streaking away from wound

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• Give the patient paracetamol to reduce a high temperature. Red around wound Heat

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• Use a pen to mark where the red tracking or red area extends to and record the time. Note if the red area is increasing and how fast.

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• Seek medical attention and antibiotics if the infection does not decrease.

Septic shock is caused by a severe bacterial infection and can be life-threatening. See page 64.

Figure 12.4 Infected wound

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Once the wound is dressed, the patient should minimise any movement of the wounded area to promote healing. Clean the wound and change the dressing daily or when it becomes wet or dirty. It is normal for a healing wound to be red, tender and hot, but look out for signs of infection.

WOUND DRESSINGS Dressings are applied to wounds for several purposes: • To help apply pressure on a bleeding wound • To keep infection from entering the wound • To absorb blood and other matter from the wound

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• To protect the wound from further damage

• Sometimes, simply to reassure the patient

Wound dressings need to be sterile, non-adhesive and lint-free. Materials like cotton wool will leave fibres in the wound and should not be used. There are many different types of commercial wound dressings available:

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• Sterile dressings come in a range of sizes. They should be used as the first cover on the wound, as they help prevent infection and will not stick to the skin. Note that all sterile dressings have an expiry date, and that the contents of any package that is broken or torn will no longer be sterile.

• Gauze has good absorbent qualities, but it will stick to an open wound. Use gauze on top of a non-stick dressing to absorb blood and other matter.

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• Rolled crepe bandages can be used as dressing pads, as well as for holding pads in place on limbs.

• Triangular bandages can be folded to the size needed for a dressing.

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• Paraffin gauze is mostly used when skin layers have been removed, resulting in bleeding or moist surfaces, and for blisters, when you do not want a dry dressing to become embedded in the wound. To use paraffin gauze: Clean the wound thoroughly.

Cover the wound with paraffin gauze.

Place an absorbent pad over it.

Secure the dressings with a bandage or tape.

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Clean the wound and change the dressing daily. If the paraffin gauze sticks to the wound, moisten it with saline solution to make removal easier.

• Non-absorbent, non-adhesive dressings are excellent for blisters and small wounds. Individual strip dressings can also be used on small wounds, as long as the sticky part is not on top of the broken skin. • Sticking plaster and tapes can be used to hold dressings in place. You may need to improvise with what you have in your pack, for example, clean handkerchiefs, sanitary pads, clean clothing or pack towels.

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WOUND CLOSURES Wound closures are used if the wound is minor and superficial. Remember, a wound that is closed cannot drain, allowing a rapid build-up of infection underneath the closed skin. Do not use closures:

• If the wound is deep

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• If the edges of the wound do not match – this may cause a scar

• In moist areas, such as the armpit or groin

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• On body parts with a lot of movement, such as joints • If the wound is not completely clean

Figure 12.5 Wound closures

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For superficial wounds, you can use butterfly closures (buy in packs or cut your own), zinc oxide tape or Mefix. Insulation or duct tape can also be used.

To apply wound closures:

Wash and dry the wound and surrounding area, taking extra care and time with skin flaps.

Apply half the closure to one side of the wound. Then draw the skin together, sticking the other half of the closure to the skin on the other side of the wound.

Start the next closure on the opposite side of the wound.

Work from one end of the wound to the other, drawing the skin edges together evenly.

Leave gaps between the closures to allow any blood or fluid to drain away.

Cover the wound with a dressing, change it daily and watch for infection.

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When caring for wounds, good hygiene is essential to prevent the spread of disease and infection. Before starting to clean and dress the wound, gather all the materials you need, keeping everything as clean as possible. Wash your hands thoroughly before and after you care for the wound. Use disposable gloves or cover any cuts on your hands with a waterproof dressing. Dispose of all used dressings safely, preferably by burning (unless you are in a high fire-risk area), to prevent the spread of infection.

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EXTENDED CARE AND EVACUATION GUIDELINES Evacuate all patients with: • Severe blood loss

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• Large wound areas

• Infected wounds

• Amputations

The urgency of the evacuation will depend on the degree of shock and the size of the wound. Infection will be a major risk.

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Before evacuation, treat the patient for shock and keep them warm. Handle them gently so as not to disturb the wound. Do not remove the dressings, as this could disturb the wound and restart the bleeding.

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Give the patient pain relief and sips of fluid if they are fully conscious. If the patient is unconscious, place them in the recovery position and monitor their vital signs.

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MANAGEMENT OF SPECIFIC WOUNDS io n

CHEST WOUNDS

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Assessment and management of chest wounds where the chest cavity and/or lung has been penetrated is covered on pages 58–59.

AMPUTATION

In some cases, surgeons may be able to re-attach an amputated body part in hospital. For this to be successful, it is important that you take appropriate care of the amputation site and the severed body part. • Treat the bleeding and wound as described on page 146. • Do not try to clean, or put anything on, the severed body part. This can damage the tissue beyond repair. • Place the body part in a clean plastic bag to keep it clean and dry. Clearly label the bag with the patient’s name and the date and time of the amputation.

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• Arrange an urgent evacuation.

IMPALED/EMBEDDED OBJECTS

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• Remove the object if it is small, loosely embedded and can be easily removed.

Impaled/embedded objects can range from small splinters to speargun arrows.

• Leave a large embedded object in place. Removal may cause severe bleeding and further injury.

• Stabilise a large embedded object by placing padding around it. If possible, build up the padding to just over the height of the object, so that a bandage can be placed over the injury without putting any pressure on the object.

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• Immobilise the injured body part.

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• Arrange an evacuation.

Twist bandage into ring.

Hold in place by bandaging over ring and embedded object.

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Figure 12.6 Stabilising an embedded object

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• Wrap insulating material around the bag, and keep it cool by wrapping the sealed bag in another bag filled with cold water and ice. The amputated part must be kept dry.

FISH-HOOK WOUNDS The risk of infection from fish-hooks is very high. If the hook is only superficially embedded, you should remove it.

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• If the barb has gone through skin but is close to the skin surface, and you have something (for example, pliers) to cut the barb, gently push the hook further in following the curve of the hook until the barb comes through the skin. Cut the barb off, and withdraw the hook (see figure 12.7a).

• If the barb of the hook has not penetrated the skin, and the hook is close to the skin surface, carefully pull the hook out.

String-jerk technique

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Cut off barb, then remove hook.

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Figure 12.7 Removing fish-hooks The string-jerk technique is another method to remove the hook (see figure 12.7b). Loop a length of string about 30cm long around the curve of the hook and wrap the ends around your index finger. Push down on the eye and shank of the hook with your free hand to disengage the barb. Align the string with the long axis of the fish-hook, and give it a jerk; the hook will come out easily. As the barb follows in the shadow of the hook, there is minimal pain. After removing the hook, thoroughly clean the area and treat as for an open wound. The patient may need a tetanus injection and antibiotics. If the hook is more than superficially embedded, treat it as an embedded object, and arrange an evacuation.

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Varicose veins are caused by the valves inside the vein failing, creating pressure on the good valves. Sometimes even a minor knock can break a varicose vein, causing it to bleed profusely. Varicose veins are most common on the legs. Wearing gaiters can protect the legs. If a varicose vein ruptures: • Apply pressure directly over the site.

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• Lay the patient down, reassure them, and treat them for shock. • Elevate the affected limb above the heart.

• Manage as for a general wound (see page 146).

• Once the bleeding has stopped, the patient needs to rest, discontinuing any physical activity. Any activity or movement may cause bleeding to restart.

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• Arrange an evacuation.

ABDOMINAL WOUNDS

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Treat abdominal wounds as for general wounds unless the wound has extended through to the abdominal cavity. If this has happened, abdominal organs may protrude and may be damaged. There is a high risk of infection.

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• Position the patient so they are lying or semi-sitting with their knees raised to relieve tension in the abdomen.

Raising knees relieves tension in abdomen

Figure 12.8 Managing an abdominal wound

• Do not try to forcibly replace any organs. Gentle traction on the puncture site may, however, allow the displaced abdominal contents to return to their normal position. To apply traction, gently lift up the edges of the wound using tweezers or spoons that have been sterilised in boiling water. • Cover the wound with a clean, damp dressing, plastic bag, foil, survival blanket or plastic cling film. • If the patient is unconscious, place them in the recovery position and treat as above. • Arrange an urgent evacuation.

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RUPTURED VARICOSE VEINS

Gunshot wounds usually have a small entry hole with a much larger exit hole. A bullet can cause severe damage to blood vessels, internal organs, muscles, nerves and bones. Damage depends on where the bullet enters and the part of the body it travels through.

GUNSHOT WOUNDS

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Small entry hole

• Check the patient’s ABCs and treat them for shock.

• Do a thorough head-to-toe check for other injuries as bullets can ‘bounce’ and damage other areas.

Larger exit hole

Internal damage

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• Check for both entry and exit wounds. Treat them as for general wounds.

Figure 12.9 Gunshot wound

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• Arrange an evacuation.

SCALP WOUNDS

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The scalp is fairly thin, with many blood vessels. Wounds to the scalp bleed a lot, and because the scalp is stretched over the skull, they also gape, sometimes making the wound appear worse than it is.

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• Check for any skull fracture. • Treat as for an open wound.

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• You may need to maintain direct pressure after the bandage has been applied, as it is difficult to bandage the head with sufficient pressure to control bleeding. DO NOT apply direct pressure if there is a skull fracture.

• If possible, sit the patient upright as this will reduce bleeding.

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NOSE BLEEDS

Nose bleeds can be caused by sneezing, blowing the nose, an increase in altitude, a direct blow or changes in temperature. • Check for a skull fracture and a broken nose if the nose started bleeding after an accident. • Sit the patient up, leaning forward. Remember that swallowing blood may cause the patient to vomit. • Apply direct pressure by pinching the nostrils just below the bony part of the nose. If the nose is broken, slow the bleeding by applying a cold compress rather than direct pressure.

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• After 10 minutes, release the direct pressure, but reapply immediately for another 10 minutes if the bleeding has not stopped. • When the bleeding has stopped, allow the patient time to rest. Advise them not to blow their nose or disturb the clot. Exertion may also disturb the clot. If bleeding does not stop after 1 hour or the estimated blood loss is more than a cup (250ml), arrange an evacuation, as medical attention may be needed.

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EAR BLEEDS

Bleeding from inside the ear occurs when the eardrum is perforated. This usually happens with sudden pressure changes (such as diving or going to higher altitude quickly). Perforation of the eardrum is more likely if the patient has hay fever, a cold or an ear infection. Straw-coloured fluid coming from the ear is usually from an infection and may indicate that the eardrum is perforated.

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Following trauma, straw-coloured fluid leaking from the ear could indicate a fractured skull. Cerebrospinal fluid mixed with blood does not clot.

• If the patient is conscious, sit them down with their head leaning towards the injured side, allowing the fluid to drain.

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• If the patient is unconscious, place them in the recovery position, injured side down.

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• Cover the ear with a clean dressing to help prevent infection getting into the ear canal. • Never plug the ear, as this can cause a build-up of pressure on the brain.

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• Arrange an evacuation.

MOUTH BLEEDS

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If bleeding from inside the mouth is caused by a broken jaw, follow the treatment for fractures. Otherwise:

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• Position the patient with the head forward and, where appropriate, leaning the head towards the injured side. Remember that swallowed blood may cause vomiting. • Have the patient apply a small pad over the bleed. (Larger pads may cause the patient to gag.) Mouths are very slippery, so direct pressure may need to be applied by pressing on both the inside and outside of the cheek or lips, or by holding the top and bottom of the tongue. • If the patient is bleeding from a tooth socket, apply direct pressure for 10–20 minutes. If this does not stop the bleeding, remove the dressing very gently so as not to disturb the clotting, and use a fresh dressing to maintain pressure for another 10 minutes. • Have the patient rinse and spit with sips of water or saline, to rinse mouth out.

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• Apply a cold compress to the nose and forehead.

BLISTERS

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Try to prevent blisters on the feet by taping possible trouble spots and by wearing the right size boots and socks. Keep boots firmly laced. Keep socks free from grit. Keep feet and socks dry, if possible, changing socks after river crossings. Remove wet boots and socks during rest breaks and when you stop to make camp.

Blisters are caused by friction. They can turn a great outdoor trip into a miserable experience. Even a short walk with ill-fitting boots can cause painful blisters and therefore delay the party’s progress.

Some people who feel a blister starting may press on rather than hold up the group. Encourage party members to stop and treat hot spots as soon as they are felt, rather than ruin an otherwise good day.

• Cover hot spots with smooth tape or a gel dressing.

Treat hot spots (rubbing) as they are felt.

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• Cover a small blister with gauze or a gel dressing, taped in place to keep pressure off the blister.

Use wide strips of tape. Avoid wrinkles.

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Tape hot spots to prevent blisters forming.

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Figure 12.10 Managing blisters

A large, closed, fluid-filled blister on the heel or foot will need to be drained before the patient can walk. To drain a blister: 1.

Wash around the area with warm water and soap.

Pierce each side of the blister with a needle or sharp knife that has been sterilised by being held in a flame for a few seconds.

Drain the fluid carefully and cover the wound with gauze or a gel dressing and tape.

Treat the open blister as an open wound (see page 146).

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CHAPTER 13:

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ENVIRONMENTAL MEDICAL CONDITIONS .A

IN THIS CHAPTER:

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HEAT-RELATED CONDITIONS

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COLD-RELATED CONDITIONS

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SUN BUMPS 174 HIGH-ALTITUDE PROBLEMS

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LIGHTNING STRIKE 179

AVALANCHE 182

PHOTO Kerry Adams

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ELECTRIC SHOCK 181

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Body temperature is regulated by the brain through heat-control mechanisms that aim to keep the body core (head and trunk, including vital organs like brain, heart and lungs) as close as possible to 37°C (99°F). The body’s outer shell (skin and underlying muscles) can tolerate a wide range of temperatures, but the core is far more sensitive to temperature changes.

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Other environmental medical conditions can be caused by exposure to water, avalanche, high altitude, sun and electrical currents.

Most environment-induced conditions are related to being too hot (heat exhaustion, heat stroke) or too cold (cold exhaustion, hypothermia, cold shock, frostbite).

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COLD

WARM

36º

CORE

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37º

32º

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37º

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28º

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34º SHELL 31º

Figure 13.1 Thermograph. The brain aims to keep the body core at 37°C.

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HYPERTHERMIA

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Hyperthermia is a raised core temperature, resulting in heat exhaustion or heat stroke. Hyperthermia is usually caused by being physically active in a hot environment, combined with other risk factors, such as:

• Not enough rest stops to replace fluids lost through sweating

• Activity too strenuous for the participant

• Humidity, which slows the evaporation rate of sweat and therefore slows cooling

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• Age – very old and very young people have a decreased ability to regulate temperature

• Pre-existing medical conditions

• Some prescription and over-the-counter medications, illicit drugs and plant products Move person to cool, shaded area.

Sponge head and neck and bare skin with cool water.

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Heat exhaustion occurs when the core temperature is slightly raised but below 39°C (102°F). If noticed early, the symptoms of heat exhaustion are easy to treat. This can prevent the life-threatening later stages. Dehydration, resulting from lack of fluids, contributes significantly to heat exhaustion. The patient may show symptoms of shock and a circulatory emergency because of the reduction in their blood volume due to loss of fluids.

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Heat exhaustion

See the following table for information about the symptoms and treatment of heat exhaustion.

Give cool drinks.

Remove excess clothing.

Figure 13.2 Managing heat exhaustion

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HEAT-RELATED CONDITIONS

Heat stroke Heat stroke is when the core temperature reaches 39°C (102°F) or higher. If symptoms of heat exhaustion are ignored, the core temperature can climb and the medical emergency of heat stroke (also called sunstroke) will occur.

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A person suffering from heat stroke may take up to a week to recover. There is also the possibility of damage to internal organs, which should be assessed once medical help is available.

This condition is serious and can lead to permanent damage of organs such as the kidney, liver, heart and brain, and ultimately to death. The onset can be very rapid and is characterised by changes in mental function.

See the following table for information about the symptoms and treatment of heat stroke.

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Provide shade.

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Fan to help remove heat.

Sponge bare skin with cool water, or cover body with cool wet clothes.

Figure 13.3 Managing heat stroke

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Place the patient in the recovery position.

CHAPTER 13 | ENVIRONMENTAL MEDICAL CONDITIONS

HEAT STROKE

Symptoms

Pale, cool skin

Hot skin (moist or dry)

Dizzy and faint because blood supply to brain is lessened due to skin blood vessels dilating

Confusion and irrational behaviour

Headache, nausea

Loss of coordination

Vomiting

Loss of consciousness

Thirst

Convulsions

Increased pulse

Rapid pulse

Core temperature up to 39°C (102°F)

Core temperature above 39°C (102°F).

Treatment

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HEAT EXHAUSTION

Move to cooler, shaded area.

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Sponge skin with cool water, especially head and neck.

Remove excess clothing.

Use cool water. Do not use ice-cold water, which causes blood vessels to constrict and could hinder cooling. Also, ice-cold water could cause shivering, which creates heat via muscle activity. Cover patient in cool, wet clothing, replacing each item as it warms up. Fan the patient.

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If patient is dizzy, sit or lay them down and raise their feet.

URGENTLY COOL PATIENT.

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Give fluids, electrolytes if possible.

Put the patient in the recovery position and monitor their ABCs while continuing to cool them.

Extended care and evacuation guidelines

Evacuation guidelines

Allow patient plenty of rest, lighten their load and continue with activity.

Arrange an urgent evacuation.

See page 204 for information on dehydration.

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Any two of the three elements of WET, WIND and COLD will set the scene for hypothermia. Other factors that increase the risk of hypothermia are:

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Cold-related conditions, such as cold exhaustion and hypothermia, are very real dangers in the outdoors. Heat loss can occur due to inappropriate clothing, inadequate food and fluids, a sudden drop in temperature, rain or the party being delayed in a windy spot. A patient lying in direct contact with the ground; a sweat-drenched tramper stopping for a while in a cool breeze; or a kayaker paddling in cold, windy conditions will all be suffering major heat loss.

• Lack of fitness – the person trailing behind the group is using energy less efficiently than other group members and is losing more heat from puffing, panting and sweating.

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• Recent injury or illness, such as a virus, lowers the body’s resistance to cold.

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• Stopping after exercise – up to 70 percent of the body’s heat is produced by muscle activity, particularly use of the large muscles. An unexpected delay combined with wet, wind and cold can put the whole party at risk of hypothermia.

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• Lack of food, fluid and oxygen (at altitude) also increase the risk of hypothermia.

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Wearing appropriate clothing layers to trap heat is one of the best ways to prevent hypothermia. Fabrics like wool, polypropylene and fleece retain most of their insulating properties even when wet. Wet cotton (such as T-shirts and denim jeans) can suck the heat from your body. In cold, wet and windy conditions, cover all exposed skin, including the legs, with a wind and waterproof layer. Do not forget to cover the head and neck. They can lose a lot of the body’s heat because of the large blood flow to this region.

Figure 13.4 How heat is lost from the body

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COLD-RELATED CONDITIONS

Cold exhaustion is when the body’s core temperature drops to between 37°C (99°F) and 35°C (95°F). If detected early, cold exhaustion is easy to treat. In this first stage of core cooling (before hypothermia), the mind is still alert and willing to cooperate, but the body is not always capable of responding.

Assessment

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The body’s core temperature can only be accurately assessed by a low-reading thermometer. Someone with a cold core will have signs and symptoms that are easily recognisable by other alert party members. Even so, the signs are often ignored or misunderstood, sometimes with tragic results.

A person with cold exhaustion will:

• Complain of feeling cold/chilled even when still exercising

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• Shiver (this involuntary muscular activity can produce heat equivalent to a person walking at a fast pace)

• Have numb limbs

• Feel tired (often due to lack of food, water, fitness)

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If one person is found to have cold exhaustion, assume all group members are developing a low core temperature, including you.

Warm, dry clothes

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Warm, sweet drink

Insulation

High energy food

Figure 13.5 Managing cold exhaustion

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COLD EXHAUSTION

Management • Prevent further heat loss by removing any damp clothing and replacing it with dry clothing, then adding warm and windproof layers, particularly to the head. Move the patient to a sheltered spot, if possible. • Increase heat production by giving the patient high-energy food and warm sweet drinks.

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• After a short stop get them exercising again, particularly using the leg muscles.

Extended care and evacuation guidelines

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Your priority is to prevent a recurrence of cold exhaustion. Consider altering the pace of the activity to match the person’s fitness, and ensure they have adequate food and drink. Consider ceasing the activity or evacuating if you do not have sufficient resources (for example, warm dry clothing, enough food and drink) to prevent a recurrence of cold exhaustion.

HYPOTHERMIA

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If the symptoms of cold exhaustion are ignored, the patient’s core cools further, the brain becomes affected, and they are no longer able to help themselves or even recognise the problem. Cold exhaustion can turn into hypothermia.

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Hypothermia is a decreased core temperature that impairs normal brain and muscle function. It occurs when the body’s heat production cannot keep up with the loss of heat. The worsening stages of hypothermia begin when the core temperature falls below 35°C (95°F).

Middle stage: The ‘umbles’

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Early stage: Feeling cold

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Figure 13.6 Warning signs of hypothermia

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Late stage: Shivering stops, unconsciousness

A person suffering from hypothermia will exhibit some or all of the following signs and symptoms: • The ‘UMBLES’ • Grumbles – they may complain or become argumentative • Fumbles – hand/eye coordination may deteriorate • Mumbles – they may mutter and speak unclearly

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• Stumbles – they may trip without reason

• Tumbles – they may fall without obvious cause

• Refusing to admit anything is wrong, showing apathy and lack of concern

• Character changes – the most sensible person may appear confused and make stupid decisions

• Muscle stiffness, slowing the person down

• Shivering, controlled by the brain, may stop

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• Removing clothing in the belief that they are too hot

These symptoms can progress to:

• Loss of consciousness

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• Bluish-grey skin

• Slow pulse and breathing, with the pulse difficult to detect

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Management

• Cardiac arrest

Management of hypothermia focuses on preventing further heat loss and re-warming the core. The sufferer will no longer be able to make rational decisions or recognise the danger. They will not be able to physically re-warm themselves.

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• Have the patient stop any exercise and treat them very gently. Insignificant bumps and jolts can cause the heart to fibrillate so it is not pumping (cardiac arrest). • As with cold exhaustion, remove any damp clothing and replace it with dry clothing and warm and windproof layers, particularly on the head. • Move the patient to a sheltered spot. • Put the patient in a sleeping bag on a mat to insulate them from the cold ground. • Put other people in sleeping bags beside the patient, one in front and one behind. Another person can get in the same sleeping bag as the patient, but be aware that all heat is lost from the bag each time it is unzipped. • Give the patient warm (not hot) drinks if they are fully conscious.

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Assessment

• Re-warm the core by applying warm objects to the head, neck and chest only. These objects should be not too hot to hold in your hand. Use: • Drink bottles filled with warm water • Chemical warm packs (wrapped in a sock) Warm dry clothes

Shelter

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Warm water bottles

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Another person in sleeping bag next to patient

Insulation

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Cover head and neck

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Figure 13.7 Managing hypothermia

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Hypothermia – Frequently asked questions Should I rub the skin?

No, this re-warms the surface only, encouraging blood away from the core to the skin.

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What about putting the patient in a hot bath?

No, again this primarily re-warms the skin and the limbs, drawing the blood away from the core. This can cause cardiac arrest as the re-warming is too fast.

Is a warm fire good for the patient?

It is fine if it just heats the air that the patient is breathing in, but it is not okay if it is re-warming their skin.

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No, the brain relies on the hands and feet for information about whether the body is cooling down. Warm feet or armpits will mislead the brain into thinking the rest of the body is warm.

How about some brandy to warm the patient up?

No, the main effect of alcohol is confused, irrational behaviour which will not help. Alcohol also confuses the brain into thinking the body is warm. The brain then sends the message out to the small blood vessels in the skin to open up, allowing blood to flow to the surface to cool off, resulting in the exact opposite of what is needed.

When should I stop re-warming?

When the patient’s temperature is normal, or when they are warm but there is no sign of life. They should not be considered dead until they are warm and dead.

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Extended care and evacuation guidelines

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• When removing a person with hypothermia from a cold environment (for example, a sailor from cold water or an avalanche victim from snow), keep them horizontal and handle them carefully.

• If the patient is unconscious, monitor their ABCs constantly and place them in the recovery position.

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• Gently turn the patient every 2 hours and continue to re-warm them. • Do not allow them to move or exercise for at least 48 hours.

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• Arrange an urgent evacuation, as treatment in the field is difficult and cardiac arrest is common in severe cases.

COLD SHOCK

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Cold shock is when a person is rapidly chilled, for example, by falling into cold water or walking out of a warm hut into the snow. Heat loss is much faster in water. Hypothermia is not the immediate concern here as the core takes up to 30 minutes to become hypothermic. Several reactions occur when a person is immersed suddenly in cold water or chilled quickly: • Uncontrolled gasping, which increases the risk of inhaling water and drowning • Hyperventilation, which can cause fainting due to changed levels of carbon dioxide and acidity of the blood • Loss of coordination, which makes swimming or exiting the water difficult • Blood is shunted from the extremities to the core, increasing heart rate and blood pressure. This can cause strain on the heart, cardiac rhythm problems and heart failure

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Should I put warm water bottles at the feet or armpits?

Assessment A person with cold shock will exhibit some or all of the following signs and symptoms: • A sudden drop in blood pressure causing symptoms similar to fainting • Loss of coordination and muscle strength, making it difficult to swim or exit the water • Cold skin that is insensitive to injury

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• Pale skin, with blue lips • Nausea

Hypothermia may develop if cooling continues.

Management

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If the rescue is quick and the patient is still breathing, recovery will be quick, since the core is still above 35°C (95°F). You can warm up a cold-shock patient with warm bottles or encourage them to exercise to create muscle heat.

• Remove all wet clothing and replace with dry clothing.

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• If the patient is conscious, keep them moving to generate heat through muscle activity.

• Keep the patient warm and insulated from the ground.

• Give the patient warm, sweet drinks if they are fully conscious.

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FROSTBITE

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• If the patient is unconscious, place them in the recovery position.

Frostbite occurs when body tissue is frozen. It can occur in cold conditions when:

• Skin surfaces are exposed to the cold or come in contact with frozen objects.

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• Circulation to extremities is impaired, for example, by tight boots, crampon straps, tight gloves or some medical conditions.

• A person is wearing wet socks and boots in alpine conditions.

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Frostbite can be categorised as superficial or deep.

Assessment Superficial frostbite, or frost nip, is common on the tips of the nose, ears, cheeks, toes and fingers. • Only the surface layer of tissue is frozen. • The area appears white, waxy and painless. • The person is usually unaware of having it.

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• The body cells are frozen and the area feels solid and cold to touch. • All sensation is lost. • Skin may be pale or dull purple. • Later, the area swells and blisters develop. If it is very deep no blistering will occur.

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Deep frostbite is often compounded by hypothermia.

Management

Superficial frostbite

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• Keep the area covered and prevent it from refreezing.

Place frost-nipped fingers under armpit.

• Re-warm the area immediately by placing it against another body part, for example, place affected fingers under the armpit or place a warm hand over a nipped nose or cheek.

• DO NOT rub the skin.

Place warm hand over frost-nipped ear or nose.

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After thawing, the area may be red. Over several days, it will peel like sunburn.

Deep frostbite

Figure 13.8 Superficial frostbite (frost nip)

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• Treat hypothermia first.

• DO NOT rub the skin.

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• The best treatment is rapid re-warming. Place the affected area in a relatively large warm bath, if one is available. Start at room temperature (20°C). Increase the water temperature by 5°C every 5 minutes until you reach a temperature of 38–42°C. Maintain the water temperature constantly, as trying to warm a frostbitten body part is like trying to thaw an ice block. • The area will become very painful as it thaws, so give the patient pain relief and elevate the frostbitten body part. • Once thawed, the area may develop blisters. Do not burst them, but cover them and protect them from further injury. • DO NOT allow refreezing.

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Deep frostbite is most common in hands and feet, but can also affect the nose and ears.

This treatment may be impossible to achieve in the outdoors. If you cannot achieve rapid thawing, or if there is a chance of refreezing, it is best to leave the part frozen while walking out.

Extended care and evacuation guidelines Arrange an urgent evacuation or walk the person out. Walking on a frozen foot will not cause as much damage as walking on a partly or recently thawed foot.

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• If you are not walking the patient out, elevate the area to ease the pain and swelling.

• Separate affected fingers or toes with dressings.

• Provide food and drink as usual.

• Give the patient pain relief, for example, 400mg of ibuprofen (Nurofen) every 8 hours or 300mg of Aspirin every 6–8 hours.

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CHILBLAINS (PERNIOSIS)

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Chilblains (also called perniosis) are skin lesions that occur as an abnormal reaction to cold, damp environments. Chilblains typically occur on the extremities – fingers, toes, heels, lower legs, nose and ears. However, they can occur elsewhere, such as on the thighs of people who wade through rivers while tramping or ride horses or motorcycles in winter. The importance of wearing warm clothing to prevent chilblains cannot be overemphasised.

Assessment

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Chilblains often appear several hours after cold exposure. A person will exhibit some or all of the following signs and symptoms:

• Deep pain

• Localised, tender, inflammatory, red or purple lesions

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• Lesions that may blister or ulcerate

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Occasionally, lesions can be ongoing, especially following repeated exposure to cold and in people with underlying blood vessel abnormalities.

Management Have the patient rest and minimise pressure on the area (for example, loosen boots).

Extended care and evacuation guidelines Chilblains slowly resolve over more than 1 week with rest, but they can be severe enough to significantly limit physical activity, including walking. Evacuation may be necessary.

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Immersion foot (trench foot) occurs when the feet have been cold and wet continually for several hours, for example, in wet tramping boots, wet liners of plastic boots or wetsuit booties. The cold, wet conditions cause the blood vessels in the feet to constrict, preventing adequate circulation. Immersion foot may result in permanent muscle and nerve damage, and gangrene.

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Having dry feet at night decreases your chances of developing immersion foot. Always have a dry pair of socks to change into at night. This might mean putting your wet socks back on in the morning.

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Assessment

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Figure 13.9 Preventing immersion foot

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A person with immersion foot will exhibit some or all of the following signs and symptoms: • The feet are cold, swollen and a mottled bluish colour. They may look shiny.

• The patient may describe their feet as feeling numb or wooden.

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Management

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• Re-warm the feet gently at room temperature. • DO NOT rub the feet. • As the area warms, it will become red, dry and painful, with a full bounding pulse and tingling, itchy sensations. The patient may need pain relief. • Raise the legs above the heart to help reduce the swelling. • DO NOT break any blisters that may have formed.

Extended care and evacuation guidelines In severe cases, walking on the injured feet will cause further damage, so you will need to arrange an evacuation. Rest is essential until the patient is fully recovered, which can take weeks.

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IMMERSION FOOT (TRENCH FOOT)

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Sun bumps, or polymorphous light eruptions, can occur as a red rash, tiny blisters or lesions. They form on skin (commonly hands) after prolonged exposure to sunlight, in both cold and hot temperatures. Sun bumps are very itchy and can take longer than a week to subside. To decrease your chance of developing sun bumps at the start of a new season, cover the skin and gradually expose it to sunlight. Do not suddenly expose skin to sunlight for hours on end if it has been covered up for most of the previous season.

SUN BUMPS

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HIGH-ALTITUDE PROBLEMS

ACUTE MOUNTAIN SICKNESS

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Problems occur at high altitude (above 2500m) because of decreased atmospheric pressure and a resulting decrease in the oxygen concentration in the blood. (For reference, Mt Taranaki/Egmont is 2518m, Mt Ruapehu is 2797m, Aoraki/Mt Cook is 3754m and Mt Aspiring/Tititea is 3027m.)

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Acute mountain sickness is a general term used to describe the signs and symptoms that occur about 8 hours or more after ascent to altitudes greater than 2500m. It is thought to be caused by the relative lack of oxygen delivered to the body system and cells. Acute mountain sickness can be avoided by:

• Careful acclimatisation, ascending slowly to altitudes above 2500m

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• Drinking lots of fluids, at least 3L per day

• Limiting the amount of strenuous activity

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• Aiming for a sleeping altitude gain of only 300m per day above 3000m (that is, climb high, sleep low) • Sleeping with head and shoulders slightly elevated

You can sometimes prevent acute mountain sickness by taking 125mg of acetazolamide (Diamox) once or twice a day, starting 2 days before going to altitude and continuing to take it while above 2500m. See a doctor for a prescription and advice.

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Figure 13.10 Acute mountain sickness

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Assessment

A person with acute mountain sickness will exhibit some or all of the following signs and symptoms:

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• Headache

• Nausea

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• Loss of appetite

• Poor coordination

• Shortness of breath on exertion

• Lack of energy

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• Difficulty sleeping

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Management • Give the patient pain relief, such as paracetamol, to ease headaches. • If symptoms persist, descend and sleep at a lower altitude.

Extended care and evacuation guidelines The patient should rest at a lower altitude. If symptoms are relieved within 2 days, the patient can re-ascend. If symptoms are not relieved, the activity should be discontinued and the patient should walk out. If the patient is not able to walk out, treat them with 250mg of acetazolamide (Diamox) every 12 hours and 4mg of dexamethasone every 6 hours.

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HIGH ALTITUDE PULMONARY OEDEMA (HAPE) High altitude pulmonary oedema (HAPE) happens when fluid accumulates in the lungs. The lack of oxygen results in changes in blood pressure in the lungs, and leaking blood vessels pour fluid into the air sacs.

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A person with HAPE will exhibit some or all of the signs and symptoms of acute mountain sickness, as well as some or all of the following: • Shortness of breath, even at rest

• Coughing

• Palpitations (irregular heartbeat)

• Blue lips and fingers

• Frothy and possibly pink or blood-stained sputum

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• Gurgling sounds in the chest

• Poor balance

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• A pulse rate greater than 110 at rest, taking up to 10 minutes to return to normal after exercise (this should normally take just 3 minutes)

Management

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• Descend immediately to a lower altitude, and give the patient oxygen.

• If possible, put the patient in a portable pressure chamber, such as a Gamow Bag, which is carried by many commercial expeditions.

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• Keep the patient warm and give them fluids. • Have the patient rest in a sitting position to assist breathing.

• Give the patient 20mg of nifedipine every 8 hours.

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Extended care and evacuation guidelines

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Arrange an urgent evacuation. Continue to give the patient 20mg of nifedipine slow release every 8 hours. Acetazolamide (Diamox) and dexamethasone may also be required if acute mountain sickness and/or HACE is present (see a doctor for prescriptions and instructions for use of these drugs).

HIGH ALTITUDE CEREBRAL OEDEMA (HACE) High altitude cerebral oedema (HACE) happens when fluid accumulates in the brain causing swelling and compression. Sometimes bleeding and clotting can occur.

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Assessment

A person with HACE will exhibit some or all of the signs and symptoms of acute mountain sickness, as well as some or all of the following: • Severe headache, not relieved by simple pain relief • Poor coordination, for example, inability to catch a vertically held ski pole when it is dropped 30cm • Loss of balance, inability to walk straight

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• Hallucinations or blurred vision

• Seizures

Management

• Descend immediately to a lower altitude, and give the patient oxygen.

• Give the patient 8mg of dexamethasone.

• Keep the patient warm and let them rest.

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• If possible, put the patient in a portable pressure chamber, such as a Gamow Bag.

Arrange an urgent evacuation.

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Extended care and evacuation guidelines

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• Continue to give the patient 4mg of dexamethasone every 6 hours. • Watch for and treat HAPE.

• Monitor the patient’s level of consciousness.

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• Give the patient small amounts of fluid, but watch for vomiting.

RETINAL HAEMORRHAGES

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A retinal haemorrhage is bleeding at the back of the eye. This condition is common at high altitude and is possibly caused by the lack of oxygen and/or a high altitude cough, which leads to burst retinal blood vessels.

Assessment If the haemorrhage is affecting the central part of the retina, where most of the vision is focused, then a small gap may occur in the vision in one eye. (When the patient views a page of print with the affected eye, there will be a blurring, or gap, in the print.)

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Assessment

Management • Descend to a lower altitude. • Have the patient suck sweets to lessen the likelihood of coughing.

Extended care and evacuation guidelines

If there is continued visual disturbance, discontinue the activity. The patient should walk out and remain at a lower altitude until assessed by a doctor.

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PERIPHERAL OEDEMA

Peripheral oedema is a spongey swelling which can effect the face (around the eyes), hands and feet. It is generally more of an inconvenience than a medical problem. It can also result from exercise at sea level.

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Assessment

There will be swelling of the face, around the eyes, and hands and feet.

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Management

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SNOW BLINDNESS

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No specific treatment is required. Remove all items that may cause restrictions, such as jewellery. Elevating the feet may help to reduce swelling. Evacuation is not necessary, and the activity can continue as planned.

Snow blindness is similar to a welder’s flash injury. It is caused by reflected ultraviolet light, especially reflected from snow, burning the eye. Like sunburn, the patient is unaware of the damage being caused. The painful results occur hours later.

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When travelling on snow or bright surfaces (such as rivers or lakes), even on a dull day, you can prevent snow blindness by:

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• Always wearing goggles or sunglasses with side protection • Improvising (as a last resort) by making pinhole glasses from cardboard, by wearing a bandana over the eyes or by partially blanking over a pair of spectacles

Always carry a spare pair of sunglasses in your group’s supplies.

Assessment A person with snow blindness will develop gritty, painful, red eyes after a day in bright sun or on a bright surface. They will sometimes also have a headache and nausea.

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• If possible, get the patient to a dark place or use a blindfold to keep all light from their eyes. • Apply cold pads to the closed eyes. • Give the patient pain relief. • Protect the eyes from any exposure to light or wind.

• Keep the eyes as clean as possible.

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Extended care and evacuation guidelines

Cover eyes with bandana

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In mild cases of snow blindness, the patient will take 1–3 days to recover, and they should see a doctor on returning home. In severe cases, you will need to evacuate the patient so they can receive adequate pain relief. Local anaesthetic eye drops give instant relief but should be used sparingly and with caution, as they can affect the cornea.

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Figure 13.11 Improvising to reduce snow blindness

LIGHTNING STRIKE Lightning strikes in New Zealand are very rare and most likely to affect people on mountains. During an electrical storm, it is usually the highest point in an area that is hit by lightning. Lightning strikes can affect anyone close to them. The electrical current flows along the ground away from a strike and can electrocute someone sheltering under an overhang, in a hollow or against a wet rock wall.

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Management

Where possible, during an electrical storm: • Keep away from metal objects, such as tent poles, fishing gear and ice axes. • Avoid high peaks and ridges. • If you feel static electricity around you (your hair stands on end, your skin tingles or you hear clicking sounds), immediately squat down, keeping your hands off the ground. • Avoid using mountain radios, as the aerial is an excellent conductor.

If you are in a hut:

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• Stay inside the hut, away from all electrical and metal objects.

If you are in or on the water:

• Get out of or off the water.

• If you are on a boat, stay in the cabin or get as low as possible. Stay off the radio unless absolutely necessary.

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If you are outside:

• In wooded areas, stay under the smallest trees.

• In open areas, move away from the tallest tree or structure. Try to get at least the same distance away as the tree or structure’s height.

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• If you decide to sit out the storm, spread out from your group, squatted down, hands off ground. Keep off wet ground using a pack (with metal objects removed), sleeping mat or rope. Keep your hands and bottom off the ground. In this position, the hope is that ground current will pass only through your feet, not through your body and heart.

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• If you decide to keep moving, avoid high points and ridges. Do not discard metal gear as you may need it later, but do not hold it above your head.

ASSESSMENT

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A person struck by lightning will usually be knocked unconscious, be burnt and have injuries caused by the force of the strike, such as internal organ damage and fractures.

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MANAGEMENT • Assess the patient’s ABCs and start CPR if necessary. The heart may restart, but you may need to continue the rescue breathing if the breathing centre of the patient’s brain has been paralysed. • Check for other injuries and treat accordingly. • Look under the clothing for burns, which will appear on the sweaty parts of the body and where there are items such as metal hooks and buttons.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation.

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In the outdoors, people can get electric shocks from electric fences, exposed wiring, faulty appliances and generators. Even low-voltage electrical sources can send enough electrical current through the body to cause serious injury or death.

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Treat any source or supply of electricity with respect. Water, wet ground, human beings and most metals are good conductors of electricity. Never touch a plug, switch, wire or appliance with wet hands.

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Always treat an electric fence as if it has current running through it. Check the fence by holding a piece of dry green grass between your thumb and index finger, and allow the tip of the grass to touch the wire. If the fence is live, you will feel a buzz or tingle in your fingers that will increase as you slide the grass closer to the wire. Do not touch the wire directly. The current can cause your hand to close and stay grasping the wire, delivering not just one zap but a constant electric shock.

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If someone falls across an electric fence and is unable to get off, grab their clothing and pull them off. If they stay on the electric fence they could eventually receive enough current to kill them.

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If someone receives an electric shock and still has physical contact with the power source, do not touch them until the power has been switched off. If you are not able to switch off the current, try to move the patient away from the power source using a non-conducting material, such as a dry wooden pole.

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MANAGEMENT

• Check your own safety first. Electrical currents can jump short distances without direct contact: 1000 volts can jump a few millimetres; 40,000 volts can jump more than 10cm.

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• Remove the patient from the power source.

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• Monitor the patient’s ABCs. • Check for and treat any burns. (Refer to page 141 for the treatment of electrical burns.) • Check for and treat any other injuries.

EXTENDED CARE AND EVACUATION GUIDELINES You need to evacuate anyone who has been rendered unconscious, burnt (no matter how small the burn) or thrown with sufficient force to cause injury.

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ELECTRIC SHOCK

AVALANCHE Before going into avalanche terrain, ensure you are prepared and fully understand the dangers. For up-to-date information on avalanche conditions, go to www.avalanche.net.nz. If you are caught in an avalanche:

• Yell and wave to others in your group.

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• Attempt to get out of the flow. Angle out to the side.

• Roll onto your back with your feet downhill. Swim hard and fight to remain on the surface.

• Discard equipment.

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• As the debris starts to slow, attempt to create an air pocket in front of your face.

• Push a hand above the surface so rescuers can find you.

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PROBABILITY OF SURVIVAL WHEN BURIED IN AN AVALANCHE IN THE OPEN

100

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20 0

1st: Survival phase

120

150

180

Duration of Burial, Minutes

2nd: Asphyxia phase

3rd: Latent phase

4th: Final phase

This graph was adapted for New Zealand conditions by Don Bogie (and approved by the MSC Snow and Avalanche committee) from work by Haegeli P, Falk M, Brugger H, Etter HJ, Boyd J.(2011) on Canadian and Swiss statistics. It was produced as a planning tool for search managers. There is currently no data specific to New Zealand mountains, however these results are likely to be similar to what New Zealand conditions would present.

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2nd: The asphyxia phase. People who survive the first 10 minutes will likely die of asphyxia within 35 minutes, caused by hypoxia (insufficient oxygen) and hypercapnia (too much carbon dioxide in the blood). A fast rescue within this phase greatly increases survival rates.

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3rd: The latent phase. People who have not died from asphyxia within the first 35 minutes tend to survive longer as they have a source of oxygen. A victim who is unconscious when rescued, and had an air pocket, is potentially suffering from hypothermia and may be revived (see page 166 for hypothermia treatment). A patient who is unconscious, and had no air pocket or a mouth full of snow, is likely to be dead due to asphyxia.

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4th: The final phase. After 150 minutes of being buried, victims are likely to be suffering from hypothermia, hypoxia and hypercapnia (the Triple H syndrome). A small number of people have been rescued and have survived in this phase so persevere for as long as is safe for the rescue party.

MANAGEMENT

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Search first, then send for help as delaying increases length of burial time. When you find a patient: Gently clear their face as fast as possible. Note if they had a clear airway or an air pocket in front of their face, which suggests they have been breathing after burial.

Clear snow and debris out of their mouth. Be aware that asphyxiated patients may vomit. Breathing in the vomit will aggravate the asphyxia, so actively clear their airway.

Dig around their chest.

Assess patient’s ABCs. Start rescue breathing if they have stopped breathing.

When removing the patient from the snow, keep them horizontal and handle them gently.

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If there are no signs of life, start CPR.

Treat for shock and hypothermia (see pages 64 and 166).

Turn the person’s transceiver off as soon as you can if searching is underway for other buried people.

Arrange for an urgent evacuation. Note: Patients who have been buried for longer than 35 minutes are more likely to survive if they have an air pocket or a pocket connected to the outside air. If there are multiple unconscious victims, treat the patient who had an air pocket first as they are likely to be unconscious due to hypothermia, not dead due to asphyxia.

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1st: The survival phase. The first 10 minutes are absolutely critical for rescuers as most victims are still alive. 10 minutes should be the target in which to find a victim.

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PHOTO Peter Waworis

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IN THIS CHAPTER:

ASTHMA 186

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EXISTING MEDICAL CONDITIONS es

CHAPTER 14:

EPILEPSY 190

DIABETES 193

185

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

People with an existing medical condition usually have it under control and can enjoy a wide range of outdoor activities. On an outdoor trip, a safety management plan can ensure their maximum participation, enjoyment and safety. If a party member has an existing medical condition, ask the following questions before the trip starts: • What is the condition? • What are its possible triggers or causes?

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• What are the signs and symptoms of its onset?

• What is the immediate and long-term treatment?

• Where is your medication and how is it administered? (Remember to take extra medication in case of delays. Think about dividing medication between two packs in case a pack is lost.)

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• How do you recognise when the condition has changed from one you can manage in the field to one that has become a medical emergency, requiring evacuation?

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ASTHMA

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Asthma is a very common respiratory condition that affects people of all ages. During an asthma attack, the small airways (bronchial tubes) in the lungs narrow, and mucus is produced, which further narrows the bronchial tubes. This makes it very hard for the patient to breathe.

Asthma is commonly managed with medication, to both prevent and treat attacks. If left untreated, it can be fatal.

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The leader and one other person in the party need to be aware of several things when leading an asthmatic into the outdoors:

• What symptoms do they have?

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• What are the triggers that cause an attack? • What and where is their medication, and how is it administered? • How can they recognise when the asthma attack changes from one that can be managed in the field to one that is a medical emergency?

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Figure 14.1 Asthma – narrowing of the bronchial tubes

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Some people may arrive at an outdoor activity without their asthma medication, saying that they hardly ever get asthma now or it is never serious. This can put you in a difficult position, as there is no guarantee that they will not have an attack. Even if you are only half an hour from the road end, it could be 2 hours or more before help arrives. Will you be able to cope without the right medication? The most common outdoor triggers for asthma are: • Exercise (more than normal) • Pollen • Dust • A sudden change in temperature The best way to manage asthma is to prevent an attack by using medication before a trigger activity, for example, before starting a steep climb; moving from the protected side of a ridge into cold, exposed conditions; or stepping out of a warm hut into the cold.

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ASSESSMENT A person having an asthma attack will exhibit some or all of the following signs and symptoms: Mild to moderate asthma • A tight feeling in the chest • Shortness of breath • Wheezing when exhaling

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• Raised pulse and breathing

• Persistent cough

Severe asthma

• Distress or panic

• Difficulty speaking more than one or two words

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• Able to breathe in, but struggling to breathe out

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• Abnormal sucking in of the skin at the base of the neck and between the ribs (called intercostal in-drawing)

• Pale skin and blueness of lips, hands and feet

• Unresponsiveness

Figure 14.2 A breathing position for asthma

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• Enlarged chest due to air building up in the lungs

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MANAGEMENT

Treat an asthmatic patient as soon as possible. Asthma becomes more difficult to manage as the attack worsens.

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• Many asthmatic people carry an ‘Asthma Self Management Plan’ or ‘Child Asthma Plan’ written by their doctor. Follow this plan if possible.

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• Remove the patient from the trigger, for example, stop them exercising and/ or move them into a warmer area or away from the pollen source.

• Reassure and calm the patient. • Assist the patient into the easiest position for them to breathe, usually sitting and leaning forward onto some support, such as a pack. • Have the patient use their medication: salbutamol (Ventolin) or terbutaline (Bricanyl). • Have the patient take two puffs of a blue ‘reliever’ inhaler. • If necessary, repeat after five and ten minutes. • Encourage the patient to breathe slowly and deeply. • Give the patient small sips of fluid regularly, to prevent dehydration and help reduce the viscosity of the mucus. 188

Find a plastic drink bottle, not larger than 1L.

Cut a hole in the side or bottom of the bottle to fit the mouthpiece of the inhaler. Make it loose-fitting to allow airflow.

Place the drinking end of the bottle in the patient’s mouth, and then put one puff of the inhalant into the bottle.

Have the patient breathe in and out six times.

Add another puff from the inhaler, and have them take six more breaths.

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Reliever inhaler treats an attack

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Preventer inhaler prevents an attack

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Figure 14.3 Asthma inhalers

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EXTENDED CARE AND EVACUATION GUIDELINES

When the patient is not wheezing or coughing and their breathing has returned to normal, it is appropriate to continue with gentle activity. Urgent evacuation is needed when the patient shows signs of a severe attack and also when: • Use of the inhaler has not given relief after 6 minutes. • The patient is short of breath and unable to walk more than a few steps and/or has difficulty speaking in full sentences.

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Using an asthma inhaler requires the coordination to activate the inhaler while breathing deeply. A tired or young person having an asthma attack, or someone suffering a severe attack, may find this difficult. You will have to help them by doing the following:

EPILEPSY Epilepsy is a condition that takes the form of seizures resulting from a disturbance in the normal electrical or chemical activity of the brain. Any brain injury may cause epilepsy, but in many cases the cause is unknown. The three most common types of seizures are:

• Absence

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• Complex partial

• Tonic clonic

ABSENCE SEIZURES

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These seizures occur more commonly in children than in adults and are sometimes dismissed as daydreaming or blank spells.

Assessment

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Absence seizures involve a period, lasting no longer than a few seconds, of the patient not being aware. A person having an absence seizure will appear to go blank. This may be accompanied by staring, blinking or eye rolling. The person recovers almost immediately, and they are not confused for more than a few seconds. Absence seizures may happen many times a day.

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Management

• Be supportive and understanding.

• Repeat any conversation that the patient may have missed.

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• Be aware that the patient may have missed instructions crucial to the party’s safety during an activity, and so you may need to repeat them.

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Extended care and evacuation guidelines • If the patient is known to have absence seizures, and the seizure follows the normal pattern, there is no reason to discontinue the activity.

• Any patient not known to have epilepsy who starts to have blank spells will need to see a doctor. Any outdoor trip should be discontinued and the person walked out.

COMPLEX PARTIAL SEIZURES Complex partial seizures can involve many different behaviours. The person is still mobile and may still perform some activities automatically, while being unaware of their surroundings.

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Assessment • The person appears to be in a daze, staring blankly. • There may be movements over which they have no control, such as chewing, pulling at their hair or clothing, moving their arms and walking around.

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• Afterwards, the person may be confused, irritable and unable to talk clearly for up to 1 hour.

• The seizure typically lasts for 1–2 minutes.

• They will have no memory of events during the seizure and the confusion period.

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• If occurring in clusters, the person should recover fully between each seizure.

Management

• Speak reassuringly to the person and the rest of the party.

• Do not forcibly restrain them unless it is essential for safety.

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• Walk beside the patient, blocking access to danger. Where necessary, gently guide them by walking behind them with your hands on their shoulders.

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• When the seizure has stopped, watch the person carefully and allow them to rest until fully recovered. Then continue with the activity.

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• If the seizures occur in clusters, stop potentially risky activities.

Extended care and evacuation guidelines

• If the patient is known to have complex partial seizures, and the seizure follows the normal pattern, there is no reason to discontinue the activity.

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• Any patient not known to have epilepsy who starts to have seizures will need to see a doctor. Any outdoor trip should be discontinued and the person walked out. • An urgent evacuation is needed when the patient is having recurrent seizures or has not recovered fully after 1 hour.

TONIC CLONIC SEIZURES Tonic clonic seizures (formerly known as grand mal seizures) are characterised by convulsions and unconsciousness. The person occasionally knows that a seizure is about to start (this is called an aura).

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CHAPTER 14 | EXISTING MEDICAL CONDITIONS

Complex partial seizures often occur in clusters. The person may have 2–6 seizures over 1–2 days then no more for several weeks.

Assessment • The person may utter a cry before falling unconscious to the ground. • Their body stiffens briefly, and then muscle contractions cause jerky convulsive movements.

• Their breathing may stop for up to 30 seconds and their lips and face may turn blue.

• The seizure may last up to 5 minutes. The person may then be deeply unconscious for several minutes.

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• They may lose bowel and bladder control.

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• The patient should steadily improve and should be fully recovered within 1 hour. You may be able to rouse them, but they may still be very sleepy or have a headache.

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• Move the rest of the party away for privacy.

• Stay calm and reassure the rest of the party.

Management

• Protect the person from danger, removing hard/sharp objects from the area. Use backpacks, sleeping bags and clothing to cushion the area around them.

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• Put something soft under their head and remove glasses.

• Loosen any clothing that may restrict their breathing.

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• During the seizure turn the person onto their side, if possible, with the airway open. This is sometimes not achievable as most seizure activity is too strong. Rescuers should avoid getting injured.

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• After the seizure stops, put the person in the recovery position, insulated from the ground, until they regain consciousness.

• Offer assistance, understanding and privacy, if the person lost bladder and bowel control.

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• Watch for signs and symptoms of a possible head injury that may have occurred during the seizure. • Allow the person to sleep and rest until fully recovered before resuming activity. • DO NOT put anything in their mouth. It may cause damage or choking. • DO NOT try to restrain the person. • DO NOT be alarmed if their breathing is laboured and erratic. It takes a while for the brain to settle back into a normal rhythm.

192

• There may be bubbly saliva, possibly red if they have bitten their mouth or tongue.

Arrange an urgent evacuation if: • The seizure lasted more than 5 minutes. • One seizure follows another. • The person cannot be easily woken up into a conscious, alert and oriented state 1 hour after the seizure (they may still be very sleepy, however, and go straight back to sleep).

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• The seizure occurred in water with possible damage to lungs, which will cause breathing problems and may not be immediately apparent – the patient is at risk for 48 hours.

• This is the person’s first seizure.

• The person has a recent head injury.

• The person has a fever or a rash.

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If in any doubt, evacuation is the wisest course of action.

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DIABETES

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Diabetes is a condition where the blood sugar (glucose) levels are out of balance. Carbohydrates from the food we eat are converted to glucose. The pancreas produces insulin that enables the glucose to enter our cells, where it is converted to energy or stored for future use.

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There are two main types of diabetes:

• Type 1: Where the pancreas does not produce insulin. Insulin must be injected one or more times a day so the body’s cells can use glucose for energy.

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• Type 2: Where insulin production is too slow, or the body is resistant to insulin. Not enough exercise, poor diet and weight gain are triggers for developing type 2 diabetes. The patient can take tablets to stimulate the pancreas to produce more insulin.

With both types of diabetes, it is essential to balance food intake, exercise and medication to keep the blood sugar levels within an acceptable range. People with diabetes should discuss the planned activity with their doctor if it is outside their usual range of exercise, as extra activity may require a change in the amount of medication they take. Problems occur when a person’s blood sugar levels become too low (hypoglycaemia) or too high (hyperglycaemia). When leading a person with diabetes, the group leader needs to be able to recognise the symptoms of hypoand hyper-glycaemia, and know the appropriate action to take.

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CHAPTER 14 | EXISTING MEDICAL CONDITIONS

Extended care and evacuation guidelines

Ask the patient: ‘Have you eaten lately?’ and ‘Have you taken your insulin today?’. If they have taken insulin but have not eaten, they are likely to be hypoglycaemic (low blood sugar). If they have eaten but not taken insulin, they are likely to be hyperglycaemic (high blood sugar).

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HYPOGLYCAEMIA (LOW BLOOD SUGAR)

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Figure 14.4 Food to treat hypoglycaemia (diabetic low)

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Hypoglycaemia occurs quickly – within minutes – and is of particular concern for people treated with insulin or sulphonylurea tablets. It may be caused by: • Too much insulin

• Not enough food, especially carbohydrates

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• Missing a meal, or not eating regularly (common in the outdoors when the hut or lunch spot is further away than expected or the activity runs overtime)

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• Strenuous activity causing the body’s glucose supply to be used up more quickly than anticipated • Being in a colder environment • Drinking alcohol without food

Assessment A person with hypoglycaemia will exhibit some or all of the following signs and symptoms: • Dizziness, faintness, fatigue • Shaking, trembling • Anxiety

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CHAPTER 14 | EXISTING MEDICAL CONDITIONS

• Weakness • Sweaty, clammy skin • Hunger (can be extreme) • Headache • Palpitations • Difficulty concentrating • Pale skin

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• Tingling of lips and tongue

• Behaviour change – they may become confused, irritable and uncoordinated, and they may appear drunk

• Blurred or double vision

• Rapid deterioration, leading to unconsciousness and seizures

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Management of a conscious patient

• Immediately give the patient approximately 10–15g of quickly absorbed sugar, such as glucose tablets or 2 heaped teaspoons of sugar, honey or jam or 100–150ml of glucose or soft drink.

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• If symptoms are still present after 5–10 minutes, repeat the above.

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• Do not give the patient food until they are feeling better, which means the sugar has been absorbed. Giving food too soon will delay the absorption of the sugar and delay recovery.

• Give the patient a snack that is substantial enough to maintain glucose levels until the next meal is due, or give them the meal if it is due.

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• The patient should check that their blood sugar level is appropriate before continuing the activity.

Extended care and evacuation guidelines for a conscious patient

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If the patient feels well after treatment, there is no reason to discontinue the activity, but you MUST FIND OUT what caused this episode of hypoglycaemia, in order to prevent another attack. If there are inadequate supplies of food or treatment, the activity should be discontinued.

Management of an unconscious patient • Place the patient in the recovery position, insulated from the ground. • Give the patient a glucagon injection, if available. If there is no response after 10 minutes, give a second injection. • If no glucagon is available, rub honey or glucose paste on the inside of the patient’s cheek. • DO NOT put fluids in the patient’s mouth, because of the danger of them breathing the fluid into their lungs.

195

Extended care and evacuation guidelines for an unconscious patient Arrange an urgent evacuation. Send with the patient all tablets, injections and a written list of what medication was administered and when.

HYPERGLYCAEMIA (HIGH BLOOD SUGAR) Hyperglycaemia develops slowly over hours or days and is less common than hypoglycaemia. It may be caused by:

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• Excessive or inappropriate types of food

• Illness or stress

• Inadequate or missed doses of insulin. This can happen if the medication is lost or left behind, or if supplies run out because the group is delayed

Assessment

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Hyperglycaemia may have a gradual onset over several hours or days. A person with hyperglycaemia will exhibit some or all of the following symptoms:

• Extreme thirst

• Nausea and vomiting

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• Stomach pains

• A fruity, acetone smell on breath (smells like nail polish remover)

• Drowsiness

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• A problem may show up on blood or urine test strips

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Management

• If the patient is conscious, give them plenty of water to help prevent dehydration.

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• Insulin doses should be maintained even if the person is not eating.

• Insulin must only be administered according to the patient’s treatment plan, patient’s advice or medical advice.

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• If the patient is unconscious, place them in the recovery position.

Extended care and evacuation guidelines Hyperglycaemia is a medical emergency requiring urgent evacuation whether the patient is conscious or not.

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CHAPTER 16 | POISONS, STINGS AND BITES

y. on l os

CHAPTER 15:

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OTHER MEDICAL CONDITIONS ila

IN THIS CHAPTER:

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MENTAL ILLNESS

STROKE

200

FOREIGN BODIES IN EARS

210

200

EARACHE

211

FOREIGN BODIES IN EYES

211

HYPONATREMIA

207

TOOTHACHE

212

FEVER

207

DISPLACED TEETH

213

VOMITING

208

CHAFING

213

DIARRHOEA

209

URTICARIA (HIVES)

214

m io n PHOTO Peter Waworis

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210

204

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DEHYDRATION

CONSTIPATION

ACUTE ABDOMINAL PROBLEMS

198

197

This chapter covers stroke, mental illness, abdominal problems, dehydration, fever, vomiting, diarrhoea, constipation, ear problems, eye problems, dental problems and chafing.

Minor problems, such as constipation and chafing, need prompt attention to ensure the person does not have an uncomfortable or miserable outdoor experience.

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Your priorities are to get a detailed history, to make the patient comfortable, to treat any symptoms and to try to prevent the condition getting worse. Where possible, talk to a doctor by radio or phone. If in doubt, evacuation is the wisest course of action.

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STROKE

Area deprived of blood

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A stroke is sudden damage to the brain caused by a blood clot blocking an artery or bleeding from a burst blood vessel. A stroke may cause cognitive problems, weakness, paralysis or even death, depending on how much of the brain is damaged.

Site of bleeding

Ruptured artery

Blood clot

Figure 15.1 A blocked artery (ischaemic stroke) or bleeding artery (haemorrhage) in the brain

198

Some serious medical conditions occur unexpectedly; some take time to develop or become obvious. Remember that you are not required to make a diagnosis – that is a doctor’s responsibility.

CHAPTER 15 | OTHER MEDICAL CONDITIONS

SIGNS AND SYMPTOMS

Arms

Speech

Time

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Face

Figure 15.2 Signs and symptoms of stroke: FAST

Remember the most common signs of a stroke with the word FAST:

• Face: Can the person smile? Is one side of their face drooping?

• Arms: Can the person raise both arms? Is one arm weaker?

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• Speech: Can the person speak? Are the words jumbled or slurred?

• Time: Act FAST and call 111 immediately! Time lost may mean brain lost.

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Depending on the severity of the stroke, and what part of the brain has been affected, the patient will exhibit some or all of the above signs and symptoms. They may also exhibit some of the following (note that these can be similar to the symptoms of a traumatic head injury):

• Sudden weakness, numbness or paralysis on one side of the body

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• Difficulty understanding what is being said, confusion

• Sudden vision problems in one or both eyes

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• A sudden severe headache • Sudden dizziness, loss of balance or an unexplained fall

• The appearance of drunkenness

• Difficulty swallowing

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• Pupils unequal in size and not responding normally to light

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• Loss of bowel and bladder control • Loss of feeling • Seizures • Collapse • Unconsciousness

Transient Ischaemic Attack (TIA) symptoms are very similar to those of a stroke but may last for only a few minutes or up to 12 hours. A TIA is a warning: someone who has had a TIA is at very high risk of having a stroke. Someone who experiences symptoms such as those above, even if they fully recover, should seek immediate medical attention.

199

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Most people fluctuate along the continuum of mental health and mental illness, depending on the amount of stress or emotional difficulty they are experiencing. Mental illness is a health problem that affects how a person thinks, feels, behaves and interacts with other people. Common mental illnesses include depression, anxiety, panic attacks and eating disorders. Other mental illnesses, for example, schizophrenia and bipolar disorder, involve psychoses.

MENTAL ILLNESS

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The outdoors is often used as a means of therapy to overcome anxieties or develop emotionally. As a group leader, always ask yourself, ‘Is it truly beneficial for this person to continue with this activity?’ Sometimes the person may not be mentally ready for a challenging outdoor experience, and the challenge may actually be detrimental to their development and recovery. However, for some people the outdoor challenge may be the perfect therapy.

People with diagnosed mental illnesses may be on medication. This should be recorded on the pre-trip plan and the person should take responsibility for taking it and knowing its properties.

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If someone needs help with a mental illness while in the outdoors, do not hesitate to call for assistance, either for medical advice or for an evacuation.

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ACUTE ABDOMINAL PROBLEMS

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It can be extremely difficult to determine the cause of abdominal pain, so it is better to concentrate on the signs and symptoms that indicate a patient has a serious problem and needs urgent evacuation. Although not all abdominal pain is serious, it should be treated as such, particularly if it develops suddenly. Acute abdominal problems include appendicitis, bleeding ulcers and obstructed bowels.

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ASSESSMENT

A person with an acute abdominal problem will exhibit some or all of the following signs and symptoms: • Waves of or continuous severe pain lasting for more than 4 hours • Pain preventing sleep • Pain brought on by coughing • Pain with vomiting but not diarrhoea • Patient stops passing wind

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

• Tenderness in one specific area that the patient does not want you to touch • Patient lies on one side, knees drawn up, reluctant to move • A hard, rigid stomach

• Signs and symptoms of shock

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• Nausea and vomiting

• A raised temperature

• Extreme pain and sudden collapse

Figure 15.3 The abdomen

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MANAGEMENT

• Get a detailed history. Ask the patient:

• What/when did you last eat?

• Have you had these symptoms before?

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• When did you last go to the toilet – pee and poo? Is bowel action normal, soft, hard?

• Have you eaten anything different from the rest of the party?

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• Is this pain usual in your menstrual cycle?

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• Monitor and record the patient’s vital signs and any changes in their condition.

• Apply warm packs or gentle hand pressure over the area if it helps to relieve pain.

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• Do not give the patient food or drink if they will be evacuated soon, as surgery may be necessary.

• Rinse their mouth and moisten their lips with water.

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• Place the patient in the position most comfortable for them.

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation for acute abdominal pain. If the pain is not acute, continue management as above and consider options depending on the trip and the patient’s condition. Do not be afraid to ask for medical advice.

201

• Pain, usually beginning in the middle of the abdomen

• Ask if they have a previous history of appendicitis. • Do not give the patient food or drink, as surgery may be necessary.

• Pain when walking upright or coughing

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An acute inflammation of the appendix, which lies at the lower right-hand side of the abdomen.

MANAGEMENT as above, plus:

APPENDICITIS

SIGNS AND SYMPTOMS as above, plus some or all of:

• Arrange an urgent evacuation.

rp pu al ic to r is

• Nausea and vomiting

• After 1–3 hours, the pain moves to the lower right-hand side. The patient will not be able to lift the right leg up towards the abdomen and will not want you to touch the area

• A raised temperature • Nausea and vomiting

Inflammation of the peritoneum, the thin tissue lining the wall of the abdomen. It can be caused by a burst appendix, infection or other abdominal problems such as a perforated stomach ulcer, gall bladder or diverticula.

• General worsening of a patient who is already ill with an acute abdominal problem

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PERITONITIS

• Severe pain over the whole abdomen • Hard, rigid abdomen

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KIDNEY STONE

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A crystalline deposit that is formed in the kidney and can range in size from that of a grain of sand to a golf ball. It can be very painful when a kidney stone passes down through the ureter to the bladder and out through the urethra.

• Ask if they have a previous history of gallstones, appendicitis, pancreatitis or peritonitis, or if they could be pregnant. • Do not give the patient food or drink, as surgery may be necessary. • Arrange an urgent evacuation.

• A raised temperature • Severe gripping pain that comes and goes frequently in the lower back, and spreads down to the groin and genitals

• Blood in the urine • Pain on urination, and increased frequency of urination • Vomiting

• Encourage patient to drink as much water as possible and to move about to help flush out the stone. • You may give the patient pain relief, but it will not completely mask the pain. • Have the patient pass water into a container so that you can retrieve the stone. (It can be very tiny so look carefully.) The presence of a stone confirms that a kidney stone was the cause of pain. The patient’s doctor may want to have the stone analysed. • Arrange an evacuation if there is no improvement in 4 hours.

202

EXAMPLES OF SERIOUS ABDOMINAL EMERGENCIES

• A swelling that may be neither tender or painful • A sharp, stinging pain • A feeling of something giving way at the site

• The patient should support the swelling during coughing. • The patient should avoid lifting.

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• If the hernia is easily reducible, that is, it slides back or disappears, and the patient is comfortable, evacuation is not necessary.

A swelling under the skin caused by part of the intestine protruding through the muscle wall. Hernias are mostly found in the groin area or at the site of old surgical scars. Most are harmless, rarely causing problems. They may occur after exercise, lifting heavy objects or coughing.

HERNIA

• Make the patient comfortable, supporting their head and shoulders and bending their knees to relieve tension in the abdomen.

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• If the hernia is persistent and painful, then the activity should be discontinued and the patient should walk out.

STRANGULATED

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• A sudden painful swelling

• Not passing wind • Vomiting

A hernia when the blood supply is cut off (for example when the bowel twists or is obstructed). This needs urgent surgery.

HERNIA

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• Signs and symptoms of shock

BOWEL

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OBSTRUCTION

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• As for an uncomplicated hernia.

• A painless swelling that persists or increases and becomes painful

• Give the patient constant reassurance. • Arrange an urgent evacuation as surgery is necessary within 8 hours. • Rule out constipation.

• Nausea

• Moisten lips but do not give food or fluids.

• Vomiting

• Arrange an evacuation.

• Not passing wind See vomiting and diarrhoea (page 208).

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GASTROENTERITIS

• Generalised abdominal pain and bloating

• Do not give the patient food or drink, as surgery will be necessary.

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

UNCOMPLICATED

DEHYDRATION Dehydration is caused by not drinking enough of the right type of fluids. The adult body needs a minimum of 1–1.5L per day to maintain normal mental and physical efficiency. Our bodies lose fluid through:

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• Sweating: Up to 2L per hour on a hot day when walking steadily with a backpack

• Breathing: 250–500ml per day

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• Urination: If your urine turns dark yellow, you need to drink more. (You need to pass 500ml per day to keep the kidneys functioning.) Drink enough to produce clear urine.

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Remember to eat to replace salts.

Figure 15.4 Preventing dehydration

Dehydration can contribute to hypothermia, heat exhaustion or heat stroke, and altitude sickness. It reduces our ability to think clearly and rationally, and to move efficiently. It also increases fatigue, contributing to accidents and poor decision making. Some people who are new to the outdoors and only used to the privacy of flush toilets purposely do not drink to avoid possible embarrassment. Stressing the importance of drinking enough, explaining procedures and allowing time and privacy for toilet stops may help prevent this all too common and preventable problem.

204

ASSESSMENT A person in the early stages of dehydration will exhibit some or all of the following signs and symptoms:

• Thirst

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• Headache

• Cramp

• Irritability

• Tiredness

• Dizziness or light headedness

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A person in the late and more serious stages of dehydration will exhibit some or all of the following signs and symptoms:

• Fast pulse

• Pale skin

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• Nausea and weakness

• Loss of balance

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• Swollen, dry tongue

• Changes in mental awareness

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• Sunken eyes

• Dry lips and mouth and trouble swallowing

• Delirium

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MANAGEMENT

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• Sit the patient down and take a thorough history to find out if dehydration is the cause of the symptoms. • If possible, give the patient drinks that contain a mixture of electrolytes, minerals and glucose, which are absorbed more quickly than water. Make sure the patient does not drink too quickly, as they may not keep the fluid down. Have them sip slowly, at least half a cup per hour. Give them snow or ice to suck if they are having difficulty taking fluids. • Wait until the patient has recovered before resuming activity. Make sure they maintain an adequate fluid intake.

Avoid caffeine as it is a diuretic, which causes the body to lose more fluids. Tea, coffee, cocoa and cola contain caffeine. Also, avoid pure fruit juice and soft drinks with a high concentration of sugar, which sucks fluid from the body.

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

Drink before you start the activity. Drink often during the day – the physical and mental deterioration caused by dehydration is very subtle. Drink before you are thirsty – thirst is an early sign of dehydration. THEN DRINK SOME MORE.

You can buy commercial rehydration drinks or make your own by: • Diluting pure fruit juice by 50 percent with water. • Adding 2tsp (10ml) of sugar, honey or glucose; ¼tsp of salt; and ¼tsp of baking soda to 1L of water.

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• Adding 1tsp of sugar, honey or glucose, and a pinch of salt to one mug of water.

1 teaspoon sugar

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Pinch of salt

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Figure 15.5 Treating dehydration

EXTENDED CARE AND EVACUATION GUIDELINES

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Make sure the patient continues to drink the rehydration fluids, sipping at least half a cup every hour. Dehydration can rapidly lead to kidney failure and severe electrolyte imbalance that can only be treated in a hospital. Arrange an urgent evacuation if a patient has all of these symptoms together: • Dry mouth • High pulse (for a resting adult, a normal pulse is 60–90 beats per minute. A high pulse is 40 beats per minute above this) • Faintness • Lack of urine

206

Hyponatremia is when a person has low sodium or salt levels in their blood. Drinking too much water and not replacing salts that are lost through sweating results in the level of blood sodium being too low.

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ASSESSMENT The symptoms of hyponatremia are the same as heat exhaustion:

• Headache

• Fatigue

• Muscle cramps

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You can diagnose hyponatremia by asking questions and finding out if the patient has been drinking plenty but not eating.

MANAGEMENT

ila

The patient needs to eat salty food to balance their blood sodium levels.

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FEVER

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Fever is a raised body temperature of over 37.4°C (99°F) that usually indicates an infection (see chapter 12).

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MANAGEMENT

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• If their temperature is over 38°C, cool the patient by removing excess clothing, fanning them, placing lukewarm compresses on their forehead and neck, and allowing the moisture to evaporate. • Give the patient fever-reducing medication, such as paracetamol or ibuprofen. • Give the patient water or electrolyte drinks regularly. • Give the patient small amounts of food if they want it. • When their temperature is back to normal, allow the patient to rest and regain their energy before continuing the activity.

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

HYPONATREMIA

EXTENDED CARE AND EVACUATION GUIDELINES

If the fever is accompanied by rigors (the patient feels cold and shivers persistently, despite their high temperature), a significant infection is present and you need to consider evacuation.

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Fever accompanied by headache, neck stiffness, rash and/or a sensitivity to bright light could mean meningitis, so arrange urgent evacuation. Tell the rescue service what you suspect. They may bring antibiotics to administer immediately.

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Figure 15.6 Cooling a person with fever

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VOMITING no tb e

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Vomiting can be caused by parasites, viruses, bacteria, giardia, a food allergy, food poisoning, emotional stress, bowel or urinary obstructions, pregnancy, poor hygiene, drugs or medical problems.

MANAGEMENT

io n

• If the cause of the vomiting is minor, the patient will usually feel better after the first bout and can continue limited activity.

• Do not give the patient food or drink until vomiting has stopped, but do give them sips of cool water.

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• When vomiting has stopped, give the patient half-strength rehydration drinks to prevent dehydration (see page 206). • When the patient is able to eat, give them bland, non-fatty food. • Pay attention to hygiene.

EXTENDED CARE AND EVACUATION GUIDELINES The person will be tired and may need to rest for a day before resuming strenuous activity.

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

Arrange an urgent evacuation if the patient’s condition is deteriorating or if the patient: • Is in considerable pain • Is still vomiting after 12 hours • Is showing signs of shock or dehydration • Is not passing urine

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DIARRHOEA

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Diarrhoea is defined as a large number of loose, smelly stools. Possible causes are the same as for vomiting. If the patient also has a fever, it is likely that they have an infection.

MANAGEMENT

Attend to the patient’s possible embarrassment.

ila

• Do not give the patient fruit, dried food, milk, alcohol or any fatty or spicy foods.

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• Do give them plenty of liquids – 200ml per hour of boiled, cooled water or rehydration drink (see page 206 to make your own).

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• Keep the patient’s eating utensils sterilised and separate from the rest of the group’s. Ensure everyone pays attention to personal hygiene to prevent the spread of possible infection.

• If you suspect food poisoning, wait 12 hours before giving anti-diarrhoea medication. This enables the organism to leave the body.

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• When the patient has recovered, they may need to rest for 12 hours or more.

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There are several medications (such as Imodium, Diastop and Lomotil) that slow the abdominal cramps and diarrhoea. These medications can cause the pupils to dilate, so the patient will need sunglasses in the outdoors to protect their eyes. The medications can also cause a dry mouth, wakefulness, bowel obstruction and urine retention. Another option is codeine, which will firm up loose stools and give some relief from pain and fever.

209

EXTENDED CARE AND EVACUATION GUIDELINES Arrange an urgent evacuation if: • Diarrhoea has not stopped after 3 days. • The patient is in considerable pain. • The patient’s condition is deteriorating. • The patient is showing signs of shock and dehydration.

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• Urine output is less than 500ml per 24 hours.

CONSTIPATION

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Some people have a bowel movement each day, others every few days. Constipation occurs when there has been no bowel movement for 2 days after the patient would normally have one. A person with constipation may also have stomach pains and bad breath.

ila

Constipation can be caused by:

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• Not enough toilet stops

• A change in normal routines

• Drinking less than normal (this is the most common cause)

• A change in diet (especially with an increase in dehydrated food)

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• Some medications, such as codeine

Some people new to the outdoors may only be used to flush toilets, so explaining procedures, and providing time and privacy for toilet stops may help to prevent the problem.

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If a person is constipated, they should:

• Stop eating dehydrated food.

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• Drink more fluids. • Include fruit in their diet.

• Eat plenty of fibre, such as wholemeal bread, vegetables, muesli, prunes and bran.

FOREIGN BODIES IN EARS In the outdoors, the most common offenders are insects. A live insect in the ear can be very distressing.

210

• Lean their head to the side, with the affected ear pointing up. Gently pour warm water into the ear. This may float the foreign body out. • Have the patient see a doctor on returning home to make sure that no fragments are still present and that the eardrum is not damaged.

DO NOT poke anything inside the ear, as you could push the object further in. It is also very easy to damage the eardrum, causing severe pain and infection.

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EARACHE ic

• If the patient has earache, give them pain relief and have them wear a beanie to protect their ears from the cold.

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• If the patient has a head cold, they should blow their nose regularly and gently. This will keep the Eustachian tube (which runs from the back of the nose to the middle ear) open and prevent a build-up of fluid in the middle ear. Analgesics and nasal decongestants are often quite successful in relieving symptoms of earache.

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• Earache that is accompanied by a discharge, loss of hearing or balance, or a high temperature needs medical attention and antibiotics. The patient should be walked out. Remember to support a patient whose balance is affected.

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DO NOT put anything in the ear canal.

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FOREIGN BODIES IN EYES In fo

Foreign bodies in the eye can be very irritating and can scratch the eyeball or eyelid. Infection and damage to the cornea are possible. • Make sure the patient does not rub their eye as this can cause damage. • The patient’s eye should blink and water automatically. This often moves the object to the corner of the eye, where it can be removed with the corner of a clean handkerchief. If the object cannot be easily removed: • Flush the eye with water. • Do not try to remove the foreign body if it is stuck in or on the centre of the eye. This could cause damage to the cornea. • Cover the eye with a lightly secured soft pad. • Arrange evacuation to a medical facility.

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

If a person has an insect or other foreign body in their ear:

If the object has pierced the eye, fluid will leak out. Permanent loss of sight may follow. • Keep the patient lying flat on their back, with their head slightly up. • Very gently cover the eye. • Arrange evacuation to a medical facility.

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• Lay the patient down, and flush their eye with water for 20 minutes. If only one eye is affected, turn the patient’s head towards the affected side so the water will not wash the substance into the other eye.

If a fluid substance, such as white spirits, methylated spirits or lighter fluid, has splashed into the eye:

• Cover the eye with a lightly secured soft pad.

• Arrange evacuation to a medical facility.

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Flush eye with

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plenty of water.

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Figure 15.7 Managing foreign bodies in the eye

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TOOTHACHE

Toothache is usually caused by an infection in a tooth, which can spread to the surrounding bone and tissue. Signs of infection include: • Swelling and tenderness around the teeth or gums • A swollen face • Raised body temperature If a patient has toothache, give them pain relief. Applying clove oil to a raw cavity may also help to relieve the pain. A person with toothache should discontinue the activity and see a dentist. They may need antibiotics.

212

If a dentist sees the patient within 4 hours, they may be able to save an intact tooth that has been knocked out of its socket. It is important that you take appropriate care of the tooth: • Do not touch the tooth at the root end.

• Gently clean the displaced tooth with saline.

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• If the tooth is intact, replace the tooth in the socket, and mould tinfoil over the tooth and the teeth on each side.

• If the patient is unconscious, or the tooth cannot be replaced, keep it in a small container of saline or milk, or wrap it in plastic wrap.

• If the tooth is loose, straighten it, and splint it in place with tinfoil.

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A person with displaced teeth should discontinue the activity and see a dentist.

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CHAFING cu ra

Chafing is a common tramping discomfort that can be caused by bulky seams on clothing; cold, wet shorts rubbing on legs; pack straps rubbing against the front of the armpits; or thighs rubbing together when walking.

Chafing can be prevented by:

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• Avoiding clothing with bulky seams • Drying any sweaty areas and applying lots of talcum powder to them

• Adjusting straps and padding in likely pressure areas

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• Applying cream (for example, petroleum jelly) or smooth tape onto areas that rub when walking

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Chafing can be managed by: • Gently drying the affected skin • Covering chafed skin and the surrounding area with a protective cream (for example, petroleum jelly) • Identifying and removing the cause of the chafing, for example, by wearing clothing inside out so seams are not against the skin

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CHAPTER 15 | OTHER MEDICAL CONDITIONS

DISPLACED TEETH

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Urticaria (hives) is a group of skin conditions characterised by raised, red welts that are often itchy. Urticaria is common and is caused by the release of histamine. Although it is a sign of an allergic reaction, it can occur with no known trigger. Ask the patient if they have had contact with an allergen that triggered the reaction. If there is a trigger, treat the patient for allergies. If there is no trigger, urticaria may be a symptom of illness and you should seek medical advice.

URTICARIA (HIVES)

• Cold urticaria is caused by exposure to cold water. Symptoms can vary from small patches of itchy welts to a full-body rash. People with cold urticaria should minimise their exposure to cold water by wearing appropriate protective clothing. They should avoid sudden immersion in cold water.

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• Cholinergic urticaria (heat rash, prickly heat) is a relatively common hypersensitivity to body heat caused by exercise, overheating or stress. Small red bumps can be localised or widespread. Taking antihistamines and limiting exercise may help.

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• Delayed pressure urticaria is a deeper, more painful form of hives. It occurs where there has been pressure on the skin, such as under the waistband of trousers, under pack straps, under sock elastic, and on the soles of feet and buttocks after long periods of sitting. The hives can appear hours after the pressure and can be associated with muscle fatigue, fever and headaches. Treatment is difficult, as avoiding pressure on the skin is challenging. Alleviate by removing pressure from the affected skin, by removing clothing and resting.

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APPENDIX I | MNEMONICS USED IN FIRST AID

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CHAPTER 16:

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POISONS, STINGS AND BITES ila

IN THIS CHAPTER:

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CYANIDE

POISONING

BEE AND WASP STINGS

REDBACK SPIDER BITES

223

218

WHITETAIL SPIDER BITES

224

219

NATIVE NEW ZEALAND CENTIPEDE BITES 224

220 ONGAONGA (TREE NETTLE)

225

JELLYFISH STINGS

221

DRUGS AND ALCOHOL

226

STINGRAY WOUNDS

221

MUSHROOMS

227

222 PLANTS

228

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MOSQUITO AND SANDFLY BITES

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SEA URCHIN (KINA)

KATIPO SPIDER BITES

223

PHOTO Peter Waworis

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216

215

Poisons and allergens (substances that a particular person is allergic to) can get into the body through inhalation, absorption (through the skin), ingestion and injection.

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Poisoning can also occur through inappropriate use of drugs or incorrect use of prescription medication.

It is impossible to identify all the poisonous substances an outdoor user may come across. As part of the pre-trip planning, it is a good idea to contact the owners of any land you will be using, to find out if any poison programmes are being carried out in the area and if any buildings on the land are used to store pesticides and herbicides.

If you know of specific substances you may come in contact with, call the National Poisons Centre (0800 Poison/0800 764 766), or your own doctor, to find out how to manage a reaction to this substance in a remote location.

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Stings and bites can cause problems ranging from mild discomfort to major allergic reactions. Try to prevent insect stings and bites by covering the skin or using insect repellent. Take special care when eating and drinking outdoors, as bees and wasps can crawl inside bottles and food.

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POISONING cu ra

For information on carbon monoxide poisoning, see page 52.

Some poisons you may come across in the outdoors are: Corrosive poisons

• Poison baits

• Bleach

• Rat poison

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Non-corrosive poisons

• Dish-washing powder • Caustic soda and other alkalis

• Pesticides

• Acids

• Prescription medication

• Industrial cleaners

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• Herbicides

• Disinfectants

ASSESSMENT A patient’s reaction will depend on the type and amount of poison taken. A person who has been poisoned will exhibit some or all of the following signs and symptoms: • Breathing difficulties • Stomach pain • Nausea and/or vomiting • Odours on the breath

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CHAPTER 16 | POISONS, STINGS AND BITES

• Confusion and irrational behaviour • Drowsiness • Burns around the mouth • Diarrhoea • Skin colour changes, rash, swelling • Blurred vision • Tightness in chest

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• Sudden collapse

• Convulsions

MANAGEMENT

• Always be aware of your own safety first, especially if the patient has inhaled poison and there are fumes in the air. Avoid direct contact with the poison.

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• Check the patient’s ABCs.

• The patient may lose consciousness quickly, so ask them what and how much poison was taken, and when it was taken, as soon as possible.

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• If you can, contact emergency services immediately and ask for advice about the specific poison. If they cannot give you adequate advice about treatment and management, ask them to contact the National Poisons Centre (0800 POISON, 0800 764 766) for advice.

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• Be prepared to collect the patient’s vomit for later analysis – plastic bags will help.

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• If the patient is unconscious, place them in the recovery position, insulated from the ground. Monitor their vital signs.

• If CPR is required, you may need to use mouth-to-nose breathing for your own safety. If the patient inhaled the poison, avoid their exhaled air. If they swallowed the poison, avoid touching their vomit.

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If the poison was swallowed:

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• DO NOT make the patient vomit unless specifically advised to do so by medical personnel or the National Poisons Centre, due to the risk of the patient inhaling vomit into their lungs. • DO NOT give the patient anything to drink if it is a non-corrosive poison, such as poison baits, rat poisons, herbicides, pesticides or prescription medicine. Giving the patient fluid will cause more harm by helping the poison spread through the digestive system, increasing the rate of absorption. • If you are sure the poison is corrosive, DO NOT make the patient vomit. If the patient is fully conscious, wash their mouth out with water. Give children half a glass of water or milk, and give adults one to two glasses. Repeat this process if the patient vomits naturally. This helps lessen the corrosive action of the poison.

217

If the poison was inhaled: • Move the patient from the poison source into fresh air. • Encourage them to breathe deeply. Note: In New Zealand, there have been several deaths from carbon monoxide poisoning (see page 52) due to faulty appliances and lack of ventilation. If the poison was spilled on skin: • Remove contaminated clothing and jewellery.

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• Wash the area with water for at least 15 minutes.

EXTENDED CARE AND EVACUATION GUIDELINES

• Arrange an urgent evacuation.

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• Give any collected vomit and the poison container to the rescue crew.

CYANIDE

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ASSESSMENT

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Cyanide is used to kill possums, a major pest in the New Zealand bush. It comes in a paste or as pellets (Ferratox). Cyanide acts on the respiratory system, preventing cells from utilising oxygen. Ingestion, inhalation or skin absorption can be fatal. Hunters using cyanide and organisations taking groups into areas with cyanide should carry the antidote, amyl nitrite, in ampoule form.

A person with cyanide poisoning will exhibit some or all of the following signs and symptoms:

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• Headache

• Confused and erratic behaviour

• Convulsions

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• Cardiac and respiratory failure • Breath that smells like bitter almonds

MANAGEMENT With cyanide poisoning, there is a high risk of contamination to the rescuer, both from breathing in the vapours and from cyanide being absorbed through the skin. If cyanide poisoning is suspected, use gloves while treating the patient. Avoid vapours from the source and the breath of the affected person. • The best treatment is 100 percent oxygen, so move the patient into a wellventilated area and ensure their airway is open.

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• If the patient stops breathing, do not do rescue breaths as there is a high risk of cyanide contamination to the rescuer. Do chest compressions if there are no signs of circulation (such as colour in the skin).

EXTENDED CARE AND EVACUATION GUIDELINES

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There is nothing that can be done in the field to quickly remove cyanide poison from the body. Anyone exposed to cyanide should be evacuated immediately and seen by a doctor.

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BEE AND WASP STINGS fo

Severe allergic reactions (anaphylaxis) to stings are a real concern. See page 67 for more on anaphylaxis.

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Wasps (Vespula germanica and Vespula vulgaris) are a serious problem in some areas of New Zealand, particularly in beech forests where the populations of wasps are in plague proportions. This can make it challenging to avoid them in the outdoors. A wasp can sting multiple times. They do not leave a sting, so it is not possible to remove the venom once a person has been stung.

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In areas with wasps, several people may get stung more than once. It is a good idea to have an action plan in place before setting out. Move away from the area quickly and calmly before starting treatment.

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A bee sting stays in the skin, using a piston to pump venom through a valve. More than 90 percent of the venom is injected into the skin within 20 seconds. Use the edge of a blade or your fingernail to scrape the sting out, trying not to squeeze the sting as you do so.

MANAGEMENT AND EVACUATION • Remove the sting, if present. • Sit the patient down, keeping them quiet and still. • Put something cold on the sting site straight away to help relieve pain. • Give the patient an antihistamine tablet. It will take 20 minutes or more for the tablet to be absorbed and start to work. • If the patient was stung in the mouth, sips of cold water may help reduce swelling. • Watch for symptoms of anaphylaxis (see page 67) and administer adrenaline if appropriate. • Have the patient rest until they have recovered, before they resume activity.

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CHAPTER 16 | POISONS, STINGS AND BITES

• If the patient is still breathing, give them amyl nitrite. To administer this, hold the ampoule in a handkerchief or shirt tail. Crack it open and get the patient to inhale the vapours.

You will usually only need to evacuate the patient if: • Anaphylaxis occurs.

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• Swelling from stings to the neck, face or mouth causes airway difficulties.

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Figure 16.1 Relieve itching with a cold water pack (improvise with a bladder or plastic bag).

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MOSQUITO AND SANDFLY BITES m

Mosquito and sandfly bites are more irritating than dangerous, though people do have varying degrees of reaction to them.

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MANAGEMENT

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• Try to stop the patient scratching as this could cause the bites to become infected. • Apply a cooling lotion, such as aloe vera. • If the bites are causing a lot of discomfort, give the patient antihistamine tablets. (Antihistamine tablets can be taken in advance to decrease itching.)

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Both dead and live jellyfish can release venom when they come into contact with skin. Even small pieces of tentacle can sting. Remember to protect yourself before treating the patient.

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MANAGEMENT

• Remove any tentacles left on skin by rinsing with salt water. Do not scrape or rub the skin, or rinse it with fresh water, as this will cause the tentacles to release more venom.

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• Remove any visible tentacles with tweezers. If the tentacles are sticky, applying a drying agent, such as talcum powder, baking soda or sand, may make removal easier.

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• Once the tentacles have been removed, immerse the affected area in hot (not burning) water for 15 minutes.

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• Give the patient an antihistamine tablet.

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• Use a pack of iced water to help relieve swelling and pain.

• Monitor the patient carefully.

Figure 16.2 Bluebottle (Portuguese man-of-war) Physalia utriculus

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STINGRAY WOUNDS

Injuries from stingrays can happen when a person steps on a stingray or when they are landing one caught on a fishing line. The stingray’s tail whips up. Serrated barbs on the tail can cause very nasty wounds and also carry venom and bacteria that can cause tissue damage and intense localised pain. The wound may take the form of a laceration or a puncture, and the barb, or a piece of it, may break off and remain embedded in the skin. If any part of the person’s trunk (chest, abdomen, groin or back) is penetrated, this is a serious medical emergency because of the continuing damage to internal organs caused by the venom.

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CHAPTER 16 | POISONS, STINGS AND BITES

JELLYFISH STINGS

MANAGEMENT AND EVACUATION • Control any bleeding. • Immerse the affected part in hot water – 40°C or as hot as the patient can bear – to give temporary relief.

• If hot water fails or is not available, use cold packs.

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• Wash the wound thoroughly, preferably with saline.

• Give the patient pain relief.

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• Whether the barb is embedded or not, the patient needs immediate and expert medical help, so arrange for an urgent evacuation. Stingray wounds can take months to heal.

Figure 16.3 Stingray wounds

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SEA URCHIN (KINA)

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The common sea urchin (Evechinus chloroticus) found in New Zealand is not venomous. Injuries usually occur when a person steps on a sea urchin and the sharp spines puncture their skin. The tips of the spines may snap off and become embedded in the skin. The spine tips are fragile and crumble easily, making them difficult to remove.

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MANAGEMENT

• Clean the wound thoroughly.

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• Remove spines that are lightly embedded and still intact (these are like small splinters under the skin). • Do not remove any deeply embedded spines or spines embedded in joints – these need to be evaluated by a doctor.

Note: Embedded particles may cause infection over time, so be sure to get medical help to remove these.

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CHAPTER 16 | POISONS, STINGS AND BITES

KATIPO SPIDER BITES

The katipo spider (Latrodectus katipo) is smooth, dark and shiny. It is about 1cm in total length with a body less than ½cm long – about the shape of a small pea. It may have a red or white stripe or a series of red spots on its back. It is closely related to the Australian redback spider. Young katipo are small, black and shiny, and just as dangerous as the adult. Only the female is poisonous.

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Katipo spiders are found on or near beaches; under stones, driftwood and plants; and in discarded tins and rubbish. They are usually within 100m of the high-tide mark.

A katipo spider bite will cause localised swelling and severe pain. The patient may sweat and vomit, and feel weak and nauseous.

• Wash the site to get rid of any venom.

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• Do not apply pressure.

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• Keep the patient still and apply cold water packs to the bitten area. Cooling delays the spread of the venom.

Figure 16.4 Katipo spider, total length approximately 1cm

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• The patient will need anti-venom serum, so evacuate them as soon as possible to a hospital. Not all hospitals carry the serum, so ask emergency services to locate a hospital that does.

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REDBACK SPIDER BITES The redback spider is rarely seen in New Zealand. It is similar in appearance to the katipo but prefers highly populated areas.

MANAGEMENT Treat as for katipo spider bites.

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PHOTO COPYRIGHT: Landcare Research – Manaaki Whenua.

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MANAGEMENT

WHITETAIL SPIDER BITES

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Whitetail spiders (Lampona cylindrata and Lampona murina) have shiny black legs and a hairy, black or dark body with a white tip. They grow to 15mm. They prefer warm, dry environments and are commonly found inside and around houses. Their bite is not deadly, but reactions vary from pain only, to painful red marks, to irritated wounds needing medical attention.

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• Wash the site.

• Keep the site clean and protected as the overlying skin may break down.

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• Use a cold water pack to help relieve the pain.

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• Watch for secondary infection.

Figure 16.5 Whitetail spider

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NATIVE NEW ZEALAND CENTIPEDE BITES rm

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Native New Zealand centipedes (Cormocephalus rubriceps) are found mainly on offshore islands and in bush areas north of Taupo. They are active at night and seek warm, dry hiding places under stones and logs during the day. They are dark brown, up to 20cm long and can give a nasty bite. The skin surrounding the bite will be red, sore and swollen and the patient can feel ill, nauseous and tired for a few days.

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PHOTO: Dougal Clunie. COPYRIGHT: Landcare Research – Manaaki Whenua.

MANAGEMENT

MANAGEMENT • Wash the site. • Keep the site clean and allow the patient to rest. Watch for signs of infection. • Use a cold water pack to help relieve the pain.

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CHAPTER 16 | POISONS, STINGS AND BITES

ONGAONGA (TREE NETTLE)

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Ongaonga, or tree nettle (Urtica ferox), is a shrub that grows up to about 3m. It is a native stinging nettle and is found on the fringes of and in the bush throughout New Zealand. The leaves are pale green, narrow and triangular, with a pointed tip and coarse teeth along the sides. The leaves and leaf stalks are covered with long, rigid stinging hairs about 6mm in length. The stings are acidic.

Contact with ongaonga can cause:

• Intense, burning pain with swelling and redness in the affected area

If a patient has fallen into a bush or walked through multiple bushes, they may exhibit:

• Difficulty breathing and/or seeing

• Convulsions and paralysis

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• A severe allergic reaction or anaphylactic shock

MANAGEMENT

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• Crushed-up leaves from dock plants (Rumex spp), which sometimes grow near ongaonga, Figure 16.6 Ongaonga can relieve the pain, as they are alkaline. Some people carry dried dock leaves when tramping. These can be mixed into a poultice and applied to ongaonga stings.

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• Antihistamine tablets and use of a Ventolin inhaler may help.

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• If the patient is showing signs of anaphylaxis (see page 67), treat them with adrenaline and antihistamine tablets.

• If the patient is feeling faint, and/or showing signs of shock, lay them down with their legs raised. • If the stinging hairs are visible in the patient’s skin, use sticky tape to remove them.

EVACUATION GUIDELINES Watch for signs of general distress, such as faster pulse and breathing, and anaphylactic shock. The patient may need adrenaline, so arrange an urgent evacuation.

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PHOTO: Courtesy of Bev Davidson, Oratia Native Plant Nursery

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• Loss of coordination

DRUGS AND ALCOHOL

Different drugs have different effects on the body. Common types of drugs are:

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• Stimulants (caffeine, cocaine, methamphetamine [P])

• Depressants (heroin, morphine)

• Sedatives (alcohol, Valium)

• Hallucinogens (LSD, BZP)

• Solvents (glue, paint)

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• Marijuana

• Various plants

• Mushrooms

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Any kind of drug overdose or sudden withdrawal can lead to an altered level of consciousness, breathing difficulties, seizures and heart failure.

METHAMPHETAMINE (P)

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Methamphetamine, or P, is a highly addictive synthetic drug that affects the brain and the heart. Usage has serious short- and long-term mental and physical health effects. Signs of P use include:

• Rapid eye movement

• Increased body temperature (can lead to heat stroke and death)

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• Sweating (not related to exercise)

• Anxiety

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Signs of continued P use over time include: • Weight loss • Picking at hair or skin • Nose bleeds • Skin sores around mouth and nose • Excessive nail biting • Violence, unpredictable behaviour, mood swings

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Medical problems in the outdoors can occur through drug abuse, overdose and withdrawal. Drug overdoses can be caused by users taking more than they normally do, taking the wrong medication, forgetting they have already taken their medication or intentionally taking too much (attempted suicide).

CHAPTER 16 | POISONS, STINGS AND BITES

P usage can lead to: • Severe mental illness – paranoia, psychosis, hallucinations, violence • Stroke • Heart failure • Seizures

Management

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A person who is using or withdrawing from P can be unpredictable, both mentally and physically. Monitor their behaviour and make conscious choices about safety. If you have concerns, contact the Alcohol Drug Helpline (0800 787 797) for advice.

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MUSHROOMS

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There are many different species of mushroom and toadstool in New Zealand. Some are edible and some are poisonous. Unless you are absolutely sure that a fungus is not toxic, do not eat it.

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ASSESSMENT

Patients who have eaten poisonous fungi may be ‘mad as a hatter, red as a beet, hot as a hare’:

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• Disoriented, confused, acting strangely • Red skin

• Hot skin

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They may also have nausea, stomach cramps, diarrhoea and/or vomiting.

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MANAGEMENT • Contact the National Poisons Centre (0800 POISON, 0800 764 766) for advice on inducing vomiting. • Collect a sample of the ingested fungus for an expert to identify later. • Monitor the patient’s vital signs. • Arrange evacuation if the patient is deteriorating.

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PLANTS There are several plants in the New Zealand bush that are toxic if eaten, for example, tutu (Coriaria arborea). There are also many plants that are quite tasty.

Note: Some plants can be both edible and poisonous, depending on the time of year and growth stage. It is best to avoid these plants.

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If you choose to eat plants growing in the bush, make sure that they are not going to make you ill. Various books on edible and poisonous plants are available.

ASSESSMENT

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Signs and symptoms of poisoning from plants vary depending on the plant ingested. They may include:

• Stomach cramps, nausea, vomiting and/or diarrhoea

• Increased pulse and rapid breathing

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MANAGEMENT

• Collect a sample of the ingested plant for an expert to identify later.

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• Monitor the patient’s vital signs.

• Arrange evacuation if the patient is deteriorating.

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• Contact the National Poisons Centre (0800 POISON, 0800 764 766) for advice.

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APPENDIX III | UNIT STANDARDS

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Search first then send for help as delaying increases length of burial time.

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UROGENITAL CONDITIONS

CHAPTER 17:

IN THIS CHAPTER:

230

SEXUALLY TRANSMITTED INFECTIONS

230

HAEMORRHOIDS (PILES)

231

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URINARY TRACT INFECTION (UTI)

232

FEMALE SPECIFIC ISSUES

234

PHOTO Kerry Adams

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MALE SPECIFIC ISSUES

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The urinary tract is made up of the urethra, bladder, ureters and kidneys.

URINARY TRACT INFECTION (UTI)

Illness or injury of the genitalia and urinary tract can be painful and embarrassing. People may hesitate to tell you they have a problem. Early in the trip and in the pre-trip planning, emphasise the importance of communicating all medical issues.

ASSESSMENT

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A person with a UTI will exhibit some or all of the following signs and symptoms:

• Pain or a burning feeling during urination

• A feeling of urgently needing to urinate or needing to urinate frequently

• Passing only a tiny amount of urine even when the urge to urinate is strong

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MANAGEMENT

• Pain in the kidney and/or pelvis area

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• Cloudy urine (containing pus) or rusty red urine (containing blood)

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• Have the patient drink plenty of water to ‘flush the system’. • Give the patient Ural effervescent powder or baking soda mixed with water.

• Have patients wash the area with soap and water. Make sure they do not use antiseptics or excessive amounts of soap.

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• Have the patient see a doctor to get antibiotics if the symptoms do not subside.

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SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections are transmitted from person to person by sexual activity. They can be bacterial, viral or protozoal. Some are easily treated, but some are not. The patient should seek medical attention if symptoms persist. Sexually transmitted infections include chlamydia, syphilis, gonorrhoea, herpes, hepatitis B, hepatitis C, HIV and trichomonas.

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CHAPTER 17 | UROGENITAL CONDITIONS

ASSESSMENT Signs and symptoms of sexually transmitted infections may include: • Discomfort, pain or burning when passing urine • Abnormal discharge from vagina or penis • Blisters, sores or rashes around or on the genitals • Pain or bleeding during or after sex

• Lower abdominal pain

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• Itchiness around the genitals

• Irregular bleeding

Some sexually transmitted infections show no signs or symptoms, yet they still cause damage.

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MANAGEMENT

• Arrange an evacuation. Have the patient seek medical attention.

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HAEMORRHOIDS (PILES)

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Haemorrhoids (piles) are lumps of swollen tissue, similar to blood blisters, in or outside the anal canal. These lumps can burst and bleed. They can protrude outside the anus or remain inside. They are caused by straining (for example constipation or lifting heavy weights).

ASSESSMENT

Signs and symptoms of haemorrhoids may include:

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• Pain

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• Lumps protruding from the anus • Bleeding when passing a bowel motion

MANAGEMENT • Have the patient increase fluid and fibre in their diet to loosen the stools. • Have the patient add a little extra sugar to drinks to loosen the stools. • Give the patient creams to help reduce itching (seek medical advice on which cream to use). • Have the patient seek medical attention, to ensure that the symptoms are caused by haemorrhoids, not another condition.

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MALE SPECIFIC ISSUES Ureter

Sacrum

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Bladder

Pubic bone

Vas deferens

Rectum

Urethra

Penis

Anus

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Prostate gland

Epididymis Testis

Scrotum

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Figure 17.1 Male urogenital system

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TWISTED TESTICLE (TESTICULAR TORSION)

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Assessment

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This is when the testis twists inside the scrotum, decreasing the blood supply to the testis and causing acute pain. This can occur spontaneously (for example, when rolling over in bed) or be caused by trauma (for example, falling awkwardly in a climbing harness). It is most common in 13–18 year olds.

Signs and symptoms of testicular torsion may include:

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• Sudden pain in one testicle

• Sudden swelling • One testicle sitting noticeably higher than the other • Nausea, vomiting, abdominal pain

Management • Arrange an evacuation as this condition can lead to permanent damage. • Give the patient pain relief. • Rotating the testicle outwards may alleviate the situation. ONLY do this if immediate evacuation is not possible or if you are able to communicate with emergency services to seek advice.

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CHAPTER 17 | UROGENITAL CONDITIONS

ORCHITIS (INFLAMMATION OF THE TESTES) Orchitis is inflammation of one or both of the testes, caused by an infection from bacteria or a virus (such as mumps).

Assessment Signs and symptoms of orchitis may include:

• Swollen testicles

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• Fever and chills

• Nausea

• Malaise and fatigue

• Body aches

• Pain when passing urine

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Management

• Have the patient rest.

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• Arrange an evacuation. The patient will need antibiotics and medical attention.

EPIDIDYMITIS

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Epididymitis is an inflammation of the epididymis (the tube that connects the testicle with the vas deferens and the urinary system). It is usually caused by a bacterial infection.

Assessment

Signs and symptoms of epididymitis may include:

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• Pain that starts gradually and increases near the testicle

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• Blood in urine and abnormal discharge from the penis • Pain in the abdomen and flank • A swollen and tender scrotum • Pain or burning before or after urination

Management • Have the patient rest. • Arrange an evacuation. The patient will need antibiotics and medical attention.

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FEMALE SPECIFIC ISSUES Ovary Sacrum

Uterus

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Fallopian tube Bladder

Rectum

Uterus

Ovary

Cervix

Ovary

Cervix

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Vagina

Anus

Urethra

Pubic bone

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Figure 17.2 Female urogenital system

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MENSTRUAL CRAMPS (DYSMENORRHOEA)

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Menstrual cramps are caused by the uterus contracting due to chemicals (prostaglandin) being released into the uterine muscle. This usually occurs at the start of menstruation.

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If the pain is severe and occurs before and throughout menstruation, it may indicate endometriosis (abnormal growth of menstrual tissue outside the uterus). Mid-cycle abdominal pain usually indicates ovulation.

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Assessment Signs and symptoms of dysmenorrhoea may include: • Aching pain in the abdomen and pelvis (pain can be severe) • Feeling of pressure in the lower abdomen • Pain in the hips, lower back and inner thighs • Upset stomach and vomiting • Diarrhoea The patient may have had similar pains before.

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CHAPTER 17 | UROGENITAL CONDITIONS

Management • Have the patient rest. • Give the patient pain relief, such as ibuprofen (Nurofen) or Aspirin. • Apply a hot water bottle to the patient’s lower back or abdomen. • Have the patient avoid caffeine and alcohol.

Extended care and evacuation guidelines

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• Monitor the patient’s level of pain.

• If the patient says the pain is quite different from usual, consider other possible causes, such as miscarriage, ectopic pregnancy and abdominal problems. Arrange an evacuation. Have the patient seek medical attention.

TOXIC SHOCK SYNDROME (TSS)

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Toxic shock syndrome (TSS) is a life-threatening condition caused by toxins produced by bacteria. The toxins can spread and affect the whole body. TSS is usually associated with leaving tampons in place too long. It can also occur as a result of wounds or skin infections.

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Remind women who are new to the outdoors about the importance of changing tampons regularly and maintaining good hygiene. Discuss appropriate disposal – do not bury used products, as they take years to biodegrade.

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Assessment

Signs and symptoms of TSS may include:

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• Flu-like symptoms • Feeling ill

• Headache

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• Muscular aches • Fever • Vomiting • Diarrhoea • Fainting • Rash

• Symptoms of shock (see page 64)

Management • Have the patient remove the tampon. • Treat the patient for shock.

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Evacuation and long-term care guidelines If symptoms of shock do not decrease, evacuate urgently for medical attention.

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The micro-organism candida usually lives harmlessly on the body. However when the balance of bacteria and hormones is upset, candida can multiply, resulting in thrush. Vaginal thrush is most common during pregnancy, during menopause, when on the contraceptive pill or after taking antibiotics.

Assessment

Signs and symptoms of thrush may include:

• Vaginal discharge with a thick, white consistency, like cottage cheese

• Itchy and burning feeling when passing urine

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• Tenderness around the vagina

Management

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The patient should:

• Wear loose-fitting clothing and dry cotton underwear (change out of damp underwear or swimsuits as soon as possible).

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• Maintain good hygiene.

• Wash underwear thoroughly during an infection, preferably in hot water.

• Change tampons and sanitary towels regularly.

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• Apply prescribed anti-fungal cream.

• Avoid antiseptic creams.

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PELVIC INFLAMMATORY DISEASE (PID)

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Pelvic inflammatory disease is an infection of the uterus, fallopian tubes and peritoneum. It can have various causes, such as: • Sexually transmitted infections • Intrauterine devices (IUDs) • Miscarriage • Abortion • Giving birth

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CHAPTER 17 | UROGENITAL CONDITIONS

Assessment Signs and symptoms of PID may include: • Lower abdominal pain • Fever • Unusual vaginal discharge that may have a foul smell • Pain during intercourse • Irregular menstrual bleeding

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• Septicaemia (see page 64)

Management

• Arrange an evacuation, for medical attention and antibiotics.

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PREGNANCY

Assessment

Signs and symptoms of pregnancy include:

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• Unusual fatigue

• Enlarged and tender breasts • Nausea, maybe vomiting

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• Not having a period for 2 weeks or longer after it is due

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• Frequent urination

MISCARRIAGE (SPONTANEOUS ABORTION)

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Approximately 10–25 percent of recognisable pregnancies end in miscarriage. Most miscarriages occur within the first 13 weeks. It is a common occurrence, but it can be emotionally upsetting. The cause is often unknown.

Assessment Signs and symptoms of a miscarriage include: • Mild to severe back pain, worse than normal menstrual cramps • Contractions, like period pain • Brown or bright-red bleeding, with or without cramps • Tissue with clot-like material passing from the vagina

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Management • If bleeding settles to just a heavy period and there is no abdominal pain, it is not a medical emergency and the patient does not need to be evacuated. However, the patient should seek medical advice as soon as is practical. • If the body does not expel all the tissue, continued bleeding (haemorrhaging) and infection can occur. Arrange an urgent evacuation.

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In an ectopic pregnancy, the foetus has settled in the wrong place, usually the fallopian tube, where it cannot survive. As the foetus grows, the tube can burst, causing severe bleeding. This is a medical emergency.

ECTOPIC PREGNANCY

Assessment

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Signs and symptoms of an ectopic pregnancy include:

• The early signs of pregnancy (nausea, breast tenderness, increased frequency of urination)

• Pain in the pelvis or across the abdomen, often worse on one side

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• Pain when coughing or walking • Dark vaginal bleeding

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• Acute abdominal pain, similar to appendicitis, that may radiate up to one or both shoulders

• Signs and symptoms of shock, due to blood loss and pain (see page 64)

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Management

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Arrange an urgent evacuation.

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APPENDIX III | UNIT STANDARDS

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Search first then send for help as delaying increases length of burial time.

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EVACUATION

CHAPTER 18:

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IN THIS CHAPTER:

240

HANDOVER REQUIREMENTS

242

SENDING FOR HELP

243

HELICOPTER SAFETY

254

PHOTO Kerry Adams

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MOVING THE PATIENT

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In New Zealand, help is only a few hours or 1–2 days away for most people needing evacuation in the outdoors. You can communicate with rescue teams quickly, with mountain radios, distress beacons and mobile phones (where there is coverage). Often you can care for the patient where they are. Sometimes you need to move them to a safer site or to a helicopter landing area. Do not move the patient further than necessary.

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When possible, leave the transport of the patient to the helicopter crew or trained personnel, to minimise risk to the injured person and the party members. Concentrate on caring for the patient until help arrives.

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Carrying a stretcher in the outdoors on any surface other than flat, wide, smooth terrain, requires a minimum of 18–24 skilled people working in teams of 6–8. In narrow, rough, steep areas, or through streams where firm footing is essential, the rescuers need to form a conveyor belt to prevent injuring the patient or themselves. This process is time-consuming and can be physically and mentally exhausting.

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To get a rough estimate of the time it will take to carry someone on a stretcher, multiply the normal walking time by six, for example, a 1-hour walk becomes a 6-hour carry. The size of the party and the equipment they are carrying usually eliminates this option immediately.

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SENDING FOR HELP BY PHONE OR RADIO

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If you need assistance in the outdoors and are able to communicate by radio or phone, call 111 and ask for the police. The person who answers may not have first aid training, so they may not be aware of the life-threatening nature of some injuries. State very clearly the severity of the accident or illness, and the urgency with which medical help is needed. For example, ‘The patient has a broken thigh bone, with major loss of blood and severe shock. Help is required immediately’. Even if you believe a helicopter is required, do not request one. Emergency services will determine the response plan. Give the map series, number and grid reference, and a precise description of your location. Describe your surroundings, including high points and features. Ask the receiver to repeat your message to you so you can check that this information has been recorded accurately. Make a time to reconnect. If calling on the mountain radio outside the scheduled time, call on various channels. If there is no response, keep trying. Repeat a message even if there is no response, because sometimes your message is received without you hearing the listener.

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If you activate a distress beacon and later make contact (for example, by mountain radio), make sure you tell the listener about the activated beacon (including the serial number and owner). That way emergency services will know there is one situation, not two.

WALKING A MESSAGE OUT

Written incident and group details

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If you have no way to communicate electronically, you need to send people out with a detailed message. It is preferable for two people to go, each carrying sufficient food, water and gear for their own safety. They should clearly mark their route, using cairns, coloured materials (long strips cut from an orange survival bag are excellent) or arrows made from sticks or stones. These markers are particularly important if the remaining party is not at an easily identifiable location.

Figure 18.1 Getting help. Two people with enough gear for their own safety should go for help.

The party going out should carry a written message to the police. Even if they think they can remember the important details, they need to write them down. Memory is often unreliable in times of stress. Before sending people away for help, ensure you have gathered sufficient information. The written message should include: • What has happened, what assistance you require and the level of urgency

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• Details of the accident or illness • Details of the condition of the patient (see SAMPLE history, on page 16) and records of their vital signs showing trends • What treatment has been administered • Name, age, address and any known medical conditions or other details of the patient • The exact location of the group, preferably marked on a map • The names and addresses of all the group members

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• Any known medical conditions, allergies and so on, of the group members

• Details of the physical and mental condition of all involved

• Details about the gear the group has, such as clothing, shelter and food

• Details about the knowledge and skills the group has

• Information about the weather, river and snow conditions in the area

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• An approximate travelling time from the road end

• Advice as to whether or not a helicopter needs winching facilities, due to difficult terrain for landing

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After you send the message out, you will have to wait for assistance to arrive. The nature of assistance – whether it is a ground party or a helicopter – is a police decision. If you privately request a helicopter, you will have to pay for it.

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HANDOVER REQUIREMENTS ay

When the rescue party arrives, remember to give them the written records that you have been keeping since the incident occurred, including:

• SAMPLE history (see page 16)

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• Vital signs (at least three sets taken over time)

• Findings from your head-to-toe examination

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• The name, age, address and phone number of patient

• The name and address of a contact person for them, such as their next of kin • What treatment or medication you gave them and when, and how the patient responded

The mnemonic MIST can give some structure to your handover notes: Mechanism (what happened) Injury (what is hurt or broken) Signs and symptoms (SAMPLE, vital signs and head-to-toe examination findings) Treatment (what treatment has been provided)

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Figure 18.2 Handover requirements. Give the patient’s details, medication and any other key items to the rescue party.

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MOVING THE PATIENT Sometimes you will need to move the patient to a safer site or to a helicopter landing area. Do not move the patient further than necessary. Unless the patient is in immediate danger or the site is too difficult to treat them on, treat any injuries before moving the patient. When you are ready to move them, decide which carrying method is most suitable for the patient’s condition and the safety of the carriers. • Check the route, clearing away any obstacles. Prepare a sheltered site, with ground insulation in place, before beginning to move the patient. • If necessary, put sunglasses on the patient to protect their eyes. Use gloves, socks and a hat to keep their head and extremities warm.

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Keep the notes dry and clean in a plastic bag on or close to the patient. Also, give the rescue party any personal belongings, such as medications, that will be required by the patient.

• Make sure the carriers know how to lift, keeping their backs straight and using their leg muscles to lift. Place carriers of about the same height opposite each other. Do a practice lift and carry with an uninjured person first. • Before lifting them, tell the patient what you are doing. • Communicate with the other carriers, for example, ‘Ready to lift? Lift!’

• Move slowly and smoothly. Have someone (not a carrier) guiding the carriers, pointing out obstacles such as tree roots, rocks and holes.

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• When the patient is on a stretcher, carry them feet first when travelling on flat ground or downhill slopes. This makes breathing easier. It also lessens the risk of damage to the head should they slip off the stretcher. Carry the patient head first when you are travelling uphill.

• Lift the patient slowly.

• Have someone at the patient’s head, monitoring their condition, reassuring them and explaining what is happening.

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• Make sure carriers swap sides often to prevent back strain.

CARRYING METHODS

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One-person human crutch

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Use the one-person human crutch when a person has minor injuries and can walk with assistance. The carrier should be no taller than the patient.

• The carrier stands next to the patient, with one hand around their waist.

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• The patient puts one arm around the carrier’s back. • The patient and the carrier move together slowly.

Two-handed seat

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Use the two-handed seat when the patient cannot support themselves. This method needs two carriers of about the same height. They should remove their rings and watches first. • The carriers should be on either side of the patient. • Each carrier puts one hand under the middle of the patient’s thighs and grasps the other carrier’s wrist. • The carriers support the patient’s back with their other arms.

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Figure 18.3 Two-handed seat

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Three-handed seat with back support

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Use the three-handed seat when the patient needs some back support. This method needs two carriers of about the same height. They should remove their rings and watches first.

• The carriers should be on either side of the patient.

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• The carriers should link three hands under the patient.

• The carrier with one free hand should place their arm on the other carrier’s shoulder, firmly gripping the other carrier’s pack strap or clothing.

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Four-handed seat

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Use the four-handed seat when the patient can support themselves. This method needs two carriers of about the same height. They should remove their rings and watches first. • The carriers should be on either side of the patient. • Each carrier grasps their own left wrist and their partner’s right wrist to make a seat (see figure 18.4). • The patient places their arms around the carriers’ shoulders.

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Figure 18.4 Four-handed seat

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One-person back carry with rope Use the one-person back carry when you have a rope available, and when the patient is small and the rescuer is strong. • Divide a coiled rope into two loops. • Make a seat for the patient by placing their legs through the loops. • Place the loops over the carrier’s shoulders to act as shoulder straps. • Pass a short length of rope or webbing around the patient’s back. Cross it in front of their chest then over the carrier’s shoulders. The carrier can hold this short rope to support the patient and to lessen the likelihood of the patient falling backwards.

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CHAPTER 18 | EVACUATION

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One-person drag or two-person fore-and-aft carry

Figure 18.5 One-person back carry with rope

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(a)

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• The patient crosses their arms on their chest.

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• The carrier stands behind them, reaches through under the arms and holds the patient’s wrists. The carrier can then haul the patient backwards, with their feet dragging.

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• For a two-person carry, a second carrier can lift the patient’s feet up. The two rescuers then walk forwards, carrying the patient facing ahead.

Figure 18.6 Two-person fore-andaft carry

STRETCHERS A stretcher is used when the patient needs to be kept lying down, or if it is the safest method of transport for the patient and/or the carriers. A stretcher is the best way to move an unconscious patient. Have someone at the head of the patient checking at all times that their airway is open.

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If a stretcher is not available, you may be able to improvise one using one of the methods described below. If a stretcher carry is needed, follow the general instructions for moving the patient (see page 243), and: • Strap the patient on to the stretcher.

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• Communicate with the other carriers, and lift and lower the patient slowly on an action word. For example, the leader should call, ‘Ready to lift? Lift!’ All calls for the movement of a stretcher should be given by the person at the head of the patient.

• Have three or four people on each side of the stretcher, each kneeling on one knee. Place people of about the same height opposite each other.

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Figure 18.7 Lifting a stretcher

Figure 18.8 Carrying a stretcher

248

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You should only use improvised stretchers for carrying a patient a short distance.

Figure 18.9 Improvised pole stretcher (survival bag)

Sleeping bags or survival bags

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• Lay the patient in the centre of the bag.

• Use a minimum of four people with their hands placed at the heaviest points of the body.

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• Pull firmly outwards when lifting.

• Roll the edges of the bag close to the patient to create a strong handhold.

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If poles are available, put them inside a survival bag with a hole cut in each corner. Be aware that the cut corners of the survival bag will stretch and tear after a while.

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Flysheet or tarpaulin

• Find two 2.5m poles (for example, tent poles, walking poles or stout branches) that will bear the weight of the patient.

• Fold a flysheet or tarpaulin into a 2m by 4m rectangle.

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• Place the poles in the centre of the rectangle, perpendicular to the long edge of the sheet. The poles need to be the patient’s shoulder-width apart. Have both of the poles extending evenly beyond the sheet. These will become the handles of the stretcher. • Fold one edge of the sheet over the first pole, and place it under the second pole with at least 10cm of material to spare on the outside of the pole. Fold the other side of the sheet over both poles. This locks the first half of the sheet in place. The patient’s weight will hold all the folds in place.

Figure 18.10 Improvised pole stretcher (flysheet or tarpaulin)

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Improvised stretchers

Raincoats and jackets You will need two poles that are longer than the patient, and enough raincoats, jumpers or jackets to support the length of the patient’s body. • Pull the sleeves of the clothing inside out and pull them down the inside of the garment. This increases strength at the seams.

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• Slide the poles through the sleeves of all the items of clothing to join them together as the bed of the stretcher. Be aware of gaps forming between items on the poles. Avoid this by bunching the items together.

• Do up all zips and buttons and have them facing the top. Fold all hoods and cords into the top to prevent them snagging on obstacles.

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Figure 18.11 Improvised pole stretcher (clothing)

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Insert pole down the sleeve on the inside of the clothing. Use several pieces of clothing to prevent gaps opening up.

Packs

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• Empty three packs, removing side pockets (if possible) and securing any dangling straps.

• Position the shoulder straps up.

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• If you have two poles that are longer than the patient, slide the poles down the compression straps and secure them.

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• If you do not have poles, lay three packs end to end and link them together using the shoulder straps.

Figure 18.12 Improvised pack stretcher

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CHAPTER 18 | EVACUATION

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Take the long end of rope from one side and tie a clove hitch next to the end of each loop. Insert one loop through each clove hitch so that it extends out the other side of the clove hitch. Repeat along the other side.

Use a 50m (minimum) climbing rope. Find the centre of the rope and lay out 8 loops in a zigzag on either side of it, 16 loops in total. Adjust the width and spacing of the loops so the final product is as wide and as long as the patient. Lay the ends of the rope down around the length of the zigzags.

Rope

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Clove hitch

Continue until all the loops are bound.

Thread the remaining rope through the loops extending out the clove hitches. Continue around and around until all the rope is coiled around the stretcher.

Tighten up all the knots, tie off the ends and put a sleeping mat (or three) on top of the rope stretcher for the patient to lie on. By adding more sleeping mats, you increase the stretcher’s rigidity.

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Figure 18.13 Making a rope stretcher

Note: This stretcher is not appropriate for a patient with a spinal injury as it is not rigid enough. This stretcher takes a long time to set up. You need to size it well when laying out the zigzag loops, so that you do not have to adjust it multiple times to fit the patient. The benefits of this method are that the multiple handholds allow for multiple carriers, so the weight of the patient can be distributed over many people. This makes it easier to carry long distances and it is surprisingly comfortable for the patient.

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SLEDGES Bivvy bag • Open up a bivvy bag and place a sleeping mat inside. • Place the patient in a sleeping bag on top of mat.

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• Lay rope in a zigzag across the bag and fasten it at each object, using a clove hitch (see figure 18.14).

• Place smooth, egg-sized objects (such as stones) along the inside of bivvy bag, four on each side.

Figure 18.14 Improvised bivvy bag sledge

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• Place skis side by side, touching at the front and with 30cm between them at the back (see figure 18.15a). • Use rope to secure the skis together at the front. • Secure the skis near the bindings, using a snow-shovel handle or shortened ski pole.

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• Securely attach the snow shovel to form a seat.

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Carabiners

Figure 18.15 Ski and shovel sledge

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CHAPTER 18 | EVACUATION

Skis and snow shovel

HELICOPTER SAFETY Unless a natural landing site exists nearby, in most cases it is easier to have an injured person winched into a helicopter rather than having the ground party spend a lot of time clearing a special landing site.

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WINCHING

• Be ready to give assistance to the crew member being winched down if necessary, by reaching out to help where footing is difficult or hazardous, for example, on the side of a mountain, slippery boulders, pinnacles or ridges.

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• Be aware there will be a build-up of static electricity from the helicopter that is discharged along the winch cable to the rescue strop. Ensure that the strop is grounded and any static build-up has dissipated before touching either the strop or the rescuer riding the cable. The static discharge can be strong enough to knock an adult to the ground, especially in wet conditions.

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• Ensure the winch and strop do not get caught in trees, cables or fences.

PREPARING THE SITE

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Sometimes the helicopter will have to land, so you will need to prepare a site. • Find a large, flat, clear area.

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• Clear the area of any loose material that could be blown away by the downdraught of the helicopter’s rotor.

• Secure all equipment and clothing that could be caught up in the downdraught.

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• Thoroughly douse any fires. Embers may be blown around by the downdraught. Flying embers can make holes in tents and clothing or set fire to bush.

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• Remove and roll up the mountain radio aerial if one was used around the landing zone.

• Position the party together, squatting at the edge of the landing zone, with their backs to the wind. In this position, the party will be facing the front of the helicopter when it lands, in full view of the crew.

Helicopters land and take off into the wind. The pilot may attempt a dummy landing or hover to test the wind direction. You can indicate wind direction to the pilot by: • Standing with your back to the wind, with arms indicating the direction the wind is blowing in. • Lighting a small, smoky fire, at least 100m downwind from the landing site. Be sure to douse it thoroughly when the helicopter is coming in to land.

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• At night, holding a single strobe light overhead and upwind of the landing site, or holding a torch at the upwind end of the site. This can help direct the crew to the landing site. Shine the torch at the ground. Never shine a torch directly at the helicopter, as you may affect the crew’s vision, especially if they are using night-vision apparatus.

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REMEMBER

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At night, the crew does not have the normal visual indications of wind, so they may depend on you to indicate wind direction.

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Hats off

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No loose clothing, tents or equipment

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Figure 18.16 Indicating wind direction to helicopter pilot

ATTRACTING ATTENTION It is very easy for those on the ground to see a helicopter, but often it is very hard for the helicopter crew to spot people on the ground, especially in dense bush, or on mountains and snow. From a helicopter, people can look like small black rocks. Attract the attention of the crew by: • Tramping out a large H if you are in snow. • Placing a brightly coloured sheet, such as a yellow pack liner or orange survival bag, on the ground. Secure it with stones, sand or snow on the corners. Remove it as the helicopter approaches.

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• Securely tying a brightly coloured tie or cloth to a tree, so it flutters in the wind to show the wind direction.

• Waving brightly coloured clothing (be careful to keep the clothing secure in the downdraught when the helicopter approaches). • Reflecting light using mirrors, tin foil, a survival blanket or any other reflective material. • Lighting a smoky fire (be sure to douse it thoroughly when the helicopter is coming in to land). • Waving torches (but do not point them directly at the helicopter).

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• Asking the rescue service for direct communication with the pilot so you can help them locate you (that is, ask the rescue service for the appropriate radio frequency on which to transmit).

• Vigorously shaking tall scrub in the opposite direction of any wind.

APPROACHING THE HELICOPTER

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You should practise the following safety standards whether the rotors are turning or have stopped:

• Secure all clothing and equipment. Loose gear can get blown around by the downdraught, get caught in the rotors and cause the helicopter to crash.

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• Watch the pilot and establish eye contact. Only approach the helicopter when a crew member signals that it is okay to do so.

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• As you approach, bend down slightly to stay clear of the rotors. However, watch the crew at all times for indication of any changes to their clearance to approach.

• Approach and leave from the front of the helicopter. The pilot cannot see you at the rear of the aircraft. Remember, the tail rotor is lethal.

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• On uneven ground, always approach from the downhill side, maintaining eye contact with the pilot. The main rotor is closer to the ground on the uphill side.

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• If carrying skis, keep them horizontal. If carrying firearms, keep them pointing towards the ground. When boarding the helicopter, take care not to point any weapon towards the crew.

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• If you are blinded by dust, crouch down and wait until you can see again. Re-establish eye contact with the pilot. Do not move until the dust has settled and you are signalled to approach. • Board a hovering helicopter smoothly and slowly. Only put one person’s weight on the skids at a time. Follow the directions of the crew regarding seating arrangements. • Any dangerous cargo (such as gas cylinders, fuel bottles or ammunition) should be placed in a separate container and declared to the crew before take-off.

• Don’t use flash bulbs on cameras when the helicopter is landing or taking off.

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Figure 18.17 How to approach a helicopter

Skids

Figure 18.18 Helicopters and hills (always approach a helicopter from the downhill side)

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CHAPTER 19 | NURSING THE PATIENT

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Search first then send for help as delaying increases length of burial time.

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NURSING THE PATIENT

CHAPTER 19:

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IN THIS CHAPTER:

WRAPT 260

HYGIENE 260

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TOILETING 260

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NUTRITION 260 POSITIONING 261

EXERCISE 261

MONITOR AND RECORD

262

PHOTO Jen Riley

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SUPPORT 261

259

In some cases, people who are sick or injured will need long-term care until they recover enough to walk out or while waiting to be evacuated. After you administer first aid, there are other needs for you to consider. Where possible, encourage the patient to do what they can for themselves.

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Remember: Warmth, Reassurance, Assess again, Positioning, Treatment (see page 24).

WRAPT

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HYGIENE fo

• Make sure the patient’s face and hands are washed. Attend to their hair and teeth regularly.

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• If an immobile or unconscious patient needs a full-body wash, use plastic bags, pack liners or raincoats to protect their bedding.

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TOILETING

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• Ensure you wash your own hands thoroughly before and after helping the patient wash.

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• If the patient cannot move outside, ensure their privacy. Use a billy, plastic bags, water bottles, towels or anything you can think of that will do the job. Use plastic bags, pack liners or raincoats to protect bedding.

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• For an unconscious patient, place towels to catch urine and bowel motions. Check the towels often: wash and dry the area carefully when needed.

Ensure you wash your own hands thoroughly after helping the patient with toileting.

NUTRITION • Conscious patients need to drink small amounts regularly to prevent dehydration. Preferably, they should drink isotonic drinks, soups, water or

260

• Offer the patient small, easily digested meals, such as instant potato, pasta or porridge. • Avoid giving solid food to a patient showing signs of shock. They will not be able to absorb it and may vomit.

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POSITIONING pu

• Ensure the patient is comfortable, perhaps by swapping a tight-fitting sleeping bag with a loose one.

• Ensure there is good padding and insulation under the patient.

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EXERCISE

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• Turn unconscious or immobile patients every two hours to avoid pressure sores. Buttocks, shoulder blades, elbows and heels are particularly susceptible to pressure sores. Gentle massage can improve circulation to those areas.

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• If the patient can walk, they should do so several times a day to help circulation and breathing.

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• If a patient is immobile, encourage them several times per hour to do simple muscle stretching exercises, and to breathe deeply. A patient who is breathing shallowly should be encouraged to cough occasionally to get rid of any build-up of sputum.

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SUPPORT

Have someone stay and talk with the patient at all times. They should offer reassurance and understanding, and create privacy and quiet times for rest when needed. Remember that semi-conscious patients may still be able to hear, and they also need constant reassurance.

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diluted fruit juice. Avoid caffeinated drinks such as tea, coffee and cocoa as they increase urination.

MONITOR AND RECORD While nursing the patient, monitor and record: • Accident/illness details, including the time and date • Any medication you administer (what, when and how much) • The vital signs every 1, 2 or 4 hours, depending on the patient’s condition

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• Any changes in the patient’s general condition

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Search first then send for help as delaying increases length of burial time.

IN THIS CHAPTER:

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FATALITIES

CHAPTER 20:

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CARE OF THE DEAD

265

PHOTO Peter Waworis

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POLICE REQUIREMENTS

264

263

Fatal accidents do occur in the outdoors, and you may find yourself caring for a group member who is dying. You must do all you can, within your knowledge, to sustain their life, even if you feel your efforts may be unsuccessful. There may be some consolation in knowing that you did your best.

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A dying person may ask you to pass on messages to family and friends. Listen carefully and write down what they say for the sake of accuracy. Reassure your patient that you will treat these messages in confidence and will relay them only to the intended people.

Not all fatally injured people are unconscious. Some may be surprisingly alert and in control of their emotions. Seriously ill patients who believe they are dying need reassurance that you are doing everything you can for them.

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CARE OF THE DEAD bl

Treat the body with respect, but do not put yourself at risk to recover or evacuate the body. Protect it from the weather as much as possible. Where possible, look after any personal belongings for the next of kin.

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Advise the police of the death as soon as possible, as a doctor will be needed to legally certify the death. Remember to keep written records of the incident, as you may have to appear in a coroner’s court.

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If you come across a dead body, try to disturb the area as little as possible by having the group move away in the same direction as they approached. The police will need to do an investigation to determine the possibility of foul play and any movement in the area could destroy essential evidence.

If you come across a body that has been dead for some time, signs are not hard to recognise:

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• There will be no breathing or pulse, or any other signs of circulation.

• The body will be the same temperature as the surrounding area.

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• The skin will be a pale greyish colour, which may be darker and bluer where it touches the ground. • The pupils of the eyes will be dilated and will not respond to light. • The surface of the eyes will be glazed and dry. • There may be a smell of decay. • The limbs will be stiff (rigor mortis).

If the first four of these signs are found, it is reasonable to assume that the person is dead. However, remember that the breathing and heartbeat of a severely hypothermic patient can be so slow that they may be impossible to detect. When leading a group, be sensitive to the fact that people from different cultures will have different responses to and ways of handling a dead body.

264

When possible, leave the body and scene undisturbed. You may need to move the body if: • The body is in danger, for example, from falling rocks, a rising river, animals or debris.

• The body may get lost or swept away.

• You think it is best for the psychological safety of the group.

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• The body is in an unstable situation, such as on cliff edge or river bank.

If you do move the body, you can assist the police by:

• Taking photos before moving the body

• Marking where the body was

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• Drawing a picture of the scene before the body is moved

• Asking the group to consciously remember details of the scene

• Writing down details to help you remember them

• Trying to disturb the scene as little as possible

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• Providing location details with grid reference

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If it is physically and emotionally safe for the group, try to stay in the vicinity of the body until the police arrive. Otherwise, take careful note of the location of the body. Leave a note with the body to say it has been found and the police have been notified.

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It is best to let the police notify next of kin. Control all group communications to ensure this news does not filter out by other means (such as mobile phones in the party).

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REMEMBER

The mountain radio is on open airwaves, so do not announce that there has been a death or name the dead person. Instead, ‘request police attendance’.

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CHAPTER 20 | FATALITIES

POLICE REQUIREMENTS

266

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CHAPTER 21 | CRITICAL INCIDENT STRESS

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Search first then send for help as delaying increases length of burial time.

CHAPTER 21:

IN THIS CHAPTER:

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CRITICAL INCIDENT STRESS 268

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SIGNS AND SYMPTOMS

PHOTO Kerry Adams

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MANAGEMENT 268

267

For the purposes of this chapter, a critical incident is one where a person is severely injured, becomes critically ill or dies. Critical incident stress can be defined as a normal response, experienced by normal people, to an abnormal event. It is important that the leader and group members know that emotional reactions to an accident are normal and should be expected, and unusual behaviour from group members may be a direct result of stress.

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SIGNS AND SYMPTOMS al

People may experience critical incident stress immediately, or a few hours or even days after the event.

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• There may be physical responses such as fatigue, nausea, headaches, upset stomach, diarrhoea or shock-like symptoms.

• Emotional responses may include anxiety, fear, anger, irritability, grief, guilt and depression.

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• Thinking processes may be affected, resulting in confusion, memory lapses, reduced attention span and difficulty concentrating and making decisions.

• Having distressing dreams and mentally reliving the event are common.

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These symptoms can last for a few days, a few months or longer, depending on the severity of the incident. Group members will need emotional support during and after the incident. This includes the leader, who will not be immune to the effects of stress.

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MANAGEMENT In fo

• As soon as it is practical, that is, once the patient is stable, talk to the party about the feelings they may experience as a result of the incident. Explain that stress reactions are normal and should be expected. • Ensure the group members attend to their physical needs for food, fluids and warmth.

• It can help stressed people to have their focus shifted from the incident. Where possible, move them away from the patient and give them constructive tasks. Use clear, simple instructions. • A group member suffering an acute stress reaction may sit and stare blankly, wander aimlessly or behave irrationally. Have someone stay with them, assuring them that what they are experiencing is normal and answering their questions honestly.

268

A debriefing session after the incident helps to relieve stress by allowing people to share their experiences and have their feelings validated. It is very reassuring for group members to discover that others experienced identical or similar emotions. A debrief also allows the leader to gauge the well-being of the group.

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Timing of the debrief will usually depend on where you are, the severity of the incident and the mental and physical state of the group. A group on a day trip may be too exhausted when they reach the road end to do anything more than just go home to sleep. Parties who plan to have one or more nights in the outdoors after the patient is evacuated may benefit from debriefing once they are fed and rested. Use your judgement to decide what is in the best interest of your party. Debriefing seems to provide the best results if done within 24 hours of the incident. It must be done within a week if it is to be successful.

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Debriefing sessions are held for the express purpose of alleviating stress. They are not about evaluating performance. Any debrief for analysing the incident and its management should be held at a different time.

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Gather the group together in a quiet area. Some people find it difficult to express their feelings, so you will need to create a safe and confidential environment to enable them to do so.

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Give each person the opportunity and the time to talk about the thoughts and emotional reactions they had during the incident. Offer positive reassurance that these reactions are normal.

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Allow time for questions and to clarify what happened. Describe the possible symptoms of long-term stress, and encourage the group members to seek professional help if these symptoms persist.

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Debriefing should not create more stress, so using an external facilitator can help. Seek advice from someone like your GP, your church or the Department of Labour on how to contact a trained critical incident stress counsellor. Depending on circumstances, the group leader may ask for a counsellor to be brought to the scene, to meet the group at the road end or to act as a facilitator when the group meets for a debrief at a later date.

269

CHAPTER 21 | CRITICAL INCIDENT STRESS

DEBRIEFING

270

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IN THIS SECTION:

CHAPTER 21 | CRITICAL INCIDENT STRESS

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APPENDICES

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Search first then send for help as delaying increases length of burial time.

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MNEMONICS USED IN FIRST AID

274

FIRST AID KITS

272

PHOTO Bex Dryland

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UNIT STANDARDS 278

271

APPENDIX I:

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MNEMONICS USED IN FIRST AID

Accident details, Chief complaint, History, Eat and drink, Vital signs, Examine

Patient assessment

AEIOUTIPPS

Alcohol, Epilepsy, Insulin, Opiates, Urea and metabolites, Trauma, Psychiatric, Poison, Shock

Causes of unconsciousness

AVPU

Alert and oriented, Voice, Pain, Unresponsive

Levels of consciousness (see page 22)

CIMS

Coordinated Incident Management System

DRSABC

Danger, Response, Send for help, Airway, Breathing, Circulation/CPR

FAST

Face, Arms, Speech, Time

MIST

Mechanism (what happened), Injury, Signs and symptoms, Treatment (that patient has received)

PEARL

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ACHIEVE

Managing an emergency using multiple agencies (see page 12) The first step of patient management (see page 14) Recognising signs of a stroke (see page 199)

Handing over information to emergency services (see page 242) Vital signs, symptoms of head injury (see page 24)

Preserve (life), Prevent (the patient deteriorating), Promote (recovery)

The aims of first aid

PQRST

Provoking pain, Quality, Region/Radiating, Severity (1–10), Timing (how long has the patient had this pain?)

Quantifying pain

RICE

Rest, Icy cold, Compression, Elevation

Treatment for sprains and other soft tissue injuries (see page 129)

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Pupils Equal and Reactive to Light

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PPP

272

Signs/symptoms, Allergies, Medications, Past medical history, Last ins and outs, Events prior

Second assessment of a patient (see page 16)

SCALD

Size, Cause, Age (very young or elderly), Location (face, hands, feet, genitals), Depth

Assessing the severity of a burn (see page 138)

SOAP note

Subjective Objective Assessment Plan

Patient assessment and the following plan

Subjective – symptoms, what does the patient feel?

Doctors often use this method when taking notes on a patient

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SAMPLE questions

Objective – signs, what does the first-aider see, feel and hear?

Head-to-toe exam

Vital signs Assessment – diagnosis

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Long-term care of patient (see page 24)

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Warmth, Reassurance, Assess again, Positioning, Treatment

WRAPT

Plan – what are we going to do?

273

APPENDIX I | MNEMONICS USED IN FIRST AID

SAMPLE

APPENDIX II:

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SUGGESTED PERSONAL FIRST AID KIT

FIRST AID KITS

ITEM

Crepe bandages 100mm

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Triangular bandage cloth (sterile)

Plastic strip dressing (Band-Aids)

Dressing strip

QUANTITY

1 1 6–10 1 2–3

Gauze dressings

2–3

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Non adherent sterile dressings various sizes

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Sticking tape Paracetamol

Ibuprofen

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Antihistamine tablets

Insect repellent

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Sunblock

1 roll 5–10 5 3–6 1 1

Lip balm

Safety pins

Scissors

Disposable gloves

Disposable CPR face shield

Notebook

Pencil

Personal medication

274

2 10–12

Dressing strip

APPENDIX II | FIRST AID KITS

pu 3

Non adherent sterile dressings – large

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Gauze dressings

Wound dressing (large, for example, sanitary pads)

Butterfly closures

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Sticking tape

1 1 10 1 roll 2

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10 10 5

Antihistamine tablets

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Alcohol wipes Paracetamol

Betadine for grazes

Ibuprofen

Wound dressing (small)

Saline 30ml

Triangular bandages cloth (sterile) Plastic strip dressing (Band-Aids)

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QUANTITY 1 of each

ITEM Crepe bandages 10cm and 15cm

SUGGESTED GROUP FIRST AID KIT

Diarrhoea treatment: Gastrolyte sachets for dehydration, diarrhoea,

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vomiting

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Chemical warming packs

Low-reading clinical thermometer

Scissors

Tweezers

Safety pins

Needle

Fine strong thread, such as dental floss Disposable gloves

Disposable CPR face shield

Notebook and pencil

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PERSONAL FIRST AID KIT FOR MOUNTAINEERING ITEM

QUANTITY ITEM

QUANTITY

Notebook

Small pencil

Low-reading clinical thermometer

Rubber gloves

DRESSINGS Zinc oxide sticking plaster

Alcohol Steriswabs

2.5cm width roll

Betadine (iodine) swabs

Extra large Tubular gauze bandage

(ie Tubegauze bandage) - 30cm

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Triangular bandage

Small Systenet bandage - 30cm

Sanitary pad

Large safety pins

Medium safety pins

Small safety pins

Handyplast elastic dressing

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Mefix - 5cm width roll Rondoflex bandage

Medium Systenet bandage - 30cm

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Insulation tape

(ie Tubegauze bandage) - 30cm

Selection of strip dressings

Large Tubular gauze bandage

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Sterile gauze squares 75mm x 75mm 10 Steri-strips (packet of 5)

Paranet gauze

Small pair eye scissors

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with pad 8cm x 0.9mm

Buccastem 3mg (anti-nausea)

Codeine 15mg

Nifedipine 10mg*

Ibuprofen 200mg

Dexamethasone 4mg*

Imodium 2mg

Throat lozenges

Phenergan 10mg

Soluble Aspirin 300mg

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TABLETS

Paracetamol 500mg

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AA batteries

Pen torch

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DIAGNOSTICS

QUANTITY ITEM

QUANTITY

RESUSCITATION Plastic suction catheter

20cc plastic syringe

Oropharyngeal airway size 4

STERILISING Iodine in dropper bottle (in

Salt in film container

protective container)

Puritabs

Cotton buds

Amethocaine minums eye drops* 1

Chloromphenicol eye ointment

Hypodermic 22G needle**

Eye pad

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Sunblock

is Diclofenac (Voltaren)

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suppository 50mg

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Bactroban 15g

Gastrolyte sachet

OTHER

EYES

Lip balm

Sterile saline squeeze pack

Insect repellent in sealed

plastic bag

PACKING

Medium cling seal plastic bags

Small cling seal plastic bags

Large cling seal plastic bags

Screw-top clear plastic container

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Light waterproof container

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*prescription **medical supervision recommended

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APPENDIX II | FIRST AID KITS

ITEM

APPENDIX III:

UNIT STANDARDS

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This manual addresses the following unit standards:

• 26551: Provide first aid for life-threatening conditions

• 26552: Demonstrate knowledge of common first aid conditions and how to respond to them

• 424: Assess and manage an emergency care situation during an outdoor recreation activity

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These Unit Standards were correct at the time of printing. For the most up-todate information, please check www.nzqa.govt.nz CHAPTER REFERENCE

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UNIT STANDARD

Chapter 3: CPR

Assessment against this unit standard must include:

Chapter 4: Airway emergencies

26551: Provide first aid for life-threatening conditions

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• provision of CPR for an adult, a child, and an infant

Chapter 6: Circulation emergencies

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• treating a conscious casualty with a foreign-body obstructed airway for an infant, and either an adult or a child

• controlling severe bleeding, including at least one activity on one person. Chapter 1: Accident management

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Outcome 1: Assess the scene for hazards

1.1 Any hazards to self, casualty, and bystanders are identified.

Chapter 1: Accident management Chapter 1: Accident management

Outcome 2: Assess the casualty for life-threatening conditions.

Chapter 1: Accident management

Range: Level of consciousness, airway, breathing, severe bleeding.

Chapter 2: Patient assessment and management

2.1 Casualty is assessed for life-threatening conditions in accordance with the primary reference.

Chapter 1: Accident management

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1.2 Identified hazards are eliminated, isolated, or minimised in accordance with the primary reference.

Chapter 2: Patient assessment and management Details for other specific conditions throughout manual.

278

CHAPTER REFERENCE

Outcome 3: Provide first aid for life-threatening conditions.

Chapter 2: Patient assessment and management

Range: Stable side position [recovery position], head tilt/ chin lift, CPR, clearing an obstructed airway of a foreign body, controlling severe bleeding, sending for help.

Chapter 3: CPR Chapter 4: Airway emergencies Chapter 6: Circulation emergencies Chapter 7: Care of an unconscious patient

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Details for other specific conditions throughout manual. As above

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26552: Demonstrate knowledge of common first aid conditions and how to respond to them

3.1. First aid is provided for life-threatening conditions in accordance with the primary reference.

Outcome 1: Identify common first aid conditions.

Range for common first aid conditions:

Covered throughout manual. Each of the listed conditions has its own section.

• injuries – fractures, wounds, burns, soft tissue injuries;

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• medical conditions – seizures, diabetic emergencies, breathing difficulties; anaphylaxis, chest pains, stroke;

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• for each first aid condition, three signs and/or symptoms, one response to the condition, and an example of when help should be sought must be given;

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• for each injury, at least two pieces of first aid equipment that would be relevant to the condition must also be identified. Covered throughout manual. Each of the listed conditions has its own section.

1.1 The identification of common first aid conditions is in accordance with the primary reference.

Covered throughout manual.

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Outcome 2: Describe common first aid conditions and how to respond to them. 2.1 The description of common first aid conditions and the response to them is in accordance with the primary reference.

Covered throughout manual. Each of the listed conditions has its own section.

2.2 The description of when help should be called is in accordance with the primary reference and New Zealand emergency services guidance.

Chapter 18: Evacuation

2.3 The description of first aid equipment used to treat the injuries is in accordance with Department of Labour guidelines.

Covered throughout manual.

279

APPENDIX III | UNIT STANDARDS

UNIT STANDARD

CHAPTER REFERENCE

UNIT STANDARD

424: Assess and manage an emergency care situation during an outdoor recreation activity The term chosen discipline refers to the outdoor recreational activity relevant to the candidate’s profession or recreation (eg rafting, tramping, diving etc). The term group refers to a minimum of three people including the patient. Long-term refers to being 2–12 hours away from outside help.

1.1 Available information related to injuries and/or medical problems commonly associated with the chosen outdoor activity is accessed and explained.

Details for specific conditions throughout manual.

1.2 Pre-trip emergency planning for the chosen discipline is explained.

Introduction

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Range: Emergency planning includes but is not limited to – emergency equipment, internal and external communication, first aid kit contents, knowledge of group’s skill-set and health issues.

Chapter 1: Accident management

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1.3 The initial response to an emergency care situation is explained in terms of ensuring the safety of the first aider, group and patient is not compromised; hazards to be recognised; and controls to be put in place.

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Details for specific conditions throughout manual.

Outcome 1: Explain long-term management requirements for an emergency care situation in an outdoor recreation environment.

Outside help refers to secondary professional assistance such as Ambulance, Police, Search and Rescue.

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Range: Initial response includes but is not limited to – minimising harmful environmental conditions, establishing a ‘safe’ area for group members, establishing communications. Chapter 1: Accident management

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1.4 The need for group and resource management is explained in terms of establishing and maintaining group morale and safety, and delegation of appropriate tasks using effective communication.

Chapter 20: Fatalities

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1.5 The handling of fatalities is described according to police requirements, with variations identified which may be necessitated by conditions, resources and safety considerations.

Chapter 18: Evacuation

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1.6 Suitable carry techniques are described in terms of patient condition, resources and people available, and terrain and distance to be covered, and in accordance with current industry practice and first aid protocols. Range: Evidence is required of a minimum of three carry techniques. 1.7 Information required and actions to be taken by outside help or emergency services are explained.

Chapter 18: Evacuation

1.8 Factors affecting a decision to evacuate a patient and/or group are described in accordance with current industry practice and first aid protocols.

Chapter 1: Accident management

Range: Factors may include but are not limited to – number of patients, patients’ condition, number and condition of group, location, equipment, weather and environmental conditions.

Chapter 18: Evacuation

280

Chapter 2: Patient assessment and management Also mentioned throughout manual.

APPENDIX III | UNIT STANDARDS

CHAPTER REFERENCE

UNIT STANDARD Outcome 2: Assess and manage a patient’s condition long-term in an outdoor recreation environment.

Chapter 1: Accident management

2.1 The patient’s condition is monitored and managed until outside help arrives.

Chapter 2: Patient assessment and management

Range: Monitoring includes but is not limited to – monitoring and documenting vital signs (including peripheral circulation), general patient observations, patient position and comfort.

Chapter 18: Evacuation Chapter 19: Nursing the patient

Chapter 2: Patient assessment and management

2.3 Decision to request outside help is made and justified in terms of group safety, patient condition, weather considerations and location.

Chapter 2: Patient assessment and management

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2.2 Actions and decisions are justified in terms of the patient’s first aid needs, age, gender, and culture.

Details for specific conditions throughout manual.

Chapter 18: Evacuation

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Details for specific conditions throughout manual. Chapter 1: Accident management

2.4 Decision to secure the patient where found or transport the patient to an alternative location is made and justified.

Chapter 2: Patient assessment and management

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Chapter 13: Environmental medical conditions

Chapter 1: Accident management Chapter 2: Patient assessment and management Chapter 13: Environmental medical conditions Chapter 18: Evacuation Chapter 19: Nursing the patient

2.6 Management of group performing a log roll procedure for a patient with a suspected spinal injury to provide thermal insulation is in accordance with current industry practice and first aid protocols.

Chapter 9: Fractures and dislocations

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2.5 Effective protection from environmental conditions is provided for the patient.

Chapter 18: Evacuation

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2.7 A non-ambulatory patient is carried 10 metres in a safe manner that is justified in relation to their condition, resources, people available, and terrain to be covered. Range: Justification for move includes but is not limited to – patient safety, comfort, emergency. 2.8 On-site resources and the equipment available in the group or surroundings are used, and items are improvised to maximise the safety of the group and patient and chances of their survival.

Chapter 18: Evacuation

2.9 The group’s needs are identified and decisions made to ensure on-going group safety.

Chapter 1: Accident management

Range: Decisions may include but are not limited to – continue with the outdoor recreation activity, evacuate.

Chapter 21: Critical incident stress

Chapter 18: Evacuation Details for specific conditions throughout manual.

281

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REFERENCES

American Academy of Orthopaedic Surgeons. Series editor: AN Pollack. (2010). Emergency care and transportation of the sick and injured (10th ed.). Ontario, Canada. Jones and Bartlett Publishers.

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Anderson, M., & Price, D. (1991). Hypothermia. Wellington, New Zealand Mountain Safety Council.

Auerbach, P.S. Donner H.J., & Weiss, E. A. (2008). Field guide to wilderness medicine. Philidelphia, USA. Mosby Elsevier.

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Bogie, D. (1992). Alpine rescue techniques. Wellington, New Zealand Mountain Safety Council.

Coleman, J., Heine, A., Taylor, I., & Webb, S. (1989). Outdoor First Aid. Wellington, New Zealand Mountain Safety Council.

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Curl, R. (1995). NZ Land Search and Rescue field guide. New Zealand, NZ Land SAR Inc.

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Duff, J., & Gormly, P. (2007). Pocket first aid and wilderness medicine. Singapore. Cicerone Press.

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Elsensohn, F.MD, editor (2001). Consensus guidelines on mountain emergency medicine and risk reduction, First Edition. Recommendation Nr: 13 On site Treatment of Avalanche victims. Italy, ICAR MEDCOM International Commission for Mountain Emergency Medicine and UIAA MEDCOM International Federation of Alpine Organisations.

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Fitzharris, P. (1996, August). Insect sting allergy treatment. New Ethicals, v33, pp. 31–39. Forgey, W.W. (1999). Wilderness medical society practice guidelines for wilderness emergency care. Merrivale, USA, ICS Books Inc. Forgey, W.W. (2000). Wilderness Medicine Beyond First Aid. Fifth Edition. Guilford, Connecticut. The Globe Pequot Press. Goldring, R., & Mullins, W. (1995). Bushcraft–Outdoor skills for the New Zealand Bush. Wellington, New Zealand Mountain Safety Council. Isaac, J. (1998). Outward bound wilderness first aid handbook. USA. Falcon Guides, Globe Pequot Press.

282

REFERENCES

Jones, L. (2007). Outdoor first aid course instructor notes. Wellington, New Zealand Mountain Safety Council. Mason, Pip. (2000). Saving Lives: NZ Resuscitation Guidelines. Level 2. Wellington, New Zealand Resuscitation Council. Memmler, R. L., Janson Cohen, B., & Lin Wood, D. (1992). Structure and function of the human body. Philadelphia, USA. J.B.Lippincott Company. Mistovich, J.J., Hafen, B.Q., & Karren., K.J. (2004). Prehospital emergency care (7th ed.). New Jersey, USA, Pearson Education Inc.

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New Zealand Department of Labour. (2011) First aid for workplaces – a good practice guide. Wellington. Department of Labour.

Oakley, A. (gave expert guidance in developing article) (2012, April). Diagnosis and treatment of urticaria. Best Practice Journal, 43. pp. 6–13.

Prattley, G. (1992). Alpine rescue technique (3rd ed). Wellington. New Zealand Mountain Safety Council.

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The Order of St. John New Zealand. (1999). The St. John New Zealand first aid manual. Auckland, Penguin Books (NZ) Ltd.

Schimelpfenig, T., & Lindsey, L. (1991). NOLS wilderness first aid. USA , National Outdoor Leadership School.

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Schimelpfenig, T. (2006). NOLS wilderness medicine. USA. Stackpole Books.

Tasmanian Outdoor Leadership Council. (1996). Managing risks and critical incidents in outdoor programs. Australia.

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Thatcher, L. & Janes, R. (2012, March). Latrodectism: case report of a katipo spider (Latrodectus katipo) bite and review of the literature. New Zealand Medical Journal Digest, Issue 31. pp.92–94.

Tilton, B. (2010). Wilderness first responder. National Outdoor Leadership School. USA. Morris Book Publishing.

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The New Zealand Resuscitation Council, compiled by Duncan Galletly. (2005). Emergency care for first responders. Wellington, New Zealand Resuscitation Council.

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Weiss, E.A. (1998). Backpacker Wilderness 911. Seattle, USA. The Mountaineers Books. Wilkerson, M.D. (2001). Medicine for mountaineering and other wilderness activities. Seattle, USA. The Mountaineers Books. Wyatt, G (2005). Alpine Skills. Wellington. New Zealand Mountain Safety Council.

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WEBSITES AdventureSmart www.adventuresmart.org.nz AED Locations www.aedlocations.co.nz Alcohol Drug Association New Zealand www.adanz.org.nz Allergy New Zealand www.allergy.org.nz

Australasian Society of Clinical Immunology and Allergy www.allergy.org.au

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The Asthma Foundation www.asthmanz.co.nz

Civil Aviation of New Zealand www.caa.govt.nz

Diabetes New Zealand www.diabetes.org.nz

Emergency communications www.beacons.org.nz

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Epilepsy New Zealand www.epilepsy.org.nz

Landcare Research www.landcareresearch.co.nz

Health and safety, Labour Group, Ministry of Business, Innovation and Employment www.osh.govt.nz

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Leave No Trace New Zealand – Outdoor ethics www.leavenotrace.org.nz

Medicinenet www.medicinenet.com

MedicAlert Foundation www.medicalert.co.nz

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Medscape www.emedicine.medscape.com

Metservice – New Zealand weather forecasts www.metservice.org.nz

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National Incident Database www.incidentreport.org.nz New Zealand Avalanche Centre www.avalanche.net.nz

New Zealand Department of Conservation www.doc.govt.nz

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New Zealand Dermatological Society Incorporated www.dermnetnz.org/ reactions/urticaria.html

New Zealand Drug Foundation www.drugfoundation.org.nz

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New Zealand Mountain Safety Council www.mountainsafety.org.nz New Zealand National Poisons Centre www.poisons.co.nz New Zealand Resuscitation Council Inc www.nzrc.org.nz New Zealand Qualifications Authority www.nzqa.govt.nz Sea Kayaker Magazine www.seakayakermag.com/2008/Feb08/cold-shock.htm Stroke Foundation of New Zealand Inc www.stroke.org.nz Walking Access www.walkingaccess.govt.nz

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CONTRIBUTORS

CONTRIBUTORS ABOUT THE AUTHOR

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At the time of co-authoring the second edition of this manual, Christine McLeod (née Griffin) had been an Outdoor First Aid instructor with the MSC since 1989 and was a member of the MSC Outdoor First Aid committee.

With colleague Liz Maire, Christine co-founded Women’s Outdoor Pursuits (WOPS). She has many years of practical experience leading several thousands of people of all ages into the outdoors.

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Since the publication of the second edition, Christine has gone on to facilitate Education Outside The Classroom safety and risk management seminars as well as continuing to teach first aid. She makes the most of life, living near the beach and enjoying the magic and mayhem of grandchildren.

ABOUT THE MANAGING EDITOR

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Jen Riley has been leading people in various outdoor pursuits, including tramping, kayaking, rafting, sailing and rock climbing, for nearly 20 years. During extended wilderness expeditions and shorter adventures, in New Zealand and overseas, she gained practical experience dealing with numerous first aid situations and emergencies. She is also a qualified science and English language teacher.

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ABOUT THE MEDICAL ADVISOR

Dr Dick Price is a GP in Timaru, with extensive experience in anaesthetics and intensive care. He is also a seasoned mountaineer.

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He is currently the medical advisor to the MSC. He tutors in wilderness and polar medicine and is a life member of the New Zealand Alpine Club. He is involved with South Canterbury LandSAR: on their alpine team and as their local medical advisor. He is also a member of Sports Medicine New Zealand. He has been an advisor to the International Liaison Committee on Resuscitation, the New Zealand Resuscitation Council, New Zealand Search and Rescue, New Zealand Ski Patrol Association. He was the New Zealand representative on the International Mountaineering and Climbing Federation (UIAA) and reviewed articles for the Wilderness and Environmental Medicine journal. Dr Price’s medical interests include wilderness and altitude medicine, hypothermia and frostbite, avalanche rescue and helicopter strop rescue. He has been alpine climbing since 1970 and has several first ascents to his name, including the first winter ascent of the North Ridge of Aoraki, Mt Cook (1978) and the first New Zealand expedition ascent of an 8000 metre peak, Mt Xixibangma (1987). He has been on six expeditions to Mt Everest and successfully summited via the North Ridge in 1997. 285

asthma 67, 186–189

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INDEX

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airway emergencies 29, 44–50

devices 36–37

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AED (automated external defibrillation)

adrenaline 67–68, 219, 225

accident management planning 6–12 Achilles tendon 132–133

alcohol 226

allergies and allergic reactions 17, 52, 64, 67–68, 214, 216, 219

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altitude problems see high-altitude problems

amputation 152–153

anaphylactic shock 64, 67–68, 219–220, 225

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angina 70

ankle injuries 16, 18, 133 fractures 122–124 sprains 129–131 appendicitis 202 arms examination 21 fractures 114–116 assessment 8–25 burns 137–138 fractures 100 triage 11 wounds 145–146

286

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abdomen acute problems 200–203 examination 20, 200–201 pain 18, 200, 231–234, 237–238 wounds 155

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AVPU scale 22

avalanche burial 29, 182–183

back see spinal injuries bee stings 219–220 bites 216, 220, 223–224 bleeding external 74–79 internal 80–81 nose, ear, mouth 156–157 blisters 158 blood clots 73–74, 92, 198 body temperature 24, 160–170, 207–208 bowel obstruction 203 breathing emergencies 44–59, 74 burns 136–142

C carbon monoxide poisoning 52–54 cardiac emergencies 29, 34, 71–73 cardiopulmonary resuscitation (CPR) 27–42,

47, 49 adults 32–37 children 37 frequently asked questions 41–42 infants 38–39, 49

care giving 8–9, 24–25 unconscious patients 83–90 carrying patients 240, 243–253

drowning and submersion 29–30, 40 INDEX

DRSABC 14–15 drug overdoses 226–227

centipede bites 224 cerebral oedema 176–177

chafing 213 chemical burns 141 chest injuries 20, 55–59

ears

chilblains 172

electric shock and burns 141, 181

electrolytes 163, 205–207

embedded objects 153

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emergency services 12, 240–241 epilepsy 190–193

concussion 93–94

contact lenses 85

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Coordinated Incident Management System

crush injuries 81–82

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CPR see cardiopulmonary resuscitation

cuts 74–79, 144–151

evaporation 161 examination 10–15 eyes 24, 177–179 foreign bodies 211–212

F fainting 69

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cyanide poisoning 218–219

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constipation 210

consciousness levels 14–17, 22, 84–85, 92–96

cramp 134

evacuation 239–257 burn victims 142 carrying methods 244–253 open chest injury 59 sending for help 240–242 spinal injuries 111 waiting for 14, 30

compression head injuries 94–96

corrosive poisons 216–217

ectopic pregnancy 238

collarbone fractures 112

(CIMS) 12

foreign bodies 210–211

cold-related conditions 164–173 chilblains 172 cold exhaustion 165–166 cold shock 169–170 frostbite 170–172 hypothermia 166–169 immersion foot/trench foot 173

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circulation emergencies 61–81, 120–121, 123

bleeding 157 earache 211

choking 44–50

fatalities 264–265

deaths 264–265

feet 158, 173, 178 circulation to 120–121, 123 fractures 124

debriefing 10, 269 defibrillation 36–37 dehydration 204–206 delegation 8–9 dentures 85 diabetes 193–196 diarrhoea 209–210 dislocation 67, 125–126 distress beacons 241

feeding patients 260–261

fever 207–208 fingers see hand injuries first aid kits 274–277 fish-hook wounds 154 flail chest 55–56 foreign bodies/objects 153–154 in ears 210–211 in eyes 211–212 287

fractures 97–124 ankle and foot 124 arms and hands 114–117 assessment 100 collarbone 112 immobilising 100–101 infection 102–103 jaw 104 knee 122 lower leg 122–123 management 100–103 pelvis 118 ribs 113 skull 103–104 thigh (femur) 119–121 frostbite 170–172

hernias 203 high-altitude problems 174–179 acute mountain sickness 174–175 high-altitude cerebral oedema (HACE) 176–177 high-altitude pulmonary oedema (HAPE) 176 peripheral oedema 178 retinal haemorrhages 177–178 snow blindness 178–179 (existing)

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hives 214

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hyperthermia 161

hygiene 145, 260 hyperglycaemia 196

hyperventilation 54–55

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hypoglycaemia 194–196

hyponatremia 207

hypothermia 166–169

gastroentiritis see diarrhoea; vomiting

grazes 148–149, 275

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gunshot wounds 156

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H haemorrhoids 231

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greenstick fractures 115

immersion foot 173 impaled objects 153 infection of wounds 102–103, 149 inhalation burns 140 insect bites 220

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hand and wrist injuries dislocation 125–126 fractures 117 sprains 129–130 handover requirements 242–243

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head injuries 91–96 examination 20, 94–95 fractured jaw 104 fractured skull 103–104 scalp wounds 156 heart attacks 71–72 heart failure 72–73 heat exhaustion 161 heat stroke 162–163 Heimlich manoeuvre 47 helicopters 242, 254–257 help, calling for 30–31, 240–242 hepatitis 145, 230–231 288

history (medical) see medical conditions

J jellyfish stings 221

K katipo spider bites 222 kidney stone 202 kina 222 knee injuries dislocations 125–126 fractures 122 sprains 129

P pain 16–19, 24–25 abdominal 18, 200–203, 231–234, 237–238 chest 70–72, 74 from fractures 99–102, 128 paralysis 105, 111, 198–199, 225

lacerations 144 leadership 8–9, 268–269 leg injuries 21 fractures 119–124 lightning strikes 179–180

pelvic inflammatory disease 236–237 pelvis 21, 118

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peritonitis 202

poisoning 216–219 carbon monoxide 52–54 mushrooms 227 other plants 228 positioning a patient 25, 32–34 emergency rollover 88–90 with spinal injuries 105–111 when unconscious 85–90 pregnancy 237–238

medications (existing) 17

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menstrual cramps 234–235

mental illness 200

methamphetamine (P) 226–227

miscarriage 237–238

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mosquito bites 220

mouth bleeds 157

mountain sickness, acute 174–176

mountain radio 30–32, 180, 240–241, 265

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mouth-to-nose breathing 36

muscle ailments 132–134, 167, 170

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muscle spasms (in fractures) 99, 101, 107, 119–121

piles 231

medical ID jewellery 21

perniosis 172

medical conditions (existing) 17, 186–196

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mushroom poisoning 227

peripheral oedema 178

prescription medicines 17 pressure points 76–77 pre-trip planning 4 pulmonary embolism 74 pulse 22–23 puncture wounds 144

neck injuries 20, 33, 90

redback spider bites 223–224

nose bleeds 156–157

rehydration drinks 206

nursing patients 259–262

rescue breathing 35–36, 40 for infants 39 respiration rate 23, 33–34

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near-drowning see drowning and submersion

recording information 9, 16, 19, 22, 262 for rescuers 241–243 recovery position 85–88

respiratory distress 51–59, 74 retinal haemorrhages 177–178 rib injuries 55–57, 113

obstruction of airway 29, 44–50 ongaonga stings 225 oximeters 22

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INDEX

tourniquets 78–79, 81 toxins 64, 78, 81–82 toxic shock syndrome 235–236 traction 119–121

sandfly bites 220 scalp wounds 156

tree nettle stings 225

sea urchin wounds 222

trench foot 173

seizures 190–193, 226–227

triage 11

sexually transmitted infections 230–231

tutu 228

shock 64–68 anaphylaxis 67–68 shoulders 20 dislocation 125–126 skin signs 23–24, 44

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sledges 252–253

unconsciousness 16, 84–90 after choking 47, 49 see also consciousness levels; fainting

slings 112–117, 125

snow blindness 178–179 soft tissue injuries 127–134

urinary tract infection 230

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spider bites 223–224 splints 101, 114, 119–123, 133

urogenital conditions 229–238 female specific issues 234–238 male specific issues 232–234

sprains 129–131

urticaria (hives) 214

spinal injuries 21–22, 33, 105–111

strains 132

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stretchers 240, 247–251

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stress after critical incidents 268–269

sun bumps 174

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varicose vein ruptures 155 vasovagal events 69 vomiting 208–209

W warmth 24–25

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survival bags 249

sunburn 141

stings 219–221, 225

stroke 198–199

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stingray wounds 221–222

stable-side position (recovery position) 85–88

wasp stings 219–220

temperature (body) 24, 160–170, 207–208

wounds 143–158 abdominal 155 assessment 145–146 cleaning 148–149 closures 151 dressings 150 embedded objects 153–154 fish hooks 154 gunshot 156 infection 149 management 146–149

teeth 212–213 tendonitis 132–133 testicles 232–233 tetanus 146, 154 thermometers 24, 165 thigh injuries 119–121 thrombosis 73 thrush 236 toileting (patients’) 260 toothache 212 290

whitetail spider bites 224

WRAPT 14, 24–25

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INDEX

NOTES

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NOTES

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NOTES

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NOTES

NEW ZEALAND OUTDOOR FIRST AID on l

The third edition of the New Zealand Outdoor First Aid manual contains essential information about how to handle first aid and medical emergencies in New Zealand’s outdoors.

This manual is suitable for all outdoor enthusiasts, but especially useful for those leading groups in the outdoors. Learn how to manage a variety of scenarios and deal with any incidents that might occur confidently and effectively.

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This edition has been completely revised by medical specialists. It includes new photographs, revised illustrations and up-todate information on current New Zealand outdoor safety and medical standards.

CPR

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Diabetes

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Asthma

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Airway emergencies

Accident management

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Topics covered in the manual include:

Head injuries Heat exhaustion and heat stroke Heart attacks Hypothermia Medical conditions Poisons, stings and bites

Fractures and dislocations

Wound care and infection

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Evacuation

A New Zealand Mountain Safety Council Publication