Fpos manual web by Brian Nicolson

First Person on the Scene I

COURSE MANUAL

welcome Welcome to Horizon and to the First Person on the Scene (FPOS) Intermediate course. This course is designed for professionalâ&#x20AC;&#x2122;s that work in remote and hostile environments. The course has been attended in the past by search and rescue teams, members of the media, expedition team members and large amounts of personnel from the security industry. We hope that this course will give you the confidence to work in a somewhat unique environment, with the minimum amount of equipment and help available. At Horizon, we are aware of the risks that you undertake every day. All members of the training team are experienced at working in remote environments all over the world, from the Arctic, Temperate, Desert, Jungle,

Bush and Savannah. We have also had experience with high altitude, diving injuries and long-term care whilst carrying out long evacuations by air and road. We also have a policy of continued development. All of our training team and Remote Area Medical Providers have to complete regular updates and attend courses and clinical attachments to maintain skills at the very highest level. This continued professional development is passed on to you the student when you attend a course such as this one. This course and this manual have been written together to ensure that they complement each other. The content that is displayed as a part of the lectures and skill stations

is also contained in this manual for future reference. The course content is approved by Edexcel who have accredited the course at the First Person on Scene (FPOS) intermediate level. This course will give you the knowledge to perform the skills, however it is your responsibility to stay current and up to date with the latest thinking and ideas. This course does not give you a license to practice. In order to carry out the skills described in this manual and on the course you must have permission from the medical director of your company or organisation. We hope that you enjoy the course. Horizon

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Course Introduction & HSE Legislation

Trauma Emergencies

Mechanisms of Injury Initial Assessment Overview Primary Survey Guide The Unconscious Casualty Airway Management with C Spine Control Life Threatening Chest Conditions Control of Severe Bleeding Burns Musculoskeletal Trauma Head Injuries Spinal Injuries Drowning & Near Drowning Eye and Ear Injuries Casualty Centred Rescue - Improvised Extrication from Vehicles

7 13 16 17 18 24 27 33 36 38 41 46 49 51

Triage and Major Incidents

Medical Emergencies

Angina Myocardial Infarction Basic Life Support Automated External Defibrillation The Choking Casualty Asthma Anaphylaxis Epilepsy Diabetes Stroke

61 62 63 66 70 72 73 75 77 78

Poisons and Poisoning

Environmental Injuries

Cold Injuries Heat Injuries

81 83

Annexes

Crash Helmet Removal UK Resuscitation Guidelines (2010)UK Resuscitation Guidelines (2010)UK Resuscitation Guidelines (2010)UK Resuscitation Guidelines (2010)UK Resuscitation Guidelines (2010)Helicopter Safety Needle Decompression H2S Poisoning Suggested Medical Equipment List

88 90 91 92 93 94 95 96 97 99

Adult BLS Algorithm AED Algorithm Adult Choking Algorithm Child BLS Algorithm Child Choking Algorithm

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Course Introduction & HSE Legislation Challenging environments emergency responder, first person on scene and emergency responder course Course Structure • Presentations • Skill Stations • Moulage • Continuous Assessment • Written Examination • Practical Moulage Assessment Pre-Deployment Procedures • Team health check - Recent & underlying medical conditions & current meds. - Dental fitness - Resting pulse check - Pupils - Vaccination state • Risk assessment • Basic team F/A training • Equipment • Clients: - Recent & underlying medical conditions & current meds. - Resting pulse check - Vaccination state • Medical facility and evacuation routes (national & international) • Hospital site survey Risk Assessment (RA) • Written RA considers the following: - Hazard ID - Hazard analysis - Risk analysis - Risk assessment - Risk management Personal Protection Methods • Threat - Blood borne viruses transmitted through blood - blood contact. • Hepatitis B & C • HIV • Vaccination - Consider need for Hepatitis B • Disposal - Waste disposed of in plastic bags. Local authority guidance for disposal

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• Protection - Protective gloves & face shield/mask - Cover own wounds - Wear protective glasses if possible - Needle-stick precautions - tactical approach!

The Role of First Person on Scene/Challenging Environments Emergency Responder Interventions have been shown to effect improvement in outcome and patient survival is often simple and focussed on three key areas: • Airway assessment and stabilisation of the neck • Breathing assessment and support • Circulatory assessment and support Where there is evidence of catastrophic life-threatening external, compressible bleeding, control of this takes precedence over anything else. These are conventionally described as basic life support, and the combination of breathing and circulatory support is called cardio-pulmonary resuscitation (CPR). These skills are enhanced by: • basic life support • defibrillation (stimulating the heart with an electric shock) • and sometimes with the administration of oxygen As part of the FPOS teaching programme, the provider will also be taught to appreciate some of the signs and symptoms relevant to various life-threatening conditions, including heart attack, asthma and loss of consciousness. Unnecessary deaths from cardiac arrest may be reduced by a series of interventions known as the “Chain of Survival”. In relation to cardiac arrest there are four links in the chain: • early emergency service access • early basic life support • early defibrillation • early advanced life support The less time spent between each link, the greater the chances of survival. The trained FPOS provider is vital to the delivery of the first three of these components. By making a primary assessment and following the advice described in this manual, the provider will aim to maintain the patient’s airway, breathing and circulation until advanced life support is available. Simple airway control using the practical skills taught may save a life.

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Patient Consent As a responder, you may be called to assist patients prior to the arrival of an emergency response. As with all emergency care, treatment is offered to patients but carried out only when it is clear that the patient understands what is to be done and gives his/her consent. If the patient is not able to understand or respond, then a relative may be asked. Relatives can express a view, but cannot give legal consent. In the case of an unconscious patient or during a cardiac arrest, it is permissible to commence treatment without consent as delay would decrease the chances of a successful outcome. Whilst relatives cannot stop a responder delivering care, they may become aggressive if you do not stop when asked. In these circumstances, if you feel you are at risk, withdraw and inform the emergency services. Attempts to treat a conscious patient without their consent could lead to conflict and even a charge of physical assault.

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Trauma Emergencies Chapter Mechanisms of Injury

Page 8

Initial Assessment Overview

Primary Survey Guide

The Unconscious Casualty

Airway Management with C-spine Control

Life Threatening Chest Conditions

Control of Severe Bleeding

Burns

Musculo-skeletal Trauma

Head Injuries

Spinal Injuries

Drowning/near drowning

Eye and Ear injuries

Casualty Centred Rescue- Improvised Extrication from Vehicles

Triage and Major Incidents

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MECHANISM OF INJURY Index of Suspicion 90% of making a Correct Diagnosis is accomplished by Obtaining a Complete and Accurate History

The difference between a good clinician and an indifferent one is the time spent on history taking’ Sir Farquhar Buzzard - 1933

The main mechanisms of injury associated with the remote setting today can be divided into three main areas. The advent of terrorism has resulted in an increased risk to both the traveler and the professional. This said Road traffic collisions and other vehicle related incidents remain a big risk in the remote environments. The mechanisms at a physical level can be divided into: • Blunt trauma • Penetrating trauma • Blast injuries

Blunt Trauma Two types of forces involved: • Change of speed (shear) • Compression

Blunt trauma can result in a change in speed of the victim in mechanisms such as road traffic collisions (RTC’s). When this occurs the body can come to a sudden stop or have a sudden and sharp increase in speed. When this occurs the organs of the body can be subjected to tearing forcing as they are displaced internally. Also the organs can become compressed as demonstrated above resulting in damage and internal bleeding.

Penetrating Trauma This can be divided into 3 types: • Low Energy • Medium Energy • High Energy

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Low Energy Injuries eg - Knife or other impaling objects The energy imparted by the penetrating implement causes damage limited to the path of penetration. The difficulty in managing these injuries is the object can sometimes be found in-situ with the shape, size and construction of the implement hidden from view of the rescuer. Medium and High energy injuries e.g.: Bullet wounds, machinery fragments involved in industrial accidents, shrapnel resulting from explosions. The stages of injury with both medium and high energy transfer injuries include: • Stretch & shear • Cutting • Cavitation • Thermal injury Whilst medium energy injuries result in lower levels of cavitation the outcome of the casualty will be related to the type of tissue struck, where the injuries occurs on the body and the amount of energy transferred into those tissues.

Stretch & shear This is dependant on • The missile shape - the larger the missile the more potential surface area that can strike the body, irregular shapes can result in more energy transfer therefore more tissue destruction. This can be related to the following when discussing ballistic injuries and properties of bullets: • Angle of impact • Yaw (up to 15cm on entering tissue) • Tumbling (caused by deflection)

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This wound completely missed the brain and caused a potential airway obstruction.

Cutting The front aspect of any projectile forces compression of air as it travels at speed, the higher the velocity increases the level of compression of air. Large amounts of PSI air pressure is present immediately in front of high velocity projectiles that can result in cutting of tissues instantly prior to projectile strike on the body.

Cavitation Temporary Cavitation As the projectile moves through body tissue it gives up energy laterally causing the tissue to be forced away from the path of the projectile. The amount of lateral movement is dependant on the amount of energy given up by the object; high-energy projectiles can produce large areas of temporary cavitation whilst medium energy object can produce little or no cavitation effect. Temporary cavitation occurs 1 - 3 milliseconds after penetration and can be up to 30x the frontal diameter of the projectile. Factors affecting temporary cavitation include • Deformation & density of tissue struck • Energy possessed by the projectile on impact Permanent cavitation The amount of permanent cavitation is dependant upon the tissue type that the projectile strikes. In dense tissue the permanent cavity can be equal to the temporary cavity due to the tissues inability to stretch and rebound.

Specific Injury Types Soft Tissue • Huge areas due to cavitation effect • Massive pulping of muscle • Permanent cavity containing foreign material Skull / Brain • Massive Destruction • Rarely survivable • Pressure causes # along suture lines

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Chest/Lungs • Easily Stretch • Causes Pneumo. & Haemo. • Often survivable • Low density = less KE transfer Heart • Massive Destruction • Rarely survivable • Muscle density • Pressurised fluid spaces Abdomen/ Solid Organs • Liver, Spleen & Kidneys • Usually rapidly fatal • Lack elasticity — tear when stretched • Permanent cavity may = temp. cavity Hollow Organs • GI Tract • If empty > Elasticity • If full tear more readily • >chance of survival • >infection risk Extremities • Bone • Multiple fractures causing potential secondary missiles • ? Cavitation effect • Blood Vessels / Nerves • More flexible than bone - >ability to tolerate cavitation

Blast Injuries Classification of Blast Injuries • Primary Blast Injuries • Secondary Blast Injuries • Tertiary Blast Injuries • Miscellaneous Primary Blast Injuries Caused by the direct effects of the pressure wave/shock front on the body with the greatest effect on gas containing organs. These May occur with out any external signs of injury.

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Effects of Pressure Wave on Air Containing Organs

Organs Affected in Primary Blast Injuries • Ear • Lungs • Intestine • Heart • Central Nervous System Blast Ear Common with other forms of injury, small overpressures can injure the ear with tympanic membrane rupture being very common. Ossicle dislocation and cochlear injury can also occur. Symptoms include tinnitus or hearing loss Blast Lung • Disruption of alveolar capillary interface • Disruption of bronchi and attachments • Disruption of pulmonary vessels • Accumulation of blood and fluid • Blood flow Shunting • ARDS • Pulmonary contusion • Pneumomediastinum

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Blast Gut Stress waves Shear waves Most immediate deaths as a result of pure primary blast injury are related to air embolism to the heart or brain Injuries indicative of high probability of primary blast injury • Traumatic amputation • Hearing loss either temporary or permanent • Neurological findings • Shock • Severe respiratory distress Secondary Blast Injuries The blast winds cause the secondary classification of injuries and include the following: • Shrapnel/missile injuries • Objects striking the body • Structures become displaced • Fall/collapse resulting in crush/bury injuries • Account for greatest number of victims Tertiary Blast Injuries • Victim becomes a missile/thrown against objects Miscellaneous Blast Injuries Miscellaneous injuries as a result of exposure to blast mechanism include burns and fractures which in themselves can be life threatening. Incidence of Primary Blast Injury in Terrorist Bombings 5,600 explosions studied over 12 years prior to September 2001 • 495 fatalities • 78% died at the scene • 13% died within 24 hours • 66% had central nervous system injuries • 51% had skull fractures Injuries include: • Penetrating Trauma • Blunt Trauma • Blast Injuries • Burns Management Principles • Identify life-threatening injuries • Immediate treatment of life threatening injuries • Stabilization of other injuries • Transfer to definitive care location There are several types of injuries related to blasts, it is important to remember primary blast injuries may go unrecognised for some time and communication with the casualty/casualties may be difficult.

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THE INITIAL ASSESSMENT OVERVIEW Casualties can be divided into 2 main types Trauma and Non Emergencies

Trauma Types of injury: Life threatening • Airway obstruction • Tensioned air in the chest (air under pressure) • Open chest wound • Massive chest bleed • Flail chest • Severe arterial bleeding Potentially life threatening Serious Minor

Non Trauma (Medical) Emergencies Life Threatening Medical Conditions • Angina • Cardiac Arrest/Myocardial infarction • Asthma • Anaphylaxis • Epilepsy • Environmental injuries

Incident Procedure Secure the scene or remove casualties to a safe area, examples include: • Defeat the attacker • Break contact • Find safe area/cover • Traffic control Send an initial incident report Use SA F E • S - Shout / Send / Signal for HELP! • A - Assess the scene/Approach with caution/achieve control • F - Find and/or free the casualty/ies • E - Evaluate requirements. ETHANE report

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E T H A N E Report E - Exact location T - Type of incident H - Hazards (actual and potential) A - Access N - Number of casualties E - Equipment required

Casualty Assessment Rapid Primary Survey (RaPS) • Quick History - What happened? • Is patient conscious? Shake and shout! • Can the patient complete a full sentence? - “Count to 10 as quick as you can” or “ Tell me your address as quick as you can • Rapid examination of all 4 limbs for severe bleeding Primary Survey Aim.- To identify and treat any life threatening injuries Control of major haemorrhage. • Use Tourniquet or other methods to “turn off the tap” of Arterial bleeds. • Once blood flow stopped or reduced to acceptable level then move on to Airway. Airway • Manual techniques - jaw thrust/chin lift • Adjuncts (Oropharyngeal / Nasopharyngeal) • Postural drainage • Suction • Oxygen • C-Spine control if appropriate to mechanism Breathing • Mechanism of injury? • FLAP assessment • Breathing rate F.L.A.P. • F - Feel for - Equal L & R movement/Collarbone, breastbone and ribs. • L - Look for - Open wounds, bruising & abrasions. • A - Check armpits and breasts. • P - Pat the back - Check for obvious wounds and blood on the hands. Circulation • Assess pulse rate (radial, femoral, carotid) • Check capillary refill time (< 2 secs) • Check all long bones and cavities (chest, abdomen, pelvic and femoral) for signs of bleeding

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Disability • Check pupils • Are they equal on both sides? • Do they react to light? • Level of consciousness (A.V.P.U.) • Alert • Responds to voice • Responds to pain • Unresponsive Assess for: S - Signs and symptoms A - Allergies M - Medication that the patient is taking P - Past medical history L - Last oral intake E - Events leading up to the incident Environment control • Package • Keep warm or keep cool depending on climate. • Recheck all treatments and improve if required. Document and make notes: • M- Mechanism of Injury • I - Injuries found • S - Signs (Pulse, respiratory rate, CRT etc.) • T - Treatments given Report Incident • To Employer • To Health and Safety Executive (see regulations) Summary There is a difference between trauma and medical conditions. RaPS is used when the scene is uncertain and insecure. Primary Survey identifies immediate life threatening injuries and allows for treatment. Major Bleeds -Airway -Breathing - Circulation in that order ALWAYS!

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PRIMARY SURVEY GUIDE SAFE APPROACH 1. Shout/send/signal for help: Who/how/confirm 2. I am surveying the scene: Are there any dangers to myself? 3. I am surveying the scene: Are there any immediate dangers to the casualty? 4. What are the mechanisms of injury? 5. Are there any other victims? 6. Do I need to communicate with anyone? ASSESS RESPONSIVENESS 1. My name is........................... , What is your name? Can you hear me? 2. I am shaking/pinching: What is the patients response? CONTROL OF MAJOR HAEMORRHAGE. 1. Is there any major external arterial bleeding? 2. If so use of tourniquet for limbs or other techniques taught for central areas. AIRWAY 1. I am looking inside the casualtyâ&#x20AC;&#x2122;s mouth: Can I see any obstruction/blood/vomit or foreign bodies? 2. I am performing a jaw thrust/chin lift: Is the airway patent? 3. I am inserting an OP/NP airway: Is the airway safe? 4. Is suction required? 5. Do I have Oxygen available? BREATHING ASSESSMENT 1. Is the patient breathing? What is the rate and quality of the respirations? 2. Does the casualty have a carotid pulse? 3. Oxygen (if available) for airway difficulty, head injury, or shock. 4. Assist respirations if respirations are less than 10 or greater than 30. 5. I am looking at the patients skin colour: Is there signs of cyanosis? BREATHING 1. I am looking at the chest: Are there any penetrations, contusions, deformities or paradoxical movement? 2. I am feeling the chest wall: Are both sides moving equally? Is there any instability on either side? 3. I am checking the back (if not already done so earlier): Are there any penetrations, contusions, deformities or paradoxical movement? 4. I am reassessing the airway: CIRCULATION 1. Is severe bleeding still under control? 2. Does the casualty have a radial pulse at each wrist? What is the rate? What is the strength? What is the rhythm? 3. I am assessing the Capillary Refill Time (CRT): Is the CRT greater than 2 secs? 4. I am reassessing the airway and breathing? 5. I am assessing the casualtyâ&#x20AC;&#x2122;s cardiovascular status: Has the CV status improved and is it remaining that way? 6. I am reassessing the airway and breathing. DISABILITY 1. I am assessing the level of consciousness: What is the AVPU score? 2. I am shining a torch into the pupils. Are the pupils of equal size and do they react to light? 3. I am reassessing the airway, breathing and circulation.

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THE UNCONSCIOUS CASUALTY Causes of unconsciousness • Fainting • Head Injury • Heart attack • Poisoning • Electrocution • Diabetes • Asphyxia • Shock • Stroke • Drugs/poisons • Hyperthermia • Hypothermia • Epilepsy Definition Unconsciousness is defined as a reduced or absent response to a stimulus. Management 1. SAFE Approach 2. Dealing with ABC is the immediate response. Casualties are most likely to die from - a blocked airway - a casualty looking up to heaven - Cardiac arrest (Ml) - Profuse bleeding 3. Treat for other injuries 4. Place the patient in the recovery position if you are injuries allow. • (Beware pelvic & spinal injury)

1 Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm uppermost. Grasp the far leg just above the knee and pull it up, keeping the foot on the ground

2. Bring his far arm across the chest and hold the back of the hand against the victims nearest cheek

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MANAGEMENT OF AIRWAY & CERVICAL SPINE Respiratory System • Oxygen is essential to life. • No part of the body can function without oxygen. • When oxygen is absent or reduced death can occur within minutes. • 21% Oxygen is present in our atmosphere. Anatomy Consists of: Upper airway above the Adams apple Lower airway below the 18Adams apple The lungs containing: • Bronchioles • Air sacs • Blood supply Airway Obstruction - Causes

The tongue is the most common airway obstruction

Foreign body/blood/vomit etc

Swelling

Assessment • Look for - If conscious - position of best function - Intercostal muscles - Tracheal tugging and see-saw breathing, indicator of complete airway obstruction with continued breathing effort - Respiratory Rate (between 10 - 29 sufficient) • Listen for - Cough - Snoring (Stridor) - Hoarseness - Abnormal voice

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• Feel - Chest movement - Air on the cheek Important Assessment Points • The unconscious patient may have no obvious signs • Noisy breathing means progressive airway obstruction • Silent breathing may mean complete obstruction Simple Airway Action • A - Assess patency - Look - Listen - Feel • L - Look inside the mouth - Finger sweep/suction • O - Open the airway - Manual then adjunct • A - Assess patency again - Look - Listen - Feel

Cervical Spine • In all cases of: - Significant blunt trauma above the line of the collar bone - A deceleration injury such as RTA, fall from a height or explosion - A fall front 2x the casualties height - If in doubt THE NECK AND SPINE SHOULD BE PROTECTED BY IMMOBILISING THE HEAD There are a number of ways to protect the C spine: • The method that you use will depend on: - The availability of help - The equipment that you have available • If the patient is at risk from immediate danger then: SALVAGE OF LIFE TAKES PRECEDENCE OVER SALVAGE OF LIMB Manual Airway Opening Techniques

Chin lift

Jaw Thrust

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Suctioning In the remote area, secretions must be removed without the benefit of electrically powered suction devices. A number of innovative products are on the market that the remote area medic might want to consider for the medical kit (Figure 3-8). Gloves and a face shield (Plastic Square with a small one-way valve to place over the victims face) can be tucked into an old 35-mm film container or one of the small pouches marketed specifically for this purpose. Alternatively, a small plastic bag with a slit in it for the mouth and nostrils can be placed over the victims face for rescue breathing. Debris can be swept from the mouth with a finger wrapped in a T-shirt or other available cloth. The victim can be positioned so that gravity facilitates drainage of blood, vomit, saliva, and mucous; something absorbent or basin like can be placed at the side of the mouth to catch drained effluvia. Suction Devices such as Suction Easy can be included in an expedition first-aid kit not just for secretion management purposes but also for gentle wound irrigation and burn dressing or wet compress moisturizing. The rubber self-inflating bulbs marketed for infant nasal suctioning can also be used to suction out debris from the mouths and noses of adults. Large syringes with a piece of oxygen tubing attached can also be used for suction and wound irrigation. Secretion removal by gravity or suctioning is key to the management of epistaxis and for maintaining the airway of a victim with mandibular fractures. Rules for Suctioning: • Only suction as far as the eye can see. • Never push down the back of the throat. • Max. 10 seconds at a time. • Suction on withdrawal only.

Airway Adjuncts Oropharyngeal Airway • Helps control backward displacement of the tongue and provides a free air passage from the mouth to the hypopharynx. • May provoke vomiting, retching or laryngeal spasm. • Removed at first sign of intolerance. Sizing an OP airway. • Measured from the angle of the jaw to the contra of the front teeth Nasopharyngeal Airway More suited to dealing with semi-conscious trauma casualties but not as protective as the oral airway, caution should be used when using this airway adjunct with facial trauma and basal skull fractures. Sizing of the NP airway • Size 6 - average adult female • Size 7 - average adult male After insertion of any adjunct, airway device, or surgical airway, re-assess patency

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Masks and One-Way Valves The purpose of the one-way non-re-breathing flap-valve is to permit air to be pushed into the victim through one aperture while exhaled air (and secretions) are exhausted through a separate route, thus helping minimise exposure to infectious substances. These one-way valves are small, lightweight, and inexpensive and would be easy to tuck into a small container along with gloves and a face barrier. Face masks differ in shape, type of seal, transparency, and materials used for construction. The mask is composed of three parts: body, seal (or cushion), and universal connector. The mask body is usually domed to allow room for a wide range of chin, mouth, and nose sizes and is usually transparent or semitransparent to facilitate visualization of emesis or blood. The seal is the brim of the mask that comes into contact with the face. The two types of seals are the cushion type (often inflatable) and a soft rubber type that is an extension of the body of the mask moulded to fit the contours of the face. The universal connector at the peak of the mask dome provides a 22-mm female adaptor that connects the mask to a one-way valve to go to the rescuers mouth, the elbow of an Air-Mask-Bag-Unit (AMBU bag), or the breathing circuit of a ventilator. Non-cushioned masks are more difficult to use and demand a greater array of sizes. The cushioned masks are a far better choice for responding to out-of-hospital emergencies. In general, the more generous the cushion, the greater its adaptability to a variety of facial sizes and shapes, and the less practice required to achieve and maintain a good seal between mask and face. On the other hand, the greater the volume of air involved in creating the cushion and the more flexible the materials of the cushion, the more vulnerable the cushion becomes to the effects of altitude and temperature. For a mask intended for use in the wilderness, the feature of a self-sealing nipple to permit adjustment of the volume and pressure of air within the cushion is strongly advised. For maximum ease of use, a high-volume, low-pressure cushion (the softest, biggest one) should be kept well enough inflated so that there is an air-filled buffer and yet a smooth contact surface between the cushion and the various contours of the face. Despite optimal cushion inflation, however, some facial shapes provide special challenges. For example, a seal may be difficult to achieve on the bushy-bearded individual. If the beard cannot be rapidly modified, the rescuer could consider using petroleum jelly, hand lotion or K-Y jelly to try to slick down the beard and seal over areas where air could leak out. This manoeuvre has the disadvantage of making the rescuers hands slick and the cushion of the mask slippery, so both of the rescuers hands will be needed to maintain the mask fit. The rescuer also runs the risk of greasing up anything else handled during the resuscitation. Another challenging facial contour is the prominently chinned, long-faced, and edentulous older individual. With the facial laxity that comes with age and without bordering teeth, the cheeks tend to cave in. Again, a two-handed mask technique is probably necessary. The thumbs press down on either side of the mask, and the fingers pull up on the jaw and bunch up as much of the cheek tissues as possible. A second pair of hands might be needed to bunch up the tissues around the entire lower perimeter of the mask. The stiffer the cushion, the harder it is to make this seal. Another manoeuvre to consider in this situation is to roll up two gauze or cloth packs to tuck into the mouth and distend the cheeks. The risks of this manoeuvre are dislodgement and possible aspiration of the packs, and retrograde displacement of the tongue despite a good jaw lift. If there is any choice in the matter, it is almost always easier to mask-ventilate an individual with dentures in place than one with dentures removed, so if intact and secure, dentures should be left in place during field resuscitation. A third challenging facial contour is that of the average infant, any chubby-cheeked babytoothed tonsil-abundant young child, or a moon-faced short-necked adult. The key to successful mask ventilation in these situations is to keep the victims mouth open and the soft tissues from folding in on themselves from gravity and extrinsic compression. One approach is to mask-ventilate over a pacifier, oral airway, nasopharyngeal airway, or improvisational hollow object intended to hold the lips apart, the mouth open, and the tongue pressed down to the floor of the mouth and away from the back of the throat. Several masks with one-way valves are specifically packaged and marketed for the adventurer or remote-site responder. Carrying cases for travellers mask-and-valve products can be impact and puncture-resistant, colourful and readily identifiable, and usable for alternate purposes (e.g., catching water, corralling small objects, or transporting severed digits or avulsed teeth) and can display instructions for CPR or useful illustrations of airway anatomy. To select the most widely adaptable “first-aid kit” mask-and-valve product, look for the following features: transparent and easily bendable mask body materials that retain little “memory” of residing in their carrying positions and do not become stiff, brittle, or nondeformable in cold temperatures; an inflatable cushion seal that can be adjusted for changes in temperature and altitude; a flexible high-volume low-pressure cushion seal able to conform to many different face sizes and shapes; a mask span that can be used on both small and large victims; tough materials

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resistant to cracks and punctures; and a compact mask or carrying case that does not take up disproportionate space in the first-aid kit and a mask that has the ability to have supplementary oxygen delivered to the patient. Administer Oxygen Therapy Oxygen as a therapeutic drug in pre-hospital care os potentially life saving and should be applied as soon as available. Oxygen should be administered via a non-rebreathing facemask which has a reservoir bag attached, in order to increase the saturation of oxygen delivered to the lungs of the casualty. The flow rate is of oxygen is considered to be optimum at 12 -15 liters per minute, a common size of oxygen cylinder (D) will contain approximately 22 minutes of oxygen if full. In remote settings the delay of evacuation or long evacuation times will often result in the casualty being in First/ Emergency responder care for longer than 22 minutes. In these situations it is better for the casualty to receive a continuous, but lower, flow of oxygen rather than have no oxygen therapy after 22minutes. Therefore if a delayed or long casualty evacuation is envisaged the responder should consider lowering the flow rate to 6 - 8 liters per minute after an initial period at 12 - 15 liters per minute although a different mask type will be needed for these lower flow rates. EmOX EmOX is a method of producing 99.7% pure oxygen from a chemically driven exothermic reaction. The remaining 0.3% is humidity. Outline Operation: Sodium Percarbonate is added to a flask containing 0.51 of water. A Magnesium Catalyst is added, thus producing oxygen. The cylinder is non-pressurized. Chemicals are non-explosive and non-flammable. Chemicals have been approved “Safe to Fly - Non Hazardous” by South African Airways. Shelf Life: Shelf Life is indefinite if long-term storage is dry and below 30˚C Capability: The complete system described above can deliver 02 for 45 Minutes. The time can be increased by adding additional packs of Sodium Percarbonate and water. Pack Contents: The above pack weighs 1.75Kg, containing: • Face Mask and 02 Tubing (OnIy use supplied types) • Cylinder and Humidification device • Sodium Percarbonate (x3) 2509 each • Magnesium Oxide (x3) • 5OOmI Water container (filled) Chemistry: The exothermic reaction heats the flask contents to 8O˚C. The temperature of Oxygen Produced (at the patient end) is 26˚C. This is directly proportional to the length of oxygen tubing. If more than 0.51 of water is added a lower flow is achieved. If more than 250g (i.e. more than one pack) of Sodium Percarbonate is added a greater flow is achieved but compromises the humidification device and therefore should not be done. The water can be from a tap, river indeed sea-water has been used and does not affect oxygen production. Human and animal urine cannot be used.

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Ventilation Support Effective oxygenation of the red cells by inhalation and removal of carbon dioxide by exhalation is only achieved through a good rate, rhythm and depth of breathing. By way of a reminder, an adult at rest breathes between 12 and 20 times per minute with sufficient volume to make the chest rise. In some patients lying on the ground, the chest does not often move; it is the abdominal muscles that are doing the work. The adequacy of this type of breathing needs to be further assessed by feeling for airflow from the mouth, as there may be insufficient volume thereby requiring ventilatory support. When a patient fails to breathe, or is not ventilating effectively (moving air in and out of the lungs), it may be necessary to take over or support their breathing by: • mouth to mouth • pocket mask Summary • Airway Management takes priority following the control of major haemorrhage. • C spine should not detract from airway • Simple things first • OP and NP will cope with many problems • If simple measures work - LEAVE ALONE • If in trouble with sizes - think small • Once opening technique performed - confirm by Look - Listen - Feel • Administer oxygen through oxygen face mask with reservoir bag • Take a respiratory rate

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LIFE THREATENING CHEST INJURIES The four main life threatening chest injuries discussed are: • Tensioned Air in the Chest. • Open Chest Wound. • Massive Internal Chest Bleeding. • Flail Chest.

Respiratory Function Respiration (external) is the process by which oxygen passes from inspired air into the blood, and waste products are eliminated. The rib muscles and diaphragm contract causing the chest cavity to increase in size, this causes negative pressure inside the chest, air is then drawn in through the nose and mouth, passing down the throat into the windpipe. It passes into each lung terminating in minute air sacs each surrounded by tiny blood vessels where respiratory gasses are exchanged. The Goal Posts of Life’ for respiration are 10-30!

Chest Anatomy Lungs: A tough protective layer, called pleura surround the lungs. The lungs are always partially inflated with residual air. The chest wall lined is with the same type of layer. Both the layers are lubricated and in contract with each other, allowing the lungs and chest wall to move without friction during respiration. The area between the pleura is a potential space and in times of traumatic injury can become an actual space replacing the area in which the lung can expand into.

Tensioned Air in the Chest (Tension Pneumothorax) Mechanism: This injury can be caused by • Blunt trauma • Penetration trauma • Spontaneous Trauma occurs to the lung and air escapes in to the space between the protective layers. More air fills the space with each breath. As the lung collapses air replaces lung in that space.

Inferior Edge of Lungs

As pressure increases the heart and blood vessels are squeezed and their function is impaired.

Tension Pneumothorax

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Signs and Symptoms • Pain • Possibly coughing up blood or blood stained sputum • Difficult rapid shallow breathing and distress • Weak, rapid pulse • Distended neck veins • Decrease in conscious level • Tracheal deviation away from the side of injury • Air trapped under the skin

Open Chest Wound Mechanism: This injury is commonly caused by injuries such as • Stabbing • Gunshot wound • Shrapnel The mechanism of breathing continues but air can be drawn in via the wound rather than through the air passages. Types: • Small • Larger than 2/3rds the diameter of the windpipe • Multiple wounds Signs and Symptoms • Pain • Possibly coughing up blood or blood stained sputum • Difficult rapid shallow breathing and distress • Weak, rapid pulse • Air may be sucked into a chest • Blood stained bubbles • Possible air hunger (reduced movement of air through the mouth as air is drawn in via the wound) Treatment • Airway and oxygen • Maintain airway • Seal all open wounds except one. • Apply Adhesive Chest Seal - Do not allow chest seal to become bent. - Alternative is a three-sided dressing. • Lay casualty on the UNINJURED side • Monitor pulse & respiratory rate • Transport to medical care ASAP!

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Massive Internal Chest Bleed Mechanism: This injury is caused when an artery in the chest is damaged and blood fills the space between the two protective linings, also it can involve the lung collapsing which will involve air trapped as well as blood, by either: • Blunt trauma • Penetrating trauma Treatment • Little can be done by First Aid. • Responsibility is to recognise a serious life threatening chest injury and move rapidly to medical care i.e. a SURGEON

Flail Chest Mechanism of injury is mostly through blunt trauma Definition: Where 2 or more ribs are broken in 2 or more places. The underlying lung can be badly bruised and leak fluid into air sacs. Signs & Symptoms • Fractured ribs cause severe pain. • Movement of flail segment opposite to that of chest wall may be seen (paradoxical movement) • Feels as though casualty is suffocating. • Difficult & painful breathing. • Anxious & distressed. • Segment loses rigidity. • Frothy blood stained sputum, indicating lung puncture. Treatment • Airway & Oxygen • Treat semi-sitting leaning toward good lung • Stabilise and secure unstable segment - do not restrict chest movement • Monitor pulse & respiration rate • Transport to medical care ASAP! Summary Chest injuries are common in blunt and penetrating trauma and are a major cause of death. Of those surviving, recognition of a serious chest injury, simple skills and rapid transport to medical aid will be the difference between death and survival. DON’T FORGET OXYGEN IF AVAILABLE

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CONTROL OF SEVERE BLEEDING Severe bleeding is rapidly fatal, and any bleeding can lead to hypovolaemic shock, which, if not treated, can result in coma and death.

The Circulation system consists of: The Heart This is a muscular pump for the circulatory system and is discussed further within the medical emergencies chapter. Blood Vessels Divided into: • Arteries; these are muscular tubes which carry Oxygen filled blood under pressure from the heart to the organs and tissues of the body. • Veins; these are smaller, thinner tubes which carry blood from the tissues and organs of the body back to the heart and lungs, they work at low pressure and against gravity. • Capillaries; these are small tubes which surround the tissues and organs of the body and allow the transfer of Oxygen to the tissues and removal of Carbon Dioxide. Blood This is the fluid of the circulatory system, which carries oxygen to the organs and tissues, removes carbon dioxide, helps to fight infection and carries clotting material to haemorrhaging areas.

Normal circulatory values The average normal heart rate is between 60 - 80 beats per minute although this can be lower such as in athletes or higher. The pulse can be felt at any point where an artery crosses a bone close to the surface of the skin.

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Assessment Count the radial pulse Rate in beats per minute Assess capillary Refill Time (forehead or finger) Look at skin colour (pallor) Look for bleeds: “Blood on the floor and 4 more • Blood on the floor and other external bleeds • 4 more areas to check (cavities) where internal blood loss can be catastrophic - Chest - assessed within Breathing assessment - Abdomen - Pelvis - Long bones - Femur and Humerus The Goal Posts of Life’ for circulation are a radial pulse of between 40-120!

Types of Bleeding Severe/Immediate threat to life: • Bright red blood spurting in time with the heart beat. • Massive varicose vein bleeding • Internal organ bleeding Dangerous: • Large wounds continuously bleeding. • Foreign body impalement. • Open fractures. Minor: • Other wounds such as lacerations & abrasions • These require cleansing and dressing properly.

Bleeding Control Methods • Direct pressure - this, if done correctly, is suitable for most bleeding wounds. • Elevation of a limb, in conjunction with direct pressure - this reduces blood flow to limbs, therefore reducing haemorrhaging and re-directs approximately 15% of valuable blood out of limbs and into the core areas, allowing vital organs to be supplied with oxygen and removal of carbon dioxide. • Compression dressings - varieties in quality will directly affect the ability of dressings to assist with compression and clotting of wounds. • Pressure points - Instant control; easily achieved but requires knowledge of specific points where arteries run along of over a bone against which it can be compressed. • Wound packing - Large wounds, avulsions etc, allows direct pressure to be applied to the specific site of haemorrhage within the wound. • Splinting - Reduces haemorrhaging by causing direct pressure onto internal bleeds, it also has an effect of reducing pain and carries the benefits of this such as reduced pulse rate, reduced demand for oxygen etc. • Pressure enhancement. Compression improvement via such methods as first care bandage windlass system or improvised windlass greatly improved the control of haemorrhage in large bleeds. • Tourniquet - This has been controversial over the years but improvements in tourniquet products and more evidence has brought the use of the tourniquet firmly into the forefront of treatment for severe/life threatening haemorrhage, especially in remote environments.

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â&#x20AC;˘ Haemostatic agents - More products each year are being manufactured for use in haemorrhage control. Haemostatic agents are now well researched and have been shown to be lifesaving when used on appropriate wounds/bleeds and within the haemorrhage control cascade.

Pressure points Several pressure points are used as indirect pressure, mainly: * Brachia! (No 5 in figure below) - for incompressible bleeds in the arms, the brachial pressure point is found on the interior (medial) aspect of the arm between the bicep and tricep muscle, along the humerus bone. * Femoral (No 11 in figure below) - for incompressible bleeds in the lower limbs, situated on the front (anterior) aspect of the pelvis slightly above (superior) to the inguinal groove Other pressure points are shown below with compressible sites highlighted in bold: 1. Temporal artery 2. Facial artery 3. Subclavian artery 4. Axillary artery (use pad) 5. Brachia! artery (digital pressure or tourniquet) 6. Radial artery 7. Ulnar artery 8. Popliteal artery (use pad behind knee) 9. Anterior tibial artery 10. Posterior tibial artery 11. Femoral artery 11a. Femoral artery (use tourniquet) 12. Common carotid artery

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Tourniquets The aim of a tourniquet: To control severe life threatening bleeding as soon as possible. Rules on Tourniquets: • Note the time of application • Only applied on single bones above elbows and knees • Slowly release to assess haemorrhage control every 15 minutes • Once tourniquet has been applied for 2 hours it is to remain on until definitive care is reached

Haemostatic agents. For emergency response professionals, the use of Haemostatic agents to assist stopping traumatic bleeding can be life saving. Achieving haemostasis helps to stabilize the patient and provides a longer time-window to transport the patient to further medical treatment. They are typically used upon determination that conventional methods have been inadequate to stop bleeding. • Apply direct, firm pressure to wound using sterile gauze dressing or best available substitute. • If moderate to severe bleeding continues after 90 seconds, use haemostatic agent. • Remove previously applied bandages making certain to wipe away as much excess blood and liquid in wound area as possible. • Immediately begin a gradual pour or packing of agent onto source of bleeding. • Immediately bandage wound using compression style bandage or best available dressing and apply firm direct pressure. Different types currently available include: • Quickclot ACS and Combat trauma gauze.. • Hemcon. • Celox Gauge and granules.

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Shock Shock is defined as a lack of oxygen to the tissues, through whatever cause. There are several types of shock but shock occurs when one of the essential aspects of the circulatory system is compromised, through: • Blood loss and body water loss • Anaphylactic shock • Nervous system shock • Cardiac shock If the initial injury does not kill your casualty, shock may well do so!

Problems with the heart (pump), ie: - Heart attack - Angina - Cardiac tamponade - Developed Tension Pneumothorax

Problems with the blood (fluid), ie: - External Haemorrhage - Internal Haemorrhage - Severe dehydration - Burns

Problems with the Vessels (arteries and veins), ie: - Septic shock - Spinal cord injury - Some drugs and poisons

Signs and Symptoms • Restless & anxious. • Increase in respiratory rate - fast & shallow. • Increase in pulse rate - fast & shallow. • Cold and clammy skin. • Pale. Later signs • Blood pressure drops and radial pulse may be lost. • Breathing may become laboured & weak. • Conscious level decreases, causing confusion, disorientation, unconsciousness & death.

Internal Bleeding Suspect serious internal bleeding in a casualty who has signs of shock but no apparent external loss. Treatment • Maintain airway • Oxygen if available at 12-15/per minute. • Control all compressible bleeding. • Elevate the legs. • No food or water except to wet the lips. • Keep warm and insulate from cold surfaces. • Monitor and record vital signs.

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Summary Severe bleeding is a major cause of immediate death in trauma, performing the basic skills of haemorrhage control well enhances the likelihood of survival dramatically. Shock is a major cause of delayed death due to lack of oxygen being delivered to vital organs and the build up of carbon dioxide in the tissues. Shock can be prevented or delayed by treatment of the cause.

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BURNS Aim: To discuss treatment and management of• Thermal burns and scalds. • Chemical burns.

Introduction • Burns are a common cause of injury. • Both burns and scalds cause similar injuries. • The source is heat i.e. sun, excess heat/cold, friction, hot liquid/vapour • Burns may be associated with other injuries (think burns and what else) • Chemical burns are caused by acids or corrosive alkalis

Description of burns Superficial burns involve the outermost layer of skin, signs include: • Redness • Tender • Swelling Healing occurs in 5-10 days providing treatment is prompt Partial Thickness burns involve the middle layer of skin, signs include: • As above • Blistering Healing occurs in 10-20 days providing treatment is prompt Full Thickness burns involve all the layers of skin and can go down to underlying tissue: • Deep & often painless • Pale, waxy or charred

Critical Burns Burns that cause potential life threatening injuries include: • Burns to face/mouth • Inhalation burns • Partial thickness exceeding - 10% surface area (Adult) - 15% surface area (Child) - 5 % surface area (Elderly) • Full thickness over 10% • Superficial over 75% • A burn complicated by fractures or major soft tissue injury • Associated medical conditions • Chemical/electrical

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Assessment The palm of the patients hand with fingers together = 1% Do not count areas of redness when assessing.

Actions & Treatment • Halt the burning process • Within 10 minutes - cool for 10 minutes • Use cold running water if possible • Remove constricting items such as rings, watches • Remove burned clothing unless stuck • Apply burns dressing, types include: • Cling film • Cold gel packs • Non adherent dressings • For hands - place in plastic bag and seal at wrist, keep moist • Significant burns will send the casualty into SHOCK, consider appropriate treatment Do not • Burst blisters (these are sterile environments, you will introduce infection) • Apply adhesive dressings (any healing tissue will be ripped off on dressing removal) • Apply creams or lotions (if these are the wrong type they can promote the burning process and introduce infection, they will be removed on arrival at hospital causing further pain) • Apply ice directly to the bum (this will potentially cause a freezing injury)

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Facial Burns Facial burns pose a threat to the airway due to inflammation and swelling which can quickly lead to an obstructed airway. Signs of airway burns include: • Hoarse voice - very serious sign • Breathing difficulty • Swelling of lips & tongue • Singing of nasal & facial hair • Soot around nose or mouth Treatment A casualty with potential airway burns needs to be moved to medical care ASAP! Swelling to the tissues inside the oral cavity and pharynx can swell dramatically and occlude the airway. Maintain the airway as much as possible, cool burns area around the air passages. Oxygen therapy should be applied and if possible cooled.

Electrical Burns • Switch off current and rescue casualty, ensuring scene safety • Assess ABC and manage appropriately • Perform BLS if required (electrical burns can impact the electrical activity of the heart) • Place the casualty in the recovery position if unconscious • Cover with dry dressing • Look for entry and exit wound • Seek medical care Chemical Threat May be used to distract first/emergency responders and security teams and disable response, examples include: • MACE/CS • Acid and alkali sprays • Industrial chemical accident • Domestic materials - oven cleaner, paint stripper etc • Phosphorous Treatment • Remove from danger with due care to self contamination GLOVES at least • Wash off chemical ASAP with copious water for 20 minutes • Remove contaminated clothing • Irrigate eyes and mouth if ingested • Cover burns • Seek medical care ASAP • Pass info on chemical to EMS service. REMEMBER BURNS AND WHAT ELSE!

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MUSCULO-SKELETAL INJURIES Background Can be a cause of early deaths due to severe bleeding. Late complications can occur due to infection and non-union of fractures and also can be a significant cause of disability.

Definitions Fracture - “is a soft tissue injury complicated by a break in the bone” Dislocation - “is the displacement of a bone in a joint” Fractures & dislocations often cause damage to: • Skin • Fascia • Muscle • Tendon • Blood vessels • Nerves

Pre-hospital treatment Any treatment assumes there is a delay in evacuation. Treatment is dependent upon the equipment available and the local situation. Closed v Open fracture Closed • Skin intact • Swelling • Blood clot/bruise under the skin Open • Skin broken • Visible haemorrhage • Bone exposed • Contamination Signs & Symptoms • Intense pain - especially on movement. • Swelling & bruising. • Deformity/shortening of limb. • Loss of function & inability to move injured area. • Blood loss & shock.

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Fracture Treatment • Check pulse distal from wound before and after treatment to ensure blood supply is present at the distal end of the limb. • Dress associated wounds. • Re-align limb to its neutral position - use gentle but progressive traction if bent or badly angled. • Immobilise through splinting • Provide pain relief Splintage • Include joints above and below fracture, ensuring that limb is in neutral position and any rotational movement is reduced • Use torso or uninjured leg if necessary.

Joints Treat joints in most comfortable position for the casualty, distal pulses need to be checked to ensure circulation is present. Joint injuries should only be manipulated if distal circulation is not present due to the complex structures within the area. Upper limb: • Sling for humerus. • SAM splint for forearm (sugar tong). • Box splints Lower limb: • Traction for femur / knee / tibia. • SAM splint for ankle. • Use of good leg for immobilisation

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HEAD INJURIES Statistics Head injuries are the biggest killer of children over the age of one year and are the commonest cause of death aged 15 - 24 years. In adults alcohol is commonly involved with 9 people per 100,000 dying from head injury annually. Post head injury care is very expensive.

Anatomy “A Blancmange in a Rigid Box”

Physiology The brain needs oxygen and is very sensitive to any changes in the balance of oxygen and carbon dioxide.

Primary Injury & Secondary Injury Primary Injury Caused by both blunt and penetrating trauma • i.e. Bullet, Machete, Brick • Common injury in frontal impact RTC • Penetrating trauma to the Head is often fatal Fractured Base of Skull injury (#BOS) Usually caused from blunt trauma, signs can develop slowly Signs & symptoms: • Raccoon eyes (bruising around both eyes) • CSF leak from eyes, ears or mouth • Mastoid bruising (battles sign): bruising behind the ear, this is a sign that will develop over time and will not be present in the first few minutes after injury

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Secondary Injury Not much can be done for the primary injury but we can influence the secondary injury, which results in an increase in pressure within the brain which in turn will lead to: If a casualty in unconscious or has reduced levels of consciousness after the ABCs have been addressed then it is due to an impairment to the working of the brain functions through whatever cause. This is assessed in D of the primary survey. Brain Tissue Hypoxia Important Points • A decrease in 02 leads to the brain swelling. • An increase in CO2 leads to dilation of vessels Both of these will result in: • Increased bleeding • Increased pressure Any decrease in Blood pressure through other injury leads to the head injury worsening as the blood cannot get enough oxygen into the brain = a decrease in 02 and the whole pattern starts again. • Head injuries also respond badly to temperature changes • Speed of evacuation has a direct influence on long term prognosis Signs and symptoms • Change in Level of Consciousness • Weakness or abnormal movement in arms/legs • Changes in the size of the pupil(s) and the speed of reaction to light Assessment of D = Disability in the Primary Survey • Consider the Mechanism of injury and associated injuries suspected • Assessing the patients state before injury can be important (never assume drunkenness!) • Document findings and communicate • Reassess often and establish 39trend over time AVPU A - alert V - verbal commands only P - painful stimuli only U - unresponsive Pupils (P.E.A.R.L.) • Pupils Equal And Reacting to Light

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Severe Head Injury This will require urgent evacuation to a definitive care facility and presents with: • Unequal eye opening • Unequal Motor response • Open injury with brain exposure Deterioration of head injuries These injuries will need urgent evacuation and is defined by: • A fall in LOC • Increase in severity of headache • Increase in size of one pupil • Developing one sided weakness

PTA = Post Traumatic Amnesia RTD = Return to Duty

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SPINAL INJURIES Introduction In the UK there are approximately 500 new injuries every year of a spinal nature. There is an increase in the number of incidents in the under 30’s this is probably due to the increasing number of adventurous sports people are undertaking. As the world becomes a smaller place with the advent of globalisation more and more sports/adventure holidays are identified and the risk is increased. Although relatively rare, spinal injury is devastating to the patient his/her family and society as a whole. Spinal care is extremely expensive not only in financial cost but in carer time and effort. C-Spine clearance in the Field An immobilised patient in a hostile environment is a liability to himself and his colleagues. The difficulty and dangers of prolonged spinal immobilisation, especially in a remote and hostile environment, should therefore not be underestimated. The remote area medic has a particular interest in avoiding unnecessary spinal immobilisation. Even in an orthodox environment immobilisation can cause problems: the patient can find the experience uncomfortable or distressing and nursing care of an immobilised patient is demanding. More importantly prolonged immobilisation on a rigid long board can cause significant ulceration of the skin. The problems associated with spinal immobilisation will be exacerbated in a remote environment given the shortage of staff and the inherent delay in proving or discounting spinal injury by x-ray. Where possible seek topside support before attempting to clear the cervical spine. Be aware of individual patient factors that may influence the response to pain, e.g. medications, cultural and behavioural norms and the circumstances of the incident. Remember, if there is suspicion of spinal injury in any one part of the spine requiring immobilisation then the whole spine will usually need to be immobilised. ATLS now recognises and discusses the possibility of ruling out cervical spinal injury on clinical grounds. The following guidelines can be used to “clear” the cervical spine, which is to indicate in which patients cervical spinal injury might be safely ruled out on clinical grounds without access to radiological examination. Consider spinal injury with a mechanism of injury associated with: • Blunt trauma above the clavicles • RTC • Diving • Forced movement of the neck • Falls from heights • In any doubt

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Full spinal immobilisation should be instituted or continued in the presence of: • Decreased conscious level • History of loss of consciousness • Alcohol or drugs (prescribed or abused) • Significant neck or back pain • Deformity, swelling or tenderness of the cervical spine • Neurological signs or symptoms related to the spinal cord • Significant and therefore distracting pain from other injuries • Bony tenderness, swelling, bagginess, deformity, steps or crepitus If all these are negative, check neck movements in all directions. If symptom free then spinal immobilisation may be discontinued.

Anatomy The spinal column (or vertebral column) extends from the skull to the pelvis and is made up of 33 individual bones termed vertebrae. The vertebrae are stacked on top of each other group into four regions: Term

No of Vertebrae Body Area

Cervical

Neck

Thoracic

Chest

Lumbar

Lower back

Sacrum

5 (fused)

Pelvis

Coccyx

Tailbone

The spine is made up of vertebrae, which articulate with each other. A typical vertebra has a body, two pedicles and two laminae joining over the spinal canal. The spine is made up of vertebrae, which articulate with each other. A typical vertebra has a body, two pedicles and two laminae joining over the spinal canal. Manual immobilisation Manual immobilisation of the head and the neck will usually be required in any patient who has had a cervical collar applied or who is about have one applied until the entire spine is immobilised, especially while the patient is in an unstable environment (e.g. a vehicle), or if they are being moved or if they are agitated and poorly compliant.

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Cervical collars A suspected cervical spine injury should be immobilised until x-rays exclude the injury. If there are likely to be serious delays consider clearing the cervical spine as described above. A cervical spine collar should never be used in isolation, it should be a case of all or nothing in regards to C Spine management. Application • Preferably a two-person procedure • Check the method of sizing for the particular collar used • Pass the back of the collar under the neck with an assistant maintaining in-line stabilisation • Pass the anterior portion with the chin rest around the neck to Velcro with the posterior part • Ensure that the neck/head is now held in a neutral position • Check that the patient is comfortable and that the collar is not pinching ears, etc Caution These cervical collars do not completely prevent rotation of the neck, therefore the rest of the spinal column must also be immobilised. Incorrect placement may result in airway obstruction it can also reduce venous return from the head and therefore increase intracranial pressure with prolonged use.

Neurogenic Shock Due to the disruption of the sympathetic outflow from Tl.-L2 due to injury (penetrating or blunt), a triad of hypotension and bradycardia and sometimes hypothermia can be seen; this is referred to as neurogenic shock. The patient may present with acute hypotension without associated blood loss. A classic sign and symptom is Priapism (erection), tachycardia; swollen hands and feet are also signs and symptoms. The treatment must be in line with maintaining patients haemodynamic status. Caution must be taken when administering fluids. Atropine is the drug of choice administered intravenously over 5 mins up to a maximum of 3 mg.

Spinal Shock This is a transient state, which is caused by the reflex depression of the spinal cord below the level of injury with associated loss of sensor motor functions. An initial increase in BP is noted due to catecholamine release but this is followed by hypotension. Paralysis of the bladder and bowel sometimes occur with associated priapism. These symptoms tend to last several hours to days until the reflex arcs below the level of injury begin to function again. Due to the transient nature of this the remote area medic must manage a patient with this type of injury and symptoms as if he/she has sustained permanent spinal cord damage. Log roll Use: • To inspect the back of someone suspected of a spinal injury • To put a patient onto a spinal board Method This is preferably a five-person technique • Check the patients pockets for items that may cause pressure on the skin • The team leader will take control of the head and neck and maintain in-line stabilisation of the cervical spine during the roll • The second person takes the shoulders • The third person takes the pelvis • The fourth person takes the legs • The casualty is rolled on command of the team leader towards the turners ensuring that there is no twisting of the spine

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• The fifth person can then inspect the back or slide the spinal board underneath • The casualty is rolled back by the reverse of the above Caution • Ensure there is no twisting of the spine during the turn • If there are not enough assistants then bystanders may have to help • If there are only three people then one person takes the shoulders/pelvis and the other the pelvis/legs

Spinal Board This is usually a non-metallic board that has handgrips and straps for securing a casualty. It is used in conjunction with a cervical collar and the universal head immobiliser for patients with suspected spinal injuries. Use: • For a vehicle occupant slide underneath the patient and rotate patient onto the board avoiding twisting of the spine • Use the log roll to place a patient who is on the ground with a suspected spinal injury onto the spinal board • Secure the patient with the chest, abdomen and leg straps • Secure the head immobiliser on the board

Head blocks

Spider straps

Caution Can cause pressure sores within one hour, therefore consider other stretchers, e.g. vacuum mattress. Sometimes it is advantageous to slide the spinal board under the vacuum mattress for extra support and this also stops the vacuum mattress becoming damaged. Pressure sores are a brake down in the skin area over lying bony prominence. The main cause of pressure sores as the name states is undue pressure on an affected area. In initial phases after injury the patient is unable to turn himself and to relief pressure this should be done in a spinal unit once the casualty has reached definitive care.

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Kendrick extrication device - KED This device provides support and stabilisation to the upper spine Use: Extrication from a vehicle for a suspected spinal injury Method • Use manual in-line cervical stabilisation • Apply a cervical collar • Position the ked between the casualty and the seat • Fold the wings around the patients chest and tighten the straps avoiding respiratory impairment • Pass the leg straps around the legs and tighten • Fill the space behind the head with the pad provided • Tighten the head straps • The patient is now ready to be moved Caution When the patient is to be placed supine, e.g. onto a spinal board or vacuum mattress, the leg straps will have to be loosened so that the legs can be straightened. Whilst useful to ensure spinal protection prior to moving it can be time.-consuming, so it can be quicker to extricate with the spinal board (e.g. for the patient with time.-critical injuries).

Vacuum mattress Use: Provides comfortable, rigid support for the spine and is preferable to spine board for the long distance transfer of patients with spinal injury. Method • Place patient on mattress and secure with the straps • Connect pump and extract air, moulding the mattress around the body contours and taking care especially to the head and neck Caution • Never lift by holding at the ends only, as it will bend • Slide the mattress and patient from one surface to another, lift with many hands or place into a basket stretcher or onto a spinal board • Vulnerable to punctures and slow leaks (keep puncture repair kit and pump to hand

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DROWNING & Near drowning Drowning is a very common cause of death in the UK. It happens to be the fourth leading cause of death in men under the age of 35 years old. Alcohol and drugs are a significant factor in drowning incidents in young men. It’s the second leading cause of death in children. 40% of all drowning deaths in children occur in children under the age of 5. “Near Drowning” is the term given to a survivable drowning episode. There are two different types of drowning that cause death, “wet” & “dry”

Water blocking a small airway

“Wet” Drowning The above diagram demonstrates water blocking a small airway. This happens when an individual can no longer hold their breath under the water. They gasp and try to inspire air, and the water is aspirated into the lungs. This water will block the airways resulting in hypoxia, which will then result in hypoxic cardiac arrest and death. You only require lOmls of inhaled water per kg of bodyweight to be fatal.

“Dry” Drowning In dry drowning very little or no water enters the lungs. This can be due to the fact that the larynx goes into spasm when hit with cold water, making it difficult for the water to be aspirated into the lungs. It is however, more likely to be because of the primary cardiac arrest due to the stimulation of the vagus nerve which sits behind the larynx. Dry drowning is responsible for between 10 & 25% of drowning deaths.

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What happens during immersion in cold water? Body Temperature The body temperature decreases rapidly. If the water is below 10 degrees it makes it extremely difficult for the body to generate warmth, despite rapid movement in the water. At this point the symptoms of hypothermia commence. Respiratory System Due to the coldness of the water our breathing becomes rapid and shallow and will result in the individual becoming exhausted. If the water is below 5 degrees an individualâ&#x20AC;&#x2122;s ability to hold their breath is reduced to a maximum time of approximately 5 seconds. Circulatory system Water exerts a pressure on the body. If an individual is upright in water there is an approximate distance from their head to their feet of 1.3m or l3Ocm. This make l3Ocm of water pressure which equates to approximately lOOmmHG as mercury is 13 times denser than water. This hydrostatic pressure is a very important factor that should be taken into consideration when removing an individual from water. In an upright position the most pressure will be at the feet, getting less, working in an upwards direction towards the head. If the individual is removed from the water in an upright position this will cause a sudden drop in blood pressure which could result in cardiac arrest. The hypothermic affects of the cold water will also cause a reduction in circulating VOLUME.

= Water Height = 1.3m = 130cm

Pressure = 130 cm of water = 100mmhg Pressure of water at feet is 100mmhg. This reduces to 0 at surface.

Hydrostatic Pressure Diagram

The diving reflex The diving reflex is something that occurs in mammals however its significance in adults is uncertain. It seems to be more developed in Children and could explain why children are able to survive prolonged immersion in cold water. When cold water stimulates areas of the face and neck a reflex bradycardia occurs. This bradycardia combined with the cold temperature of the body can have a protective effect on the individual, as it reduces the oxygen requirements of the brain & other tissues which have a high metabolic requirement.

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Effects of Near Drowning The effects of near drowning are dependant on the length of time the individual has been immersed in water, the temperature of the water and the amount of water inhaled. Initial Effects The quickest problem to occur is hypoxia. The individual will become confused, and lethargic which will eventually lead to unconsciousness and cardiac arrest. It is important to be aware that the individual will also be suffering at this point from hypothermia. Delayed/ Secondary Effects Although the amount of water that gets inhaled into the lungs is a very small amount it has a number of consequences as it causes pulmonary oedema to occur and a reduction in surfactant. This initially may not cause the individual any problems as these problems develop over a few hours, at which point they will have very noticeable respiratory problems. This problem is what we determine as secondary drowning. During this secondary phase, infection can be a potential problem. This is due to the fact that the individual may have inhaled water containing sewerage or rat urine. When making your diagnosis two important points to remember are the underlying injuries and causes that may be present alongside the drowning diagnosis. Remember cervical spine injuries; classically diving related, especially for those people who have divided into water that is shallower than anticipated. Also remember hypothermia. There is a high probability that the patient will be hypothermic after being submersed in cold water for any length of time. Treatment Remove the individual from the water, whilst trying to maintain them in as horizontal a position as possible. Airway The airway may present totally patent. If the patient is unconscious their tongue may be blocking the airway or there may be water in the oropharynx. Check the airway and clear any water, vomit or debris using suction under direct vision. In this kind of individual if you have the skills, then a laryngeal mask or endotracheal tube should be your choice of airway as itâ&#x20AC;&#x2122;s prevents gastric contents from aspirating into the lungs if regurgitation occurs. However if you do not have the required skills to fit one of these airways op or np airway can be used with careful insertion. These individuals are highly likely to regurgitate their stomach contents during cpr as the stomach may well be full of water, and blowing air into it will cause regurgitation. Breathing Breathing may be normal, itâ&#x20AC;&#x2122;s therefore important to remember to auscultate the chest for crepitations significant of secondary drowning. Breathing may also be absent with or without cardiac arrest. Do not attempt to put the individual in a head down position in an attempt to drain water from the lungs. This will cause unnecessary intracranial pressure. Circulation The pulse can be very variable, due to the cold extremes the individual has been subjected to. If there is no palpable pulse then immediate CPR should be commenced. You should aim to warm your patient gently on removal from the water as the hypothermia will cause problems with circulation. This can be done by introducing warm iv fluids or a simple measure aboard a ship is to put a duvet cover into a tumble dryer and then cover the patient. It is important to get these individuals to definitive care as soon as possible.

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EYE & EAR INJURY The eyes have a self-protection mechanism where the outer layer bathes itself constantly in fluid to keep itself clean. A speck of dust, eyelash or contact lens can float on the eye and is normally easily removed. However instances occur when the eye cannot “wash” itself and first aid management is required.

Foreign Body Signs And Symptoms • Blurred vision. • Pain or discomfort to the eye. • Redness and watering of the eye. • Eyelid screwed tightly in spasm. Management • Advise casualty not to rub eye. • Sit casualty facing the light. • Gently separate the eyelids to examine the whole eye. • If you can see a foreign body on the whites of the eye wash it out. Eye Wash • Tilt affected eye away from tear duct i.e right eye tilted to right shoulder. • Sluice with clean, running water at room temperature. • If foreign body is not adhered to eye lift it off with a damp swab or triangle of card. • If the foreign body is stuck to or embedded in the eye cover the affected eye with an eye pad and bandage and transport to nearest hospital facility. • Do not attempt to remove an embedded foreign body or anything sticking to the iris (coloured part of the eye).

Chemical Burns To The Eye Chemical splashes to the eye can cause serious injury to the eye if not treated quickly. The damage to the surface of the eye can lead to scarring and even blindness. Caution must be given when irrigating the eye that contaminated water does not splash the casualty, yourself or the good eye. Signs And Symptoms • Intense pain in the eye. • Inability to open the eye. • Redness and swelling. • Copious watering. • Obvious evidence of chemical substance in immediate area. Management The eye needs copious irrigation. • Hold affected eye under running cold water if possible. • Adopt position as for eye bath. • Wear gloves. • Protect casualty’s face with towel to prevent chemical burns to the skin • Irrigate both sides of the eyelid thoroughly. • If eye in spasm gently pull eyelids open. • Apply sterile dressing (gauze pad) over injured eye. • Ensure casualty does not rub and irritate the eye and possibly spread contaminant to fingers.

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• Remove casualty to hospital. • Identifying chemical if possible

Flash Burns A flash burn is an extremely painful injury. The surface of the eye is damaged due to over exposure to ultra violet light or prolonged glare from the suns reflective rays. It can take up to 7 days for this condition to recover. Signs And Symptoms • Intense pain in affected eye(s). • A gritty feeling in the eye(s). • Sensitivity to light. • Redness and watering of the eye(s). Management • Do not remove contact lenses. • Reassure the casualty. • Protect eyes with eye shields. • Arrange for the transfer of casualty to hospital.

Ear Damage Blasts Ear damage may occur following an excessively loud blast. One ear is usually affected as the head turns to avoid the blast. The casualty may experience persistent ringing in the ears, screeching noises which may persist long term. Casualties may appear rude, uncooperative due to their lack of hearing, disturbed volume control.

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CASUALTY CENTERED RESCUE: Improvised Extriction from Vehicles The Casualty centered approach To be of use the team / Individual needs to have had appropriate training and reasonable experience of road traffic collision care. FPOS 1 Responders may initially assess and treat and then support medical / rescue teams in the following ways: • To get telephone / Radio advice for difficult situations / locations or to help make difficult decisions • To arrange access to specialist skills/equipment i.e. Cricothyroidotomy, chest drain, certain specialised drugs and IV access techniques • To help manage the trapped patient in a general manner, bringing their experience to help avoid possible problems; i.e. acting as a roadside consultant to the local rescue agencies. Every trapped patient should have the benefit of an experienced Practitioner if optimal care is to be given. It also allows rescue crews the opportunity of learning from the practitioner’s experience of similar problems in the past. This will only be of value if the practitioner is properly trained and experienced. In this way the concept of seamless care from accident to definitive treatment can be promoted using, if necessary, the practitioner’s presence at the scene to facilitate decisions regarding “the right patient to the right hospital in the right time” rather than the current practice in most services / locations of having to take the casualty to the nearest hospital, whether or not it has the facilities to cope with that particular casualty. “

Reading the Scene Examination of the accident scene helps to predict the kind of injuries that the victim may have sustained and these injuries should be positively sought. It is therefore essential to take an overall impression at the accident scene as we (the rescuers) approach. This requires great discipline, not to be distracted into doing what others expect of you or what your emotions want you to do. In addition it is essential that we assess safety not only from the rescuers point of view but also considering overall scene safety and the safety of all the casualties involved in the incident. From a background of knowledge and observation it should be possible to predict the injuries that the casualty may have sustained even although these injuries may not be apparent on ones first examination. Injury Prediction Let us look at certain situations in order to illustrate injury prediction, remembering at all times that there are potentially three collisions in any accident, all having the potential to produce damage to the body. These collisions are: • Firstly, that of the vehicle collides with another object. • Secondly the occupant of the vehicle colliding with the inside of the vehicle which has now stopped. • Thirdly the victims own body structures or organs move within the body cavities. When assessing a casualty remember that the possibility of unrecognised injury is increased when: • There has been a fatality in the same vehicle • The impact speeds are greater than 30 mph • There has been ejection from the vehicle of the casualty • The casualty has been involved in a rollover • The casualties vehicle has been hit from the side • There is significant deformity of the vehicle length or width • There has been a fall from height of over x2 or x3 the patients height • There has been a fall of greater than 6 meters

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Road Traffic Collisions Cars In dealing with road traffic collisions, discover whether the accident involved a frontal, side or rear impact, and whether a rollover has occurred. Look for deformity of the vehicle and the potential intrusion into the passenger or driver compartments caused by forces from outside. Objects within the vehicle may cause injury as they move at speed through the passenger compartment during a deceleration incident. Look for clues from inside the vehicle, which may suggest occupant injury: hand baggage in front seat area (originally in boot!) Frontal Impacts Frontal impacts occur when the front or front comer of the vehicle collides with another vehicle or a stationary object. Whether the occupants of the vehicle were restrained or unrestrained by seat belts alters the patterns of injury that may be seen. The forces imparted to the occupants are related to the solidity of the object hit and the speed. The unrestrained front seat occupant will move forward, there will be extension of the lumbar spine, their knees will hit the parcel shelf or fascia and often there will be upward movement of the body so that the head hits the vehicle roof. This will then be followed by flexion of the neck as the body continues to move forwards in an unrestrained way and the head will then hit and often break the windscreen. In the case of a driver, the chest then comes in contact with the steering wheel. The occupant will then tend to move backwards and there may well, at this point, be hyperextension of the neck. Restrained front seat occupants still tend to move forward and depending upon the force there may be injuries from the seat belt, both the chest and the lap components of the modern system. The occupant will still tend to flex their cervical spine and the head can still come in contact with either the windscreen or the steering wheel. Other injuries seen in this type of impact are those associated with the arms and legs moving forward and hitting the dashboard. Multiple limb fractures are often the result. Airbags can reduce the forward movement but may be associated with different but less severe injuries, particularly to the arms and wrists or abrasions to the face and neck. Injuries to rear seat occupants on the whole are less severe, but an unrestrained rear seat passenger will be thrown forward causing either injury to themselves or possibly further injury to the front seat occupants. The rear seat occupants may suffer neck and knee injuries or if they have been restrained by a lap belt may have injuries to the abdominal viscera. During the impact it is possible that the doors may have burst open and any unrestrained passenger may have been ejected causing further injury. Unrestrained rear seat passengers, particularly children or babies may have been thrown through the windscreen. Expected injuries from frontal impact: Lower Limb Injuries • Fracture Patella - Dashboard • Dislocated Knee - Dashboard • Femoral shaft fracture - In direct • Dislocated hip - indirect • Tibial fracture - Dashboard Abdominal compression (Seat Lap belt) • Rupture of hollow organs - stomach, bowel • Compression of solid organs- liver spleen kidneys Thorax Compression Skeletal (Steering Wheel) • Rib Fractures • Sternal Fractures • Flail chest

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Thorax Compression Viseral (Steering Wheel) • Heart - Tamponade contusion • Lungs - Heama- Pnuemo Thorax • Traumatic tear of arch of aorta Head Injuries Direct (Windscreen) • Frontal laceration • Skull Fracture Head Injuries Indirect (Sheer forces) • Whip Lash • Severed Spinal cord Head-on Impact As the knee of the front seat occupant hits the inside of the car forces are transmitted along the leg, there may be dislocation of the knee, damage to the patella, fracture of the femur or posterior dislocation of the hip. Transmitted forces through the brake pedal particularly as the brake is being forcibly applied at the time of impact may result in mid foot, hind foot or ankle fracture dislocations. If the person was unrestrained, as the body moves forwards and upwards, and depending on whether the steering wheel hits primarily the chest or the abdomen, rupture of the organs within the body cavities may result. There may be rupture of the liver or intestines but the injury to look for, is rupture of the diaphragm. As the forces compress the abdomen the diaphragm can rupture and the abdominal contents may enter the chest cavity. This injury should be remembered particularly when assessing ventilation or if invasive procedures such as chest drains are to be considered. There may also be tearing of the vessels on the posterior abdominal wall. The only clue to these potential serious injuries may be pattern bruising which may extend across the abdomen or chest. If the chest itself has taken more of the force there may be rib injuries, producing a flail chest, pulmonary or myocardial contusion, or possibly thoracic aorta or coronary arteries damage. Finally, the lungs themselves may have been ruptured. As the occupant became aware of the impending accident they may gasp, hold their breath and at the point of impact the respiratory system may, in essence, be a closed system. This may cause the lungs to rupture creating a pneumothorax or potentially a tension pneumothorax. Damage to the head may result when it either strikes the roof, and/or the windscreen resulting in laceration or fracture of the skull. The brain underneath may receive the typical contra-coup type injury and there may be more widespread vessel damage with the development of an extradural or subdural haematoma or intracranial injury. The cervical spine may receive flexion or extension injuries resulting in either soft tissue or bony injury. In the prehospital situation, the potential for cervical spine injury should be recognised at all times. If there is any injury to the person above the clavicles then cervical spine injury should be assumed until that person has been assessed and X-rayed in an accident department. Remember, ejection from a vehicle is associated with a six times greater mortality than a restrained and retained occupant.

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Rear Impact Rear impact may cause hyperextension injuries to the cervical spine or spinal injuries at a lower level to the occupants of the vehicle. Much will depend on the use of correctly fitted seat belts and properly adjusted head restraints. In rear impact collisions it is again essential to understand how the accident occurred. If the vehicle was stationary and struck from behind the occupant will be accelerated forward and will often suffer a hyperextension injury to the cervical spine. However, if the accident was a result of the driver braking very suddenly and strikes the car in the front and at the same time is struck from the rear, the injury pattern will be a mixture of injuries seen in a head-on collision coupled with that of a rear collision. If a car skids or spins, it may be travelling backwards when the impact occurs. The movement of the body in this situation will produce a different pattern of injury. Front Seat Passengers • Posterior chest/Spinal injuries (From Rear Passengers impact) • Whiplash Rear Passengers • Spinal trauma • Knee/Femoral injuries • Whiplash Side Impact Side impact may produce injuries such as arm and leg fractures, chest or abdominal injury (these injuries may be time critical due to bleeding) which will obviously depend upon which side of the body was hit and how much intrusion has taken place into the passenger or driver compartment. This type of impact is often more serious because of the engineering difficulties in making vehicles resistant to side impact. Left Sided • Rib Fractures Pulmonary contusion • Splenic Injury • Renal Contusion • Upper limb fractures • Femoral/pelvic Fractures • Head/Neck injuries & Brain injury Right Sided • Rib Fractures Pulmonary contusion • Hepatic Injury • Renal Contusion • Upper limb fractures • Femoral/pelvic Fractures • Head/Neck injuries & Brain injury With side impact there are two possible injury patterns and these will depend whether the car was hit squarely on the side or whether it was hit more towards one comer or the other. In the latter type of collision, the car hit on the side may rotate around the point of impact and this motion may create further injury. Side impact without any movement away from the impact or rotation often results in greater damage to the occupant causing injury to the arm, clavicle and chest wall on the side of the impact resulting in a fractured clavicle or a flail chest. There may be injury to the organs on that side (either the lungs or abdominal contents) There may be damage to the pelvis and femur on the side of impact. Head and scalp injuries may occur as the side of the car and the head collide producing either external lacerations or possibly internal cerebral haemorrhage. The cervical spine often suffers considerably in side impact because the forces produce not only lateral flexion but also rotation producing tears and strains in the ligaments as well as fractures of the spine itself.

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If there has been impact more to the front comer of the car there may be additional injuries to the lower limbs depending upon the amount of intrusion that has occurred into the front well of the car. Rollover or Somersault These events often cause multiple injuries with a mixture of the patterns of injury described above. In addition there may be vertebral column injuries due to compressive forces with collapse of the roof. Deceleration Injuries In deceleration injuries not only will the body sustain injury as a result of contact with some point of the interior of the car or due to excessive bending or twisting of the body but deceleration produces significant injury to certain body structures which may not be obvious initially. Organs or structures within the body moving forward or twisting around a fixed point bring about deceleration injuries. This will often result in injury to the thoracic aorta (particularly rupture), injury to the liver or damage to the coronary arteries. It is also possible to have damage to the cerebral blood vessels. Within the abdomen there may be mesenteric tears caused at the point of attachment of the mesentery with the small or large intestine or it is possible to have damage to the kidneys or renal system. Head Direct Force • Frontal Laceration & Fractures with underlying cerebral contusion. • Head Indirect Force (Shear) • Vascular shear subdural haematomas Spinal • Hyperextension and flexation resulting in brain stem tear. Thoracic Direct • Rib and sternal fractures underlying contusions Thorax indirect • Traumatic aortic tear • Airbags being deployed Airbags Airbags and seat belt pre-tensioners are found on more and more cars. Airbags are commonly fitted into the steering wheel on the drivers side but some cars have passenger airbags, side impact or roof impact bags as well. The system is activated by a head-on accident or within 100 of a direct head-on accident. Within milliseconds of an accident the airbag is inflated and then rapidly deflated. The driver moves forward and actually hits the airbag as it is deflating. The whole process works so quickly that people who have been involved in an accident, in which airbags have been deployed, have very little recollection of the airbag at all and often report that the airbag did not work. Following deployment the inside of the car will be filled with a white talc-like powder, which is completely inert, and the patient also looks white. Airbag deployment has reduced the number of facial and chest injuries but there have been reports of increased hand and arm injuries. The fear of emergency care workers revolves around the concern that an airbag may activate during a rescue. Unfortunately even following disconnection of the battery the capacitor in the airbag system may retain its charge for a considerable length of time but it is unlikely that an airbag will be activated. The fire service can give expert advice on safety. Vehicles having airbags fitted will usually display an airbag symbol on the windscreen. Some seat belt pre-.tensioners have explosive charges, which fire under particular load conditions and increase the tension in the seat belt so improving the effectiveness of the belt system. Again care is required because casual handling and cutting of seat belts may activate the firing mechanism.

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Motor Cycle Accidents Injuries to motorcyclists are often due to the motorcyclist being thrown off his bike during the accident. Injuries are due to the motorcyclist coming in contact with the motorcycle, another vehicle or surface on which the motorcyclist lands. Always check the helmet for signs of damage and look for pattern bruising during the secondary survey and send the helmet to hospital with the patient. As the motorcyclist moves forward and upwards often their thighs will strike the handlebars resulting in mid-shaft femoral fractures, which can often be bilateral. Other forms of impact may cause the rider to be thrown off the bike and as a result may strike other parts of the motorcycle or other vehicles causing either lacerations or fractures to the part of the body struck. If the motorcyclist is not thrown clear then there may be resulting crushing of the lower limb as the motorcycle lands on the rider or dislocation of the ankle as the bike drags the rider. These injuries may often produce a lot of soft tissue mutilation. Depending upon the way in which the motorcyclist lands and the surface upon which he is landing on further injury may be produced. It must also be remembered that there is the potential for a second accident with the motorcyclist being struck by another vehicle. It should be remembered that motorcycle helmets, although providing considerable protection to the head and face provide no protection at all to the cervical spine. Pedestrian Accidents The patterns of injury in pedestrian accidents vary depending whether an adult or child was involved because of their obvious difference in height. Modem cars have â&#x20AC;&#x153;softâ&#x20AC;? frontal structures and the aerodynamic styling tends to lift adults onto the bonnet. The fitting of bull bars to the front of cars removes this safety feature. Adults are usually struck on the lower legs producing fractures of the tibia and fibula and then depending upon how the pedestrian was thrown, they will either be hit by the vehicle producing injury to the thorax, abdomen, pelvis, or possibly to the head. Injury may also be caused as the pedestrian comes into contact with the ground producing abrasions or, more significantly, depending upon the speed and attitude of the body, spinal injury. There also exists the potential for further damage as a second vehicle may hit the pedestrian. Children being smaller are hit higher in the body and therefore often receive injuries to their femurs or pelvis as the first point of impact. As they are lighter than adults they tend not to be thrown clear but often may be caught up by the vehicle and dragged along, either being run over by a wheel or coming to rest underneath the vehicle with the potential for injury particularly from the hot exhaust system. Adults The vehicle bumper resulting in open or closed lower limb fractures strikes lower limbs. The thorax is hit by the windscreen and the patient head hits the roadside Children The vehicle bumper resulting in open or closed lower limb fractures strikes lower limbs. The abdomen is hit by the bonnet resulting in injury to the internal organs and the patient head hits the roadside

Phases of Rescue 1 Scene safety-Assessment of scenario- Perimeter Security / Fire risk / Vehicle stability / passive safety systems 2 Immediate contact with casualty, assess priority .CCA! Nominate casualty carer. 3. Rapid entry, door/rear /hatch, Time Critical 4 Rescue- disentanglement procedure, space creation techniques. Relocating material (cut/pull). 5 Extrication of casualty from vehicle, Immobilise. Minimise twisting/potential for damage 6 Evacuation method-requires early consideration (comms).

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Improvised Extrication • Perimeter Security -Con Ops/SOP Vehicle specificFIRE (DP extinguisher, Isolate battery, suppress leaks) PASSIVE SYSTEMS (deployment path, accidental triggering) HAZ SUBSTANCES cargo, other vehicles, weapon/ammunitions • Stability of wreckage. - Assess type/No. Vehicles- generic design - Read wreckage- deformation will indicate injuries - Ensure control measures active. - Improvised Extrication • Space Creation Techniques - Minor damage - Open Doors!! - Windows-glass- Rear door/hatch - Major damage-Windows, glass - Rear hatch - Breach doors! - Cut, pull away, push. - Roof removal by cutting pillars. LIMITED!!! - 3 rd door creation. LIMITED!!!

Casualty Centred Approach • AIRWAY- basic, don’t focus on dramatic injuries elsewhere! C spine control! • Breathing- assess rate/function. • Circulation-overt haemorrhage! Control. • Disability-AVPU. Record GCS • Revisit vital signs-Time is Critical! Improvised equipment • Bottle jack • Wheel brace • Hacksaw • Hooligan bar • Jerry-cans • Rope • Floor mats • Sandbags • Tape • Glass hammers/seat belt cutter

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TRIAGE AND MAJOR INCIDENTS A major incident within a medical aspect is defined as an incident that overwhelms the medical support available. In remote settings a major incident could be defined with only a handful of casualties, a situation that would be a daily occurrence on the motorways of Europe or America, due to the remoteness and lack of medical infrastructure available. In Order to ensure medical assets, whether doctors, nurses, paramedics or emergency/first responders, are able to mobilise appropriate support, allocate medical equipment, treat and evacuate casualties in an order that would do the best for the most, the Triage system is used. Triage aims to identify casualties by order of priority for both treatment and subsequent evacuation by sorting them into the following priorities: P1 - requires immediate resuscitation and/or surgery (IMMEDIATE) (Red) P2 - requires urgent access to resuscitation/surgery (URGENT) (Yellow) P3 - Can cope with a delay in access to treatment (DELAYED) (Green) D - Dead (White) In severe cases a category of P1 hold can be invoked if large numbers of casualties are present with limited medical equipment and evacuation assets are present, the senior medical provider {silver/operational command) on the ground is the only person that should invoke this category in liaison with Gold command (strategic medical representative). A P1 hold category is one that is in need of immediate resuscitation and or surgery but is unlikely to survive an evacuation journey therefore tying up this facility when it could be used for a more survivable P1 or P1â&#x20AC;&#x2122;s. The senior First aider/medical provider should not be performing triage unless as a last resort but should set up a Casualty treatment area (Casualty clearing station) near the scene. This is where all available medical equipment should be located in order to enable treatment of several casualties simultaneously.

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Medical Emergencies Chapters

Page

Angina

Myocardial Infarction

Basic Life Support

Automated External Defibrillation

The Choking Casualty

Asthma

Anaphylaxis

Epilepsy

Diabetes

Stroke

Poisons and Substance Abuse

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ANGINA Definition Angina is defined as a temporary lack of oxygen to the myocardial tissue and the accumulation of carbon dioxide and lactic acid during an increased period of oxygen demand. This is usually related to exertion. Signs & Symptoms • Central Chest Pain • Gripping and Episodic • Often radiates from jaw down left arm • Typically described as “dull” or “aching” • Often mistaken as acute indigestion. • Shortness Of Breath • Casualty may yawn excessively. • Grayish pallor to skin. • Increased respiratory rate. • Exhaustion • Casualty may experience sudden and extreme weakness. • Weakness exceeds level of exertion. • Anxiety • Pain, shortness of breath and weakness will raise the anxiety enhancing his symptoms level of the casualty Management The aims of the First Responder are to ease the strain on the casualty’s medical help if necessary. • Reassure the casualty. • Assess for any hazards. • Sit the casualty down. • Casualty may have own medication i.e.. Tablets or “puffer”, assist them to take it. • Encourage the casualty to rest away from spectators. • Monitor and record breathing and pulse rate every 10 minutes. If pain persists following rest and medication, obtain medical help heart and obtain

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MYOCARDIAL INFARCTION (HEART ATTACK) Definition MYOCARDIAL INFARCTION is the process of death or damage to an area of the heart muscle. Statistics • There are 160,000 Sudden cardiac deaths each year in the UK. • 70% Of Pre-hospital cardiac arrests respond to defibrillation. • MI is the leading cause of death in the over 45 year age group. • Defibrillation accounts for 97% of all the lives saved. Signs & Symptoms • A severe chest pain that may radiate to one or both sides of the chest, into the neck, jaw, arms or back. • Pain is persistent and often described as “vice-like” or “crushing” This can occur at rest. • Sweating. “Cold sweat” • Faintness, giddiness. • Nausea. • Vomiting when pain is of a sudden onset. • Shallow breathing. • Casualty may appear grey with cyanosis to extremities. • Blue tinge and dry lips.A weak, rapid or irregular pulse. • A sense of impending doom. • Collapse, often without warning. Management • Reassure the casualty. • Assess for hazards. • Make the casualty comfortable. • Usually in a sitting position, head and neck supported with knees slightly bent. • Summon urgent medical help. • Explain you suspect a “heart attack” • Monitor and record respiratory and pulse rate every 10 minutes. • ABCs & Oxygen @ 6 litres per minute • If casualty has angina medication assist them to take tablet (under tongue) or spray. • If pain persists and casualty conscious and not vomiting administer 3OOmgs of Aspirin to chew. (Check for allergy to Aspirin first).

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BASIC LIFE SUPPORT (BLS) In Accordance with the Resuscitation Council (UK) Guidelines 2010 Aim: To perform Basic Life Support (CPR)

CPR/BLS is a part of the “Chain of Survival” and shouldn’t be considered in isolation.

SAFE Approach • Shout, send, signal for help • Approach with care • Free the casualty and yourself from danger • Evaluate the casualty The rescuer should follow the SAFE approach and check for: • Electrical dangers • Traffic • Hazardous chemicals • Rescue from water • Falling masonry • Etc Adult Basic Life Support Sequence 1. Ensure safety of you and the casualty 2. Check the victim for response a. Gently shake his shoulders and ask loudly “Are you alright?” 3. a. If he responds: i. Leave him in the position in which you find him (provided that there is no further danger) ii. Try to find out what is wrong and get help if needed iii. Reassess him regularly 3b. If the victim DOES NOT respond: i. Shout for help ii. Tum the victim onto his back and then open the airway using the head tilt chin lift technique

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4. Keeping the airway open, look listen and feel for normal breathing a. Look for chest movement b. Listen for breath sounds at the victims mouth c. Feel for air against the side of your cheek i. In the first few minutes after a cardiac arrest, a victim may be barely breathing or taking infrequent noisy gasps. Do not confuse this with normal breathing. ii. Look, listen and feel for no more than 10 seconds to determine if the victim is breathing normally. If you are in any doubt, act as if the breathing is not normal 5. a. If he is breathing normally: i. Turn him into the recovery position ii. Send for help or call an ambulance iii. Check for continued breathing 5b. If he is breathing normally: i. Ask someone to call for help. If you are on your own, go and get help (you may need to leave the victim). Start chest compressions as follows: 1. Kneel by the side of the victim 2. Place the heel of one hand in the contra of the victims chest 3. Place the heel of your other hand on top of the first hand 4. Interlock the fingers of your hands and ensure that the pressure is not applied over the victims ribs. Do not apply any pressure over the upper abdomen or the bottom end of the bony of the bony sternum (breastbone) 5. Position yourself vertically above the victims chest and with your arms straight, press down on the sternum 5 - 6 cm 6. After each compression, release all of the pressure on the chest without loosing contact between your hands and the sternum. Repeat at a rate of about 100-120 times a minute (a little less than two every second) 7. Compression and release should take an equal amount of time 6. a. Combine chest compressions with rescue breaths i. After 30 compressions open the airway again using the head tilt chin lift ii. Pinch the soft part of the victims nose closed, using an index finger and thumb of your hand on his forehead iii. Allow his mouth to open, but maintain chin lift iv. Take a normal breath and place your lips around his mouth making sure that you have a good seal v. Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his chest rise as in normal breathing; this is an effective rescue breath vi. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out vii. Take another normal breath and blow into the victims mouth once more to give a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions viii. Continue with chest compressions and rescue breaths in a ratio of 30:2 ix. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation x. If your rescue breaths do not make the chest rise as in normal breathing, then before our next attempt: 1. Check the victimâ&#x20AC;&#x2122;s mouth and remove any visible obstruction 2. Recheck that there is adequate head tilt and chin lift 3. Do not attempt more than two breaths each time before returning to chest compressions xi. If there is more than one rescuer present, another should take over CPR about every 2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers

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6b. Chest-compression-only CPR i. If you are not able, or are unwilling, to give rescue breaths, give chest compressions only ii. If chest compressions only are given, these should be continuous at a rate of 100-120 a minute iii. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation 7. Continue resuscitation until: a. qualified help arrives and takes over, b. the victim starts breathing normally, or c. you become exhausted

UNRESPONSIVE ?

Shout for help

Open airway

NOT BREATHING NORMALLY ?

Call 999

30 chest compressions

2 rescue breaths 30 compressions

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Automated External Defibrillation Principles of AED operation Most common cause of cardiac arrest is from myocardial infarction leading to dysrhythmia

Definition of defibrillation “the delivery of a DC electric current to the heart for the purpose of the termination of Ventricular Fibrillation or pulseless Ventricular Tachycardia”

There are 3 types of defibrillation, these are: • Implanted defibrillation • Internal defibrillation • External defibrillation - Manual - Semi automatic - AEDs

Types of AEDs AEDs are sophisticated, reliable, safe, computerised devices that deliver defibrillatory shocks to victims of cardiac arrest. They use voice and visual prompts to guide rescuers and are suitable for use by both lay rescuers and healthcare professionals. All AEDs analyse the victims rhythm, determine the need for a shock and then deliver a shock. A semi-automatic AED advises the need for a shock, but this has to be delivered by the operator when prompted. Sequence of Actions 1. Make sure the victim, any bystanders and you are safe. a. If two rescuers are present, assign tasks 2. If the victim is unresponsive and not breathing normally: a. Send someone for the AED and to call an ambulance. If you are alone you will have to leave the victim and do this yourself 3. Start BLS 4. As soon as the AED arrives: a. Switch on the AED and attach the electrode pads. If more than one rescuer is present, continue CPR whilst this is being done. b. Follow the visual/voice prompts c. Ensure that nobody touches the victim whilst the AED is analysing the rhythm 5. If a shock is advised a. Ensure that nobody touches the victim b. Push the shock button as directed c. Continue as directed by the voice/visual prompts 6. If no shock is indicated: a. Immediately resume CPR using a ratio of 30 compressions to 2 breaths b. Continue as directed by voice/visual prompts

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7. Follow the AED prompts until: a. Qualified help arrives and takes over b. The victim starts to breathe normally c. You become exhausted

AED Application: • Remove clothing from upper torso front of chest area whilst continuing CPR if possible • “Remember Patient Modesty is Secondary to Defibrillation” • Before defibrillation check patient for; - Jewellery - Clothing - Medication patches, i.e.... GTN - Pacemakers Safety rules to be observed before each shock sequence • Do not apply patches to yourself! • Ensure all clear and shout “clear” before each shock • Ensure patients environment is suitable to provide safe defibrillation • Never discharge patches into atmosphere dump charge if not required (I.e use discharge button). Environmental Factors Do not shock in the following conditions until hazard is removed • Patient is on a wet floor or in water - Remove patient from water continuing BLS where possible - Place patient on a dry surface - Ensure you are on a dry surface • If raining or wet, dry the chest before applying patches • Volatile or explosive atmospheres or fluids - Move patient upwind away from gas & volatile fumes - If fluid, follow same procedures as in wet patient but ensure as much of fluid is washed from patient as possible - Take advise from Fire Service before shock sequence delivered - Continue BLS throughout

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AED Algorithm Unresponsive? Call for help Open airway Not breathing normally

Send or go for AED Call 999

CPR 30:2 Until AED is attached

AED assesses rhythm

Shock advised

No Shock advised

1 Shock

Immediately resume CPR 30:2

for 2 min

Continue until the victim starts to wake up, i.e. moves, opens eyes and breathes normally

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Assess for: S - Signs and symptoms A - Allergies M - Medication that the patient is taking P - Past medical history L - Last oral intake E - Events leading up to the incident Summary • There are many causes of unconsciousness. • Initiate the initial assessment of all unconscious casualties. • Patients may become unconscious in your care. • Airway - Breathing - Circulation saves lives. • Maintain ABC and move rapidly to medical care. • If required place in recovery position.

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THE CHOKING CASUALTY Because recognition of choking (airway obstruction by a foreign body) is the key to successful outcome, it is important not to confuse this emergency with fainting, heart attack, seizure or other conditions that may cause sudden respiratory distress, cyanosis or loss of consciousness. Foreign bodies may cause either mild or severe airway obstruction. The signs and symptoms enabling differentiation between mild and severe airway obstruction are summarised below. It is important to ask the conscious victim 70Are you choking?

General signs of choking • Attack occurs while eating • Victim may clutch neck Signs of minor airway obstruction

Signs of severe airway obstruction

Response to question “Are you choking?” • Victim speaks and answers “YES”

Response to question “Are you choking?” • Victim is unable to speak • Victim may respond by nodding

Other signs • Victim is able to speak, cough and breathe

Other signs • Victim is unable to breathe • Breathing sounds wheezy • Attempts at coughing are silent • Victim may become unconscious

Adult Choking Sequence 1. If the victim shows signs of minor airway obstruction: a. Encourage him to continue coughing, but do nothing else 2. If the victim shows signs of severe airway obstruction and is conscious: a. Give up to 5 back blows i. Stand to the side and slightly behind the casualty ii. Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway iii. Give up to 5 sharp blows between the shoulder blades with the heel of your other hand b. Check to see if each back blow has relieved the obstruction. The aim is to relieve the obstruction with each blow rather than necessarily give all 5 c. If 5 back blows fail to relieve the airway obstruction give up to 5 abdominal thrusts i. Stand behind the victim and put both arms round the upper part of his abdomen ii. Lean the victim forwards iii. Clench your fist and place it between the navel and the bottom of the sternum iv. Grasp this hand with your other hand and pull sharply inwards and upwards v. Repeat this up to 5 times d. If the obstruction is still not relieved, continue alternating 5 back blows with 5 abdominal thrusts 3. If the victim becomes unconscious: a. Support the victim carefully to the ground b. Call for an ambulance c. Begin CPR from 5B of the BLS algorithm. Chest compressions should be started even if a carotid pulse is present in the unconscious choking casualty

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Assess severity

Severe airway obstruction

Mild airway obstruction

(ineffective cough)

(effective cough)

Unconscious Start CPR

Conscious

Encourage cough

5 back blows

Continue to check for deterioration to ineffective cough or until obstruction relieved

5 abdominal thrusts

Upon arrival of the Ambulance • Give brief history • Times, e.g. “ have been doing CPR for 5 min with no response” • Remain to assist with equipment Points to note: • BLS is part of the Chain of Survival • All age groups can perform it • There is no proven risk of infection • The rescuer is covered for liability under UK law

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ASTHMA Asthma is a condition where the muscles of the air passages go into spasm and the lining of the airways swell. This results in narrowing of the airways making breathing difficult. Asthma can be life threatening and requires early management to prevent development of respiratory or cardiac arrest. Signs & Symptoms • Difficulty in breathing - usually with a very prolonged “breathing out” phase. • Wheezing or crackling as the casualty breathes out. • There may also be: • Distress and Anxiety. • Difficulty in speaking. • Cyanosis. • Dry, tickly cough. • Casualty may be exhausted. The patient is often found sitting up, often leaning forward and fighting to breathe. Management • ABC’s & Oxygen • Keep the casualty calm. • Reassure the casualty. • Encourage the casualty to adopt a comfortable sitting position. • Encourage the casualty to breathe slowly and deeply. • Assist the casualty to take “relieving” medication = Ventolin(Salbutamol) • If the attack is mild and relieved within 5-10 minutes ask the casualty to take a further dose of medication. • Monitor and record breathing and pulse rate every 10 minutes. • Management Severe Attack • If severe or prolonged call for medical assistance. Do Not: • Let the casualty lie down. • Do not use “preventer inhaler” medication to treat the attack = (Beclamethasone/Becotide etc)

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ANAPHYLACTIC SHOCK Definition: Anaphylactic shock or Anaphylaxis is a severe allergic reaction or hypersensitivity, often affecting the whole body. It is a serious, potentially fatal condition that may develop rapidly in susceptible individuals. THE COMMON CAUSE OF DEATH FROM ANAPHYLAXIS IS AN OBSTRUCTED AIRWAY Nature When an allergen is introduced into the human body, chemical substances may vigorously react and produce an overdose of histamine. The capillaries become more permeable and leak plasma (including histamine and other defensive organisms) into the tissues of the body; this reduces the Blood pressure, inflames the airway passages and increases the pulse/respiratory rates. Allergen Introduction The usual methods of allergen introduction include: • Injection of drugs, vaccines (commonly penicillin) • Ingestion of food substances, additives, commonly sea food • Absorption of wasp & bee stings • Scorpion stings • Inhalation-chemicals, aerosols • Snake anti-venom ALMOST ALL FOREIGN SUBSTANCES CAN BECOME AN ALLERGEN Signs And Symptoms The sequence of events from itching to a development of breathing difficulty and on to cardiac arrest may occur within seconds and death is imminent unless the condition is recognised and treatment is commenced immediately.

Normal Appearance

• Circulatory System: • Decreased blood flow to heart muscle. • Blood squeezed from the heart is reduced. • The body’s blood vessels widen. • The capillaries become leaky. • Rapid pulse • Respiratory System: • Spasm and swelling of bronchi. • Blood vessels in the lungs constriction. • Swelling around the 73Adams apple • Impaired breathing, tight chest, gasping for air • Skin • Swelling • Hives - feels like a nettle rash • Itching

Severe allergic reaction (anaphylaxis)

• Red, blotchy skin eruption • Swelling of face and neck • Puffiness around eyes

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Management • ABC’s & Oxygen • Arrange for urgent removal to hospital • Reassure casualty • If casualty is conscious sit in upright position • If casualty unconscious maintain airway and check breathing Some people are aware of having a severe allergy and will carry medication. An Epi-Pen syringe contains epinephrine (adrenaline 1:1,0OO), usually 0.3 or O.6mg. If necessary help the casualty administer medication, or, if trained, administer it yourself. If more than one epi-pen is available then be prepared to administer a second after 3 to 5 minutes if no improvement is seen.

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EPILEPSY The brain consists of more than 100 billion nerve cells, which all communicate with one another; some provoke others into sending further messages (excitation), while others tend to block them (inhibition). The proper working of the brain depends on a balance between these: too many nerve cells sending messages at once without enough being blocked can produce a sort of electrical storm - or a seizure. Epilepsy is the continuing tendency to have such seizures Causes Common causes include brain damage from birth injuries, head injuries, stroke, brain tumours and alcoholism. Some seizures probably have a genetic basis, although it’s rare for epilepsy to run in families. However, no one apparent cause has been found. 60 - 70% of all sufferers are from an unknown cause. 2 % of the UK population will have two or more seizures during their lives. Seizures can occur without any obvious cause, but the risk is much greater in those who’ve suffered brain damage. These seizures can occur many years after the injury. Certain recreational drugs and alcohol can induce seizures. While the drug in question can bring on the first seizures, eventually spontaneous seizures may occur even after drug use has stopped. Epilepsy, except in rare circumstances, isn’t inherited, although the risk of developing epilepsy may be increased slightly in relatives of those who have the condition. Types of seizure There are two types of seizure: Generalised seizures Start in both sides of the brain at once and cause the person to lose consciousness • Tonic-clonic (grand-mal) - Sudden onset of rigid tonic phase - Followed by a convulsion (clonic phase) where muscles jerk - Episode lasts for a few seconds to minutes - Associated with tongue biting and incontinence of urine - Followed by period of drowsiness or coma for several hours • Typical absence (petit mal) - Usually disorder of childhood - Sufferer ceases activity, stares and pales for a few seconds • Myoclonic seizures - Rare form of epilepsy - Involves involuntary muscle jerks Signs and symptoms • Uunconsciousness, casualty becomes rigid • Lips may turn blue and face and neck may become congested • Breathing may cease • Convulsive movements may begin. Jaw may be clenched and saliva appears at the mouth. Biting of tongue • Loss of bladder or bowel control • Muscles relax and casualty recover, often unaware of their actions • Followed by a period of deep sleep

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Management • Protect casualty from injury and protect dignity • Treat ABC • Loosen clothing around head and neck • Place casualty in recovery position once fitting has stopped • Monitor ABCs Remember! - If unconscious for more than 10 minutes, convulsing for more than 5 minutes, having repeated fits or is unaware of his/her condition, seek immediate medical help Partial seizures Begin in one part of the brain, then spread to affect other parts Simple Partial (Jacksonian) • Originate in the motor cortex of the brain resulting in jerking movement • Typically begin in the comer of the mouth or the thumb • Movements spread to involve the limbs on the opposite side of the epileptic focus Temporal lobe • Simple seizure associated with hallucinations or feelings of unreality or undue familiarity Signs and symptoms • Sudden switching off • Staring blankly • Localised twitching eyelids lips limbs • Automatic movements, lip smacking, chewing noises Management • Protect the casualty until they are fully recovered • Remove possible sources of harm • Sit casualty down • Reassure • Protect dignity • Arrange after care if required People with epilepsy may be on medication and a seizure may occur if they miss a prescribed dose. They will often carry a card or warning bracelet indicating they are epileptic. This card may give details of the patterns of their seizures.

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DIABETES Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood is too high because the body cannot metabolise it properly. Glucose comes from the digestion of starchy foods such as bread, rice, potatoes, chapattis, yams and plantain, from sugar and other sweet foods, and from the liver, which makes glucose. Insulin is vital for life. It is a hormone produced by the pancreas, which helps the glucose to enter the cells where it is used as fuel by the body. The main symptoms of untreated diabetes are increased thirst, going to the loo all the time especially at night, extreme tiredness, weight loss, genital itching or regular episodes of thrush, and blurred vision. Types of Diabetes There are two main types of diabetes. These are: • Type 1 diabetes, also known as insulin dependent diabetes • Type 2 diabetes, also known as non.-insulin dependent diabetes Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. It is treated by insulin injections and diet and regular exercise is recommended. Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). This type of diabetes usually appears in people over the age of 40, though in South Asian and African-Caribbean people often appears after the age of 25. It is treated by diet and exercise alone or by diet, exercise and tablets or by diet, exercise and insulin injections. The main aim of treatment of both types of diabetes is to achieve blood glucose and blood pressure levels as near to normal as possible. This, together with a healthy lifestyle, will help to improve well being and protect against long.term damage to the eyes, kidneys, nerves, heart and major arteries.

How Is Diabetes Treated? Although diabetes cannot be cured, it can be treated very successfully. Knowing why people with diabetes develop high blood glucose levels will help to you understand how some of the treatments work. Blood glucose levels When sugar and starchy foods have been digested, they turn into glucose. If somebody has diabetes, the glucose in their body is not turned into energy, either because there is not enough insulin in their body, or because the insulin that the body produces is not working properly. This causes the liver to make more glucose than usual but the body still cannot turn the glucose into energy. The body then breaks down its stores of fat and protein to try to release more glucose but still this glucose cannot be turned into energy. This is the reason why people with untreated diabetes often feel tired and lose weight. The unused glucose passes into the urine, which is why people with untreated diabetes pass large amounts of urine and are extremely thirsty. Type 1 diabetes is treated by injections of insulin and a healthy diet. Type 2 diabetes is treated by a healthy diet or by a combination of a healthy diet and tablets. Sometimes people with Type 2 diabetes also have insulin injections, although they are not totally ‘dependent’ on the insulin. Treatments for Type 1 diabetes People with Type 1 diabetes need injections of insulin for the rest of their lives and also need to eat a healthy diet that contains the right balance of foods. Insulin cannot be taken by mouth because the digestive juices in the stomach destroy it. People with this type of diabetes commonly take either two or four injections of insulin each day. Treatments for Type 2 diabetes People with Type 2 diabetes need to eat a healthy diet that contains the right balance of foods. If your doctor or diabetes nurse finds that this alone is not enough to keep your blood glucose levels normal, you may also need to take tablets. There are several kinds of tablets for people with Type 2 diabetes. Some kinds help your pancreas to produce more insulin. Other kinds help your body to make better use of the insulin that your pancreas does produce. Another type of tablet slows down the speed at which the body absorbs glucose from the intestine.

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STROKE The term stroke is applied to the sudden blockage or rupture of a blood vessel in the brain. Without a constant blood supply brain cells can be damaged or destroyed. Stroke is a MEDICAL EMERGENCY requiring early treatment and an accurate diagnosis. Where injuries to the brain occur as a result of trauma, there is a risk of either bruising to the brain tissue - concussion - or the development of clot either within or around the brain. Concussion may produce loss of consciousness or simply a state of confusion, but should never be treated lightly and the patient always referred for further investigation, usually in hospital as appropriate. Signs and Symptoms Presentation: stroke classically presents with the sudden onset of one or more of the following: • Limb weakness or numbness of arms or legs • Weakness of the face on one side • Difficulty with speech, or understanding speech • Clumsiness Stroke is more common in older age groups, and particularly those with raised blood pressure, but cannot be excluded in the younger patient. For suspected stroke, use the FAST test. F Facial Movements: Ask the patient to smile or show teeth. Look for NEW lack of symmetry A Arm Movements: Ask the patient to lift their arms together and hold. Does one arm drift or fall down? S Speech: If the patient attempts a conversation. Look for NEW disturbance of speech T Test all three. If one element is abnormal, suspect stroke and transfer to hospital Management • Assess Airway, Breathing, Circulation and Disability • Airway management and oxygen therapy are high priorities to avoid 78secondary brain injury • If conscious sit up • Patients should be nil by mouth • Someone who witnessed the onset of symptoms should be encouraged to accompany the patient • All medication should be brought with the patient The patient should be transferred to hospital as an emergency response with a pre-alert. The patient should be transferred to a contra with provision for specialist stroke care. Remember: hearing may be intact, so re-assurance may be helpful to the patient and the relatives

Transient ischemic attack An ischaemic stroke event with complete recovery within 24 hours is called a Transient Ischemic Attack or TIA. A TIA occurs when there is a temporary blockage of a blood vessel in the brain. Most TlAs only last a short time and present with the symptoms of a stroke. Those with TIA have a greater risk of developing a stroke within 24 hours of onset of symptoms, than does a person with chest pain is to go on to have a heart attack. Any patient with a suspected TIA requires urgent specialist medical assessment even if all the symptoms seem to have gone. Do not delay, if the patient has symptoms of suspected stroke or TIA they require an emergency response.

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POISONS & SUBSTANCE ABUSE A poison is a substance that if taken into the body insufficient quantity may cause temporary or permanent damage. Poisons may be swallowed, inhaled, injected, or splashed onto the skin. The signs and symptoms of poisoning depend on the poison and its entry route. Almost every environment contains potentially poisonous substances i.e. detergents, bleaches, bacteria, plants animals. Reactions to the poisons often induce vomiting which carries additional dangers to the casualty. Management Aims of the first responder are to: • Maintain the airway, breathing and circulation of the casualty. • To remove any contaminated clothing. • To identify the poison. • To obtain medical assistance. • If casualty becomes unconscious place in recovery position. N.B. • Do not attempt to induce vomiting. • If mouth-to-mouth resuscitation is required and the casualty has suspected poison around head and neck area use a plastic face shield or pocket mask to protect you.

Substance Abuse A variety of illicit or prescribed drugs and substances may be taken by accident or in a deliberate abusive capacity. Substance abuse might be suspected if the casualty is acting irrationally without known cause, slurred speech, uneven gait, and abusiveness, drowsy or unconscious. Substance abuse may be administered deliberately or accidentally by: • Ingestion • Inhalation • Injection • Absorption through the skin Management • If the casualty is conscious remain with the casualty and seek medical advice. • Identify the substance and advice will be given regarding the First Aid Management of the casualty. • If the casualty is unconscious place in the recovery position and maintain airway. • Transport to hospital immediately.

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Environmental injuries Chapters

Page

Cold Injuries

Heat Injuries

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COLD INJURIES Hypothermia Causes: • Immersion in water • Poor protection • Injury • Unconsciousness • Poor nutrition • Fatigue Heat is lost in several ways, such as: • Convection • Respiration • Conduction • Evaporation • Radiation Signs & Symptoms of Hypothermia Sequence of events in relation to body temperature can be seen as follows: Normal temperature

37˚C

Shivering starts / feeling of being cold.

35/36˚C

Confusion & amnesia starts

34/35˚C

Shivers cease and muscles seize

33˚C

Irregular Pulse

32oC

Drowsiness / semi-conscious

31˚C

Unconsciousness

31/3OoC

Pupils dilated/loss of reflex

3O˚C

Pulse absent/ apparent death

28˚C

Death.

28˚C

A CASUALTY IS NEVER DEAD UNTIL THEY ARE WARM AND DEAD Management Of Hypothermia Do • Prevent further heat loss • Insulate patient • Give patient warm drinks • Allow body to warm gradually • Consider warmed IVI therapy and Sugar replacement Do Not • Strip clothing unless wet • Give alcohol • Move patient • Apply external heat (FIRE, HOT BATHS)

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Frostbite The definition of Frostbite is a condition brought on by exposure to sub zero temps causing freezing injury to the exposed/wet parts of the body. This can vary from light surface damage to full thickness freezing. Signs & Symptoms • Paresthesia in affected part • Limb movement is impaired • Continued exposure leads to numbness • Skin appears waxy, cold, hard & stiff Treatment • Remove from cause • Gently warm the affected part • Elevate • DO NOT expose to direct heat • DO NOT rub The dangerous issue with Frostbite is that they will be susceptible to refreezing, only warm affected part if you can protect the casualty from suffering a re-freezing injury. If a freezing injury was allowed to freeze - thaw - re-freeze, then the damage to the cells can be catastrophic and loss of limb can occur. AVOID FREEZE - THAW - RE-FREEZE

Immersion Foot Definition - a non-freezing injury previously called trench foot. This occurs when tissue is immersed in water for a prolonged period where the temperature is above freezing. Signs & Symptoms • Feet become white/mottled • Loss of sensation • Cold to touch • Tissue becomes swollen Treatment • Remove from cause • Gently clean and dry • Expose foot to room temperature • Handle with extreme care to reduce tissue damage, do not rub

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HEAT ILLNESS Regulation of heat is controlled via the Brain, specifically the Thalmus and the Hypothalmus. This controls blood flow to the Skin and therefore the amount of cooling occurring at the body surface through peripheral vasodilation. The Kidneys are involved in fluid loss and retain of excrete fluid according the needs of the body. Heat illness causes include: • Excessive sweating • Inadequate fluid intake • High temperatures at work • Excessive periods of sun Prevention is the Best form of Defence. Prior preparation & planning prevents heat illness (management/leadership issue) with basic common sense and education.

Water Balance Fluid (water based) makes up approximately 55 - 60% of our body weight and is vital for the body to maintain life. It is not only water that is important but also electrolytes that are present within the body fluid, the main electrolytes are: • Sodium (Na +) • Potassium (K +) • Chloride (CI -) • Calcium (Ca 2+) • Bicarbonate (HCO3 -) Fluid is stored in 3 main areas within the body: • Extracellular - Intravascular: Plasma - Interstitial: Within the tissues but outside the cells • Intracellular The amount of water contained in each area is approximately as follows: • 2/3 - Intracellular • 1/3 - Extracellular - 80% Interstitial - 20% Plasma Therefore a male weighing 9Okg will have the following fluid distribution, each kg of weight is equal to 1 litre: • Total water weight = 54kg • Intracellular = 36kg or litres • Interstitial = 14.5 kg or litres • Intravascular = 3.6kg or litres

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Water is lost in the following ways; the amount varies dependant on clothing, ambient temperature and work levels: • Breathing 250cc -15OOcc • Perspiration 5OOcc - 15OOOcc • Urine 5OOcc - 15OOcc A potential maximum total = 18,OOOcc with a daily normal loss of approximately 2250 mls The body will constantly try to maintain its blood pressure by drawing in fluid from the interstitial spaces with in turn will draw fluid from the cells of the body. Dehydration Effects From Water/Salt Loss Reduced mental performance

1ltr

Reduced industrial performance

2ltrs

Difficulty in walking and seeing

4ltrs

Coma or Death

6ltrs

Planning Factors The following factors can be employed in order to reduce the prominence of Heat illness: • Acclimatisation (this reduces the amount of salt loss in comparison to water and can take over 10 days to occur in fit healthy adults) • Weather including humidity (Avoidance of the hottest/more humid parts of the day initially) • Physical activity (reduced levels of activity initially gradually building to full activity with acclimatisation) • Fluid therapy - not wine or alcohol (water plus food to provide sodium, chloride and potassium) • Clothing (loose layers with cotton type material are the best) • Illness dehydration, vomiting, fever (these all increase fluid loss especially body salts) • Avoid Drugs - eg. ecstasy, diuretics

Heat Disorders • Sunburn • Prickly heat rash • Heat illness • Heat injury (Heat stroke)

Heat Cramps Caused by salt depletion, usually due to inadequate food intake of excessive water intake with no salt replacement). Signs • Tachycardia • Pale / Clammy skin • Salt depletion -Sodium/Potassium • Nausea • Headache • Normal temperature • Tingling

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Treatment • Move to shaded area • Lie / sit casualty down • Oral fluids (salt replacement sachets in clean water - avoid oral salt tablets as they can induce vomiting) • Enforced rest for 12 + hrs If Heat cramps are left untreated it may develop into Heat Exhaustion

Heat Exhaustion When taking the temperature of any environmental illness it should be taken from the core as oral or armpit measurements can give false and lower temperatures. There are two methods for achieving this: • Rectal - this requires exposure of the casualty and holding the thermometer in place for at least 2 minutes. • Tympanic - Becoming the preferred option as in only take a few seconds without exposure of the casualty, cheaper tympanic thermometers are less accurate than both more expensive models and the digital rectal option. Clinical Signs • Pallor - initially pale • Raised temperature • Skin / sweating +++ and warm • Pulse - rapid and weak • Respirations - shallow becoming rapid • Muscular cramps - twitching • Fatigue • Headaches - dizziness • Change in mental state • Unconsciousness Management • Move to cool environment • Manage ABCs • Place at rest • Administer cool drinks in small quantities - oral • Administer oral salt replacement solution / Dioralyte or Rehydrate • Cool the casualty slowly by fanning/sponging • Cool packs in groin and armpit areas • Monitor temperature REMEMBER SALT CAN INDUCE VOMITING

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Heat Stroke This can occur when the core body temperature is raised past 41oC; the danger is that sweating (the body’s cooling mechanism) stops!! Symptoms & Signs • Hot, dry flushed skin • Slow bounding pulse • Slow noisy breathing • Abnormal behaviour • Unconscious • Confused/delirium and fainting *• Seizures • Severe headache • Nausea Management • Remove clothing • Wrap in wet cool sheet - avoid hypothermia • Fan patient • Cold packs around arms and groin (if available) • Oral fluids if conscious - water, Rehydrate etc • Administer sugar - i.e. hypostop • Consider cool IV fluids • Monitor temperature • Monitor urine output • Check the rest of patrol • Early evacuation

Prickly Heat Rash This is caused by blocked sweat glands by dirt and salt crystals creating a pressure under the skin. This can be as a result of poor hygiene or excessive sweating in a dirty environment. Signs & Symptoms • Intense irritation over affected part of skin, this usually occurs in areas such as waistbands, shoulders under Bergen straps, backs during long treks with bergens/backpacks. • Red spotty rash over affected area. Treatment • Usually relieved in the short term with cool water • DO NOT apply creams/powders as these further block the pores • Use antiseptic (ideally non-scented) soap with a rough flannel/sponge to wash in order to remove the crystals from the pores. • Prevention is the best treatment in this illness - there are no magic treatments

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Annexes Chapters

Page

Removal of Crash Helmet

Resuscitation Algorithms

Helicopter Safety

101

Needle Decompression

102

H2S Poisoning

103

Suggested Medical Equipment list

105

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Removal of Crash Helmets There may be occasions when a patient presents with an airway problem whilst wearing a protective helmet (for example, horse rider, cyclist, motorcyclists, skate boarder). When dealing with these patients, the priority is to maintain and protect and open airway. Remember: airway is always the first priority It is important to balance the potential harm that can be done in removing a helmet too soon or leaving it on for too long. In all cases lift the visor. There are three situations to consider: 1) The patient is conscious and able to talk freely 2) The patient is unconscious and has a clear airway 3) The patient is unconscious and the airway is blocked (partial or complete) In situation (1), it is advisable to leave the helmet in place whilst maintaining in-line stabilisation* and close assessment of the airway. Occasionally, a conscious patient becomes distressed by the helmet, in which case it should be removed in accordance with the principles described in (3) below. *In-line stabilisation is the alignment of three anatomical landmarks (nose, sternum and the contra point at the pubic bone) in one straight line. This principle helps to maintain the spinal column in a neutral position thus reducing the risk of further injury to the underlying spinal cord and vertebrae. In situation (2), it is advisable to leave the helmet in place whilst maintaining in-line stabilisation but be prepared to act quickly if there are developing signs of compromise to the airway, for example sounds of gurgling, snoring or stridor are heard or the patient retches or vomits. In situation (3), it is recommended that the helmet be removed in-line with the following guidance: The removal of protective helmets should be carried out by two people. It may be necessary to utilise a bystander to assist with this, and therefore you should be familiar with both roles in order that you can coach and guide them.

Procedure for helmet removal by two people Have scissors to hand when removing a helmet as you may need to cut the chinstraps. Rescuer 1 • Lift the visor. • In-line stabilisation is achieved by placing the hands on each side of the helmet with the fingers on the patients jaw. This will prevent slippage of the strap if it is loose. • At this point the chinstrap securing the helmet can be undone by Rescuer 2; if this is not possible cut with scissors. • Remove any spectacles/sunglasses that the patient may be wearing. Rescuer 2 • On instruction from Rescuer 1, undo or cut the chinstrap • Place one hand on the patients chin, with the fingers and thumbs cupping and supporting the jaw. • Slide the other hand round to the back of the neck and cup and support the base of the skull. • Both hands now should be stabilising the head and protecting against any movement caused by Rescuer 1. Rescuer 1 • You can now remove the helmet. • This is done by 88walking the helmet off the head with gentle rocking motion front and back. Helmets are egg shaped and can be made easier to remove by pulling apart outwards the base to clear the ears. • Care has to be taken here to ensure that the nose is not caught during the 88walking off’ phase. • Once the helmet has been removed, instruct Rescuer 2 to slowly lower the patients head to the floor.

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Rescuer 2 • Rescuer 1 can now remove the helmet. • Whilst this is happening, your hands should continue to stabilise the head and counter any movement created during the 89walking off’ by Rescuer 1. • Once the helmet has been removed, the head will be clear of the floor (by the thickness of the helmet). Gently lower the head under control when instructed by Rescuer 1. Remember, the head will suddenly feel heavy. Care must be taken not to drop it. Rescuer 1 • With the helmet removed, you should position your hands on the side of the patients head and adopt a position where in.-line stabilisation can be achieved, replacing the role of Rescuer 2. • The hands should not cover the ears of the patient during this manoeuvre as it may impede their hearing. Kep your head low so you can check the alignment of the chin, sternum and pelvis. Rescuer 2 • Remove hands from the patients chin and the base of skull as advised by Rescuer 1. Once removed, the helmet should be inspected for damage, which may provide clues to the mechanism of injury. You should continue to manage the patient according to ABC priorities. The helmet should be retained and transferred to hospital with the patient as part of the patients 89history. Remember: vomiting may have serious and potentially fatal consequences if the patient is wearing a full-face helmet.

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Resuscitation Algorithms Adult Basic Life Support

UNRESPONSIVE ?

Shout for help

Open airway

NOT BREATHING NORMALLY ?

Call 999

30 chest compressions

2 rescue breaths 30 compressions

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AED Algorithm

Unresponsive? Call for help Open airway Not breathing normally

Send or go for AED Call 999

CPR 30:2 Until AED is attached

AED assesses rhythm

Shock advised

No Shock advised

1 Shock

Immediately resume CPR 30:2

for 2 min

Continue until the victim starts to wake up, i.e. moves, opens eyes and breathes normally

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Adult Choking Treatment Algorithm

Assess severity

Severe airway obstruction

Mild airway obstruction

(ineffective cough)

(effective cough)

Unconscious Start CPR

Conscious

Encourage cough

5 back blows

Continue to check for deterioration to ineffective cough or until obstruction relieved

5 abdominal thrusts

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Paediatric Basic Life Support (Healthcare professionals with a duty to respond)

UNRESPONSIVE?

Shout for help

Open airway

NOT BREATHING ? NORMALLY

5 rescue breaths

NO SIGNS OF LIFE?

15 chest compressions

2 rescue breaths 15 compressions

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Paediatric Adult Choking Treatment Algorithm

Assess severity

Ineffective cough

Conscious Unconscious 5 back blows Open airway 5 breaths

5 thrusts

Start CPR

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Effective cough

Encourage cough Continue to check for deterioration to ineffective cough or until obstruction relieved

Helicopter Safety Helicopter Landing Area Preparation • Locate an area approximately 25m x 25m (8Oft x 8Oft) that is unobstructed, level and close to the scene • A white or light coloured sheet is good for spotting from 250m.-300m (800-lOOOft) but should be removed and secured as soon as it is established that the helicopter has seen the area • The site should be cleared of all loose objects, make sure all loose clothing is fastened and keep all children and animals under control • Report any obstacles (e.g. cables, poles, trees, etc.) to the pilot if possible • Never shine fights at the helicopter • Stand in an area as an 95X • Always wear eye protection • The crew must be informed of any hazardous materials involved, i.e. smoke, gas clouds, etc.

Helicopter Landing Area Safety • Only approach the helicopter with the flight crews permission, and wait for the pilots thumbs up • The only route you should take to the aircraft is within the cone of 45 angle from the front of it • Never approach the helicopter from an uphill slope • DO NOT walk near the tail rotor or vents and exhausts • DO NOT use flash photography or camera fights during take offs or landings Please note: stretcher loading is generally from the port (left) side or centrally from the rear of the aircrafts cabinalways follow the directions of the flight crew. Remember: The danger area should only be entered when escorted by a member of the aircrew- even if the rotors are not turning.

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Needle Thoracocentesis (Chest Needle Decompression) This procedure is for the rapidly deteriorating casualty who has a life-threatening tension pneumothorax. If this technique is used with a casualty who does not have a tension pneumothorax, there is a 10 to 20% risk of producing a pneumothorax or causing damage to the lung, or both. In such cases, insertion of a chest drain is mandatory. A large bore (12 or 14 gauge) cannula is inserted into the 2nd intercostal space (Figure 4- / 7). Identify landmarks - find the angle of Louis. Run a finger along the second rib until the mid-line of the clavicle. Underneath this rib is the intercostal space where the needle will be inserted. The needle should be inserted over the top of the 3rd rib and not below the 2nd. This is because there is a neurovascular bundle that sits below the rib (Figure 4-18). The cannula is then inserted at a 900 angle to the skin. The cannula should be advanced up until the hub of the cannula is adjacent to the skin. Then the needle is fully removed. A hiss of air may be heard at this point. The breathing rate will decrease. The cannula must then be protected so that it cannot become kinked or blocked. This procedure is not definitive. It will buy time whilst a chest drain is setup before insertion. If no formal chest drain is available, the process can be repeated and multiple needles put in place until the casualty can be evacuated to a facility that is equipped to deal with the problem. After the needle has been inserted, a reassessment of the casualty must take place in order to see if the intervention has worked.

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Hydrogen Sulphide (H2S) Poisoning Hydrogen sulphide (H2S, CAS# 7783-06-4) is an extremely hazardous, toxic compound. It is a colourless, flammable gas that can be identified in relatively low concentrations, by a characteristic rotten egg odour. The gas occurs naturally in coal pits, sulphur springs, gas wells, and as a product of decaying sulphur-containing organic matter, particularly under low oxygen conditions. It is therefore commonly encountered in places such as sewers, sewage treatment plants (H2S is often called sewer gas), manure stockpiles, mines, hot springs, and the holds of fishing ships. Industrial sources of hydrogen sulphide include petroleum and natural gas extraction and refining, pulp and paper manufacturing, rayon textile production, leather tanning, chemical manufacturing and waste disposal. Hydrogen sulphide has a very low odour threshold, with its smell being easily perceptible at concentrations well below 1 part per million (ppm) in air. The odour increases as the gas becomes more concentrated, with the strong rotten egg smell recognisable up to 30 ppm. Above this level, the gas is reported to have a sickeningly sweet odour up to around 100 ppm. However, at concentrations above 100 ppm, a personâ&#x20AC;&#x2122;s ability to detect the gas is affected by rapid temporary paralysis of the olfactory nerves in the nose, leading to a loss of the sense of smell. This means that the gas can be present at dangerously high concentrations, with no perceivable odour. Prolonged exposure to lower concentrations can also result in similar effects of olfactory fatigue. This unusual property of hydrogen sulphide makes it extremely dangerous to rely totally on the sense of smell to warn of the presence of the gas.

Health Effects of Hydrogen Sulphide H2S is classed as a chemical asphyxiant, similar to carbon monoxide and cyanide gases. It inhibits cellular respiration and uptake of oxygen, causing biochemical suffocation. Typical exposure symptoms include: LOW MODERATE

HIGH

0 - 10 ppm

Irritation of the eyes, nose and throat

10 - 50 ppm

Headache Dizziness Nausea and vomiting Coughing and breathing difficulty

50 - 200 ppm

Severe respiratory tract irritation Eye irritation / acute conjunctivitis Shock Convulsions Coma Death in severe cases

Prolonged exposures at lower levels can lead to bronchitis, pneumonia, migraine headaches, pulmonary oedema, and loss of motor coordination.

Working with Hydrogen Sulphide Most countries have legal limits in force that govern the maximum allowable levels of exposure to hydrogen sulphide in the working environment. A typical permissible exposure limit in many countries is 10 ppm. While the distinctive odour of H2S is easily detected, its olfactory fatigue effects mean that one cannot rely on the nose as a warning device. The only reliable way to determine exposure levels is to measure the amount in the air. Regular monitoring will help to identify areas and operations likely to exceed permissible exposure limits, and any areas that routinely pose overexposure hazards should be equipped with continuous monitoring systems. With a density of 1.19, hydrogen sulphide is approximately 20 percent heavier than air, so this invisible gas will collect in depressions in the ground and in confined spaces. The use of direct reading gas detection instrumentation should be required before entering confined spaces such as manholes, tanks, pits, and reaction vessels that could contain an accumulation of H2S gas. Wherever possible, exposure should be minimised by employing adequate engineering controls and safe working practices. Such methods include ensuring good ventilation and changing work procedures and practices. Where engineering controls cannot adequately control levels of exposure, it may be necessary to supplement them with the use of suitable persona/ protective equipment (PPE) such as supplied-air respirators. A qualified industrial hygienist or safety professional should be consulted for guidance on the suitability and correct use of respirators.

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Should a co-worker ever be overcome by H2S gas, do not attempt a rescue until you are properly protected yourself. The rescuer can very easily get caught out by venturing into a confined space without adequate protection. Remember that at levels above 200 ppm, collapse, coma and death due to respiratory failure can occur within seconds after only a few inhalations so you can be overcome yourself very quickly. Such incidents are sadly all too common and only serve to make the rescue effort twice as difficult. NOTE: The information contained in this factsheet is presented for informative purposes only and should not be construed as legal advice or opinion. You should consult the hydrogen sulphide standard for your country or consult the appropriate health and safety regulatory body for guidance.

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Suggested Medical Equipment List Trauma Snatch Bag The trauma snatch bag is a small hand held bag designed for use by individuals at FPOS 1 level. Although small, the snatch bag has the capability to deal with a range of various traumatic injuries. Item Quantity Nasopharyngeal airway size 7mm

Nasopharyngeal airway size 6mm

Aquagel 5g Sachet

Oropharyngeal airway size 3

Oropharyngeal airway size 4

CPR pocket mask with 02 inlet

Suction easy device

Asherman Chest Seal

First care emergency bandage 6â&#x20AC;?

Crepe bandage 7.5cm x 4m

Sterile Gauze 7.5cm x 7.5cm 5pk

Kerlix large gauze roll

Combat application tourniquet

Burns cling

Burns dressing lOcm x lOcm

Triangular bandage

Elastic bandage E.A.B 7.5cm x 4.5m

Sam splint, adult

Tuff cut scissors

Blunt/Sharp scissors

Nitrile gloves

5 pairs

Alcohol hand rub 50mI spray (Hazardous for airfreight)

Non adherant dressings lOcm x lOcm

Eye pad no:16

Zinc Oxide tape 2.5cm x lorn

Assorted plasters 20 pk

Steri-strips

Cyalume snaplight 12 hour

Triage card

Tactical snatch bag black Cordura

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