EPFA by Safety Publishing Ltd

Emergency Paediatric

First Aid

Safety Publishing Ltd 483 Green Lanes London N13 4BS

info@safetypublishing.co.uk www.safetypublishing.co.uk

Contents Airway

Assessment

BLS Child

BLS Infant

Bites and Stings

Bleeding

Calling Emergency Services

Choking

C.P.R.

Cross Infection

Defibrillation

Febrile convulsions

First Aid Kit

Minor injury

P.P.E.

Recovery Position

Scene Safety

Seizure

Shock

Wound Dressing

2 E.P.F.A. Emergency Paediatric first aid Emergency Paediatric first aid training is designed for people who work with or spend time with children and who may be called upon to offer first aid in the event of injury or sudden illness. This could include parents, babysitters or those employed in professional childcare situations.

Learning outcomes 1. ▪ ▪ ▪ ▪ ▪ ▪ 2. ▪ ▪ ▪ 3. ▪ ▪ ▪ 4. ▪ ▪ 5. ▪ ▪ 6. ▪ ▪ 7. ▪ ▪ 8. ○ ○ ○ ○

Understand the role and responsibilities the emergency Paediatric first aider. Explain the role and responsibilities of the Paediatric first aider. Explain how to minimise the risk of infection to self and others. Identify criteria for using personal protective equipment. Understand contents of Paediatric first aid kit. Understand the importance of reporting and record keeping. Define an infant or child with regard to first aid. Assessment Conduct a scene survey Conduct a primary survey on an infant and child Know when and how to call for help. Provide first aid to an infant/child who is unresponsive and breathing normally Use of the recovery position Monitoring and infant/child whilst in the recovery position. Treat an infant or child suffering a seizure. Be able to provide first-aid for an infant/child who is unresponsive and not breathing normally. Basic life support for infant/child Administer CPR using an infant and child mannequin. Recognise foreign body airway obstruction Give first aid for an infant or a child whose choking Identify severity of choking event Give first aid to infant or child with external bleeding. Explain the effect of severe blood loss on an infant or a child. Demonstrate control of external bleeding. Provide first aid to an infant or child suffering from shock. Recognise the signs and symptoms of blood loss shock. Treat a child or infant suffering from blood loss shock. Give first-aid to an infant or child with bites, stings and minor injuries Bites Stings Minor wounds Grazes

○ Bruises ○ Minor splinters ○ Nosebleeds

Role and Responsibilities First Aid Paediatric First aid is, quite simply, the initial treatment given to a baby or child who suffers injury or sudden illness. If the injury or illness is minor then it may be the only help that the child receives or needs. If the condition is more serious then first aid may be given until the child is handed over to a better qualified person or medical practitioner, who could be a paramedic or doctor. The basic principle of first aid is to keep the child alive, to prevent their condition from deteriorating and to hand them over in the best possible condition in the circumstances. The Paediatric First Aider should possess the following skills, and be able to: ▪ deal with conditions which are immediately or potentially life-threatening. ▪ provide first aid for conditions which may not be life-threatening but will require treatment to prevent further harm, before the emergency medical services arrive ▪ provide first aid response in cases where injuries are minor and the treatment may be all the child requires ▪ provide reassurance to the patient as well as other children in the vicinity ▪ record all actions and interventions and pass this information on when handing over to better qualified persons ▪ be aware of the location and contents of emergency first aid kits ▪ be aware of the need for and competent in, raising the alarm or calling emergency services in a timely manner ▪ Make themselves aware of any pre-existing conditions suffered by children in their care ▪ display the personal skills needed, including composure, competence and selfconfidence, while understanding their limitations ▪ be prepared to do what is necessary to maintain their knowledge and skills to the required level ▪ work only within the scope of their training and competence.

4 Role and responsibilities Cross infection and personal protection When dealing with an adult casualty the first aider has to be very aware of the risk of infection with blood-borne viruses such as HIV or hepatitis. This risk is much less when dealing with infants and children. If the infant or child is a member of the first-aiderâ&#x20AC;&#x2122;s family then any risk would be known and probably immaterial. If dealing with blood or other body fluids it is still considered best practice to wear gloves or other form of barrier device and these should be available in first-aid kits. Whether a Paediatric first aider would feel justified in withholding treatment due to the absence of these barrier devices is a judgement for themselves.

First Aid Kits Are you aware of the location and contents of firstaid kits? If not, the best time to familiarise yourself with them will be before you need one. First-aid kits should be clearly marked with the symbol of first-aid, a white cross on a green background. They should contain only first-aid equipment. Contents of first aid boxes would depend upon the assessment of risk and any specific problems that might be anticipated. The contents of a box in the home is likely to be very different to a box in a professional child care setting. Suggested minimum contents General Guidance Leaflet 1 Disposable gloves, nitrile preferred Sterile wrapped plasters

2 pairs 20 assorted

Sterile eye pad, with bandage

Triangular bandages

Wound dressings with bandage Individually wrapped wound wipes (Non alcohol)

6 medium - 2 large 6

Safety Pins 6 assorted Some of this equipment may date expire so needs to be checked regularly. Any equipment used should be replaced as soon as possible. These are suggestions only and are minimum quantities. Your kit may be different, to meet your requirements.

Role and Responsibilities Making an Emergency Call 112 or 999 are the free 24-hour numbers to call for emergency help When you get through the operator will ask you which service you require. If you ask for an ambulance the ambulance controller will then take details of why you need help. The initial questions are to prioritise just how urgent the problem is. In particular they will ask you if the person you’re calling about is unconscious, has breathing difficulties or is bleeding as these conditions may be immediately life-threatening and need the fastest response. ▪ Try to stay calm and to pass on to ambulance control as much information about the casualty’s condition as you can. ▪ Only pass on information you know to be true, guesses or assumptions may mean you are given inaccurate advice. ▪ Give as much information about your location as possible to help the ambulance crew find you. ▪ Don’t hang up until the ambulance controller tells you to. ▪ In an emergency the controller is trained to talk you through procedures or to remind you to do checks that you may not have thought of. This can be reassuring at a very tense time. ▪ If you are calling from the street then stay with the casualty. ▪ If you are calling from home then make sure doors are open and pets shut away. ▪ At night leave all your lights on to make it easier for the ambulance to find you.

Record Keeping If the event takes place within a professional childcare environment then there will almost certainly be better qualified first-aiders in attendance and they will take on the role of producing records and reports. However, they will still need to know what you saw and what you did. In a public environment or at home then healthcare professionals such as paramedics or doctors will need to know what you saw and what you did. It is a very good idea to write down these details as soon as possible after the event whilst your memory is still clear.

Infant or child? ▪ A neonate is birth to one month ▪ An infant is one month to one year ▪ A child is one year to puberty. If you are unsure whether a child may have reached puberty, treat them as an adult.

Assessment Scene safety At the scene of any incident that might involve injury it is very important that the first person at the scene carefully assesses the risk of injury to themselves, the victim or anyone else in the vicinity. This reduces the risk of the first-aider becoming a victim and therefore unable to assist their patient. As you approach the scene look carefully for anything that is or may become a risk to your own health and safety. Look particularly for things like electricity, escaping gas, fire or smoke, traffic or immersion in water. Remember that circumstances can change quickly, so remain alert and be prepared to respond appropriately.

Primary survey When faced with an infant or child who has been injured or suffered sudden illness you need to rapidly gather as much information as possible and also undertake first-aid treatments based on that information. This gathering of information is known as the primary survey. The first stage of the primary survey is to assess the situation and if possible try to decide what may have happened and how. If you know what has happened or how it has happened then that may indicate what is wrong with the child. As an example, if a child has fallen from a height of more than a metre we might assume that they have suffered a head injury or possibly a spinal injury, based purely on what happened. If a child was seen eating small sweets and suddenly appeared to have a problem breathing we might assume that they have suffered an obstruction to their windpipe due to the sweet “going down the wrong way” The next stage would be to assess the condition of the child at that moment. There are certain things that we need to know immediately: ▪ Are they safe where they are? (Danger) ▪ Are they conscious or responsive? (Response) ▪ Are they able to breathe normally? (Airway) ▪ Are they breathing normally? (Breathing) ▪ Are they bleeding or in shock? (Circulation) Remember – D.R.A.B.C.

Danger In the vast majority of cases casualties should be moved as little as possible, prior to the arrival of the emergency services. The best position to treat them in is the position that you find them in. However, if there is an imminent threat to the casualty from their environment or surroundings then it may be essential to move them to a safer environment. If electric shock is suspected, ensure that the electrical supply is isolated, ideally at the main switch, so if you can remove the danger from the casualty then do so, or failing that, remove the casualty from the danger.

Assessment Response As you approach your casualty start to get an impression of their level of consciousness. If they are sitting up, looking around and crying then you can be certain that they are fully conscious and therefore they are breathing and their heart is beating. (Crying is a wonderful sound to a Paediatric first aider in an emergency) On the other hand, if they are lying still and not making any noise you might be concerned that they are unconscious. Now your greatest priority is to find out if they are able to breathe, if they are breathing normally and what other serious injury they may have suffered. Now your priorities are A.B.C.

A airway

Can they breathe? If they are unconscious open the airway with head tilt / chin lift. If they are conscious treat conditions such as choking.

B breathing

Are they breathing normally? If they are unconscious and not breathing normally give 5 rescue breaths and perform CPR for one minute before raising the alarm. If they are unconscious and breathing normally examine them for other injuries and place them carefully into the recovery position If they are conscious but have breathing problems such as Asthma treat this condition before moving to the next step.

C circulation

Are they bleeding or in shock? Control any serious bleeding and look for and treat the effect of blood loss or shock Call 999 / 112 for an ambulance.

Airway As food enters the back of the throat it sets off a series of reflexes which cause the opening to the windpipe to be temporarily closed off, preventing the food from ‘going down the wrong way’. This is the swallow reflex. If this mechanism fails, the food may enter the top of the windpipe. This causes another set of reflexes to trigger which results in a forceful cough that blows the object clear. This is called the cough reflex. These reflexes are lost in the unconscious child. This means that the airway is unprotected and that anything in the child’s mouth could drop into their windpipe and block it. This could include food, blood, saliva and most commonly, the tongue.

Assessment Airway (continued) As we become unconscious our muscles start to relax. The tongue is a muscle and as it relaxes it tends to fall to the back of the throat, blocking it. If the airway is blocked no oxygen can reach the lungs to be transferred to the blood stream. With no oxygen in the blood, tissues will begin to die.

Blocked airway Breathing The air that we breathe in contains around 21% oxygen. We keep enough for our own needs but still breathe out a mixture that contains about 17% oxygen. This is more than enough to sustain life and it means that we can use our expired air to keep someone else alive. When we blow our expired air into a childâ&#x20AC;&#x2122;s lungs, oxygen will be absorbed into their blood stream automatically, ready to be circulated.

Circulation Are there any visible signs of severe bleeding? If they are bleeding severely then your priority would be to control bleeding with the application of direct pressure using your hands, pad or wound dressing. Once the serious bleeding is controlled down 999/112 for an ambulance Be alert for and be ready to treat shock.

Basic Life Support - Child Approach with CARE Make sure that there is no danger to yourself, the child or bystanders.

Check for RESPONSE ▪ Speak loudly to the child, ask them to open their eyes. ▪ Gently stimulate them by tapping them on the shoulder. ▪ Never forcefully shake the child. ▪ Watch their face for signs of eye opening or movement.

If they RESPOND ▪ If the child responds by opening their eyes, speaking or trying to move: ▪ keep them in the position that you find them. ▪ Check for other injuries and treat any conditions that are immediately life threatening. ▪ Send for help or raise the alarm. ▪ Continue to monitor their condition until the arrival of trained help.

If there is NO RESPONSE ▪ Shout loudly for help Shout for HELP ▪ If someone is nearby ask them to wait as you may need their assistance. ▪ If you are alone, shout for help loudly to try to attract attention, but do not leave the child.

Open the AIRWAY ▪ Place one hand on their forehead and press gently downward. ▪ Place the tips of your fingers under the bony part of their jaw to lift and support their chin. ▪ Rotate their head gently backward.

10 Basic Life Support - Child Check for NORMAL BREATHING Kneel next to them with your cheek over their nose and mouth looking down their chest towards their toes. ▪ Look – for chest movement. ▪ Listen – for breath sounds. ▪ Feel – for breath on your cheek. ▪ Take no more than 10 seconds to check.

If they are BREATHING NORMALLY ▪ Treat any immediately life-threatening injury. ▪ Turn them into the recovery position as soon as it is practical to do so. ▪ Continue to monitor their breathing until the arrival of help.

If they are NOT BREATHING NORMALLY ▪ Give five rescue breaths Give RESCUE BREATHS

Ensure that the airway is open (head tilt – chin lift)

Pinch the soft part of their nose between the index finger and thumb of the hand which is pressing on the forehead.

Basic Life Support - Child 11 Give RESCUE BREATHS (Cont.)

Take a breath and place your lips around their mouth, ensuring that you have a good seal. Blow steadily into their mouth for about one second until you see their chest rise.

Lift your head away whilst maintaining head tilt – chin lift and allow the air to come out of their mouth.

Airway obstruction If you have difficulty achieving an effective breath it probably means that the airway is obstructed. ▪ Re-check their mouth and remove any obvious obstruction (do not use a blind finger sweep). ▪ Make sure the head is tilted and the jaw is lifted properly. ▪ Make sure you are making a good seal around the mouth. ▪ Repeat up to five attempts to give effective inflations. ▪ If unsuccessful move on to chest compressions.

Give CHEST COMPRESSIONS ▪ The objective of chest compression is to use the child’s own heart as a mechanical pump. ▪ The heart is like a rubber ball, as you compress it blood is forced out and due to the system of one-way valves the blood is forced into the correct delivery pipes or arteries. ▪ When pressure is released the elastic nature of the heart means that blood is drawn back into it. Again, valves positioned at the entry and exit of the chambers keeps the blood flowing in the correct direction. ▪ The child should be on a firm flat surface for chest compressions to be fully effective.

12 Basic Life Support - Child Give CHEST COMPRESSIONS

Place the heel of one hand over the lower third of the child’s breastbone. Lift the fingers to ensure that you do not press on the ribs.

Position yourself with your shoulder over the chest and with your arm straight. Push vertically downward with enough force to compress the chest by one third of its depth.

▪ In larger children or with small rescuers this may be done with both hands, as in adult chest compression. ▪ Repeat at a rate of 120 compressions a minute. ▪ Give 30 effective chest compressions.

Combine CHEST COMPRESSION and RESCUE BREATHING ▪ After 30 chest compressions stop and give two more rescue breaths. ▪ Alternate 30 compressions with two rescue breaths. ▪ If there is no response after one minute, and nobody has called for help, stop and dial 999 for an ambulance. ▪ When you know that help is coming, continue with rescue breathing/chest compressions at a ratio of 30 to 2 until help arrives and someone takes over. ▪ If there is more than one rescuer present, change over every two minutes. ▪ Try to keep the chest compressions at a regular speed and depth.

▪ Keep pauses or stoppages as short as possible

Basic Life Support - Infant 13 Approach with CARE ▪ Make sure that there is no danger to yourself, the baby or bystanders.

Check for RESPONSE ▪ Gently stimulate the baby by speaking loudly to them and by moving a limb or tapping their hand or foot.

Never shake a baby! If they RESPOND If the baby responds by opening their eyes or trying to move: ▪ keep them in the position that you found them. ▪ check for other injuries and treat any conditions that are immediately life-threatening. ▪ send for help or raise the alarm. ▪ continue to monitor their condition until the arrival of trained help.

If there is NO RESPONSE ▪ Shout “HELP” and start A.B.C. Open the AIRWAY ▪ Place one hand on the baby’s forehead and press gently downward to rotate the head backward. ▪ Place the tip of one finger under the bony part of the jaw to lift and support the chin. ▪ Be careful not to over extend the neck. ▪ The finished position should be with the baby’s eyes pointing straight upward.

14 Basic Life Support - Infant Check BREATHING ▪ Place your ear closely over the nose and mouth of the baby. ▪ Look down the chest towards the toes. ▪ Look for movement of the chest or abdomen. ▪ Listen for breath sounds. ▪ Feel for breath on the cheek. ▪ Take no more than 10 seconds to check.

If the baby IS BREATHING NORMALLY ▪ Treat any immediately life-threatening injury. ▪ Turn them onto their side as soon as it is practical to do so. ▪ Continue to monitor until the arrival of help.

If the baby IS NOT BREATHING NORMALLY ▪ If someone else is available send them to dial 112/999 to call an ambulance ▪ If you are on your own start rescue breathing and chest compressions and continue for around one minute before calling the ambulance. ▪ Deliver five effective rescue breaths ▪ Ensure the airway is open. ▪ Take a breath and place your lips around the baby’s nose and mouth ensuring that you have a good seal. ▪ Blow out gently into the baby’s mouth until you see the chest rise. ▪ Lift your head away from the baby while maintaining head tilt – chin lift. and allow the air to come out of the baby’s mouth. ▪ Repeat this sequence five times.

Basic Life Support - Infant 15 Airway obstruction If you have difficulty achieving an effective breath it probably means that the airway is obstructed. ▪ Re-check the baby’s mouth and remove any obvious obstruction (do not use a blind finger sweep). ▪ Make sure that the head is tilted and the jaw is lifted properly. ▪ Make sure that you are making a good seal around the baby’s mouth. Repeat up to 5 attempts to give effective inflations. If still unsuccessful move on to chest compressions.

CHEST COMPRESSIONS - infant ▪ Place the tips of two fingers over the lower third of the baby’s breastbone. ▪ Press down on the breastbone to a depth of one third of the depth of the baby’s chest. ▪ Release the pressure keeping your fingers in contact with the baby’s chest. ▪ Give 30 compressions at a speed of 120 compressions a minute.

Combine CHEST COMPRESSIONS with RESCUE BREATHING Combine rescue breathing with chest compressions at a ratio of 30 chest compressions to 2 rescue breaths. Deliver CPR for one minute before going to telephone for help. Maintain CPR until: ▪ The baby shows signs of recovery. ▪ Someone else takes over. ▪ You become exhausted.

16 Defibrillation When to go for HELP ▪ It is vital to raise the alarm as soon as possible. ▪ If there is more than one rescuer, one should start CPR whilst the other goes for help. ▪ If you are on your own, perform 5 sets of 30:2 CPR before going for help. ▪ It may be possible to take the baby with you to the telephone.

Defibrillation and children Thankfully it is rare to have to use an AED on a child. Their use however can be life-saving in some circumstances. Standard AEDs are suitable for use on children older than eight years and the rescuer should use the same procedures and techniques as for adults. Where it is likely that the equipment will be used on a child between the ages of one year and eight years of age then special paediatric pads should be available and should be used. These pads reduce the power delivered by the AED to a lower and safer level. If the child is of an appropriate size then pad positioning should be as for an adult. For very small children or babies then one pad should be placed centrally on the front of the baby’s chest and the other pad placed on their back, between the shoulder blades.

The Recovery Position The aim of the recovery position is to maintain the airway by placing the child in a position on their side, with the head lower than the chest. This allows the tongue to fall forward and allows drainage of blood, saliva or stomach contents from the mouth, by gravity. If corrosive stomach contents were allowed to enter the windpipe and lungs either by gravity or breathing in, the effect would be to cause a rapid and often fatal inflammation of the lining of the lungs. The inflamed or burnt surfaces produce large amounts of fluid and the child can literally drown in their own body fluids. This problem occurs because the muscle (sphincter) at the opening to the stomach relaxes in unconsciousness allowing corrosive stomach contents to be regurgitated into the mouth. The following criteria should be met: ▪ they should be placed on their side with the mouth lower than the chest, to allow for free drainage. ▪ there should be no pressure on the chest. ▪ the position should be stable and allow easy access to the airway. ▪ it should be possible to return the child onto their back easily.

Method ▪ Before attempting to move them make sure that there is nothing in the immediate area which may be dangerous. ▪ Have a good look at them checking for obvious injuries, these may not prevent you from moving them but they may modify the way it is done. ▪ Remove their spectacles if worn and any bulky items from their pockets. ▪ Kneel beside them. ▪ Open their airway with head tilt/chin lift.

Take the arm nearest to you and place it at right angles to the body with the elbow bent and the palm of the hand uppermost. Let it fall naturally into position, don’t force it.

18 Recovery Position

Bring the furthest arm across the chest and place the back of the hand against the childâ&#x20AC;&#x2122;s nearest cheek, holding it there with your hand.

With your other hand, grasp the furthest leg just above the knee and pull it up, bending the knee but keeping the foot on the floor. Keeping the childâ&#x20AC;&#x2122;s hand against their cheek, pull on the leg to roll them towards you onto their side.

Adjust the upper leg so that hip and knee form right angles. Tilt the head back and open the airway.

Adjust the hand under the chin to keep their head tilted back. Monitor breathing and pulse and periodically check the circulation in the lower arm.

If you have not already done so, raise the alarm.

Seizure 19 Seizure / epilepsy A seizure is most often caused by an abnormal electrical disturbance in the brain. It can cause changes in body movement or function, sensation, awareness or behaviour and can last from just a few seconds to a condition which will not stop. There are many different types of seizure with many different causes. Probably the most common type of seizure that would require first aid attention is called the tonic / clonic seizure.

Seizure recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Possible known history of seizures. They may appear uneasy or nervous immediately prior to the fit. They may fall to the ground with a loud cry. Breath holding or irregular breathing. Cyanosis / congestion of the face. Muscle rigidity, followed by uncontrolled movements of limbs and trunk. Sometimes teeth grinding. Sometimes the lips or tongue may be bitten and there may be flecks of foam or blood on the lips.

Take ACTION

A C T I O N

Assess

Assess the situation – are they in danger of injuring themselves? Remove any nearby objects that could cause injury.

Cushion

Cushion the head (with a pillow or clothing) to protect them from head injury.

Time

Check the time – if the seizure lasts longer than five minutes you should call an ambulance.

Identify

Look for a medical bracelet or ID card – it may give you information about the person’s seizures and what to do.

Over

Once the seizure is over, put them on their side (in the recovery position) Stay with them and reassure them as they come round.

Never

Never try to restrain the person, put something in their mouth or try to give them food or drink.

Call an ambulance if: ▪ It is their first seizure. ▪ They remain unconscious for more than a minute or so.

▪ The seizure lasts for more than a few minutes. ▪ They have repeated seizures.

20 Febrile Convulsions Febrile convulsions Sometimes very young children may have fits if their temperature becomes too high, usually over 39°C. These are called febrile convulsions and often happen at the start of an infectious illness such as flu. They are likely to affect children in the age range of six months to five years.

Febrile convulsions - recognition ▪ The child will lose consciousness. ▪ The body, legs and arms will go stiff. ▪ The legs and arms start to jerk and the head may be thrown back. ▪ The skin may be pale or even appear blue. ▪ The convulsion lasts for a few minutes and gradually subsides.

Febrile convulsions - treatment ▪ Treat as for a seizure. ▪ Let the convulsion follow it’s course, whilst protecting the child from injury or harm. ▪ Place the unconscious child in the recovery position. ▪ If the seizure is prolonged or the child suffers repeated seizures, dial 999 or 112 for an ambulance. ▪ Always consult the child’s doctor following a seizure. ▪ You can help to lower the child’s temperature by removing excess clothing or bed clothing and opening windows. It is not recommended to sponge the child’s skin with cold water as this may lower the temperature too quickly.

Airway Obstruction The majority of choking events occur whilst the child is eating or playing, often when a carer is present. If these events are witnessed, treatment is usually carried out quickly whilst the child is still conscious. When a child chokes the immediate response is coughing. This is likely to be the most effective and safest way of removing the obstruction. If coughing is not effective however, or the foreign body completely obstructs the airway, treatment needs to be immediate. You might suspect choking on a foreign body if: ▪ the child develops very sudden breathing problems. ▪ there are no other signs of illness or other obvious explanation. ▪ the child was playing with small objects or eating immediately prior to the event.

Choking - general signs Effective Cough ▪ ▪ ▪ ▪

Loud cough Able to speak or cry Able to breathe before coughing Fully conscious

Ineffective Cough ▪ ▪ ▪ ▪

Silent or quiet cough Unable to speak or cry Unable to breathe Decreasing level of consciousness

Effective cough - treatment If the child is coughing you do not need to do anything. The cough is the best way to clear the airway so encourage them to cough and monitor their condition continuously. If the cough becomes non-effective, start treatment to clear the airway.

22 Airway Obstruction

Airway Obstruction

Ineffective cough - treatment ▪ Bend them forward. ▪ Give up to five firm blows between the shoulder blades. ▪ Check the mouth and remove any foreign objects. ▪ If the back blows don’t work give up to five abdominal thrusts. ▪ Stand behind them and place a fist over the upper abdomen beneath the rib cage. ▪ Grasp the fist with your other hand and pull sharply upward and inward, up to five times. ▪ Check the mouth and remove any foreign objects. ▪ If this is unsuccessful, revert to back blows and repeat the cycle. ▪ If the airway is still not clear call an ambulance and continue with the cycle until the ambulance arrives or the airway is cleared.

Ineffective cough - unconscious child ▪ Place them on a firm flat surface. ▪ Call or send for help if possible, but do not leave the child. ▪ Open the mouth and look for any obvious foreign object.

▪ If you see one, attempt to remove it.

Airway Obstruction Ineffective cough - unconscious child (continued) ▪ Attempt to give five rescue breaths (make five attempts if necessary). ▪ Give thirty chest compressions. ▪ Re-check the mouth and remove any object which has been dislodged. ▪ Give two rescue breaths. ▪ Repeat the cycle for one minute. If unsuccessful: ▪ call an ambulance ▪ continue the cycle of 30 compressions to 2 breaths until the ambulance arrives

Ineffective cough - conscious infant Give up to five back blows ▪ Lay the baby face down along the thigh, supporting the head with the hand. ▪ Make sure the head is lower than the body. ▪ Give up to five blows in the middle of the baby’s back, using the heel of the other hand. ▪ If the obstruction is relieved it is not necessary to give all five blows. ▪ Check the baby’s mouth and remove any foreign material found.

24 Airway Obstruction Ineffective cough - conscious infant (continued) If back blows are unsuccessful, give five chest thrusts ▪ Turn the baby over onto their back. ▪ Feel for the breastbone with two fingers and place the fingertips about a fingers width above the point where the ribs meet. ▪ Give up to five sharp downward thrusts, similar to chest compressions but sharper and at a slower rate. ▪ Check the baby’s mouth for any foreign objects, which should be removed. If necessary repeat the sequence of back blows and chest thrusts three times and if still unsuccessful take the baby with you to the telephone and call an ambulance.

Ineffective cough - unconscious infant ▪ Place them on a firm flat surface. Call or send for help if possible, but do not leave the baby. ▪ Open the mouth and look for any obvious foreign object. ▪ If you see one attempt to remove it. ▪ Attempt to give up to five rescue breaths.

▪ Assess the effectiveness of each breath, if the breath does not make the chest rise re-position the head before attempting the next breath.

Airway Obstruction Ineffective cough - unconscious infant (continued) If the chest does not rise: ▪ Immediately start chest compressions combined with rescue breathing at a ratio of thirty compressions followed by two breaths. ▪ When opening the airway to give rescue breaths check the mouth for obstructions and remove them if possible. ▪ Repeat the cycle for one minute. If still unsuccessful, call an ambulance.

Airway obstruction - summary of actions Signs of choking

Effective cough?

Severe Obstruction

Unresponsive

YES

Encourage coughing

Up to 5 back blows

Attempt 5 breaths

Up to 5 abdominal thrusts (Child)

Start CPR at 30:2

Up to 5 chest thrusts (Baby)

Continue to check for change to ineffective cough or relief of obstruction

26 Shock Shock – definition Shock is a condition which results from the failure of the circulation to supply oxygen and nutrients to the tissues and to remove waste products from them. It is often associated with a sudden drop in blood pressure. The low oxygen levels in the tissues results in impaired cell function, death of tissue and organ failure. In children, the most likely cause of shock is fluid loss associated with bleeding or burns. This is known as hypovolaemic (low blood volume) shock. Another cause may be a severe allergy to such things as an insect sting or eating peanuts (anaphylaxis) Shock is always serious and requires urgent medical attention.

Shock – recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Appropriate history (cause) Pale, cold clammy skin Cyanosis (blue tinge to lips or face) Rapid weak pulse Rapid shallow breathing Cold and shivering Thirst or dry mouth Confused or disorientated Nausea and vomiting Yawning and sighing

Shock – treatment Treat the cause (i.e. control bleeding) Give lots of reassurance Lay them down and elevate their legs, if the injuries permit Keep them warm but do not apply any heat source such as hot water bottles ▪ Give nothing to eat or drink but moisten their lips if they complain of thirst ▪ Ensure urgent medical attention ▪ ▪ ▪ ▪

Bleeding Blood Loss When we discuss blood loss we are actually referring to blood lost from the circulatory system. We may therefore be talking about internal or external bleeding.

External bleeding This is the easiest to see and the easiest to treat. Blood will be visible, flowing from a wound on the surface of the body.

External bleeding - treatment Direct pressure: this is pressure which is applied directly over the bleeding point. It may be applied over a pad of absorbent material or directly by the fingers or thumbs. The aim of direct pressure is to slow down the flow of blood sufficiently and for long enough to allow the formation of a blood clot. Blood clotting takes place in 5 to 10 minutes in normal circumstances and for this reason pressure should be maintained for at least 10 minutes to be confident that clotting has taken place. The most common reason for the failure of direct pressure to work is the temptation to lift the dressing to check on progress every few minutes. As soon as it becomes available a clean dry dressing should be applied to the wound and held in place by a bandage, applied tightly enough to apply pressure to the wound but not so tightly as to interfere with the circulation of the blood below the bandage. Elevation: to reinforce the effect of pressure, wherever possible the affected limb should be elevated above the level of the heart to reduce blood flow, paying due consideration to other injuries.

28 Wound Dressing Wound dressing ▪ Select a dressing of an appropriate size for the wound. ▪ Handle the dressing by the bandage, do not touch the face of the dressing, to keep it clean. ▪ Tie the dressing firmly in place by knotting the two ends. If blood soaks through the dressing apply another dressing on top of the first. If blood soaks through the second dressing remove both and re-apply a new dressing, making sure that pressure is applied directly over the wound.

Minor wounds ▪ Wash carefully with clean water ▪ Dry thoroughly ▪ Apply a clean dry dressing

▪ Make a record

Minor injuries Graze Grazes are often caused by a sliding fall onto a rough or dirty surface. They are usually contaminated by dirt and grit. They should be washed thoroughly under a running tap, if possible, to remove dirt contamination. It is often less painful to allow the casualty to do this themselves.

Bruise Bruises are caused by bleeding into or underneath the skin. They may be caused by minor bleeding at the site of an impact or may indicate more serious internal injury. The treatment of bruising is to elevate the injury and apply an ice pack, where possible or where injuries allow. This reduces blood flow to the injury and results in less swelling It is important to look at how the injury was caused and to be alert for more serious internal bleeding. Sometimes, bruising from deeper injuries may not become visible for hours or even days following the injury. If you suspect the possibility of internal injury then you must seek medical advice urgently

Splinters

Small pieces of wood or wire that are embedded in the skin can be carefully removed, Clean the area with soap and water before removal is attempted

Grasp the end of the splinter firmly with clean forceps. Pull the splinter out in a straight line, in the opposite direction to the way it entered.

Squeeze the wound firmly to produce a small drop of blood. Apply a small dressing or adhesive plaster.

30 Bites and stings Nosebleed Nosebleeds occur when the blood vessels in the nose are damaged or rupture spontaneously. Although nosebleeds are usually unpleasant rather than dangerous, they can occasionally lead to serious blood loss if not controlled. Recurring nosebleeds with no obvious cause should be investigated. Sit the casualty down with the head leaning well forward. Help or encourage the casualty to pinch the soft part of the nose, just below the bony part, for at least 10 to 15 minutes to allow for blood clot formation. If this is not successful refer the casualty for medical attention, maintaining pressure on the nose. If it is successful, as is usual, tell the casualty not to sniff hard, blow their nose, or do anything which may disturb the blood clot for at least six hours.

Bites and Stings Animal bite Most bites are inflicted by dogs and possibly cats. Even small animals can cause a nasty injury and large animals can be particularly dangerous. If the bite has broken the skin or drawn blood then : ▪ Control bleeding and treat shock. ▪ Wash small wounds with clean water. ▪ Arrange for medical attention. There is always a risk of infection from a bite and in addition there may be a requirement for tetanus protection.

Bites and stings Insect stings A sting occurs when venom is injected through a hollow tube into the skin or underlying tissue. Most insect bites and stings are likely to cause discomfort rather than danger but being stung or bitten is possibly painful and may cause the child to become distressed.

Insect stings - recognition The most common stinging insects in UK are the bee, wasp or hornet and the sting will often cause an immediate and possibly intense burning pain at the site, followed very quickly by swelling and redness around the sting. This will usually ease after a few hours. The biggest threat from such a sting would be a severe allergic reaction, or anaphylaxis A less serious allergic response may lead to localised swelling. The swelling and redness may spread to be several centimetres across or may even involve a whole arm or leg. It will usually go away over a few days. It is not dangerous unless it affects the airway but in severe cases it may cause blister formation or infection, if the skin breaks down. A wasp will not usually leave its sting behind and may sting more than once but a bee’s sting is barbed and will remain in the skin, with its venom sac attached. It is important not to press on this as it will push more venom into the wound.

Insect sting - treatment ▪ If the child has been stung by a bee and the sting is still in the skin it should be removed as soon as possible. Delay could lead to more venom being pushed into the tissues, ▪ It is important not to try to grip or squeeze the sting as this may squeeze more poison from the sac. ▪ The best method is to scrape the sting out using something like the edge of a card, the back of a knife or your fingernail.

32 Bites and stings Insect sting - treatment ▪ If you see any signs of a general allergic reaction then get medical help urgently. Phone 999 for an ambulance. Be alert for swelling in or around the mouth and lips. ▪ If the child has been stung multiple times they require the same urgent medical attention. ▪ Apply a cold compress to the site. Ice or frozen peas wrapped in a cloth or a cold wet flannel. Repeat as required. ▪ If there is a localised allergic reaction with swelling, redness and itching then they may benefit from an anti histamine either by mouth of as a cream or ointment, Check with their parents or Dr. ▪ If there is a small local reaction (most commonly) then after the cold compress the itching and swelling will go away over time.

Insect bite A biting insect does not inject venom when it bites, but there is often an allergic reaction to the insect’s saliva. Some biting insects, such as mosquitos feed from blood and may inject an anti blood clotting agent which may increase the allergic reaction. Blood feeding insects may also carry and pass on other diseases, such as malaria in the mosquito and Lyme disease from ticks. Although rare in the UK, remember that children may go on foreign holidays and visits and may have been bitten whilst away.

Insect bite - treatment ▪ Insect bites can cause severe itching, particularly where there are multiple bites from such things as fleas or bed bugs. ▪ Cool compresses can help in the early stages but there may be a requirement for antihistamine creams or ointments or even tablets, check this with the Doctor. ▪ Calamine lotion can be soothing on inflamed skin. ▪ Observe the site carefully for redness or swelling for several days after the bite. This may be an allergic response or possibly skin infection, particularly if the child has been scratching a lot. ▪ Ticks should be removed with a pair of fine tweezers. ▪ This is probably best done by someone with experience as it is easy for the tick to break, leaving the head part embedded.