FAR preview

3std Edition

First Aid responder

Abdominal thrust Abrasion Agonal Breathing Airway Amputation Anaphylaxis Asthma A.V.P.U. scale Back blows Back Pain Bandages Basic life support Bleeding Bones Burns Care principles Chain of survival Chemical burns Chest compressions Chest injury Chest pain Choking Cold, Effect of Communication Compression injury Concussion Coronary thrombosis CPGs C.P.R.

20 41 24 26 45 39 32 56 20 55 42 24 41 49 59 16 23 60 25 48 17 19 63 65 58 58 17 12 26

Critical Incident Stress Crush injury Defibrillator Diabetes Direct pressure Dislocation Dressings Electrical burns Emergency call Examining the patient Fractures Gases, inhalation Heart attack Heat, effects of History - SAMPLE HIV / AIDS Hand washing Hypoglycaemia Hypothermia Infection control Inhaler, asthma Insulin Internal bleeding Kidney failure Laceration Learning outcomes Level of consciousness Neck injury Nosebleed

Where page numbers for CPGs are given, they refer to the page numbers from the list of CPGs published by PHECC online as FAR CPGs 2017: http://www.phecit.ie

66 45 28 33 41 54 42 61 13 9 49 36 17 62 6 15 15 33 63 15 32 33 42 45 41 2 56 52 44

Obstructed airway PPE Poisoning and overdose Primary survey Prolapsed disc Pulse Quiz Recovery position Regurgitation Rescue breathing Resuscitation Scalp wound Scene Safety Secondary survey Seizures Shock Signs Skeleton Spinal Injury Sprains Strains Sudden cardiac arrest Symptoms Temperature Unconsciousness Vertebrae Vital signs Wounds Wound dressing

20 15 35 3 55 10 68 57 27 26 24 47 14 5 34 40 7 49 52 54 54 22 7 11 56 51 10 41 42

2 Introduction

First Aid Responder

Units 1.

2.

3.

4.

5.

6.

Assessment Incident procedure Cardiac first response Medical emergencies Injury management/shock The unconscious patient

7.

8.

9.

10.

11.

Burn and electrical injury Abnormal body temperature Information management Communications Well-being of the FA responder

First Aid Objectives 1. First aid is, quite simply, the initial treatment given to someone who suffers injury or sudden illness, usually at the scene and at the time.

2. If the injury or illness is minor then it may be the only help that the casualty receives or needs.

3. If the condition is more serious then first aid may be given until the casualty is handed over to the appropriate medical practitioner, who could be a paramedic or doctor, or to the care of a hospital emergency department.

4. The basic principle of first aid is to keep the casualty alive, to prevent their condition from deteriorating and to hand them over in the best possible condition in the circumstances.

5. In Ireland, a First Aid Responder may be a healthcare practitioner or a member of the public who has undertaken training on an approved first aid response course, following the standards produced by Pre-Hospital Emergency Care Council, or PHECC, which includes training in Cardiac First Response.

6. The objective of this training is to allow a First Aid Responder to have the skills to manage a patient who has become suddenly ill or injured in the pre-hospital environment, until the arrival of emergency medical services.

7. The First Aid Responder should assess and manage these patients in accordance with PHECC Clinical Practice Guidelines (CPGs) 8. First aid responders must also demonstrate a commitment to the process of maintaining their competence in first aid and CFR.

Learning Outcomes ▪ Recognise and assess the causes and effects of sudden illness or injury and call for Emergency Medical Services.

▪ React to such prehospital emergency is utilising PHECC CPG s ▪ Respond in a safe effective and appropriate manner to such emergencies utilising the first-aid response skill set

▪ Record and report actions and interventions taken whilst responding to and managing such incidents and also during handover to Emergency Medical Services ▪ Retain a professional and caring attitude in their performance as first-aid responders

First Aid Responder

Unit 1

Assessment-Primary Survey

ASSESSMENT

Primary survey This is the rapid initial assessment to find and simultaneously treat conditions that are immediately life-threatening

Primary survey - adult protocol Approach with care 1. Be aware of potential danger to yourself, bystanders or the casualty.

2. Think about what people have told you concerning the nature of the incident.

3. Consider the use of infection control procedures, particularly gloves, as you approach the casualty.

Control catastrophic external haemorrhage 1. If they are bleeding heavily, use pads and direct pressure to control the bleeding.

2. Use others seem to apply direct pressure, if appropriate.

Control cervical spine 1. If anything about the incident suggests the possibility of spinal injury, then immobilise the head and neck 2. Use others at the scene to keep the head and neck immobilised, where appropriate Assess response 1. If they are unresponsive, call 999/112 for help and request an AED if one is available Open the airway 1. Open the airway with head tilt/chin lift If the airway is obstructed 1. Take measures to clear the airway Check for normal breathing 1. If not breathing normally, start CPR 2. If breathing normally but unresponsive, place into the recovery position 3. Measure and record vital signs such as pulse, respirations and level of response 4. Gather together information and call 999/112 for ambulance assistance as required Maintain care 1. Continue to monitor their condition 2. Reassure them continuously 3. Carry out first aid procedures as appropriate 4. Hand them over to an appropriate practitioner

3

4 Primary Survey

First Aid Responder

D

Are you, or anyone else in danger?

Be aware of the threat to you or others as you approach the casualty.

Can you deal with it, can you move the casualty away from it or do you need to wait for assistance? Do not become a victim yourself.

R

Can you wake them up?

Do they respond to your voice or a gentle shake?

If not, proceed to ABC

A

Can they breathe?

If the person is unconscious open the airway with head tilt / chin lift (Page 13).

Danger

Response

Airway

B

Breathing

C

Circulation

Are they breathing normally?

If they are unconscious and not breathing normally first call 999/112 for help then start CPR. If they are unconscious and breathing normally examine them for other injuries and place them carefully into the Recovery Position (Page 11).

If they are conscious but have breathing problems such as Asthma treat this condition before moving to the next step.

Are they bleeding or in shock?

Control any serious bleeding (Page 23) and look for and treat the effect

First Aid Responder

Assessment-Secondary Survey

Secondary survey MEDICAL - adult protocol Conducted after the primary survey Record vital signs 1. Measure and record pulse, breathing and estimated BP and note the time of the record Patient acutely unwell?

1. Formulate RED card information and send for emergency ambulance Patient NOT acutely unwell?

1. Obtain history of present complaint 2. Take a SAMPLE history 3. Check them for medicines carried or medical alert jewellery Maintain care 1. Continue to monitor their condition 2. Reassure them continuously 3. Carry out first aid procedures as appropriate

Secondary survey TRAUMA - adult protocol Conducted after the primary survey Obvious minor injury?

1. Treat as appropriate Injury not minor?

1. Examine obvious injuries 2. Record vital signs and note the time of record 3. Obtain SAMPLE history 4. Complete head to toe examination as appropriate 5. Check for medications/medical alert jewellery Identify positive findings 1. Initiate appropriate care for any conditions you have found 2. Formulate RED card information and send for an ambulance 3. Carry out first aid procedures as appropriate 4. Hand them over to an appropriate practitioner

5

6 Secondary Survey

First Aid Responder

Secondary survey – procedure This is a detailed examination of the casualty to determine what other conditions or injuries they may be suffering from.

During the secondary survey the casualty should be checked methodically for any clues as to their current condition. Ideally, these checks should take place with them in the position found, at least until you have ensured that it is safe to move them. Whenever possible, make a note of your findings.

There are three elements to the secondary survey: ● History / mechanism of injury (MOI) ● Symptoms ● Signs

MOI or mechanism of injury This is the sequence of events that results in particular injury or injuries. It refers to the physical forces (acceleration, deceleration, impact etc.) that cause injury to the body.

The more severe these forces are, the more likely it is that the casualty has suffered serious injury.

Sometimes the MOI alone is sufficient to suggest certain injuries particularly to the head and spine. For example: ● Falls from height ● Any trauma patient with altered level of consciousness ● Penetrating trauma to head, neck and torso

Taking a history This means asking questions of the patient to try and find out what has happened to them and how they come to be in the situation they are in at the moment.

Medical practitioners may take a very detailed history, the first-aid are much less so, but it is a very useful tool for any responder to help them to decide what may be wrong and then what they need to do.

The first thing to remember when you are asking the patient questions is to listen carefully to the answers.

Remember that while you are taking the history or talking to the casualty their condition may change and therefore your priorities may change. You may have to react quickly should they, for instance, become unconscious or should their breathing change.

As a general guide to the sort of questions you might ask, remember SAMPLE

First Aid Responder

Assessment-Secondary Survey

Signs and symptoms A sign is something that we may see for ourselves. A symptom is a feeling described by the patient Signs – from the time that you arrive at the scene you will be looking for signs to tell you what happened.

These may be signs concerning the event or the immediate environment.

When you look at the patient you’d be noting any obvious signs like the appearance, skin colour, movement and the way they are acting. During the secondary survey you will be looking more closely for less obvious signs such as blood on the patient or on their clothing, swelling, deformity or wrongly shaped limbs. You may have to examine the patient closely before you see some of these signs.

Symptoms – a symptom is a feeling as described by the patient. The most common symptom following injury is probably pain. Pain is a useful symptom, but may be misleading. Some minor injuries, like a sprained ankle, may be extremely painful whereas other more serious injury may produce little or no pain. A patient will always tell you about the most painful thing rather than the most serious problem. A simple question to find out about the patient’s pain could be something like “so how are you feeling now, do you have any pain anywhere?” Let them tell you about their pain and listen carefully to what they say. Ask them to ▪ ▪ ▪ ▪ ▪

A dull ache or a sharp cutting pain?

There are all the time or does it come and go?

Does it get worse when they move?

Is there anything else that makes it feel worse?

Does anything make it feel better?

▪ Is it a pain they’ve had before and if so, is it worse this time?

▪ Does the pain get worse if you touch the area (tenderness)

Other symptoms they may describe could include: ▪ ▪ ▪ ▪ ▪ ▪

Feeling hot or cold Feeling dizzy or sick Feeling anxious or frightened Feeling restless Feeling tired Dry mouth

▪ ▪ ▪ ▪ ▪ ▪

Numbness or tingling Short of breath Blurred vision Double vision Loss of hearing Tinnitus (ringing or hissing in the ears)

7

8 Secondary Survey

First Aid Responder

A. Allergies Rather than asking are you allergic to this or that it is probably better to ask “have you ever had an allergic reaction?� then let them tell you about it.

M. Medication Ask them about any prescription medicine they may be taking and also what it is for. You should also ask about any over-the-counter medicine such as paracetamol that they may not think to tell you about.

This might also be a good time to make a diplomatic enquiry about any use of recreational drugs or alcohol.

P. Past medical history This would be the follow-on after they have told you about their prescribed medicines.

L. Last Oral Intake When and what did they last eat? This might be of interest, particularly if they have gastric problems at the moment.

It is also an indicator of the general health and appetite. If they have suffered injury or possibly internal bleeding then they will almost certainly require surgery and an anaesthetic so knowing when they last ate could be important.

E. Event The events leading up to the present illness or injury. In the event of accidental injury then what happened? How did it happen? Why did it happen? In the event of sudden illness when did it start?

Has it got worse? If so how quickly and in what way?

What happened or how it happened in the event of accidental injury can be very important in suggesting what injury may have been suffered. For instance, any fall from more than three metres should automatically suggest a spinal injury even if there is no other evidence to suggest it.

Asking and getting answers to all of these questions assumes that the patient is sufficiently aware or able to answer.

If that is not the case then you may be able to get information from family members or bystanders who may have witnessed what happened. Taking a history is very important and is not easy. It is unlikely that in most cases it will follow the procedure as outlined above. It is usually much more confused and fragmented and it is up to the responder to gather as much information as necessary to be able to offer the optimum care to the patient.

How much history and in what depth usually depends on the level of training of the responder and should be appropriate to the level of care that they may offer.

First Aid Responder

Top to Toe Assessment-

Check their Face and Head Look for blood or watery liquid, or possibly a mixture of both, leaking from the nose or ears.

Look for bruising around the eyes, particularly where there is no damage to the face.

Look for damage inside and around the mouth, which may later lead to airway problems.

Look at the colour of the skin, in particular look for blue or grey appearance of the lips or earlobes (cyanosis) which may indicate low levels of oxygen.

Look for obvious signs of blood or swelling around the head or in their hair.

Check the pupils of the eyes to see if they are of equal size and reacting normally to light.

Check the neck Ask them to keep their head and neck still.

Loosen any tight clothing around the neck.

Look for and remove any ligature.

Look for bruises or abrasions that might suggest strangulation.

Ask them if they have any pain in their neck.

Ask them if they have any strange sensations in their arms and legs.

Check for pins and needles or burning sensations in the extremities.

If the history of the incident suggests spinal injury then you must assume it.

Look at the chest Look for signs of obvious injury such as blood on the clothing.

Ask them to take a deep breath and watch their face for signs of discomfort.

Does the chest move equally on both sides?

Listen for coughing or noisy breathing.

Listen for any unusual sounds.

Look at the collarbones for evidence of bruising, swelling or deformity.

Check the abdomen Ask them if they have any abdominal pain.

Is the pain in any particular area of the abdomen?

Has the pain stayed in one place on moved?

Do they feel sick or have they vomited?

Palpate the abdomen only if you have been trained to do so.

Check their arms Ask them if they have any pain in their arms.

Ask them if they can move their arms normally.

Do they have full movement in their elbows and wrists?

Look for signs of obvious injury such as blood, swelling or deformity.

Ask them if they have any strange sensations, such as pins and needles or burning sensations in the arms and hands.

Check their grip by getting them to squeeze your fingers.

Contrast and compare both sides at the same time.

Check their legs Ask them if they have any pain in the legs.

Ask them if they can move their legs normally.

Contrast and compare one leg with the other.

Do they look the same size and shape?

Are they pointing in the correct direction?

Do they have any odd sensations, such as pins and needles, in the legs and feet?

If possible, feel and look at the skin of the feet.

Is it cold to the touch or grey blue in appearance? This could indicate injury or circulatory problem.

9

10 Vital Signs

First Aid Responder

Vital Signs Check the Pulse A pulse is a wave of high pressure blood in an artery, produced by the contraction of the heart. The pulse rate corresponds to the heart rate.

A pulse can be felt wherever an artery passes close to the surface of the skin. The areas most commonly used are the wrist and the neck.

When checking a pulse it is better to use the pads of the fingers, rather than the tips, as the pads are more sensitive.

Normally you would count the pulse for 30 seconds and multiply the figure by two. If the pulse is very abnormal then you may want to count it for the full minute.

The pulse may be described as: ▪ Strong or weak ▪ Fast or slow ▪ Regular or irregular The normal pulse rate for an adult at rest is said to be 60 to 100 beats per minute although some individuals may normally fall outside this range. The pulse rate, or heart rate may change with such factors as exercise, excitement, fear and illness.

Radial pulse

Carotid pulse

Assessing breathing It can be difficult to assess the patient’s breathing accurately, particularly if they are aware that this is what you are doing. If you say to someone “I want to check your breathing, just breathe normally” then breathing normally is the last thing they will do.

To get around this problem the best way is to measure their breathing when they think you are doing something else. A simple method is to check the pulse in their wrist for 30 seconds and make a mental note of the result. Then, without letting go of the wrist, watch their chest for signs of movement and listen carefully to their breathing for the next 30 seconds. They will assume that you are just checking their pulse for a minute and will be unaware that you are checking their breathing, so they will breathe normally.

When you watch the chest move, look for even movement on both sides and watch their face as they breathe, looking for signs of pain as the chest moves.

Normal breathing should be effortless and almost silent, so listen for noises as they breathe.

These may be coughing, wheezing, bubbling or anything that sounds abnormal.

Count the number of times they breathe in 30 seconds and multiply the result by two. A normal breathing rate for an adult at rest is 12 – 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

After measuring anything it is always a good idea to note the result and also the time that you measured it.

This will help to monitor improvement or deterioration in their condition.

First Aid Responder

Vital Signs 11

Assessing Skin Colour The colour of skin is assessed by visual inspection. It is not an exact assessment if you were unaware of the patient’s original skin colour.

What may be useful is to note any changes in skin colour over the period that you’re observing it.

Skin colour can be described as: ▪ Pale ▪ Flushed ▪ Cyanosed or blue.

▪ Grey tinged

▪ Yellow

Assessing temperature First aiders would not be measuring temperature with a thermometer, but would have to rely on touch.

To measure temperature of the skin it is better to use the backs of the fingers laid lightly on the skin surface.

Skin temperature may be described as: ▪ Warm or cool ▪ Hot or cold ▪ Moist or dry

Assessing blood pressure Blood pressure is the head of pressure within the circulatory system that is produced by the pumping action of the heart. It is a very good method of assessing the effectiveness of the circulatory system in supplying blood and oxygen to the tissues.

A simple method would be to measure what is called capillary refill times..

The capillaries are fine blood vessels found beneath the skin, responsible for giving the skin it’s pink colour.

If you press firmly on the skin it will squeeze the blood out of the capillaries causing the skin to look white.

When you release the pressure quickly the capillaries will take a little time to refill and for the skin to go back to its normal colour. In a person with good circulation and blood pressure this should just be a second or so. If it takes longer than 2 to 3 seconds this would indicate poor circulation and probably lower than normal blood pressure.

An easy place to do this assessment would be the beds of the fingernails.

Squeeze the nail firmly and release quickly. The nail should look white, but should return to pink in less than 2 seconds.

Assess level of consciousness – see page

12 Incident Procedure

First Aid Responder

Incident Procedure Roles and Responsibilities ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Exhibit a calm and professional demeanour Ask questions and listen carefully to the answers Be aware of your own safety as well as that of the casualty and others at the scene Remember the three Ps - Preserve life, Prevent further harm, Promote recovery If more than one patient, decide on priority for treatment Conduct a primary survey and react to your findings appropriately Call 999/112 in a timely manner or ensure someone else does Conduct a secondary survey to assess the patient’s condition Decide on clinical priorities Administer appropriate care within the parameters of your training Offer continuous reassurance Continue to care for and monitor the patient’s condition until the arrival of the emergency medical services

Continuum of patient care Duty as a responder: ▪ All responders have a shared duty of care at the scene.

▪ Each individual responder is accountable for his/her own actions.

▪ The most qualified person at the scene takes the lead.

▪ Treat the patient’s illness/injury within the parameters of your training.

▪ Communicate effectively with others at the scene.

▪ Complete patient care forms accurately.

▪ Carry out accurate and efficient handover to arriving EMS.

Handover to EMS Duty as a responder: ▪ Keep it simple.

▪ Assemble the information that you need to pass on, ideally in chronological order.

▪ Record what you have seen, what you have done,the effects of your actions and the time when things occurred.

▪ Pass on only information that you know to be true and accurate.

▪ Be short and to the point

Clinical practice guidelines All references to clinical practice guidelines or CPGs found throughout this Handbook refer to the 2017 edition CPGs produced by PHECC Ireland. PHECC CPGs describe what is considered to be best practice in the emergency treatment of individuals suffering from injury or acute illness.

Because pre-hospital care may be delivered by a wide range of responders from first aiders to doctors, CPGs lay out what would be best practice in most situations but are not intended to be a substitute for good clinical judgement.

It would be impossible for CPGs to cover every eventuality so treatment should always take into consideration the responders assessment of the patient and the circumstances.

The responder must always work in the best interest of the patient within the scope of practice for his/her clinical level. Consultation with fellow responders and/or practitioners in challenging clinical situations is strongly advised..

First Aid Responder

Emergency Call 13

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 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 chest pain as these may be 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.

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.

In the workplace it is often a good idea to send someone to the gate to meet the ambulance and direct them to the scene of the accident.

The PHECC Red Card The Red card has been developed by PHECC to help responders prepare, prior to calling an ambulance.

The card will prompt appropriate information from An Garda Siochana and Fire Service personnel on scene who require an emergency ambulance to attend.

The red card protocol assists the Emergency Medical Controller to facilitate an appropriate and timely response following a request for an emergency ambulance

Red cards are available free of charge from the PHECC offices or they may be purchased online from the PHECC website.

14 Scene Safety

First Aid Responder

Scene Safety Accidental injury may be the result of dangerous occurrences.

The problems that caused the accident may persist and offer a threat to first aiders and subsequent rescuers.

It is vital that the first aider is aware of this when attending an accident scene.

First aiders should not intentionally place themselves in a dangerous situation.

You cannot help the casualty if you become a casualty yourself.

As you approach the scene look for threats to your own safety. These may be obvious such as moving traffic, fire or unstable structures, or much less obvious such as escaping gas or possibly the electric cable that the casualty is laying on and hiding.

Be alert, use all of your senses and remember that although it may be safe to approach now, things can change quickly, so keep monitoring the situation.

There may also be a human element to contend with. If, for example, the casualty has been a victim of assault, the aggressor may still be in the area.

Bystanders may get in the way or may be tempted to try and help the casualty in inappropriate ways.

Identify yourself as a first aider and if you feel that you are the best qualified person at the scene attempt to take control. Delegate tasks such as controlling traffic or keeping people back from the casualty, to other bystanders. It may be possible to use technically qualified people such as electricians to ensure the area is safe.

If there are multiple casualties, then bystanders might be used to help in first aid duties or just to reassure casualties with minor injuries, although you must bear in mind that the bystanders may have witnessed the events themselves and may also be in need of reassurance.

Take control of the safety of the casualty and if necessary protect them from the inexpert attention of untrained people who are only trying to help but may cause further damage.

In general terms, the seriously injured casualty should only be moved if it is to save their life, at least initially.

First Aid Responder

Infection Control 15

Infection Control Procedures Blood Borne Pathogens Pathogens are micro-organisms that cause disease.

Blood-borne pathogens are viruses or bacteria that are present in human blood and body fluids and which can infect and cause disease in humans. The two most important of these are Human Immunodeficiency Virus (HIV) and the Hepatitis B virus (HBV).

The most common spread is through sexual transmission or IV drug use. However, any contact with infected body fluids or blood could potentially carry the risk of infection.

Personal Protective Equipment Personal protective equipment (PPE) may include clothing and equipment worn by an individual when undertaking activities which could result in exposure to blood-borne pathogens.

PPE always starts with gloves but could include aprons and pocket masks.

Gloves and aprons protect your clothing and hands from coming into contact with blood.

Vinyl or nitrile gloves are preferred to latex as there is a possibility of a serious allergic response to latex Pocket mask refers to any one of several types of devices that may be used whilst performing CPR or rescue breathing.

Safe working practice Treat all blood and body fluids as if they were infectious.

Wear appropriate personal protective equipment.

When delivering rescue breaths, use a pocket mask equipped with a one-way valve.

Contain spills immediately, then clean up and disinfect the area.

Clean up contaminated sharps or broken glass with tongs, forceps or a brush and dust pan.

Handle all waste as if it contain sharps or infectious material.

After removing PPE, wash hands and other affected areas with soap and water.

Place all potentially infectious materials and contaminated items in closed containers or bags, clearly marked as infected waste or biohazard.

If you think you have been exposed Flush the area with water and then wash vigorously with soap and water.

If you have an open wound, squeeze it gently to make it bleed.

Seek emergency medical treatment following an exposure incident.

Seek counselling regarding the risk of HIV or HBV infection and any other follow-up treatment that may be needed.

Disposal of clinical Waste Dispose of all potentially infected sharps into a properly constructed and marked sharps container.

Sharps containers should be disposed of by incineration.

Dispose of other material such as dressings, swabs, gloves etc into appropriately marked bags.

These bags should be disposed of by incineration.

Ambulance crews on scene would be able to assist or advise on the disposal of clinical waste.

16 Care Principles PHECC Care Principles

First Aid Responder

CPGs 2017 Page 14

1. Ensure the safety of yourself, other emergency service personnel, your patients and the public.

▪ ▪ ▪ ▪ ▪ ▪ ▪

Review all pre-arrival information.

Consider all environmental factors and approach only when it is safe to do so.

Identify potential and actual hazards and take the necessary precautions.

Liaise with other emergency services on scene.

Request assistance, if required, in a timely fashion, particularly for higher clinical levels.

Ensure the scene is as safe as is practicable.

Take standard infection control precautions.

2. Call for help early ▪ Ring 999/112 using the RED card process, or: ▪ Obtain practitioner help on scene through predetermined processes.

3. Patients have Capacity: ▪ 4.

▪ ▪ ▪ 5.

▪ ▪ ▪ ▪ ▪

in respect to clinical decisions affecting themselves, unless the contrary is shown (Assisted Decision Making (Capacity) Act 2015) Seek consent before initiating Care Patients have the right to determine what happens to them and their bodies.

For patients presenting as P or U on the AVPU scale, implied consent applies.

Patients may refuse assessment, care and/or transport.

Identify and manage life threatening conditions Locate all patients.

If the number of patients is greater than resources, ensure additional resources are sought.

Assess the patient’s condition appropriately.

Prioritise and manage the most life threatening conditions first.

Provide a situation report to ambulance control centre (112/999) using the RED card process as soon as possible after arrival at the scene.

6. Ensure adequate Airway, Breathing and Circulation ▪ Ensure the airway is open.

▪ Commence CPR if breathing is not present.

▪ If the patient has abnormal work of breathing, ensure 999/112 is called early.

7. Control all external haemorrhage 8. Identify and manage other conditions 9. Place the patient in the appropriate posture according to the presenting condition 10. Ensure the maintenance of normal body temperature (unless a CPG indicates otherwise) 11. Provide reassurance at all times 12. Monitor and record the patient’s vital observations 13. Maintain responsibility for patient care until handover to an appropriate responder/practitioner 14. Complete patient care records following an interaction with the patient 15. Identify the clinical leader on scene

Cardiac First Response 17

First Aid Responder

3. Cardiac First Response

CPGs 2017 Page 25

Recognise Life Threatening Emergency There are said to be four major life threats ▪ Heart attack ▪ Stroke ▪ Foreign body airway obstruction ▪ Sudden Cardiac Arrest

Heart Attack Heart attack occurs when a blockage in one of the arteries that is bringing oxygenated blood to the heart muscle is blocked by the formation of a blood clot.

The blockage may be partial, allowing reduced blood flow, or it may be complete, cutting off all blood flow to the affected muscle. Without blood, and the oxygen that it carries, the affected muscle will begin to die. In serious cases this could lead to a sudden cardiac arrest. The sooner that the patient receives medical care, the better their chance of surviving their heat attack

Cap ruptures Plaque with Blood clot forms fibrous cap

Blocked coronary artery

Death of heart tissue due to blocked coronary artery

Heart attack - Recognition ▪ Central chest pain, often described as squeezing or crushing, or as a feeling of pressure in the chest.

▪ Pain may spread to the neck and one or both arms.

▪ More commonly, the left arm.

▪ Pain may start at any time with no obvious cause.

▪ Pain does not improve with rest.

▪ They may look pale or grey.

▪ There maybe blueness of the lips (cyanosis) ▪ Pulse may be rapid, weak and irregular.

▪ They may be sweating.

▪ They may complain of shortness of breath.

▪ They may feel dizzy or weak.

▪ They may collapse suddenly.

18 Cardiac First Response

First Aid Responder

Heart Attack - treatment The primary aim is to reduce the load on the heart by placing the casualty at rest and then to call urgently for medical attention.

▪ Place the casualty at rest.

▪ Make them as comfortable as possible to ease the strain on the heart.

▪ A half sitting position with the head and shoulders raised and the knees bent and supported would be preferred, but be guided by the casualty.

▪ Support them with folded blankets or pillows.

▪ If the chest pain does not subside after a few minutes rest, assume a heart attack.

▪ Reassure the casualty continuously. Anxiety and fear will increase the heart rate and increase the load on the heart.

▪ Dial 999/112 for an ambulance.

▪ Inform ambulance control that you suspect a heart attack.

▪ If the patient has previous history of chest pain and has angina medication such as tablets of spray, then assist them to take their medication.

▪ If available, give one aspirin tablet, chewed rather than swallowed.

▪ Monitor their level of consciousness and breathing and check the pulse frequently.

▪ Record your findings.

▪ Try to stay calm and matter-of-fact yourself.

▪ Be prepared to offer life support as appropriate.

Aspirin in cardiac chest pain Aspirin has a useful anticoagulant effect and one 300mg tablet given at the time of chest pain can reduce the risk of the blood clot in the coronary artery enlarging and causing further damage.

However, there are some side effects of aspirin and it should not be used in patients below the age of 16 or those who have known allergy to aspirin, history of gastric ulcers, particularly bleeding ulcers, or any other bleeding problem.

Heart attack in women Heart attack is a major killer of women, but the signs and symptoms may be slightly different to those seen in men and there is a danger that they may be missed or misunderstood.

Women may suffer chest pain, like men, but very often it is not such an important or obvious feature.

In particular, look out for: ▪ Indigestion or wind pain ▪ Dizziness, nausea or vomiting ▪ Unexplained weakness or fatigue

▪ Pain between the shoulder blades ▪ Recurring chest discomfort ▪ Anxiety

Cardiac First Response 19

First Aid Responder Stroke

CPGs 2017 Page 33

Stroke is a condition in which the blood supply to part of the brain is interrupted, leading to localised brain injury and the death of brain tissue.

Types of stroke Haemorrhagic (bleeding) stroke

Ischaemic (reduced blood supply) stroke

Internal bleeding

Damaged brain tissue

Bleeding point Blockage in blood vessel

Stroke - Recognition ▪ May be severe headache or sudden loss of consciousness.

▪ General feeling of being unwell.

▪ Paralysis or weakness affecting one side of the body.

Stroke is a medical emergency and responds well to urgent medical treatment, to help diagnose it quickly remember the FAST test

FACE

ARMS

Check their face Can they lift both arms Has the mouth drooped? equally?

SPEECH Is their speech slurred?

Can they understand you?

TIME Time is critical Call 999 now

If they fail any one of the tests call an ambulance immediately.

Prompt medical care can reduce further damage to the brain and help them to recover more completely Stroke - treatment ▪ Call urgently for medical attention ▪ Reassure them continuously ▪ Lay them down with their head slightly raised

▪ Place them in the recovery position if they are or if they become, unconscious ▪ Continue to monitor their condition until the arrival of the ambulance

20 Choking

First Aid Responder

Foreign body airway obstruction 1

Choking ▪ ▪ ▪ ▪ ▪

2

The problem often occurs whilst eating.

They will often stand up and clutch their neck.

They will look anxious or distressed.

Encourage them to cough.

If they are coughing, do not slap them on the back as this may encourage the object to drop further into the airway.

Back Blows ▪ Bend them forward.

▪ Support them on the near shoulder.

▪ Give up to five blows with the heel of the hand between the shoulder blades.

3

Abdominal Thrusts ▪ If back blows are unsuccessful, stand behind the casualty and reach with your arms around the upper abdomen, between the belly button and the point of the breastbone.

▪ Make a first with one hand and place the fist, thumb end first against the soft part of the abdomen just below the point of the breastbone. Grasp your first with the other hand.

▪ Pull sharply backward and upward, bending from the elbows at an angle of about 45° to the horizontal.

▪ Repeat up to five times, checking after each thrust.

▪

If they are, or they become, unconscious: ▪ Lower them carefully to the ground.

▪ Make sure an ambulance is called.

▪ Immediately start CPR with 30 chest compressions.

▪ Continue CPR until they are breathing normally.

▪ After each cycle of CPR check mouth for object and attempt to remove.

Seek medical attention If your efforts to relieve the obstruction have been successful it is still important that the casualty receives medical attention, particularly if they have suffered a serious obstruction and have required abdominal thrusts.

First Aid Responder Treatment - Child

Choking Child / Infant 21 CPGs 2017 Page 44

▪ Follow the general guidelines for obstructed airway in an adult. Moderate the force required for back blows and abdominal thrusts.

▪ If not effective dial 999/112 for an ambulance

Treatment - Infant If the infant is unable to cry or breathe: ▪ Lay them down supported on your thigh, supporting the head with the hand.

▪ Make sure the head is lower than the body.

▪ Give 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.

▪ If back blows are unsuccessful, give five chest thrusts.

▪ Place two fingers on the breastbone about a fingers width above the point where the ribs meet.

▪ Give up to 5 sharp downward thrusts, similar to chest compressions but sharper and at a slower rate.

▪ The aim is to relieve the obstruction, not necessarily to give all five chest thrusts.

▪ 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.

22 Sudden Cardiac Arrest

First Aid Responder

Sudden Cardiac Arrest Sudden cardiac arrest (SCA) is a condition in which the heart suddenly and unexpectedly stops beating.

Although more common in people with a history of heart disease it can affect anyone at any time.

Unless SC A is treated within very few minutes it will usually result in death of the patient.

The heart has an electrical system which controls the rate and rhythm of the heartbeat. Problems with this electrical system can cause irregular heartbeats, called arrythmias.

There are many different types of arrythmia, some can make the heart beat too fast, some too slow and some with an irregular rhythm. Some may cause the heart to stop pumping blood to the body.

These are the arrhythmias that cause sudden cardiac arrest.

A sudden cardiac arrest is not the same as a heart attack. Sudden cardiac arrest involves a disturbance in the electrical system, whereas a heart attack is a problem with blood supply to the heart muscle. Sudden cardiac arrest however, may happen during or after recovery from a heart attack.

People who have had a heart attack are at higher risk for sudden cardiac arrest, although it may affect anyone.

Most people who suffer SCA will die from it, often within minutes. The only treatment that is likely to reverse the condition is defibrillation. A defibrillator is a device that sends an electric shock to the heart to restore its normal rhythm.

Defibrillation The machine used to deliver the shock is a defibrillator and the type of machine most commonly used outside of a specialist hospital unit would be an Automated External Defibrillator or AED. Defibrillators have been in use for many years, but their use in the past has been restricted to individuals with specialist knowledge.

The problem has never been in knowing how to shock but in knowing when to shock and the danger was in giving a shock to someone who didn’t need one. The AED has solved this problem by using a computer to recognise whether or not a casualty needs a shock, and by not charging up or delivering a shock to someone who would not benefit from one.

This means that AEDs can be used safely by non-medical people to save lives in sudden cardiac arrest.

Chain of Survival 23

First Aid Responder

The Chain of Survival The chain of survival demonstrates the steps that are necessary to increase the casualty’s chance of surviving sudden cardiac arrest. Their chances will be greatly improved when all of the links are in place.

Early Access

Early CPR

Early De-fib

Early Advanced Care

Good post arrest care

Early Access - Early recognition and an immediate 999 call are critical. If there is an AED close by, send somebody to fetch it if possible.

Early CPR The emphasis is on immediate and good quality chest compressions. If you are trained, provide 30 chest compressions and two rescue breaths and repeat the cycle until the AED is ready or emergency medical responders arrive and take over. If you are not trained then concentrate on chest compression only*.

Early Defib As soon as an AED (Automated External Defibrillator) becomes available it should be attached to the patient’s chest and you should follow the visual and voice prompts. AEDs are simple and safe to use, even if you have not received specific training. There is no reason to delay defibrillation.

Early ACLS Effective advanced life support will be provided by the emergency medical responders and may include high-quality CPR, defibrillation, oxygen and use of medicines or appropriate devices.

Good Post Arrest Care Comprehensive, multidisciplinary system of care which will include close monitoring, specific medication and an action plan for effective ongoing care.

*Compression Only Resuscitation

CPGs 2017 Page 23 Cardio Pulmonary Resuscitation means combining chest compressions with rescue breathing. If for any reason the rescuer does not feel confident in performing full CPR then they should start compression only resuscitation immediately.

Press in the middle of the chest at least 100 times a minute until the arrival of the ambulance or until a trained person takes over and starts full CPR.

24 Basic Life Support

First Aid Responder

Basic Life Support

CPGs 2017 Page 21

Approach with CARE Make sure that there is no danger to yourself, the casualty or bystanders.

Check RESPONSE AND BREATHING ▪ ▪ ▪ ▪ ▪

Check initially in the position that you find them.

Speak loudly to them.

Use their name or ask them to open their eyes.

If no response, shake them gently by the shoulder.

Whilst checking for response perform a quick check for normal breathing.

▪ It is not uncommon, immediately after a cardiac arrest, for the casualty to be taking what appear to be short irregular gasps for breath. This is AGONAL BREATHING and should not be mistaken for normal breathing.

If they respond: ▪ Leave them in the position that you find them.

▪ Check to find out what might be wrong.

▪ Observe and reassess regularly.

If they do not respond, but they are BREATHING NORMALLY ▪ Examine them carefully for any immediately life-threatening injury such as severe bleeding and treat if possible.

▪ Turn them carefully into the recovery position as soon as it is practical to do so.

If they do not respond, but they are NOT BREATHING NORMALLY ▪ Ensure that an ambulance has been called and that an AED has been sent for.

▪ Deliver 30 chest compressions

Call an AMBULANCE (999 / 112) ▪ If the casualty is not breathing normally, or you are unsure, dial 999/112 for an ambulance immediately.

▪ You could send somebody else to do this should they be available but if you have a mobile phone and can call an ambulance without leaving the casualty then this may be a better idea.

▪ If your telephone has a speaker phone then switch it on.

▪ The emergency medical dispatcher will be able to reassure and support you as they talk you through the procedure for performing CPR ▪ They will also ensure that the nearest available AED is sent to your location as quickly as possible

Basic Life Support 25

First Aid Responder Deliver CHEST COMPRESSIONS

Chest compressions should be performed with the casualty laying flat on their back on a firm surface. It should not be necessary to undress the casualty or expose the chest, unless they are wearing very heavy outer clothing. (Clothing removed in illustrations for clarity)

Kneel by their side, level with the chest. Place the heel of one hand in the centre of the chest on top of the lower half of the breastbone.

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

Interlock your fingers to stop them pressing on the chest wall

Position yourself so that your shoulders are directly above their chest, the arms are straight and the elbows are locked.

▪ Push straight down on their chest to a depth of 5 to 6 cm.

▪ Release the pressure completely between strokes, keeping your hand in contact with the chest.

▪ Movements should be smooth and not jerky.

▪ Erratic or violent movements may injure the patient and will not pump blood efficiently.

▪ Compress the chest at a rate of 100 to 120 compressions per minute.

▪ It is important to maintain the quality, rate and depth of the compressions.

5-6 cms

Deliver 30 chest compressions

Your performance is liable to deteriorate as you get tired, so for this reason it is recommended that if another rescuer is available and can perform chest compressions you should change over every two minutes.

26 Basic Life Support

First Aid Responder

Open the AIRWAY ▪ Undo anything tight around the neck and remove their glasses, if worn.

▪ Place one hand on the forehead and two fingers of the other hand under the bony part of the jaw.

▪ Gently rotate the head backward and lift the jaw.

▪ This lifts the tongue and straightens the airway.

Deliver RESCUE BREATHS Air in the atmosphere contains about 21% oxygen. When we breathe we only use what we need, about 4%, so the air that we breathe out still contains around 17% oxygen.

This is more than enough to maintain life in our patient.

Use the fingers of the hand performing the head tilt to pinch the nose closed. Take a normal breath.

Seal your lips around their mouth and blow steadily until the chest rises.

Each breath should cause the chest to rise as in normal breathing

Release the nose and keeping the airway open let them breathe out. Re-seal your lips and give a second rescue breath.

Give two breaths in total.

▪ Each breath should take about one second to deliver.

▪ Watch the chest as the breath is delivered, to ensure that it rises.

▪ If you experience problems giving an effective breath it is probably because the airway is not clear.

▪ Recheck the mouth and remove any visible obstruction.

▪ Make sure the head is tilted and the jaw is lifted correctly and that you have a good seal around their mouth.

▪ Repeat your attempts to give effective breaths but do not attempt to give more than two breaths before returning to chest compressions.

Cardio Pulmonary Resuscitation (CPR) CPR means combining chest compression with rescue breathing.

▪ Give 30 chest compressions followed by two rescue breaths. Ratio 30:2

Continue until: ▪ The casualty shows obvious signs of recovery, such as opening their eyes or coughing.

Or the AED arrives

Basic Life Support 27

First Aid Responder Chest Compression Only Resuscitation

Research has shown that chest compression only resuscitation may be as effective as ventilation/compression in the first few minutes following a sudden cardiac arrest, if the cardiac arrest was not caused initially by a breathing problem.

If you are unable or unwilling to give rescue breaths, continue with compression only resuscitation.

Give chest compressions to a depth of 5 – 6 cm at a rate of 100 – 120 compressions minute.

Continue chest compressions without a break, stopping to check the casualty only if they show obvious signs of recovery.

Regurgitation During Resuscitation Regurgitation is common during resuscitation attempts.

If it occurs: ▪ Turn them on to their side, facing away from you.

▪ Support their weight on your legs to prevent them from rolling back.

▪ Ensure their head faces down and that their open mouth is the lowest point, to ensure drainage.

▪ Remove debris from the mouth with your fingers.

▪ Place them onto their back and resume CPR as soon as possible.

Resuscitation of Children People are often worried about performing basic life-support techniques on children.

The most important thing is to do something rather than to hesitate, trying to remember different protocols or worrying about doing harm. If in doubt, children should receive the same treatment as adults. The only change is that the chest should be compressed to one third depth.

If you can remember these differences however then the following changes may be beneficial.

Open the airway with head tilt/ chin lift.

Check for normal breathing.

Take no more than 10 seconds

If they are not breathing normally start with 30 chest compressions.

Continue CPR (30:2) Follow chest compressions with 2 rescue breaths

Continue CPR until the arrival of the AED or ambulance crew.

Connect the AED and follow the voice prompts.’

If unable to ventilate, perform compression only CPR

28 Basic Life Support

First Aid Responder

Resuscitation of Infants

Open the airway with head tilt/ chin lift. Be careful not to over extend the neck Check for normal breathing.

Take no more than 10 seconds

If they are not breathing Continue CPR until the arrival of normally start with 30 chest the AED or ambulance crew. compressions. Use two fingers on Connect the AED and follow the the breastbone. voice prompts. rd If unable to ventilate, perform Compress to 1/3 depth of chest After chest compressions give 2 compression only CPR rescue breaths

Access and Use the AED An AED can be used safely by almost anyone, so its use is not restricted to trained rescuers. However, training is preferred to improve performance, leading to a better outcome.

When using an AED keep interruptions to chest compressions to a minimum.

Do not stop to check the casualty or discontinue CPR unless they show obvious signs of recovery, such as opening their eyes, speaking or starting to breathe.

The AED The appearance of individual AEDs may vary from maker to maker but they all have similar layouts and properties. The essence of AED design and use is simplicity, so you should be able to use any AED in exactly the same sequence.

One type of AED may be used for illustration, but the instructions apply equally to all.

Activate the AED ▪ Some AEDs will automatically switch on when you open the lid.

▪ With others you may have to press the ON button.

▪ Attach the leads to the AED if necessary Attach the Pads ▪ Remove the pads from any outer packing.

▪ Look carefully at the instructions on the pads.

▪ Peel off any backing paper and stick the pads onto the casualty’s chest, as shown.

▪ One pad should be placed below the right collarbone, next to the breastbone.

▪ The other pad should be placed below the left armpit, on the side of the chest wall, over the lower rib cage.

▪ It is not important which way round the pads are placed.

First Aid Responder

Basic Life Support 29

Pad placement ▪ The casualty’s chest should be exposed to enable correct pad placement.

▪ If the chest is wet it may prevent the pads from sticking and making a good contact. Towel dry is usually sufficient.

▪ Excessive chest hair may also prevent effective contact.

The area where the pads are to be placed should be quickly shaved if possible. Do not delay defibrillation if a razor is not immediately available.

▪ It is important that the left side pad is placed well back to the side of the rib cage. If it is too close to the front, current travelling from pad to pad will travel across the front of the chest, missing the heart.

▪ With the pad placed well to the side, the current will travel from pad to pad through the heart muscle.

Using the AED Analyse ▪ Keep clear during analysis.

▪ Ensure that nobody touches the casualty whilst the AED is analysing the heart rhythm, as this may lead to inaccurate results.

▪ Do not stop chest compressions for more than 10 seconds during analysis.

▪ Follow voice prompts.

No shock indicated ▪ If the voice prompts direct you to start CPR, start chest compression and rescue breathing immediately.

▪ Maintain CPR for 2 min or until prompted to stop.

▪ Continue to follow voice prompts.

30 Basic Life Support

First Aid Responder

Shock indicated ▪ Ensure that everybody is clear of the casualty.

▪ Press the shock button as directed.

▪ After the shock is delivered, continue CPR for 2 min or until directed to stop.

▪ Allow the AED to analyse.

▪ Continue to follow voice prompts.

AED flowchart AED Analyses rhythm

Shock advised

NO shock advised

Give one shock

Resume CPR For 2 minutes

Resume CPR For 2 minutes Continue until they start to breathe normally

AED Storage ▪ The AED should be stored in a secure and easily accessible location.

▪ Storage should be clean and dry.

▪ If located in a public area, security may be maintained by having the unit enclosed in a cabinet with a breakable seal arrangement.

▪ Cabinets should have a clear door so that the AED is clearly visible.

▪ They should allow easy checking of the units flashing “ready” light.

▪ Many cabinets will also have an alarm that is activated when the unit is removed or the door opened.

▪ This may be audible or visual, for example a flashing strobe light.

▪ The location of the AED should be clearly signed using the accepted international sign.

First Aid Responder

Basic Life Support

AED safety An AED is like any other electrical appliance in that certain safety precautions should be observed to minimise the risk of injury to the operator, assistants or the casualty.

▪ Keep the electrodes (pads) separate: do not allow them to touch when the machine is switched on. This could complete the circuit and could be dangerous.

▪ Never connect the pads to anyone except a casualty in suspected cardiac arrest: A live AED should never be connected to anyone for demonstration or training purposes.

▪ Be aware of patches on the skin: some medications, particularly GTN, may be administered via skin patches. Avoid placing electrodes directly over the patch.

▪ Be aware of implants: devices such as pacemakers or cardioverters may be implanted under the skin. Their presence is often marked by a scar or bump. They are most commonly found high on the left side of the chest and so are not often a problem for pad placement Try to keep pads 10 cm away if possible.

▪ Be aware of inflammable environments: because of the risk of sparks, the casualty may have to be removed from an area containing flammable vapours before a shock is given.

▪ Risk of shock to others: if the pads are making good contact then there is very little risk of shock to others, even in a wet or conductive environment, as long as they are not in direct contact with the casualty. Current will travel from one pad to the other and not into the surrounding area.

AEDs 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.

There may be a potential problem with some AEDs as they are calibrated to recognise adult abnormalities and deliver a shock which is appropriate for an adult. The strength of this shock through a child’s heart may be sufficient to cause damage to the heart muscle, to the point of making resuscitation impossible. Therefore, if you are in a situation where there is a likelihood of having to treat a child, it would be a good idea to have a set of child pads stored with the AED. These pads and leads are designed to reduce the power of the shock delivered to the child and to limit any possible damage to the heart.

In most cases the pads are designed to be placed in the same position as adult pads but if the child is very small and there is insufficient room on the chest wall then the pads can be placed centrally on the chest and upper back,directly opposite one another.

Children over the age of 8 years can be treated with adult pads and protocol whilst children between 1 and 8 years should be treated with paediatric pads if available.

If no paediatric pads are available use adult pads front and back.

Although there may be some risk it is better than doing nothing.

31

32 Medical Emergencies - Asthma

4.

First Aid Responder

Common Medical Emergencies

Asthma

CPGs 2017 Page 20

Asthma is a condition which affects the lungs.

In an acute asthma attack, the tiny air pipes which carry air to the air sacs become narrowed due to inflammation and muscle spasm of the wall of the pipe.

Normal Bronchiole This leads to difficulties in passing air through them, causing a feeling of tightness in the chest and difficulty in breathing. As the air is forced through the narrow pipes it causes a wheezing sound.

Most asthma sufferers will have been diagnosed by their doctors and will be receiving treatment in the form of drugs which suppress the condition (avoidance) and drugs which relax the spasm of the air pipes (treatment) These drugs are usually given in the form of an inhaler or puffer which squirts a mist of drug into the mouth. It is then inhaled into the lungs and passes into the bloodstream.

If a patient is having an acute attack they require a drug which will relax Asthmatic Bronchiole their spasm. This will be in a blue inhaler.

Acute asthma attack - recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪

Possible known history of the condition.

Difficulty in breathing.

Coughing.

Noisy wheezing breathing.

Difficulty in walking or talking.

Cyanosis (blue lips/complexion) Anxiety and distress.

Acute asthma attack - treatment Treat ALL asthma attacks as an emergency, until proven otherwise ▪ Dial 999 / 112 for an ambulance ▪ Place them at rest in a sitting position.

▪ Leaning forward onto a table or chair back can be helpful.

▪ Reassure them.

▪ Encourage them to breathe slowly and deeply.

▪ Encourage them to use their blue reliever inhaler as appropriate.

▪ Maintain care until the arrival of the ambulance

First Aid Responder

Medical Emergencies - Diabetes 33

Diabetes

CPGs 2017 Page 29

This is a condition where the sufferer has a problem in burning up sugar due to the lack of the hormone insulin. This may lead to an imbalance in the sugar levels in the blood. Diabetes can start very slowly and may go unnoticed for a long time. Because of the slow onset it is seldom a problem for first aiders. As the condition progresses, the sufferer will seek medical advice from their doctor.

Blood sugar level that is too low, (hypoglycaemia) is often caused when a diabetic injects insulin and then fails to take enough sugar to counteract the effect. As this condition is the most immediately dangerous it is the aspect that first aiders should be most familiar with.

Diabetes - recognition ▪ Weight loss with a good appetite.

▪ Thirst ▪ Passing large amounts of urine, frequently.

▪ ▪ ▪ ▪

Tired and listless.

Flushed dry skin* Strong smell of acetone on the breath* Dropping level of consciousness*

Diabetes - treatment ▪ No real first aid is required, advise them to see their doctor.

▪ In later stages, or if unconscious, treat as a medical emergency and call an ambulance.

Hypoglycaemia - recognition ▪ History of diabetes ▪ Receiving insulin or other hypoglycaemic drugs ▪ May suddenly become confused, disorientated or aggressive

▪ ▪ ▪ ▪

Pale or grey appearance Profuse sweating Rapid and strong pulse Diminishing level of consciousness

Hypoglycaemia - treatment If conscious: ▪ Give sugar in the form of several teaspoons in a glass of water, sugary sweets, non-diet sweet drinks or whatever is to hand as quickly as possible.

▪ If recovery is not swift, repeat.

▪ Refer to medical help if no rapid response.

If unconscious: ▪ Place in the recovery position ▪ Refer to medical help urgently, with history if available.

34 Medical Emergencies - Seizure

First Aid Responder

Seizure A seizure is 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.

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 the lips or tongue may be bitten and there may be flecks of foam or blood on the lips.

Do ▪ Protect them from injury (remove or cushion dangerous objects) ▪ Cushion or protect the head ▪ Time the seizure, if it lasts for more than five minutes call an ambulance.

Don’t

▪ When the movement stops, protect their airway with the recovery position.

▪ Stay with them until they are fully recovered ▪ Remain calm and reassuring

▪ Attempt to restrain them or stop them from moving.

▪ Try to move them unless they are in danger ▪ Put anything in their mouth

▪ Attempt to wake them up or bring them round ▪ Give them anything to eat or drink until they are fully recovered.

Call an ambulance if: ▪ ▪ ▪ ▪

You know it is their first seizure The seizure lasts for more than five minutes They are injured during the seizure You believe they need urgent medical attention

▪ They have repeated seizures ▪ You know they have diabetes or they are pregnant

Be suspicious of cardiac arrest in any patient presenting with seizure and carefully assess their breathing following the seizure. Be prepared to offer life support as appropriate Seizures in water

If someone starts to have a seizure while in water, including a bath

Do ▪ Support them in the water with the head tilted so that their face and head stay above the surface ▪ Remove them from the water as soon as the movements of the seizure have stopped

▪ Carefully check their breathing and go onto CPR if they are not breathing normally ▪ If they are breathing normally, place and carefully into the recovery position

Don’t ▪ Attempt to restrain them other than to protect the airway.

▪ Do not put anything in their mouth ▪

Always call an ambulance following immersion. They may have inhaled water which can have serious long-term effects.

Poisons 35

First Aid Responder Poisoning and Overdose

CPGs 2017 Page 31

A poison is defined as any substance that irritates, damages or impairs the function of the body’s tissues.

Casualties tend to be exposed to poison in one of four ways: ▪ Ingestion or swallowing.

▪ Inhalation of gases or vapours.

▪ Injection, either accidental or intentional.

General treatment for poisoning Although there are specific treatments for particular types of poisoning, it is probably true to say that the general procedure for dealing with poisoning cases follows the same steps.

▪ Remove the source.

▪ Treat the effect.

▪ Get medical help.

▪ Assemble and pass on as much history/evidence as possible.

Absorbed poison This type of poisoning most often occurs accidentally as a result of chemical spillage etc. It is rare in the work environment due to the use of appropriate personal protective equipment.

▪ The contaminated area should be flooded with water to dilute and remove as much chemical as possible.

▪ Give life support as required (being aware of your own safety) and get the casualty to medical help with as much information as possible.

Injected poison Poisons may be injected both accidentally or intentionally. The most common type of intentional injection of poison would be intravenous drug abuse. This is rare in the work environment.

Overdose of opiate drugs such as heroin tends to occur when higher quality heroin becomes available. The major side-effect of opiate overdose is respiratory depression and possibly respiratory arrest. The patient would require basic life support, particularly rescue breathing. Be aware of the risk of blood-borne disease which would be higher in someone injecting drugs. It would be advisable to use a pocket mask or other protective device. There is also a potential risk from the patient’s companions who may not want you to interfere with their activities.

Accidental injection could include standing on a spike or nail, which could cause infection. All puncture wounds require medical attention, and the casualty may need antibiotics and possibly tetanus protection.

36 Poisons

First Aid Responder

Inhaled poison Once again poison, in the form of gases or vapours, may be inhaled accidentally or intentionally .

Intentional inhalation generally refers to glue sniffing or solvent abuse. Solvents are widely available from a variety of sources and are generally easily obtainable. This makes them very popular with young people who may not have access to other products such as alcohol.

The vapours are often concentrated by putting the product into a plastic bag and sealing the bag around the nose and mouth to increase the effect. The effect is dependent upon various factors such as the actual product or the dose taken, but can range from inebriation or hallucinations to unconsciousness and subsequent aspiration of vomit or sudden death, .

Inhaled drugs enter the bloodstream very quickly so the effect is often rapid. In some people this could include sudden cardiac arrest, even at their first and only attempt.

First aid treatment would depend upon the condition of the casualty and may include basic life support and CPR. In the unconscious casualty vomiting is common so careful protection the airway and placement into the recovery position is very important.

Be aware that the behaviour of the casualty and thei companions could be unpredictable and possibly violent.

Accidentally inhaled poisons may result from fire or industrial processes. There is a particular risk to rescuers from poisonous gas that may not be immediately obvious. Many dangerous fumes are colourless, odourless and tasteless and their presence may not be noticed until it is too late.

The treatment for almost all inhalation poisoning is to remove the casualty to fresh air, if it is safe to do so and to summon help urgently as the casualty will almost certainly benefit from being given oxygen.

In some work situations where there is a known risk, selected persons may be trained to act as rescuers and in the use of breathing apparatus, whilst others may be trained to administer oxygen.

If this is the case, these personnel should be summoned urgently.

If trained rescuers are not available then rescue should be left to properly equipped members of the Emergency Services.

After rescue the casualty will require primary survey airway protection and possibly basic life support, particularly rescue breathing, as soon as possible.

First Aid Responder

Poisons 37

Ingested poison Swallowed poisons probably account for more cases of poisoning than all others combined. They may be accidental or intentional. It may result from swallowing a toxic substance or from swallowing a larger than normal amount of a normally non-poisonous material such as alcohol or some types of medicine.

Swallowed poisons occur in two forms, corrosive and systemic. The treatment will vary in each case.

Corrosive poison The mode of action is to burn the tissues and the main danger results from chemical burns to the mouth and throat that may lead to swelling and obstruction of the airway. Treatment should be to limit the damage by washing out the mouth and encouraging the casualty to take continuous sips of a bland liquid.

Under no circumstances should you attempt to induce vomiting as this may lead to further burning.

Offer life support as appropriate, remembering to use personal protective measures as required.

Get the casualty to medical help urgently and pass on as much history as possible

Systemic poison These have an effect on the body’s systems and include such things as alcohol and some medicines.

They are often taken intentionally and the effect is dose related. They have to be digested and so there is often a time delay between ingestion and effect. Because of this the quicker they can get effective treatment the better the likely outcome.

The best treatment for overdose or accidental poisoning by mouth is the general treatment for poisoning.

Support and maintain ABC. Monitor their level of consciousness using the AVPU scale.

If they become unconscious, maintain their airway and place them into the recovery position.

If this is an intentional overdose or suicide attempt then their behaviour may be irrational and emotional.

If alcohol is involved, then their behaviour and the behaviour of their companions may be unpredictable and potentially violent.

Get to medical help with as much information as possible.

Dial 999/112 for an ambulance.

Try to get as much information as possible about the substance taken, the amount taken and the time it was taken. In overdose the information given by the patient is generally unreliable. Try to get information from witnesses and look for evidence at the scene.

This would include tablet containers or bottles.

38 Medical Emergencies - Faint

First Aid Responder

Fainting

CPGs 2017 Page 28 Fainting is characterised by a brief loss of consciousness caused by a temporary reduction in blood supply to the brain, often associated with a drop in blood pressure.

Although a simple faint is common and not usually dangerous, it may indicate other more dangerous conditions, such as heart disease.

Fainting – causes Most fainting events are caused by temporary malfunction of part of the nervous system. This may result from an external trigger such as: ▪ Exposure to an unpleasant sight or experience.

▪ Standing still for long periods.

▪ Spending time in hot or stuffy environments.

▪ Sudden emotional upset.

▪ Fear, anxiety or pain.

Other factors that could lead to a drop in blood pressure could include: ▪ Dehydration.

▪ Untreated diabetes.

▪ Some medication.

▪ Sudden change of position, as in standing up quickly.

Fainting –recognition Some people will not experience any warning symptoms before they suddenly lose consciousness.

Others may only have a few seconds warning just before fainting, but most people will experience some of the following: ▪ Yawning.

▪ Feeling lightheaded.

▪ Sudden clammy sweat.

▪ Visual disturbances.

▪ Nausea.

▪ Ringing in the ears.

▪ Fast, deep breathing.

▪ Unsteadiness and loss of strength.

Fainting –treatment The aim of treatment is to restore blood flow to the brain and the best way to do this is to lay the patient flat and elevate their legs, higher than their heart. This uses gravity to drain blood from the legs and send more to the brain.

If you sit the casualty down with their head between their knees there is a real risk that they may suddenly become unconscious and topple forwards, landing on their head. Laying down is much safer. The casualty should regain consciousness within a minute or two.

Afterwards they may feel confused, disorientated or tired for a short while. They may not have any memory of what happened immediately prior to the faint. Assuming they are not injured they can probably resume normal activity after a period of rest.

Anyone who does not wake up within 2 to 3 minutes is a medical emergency. Place them in the recovery position and call 999/112 for an ambulance.

First Aid Responder

Medical Emergencies - Anaphylaxis 39

Anaphylaxis

CPGs 2017 Page 45

Anaphylaxis is an extreme and severe allergic reaction that may develop very rapidly following exposure to the substance to which the sufferer is sensitive. This may include nuts, fish and shellfish, dairy products and eggs. Non-food causes may include insect stings, antibiotics and latex.

Anaphylaxis - recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Swelling/puffiness of the face.

General flushing the skin.

Swelling of the mouth and tongue.

Difficulty in swallowing or talking.

Alteration of the heart rate.

Widespread blotchy skin rash.

Severe asthma.

Feeling of weakness.

Indications of shock.

Abdominal pain.

Nausea and vomiting.

Anaphylaxis - treatment ▪ Call 999/112 for an ambulance.

▪ Pass on any information you may have on the casualty’s medical history or condition.

▪ If they are carrying an auto injector of adrenaline (Epi-pen or Jext injector) and are able to use it, then encourage them to do so.

▪ If you have been trained and specifically authorised to use the auto injector, then use it to inject the casualty

▪ If they have problems with breathing then place them in a half sitting position.

▪ If they show signs of shock, then lay them down.

▪ Closely monitor their condition until the arrival of Emergency Medical Services.

▪ Be prepared to offer life support.

EpiPen Injector

40 Shock

First Aid Responder

Shock Shock occurs when the circulation is unable to supply sufficient oxygen to the tissues. It is often associated with a sudden drop in blood pressure.

Causes of shock Fluid or blood loss This will reduce the volume of the blood left in the circulation. As the volume drops the pressure within the system will drop, adding to the problem. There is now less blood at lower pressure and so the circulation begins to fail.

The medical name for this type of shock is hypovolaemic shock.

In the early stages, the body will try to compensate for the low blood pressure and lack of circulation.

It can do this by speeding up the pump (raising the heart rate) and by tightening or constricting the small blood vessels to raise the pressure within them.

This is called the compensatory mechanism. In cases of minor shock it may be enough to maintain blood pressure but in many cases it is only of short-term benefit. The most important treatment would be to stop any further blood / fluid loss and if necessary replace some or all of the fluid that has been lost, possibly by blood transfusion.

Heart failure If the pumping effect of the heart is reduced, possibly due to damage caused by heart attack, then the pressure within the system (BP) is likely to drop. The effect of this will be reduced circulation and shock.

Nervous shock This results from stimulation of some parts of the nervous system. It could be associated with mechanical damage to nerves as might occur with a fractured spine and damage to the spinal cord, or it may be stimulation caused by pain, fear, or a sudden unexpected, usually bad, occurrence.

This type of shock, that begins in the nervous system, is called neurogenic shock.

Recognition of shock

May be confused or disorientated Skin feels cold and clammy Feels cold and shivery Nausea May vomit

Pale appearance May be bluish tinge to lips Dry mouth, thirst Rapid shallow breathing

Rapid weak pulse

Treatment of shock ▪ Treat the cause where possible ▪ Reassure them ▪ Lay them down and elevate their legs, if their injuries permit ▪ Keep them warm ▪ Do not use external heat sources such as hot water bottles

▪ Give nothing by mouth ▪ Moisten their lips if they complain of thirst ▪ Discourage smoking ▪ Do not give alcohol ▪ Get urgent medical attention

Bleeding and Blood Loss 41

First Aid Responder

Bleeding

CPGs 2017 Page 35

Personal protection

Before dealing with a bleeding injury it is advised that the first aider takes basic precautions against blood-borne viruses such as HIV and hepatitis.

This should include wearing gloves from the first aid kit.

Wounds A wound may be defined as an abnormal break in the tissues which allows the escape of blood and the entry of germs.

Some types of wounds are described below.

Incision This is a clean cut type of injury usually made by a sharp edged object such as a knife blade or broken glass. This type of wound has a tendency to bleed profusely due to the fact that the blood vessels have been sliced cleanly, leaving an open end for the blood to escape. Infection is not common as the blood flow keeps the wound clean.

Laceration A laceration is a ripping or tearing injury, producing a jagged edged wound.

Blood loss tends not to be so severe due to the stretching and then contraction of the severed blood vessels, but infection is often a problem.

Puncture This is, as the name suggests, a stabbing or penetrating type of injury.

Puncture wounds may seem the least dramatic, producing very little obvious bleeding and a very small surface wound, but they must always be treated seriously as it is impossible for the first aider to estimate the extent and severity of the internal damage.

Contusion A contusion is a bruising type of injury, often the result of a blow with a blunt instrument. The contusion may be closed (bruising) or may be open, if the tissues have split open at the point of contact.

Abrasion Abrasions, often called grazes, are injuries that affect the surface of the skin.

Control of bleeding Remember P.E.E.P. to control bleeding

P Position

Sit or lay the casualty down (if their injuries permit)

E

Expose

Remove or cut clothing to gain proper access to the injury

E

Elevate

If the wound is on a limb and other injuries permit, elevate the wound above the level of the heart.

P

Pressure hand or a wound dressing

Apply direct pressure to the bleeding point using your

42 Bleeding and Blood Loss

First Aid Responder

Application of a wound dressing

Apply without touching the face of the dressing, to keep it clean.

Use the long end of the bandage to hold the dressing in place.

Take care to cover all four edges of the dressing

Retain the short end of the bandage.

Tie off by tying the two ends of the bandage together.

Wound dressing ▪ If blood soaks through the dressing, apply another one on top of the first.

▪ After applying the dressing and bandage, make sure it is not too tight by checking the circulation below the bandage site.

▪ Remember that injuries swell, so you may have to go back and check again from time to time.

▪ Tell the casualty to look out for signs of swelling or puffiness below the site, as well as for numbness or pins and needles.

▪ If you can feel a pulse below the injury it means that the blood supply is adequate.

▪ Check the blood supply to the extremities by checking capillary refill.

▪ Squeeze the fingernail firmly between finger and thumb.

▪ This will squeeze all of the blood out and the nail will go white.

▪ When you release the nail, the capillaries should refill in 1 to 2 seconds and the nail should go back to looking pink. If it stays white for more than three seconds, it means that the capillaries are refilling too slowly and the blood supply is reduced.

▪ You will need to loosen the bandage without disturbing the dressing.

Internal bleeding Internal bleeding occurs when blood is lost from the blood vessels, but retained within the body, usually within one of the body cavities such as the skull, thorax, abdomen or large muscles.

Internal bleeding may remain concealed or may subsequently become revealed by visible blood issuing from one of the body openings such as the mouth, nose or rectum.

Internal Bleeding - recognition ▪ History, may include a history of violent injury or medical conditions, such as ulcers.

▪ Signs and symptoms of blood loss shock, with no obvious external bleeding.

▪ Pain and tenderness over the affected area.

▪ Bruising or discolouration over the affected area.

▪ The appearance of blood at one of the body openings.

Assessment-Primary Survey 43

First Aid Responder Revealed Internal Bleeding – Appearance Blood appearing from:

Appearance and possible cause

Ears

Fresh blood or blood mixed with clear fluid.

Would suggest bleeding from inside the head.

Nose

Fresh blood would indicate a nosebleed but if the history suggests a head injury then bleeding inside the head.

Coughed up

Frothy, bright red blood. Injury to the lung.

Vomited

Brown, grainy has the appearance of coffee grounds. Bleeding into the stomach.

Anus

May be bright red from piles, may be mixed with mucus from inflamed or bleeding colon.

Black and sticky tar -like bleeding from higher up in the digestive system.

Urine

Urine may appear dark or smoky. Blood may be visible.

Kidney stones, damage to the bladder following fractured pelvis.

Beneath the skin

Bruising, may not be immediately apparent.

Bleeding into muscles from fractures or contusions

Internal Bleeding - treatment Assess the situation and deal with any immediate danger.

Assess their level of consciousness and treat appropriately.

Lay them down with their limbs elevated, if their injuries permit.

Reassure them and keep them calm.

Keep them warm and loosen any tight clothing.

Continue to monitor their pulse, respirations and level of consciousness.

▪ Give nothing by mouth, they may need emergency surgery and a general anaesthetic.

▪ ▪ ▪ ▪ ▪ ▪

44 Specific Injury

First Aid Responder

Minor wounds ▪ Wash carefully with clean water.

▪ Dry thoroughly.

▪ Apply a clean dry dressing.

Other types of minor injury, such as grazes, can be treated in the same way. If clean water isn’t available for cleansing then it may be possible to use non-alcohol-based cleansing wipes from the first aid kit.

Advise them to observe the injury in case it shows signs of becoming infected, i.e. swelling, pain, redness or discharge.

If it does they will need to seek medical advice.

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.

Sometimes recurrent nosebleeds may be associated with high blood pressure or arterial disease, or even allergies and infections.

Repeated nosebleeds with no apparent cause should be investigated.

Nosebleed - treatment ▪ Sit them down with the head leaning well forward.

▪ Encourage or help them to pinch the soft part of the nose, just below the bony part, for at least 10 to 15 min, to allow for blood clot formation.

▪ If this is not successful then refer them to medical attention, maintaining pressure on the nose.

▪ If successful, as in most cases, tell them not to sniff hard, blow the nose or do anything which may disturb the blood clot, for at least six hours.

First Aid Responder

Specific Injury 45

Amputation ▪ Traumatic amputation is the loss of a body part, usually a finger, toe, arm or leg that occurs as a result of an accident.

▪ Modern surgical techniques mean that in some places and in some cases, the lost part may be reattached.

▪ It is important therefore to retain any amputated part, keeping it as clean and dry as possible.

▪ It should be placed initially in a polythene bag or wrapped in plastic or clingfilm.

▪ This package should then be wrapped in soft material such as tissue or gauze, to protect it.

▪ This may then be placed inside an ice pack, avoiding direct contact with the ice, and sent to hospital with the casualty.

▪ Control bleeding with direct pressure and elevation.

▪ Apply a dressing and firm bandage.

▪ Anticipate and treat shock.

▪ Transfer them to a hospital.

Crush injury Crush injuries are particularly dangerous if the victim suffers crushing to a large muscle mass, such as the thigh. The effect will be to cause severe tissue damage and possibly fractures at the site of injury. There may also be reduced or absent circulation below the crush site.

Prolonged entrapment Prolonged crushing would cause extensive soft tissue damage which may not be immediately obvious due to the pressure. Once the pressure is released the fluid loss may be sudden and dramatic leading to fluid loss shock. More seriously, toxic waste will build up in the damaged tissue and if this is released suddenly into the circulation these may cause kidney failure. This process is called crush injury syndrome and it is potentially fatal.

Crush Injury - treatment If you can release them immediately, then do so.

Control bleeding and treat shock.

Get urgent medical attention.

If they have been trapped for longer than 15 min, then do not attempt to release them.

▪ Send urgently for medical assistance.

▪ ▪ ▪ ▪

Abdominal Injury A penetrating injury to the abdomen may cause a wound in the abdominal wall which opens directly into the abdominal cavity.

This may lead to internal bleeding, contamination of the abdominal cavity or the escape of abdominal contents through the wound on to the surface of the abdomen.

Abdominal Injury - treatment ▪ ▪ ▪ ▪ ▪ ▪ ▪

Position them so the wound does not gape.

This may be half sitting with the knees raised.

Carefully inspect the wound.

If the abdominal contents have not escaped, apply a wound pad and firm bandage.

If the abdominal contents have escaped, do not handle them or attempt to replace them.

Cover them lightly with clean, soft and non-fluffy material.

Get urgent medical attention

46 Specific Injury

First Aid Responder

Graze Graze is an abrasion injury usually caused by a sliding fall onto a rough surface or possibly by using hand tools such as files or electric grinders.

They are not usually serious although in some cases they may be quite large and also extremely painful. The main problem is that they tend to be contaminated with dirt and so infection could become a problem later.

Graze - treatment ▪ The graze should be washed thoroughly, ideally under a running tap, to remove dirt and contamination.

▪ This can be a painful procedure and it is often better to allow patients to do it for themselves, if that is appropriate.

▪ Cleaning does need to be thorough to avoid subsequent problems such as infection.

▪ Once clean the wound can be covered with a light, preferably non-stick, dressing.

▪ Advise the patient to observe for a few days for signs of infection such as redness, swelling or pain.

▪ Ensure that all such minor injuries are properly recorded.

Bruise Bruises are caused by bleeding into or below the skin.

They may be caused by minor bleeding at the site of impact or may indicate more serious internal injury so it is important to look at how the injury occurred and to be alert for more serious internal bleeding.

Sometimes, bruising from deeper injuries may not become visible for hours following the injury. If you suspect the possibility of internal injury then you should seek medical advice urgently.

Bruise - treatment ▪ For superficial bruises the treatment would be to elevate the injury, if appropriate, and apply an ice pack.

▪ This will help to reduce blood flow to the injury and result in reduced swelling and bruising.

▪ Because bruises could be a sign of more serious injury you should examine the patient carefully and take a careful history to satisfy yourself that internal bleeding or serious internal injury is unlikely to be the cause.

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.

First Aid Responder

Specific Injury 47

Embedded Foreign Body An embedded foreign body is any object in or on a wound that cannot be simply flicked or wiped off.

Do not attempt to remove an embedded foreign body, as this may cause increased damage to the casualty. The object may also be acting as a plug for the wound and helping to control blood loss.

If necessary pressure can be applied around or to either side of the foreign body with your hands or with dressings. The general principle is to apply the dressing around the foreign body rather than on top of it.

Casualties with large foreign bodies should be left in the position that you find them and medical help should be summoned urgently.

If the object is small it should be well padded and supported before the casualty is moved. It may be necessary to reduce the size of the object before the casualty can be moved safely and this is a job best performed by the emergency services.

Scalp Wound Scalp wounds are a relatively common injury, as the skin and underlying tissues are easily compressed against the skull lying just underneath, causing them to burst open. Because of the very rich blood supply to this area of the body, blood loss from the scalp wound may be greater than Any injury to the scalp or head carries with it a risk of underlying skull fracture, internal bleeding, a change in the level of consciousness and also injury to the neck, if violence has been a factor.

It is common for this type of injury to affect people who have fallen or possibly been fighting and it is often seen along with inebriation from alcohol or other drugs, which may mask some head injury symptoms.

All such injuries need to be treated with great care.

If, at any time, the casualty exhibits a change in level of consciousness or becomes unconscious. then you must apply the treatment for an unconscious casualty. Check their ABC and if they are breathing normally place them carefully into the recovery position before dialling 999/112 for an ambulance.

Scalp Wound - treatment A bleeding scalp wound will respond to direct pressure over the wound to control bleeding. However, care must be taken because of the risk of underlying injury.

If too much direct pressure is applied onto the injury and there is an underlying fracture as in the illustration, it is easy to see how the fracture could be pushed inwards, potentially increasing the likelihood of damage to the brain underneath.

In most cases it is better to spread the pressure by using the flat of the hand over a large dressing and then to hold the dressing in place with a bandage.

The casualty’s level of consciousness and response should be monitored continuously and should it change then you will have to apply the appropriate treatment for a head injury.

Remember, in the unconscious casualty, maintenance and protection of the airway takes priority.

48 Chest Injury

First Aid Responder

Chest Injury The inside wall of the chest and the surface of the lung are lined with a double skinned membrane called the pleura. If the chest wall is punctured the suction effect caused in normal breathing may draw air in through the puncture wound and into the space between the layers of the pleura– a pneumothorax.

Air trapped in this space will prevent the lung from expanding, or cause the lung to collapse on the affected side. If the puncture wound is large enough the suction effect at the nose and mouth will also decrease, leading to less air entering the good lung.

Chest Injury- recognition ▪ History of injury to the chest.

▪ Blood on the clothing or skin.

▪ The injury may be on the front or the back of the chest.

▪ Sucking sound on breathing in (air being drawn in through the wound) ▪ Bubbling sound on breathing out (air being expelled from the wound) ▪ Shortness of breath/difficulty breathing.

▪ Pale skin, possibly cyanosed.

▪ May be coughing up frothy blood.

Decreased air entry

Chest Injury- treatment ▪ Dial 999/112 for an ambulance.

▪ Place them in a sitting or half sitting position, leaning toward the injured side. This allows drainage away from the good lung ▪ Leave the wound open to the atmosphere to allow free movement of air in and out of the chest cavity.

▪ This is to prevent a buildup of air pressure in the space around the affected lung, leading to a tension pneumothorax.

▪ A light dressing held in place will help to control any bleeding if necessary.

▪ Be alert for the dressing sticking to the wound and becoming a plug for the hole, preventing the free movement of air.

▪ If you suspect this may be happening, remove the dressing immediately.

Pleura Pneumothorax Air is drawn in

First Aid Responder

Musculoskeletal Injury 49

Musculoskeletal Injury The Skeleton The musculoskeletal system consists of individual bones, supported and joined by ligaments, tendons muscles and cartilage.

The skeleton has six functions: Shape and support – the skeleton forms a framework that supports us.

Mobility – muscles pulling on bones around joints move us around.

Protection – the bones in the centre contain and protect the internal organs.

Storage – the bones act as a storage depot for mineral salts, particularly calcium.

Attachment – the bones form attachment points for muscles, tendons and ligaments.

Blood cell production – the bone marrow within the larger bones is where we manufacture new blood cells.

Bones Bones are living tissue with a blood supply and a nerve supply. They consist mainly of mineral salts such as calcium which gives them strength and rigidity. Should bones be damaged, they are able to generate new tissue and to repair themselves.

Fractures The word fracture simply means broken. This could mean a hairline crack or the bone could be in pieces.

Fractures may be due to direct force or indirect force. With direct force the bone breaks at the point of impact, with indirect force the force of impact is transmitted along the bone, causing a fracture some distance away.

Fractures may be classified in one of four groups: ▪ Closed fracture ▪ Open fracture ▪ Complicated fracture

Closed fracture ▪ Occurs when the bone is broken but is not severely displaced and has not penetrated the skin or other organs.

50 Musculoskeletal Injury

First Aid Responder

Open fracture ▪ Occurs when the broken bone penetrates the skin, causing a wound that may cause severe blood loss.

▪ Infection is also often a problem.

▪ Once bleeding is controlled, the wound should be covered to keep it as clean as possible.

▪ The immobilisation of the fracture is less important and can probably wait until the arrival of the ambulance or other trained help, along with more advanced immobilisation equipment.

Complicated fracture ▪ A complicated fracture may be either one of the previous two.

▪ In this injury, a broken bone has damaged or has allowed damage to occur to, other organs.

▪ A classic example would be a fracture of the spine which is complicated by damage to the spinal cord, or a pelvic fracture which has damaged the bladder.

Greenstick fracture ▪ Because children’s bones are softer and more pliable than adults, they tend to bend rather than break.

▪ Sometimes a part of the bone breaks.

▪ This incomplete fracture is known as a green stick fracture because it breaks like a green branch or twig.

Fracture - recognition ▪ ▪ ▪ ▪

Swelling Bruising (later) Deformity Shortening of the limb

▪ ▪ ▪ ▪

Signs of shock Sound of bone breaking Feeling of bone breaking Pain and tenderness at the fracture site

Fracture - treatment ▪ Deal with any more urgent problems first ▪ Do not move the casualty, unless absolutely necessary

▪ Immobilise the fracture prior to any movement ▪ Be prepared to treat shock ▪ Get medical attention

Musculoskeletal Injury 51

First Aid Responder Fractured skull

The skull is a bony box that contains and protects the brain. It is a strong rigid structure and it usually requires significant force to break it.

Given this amount of force applied to the head, there may well be other injury, particularly to the brain, or possibly to the neck.

Fractures to the vault or roof of the skull are most often caused by direct force or violence, such as a blow to the head or striking the head against a solid object. The fracture may be pushed inward or depressed, like the shell of an egg.

A fractured base of skull is most commonly caused by a fall or jump from a height, landing on the feet. Force is transmitted from the feet, through the legs, into the spine and so into the base of the skull. There may be no obvious signs but the history should suggest it.

Fractured Skull - recognition ▪ ▪ ▪ ▪ ▪ ▪

History of a blow to the head or fall from height Changed level of consciousness Possible scalp or facial wound Blood or watery fluid from the nose and ears Swelling and bruising around the eyes Neck stiffness

Fractured Skull - treatment ▪ ▪ ▪ ▪

Assess and monitor the level of consciousness Maintain an open airway Immobilise the head and neck

▪ Recovery position if unconscious ▪ Head and shoulders raised if conscious ▪ Offer life-support as appropriate

The Spine The spine is a column of 33 bones called vertebrae stacked one on top of the other. The vertebrae are separated by pads of cartilage called intervertebral discs. The discs consist of a tough fibrous shell with a softer jelly like inner and they function as cushions or shock absorbers.

Running in the space behind the vertebral bodies is the spinal cord. The spinal cord is the main cable that carries information from the body to the brain and directions from the brain to the body. Branching out from the spinal cord at the level of each vertebra there are spinal nerves that carry the information in and out of the cord.

It is possible to injure the spine without damaging the spinal cord and it is also possible to damage the cord without fracturing the spine.

Vertebral Body

Intervertebral disc

Spinal Cord Spinal Cord

Spinal Nerve

52 Introduction

First Aid Responder

Spinal Injury

CPGs 2017 Page 39

Fractures of the spine in themselves may be fairly moderate injuries.

They become major problems if an injury to the spinal cord is involved and in any injury to the spine this cannot be discounted. Damage to the spinal cord may affect all those parts of the body below the site of Vertabral fracture the injury, so obviously the higher on the spine injury occurs the more potentially dangerous it is for the casualty. This is a condition where inappropriate handling could turn a small injury into a major problem.

Do not rely on looking at or pressing on the casualty’s spine looking for abnormalities. Most first aiders are not skilled enough to detect or discount, spinal injury.

If the nature of the incident suggests the possibility of a spinal fracture assume it to be the case and treat accordingly.

Spinal cord injury

Recognition ▪ ▪ ▪ ▪ ▪ ▪

History of violence Blow to the spine or fall from height Penetrating injury, such as a stab wound Head injury Pain at site Change of sensation below site

▪ Numbness, pins and needles or burning sensation in arms or legs ▪ Lack of movement or uncontrolled movement below injury site ▪ Loss of bowel or bladder control

Q. When should I suspect a spinal injury?

A. Whenever you think of it.

Something about the event or possibly the position of the casualty must have made the thought cross your mind. If you think to yourself “I wonder if he’s hurt his back?” then he has until somebody else proves differently.

Most indicators of a spinal injury come either from the history/mechanism of injury or are what the patient describes or tells you. If the casualty is unconscious or unable to communicate then all you have left is the history or the mechanism of injury.

Be suspicious. If it might have happened then it has happened until a properly equipped expert proves it hasn’t.

Treatment Do not move the casualty unless it is to save or preserve their life.

If the casualty is unconscious, protection of the airway takes priority.

▪ Dial 999/112 for an ambulance ▪ Keep the conscious casualty in the position found.

▪ Try to stabilise their neck and spine.

▪ Reassure them continuously.

▪ Ask them to keep still and not to attempt to move.

▪ Stabilise the neck first.

▪ Immobilise by supporting head, trunk and legs.

▪ Be prepared to place the unconscious person carefully into the recovery position if they have a problem maintaining their airway or they start to vomit.

▪ Roll the casualty like a solid log.

▪ Avoid twisting or bending.

First Aid Responder

Assessment-Primary Survey 53

Upper Limb Fracture Although upper limb fractures are seldom life-threatening injuries of themselves, they may lead to serious blood loss and shock, so the casualties should always be closely monitored for the onset of this condition.

Recognition ▪ ▪ ▪ ▪ ▪

History of injury Pain and tenderness Swelling and bruising Deformity Crepitus

Treatment ▪ Treat any obvious wound or bleeding.

▪ Allow them to support their own arm if they are happy to do so.

▪ Immobilise with the appropriate sling if required.

▪ Elevate where possible.

▪ Check circulation and sensation below the fracture site.

▪ Refer to medical help

Leg Fracture Due to the fact that the bones of the lower limb are much heavier and stronger, it requires greater force or violence to break them. This leads to a greater likelihood of other injury, internal bleeding and shock.

Recognition ▪ ▪ ▪ ▪ ▪ ▪ ▪

History of injury.

Pain and tenderness.

Swelling and bruising.

Rotational deformity.

Shortening of the limb.

Signs and symptoms of shock.

Front of lower leg often an open fracture.

Treatment Treat any obvious wound or bleeding.

Check circulation and sensation below the fracture site.

Elevate where possible.

Do not move them unless absolutely necessary.

Be alert for and be prepared to treat, shock.

Do not apply splints or tie the legs together unless moving the casualty to rescue them from danger.

▪ Take or send them to hospital.

▪ ▪ ▪ ▪ ▪ ▪

54 Introduction

First Aid Responder

Dislocations These occur when a joint has been pulled or twisted apart and the bones have not returned to their correct positions.

The bones are then said to be dis-located or located wrongly.

Dislocations may or may not be associated with a fracture.

Recognition ▪ ▪ ▪ ▪ ▪

History of injury Pain and tenderness Swelling and bruising Deformity at a joint Loss of mobility

Treatment ▪ ▪ ▪ ▪ ▪

Treat as fracture Immobilise, ideally in the position found Be alert for and be prepared to treat, shock Do not be tempted to try to “pop it back in” Send or transport to hospital

Soft Tissue Injury The soft tissues are the muscles, ligaments, tendons and cartilage that connect us together and move us around.

▪ Muscles provide the power ▪ Ligaments connect bone to bone around a joint ▪ Tendons connect muscle to bone and transmit power Soft tissue injuries are either: ▪ Strains ▪ Sprains

Muscle Bone

Sprain A sprain occurs when the ligaments that support a joint are overstretched and torn.

It commonly results from rotating or twisting the ankle.

It can be very difficult to tell the difference between a severe sprain and a fracture, so all doubtful injuries should be treated as fractures until an x-ray has been performed.

Recognition ▪ ▪ ▪ ▪ ▪

History of twisting the ankle or overstretching the joint Immediate pain Swelling Discolouration Bruising (later)

R.I.C.E. Treatment ▪ ▪ ▪ ▪

Rest Ice Compress Elevate

Ligament Tendon

First Aid Responder

Assessment-Primary Survey 55

Back pain Back pain is very common. Four out of five of us are likely to experience one or more episodes of back pain at some time in our lives.

Most sudden back pain is due to muscle spasm caused by tiredness or strain injury, but it may be due to a slipped disc, wear and tear on the joints or a trapped spinal nerve.

A sudden attack of back pain may be very painful but it is not often very serious and it does not usually require medical attention. In most cases the best treatment is to keep as mobile as the pain will allow.

Bed rest or lying still for days will make the muscles seize up and begin to waste away. This means that they will take much longer to recover.

Things that may provoke back pain include: ▪ Heavy manual activity ▪ Reaching, twisting and lifting ▪ Lifting and carrying ▪ Repetitive handling tasks ▪ Poor posture ▪ Slips or trips Although back pain is not usually serious you should see a doctor if you have any of the following: ▪ You feel ill or have a high temperature as well as severe back pain.

▪ You feel numb or have pins and needles in both legs, around the genital area, the insides of the tops of the thighs or around your back passage.

▪ You become incontinent.

Disc bulge ▪ The pain is getting worse for no apparent reason

Slipped disc In this condition properly called a herniated or prolapsed intervertebral disk or P.I.D. the disc, usually in the lower back, ruptures and protrudes or bulges into the space occupied by the spinal nerves. The effect of this is to cause pain, which may travel along the pathway of the nerve affected. The most common nerve to be affected is the sciatic nerve and the pain is referred to as sciatica.

Slipped disc - recognition

Pressure on Spinal Nerve

Herniated disc ▪ Pain over the lower back ▪ May come on suddenly or may have slow onset ▪ It may be sharp and cutting, a dull ache or a feeling of pressure ▪ Pain down the back of one or both legs (sciatica) caused by pressure on the sciatic nerve ▪ Numbness or pins and needles over the lower legs or feet ▪ Often made worse by standing Although prolapse is more common in the lower back, it may also occur in the neck, causing the above symptoms in the neck shoulders or arms.

Slipped disc - treatment ▪ ▪ ▪ ▪ ▪

If the pain is severe, they will want to rest.

They should be encouraged to keep as mobile as the pain will allow.

Ice packs or warmth over the affected area can help the pain.

If the pain persists, the casualty should see their GP. Simple painkillers such as aspirin or paracetamol may help, but sometimes anti-inflammatory drugs may be more effective.

56 The Unconscious Patient

6.

First Aid Responder

The Unconscious Patient

CPGs 2017 Page 26

The Unconscious Patient Unconsciousness can be defined as a reduction in activity in the nervous system, that leads to changes in the casualty’s responses to the world around them.

The management of the unresponsive casualty may be the most important thing that a first aider will learn.

Any casualty who is unconscious is in grave danger due to the absence of the cough and swallow reflexes which guard the airway. Anything in their mouth could block the airway. This may include food, blood, saliva and vomit, but most commonly, their own tongue.

Causes of Unconsciousness A person may become unresponsive due to direct injury to the brain from such conditions as concussion, haemorrhage or head injury.

They may also become unresponsive due to indirect causes such as drugs, including alcohol, heart attack, diabetes or infections.

Treatment of Unconsciousness ▪ Perform a Primary Survey to establish airway and breathing.

▪ Dial 999 for an ambulance.

▪ Perform a Secondary Survey to find and treat (if required) other injuries.

▪ Place the casualty carefully into the recovery position to maintain the airway.

▪ Continue to observe and monitor.

Whatever the initial cause the immediate First Aid treatment would be the same.

A

▪ ▪ ▪ ▪

Fully Conscious and Aware Eyes open spontaneously Reacting normally to events Reflexes are normal

V

▪ ▪ ▪ ▪ ▪

Appears sleepy with eyes closed Eyes open to speech or sound Speech may be slurred May make uncoordinated movements Reflexes are intact

P

▪ ▪ ▪ ▪

Appears deeply asleep with eyes closed Does not open eyes to speech Limited response to painful stimulus Functioning reflexes

U

▪ ▪ ▪ ▪

Appears deeply asleep with eyes closed Does not open eyes Does not respond to any stimulus Reflexes absent

Alert

Verbal

Pain

Unresponsive

A patient with a response of anything other than ‘A’ will require emergency attention.

The Unconscious Patient 57

First Aid Responder

Care of the Unconscious Patient ▪ ▪ ▪ ▪ ▪ ▪

Perform a primary survey to establish airway and breathing.

Offer basic life-support as appropriate.

Perform a secondary survey to find and treat (if required) other injuries.

Place them carefully into the recovery position to maintain and protect the airway.

Send for medical help.

Continue to observe and monitor their condition, particularly their breathing.

The Recovery Position The aim of the recovery position is to maintain and protect the airway by placing the casualty in a position on their side with the head lower than the chest.

▪ ▪ ▪ ▪

Check the area for dangerous objects.

Remove the casualty’s glasses, if they are wearing them.

Remove sharp or bulky items from their pockets.

Remove any potential constriction from around the neck.

Place the hand closest to you up and out of the way.

Pull gently on the knee to roll them toward you.

Bring the furthest arm across and hold the hand alongside the face.

Pull up on the knee to prevent them from rolling back. Knee and hip should be at 90°

Reach down to the further knee and pull it up keeping the foot flat on the floor

Adjust the head to keep the airway open

58 Head Injury

First Aid Responder Brain strikes Inside of skull

Concussion

Concussion occurs following a blow or sudden violent movement to the head and is caused by jarring of the brain.

It is characterised by a sudden loss of consciousness which is usually of fairly short duration.

A concussion is a generally mild brain injury that normally resolves completely, however, a second concussion injury occurring before the first is completely healed could lead to permanent damage.

Concussion - recognition ▪ History of a blow to the head or fall from height ▪ Possible scalp wound or swelling ▪ Sudden, short-term unconsciousness

▪ ▪ ▪ ▪

Headache Rapid weak pulse Pale cold skin Sweating

Concussion - treatment ▪ Assess the level of consciousness ▪ If unconscious check ABC ▪ Place an unconscious casualty into the recovery position ▪ Continue to monitor their vital signs

▪ Call 999/112 for an ambulance, if their condition deteriorates ▪ Advising them to seek medical attention if there is any change in their condition after recovery

Compression In compression injury there may be a history of a blow to the head or a fall from a height. The casualty may complain of pain in the head but may not immediately lose consciousness. Either swelling of the brain or bleeding inside the head causes the problem.

Compression Injury - recognition ▪ History of a blow to the head or a fall from height ▪ Possible scalp wound or swelling ▪ Headache, getting worse

▪ Blood or fluid appearing at the nose, ears or around the eyes ▪ Pupils dilated and not responding to light ▪ Flushed complexion with warm dry skin ▪ Dropping level of consciousness

Compression Injury - treatment Assess the level of consciousness.

Check ABC Dial 999/112 for an ambulance Give life-support as appropriate If conscious, place them in a half sitting position with their head and shoulders elevated ▪ Support and immobilise the neck ▪ ▪ ▪ ▪ ▪

▪ If unconscious and breathing, place them in the recovery position ▪ Keep the bleeding ear downward to encourage drainage ▪ Continue to monitor their condition until the arrival of the ambulance

Burn Injury 59

First Aid Responder

7.

Burn Injury

CPGs 2017 Page 34

A burn is a wound, which results in destruction of mainly surface tissue or skin.

Burns are usually typed according to source or cause.

Different causes may produce different effects.

Burn by Type or Cause Thermal burns: caused by the exposure of tissue to heat, often subdivided into two categories; dry heat and moist heat (scald). Dry heat can be at any temperature and damage is usually limited to the point of contact.

Scald is often larger, as the liquid spreads. It may not be as intense because the temperature is usually limited to the boiling point of the liquid.

Electrical burns: contact with electricity may cause very severe burning, although there may well be other problems associated with electrocution, which would take priority.

Chemical burns: caused by exposure to corrosive chemicals such as acids and alkalis.

Radiation burns: could be any form of radiation but the most common is ultraviolet radiation, or sunburn.

Estimating Severity ▪ Depth of the burn ▪ Extent of the burn ▪ Site of the burn

▪ Casualty’s general health ▪ Casualty’s age ▪ Cause of the burn

▪ Burns can be described as: ▪ Superficial – affects only the surface layers of the skin. They heal quickly with no scarring.

▪ Partial thickness – go into, but not through, the skin. They may cause blistering and obvious fluid loss and are very painful. Shock is often a problem.

▪ Full thickness – go through the skin, take longer to heal and tend to cause more long-term problems such as infection or scarring.

Superficial burn ▪ Superficial burns affect only the surface and cause reddening of the skin, a common example being sunburn.

▪ As the skin surface is not broken they do not cause excessive fluid loss or infection and healing is usually rapid with no long-term problems.

Partial thickness burn ▪ Partial thickness burns are characterised by blister formation.

▪ The burn penetrates through the surface layers causing considerable fluid loss from the damaged tissues.

▪ The fluid forms blisters when trapped beneath the unbroken skin.

▪ Intense pain may also be a feature, along with a wet appearance and a red, white or mottled look.

▪ Fluid loss and pain from large burns will inevitably lead to shock.

60 Burn Injury

First Aid Responder

Full thickness burn ▪ Deep burns penetrate through the full thickness of the skin and may affect underlying organs such as fat and muscle.

▪ The burned area is often black or grey with a dry leathery appearance.

▪ The actual burn site may feel quite numb to touch, due to the destruction of nerve endings.

▪ Healing is usually delayed, infection frequently being a problem and skin grafting often being required.

▪ Deep burns always require medical attention.

Extent of burn It is of great importance to be able to accurately estimate the area of the burn, as this is the primary indicator of the amount of fluid loss suffered by the casualty and therefore how quickly they may suffer from fluid loss shock.

Any partial thickness burn that is larger than the palm of the casualty’s hand (about 1% of the total Body Surface Area) would require medical treatment.

1%

All deep burns regardless of size require medical attention. In addition, you should also send the patient for treatment for burns with a mixed pattern of depth or where you are unsure about the size or severity of the burn.

Management of Burn Injury ▪ Remove the source of heat from the casualty or the casualty from the source.

▪ Check for burns in the airway.

▪ Cool the burn with cool clean water or other clean liquid for up to 15 min.

▪ Cover the burn with a clean, non-fluffy, dressing.

▪ Plastic or clingfilm is ideal.

▪ Avoid touching, or coughing on the burn.

▪ Do not burst blisters.

▪ Do not apply any creams, ointments or fats to the injury.

▪ Remove any tight or constricting items, before swelling becomes a problem.

▪ Do not remove clothing stuck to the burn

Chemical Burn Corrosive chemicals, whether acid or alkaline, will produce burns when brought into contact with the skin. The severity of the injury will depend upon factors such as the chemical, its strength and the time it is allowed to remain in contact with the skin.

Treatment of chemical burns however, will follow the same regime regardless of the chemical involved and consists of: ▪ Flood the affected area with copious amounts of water until all traces of chemical are removed.

▪ This has the effect of both diluting the chemical to a safer level and physically removing it.

▪ Do not waste time searching for specific neutralising agents, commence dilution without delay.

▪ Ensure contaminated water drains away safely.

First Aid Responder

Burn Injury 61

Electrical Burn Injury In the case of electrical burns, it should be remembered that the burn might well be the least of the casualty’s problems. With this injury several factors should be borne in mind: Danger to the rescuer Effect of electrocution Potential severity of the injury Possible other injuries There may be an exit wound There may be other injuries if, for example, the victim was thrown across the room.

▪ Although electrical burns can appear to be small on the surface they invariably produce extensive and severe damage deep to the wound.

▪ All electrical burns should be assessed and treated by a doctor.

▪ ▪ ▪ ▪ ▪ ▪

Inhalation Injury Burns to the airway are particularly dangerous, as swelling of the tongue or throat may interfere with breathing.

Airway burns may be caused by inhaling hot gas or smoke, with the added problem that these products may also be poisonous.

Recognition History of exposure to fire Redness or scorching to the cheeks Soot or staining around the nose and mouth Small blisters on the lips or inside the nose Shrivelled or burnt tips of beard or moustache Hoarse voice Wheezy or noisy breathing Cough, sometimes coughing up soot stained mucus ▪ Difficulty in breathing ▪ Signs or symptoms of poisoning ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Treatment ▪ ▪ ▪ ▪ ▪

Cold drinks or mouthwash Early medical attention, First priority for treatment and evacuation Pass on history to medical authorities Be prepared to offer life-support as required

62 Hyperthermia

8.

First Aid Responder

Extremes of temperature

CPGs 2017 Page 38

Hyperthermia, Recognition and Management Heat Exhaustion Heat exhaustion is caused by loss of fluid and salts due to excessive sweating. It is commonly found in people working or exercising in hot humid conditions that they are not used to.

Recognition ▪ History of exposure to a hot environment ▪ Pale clammy skin ▪ Profuse sweating ▪ Headache

▪ Dizziness and nausea ▪ Temperature may be normal or even below normal due to the profuse sweating

Treatment ▪ Remove them to a cool environment ▪ Lay them down and elevate their legs ▪ Give them copious cool drinks (isotonic sports drinks are preferred) ▪ Keep them at rest and monitor their vital signs

Heat Stroke Heat stroke often results from excessive exercising or heavy manual labour in a hot or humid environment.

It is caused by the failure of the body’s temperature regulating mechanism.

Recognition ▪ Hot, flushed and dry skin ▪ Headache and dizziness ▪ Rapid drop in level of response

▪ Restlessness and mental confusion ▪ Rapid, very strong or heavy pulse ▪ Body temperature above 40° c.

Treatment ▪ Remove them to cool area and remove all outer clothing ▪ Cool the casualty urgently with the application of cold but not icy water ▪ Dial 999/112 for an ambulance ▪ Wrap them in a cold wet sheet, if available, to encourage evaporation ▪ Monitor their vital signs and be prepared to give life support if required

Use a fan

Use cold compresses

Lay down and elevate the feet

Give drinks if conscious

Hypothermia 63

First Aid Responder

Hypothermia, Recognition and Management Hypothermia occurs when the body temperature drops below 35° C. Moderate hypothermia (31° C to 35° C) can often be reversed, but severe hypothermia (lower than 30° C) is often fatal. However, low temperature reduces activity in the brain and therefore its requirement for oxygen, so casualties should never be considered beyond recovery. It is always worth persisting with life-saving procedures until the arrival of medical help.

The onset of hypothermia may be quite sudden, as in accidental immersion in cold water, or may develop over several days, as in the case of an elderly person in an unheated room.

Treatment will vary according to various factors such as the age and physical condition of the casualty, the cause of the hypothermia and the environment that the casualty is in.

36.5-37.5°C

Normal adult

34-36°C

Mild hypothermia

32-34°C

Moderate hypothermia

3-32°C

Deep hypothermia

<30°C

Critical hypothermia

Recognition ▪ ▪ ▪ ▪ ▪

Shivering Cold pale skin Apathy Disorientation Slurred speech

▪ ▪ ▪ ▪

Staggering gait Dropping level of consciousness Slow shallow breathing Collapse and sudden cardiac arrest

Treatment Young casualty / sudden hypothermia ▪ Remove them to shelter ▪ Remove wet clothing, if appropriate ▪ If available, place them into a warm bath or shower (40° C) ▪ Do not leave a re-warming casualty alone

▪ When they feel normal and have stopped shivering they may be gently dried and dressed in warm dry clothing, or placed in bed with blankets or duvet ▪ Give warm sugary drinks

*After immersion in water and subsequent rescue, blood pressure may be low and may continue to fall as the casualty re-warms. (Post rescue collapse) Observe closely for signs of shock and be prepared to treat it. Casualties should be re-warmed sitting or lying, not standing.

Elderly Casualty / slow onset (be aware that hypothermia may be disguising other serious medical conditions) ▪ Place in bed in a warm, not hot, room ▪ Insulate them with layers of blankets or duvet ▪ Allow them to re-warm slowly

▪ Monitor the level of consciousness and vital signs ▪ Be prepared to offer life support as required

64 Information Management

9.

First Aid Responder

Information Management

Patient Care Reports Each time a patient is seen or treated you should make out the patient care record.

There are two patient care records currently in use for first-aid responders.

▪ The ambulatory care report ▪ The cardiac first responder care report It is important that records are made that are : ▪ ▪ ▪ ▪

Complete Valid Accurate Reliable

▪ Relevant ▪ Legible ▪ Available in a timely manner

Entries should be made in black ballpoint Date be re-coded as DD/MM/YYYY Time to be entered as 24 hour clock: 00:00 Information recorded should be legible.

Records should be kept as complete as possible.

Information should be recorded at the time or as soon as possible afterwards.

You should record only what you know to be fact. You should not include opinion or conjecture.

Care reports should include: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Details of the incident, including date, time and location Personal details of the patient, including name address date of birth Patients past medical history Information on the patient’s current condition including injuries or illness found The care management provided to the patient Patient disposition, as in discharged, transferred to ED, referred to GP, refused further care Responder details Medications administered if any Record of any vital signs and timing Any additional information

Handover of patient ▪ The respondent should hand over care of the casualty and control of the situation to emergency medical services or qualified medical practitioners as and when they arrive on scene.

▪ The top copy of the report should accompany the patient.

▪ The bottom copy of the report will remain the property of the service provider who administers care to the patient ▪ All patient reports recording the patient’s care will be handed over to the ED/destination facility as part of the record of the continuum of care for the patient

First Aid Responder

10.

Communication 65

Communication

Seeking Consent Types of consent: 1. Expressed consent 2. Implied consent 3. Consent for minors Expressed consent ▪ The patient actually tells you that they want you to provide treatment for them.

▪ This consent can be verbal or non-verbal (written).

▪ Consent must be “informed” which means they must understand and be aware of the procedure involved, prior to giving consent.

▪ They must be of minimum legal age to give consent (16).

Implied consent ▪ This assumes that the casualty is unconscious and you believe that they would provide consent if they were able.

▪ You should never hesitate to treat an unconscious casualty, once it is safe to do so.

Consent for minors ▪ Minors cannot refuse treatment.

▪ If parents or guardians are present you should seek consent from them.

▪ If a parent or guardian is unavailable and the patient requires emergency care, do not hesitate to give appropriate emergency medical care.

Communication ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Identify yourself and state function (my name is Billy, I am a first aid responder).

Tell them what you are going to do – before you do it.

Ask questions calmly, with a reassuring voice.

Allow the casualty to tell you what happened.

Be seen to be listening closely to what the casualty says.

Do not be judgemental, use active listening skills.

Acknowledge the casualty’s feelings.

Do not be patronising.

Empathy: ▪ This is a helpful concept when dealing with casualties in a crisis.

▪ Empathy is recognising the casualty’s feelings and trying to understand what and how they are feeling.

When communicating with children: ▪ Squat down to their eye level, do not tower over them.

▪ Introduce yourself and tell them your role and function.

▪ Allow them to stay with their caregiver.

▪ Explain what you are going to do, before you do it.

▪ Listen to them.

▪ Allow time to create a rapport with the child, if the situation allows.

66 Critical Incident Stress

11.

First Aid Responder

Well-being of the First Aid Responder

Critical Incident Stress Many first aiders will never have to deal with anything particularly serious. The life or death situation is the exception rather than the rule. However, first aid has the potential to rapidly become a life or death situation.

The level of stress produced in the circumstances is very often much higher than the average person is used to dealing with and this can lead to a stress condition after the event.

Critical incident - definition

A powerful and overwhelming event that lies outside the range of usual human experience.

It has the potential to exhaust one’s usual coping mechanisms, resulting in psychological distress and disruption of normal adaptive functioning Events which may lead to these high stress levels include: ▪ Witnessing severe injury or death, particularly to young people or children.

▪ Witnessing the effects of sudden serious illness.

▪ Multiple casualty incidents ▪ Dealing with injury or illness in the elderly

Critical incident stress – physical signs ▪ ▪ ▪ ▪ ▪ ▪

Fatigue Nausea Muscle tremors Chest pain Breathing difficulty Elevated blood pressure

▪ ▪ ▪ ▪ ▪ ▪ ▪

Elevated heart rate Thirst Visual difficulties Vomiting Teeth grinding Muscular weakness Dizziness

▪ Profuse sweating ▪ Chills ▪ Signs of circulatory shock ▪ fainting

Critical incident stress – cognitive signs ▪ ▪ ▪ ▪ ▪ ▪

Blaming someone Mental confusion Poor attention span Poor decision-making Alertness changes Poor concentration

▪ Memory problems ▪ Difficulty identifying familiar objects or people ▪ Increased awareness of surroundings

▪ ▪ ▪ ▪ ▪ ▪

Poor problem-solving Poor abstract thinking Loss of orientation Disturbed thinking Nightmares Flashbacks

Critical incident stress – emotional signs ▪ ▪ ▪ ▪ ▪

Anxiety Guilt Grief Denial Panic

▪ ▪ ▪ ▪ ▪

Emotional shock Fear Uncertainty Loss of control Depression

▪ Inappropriate responses ▪ Apprehension ▪ Feeling overwhelmed ▪ Intense anger

Critical Incident Stress

First Aid Responder Critical incident stress – behavioural signs ▪ Change in activity ▪ Changing speech patterns ▪ Withdrawal ▪ Emotional outbursts ▪ Suspiciousness

▪ Loss or increase of appetite ▪ Alcohol consumption ▪ Inability to rest ▪ Antisocial acts ▪ Physical complaints

▪ Intensified startle reflex ▪ Pacing ▪ Erratic movements ▪ Changes in sexual functioning

Critical incident stress - diagnosis As can be seen, critical incident stress can have many and far-reaching consequences.

It is likely that a sufferer would be exhibiting a few of the signs rather than all of them.

A combination of the history of exposure to a critical incident, combined with exhibiting some of the signs of critical incident stress would be sufficient to make a diagnosis.

Minimising Critical incident stress You cannot avoid critical incident stress completely but there are steps you can take to minimise its effect.

Prepare yourself, mentally and physically.

▪ Practice and Preparation Prevent Poor Performance, practice your skills and competencies regularly, so that in an emergency they become second nature.

▪ Prepare physically, keep healthy ▪ Prepare equipment, ensure that you are aware of all equipment carried and competent in its use. Don’t try to learn how to use it in an emergency.

▪ Maintain a positive mental attitude, remember it is the event that is abnormal, not you.

▪ Gather as much information as possible about the event.

▪ If the event is ongoing, take regular breaks.

▪ Listen to and follow the directions of more senior or better qualified people at the scene.

After the event ▪ Be aware of your feelings and be prepared to ask for help if necessary.

▪ Do not bottle up your emotions but talk with people that you trust.

▪ If your organisation suggests debriefing sessions or counselling be prepared to take part and use it constructively.

▪ Keep active and keep occupied.

▪ Don’t isolate yourself and dwell on the circumstances.

▪ Learn what you can from the incident.

▪ Avoid excess alcohol.

67

1. The cough reflex and the swallow reflex.

2. The patient’s own tongue. As it relaxes it may fall backwards and block the opening to the airway.

3. The recovery position. The recovery position should have a finished position with the head lower than the chest and the patient on their side, to aid drainage of blood, saliva or stomach contents.

4. Your own safety, particularly if you are the only rescuer. After that, the safety of the patient and anyone else in the vicinity.

5. Head tilt – chin lift. This will lift the tongue of an unconscious patient away from the back of the throat and also straighten out the airway. It should be done with care.

6. No more than 10 seconds. If the patient is not breathing normally it is important that you start chest compressions without delay.

7. 999 or 112. If you are using a mobile phone it can be very useful to turn on the speaker so that you can describe things to the ambulance controller as you see them and they can offer advice.

8. 100 to 120 compressions per minute at a depth of 5 – 6 cm. It is important to maintain the rate and depth, so if you get tired it would help to change over with another first aider every two minutes.

9. 30 compressions to 2 breaths. If you are unable or unwilling to give rescue breaths then just continue with chest compression only resuscitation at 100 –120 compressions per minute.

10. Reasons for stopping CPR would be: if the patient showed obvious signs of recovery , if you are directed to stop by qualified person, you become too exhausted to continue.

Answers – Unconscious Patient/Basic Life Support 1. What are the names of the two reflexes that protect the airway when swallowing?

2. What is the most common object to block an unconscious person’s airway?

3. In what position would you place an unconscious but breathing casualty, assuming other injuries allow?

4. As you approach an unresponsive casualty, what is the first thing that you should be aware of?

5. What are the two steps that you would take to open an unconscious person’s airway?

6. What is the maximum time you should spend checking for normal breathing?

7. What are the two free emergency numbers to call the emergency services in Ireland?

8. At what depth and rate would you compress the chest of an adult when performing CPR? 9. What is the ratio between compressions and breaths when performing CPR on an adult?

10. When would you stop performing CPR?

Test Your Knowledge – Unconscious Patient/Basic Life Support

68 Quiz

First Aid Responder

1. Automated External Defibrillator 2. On the right-hand side of the chest, to the right of the breastbone and immediately below the centre of the right collarbone.

3. It needs to be well back on the left-hand side of the chest to ensure that current travelling from pad to pad will travel through the heart rather than across the front of the chest.

4. Nobody should touch or move the patient whilst the AED is analysing. It could give a false result and could even mean defibrillating somebody who doesn’t need it.

5. You should not interrupt CPR for more than 10 seconds whilst the machine is analysing.

6. You should ensure that nobody is touching the patient when you give the shock.

Shout “clear” and look carefully around the patient before pressing the button.

7. Two minutes, or until prompted to stop by the AED. 8. Metallic jewellery or piercing, medicated patches such as glyceryl trinitrate, pacemaker or cardioverter implants. Try to maintain a distance of 10 cm.

9. A towel in case the chest is wet, a disposable razor in the case of excessive chest hair.

Tuf Cuts or shears to help expose the chest quickly, spare battery, spare pads, paediatric pads if required.

10. Yes, it would be better than doing nothing although there are some risks. Use

Answers – Using an AED What do the initials AED stand for?

Where would you place the (patient’s) right-hand chest pad?

What is important about the placement of the left-hand chest pad?

Should one rescuer continue CPR whilst the AED is analysing?

How long should you analyse for, before continuing with CPR? What safety precautions should you take before pressing the “shock” button?

If no shock is indicated, for how long would you perform CPR before analysing again?

What are the things that a patient may have on their chest that you would need to be aware of when placing the chest pads?

9. What other items might be stored with the AED? 10. Can an adult AED be used on a child?

1.

2.

3.

4.

5.

6.

7.

8.

Test Your Knowledge – Using an AED First Aid Responder

Quiz 69

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Fluid loss from bleeding or Burns, problems with the heart such as heart failure or heart attack. Problems with the nervous system such as injury, pain or fear. Allergy, in anaphylaxis.

Pale cold clammy skin, rapid weak pulse, rapid shallow breathing, nausea and vomiting, dizziness, cyanosis, mental confusion, weakness and collapse, dry mouth or thirst, feels cold.

Arteries, supply blood from the heart to the body. Veins return blood from the body to the heart. Capillaries are the tiny blood vessels that link arteries to veins and feed into individual cells.

If available, use gloves from the first-aid kit. In emergences you might consider putting plastic or polythene bags over your hands. Try to avoid direct contact with the blood.

Direct pressure should be applied for at least 10 minutes to ensure blood clot formation. In some people it may take longer if they are taking medications like aspirin or anticoagulants.

Place another dressing on top and bandage firmly. If blood soaks through the second dressing, remove both dressings and re-apply a fresh dressing, ensuring it is directly over the bleeding point.

Make sure the bandage is not too tight by checking circulation below the site. You can do this by finding a pulse or by checking capillary return in a fingernail.

If the foreign body is very small and superficial, the type you might refer to as a splinter. If in doubt do not attempt to remove it.

Bruising, particularly on the torso, may indicate internal bleeding. Be aware that bruising may not appear immediately.

By sealing it you run the risk of causing Tension Pneumothorax and build up of pressure. Leave it open to atmosphere

Answers â&#x20AC;&#x201C; Shock, Bleeding and Blood Loss 6.

7.

8.

9.

10.

5.

1.

2.

3.

4.

Give two causes of acute circulatory shock.

Give three signs or symptoms of acute circulatory shock.

Name the three types of blood vessel.

When dealing with a bleeding injury, what personal protective equipment would you want to use?

For what minimum time would you apply direct pressure to ensure blood clot formation?

If blood soaked through a wound dressing, what would you do?

After applying a dressing and bandage, what checks would you make?

When might you remove an embedded foreign body?

What serious condition might bruises be a sign of?

Penetrating injury to the chest. Would you seal it or leave it open?

Test Your Knowledge â&#x20AC;&#x201C;Shock, Bleeding and Blood Loss

70 Quiz

First Aid Responder

First Aid Responder Notes

Notes

71

72 First Aid Responder Notes

Introduction